Manual Therapy for

Musculoskeletal Pain Syndromes

an evidence- and clinical-informed approach
For Elsevier
Co nte nt Strate g is t: Rita Dem etriou -Sw anw ick
Co nte nt De ve lo pme nt Spe c ialis t: N icola Lally
Pro je c t Manag e r: Shereen Jam eel
De s ig ne r / De s ig n Dire c tio n: Miles H itchen
Co py Edito r: Chris Wyard
Illus tratio n Manag e r: Em ily Constantino
Illus trato rs : Graem e Cham bers and Wend y Beth Jackelow
Manual Therapy for
Musculoskeletal Pain Syndromes
an evidence- and clinical-informed approach
Edited by
César Fernández-de-las-
Peñas PT, MSc, PhD
Head, Physical Therapy, Occupational Therapy,
Rehabilitation and Physical Medicine,
Universidad Rey J uan Carlos, Alcorcon,
Madrid, Spain
Researcher, Center for Sensory-Motor Interaction
(SMI), Aalborg University, Aalborg, Denmark
J oshua A. Cleland PT, PhD
Professor, Physical Therapy, Franklin Pierce
University, Manchester, NH, USA
J an Dommerholt PT, DPT
Physical Therapist, Bethesda
Physiocare / Myopain Seminars, Bethesda,
MD, USA
Forewords by
Ola Grimsby PT, DMT, FAAOMPT
The Ola Grimsby Institute Consortium Inc.
Rob A.B. Oostendorp
PhD, PT, MPT
Emeritus professor of Manual Therapy, Faculty of
Medicine and Pharmacy, Vrije Universiteit
Brussel, Brussels, Belgium
Emeritus professor of Allied Health Sciences,
Faculty of Medical Sciences, Radboud
University Nijmegen, Nijmegen, The
Netherlands
Prof. Dr. Andry Vleeming
PT, PhD
Department of Anatomy, Medical College of the
University of New England, Maine, USA
Department of Rehabilitation Sciences and
Physiotherapy, Faculty of Medicine and Health
Sciences, Ghent University, Belgium
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N otices
Know led ge and best practice in this eld are constantly changing. As new
research and exp erience broad en our u nd erstand ing, changes in research
m ethod s, p rofessional practices, or m ed ical treatm ent m ay becom e
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Forewords
Foreword by Ola Grimsby
Manu al therap y has d evelop ed from a selection of techniqu es
from H ippocrates throu gh variou s schools of thou ght for
m any generations. It has d ocu m ented its valid ity sim p ly
by surviving the scru tiny of tim e. From the skill of its practi-
tioners, new generations have re ned and m od i ed the
p erform ance and over tim e it has em erged as a scienti c,
m u ltid iscip linary, evid ence-gu id ed ap p roach to rehabilitation
m ed icine.
The evalu ation and treatm ent of fu nctional range of m otion
follow ed the p rincip les of joint biom echanics up to the 1970s.
In the 1980s w e then learned to u nd erstand and assess pain
concep ts and how m anu al therap y in u ences inhibition and
facilitation through neu rop hysiology. From histology and the
cellu lar rep air cu rricu lu m , w e ad d ed the op tim al stim u li for
tissu e rehabilitation and thu s w id ened the concep t of m anu al
therap y interventions in the 1990s. As ou r u nd erstand ing
grew of the biom echanical and nu tritional energy essential for
cellu lar rep air, su p p lem ents su ch as vitam ins, herbs and m in-
erals becam e an im portant ad d ition to the patient’s health-
care. In the last 15 years, m ed ical technology from im agery
and electroneu rom yography, as w ell as clinical com petencies
from psychology, d iagnostic m ethod ology and pharm acol-
ogy, have shed light on ou r p atient care and ou r ou tcom e
stu d ies. A grow ing volu m e of m u ltid iscip linary research is
assisting the evolu tion of the scienti c basis for m od ern
m anu al therap y assessm ent and interventions.
Within this com m u nity of rehabilitation schools of thou ght,
w e have tod ay a num ber of ‘fam ilies’. Manu al therap y has
becom e an u m brella of integrated rehabilitation services, and
it is of great im p ortance to u nd erstand how the contribu tors
of this textbook exhibit su f cient com m onality to be u nited
u nd er this one head line. It is even m ore im p ortant to ap p reci-
ate how these schools of thou ght d iffer from each other w hile
still contribu ting to the com p lete, com p lex p ictu re of the com -
m u nity of m anu al therap y.
The three ed itors of M anual Therapy for M usculoskeletal Pain
Syndromes: an evidence- and clinical-informed approach have
au thored and also coord inated the efforts of som e of the m ost
p rom inent authors, scientists and clinicians in the interna-
tional w orld of m anu al therap y. The chap ters are clinically
relevant, w ell referenced and cover a w id e variety of essential
top ics. Each chap ter sp eaks of p ersonal exp erience and
grou nd ed theory w ith passion and p urpose.
It is w ith ad m iration and resp ect that I recognize the efforts
behind this m onum ental task. The book is an asset to the
m anu al therap y com m u nity, a reference of cu rrent achieve-
m ents and a triu m p h in the p rocess of interacting and
coord inating the d ifferent com p onents of m u scu loskeletal
assessm ent and rehabilitation. It is a d ocu m ent that shou ld be
fou nd on the shelves of every clinician, ed u cator, scientist and
library and it should serve as a com pass for clinical com peten-
cies, research as w ell as fu tu re d evelop m ents.
My w arm est congratu lations go to the au thors and ed itors.
Ola Grimsby, PT, DM T, FA A OM PT
The Ola Grimsby Institute Consortium, Inc.
Foreword by Rob A.B. Oostendorp:
Learning from the past as a bridge to
the future of manual therapy
With a requ est to w rite a forew ord , before m e lies the su b-
stantial m anu scrip t of M anual Therapy for M usculoskeletal Pain
Syndromes: an evidence- and clinical-informed approach.
The history of this book has a particular and very special
m eaning for m e. Peter H u ijbregts, a fellow cou ntrym an, one
of m y closest friend s and one of m y best stu d ents d u ring m y
tim e at the Free University of Bru ssels, Belgiu m , m ad e a
sp ecial contribu tion to the creation of this book. Althou gh
Peter sad ly passed aw ay at far too you ng an age on 6 N ovem -
ber 2010, som ething of his spirit perm eates this book and
em bod ies his know led ge of the eld of m anu al therapy and
his enthu siasm in sharing this know led ge w ith others. The
ed itors, along w ith a large num ber of p rom inent au thors, d o
him a great honou r by d ed icating this book to him . A w ond er-
ful gesture!
Manu al therap y has u nd ergone rap id d evelop m ent over
recent d ecad es and this fascinating jou rney is reported in the
book before you . H ow ever, and d espite the signi cant accrual
of know led ge, m anu al therap y still stru ggles w ith signi cant
u ncertainties concerning the m anu al assessm ent of p atients
w ith m uscu loskeletal d isord ers. While this book d escribes
the state of the art for m anu al therapy as of 2014, the cu rrent
statu s of the eld serves to u nd erline the u rgent need for
valid d iagnostic and classi cation criteria, together w ith the
need for international harm onization in ord er to increase
the com p arability of clinical trial d ata. Fu rther u ncertainties
relate to treatm ent regim ens per se. It is striking that rand -
om ized clinical trial (RCT) rep orts d evote su bstantial atten-
tion to the d esign and m ethod ology of the stu d y, bu t relatively
little attention to the m anual d iagnostic and therapeu tic
interventions. Whereas the d escription of the stu d y d esign
and m ethod s generally form a su bstantial p art of a m anu -
scrip t, m anu al therap y interventions are often d escribed in
only a few sentences. Many cu rrent RCTs even lack cru cial
d etails on the m anu al therap y intervention exam ined . In
ord er to interp ret resu lts from ind ivid u al stu d ies to clinical
p ractice it is im p ortant to have m ore d etailed inform ation
abou t the ‘w ho, w hat, w hen and w here’ of the intervention,
especially given that interventions are generally tailored to

m eet the need s of the ind ivid u al p atient. Althou gh it is
w id ely accepted that m anipu lation and m obilization are the
m ainstay of treatm ent, there is still a notable lack of p roven
inform ation on treatm ent. The goal of the CIRCLe SMT (Con-
sensu s on Interventions Rep orting Criteria List Sp inal Manip -
u lative Therap y) stu d y is therefore to d evelop a m inim u m set
of criteria for the d escrip tion of sp inal m anip u lative therap y
in RCT reports.
Im portant aspects of the transition from the past as a brid ge
to the fu ture of m anu al therapy are: (1) the transition from
au thority-based p ractice to evid ence-based practice, (2) the
transition from the International Classi cation of Diseases
(ICD) to the International Classi cation of Fu nctioning, Dis-
ability and H ealth (ICF), and (3) the transition from m anual
therap y as a u nim od al treatm ent to an integration of m anu al
therap y into the cu rrent u nd erstand ing of the neu rop hysiol-
ogy and p sychology in relation to p ain (m u ltim od al m anu al
therap y).
The transition from authority-based practice
to evidence-based practice
Whereas in the p ast the practice of m anual therap y w as alm ost
exclu sively au thority based , tod ay the practice is based on the
best-available evid ence. Within the d e nition of evid ence-
based m ed icine (EBM), three d im ensions d e ne evid ence
from clinical p ractice: external scienti c evid ence, clinical
expertise of the practitioner and the w ishes, values and expec-
tations of the p atient. The relative allocation of attention to
these three d im ensions in ed u cation, clinical p ractice and
research u ltim ately d eterm ines the quality of m anu al therapy.
Within this com p rehensive book, the variou s chap ters aim to
re ect this proportional d istribu tion and in m ost chap ters
particu lar attention is paid to the transp arency of clinical rea-
soning based on clinical exp ertise. This book w ill certainly
contribu te to an increase in the transp arency of m anu al
therap y.
The transition from the International
Classi cation of Diseases (ICD) to the
International Classi cation of Functioning,
Disability and Health (ICF)
In the p ast, m anual therapy w as chie y organized around the
ICD (this trad itional classi cation is also follow ed by the
chap ters of this book), w hereas tod ay the com p onents of
the ICF (in ad d ition to the ICD) increasingly form the basis
for patient health pro les. In ad d ition to a focu s on bod y func-
tion and stru ctu re, there is an increasing focu s on p articip a-
tion in society and on p ersonal and environm ental factors in
the onset and p ersistence of health p roblem s. Over the p ast
d ecad es, clinical and scienti c und erstand ing of (chronic)
m u scu loskeletal p ain has increased su bstantially and it is now
w ell established that a m od el restricted to bod y function and
stru ctu re falls far short in d iagnosing and treating p atients
w ith m u sculoskeletal pain. H ow ever, the m ajority of m anu al
therap ists w ere ed u cated in this biom ed ical m od el, and
m anu al therap y has a very long history of biom echanical
d iagnostics and treatm ent. Many of the authors of this book
now ad vocate a transition to a biop sychosocial m od el in
Forewords xv
p atients w ith m u scu loskeletal d isord ers. This m od el d oes not
im ply ignoring bod y function and structu re. Rather, these
biological issu es are integrated into a w id er and m ore com -
p rehensive biop sychosocial m od el.
The transition from unimodal manual therapy
to an integration of manual therapy into the
current understanding of the neurophysiology
and psychology of pain
Consid eration of the con icting scienti c assessm ents fou nd
in pu blications that have evalu ated the effectiveness of m anu al
therap y show s that those carrying ou t the evalu ation focu s
m ainly on the m ethod ological qu ality of the stu d ies (inclu d -
ing stud y d esign, rand om ization, blind ing and ou tcom e
m easu res) and hard ly tou ch u p on p ossible theoretical exp la-
nations for the lim ited effectiveness of m anu al therap y. Valu -
able insights could be gained from a d eeper inquiry into the
theoretical backgrou nd to the qu estion of w hy the effective-
ness of m anu al therap y in p atients w ith chronic p ain ap p ears
to be lim ited .
Patients w ith chronic p ain w ho requ est help from a m anu al
therap ist often exp erience a red u ction in p ain d u ring the
initial treatm ent period bu t notice that the effect of treatm ent
d eclines and that the period betw een treatm ents becom es
shorter. It is therefore ad visable to d ocu m ent accu rately a
history of p reviou s treatm ent w hen taking a p atient’s history
because p revious treatm ent m ay have either a positive or a
negative effect on the ou tcom e.
The logical response of m ost patients d uring a (su b)acu te
stage of p ain, a new ep isod e of p ain or an increase in p ain is
to avoid m ovem ents and activities in the exp ectation that
increased pain can thereby be prevented . These behaviours
often ap p ear to be effective and p ain u su ally d ecreases after
a few hou rs or d ays. H ow ever, in a lim ited num ber of p atients
a fear of certain m ovem ents and activities grad u ally d evelops,
ow ing to an attribu ting cognition that p ain translates to an
increase in tissu e d am age and d am age to m uscles and joints.
This increasing fear lead s to less and less tim e being d ed icated
to activities, and resu lts in a viciou s circle of fear, p assivity,
d isu se and d epression. A p atient’s exp erience of pain can
result in loneliness, fears of never being pain free, and a sense
of feeling trap p ed w ithin a p ainfu l bod y. These p atients often
experience severe effects, m anifesting as signs of sensitization
of the central nervou s system . Und er the cond ition of central
sensitization, the central nervou s system is insu f cient or no
longer able to orchestrate peripheral and central nociceptive
p ain m echanism s, inclu d ing a su stained inhibition of m otor
function, physical activities and general activities. The d evel-
op m ent, im p lem entation and evalu ation of clinical gu id elines
for therapeutic ed ucation based on actual p ain–neu rop hysi-
ological and p sychological insights, before and d u ring the
active rehabilitation p rocess, stand in the spotlight in m u lti-
m od al m anu al therap y. The ed itors and the au thors of this
book have clearly u nd erstood that the transition of m anu al
therap y to a m u ltim od al ap p roach is a necessary p rerequ isite
for a bright fu ture for m anu al therapy.
Manu al p hysical therap ists shou ld be fam iliar not only
w ith the biopsychosocial context of p ain, but also w ith m od ern
insights d erived from pain neuroscience and psychology
 xvi Forewords
concerning reconcep tu alization of p ain. In fact, a su stained
biom ed ical ap proach can even lead to an iatrogenic effect,
w hich resu lts in an increase in pain. Althou gh increasing evi-
d ence supp orts a role for psychological and social factors in
the em ergence and p ersistence of chronic m u scu loskeletal
p ain, the m ajority of clinicians have received an ed u cation
w ith a solely biom ed ical focus – a focus that is also evid ent in
the p rofession of m anu al p hysical therap y. This focu s is
re ected in a long trad ition of treatm ent options for p atients
w ith m uscu loskeletal d isord ers based on biom echanical prin-
cip les. This em p hasis on biom ed ical asp ects ap p ears to shap e
a therap ist’s know led ge, attitud es, beliefs and behaviou r
tow ard s (chronic) m u scu loskeletal p ain. An ad d itional barrier
to the accep tance of the em erging biop sychosocial m od el is
that the em ergence of new or revised theory and su bsequ ent
changes in p ractice are often characterized by a signi cant
tim e-lag. This book m akes an im p ortant contribu tion to the
transition from m anu al therap y in a narrow sense to m anu al
therap y in a broad er sense, inclu d ing the ap p lication of
m od ern neu rop hysiological and p sychological insights. This
book therefore form s a brid ge from the past to the fu ture, and
w ill bene t not only p atients bu t also m anu al physical thera-
p ists w orld w id e.
The book now in front of you also d ocu m ents how the
theory and p ractice of m anu al therap y have changed over
tim e. Cu rrent know led ge often has a half-life of only a few
years and w hat is now stand ard practice in m anu al therap y
m ay qu ickly becom e ou td ated . Exp erim ental and clinical
qu estions that are now u nansw ered can be exp ected to be
answ ered in the near or not-too-d istant futu re. This ongoing
p rogress bod es w ell for fu tu re ed itions of this excellent book.
The au thors w ho contribu ted to the p resent volu m e have
each brought d eep know led ge of m anu al therapy to their
ind ivid u al chap ters, ju st as the ed itors, César Fernánd ez-d e-
las-Peñas, Joshu a Cleland and Jan Dom m erholt, have u sed
their skill and u nd erstand ing to m aintain consistency betw een
chap ters. I w ou ld therefore like to congratu late both the
au thors and the ed itors on the ap p earance of this stand ard
w ork in the eld of m anu al therapy.
Rob A .B. Oostendorp, PhD, PT, M PT, Emeritus professor of
M anual Therapy,
Faculty of M edicine and Pharmacy, Vrije Universiteit Brussel,
Brussels, Belgium
Emeritus professor of A llied Health Sciences, Faculty of M edical
Sciences,
Radboud University N ijmegen, N ijmegen, The N etherlands
Foreword by Prof. Dr Andry Vleeming
This textbook w as conceived by a resou rcefu l ed itorial team
w ith a straightforw ard am bition: to create a m anu al treatm ent
book of m u sculoskeletal pain synd rom es. A d iversi ed inter-
national grou p of colleagu es w ith clinical and scienti c
exp erience have contribu ted to speci ed chapters on the basis
of both evid ence- and clinical-inform ed know led ge and
exp erience.
The am bitions for the textbook are w ell d e ned to conceive
an integrated app roach of effective m anu al treatm ent and to
brid ge apparent d ifferences in therapeu tic opinions. In par-
ticu lar, the text em p hasizes that m anu al techniqu es need to
be intrinsically related to neu roscience concepts, w hich
requ ires an integrated clinical ap proach. It encourages the
su bstitu tion of m anu al techniqu es from ‘hand s on’ to ‘hand s
w ith the involvem ent of the patient’. This com m ences a joint
p artnership betw een the clinician and the p atient, enabling
them to fathom their p ain and p roblem s. The p atient is chal-
lenged and engaged in their rehabilitation, w ith su f cient
u nd erstand ing of how integrated treatm ent and training
ad herence is the core of a su ccessfu l treatm ent app roach.
Clinicians w orking w ith any kind of m anu al treatm ent
m od ality shou ld stu d y this textbook, p articu larly to d eep en
their know led ge and to realize that d u ring m anu al treatm ent
the nervou s system is su rely involved . Therefore m anu al tech-
niqu es shou ld be com bined w ith a cognitive ap p roach su ch
as therapeu tic neu roscience ed ucation.
This inform ational textbook is a p rofound and accessible
com p osition of m any know led geable clinicians, recom m end -
ing an integrated treatm ent approach to rehabilitate patients
effectively. Likew ise, it is an innovative approach to m anu al
treatm ent techniqu es and clearly re ects how p atients can
bene t from it.
This book is a fascinating and highly read able accou nt of
m anu al treatm ent p ractices that shou ld be end orsed to m any
clinicians. Pass this textbook on to you r colleagu es!
Prof. Dr A ndry V leeming, PT, PhD, Department of A natomy,
M edical College of the University of N ew England, M aine, USA
Department of Rehabilitation Sciences and Physiotherapy,
Faculty of M edicine and Health Sciences, Ghent University,
Belgium

What insp ired u s to invite a w id e variety o contributors rom
all over the w orld to this book is the realization that m anu al
therap y can no longer be sep arated rom the em erging con-
cep ts and know led ge com ing rom p ain neu rosciences. In act,
m anu al therap y is p robably the m ost-u sed treatm ent ap p roach
by m any healthcare pro essionals, inclu d ing p hysical thera-
p ists, osteop aths, chiropractors, m assage therap ists, m ed ical
d octors, etc. Whereas, trad itionally, som e m anu al physiother-
ap ists w ou ld ad vocate that they w ould not be treating pain
cond itions, bu t instead ocu s only on d ys u nctional m ove-
m ent p atterns, in act m anu al therap y can be u nd erstood only
w hen w e consid er both the m echanical and the neu rophysi-
ological u nd erlying m echanism s (Bialosky et al 2009). N ot
only can m anu al therap y interventions trigger p erip heral and
central nervou s system resp onses in acu te and esp ecially
chronic p ain cond itions, bu t the central nervou s system itsel
p lays a critical role in the personal experience and presenta-
tion o p ain.
Be ore w e d iscu ss the d etails o this textbook, w e w ou ld
like to take a m om ent to acknow led ge the contributions to this
book by our d ear riend and colleagu e Peter H u ijbregts, w ho
not only contribu ted as an au thor or co-au thor o several
chap ters, bu t also conceived the need to p u t together a book
o this m agnitu d e and ocu s. Un ortu nately, Peter p assed
aw ay u nexp ected ly long be ore this book cam e to ru ition,
bu t, throu ghout the preparatory w ork, his spirit and inspira-
tion p erm eated ou r e orts. We are sad d ened that cou ntless
p eop le w ill never have a chance to be p ersonally in u enced
by him . Peter w as one o those persons you cou ld not orget
i you w ere ortu nate enou gh to have him cross your path. H e
w as alw ays up or d iscu ssing the historical origins o m anual
therap y or the cu rrent evid ence su p p orting the e ectiveness
o interventions. We w ill never orget his sense o hum our –
m any tim es Peter entertained the room w ith his w it and
com ed y. H e has had a rem arkable in u ence on m any p ro es-
sionals w ho have been ortu nate enou gh to encou nter him .
H is passing has le t a hu ge void in the m anual therapy com -
m u nity arou nd the w orld . We are p rou d to d ed icate this book
to the m em ory o Peter H u ijbregts and w e hop e w e have su c-
ceed ed in m aking his d ream a reality.
The parad igm w e have chosen or this book is the
evid ence- and clinical-in orm ed parad igm . It has been m ore
than 30 years since a grou p o clinical epid em iologists at
McMaster University introd u ced the evid ence-based p ractice
p arad igm to rep lace the trad itional parad igm (Guyatt 2008).
Accord ing to the trad itional parad igm , d iagnosis and m an-
agem ent w ere gu id ed m ainly by a pathophysiological ration-
ale and by know led ge provid ed by respected au thorities in
the f eld . The m ain eatu re o the evid ence-based p arad igm
is that the d iagnosis and m anagem ent should be guid ed
m ainly by the best-available scientif c evid ence; how ever, the
evid ence-based practice parad igm has been m et w ith and
continu es to m eet consid erable resistance rom the clinical
f eld . Its early d ef nition as the ‘conscientiou s, exp licit, and
jud iciou s use o cu rrent best evid ence in m aking d ecisions
abou t the care o ind ivid u al patients’ (Sackett et al 1996, p 71)
Preface
seem ed to m irror the o ten-heard criticism s o over-reliance
on research evid ence at the exp ense o clinical exp erience and
d isregard o social context. Althou gh evid ence-based practice
has now evolved to w here it ad op ts a m ore inclu sive view o
scientif c evid ence, recognizing not only the valu e o d i erent
research d esigns, but also o clinical expertise, patient values
and p re erences and even contextual actors in the clinical
d ecision-m aking process (Rycro t-Malone 2008), the evid ence-
in orm ed parad igm is a m ore app ropriate parad igm in w hich
the clinician takes the available evid ence rom research into
account w hen m aking a clinical d ecision w ith regard to ind i-
vid u al p atient m anagem ent bu t w here evid ence d oes not
com p letely d ictate this d ecision (Pencheon 2005).
Throughou t this textbook, the chap ter au thors have inte-
grated clinical experience and expertise and reasoning based
on a neu rop hysiological rationale w ith the m ost u p d ated evi-
d ence, thereby in e ect com bining the best o the trad itional
and evid ence-based p arad igm s in a new parad igm that is
tru ly rep resentative o w hat clinicians d o in everyd ay clinical
p ractice. We believe that this ap p roach has created a book that
p rovid es p ractising clinicians w ith w hat they need to know
or real-li e screening, d iagnosis and m anagem ent o patients
w ith m u scu loskeletal p ain.
The textbook is d ivid ed into 11 parts. In the general intro-
d uction, several authors review the epid em iology o upper
and low er extrem ity p ain synd rom es and the p rocess o
taking a com p rehensive history in p atients a ected by p ain.
In Chap ter 5, the basic p rincip les o the p hysical exam ination
are covered , w hile Chap ter 6 p laces the f eld o m anu al
therap y w ithin the context o contem p orary p ain neu ro-
sciences and therap eu tic neu roscience ed u cation. For the
rem aining sections, the textbook alternates betw een the upp er
and low er qu ad rants. Parts 2 and 3 provid e state-o -the-art
u p d ates on m echanical neck p ain, w hip lash, m yelop athy,
rad icu lop athy, thoracic ou tlet synd rom e, perip artu m p elvic
p ain, joint m obilizations and m anip u lations and therap eu tic
exercises, am ong others. Parts 4 to 9 review pertinent and
u p d ated asp ects o the shou ld er, hip , elbow, knee, the w rist
and hand , and f nally the ankle and oot. The last tw o p arts
o the book are d evoted to m u scle-re erred p ain and neu ro-
d ynam ics, w hich are tw o o ten-und ervalued areas p ertinent
to m anu al p hysiotherap y.
We anticip ate that this textbook w ill becom e the stand ard
in m anu al therap ies and w e hope that it w ill brid ge apparent
d i erences in opinions. We aim to u nite d i erent healthcare
d isciplines using m anu al therap y as their therap eutic ap -
p roach. In the end , the w el are o ou r p atients need s to be the
gu id ing princip le. We hope that the cu rrent textbook w ill
u ltim ately benef t m any p atients w orld w id e.
César Fernández-de-las-Peñas
M adrid, Spain
Joshua A. Cleland
Concord, N H, USA
Jan D ommerholt
Bethesda, M D, USA
 xviii Preface

References Pencheon D. 2005. What’s next or evid ence-based m ed icine? Evid Based
H ealth Care Pu blic H ealth 9: 319–321.
Rycro t-Malone J. 2008. Evid ence-in orm ed practice: rom ind ivid u al to
Bialosky JE, Bishop MD, Price DD, et al. 2009. The m echanism s o m anual
context. J N u rs Manag 16: 404–408.
therap y in the treatm ent o m usculoskeletal pain: a com prehensive m od el.
Sackett D, Rosenberg WMC, Gray JAM, et al. 1996. Evid ence based m ed icine:
Man Ther 14: 531–538.
w hat it is and w hat it isn’t. BMJ 312: 71–72.
Guyatt G. 2008. Pre ace. In: Gu yatt G, Rennie D (ed s) User ’s gu id e to the
m ed ical literature: a m anual or evid ence-based clinical practice, 2nd ed n.
Chicago: AMA Press, p xxi.
 In Memoriam

Peter Huijbregts
This pa ge inte ntiona lly le ft bla nk
 P AR T 1
General Introduction
1 Epidemiology of Upper Extremity Pain Syndromes 3
Louise Thwaites and Karen Walker-Bone
2 Epidemiology of Lower Extremity Pain Disorder 13
Adam P. Goode and Sean D. Rundell
3 History Taking 22
Peter A. Huijbregts
4 History Taking for Patients with Lower Extremity Syndromes 36
Megan Burrowbridge Donaldson and Kristina Averell
5 Physical Examination 47
Shane Koppenhaver, Timothy Flynn and Jennifer Crane
6 Treating the Brain in Chronic Pain 66
Adriaan Louw
7 Mechanical Diagnosis and Therapy for the Spine: McKenzie Method 76
Stephen May and Richard Rosedale
8 Mechanical Diagnosis and Therapy for Extremity Problems: McKenzie Method 85
Stephen May and Grant Richard Burges Watson
This pa ge inte ntiona lly le ft bla nk
 PART 1 •  General Introduction
Epidemiology of Upper Extremity Pain Syndromes
CHAP TER CONTENTS
Introduction  3
Epidemiological issues  3
Terminology  3
Non-specif c pain  4
Classif cation criteria  4
Study design  5
Population  5
Measurement o  exposure  5
Occurrence o  upper extremity disorders  6
Prevalence o  upper extremity pain  6
Prevalence o  specif c upper extremity disorders  6
Health care utilization and impact  9
Risk  actors  or upper extremity disorders  9
Gender  9
Age  10
Anthropometry  10
Hand dominance  10
Hormonal  actors  10
Occupational risk  actors: physical / mechanical  actors  10
Occupational risk  actors: psychosocial  10
Conclusion  11
Introduction
In the 21st centu ry, u p per extrem ity pain synd rom es are
com m on and cau se su bstantial d isability. Their greatest
im pact is o ten elt in the w orkplace becau se these cond itions
com m only a ect w orking-age ad u lts, in w hom they m ay
cau se absence throu gh sickness as w ell as restricted w ork-
place p er orm ance. Up p er extrem ity p ain m ay resu lt rom
a very w id e range o clinical cond itions; how ever, this text
ocuses on pain arising rom non-trau m atic non-articular
so t tissu es – that is, exclu d ing p ain resu lting rom acu te
trau m a, m alignancy and chronic in am m atory rheu m atic
d iseases such as rheu m atoid arthritis (Box 1.1). N on-articu lar
so t tissu e d isord ers inclu d e som e relatively w ell-d ef ned
‘specif c’ p athoanatom ical cond itions su ch as lateral epi-
cond ylalgia, d e Qu ervain’s tenosynovitis and carp al tu nnel
synd rom e (CTS). H ow ever, u p p er extrem ity p ain m ay also be
re erred rom pathology occu rring in the cervical spine
Chapter  1  
Lo u is e Th w a ite s , Ka re n W a lke r- Bo n e
(cervicobrachial d isord ers). Moreover, u pper extrem ity pain
can also com m only occu r in the absence o d istinct p athoana-
tom ical p hysical signs, w hen it is m ost u se u lly d escribed as
‘non-specif c’ regional pain so as to avoid im plied causation.
The resu lts o ep id em iological stu d ies in general popu la-
tion sam ples suggest that, at any given p oint in tim e, 20–53%
o the ad u lt p op u lation in Western cou ntries exp erience u p p er
extrem ity pain sym ptom s. Over a li etim e, the estim ated prev-
alence is > 70% (Walker-Bone et al 2003a; H uissted e et al
2006). These d isord ers occur com m only in the w orking pop u-
lation, cau sing consid erable m orbid ity and sickness absence,
and thereby a signif cant econom ic im pact (Silverstein et al
1998). In the d eveloped w orld , m uscu loskeletal d isord ers
cau se the m ajority o occu p ational ill-health, and u p p er
extrem ity pain is second only to back pain as a cau se o w ork-
related illness (Palm er 2006). Accord ing to a recent UK esti-
m ate, u p p er extrem ity d isord ers w ere resp onsible or an
estim ated annu al loss o 3.64 m illion w orking d ays in 2009 / 10
(H ealth and Sa ety Execu tive 2012) and this ap pears to have
been relatively constant over at least the past d ecad e (Jones &
Clegg 1998). This com p ares w ith an estim ated 52 m illion
w orking d ays lost because o low back pain (Mac arlane et al
2009). Using pu blished criteria or exam ining w ork-related ness
o upp er extrem ity d isord ers, approxim ately 70–95% o u p per
extrem ity m uscu loskeletal pain in w orking popu lations could
be classif ed as ‘w ork related ’ (Roqu elau re et al 2006), bu t this
m ay not im p ly a cau sal relationship .
Given these rates o occu rrence and the associated levels o
d isability, it could be reasonably exp ected that the epid em iol-
ogy o these cond itions w ou ld be thorou ghly investigated and
u nd erstood . Un ortu nately, or m any reasons, this is not cu r-
rently the case. In act, high-qu ality epid em iological research
in this f eld has been ham p ered in several d i erent w ays
resulting in the con usion and controversy that beset this
f eld . In ord er to u nd erstand the available ep id em iological
d ata that m ake u p the m ajority o this chapter, w e w ill brie y
explain the ep id em iological issues in the next section.
Epidemiological Issues
Terminology
As w ith other branches o m ed icine, the origins o m uch o
the term inology or sp ecif c u p p er extrem ity d isord ers are to
 4 PART 1 • 1 • Epidemiology o  upper extremity pain syndromes

rarely present. Rather, histopathological stud ies suggest

Bo x 1 .1 C a u s e s o f u p p e r e xtre m ity p a in that rep etitive m echanical overload p rod u ces d egenerative
Outs ide  the  s c o pe  o f this  te xt changes w ithin the tend on su bstance lead ing to eventu al col-
lagen f bril m icro- ailure. A sim ilar p athological pictu re is
Rhe um atologic al c onditions seen in tend ons as they p ass throu gh the synovial-lined f bro-
Inf ammatory arthritis , e.g. rheumatoid arthritis , ankylos ing osseou s tu nnels at the w rist. Thu s technically ‘tend inosis’
spondylitis w ould be a m u ch m ore accu rate clinical term then tend onitis
Osteoarthritis – reserving the latter term and ‘tenosynovitis’ or u se only in
Systemic lupus erythematosus (SLE) the p resence o tru e synovial in am m ation (e.g. in rheu m a-
Fibromyalgia s yndrome toid arthritis). H ow ever, it shou ld be borne in m ind that his-
Polymyalgia rheumatica / temporal arteritis tology is rarely available in the d iagnosis or m anagem ent o
Sys te m ic c onditions
these cond itions in p ractice and the clinician m ay be aced
Malignancy (primary or s econdary)
w ith patients p resenting w ith a second ary in am m atory reac-
tion visible in the p aratenons overlying d egenerate tend ons.
Stroke
It is unsu rprising, there ore, that term s that m ay be techni-
Myocardial in arction and coronary artery s yndromes cally inaccu rate p athologically nevertheless continu e to
Multiple s cleros is p revail in clinical p ractice.
Diabetes mellitus
Diaphragmatic irritation (liver dis eas e, s plenic dis eas e)
Ac ute traum a
Non-speci c pain
Fracture / dis location Upp er extrem ity pain requently occu rs in the absence o
Within the  s c o pe  o f this  te xt clinical signs that f t into the conventional anatom ical–
Spe c if c non-artic ular c onditions p athological m od el (‘non-specif c’ pain). As long ago as 1713,
Adhes ive caps ulitis Ram azzini d escribed an u p p er extrem ity d isord er related
to ‘constant sitting, p erp etu al m otion o the hand in the
Rotator cu s yndrome
sam e m anner and the attention and ap p lication o the m ind ’
Subacromial bursitis
(Ram azzini 1940). Since then, u pper extrem ity pain has been
Acromioclavicular joint dys unction d escribed occu rring am ong d i erent groups o w orkers m any
Lateral epicondylitis tim es (e.g. w riter ’s cram p (British Civil Service 1830s) and
Medial epicondylitis telegrap hist’s cram p (UK 1908)). In the last hal o the 20th
Tenos ynovitis centu ry, occu p ational cervicobrachial d isord ers (Jap an),
De Quervain’s dis eas e cu m u lative trau m a d isord ers (CTDs) (USA), rep etitive strain
Carpal tunnel s yndrome injury (RSI) (Au stralia) and w ork-related up per lim b d isor-
d ers (WRULD) (UK) w ere term s u sed in d i erent countries
Non-s pe c if c pain s yndrom e s or synd rom es sim ilar to each other occu rring in variou s
Occupational cervicobrachial disorder grou ps o w orkers. These term s have sim ilarly been u sed to
Cumulative trauma dis order (CTD) d escribe pain at d i erent sites in the neck and up per lim b
Repetitive s train injury (RSI) w ith no conf rm ed pathoanatom ical abnorm ality, bu t they
Work-related upper limb disorder (WRULD) w ere overlap ping and their u sage varied (Robinson & Walker-
Work-related upper extremity mus culos keletal dis order Bone 2009). It is now w id ely believed that term s su ch as these
(WRUEMSD) w ith im plied cau sation have im pacted negatively on research
Non-s peci c orearm pain in this f eld (H elliw ell 1995; Palm er et al 2012). For one thing,
su ch tau tological term s im p ly blam e or even negligence by
an em ployer and so this is now a f eld w here m uch o the
investigation has m oved into the law cou rts rather than the
research laboratories. Second ly, i a pain has, because o its
be ound in m ed ical history, d ating back rom the original
nom enclatu re, been attribu ted to a typ e o occu p ation, it is
p u blications o the f nd ings associated w ith an ind ivid u al
very d i f cu lt to investigate any other p ossible aetiological
clinical synd rom e (e.g. ‘law n tennis arm ’ (Morris 1882)). Som e
actors system atically as the a ected ind ivid u al alread y has
cond itions have ep onym s (d e Qu ervain’s tenosynovitis) and
f xed p reconcep tions.
others have nam es based on the p resu m ed p athoanatom ical
basis o the cond ition (tend onitis, epicond ylitis, tenosynovi-
tis). Controversy has ensu ed becau se o the m u ltip licity o Classi cation criteria
d isease labels and d iagnostic criteria ad opted both in clinical
p ractice and in research, requ ent am biguity in the coverage In clinical practice, d iagnostic criteria are used to separate
and bou nd aries o case d ef nition, and a lack o re erence typ es o d isease w ith d i erent cau sation, treatm ent or p rog-
stand ard s (Palm er et al 2012). Recently there have been nosis. It is an absolu te requ irem ent o ep id em iological research
attem pts to stand ard ize som e o these term s aim ing to su it that the p roblem u nd er stu d y is clearly d ef ned . We have
m ore closely ou r m od ern view o the u nd erlying p athop hysi- alread y seen that non-specif c p ains are w id ely classif ed
ology (H u tson 2006). For exam ple, in non-rheum atological u sing d i erent system s in d i erent cou ntries. H ow ever, even
cond itions that a ect tend ons (tend onitis) and p resent w ith am ongst the specif c upp er extrem ity cond itions, classif ca-
p ain, there is grow ing evid ence that tru e in am m ation is tion criteria m ay d i er w id ely and ew have a ‘gold stand ard ’

d iagnostic test. There ore, case d ef nitions u sed in epid em io-
logical stud ies have historically u sed textbook d ef nitions or
au thors’ p ersonal opinions. A review by Van Eerd et al (2003)
id entif ed 27 classif catory schem es or up per lim b d isord ers
that w ere p rop osed ollow ing m u ltid iscip linary w orkshop s
and consu ltations w ith exp erts, none o w hich w ere id entical.
In a system atic review o stu d ies investigating incid ence and
p revalence o u p p er extrem ity d isord ers, H u issted e et al
(2008) ou nd variation in point prevalence rom 1% to 53%,
largely d u e to d isparity o case d ef nitions. Withou t consistent
and clear classif cation, reliable d ata regard ing d isease bu rd en
and its health and socioeconom ic im pact are im possible to
obtain. This in tu rn im p acts u p on treatm ent and p revention
strategies and u tu re research.
Bu chbind er et al (1996) exam ined existing classif cation
schem es or so t tissu e d isord ers o the neck and u p p er lim b.
They ou nd m ajor inad equacies su ch as ailure to be com pre-
hensive and overlap o categories, and consequ ently su g-
gested criteria by w hich utu re classif cation system s m ight
be better assessed . In an attem p t to im prove consensu s over
classif cation, several m u ltid iscip linary grou p s convened and
p rod uced their ow n classif cations system s (H arrington et al
1998; Slu iter et al 2001). H ow ever, these too have been criti-
cized or re ecting the op inions o w orkshop p articip ants
w ithou t clear d ef nitions o extent or d uration o sym ptom s
and w ithou t any orm al testing. A system atic review o 117
articles show ed very ew attem pts to establish the valid ity o
classif cation system s, w ith only one show ing rigorou s testing
o valid ity and reliability (Walker-Bone et al 2003b).
The Sou tham p ton exam ination sched u le w as d evelop ed
rom the m u ltid isciplinary UK w orkshop consensu s state-
m ent on classif cation o m u scu loskeletal d isord ers o the
u p p er lim b and w as tested in both hosp ital and general p op u -
lations (Fig. 1.1) (Palm er et al 2000; Walker-Bone et al 2002).
Overall f nd ings show ed a valid rep rod u cible system or the
exam ination o up per lim b d isord ers that w as su itable or use
in large-scale ep id em iological research, although it per orm ed
better in hospital patients (Palm er et al 2000) w ith the m ost
clear-cu t clinical p resentations com p ared w ith com m u nity
p atients (Walker-Bone et al 2002).
More recently a ‘com p laints o the arm , neck and / or
shou ld er ’ (CAN S) classif cation w as p rop osed by a grou p
com p rising 11 m ed ical and p aram ed ical d isciplines, w hich
aim ed to obtain consensu s and establish a category o specif c
and non-sp ecif c cond itions d ef ned as m u scu loskeletal com -
p laints o the arm , neck and should er not cau sed by acu te
trau m a or any system ic d isease (H u issted e et al 2007). A f nal
grou p o 23 cond itions, categorized as specif c d isord ers, w as
p rod uced ; all other cond itions w ere classif ed as non-sp ecif c
d isord ers.
Study design
N eck and u pper lim b d isord ers are requ ently episod ic and
recu rrent; there ore m ost stu d ies exam ine prevalence, rather
than incid ence, u sing a cross-sectional d esign. Investigators
o ten choose d i erent p eriod p revalence case d ef nitions; or
exam ple, ‘neck pain lasting > 1 d ay in the p ast 7 d ays’ (1-w eek
prevalence) is one possible case d ef nition, w hich w ill yield a
d i erent p revalence estim ate rom ‘neck pain lasting > 6
m onths in the past year ’ (1-year p revalence o chronic neck
pain) and also rom ‘neck p ain ever ’ (li etim e p revalence o
Epidemiological issues 5
Rotator cuff tendinitis
Bicipital tendinitis
Shoulder capsulitis
Lateral
epicondylitis
Medial
epicondylitis
De Quervain’s disease
Tenosynovitis of the wrist
Carpal tunnel syndrome
Non-specific forearm pain
Figure 1.1 Upper extremity disorders for which consensus criteria were
developed by the HSE Delphi workshop.
neck p ain). Many o the stu d ies have eschew ed the d i f cu lties
o classif cation and chosen instead to m easu re the p revalence
o sel -rep orted p ain at d i erent sites o the neck and / or
u p p er lim b, u sing this as the ou tcom e (Walker-Bone et al
2003b).
Population
Mu ch o the available ep id em iological research has been
carried ou t in w orkp lace or occu p ational grou p s, rather
than in general p op u lation sam p les. This choice o setting,
how ever, incu rs the risk o resu lts biased by the ‘healthy
w orker ’ e ect, in w hich those m ost severely a ected are o
sick or m ed ically retired and there ore are not p resent in the
w orkp lace. Moreover, m any stu d ies have rep orted on up per
extrem ity synd rom es by re erring to w orkers’ com p ensation
claim s, w hich again m ay u nd erestim ate the tru e occu rrence
o d isord ers and bias resu lts tow ard s the m ost severe
typ es o cond itions cau sing the w orst levels o d isability
(Roqu elaure et al 2006).
Measurement of exposure
One o the greatest challenges to occu p ational research lies in
m easu ring the exp osu re to d i erent typ es o occu p ational
actors. It is relatively uncom m on in any p articu lar occu pa-
tion or there to be exp osu re to only a single typ e o p hysical
risk actor; m anu al occu p ations requ ently involve com bina-
tions o exp osu re (e.g. orce and vibration, or p u lling and
p u shing) thu s m aking the exp osu re d i f cu lt to d ef ne and
m easu re objectively. Direct observation and vid eo su rveil-
lance are pre erred m ethod s or qu anti ying these bu t they are
tim e consu m ing and exp ensive, so are not p racticable or
large stu d ies. Surrogate m arkers su ch as job title or
 6 PART 1 • 1 • Epidemiology o  upper extremity pain syndromes
occu p ation classif cation have been regu larly em p loyed in
stu d ies, bu t are generally less sensitive. Thu s su bjective, ret-
rospective reporting o exposure is requ ently u sed ; how ever,
this relies on ind ivid u als’ recall and estim ation o tim es, orces
and other p hysical actors and m ay also be in u enced by their
p ersonal belie s abou t the cau sation o their sym p tom s. Som e
investigators have attem p ted to overcom e these by u sing a
com bination o su bjective rep orting and d irect observation
valid ation (And ersen et al 2007).
To su m m arize, there is little d ou bt that u p p er extrem ity
p ain is com m on, recu rrent and d isabling. There are several
w eaknesses inherent in our know led ge and und erstand ing o
the occu rrence, risk actors and im p act o these cond itions,
w hich have arisen or m ethod ological reasons. This has pro-
d u ced a f eld that is both con u sing and contentiou s, and
controversy rem ains over even basic asp ects. The read er m u st
there ore p u t the ollow ing section into this context.
Occurrence of Upper Extremity
Disorders
Prevalence of upper extremity pain
The results o epid em iological surveys suggest that neck pain
m ay a ect 10–17% o ad ults at any point in tim e, and as m any
as 71% d u ring a li etim e, and that p ain in the up per lim b has
a point p revalence o 7–26% (Walker-Bone et al 2004a). Many
o the stu d ies are p oorly com p arable ow ing to w id e variation
in the case d ef nition and p op u lation characteristics. Shou ld er
p ain lasting > 1 d ay in the p reviou s m onth, or exam ple, w as
estim ated to a ect 13% o m en and 15% o w om en aged 53
years in one stud y (Bergenud d et al 1988), w hereas in another
26% o m en and 19% o w om en aged 31–74 years reported
cu rrent shou ld er p ain and restricted m ovem ent (Alland er
1974). Point prevalence and period prevalence estim ates or
the occu rrence o u p p er extrem ity p ain, together w ith their
case d ef nitions, are su m m arized in Table 1.1. Although ew
sp ecif c conclu sions can be d raw n, the available d ata su ggest
that all u p p er extrem ity p ain synd rom es are com m on, are
generally reported m ore o ten by w om en than by m en and
tend overall to occu r m ore requ ently in p roxim al (neck / shou l-
d er) than in d istal areas – althou gh hand / w rist p ain is m ore
requ ent than elbow pain. Broad ly, these d em ographic f nd -
ings rom general p op u lation stu d ies have been rep licated in
w orking populations. French w ork orce d ata show ed a
12-m onth p revalence o u p per extrem ity m u scu loskeletal
sym p tom s o 35% in w om en com p ared w ith 27% in m en
(Roqu elau re et al 2006) and sim ilar Danish d ata estim ated the
p revalence rates o chronic u pp er extrem ity sym ptom s as
11.3% am ong w om en com pared w ith 7.7% am ong m en
(H u issted e et al 2008).
In general, w here stu d ies have com pared d i erent types
o w orkers, p revalence rates are higher in cu rrent w orkers
than the non-w orking general pop ulation (8.1 vs 6.1% in The
N etherland s). Rates also vary accord ing to the specif c occu -
p ational group . In one stu d y in the USA, 50% o college stu -
d ents reported upp er extrem ity m u sculoskeletal sym ptom s
(Menend ez et al 2008). Sim ilarly high p revalence rates have
been reported in com pu ter w orkers (Tornqvist et al 2009) and
textile w orkers (H u issted e et al 2006). In Denm ark, 37% o
w orking ad ults rep orted m od erately severe neck and shou l-
d er pain, com p ared w ith 49% o kitchen and cleaning w orkers
and 22% o skilled w orkers (And ersen et al 2007). In French
w orkers und ergoing rou tine m ed ical exam inations, upp er
extrem ity pain d isord ers w ere m ost com m on in those w orking
in the m anu acturing ind ustries and pu blic ad m inistration;
the highest rates o occu rrence w ere in u nskilled ind u strial
and agricu ltu ral w orkers, d rivers and m ale pu blic service
em ployees and em ale p ersonal care w orkers (Roqu elau re
et al 2006). The highest risk seen am ongst these occu pational
grou ps in France w as consistent w ith those occu pations at
highest risk or com p ensation claim s in the USA (Silverstein
et al 1998).
Although m ost d ata on u pper extrem ity sym p tom s com es
rom the Developed World , it is interesting that one stu d y
am ongst o f ce w orkers in Su d an using the CAN S classif ca-
tion system has show n sim ilar p revalence rates to those seen
in Western popu lations (Eltayeb et al 2008).
Prevalence of speci c upper extremity
disorders
There are relatively ew popu lation-based su rveys aim ed at
d eterm ining anatom ical locations or specif c cau ses o upp er
extrem ity pain. Di erences in d iagnostic and classif cation
p roced u res, as d iscu ssed earlier, ad d to the d i f cu lty in inter-
p retation. Table 1.2 su m m arizes the resu lts o the available
p op u lation-based p revalence stu d ies or sp ecif c cond itions,
together w ith the case d ef nitions u tilized . Shou ld er cond i-
tions ap p ear to occu r m ost requ ently, in line w ith the relative
requency o should er pain; CTS and ep icond ylitis are the
next m ost com m only observed . There is a p rep ond erance o
d ata available on the occu rrence o CTS, probably because o
its relative requ ency and the availability o nerve cond uction
stu d ies as a test that is to som e extent stand ard ized . The inci-
d ence o CTS has been estim ated at app roxim ately 1 p er 1000
o the general p op u lation, w ith higher rates am ong w om en
than am ong m en (1.5 per 1000) (Walker-Bone et al 2004a).
Rates o p revalence range rom 0.9% to 5% d epend ing u pon
the case d ef nition u tilized .
There is a m u ch greater bod y o literatu re on sp ecif c cond i-
tions stu d ied in d i erent occup ational settings – w hich gener-
ally com pares the prevalence o one or m ore specif c u p p er
extrem ity d iagnoses in group s o w orkers w ith d i erent types
o occu p ational exp osu re (e.g. rates o p revalence o ep i-
cond ylitis w ere com p ared betw een m eat p ackers and cu tters
and those w orking in ad m inistration in m eat actories in the
stu d y by Viikari-Ju ntu ra (1983)). These stud ies w ere exten-
sively and critically review ed in 1993 by the US N IOSH
organization (Bernard 1997); this report highlighted the ubi-
qu itou s natu re o the m ethod ological shortcom ings in the
available stu d ies, d raw ing attention to the sam e issu es as in
the occu p ation-based stu d ies d escribed above.
Despite these inherent w eaknesses, it is notable that a
French stu d y, in w hich d ata w ere collected by a regional
netw ork o occu p ational p hysicians, show ed that > 50% o a
sam ple o 2685 w orking ad u lts exp erienced non-sp ecif c
u p p er extrem ity m u scu loskeletal sym p tom s in the p reced ing
 Occurrence o  upper extremity disorders 7

Table 1.1 Population-ba s e d pre vale nce e s tima te s or the occurre nce o uppe r e xtre mity re gional pain
Size of Pre va le nce Pre va le nce Pre va le nce
p op ula tion e s tima te e s tima te e s tima te
Ca s e d e nition s a mp le d Age (ye a rs ) me n (%) wome n (%) a ll (%)

Ne c k pain
Period prevalence Pain lasting > 1 week in past month 5752 > 16 11 17 14
Neck pain, tendernes s or sti nes s in 537 18–65 – – 12
pas t year
Troublesome neck pain in the past year 7648 18–67 29 40 34
Pain las ting > 1 day in past year 800 > 30 15 17 –
Pain lasting > 1 day in past week 9698 25–64 21 26 24
(Walker-Bone et al 2004a)
Point prevalence Currently su ering rom neck pain 10532 20–65 10 18 –
Pain lasting > 1 month 1806 25–74 15 19 17
S ho ulde r pain
Period prevalence Pain lasting > 1 week in past month 5752 > 16 14 17 16
Pain lasting > 1 day in past month 574 53 13 15 14
Pain lasting > 1 day in past week 9698 25–64 21 26 24
(Walker-Bone et al 2004a)
Point prevalence Current pain las ting > 3 months 1806 25–74 – – 7
Current pain and restricted movement 15268 31–74 26 19 20
Current shoulder pain 644 > 70 – – 26
Elbo w pain
Period prevalence Pain lasting > 1 week in past month 5752 > 16 6 6 6
Pain lasting > 1 day in past week 9698 25–64 12 10 11
(Walker-Bone et al 2004a)
Point prevalence Pain lasting > 3 months in 1806 25–74 8 12 11
elbow / orearm
Wris t / hand pain
Period prevalence Pain in the hand lasting > 1 week in the 5752 > 16 12 20 –
pas t month
Pain lasting > 1 day in past week 9698 25–64 19 23 21
(Walker-Bone et al 2004a)
Point prevalence Current pain in hand / wris t las ting > 3 1806 25–74 9 17 13
months
(Updated rom Walker-Bone et al (2003a).)

year, w ith ap p roxim ately 30% a ected in the p reced ing w eek
(Roqu elau re et al 2006). Overall, the 12-m onth p revalence o
‘specif c’ u pper lim b m u sculoskeletal d isord ers (rotator cu
synd rom e, lateral ep icond ylitis, u lnar tu nnel synd rom e, CTS,
d e Qu ervain’s d isease, and exor–extensor peritend initis or
tenosynovitis o the orearm –w rist d ef ned accord ing to spe-
cif c criteria) w as ou nd to be 13%.
Another im portant em erging f nd ing is that concu rrent
pain at d i erent anatom ical locations in the up per lim bs is
com m on (Walker-Bone et al 2004b). In a recent Du tch stu d y,
33% o ad u lts rep orted pain at tw o d i erent anatom ical sites
in the up p er extrem ity, w ith a u rther 8.5% experiencing pain
at three sep arate sites (H uissted e et al 2008). In ad d ition, ‘spe-
cif c’ and ‘non-sp ecif c’ cau ses o p ain com m only occu r
together; or exam p le, eatu res o hyp ersensitivity and allod y-
nia have been show n to occu r w ith lateral ep icond ylitis and
trigger p oints are w id esp read in other arm p ain synd rom es
(H u issted e et al 2008; De-la-Llave-Rincón et al 2009). It
ap pears that m u scu loskeletal pain synd rom es clu ster w ithin
an ind ivid ual, but it is currently u nclear w hether this is an
e ect o enhanced pred isposition to the risk actors, or p sy-
chosocial actors su ch as som atization, or w hether it occu rs as
a consequence o changed u se o the m u sculoskeletal system
p recip itated by the onset o p ain at one site.
8 PART 1 • 1 • Epidemiology o  upper extremity pain syndromes

Table 1.2 Population-ba s e d occurre nce o s pecif c uppe r e xtre mity mus culos ke le ta l dis orde rs
Size of Pre va le nce Pre va le nce Pre va le nce
Ca s e de nition (re fe re nce for pop ula tion Age e s tima te e s tima te e s tima te
orig ina l d a ta in p a re nthe s e s ) s a mp le d (ye a rs ) me n (%) wome n (%) a ll (%)

S ho ulde r
Rotator cu dis order Pain in the s houlder region 644 > 70 – – 15
accompanied by pain on resis ted
abduction, external rotation or internal
rotation (Chard et al 1991)
Rotator cu tendinitis Pain in the deltoid region and pain on 9698 25–64 4.5 6.1 –
res isted active movement (Walker-Bone
et al 2004b)
Adhes ive caps ulitis Pain in the deltoid area and equal 9698 25–64 8.2 10.1 –
restriction o active and passive
glenohumeral movement with a
capsular pattern (Walker-Bone et al
2004b)
Acromioclavicular Pain over the acromioclavicular joint 9698 25–64 1.0 1.0 –
joint dys unction and tendernes s over the joint and a
positive acromioclavicular stres s test
(Walker-Bone et al 2004b)
Elbo w
Lateral epicondylitis History o pain in the elbow region or 15268 31–74 – – 2.5
> 1 month, tenderness over lateral
epicondyle and pain increased when
hand pronated against resis tance and
increased pain on carrying (Allander
1974)
Lateral epicondylitis Lateral epicondylar pain and tenderness 9698 25–64 1.3 1.1 –
and pain on res isted extens ion o the
wrist (Walker-Bone et al 2004b)
Lateral epicondylitis Not stated (Verhaar 1994) 708 20–80 – – 4.4
Medial epicondylitis Medial epicondylar pain and tendernes s 9698 25–64 0.6 1.1
and pain on res isted f exion o the wris t
(Walker-Bone et al 2004b)
Wris t / hand
De Quervain’s Pain over the radial styloid and tender 9698 25–64 0.5 1.3 –
dis ease s welling o the rs t extensor
compartment and either pain
reproduced by resisted thumb
extension or positive Finkels tein’s test
(Walker-Bone et al 2004b)
Tenosynovitis Pain on movement localized to the 9698 25–64 1.1 2.2 –
tendon s heaths in the wrist and
reproduction o the pain on resis ted
active movement (Walker-Bone et al
2004b)
Carpal tunnel Pain or paraes thes ia or s ens ory los s in 9698 25–64 1.2 0.9 –
syndrome the median nerve distribution and one
o : Phalen’s tes t positive, Tinel’s tes t
positive, nocturnal exacerbation o
s ymptoms, motor loss with wasting o
abductor pollicis brevis (Walker-Bone
et al 2004b)
Continued
 Risk  actors  or upper extremity disorders 9

Table 1.2 Population-ba s e d occurre nce o s pe cif c uppe r e xtre mity mus culos ke le ta l dis orde rs —cont’d
Size of Pre va le nce Pre va le nce Pre va le nce
Ca s e de nition (re fe re nce for p op ula tion Age e s tima te e s tima te e s tima te
orig ina l d a ta in p a re nthe s e s ) s a mp le d (ye a rs ) me n (%) wome n (%) a ll (%)

Carpal tunnel Clinical diagnos is o CTS (Atros hi et al 2466 25–74 3 5 4

syndrome 1999)
Carpal tunnel Electrophysiological diagnos is o CTS 2466 25–74 4 5 5
syndrome (Atroshi et al 1999)
Carpal tunnel Clinical and electrophysiological 2466 25–74 2 3 3
syndrome diagnos is o CTS (Atros hi et al 1999)
Carpal tunnel Electrophysiological diagnos is o CTS 715 25–74 1 6 5
syndrome (de Krom et al 1992)
Carpal tunnel Electrophysiological motor latency 820 18–75 8 6 7
syndrome > 4.5 ms (Ferry et al 1998)

Table 1.3 Dis a bility as s ocia te d with uppe r e xtre mity pa in

Healthcare Utilization and Impact No Some
As stated above, up per extrem ity d isord ers can cau se con- d if culty d if culty Imp os s ib le
sid erable d isability; there ore they requ ently lead to health- (%) (%) to do (%)
care u se and p resentation in p rim ary care or rheu m atology
Impact o regional pain at di erent s ites on ability to per orm
clinics (Tu rk & Ru d y 1990). Chronic sym p tom s (lasting
normal daily activities (e.g. work, hobbies , housework)
u su ally at least 3 m onths) are associated w ith greater health-
care u se and higher levels o d isability. Du tch p op u lation d ata Neck pain 30 59 11
show that, in ind ivid u als m eeting the CAN S criteria or Shoulder pain 28 48 11
chronic sym ptom s (p ain lasting m ore than 3 m onths in the
last 12 m onths), 58% rep orted u se o healthcare in the last 12 Elbow pain 29 58 12
m onths – 81% o these p atients consu lted their general p rac- Wris t / hand pain 28 58 13
titioner, 59% a m ed ical sp ecialist and 54% a p hysiotherapist
Pain at any s ite 31 56 13
(H u issted e et al 2008). Com parable d ata w ere seen or
resp ond ents to a British popu lation-based stud y, such that Impact o pain at any 41 55 4
39% o those w ith p ain had seen a d octor in the p reced ing 12 site on s leeping
m onths, 11% a physiotherapist and 10% a chirop ractor, w hile Impact o pain at any 34 46 5
24% had been p rescribed m ed ication or their com plaint site on driving
(Walker-Bone 2002). In the Du tch stud y, healthcare users
reported m ore sickness absence than non-healthcare u sers; Impact o pain at any 30 58 8
37.2% rep orted sickness absence d ue to u pp er extrem ity site on dressing
sym p tom s, com p ared w ith 9.3% non-healthcare u sers, and Impact o pain at any 67 34 3
12.4% rep orted sickness absence or m ore than 4 w eeks. site on carrying bags
H ealthcare users also reported m ore recu rrent and constant NB Not all rows add up to 100% as not all res pondents completed every
pain and m ore lim itation in d aily li e d u e to their sym ptom s ques tion.
(48.9% com p ared w ith 8.5%). (Adapted rom Walker-Bone 2002.)
In a com parision o specif c and non-sp ecif c up per extrem -
ity d isord ers in the UK, sp ecif c d iagnoses w ere also associ-
ated w ith m ore healthcare u se – although u se o sel -prescribed
m ed ication in p eop le w ith sp ecif c d iagnoses w as sim ilar to
that in those w ith non-specif c p ain. In total, 69% o subjects
Risk Factors for Upper Extremity
w ith u pper extrem ity pain rep orted d i f cu lty w ith their w ork, Disorders
hobbies or hou sew ork (Table 1.3) and 59% reported d i f culty
sleep ing d u e to their p ain. Sp ecif c u p p er lim b cond itions Gender
w ere reported by those a ected to be m ore d isabling than
non-sp ecif c p ain (Walker-Bone et al 2004a). As an exam ple, As w ith other sites o m u sculoskeletal pain, there is a higher
11.5% o people w ith sp ecif c should er d iagnoses rep orted p revalence o w om en rep orting u p p er extrem ity p ain com -
d i f cu lty in carrying a shopping bag, com pared w ith just p ared w ith m en. H ow ever, in p rim ary care w om en also tend
6.1% o p eople w ith non-specif c shou ld er p ain (Walker-Bone to consu lt m ore requ ently than m en w ith a range o other
2002). sym p tom s, hence these d i erences m ay re ect a gend er
 10 PART 1 • 1 • Epidemiology o  upper extremity pain syndromes
d i erence in the threshold or seeking help . Alternatively,
w om en m ay be m ore vulnerable to actors causing m uscu -
loskeletal p ain, becau se o either their p hysical size and
strength or constitu tional d i erences su ch as horm onal actors
(Walker-Bone et al 2003a). Few er d ata are available com p ar-
ing p revalence rates betw een m en and w om en or sp ecif c
cond itions, bu t there is som e evid ence that w om en are m ore
com m only a ected by tenosynovitis, d e Qu ervain’s d isease,
shou ld er cap su litis and CTS. H ow ever, epicond ylitis has gen-
erally been ound to be m ore com m on am ong m en than
w om en.
Age
Mu scu loskeletal p ain is rep orted m ore requ ently w ith age in
both gend ers, w ith a peak in the m id d le years (50–60 years)
and a m od est red u ction in p revalence in subsequ ent d ecad es
o li e. The p attern in sp ecif c cond itions is less w ell stu d ied ,
bu t there is evid ence o a sim ilar age cu rve or lateral epi-
cond ylitis, CTS am ong w om en and p ossibly d e Qu ervain’s
d isease and tenosynovitis.
Anthropometry
Obesity is associated w ith an increased requ ency o rep orting
neck and u p p er extrem ity p ain. Moreover, the d isability
cau sed by p ain u l cond itions also increases w ith bod y m ass
ind ex (BMI). It is a consistent f nd ing that the risk o CTS
increases w ith BMI su ch that, in one US su rvey, the risk o
CTS increased by 8% or every 1 u nit o increase in BMI.
Hand dominance
O ten u sed as a su rrogate or occu p ational stressors, hand
d om inance has been inclu d ed in som e o the m ore recent
w orkplace stu d ies (Shiri et al 2007). In p articu lar, ep icond yl-
itis has been d em onstrated to occu r m ore requ ently in the
d om inant arm than in the non-d om inant arm .
Hormonal factors
CTS occu rs m ore requ ently in w om en d u ring p regnancy and
lactation and soon a ter the m enop au se than at other tim es
(Walker-Bone et al 2003a). H ysterectom y w ithou t oophorec-
tom y has been ou nd to lead to a d ou bling o the risk o CTS,
com p ared w ith hysterectom y and oop horectom y. Both the
oral contracep tive p ill and horm one rep lacem ent therap y
(H RT) have also been associated w ith an increased risk o
CTS. Case rep orts also su ggest that d e Qu ervain’s d isease is
m ore com m on d u ring p regnancy or early p ost-p artu m . These
relationships im ply a horm onal e ect, perhap s related to
oed em a o the non-articu lar tissu es, bu t the u nd erlying m ech-
anism rem ains to be elu cid ated .
Occupational risk factors:
physical / mechanical factors
Occu p ational and p hysical w orkp lace exp osu res have been
show n to be risk actors or u p p er extrem ity p ain d isord ers,
although the d i f cu lties in accu rately estim ating these have
alread y been d iscu ssed . Many epid em iological stu d ies have
investigated these actors and this literatu re has been the
su bject o several com p rehensive review s, all o w hich
com m ent on the heterogeneity o d esign, and variation in
assessm ent o outcom es and exp osu res, m od e o analysis and
p resentation. Few stand u p to rigorou s m ethod ological exam -
ination (Bu chbind er et al 1996).
As w ith low back pain, m echanical load , repetitive w ork
and abnorm al w orking p ostures are all associated w ith the
d evelopm ent o up per extrem ity sym p tom s (Mac arlane et al
2000). Li ting heavy load s, stand ing or long period s and
p u shing / p u lling are m ore likely to be associated w ith low
back pain than up per extrem ity sym ptom s (And ersen et al
2007). N evertheless, stand ing or long p eriod s has been show n
to be associated w ith an increased risk o regional m u scu -
loskeletal p ain at any anatom ical site (hazard ratio (H R) 1.6,
95% conf d ence interval (CI) 1.2–2.3) (And ersen et al 2007).
The f nd ings o several system atic review s conclud e that
there is strong evid ence that neck p ain is associated w ith
w orking in su stained and abnorm al postu res, su ch as p ro-
longed sitting w ith the neck or tru nk held in exion or rota-
tion, or a com bination o both (Bernard 1997). There is also
evid ence su ggesting that neck and neck / shou ld er sym ptom s
are increased w hen w ork involves orce ul and / or rep etitive
tasks; how ever, to d ate there is no convincing evid ence that
vibration increases the risk o neck or neck / shou ld er p rob-
lem s. Shou ld er pain is also associated w ith heavy physical
w ork – intensive and repetitive shou ld er w ork, esp ecially
overhead , both increase the risk. Fu rtherm ore, the level o risk
ap pears to be m axim al in occup ations that involve com bina-
tions o exp osu res, su ch as w orking overhead u sing a heavy
tool. Elbow cond itions have also been associated w ith exp o-
su re to intensive orces in the w orkp lace, p articu larly w hen
w orkers are regu larly exposed to com binations o repetition,
orce and abnorm al p ostures. Repetitiou s m ovem ents m ay
increase the risk o CTS, as m ay orce u l w ork and exposu re
to vibration (Bernard 1997). Once again, how ever, the evi-
d ence is strongest that occu pations involving com binations o
orce, vibration and repetition are m ost likely to increase the
risk o CTS synd rom e (Abbas et al 1998). When a job involves
exp osure to aw kw ard orearm , w rist and f nger postu res, this
too m ay p lay a role. H ow ever, p rolonged u se o a keyboard
at w ork has not been convincingly d em onstrated to be a risk
actor or CTS.
H and / w rist tend onitis or tenosynovitis has been observed
in a w id e range o d i erent occupational grou ps ranging rom
tobacco p ackers to actory w orkers d u ring World War II,
au tom obile assem bly w orkers, scissor m anu actu rers and
textile w orkers (Walker-Bone et al 2003a). It app ears that
exp osure to high levels o orce, repetitious tasks and su s-
tained abnorm al f nger / w rist p ostu res are the m ost risky.
The u nd erlying m echanism is poorly researched , but it m ay
w ell represent a physiological / m echanical response o the
tend on to chronic m echanical stressors.
Occupational risk factors: psychosocial
Psychosocial actors su ch as p erceived w orkload , p sychologi-
cal stress and su p p ort have been consistently show n to be
im p ortant risk actors or u pper extrem ity pain d isord ers.
H ow ever, exposu re to psychosocial risk actors is also

d i f cu lt to m easu re accu rately and lacks any stand ard m eas-
u rem ent system , and it is there ore u su ally estim ated rom
su bjective rep orts. The Eu rop ean Leagu e against Rheu m atism
(EULAR) review ed the literatu re on these actors w ith the aim
o establishing w hether review s o risk actors or w ork-
related m uscu loskeletal d isord ers reached consistent conclu-
sions (Mac arlane et al 2009). The resu lting paper looked at
ou r regional pain synd rom es, tw o o w hich w ere o the u pper
extrem ity, and reported that the m ost consistent conclu sions
related to psychosocial exposu res: high w ork d em and s and
low job d em and s (m onotonou s or insu f cient u se o skills),
and low w ork control (Bongers et al 2006). In a p rospective
UK stud y o risk actors or non-specif c orearm pain, Mac-
arlane et al (2000) ound that psychosocial actors w ere
im portant p red ictors o the d evelop m ent o u pper extrem ity
sym p tom s, inclu d ing p sychological d istress (od d s ratio (OR)
1.8, 95% CI 0.8–4.0) and aspects o illness behaviou r (OR 6.6,
95% CI 1.5–29) as w ell as exp osure to repetitive physical tasks
(OR 2.9, 95% CI 1.2–7.3). Another British stud y sim ilarly
ou nd that m inim al job control and little su pervisor su pport
w ere im p ortant risk actors (OR 1.6, 95% CI 1.3–1.8 and OR
1.3, 95% CI 1.1–1.5, respectively) (Sim et al 2006).
Conclusion
Upper extrem ity pain synd rom es are com m on in both the
general population and the w orkp lace and are associated w ith
high levels o m orbid ity and d isability. Until recently, ep id e-
m iological research has been ham p ered by lack o clear case
d ef nitions; how ever, increasing use o stand ard ized classif -
cation schem es allow s or m ore m eaning u l analysis and com -
parisons betw een settings and over tim e. Much o the up per
extrem ity pain that occurs is best classif ed as ‘non-specif c’
as there are no clear-cu t p athoanatom ical eatu res; how ever,
there is an exp and ing literatu re exp loring aetiological actors
in non-specif c pain. It is clear that m any up per extrem ity pain
cond itions can be classif ed as ‘w ork related ’ and that there is
a num ber o p otentially m od if able w orkp lace risk actors.
Although physical w orkplace actors (su ch as orce, abnorm al
postu re and rep etition, p articu larly in com bination) are im p li-
cated in the exacerbation or even cau sation o these cond i-
tions, there is grow ing evid ence that p sychosocial actors also
play a signif cant role. This suggests that interventions in the
w orkplace based solely upon m echanical exposu res (e.g.
ergonom ic keyboard s and w orkstations) m ay not be 100%
su ccess u l u nless attention is also p aid to p sychosocial risk
actors such as control over w ork, d em and s o the job and
su p p ort in the w orkp lace.
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 PART 1 •  General Introduction
Epidemiology of Lower Extremity Pain Disorder
CHAP TER CONTENTS
Introduction  13
Prevalence and incidence of speci c lower extremity disorders  13
Lumbar conditions  13
Hip conditions  16
Labral tears  17
Greater trochanteric pain syndrome  17
Knee conditions  17
Foot and ankle conditions  18
Healthcare utilization and impact  19
Conclusion  20
Introduction
Mu scu loskeletal d iseases are a m ajor p u blic health p roblem
and are the lead ing cau se of physical d isability (Weinstein
2000). The Bone and Joint Initiative has reported a rapid
increase in m u scu loskeletal chronic cond itions, m any of
w hich m ay result in chronic pain (Jacobs 2011). As w ith m any
chronic cond itions, m u scu loskeletal p ain and d isease can
have long-term im p acts on p eop le’s qu ality of life, p lace
a large bu rd en on healthcare system s and affect society as
a w hole.
Mu scu loskeletal cond itions affect m any p eop le. The esti-
m ated p revalence of m u scu loskeletal d isease varies su bstan-
tially betw een 2% and 65% d epend ing on the cond ition
(Picavet & H azes 2003). Gend er d ifferences also exist, w ith
chronic m u scu loskeletal cond itions affecting ap p roxi-
m ately 53 in every 100 fem ales and 45 in every 100 m ales
(Jacobs 2011).
This chap ter d escribes som e of the m ost com m on m u scu-
loskeletal cond itions in the low er extrem ity (Fig. 2.1). Many
of these cond itions can lead to chronic sym p tom s greatly
im pacting d aily function and lead ing to d isability. Pain in the
low er extrem ity m akes up a su bstantial am ou nt of the m uscu-
loskeletal d iseases and is one of the m ost com m on reasons for
seeking care from a m ed ical provid er. In 2008, three of the
fou r m ost com m on m ed ical cond itions reported w ere m u scu-
loskeletal cond itions im p acting the low er extrem ity (i.e. low
back pain (LBP), chronic joint pain and arthritis) (Pleis et al
2009). Back pain, the m ost prevalent cond ition im pacting the
low er extrem ity, accou nted for over 45 m illion healthcare
Chapter 
2  
Ad a m P. G o o d e , S e a n D. Ru n d e ll
visits annu ally, and of those rep orting chronic joint p ain the
m ost com m on joint affected w as the knee (Pleis et al 2009).
Within the low er extrem ity, p ain synd rom es m ay take on
m any form s and p resent in m any d ifferent joints, m u scles or
tend ons. The focu s of this chap ter is on those low er extrem ity
p ain d isord ers (i.e. chronic p ain, osteoarthritis (OA), sp rains
and strains) that are com m only treated by techniqu es such as
m anu al therap y and exercise. Cond itions su ch rheu m atic d is-
eases, w ork-related m uscu loskeletal d isord ers and m alig-
nancy or system ic issu es w ill not be covered .
An estim ated 7.4% of the United States gross d om estic
p rod u ct is sp ent on annu al d irect and ind irect costs for bone
and joint health. Desp ite the im p act on healthcare costs and
p ersonal nancial bu rd en, an estim ated 2% of the N ational
Institutes of H ealth bu d get is spent on m u sculoskeletal cond i-
tions (Jacobs 2011). The m ajority of research in the area of
low er extrem ity pain d isord ers has been tow ard s u nd erstand -
ing their prevalence. Many stud ies are cond ucted u sing ret-
rosp ective chart review s, second ary d ata analysis and sam ples
of convenience; how ever, these factors lim it the ability to
u nd erstand the tru e bu rd en of d isease. Many ep id em iological
stu d ies have inconsistent case d e nitions or m ethod ological
d ifferences in stu d y d esign that result in variable estim ates.
Another lim ited area of research is that of incid ence, or new
cases of d isease in a given p eriod . Du e to the lim ited nu m ber
of these stu d ies, in this chap ter w e focu s on the bu rd en (p rev-
alence) of d isease from popu lation-based stu d ies or report
lim itations in sam pling from non-population-based stud ies;
w e report incid ence estim ates w hen they are available.
Prevalence and Incidence o Specif c
Lower Extremity Disorders
Lumbar conditions
Prevalence
Table 2.1 su m m arizes selected stud ies, their outcom e m eas-
u res, overall p revalence estim ates and strati ed p revalence
estim ates by gend er for LBP, sciatica and lu m bar spinal steno-
sis. Back p ain has a large im p act on society and ind ivid u als.
The Global Burd en of Diseases, Injuries, and Risk Factors
Stu d y in 2010 fou nd that back p ain continu es to be the nu m ber
one health cond ition in term s of years lived w ith d isability,
 14 PART 1 • 2 • Epidemiology of lower extremity pain disorder

Low back
pain
Hip OA Hip pain
Greater trochanteric Labral tear
pain syndrome
Sciatica

Knee pain Meniscus

Knee OA Patellofemoral
injury
pain syndrome

Achilles
tendinopathy

Figure 2.1 Musculoskeletal conditions in the lower extremity covered in this chapter. OA, osteoarthritis.

Table 2.1 Pre va le nce of lumba r-re late d conditions

Author ye a r De f nition Sa mple s ize Pre va le nce Pre va le nce Ove ra ll
e s tima te e s tima te p re va le nce
(me n) (%) (wome n) (%) (%)

Lo w bac k pain
Hoy et al 2012 Mean prevalence or any def nition Sys tematic review 29.4 35.3 31.0
o 165 s tudies
Deyo et al 2006 Prevalence o LBP within past 31 044 24.3 28.3 26.4
3 months
Cass idy et al 1998 Point prevalence 1131 N/R N/R 28.7
Li etime prevalence 84.0
S c iatic a
Heliövaara et al 1987a Point prevalence o lumbar-dis c-related 7217 5.1 3.7 4.8
leg pain
Hillman et al 1996 Any leg pain or related paraesthes iae 3184 N/R N/R 17.8
within the previous year
S pinal s te no s is
Kalichman et al 2009 Lumbar s pinal s tenosis seen on CT scan 191 N/ R N/ R 23.6
N / R = not reported.

both w orld w id e and in the United States (Mu rray et al 2013;
Vos et al 2013). Prevalence is an im portant com p onent for
d eterm ining the burd en of d isease. H ow ever, the prevalence
of LBP is often d escribed variou sly in the literatu re – various
m ethod s, d e nitions and tim e-p eriod s of p revalent LBP have
been u sed . Consequ ently, this prod u ces a w id e variation in
the estim ated p revalence of LBP. H oy et al (2012) cond u cted
a system atic review on the p revalence of LBP, and found
estim ates ranging from 1.2% to 85.5%. From these stud ies, the
estim ated overall m ean p revalence of back p ain w as 31.0%.
The m ean point prevalence w as 18.7%, and the m ean 1-year
p revalence w as 38.0%. Prevalence estim ates d iffer d ep end ing
on stu d y qu ality, d e nition of back p ain and tim e-p eriod . The
above authors recom m end cau tion w hen interpreting a single
su m m ary m easu re of p revalence d u e to this heterogeneity
(H oy et al 2012).
 Prevalence and incidence of speci c lower extremity disorders
The sam e system atic review also fou nd that the p revalence
of LBP w as greater in fem ales than in m ales. The m ean overall
p revalence of LBP for fem ales w as 35.3%, w hereas m ales had
a m ean overall p revalence of 29.4%. The p revalence of LBP
also varied over the lifesp an. The overall p revalence of LBP
w as highest for 40–69-year old s com pared w ith those w ho
w ere 20–29 or 80–89 years old . Ad olescents had a higher prev-
alence of LBP com p ared w ith 20–29-year old s, although this
d ifference w as not signi cant (H oy et al 2012). These nd ings
are consistent w ith a system atic review by Jeffries et al (2007)
on ad olescent sp inal p ain, w hich su ggests that 7–51% of ad o-
lescents rep ort LBP w ithin the previou s year, and 7–72%
report ever having had LBP d u ring their lifetim e.
Recent evid ence since the system atic review by H oy et al
(2012) ind icates that the d ifference in p revalent LBP betw een
old er and you nger ad u lts is still u nclear. Macfarlane et al
(2012) cond u cted a p op u lation-based stu d y in the United
Kingd om and fou nd that the p revalence of back p ain w ithin
the p revious m onth peaked for ad u lts aged 41–50 years
(29.8%) and d ecreased to 25.5% for ad u lts > 80 years of age.
These nd ings m irror the cu rvilinear pattern of prevalent LBP
w ith increasing age observed by H oy et al (2012). H ow ever,
Macfarlane et al (2012) also rep orted that the p revalence of
high-grad e back p ain, m easu red u sing the Chronic Pain
Grad e (CPG) scale, p rogressively increased w ith old er age –
the highest p revalence of high-grad e pain being 10.0% am ong
p eop le aged > 80 years.
In the United States, Deyo et al (2006) estim ated that the
p revalence of LBP d u ring the previou s 3 m onths w as fairly
sim ilar to the stu d ies d iscu ssed above. The age-ad ju sted p rev-
alence w as 26.4%. The p revalence of LBP w as highest am ong
those 45–64 years old (29.8%), and it d rop ped slightly for
those aged 65 and old er – it w as 28.8% for those aged 65–74
years and 28.7% for those aged > 74 years.
Overall, the variety of LBP d e nitions and research m ethod s
u sed for p revalence stu d ies m akes com p arisons betw een
stu d ies and betw een age grou p s challenging. H ow ever, the
evid ence clearly d em onstrates that LBP is a com m on health
cond ition and has a large bu rd en w orld w id e.
Sim ilar to back p ain, sciatica is a sym p tom . Althou gh there
is no stand ard d e nition, it typ ically involves low -back-
related leg pain. Sciatica is com m only associated w ith sp inal
nerve root involvem ent, bu t this is not alw ays necessary
accord ing to som e d e nitions (Alexop ou los et al 2008). Con-
sistent w ith the lack of a com m on d e nition, there are variable
estim ates for the p revalence of sciatica. A review by Konstan-
tinou and Du nn (2008) fou nd p revalence estim ates for sciatica
ranging from 1.2% to 43%. A Finnish pop u lation-based stu d y
estim ated the point p revalence of lu m bar-d isc-related leg
p ain, d iagnosed u sing sym p tom s and a physical exam , to be
4.8% (95% con d ence interval (CI) 4.3–5.2%) (H eliövaara
et al 1987a). Males had a higher prevalence of lu m bar-d isc-
related leg p ain than fem ales: 5.1% and 3.7% resp ectively.
These authors also found the prevalence w as highest am ong
those aged 45–64 years (H eliövaara et al 1987a). The preva-
lence of any leg pain or related paraesthesiae w ithin the previ-
ou s year w as estim ated to be 17.8% in the British pop u lation,
and 45.6% of those reporting back pain w ithin the previou s
year also reported leg pain (H illm an et al 1996).
Lu m bar sp inal stenosis is one of the few rad iograp hic fea-
tu res associated w ith back p ain (Jarvik & Deyo 2002; Su ri et al
2010). There is no com m only accepted d e nition of lu m bar
15
sp inal stenosis (Mam isch et al 2012), bu t the N orth Am erican
Sp ine Society d e nes it as ‘bu ttock or low er extrem ity p ain,
w hich m ay occu r w ith or w ithout LBP, associated w ith d im in-
ished space available for the neu ral and vascu lar elem ents in
the lu m bar sp ine’ (N orth Am erican Spine Society (N ASS)
2007). Kalichm an et al (2009) stu d ied lu m bar sp inal stenosis
in a sm all su bsam p le of the Fram ingham Stu d y w ho received
com p u ted tom ography (CT) scans. They found up to 23.6%
of ad u lts m ay have anatom ical lu m bar sp inal stenosis, and
the prevalence increased to 38.8% in those over 60 years of
age (Kalichm an et al 2009). There w as no d ifference in p reva-
lence betw een fem ales and m ales. Old er age and higher bod y
m ass ind ex (BMI) w ere factors associated w ith having lu m bar
sp inal stenosis ≤ 12 m m , and LBP w as associated w ith having
lum bar spinal stenosis ≤10 m m (Kalichm an et al 2009). A
Japanese stud y m easured sym ptom atic lum bar spinal steno-
sis u sing a qu estionnaire / d iagnostic su p p ort tool (Yabu ki
et al 2013). The prevalence of sym p tom atic lu m bar sp inal ste-
nosis w as 5.7% and increased w ith old er age; of those aged
70–79 years, 10.8% had sym p tom atic lum bar spinal stenosis.
As w ith other stu d ies, d ifferences in d e nitions and m easu re-
m ent of lu m bar sp inal stenosis m ake com p aring p revalence
estim ates a challenge. H ow ever, the prevalence of lum bar
sp inal stenosis d oes ap p ear to increase w ith ad vancing age.
Incidence
Stu d ies on the incid ence of LBP are less com m on. ‘Incid ent
LBP’ is typically m easured as the rst-ever ep isod e of LBP or
any episod e of LBP (w hether new or recu rrent). The cum u la-
tive incid ence for rst-ever ep isod es of LBP m ay range from
6.3% to 15.4% (H oy et al 2010). Croft et al (1999) cond u cted a
1-year cohort stu d y of 2715 back-p ain-free ad u lts aged 18–75
years in the United Kingd om and fou nd that the cu m u lative
incid ence of a rst-ever LBP episod e w as 15.4%.
The 1-year incid ence of any back pain ep isod e m ay range
from 1.5% to 36.5% of a p op ulation (H oy et al 2010). A
p op u lation-based su rvey of ad u lts 20–69 years old from
Saskatchew an, Canad a, fou nd the cu m u lative incid ence for a
back pain ep isod e to be 18.6% (95% CI 14.2–23.0%), an inci-
d ence that d id not d iffer accord ing to age or gend er (Cassid y
et al 2005). The above estim ates su ggest that new episod es of
back pain are also fairly com m on at a popu lation level.
Sp eci c to old er ad u lts, a cohort stu d y of com m u nity-
d w elling ad u lts 70 years of age or m ore fou nd the cu m u lative
incid ence of restricting LBP over 10 years to be 77% in m ales
and 82% in fem ales. The incid ence rate w as 32.9 per 1000
p erson-m onths, and the vast m ajority of ep isod es (80%) w ere
less than 1 m onth (Makris et al 2011).
There are few popu lation-based stud ies on the incid ence of
sciatica. H eliövaara et al (1987b) estim ated the incid ence of
sciatica from a herniated d isc that resu lted in a hosp italization
w ithin the Finnish p op ulation; they fou nd an incid ence of
only 2.75 per 1000 person-years, and a cu m ulative incid ence
of 0.65%. A m ore recent Finnish stu d y of city em p loyees
fou nd a cu m u lative incid ence of back pain rad iating into the
calf and foot of 35% am ong fem ales and 37% am ong m ales
over a 5–7-year span (Kaila-Kangas et al 2009). Sciatic sym p-
tom s w ere ascertained u sing a qu estionnaire, so recall bias is
likely. Ad d itionally, this stu d y w as lim ited to p articip ants
aged 40 years or old er. Incid ent sciatica ap p ears m u ch less
com m on than incid ent back p ain, bu t the lim ited qu antity of
 16 PART 1 • 2 • Epidemiology of lower extremity pain disorder

stu d ies m akes it d if cu lt to d raw rm conclu sions or
com p arisons.
Hip conditions
Hip symptoms and osteoarthritis
Table 2.2 d escribes the stu d ies, m easu res, overall and strati-
ed p revalence estim ates by gend er for the hip joint. H ip p ain
and osteoarthritis (OA) have received little attention in
p opu lation-based stu d ies d esp ite their im p ortance and im pact
on general p hysical fu nction. Both the N ational H ealth and
N u trition Su rvey (N H AN ES) and the Johnston Cou nty Oste-
oarthritis (JoCo OA) Project have been d eterm ining the p reva-
lence and incid ence of hip pain and OA since the 1990s
(Tep per & H ochberg 1993; Jord an et al 2009). In the JoCo OA
Project (Jord an et al 2009), the overall prevalence of hip OA
w as 28.0%, w ith a higher p revalence am ong Caucasian w om en
(29.1%) and African-Am erican m en (33.2%). In contrast, in the
N H AN ES-I stu d y (Tepper & H ochberg 1993), the estim ated
p revalence of hip OA w as 3.1%, w ith sim ilar estim ates for
m en and w om en.
There are also w id e variations in the estim ated p revalence
of hip sym p tom s betw een the JoCo OA Project and the
N H AN ES stu d y. In the JoCo OA Project (Jord an et al 2009),
the estim ated p revalence of hip p ain w as 36.0%, w ith a higher
p revalence am ong w om en bu t sim ilar estim ates in Caucasians
and African-Am ericans. In contrast, the prevalence of hip
p ain in the N H AN ES-III stud y w as 14.3%, bu t sim ilar to the
JoCo OA Project there w as a higher prevalence in w om en
(Law rence et al 2008). Differences in the questions u sed to
ascertain hip sym p tom s are a likely reason for the variations.
The JoCo OA Project ap plied a broad er case d e nition; it
includ ed aching and stiffness as w ell as pain in the case qu es-
tion. There are also large d ifferences in the p revalence of hip
OA betw een the JoCo OA Project and N H AN ES. Possible
reasons for these d iscrepancies includ e variability in rad io-
graph read ings by the rad iologists (the N H AN ES-I rad io-
graphs m ay not re ect the true prevalence of hip OA ow ing
to u nd er-read ing of lm s), a higher p revalence of rad io-
graphic hip OA am ong ru ral m en in the JoCo OA Project, and
geograp hic variations in risk factors (Jord an et al 2009). N evitt
et al (1995) estim ated the p revalence of hip p ain and OA in a
p op u lation of p ostm enop au sal w om en (and therefore the
nd ings from this stu d y are generalizable only to w om en).
They fou nd a p revalence of hip pain (35.0%) consistent w ith
the JoCo OA Project. H ow ever, their hip OA estim ates w ere
closer to N H AN ES. The em p hasis of this stu d y w as on osteo-
p orosis and therefore their stu d y sam p le w as m arked ly d if-
ferent from the general com m u nity-based sam p les in the JoCo
OA Project and N H AN ES. Desp ite the d ifferences in stu d y
sam p les and qu estions to d e ne hip sym p tom s and OA, these
cond itions are also com m on in the general p op u lation and
have su bstantial im p act on general p hysical fu nction.

Table 2.2 Pre va le nce of hip-re late d pain conditions

Author ye a r De f nition Sa mp le Pre va le nce Pre va le nce Ove ra ll
s ize e s tima te (me n) (%) e s tima te pre va le nce
(wome n) (%) (%)

Hip OA
Jordan et al 2009 K-L score 2–4 3068 Caucas ian 23.8 Caucas ian 29.1 28.0
A rican-American 33.2 A rican-American 31.2
Nevitt et al 1995 Score o 2–4 4855 N/A 11.9 N/A
NHANES-I (Tepper & K-L score 2–4 2358 3.2 3.0 3.1
Hochberg 1993)
Hip pain
Jordan et al 2009 ‘On mos t days , do you have 3068 Caucas ian 31.7 Caucas ian 39.4 36.0
pain, aching, or s ti ness in A rican-American 32.0 A rican-American 40.3
your (right, le t) hip?’
Nevitt et al 1995 ‘Hip pain on most days or 4855 N/A 35.0 N/A
1 month’
NHANES-III (Lawrence ‘Signif cant pain on mos t days 6596 11.9 16.2 14.3
et al 2008) over the preceding 6 weeks’
Labral te ar
Narvani et al 2003 MRI 18 N/R N/R 22
McCarthy et al 2001 Arthroscopy 436 54.4 45.6 55.0
Gre ate r tro c hante ric  pain s yndro me
Segal et al 2007 Tenderness to palpation 3206 1.9 6.6 Unilateral 15.0
Bilateral 8.5
Tortolani et al 2002 Clinical examination 252 N/R N/R 20.2
K-L = Kellgren and Lawrence; N / A= not available; N / R = not reported.
 Prevalence and incidence of speci c lower extremity disorders 17

Incidence (2002) estim ated the prevalence of GTPS, u sing a m ed ical

The incid ence of hip OA has only recently been estim ated ,
and d ifferences have been fou nd betw een African-Am ericans
and Cau casians. The age- and sex-stand ard ized incid ence
of hip OA is estim ated to be 88 p er 100 000 person-years
(Oliveria et al 1995). The ad justed incid ence of hip OA in
African-Am ericans is signi cantly low er (hazard ratio (H R)
0.44, 95% CI 0.27–0.71) than in Cau casians (Kop ec et al 2013).
Labral tears
Acetabu lar labral tears have received increasing attention in
recent years, and p articu larly the role that labral tears m ay
play in chond ral d am age and d evelop m ent of hip OA. In one
stu d y the p revalence of hip labral tears w as estim ated at
22–55% (McCarthy et al 2001), but as this stud y w as con-
d u cted in a sam ple of patients w ith existing groin or hip p ain
a popu lation-based estim ate of hip labral tears is still unavail-
able. Sim ilarly, there are as yet no pop u lation-based stu d ies
on the incid ence of hip labral tears.
Greater trochanteric pain syndrome
Greater trochanteric p ain synd rom e (GTPS) can be a challeng-
ing cond ition to d iagnose and treat. Few stud ies have been
cond u cted w ithin a w ell-d e ned p op u lation. Tortolani et al
chart review, to be ap p roxim ately 20% am ong p atients seeking
care for LBP. Segal et al (2007) cond u cted the only p op u lation-
based stu d y of GTPS in 2954 su bjects w ithin the Mu lticenter
Osteoarthritis Stu d y. They u sed a clinical exam ination w ith a
stand ard ized d olorim eter to calibrate nger p ressu re p rior to
exam ination, and fou nd the p revalence of u nilateral GTPS to
be 11.7%, w ith a higher prevalence in w om en (15.0%) than in
m en (6.6%) (Segal et al 2007). The higher prevalence estim ate
of 20% in the Tortolani et al (2002) stu d y is m ost likely to be
d ue to the d ifferences in selection of subjects and the broad
d e nition of GTPS, as the stu d y participants w ere id enti ed
throu gh a retrosp ective m ed ical chart review and w ere there-
fore seeking care. N o p op ulation-based stu d ies have been
cond u cted on the incid ence of greater trochanteric p ain
synd rom e.
Knee conditions
Knee symptoms and osteoarthritis
Table 2.3 d escribes the stu d ies, m easu res, overall p revalence
and strati ed prevalence estim ates by gend er for pain related
to the knee joint. Sim ilar to the p revalence estim ates for the
hip , su bstantial variability exists in those for knee sym p tom s.
In the JoCo OA Project the overall prevalence of knee sym p-
tom s w as 43.3%, w ith a higher prevalence in w om en (47.6%)

Table 2.3 Pre va le nce of kne e -re late d pain conditions

Author ye a r De f nition Sa mple s ize (n) Pre va le nce Pre va le nce Ove ra ll
in me n in wome n p re va le nce
(95% CI) (%) (95% CI) (%) (95% CI) (%)

Kne e  pain
Jordan et al 2007 ‘On most days, do you have 3018 37.4 (35.4–39.4) 47.6 (45.7–49.6) 43.3 (41.7–44.9)
pain, aching, or sti ness in
your (right, le t) knee?’
NHANES-III (Anders en ’Signif cant knee pain on 6596 18.1 23.5 N/ A
et al 1999) mos t days over the
preceding 6 weeks ’
Framingham ‘Ever had pain in or around 1805 symptoms 6.8 (s ymptomatic 11.4 (s ymptomatic 16.1
Os teoarthritis Study a knee o mos t days or at 1424 radiographs OA) OA)
(Fels on et al 1987) least a month’
Kne e  OA
Jordan et al 2007 K-L score 2–4 3018 23.7 (26.5–29.2) 31.0 (29.2–32.8) 27.8 (26.5–29.2)
NHANES-III (Anders en K-L score 2–4 2415 31.2 (26.4–35.9) 42.1 (38.2–46.0) 37.4 (35.0–39.8)
et al 1999)
Framingham K-L score 2–4 1420 30.9 34.4 33.0
Os teoarthritis Study
(Fels on et al 1987)
Me nis c us  te ar
Englund 2008 MRI 991 33 (28.0–37.0) 19 (15.0–24) 35 (32.0–38.0)
Pate llo fe mo ral pain s yndro me
Boling et al 2010 Medical record review 1525 15.3 (13.7–16.9) 12.3 (11.1–13.4) 13.5 (11.7–15.3)
N / A= not available; K-L = Kellgren and Lawrence.
 18 PART 1 • 2 • Epidemiology of lower extremity pain disorder
(Jord an et al 2009). In the N H AN ES-III stud y there w as also
a higher p revalence of knee sym ptom s in w om en (23.5%)
(Law rence et al 2008); how ever, the estim ates across the
gend ers w ere substantially low er than those found in the JoCo
OA Project. Variability in knee sym p tom qu estions is the
reason for this inconsistency.
The p revalence estim ates for knee OA are m ore sim ilar
across stu d ies. In the JoCo OA Project the overall p revalence
of knee OA w as 27.8%, w ith a higher p revalence fou nd
in w om en (31.0%) (Jord an et al 2009). Sim ilarly, in the
N H AN ES-III stu d y the overall prevalence w as 37.4%
(Law rence et al 2008) and in the Fram ingham OA Stud y it
w as 33.0% (Felson et al 1987). Both the N H AN ES-III and the
Fram ingham OA Stu d y reported a higher p revalence in
w om en. The d ifferences betw een knee OA found in the JoCo
OA Project com p ared w ith the N H AN ES-III stu d y are thou ght
to be p rim arily d u e to the u se of non-w eight-bearing rad io-
graphs in the N H AN ES stu d y. Sym ptomatic knee OA w as
very prevalent in the JoCo OA Project (m en 13.5% and w om en
18.7%) (Jord an et al 2007). Sim ilarly, nd ings from the
Fram ingham OA Stud y ind icate a higher prevalence of sym p-
tom atic OA in w om en (11.4%); how ever, these estim ates are
m u ch greater than those in the JoCo OA Project. The increas-
ing rate of obesity over the tim e p eriod s w hen these stu d ies
w ere cond ucted is a possible reason for this d iscrep ancy
(Jord an et al 2007).
Incidence of knee osteoarthritis
Age- and sex-stand ard ized incid ence rate of sym ptom atic
knee OA is 240 p er 100 000 p erson-years (Oliveria et al 1995).
These rates increase w ith age and level off around the age of
80 years (Bu ckw alter et al 2004). The lifetim e risk of d evelop -
ing sym p tom atic knee OA is estim ated to be ap p roxim ately
40% in m en and 47% in fem ales.
Meniscus injury
Meniscal inju ries are extrem ely p revalent, bu t p op u lation-
based stu d ies are rare. The m ajority of m eniscal injuries occu r
in the athletic p op u lation from contact and non-contact inju ry,
bu t d egenerative m eniscal injury is also possible. The variety
of p otential inju ry exp osu res occu rring across sp orts lead s to
su bstantial variability in m eniscal inju ry p revalence estim ates
across stu d ies. One previou s stu d y cond u cted w ithin the
Fram ingham censu s tract estim ated the prevalence (35%) of
right knee lateral or m ed ial m eniscus d am age am ong a sam p le
of m id d le-aged and eld erly ad u lts (Englund et al 2009b). This
stu d y fou nd that m en had a su bstantially greater p revalence
(33%) of m eniscal tear com pared w ith w om en (19%). Since
these resu lts w ere d erived from a p op u lation-based sam p le,
these au thors w ere able to id entify that 23% of subjects had a
m eniscal tear w ithou t rep orting knee sym p tom s. A com m on
qu estion is w hether m eniscal d am age m ay lead to knee OA.
In this stu d y a large prop ortion (63%) of su bjects w ith
sym p tom atic OA had evid ence of a m eniscu s tear. Other
stu d ies have also noted the p resence of m eniscu s inju ry to be
a p otent risk factor for the d evelopm ent of knee OA (Englu nd
2008; Englu nd et al 2009a).
Patellofemoral pain syndrome
Anterior knee p ain, caused from patellofem oral pain syn-
d rom e (PFPS), is one of the m ost com m on knee com plaints
(Davis & Pow ers 2010). PFPS is a com m on d iagnosis w ithin
the athletic p op u lation, and ru nners in p articu lar (Devereau x
& Lachm ann 1984). There are few population-based stu d ies.
Boling et al (2010) cond u cted an epid em iological stu d y to
d eterm ine the p revalence and incid ence of PFPS am ong 1525
m ilitary cad ets at the United States N aval Acad em y. Given
p reviou s rep orts of a gend er d ifference, w ith fem ales having
a higher p revalence, these au thors exam ined gend er d iffer-
ences w ith a sam p le that w as app roxim ately one-half fem ale.
Particip ants u nd erw ent a clinical exam ination at baseline and
w ere follow ed prosp ectively. The prevalence of PFPS w as
13.5% (95% CI 11.7–15.3%) in the sam ple, w ith a higher p reva-
lence in w om en (15.3%, 95% CI 13.7–16.9%) than in m en
(12.3%, 95% CI 11.1–13.4%). In ad ju sted longitu d inal analyses,
w om en w ere 2.23 (95% CI 1.16–4.10) tim es m ore likely to
d evelop PFPS (Boling et al 2010).
Foot and ankle conditions
Ankle sprains
Table 2.4 presents selected stu d ies, their m easu res, overall
and strati ed p revalence estim ates by gend er for com m on
m u scu loskeletal cond itions at the ankle and foot. Ligam ent
sp rains are a com m on inju ry at the ankle. Doherty et al (2014)
p erform ed a large m eta-analysis of ankle sp rain inju ries. They
fou nd the p ooled p revalence of ankle sp rains w as 11.88%
(95% CI 10.56–13.19%) w hen u sing estim ates from high-
qu ality stu d ies only. The p ooled p revalence estim ates w ere
sim ilar betw een m ales and fem ales. The p revalence of ankle
sp rains w as greatest in child ren (12.62%, 95% CI 11.81–
13.43%), w hereas the p revalence estim ates in ad olescents
(10.55%, 95% CI 9.92–11.17%) and ad ults (11.41%, 95% CI
11.28–11.54%) w ere slightly low er (Doherty et al 2014).
The m eta-analysis by Doherty et al (2014) also created
p ooled estim ates for the incid ence of ankle sp rains. The
overall incid ence w as 11.55 p er 1000 exposu res (95% CI 11.54–
11.55) am ong their high-qu ality stu d ies. Fem ales had m ore
than d ouble the estim ated incid ence of ankle sprains: 13.6 p er
1000 exp osures (95% CI 13.25–13.94) versu s 6.94 p er 1000
exp osures (95% CI 6.–7.09) for m ales. Fu rtherm ore, ad oles-
cents and child ren have m ore incid ent ankle sp rains than
ad u lts: 1.94 (95% CI 1.73–2.14) and 2.85 (95% CI 2.51–3.19)
ankle sp rains per 1000 exp osures respectively, w hereas ad u lts
had 0.72 ankle sprains p er 1000 exposures (95% CI 0.67–0.77)
(Doherty et al 2014).
The incid ence of ankle sprains requ iring an em ergency
d ep artm ent visit in the United States p op ulation is 2.15 p er
1000 p erson-years (Waterm an et al 2010). Teenagers (15–19
years old ) had the highest incid ence of any age group , at 7.2
p er 1000 person-years. Overall, there w as no d ifference in
incid ent ankle sprain betw een m ales and fem ales (Waterm an
et al 2010). These estim ates p robably u nd erestim ate the tru e
incid ence of ankle sprains in the United States, how ever, since
m any p eop le exp eriencing an ankle sp rain m ay not seek care
in an em ergency d epartm ent.
Lateral ankle sp rain is the m ost com m on site for incid ent
sp rains; there w ere 0.93 lateral ankles sprains p er 1000 athletic
exp osures. Synd esm otic sprains w ere the next m ost com m on,
w ith 0.38 per 1000 athletic exposu res, and m ed ial ankle
sp rains w ere least com m on, w ith 0.06 per 1000 athletic exp o-
su res (Doherty et al 2014).

Table 2.4 Pre va le nce of foot / ankle pa in conditions
Author ye a r De f nition Sa mp le s ize (n)
Ankle  s prains
Doherty et al 2014 Pooled prevalence o ankle Meta-analysis o 181
s prains s tudies
Ac hille s  te ndino pathy
de Jonge et al 2011 Achilles pain above the 57 725
insertion
McKean et al 2006 Sel -reported Achilles injuries 981 runners over 40
Plantar fas c iitis
McKean et al 2006 Sel -reported plantar as ciitis 2886 runners
N / R = non-reported.
Achilles tendinopathy
There are few popu lation-based estim ates for the p revalence
of Achilles tend inop athy. In the Du tch p op u lation, d e Jonge
et al (2011) rep orted that 0.2% of registered general practice
patients have Achilles tend inop athy. H ow ever, its prevalence
m ay be higher in d istance ru nners. One stu d y fou nd that 6.2%
of ru nners aged over 40 years at a relay race had self-rep orted
Achilles tend inop athy over the previou s 12 m onths (McKean
et al 2006). Also, runners aged over 40 years had a greater
prevalence than those aged less than 40 years (McKean et al
2006). Jacobs & Berson (1986) found the p revalence in ru nners
w as 2.9% over a 2-year span.
Pop u lation-based estim ates for the incid ence of Achilles
tend inop athy are also rare. The stu d y by d e Jonge et al (2011)
looked at incid ent general practitioner visits for m id -portion
Achilles tend inopathy in their Dutch popu lation sam ple.
These au thors fou nd an incid ence rate of 1.85 per 1000 regis-
tered general p ractice p atients. The incid ence w as sim ilar
betw een m ales and fem ales. Patients aged 41–65 years had
the highest incid ence, at 2.4 per 1000 (d e Jonge et al 2011).
Although very generalizable to the Dutch p opu lation, this
stu d y m ay u nd erestim ate the real incid ence of Achilles tend i-
nop athy since not all ind ivid u als m ay seek care for their
injury.
Incid ent Achilles tend inopathy has been estim ated to occur
in 10.9% of ru nners (Lysholm & Wikland er 1987). In fact,
Knobloch et al (2008) fou nd incid ent Achilles tend inopathy to
be the m ost com m on injury in a cohort of ru nners. The inci-
d ence rate w as 0.16 per 1000 kilom etres ru n (Knobloch et al
2008). A stu d y looking at elite track and eld athletes d u ring
a 2009 w orld cham p ionship m eet fou nd the cum u lative inci-
d ence of Achilles tend inop athy to be 6.1 p er 1000 athletes
d u ring the m eet (Alonso et al 2010; Sobhani et al 2013).
Plantar fasciitis
Plantar fasciitis is a frequ ent reason for p hysician visits and
one of the m ost com m on reasons for heel p ain. Du ring the
years 1995 to 2000, the average nu m ber of p hysician visits for
plantar fasciitis w as 1 005 000 per year in the USA (Rid d le &
Schap p ert 2004). Despite being a fairly com m on reason for
Healthcare utilization and impact 19
Pre va le nce Pre va le nce Ove ra ll
in me n in wome n pre va le nce
(95% CI) (%) (95% CI) (%) (95% CI) (%)
11.0 (10.8–11.2) 10.6 (10.8–11.2) 11.9 (10.56–13.19)
N/R N/R 0.2
N/R N/R 6.2
N/R N/R 8.4
seeking healthcare, p op u lation estim ates for the p revalence of
p lantar fasciitis are scarce. H ow ever, w ithin sp orting p op u la-
tions som e stu d ies have estim ated the p rop ortion of p eop le
w ith plantar fasciitis. The 1-year p revalence in triathletes is
estim ated to be 3.9% (Collins et al 1989). In d istance runners
it is estim ated to be 8.4%, and there is no d ifference in preva-
lence for ru nners aged 40 years or old er com pared w ith those
less than 40 years of age (McKean et al 2006). In another
stu d y, the prevalence in runners w as reported to be 2.4% over
2 years (Jacobs & Berson 1986).
There are a few estim ates of incid ent plantar fasciitis in
active or athletic populations. In the stu d y by Kochen et al
(2009), the incid ence of p lantar fasciitis for an active-d u ty
m ilitary popu lation in the United States w as 10.5 p er 1000
p erson-years. Fem ales had alm ost tw ice the incid ence rate of
p lantar fasciitis com pared w ith m ales: 18.0 per 1000 p erson-
years and 9.2 per 1000 person-years respectively. Service
m em bers w ho w ere 40 years old or m ore had the highest rate
of plantar fasciitis, at 16.6 per 1000 person-years; this w as
m ore than three tim es as high as for 20–24-year-old s. In other
stu d ies, the incid ence rate of p lantar fasciitis am ong ru nners
w as 0.004 per 1000 kilom etres ru n (Knobloch et al 2008). In
elite track athletes, incid ent plantar fasciitis w as less com m on
than Achilles tend inopathy, at 0.7 per 1000 participating ath-
letes (Alonso et al 2010; Sobhani et al 2013).
Healthcare Utilization and Impact
The p op ulation is ageing and therefore chronic cond itions are
becom ing m ore prevalent, lead ing to increased m orbid ity.
With increasing longevity, the healthcare system is su staining
severe nancial p ressu re to m aintain care. An estim ated $950
billion d ollars in d irect and ind irect d ollars costs are spent on
m u scu loskeletal d isease. Ind ivid u als w ith m u scu loskeletal
d iseases have a large im pact on the healthcare system ,
w ith costs increasing from $5151 per p erson in 1996–98 to
$6429 in 2004–06, rep resenting a 25% increase in exp end itu re
(Jacobs 2011).
The econom ic burd en of LBP is extensive. For the entire
United States popu lation, the annual m ed ical costs for LBP
w ere $86 billion in 2005 and estim ated to be over $100 billion
 20 PART 1 • 2 • Epidemiology of lower extremity pain disorder
in 2010 (Martin et al 2008). LBP-associated costs and health-
care u tilization am ong Med icare bene ciaries have increased
d isproportionately, com pared w ith Med icare enrollm ent
(Weiner et al 2006). As the popu lation ages and Med icare
coverage grow s, the US healthcare system w ill have an
increased bu rd en.
LBP is the second m ost com m on reason for p hysician visits
in the United States (H art et al 1995). Ma et al (2013) have
recently exam ined trend s from 1999–2000 to 2009–10 in the
United States for speci c types of back-related healthcare u se.
Physical therap y u tilization has rem ained relatively stable
over the 10-year period ; ap p roxim ately 15–20% of patients
w ith back pain u tilized physical therap y services d u ring this
tim e-p eriod . The p rop ortion of p atients receiving rad iograp hs
has also rem ained fairly stable (app roxim ately 13–17%), but
the u se of ad vanced im aging for ind ivid u als w ith LBP had
increased from 7% to about 11% by 2010. Use of non-steroid al
anti-in am m atory m ed ication for back p ain has actu ally
d ecreased , w hereas the use of opioid s has increased from
19.3% to 29.1% of p atients. Other stu d ies show that the use of
lu m bosacral injections for back p ain (Fried ly et al 2007) and
com p lex sp inal fu sion su rgeries for sp inal stenosis (Deyo et al
2010) also have trend s of increasing usage.
Osteoarthritis is one of the m ost com m on m u scu loskeletal
cond itions lead ing to fu nctional im p airm ent and d isability.
OA, in general, accou nts for su bstantial m orbid ity, healthcare
u tilization, and high annu al d irect and ind irect costs. Patients
w ith OA are subject to rou ghly d ouble the healthcare costs of
those w ithou t OA. Yelin et al (2007) rep orted no changes in
total healthcare costs am ong patients w ith OA from 1997 to
2003. H ow ever, a p reviou s stud y (MacLean et al 1998) from
1991 to 1993 rep orted that m ed ication costs had m ore than
d ou bled and ou tpatient charges increased su bstantially over
that p eriod .
The m ost com m on site for low er extrem ity OA is the knee
and hip . A com m on treatm ent for end -stage OA in the knee
and hip is total joint arthroplasty. Ku rtz et al (2007) antici-
p ated that su ch su rgeries w ould increase at a rapid rate
betw een 2005 and 2030 – by 174% for total hip joint arthro-
p lasty and 673% for knee arthroplasty. In 2007, the estim ated
annu al cost of knee and hip arthroplasty w as $15.6 billion
d ollars (Ong et al 2006). Despite the high volu m e and cost
associated w ith hip and knee arthrop lasty, the im provem ents
in p ain and fu nction ap p ear to be ju sti ed , how ever.
Ankle sprain is a com m on m u sculoskeletal cond ition that
often becom es chronic or recu rrent (Verhagen et al 2000), and
the associated healthcare costs and u tilization create a large
bu rd en on the healthcare system . It is the m ost com m on low er
extrem ity inju ry responsible for em ergency visits in the
United States, at 206 p er 100 000 visits (Lam bers et al 2012).
Although no recent d ata on healthcare costs associated
w ith ankle sprains in the United States are available, in the
N etherland s it w as estim ated that sp orts-related ankle sprains
m ay cost 187.2 m illion Eu ros (H u pp erets et al 2010). Clearly,
m ore w ork is need ed to u nd erstand better the healthcare u ti-
lization and associated costs for ankle sp rains.
Conclusion
Und erstand ing the epid em iology of low er extrem ity pain
synd rom es is clearly im p ortant for p ractitioners as the
p revalence of d isease has im p lications for accu rate d iagnosis.
Prevalence is often the basis for p re-test p robabilities of d iag-
nostic tests. The p revalence of low er extrem ity p ain syn-
d rom es varies su bstantially w ith respect to location and
d iagnosis. In som e cases, the prevalence and incid ence esti-
m ates from p op u lation-based stu d ies contrad ict one another,
and this is in large part d u e to the qu estions used to ascertain
case d e nitions. Althou gh m u scu loskeletal low er extrem ity
p ain synd rom es are increasing, p op u lation-based research on
the incid ence, p revalence and risk factors is insu f ciently
stu d ied and rare. N ot only d oes m ore w ork need to be d one
in this area to u nd erstand the d isease bu rd en better, bu t uni-
form ity in qu estion d esign and d iagnosis are critical to achieve
better consistency betw een estim ates. The im p act of d isease
incid ence and prevalence on healthcare utilization and costs
m akes it im p erative to u nd erstand fu rther the ep id em iology
of low er extrem ity p ain synd rom es.
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 PART 1 • General Introduction
History Taking
3 Chapter
P e te r A. Hu ijb re g ts
CHAP TER CONTENTS
Introduction 22
Patient pro le 23
Location and description of symptoms 24
Symptom behaviour 26
Symptom history 27
Medical history 28
Systems review 29
Conclusion 34
Introduction
In all healthcare professions includ ing physical therapy there
are ve elem ents to p atient m anagem ent. An exam ination is
u su ally follow ed by evalu ation of the exam ination nd ings,
establishing a d iagnosis, prod u cing a prognosis and a plan of
care and , nally, p erform ing the interventions (Am erican
Physical Therap y Association (APTA) 2001). In physical
therap y the exam ination u su ally consists of history taking,
system s review, and tests and m easu res and it serves to p rovid e
d ata used in the clinical-reasoning process. Du ring this process
the clinician d evelop s, in an ongoing m anner, m u ltip le com -
p eting d iagnostic hyp otheses. Data acqu ired d u ring the exam -
ination are then u sed to su p p ort or refu te these variou s
hyp otheses. This hyp othesis-testing p rocess gu id es the form at
and content of the ongoing exam ination process u ntil the clini-
cian d ecid es that su f cient inform ation is obtained to m ake a
d iagnostic or m anagem ent d ecision (Jones 1995).
Within the p rofession of p hysical therap y there are m any
d istinct approaches to patient m anagem ent. The speci c
inform ation that a clinician looks for, the ord er in w hich it is
obtained and the em p hasis that is given to the d ata collected
w ill all vary d epend ing on the p hilosophy to w hich the ind i-
vid u al clinician su bscribes. H ow ever, all ap p roaches end u p
testing hyp otheses related to (Jones 1995):
1. Source of the sym ptom s
2. Contributing factors inclu d ing environm ental,
behaviou ral, em otional, psychosocial,
system ic / p athological and m u scu loskeletal factors
3. Precau tions or contraind ications to exam ination and
m anagem ent
4. Managem ent
5. Prognosis.
Irrespective of m anagem ent philosophy, the need to test the
above-m entioned types of hyp otheses lead s to a consistent
content of the history com p onent of exam ination, w ith history
item s related to six categories (Boissonnau lt & Janos 1995)
(Box 3.1):
1. Patient pro le
2. Location and d escription of sym ptom s
3. Sym ptom behaviou r
4. Sym ptom history
5. Med ical history
6. Review of system s.
In the exam ination, history taking and physical exam ination
are inextricably linked . H istory taking allow s the clinician to
gather inform ation that is u sed in the su bsequ ent physical
exam ination to establish the patient’s concord ant or com pa-
rable signs. A concord ant sign consists of p ain or other sym p-
tom s rep rod u ced u p on p hysical exam inations that are
ind icated by the p atient as his or her chief com plaint – that is,
the reason for seeking ou t therap y (Laslett et al 2003). Withou t
this inform ation d erived from history taking, the clinician
w ould be u nable d uring the exam ination to d istingu ish
betw een concord ant and d iscord ant signs. Discord ant signs
are nd ings on p hysical exam ination seem ingly im plicating a
sou rce of sym p tom s that are, how ever, in no w ay related to
the chief com p laint (Cook 2007).
Du ring history taking the clinician also should seek to get
an im pression of patients’ com m unication ability, affect, cog-
nition, langu age, and learning style (APTA 2001). In ad d ition,
the history allow s the clinician to gain insight into p atients’
u nd erstand ing of their ow n health p roblem , u nd erlying
p athology or d ysfu nction, m echanism of inju ry or aetiology,
and contribu ting factors. It provid es inform ation on p atient
goals (that m ay or m ay not be realistic or attainable w ith
interventions w ithin the physical therap y scope of p ractice)
and patient m otivation and w illingness to change (Brou w er
et al 1999).
Data collection in the history also establishes a baseline
against w hich to com pare the resu lts of the treatm ent (Cook
2007). Baseline d ata can, of course, consist of answ ers to qu es-
tions asked d u ring the history and nd ings on p hysical exam -
ination tests; how ever, the often-d ichotom ous (and even m ost
continu ou s) variables of this natu re u su ally lack the su f cient
 Patient pro le 23

ou tcom e m easu res. Som e valid ated m easu res collected as

Bo x 3 .1 His to ry- ta kin g c o n te n t p art of history taking serve a p rognostic p u rp ose; the Tam p a
Patie nt pro le Scale of Kinesiop hobia (TSK) is a good exam p le of su ch a
p rognostic tool relevant to p atients w ith neck p ain (Vlaeyen
• Age et al 1995).
• Sex In ad d ition to d ata collection, the history (and subsequ ent
• Ethnic origin p hysical exam ination) also serves another im p ortant p u rp ose.
• Marital status A skilfu lly ap p lied fu nnel sequ ence w here op en-end ed qu es-
• Social situation tions are follow ed by sp eci c closed -end ed follow -u p qu es-
• Occupation tions, p arap hrasing by the therap ist of inform ation p rovid ed
• Leisure activities
by the patient to establish effective and accu rate com m unica-
tion, ap p rop riate intonation, and attentive non-verbal com -
Lo c atio n and de s c riptio n o f s ympto ms
m u nication, inclu d ing ap p rop riate therap ist bod y p ostu re and
• Chief complaint facial expression, all allow the clinician to establish a profes-
• Presence and location of pain, s ens ory abnormalities, sional relationship based on m u tu al coop eration, resp ect, and
s trength de cits, range of motion de cits , in ammatory tru st (Good m an & Snyd er 1995; Brou w er et al 1999).
s ymptoms
• Character of symptoms
S ympto m be havio ur
• Cons tant, episodic, or intermittent
Patient Pro le
• Aggravating factors
During this portion of the history the clinician collects and
• Easing factors record s d em ographic d ata on patient age, sex, ethnic origin,
• Diurnal variation m arital statu s, social situ ation, occu p ation and leisu re activi-
S ympto m his to ry ties. Variou s p athologies are m ore com m on based on age and
• Nature / mechanis m of ons et sex (Table 3.1). There is strong evid ence for old er age as a poor
• Symptom change s ince onset p rognostic ind icator w ith regard to m echanical neck p ain
(McLean et al 2007; Carroll et al 2008b). Sex also seem s to
• Treatment received
affect prognosis for som e neck and arm pain synd rom es.
Me dic al his to ry Wom en are at a greater risk than m en for d evelop ing p ersist-
• Current and past illness es ent problem s after cervical w hip lash injury (od d s ratio (OR)
• Hospitalizations 1.54, 95% con d ence interval (CI) 1.16–2.06) (Walton et al
• Family medical history 2009), w hereas m en are at higher risk of d eveloping persistent
• Medication use arm and especially elbow pain (OR 1.9, 95% CI 1.2–3.2) (Ryall
• Substance abuse et al 2007).
Ethnicity m ay also p red isp ose p atients to certain d iseases
• Nutritional status
w ith, for exam ple, sickle cell d isease (and its m uscu loskeletal
• Medical tes ts and res ults (imaging, blood work, urinalysis , p resentation) m ore p rom inent in the Black p op u lation and
electrodiagnos is , cerebros pinal uid analys is , biops ies , etc.) skin cancer m ore p rom inent in the White p op u lation (Bois-
Re vie w o f s ys te ms sonnault & Janos 1995). White, Asian or H isp anic ethnic origin
• Gastrointestinal sys tem p red isp oses w om en to osteop orosis, w hereas Black w om en
• Urogenital sys tem are less likely to be osteopenic (H uijbregts 2001; Siris et al
• Cardiovas cular s ystem 2001; Sou th-Paul 2001).
• Pulmonary system Inform ation on m arital status and social situ ation (includ -
ing questions on the available supp ort netw ork, ad aptations
• Musculoskeletal system
in hom e and w ork situ ation, d urable m ed ical equ ipm ent
• Neurological s ystem availability and d isp osable incom e) helps the therapist estab-
• Integumentary s ystem lish realistic goals, bu t m ay also ind icate areas relevant to
• Psychosocial factors intervention. Qu estions on leisure activities and occu pation
can id entify cau sative or contribu ting factors, bu t also estab-
lish load ing requirem ents and thu s approp riate rehabilitation
resp onsiveness required of an outcom e m easure. Therefore, goals. Occup ational exposure to ind ustrial toxins (e.g. asbes-
ou tcom es are p referably collected u sing reliable, valid and tos, lead , agricu ltu ral p esticid es or arsenic), extrem e tem p era-
resp onsive questionnaire-type ou tcom es. These outcom e tu res, rep etitive or su stained p ostu res and m ovem ents, or
m easu res can be generic – that is, collect d ata on general excessive em otional or m ental pressure m ay pred ispose
health statu s, su ch as the Short Form (SF)-36 (Ware et al p atients to p athology. For exam p le, exp osu re to silica, coal
1993) – or they can be m ore speci c to a cond ition. Exam ples d ust, ou r d ust, or asbestos can lead to pu lm onary p athology
of cond ition-sp eci c ou tcom e m easu res relevant to p atients (Boissonnault & Janos 1995; Good m an & Snyd er 1995). Occu -
w ith neck and arm pain inclu d e the N eck Disability Ind ex p ational variables can also affect p rognosis. Prognosis w ith
(Vernon & Mior 1991) and the DASH (Disabilities of the Arm , regard to neck p ain is better for w hite-collar than for blue-
Shou ld er, and H and ) tools (H u d ak et al 1996). Subsequ ent collar w orkers and w orse if p atients have little in u ence on
chap ters w ill d iscu ss variou s relevant cond ition-sp eci c their w ork situ ation (Carroll et al 2008a).
 24 PART 1 • 3 • History taking

Table 3.1 Some a ge - and s e x-re late d me dical conditions

range of m otion d e cits and in am m atory sym p tom s. The
su bsequ ent chap ters w ill ad d ress location and d escrip tion of
Dia g nos is Ag e (ye a rs ) Sex sym p tom s relevant to the resp ective neu ro-m u scu loskeletal
d ysfu nctions in m ore d etail.
Mus c ulo s ke le tal Inherent in testing com peting hyp otheses w ith regard to
Rotator cuff 30+ the sou rce of sym p tom s is ru ling ou t variou s cond itions that
degeneration can resu lt in a sim ilar p resentation. These cond itions are not
lim ited to the m echanical neuro-m uscu loskeletal d ysfunc-
Spinal s tenos is 60+ Men > women
tions w ith an ind ication for p hysical therap y m anagem ent,
Costochondritis 40+ Women > men bu t also inclu d e visceral or other system ic pathology that m ay
Ne uro lo g ic al ind icate a need for referral or at the very least affect physical
therap y m anagem ent and p rognosis. N ote that the role of the
Guillain–Barré Any age (history of p hysical therap ist is not to establish a sp eci c d isease-level
syndrome infection) m ed ical d iagnosis bu t rather to screen for d isease u sing a
Multiple s cleros is 15–50 system s ap p roach (Boissonnault & Janos 1995).
Although in physical therapy clinical p ractice w e certainly
Neurogenic claudication 40–60+
encou nter p atients w ith cutaneous pain related to the skin and
S ys te mic other su p er cial stru ctu res, d eep som atic, tru e visceral and
AIDS / HIV 20–49 Men > women
neu rop athic p ain are m ore relevant to p hysical therap y d if-
ferential d iagnosis. N eu rop athic pain results from a p rim ary
Coronary artery dis ease 40+ Men > women lesion or d ysfu nction in the p eripheral or central nervous
Mitral valve prolapse Young Women > men system . Painfu l neu rop athies are characterized by sp ontane-
ou s and / or abnorm al stim u lu s-evoked p ain related to the
Bürger dis ease 20–40 (s mokers) Men > women p resence of allod ynia, w hereby p ain is cau sed by norm ally
Aortic aneurysm 40–70 Men > women innocuou s stim uli, and / or hyp eralgesia, in w hich case p ain
intensity evoked by norm ally p ainful stim u li is increased
Breast cancer 45–70 Women > men
(Merskey & Bogd uk 1994). Deep som atic pain can originate
Hodgkin lymphoma 20–40; 50–60 Men > women in the bone, m uscle, tend on, capsule and ligam ent, perios-
Os teoid osteoma 10–20 Men > women teu m , artery and nerve connective tissu e stru ctu res (Boisson-
nau lt & Janos 1995). It can also be the resu lt of visceral
Pancreatic cancer 50–70 Men > women p athology w ith irritation of the p arietal p eritoneu m . Tru e
Skin cancer Rarely before puberty Men = women visceral p ain is a d eep p ain felt at the site of nocicep tive
stim u lation of the affected internal organ (McCow in et al
Gallbladder dis ease 40+ Women > men
1991; Good m an & Snyd er 1995). The pred om inant clinical
Gout 40–59 Men > women p resentation of both d eep som atic and visceral p ain is the
Gynaecological 20–45 Women
associated referred pain p attern. Related to convergence of a
conditions
greater num ber of prim ary afferent neurons on a lesser
nu m ber of second ary afferent neu rons and su bsequ ent corti-
Pros tatitis 40+ Men cal m isinterp retation of the tru e location of nocicep tive affer-
Primary biliary cirrhosis 40–60 Women > men ent inpu t, the patient w ill rep ort referred pain m ore
su p er cially in tissu es that are segm entally related to the d ys-
Reiter s yndrome 20–40 Men > women functional tissu e or organ (Van d er El 2010).
Rheumatic fever 4–8; 18–30 Women > men Referred p ain p atterns have been established for m u scles
and w ill be d iscu ssed in d etail in Chap ter 59, as w ill neu ro-
Shingles 60+
p athic (inclu d ing rad icu lar) p ain. Chap ter 9 (Mechanical neck
Spontaneous 20–40 Men > women p ain) d iscu sses referral p atterns established for cervical zyga-
pneumothorax p op hyseal joints, d orsal ram i, and d iscs (Fuku i et al 1996;
Thyroiditis 30–50 Women > men Grubb et al 2000; Cooper et al 2007). Most relevant for sug-
gesting possible visceral pathology in p atients presenting
Vascular claudication 40–60+ w ith neck, thoracic and arm pain are the referral p atterns
Os teoporos is 50+ Women > men related to the card iovascular, pulm onary and gastrointestinal
Sources: Bois s onnault & Bass 1990a, 1990b; Goodman & Snyder 1995;
system s, althou gh a thorou gh exam ination even of p atients
Huijbregts 2001; South-Paul 2001. w ith pred om inant neck and arm sym ptom s cannot a priori
exclu d e pathology in other system s. Figure 3.1, therefore, p ro-
vid es visceral referral p atterns to the neck, arm and tru nk
from all system s (Boissonnault & Janos 1995).
Location and Description of Symptoms Although seriou s gastrointestinal d isease rarely causes
p ain w ithou t concom itant d igestive sym p tom s, it is im p or-
Although a patient’s chief com plaint often revolves arou nd tant to know that both a p ep tic u lcer and oesop hagitis can
p ain and p ain-related fu nctional lim itations, sym p tom s that cau se p ain in the u p p er and m id -abd om en, m id -thoracic
need to be investigated w ith regard to location and d escrip - region, anterior chest, neck and bilateral shou ld ers. The
tion also inclu d e sensory abnorm alities, strength d e cits, m echanism for referral from the stom ach and oesop hagu s to

Figure 3.1 Visceral referral patterns.
the neck and shou ld ers is related to irritation of the ad jacent
d iap hragm w ith its segm ental innervation d erived from C3
to C5 throu gh to the p hrenic nerve. The liver and pancreas
norm ally refer to the right u p p er and m id -thoracic sp ine or to
the thoracolu m bar and u p p er abd om inal region resp ectively,
bu t again through irritation of the d iaphragm can also cause
neck and shou ld er p ain, w ith the liver referring the right sid e
of the anterior, lateral and p osterior neck (Boissonnau lt &
Bass 1990a). The gallblad d er generally refers to the right
costal m argin or ep igastriu m , bu t in som e p atients also
refers pain to the bilateral or unilateral infrascap ular region
(Vestergaard -Mid d elfart et al 1998). Grieve (1994) noted that
a hiatal hernia can present w ith w id espread chest and bilat-
eral shou ld er p ain.
Card iovascu lar p athology can also be the cau se of p ain in
p atients w ith neck and arm sym ptom s. Pain originating in the
heart can refer to the face, jaw, neck, the p record ial region,
epigastriu m and less com m only the posterior thorax. Up per
extrem ity referral can be bilateral or unilateral, bu t is m ost
com m only in a left C8 d istribu tion (Boissonnault & Bass
1990b; Grieve 1994). Sw ap & N agu rney (2005) provid ed d iag-
nostic accu racy d ata for history item s related to p ain d escrip -
tion and location in the clinical d iagnosis of acu te m yocard ial
infarction (Table 3.2). Diffu se throbbing or aching pain in the
m id -back, abd om en, chest and left shou ld er m ay ind icate a
sym p tom atic aortic aneu rysm (Boissonnau lt & Bass 1990b). A
su d d en tearing chest p ain rad iating into the neck, d orsal
tru nk, abd om en and legs m ay ind icate a d issection of the
ascend ing aorta or aortic arch (Grieve 1994). Pain from inter-
nal carotid artery d issection is felt in the ip silateral frontotem -
p oral and p eriorbital region, w hereas pain from vertebral
Location and description of symptoms 25
Table 3.2 Diagnos tic accuracy data pain location a nd
de s cription in the diagnos is of acute myocardia l infa rction
Pa in de s crip tor Pos itive like lihood
ra tio (95% CI)
Inc re as e d like liho o d o f
myo c ardial infarc tio n
Radiation to right arm or s houlder 4.7 (1.9–12)
Radiation to both arms or s houlders 4.1 (2.5–6.5)
Radiation to left arm 2.7 (1.7–3.1)
Worse than previous angina or s imilar 1.8 (1.6–2.0)
Des cribed as press ure 1.3 (1.2–1.5)
De c re as e d like liho o d o f
myo c ardial infarc tio n
Des cribed as pleuritic 0.2 (0.1–0.3)
Des cribed as sharp 0.3 (0.2–0.5)
Inframammary location 0.8 (0.7–0.9)
(Adapted from Swap & Nagurney 2005.)
artery d issection is rep orted in the ipsilateral occipital region
(Triano & Kaw chu k 2006). Figu res 3.2 and 3.3 show pain refer-
ral p atterns for m ajor vascu lar stru ctu res.
The pu lm onary system prod u ces local thoracic and chest
p ain, bu t can also cau se referred p ain to the neck and shou l-
d ers. As w ith seriou s gastrointestinal pathology, noted pul-
m onary p athology in ad d ition to p ain w ill generally p resent
w ith other sym ptom s includ ing strid or, cou ghing, w heezing,
d yspnoea, hoarseness, fever or a sore throat. Pleu risy origi-
nating in the p arietal p leu ra refers to the scap u lar, axillary
and nip ple regions (Boissonnau lt & Bass 1990b; Grieve 1994).
A Pancoast tu m ou r of the ap ex of the lu ng m ay cau se neck,
shou ld er and u p per extrem ity pain in a C8–T1 d istribu tion
m im icking thoracic ou tlet synd rom e or low cervical rad icu -
lop athy (Boissonnau lt & Bass 1990b, 1990c).
With both visceral and d eep som atic stru ctu res cau sing the
sam e p oorly localized , vagu e and d eep -aching som atic p ain,
the d escrip tion or character of p ain is less relevant in the d if-
ferential d iagnosis betw een m echanical neuro-m uscu loskeletal
d ysfu nction and visceral pathology (Boissonnau lt & Bass
1990a; Good m an & Snyd er 1995). H ow ever, som e p ain
d escriptors have been suggested or show n to have d iagnostic
valu e. Pressu re-like p ain is ind icative of acu te m yocard ial
infarction, w hereas pain d escribed as sharp or p leuritic
d ecreases the likelihood of this cond ition (Sw ap & N agu rney
2005). Good m an & Snyd er (1995) suggested p ain character-
ized as knife-like, boring, colicky, com ing in w aves, or d eep
aching as p ossibly ind icative of visceral problem s. Cram ping
or colicky p ain m ay be related to the rhythm ic contraction and
relaxation of the sm ooth m u scle w all of a hollow viscus that
m ay last u p to a few m inu tes p er cycle. Throbbing, cram p ing
or aching p ain m ay also be su ggestive of card iovascu lar
involvem ent, as is pain d escribed as p ressu re, tightness or
heaviness (Boissonnau lt & Janos 1995). Tearing pain has been
associated w ith aortic d issection (Grieve 1994). A stabbing,
p u lsating, aching, thu nd erclap -like head ache m ay ind icate
cervical (vertebral and internal carotid ) artery d issection
 26 PART 1 • 3 • History taking

Figure 3.2 Vascular referral patterns: a, common carotid artery; b, subclavian artery; c, descending aorta; d, internal iliac artery, e, external iliac artery.

A Vertebral artery B Internal carotid artery

Figure 3.3 Vascular referral patterns: (A) vertebral artery, (B) internal carotid artery.

(Triano & Kaw chu k 2006). Clinicians shou ld note, how ever,
the overlap of at least a nu m ber of these pain d escrip tors w ith
p ain of m yofascial or other som atic aetiology.
Symptom Behaviour
Sym p tom behaviou r can be d e ned as a change in location,
intensity and / or qu ality of sym p tom s related to aggravating
and easing factors (Boissonnau lt & Janos 1995). When inves-
tigating sym p tom behaviou r, the clinician seeks to nd ou t
w hether sym ptom s are interm ittent, episod ic or constant, if
there is a 24-hou r or d iurnal pattern to the sym p tom s, and to
get inform ation abou t aggravating or easing factors.
Physical therap ists shou ld exp ect that p ain associated w ith
m echanical neu ro-m u scu loskeletal d ysfu nction is aggravated
and eased by p ostu res and activities. This is not to say that
the p ain and sym p tom s from m echanical d ysfu nction are
alw ays interm ittent, as esp ecially in the acute stage w here
in am m ation is pred om inant the sym ptom s can be constant,
althou gh intensity w ill still be affected by postures or activi-
ties (Boissonnau lt & Janos 1995). Episod ic sym p tom s are su g-
gestive of system ic d isease, especially a progressive pattern
w ith cyclical period s w here the p atient feels better and then

again w orse, should raise the clinician’s ind ex of susp icion
w ith regard to system ic aetiology (Good m an & Snyd er 1995).
A d iu rnal p attern w hen not related to consistent m echani-
cal aggravation (as m ay som etim es occu r w ith occu p ational
d em and s) also suggests system ic pathology. Exam ples are the
p ain related to a d u od enal u lcer that w ill consistently start
som e 2 hou rs after eating (Boissonnault & Bass 1990a). Par-
ticu larly om inou s in this regard is night p ain. In this context,
w e d o not think of the pain that w akes u p the patient bu t is
easily relieved by changing positions. Various stud ies have
reported an association of this type of night pain w ith osteo-
arthritis especially of the lu m bar, hip and knee joints (Acheson
et al 1969; Siegm eth & N oyelle 1988; Fold es et al 1992; Jonsson
& Strom qvist 1993). N ight pain becom es relevant as a red ag
ind icating the need for m ed ical referral if the patient rep orts
that this pain is the w orst p ain over a 24-hour p eriod and / or
if this night pain resu lts in their being unable, or requiring
consid erable effort, to get back to sleep (Boissonnau lt & Janos
1995; Good m an & Snyd er 1995).
Sym p tom s of visceral p athology can often be elicited and
relieved by factors that are clearly not m echanical in natu re.
We d iscu ssed above the p ain from a d u od enal u lcer occu rring
som e 2 hou rs after eating. Du od enal p ain can often be relieved
by eating again or by taking antacid m ed ication. Gastrointes-
tinal p athology shou ld be su sp ected if the p atient rep orts that
ingestion of certain food s, or food in general, precipitates or
alleviates sym p tom s. Pain in the right costal m argin or epi-
gastrium and the infrascapu lar region(s) after eating high-fat
food m ay im plicate the gallblad d er as the sou rce of pain
sym p tom s (Boissonnau lt & Bass 1990a). Pain d ecreased w ith
fasting, after a bow el m ovem ent, or after vom iting also im pli-
cates the gastrointestinal system . Ingestion of caffeine, esp e-
cially w hen com bined w ith sm oking, raises the blood p ressu re
for som e 2 hou rs, w hich m ay lead to card iovascular sym p -
tom atology in hyp ertensive p atients. Alcohol consu m p tion
and fever increase the systolic thru st and m ay elicit pain origi-
nating in arteries. Increased m etabolic d em and not related to
p hysical activity, as occu rs w ith em otion or exp osu re to
extrem e tem peratures, m ay elicit card iovascular sym ptom s
(Good m an & Snyd er 1995).
Associating sym ptom s aggravated w ith postures and
activities solely w ith benign m echanical d ysfu nction is,
how ever, a d angerou s oversim p li cation of the clinical p ictu re
(Grieve 1994). Activity-related card iovascular sym ptom s
includ ing vascu lar claud ication and pain d u e to coronary
ischaem ia in patients w ith coronary artery d isease or pu lm o-
nary system p ain from the p leu ra and trachea w ith resp ira-
tory m ovem ent requ ire no fu rther exp lanation. Perhap s less
obviou s is p ain d u e to d istension of a hollow organ aggra-
vated by increased intra-abd om inal p ressu re and relieved by
p ositions that red u ce pressu re or su pport the painfu l organ.
For exam ple, the pain from acu te gallblad d er d istension
d ecreases w ith slight trunk exion, w hereas exion and ipsi-
lateral sid e-bend ing m ay relieve kid ney pain. Seated exion
or bringing the knees to the chest in su p ine m ay d ecrease
p ancreatic p ain. Bend ing over increases the systolic thru st and
m ay aggravate p ain arising from arteries (Good m an & Snyd er
1995). The pain from pericard itis is aggravated by coughing
or changing p osition and relieved by leaning forw ard .
Pain w ith sw allow ing or breathing m ay be related to the
m echanical com p ression of the oesop hagu s or bronchi cau sed
by an aortic aneu rysm . Although d ysp noea w ou ld lead a
Symptom history 27
Table 3.3 Diagnos tic accuracy data s ymptom be ha viour (a nd
as s ociate d s ymptoms ) in the diag nos is of acute myocardial
infarction
Symp tom be ha viour Pos itive like lihood
ra tio (95% CI)
Inc re as e d like liho o d o f
myo c ardial infarc tio n
Associated with exertion 2.4 (1.5–3.8)
Associated with diaphoresis 2.0 (1.9–2.2)
Associated with nausea or vomiting 1.9 (1.7–2.3)
De c re as e d like liho o d o f
myo c ardial infarc tio n
Des cribed as pos itional 0.3 (0.2–0.5)
Reproducible with palpation 0.3 (0.2–0.4)
Not ass ociated with exertion 0.8 (0.6–0.9)
(Adapted from Swap & Nagurney 2005.)
clinician to su sp ect card iovascu lar or p u lm onary p athology, a
p atient rep ort of noctu rnal shortness of breath relieved by
sitting u p or sleep ing w ith m u ltip le p illow s (orthop noea)
shou ld raise even greater su sp icion. Sw ap & N agu rney (2005)
p rovid ed d iagnostic accu racy d ata for history item s related to
(non)-m echanical sym ptom behaviour in the clinical d iagno-
sis of acu te m yocard ial infarction (Table 3.3). One system
often overlooked w hen screening for p athology u sing a
system s ap p roach is the m u scu loskeletal system ; system ic
in am m atory cond itions, infection and fractures are all likely
to be aggravated and eased m echanically and m ay thereby be
m istaken for benign m echanical d ysfu nctions (Boissonnau lt
& Bass 1990c).
An inventory of pain sym ptom behaviou r also serves the
p u rp ose of id entifying lim itations in activities and restrictions
in particip ation resu lting from d ysfu nction or pathology. This
w ay the clinician gets an im pression of severity, w hich is the
su bjective id enti cation of how signi cantly the p atient has
been affected by this cu rrent health problem . In ad d ition,
qu estioning the p atient w ith regard to sym p tom behaviou r
also provid es the clinician w ith inform ation on irritability.
Irritability or reactivity is a concep t that tries to quantify how
stable a cond ition is – in other w ord s, how qu ickly d oes a
stable p resentation d egenerate in the p resence of aggravating
factors? Irritability is a three-d im ensional concep t. The clini-
cian collects inform ation not only (1) on aggravating factors
but also (2) on d uration and severity of a cond ition once
aggravated and (3) on w hat the patient need s to d o to again
relieve or d ecrease sym p tom s (Cook 2007).
Symptom History
In the sym ptom history portion the therapist constru cts a
chronological d escrip tion of the cu rrent health p roblem
inclu d ing inform ation on onset, changes in sym p tom s since
onset, and treatm ent received for the cu rrent p roblem
(Boissonnault & Janos 1995). This allow s d eterm ination of
 28 PART 1 • 3 • History taking
the stage of the health p roblem , w hich re ects the p atient’s
interp retation of cu rrent com p laints and im p airm ents as com -
p ared w ith a given p oint in the past. H ealth problem s can be
w orse, better or the sam e w ith regard to sym ptom s and
im p act on fu nction, lead ing the clinician to characterize a
cond ition as stabilized , stagnated or p rogressed (for better or
w orse). Together w ith inform ation on severity and irritability
gained from the sym ptom behaviou r portion, know led ge
w ith regard to the stage of a cond ition d eterm ines precau tions
w ith regard to su bsequ ent exam ination and guid es m anage-
m ent (Cook 2007). If the stage, severity and irritability of a
cond ition d o not m atch the exp ected norm al cou rse of a
m echanical d ysfu nction of trau m atic aetiology, w here an
acu te in am m atory stage w ith m od erate to high severity and
high irritability is follow ed by a p rogressively less irritable
and severe su bacu te and / or chronic stabilized , stagnated or
im p roved p resentation, system ic p athology m ay be su sp ected .
Likew ise, a cyclical or ep isod ic p resentation shou ld raise su s-
p icion w ith regard to non-m echanical p roblem s.
Althou gh clinicians m ight associate an insid iou s, slow, pro-
gressive onset m ore w ith system ic pathology and a clear trau-
m atic m echanism of acu te inju ry w ith m echanical d ysfu nction,
the clinician need s to consid er system ic p athology even w hen
com p laints seem to have been brou ght on acu tely by trau m a.
For exam ple, pathological fractures in bones w eakened by
osteop orosis, osteom alacia, infection and tu m ou rs m ay resu lt
from sim ilar traum atic m echanism s that can also cause
m echanical neu ro-m u scu loskeletal d ysfu nctions (Boisson-
nau lt & Janos 1995). Acute-onset m onoarthritis has to be con-
sid ered infective u ntil p roven otherw ise (Woolf & Åkesson
2008). In contrast, m echanical d ysfu nctions related to overu se
or chronic p ain synd rom es associated w ith p erip heral and
central sensitization are characterized by an insid iou s onset
and a slow, p rogressive presentation.
Collecting inform ation on the natu re and the resu lts of
p reviou s treatm ents p rovid es gu id ance w ith regard to m an-
agem ent. After all, rep licating previou sly u nsu ccessful treat-
m ent m akes little sense. H ow ever, w hen the p atient rep orts
no im p rovem ent d esp ite seem ingly app rop riate p reviou s
treatm ents then once again the ind ex of susp icion for system ic
p athology is raised (Good m an & Snyd er 1995).
Medical History
In the m ed ical history portion the physical therapist collects
inform ation on the p atient’s cu rrent and p ast illnesses, hosp i-
talizations, fam ily m ed ical history, m ed ication u se, su bstance
abu se, nu tritional status and m ed ical tests and resu lts.
Cu rrent illnesses m ay affect p hysical therap y d iagnosis,
p rognosis and m anagem ent (Boissonnau lt & Janos 1995). Car-
d iovascular and pu lm onary pathology of course often affect
exercise tolerance. Althou gh less acutely, gastrointestinal
p athology, esp ecially if it resu lts in m alabsorp tion, also lim its
how m u ch exercise a p atient can p erform . Know led ge of p ast
and concu rrent illnesses affects d iagnosis. A m ed ical history
of p reviou s cancer w ith a p resentation not ind icative of
m echanical d ysfu nction shou ld raise the clinician’s ind ex of
su sp icion. Metastases from p rim ary tu m ou rs in the p rostate,
lu ng, breast, kid ney and colon p referentially occu r in the
sp ine (Boissonnau lt & Bass 1990c). In fact, patients w ith breast
cancer have an 85% lifetim e incid ence of bony m etastases,
especially in the thoracic spine (Greenhalgh & Selfe 2004). A
history of, for exam p le, rheu m atic fever increases the risk of
valvu lar heart d isease (Boissonnault & Bass 1990b). Previous
su rgery, even in the absence of constitu tional sym p tom s,
carries an increased risk of iatrogenic infection u p to several
m onths after the su rgery. Cancer, certain card iovascu lar con-
d itions, d iabetes, osteoporosis and kid ney d isease all have a
fam ilial tend ency (Boissonnault & Bass 1990a). A thorough
qu estioning w ith regard to m ed ication often u ncovers ad d i-
tional concu rrent p athology bu t, conversely, the therap ist
also need s to be aw are of ad verse effects of m ed ication that
m ay m im ic m echanical d ysfu nction or p red isp ose the p atient
to p athology. The d ep th and bread th of know led ge requ ired
for the therapist to elicit and be able to interpret a com -
p rehensive m ed ical history is w ell illu strated w hen, for
exam ple, review ing the variou s causes d escribed for second -
ary osteoporosis as one of the relevant pathologies to be con-
sid ered in p atients com p laining of neck, tru nk and arm p ain
(Box 3.2).
The m ed ical history m ay also provid e less om inous prog-
nostic ind icators. Concu rrent chronic p ain at sites other than
the arm increases the risk of arm pain continu ing u p to 12
m onths after initial onset (OR 1.6–2.4 based on the site of pain)
(Ryall et al 2007). Shou ld er pain concom itant w ith neck p ain
ind icates a poorer prognosis for resolu tion of the neck pain
(McLean et al 2007). Concom itant neck pain is a pred ictor of
shou ld er pain at 6 w eeks, w hereas concom itant low back
p ain is a p red ictor for continu ed should er pain at 6 m onths
(Kuijpers et al 2006). Concom itant low back pain also serves
as a poor p rognostic ind icator in patients w ith neck p ain (H ill
et al 2004; H oving et al 2004). Previou s neck pain ind icates a
p oorer p rognosis for occu p ational neck p ain (Carroll et al
2008b) and a higher risk of chronic pain post-w hiplash injury
(OR 1.7, 95% CI 1.17–2.48) (Walton et al 2009).
Although patients are less likely to freely d iscuss this, the
therap ist need s to also be attentive of ind ications of su bstance
abu se. Excessive alcohol u se increases not only the risk of
osteop orosis bu t also that of cirrhosis and neu rod egenerative
cond itions. It can also cau se osteonecrosis and su bsequ ent
p athological fractu res. The therap ist also need s to be aw are
of an alcohol-related altered p ercep tion of p ain and fatigu e
and of the interaction of alcohol w ith nu m erous m ed ications
(Good m an & Snyd er 1995; H uijbregts 2000; H uijbregts &
Vid al 2004). As an exam ple of the effects of illicit d rugs,
cocaine and am p hetam ines increase the p rod u ction of ad rena-
line (epinephrine) causing system ic vasoconstriction, resu lt-
ing in increased blood pressure and possibly seizures,
d ysrhythm ia and tachycard ia. Cocaine use has also been asso-
ciated w ith an increased risk of stroke, aortic ru p tu re, p u lm o-
nary oed em a and clotting d isord ers (Good m an & Snyd er
1995). Intravenous d ru g use increases the chances of blood -
borne infections (Boissonnault & Bass 1990c). Card iovascular
health risks of sm oking need no fu rther d iscu ssion, bu t
sm oking also increases the risk of gastrointestinal p athology
and osteoporosis (Boissonnau lt & Bass 1990a; H u ijbregts 2001;
Sou th-Pau l 2001). Sm oking also generally retard s m u scu-
loskeletal healing. For exam ple, a cu rrent sm oking habit is a
p oor prognostic ind icator for continu ed arm pain at 12 m onths
(OR 3.3, 95% CI 1.6–6.6) (Ryall et al 2007).
N u tritional statu s affects d iagnosis and p rognosis and the
therap ist need s to have at least a basic know led ge base in this
area. General m alnu trition in the sense of insuf cient d ietary
 Systems review 29

Bo x 3 .2 S e c o n d a ry c a u s e s o f o s te o p o ro s is

Nutritio nal de c ie nc ie s Bo ne marro w dis o rde rs

• Excess ive cons umption of phos phates, oxalates, alkalis, • Diss eminated carcinoma
fatty acids, dietary bre, proteins, re ned sugar, caffeine, • Haemolytic anaemias
alcohol and sodium • Leukaemia
• Insuf cient intake of calcium and / or vitamin D • Lymphoma
Endo c rine dis e as e s • Multiple myeloma
• Acromegaly • Systemic mas tocytosis
• Anorexia nervos a Co nne c tive tis s ue dis e as e s
• Athletic amenorrhoea • Ehlers–Danlos s yndrome
• Cystic brosis • Glycogen storage diseases
• Delayed puberty • Homocystinuria
• Diabetes mellitus (untreated) • Hypophos phatas ia
• Female hypogonadis m • Marfan syndrome
• Growth hormone de ciencies • Osteogenesis imperfecta
• Haemochromatos is Me dic atio n
• Hypercortisolism (Cushing dis eas e) • Anticonvuls ants
• Hyperparathyroidis m • Chemotherapy
• Hyperprolactinaemia • Ciclos porin
• Hyperthyroidism • Glucocorticoids
• Hypothalamic amenorrhoea • Gonadotrophin-releas ing hormone (GnRH) agonis ts
• Idiopathic hypogonadotrophic hypogonadis m • Heparin
• Klinefelter s yndrome • Methotrexate
• Male hypogonadis m • Phenobarbital
• Oophorectomy • Phenothiazines
• Premature and primary ovarian failure • Thyroxine
• Primary gonadal failure Mis c e llane o us
Gas tro inte s tinal dis e as e s
• Immobilization
• Alactasia • Rheumatoid arthritis
• Chronic obs tructive jaundice • Smoking
• Malabsorption s yndromes
• Primary biliary cirrhosis and other cirrhoses
• Subtotal gas trectomy
(Sources : Huijbregts 2001; South-Paul 2001.)

glu cose and protein intake retard s m u sculoskeletal healing,

bu t high-p rotein d iets u sed to com bat m alnu trition especially
in the eld erly can cau se d ehyd ration, w hich also im p airs
healing (Posthau er 2006). Am ino acid d e ciencies (e.g.
arginine, m ethionine and glutam ine) negatively affect the
cou rse of the norm al in am m atory p rocess. De ciencies in the
trace m inerals m anganese, cop p er, calciu m , m agnesiu m and
iron d ecrease collagen synthesis. De ciencies in zinc and vita-
m ins A, B, C and E im p air the im m u ne resp onse relevant to
m u scu loskeletal healing (Arnold & Barbu l 2006; Broughton
et al 2006; Cam p os et al 2008). If nutritional d e ciencies are
su ggested in the history then a nu tritional w ellness assess-
m ent by the therap ist and , if ind icated , referral to a d ietitian
are ind icated (Fair 2010).
Finally, the therapist shou ld ask the patient about m ed ical
d iagnostic p roced u res that m ay have been d one (e.g. im aging,
blood w ork, u rinalysis, electrod iagnosis, cerebrospinal uid
analysis and biopsies). Know ing w hich tests have alread y
been d one w ith know led ge of their nd ings is obviously
help fu l in d iagnosis and m anagem ent.
Systems Review
Screening for system ic p athology occu rs as p art of the history
and physical exam ination bu t also throughou t the m anage-
m ent p rocess, w here w e continu ou sly m onitor the p atient’s
cond ition and also resp onse to seem ingly ap p rop riate treat-
m ent (Cook 2007). We have d iscussed how therap ists screen
for m ed ical d isease at the system s level, u nlike m ed ical physi-
cians, w ho seek to d iagnose p atients at the d isease level
(Boissonnault & Janos 1995). Despite this d istinction, the ther-
ap ist need s to have consid erable acu m en w ith regard to
know led ge of pathology so as to screen optim ally even at the
system s level.
The m ed ical-screening or system s review portion of the
history (and p hysical exam ination) serves a nu m ber of p u r-
p oses. First and forem ost, by w ay of ru ling ou t system ic
p athology it allow s for su f cient con d ence that a p atient
p resentation is in fact based on a m echanical neu ro-
m u scu loskeletal d ysfu nction and , therefore, m ay p ose an
 30 PART 1 •
Bo x 3 .3 C h e c klis t fo r re vie w o f g e n e ra l h e a lth
s ta tu s
• Fever / chills
• Unexplained perspiration
• Night sweats
• Recent infection
• Unexplained weight change
• Malais e
• Nausea / vomiting
• Bowel dysfunction
• Numbness
• Weakness
• Pallor
• Dizzines s / lightheadedness
• Syncope
• Night pain
• Dif culty in breathing
• Dif culty urinating
• Urinary frequency changes
• Sexual dysfunction
(Sources : Bois s onnault & Janos 1995; Goodman & Snyder 1995.)
ind ication for p hysical therap y m anagem ent. Second ly, the
system s review m ay raise the ind ex of su sp icion w ith regard
to a system ic aetiology of the p atient p resentation and ind i-
cate the need for referral for m ed ical–surgical evalu ation.
Starting a system s review w ith a list of general health statu s
ind icators, either as p art of the patient–therap ist face-to-face
encounter or in the form of an intake questionnaire review ed
p rior to the exam ination by the clinician, can ind icate the need
for a m ore in-d epth system s review (Box 3.3). A num ber of
these general health statu s ind icators have been d iscu ssed
above and som e retu rn in m ore speci c system s-based qu es-
tions. Fever and night sw eats are characteristic sym p tom s of
system ic d isease. Weight loss of 10% over a 4-w eek p eriod not
related to lifestyle changes (d iet, exercise) m ay ind icate d ia-
betes, hyperthyroid ism , d epression, anorexia nervosa or neo-
p lastic d isease. H ow ever, an u nexp lained w eight gain m ay
also be relevant in that it can be the result of congestive heart
failu re and again neoplastic d isease or hyperthyroid ism
(Good m an & Snyd er 1995). The need for a m ore in-d epth
system s review becom es greater if, as the history taking
p rogresses, other p ortions of the history as d iscussed above
also yield ind icators of system ic aetiology or contribu tion to
p atient presentation. Althou gh no such list can ever be com -
p rehensive, Table 3.4 provid es su ggestions for m ore speci c
system s-based qu estions. Positive nd ings on any of the qu es-
tions in the system s-based review shou ld again p rom p t
fu rther investigation. Table 3.5 provid es an exam ple for
fu rther investigation of ind icators for the need for u rgent
m ed ical referral (red ags) in the case of a p atient rep orting
head ache (H u ijbregts 2009).
The third and nal p u rp ose of m ed ical screening is to also
p rovid e the clinician w ith inform ation on system ic p athology
that can affect p rognosis / rehabilitation potential or that d ic-
tates choice and p rogression of p hysical therap y interventions
(Boissonnau lt & Janos 1995).
3 • History taking
Bo x 3 .4 Dia g n o s is o f p a n ic d is o rd e r
S ig ns and s ympto ms (diag no s is re quire s fo ur)
• Sweating
• Rapid heart rate, palpitations, pounding heart
• Tremor
• Shortness of breath
• Feeling of choking
• Chest pain
• Naus ea / abdominal dis tress
• Dizziness
• Lightheadedness
• Feeling of unreality
• Fear of los ing control
• Fear of dying
• Paraesthesiae
• Hot ashes
As s o c iate d s ig ns and s ympto ms
• Ins omnia
• Anxiety
• Depres sion
• Chronic fatigue
• Gastro-oes ophageal re ux
(Adapted from Huijbregts & Vidal 2004.)
Relevant to the d ifferential d iagnosis of a m u ltitu d e of
sym p tom s su ggestive of visceral p athology and w ithin the
context of screening for p sychosocial factors in p atients w ith
neck and arm p ain is the d iagnosis of p anic d isord er (Box 3.4)
(H u ijbregts & Vid al 2004). Psychosocial factors often serve as
p rognostic ind icators. Dep ression is an ind ep end ent risk
factor for d eveloping su bsequent low back or neck pain
(Carroll et al 2004) bu t also pred icts poorer ou tcom e after
cervical w hip lash inju ry (Carroll et al 2008c). Passive coping
and fear of m ovem ent also serve as poor p rognostic ind icators
after w hip lash injury (Carroll et al 2008c) and fear of m ove-
m ent is also a consistent im p ed im ent to recovery from su b-
acute neck p ain at both the 12- and 52-w eek m arks (Pool et al
2010). Fear of m ovem ent can be quanti ed using the Tam p a
Scale of Kinesiop hobia tool (Vlaeyen et al 1995). It w ill also
serve the clinician w ell to be fam iliar w ith the p resentation of
d ep ression (Box 3.5). Arroll et al (2003) rep orted a sensitivity
of 97% and a sp eci city of 67% in the clinical d iagnosis of
d ep ression in prim ary care for the follow ing tw o qu estions:
1. During the last m onth have you often been bothered by
feeling d ow n, d epressed , or hopeless?
2. During the last m onth have you often been bothered by
little interest or p leasu re in d oing things?
Although as therapists w e tend to concentrate on m echanical
d ysfu nction of the m uscu loskeletal system , in ou r system s
review w e shou ld not overlook the p ossibility of m u sculoskel-
etal pathology includ ing fractu res and infectious, in am m a-
tory and neop lastic d isease. Ind icators for neop lastic d isease
have been d iscu ssed above. Chap ter 11 d iscu sses cervical
m yelop athy as a d ifferential d iagnostic p ossibility in p atients
w ith neck and arm pain. In this era of d irect access to physical
 Systems review 31

Table 3.4 Sugge s te d que s tions for s ys te ms re vie w

Sys te m Que s tions

Cardiovascular Do you ever experience ches t pain (angina)?

Do you experience exces sive unexplained fatigue?
Do you have shortnes s of breath?
Do you ever note chest palpitations?
Have you noted lightheadedness ?
Have you ever fainted?
Do you experience widespread leg pains ?
Have you noted swelling in the feet, ankles or perhaps the hands?
Pulmonary Do you ever experience ches t pain?
Do you have shortnes s of breath?
Have you been coughing more lately?
Have you noticed a change in your breathing?
Do you have dif culty catching your breath when lying at; do you have to s leep propped up on multiple pillows ?
Gas trointes tinal Have you had dif culty swallowing?
Have you noticed intolerance to s peci c foods ?
Have you had abdominal pain?
Has your stool been black in colour?
Have you had rectal bleeding?
Has your stool been different in cons istency (diarrhoea, tarry stool)?
Have you been cons tipated?
Genitourinary Any dif culty urinating?
Have you noted blood in your urine?
Have you noted an increas ed frequency with regard to urination?
Have you noted an increas ed urgency with regard to urination?
Have you noted an increas ed dif culty with initiating urination?
Have you noted decreased force with urination?
Have there been epis odes of impotence?
Have there been any changes with regard to menstruation?
Have you experienced pain with intercourse?
Have you noted incontinence for urine and / or stool?
Integumentary Have you recently experienced any ras hes?
Have you noticed any enlargement or bleeding of moles?
Have you noted any itching or burning of the s kin?
Have you noticed any areas of blis tering?
Neurological Have you been experiencing headaches or vis ion changes ?
Have you noted dizziness or vertigo?
Have you been experiencing seizures or uncons cious nes s?
Do you ever experience weakness or paraes thesiae?
(Sources : Bois s onnault & Bas s 1990a; Goodman & Snyder 1995; Flynn et al 2008.)

therap y services, therap ists need to be able to screen for the

Bo x 3 .5 S ym p to m s a s s o c ia te d w ith d e p re s s io n p resence of fractu res. With regard to cervical sp ine inju ries,
• Persis tent sadness or feelings of emptiness both the N EXUS (N ational Em ergency X-rad iography Utiliza-
tion Stu d y) and the Canad ian cervical (C)-sp ine ru le need to
• Sense of hopeless nes s
be consid ered (Eyre 2006). The N EXUS rule recom m end s
• Frequent or unexplained crying spells cervical p lain- lm rad iograp hy u nless all ve criteria below
• Problems with s leeping are m et:
• Feelings of guilt
1. Absence of p osterior m id line cervical sp ine tend erness
• Los s of interes t or pleas ure in normal activities 2. N o evid ence of intoxication
• Fatigue or decreas ed energy 3. N orm al level of alertness / consciou sness
• Dif culty in concentrating, remembering and decision 4. Absence of focal neu rological d e cit
making
5. Absence of d istracting inju ries.
• Appetite los s (or overeating)
Althou gh the N EXUS rule has show n a sensitivity of 99.6%
(Adapted from Goodman & Snyder 1995.) and a sp eci city of 12.9% and also 100% sensitivity in sep arate
 32 PART 1 • 3 • History taking

Table 3.5 Re d a g indica tors in the his tory ta king of patie nts with he adache s indicating the ne e d for urge nt re fe rral
Fa ctor ‘Re d f a g’ ind ica tors

Demographics New onset of headache or change in existing headache pattern in patients over 50
Location of pain Pers istent unilateral location of headaches
Onset and cours e of New-ons et headache
headache Ons et of a new headache type
Unexplained change for the wors e in pattern of exis ting headache
Progres sively wors ening headache
Abrupt, split-second onset of headache: thunderclap headache
Character and intensity of New pain level, especially when described as worst-ever
headache Clus ter-type headache
Aggravating and easing Headache aggravated or brought on by phys ical exertion, coughing, s neezing, s training or s exual activity
factors Noted effect of position changes on pain
No response to s eemingly appropriate treatment
Neurological symptoms Seizures , confus ion, changes in alertness , apathy, clumsiness , unexplained inappropriate behaviour,
brainstem symptoms , bowel and bladder s ymptoms , neck exion s tiffness , aura preceding the
headache (especially one with quick diffus ion), or weakness (not cons istent with an exis ting diagnos is
of migraine headaches or other pathology explaining thes e symptoms)
Pre-s yncope or syncope s tarting off headache
Otolaryngological s ymptoms Ass ociated eye pain and s imultaneous vision changes
Systemic s ymptoms Fever, weight loss , temporal artery tenderness , profuse vomiting (es pecially when not as sociated with
nausea), photophobia, phonophobia, or developing rash (not cons istent with an exis ting diagnosis of
migraine headaches )
Headache that awakens a patient from night sleep (especially in children)
Medical his tory Medical his tory of cancer and human immunode ciency virus (HIV) infection
Head or neck injury
Uncontrolled hypertens ion
Medication history Us e of anticoagulant medication in combination with even minor trauma
Family history Absence of a family his tory of migraine in children with migraine-like s ymptoms
(Adapted from Huijbregts 2009.)

stu d ies in a geriatric and a p aed iatric p op u lation, w ith d is- Table 3.6 ORAI s coring s ys te m
tracting inju ries d e ned as long-bone fractu res, d egloving
inju ries, and extensive bu rns and lacerations, it w as obviou sly Va ria b le Score
d eveloped and valid ated in an em ergency room and not in a
p rim ary care p hysical therap y setting (Eyre 2006). The Cana- Ag e (ye ars )
d ian C-spine rule, although su ffering from the sam e spectrum ≥ 75 15
bias and thereby expected to overestim ate sensitivity and
65–74 9
u nd erestim ate sp eci city w hen ap p lied in a p hysical therap y
p rim ary care setting (Cook et al 2007), still seem s m ore rele- 55–64 5
vant to therap ists (Fig. 3.4). When com pared in nine Canad ian 45–54 0
em ergency d epartm ents the Canad ian C-spine rule show ed
99.4% sensitivity and 45.1% speci city, versu s 90.7% sensitiv- We ig ht (kg )
ity and 36.8% sp eci city for the N EXUS rule (Eyre 2006). < 60 9
We d iscu ssed osteop orosis in the m ed ical history p ortion
60–69 3
above (see Box 3.2). Cad arette et al (2000) d evelop ed the Oste-
op orosis Risk Assessm ent Instru m ent (ORAI) (Table 3.6). ≥ 70 0
Screening w om en w ith a score ≥ 9 yield ed a sensitivity of Curre nt o e s tro g e n us e
93.3% (95% CI 86.3–97.0%) and a speci city of 46.4% (95% CI
41.0–51.8%) for osteop enia. The sensitivity for a d iagnosis of Yes 0
osteoporosis w as 94.4% (95% CI 83.7–98.6%). A score < 9 on No 2
this instru m ent w ou ld thu s seem to red u ce the likelihood of
(Adapted from Cadarette et al 2000.)
a susp ected osteop orotic fractu re in fem ale p atients.
We d iscu ssed su rgery as a risk factor for su bsequ ent blood -
borne or haem atogenou s infection. Recent infection w as an

≥ 3.3). Risk factors for, for exam ple, d iscitis also includ e intra-
Figure 3.4 Canadian cervical-spine rule.
Table 3.7 Clinical ndings in s e rone ga tive s pondyloarthropa thie s
Dis e a s e
Ankylos ing s pondylitis
Psoriatic arthritis
Enteropathic arthritis
Reiter s yndrome
(Sources : Katz & Liang 1991; McCowin et al 1991.)
Systems review 33
item includ ed in ou r general health status checklist (see Box
venou s d ru g u se and im m u nosu p p ression (as occu rs for
exam ple in patients w ith AIDS and H IV). Infection can also
lead to vertebral osteom yelitis. Risk factors for pyogenic
(bacterial) osteom yelitis includ e (Vincent & Benson 1991;
H eggeness et al 1993):
• intravenous d ru g use
• d iabetes
• u rinary tract infection
• stab w ou nd s
• gunshot w ou nd s
• sickle cell d isease
• im m u nod e ciency
• pre-existing paraplegia
• non-operatively treated thoracolu m bar fractu res
• m etal im plants
• polym ethylm ethacrylate
• u rology or d ental proced u res in patients w ith m etal
≥ im plants w ithout antibiotic prop hylaxis.
The m ost com m on system ic in am m atory d iseases relevant
to p atients w ith neck and arm p ain inclu d e rheu m atoid arthri-
tis and seronegative sp ond yloarthrop athies. Pathological
changes in sp ond yloarthrop athies involve joints bu t also
entheses or insertions of ligam ents, tend ons and capsu le to
the bone. Esp ecially these enthesop athies and initially the
sp inal articu lar m anifestations m ay be m istaken for m echani-
cal d ysfu nctions in p atients w ith neck and arm p ain. Table 3.7
Clinica l p re s e nta tion
Affects s acroiliac, zygapophyseal and cos tovertebral joints
Pain in heels , is chial tuberos ities, iliac crests, humeral epicondyles, and shoulders
Nocturnal pain
Morning pain and s tiffnes s
As ymmetric peripheral arthritis yet often symmetric arthritis in both hips
Uveitis with pain and photophobia
As ymmetric oligoarthritis, symmetric polyarthritis
Back or peripheral joint initial s ymptom
Unilateral sacroiliac involvement
More frequent in patients with ps oriatic s kin involvement
Occurs in patients with Crohn diseas e or ulcerative colitis
Morning pain and s tiffnes s
Affects s acroiliac, zygapophyseal and cos tovertebral joints
May include periostitis, os teonecros is, septic hip arthritis , granulomatous in ammation of the bone, synovium
and muscle
May include ulceration of the perineum, oropharynx and rectum
Erythema nodos um and pyoderma gangrenosum
Can develop after or during infection els ewhere in body
Lumbopelvic and lower limb arthritis
Genitourinary s ymptoms: mucopurulent discharge, dys uria, vaginitis , cervicitis
Ocular dis ease: conjunctivitis or iritis
Systemic s ymptoms: fever, anorexia, weight los s, fatigue
Heel pain, Achilles tendonitis, dactylitis
Mucocutaneous lesions of oropharynx, soles , palms and nails
 34 PART 1 • 3 • History taking
p rovid es inform ation on clinical nd ings in p atients w ith
in am m atory joint d isease (Katz & Liang 1991; McCow in et al
1991).
Conclusion
H istory taking is inextricably linked to physical exam ination
in the exam ination p hase of p atient m anagem ent. Althou gh
variou s ap p roaches to p atient m anagem ent w ithin p hysical
therap y d iffer w ith regard to the sp eci c inform ation they
seek to collect d u ring history taking, the ord er in w hich they
collect these d ata and the im p ortance they p lace on them ,
clinicians can still id entify six consistent and d istinct catego-
ries in all history taking. Within this chapter w e have
ad d ressed this general content of history taking w ith speci c
attention to the system s review com ponent and to screening
for system ic pathology in patients w ith neck and arm pain
d uring their history. Subsequ ent chapters w ill ad d ress in
m ore d etail the history nd ings speci c to the d ysfu nctions
d iscu ssed . With a p aucity of d ata on d iagnostic accuracy rel-
evant to history item s, history taking still heavily relies on
extrapolation of basic science know led ge, experience and
authority-based know led ge. Rather than d evalu ing the role of
the history w ithin the evid ence-inform ed p arad igm as a resu lt
of this absence of d iagnostic accu racy research, this chap ter
has sought to ind icate the d ep th and bread th of know led ge
required from the clinician w hen the goal is to elicit from the
p atient a com p rehensive and clinically u sefu l history.
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 PART 1 •  General Introduction
4  Chapter 
History Taking for Patients with Lower Extremity Syndromes
M e g a n Bu rro w b rid g e Do n a ld s o n , Kris tin a Ave re ll
CHAP TER CONTENTS
Purpose of the interview  36
Communication style and approach  37
Medical interview content  37
Systems review and differential diagnosis inquiry  37
Neurological screen  38
Cardiovascular screen  38
Gastrointestinal screen  39
Non-mechanical pathologies: differential diagnosis  39
Psychosocial factors  40
Red  ags  40
Symptom investigation  40
Nature and behaviour of the problem  41
History-taking questions speci c to lower extremity   both the clinician and the patient (Ed w ard s et al 2004). The
pain syndromes  42
Central and peripheral nerve sensitization  42
Speci c low-back-associated musculoskeletal   w ell-structured history-taking practice involving a screening
pain syndromes  42
Lumbar spinal stenosis  42
Nerve root compression / radiculopathy  43
Lumbar disc herniation  43
Clinical lumbar instability  43
Speci c lower-extremity-associated musculoskeletal   There are a variety o m ed ical interview ap proaches
pain syndromes  43
Hip osteoarthritis  43
Other hip pathology  43
Knee osteoarthritis  43
Patellofemoral pain syndrome  43
Knee meniscal injury  44
Knee ligamentous injury  44
Achilles tendinopathy  44
Heel pain / plantar fasciitis  44
Conclusion  44
Purpose of the Interview
Within the United States, m ost states allow p hysical therap ists
to evalu ate p atients w ithou t a re erral rom another health-
care p ro essional. The m ajority o those states u rther im p rove
accessibility by allow ing physical therapists to evalu ate and
treat, u nd er certain cond itions, p atients w ithou t a re erral.
Patients w ith low er extrem ity synd rom es m ay p resent w ith a
m yriad o clinical p resentations or p hysical therap y to d i -
erentiate; som e m ay be w ell d ef ned and som e range to very
com p lex. In m any instances, p hysical therap ists are involved
in prim ary care settings that require ad vanced skill sets o
d i erential d iagnosis and d ecision m aking to treat this popu -
lation app ropriately.
The exam ination p rocess has three com ponents that are
closely related , in that they o ten occu r concu rrently: (1)
p atient history, (2) system s review and (3) tests and m easu res
(Jarvik & Deyo 2002). A thorough exam ination beginning
w ith a w ell-constru cted interview that helps to d evelop a plan
or the physical exam ination can provid e d iagnostic value or
m ed ical interview is a critical com p onent o an exam ination
or d ecision m aking, screening and d i erential d iagnosis. A
p rocess and / or d i erential d iagnosis p rovid es critical in or-
m ation regard ing the general health statu s, li estyle and w ell-
being o the patient. Although the m ed ical interview occurs
in m ost m ed ical interactions, it rem ains w id ely u nd erstu d ied
w ith respect to the best typ e o app roach and the m ost accu-
rate questions or yield ing a d iagnosis.
d escribed w ithin the literature. H ow ever, a patient-centred
ap proach or collaborative interview is a style o interview ing
that has led to better interventions and im p roved p atient ou t-
com es (Dw am ena et al 2012).
Centring the care arou nd the p atient encou rages: (a) shared
control o the consu ltation, d ecisions abou t interventions or
m anagem ent o the health p roblem s w ith the p atient, and / or
(b) a ocu s in the consu ltation on the patient as a w hole person
w ho has ind ivid u al pre erences situated w ithin social con-
texts (Dw am ena et al 2012). This can be a challenge or every
clinician, and althou gh it is learned d u ring entry-level ed u ca-
tion, it is not enou gh sim p ly to learn these skills w ithou t
signif cant p ractice (Beck et al 2002). Cu rrent literature pro-
vid es evid ence that clearly illu strates the u nd am ental rela-
tionship s existing betw een e ective com m u nication and
the qu ality o w orking relationship s, the d egree o p atient
sa ety, and the satis action levels both o the p atient and
o the healthcare p rovid ers (Walter et al 2005; Asnani 2009;
Dw am ena et al 2012).

Communication Style and Approach
Although there are m any pu rposes to taking an e ective
history, the style and ap p roach in w hich the m ed ical inter-
view or history taking is cond u cted ap p ears to im p act on the
patient’s clinical outcom e based on system atic review and
m eta-analysis (H enry et al 2012). The interview is a p rocess
o the clinician seeking in orm ation, re ective listening and
exploration o a variety o related m ed ical cond itions based
on the p atient’s clinical p resentation / sym p tom s (Taylor
2009). The Calgary–Cam brid ge gu id es provid e su ggestive
m od els or cond u cting the m ed ical interview and are u sed
w id ely throughou t Eu rope and N orth Am erica or teaching
and assessm ent (Ku rtz et al 2003; Silverm an et al 2011). These
guid es have been presented and su bstantiated w ithin the lit-
eratu re and should be consid ered or ed ucational training o
clinicians and or u se in clinical p ractice. These interview
guid es sim ultaneously provid e structure and em phasize rela-
tionship bu ild ing w ith the p atient (Kurtz & Silverm an 1996;
Ku rtz et al 1998). The basic p rocess inclu d es: (1) initiating the
session, (2) gathering in orm ation, (3) per orm ing the p hysical
exam ination, (4) exp lanation and p lanning, and (5) closing the
session. Continu ou s attention to p rovid ing stru ctu re to the
interview and bu ild ing a relationship m ust be m aintained
throu gh this ram ew ork.
This com m unication gu id e id entif es the role that patients’
percep tions m ay have regard ing their m ed ical cond ition.
Op en conversation regard ing the p atient’s ears and m otiva-
tion, and com m itm ent level to p articip ating in care, allow s the
clinician to exp lore barriers to care w ith the p atient (Britt et al
2004). This type o m ed ical interview ing is also know n as
m otivational interview ing (MI) – a collaborative conversation
style that is a p atient-centred ap p roach acknow led ging the
patient’s exp ertise in his / her ow n problem s and em pow ering
the p atient (Rollnick et al 2008). Beginning w ith the m ed ical
interview and subsequ ent interactions, it is im portant to
encourage patients to be able to solve problem s, m ake d eci-
sions and overcom e barriers and setbacks w ithin a su p p ortive
relationship rom the m ed ical care provid er. A m eta-analysis
and system atic review on MI ou nd that it ap peared to be
u se u l in clinical settings, and that only one session cou ld be
e ective in enhancing read iness to change and action that is
d irected tow ard reaching health behaviou r-change goals
(VanBu skirk & Wetherell 2014). Ad d itionally, a large bod y o
literature su pports the notion that involving patients in the
interview m ay im p rove ad herence w ith prescription and
treatm ent (Street et al 2009; Street & H aid et 2011; VanBu skirk
& Wetherell 2014).
Medical Interview Content
The value o the m ed ical interview has been signif cant in
prim ary care, w ith p hysicians reporting that the history alone
w as su f cient to m ake a d iagnosis in arou nd 75% o patients,
physical exam ination in arou nd 10% and lab or im aging
investigation in a u rther 10% (H am p ton et al 1975; Peterson
et al 1992; Good m an & Snyd er 2009). The d iagnostic valu e o
the clinical su bjective rep ort is w id ely u nd erstu d ied throu gh-
ou t the literatu re w ithin stu d y d esign typ es or d iagnostic
Systems review and differential diagnosis inquiry 37
accu racy. H ow ever, based on the best evid ence that exists to
d ate, there are som e qu estions or content item s contained
w ithin the m ed ical interview that should help the clinician
d i erentiate low er extrem ity pain synd rom es rom other con-
d itions. Regard less o the content-specif c questions, the inter-
view shou ld be p lanned care u lly and shou ld u tilize a good
intake orm / strategy that inclu d es m any key qu estions abou t
the p atient’s cond ition.
In m any o low er extrem ity p ain synd rom es, there are a
variety o clinical p resentations; there ore it is su ggested to
take a system s ap p roach to the content o item s in the m ed ical
interview. The system s approach should be screened as an
initial process to aid in a d i erential d iagnosis and rule out
other system s as p otential p ain generators. Typ ically there are
three goals at the end o the interview : (1) u nd erstand ing the
p atient’s p roblem and p otential cau ses, (2) id enti ying the
e ect o the p roblem on the p atient’s li estyle, and (3) p lan-
ning the objective exam ination (Wool 2003).
The use o intake orm s to gain in orm ation regard ing
d em ographics and m ed ical history or the patient m ay save
signif cant tim e w hen com p leted ou tsid e o the m ed ical inter-
view. Integrating the f nd ings rom the p atient intake orm ,
sel -rep orted ou tcom e orm s, initial re erral (i one exists) and
observations o the p atient in the w aiting room can evoke a
w id e range o clinical hypotheses or consid eration (Good m an
& Snyd er 2009). These orm s shou ld help initiate the conver-
sation and allow the therap ist to generate ad d itional qu es-
tions to assist in the d ecision-m aking p rocess. Clearly, the
initial hypotheses are d erived rom clinicians’ know led ge
base and clinical experience, and d i erences exist betw een
novice and exp ert clinicians (H iggs 1992).
Many o these cond itions, inclu d ing m ajor healthcare
burd ens su ch as low back pain (LBP) and osteoarthritis (OA)
o the hip , knee and ankle, are o ten recu rrent, p rogressive
and lead to a signif cant d ecrease in qu ality o li e. The p rac-
titioner shou ld consid er the p hysical d iagnostic p ossibilities
contribu ting to the p roblem , bu t m u st also exp lore the u ll
range o actors that m ay contribu te to the p atient’s health and
im pact o the cond ition on the patient’s li e. Sel -reported
ou tcom e m easu res cap tu re in orm ation contained w ithin the
d om ains o pain, d isability, u nction, quality o li e, job
satis action, ear and / or p sychosocial concerns, w hich are
im portant or the com plexity o low er extrem ity synd rom es
(H arris-H ayes et al 2013). Captu ring in orm ation rom m ore
than one d om ain m ay be help u l in u nd erstand ing and
m anaging the p atient w ith low er extrem ity p ain synd rom es
(Table 4.1).
Systems Review and Differential
Diagnosis Inquiry
The goal o the screening process is recognition o the need
or a physician re erral, sp eed ing up the d iagnosis o system ic
and other p athological p rocesses (Boissonnau lt 2011). A
p rim ary p u rp ose o the screen is to id enti y sym p tom s u nu su al
or neu ro-m u sculoskeletal cond itions that m ay have been
overlooked d u ring the investigation o the p atient’s chie
p resenting sym p tom s. There is consid erable overlap o
sym p tom s betw een d isease and neu ro-m u scu loskeletal con-
d itions (Koes et al 2006); there ore the history should aim to
 38 PART 1 • 4 • History taking for patients with lower extremity syndromes

Table 4.1 Se l -re porte d outcome me as ure s or patie nts with lower e xtre mity pain s yndrome s
Na me of outcome me a s ure De s cription

Short Form 36 (MOS SF-36)
Patient-speci c Functional
Scale (PSFS)
Os wes try Low Back Dis ability
Ques tionnaire (OLBDQ)
The Functional Rating
Index (FRI)
Roland–Morris Disability
Ques tionnaire
Fear-avoidance Belief
Ques tionnaire (FABQ)
WOMAC (Western Ontario
and McMas ter Univers ity
Os teoarthritis Index)
Knee Outcome Survey
Lower Extremity Functional
Scale (LEFS)
A s elf-report ques tionnaire consis ting of 36 ques tions, an eight-s cale pro le of physical, mental health
and well-being; highly used throughout physical therapy res earch; most well-known to evaluate health-
related quality of life (HRQOL) (Ware et al 1993).
Investigates functional s tatus by as king patient to nominate activities that are dif cult to perform based on
their condition and rate the level of limitation with each activity. This measure is valid and res ponsive to
change in patients with knee pain, LBP, neck pain and cervical radiculopathy (Stratford et al 1995).
This tool quanti es a patient’s functional status by ass ess ing pain-related dis ability in pers on’s with LBP.
This meas ure has been s tudied and is a reliable and valid tool (Fairbank et al 1980).
This meas ure is speci cally designed to meas ure quantitatively the subjective perception of function and
pain of the s pinal mus culos keletal sys tem in a clinical environment. The measure appears to have good
reliability and validity (Feise & Menke 2001).
This is a health status meas ure, des igned to as ses s phys ical disability due to LBP. Correlates well with
OLBDQ and SF-36 (Roland & Morris 1986; Roland & Fairbank 2000).
The FABQ ass ess es patient beliefs with regard to the effect of physical activity and work on their LBP. It
cons ists of 16 items and patients rate their agreement with each s tatement on a 7-point Likert scale. A
higher s core indicates more strongly held fear-avoidance beliefs. Two subs cales are contained: 7-item
work s ubscale and 4-item phys ical activity s cale. Previous s tudies have found FABQ work s ubscale to be
as sociated with current and future dis ability and work loss in patients with chronic and acute LBP
(Waddell et al 1993; Williamson 2006).
This tool meas ures symptoms and physical dis ability, originally developed for people with OA of the hip
and knee. It has been studied with reliability and validity for OA (Bellamy et al 1988).
There is an indication to us e this tool with patients with a non-speci c knee injury. It has reliability and
validity. It is respons ive for functional limits for a variety of impairments (Irrgang et al 1998).
Indications : all lower extremity conditions; reliability and validity: strong for hip and knee total arthroplasty;
us eful with patients following arthroplas ty. In a 1999 study, this scale was adminis tered with the SF-36,
the acute version. In the conclusion of the s tudy, retes t reliability of the LEFS s cores was found to be
excellent. The minimal detectable clinical change within the score was at leas t 9 scale points and this
s cale was recommended over the SF-36 (Binkley et al 1999; Stratford et al 1999).

d i erentiate betw een these potential cau ses. O ten a planned
list o general health statu s ind icators to be u sed at the initial
p hysical therap y visit d u ring intake m ay lead to an ind ication
o a m ore in-d ep th system s review d u ring the su bsequ ent
history taking or p hysical exam ination (Table 4.2).
General rep orts o atigu e, ever, chills, sw eats and w eight
loss are com m on concerns i rep orted on intake or in su bjec-
tive com p laints, as these are com m only associated w ith
seriou s illnesses, in ections, cancer, and end ocrine and con-
nective tissu e d isord ers. In ective sp ond ylitis (a non-
m echanical cond ition) is com m only associated w ith ever and
has a sensitivity o 98% and a specif city o 50% (Lu rie 2005).
Unexplained w eight changes can be related to d iabetes,
hyp erthyroid ism , d ep ression, anorexia nervosa or neop lastic
d isease and shou ld p rom pt u rther inquiry. Excessive w eight
gain is o ten associated w ith u id retention (oed em a, ascites),
w hich can be a m ani estation o cond itions such as con-
gestive heart ailure, liver or renal d isease and preeclam psia
(H all 2003).
Neurological screen
N eu rological sym p tom s su ch as progressive leg paraesthe-
siae, nu m bness and / or w eakness m ay be cau sed by a
p erip heral nerve entrap m ent or sp inal nerve root lesion and
requ ire u rther inquiry. Any unu su al d escrip tions o altered
sensation, bilateral extrem ity d ef cit, d i f cu lty in u rinating, or
change in its requ ency, also requ ire u rther neu rological
investigation, as concerns abou t bilateral sym ptom s and / or
u rination relate to the m ed ical d iagnosis o cau d a equ ina.
Qu estions regard ing the sym p tom o u rinary retention have
a sensitivity o 90% and sp ecif city o 95% (Deyo et al 1992).
Cau d a equ ina also p resents w ith u nilateral or bilateral leg
p ain, num bness and / or w eakness in over 80% o cases (Deyo
et al 1992).
Cardiovascular screen
The card iovascu lar system can also re er pain and or sym p-
tom s (inclu d ing oed em a) into the low er extrem ity, so requ ires
d i erential d iagnosis. In peripheral oed em a the clinician w ill
need to ru le ou t venou s insu f ciency, congestive heart ailu re
and pu lm onary hyp ertension as causes, as w ell as d eep-vein
throm bosis, w hich is m ore associated w ith u nilateral oed em a
(Boissonnault 2011). Occlu sive arterial d isease is a com m on
p roblem in the eld erly and in sm okers, and m ay p resent
as clau d ication (Siracuse et al 2012). The presentation m ay
be sim ilar to other low er extrem ity synd rom es w ith pain,
 Systems review and differential diagnosis inquiry 39

Table 4.2 Ge ne ral s ys te ms re vie w que s tions

Ca rd io / p e rip he ra l va s cula r a nd p ulmona ry s ys te m q ue s tions Ga s trointe s tina l s ys te m q ue s tions re g a rd ing the following
re ga rd ing the following

Dys pnoea Swallowing dif culties

Cough Indigestion, heartburn
Palpitations Food intolerance
Syncope Bowel dys function
Sweats Colour of s tool
Cold distal extremities Shape, calibre of stool
Skin discoloration Cons tipation
Open wounds / ulcers Diarrhoea
Clubbing of the nails Dif culty in initiating eating
Wheezing, s tridor Incontinence
Ge nitourina ry s ys te m que s tions re ga rding the following Re p rod uctive s ys te m que s tions re ga rding the following

Urinary changes Male gender

Colour Urethral discharge
Flow Sexual dysfunction
Reduced calibre or force of urine stream Pain during intercours e
Incontinence Female gender
Vaginal dis charge
Pain with intercours e
Menstruation changes
Menopaus e
(Adapted from Bois s onnault 2011.)

oed em a and / or cram p ing sensations in the bu ttocks, Table 4.3 We lls ’ clinical de cis ion rule or de e p-ve in
thighs or calves. H ow ever, clau d ication p ain is typ ically asso- thrombos is
ciated w ith increased p hysical activity and is relieved by rest
(Siracu se et al 2012). Aortic aneu rysm s are potentially d anger- Clinica l pre s e nta tion (que s tions a nd ob s e rva tion) Score
ou s cond itions and m ay p resent as d eep , d i u se, throbbing,
Do you have active cancer (within 6 months of 1
or aching m id -back, chest, le t shou ld er or abd om inal p ain (d e
diagnosis or receiving palliative care)?
Virgilio & Chan 2010). I related to a recent surgical event or
a red u ced level o activity, the clinician w ill need to ask qu es- Do you have paralys is, paresis or recent immobilization 1
tions related to d eep -vein throm bosis (Wells et al 1997). The of the lower extremity?
Wells clinical p red iction ru le has been show n to be a reliable Have you been bedridden for more than 3 days or had 1
and valid tool or clinical assessm ent or pred icting the risk major s urgery in the las t 4 weeks?
o d eep -vein throm bosis in the low er extrem ity (Table 4.3).
Do you have localized tendernes s in the centre of the 1
pos terior calf, the popliteal space, or along the femoral
Gastrointestinal screen vein in the anterior thigh / groin?
The gastrointestinal system can also re er p ain and / or sym p- Have you noticed entire lower extremity s welling? 1
tom s into the low er extrem ity and need s to be ru led ou t as a Observation: unilateral calf swelling (> 3 mm compared 1
sou rce o p ain in p atients p resenting w ith low er extrem ity with contralateral s ide)
pain synd rom es. Qu estions on intake regard ing changes in
bow el habits should act as an initial screen. I su ch changes Observation: collateral super cial veins 1
are reported then the clinician should ask ad d itional ques- An alternative diagnosis is more likely (cellulitis , calf −2
tions abou t the p resence o blood in stools, or black stools, to strain, pos toperative swelling)
screen or colon cancer (Good m an & Synd er 2009). Also, vis- (Source: Wells et al 1997.)
ceral organ sym p tom s vary d ep end ing on the u nction o
the p articu lar organ. Rep orts o u ctu ating sym p tom s m ay
be related either to eating habits or to bow el or blad d er u nc-
tion. Certain ood s m ay p recip itate the onset o sym p tom s Non-mechanical pathologies:
or m ay a ect their intensity. Som e d isord ers m ay be associ- differential diagnosis
ated w ith blad d er u llness or constip ation, u rination or d e -
ecation. It is there ore im portant to ask about the total area in There are other non-m echanical p athologies that need to be
w hich the pain and related sym ptom s occu r to pinpoint the consid ered in d i erential d iagnosis and screening o the
contribu ting cau ses w hen p atients rep ort gastrointestinal low er extrem ity (Koes et al 2006). Many o these cond itions
changes (Good m an & Synd er 2009). can w orsen at night, althou gh p resenting as com m on low er
 40 PART 1 • 4 • History taking for patients with lower extremity syndromes
extrem ity pain synd rom es and behaving sim ilarly to m echan-
ical p ain p resentations. For exam p le, seronegative sp ond y-
loarthrop athies need to be consid ered w hen p rogressive
back pain is present in a you ng patient w ith u ctu ating
in am m atory sym p tom s m ani esting as m orning sti ness or
im p rovem ent w ith exercise. Cond itions inclu d ing ankylosing
sp ond ylitis (AS), Reiter ’s synd rom e, p soriatic arthritis and the
arthritis o in am m atory bow el d isease all requ ire ad d itional
m ed ical testing to establish a d iagnosis (Atlas & Deyo 2001).
H ow ever, AS m ay be elicited rom questions that establish a
slow onset, age < 40, long-term d iscom ort (> 3 m onths) and a
uctuating in am m atory pattern (i.e. m orning sti ness and
im p rovem ent o d iscom ort w ith exercise). These qu estions
help ing to ru le in AS have a sensitivity o 23% and a specif city
o 82% (Deyo 1991).
Psychosocial factors
Psychosocial actors also m ay m ani est in the p resentation o
m u scu loskeletal p ain, both regional and general. A system atic
review (Chou & Shekelle 2010) id entif ed the baseline pred ic-
tors o p ersistent d isabling LBP to be m alad ap tive p ain-cop ing
behaviou r, non-organic signs, unctional im pairm ent, low
general health status, and the presence o psychiatric com or-
bid ities; conversely, low levels o ear avoid ance and u nc-
tional im p airm ent p red icted recovery at 1 year. Consistent
evid ence has been ou nd to su pport the role o variou s psy-
chological actors in p rognosis, althou gh the literatu re is less
consistent regard ing w hich o these actors are m ost p rognos-
tic (N icholas et al 2011; Grovle et al 2013).
Red Flags
The presence o any o the ‘red ags’ shou ld be noted at the
initial assessm ent. This step is critical in d eterm ining w ho is
and w ho is not a cand id ate or physical therapy, and requ ires
both recognizing and ru ling out the presence o red ags
(Koes et al 2006). Such ags are, by d ef nition, signs and
sym p tom s that m ay relate a d isord er to a seriou s p athology
bu t m ay also re ect a m uscu loskeletal cond ition (Sizer et al
2007). Typ ically, they are eatu res rom a patient’s clinical
history and p hysical exam ination that are thou ght to be asso-
ciated w ith a higher risk o seriou s p athology or m alignancy
(Boissonnau lt 2011). There are several regional screening tools
to help recognize p otential seriou s d isord ers (red or yellow
ags) that aid in d i erential d iagnosis o m uscu loskeletal con-
d itions com m only encountered by physical therapists and
that requ ire qu estions rom the m ed ical interview (Fritz &
Flynn 2005).
Low back p ain, bu ttock p ain and / or p ain in the low er
extrem ity m ay be related to spinal m alignancy, w hich is the
m ost com m on site or bony m etastases, a ecting up to 30–70%
o p atients (Cook et al 2011a). H ow ever, lum bar m ovem ent
restrictions m ay reprod u ce m echanical pain in patients w ith
or w ithou t cancer (Cook et al 2011b). Recently, a w ell-
cond u cted system atic review ou nd that a p reviou s history o
cancer m eaning u lly increased the likelihood o m alignancy,
w ith a high p ositive likelihood ratio (H enschke et al 2013).
Ad d itionally, the sam e Cochrane system atic review ou nd
that other red ags have high alse-p ositive rates lead ing to
Table 4.4 Re d f ags to s cre e n or ma lignancy in patie nts with
low back pain
Clinica l his tory q ue s tions Pos t-te s t
prob a b ility (%)
Do you have a previous his tory of cancer? 4.6
Have you experienced any unexplained 1.2
weight los s?
Have your s ymptoms improved after 0.9
1 month (if the result is negative)?
Age > 50 years? 0.8
Have you had symptoms (this episode) 0.8
> 1 month?
Do you have severe pain? 0.5
Have you tried bedrest with no relief? 0.6
(Source: Hens chke et al 2013.)
u nnecessary and p otentially harm u l investigations, su ch as
rad iation. It conclud ed that, at this tim e, there is a lack o
evid ence and stu d ies w ith su f cient statistical p ow er to
p rod u ce p recise estim ates o sensitivity and sp ecif city o red
ags (H enschke et al 2013); d espite their inclu sion in the
gu id elines, the u se u lness o screening or ‘red ags’ or
m alignancy in p atients w ith LBP continu es to be d ebated and
there rem ains very little in orm ation on their d iagnostic
accu racy and how best to use them in clinical p ractice
(Und erw ood 2009). It is there ore recom m end ed that clini-
cians u tilize m ore than one o the single red ag qu estions
that are p resented in Table 4.4 (Dow nie et al 2013; H enschke
et al 2013).
Fractu res are also a com m on red ag and are o ten a cau se
or LBP and related leg sym ptom s. Vertebral com pression
ractures are the m ost com m on osteoporosis-related spinal
ractures, p resenting w ith clinical sym ptom s o back pain,
postu re changes, loss o height, u nctional im pairm ent, d isa-
bility and d im inished qu ality o li e. A recent system atic
review (Dow nie et al 2013) id entif ed three red ags w ith
p otentially u se u l p ositive likelihood ratios that w ou ld be
u se u l to cap tu re in p rim ary care settings; these are signif cant
trau m a, old er age and corticosteroid u se. Ad d itionally, m eta-
tarsal insu f ciency ractu res in both m en and w om en have
been id entif ed as early sign o osteoporosis (Tom aczak &
VanCou rt 2000). It has been reported , how ever, that m any red
ags in cu rrent gu id elines either provid e virtu ally no change
in probability o ractu re or have untested d iagnostic accuracy
(Dow nie et al 2013).
Symptom Investigation
Du ring intake and / or d u ring the m ed ical interview, it is
im p erative to id enti y specif c m ovem ent patterns that alter
the p atient’s sym p tom s or better and / or w orse. Cond itions
associated w ith in am m ation m ay w orsen either w hen at rest
or d u ring aggressive m ovem ents (Maitland 2001). To stream -
line the m ed ical interview, som e o the initial sym ptom inves-
tigation can be com p leted on the m ed ical history intake orm
(Table 4.5). On this, the patient need s to characterize the
 Nature and behaviour of the problem 41

Table 4.5 Intake in ormation or patie nts with lowe r e xtre mity pain s yndrome s
Inta ke que s tions re la te d to Purp os e of the conte nt

Patient pro le and demographics
Des cription of the problem
Nature and behaviour of the
condition
Pertinent medical his tory
Patient goals and barriers to care
Relates to the epidemiology with prevalence and incidence of related conditions based on age,
gender and ethnicity
Characterize the problem and determine caus e (if one exists ), determine chief complaint, and other
related concerns
Concordant / familiar / comparable s ign – movement associated with the pain in which the patient is
s eeking care
Patient’s pers pective of the condition (concerns , expectations , feelings, beliefs )
Severity: intensity of the patients symptoms as they relate to a functional activity or time of day
Irritability: how quickly a s table condition degenerates in the presence of pain-causing inputs
Nature: represents the s tructures at fault, or involved in the syndrome; may also inquire as to the
aggravating factors or relieving factors; may also inquire as to pres entation: constant, intermittent,
and / or episodic
Stage of pathology: as ses sment of the stage of healing in which the condition is pres enting
Stability: s ymptom progress ion over time (better, wors e, s taying the same)
Use intake forms to minimize ques tions for screening
Review of s ys tems for differential diagnos is of viscerogenic, vas culogenic, s pondylogenic, neurogenic
and / or psychogenic pain generators
Determine whether potential related medical components may be related to clinical pres entation
Bas eline for current medication use, general wellnes s, activity level, current medical conditions
and / or medical tes t for pres ent condition
Commonly used to identify motivation to improving current health status
Related to adherence to plan of care and self-ef cacy, which are prognostic variables to s ucces sful
outcomes
Treatment alternatives in accordance to patient-centred care

problem and d eterm ine the cau se (i one exists), the chie
com p laint, and other related concerns. Sym p tom s that vary
over the cou rse o the d ay have been associated w ith neu ro-
m u scu loskeletal im p airm ents or m ovem ent d isord ers. Su ch
cond itions typ ically u ctu ate as the m echanical load s on the
bod y increase or d ecrease w ith tim e o d ay, onset or cessation
o sp ecif c activities, and ad op tion or avoid ance o certain
postu res. Som e sp inal and / or extrem ity pain synd rom es can
also p resent w ith alteration in pain presentation (inclu d ing
perip heralization or centralization) in various postures or
positions w ith rep etition o m ovem ent (Maitland 2001).
H istory qu estions that id enti y alleviating and aggravating
positions can help the clinician to p inp oint m echanical
cond itions associated w ith m u scu loskeletal cond itions. For
instance, non-in am m atory cond itions m ay w orsen d uring
very aggressive u ngu ard ed m ovem ents. H ow ever, i , u p on a
com p lete exam ination, the p atient d oes not rep ort or p resent
w ith a sym p tom pattern consistent w ith a m u sculoskeletal
cond ition, u rther screening or cond itions related to sp ecif c
bod y system s should then be cond ucted . A pain pattern asso-
ciated w ith system ic d isease is o ten a p rogressive p attern
w ith a cyclical onset (Good m an & Snyd er 2009). Ad d itionally,
an insid iou s onset o sym p tom s and / or reports o atypical
sym p tom s or sym p tom behaviou r m ay raise su sp icions o a
seriou s u nd erlying cond ition.
Du ring the interview, it is im p ortant to help the patient
id enti y the prim ary reason or seeking care. In the physical
exam ination this is term ed the concord ant sign, w hich is d is-
tingu ished rom other sym p tom s p rod u ced d u ring the p hysi-
cal assessm ent. The concord ant sign need s to be id entif ed
d u ring the interview to allow both the patient and the
clinician to ascertain the key com p laint (Maitland 2001; Laslett
et al 2003). A patient w ith a low er extrem ity synd rom e m ay
also present w ith one or m ore d iscord ant signs; this m ay be
d escribed as pain u l or abnorm al, bu t not related to concord -
ant sign. The d iscord ant sign is u nlike the pain or w hich the
p atient has sou ght treatm ent (Maitland 2001).
Nature and Behaviour of the Problem
It is im p ortant to constru ct the sym ptom history d u ring the
history-taking session. This involves d eterm ining the stage o
the health p roblem . The p rim ary p u rp ose is or the clinician
to d eterm ine the cau se o inju ry and to elicit a care u l exp lana-
tion o the sym p tom s. Discu ssion o the concord ant sign and
natu re o the p roblem is u rther investigated , w hile the tim ing
o the event is closely associated w ith the stage o the d isord er
(Maitland 2001).
The natu re and behaviou r o the cond ition require the
clinician to ask qu estions regard ing the severity, natu re, irri-
tability, stage o p athology and stability o the sym p tom s.
Again, as w ith m any other history-taking com ponents, m any
o these concep ts have not been w ell d escribed or stu d ied
w ithin the literatu re. The severity d escribes the intensity o
the p atient’s sym p tom s in relation to a u nctional activity or
tim e o d ay; this typ ically involves the p atient rating the p ain
severity on a rating scale (e.g. the nu m eric p ain rating scale)
to p rovid e a baseline or com p arison w ith that elicited by
variou s m ovem ents d u ring the p hysical exam ination (Farrar
et al 2001). The natu re o the patient’s sym ptom s re ers to the
 42 PART 1 • 4 • History taking for patients with lower extremity syndromes
p ain presentation as being constant, interm ittent, and / or ep i-
sod ic in behaviou r; the clinician shou ld also ask the p atient
abou t actors that aggravate or relieve the p ain.
Irritability is another pain behaviou r concept that relates to
how qu ickly a stable cond ition d egenerates in the p resence o
p ain-cau sing inpu ts. This concept can be operationally d ef ned
by three criteria: (1) w hat d oes the p atient have to d o to set
this cond ition o , (2) how long d o the sym p tom s last and how
severe are the sym p tom s, and (3) w hat d oes the p atient have
to d o to calm the sym p tom s d ow n. Patients w ith high levels
o irritability m ay o ten be cau tiou s o aggressive treatm ent
because they w ill typically w orsen w ith selected activities
(Zu sm an 1998; Maitland 2001).
The stage o the p athology or cond ition relates sp ecif cally
to the stage o healing or the inju ry or sym p tom p resentation,
w hereas the stability o the sym ptom presentation re ers to
the sym p tom p rogression over tim e as im p roving, w orsening,
or staying the sam e.
History-taking Questions Speci c to
Lower Extremity Pain Syndromes
Leg p ain is a requ ent accom p anim ent to LBP, bu t can also
o ten p resent in the absence o LBP and can be qu ite d ebilitat-
ing. The stru ctu res o ten involved w ith leg p ain (w ith or
w ithou t LBP) w ill be presented and classif ed in this chap ter
as (1) central sensitization, (2) peripheral nerve sensitization
(w ith or w ithou t d enervation), and (3) m u scu loskeletal pain
rom non-neural stru ctures (Scha er et al 2009). Each o the
variou s stru ctu res involved can p resent w ith a d istinct p attern
o signs and sym p tom s that the p atient m ay d escribe d u ring
the interview or on the intake orm , althou gh u rther research
in p ain science is ind icating that there is signif cant crossover
betw een the patterns (Scha er et al 2009).
The sections below d eal w ith sp ecif c qu estions that clini-
cians m ay ask d u ring history taking to assist their hyp othesis
generation and d ecision m aking. Where possible, along w ith
the characterization statem ents, su bjective history qu estions
and / or sel -rep ort qu estionnaire item s a f liated w ith a spe-
cif c cond ition, the d iagnostic od d s ratios (DOR), sensitivity
(SN , the ability o the test to id enti y p ositively an ind ivid ual
w ho has the problem accord ing to the re erence test), sp ecif -
city (the ability o the test to p ositively exclu d e an ind ivid u al
w ho d oes not have the problem accord ing to the re erence
test) and likelihood ratios (+LR or −LR) are inclu d ed (Cook
et al 2007; see also Ch 5). H ow ever, in m any instances su ch
statistical in orm ation is not available, and in su ch cases the
text rep orts the best available evid ence regard ing history
taking related to sp ecif c low er extrem ity p ain synd rom es.
Central and peripheral nerve sensitization
The research literatu re ind icates there are certain history-
taking qu estions that can be u sed to exam ine low er extrem ity
synd rom es inclu d ing cond itions associated w ith central
sensitization, p erip heral nerve sensitization and m u scu loskel-
etal pain. (For purp oses o this chapter, central sensitization
is op erationally d ef ned as an am p lif cation o neu ral signal-
ling w ithin the central nervou s system (CN S) that elicits p ain
hyp ersensitivity (Wool 2011); peripheral sensitization is
op erationally d ef ned as increased resp onsiveness and
red u ced threshold o nocicep tors to stim ulation o their recep-
tive f eld s. This inclu d es nocicep tive p ain, w hich re ers to p ain
cond itions assu m ed to be p red om inantly d riven by the activa-
tion o p erip heral nocicep tive sensory f bres.) Tw o stu d ies
have exam ined low back w ith leg p ain that cou ld not be
traced back to an anatom ical abnorm ality, inclu d ing central
sensitization and nocicep tive LBP w ith or w ithou t leg p ain.
Patients exp eriencing p ain d isp rop ortionate to inju ry, d isp ro-
p ortionate aggravating / easing actors and other p sychoso-
cial sym p tom s w ere very likely to be d iagnosed w ith central
sensitization (DOR 15.19, 30.69 and 7.65 resp ectively) (Sm art
et al 2012a, 2012b). Ind ivid u als com plaining o localized or
interm ittent pain w ere m ore likely to be d iagnosed w ith noci-
ceptive LBP (DOR 69.79 and 4.25 respectively) (Sm art et al
2012a, 2012b).
Speci c Low-back-associated
Musculoskeletal Pain Syndromes
There are a variety o low back or spinal cond itions that
shou ld be consid ered w hen ad d ressing p atients w ith low er
extrem ity pain synd rom es. In the m any stu d ies on these syn-
d rom es, a variety o questions have been u sed by the research-
ers / authors to id enti y a specif ed low er quarter cond ition.
Sp ecif cally or the lu m bar sp ine, several stu d ies have exam -
ined the d iagnostic accuracy o history-taking item s or
lum bar spinal stenosis (LSS), lum bar sacral nerve root com -
p ression / rad icu lop athy, lu m bar d isc herniation, and clinical
lum bar instability.
Lumbar spinal stenosis
A variety o su bjective history qu estions / sel -rep ort item s
have been stu d ied or their u se u lness in the d iagnosis o LSS;
all o the ollow ing m et criteria or at least a sm all increase in
the p robability o an LSS d iagnosis. In the stu d y by Cook et al
(2011a), the m ost strongly d iagnostic com bination o sel -
rep ort item s com prised : (1) bilateral sym ptom s, (2) leg pain
m ore than back pain, (3) p ain d uring w alking / stand ing, (4)
p ain relie upon sitting, and (5) age > 48 years. Failu re to m eet
the cond ition o any one o these f ve p ositive exam ination
f nd ings d em onstrated a high sensitivity (0.96) and a low
LR− (0.19); m eeting the cond ition o ou r o the f ve yield ed a
LR+ o 4.6 and a post-test probability o 76%. Other stu d ies
have id entif ed that increasing p atient age (old er than 48
years) increased the LR+ o having the cond ition (Katz et al
1995; Konno et al 2007; Su gioka et al 2008). Katz et al (1995)
also ou nd the ollow ing qu estions help u l: d oes the p atient
have the ollow ing: severe leg p ain (LR+ 2.00), no p ain w hen
seated (LR+ 6.60), sym ptom s that im p rove w hen seated (LR+
3.10), or leg nu m bness (LR+ 2.62)? Konno et al (2007) id enti-
f ed ad d itional qu estions inclu d ing: p ain that is w orse w hen
w alking bu t relieved by taking a rest (DOR 70.77), p ain that
is w orse on stand ing (DOR 11.38), and num bness arou nd the
bu ttocks (DOR 77.0). Ad d itionally, Sugioka et al (2008)
inquired w hether the pain w as reported as lasting or m ore
than 6 m onths (DOR 2.17), the patient w as w alking m ore
slow ly than u su ally (DOR 2.28), w as sitting d ow n because o
low er extrem ity pain (DOR 2.01), or need ed to w ake u p to
 Speci c lower-extremity-associated musculoskeletal pain syndromes
u rinate at night (DOR 2.34); p ositive resp onses related to a
slightly to m od erately increased p robability o having LSS.
Nerve root compression / radiculopathy
The m ost signif cant history com ponent or nerve root com -
pression is the location o p ain, w hether the sym ptom s present
w ithin a d erm atom e d istribu tion, and / or w hether sym ptom
rad iation w as the m ost signif cant history com p laint (DOR
24.29) (Sm art et al 2012a, 2012b). Fu rtherm ore, qu estions
abou t w hether the p atient exp erienced m ore pain w ith cou gh-
ing, sneezing or straining (DOR 3.20), as w ell as sel -rep orts
o m u scle w eakness (DOR 2.20), sensory loss (DOR 2.10) or o
d istu rbed urinary p assage (DOR 2.3), have been associated
w ith the d iagnosis o lu m bar sacral nerve root com pres-
sion / rad icu lop athy (Coster et al 2010). Ad d itionally, there
app ears to be an age relationship as old er-aged patients (51–81
years) have an increased p robability o being d iagnosed w ith
this cond ition (DOR 2.2) (Vroom en et al 2002).
Lumbar disc herniation
In the d iagnosis o lu m bar d isc herniation, only a ew stu d ies
have com p ared f nd ings w ith a re erence stand ard , and som e
stu d ies have signif cant risk o bias. At this p oint, som e o the
key history item s that yield som e benef t in screening or pos-
sible lu m bar d isc herniation inclu d e p reviou s non-sp inal
surgery (DOR 3.52), ed u cation level (DOR 3.22), and progres-
sive sciatic pain (DOR 2.77) (Vucetic et al 1997).
Clinical lumbar instability
Although w ithin the literature there are som e stud ies testing
the accu racy o clinical tests or lu m bar stability / instability,
no stu d ies have u niqu ely analysed history taking. A system ic
review by Alqarni et al (2011) ou nd that p hysical therap ists
typ ically u tilize tests su ch as the p osterior shear test, the
prone instability test, the Beighton hyperm obility scale, the
prone leg extension test, and tests or the instability catch sign,
the p ain u l catch sign and the ap p rehension sign (p resented
later in this book). Other possibly u se ul qu estions that need
to be stu d ied or their d iagnostic accu racy are based on a
Delphi stud y (by a panel o clinical experts): clinicians typi-
cally inqu ire abou t ep isod es o giving w ay or the back giving
ou t, p ain throu gh the range o m otion, p ain u l locking or
catching d u ring tw isting or bend ing o the sp ine d u ring tran-
sitional activities, p ain d u ring su d d en activities, and p ain
w ith li ting, sneezing and / or returning rom a exed - orw ard
position (Cook et al 2006).
Speci c Lower-extremity-associated
Musculoskeletal Pain Syndromes
Hip osteoarthritis
For the d iagnosis o hip osteoarthritis (OA), som e o the key
history item s that shou ld be inclu d ed are as ollow s (Su tlive
et al 2008; Morvan et al 2009). Does the patient have bu ttock
pain / hip / groin p ain (w hich yield s a LR+ range rom 1.74 to
43
6.4 and LR− o 0.52)? Does the patient com plain o p ain w hen
clim bing stairs or w alking d ow n slop es (yield s an LR+ o
2.10)? Does the p atient sel -report squ atting as an aggravating
actor (yield s an LR+ o 1.8 and LR− o 0.42)? Does the p atient
have p osterior hip p ain (yield s an LR+ o 6.1 and LR− o 0.79)?
Lastly, d oes the patient sel -id enti y lim ited m otion o the hip
(yield ed a sm all LR+ o 2.86)?
Other hip pathology
A system atic review by Bu rgess et al (2011) exam ined the
d iagnostic accuracy o patients’ su bjective statem ents associ-
ated w ith labral pathology. They id entif ed tw o stu d ies that
ou nd patients w ith labral pathology presented w ith anterior
groin pain (sensitivity o 100% and a sp ecif city o 40%), or
rep orted clicking (w ith sensitivity ranging rom 57% to 100%).
Tijssen et al (2012) cond u cted a second system atic review ;
these au thors grou p ed p atients exhibiting the m echanical
sym p tom s o clicking, locking, p op p ing or giving w ay together
rom a com bination o three o their inclu d ed stu d ies (Farjo
et al 1999; O’Leary et al 2001; Bu rnett et al 2006) and ou nd
that rep orts o m echanical sym p tom s yield ed a range o sen-
sitivity o 53% to 100%. Little is know n about the d iagnostic
accu racy o not only the history taking bu t also the physical
exam ination in screening or em oro-acetabular im pingem ent
(FAI), althou gh this cond ition is now increasingly recognized
as a cau sative actor o m any intra-articu lar hip lesions and
labral pathology. Som e stud ies have d escribed the clinical
characteristics and sym p tom s; how ever, no stu d ies have
exam ined the d iagnostic accu racy o history qu estions related
to these or FAI.
Knee osteoarthritis
The knee is a signif cant target o osteoarthritis (OA). Morvan
et al (2009) ou nd three qu estions d u ring the interview to be
u se u l, as they w ere related to a sm all increase in the p robabil-
ity o having knee OA. These qu estions inclu d ed having
had pain or at least 4 w eeks (w hich yield ed a sensitivity o
0.95, specif city o 0.46, LR+ o 1.77, and LR− o 0.10), having
p ain w hile clim bing stairs or w alking d ow n slop es (a sensitiv-
ity o 0.81, specif city o 0.63, LR+ o 2.19 and LR− o 0.30),
and having sw elling in one or both knees (a sensitivity o
0.47, sp ecif city o 0.84, LR+ o 3.10 and LR− o 0.62) (Morvan
et al 2009).
Patellofemoral pain syndrome
Cook et al (2012) cond u cted a system atic review that id enti-
f ed som e qu estions that m ay be help u l in id enti ying p atients
w ith patello em oral pain synd rom e (PFPS). Within their
inclu d ed stu d ies they id entif ed that sel -rep orted pain d uring
squ atting p resents w ith a range o low LR+ ( rom 1.3 to 1.8)
and LR− (betw een 0.9 and 0.1) rom three stud ies rep orted in
a system atic review. Fu rther, sel -reports o p ain d u ring
kneeling also have a low LR+ (1.7) and LR− (0.3). Sel -rep orted
p ain d u ring p rolonged sitting or exion o the knee w as cap -
tu red in three stu d ies and ranged rom low to m od erate shi ts
in probabilities rom LR+ (1.7 to 7.4) and LR− (0.3 to 0.5). Pain
reports d u ring stair clim bing had a w id er range o LR+ ( rom
1.3 to 11.6) and LR− ( rom 0.6 to 0.1) rom three stud ies that
 44 PART 1 • 4 • History taking for patients with lower extremity syndromes
cap tu red this item . The w id e ranges o d i erential d iagnosis
id entif ed by the au thors o the system atic review m ay be d u e
to the high variability in re erence stand ard s or d iagnosis as
w ell as in the d ef nitions o PFPS am ongst the stu d ies includ ed
(Cook et al 2012).
Knee meniscal injury
There are tw o history-taking item s that have been id entif ed
or d iagnosing knee m eniscal inju ries. One stu d y ou nd that
the sel -rep orted sensations o giving w ay and locking d u ring
history taking had a d iagnostic accu racy o 49.2% and 60.9%
resp ectively, com pared w ith MRI f nd ings, w ith specif cities
o 0.84 and 0.96 resp ectively (Yan et al 2011). Wagem akers
et al (2008), in another d iagnostic accu racy stud y, id entif ed
that a qu estion clu ster o being old er (‘age over 40 years’),
‘continu ation o activity im possible’, and reports o ‘w eight-
bearing d u ring trau m a’ w as associated w ith a slightly
increased p robability (LR+ 2.0) o m eniscal inju ry.
Knee ligamentous injury
More d iagnostic accu racy stu d ies have exam ined anterior
cru ciate ligam ent (ACL) inju ry than m any o the other typ es
o ligam entou s inju ries (Benjam inse et al 2006). One stud y
sep arated history com p onents w ithin the exam ination rom
the p hysical exam ination, to id enti y the d iagnostic valu e
(Wagem akers et al 2012). This stud y u rther exam ined history-
taking clu sters or both p artial and com p lete ACL lesions. The
history-taking item s o rep orted sw elling / e u sion yield ed
an LR+ o 1.6, LR− o 0.8 or id enti ying p artial tears and LR+
o 2.0, LR− o 0.6 or id enti ying com plete tears. Reports o a
‘popping sensation’ yield ed an LR+ o 2.3, LR− o 0.5 or
p artial tears, and LR+ o 2.1, LR− o 0.5 or com p lete tears. The
sel -rep orted sensation o ‘giving w ay’ yield ed a sm all shi t
in p robability (w ith an LR+ o 1.6, LR− o 0.6 or partial tears,
and LR+ o 1.7, LR− o 0.6 or com plete tears). When com bined
in a clu ster, the history f nd ings yield ed a specif city o 0.99,
a sensitivity o 0.18 and LR+ o 17.7 or partial tears com p ared
w ith MRI. Com plete ACL tears yield ed a large, albeit slightly
sm aller shi t com p ared w ith p artial tears, w ith an LR+ o 9.8,
an LR− o 0.8 and sim ilar specif city (0.98) and sensitivity
(0.18). Many other item s w ere evalu ated , inclu d ing sw elling,
crep itation, p ain score, typ e o inju ry and others; how ever,
none o these w ere inclu d ed w ithin the f nal d iagnostic m od el
or assessing ACL lesions (Wagem akers et al 2012).
Achilles tendinopathy
Di erential d iagnosis o Achilles p athology can be very chal-
lenging w ithin the research literatu re and clinical p ractice.
The re erence stand ard or this d iagnosis is ultrasound and
there w as one stu d y that p resented d ata on the d iagnostic
accuracy o sel -rep orted item s or questions or this cond ition
(H u tchison et al 2013). Sel -reported pain w ith palp ation o
the tend on p resented w ith a sensitivity o 0.84 and sp ecif city
o 0.73. Ad d itionally, the subjective report o p ain at 2–6 cm
above the insertion into the calcaneu s show ed a sensitivity o
0.78 and sp ecif city o 0.77. Althou gh not w ell exam ined
w ithin the literatu re, these tw o key history-taking item s m ay
p rove to be u se u l in screening or this cond ition.
Heel pain / plantar fasciitis
There are several com m on history item s that clinicians have
u sed or years to help w ith the d i erential d iagnosis o this
cond ition. Clinically, p atients o ten rep ort p ain d u ring their
f rst step s in the m orning or a ter p rolonged sitting, and m ay
also report sharp p ain w hen the m ed ial plantar calcaneal
region is touched / palpated . H ow ever, there are m any other
cond itions that can also cau se heel p ain, inclu d ing (bu t not
lim ited to) nerve entrap m ent, lu m bar spine cond itions and
neu rop athies (Cole et al 2005). N o d iagnostic accu racy stud ies
have been ou nd to d ate that exam ine the p atient history or
p lantar asciitis. Interestingly thou gh, the history taking is
nevertheless signif cantly valu ed in the classif cation and / or
d iagnosis o heel pain / plantar asciitis w ithin clinical p rac-
tice gu id elines or p hysical therap y (McPoil et al 2008).
Conclusion
As evid ence-based clinicians, p hysical therapists need to
u tilize the best evid ence w ith regard s to d evelop ing the
su bjective interview. The history-taking ap p roach / style and
content o qu estions are both u nd erstu d ied w ithin the cu rrent
literature in physical therapy. H ow ever, in this chap ter several
qu estions that shou ld aid in d ecision m aking have been p re-
sented based on bod y stru ctu res o ten involved w ith leg p ain
(w ith or w ithou t low back p ain), includ ing questions to d i -
erentiate and screen or red ags and pain re erral to other
system s. Pain / sym p tom s that are not generated rom other
system s or d u e to red ag / p athological cond itions have also
been p resented as qu estions to id enti y central sensitization,
p erip heral nerve sensitization (w ith or w ithou t d enervation)
and m u scu loskeletal pain. Although in clinical p ractice the
history and clinical exam ination are not isolated , the orm o
history qu estions w ithin the m ed ical interview and their con-
tribu ting valu e or d ecision m aking rem ain u nd erstu d ied
w ithin the literatu re com pared w ith stu d ies o the physical
exam ination testing. We m ay not know the real valu e o the
history w ith regard s to d iagnostic accu racy. H ow ever, litera-
tu re d oes su p p ort its valu e w ithin a tailored , p atient-centred
ap proach to im proving p atient satis action w ith care and
p atient ou tcom es in m any m u scu loskeletal cond itions.
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Wool CJ. 2011. Central sensitization: im plications or the d iagnosis and treat-
m ent o pain. Pain 152: S2–S15.
Yan R, Wang H , Yang Z, et al. 2011. Pred icted probability o m eniscu s tears:
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Zu sm an M. 1998. Irritability. Man Ther 3(4): 195–202.
 PART 1 •  General Introduction
S h a n e Ko p p e n h a ve r, Tim o th y Flyn n , J e n n ife r C ra n e
CHAP TER CONTENTS
Introduction  47
Observation and screening for medical conditions  48
Screening for severe injuries to the spine  50
Screening for neurological de cits  51
Nerve root examination  51
Upper motor neuron examination  59
Cranial nerve examination  60
Clearing the spine  60
Region-speci c examination  63
Introduction
The physical exam ination is a continu ation of a com prehen-
sive p atient history and interview. N o m atter how thorou gh
the p hysical exam ination is, it cannot su bstitu te for an incom -
plete p atient history. After com pleting the history and p atient
interview, the exam iner shou ld have an appreciation of the
severity of sym p tom s, the p otential irritability of the cond i-
tion (once p rovoked , how long d o sym p tom s take to ease?)
and the stage of the process (acu te, subacute, or chronic).
The clinician shou ld also have form ed a reasonable hypoth-
esis, or several com peting hypotheses, abou t the likely pathol-
ogy or treatm ent classi cation, as w ell as an initial p rognostic
assessm ent. Fu rtherm ore, the clinician shou ld have an initial
u nd erstand ing of the social, environm ental and behaviou ral
factors in u encing the p atient’s status. The physical exam ina-
tion then focu ses on testing these initial hyp otheses form ed
d u ring the history taking and on gaining any ad d itional
inform ation necessary to establish an appropriate treatm ent
plan and p atient p rognosis. It shou ld be system atic, yet ad apt-
able to the ind ivid u al p atient nd ings that sup p ort or refu te
the exam iner ’s p rim ary and alternative hyp otheses. Finally,
the real p ow er of a com p rehensive p hysical exam ination to
aid in healing cannot be und erestim ated . An exam ination
is a therapy in that, if p erform ed in a com petent and com -
passionate fashion, facilitates a positive clinician–patient
relationship.
A com p rehensive p hysical exam ination consists rst of
u sing variou s tests and m easu res to screen the neu rom otor
and vascu lar system s and subsequ ently focusing on
Chapter  5  
Physical Examination
region-speci c proced ures. H ow ever, before d iscussing the
tests involved in the p hysical clinical exam , this chap ter d is-
cu sses the p sychom etric p rop erties of the variou s tests and
m easu res the clinician m u st u nd erstand in ord er to select the
m ost u sefu l tests, accu rately interp ret their resu lts, and m ove
forw ard w ith appropriate treatm ent (see also Ch 4).
The assessm ent of d iagnostic tests involves exam ining
several d ifferent p rop erties, inclu d ing reliability and d iagnos-
tic accu racy. Reliability d escribes the d egree of consistency
w ith w hich an instrum ent or rater m easu res a particu lar
attribute (Portney & Watkins 2009). The reliability of a test
tells the clinician the p rop ortion of the m easu re that is a tru e
representation, and the proportion that is a resu lt of m eas-
u rem ent error. Intra-rater reliability is the consistency be -
tw een d ifferent m easu rem ents taken by one p erson, w hereas
inter-rater reliability is the consistency betw een m easu re-
m ents taken by tw o or m ore p eop le. Reliability is m ost often
qu anti ed by the u se of reliability coef cients that range
betw een 0 (no agreem ent) to 1 (perfect agreem ent). Intra-class
correlation coef cients (ICCs) are the m ost com m on reliability
coef cients u sed to estim ate reliability of d ata that is m eas-
u red on a continu ou s scale (e.g. d egrees of range of m otion).
Kap p a (κ) coef cients are the preferred reliability coef cients
u sed w ith categorical d ata (e.g. p ositive vs negative) as they
statistically correct for change associations. Interp retations of
reliability coef cients vary, bu t generally are as follow s: < 0.50
rep resents p oor reliability, 0.50–0.74 represents m od erate
reliability, and greater than 0.75 represents good reliability
(Portney & Watkins 2009).
The diagnostic accuracy of a test is m ost often quanti ed
by the m easu re of agreem ent betw een the test and a reference
stand ard , w hich is the criterion that is consid ered the closest
representation of w hether or not a d isord er is present. The
results of the reference stand ard are com p ared w ith the resu lts
of the clinical test being stu d ied , to d eterm ine the p ercentage
of p eop le w ho w ere correctly d iagnosed w ith the test u nd er
investigation. When interpreting the reported d iagnostic
u tility of a test, it is vital for clinicians to keep in m ind both
the reference stand ard u sed and the p op u lation that w as
stu d ied ; this w ill help them to d ecid e w hether the resu lts are
ap plicable to their ow n p atient p opu lation. Diagnostic accu -
racy is typ ically exp ressed in term s of sensitivity and sp eci -
city, and positive–negative likelihood ratios. Sensitivity (tru e
p ositive rate) is d e ned as the ability of a test to id entify cor-
rectly p atients w ho have a particular d isord er (Portney &
Watkins 2009; Straus 2011). A highly sensitive test is m ost
 48 PART 1 • 5 • Physical examination
valu able w hen it is negative, as this can help to ru le ou t a
sp eci c d iagnosis. H ow ever, highly sensitive tests w ill often
be positive in a nu m ber of ind ivid u als that d o not have the
d isord er being stud ied . Therefore a positive result of a highly
sensitive test is of less valu e than a negative resu lt. Specif city
(true negative rate), in contrast, is the ability of a test to id en-
tify correctly p atients w ho d o not have a p articu lar d isord er.
H ighly speci c tests are good at ru ling in a cond ition and , as
su ch, a p ositive nd ing w ou ld p robably be a tru e p ositive. A
p erfect p red ictor w ou ld be d escribed as 100% sensitive (i.e.
p red icting all peop le from the sick grou p as sick) and 100%
sp eci c (i.e. not p red icting anyone from the healthy grou p
as sick).
Likelihood ratios (LRs) are often m ore clinically u seful
than sensitivity and sp eci city as they d eterm ine shifts in the
p robability of the p atient having a speci c d isord er (H ayd en
& Brow n 1999). LRs are calcu lated by incorp orating both the
sensitivity and sp eci city of a test and can be u sed to estim ate
d irectly the likelihood that the d isord er is present. If the test
u nd er investigation is p ositive, then the p ositive likelihood
ratio (+LR) is u sed to d eterm ine the increased likelihood that
the p atient has the d isord er. If the test is negative, the negative
likelihood ratio (−LR) is u sed to d etermine the d ecreased
p robability of the p atient having the d isord er. The follow ing
scale is u sed to d eterm ine the signi cance of +LRs: 10 or
greater generates a large and often conclusive shift in prob-
ability, 5–10 generates m od erate shifts in probability, 2–5 ind i-
cates sm all bu t occasionally im portant shifts, and less than 2
ind icates a rarely im p ortant shift in p robability (Portney &
Watkins 2009). With −LRs, less than 0.1 ind icates a large shift
in probability, 0.1–0.2 d em onstrates a m od erate shift, 0.2–0.5
ind icates a sm all shift, and 0.5–1 show s a rarely im p ortant
shift (Portney & Watkins 2009).
Clinicians shou ld select tests and m easu res that are reliable
and have high d iagnostic u tility. For exam ple, screening tests
refer to a grou p of tests that can be u sed to d ecrease the likeli-
hood of a p articu lar cond ition being present. Therefore a
screening test shou ld be highly sensitive and have a sm all
−LR. The real value in a screening test is that a negative resu lt,
w hen u sing a highly sensitive test w ith a very sm all −LR,
d ram atically low ers the probability that the patient has the
cond ition (i.e. the clinician can con d ently ‘ru le it ou t’). Typ i-
cally, screening tests w ill have an increased nu m ber of false
p ositives (since they are highly sensitive) and thu s a p ositive
screening test shou ld alert the clinician to p erform a m ore
thorou gh investigation to ru le in or ru le ou t the cond ition.
On the other hand , region-sp eci c p roced u res are generally
d ed u ctive in natu re, and shou ld be highly sp eci c and have
large +LRs. It is im p erative therefore that clinicians u nd er-
stand the d iagnostic p rop erties of the clinical exam ination
tests they p erform . For exam p le, frequ ently clinicians w ill get
a p ositive test resu lt w hen u tilizing a highly sensitive test
(−LR is sm all) and im m ed iately label the p atient w ith that
d isord er w ithout consid ering the p ossibility of a false-p ositive
test resu lt. This is often w hy novice clinicians becom e m ore
confu sed the m ore testing they d o, as m ore testing w ill
increase the nu m ber of false p ositives.
The screening p ortion of the p hysical exam ination is a con-
tinu ation of the review of system s that occu rs d u ring the
p atient history. Whereas som e elem ents shou ld be rou tinely
p erform ed on all p atients, the inclu sion of other com ponents
w ill be d riven by nd ings from the history and other physical
exam ination. Most inclusively, a com prehensive screening
exam ination w ill consist of:
• observation
• screening for know n and unknow n m ed ical d iseases or
cond itions
• screening for severe injuries to the spine
• screening for neurological d e cits
• ‘clearing’ the spine (in other w ord s, rem oving the cervical
or lu m bar sp ine stru ctu res as p rim e contribu tors to the
patient’s com p laints).
The region-speci c portion of the p hysical exam ination shou ld
also be tailored by the history and other nd ings d u ring the
physical exam ination. A com prehensive region-speci c exam -
ination, how ever, w ill alw ays consist of:
• active m ovem ents
• passive m ovem ents (w ith and w ithou t overpressure)
• palpation
• clinical special tests.
Becau se the screening p ortion of the p hysical exam ination is
basically the sam e regard less of the speci c location of prim ary
sym p tom s, it w ill be the focu s of this general p hysical exam i-
nation chap ter. Althou gh the region-sp eci c p art of any
exam ination shou ld includ e the sam e general com ponents,
the sp eci c evalu ative p roced u res w ill d ep end on the location
of p rim ary sym p tom s and the p otential joints and soft tissu es
involved . H ow ever, em erging evid ence d em onstrates that
m any sp ine and extrem ity p ain synd rom es are ap p rop riately
m anaged w ith m anu al techniqu es targeted at the sp ine
(H u rw itz et al 2002; Child s et al 2004; Cleland et al 2007;
Iverson et al 2008; Boyles et al 2009) and thus those regions
that w ill be treated requ ire screening p rior to p erform ing
m anu al interventions. Su bsequ ent chap ters w ill focu s on the
relevant pathology-speci c exam ination p roced ures for spe-
ci c d isord ers.
Observation and Screening for
Medical Conditions
The initial qu estions that shou ld be at the forefront of a m us-
cu loskeletal p ractitioner ’s m ind d u ring the p hysical exam ina-
tion is w hether or not the p atient’s sym p tom s are consistent
w ith neuro-m uscu loskeletal pathology and w hether the
p atient m ay requ ire im m ed iate referral to another sp ecialist.
As d iscu ssed in Chap ters 3 and 4, m any visceral pathologies
can cau se sym p tom s that m ay be confu sed w ith neu ro-
m u scu loskeletal cond itions, screening for w hich is p rim arily
d one by cond u cting a com prehensive and d etailed patient
history and interview. H ow ever, sym p tom s from neu ro-
m u scu loskeletal p athology shou ld also be able to be
reprod uced and / or exacerbated d u ring a com prehensive
neu ro-m u scu loskeletal p hysical exam . When p atients rep ort
sym p tom s of m od erate to severe intensity that the exam iner
is u nable to rep rod u ce and / or exacerbate d u ring the physi-
cal exam , he or she shou ld be highly su sp iciou s of u nd erlying
m ed ical p athology.
Signs of non-neu ro-m u scu loskeletal p athology can often be
noted d u ring the initial observation p ortion of the p hysical
exam ination. For this reason, the clothing over any region of
 Observation and screening for medical conditions  49

sym p tom s shou ld be rem oved and the area shou ld be closely
inspected for any abnorm alities. Prim ary skin lesions (e.g. a
m acu le, p ap u le, p atch, w heal, or cyst) m ay be im m ed iately
d iscoverable d u ring observation. Although m ost prim ary
skin lesions are not em ergent, a m u scu loskeletal p ractitioner
m ay be the rst p rovid er to d iscover the lesion, and at a
m inim u m the p atient shou ld be told to d iscu ss the lesion w ith
their p rim ary care p rovid er. H ow ever, p rim ary skin lesions
that are associated w ith fever, d if cu lty in breathing or sw al-
low ing, or tend erness w ith m u cosal involvem ent m ay be life
threatening and requ ire im m ed iate em ergent referral (Cole &
Gray-Miceli 2002).
Du ring observation, p rovid ers m ay ad d itionally d iscover
signs of fever, an abd om inal m ass or atrau m atic sw elling. The
p resence of a p ulsatile abd om inal m ass m ay represent an
abd om inal aortic aneu rysm and this requires im m ed iate
em ergent referral. Atraum atic sw elling, especially joint effu-
sion, m ay signify an infectiou s or m alignant p rocess and
shou ld p rom p t fu rther exam ination and / or im m ed iate
referral to another specialist.
Vascular d isord ers of the cervical arterial system (i.e. ver-
tebrobasilar and carotid arteries) can p resent as head and neck
p ain. Occlu sion of these arteries m ay lead to ischaem ia w ith
sym p tom s ranging from d izziness, d ip lop ia, d ysarthria, d ys-
p hagia, d rop attacks, nau sea, nystagm u s, facial num bness,
ataxia, vom iting, hoarseness, loss of short-term m em ory,
vagu eness, hyp otonia / lim b w eakness, anhid rosis (lack of
facial sw eating), hearing d isturbances, m alaise, perioral d ys-
aesthesia, p hotop hobia, p apillary changes, clu m siness and
agitation to p erm anent neu rological d am age and d eath (Kerry
& Taylor 2009). Dam age to the arterial system , particularly
the vertebrobasilar artery, has been linked to cervical m anip u -
lation (Ernst 2007). Several screening proced u res have been
ad vocated to id entify patients at risk for vertebrobasilar insu f-
ciency. The tests u su ally involve cervical p ostu res that p u t
stress on the vertebrobasilar system and m onitor for signs
and sym ptom s suggestive of su ch com p rom ise (e.g. d izziness,
d iplopia, d ysarthria, nystagm u s, etc.) (Child s et al 2005).
Unfortunately no stud ies have d em onstrated the ability of
su ch tests to id entify effectively either those p atients w ith
vertebrobasilar insu f ciency or those at risk of having a
cerebrovascu lar accid ent. Table 5.1 provid es a su m m ary of
p hysical exam ination p roced u res d esigned to d ifferentiate
vascu lar head and neck p ain. Kerry and Taylor (2009) have
p rovid ed p ru d ent ad vice to clinicians by encou raging them
to d evelop a high ind ex of su sp icion for cervical vascu lar
p athology, p articu larly in cases of cervical trau m a. More
recently, an international fram ew ork for exam ining the cervi-
cal region p rior to m anu al interventions has been d evelop ed
(Rushton et al 2014). H ow ever, the clinician m u st balance this
‘alertness’ w ith the know led ge that the chronic-pain m ental-
ity and p sychological factors are m ajor issues in this patient
grou p and should , therefore, be sensitive to the possible
im pact of reinforcing biom ed ical beliefs about a chronic-pain
ep isod e.
At a m inim u m , screening for cervical artery d ysfu nctions
shou ld inclu d e a d etailed historical exam (w hen the p atient
reports of trau m a and / or signs or sym ptom s consistent w ith
com p rom ise to the vascu lar system ), and the p hysical exam
p ortion of screening shou ld inclu d e rou tine p hysical

Table 5.1 Importa nt phys ica l e xamination proce dure s for diffe re ntia ting vas culoge nic he ad a nd ne ck pain
Te s t Purpos e Evide nce s ta tus Limita tion a nd a dva nta g e s

Functional positional A ects ow in contralateral
test, cervical rotation vertebral artery. Limited e ect on
internal carotid artery.
Functional positional A ects ow in internal carotid
test, cervical extens ion arteries. Limited e ect on
vertebral arteries .
Blood pres sure Measure o cardiovas cular health.
examination
Cranial nerve Identif es s pecif c cranial nerve
examination dys unction resulting rom
ischaemia or vessel compres sion.
Eye examination Ass ists in diagnos is o pos sible
neural def cit related to internal
carotid artery dys unction.
Handheld Doppler Direct ass ess ment o blood- ow
ultrasound velocity.
(Modif ed and adapted rom Kerry R, Taylor AJ. 2006. Cervical arterial dys unction ass es s ment and manual therapy. Man Ther 11: 243–253.)
Poor s ensitivity, variable specif city. Only as sesses posterior
Blood- ow studies support e ect circulation. Res ults should be
on vertebral artery ow. interpreted with caution.
Recommended by existing
protocols. Cannot predict
propensity or injury.
No s pecif c diagnos tic utility Primarily as ses ses anterior
evidence available. Blood- ow circulation.
s tudies s upport e ect on internal
carotid artery ow.
Correlates to cervical arterial Reliability dependent on
atherosclerotic pathology. equipment, environment and
experience. Continuous, not
categorical, meas ure.
No s pecif c diagnos tic utility Reliability dependent on
evidence available. experience.
No s pecif c diagnos tic utility Eye symptoms may be early
evidence available. warning o serious underlying
pathology.
Limited manual therapy s pecif c Reliability dependent on
evidence. Existing s tudies suggest equipment, environment and
good to require urther s tudy. experience.
 50 PART 1 • 5 • Physical examination
Figure 5.1 Observing eyes during combined extension, rotation and side-
bending motion. (From Flynn et al 2008, with permission.)
assessm ent u sing increm entally greater m ovem ents and load s
of the cervical sp ine (Ru shton et al 2014). When ‘clearing’ the
cervical sp ine (see later section), the exam iner shou ld con-
stantly observe the p atient’s resp onse d u ring cervical range
of m otion, esp ecially d u ring rotation and com bined exten-
sion, rotation and sid e-bend ing m otions (Fig. 5.1). In ad d ition
to assessing for nystagm u s, the exam iner shou ld also note the
p resence of d izziness, lighthead ed ness, im p aired sensation to
the face, blu rred vision, or other signs or sym p tom s consistent
w ith com prom ise to the vertebrobasilar com plex.
A thorou gh history is vital w hen screening the lu m bar
sp ine for m ed ical cond itions su ch as sp inal tu m ou r or infec-
tion. Most red ags for both m alignancy and infection are
d iscovered d u ring the patient interview, and are m ore d iag-
nostically valu able w hen com bined w ith the nd ings of the
p hysical exam ination, as op posed to in isolation (H enschke
et al 2007, 2009). As alw ays, the clinician should learn to
be suspicious w henever the patient d em onstrates sym ptom s
or exam nd ings inconsistent w ith neuro-m u scu loskeletal
p athology.
Screening for Severe Injuries
to the Spine
Und iagnosed vertebral fractu re should be a concern to the
clinician w hen d ifferentiating the origin of sym p tom s in the
sp ine, esp ecially after any sort of trau m a. The Canad ian
C-sp ine ru le and the N EXUS low -risk criteria are clinical d eci-
sion ru les that ind icate w hen to ord er cervical sp ine rad io-
graphs to ru le ou t cervical fractu res (Stiell et al 2003) and
these have been d etailed in Chap ter 3. Both criteria are excel-
lent at ru ling ou t clinically im p ortant cervical sp ine fractu res
(Stiell et al 2003) and the Canad ian C-spine ru le has been
show n to be su p erior to clinician ju d gem ent in ord ering rad i-
ograp hy (Band iera et al 2003).
In screening for fractu re in the lu m bar spine, m ost red ags
shou ld be d iscovered w hilst taking the p atient history. A sys-
tem atic review (H enschke et al 2008) d iscu ssed ve red ags
Figure 5.2 Sharp–Purser test. (From Flynn et al 2008, with permission.)
that are essential to the history w hen screening for lu m bar
vertebral fractu re: acu te trau m a, acu te p ain and tend erness,
age > 50 years, fem ale gend er and d istracting p ainfu l inju ry.
A fu rther stu d y (H enschke et al 2009) d erived a clinical pre-
d iction ru le id entifying fou r featu res that w ere rep orted to
p red ict lu m bar sp inal fractu re: age > 70 years, fem ale gend er,
signi cant trau m a and p rolonged u se of corticosteroid s. The
researchers fou nd that the presence of three or m ore of these
factors increased the post-test probability of vertebral fracture
from 0.5% to 52%; how ever, this nd ing has not been vali-
d ated at this tim e. These stu d ies accentuate the im portance of
taking a thorou gh history in p atients w ith low back p ain.
In ad d ition, u pper cervical spine instability shou ld be
screened for in the p resence of any p red isp osing factors, esp e-
cially before ad m inistering any m echanical treatm ent su ch as
m obilization, m anip u lation, or traction of the u p p er cervical
sp ine. Up p er cervical sp ine instability has been associated
w ith traum a and infection, and is also com m only reported in
p atients w ith rheu m atoid arthritis becau se of the chronic
in am m ation and su bsequent tissu e d egeneration in this con-
d ition (Sizer et al 2007). Ad d itionally, people w ith congenital
d isord ers such as Dow n synd rom e (Salm an Riaz 2007), Marfan
synd rom e (Dem etracopou los & Sp onseller, 2007) and other
skeletal d ysp lasias (Song & Maher 2007) are at increased risk
of exp eriencing u p p er cervical sp ine instability.
Several clinical tests have been p u rp orted to screen for
u p p er cervical sp ine instability by testing for laxity of the
transverse ligam ent of the atlas (TLA), of w hich the TLA test
and the Sharp –Pu rser test are perhaps the m ost w id ely know n.
To p erform the TLA test, the exam iner grasp s the craniu m of
a sitting p atient w ith one hand w hilst stabilizing C2 against
C3 in a ventral–caud al d irection. The exam iner then translates
the craniu m and C1 in a ventral d irection. The test is rep eated
in each lateral d irection and consid ered to be positive w hen
sym p tom s are rep rod u ced d u ring the test (Sizer et al 2007).
The Sharp–Pu rser test is perform ed on a patient w ho is sitting
w ith the neck in a sem i exed position. With one hand on the
p atient’s forehead and the ind ex nger of the other hand on
the sp inou s p rocess of axis, the exam iner ap p lies p osterior
p ressu re throu gh the p atient’s forehead (Fig. 5.2). A slid ing

m otion of the head p osteriorly in relation to the axis ind icates
a p ositive test for atlanto-axial instability. Althou gh the d iag-
nostic u tility of the TLA test is u nknow n, the single stu d y to
investigate the Sharp–Pu rser test fou nd it to be highly sp eci c
in id entifying u pper cervical sp ine instability as d e ned by
rad iographic evid ence of an atlantod ens interval of greater
than 3 m m (Uitvlugt & Ind enbaum 1988). The resu lting +LR
of 17.3 and −LR of 0.32 su ggest that the Sharp –Purser test m ay
be very helpful in both ruling in and ruling ou t u pper cervical
sp ine instability. H ow ever, this w as stu d ied only in su bjects
w ith rheum atoid arthritis, so it is not know n how this test
w ou ld p erform in a d ifferent popu lation.
Furtherm ore, as w ith m ost screening tests, the paucity of
stu d ies investigating tests for u p p er cervical sp ine instability
shou ld not p revent clinicians from p erform ing them or,
p erhap s m ore im portantly, u sing robust clinical reasoning
d u ring screening for su ch d isord ers. The im portance of clini-
cal reasoning and u p p er cervical ligam ent testing has been
w ell d ocu m ented in case stu d ies (Elliott & Cherry 2008;
Mintken et al 2008) that illu strate the potential effects of up per
cervical sp ine instability as w ell as how p ositive ou tcom es can
be obtained if properly d iagnosed .
Screening for Neurological De cits
In ad d ition to screening for m ore seriou s neu rological d is-
eases, m uscu loskeletal provid ers should attem p t to screen for
rad icu lopathies and m yelopathies. Rad icu lopathies are d isor-
d ers of the sp inal nerve roots as they exit the spinal colu m n.
They are m ost com m only cau sed by d isc herniation or other
sp ace-occu p ying lesions and resu lt in in am m ation and / or
im pingem ent of the nerve root (Wainner et al 2003). Patients
w ith cervical rad icu lopathy m ay or m ay not exp erience
pain, w hich if p resent com m only occu rs in the neck, up per
extrem ity and thoracic regions (Slipm an et al 1998). Pain
associated w ith lu m bar rad iculop athy is often d escribed
as ‘aching’, ‘bu rning’ or ‘sharp’ p ain that typ ically presents
in the low back, bu ttocks, and one or both legs (Tom ić
et al 2009). Ad d itionally, both cervical and lu m bar rad icu-
lopathy com m only cause u nilateral extrem ity strength, sensa-
tion and re ex d e cits that are con ned to the d istribu tion
of the affected nerve root(s) (Mu rphy et al 2009; Tom ić
et al 2009). With lum bar rad iculop athy (w ith the exception
of S1), the sym p tom s are less likely to follow speci c d er-
m atom al p atterns than w ith cervical rad icu lop athy (Mu rp hy
et al 2009).
Myelop athies, as op p osed to rad icu lop athies, are d isord ers
of the sp inal cord and are d iscu ssed in d etail in Chap ter 11.
Theoretically, they can occu r at any vertebral level from C1
to w here the sp inal cord term inates at ap proxim ately L1
(Macd onald et al 1999); how ever, they are m ost com m on in
the cervical sp ine. Initial sym p tom s of cervical m yelop athy
tend to be d escribed as generalized neck p ain or stiffness.
Myelop athies of the m id -cervical spine (C3–C5) often progress
to cau se m ore d istal p ain and sym p tom s of nu m b and / or
‘clu m sy’ hand s. In the low er cervical spine (C6–T1), sym p -
tom s typ ically also inclu d e w eakness and p rop riocep tive
losses in the legs that can resu lt in gait d isturbances.
Myelop athies and rad icu lop athies can often be d if cu lt
to d istingu ish from one another. Moreover, they are not
Screening for neurological de cits 51
m u tu ally exclu sive as m any p atients have d isord ers that
affect both the nerve roots and the sp inal cord . That said , the
tw o m ost obviou s d iscrim inators betw een the cond itions
are the presence of bilateral or u nilateral sym p tom s and of
u p p er m otor neu ron or low er m otor neu ron sym p tom s.
Patients w ith sim p le (single u nilateral level) rad icu lop athies
classically p resent w ith u nilateral low er m otor sym p tom s
only, w hereas p atients w ith m yelop athies typ ically p resent
w ith bilateral sym ptom s that includ e u pper m otor neu ron
signs. Moreover, a rad icu lop athy affecting a single nerve
root can theoretically be id enti ed by the pattern and location
of d erm atom al and m yotom al sym p tom s. (Read ers are
referred to Chs 11 and 17 for further d iscu ssion on these
cond itions.)
Cau d a equ ina synd rom e is a related neu rological cond ition
in w hich com pression to the caud a equina cau ses acu te
d am age to the lu m bar plexus (nerve roots) of the spinal canal
below the term ination of the spinal cord at L1 (Macd onald
et al 1999). Like m any other red ags in p atient care, this
synd rom e shou ld be d iscovered d u ring a thorou gh p atient
history taking and is consid ered a m ed ical em ergency. The
low er m otor nerves com prising the cau d a equ ina su pply the
m ajority of the sensory and m otor innervation to m ost of
the low er extrem ities and p elvic region and , as su ch, the
sym p tom s inclu d e m u ltisegm ent sensory and m otor changes.
The m ost com m on sym ptom s that the clinician should inqu ire
abou t includ e bilateral leg p ain, sad d le region anaesthesia,
loss or change in bow el and blad d er control, and severe
back p ain (Fraser et al 2009; Shi et al 2010). The clinician
shou ld m ake it a p riority to screen for this cond ition, as it
is a m ed ical em ergency frequently requ iring im m ed iate surgi-
cal intervention.
Nerve root examination
Trad itional neu rological screening consists of sensation,
m u scle stretch re ex and m anu al m u scle testing. Althou gh for
d ecad es it has been consid ered a key com ponent of any stand -
ard neu ro-m u sculoskeletal exam ination, very little evid ence
exists regard ing the d iagnostic u tility of trad itional neurologi-
cal screening. The one stu d y (Wainner et al 2003) to investi-
gate the d iagnostic u tility of neurological testing in the u pper
qu arter d id so by com p aring nd ings w ith a d iagnosis of
cervical rad icu lop athy via need le electrom yograp hy and
nerve cond u ction stu d ies. The nd ings from this stu d y su g-
gested that neurological testing in the u pper qu arter is of
only m od erate bene t, and is m ost robu st w hen com bining
m u ltip le p ositive nd ings, as op p osed to taking the resu lts
in isolation.
Stu d ies investigating the d iagnostic u tility of neu rological
testing of the low er qu arter rep ort sim ilar nd ings. In a
Cochrane review (van d er Wind t et al 2010), au thors ap praised
the available evid ence of neu rological testing to id entify
rad icu lop athy d u e to lum bar d isc herniation. Sensation,
m u scle strength and re exes w ere of little help w hen u sed in
isolation, bu t w ere of m od erate utility if u sed in com bination
in screening for lu m bar rad iculopathy. These resu lts, how ever,
w ere obtained in popu lations w ith a very high prevalence of
d isc herniation (> 75% in nearly all stu d ies); therefore they
cannot necessarily be generalized to p op u lations w ith a low er
p revalence of that cond ition.
 52 PART 1 • 5 • Physical examination

Althou gh nd ings from these stu d ies suggest that neu ro-
logical exam testing m ay be m arginally help fu l in id entifying
rad iculopathy, it is im portant to note the challenges of per-
form ing such research. First of all, there is no u niversally C2
agreed -u p on d e nition of rad icu lopathy; som e sou rces d e ne C3
it solely by the clinical exam (Magee 2008), w hereas others use C4
im aging or electrop hysiological nd ings as the criterion C5 C6
stand ard (Ru binstein et al 2007; van d er Wind t et al 2010). T1
T2
Ad d itionally, there is w id e ind ivid ual anatom ical variation in T3
T4
nerve root innervations (Magee 2008), w hich m eans that oper- T5
T6
ational d e nitions of w hat constitu tes positive nd ings for T7
each nerve root m ay greatly affect the rep orted d iagnostic T8
T9
u tilities of the tests. Lastly, the sym p tom s associated w ith
T10
rad icu lopathies have been reported to be highly variable and T11
som ew hat u np red ictable (Slip m an et al 1998; Cook 2007; L1 T12
Mu rp hy et al 2009; Tom ić et al 2009); this natu rally d ecreases C6
L2 C8
the ability of even a highly reliable test to id entify u nd erlying S2,3 C7
p athologies. L3
Therefore, w e ad vocate that sensation, m u scle stretch
re ex and m anu al m uscle test screening be rou tinely per-
form ed as a p art of every m u scu loskeletal exam ination. In L4
ad d ition to being p ru d ent from a neu rological perspective,
sensation, m u scle stretch re ex and m anu al m u scle testing
is largely consid ered the stand ard of care and therefore
shou ld also be p erform ed from a legal / ethical p ersp ective. Cervical (C)
Finally, the results of the neu rological screening can be used Thoracic (T)
L5
as interim ou tcom e m easu res to ju d ge a p atient’s response
Lumbar (L)
to treatm ent.
Sacral (S)

Sensation
Although light tou ch and p in-prick are the m ost com m on
testing p roced u res, sensation can also be tested by variou s
other m ethod s inclu d ing tw o-p oint d iscrim ination, vibration
and tem peratu re testing. In general, d erm atom al p atterns of
sensory changes are thou ght to be associated w ith rad icu lop a-
thies, w hereas m u ltip le-level and / or bilateral p atterns of
d erm atom al changes are associated w ith m yelopathies (Sizer
et al 2007). Althou gh there is som e ind ivid ual anatom ical
variation in d erm atom al nerve root innervations (Magee
2008), Figu re 5.3 illu strates a typ ical d erm atom al m ap .
Wainner et al (2003) tested p in-prick sensation grad ed as
norm al or abnorm al, and fou nd p oor d iagnostic u tility for
id entifying cervical rad icu lop athy at all d erm atom al levels.
With the excep tion of the C5 d erm atom e, d ecreased sensation
d em onstrated +LR p oint estim ates of < 1 and −LR estim ates
of > 1. H ow ever, the fact that both +LR and −LR con d ence
intervals inclu d ed ‘1’ for all d erm atom al levels ind icates
that the p resence of d ecreased sensation in isolation is not
a robu st m easu re of the p robability of having cervical
rad iculopathy.
In the lu m bar sp ine, sensory exam nd ings are sim ilar.
Many stu d ies have assessed the d iagnostic u tility of sensory
testing, w ith u nrem arkable resu lts. One stu d y (Lau d er et al
2000a) assessed sensation via pin-prick and vibration, and
reported the nd ing as abnorm al w hen either sensation w as
red uced on the sid e of the lesion. They reported a sensitivity
of 0.50, sp eci city of 0.62, +LR of 1.32 and −LR of 0.81. In isola-
tion, this gives the clinician very little con d ence w hen u sing
sensory testing to assess nerve root involvem ent. Sim ilarly, a
Cochrane review (van d er Wind t et al 2010) reported a range
of sensitivities for sensory testing from 0.39 to 0.68, and
S1
Figure 5.3 Typical dermatomes.
sp eci cities ranging from 0.62 to 0.89. As d iscu ssed earlier in
this chap ter, screening tests shou ld id eally be m ore sensitive
than sp eci c, so that clinicians can con d ently ru le ou t the
d isord er in the presence of a negative test. The fact that m ost
stu d ies have fou nd higher sp eci city than sensitivity in
sensory testing su ggests that, w hen cond u cting a lu m bar
sensory exam , the clinician shou ld be scep tical of a negative
result as it m ay, in fact, be a false negative.
N evertheless, a sensory screen provid es a baseline level of
p atient p resentation and shou ld d rive the exam iner ’s su bse-
qu ent testing, p articu larly if there is m u ltisegm ental or bilat-
eral loss of sensation.
Myotomes
Like sensation, m anu al m u scle testing has also been rep orted
u sing variou s m ethod s. Mostly com m only, isom etric strength
is tested by provid ing m anu al resistance to the m u scle in the
m id range of a joint’s range of m otion. The p atient is instru cted
to ‘not let m e m ove you ’ as the exam iner exerts enou gh force
to su rp ass (break) the p atient’s m axim al isom etric resistance.
The p atient’s m axim um resistance is generally grad ed on a
scale from 0 to 5, w ith som e clinicians ad d ing + or − to d elin-
eate the scale fu rther:
• 5 (normal): com p lete range of m otion against gravity
w ith full resistance
 Screening for neurological de cits 53

Table 5.2 Manual mus cle te s ting for the ce rvica l ne rve roots
Ne rve root Prima ry mus cle s Te s t proce dure
inne rva te d

C1 and C2 Mus cles that ex the neck The examiner stabilizes the trunk with one hand and applies a pos teriorly directed orce
through the patient’s orehead while matching the resis tance.
C3 Mus cles that side-bend The examiner stabilizes the shoulder with one hand and applies a orce away rom the
the neck s ide to be tested while the patient is instructed to match the res istance.
C4 Muscles that elevate the The patient is ins tructed to elevate the shoulders .
shoulders The examiner applies an in eriorly directed orce through the s houlders while the patient
is instructed to match the res istance.
C5 Deltoids The patient is instructed to abduct their shoulders to 90°. The examiner applies a orce
into adduction while the patient resis ts .
C6 Biceps braquii and The patient’s elbow is exed to 90° and the orearm s upinated. The examiner applies a
extens or carpi radialis orce into extension while the patient res ists .
brevis and longus The patient’s elbow is exed to 90°, orearm pronated, and wrist extended and radially
deviated. The examiner applies a orce into exion and ulnar deviation while the
patient resis ts.
C7 Triceps braquii and exor The patient’s elbow is exed to 90° and the examiner applies a orce into elbow exion
carpi radialis while the patient res ists .
The patient’s elbow is exed to 90° with the wrist exed and radially deviated with
orearm supinated. The examiner applies a orce into wrist extens ion and ulnar
deviation while the patient resis ts.
C8 Abductor pollicis brevis The examiner places the thumb in abduction. The examiner applies a resis tance through
the proximal phalanx in the direction o abduction while the patient resis ts.
T1 First dors al inteross ei The examiner separates the index and middle f nger and applies a orce against the
lateral as pect o proximal phalanx o the index f nger into adduction.

• 4 (good): com p lete range of m otion against gravity w ith
som e resistance
• 3 ( air): com p lete range of m otion against gravity
• 2 (poor): com p lete range of m otion gravity elim inated
• 1 (trace): evid ence of slight m u scle contraction
• 0 (zero): no evid ence of m u scle contraction.
Although all m u scles are innervated by m u ltip le nerve roots,
those m u scles that are p rim arily innervated by each level are
selected to screen the cervical and lu m bar nerve roots and
these are listed in Tables 5.2 and 5.3; the testing of each m u scle
is illu strated in Figu res 5.4–5.18.
Wainner et al (2003) tested m anu al m u scle testing d ichot-
om ized as either norm al or abnorm al, and generally fou nd
p oor d iagnostic u tility for id entifying cervical rad icu lopathy.
Although the +LR p oint estim ates for the d eltoid s and bicep s
w ere 2.1 and 3.7 resp ectively, LR con d ence intervals for
every m u scle inclu d ed ‘1’, ind icating that the p resence of
isolated w eakness m ay not alter the probability of having
cervical rad icu lop athy.
A Cochrane review assessed seven stu d ies that looked at
strength of m u scles innervated by lu m bar nerve roots. They
fou nd sim ilar resu lts, w ith sensitivities ranging from 0.29
to 0.62, and sp eci cities ranging from 0.50 to 0.89 (van d er
Wind t et al 2010). In both the cervical and lum bar spine,
w eakness in one m yotom e alone d oes not provid e ad equate
inform ation. H ow ever, nd ings of gross w eakness or m u lti-
segm ental w eakness have not been stu d ied , and these are
m ore likely to be su ggestive of m yelop athy, p erip heral nerve
injury or neu rom uscu lar d isease.
Ref exes
Attenuated m uscle stretch re exes (MSRs) su ggest low er
m otor neu ron p roblem s, m ostly com m only of the sp inal nerve
roots (i.e. rad icu lopathy). H yperactive m u scle stretch re exes
can p resent an increased single resp onse and / or rep etitive
response (clonu s). Generally, the cervical nerve roots are
screened by testing the bicep s, brachiorad ialis and tricep s
MSRs and the lu m bar nerve roots are assessed by testing the
p atellar and Achilles MSRs. These are illu strated in Figures
5.19–5.23. As w ith m yotom es and sensation, MSR testing has
been reported to be poorly sensitive for id entifying (i.e. ru ling
ou t) cervical and lu m bar rad icu lop athy (Lau d er et al 2000b;
Wainner et al 2003; van d er Wind t et al 2010), perhaps becau se
m any abnorm alities of both efferent and afferent p athw ays
via electrom yograp hy have been fou nd to be su bthreshold
d uring MSR testing (Miller et al 1999). H ow ever, tw o stu d ies
(Laud er et al 2000b; Wainner et al 2003) found that the p res-
ence of a d ecreased biceps re ex su bstantially increased the
p robability of p atients having (i.e. ru ling in) a cervical rad icu -
lop athy (+LR 4.9–10). The nd ings of the stu d ies con icted ,
how ever, regard ing the u tility of a d ecreased brachiorad ialis
or tricep s re ex. Laud er et al (2000b) fou nd +LRs of 2.0 for a
d ecreased triceps re ex and 8.0 for a d ecreased brachiorad ia-
lis re ex, w hereas Wainner et al (2003) fou nd +LRs that d id
not alter the p robability of having cervical rad icu lop athy.
In assessing the lu m bar nerve roots, Lau d er et al (2000a)
fou nd the patellar re ex to have high speci city at 0.93, w ith
a +LR of 7.14. H ow ever, a Cochrane review (van d er Wind t
et al 2010) found a w id e range for both Achilles and p atellar
 54 PART 1 • 5 • Physical examination

Table 5.3 Manual mus cle te s ting for the lumbar ne rve roots
Ne rve root Prima ry mus cle s inne rva te d Te s t proce d ure

L2–L3 Hip exors The patient exes the hip to near end range and the examiner applies a orce to
the anterior thigh into hip extension while the patient res ists .
L3–L4 Knee extensors The patient extends the knee to a pos ition slightly les s than ull extension. The
examiner stabilizes the patient’s thigh with one hand and applies pres sure on the
anterior dis tal tibia into knee exion with the other while the patient res ists .
Step-up: the patient is instructed to step up onto a step s tool. I the patient exhibits
di f culty this could sugges t involvement o the L3–L4 nerve root.
L4 Ankle dors i exors The patient dors i exes the ankle with slight inversion. The examiner stabilizes the
distal tibia with one hand and the other hand applies press ure on the dors um o
the oot into plantar exion with s ome eversion while the patient res ists .
L5 Hallux extension The great toe is placed into extension. The examiner stabilizes the oot with one
hand and applies pres sure on the dorsum o the distal phalanx o the big toe
into exion while the patient res ists .
L5–S1 Ankle plantar- exors The patient is as ked to rise up on the toes . Inability or di f culty to do so in relation
to the oppos ite s ide may be indicative o involvement o the L5–S1 nerve root.
S1–S2 Ankle evertors The ankle is placed in ull eversion and dorsi exion. The examiner s tabilizes the
distal tibia with one hand and with the other hand applies press ure on the lateral
aspect o the oot into plantar exion and invers ion while the patient resis ts.

Figure 5.4 Cervical exion (C1–C2). (From Flynn et al 2008, with permission.) Figure 5.6 Shoulder elevation (C4). (From Flynn et al 2008, with permission.)

Figure 5.5 Cervical side-bending (C3). (From Flynn et al 2008, with permission.) Figure 5.7 Shoulder abduction (C5). (From Flynn et al 2008, with permission.)
 Screening for neurological de cits 55

Figure 5.8 Elbow exion (C6). (From Flynn et al 2008, with permission.) Figure 5.11 Finger abduction (T1). (From Flynn et al 2008, with permission.)

Figure 5.9 Elbow extension (C7). (From Flynn et al 2008, with permission.) Figure 5.12 Hip exion (L2–L3).

Figure 5.10 Thumb abduction (C8). (From Flynn et al 2008, with permission.) Figure 5.13 Knee extension (L3–L4).
 56 PART 1 • 5 • Physical examination
Figure 5.14 Step up (L3–L4).
Figure 5.15 Ankle dorsi exion (L4).
re exes. Achilles MSR, as assessed in seven d ifferent stud ies,
d em onstrated sensitivities ranging from 0.31 to 0.62, and
speci cities ranging from 0.60 to 0.89. Patellar MSR values
also varied greatly in the stu d ies assessed , m aking conclu-
sions d if cu lt to d raw. Given the challenges of p erform ing
su ch stu d ies and the lack of a su p erior evid ence-based alter-
native, how ever, it is recom m end ed that sensation testing,
m anu al m u scle testing and re ex testing are p erform ed for all
p atients w ith spinal or extrem ity d isord ers.
Neurodynamic assessment
In ad d ition to assessing sensation, m anu al m uscle testing and
MSRs, there are several tests that have been su p p orted in
literatu re to help ru le ou t rad icu lop athy in both the cervical
Figure 5.16 Hallux extension (L5). (From Flynn et al 2008, with permission.)
Figure 5.17 Plantar exion (L5–S1).
and lum bar spine. In the cervical neu rological exam , tw o
ad d itional tests have been id enti ed that, w hen p erform ed in
conju nction w ith cervical range of m otion w ith overp ressu re,
su bstantially alter the p robability of a p atient’s sym p tom s
originating from the cervical sp ine, or m ore sp eci cally the
p resence of cervical rad icu lop athy. Wainner et al (2003)
reported that w hen patients w ere fou nd to have a positive
u p p er lim b tension test A, d istraction test, Sp u rling’s test, and
cervical rotation less than 60° to the ipsilateral sid e, their prob-
ability of having a cervical rad icu lopathy w as increased from
23% to 90% (+LR 30.3). If three of these four tests w ere p osi-
tive, the p robability of having cervical rad icu lop athy changed
from 23% to 65% (+LR 6.1). Spu rling’s test is cervical sid e-
bend ing w ith a d ow nw ard and m ed ially d irected overpres-
su re, and is therefore inclu d ed in the general cervical screening
 Screening for neurological de cits 57

Figure 5.18 Ankle eversion (S1–S2). Figure 5.21 Testing triceps muscle stretch re ex. (From Flynn et al 2008, with
permission.)

Figure 5.19 Testing biceps muscle stretch re ex. (From Flynn et al 2008, with Figure 5.22 Testing patellar muscle stretch re ex. (From Flynn et al 2008, with
permission.) permission.)

Figure 5.20 Testing brachioradialis muscle stretch re ex. (From Flynn et al Figure 5.23 Testing Achilles muscle stretch re ex. (From Flynn et al 2008, with
2008, with permission.) permission.)
 58 PART 1 • 5 • Physical examination

Figure 5.24 Cervical distraction. (From Flynn et al 2008, with permission.)

exam ination (see Ch 11). To perform cervical d istraction, the

exam iner grasps a su pine patient u nd er the chin and occipu t
w hile slightly exing the patient’s neck and applies a d istrac-
tion force of ap proxim ately 14 p ou nd s (6 kg) (Fig. 5.24). The
test is consid ered p ositive if the p atient’s sym p tom s are
red uced d u ring the m anoeu vre. The u pper lim b tension test
A is also p erform ed w ith the p atient su p ine. The exam iner
then p erform s the follow ing m ovem ents in ord er (Fig. 5.25):
1. Scap ular d epression
2. Shou ld er abd u ction
3. Forearm supination
4. Wrist and nger extension
5. Shou ld er lateral rotation
6. Elbow extension B
7. Contralateral / ipsilateral cervical sid e-bend ing.
A p ositive resp onse is d e ned by any of the follow ing: Figure 5.25 Upper limb tension test: (A) starting position, (B) ending position.
1. Patient sym ptom s reprod u ced (From Flynn et al 2008, with permission.)
2. Sid e-to-sid e d ifferences in elbow extension > 10°
3. Contralateral cervical sid e-bend ing increases sym ptom s
or ip silateral sid e-bend ing d ecreases sym p tom s.
The u pper lim b tension test A (m ed ian nerve bias) u sed in
isolation is helpfu l for ru ling out cervical rad icu lopathy. The
d iagnostic accu racy has been d em onstrated to be su bstantial
(sensitivity 0.97, −LR 0.12) and thu s a negative test signi -
cantly red u ces the likelihood that a cervical rad icu lop athy is
p resent. (Read ers are referred to Ch 65 for further d iscussion
of neu rod ynam ic testing.)
In the lum bar spine, the straight leg raise (SLR) has been
show n to be a good screening tool for ru ling ou t lu m bar
rad icu lopathy (Devillé et al 2000). Pooled estim ates from a
m eta-analysis of 11 patients (Devillé et al 2000) yield ed a sen-
sitivity of 0.91, sp eci city of 0.26, +LR of 1.23 and −LR of 0.35,
ind icating that a negative resu lt is likely to be a tru e negative.
The SLR is typ ically p erform ed w ith the p atient su p ine and
knees fu lly extend ed , w ith their ankles in neutral d orsi exion.
The exam iner p assively exes the hip w hile m aintaining the
knee in extension. The am ount of hip exion is record ed at
the p oint of p ain or p araesthesia in the back or leg (Fig. 5.26).
A p ositive resu lt is d escribed as rep rod u ction of sym p tom s at Figure 5.26 Straight leg raise. (From Flynn et al 2008, with permission.)
 Screening for neurological de cits 59

Figure 5.27 Slump test. (From Flynn et al 2008, with permission.) Figure 5.28 Hoffman’s re ex. (From Flynn et al 2008, with permission.)

40° or less. The slu m p test is another useful screening tool to

help the clinician ru le ou t lu m bar rad icu lop athy, w ith an esti-
m ated sensitivity of 0.84 and a +LR of 4.94 (Majlesi et al 2008).
It is perform ed w ith the patient sitting w ith the back straight.
From here, the patient is instructed to slum p into lu m bar and
thoracic exion w hile looking straight ahead , then to ex the
neck fu lly and extend one knee, and nally to d orsi ex the
ipsilateral foot (Fig. 5.27). The test is consid ered p ositive if it
reprod uces the p atient’s fam iliar pain. (Ch 65 of this textbook
d escribes the slum p test in m ore d etail.)

Upper motor neuron examination

Although p robably not required for all patients, further neu -
rological exam ination shou ld be perform ed w hen ind icated
by the history, observation or a trad itional neurological
screen. For exam p le, if a p atient rep orts su bjective com p laints
of bilateral neu rological involvem ent, a history of neck trau m a
and / or problem s w ith balance or w alking, the exam iner
shou ld inclu d e an u p p er m otor neu ron exam ination as a p art
of the neu rological screen. Moreover, if the exam iner w it-
nesses p roblem s w ith coord ination or gait d istu rbances
d u ring visual observation or clonu s d u ring m u scle stretch
re ex testing, he / she m ay su spect d isturbances of the corti-
cosp inal and sp inocerebellar tracts w ithin the sp inal cord and
fu rther testing is also ind icated . Whereas d isru ptions of the
sp inal nerve roots generally cau se attenu ation of m otor
re exes, d isord ers of the central nervous system usually result
in d isrup tion of the u pper m otor neuron’s regu latory control
over the m otor re exes and they becom e hyp er-re exive.
Although no stu d ies, to ou r know led ge, have investigated the
d iagnostic utility of tests of the u pper m otor neu ron system ,
the follow ing are a p ru d ent set of p roced u res that have been
ad vocated to id entify upp er m otor neu ron p roblem s.
H offm an’s re ex (Fig. 5.28) is tested w ith the patient seated
and w ith the head in a neu tral p osition. The exam iner icks
the d istal p halanx of the m id d le nger and the test is consid -
ered positive if there is exion of the interphalangeal joint of
the thu m b, w ith or w ithou t exion of the ind ex nger ’s p roxi-
m al or d istal interp halangeal joints.
Figure 5.29 Babinski sign. (From Flynn et al 2008, with permission.)
Babinski sign (Fig. 5.29) is tested w ith the patient su pine.
The exam iner strokes the plantar surface of the foot w ith a
ngernail or instru m ent from the p osterior lateral su rface
tow ard s the ball of the foot. The test is consid ered p ositive if
the great toe extend s and the other toes fan ou t.
Clonu s (Fig. 5.30) is generally assessed in the gastrocne-
m iu s and soleu s m u scles and can be assessed w ith the p atient
either seated or sup ine. The exam iner rap id ly d orsi exes the
ankle and the test is consid ered p ositive if the qu ick stretch
results in re exive tw itching of the plantar- exors.
Rom berg test (Fig. 5.31) is p erform ed w ith the patient
stand ing w ith feet close together. The p atient is then instru cted
to close the eyes and the test is consid ered p ositive if the
am ount of sw ay is increased w hen the eyes are closed , or if
the p atient loses balance.
The scapu lohum eral re ex is evalu ated from u pper m otor
neuron signs from the up per cervical spine (C1–C4). The
exam iner strikes the su perior tip of the patient’s lateral
acrom ion process and / or the superior m id p oint of the
 60 PART 1 • 5 • Physical examination

scap u lar sp ine w ith a re ex ham m er. A test is consid ered
p ositive w hen the patient involuntarily shru gs and / or
abd u cts the shou ld er (Shim izu et al 1993; Sizer et al 2007).
Lherm itte’s sign is elicited w hen cervical exion cau ses
tingling and / or an ‘electrical shock’ in the m id line of the
thoracic sp ine; it is thou ght to signify the p ossible p resence of
sp inal cord cond itions inclu d ing m u ltip le sclerosis, tu m ou rs
or other sp ace-occu p ying lesions (Sizer et al 2007; Gem ici
2010).
u p p er m otor neu ron screen, a cranial nerve exam ination is
recom m end ed w hen ind icated by the history, observation or
trad itional neu rological screen. Som e exam p les of ind ications
are if patients report signi cant traum a to the head or neck,
sym p tom s su ch as p ain, w eakness or nu m bness in the head ,
face or neck, visu al or other sensory d isturbances, or trouble
w ith eating, d rinking or sw allow ing. Table 5.4 lists the 12
cranial nerves and a typ ical exam ination of each.

Cranial nerve examination Clearing the Spine

The 12 cranial nerves are peripheral nerves carrying m otor Even in the absence of neu rological d e cit, it is not u ncom -
and sensory inform ation to the head , face and neck. Like the m on for sym p tom s anyw here in the u p p er or low er

Figure 5.30 Testing for clonus. (From Flynn et al 2008, with permission.) Figure 5.31 Romberg test. (From Flynn et al 2008, with permission.)

Table 5.4 Crania l ne rve s and cranial ne rve e xamination

Cra nia l ne rve numb e r Function Te s t

I: Ol actory Sensory rom ol actory epithelium As ses s the ability to smell common s cents .
II: Optic Sensory rom retina o eyes As ses s peripheral vis ion by having pers on read an eye
chart.
III: Oculomotor Motor to muscles controlling upward, As ses s pupil constriction as a reaction to light.
downward, and medial eye movements ,
as well as pupil cons triction
IV: Trochlear Motor to mus cles controlling downward and Ass ess the ability to move eye downward and inward by
inward eye movements as king patient to ollow your f nger.
V: Trigeminal Sens ory rom ace and motor to muscles o Test sensation o ace and cheeks as well as corneal
mas tication re ex. Ass ess the patient’s ability to clench the teeth.
VI: Abducens Motor to mus cles that move eye laterally Assess patient’s ability to move eyes away rom midline by
asking him to ollow your f nger with his eyes.
VII: Facial Motor to muscles o acial expres sion and As ses s symmetry and s moothnes s o acial express ions .
s ens ory to anterior tongue Tes t tas te on anterior two-thirds o tongue.
VIII: Vestibulocochlear Hearing and balance As ses s by rubbing f ngers by each ear. Patient s hould hear
both equally. Can als o as k patient to per orm balance
test.
Continued
 Clearing the spine 61

Table 5.4 Crania l ne rve s a nd cranial ne rve e xamina tion—cont’d

Cra nia l ne rve numb e r Function Te s t

IX: Glos sopharyngeal Controls gag re ex and sens ory to posterior As sess gag re ex and taste on the pos terior tongue.
tongue
X: Vagus Controls muscles o pharynx, which acilitate As k patient to s ay ‘ah’ and watch or elevation o s o t
s wallowing palate.
Provides s ens ory to thoracic and abdominal
visceral region
XI: Access ory Motor to trapezius and s ternocleidomastoid Muscle testing o trapezius.
muscles
XII: Hypoglossal Motor to mus cles o the tongue Ask patient to stick tongue straight out. Tongue will deviate
towards injured side.

Figure 5.32 Cervical exion with overpressure. (From Flynn et al 2008, with Figure 5.33 Cervical extension with overpressure. (From Flynn et al 2008, with
permission.) permission.)

extrem ities to originate m ore proxim ally, especially from the

sp ine. Therefore, it is recom m end ed that exam iners p erform
a screening exam ination of the region proxim al to the prim ary
area of sym p tom s and , at a m inim u m , ensu re that d istal
sym p tom s are not p rim arily altered w ith m ovem ents of
the sp ine. The cervical- and lu m bar-screening exam ination
shou ld consist of active range of m otion of exion, extension,
bilateral sid e-bend ing, bilateral rotation, and com bined
extension, sid e-bend ing and rotation (quad rant). If no sym p-
tom s are p rod u ced w ith a fu ll active range of m otion, the
exam iner shou ld then ad d slow overp ressu re to each m otion
(Figs 5.32–5.39).
The next com ponent of ‘clearing’ the cervical or lu m bar
sp ine as the p rim e contribu tor to the p atient’s sym p tom s is a
central p osterior-to-anterior accessory glid e of each vertebra.
This is com m only referred to as ‘spring testing’, w hich tests
for segm ental m ovem ent and p ain response. In both the cervi-
cal and lu m bar sp ine, this is tested w ith the p atient in p rone
position. When testing the cervical sp ine, the exam iner con- Figure 5.34 Cervical side-bending with overpressure. (From Flynn et al 2008,
tacts the sp inou s p rocess w ith the thu m bs. The lateral neck with permission.)
m u scu latu re is gently p u lled p osteriorly w ith the ngers. At
this p oint, a p osterior-to-anterior force is im p arted in a p ro-
gressive and oscillatory fashion over the spinous process (Fig.
5.40). The test is positive if the p atient reports reprod u ction
 62 PART 1 • 5 • Physical examination

Figure 5.35 Cervical rotation with overpressure. (From Flynn et al 2008, with Figure 5.38 Lumbar side-bending with overpressure. (From Flynn et al 2008,
permission.) with permission.)

Figure 5.36 Lumbar exion with overpressure. (From Flynn et al 2008, with Figure 5.39 Combined lumbar extension, rotation and side-bending with
permission.) overpressure. (From Flynn et al 2008, with permission.)

Figure 5.37 Lumbar extension with overpressure. (From Flynn et al 2008, with Figure 5.40 Posterior–anterior mobility of cervical spine. (From Flynn et al
permission.) 2008, with permission.)

Figure 5.41 Posterior–anterior mobility of lumbar spine. (From Flynn et al
2008, with permission.)
of their p ain or sym p tom s. The clinician then ad d itionally
jud ges the segm ent to be hypom obile, norm al or hyperm obile.
This test has been show n to be a good screening tool in
p atients w ith neck pain, w ith a sensitivity of 0.82 and a −LR
of 0.23 (Sand m ark & N isell 1995).
To assess p osterior–anterior m obility of the lu m bar spine,
the p atient is p ositioned in p rone. The exam iner contacts
the sp inou s p rocess w ith the hyp othenar em inence ju st d istal
to the p isiform . The exam iner shou ld be d irectly over the
contact area and , keep ing the elbow s extend ed , u se their
u p p er bod y to im p art a p osterior-to-anterior force in a p ro-
gressive and oscillatory fashion (Fig. 5.41). This is repeated
w ith all lu m bar segm ents. The clinician jud ges each segm ent
as being hyp om obile, norm al or hyperm obile, and reports
w hether or not it reprod uced the patient’s fam iliar pain. One
stu d y (Fritz et al 2005) has show n this test to be speci c (spe-
ci city 0.95, +LR 8.86) in p atients w ith rad iograp hic evid ence
of lu m bar instability. The clinician shou ld bear in m ind ,
how ever, that in the event of a negative resu lt it m ay be a false
negative. It is notew orthy that this stu d y w as not looking at
p atient w ith trau m atic instability requ iring m ed ical or surgi-
cal attention; instead it w as u sed in d irecting treatm ent later,
after a com p lete regional exam .
The nal com ponent of ‘clearing’ the cervical or lu m bar
sp ine as the p rim e contribu tor to the p atient’s sym p tom s
includ es p alpatory exam ination of the joint and m u scle struc-
tu res. Sp eci cally, p alp ating for trigger p oints w ithin the
sp ine and tru nk m u scu latu re that m ay refer p ain d istally is
ap p rop riate. (Ch 59 of this textbook includ es further inform a-
tion on referred p ain from trigger p oints.)
Region-speci c Examination
Like the screening p ortion, the clinician shou ld focu s the
region-speci c portion of the physical exam ination on testing
hyp otheses form ed d u ring the p atient history. Unlike the
screening p ortion, how ever, the region-sp eci c p ortion of the
physical exam ination generally consists of d ed u ctive p roce-
d u res aim ed at (1) narrow ing in on a p atient’s concord ant sign
and (2) gathering know led ge of how sp eci c m ovem ents
Region-speci c examination 63
affect the p atient’s sym ptom s. As d escribed in Chap ters 3 and
4, a patient’s concord ant sign consists of the fam iliar sym p-
tom s that cau sed them to seek m ed ical care (Laslett et al 2003).
During the region-sp eci c exam ination, concord ant signs are
d istinguished from d iscord ant signs, w hich are sym ptom s
that are u nlike the p ain or other sym p tom s that cau sed
the p atient to seek treatm ent (Laslett et al 2003). Clearly
establishing a p atient’s concord ant sign and know ing speci -
cally w hat m ovem ents or p roced u res p rim arily rep rod u ce
su ch sym p tom s is a p ragm atic m ethod for establishing a
p athoanatom ical d iagnosis. H ow ever, even w hen establish-
m ent of a sp eci c p athoanatom ical d iagnosis is not p ossible,
know led ge of a patient’s concord ant sign and the m ovem ents
or p roced u res that sp eci cally rep rod u ce that sign can be
u sed to gu id e p atient m anagem ent and evalu ate treatm ent
effectiveness. As w ill be d etailed in later chap ters, reassessing
a patient’s concord ant sign im m ed iately after each treatm ent
p roced u re is an objective m ethod of evalu ating the effective-
ness of the p roced u re and gu id ing the choice of w hich treat-
m ent p roced u re to p erform next. Therap eu tic bene ts
obtained u sing this m ethod w ithin a single treatm ent session
have been show n to be p red ictive of longer-term clinical ben-
e ts (H ahne et al 2004).
The region-speci c portion of the p hysical exam ination
shou ld generally consist m ostly of:
• active m ovem ents
• p assive m ovem ents
• p alpation
• clinical sp ecial tests.
Active m ovem ents are physiological m ovem ents perform ed
exclu sively by the patient in each m otion p lane for a selected
joint. The goals of active m ovem ents are both to id entify con-
cord ant versu s d iscord ant signs and to d eterm ine the effect
of the sp eci c active m ovem ents on those signs. Since all
active m ovem ents are w ithin the p atient’s com p lete control,
starting an exam ination w ith active m ovem ents begins the
d ed uctive exam ination process in a safe and grad u ally m ore
aggressive m anner. Consistent w ith this concept of increm en-
tally increasing load s, the exam iner w ill follow active m ove-
m ents that d o not cau se sym p tom s w ith overp ressu re, w hich
is m anual p ressu re in each d irection at the end range of
m otion. The overp ressu re shou ld start gently and the p res-
su re w ill be grad u ally p rogressed w hile carefu lly m onitoring
the p atient’s resp onse.
Passive m ovem ents inclu d e both p assive p hysiological
m ovem ents and p assive accessory m ovem ents p erform ed
exclu sively by the exam iner. Physiological m ovem ents are
joint m ovem ents that can be perform ed actively by the p atient,
su ch as exion, extension, sid e-bend ing and rotation. Acces-
sory m ovem ents are joint m ovem ents that cannot be p er-
form ed by the patient and generally occu r across joint planes,
su ch as anterior or p osterior glid es. Com p aring sym p tom
response d u ring passive physiological m ovem ents w ith that
of active p hysiological m ovem ents gives the exam iner infor-
m ation abou t the natu re of the affected tissu e and w hether it
is likely to be contractile (e.g. m u scle, tend on) or not (e.g. liga-
m ent, bone, cartilage, nerve). Ad d itionally, assessing p assive
p hysiological m otion allow s the exam iner to assess the tru e
full range of m otion w ithou t the lim itations of m u scle fu nc-
tion and p atient m otivation, and also p erm its the exam iner to
assess the type of resistance encou ntered at the end of joint
 64 PART 1 • 5 • Physical examination
m otion (‘end feel’). Assessm ent of p assive accessory m otion
is help fu l to localize m ore p recisely the tissu es and area
resp onsible for the concord ant sign. In the spine, for exam ple,
p assive accessory intervertebral m otions help the exam iner
isolate the sid e and sp eci c sp inal level(s) of p rim ary sym p -
tom s. Ad d itionally, m any m anu al p ractitioners u se assess-
m ents of both the am ou nt and qu ality of accessory m otions
to m ake treatm ent d ecisions abou t how and w here to d eliver
joint m obilization and / or m anipu lation. Althou gh assess-
m ents of joint m obility have consistently been show n to be
u nreliable (Mootz et al 1989; Binkley et al 1995; Maher et al
1998; Sm ed m ark et al 2000; H icks et al 2003; Fritz et al 2005;
Arab et al 2009), there is som e evid ence that such assessm ents
are help fu l in treatm ent selection and p atient m anagem ent
(Flynn et al 2002; Fritz et al 2005; H icks et al 2005; Brennan
et al 2006).
Palp ation is a stand ard p roced u re for alm ost any sort of
m ed ical exam ination. Like p assive accessory m otion testing,
it can help fu rther localize the tissu es and areas resp onsible
for the concord ant sign. Also, like passive accessory m otion
testing, p alp ation can help d ifferentiate w hether an area of
sym p tom s rep resents the p rim ary sou rce of sym p tom s or is
m ore likely to com p rise referred sym p tom s that actu ally orig-
inate in another location. For exam p le, p ain in the p roxim al
lateral forearm m ay be cau sed by local tissu es u nd erlying the
area (tend onopathy or ep icond ylalgia) or m ay be referred
from the cervical spine or shou ld er.
Clinical sp ecial tests are p roced u res u sed to id entify sp e-
ci c d iagnoses fu rther. They inclu d e com binations of active
and p assive m ovem ents, resistive tests and fu nctional tests,
and are generally both region and d iagnosis sp eci c. H u n-
d red s (perhaps thou sand s) of special tests have been ad vo-
cated based on clinician exp erience and biological p lau sibility.
A grow ing nu m ber of sp ecial tests have been scru tinized in
d iagnostic research by com paring their outcom es w ith those
of reference stand ard tests. Whenever p ossible, it is recom -
m end ed that clinicians select sp ecial tests and p roced u res
w ith know n d iagnostic u tility that have d em onstrated high
sp eci city and large +LRs.
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 PART 1 •  General Introduction
Treating the Brain in Chronic Pain
6  Chapter 
Ad ria a n Lo u w
CHAP TER CONTENTS
Changes in the nervous system and brain in people with   cep tive p athw ays.
chronic pain  66
Neuromatrix  66
Structural changes in the brain  68
Functional changes in the brain  69
Descending pathways  69
Treatment  70
Therapeutic neuroscience education – restricting meaning  71
Graded motor imagery – restructuring brain / body maps  73
Conclusion  73
Changes in the Nervous System and
Brain in People with Chronic Pain
Peop le’s p ain exp erience is com plex, ind ivid u alized and 100%
p rod uced by their brain (Moseley 2003a, 2007). Pain is a d eci
sion taken by the brain, based on the p ercep tion of threat
(Moseley 2007; Lou w & Pu ented u ra 2013). In contrast to pain,
of w hich the ind ivid u al w ill alw ays be aw are, nocicep tion can
be present w ithou t any aw areness. This d ichotom y is the basis
of the Cartesian m od el of p ain (1654), w hich assu m es that
tissu e inju ry or d isease states are synonym ou s w ith p ain
(H ald em an 1990; Gold berg 2008; Lou w & Puented u ra 2013).
N ot only is this false, but it still seem s to be the prevailing
m od el for treating p ain (Gold berg 2008). Furtherm ore, this
m od el of seeking ‘w hat tissu es to blam e’ m ay in fact be a
signi cant sou rce for the increased ep id em ic of chronic p ain
w orld w id e (H ald em an 1990; Gold berg 2008; Lou w & Pu ent-
ed u ra 2013). For any clinician interested in treating people in
p ain, esp ecially chronic p ain, the brain shou ld be the prim ary
target for d irecting treatm ent (Melzack 2001). It is now w ell
established that the central nervous system (CN S) and brain
u nd ergo several signi cant changes in ind ivid u als exp erienc
ing chronic p ain and m ay contribu te to the d evelop m ent and
m aintenance of chronic p ain states (Flor et al 1997; Flor 2000;
Schm id t Wilcke et al 2006; Apkarian et al 2009; Tracey &
Bu shnell 2009). It is thu s proposed that treatm ent shou ld aim
to restore these changes in the brain and CN S as a m eans to
ease the pain and su ffering of the patient w ith chronic pain.
Four key changes are d iscu ssed in this chapter: the pain
neu rom atrix, stru ctu ral changes in the brain, fu nctional
changes in the brain, and alteration of d escend ing antinoci
Neuromatrix
It is now w ell established that, d uring a pain experience,
m u ltip le areas of the brain are activated (Fig. 6.1) (Flor 2000,
2003; Melzack 2001; Moseley 2003a). This nd ing is contrary
to a aw ed historical view of a single p ain area in the brain
(Melzack 2001). This w id espread brain activation d uring a
p ain exp erience has becom e know n as the ‘p ain neu rom atrix’,
a term introd u ced by Ron Melzack in 1996. The p ain neu ro
m atrix is d e ned as a p attern of nerve im p u lses generated by
a d istributed neural netw ork in the brain (Melzack 2001). Pain
then, is p rod u ced by the ou tp u t of this w id ely d istribu ted
neu ral netw ork in the brain rather than d irectly by sensory
inpu t evoked by injury, in am m ation or other pathology
(Melzack 2001; Moseley 2003b). Althou gh care should be
taken in generalization, it is now w ell established that com m on
areas are activated d uring variou s pain exp eriences and these
areas have becom e synonym ou s w ith the pain neu rom atrix
(Melzack 2001; Flor 2003; Moseley 2003b; Pu ented u ra & Lou w
2012). The m ost com m on areas associated w ith the pain neu
rom atrix are the anterior cingu late, prim ary sensory cortex,
thalam u s, anterior insu la, and the p refrontal and p osterior
p arietal cortices (Flor 2000, 2003; Moseley 2003b). Du ring a
p ainfu l task, it is believed that these increasingly active brain
areas com m u nicate w ith each other, d eveloping in essence a
p ain m ap (Fig. 6.2) (Louw & Pu ented u ra 2013).
The pain neurom atrix provid es tw o im m ed iate clinically
im p ortant featu res. First, there are no speci c pain areas in
the brain and second ly, d u ring a p ain exp erience, p ain acti
vates several areas of the brian. In chronic p ain these areas are
likely to be ‘enslaved ’ by pain (Pu ented u ra & Lou w 2012;
Lou w & Puented ura 2013). For exam ple, a patient engaging
in m otor control exercises such as a co contraction of the
transversu s abd om inis and m u lti d u s (sp eci c sp inal stabili
zation exercises) (Richard son et al 2004) m ay have a hard tim e
executing the precise m otor control activities prescribed by
this ap p roach, since the m otor cortex is being u tilized as p art
of the p ain neu rom atrix (Moseley & H od ges 2002). From a
clinical p oint of view, this statem ent is p rofou nd . For too long
have p atients w ho are u nable to p erform these p recise and
intricate exercises been accu sed of m alingering, or being lazy
 Changes in the nervous system and brain in people with chronic pain 67

Figure 6.1 A single case unctional magnetic resonance imaging ( MRI) study o a patient with low back pain. The rst row indicates the brain activity while the subject
is in a rested state and the second row indicates the same subject’s scan while performing a painful task (anterior pelvic tilt). Note the widespread activity in the brain during
a painful task.

Area Primary function

1 5
1 Premotor cortex Organize and prepare movements
2
2 Cingulate cortex Concentration and focus
3 6
4 3 Prefrontal cortex Problem solving and memory
8
7
4 Amygdala Fear, conditioning and addictions
9
5 Sensory cortex Sensory discrimination

6 Hypothalamus/ Stress responses, automonic

thalamus regulation and motivation

7 Cerebellum Movement and cognitions

8 Hippocampus Memory, spatial recognition and

fear conditioning

9 Spinal cord Gating from the periphery

Figure 6.2 An illustration o the pain neuromatrix theory. (Image adapted from Louw A, Puentedura EJ. 2013. Therapeutic neuroscience education, Vol 1. Minneapolis,
MN: OPTP. p 76. Copyright Adrian Louw.)

or not m otivated , yet from a neu roscience p ersp ective there
is a ju sti ed reason for their d if culty w ith these exercises.
Sim ilarly, the p ain neu rom atrix theory of p ain u sing other
areas exp lains m any issu es com m only seen in p atients w ith
chronic pain – su ch as problem s w ith focus, concentration and
regulating bod y tem p erature, sleep d isturbances, or short
term m em ory issu es (Sapolsky 1994; Lu erd ing et al 2008).
More im p ortantly, u nd erstand ing these issu es and being able
to exp lain this to p atients w ith chronic p ain is the cornerstone
of therap eu tic neu roscience ed u cation (TN E) (Lou w et al
2011a).
The second key issu e of the p ain neu rom atrix is the ind i
vid u al’s exp erience of p ain (Moseley 2003a). Given the enor
m ou s com p lexity of neu ronal activation, synap tic activity,
neu rotransm itters and m od u lators, the p rim ary p ain m ap can
also be in uenced by neighbou ring neu ral circuits, w hich w ill
p robably in u ence the ind ivid u al p ain exp erience (Fig. 6.3)
(Pu ented ura & Louw 2012).
The fact that an ind ivid ual’s p ain m ap can be tu ned up or
d ow n by the ad jacent m aps w ith regard s their know led ge,
exp eriences, beliefs, etc. m akes each person’s pain experience
even m ore ind ivid u alized and com p licated . A skilled clinician
shou ld realize that a p ain exp erience is associated w ith variou s
su ch issu es, w hich m ay need to be ad d ressed in treatm ent
as w ell. The pain neurom atrix allow s, in essence, a neuro
science view of the interaction of a p ain circu it w ith variou s
bio psychosocial factors (yellow ags) that have been associ
ated w ith p oor ou tcom es (Kend all et al 1997; Kend all &
 68 PART 1 • 6 • Treating the brain in chronic pain
Figure 6.3 The primary pain map can also be inf uenced by neighbouring neural circuits. (Image adapted from Louw A, Puentedura EJ. 2013. Therapeutic neuroscience
education, Vol 1. Minneapolis, MN: OPTP. p 77. Copyright Adrian Louw.)
Watson 2000). Ad d ing fu rther to the com plexity of the neu ro
m atrix and ad jacent m ap s is the H ebbian theory, w hich p ro
p oses that ‘neu rons that re together w ire together ’ (Am it
et al 1994). This is a scienti c theory in neu roscience that
explains the ad aptation of neu rons in the brain d uring the
learning p rocess. It d escribes a basic m echanism for synap tic
p lasticity w herein an increase in synaptic ef cacy arises from
the p resynap tic cell’s rep eated and p ersistent stim u lation of
the p ostsynap tic cell. The theory fu rther su ggests that w hen
an axon of cell A is near enou gh to excite a cell B and repeat
ed ly or persistently takes part in ring it, som e grow th process
or m etabolic change takes p lace in one or both cells su ch
that A’s ef ciency, as one of the cells ring B, is increased
(Doid ge 2007). It is believed that the neurotransm itter
d opam ine, w hich plays a m ajor role in rew ard d riven learn
ing, m ay also p lay a signi cant role in w iring p athw ays
together. Every typ e of rew ard that has been stu d ied increases
the level of d op am ine transm ission in the brain, and a variety
of highly ad d ictive d ru gs, inclu d ing stim u lants su ch as
cocaine and m etham p hetam ine, act d irectly on the d op am ine
system . A chronic p ain p atient’s brain may thu s, in effect,
becom e m ore pro cient in running its pain m ap. In clinical
term s, less stim u lation m ay be need ed to activate the p ain
m ap , w hich is the hallm ark of central sensitization (Woolf
2007; N ijs et al 2010).
Structural changes in the brain
Several stu d ies have com p ared the brain stru ctu re (volu m e of
grey and w hite m atter) of healthy ind ivid u als w ith those suf
fering from chronic pain (Ap karian et al 2004; Schm id t-Wilcke
2008; Schm id t Wilcke et al 2008). It is now w ell established
that, in p eop le w ith chronic p ain, variou s areas of the brain
u nd ergo volu m e changes inclu d ing the d orsolateral p refron
tal cortex, right anterior thalam u s, brainstem , som atosensory
Denotes synaptic modulation
Beliefs
Knowledge, logic
Social context
Anticipated consequences
Other sensory cues
cortex and the p osterior p arietal cortex (Ap karian et al 2004;
Schm id t Wilcke et al 2008). Several key issues are raised that
im p act on the treatm ent of patients w ith chronic p ain. First,
it is interesting to note that there is a relationship betw een the
extent of brain d ensity changes and pain intensity (Schm id t-
Wilcke et al 2006). This nd ing correlates w ith a grow ing
bod y of research ind icating that acu te pain, especially p ain
intensity, m ay ind eed by a big pred ictor in the d evelopm ent
of chronic p ain (Woolf & Salter 2005; Jull et al 2007; Woolf
2007). It is now w ell established that p ersistent and high
intensity nociceptive bom bard m ent of the CN S lead s to sig
ni cant, long lasting neu rop lastic changes that m ay be
irreversible (Woolf & Mannion 1999; Woolf & Salter 2005;
Woolf 2007; Latrem oliere & Woolf 2009). The m ore interesting
p henom enon of stru ctu ral changes in the brain is the ability
to restore grey m atter; hence changes in grey m atter fou nd in
chronic p ain p atients m ay not re ect tru e brain d am age bu t
rather a reversible consequence of the pain exp erience
(Rod ríguez Raecke et al 2009). Treatm ents aim ed at altering
inform ation to the brain (affecting nocicep tion, ed ucation,
etc.) have d em onstrated an ability to restore grey m atter to
the brain in chronic p ain states (d e Lange et al 2008; Rod ríguez-
Raecke et al 2009; Gw ilym et al 2010; Sem inow icz et al 2011,
2013); it is also interesting to note that, apart from the increase
in grey m atter in the brain, a p ositive effect on pain, pain cata
strop hization and d isability w as also achieved in these treat
m ents. Althou gh care shou ld be taken to interp ret the
correlations fou nd in these resu lts, the above stu d ies along
w ith a grow ing bod y of evid ence su ggest that strategies
aim ed at structural reorganization of the brain m ight be
u tilized as a m eans of treating chronic p ain (Apkarian et al
2004; d e Lange et al 2008; Schm id t Wilcke 2008; Schm id t-
Wilcke et al 2008; Rod rígu ez Raecke et al 2009; Gw ilym et al
2010; Sem inow icz et al 2011; Wand et al 2011; Sem inow icz
et al 2013).
 Changes in the nervous system and brain in people with chronic pain
Somatosensory cortex
s
rm
d
er
b
an
A
m
ng
H
hu
Fi
T
Eye
Nose
Face
Lips
Gums
Teeth
Jaw
Tongue
Figure 6.4 Somatosensory homunculus. (Image adapted from Louw A, Puentedura EJ. 2013. Therapeutic neuroscience education, Vol 1. Minneapolis, MN: OPTP. p 70.
Copyright Adrian Louw.)
Functional changes in the brain
It is w ell established that the physical bod y of a person is
represented in the brain by a netw ork of neurons, w hich is
often referred to as a rep resentation of that p articu lar
bod y part in the brain (Pen eld & Bold rey 1937; Flor 2000;
Wand et al 2011). This representation refers to the pattern of
activity that is evoked w hen a p articu lar bod y p art is stim u
lated . The m ost fam ou s area of the brain associated w ith rep
resentation is the p rim ary som atosensory cortex (S1) (Fig. 6.4)
(Pen eld & Bold rey 1937; Flor 2000; Stavrinou et al 2007;
Wand et al 2011).
These neu ronal rep resentations of bod y p arts are d ynam i
cally m aintained (Flor et al 1997, 1998; Maihofner et al 2003;
Moseley 2005a, 2008a; Lotze & Moseley 2007). It has been
show n that patients w ith chronic p ain d isp lay d ifferent S1
representations to those in people w ith no pain (Flor et al
1997, 1998; Maihofner et al 2003; Moseley 2005b, 2008a; Lotze
& Moseley 2007). The interesting phenom enon associated
w ith cortical restru cturing is the fact that the bod y m aps
expand or contract, in essence increasing or d ecreasing the
bod y m ap representation in the brain. Fu rtherm ore, these
changes in shap e and size of bod y m ap s seem to correlate to
increased pain and d isability (Flor et al 1997; Lloyd et al
2008). Although variou s factors have been linked to the d evel
op m ent of this altered cortical rep resentation of bod y m ap s
in S1, su ch as neglect and d ecreased u se of the p ainfu l bod y
part (Marinu s et al 2011), it is believed that altered im m une
activity m ay be a signi cant source of the ‘sm u d ging’ of bod y
m ap s (Flor et al 1997; Beggs et al 2010). An astou nd ing fact of
this reorganization of bod y m ap s is the fact that it occu rs fast.
It has been show n that, w hen fou r ngers are w ebbed together
for ju st 30 m inu tes, cortical m aps change in association w ith
69
ip
d
r
un
k
ea
de
H
ec
Tr
H
ul
N
ho
Knee
S
Leg
Foot
Toes
Genitals
the ngers (Stavrinou et al 2007). This nd ing has signi cant
clinical im p ortance as it u nd erscores the im p ortance of strate
gies su ch as m ovem ent, tactile and visual stim u lation of the
CN S and brain early in a pain experience to help m aintain S1
representation. Furtherm ore, it has now also been show n that
p atients w ith chronic p ain stru ggle w hen id entifying left and
right bod y parts (left–right d iscrim ination) (Moseley 2004a;
Moseley et al 2005). Although m ost recent pain research has
focu sed on the S1 reorganization, it is also im portant from a
rehabilitation perspective to realize that changes also occur in
the prim ary m otor cortex (M1) (Tsao & H od ges 2007; Tsao
et al 2008), w hich is organized accord ing to m ovem ents, not
m u scles (Wolpert et al 2001). For exam ple, in spinal stabiliza
tion exercises, it w as fou nd that the M1 representation of
contraction of the transversu s abd om inis m u scle w as shifted
and enlarged in p atients w ith recurrent low back p ain, and
that both the location and size of the m ap volu m e w ere associ
ated w ith slow er onset of transversus abd om inis m uscle activ
ity as part of the postu ral ad ju stm ent associated w ith rapid
arm m ovem ent (Tsao et al 2008). People w ith chronic low
back pain also exhibit an exp and ed area of cortical activity in
p rep aration for arm m ovem ent and a d ecrease in sp eci c
cortical resp onses in relation to observed d elayed onset of
d eep abd om inal m u scle activity (Jacobs et al 2010).
Descending pathways
A p erson’s p ain exp erience is com p lex and m u ltifactorial, one
factor of w hich is the CN S and brain’s d escend ing antinoci
cep tive system (Field s et al 2005; Giesecke et al 2006). It is w ell
established that various neurophysiological m echanism s in
the CN S and brain, esp ecially the m id brain, control the
am ou nt of inform ation that the brain m ay receive from the
 70 PART 1 •
Sample
Tissues
Environment
Figure 6.5 The bidirectional top-down and bottom-up approach to treating pain. (Modi ed and adapted from Gifford LS. 1998. Pain, the tissues and the nervous system.
Physiotherapy 84: 27–33.)
tissu es. This bid irectional system m ay allow inform ation to be
enhanced (facilitation) or d ow n regu lated (inhibition); for
exam ple, d u ring sporting events or w ar, severe injuries are
often rep orted as alm ost p ainless (Melzack et al 1982). One
area that has gained m u ch interest is the m id brain periaque
d u ctal grey (PAG). The PAG integrates inputs from the lim bic
forebrain and d iencephalon w ith the nociceptive input
received by the d orsal horn (Band ler & Keay 1996). Further-
m ore, fu nctional neu roim aging stu d ies in hu m ans ind icate
that PAG activation by nocicep tive inp u ts is m od u lated by
attention, em otion, expectation of p ain, and expectation
related p lacebo analgesia (Tracey et al 2002; Parry et al 2008;
Wiech & Tracey 2009). Consid ering that patients w ith chronic
p ain d isp lay a d ecreased ability to engage the end ogenou s
m echanism s of the brain, it is com m only believed that the
PAG is negatively affected in p atients w ith chronic p ain
(Peyron et al 2000; Sterling et al 2001; N ijs et al 2012). For
exam ple, it has been show n that in patients w ith chronic low
back p ain there are lesser increases in blood ow in the PAG
com p ared w ith controls w hen exp osed to equ ally p ainfu l
stim u li (Giesecke et al 2006). The d ecreased ability of the PAG
to alter sensory inform ation, su ch as touch, is likely to be a
p art of the clinical m anifestation of central sensitization (Woolf
2007; N ijs et al 2011).
Treatment
Many changes occu r to the CN S and brain in p eop le w ith
chronic p ain, and this chap ter focu ses on fou r key changes.
Ad d ressing and correcting these changes m ay be key in
help ing peop le w ith chronic p ain – a statem ent that is vali
d ated by the em erging and grow ing evid ence for the u se of
treatm ents aim ed at restoring these changes in the CN S and
brain, su ch as grad ed m otor im agery (GMI) (Moseley 2004b,
2006; Daly & Bialocerkow ski 2009; Bow ering et al 2013),
6 • Treating the brain in chronic pain
Tissues
Environment
sensory d iscrim ination (Moseley & Wiech 2009) and TN E
(Moseley 2002; Moseley et al 2004; Lou w et al 2011b). Und er-
stand ing that p ain is an ou tp u t p rod u ced by the brain, based
on p ercep tion of threat, is key w hen it com es to selecting
ap prop riate treatm ents The brain, CN S and peripheral
nervou s system along w ith the im m u ne and end ocrine
system s shou ld be seen as a living organism seeking inform a
tion at all tim es and ad ap ting as need ed . Feed ing the brain
inform ation (sensory, visu al, aud itory, tactile, etc.) is im por
tant for how the brain m ay p erceive threat: it creates an
op p ortu nity to lessen that threat and u ltim ately the p ain exp e
rience. This brain feed ing process can be perform ed through
variou s avenu es, w hich can be categorized into a top d ow n
and bottom u p ap p roach to in u encing the p ain exp erience
(Fig. 6.5).
Trad itionally, clinicians have either follow ed a top d ow n
(cognitive) or a bottom u p ap proach (su ch as m anu al therapy)
to treat p ain. It is strongly su ggested , how ever, that the tw o
ap proaches are not m u tually exclusive and clinicians are
therefore u rged to consid er a com bination of the tw o. View ing
this as either a tissu e or a cognitive issu e w ou ld be contrary
to the m od ern neu roscience view of p ain and p rop agates the
Cartesian m od el of p ain, w hich seeks to d eterm ine w hether
p ain is either p hysical or p sychological in natu re. Pain involves
both p rocesses and so requ ires treatm ent that ad d resses both.
For exam ple, stud ies on TN E have show n com pelling evi
d ence of bene t in treating p eop le w ith chronic pain (Lou w
et al 2011a), bu t also that TN E w orks best if com bined w ith
m ovem ent based therap ies su ch as m anu al therap y and exer
cise, thu s feed ing the brain inform ation ‘from both end s’
(Ryan et al 2010; Lou w et al 2011b). Likew ise, cervical spine
m anip u lation has been show n to be ef caciou s in treating
acute neck pain, bu t a param ou nt pred ictor of su ccess is
p atients’ beliefs that sp inal m anip u lation w ill help their p ain
(Pu ented ura et al 2012). A skilled clinician w ill therefore aim
to ad d ress both ap p roaches in p eop le w ith chronic p ain.

This neu roscience view of altering the inform ation that the
CN S and brain receive op ens the d oorw ay to m any therap ies,
and it is fu rther p roposed that any treatm ent aim ed at altering
the inform ation the brain gets m ay ind eed be of therap eu tic
valu e. For instance, it has long been established that treat
m ents su ch as transcu taneou s electrical neu rom u scu lar stim u
lation (TEN S) and electrical stim u lation, via the p ain gate, can
have an effect on the inform ation received by the d orsal horn
of the sp inal cord and u ltim ately the brain, p ain neu rom atrix
and the p erson’s pain exp erience (Wall 1996; Melzack 1999).
Likew ise, a nu m ber of stu d ies have fou nd that variou s m anu al
treatm ents su ch as sp inal m obilization and sp inal m anip u la
tion, exercise, need ling techniqu es and so forth can elicit an
end ogenous process and thu s p ositively affect a person’s pain
state (Vicenzino et al 1996; Sterling et al 2001; George et al
2006; Fernánd ez Carnero et al 2008). This is especially tru e in
m ore acu te, su bacu te and p erip herally evoked p ain states.
N evertheless, a w ell m eaning clinician u tilizing sou nd clinical
reasoning and an u pd ated know led ge of p ain science and
p ain m echanism s shou ld view any and all treatm ents from a
p ersp ective of altering d anger inform ation being relayed to
the CN S and brain so as to lessen p erceived threat and there
fore u ltim ately the patient’s pain experience. The treatm ents
d escribed below w ill focus on tw o of the em erging therap ies
associated w ith restru cturing the CN S and brain in p atients
w ith chronic pain.
Therapeutic neuroscience education –
restricting meaning
Recent research into ed u cational strategies for p atients w ith
chronic p ain show s an increased u sage of TN E (Moseley 2003a,
2004c, 2005a; Moseley et al 2004). TN E aim s to red uce pain and
d isability by helping patients gain an increased und erstand ing
of the biological and p hysiological p rocesses involved in their
pain exp erience (Ryan et al 2010; Lou w et al 2011b). TN E
d iffers from trad itional ed u cation strategies by focu sing not
on anatom ical or biom echanical exp lanations for p ain, bu t
rather on the neu rophysiological and neu robiological pro
cessing and rep resentation, and m eaning of p ain (Moseley
2005a; Meeu s et al 2010; Ryan et al 2010). It has further been
d em onstrated that patients are capable of und erstand ing the
neu rop hysiology of their p ain, w hereas p rofessionals tend to
u nd erestim ate their p atient’s ability to u nd erstand the com p lex
issues related to it (Moseley 2003c). A recent system atic review
provid es strong su ggestive evid ence w ith resp ect to the ef
cacy of TN E in ad d ressing p ain, d isability and p hysical p er
form ance in m uscu loskeletal p ain, p articu larly sp inal d isord ers
(Lou w et al 2011a). Stu d ies of treatm ent u tilizing TN E have,
furtherm ore, show n it to d ecrease fear and to change patients’
percep tion of their p ain (Moseley 2003c), to have an im m ed iate
effect in im p roving patients’ attitu d es abou t pain (Moseley
2003b), and show im provem ents in pain, cognition and physi
cal p erform ance (Moseley 2004c), increase pain threshold s
d u ring p hysical tasks (Moseley et al 2004), im prove ou tcom es
of therap eu tic exercises (Moseley 2002), and signi cantly
red u ce w id esp read brain activity characteristic of a pain expe
rience (Moseley 2005a).
A very im p ortant clinical issu e regard ing TN E need s d is
cu ssion, how ever. As p ointed ou t earlier, in line w ith the Car
tesian m od el of p ain (1654), m any clinicians still seem to
Treatment 71
d ecid e that a patient’s pain is either p hysical or psychological,
and if m ore psychological then TN E is the ap p roach that is
m ore su ited . TN E has therefore becom e synonym ou s w ith
lengthy one on one psychoed u cational sessions betw een a
p atient and therap ists arou nd a table, the latter trying to get
the p atient to ‘believe’. TN E shou ld , rather, be u sed in con
junction w ith m ovem ent based treatm ents and seen as a d u al
p rocess that constantly feed s the brain and CN S w ith inform a
tion. Fu rtherm ore m ovem ent, w hen ap p lied and u tilized
w ithin a TN E m od el, is better und erstood , less feared and has
a d ifferent m eaning, as pain exp erienced d u ring a m ovem ent
is und erstood as arising not so m u ch from the injury itself as
from an oversensitized nervous system (Lou w et al 2013).
The original question now arises: if in patients w ith chronic
p ain there are CN S and brain changes su ch as increased brain
activity (pain neu rom atrix), structural and fu nctional changes
w ithin the brain and altered antinociceptive activity of the
PAG, d oes TN E have the ability to im pact these changes posi
tively? To d ate, tw o single case fMRI (fu nctional m agnetic
resonance im aging) stud ies have investigated the speci c
effect of TN E on brain activity (Moseley 2005a; Lou w et al
su bm itted for p u blication). Althou gh care shou ld be taken in
extrap olating the nd ings of these tw o single case stud ies,
both found a sim ilar red u ction in w id espread brain activity
associated w ith perform ing a painful task after a TN E session,
com p ared w ith p erform ing the sam e task p rior to TN E (Fig.
6.6). These prelim inary nd ings m ay ind eed ind icate that
TN E lessens threat, lead ing to a d eactivation of the pain neu
rom atrix (Moseley 2005b). The nd ings from these fMRI
stu d ies, along w ith the au thors’ interp retation of its effect on
the p ain neu rom atrix, are u nd erscored by stu d ies nd ing that
TN E has a positive effect on pain, pain catastrophization and
d isability (Moseley 2002, 2003a; Moseley et al 2004; Lou w et al
2011b).
With regard s to stru ctu ral changes, no stu d ies sp eci c
to TN E have been cond u cted ; how ever, recent cognitive
behavioral therapy (CBT) stud ies have fou nd grey m atter
increases in the brain follow ing CBT (d e Lange et al 2008;
Sem inow icz et al 2013). H ow d oes this apply to TN E? TN E is
cognitive therap y and its ability to restru ctu re the m eaning of
p ain p robably rep resents the ‘C’ of CBT. TN E aim s to restru c
tu re threat and the m eaning of p ain, w hich is a cornerstone
of CBT (Bennett & N elson 2006; Ang et al 2010). Fu tu re stud ies
shou ld investigate w hether the increases in grey m atter d o
correlate w ith cognitive restru ctu ring and so are m ore d irectly
sp eci c to TN E. To d ate, how ever, no stu d ies have been con
d ucted to d eterm ine w hether TN E is associated w ith fu nc
tional changes in bod y m ap s in the brain. It m ay, how ever,
have an effect on the PAG and the antinocicep tive system .
TN E is ind irectly associated w ith d ecreased levels of pain
experience, and increases in pressure p ain threshold s and the
ability to exercise and m ove m ore d espite pain (Lou w et al
2011b). These nd ings m ay give an insight into the effect of
TN E on the antinociceptive system of the PAG. In a recent
fMRI case stud y using TN E preop eratively for lu m bar rad icu
lop athy, pre and post TN E changes to the PAG w ere observed
(Louw et al su bm itted for p ublication). During a painful task,
the p atient w ith low back p ain d isp layed w id esp read brain
activity (see Fig. 6.6). Closer analysis revealed signi cant acti
vation of the PAG (Fig. 6.7A). Although care should be taken
to extrap olate from one case stu d y as w ell as w ith resp ect to
the variou s u nknow ns regard ing fMRI (Moseley 2008a), it is
 72 PART 1 • 6 • Treating the brain in chronic pain

Figure 6.6 A single-case unctional magnetic resonance imaging ( MRI) study o a patient with low back pain. The rst row indicates the brain activity while the subject
is in a rested state and the second row indicates the same subject’s scan while performing a painful task (anterior pelvic tilt). The third row indicates the same painful task
performed after a 30-minute TNE session.

A B

Figure 6.7 (A) Brain activity during a pain ul task. Scan showing activation o the PAG (green circle). (B) The brain scan o the same patient, per orming the same
task ollowing a TNE session, showing a deactivated PAG.

plausible that the PAG w as activated in resp onse to a ‘threat
ening’ m ovem ent that this patient associated w ith a painfu l
task. Follow ing TN E, how ever, the sam e p ainfu l task d id not
resu lt in a sim ilar activation of the PAG (Fig. 6.7B). In line
w ith cu rrent beliefs that TN E reconcep tualizes p ain and
d ecreases fear associated w ith m ovem ent, one could interpret
this single case as show ing that the PAG no longer need ed
activation, as the incom ing nociception w as und erstood after
the TN E session. H ow ever, fu tu re larger stu d ies are need ed
to investigate the sp eci c effect of TN E on the antinocicep tive
system s, su ch as the PAG.
Graded motor imagery – restructuring
brain / body maps
Therap eutic treatm ents d irectly aim ing at correcting func
tional changes in the brain have gained increased attention,
especially in ad vanced pain states su ch as com plex regional
pain synd rom e (CRPS) (Daly & Bialocerkow ski 2009; Wand
et al 2011). Grad ed m otor im agery (GMI), a stru ctu red ,
sequ ential series of cortical exercises, aim s to re establish the
cortical d e cits d escribed p reviou sly (Moseley 2004b, 2006;
Daly & Bialocerkow ski 2009; Bow ering et al 2013). GMI con-
tains strategies su ch as norm alizing a p erson’s ability to rec
ognize left or right bod y p arts or m ovem ents (laterality),
m otor im agery or visu alization of static and d ynam ic u se of a
bod y part and m irror therapy. Apart from the increased inter
est, GMI has show n increasing evid ence of ef cacy as a m eans
to in u ence p ositively su ch p ain states su ch as CRPS (McCabe
et al 2003; Moseley 2004b, 2006; Daly & Bialocerkow ski 2009;
Bow ering et al 2013). Ad d itional strategies aim ed at restruc
tu ring cortical m ap s, su ch as sensory d iscrim ination, grap he
sthesia and tw o p oint d iscrim ination, have been p rop osed
and utilized alongsid e GMI to help facilitate these cortical
changes (Moseley 2008b; Moseley et al 2008; Moseley & Wiech
2009; Lu om ajoki & Moseley 2011). Desp ite these early results
and grow ing evid ence, read ers are cau tioned that m any
u nknow ns still rem ain in this early thou ght p rocess of cortical
restructuring, althou gh early nd ings d o show prom ise. Tra
d itional treatm ents such as m anual therap y and being precise,
sp eci c and even vocalizing the intent and nd ings, su ch as
a central p osterior–anterior m obilization on the C4 spinal
level, cou ld also be seen as a form of cortical restructuring. As
w e gain m ore and m ore insight into the exact cortical changes
that occu r (i.e. tw o p oint d iscrim ination), treatm ents can
becom e m ore d eliberate and targeted tow ard s creating a
bottom u p feed ing of the brain – in w hich the senses (tou ch,
sight, sou nd , etc.) are u sed to help the brain u nd erstand m ore,
lessening perceived threat and restoring bod y parts.
Conclusion
The d ecad e of the brain has com e and gone, yet w e have
barely scratched the su rface. The new neu roscience view of
pain, esp ecially m u scu loskeletal p ain, has created signi cant
ad vances for p atients and clinicians. For patients, neu roplas
ticity gives hop e and p eop le w ith ad vanced p ain states su ch
as CRPS can receive m u ch need ed non su rgical and non
pharm acological help. For the clinician there is also hope. For
Conclusion 73
too long has chronic p ain been seen as a black hole from w hich
there is no retu rn. The ad vances d escribed in this chap ter
allow clinicians to cease fearing chronic p ain p atients, bu t
instead to create both new p arad igm s and new treatm ents. N o
hu m an stru ctu re can have an im p act on p ain as m u ch as the
brain: ‘no brain, no pain’.
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 PART 1 •  General Introduction
Mechanical Diagnosis and Therapy
7  
Chapter 
for the Spine: McKenzie Method
S te p h e n M a y, Ric h a rd R o s e d a le
CHAP TER CONTENTS
Introduction  76
The literature base for MDT  77
Epidemiological perspective  77
Review of anatomy and biomechanics in MDT  78
Review of proposed pathology and anatomy in MDT  79
Evidence regarding diagnosis in MDT  80
Evidence regarding prognosis in MDT  80
Evidence regarding conservative treatment with MDT  80
Conclusion  82
Introduction
The m ethod of Mechanical Diagnosis and Therapy (MDT) w as
d evised by Robin McKenzie, a N ew Zealand physiotherapist,
d u ring the 1950s and 1960s follow ing a chance clinical encoun-
ter. A p atient had lain on a treatm ent cou ch w ith the head end
raised in a prone position follow ing several episod es of unsu c-
cessfu l treatm ent for his back and leg p ain. When Robin
McKenzie entered the room several m inu tes later he w as
shocked to see the p atient lying in this p osition, as in those
d ays extension w as consid ered a very u nsu itable position for
p atients w ith leg p ain. H ow ever, before McKenzie cou ld say
anything the p atient volu nteered the inform ation that his leg
p ain ‘had not felt so good in w eeks and m ost of it had gone,
although the back felt a bit w orse’. It w as McKenzie’s rst
encounter w ith w hat he cam e to term centralization.
Over the ensu ing years Robin McKenzie continu ed to
experim ent w ith su stained positions and then m ore com -
m only w ith rep eated m ovem ents. H e u sed rep eated m ove-
m ents so that p atients w ere able to continu e the exercises
ind ep end ently at hom e by rep eating them every few hou rs.
Self-m anagem ent w as to becom e a central tenet of the m ethod .
Robin McKenzie fou nd that extension d id not help all p atients;
in fact, it m ad e som e w orse, so he exp erim ented w ith exion
and frontal p lane m ovem ents. H e found that som e patients
w ere effectively treated w ith these other d irections of m ove-
m ent and so his assessm ent d evelop ed to exp lore the p otential
for d ifferent d irections of m ovem ent to prod uce a positive
effect on sym ptom s.
In attem pting to ad apt his nd ings from the lu m bar spine
to the cervical sp ine, McKenzie fou nd that his initial su ccess
w as som ew hat m ore lim ited . H ow ever, his efforts w ere
assisted w hen he w as m ad e aw are of the w ork of Dr Laurens
Penning, a neu rorad iologist from Am sterd am . This led Robin
McKenzie to begin also to exp lore the effects of retraction
and protru sion as w ell as exion and extension m otions, cu l-
m inating in his nd ing m u ch greater su ccess w hen u sing
retraction prior to m oving the neck into extension (Ord w ay
et al 1999).
Positive effects in the lu m bar and cervical sp ine inclu d ed
centralization or a lasting d ecrease in sym p tom s and an
increase in the red u ced range of m ovem ent in response to
repeated m ovem ents or su stained positions. The m ovem ents
or p ostu res that p rod u ced these resp onses becam e know n as
the directional preference. The key to d irectional preference
w as that these positive therapeu tic effects w ere apparently the
resu lt of therapeu tic interventions, and not sim ply the effect
of a natu ral history. Centralization and d irectional p reference
in response to repeat m ovem ents are now central tenets of
the m ethod , and are characteristic of w hat Robin McKenzie
term ed derangement syndrome. These p henom ena have su b-
sequ ently becom e the focu s of som e research over the years
as the im plications of this response to sim ple end -range exer-
cises and load ing strategies are w id e ranging and som etim es
clinically signi cant.
Thu s grew an assessm ent and m anagem ent process that
w as based on a hand s-off, patient-centred exercise-based
approach, w ithout em p hasis on therapist-centred p alp ation
or m obilization p roced u res. If, how ever, the p atient either d id
not d em onstrate a p ositive d irectional p reference or cam e to
a plateau after initial im provem ent then therap ist-generated
forces could be ad d ed into the patient-generated forces. This
principle of the m ethod w as term ed force progression. The
u se of d ifferent starting p ositions or d ifferent d irections of
m ovem ent, su ch as stand ing or lying, or frontal p lane m ove-
m ents as op p osed to sagittal p lane m ovem ents, w ere term ed
force alternatives.
McKenzie also recognized that not everybod y show ed a
rapid pain-change response. A su bgroup of patients respond ed
w ell to repeated painfu l end -range m ovem ents, bu t only
grad u ally im p roved and restored a red u ced range of m ove-
m ent over tim e. This su bgrou p of m echanical classi cation

w as know n as dysfunction syndrome. An even sm aller
grou p, often you ng patients w ith very poor posture, had a
norm al p hysical exam ination w ith only su stained p ostu res
provoking the sym p tom s. These p atients respond ed to
postu ral correction, and therefore this su bgroup w as nam ed
postural syndrome. McKenzie hypothesized that this group
m ight rep resent the m ild end of the back and neck p ain con-
tinu u m before p rogression to m ore d isabling cond itions
su ch as d erangem ent. The key w as that McKenzie recognized
that sp inal p ain cond itions p resented in d ifferent, bu t very
d istinct, w ays. Another core aspect of the m ethod w as set in
m otion – that of su bclassi cation. Robin McKenzie also rec-
ognized that not everybod y cou ld be classi ed w ithin one of
the above three synd rom es; those ou tsid e these su bgrou p s
w ere term ed non-mechanical syndromes and now represent
the MDT ‘other ’ classi cations. H ow ever, it is im p ortant to
note that not all p atients w ith sp inal p ain cond itions can be
prop erly inclu d ed in any of these su bgroup s.
The Literature Base for MDT
After m any years d eveloping and then teaching the m ethod ,
McKenzie started to d escribe it; rst in a series of Treat Your
Own Back / N eck booklets aim ed at p atients (McKenzie 1980,
1983), and then in tw o textbooks for clinicians d escribing the
m anagem ent strategy for the lu m bar and then the cervical
and thoracic sp ines (McKenzie 1981, 1990). At these points
in tim e there w as lim ited scienti c evid ence to su p p ort the
concep ts ou tlined above and their relevance to clinical p rac-
tice. H ow ever, since 1990 there has been a grow ing bod y of
evid ence that has end orsed certain asp ects of the m ethod ,
especially in the lum bar spine. Evid ence is still lim ited
w ith respect to the cervical spine and the extrem ities, bu t is
becom ing m ore su bstantial. Du ring the early to m id 2000s
the original textbooks w ere carefu lly revised , inclu d ing the
contextu al backgrou nd for back and neck p ain, d escribing
the technical asp ects of u sing the ap p roach, and giving
the evid ence relevant to the m ethod (McKenzie & May
2003, 2006).
McKenzie had alw ays recom m end ed that the concep ts he
d escribed w ere equ ally applicable to extrem ity problem s and
the rst of the last series of books w as abou t the ap p lication
of this ap p roach to m u scu loskeletal p roblem s in the u p p er
and low er extrem ities (McKenzie & May 2000). This d evelop-
m ent also inclu d ed d istingu ishing betw een articu lar and
contractile d ysfu nctions; articu lar d ysfu nctions p resent w ith
painful end -range restrictions of m ovem ent at joints, w hereas
contractile d ysfu nctions p resent w ith p ain on load ing contrac-
tile tissu es, notably tend ons, w ith resisted or active m ove-
m ents. Instru ction in the u se of the m ethod s as ap p lied to
extrem ity problem s is now includ ed in the training courses.
(The u se of MDT in the extrem ities is d ealt w ith in m ore d etail
in Ch 8.)
When McKenzie began to d escribe the m ethod of MMDT
he w as initially m et w ith consid erable scep ticism , esp ecially
by m ed ical colleagues. In ord er to confront or challenge these
criticism s, a series of m od els to d escribe the su bclassi cation
synd rom es w ere d evelop ed . H ow ever, these w ere very m u ch
theoretical m od els rather than clear-cu t p athological scenar-
ios. It m u st be recognized that the op erational d e nitions for
Epidemiological perspective 77
all m echanical synd rom es and for the other synd rom es are
based entirely on clinical p resentations and resp onses (Table
7.1). The m ethod is not reliant on d iagnostic m od elling,
althou gh p athological criteria can be su ggested in certain
instances, especially am ongst the other categories. The follow -
ing sections w ill focu s on the app lication of the McKenzie
m ethod in the lu m bar and the cervical sp ine.
Epidemiological Perspective
The epid em iological nature of low back p ain and other m us-
cu loskeletal p roblem s is w ell know n. Desp ite early claim s that
the m ajority of low back p ain is acu te and only a sm all p rop or-
tion is chronic, m ore recent evid ence contrad icts this p ersp ec-
tive. Low back p ain is frequ ently p rotracted and chronic, and
show s lim ited im p rovem ent betw een 3 m onths and 1 year
(Abbott & Mercer 2002; Pengel et al 2003; H ayd en et al 2010).
This p ersistence is seen in over 50% of those w ith acu te low
back pain (Pengel et al 2003; H ayd en et al 2010). Furtherm ore,
even in those w ho recover quickly, recu rrence in the su bse-
quent year is extrem ely com m on – happ ening in about 70%
of those w ith an initial ep isod e (Abbott & Mercer 2002; Pengel
et al 2003). One su rvey of nearly 600 p atients w ith low back
p ain fou nd that 73% reported p reviou s episod es, and over
60% rep orted a w orsening of sym ptom s over tim e w ith su b-
sequ ent ep isod es (Donelson et al 2012).
Although there are few er stud ies related to the cervical
sp ine, the p attern ap p ears to be m irrored there. A system atic
review of the p rognosis of acu te neck pain reported that the
ou tcom e is relatively p oor and resolu tion com m only incom -
p lete w ith regard s to both p ain and d isability (H ush et al
2011). In fact, im provem ent in both pain and d isability
ap peared to cease after 6.5 w eeks w ith no fu rther im p rove-
m ents up to 1 year. The rem aining sym ptom s w ere severe
enough to interfere w ith d aily life activities and ad versely
affect qu ality of life (H u sh et al 2011) and even com p ared
u nfavou rably w ith the ou tcom es rep orted for low back p ain
(Pengel et al 2003).
H ence, d espite the fact that spinal pain is m ore com m only
cared for conservatively, becau se of the extrem ely large p op u -
lation num bers the im pact on healthcare is enorm ou s. It is
d if cu lt to estim ate the cost for su ch a com m on cond ition, for
w hich p atients m ight seek a m yriad of healthcare provid ers;
how ever, one review (Dagenais et al 2008) fou nd that physical
therap y absorbed the largest p rop ortion of d irect m ed ical
costs (17%), but ind irect, societal costs rep resented the m ajor-
ity of overall costs associated w ith back p ain. It w as estim ated
that in 2005 the m ean m ed ical expend itu re in the USA for
those w ith spine p roblem s w as over $6000 – nearly d ou ble
that of those w ithou t sp ine p roblem s (Martin et al 2008); this
rep resented a 65% increase from 1997, d espite w hich lim ita-
tions in p hysical fu nction had increased .
Clinicians shou ld exp lore all p ossible avenu es for p atients
w ith spinal p ain to treat their sym ptom s effectively and to
involve them in their ow n treatm ent. The p hysical therapist’s
p rim ary role shou ld be to assess, d iagnose and gu id e the
p atient in the therap eu tic p rocess. As m u ch as is p ossible,
p atients shou ld actu ally be involved in their ow n therap eu tic
p rocess. In that w ay, they shou ld be able to m anage the cu r-
rent and fu ture episod es. For instance, if the m ain p roblem
 78 PART 1 • 7 • Mechanical diagnosis and therapy for the spine: McKenzie method

Table 7.1 Ope rational de nitions for me cha nica l s yndrome s and ‘othe r’
Me c hanic al s yndro me s
Derangement
Articular dysfunction
Contractile dysfunction
Pos tural s yndrome
‘Othe r’
Spinal s tenos is
Isthmic s pondylolisthes is
Hip
Sacroiliac joint (SIJ)
Mechanically inconclusive
Chronic pain
Centralization or progressive abolition of distal pain in res ponse to therapeutic loading
Each progress ive abolition retained over time until all symptoms are abolished
Back pain is als o abolished
Changes in pain remain better
Accompanied by changes in mechanical pres entation, such as increase in range of movement
Local pain only
Intermittent pain only
At least one movement is restricted and res tricted movement consistently produces concordant pain at
end range
No rapid reduction or abolition of s ymptoms
No lasting production or peripheralization of symptoms
Intermittent pain only
Concordant pain reproduced with res isted movement
Active movements may als o be painful
Local pain only
Intermittent pain only
Concordant pain with static loading
Abolition of pain with pos tural correction
No pain with repeated movements
No los s of range of movement
No pain during movement
Leg symptoms when walking, eased in exion
Minimal extension
Sustained extension provokes leg symptoms
Sports -related injury in adoles cence
Wors e with s tatic loading
Pain on walking, eas ed with sitting
Speci c pain pattern
Pos itive hip tests
Three or more positive SIJ pain provocation tes ts
Inconsis tent res ponse to loading strategies
No obs truction to movement
Persis tent wides pread pain
Aggravation with all activity
Exaggerated pain behaviour
Inappropriate beliefs and attitudes about pain

conform s to the typ ical natu ral history, then d u ring reoccu r-
rences the patient shou ld be able to app ly the sam e principles
and exercise p rogram m es they found successfu l w ith their
p reviou s ep isod e to treat and m anage the current one. Other
app roaches that encou rage therapist d ep end ency and leave
the p atient as only a p assive recip ient of care shou ld be com -
p lem ented w ith m ore active approaches inclu d ing the McKen-
zie m ethod and exercise p rogram m es. Therap ists need to
consid er the broad er im p lications of the available m anage-
m ent strategies and ask them selves w hether they have fu lly
explored the potential therapeutic op tions for teaching
p atients to p articip ate in their ow n m anagem ent.
Review of Anatomy and Biomechanics
in MDT
Mechanical Diagnosis and Therap y u ses the p hysiological
m ovem ents that are available at the joints concerned . For
instance, in the exam ination of spinal problem s, sagittal p lane
m ovem ents, exion and extension m otions are alw ays exam -
ined rst as m ost spinal problem s resp ond in this plane of
m ovem ent. Extension is the m ovem ent that is the m ost
com m on d irection of p reference. This w as con rm ed in a

stu d y of N ew Zealand patients from 34 physical therap ists
(H efford 2008); this stu d y of 340 patients looked at the pro le
of synd rom es and the d irectional p reference p revalence. Of
the 187 lu m bar sp ine patients in the d erangem ent category
70%, 6% and 24% w ere given extension, exion and lateral
m ovem ents resp ectively to centralize or to have a lasting p osi-
tive sym p tom atic effect. For the 111 cervical sp ine p atients,
treatm ent d irections for the d erangem ents w ere sim ilar: 72%,
9% and 19% for extension, exion and lateral m ovem ents
resp ectively (H efford 2008). The one exception to starting
alw ays w ith sagittal p lane m ovem ents is those few patients
w ho present w ith a lateral shift or acu te w ry neck, in w hich
case m anagem ent is initiated in the frontal p lane.
The frontal plane m ovem ent that is u tilized in McKenzie
assessm ent of the lu m bar sp ine is the sid e-glid e in stand ing.
This m ovem ent tend s to focus m ovem ent on the low er lum bar
sp ine w here m ost of the issu es occu r, w hereas w ith sid e-
exion the upp er lum bar spine is m ore engaged (Mu lvein &
Ju ll 1995). When a patient presents w ith a lateral shift it is the
sid e-glid e in stand ing m ovem ent that is the one m ost
obstru cted , so in assessing this m ovem ent the therap ist is able
to reveal w hether there is any loss and tend ency tow ard s this
p articu lar lu m bar d eform ity.
In the cervical spine it is im portant to rem em ber that pro-
tru sion and retraction are p art of sagittal p lane m ovem ents.
Retraction fu lly exes the u p p er cervical sp ine and extend s
the low er cervical sp ine; conversely, p rotru sion fu lly extend s
the u p p er cervical sp ine and exes the low er (Penning 1998).
One of the clinical im p lications is that fu lly restoring retrac-
tion is a p rerequ isite to recovering fu ll extension. If retraction
has not been restored , extension m ay not have the d esirable
sym p tom atic effect. Frontal p lane m ovem ents are tested only
w hen the sagittal plane has been fu lly exhau sted and they are
requ ired in a sm aller subgrou p of patients. Rotation or lateral
exion is tested d u ring the assessm ent in this circum stance,
and in a m inority of patients either one of these m ay p rovid e
a d irectional p reference for the lateral p rincip le.
Review of Proposed Pathology
and Anatomy in MDT
The system of MDT is essentially based on non-pathology-
sp eci c m echanical synd rom es w hose op erational d e nitions
are d erived from the sym ptom atic and m echanical responses
(see Table 7.1). H ow ever, som e conceptu al m od els that m ight
explain these sym ptom atic responses have been su ggested
(McKenzie & May 2000, 2003, 2006; May 2006).
The conceptu al m od el offered to exp lain d erangem ent syn-
d rom e in the sp ine relates to the d ynam ic d isc m od el (Wetzel
& Donelson 2003; Kolber & H anney 2009). Within this m od el
it is suggested that internal intervertebral d isc d isru ption and
d isplacem ent of d isc m aterial can resu lt in pain and im p aired
m ovem ent. The end of the p athological continu u m w ou ld
be extru sion or sequ estration of d isc m aterial throu gh the
ou ter restraining annu lu s brosu s. This frank herniation
cau ses sciatica or cervical rad icu lop athy. H ow ever, at the
m ild end of the continu u m , there w ou ld be easily reversible
internal d isc d isplacem ent resu lting in back or neck p ain, w ith
or w ithou t som e referred sym p tom s. With increasing d isc
Review of proposed pathology and anatomy in MDT 79
d isp lacem ent there w ou ld be m ore signs and sym ptom s. The
d irection of the d isp lacem ent w ould ind icate the therapeu tic
load ing necessary; m ost com m only posterior and p osterior–
lateral d isplacem ents w ou ld requ ire extension forces, anterior
d isp lacem ent w ou ld require exion forces, and lateral d is-
p lacem ent w ou ld requ ire frontal p lane p roced u res.
The concep tual m od el in no w ay im plies that the McKenzie
m ethod can be u sed only to treat d iscogenic p ain, as has been
m isinterp reted by som e clinicians and researchers. Althou gh
it is only a conceptu al m od el, there are a nu m ber of stu d ies
that valid ate it. The d isc is a com m on sou rce of back and leg
p ain (Ohnm eiss et al 1997; Milette et al 1999), centralization
has been associated w ith d iscogenic p ain (Donelson et al 1997;
Werneke et al 1999), and in vivo stu d ies have show n the d isc
to be m obile w ith load ing strategies (Brau lt et al 1997;
Ed m ond ston et al 2000). N u m erous other stu d ies su pporting
the d ynam ic d isc m od el as a sou rce of sym p tom s have been
d escribed (Wetzel & Donelson 2003). A system atic review su p-
p orted the d ynam ic d isc m od el in the lu m bar sp ine, althou gh
noted som e inconsistencies in its ap p lication to the p resence
of d isc d egeneration (Kolber & H anney 2009).
There has been som e controversy over the app lication of
this concep tu al d isc m od el in the cervical sp ine (Mercer & Ju ll
1996). This w as provoked w ith the recognition that the cervi-
cal d isc is m orp hologically and biochem ically d istinct from
the lu m bar d isc (Mercer & Bogd u k 1999). Despite these d if-
ferences, a m ore recent stress pro lom etry stud y show ed that
cervical d iscs u su ally have a hyd rostatic nu cleu s. The d iscs
exhibit a high concentration of com pressive force anteriorly
w ith exion and high com pressive stress posteriorly in exten-
sion (Skrzpiec et al 2007). These nd ings of sim ilarities in
p rop erties betw een the cervical and lu m bar d iscs m ay go
som e w ay to exp lain sim ilarities in the clinical resp onse
observed betw een the tw o regions. It is clear that w e cannot
so read ily d ism iss the d isc m od el d esp ite other d ocu m ented
d ifferences. Sim ilarities and d ifferences asid e, in the cervical
as in the lum bar sp ine, it is the sym p tom atic and m echanical
responses that d eterm ine classi cation and the appropriate
therap eu tic choice. The d iagnosis of d erangem ent rem ains
non-p athoanatom ical.
The conceptual m od el und erlying the d ysfu nction syn-
d rom e is the m echanical d eform ation of stru cturally im paired
soft tissu e. This is cau sed by trau m a, p reviou s d erangem ent
or d egenerative changes. After this initial event, fu ll rehabili-
tation or rem od elling d oes not hap p en su f ciently or ap p ro-
p riately (H u nter 1994); there follow s a lengthy history of
several m onths in w hich the p atient m ay be left w ith a p ainfu l
im pairm ent associated w ith restricted m ovem ent in a single
d irection, or less com m only in m ultiple d irections. Dysfu nc-
tions m ay affect articu lar or p eri-articu lar stru ctu res, su ch as
occu rs in early osteoarthritis (McCarthy et al 1994). They also
m ay affect contractile tissu e, m ost com m only tend ons, su ch
as the com m on extensor origin at the elbow, the tend ons at
the shou ld er or the Achilles tend on, lead ing to tend inop athy
(Littlew ood 2012). Dysfu nction also, rarely, affects neu ral
stru ctu res; this w ou ld be classi ed as an ad herent nerve root
and m ight occu r after the partial resolution of an ep isod e of
sciatica (Melbye 2010). Ad herent nerve root presents w ith
very lim ited range of exion in stand ing, w hich p rod u ces leg
sym p tom s at end range. In the d irection of the d ysfu nction
the p ain is p rod u ced consistently each tim e, regard less of how
 80 PART 1 • 7 • Mechanical diagnosis and therapy for the spine: McKenzie method
m any rep etitions are d one, bu t ceases w hen the m ovem ent is
end ed . (Read ers are referred to Ch 65 for further d iscu ssion
on neu rod ynam ics.) Articu lar d ysfu nctions typ ically p resent
w ith restricted and p ainful end -range m ovem ents in certain
p atterns – for instance at the knee w ith loss of exion and / or
extension, or at the hip w ith loss of m ed ial rotation and
exion. Contractile d ysfu nction p resents u su ally w ith fu ll, bu t
p ossibly p ainfu l, active m ovem ent; the p atient’s fam iliar pain
is p rod u ced w hen the relevant m ovem ent is resisted , su ch as
resisted w rist extension or resisted shou ld er abd u ction.
The concep tu al m od el for the p ostu ral synd rom e relates to
p ain that is ind u ced becau se soft tissu es are overstretched ,
blood ow is restricted and the tissu e is starved of oxygen.
This occurs w ith su stained load ing over the tissu e for a period
of tim e. It is not frequ ently seen in the clinic as the sym p tom s
are relatively m ild , bu t is com m only fou nd in stud ent-age
p opu lations (Wom esley & May 2006; May et al 2011). It is
associated w ith p oor p ostu re and is hypothesized to lead to
the m ore d isabling synd rom es associated w ith later life.
(Read ers can nd further inform ation on soft tissue d isord ers
in Part 10.)
Again, it is im portant to em p hasize the fact that these
m echanical synd rom es are classi ed by their sym p tom atic
and m echanical resp onses (see Table 7.1); therefore, these
m echanical synd rom es are d e ned by their resp onse to
repeated m ovem ents. The conceptu al m od els su ggested
above are no m ore than that: concep tu al m od els.
Evidence Regarding Diagnosis in MDT
Diagnostic accuracy d epend s on tw o psychom etric prop er-
ties: valid ity and reliability. In ord er to establish the valid ity,
both the sensitivity and the speci city (see Ch 5) are evaluated
so as to gau ge how accu rate sp eci c criteria or clinical tests
are in m aking a p athology-sp eci c orthop aed ic d iagnosis. In
the McKenzie system a sp eci c p athological d iagnosis is not
being sought; therefore, the m ain requirem ent is to know
w hether the assessm ent p rocess is reliable betw een clinicians.
In a system atic review of 48 reliability stud ies on physical
exam ination proced ures for patients w ith non-speci c low
back pain (May et al 2006) m ost proced ures show ed lim ited
reliability. With an upp er threshold of kappa / intra-class cor-
relation coef cient of 0.85, m ost p roced u res d em onstrated
either con icting evid ence or m od erate to strong evid ence
of low reliability. When a low er threshold w as u sed – a kap p a
(κ) / intra-class correlation coef cient of 0.70 – the proced u re
of p ain resp onse to several rep eated m ovem ents d em on-
strated m od erate evid ence for high reliability.
In fact, several exp loratory proced ures inclu d ing m anu al
p alp ation, visu al observation and m obility assessm ents have
also show n w eak reliability. An inaccu rate d iagnosis is the
likely sequ el and m anagem ent strategies shou ld be based on
reliable assessm ent ou tcom es. In su ch a scenario – that is, pain
resp onses to rep eated m ovem ents – as testing used for d irec-
tional p reference and centralization has d em onstrated reason-
ably good levels of reliability it therefore can constitute a
p rop er m ethod of establishing a classi cation and d eterm in-
ing m anagem ent strategies. Five stu d ies have exam ined the
reliability of the McKenzie classi cation system itself; of these,
three rep orted kap p a values of 0.7 or greater, one rep orted
m od erate agreem ent on cervical classi cation (Dionne et al
2006) and one rep orted poor kapp a valu es but the therapists
involved had lim ited know led ge of the classi cation system
(May et al 2006).
Evidence Regarding Prognosis in MDT
Within p hysical therap y exam ination p roced u res, centraliza-
tion has been d em onstrated to be a good p rognostic factor.
Centralization is d e ned as the abolition of d istal p ain in
response to therapeutic loading. Distal or leg pain can com e or
go d u ring the natural history of back pain; this is not the sam e
as centralization or d irectional preference, w hich by d e nition
m u st be d em onstrated d u ring rep eated m ovem ents or other
therap eu tic interventions. This d istinction is im p ortant as
m ost of the evid ence abou t these clinical p henom ena d erives
from their clinically d riven natu re.
One system atic review of 22 articles investigating p rognos-
tic valu e (Chorti et al 2009) revealed that d irectional prefer-
ence (i.e. changes in pain location and / or intensity ind u ced
by repeated spinal m ovem ents) show ed evid ence supp orting
the u se of these resp onses to inform m anagem ent. A m ore
recent system atic review located 54 articles for centralization
and eight for d irectional preference (May & Aina 2012). Cen-
tralization show ed a prevalence rate of 44% in a total of 4745
p atients, w ith a higher rate in acu te (74%) than in su bacu te or
chronic patients (42%). The p revalence rate of d irectional pref-
erence w as 70% in 2368 patients. It is clear that these clinical
p henom ena are com m only encou ntered in sp inal p atients.
Out of 23 stud ies investigating the prognostic valid ity of cen-
tralization, 21 d em onstrated a positive effect in those p atients
w ho d em onstrated centralization, com pared w ith those w ho
d id not. For both centralization and d irectional preference, in
seven ou t of eight stu d ies there is evid ence that they are
u sefu l treatm ent-effect m od i ers. The im p lications of these
nd ings are that these clinical resp onses, based on this
m echanical assessm ent, are evid ence-based w ays of establish-
ing appropriate m anagem ent strategies for su bgroup s of
p atients w ith sp inal p roblem s.
Evidence Regarding Conservative
Treatment with MDT
When evalu ating treatm ent ef cacy the id eal stu d y d esign is
the rand om ized controlled trial (RCT). System atic review s are
u sed to su m m arize this evid ence analytically and gu id elines
then u se these system atic review s to m ake their p rescrip tive
m anagem ent su ggestions. A nu m ber of system atic review s
related to he McKenzie m ethod have been pu blished (Table
7.2), all of w hich provid e som e su pport for the ef cacy of
MDT or classi cation-based m anagem ent of lu m bar sp ine
p roblem s.
A few of the rand om ized controlled trials on the u se of
the McKenzie system in the lu m bar sp ine are w orth highlight-
ing. A m u lticentre trial of ind ivid u als w ith acute and chronic
low back p ain challenged the gu id eline ad vice that no one
sp eci c exercise or rep eated m ovem ent is better than any
other (Long et al 2004). This w as the rst clinical trial to su b-
grou p patients prior to rand om ization u sing the d erangem ent
 Evidence regarding conservative treatment with MDT 81

Table 7.2 Conclus ions from s ys te ma tic re vie ws re garding e vide nce for the McKe nzie me thod and cla s s i ca tion s ys te ms
Re fe re nce Numb e r of RCTs Re mit Conclus ions

Clare et al 2004 6 Us e of McKenzie principles Short-term 8.6% greater reduction in

Meta-analys is of data pain, 5.4% greater reduction in dis ability
than controls
Cook et al 2005 5 – high quality (PEDro) Therapeutic exercis es with patients 4 / 5 s igni cantly better than control
class i ed us ing s ymptom res ponses group
Machado et al 2006 11 – mostly high quality McKenzie method Short-term 4.2% greater reduction in
Meta-analys is of data pain, 5.2% greater reduction in dis ability
than controls
Slade & Keating 2007 6 – high quality Unloaded exercises ; 4 / 6 McKenzie Short-term mean difference favoured
exercises McKenzie for pain 0.36–0.63 and for
function 0.45–0.47
Fersum et al 2009 5 Subclass i cation systems and Subclass i cation systems signi cantly
matched interventions for manual better reduction in pain and dis ability
therapy and exercis e short term, long term for pain
Kent et al 2010 4 – high quality Targeted manual therapy or exercis e One study s howed McKenzie method
therapy had s igni cantly better effects s hort term
Slater et al 2012 7 – quality of evidence low Subclass i cation systems and Signi cant treatment effects favoured
matched intervention for manual the clas si cation-based treatment
therapy compared with controls in pain and
disability short and medium term
Surkitt et al 2012 6 – 5 high quality Management using directional Moderate evidence that DP is
preference (DP) signi cantly more effective than controls
in short and long term

classi cation. Tw o hu nd red and thirty p atients classi ed w ith
d erangem ent synd rom e w ere rand om ized into three groups:
one in w hich they p erform ed the m atched exercise to their
d irectional preference, one in w hich they exercised in the
op p osite d irection to their d irectional p reference and one in
w hich they w ere given ‘evid enced -based ’ general exercises.
The m atched grou p im p roved to a signi cantly greater d egree
for all ou tcom es, w hich inclu d ed leg pain, back p ain, d isabil-
ity, m ed ication u se, d epression and interference w ith activity.
Over 90% of the m atched group rated them selves as better or
resolved at 2 w eeks, com p ared w ith ju st over 20% of the
opposite grou p and ju st over 40% of the evid enced -based
grou p. The m agnitud e of d ifferences betw een the groups
d em onstrates clearly that, in this sam ple of patients w ith low
back pain, the d irection of exercises they w ere given d id
m atter. All of the p atients inclu d ed in the stu d y had a favou r-
able p rognosis, so the d ram atic d ifferences in ou tcom es w ere
highly d ep end ent on the m atching of the exercises to the
sp eci c p atient d irection. A follow -u p stu d y show ed the
resu lts of the introd uction of d irectional preference exercises
to those p atients w ho w ere w orse or u nchanged d u ring the
initial 2-w eek trial p eriod (Long et al 2008). Su bstantial
im provem ents in pain and fu nctional ou tcom es w ere the
resu lt, m irroring the effect on the original d irectional prefer-
ence grou p in the trial.
Another high-quality rand om ized controlled clinical trial
com p ared the McKenzie m ethod w ith chirop ractic m anip u la-
tion in 350 p atients w ho d em onstrated either centralization or
p erip heralization (Petersen et al 2011). Both grou ps im proved ,
bu t the nu m ber of patients w ithin the McKenzie grou p report-
ing success w as greater. The McKenzie grou p had signi -
cantly greater im p rovem ent than the m anip u lation grou p in
regard s to fu nction and global p erceived effect at both 2
m onths and 12 m onths. A greater nu m ber of w ithd raw als
in the m anipu lation grou p reinforced the conclusion that
McKenzie therap y is a su itable m ethod for ind ivid u als
show ing either centralization or p erip heralization. A p ossible
im plication of this stud y is related to the fact that, in patients
exhibiting centralization or peripheralization, an active inter-
vention su ch as McKenzie therap y (w here the forces are
ap plied by the p atients them selves) can be m ore effective than
a passive intervention su ch as m anipu lative therap y (w here
it is the clinician w ho applies the forces).
The last high-qu ality trial w as cond u cted on ind ivid uals
reporting severe sciatica (Albert & Manniche 2012), in w hich
181 patients w ere rand om ized into tw o treatm ent grou ps: a
‘sym ptom -guid ed ’ exercise grou p that u tilized the McKenzie
system and w ere given stabilization exercises, and a sham
exercise group in w hich patients w ere given low -d ose
exercises. Despite patients’ expectations of having greater
im provem ent w ith the low -d ose exercises, signi cantly m ore
p atients in the grou p given McKenzie stabilization exercises
experienced im p rovem ent and there w as a trend tow ard s sig-
ni cance in leg p ain red u ction com p ared w ith the sham
grou p. Perhaps the m ost d ram atic d ifferences w ere exhibited
in the neurological signs at the end of treatm ent and at 1 year.
There w as a signi cant 40% and 43% red uction in the num ber
of ind ivid u als w ith m otor d e cit and sensory d istu rbance
respectively by the end of McKenzie treatm ent, versus a 13%
and 30% red u ction respectively in the sham grou p. These d if-
ferences rem ained signi cant at 1 year. N evertheless, there is
certainly the need for fu rther high-qu ality trials in the lu m bar
 82 PART 1 • 7 • Mechanical diagnosis and therapy for the spine: McKenzie method

Table 7.3 Guide line re comme ndations for the McKe nzie s ys te m
Guide line As p e ct of McKe nzie s ys te m De gre e of re comme nda tion
re comme nde d

Danish Ins titute for Health Technology
As ses sment (1999)
American College of Occupational and
Environmental Medicine (2005)
Quebec CLIP guidelines (Ross ignol et al
2007)
Work Los s Data Ins titute (2008)
Michigan Quality Improvement
Cons ortium Guideline (Goertz et al 2012)
Journal of Family Practice Guideline
(Bach & Holten 2009)
APTA Guideline (Delitto et al 2012)
As ses sment, treatment and As a diagnos tic and prognos tic method for
prognos is both acute and chronic low back pain (LBP)
Treatment recommended for certain conditions
McKenzie approach Supported as a clas si cation s ys tem for acute
and subacute LBP
McKenzie approach Low recommendation for acute LBP
Moderate recommendation for s ubacute LBP
Low recommendation for chronic LBP
As ses sment, s ubgrouping using Recognized reliability of as ses sment, the value
centralization, treatment effects of s ubgrouping using centralization
Treatment recommended for acute and chronic
for pain and dis ability in the short term
McKenzie exercis es Level A evidence for pain radiating below knee
McKenzie exercis es Grade A recommendation for pain radiating
below knee
Centralization and directional Supported by strong, level-A evidence
preference exercises

sp ine bu t, as can be seen from the exam p les above and the
system atic review s (see Table 7.2), signi cant progress has
been m ad e. In fact, this progress is re ected by som e of the
recom m end ations in low back pain guid elines published by
variou s institu tions (Table 7.3).
The evid ence base for the ef cacy of the McKenzie system
in the cervical sp ine is m ore lim ited at this p oint in tim e, bu t
three trials are w orthy of m ention. A Sw ed ish rand om ized
controlled trial com p ared general exercise, McKenzie therap y
and a control grou p in patients w ith neck p ain (Kjellm an &
Oberg 2002). The only signi cant resultant d ifferences in this
three-grou p com p arison w ere in general health and a p sycho-
som atic and d ep ressive scale, w here only the McKenzie grou p
show ed signi cant im p rovem ents. In a fu rther tw o-grou p
analysis, the McKenzie grou p show ed signi cantly greater
im p rovem ents than the control group for pain intensity at 3
and 6 m onths and for d isability p ost treatm ent. Ad d itional
healthcare u se w as m u ch less in the McKenzie grou p . In a
Polish clinical trial inclu d ing 61 ind ivid u als w ith chronic cer-
vical d erangem ent, McKenzie therap y w as com p ared w ith
‘trad itional therapy’ and found to be signi cantly m ore effec-
tive in term s of red u ctions in head , u p p er extrem ity and
overall p ain as w ell as in the nu m ber of p ain-free d ays (Gu zy
et al 2011). The other trial of signi cance in the cervical spine
w as cond u cted on 97 patients suffering from w hiplash-
associated d isord ers (Rosenfeld et al 2000). In this high-qu ality
trial, p atients w ere rand om ized into an active intervention
grou p based on McKenzie principles and a ‘stand ard ’ inter-
vention grou p . At the 6-m onth follow -u p , the pain w as sig-
ni cantly less in the McKenzie active grou p . The p atients
w ere then follow ed up for 3 years and the McKenzie active
grou p still had signi cantly less pain, less need for sick leave
and a better chance of regaining the form er range of cervical
m otion (Rosenfeld et al 2003). An econom ic analysis of the
stu d y d em onstrated low er costs for the McKenzie active
grou p both for healthcare and for lost prod uctivity (Rosenfeld
et al 2006).
With the nd ing regard ing the high p revalence of d erange-
m ents in the cervical and thoracic sp ine (H efford 2008), and
thu s the p otential for a signi cant p op u lation that m ay exp eri-
ence a rapid response to sim p le end -range exercises, the need
for clinical trials exploring the McKenzie system w ith the
cervical sp ine is com p elling.
Conclusion
The system of MDT has scienti c evid ence su pporting its u se,
especially in regard s to its reliability, its prognostic valid ity
and its effectiveness for treating p atients w ith low back p ain.
It is an assessm ent and m anagem ent system that can be u sed
as a screening tool for several patients w ith m u sculoskeletal
p roblem s, and is able to broad ly d istingu ish resp ond ers from
slow resp ond ers and from non-resp ond ers to a sp eci c
therap y. The three m echanical synd rom es resp ond in a p re-
d ictable w ay, the biggest proportion of w hich w ill be d erange-
m ent, w hich w ill resp ond rap id ly to rep eated m ovem ents
w ith centralization or a lasting d ecrease in sym ptom s. These
responses of centralization and d irectional p reference are su p-
p orted in the literatu re w ith resp ect to their p rognostic valu e.
A few p atients w ill p resent w ith d ysfu nction, w hich w ill
respond m ore slow ly to rep eated m ovem ents, and a very few
w ill present w ith p ostural synd rom e. Patients not classi able
in one of the m echanical synd rom es m ight be classi ed as one
of the ‘other ’ classi cations. The resp onse of the ‘others’ to
intervention is less pred ictable: som e m ay respond w ell, som e
p artially and som e m ay need a referral for other interventions.
Classi cation is based on the op erational d e nitions p re-
sented . The evid ence base is su bstantial regard ing the lu m bar

sp ine, bu t less, thou gh accu m u lating, regard ing the cervical
sp ine and the u se of MDT in the extrem ities.
Given the con nes of the chap ter, only a lim ited reference
base has been cited . (For fu ll access to reference citations see
Core reference list at w w w.m ckenziem d t.org.)
Acknowledgements
In m em ory of Robin McKenzie 1931–2013.
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 84 PART 1 • 7 • Mechanical diagnosis and therapy for the spine: McKenzie method
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 PART 1 •  General Introduction
Mechanical Diagnosis and Therapy for
Extremity Problems: McKenzie Method
CHAP TER CONTENTS
Introduction  85
Brief epidemiology of extremity musculoskeletal pain conditions  85
Medical diagnosis for extremity conditions  86
Anatomy and biomechanics in MDT  86
Proposed pathological model in MDT  87
Evidence regarding diagnosis in MDT  88
Evidence regarding prognosis in MDT  88
Evidence regarding treatment of extremity conditions with MDT  88
Conclusion  89
Introduction
In the introd uction to his rst textbook, Robin McKenzie
(1981, p xix) w rote: ‘the p roced u res for the lu m bar sp ine to
arrive at ap p rop riate conclu sions regard ing d iagnosis and
treatm ent m ay also be ap p lied su ccessfu lly to the thoracic and
cervical sp ine, and ind eed to all p erip heral joints and their
su rrou nd ing soft tissu es. Irresp ective of the p resenting p athol-
ogy, the p rincip les of d iagnosis and treatm ent rem ain the
sam e.’ H ow ever, the system of m echanical d iagnosis and
therap y (MDT) w as generally not ap p lied to p erip heral or
extrem ity m u sculoskeletal problem s in the early years after
this p u blication. This changed after 2000, w hen a text d escrib-
ing and illustrating the use of MDT principles for extrem ity
problem s w as nally pu blished (McKenzie & May 2000).
Over the follow ing d ecad e, literatu re has been p u blished that
is grad u ally giving som e scienti c su pport to the McKenzie
m ethod in the extrem ities (McKenzie et al 2009, 2012). This
chap ter w ill introd u ce the u se of MDT in the extrem ities and
d escribe the existing literatu re.
In term s of the issu es being d iscu ssed in this chapter, the
general com m ents refer to all extrem ity cond itions, but shou l-
d er and knee problem s are frequently id enti ed as the m ost
com m on extrem ity p roblem s seen in clinical p ractice. For
instance, in an au d it of 1713 patients d ischarged from an
ou tp atient d ep artm ent in p rim ary care in the UK, abou t half
the p atients had sp inal p ain and abou t half had extrem ity
Chapter  8
S te p h e n M a y, G ra n t Ric h a rd Bu rg e s W a ts o n
p ain. Patients w ith shou ld er and knee p roblem s rep resented
11% and 13% of the total respectively, w ith other extrem ity
joints com prising abou t 4% each (May 2003). There are a
nu m ber of ep id em iological asp ects to extrem ity m u scu loskel-
etal problem s that requ ire elaboration, as som e of the trad i-
tional p ercep tions of extrem ity p roblem s have not stood u p
to the actu al evid ence that exists. For instance, it u sed to be
consid ered that m ost extrem ity p roblem s w ere short lived ,
easily cured and cou ld be easily d iagnosed w ith valid and
reliable p hysical exam ination proced u res, but increasingly the
evid ence su ggests this is not the case. (Chs 1 and 2 d iscussed
ep id em iological issues for the u pper and low er extrem ity
respectively.)
Brief Epidemiology of Extremity
Musculoskeletal Pain Conditions
Mu scu loskeletal p roblem s in general are a m assive bu rd en in
the general population. In a su rvey of nearly 6000 p articip ants
cond u cted across eight European cou ntries, over 60% of
fem ale particip ants and over 40% of those over 60 years of age
reported m u sculoskeletal sym p tom s of som e kind (Woolf et al
2004). Althou gh substantial d ifferences in the prevalence rates
of u p p er extrem ity d isord ers w ere rep orted in one system atic
review across 13 stud ies, one stu d y reported a lifetim e p reva-
lence rate of 29% (H u issted e et al 2006). In 2005 in Japan, in
those over 30 years of age the prevalence rate of back, hip and
knee pain w as rep orted as 24%, 4% and 10% respectively
(Su ka & Yoshid a 2009). In a su rvey of over 800 p eop le aged
58 years in Scotland , 31% reported knee pain, 21% shou ld er
p ain, 16% hip pain, 13% hand p ain, 23% pain in the ankles or
the toes and less than 10% pain in the elbow or the w rist
(Ad am son et al 2006).
Despite the fact that not everybod y w ith m u sculoskeletal
p roblem s seeks care for treatm ent, they constitu te a m ajor
healthcare expend itu re, as they accou nt for 15% of all consu l-
tations in general p ractice in the UK (McCorm ick et al 1995).
In fact, typ ically in a prim ary care physical therapy d epart-
m ent, half the p atients attend w ith an extrem ity p roblem
(May 2003). It has generally been thought that the natural
 86 PART 1 • 8 • Mechanical diagnosis and therapy for extremity problems: McKenzie method
history of extrem ity m u scu loskeletal p roblem s is good , bu t
cu rrent evid ence su ggests that extrem ity p roblem s have a
sim ilar history of p rotracted ep isod es, recu rrence and failed
treatm ents as lu m bar spine p roblem s. For instance, of 251
p atients w ho p resented w ith a new episod e of knee pain, only
25% and 44% rep orted fu ll recovery at 3 and 12 m onths
resp ectively (van d er Waal et al 2005). Forty per cent of ind i-
vid u als w ith shou ld er problem s still rep ort problem s 1 year
after seeking care, d espite treatm ent includ ing p hysiotherapy,
corticosteroid injections and non-steroid al anti-in am m atory
d rugs (Croft et al 1996). Sim ilarly, from 181 patients w ith
elbow p ain follow ed u p in p rim ary care, 13% rep orted recov-
ery at 3 m onths and only 34% at 12 m onths (Bot et al 2005).
Furtherm ore, Vincenzino and Wright (1996) found that elbow
p ain had a recu rrence rate of 25–50%.
Medical Diagnosis for Extremity
Conditions
The other m yth that has p ersisted in extrem ity p roblem s is
that a stru ctu ral d iagnosis is easy to m ake u sing stand ard
orthop aed ic tests. Unfortu nately this is not as sim p le as su s-
p ected . For shou ld er pathology, the literatu re related to
m ed ical d iagnosis is extensive and inclu d es m u ltip le system -
atic review s; consequ ently only a few are referenced here. In
a m eta-analysis of 45 stu d ies (H eged u s et al 2008), only half
of them d em onstrated high qu ality and only tw o had ad e-
qu ate sam p le size; in ad d ition, all tests exhibited either rea-
sonable or p oor sensitivity bu t p oor sp eci city, or vice versa.
The authors of this review conclud ed that cu rrently there is a
lack of clarity w ith regard to w hether com m on orthop aed ic
sp ecial tests u sed rou tinely in clinical exam ination are clearly
u sefu l in d ifferential d iagnosis at p roblem s of the shou ld er.
Review s abou t tests for sp eci c p athologies are very sim ilar.
For instance, for su p erior labral anterior–p osterior tears, it
w as conclu d ed that none of the tests exhibited strong valid ity
(Dessau r & Margarey 2008; Walton & Sad i 2008; Mu nro &
H ealy 2009). Sim ilarly, m ost tests attem pting to id entify
rotator cu ff p athology are not usefu l and cannot be recom -
m end ed for clinical p ractice (H u ghes et al 2008). (Read ers are
referred to other chapters in this book for fu rther inform ation
on clinical d iagnosis of u p p er extrem ity cond itions.)
The situ ation is sim ilar for knee p roblem s. System atic
review s conclu d ed that no single test appears to d iagnose a
torn m eniscu s accu rately since p ooled sensitivity and p ooled
sp eci city for McMu rray’s, Ap ley’s and joint line tend erness
w ere resp ectively 70% and 71%, 60% and 70%, and 63% and
77% (H eged u s et al 2007). The review cond u cted by H ing
et al (2009) conclu d ed that the McMu rray’s test is of lim ited
clinical valu e ow ing to low sensitivity. Another review
su m m arized the d iagnostic od d s ratios (ORs) and fou nd
joint line tend erness to be the m ost accurate (OR 10.98), bu t
McMu rray’s test (OR 3.99) and Ap ley’s test (OR 2.2) w ere
w eak (Meserve et al 2008).
A system atic review investigating reliability stu d ies of
ind ivid u als w ith shou ld er p roblem s fou nd that the m ajority
of high-qu ality stu d ies rep orted p oor reliability for the p roce-
d u res investigated (May et al 2010). For instance, kappa
valu es for the H aw kins–Kenned y test ranged from 0.18 to
0.91, for N eer ’s sign they ranged from 0.10 to 1.00, for the
em p ty can test from 0.44 to 0.49, and for Gerber ’s lift-off
test from 0.18 to 0.45. In an assessm ent of the p hysical
exam ination of the knee, inter-tester reliability for d ichoto-
m ou s and ord inal exam ination item s w as fou nd to be gener-
ally p oor, ranging from −0.08 to 0.43 (Wood et al 2006). In the
assessm ent of four tests for p atellofem oral alignm ent, kapp a
valu es w ere 0.10–0.36 (Fitzgerald & McClu re 1995).
Obviou sly any history taking and exam ination focu sing
on m aking a d iagnostic conclu sion w ill involve m u ltip le
item s from all aspects of the assessm ent process, bu t the
evid ence su ggests that stand ard orthop aed ic tests have
shortcom ings in term s of both valid ity and reliability. One
review that looked at the valu e of d iagnostic labelling at the
shou ld er in term s of consistency and treatm ent ou tcom es
(Schellingerhou t et al 2008) conclud ed that a grou p classi ca-
tion based on p rognostic and reliable treatm ent ind icators
shou ld be u sed instead . In su ch a scenario, MDT can help to
ad d ress som e of these criteria.
Anatomy and Biomechanics in MDT
As alread y stated the MDT m ethod u ses non-speci c classi -
cations, w hich are d e ned by clinical op erational d e nitions
(Table 8.1) and not by stru ctu rally speci c anatom ical d iag-
noses. One su rvey of exp erienced therap ists’ classi cation of
388 patients found that althou gh the d erangem ent category
Table 8.1 Ope rationa l de nitions for MDT clas s i cations
and othe r
Derangement Las ting abolition or decreas e of symptoms ,
and / or an increase in res tricted range of
movement in res ponse to repeated
movements
Articular Intermittent pain consis tently produced at a
dysfunction res tricted end range with no rapid change
of s ymptoms or range
Contractile Intermittent pain, cons istently produced by
dysfunction loading the musculotendinous unit, for
ins tance with an isometric contraction
agains t res istance
Pos tural Only produced by s ustained loading, which,
syndrome once avoided, the rest of the phys ical
examination would be normal
Other categories* Failure to clas sify as one of the above
mechanical s yndromes and considered to
be non-mechanical according to operational
de nitions (see below), such as recent
trauma, post surgery or chronic pain state
*Before any of thes e other categories are cons idered a full mechanical evaluation
mus t be conducted, which may occur over s everal days . The mechanical
syndromes (derangement, articular dysfunction, contractile dys function and
pos tural s yndrome) mus t be abs olutely rejected before any of thes e categories
are cons idered. To meet other categories, patients must fail to meet operational
de nitions for mechanical s yndromes and meet operational de nitions for other
categories as des cribed.

w as m ost com m on (37%), as in the sp ine, d ysfu nctions w ere
also not u ncom m on (May & Rosed ale 2012) (Fig. 8.1). In the
sp ine, d irectional p reference for d erangem ent synd rom e is
p red om inantly in the sagittal p lane (Ch 7). Within the extrem -
ities, although extension and exion still featu red strongly
load ing, strategies w ere m ore varied for both d erangem ent
and d ysfunctions (May & Rosed ale 2012). In the large group
classi ed as ‘other ’, 20% of the 36% occu rred after either
su rgery or trau m a. Figu re 8.2 p rovid es exam ples from the
shou ld er and knee p roblem s, w hich w ere the tw o m ost
com m on extrem ity p roblem s. It is hyp othesized that the
greater num ber of load ing strategies used in the extrem ities
is a prod uct of the nu m ber of d egrees of freed om available at
som e of the extrem ity joints, esp ecially at the shou ld er and
the hip . Figu re 8.2 show s m uch m ore varied load ing strategies
at the shou ld er com pared w ith the knee, w here only extension
and exion w ere u sed . Other com m on patterns em erged in
contractile d ysfu nctions, su ch as abd u ction at the shou ld er
(9 / 14), w rist extension at the elbow (9 / 14), and extension at
the knee (7 / 9).
CLASSIFICATION
Other Derangement
36% 37%
AD CD
10% 17%
CD: contractile dysfunction; AD: articular dysfunction
Figure 8.1 Final classi cation recorded by 30 therapists on 388 extremity
patients. (Source: May & Rosedale 2012.)
SHOULDER DERANGEMENTS (N=51)
8%
25%
4%
49% 4%
10%
A B
Figure 8.2 Direction of loading strategies in derangements: (A) at the shoulder and (B) at the knee. (Source: May & Rosedale 2012.)
Proposed pathological model in MDT 87
Proposed Pathological Model in MDT
The proposed system of MDT is m ainly based on non-speci c
m echanical synd rom es w hose op erational d e nitions are
d erived from sym ptom atic and m echanical responses (see
Table 8.1). H ow ever, conceptu al m od els exp laining these
sym p tom atic resp onses have been p rop osed (McKenzie &
May 2000, 2003, 2006).
In sp inal problem s the McKenzie m ethod of MDT has been
associated w ith intervertebral d isc p athology, even thou gh
this has been u sed as a concep tu al m od el only for d erange-
m ents. Clearly the d ynam ic d isc m od el d oes not t in w ith
p atients w ith extrem ity p roblem s, in w hich inter-joint d iscs
are few, thou gh they d o exist – such as at the tem p orom an-
d ibular joint (Krog & May 2012). H ow ever, intra-articular
inclusions are characteristic of complex synovial joints, su ch as the
fat pad s and broad ipose m eniscoid s found in cad aver elbow
joints (Mercer & Bogd u k 2007). It is conceivable that such
stru ctu res m ay cau se p roblem s: ‘internal displacement of articu-
lar tissue of whatever origin will cause pain … and obstruct move-
ment’ (McKenzie & May 2000, p 84). Again, it shou ld be
em phasized that this is a theoretical and conceptu al m od el
su ggested for giving biological p lau sibility and that the op er-
ational d e nition is not at all d epend ent on this, bu t rather on
sym p tom atic and m echanical resp onses.
The conceptual m od el und erlying the d ysfu nction syn-
d rom e is that there has been som e traum a, previou s d erange-
m ent or d egenerative changes in the affected tissu e. There is
alw ays a lengthy history of m onths, bu t after the initial event
no effective rem od elling has occu rred (H unter 1994; Scott et al
2004). Becau se of this the patient is left w ith a painfu l im pair-
m ent, w hich m ay be associated w ith restricted m ovem ent
d epend ing on the type of d ysfu nction. Dysfunctions m ay
affect articular or periarticu lar stru ctu res, su ch as occu rs in
early osteoarthritis (McCarthy et al 1994). Articular d ysfunc-
tions typ ically p resent w ith restricted and p ainfu l end -range
m ovem ents in certain patterns – for instance, at the knee w ith
loss of exion and / or extension, or at the hip w ith loss of
m ed ial rotation and exion. This is sim ilar to the concep t of
cap su lar p atterns ou tlined by Cyriax (1982), in w hich irritation
of the joint cau ses p ainfu l and restricted range of m ovem ent,
typ ically bu t not alw ays in certain p atterns at d ifferent joints.
KNEE DERANGEMENTS (N=44)
4% 5%
Ext
Flex
Ext
Add
Flex
LR
Multiple
MR
Multiple
91%
 88 PART 1 • 8 • Mechanical diagnosis and therapy for extremity problems: McKenzie method
Both active and p assive m ovem ents w ill p rod u ce p ain at
a restricted range of m ovem ent in one or m ore d irections,
w hich w ill be consistently reprod uced every tim e the joint
is m oved .
Dysfunction m ay also affect contractile tissu e, m ost com -
m only tend ons, su ch as in lateral ep icond ylalgia, shou ld er
tend inop athy or Achilles tend inop athy (Littlew ood 2012).
Mu scle can be also affected (see Part 10). Contractile d ysfunc-
tion p resents u su ally w ith fu ll bu t p ossibly p ainfu l active
m ovem ent and the p atient’s p ain is rep rod u ced w hen the
relevant m ovem ent is resisted (e.g. resisted w rist extension in
lateral ep icond ylalgia, or a resisted shou ld er abd u ction in
tend inop athy at the shou ld er).
With all d ysfu nctions, p ain is elicited by active, p assive or
resisted m ovem ents; the pain com es on each tim e, how ever
m any tim es it is rep eated , and ceases w hen the m ovem ent is
end ed . Again it should be em p hasized that the operational
d e nitions are based on the sym p tom atic and m echanical
resp onses ou tlined above, but clinical d e nitions are not
d epend ent on the conceptu al m od els su ggested above. Pos-
tu ral synd rom e (d escribed in Ch 7) is rarely used in the clas-
si cation of p atients w ith extrem ity p roblem s. N evertheless,
the concep tu al m od els above are ind eed no m ore than con-
cep tu al m od els; they m ay or m ay not be entirely accu rate,
bu t u ltim ately are not relevant to the effectiveness of the
m ethod .
Evidence Regarding Diagnosis in MDT
The MDT system is not seeking to m ake speci c pathoana-
tom ical d iagnoses in term s of the MDT non-sp eci c m echani-
cal synd rom es; these are established u sing the op erational
d e nitions laid out in Table 8.1. Som e reliability stu d ies have
explored the ability of clinicians to agree on MDT classi ca-
tions. Kelly et al (2008), in a p ilot stud y, evaluated the agree-
m ent on extrem ity McKenzie assessm ent and fou nd reasonable
agreem ent (82% agreem ent, kapp a 0.70). In a follow -u p stu d y
w ith 97 exp erienced McKenzie clinicians evalu ating 25 p atient
vignettes, the overall agreem ent w as 92%, w ith kapp a scores
of 0.83 (May & Ross 2009). These stu d ies w ould suggest that
clinicians exp erienced in the m ethod are su f ciently able to
agree on the classi cation.
Tw o stu d ies show ed that, from 1000 p atients w ith extrem -
ity problem s, betw een 64% and 72% w ere classi ed w ith a
m echanical synd rom e, attesting to the clinical u tility of the
system (May 2006; May & Rosed ale 2012). If patients d o not
m eet the op erational d e nition of one of the m echanical syn-
d rom es after several assessm ent sessions, then one of the
‘other ’ classi cations can be consid ered (see Table 8.1).
Evidence Regarding Prognosis in MDT
Since the u se of the MDT system in the extrem ities is relatively
recent, practitioners w ere initially u nfam iliar w ith these class-
i cations ap p lied to the extrem ities. From su rveys inclu d ing
m u ltip le p ractitioners u tilizing the MDT m ethod in the
extrem ities and inclu d ing d ata from 753 patients (May 2006),
the p revalence of MDT classi cations in the extrem ities w as
as follow s: d erangem ent 19%, articu lar d ysfu nction 26%, con-
tractile d ysfu nction 27% and other 28%. In this stud y, 72%
w ere classi ed w ith a m echanical synd rom e (May 2006). In a
m ore recent su rvey involving 30 therapists w orld w id e and
d ata on 388 consecu tive p atients (May & Rosed ale 2012), a
sim ilar p rop ortion (64%) w as classi ed w ith MDT synd rom es,
bu t the proportions w ithin this category w ere d ram atically
d ifferent: d erangem ent 37%, articu lar d ysfu nction 10%, con-
tractile d ysfunction 17% and other 36%. The rise in those
classi ed w ith d erangem ent m ay ind icate a learning p rocess
in recognition of this synd rom e, and the im portance of experi-
ence in and continued application of the system to m axim ize
its potential.
The reason w hy a d oubling of recognition of d erangem ent
and a subsequ ent d ecrease in the ‘other ’ m echanical classi ca-
tions w as fou nd can be related to the fact that, by d e nition,
d erangem ent is associated w ith a rap id response to repeated
m ovem ents, and in the sp ine this classi cation has been asso-
ciated w ith a good p rognosis (Ch 7). The d ata provid ed in the
next section attests to early evid ence that the classi cation of
d erangem ent in the extrem ities is also associated w ith rap id
p ositive changes in sym p tom s, su ch as in case stu d ies at the
shou ld er joint (Aina & May 2005), or tem porom and ibu lar
joint (Krog & May 2012), and in a rand om ized controlled
trial w ith p atients w ith osteoarthritis of the knee (Rosed ale
et al 2014).
The p rognosis of patients w ith articu lar and contractile
d ysfunctions is, by the very nature of their problem s,
slow er – bu t generally equ ally good . Rap id changes are not
exp ected in these grou ps, bu t change is generally forthcom ing
over a longer tim e p eriod , p ossibly a few m onths, as the
tissu es are rem od elled w ith the ap p rop riate load ing strategy.
So m anagem ent in these cases m u st em p hasize the im p or-
tance of m aintaining the ap p rop riate rehabilitation rou tine to
d eterm ine a long-term return to fu ll and pain-free fu nction.
Evidence Regarding Treatment of
Extremity Conditions with MDT
Conservative treatm ent based on the McKenzie m ethod is
fou nd ed on the classi cation as per the operational d e nitions
in Table 8.1. A p atient w ith d erangem ent p erform s rep eated
m ovem ents that d ecrease and can abolish sym p tom s and
restore a fu ll range of m ovem ent, w hich is the d irectional
p reference. Som etim es op p osite m ovem ents aggravate sym p -
tom s; therefore tem p orary avoid ance of certain m ovem ents
m ight also be ind icated . A p atient w ith articu lar d ysfu nction
repeats m ovem ents into the restricted painful m otion, and
in one p atient w ith a contractile d ysfunction the repeated
resisted m ovem ents rep rod u ce the sym ptom s. These m ove-
m ents m ay be isom etric exercises, active m ovem ents or eccen-
tric exercises; the d egree of load ing is d eterm ined by the level
of p ain resp onse. Som e p ain or d iscom fort m ay be p rod u ced ,
bu t any aggravation should d isappear quickly w hen the
load ing is rem oved .
The em phasis for all synd rom es shou ld includ e self-
m anagem ent, w ith a p atient-centred ap p roach to m anage-
m ent and w ith an em p hasis on ed u cation to ensu re that
p atients know w hat exercise they need to p erform , the nu m ber
of rep etitions and the rationale. Generally a few exercises at
a tim e are given, and patients d em onstrate that they know
w hat they are d oing before leaving the session, w hich tend s
to increase com p liance. The actu al d irection of load ing w ill

d ep end on the therap ist’s clinical-reasoning process. In fact,
there are certain p atterns that are m ore com m on, bu t the
MDT system allow s variability in the p rescrip tion of sp eci c
exercises.
As d iscu ssed in the introd uction, scienti c evid ence base
for the use of MDT in the extrem ities is relatively new. After
the textbook by McKenzie and May (2000), a nu m ber of case
stu d ies began to em erge in the scienti c literatu re. These case
stu d ies inclu d ed ind ivid u als classi ed w ith d erangem ent at
the shou ld er (Aina & May 2005), the rad iocarpal joint (Kaneko
et al 2009), the tem p orom and ibu lar joint (Krog & May 2012),
and the knee joint (Lynch & May 2013). There are a num ber
of featu res that stand ou t from these stu d ies, p articu larly the
p ossible length of the previou s history and p ast u nsu ccessfu l
treatm ents, bu t a rap id and lasting resp onse to MDT. The
p atient w ith a tem p orom and ibu lar d erangem ent exhibited
sym p tom s for m any years, bu t rem ained resolved at long-
term follow -u p at 1 year (Krog & May 2012). Several of the
other case stud ies also had 1-year follow -u p s w here p atients
rem ained fully asym ptom atic (Kaneko et al 2009; Lynch &
May 2013), or w here m inor sym p tom s had returned but w hich
had been sw iftly resolved by self-m anagem ent u sing MDT
repeated m ovem ents (Kaneko et al 2009). H ow ever, cause-
and -effect relationship s cannot be inferred from case reports.
In all these case stu d ies, resolution of the d erangem ent m eant
red u ction, and som etim es abolition, of pain and return to
fu nction, inclu d ing in 1 subject retu rn to an intense sw im m ing
training p rogram m e (Lynch & May 2013). Treatm ent of these
ind ivid u als w as accom plished by clinical reasoning on the
p art of the therap ist to d eterm ine the ap propriate d irectional
p reference that red u ced or abolished the pain. In the variou s
stu d ies this involved : hand behind the back w ith overp res-
su re at the shou ld er (Aina & May 2005), d istraction w ith
lateral m ovem ent at the w rist (Kaneko et al 2009), lateral over-
p ressu re to the jaw (Krog & May 2012) and extension w ith
overp ressu re at the knee (Lynch & May 2013). It w as also
fou nd that repeated m ovem ents op posite to the d irectional
p reference cou ld cau se the sym p tom s to retu rn tem p orarily
(Aina & May 2005).
One case stu d y also d escribed how a p atient w ith p ain at
the tip of his shou ld er, involved in lifting heavy load s d u ring
his w ork, and w ith a p ositive m agnetic resonance im aging
show ing a com p lete tear of su bscap u laris m u scle and a typ e
2 SLAP lesion, im p roved his sym ptom s w ith rep eated m ove-
m ents of retraction and extension of the neck (Menon & May
2013). At 1-year telep hone follow -u p, the patient reported that
he had generally rem ained asym p tom atic.
Another case stu d y d escribed a contractile d ysfunction of
the shou ld er in a 57-year old m an w ith a 1-year history of
sym p tom s (Littlew ood & May 2007). There w as no pain at
rest; he had com plete active and p assive range of m ovem ent,
a painfu l arc on abd uction, and pain on resisted abd u ction
and lateral rotation. The p atient w as instru cted to p erform
active abd u ction exercises w here pain w as felt. One m onth
later, he rep orted a red u ction in sym p tom s, and at 10 w eeks
from initial consu ltation he reported no pain or functional
d isability. (N ote here the longer tim e-fram e to resolution, as
w ou ld be expected w ith this typ e of classi cation.)
One trial involved p atients w ith contractile d ysfu nction
at the shou ld er, bu t at present this trial is ongoing and the
only p u blished m aterial for this involves the trial p rotocol
(Littlew ood et al 2012), the d evelopm ent of the exercise
p rogram m e (Littlew ood et al 2013a) and the pilot stud y
Conclusion 89
(Littlew ood et al 2013b). The self-m anaged com ponent of this
trial com p rised an initial assessm ent to consid er baseline
functional problem s, exercise load ing, barriers to im plem en-
tation and p ossible solu tions, and p ossible follow -u p ap p oint-
m ents or telep hone follow -u p s if thou ght necessary. The
stand ard p hysiotherap y consisted of m u ltip le interventions
and m ultip le treatm ent sessions. The self-m anaged grou p
received an average of 3.9 sessions, w hereas the stand ard
p hysiotherapy grou p received 7.6 sessions. The p ilot stu d y
fou nd no signi cant d ifferences betw een the group s, in term s
of shou ld er d isability and general heath m easu res. The
m echanical synd rom e of contractile d ysfu nction cou ld also be
referred to in speci c term s as a rotator cu ff tend inopathy
(Littlew ood 2012); this p aper explores cu rrent und erstand ing
in relation to pathology, d iagnosis, treatm ent and prognosis
related to contractile d ysfunction and rotator cu ff tend inopa-
thy. It also exp lores the strengths of this su bclassi cation as
w ell as issues w here further progress need s to be m ad e. The
review highlights the im p ortance of load ed exercises for this
cond ition.
The u se of load ed exercises for contractile d ysfu nction,
especially bu t not only eccentric exercises, is w ell established
in this group. Other stu d ies on this d ysfu nction in the extrem i-
ties involved the shou ld er (H olm gren et al 2012), groin
(H olm ich et al 2011), elbow (Ram an et al 2012), patella tend on
(Bolgla & Boling 2011) and Achilles tend on (Scott et al
2011) – all com m on sites of tend on problem s. (Read ers are
referred to Parts 4–9 for appropriate exercise p rogram m es
targeted at these d ifferent regions and cond itions.)
The strongest evid ence for the u se of MDT in the extrem i-
ties for d erangem ent classi cation com es from a single rand -
om ized controlled trial (Rosed ale et al 2014). Patients w ith
established knee osteoarthritis (n = 180) w ere recru ited from a
tertiary centre w here they had been referred for p ossible knee
replacem ent, and rand om ized to an intervention or a control
grou p. The intervention grou p received an MDT assessm ent,
and those classi ed as d erangem ent w ere given d irectional
p reference exercises, w hereas those classi ed as MDT non-
respond ers w ere given evid ence-based exercises. The control
grou p rem ained on the w aiting list. Pain and fu nction w ere
assessed at 2 w eeks and 3 m onths u sing established ou tcom e
m easures. At 2 w eeks and 3 m onths, the MDT grou p had
signi cantly low er p ain and better fu nction than both the
control grou p and the MDT non-resp ond ers. Desp ite being a
grou p of patients w ith established osteoarthritis in their 60s
and referred for total knee replacem ent, 40% of those ind i-
vid u als w ho received MDT assessm ent w ere classi ed as
d erangem ent. This is a very sim ilar p roportion to the 43% of
p atients w ith knee p roblem s classi ed as d erangem ent in the
p reviou sly qu oted su rvey (May & Rosed ale 2012), w hich w as
in m ostly private, stand ard ou tpatient clinics. It is rem arkable
that, d esp ite very d ifferent p op u lation grou p s, the p revalence
of d erangem ent w as so sim ilar, w hich ind icates the im p or-
tance of this p op u lation grou p in m u scu loskeletal p roblem s
in general.
Conclusion
Mechanical Diagnosis and Therap y u ses a non-sp eci c clas-
si cation for extrem ity p ain cond itions inclu d ing d erange-
m ent, articu lar and contractile d ysfu nction, p ostu ral and
other, w hich ind icates how the p roblem can be m anaged : for
 90 PART 1 • 8 • Mechanical diagnosis and therapy for extremity problems: McKenzie method
d erangem ent establish the d irectional p reference, for articu lar
d ysfunction apply end -range load ing, and for contractile
d ysfunction ap ply resisted or active load ing. Derangem ents
generally respond qu ickly to self-applied exercise pro-
gram m es. The operational d e nitions of these synd rom es
are all based on clinical sym p tom atic and m echanical
p resentations.
The McKenzie ap p roach has been w ell established for
sp inal p roblem s for m any d ecad es, w hereas its u se in extrem -
ity p roblem s is m ore recent. Som e d ifferences ap p ly, m ost
notably in the p revalence rates of the d ifferent synd rom es,
w ith d erangem ent being the m ost p rom inent su bclassi cation
in sp inal p roblem s, w hereas d ysfu nctions seem to be m ore
com m on in extrem ity p roblem s. Desp ite these d ifferences, the
sam e m anagem ent strategies ap p ly to both extrem ity and
sp inal p roblem s. The evid ence base for the u se of MDT in
extrem ity p roblem s is clearly lim ited at this m om ent. There
exist nu m erous case stu d ies, and som e reliability and su rvey
stu d ies, and trials into its effectiveness begin to be
p u blished .
Acknowledgement
In m em ory of Robin McKenzie 1931–2013.
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This pa ge inte ntiona lly le ft bla nk
 P AR T 2
Cervicothoracic Spine
in Upper Extremity
Pain Syndromes
9 Mechanical Neck Pain 95
Bryan S. Dennison and Michael H. Leal
10 Whiplash-associated Disorders 110
Michele Sterling
11 Differential Diagnosis and Treatment of Cervical Myelopathy, Cervical Radiculopathy
and Cervical Myeloradiculopathy 118
Chad Cook and Amy Cook
12 Thoracic Outlet Syndrome 132
Susan W. Stralka
13 Thoracic Spine Manipulation 142
William Egan, Paul E. Glynn and Joshua A. Cleland
14 Joint Mobilization and Manipulation of the Cervical Spine 158
John R. Krauss, Douglas S. Creighton, Joshua A. Cleland and
César Fernández-de-las-Peñas
15 Therapeutic Exercise for Mechanical Neck Pain 174
Carol Kennedy
This pa ge inte ntiona lly le ft bla nk
 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
CHAP TER CONTENTS
Mechanical neck pain def nition  95
Prevalence o  mechanical neck pain  96
Financial impact o  mechanical neck pain  97
Risk  actors and prognosis in mechanical neck pain  97
Review o  anatomy specif c to mechanical neck pain  99
Causes o  mechanical neck pain  99
Clinical presentation o  neck pain  100
Proposed management o  mechanical neck pain  100
First level o  classif cation  101
Red  ag screening  101
Yellow  ag screening  103
Second level o  classif cation  103
Cervical spine sel -report measures o  pain and  unction  105
Numerical Pain Rating Scale  106
Neck Disability Index  106
Patient Specif c Functional Scale  106
Fear-avoidance Belie  Questionnaire  107
Global Rating o  Change scale  107
Conclusion  107
Mechanical Neck Pain De nition
N eck pain is a com m on problem , increasingly a ecting ind i-
vid u als w orld w id e (H ogg-Johnson et al 2009). Prevalence
d ata su ggest that neck p ain can span the ages, a ecting chil-
d ren and the eld erly alike, w ithout gend er d iscrim ination.
Sim ilar to low back p ain, neck p ain is ep isod ic in natu re
(H ogg-Johnson et al 2009). Recent analysis su ggests that neck
pain ollow s a ‘chronic–ep isod ic course’ (H oy et al 2010).
Absolute resolu tion o sym p tom s evad es the m ajority o neck
pain su erers (Carroll et al 2009) resu lting in both qu ality-
o -li e and econom ic im p acts (Borghou ts et al 1999; Wright
et al 1999).
Despite its com m on presence, there is w id e variability in
d ef ning neck pain (Fejer et al 2006). This is d ue, in p art, to
the p resence o both p hysical and p sychosocial contribu tors
to cervical sp ine p ain. As a resu lt o the m u lti actorial p resen-
tation o neck p ain and the inability to id enti y the exact
sou rce o p resenting cervical sp ine sym p tom s (Borghou ts et al
1998), the label ‘non-specif c neck pain’ has been assigned to
Chapter  9  
Mechanical Neck Pain
Brya n S . De n n is o n , M ic h a e l H. Le a l
any u nd iagnosable sym p tom atic d isord er o the cervical
sp ine. The vagu eness o this d escrip tive term has resu lted in
urther variance o w hat com prises non-specif c neck pain. As
su ch, d escrip tive term s su ch as occu p ational cervicobrachial
d isord er, tension neck synd rom e, cervical spond ylosis, tho-
racic ou tlet synd rom e, cervical osteoarthritis and m echanical
neck p ain have been synonym ou sly ap p lied to non-sp ecif c
neck p ain (Koes & H oving 2002). Contributing to this term i-
nology con u sion is the reality that sp ecif c, valid and rep ro-
d ucible d iagnostic criteria are absent (Buchbind er et al 1996a,
1996b).
In an e ort to stand ard ize a w orking d ef nition o neck
p ain, step s have been taken to id enti y the sym p tom atic
bou nd aries that com prise the neck pain experience. The ol-
low ing d ef nition or neck pain or cervical spinal pain w as
p rop osed (Fig. 9.1):
Pain perceived as arising rom anywhere within the region
bounded superiorly by the superior nuchal line, in eriorly by an
imaginary transverse line through the tip o the f rst thoracic
spinous process, and laterally by the sagittal planes tangential to
the lateral borders o the neck.
(Merskey & Bogduk 1994, p 11)
In 2009, The N eck Pain Task Force pu t orth its w orking d ef -
nition or neck sym p tom s covering non-d escrip t term s su ch
as non-specif c, so t tissue and m echanical neck pain. The
Task Force exclu d ed neck p ain associated w ith system ic or
p athological d isease, or neck p ain as a resu lt o ‘skin lesions,
throat d isord ers, tu m ou r, in ections, ractu res and d isloca-
tions’ (Guzm an et al 2009). They d ef ned neck pain as sym p-
tom s ‘located in the anatom ical region o the neck as ou tlined
(Fig. 9.2), w ith or w ithout rad iation to the head , tru nk and
u p p er lim bs’ (Guzm an et al 2009).
The d ef nitions above are intend ed to provid e a u ni orm
d ef nition or neck pain. H ow ever, the ollow ing op erational
d ef nitions have been u sed in research to d ef ne m echanical
neck p ain. Cleland et al (2005) d ef ned m echanical neck
p ain as ‘non-sp ecif c p ain in the area o the cervico-thoracic
junction that is exacerbated by neck m ovem ents’. Others
(Martínez-Segu ra et al 2006; Fernánd ez-d e-las-Peñas et al
2007b; González-Iglesias et al 2009a, 2009b; Mansilla-Ferragu t
et al 2009) have u sed the ollow ing d ef nition o m echanical
neck p ain by Fernánd ez-d e-las-Peñas et al (2007a), or a slight
variation thereo : ‘generalized neck and / or shou ld er p ain
w ith m echanical characteristics includ ing: sym ptom s
 96 PART 2 • 9 • Mechanical neck pain

2010, the Global Bu rd en o Disease (GBD) stu d y u sed the

anatom ical d ef nition rom the N eck Pain Task Force (as
d escribed Gu zm an et al 2009) along w ith the ollow ing case
d ef nition: ‘neck p ain (+ / − p ain re erred into the u p p er
Cervical lim b(s) that lasts or at least 1 d ay’ (H oy et al 2014).
spinal pain These operational d ef nitions o neck pain d enote the loca-
tion o and p otential p rovocative m anoeu vres or the p atient’s
sym p tom s, bu t d o not in er cau sation o the p atient’s p er-
ceived sym p tom s. This d ilem m a has led to e orts being m ad e
A in current research to explain the neck pain experience and
guid e e ective interventions.

Suboccipital Prevalence of Mechanical Neck Pain

Upper
cervical
Lower
cervical
B
Figure 9.1 Topographical de nition of mechanical neck pain.
Superior nuchal line
Spine of scapula
A m ated point prevalence o neck p ain w as 4.9% or 0 years to
Superior nuchal line
External occipital
protuberance
Superior border
clavicle
Suprasternal
B notch
Figure 9.2 A new conceptual model of mechanical neck pain. (Based on
Guzman et al 2009, with permission.)
p rovoked by m aintained neck postu res or by m ovem ent, or
by p alpation o the cervical m uscles’. Still others have grou ped
sym p tom s like head ache o cervical origin, m echanical neck
d isord er w ith rad icu lar signs and sym ptom s, neck d isord er
associated w ith w hiplash and neck d isord er associated w ith
d egenerative changes as su bsets o m echanical neck d isord ers
(Gross et al 2002). Kanlayanap hotporn et al (2009) u sed the
ollow ing d ef nition o neck pain: ‘pain prim arily conf ned
in the area on the p osterior asp ect o the neck that can be
exacerbated by neck m ovem ents or by su stained postu res’. In
N eck pain presents a global healthcare challenge to the
m ed ical p ro ession w ith p ersonal and econom ic im p act. Prev-
alence estim ates are o interest to researchers in ord er to help
assess the p opulation im pact o neck pain and d irect u tu re
investigations into the aetiology and m anagem ent o this phe-
nom enon. This ability to accu rately analyse the w orld w id e
im p act o neck pain is challenged by the im m ense variation
in the resu lts and qu ality o the research to d ate.
In an e ort to ad d ress the m ethod ological issues noted in
p reviou s p revalence research, H oy et al (2014) took on a
6-year challenge o estim ating the global bu rd en o neck p ain.
This stud y represented the f rst tim e global d ata or neck p ain
had been estim ated . The intent o the 2010 GBD stu d y w as to
report the global bu rd en o neck pain w hile consid ering the
risk o bias in the stu d ies u sed to d eterm ine the bu rd en esti-
m ates (H oy et al 2014). The resu lts o the stud y revealed a
high p revalence and bu rd en or neck p ain globally. The stu d y
evalu ated 291 global d iseases and inju ries. N eck pain ranked
‘the 4th greatest contribu tor to global d isability and 21st in
term s o overall bu rd en’ (H oy et al 2014). The global esti-
100 years o age. The prevalence w as higher in w om en than
in m en, w ith a peak prevalence at abou t 45 years o age (H oy
et al 2014).
Other stu d ies have looked at p revalence rates or neck
pain, but e orts w ere not m ad e, as in the GBD stud y, to
control or the risk o bias. Method ological issu es need to be
recognized as they can overin ate analyses (i.e. m ean preva-
lence rate) (H oy et al 2012). H ence in the ollow ing stud ies the
p revalence estim ates need to be interp reted cau tiou sly ow ing
to the p otential p resence o m ethod ological bias.
A system atic review by Fejer et al (2006) investigated the
w orld w id e prevalence o neck pain as reported in the litera-
tu re rom 1980 to 2002. Their search resulted in 56 p apers
m eeting their inclu sion criteria rom Scand inavia (46%), the
rest o Eu rop e (23%), Asia (16%) and N orth Am erica (11%).
Au stralia (tw o papers) and Israel (one paper) also m ad e con-
tribu tions investigating the p revalence o neck p ain in their
respective cou ntries. Variation in the investigated stu d ies w as
obvious. Various sam p le sizes w ere seen ranging rom 300 to
51 050 su bjects. Variation as to w hat constitu ted neck p ain, in
term s o both anatom ical location and an op erational d ef ni-
tion, w as present as w ell. H ow ever, in 79% o the stu d ies
investigated , unbiased and rand om ized popu lation sam p les
w ere used . Over hal o the stud ies critiqued had sam ple sizes
o over 1000 subjects. The m ost com m on categories o
 Prevalence o  mechanical neck pain 97

p revalence p eriod s investigated and their collective resu lts Table 9.1 Pre va le nce of me chanical ne ck pain
are shared below.
The point prevalence o neck pain w as investigated in eight World
stu d ies (13%) and ranged rom 5.9% to 38.7%. These d ata w ere pop ula tion
urther broken d ow n by age categories, resu lting in preva- Ne ck p a in Age (ye a rs ) (%)
lence ranges o 5.9–22.2% or ind ivid uals aged 15–74 years
Point prevalence 15–74 5.9–22.2
and 38.7% or ind ivid u als sp ecif cally over the age o 65.
65+ 38.7
One-w eek p revalence d ata w ere investigated in six stu d ies
(10%) w ith a range o 1.4–36%. H ow ever, one stud y used a One-week prevalence 15–90 1.4–19.5
u niqu e d ef nition o neck p ain not u sed in others. Exclu d ing One-month 16–79 15.4–41.1
this stu d y resu lted in f ve rem aining stu d ies w ith a range o prevalence 8–10 and 14–16 6.9
1.4–19.5% o ind ivid u als aged 15–90 years o age reporting a
1-w eek p revalence o neck pain. Six-month prevalence 18–80 6.9–54.2
One-m onth p revalence statistics w ere investigated in six 18 ( emale population) 45
stu d ies (10%) resu lting in a range o 15.4–41.1% or ind ivid u - 12 (male population) 6
als betw een 16 and 79 years o age. One stud y by Wed d erkop p One-year prevalence 17–70 16.7–75.1
et al (2001) investigated child ren (aged 8–10 years) and ad o- Secondary s chool and 15.8–22.1
lescents (aged 14–16 years) and reported a 1-m onth preva- 13–18
lence rate o neck p ain o 6.9%. 65+ 8.8–11.6
Seven stu d ies (11%) reported 6-m onth p revalence d ata or
ad u lts aged 18–80 years ranging rom 6.9% to 54.2%. Three o Li etime prevalence 18–84 14.2–71
these stu d ies rep orted ranges rom 6% to 45% or m ales o 60–79 17.1
12-year-old and em ales o 18-year-old em ales resp ectively. Global point 0–100 4.9
The largest rep orted p revalence rate w as in the 1-year prevalence
category. Tw enty-tw o stu d ies (39%) rep orted ranges rom
16.7% to 75.1% or ind ivid uals aged 17–70 years. Tw o stu d ies
reported ranges or ad olescents. N iem i et al (1997) rep orted a p revalence estim ates (i.e. 1-year prevalence estim ates w ere
1-year p revalence rate o 15.8% or 714 high school stu d ents higher than 1-m onth prevalence estim ates). Gend er d i er-
(408 girls, 306 boys – age ranges not sp ecif ed ). A second stud y ences w ere also seen: w om en consistently reported neck pain
by H olm en et al (2000) reported 1-year prevalence d ata or 83% m ore o ten than d id m en (25 out o 30 stu d ies; Table 9.1).
4279 ju nior high and high school stu d ents aged 13–18 years.
In this p opu lation, ad olescents rep orted a 22.1% 1-year preva-
lence o neck and shou ld er pain. In ad d ition, the system atic Financial impact of mechanical neck pain
critical review by Fejer et al (2006) w ent on to d elineate a In ad d ition to d isability, neck p ain carries signif cant eco-
range o 8.8–11.6% 1-year prevalence as reported by three nom ic im p act. In the N etherland s, total costs o neck p ain
stu d ies (Woo et al 1994; Isacsson et al 1995; Brochet et al 1998) w ere estim ated to be $686.2 m illion, w hich com prised abou t
in eld erly pop ulations (age > 65, 68 years o age, and age > 70 1% o the 1996 total healthcare expend itu re in the N ether-
resp ectively). land s. H ealth service costs or patients w ith neck p ain, d enoted
Li etim e p revalence rates w ere rep orted in eight stu d ies as ‘d irect (m ed ical) costs’, com prised $159.6 m illion o the
(13%), tw o o w hich w ere gathered rom the Tokelau Island s $686.2 m illion total cost. The rem aining $526.5 m illion rep re-
in the Sou th Pacif c Ocean. There, li etim e prevalence rates sented ‘w ealth lost to society’ or ‘ind irect (non-m ed ical) costs’
ranged rom 0.2% to 2.1%. The rem aining six stu d ies reported (Koopm anschap & Ru tten 1996) as a resu lt o neck pain
p revalence rates o 14.2–71% or ind ivid uals aged 18–84 years. (Borghou ts et al 1999). In the US, cervical sp ine d isord ers
One stu d y (Aoyagi et al 1999) ocu sed on 860 w om en o ages p resent challenges to the healthcare system , accou nting or
60–79 years living in Jap an or H aw aii. The resu lts o this stu d y billions o d ollars spent on ind em nity and m ed ical costs in the
rep orted a 14.8% li etim e p revalence (i.e. asking ‘w hich o w orkers’ com p ensation system , w hich are second only to
your joints have ever been pain u l?’) o neck joint pain in the w orkers’ com pensation costs associated w ith lu m bar spine
com bined p op u lations. H ow ever, in the system atic critical d isord ers (Wright et al 1999).
review by Fejer et al (2006), one o the inclusion criteria w as
to look at p op u lations that w ere rep resentative o the general
p op u lation. In light o this, the H aw aiian–Japanese cohort Risk factors and prognosis in mechanical
w as not consid ered representative o the H aw aiian popula- neck pain
tion. There ore, only the Jap anese d ata w ere inclu d ed , resu lt-
ing in a li etim e p revalence or this grou p (n = 222) o 17.1%. In light o cu rrent evid ence, neck pain cannot be looked at in
In sum m ary, the literature has revealed varying d escrip - isolation. Rather, this phenom enon is generally non-trau m atic
tors o neck p ain, w hich can a ect the qu ality o the stu d ies. and m u lti actorial w ith evid ence su pporting the d u al inter-
Interestingly, Fejer et al (2006) d id not f nd a correlation action o the physical and psychosocial arenas (Ariens et al
betw een the variation in the stud ies they review ed and preva- 2001; Cro t et al 2001; Côté et al 2009; Gu zm an et al 2009;
lence estim ates. This su ggests that the qu ality o the stu d ies Jull & Sterling 2009; Sterling 2009) as contribu tors to the
(presence o heterogeneity) review ed m ay not be a actor in p ain exp erience. There seem s to be a greater ap p reciation or
neck p ain p revalence estim ates. In ad d ition, the longer the the p sychological contribu tors to neck p ain, bu t a clinical
d u ration o the p revalence period the higher are the reported tend ency to continu e to ocu s narrow ly on the p hysical actors
 98 PART 2 • 9 • Mechanical neck pain
p otentially involved in neck p ain. The resu lts o a recent
international, m u ltid iscip linary su rvey (Walton et al 2013a)
su ggested that clinician ap p reciation o p sychological / behav-
iou ral actors had a large im p act on p atient p rognosis. Desp ite
this, the su rvey also rep orted p hysical f nd ings as the m ost
requ ently analysed actors or patients w ith neck pain. These
f nd ings continu e to highlight the d iscrep ancy betw een
cu rrent best evid ence and clinical p ractice (Walton et al
2013a).
Id enti ying risk actors or, or pred ictors o , neck pain is
u se u l in help ing to d irect both m easu res to p revent initial
neck inju ry (p rim ary p revention) and interventions or
ad d ressing actors that contribu te to p ersistent sym ptom s
and / or recu rrent neck p ain (second ary prevention) (H ill
et al 2004). H istorically, risk actors or neck pain have been
broken d ow n into categories: w ork-related or non-w ork-
related risk actors. The categories can be broken d ow n u rther
into three basic su bgrou ps: (1) physical risk actors, (2) psy-
chosocial risk actors and (3) ind ivid u al risk actors (i.e. cop ing
behaviou rs) (Ariens et al 2000, 2001).
Early research (1966–1997) into risk actors (Ariens et al
2000, 2001), both physical and psychological, consisted prim a-
rily o m ethod ology u sing cross-sectional stu d y d esigns.
H ow ever, this style o research inqu iry lim its the ability to
establish cau se-and -e ect relationships (Cro t et al 2001;
Carroll et al 2009). Research has evolved over the last 10 years,
im p roving u p on this m ethod ological d ilem m a by contribu t-
ing larger nu m bers o p rosp ective stu d ies (Côté et al 2009).
Prosp ective stu d y d esigns allow a m ore conf d ent establish-
m ent o relationship s and thu s contribu te m ore signif cantly
to the system atic review p rocess.
Prevalence o neck pain in working individuals
A recent system atic review (Côté et al 2009) sou ght to inves-
tigate the p revalence o neck p ain risk actors in w orking
ind ivid u als. The researchers ou nd that requ ent or p ersistent
neck d isord ers can d evelop in at least 5% o the w ork orce,
w ith 10% o those that d evelop neck pain su ccu m bing to
activity lim itation (d u e to neck pain) on at least one occasion.
Over hal o those w orkers (50%) w ho d evelop neck pain w ill
go on to rep ort it 1 year later (Carroll et al 2009). Id entif cation
o the actors contribu ting to neck p ain has p ointed research-
ers aw ay rom single risk actors and tow ard s com plex rela-
tionship s involving interactions betw een ind ivid u al, cu ltu ral
and w ork-related variables. For instance, age, p revious m u s-
cu loskeletal p ain, qu antitative job d em and s, social su p p ort at
w ork, job insecurity, low physical capacity, poor com pu ter
w orkstation d esign and w ork p osture, sed entary w ork posi-
tion, rep etitive w ork and p recision w ork are all actors con-
tribu ting to an ep isod e o neck p ain. Other actors contribu ting
to its d evelop m ent inclu d e gend er, a history o head ache,
em otional problem s, sm oking, aw kw ard w ork postu res,
p hysical w ork environm ent and ethnicity (Box 9.1).
Prognostic actors o neck pain in
working individuals
Prognostic actors or w orkers w ith neck p ain have also been
investigated (Carroll et al 2009), revealing that 60% o w orkers
still note p ersistent or recurrent neck p ain 1 year a ter the
onset o sym p tom s. Gend er also p lays a role in neck p ain,
Bo x 9 .1 Ris k fa c to rs fo r m e c h a n ic a l n e c k p a in in
w o rkin g p o p u la tio n
Ris k fac to rs : an e pis o de  o f ne c k pain
• Age
• Previous mus culoskeletal pain
• Quantitative job demands
• Social support at work
• Job insecurity
• Low phys ical capacity
• Poor computer works tation design and work posture
• Sedentary work position
• Repetitive work
• Precision work suggests an epis ode o neck pain
Ris k fac to rs : de ve lo ping  ne c k pain
• Gender
• His tory o headache
• Emotional problems
• Smoking
• Awkward work postures
• Physical work environment and ethnicity
Bo x 9 .2 P ro g n o s tic va ria b le s fo r m e c h a n ic a l n e c k
p a in in w o rkin g p o p u la tio n
Po o r pro g no s tic  variable s
• Prior neck pain
• Musculoskeletal pain
• Prior sick leave and occupational type (blue-collar vs
white-collar, etc.)
• Having little s el -perceived inf uence over one’s own work
situation
Favo urable  pro g no s tic  variable s
• Changing jobs ( or sewing machine operators )
• Exercis e
w ith w om en m ore likely than m en to report persistent or
recu rrent pain. Ou tcom es such as prior m uscu loskeletal pain,
p rior sick leave and occu p ational typ e (blu e-collar versu s
w hite-collar w ork) w ere associated w ith poorer neck p ain
p rognosis. The only p sychosocial variable that d em onstrated
a prognostic role w as a report o having little sel -p erceived
control over one’s w ork situ ation. This w as associated w ith a
urther report o neck p ain 4 years later. A challenge ollow ing
the id entif cation o these ind icators o p oor p rognosis is
the realization o the p erson’s lim ited ability to m od i y these
variables. H ow ever, im p roved ou tcom es have been noted
a ter changing jobs ( or sew ing m achine operators) and taking
u p exercise (Box 9.2).
Prevalence o neck pain in the general population
H ogg-Johnson et al (2009) review ed the literatu re on risk
actors in the general p op ulation. Their review revealed

Bo x 9 .3 Ris k fa c to rs fo r m e c h a n ic a l n e c k p a in in
g e n e ra l p o p u la tio n
Unfavo urable  ris k fac to rs
• Middle age
• Additional health complaints
• Psychological actors
Favo urable  ris k fac to rs
• Younger age
equivocal f nd ings regard ing age as a risk actor. The inci-
d ence o neck p ain occu rs across all ages, increasing in its
p revalence as the years pass. There d oes, how ever, app ear to
be a peak in the prevalence o neck p ain in the m id d le years
o li e, w ith low er p revalence in the m ost eld erly.
Evid ence has su ggested a m u lti actorial p resentation o
neck p ain. This inclu d es ad d itional health com p laints (i.e.
head ache, low back p ain, p oorer sel -rated health) that accom -
p any the com p laints o neck pain. Contrary to popu lar
assu m p tions in m ed icine, cervical sp ine d isc d egeneration is
not ou nd to be a risk actor or neck p ain. In ad d ition to
p hysical risk actors, p sychological actors are pred icted and
p resented w ith neck pain com plaints (Box 9.3).
Prognostic actors or neck pain in the
general population
Carroll et al (2008) investigated prognostic actors in the
general popu lation. N eck pain a ects each sex, bu t w ith
higher rep orts am ong w om en than m en. H ow ever, gend er
only w eakly p red icts neck p ain recovery. You nger age is
associated w ith a m ore avou rable prognosis. In contrast, old
age is a p red ictor o p oorer p rognosis and a w eak pred ictor
o recovery. H ow ever, m id d le-aged ind ivid u als (45–59 years
o age) w ere at the highest risk and carried the p oorest p rog-
nosis or neck p ain. Recovery is now being view ed as a m u l-
ti actorial entity – m u ch like the cu rrent thinking behind the
cau ses o neck p ain (i.e. that they are m u lti actorial in natu re).
Recovery likew ise is d ep end ent on sym p tom severity and
qu ality, im p airm ent, activity and p articip ation-level inter er-
ence, au tonom y, spontaneity and satis action w ith the sense
o sel (Walton et al 2013b).
In stud ies o neck pain, physical activity and exercise are
assessed by sel -reported qu estionnaires. This poses chal-
lenges w ith regard s the conclu sions one is able to d raw rom
this d ata. Regu lar p hysical activity is avou rable or a nu m ber
o m u scu loskeletal issu es rom a p rop hylactic p ersp ective,
inclu d ing being a com p onent o neck p ain m anagem ent.
H ow ever, prognostic stu d ies evalu ating its e ect have pro-
vid ed no relationship betw een the p ersistence or recu rrence
o neck p ain w hen com p ared at the start and at the end o the
stu d ies.
Psychosocial health p lays a actor in the p rognosis o neck
pain. For ind ivid u als w ho utilize a p assive coping m echa-
nism , the ou tcom es w ere w orse com p ared those w ith greater
social su p p ort and better p sychological health. In contrast,
neck p ain is associated w ith p oorer p sychological health,
w hich is also a risk actor or a new episod e o neck pain
(Box 9.4).
Causes o  mechanical neck pain 99
Bo x 9 .4 P ro g n o s tic va ria b le s fo r m e c h a n ic a l n e c k
p a in in g e n e ra l p o p u la tio n
Po o r pro g no s tic  variable s
• Middle age
• Pass ive coping mechanism
Favo urable  pro g no s tic  variable s
• Younger age
• Greater s ocial s upport
• Better ps ychological health
Review of Anatomy Speci c to
Mechanical Neck Pain
Any innervated structure in the cervical spine can contribute
to a pain state – or exam ple, the p osterior m uscu latu re, cervi-
cal zygap op hyseal joints, lateral atlanto-occip ital joint, atlanto-
occip ital joint, m ed ian atlanto-axial joint, d u ra m ater o the
sp inal cord , p revertebral and lateral m u scles o the neck,
intervertebral d iscs, vertebral artery, synovial joints, anterior
and p osterior longitu d inal ligam ents, atlanto-axial ligam ents,
and internal carotid artery (Bogd u k 2003). The read er is
re erred elsew here or m ore d etailed d iscu ssions o the cervi-
cal sp ine anatom y and its associated innervations (Bogd u k
2002, 2003; Bogd uk & McGu irk 2006). H ow ever, it is im por-
tant to note that, thou gh these innervated stru ctu res can cer-
tainly be cred ited w ith the p ain exp erience, the p resence o
innervation alone d oes not conf rm the structure as the source
o sym p tom s (Bogd u k 2003).
Causes of Mechanical Neck Pain
Sim ilar to low back p ain, id enti ying the exact sou rces o neck
p ain is a challenging, i not im p ossible, task. The ability o any
innervated stru cture in the cervical sp ine to contribute to a
p ain state m akes id entif cation o the sou rce o neck p ain a
challenge (Bogd u k 2002). Fu rtherm ore, p athological cond i-
tions (e.g. m alignancy, cervical m yelop athy, ractu re, sys-
tem ic d isease and arterial d ys u nction) can also contribu te to
neck p ain.
Cu rrent sp inal research, in both the low back and the cervi-
cal sp ine regions, is encou raging a shi t in clinical d ecision
m aking aw ay rom p reviou sly em p hasized tissu e-based
m od els o p ain tow ard s m u lti actorial m od els o p ain (Ariens
et al 2000; Gu zm an et al 2009). The biom ed ical m od el is
repeated ly ou nd to accou nt or only part o the pain experi-
ence in certain sp inal cond itions. The International Associa-
tion or the Stu d y o Pain (IASP) has there ore encou raged a
broad er clinical-reasoning ram ew ork w hen w orking w ith
p atients in p ain. Sp ecif cally, it has encou raged clinicians to
consid er p ossible hyp otheses beyond tissu e-based sou rces.
Assisting clinicians to m ove beyond sim ple tissue-based
sou rces, the IASP has p rovid ed the ollow ing d ef nition o
p ain: ‘an u np leasant sensory and em otional exp erience associ-
ated w ith actu al or potential tissu e d am age, or d escribed in
term s o su ch d am age’ (Merskey & Bogd u k 1994, p 210).
 100 PART 2 • 9 • Mechanical neck pain

Based on cu rrent evid ence su ggesting the ailu re o tissu e-

based m od els to explain accu rately all the types o neck pain,
tod ay’s clinician m u st be aw are o both ‘actu al’ and ‘p otential’ C2–3
C3–4
sou rces o neck p ain. Thu s, a bio-p sychosocial m od el is now
being looked to as a m ore com p rehensive m od el o sp ine pain. C5–6
This m od el allow s or a com bination o biom ed ical, p sycho- C4–5
logical and social contribu tors to neck p ain. It has been intro-
d u ced in an attem p t to account m ore accurately or the
C6–7
m u ltid im ensional asp ect o neck p ain (Ju ll & Sterling 2009;
Sterling 2009).
N eck pain and cervical rad icu lar pain are tw o categories
that have been id entif ed in sp ine-related p ain o the cervical
region. Cervical rad icular p ain – pain that is p erceived in the
u p p er lim b (Slip m an et al 1998; Bogd u k 2003) – em anates Figure 9.3 Referral patterns from spine zygapophyseal joints and intervertebral
discs. (From Bogduk 2002, with permission.)
rom the cervical spine. Due to the ability o the cervical spine
to create p ain locally in the neck as w ell as d istally in the
u p p er extrem ity, the term s ‘cervical rad icu lar p ain’ and ‘neck C1–2: 0.14
C1–2: 0.02 C2–3: 0.81
p ain’ are u sed interchangeably. This association, how ever, is C2–3: 0.92 C3–4: 0.05
incorrect. Desp ite the com m onality o the cervical anatom ical C3–4: 0.06
region resp onsible or creating sym ptom s, neck pain and cer- C5–6: 1.00
C2–3: 0.89
vical rad icu lar p ain are not interchangeable term s. Ad d ing to C3–4: 0.11
this con u sion is the u se o the term ‘cervical rad icu lop athy’
as a synonym or cervical rad icu lar pain. Brie y, cervical
rad icu lopathy is a ‘neurologic cond ition, characterized by
objective signs o loss o neu rological u nction, that is, som e
com bination o sensory loss, m otor loss, or im p aired re exes C4–5: 0.07 C1–2: 0.17 C1–2: 0.05
in a segm ental d istribu tion’ (Bogd u k 2003, p 456). This is a C5–6: 0.73 C4–5: 0.01
C2–3: 0.76 C2–3: 0.92
C6–7: 0.46 C5–6: 0.77
resu lt o pathology involving com pression or com prom ise o C6–7: 0.22
C3–4: 0.08 C3–4: 0.02
the sp inal nerve roots or the sp inal nerve itsel . It is objectively
C5–6: 0.54
assessed as a loss o unction and not p ain. I p ain is involved C6–7: 0.46 C5–6: 0.87
in a com p ressive cond ition in the cervical sp ine, it is d u e to C5–6: 0.35 C6–7: 0.13
com p ression o the d orsal root ganglion (see Ch 10). Com pres- C6–7: 0.65
sion o nerve roots d oes not cau se illicit nocicep tive activity
(H ow e et al 1977). Com pression o the d orsal root ganglion Figure 9.4 Referral patterns from spine zygapophyseal joints and intervertebral
evokes activity in the Aβ and C f bres (H ow e et al 1977). This discs. (Data taken from Cooper & Bogduk 2005.)
neu ral behaviou r is m ore than nocicep tive activity (w hich is
p red om inantly Aδ- and C-f bre transm ission). Because o the cond itions, w hich then allow s them to p rioritize their evalu -
involvem ent o the Aβ f bres w ith d orsal root ganglion com - ation and m atch the p atient to those interventions that are
p ression, this establishes a d istinction betw een rad icu lopathy associated w ith a higher level o su ccess (Yin & Bogd u k 2008).
(a re ection o a loss o nerve u nction and not necessarily The patient w ith neck pain creates a clinical reasoning chal-
p ain) and rad icu lar p ain (a re ection o d orsal root ganglion lenge ow ing to the vast num ber o possible causes behind the
involvem ent beyond sim p le nocicep tive u nction). Paraesthe- p atient’s chie com p laint. Clinicians com m only evalu ate their
sia is associated w ith rad icu lar p ain, w hich re ects involve- p atients by looking or a am iliar p attern o sym p tom s that
m ent o Aβ f bres (Bogd u k 2003). From this perspective, the w ill then lead them to hypothesize a particular tissu e-based
seem ingly intu itive thou ght that p ain resu lts rom ‘p inched ’ sou rce o the p atient’s chie com p laint. In this resp ect, research
or ‘com p ressed ’ nerves d oes not hold tru e u nless the d orsal com p aring norm al and sym p tom atic p atients has p rovid ed
root ganglion is involved in that com pression. id entif able re erral patterns or the cervical spine zygapophy-
seal joints and intervertebral d iscs (Figs 9.3–9.4), spinal nerves
(Fig. 9.5) and so t tissu e (Fig. 9.6). N ociceptive stim ulation o
the cervical sp ine, w ithou t involvem ent o cervical nerves or
Clinical Presentation of Neck Pain nerve roots, can re er sym p tom s to the u p p er lim b, anterior
chest w all, interscap u lar region and head (Gru bb & Kelly
Within a sou nd clinical reasoning ram ew ork, it is still im p or- 2000; Bogd u k 2002, 2003; Bogd uk & McGuick 2006) (Fig. 9.7).
tant or p hysical therap ists to have an ap p reciation or p oten-
tial tissu e-based contribu tors to neck p ain. Ep id em iological
stu d ies have p rovid ed su p p ort or p revalence rates o neck
p ain rom arou nd the w orld . This in orm ation is use u l or
Proposed Management of Mechanical
help ing clinicians to d irect research and m ake p red ictions Neck Pain
abou t this su bgrou p o p atients. Althou gh these stu d ies are
not u se u l or p rovid ing insight into the sou rces o neck p ain, Cu rrent best evid ence has ad vocated a treatm ent-based clas-
an ap preciation o the p ossible contribu tors to neck pain can sif cation ap p roach or the m anagem ent o p atients w ith neck
assist clinicians in id enti ying pre-test p robabilities or neck p ain. Em p hasis has been p laced on m atching the p atient to

C4 C5
C6 C7
Figure 9.5 Referral patterns from C4, C5, C6 and C7 spinal nerves. (From
Bogduk 2002, with permission.)
C5 C6
C7 C8
Figure 9.6 Referral patterns from interspinous muscles. (From Bogduk &
McGuirk 2006, with permission.)
op tim al interventions based on the id entif cation o signs and
sym p tom s collected d u ring the p atient interview and p hysical
exam ination (Child s et al 2004, 2008; Cleland et al 2006;
Fritz & Brennan 2007). The clinical d ecision-m aking process
involved in app lying this treatm ent-based classif cation strat-
egy consists o tw o d istinct levels (Cleland et al 2006). The
f rst level requ ires that the therap ist d eterm ine w hether the
patient w ill benef t rom p hysical therap y services throu gh a
Proposed management o  mechanical neck pain 101
Figure 9.7 Referral patterns from nociceptive stimulation of the cervical spine.
com p rehensive m ed ical screen inclu d ing red and yellow ag
assessm ents. The second level o the classif cation schem a
involves d irecting the patient to their m atched intervention(s)
or su bgrou p based on p resenting signs and sym p tom s, as w ell
as the resp ective p hysical exam ination f nd ings (Cleland et al
2006; Fritz & Brennan 2007).
First level of classi cation
Step one o this classif cation ap p roach begins w ith a com p re-
hensive review o the p atient’s m ed ical history and a m ed ical
screen encom p assing a review o both the general health
and specif c system s (Boissonnault 2005). General health
qu estions shou ld be asked o all p atients by inqu iring abou t
the ollow ing: (1) atigu e, (2) m alaise, (3) w eakness, (4) u nex-
p lained w eight loss / gain, (5) nau sea, (6) p araesthesia or
nu m bness, (7) d izziness or lighthead ed ness, (8) change in
m entation or cognition and (9) chills, sw eats, or ever.
Patient sel -ad m inistered qu estionnaires can assist w ith
this d ata collection. These have been show n to be accu rate or
reporting im portant health history in orm ation and or assist-
ing the clinician to d ecid e w hether or not to p roceed u rther
to the second level o classif cation (Pecoraro et al 1979; Bois-
sonnault 2005).
A sp ecif c system screen (card iovascu lar, p u lm onary, gas-
trointestinal, u rogenital, end ocrine, nervou s system , integu -
m entary) ollow s based on the initial in orm ation gathered
rom the general health questions review, includ ing the bod y
chart and sel -ad m inistered qu estionnaires. The p atient inter-
view is a key com p onent in attem p ting to recognize seriou s
sp inal p athology that m ay w arrant ad d itional concern, inclu d -
ing appropriate m ed ical ollow -u p w ith a prim ary care prac-
titioner (Greene 2001; Greenhalgh & Sel e 2009).
Red ag screening
A screen or p ossible red ags (signs or sym p tom s that m ay
su ggest a m ore seriou s u nd erlying p athology) is the f rst step
in the classif cation p rocess or d eterm ining w hether physical
therap y services are ap p rop riate or the p atient (N ord in et al
2009). It has been suggested that the clinician need s to d eter-
m ine one o three p otential cou rses o action a ter the initial
m ed ical screening is com p lete: to treat the ind ivid u al and
p roceed to the second level o classif cation, to treat the p atient
and proceed to the second level o classif cation w ith notif -
cation to the ind ivid u al’s p hysician regard ing signs or sym p -
tom s that m ay w arrant concern, or to re er the p atient to a
 102 PART 2 • 9 • Mechanical neck pain
p hysician, w ithout any orm o treatm ent d u ring the initial
visit, or u rther d iagnostic w ork-u p d u e to the p atient inter-
view / exam ination f nd ings (Boissonnault 2005). There is a
sm all p revalence o m ore seriou s related sou rces su ch as
sp inal ractu res, sp inal or central cord com p ression, neop las-
tic cond itions, vascu lar com p rom ise, system or in am m atory
d isease, as w ell as up per cervical spine ligam entous instabil-
ity, o w hich the p ractising clinician shou ld be aw are. The
m ed ical screening p rocess, com bined w ith a thorou gh red ag
screen, alerts the clinician to the p ossibility o a m ore seriou s
u nd erlying cond ition (Cleland et al 2006).
Spinal ractures
Sp inal ractu res u su ally occu r w ith som e typ e o m echanical
trau m a or inju ry. Typ ically ractu res occu r rom a all, blu nt
trau m a, the ap p lication o com p ressive or axial load orce, or
as the resu lt o a m otor vehicle collision. It has been show n
that risk actors su ch as a p atient’s age, as w ell as the height
o the all (> 3 m ), are risk actors that increase the risk o cervi-
cal sp ine ractu res. Incid ents involving axial load s, d iving
incid ents and collisions all raise the risk o p otential cervical
sp ine ractu re. The highest occu rrences take p lace w ith m otor
vehicle collisions at sp eed s > 100 km / h (Thom p son et al
2009). The Canad ian cervical (C)-spine ru le (see Ch 3) is a
clinical p red iction ru le that is u sed to d eterm ine w hether cer-
vical sp ine rad iograp hy is need ed or an alert and stable ind i-
vid u al w ho has su ered a cervical sp ine inju ry (Stiell et al
2001, 2003). The ru le is based on various high- and low -risk
criteria as w ell as the ability o a p atient to rotate the neck. I
the ru le is p ositive and the p atient has not had any rad io-
graphs per orm ed , the therap ist should ensure that the appro-
p riate rad iographic evalu ation is u nd ertaken prior to the
initiation o orm al p hysical therap y services.
Cervical myelopathy
Cervical m yelop athy is a d isord er that involves com p ression
o the sp inal cord canal resu lting in neu rological com p rom ise.
Canal obstru ction can be cau sed by a variety o actors, inclu d -
ing d egenerative changes o the intervertebral d iscs, hyp er-
trop hy o the ligam entu m avu m , or osteop hyte orm ation
d u e to the d egenerative processes occurring at the interverte-
bral d isc level. Cervical m yelop athy is reported as the m ost
com m on orm o sp inal cord d ys u nction in ind ivid u als over
the age o 55, a ecting 90% o ind ivid u als as they ap proach
their seventies (Cook et al 2009). Com m on sym ptom s includ e
sensory d istu rbances o the hand s, gait d istu rbances or
balance u nstead iness, d ecreased m otor strength w ith associ-
ated m u scle w asting in the u pp er extrem ities, as w ell as bow el
and blad d er d istu rbances. Cu rrent research has reported only
m od erate to su bstantial reliability or the clinical tests or
cervical sp ine m yelop athy. Fu rtherm ore, p er orm ing a clu ster
o com m only u sed tests or this d isord er d oes not im p rove
the d iagnostic accu racy above that o the Babinski test alone
(Cook et al 2009). (Read ers are re erred to Ch 11 or u rther
in orm ation on cervical m yelop athy.)
Primary neoplastic conditions
Prim ary neop lastic cond itions are rare in the cervical sp ine,
representing only 0.4% o all tu m ou rs and accou nting or less
than 5% o tu m ours that occur above the sacru m (Abd u &
Provencher 1998). A m ore com m on clinical presentation m ay
be rom a Pancoast tum our, w hich is a m alignant tu m our o
the u p p er ap ices o the lu ngs or w ithin the su p erior p u lm o-
nary su lcu s o the lu ng. It has been estim ated that Pancoast
tu m ou rs account or 2–5% o all cancers o the lu ng (Kovach
& H u slig 1984). A com m on clinical presentation w ill inclu d e
shou ld er p ain that rad iates into the arm and / or hand w ith
or w ithou t the p resence o neck p ain. These ind ivid u als
m ay or m ay not have p u lm onary signs or sym p tom s. O ten a
p atient m ay exhibit a clinical p resentation sim ilar to H orner ’s
synd rom e or an u lnar nerve d erm atom al p attern d u e to the
close p roxim ity o the tu m ou r to the low er tru nk o the bra-
chial plexus (C8–T1). Pancoast tu m ours a ect m en m ore
than w om en and typ ically show an increased incid ence
rate over the age o 50, especially in those w ith a history o
tobacco u sage. In the low back literatu re a system atic review
that looked at screening or m alignancy ou nd that i ou r
variables w ere absent in the p atient evalu ation p rocess d iag-
nostic sensitivity w as 100%. The our variables w ere: age >50,
a previou s history o cancer, unexplained w eight loss (m ore
than 5-10% o the bod y w eight w ithin a m onth) and ailu re to
im p rove a ter 1 m onth. (H enschke et al 2007). Given the act
that lu ng cancer is the lead ing cau se o d eath am ong active
cancers and is the second m ost com m on cancer in m en and
w om en in the United States (Centers or Disease Control
2014), it is im portant that clinicians screen or the d isease
ap prop riately.
Cervical arterial dys unction
Cervical arterial d ys u nction (CAD) is a recent term that
d escribes the arterial events that can occu r in both the anterior
and posterior arterial system s o the cervical spine. The ante-
rior system is com posed o the internal carotid arteries and
p rovid es blood ow to the eyes as w ell as the cerebral hem i-
sp heres. The p osterior system is com p osed o the vertebro-
basilar arteries and p rovid es blood ow to the hind brain
(Kerry & Taylor 2009). These pathologies can m im ic cervi-
cocranial p ain. The clinician m u st be able to d iagnose d i er-
entially betw een a likely arterial presentation and sym ptom s
d u e to a m u sculoskeletal sou rce based on physical exam ina-
tion f nd ings encou ntered d u ring a com p rehensive screen and
su bsequ ent p hysical exam ination. The exact p revalence rate
o sp ontaneou s vertebral d issections and vertebrobasilar
insu f ciency is unknow n. There ore the clinician shou ld have
a high su spicion o CAD, especially in cases involving cervical
sp ine trau m a. Althou gh the p revalence rate or these cond i-
tions is qu ite low, the clinician shou ld be aw are o the lim ita-
tions su rrou nd ing the cu rrent objective exam ination or CAD.
This aw areness shou ld lead to d ecreased clinical-reasoning
errors, w hich occu r w hen these tests are used in isolation
d u ring the d i erential d iagnosis process.
This p arad igm shi t encou rages the p atient interview to
includ e a thorough review o vascular risk actors such as
hyp ertension, hyp ercholesterolaem ia, d iabetes m ellitu s, a
history o sm oking, in ection, coagu lation abnorm alities and
d irect vessel traum a. During the objective com ponent o the
evalu ation, ad d itional tests su ch as a cranial nerve and eye
exam ination can be used to assist the clinician to a com pre-
hensive p ersp ective on the p atient’s cu rrent haem od ynam ic
statu s (Kerry & Taylor 2009). This com p rehensive evalu ation
is extrem ely im portant as current literatu re su pports the

hyp othesis that neck m ovem ents are not valid screening tools
or d eterm ining w ho is at risk o a vertebrobasilar artery d is-
section (H ald em an et al 1999). The concept o prem anipu la-
tive testing has also been d iscou raged w hen there is a strong
su sp icion o a vertebrobasilar artery d issection. It has also
been su ggested that prem anipu lative testing ad d s little to the
clinical in orm ation need ed or d ecision m aking. In light o
this, clinicians shou ld qu estion w hether or not p rovocation
tests ad d any benef t to the p atient-screening p rocess and
realize that a com p rehensive app roach to screening or cervi-
cal arterial d ys u nction is the key to early id entif cation (Thiel
& Rix 2005). In 2012, the International Fed eration o Ortho-
p aed ic Manipu lative (IFOMPT) cam e to a consensus regard -
ing a ram ew ork or the clinical approach tow ard s CAD. This
international grou p established gu id elines that clinicians
cou ld ollow be ore ap p lying m anu al therap y and giving
exercises in patients w ith suspected CAD. The team , repre-
senting 22 cou ntries, cam e to an agreem ent regard ing the
ollow ing: (1) althou gh CAD and its sid e e ects are rare it is
a cond ition that clinicians should be aw are o in their m uscu -
loskeletal assessm ent, (2) the p resence or risk o CAD cannot
be conclud ed rom the resu lt o one clinical test, and (3) a
strong clinical-reasoning ram ew ork m u st be p resent in ord er
both to u nd erstand all com ponents o the patient’s presenta-
tion, rom the risk–benef t ap p reciation to the im plications o
in orm ed consent and jurisd ictionally specif c requirem ents,
and to enable the sa e practice o m anu al therapy overall in
the cervical sp ine region (Ru shton et al 2014).
Clinical cervical spine instability
Clinical cervical sp ine instability (CCSI) can occu r rom a
variety o trau m atic and non-trau m atic events. It has been
d i f cu lt to d iagnose ow ing to the su btle clinical eatu res that
are associated w ith this cond ition (Cook et al 2005), the rela-
tive low p revalence rate, and the lack o clinical tests that have
show n reliability and valid ity in assisting clinicians in their
clinical d ecision-m aking p rocess (Mintken et al 2008). The cli-
nician shou ld u nd ertake a screening p rocess ocu sed on ru ling
ou t ligam entou s instability a ter inju ry to the cervical sp ine,
especially a ter a all, blunt trau m a or a m otor vehicle acci-
d ent. There are also a variety o non-trau m atic d iagnoses o
w hich clinicians shou ld be aw are that carry the potential or
ligam entou s instability – su ch as rheu m atoid arthritis, Dow n
synd rom e, ankylosing sp ond ylitis, as w ell as p rolonged oral
contracep tive or corticosteroid u se (Boissonnau lt 2005). A
com bination o the ap p lication o the Canad ian C-sp ine ru le
and a thorou gh history and p hysical exam ination aim ed at
id enti ying ligam entou s stru ctu res is a key com ponent o the
clinician’s exam ination p rocess w hen attem p ting to ru le ou t
ligam entou s instability. Despite the absence o strong em p iri-
cal d ata or testing the integrity o the alar and transverse
ligam ents, these are consid ered essential com p onents o the
evaluation process, and are o ten per orm ed because o poten-
tial m ed icolegal ram if cations (Cleland et al 2006). From a
clinical-reasoning p ersp ective, how ever, it is help u l to u nd er-
stand that, becau se o the w eak em p irical evid ence behind
these tests, one m u st exercise cau tion in term s o ru ling ou t
the d iagnosis w hen a negative resu lt is obtained on either o
these tests.
In ad d ition to the p hysical exam ination f nd ings, the patient
interview m ay m ake revealing statem ents that increase the
Proposed management o  mechanical neck pain 103
p robability o CCSI. A large Delp hi stu d y (Cook et al
2005) reported com m on su bjective id entif ers as noted by
exp ert physical therap ists (Board Certif ed Orthop aed ic
Clinical Sp ecialists (OCS) and Fellow s o the Am erican
Acad em y o Orthopaed ic Manual Physical Therap ists
(FAAOMPT)); a consensu s o com m on patient com plaints
w ere noted as ollow s: ‘intolerance to prolonged static pos-
tu res’, ‘ atigu e and inability to hold head u p ’, ‘better w ith
external su pport, includ ing hand s or collar ’, ‘ requent need
or sel -m anip ulation’, ‘ eeling o instability, shaking, or lack
o control’, ‘ requ ent ep isod es o acu te attacks’, and ‘sharp
p ain, p ossibly w ith su d d en m ovem ents’. These p atient rep orts
m ay assist the clinician in id enti ying p atients w ith CCSI.
Yellow ag screening
A ter clinicians have com pleted the f rst level o classif cation
and conclu d ed that there are no red ags or system ic issu es
p resent, the next step in the evalu ation p rocess is to p er orm
a yellow ag assessm ent. Yellow ags are d ef ned as patient
ind icators that require u rther investigation by the clinician
regard ing the cognitive and behavioural aspects o the patient
p resentation (Pincus et al 2002). These psychosocial variables
have been rep orted ly linked to neck p ain in both the acu te
and the su bacu te tissu e healing phases (Linton 2000; Bot
et al 2005; Carroll et al 2008). Epid em iological stu d ies have
d em onstrated that 47% o all ind ivid u als w ho exp erienced a
neck p ain ep isod e had either continu ed p ersistent p ain or
a w orsening o sym p tom s at an annual ollow -u p (Côté
et al 2004).
Fear o m ovem ent has been id entif ed in the research litera-
tu re as a p sychosocial ind icator that can assist in p red icting
d isability in the neck pain p op ulation. It m ay be a key variable
in exp laining w hy ind ivid uals continue to have pain u p to a
year a ter their initial episod e. The Fear-avoid ance Belie s
Qu estionnaire (FABQ) is a tool that the clinician can u se to
objecti y the p atient’s ear o m ovem ent. Althou gh p rim arily
stu d ied in the low back p ain p op u lation, there is evid ence to
su ggest there are sim ilar p rognostic cap abilities, althou gh
w ith w eaker statistical associations, or unctional ou tcom es
u sing this tool in the cervical sp ine p op u lation (George et al
2001). Once the clinician d eterm ines the presence o any
yellow ags, the treatm ent p lan can be ad justed accord ingly
( ear-avoid ance-based m od el), w hich m ay includ e in orm ing
the p atient’s p rim ary care p hysician or re erring the ind ivid -
u al regard ing the clinical f nd ings that m ay a ect the p atient’s
utu re p rognosis.
Second level of classi cation
Once the p atient has been evalu ated or any p otential red and
yellow ags and the d ecision is m ad e that the ind ivid u al is
ap prop riate or physical therapy services, the clinician can
then m ove to the second level o classif cation (Fig. 9.8). H ere
the clinician can start to classi y the p atient in term s o key
im pairm ents, app ropriately m atching him or her to selected
interventions. This cu rrent treatm ent-based classif cation
system is based on p resenting signs and sym p tom s obtained
rom the history and physical exam ination, w ith su bsequent
d ecision m aking using a clinical algorithm (Fritz & Brennan
2007). Ind ivid uals are then m atched accord ing to the m ost
 104 PART 2 • 9 • Mechanical neck pain

Step 1 Was the MOI an MVA

Step 2
Red flags or
Classification
Yellow flags whiplash related
Yes

No
Red flags Is the duration
Patient history and interview of symptoms
<30 days? No
Chief complaint(s)
Are there any signs
Functional limitations Yes
Yes of nerve root Centralization
Review of medical history
compression?
Review of systems (general health) Is the initial
Review of specific systems pain rating >7 No No
Yellow flags or initial
FABQ NDI >52 Are symptoms
Yes
distal to the
Yes
elbow?

Pain control
No

Is there a Do neck Is their chief

Non-cervicogenic Yes diagnosis or Yes movements Yes complaint
headache symptoms of affect the headache(s)
migraines? headache? with neck pain?

No No No

Headache Non-cervicogenic Is the duration

headache Yes Exercise and
of symptoms
conditioning
>30 days?

No

No Is the patient Yes

Mobility
> 60 years old?

Figure 9.8 Treatment-based classi cation algorithm. FABQ= Fear-avoidance Beliefs Questionnaire; MOI= mechanism of injury; MVA= motor vehicle accident; NDI= Neck
Disability Index. (Based on Fritz & Brennan 2007, with permission.)

ap p rop riate interventions m ost likely to benef t their current
clinical p resentation (Child s et al 2004; Fritz & Brennan 2007).
Prelim inary stu d ies o this treatm ent-based classif cation have
show n that ind ivid u als receiving m atched interventions w ere
ou nd to have strong associations w ith greater im provem ents
in N eck Disability Ind ex (N DI) scores, as w ell as p ain ratings,
than ind ivid u als receiving non-m atched interventions (Fritz
& Brennan 2007).
Mechanical neck pain classif cation
Mechanical neck p ain is o ten m anaged w ith a conservative,
non-su rgical ap p roach, w hich has trad itionally been the m ain-
stay o treatm ent interventions or this p op u lation. Physical
therap ists have historically u sed a variety o d i erent inter-
ventions inclu d ing m od alities, joint m obilization and / or
m anip u lation, therap eu tic exercise and m echanical traction
on the cervical sp ine (Cleland et al 2007). These interventions
have largely been accep ted as the stand ard p ractice o care,
although high-qu ality evid ence d escribing their u sage is o ten
absent or inconclu sive (Child s et al 2004; Fritz & Brennan
2007). This ind ivid u alized and personalized clinical d ecision-
m aking ap p roach to p atient care has been d escribed as
p ro essional u ncertainty or Wennberg’s hyp othesis. Wenn-
berg’s hypothesis states that, w hen a clinician is aced w ith
d iagnostic u ncertainty, treatm ent options are based on id io-
syncratic actors. This ou tcom e can lead to d i erences am ongst
p rovid ers in term s o the evalu ative m ethod s o their p atients
as w ell as su bsequ ent treatm ent op tions (Wennberg et al 1982;
Jette & Jette 1997). A previous critical appraisal revealed a
scarcity o evid ence or the treatm ent o ind ivid u als w ith neck
p ain. The researchers conclu d ed that m ore d ecisive research
w as need ed to supp ort conclusions regard ing the e f cacy o
p hysical therap y interventions or p atients w ith neck p ain
(H oving et al 2001).
A series o review s rom the Cochrane Library rep orted
that exercise, m obilization, m anip u lation and electrotherap y
had lim ited evid ence o e f cacy, and it w as u nclear w hether
there w ere any p otential benef ts o their u se. Su ggestions or
im p roving the valid ity and statistical strength o u ture trials
includ ed obtaining larger patient sam p le sizes as w ell as
establishing a m od el or the stand ard ization o treatm ent in
this p op u lation (Gross et al 2004; Kroeling et al 2005). Varia-
bility in practice and the absence o u ni orm pro essional d eci-
sion m aking have been rep orted as key p otential cau ses or
the lack o high-qu ality stu d ies w ithin the neck p ain
 Cervical spine sel -report measures o  pain and  unction  105
p op u lation. Sm aller e ect sizes lead ing to a air to m od erate
qu ality o evid ence rating, com bined w ith rep orted su bse-
qu ent d ata w ith only m od erate su ccess in p atient ou tcom es,
cou ld p otentially be a resu lt o this lack o stand ard ization o
care (Fritz & Brennan 2007).
Treatment-based classif cation
Du e to the lack o high-qu ality evid ence or the m anagem ent
o this p op u lation, a treatm ent-based classif cation (TBC)
system w as p rop osed that cou ld assist p ractitioners in their
clinical d ecision-m aking p rocess (Wang et al 2003; Child s et al
2004; Fritz & Brennan 2007). This is d i erent rom a pathoana-
tom ical ap p roach to p atient care, w hich is in u enced by the
search or the correct ‘d iagnosis’ or tissu e sou rce. The p atho-
anatom ical ap p roach has been show n to largely be a ailu re
based on the inad equacies o the m ed ical m od el or low back
pain (Fritz & Brennan 2007). Previou s stu d ies have show n
that d iagnostic u ncertainty at the p rim ary care level is as high
as 85% in the low back popu lation. One can there ore in er
that this w ou ld be a sim ilar statistic or the cervical sp ine
popu lation (Jarvik 2003). When a TBC system is not em ployed ,
clinicians ap p ly p hysical therap y interventions w ith the p er-
cep tion that the p atient has an equ al chance o ailu re or
su ccess, largely based on a p athoanatom ical m od el. The clas-
sif cation ap p roach u ses a clinical-reasoning p rocess that
ocuses on classi ying clinical d ata into certain categories or
the p u rp ose o m aking clinical d ecisions regard ing therap eu -
tic m anagem ent. This cu rrent TBC m od el there ore assists the
clinician in su bgrou p ing larger grou p s o p atients into sm aller,
sim ilar hom ogeneou s entities. The ocu s is less on the id enti-
f cation o a p athoanatom ical sou rce and m ore on recognizing
key im pairm ents gained rom the patient history, sel -report
m easu res and the resu lts o the p hysical exam ination to gu id e
the treatm ent ap p roach (Child s et al 2004; Fritz & Brennan
2007).
Classif cation categories
Although high-qu ality evid ence is absent, there have been
a series o stu d ies that help gu id e intervention strategies
once the p atient has been classif ed into a su bgrou p . These
interventions are the prod u ct o cu rrent best-available evi-
d ence. They are su pplem ented w ith expert opinion and
com m on p ractice w hen necessary. The cu rrent treatm ent-
based classif cation system or patients w ith neck p ain com -
prises f ve classif cation categories (Fritz & Brennan 2007):
m obility, centralization, exercise and cond itioning, p ain
control, and head ache. An algorithm is u sed to aid the clini-
cian in d eterm ining w hich ap p rop riate classif cation their
patient shou ld be assigned to (see Fig. 9.1). Interventions
are ap plied accord ing to best current evid ence and stand ard
practice o care.
Patients in the m obility classif cation w ill o ten p resent
w ith a recent onset o sym p tom s, rarely have upp er qu arter
sym p tom s (active range o m otion d oes not p erip heralize
sym p tom s and no signs o nerve root com p ression) and
u su ally d em onstrate active range-o -m otion d iscrep ancies. In
the m obility classif cation, m atched interventions w ill inclu d e
m obilization / m anip u lation d irected at the cervical or tho-
racic sp ine. N eu rom u scu lar re-ed ucation and strengthening
o the d eep neck exors are also inclu d ed as interventions
w ithin this subgrou p (Cleland et al 2005, 2007, 2010; Masarac-
chio et al 2013).
The centralization classif cation typically consists o
p atients p resenting w ith a re erral p attern o p ain into the
u p p er extrem ity and / or hand s, w ith or w ithou t concom itant
neck p ain. There m ay be p ain rad iating into one or both o the
u p p er extrem ities, as w ell as p erip heralization o sym p tom s
w ith active range o m otion. A test item cluster has been
d eveloped to assist the practitioner in d eterm ining w hether
the p atient’s p res entation rep resents cervical rad icu lop athy.
The ou r item s o this cluster are: ipsilateral cervical spine
rotation < 60°, a positive up per lim b m ed ian nerve neu rod y-
nam ic test, relie o their cu rrent sym p tom s w ith m anu al d is-
traction, and a p ositive Sp u rling’s test (Wainner et al 2003).
Typ ical interventions m ay inclu d e m anu al m echanical cervi-
cal traction (Raney et al 2009) and cervical retraction exercises
based on the centralization phenom enon. Cu rrent research
has also p rop osed a m anu al therap y ap p roach inclu d ing
m obilization and m anip u lation techniqu es d irected at the cer-
vical and thoracic sp ine (Cleland et al 2007; You ng et al 2009).
Sym p tom resp onse is then record ed or p ossible centraliza-
tion or p erip heralization o sym p tom s. This has been show n
to assist in the clinician’s p rognostic reasoning (Werneke &
H art 2003; Werneke et al 2008). (See Ch 7 or d etails on the
centralization p henom enon.)
Within the exercise and cond itioning classif cation, p atients
w ill have low er pain and d isability scores, a longer d u ration
o sym p tom s (> 30 d ays), no signs o nerve root com p ression,
and no signs o perip heralization or centralization. Com m on
interventions w ill includ e both general strengthening or the
u p p er qu arter as w ell as m otor control exercises ocu sed on
the d eep neck exor m u scle area (Bron ort et al 2001). Ind i-
vid u als o ten begin in one sp ecif c classif cation and then
m ove into this category as they start to im p rove.
The pain control classif cation includ es ind ivid u als w ho
have higher initial p ain and d isability scores, a recent onset
o sym p tom s, w hich is u su ally d u e to trau m a, concom itant
cervicogenic head aches and re erred p ain into the u p p er
qu arter, as w ell as p oor tolerance to p articip ation in the p hysi-
cal exam ination. Interventions inclu d e p ain-relieving m od ali-
ties and cervical sp ine range-o -m otion exercises.
Finally, the head ache classif cation includ es patients w ho
p resent w ith a one-sid ed or u nilateral head ache p attern w ith
certain cervical sp ine m otions exacerbating the sym p tom s.
The ollow ing interventions have been recom m end ed or
this p op u lation: cervical sp ine m anip u lation or m obilization,
m otor control exercises or the d eep neck exor m u scles,
and strengthening o the up p er qu arter m u scu latu re (Ju ll
et al 2002).
Cervical Spine Self-report Measures
of Pain and Function
The ad m inistration and collection o sel -report m easu res are
gaining increased aw areness in physical therapy clinical
p ractice and p u blished research. These health statu s qu es-
tionnaires look at a variety o variables su ch as general
health, u nctional lim itations and cu rrent levels o the ind i-
vid u al’s sel -p erceived d isability. It has been ad vocated that
the u se o these m easu res can assist the p ractitioner in their
 106 PART 2 • 9 • Mechanical neck pain
clinical p er orm ance as w ell as their overall p ro essional
accou ntability to the patient in p rovid ing the best care pos-
sible (Delitto 2006). Despite the critical im portance o the
integration o ou tcom e tools into clinical p ractice, a recent
international m u ltid iscip linary su rvey show ed that there
continu es to be a su bstantial need to im p lem ent m ore
consistent ou tcom e m easu rem ents in clinical p ractice
(MacDerm id et al 2013).
Com m on m easu res in the cervical sp ine p op u lation inclu d e
the N u m eric Pain Rating Scale (N PRS), N eck Disability Ind ex
(N DI), Patient Sp ecif c Fu nctional Scale (PSFS), Fear-avoid ance
Belie Qu estionnaire (FABQ), and the Global Rating o
Change scale (GRC). When ap p lying these m easu res to a
sp ecif c p atient p op u lation it is help u l to know the tool’s
p sychom etric p rop erties, esp ecially the m inim um d etectable
change (MDC) and the m inim u m clinically im p ortant d i er-
ence (MCID). It is help u l to d ef ne MDC and MCID as their
valu e is related to the clinical relevance o the m easu re u sed
as w ell as d eterm ining w hether a clinical m eaning u l change
had occu rred based u p on a certain treatm ent ap p roach. The
MDC is d ef ned as the least am ou nt o change that alls
ou tsid e o the norm al m easu rem ent error (Kovacs et al 2008).
MCID is the sm allest am ou nt o change, or d i erence that the
p atient perceives as being benef cial (Jaeschke et al 1989).
Cu rrently there is a lack o p u blished evid ence su ggesting
an optim al tim e- ram e or an app rop riate ollow -u p w hen
u sing sel -rep ort m easu res. The au thors there ore recom m end
that a nu m eric p ain rating (N PRS) and change betw een ses-
sions (GRC) be m easu red at each visit. Tools that look at
p erceived u nctional lim itations (PSFS) shou ld be m easu red
w eekly. Fear-avoid ance behaviou r (FABQ) and sel -reported
d isability (N DI) should be evaluated at the initial evaluation
and at tim e o d ischarge (Table 9.2). One m ay ad m inister these
tools m ore o ten based on the p atient’s sp ecif c case p resenta-
tion. These are general gu id elines to assist the clinician in their
p relim inary usage o these tools in the clinical setting.
Numerical Pain Rating Scale
The N u m erical Pain Rating Scale (N PRS) is a subjective
m easure in w hich ind ivid u als rate their pain on an 11-point
num erical scale. The scale ranges rom 0 (no p ain at all) to 10
(w orst im aginable pain). It has been show n that a com posite
scoring system inclu d ing best, w orse and cu rrent level o p ain
over the last 24 hou rs is su f cient to pick u p changes in pain
intensity w ith m axim al reliability (Jensen et al 1999). The
MCID has been ou nd to be a change in score o 1.3 p oints or
higher in the m echanical neck p ain p op u lation (Cleland et al
Table 9.2 Se lf-re porte d me as ure s for the ce rvical s pine population
Me a s ure Score
Numeric Pain Rating Scale (NPRS) 0–10
Patient Speci c Functional Scale (PSFS) 0–10
Neck Dis ability Index (NDI) 0–50
Global Rate o Change (GROC) (−5)–(+5)
Fear-avoidance Belie s Questionnaire (FABQ) 0–24 (PA)*
*PA= phys ical activity s ubs cale.
2008). MacDerm id et al (2013) reported that a single-item p ain
assessm ent (num eric or visu al analogu e scale) w as p er orm ed
in alm ost 75% o p atient cases w ith neck pain across 24 cou n-
tries in an international su rvey. It w as by ar the m ost com m on
orm o outcom e m easurem ent record ed on a patient-by-
p atient basis.
Neck Disability Index
The N eck Disability Ind ex (N DI) is the m ost com m on region-
sp ecif c tool in u se or m easu ring neck-related d isability. It
has been show n to be both a reliable and a valid tool. In one
stu d y, there w as no d i erence in N DI scores in p atients w ith
or w ithou t u nilateral arm p ain su ggesting that the N DI ad e-
qu ately accou nts or u p p er extrem ity sym p tom s in conju nc-
tion w ith neck p ain (You ng et al 2009). There are 10 qu estions,
each scored w ith a possible 0–5 valu e, w ith the larger nu m ber
ind icating a higher sel -reported d isability statu s. The score
on this qu estionnaire can there ore range rom 0 to 50. In
ord er to calcu late a p ercentage, one sim p ly m u ltip lies the f nal
valu e by 2. In this stud y the MCID w as ou nd to be 7.5 p oints
and the MDC 10 p oints. It is recom m end ed that the MDC be
u sed as this exceed s the stand ard error o m easu rem ent that
one w ou ld f nd w ith this tool i accep ting the cu rrent MCID
valu e (7.5 points) (Young et al 2009). It also has been reported
that the natu ral cou rse o neck p ain u nd er p hysical therap y
m anagem ent show s a linear p rogression in both p ain and
d isability. Walton et al (2014) ou nd that neck p ain via nu m eric
rating scale (N RS) im proved by 0.5 p oints p er w eek and the
N DI im proved at a rate o 1.5 p oints per w eek or the f rst 4
w eeks o care. They also ound tw o d i erent m ean trajectories
w ithin the N RS (stable and im proving pain) and three w ithin
the N DI (w orsening, rap id im p rovem ent and slow im p rove-
m ent in d isability), again bringing im p ortance to the act that
neck p ain is a heterogeneou s cond ition.
Patient Speci c Functional Scale
The Patient Specif c Fu nctional Scale (PSFS) is an outcom e
m easu re that asks the p atient to id enti y and rate lim ited
unctional activities. It is based on a 0–10 scale, w ith score o
10 establishing the patient’s ability to p er orm the activity
p rior to inju ry and 0 rep resenting a cu rrent inability to per orm
the activity at all. The PSFS has been show n to be highly reli-
able in the neck p ain popu lation (Westaw ay et al 1998). Cu r-
rently there is a lack o evid ence that su pports an actual MCID
or this tool in the m echanical neck p ain popu lation, but a
stu d y looking at ind ivid u als w ith su sp ected cervical sp ine
MCID / MDC Fre q ue ncy
1.3 Every s es sion
2 Weekly
7.5 / 10.2 Initial and dis charge
+2 Every ses sion
> 19 (PA)* Initial and dis charge

rad icu lop athy established an MCID o 2 p oints (Cleland et al
2006).
Fear-avoidance Beliefs Questionnaire
The Fear-avoid ance Belie s Qu estionnaire w as originally
d evelop ed in 1993. It w as u sed to m easure su bjects’ belie s
and ears about how their physical activity or w ork activity
m ay contribu te to their cu rrent p ain state (Wad d ell et al 1993).
The FABQ consists o a total o 16 qu estions, w hich can be
scored rom 0 to 6. Outlier qu estions are p resent, resulting in
the w ork su bscale (FABQW) containing a total o 42 p oints
(questions 6, 7, 9, 10, 11, 12, 15) w hile the physical activity
subscale (FABQPA) has a total o 24 p oints (questions 2, 3, 4,
5). One 2007 stu d y used this tool in the d evelopm ent o a
clinical p red iction ru le or those ind ivid u als w ith neck p ain
w ho m ay benef t rom thoracic spine m anipu lation, exercise
and patient ed u cation. The stu d y ound that a score o < 12 on
the FABQPA w as one o the p red ictors o a su ccess u l ou tcom e
(Cleland et al 2007). An ad d itional stu d y in 2007 show ed that
a chronic neck p ain su bsam p le total score o 41/ 66 or the
FABQ (T), 19/ 24 or the FABQPA and 19/ 42 or the FABQW
cou ld id enti y p rolonged d isability 6 m onths later (Land ers
et al 2008). Cleland et al (2008) looked at the psychom etric
prop erties o the FABQ or m echanical neck p ain and ound
a air bu t statistically signif cant correlation betw een concu r-
rent m easures o pain and d isability. Overall there w as a
w eaker relationship betw een m easures o ear and avoid ance
w ith p ain and d isability in the m echanical neck pain popula-
tion com p ared w ith stu d ies regard ing the low back p op u la-
tion. H ow ever, the FABQW d oes ap p ear to be an im p ortant
actor to m easu re in m echanical neck pain patients. This is
especially im portant w ith regard s to looking at prognostic
actors that m ay contribute to return to w ork ability and the
risk o ongoing chronicity.
Global Rating of Change scale
The Global Rating o Change scale (GRC) is used to look at
patients’ sel -p erceived progress d u ring the cou rse o their
treatm ent. This tool ad d s objectivity to the requ ently asked
clinical question, ‘H ow are you eeling tod ay – better, w orse,
or the sam e com p ared w ith w hen you f rst started p hysical
therap y?’ The GRC asks p atients to rate their p rogress rom a
previou s p oint in their care (o ten the initial evalu ation) to
their cu rrent state. The m ost com m on version o this scale
u sed in the p hysical therapy literature is a 15-point scale that
has d ata p oints ranging rom −7 (a great d eal w orse) to +7 (a
great d eal better). The original literature that had d escribed
this tool w as based on a p atient p op u lation that w as d iag-
nosed w ith chronic lu ng or heart d isease (Jaeschke et al 1989).
The au thors used the 15-p oint scale to d ef ne treatm ent success
u sing an arbitrary cu t-o system . A recent review o the GRC
ou nd that u se o an 11-p oint scale ranging rom −5 (very
m u ch w orse) to +5 (com pletely recovered ), as op posed to a
15-point scale as p reviou sly m entioned , yield ed the sam e
resu lts in term s o resp onsiveness. Given the lack o em pirical
evid ence or the arbitrary cu t-o p oints u sed in the 15-point
scale, it is the au thors’ op inion that the 11-p oint scale shou ld
be u sed w ith a corresp ond ing MCID o 2 p oints (Kam p er et al
2009).
Conclusion 107
Conclusion
N eck pain is a com m on occurrence that a ects ind ivid uals
around the w orld . Sim ilar to low back p ain, it is d i f cu lt
to id enti y exact contribu tors to neck p ain, strengthening the
likelihood o a m u lti actorial presentation or this pain state.
Epid em iological stu d ies provid e d ata to gu id e utu re research
w ith the goal o optim izing m anagem ent strategies. Physical
therap ists m u st be aw are o cu rrent best-p ractice stand ard s
regard ing neck pain. This includ es screening p atients or the
ap prop riateness o physical therapy services p rior to initiat-
ing treatm ent. Once the d ecision is m ad e to proceed w ith
p hysical therap y care, a treatm ent-based classif cation system
is proposed as an id eal starting p oint or m anaging this popu-
lation. Ou tcom e m easu res provid e objective d ata to su pport
the clinical d ecision-m aking p rocess or ind ivid u als w ith cer-
vical sp ine p ain. Fu tu re research is need ed to p rovid e u rther
insight into the m anagem ent o patients w ith neck pain.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
10
Whiplash-associated Disorders
 Chapter 
M ic h e le S te rlin g
CHAP TER CONTENTS
Introduction  110
The whiplash condition  111
Classif cation o  whiplash injury  111
Physical and psychological characteristics o  the whiplash condition  111
Motor and sensorimotor control dys unction  111
Augmented pain processing mechanisms in whiplash  112
Psychological  actors in whiplash-associated disorders  113
The prediction o  outcome  ollowing whiplash injury  113
Implications  or assessment o  whiplash  114
Implications  or management o  whiplash-associated disorders  114
Conclusion  115
Introduction
Whip lash-associated d isord ers (WAD) are com m on, d isabling
and costly cond itions that u sually occur as a consequ ence
of a m otor vehicle crash (MVC). Recent d ata ind icate that
rapid im provem ent in levels of pain and d isability occu r in
the rst 3 m onths p ost inju ry w ith little if any change after
this p eriod and that u p to 50% of inju red people w ill not fu lly
recover (Carroll et al 2008; Kam per et al 2008; Sterling et al
2010). The associated cost second ary to w hiplash injury,
inclu d ing m ed ical care, d isability, lost w ork p rod u ctivity,
as w ell as p ersonal costs, is su bstantial (Crouch et al 2006;
MAIC 2012).
Based on cu rrent d ata, w hip lash in both the acu te and the
chronic stages is resistant to treatm ent. A review by Teasell
et al (2010) of interventions for the m anagem ent of acu te
w hip lash id enti ed only 16 rand om ized controlled trials of
varying m ethod ological qu ality and ve non-rand om ized
trials in the English literatu re over the past 30 years. The
inclu d ed trials involved eclectic ap p roaches in variou s con-
gu rations, inclu d ing ad vice to rem ain active or p rescrip tion
of exercise in variou s form s (w ith or w ithou t m anip u lative
therap y), im m obilization in a collar, ed u cational interven-
tions, acu p u nctu re and p u lsed electrom agnetic eld therap y.
The authors conclu d ed on the available evid ence that activity-
based therapies seem ed to be m ore effective. N evertheless,
insp ection of these trials reveals that ou tcom es p ertaining to
recovery and non-recovery rates rem ain relatively consistent,
in accord w ith the nd ings of the natu ral cou rse of w hiplash
(Carroll et al 2008; Sterling et al 2010).
Since this review, tw o fu rther rand om ized controlled trials
for acute w hip lash-associated d isord ers have been con-
d u cted . One trial in Australia investigated m u ltid isciplinary
(physiotherapy, m ed ication and psychology) m anagem ent
com p ared w ith u su al care. Again ou tcom es w ere equ ivocal
w ith no ad d itional bene t of early m u ltid isciplinary care and
still a chronicity rate of 50% for both grou p s – a prop ortion
that is no d ifferent from the u su al clinical p athw ay (Jull et al
2013). The second trial w as cond u cted in accid ent and em er-
gency d ep artm ents in the UK. The resu lts show ed that a six-
session p hysiotherap y p rogram m e of exercise and m anu al
therap y p rovid ed only m od est short-term bene t w hen
com p ared w ith a single p hysiotherap y session com p rising
m ainly ad vice on activity and exercise, and that this bene t
w as not cost effective (Lam b et al 2013). Moreover only
45–50% of the particip ants reported their cond ition as being
‘m u ch better ’ or ‘better ’ – again a low recovery rate that is
little d ifferent to the usual natu ral p attern of recovery follow -
ing the injury.
Furtherm ore, trials of treatm ent for the chronic stage of the
cond ition inclu d ing variou s form s of exercise have offered
only m od est effects, w ith only 10–20% of ind ivid u als having
a com pletely su ccessful outcom e – that is, m inim al or no
d isability at the 12-m onth follow -u p (Ju ll et al 2007; Stew art
et al 2007). A recent large trial of a com prehensive exercise
ap proach (speci c neck, should er gird le and sensorim otor
control exercises together w ith fu nctional and general exer-
cise) p rovid ed no ad d itional bene t com p ared w ith a single
p hysiotherap y ad vice session su p p lem ented w ith telep hone
su p p ort (Michaleff et al 2014).
The d isappointing results of recent rand om ized controlled
trials for acu te and chronic WAD d em and a rethink of the
cond ition and its m anagem ent. There is a w ealth of evid ence
available d em onstrating the p resence of com p lex p hysiologi-
cal and p sychological factors. Do these factors need to be
taken into consid eration in the d evelop m ent of new interven-
tions for WAD, m ore than has so far been the case?
This chapter w ill review the w hip lash cond ition, its clas-
si cation and the p red iction of ou tcom es follow ing the inju ry
before outlining cu rrent evid ence for the physiological and
psychological features of the cond ition. Finally, the im p lica-
tions of this research on the assessm ent and m anagem ent of
the cond ition w ill be d iscu ssed .
 Physical and psychological characteristics o  the whiplash condition
The Whiplash Condition
An MVC can lead to bony or soft tissu e d am age, w hich in
tu rn m ay resu lt in a variety of clinical m anifestations called
w hiplash-associated d isord ers. The prim ary sym ptom is neck
pain, althou gh head ache, arm pain, paraesthesia, d izziness
and cognitive d if cu lties are also frequ ently reported (Sp itzer
et al 1995).
It is conceivable that virtu ally any cervical spine structu re
m ay su stain inju ry follow ing w hip lash. Bioengineering
stu d ies w here cad avers w ere su bjected to sim u lated rear-end
crashes have d em onstrated p ertu rbations in segm ental m ove-
m ent inclu d ing intersegm ental hyp erextension, S-cu rve for-
m ation and d ifferential acceleration of the u p p er cervical
sp ine (Cu sick et al 2001). This, together w ith evid ence from
au top sy and anim al stu d ies (Winkelstein et al 2000), ind icates
that lesions m ay occu r to cervical stru ctu res inclu d ing bony
elem ents, intervertebral d iscs and zygapophyseal joints,
ligam ents, m uscles and nerve tissu es. Unfortu nately, in vivo
id enti cation of structural pathology has p roved to be d if -
cu lt, w hich is p robably d u e to the insensitivity of cu rrent
rad iological d iagnostic im aging (Curatolo et al 2011). The best
available evid ence relates to the zygap ophyseal joints and
w as d em onstrated by placebo-controlled nerve blocks (Lord
et al 1996; Cu ratolo et al 2011).
Whilst it cou ld be argu ed to be bene cial if sp eci c stru c-
tu ral lesion(s) cou ld be id enti ed in w hip lash-inju red p ersons,
at the cu rrent tim e this is u su ally not possible. Therefore, it is
im p ortant to consid er p rocesses that m ay u nd erlie the initia-
tion of w hip lash p ain and also the m aintenance of sym p tom s
in those w ho d o not recover (Sterling et al 2011c). This m ay
allow for the d evelop m ent and testing of interventions to
target these p rocesses and im p rove ou tcom es. These p roc-
esses m ay vary d epend ing on the stage of the inju ry and so
this w ill also need to be consid ered .
Classif cation o Whiplash Injury
Classi cation system s have been p rop osed in ord er to assist
in the early assessm ent, p rognosis and m anagem ent of w hip -
lash. The m ost com m only used classi cation system is the
Qu ebec Task Force (QTF) system (Spitzer et al 1995). This
broad ly d e nes the cond ition into fou r grou ps: WAD I (neck
com p laint w ithou t m u scu loskeletal signs), WAD II (w ith m u s-
cu loskeletal signs), WAD III (w ith neu rological d e cits) and
WAD IV (w ith a fractu re or d islocation). Althou gh this system
provid es som e necessary inform ation related to cond ition
classi cation, a m ajor system atic aw exists as the m ajority of
w hiplash-injured people are grou ped w ithin one classi cation
(WAD II), w hich falsely assum es hom ogeneity of the m ost
com m on com p laints w ithin this p atient grou p (Sterling 2004).
N evertheless, the system at least provid es a com m on lan-
guage for effective com m unication betw een healthcare and
non-healthcare p rovid ers involved in the m anagem ent of
peop le w ith WAD.
To d ate, neither the QTF classi cation system for WAD nor
trials investigating variou s m anagem ent ap p roaches for this
cond ition have fu lly consid ered both the p hysiological and
psychological factors that are em erging as p laying a role in
111
the p ain and d isability of w hip lash. It is ap p arent that w hip -
lash is a m ore com plex cond ition than had previou sly been
assum ed . Furtherm ore, it is also em erging that w hip lash is in
som e w ays d ifferent from neck p ain cond itions of a non-
trau m atic natu re (m echanical id iop athic neck p ain). In p ar-
ticu lar, chronic w hip lash show s m arked sensory featu res
ind icative of central nervous system hyp erexcitability that
have now consistently been show n not to be a featu re of
chronic non-trau m atic neck p ain (Scott et al 2005; Elliott et al
2009a; Chien et al 2010).
Physical and Psychological
Characteristics o the Whiplash
Condition
H istorically m uch past research and certainly the clinical
assessm ent of sp inal p ain cond itions, inclu d ing w hiplash, has
aim ed to id entify the p athoanatom ical sou rce(s) of the p atient’s
reported sym ptom s. This ap proach has had lim ited success as
a pathoanatom ical d iagnosis is not possible in the vast m ajor-
ity of patients w ith com m on m u sculoskeletal pain cond itions,
nor d oes su ch a d iagnosis necessarily shed light on the m ost
op tim al intervention for a sp eci c cond ition or p atient. As a
consequ ence, the focu s has shifted in recent years m ore
tow ard s attem p ting to id entify the u nd erlying m echanism s or
p rocesses of the p atient’s p ain synd rom e. The p u rp ose of this
m ore sp eci c d iagnosis and classi cation of m u scu loskeletal
p ain synd rom es is to help tailor interventions tow ard id enti -
able u nd erlying processes so as to try to im prove treatm ent
su ccess, p articu larly in som e of the m ore recalcitrant cond i-
tions. Of all neck and u p p er qu ad rant cond itions, there is
arguably the m ost d ata available for m otor, sensory and p sy-
chological characteristics of w hip lash. One reason for this m ay
be the easily d e ned onset of inju ry (MVC) com p ared w ith the
m ore insid iou s onset often occu rring in other cond itions.
Motor and sensorimotor control dys unction
One of the m ost com m on clinical characteristics of p atients
w ith WAD is that of either m ovem ent loss or d ecreased cervi-
cal range of m ovem ent (Dall’Alba et al 2001). Most prospec-
tive stu d ies have show n that all w hip lash-inju red su bjects
have a loss of cervical active range of m ovem ent from soon
after injury (Kasch et al 2001; Sterling et al 2003b) that persists
in those w ho d o recover (Sterling et al 2003b). Altered pat-
terns of m u scle recru itm ent in both the cervical sp ine and the
shou ld er gird le regions have been clearly show n to be fea-
tu res of chronic WAD (N ed erhand et al 2002; Ju ll et al 2004).
Longitud inal d ata d em onstrate that these changes are app ar-
ent from very soon after inju ry (Sterling et al 2003b). Sterling
et al (2003b, 2006) observed that the d istu rbed m otor patterns
p ersisted , not only in those w ith ongoing chronic sym p tom s
but also in those w ith m ild er pain and d isability and in those
w ho reported fu ll recovery, w ith these phenom ena occu rring
at signi cant tim e-p eriod s post injury – u p to 2 years. These
p ersisting d e cits in m u scle control m ay leave recovered ind i-
vid u als m ore vu lnerable to fu tu re ep isod es of neck p ain, bu t
this p rop osal need s to be su bstantiated w ith fu rther investiga-
tion. Altered p atterns of m u scle recru itm ent are not u niqu e to
 112 PART 2 • 10 • Whiplash-associated disorders
w hip lash and id entical changes have also been observed in
neck p ain of insid iou s onset (id iop athic neck p ain) (N ed er-
hand et al 2002; Jull et al 2004; Wood hou se & Vasseljen 2008).
These nd ings suggest that the d river of such m otor changes
m ay be m ore the nocicep tive inp u t than the inju ry m echanism
itself.
Morp hological changes to cervical sp ine m u scles have also
been d em onstrated in people w ith chronic w hiplash. Using
m agnetic resonance im aging (MRI), Elliott et al (2006, 2009b,
2010) d em onstrated the p resence of fatty in ltrate in both d eep
and su p er cial cervical extensor and exor m u scles in WAD
p atients com pared w ith an asym ptom atic control grou p.
Although the fatty in ltrate w as generally higher in all m uscles
investigated for the p atient grou p , it w as highest in the
d eeper m u scles, the rectu s capitis posterior m inor and m ajor
and m u lti d i (Elliott et al 2006). In contrast to m uscle recru it-
m ent changes, available d ata ind icate that sim ilar m orp hologi-
cal changes are not ap p arent in ind ivid u als w ith chronic
id iop athic neck p ain (Elliott et al 2014). The relevance of these
nd ings in term s of p ain, d isability or fu nctional recovery and
the cau se of the m u scle changes are not yet know n.
Dysfunction of sensorim otor control is also a featu re of
both acute and chronic WAD. Greater joint-repositioning
errors have been found in patients w ith chronic WAD and also
in those w ithin w eeks of their inju ry (Sterling et al 2003b;
Treleaven et al 2003). Loss of balance and d istu rbed neck-
in u enced eye m ovem ent control are p resent in p atients w ith
chronic WAD (Treleaven et al 2005a, 2005b). It is im portant to
note also that sensorim otor d istu rbances seem to be greater
in ind ivid u als w ho also rep ort d izziness in association w ith
their neck p ain (Treleaven et al 2003).
Most of the d ocu m ented m otor d e cits (m ovem ent loss,
altered m u scle recru itm ent p atterns) seem to be p resent in
w hip lash-injured ind ivid uals irresp ective both of reported
p ain and d isability levels and of the rate or level of recovery
(Sterling et al 2003b). Ad d itionally, apart from cervical m ove-
m ent loss, m otor d e cits d o not have p red ictive cap acity
(Daenen et al 2013). Furtherm ore, treatm ent d irected at reha-
bilitating m otor d ysfu nction and im proving general m ove-
m ent show s only m od est effects on rep orted p ain and
d isability levels (Ju ll et al 2007; Stew art et al 2007; Michaleff
et al 2014). Together these nd ings su ggest that m otor d e cits,
althou gh p resent, m ay not p lay a key role in the d evelop m ent
and m aintenance of chronic or persistent sym p tom s follow ing
w hip lash inju ry. This is not to say that m anagem ent app roaches
d irected at im p roving m ovem ent m otor d ysfunction shou ld
not be p rovid ed to p atients w ith w hip lash as these w ill be
im p ortant to overall general health. Rather the id enti cation
of m otor d e cits alone m ay not equ ip the clinician w ith u sefu l
inform ation to gau ge either p rognosis or potential resp onsive-
ness to p hysical interventions.
Augmented pain-processing mechanisms
in whiplash
There is now consid erable and consistent evid ence of sensory
d istu rbances in WAD that ind icate the presence of augm ented
central nocicep tive p ain-p rocessing m echanism s. Changes
inclu d e sensory hyp ersensitivity (or d ecreased p ain thresh-
old s) to nu m erou s stim u li su ch as p ressu re, therm al or electri-
cal stim u lation and light tou ch in both acu te and chronic
WAD (Sterling et al 2003a; Stone et al 2012; Van Oosterw ijck
et al 2013). Sensory hyp ersensitivity is found not only over
the cervical sp ine (area of inju ry) bu t also at rem ote u ninju red
areas su ch as the up per and low er lim bs (Koelbaek-Johansen
et al 1999; Sterling et al 2003a). The absence of tissue d am age
at the site of testing suggests that central sensitization of
nocicep tive p athw ays is the cau se of the p ain sensitivity.
Wid esp read hyp oaesthesia (elevated d etection threshold s)
occu rring concu rrently w ith hyp ersensitivity, as w ell as less-
ef caciou s cond itioned p ain m od u lation, has also been fou nd
in patients w ith WAD – ind icating d istu rbances in central
inhibitory processes as w ell (Chien et al 2009; N g et al 2014).
H ypersensitivity has been show n to be present not only in
testing involving a cognitive resp onse from the p articip ant;
also, facilitated exor w ithd raw al re exes in the low er lim bs
of p articip ants w ith chronic WAD have been d em onstrated
follow ing electrical stim u lation of the su ral nerve (Lim et al
2011). In the latter test, re ex activity of the biceps fem oris w as
m easu red and evid ence of sp inal cord hyp erexcitability
(central sensitization) w as provid ed w ithout relying on the
su bject’s self-rep orted resp onse to the stim u li, as is requ ired
w ith pain threshold testing. It has also been show n that the
heightened re ex resp onses are not associated w ith p sycho-
logical factors su ch as catastrophization and d istress (Sterling
et al 2008).
In contrast to the apparently uniform presence of m otor
d ysfunction, sensory d istu rbances seem to d ifferentiate w hip-
lash from less severe neck p ain cond itions and w hiplash sub-
grou pings w ith higher or low er levels of self-reported pain
and d isability. Ind ivid u als w ith chronic WAD m anifest a m ore
com p lex p resentation, involving low ered p ain threshold s to
pressu re, heat and cold stim uli in areas rem ote to the cervical
sp ine, w hich are not p resent in those w ith id iop athic (non-
trau m atic) neck p ain (Scott et al 2005; Elliott et al 2009b; Chien
et al 2010). Sim ilarly, w id espread hypoaesthesia to vibration,
therm al and electrical stim u lation, althou gh p resent in WAD,
is not a featu re of id iopathic neck p ain (Chien et al 2010).
H ow ever, the presence of central hyperexcitability is not
u niqu e to w hip lash; other p ainfu l m u scu loskeletal cond itions
su ch as brom yalgia, tension-typ e head ache and m igraine
also m anifest su ch signs (Yu nu s 2007). With resp ect to the
cervical sp ine and u p p er qu ad rant, w id esp read sensory
hyp ersensitivity is a featu re of cervical rad icu lop athy, as both
p atients w ith this cond ition and those w ith w hip lash rep ort
sim ilar p ain and d isability levels (Chien et al 2008). This
nd ing su ggests that chronic w hip lash and chronic cervical
rad icu lopathy share sim ilar und erlying m echanism s bu t
d iffer from id iop athic neck pain – thus illu strating the d iver-
sity of p rocesses involved in variou s neck p ain cond itions.
The reason w hy som e w hiplash-inju red p eop le d evelop a
hyp ersensitive state is not clear. N u m erou s cervical sp ine
stru ctu res are im p licated as p otential sou rces of nocicep tion
follow ing w hip lash injury (Cu ratolo et al 2011). It is possible
that inju ries to d eep cervical stru ctu res d o not rap id ly heal
and thu s becom e a nocicep tive ‘d river ’ of central nervou s
system hyp erexcitability; recent evid ence su p p orts this
hyp othesis (Sm ith et al 2014). Ad d itionally, the sensory hyper-
sensitivity seen in p atients w ith w hip lash is also associated
w ith other d isturbances such as im paired sym p athetic vaso-
constriction (Sterling 2006), stress-related factors (Sterling
et al 2011b) and pain catastrophization (Rivest et al 2010).
There is also em erging evid ence that certain ind ivid uals m ay

have a genetic vu lnerability to higher levels of p ain and the
d evelopm ent of augm ented central nocicep tive processing
(McLean et al 2011). The co-occu rrence of these factors su g-
gests that a com plex interplay betw een various m echanism s
m ay lead to this alm ost-system ic resp onse in som e ind ivid u -
als follow ing w hip lash inju ry. Research is now focu sing on
investigating su ch com plex m od els that m ay in the fu ture
shed light on this intrigu ing issu e (McLean et al 2005;
Passatore & Roatta 2006; Sterling & Kenard y 2006).
Psychological actors in whiplash-associated
disorders
There is no d ou bt that chronic w hiplash is associated w ith
psychological d istress, inclu d ing affective d istu rbances,
anxiety, d ep ression and behavioural abnorm alities su ch as
fear of m ovem ent (William son et al 2008). Psychological d is-
tress is also p resent in the acu te p ost-inju ry stage, w ith m ost
peop le show ing som e d istress regard less of pain and d isabil-
ity levels (Sterling et al 2003c). Data from som e stu d ies ind i-
cate that the ongoing p sychological d istress is associated w ith
non-resolving p ain and d isability. A large cross-sectional
stu d y show ed an association betw een anxiety, d ep ression and
pain and d isability in people w hose accid ents had occu rred
over 2 years p reviou sly, bu t not in those w ith acute inju ry,
w hich su ggests that sym ptom persistence is the trigger for
psychological d istress (Wenzel et al 2002). Longitud inal d ata
ind icate that initially elevated levels of d istress d ecrease in
those w ho recover, in a m anner closely p aralleling the d ecreas-
ing levels of pain and d isability (Sterling et al 2003c).
Uniqu e psychological factors m ay be involved in the aetiol-
ogy and d evelop m ent of chronic w hip lash (Sterling et al
2003c) com p ared w ith other painful m u scu loskeletal cond i-
tions. For exam p le, the role of fear-of-m ovem ent beliefs seem s
to be a less im p ortant factor in w hip lash (Sterling et al 2005)
than in low back p ain (Vlaeyen et al 1995). The role of cop ing
styles or strategies in w hip lash is u nclear, how ever. Som e d ata
ind icate that a palliative reaction (e.g. seeking palliative relief
of sym p tom s su ch as d istraction, sm oking or d rinking) w as
associated w ith longer sym ptom d uration (Bu itenhu is et al
2003; Carroll et al 2006); in contrast, Kivioja et al (2005) fou nd
no evid ence that d ifferent cop ing styles in the early stage of
injury in u enced the ou tcom e at 1 year p ost accid ent. The
d ifferent cohort inception tim es of these stu d ies m ay accou nt
for the d ifferences in nd ings, ind icating that coping strate-
gies m ay vary d epend ing on the stage of the cond ition.
One factor that is likely to be u niqu e to WAD (com p ared
w ith other com m on m u scu loskeletal cond itions), d ue to the
m od e of onset being a trau m atic event, is that of p ost-trau m atic
stress. Sym p tom s of p ost-trau m atic stress have been show n to
be present in a proportion of people follow ing a w hiplash
injury d u e to an MVC (Kongsted et al 2008; Sterling et al 2010)
and these sym p tom s have show n p rognostic capacity for poor
functional recovery at 12 m onths and 2 years p ost MVC
(Buitenhu is et al 2006; Sterling et al 2011b, 2012). These stu d ies
m ostly u tilized the Im p act of Events Scale (IES) (H orow itz
et al 1979), an instru m ent that m easures d istress associated
w ith a sp eci c event (in the case of w hiplash an MVC),
although it shou ld be noted that a d iagnosis of p ost-trau m atic
stress d isord er cannot be m ad e from IES scores. H ow ever,
recent d ata u tilizing a m ore robu st tool, the Post-trau m atic
The prediction o  outcome  ollowing whiplash injury 113
Diagnostic Scale (PDS) (Foa et al 1997), d em onstrated that
22% of a prospective sam ple of 155 w hiplash-inju red p eop le
had a p robable d iagnosis of p ost-trau m atic stress d isord ers at
3 m onths post MVC, w ith this gure d ropp ing slightly to 17%
by 12 m onths p ost inju ry (Sterling et al 2010). These nd ings
ind icate the need for further psychological evaluation of these
p atients, and clinicians shou ld consid er this factor in their
assessm ent of w hip lash-injured p eople.
The Prediction o Outcome Following
Whiplash Injury
The cap acity to pred ict those at risk of poor recovery follow -
ing w hiplash inju ry is im portant because it m ay allow the
institu tion of app ropriate early interventions targeted at
m od i able risk factors. This cou ld p otentially red u ce the tran-
sition to chronicity in those ind ivid u als d eem ed to be at risk.
N u m erou s factors have been investigated for their prognostic
cap ability, inclu d ing sociod em ograp hic statu s, crash-related
variables, com p ensation and / or litigation, and p sychosocial
and physical factors. H ow ever, system atic review s of pro-
sp ective cohort stu d ies on w hip lash fou nd that greater initial
p ain intensity and greater initial d isability w ere the m ost con-
sistent p red ictors of d elayed fu nctional recovery (Carroll et al
2008; Kam per et al 2008; Walton et al 2009, 2013b). A m eta-
analysis ind icated that initial p ain scores of greater than 5.5
on a visu al analogu e scale from 0 to 10 and scores of greater
than 29% on the N eck Disability Ind ex are u sefu l cu t-off
scores for clinical u se (Walton et al 2009).
Other factors rep orted by ind ivid u al system atic review s
includ e p ost-inju ry psychological factors such as coping strat-
egies (Carroll et al 2008), ed u cational level no higher than
second ary, fem ale gend er, a history of p reviou s neck p ain
(Walton et al 2009), and sym ptom s of post-trau m atic stress
and p oor self-ef cacy (William son et al 2008). Whereas som e
of these factors su ch as p ain intensity and p sychological d is-
tress m ay be m od i able, m any of the others (e.g. age, ed u ca-
tion) are not. Fu rtherm ore, w hen p otentially m od i able factors
of initial p ain and d isability levels are consid ered alone,
althou gh having high sp eci city they had relatively low sen-
sitivity to p red ict those w ith ongoing m od erate to severe
sym p tom s at 6 m onths p ost-accid ent (Sterling et al 2005).
Cold hyp eralgesia has been show n to p red ict d isability and
m ental health ou tcom es at 12 m onths post inju ry (Sterling et al
2006, 2011b), and d ecreased cold pain tolerance m easured w ith
the cold p ressor test p red icted ongoing d isability (Kasch et al
2005). A recent system atic review conclu d ed that there is m od -
erate evid ence available to su pport cold hyperalgesia as an
ad verse prognostic ind icator (Gold sm ith et al 2012). Other
sensory m easu res su ch as low ered p ressu re-p ain threshold s
(m echanical hyperalgesia) show inconsistent prognostic
cap acity, how ever. Walton et al (2011) rep orted that d ecreased
p ressu re-p ain threshold s over a d istal site in the leg p red icted
neck-p ain-related d isability at 3 m onths post inju ry, bu t others
have show n that this factor is not an ind ep end ent p red ictor of
later d isability (Sterling et al 2006). The exact m echanism s
u nd erlying the hyp eralgesic resp onses are not clearly u nd er-
stood , bu t are generally acknow led ged to re ect au gm ented
nocicep tive p rocessing in the central nervou s system or central
hyp erexcitability (Curatolo et al 2004; Stone et al 2012).
 114 PART 2 • 10 • Whiplash-associated disorders
The p sychological factor of p ost-trau m atic stress sym p -
tom s is em erging as a d om inant one in p oor ou tcom e follow -
ing w hip lash inju ry (Bu itenhu is et al 2006; Sterling et al 2012).
Ad d itional p sychological factors su ch as high levels of pain
catastrop hizing, d ep ressed m ood and low exp ectations of
recovery have also been id enti ed , in som e stu d ies, as being
p red ictive of p oor fu nctional recovery (Sterling et al 2011a).
The role of the controversial issu e of com p ensation-related
factors is inconclu sive, w ith som e stu d ies nd ing that these
have p red ictive cap acity (Carroll et al 2008) and others report-
ing that they d o not (Sterling et al 2005). A recent system atic
m eta-review ou tlined the lim itations of research exam ining
the in u ence of inju ry com p ensation on health ou tcom es,
inclu d ing the low qu ality of p rim ary research p ap ers in this
area, the heterogeneous natu re of com p ensation schem es
stu d ied and the lack of u se of valid ated health ou tcom e m eas-
u res (Sp earing et al 2012). These au thors could nd only one
system atic review that cou ld be consid ered both internally
and externally valid and , based on this, their conclu sion w as
that there is evid ence of ‘no association betw een litigation
and poor health ou tcom es am ong people w ith w hip lash’
(Spearing & Connelly 2011, p 23).
Implications or Assessment o
Whiplash
It is clear from current d ata that the w hiplash cond ition
involves com p lex interactions betw een p hysiological and p sy-
chological factors. Althou gh the p resence of high initial levels
of p ain and / or d isability is a consistent p red ictor of p oor
ou tcom e (Walton et al 2009, 2013b), the ad d itional p resence of
sensory hyp ersensitivity (p articu larly cold hyp eralgesia) and
also p ost-traum atic stress sym p tom s has been show n to
im p rove p red ictive cap acity su bstantially (Sterling et al 2005).
The long-term fu nctional statu s follow ing w hip lash m ay be
established w ithin a few m onths of inju ry, w ith little fu rther
im p rovem ent after this tim e (Kam per et al 2008; Sterling et al
2010). This reiterates the im portant role that clinicians play in
the early p ost-inju ry stage and even tow ard s the p revention
of chronicity.
The p atient assessm ent w ill need to inclu d e an ad equ ate
history, su ch as p reviou s history of neck p ain and head ache,
as w ell as the p ossible m echanism of inju ry. The p atient
shou ld be screened for the p resence of any ‘red ag’ cond ition
(WAD IV – fractu re or d islocation). Althou gh accid ent-related
featu res have not been found to be consistent prognostic ind i-
cators of ou tcom e (Walton et al 2009), they have show n som e
p red ictive cap acity in certain stud ies (Stu rzenegger et al
1995). Since p ain and d isability levels have been repeated ly
d em onstrated to be a consistent ind icator of prolonged recov-
ery (Walton et al 2013a, 2013b), it is essential that a valid ated
m easu re, su ch as the N eck Disability Ind ex (N DI) or N u m eric
Pain Rating scale, is u sed in the initial assessm ent. Certain
p hysical factors, su ch as cold hyperalgesia and loss of neck
m ovem ent, are p red ictive of p oor recovery and so their p res-
ence m u st also be carefully assessed . With resp ect to w hiplash
inju ry, the p sychological factor of p ost-trau m atic stress
app ears to be involved in the transition from the acu te to the
chronic stage of the cond ition and so clinicians shou ld inclu d e
a m easu re of post-trau m atic stress sym p tom s (e.g. u sing the
IES) in their assessm ent of w hiplash-inju red patients.
At present, sensory exam ination su ch as that required to
d etect the variety of sensory d isturbances outlined above is
rarely p erform ed , and if it is perform ed it is u sually lim ited
to ru d im entary assessm ent of m u scle p ow er, d eep tend on
re exes and light-touch sensation. More d etailed assessm ent
of sensory changes in p atients w ith WAD m ay be help fu l. The
rst stage of this assessm ent w ou ld be thorou gh record ing of
the p atient’s sym p tom s inclu d ing the natu re of p ain. Althou gh
the u sefu lness of sym p tom classi cation as a w ay of clarifying
p ain m echanism s is d ebatable, it is a necessary p art of the
p atient assessm ent (Jensen & Baron 2003). In recent tim es,
qu estionnaires have been d evelop ed that aim to id entify
neu rop athic-like p ain sp eci cally (Bennett et al 2007). Using
the S-LAN SS qu estionnaire (Bennett et al 2005), it has been
show n that 20% of an acu te w hip lash cohort is likely have a
p red om inantly neu rop athic p ain cond ition, certain qu estion-
naire item s being p articu larly associated w ith higher levels of
p ain and d isability (Sterling & Ped ler 2009).
Qu antitative sensory testing can also be u sed . This cou ld
includ e the m easu rem ent of m echanical p ain threshold s w ith
p ressu re algom etry and d eterm ination of the p resence of allo-
d ynia w ith light tactile stim u lation. There is m od erate evi-
d ence for cold hyperalgesia as a pred ictor of poor recovery
(Gold sm ith et al 2012) and that it m ay be associated w ith lack
of treatm ent resp onsiveness (Ju ll et al 2007), althou gh a later
m ore highly p ow ered rand om ized controlled trial d id not
su p p ort this nd ing (Michaleff et al 2014). It is m ore d if cu lt
to m easu re clinically bu t a recent stu d y com p aring the u se of
ice application to the neck w ith cold pain threshold s obtained
via the Som ed ic Therm otest® system ind icated that p ain
> 5 / 10 w ith ice w as a good ind ication of cold hyperalgesia
(Maxw ell & Sterling, 2012), although fu rther stu d ies are
requ ired to fu rther valid ate this m easure.
H ow ever, it shou ld be noted that, thou gh such sensory
assessm ents can p rovid e u seful inform ation, at p resent there
is no consensu s over the m ost ap propriate m ethod to u se and
the reference stand ard w ith w hich to com p are nd ings. The
d evelopm ent of the m ost appropriate sensory exam ination of
w hiplash-injured patients is at an early stage and m ovem ent
tow ard s fu rther d evelop m ent into clinically valid and u sefu l
m easu res is of vital im p ortance.
Physiotherap ists rou tinely assess the cervical range of
m ovem ent and this w ill rem ain a m ainstay of assessm ent of
w hiplash ow ing to the p rognostic capacity of this m easure.
H ow ever, assessm ent w ill also need to inclu d e m u scle recru it-
m ent p atterns of the cervical and shou ld er gird le regions.
Fu rtherm ore, the assessm ent of sensorim otor control is rela-
tively sim p le to u nd ertake in the clinical situ ation and w ill be
p articu larly im p ortant in w hip lash-inju red p atients w ho
report d izziness associated w ith their neck pain. Read ers are
referred to Ju ll et al (2008) for a d etailed accou nt of how to
u nd ertake these assessm ents.
Implications or Management o
Whiplash-associated Disorders
An im portant aim for the treatm ent of acu te WAD is the
id enti cation of people at risk of poor recovery, and then

prevention of the d evelop m ent of chronic pain and d isability.
Cu rrently, thou gh, there is a p au city of evid ence available to
guid e the clinician on how best to achieve this goal, w hich is
fru strating for clinicians and researchers alike. Whereas there
is now m u ch better u nd erstand ing of the characteristics of the
cond ition and factors p red ictive of p oor recovery, m u ch less
progress has been m ad e in the d evelopm ent of im p roved and
effective interventions. The next logical step in the research
process is to d eterm ine the effectiveness of targeting these
factors, m any of w hich are potentially m od i able, w ith m ore
sp eci c interventions.
Ed u cation and ad vice to retu rn to activity and exercise w ill
rem ain the cornerstones of early treatm ent for WAD, but they
requ ire fu rther investigation to d eterm ine the m ost effective
form of exercise, its d osage and w ays to d eliver the approaches.
Activity and exercise m ay be suf cient for patients at low risk
of d evelop ing chronic p ain (Ritchie et al 2013), although this
prop osition is yet to be form ally tested . Those p atients at
higher risk of p oor recovery w ill p robably need ad d itional
treatm ents alongsid e the basic ad vice / activity / exercise
app roach. This m ay inclu d e m ed ication to target pain and
nocicep tive p rocess as w ell as m ethod s of ad d ressing early
psychological resp onses to inju ry. H ow ever, a recent trial of
m u ltid iscip linary interventions for acu te WAD d em onstrated
that this m ay not be so easy to achieve (Ju ll et al 2013); the
particip ants in this trial not only fou nd the sid e effects of
m ed ication u naccep table bu t w ere also less com p liant w ith
attend ance to a clinical psychologist (46% of participants
attend ed few er than 4 of 10 sessions) com pared w ith attend -
ance w ith the p hysiotherap ist (12% attend ed few er than 4
sessions over 10 w eeks). It is possible that peop le w ith acute
w hiplash injury see them selves as having a ‘physical’ inju ry
and thu s are m ore accep ting of p hysiotherap y. The bu rd en of
requ iring visits w ith several practitioners m ay also lead to
poor com p liance. Physiotherap ists m ay therefore be the best-
placed healthcare p rovid ers to d eliver psychological interven-
tions for acu te WAD. This ap p roach has been investigated in
m ainly chronic cond itions su ch as arthritis (H u nt et al 2013)
and in the m anagem ent of acu te low back pain (H ill et al 2011)
w ith resu lts show ing som e early prom ise. H ow ever, this is not
to say that p atients w ith a d iagnosed p sychop athology su ch
as d epression or p ost-trau m atic stress d isord er shou ld be
m anaged by p hysiotherap ists; of cou rse, su ch p atients w ill
requ ire referral to an ap propriately trained p rofessional.
Physiotherap ists m ay also need to take a greater role in the
overall care p lan of the p atient w ith acu te WAD. This w ou ld
m ean having exp ertise in the assessm ent of risk factors and
an u nd erstand ing of w hen ad d itional treatm ents su ch as
m ed ication and p sychological interventions m ay be requ ired .
Although in m ost ju risd ictions this is still the role of
general m ed ical practitioners, physiotherapists m ay be better
equipped in term s of tim e available for effective assessm ent,
treatm ent p lanning and m onitoring recovery and p rogress.
In the case of chronic WAD, m ore effective interventions
need d evelop m ent and testing. It is becom ing clear that m an-
agem ent ap proaches focusing pred om inantly on physical
rehabilitation are achieving only sm all effect sizes. H ow ever,
it is im p ortant for the long-term general health of patients that
they u nd ertake regu lar activity and exercise and it is a concern
if chronic pain p revents them from d oing this. Rand om ized
controlled trials are need ed that com bine activity / exercise
app roaches w ith other interventions such as p sychological
Conclusion 115
ap proaches, ed u cational approaches and m ed ication. The
op tim al com bination and d osage of su ch ap p roaches w ill
need to be d eterm ined .
WAD, w hether or acu te or chronic, is a challenging and
com p lex cond ition. With clear evid ence em erging of a m yriad
of p hysical and p sychological factors op erating to varying
d egrees in ind ivid ual patients, it is also clear that practitioners
involved in the m anagem ent of WAD w ill need speci c skills
in this area. Physiotherap ists are the healthcare provid ers w ho
p robably see the greatest nu m ber of p atients w ith WAD and ,
by virtu e of the health system set-up , spend the m ost tim e w ith
these ind ivid u als. Physical therap ists are therefore w ell p laced
to take on a coord ination or ‘gatekeep er ’ role in the m anage-
m ent of WAD, and research into health services m od els that
inclu d e physiotherap ists in su ch a role is also need ed .
Conclusion
Whip lash is a com plex, heterogeneou s, intrigu ing cond ition
involving both physical (m otor and sensory) d istu rbances and
p sychological d istress. It is also one of the m ost fru strating
cond itions for clinicians to m anage. It w ou ld ap p ear that the
qu est to u nd erstand WAD better has only ju st begu n and the
results from recent research efforts have p aved the w ay for
further d irections for research. As new know led ge em erges,
the clinical assessm ent of the cond ition w ill becom e m ore
inform ed and this w ill translate to im proved ou tcom es for
injured people.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
11  
Chapter 
Differential Diagnosis and Treatment of Cervical Myelopathy,
Cervical Radiculopathy and Cervical Myeloradiculopathy
C h a d C o o k, Am y C o o k
CHAP TER CONTENTS
Introduction  118
Review of proposed pathology and patho-biomechanics  119
Clinical signs and symptoms  119
Myelopathy  119
Radiculopathy  120
Myeloradiculopathy  120
Current best evidence with regard to diagnosis  120
Cervical myelopathy  120
Cervical radiculopathy  122
Cervical myeloradiculopathy  124
Imaging  124
Nerve condition responses  125
Essential aspects of differential diagnosis  126
Current best evidence with regard to prognosis  126
Current best evidence with regard to treatment  127
Conservative approaches  127
Surgical approaches  128
Introduction
Cervical sp ine p ain is a com m on m u scu loskeletal com -
p laint a ecting 66–70% o ind ivid u als w ithin their li etim e
(And erson et al 1993), w ith 54% having experienced sym p-
tom s w ithin the p reviou s 6 m onths (Côté et al 1998). Cervical
sp ine p ain can signi cantly a ect p hysical and social u nction
(Brow n et al 2009), w ith correspond ingly high levels o health-
care u sage and costs (Brattberg et al 1989) and u p to 5% o
ind ivid u als ind icating high d isability (Côté et al 1998). Cervi-
cal sp ine p ain is m ore p revalent in ind ivid u als w ho are ed u -
cated , w ho have a history o inju ry or trau m a, or w ho su er
rom consistent head aches (Brow n et al 2009).
Cervical sp ine p ain can originate rom a tu m ou r, inju riou s
event, in ection, inf am m atory d isord er, m etabolic cond ition
and / or d egeneration (Ahn et al 2007; Bind er 2007). The m ost
com m on cau se is d egeneration – o ten term ed cervical spond -
ylosis. This is caused by d egeneration o tissues such as the
cervical d isc and cartilaginou s end p lates, osteop hytes along
the vertebral bod y, acets and u ncovertebral joints, and ossi-
cation or thickening o the ligam entu m f avu m and p osterior
longitud inal ligam ent (Rao & Fehlings 1999; McCorm ick
et al 2003).
Tw o sp eci c d iagnoses associated w ith d egenerative
changes in the cervical sp ine are: (1) cervical m yelop athy and
(2) cervical rad icu lopathy. Both cond itions involve d ebilitat-
ing neurological sym p tom s that m ay p rogress tow ard d isabil-
ity i inad equately treated (McCorm ick et al 2003). In severe
cases, rad icu lop athic and m yelop athic changes can occu r
sim u ltaneou sly, resu lting in m yelorad icu lop athy. Cervical
m yelorad icu lop athy is a m ajor m anagem ent challenge and
o ten lead s to signi cant m ovem ent d isord ers (Wong
et al 2004).
It has been p u rported that m yelop athy is p resent in 90% o
ind ivid u als by the seventh d ecad e o li e (Dvorak 1998) and
is recognized as the m ost com m on orm o spinal cord d ys-
unction in ind ivid u als over the age o 55 (Brow n et al 2009).
Cervical m yelop athy m ost com m only a ects m ales (Mont-
gom ery & Brow er 1992) and those o Asian d escent (Jayaku -
m ar et al 1996). It is believed that a large p ercentage o eld erly
p atients have m ild cervical m yelop athy that o ten goes u nno-
ticed , as the signs and sym p tom s are requ ently attribu ted to
a norm al ageing process (Brow n et al 1991, 2009). A d elayed
d iagnosis o cervical m yelopathy is requ ent am ong prim ary
care p hysicians (Behrbalk et al 2013) and other rst-line
p ractitioners.
Cervical rad icu lop athy is d e ned as an abnorm ality o a
nerve root, w hich originates in the cervical sp ine (Polston
2007). It has a p u rported prevalence o 3.3 cases per 1000
p eop le (Wainner et al 2003) to 83.2 p er 100 000 (Polston 2007),
a ecting m en m ore requ ently than w om en (Rad hakrishnan
et al 1994). The cond ition has a peak annu al incid ence o 2.1
cases per 1000, and occu rs m ost com m only in the ou rth and
th d ecad es o li e (Wainner & Gill 2000). The seventh (60%)
and the sixth (25%) cervical nerve roots are the m ost com m on
regions a ected (Malanga 1997).
The natural history o m yelorad icu lopathy is u nclear – the
signs and sym p tom s are inconsistent and the p athop hysiolog-
ical m echanism s are m u lti actorial in natu re. The prevalence
o m yelorad icu lopathy is unknow n – althou gh p atients w ith
m ovem ent d isord ers su ch as cerebral p alsy, torticollis and
Tou rette synd rom e d em onstrate accelerated p rop ensity or

sp ond ylosis and m yelorad icu lop athy (Wong et al 2004).
In ectiou s cond itions su ch as schistosom iasis are the m ost-
investigated d isease processes associated w ith m yelorad icu -
lopathy in the literature.
Cervical m yelop athy, cervical rad icu lop athy and cervical
m yelorad icu lop athy m ay cau se signi cant p ain and d ebilita-
tion and are the ocu s o this chap ter. In p articu lar, w e p lan
to ocu s on correct d iagnosis, p rognosis and cu rrently recom -
m end ed treatm ent o each cond ition.
Review of Proposed Pathology and
Patho-Biomechanics
Myelop athy, rad icu lop athy and m yelorad icu lop athy involve
both structural and m ovem ent-related abnorm alities. Pro-
gressive d egenerative changes resu lt structurally in d isc
height losses and red u ction o sp ace in the sp inal canal and
intervertebral oram ina. Stru ctural changes to the interverte-
bral d iscs, ligam ents and capsule lead to viscoelastic losses
and m ovem ent abnorm alities (Pope 2001). In particular,
f exion–extension m ovem ents m ay cau se a variety o neuro-
logical sym ptom s in severe d egenerated cond itions (Wilson
et al 1991). Du ring extension, the spinal canal shortens
and narrow s becau se o in old ing o ligam ents. The ligam en-
tou s in old ing cau ses d orsolateral encroachm ent in the
canal. In ad d ition, the d isc m ay bu lge p osteriorly in selected
situ ations, u rther red u cing sp ace d orsolaterally. These stru c-
tu ral changes m ay lead to kinetic changes su ch as d ecreased
m ovem ent, com p ression o d orsolateral nerve roots or
nerve root ganglia, com p ression o the sp inal cord and p ain
(Pop e 2001).
Cervical sp ine m yelop athy is hallm arked by the stenotic
encroachm ent o the cervical sp inal cord and correspond ing
neu rological changes (Brow n et al 2009). This encroachm ent
m ay lead to stru ctu ral and vascu lar changes and originates
rom sagittal narrow ing o the spinal canal. The narrow ing
m ay cau se com p ression o the sp inal cord and o ten originates
rom : (1) osteop hytes second ary to d egeneration o interver-
tebral joints, (2) sti ening o connective tissues su ch as the
ligam entum f avu m at the d orsal aspect o the spinal canal,
w hich can im pinge on the cord by ‘bu ckling’ w hen the
spine is extend ed , (3) d egeneration o intervertebral d iscs
together w ith subsequ ent bony changes, and (4) other d egen-
erative connective tissu e changes (Wong et al 2004). N on-
d egenerative, stru ctu ral-based cond itions m ay be associated
w ith syringom yelia, an arachnoid cyst, a tu m ou r or epid ural
lipom atosis (Du rrant & Tru e 2002).
Dynam ic m ovem ents o the sp inal cord are regu lated by
the sp inal colu m n and the anchoring elem ents o the sp inal
cord . The p rim ary anchoring elem ents are the d entate liga-
m ents and the lu m term inale (Durrant & Tru e 2002). In
norm al su bjects, length changes o the sp inal cord range rom
4.5 to 7.5 cm , w ith f exion increasing tension in the sp inal cord
and extension d ecreasing tension (Breig 1978). Spinal cord
com p ression occu rs rom a nu m ber o m echanism s, m ost
notably the riction that is p resent rom d egenerative changes
d u ring m ovem ents o extension and f exion. Ventral osteo-
phytes can prevent m ovem ent o the sp inal cord up w ard s and
d ow nw ard s d uring physiological m otions (Bartels et al 2007).
Furtherm ore, thickening o tissu es and bony changes, w hich
Clinical signs and symptoms 119
results in a spond ylitic bar, increases the riction placed upon
the sp inal cord d u ring m ovem ents and cau ses p erm anent
d am age (Bartels et al 2007).
Cervical rad icu lop athy is cau sed by a cascad e o events
that lead s to nerve root d istortion, intraneu ral oed em a,
im p aired circu lation and ocal nerve ischaem ia, a localized
inf am m atory response and altered nerve cond u ction
(Truu m ees & H erkow itz 2000). The localized inf am m atory
response is stim u lated by chem ical pain m ed iators w ithin the
d isc, w hich m ay incite the prod u ction o inf am m atory
cytokines, su bstance P, brad ykinin, tu m ou r necrosis actor-α
and prostagland ins (Albert & Mu rrell 1999; Rhee et al 2007).
These chem ical p ain m ed iators are not typically present in
chronic d isc lesions (Durrant & Tru e 2002). Along w ith the
p rod u ction o chem icals, the m em brane su rrou nd ing the
d orsal root ganglion, w hich is m ore perm eable allow ing a
local inf am m atory response, m ay contribute to cervical rad ic-
u lop athy (Rao & Fehlings 1999).
The m ost com m on com p ressive causes o cervical rad icu-
lop athy are d isc herniation and d egenerative spine com po-
nents su ch as osteop hytes, acet joint hyp ertrop hy and
ligam ent hyp ertrophy (Truu m ees & H erkow itz 2000). Disc
herniation occu rs w hen nu clear m aterial rom an acu te so t
d isc herniation im pinges on a nerve root either posterolater-
ally or intra oram inally (Rhee et al 2007). The d egenerative
cau ses are associated w ith a loss o d isc height and a ‘hard
d isc’ bu lging w ith resu ltant com pressive elem ents su ch as the
ligam ents (Albert & Mu rrell 1999) and osteophytes (Rhee et al
2007). Location-w ise, anterior causes (so t or hard d isc hernia-
tion and osteop hytes rom the u ncinate p rocesses) are the
m ost com m on cau se o rad icu lar sym p tom s (Rhee et al 2007).
Other cau ses inclu d e ischaem ia, trau m a, neop lastic in ltra-
tion, sp inal in ections, p ost-rad iation, im m u ne-m ed iated
d iseases, lipom a and congenital d isord ers (Tru u m ees &
H erkow itz 2000).
Cervical m yelorad icu lop athy is believed to occu r d u ring
chronic sp ond ylosis and rep etitive com p ressive d am age to
the cervical sp inal cord and roots, bu t m ay also occu r acu tely
u p on a f exion / extension inju ry (Lew is et al 2008). Com pres-
sion m ay resu lt rom anterior sp ond ylotic sp u rs, p osterior
in old ing o ligam ents, or both (Frank 1993). Changes m ay
involve d em yelination, vascu lar com prom ise and inf am m a-
tion o the nerve roots.
Clinical Signs and Symptoms
Myelopathy
Myelop athy is characterized by a variable d istribu tion p attern
(Brow n et al 2009) and m ay involve clinical nd ings in the
low er extrem ities rst, w ith su bsequent gait-related changes,
w eaknesses o the legs and spasticity (Bartels et al 2007;
H arrop et al 2007). Gait d isturbances are associated w ith
u p p er m otor neu ron changes involving d ys u nctional corti-
cosp inal and sp inocerebellar tracts. Later, low er m otor neu ron
nd ings in the u p p er extrem ities m ay occu r, su ch as loss o
strength, atrop hy and d i cu lty in ne nger m ovem ents
(Cook et al 2007, 2009; H arrop et al 2007).
Ad d itional signs and sym ptom s o cervical m yelopathy
m ani est as p ain in the cervical, u p p er qu arter region or
 120 PART 2 • 11 • Differential diagnosis and treatment of cervical myelopathy
shou ld er, w id esp read nu m bness, p araesthesia, and sensory
and ataxic changes o the low er extrem ities (Polston 2007).
Find ings m ay includ e tetrasp asticity (Dvorak 1998), gait-
related clum siness (Dvorak 1998), sp asticity, hyper-ref exia
(Crand all & Batzd or 1966) and the presence o p rim itive
ref exes (H aw kes 2002). Other clinical nd ings ind icative o
p rogressive d ecline includ e acqu ired sp astic p araparesis
(H aw kes 2002), tetrap aresis and paraparesis (Montgom ery &
Brow er 1992). Becau se the signs and sym ptom s are o ten
sequ ential, w eakness and sti ness o the legs (Ad am s &
Victor 1999) typ ically preced e pain and the occasional
nd ings o bow el and blad d er changes (Thongtrangan
et al 2004).
There is a d istinct p ossibility o m ixed p resentation o signs
and sym p tom s w ith m yelop athy. Ref exes and sensibility
changes m ay actu ally be d ep ressed at the level o com p res-
sion (C5–C8), w ith hyp er-ref exia at the levels below the lesion
(Brow n et al 2009). In ad d ition, uncom m on sym p tom s m ay be
p resent w ith m yelopathic cond itions, includ ing restless legs
second ary to loss o d escend ing inhibition o the corticosp inal
tract, nau sea, d izziness and d ysp hagia, w hich can occu r rom
com p ression o vertebral artery (Brow n et al 2009).
Radiculopathy
For cervical rad iculop athy, neurological sym p tom s m ay lead
to p ain, m otor w eakness or sensory d e cits along the a ected
nerve root (Rao & Fehlings 1999; Polston 2007; Rhee et al
2007). Depend ing on the nerve root a ected , sym ptom s m ay
exist concurrently in the neck, shou ld er, u pper arm and
orearm (Polston 2007). O ten, p ain and sensibility changes
are not consistent and m ay resu lt in a d u ll ache to a severe
bu rning pain in the neck and arm . Pain is typically noted in
the m ed ial bord er o the scap u la and shou ld er, w hich can
p rogress d ow n the ip silateral arm and hand along the sensory
d istribu tion o the involved nerve root (Wol & Levine 2002).
The pain m ay not be localized , how ever, becau se m u ltiple
nerve roots can cau se sim ilar d istribu tion p atterns (Ellenberg
et al 1994).
Motor w eakness associated w ith rad icu lop athy m ay
p rovid e a variety o clinical scenarios and is associated w ith
sp eci c nerve root levels (Polston 2007). Sp eci c nerve root
w eakness typically presents in the ollow ing patterns: scapu -
lar w eakness w ith C4; shou ld er abd u ction or orearm f exion
w eakness w ith C5; w rist extension / su pination w ith C6;
tricep s or w rist f exion / p ronation w ith C7; and nger
f exors / interossei w ith C8 (Tsao et al 2003). Another stu d y
(Tsao et al 2003) noted that m otor w eakness, o ten w ith as-
cicu lations, is present in 61% to 68% o patients. Ad vanced
cervical rad icu lop athy cases m ay p resent w ith m u scle w asting
and ascicu lations (Polston 2007). H end erson and colleagu es
(1983) noted that tricep s w eakness d u e to C7 rad icu lopathy
w as p resent in 37% o the 846 su bjects, w hereas biceps w eak-
ness w as p resent in 28%.
Sensibility changes (sensation variations) o the a ected
nerve roots m ay help to localize the level o the lesion. C4
nerve root d istribu tion tend s to a ect the shou ld er and u p p er
arm , C5 nerve root d istribu tion the lateral asp ect o the arm ,
C6 nerve root d istribu tion the lateral asp ect o the orearm ,
hand and thu m b, C7 nerve root d istribu tion the d orsal lateral
orearm and third d igit, and C8 nerve root d istribution the
m ed ial orearm , hand and ou rth and th d igits (Chien
et al 2008).
Cervical rad icu lop athy typ ically p resents w ith d im inished
d eep tend on ref exes (m uscle stretch ref ex). Such ref exes are
an involu ntary response, w hich o ers an objective assessm ent
o neu rological im p airm ent (Du rrant & Tru e 2002). Loss o
d eep tend on ref exes is usually said to be the m ost reliable
clinical nd ing (Marshall & Little 2002) and has been noted
in 70% o the cases (Tsao et al 2003). Generally, the d ecline in
ref exes ollow s a pred ictable rad icu lar pattern.
Myeloradiculopathy
The signs and sym ptom s o cervical m yelorad iculop athy lead
to a com p lex clinical p resentation (Baba et al 1998). In m ost
cases, the p resentation o m yelorad icu lop athy involves both
the card inal signs and the sym p tom s o the tw o sep arate d is-
eases. For exam ple, a com m on presentation com p rises rad icu-
lar sym ptom s in the arm (pain and w eakness) and m yelop athic
sym p tom s in the legs (gait d istu rbances, loss o p osition and
vibratory sense, and sp asticity) (Frank 1993).
The challenges occu r w hen clinical signs and sym ptom s
overlap . In these selected cases, w hich typ ically involve highly
a ected , chronic sp ond ylitic changes, d i erentiation o the
cond ition is less p robable.
Current Best Evidence with
Regard to Diagnosis
Cervical myelopathy
Patient history
In m ost cases, m yelopathic changes are slow and p rogressive
(Masd eu et al 1997). Initial sym ptom s are typically vagu e and
are o ten m istaken as changes associated w ith ‘old age’. O ten,
p atients w ill ind icate p roblem s a ter a p eriod o rest or inac-
tivity (Bed narik et al 2004). Gait p roblem s are the rst sym p-
tom s associated w ith m yelop athy bu t it is o ten the m otor
changes (su ch as sp asticity, w eakness and clu m siness o the
arm s and hand s) that w arrant the carrying ou t o w ork-u p
(Masd eu et al 1997; Bed narik et al 2004). Tw enty to sixty-tw o
p er cent o ind ivid u als w ith cervical m yelop athy w ill d eterio-
rate by 3–6 years, w ith average u nctional d eclines o 8% by
1 year and 23% by 4 years (Fehlings et al 2013).
Myelop athic changes occu r either a ter a p rolonged bou t
o sp ond ylitic changes or a ter trau m a in p atients w ith rela-
tively recent d egenerative changes. Most p atients are old er,
have exp erienced range-o -m otion (ROM) lim itations or p ain
w ith selected p ositions su ch as end -range rotation and exten-
sion, and have rou tinely had bou ts o rad icu lop athy in the
p ast (Bed narik et al 2004). In act, the strongest p red ictor o
utu re m yelopathy is a history o rad iculopathy (Bed narik
et al 2004).
Sensory changes are inconsistent bu t generally occu r later
m ore o ten than early, and in the u p p er extrem ities m ore than
the low er extrem ities (Masd eu et al 1997). Initial sym p tom s in
m ild er cases can start w ith hand clu m siness or nu m bness,
w hich m ay be u nilateral at rst, be ore gait abnorm alities are

noted (Polston 2007). H and clu m siness or num bness involves
less sensory loss than m otor d ys u nction and is, in essence,
an apraxia o the d istal u pp er extrem ities and hand s (Good
et al 1984). Dim inished vibration sense is o ten seen in the
low er extrem ities (Masd eu et al 1997).
Other sym p tom s m ay inclu d e d ecreased ap p reciation o
p ain, hot or cold , d ecreased response to sharp or d u ll p ain,
and restless legs (Brow n et al 2009). Long-term cases m ay
involve w asting or asciculation o the biceps (H arrop et al
2007). In very rare cases, bow el and blad d er d istu rbances m ay
occu r; p resence o u rinary retention, d ribbling incontinence
or ecal incontinence shou ld raise concern o a cond ition other
than m yelop athy su ch as cau d a equ ina synd rom e (Masd eu
et al 1997).
Outcome measures
There are a nu m ber o clinician-scored ou tcom e m easu res or
m yelop athy rep resented in the literatu re. The N u rick score
com p rises ve d e nitive exp lanations o the e ects o the
cond ition and is scored rom 0 to 5 (0 representing root
involvem ent bu t no evid ence o spinal cord d isease, and 5
representing chair-bound or bed rid d en statu s). H ow ever, it
su ers rom a lack o resp onsiveness as each grad e ref ects
su bstantial ju m p s in clinical cond ition (N urick 1972).
The m ost-used score app ears to be the Japanese Orthop ae-
d ic Association (JOA) score, w hich is e ective at m easu ring
changes in p atients’ cond itions (Vitzhu m & Dalitz 2007). The
JOA is a d isease-speci c, physician-oriented scale d esigned to
assess the neu rological statu s o a p atient that allow s su rgeons
to m easu re p re- and p ost-intervention changes. The scale
involves a num ber o constructs inclu d ing scoring o eed ing,
u p p er extrem ity shou ld er and elbow u nction, low er extrem -
ity gait capabilities, sensory involvem ents, and bow el and
blad d er control (Dalitz & Vitzhu m 2008).
The Europ ean Myelopathy Score (EMS) is a d isease-speci c,
physician-oriented scale that involves a nu m ber o constru cts
includ ing gait u nction, w alking d ys unction, clim bing stairs,
blad d er and bow el u nction, hand w riting, eating, d ressing,
and activities associated w ith sensory loss and proprioception
(Vitzhu m & Dalitz 2007). The scale is m ore sensitive to change
than the JOA and the N u rick scores, bu t is not rou tinely u sed
in clinical practice.
Physical examination
Observation
Diagnosis o m yelopathy is challenging, particularly in the
early stages o the cond ition, as sym ptom s m ay present vari-
ou sly as hyp er-ref exia (MacFad yen 1984; Polston 2007),
clu m siness in gait (Matsu d a et al 1991; Bed narik et al 2004),
neck sti ness (Montgom ery & Brow er 1992; Chiles et al 1999),
shou ld er p ain (Lev et al 2001), paraesthesia in one or both
arm s or hand s (Good et al 1984) or rad iculopathic signs
(N u rick 1972; Montgom ery & Brow er 1992).
Active and passive movements
Both active and p assive neck m ovem ents are o ten lim ited –
sp eci cally rotation, sid e-f exion and extension. ROM loss in
the u p p er extrem ity is ou nd inconsistently. Sym p tom s m ay
or m ay not be rep rod u ced d u ring m ovem ents. In som e cases,
Current best evidence with regard to diagnosis  121
extension triggers neurological sym ptom s d ow n the thoracic
sp ine, bu t this cond ition typ ically occu rs only in p atients w ith
chronic sp ond ylar changes.
Gait sym p tom s associated w ith m yelop athy are slow
and p rogressive. These m ay involve d i cu lty in initiating
m ovem ents, w alking briskly and a tend ency to trip (Masd eu
et al 1997). Other gait changes includ e d evelopm ent o p ara-
p aresis, d escribed as heaviness o legs, trem bling and cram p -
ing o thigh and cal m u scles, and d i culty in negotiating
step s, cu rbs and getting in and ou t o vehicles (Masd eu
et al 1997).
On som e occasions, sym p tom s m ay inclu d e hyp er-ref exia,
w hich in severe cases m ay involve bilateral clonus and exten-
sor p lantar ref exes. Pathological ref exes are generally p resent
only in p atients w ith long-stand ing, chronic d egenerative
cond itions (Brow n et al 2009). Upper extrem ity ref ex changes
are less consistent and o ten d ep end on the site o structu ral
im pairm ent (Masd eu et al 1997). H igher level cervical involve-
m ent can cau se hyp er-ref exia throu ghou t the u p p er and
low er extrem ities. Mid or low er levels o cervical involvem ent
m ay resu lt in hyp oref exia (rad icu lar sym p tom s) at levels
above the site o the inju ry and hyp er-ref exia below these
levels.
Clinical tests su ch as single leg stance, tand em w alking and
basic coord ination exercises w ill be challenges to patients
w ith m yelopathy. Coord ination testing such as nose-to-hand
tests, braid ing, Frenkel’s test and arm rolling are o ten p oorly
p er orm ed in p atients w ith late-stage m yelop athy. Patients
m ay overshoot targets, d em onstrate p oor d exterity d u ring
activities and stru ggle w ith ne m otor tasks.
Conf rmation tests
The clinical exam ination or m yelopathy inclu d es the u se o
H o m ann’s test (Em ery et al 1998; Cook et al 2007, 2009),
d eep tend on ref ex testing (Denno & Mead ow s 1991; Cook
et al 2007, 2009), inverted supinator sign (Estanol & Marin
1976), su prapatellar qu ad riceps ref ex testing (d e Freitas &
And re 2005), hand w ithd raw al ref ex testing (Denno &
Mead ow s 1991), Babinski sign (Ghosh & Prad han 1998) and
clonu s (Young 2000). N early all o these tests are sp eci c (as
op p osed to sensitive) and are u se u l or ru ling in a su sp ected
cond ition rather than ru ling ou t the cond ition. Desp ite the act
that m ost o these tests are rou tinely u sed to screen or m ye-
lop athy, the inherent d iagnostic accuracy o each test lim its
its e ectiveness or screening.
Hoffmann’s test or ‘sign’ consists o involu ntary f exion o
a varied com bination o the neighbou ring ngers and / or
thu m b, and is com m only u sed to d etect an u p p er m otor
neu ron d ys u nction (Em ery et al 1998). The test is p er orm ed
by stabilizing the m id d le nger proxim al to the d istal inter-
p halangeal joint and striking its ngernail w ith the op p osite
hand . A nu m ber o stu d ies have analysed the sensitivity and
sp eci city o the test, and have d em onstrated that it is gener-
ally a sp eci c test, having yield ed sensitivity valu es ranging
rom 25% to 68% (Glaser et al 2001; H ou ten & N oce 2008;
Cook et al 2009) (Fig. 11.1).
The inverted supinator sign is a C7 response d u ring a d eep
tend on ref ex assessm ent o C6 (brachiorad ialis). The test is
per orm ed in the sam e ashion as a brachiorad ialis d eep
tend on ref ex test and the resp onse or a p athological nd ing
involves nger f exion and / or elbow extension, as against a
 122 PART 2 • 11 • Differential diagnosis and treatment of cervical myelopathy
Figure 11.1 Hoffman’s test.
Figure 11.2 Inverted supinator sign.
norm al resp onse o w rist p ronation and / or elbow f exion. To
ou r know led ge, the test has been investigated only once and
has d em onstrated a sensitivity o 61% and sp eci city o 78%
(Cook et al 2009) (Fig. 11.2).
The Babinski test involves the elicitation o an extensor toe
sign d u ring stroking o the p lantar asp ect o the oot. The test
is also m ore sp eci c than sensitive, d em onstrating a sensitiv-
ity o 33% (H ou ten & N oce 2008) and o 24% in tw o m ore
recent stud ies (Cook et al 2009). Cook et al (2009) ou nd the
Babinski sign to have the best d iagnostic valu e o all the con-
rm ation tests, p rovid ing a p ositive likelihood ratio (+LR) o
4.0 (1.1–16.6).
A nd ing o rep etitive beats o three or m ore a ter striking
the anterior asp ect o the p atient’s oot w hilst sitting is associ-
ated w ith a positive nd ing o clonu s. Clonu s has been inves-
tigated in tw o stu d ies; how ever, both o these have
d em onstrated p oor sensitivity (10% in H ou ten & N oce 2008,
and 14% in Cook et al 2009).
A clinical p red iction ru le consisting o the H o m ann’s test,
Babinski’s sign, the inverted su p inator sign, age > 45 years
and any notable gait abnorm ality w as associated w ith a d iag-
nosis o cervical sp ine m yelop athy (Cook et al 2010). I none
o the sym p tom s w ere p resent, the p ost-test likelihood o the
cond ition w as less than 9%. I three o the ve variables w ere
p resent, the p ost-test likelihood o the cond ition increased to
94%. At p resent, how ever, this clinical pred iction ru le has not
been valid ated ind epend ently.
Cervical radiculopathy
Patient history
It is im portant to d eterm ine the ind ivid ual’s m ain com -
p laint – or exam ple, nu m bness, w eakness, or location o
sym p tom s (Wol & Levine 2002). I p ain is a com plaint then
a pain d raw ing is bene cial to establish its pattern and loca-
tion. A p ain d raw ing allow s the clinician to d eterm ine w hether
the p ain rad iates and , i so, the d istribu tion o the sym p tom s
(H onet & Puri 1976). In ad d ition to id enti ying the m ain com -
p laint, it is im p ortant to isolate any activities or head m ove-
m ents that trigger the concord ant sym p tom s. One m u st also
check or p resence o concom itant sym p tom s su ch as gait
changes, or bow el, blad d er or low er extrem ity cond itions that
are su ggestive o m yelopathy, and ad d ress w hether there
w ere any sim ilar episod es in the past and w hether any treat-
m ent w as p rovid ed or the p resent and / or p ast ep isod es.
Id enti cation o the d em ographic and social history inclu d ing
age, sex, stress, occup ation, recreational activities and nicotine
u sage is su ggested (H onet & Pu ri 1976).
Outcome measures
There are no speci c outcom e m easures or cervical rad icu -
lop athy. The N eck Disability Ind ex (N DI) is the m ost re-
qu ently u sed u nctional ou tcom e tool or cervical-related
d isabilities. This outcom e assessm ent tool w as created by
m od i ying the Osw estry Disability Ind ex and is extrem ely
reliable. The N DI d eterm ines the extent o d isability and is
d esigned to m easure activity lim itations d u e to neck pain and
d isability (Pietrobon et al 2002). It has been u sed regu larly in
p reviou s stu d ies that have investigated u nctional statu s
(Sm ith 1979).
A visu al analogu e scale (VAS) or a nu m eric analogu e scale
is a com m on scale used to quanti y p ain and has historically
been u sed as an outcom e tool (Dow nie et al 1978; Langley &
Shep peard 1985). The VAS or pain in the cervical spine d oes
have a test–retest reliability o 0.95 to 0.97 (McCorm ick et al
2003) and MCID (m inim al clinically im p ortant d i erence) o
12 ± 3 m m (Kelly et al 2005). The VAS involves quanti cation
o p ain on a nu m bered line (i.e. rating the level o p ain he / she
is currently experiencing as 0–100: 0 ind icates no p ain and 100
ind icates the w orst pain im aginable). The scale is easy to
ad m inister, but lacks any d im ensionality other than intensity
(Szp alski & Gu nzbu rg 2001).
Physical examination
Observation
Patients w ith cervical rad icu lop athy w ill o ten hold their
head aw ay rom the a ected sid e and avoid rotation to
that sid e (Wol & Levine 2002). In som e cases, patients m ay
crad le their a ected arm or p lace it behind or on top o their
head to red u ce the tension on the nerve root (David son
et al 1981).
Active and passive movements
All planes o m otion o the cervical spine shou ld be assessed
w ith active and passive m ovem ents. The active ROM is typi-
cally d ecreased , and sp eci cally rotation to the a ected sid e
(Wainner et al 2003) and extension. ROM assessm ent is
 Current best evidence with regard to diagnosis  123

typ ically reliable and is consid ered a u se u l clinical m easu re

(Fletcher & Band y 2008). Resp onses to look or inclu d e any
m ovem ents associated w ith the p ain / sym p tom s noted
d u ring the history portion o the exam .

Conf rmation tests

Neurological testing
Derm atom e testing involves exam ination o m otor u nction,
sensibility changes and d eep tend on ref ex m od i cations
along a nerve root d istribu tion. Cervical nerve roots exit
above their corresp ond ingly nu m bered p ed icles (e.g. C6 exits
betw een C5 and C6 vertebrae) w ith the exception o the C8
nerve root, w hich exits above T1. With in requ ent exceptions,
d isc herniation or som e other space-o end ing stru cture at a
speci c site (e.g. C4–C5) w ill a ect the nerve root rom that
site (Rhee et al 2007).
For tw o prim ary reasons, it is im portant to note that the
absence o rad iating sym ptom s in a d erm atom al d istribu tion
d oes not ru le out the presence o nerve root com pression
(Rhee et al 2007). First, the presence o u pper trap ezius or Figure 11.3 Spurling’s sign.
interscapu lar pain m ay be the extent o the sym ptom s or that
patient (Rhee et al 2007); as the cond ition progresses, sym p -
tom s m ay or m ay not m igrate to the u p p er arm . Second ly, the
clinical tests associated w ith m otor testing, sensibility testing
and d eep tend on ref ex testing have rou tinely d em onstrated
very low sensitivity valu es, w hich su ggests that the clinical
nd ings m ay be below the threshold o these p articu lar tests
(Cook & H eged u s 2008). The m ost com m on nerve roots
a ected are C5, C6, C7, C8 and T1. Sp eci c nerve roots m ay
d em onstrate pred ictable patterns o m otor u nctional losses,
sensory changes or ref ex changes.
A m anu al m u scle test is p er orm ed to id enti y m inim al
w eakness along a m yotom e d istribu tion to d eterm ine a local
nerve root involvem ent. Accord ing to Yoss et al (1958), a
m anu al m u scle test o ers greater sp eci city than either ref ex
or sensory testing, and single-root-level involvem ent can be
d iagnosed clinically 75–80% o the tim e. The m anual m u scle
Figure 11.4 Cervical distraction test.
tests m ay best be initiated in a gravity-ind u ced p osition, w ith
testing o the u ninvolved lim b rst in ord er to com p are both
sid es. The clinician shou ld look or su btle changes and ap p ly o rad icu lar p ain are either rep rod u ced or w orsen. Accord ing
the orce p roxim al to the next d istal joint (Ellenberg et al 1994; to H onet et al (1976), Sp u rling’s sign d em onstrates high sp e-
Malanga 1997). The ollow ing grad ing o 0 to 5 is recom - ci city and low sensitivity or cervical rad icu lop athy (Cook &
m end ed : 0 / 5 no m ovem ent; 3 / 5 antigravity; 5 / 5 norm al H eged u s 2008) (Fig. 11.3).
(H onet & Pu ri 1976). The cervical distraction test is another test o ered or cer-
The grad ing o d eep tend on ref exes (DTR) ranges rom 0 vical rad icu lop athy assessm ent. The test is p er orm ed w ith
(absent) to 4 (clonu s, very brisk). Ref ex abnorm ality is ound the p atient su p ine and the clinician su p p orting the head w ith
prim arily rom nerve root involvem ent o C5 through to C8 a chin crad le grip. The clinician app lies a traction orce to the
(Polston 2007; Chien et al 2008). The DTR is tested w ith the cervical area. I sym p tom s are red u ced w ith this test, it is
m u scle o the tend on relaxed and the clinician ap p lying a consid ered p ositive. Viikari Ju natu ra et al (2000) noted a sp e-
slight stretch to the tend on, ollow ed by tap p ing the tend on ci city o 100, w ith a QUADAS score o 11 or ruling in cervi-
w ith a ref ex ham m er. Ref ex abnorm ality o the d eltoid , cal rad icu lop athy (Fig. 11.4).
bicep s and brachiorad ialis is noted rom C5 and C6 involve- Another test to consid er is the upper limb tension sign
m ent, the tricep s rom C7, and the nger f exors rom C8 (ULTT). Accord ing to Cook and H eged us (2008), this test is
(H onet & Pu ri 1976). excellent as a screening test or ruling out cervical rad icu lopa-
thy. The test is p er orm ed w ith the p atient su p ine, the orearm
Provocation tests su p inated , and the w rist and ngers extend ed . Ulnar d evia-
There are only a ew provocation tests that are typically per- tion is ap p lied . I no sym p tom s are rep rod u ced the clinician
orm ed w hen assessing or cervical rad icu lopathy. Spurling’s then extend s the elbow. I sym p tom s are still not rep rod u ced
sign com bines the m otions o cervical lateral bend ing and then lateral f exion o the cervical sp ine is p er orm ed . Rep ro-
com p ression, w hich red u ces sp ace w ithin the oram inal area d uction o concord ant, asym m etric sym p tom s in the d istal
(Tsao et al 2003). The test is consid ered positive i sym p tom s area d enotes a positive test (Fig. 11.5).
 124 PART 2 • 11 • Differential diagnosis and treatment of cervical myelopathy
Figure 11.5 Upper limb tension sign.
Wainner et al (2003) d evelop ed a clinical p red iction ru le or
ru ling in cervical rad icu lop athy. The com bined tests inclu d e
Sp u rling’s, ROM < 60°, the cervical d istraction test and ULTT.
When all ou r tests are p ositive the sp eci city w as 99%, w ith
an LR+ o 30.0 (QUADAS = 10).
Cervical myeloradiculopathy
Patient history
The m ost com m on reports o sym ptom s inclu d e su btle
neck p ain, rad icu litis and rad icu lar p ain in the arm s, and
trou ble w ith gait or coord ination o the low er extrem ities.
Electrop hysiological evid ence o cervical rad icu lop athy and
rad iographic evid ence o cervical m yelopathy have been
show n to p red ict u tu re d isease p rogression and m ay w arrant
su rgical intervention (Fehlings et al 2013). In chronic cond i-
tions, p atients m ay also ind icate d i cu lty w ith u p p er extrem -
ity coord ination activities. Most o the rep orted signs and
sym p tom s are analogou s to concom itant m yelop athy and
rad icu lopathy. Other than in ectiou s cond itions, m ost m yelo-
rad icu lopathic sym ptom s are insid ious, progressive and have
a chronic presentation.
Physical examination
Positive nd ings m ay occu r w ith stenotic m ovem ents o rota-
tion, sid e-f exion and extension. Most p atients w ill exhibit
p roblem s w ith gait exam ination but typ ically only d uring
higher level gait changes su ch as single-legged stance, tand em
w alking and Rom berg positions. Coord ination losses m ay be
p revalent in the low er and , p otentially, u pp er extrem ities,
w ith sensation changes m ost com m on in the u pper
extrem ities.
Outcome measures
There are no exclu sive outcom e m easu res or m yelorad icu -
lop athy, thu s the sam e tools u sed or m easu rem ent o
m yelop athy (e.g. N u rick scale, JOA score and EMS) and rad ic-
u lop athy (N DI and VAS) are u sed to evalu ate changes in
p atients’ cond itions.
Conf rmation tests
There are no d ed icated clinical tests d esigned to id enti y m ye-
lorad icu lopathy. Typ ically, the sam e tests used to con rm
m yelop athy (e.g. H o m ann’s test, inverted su p inator sign)
and rad iculopathy (Spu rling’s sign, cervical d istraction test)
are u sed in the clinical con rm ation phase.
Imaging
Plain f lm radiograph
Plain lm rad iograp hy is u se u l in id enti ying stenosis and
the extensiveness o d egenerative joint d isease (Brow n et al
2009). In ad d ition, rad iography is u sed to d eterm ine canal
stenosis and , at present, 13 m m or less o anterior–posterior
(sagittal d iam eter) w id th is consid ered a risk actor in the
d evelopm ent o m yelopathy (Brow n et al 2009). N evertheless,
sm aller p atients m ay have d ecreased d iam eters and hence this
valu e m ay not be as u se u l as a ratio m easu re (Brow n et al
2009). Rad iographs are o ten u sed to d eterm ine the extent o
d egeneration.
Magnetic resonance imaging and computed
tomography scan
Magnetic resonance im aging (MRI) is consid ered the best
im aging m ethod or m yelopathy becau se it expresses the
am ount o com p ression p laced on the spinal cord (Fuku shim a
et al 1991), and d em onstrates relatively high levels o sensitiv-
ity (79–95%) and sp eci city (82–8%) (LR+ 4.39 to 7.92; LR−
0.06 to 0.27) in id enti ying selected abnorm alities su ch as
sp ace-occu p ying tu m ou rs (Fujiw ara et al 1989), d isc hernia-
tion (Yousem et al 1992) and ligam entous ossi cation (Mizu no
et al 2001). The MRI provid es the ability to rule ou t a tum our
or syrinx (f u id - lled cavity that d evelop s in the sp inal cord )
and d etailed view s o the spinal cord , intervertebral d isc, ver-
tebral osteop hytes and ligam ents – all structu res that p oten-
tially com p ress the sp inal cord (Gross & Benzel 1999).
Fu rtherm ore, MRI nd ings have been show n to correlate w ith
p reop erative severity o cervical com p ressive m yelop athy
and prognosis a ter surgery (Ono 1977; Yousem et al 1992).
Patients w ith ad vanced cord changes o ten d em onstrate p oor
ou tcom es a ter su rgery and those w ith only m inor com p res-
sion tend to d em onstrate air recovery or retard ation o p ro-
gression o sym p tom s (Yoshim atsu et al 2001).
Changes associated w ith m yelop athy m ay lead to anterior–
posterior w id th red u ction o the sp inal cord , cross-sectional
evid ence o cord com pression, or obliteration o the subarach-
noid sp ace (Fu ku shim a et al 1991). At present, there are no
d e nitive objective nd ings on MRI consistently d escribed
by rad iologists that are ref ective o m yelopathy, w ith the
exception o m yelom alacia, w hich is id enti ed through
changes in signal intensity to the cord . Su ch changes have
been d escribed as the m ost appropriate ‘gold stand ard ’
or con rm ation o a spinal cord com pression m yelopathy
(Fu ku shim a et al 1991), bu t are also present only in ad vanced
chronic cases (Fig. 11.6).
MRI nd ings are not conclu sively ind icative o cervical
m yelop athy (Bed narik et al 2004). Cord -related changes and
su bsequ ent sym p tom s rom cervical m yelop athy overlap
w ith other types o intrinsic m yelopathy, su ch as m ultiple

Figure 11.6 MRI changes re ecting cord compression and myelomalacia.
sclerosis, syrinx and am yotrop hic lateral sclerosis. Care u l
screening o the MRI, inclu d ing the p resence o T2-w eighted
changes, is cru cial to show clear, relevant sp inal cord com -
p ression (Je reys 2007). False positives are com m on because
cord com p ression alone d oes not d irectly equ ate to clinical
signs and sym p tom s (Estanol & Marin 1976). Diagnosis is
u su ally m ad e rom a d etailed history o p rogressive p atient
sym p tom s, w eakness and hyp er-ref exia on exam ination,
and clear com p ression o the spinal cord at an ap prop riate
sym ptom atic level on the MRI scan, w ith or w ithou t T2
changes. Since T2 MRI changes u sually d o not abate w ith
su rgery (Wad a et al 1999), these changes are ind icative
m ore o d am age than o reversible ischaem ia. A d ed icated
criterion stand ard su ch as the singu lar u se o an MRI
scan u sed to d eterm ine m yelop athy d oes not exist (Su ng &
Wang 2001).
The MRI has d em onstrated su periority in id enti cation o
a herniated nu cleu s pu lposu s (Wilm ink 2001) and structural
changes rom sp ond ylosis (Wilm ink 2001). It has d em on-
strated com p arable nd ings w ith m yelograp hy and cervical
rad icu lopathy m yelography (Larsson et al 1989), bu t m ay
exhibit lim itations in id enti ying the extent o root com p res-
sion (Barlett et al 1996).
It is d i cu lt to d i erentiate a so t and a hard d isc hernia-
tion throu gh im aging m ethod s (Rhee et al 2007). Speci city o
the MRI or nerve root com p ression is su sp ect; how ever, it
id enti es abnorm al nd ings in 10% o su bjects w ho w ere
asym p tom atic (Bod en et al 1990). Sensitivity o an MRI is very
good (Birchall et al 2003). Signi cant com pression can occur
be ore changes are seen clinically (Birchall et al 2003).
As a w hole, the m ost com p elling nd ings are associated
w ith com p lete occlusion o the entrance to the intervertebral
orem an by a laterally m igrated m ass on MRI, ollow ed by
narrow ing o a oram en by osteop hytes (w hich m ay cau se
nerve root sw elling). The p oorest association inclu d es d isc
herniation becau se the nerve root can o ten m ove ou t o the
w ay o the o end ing intru d er (Birchall et al 2003).
Com p u ted tom ograp hy (CT) is less com m only u sed in
assessm ent o the extent o d egeneration o the cervical spine.
Although it is less costly, aster and m ore reliable, it d oes have
signi cant lim itations in d etection o both cervical rad icu lop a-
thy and m yelop athy. The inherent low -contrast resolu tion
d u ring assessm ent o so t tissue obviates the need or a CT
Current best evidence with regard to diagnosis  125
m yelograp hy, w hich is trou blesom e w hen d ealing w ith sm all
d isc herniation or lim ited intru sion into the intervertebral
oram ina (Maigne & Deligne 1994).
Nerve condition responses
Asid e rom MRI, a neurom u scu lar test such as an electrom yo-
gram / electroneu rogram (EMG / EN G) is o ten u sed to d i -
erentiate cervical m yelopathy rom carpal tunnel synd rom e,
or other p erip heral nerve p roblem s. Since cervical m yelop a-
thy is an u p p er m otor neu ron synd rom e, the EMG is exp ected
to d isp lay a norm al nd ing u nless there are intervening
root or peripheral nerve problem s. Kang and Fan (1995)
rep orted norm al resu lts or EMG in 100% o patients d iag-
nosed w ith cervical m yelop athy. Evoked p otentials have
d em onstrated the greatest assistance w ith the d iagnosis o
cervical m yelop athy. Motor evoked p otentials have a rep orted
70% sensitivity in the u pper extrem ity m u scles and 95% sen-
sitivity in m u scles o the low er extrem ity or the d iagnosis o
cervical m yelop athy (De Mattei et al 1993). From an electro-
d iagnostic stand point, the u se o sensory evoked p otentials
(SEP) has d em onstrated su perior d iagnostic ability, as Kang
and Fan (1995) reported abnorm al SEP in 19 o 20 patients
d iagnosed w ith cervical m yelopathy.
Tests o nerve cond ition resp onses su ch as EMG and nerve
cond u ction stu d ies (o ten abbreviated to N CV, V stand ing or
velocity) are occasionally u sed to d i erentiate rad icu lop athy
or p eripheral entrap m ent d isord ers (Rhee et al 2007). Becau se
o lim itations in nerve cond ition testing, the MRI has su p -
p lanted nerve cond ition resp onses as the tool o choice
(Polston 2007). For exam ple, o the cervical spinal nerves, only
C4–C8 have lim b representation that allow s d i erentiation
(Truu m ees & H erkow itz 2000). In ad d ition, results o the tests
m ay vary consid erably d ep end ing on the age o the lesion, the
segm ental level analysed and the d iagnostic ap p lication o the
test (Polston 2007).
EMG is an electrical record ing o m u scle activity and
involves insertion o a ne need le into the tested m u scle. In
ord er to d iagnose w ith EMG, the read ing m u st be abnorm al
or tw o or m ore d i erent m uscles and perip heral nerves rom
the sam e nerve root (Du rrant & True 2002). The EMG is con-
sid ered a u se u l d iagnostic tool or cervical rad icu lop athy
(Durrant & True 2002). Tw o record ings are taken, one at rest
and one d uring a contraction. A norm al response involves
only brie EMG activity d u ring need le insertion, then no activ-
ity w hen the m uscle is at rest. Du ring contraction, m otor u nit
action potentials that ref ect electrical activity w ithin the
m u scle ap p ear on the record ing screen, w ith corresp ond ing
increases as m ore m u scle bres are solicited .
Abnorm al resp onses exhibit electrical activity at rest, alter-
ations in the pattern o ring activity, and d ecreases in am pli-
tu d e and d u ration o the sp ikes on the record ing screen. The
nd ings m ay d em onstrate contractions o other m u scles
(com pensatory) and p oor recruitm ent in nerve-related d isor-
d ers su ch as rad icu lopathy. Concentric need le EMG testing
has d em onstrated sensitivities o 50–93% and ap p ears to be
the best and m ost w id ely accep ted m ethod o electrod iagnos-
tic testing (Prahlow & Bu schbacher 2003).
An N CV consists o stim ulation o the nerve and record ing
o the evoked p otential, either rom the m u scles or rom the
nerve (to stu d y the sensory resp onse). N CV assesses the
extent o axonal loss o large m yelinated nerve bre (Cook
 126 PART 2 • 11 • Differential diagnosis and treatment of cervical myelopathy

Table 11.1 Diffe re ntiation of re fe rre d pain cha racte ris tics
Cha ra cte ris tic Ra d iculop a thy Mye lop a thy Soma tic re fe rre d p a in Vis ce ra l p a in

Axial dis tribution + + + +

Upper extremity muscle weaknes s + + − −
Lower extremity muscle weaknes s + + − −
Upper extremity sens ory disturbance + + − −
Lower extremity sens ory disturbance + + − −
Clumsiness − + − −
Gait dis turbance + or − + − −
Spurling’s s ign + − + or − −
Sensory def cit + or − + or − − −
Los s o vibratory s ense − Yes (LE) − −
Tendon re ex changes Diminished + or − Increas ed − −
Mus cle was ting Unilateral + or − Bilateral − −
Babins ki s ign − + − −
Ho man’s sign − + − −
Muscle tone Normal Increas ed Normal Normal
Limb tens ion test + + or − − −
LE = lateral epicondylitis.

et al 2009). The test involves m easu rem ent o the tim e d elay
betw een stim u lation and response at tw o stim u lation
sites w ith a calcu lation o the d istance betw een the sites
(Sm ith 1979).
The tw o late resp onses m ost com m only analysed inclu d e
the H -ref ex and the F-w ave. The H -ref ex (H o m ann’s ref ex)
assesses an a erent 1a sensory nerve and an e erent alpha
m otor nerve. The F-w ave analyses m otor nerves only and is
o ten norm al in p atients w ho have su sp ected rad icu lop athy.
Becau se o a p rop ensity or p oor sensitivity, N CV tests shou ld
never be u sed in isolation (Rhee et al 2007).
Selective d iagnostic nerve root block (SN RB) is a test to
id enti y w hether a sp eci c nerve root is cau sing the p atient’s
p ain. The test is consid ered both sensitive and sp eci c or
rad iculop athy (Malanga 1997).
Essential Aspects of Differential
Diagnosis
Tw o d e nitive elem ents o d i erential d iagnosis are neces-
sary. First, one m u st ru le ou t the p resence o red f ags su ch as
ever, chills, history o cancer, intravenou s d rug u se and other
sinister cond itions. Second ly, in ectiou s cond itions su ch as
schistosom iasis w ill generally have a rap id onset (w hich is
u ncharacteristic o sp ond ylotic cau ses) and m ay p rogress
m ore rap id ly tow ard s d ebilitation. Cervical m yelop athy
requ ires d i erentiation rom a nu m ber o other cond itions
inclu d ing am yotrop hic lateral sclerosis, m u ltip le sclerosis,
sp inal cord tu m ou rs and cerebrovascu lar d isease (Brow n et al
2009). In som e cases, viral d iseases can cau se spinal cord
d egeneration. The m ost d i cult d i erential d iagnosis is
w hen both rad icular and m yelopathic changes are p resent
(Table 11.1).
Current Best Evidence with
Regard to Prognosis
Prognosis or m yelop athy and m yelorad icu lop athy w ithou t
su rgical intervention is m ixed . It is generally assu m ed that the
cond ition, w hich is a p rogressive d egenerative p rocess, w ill
result in continuing w orse ou tcom es over tim e; how ever, a
nu m ber o su bjects w ith m ild cases o cord com p ression w ho
d o not receive prop hylactic surgery d o not d ecline and m ain-
tain their cu rrent level o u nction (Matsu m oto et al 2000).
Tw o recent clinical p red iction ru les have su ggested that
shorter d u ration o sym p tom s, non-sm oking, absence o p sy-
chological com orbid ity, you nger age, a N u rick grad e o 2 or
less, and gait abnorm ality at baseline are all associated w ith
p ositive ou tcom es at 1 year (Pu m berger et al 2013; Tetreau lt
et al 2013).
There is lim ited research on the prognosis o cervical rad ic-
u lop athy. Most au thors ind icate that abou t tw o-third s o cer-
vical rad icu lop athy cond itions resolve w ith conservative care
(Lees & Tu rner 1963). Som e authors note that, d ue to the
benign cou rse o cervical rad iculop athy, in w hich u p to 75%
recovery naturally, conservative care is the recom m end ed
initial treatm ent (Polston 2007). A long-term ollow -u p stu d y
o 51 su bjects w ith cervical rad iculop athy w ho w ere treated
conservatively show ed that 45% had one episod e o pain and
30% had m ild sym ptom s (Lees & Tu rner 1963).

Current Best Evidence with
Regard to Treatment
Conservative approaches
Myelopathy
Conservative m anagem ent inclu d ing treatm ent o p ain, o
gait im p airm ents, lim b m obility, and red u ction o risk o
alls m ay be appropriate or a num ber o patients because
m yelop athy m ay exhibit only m inor im p airm ent w ith no p ro-
gression (Matsum oto et al 2000). Initially, im m obilization o
the cervical sp ine w ith a collar is u sed to stabilize the sp ine
in neu tral or slight f exion. Althou gh som e evid ence exists
or the e ective treatm ent o early m yelop athic changes via
conservative p hysical therap y interventions (i.e. traction and
thoracic m anip u lation) (Brow d er et al 2004; Mu rp hy et al
2006), conclusive evid ence or the e ectiveness o surgical
intervention or m yelop athy suggests that surgery should be
pu rsu ed w hen sym ptom s are progressive and d estru ctive
(Fu jiw ara et al 1989). Conservative care has been show n to be
bene cial in 30–50% o p atients (McCorm ick et al 2003);
how ever, there is a p au city o evid ence to su p p ort m ost con-
servative ap p roaches or m yelop athy and u tu re research is
d e nitely need ed (Rhee et al 2013).
Treatm ent a ter su rgical intervention m ay inclu d e strength-
ening o w eakened areas, gait training and p roprioceptive
exercises. At present, there is no literature that either su pports
or re u tes the u se o conservative rehabilitation a ter su rgical
m anagem ent o m yelop athy.
Radiculopathy
A step w ise ap p roach ad d ressing p red om inant signs and
sym p tom s o cervical rad icu lop athy is o ten u sed . Typ ically,
d u ring the acu te stage o cervical rad icu lopathy the treatm ent
shou ld aim at red u cing inf am m ation and p ain, at ed u cating
the p atient and at avoid ing increasing any neu rological d e -
cits. Treatm ent or inf am m ation and p ain m ay inclu d e ice,
heat, non-steroid al anti-inf am m atory d ru gs (N SAIDs), anal-
gesics, rest, possible im m obilization and traction.
A d erivation clinical p red iction ru le has been d evelop ed
that ou tlined p atients w ith neck p ain w ho w ere m ost likely to
bene t rom a concom itant program m e o cervical traction
and exercise (Raney et al 2009). The stu d y id enti ed : (1) a
positive abd u ction test, (2) p erip heralization o sym ptom s, (3)
a p ositive u p per lim b tension test, (4) a positive neck d istrac-
tion test and (5) age > 55 years. Althou gh the au thors rep orted
an increase in p ost-test probability o im provem ent to 94.8%
w hen our o these ve variables w ere present, the nd ings
shou ld be interp reted w ith cau tion as they d em onstrated very
w id e con d ence intervals (2.5–227.9).
There is no evid ence that im m obilization via a cervical
collar / brace w ill red u ce the d u ration or severity o cervical
rad icu lopathy (N aylor 1979). I im m obilization is em ployed ,
the tim e- ram e should be lim ited to 1–2 w eeks ow ing to the
negative e ects rom long-term im m obilization. Lim ited evi-
d ence is available to su pport traction as an early intervention.
A recent rand om ized clinical trial by Young et al (2009)
reported no signi cant d i erences betw een tw o patient
Current best evidence with regard to treatment  127
grou ps classi ed w ith cervical rad icu lopathy w hen evaluat-
ing the e ectiveness o m echanical cervical traction. Jensen
and H arm s-Ringd ahl (2007) ou nd that, w hen com p aring
acute and chronic neck pain interventions, ROM had the
strongest evid ence in term s o red u cing p ain in the acu te
p hase, and com bined p hysical agents or acu te and chronic
p ain red u ction.
Patient ed u cation shou ld ad d ress the cau se o the p ain,
and activity m od i cation to im p rove or red u ce u rther
p rogression o sym p tom s ad vancem ent. Patients show ed
red u ction in pain and increased satis action w hen instru cted
on an ind ivid u al hom e exercise p rogram m e com p ared
w ith w ritten in orm ation (Jensen & H arm s-Ringd ahl 2007).
Patients shou ld have a hom e p rogram m e o stretching
and strengthening once the rad icu lopathy sym ptom s have
resolved .
Du ring subacute m anagem ent, physical therapy is typi-
cally p rescribed . The literatu re to d ate has not veri ed the
long-term bene ts o m od alities su ch as heat, ice, m assage,
u ltrasou nd and electrical stim u lation, althou gh these have
been show n to have som e bene t in u ncontrolled stud ies
(Rhee et al 2007). Once the p atient’s pain and inf am m ation
are red uced , a progression by p hysical therap y to ad d ress
ROM, f exibility and strength shou ld be initiated . Strengthen-
ing exercises includ e isom etrics o the cervical m uscles and
isotonics or stabilization o the scapu lar region, w hich
inclu d es the trapeziu s, rhom boid s, serratu s anterior and latis-
sim u s d orsi m u scles (Malanga 1997). Progression to resistive
exercises is appropriate so long as the patient’s sym ptom s are
not aggravated . The literatu re also encou rages continu ed
aerobic exercise throu ghou t the cou rse o rehabilitation to
red u ce overall d econd itioning (Malanga 1997; Tsao et al
2003). N erve-glid ing exercises have been show n to be m ore
e ective than a control grou p or short-term im provem ents
and shou ld be consid ered as a conservative care op tion
(N ee et al 2012). Also, absence o neu ropathic p ain, old er
age and low er d e cits in m ed ian nerve neurod ynam ic
test range o m otion p red ict su ccess u l ou tcom es (N ee
et al 2013).
Steroid injection is a com m on intervention in p atients w ith
cervical rad icu lop athy or red u ction o inf am m ation althou gh
there have been only a ew rand om ized clinical trials to
su p p ort the e cacy o the ap p roach (Polston 2007). These
injections are o ten o ered w hen a patient is not respond ing
to a cou rse o conservative treatm ent inclu d ing m ed ications,
rest and physical therapy. The stu d ies that have been per-
orm ed show a positive ou tcom e o u p to 60% or long-term
relie (Malanga 1997).
Overall, there is low -qu ality evid ence su ggesting qu icker
retu rn to ou tcom es or su rgery com pared w ith a conservative
ap proach; how ever, it is w orth noting that the stu d ies su g-
gesting su ch bene t have a high risk o bias (van Mid d elkoop
et al 2013).
Myeloradiculopathy
At present, conservative treatm ent or m yelorad icu lopathy
inclu d es palliative care, gait training by p hysical therapists,
and ROM and strengthening exercises to retard the p rogres-
sion o the d egenerative changes. H ow ever, there is a d earth
o evid ence to su p p ort conservative care or this cond ition as
m ost p atients d o receive su rgical intervention.
 128 PART 2 • 11 • Differential diagnosis and treatment of cervical myelopathy
Surgical approaches
Su rgical ap p roaches are aim ed at rem oving the o end ing
com p ressive d isord ers rom the nerve and d ecom p ressing the
cord to allow the cord to m ove w ithou t riction and u rther
d am age (Frank 1993). In ord er to d ecid e w hich su rgical
app roach to use, su rgeons m ust consid er the lesion location
(Witw er & Trost 2007), the num ber o levels involved (Witw er
& Trost 2007), the speci c pathology (Witw er & Trost 2007),
the p atient’s age, neu rological u nction and cervical align-
m ent (H eller et al 2001) and rad iographic im aging (Witw er &
Trost 2007) as w ell as an ind ivid ual surgeon’s am iliarity w ith
the techniqu e (H eller et al 2001).
Su rgical treatm ent has been show n to retard the e ects o
cervical m yelop athy w hen it is cau ght qu ickly (Fujiw ara et al
1989). A num ber o actors can inf u ence the outcom e o
su rgery, m ost notably: chronicity o sym p tom s (Matsu m oto
et al 2000), w hether rad icu lopathy is also present w ith m ye-
lop athy (Sham ji et al 2009), and the person’s age and integrity
o their sp ine (Fu jiw ara et al 1989). In ad d ition, the type o
su rgical ap p roach is o ten selected based on the sym p tom s at
hand . All su rgeries involve som e elem ent o d ecom p ression
o the sp inal canal and m ay involve an anterior or p osterior
app roach (McCorm ick et al 2003). At present, a series o trials
have ailed to p rove the su p eriority o one over the other,
although short-term com p lications are higher in p atients w ho
receive posterior ap proaches (Cybu lski & D’Angelo 1988).
It is im portant to note that, on som e occasions, continu ed
neu rological d eterioration can occu r a ter su rgery second ary
to ischaem ia (Sm ith-H am m ond et al 2004). This cond ition is
a d iagnosis o exclu sion (once haem atom a and d islocation are
ru led ou t) and has a grad u al bu t d am aging p rogression.
Anterior approaches
Anterior su rgery is p er orm ed or u nilateral or bilateral rad ic-
u lop athy or m yelop athy w hen there is a single d om inant
level, or in the ace o kyp hosis. Anterior u sion is consid er-
ably m ore com m on, bu t is associated w ith increases in opera-
tive tim e and u se o instru m entation (Iw asaki et al 2007).
Generally, anterior d ecom p ression and u sion is p er orm ed
w hen one or tw o levels o cervical m yelopathy are present
(Cybulski & D’Angelo 1988). The approach generally involves
an anterior osteop hytectom y and rem oval o the vertebral
bod ies. One signi cant bene t o this ap proach is that u rther
orm ation o anterior and posterior bony spu rs should be
p revented , spu rs present m ay actu ally regress and , as the
segm ent is d istracted d u ring the su rgery, the bu ckling o the
ligam entu m f avu m is im p roved (Masaki et al 2007).
The p roced u re involves a transverse (one or tw o levels) or
vertical (m u ltip le levels) anterior ap p roach ollow ing the
anterior bord er o the sternocleid om astoid m u scle. The d iscs
are rem oved and replaced , typically w ith a bone intrad isc
transp lant. In m ost cases, anterior p lating is p rovid ed to
red uce the risk o non-union. The ap proach is consid ered
u se u l w hen ad d ressing the vascu lar elem ents associated w ith
m yelop athy and it m ay resu lt in less scar orm ation than that
seen w ith a p osterior ap p roach (Masaki et al 2007).
The su ccess rate or anterior d ecom p ression and u sion is
very high (90%) (Masaki et al 2007) and com plications are
generally low (Cybu lski & D’Angelo 1988). Many have pro-
m oted the u se o anterior u sion, ind icating that it resu lts in
ew er com plications, vascu lar d am age and less osteophyte
grow th than either lam inectom y or lam inoplasty (Masaki
et al 2007). Furtherm ore, an anterior approach m ay be pre-
erred over a posterior ap proach su ch as lam inoplasty w hen
ossi cation o the p osterior longitu d inal ligam ent is p revalent
(Glaser et al 2001). H ow ever, p hysician pre erence and skill-
set p robably d ictate the selection o the su rgical m ethod to a
greater extent than d o patient presentation and pu blished
ou tcom es.
Posterior approaches
Posterior su rgery is p re erred in cases o d e orm ity, in m u lti-
segm ental and d orsal p athology (Witw er & Trost 2007) and
in severe m yelopathy as it m ore com p letely d ecom p resses the
entire relevant cervical spine, bu t is not pre erred w hen there
is a single d om inant level or in kyphosis (Iw asaki et al 2007).
When m u ltiple levels are involved , partial rem oval o tw o or
m ore vertebral bod ies, p lu s rem oval o the p osterior longitu -
d inal ligam ent and any rem aining spurs, m ay be necessary.
Anterior ap proaches are not w arranted w hen rad icu lar sym p -
tom s are p red om inant.
There are tw o p rim ary posterior approaches to m yelop a-
thy: (1) lam inectom y w ith usion and (2) lam inop lasty. Post-
erior lam inectom y and u sion is ind icated w hen cervical
stenosis cau ses low er extrem ity and / or u p p er extrem ity loss
o u nction. Com p lications have inclu d ed nerve d am age,
lack o u sion, high levels o blood loss d uring su rgery, insu -
cient d ecom p ression, and in ection (Epstein 2003). A lam i-
nop lasty is ind icated in cases o cervical stenosis, w hich has
originated rom p osterior longitu d inal ligam ent ossi cation,
bu ckling o the ligam entu m f avum or stru ctu ral changes
w ithin the spinal canal. The m ost com m on com plications
reported have inclu d ed loss o ROM, inad equate d ecom pres-
sion, and loss o sagittal alignm ent (Ep stein 2002). The surgi-
cal ap p roach involves d ecom p ression o the sp inal cord
p osteriorly by enlarging the sp inal canal bu t retaining the
lam inae. A lam inop lasty is not consid ered su perior to an
anterior or p osterior app roach because it d ecom p resses
less sp ace.
A lam inop lasty involves one o tw o m ethod s, the m ost
com m on being an op en-d oor lam inop lasty. A cervical op en-
d oor lam inop lasty expand s the d iam eter o the spinal canal,
d ecom p ressing the nerves and spinal cord . This su rgery is
typically p er orm ed in abou t 2 h. During a cervical lam ino-
p lasty, an incision is p er orm ed in the back o the neck. The
p osterior p ortion o the bony sp inal canal, or lam ina, w ill be
elevated . A portion o the thickened ligam ent w ill also be
rem oved . The spinal canal d iam eter w ill be w id ened , d ecom -
p ressing the sp inal cord and nerves. The lam ina w ill then be
held in the op en p osition u sing titaniu m m inip lates.
A lam inectom y and u sion ap p roach generally involves
p osterior u nilateral or bilateral rem oval o the lam ina and a
p artial acetectom y. Cand id ates are p atients w ho have ad e-
quate p reservation o the cervical lord osis (m inim u m o 10°)
(Epstein 2002). O ten, the d ecom pression represents tw o seg-
m ents above and below and is m u ch m ore extensive than an
anterior d ecom p ression. The p roced u re typ ically involves a
p osterior m id line incision and d issection o the p aracervical
m u scles rom the spinou s processes betw een C2 and T1
(H eller et al 2001). The lam inectom y requ ires rem oval o
either m od erate or large am ou nts o the acets, urthering the

likelihood o instability a ter su rgery u nless u sion is em ployed
concu rrently.
To ou r know led ge, there is only one stu d y (Kam insky et al
2004) that has retrosp ectively analysed ou tcom es or patients
w ith m yelopathy and rad iculop athy, and one stud y (H erkow -
itz 1988) that retrospectively com pared anterior cervical
usion, p osterior u sion and lam inectom y, and lam inoplasty.
A third stu d y (N akano et al 1988) has analysed ou tcom es or
patients w ith m yelorad icu lopathy. H ow ever, no stud ies to
d ate have prospectively rand om ly assigned com parable
patients w ith m yelop athy so as to com pare ou tcom es a ter
lam inoplasty or lam inectom y and usion.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
Thoracic Outlet Syndrome
12  
Chapter 
S u s a n W. S tra lka
CHAP TER CONTENTS
Overview and history of thoracic outlet syndrome  132
Pathoanatomical causes of thoracic outlet syndrome  132
Functional causes of thoracic outlet syndrome  133
Entrapment sites  133
Aetiology of thoracic outlet syndrome  134
Clinical symptoms of thoracic outlet syndrome  134
Neurological symptoms  135
Arterial symptoms  135
Venous symptoms  135
Sympathetic-mediated pain in thoracic outlet syndrome  136
Diagnosing thoracic outlet syndrome  136
Differential diagnosis  136
Provocative test – used in diagnosis of thoracic   term ‘thoracic ou tlet com p ression synd rom e’. The clinical
outlet syndrome  136
Imaging assessment of thoracic outlet syndrome  138
Clinical treatment and management of thoracic outlet syndrome  138
Therapy evaluation of thoracic outlet syndrome  138
Breathing patterns  138
Muscle imbalance  138
Joint stiffness  139
Neurogenic pain  139
Intervention for thoracic outlet syndrome  139
Conclusion  140
Overview and History of Thoracic
Outlet Syndrome
Thoracic ou tlet synd rom e (TOS) is a broad term u sed to
d escribe upp er extrem ity sym ptom s. These sym p tom s are
related to com pression or tension of the brachial plexu s, the
su bclavian artery and su bclavian vein in an area located
above the rst rib and behind the clavicle. Often, one patient
m ay be seen by nu m erou s sp ecialists before this synd rom e is
id enti ed . The anterior scalene m u scle, the m id d le scalene
m u scle and the rst rib bord er the thoracic ou tlet. Pathologi-
cal or d ysfu nction related to these stru ctu res as w ell as the
clavicle bone, p ectoralis m inor, om ohyoid , su bclaviu s, scalene
m inim us, cervical rib or transverse process of C7 have been
associated w ith TOS (Mackinnon et al 1996). These neurovas-
cu lar stru ctu res in their cou rse from the interscalene triangle
to the axilla are covered w ith a fascial sheath that is p art of
the d eep cervical fascia, w hich can becom e p roblem atic
(Atasoy 2004). Fibrou s band s, both congenital and acquired ,
also restrict m ovem ents of the clavicle and rst rib. The term
‘TOS’ d oes not specify the com pressing agent and d oes not
id entify the structu re being com pressed . Therefore this syn-
d rom e shou ld be d ifferentiated by u sing the term s arterial
TOS (ATOS), venou s TOS (VTOS) or neurogenic TOS (N TOS).
Peet rst u sed the term ‘thoracic outlet synd rom e’ in 1956
and ind icated that com pression of neu rovascu lar structu res
occu rs in the interscalene triangle causing cervical–brachial
p ain, nu m bness and other d isord ers of the u p p er extrem ity;
he u sed this term to grou p them u nd er one nam e rep resenting
a single com m on elem ent of neurovascular stru ctu res (Sam ar-
asam et al 2004). It w as not u ntil 1958 that Robb p rop osed the
signs are variable ow ing to the variety of tissu e that can be
involved , as w ell as the com pression or entrapm ent area (Fig.
12.1). Tod ay TOS is classi ed accord ing to the three areas: the
brachial plexu s (N TOS), w hich com p rises 90% or m ore of
cases, the su bclavian vein (VTOS), w hich occurs in 6–7%, and
the su bclavian artery (ATOS), w hich occurs in 3–4% (Sand ers
et al 2008).
Com p ression of the vascu lar system is easier to id entify
and presents m ore urgently in arterial or venou s throm bosis
than d o sym p tom s in N TOS (Fu gate et al 2009). The m ain
controversy in p atients w ith the last synd rom e (N TOS) relates
to d iagnosis. N eu rological-typ e com p laints su ch as p araesthe-
sia, nu m bness and p ain m u st be based on interp retation of
the history, sym p tom s or clinical exam ination. These sym p -
tom s m ake the N TOS som ew hat of an enigm a as som e health-
care p rofessionals tend to overd iagnose it w hereas others
u nd erd iagnose it, w ith or w ithou t correlating the clinical
signs and sym p tom s.
Pathoanatomical Causes of Thoracic
Outlet Syndrome
The thoracic outlet region includ es three m ajor areas in w hich
com p ression can occu r: the interscalene sp ace or triangle, the
costoclavicu lar sp ace and the su bp ectoralis m inor sp ace.
Other cau ses are congenital bony stru ctu res, brom u scu lar
anom alies, p ostural d eviations and m uscle im balances. It has
been rep orted that su bjects w ho have congenital bony or

Figure 12.1 Anatomy of the thoracic outlet area.
brom u scu lar variations in the thoracic ou tlet region and
experience som e type of trau m a are at risk of d eveloping TOS.
Trau m a can resu lt in m u scle sp asm , in am m ation and bro-
sis, w hich fu rther narrow the sp aces and resu lts in com p res-
sion of the neu rovascu lar stru ctu re (Atasoy 2004).
The incid ence of a cervical rib is less than 1% and m ay be
bilateral. The cervical rib size varies from a bony exostosis to
a fu ll-grow n cervical rib w ith ligam entous cartilaginou s or
bony attachm ent to the rst rib. The fem ale : m ale ratio is 2 : 1
(Atasoy 2004). A cervical rib or other rib anom alies cause the
brachial p lexu s to be p ulled against the fascial band s and
C8–T1 sym p tom s can d evelop. A cervical rib, along w ith
forw ard shou ld ers and p oor postu re, can cau se p ressu re on
the p lexu s and the vessels. Follow ing a fractu re of the rst rib,
excess callou s form ation can occu r creating a narrow space,
and lead ing to p ressu re on the brachial p lexus and su bclavian
vessels.
Functional causes of thoracic outlet syndrome
Poor p ostu re, abnorm al breathing p atterns, cervical or tho-
racic d ysfu nctions, m uscle im balances and shou ld er p atholo-
gies are com m only seen in TOS (m ed ifocu s.com 2009).
Abnorm al p osture in w hich the head and shou ld ers are held
in a forw ard position along w ith arm elevation greater than
90° m ay cau se neu rovascu lar consequ ences. Over tim e, short-
ening of variou s neck m uscu latu res m ay occu r, w hich in tu rn
cau ses p osterior shou ld er gird le w eakness. The longu s and
longissim u s cervicis, u pper and m id d le rhom boid s and low er
trap eziu s becom e w eakened . To com p ensate for the forw ard
orientation of the glenoid fossa of the hu m eru s, the serratu s
anterior m u scle becom es shortened by abd uction of the
scap u la. This scenario cau ses lengthening of the low er and
m id d le trap eziu s in su p p orting the scap u la, cau sing a m echan-
ical d isad vantage and early fatigu e. These alterations result
in the u pper trapeziu s, rhom boid s m ajor and m inor m uscles,
along w ith the levator scapu lae, having to fu nction as acces-
sory m u scles to elevate the shou ld er and arm .
The entire cycle continu es to cau se w eakness in som e
m u scles and shortening of other m u scles. Other fu nctional
causes, su ch as abd u ction over 110°, p u t tension on the m ed ian
nerve and cau se the ancillary artery to be com p ressed in the
Pathoanatomical causes of thoracic outlet syndrome 133
bicip ital groove. In the axilla, com pression can be cau sed by
a brous extension of the latissim u s d orsi and p ectoralis
m ajor m u scles as they insert in the bicip ital groove. With arm
abd u ction or external rotation, the neu rovascu lar bund le is
com p ressed u nd er the arch, p rod u cing sym p tom s. There are
histop athological changes that occu r to a nerve u nd ergoing
chronic com p ression, w hich takes p lace in TOS. A thorou gh
history, com p rehensive p hysical exam ination and sp eci c
p rovocation test can id entify the stru ctu re cau sing com p ro-
m ise as w ell as to help to d eterm ine m u scle w eakness and
tightness.
Entrapment sites
Interscalene space triangle
The neu rovascular bund le that inclu d es the brachial plexus
tru nks and su bclavian vessels ru ns from the base of the neck
tow ard s the axilla and the arm . The rst narrow ing area is the
m ost p roxim al and is nam ed the interscalene triangle. This
triangle is bord ered by the anterior scalene m u scle anteriorly,
the m id d le scalene m u scle p osteriorly, and inferiorly along
w ith the base by the m ed ial su rface of the rst rib (Atasoy
2004) (Fig. 12.2).
The scalene m inim u s m uscle, w hich is found in only
30–50% of TOS cases, is located betw een the su bclavian artery
and the T1 root of the brachial p lexus, w hich can be a sou rce
of com p ression. The anterior and m id d le scalene m u scles are
respiratory m u scles, w hich elevate the rst rib as w ell as
slightly ex and rotate the neck. The insertion of these m u scles
in the rst rib overlaps and cau ses a V form ation. This over-
lapping creates a narrow space, w hich elevates the position
of the su bclavian artery and the brachial p lexu s. It has been
noted that in som e cases the m id d le scalene m u scle inserts
along the fu ll length of the rst rib, creating a narrow space
throu gh w hich the neu rovascu lar stru ctu res m u st p ass. When
there is overlap p ing of the scalene m u scle, there is also a
p rom inent transverse process of the C7 process and the cervi-
cal rib. This has often been d escribed as a U or sling form ation
by these m uscles, w hich m ay cau se elevation and pressure
from the structures below. At the proxim al portion of the
triangle, the scalene m u scles m ay overlap , w hich again cau ses
 134 PART 2 • 12 •
Figure 12.2 Three potential spaces in the thoracic outlet area that can be responsible for TOS.
a d ecrease in the opening and hence pressu re from the bra-
chial p lexu s above. It has been noted that, at tim es, a thick
brou s coverage of the p lexu s extend ing from the scalene
sheath can cau se ad hesions and p ressu re on the p lexu s. The
scalene m u scles can scar or hyp ertrop hy w ith trau m a or
repetitive m otion that fu rther contributes to com pression.
Som e researchers have fou nd atrop hy of typ e II m u scle bres,
p red om inance of typ e I bres and a 25% increase in connec-
tive tissu e in the scalene m u scles (Sand ers 1990) follow ing
inju ry.
Costoclavicular space
The costoclavicu lar space is a triangu lar area bord ered ante-
riorly by the m id d le third of the clavicle, posterom ed ially by
the rst rib, and p osterolaterally by the u p p er bord er of the
scap u la (Talu 2005). The su bclavian artery, vein and brachial
p lexu s all p ass throu gh the costoclavicu lar space (see Fig.
12.2). Com p ression of the brachial p lexu s and the su bclavian
artery and vein can occur as the resu lt of congenital abnor-
m alities, trau m a to the rst rib or clavicle, and stru ctu ral
changes in the su bclavian m u scle or the costocoracoid
ligam ent.
Com p ression can occu r if the clavicle or rst rib is fractu red
follow ed by a haem atom a occu rring at the fracture site result-
ing in excessive scar tissu e and callu s bu ild -u p . As m entioned
earlier, persons w ith forw ard shou ld ers, w hich represents
p oor p ostu re or a d isabling illness, m ay d evelop narrow ing
of the costoclavicu lar sp ace, w hich has been show n to lead to
TOS sym ptom s. With shou ld er abd u ction, the scap ula and
coracoid m ove d ow nw ard s, w hich cau ses traction on the su b-
claviu s m u scle and costocoracoid ligam ent, ad d ing ad d itional
p ressu re on the neu rovascu lar stru ctu res. The clavicle, d uring
shou ld er abd u ction, m oves backw ard s and u pw ard s 30–35°
at the sternoclavicu lar joint, w hich m ay ad d to the narrow ing
to the costoclavicu lar sp ace.
Subpectoralis minor space
The subpectoralis m inor sp ace is located ju st below the cora-
coid p rocess and u nd er the p ectoralis m inor m u scle insertion
Thoracic outlet syndrome
to this p rocess (see Fig. 12.2). The pectoralis m inor ru ns from
the third to the fth ribs over the thorax and end s at the cora-
coid p rocess. This m u scle is com p letely covered by the p ecto-
ralis m ajor m uscle. With shortening, the p ectoralis m inor can
lead to a narrow ing in the subp ectoralis m inor space, increas-
ing pressu re on the blood vessels and brachial plexu s. The
tight p ectoralis m inor m u scle m ay also com p ress the neu ro-
vascu lar stru ctu res d u ring hyp erabd u ction. Wright term ed
this synd rom e hyperabduction syndrome, w hich closes
d ow n the costoclavicu lar space d u e to the u p-and -d ow n
m otion of the clavicle (Beyer & Wright 1951).
Aetiology of Thoracic Outlet Syndrome
TOS is 3–4 tim es as frequent in w om en as in m en betw een the
ages of 20 and 50 years (Brism ée et al 2004). It is speculated
that fem ales have less-d evelop ed m u scles, a greater tend ency
for d rooping shou ld ers ow ing to ad d itional breast tissu e, a
narrow ed thoracic ou tlet and an anatom ical low er sternu m
– all changing the angle betw een scalene m u scles. This m ay
be one reason w hy fem ales are m ore prone to d eveloping this
synd rom e (H u rsh & Thanki 1985); another could be an
increase in horm ones that cau se laxity, as a resu lt of w hich
there is su p erior su blu xation of the rst rib (Brism ee et al
2004) (Table 12.1). Com m on sym ptom s collected from 17
reports are listed in Table 12.2 (Sand ers & H au g 1991).
Clinical Symptoms of Thoracic
Outlet Syndrome
The term ‘vascular TOS’ is non-speci c and it d oes not im p ly
neu rogenic, arterial or venou s com p ression; nor d oes it
ad d ress w hich stru ctu re is involved . H istorically, sym p tom s
and physical nd ings are m ore sp eci c (Sand ers et al 2008);
p atients typ ically com p lain of p ain in the su bscap u lar, scap u -
lar, cervical and cervical thoracic regions and of occipital
head aches. Paraesthesia and nu m bness m ay be p resent in the
 Clinical symptoms of thoracic outlet syndrome  135

Table 12.1 Conditions ca us ing ne rve tra uma

inclu d es sym ptom s involving the C5, C6 and C7, w hereas the
low er plexus princip ally involves the C8–T1 levels.
Ae tiology % When the u pper p lexu s is involved , there is pain in the sid e
of the neck and this p ain m ay rad iate to the ear and face.
Neck trauma 86
H ead aches are not uncom m on w hen the upp er plexu s is
Rear-end motor vehicle accident 32 involved . Som e patients state that on the affected sid e there
Side- or front-end motor vehicle accident 24 is a ‘stuffy ear ’. Often the pain rad iates from the ear posteri-
orly to the rhom boid s and anteriorly over the clavicle and
Work injury, including repetitive strain injuries 22 p ectoralis regions. The p ain m ay m ove laterally to the trap e-
Other neck trauma 8 zius and d eltoid m u scles and d ow n the C5–C6 rad ial nerve
area. Low er plexus p atients have sym ptom s that p resent in
Cervical or anomalous rs t rib 2 the anterior or p osterior shou ld er region and rad iate d ow n
Unknown or s pontaneous 12 the u lnar sid e of the forearm into the hand , the ring and sm all
ngers, as w ell as m u scle tend erness w ith trigger p oints that
can be located in the su p raclavicu lar and infraclavicu lar areas.
H ead aches m ay be d isabling and can increase w ith arm activ-
Table 12.2 Symptoms rom ne rve irritation ity. At tim es, the pain w ith low er p lexus involvem ent m im ics
the p ain associated w ith card iac angina.
Symptoms %
Inju ry or repetitive stresses causing chronic m uscle spasm
Neck pain 92 m ay p recip itate the synd rom e. A com m on p roblem is
hyperextension– exion or w hiplash inju ry of the neck. The
Shoulder pain 70 TOS sym ptom m ay show u p im m ed iately, or m ay be d elayed
Arm pain 80 for w eeks or m onths. Cervical and shou ld er sprain sym ptom s
u su ally occu r im m ed iately after the w hip lash w ith p ersisting
Paraes thesia 95
sym p tom s of neck and shou ld er p ain and stiffness before
All ve ngers 46 being d iagnosed as TOS (Brantigan & Roos 2004). As the
Fingers 1–3 30 w hiplash sym ptom s grad ually im prove over tim e, the p ost-
trau m atic TOS involving the brachial p lexu s w orsens.
Fingers 4–5 14
No paraesthes ia 10
Arterial symptoms
(Modi ed from Sanders & Haug 1991.)
Sym p tom s of ATOS u su ally d evelop sp ontaneou sly and are
u nrelated to trau m a or w ork. These p atients often have tru e
clau d ication of the arm , p articu larly w hen the arm is elevated .
entire hand region or parts of it. Often the sym ptom s are These arterial sym ptom s occur from com pression of the su b-
exacerbated w hen the p erson u ses the arm s in an elevated clavian artery in the area of the rst rib. Arterial sym p tom s
p osition and there is a heavy, tired , aching sensation along d iffer from the w hole-arm nu m bness and heaviness that per-
w ith nu m bness or paraesthesia. sists w hen the arm is elevated in p atients w ith neu rological
Com m on clinical p resentations of TOS inclu d e: TOS, as w ell as presenting w ith very little shou ld er or neck
• nu m bness / tingling that often occu rs in the ring and sym p tom s. In p atients w ith arterial sym p tom s, a cervical rib
sm all ngers bu t can encom p ass the entire hand or an enlarged transverse process of C7 m ay be cau sing the
• p araesthesiae occu rring at night and / or d u ring d aily p roblem .
activities Physical nd ings are those of arterial occlu sion: loss of
• vagu e p ain in the u ninvolved extrem ity, w hich can occu r p u lses at rest, p erhap s colou r changes and ischaem ic nger
in hand , elbow, shou ld er and / or cervical sp ine tip s as w ell as cold ness, p araesthesia and fatigu e. Arterial
• su bjective com p laints of hand / arm w eakness, esp ecially sym p tom s inclu d e d igital and hand ischaem ic sym p tom s
w ith arm s raised overhead (cold ness, pallor, paraesthesia and fatigu e of the arm ). In the
• su bjective com p laints of sw elling in the absence of tru e su p raclavicu lar area, there is som etim es a tend er lu m p , bony
sw elling p rom inence or even p u lsation of the su bclavian artery. Arte-
• the com m on sym p tom s collected from the 17 rep orts rial TOS accou nts for less than 5% of TOS and typically resu lts
listed in Table 12.2. from long-term interm ittent vascular com pression. A cervical
X-ray is u sed as a screening test to ru le ou t ATOS (Brantigan
& Roos 2004).
Neurological symptoms
TOS sym ptom s m ay d evelop sp ontaneou sly or follow ing Venous symptoms
injury in the neck and / or shou ld er region. A list of cond itions
cau sing nerve trau m a is given in Table 12.1. Basic concepts of The VTOS com prises only 2–3% of all TOS p atients. Venou s
TOS are a m echanical pred isposition (Brantigan & Roos 2004); sym p tom s m ay be p reced ed by excessive activity u sing the
sym p tom s are p rim arily cau sed by neu rological stru ctu ral u p p er extrem ity. The p recip itating factor that lead s to throm -
anom alies. Trau m a m ay p recipitate the neu rological type of bosis is typically excessive arm activity su ch as throw ing a
TOS in certain susceptible ind ivid uals. The upp er p lexu s baseball, sw im m ing, w eightlifting or w orking w ith arm s
 136 PART 2 • 12 • Thoracic outlet syndrome
elevated . Sw elling, oed em a, cyanosis and arm d iscom fort,
w hich is aggravated w ith exercise, along w ith d istend ed
su p er cial veins, shou ld er and chest w all, are com m on venou s
sym p tom s.
It is not uncom m on to have a su bclavian vein throm bosis
at the rst-rib level. When this occu rs, there is a su d d en onset
of d u sky cyanosis, oed em a and extrem e lim b d iscom fort. It is
im p ortant to d iagnose this im m ed iately and su rgical d ecom -
p ression is necessary so that the sym ptom s d o not becom e
chronic. Physicians w ho d iagnose only the vascu lar form s of
TOS are m isd iagnosing the vast m ajority of patients w ho have
non-vascu lar TOS (Brantigan & Roos 2004).
Sympathetic-mediated Pain in Thoracic
Outlet Syndrome
Som e of the p ainfu l sym p tom s in ind ivid u als w ith N TOS m ay
be d ue to overlapping signs and sym ptom s of com plex
regional pain synd rom e (CRPS) (Kaym ak & Ozcakar 2004). In
N TOS, the cold ness and colou r changes m ay not be cau sed
by ischaem ia d ue to obstruction of the su bclavian vessels, bu t
d u e to an overactive sym pathetic nervous system (SN S). Allo-
d ynia, hyperalgesia, prolonged period s of red or blue hand ,
p ersistent oed em a, excessive w arm th and sw eating changes
are often p resent.
Sym p athetic-m ed iated p ain m ay be related to a d irect
inju ry to the sym p athetic axons in the cord s or tru nks of the
brachial plexus as w ell as an activation of the som ato-
sym p athetic re ex in w hich a som atic root inju ry w ill activate
the sym p athetic system over several ascend ing and d escend -
ing d erm atom es (Schw artzm an 1987; Casey et al 2003). Ana-
tom ically, the SN S bres ru n on the circu m ference of the
nerve root of C8, T1 and low er tru nk of the brachial plexus.
When the nerves are com p ressed the sym pathetic bres are
activated , p rod u cing Raynaud ’s phenom enon. This m ay
explain how cold ness and colou r changes are frequently seen
w ith both N TOS and ATOS.
Often, clinicians u se the term ‘com p ressor ’ or ‘releaser ’ to
categorize sym p tom s. The term compressor is u sed to evalu -
ate p atients w ho com p lain of sym ptom s w hen p erform ing
overhead activities. These p atients have no p araesthesia at
night u nless the arm is overhead or their occu p ation requ ires
overhead w ork for long p eriod s. This com p ression occu rs
w hen the arm is raised overhead , w hich then causes the
brachial plexu s to turn over the rst rib then und er the
clavicle at the costoclavicu lar sp ace. When the p atient low ers
the arm , the com p ression on the blood su p p ly to the nerve
is off and the sym p tom s d ecrease. The Roos test is often
p ositive w hen a p atient has w hat is com m only called com -
p ressor TOS.
The term releaser is u sed to id entify p atients w ho exp eri-
ence sym ptom s prim arily at night, w ho w ork in m ore sed en-
tary jobs, or w ho m ay have p oor p ostu re along w ith large or
heavy u p p er extrem ities. The term release phenomenon
m eans the brachial p lexu s is being p u lled d ow n, then venou s
p ooling occu rs arou nd the nerve, w hich inhibits blood ow
to the p erip heral nerve. Gravity has an effect w hen sitting and
stand ing, w hich p laces tension on the nerve. When the p atient
lies d ow n, the tension is grad u ally released and the blood
ow returns to the nerves. As reported by Liu (p ersonal
com m u nication), it takes 4–6 hours after the rem oval of com -
p ression for the blood ow to retu rn to the nerve. This m ay
exp lain w hy a patient aches at the sam e tim e every night w ith
p araesthesia or p ain. Lu nd borg (1970) believes this occu r-
rence at night is d u e to the axons ring and so patients experi-
ence p araesthesia.
Wom en rep ort the release p henom enon m ore often than
m en ow ing to the w eight of the breasts p u lling on their bra
strap s and / or kyp hotic p ostu re. The bra strap s are cap able
of creating com p ression of the brachial p lexu s, w hile the
kyphotic posture, in w hich there is an increase of the shou ld er
gird le, cau ses increased tension of the brachial plexu s and
closes d ow n the thoracic ou tlet. Brism ée et al (2004) fou nd
that w om en w ere fou nd to rep ort sym p tom s associated w ith
the release p henom enon abou t tw ice as often as m en.
Diagnosing Thoracic Outlet Syndrome
The d iagnosis of TOS is essentially based on history and clini-
cal exam ination. In ord er to d iagnose accu rately, the clinical
p resentation m u st be evalu ated as either neu rogenic or vas-
cu lar. N eu rogenic p resentation is linked to com p ression of the
brachial p lexus and vascular to com p ression of the su bclavian
vessels. TOS m anifestations are varied and there is no single
d e nitive test. Com m on sym ptom s experienced w ith TOS
includ e paraesthesia, num bness, pain and bu rning. Ad vanced
sym p tom s inclu d e m u scle w eakness, esp ecially in the u lnar
nerve d istribu tion.
Diagnosis is based on a total clinical picture that com prises
a careful m eticu lous history, review of m ed ical record s and
clinical exam ination. For N TOS, the exam ination also inclu d es
tend erness over the scalene m u scles, trap eziu s m u scle and
anterior chest w all, a p ositive Tinel’s sign over the brachial
p lexu s in the neck, red u ced sensation to very light tou ch in
the ngers and a p ositive resp onse to several p rovocative
m anoeu vres that p u t stress on the p lexu s to elicit sym p tom s.
A list of these m anoeu vres and incid ence of p ositive resp onses
is seen in the sym ptom s in Table 12.2.
Differential diagnosis
To have a p recise d iagnosis, it m u st be m ad e by history,
p hysical exam ination, p rovocative tests and , if need ed , u ltra-
sou nd , rad iological evalu ation and / or electrod iagnostic eval-
u ation (Brantigan & Roos 2004). There are m u ltiple d iagnoses
to consid er in the d ifferential d iagnosis of TOS. Consid eration
m u st be given to m u scu loskeletal p athology that cou ld m im ic
a TOS presentation. Cervical rad iculop athy as w ell as u lnar
neu rop athy m ay p resent w ith sim ilar sym p tom s as TOS,
includ ing hypothenar and / or intrinsic w asting (Box 12.1).
Provocative test – used in diagnosis of
thoracic outlet syndrome
The physical exam ination as w ell as the other tests m u st be
d one so as to avoid exacerbating sym ptom s. Clinicians rely
on clinical tests for alteration of rad ial p u lse. A few of these
tests are listed below (for all tests, the p atient is in a seated
p osition and the exam iner p alp ates the rad ial p u lse):

Bo x 1 2 .1 Diffe re n tia l d ia g n o s is o f th o ra c ic o u tle t
s yn d ro m e
• Cervical dis c disease
• Cervical facet dis eas e, s pondylosis
• Malignancies (Pancoast tumour, local tumours, e.g. nerve
s heath tumours, spinal cord tumours )
• Peripheral nerve entrapments (ulnar and / or median nerve
entrapment)
• Brachial plexitis
• Shoulder pathology
• Muscular s pasms , bromyalgia
• Neurological disorders (multiple scleros is)
• Ches t pain, angina
• Vas culitis
• Vas os pastic disorder (Raynaud disease)
• Neuropathic syndromes of upper extremity (CRPS I, II)
• Thoracic 4 (T4) syndrome
• Sympathetic-mediated pain
• Dull pain, discomfort, aching with tightness in
mid-thoracic area
• Adson test: The p atient is asked to rotate the head and
elevate the chin tow ard s the affected sid e. If the rad ial
pu lse on that sid e is absent or d ecreased then the test is
positive, show ing that the vascu lar com ponent of the
neu rovascu lar bu nd le is com p ressed by the scalene
anterior m u scle or cervical rib. This test has show n
a sensitivity of 79% and sp eci city of 76% (Gillard
et al 2001).
• Wright’s test: The p atient’s arm is hyperabd u cted . If
there is a d ecrease or absence of a p u lse on one sid e then
the test is p ositive, show ing that the axillary artery is
com p ressed by the p ectoralis m inor m u scle or coracoid
process d u e to stretching of the neu rovascu lar bu nd le.
Gillard et al (2001) fou nd a sensitivity of 70% and
sp eci city of 53% for p u lse abolition.
Patients w ith interm ittent sym p tom s that are associated w ith
sp eci c m ovem ents or p ositions of the u p p er qu ad rant, w hich
increases or d ecreases the com p ression and tension of neu ral
stru ctu res, w ill need to u tilize these tests below :
• Roos test: The p atient has arm s at 90° abd uction and the
therap ist p u ts d ow nw ard s p ressu re on the scap u la as the
patient op ens and closes the ngers. If the TOS
sym p tom s are rep rod u ced w ithin 90 second s, the test is
positive.
• Cyriax release test: The patient can be sitting or stand ing
w ith arm s su pported or resting on a pillow w ith forearm s
at neu tral for a p eriod of at least 3 m inu tes – as
sym p tom s su ch as p araesthesia and nu m bness m ay not
occu r instantly. This p osition p assively elevates the
shou ld er gird le bilaterally w ith the p atient’s tru nk
positioned p osteriorly to assure should er gird le end
range. A positive test is w hen a release phenom enon
occu rs, inclu d ing rep rod u ction of sym p tom s. One theory
su ggests that p araesthesia is the m ost com m on sym p tom
for those ind ivid uals w ith a release phenom enon
Diagnosing thoracic outlet syndrome 137
Table 12.3 Pos itive phys ical f ndings
Pos itive phys ica l f ndings – 50 p a tie nts %
Upper limb tension tes t (ULTT) 98
90° abduction in external rotation 100
Scalene muscle tenderness 94
Scalene press ure yields radiating symptoms 92
Neck rotation to opposite side 90
Head tilt to oppos ite s ide 90
Sensation to light touch 68
(Modi ed from Sanders et al 2008.)
follow ed by nu m bness and occasionally pain. Accord ing
to Cyriax (1978), paraesthesia and nu m bness app ear
w hen a nerve tru nk or cord is rst com pressed , follow ed
by a return of norm al sensation. After pressure is
released from the plexu s, these sym ptom s reoccu r
latently. This ou tcom e is d ifferent from the phenom enon
associated w ith nerve root com p ression, w hich p rod u ces
persistent sym p tom s until the root pressure is released
(Cyriax 1978; Brism ée et al 2004). Brism ée et al (2004)
show ed that a 1-m inu te m od i ed Cyriax release test is
the op tim al tim e lim it to m axim ize the sp eci city of the
test (speci city of 97%).
• Costoclavicular test: This test m ay be used for both
neu rological and vascu lar com p rom ise. The p atient
brings his should ers posteriorly and hyper exes his chin.
A d ecrease in sym p tom s m eans that the test is p ositive
and that the neu rogenic com ponent of the neu rovascu lar
bu nd le is com pressed . This test has show n a speci city
ranging from 53% to 100% d ep end ing on the assessm ent
of vascu lar changes or p ain resp ectively (Ryan & Jensen
1995; N ord et al 2008).
• Elevated f rst-rib test: For right rst-rib elevation,
patients w ill d em onstrate a signi cant loss of right lateral
exion, w ith hard end - ll in the p osition of left rotation
ind icating an elevated hypom obile rst rib on the
involved sid e. The second phase of the test consists of
passively rotating the neck to the sym p tom atic sid e to
end range, follow ed by lateral exion of the neck to the
op p osite sid e. This test is consid ered p ositive w hen there
is a d ecrease of lateral exion and a hard end - ll on the
effected sid e com pared w ith the contralateral sid e.
• Upper limb neurodynamics testing: This test is u sed to
ru le ou t neu rogenic p ain and to p rovoke sym p tom s.
N eu ral tissu e assessm ent can be assessed by active
m ovem ent d ysfu nction, p assive m ovem ent d ysfu nction,
ad verse resp onse to neural tissu e provocation test,
hyp eralgesic resp onse to p alp ation of nerve tru nks,
hyp eralgesic resp onses to p alp ation of related cu taneou s
tissu e and evid ence of related local p athology (H all &
Elvey 1999). (For this topic see Ch 64.)
The stu d y by Sand ers et al (2008) reported on 50 patients w ith
p ositive p rovocative testing (Table 12.3). Gillard et al (2001)
show ed that a clu ster of tw o p rovocative tests d isp layed the
highest sensitivity (90%), w hereas a clu ster of ve provocative
tests increased the speci city to 84%.
 138 PART 2 • 12 • Thoracic outlet syndrome
Imaging assessment of thoracic
outlet syndrome
TOS presents a challenge to d iagnosticians and controversy
exists regard ing w hat test and im aging assessm ent shou ld
be used for d iagnosis. Unfortunately, m any physicians d ou bt
the d iagnosis of the p athology becau se it cannot be rad io-
graphically or electrophysiologically d eterm ined . One school
of thou ght su ggests that p atients m u st d em onstrate tru e
neu rological signs to be d iagnosed w ith TOS and be con-
rm ed by electrom yograp hy or nerve cond u ction velocity for
brachial plexus com pression and / or Doppler stu d ies for
vascu lar com p rom ise as w ell as rad iograp hy to ru le ou t cervi-
cal rib.
Another school of thou ght w ou ld d iagnose TOS by the
interp retation of the history, sym p tom s and clinical exam ina-
tion. Clinical testing of TOS has been highly d ebated in litera-
tu re and no single test or qu estionnaire is u niversally accep ted
for its d iagnosis (Mackinnon & N ovak 2002).
Clinical d iagnosis can be assisted by the u se of im aging to
d em onstrate the nature and location of the structure und ergo-
ing com p ression and the stru ctu re p rod u cing com p ression,
bu t this is not alw ays necessary. The rst rad iographic proce-
d u re shou ld be a cervical plain rad iography to assess for bone
abnorm alities as w ell as to d ifferentiate the d iagnosis. Com -
p u ted tom ograp hy (CT) and angiography or m agnetic reso-
nance im aging (MRI) shou ld be p erform ed w ith p ostu ral
m anoeu vres in ord er to show the com p ression d ynam ically
(Dem ond ion et al 2006).
Clinical Treatment and Management of
Thoracic Outlet Syndrome
Conservative treatm ent is ind icated in p atients u nless there is
signi cant neu ral loss or vascu lar com p rom ise (Leffert 1991).
The focu s for conservative treatm ent is to d ecrease extrinsic
p ressu re, red u cing intrinsic irritation. The goal is to d ecrease
p ressu re on the neu rovascu lar bu nd le and give p atients the
tools to m anage their TOS. Conservative m anagem ent of TOS
consists of (in no p articu lar ord er): restoring norm al breathing
p atterns, red u cing in am m ation, d ecreasing m uscle tension,
elongating tight m uscles, strengthening w eak m u sculatu re,
m aintaining neu ral excu rsion and m obile joints, im p roving
p ostu re and bod y m echanics, and restoring m u scle balance
(Watson et al 2009).
Therapy evaluation of thoracic
outlet syndrome
The su bjective history exam ination is m ost helpfu l to u nd er-
stand p atients’ p ercep tion of the sym p tom s and d u ration of
tim e or chronicity of the sym p tom s. The d iagnosis and effec-
tive treatm ent of p atients p resenting w ith TOS is challenging
ow ing to its being a synd rom e involving m any p ain sou rces.
Provocation and sp eci c fu nctional tests p rovid e inform ation
to d esign an orthop aed ic m anu al therap y m anagem ent p ro-
gram m e as w ell as ad d ress other d ysfu nctions. TOS can cau se
p ain in the cervical and thoracic area and sp eci c m uscle
grou ps, and paraesthesia and num bness in the u pper extrem -
ity. It is im portant to id entify the stru cture cau sing the
sym p tom s and to id entify areas of hyp om obility or hyp erm o-
bility. The provocation tests are im portant to assist in isolating
the p ain generators and the m obility testing d eterm ines areas
of segm ental d ysfu nction. It is this au thor ’s exp erience that
id entifying the abnorm alities in the follow ing areas and
d esigning a treatm ent program m e arou nd these abnorm ali-
ties w ill assist in su ccessfu l ou tcom es.
Breathing patterns
Analysing the patient’s breathing p attern cannot be u nd er-
stated . Patients w ith TOS tend to breath w ith their u p p er
thorax w ithou t any abd om inal m ovem ent. When this occu rs
the accessory m u scles, p articu larly the scalene, elevate the
rst rib cau sing narrow ing of the thoracic ou tlet. When exam -
ining a patient w ho u ses the accessory respiratory m u scle, as
op p osed to d iap hragm atic breathing, it is not u ncom m on
to nd a d ecrease in hand tem p eratu re and d ecrease in
blood ow becau se of abnorm al sym pathetic tone or vascular
com p rom ise. The sym p athetic nervou s system u ses this
norm al p rotective resp onse of vasal restriction that alters
blood ow. It is im p ortant to change the breathing p attern to
a m ore relaxed d iaphragm atic breathing that allow s for
op ening in the thoracic ou tlet and red u ces m u scle tension.
The abnorm al breathing pattern of not using the d iap hragm
p erp etu ates a viciou s cycle of p ain, sp asm and congestion.
The key to teaching is to ask the patient to lie su pine w ith
both hand s p laced on the u pper abd om en and low er rib cage.
The abd om en lifts w ith respiration and low ers w ith expira-
tion. Observing hand m ovem ent w ill d eterm ine w hether
breathing is d one correctly. The scalene, in abnorm al breath-
ing, tend s to contract through the fu ll insp iratory phase. This
m aintains the elevation of the rst rib, w hich in tu rn w ill
com p rom ise the sp ace for the su bclavian vein to rem ain
u ncom p ressed .
By p erform ing relaxed rep eated breathing p atterns, there
is a d ecrease in m u scle tension. Im balances in the pressure
grad ients w ith TOS cau se an increase in tu nnel pressure,
w hich resu lts in venous stasis and hypoxia. If this hypoxia
continu es the oed em a arou nd the nerve, as w ell as broblastic
changes, can cau se scarring. Ed gelow (2004) u ses an analogy
to d escribe this situ ation as a river ow ing into a lake and a
river ow ing out of the lake, in w hich the in ow equals the
ou t ow. In this state, the volu m e of the lake is constant, the
oxygen content is high, and the p ollu tion content is low.
Shou ld there be an obstru ction affecting the ou t ow, then the
volu m e of the lake w ou ld increase, the oxygen content w ou ld
d ecrease and the pollution w ou ld increase.
Muscle imbalance
Mu scle im balance is a m ajor sou rce of sym p tom s in p atients
w ith TOS. Abnorm al postu res such as forw ard -held head ,
round ed shou ld ers and protracted shou ld ers are d am aging
p ostu res for the scap u lar and neck m u scles and shou ld be
ad d ressed im m ed iately. It is im portant to m ake su re that the
scalene m u scles, w hich elevate the rst rib, are not tense. If
the scap u la m u scles are w eak, then an abnorm al scap u lar
m ovem ent p attern w ill resu lt in w eakness in the m id d le and
 Clinical treatment and management of thoracic outlet syndrome
low er trapeziu s and serratu s anterior m u scles. The scalene
can overw ork, cau sing m ore entrap m ent. An evalu ation of
p ostu re shou ld includ e evalu ating m u ltiple joint and scapu la
m ovem ents. It is im p ortant to assist the scap u la p osition at
rest and see w hether the scapu la is d ep ressed and d ow n-
w ard ly rotated , w hich can be a contributing factor to TOS. In
the above exam p le, the scap u la w ou ld be low er than T2–T7
and the slop e of the shou ld ers w ou ld be increased , w hich
w ou ld m ake the neck appear longer. With scapu la d epression
d u ring overhead reaching, there are changes occu rring at the
acrom ioclavicu lar (AC) joint esp ecially w ith large and heavy
arm s. The AC joint, u su ally at the end range, w ill show creases
that increase in overhead activities. A d ow nw ard ly rotated
scap u la can be id enti ed becau se its inferior angle is closer to
the sp ine than the su p erior angle. Another w ay to assess
scap u la d ow nw ard rotation is evalu ating m ovem ent into
exion and abd u ction; this m ovem ent norm ally causes signs
of p u lling or p ain located in the teres m ajor and latissim u s
d orsi region (Sahrm ann 2002).
Joint stiffness
The brachial plexu s can be com pressed w ith joint stiffness or
cap su lar tightness. Several au thors have p rop osed m obiliza-
tion of the cervical, thoracic, sternoclavicu lar, AC and cos-
totransverse joints to im p rove joint stiffness or hyp om obility,
range of m otion and capsular tightness in u pper qu ad rant
cond itions (Brism ée et al 2005; Vanti et al 2007). Manual
therap y techniqu es aim ed at the joints, soft tissu e and neu ral
stru ctu re of the u p p er qu ad rant inclu d ing the cervical and
thoracic sp ine have been su ccessfu l in treatm ent. Research has
show n that thoracic m obilization, esp ecially at the T4 area, is
help fu l to p rovid e an inhibitory in u ence on the SN S and
cau ses im m ed iate p ost-treatm ent p ain relief (Yip -Menck et al
2000). Thoracic m obilization has proven effective in im prov-
ing postu re, hand and skin tem peratu re as w ell as pain in
TOS (see Ch 13). The stu d y by Stralka (2000), u sing grad e
III oscillation m ovem ent p osterior-anterior at T4 level,
show ed sim ilarities in increased hand and skin tem p eratu re.
Taskaynatan et al (2007) rep orted that inclu sion of m echanical
cervical traction red u ced com p laints of nu m bness in p atients
w ith TOS.
Evid ence exists that thoracic joint m obilization d ecreases
pain (Colachis et al 1966; Saal et al 1966; Brow d er et al 2004)
and it has been theorized that biom echanical d istu rbances
of the thoracic sp ine can contribu te to cervical d isord ers
(Greenm an 1996; N orland er et al 1997; Brow d er et al 2004;
Gross et al 2004). When the SN S resp ond s there is a norm al
protective resp onse of vasoconstriction that alters blood ow.
Au tom atic im proper breathing patterns along w ith pain,
stress and anxiety can cau se SN S activity that m aintains a
cycle of p ain, tension and d ysfu nction. The involvem ent of
the SN S by researchers is controversial – bu t m y experience
has show n that, by changing the sym p athetic activity, there
can be a p ositive in u ence on the p atients’ sym p tom s.
Neurogenic pain
It is the au thor ’s experience that u pper lim b nerve tension
testing p rovocative m anoeu vres along w ith clinical exam ina-
tion are extrem ely help fu l in id entifying N TOS. N eu ral
139
m obility is an im p ortant p art of a su ccessfu l ou tcom e. The
p rovocation testing w ill reveal w hether the p atient is a releaser
or a com p ressor, and this is u sefu l in ed u cating the p atient as
to w hich p ositions of com fort w ill d ecrease sym p tom s. The
u p p er lim b nerve tension testing is u sefu l for id entifying
the area of sp eci c brachial p lexu s entrap m ents. With TOS,
the low er tru nk / m ed ial cord (C7–T1) is m ost com m only
involved . The u pper lim b nerve tension testing and Tinel’s
test often locate the neu rogenic irritability both p roxim al and
d istal, w hich is com m only referred to as a d ouble-cru sh syn-
d rom e (Plew a & Delinger 1998). These tests shou ld not aggra-
vate the sym p tom s (see Ch 65).
Rep rod u ction of rad iating neu rogenic arm p ain w ith p ar-
aesthesia is a p ositive response. When this test is positive, it
is an ind icator of com pression against the nerve roots or bra-
chial p lexu s.
Intervention for thoracic outlet syndrome
There are m any schools of thou ght contribu ting to the therapy
and m anagem ent of TOS. Peter Ed gelow, a p hysiotherapist,
u tilizes three concep ts that are the gu id ing p rincip les for
effective treatm ent of neu rovascu lar entrapm ent, w hich are
built on the fund am ental id ea that entrapm ent occurs as a
consequ ence of trau m a affecting the nerve or vascu lar system
(Ed gelow 2004). H is rst concep t is patient em pow erm ent,
w hich m eans patients m u st be responsible and in control of
their ow n care in ord er for treatm ent to be long lasting. The
im portance of treating the w hole person cannot be und eres-
tim ated and is su p p orted by this au thor. The m ost su ccessfu l
ou tcom es are obtained w ith ap p lication of a m u ltifactorial
ap proach starting w ith patients being em pow ered to take care
of their ow n p roblem s by u nd erstand ing both their TOS
d ilem m a as w ell as the treatm ent solu tion. In treatm ent, it is
im portant to gain patients’ tru st, stay in contact w ith them
and m ake su re they u nd erstand their problem . The im pact of
having this long-lasting p ain synd rom e w ithou t correctly
being d iagnosed as TOS is that ind ivid uals feel they are losing
control of their life. Restoring the feeling of ‘being in control’
has a p ositive im p act on the ind ivid u al. H ow ever, it has been
m y exp erience that there is no qu ick x in treating p atients
w ith TOS; that is w hy p atients m ust und erstand the length of
the p rogram m e and be d iligent w ith the exercise p rogram m es.
It is also im portant for the patient to u nd erstand the risks and
rew ard s in paying close attention to sym p tom s; u nd erstand -
ing the problem and the solution reinstates control in the
p atient’s life. Ed gelow (2004) also su ggests that ind ivid ual
risk factors, health habits, d aily living d em and s and belief
system s that can be controlled are im p ortant for the treatm ent
of TOS.
The second concept is that neu rovascu lar entrapm ent is a
p roblem of stenosis. Stenosis shou ld not be thou ght of as a
rigid narrow ing of an anatom ical p art, bu t rather a series of
events and circu m stances. These events m ay resu lt in irre-
versible narrow ing. The stenosis cau sed by the p resence of a
cervical rib or d ysfu nction of the scalene m ay be irreversible,
but the stenosis d u e to abnorm al breathing patterns and
abnorm al p ostu re can be reversed (Ed gelow 2004).
The third concept Ed gelow stresses is that of uid d ynam -
ics. As stru ctu ral and u id changes cau se restriction in the
size of the thoracic ou tlet, they also cau se changes in the p res-
su re grad ient, w hich also affects the local neu ral circu lation
 140 PART 2 • 12 • Thoracic outlet syndrome
and the venou s and lym phatic retu rn to the entire u pper
extrem ity.
Conclusion
Com m u nication betw een the referring p hysician and p hysical
therap ist is a necessity to assu re p ositive ou tcom es. Many
au thors com bine treatm ent of soft tissu es and joints w ith
neu ral tissu e treatm ent (Ed gelow 2004). This m anagem ent
inclu d es p ostu re correction, treatm ent of affected stru ctu res
– inclu d ing nerve excu rsions, m u scu lar and articular struc-
tu res – as w ell as ad d ressing the em otional com ponent, w hich
is necessary for su ccessfu l ou tcom es.
The goal of treatm ent is to teach the p atient to op en u p the
sp ace betw een the clavicle and rst rib by stretching tight
m u scles, strengthening w eak m u scu latu re, d ecreasing nerve
tension in the u p p er qu ad rant, im p roving tem p eratu re d iffer-
ences in the hand , im proving d iap hragm atic breathing and
increasing sp inal m obility in the cervical–thoracic area. A
clear u nd erstand ing and interp retation of the p rovocative test
are necessary for su ccessfu l outcom es. Patients m u st realize
that a p eriod of 6 m onths or longer m ay be necessary to m ake
a lasting effect on their sym ptom s.
As w e m anage p atients, I have found that they m ay p erform
stretching exercises w ithou t u sing p rop er techniqu es. Most
p atients d o not u nd erstand that lateral exion w ithou t stabi-
lizing the rst rib continu es to ad d ad d itional com p ression
and tension in the scalene m u scles. They m u st be instru cted
in lateral exion w ith slight rotation along w ith u sing a tow el
or a strap to hold the rib in a cau d al p osition.
A total-w ellness concep t of good eating habits and aerobic
cond itioning shou ld also be follow ed . Many TOS p atients are
in p oor aerobic cond ition, w hich resu lts in d ecreased resp ira-
tory fu nction and overu se of the scalene, trap eziu s and ster-
nocleid om astoid m u scles. Postu ral correction, inclu d ing
sp inal extension, w ill allow better chest exp ansion w ith insp i-
ration resulting in d iaphragm atic excursion and w ill d ecrease
the u sage of the accessory resp iratory m u scles (Mackinnon &
N ovak 2002).
Clinical exp erience has show n that, by id entifying the
m echanical origin of sym p tom s, a su ccessfu l treatm ent p ro-
gram m e consisting of sym p tom alleviation is m ost helpfu l,
along w ith em p ow ering patients to be in charge of their ow n
sym p tom s. Ed u cating the p atient in p rop er p ostu re and
breathing p atterns both at w ork and at leisu re is the corner-
stone for d esigning a treatm ent p rogram m e. Physical therap y
that ad d resses p ostu ral abnorm alities, neu ral m obility, joint
m obility and m u scle im balances is effective in relieving sym p -
tom s of TOS.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
Thoracic Spine Manipulation
13  Chapter 
W illia m Eg a n , P a u l E. G lyn n , J o s h u a A. C le la n d
CHAP TER CONTENTS
Introduction  142
Regional interdependence o  the thoracic spine, rib cage and   tom s rad iating to the u p p er extrem ity below the shou ld er.
the upper quarter  143
Biomechanical relationship between the thoracic spine and   d isease or contraind ications, you elect to perform thru st
upper quarter  143
Pain re erral patterns o  the thoracic spine  143
Association between thoracic spine impairments and upper  
quarter pain syndromes  143
Evidence  or manual therapy management o  the thoracic spine  
and rib cage in upper quarter pain syndromes  144
Examination and screening o  the thoracic spine and rib cage in  
patients with upper quarter musculoskeletal pain  148
Postural screen o  the thoracic spine and rib cage  148
Thoracic spine active range o  motion  149
Mobility testing o  the f rst rib  149
Segmental mobility testing o  the thoracic spine and rib cage  149
Interpretation o  the examination and reassessment  149
Manual therapy interventions  or the thoracic spine and rib cage  150
Seated upper thoracic thrust manipulation  150
Seated mid-thoracic thrust manipulation  151
Prone upper thoracic thrust manipulation  151
Prone mid-thoracic thrust and non-thrust manipulation  151
Supine upper and mid-thoracic thrust manipulation  152
Seated f rst-rib thrust and non-thrust manipulation  153
Supine f rst-rib thrust and non-thrust manipulation  154
Prone or side-lying ribs non-thrust manipulation  154
Supine ribs thrust manipulation  154
Exercise interventions to augment the manual   regions.
therapy techniques  154
Conclusion  155
Introduction
For ind ivid uals w ith u pper quarter m uscu loskeletal d isor-
d ers, the thoracic sp ine is infrequ ently the prim ary source of
sym p tom s. H ow ever, taking into accou nt the concep t of
regional interd epend ence, the thoracic spine and rib cage can
p lay a signi cant role in the p erp etuation and m anagem ent
of u p p er qu arter p ain (Wainner et al 2007; Sueki et al 2013).
For instance, a 45-year-old fem ale p resents to you r clinic w ith
m echanical neck p ain. H er p ain is of recent onset, occu rring
insid iou sly w ithin the last 2 w eeks, and she d enies any sym p -
After a clinical exam ination that id enti ed no signs of serious
m anip u lation targeting her u p p er and m id thoracic sp ine.
You also instruct her on m obility exercises for her cervical
sp ine as w ell as d eep neck exor retraining. The p atient
retu rns 3 d ays later and reports a 3-p oint red u ction on the
N u m erical Rating of Pain Scale (N RPS) and a 25% d ecrease
on the N eck Disability Ind ex (N DI).
You also exam ine a 37-year-old m ale w ith right shou ld er
p ain; signs and sym p tom s are consistent w ith su bacrom ial
im p ingem ent synd rom e as w ell as m obility im p airm ents of
his thoracic sp ine and rib cage. You p erform a thru st m anip u -
lation of the patient’s up per and m id thoracic sp ine in ad d i-
tion to non-thru st m obilization of the p atient’s rib cage.
Im m ed iately follow ing the m anipu lation the patient reports a
50% d ecrease in resting pain and his p ain-free active should er
elevation is increased by 10°. You instruct the p atient in tho-
racic extension m obility exercises as w ell as strengthening
exercises for the low er trap ezius and serratu s anterior m u scles.
Up on retu rn to the clinic 5 d ays later, the p atient’s score on
the Shou ld er Pain and Disability Ind ex (SPADI) is d ecreased
by 25%. These tw o hyp othetical clinical scenarios are based
on the nd ings from recent clinical trials (Bergm an et al 2004;
González-Iglesias et al 2009b). Therefore, ad d ressing im pair-
m ents in the thoracic region can lead to im p rovem ents in p ain
and d isability in patients w ith d ifferent u pp er qu arter m u scu -
loskeletal d isord ers inclu d ing the neck, shou ld er and elbow
In the m anagem ent of patients w ith upper qu arter d isor-
d ers the thoracic sp ine has trad itionally been overlooked .
H ow ever, there is evid ence suggesting a strong biom echanical
relationship betw een the thoracic spine, rib cage and the u pper
qu arter (Sobel et al 1996; Kebaetse et al 1999; Theod orid is &
Ru ston 2002; Crosbie et al 2008). Further, stud ies have show n
that m anu al therap y treatm ent d irected tow ard s the thoracic
sp ine can have a p ositive im p act on the ou tcom es of ind ivid u -
als w ith d isord ers of the u p per extrem ity and cervical sp ine
(Winters et al 1997; Bergm an et al 2004; You ng et al 2009;
H u ism an et al 2013). This chap ter covers anatom ical- and
biom echanical-related aspects of the thoracic sp ine, scienti c
and clinical evid ence for the relevance of the thoracic sp ine
 Regional interdependence o  the thoracic spine, rib cage and the upper quarter  143
for up per quarter pain synd rom es, thoracic spine and rib cage
exploration and m anip ulative interventions.
Regional Interdependence of
the Thoracic Spine, Rib Cage and
the Upper Quarter
Biomechanical relationship between
the thoracic spine and upper quarter
The structure and fu nction of the thoracic spine and rib cage
create a sym biotic relationship w ith the cervical sp ine and
u p p er extrem ity. The thoracic colu m n serves as the base of
su p p ort for the cervical sp ine and is intim ately involved w ith
the neck at the region of the cervicothoracic ju nction. Stiffness
and m ovem ent im pairm ents of the cervicothoracic ju nction
are com m on nd ings in patients w ith prim ary com plaints of
neck p ain, head aches or u p p er extrem ity p ain synd rom es
(Sobel et al 1997; Piva et al 2006; Cleland et al 2007a; Berglu nd
et al 2008). The posture of the thoracic sp ine has been show n
to in u ence the p ostu re of cervical sp ine and u p p er extrem ity
(Kebaetse et al 1999). For instance, an increase in the thoracic
kyphosis, w hich is com m on in the typ ical of ce w orker, is
associated w ith a forw ard head postu re as w ell as an abd u cted
and anteriorly tip ped scap ular p osition. To achieve full fu nc-
tional m ovem ent of the cervical sp ine and u p p er extrem ities,
concom itant m otion of the thoracic sp ine and rib cage and an
erect, neu tral thoracic p osture are requ ired . For exam ple, full
u p p er extrem ity elevation is accom p anied by thoracic exten-
sion and ip silateral sid e-bend ing (Theod orid is & Ruston
2002). Theoretically this w ould also requ ire external rotation
of the ip silateral ribs, w hich has been associated w ith thoracic
sp ine extension (Crop per 1996). It has been show n that a
slou ched or exed thoracic p ostu re lead s to d ecreased scap u -
lar p osterior tipping d uring m axim um glenohum eral abd u c-
tion m otion and d ecreased abd u ction force at 90° of abd u ction
com p ared w ith an erect thoracic p ostu re (Kebaetse et al 1999).
Key p ostu ral m u scles sp an from the thoracic sp ine to scap u lar
regions. These m u scles inclu d e the m id d le and low er portions
of the trap eziu s and the serratu s anterior. Postu ral or m ove-
m ent im p airm ents in the thoracic region cou ld p lay a role
in d ysfu nction of these m uscles and therefore have a d irect
in uence on m ovem ent im pairm ents and pain in the cervical
and u p p er extrem ity regions. Tw o stud ies fou nd that low er
trap eziu s m u scle strength increased after either thru st m anip -
u lation or non-thru st m obilization targeting the m id to
low er thoracic spine (Liebler et al 2001; Cleland et al 2004a).
Although both of these stu d ies involved asym ptom atic sub-
jects and m easu red im m ed iate changes in strength only, they
su ggested a clinically signi cant relationship betw een the
thoracic sp ine and the low er trap eziu s m u scle.
Pain referral patterns of the thoracic spine
It is uncom m on for the thoracic spine to cause referred p ain
to the cervical or u p p er extrem ity regions. The cervical sp ine
and u p p er extrem ities d o not receive d irect innervation from
the thoracic roots, w ith the excep tion of the rst thoracic
nerve root. H ow ever, the sym p athetic nervou s system via
the sym p athetic chain, ru nning anterior to the costovertebral
joints, can have a system ic effect and contribu te to sym ptom s
in the neck and u pper extrem ities. A clinical synd rom e referred
to as the ‘T4 synd rom e’ has been d escribed as a constellation
of signs and sym p tom s associated w ith stiffness of the u p p er
to m id thoracic region (Conroy & Schneid ers 2005). Typical
signs and sym p tom s inclu d e head aches, neck p ain and arm
p ain, and bilateral ‘stoking glove’ p araesthesiae. It is thou ght
that these signs and sym p tom s cou ld be resu lting in p art from
d ysfu nction of the thoracic spine and its in u ence on the
sym p athetic nervou s system .
Fu rtherm ore, a p ublished case rep ort d escribed a d ecrease
in sym ptom s in a patient w ith upp er extrem ity com p lex
regional pain synd rom e after a thrust m anipu lation d irected
to the u p p er thoracic sp ine (Menck et al 2000). In pain-
m ap p ing stu d ies of the thoracic sp ine facet joints and cos-
totransverse joints, local p ain ad jacent to the injected site is
m ost com m only rep orted (Dreyfuss et al 1994; Fuku i et al
1997; You ng et al 2008). Subjects in these stu d ies have not
reported referred p ain into the neck or the u pper extrem ity
regions. Given the lack of a neuroanatom ical relationship w ith
the cervical sp ine or u p p er extrem ities, this is not su rp rising.
Patients w ith sym p tom atic thoracic d isc herniation typ ically
report thoracic spine and chest w all p ain and d o not report
neck or arm p ain (Wood et al 1999). With the exception of
sym p tom s originating from the u p p er tw o thoracic segm ents
and the thoracic sym pathetic chain, the thoracic sp ine as a
d irect source of referred pain or sym ptom s to the cervical
sp ine or u p p er extrem ity regions is u nlikely.
Association between thoracic spine
impairments and upper quarter
pain syndromes
Postu ral im p airm ents and m ovem ent d ysfu nctions of the tho-
racic spine have been fou nd in p atients w ith u p p er qu arter
m u scu loskeletal d isord ers. In a series of stu d ies, N orland er
et al (1996, 1997) fou nd that m ovem ent d ysfunction of the
u p p er thoracic sp ine w as associated w ith u p p er qu arter
sym p tom s in a grou p of lau nd ry w orkers. In their initial stu d y
and 2-year follow -u p, N orland er et al (1996, 1997) fou nd that
a d ecrease in forw ard exion m obility of C7–T1, com pared
w ith T1–T2, pred icted com plaints of neck and shou ld er pain.
They referred to this nd ing as an ‘inverse C7–T1 relation-
ship’, becau se in healthy su bjects they fou nd that C7–T1
had greater exion m obility than T1–T2. In a third stu d y,
N orland er and N ord gren (1998) found that a red u ction in
forw ard exion m obility of C7–T1 and T1–T2 w as associated
w ith a threefold increase in com plaints of neck p ain, head -
aches, shou ld er pain and bilateral hand w eakness in a grou p
of electrical and lau nd ry w orkers. These au thors hyp othe-
sized that sensory inp u t from joint recep tors of the d ysfu nc-
tional thoracic segm ents cou ld p otentially contribu te to the
neck and shou ld er sym p tom s. Fu rther research is requ ired to
m ake d e nitive conclu sions.
Movem ent d ysfu nction of the thoracic sp ine, rib cage and
shou ld er gird le has been associated w ith p atients rep orting
shou ld er pain in prim ary care practices. In a 12–18-m onth
follow -up of patients w ith shou ld er com plaints, Winters et al
(1999) fou nd that patients w ho reported that their shou ld er
p ain w as not ‘cu red ’ w ere m ore likely to have p ain or lim ited
 144 PART 2 • 13 • Thoracic spine manipulation
m obility of the shou ld er gird le. These au thors d e ned the
shou ld er gird le as the cervical and u p p er thoracic sp ine, or
u p p er ribs. This w as in com p arison to p atients d iagnosed
w ith a synovial d isord er originating from the glenohu m eral,
acrom ioclavicu lar or su bacrom ial joints w ithou t d ysfu nction
of the shou ld er gird le. In another stu d y, it w as show n that
p atients p resenting w ith should er gird le d isord ers respond ed
w ell to m anip ulative therapy targeting im pairm ents in this
region, w hereas patients w ith synovial d isord ers respond ed
best to steroid injection (Winters et al 1997).
Lateral elbow p ain, a com m on u p p er extrem ity m u scu -
loskeletal d isord er, has been associated w ith several im p air-
m ents. Am ongst these are p ain and m obility restrictions of the
cervical and thoracic sp ine. One stu d y fou nd that su bjects
w ith lateral elbow pain had signi cantly higher frequ ency of
p ositive resp onses w ith sp ring testing over the T1–T7 regions
com p ared w ith su bjects w ithou t elbow pain (Berglu nd et al
2008). H ow ever, d e nitive conclu sions cou ld not be d raw n
abou t the association betw een p ain w ith thoracic spring
testing and lateral elbow p ain in this stu d y, and this nd ing
m ay be attribu ted to the p henom enon of central sensitization
of p ain. N evertheless, assessm ent and m anagem ent of tho-
racic spine im pairm ents in patients w ith elbow pain is the
consid eration in the clinic. In a sm all p ilot stu d y and a larger
retrospective stu d y, Cleland et al (2004b, 2005a) fou nd that
p atients w ho received m anu al therap y proced u res targeting
the cervical and thoracic region in ad d ition to treatm ent of the
elbow achieved m ore favourable ou tcom es than d id those
p atients w ho received m anagem ent of the elbow only.
Evidence for Manual Therapy
Management of the Thoracic Spine
and Rib Cage in Upper Quarter
Pain Syndromes
Du e to the relatively sm all num ber of patients w ith prim ary
com p laints of thoracic sp ine and chest w all p ain, there is only
low -qu ality evid ence su p p orting the u se of m anu al therap y
p roced u res in the m anagem ent of thoracic spine and chest
w all pain. In a pilot stu d y, Schiller (2001) fou nd that patients
w ith m echanical thoracic spine pain show ed a signi cantly
greater red uction in pain scores after six treatm ents of m anip-
u lative therap y targeting the thoracic sp ine com p ared w ith a
p lacebo control group . Techniques utilized in the stud y w ere
short lever thru sts w ith d irect contact on the transverse p roc-
esses. In a case report Kelley and Whitney (2006) d escribed
the im m ed iate relief of right low er chest w all p ain after a non-
thru st m anip u lation of the m id thoracic sp ine in an ad olescent
athlete. Fru th (2006) reported a case of a patient w ith right
u p p er thoracic p ain that w as resolved after seven p hysical
therap y visits inclu d ing non-thru st m anip u lation of the ribs,
ischaem ic com p ression of trigger p oints and therap eu tic exer-
cise. In a retrospective review of 73 p atients reporting to a
rheu m atology clinic w ith a prim ary com plaint of thoracic
sp ine p ain, Bru ckner et al (1987) rep orted that the m ajority of
the patients w ere either p ain free (77%) or noted slight
im p rovem ent (15%) after p ostu ral ad vice and m anipulative
treatm ent of the thoracic spine. The m ajority of patients (75%)
in this retrospective review reported m id -thoracic pain and
abou t half also com plained of anterior chest w all pain. Patients
w ith chest w all pain should receive a d ifferential d iagnosis to
ru le ou t card iac and visceral d isord ers. Mu scu loskeletal p ain
involving the thoracic spine can potentially cau se pseu d oan-
ginal or pseud ovisceral pain.
There have been tw o rep orts in the literature concerning
p atients w ith anterior chest or abd om inal p ain w ho have been
w orked u p for card iac and visceral d isord ers w ith negative
nd ings (H am berg & Lind ahl 1981; Benham ou et al 1993).
These patients w ere fou nd to have m echanical thoracic pain
that resp ond ed to either m anip u lation of the thoracic sp ine or
injection of the costovertebral joints. Another stu d y id enti ed
historical qu estions that assist the clinician in d eterm ining the
sou rce of a p atient’s abd om inal p ain as being m u scu loskeletal
in origin (Sparkes et al 2003). For abd om inal pain to be con-
sid ered of m u scu loskeletal origin, the p atient shou ld answ er
yes to tw o questions and no to one qu estion. This lead s to a
p ositive likelihood ratio of 4.2 that the p atient’s p ain is of
m u scu loskeletal origin.
The ‘yes’ questions are:
• Does coughing, sneezing, or taking a d eep breath m ake
your pain feel w orse?
• Do activities such as bend ing, sitting, lifting, tw isting, or
tu rning over in bed m ake you r p ain feel w orse?
The ‘no’ question is:
• H as there been any change in you r bow el habits since the
start of you r sym p tom s?
There has been a recent em ergence in the literature of stud ies
investigating the effect of m anu al therapy proced u res target-
ing the thoracic sp ine in p atients w ith neck d isord ers. Given
the sm all risk of seriou s ad verse events associated w ith cervi-
cal thru st m anip u lation, som e au thors ad vocate thoracic
thru st m anip u lation as a safe alternative to cervical m anip u la-
tion esp ecially in the p resence of severe sym p tom s or rad icu -
lop athy, or p ost w hiplash (Piva et al 2000; Pho & God ges 2004;
Child s et al 2005). There are a few stud ies show ing that
p atients w ith m echanical neck p ain bene t from thru st
m anip u lation of the thoracic sp ine. These inclu d e tw o case
series, nine rand om ized clinical trials, a p relim inary clinical
p red iction ru le stu d y and tw o system atic review s (Savolainen
et al 2004; Cleland et al 2005b, 2007a, 2007c, 2010; Fernánd ez-
d e-las-Peñas et al 2007; Krauss et al 2008; González-Iglesias
et al 2009a, 2009b; Cross et al 2011; Lau et al 2011; Pu ented ura
& Land ers 2011; H u ism an et al 2013; Masaracchio et al 2013).
These stu d ies are of varying qu ality, and som e of the evid ence
is con icting, but in su m provid e substantial evid ence that
p atients w ith m echanical neck p ain can exp erience clinically
m eaningfu l im p rovem ent in p ain and d isability follow ing
thru st m anip u lation of the thoracic sp ine. It is im p ortant to
note, how ever, that in several of the stu d ies the thoracic sp ine
m anip u lation w as au gm ented by a therap eu tic exercise p ro-
gram m e. In these stud ies variou s techniques w ere u tilized
includ ing seated , prone and supine thru sts targeting both
the m id and u p p er thoracic sp ine. Table 13.1 p rovid es an
overview of these stu d ies involving p atients w ith m echanical
neck p ain.
N eck pain after a w hiplash inju ry is very com m on. There
has been one rand om ized clinical trial and one case rep ort
concerning m anip u lation of the thoracic sp ine in p atients
w ith neck pain after a w hip lash injury. In a tw o-part stu d y,
 Evidence  or manual therapy management o  the thoracic spine and rib cage in upper quarter pain syndromes  145

Table 13.1 Ove rvie w of s tudie s involving thoracic s pine manipulation for pa tie nts with me chanical ne ck pain
Author ye a r Stud y d e s ig n Sub je cts Inte rve ntions Outcome s

Cleland et al 2005b RCT 36 patients with Supine thoracic thrust Immediate clinically s ignif cant reduction
mechanical neck manipulation vs placebo. in neck pain ollowing thrust compared
pain with placebo.
Cleland et al 2007c RCT 60 patients with 6 sessions o thoracic thrus t At the completion o 6 sessions the thrust
mechanical neck manipulation and exercis e vs group achieved clinically s ignif cant
pain non-thrus t manipulation and more reduction in pain and dis ability
exercis e. as meas ured by the NDI compared
with the non-thrust group.
Cleland et al 2007a Pros pective 78 patients with All s ubjects received up to 2 The ollowing variables compris ed the
cohort study mechanical neck s ess ions o thoracic thrus t clinical prediction rule or patients who
pain manipulation targeting both the would achieve clinically meaning ul
mid and upper thoracic s pine improvement on the Global Rating o
and ROM exercis e or the Change s cale:
cervical s pine. 1. Symptoms < 30 days
Patients achieving at least 3 o 6 2. No symptoms below the s houlder
variables have a pos itive 3. Looking up does not aggravate
likelihood ratio o 5.5 or a symptoms
s ucces s ul outcome with the 4. FABQPA score < 12
intervention. 5. Diminished upper thoracic spine
kyphosis
6. Cervical extens ion ROM < 30°.
Cleland et al 2010 RCT 140 patients with 2 sessions o thoracic spine There was a clinically meaning ul
mechanical neck manipulation and cervical di erence in dis ability at short- and
pain. range o motion exercise long-term ollow-up and pain at
Hal o the patients ollowed by 3 s ess ions o s hort-term ollow-up avouring thoracic
in each group cervical s trengthening and s pine manipulation combined with
met 3 o the s tretching exercis es, vs exercis e compared with exercis e alone.
variables or the 5 sessions o cervical Status on the above-mentioned CPR did
above-mentioned s trengthening and stretching not a ect the outcome within either
CPR. exercis e. group.
Cross et al 2011 Systematic 6 RCTs involving In all 6 studies the experimental E ect sizes or pain in avour o thoracic
review patients with group received thoracic s pine s pine manipulation varied rom small
mechanical neck manipulation. Note: All six o to large across studies .
pain thes e s tudies are included in E ect sizes or patient reported neck
this table. dis ability ques tionnaires in avour o
thoracic manipulation were moderate
to large.
Fernández-de-las- Cas e Series 7 patients with All patients received a single All patients achieved an immediate
Peñas et al 2007 mechanical neck thrus t manipulation in s itting reduction in res ting pain and improved
pain targeting the upper thoracic cervical range o motion ollowing the
s pine. manipulation.
Flynn et al 2001 Cas e series 26 patients with All patients received thrust Immediately pos t intervention, patients
neck pain manipulation targeting experienced a clinically meaning ul
hypomobile s egments improvement in cervical ROM and a
including the upper and mid reduction in res ting pain.
thoracic s pine and rib cage.
González-Iglesias RCT 45 patients with 6 sessions o TENS, exercis e Patients in the manipulation group
et al 2009a mechanical neck and mass age vs the same achieved a clinically s ignif cant greater
pain programme plus thoracic spine reduction in pain and disability s cores
thrus t manipulation in s itting and increased cervical range o motion
1× / week × 3 weeks. compared with the non-manipulation
group at the completion o the
intervention.
Continued
146 PART 2 • 13 • Thoracic spine manipulation

Table 13.1 Ove rvie w of s tudie s involving thoracic s pine manipulation for patie nts with me cha nica l ne ck pain—cont’d
Author ye a r Stud y d e s ig n Sub je cts Inte rve ntions Outcome s
González-Iglesias RCT 45 patients with 5 ses sions on electrothermal Patients in the manipulation group
et al 2009b mechanical neck therapy vs the s ame treatment achieved a clinically s ignif cant greater
pain plus a seated thoracic thrust reduction in pain and disability s cores
manipulation 1× / week × 3 than the non-manipulation group at the
weeks . end o the intervention, and at 2-week
ollow-up. The manipulation group
continued s how a clinically meaning ul
improvement in pain compared with
the non-manipulation group at the
4-week ollow-up.
Huis man et al Systematic 10 RCTs involving In all 10 studies the experimental 8 o the 10 studies reported a clinically
2013 review 677 patients with group received thoracic s pine s ignif cant reduction in pain and
mechanical neck manipulation. dis ability with thoracic s pine
pain Note: All 10 o these studies are manipulation.
included in this table. There is insu f cient evidence to s tate that
thoracic s pine manipulation is s uperior
to control interventions at this time.
Kraus s et al 2008 RCT 22 patients with Thoracic thrust manipulation to The thoracic manipulation group reported
mechanical neck the T1–T4 segments in supine a clinically meaning ul increas e in right
pain vs a control group and le t cervical rotation range o
motion and a decrease in pain with
right cervical rotation compared with
the control group.
Lau et al 2011 RCT 120 patients with 8 ses sions o thoracic spine The thoracic manipulation and exercise
chronic neck manipulation, in rared radiation group reported a clinically meaning ul
pain therapy, exercis e, and di erence in neck pain and disability
education vs 8 ses sions o compared with the control group at
in rared radiation therapy and 6-month ollow-up.
education alone.
Mas aracchio et al RCT 64 patients with 2 ses sions o thoracic spine The thoracic spine manipulation and
2013 mechanical neck thrus t manipulation, cervical cervical non-thrust manipulation group
pain s pine non-thrus t manipulation, reported a clinically meaning ul
and cervical range o motion di erence in neck pain and disability at
exercis e vs 2 sessions o 1-week ollow up compared with the
cervical spine non-thrust cervical non-thrust manipulation group.
manipulation and exercise.
Puentedura et al RCT 24 patients with 2 ses sions o thoracic spine The cervical spine manipulation and
2011 neck pain who manipulation and range o exercis e group reported a clinically
met at least 4 motion exercise ollowed by meaning ul di erence in neck pain and
out o the 6 3 ses sions o cervical disability at short- and long-term
variables on the s trengthening and stretching ollow-up compared with the thoracic
thoracic spine exercis e vs 2 sessions o s pine manipulation group.
manipulation cervical spine manipulation
CPR and range o motion exercis e
ollowed by 3 s ess ions o
cervical strengthening and
s tretching exercise.
Savolainen et al RCT 75 subjects with 4 ses sions o thoracic Subjects in the manipulation group
2004 mechanical neck manipulation vs ins truction in reported a signif cantly lower level o
pain an exercis e programme. worst perceivable pain at 12-month
ollow-up.
Sillevas et al 2010 RCT 100 patients with 1 ses sion o thoracic s pine No within or between group di erences
chronic neck manipulation vs placebo. in pain or s ympathetic nervous sys tem
pain activity at immediate ollow-up.
RCT = randomized controlled trial; ROM = range o motion; CPR = clinical prediction rule; NDI= neck dis ability index; TENS = transcutaneous nerve stimulation.
 Evidence  or manual therapy management o  the thoracic spine and rib cage in upper quarter pain syndromes  147
Fernánd ez-d e-las-Peñas et al (2004) rst com pared the inci-
d ence of thoracic spine d ysfu nction in patients suffering
m echanical neck p ain w ith those w ho had neck p ain from a
w hiplash. Thoracic spine d ysfunction w as id enti ed by pal-
p ation for asym m etry in thoracic exion and pain, or hypo-
m obility associated w ith sp ring testing of the thoracic sp ine;
based on these criteria, 69% of patients w ith w hip lash had
thoracic joint d ysfu nction com p ared w ith 13% w ho had
m echanical neck p ain. In the second p art of the stu d y, 88
p atients w ith w hiplash w ere rand om ized to receive either 15
sessions of p hysiotherap y consisting of electrotherm al m od al-
ities, ultrasound , m assage and exercise or the sam e physio-
therap y w ith the ad d ition of tw o sessions of thoracic
m anip u lation. The m anip u lation techniqu e u tilized w as a
sup ine thru st techniqu e targeting the T4–T5 segm ent. At the
com p letion of the stu d y, the grou p receiving the thoracic
m anip u lation exp erienced signi cantly greater red u ction in
neck p ain, m easu red on a visu al analogu e scale (VAS), com -
p ared w ith the p hysiotherapy grou p.
Pho and God ges (2004) p resented a case report of a patient
w ith neck p ain after a w hiplash injury. Initial m anagem ent of
the p atient inclu d ed thoracic sp ine thru st and non-thru st
m anip u lation d u ring the rst tw o treatm ent sessions as the
cervical sp ine w as d eem ed too irritable for assessm ent and
treatm ent in the initial stages. The p atient exp erienced a fu ll
resolu tion of sym p tom s, d isability and range-of-m otion d e -
cits after fou r sessions of p hysical therap y. There is em erging
evid ence that thrust and non-thru st m anipu lation of the tho-
racic sp ine com prise an integral part of m u ltim od al approaches
in the m anagem ent of patients w ith cervical rad iculopathy.
Cleland et al (2005c) and Wald rop (2006) pu blished case series
of p atients d iagnosed w ith cervical rad icu lop athy u sing a
sim ilar m u ltim od al interventional ap p roach. Interventions
includ ed thrust m anipu lation of the thoracic spine, non-thru st
m anip u lation of the cervical sp ine, interm ittent traction and
therap eu tic exercise. In both case series, the m ajority of
p atients exp erienced a clinically m eaningfu l red u ction in p ain
and d isability at the end of the p hysical therapy intervention
and at m ed ium -term follow -up . In a p rospective cohort stud y
involving patients w ith cervical rad iculop athy, Cleland et al
(2007b) id enti ed variables that pred icted short-term success
w ith physical therapy m anagem ent. Success w as d e ned as
su rp assing the m inim ally clinically im p ortant d ifference on
the N DI, the Patient Sp eci c Fu nctional Scale, the N RPS, and
the Global Rating of Change (GRC) scale. The p red ictor vari-
ables w ere age < 54, looking d ow n d oes not w orsen sym p-
tom s, the d om inant arm is not affected , and the p atient
received m ultim od al therapy inclu d ing cervical traction,
m anu al therap y that typ ically inclu d ed thoracic sp ine m anip -
u lation, and d eep neck exor strengthening d u ring at least
50% of the visits. Patients m eeting three of these four variables
had a p ositive likelihood ratio of 5.2 for su ccess. In a high-
qu ality rand om ized controlled trial, Young et al (2009) com -
p ared a m u ltim od al ap proach includ ing thoracic spine thru st
m anip u lation, cervical non-thru st m anip u lation and thera-
p eu tic exercises w ith and w ithou t m echanical cervical traction
in patients w ith cervical rad iculop athy. Patients received an
average of tw o treatm ent sessions per w eek for 4 w eeks. Ther-
ap ists w ere requ ired to inclu d e at least one m anu al therap y
intervention targeting both the m id and u pper thoracic sp ine
d u ring each visit. Thru st techniques w ere cond u cted in sitting,
su p ine and p rone. Both grou p s exp erienced a clinically
m eaningful d ecrease in pain and d isability at 2 and 4 w eeks,
w ith no d ifferences betw een the grou ps.
In ad d ition to cervical rad icu lopathy there is som e evi-
d ence that thrust m anipulation of the thoracic spine can assist
w ith the m anagem ent of patients w ith m ild , grad e I cervical
com p ressive m yelop athy. In a case series involving seven
p atients, Brow d er et al (2004) rep orted that a m u ltim od al
m anagem ent p rogram m e of thoracic sp ine thru st m anip u la-
tion and interm ittent m echanical cervical traction resu lted in
a clinically m eaningfu l red u ction in pain and d isability in all
p atients w ith an average of nine treatm ent sessions. Althou gh
it is d if cu lt to parcel ou t the ind ivid ual effects of thoracic
sp ine m anip u lation from these stu d ies, it w as inclu d ed in all
of them and p robably p lays an integral p art of the m u ltim od al
m anagem ent of p atients w ith cervical rad icu lop athy. In the
au thors’ experience, m ost p atients w ith cervical rad icu lopa-
thy rep ort signi cant relief of sym p tom s, esp ecially in the
scap u lar region, and im p rovem ent in cervical range of m otion
im m ed iately follow ing thoracic thru st m anipu lation.
Patients w ith cervicogenic head ache form a clinically
im portant subgrou p for the clinician specializing in m uscu-
loskeletal d isord ers. Conservative m anagem ent involving
m anu al therap y and exercise has been show n to p rod u ce clini-
cally m eaningfu l bene ts for p atients in this su bgrou p (Jull
et al 2002). Postu ral and m obility im pairm ents involving the
thoracic region can p lay a role in the p erp etu ation of these
head aches. Fu rtherm ore, thru st and non-thru st m anip u lation
of the thoracic sp ine cou ld cau se a red u ction in head ache p ain
by alternating the tension of m u ltisegm ental m u scle spanning
from the thoracic to the u pper cervical region. In the rand -
om ized trial cond u cted by Ju ll et al (2002), patients receiving
m anu al therap y, exercise or a com bination of the tw o achieved
a clinically m eaningfu l red u ction in head ache frequ ency and
intensity. Manual therapy p roced u res w ere selected by the
clinician and inclu d ed both thru st and non-thru st m anip u la-
tions of the cervical and u p p er thoracic sp ine based on the
p atient’s im p airm ents, signs and sym p tom s. The exercise p ro-
gram m e includ ed p ostural, m otor control and end urance
exercises targeting the d eep cervical exors and scapular sta-
bilizing m u scles. In a case report of a patient w ith a head ache,
Viti and Paris (2000) rep orted a red u ction in the p atient’s
head ache pain 4 d ays follow ing a thru st m anip u lation of the
u p p er thoracic sp ine. Previou s m anagem ent of the p atient’s
im pairm ents of the u pper cervical region over ve visits had
failed to prod uce a change in sym ptom s. Prelim inary evi-
d ence su ggests that thru st and non-thrust m anipulation of the
thoracic sp ine can p lay a role in the m u ltim od al m anagem ent
of p atients w ith cervicogenic head ache; how ever, ad d itional
high-qu ality research is requ ired to investigate this hyp othe-
sis fu rther.
As m entioned above, the thoracic sp ine is intim ately
involved w ith the shou ld er region ow ing to the concom itant
m otion of the thoracic sp ine d u ring m ovem ents of the shou l-
d er. Ad d itionally a neu tral, erect posture is requ ired for full
range of m otion of the shou ld er. Three high-qu ality stu d ies
have investigated the u se of thru st and non-thru st m anip u la-
tion of the thoracic region in p atients w ith shou ld er d isord ers
(Winters et al 1997; Bang & Deyle 2000; Bergm an et al 2004).
In tw o separate rand om ized clinical trials, Winters et al (1997)
and Bergm an et al (2004) both reported that m anipu lative
therap y targeting the cervical sp ine, u p p er thoracic sp ine and
u p p er rib cage led to a clinically m eaningfu l red u ction in p ain
 148 PART 2 • 13 • Thoracic spine manipulation
and d isability, at short- and m ed iu m -term follow -u p, in
p atients su ffering shou ld er p ain w ith signs and sym p tom s of
shou ld er gird le d ysfu nction. Com p arison grou p s inclu d ed
non-m anip u lative p hysiotherap y, u su al m ed ical care, or
steroid injection. Patients in both stu d ies received u p to six
sessions of m anip u lative therap y p rovid ed by exp erienced
m anu al p hysical therap ists. Bang and Deyle (2000) com p ared
exercise alone w ith exercise w ith m anual therapy in patients
w ith su bacrom ial im pingem ent synd rom e. Patients in both
grou ps received six sessions of treatm ent. At the com pletion
of the stu d y, p atients in the m anu al therap y grou p exp eri-
enced a clinically m eaningfu l red uction in pain, d isability and
im p rovem ent in strength com p ared w ith the exercise grou p .
Manu al therap y inclu d ed both thru st and non-thru st m anip u -
lation of the glenohu m eral joint, clavicle, cervical sp ine, tho-
racic spine and rib cage.
These three stud ies provid e evid ence that m anual therapy
m anagem ent of the thoracic sp ine, as p art of a m u ltim od al
treatm ent p rogram m e, can lead to p ositive ou tcom es for
p atients w ith shou ld er pain. H ow ever, it is u nclear how m u ch
m anu al therap y of the thoracic sp ine, in isolation, contribu tes
to the ou tcom e. Boyles et al (2009) ad d ressed this qu estion in
a p rosp ective case series of 54 patients w ith shou ld er im pinge-
m ent synd rom e. They rep orted that p ain, d isability and global
rating of change w ere im proved 48 hou rs after perform ing
thru st m anip u lation of the u p p er and m id thoracic sp ine and
rib cage. Seated thru st techniqu es w ere utilized to m anipu late
the thoracic sp ine and a su p ine techniqu e w as u sed to m anip -
u lation the ribs. Althou gh it is u nlikely that the thoracic and
rib joints can d irectly refer pain to the shou ld er region, Boyle
(1999) reported that tw o patients’ shou ld er sym ptom s w ere
com p letely resolved after non-thru st m anip u lation of the ip si-
lateral second rib.
Mintken et al (2010) rep orted the resu lts of a clinical p red ic-
tion ru le d erivation stu d y involving thoracic sp ine m anip u la-
tion for p atients w ith should er pain. In this stu d y, 80 patients
w ith a variety of should er d isord ers, exclud ing those w ith
contraind ications to thoracic sp ine thru st m anip u lation,
received u p tw o sessions of thoracic spine thru st m anipu la-
tion, cervical non-thru st m anip u lation and sp inal m obility
exercises. A rating of at least +4 on the 15-p oint GRC scale w as
u sed as the m arker for su ccess. Based on this criterion, 61%
of the p atient p op u lation had a su ccessfu l ou tcom e w ith u p
to tw o sessions of the aforem entioned intervention p ro-
gram m e. Using stepw ise logistic regression, the au thors
d erived ve variables that w ere p red ictive of success w ith the
intervention p rogram m e: p ain-free shou ld er exion range of
m otion < 127°, shou ld er internal rotation at 90° of abd u ction
< 53°, a negative N eer test, not taking m ed ications for pain,
and d u ration of sym ptom s < 90 d ays. Patients m eeting at least
three of these ve variables had a p ositive likelihood ratio of
5.4 for a su ccessfu l ou tcom e, w hich translates into an 89%
p ost-test p robability of success. This single-arm trial has lim i-
tations and the clinical p red iction ru le is aw aiting d erivation
w ith a rand om ized controlled trial. H ow ever, this stud y ad d s
to the evid ence that thoracic sp ine m anip u lation, as p art of a
m u ltim od al intervention p ackage, can lead to d ecreased p ain
and d isability for p atients w ith shou ld er pain.
To investigate fu rther the p otential m echanism s behind
d ecreased pain and im p roved m obility associated w ith tho-
racic m anipu lation for su bjects w ith shou ld er p ain, Mu th et al
(2012) com p leted a laboratory-based stu d y. The researchers
u sed su rface electrom yograp hy and an electrom agnetic track-
ing d evice to m easu re scapular m uscle activity and kinem at-
ics pre and post thoracic spine m anipu lation, in 30 patients
aged 18–45 years w ho had signs of rotator cu ff tend inop athy.
Post m anip u lation there w ere no signi cant d ifferences in
scap u lar m u scle activity or kinem atics, w ith the excep tion
of a sm all increase in m id d le trap eziu s m u scle activity and
a sm all d ecrease in scapular u pw ard rotation. H ow ever,
im m ed iately after m anip ulation, su bjects reported a signi -
cant d ecrease in p ain w ith p rovocative shou ld er testing and
active shou ld er elevation. Subjects also rep orted a clinically
signi cant im p rovem ent in shou ld er fu nction via stand ard -
ized self-rep orted qu estionnaires at 7–10 d ays post m anip u la-
tion. The au thors conclu d ed that thoracic sp ine m anip u lation
lead s to an im m ed iate im provem ent in should er function and
d ecreased pain, but these nd ings are not explained by a
change in scap u lar m u scle activity or kinem atics.
As d escribed above, m obility im pairm ents and tend erness
of the thoracic sp ine are com m on in p atients rep orting lateral
elbow pain (Berglu nd et al 2008). Manual therapy m anage-
m ent of the cervicothoracic sp ine, in ad d ition to local treat-
m ent d irected to the elbow, has been show n to lead to
im p roved ou tcom es in few er visits, com pared w ith local treat-
m ent of the elbow alone (Cleland et al 2004b, 2005a).
Examination and Screening of
the Thoracic Spine and Rib Cage
in Patients with Upper Quarter
Musculoskeletal Pain
A fu ll com p rehensive m u scu loskeletal exam ination involving
m ed ical screening, p atient history and a p hysical exam ination
shou ld be u nd ertaken for all p atients w ith u p p er qu arter
region com plaints. What follow s are the selected exam ination
p roced u res that assist w ith id entifying im p airm ents that
w ould be am enable to m anipu lation of the thoracic spine
and rib cage. The read er is referred to other chap ters of this
book for other exam ination proced ures. The exam ination
is d escribed by the patient’s p osition.
Postural screen of the thoracic spine
and rib cage
The exam ination of the thoracic spine begins w ith a postural
screen aim ing to id entify regions of the thoracic sp ine that
d eviate from w hat is consid ered a norm al, sm ooth thoracic
kyphosis. Areas of increased or d ecreased kyphosis involving
the u p p er, m id and low er thoracic regions can be record ed .
Observation for thoracic p ostu ral d eviation in this fashion
has fair-to-m od erate reliability (Cleland et al 2006). For the
clinical p red iction ru le d evelop ed by Cleland et al (2007a),
a red uction in the u pper thoracic kyphosis em erged as a pre-
d ictor variable for success w ith thoracic m anipulation in
p atients w ith m echanical neck p ain. The exam iner can p alp ate
for alterations in the norm al thoracic curvature by running his
or her ngers along either sid e of the thoracic sp ine in the
region of the parasp inal m u scles. Areas of altered soft tissue
tension and tend erness su ggestive of u nd erlying segm ental
 Examination and screening o  the thoracic spine and rib cage in patients with upper quarter musculoskeletal pain  149
d ysfunction can be d etected . Ad d itionally, the exam iner can
p alpate the rib angles for tend erness by having the patient
p lace his or her ip silateral hand on the opposite shou ld er
to abd u ct the scap u la ou t of the w ay. Tend erness of the rib
angle is su ggestive of u nd erlying d ysfu nction of the rib (Flynn
et al 2001).
Thoracic spine active range of motion
Active m obility testing of the thoracic spine in sitting com -
m ences w ith testing the p atient’s active range of m otion in
card inal p lanes. Overp ressu re is ap p lied if the m otion is not
pain p rovoking. Range of m otion can be record ed u sing a
bu bble inclinom eter over selected thoracic levels. The incli-
nom eter is p laced in the sagittal p lane for exion / extension
and in the frontal p lane for sid e-bend ing (Molina et al 2000).
Seated active thoracic rotation follow ed by clinician overp res-
su re can serve as a clinically ef cient screen of thoracic sp ine.
Pain and a visu al gross ju d gem ent of range of m otion can be
record ed qu ickly w ith this test.
Mobility testing of the rst rib
Screening for elevation of the rst rib is com p leted in sitting
w ith the exam iner palpating the relative height of the rst rib.
The rst rib is fou nd and p alpated by stand ing behind the
patient and p u lling back the u pper trap eziu s m uscle. The
clinician can then rest his or her ngers on the p osterior su p e-
rior asp ect of the rst rib and m ake a visu al jud gem ent of the
relative height of the rst rib. The cervical rotation lateral
exion test (CRLF) ad vocated by Lind gren et al (1989) can
also be p erform ed to screen for elevation of the rst rib.
Du ring this test the cervical sp ine is passively rotated to the
contralateral sid e and then m axim ally sid e-bent in the sagittal
plane. A red u ction in sid e-bend ing m obility is su ggestive of
an elevated rst rib on the sid e opp osite from that to w hich
the cervical sp ine w as rotated .
Mobility testing of the rst rib w ith the p atient in su p ine is
u nd ertaken by the clinician ap p lying a cau d al glid e to the
posterior, su p erior asp ect of the rst rib u sing the palm ar sid e
of the second m etacarp al p halangeal joint. Mobility or p ain is
record ed and is su ggestive of d ysfunction of the rst rib. The
clinician can also screen the rst rib d u ring insp iration and
expiration by palpating the anterior aspect und erneath the
m ed ial clavicle. A relative red u ction in the excu rsion of m otion
d u ring inspiration and expiration is suggestive of hyp om obil-
ity of the rst rib.
Segmental mobility testing of the thoracic
spine and rib cage
The rem aining ribs can be screened in a sim ilar fashion and ,
conventionally, they are exam ined in grou p s of three to fou r
d ivid ing the rib cage into the up per, m id and low er regions.
The clinician can also perform passive accessory m obility
of the anterior ribs by sp ringing in an anterior to p osterior
d irection over the costosternal joints u tilizing the thum bs
(Maitland et al 2001). The clinician record s the presence or
absence of p ain and notes w hether the m obility is norm al,
hyp om obile or hyp erm obile for each rib (H eid erscheit &
Boissonnau lt 2008).
Segm ental m obility testing of the thoracic sp ine, u tilizing
p osterior to anterior sp ring testing, is cond u cted w ith the
p atient p rone. The clinician screens the thoracic sp ine for
m obility and p ain by ap p lying his or her hyp othenar em i-
nence to the thoracic sp inou s p rocess and p rod u cing a grad ed
p osterior-to-anterior force. The exam iner record s the p resence
or absence of p ain and notes w hether the m obility is norm al,
hypom obile or hyp erm obile for each thoracic segm ent
(Cleland et al 2006; H eid erscheit & Boissonnau lt 2008). The
clinician can sp ring u nilaterally over the thoracic transverse
p rocesses in a sim ilar fashion. The ribs are also screened for
m obility and p ain. Using a crossed -hand s techniqu e, the clini-
cian stabilizes the op p osite sid e of the thoracic sp ine w ith his
or her hyp othenar em inence lateral to the sp inou s p rocess and
sp rings over each rib angle, u tilizing the hyp othenar em i-
nence of the op p osite hand . Segm ental m obility testing of
the thoracic sp ine has p oor-to-fair inter-rater reliability for
assessm ent of both p ain and m obility in p atients w ith neck
p ain (Cleland et al 2006). In tw o stud ies involving su bjects
w ithou t sym ptom s, reliability of segm ental m obility testing
of the thoracic sp ine and ribs im p roved w hen an exp and ed
d e nition of agreem ent w as u tilized (Christensen et al 2002;
H eid erscheit & Boissonnau lt 2008); d ue to the potential inac-
cu racy of id entifying a sp eci c thoracic sp inal level, these
au thors allow ed for m obility agreem ent w ithin and betw een
raters to w ithin ±1 vertebral level.
Interpretation of the examination
and reassessment
Using a com pilation of the above exam ination proced u res, the
clinician can m ake a reasonable clinical ju d gem ent regard ing
the p resence / absence of thoracic sp ine m obility im p airm ents.
Mobility im p airm ents of the thoracic sp ine and rib cage are
com m on clinically, both in p atients w ith u p p er qu arter
m u scu loskeletal p ain and also in those w ithou t sym p tom s
(H eid erscheit & Boissonnault 2008). Sim ilar to other spinal
regions, thoracic spine m obility becom es red uced w ith
increasing age (Ed m ond ston & Singer 1997). Previous experts
in m anipulative therap y have d escribed a d etailed exam ina-
tion schem e in attem p ts to id entify the segm ent and the d irec-
tion of sp eci c m obility im p airm ents of the thoracic sp ine and
rib cage. Follow ing these biom echanical d iagnoses, a m anip u-
lative proced u re is then selected that m atches the speci ed
m ovem ent d ysfu nction. As stated above, reliability of seg-
m ental m obility testing of the thoracic sp ine and rib cage is
fair. Ad d itionally, research has show n that exam ination and
m anu al therap y intervention p roced u res affect a region of
the sp ine rather than a sp eci c segm ent (Pow ers et al 2003;
Ross et al 2004). We therefore p ropose a pragm atic exam ina-
tion p rocess based on recent evid ence. For exam p le, to id en-
tify m obility im p airm ents of a region of the thoracic sp ine, the
exam iner should nd increased or d ecreased thoracic kypho-
sis in that region, lim ited active range of m otion, soft tissu e
hyp ertonicity or tend erness, and hyp om obility w ith sp ring
testing. This exam ination schem e is also ap p lied to the rib
cage. Tend erness over the rib angle, red u ced excu rsion d u ring
respiration and hypom obility w ith spring testing over the
anterior or posterior aspect of the rib all suggest a m obility
im pairm ent of the rib. To id entify a m obility im pairm ent of
the rst rib, the exam iner cou ld u se a com bination of red u ced
 150 PART 2 • 13 • Thoracic spine manipulation
m obility w ith sp ring testing, red u ced excu rsion d u ring resp i-
ration, tend erness over the rib angle, the presence of p er-
ceived su p erior elevation of the rib and a p ositive CRLF test.
To id entify the thoracic sp ine as a p ain generator or sou rce of
the p atient’s sym p tom s, the p atient’s fam iliar sym p tom s
shou ld be rep rod u ced w ith exam ination p roced u res. For
exam ple, in the case report by Boyle (1999) the clinician rep ro-
d u ced the patient’s fam iliar should er pain w ith p osterior to
anterior sp ring over the shaft of the ipsilateral second rib.
Often clinicians ap p ly m anu al therap y p roced u res to an
asym p tom atic region of the thoracic spine in patients w ith
neck or u p p er extrem ity d isord ers. Therefore, w e recom m end
that the clinician bases the su ccess or valu e of a p articu lar
techniqu e on the effect it has on fu nctional m ovem ent of the
region of sym ptom s. For exam p le, follow ing m anipu lation of
the thoracic sp ine, the clinician can then reassess the p ain and
range of m otion associated w ith shou ld er elevation in a
p atient w ith su bacrom ial im p ingem ent synd rom e. Likew ise,
p ain-free grip strength cou ld be retested after thoracic or rib
thru st m anip u lation for a p atient w ith lateral elbow p ain. For
p atients w ith p rim ary com p laint of thoracic sp ine p ain, fu nc-
tional reassessm ent p roced u res involving the thoracic sp ine,
su ch as seated tru nk rotation, are u tilized .
Manual Therapy Interventions for
the Thoracic Spine and Rib Cage
Com p lications from thru st or non-thru st m anip u lation of the
thoracic sp ine are rare. As p art of a com p rehensive exam ina-
tion, a p atient shou ld be screened for cond itions that requ ire
m ed ical referral or contraind icate m anip u lation. Typ ical con-
traind ications for m anip u lation in the thoracic region w ou ld
inclu d e bone w eakness or d em ineralization resu lting from
neop lasm s, trau m a, infection or m etabolic cond itions (osteo-
p orosis). The presence of signs of central cord com pression,
su ggesting a p ossible m assive thoracic d isc herniation, also
contraind icates m anip u lation u ntil d iagnostic im aging is
obtained . When d ecid ing w hether an ind ivid u al p atient
w ou ld bene t from thoracic m anipu lation, it is helpfu l to
consid er the inclu sion and exclu sion criteria of clinical trials
involving thoracic m anip u lation. For exam p le, several trials
had an age lim it of 18–60 (Cleland et al 2005b, 2007a, 2007c,
2010; Masaracchio et al 2013) w hereas in others the lim it w as
18–45 (González-Iglesias et al 2009a, 2009b). With proper
p atient screening, thoracic sp ine m anipu lation is inherently
safe p rovid ed the clinician is p rop erly trained in the tech-
niqu es and avoid s the u nnecessary u se of excessive force or
am p litud e. Minor sid e effects of tem p orary soreness are
com m on after m anip u lation, so it is help fu l to w arn p atients
so that they are not alarm ed (Cleland et al 2007c).
Biom echanical theories abou nd to exp lain the m echanism s
by w hich sp inal m anipu lation prod u ces clinically im portant
red uction in pain and d isability. Speci cally for the thoracic
sp ine, it is thou ght that an im p rovem ent in m obility in the
thoracic region follow ing m anip u lation allow s for enhanced
p ain-free m obility of the cervical or u pp er extrem ity region.
It has also been proposed that im p roving m obility in the
thoracic sp ine w ill take stress off of ad jacent, hyp erm obile
cervical sp ine or shou ld er joints. H ow ever, evid ence is em erg-
ing that m echanism s behind the effects of m anu al therap y
p roced u res have a p red om inantly neu rop hysiological com p o-
nent (Bialosky et al 2009). Analgesic effects after m anipu lation
are thou ght to occur at the peripheral, spinal cord and central
nervou s system levels. Effects inclu d e a red u ction in re exive
m u scu lar activity su rrou nd ing the sp inal region m anip u lated ,
inhibition of pain prod uction throu gh gaiting m echanism s
and activation of end ogenou s opioid s, and alteration of pain
p rocessing in the brain. N on-sp eci c effects involving a
p lacebo resp onse and p atients’ exp ectations of the treatm ent
p robably p lay a role in the effects of m anu al therap y (Bialosky
et al 2008). With this in m ind , clinicians can select particu lar
m anip u lative techniqu es based on p atient com fort, clinician
exp erience and skill, and evid ence from high-qu ality research
as opp osed to selecting a proced u re that m atches a particu lar
biom echanical lesion. Descriptions of m anual techniques for
both the thoracic spine and ribs follow ; techniques for this
chap ter w ere selected based on w hat has been u tilized in
p u blished clinical trials and the au thors’ clinical exp erience.
For a com prehensive d escription of other thoracic spine
m anip u lation techniqu es, read ers are referred to other texts
(Flynn et al 2001; Maitland et al 2001; Gibbons & Tehan 2006).
In keeping w ith the recent recom m end ations for m anual
therap y term inology, all p roced u res w ill be referred to as
m anip u lations (Mintken et al 2008). Thru st m anipu lation w ill
refer to those techniqu es involving a quick or high-velocity
thru st. N on-thru st m anip u lations are techniqu es ap p lied w ith
low er velocity in a grad ed fashion.
Seated upper thoracic thrust manipulation
The patient sits on a treatm ent table w ith his or her hand s
clasp ed behind the neck, and as low d ow n on the cervical
sp ine as p ossible (Fig. 13.1). The clinician stand s behind the
p atient, loop s the hand s throu gh the p atient’s arm s and p laces
the hand s clasp ed over the p atient’s hand s. The clinician then
leans backw ard s to take u p slack in a sup erior d irection. A
thru st is d elivered by the clinician thru sting u p w ard s tow ard s
the ceiling in an attem p t to create a d istraction force in the
p atient’s u p p er thoracic region. The thru st shou ld be gener-
ated by the clinician’s legs. Care is taken w ith this p roced ure
Figure 13.1 Seated upper thoracic thrust manipulation.
 Manual therapy interventions  or the thoracic spine and rib cage  151

Figure 13.3 Prone upper thoracic thrust manipulation.

Figure 13.2 Seated mid-thoracic thrust manipulation.

not to strain to the p atient’s shou ld er gird le. If the p atient

experiences shou ld er d iscom fort or is unable to attain the posi-
tion w ith his or her arm s then this techniqu e is aband oned .

Seated mid-thoracic thrust manipulation

The patient sits on the treatm ent table w ith his or her arm s
across the bod y w ith the hand s grasp ing the op posite poste-
rior shou ld er region (Fig. 13.2). Clinical experience suggests
that the m ost com fortable p osition is w ith the elbow s in p aral-
lel; this also allow s for the clinician to attem p t the technique
on a larger p atient. The clinician ap p lies the sternu m to the
patient’s m id -thoracic sp ine. Alternatively a rolled tow el can
be placed horizontally on the cau d al vertebra of the segm ent
of interest betw een the p atient and the clinician in an attem p t
to be segm ent sp eci c. The clinician reaches rou nd the p atient
and grasps the p atient’s low er elbow. If possible the clinician Figure 13.4 Prone mid-thoracic thrust and non-thrust manipulation.
interlocks the hand s. The clinician takes u p slack by ad d u ct-
ing the arm s, retracting the should er gird le, and pu shing the
chest tow ard s the p atient’s thoracic sp ine. A high-velocity lateral sid e-bend ing and extension u ntil the spinous p rocess
thru st is p erform ed by the clinician thru sting throu gh the of the segm ent begins to rst m ove. The clinician d elivers the
patient’s arm s in an anterior-to-posterior d irection w hilst thru st to the sp inou s p rocess by translating it across the table
keeping the chest p ushed forw ard s. Som e clinicians attem pt in an attem pt to ‘gap’ the joint on the opposite sid e. During
to p rod u ce a d istractive force by lifting the p atient d u ring this the thru st the clinician m aintains the p atient’s head and neck
proced u re, althou gh w ith a larger p atient this could poten- p osition w ith the op p osite hand . Care is taken to avoid thru st-
tially inju re the clinician. If the clinician cannot reasonably ing through the p atient’s head and neck. If the p atient exp eri-
reach his or her arm s around the patient, another technique ences pain in the cervical region d u ring the technique it can
shou ld be selected . be attem pted from the other sid e w ith the cervical sp ine
rotated in the opposite d irection, or another techniqu e shou ld
be selected .
Prone upper thoracic thrust manipulation
With the p atient lying p rone, the clinician stand s to one sid e Prone mid-thoracic thrust and
of the p atient. The clinician rotates the p atient’s head and neck non-thrust manipulation
to the op p osite sid e (Fig. 13.3). The clinician then applies
either the thum b or p isiform to the lateral aspect of the spinous With the p atient p rone the exam iner ap p lies the hyp othenar
process of the cau d al vertebra of the segm ent of interest. Slack em inences just lateral to the sp inou s processes over the m id -
is taken up by the clinician applying the other hand to the thoracic region (Fig. 13.4). Slack is taken u p by the exam iner
patient’s head and gently ap plying further rotation, contra- slightly tw isting his or her hand s in ord er to obtain a soft
 152 PART 2 • 13 • Thoracic spine manipulation

tissu e or skin lock. From this p osition, grad ed non-thru st

m anip u lations or a thru st m anip u lation can be d elivered in a
p osterior-to-anterior d irection tow ard s the table. The thru st
can d eliver after the p atient exhales. Care is taken to avoid
p rod u cing excessive force or am plitud e w ith this p roced u re.
The clinician should ensu re that the contact is ju st lateral
to the sp inou s p rocess so as to avoid inju ry to the p atient’s
ribs. The clinician should ad ju st the angle of the hand place-
m ent, based on the contou r of the p atient’s kyp hosis, in ord er
to rem ain p erp end icu lar to the sp ine.

Supine upper and mid-thoracic

thrust manipulation
With the p atient su p ine the clinician instru cts the p atient to Figure 13.6 Open hand for supine upper and mid-thoracic thrust manipulation.
roll to his or her sid e. The clinician places one hand on the
cau d al vertebra of the segm ent of interest in the u p p er or m id
thoracic region. The clinician’s hand then serves as the fu lcru m
for the m anipulation. A nu m ber of hand -hold s are possible,
inclu d ing either a p istol grip or an op en-hand techniqu e. With
the p istol grip the transverse p rocesses of the thoracic segm ent
are stabilized by the clinician’s hypothenar em inence and
second m etacarp op halangeal joint w ith the sp inou s p rocess
in betw een (Fig. 13.5). With the open-hand technique, the
clinician ap p lies his thenar em inence to one sid e of the tho-
racic spine ju st lateral to the spinous process (Fig. 13.6). The
clinician then rolls the p atient back to the fu lly su p ine p osition
w hilst m aintaining the hand position. The patient is instru cted
to either clasp his or her hand s behind the neck (Fig. 13.7) or
cross the arm s across the chest w ith the elbow s p arallel (Fig.
13.8). Patient arm positioning is based on patient and clinician
p reference. Som e patients p refer the hand s clasp ed behind the
neck to avoid p ressu re on the chest or breast tissu e. Others
report d iscom fort in the cervical region or are u nable to obtain
this p osition ow ing to in exibility of the u p p er extrem ities.
From this p osition, the clinician uses the other hand to ex or
extend the patient d ow n the region of interest so pressu re is Figure 13.7 Supine upper and mid-thoracic thrust manipulation with hands
felt just over the clinician’s bottom hand serving as the behind the neck.
fu lcru m . This is accom plished by the clinician either crad ling
the p atient’s head and neck (Fig. 13.9) or u sing the p atient’s
arm (Fig. 13.10).
Clinical exp erience su ggests that extension is u su ally u ti-
lized in the up p er thoracic region from T1 to T3, w hereas

Figure 13.8 Supine upper and mid-thoracic thrust manipulation with arms
Figure 13.5 Pistol grip for supine upper and mid-thoracic thrust manipulation. across the chest.
 Manual therapy interventions  or the thoracic spine and rib cage  153
Figure 13.9 Supine upper and mid-thoracic thrust manipulation with head
exion.
Figure 13.10 Supine upper and mid-thoracic thrust manipulation with hand
exion.
exion is u sually u tilized in the m id thoracic region (T4–T9).
The clinician then takes up the slack by ap plying an anterior-
to-p osterior and slightly cranial force throu gh the p atient’s
arm s and tow ard s the fu lcrum on the table. A thrust is d eliv-
ered by the clinician through the patient’s arm s and tow ard s
the table. The thru st can be d elivered after p atient exhalation.
Care is taken to avoid p rod u cing excessive force or am p litu d e
w ith this techniqu e. If the patient exp eriences pain in the
shou ld er the techniqu e can be m od i ed so that one of the
patient’s arm s is crossed over the chest w hile the p ainful
shou ld er is left com fortably on the table (Fig. 13.11).
Seated rst-rib thrust and
non-thrust manipulation
The p atient sits on the table and the clinician stand s behind
the p atient w ith one foot on the table and the knee in the
Figure 13.11 Supine upper and mid-thoracic thrust manipulation adapted for
patients with painful shoulder.
Figure 13.12 Seated rst-rib thrust and non-thrust manipulation.
p atient’s axilla on the sid e op p osite that of the m anip u lation
(Fig. 13.12). The clinician app lies the chest to the p atient’s
thoracic region and p laces the forearm along the p atient’s
head and cervical region, again on the op p osite sid e. The clini-
cian contacts the p osterior, su p erior asp ect of the p atient’s rst
rib w ith either the p alm ar aspect of the second m etacar-
p op halangeal joint or the hyp othenar em inence. The clinician,
u sing the w hole bod y, translates the p atient tow ard s the knee
to p rod u ce sid e-bend ing of the cervical and thoracic region
tow ard s the sid e to be m anip u lated . This p laces the p atient’s
scalene m u scles on slack and brings the rst rib tow ard s the
clinician’s thru sting hand . Fu rther localization is achieved by
the clinician slightly retracting the p atient’s cervical sp ine and
 154 PART 2 • 13 • Thoracic spine manipulation

Figure 13.13 Supine rst-rib thrust and non-thrust manipulation. Figure 13.14 Side-lying ribs non-thrust manipulation.

rotating it to the opp osite sid e. The clinician can then d eliver
grad ed non-thrust m anipu lations, or a thru st in a cau d al and
m ed ial d irection. Care is taken not to comp ress the p atient’s
cervical sp ine w ith the non-thru sting hand .

Supine rst-rib thrust and

non-thrust manipulation
With the p atient su p ine, the clinician contacts the p osterior,
su p erior asp ect of the p atient’s rst rib w ith the p alm ar asp ect
of the second m etacarp op halangeal joint (Fig. 13.13). With the
op p osite hand the clinician then sid e-bend s the p atient’s neck
tow ard s the sid e to be m anip u lated so as to p u t the scalene
m u scles on slack. The clinician p erform s grad ed non-thru st
m anip u lation or a thru st in a cau d al and m ed ial d irection; the
thru st can be p erform ed after p atient exhalation.

Prone or side-lying ribs
non-thrust manipulation
To p erform non-thru st m anip u lation of the ribs, the clinician
can contact either the rib angle in p rone or the costosternal
joints in supine, and apply non-thru st m obilizations. These
non-thru st m anip u lations can also be p erform ed in sid e-lying
w ith the patient’s tru nk rotated to either sid e in ord er to
im p rove thoracic sp ine rotation (Fig. 13.14).
Figure 13.15 Contact for supine ribs thrust manipulation.
throu gh the p atient’s arm s and tow ard s the table. The thru st
can be d elivered after p atient exhalation. Care is taken to
avoid using excessive am p litu d e or force. This technique
tend s to be less com fortable than the su p ine thoracic thru st so
it is best to perform it qu ickly so that pressure is not applied
to the p atient’s rib for a long p eriod of tim e.

Supine ribs thrust manipulation Exercise interventions to augment the manual

This techniqu e is alm ost id entical to the su pine thoracic thrust
m anip u lation. To m anip u late the rib, the clinician stand s on
the op p osite sid e of the rib to be m anip u lated . The clinician
instru cts the p atient to roll to one sid e and contacts the rib ju st
lateral to the transverse p rocess w ith the thenar em inence
(Fig. 13.15). The p atient is rolled back into the su pine position.
The patient is then instructed to either clasp the hand s behind
the neck or p lace the arm s across the chest. The clinician then
exes or extend s the patient’s trunk to localize the force
tow ard s the rib. The clinician d elivers a thru st to the rib
therapy techniques
Typ ically both thoracic thru st and non-thru st m anip u lations
are au gm ented by patient self-m obilization exercises. In the
au thors’ clinical exp erience, it is ad vantageou s to follow
m anu al therap y p roced u res im m ed iately w ith active exercise.
It has been su ggested that m anu al therapy provid es a w ind ow
of op p ortu nity after w hich exercise is facilitated (Raney et al
2007). The read er is d irected to other chapters of this book for
u p p er qu arter strengthening and stretching exercises and for

m obility exercises involving other u p p er qu arter regions. The
follow ing text d escribes exercises to im p rove thoracic spine
and rib cage m obility.
For the patient w ho lacks extension range of m otion, an
extension m obilization exercise can be utilized . The p atient is
instru cted to clasp the hand s behind the neck in ord er to sta-
bilize the cervical spine. A fu lcru m is placed in the region to
be m obilized and the patient p erform s thoracic extension over
the fu lcru m . Several objects can be u tilized as a fu lcru m ,
includ ing the arm of a cou ch, the back of a chair, a foam roller,
a rolled tow el or a m obilization w ed ge.
For the p atient lacking thoracic spine exion, a ‘ exion
m obilization’ exercise is u tilized . This can be accom p lished in
either quad rup ed or w ith the patient’s hand s on the w all in
a pu sh-u p p osition. The patient is instru cted to ex the cervi-
cal and thoracic sp ine and p rotract the scap u lae. This exercise
has the ad d ed bene t of activating the serratu s anterior
m u scles.
Patients w ith rib m obility restrictions can be instru cted in
the ‘barrel hu g’ exercise. With the p atient seated , the clinician
instru cts the p atient to p retend that he / she is hold ing onto a
large barrel, w hich prod uces thoracic exion and should er
gird le protraction. The p atient is then instru cted to sid e-bend
and rotate the tru nk aw ay from the sid e of the hypom obile
rib. The patient can be instru cted to p erform this d u ring fu ll
exhalation.
The ‘sid e-lying arm sw eep’ exercise can be used for general
thoracic sp ine and rib cage m obility. The p atient lies on one
sid e and , starting w ith the arm overhead , sw eep s the arm
d ow nw ard s tow ard s the legs and the back, u p and arou nd to
the starting p osition. The p atient can p au se in areas w here
stiffness or a stretching sensation is felt and oscillate the
shou ld er gird le into p rotraction / retraction and tru nk into
rotation.
First-rib hypom obility is ad d ressed by the patient applying
a d ow nw ard p ressu re to the rib w ith a rolled tow el or sheet.
The sheet or tow el is loop ed over the patient’s shou ld er and
onto the rst rib. The p atient is instru cted to d rop the ip silat-
eral shou ld er d ow n and sid e-bend the cervical spine tow ard s
the rib to p u t the scalene m u scles on slack. Using the tow el,
the p atient can ap p ly a m obilization to the rib in a cau d al
d irection.
Conclusion
In patients w ith u pper qu arter m uscu loskeletal d isord ers, the
thoracic sp ine and rib cage m ay p lay a signi cant role. The
thoracic sp ine and rib cage are biom echanically linked to the
cervical sp ine and u p p er extrem ity. Mobility im p airm ents of
the thoracic sp ine and rib cage are com m on in p atients w ith
u p p er qu arter d isord ers. Evid ence has show n that m anu al
therap y interventions targeting the thoracic sp ine and rib
cage can lead to p ositive ou tcom es in p atients w ith a variety
of u p p er qu arter m u scu loskeletal d isord ers. Utilizing the
concep t of regional interd ep end ence, the clinician shou ld
screen the thoracic sp ine and rib cage and ad d ress im p air-
m ents fou nd in p atients p resenting w ith neck, shou ld er and
elbow d isord ers. Thoracic sp ine m anual therapy proced ures
are rarely u sed in isolation, bu t instead com p rise part of a
com p rehensive, m u ltim od al treatm ent p rogram m e u tilizing
m anu al therap y for other u p p er qu arter regions, exercise and
Conclusion 155
p atient ed u cation. Fu tu re research w ill assist the clinician
in id entifying patients w ho w ill bene t from thoracic m ani-
p u lation and also in d eterm ining the op tim al d osage of
m anip u lation.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
14
Joint Mobilization and Manipulation of the Cervical Spine
 Chapter 
J o h n R . Kra u s s , Do u g la s S . C re ig h to n , J o s h u a A. C le la n d , C é s a r Fe rn á n d e z - d e - la s - P e ñ a s
CHAP TER CONTENTS
Introduction 
Evidence for cervical manipulation and mobilization 
158
158
Hypothesized mechanisms of effect  159
Speci city of manipulation and mobilization  159
Selecting patients for cervical manipulation and mobilization  160
Adverse reactions to cervical manipulation and mobilization  160
Translatoric spinal manipulation and mobilization  161
Translatoric traction techniques  161
Translatoric articular / facet separation techniques  162
Translatoric facet-gliding techniques  165
Posterior–anterior cervical mobilization  168
Posterior–anterior unilateral upper cervical spine  
mobilization  168
Posterior–anterior unilateral mid-cervical spine  
mobilization  168
Transverse unilateral mid-cervical spine mobilization  169
Cervical spine manipulative procedures  169
C2–C6 separation of zygapophyseal articular joint:   d ence su pporting thoracic m anipu lation for neck p ain
manipulation in rotation  169
Atlanto-axial separation of zygapophyseal articular joint:   Iglesias et al 2009; Saaved ra-H ernánd ez et al 2013), clinicians
upper cervical spine manipulation  170
Conclusion  170
Introduction
It is estim ated that 18–250 m illion m anipulations are per-
form ed in the United States each year (Shekelle & Cou lter
1997; Licht et al 2003), w ith over 2 m illion cervical m anip u la-
tions p erform ed on the cervical sp ine in Britain and Scotland
alone (Thiel & Bolton 2004). The technique of m anipulation
and m obilization of the sp ine w as d ocu m ented as far back as
400 bc e (Sigerist 1951) and it continu es to be u sed by m od ern
m ed ical p rofessionals, inclu d ing p hysical therap ists, chiro-
p ractors and osteop aths, in the treatm ent of neck and head
p ain. H ow ever, d esp ite the long history and continu ed u se of
these m anu al therap y interventions, there rem ains d ebate su r-
round ing the safety and ef cacy of cervical spine m anipula-
tive treatm ent.
Evidence for Cervical Manipulation
and Mobilization
There is consid erable evid ence su ggesting that m anip ulation
and m obilization are effective in im m ed iately im p roving
the cervical range of m otion, d ecreasing neck p ain and
im p roving fu nction w hen applied to the cervical (Piku la 1999;
Martinez-Segura et al 2006; Pu ented u ra et al 2012b; Saaved ra-
H ernánd ez et al 2013) and thoracic (Cleland et al 2005,
2007a, 2010; Krau ss et al 2008; González-Iglesias et al 2009;
Saaved ra-H ernánd ez et al 2013) spine. Furtherm ore, other
stu d ies su p p ort the effectiveness of cervical sp ine m anip u la-
tion / m obilization for d ecreasing sym p tom s in the shou ld er
(McClatchie et al 2009) and the elbow (Cleland et al 2004). In
a retrospective case au d it of 112 cases, Cleland et al (2004)
show ed that signi cantly few er treatm ents w ere requ ired for
those p atients w ith lateral ep icond ylalgia w ho received ad d i-
tional m anu al therap y to the cervical sp ine.
It should be noted that, w hereas there is consid erable evi-
(Cleland et al 2005, 2007a, 2010; Krauss et al 2008; González-
m u st also consid er the ad d ed bene t of incorp orating cervical
sp ine m anip u lation into a m u ltim od al treatm ent ap p roach.
Pu ented u ra et al (2011) com pared the effects of cervical spine
m anip u lation w ith thoracic sp ine m anip u lation for the m an-
agem ent of a grou p of patients w ith m echanical neck pain
w ho m et four out of six of the clinical pred iction ru le criteria
for thoracic spine tru st m anipu lation based on Cleland et al
(2007a). The resu lts fou nd that the grou p receiving cervical
sp ine m anip u lation exp erienced greater im p rovem ents in
p ain and fu nction at both the short- and long-term follow -u p s.
Saaved ra-H ernánd ez et al (2013) rep orted that, in p atients
w ith chronic m echanical neck pain, the inclusion of cervical
m anip u lation into a m u ltim od al m anip u lative intervention
lead s to a greater red uction in d isability than the application
of cervical sp ine m anip u lation alone. In ad d ition, a nu m ber
of stu d ies have ind icated that single ap p lications of cervical
or thoracic m anip u lation are m ore effective than single ap p li-
cations of m obilization in im m ed iately red u cing cervical p ain
and increasing range of m otion and fu nction (Martinez-
Segura et al 2006; Cleland et al 2007b; Du nning et al 2012). In

contrast, other stu d ies fou nd that ap p lications of either treat-
m ent ap p ear to yield sim ilar resu lts in term s of effects (Cassid y
et al 1992; H u rw itz et al 2002; Leaver et al 2010).
In the m anagem ent of chronic neck pain (p ain lasting m ore
than 6 m onths), m u ltim od al intervention com bining m anip u-
lation or m obilization w ith exercise, or cervical w ith thoracic
m anip u lations, resu lts in su p erior ou tcom es com p ared w ith
u sing either therap y in isolation (Gross et al 2002a, 2002b,
2004; Du nning et al 2012; Saaved ra-H ernánd ez et al 2013;
Vincent et al 2013). Finally, the early u se of m obilization and
m anip u lation in the m anagem ent of acu te neck d isord ers
app ears to be associated w ith better ou tcom es than w hen
these treatm ents are d elayed (Boissonnault & Bad ke 2008).
Hypothesized Mechanisms of Effect
H istorically, several potential m echanism s have been hypoth-
esized to accou nt for the ou tcom es associated w ith m anipula-
tion and m obilization. Biom echanical effects have been
sp ecu lated to occu r, d u e to one or m ore of the follow ing
m echanism s: (1) release of entrapp ed synovial fold s or plica,
(2) relaxation of hyp ertonic m uscle by su d d en stretching, (3)
d isru p tion of articular or p eriarticu lar ad hesions, (4) restora-
tion of the p rop er m id -position at rest and (5) restoration of
norm al p hysiological range of m otion in joints that are ‘stu ck’
in an end -range position (Shekelle 1994; Evans 2002). Ana-
tom ical stru ctu res (Bogd u k & Ju ll 1985; Giles & Taylor 1987;
Mercer & Bogd uk 1993) and biom echanical m echanism s
(Palfrey & N ew ton 1970; Sem lak & Fergu son 1970) have been
id enti ed that p artially su p port m echanism s 1–3; how ever,
sup p ortive evid ence for m echanism s 4–5 is still lacking (Gal
et al 1995, 1997; Evans 2002).
One event that has been hyp othesized to accou nt for som e
of the biom echanical m echanism s associated w ith the p ositive
resu lts of spinal m anipulation and m obilization is the form a-
tion and release of gas bu bbles w ithin the synovial u id
d u ring m anipu lation. This event generates a ‘cracking,
popp ing or clicking’ noise, term ed a cavitation, and has been
view ed as a sign that the m anip u lation w as ap p lied correctly
(Evans & Breen 2006). H ow ever, several stu d ies su ggest that
im p rovem ent in p ain and range of m otion follow ing m anip u -
lation m ay not be d ep end ent on the generation of joint cavita-
tion (H erzog et al 1995; Flynn et al 2003, 2006; Ross et al 2004).
It has been also suggested that the biom echanical effects of
m anip u lation m ay be only p artially resp onsible for the p atient
im p rovem ents associated w ith m anu al therap y techniqu es
d irected at the neck (Bialosky et al 2009b). N eu rophysiologi-
cal effects are p robably contribu ting to the overall effect of
m anu al therap y and can be fu rther classi ed as p erip heral,
sp inal and su p rasp inal m echanism s (Sterling et al 2001;
Bialosky et al 2009b). Perip heral m echanism s are associated
w ith red u ction of blood and seru m levels of cytokines, and
changes in levels of β-end orphin, N -palm itoylethanolam id e,
anand am id e, serotonin, end ogenou s cannabinoid s and su b-
stance P (McPartland et al 2005; Teod orczyk-Injeyan et al
2006; Degenhard t et al 2007).
In ad d ition to peripheral nervou s system m echanism s,
m anip u lation and m obilization have been p rop osed to im p act
on sp inal cord m echanism s (Pickar & Wheeler 2001; Malisza
et al 2003a, 2003b; Boal & Gillette 2004). For exam ple, it has
Speci city of manipulation and mobilization  159
been show n that cervical spine m anipulation exerts a hy -
p oalgesic effect and can resu lt in increased p ain p ressu re
threshold s at the neck and elbow in both healthy su bjects
(Fernánd ez-d e-las-Peñas et al 2007, 2008) and ind ivid uals
w ith lateral elbow pain (Fernánd ez-Carnero et al 2008). Ad d i-
tionally, healthy ind ivid u als and p atients w ith low back p ain
have exhibited increased tolerance to therm al stim u li follow -
ing a lu m bop elvic m anipulation (Bialosky et al 2009a).
Changes in d orsal horn activation in the sp inal cord
(Malisza et al 2003a), an end ogenous opioid response (Vernon
et al 1986) and im proved psychological outcom es (William s
et al 2007) have also been associated w ith joint m obilization
and m anipu lation. Lastly, m anipulation and m obilization
m ay red u ce sp inal cord resp onses throu gh activation of
su p rasp inal d escend ing p ain inhibition throu gh the anterior
cingu lar cortex, am ygd ala, p eriaqu ed u ctal grey and rostral
ventrom ed ial m ed u lla (H sieh et al 1995; Vogt et al 1996;
Derbyshire et al 1997; Iad arola et al 1998; Peyron et al 2000;
Pickar 2002; Mou lton et al 2005; Gu o et al 2006; Bee &
Dickenson 2007; Oshiro et al 2007; Stau d et al 2007).
Speci city of Manipulation
and Mobilization
Based on the available literatu re, it is likely that both biom e-
chanical and neu rop hysiological m echanism s accou nt for the
p rincip le ou tcom es (p ain red u ction and m otion im p rove-
m ent) associated w ith m obilization and m anip u lation
(Bialosky et al 2009b). Accepting this notion, the qu estion has
been raised of w hether m anu al therapy techniques need be,
and can be, sp eci c in term s of the m ovem ents and ou tcom es
generated in the spine d uring treatm ent (Cleland & Child s
2005; Flynn 2006; Aquino et al 2009; Schom acher 2009). Stud ies
have exam ined the effects of m anip u lative techniqu es u sing
centrally ap p lied p osterior to anterior p ressu res (central PAs)
on the sp inou s p rocesses in the lu m bar and cervical sp ines
(Pow ers et al 2003; Ku lig et al 2004; Lee et al 2005). These
au thors conclu d ed that the greatest m otion w as generated at
the p oint of contact. They also conclu d ed that m otion w as
generated at segm ents both cranial and caud al to the point of
contact. Ou tcom es stu d ies u sing the sam e m obilization tech-
niqu e conclu d ed that there w as no d ifference in levels of p ain
based on w hether the m ost painfu l segm ent w as treated or
w hether a rand om ly selected segm ent w as treated (Beneck
et al 2005; Land el et al 2008; Aquino et al 2009). When evalu-
ating the ou tcom es-based stu d ies that u sed the central PA
techniqu e, only som e of the stu d ies ind icated the am ou nt of
force u sed d u ring m obilization (Maitland grad e IV) (Beneck
et al 2005; H engeveld et al 2005; Land el et al 2008); the other
left the d ecision of force to the d iscretion of the therapist,
w hich w as not speci ed (Aqu ino et al 2009). Finally, the out-
com es that w ere rep orted w ere im m ed iate in natu re and
p rovid e no insight into the im p lications of rep eated ap p lica-
tions of these techniqu es in term s of both p ositive effects and
ad verse responses.
Cau tion shou ld be u sed therefore w hen generalizing the
results of these stud ies to all m obilization and m anip ulation
techniqu es. Althou gh these stu d ies p rovid e valu able insights
into the inter-relationship of m ovem ent betw een vertebrae
w hen a single central force is app lied to the sp ine in a
 160 PART 2 • 14 • Joint mobilization and manipulation of the cervical spine
m id -p osition, they exam ine only one techniqu e. In ad d ition,
the techniqu e m akes no attem p t to stabilize ad jacent sp inal
levels, leaving the d egree of sp eci city in qu estion. It has been
sp ecu lated that p oorly localized and overly forcefu l m anip u -
lations m ay p rovoke ad verse resp onses w hen ap p lied throu gh
d egenerative spinal segm ents (Assend elft et al 1996; Mu rp hy
2006; Mu rp hy et al 2006). For exam ple, rotational m anipula-
tion of the cervical sp ine has been associated w ith increased
risk of carotid or vertebral artery d issection (Assend elft et al
1996; Sm ith et al 2003). H ow ever, recent stu d ies d ebate this
assertion (H erzog et al 2012; Thom as et al 2013; Qu esnele et al
2014). Thom as et al (2013) conclu d ed that end -range rota-
tional techniqu es d o not alter blood ow to the brain any
m ore than other m anu al therap y techniqu es. To d ate no
stu d ies have d irectly com p ared the im p lications of attem p ting
to stabilize an ad jacent segm ent or not d u ring a m anip u lation
on either ou tcom es or ad verse events.
It seem s reasonable that, in ord er to m inim ize the risk of
ad verse events hyp othesized to be associated w ith spinal
m anip u lation, it is necessary to screen ind ivid u als carefu lly
w hen u sing m anual therap y techniques. Ad d itionally, there
seem s to be a general consensu s am ongst the m ajority of
m em ber organizations belonging to the International Fed era-
tion of Orthop aed ic Manip u lative Physical Therap ists
(IFOMPT) regard ing the need to red uce the use of rotation
forces d u ring m anip ulation of the cervical spine (Carlesso &
Rivett 2011).
Selecting Patients for Cervical
Manipulation and Mobilization
Selection of p atients w ho resp ond p ositively to m anip u lation
and w ho w ill not exp erience ad verse resp onses has trad ition-
ally been attem pted throu gh the u se of a com p rehensive
history and p hysical exam and the u se of p rem anip u lative
testing su ch as the vertebral artery test (Carlesso & Rivett
2011). The literature suggests that serious ad verse events m ay
be partially prevented through ad equate screening for abso-
lu te contraind ications and m anip u lative ‘red ags’ (Child s
et al 2005; Pu ented u ra et al 2012a). Absolute contraind ica-
tions to cervical m anip u lation inclu d e acu te fractu res, d isloca-
tions, ligam entou s ru p tu res, instability, infection, tu m ou rs,
acute m yelop athy, acu te soft tissu e injury, osteop orosis,
ankylosing sp ond ylitis, rheu m atoid arthritis, vascu lar d isease,
vertebral artery abnorm alities, connective tissu e d isease
and anticoagulant therap y (Pu ented u ra et al 2012a). Relative
contraind ications to cervical m anip u lation inclu d e p reviou s
d iagnosis of vertebrobasilar insu f ciency, facial / intraoral
anaesthesia / p araesthesia, visu al d istu rbances, d izziness /
vertigo, blu rred vision, d ip lop ia, nau sea, tinnitu s, d rop
attacks, d ysarthria, d ysp hagia and no change or w orsening of
sym p tom s after m u ltip le m anip u lations (Pu ented u ra et al
2012a). Unfortunately, althou gh ad equ ate screening m ay
red uce the risk of serious ad verse events it d oes not elim inate
it (Pu ented ura et al 2012a), nor d o tests and m easures su ch as
the vertebral artery test ap p ear to p red ict accu rately the
resp onses of these vascu lar structures to rotational m anipu la-
tion (Arnold et al 2004; Thiel & Rix 2005).
Other attem p ts to im p rove p atient selection inclu d e the u se
of clinical p red ication ru les (CPRs) that, in general, attem p t
to m atch p atient characteristics to p atient interventions
(Child s & Cleland 2006). In term s of m anipulation, efforts in
this area have resu lted in CPRs that id entify ind ivid u al char-
acteristics (e.g. nu m ber of d ays since onset of sym p tom s and
joint hyp om obility) and cond itions (acu te neck pain, cervico-
genic head aches and rad iculopathy) that resp ond favou rably
to m anip u lation in the lu m bar, thoracic and cervical sp ines
(Flynn et al 2002; Child s et al 2004; Cleland et al 2006, 2007a,
2007c; Flem ing et al 2007; Pu ented ura et al 2012b). Althou gh
CPRs p rovid e valu able insight into the connection betw een
exam ination nd ings and treatm ent resp onse, stu d ies p er-
form ed for neck-related cond itions have yet to be valid ated .
In fact, Cleland et al (2010) attem pted to valid ate the CPR for
m anip u lating the thoracic sp ine for ind ivid u als w ith m echan-
ical neck p ain; how ever, the results show ed that the original
CPR (Cleland et al 2007a) w as not fou nd to be valid in the
new grou p of p atients. Therefore, it has been recom m end ed
that fu rther research is necessary before these CPRs can be
generally applied w ith con d ence (H ancock et al 2007; May
& Resend ale 2009).
In contrast to relying solely on screening for contraind ica-
tions and red ags or selecting p atients w ho m atch a p refab-
ricated m anipulative techniqu e, the au thors su ggest a m ore
clinically p ragm atic ap p roach of d esigning / tailoring the
m anip u lative techniqu e to each p atient’s sp eci c m ovem ent
im p airm ent. The m ain p rinciple behind this approach is the
notion that m anu al stabilization, segm ental p re-p ositioning
and the d irection of force u sed d uring m anip ulation or m obi-
lization im pact the am ou nt of force and d irection of m ove-
m ent generated w ithin the treatm ent segm ent and the
su rrou nd ing sp inal levels (Krau ss et al 2006). The sp eci c
forces used d uring treatm ent are d isc traction, facet separa-
tion or facet glid ing as either su stained stretches (m obiliza-
tions) or im p u lses (m anip u lations). The selection of the
sp eci c typ e of cervical techniqu e (d isc traction, facet sep ara-
tion or facet glid ing) and the d egree to w hich m anu al stabili-
zation and p re-positioning of non-treatm ent segm ents are
u sed d ep end s on: (1) the am ou nt and type of m otion restric-
tion (tissu e resistance), (2) the nu m ber of restricted sp inal
levels, (3) sym ptom d uration and intensity, (4) the d egree of
anatom ical and p athom echanical changes at both the treat-
m ent segm ent and the ad jacent spinal segm ents and (5) the
d egree to w hich it is allow ed to prod u ce / reprod uce the
p atient’s sym p tom s (Maitland et al 2005). Evid ence su pports
the in u ence of p re-p ositioning and m anu al stabilization in
red u cing m ovem ent in ad jacent spinal levels for the u pper
cervical sp ine (Cattrysse et al 2007a, 2007b). In ad d ition, there
is also lim ited evid ence that techniques using these principles
can be ap p lied w ithou t ad verse resp onse to p atients w ith
d egenerative spinal cond itions (Creighton et al 2005;
Kond ratek et al 2006).
Adverse Reactions to Cervical
Manipulation and Mobilization
When consid ering the issue of safety, ad verse reactions asso-
ciated w ith m anip u lation and m obilization range from m inor
and self-lim iting inju ries such as head aches, stiffness and
lim itations in m otion (Senstad et al 1996; Lebou ef-Yd e et al
1997; Cagnie et al 2004; H urw itz et al 2005) to serious injuries

includ ing perm anent neu rological d e cits, d issection of a
carotid or vertebral artery, and d eath (Di Fabio 1999; Ernst
2002; H ald em an et al 2002; Licht et al 2003; Op p enheim et al
2005). Ad d itional ad verse responses potentially associated
w ith cervical sp ine m anipu lation includ e w orsening of pre-
existing d isc herniation, acute d isc herniation resulting in
both rad iculop athy and m yelopathy and , in patients w ith cer-
vical sp ond ylotic changes, w orsening of both rad icu lop athy
and m yelop athic d istu rbances (Lee et al 1995; Pad u a et al
1996; Malone et al 2002; Tseng et al 2002). Evid ence from the
scienti c literatu re su ggests that ad verse reactions are m ore
likely follow ing sp inal m anipu lation than m obilization and
they occu r in the cervical sp ine m ore often than in other sp inal
regions (Senstad et al 1996; Lebouef-Yd e et al 1997; H u rw itz
et al 2005). An estim ated 35–65% of p atients rep ort m inor
sid e effects follow ing their rst m anip u lation (Senstad et al
1996; Lebou ef-Yd e et al 1997; Cagnie et al 2004; H u rw itz et al
2005). In general, it ap pears that m inor ad verse responses
occur at a higher rate (one incid ent for every 476–1573 m anip-
u lations) (Di Fabio 1999) com pared w ith serious ad verse
resp onses, w hich occur at an estim ated rate of 1 incid ent per
20 000–3 000 000 m anip u lations (H urw itz et al 1996; Lebou ef-
Yd e et al 1997; Shekelle & Cou lter 1997; Di Fabio 1999; Gross
et al 2002a; H ald em an et al 2002; Licht et al 2003; Op p enheim
et al 2005).
The actu al nu m ber of ad verse resp onses to cervical m anip -
u lation is d if cu lt to estim ate ow ing to factors su ch as p racti-
tioner u nd er-rep orting, failu re to follow u p p atients w ho d o
not retu rn for treatm ent after receiving sp inal joint m anip u la-
tion, and the p otential d elay in sym p tom onset follow ing
m anip u lation (Assend elft et al 1996; Di Fabio 1999; N orris
et al 2000; Ernst 2002; Opp enheim et al 2005; Carlesso et al
2010a). With the exception of the m ost severe cases, the clas-
si cation of ad verse resp onses w ithin the literatu re has lacked
clear and consistent nom enclatu re, esp ecially regard ing loss
of fu nction and follow -u p treatm ent (Carlesso et al 2010b). To
ad d ress this, Carnes et al (2010) su ggest a three-layered p rag-
m atic ap p roach to the qu ali cation of ad verse events that
includ es the d u ration, severity, d escription, treatm ent and
fu nctional im plications of the ad verse response to m anip ula-
tion. Using these qu ali ers, m ajor, m od erate and m inor
ad verse events w ou ld be d escribed as follow s: (1) m ajor
ad verse events are m ed iu m to long term in d uration, m od er-
ate to severe in severity, d escribed as u naccep table by the
p atient and require fu rther treatm ent for resolution; (2) m od -
erate ad verse events are the sam e as m ajor ad verse events
in all respects except that they are m od erate in severity;
and (3) m ild ad verse events are of short d u ration, m ild in
severity, self-lim iting and requ ire no fu rther treatm ent (Carnes
et al 2010).
Althou gh serious ad verse events have been associated w ith
cervical m anip u lation, a cau se-and -effect relationship cannot
be d irectly inferred . A stud y by Cassid y et al (2008) review ed
818 cases of vertebral artery strokes ad m itted to hospitals in
Ontario, Canad a, betw een 1993 and 2002. The au thors found
that the risk of p atients having a sp ontaneou s vertebrobasilar
artery stroke associated w ith chirop ractic visits is the sam e as
that for p atients seeing their p rim ary care p hysician for
reports of neck and head p ain. In fact, it has been rep orted
that ind ivid u als p resenting w ith a vertebral artery d issection
typ ically exp erience head and neck p ain in a sim ilar d istribu -
tion to that of m echanical neck p ain (Kerry & Taylor 2006)
Translatoric cervical manipulation and mobilization  161
Therefore careful screening of subjects w ith neck and head
p ain is essential in an attem p t to d eterm ine w hether sym p -
tom s m ay p otentially be vascu lar in natu re or if the p atient is
p resenting w ith m echanical neck p ain. Kerry and Taylor
(2006) have d escribed com m on sym ptom s that ind ivid u als
w ith vertebrobasilar insuf ciency m ay experience, such as
d izziness, d rop attacks, d iplopia, d ysarthria, d ysphagia,
ataxia, nausea, nu m bness and nystagm u s. Pu ented u ra et al
(2012a) review ed 134 case reports of patients w ho had expe-
rienced an ad verse event associated w ith a cervical spine
m anip u lation. The nd ings ind icated that if p rop er screening
of red ags and contraind ications w ere p erform ed then
44.8% of those ad verse events w ould have potentially been
p revented .
Translatoric Cervical Manipulation
and Mobilization
The techniques presented in this section w ere co-d eveloped
by Fred d y Kaltenborn (PT, OMT) and Olaf Evjenth (PT, OMT)
of N orw ay. The em p hasis of these techniqu es is an attem p t to
avoid m od erate to severe ad verse responses (Carnes et al
2010) and to try to m axim ize outcom es in term s of pain,
m obility and d isability. Interestingly, the challenges Kalten-
born and Evjenth faced as they began d eveloping these tech-
niqu es in 1970 continu es to be re ected tod ay in term s of
ad verse responses, m echanism s of effect, sp eci city and ou t-
com es (Krauss et al 2006; Kaltenborn 2008). For the pu rposes
of this section w e u se term inology consistent w ith an interna-
tional persp ective w here: (1) m anipu lation is d e ned as a
high-velocity low -am p litu d e m ovem ent d elivered at the end
of available restricted joint m otion and w ithin the norm al
anatom ical range of joint m otion, and (2) m obilization is
d e ned as a low -velocity varying am plitu d e (static hold ing,
low or m od erate am plitud e) m ovem ent d elivered at variou s
p oints in the joints restricted range of m otion or at the end of
the available restricted joint m otion and w ithin the norm al
anatom ical range of joint m otion. More speci cally, m obiliza-
tion forces are ap p lied w ithin the available range of joint
m otion in a static or oscillatory m anner w hen p ain and / or
orthop aed ic cond itions associated w ith tissu e w eakness and
loss of stru ctu ral stability of a m otion segm ent are p resent
(Miyazaki et al 2008). In contrast, m anipulation, and som e-
tim es m obilization, is ap p lied at the end of available joint
m otion w hen p ain and / or orthop aed ic cond itions associated
w ith tissu e tightness are p resent.
Techniqu es p resented in this section of the chap ter
are grou p ed accord ing to typ e and d escribed u sing the
Am erican Acad em y of Orthoped ic Manu al Physical Thera-
p y’s (AAOMPT) recom m end ed stand ard ized term inology,
w hich inclu d es: (1) the rate of app lication, (2) location in range
of available m ovem ent, (3) d irection of force, (4) target of
force, (5) relative stru ctu ral m ovem ent and (6) p atient posi-
tion (Mintken et al 2008). Ad d itional insights regard ing the
u se of the techniqu es and errors to avoid are also p rovid ed .
Translatoric traction techniques
Translatoric traction techniqu es are u sed to u nload / d ecom -
p ress the d isc joint and intervertebral foram en contents
 162 PART 2 • 14 • Joint mobilization and manipulation of the cervical spine
Figure 14.1 C2–C7 disc traction in supine.
(nerves, arteries, veins and lym phatics). Disc traction m anipu -
lations are p erform ed at a right angle to the d isc joint in w hat
is essentially a cranially d irected force. Du ring d isc traction,
bilaterally applied m anipu lative forces are used in an attem pt
to generate equ al m ovem ent / traction of all p arts of the
intervertebral joint.
C2–C7 disc traction in supine (Fig. 14.1)
The patient is su pine in a position of greatest com fort w here
signs and sym p tom s are m ost m inim al. The therap ist stand s
facing the top of the patient’s head . The therapist’s left and
right hand s contact the posterior surface of the transverse
p rocesses, lam ina, inferior articu lar processes and spinous
p rocess of the cranial vertebra in the treatm ent segm ent. A
belt m ay be placed arou nd the therapist’s w aist and over the
therap ist’s hand s to assist in the generation of traction forces.
The slack in the treatm ent segm ent is taken u p in a cranial
d irection w ith both hand s and the m anipu lation or m obiliza-
tion is d elivered u sing the sam e d irection of m otion.
Specif city: Generally low ; d egree to w hich traction occu rs
in the sp inal segm ents cau d al to the p oint of contact is d ep end -
ent on factors such as am ount of force u sed and the am ou nt
of m otion available at each sp inal segm ent.
N ote: In cases of cervical nerve irritation second ary to
d isc d egeneration, the au thors recom m end d isc traction
m obilization and m anip u lation. If rad icu lar irritation is not
stable – in other w ord s the rad icu lar d iscom fort is severe and
variable – generally w e recom m end oscillatory d isc traction
m obilization. Above all, w e feel that su ccess in term s of im m e-
d iate rad icu lar sym ptom red uction w ith m anu al d isc traction
is often a m atter of p ositioning as op p osed to a m atter of
m anip u lative sp eed or force. We attem p t to p osition the
p atient’s affected segm ents using a com bination of exion,
sid e-bend ing and rotation su ch that the p atient’s sym p tom s
d ecrease prior to the beginning application of the d isc traction
m obilization p roced u re. Finally, the cranial vertebra of the
involved segm ent m u st be u sed in ord er to try to d ecom p ress
the irritated nerve root.
C2–C7 disc traction seated (Fig. 14.2)
The patient is sitting in a p osition of greatest com fort w here
signs and sym p tom s are m ost m inim al. The therap ist stand s
Figure 14.2 C2–C7 disc traction seated.
in front of and to the right of the p atient. The therap ist’s right
hand contacts the left sid e of the inferior articu lar p rocess and
lam ina of the cranial vertebra in the treatm ent segm ent. The
right sid e of the therap ist’s chest is p laced against the right
sid e of the p atient’s head . The therap ist’s left hand contacts
the bilateral lam inae of the cau d al vertebra. The slack in the
treatm ent segm ent is taken u p in a cranial d irection w ith the
right hand and chest. The therapist’s left hand presses in a
cau d al d irection as the slack is taken u p . The m anip u lation or
m obilization force is d irected cranially.
Specif city: This techniqu e seem s to be m ore speci c than
the su p ine version becau se of m anu al stabilization of the
cau d al vertebrae; how ever, this is still consid ered a low er
sp eci city techniqu e.
N ote: We often u se seated d isc traction m obilization and
m anip u lation in p atients w ho p resent w ith single or m u ltiseg-
m ent hyp om obility, w hich is m ore com m only seen in old er
p atients w ith late-grad e d isc d egeneration (Miyazaki et al
2008). Patients w ho are less sym ptom atic – in other w ord s
m ore ‘stiffness (resistance) d om inant’ – m ay bene t from the
increased speci city and resu ltant increased m anipu lative
force that this techniqu e facilitates. N ote in Figu re 14.2 how
the non-m anip u lating hand m anu ally stabilizes the cau d al
vertebra in a ventral and cau d al d irection p rior to ap p lying a
cranially d irected m obilization or m anip u lation.
Translatoric articular / facet
separation techniques
The biom echanical objective of translatoric articular / facet
sep aration techniqu es is to u nload or d ecom p ress the articu lar
su rfaces of the occip ito-atlanto (OA) and atlanto-axial (AA)
joints and the facet joints in the low er cervical spine. Obvi-
ou sly, any articu lar / facet sep aration techniqu e w ill ind u ce
som e of the p otential neu rop hysiological m echanism s brie y
d iscussed earlier in this chap ter.
Techniqu es grou p ed in this category generate sep aration
of the articu lar surfaces (OA and AA articulations and C2–C7
facets), w hich is d ifferent from d isc traction in that separation
of all p oints of the articu lar su rface is not equ al. This is d u e
in part to the u se of u nilaterally generated im pu lses in ad d i-
tion to the orientation of the facet su rfaces. In the u p p er cervi-
cal sp ine, as the articu lar su rfaces of the joints are p ositioned

Figure 14.3 Occipito-atlanto separation in supine.
in the transverse plane, the m anipulation is d irected cranially
and slightly m ed ially to m aintain bony contact. In the low er
cervical sp ine, the facet joints are oriented ap proxim ately 45°
from the horizontal. To generate the greatest am ount of facet
sep aration in the low er cervical sp ine the treatm ent segm ent
is positioned in opp osite sid e-bend ing and rotation and the
m anip u lation is d irected in a ventral, m ed ial and cau d al
d irection. If applying this techniqu e w ith a thrust, the position
of the segm ent and the cervical facet joint shou ld be su ch
that the facet is in its m ost loosely p acked p osition for
sep aration.
Occipito-atlanto separation
in supine (Fig. 14.3)
The patient is positioned sup ine w ith slight left sid e-bend ing,
right rotation and d orsal exion of the occiput on the atlas.
The therapist is p ositioned to the left of the patient’s head ,
neck and shou ld er. The therap ist’s right hand and forearm are
positioned behind the p atient’s head and against the right
sid e of the p atient’s face. The therap ist’s left hand contacts the
inferior ed ge of the patient’s left m astoid process. The slack
betw een occiput and atlas is taken up in a cranial d irection by
the therap ist’s right hand and chest. The m anip u lation / m obi-
lization is d elivered by the left hand in a cranial d irection.
Specif city: This is typ ically an articu lation that resp ond s
w ith a cavitation w hen the technique is perform ed w ith the
correct sp eed and p re-p ositioning. N o attem p t is m ad e to
stabilize cau d ally so m ovem ent w ill occu r below the p oint of
contact.
N ote: The au thors feel that loosening the OA joint is often
necessary in cases of u p p er cervical m otion im p airm ent. A
few d egrees of coup led sid e-bend ing and rotation are avail-
able at the C0 / C1 segm ent, bu t given the ligam entous con-
nection (alar ligam ent) betw een the lateral m asses of the
occip u t and the d ens process of C2, im provem ent of m obility
at C0 / C1 can in som e cases also im p rove cou pled rotation at
the C2 m otion segm ent. Im p rovem ent of cou p led rotation at
either the C0 / C1 segm ent or the C2 / C3 segm ent can often
im prove u pper cervical spine cou pled rotation. Anecd otally,
in patients w here arthritic d egeneration has resulted in cap-
su lar shortening at the OA joint and in p atients w ho rep ort
an increase in occipital pain w ith active and passive up p er
Translatoric cervical manipulation and mobilization  163
Figure 14.4 Atlanto-axial separation in side-lying.
cervical m otion, the au thors have fou nd good red u ction
in occipital pain referral after the application of OA traction
m anip u lation.
Atlanto-axial separation
in side-lying (Fig. 14.4)
The p atient is positioned in sid e-lying w ith slight right sid e-
bend ing, left rotation and d orsal exion of the atlas on the
axis. The therapist is positioned behind the patient’s head ,
neck and u p p er torso. The therap ist’s right hand and forearm
are p ositioned u nd er the right sid e of the p atient’s head w ith
the ind ex and m id d le ngers cu p p ed arou nd the p atient’s
chin. The therap ist’s left hand contacts the inferior ed ge of the
p atient’s transverse p rocess and p osterior arch of atlas. The
slack betw een atlas and axis is taken u p in a cranial d irection
by the therapist’s right hand and chest. The m anipulation
or m obilization is d elivered by the left hand in a cranial
d irection.
Specif city: Generally low ; the d egree to w hich traction
occu rs in the sp inal segm ents cau d al to the p oint of contact is
d epend ent on factors such as am ount of force used and the
am ou nt of m otion available at each spinal segm ent.
N ote: We feel that rotational pre-positioning to the u pper
cervical segm ents u sing a slow m ovem ent that the p atient can
stop is a safe and accep table w ay to take u p available cap su le–
ligam entous slack. Consistent w ith the teaching of the m ajor-
ity of m em ber organizations of IFOMPT, som e au thors of this
chap ter d iscou rage the u se of high-velocity rotational m anip -
u lation of the atlas on the axis (Carlesso & Rivett 2011). Rather,
after slow rotational pre-positioning of the u pp er cervical
region, the authors recom m end short-am plitu d e translational
m ovem ents in a cranial d irection of the atlas on the axis
as seen in Figu re 14.4. Ad d itionally the au thors rarely nd
signi cant cap su lar restriction of the lateral AA joint (Laksh-
m anan et al 2005).
C2–C7 facet separation seated version 1 (Fig. 14.5)
With the p atient seated , the p atient’s cervical sp ine d ow n
throu gh the treatm ent segm ent is p ositioned in right sid e-
bend ing and left rotation. The therapist stand s to the left of
the p atient. The therap ist’s left hand su p p orts the right
 164 PART 2 • 14 •
Figure 14.5 C2–C7 facet separation seated version 1.
p osterior ed ge of the transverse p rocess, articular process and
lam ina of the cranial vertebra in the treatm ent segm ent. The
therap ist’s right thu m b contacts the lam ina and su p erior artic-
u lar p rocess of the cau d al vertebra in the treatm ent segm ent.
The slack in the treatm ent segm ent is taken up through pre-
p ositioning in right sid e-bend ing and left rotation and by
app lying a slight cranial force on the cervical sp ine w ith the
left hand and shou ld er. The m anip u lation is d elivered by the
therap ist’s right thu m b in a ventral, m ed ial and cau d al
d irection.
Specif city: This techniqu e is m ore speci c than others in
term s of the m otion generated at the treatm ent segm ent and
the d irect m anu al contact p oint on the inferior facet. In ad d i-
tion, the p re-p ositioning and su p p ort of the cranial vertebra
m ay red u ce m otion in segm ents cranial to the treatm ent
segm ent. Movem ent of the cau d al segm ents m ay occu r
tow ard s a m id -p osition.
N ote: In com p licated cervical p resentations (e.g. m id to
low er cervical d isc d egeneration w ith sym p tom atic hyp erm o-
bility or rad icu lar irritation (Dai 1998) ), this version of facet
joint d istraction can allow for sim u ltaneou s app lication of
m anu al traction. This is ap p lied w ith the therap ist’s non-
m anip u lating hand and the chest w hile the therap ist’s thu m b
app lies a sp eci c facet joint d istraction to the hypom obile
level. Ap p lication of a su stained m anu al traction takes u p
ligam entou s slack and p revents excessive angu lar and trans-
lational m ovem ent at d egenerated hyp erm obile cervical seg-
m ents or segm ents w ith d iscogenic or sp ond ylotic irritation.
C2–C7 facet separation seated
version 2 (Fig. 14.6)
With the p atient seated , the p atient’s cervical sp ine d ow n
throu gh the treatm ent segm ent is p ositioned in left sid e-
bend ing and right rotation. The therapist stand s to the left of
the p atient. The therap ist’s left forearm is p laced against the
left sid e of the p atient’s face and neck su p p orting the head
p osition. The rad ial bord er of the therapist’s right second
m etacarp op halangeal (MCP) joint contacts the lam ina and
su p erior articu lar p rocess of the cau d al vertebra in the treat-
m ent segm ent. The slack in the treatm ent segm ent is taken u p
throu gh p re-p ositioning in left sid e-bend ing and right rota-
tion. The m anip u lation or m obilization is d elivered by the
Joint mobilization and manipulation of the cervical spine
Figure 14.6 C2–C7 facet separation seated version 2.
rad ial bord er of the therapist’s right hand in a ventral, m ed ial
and cau d al d irection.
Specif city: This technique also seem s to be sp eci c in term s
of the m otion generated at the treatm ent segm ent and the
d irect m anu al contact point on the inferior facet. In ad d ition,
the p re-p ositioning and su p p ort of the cranial vertebra cou ld
red u ce m otion in segm ents cranial to the treatm ent segm ent.
Movem ent of the cau d al segm ents m ay occu r tow ard s a
m id -p osition.
N ote: The authors often apply this version of facet d istrac-
tion in the m ore ‘stiffness-d om inant’ p atients. A case rep ort
fou nd that this version of facet d istraction w as u sefu l w hen
ap plied below a d egenerated hyp erm obile m id to low er (C4–
C6) cervical segm ent (Kond ratek et al 2006). H ow ever, care
shou ld be taken w hen ap p lying this techniqu e above a sym p -
tom atically d egenerated hyp erm obile segm ent, given the
com p ressive load cau sed by the cau d al force com p onent of
this techniqu e. The au thors have also fou nd that this m anu al
intervention d oes not signi cantly change vertebral artery
ow velocity or lum en d iam eter (Creighton et al 2011).
C2–C7 facet separation in supine
contralateral gap (Fig. 14.7)
With the p atient su p ine, the p atient’s cervical sp ine d ow n
throu gh the treatm ent segm ent is p ositioned in left sid e-
bend ing and right rotation. The therap ist stand s to the left of
the p atient’s head , neck and shou ld er. The therap ist’s right
forearm is p laced against the right sid e of the p atient’s face
su p p orting the head p osition. The rad ial bord er of the thera-
p ist’s left second MCP joint contacts the left inferior and su p e-
rior articular processes of the treatm ent segm ent. The slack in
the treatm ent segm ent is taken u p throu gh p re-p ositioning in
left sid e-bend ing and right rotation. The m obilization / m anip-
u lation is d elivered by the rad ial bord er of the therap ist’s
left hand in a m ed ial, slightly cranial and slightly d orsal
d irection.
Specif city: This techniqu e is consid ered m od erately sp eci c
in term s of the m otion generated at the treatm ent segm ent.
Sp eci city is enhanced by taking u p soft tissu e slack in the
treatm ent segm ent throu gh p re-p ositioning in sid e-bend ing
and rotation. Im p ulses that are too long or m ovem ent of the
su p p ort hand and therap ist’s bod y m ay generate u nw anted

m ovem ent in the sp inal segm ents cranial and cau d al to the
treatm ent segm ent.
N ote: The au thors often ap p ly this m obilization / m anip u la-
tion techniqu e in p atients w ho d em onstrate facet joint hyp o-
m obility and overlying soft tissu e tend erness on the sam e
sid e. Figu re 14.7 show s how the right facet joint is sep arated
u sing a m anu al contact and m anip u lative force ap p lied on the
left sid e of the neck.
C7 facet separation in supine (Fig. 14.8)
With the p atient su p ine, the p atient’s C7 spinal segm ent is
positioned in slight left sid e-bend ing and right rotation. A
large m obilization w ed ge (N orsk w ed ge pictu red ) is placed
u nd er the u p p er thoracic sp ine w ith the base facing cranial
and p ositioned u nd er T1. The therap ist stand s to the left of
the p atient’s shou ld er. The u lnar bord er of the therap ist’s left
hand p resses in the d irection of the anterior su rface of the
Figure 14.7 C2–C7 facet separation in supine contralateral gap.
Figure 14.8 C7 facet separation in supine.
Translatoric cervical manipulation and mobilization  165
p atient’s right transverse process of C7. The therap ist’s right
hand is p laced over the left to su p p ort the contact and w rist
and hand p osition. The slack in the treatm ent segm ent is
taken u p throu gh p re-p ositioning. The m anip u lation or m obi-
lization is d elivered by the ulnar bord er of the therapist’s left
hand in a d orsal, lateral and cranial d irection.
Specif city: Du e to the contact on C7 and the rm stabiliza-
tion p rovid ed by the w ed ge, this techniqu e is consid ered
m od erately sp eci c.
N ote: In patients w ith hypom obile C7 / T1 segm ents, the
au thors of this chapter have fou nd that this m obiliza-
tion / m anip u lation techniqu e p rovid es a good stretch to the
p eriarticular structu res at the C7 / T1 articu lation.
Translatoric facet-gliding techniques
Translatoric facet-glid ing techniqu es are d irected p arallel to
the articu lar su rfaces in the u p p er and low er cervical sp ines.
In the up per cervical spine the m anipulative force is princi-
p ally d irected in a ventral and d orsal d irection. In the low er
cervical sp ine (C2–C7) the force d irections are ventral, m ed ial
and cranial and d orsal. The d ecision regard ing the d irection
of m ovem ent u sed for glid ing techniqu es is d eterm ined by
the d irection of restricted m otion. More sp eci cally, d orsal
glid ing at the OA joint is u sed w hen ventral exion of the joint
is restricted , and ventral glid ing at the OA joint is u sed w hen
d orsal exion is restricted . In the low er cervical spine, ventral
cranial glid ing is u sed w hen ventral exion is lim ited , or in
the case of a right u nilateral restriction w hen ventral exion
and left sid e-bend ing and left rotation are restricted . Dorsal
cau d al glid ing is u sed w hen d orsal exion is restricted , or in
the case of right u nilateral restrictions w hen d orsal exion
and right sid e-bend ing and rotation are restricted . During
these techniqu es it is im p ortant that the com p ression forces
are avoid ed d u ring glid ing. This is accom p lished by ap plying
a sm all am ou nt of (Kaltenborn grad e 1) traction to the joint
p rior to glid ing.
 166 PART 2 • 14 • Joint mobilization and manipulation of the cervical spine

Figure 14.9 Occipito-atlanto unilateral dorsal glide in supine. Figure 14.10 C2–C6 facet ventral-cranial glide in supine.

Occipito-atlanto unilateral dorsal glide

in supine (Fig. 14.9)
The patient is positioned in su pine w ith slight ventral exion
of the occip u t on the atlas. The therap ist stand s facing the
head of the p atient. The therap ist’s left hand is p laced p oste-
riorly u nd er the p atient’s occiput. The therapist’s left should er
is p ositioned anteriorly on the p atient’s forehead su p erior to
the p atient’s left eye. The therap ist’s right hand contacts and
stabilizes the right transverse p rocess and p osterior arch of
atlas w ith the MCP and rad ial bord er of their ind ex nger.
The slack in the right OA joint is taken up by applying a
d orsal and m ed ial pressure w ith the therapist’s left shou ld er
in the d irection of the stabilizing hand . The m obilization force
is ap p lied in a d orsal and m ed ial d irection by the therap ist’s
left shou ld er.
Specif city: This techniqu e can be consid ered speci c d u e to Figure 14.11 C2–C6 facet ventral-cranial glide seated.
segm ental p re-p ositioning and the rm stabilization p rovid ed
to the atlas by the therap ist’s hand p ositioned betw een the
p osterior arch of atlas and the treatm ent table. Specif city: Du e to the u se of sp inal locking and m anu al
N ote: We have fou nd that the occipu t d orsal m obilization reinforcem ent this technique seem s to be speci c. When
techniqu e often red u ces com p laints of u p p er cervical p ain app lied correctly this technique typically generates a
and im p roves u p p er cervical exion. This im proved m otion cavitation.
gives patients w ith postu ral im pairm ents an im proved ability N ote: Loosening cou p led rotation and sid e-bend ing at the
to bring their eyes into a m ore horizontal p osition. C2 segm ent m ay assist in im proving rotation of the d ens
w ithin its osteoligam entou s ring. This im proves the ligam en-
C2–C6 facet ventral-cranial glide tou s tensioning m echanism betw een the alar ligam ent and the
in supine (Fig. 14.10) occipu t. As a resu lt, im proved coup led rotation at the C2
segm ent m ay enhance cou p led m otion at the OA segm ent.
The patient is p ositioned sup ine w ith the low er cervical
sp ine in left sid e-bend ing, right rotation and slight ventral C2–C6 facet ventral-cranial glide
exion. The treatm ent segm ent is p ositioned in right sid e- seated (Fig. 14.11)
bend ing, right rotation and slight ventral exion. The thera-
p ist is p ositioned to the left of the patient’s head , neck and The patient is seated w ith the low er cervical spine in right
left shou ld er. The therap ist’s right hand and forearm are p osi- sid e-bend ing, left rotation and slight ventral exion. The
tioned u nd er the right sid e of the p atient’s head w ith the u lnar treatm ent segm ent is p ositioned in left sid e-bend ing, left rota-
sid e of the hand contacting the right inferior articu lar p rocess, tion and slight ventral exion. The therap ist is p ositioned to
lam ina and sp inou s p rocess of the cranial vertebra in the the left of the p atient’s head , neck and left shou ld er. The rad ial
treatm ent segm ent. The slack in the treatm ent segm ent is bord er of the therapist’s left hand contacts the right inferior
taken u p d u ring p re-p ositioning. The m anip u lation is ap p lied articu lar process of the cranial vertebra in the treatm ent
by the therapist’s left hand in a ventral, m ed ial and cranial segm ent. The therap ist’s right thu m b p resses ventrally and
d irection. m ed ially against the left sid e of the cau d al vertebra’s lam ina.
 Translatoric cervical manipulation and mobilization  167

Figure 14.12 C2–C6 facet dorsal-caudal glide seated. Figure 14.13 C7 facet ventral-cranial glide in supine.

Slack in the treatm ent segm ent is taken u p d u ring p re-

p ositioning. The m anip ulation is ap p lied by the therapist’s
left hand in a ventral, m ed ial and cranial d irection.
Specif city: Du e to the u se of sp inal locking and m anu al
reinforcem ent this technique can be speci c.
N ote: When m anipu lating the C2 segm ent, care m u st be
taken that the m anip u lating hand is not p laced on the atlas.

C2–C6 facet dorsal-caudal glide

seated (Fig. 14.12)
The patient is seated w ith the low er cervical spine in left sid e-
bend ing, right rotation and slight extension. The treatm ent
segm ent is p ositioned in right sid e-bend ing, right rotation
and d orsal exion. The therap ist is p ositioned to the left of the
patient’s head , neck and left shou ld er. The rad ial bord er of
the therap ist’s left hand contacts the right inferior articu lar
process of the cranial vertebra in the treatm ent segm ent. The
therap ist’s left thu m b p resses ventrally and m ed ially against
the left sid e of the cau d al vertebra’s lam ina. The slack in the
treatm ent segm ent is taken u p d u ring p re-p ositioning. The
m anip u lation is ap p lied by the therap ist’s left hand in a
d orsal, m ed ial and cau d al d irection.
Specif city: This techniqu e can be sp eci c d u e to sp inal p re-
positioning and m anual stabilization; how ever, som e m ove-
m ent m ay occu r above and below the treatm ent segm ent.
N ote: This m obilization app ears to be effective in im p rov-
ing cervical rotation restriction but m ay increase cervical
sym p tom s from an infra-ad jacent segm ent that is com p res-
sion sensitive (e.g. irritated nerve root). If this is encou ntered ,
the au thors recom m end the ad d ition of a cranially d irected
traction force ap p lied to the p atient’s head by the p ractition-
er ’s chest d u ring the m obilization proced u re.
C7 facet ventral-cranial glide in supine (Fig. 14.13)
The p atient is p ositioned su pine w ith the C7 in left sid e-
bend ing, left rotation and slight exion. The therapist is posi-
tioned to the left of the p atient’s head , neck and left shou ld er.
The rad ial bord er of the therapist’s right hand contacts the
right inferior articu lar process of C7. The therap ist’s left hand
presses d orsally on the patient’s right should er to stabilize T1.
The slack in the treatm ent segm ent is taken u p d u ring
Figure 14.14 C7 facet ventral-cranial glide seated.
p re-p ositioning. The m anip u lation is ap p lied by the thera-
p ist’s right hand in a ventral, m ed ial and cranial d irection.
Specif city: Som e m ovem ent m ay occu r in the sp inal seg-
m ents cranial to C7; how ever, very little m otion shou ld occu r
in the sp inal segm ents below.
N ote: In patients w ith hypom obile C7 / T1 segm ents, the
au thors of this chapter have fou nd that this m obiliza-
tion / m anip u lation techniqu e p rovid es a good stretch to the
p eriarticular structu res at the C7 / T1 articu lation.
C7 facet ventral-cranial glide seated (Fig. 14.14)
The patient is seated w ith the C7 in slight left sid e-bend ing,
left rotation and slight exion. The therap ist is p ositioned in
front of the patient w ith his left knee positioned anteriorly
contacting the p atient’s right shou ld er and chest. The u lnar
bord er of the therapist left hand contacts the posterior su rface
of the transverse process of C7 on the right. The u lnar bord er
of the therap ist’s right hand contacts the left p osterior lam inae
and facets of C7 and T1. The slack in the treatm ent segm ent
is taken u p d uring p re-p ositioning. The m anip ulation is
ap plied by the therap ist’s left hand in a ventral, m ed ial and
cranial d irection.
 168 PART 2 • 14 •
Figure 14.15 C7 facet dorsal-caudal glide seated.
Specif city: Little m ovem ent shou ld occur above or below
the treatm ent segm ent.
N ote: Patients w hose cervical cond itions are less p ainfu l
and m ore d om inated by stiffness, or w ho perhaps present
only w ith cervical d iscom fort closer to the end range of
an active cervical m ovem ent, often resp ond w ell to this
techniqu e.
C7 facet dorsal-caudal glide seated (Fig. 14.15)
The p atient is seated w ith the C7 in slight left sid e-bend ing,
left rotation and d orsal exion. The therap ist is p ositioned in
front of the patient w ith his left knee positioned anteriorly
contacting the p atient’s right shou ld er and chest. The u lnar
bord er of the therapist right hand contacts the posterior
su rface of the transverse process of C7 on the left. The u lnar
bord er of the therapist’s left hand contacts the right posterior
lam inae and facets of C7 and T1. The slack in the treatm ent
segm ent is taken u p d u ring p re-p ositioning. The m anip u la-
tion is ap p lied by the therap ist’s right hand in a d orsal, m ed ial
and cau d al d irection.
Specif city: Little m ovem ent shou ld occur above or below
the treatm ent segm ent.
N ote: Patients w hose cervical cond itions are less p ainfu l
and m ore d om inated by stiffness, or w ho perhaps p resent
only w ith cervical d iscom fort closer to the end range of
an active cervical m ovem ent, often resp ond w ell to this
techniqu e.
Posterior–anterior Cervical
Mobilization
Posterior–anterior cervical joint m obilization can be used as
an assessm ent or treatm ent m ethod (Maitland et al 2005).
When selecting the techniqu e, the therap ist has to m ake the
follow ing im portant d ecisions: (a) to w hat d egree it is allow ed
to p rod u ce / rep rod u ce the p atient’s sym p tom s and (b) to
w hat d egree it is necessary to m obilize into tissu e resistance.
Maitland et al (2005) p erform ed treatm ent techniqu es in an
oscillatory m anner. These oscillations can be p erform ed w ith
d ifferent am plitu d es in d ifferent positions in the range of
Joint mobilization and manipulation of the cervical spine
Figure 14.16 Posterior–anterior unilateral upper cervical spine mobilization.
m ovem ent (read ers are referred to the textbook M aitland’s
vertebral manipulation (Maitland et al 2005) for further infor-
m ation on the Maitland ap p roach). In the cu rrent section w e
w ill d escribe the m ost com m on p osterior–anterior joint m obi-
lization targeted to the cervical spine.
Posterior–anterior unilateral upper cervical
spine mobilization (Fig. 14.16)
The p atient is prone w ith the cervical spine in a neutral p osi-
tion. The p ad s of the therap ist’s left and right thu m bs contact
over the posterior–lateral aspect of atlas (C1) in line w ith the
OA (C0–C1) joint on the targeted sid e. The therap ist’s arm s
and thum bs are d irected slightly m ed ially and cranially. The
rem aining portions of the therap ist’s hand s rem ain relaxed
and in contact w ith the left and right sid es of the up p er
neck. Oscillatory p ressu re is d irected throu gh the thu m bs in
a posterior–anterior d irection on C1. When perform ed cor-
rectly a sm all extension m ovem ent of the head w ill occu r
w ithou t any rotation or sid e-bend ing.
N ote: This techniqu e m ay be u sed for the treatm ent of cer-
vicogenic head ache. If head ache p ain is p resent w ith p ressu re
at C1, the oscillatory am plitu d e and starting d ep th m ay cau se
slight d iscom fort d u ring its ap p lication. H ow ever, the head -
ache sym ptom s shou ld grad u ally ease and not w orsen as
treatm ent p rogresses.
Posterior–anterior unilateral mid-cervical
spine mobilization (Fig. 14.17)
The p atient is prone w ith the cervical spine in a neutral p osi-
tion. The p ad s of the therap ist’s left and right thu m bs contact
over the articu lar p rocess (m id -cervical segm ent illu strated ).
The therapist’s arm s and thu m bs are d irected slightly m ed i-
ally (app roxim ately 30°). The rem aining p ortions of the thera-
p ist’s hand s rem ain relaxed and in contact w ith the left and
right sid es of the u pper neck. Oscillatory pressure is d irected
throu gh the thu m bs in a p osterior–anterior d irection on the
treatm ent articu lation. When p erform ed correctly a sm all
extension m ovem ent of the head w ill occu r w ithou t any rota-
tion or sid e-bend ing.

Figure 14.17 Posterior–anterior unilateral mid-cervical spine mobilization.
Figure 14.18 Transverse unilateral mid-cervical spine mobilization.
N ote: Care shou ld be taken w hen applying this technique
ad jacent to a sp inal segm ent w ith reactive hyperm obility or
rad icu lopathy. If these cond itions are present then either the
oscillatory am p litu d e or starting d ep th of m ovem ent shou ld
be ad justed to avoid provocation of neu rogenic sym ptom s.
Transverse unilateral mid-cervical spine
mobilization (Fig. 14.18)
The patient is prone w ith the cervical spine in slight extension
and neu tral sid e-bend ing and rotation. The therapist stand s
on the sid e of the p atient. The p ad s of his left and right
thu m bs contact the right sid e of the sp inou s p rocess / lam ina
(m id -cervical segm ent illustrated ). The therapist’s arm s and
thu m bs are d irected m ed ially. The rem aining p ortions of the
therap ist’s hand s rem ain relaxed and in contact w ith the
d orsal sku ll and u pper thoracic spine. Oscillatory pressu re is
d irected through the thum bs in a lateral to m ed ial d irection
on the sp inou s p rocess. When p erform ed correctly a sm all
sid e-bend ing and rotation m ovem ent of the neck w ill occu r
w ithou t any exion or extension.
N ote: Becau se the spinou s process contact used in this tech-
niqu e can easily generate m ovem ent, only very gentle and
Cervical spine manipulative procedures 169
sm all oscillations shou ld be u sed . In ad d ition, care shou ld be
taken to avoid d iscom fort d u e to thu m b tip p ressu re. This
techniqu e is m ost ind icated for p atients exp eriencing u nilat-
eral cervical sym p tom s.
Cervical Spine Manipulative
Procedures
There are num erous factors that m ay help d eterm ine the su it-
ability of the p atient to receive cervical joint m anip u lation.
These factors d epend on both the patient and the clinician. In
d eterm ining w hether spinal m anipulation should be the
ap prop riate intervention for a patient, it is generally recom -
m end ed that the clinician assesses joint glid e and end feel at
the end of the available p assive range in the segm ent id enti-
ed as d ysfu nctional, for d etection of a rm end feel that
arrives slightly early in the p assive range of m otion (Krau ss
et al 2006; Pettm an 2006). There is little evid ence, how ever, to
gu id e the clinician w ith regard to the valid ity of assessing end
feel as an ind icator for joint m anipu lation. Therefore, proper
clinical reasoning shou ld d eterm ine w hether this intervention
is the m ost appropriate for a particu lar ind ivid ual at any
m om ent d u ring the treatm ent.
There are three im portant com p onents of the spinal m anip-
u lation requ iring consid eration: velocity, am p litu d e and
force. It has been argued that the term ‘high-velocity’ m ay be
a m isnom er, since the technique starts at zero velocity, and it
has therefore been referred to by several au thors as a ‘high-
acceleration’ rather than a ‘high-velocity’ techniqu e (Pettm an
2006). Second ly, keep ing the am plitud e low m inim izes the
p otential risk of d am age to the joint com p lex and its su r-
round ing tissu es, p articu larly m anipu lations targeted to the
u p p er cervical sp ine. Third ly, the m agnitu d e of the force is
also im portant. If ad equ ate localization and accum u lative
tension of the m ovable barrier is achieved , little force is
requ ired for successfu l techniqu e. Som e factors that m ay be
associated w ith p oor outcom es w ith cervical joint m anipu la-
tion are listed in Box 14.1 (Krau ss et al 2006).
C2–C6 separation of zygapophyseal articular
joint: manipulation in rotation (Fig. 14.19)
The patient is su pine w ith the cervical spine in a neutral
p osition. The MCP joint of the ind ex nger of the therap ist
m akes contact over the p osterior–lateral aspect of the articu lar
p rocess of the cranial vertebra in the treatm ent segm ent. The
therap ist crad les the p atient’s head w ith the other hand .
The cervical spine is slightly exed d ow n to the targeted
segm ent. Gentle ip silateral sid e- exion and contralateral rota-
tion to the targeted sid e are introd u ced u ntil slight tension is
p erceived in the tissu es at the contact p oint. A high-velocity
low -am plitud e cervical spine m anipulation is d irected
u p w ard s and m ed ially in the d irection of the su bject’s con-
tralateral eye.
N ote: Do not com bine rotation and sid e-bend ing in the
m anip u lative force, becau se this m ay increase the friction at
the joint su rfaces and tension in the p eriarticu lar stru ctu res,
w hich m ay cause the operator to increase the force of the
thru st to overcom e this resistance.
 170 PART 2 • 14 •
Figure 14.19 C2–C6 separation of zygapophyseal articular joint: manipulation
in rotation.
Bo x 1 4 .1 Fa c to rs a s s o c ia te d w ith p o o r o u tc o m e s
w ith c e rvic a l jo in t m a n ip u la tio n
Clinic ian-re late d fac to rs
• Inadequate clinical training and experience
• Inadequate patient physical examination
• Diagnostic error
• Poor choice of manipulative procedures
• Incorrect patient positioning during technique
• Poorly applied technique
• Excess ive manipulative force or amplitude
• Lack of interpers onal and communication skills
Patie nt-re late d fac to rs
• Personal expectations of the patient
• Prior experiences with previous clinicians (mostly bad)
• Emotional, ps ychological and behavioural factors
• Patient fear and apprehension
• Too much pain in too many directions of s pinal motion
• Congenital abnormalities
• Multiple medical comorbidities
Atlanto-axial separation of zygapophyseal
articular joint: upper cervical spine
manipulation (Fig. 14.20)
The p atient is su pine w ith the cervical spine in a neu tral posi-
tion. The MCP joint of the ind ex nger of the therap ist con-
tacts over the p osterior–lateral aspect of the articu lar process
of the AA (C1–C2) joint in the targeted sid e. The therapist
grasp s the patient’s chin w ith the other hand and u ses the
forearm to su pport the patient’s head . The cervical spine is
exed approxim ately over the targeted segm ent. Gentle con-
tralateral rotation to the targeted sid e is introd u ced u ntil
slight tension is p erceived in the tissu es at the contact p oint
(AA joint). A lateral glid e of the AA joint is slightly intro-
d u ced to increase the tension. A high-velocity low -am plitud e
Joint mobilization and manipulation of the cervical spine
Figure 14.20 Atlanto-axial separation of zygapophyseal articular joint: upper
cervical spine manipulation.
u p p er cervical sp ine m anip u lation is execu ted horizontally in
the d irection of the su bject’s contralateral eye.
N ote: It is im p ortant to note that the u pper cervical spine
m anip u lation is not execu ted by increasing the rotation of the
cervical sp ine, w hich is a d angerou s m ovem ent for the verte-
bral artery. The im p ulse is ap plied in the lateral glid e of the
AA joint.
Conclusion
In su m m ary, recent years have seen great ad vances in our
u nd erstand ing of the factors associated w ith su ccessfu l m an-
agem ent of neck and arm p ain throu gh the use of m obilization
and m anipu lation of the cervical sp ine. H ow ever, questions
and challenges still rem ain unansw ered and requ ire contin-
u ed op en d iscu ssion by all p ractitioners of these interven-
tions. Ad vancem ent in ou r u nd erstand ing of the p ossibilities
and p itfalls of the clinical practice of cervical m obilization and
m anip u lation requ ires continu ed carefu l exam ination of p rac-
titioners’ beliefs, w hether they are based on em erging litera-
tu re or exp ert op inion.
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 PART 2 •  Cervicothoracic Spine in Upper Extremity Pain Syndromes
15
Therapeutic Exercise or Mechanical Neck Pain
 Chapter 
C a ro l Ke n n e d y
CHAP TER CONTENTS
Introduction  174
Exercises for motor function  175
Recruitment  175
Strength and endurance  176
Side- exion / rotation exercises for asymmetric weakness  179
Motor control  180
Mobility exercises  182
Generalized active range of motion  182
Articular / self-mobilization  183
Myofascial extensibility  184
Neurodynamics  185
Postural correction exercises  185
Muscle imbalance  185
Articular system  186
Neuromeningeal system  186
Posture corrections  186
Somatosensory dysfunction  186
Introduction
The u se of speci c therap eutic exercise as an ad ju nct to
m anu al therap y treatm ent has been a m ajor em p hasis of p hys-
iotherap y in recent years as p art of the m u ltim od al ap p roach
to m anagem ent of acu te and chronic m echanical neck p ain
(MN P). It can be challenging to d evelop a com prehensive
exercise p rogram m e, attem pting to ad d ress the m any factors
involved , yet not overload or irritate the neck.
In a system atic review of the conservative m anagem ent of
MN P, Gross et al (2007) found strong evid ence of bene t for
long-term p ain red u ction, im p roved fu nction and p ositive
global p erceived bene t for a com bination of m anu al therapy
and exercise for su bacute and chronic m echanical neck d isor-
d ers. There w as also m od erate evid ence for long-term
im p roved fu nction for neck-strengthening and stretching
exercises in chronic su bjects. For the u se of vertigo exercises,
there w as m od erate evid ence for high global p erceived effect.
Sarig-Bahat (2003), in a review of the u se of exercise alone,
conclu d ed that there w as strong evid ence su p p orting the
effectiveness of d ynam ic resisted strengthening and p roprio-
cep tive exercises. There w as also m od erate evid ence to
su p p ort the u se of early m obility exercises for acu te w hip lash-
associated d isord er (WAD). Several stu d ies (Jull et al 2002;
Ylinen et al 2006; Walker et al 2008) have show n im prove-
m ents to be m aintained over the long term of 1 to 3 years,
even thou gh continuation of hom e exercises follow ing the
initial training w as inconsistent (Ylinen et al 2007a).
An upd ated Cochrane Review has recently conclu d ed
that there is m od erate-qu ality evid ence su p p orting com bined
sp eci c cervical and scapu lar–thoracic stretching and strength-
ening for pain relief post treatm ent and at interm ed iate
follow -u p, and im proved fu nction in both the short term and
the interm ed iate term for chronic neck p ain (Kay et al 2012).
Low - to m od erate-qu ality evid ence show s no bene t of u p p er
extrem ity or general exercise p rogram m es alone. Low - to
m od erate-qu ality evid ence su p p orts self-m obilization and
low -load neck and scapu lar end u rance exercises in red u cing
p ain, im p roving fu nction and global p erceived effect in the
long term for cervicogenic head ache. Low -quality evid ence
su p p orts neck-strengthening exercise p rogram m es in acu te
cervical rad icu lop athy for p ain relief in the short term .
Mod erate-qu ality evid ence d em onstrates that p atients are
very satis ed w ith their care w hen treated w ith therap eu tic
exercise (Kay et al 2012).
Su p ervised exercise p rogram m es have been fou nd to be
m ore effective than either hom e exercise or exercise ad vice in
im p roving self-ef cacy, fear of m ovem ent / re-inju ry and
p ain d isability (Taim ela et al 2000; Bu nketorp et al 2006). In
their qu alitative stu d y, Escolar-Reina et al (2010) fou nd that
p atients w ere m ore likely to ad here to their hom e exercise
p rogram m e in the follow ing circu m stances: the exercises
w ere not too tim e consu m ing or d isruptive to their d aily
routine, they w ere not too com p lex, they had received ad e-
qu ate feed back and su p ervision w hen learning the exercises,
and the therapist style and exercise experience had been
p ositive.
Conley et al (1997) d em onstrated that exercises focu sing on
the u p p er extrem ity d id not resu lt in hyp ertrop hy of the cervi-
cal m u scu latu re; strengthening had to be d irected sp eci cally
to the neck.
Although it is clear that cervical exercise program m es are
an effective com p onent in the m anagem ent of neck p ain, the
typ e of exercise that is m ost effective has not yet been d eter-
m ined . Variou s p rogram m es of low -load craniocervical
exion (CCF) exercises, higher load head -lift exercises and

resisted static and d ynam ic exercises have all been fou nd to
be effective in term s of red ucing pain and im proving fu nction,
bu t one is not necessarily superior to the others (Jord an et al
1998; Rand lov et al 1998; Bronfort et al 2001; Ju ll 2000; Falla
et al 2006; Vassiliou et al 2006). H igher load ed exercises d o
seem to be m ore effective in increasing overall strength and
d ecreasing fatigability (Falla et al 2006; Ylinen et al 2006). The
low er load exercise has been show n to be su perior for pos-
tu ral control (Falla et al 2007a) and norm alizing patterning
d u ring craniocervical exion. The higher load program m es
have not been tested in grou p s w ith higher p ain levels and
m ay not be ap p rop riate for that p atient p op u lation. Gains
m ad e w ith an exercise ap p ear to be d irectly linked to the
m od e of that exercise. O’Leary et al (2012) com p ared a coor-
d ination (the CCF nod task w ith the pressure biofeed back
u nit) and end u rance (isom etric exor end u rance training)
exercise grou p w ith a m obility control grou p over 10 w eeks.
All three groups achieved im p rovem ent in pain and d isabil-
ity, but each group im proved pred om inately in the m otor
perform ance of their assigned m od e of exercise, w ith only
m inim al change in the other d om ains. It is im p ortant to con-
sid er this and inclu d e variou s m od es of exercise w hen d esign-
ing com prehensive cervical rehabilitation program m es.
This chapter d escribes variou s therap eutic exercise inter-
ventions for the com m on im p airm ents seen in p atients w ith
m echanical neck p ain.
Exercises for Motor Function
Abnorm al recruitm ent patterning of the anterior cervical
m u scles occu rs in su bjects w ith neck p ain, w ith a tend ency
tow ard s overd om inance of the su p er cial m u scle grou p s and
inhibition of the d eep spinal stabilizers (Ju ll 2000; Sterling
et al 2003, 2004; Falla et al 2004a; Ju ll et al 2004, 2007a). This
im paired recruitm ent pattern appears to be m ore d irectly
linked to neck pain and its intensity than to the chronicity or
d egree of d isability (Cagnie et al 2011a; O’Leary et al 2011).
Su bjects w ith neck p ain also d em onstrate abnorm alities in
extensor m uscle recruitm ent and patterning, w ith excessive
su p er cial activity and inhibition of the d eep er layers and
d elayed relaxation tim es (Cagnie et al 2011b; Elliott et al
2010a; Schom aker & Falla 2013). In low -load situ ations this
im balance is m ore apparent, althou gh there is also tru e w eak-
ness and lack of end u rance of both d eep and su p er cial
m u scle grou p s (Falla et al 2003; O’Leary et al 2007). A tim ing
d elay of the neck stabilizers occu rs d u ring arm m otion, m ost
noticeably the d eep neck exors (DN F), com p rom ising sp inal
control d u ring u p p er extrem ity fu nction (Falla et al 2004b).
Stu d ies have show n a tend ency tow ard s overactivity in the
u p p er trap eziu s m u scle (UFT) and anterior su p er cial neck
m u scles d u ring rep etitive arm activities and head lift, w ith
prolonged relaxation tim es p ost activity (N ed erhand et al
2000, 2002; Falla et al 2004c; Szeto et al 2005). On im aging,
su bjects w ith neck p ain or head ache exhibit atrop hy and his-
tological changes of the d eep neck exor and extensor m u scles
at the effected segm ent (H allgren et al 1994; Uhlig et al 1995;
Kristjansson 2004; Elliott et al 2006, 2008a, 2008b, 2009, 2010b,
2011; Fernánd ez-d e-las-Peñas et al 2007, 2008). Changes
app ear to be m ore p rofou nd in su bjects w ith traum atic (WAD)
as com p ared w ith insid ious onset neck p ain.
Exercises for motor function 175
Clinically then, it seem s im p ortant to begin m otor retrain-
ing in m echanical neck pain patients by focusing on the ability
to recru it and isolate the d eep neck exors and extensors in
low -load situations. Prolonged hold s em phasize the end u r-
ance fu nction. Du ring any up per extrem ity exercises, a p reset
DN F recru itm ent nod to neu tral could p otentially help retrain
the tim ing im p airm ent. It is im p ortant to encou rage com p lete
relaxation of all m u scle groups, particu larly su per cial ones,
follow ing exercise and activity. Progression onto higher load
exercises w ill then regain strength of the fu ll synergy, but one
m u st ensu re that there is contribu tion from the d eep er m u scle
grou ps. Depend ing on the patient’s occupation and activities,
this m ay requ ire ad d itional load beyond the w eight of the
head .
Recruitment
Deep neck f exors
The basic exercise u sed to retrain the DN F is the head nod of
CCF. Althou gh longu s cap itu s and colli m u scles are often
consid ered together as the DN F, Cagnie et al (2008) show ed
that the longu s cap itu s is the p rim ary m u scle d u ring this
m otion. The p atient is instru cted in the p rop er techniqu e of
CCF. Throu gh p alp ation of the anterior neck both the sterno-
cleid om astoid (SCM) and anterior / m id d le scalene are m oni-
tored , nod d ing as far into range as p ossible w ithou t activating
these m u scles. If the cervical extensors are p articu larly tight,
the su p er cial exors w ill contract early to overcom e the
resistance, m aking it m ore effective to lengthen those rst to
allow a freer nod m otion. Unw anted hyoid m u scle activity is
m inim ized by having the tongu e rest in the roof of the m ou th,
w ith the jaw relaxed . The head m ust rem ain in contact w ith
the su rface, bu t retraction avoid ed . Cu es su ch as ‘slid e the
back of you r head u p the su rface’ or ‘look d ow n w ith your
eyes as you initiate the nod ’ m ay help the patient recruit the
d eep m u scles in isolation. The nod shou ld be held for a count
of 10 and repeated 10 tim es, tw ice d aily (Jull et al 2002). The
argum ent cou ld be m ad e that to tru ly learn and solid ify a new
m ovem ent p attern, som e form of this exercise and any other
m otor p attern retraining exercises shou ld be rep eated m u lti-
p le tim es a d ay, even if for ju st a few rep etitions.
DN F recru itm ent and isolation can be perform ed either in
su p ine or u p against the w all. Theoretically the w all p osition
is easier because of gravity-assist, but som e patients w ill relax
the su p er cial m u scles m ore effectively in lying and p atients
w ith p oor postu re are often better sup ported in that position.
In stand ing, the head m u st rem ain in contact w ith the w all
throu ghou t the exercise to ensu re the u se of the exors, rather
than eccentric extensor activity (Fig. 15.1). In su pine position,
the u se of a tow el roll help s to su p p ort the norm al lord osis of
the cervical sp ine. H ow ever, som e p atients nd the roll
u ncom fortable or w ill tend to p ress back against it u sing
retraction instead of the correct CCF m otion. Pillow su pport
tend s to be easier than none. Clinical reasoning shou ld be
u tilized to d eterm ine w hich op tion is op tim al for any given
p atient.
In patients w ith longstand ing bracing patterns of their
neck, the SCM and scalene m u scles often becom e so facilitated
that they are u sed as p rim ary m u scles of resp iration. Dow n-
training m ay start w ith d iap hragm atic breathing exercises,
 176 PART 2 • 15 •
Figure 15.1 Wall slide deep neck exor recruitment exercise. Keeping the head
in contact with the wall, the head is nodded as ar as possible without any activity
in the superf cial muscles, palpated at the anterior neck.
Figure 15.2 Muscle energy recruitment technique. Recruitment o the right
C2 / 3 multif dus muscle is achieved by utilizing a muscle energy type technique.
encouraging lateral costal m otion w hilst m onitoring the SCM
and scalene to red u ce their excessive activity.
Deep neck extensors
Isolated recru itm ent of a segm ental m u scle is d if cult, but
a ‘m u scle energy’ typ e techniqu e or electrical m u scle stim u la-
tion m ay help teach the p atient to feel the d esired localized
contraction of m u lti d u s or a p osterior su boccip ital m u scle
(Fig. 15.2). The p atient can then practise an au to-resisted iso-
m etric or concentric contraction at the affected level (Fig.
15.3). Resistance m ust be light to encou rage d eep rather than
su p er cial m u scle contraction. In su p ine, a tow el roll u nd er
the neck m ay help the p atient p erform a u nilateral exten-
sion qu ad rant m otion to facilitate m u lti d u s contraction.
Schom aker et al (2012) fou nd that resistance ap p lied at the
vertebral arch of C2 w as m ore effective in p referentially
recruiting d eeper rather than sup er cial extensors, com p ared
w ith p ressu re at the occip u t or C5.
Another m ethod to recruit the DN F is to u se a segm ental
extension m otion from a slu m p position starting in the thorax
Therapeutic exercise for mechanical neck pain
Figure 15.3 Auto-resisted deep neck extensor muscle exercise. The patient is
taught to resist extension / side- exion at the a ected level to recruit the multif dus
muscle segmentally.
and m oving cranially (Fig. 15.4A–C). If the chin is kept tu cked
initially, the su per cial m u scles w ill be less active d u ring this
m otion (Mayoux-Benham ou et al 1997). As m otion is per-
form ed segm entally, focus is on the d eeper m u scle layers. The
m otion m u st also be kep t u id and relaxed , as bracing w ill
only encou rage the rigid ity that is so often seen in p atients
w ith chronic neck pain.
Strength and endurance
As stated previou sly, althou gh both low -load (CCF nod ) and
higher load (head -lift) exercises ap p ear equ ally effective in
red u cing p ain and d isability, higher load exercise using ad d ed
resistance m ay be m ore effective in regaining full strength and
end u rance. Therefore, to optim ize retu rn of norm al neck
m u scle fu nction, higher load exercise p rogressions shou ld be
includ ed at som e p oint in the rehabilitation program m e.
H ow ever, in cases of m ore severe neck p ain, higher load exer-
cises, if d one too early, tend to exacerbate the p ain, w hich
w ould further inhibit norm al m uscle function. In those
p atients w ith longstand ing p rotective bracing and rigid ity, it
w ould seem cou nterintu itive to ad d higher load s, w hich
encou rage even m ore su per cial m u scle activation. On the
other hand , p atients w ith low -intensity neck p ain and gener-
alized m u scle w eakness w ould tolerate and bene t from fairly
rap id progression to higher load exercises as long as they
d em onstrate appropriate m uscle balance. As the d eep m u scu-
lature should contract to stabilize the sp ine prior to any
load ing, initiating and m aintaining a DN F nod throughou t
the higher load ed exercises w ou ld encou rage op tim al
p atterning.
Higher load f exor progressions
Au to-resisted exercises can be grad ed and are low er load
than head -lift exercises. The u se of hand s or a ball u nd er the
chin to resist an isom etric or concentric contraction encou r-
ages the CCF p attern. An isom etric hold ing contraction can
be progressed in sitting by having the p atient nod to cervical
neu tral and m aintain this as they lean back at the hip s to ad d
gravity resistance. This can be fu rther progressed by perform -
ing the sit-back on an exercise ball, m oving farther back

A B
Figure 15.4 Segmental extension from slump: (A) Starting in a exed slump position, segmental extension proceeds rom the mid-thoracic spine cranially. (B) Once the
thorax is in neutral, segmental extension continues rom the lower cervical spine to the craniovertebral region. (C) In the erect position, the nod is released to the neutral
neck position.
Figure 15.5 Sit-back exor strength progression. The patient can increase
loading or the cervical exors doing sit-back exercises on the ball, maintaining a
neutral deep neck exor nod.
into range and hold ing for progressively longer p eriod s of
tim e (Fig. 15.5).
A nod lift-off m otion can be p erform ed on an incline (Fig.
15.6). The patient u ses a nod m otion to lift the head just off
the su rface to a neu tral p osition. End u rance can be em p ha-
sized by p rogressively increasing the hold tim e and the exer-
cise m ad e m ore d if cu lt by grad u ally red u cing the angle of
the incline.
Theraband ® can be used to ad d resistance. As an isom etric
exercise in sitting, the patient ad opts a cervical-neutral nod
w ith the band around the forehead and , w hile m aintaining
Exercises for motor function 177
C
Figure 15.6 Nod lift-off on an incline. The patient li ts the head o the incline
using a deep neck exor nod action, holding a cervical-neutral posture.
neu tral, leans forw ard s at the hip s to ad d resistance (Fig. 15.7).
Alternatively, the band can be u sed to resist a throu gh-range
isotonic exercise, ensu ring that forw ard translation is control-
led . In stand ing, lunges can be u sed to increase the tension in
the band , w ith the p atient m aintaining a neu tral nod p osition
throu ghou t the step forw ard and then back to the start p osi-
tion. Becau se of the higher balance challenge, there is a d egree
of p ertu rbation im p arted to the head and neck, w hich
d em and s a higher d egree of d ynam ic stabilization (Fig. 15.8).
In sup ine, a head -lift exercise can be perform ed in tw o d if-
ferent w ays. As an isom etric contraction, the patient m ain-
tains a neu tral nod and lifts the head off the su rface, hold ing
for p rogressively longer period s of tim e. Another op tion is an
isotonic segm ental exion curl-u p exercise, continu ing the
nod throu gh to inner range (Fig. 15.9). In an MRI stu d y,
 178 PART 2 • 15 • Therapeutic exercise for mechanical neck pain
Figure 15.7 Elastic band resisted exors. Maintaining a cervical nod, the body is
leaned orwards at the hips to increase the tension in the band to strengthen the
cervical exor synergy.
Figure 15.8 Elastic band forward lunge. Maintaining cervical neutral, a orward
lunge motion is per ormed applying a exor strength load with a perturbation.
Cagnie et al (2008) show ed that the longus capitus and colli
along w ith the SCM w ere all m ore active w ith this second
exercise, w ith relatively greater contribu tion from the DN F in
the cu rl-u p exercise than in the neu tral nod -lift op tion. It m ay
be bene cial to u se a tow el roll as a fu lcru m u nd er the neck
to encou rage the cu rl-u p action.
Figure 15.9 Curl-up head lift. The patient initiates the exercise with a
craniocervical exion motion and continues to ex through to inner range. The towel
roll can acilitate the segmental nature o the motion.
Higher load extensor progressions
DN F strengthening can be progressed by increasing the load
effect of gravity in fou r-point kneeling (4PK). The start posi-
tion is w ith the head d rop p ed into fu ll exion and the back
sagged (Fig. 15.10A). The patient is rst instru cted to nd
neu tral lu m bop elvic p ostu re. Then he or she is tau ght to
obtain a neu tral thorax by p ressing u p throu gh the arm s to a
slight kyp hosis, not over exing (Fig. 15.10B). Keeping the chin
tu cked initially, and starting at the low er cervical sp ine, the
head is brou ght in line w ith the tru nk throu gh segm ental
extension. The chin tu ck is relaxed slightly at the end of the
m otion to ensu re that a neu tral cervical lord osis is obtained
rather than over-retraction, w ith the p lane of the face parallel
to the oor (Fig. 15.10C). This position is held for the cou nt of
10 second s. By reversing the m otion, starting w ith segm ental
exion at the u pper cervical spine until the head is hanging
in full exion, eccentric load ing of the cervical extensors
occu rs. For less load ing, the p osition is m od i ed to a forw ard
lean at either the w all or a counter. If the patient is u nable to
tolerate the load throu gh the w rists, the p rone on-elbow s
p osition m ay be u sed , or the p atient can lie ju st over the end
of the bed and p erform only the cervical com p onent of the
m otion. Once a p atient can accom p lish this m otion, the exer-
cise is p rogressed into hyp erextension, controlling any col-
lapse of the m id -cervical spine into anterior translation.
Ad d ing p u re rotation in the neu tral 4PK p osition w ill focu s
on retraining the p osterior su boccip itals as the u p p er cervical
sp ine is resp onsible for the m ajority of cervical sp ine rotation
(Fig. 15.11).
An alternative exercise can be d one prone over an exercise
ball (Fig. 15.12). The head is brou ght u p into cervical neutral,
the arm s lifted u sing the scap u lar stabilizers, and then the
tru nk is lifted off the ball into thoracic extension. This incor-
p orates the essential interaction betw een the head , neck,
shou ld er gird le and thoracic sp ine.
Elastic band resistance can be u sed to obtain a grad ed
increase in load in the 4PK p osition. Alternatively, in sitting,
the p atient ad op ts a cervical-neu tral nod w ith the band arou nd
the back of the head , and w hile m aintaining neu tral, leans

A
C
Figure 15.10 Segmental extension in four-point kneeling: (A) The exercise starts
with the head hanging into exion and the thorax sagged between the scapulae.
(B) Lumbosacral neutral is ound and then thoracic neutral achieved by pressing
up through the arms. (C) Subsequently the cervical spine is extended segmentally
starting at the cervicothoracic junction until the head and neck reach neutral.
Exercises for motor function 179
Figure 15.11 Pure rotation in neutral four-point kneeling. Pure rotation is added,
ensuring no compensatory side- exion / extension, to challenge the posterior
suboccipital muscles, practise motor control and address asymmetrical muscle
weakness.
Figure 15.12 Integrated extension. Prone on a ball, the head and neck are
brought up into cervical neutral, the arms li ted o the ball to activate the scapular
stabilizers, and then the sternum li ted o the ball to recruit the thoracic extensors.
backw ard s at the hip s to ad d resistance. A backw ard lunge
in the stand ing position, again m aintaining the cervical-
neu tral nod p osition, is another op tion, w hich ad d s a fu rther
p ertu rbation challenge. The p atient cou ld also hold the band
in front and resist a retraction m otion to neu tral (Fig. 15.13).
Clinical reasoning shou ld be u sed to d eterm ine w hich of
these exercises w ou ld op tim ally ad d ress a p atient’s sp eci c
d ysfu nction.
Side- exion / rotation exercises for
asymmetric weakness
In m any patients w ith u nilateral d om inant sym ptom s, atrophy
and w eakness w ill be m ore profou nd on that sid e. Althou gh
the p reviou sly d escribed exercises often regain strength bilat-
erally, there m ay be certain situ ations w here load ing asym -
m etrically throu gh rotation and sid e- exion m ay be m ore
 180 PART 2 • 15 •
ap p rop riate. Many of these exercises w ou ld also be consid -
ered m otion control exercises.
Using a foam w ed ge pillow, the slope can act as resistance
w hen the head is placed in an offset position. The p atient is
instru cted to m aintain a p reset DN F nod throu ghou t the exer-
cise (Fig. 15.14A). In the right offset position, the head is
slow ly low ered d ow n the slop e into right rotation, u tilizing
eccentric control of the m uscles on the left sid e of the neck
(Fig. 15.14B). The m otion is then reversed , u sing the left
m u scles concentrically to bring the head back to the start p osi-
tion and continu e u p the slop e into fu ll left rotation. The head
is then retu rned to neu tral and the nod relaxed before
repeating.
Pure rotation p erform ed in either the 4PK position or the
nod lift-off on the incline w ill ad d asym m etric load to the
exors or extensors resp ectively (Fig. 15.15, see also 15.11).
The p atient is instructed to avoid the com m on com pensations
of either sid e- exion or craniovertebral extension, p articu larly
Figure 15.13 Band retraction. The band is held looped around the back o the
head to apply resistance to a nod / retract motion to strengthen the cervical
extensors.
A B
Figure 15.14 Wedge pillow offset: (A) The head is placed in the right o set position on the wedge pillow. (B) Maintaining a deep neck exor nod throughout, the head is
slowly rotated down the slope, working the le t-sided muscles eccentrically. The exercise is completed by returning the head back up the slope continuing to ull le t rotation
and then back to neutral.
Therapeutic exercise for mechanical neck pain
tow ard s the end of range. Diagonal m otion into a exion
qu ad rant d u ring a su p ine cu rl-u p exercise, or an extension
quad rant in 4PK w ill also bias the load u nilaterally.
Isom etrics can be perform ed into the w eak rotation or sid e-
exion. Wall su pport and a preset nod w ill help prevent
u nw anted translation. An elastic band can be u sed as resist-
ance for isom etric or isotonic exercise into sid e- exion or rota-
tion, and sid ew ays or d iagonal forw ard or backw ard lu nges
can also be u sed to p rovid e an asym m etric load .
The w eight of the head can be u sed as load in a sid e-lying
p osition, w ith or w ithou t a p illow or tow el roll u nd er the neck
to act as a fu lcru m . Once again, the p reset nod is p erform ed
p rior to tilting the head u p into sid e- exion, em p hasizing the
angular m otion rather than translation.
Motor control
For u pper qu ad rant fu nction, it is necessary to have the ability
to m aintain cervical neu tral d u ring u p p er lim b m otion and
load ing. Deep and sup er cial m u scle balance, tim ing, as w ell
as relaxation post activity need to be ad d ressed . Falla et al
(2008) fou nd that neither low nor higher load exor exercise
p rogram m es resu lted in im p rovem ent of the m u scle recru it-
m ent tim ing abnorm alities d u ring arm lift, so p erhap s this
need s to be p ractised as a sp eci c fu nctional exercise. It is also
im p ortant to have segm ental control d u ring head and neck
m ovem ents, as m any d aily activities requ ire a m obile neck.
Cervical neutral during limb load
Clinical reasoning m u st be ap p lied to each p atient p resenta-
tion to d eterm ine w hich arm m ovem ents, in w hich p ositions,
w ith w hich load , are best su ited for that p atient at that stage
of rehabilitation. The p atient m u st be cu ed on how both to
achieve optim al postu re and to u se a preset DN F nod to acti-
vate the stabilizers p rior to any lim b-load m otion. The p atient
m ay be asked to release and reset this nod p rior to each rep eti-
tion to focu s on the tim ing p attern, or if end u rance is the goal
then the nod d ed , cervical-neu tral p osition shou ld be held
throu ghou t all rep etitions for each set of the exercise.

Figure 15.15 Pure rotation in nod lift-off. Pure rotation is added to the nod li t-o
exercise on an incline to increase the loading, target asymmetric weakness and
practise higher load spinal motor control.
• Positions: In a p atient w ith an irritable neck and poor
m otor control, arm m ovem ents m ay be p erform ed w ith
the p atient in su p ine on a m at before p rogressing to a fu ll
or half foam roll. In the lying p osition, gravity along w ith
head contact on the su rface help s to p revent the tend ency
to p rotru d e the head d u ring overhead lim b m otion.
When p rogressing into sitting and then stand ing, su pp ort
against the w all can give feed back of head position.
Sitting can be p rogressed to u nsu p p orted sitting on a
ball, and stand ing progressed to stand ing on a w obble
board . The 4PK p osition p articu larly challenges control of
the anterior head d rift so com m only seen w ith the
forw ard head postu re (FH P), and is sim ilar to the load s
experienced by those w ho lean forw ard s for their
occu p ation or activities.
• Arm motions: Arm m ovem ents are chosen starting w ith
those that are the least p rovocative, and p rogressing to
those that challenge sp inal control. Bilateral exion
stresses anterior translation in the neck, w hereas
u nilateral exion or abd u ction stresses lateral translation.
Starting w ith m ovem ents below shou ld er level is less of a
challenge. Recip rocal m ovem ents of the arm s create a
pertu rbation at the neck that increases as the speed of
m ovem ent increases. Often there is an associated m u scle
im balance at the shou ld er gird le that need s to be
ad d ressed and then these arm m otions are u sed to
im p rove the scap u lar resting p osition, m u scle balance
and control, and sim ultaneously challenge m aintenance
of cervical neu tral. If before each arm m ovem ent the
patient is rem ind ed to p erform a preset DN F nod , both
the tim ing and m otor control are em p hasized . Care m u st
be taken to ensu re that these should er gird le exercises are
not at too high a level for the p atient to m aintain cervical
neu tral. Often the focu s is on d ow n-training those
m u scles that are overactive, as m u ch as tru e
strengthening of the w eak m u scles.
• Resistance: Weight m ay be ad d ed to the lim b m otions
throu gh free w eights, elastic tu bing and p u lleys. Initially
keeping w eights low and em phasizing prop er m ovem ent
patterns w ill d o m ore for m otor control than the
Exercises for motor function 181
Figure 15.16 Motor control with limb load. Positioned on a oam roll, a deep
neck exor nod is maintained whilst strengthening the lower trapezius muscle to
improve both spinal and scapular control.
strengthening effect of higher load s. It is m ost ef cient if
the resisted exercises are focu sed on strengthening those
scap u lar stabilizers requ ired to im p rove shou ld er gird le
fu nction (Fig. 15.16).
Segmental control during neck motion
The neu tral zone is that portion of the range of m otion in
w hich there is m inim al resistance to m ovem ent by the inert
stabilizing stru ctu res of the sp ine (Panjabi 1992). The joints of
the cervical sp ine, p articu larly the craniovertebral joints, have
a large neu tral zone com p ared w ith other regions of the sp ine.
Motion w ithin this p ortion of the range relies heavily on the
d ynam ic control of the stabilizing m uscu latu re.
Som e segm ental m otor control exercises are low load and
can be integrated into the exercise p rogram m e at the early
stages of rehabilitation. Using the foam w ed ge p illow w ith
the head starting on the p eak allow s controlled non-w eight-
bearing m otion. The patient begins the exercise by perform ing
the DN F p reset nod and then controls the neck m otion as the
head m oves d ow n the slop e in one d irection, back to the p eak
and then to the opposite sid e. As d escribed p reviou sly for
strengthening, the offset p osition w ou ld ad d a fu rther load to
challenge the m otor control (see Fig. 15.14).
Pu re eye-level rotation and p u re sid e- exion can be p rac-
tised throu gh the m axim al range that can be p erform ed
w ithou t losing controlled u nip lanar m otion. They can be d one
at the w all, keep ing the head in contact w ith it to give feed -
back for the m aintenance of cervical neu tral. For sid e- exion,
m irror feed back can also be ad d ed . For rotation a laser p ointer
head band can be u sed , as scribing a horizontal line d u ring
rotation w ill ensu re the eye-level pu re rotation p attern. H igher
load p ure rotation exercises can be d one in both the incline
nod lift-off and 4PK positions (see Figs 15.11, 15.15). This
ensures that these positions are being m aintained w ithou t
rigid ity, as the neck is still free to m ove.
Controlled exion / extension has been p reviou sly
d escribed as a segm ental m otion from a slu m p p osition up to
 182 PART 2 • 15 •
neu tral and retu rning to exion. This can be p erform ed ini-
tially in sitting and then p rogressed to 4PK (see Figs 15.4,
15.10). Controlled hyperextension can be practised in sitting
or 4PK, ensu ring that there is no collapse into anterior transla-
tion d u ring the m otion (Fig. 15.17). Controlled hyperexten-
sion in the seated lean-back p osition is a fu rther challenge to
the exor grou p and is a u sefu l exercise for p atients w ho need
to w ork looking overhead . It is im p ortant to control any ten-
d ency to collapse in the m id -cervical spine, and also to initiate
the retu rn w ith a nod d ing p attern (Fig. 15.18A–C).
Mobility Exercises
Red u ced cervical sp ine m obility is a featu re of ind ivid u als
w ith neck pain (Dall’Alba et al 2001; Du m as et al 2001; Kasch
et al 2001; Ogince et al 2007). Potential sources of this m obility
Figure 15.17 Spinal motion control in four-point kneeling. Hyperextension is
practised in 4PK controlling or collapse into anterior translation.
A B
Figure 15.18 Controlled extension pattern in lean-back: (A) The head is taken back into extension as ar as can be controlled and is pain ree. (B) Return rom end o
range is initiated with a nod motion. (C) The head is brought back into a ull craniovertebral nod position.
Therapeutic exercise for mechanical neck pain
im p airm ent inclu d e the joint structures, m yofascial extensibil-
ity or abnorm al tension w ithin the neu rom eningeal system .
Pain and fear avoid ance m ay p lay a role in lim iting a p atient’s
w illingness to m ove actively. Cervical m obility m ay also be
affected by the starting position of the should er gird le. If
retesting the cervical active range of m otion w ith the scapula
p osition corrected im m ed iately resu lts in increased range,
then m otor control arou nd the shou ld er need s to be ad d ressed .
As a m u ltim od al app roach inclu d ing both m anual therapy
and exercise is the m ost effective in m anaging neck p ain
(Gross et al 2007), m otion regained by m anual therapy shou ld
be m aintained w ith speci c exercise.
Generalized active range of motion
Even in the earliest stages of acu te WAD, p atients can be
instru cted in active p ain-free m obility exercises. Initially these
m ovem ents m ay be p erform ed non-w eight-bearing in su p ine
w ith pillow su pport. A foam w ed ge pillow can be u sed to
assist the m otion d ow n the slope of the w ed ge. This exercise
d oes tend to com bine ipsilateral sid e-bend ing and rotation
w ith slight extension. If there is a concern regard ing foram e-
nal com p ression, the exercise shou ld be m od i ed , p erhap s
restricting the m ovem ent to the sid e opp osite on w hich the
sym p tom s occu r so as to encou rage ‘op ening’ of the interver-
tebral foram en.
In a series of stud ies, Rosenfeld et al (2000, 2003, 2006)
fou nd that WAD su bjects w ho p erform ed repeated cervical
rotation 10 tim es p er hou r had less p ain, less sick tim e and a
better range of m otion at 3 years than controls, and m ore so
if the m ovem ents w ere started early on in treatm ent (w ithin
96 hou rs) rather than later (> 2 w eeks).
Movem ent m ay start u nip lanar, bu t com bined m ovem ents
into the exion ovoid of m otion w ill bias lengthening of stru c-
tu res u nilaterally. When attem p ting to regain a loss of exten-
sion, consid eration m u st be given to the effects on vascu lar
and neu rological tissu es, p articu larly in the extension qu ad -
rant. Often the p roblem w ith extension range is com pression
pain rather than d ecreased length, and perhaps here a m otor
C
 Mobility exercises 183

control ap p roach w ou ld be m ore ap p rop riate. Segm ental joint
restrictions of extension can be ad d ressed w ith the localized
self-m obilization exercises d escribed below.
Althou gh the focu s here is on m obility, practising correct
m ovem ent p atterns shou ld be em p hasized from the start.
Integration of m obility exercises w ith m otor control w ill
achieve greater su ccess in obtaining pain-free fu nctional
m ovem ent.
Articular / self-mobilization
Segm ental m obility restrictions are best treated w ith m anu al
therap y w ith sp eci c self-m obilization exercises to m aintain
the range gained . The p atient can be tau ght to localize the
m otion to the involved segm ent w ith his or her ngers or the
ed ge of a tow el. An atlanto-axial (AA) tow el rotation m obili-
zation exercise has been fou nd to be effective in the treatm ent
of cervicogenic head aches (H all et al 2007). The follow ing
are instru ctions for segm ental self-m obilization exercises
(Fig. 15.19):
Craniovertebral region
Occip ito-atlanto (OA) exion (bilateral / u nilateral):
• Sit tall in a chair.
• Stabilize the neck by placing clasp ed hand s just u nd er the
sku ll, being carefu l not to p u ll the neck forw ard s.
• N od the head on the neck, tu cking the chin back, lifting
the sku ll at the back (Fig. 15.19A).
• To bias to one sid e, tilt the head aw ay from the stiff sid e
and rotate the chin tow ard s the arm pit on that stiff sid e
(Fig. 15.19B).
OA extension (u nilateral):
• Sit tall in a chair.
• Stabilize the neck by placing clasp ed hand s around the
neck hold ing back, ju st u nd er the angle of the jaw on the
stiff sid e.
• Tip the head tow ard s the stiff sid e, rotating aw ay and
poking the chin forw ard s and tow ard s the op posite
elbow (Fig. 15.19C).

A B C

D E F

G H I

Figure 15.19 Self-mobilization exercises: (A) Bilateral OA exion. (B) Unilateral OA exion. (C) Unilateral OA extension. (D) AA right rotation. (E) Bias right lateral AA
joint. (F) Bias le t lateral AA joint. (G) Mid-cervical unilateral exion. (H) Unilateral extension. (I) Le t lateral glide.
 184 PART 2 • 15 •
AA joint rotation (right rotation restriction):
• Sit tall in a chair.
• Stabilize the neck by p lacing clasp ed hand s behind the
neck w ith little ngers at the large bu m p at the top of the
neck below the sku ll, being carefu l not to p u ll the neck
forw ard s.
• Tu rn the head into p u re right rotation, keep ing the eyes
level and not allow ing any tilt or chin p oke.
• To bias to right joint:
• tuck the chin into a bit of exion before rotating
• hold the neck forw ard w ith right hand behind neck on
the right sid e (Fig. 15.19E).
• To bias to left joint:
• tip chin u p slightly before rotating
• hold the neck backw ard w ith left hand slightly in front
of neck on the left sid e (Fig. 15.19F).
• A tow el can also be u sed to stabilize and overp ress the
rotation m otion (Fig. 15.19D).
Mid-cervical spine
• Use one hand to nd the stiff joint (thick, tend er sp ot at
back / sid e of neck).
• Stabilize the bottom bone of that joint by p u shing in
gently w ith the ngers.
• A tow el can be u sed to xate the joint and ap p ly
overp ressu re.
• For exion:
• nod the head into exion, tilt and rotate aw ay from the
stiff joint
• a tug should be felt at the stiff joint (Fig. 15.19G).
• For extension:
• tip the head back, sid e bend and rotate tow ard s the
stiff joint
• use pressure u p and in w ith ngers to focu s the
m otion to the stiff joint
• the w hole of the head and neck should not have to go
into extension (Fig. 15.19H ).
• For left lateral glid e right sid e- exion:
• the left hand reaches around from the opposite sid e to
p ull the top bone across into left lateral glid e as the
head is tip ped tow ard s the stiff right sid e (Fig. 15.19I)
or
• as the head is tilted tow ard s the right, the top bone is
p ushed laterally to the left to encou rage the lateral
glid e requ ired for sid e-bend ing.
Myofascial extensibility
Ind ivid uals w ith neck pain, particu larly cervicogenic head -
ache, have a higher incid ence of m uscle tightness than d o
controls (Zito et al 2006; Jull et al 2007a). Stretching exercises
have been fou nd to be effective in red u cing neck p ain in som e
p opu lations (Gross et al 2007; Ylinen et al 2007b). For ind i-
vid u als w ith WAD, excessive activity and p rolonged relaxa-
tion tim es have been fou nd for several m u scle grou p s. In
these cases, a focu s on m otor p atterning and relaxation fol-
low ing activity m ay be m ore valu able than stretching. The
resting position of the scap ula m ay place a m u scle in a length-
ened position, m aking it feel tight to the patient even though
Therapeutic exercise for mechanical neck pain
it is not short. Probably as a protective m echanism , UFT has
been fou nd to be tighter in su bjects w ith ad verse tension in
the neu rom eningeal system (Ed gar et al 1994) and so this
shou ld be ad d ressed p rior to any lengthening exercises for
the UFT.
Mu scles that tend to tighten are the p osterior su boccip itals,
long cervical extensors, anterior and m id d le scalene, SCM,
levator scapula and u pper trapezius (Jand a 1994). Length tests
are w ell d escribed elsew here (Kend all & McCreary 1983), and
these shou ld be u sed to con rm tru e m u scle shortening before
institu ting a stretching program m e. The effects of a speci c
m u scle-lengthening exercise on either stiff or hyp erm obile
joints shou ld also be consid ered , and the exercises m od i ed
as ind icated . To elongate tissu e, the exercise shou ld be p er-
form ed as a p rolonged hold for 20–30 second s, and rep eated
3–5 tim es.
In patients w ith tight cervical extensors, there is often a
region of relative exibility in the upp er or m id -thoracic
sp ine. Perform ing the lengthening exercise at the w all w ith
the thoracic sp ine in contact w ith the w all or tow el roll w ill
focus the stretch to the u pper and m id -cervical regions. For
the su boccip ital grou p , the nod m otion is the focu s, and a st
p laced u nd er the chin m ay im p rove the localization as a
p assive stretch is ad d ed (Fig. 15.20). As the long extensors
attach at the base of the sku ll, this nod m u st be m aintained as
the head is d rop p ed fu rther forw ard s to lengthen the rest of
the long cervical extensors (Fig. 15.21). Tilting the head to the
right or left is ind icated for asym m etric tightness.
As the scalene m uscles tend to be overd om inant in patients
w ith neck p ain, active lengthening w ith a focus on ‘letting go’
m ay be the m ost ap p rop riate ap p roach. When p erform ed at
the w all in a neu tral p reset DN F nod , the tend ency to collap se
into extension d u ring lengthening is m inim ized (Fig. 15.22).
For the m id d le scalene, pu re sid e- exion is perform ed . For
the anterior scalene, ad d ing rotation tow ard s the stiff sid e
localizes stretch to that portion of the m uscle. Either m anually
stabilizing the rst rib or breathing ou t w ill p revent the rib
from elevating as the m u scle is lengthened . If the m uscle is
Figure 15.20 Suboccipital lengthening exercise. Standing at the wall, using a
nod motion and a f st under the chin helps to ocus the stretch to the suboccipital
muscles.

Figure 15.21 Cervical extensor lengthening exercise. Maintaining the thorax
against the wall and keeping a chin tuck position helps ocus the stretch to the long
cervical extensors.
Figure 15.22 Scalene medius lengthening exercise. Standing at the wall and
maintaining a chin nod helps prevent collapse into extension while lengthening the
scalene as a group into pure side- exion. The f rst rib is f xated on the sti side. To
bias to the anterior scalene, the head can be rotated slightly to the sti side.
tru ly short, the p atient m ay u se the op p osite hand to increase
the stretch p assively.
The SCM also has a tend ency tow ard s overactivity bu t
often regains its norm al length by focu sing on DN F recru it-
m ent. The m u scle can be lengthened by sid e- exion aw ay,
rotation tow ard s, and extension of the head on the trunk w ith
the chin held tu cked .
To stretch the levator scap u la, the neck m u st be exed ,
sid e- exed and rotated aw ay. There are tw o band s d escribed
in the literature (Behrsin & Maguire 1986; Diener 1998). The
Postural correction exercises 185
vertical band is lengthened fu rther by ad d ing u p w ard rota-
tion and d ep ression of the scap u la w ith the arm overhead .
The horizontal bres m ay be m ore effectively lengthened
by d epression and d ow nw ard rotation w ith the arm behind
the back.
The UFT are lengthened by d ropping the head into exion,
sid e- exing aw ay and rotating tow ard s the stiff sid e. The
scap u la is d ep ressed and d ow nw ard ly rotated by reaching the
hand d ow n behind the back.
Neurodynamics
Ad verse tension in the neurom eningeal system can affect
cervical sp ine m obility. The assessm ent and interventions
focused on this com p onent are d ealt w ith in Chap ter 65 of this
book.
Postural Correction Exercises
The optim al postu re is that of cervical neutral, w here the head
is located d irectly above the should ers and tru nk. The cranio-
vertebral region is in relative exion and the m id -cervical
sp ine m aintains a slightly lord otic p osition, w ith the p lane of
the face being vertical. A slightly kyp hotic cu rve is consid ered
neu tral for the thoracic sp ine. The m ost com m on p ostu ral
im pairm ent of the cervical spine is the FH P.
FH P has historically been associated w ith an increased like-
lihood of neck pain, although the research is inconsistent
(Watson & Trott 1993; Treleaven et al 1994; Michaelson
et al 2003; Yip et al 2008). H arm an et al (2005) found that a
p ostu ral correction exercise p rogram m e resu lted in signi -
cant im p rovem ent in static m easu res of FH P. Falla et al
(2007a) investigated the ability to m aintain erect p ostu re over
tim e w hilst com p leting a com p u ter-typ e task. There w as
an increase in thoracic exion and forw ard d rift of the head
over tim e in su bjects w ith neck p ain com p ared w ith controls,
w hich show ed a sim ilar but lesser tend ency. Low -load CCF
training or higher load strength exercise both resu lted in
im proved control of the thoracic p osture, but only the CCF
training grou p show ed im p rovem ent in cervical p ostu re. Both
grou ps show ed a sim ilar d ecrease in pain and d isability. Acti-
vation of the DN F is higher in su bjects instru cted in lu m bop el-
vic p ostu ral correction w ith verbal and hand ling cu es than in
those su bjects m erely told to ‘sit straight’, w hich su ggests that
sp eci c p ostu ral instru ction is im p ortant (Falla et al 2007b).
Patients m u st be ind ivid u ally assessed to d eterm ine the
cau se of their FH P and therefore the focu s of their sp eci c
p ostu ral correction. The follow ing areas need to be ad d ressed
w ith exercise intervention, m uch of w hich has alread y been
d iscussed in p revious sections of this chapter.
Muscle imbalance
The follow ing m uscles tend to w eaken and requ ire recruit-
m ent, strength or end u rance exercises: d eep neck exors and
extensors, scap ular stabilizers and u pper thoracic extensors.
With FH P, the follow ing m u scles tend to tighten and requ ire
lengthening exercises: cervical extensors (suboccipital and
long super cial extensors), scalene, u pper trapezius, levator
scap u la, and p ectoralis m ajor and m inor.
 186 PART 2 • 15 • Therapeutic exercise for mechanical neck pain
Articular system
The follow ing regions tend to becom e hypom obile and require
m obility exercises to regain range: u p p er cervical exion, cer-
vicothoracic extension, and u p p er and m id -thoracic exten-
sion; p atients w ith lord otic u p p er thoracic sp ines m u st regain
exion to a neutral kyphosis.
Neuromeningeal system
Ad verse tension in the neurom eningeal system m ay also con-
tribu te to p ostu ral abnorm alities in the u p p er qu ad rant and
m u st be assessed and ad d ressed d ep end ing on the sp eci c
d ysfunctions fou nd (see Ch 65).
Posture corrections
Depend ing on exactly w hich m echanism s have cau sed the
im p aired p ostu re, sp eci c cu es can be u sed to teach p atients
how to attain a m ore op tim al resting p osition. This can be
reinforced throughou t their exercise program m e. Often after
cu ing a neu tral lu m bop elvic lord osis and a sternal lift, the
head au tom atically com es back in line w ith the tru nk. Dep end -
ing on how the head has d rifted forw ard s, varying d egrees of
retraction, occip ital lift or nod can be ad d ed . Pearson and
Walm sley (1995) show ed that rep eated retractions in asym p -
tom atic su bjects im p roved cervical resting p ostu re. Care m u st
be taken to avoid over-retraction, how ever. It is also im por-
tant to ed u cate the p atient on neu tral scap u lar p ositioning.
The patient can practise these corrections in m u ltiple posi-
tions, m any tim es a d ay (Fig. 15.23).
The DN F nod exercise can be u tilized to ad d ress m any of
the d ysfu nctions seen w ith p ostu ral im p airm ent and w hen
d one at the w all can also im p rove proprioceptive aw areness.
It w ill m obilize craniovertebral exion, lengthen the tight pos-
terior stru ctu res and begin to recru it the DN F show n to
im p rove the ability to p revent forw ard d rift of the head . The
segm ental extension from a slu m p p osition in sitting and 4PK
is also an effective exercise to control FH P. Often thoracic
extension m obility m ust be regained , and then the m uscles
that help m aintain op tim al thoracic and shou ld er gird le
p ostu re m u st be re-ed ucated and strengthened . Alternatively,
those p atients w ith a attened or lord otic u p p er thoracic sp ine
and excessive bracing of the long, super cial thoracic exten-
sors m u st learn to relax by d rop p ing the sternu m d ow n
slightly to regain a neu tral kyp hotic sp ine.
The p atient then p ractises the m aintenance of op tim al
p ostu re w hile incorporating arm m ovem ents, initially
u nload ed bu t then ad d ing free w eights, tu bing or p u lleys.
Progression to an u nstable base w ill increase the challenge
and also assist in balance control. Using m ovem ents and posi-
tions requ ired for w ork or sp ort w ill help carry over the p os-
tu ral control to fu nctional activity. These typ es of exercises
and their p rogressions have been d escribed in the m otor
control section of this chap ter (see Fig. 15.16).
Somatosensory Dysfunction
Su bjects w ith neck p ain, p articu larly those w ith WAD and
sym p tom s of d izziness, exhibit im p airm ents of balance,
Figure 15.23 Postural cueing. Physical and verbal cues are used to assist the
patient to f nd both lumbosacral and thoracic neutral. Any urther correction required
or the head and neck is achieved through a combination o nod, occipital li t and
retraction as needed.
kinaesthetic aw areness, eye m ovem ent control and eye–head
coord ination (Revel et al 1991; H eikkila & Astrom 1996;
Lou d on et al 1997; Treleaven et al 2003, 2005a, 2005b, 2006,
2011; Kristjansson & Falla 2009). This has been d escribed in
d etail earlier in the text and the read er is d irected to Chap ter
10 for further inform ation.
Sp eci c exercises focu sing on sensorim otor control can be
u sed to im p rove these im p airm ents, and have also been fou nd
to im p rove p ain, m obility and d isability as a second ary gain
(Revel et al 1994; H ansson et al 2006; Jull et al 2007b). Manual
therap y also im p roves sensorim otor fu nction and so shou ld
be inclu d ed w ith exercise for optim al m anagem ent of this
p atient su bgrou p (Karlberg et al 1996; Palm gren et al 2006;
Reid et al 2008).
Balance retraining can be p rogressed throu gh variou s
levels of challenge, starting w ith narrow ed or tand em stance
on a rm su rface w ith eyes op en, and p rogressing at the other
end of the continuu m to single-leg stance on an unstable
su rface w ith eyes closed . Physiotherap ists are fam iliar w ith
the m u ltitu d e of op tions that can be em p loyed to retrain
balance, and shou ld u se clinical reasoning to d evelop a pro-
gressive exercise p rogram m e suited to the need s of the spe-
ci c p atient.
Kinaesthetic aw areness can be trained in several w ays.
Recru itm ent exercises for the p osterior su boccip ital m u scles
su ch as pu re rotation in 4PK m ay be useful as these m u scles
have su bstantial p rop riocep tive inp u t. Using the p ressu re bio-
feed back cu ff, patients can practise nod d ing to speci c points
in range w ith their eyes closed , then checking and correcting
the p osition on the gau ge once they op en their eyes. H ead
repositioning to neu tral or speci c p oints in range can be

Figure 15.24 Kinaesthetic awareness and eye movement control. Tracing a
f gure with a laser pointer attached to the head acilitates both position sense and
eye / head control.
practised w ith a laser p ointer and target. H ow ever, a recent
stu d y show ed that rep ositioning of the tru nk u nd er the
head w as a m ore sensitive test and this m ay have fu tu re
im plications for both testing and retraining kinaesthetic
aw areness (Chen & Treleaven, 2013). Tracing a gu re w ith the
pointer w ou ld com bine eye / head control w ith p osition sense
(Fig. 15.24).
Eye m ovem ent control exercises inclu d e, for exam p le, fol-
low ing a m oving target, gaze xation w hilst m oving the head ,
as w ell as eye / head coord ination m ovem ents.
Several com p onents of sensorim otor fu nction can be com -
bined in a single exercise to increase the challenge and assist
in carry-over to m ore fu nctional activities. For exam p le, the
patient can practise gaze xation or eye m ovem ent control
w hilst tand em w alking and changing d irections.
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 P AR T 3
Lumbar Spine Pain
Syndromes
16 Mechanical Low Back Pain 191
Scott Burns, Edward Foresman, Stephenie Kraycsir and Joshua A. Cleland
17 Lumbar Radiculopathy 199
Chad Cook and Mark Wilhelm
18 Lumbar Spine Instability 210
Bryan S. Dennison and Michael H. Leal
19 Lumbar Spine in Lower Extremity Pain Syndromes 221
Scott Burns, Paul E. Glynn, Edgar Savidge and Joshua A. Cleland
20 The Contribution of the Pelvic Floor Muscles to Pelvic Pain 226
Ruth Jones
21 Chronic Low Back Pain 236
Mark D. Bishop, Joel E. Bialosky and Charles W. Gay
22 Joint Mobilization and Manipulation of the Lumbar Spine 245
Emilio J. Puentedura
23 Therapeutic Exercise for Mechanical Low Back Pain 255
Carol Kennedy and Lenerdene Levesque
24 Sacroiliac Joint as a Source of Pain: Diagnosis and Management 274
Kenneth E. Learman
This pa ge inte ntiona lly le ft bla nk
 PART 3 •  Lumbar Spine Pain Syndromes
Chapter  16
S c o tt Bu rn s , Ed w a rd Fo re s m a n , S te p h e n ie Kra yc s ir, J o s h u a A. C le la n d
CHAP TER CONTENTS
Introduction  191
Screening  191
Staging process  192
Stage I  192
Stage II and III individuals  197
Conclusion  197
Introduction
Low back p ain (LBP) is a very com m on and costly d iagnosis
w orld w id e (Dagenais et al 2008; Itoh et al 2013). In the United
States, it has been rep orted that w ithin the last 3 m onths
26–31% o ad ults have exp erienced an ep isod e o LBP lasting
at least 1 d ay (Deyo et al 2006; Strine & H ootm an 2007). In
a cross-sectional ep id em iological stu d y in Sp ain, app roxi-
m ately 20% o p eop le experienced a signif cant episod e o LBP
(Fernánd ez-d e-las-Peñas et al 2011). In Japan, a stead y increase
in cost o care or w ork-related low back inju ries w as observed
rom 2002 to 2011 (Itoh et al 2013).
Mechanical LBP w as the f th m ost com m on reason that
patients sou ght care rom their physicians (H art et al 1995).
In the United States, the num ber o physician visits related to
LBP increased rom an estim ated 15 m illion to 34 m illion rom
1995 to 2007 (H art et al 1995; Deyo et al 2006). Itoh et al (2013)
also show ed a sim ilar increase in prevalence in Japanese
w ork-related low back inju ries.
Rehabilitation p ro essionals, inclu d ing chirop ractic,
m anu al therap y and m assage p ro essionals, are com m only
u tilized in the treatm ent o LBP. H ow ever, the cost associated
w ith these interventions is highly variable and has yield ed
m ixed resu lts. Dagenais et al (2008) have rep orted that reha-
bilitation pro essionals, includ ing chiropractors and physical
therap ists, accou nted or ap proxim ately 3–61% o d irect
m ed ical costs associated w ith the m anagem ent o LBP.
Overall, there is an increase in p atients seeking care or their
LBP and the costs associated w ith their care; how ever, op tim al
m anagem ent o these ind ivid u als continu es to be elu sive.
Several clinical p ractice gu id elines ou tline variou s thera-
peu tic ap p roaches w hen it com es to m anaging a p atient w ith
LBP (Koes et al 2001; Staal et al 2003; Airaksinen et al 2006;
Delitto et al 2012). Althou gh there is no universal approach
Mechanical Low Back Pain
to treatm ent o ind ivid u als w ith LBP, the treatm ent-based
classif cation system o ers a sim p le and non-com p lex
ap proach to the m anagem ent o these patients. The aim o the
treatm ent-based classif cation ap p roach is to id enti y a p atient
that is likely to resp ond to a p articu lar intervention early in
the cou rse o care to op tim ize the ou tcom es. The treatm ent-
based classif cation app roach m ay be applied to varying LBP
cond itions, bu t acu te, m echanical LBP m ay be the m ost ap p ro-
p riate. The treatm ent-based classif cation ap p roach has show n
su f cient reliability or clinical u se, bu t it has som e lim itations
(Stanton et al 2011).
The treatm ent-based classif cation system or LBP attem p ts
f rst to p lace a p atient into a stage based on d isability and
d u ration o sym ptom s (see Table 16.2). Stage I generally cap-
tu res p atients w ith acu te LBP w ho have higher p ain and d is-
ability scores. In stage I, there are clinical characteristics that
assist in allocating p atients into one o ou r sep arate treatm ent
su bgrou p s as a strategy to im p rove p atient ou tcom es (Delitto
et al 1995; Brennan et al 2006). These su bgroups inclu d e:
m anip u lation, sp ecif c exercise, stabilization and traction.
In this chapter, w e w ill ocus on the application o stage I
evalu ation and intervention or ind ivid uals w ith m echanical
LBP only. We w ill outline the treatm ent-based classif cation
staging p rocess as w ell as review the sp ecif c exam ination and
intervention techniques. Specif c cond itions su ch as lum bar
rad icu lop athy or spinal stenosis w ill be covered in other
chap ters o this textbook.
Screening
The f rst step in using the treatm ent-based classif cation
system or LBP is to d eterm ine w hether the p atient is ap p ro-
p riate or conservative care. A clinician m u st p er orm a care u l
historical exam ination and p hysical exam ination to establish
w hether the patient has any red ag ind icators or re erral.
Red ags are consid ered clinical f nd ings that m ay ind icate a
seriou s p athology is p resent (Delitto et al 2012). Seriou s
p athologies that a clinician m ay encou nter d u ring evalu ation
o LBP inclu d e: neop lastic cond itions, sp inal ractu re, in ec-
tion, cau d a equ ina synd rom e and ankylosing sp ond ylitis
(Table 16.1).
H enschke et al (2009) d em onstrated , in an inception cohort
o 1172 p atients receiving prim ary care or acu te LBP, that 11
cases (0.9%) w ere o seriou s p athology. The m ost com m on
 192 PART 3 • 16 • Mechanical low back pain

Table 16.1 Common re d ag conditions or individuals pre s e nting with lumbar s pine compla ints
Ne opla s tic cond itions Sp ina l ra cture s Spina l in e ction Ca ud a e q uina Ankylos ing
s ynd rome s pond ylitis

Prior history of cancer Major trauma, s econdary Recent fever and chills Serious and / or Male > female
Age over 50 years to direct blow to spine, Recent bacterial infection progres sive Get out of bed at night
Unexplained weight los s s ports injury, motor or a history of IV drug neurological de cit of s econdary to pain
Symptoms are unrelieved vehicle accident, or a abus e bilateral lower Stiffness in the morning
with bed rest fall from a height History of immune extremities Age at onset < 35 years
Compres sion fracture suppress ion (from Recent ons et of bladder No relief when lying
(particularly in older steroid use, transplant, dysfunction, such as down
adults ) or dis ease process ) urinary retention, Relief with exercise and
Minor trauma or increased frequency or activity
s trenuous lifting in over ow incontinence
older or potentially Groin region anaesthes ia
os teoporotic athletes
Prolonged corticosteroid
us e

seriou s p athology w as sp inal racture, w hich accou nted or 8

Table 16.2 Stag ing proce s s or the tre atme nt-bas e d
o the 11 cases. The au thors state that p atients w ith an age > 70
cla s s if ca tion alg orithm
years, prolonged use o corticosteroid s and / or signif cant
trau m a m ay be at greater risk or sp inal ractu res. Malignancy Sta ge I Sta ge II Sta ge III
m ay also be an im p ortant red ag cond ition to screen in
p atients w ith LBP, w ith it accou nting or app roxim ately 0.7% Functional Unable to: Exceeds all Able to
(Deyo & Diehl 1988). Several historical qu estions m ay be capacity • stand ≥ 15 criteria of perform
u se u l to d eterm ine the risk o m alignancy inclu d ing age > 50 minutes s tage I bas ic
years, previou s history o cancer, unexplained w eight loss, • sit ≥ 30 Dif culty with functional
ailu re to im p rove w ith 1 m onth o conservative care and no minutes basic ADLs
relie w ith bed rest. A previou s history o cancer w as m ost • walk ≥ 14 mile functional Cannot
p red ictive o current m alignancy (Deyo et al 1992). (400 m) activities of participate
Med ical qu estionnaires are o ten u sed in screening o daily living fully in
red ags in the treatm ent o m echanical LBP to id enti y (ADLs) (e.g. sport
sym p tom p resentation su ch as onset o sym p tom s, p rogres- vacuuming,
sion, natu re, pattern o behaviour in a 24-hou r p eriod , and lifting)
sp ecif c m ovem ents or p ositions that a ect sym p tom s (Delitto Modi ed ≥ 20% ≤ 20% ≤ 20%
et al 2012). Ad d itionally, the clinician should also be con- Os westry
sciou s o p sychosocial actors the p atient exhibits becau se Dis ability
they m ay contribu te to the p atient’s p ersistent p ain and d is- Score
ability. Psychosocial variables m ay be id entif ed u sing sp ecif c
ou tcom e m easu res su ch as the Fear-avoid ance Belie s Qu es-
tionnaire, Su bgrou p s or Targeted Treatm ent (STarT) Back
Screening Tool, Pain Catastrop hizing Scale, etc. p ain and d isability ratings have begu n to d ecrease and the
Other im p ortant ou tcom e m easu res used in the m anage- p atient is beginning to retu rn to d aily rou tines. Patients in
m ent o LBP inclu d e the Osw estry Disability Ind ex and stage III have relatively little p ain or d isability, bu t requ ire
Roland Morris Disability Qu estionnaire. These ou tcom es can p hysical cond itioning to retu rn to great p hysical d em and s
help the clinician to id enti y the p atient baseline statu s in (Delitto et al 1995; Fritz et al 2007) (Table 16.2).
regard to pain, unction and d isability. (For ad d itional in or-
m ation regard ing the p hysical exam ination see Ch 5.)
Stage I
Stage I ad d resses ou r com m on rehabilitation strategies that
Staging Process are com m only im plem ented or patients w ith acu te LBP
includ ing m anip ulation, d irectional pre erence exercise, sta-
The next step in using the treatm ent-based classif cation bilization exercise and traction. Each su bgrou p has sp ecif c
system or treatm ent o m echanical LBP is to classi y p atients tests and m easu res, w hich assist the clinician in id enti ying
into one o three stages accord ing to severity o sym p tom s by the ap p rop riate su bgrou p (s) (Table 16.3).
u sing to their activity level and d isability score rom the Directional pre erence exercise and sp inal m anipulation
Osw estry Disability Ind ex (Delitto et al 1995). Stage I inclu d es m ay be the m ost com m only u sed in the treatm ent o p atients
p atients w ith acu te onset w here pain and d isability ratings are w ith acute LBP. George and Delitto (2005) ou nd that, o 131
highest. Stage II inclu d es p atients w ith su bacu te p ain and p articip ants w ith acute LBP, 38.9% w ere classif ed or sp ecif c

Table 16.3 Stage I s ubgroups a nd criteria
Ma nip ula tion Sp e cif c e xe rcis e
No s ymptoms distal to the knee Exte ns io n
Acute onset ≤ 16 days Symptoms distal to the buttock
Fear-avoidance Beliefs Directional preference for extension
Ques tionnaire – work Symptoms peripheralize with exion
subs cale ≤ 19 Centralization with extension
Lumbar hypomobility of at leas t Fle xio n
one s egment Age ≥ 50 years
One hip pass ive internal rotation Directional preference for exion
≥ 35° (measured in prone) Evidence of s pinal s tenosis on imaging
Late ral s hift
Visible frontal plane deviation
Directional preference for lateral
translational movements
exercise, 32.1% or m anipu lation, 21.4% or stabilization and
7.6% or traction.
This su bgrou ping strategy is a sim plistic m ethod u sed to
guid e the clinician in provid ing an appropriate intervention
to a p atient w ith acu te LBP. H ow ever, this system is not
p er ect. O ten tim es, p atients m ay be categorized into m u lti-
p le su bgrou p s, w hich w ill com plicate the d ecision m aking
o the clinician. On the other hand , som e p atients m ay not
be classif able w ithin this ram ew ork. Stanton et al (2011)
rep orted that ap p roxim ately 50% o ind ivid u als w ith LBP
w ere categorized into a single subgrou p, 25% f tted m ore than
one su bgrou p and 25% d id not f t any su bgrou p . It is im p or-
tant to realize the lim itations o the treatm ent-based classif ca-
tion ap p roach and that it is a d ynam ic and u id categorization
p rocess requ iring the constant assessm ent o the p rovid er.
Spinal manipulation group
Manip u lation re ers to p er orm ing a high-velocity, low -
am p litu d e thru st p roced u re to a p atient’s lum bar spine. It is
im portant to realize that spinal m anipulation or the pu rposes
o this chap ter d oes not inclu d e non-thru st oscillatory m obi-
lizations that are also com m only per orm ed in rehabilitation
settings and are re erred to as sp inal m obilization.
Flynn et al (2002) com pleted a d erivation stud y to id enti y
patient characteristics that w ere likely to lead to d ram atic
su ccess u sing sp inal m anip u lation. Five p red ictor variables
w ere id entif ed : short d uration o sym ptom s (<16 d ays), no
sym p tom s d istal to the knee, a Fear-avoid ance Belie s Qu es-
tionnaire w ork su bscale score < 19, at least one hip w ith > 35°
internal rotation range o m otion and hyp om obility o one
lum bar segm ent. In that d erivation trial, a su pine lu m bopelvic
m anip u lation (see Fig. 16.1) w as p er orm ed and a basic m obil-
ity hom e exercise w as p rescribed . The patients retu rned 48
hou rs later to d eterm ine w hether d ram atic su ccess w as
achieved . In this stud y a 50% red u ction o the Osw estry Dis-
ability Ind ex w as the ind icator o su ccess. I p atients ailed to
m eet this criterion on the 48-hour ollow -u p the sam e m anip-
u lation techniqu e w as app lied and the p atient retu rned 2 d ays
later. Flynn et al (2002) d eterm ined that p atients w ith ou r ou t
o the f ve p red ictor variables had a 95% chance o achieving
the rap id im p rovem ent in d isability rating. A valid ation
stu d y exam ining these p red ictor variables w as p er orm ed and
Staging process 193
Tra ction Sta b iliza tion
Pres ence of leg s ymptoms Age ≤ 40 years
Signs of nerve root Straight leg raise ≥ 91°
compres sion (myotomal, Aberrant motions
dermatomal or re ex Pos itive prone ins tability test
abnormalities )
Peripheralization with
extension
Positive cros sed s traight
leg rais e
conf rm ed that the f ve variables d id ind eed id enti y a su b-
grou p o p atients w ho are m ore likely to respond to the
m anip u lation. From that ollow -u p stu d y, the au thors id enti-
f ed the ‘tw o- actor ’ ru le: p atients w ithou t sym p tom s below
the knee and onset o ≤ 16 d ays had a 91% chance o experienc-
ing signif cant d isability and pain red uction w ithin 48 hours
a ter lu m bar thrust m anipu lation (Child s et al 2004).
I the sup ine lum bopelvic thrust m anip ulation is not pos-
sible w ith a p articu lar p atient second ary to d iscom ort, an
alternative techniqu e has been show n to be equ ally e ective.
This is a neu tral sid e-lying lum bar techniqu e (see Fig. 16.2).
N on-thrust oscillatory m obilization techniques m ay also be
im p lem ented ; how ever, there appears to be a signif cant d i -
erence i a su bgroup o patients receive the high-velocity,
low -am plitud e thru st m anipu lation (Cleland et al 2006).
In ord er to apply this m anipulative technique to a p atient
in the clinical setting, the clinician need s to ensure a solid
u nd erstand ing o the tests and m easu res u sed to id enti y
p otential resp ond ers. Ad d itionally, in these stu d ies su bjects
w ere betw een the ages o 18 and 60 years w ith a chie com -
p laint o LBP w ith or w ithou t leg sym p tom s. Su bjects w ere
exclu d ed i they exhibited any sign o nerve root com pression,
had had su rgery to the lu m bar sp ine, w ere cu rrently p regnant
or had a history o osteop orosis.
In ord er to id enti y accu rately those p atients w ho m ay f t
into this subgrou p, it is im portant to p er orm the pred ictor
variables in a sim ilar ashion that w as p er orm ed in the
stu d ies. Using a bu bble inclinom eter on the lateral asp ect o
the f bu la, internal rotation range o m otion o the hip is p er-
orm ed w ith the patient in the prone p osition and the knee
p assively exed to 90°. The clinician passively internally
rotates the lim b u ntil the visual observation o pelvic m ove-
m ent occu rs or p assive end eel o the hip joint is reached .
Mobility o the lu m bar sp ine is assessed u sing p osterior–
anterior spring testing at each lum bar level. The clinician w ill
d eterm ine the presence / absence o pain and m obility at each
segm ental level (Flynn et al 2002).
Many d i erent m anip u lation and m obilization techniqu es
have been d escribed , bu t there is p resently no evid ence or
the su p eriority o one ap p roach over another. In act, em erg-
ing evid ence su ggests that the choice o techniqu e m ay not be
as im portant as w as p reviously thou ght (Chirad ejnant et al
2003; Cleland et al 2009). The correct id entif cation o the
 194 PART 3 • 16 •
Figure 16.1 Lumbopelvic manipulation performed with the patient supine.
p atient w ho actu ally need s m anip ulation is likely to be m ore
im p ortant than the p articu lar techniqu e chosen by the thera-
p ist. Part o the exp lanation or the lack o im portance o the
sp ecif c techniqu e m ay be that m anip u lation p roced u res are
less sp ecif c than w as p reviou sly thou ght. Be a and Mathew s
(2004) exam ined the relationship betw een m anip u lation tech-
niqu es targeted at sp ecif c sp inal levels and the sp inal levels
actu ally p rod u cing a cavitation d u ring the techniqu e. The
au thors rep orted no signif cant correlation betw een the sp inal
levels p rod u cing the cavitation sou nd s and the sp inal levels
targeted by the techniqu e.
It is im portant to note that m anip ulation, or any m anu al
therap y, is not com m only u tilized in isolation. Typ ically p hys-
ical therap ists m ay instru ct a p atient in other therap eu tic
activities inclu d ing m obility, exibility and strengthening
exercises. H ere w e d escribe tw o sp inal m anipulative tech-
niqu es com m only u sed or m echanical LBP, bu t read ers are
re erred to Chap ter 22 or ad d itional in orm ation regard ing
m anip u lation techniqu es o the lu m bar sp ine.
Manipulation performed with the patient supine (Fig. 16.1)
The sup ine lum bar m anipu lation technique w as u tilized in
the d erivation (Flynn et al 2002) and valid ation stud y (Child s
et al 2004). The techniqu e is per orm ed w ith patients in su pine
and the clinician on the sid e opp osite to their sym p tom s. The
p atient is asked to interlace the f ngers behind the head . The
clinician creates ip silateral sid e-bend ing o the lu m bar sp ine
by m oving the low er extrem ities tow ard the sid e o sym p -
tom s. The u p p er bod y o the p atient is sid e-bent tow ard s the
sid e o sym p tom s and contralaterally rotated . The clinician
contacts the involved anterior su p erior iliac sp ine o the
p atient w hilst contralaterally rotating the patient’s u pp er
bod y. The clinician provid es an anterior-to-posterior orce
throu gh the p elvis. I the p atient is u ncom ortable or u nable
to relax d u ring the set-u p o the p roced u re, it is ad vised to
select an alternative techniqu e.
Manipulation performed with the patient
side-lying (Fig. 16.2)
The sid e-lying neutral lum bar m anipu lation is com m only
u sed in rehabilitation settings. In this p roced u re, the clinician
w ill attem p t to target a particular lu m bar segm ent that w as
Mechanical low back pain
Figure 16.2 Lumbar spine manipulation performed with the patient side-lying.
id entif ed as being hypom obile and / or pain u l d u ring physi-
cal exam ination. As d escribed above, it m ay be challenging to
d irect the m anip ulative orce at a particu lar segm ent bu t, in
act, it m ay m ove the entire lu m bar region.
The clinician should p lace the p atient in the sid e-lying p osi-
tion w ith the p ain u l sid e u p . The clinician begins by exing
the top leg u ntil m otion is p alp ated at the targeted lu m bar
level. The next step is to rotate the patient’s trunk d ow n to
the targeted level. Once this p osition is achieved , the clinician
shou ld d eterm ine the p atient’s com ort level and p roceed
only i the p atient is able to tolerate the p osition. The clinician
w ill stabilize the torso w ith one orearm , w hile the cau d al
orearm w ill rotate the p elvis tow ard the clinician. During this
tim e, the clinician is attem p ting to engage the hyp om obile
segm ent. Once engaged , the clinician m ay elect to d eliver a
high-velocity, short-am p litu d e thru st throu gh the p elvis.
Specif c exercise group
Patients ap p rop riate or the sp ecif c exercise su bgrou p o
the treatm ent-based classif cation d em onstrate a d irectional
p re erence or m ovem ent d u ring the exam ination, w hich is
an im provem ent in sym ptom s or range o m otion in resp onse
to a sp ecif c single or rep eated tru nk m ovem ents and p osi-
tioning techniqu es (Werneke et al 2011). There are three
com m on categories o d irectional p re erence in this su bgrou p
includ ing extension, exion and lateral shi t. Directional
p re erence m ay ju st ind icate a p osition or m otion im p roving
sym p tom s; how ever, centralization o sym p tom s m ay also
be noted d uring the exam ination. Centralization is w hen
re erred spinal sym ptom s are progressively abolished in
a d istal-to-proxim al d irection in resp onse to d eliberate ap pli-
cation o m ovem ents or p ostu res, and it is cru cial in id enti y-
ing ind ivid u als likely to benef t rom sp ecif c exercise
p rogram m es (Werneke & H art 2001; Aina et al 2004; Werneke
et al 2008).
Utilizing the treatm ent-based classif cation approach, the
clinician assesses or a d irectional p re erence in w eight-
bearing or non-w eight-bearing positions or a particular
d irection o m ovem ent o the lu m bar sp ine w ith the m ain goal
o centralization o sym p tom s (Brow d er et al 2007). Matching
the ind ivid u al to the ap p rop riate d irectional p re erence cate-
gory is o p articu lar im portance as it has been rep orted that
84% o ind ivid u als m atched to the ap p ropriate d irection o
exercise had signif cant red u ctions in pain and d isability
w ithin the f rst 2 w eeks o treatm ent (Long et al 2008).
Dosage o d irectional pre erence exercises is variable;
how ever, Brow d er et al (2007) instructed su bjects to per orm

one set o 10 rep etitions requ ently throu ghout the d ay.
Postu re ed u cation m ay also be im p ortant or instru cting
p atients in activities or p ositions that m ay alter their sym p-
tom s. H ere w e brie y su m m arize treatm ent consid erations or
sp ecif c exercise-oriented classif cation.
Flexion-oriented exercises
A d irectional p re erence or exion is m ost com m on in old er
ad u lt pop u lations (age > 50 years) typically w ith im aging evi-
d ence or a m ed ical d iagnosis o lum bar spinal stenosis (Fritz
et al 2007). Patients w ho have lum bar stenosis are likely to
report pain w ith w alking or extension o lu m bar sp ine, or
bilateral low er extrem ity sym p tom s, and their sym ptom s are
relieved w ith sitting.
Patients in a exion-oriented sp ecif c exercise classif cation
m ay benef t rom p er orm ing rep eated end -range exion
exercises. Flexion exercises are u su ally easiest to per orm w ith
the p atient in the su p ine or qu ad ru p ed p ositions. The p oste-
rior pelvic tilt or single / d ou ble knee to chest exercise m ay be
good exercises to prom ote exion o the lum bar spine. Exer-
cises shou ld be d osed accord ing to p atient resp onse and p er-
orm ed requently throughou t the d ay as p art o a hom e
exercise program m e.
Patients in the exion-oriented sp ecif c exercise classif ca-
tion tend to be old er, w ith d egenerative joint changes, and
sti ness o the lu m bar sp ine and hip joints. I sti ness is
d etected in the lu m bar spine w ith p assive accessory m obility
testing, m obilizations m ay be p er orm ed . Prone p osterior-to-
anterior m obilization is u se ul or m any patients, w ith the
lum bar sp ine p ositioned in som e exion w ith the aid o
pillow s p laced u nd er the abd om en to avoid p erip heralization
o sym p tom s d u e to excessive extension. The clinician p er-
orm s the m obilization by contacting the lu m bar spinous
process w ith the hyp othenar em inence o the hand and p er-
orm ing oscillatory m obilizations. The clinician should be
m ind u l to avoid any w orsening o p atients’ sym p tom s.
Ad d itionally, case stu d ies involving patients w ith lu m bar
stenosis have ad vocated intervention strategies inclu d ing
m obilization or m anip u lation or the lu m bar sp ine and / or
hip joint, general low er extrem ity strengthening exercise,
neu ral m obilizations and a w alking p rogram m e p ossibly
acilitated w ith bod y w eight-su pported tread m ill am bulation
(Mu rphy et al 2006; Whitm an et al 2006).
Extension-oriented exercises
Extension-oriented exercises or McKenzie exercises have been
recom m end ed as a p otential intervention or ind ivid u als w ith
pain rad iating below the knee (Bach & H olten 2009). Approxi-
m ately 40–56% o ind ivid u als w ith acu te LBP w ith rad icular
sym p tom s w ill achieve centralization w ith extension-oriented
exercises (Aina et al 2004). When p er orm ing extension-
oriented exercises, the clinician is attem p ting to d eterm ine the
presence o d irectional pre erence and / or centralization.
Extension-oriented exercises p rogram m es can be p re-
scribed in a variety o w ays. In the beginning, the extension-
oriented exercises shou ld be com p leted u sing p atient-generated
orces only. This m ay includ e exercises su ch as prone lying,
prone on elbow s and prone p ress-u ps. These exercises have
d em onstrated superior short-term ou tcom es com pared w ith
non-steroid al anti-in am m atories (N SAIDs) or ed u cational
booklets (Bu sanich & Verscheu re 2006). Ed u cation shou ld be
Staging process 195
also provid ed to the p atient to avoid positions that aggravate
or p erip heralize the sym p tom s. (Read ers are re erred to Ch 7
or ad d itional in orm ation regard ing the McKenzie m ethod
ap plied to the sp ine.)
Joint mobilization to promote extension
Depend ing on the patient sym ptom resp onse, the clinician
m ay elect to p rovid e a m anu al orce to p rom ote ad d itional
relie o sym p tom s or centralization. A com m on m anu al orce
m ay be p osterior–anterior lu m bar m obilizations in the p rone
or extend ed p osition. The p atient m ay be p rogressively p osi-
tioned into m ore extension by having the p atient p rone on the
elbow s or per orm ing a prone press-u p w hilst the m obiliza-
tions are d elivered . Research su ggests that the sp ecif c choice
o a m obilization techniqu e is not im p ortant or achieving
p ain relie – only that the m obilization is being p er orm ed in
the low er lu m bar sp ine instead o the u p p er lu m bar sp ine
(Chirad ejnant et al 2003).
Lateral shift exercises
Ind ivid u als w ith lateral d eviation or shi t o the lum bar spine
have been associated w ith p oor p rognosis (Porter & Miller
1986) especially w hen this is present w ith a crossed straight
leg raise (Khu ash & Porter 1989). Lateral d eviation or a
lateral lu m bar shi t is a com m on presentation in the treatm ent
o LBP and has been thou ght to be associated w ith d isc p athol-
ogy, bu t the exact m echanism is u nknow n (Laslett 2009).
McKenzie (1981) d ef nes a lateral lu m bar shi t as lateral d is-
p lacem ent o the p atient’s tru nk in relation to the p elvis and
is clinically relevant i sid e-glid e tests change p atient rep ort-
ing o pain intensity or location.
Patients w ith a lateral shi t d e orm ity w ho are able to cen-
tralize their sym p tom s w ith p elvic translocation m ovem ent
testing in stand ing are treated w ith w eight-bearing shi t cor-
rection exercises. The p atient should be taught to per orm the
p elvic translocation m ovem ent in the d irection that p rod u ced
the centralization d u ring the exam ination. The extension-
oriented exercises d escribed or the extension sp ecif c exercise
classif cation m ay also be help u l once the visible shi t has
been red uced .
I a patient’s sym p tom s p eripheralize w ith w eight-bearing
p elvic translocation m ovem ents, the clinician m ay op t to try
non-w eight-bearing exercises. These exercises com m ence
w ith the patient in prone and the clinician attem pts to trans-
late the pelvis to correct the shi t. Positioning the table into
som e exion or the u se o p illow s u nd er the abd om en m ay
be necessary in ord er to red u ce p ain and avoid perip heraliza-
tion o sym p tom s, i the p atient is u ncom ortable in p rone.
Once the lateral shi t ap p ears to be red u ced , the clinician m ay
op t to begin extension-oriented exercises w ith or w ithou t
m anu al therap y interventions.
Stabilization group
Patients w ith lu m bar segm ental instability have been p ro-
p osed as a u niqu e su bgrou p o p atients w ith LBP; how ever,
there have been con icting stu d ies regard ing criteria to d ef ne
this cond ition (O’Su llivan 2000; H icks et al 2003). A clinical
p red iction ru le w as d ef ned by H icks et al (2005) or patients
w ho w ould be su ccess ul, w ith a stabilization classif cation or
treatm ent and inclu d e: age < 40 years, positive p rone instabil-
ity test, presence o aberrant m ovem ents and a p assive straight
 196 PART 3 • 16 • Mechanical low back pain
leg raise test > 91°. I three o our variables w ere p ositive the
likelihood o su ccess u sing this p articu lar stabilization p ro-
gram m e w ould be im proved .
Examination items
The prone instability test has p atients su pporting their torso
at the end o the table w ith their eet on the oor. The exam -
iner ap p lies a p osterior–anterior orce on each lu m bar
segm ent, assessing or p ain rep rod u ction. I p ain rep rod u c-
tion is noted , the p atient is asked to li t the eet rom the
grou nd and the p osterior–anterior p ressu re is reap plied . I
p ain is elicited this w ould ind icate a p ositive test (Schneid er
et al 2008).
Du ring supine p assive straight leg raise test, the exam iner
p assively exes the hip w ith the knee extend ed u ntil the
exam iner eels resistance, and hence range o m otion is
record ed (H icks et al 2005). Aberrant m ovem ents are clinical
signs o lu m bar segm ental instability and inclu d e: p ain u l arc
d u ring exion or upon retu rn to extension, an instability
catch, Gow er sign or ‘thigh clim bing’, and reversal o lu m -
bopelvic rhythm (H icks et al 2003). (For operational d ef ni-
tions o these cond itions, see the stu d y by H icks et al (2003).)
Intervention
H icks et al (2005) d esigned a com p rehensive sp ine stabiliza-
tion p rogram m e to challenge the transversu s abd om inis,
erector sp inae, m ultif d u s and quad ratu s lum boru m m uscles.
In their program m e, repeated su bm axim al e orts w ere
encouraged in ord er to im itate the typical u nction o these
m u scle grou p s in sp ine stabilization. Ad d itionally, exercise
selection shou ld be based u p on the p atient’s u nctional
d em and s and p rogression o exercises should be d ep end ent
on the resp onse and tolerance o the patient. In this stu d y, 54
su bjects com p leted the 16-session sup ervised exercise p ro-
gram m e. App roxim ately 33% o subjects experienced a 50%
or greater red u ction in d isability. On the contrary, 28% o
su bjects exp erienced no change or w orsening in sym p tom s.
Patients in the stabilization classif cation shou ld be ed u -
cated to avoid end -range m ovem ents o the lu m bar sp ine in
ord er to avoid p ositions that m ay overload the p assive stabi-
lizing stru ctu res o the sp ine. Li ting even light load s rom a
p osition o near-end -range lu m bar sp inal exion shou ld be
avoid ed becau se o the potentially d am aging orces created
in the ligam ents and intervertebral d iscs o the sp ine by su ch
m ovem ents (McGill 1988).
Althou gh the literatu re supp orts the u se ulness o active,
strengthening exercise p rogram m es, stu d ies com p aring d i -
erent stabilization strengthening rou tines have generally not
ou nd any d i erences w hen used in airly heterogeneou s
grou ps o patients (Danneels et al 2001; Kou m antakis
et al 2005).
One p otential ap p roach to id enti ying an ap p rop riate exer-
cise rou tine is to id enti y exercises that op tim ally challenge
im p ortant stabilizing m u scles w ithou t im p osing any p oten-
tially d angerou s load s on the sp ine. The transversu s abd om inis
m u scle is o ten a avou rite target d u ring rehabilitation o
p atients w ith LBP. Training the transversu s abd om inis m ay be
initiated by teaching the p atient the abd om inal-bracing
m anoeu vre (Richard son & Ju ll 1995) by d raw ing the navel up
tow ard s the head and in tow ard s the sp ine so that the stom ach
attens but the spine rem ains in its neu tral position. Research
has show n that the abd om inal-bracing m anoeu vre w ill acti-
vate the transversu s abd om inis to a greater extent than a
trad itional p elvic tilt exercise, in w hich the p atient is instru cted
to atten the sp ine (Urquhart et al 2005). The clinician w ill
need to instru ct the p atient to avoid engaging su p erf cial m u s-
cu latu re su ch as the rectu s abd om inis. Once the p atient can
p er orm the abd om inal-bracing m anoeu vre p rop erly, m ore-
challenging activities can be ad d ed , su ch as brid ging or
m arching in hook-lying. It is recom m end ed that abd om inal
bracing shou ld be com bined w ith other aspects o the stabili-
zation p rogram m e, and eventually be incorporated into m ore
unctional positions and postu res that w ould challenge each
ind ivid u al patient in his or her everyd ay activities.
The obliqu e abd om inal m uscles can be exercised e ectively
w ith the horizontal sid e su pport exercise or sid e p lank. This
exercise p rod u ces high levels o electrom yographic (EMG)
activity in the oblique abd om inals w ith low com p ression
orces (Kavcic et al 2004). To per orm the horizontal sid e
su p p ort exercise, the p atient is sid e-lying w ith the knees bent
or straight w hilst the torso is su p p orted on the orearm . The
p atient then li ts the p elvis rom the table and p laces the sp ine
in a neu tral p osition. The patient shou ld per orm the sid e
su p p ort exercise or p rogressively longer su stained p eriod s o
tim e and higher rep etitions. I asym m etry exists, it shou ld be
a goal to achieve equ ality in strength and end u rance betw een
sid es.
Strengthening o the erector sp inae m u scles m ay be im p or-
tant becau se these are the p rim ary sou rce o extension torqu e
or li ting tasks. The erector spinae m u scles prod uce the exten-
sor orce need ed or li ting, w hereas the segm ental extensors,
p rim arily the m u ltif d u s m u scles, p rovid e stabilization o ind i-
vid u al lu m bar m otion segm ents. Cu rrent evid ence su ggests
that the m u ltif d u s tend s to atrop hy in p atients w ith chronic
LBP, and ailu re to regain norm al m orp hology and end u rance
o m u ltif d u s and erector sp inae m u scles m ay be a risk actor
or recurrence o LBP (Danneels et al 2001; Kou m antakis et al
2005). Research has u rther show n that the m u ltif d us m uscles
d o not au tom atically recover ull strength and end u rance a ter
the f rst ep isod e o LBP, u nless sp ecif c exercises are p er orm ed
(H id es et al 1996). These f nd ings em phasize the need or clini-
cians to ocu s attention on rehabilitation o the extensor m u s-
cu latu re, w ith a p articu lar ocu s on regaining end u rance and
strength o the m u ltif d u s m u scles.
The erector spinae and m ultif d us m u scles can be trained
u sing extension exercises. Cau tion m u st be em p loyed ,
how ever, becau se extension exercises also tend to p rod u ce
high levels o com p ression on the lu m bar sp ine, w hich m ay
not be tolerated by all p atients. A relatively sa e p atient p osi-
tion rom w hich to begin an extension exercise p rogram m e is
qu ad ru p ed . Whilst in the qu ad ru p ed p osition, the p atient
m ay be asked to extend one leg or one arm to a horizontal
p osition w hilst m aintaining the abd om inal bracing. Raising
the op p osite arm and leg sim u ltaneou sly o ers m ore e f cient
training o the m u ltif d u s and erector sp inae m u scles w ith
su f cient m u scle EMG activity levels, w hile m aintaining sa e
levels o lum bar com pression (Kavcic et al 2004). Brid ging
exercises per orm ed rom a supine or hook-lying p osition
w hile m aintaining abd om inal bracing also p rovid e a rela-
tively sa e and e ective m ethod or activating the m u ltif d u s
and erector spinae m uscles. H aving the patient extend one leg
rom the brid ge p osition requ ires slightly greater lu m bar
extensor m u scle activity (Kavcic et al 2004).

Traction group
There is con icting evid ence or the e f cacy o interm ittent
m echanical lu m bar traction or p atients w ith LBP (Delitto
et al 2012). It has been prop osed that sciatica is a prim ary
actor or traction being benef cial in ind ivid uals w ith LBP.
The su bgroup o patients that w ill benef t rom m echanical
traction has been rep orted by Fritz et al (2007) in a rand -
om ized clinical trial o 64 su bjects to inclu d e: presence o
sciatica, signs o nerve root com p ression, p erip heralization o
sym p tom s w ith extension m ovem ents, and a p ositive crossed
straight leg raise test.
Ind ivid uals w ith m echanical LBP and w ho f t this sub-
grou p o ten exhibit signs o nerve root com pression includ ing
m yotom al, d erm atom al and / or d eep tend on re ex abnor-
m alities. A crossed straight leg raise is p er orm ed id entically
to the straight leg raise test excep t that the op p osite extrem ity
is raised . It is a positive test i p ain is reprod u ced in the
involved extrem ity.
Mechanical traction is m ost o ten p er orm ed w ith the
patient p rone, bu t m ay also be p er orm ed in su pine p osition.
I the patient is su pine, exing the hips and knees w ill tend
to p lace the lu m bar sp ine into m ore exion – a position that
m ay be m ore ap p rop riate and com ortable or old er p atients
w ith im aging f nd ings suggesting lum bar spinal stenosis. The
goal o treatm ent w ith m echanical traction is to centralize the
patient’s sym p tom s and p erm it the p atient to p rogress into
another classif cation, m ost o ten a sp ecif c exercise classif ca-
tion. Patients w ithin the traction classif cation shou ld be m on-
itored closely. I reassessm ent show s that the patient is able
to centralize sym p tom s w ith active m ovem ents, p rogression
to a sp ecif c exercise classif cation w ou ld be ind icated . I the
patient’s sym p tom s and signs o nerve root com p ression con-
tinu e to w orsen, re erral or injections, m ed ication or other
treatm ent op tions su ch as su rgery m ay be w arranted .
In the rand om ized clinical trial per orm ed by Fritz et al
(2007), 91% o the ind ivid u als w ho d em onstrated perip herali-
zation w ith extension achieved a 50% d ecrease in their
m od if ed Osw estry Disability Ind ex scores w ith the ad d ition
o m echanical traction. Ad d itionally, they exp erienced an
average im provem ent o 29 p oints com pared w ith 13 in the
extension-oriented exercise-only grou p (Fritz et al 2007).
Static traction w as applied or 12 m inutes at an intensity o
40–60% o the patient’s bod y w eight based on tolerance and
sym p tom resp onse. A ter com p leting the traction, the su bjects
rem ained p rone or at least 2 m inu tes, and then per orm ed a
set o p rone p ress-u p s be ore retu rning to w eight-bearing.
This treatm ent w as app lied or a m axim u m o 12 sessions over
a 6-w eek tim e ram e (4 sessions per w eek or the f rst 2 w eeks,
then once a w eek in w eeks 3–6).
Stage II and III individuals
The app ropriate m anagem ent o the ind ivid u al w ho is in
stage II or III o the treatm ent-based classif cation is not clear.
Most com m only, su bjects in these stages are m anaged u sing
an im p airm ent-based ap p roach. The clinician w ill target
im pairm ents in exibility, strength, end urance and joint
m obility w ith interventions. Evans et al (2010) observed that
ind ivid u als had im pairm ents in strength, exibility and neu-
rom u scular control o m u scles su rrou nd ing the hip and pelvis
Conclusion 197
region. These f nd ings m ay ind icate potential areas to target
w ith intervention program m es.
Im pairm ents m ay be read ily apparent in the local areas, bu t
m ay also be p resent in ad jacent regions. Im p airm ents in ad ja-
cent regions m ay also contribu te to the p rim ary com p laint o
LBP and shou ld be exam ined by the clinician (Whitm an et al
2006; Wainner et al 2007; Burns et al 2010).
Another signif cant com ponent o the m anagem ent o ind i-
vid u als in stage II or III inclu d es issu ance o a hom e exercise
p rogram m e aim ed at red u cing the recu rrence o LBP. A com -
p rehensive hom e exercise p rogram m e that targets id entif ed
m u scu loskeletal im p airm ents and incorp orates task-sp ecif c
exercises is pre erred (Delitto et al 1995; George & Delitto
2002). The clinician m ay choose to blend exercises that ocu s
on neu rom u scu lar control, strength, end u rance and m obility.
With all exercise p rogram m es, ed u cation regard ing ad her-
ence, proper p rogression and avoid ance o overtraining is
essential. In the acu te LBP popu lation, ad vice and ed u cation
ap pears benef cial, bu t there is con icting evid ence regard ing
the in u ence o ed u cation on the recu rrence o LBP (Lid d le
et al 2007).
Conclusion
The treatm ent-based classif cation approach has su f cient
reliability or use w ithin clinical practice settings and m ay
assist p rovid ers in app rop riately m atching patients w ith LBP
to a p articu lar intervention w ith the intent o m axim izing
p atient ou tcom es. This is one em erging ap p roach to the m an-
agem ent o m echanical LBP; how ever, a plethora o m anage-
m ent m od els exists and u sage w ill be at the d iscretion o the
ind ivid u al provid er.
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 PART 3 •  Lumbar Spine Pain Syndromes
CHAP TER CONTENTS
Aetiology and background  199
Prevalence  199
Def nitions  199
Natural history  200
Clinical signs and symptoms  200
Anatomy and pathogenesis o  lumbar radiculopathy  200
Anatomy  200
Pathogenesis  201
Essential aspects o  di erential diagnosis  201
An evidence-based clinical examination  201
Patient history  201
Physical examination  202
Provocation tests  202
Outcome measures  204
Imaging  204
Nerve condition responses  204
Current best evidence with regard to treatment  205
Conservative approaches  205
Injection  207
Surgical approaches  207
Aetiology and Background
Prevalence
Low back p ain (LBP) is a com m on, d isabling d isord er that
places a bu rd en both on ind ivid u als and on society, w ith
associated loss of w ork and m ed ical costs (van Tu ld er et al
1995; Assend elft et al 2004). Stu d ies of LBP have proposed
point p revalences betw een 6% and 33% and 1-year p reva-
lences betw een 22% and 65% (Loney & Stratford 1999; Walker
2000; Dagenais et al 2010). The lifetim e p revalence of LBP has
been estim ated at ap proxim ately 84% (Airaksinen et al 2006).
In the United States of Am erica (USA) alone, treatm ents for
LBP cost over $50 billion annu ally, w hereas ind irect costs for
LBP are estim ated at $7.4–19.8 billion; increm ental costs
for LBP exceed $26 billion a year (Liled ahl et al 2010). Com -
bined annu al estim ates in the USA have exceed ed $90 billion
in total costs (Foster 2011).
Chapter  17 Lumbar Radiculopathy
C h a d C o o k, M a rk W ilh e lm
De nitions
Low back d isord ers are best d ivid ed by their m echanical
and non-m echanical origins, w ith the relatively rare non-
m echanical origins consisting of: (1) neop lasias, su ch as m u l-
tip le m yelom a, lym p hom a / leu kaem ia, and breast, lu ng,
p rostate, kid ney, sp inal cord , vertebral and retrop eritoneal
tu m ou rs; (2) infections, such as osteom yelitis, sep tic d iscitis,
p araspinou s abscess, epid u ral abscess and shingles; (3) in am -
m atory arthritis, inclu d ing ankylosing sp ond ylitis, p soriatic
sp ond ylitis, Reiter ’s synd rom e, and Scheu erm ann’s and Paget
d iseases; (4) visceral, w hich m ay includ e sym p tom s originat-
ing from an aortic aneu rysm , prostatitis, end om etriosis, neph-
rolithiasis, p yelonephritis, p erinephric abscess, pancreatitis,
cholecystitis, or a p enetrating u lcer (Jarvik & Deyo 2002).
Mechanical origins of LBP are fu rther d ivid ed into cond itions
su ch as anatom ically oriented LBP and low -back-related leg
p ain. Lu m bar rad icu lop athy is consid ered the m ost com m on
form of neuropathic pain (Dw orkin et al 2007).
Lu m bar rad icu lop athy is a su bclassi cation of LBP that is
often characterized by a rad iating p ain in one or m ore lu m bar
d erm atom es that m ay or m ay not be accom panied by other
rad icu lar irritation sym ptom s (Van Boxem et al 2010). In the
literatu re, the term s ‘rad icu lar pain’, ‘sciatica’ and ‘rad icu -
lop athy’ are also often used interchangeably (Van Boxem et al
2010), d espite the fact that these term s d o not necessarily
d escribe the sam e cond itions. By d e nition, radicular pain is
a sym p tom that involves a region beyond the spine, and it is
very p ossible that the rad icu lar p ain d oes not originate w ithin
the low back. Sciatica is also consid ered a sym ptom rather
than a d iagnosis (Konstantinou & Du nn 2008), and it charac-
teristically involves rad iating leg p ain that follow s a d er-
m atom al p attern (Koes et al 2007) along the d istribution of the
sciatic nerve (Stafford et al 2007). Although sciatica m ay also
not originate in the low back, it is thou ght that 90% of cases
of sciatica are cau sed by a lu m bar herniated d isc (Koes et al
2007). Lumbar radiculopathy is objective loss of sensory
and / or m otor fu nction as a result of cond uction block of one
or m ore lu m bar nerves. Sym p tom s m ay inclu d e nu m bness,
m otor loss, m u scle w asting, w eakness, and loss of re exes
(Govind 2004), and lum bar rad icu lopathy can be d iagnosed
w ith one or all of these sym ptom s. Cau sally, for this book
chap ter, lu m bar rad icu lop athy w ill be consid ered as p ain
rad iating into one or m ore d erm atom es cau sed by nerve
root irritation / in am m ation and / or com pression. Lum bar
 200 PART 3 • 17 • Lumbar radiculopathy

rad icu lopathy m ay have rad icular p ain and m ay also be Table 17.1 De s cription o lumbar radiculopa thy by s e ve rity
d escribed as sciatica; how ever, not all rad icu lar pain or sci-
atica is rad icu lop athy. Se ve rity De s cription Se ns ory
le ve l a nd motor
involve me nt
Natural history Mild Pure sensory / pain ul radicular No
pattern, characterized by
In the general p opu lation, the annu al p revalence of lu m bar
radicular pain and a s egmental
rad icu lop athy has been rep orted as from 9.9% to 25%, w hereas
pattern o s ensory dys unction
the point p revalence is reported at 4.6% to 13.4% and lifetim e
but no other neurological def cits
p revalence is estim ated at 1.2% to 43% (Konstantinou & Du nn
2008). The m ost frequent region for lum bar rad iculop athy is Moderate Mild motor def cit pattern, Yes
L5 (H su et al 2011). Cook et al (2013) recently captu red risk characterized by radicular pain,
factors for rst-tim e incid ence of lu m bar rad icular pain. Pre- sens ory dys unction and mild
ventable and m od i able risk factors inclu d ed sm oking, non-progres sive s egmental motor
obesity and a nu m ber of occu p ational factors. Cau tion m u st weakness and / or re ex change
be used , how ever, since these factors are also associated w ith Severe Marked motor def cit pattern, Yes
a m yriad of other p otentially contribu ting elem ents su ch as characterized by radicular pain
u nhealthy lifestyle choices or low er socioeconom ic statu s. and sensory dys unction with
Furtherm ore, rad icu lar sym ptom s w ere poorly operationally severe or worsening motor
d e ned across stu d ies. def cits
Most cases of rad icu lop athy are self-lim iting, and sym p -
tom s resolve over the cou rse of w eeks to m onths (Casey 2011).
Once acqu ired , sym p tom s associated w ith lu m bar rad icu lop -
athy often resolve w ithin 2–4 w eeks w ith or w ithout treat-
m ent (van Tu ld er et al 2010). The few w hose sym ptom s d o
Anatomy and Pathogenesis of Lumbar
not resolve rep ort higher levels of d isability, loss of fu nction, Radiculopathy
and pain than d o LBP-only ind ivid uals (Good e et al 2011).
Weber (1993) reported that pain com pletely or partially Anatomy
resolves in 60% of the p atients w ithin 12 w eeks of onset, bu t
also id enti ed abou t 30% of the patients w ho still had sym p- A qu ick review of the anatom y of the lu m bar sp ine m ay
tom s after 3 m onths to 1 year. Old er subjects w ith lu m bar im p rove the u nd erstand ing of the pathogenesis of lum bar
stenosis generally have a p oorer overall ou tcom e (Van Boxem rad icu lopathy. The lu m bar spine consists of ve lu m bar ver-
et al 2010). tebrae, ve correspond ing intervertebral d iscs, 12 facet joints
(T12–L1 to L5–S1) and m u ltiple ligam ents, and m u scu lar and
neu rological contribu tions. The d esign of the lu m bar sp ine
Clinical signs and symptoms allow s viscoelastic m otion, energy absorbance and m ove-
m ents w ith six d egrees of freed om . These fu nctions d ep end
There are a nu m ber of signs and sym ptom s associated w ith on m u scu lar, bone and ligam entou s com p onents for m echani-
lu m bar rad icu lop athy. Sym p tom s inclu d e d e nitions of p ain cal tasks (Bogd uk 1997).
af liated along d erm atom es. Derm atom es are d e ned as an Lu m bar vertebrae can be d ivid ed into three sections from
area of skin su p p lied w ith afferent nerve bres by a single anterior to posterior. The anterior p ortion is the vertebral
p osterior sp inal root. Sym ptom s inclu d e pain, nu m bness and bod y, w hich is essentially at on the su perior and inferior
tingling in the legs, and corresp ond ing LBP. The m ost com m on su rfaces and p rovid es contact p oints for the intervertebral
d escriptors for pain includ e period ic bouts of attacks and , d isc (Bogd uk 1997). The m id d le section in the lu m bar spine
w hen present, burning and prickling sensations (Mahn et al includ es the p ed icles, w hich are strong p osterior projections.
2011). Sym ptom s can also be categorized by location and The p osterior portion of the vertebrae inclu d es the inferior
severity. H su et al (2011) d escribe lu m bar rad icu lop athy from and su perior articu lar p rocesses, the spinous p rocess and the
the least severe to the m ost severe (Table 17.1). transverse p rocesses.
Signs inclu d e id enti able objective nd ings af liated w ith The vertebral (sp inal) canal and the intervertebral foram en
m yotom es. Myotom es are d e ned as a grou p of m u scles are su rrou nd ed by a nu m ber of anatom ical structu res. The
innervated by a single sp inal nerve. Signs m ay inclu d e w eak- anterior w all of the vertebral canal is form ed by the p osterior
ness and p otential w asting of m u scles, and d im inished su rfaces of the lu m bar vertebra and the p osterior w all is
re exes, generally along the L4, L5 or m yotom e p attern (Lee- form ed by the lam ina and ligam enta ava of the sam e verte-
Robinson & Lee 2010). Deep tend on re exes are an involun- bra (Bogd u k 1997). Laterally, the facets provid e a partial
tary resp onse, w hich offers an objective assessm ent for barrier. The intervertebral foram en is su rrou nd ed by the d isc
neu rological im p airm ent (Du rrant & Tru e 2002). Loss of d eep anteriorly, the p ed icle inferiorly and sup eriorly, and by the
tend on re exes is u su ally said to be the m ost robu st clinical zygapop hyseal joints p osteriorly (Bogd u k 1997). Structural
nd ing associated w ith lu m bar rad icu lop athy (Marshall & d am age or a space-occu pying lesion in any of these regions
Little 2002). Re ex loss m ay occu r at the Achilles tend on (an m ay increase the risk of d evelop ing lu m bar rad icu lop athy.
S1 p roblem ), at the knee extensors (p rim arily L4 but also L2 Clinical p resentations of lu m bar rad icu lop athy vary
and L3) or less com m only at the ham strings (L4–S2). accord ing to the level of nerve root or roots involved . All

lum bar and sacral sp inal nerve roots originate at the T10 to
L1 vertebral level, w here the sp inal cord end s at the conu s
m ed u llaris. The roots then cou rse d ow n throu gh the sp inal
canal, form ing the cau d a equ ina, u ntil each root exits at its
resp ective intervertebral foram en. All lum bar nerve roots exit
the sp inal canal at the neu ral foram ina below their resp ective
vertebrae. For exam ple, the L5 nerve roots exit via the neural
foram ina at the L5 / S1 d isc sp ace level. Thu s, p osterolateral
d isc herniation of the L3 / L4 d isc u su ally com p resses the L4
nerve root, w hereas a p osterolateral d isc herniation of the
L4 / L5 d isc typ ically com presses the L5 nerve root.
Each sp inal nerve arises from a ventral and a d orsal nerve
root, w hich m eet to form the sp inal nerve in the intervertebral
foram en (Bogd u k 1997). Dorsal root ganglia tend to be located
w ithin the neural foram ina, and not the spinal canal. H ow ever,
at the low lu m bar levels there is a tend ency for d orsal root
ganglia to resid e proxim al to the neural foram ina, w ithin the
sp inal canal (H su et al 2011). Each d orsal root com m unicates
to a d orsal root ganglion that contains the cell bod ies of the
sensory bres of the d orsal roots. The d orsal root transm its
sensory bres w hereas the ventral root p rim arily transm its
m otor bres (Bogd u k 1983). Each spinal nerve exits the
intervertebral foram en w ith d ural stru ctu res, an extension of
the d u ra m ater and arachnoid m ater, w hich is com m only
referred to as the d ural sleeve (Bogd uk 1983). In the interver-
tebral foram en, the am ou nt of space is extrem ely lim ited –
thu s the stru ctu res in this region are p red isp osed to p roblem s
associated w ith sp ace-occu p ying lesions.
Pathogenesis
Lu m bar rad icu lop athy m ay have both m echanical and non-
m echanical origins. Mechanically, lu m bar rad icu lop athy is
m ost com m only associated w ith a lu m bar d isc herniation, bu t
it can also be associated w ith spond ylolisthesis, spond ylolysis
or lu m bar stenosis. N on-m echanical contribu tors m ay be syn-
ovial cysts, infection, tu m ou rs and / or vascu lar abnorm alities
(Govind 2004). Sp ace-invad ing lesions are typically the initial
ingred ients in the d evelopm ent of lum bar rad iculop athy.
In 1934, Mixter and Barr (1934) rst im plicated the role of
a lu m bar d isc herniation as the cau se of several lum bar rad ic-
u lar p ain synd rom es. Their im p licit p rincip le had been a p re-
pond erate assu m p tion that com pression of neu ral elem ents
w as the sole aetiological factor lead ing to the m anifestation of
sym p tom s (DePalm a et al 2005). Subsequ ent know led ge has
show n, how ever, that m echanical in u ence is not the sole
aetiological factor.
H erniated lu m bar d iscs cause m echanical and chem ical
irritation of the nerve roots lead ing to com plaints of rad icu -
lopathy (Bru ggem an & Decker 2011). For lu m bar rad iculopa-
thy to be p resent there m ust be: (1) m echanical stim u lation,
typically throu gh com p ression or tension, and (2) a chem i-
cally m ed iated non-cellu lar in am m atory reaction, w hich
m ight occu r throu gh a d isc ru p tu re. N erve roots su bjected to
su stained com p ression or tension for extend ed p eriod s m ay
becom e sensitized to m echanical stim u lation. Long-term
contribu tions of m echanical / chem ical irritation m ay lead to
vascu lar changes of the nerve inclu d ing focal d em yelina-
tion, intraneu ral oed em a, im p aired m icrocircu lation, Walle-
rian d egeneration and , p otentially, partial axonal d am age
(Govind 2004).
An evidence-based clinical examination 201
There are nd ings supp orting that m echanical stim u lation
is not the only elem ent responsible for lu m bar rad iculop athy.
There is little correlation betw een the severity of lum bar
rad icu lopathy and the size of the space-occupying lesion
(DePalm a et al 2005), speci cally a lu m bar d isc herniation,
w hich is m easu reable u sing m agnetic resonance im aging
(MRI). Large d isc herniations m ay cause no sym ptom s
(H alperin et al 1982; Wiesel et al 1984). In som e cases, ind i-
vid u als have resolved sym p tom s d esp ite the retained p res-
ence of a notable m ass (Govind 2004). Fu rtherm ore, a nu m ber
of stu d ies (Ryd evik et al 1984; Ozaktay et al 1995; N ygaard
et al 1997) have reported the bene t of hyd rocortisone
injections for intervertebral-d isc-associated lum bar rad icu -
lopathy. Conservative treatm ent is often effective, d espite
non-resolu tion of the d isc herniation (Mu llem an et al 2006).
Ind eed , since the early 1950s, a grow ing bod y of evid ence has
su pp orted the clinical u tility of transforam inal, or selective
nerve root, injections of anaesthetic or corticosteroid s.
Essential Aspects of
Differential Diagnosis
Lum bar rad iculopathy is a clinical d iagnosis that uses im aging
for con rm ation. In the m ajority of cases, a herniated d isc is
the offend ing com p ressive d isord er w ith other m echanical
cond itions su ch as sp ond ylolisthesis, sp ond ylolysis or lu m bar
stenosis. Com p eting d iagnoses m ay inclu d e cau d a equ ina
synd rom e (CES), infectiou s cond itions, synovial cysts, tu m ou r
and / or vascu lar abnorm alities (Govind 2004). As a clinical
d iagnosis, im m ed iate im aging is not recom m end ed if the
d iagnosis can be m ad e early. H su et al (2011) recom m end
im m ed iate im aging for rad icu lopathy w ith u rinary retention,
sad d le anaesthesia, bilateral neu rological sym p tom s or signs,
su sp ected neop lasm and su sp ected ep id u ral abscess. If infec-
tion is su sp ected , a lu m bar p u nctu re and cerebrosp inal u id
analysis are w arranted . As w ith all cond itions that originate
at the low back, a strong and d etailed clinical exam ination is
necessary for p rop er treatm ent d ecision m aking.
An Evidence-based Clinical
Examination
Patient history
It is im portant to d eterm ine the m ain com plaint (e.g. nu m b-
ness, w eakness, location of sym p tom s) of the su bject (Wolff
& Levine 2002). Pain and sensory sym ptom s su ch as paraes-
thesia, d ysaesthesia, hyp eraesthesia or anaesthesia that
involve a speci c lu m bar d erm atom e are su ggestive of a d iag-
nosis of lu m bar rad icu lop athy (H su et al 2011). Pain that
w orsens d u ring forw ard -bend ing or straightening of the leg
at the knee m ay be associated w ith lum bar rad icu lop athy.
Pain that w orsens d u ring bow el straining (the Valsalva
m anoeu vre) m ay be associated w ith lu m bar herniated
d isc and subsequent rad icu lopathy. Bow el / blad d er sym p-
tom s (new u rinary retention or incontinence) w ith LBP, bilat-
eral sciatica, sad d le hypo-aesthesia or anaesthesia, m otor
w eakness of the low er extrem ities, im pairm ent of anal,
 202 PART 3 • 17 • Lumbar radiculopathy
bu lbocavernosus, m ed iop lantar and Achilles tend on re exes
bilaterally, rectal and blad d er sphincter d ysfunction as w ell as
sexu al im p otence all su ggest CES, and so d em and im m ed iate
w ork-u p (Orend ácová et al 2001).
Mu scle w eakness is less com m only a com p laint of ind i-
vid u als w ith lu m bar rad icu lop athy. Certainly, w eakness at
sp eci c m u scles w ithin lu m bar m yotom es shou ld also raise
su sp icion for the d iagnosis of lu m bar rad icu lop athy. Com -
p laints of w eakness m ay be sp eci c to fu nctional d if culties
su ch as w alking w ith sm ooth coord ination, d if cu lty in
getting u p from a chair, or d ragging one’s foot d uring the
sw ing p hase of gait.
If pain is a com plaint, a p ain d raw ing is bene cial to estab-
lish a p attern and location of the p ain. A p ain d raw ing allow s
one to d eterm ine w hether the p ain rad iates and , if so, the
d istribu tion of the sym ptom s (H onet & Pu ri 1976). It is also
im p ortant to isolate activities or sp eci c lu m bar m ovem ents
that trigger the concord ant sym p tom s. These nd ings m ay
help d evelop an ed u cational p lan for p ain relief bu t m ay also
p rovid e im p ortant inform ation that can be u sed to d irect
treatm ent.
General nd ings su ch as d u ration of sym p tom s, history of
LBP, history of sm oking and obesity, and a nu m ber of occu -
p ational factors (e.g. heavy w ork load , d isd ain tow ard s su p er-
visor or job, etc.) are risk factors for the d evelop m ent of
lu m bar rad icu lop athy, bu t have also been show n to be
p rognostic factors for d elayed ou tcom e (Cook 2012a, Cook
et al 2013).
Physical examination
Observation
Although a ‘ attened ’ low back posture has been clinically
af liated w ith lu m bar rad icu lop athy, there is no evid ence to
su p p ort this w ithin the literatu re. The p resence of m u scle
w asting along m yotom al patterns is related to long-term ,
severe rad icu lop athy. Those w ith severe lu m bar rad icu lop a-
thy m ay stand w ith their affected lim b in knee exion to
red uce the tension that m ay occur w ith an extend ed knee. On
occasions w here a herniated lu m bar d isc is p resent as the
cau se of rad icu lop athy, the p atient’s p ostu re and gait shou ld
be exam ined for lateral list (H um phreys & Eck 1999). An
acquired scoliosis m ay occu r as w ell as a m echanism to red u ce
nerve tension or foram en com p ression.
Active and passive movements
All planes of m otion of the lu m bar spine shou ld be assessed
w ith active and passive m ovem ents. Resp onses to look for are
any m ovem ents that are associated w ith the p ain / sym ptom s
noted d u ring the history p ortion of the exam . Often, forw ard
tru nk exion is accom p anied by p erip heralization of sym p -
tom s tow ard s the legs or bu ttocks. Rep eated m ovem ent into
exion often w orsens the nature of the sym ptom s. Extension
m ay originally p resent w ith sharp LBP bu t m ay also d im inish
the rad icu lar sym p tom s w ith rep eated m ovem ents.
Neurological testing
N eu rological testing involves exam ination of m otor function,
sensibility changes and d eep tend on re ex m od i cations
along a nerve root d istribu tion. It is im p ortant to note that
absence of rad iating sym ptom s in a d erm atom al d istribu tion
d oes not rule out the presence of nerve root com pression
because this nd ing has low sensitivity (Rhee et al 2007).
A m anu al m u scle test is p erform ed to id entify m inim al
w eakness along a m yotom e d istribu tion to d eterm ine a local
nerve root involvem ent. The follow ing grad ing of 0 to 5 is
recom m end ed : 0 / 5 no m ovem ent, 3 / 5 antigravity and 5 / 5
norm al (H onet & Pu ri 1976). Cook and H eged us (2012) rep ort
the valu es from a nu m ber of stu d ies that have ad d ressed
m anu al m u scle testing and all fou nd higher sp eci city valu es
than sensitivity valu es. Sensibility testing involves assessm ent
of changes in p atient rep orts of sensation along d erm atom es.
Typ ically, testing m easu res are con ned to assessm ent of light
tou ch, w hether or not one can feel a p in-p rick, or d ifferentiate
hot from cold . The grad ing of d eep tend on re exes is from 0
(absent) to 4 (clonu s, very brisk). Deep tend on re exes shou ld
be assessed at both the quad riceps (L2 / L3 / L4) and Achilles
(S1) tend ons. Unfortu nately, there is no reliable re ex to
assess L5, the m ost com m on root com pressed in m echanical
lum bar rad icu lopathy. As w ith m anu al m u scle testing and
sensibility testing, the sensitivity of these tests is low and the
reliability d epend s on the skill level of the clinician perform -
ing the testing.
All neurological testing is based on the assu m ption of the
regularity of d erm atom es and m yotom es. Although lum bar
rad icu lopathy requ ires clinical con rm ation of pain along a
d erm atom e, w eaknesses along m yotom es or som e com bina-
tion of these characteristics, variability exists w ithin su bjects
regard ing m yotom e and d erm atom e patterns (Lee et al 2008).
Areas of overlap of sensory regions are called non-au tonom ou s
zones: areas in w hich nerves m ay su p ply sensation. Au tono-
m ou s zones are areas in w hich ind ivid u al or d ed icated nerve
roots su pply sensation. Foerster (1933) id enti ed the m ost
exclu sive of these: the sole of the foot (S1), the d orsum of the
foot (L5), the m ed ial calf (L4), and the anterior thigh (L2 and
L3). Table 17.2 d e nes the areas of p ain throu gh sensibility
testing, w hereas Table 17.3 d escribes exp ected m u scle w eak-
nesses cap tu red throu gh m yotom al testing.
Provocation tests
Straight leg raise
The straight leg raise (SLR) is the com m on p rovocation test
u sed w hen d ifferentially d iagnosing lu m bar rad icu lop athy.
The SLR w as rst operationally d escribed in 1864 by Dr
Charles Lasègu e, bu t it w as his stu d ent, Forst, w ho u sed the
test to d escribe p resent-d ay rad icu lop athy (Scaia et al 2012).
Although the test is som etim es perform ed variably, the clas-
sical p erform ance involves the p atient lying horizontally in
su p ine p osition on an exam iner ’s table. The knee rem ains
fully extend ed , w hile the exam iner raises the patient’s leg
slow ly off the table (w hile su p p orting the knee w ith one hand
to m aintain fu ll extension). The exam iner continu es to raise
the leg u ntil the m axim u m exion of the hip is reached or
u ntil the p atient rep orts the onset of leg p ain (or sym p tom
p rovocation) in the involved extrem ity (Scaia et al 2012).
Other m ethod s of p erform ance inclu d e m easu rem ent of d if-
ferences in the angle at the hip in w hich the SLR is reached
(in com p arison w ith the other leg).

Table 17.2 De rmatomal re gions o pain or lumbar radiculopathy
Re g ion Ana tomica l d e s crip tion
L1 Symptoms on pres entation generally involve pain,
paraesthes ia, and sens ory loss in the inguinal
region
L2–L3 Sens ation may be reduced over the anterior thigh
L3–L4 Sens ation may be reduced at the medial as pect
o the lower leg at and below the knee
L5 Back pain that radiates down the lateral as pect o
the leg into the oot; s ens ation changes laterally
Table 17.3 Myotomal re gions and f ndings or lumba r ra diculopathy
Re g ion Ana tomica l d e s crip tion
L1 Rarely, minor hip exion weaknes s is present
L2–L3 Some hip exion and knee extension weakness
L3–L4 Knee extens ion weaknes s
L5 Strength can be reduced in oot dors i exion, toe
extens ion, oot inversion and oot evers ion; weaknes s
o leg abduction may also be evident in s evere cas es
In surgical p op ulations the SLR is associated w ith a d isc
herniation in m ost stu d ies and it has d em onstrated high sen-
sitivity (p ooled estim ate 0.92, 95% CI 0.87–0.95) w ith w id ely
varying sp eci city (0.10–1.00, pooled estim ate 0.28, 95% CI
0.18–0.40) (van d er Wind t et al 2010). Becau se w hat consti-
tu tes a p ositive test has varied so signi cantly w ithin the lit-
eratu re, Scaia et al (2012) evalu ated the d iagnostic accu racy of
the p ain-p rovocation-based SLR only and fou nd variations in
sensitivity and sp eci city. If the test is tru ly m ore sensitive
than sp eci c, it shou ld be u sed to ru le ou t lu m bar
rad icu lopathy.
Bowstring sign
The bow string sign is a variation of the SLR in w hich an end
m anoeu vre is u sed to d ifferentiate w hether nerve tension is
the cau se of the sym p tom . The exam iner raises the p atient’s
extend ed leg (at the knee) on the sym ptom atic sid e w ith the
foot fu lly d orsi exed . The leg raise continu es u ntil the patient
reports pain. The bow string sign refers to the relief of rad icu-
lar pain w hen the knee is exed d uring a positive straight leg
raise (H su et al 2011).
Crossed straight leg raise
The crossed SLR test (w hich is also know n as the w ell leg raise
test) is p erform ed in a sim ilar fashion to the SLR test, excep t
that the op p osite lim b to the affected leg is the one that is
raised . The knee rem ains fully extend ed w hile the exam iner
raises the patient’s leg slow ly off the table (w hile su pporting
the knee w ith one hand to m aintain fu ll extension). The exam -
iner continu es to raise the leg until the m axim u m exion of
the hip is reached or u ntil the p atient rep orts the onset of leg
pain (or sym p tom p rovocation) in the involved extrem ity
An evidence-based clinical examination 203
Te s ting Fre q ue ncy
Sens ibility testing near the inguinal region Not common
Sens ibility testing at the anterior thigh above Uncommon
the knee
Sens ibility testing at the medial knee and Common
lower medial leg
Sens ibility testing at the lateral as pect o the Very common
lower leg
Te s ting Fre q ue ncy
Hip exor manual mus cle testing Not common
Hip exor testing in s upine with knee extended Uncommon
Knee extension tes ting in sitting Common
Strength tes ting o ankle dorsi exion and hip Very common
abduction
(Cook & H eged u s 2012). A Cochrane review (van d er
Wind t et al 2010) reported high speci city (p ooled estim ate
0.90, 95%CI 0.85–0.94) w ith consistently low sensitivity
(pooled estim ate 0.28, 95% CI 0.22–0.35), w hich su ggests that
a p ositive nd ing should ru le in the d iagnosis of lu m bar
rad icu lopathy – although a negative nd ing is u nlikely to
ru le it ou t.
Slump sit test
Cook and H eged u s (2012) d escribe the slu m p sit test as
follow s. The patient sits straight w ith the arm s behind the
back, the legs together and the p osterior aspect of the knees
against the ed ge of the treatm ent table. The p atient then
slu m p s as far as p ossible, p rod u cing fu ll tru nk exion; the
exam iner applies rm overpressure into exion to the patient’s
back, being carefu l to keep the sacru m vertical. While m ain-
taining fu ll sp inal exion w ith overp ressu re, the exam iner
either asks the patient to extend the knee or passively extend s
it. The exam iner m oves the foot into d orsi exion w hile m ain-
taining knee extension. N eck exion is then ad d ed to assess
sym p tom s. N eck exion is released to see w hether sym p tom s
abate. A positive test is concord ant rep rod u ction of sym p -
tom s, sensitization and asym m etry nd ings. Althou gh not
nearly as w ell investigated as the SLR, the test ap p ears to have
sim ilar d iagnostic accuracy – d em onstrating greater sensitiv-
ity than speci city.
Femoral nerve tension test
The fem oral nerve tension test is perform ed by placing the
p atient p rone on the table and p assively extend ing the hip
and leg straight up off of the p lane of the table (H su et al
2011). Theoretically, this proced ure places tension on the
 204 PART 3 • 17 • Lumbar radiculopathy
u p p er lu m bar nerve roots (L2, L3 and L4) althou gh it is likely
that the test is p rim arily u sefu l d u ring assessm ent of a far
lateral d isc herniation. Its d iagnostic accu racy has been
stu d ied only once, and w as fou nd to d em onstrate high
sensitivity for extrem e lateral d isc herniation (Cook &
H eged u s 2012).
Outcome measures
Functional outcom e scales are characterized by their proper-
ties of reliability, valid ity and resp onsiveness to clinical
changes. These p rop erties ensu re that d ata are collected and
interp reted in a system atic and rep rod u cible w ay, allow ing
com p arison betw een d ifferent p atient p op u lations (Pietrobon
et al 2002). Fu nctional ou tcom e scales allow clinicians
to d evelop a baseline level of d isability for p atients and help
to qu antify the p atient’s cond ition for better overall
u nd erstand ing.
There are no sp eci c ou tcom es m easu res for lu m bar rad ic-
u lop athy. H ow ever, tw o com m only u sed ou tcom e instru m ent
scales for LBP that are ap p rop riate for lu m bar rad icu lop athy
are the Roland Morris Disability Qu estionnaire (RMQ) and
the Osw estry Disability Ind ex (ODI). Both are consid ered
region-speci c qu estionnaires (each focu ses on one area of the
bod y) and have been w ell d ocu m ented in the literatu re.
The ODI is a m u ltid im ensional scale and has been u sed to
d ocu m ent changes in m u scle activity, pain and psychological
factors and w ork statu s (Taylor et al 1999). The ODI has been
u sed to evalu ate p re- and p ost-su rgical ou tcom es, as w ell as
a benchm ark for d eterm ination of treatm ent effectiveness.
Four versions of the ODI are available in English and nine in
other langu ages. The d ata for the ODI p rovid e both valid ation
and stand ard s for other users and ind icate the pow er of the
instru m ent for d etecting change in sam p le p op u lations (White
& Velozo 2002).
The RMQ is a one-d im ensional scale and is a u sefu l short
fu nctional d isability questionnaire that focu ses on activity
intolerances related to the im p airm ent associated w ith LBP.
The RMQ w as originally d eveloped from the Sickness Im p act
Pro le (SIP) althou gh the RMQ is m u ch sim p ler, qu icker and
easier to u se (Taylor et al 1999). As w ith the ODI, the RMQ
has been u sed in all form s of ou tcom e investigation inclu d ing
research. Like m ost valuable ou tcom e instru m ents, it is par-
ticu larly resp onsive to change in acu te p op u lations w ith LBP
(Bom bard ier 2000).
Althou gh not consid ered a functional ou tcom es m easure,
report of pain is frequ ently used to m easu re change associ-
ated w ith an intervention. Pain severity outlines the self-
reported valu e of ‘how m u ch the p ain hurts’ versu s pain
affect, w hich re ects a m ental status affect associated w ith
continu ou s p ain (Bom bard ier 2000). Tw o exam p les of m eas-
u res associated w ith p ain severity inclu d e the visu al analogu e
scale (VAS) and the nu m eric p ain rate scale (N PRS).
Imaging
There are a num ber of im aging m ethod s u sed to con rm the
p resence of lum bar rad icu lopathy. Becau se lu m bar rad icu -
lop athy is a clinical d iagnosis, a d etailed clinical exam ination
shou ld alw ays occu r p rior to the u se of im aging. Im aging is
su bstantially overu sed for p atients w ith LBP and shou ld be
consid ered only after a 30-d ay period and failu re to resp ond
to conservative care (van Tuld er et al 2006; Chou et al 2009).
Plain f lm radiograph
Plain lm rad iograp hy is u sefu l in id entifying stenosis and
the extensiveness of d egenerative joint d isease (Brow n et al
2009). Rad iographs can show narrow ing in the op enings and ,
on rare occasions, signs of infection, bu t fail to p rovid e an
accu rate view of soft tissue. In ad d ition, they u se ionizing
rad iation that can d am age the bod y and could p otentially
cau se cancer. Consequ ently, p lain rad iograp hs are not recom -
m end ed in the w ork-u p of lu m bar rad icu lop athy u nless there
is a need to evalu ate for infection, fractu re, m alignancy, exten-
siveness of d egenerative changes, d isc sp ace narrow ing or
typ e of p rior su rgery (H su et al 2011).
Magnetic resonance imaging
A m agnetic resonance im age d oes not u se ionizing rad iation,
has good visu alizing cap acities, esp ecially of the soft tissu es,
and is consid ered the m ost u sefu l m ethod for the d etection of
sinister d isord ers su ch as sp inal infections and sp inal m etas-
tases (Wassenaar et al 2012). MRI has d em onstrated superior-
ity in id enti cation of a herniated nucleu s pu lposu s (Wilm ink
2001; Wassenaar et al 2012) and stru ctu ral changes associated
w ith d egeneration su ch as stenosis (Wilm ink 2001). It has also
been id enti ed as u seful for assessing nerve root com pression
(Wassenaar et al 2012).
Wassenaar et al (2012) recently evaluated the d iagnostic
accu racy of MRI for a herniated d isc, nerve root com p ression
and stenosis. For id enti cation of a herniated d isc, MRI has a
p ooled su m m ary estim ate of sensitivity and speci city of 75%
(95% CI 65–83%) and 77% (95% CI 61–88%) respectively. This
p rovid es a positive likelihood ratio of 3.30 (95% CI 1.76–6.21)
and a negative likelihood ratio of 0.33 (95% CI 0.21–0.50). For
the tw o stu d ies that evalu ated nerve root com p ression, the
results d em onstrated a range of sensitivity from 81% to 92%
and a range of speci city from 52% to 100%. For lu m bar ste-
nosis, the MRI show ed high sensitivities of 87% and 96%
cou pled w ith low er speci cities of 68% and 75%. These resu lts
su ggest that errors in d iagnoses are p ossible u sing MRI, esp e-
cially since sp eci city valu es are not very strong.
Computed tomography scan
Com p u ted tom ograp hy (CT) is less com m only u sed in assess-
m ent of the extent of d egeneration of the lu m bar sp ine. A CT
scan can assess osseou s stru ctu res better than either p lain
rad iography or MRI; how ever, CT alone is u nable to visualize
nerve roots, so it is not help fu l in the d irect im aging of a
rad icu lar p rocess (H su et al 2011). For id entifying a lum bar
d isc herniation, CT has a sim ilar pooled sum m ary estim ate of
d iagnostic accu racy w ith a sensitivity of 77.4% and sp eci city
of 73.7%, com pared w ith a reference stand ard of su rgical nd -
ings (van Rijn et al 2012). These values are m arked ly sim ilar
to MRI.
Nerve condition responses
The m ost com m only u sed nerve cond ition responses for
testing lu m bar rad icu lop athy are electrom yograp hy (EMG)

and nerve cond uction stu d ies (N CS). The tw o tests are gener-
ally used in com bination. Both N CS and EMG have higher
d iagnostic u tility for lum bar rad icu lopathy w hen neurologi-
cal w eakness has been present for at least 3 w eeks, w hich is
also w hy these tests are ord ered for ind ivid uals w ith persist-
ent unexplained sym ptom s (H su et al 2011). In ad d ition, the
tests are not nearly as u sefu l if the severity or rad icu lop athy
is con ned to pain or sensory loss only (H su et al 2011).
Tests su ch as EMG and N CS are occasionally u sed to d if-
ferentiate rad icu lopathy for peripheral entrapm ent d isord ers
(Rhee et al 2007). Yet d ifferentiating peripheral neuropathy
and lu m bar rad icu lop athy in patients w ith lu m bar stenosis
u sing EMG and rou tine N CS is clinically challenging, becau se
p erip heral entrap m ent and low back d isord ers m ay be p resent
sim u ltaneou sly in old er p atients (Plastaras 2003). EMG is an
electrical record ing of m uscle activity and involves insertion
of a ne need le into the tested m u scle. In ord er to d iagnose
w ith an EMG, the read ing m u st be abnorm al for tw o or m ore
d ifferent m uscles and peripheral nerves from the sam e nerve
root (Du rrant & Tru e 2002). Tw o record ings are taken, one at
rest and one d u ring a contraction. A norm al resp onse involves
only brief EMG activity d u ring need le insertion, then no activ-
ity w hen the m uscle is at rest. Du ring contraction, m otor u nit
action p otentials that re ect electrical activity w ithin the
m u scle ap p ear on the record ing screen, w ith corresp ond ing
increases as m ore m uscle bres are solicited .
A nerve cond u ction velocity (N CV) test consists of stim u la-
tion of the nerve and record ing of the evoked p otential, either
from the m u scles or from the nerve (to stu d y the sensory
resp onse). N CV assesses the extent of axonal loss of large
m yelinated nerve bres (Cook et al 2009). The test involves
m easu rem ent of the tim e d elay betw een stim u lation and
resp onse at tw o stim u lation sites w ith a calcu lation of the
d istance of the sites (Sm ith 1979).
The tw o late responses m ost com m only analysed are the
H -re ex and the F-w ave. The H -re ex (H offm ann’s re ex)
assesses an afferent 1a sensory nerve and an efferent alpha
m otor nerve. H -re ex testing tend s to be m ore sp eci c than
sensitive (Cho et al 2010). The Am erican Association of N eu-
rom u scular and Electrod iagnostic Med icine conclu d ed that
p erip heral lim b EMG H -re ex testing is recom m end ed for
d iagnosis of lu m bar rad icu lopathy (H su et al 2011). The
F-w ave analyses m otor nerves only and is often norm al in
p atients w ho have susp ected rad icu lopathy. F-w ave stud ies
have d em onstrated p oor sensitivity (Cho et al 2010) and
because of this shou ld never be used in isolation (Rhee
et al 2007).
Current Best Evidence with
Regard to Treatment
Conservative approaches
A bou t of conservative care is recom m end ed p rior to interven-
tions su ch as su rgery or injection therap y. Typ ically, d u ring
the acu te stage of lu m bar rad icu lop athy the treatm ent shou ld
aim at red u cing in am m ation and p ain, patient ed u cation and
avoid ance of increasing any neurological d e cits. Treatm ent
for in am m ation and p ain m ay inclu d e ice, heat, non-steroid al
anti-in am m atory d ru gs (N SAIDs), analgesics, rest and
Current best evidence with regard to treatment  205
traction. A com bination of ap p roaches is generally p rovid ed
in clinical practice.
H ahne et al (2010) evalu ated the bene t of m ultiple treat-
m ent op tions associated w ith lu m bar rad icu lop athy. Within
their review, they id enti ed that there is m od erate evid ence
that stabilization exercises are better than no treatm ent at
short-term follow -u p . Kenned y and N oh (2011) also recom -
m end ed core stabilization exercises to correct p ossible altera-
tions to sp ine biom echanics as a resu lt of lu m bosacral
rad icu lop athy. Prior to these tw o stu d ies, Mu rp hy et al (2009)
had fou nd that lu m bar stabilization exercises w ere bene cial
w hen inclu d ed as part of a m u ltim od al treatm ent approach
for ind ivid u als w ith lu m bar rad iculop athy second ary to a
herniated d isc as con rm ed by MRI. In that stu d y, the need
for lu m bar stabilization exercises w as based on the result of
three tests: (1) the hip extension test, (2) the segm ental insta-
bility test and (3) the active SLR test.
H ahne et al (2010) also reported that m anipu lation w as
better than sham m anip ulation at short-term and interm ed iate-
term follow -u p for p eop le w ith acu te lu m bar d isc herniation
and rad icu lopathy w ho had an intact annulu s. The m anip ula-
tion techniqu es u sed in the three trials w ere d ifferent bu t
consisted of versions of soft tissu e m anip u lation or m assage
along w ith high-velocity rotational thru sts (Fig. 17.1). A high-
velocity, rotational lu m bar sp ine thru st is theorized to isolate
a given segm ent to im prove m ovem ent and to relieve p ain.
The actu al bene ts beyond the clinical effects reported , w hich
are associated w ith this techniqu e for p atients w ith rad icu-
lop athy, are only specu lative.
The au thors also reported that no d ifference exists betw een
traction, laser and u ltrasou nd at short- and interm ed iate-term
follow -up (H ahne et al 2010). One stu d y includ ed in the
review p rovid ed m od erate evid ence that the ad d ition of
m echanical traction to electrotherap y m ethod s (hot p ack,
u ltrasou nd and d iad ynam ic cu rrents) and m ed ication (ibu -
p rofen, m ep henoxalone and p aracetam ol) red u ce the risk of
rad icu lop athy at short-term follow -u p, bu t provid e no ad d i-
tional short-term bene t for p ain intensity or risk of having
LBP (Oztu rk et al 2006). A Cochrane system atic review assess-
ing the use of traction for treatm ent of LBP w ith and w ithou t
Figure 17.1 A high-velocity, rotational lumbar spine thrust manipulation.
 206 PART 3 • 17 •
sciatica conclu d ed that, w hereas there w ere a few low -qu ality
p ap ers rep orting p ositive resu lts, the m ajority of cu rrent lit-
eratu re suggests that traction m ay not be effective and that
u sing traction as a stand -alone treatm ent is not su p p orted by
the cu rrent evid ence (Clarke et al 2007).
Traction can be p erform ed u sing d ifferent m ethod s, inclu d -
ing m echanically ap p lied ap p roaches and m anu ally ap p lied
ap proaches by either the treating physical therapist or the
p atient (au totraction) (Clarke et al 2007; H ahne et al 2010).
Whereas m ost of the stu d ies includ ed in the system atic review
by Clarke et al (2007) assessed the effect of m echanical trac-
tion, there w ere a nu m ber of stu d ies d escribing a w id e variety
of au totraction techniqu es and tw o stu d ies that u sed m anu al
traction by the clinician. These last tw o stu d ies u sed a su p ine
m ethod d u ring w hich a m anu al traction force w as p rod u ced
by the clinician’s bod y and transferred to the p atient through
a harness xed arou nd the p atient, w hich then p rovid ed the
d istracting force (Clarke et al 2007). N either of these tw o
stu d ies w as able to d em onstrate a signi cant d ifference
betw een this technique and other traction techniques, or a
com p arison intervention of isom etric exercises (Clarke et al
2007). Cook (2012b) ad vocates the u se of m anu al traction tech-
niqu es in ord er to d irect the d istraction force m ore easily to
the ap p rop riate region. These m anu al traction m ethod s
m ay inclu d e sid e-lying gap p ing p roced u res d esigned to
d ecom press the targeted segm ent (Fig. 17.2) and su pine
m ethod s, w hich p rovid e a gentler d ecom p ression p roced u re
(Cook 2012b).
Fritz et al (2007) id enti ed a su bgrou p of p atients w ho are
m ore likely to bene t from m echanical traction. The baseline
characteristics associated w ith greater im p rovem ent w ith
m echanical traction w ere: p resence of leg sym p tom s, signs of
nerve root com p ression and either p erip heralization w ith
extension m ovem ents or a positive crossed straight leg raise
(Fritz et al 2007). Mechanical traction w as com bined w ith
extension-oriented treatm ent and com pared w ith extension-
oriented treatm ent alone. Mechanical traction w as ad m inis-
tered for a 2-w eek period w hile the extension-oriented
treatm ent w as continued for an ad d itional 4 w eeks. At the
2-w eek assessm ent, p atients in the m echanical traction grou p
d em onstrated signi cantly m ore im provem ent than those
Figure 17.2 Side-lying manual traction technique.
Lumbar radiculopathy
receiving extension-oriented treatm ent alone. At the 6-w eek
follow -u p, how ever, there w as no signi cant d ifference
betw een the tw o grou ps – both d em onstrating signi cant
im p rovem ent over baseline m easu rem ents (Fritz et al 2007).
Mu ch of the available research assessing the u tility of trac-
tion seem s to su ffer from p oor research d esign in general,
w hich can lead to confusion over the effectiveness of the tech-
niqu e (Krau se et al 2000). Many of the stud ies includ ed in the
system atic review by Clarke et al (2007) u sed low -d ose trac-
tion as a sham intervention, althou gh it has been show n that
a sim ilar low -d ose sham traction force show ed an im p rove-
m ent of 50% in a popu lation w ith non-sp eci c LBP (Beu rskens
et al 1997). An effect of this size show n by a com parative sham
intervention m ay m inim ize the stated effect of the original
intervention (Krau se et al 2000).
Mechanically oriented lu m bar rad icu lop athy m ay bene t
from various lu m bar-related m ovem ents. Du ring the m echan-
ical portion of the assessm ent, p articu lar d irections of lum bar
m ovem ent m ay be id enti ed as: (1) im proving sym p tom s
(centralizing), (2) m aking sym p tom s w orse (p eripheralizing)
or (3) no change in sym p tom s. Centralization is characterized
by sym p tom s that are progressively abolished in a d istal-to-
proxim al p attern d u ring end -range lu m bar m ovem ent tests
(McKenzie & May 2003). If a patient’s sym ptom s are found to
centralize u p on end -range m ovem ents d u ring exam ination,
these end -range load ing m ovem ents, w hich are com m only
referred to as d irectional p reference, m ay be u sed as treatm ent
op tions (McKenzie & May 2003, see also Ch 7). Several stu d ies
have rep orted som e su bjects exp eriencing an increase in local-
ized LBP w hile concurrently experiencing centralization of
rad iating sym p tom s; this d oes not p reclud e the possibility of
further centralization from continu ed end -range exercises and
shou ld not ru le ou t rep eated end -range exercises as a treat-
m ent op tion (Kopp et al 1986; Mu rp hy et al 2009).
The m ost com m on m ovem ent d irections for centralization
are end -range extension, right or left sid e glid e, and exion
(Mu rphy et al 2009). Betw een 42% and 61% of p atients w ith
lum bar rad icu lopathy second ary to a herniated d isc w ere
fou nd to have sym p tom s that centralize w ith end -range
m ovem ents (Kopp et al 1986; Alexand er et al 1992; Mu rp hy
et al 2009). Only one of these stu d ies (Mu rphy et al 2009)
assessed d irections other than extension as a possible sou rce
of centralization w hereas the others (Kopp et al 1986;
Alexand er et al 1992) assessed only centralization as a result
of extension. If all m ovem ent d irections w ere assessed as
p otential centralizing m ovem ents then the p ercentage of
p atients w ho centralized w ith p assive end -range m ovem ents
m ight be closer to the u p p er range rep orted earlier (Wetzel &
Donelson 2003; Murphy et al 2009). Repeated end -range
m ovem ents in lying or stand ing have show n to be m ore ben-
e cial in patients w ith acu te rad icu lopathy second ary to d isc
herniation w ho also have an intact annu lu s (Kop p et al 1986).
A recent stu d y by Werneke et al (2008) in patients w ith rad iat-
ing LBP su ggested that sym ptom s w ere m ore likely to central-
ize for patients w ith acu te sym p tom s (less than 21 d ays
d u ration) and for patients aged betw een 18 and 44 years.
Ad d itionally, centralization ap pears m ore likely to occur in
p atients w ho have less d istally rad iating sym p tom s, bu t the
tim e to com p lete centralization of sym p tom s d id not correlate
w ith rad iating d istance (Su fka et al 1998). Patients w ho have
centralization of p ain as a resu lt of end -range m ovem ents in
any d irection have been show n to be associated w ith m ore
 Current best evidence with regard to treatment  207

favourable short-term and long-term ou tcom es than those choice for lu m bar rad icu lop athy has increased signi cantly
w ho d o not centralize (Su fka et al 1998; Werneke et al 2008; over the last several years. The m ost com m only u sed su rgical
Mu rp hy et al 2009). In contrast, those w ho have perip herali- ap proaches involve a form of d ecom pression su rgery, or
zation of sym p tom s, w hich occu rs in only a sm all p ortion of fusion and d ecom pression.
the p op u lation, ap p ear to be associated w ith a m ore negative The p osterior lu m bar d iscectom y, hem ilam inotom y and
ou tcom e (Mu rphy et al 2009). foram inotom y w as the m ost com m only perform ed d ecom -
p ressive proced u re of the lu m bar sp ine in the early 2000s
(Storm et al 2002), bu t the u se of spinal fu sion in com bination
Injection w ith d ecom pression, sp eci cally com plex spinal fu sion, has
increased d ram atically in recent years. Betw een 1998 and
Ep id u ral steroid injections are frequ ently u sed d u ring the
2008, the annu al num ber of spinal fusion d ischarges for treat-
treatm ent of lu m bar rad icu lop athy. Desp ite the con icting
m ent of lu m bar rad icu lop athy or other related cond itions
evid ence of their bene t, epid u ral steroid injections for old er
increased 2.4-fold , or by app roxim ately 137% (Rajaee et al
Am ericans have increased d ram atically over the last several
2012). The num ber of rep orted d ischarges w ith spinal fu sion
years (Argoff & Sim s-O’N eill 2009). In 1999, nearly 50 m illion
increased corresp ond ingly from 174 223 in 1998 to 413 171 in
d ollars w ere spent on lu m bar epid u ral steroid injections.
2008 (Rajaee et al 2012). For old er ad ults w ith stenosis, overall
The prem ise behind epid ural steroid injections is based on
su rgical rates d eclined slightly betw een 2002 and 2007, bu t the
the recognition that in am m atory m ed iators affect the nerve
rate of com plex fu sion p roced u res increased 15-fold , from 1.3
root d uring lu m bar rad icu lopathy and that steroid s d ecrease
to 19.9 per 100 000 bene ciaries. Com p lex fu sions harbou r
sw elling in the localized , targeted region. The rst rep orted
greater risks w ith surgery – 5.6% experiencing life-threatening
treatm ent w as in 1952 (DePalm a et al 2005). A year later,
com p lications versu s 2.3% w ith d ecom pression alone (Deyo
Lievre et al p u blished the resu lts of a series of p atients treated
et al 2010). Certainly, w ith risks such as these, careful patient
w ith perirad icular steroid injections (DePalm a et al 2005).
selection is the key to su ccessfu l su rgical intervention.
There are tw o p rim ary form s of ep id u ral steroid injections,
Determ ining w ho is a surgical cand id ate for lum bar rad icu-
w hich u nfortu nately are often consid ered universal. The
lop athy is no easy task. Generally, patients w ith lum bar rad ic-
interlam inar (or translam inar) ep id u ral injection involves
u lop athy also p resent w ith a variety of com orbid ities as w ell
injectant targeted betw een the lam ina of the offend ing site. It
as m isconcep tions about the bene t and risks associated w ith
requ ires relatively large volu m es of the injectant for d eliver-
su rgery. In ad d ition, becau se lu m bar rad icu lop athy often has
ing steroid s to the target site; this has the risk of an extra-
a favourable p rognosis, id enti cation of those w ith tru e neu -
epid ural and intravascular need le placem ent. Transforam inal
rological problem s that have not respond ed to conservative
epid ural injections are targeted near the nerve root in the
treatm ent is w arranted . It is cru cial to d eterm ine the extent of
intervertebral foram en. A transforam inal ep id u ral steroid
the d isability and this is best id enti ed throu gh p atient-rep ort
injection u ses a sm all volu m e of local anaesthetic to anaesthe-
m easu res or throu gh a carefu l p atient history. Im aging m ay
tize the sp inal nerve, bu t it w ill also p artially anaesthetize the
be u sefu l to help verify the presence or absence of a pathologi-
d u ra, the posterior longitud inal ligam ent, the intervertebral
cal cond ition and the offend ing anatom ical location (Storm
d isc and the facet joint. A u oroscopy-guid ed approach is
et al 2002).
com m only u sed to im p rove the location of the treatm ent.
The L4–L5 and L5–S1 levels are responsible for greater than
The International Sp inal Injection Society (ISIS) recom -
95% of lum bar d isc herniations, w ith L5–S1 herniations occu r-
m end s the u tilization of the nom enclatu re based on the p recise
ring slightly m ore frequ ently. Much less com m on are hernia-
anatom ical d escrip tors – that is, transforam inal and interlam i-
tions at the L1–L2, L2–L3 and L3–L4 levels, w hich account for
nar for the d escrip tion of ep id u ral injections (Su ng 2006). As
less than 5% of herniations (Patten 1995). Surgery m u st be
w ith all non-conservative treatm ents, there are risks. These
consid ered im m ed iately if CES is su sp ected as this cond ition
risks inclu d e a sm all risk of infection, d ural pu ncture (w hich
is a spinal em ergency; CES occu rs in ap proxim ately 2%
can lead to head aches), bleed ing and , althou gh extrem ely
of cases of herniated lu m bar d iscs (Gitelm an et al 2008).
rare, nerve d am age.
In this synd rom e, patients experience a com bination of
There is som e evid ence that transforam inal injections are
sad d le anaesthesia, abnorm al low er extrem ity re exes, and
su p erior to p lacebo injections and even stronger evid ence that
neu rogenic bow el or blad d er sym p tom s (Bru ggem an &
these injections shou ld be u sed as su rgery-sp aring interven-
Decker 2011).
tions. Strong evid ence exists for interlam inar ep id u ral steroid
Potential su rgical cand id ates need to know the risk associ-
injection for short-term relief and lim ited evid ence for long-
ated w ith su rgery as w ell. Life-threatening risks are esp ecially
term relief in m anagem ent of lu m bar rad icu lop athy (Bosw ell
p revalent w ith com p lex sp inal fu sion; how ever, other risks
et al 2007). There is also good evid ence that transforam inal
su ch as soft tissue infection (0.4–2%), m eningitis, d iscitis,
injections are m ore effective than interlam inar injections
osteom yelitis, bleed ing, arachnoid itis, nerve root inju ry
(Roberts et al 2009). Despite these positive nd ings, injection
(< 1%), perm anent num bness, w eakness or paralysis, blad d er
therap y is not recom m end ed by m ost gu id elines for treatm ent
or bow el d ysfu nction, sexu al d ysfu nction, d u ral tears w ith
of LBP (Koes et al 2010).
cerebrosp inal u id leak and p seu d om eningocoele form ation,
d eep venou s throm bosis, d elayed sp inal instability and fusion
Surgical approaches failu re and p seu d oarthrosis form ation, and anaesthetic risks
(inclu d ing d eath) are all possible (Abram ovitz 1993). There is
Su rgical ap p roaches are aim ed at rem oving the offend ing no su ch thing as ‘m inor ’ lu m bar sp ine su rgery, and therefore
com p ressive stru ctu res from the nerve (Frank 1993). In the the risks m u st alw ays be w eighed against the p otential
United States, the increase in spinal surgery as a treatm ent of rew ard s.
 208 PART 3 • 17 • Lumbar radiculopathy
So far, the rew ard s associated w ith su rgery (in the absence
of CES) ap p ear to be short term only. For rad icu lop athy w ith
herniated lu m bar d isc, there is good evid ence that stand ard
op en d iscectom y and m icrod iscectom y are m od erately su p e-
rior to non-surgical therap y (a non-stand ard ized conservative
ap proach) for im p rovem ent in p ain and fu nction through 2 to
3 m onths. For sym p tom atic sp inal stenosis w ith or w ithou t
d egenerative spond ylolisthesis, there is good evid ence that
d ecom pressive surgery is m od erately su perior to non-su rgical
therap y (a non-stand ard ized conservative ap p roach) throu gh
1 to 2 years. On average, both grou p s – conservative and
surgical – exp erience im provem ent w ith or w ithou t su rgery,
and the bene ts associated w ith su rgery d ecrease w ith long-
term follow -u p (Chou et al 2009).
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 PART 3 •  Lumbar Spine Pain Syndromes
Lumbar Spine Instability
18  Chapter 
Brya n S . De n n is o n , M ic h a e l H. Le a l
CHAP TER CONTENTS
Historical appreciation of low back pain  210
Guideline adherence and practice variability  211
Diagnostic challenge of low back pain  211
The treatment-based classi cation system  212
Research investigating the treatment-based classi cation system  213
The treatment-based classi cation system: focus on the   as a w hole to change its ap p roach to m anaging this cond ition
stabilization subgroup  213
Clinical management of lumbar spine instability  214
First level of classi cation and the patient interview  214
Self-reported symptoms and clinician pattern recognition  214
Second level of classi cation: physical examination  215
Evidence for physical examination  ndings  216
Sequencing of the physical examination  216
Proposed clinical examination for lumbar spine instability  216
Screening tests  216
Con rmatory tests  217
Clinical prediction rules in the treatment-based  
classi cation system  218
Conclusion  219
Historical Appreciation of
Low Back Pain
The d iagnosis and m anagem ent o low back pain has a ected
the w orld or centu ries – seem ingly reaching back to the
beginning o tim e itsel . The Ed w in Sm ith papyru s is the
old est su rviving m anu script, d ating back to at least the 17th
centu ry bc , d escribing scienti c observation o signs and
sym p tom s o sp ine inju ries, classi cations o sp ine inju ries,
hyp otheses on m echanism s o sp ine inju ries and su ggested
treatm ent or these inju ries (van Mid d end orp et al 2010). It is
interesting to observe, w hen looking at the d escrip tions o the
sp ine inju ries rom the Ed w in Sm ith p ap yru s, how am iliar
the ancient sp ine inju ries are to m od ern-d ay sp ine inju ries
encountered in p rim ary or em ergency care tod ay. In light o
this, the great researcher and p hysician, Gord on Wad d ell,
qu estioned w hether anything has really changed , over thou -
sand s o years, w ith regard s to back p ain (Wad d ell 1995). H e
d id acknow led ge the progressive change in the understanding
and management o low back p ain that has occu rred over the
years. Bu t this progress is su spect w ith regard s to any appreci-
able inf uence ou r cu rrent und erstand ing and m anagem ent
have had on improving the prevalence or d isastrou s e ects o
low back p ain (Martin et al 2008). In 1995, Wad d ell classically
noted that ‘Low back p ain is a tw entieth-centu ry health care
d isaster.’ H e w ent on to encou rage the healthcare com m u nity
(Wad d ell 1995). N ine years later, in 2004, the ultim ate m an-
agem ent o low back pain had not im proved . Wad d ell once
again recognized the ongoing d ilem m a o low back pain and
the lack o im p rovem ent in m anaging this cond ition. H e
noted ‘Back pain w as a 20th-centu ry m ed ical d isaster and the
legacy reverberates into the new m illenniu m ’ (Wad d ell 2004).
Moving ahead into the ‘new m illenniu m ’, low back p ain con-
tinu es to p lagu e the m od ern w orld as Wad d ell noted . The
Global Bu rd en o Disease (GBD) Stu d y 2010 sou ght to inves-
tigate the w orld w id e e ects o low back p ain. For the stu d y,
low back p ain w as operationally d e ned as ollow s: ‘Activity-
lim iting low back p ain (+ / − pain re erred into one or both
low er lim bs) that lasts or at least 1 d ay. The ‘low back’ is
d e ned as the ‘area on the posterior aspect o the bod y rom
the low er m argin o the tw el th ribs to the low er glu teal old ’
(H oy et al 2010). The resu lts o the GBD stu d y, using the
op erational d e nition above, conclu d ed that low back p ain is
now recognized as the global ‘lead ing cau se o d isability in
both d evelop ed and d eveloping countries’, tru m ping 290
other d iseases and inju ries that w ere evalu ated in the GBD
stu d y (Buchbind er et al 2013). In ad d ition to its rise to the
top billing as the ‘lead ing cause o d isability’ in 2010, low
back pain also ju m ped rom the 12th-ranking global contribu -
tor to d isability-ad ju sted li e years (DALYs) in 1990, to the
7th-ranking global contribu tor to DALYs in 2010 (http:/ /
w w w.healthm etricsand evalu ation.org/ gbd / visu alization s/
gbd -arrow -d iagram) (Table 18.1). Ad d ing to the societal
im p acts o ongoing, bu t increasing, d isability and increasing
p revalence, there has also been an increasing econom ic bu rd en
associated w ith low back pain as costs associated w ith m anag-
ing the cond ition have risen. In the United States alone there
w as a 65% increase in costs associated w ith m anaging sp inal
p ain (neck and low back) rom 1997 to 2005. The estim ated
increase in costs or neck and low back p ain in 2005 alone
totalled 85.9 billion d ollars. This w as a su bstantial increase in
costs rom 1984 and 1994 (Martin et al 2008, Fig. 18.1).
 Diagnostic challenge of low back pain  211

Table 18.1 Top global rankings  o  dis e a s e s  a nd injurie s  with  Table 18.2 Barrie rs  to guide line  adhe re nce
re s pe ct to dis ability-adjus te d li e  ye ars
Cabana et al Competing practice demands
1990 2010 (1999) The limited time to apply an increas ing
number of guideline recommendations
1. Lower res piratory infections 1. Is chaemic heart disease
Deyo (2011) Clinician unawareness of newer guidelines
2. Diarrhoeal diseas es 2. Lower respiratory infections
and evidence
3. Preterm birth complications 3. Stroke A paucity of de nitive evidence for or agains t
4. Ischaemic heart dis eas e 4. Diarrhoeal dis eases certain practices
Emergence of local practice styles
5. Stroke 5. HIV/ AIDS Medicolegal concerns
6. COPD 6. Malaria Inconsis tent, s ometimes contradictory, expert
recommendations
7. Malaria 7. Lo w bac k pain
8. Tuberculosis 8. Preterm birth complications
9. Protein-energy malnutrition 9. COPD (Osterberg & Blaschke 2005). This m yopic view o ad herence,
10. Neonatal encephalopathy 10. Road injury ocusing only on the p atient’s role, has changed d u e to the
increasing use o m ed ical clinical p ractice guid elines in the
11. Road injury 11. Neonatal encephalopathy 1990s. The increasing u se o these gu id elines in m ed icine has
12. Lo w bac k pain 12. Protein-energy malnutrition broad ened the d iscu ssion o ad herence, m oving beyond
Table adapted from IHMW webs ite http://www.healthmetricsandevaluation.org/. narrow ly ocu sed analyses o p atient behaviou r to inclu d e
Note that, in 2010, the rankings are s hown only for the corres ponding healthcare p rovid er behaviou r (Cabana & Kiyoshi-Teo 2010).
dis eas es / injuries noted in 1990. COPD = chronic obs tructive pulmonary dis eas e. Discussions on ad herence now app reciate the collaborative
interaction betw een patients and healthcare provid ers. Analy-
sis o healthcare p rovid er ad herence to p ractice gu id elines in
$100 the clinical setting has revealed that healthcare p rovid ers w ere
$90 $85.9 not m u ch better than p atients w hen it cam e to ad herence
$80 (Cabana 2010). Speci cally to low back pain, physicians
$70 (Bishop & Wing 2006; Feu erstein et al 2006; William s et al
$60 2010; Ivanova et al 2011) and physical therap ists (Bekkering
$50 et al 2005; Delitto 2005; Strand et al 2005; Sw inkels et al
$40 $33.6 2005; Feuerstein et al 2006; Fritz et al 2007b) alike exhibit
$30 d e ciencies in ad hering to low back clinical p ractice gu id e-
$20 $12.9 lines. The lack o com pliance w ith clinical practice guid elines
$10 p rovid es am p le op p ortu nity or the p ossibility o variation
$0 in clinical practice (Deyo 1986) and resu ltant ad verse risks
1984 1994 2005 (William s et al 2010). It is recognized that variability in prac-
tice is associated w ith su bop tim al ou tcom es (Feuerstein et al
Figure 18.1 Spine-related medical expenditures. (Adapted from Martin et al
2008.) Note that the data are expressed in billions of dollars. 2006). Conversely, the u se o clinical p ractice gu id elines is
associated w ith sup erior ou tcom es and im p roved cost m an-
agem ent (McGu irk et al 2001; Brennan et al 2006; Fritz et al
Disapp ointingly, increased costs, ad vances in u nd erstand ing 2007b, 2008; Cabana 2010). The pu blication o practice
and technology associated w ith m anaging low back p ain have gu id elines is not su cient to ensure clinical incorp oration
not resu lted in equ al d ecreases in rep orted low -back-related (Gross et al 2001). Multi actorial challenges exist in im ple-
d isability over tim e (Martin et al 2008; Deyo 2011). m enting clinical p ractice gu id elines into cu rrent p ractice
(Table 18.2).

Guideline Adherence and

Practice Variability
Recognizing the ongoing challenge o low back p ain on a
global scale, physical therapists have d irected research e orts
to d irect care m ore e ectively and accu rately to ind ivid u als
w ith low back pain. One o the hypothesized challenges
to e ciently m anaging low back p ain is the p resence o p rac-
tice variability and a lack o ad herence to clinical p ractice
guid elines am ong healthcare provid ers. Trad itionally, the
patient w as the centre o the ad herence d iscu ssion i su bop ti-
m al ou tcom es w ere associated w ith p atient non-ad herence
to the p rovid er ’s su ggested m anagem ent recom m end ations
Diagnostic Challenge of
Low Back Pain
In an e ort to m axim ize outcom es and red u ce costs associated
w ith the global challenge o low back pain, p hysical therapists
have m ad e e orts to d ecrease p ractice variability by establish-
ing evalu ation and treatm ent system gu id elines that can
better in orm and gu id e physical therapy m anagem ent strate-
gies or low back pain. One such e ort has been the d evelop -
m ent o a treatm ent-based classi cation system or low back
p ain (Delitto et al 1995). The basis or the d evelopm ent o the
treatm ent-based classi cation system w as the recognized
 212 PART 3 • 18 •  Lumbar spine instability
ailu re o a d iagnostic, pathoanatom ical m od el to explain w ith
accuracy and su ccess ully treat ind ivid u als w ith low back
p ain. The d iagnostic enigm a o low back pain d rove the d evel-
op m ent o the treatm ent-based classi cation system s. Du e to
the com p lex natu re o low back sym p tom s, p athoanatom i-
cally based clinical exam ination and d iagnostic testing had
not p roven u se u l m eans or d eterm ining the exact cau se o
low -back-related sym p tom s (White & Gord on 1982; Cook &
H eged u s 2011). It has been su ggested that betw een 85% and
95% o p atients w ith low back pain cannot be given an exact
d iagnosis (White & Gord on 1982; Wad d ell 2005). To com pli-
cate the d iagnostic p rocess or low back p ain u rther, it is
recognized that low back pain rarely occu rs in isolation
(H agen et al 2006; H artvigsen et al 2013). In act, p atients
p resenting w ith a com plaint o prim ary m uscu loskeletal pain
in a sp eci c region also rep ort com orbid ities and ad d itional
m u scu loskeletal p ain in other regions o their bod y. This is
especially tru e or patients w ith low back p ain (N atvig et al
2001; H agen et al 2006). The presence o w id espread pain
p henom enon ad d s to the clinical challenge o d eterm ining an
exact d iagnosis or patients presenting w ith low back pain
and p resents p rognostic im plications w hich challenge the
p atient’s ou tcom e (Cro t 2009). Low back pain research to
d ate has largely ocu sed on narrow ly d e ned inclu sion crite-
ria ocusing, at best, on regionally d e ned sym p tom s o low
back pain or single pain sites (i.e. low back region w ith or
w ithou t re erral into one or both o the extrem ities). Very little
attention, beyond p rognostic im plications, is given to consid -
ering the potential role o the presence o m u ltisite m u scu-
loskeletal p ain and / or the p resence o other p atient
com orbid ities. These issu es have con ou nd ed the d iagnostic
p rocess or p atients w ith com p laints o low back pain. When
seeking care, p atients w ith low back p ain p resent to a health-
care p rovid er w ith sym p tom s that are assessed in light o
p red e ned d iagnoses (Tschu d i-Mad sen et al 2011). When no
p red e ned d iagnosis m atches the sym p tom p resentation(s),
these p atients are given the label o m echanical (White &
Gord on 1982; Deyo 1986) or non-speci c low back pain (Coste
et al 1991). N on-speci c low back pain has been d e ned as
‘back pain com p laints occu rring w ithou t id enti able sp eci c
anatom ical or neu ro-physiological causative actors’ by the
International Association or the Stu d y o Pain Task Force on
Pain in the Workp lace in 1995 (Zu sm an 1997). This d e nition
d escribes sym ptom s o low back pain, or d escribes low back
p ain in term s o a synd rom e, bu t is not in and o itsel a d iag-
nosis (Ced raschi et al 1999). Basically, w hat has been given
the d iagnostic label ‘non-sp eci c low back p ain’ is nothing
m ore than the d eterm ination that no other d iagnoses are
being consid ered (Frank 1993). Bu t this d iagnostic label has
d one nothing to assist healthcare p rovid ers in e ectively and
e ciently m anaging low back pain. Speci cally in physical
therap y p ractice, accu rate d iagnoses are u se u l at tim es in
clinical p ractice to assist w ith intervention d ecision m aking
w hen a speci c d iagnosis is not able to be con d ently d eter-
m ined , and the ability to d irect sp eci c care is a challenge or
the p hysical therap ist. As su ch clinicians are le t to rely on the
p resence o signs, sym ptom s and p attern recognition to begin
generating hypotheses o how best to d irect care (Delitto et al
1995). The d evelopm ent o the treatm ent-based classi cation
system w as an attem p t to im p rove the assessm ent and m an-
agem ent o ind ivid u als w ith low back p ain. To this end , the
treatm ent-based classi cation system sou ght to id enti y, a
p riori, p atients w ith clinical p resentations w ho w ill resp ond
to targeted interventions w ithou t having to rely on p athoana-
tom ical d iagnostic labels.
N ot all patients w ith low back p ain w ill resp ond to the
sam e typ e o intervention; thu s su bgrou p ing ind ivid u als w ith
low back pain m ay resu lt in m ore e cient and optim al treat-
m ent strategies (Kent & Keating 2004). To the practising clini-
cian, this ap p roach seem s glaringly obviou s. Bu t low back
p ain research has not trad itionally taken this ap p roach w hen
investigating low back pain m anagem ent strategies. Rather, it
has view ed low back p ain as a hom ogeneou s entity and
d irected treatm ent tow ard s this entity as a w hole (Malm ivaara
et al 1995). The stud y results have been a w ashou t, w ith no
urther insight gained into progressing the m anagem ent o
p atients w ith low back p ain (Rid d le 1998). The treatm ent-
based classi cation system prop osed by Delitto et al (1995)
view ed low back p ain, in contrast, as a heterogeneou s entity
and sought to id enti y unique hom ogeneou s su bgrou p s
w ithin the low back pain population. These hom ogeneou s
su bgrou p s w ou ld then receive targeted interventions.
The Treatment-Based
Classi cation System
The original Delitto classi cation w as intend ed to target
p atients w ith acu te low back p ain or acu te exacerbations o
low back p ain (Fritz et al 2007a). Delitto et al (1995) d e ned
acuteness operationally, based on the severity o the presenta-
tion and not an arbitrarily selected nu m ber o d ays since onset
o the low back sym p tom s (Delitto et al 1995; Fritz & George
2000). The original treatm ent-based classi cation system
d escribed seven d i erent classi cations or those patients pre-
senting w ith low back pain. In 2000 these seven classi cations
w ere stream lined into ou r classi cations, based on treatm ent
sim ilarities (Fritz & George 2000). The classi cation algorithm
rem ained u nchanged u ntil 2006 w hen it w as up d ated and
m od i ed again (Brennan et al 2006). This m od i cation ad d ed
ad d itional com ponents to the algorithm to assist clinicians in
id enti ying su bgrou ps w ith d e nitive classi cations. In ad d i-
tion, the u p d ate ad d ed u rther d ecision-m aking aid s to assist
the clinician w hen a p atient p resented w ith an u nclear clas-
si cation. The m od i ed algorithm w ou ld gu id e the clinician
in d eterm ining the subgrou p w hich ‘best tted ’ the p atient.
As the current bod y o know led ge increased at the tim e, the
2006 up d ate also ad d ed a hierarchical stru ctu re to the algo-
rithm (Brennan et al 2006). H ow ever, this m od i cation d id
not (unlike the 2000 version) inclu d e a traction su bgroup as
the stu d y exclu d ed p atients w ith signs o nerve root com p res-
sion. In ad d ition, the cu rrent state o evid ence at that tim e d id
not p rovid e clinicians w ith con d ence to id enti y accu rately
a su bgroup o ind ivid u als w ith low back pain w ho w ere likely
to resp ond to lu m bar m echanical traction (Fritz et al 2007a).
Finally, Stanton et al (2011) p resented an algorithm that once
m ore inclu d ed the traction su bgrou p ; they term ed this algo-
rithm a ‘com prehensive algorithm ’ ow ing to the com pleteness
o the algorithm in inclu d ing all o the classi cation su b-
grou ps plu s ad d itional d ecision-m aking aid s or patients w ith
clear and u nclear su bgrou p p resentations. Table 18.3 show s
the evolu tion o the treatm ent-based classi cation algorithm
over tim e.
 The treatment-based classi cation system: focus on the stabilization subgroup 213

Table 18.3 Tre a tme nt-ba s e d cla s s if cation alg orithm e volution ove r time

Delitto et al (1995) Fritz & George (2000) Brennan et al (2006) Stanton et al (2011)
Immobilization Immobilization Stabilization Stabilization
p
u
Lumbar mobilization
o
r
Mobilization Manipulation Manipulation
g
b
Sacroiliac mobilization
u
s
Extension s yndrome
n
o
i
t
a
Flexion syndrome Speci c exercis e Speci c exercis e Speci c exercis e
c
i
s
Lateral shift
s
a
l
C
Traction Traction Traction* Traction
Unclear class i cation criteria – not Unclear class i cation criteria – including
including traction** traction
*Traction was not included in this algorithm as patients with s igns of nerve root compress ion were excluded.
**The rs t clas si cation algorithm to include decision-making as s is tance for when a patient does not meet a s peci c s ubgroup. The algorithm s ugges ts that the clinician
identi es which subgroup the patient ts bes t.

Research Investigating the Treatment-
based Classi cation System
There has been a plethora o research evaluating the treatm ent-
based classi cation m od el. Practice m od els should be re-
evaluated as new evid ence em erges (Fritz et al 2006;
Apeld oorn et al 2010). Rid d le (1998) evalu ated the original
m od el by Delitto et al (1995) and ou nd that m any o the
system criteria lacked reliability and valid ity. The m od i ed
algorithm by Brennan et al (2006) u rther assessed the reliabil-
ity o the treatm ent-based classi cation exam ination item s
and the inf u ence o exp erience in users o the m od el (Fritz
et al 2006). The m ajority o the ind ivid u al exam ination item s
rom the algorithm w ere ou nd to have good reliability. When
jud gem ents o centralization using repeated or su stained
extension m ovem ents w ere analysed , the inter-rater reliability
w as air. The sam e w as true or jud gem ents o aberrant m ove-
m ents. When exam ining the inf u ence o clinician exp erience
and the classi cation system , Fritz et al (2006) ound that the
m od i ed algorithm cou ld be u sed reliably by p hysical thera-
pist p ractitioners regard less o the nu m ber o years o p ractice
experience or experience in u sing the classi cation system .
The resu lts pertaining to clinician exp erience are sim ilar to the
nd ings o H enry et al (2012), w hich show ed good inter-rater
reliability or novice jud gem ent in applying the algorithm as
d escribed by Fritz et al in 2006. The classi cation system has
been show to im prove the outcom es or patients treated using
this ap p roach (Brennan et al 2006). The algorithm w as urther
labelled the ‘com p rehensive algorithm ’ in 2011; w hen it w as
evaluated , this urther-re ned algorithm d em onstrated m od -
erate reliability – this level o reliability can provid e a reason-
able level o con d ence to the practising clinician or
incorporating the com p rehensive algorithm into clinical prac-
tice (Stanton et al 2011). As originally proposed by Delitto
et al (1995), the classi cation system d oes seem better su ited
or patients w ith acute sym ptom s. Ap eld oorn et al (2012a)
evaluated the algorithm pu t orth by Brennan et al in 2006
against a p op u lation o ind ivid u als in Am sterd am w ith a
current com p laint o low back p ain greater than 6 w eeks.
Their intent w as to assess the utility o the m od i ed Delitto
classi cation in a p op u lation o p atients w ith longer-term
p ain states (su bacu te and chronic). Their resu lts su ggested
that the classi cation system d oes not im p rove ou tcom es
or ind ivid u als w ith tim e-based categorized su bacu te (6–12
w eeks) and chronic (> 12 w eeks) low back pain (Apeld oorn
et al 2012a). Furtherm ore, a cost analysis revealed that the
classi cation ap p roach or su bacu te and chronic low back
p ain w as not cost e ective com p ared w ith an equ al p op u la-
tion o p atients m anaged u su ally w ith p hysical therap y
(Apeld oorn et al 2012b).
The Treatment-based Classi cation
System: Focus on the Stabilization
Subgroup
The authors o this chapter realize there is ongoing d ebate
over the u tility o the treatm ent-based classi cation system .
That d ebate is beyond the scope o this chapter. Treating clini-
cians assess their p atients as best they can to d eterm ine a
treatm ent d irection, and it is ou r hop e that w e can p resent an
evid ence-in orm ed ram ew ork, using the treatm ent-based
classi cation m od el, that w ill allow treating clinicians to
p roceed w ith con d ence w hen m anaging p atients w ith clini-
cal p resentations that seem id eally m atched to stabilization
interventions. We und erstand that there are other classi ca-
tion system s available; how ever, research to d ate su ggests
that the treatm ent-based classi cation system is id eal or
assessing and m anaging p atients w ith acute low back pain.
We ap p reciate the lim itations o the treatm ent-based classi -
cation system – sp eci cally the bias tow ard s pred om inantly
regionally d e ned low back pain w ithou t anything m ore than
p rognostic ap p reciation or m u ltisite p ain p resentations and
other com orbid ities – bu t also, in sp ite o this lim itation, that
p atients w ith low back p ain com p laints can p resent w ith p re-
d om inantly ‘localized low back pain’ sym ptom s (N atvig et al
2001), althou gh this is not the norm (Kam aleri et al 2008). The
em erging evid ence ind icates that the treatm ent-based classi-
cation system is a u se u l m anagem ent tool in this sp eci c
su bgrou p (i.e. p atients p resenting w ith localized low back
p ain), and also that p atient-related ou tcom es and costs associ-
ated w ith the treatm ent-based classi cation system im p rove
 214 PART 3 • 18 •  Lumbar spine instability
w hen the m od el is u sed in clinical practice. In keeping w ith
the originally targeted p op u lation, and the recent evid ence
su ggesting the reliability o the classi cation system in ind i-
vid u als w ith acu te low back p ain (H enry et al 2012; Stanton
et al 2011), in this chapter w e w ill ocu s on p atients p resenting
w ith acute low back sym ptom s w ho w ou ld be classi ed
into the stabilization category w ith su sp ected lu m bar sp ine
instability.
Clinical Management of Lumbar
Spine Instability
Cu rrent best evid ence has ad vocated a treatm ent-based clas-
si cation ap p roach or the overall m anagem ent o p atients
w ith low back pain. Em phasis has been placed on m atching
the p atient to op tim al interventions based on the id enti ca-
tion o signs and sym p tom s collected d u ring the p atient inter-
view and p hysical exam ination (Delitto et al 1995; Fritz &
George 2000; Fritz et al 2003; Brennan et al 2006; Werneke
et al 2009). The clinical d ecision-m aking process involved in
app lying this treatm ent-based classi cation strategy com -
p rises tw o d istinct levels. The rst level requ ires that the
therap ist d eterm ine w hether the p atient is ap p rop riate or
p hysical therapy services throu gh a com p rehensive m ed ical
screen inclu d ing a red f ag assessm ent. This initial step is
accom p lished via a com p rehensive p atient interview. The
second level o the classi cation schem a involves d irecting the
p atient to their m atched intervention(s) or subgrou p based on
p resenting signs and sym ptom s as w ell as their respective
p hysical exam ination nd ings (Fritz & George 2000; Fritz
et al 2003).
First level of classi cation
and the patient interview
Step one o this classi cation ap p roach begins w ith a com p re-
hensive review o the p atient’s m ed ical history and a m ed ical
screen encom p assing a review o both general health and
sp eci c system s (Boissonnau lt 2005). General health qu estions
shou ld be asked o all p atients inqu iring abou t the ollow ing:
(1) atigu e, (2) m alaise, (3) w eakness, (4) u nexp lained w eight
loss / gain, (5) nau sea, (6) paraesthesia or nu m bness, (7) d iz-
ziness or lighthead ed ness, (8) change in m entation or cogni-
tion, and (9) chills, sw eats or ever. Sp eci c qu estions abou t
the m echanism o inju ry or history o a trau m atic event can
be a potential ind icator or spinal ractu re. The thoracolum bar
area o the sp ine has been rep orted as the m ost com m on loca-
tion w here ractu res occu r. These are u su ally the resu lt o
m otor vehicle collisions, blu nt orce trau m a, as w ell as acci-
d ents and alls. Many o these ractu res (40–80%) are consid -
ered biom echanically u nstable (Wood et al 2014). As part o
the red f ag assessm ent, it is essential or clinicians to note any
com p laints o w eakness, sensation changes or m otor loss as
su ch sym p tom s w ou ld gu id e them to p er orm ing u ll m otor
and sensory exam ination and potential re erral or ad d itional
im aging or em ergency services. It is critical to u nd erstand that
lu m bar sp ine instability cou ld be cau sed by the trau m a or is
a second ary e ect o the event. Shou ld this be su spected , an
app ropriate re erral w ou ld need to be m ad e to clear the
ind ivid u al m ed ically be ore initiating physical therapy serv-
ices. (See Ch 4 or urther in orm ation on history taking.)
Patient sel -ad m inistered qu estionnaires can assist w ith
this d ata collection as w ell. These tools have been show n to
be accu rate or reporting im portant health history in orm a-
tion and in assisting the clinician to d ecid e w hether or not to
p roceed u rther to the second level o classi cation (Pecoraro
et al 1979; Boissonnau lt 2005). A speci c system screen (car-
d iovascular, pu lm onary, gastrointestinal, urogenital, end o-
crine, nervou s, integu m entary system s) ollow s based on the
initial in orm ation gathered rom the general health questions
review inclu d ing the bod y chart and sel -ad m inistered
qu estionnaires. The p atient interview is a key com p onent
in attem p ting to recognize seriou s spinal pathology that m ay
w arrant ad d itional concern inclu d ing approp riate m ed ical
ollow -u p w ith a prim ary care practitioner (Greene 2001;
Greenhalgh & Sel e 2009). The patient interview also d rives
the overall p lanning p rocess or the objective exam ination and
p rogression to the second stage o care and intervention ap p li-
cation. For p atients w ith su sp ected lu m bar sp ine instability
any recent im agining p roced u res m ay be o im portance to the
p ractitioner, as w ell as the sp eci c view s that w ere taken.
Although rad iograp hic nd ings are consid ered to be the m ost
qu anti able m easu re or the d i erential d iagnosis o lu m bar
sp ine instability, recent literatu re has investigated p otential
p hysical exam ination tests to assist the clinician in their d i -
erential d iagnosis process in the absence o rad iograp hs
(Alqarni et al 2011). This is a cru cial com ponent to the patient-
centred care m od el w here the u se o clinical tests to id enti y
hyp othesized lu m bar sp ine instability w ou ld p rovid e a
d ecreased exposu re to rad iation, im prove access to healthcare
and d ecrease costs associated w ith d iagnostic im aging
p roced u res.
Self-reported symptoms and clinician
pattern recognition
Sp eci c sel -rep orted sym p tom s, as w ell as exam ination nd -
ings, have been show n to be bene cial to the clinician w ith
regard to their clinical d ecision-m aking process and im prov-
ing probability estim ates or the d i erential d iagnosis o
lum bar spine instability. Patient sel -reports o recurrent
locking, catching or giving w ay o the low back d u ring active
m otions have historically been a p atient history item that
clinicians w ou ld u se to hyp othesize the p robability o lu m bar
sp ine instability (Fritz et al 1998). Fu rtherm ore, stu d ies have
also looked at the d u ration o sym p tom s, age o the p atient,
as w ell as ear-avoid ance behaviou r and d ecreased w illing-
ness to m ove as p otential variables or ind icating ind ivid u als
w ho w ou ld bene t rom a stabilization program m e (H icks
et al 2005). A Delp hi stud y cond ucted by Cook et al (2006)
looked at 168 exp ert physical therap ists’ consensu s regard ing
sp eci c su bjective and objective exam ination d ata or the
p rop er id enti cation o lu m bar sp ine instability. Physical
therap ists in this stu d y w ere either board certi ed in ortho-
p aed ics by the Am erican Physical Therap y Association
(APTA) or Fellow s o the Am erican Acad em y o Orthopaed ic
Manu al Physical Therap ists (AAOMPT). Com m on sel -
reported com plaints inclu d ed the ollow ing: pain w ith u nsu p-
p orted sitting, increasing p ain w ith su stained p ositions, a
history o p ain u l catching or locking sensation d u ring sp inal

Bo x 1 8 .1 Th re e m o s t c o m m o n p a tie n t in te rvie w
n d in g s re p o rte d b y e xp e rts * to b e m o s t like ly
a n d le a s t like ly to b e re la te d to lu m b a r s p in e
c lin ic a l in s ta b ility
Finding s m o s t like ly to be re late d to lumbar s pine
c linic al ins tability
• Reports feelings of ‘giving way’ or back ‘giving out’
• Self-manipulator who feels the need to frequently crack or
pop the back
• Frequent bouts or episodes of symptoms
Finding s le a s t like ly to be re late d to lumbar s pine
c linic al ins tability
• Pain through range of motion (i.e. through range pain)
• Intolerance of prone position
• Spine instability does not exis t
(Adapted from Cook et al 2006.)
*168 physical therapis ts identi ed as Orthopaedic Clinical Specialis ts (OCS) or
Fellows of the American Academy of Orthopaedic Manual Phys ical Therapis ts .
m ovem ent, p ain retu rning rom sp inal f exion, p ain w ith
su d d en or trivial activities, and p ain w ith transitional activi-
ties. The three most com m on agreed -u pon patient nd ings
su ggesting lu m bar sp ine clinical instability noted by the
experts, as w ell as the three m ost com m on agreed -upon
patient interview nd ings least likely related to lu m bar spine
clinical instability, are listed in Box 18.1. The experts w ere also
asked the sam e qu estion regard ing the objective exam ination
and w hat actors w ere rep orted the m ost and the least related
to lu m bar sp ine clinical instability. The three m ost com m on
objective actors rep orted by exp erts as most related to lum bar
sp ine instability, as w ell as the three m ost com m on objective
nd ings least likely to be related w ith lum bar spine clinical
instability, are listed in Box 18.2.
Second level of classi cation:
physical examination
A ter a thorou gh and com prehensive p atient interview has
been com pleted , the list o potential d iagnoses is then re ned .
The classi cation process continu es w ith the physical exam i-
nation to investigate u rther the list o the exam iner ’s p oten-
tial hyp otheses. The p hysical exam ination can inclu d e
elem ents o patient observation, active spinal m otion testing,
palp ation, m u scle length, m u scle strength, p assive physiolog-
ical and accessory m otion testing, as w ell as sp ecial tests.
Sp ecial tests and p hysical exam ination nd ings assist the cli-
nician in clinical d ecision m aking in a broad er context as
either con rm atory or screening tests. Find ings o the p hysi-
cal exam ination tests are then u sed to retain, m od i y, ru le in
or ru le ou t p reviou sly hyp othesized cond itions. It is im p or-
tant to note that m ost clinicians w ill not m ake a d ecision based
on a single test nd ing and w ill u se tests in a clu ster to
strengthen the p robability that a p atient has a sp eci c m u scu -
loskeletal d isord er (Cook & H eged u s 2011).
Diagnostic and screening tests requ ire the u se o a re er-
ence stand ard to d eterm ine their overall accuracy. The accu-
racy o a clinical special test is d e ned as the m easurem ent o
Clinical management of lumbar spine instability  215
Bo x 1 8 .2 Th re e m o s t c o m m o n o b je c tive fa c to rs
re p o rte d b y e xp e rts * to b e m o s t like ly a n d le a s t
like ly to b e re la te d to lu m b a r s p in e c lin ic a l
in s ta b ility
Obje c tive fac to rs m o s t like ly to be re late d to lumbar
s pine c linic al ins tability
• Poor lumbopelvic control, including s egmental hinging or
pivoting with movement, as well as poor proprioceptive
function
• Poor coordination / neuromuscular control, including
juddering or shaking
• Decreased s trength and endurance of local muscles at
level of segmental ins tability
Obje c tive fac to rs le a s t like ly to be re late d to lumbar
s pine c linic al ins tability
• Non-objecti able: segmental ins tability cannot be
objecti ed in the clinic
• Unresponsiveness to treatment, including manual
techniques and exercise
• Segmental instability does not exis t
(Adapted from Cook et al 2006.)
*168 physical therapis ts identi ed as Orthopaedic Clinical Specialis ts (OCS) or
Fellows of the American Academy of Orthopaedic Manual Phys ical Therapis ts .
agreem ent betw een the re erence stand ard and the clinical
test (Fritz & Wainner 2001). The re erence stand ard is consid -
ered the closest d escription o the actual d isord er being
p resent. In d iagnostic stu d ies the resu lts o the re erence
stand ard are com p ared against the clinical test in qu estion to
d eterm ine the p ercentage o ind ivid u als correctly id enti ed
or d iagnosed w ith the d isord er. Physical exam ination tests
can never absolu tely ru le in (con rm atory) or ru le ou t
(exclu d e) the presence o a su spected d isease and or pathol-
ogy. Clinical and sp ecial tests, thou gh, can be u sed to assist
the exam iner in altering the p robability or estim ate that the
p atient has a sp eci c m u scu loskeletal d isord er. Diagnostic
accu racy statistics su ch as sensitivity, speci city and likeli-
hood ratios (LRs) can assist the clinician in choosing the m ost
ap plicable test to re ne their clinical d ecision-m aking process
(Jaeschke et al 1994). (See Ch 5 or u rther d etails on p sycho-
m etric d ata o p hysical exam ination p roced u res.)
Achieving a re erence stand ard or the clinical d iagnosis o
lum bar spine instability is d i cu lt or three key reasons: (1)
there is little evid ence correlating the p athop hysiology o
sp inal instability w ith p atient’s sel -rep orted sym p tom s o
p ain and / or d isability, (2) rad iographic m easu rem ents m ay
contain errors d uring m ovem ent o less than 5 m m , w hich are
requently reported w ith lu m bar sp ine instability cases, and
(3) ‘norm al’ spine m otion has yet to be d e ned (Cook et al
2006). This is especially im portant w ith regard s to ind ivid uals
w ho show variable segm ental m obility in their spine yet
are asym ptom atic and u nctioning w ithou t any d i cu lties.
Despite these issu es, practitioners have reported a consensu s
o sim ilar p atient interview answ ers and com m ents as w ell as
p hysical exam ination nd ings that they w ou ld typ ically see
in patients w ith lu m bar sp ine instability, as m entioned p revi-
ou sly in this chap ter.
 216 PART 3 • 18 •  Lumbar spine instability
Evidence for physical examination ndings
With regard s to the p hysical exam ination and evid ence to
su p p ort its com p onents, H icks et al (2003) looked at a barrage
o clinical exam ination m easu res that w ere p rop osed to id en-
ti y the reliability com p onent o sp ecial tests looking at lu m bar
sp ine instability. The resu lts o this stu d y agreed w ith p revi-
ou s nd ings regard ing the d i cu lty w ith segm ental m obility
assessm ent in term s o the lack o reliability. Other tests inves-
tigated inclu d ed the p rone instability test and aberrant
m otions w ith range-o -m otion testing, w hich d em onstrated
higher levels o inter-rater reliability (agreem ent beyond
chance betw een exam iners). Ad d itional exam ination m eas-
u res su ch as the Beighton Ligam entou s Laxity Scale show ed
high reliability or generalized ligam entou s laxity. Becau se
these clinical tests and m easu res have a high level o reliabil-
ity, clinicians can exp ect to achieve sim ilar resu lts w hen p er-
orm ing them in the clinic. Fritz et al (2005) had also looked
at the d iagnostic utility o clinical tests or rad iograp hic insta-
bility. Flexion–extension rad iographic nd ings or 49 ind i-
vid u als w ith low back p ain w ere u sed as a re erence stand ard .
I im aging nd ings revealed speci cally either tw o segm ents
w ith rotational / translational instability or one segm ent w ith
both rotational and translational instability, this w as consid -
ered positive as a re erence stand ard or instability. The
au thors ou nd that tw o clinical p red ictor variables – a lack o
hyp om obility o the lu m bar sp ine throu gh p assive accessory
m otion testing and lu m bar f exion greater than 53° – provid ed
a su bstantial shi t in p ost-test probability or the d iagnostic
accuracy o lu m bar spine instability.
Sequencing of the physical examination
Given the d i cu lty w ith nd ing an op tim al con rm atory
or screening test w ith satis actory d iagnostic accu racy statis-
tics, it is im p erative or the p hysical exam ination p rocess
to ollow an organized and rep rod u cible m ethod ology.
Typ ical orm ats m ay ocu s on p atient p ositioning as the d eter-
m inant or w hich tests shou ld be p er orm ed , and at w hat
p oint d uring the exam ination process they occu r. An exam ple
w ou ld be the stand ing, sitting, sup ine and then prone sequ enc-
ing. Other ap p roaches m ay look at active m ovem ent ollow ed
by passive m ovem ent, palpation and other exam ination tests
(i.e. neu rological exam ination, m otor strength, m otor control,
p alp ation and sp ecial tests). It has been su ggested that m any
sp ecial tests u sed in the d i erential d iagnosis p rocess or
lu m bar sp ine instability can be broken d ow n into tw o large
su bgrou p s; this w ou ld inclu d e a series o p assive tests ol-
low ed then by active tests. Passive tests w ou ld inclu d e the
ollow ing: p assive accessory intervertebral m otion (PAIVM),
p assive p hysiological intervertebral m otion (PPIVM), the
p rone instability test (PIT) and the p rone lu m bar extension
test (PLE). Active tests m ay inclu d e observation o an instabil-
ity catch or hinge in retu rning rom sp inal f exion, as w ell
as u nctional signs that rep rod u ce the patient’s sym p tom s
su ch as going rom sit to stand or any other transitional
p ositions.
In ord er to optim ize the objective exam ination process,
p hysical tests and m easu res that sp eci cally look at screening
and d iagnostic clari cation shou ld occu r at speci c tim es
Screening tests Confirmatory tests
Passive lumbar
extension test
Percussion test
PAIVM
Supine sign PPIVM
Instability catch sign PIT
Abbreviations: PAIVM, passive accessory intervertebral motion; PPIVM,
passive physiological intervertebral motion; PIT, prone instability test
Figure 18.2 Proposed lumbar spine instability physical examination items.
d u ring the physical exam ination. With regard s to sequ encing
the exam ination, it has been recom m end ed that screening
tests are typ ically p er orm ed at the beginning o the exam ina-
tion and con rm atory tests are p er orm ed tow ard s the end o
the exam ination. The p u rp ose o sp eci c screening tests and
m easu res is to assist the exam iner in ru ling ou t p otential
d iagnosis, w hereas the pu rpose o con rm atory tests is to
valid ate or d i erentiate betw een the rem aining com p eting
d iagnoses. An ad d ed bene t to this sequ encing is that it helps
red u ce not only m isu se bias (i.e. u sing a low –LR test or high-
sensitivity test last) bu t also the recency effect, w hich occu rs
w hen the exam iner w eighs current events as m ore im p ortant
than earlier events (Cook 2010). This happens com m only
w hen a m ajority o special tests are per orm ed tow ard s the
end o the exam ination and there ore the exam iner hold s
those tests as being m ore ‘tru th u l’ than those p er orm ed
earlier. Placing tests that are highly sensitive and help ru le ou t
p otential d iagnoses that m ay be o seriou s natu re rst is a step
tow ard s red u cing these typ es o biases. In keep ing w ith the
recom m end ed sequ encing, the p hysical exam ination tests and
m easu res have been listed in ord er o screening tests rst ol-
low ed by con rm atory tests. The au thors propose the ollow -
ing clinical exam ination m od el or the exam ination o lu m bar
sp ine instability below, as w ell as the entire orm at d etailed
in Figure 18.2. The orm at or each clinical test is the d escrip-
tion ollow ed by the d iagnostic accu racy, conclu d ing w ith a
clinical su m m ary.
Proposed Clinical Examination for
Lumbar Spine Instability
Screening tests
The initial three screening tests or potential lu m bar spine
ractu re and lu m bar spine instability are reported in either a
stand ing (p ercu ssion test and instability catch sign) or a
su p ine p osition (su p ine sign). Most p atient exam inations
includ e a stand ing and / or supine com ponent based on the
p atient’s p resentation and tissu e irritability. These tw o p osi-
tions there ore w ou ld be ap p rop riate and realistic or a d ay
one assessm ent o the p atient.
 Proposed clinical examination for lumbar spine instability
Percussion test
The percussion test as d escribed by Langd on et al (2010) is
per orm ed w ith the p atient stand ing. The exam iner stand s
behind and o to the sid e o the p atient. A orce is then given
at each sp inal level w ith a closed st. Mu ltiple levels can be
assessed by going u p and d ow n the spine. A test is p ositive
w hen the patient reports a sharp or su d d en pain. This test w as
show n to be highly sensitive (88%), as w ell as having a strong
+LR o 8.8 and −LR o 0.14.
Clinical summary: The p ercu ssion test can be u sed as an
initial screen or potential com pression ractu res, especially
or patients w ho m ay not be able to ad opt a sup ine position.
Supine sign
The supine sign, also d escribed by Langd on et al (2010), is
per orm ed w ith the p atient in a su pine position. The patient
is asked to lie supine w ith only one pillow and w ith the legs
straight. The sign is p ositive w hen the p atient is u nable to lie
su p ine becau se o severe p ain in their sp ine. Statistically this
test w as both sensitive (81%) and speci c (93%) w ith a +LR o
11.6 and −LR o 0.20.
Clinical summary: Desp ite having a strong +LR, this test is
easy to per orm and can be d one early on in the exam ination
p rocess. Given its sensitivity (81%), this test shou ld be used
in com bination w ith the instability catch sign.
Instability catch sign
The instability catch sign, reported by Kasai et al (2006), is
per orm ed w ith the patient starting in a stand ing p osition.
The patient is then asked to f ex orw ard as i going to tou ch
the toes and then retu rn to an erect p osition. The test is p osi-
tive test i the p atient cannot retu rn to an erect stand ing p osi-
tion. This test is highly sensitive (85.7%) in natu re, w ith a −LR
o 0.31.
Clinical summary: This is an id eal screening test as p art o
the exam ination p rocess. The p hysical exam ination shou ld
includ e an assessm ent o active spinal m otion, and d u ring
that assessm ent the exam iner can record this nd ing qu ite
easily.
Con rmatory tests
The con rm atory or d iagnostic tests listed in this section have
been review ed rom the bod y o literature on lu m bar spine
instability and the d iagnostic capability assessm ent o these
sp ecial tests is rep orted . Positive likelihood ratios have been
provid ed to d em onstrate the probability assessm ent that one
m ay have w ith a p ositive test nd ing.
Passive lumbar extension test
The passive lu m bar extension test, as d escribed by Kasai et al
(2006), w as d esigned to look at hyp othesized stru ctu ral insta-
bility o the spine. The p atient is p laced in a prone position
w hile the exam iner li ts both extrem ities into extension to a
height o app roxim ately 30 cm w hile keep ing the knees
extend ed . A sm all pull on the legs is applied as the legs are
elevated . The test is positive test i patients report a strong
217
p ain sensation, a very heavy eeling, or a eeling that their
low back w as going to com e o that resolves u pon returning
to the starting p osition. This test w as ou nd to be both highly
sensitive and sp eci c, w ith a +LR o 8.8 and −LR o 0.2.
Clinical summary: This test is a u se u l con rm atory test or
im proving one’s probability o hypothesized structural insta-
bility o the spine as w ell as being a lum bar spine instability
screening test (84.2% sensitive). This can inclu d e p otential
biom ed ical issu es such as canal stenosis, spond ylolisthesis
and d egenerative scoliosis.
Passive accessory intervertebral motion
PAIVM w as initially investigated as a potential d iagnostic
tool or con rm atory test or rad iograp hic instability (Fritz
et al 2005). The patient is positioned in prone and the exam -
iner applies a posterior–anterior orce on the sp inou s process
u sing a thu m b p ad to thu m b p ad grip or the hyp othenar
em inence. Pressure is ap plied perp end icu lar to the spinous
p rocess o the lu m bar segm ent. The exam iner ju d ges the
m obility o the segm ent as norm al, hyp erm obile or hyp om o-
bile. The presence o pain is record ed as present or absent.
Lack o hypom obility w ith intervertebral testing w as ound
to be the best ind ivid u al test or instability, w ith a +LR o 9.0.
When both this nd ing and lum bar spine f exion w ere > 53°,
a +LR o 12.8 w as achieved .
Clinical summary: PAIVMs are u se u l con rm atory tests or
rad iograp hic instability especially i there is a lack o hypo-
m obility p resent and sp inal f exion > 53°.
Passive physiological intervertebral movements
or extension and f exion
The PPIVM d escribed by Abbott et al (2005) looked at the
ability o selected m anual tests to d etect abnorm al sagittal
p lanar m otion d erived rom f exion extension rad iograp hs.
For the extension PPIVM, the patient is rst positioned in
sid e-lying. The exam iner than p alp ates the intersp inou s sp ace
betw een tw o ad jacent spinou s processes. Keeping one nger
there, the other hand grasp s the p atient’s u p p erm ost f exed
leg and m oves the lu m bar spine rom neu tral to extension
u sing the low er extrem ity. A p ositive test is id enti ed by
d etection o excessive m ovem ent d u ring exam ination. For
f exion PPVIM, the hand placem ent and p osition o the patient
are exactly the sam e as in extension, excep t that the exam iner
m oves the u p p erm ost extrem ity rom neu tral to f exion. A
p ositive test is id enti ed by d etection o excessive m ovem ent
d uring exam ination. For PPIVM testing, the authors u sed a
ve-point ord inal scale w ith 0 and 1 ind icating hypom obility,
norm al m obility scoring a 2, w hile 3 and 4 w ere consid ered
hyperm obile. In both f exion and extension, a grad e o 4 w as
consid ered p ositive or lu m bar sp ine instability. Both PPIVMs
w ere speci c or the d iagnosis o both rotational and transla-
tional lu m bar sp ine instability, bu t show ed p oor sensitivity.
Extension PPIVMs that scored a grad e 4 had a +LR o 8.4 and
7.1 or rotational and translational instability, w hile f exion
PPIVMs scored a +LR o 4.1 and 8.7.
Clinical summary: PPIVMs in this case are u se u l con-
rm atory tests, w ith extension-oriented PPIVMs yield ing
slightly im p roved d iagnostic cap abilities over their f exion
cou nterp art.
 218 PART 3 • 18 •  Lumbar spine instability
Prone instability test
The PIT, d escribed by H icks et al (2003), is a p ain p rovocation
test. The p atient is p ositioned p rone on a table w ith the torso
and legs hanging o the ed ge o the table and eet resting on
the f oor. The exam iner then per orm s a p osterior–anterior
intervertebral m anoeu vre. The p atient is asked to rep ort any
p rovocation o p ain. The p atient then li ts the heels o the
grou nd , and the exam iner per orm s the posterior–anterior
intervertebral m anoeu vre once again. The p atient m ay be
hand -hold ing the table to help m aintain p osition d u ring the
test. A p ositive test occu rs w hen the p ain is p rovoked d u ring
the rst p art o the test bu t d isap p ears w hen the test is
repeated w ith the legs o the f oor. A system atic review by
Alqarni et al (2011) looked at a barrage o clinical tests or
d iagnostic accuracy or lum bar spine instability. Their d ata
show ed this test to have a +LR o 1.4 and a −LR o 0.7. These
valu es d em onstrate only sm all to very sm all and som etim es
rarely im portant change regard ing probability shi ts. This test
ap pears to have little d iagnostic accu racy value in isolation.
For an intervention perspective, though, it w as ound to be a
key variable in the clinical pred ication ru le or patients w ho
w ould bene t rom a lu m bar stabilization program m e or
low back p ain (H icks et al 2005). This w as interesting in that
the single-item likelihood valu e o this test in that clu ster w as
a +LR o 1.7, bu t, as a pred ictor or those patients w ho w ould
not resp ond w ell to a lu m bar stabilization p rogram m e i this
test w as negative, the +LR w as 5.0. The only other item that
w as ou nd to be m ore pred ictive or patients w ho w ould
resp ond poorly to a lu m bar spine stabilization program m e
w as the lack o lu m bar hyperm obility w ith spring testing
(+LR 9.2).
Clinical summary: Althou gh this test has poor d iagnostic
accuracy as a stand -alone test item or im proving the d iag-
nostic p robability o lu m bar sp ine instability, it is p art o a
clu ster o ou r tests in w hich i three or m ore are p ositive then
the p atient w ou ld have a +LR o 4.0 that they w ould bene t
rom a lu m bar spine stabilization exercise app roach. This test
w ou ld have a + LR o 5.0 i ou nd negative (i.e. pain d oes not
go aw ay w hile the p osterior–anterior m anoeu vre is ap plied
and the eet are u p in the air), ind icating that they w ould
not resp ond w ell to a lu m bar sp inal stabilization exercise
p rogram m e.
Clinical prediction rules in the treatment-
based classi cation system
Clinical p red iction ru les (CPRs) have been d evelop ed to
p rovid e p hysical therap ists w ith an evid ence-based tool to
assist in p atient m anagem ent and to im p rove clinical d ecision
m aking. They are u sed to assist the clinician in establishing a
d iagnosis or prognosis, as w ell as d eterm ining w hich patients
m ay bene t rom a p articu lar intervention ap p roach. Desp ite
the cu rrent im p lem entation and w id esp read p op u larity, the
app lication o CPRs in the clinical settings is not w ithou t
lim itations. CPRs requ ire an evid ence-based review and
in-d ep th analysis p rior to their im p lem entation into the clini-
cal setting. They ollow a typ ical p attern o d evelop m ent,
starting rom a d erivation com p onent, m oving to a valid ation
stage and end ing w ith an im p act analysis (Glynn & Weisbach
2011). Each stage bu ild s up on the preced ing ones as this
continu u m o qu ality and valid ity are im p roved u p on or
clinical u se.
With regard s to lu m bar sp ine instability, there is one CPR
cu rrently that has been established or the intervention
aspect in that p atient popu lation. H icks et al (2005) com -
p leted a p relim inary d evelop m ent o a CPR or d eterm ining
w hich patients w ith low back p ain w ou ld resp ond to a sta-
bilization program m e. The nd ings w ou ld be integrated
into the evolving classi cation system as the criteria or the
stabilization category. The p red iction ru le w as able to d eter-
m ine w hich variables p red icted not only su ccess bu t also
ailu re or ind ivid uals instructed in a stabilization exercise
p rogram m e. The stabilization p rogram m e w as sched u led
tw ice a w eek or 8 w eeks u nd er the su pervision o a p hysical
therap ist. These p atients w ere also given a hom e exercise
p rogram m e to p er orm d aily and w ere asked to com p lete a
com p liance log or hom e exercises to veri y that they had
com p leted those tasks. The exercise p rogram m e w as based
on cu rrent best evid ence and ocu sed on stabilizing m otor
p atterns o both global and local m u scu latu re. Rep eated
su bm axim al e orts w ere p er orm ed and exercises w ere
p rogressed by the therap ist by criteria that they w ere given.
A d escrip tion o that exercise p rotocol w ith criteria or p ro-
gression can be ound in Table 18.4. Resu lts show ed that
ou r pred ictor variables w ere id enti ed or a patient to
bene t rom a lum bar spine stabilization exercise pro-
gram m e: p ositive PIT, aberrant m ovem ents p resent, average
straight leg raise > 91° and age > 40 years old . Regard ing
aberrant m ovem ents, these m ovem ents w ou ld inclu d e any
the ollow ing d escrip tions: an instability catch, a p ain u l
arc o m otion, and patients clim bing u p their thighs w ith
their hand s to assist them ‘thigh clim bing’ (w hich has also
been d escribed as Gow ers’ sign or a reversal o the lum -
bopelvic rhythm ). I three ou t o ou r o the success pred ictor
variables w ere p resent (+LR 4.0) there w as a sm all bu t
som etim es m eaning u l increase in the p robability that the
p atient w ou ld experience at least 50% im provem ent in unc-
tion a ter 8 w eeks o lum bar stabilization. Chapter 23 exp lains
the d i erent exercises or p atients w ith lu m bar sp ine
instability.
The our variables that w ere id enti ed that ind icated
w hich patients w ou ld probably ail w ith a stabilization
treatm ent w ere: negative PIT, aberrant m ovem ents absent,
Fear-avoid ance Belie s Qu estionnaire p hysical activity sub-
scale score > 9 and no hyp erm obility w ith lu m bar spring
testing. I at least tw o o the ou r non-su ccess p red ictor vari-
ables w ere present (+LR 6.3) there w as a m od erate shi t in
p robability that the p atient w ou ld not im p rove w ith lu m bar
stabilization. In both cases, ou tcom es w ere based on p ain
and sel -rep orted qu estionnaires looking at d isability level
(Osw estry Disability Ind ex) and ear avoid ance (Fear-
avoid ance Belie s Questionnaire). Recently Rabin et al (2014)
p er orm ed a rand om ized controlled valid ation stu d y o the
p relim inary CPR. They ou nd that, althou gh they cou ld not
valid ate the CPR becau se o the sm all sam p le size and its
low relative pow er, a m od i ed CPR o aberrant m otions
and a p ositive PIT yield ed a strong p red ictive cap ability or
those p atients that w ou ld bene t rom a lu m bar sp ine stabi-
lization program m e. The authors note that, becau se these
nd ings are u nd er a p ost-hoc analysis, the next step w ou ld
be to inclu d e this m od i ed CPR in a orm al research d esign
m od el.
 Conclusion 219

Table 18.4 Stabilization e xe rcis e s  with crite ria  or progre s s ion o  e a ch e xe rcis e

Prima ry mus cle g roup Exe rcis e s Crite ria for p rog re s s ion

Trans vers us abdominis Abdominal bracing 30 reps with 8 s hold

Erector spinae / multi dus
Quadratus lumborum
Oblique abdominals
(Table bas ed on Hicks et al 2005.)
Bracing with heel s lide 20 reps per leg with 4 s hold
Bracing with leg lifts 20 reps per leg with 4 s hold
Bracing with bridging 30 reps with 8 s hold, then progres s to 1 leg
Bracing in standing 30 reps with 8 s hold
Bracing with standing row exercis e 20 reps per s ide with 6 s hold
Bracing with walking 20 reps per s ide with 6 s hold
Quadruped arm lifts with bracing 30 reps with 8 s hold on each s ide
Quadruped leg lifts with bracing 30 reps with 8 s hold on each s ide
Quadruped alternate arm and leg lifts with bracing 30 reps with 8 s hold on each s ide
Side support with knees exed 30 reps with 8 s hold on each s ide
Side support with knees extended 30 reps with 8 s hold on each s ide
Side support with knees exed 30 reps with 8 s hold on each s ide
Side support with knees extended 30 reps with 8 s hold on each s ide

Conclusion
Based on cu rrent best evid ence, clinicians are encou raged to
consid er the clinical u tility o the tests noted above in their
clinical d ecision-m aking ram ew ork. Using sp eci c tests w ith
d iagnostic accu racy assists clinicians in classi ying patients
w ith lum bar spine instability w ho can be m atched to the sta-
bilization subgrou p. In ad d ition, tests w ith ad equate d iagnos-
tic u tility can assist in the exclu sion o m ore seriou s and
sinister cond itions su ch as rank instability or p otential verte-
bral ractures. It is im portant to point ou t that these tests
ind ivid u ally or in a cluster o tests are probably m ore exten-
sive than ju st a d iagnostic tool. They can assist in d riving
treatm ent d ecisions as w ell as noting changes both w ithin and
betw een clinic sessions. The d evelopm ent o classi cation
system s is d ynam ic: evolving evid ence w ill u rther in orm the
d evelopm ent and utility o the classi cation system , w hich
w ill assist clinicians in provid ing an even better qu ality o care
or their patients w ith acute low back pain. We look orw ard
to these u tu re d evelop m ents.
References
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 PART 3 •  Lumbar Spine Pain Syndromes
Lumbar Spine in Lower Extremity Pain Syndromes
Chapter  19
S c o tt Bu rn s , P a u l E. G lyn n , Ed g a r S a vid g e , J o s h u a A. C le la n d
CHAP TER CONTENTS
Introduction  221
Lumbar spine treatment for hip disorders  221
Lumbar spine treatment for knee disorders  222
Lumbar spine treatment for foot and ankle disorders  223
Lumbar spine treatment for lower extremity neurodynamics  223
Conclusion  223
Introduction
The term ‘regional interd epend ence’ is u sed to d escribe the
relationship betw een im pairm ents in ad jacent regions of the
bod y and patients’ prim ary location of sym ptom s (Wainner
et al 2007). Most clinicians exam ine ad jacent anatom ical
regions in search of related im pairm ents; how ever, m ore
em erging research m ay ind icate a need to consid er m ore
rem ote regions (Su ter et al 1999; Bang & Deyle 2000; Low ry
et al 2008). The in u ence of m anu al therapy applied centrally
to the sp ine on the local and d istal m u scu latu re has been
stu d ied throu ghou t the bod y. In a p rosp ective cohort stu d y,
Su ter and McMorland (2002) d em onstrated the im m ed iate,
bilateral, signi cant red uction in bicep s inhibition and increase
in bicep s torqu e after a m id -cervical spine thrust m anipu la-
tion. Du nning and Ru shton (2009) perform ed a cohort stud y
on 54 asym p tom atic ind ivid u als. Participants w ere allocated
to sham cervical m anip u lation, cervical m anip u lation or
control grou p . The ind ivid u als receiving the m id -cervical
thru st m anip u lation d em onstrated a signi cant increase in
their bilateral bicep s EMG (electrom yograp hic) activity com -
pared w ith the other tw o treatm ent group s (Du nning &
Ru shton 2009). Manual therapy d irected at the thoracic spine
has also d em onstrated the ability to in u ence ad jacent areas,
su ch as the cervical sp ine (Cleland et al 2007, 2010; Gonzalez-
Iglesias et al 2009a, 2009b; Lau et al 2011) and should er (Bang
& Deyle 2000; Bergm an et al 2004; Boyles et al 2009; Mintken
et al 2010), as w ell as local m uscu latu re inclu d ing the low er
trap eziu s (Liebler et al 2001; Cleland et al 2004).
As noted , the research d em onstrating the effect of a regional
interd ep end ence ap p roach to care has been cond u cted
throu ghou t the bod y; how ever, this chap ter w ill focu s on
research pertaining to the lu m bar spine and its effect on the
 
low er extrem ities. It w ill d iscuss the regional interd epend ence
concep ts for the hip , knee, foot / ankle and the role of the
lum bar spine w ith respect to neu rod ynam ics.
Lumbar Spine Treatment
for Hip Disorders
Due to the anatom ical proxim ity and shared m u scu latu re of
the lu m bar sp ine and the hip , m u ch effort has been given to
id entifying the therapeu tic relationship betw een these tw o
areas. The term ‘hip –spine synd rom e’ w as originally pro-
p osed by Of erski and McN ab (1983) to d escribe the in u ence
of the p athological hip joint on the lu m bar sp ine. Research has
ind icated that d ecreased hip range of m otion and / or
d ecreased hip m u scle end urance m ay contribu te to low back
p ain and thu s shou ld be noted by the exam ining therap ist
(Reim an et al 2009). In a case stud y by Bu rns et al (2010) an
im pairm ent-based treatm ent approach includ ing m anual
therap y and exercise, targeted to the hip region, w as su ccess-
ful in resolving their patients’ hip as w ell as low back sym p-
tom s in fou r visits. Sym p tom relief continu ed at the long-term
follow -up points of 3 and 6 m onths. In a follow -up case series,
Burns et al (2011) took eight su bjects w ith chronic low back
p ain and p rovid ed m anu al therap y and exercises d irected at
the hip area. Treatm ent w as p rovid ed for three sessions over
a 1-w eek tim e span. Approxim ately 62% of ind ivid uals
reported w ith at least a ‘m od erately better ’ rating of perceived
im p rovem ent, and 25% red uction in m od i ed Osw estry Dis-
ability Ind ex scores w as noted . Althou gh the bod y of litera-
tu re ind icating the in u ence of hip treatm ent on the lu m bar
sp ine continu es to grow, the effect of lu m bar sp ine treatm ent
on hip cond itions has not been w ell stu d ied in isolation.
H erzog et al (1999) stud ied the im m ed iate EMG response
to lu m bar and sacroiliac thru st m anip u lation on the glu teal
m u scles of 10 asym p tom atic ind ivid u als. They fou nd a three-
fold increase in baseline EMG value in 80% of the subjects
im m ed iately after the thru st m anipu lation. Chilibek et al
(2011) evalu ated the effect of lu m bop elvic thru st m anipu la-
tion on the relative low er extrem ity strength d ifferences in
healthy su bjects. Fifty su bjects w ith at least a 15% sid e-to-sid e
low er extrem ity strength d ifference w ere rand om ized to
receive sid e-lying lum bopelvic m anipu lation or a placebo in
w hich only the set-up w as applied . Resu lts ind icated a
 222 PART 3 • 19 • Lumbar spine in lower extremity pain syndromes
signi cant change in relative strength d ifference of hip exion
in the treatm ent grou p com p ared w ith the control grou p .
Furtherm ore, hip abd uction strength increased in the w eaker
lim b im m ed iately p ost-m anip u lation, suggesting d ecreased
inhibition.
Lumbar Spine Treatment
for Knee Disorders
Although the pathoanatom ical in uence of the lu m bar sp ine
on the knee joint is p lau sible throu gh the osteokinem atic con-
nection of the p elvis, the m ore likely exp lanation for the con-
nection of these areas lies in the ability of the lu m bar sp ine to
affect the nervou s system d irectly. The contractile tissue su r-
round ing the knee joint is innervated by the fem oral and
sciatic nerves, both of w hich exit the sp ine in the lu m bar
region. Throu gh the m anual treatm ent of the lum bar spine, a
neu rop hysiological effect is created via the aforem entioned
nerves su bsequ ently in u encing the contractile tissu e, m ove-
m ent and p ain p atterns at the knee. The research su rrou nd ing
this theory has been exp and ing over the p ast d ecad e. Su ter
et al (1999) p erform ed a sm all prospective cohort stu d y of 18
ind ivid u als w ith anterior knee p ain. Su bjects w ere m easu red
before and after sid e-lying lu m bop elvic thru st m anipu lation
to d eterm ine the in u ence of the m anip u lation on knee exten-
sor m u scle strength and inhibition. Resu lts ind icated a statisti-
cally signi cant red u ction in m u scle inhibition, as w ell as a
signi cant increase in m u scle torqu e, after the thru st m anip u -
lation. Su ter et al (2000) follow ed u p this stu d y by p erform ing
a rand om ized trial in w hich 28 ind ivid u als w ere rand om ized
to receive either ju st an evalu ation or an evalu ation follow ed
by a lum bar spine m anipulation. Qu ad riceps m u scle inhibi-
tion and strength w ere m easu red before the exam ination as
w ell as im m ed iately after the exam or m anipu lation in both
grou ps. Results again d em onstrated a signi cant red u ction
in m u scle inhibition as w ell as an increase in qu ad ricep s
strength; how ever, this d id not reach the level of statistical
signi cance. To evalu ate fu rther the neu rop hysiological effect
of lu m bar m anip u lation versu s arthrokinem atic inhibition at
the knee joint, H illerm an et al (2006) com pared the effect of
sid e-lying lu m bop elvic m anip u lation and tibiofem oral d is-
traction m anip u lation on qu ad ricep s strength. A convenience
sam p le of 20 su bjects w ith p atellofem oral pain synd rom e
(PFPS) w as assigned to receive either a lum bopelvic or a tibi-
ofem oral thru st m anip u lation. Maxim u m volu ntary qu ad ri-
cep s contraction w as m easu red before and im m ed iately after
m anip u lation. The resu lts ind icated that only the grou p
receiving lum bopelvic m anipu lation show ed a statistically
signi cant increase in qu ad ricep s strength.
Althou gh the p revious stud ies d em onstrated an increase
in qu ad ricep s fu nction after lu m bop elvic m anip u lation in
p atients w ith p atellofem oral knee pain (Su ter et al 1999,
2000; H illerm an et al 2006), it w as u nclear w hich patients
w ou ld m ost be likely to bene t from these interventions.
Iverson et al (2008) d esigned a p rosp ective cohort / p red ictive
stu d y to investigate the effect of sp inal m anip u lation on p ain
and overall fu nctional change in ind ivid uals w ith PFPS.
Forty-nine subjects w ere exam ined and treated w ith a su pine
lu m bop elvic thru st m anip u lation. Im m ed iately after m anip u -
lation, they rated their p ain w ith the three fu nctional low er
extrem ity tests u sing the N um eric(al) Pain Rating Scale
(N RPS). Subjects also rated their overall fu nctional change
u sing the Global Rating of Change (GRC / GROC) scale. Of
the 49 subjects com pleting the stu d y, 45% w ere classi ed as
‘treatm ent su ccess’ based on a 50% or greater change in pain
or a fou r-p oint p ositive change on the GRC. Logistic regres-
sion analysis of p red ictive variables id enti ed a test item
clu ster of ve variables that p red icted su ccessfu l ou tcom e
w ith m anipu lation. These variables includ ed : a sid e-to-sid e
d ifference in hip internal rotation > 14°, ankle d orsi exion
w ith the knee exed > 16°, a navicu lar d rop > 3 m m , and su b-
jectively d escribing squatting as the m ost painful activity. Of
the ve p red ictive variables, a sid e-to-sid e d ifference of p rone
hip internal rotation > 14° w as the m ost p red ictive of treat-
m ent su ccess, increasing the p ost-test p robability of treatm ent
su ccess to 80% (+LR 4.9). If three ou t of ve variables w ere
p resent, this increased the p ost-test p robability of su ccess
to 94%.
Although sp inal thru st m anip ulation has been show n to
have an im m ed iate effect on qu ad ricep s fu nction (Su ter et al
1999, 2000; H illerm an et al 2006) and in certain cases on
sym p tom atic and fu nctional im p rovem ent (Iverson et al
2008), m ore-recent research ind icates that the effect m ay of
short d u ration. Grind staff et al (2009) com p ared the effect of
lum bar spinal m anipu lation, lu m bar passive range of m otion
and prone extension on quad riceps fu nction across tim e.
Forty-tw o healthy subjects w ere rand om ized to receive one
of the three interventions. Qu ad ricep s force ou tp u t and p er-
centage activation w ere m easu red before and after interven-
tion for all su bjects. Whereas second ary analysis su p p orted
p reviou s research ind icating an im m ed iate increase in qu ad -
riceps force and activation, there w as no signi cant change
in qu ad riceps function after 20 m inu tes. Grind staff et al
(2012) perform ed a sim ilar stu d y u sing subjects w ith PFPS.
In contrast to previou s research, this failed to show any sig-
ni cant change in qu ad ricep s fu nction after intervention.
Given the bread th of research ind icating the im m ed iate
effect of lu m bar m anual therapy on quad riceps fu nction and
sym p tom s, clinicians shou ld consid er the p ost-m anip u lation
p hase as an op p ortu nity to enhance m u scle fu nction and
p atient com fort throu gh the com bined effect of therap eu tic
exercise.
In fact, the com bination of lum bar spine m anu al therap y
and therap eutic exercise has been show n to be an effective
treatm ent strategy beyond the d iagnosis of knee osteoarthritis
(Deyle et al 2000, 2005). Deyle et al (2005) com p ared m anu al
therap y and exercise w ith sham u ltrasou nd in su bjects w ith
knee osteoarthritis. Su bjects in the treatm ent grou p received
m anu al therap y focu sed on the lu m bar sp ine, hip , knee and
ankle based on exam ination nd ings together w ith therap eu -
tic exercise to ad d ress knee range of m otion and strength
2–3× / w eek for 4 w eeks, w hile subjects in the control grou p
received sham u ltrasound at the knee. Resu lts ind icated that
the treatm ent grou p had signi cantly im p roved p atient-
p erceived pain, stiffness and function as w ell as 6-m inute
w alk-tim e at 8 w eeks, w hich persisted at 1 year. Fu rtherm ore,
a sm aller percentage of patients in the treatm ent grou p
requ ired injection or su rgery at 1 year com pared w ith the
control grou p . In a follow -u p stu d y, Deyle et al (2005) com -
p ared a sim ilar m anu al therap y p lu s exercise p rogram m e in
the clinic p lu s a hom e exercise reinforcem ent p rogram m e
w ith a hom e program m e in isolation in patients w ith

osteoarthritis. They fou nd that p atients treated w ith the
im pairm ent-based m anu al therapy to the low er extrem ity and
lum bar spine com bined w ith exercise had signi cantly greater
im provem ent in pain, stiffness and patient-reported fu nction
at 4 and 8 w eeks com pared w ith the hom e program m e in
isolation. Althou gh these d ifferences w ere not su stained at 1
year follow -u p, the u se of m anu al therapy and sup ervised
therap eu tic exercise p rod u ced greater short-term (< 8 w eeks)
bene ts.
A m u ltim od al treatm ent ap p roach incorp orating the entire
kinetic chain for p atients w ith knee d isord ers is fu rther su p-
p orted in a case series by Low ry et al (2008). Five patients w ith
PFPS w ere treated w ith a com bination of m anu al therap y
d irected at the lu m bopelvic region and entire low er quarter,
exercise, taping and orthotics. Treatm ents w ere ad m inistered
in an im pairm ent-based m od el and fou r ou t of ve p atients
d em onstrated signi cant im p rovem ent in pain and function.
This case series supp orts previou s research ind icating the use
of m anu al therap y at the lu m bar sp ine and low er qu ad rant
w ith exercise, and highlights the im p ortance of consid ering the
entire kinetic chain in the m anagem ent of knee d isord ers.
Lumbar Spine Treatment for Foot
and Ankle Disorders
In contrast to the knee, there are currently no know n stu d ies
on m anu al therap y to the lu m bar sp ine on su bjective, objec-
tive or fu nctional changes to the foot and ankle. H ow ever,
there is evid ence ind icating that m anu al therap y ap p lied to
the lu m bar sp ine in u ences the neu rop hysiology of the foot
and ankle, m easu red by skin cond u ctance and alteration of
the H -re ex or α -m otor-neu ron excitability (Dishm an &
Bu lbu lia 2000; Dishm an et al 2002; Perry & Green 2008; Perry
et al 2011). Dishm an et al (2002) com p ared the effect of thru st
w ith that of non-thru st lum bar spine m obilization on the
α -m otor-neu ron excitability of the gastrocnem iu s m u scle.
Seventeen su bjects w ere rand om ized to receive either a thru st
or a non-thru st m obilization and the change in am p litu d e of
the H offm an re ex (H -re ex) of the gastrocnem iu s w as
record ed . Resu lts ind icated that both interventions cau sed a
signi cant d ecrease in am p litu d e, su ggesting a d ecrease in
m otor-neu ron excitability. In a follow -u p stu d y, Dishm an et al
(2002) d em onstrated sim ilar resu lts com paring lum bar and
cervical m anip u lation on gastrocnem iu s m otor-neu ron excit-
ability. In 36 healthy ad ults, they d em onstrated that lu m bar
sp ine thru st m anip u lation created a transient d ecrease in
m otor-neu ron excitability in the calf, w hich lasted less than 60
second s. Perry and Green (2008) investigated the effect of
lum bar m obilization on the sym p athetic nervous system in
the low er extrem ity by m easu ring skin cond u ctance on the
d orsum of the foot. Forty- ve healthy ad u lts w ere rand -
om ized to receive grad e III u nilateral posterior–anterior (PA)
glid e at the lum bar spine, a placebo PA glid e, or a position
only as a control grou p . They d em onstrated a signi cant
change in skin cond u ctance w ith the m obilization grou p ,
w hereas the p lacebo and control group s show ed no change in
cond u ctance. In a follow -u p stu d y, Perry et al (2011) com -
pared lu m bar m anip u lation versu s lu m bar extension exer-
cises on skin cond u ctance as a m easu re of sym p athetic nervou s
system activity. Skin cond u ctance at the p lantar asp ect of the
Conclusion 223
foot w as record ed before and after intervention in a grou p of
50 healthy su bjects rand om ized to receive lu m bar m anip u la-
tion or extension exercises. Both grou p s exhibited a signi cant
change in skin cond u ctance w ith a signi cant greater change
in the m anip ulation grou p (76% change) than in the extension
exercise grou p (36% change). Given the neurop hysiological
effect of lu m bar m anipu lation at the low er leg, and the effect
on p ain, strength, m u scle length and fu nction at the hip and
knee, it is plausible that a sim ilar effect w ou ld be seen at the
foot and ankle. Clinical research is need ed to investigate the
effect of m anu al therapies applied to the lu m bar spine on
p ain, strength and fu nctional ou tcom e in p atients w ith foot
and ankle d isord ers. Table 19.1 p rovid es a su m m ary of key
articles associated w ith regional interd epend ence of the
low er extrem ity.
Lumbar Spine Treatment for Lower
Extremity Neurodynamics
Butler (2000) has d escribed the integration of m orp hological,
biom echanical and physiological fu nctions as neurod ynam -
ics, and im pairm ent in this system can im p act on resting
m u scle length, strength and p ain. It has been su ggested that
m anu al treatm ent of the low er back m ay in u ence afferent
and efferent pathw ays and alter low er extrem ity neu rod y-
nam ics and p lay a role in restoring m ovem ent and fu nction.
Cibulka et al (1986) stud ied the effect of sacroiliac m anipu la-
tion on resting ham string length in 20 su bjects d iagnosed w ith
ham string strain. Patients in the treatm ent grou p treated w ith
a supine lu m bop elvic m anipu lation d em onstrated a signi -
cant increase in ham string length com p ared w ith those in the
control grou p . Szlezak et al (2011) fou nd a sim ilar result on
ham string length m easu red w ith a straight leg raise. Thirty-
six healthy ind ivid u als w ere rand om ized to a m obilization
grou p, stretching grou p and control grou p. The researchers
fou nd that those in the m obilization grou p receiving u nilat-
eral PA m obilization to the lu m bar spine had an increase in
resting straight leg raise excursion com pared w ith those in the
control or stretching grou p s. H ip and knee d ysfu nction can
be a result of, and can contribute to, hypertonicity in the
ham string as a p rotective m echanism , and treatm ent of the
lum bar spine could be consid ered w ith these d isord ers.
(Ad d itional inform ation regard ing neurod ynam ics m ay be
fou nd in Chs 64 and 65.)
Conclusion
There is clearly a role of the lum bar spine in m any regions of
the low er extrem ity; how ever, m u ch rem ains u nknow n w ith
regard s to the d istinct role of interventions targeting ad jacent
regions. Cu rrently m ost of the regional interd epend ence
research has exam ined im m ed iate im p airm ent-based ou t-
com es (Cibu lka et al 1986; H erzog et al 1999; Su ter et al 2000;
H illerm an et al 2006; Chilibek et al 2011; Perry et al 2011);
how ever, m ore recent stu d ies have begu n to investigate the
functional outcom es associated w ith treating p atients w ithin
a regional interd epend ence fram ew ork (Deyle et al 2000, 2005;
Low ry et al 2008; Bu rns et al 2010, 2011).
224 PART 3 • 19 • Lumbar spine in lower extremity pain syndromes

Table 19.1 Ke y article s for lowe r e xtre mity re gional inte rde pe nde nce
Author (ye a r) Study Sa mple s ize Pa tie nt Inte rve ntions Ke y f nding s / re s ults
d e s ig n pop ula tion

Hip
Herzog et al Cas e series n = 10 As ymptomatic Spinal manipulation 80% of subjects experiences a
(1999) (asymptomatic throughout entire s pine threefold increase in gluteal EMG
males)
Chilibek et al RCT n = 50 > 15% s trength Lumbar manipulation Increase in hip exion s trength
(2011) de cits Increase in hip abduction strength
between leg
Cibulka et al RCT n = 20 Hams tring Sacroiliac joint thrus t Increase mus cle peak torque of
(1986) strain manipulation hamstrings
Kne e
Suter et al n = 18 (14 Anterior knee Side-lying s acroiliac joint Immediate increased knee extens or
(1999) unilateral; 4 pain thrust manipulation torque and decreased knee
bilateral) extens or inhibition
Suter et al RCT n = 28 (23 Anterior knee Side-lying s acroiliac joint Immediate decreased knee extensor
(2000) symptomatic; 5 pain thrust manipulation inhibition
asymptomatic)
Hillerman et al RCT n = 20 As ymptomatic Sacroiliac manipulation vs Sacroiliac joint manipulation group
(2006) tibiofemoral mobilization had increased quadriceps muscle
strength
Iverson et al Pros pective n = 49 Patellofemoral Supine lumbopelvic 45% of patients had a +4 or greater
(2008) cohort pain manipulation rating on the GROC
syndrome Tes t-item clus ter identi cation
Grinds taff et al RCT n = 42 As ymptomatic Lumbar manipulation, Immediate increase in quadriceps
(2009) individuals lumbar pas sive range force output with manipulation –
of motion or extens ion lasted 20 minutes
exercis e
Grinds taff et al RCT n = 48 Patellofemoral Lumbar manipulation, No change in quadriceps activation or
(2012) pain lumbar pas sive range force output
syndrome of motion or extens ion
exercis e
Lowry et al Cas e series n =5 Patellofemoral Impairment-bas ed manual 80% of subjects had improved pain
(2008) pain therapy to entire lower and function
syndrome quarter, exercis e, taping
and orthotics
Deyle et al RCT n = 83 Knee Impairment-bas ed manual Improved pain, stiffness , function and
(2000) osteoarthritis therapy to the lower 6-minute walk-tes t scores favouring
extremity vs s ham manual therapy group
ultrasound
Deyle et al RCT n = 134 Knee Impairment bas ed manual Improved pain, stiffness , function and
(2005) osteoarthritis therapy to the lower 6-minute walk-tes t scores favouring
extremity vs home manual therapy group (at 4 and 8
exercis e programme weeks)
Groups were equal at 1 year
Ankle  / Fo o t
Dis hman et al RCT n = 17 As ymptomatic Thrust vs non-thrust Decreas ed motor neuron excitability
(2000) lumbar manipulation of the gastrocnemius
Perry et al RCT n = 50 As ymptomatic Lumbar manipulation vs Skin conductance was increased in
(2011) extens ion exercis es the manipulation > exercise group
EMG = electromyographic, RCT = randomized controlled trial, GROC = global rate of change.

The m ajority of the cu rrent research has focu sed on the
bu ttock, hip, thigh and knee, w hile there is a relative lack of
articles d iscu ssing the relationship of the lu m bar spine in
ankle / foot d isord ers. In the u pp er extrem ity, som e research
has been cond u cted exam ining the effects of cervicothoracic
treatm ent in d istal u p p er extrem ity cond itions su ch as carp al
tu nnel synd rom e, so it is also p ossible to foresee a p otential
association betw een the lu m bar spine and d istal low er extrem -
ity cond itions (Davis et al 1998).
Althou gh the evid ence su pporting a d irect, cau sal relation-
ship m ay be lacking, the cu rrent evid ence m ay com p el the
clinician to exam ine and p otentially intervene on regions
ad jacent to and / or rem ote from a p atient’s prim ary location
of sensory sym p tom s. Im p lem entation of an im p airm ent-
based app roach to interventions w ith continu ous reassess-
m ent of the p atient’s resp onse to treatm ents m ay lead to
su p erior ou tcom es. Ad d itionally, this m ethod ology m ay assist
the clinician in id enti cation and im p lem entation of a p lan of
care that is ind ivid u ally tailored to the p atient and increase
the p robability of a su ccessfu l ou tcom e.
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 PART 3 •  Lumbar Spine Pain Syndromes
20  Chapter 
The Contribution of the Pelvic Floor Muscles to Pelvic Pain
Ru th J o n e s
CHAP TER CONTENTS
Introduction  226
Anatomy and neural control  226
Pelvic f oor muscles and lumbopelvic pain  227
Chronic pelvic pain  227
Conservative management o  chronic pelvic pain  228
A clinical-reasoned approach  or conservative management  
o  chronic pelvic pain  230
Understanding current pain science  230
Movement system dys unction  230
Pelvic f oor muscle  unction  230
Case reports  232
Conclusion  233
Introduction
The pelvic oor is a ascinating, intricate stru ctu re, w hich by
virtu e o its anatom ical p osition is a challenging, u nd erstu d -
ied region o the bod y (Ashton-Miller & DeLancey 2007). The
p elvic oor is essential or continence, pelvic organ su p port,
sexu al activity, concep tion, ertility and vaginal d elivery
(DeLancey 1990, 2005; H ow ard et al 2000; H erschorn 2004;
Baytu r et al 2005). There is also increasing evid ence that the
p elvic oor m u scles contribute to resp iration (H od ges et al
2007), spinal stability, and containm ent o intra-abd om inal
p ressu re (IAP) (H em borg et al 1985; Pool-Gou d zw aard et al
2004; Sm ith et al 2008). The physiological m echanism s by
w hich these m u scles per orm these roles are not clearly
u nd erstood yet, w hich is p red om inately d u e to a lack o su it-
able instru m entation.
Pelvic oor d ys u nction is a signif cant p roblem or both
w om en and m en and encom passes both u rinary and aecal
incontinence, p elvic organ p rolap se (POP) and p elvic p ain
(Martins et al 2007), w ith estim ates in the USA ind icating that
betw een 21% and 26% o Am erican w om en have at least one
p elvic oor d isord er, w ith the greatest p ercentage experienc-
ing u rinary incontinence (N ygaard et al 2008). Pelvic oor
d ys u nction a ects u p to 400 000 Am erican w om en so severely
that they requ ire su rgery, and 30% o those w ill require
u rther su rgery (Olsen et al 1997; Boyles et al 2003). The exact
m echanism s or the d evelop m ent o p elvic oor d isord ers
rem ain controversial; how ever, a com bination o neu ropathic
changes and m u scle, ascial or connective tissu e d am age is
m ost likely to be resp onsible (Shaf k et al 2005; Ashton-Miller
& DeLancey 2007; Petros 2007; Sm ith et al 2007).
Anatomy and Neural Control
As the pelvic oor m u scles orm the in erior asp ect o the
lum bopelvic cylind er (LPC) and IAP is generated by coactiva-
tion o the p elvic oor m u scles, the d iap hragm and the
abd om inal m u scles (H em borg et al 1985; H od ges & Gand evia
2000), this im plies that coord inated coactivation o the m uscles
o the LPC is necessary in ord er to balance the u nctional
d em and s o continence, respiration and lu m bop elvic stability
(H em borg et al 1985; H od ges & Gand evia 2000; Pool-
Gou d zw aard et al 2004; H od ges et al 2007). As the su pport
m echanism s o the p elvic oor are resp onsible or the m ain-
tenance o continence and p revention o POP d u ring increases
in IAP (Ashton-Miller & DeLancey 2007), unctionally the
p elvic oor has the d u al role o allow ing the p assage o u rine
and aeces at the app ropriate tim e, w hilst also p reventing
incontinence. There ore, given the m ultipu rpose role o the
p elvic oor m u scles, the m otor control challenge o these
m u scles is signif cant and the e f ciency o them w ill not only
rely upon the anatom ical integrity o the pelvic oor, bu t also
d ep end on the central nervou s system (CN S) response to
satis y hierarchical d em and s o u nction.
There is a constant low level o m u scle activity in the LPC
m u scles and increased activity w hen the CN S can p red ict
tim ing o increased d em and / load , su ch as occu rs in cou gh-
ing, li ting or lim b m ovem ents (Constantinou & Govan 1982;
Moseley et al 2002; Barbic et al 2003). The CN S m u st there ore
interpret the m u ltiple a erent inpu ts and generate a coord i-
nated resp onse so that m u scle activity occu rs at the right tim e,
w ith the app ropriate level o contraction.
The pelvic oor m uscles are com posed o sm ooth and stri-
ated m uscle f bres (Shaf k et al 2002), approxim ately tw o-
third s o w hich are typ e I (Gosling et al 1981) – re ecting the
need or end u rance in a continu ou s su p p ortive u nction
(Shaf k et al 2003). It is thou ght that the pelvic oor m u scles
p red om inantly contract or relax en m asse (Shaf k 1998) yet,
d u e to the separate thou gh id entical innervation o each ind i-
vid u al m u scle, there m ay also exist the cap acity or volu ntary
selective activity by w hich an ind ivid u al m u scle m ight behave

ind epend ently rom the others (Shaf k 1998; Kenton & Bru-
baker 2002). There are d i erent opinions regard ing the exact
innervation o the pelvic oor m uscles; how ever, there is con-
sensu s that the nerve su p p ly is rom the p u d end al nerve w ith
d irect branches rom the sacral nerves S3–S4 (Shaf k 2000;
Gu ad erram a et al 2005; Grigorescu et al 2008). The pu d end al
nerve carries m otor, sensory and au tonom ic f bres; conse-
qu ently both a erent and e erent p athw ays can be a ected
by its inju ry (Gray et al 1995). The p osterior em oral cutane-
ou s nerve (S1–S3 / 4) gives rise to the in erior clu neal and
perineal branches and has also been im plicated in chronic
pelvic p ain (CPP) (Darnis et al 2008; Tu bbs et al 2009).
N eural control o the pelvic organs is a ected by a coord i-
nation o som atic and au tonom ic m otor nervou s system s, and
sensory in orm ation and eed back are su p p lied by both vis-
ceral and som atic sensory f bre system s (Enck & Vod u sek
2006). The som atic innervation is largely rom the lum bar,
sacral and coccygeal p lexu ses. The p elvic sym p athetic inner-
vation p rod u ces vasom otor e ects, inhibits p eristaltic con-
traction o the rectu m and stim u lates contraction o the
internal genitals d u ring orgasm , p rod u cing ejacu lation in
m ales (Pattern & H u ghes 2008). Parasym p athetic innervation
cau ses contraction o the blad d er and rectu m or m ictu rition
and d e ecation, and clitoral or p enile erection (Pattern &
H u ghes 2008). The pelvic visceral a erents travel w ith the
parasym p athetic f bres to the spinal ganglia (S2–S4). N ocicep -
tive visceral a erents rom the p rostate, sem inal vesicles,
vagina, cervix, d istal sigm oid colon and rectu m ollow p ara-
sym p athetic f bres to the sp inal ganglia. N ocicep tive visceral
a erents rom the blad d er, ovaries and u terus travel w ith the
sym p athetic f bres to the in erior thoracic and su p erior lu m bar
sp inal ganglia (Pattern & H u ghes 2008). The autonom ic nerves
help to control m ictu rition, d e ecation and sexu al intercou rse.
The sym pathetic nerves arise rom the lu m bar splanchnic
nerves and the p arasym p athetic nerves rom the p elvic
sp lanchnic nerves. There ore, d u e to the intim ate and sim ilar
anatom ical innervations betw een the pelvic oor and pelvic
organs (a viscera–som atic relationship ), w hen evaluating the
patient w ith p elvic oor pain it is im p ortant to consid er the
lu m bosacral p lexu s, the ind ivid u al p erip heral nerves and
the sym p athetic chain.
Pelvic Floor Muscles
and Lumbopelvic pain
Wom en w ith incontinence, resp iratory d isord ers and gas-
trointestinal sym p tom s have increased risk or the d evelop -
m ent o lu m bop elvic p ain (Sm ith et al 2009). Ad d itional
evid ence exists connecting d iaphragm atic and breathing
pattern d isord ers w ith variou s orm s o pelvic gird le d ys unc-
tion (O’Su llivan et al 2002; O’Su llivan & Beales 2007) as w ell
as w ith CPP and associated sym ptom s, su ch as stress incon-
tinence (Sm ith et al 2006, 2007; H od ges et al 2007; O’Su llivan
& Beales 2007). It is also su ggested that there is a connection
betw een sacroiliac joint (SIJ) stability and respiratory and
pelvic oor u nction, particu larly in w om en (H od ges et al
2007). The d evelopm ent o low back pain d uring pregnancy
(PLBP) increases the od d s o d eveloping p elvic oor d isord er
com p laints, esp ecially there w as a negative active straight leg
raise test (Pool-Gou d zw aard et al 2004). In one stud y o
Chronic pelvic pain 227
p atients w ith PLBP, p elvic oor activity had higher resting
tone and shorter end u rance tim e (Pool-Gou d zw aard et al
2004); 52% had a com bination o low back pain and p elvic
oor d ys u nction and 82% o these stated that their com -
p laints started w ith low back p ain p rior to the p elvic oor
d ys u nction. More recently, pelvic oor m uscle d ys u nction
as m easu red by u ltrasou nd has also been ound to be p resent
in m en su ering rom CPP; the anorectal angle at rest w as
m ore acu te in u rological chronic p elvic p ain synd rom e
(UCPPS) than controls and this angle w as correlated w ith
p ain, sexu al d ys u nction and anxiety (Davis et al 2011). Fu r-
therm ore, there w as less u p w ard m ovem ent o the p elvic oor
m u scles d u ring contraction, and red u ced contractile end u r-
ance in CPP m en above norm al ind ivid u als.
As stated , there is evid ence o a d i erent response o the
p elvic oor m u scles to lum bopelvic pain – that is, either
increased or d ecreased activity (O’Su llivan et al 2002; Pool-
Gou d zw aard et al 2004; Davis et al 2011). O’Su llivan and
Beales (2007) suggested that su ch changes m ay represent a
response to a pain d isord er (i.e. it m ay be ad aptive), or m ight
p rom ote abnorm al tissu e strain and there ore be seen to be
‘m alad ap tive’, or provocative o su bsequent pain d isord ers.
Malad ap tive changes m ight in tu rn lead to a d ef cit in m otor
control or increased m otor activation resu lting in a m echa-
nism or ongoing p erip heral p ain sensitization, lead ing to
chronic p ain involving the p elvis and p elvic oor stru ctu res
(O’Su llivan 2005; Sm ith et al 2009).
In su m m ary, it is u nd erstood that, in the presence o pos-
tu ral changes, resp iratory d em and s, lu m bop elvic p ain and
stress incontinence, the u nction o the LPC m u scles can be
altered (H em borg et al 1985; H id es et al 1996; H od ges & Rich-
ard son 1996, 1998; H od ges & Gand evia 2000; Moseley et al
2002; O’Su llivan et al 2002; Jones et al 2006; H od ges et al
2007; Dickx et al 2008). There is evid ence that skilled volun-
tary activation o those relevant m u scles w ith altered m otor
recru itm ent can red u ce pain, d isability and recu rrence rate or
m u scu loskeletal cond itions (H id es et al 2001; Cow an et al
2003; Ferreira et al 2006), restore m otor coord ination inclu d -
ing au tom atic postu ral ad justm ents (Cow an et al 2003; Tsao
& H od ges 2007, 2008) and reverse cortical reorganization in
p eop le w ith recu rrent p ain (Tsao et al 2010). These f nd ings
su ggest that the m u scles o the LPC shou ld be evalu ated and
rehabilitated in patients w ith CPP. To d ate, how ever, no sci-
entif c trial has evaluated this clinical approach or the p elvic
oor m u scles in this su bgrou p o pain patients.
Chronic Pelvic Pain
Chronic p elvic p ain (CPP) is non-m alignant p ain p erceived in
stru ctu res related to the p elvis o either m en or w om en. In the
case o d ocu m ented nocicep tive p ain that becom es chronic,
p ain m u st have been continuou s or recurrent or at least 6
m onths. I non-acu te and central sensitization p ain m echa-
nism s are w ell d ocu m ented , then the p ain m ay be regard ed
as chronic, irresp ective o the tim e period (Fall et al 2010). CPP
is then su bd ivid ed into those cond itions w ith w ell-d ef ned
classical p athology, su ch as in ection and cancer, and those
w here no obviou s pathology is ou nd . Chronic pelvic pain
synd rom e (CPPS) is the occu rrence o CPP w here there is no
p roven in ection or other obviou s local p athology that m ay
 228 PART 3 •
accou nt or the p ain; it is o ten associated w ith sym ptom s
su ggestive o low er u rinary tract, sexu al, bow el or gynaeco-
logical d ys u nction and has negative cognitive, behaviou ral,
sexu al and em otional consequ ences (Fall et al 2010).
H ow ard (2003) su ggests that ap proxim ately 15–20% o
w om en aged 18 to 50 years have exp erienced CPP lasting or
m ore than 1 year, and an 8% prevalence rate or CPPS has
been estim ated in the US m ale popu lation (And erson 2008).
H ow ever, overall prevalence rates o CPP are likely to be
u nd erd iagnosed , p artly as a resu lt o the lack o agreed -u p on
d ef nitions and su bsequ ent d i f culty in categorizing CPP (Fall
et al 2010).
Du e to the sensitisation p rocesses involved in CPP (Fall
et al 2010), p ersistent pain is associated w ith changes in the
CN S that m ay m aintain the p ercep tion o p ain in the
absence o acu te inju ry, so that the p elvic oor m u scles m ay
becom e hyperalgesic, and contain m ultiple active trigger
p oints. This process m ay lead to organs becom ing sensitive,
or exam ple the u teru s in d yspareunia and d ysm enorrhoea,
or the bow el in irritable bow el synd rom e (IBS). Men w ith
chronic p rostatitis have m ore generalized p ain sensitivity
(Berger et al 2007), and cu rrent thinking suggests that i
there has been in ection or trau m a this resu lts in neu rogenic
in am m ation in p erip heral tissu es and the CN S (Pontari &
Ru ggieri 2008).
The sym p tom s o CPP / CPPS ap p ear to resu lt rom inter-
p lay betw een p sychological actors and d ys u nction in the
im m u ne, neu rological and end ocrine system s (Pontari & Ru g-
gieri 2008). It there ore seem s that therapeu tic ap proaches
shou ld ad op t treatm ent strategies that take accou nt o these
m u ltip le interacting actors.
Iliococcygeus muscle
Pubococcygeus muscle Levator ani
muscle
Puborectalis muscle
Gluteus Coccygeus
maximus muscle
A
A muscle (cut) B
B C
Figure 20.1 The pelvic oor muscles: (A) Scheme of muscles. (B) Referred pain from coccygeus or iliococcygeus muscle trigger points. (C) Referred pain from
pubococcygeus or levator ani muscle trigger points. (Reproduced from Chaitow L, Lovegrove Jones R (eds). 2012. Chronic pelvic pain and dysfunction: practical physical
medicine. London: Elsevier Churchill Livingstone, with permission. Picture from the same author.)
20 • The contribution o  the pelvic f oor muscles to pelvic pain
Conservative Management of Chronic
Pelvic Pain
Many investigators believe that the sou rce o p ain and d ys-
unction in m en and w om en w ith CPP, inclu d ing chronic
testicu lar p ain, relates to chronic tension in m yo ascial tissu e
in and around the pelvic oor (And erson et al 2005, 2009;
Cu rtis N ickel et al 2007; Planken et al 2010). The pathogenic
m echanism s associated w ith the d evelop m ent o p elvic geni-
tou rinary sym p tom s are u nknow n as it rem ains d i f cu lt to
exp lain the role o pain u l pelvic oor tissu es – particu larly
as, u p until recently, stu d ies o pelvic oor m u scle u nction
have ocu sed on the evalu ation o the strength and end u rance
o volu ntarily initiated contractions (Laycock et al 2001; Bø &
Finckenhagen 2003; Dum oulin et al 2003) rather than issues
o m otor control. Classically, trigger p oints in the p elvic oor
m u scles have been d ocu m ented as re erring sym p tom s to the
lum bar spine, p osterior thigh, coccyx, abd om en, p erineum ,
groin, testicles, penis and vu lva (And erson et al 2009) (Fig.
20.1). Specif cally the obtu rator internu s m u scle (Fig. 20.2) is
reported to re er m ost com m only to the abd om en and groin,
and to be resp onsible or a sensation as i there is som ething
insid e the rectu m or vagina (like a gol ball). Also the coccy-
geu s / ischiococcygeus is reported to re er to the coccyx and
glu teal region and to be responsible or pain occu rring
p re- / p ost-bow el m ovem ent and / or u ll-bow el sensations
and d iscom ort. The pu boccocygeu s is rep orted to be the m ost
im p ortant or m ale p elvic pain; it can re er to the tip o the
p enis, the blad d er and u rethra, and can m im ic the sensation
C
 Conservative management o  chronic pelvic pain 229

Piriformis muscle
Coccygeus muscle

Iliococcygeus muscle
Obturator internus
Tendinous arch of
the levator ani muscle

Pubococcygeus muscle

Figure 20.2 Scheme of the pelvic oor musculature. (Reproduced from Chaitow L, Lovegrove Jones R (eds). 2012. Chronic pelvic pain and dysfunction: practical physical
medicine. London: Elsevier Churchill Livingstone, with permission. Picture from the same author.)

o p ressu re or u llness o the p rostate. The iliococcygeu s can

also re er to the lateral abd om inal w all, the perineu m and anal
sp hincter, and to be resp onsible or a sensation o p rostate
ullness and pain (And erson et al 2009).
It is thou ght that there are general reasons w hy a p erson
m ay d evelop excessive tension in the m yo ascial tissu e o the
p elvic oor – su ch as straining, habitu al tightening, trau m a
and in am m ation – and there ore p otentially d evelop active
trigger p oints. Other reasons that have been su ggested inclu d e
child birth trau m a, recu rrent u rinary tract in ection, d igestive
tract d isord ers, IBS, p rolap se, p elvic su rgery, constip ation,
d e ecation d ys unction, haem orrhoid s / f stu lae / f ssu res,
sexu al abu se, p elvic in am m atory d isease / end om etriosis,
scar tissu e / ad hesions, and trau m a to the coccyx or other
p elvic trau m a (Carter 2000; Tu et al 2006; Fitzgerald et al
2009). Stu d ies using trigger point release o the p elvic oor
have show n im p rovem ent in sym p tom s o interstitial cystitis
(Weiss 2001; Doggw eiler-Wiygu l & Wiygu l 2002), altered
libid o, ejacu latory, penile and erectile p ain, urinary sym p-
tom s, and ejacu latory d ys u nction in m en w ith CPP (And er-
Figure 20.3 Scheme of the internal technique for trigger point treatment.
son et al 2006, 2009, 2011). Trigger point d eactivation o the (Reproduced from Chaitow L, Lovegrove Jones R (eds). 2012. Chronic pelvic pain
levator ani by injection w as also show n to be o signif cant and dysfunction: practical physical medicine. London: Elsevier Churchill
valu e in the m anagem ent o p atients w ith CPP (Lang ord et al Livingstone, with permission. Picture from the same author.)
2007).
A m u lticentre stu d y has d em onstrated the easibility o
p er orm ing clinical therapeu tic trials u tilizing m uscle and tissu e. Manu al techniqu es su ch as trigger p oint release w ith
connective tissu e p hysiotherap y to treat u rological CPPS or w ithou t active contraction or recip rocal inhibition, m anu al
(Fitzgerald et al 2009). A com parison grou p o p atients w ere stretching o the trigger p oint region w ere u sed on the id enti-
rand om ized to receive either total-bod y trad itional Western f ed trigger p oints. A second ary ou tcom e o the stu d y revealed
m assage w ith no m yo ascial release or internal p elvic therap y. good patient response to the internal and external physical
Those w ho w ere rand om ized to the m yo ascial therap y group therap y as com p ared w ith generalized external Western
u nd erw ent connective tissu e m anip u lation to all bod y w all m assage only (57% versu s 28% respectively). This orm o
tissu es (see Fig. 20.2) o the abd om inal w all, back, bu ttocks therap y w as exp and ed to a larger trial in w om en su ering
and thighs as w ell as internal p elvic oor m u scles clinically rom interstitial cystitis or p ain ul blad d er synd rom e; the
ou nd to contain connective tissu e abnorm alities and / or global response assessm ent response rate w as 26% in the
trigger p oint release to p ain u l m yo ascial trigger p oints (Fig. global therap eu tic m assage grou p and 59% in the m yo ascial
20.3). This w as d one until a change w as noted in the treated p hysical therap y grou p (Fitzgerald et al 2012).
 230 PART 3 • 20 •
A Clinical-reasoned Approach for
Conservative Management of Chronic
Pelvic Pain
In the m anagem ent o a patient w ith pelvic pain it w ou ld be
convenient to ocu s solely on the end organ that is p erceived
to be ‘at au lt’. H ow ever, the hu m an bod y op erates as a
system , and is m od u lated by several actors rom som atic,
p hysiological, cognitive, em otional, psychological and social
d om ains, all o w hich have the potential to in uence nocicep-
tion (Moseley 2008; Fall et al 2010). Each com ponent o the
m ovem ent system is likely to in u ence d istal and p roxim al
regions; there ore, w hen assessing (and treating) a patient
w ith pelvic pain, as clinicians w e need to ad opt a holistic
clinically reasoned ap p roach so as to id enti y the p articu lar
in u ences that have cau sed , m aintained and / or exacerbated
a patient’s cond ition, w hilst rem ind ing ou rselves that any
d ys unction observed m ay not be even relevant to the pre-
senting cond ition and w ill also be in u enced by the thera-
p ist’s p ersp ective and d i erent belie system s. The ollow ing
section d escribes the system atic ap p roach that the au thor o
the chap ter u ses, w hich takes into accou nt these m u ltip le
actors.
Understanding current pain science
It is im portant to und erstand the patient’s pain perception
and belie s and link this to cu rrent pain science. This is espe-
cially im p ortant w ith p atients com p laining o chronic p ain as
m any p atients still equ ate p ain w ith d am age and avoid activi-
ties, su ch as sitting, that ‘hu rt’. For exam p le, m any p atients
w ith CPP believe that they have pu d end al nerve entrapm ent
(PN E) and believe that sitting com presses the pu d end al nerve,
as ind icated by increasing p ain, and there ore w ill o ten only
sit w ith ‘cu t-ou t’ cu shions and avoid ‘hard ’ chairs. The clini-
cian exp laining how m u ltip le actors contribu te to the p ain
experience is an im portant w ay o red ucing the threat associ-
ated w ith pelvic p ain. A ‘10 p oints to p ain TM ’ m od el is one
concep t that a nu m ber o p atients and clinicians have ou nd
u se u l (Jones 2003, u np u blished ) (Fig. 20.4). It is an easy w ay
to d em onstrate that p ain can d evelop or many d i erent
reasons and w orks on the prem ise that pain is rarely the resu lt
o one single incid ent, bu t norm ally stem s rom a range o
Attitudes and
Recreational and beliefs Motor control and
daily activities movement patterns
Pathology Nutrition
Cultural Accumulate 10 points Previous
factors for PAIN experience
Hormones Emotional state
Social/work Genetics/tissue
environment Direct trauma type
Figure 20.4 Accumulate 10 points to pain: some factors that appear to
in uence the accumulation of a pain experience. (Adapted from Jones 2003.)
The contribution o  the pelvic f oor muscles to pelvic pain
d i erent issu es or a whole lifestyle that contribu tes to the 10
points and pain u l state. In this w ay, the patient and therap ist
can m ove aw ay rom the solely stru ctu ral p athological m od el
to one that consid ers, or exam p le, the brain in p ain, the
patient’s belie s abou t their pain and nu tritional issues, in
ad d ition to any p athology or m otor control issu es.
Movement system dysfunction
Variou s classif cations or the analysis o m ovem ent and the
su bclassif cation o m ovem ent d ys u nction have been p ro-
p osed (McGill 2002; Sahrm ann 2002; McKenzie & May 2003;
O’Su llivan 2005) and in som e instances are gaining good evi-
d ence o valid ity and reliability (Van Dillen et al 1998, 2003;
Dankaerts et al 2006; H arris-H ayes & Van Dillen, 2009). The
m u scu loskeletal actors that need to be consid ered inclu d e the
p assive and active sti ness o the lu m bop elvic sp ine and hip s,
w hich w ill be in uenced by m u scle and ascial system s, all
u nd er neu ronal control. Assessm ent o the neu ral system is
there ore critical, p articu larly neu ral m obility (H all et al 1998;
Walsh et al 2009). Stru ctu ral d i erences su ch as bony varia-
tion o the p elvis and em u r, im balances o strength, length,
tim ing and m agnitu d e o recru itm ent o the tru nk and hip
m u scles w ill also need to be assessed d u ring test m ovem ents,
as w ell as specif c unctional activities w here p ossible.
Pelvic oor muscle function
Ind ications that there m ay be a pelvic oor com ponent to the
p atient p resenting w ith p elvic p ain are clinically revealed by
u se o valid ated qu estionnaires, su ch as the N IH -Chronic
Prostatitis Sym p tom Ind ex (N IH -CPSI) or m ales (Fig. 20.5)
and the version ad apted or em ales (Fig. 20.6) (Litw in 2002).
There is strong evid ence to su ggest that qu estionnaires are a
p ow er u l tool to ind icate UCPPS (And erson 2011). In investi-
gating pelvic oor m u scle unction, it is im portant or the
therap ist to evalu ate:
1. The resting activity o the pelvic oor m uscles, to see
w hether there is over- / und eractivity
2. The voluntary activation o the pelvic oor m u scles
inclu d ing p ow er, end u rance and d irection o contraction
3. The ability o the pelvic oor m uscles to release to their
resting position
4. Structural d ys u nction, su ch as prolapse
5. N eu ral integrity, or exam ple the pu d end al nerve or
signs o irritability (p ositive Tinel’s sign)
6. Any active trigger points w ithin the pelvic oor
m u scles.
Active trigger points are particularly help ul i they are ound
to rep rod u ce the p atient’s sym p tom s; how ever, these d o not
have to be lim ited to those that re er only to these p articu lar
areas. It is im portant that the clinician exp lain to p atients w ith
CPP that m any areas m ay be hyp eralgesic and not relevant
to the p resenting cond ition, thereby red u cing the threat asso-
ciated w ith the p ain exp erienced . Clinical exp erience has
been that m en w ithout pelvic pain on palp ation o a point
close to the p rostate, near the p u bic sym p hysis, have no
re erral to the penis, w hereas m en w ith CPP have re erred
sym p tom s to the sha t or tip o the p enis. This is a p ositive
 A clinical-reasoned approach  or conservative management o  chronic pelvic pain 231

NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) (for males)

Center for Urologic and Pelvic Pain

Name: ____________________________
Date: _____________________________

Pain or Discomfort 6. How often have you had to urinate again

less than two hours after you finished
1. In the last week, have you experienced urinating, over the last week?
any pain or discomfort in the following 0 Not at all
areas? 1 Less than 1 time in 5
Yes No 2 Less than half the time
a. Area between rectum and 1 0 3 About half the time
testicles (perineum) 4 More than half the time
b. Testicles 1 0 5 Almost always
c. Tip of the penis (not related to
urination) 1 0 Impact of Symptoms
d. Below your waist, in your
pubic or bladder area 1 0 7. How much have your symptoms kept you
from doing the kinds of things you would
2. In the last week, have you usually do, over the last week?
experienced: Yes No 0 None
a. Pain or burning during 1 Only a little
urination? 1 0 2 Some
b. Pain or discomfort during or 3 A lot
after sexual climax (ejaculation)? 1 0
8. How much did you think about your
3. How often have you had pain or symptoms, over the last week?
discomfort in any of these areas 0 None
over the last week? 1 Only a little
0 Never 2 Some
1 Rarely 3 A lot
2 Sometimes
3 Often Quality of Life
4 Usually
5 Always 9. If you were to spend the rest of your life
with your symptoms just the way they have
4. Which number best describes your been during the last week, how would you
AVERAGE pain or discomfort on the days feel about that?
that you had it, over the last week? 0 Delighted
0 1 2 3 4 5 6 7 8 9 10 1 Pleased
NO PAIN PAIN AS BAD 2 Mostly satisfied
AS YOUCAN
IMAGINE
3 Mixed (about equally satisfied and
Urination dissatisfied)
4 Mostly dissatisfied
5. How often have you had a sensation of 5 Unhappy
not emptying your bladder completely after 6 Terrible
you finished urinating, over the last week? Scoring the NIH-Chronic Prostatitis Symptom Index
0 Not at all Domains
1 Less than 1 time in 5 Pain: Total of items 1a, 1b, 1c,1d, 2a, 2b, 3, and 4 =____
Urinary Symptoms: Total of items 5 and 6 =____
2 Less than half the time Quality of Life &Impact: Total of items 7, 8, and 9 =____
3 About half the time
4 More than half the time
5 Almost always

Figure 20.5 NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) (for males). (Adapted from Litwin et al. 1999. J Urol 162: 369–375.)

d iagnostic test called the ‘sign o the penis’ (SOP) (Jones 2014,
u np u blished ) and as their sym p tom s clear the SOP becom es
negative.
I active trigger points are ou nd , patients (or their part-
ners) can p ractise sel -m anagem ent u sing a variety o m ethod s
su ch as internal p elvic trigger p oint w and (Fig. 20.7) (And er-
son et al 2011), w hich in this clinician’s exp erience help s to
sp eed recovery. In ad d ition to sel -release, m any p atients need
to be ad vised to check requ ently w hether they are u ncon-
sciou sly contracting their p elvic oor, either d irectly or by
co-contracting via their abd om inal m u scles. A clinically u se u l
techniqu e involves teaching the p atient to breathe into the
abd om en w hilst sim u ltaneou sly relaxing the abd om en and
p elvic oor (Whelan 2012).
 232 PART 3 • 20 • The contribution o  the pelvic f oor muscles to pelvic pain

Female NIH-Chronic Prostatitis Symptom Index (NIH-CPSI)

Center for Urologic and Pelvic Pain

Name: ____________________________
Date: _____________________________

Pain or Discomfort
1. In the last week, have you experienced 6. How often have you had to urinate again
any pain or discomfort in the following less than two hours after you finished
areas? urinating, over the last week?
Yes No 0 Not at all
a. Area between rectum and 1 0 1 Less than 1 time in 5
vagina (perineum) 2 Less than half the time
b. Labia 1 0 3 About half the time
c. Clitoris (not related to 4 More than half the time
urination) 1 0 5 Almost always
d. Below your waist in your
pubic area 1 0 Impact of Symptoms
e. Below your waist in your 7. How much have your symptoms kept you
rectal area 1 0 from doing the kinds of things you would
usually do, over the last week?
2. In the last week, have you 0 None
experienced: Yes No 1 Only a little
a. Pain or burning during 2 Some
urination? 1 0 3 A lot
b. Pain or discomfort during or
after sexual climax? 1 0 8. How much did you think about your
symptoms, over the last week?
3. How often have you had pain or 0 None
discomfort in any of these areas 1 Only a little
over the last week? 2 Some
3 A lot
0 Never
1 Rarely Quality of Life
2 Sometimes 9. If you were to spend the rest of your life
3 Often with your symptoms just the way they have
4 Usually been during the last week, how would you
5 Always feel about that?
0 Delighted
4. Which number best describes your 1 Pleased
AVERAGE pain or discomfort on the days 2 Mostly satisfied
that you had it, over the last week? 3 Mixed (about equally satisfied
0 1 2 3 4 5 6 7 8 9 10 and dissatisfied)
NO PAIN PAIN AS BAD 4 Mostly dissatisfied
AS YOU CAN
IMAGINE
5 Unhappy
Urination 6 Terrible
5. How often have you had a sensation of
not emptying your bladder completely after
you finished urinating, over the last week?
Scoring the NIH-Chronic Prostatitis Symptom Index
0 Not at all Domains
1 Less than 1 time in 5 Pain: Total of items 1a, 1b, 1c, 1d, 1e, 2a, 2b, 3, and 4 =____
2 Less than half the time Urinary Symptoms: Total of items 5 and 6 =____
3 About half the time Quality of Life Impact: Total of items 7, 8, and 9 =____
4 More than half the time
5 Almost always or always

Figure 20.6 Female NIH-Chronic Prostatitis Symptom Index (NIH-CPSI). (Adapted from Litwin et al. 1999. J Urol 162: 369–375.)

Case Reports
Finally, to illu strate the com plexity o the clinician evaluating
a p atient w ith CPP, consid er the ollow ing short case histo-
ries w ith d iscussion a terw ard s.

Case report 1
A 50-year-old w om an com p lained o a 5-year history o
Figure 20.7 Internal pelvic trigger point wand. pelvic pain, posterior thigh p ain and ‘lum p y’ intravaginal

p ain w ith d ysp areu nia, and consequently had avoid ed
having p enetrative sex w ith her hu sband . Active straight leg
raise w as technically negative, bu t she held her breath
d u ring the test. Palp ation o L5 / S1 rep rod u ced the lu m p y
intravaginal p ain. The slu m p test w as p ositive and
rep rod u ced her p osterior thigh p ain, and she also exhibited
m ovem ent system d ys u nction in her lu m bar sp ine, moving
excessively into extension and rotation. At the tim e the
clinician had not learnt to evalu ate the p elvic oor m u scles
and conclu d ed that she had a L5 / S1 joint d ys u nction, w ith
no signs o instability bu t w ith concu rrent neu ral
involvem ent. Treatm ent consisted o f ve sessions o m anu al
therap y to the thoracic, lu m bar and SIJ w ith neu ral tissu e
m obilization, p lu s a sp ecif c hom e exercise p rogram m e to
op timize her m ovem ent system balance. She w as pain ree
on d ischarge, bu t had not resu m ed sexu al intercou rse as she
said that she w as not ‘interested ’.
Tw o years later, she retu rned to clinic having had a retu rn o
the lu m p y intravaginal p ain. There had been no specif c
p hysical event; how ever, her husband had d ied and she w as
extrem ely d istressed , believing she had not been a ‘good ’
w i e as they had not resu m ed sexu al intercou rse. On
p hysical assessm ent it w as p ossible to rep rod u ce her
intravaginal p ain both w ith p alp ation o L5 / S1 and by
p alp ation o her p elvic oor m u scles.
Case report 2
A 30-year-old ootball p layer com p laining o longstand ing
bilateral groin pain w ith ‘gap ping’ sensations at the
sym p hysis p ubis cam e or treatm ent. H e stated that there
had been a grad u al onset o anterior abd om inal w all p ain
w ith ru nning, w hich had increased in intensity over some
w eeks. H e had been d iagnosed w ith chronic le t-sid ed
osteitis p u bis, w ith a m agnetic resonance im aging scan
ind icating som e bone m arrow oed em a m argins o the
sym p hysis p ubis. H e had been treated su rgically 8 m onths
p ost inju ry bu t w as not m aking any p rogress, and w as
su bsequently d iagnosed w ith an ingu inal hernia, then a
labral hip tear, and treated su rgically again w ith no e ect.
Sym p tom s w ere aggravated by ru nning, hip abd u ction,
glu teal clenching and , on closer qu estioning, he revealed he
also had concurrent p erineal pain. An N IH -CPSI orm
revealed signs o urinary d ys unction (and urinary
requ ency), w hich he thou ght w as norm al. Palp ation o
active p elvic oor m u scle trigger points near the insertion o
the pubococcygeus m u scle reprod u ced rectal / obtu rator pain
and a ‘gap ping’ sensation at the sym physis p u bis. There w as
a negative Tinel’s sign on the p u d end al nerve; also m uscle
strength grad e 3 (m od if ed Ox ord scale) and end u rance
red u ced the sym p tom s. A ter f ve treatm ents o trigger p oint
release to the p elvic oor m u scles, the p layer w as back to
u ll-tim e ootball w ith no sym p tom recu rrence.
Case report 3
A 24-year-old em ale com p laining o vu lval p ain had been
d iagnosed w ith p u d end al nerve entrap m ent w ith p ositive
EMG f nd ings. H er aggravating actors w ere w alking,
Conclusion 233
particu larly u p hill, and bend ing, and pain w as eased by ice
and lying on her sid e. Palp ation o her sym physis pu bis
reprod uced her vu lval pain and an active straight leg raise
test w as p ositive. Treatm ent consisted o m ovem ent system
balance corrective exercises and u se o a sacral belt. Three
m onths later she su ccess u lly m anaged to clim b Mou nt
Kilim anjaro w ithou t p ain.
Conclusion
In su m m ary, the role o the therapist is to id enti y and correct
the m ovem ent system d ys u nction relating to the p resenting
cond ition. H ow ever, as m ost treatm ent op tions or p elvic p ain
are cu rrently em pirical, there is a great requ irem ent or care u l
clinical reasoning w hen ap p roaching the m anagem ent o a
p atient w ith p elvic p ain. This chap ter p resents evid ence to
allow consid eration o the pelvic oor m uscle m ovem ent
system d ys u nction as a p otential contribu tor to p elvic p ain
and other related p resenting d isord ers. Possible aid s to assess-
m ent and treatm ent are d iscu ssed .
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Conclusion 235
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 PART 3 •  Lumbar Spine Pain Syndromes
Chronic Low Back Pain
21  
Chapter 
M a rk D. Bis h o p , J o e l E. Bia lo s ky, C h a rle s W. G a y
CHAP TER CONTENTS
Introduction  236
Acute versus chronic low back pain  236
Altered nociceptive transmission in chronic low back pain  237
Neuroimaging in chronic low back pain  237
Manual interventions for chronic low back pain  239
Joint-biased manual therapies  239
Soft-tissue-biased manual therapies  240
Nerve-biased manual therapies  240
Factors associated with ef cacy of interventions in chronic   a prevalence of 15%. Shorter lengths of tim e resu lt in a m ore
low back pain  241
Expectation  241
Patient preference  241
Patient–clinician relationship  242
Conclusion  242
Introduction
Low back p ain is d e ned as p ain, stiffness or d iscom fort p ri-
m arily located below the 12th rib and above the inferior
glu teal fold . There m ay or m ay not be leg pain, or sciatica,
associated w ith low back p ain. The taxonom y u sed d escribes
an episod e of p ain includ ing term s related to the tem poral
d u ration of the pain su ch as acute, su bacu te and chronic pain
as w ell to the u ctu ations in the intensity of the p ain – recu r-
rent and transient, for exam ple (Von Korff & Sau nd ers 1996).
Of p articu lar interest in this chap ter is chronic, constant
low back p ain, hereafter called chronic low back p ain (cLBP).
The prim ary d escription of cLBP is related to the tem p oral
d u ration of the painfu l episod e. For exam ple, international
health organizations su ch as the International Association for
the Stu d y of Pain (IASP 1986) and the World H ealth Organiza-
tion (WH O) d e ne chronic p ain as p ain that has p ersisted
beyond norm al tissu e healing tim e (N ational Research Cou ncil
of the N ational Acad em ies 2008). The prem ise behind this
d e nition is that, w hatever the original insult to a peripheral
tissu e, it has m ainly resolved . The IASP su ggests that this
resolu tion shou ld have occu rred after app roxim ately 3
m onths, a length of tim e com m only u sed by other organiza-
tions su ch as the Am erican Acad em y of Fam ily Practitioners
and Agency for Qu ality H ealthcare. H ow ever, d ifferent grou ps
have su ggested as short a tim e as 7 w eeks or as long as 6
m onths of p ain is requ ired to ind icate the p resence of cLBP
(Van d en H oogen et al 1998; And ersson 1999; Walker 2000).
Alternative d e nitions also m ay includ e criteria for the
nu m ber of d ays that p ain is exp erienced ; for exam p le, Von
Korff and Saund ers (1996) su ggested that p ain should be
p resent for m ore than half the d ays w ithin a 12-m onth p eriod
in either single or m u ltiple episod es.
The resu lt of these varied d e nitions regard ing w hat actu-
ally constitu tes cLBP is that stu d ies of the prevalence of cLBP
are d if cu lt to com pare. In such a w ay, u sing the criterion of
‘p ain lasting 6 m onths or m ore’ ep id em iological stu d ies found
variable estim ate of prevalence ranging from 4% to 24%
(Ju nip er et al 2009). Despite this variation, cLBP rem ains a
signi cant social and econom ic bu rd en on healthcare system s
w orld w id e and there is evid ence that the prevalence is rising.
For exam ple, in the United States of Am erica it w as estim ated
that betw een 1992 and 2006 the p revalence of low back pain
increased by 162%. This increase w as d riven by increases of
219% in the 45–54-year age grou p (Frebu rger et al 2009).
Acute versus Chronic Low Back Pain
A fu nd am ental issu e su rrou nd ing low back p ain, both acu te
and chronic, is w hether it is a sym p tom or a d isease. It m ight
su f ce to say that, in general, acu te low back p ain is consid -
ered a sym p tom , and use of d iagnostic stu d ies to id entify an
u nd erlying sp inal p athology is not recom m end ed , for tw o
p rim ary reasons: (1) m ost acute back pain episod es resolve
over tim e, and (2) cross-sectional d ata and longitud inal
stu d ies have fou nd p oor associations betw een clinical ou t-
com es and the p resence of sp inal p athology (Deyo 2002). The
m ajority of clinical p ractice gu id elines for low back p ain
end orse app roaches w here m ost p atients (~ 90%) d o not
receive a pathoanatom ical d iagnosis, but instead receive the
label ‘non-speci c low back pain’.
In contrast, chronic pain is argu ed to be a brain d isease
(Su llivan et al 2013); for exam ple, the N ational Research
Council of the N ational Acad em ies (2008) stated , that regard -
less of w here the initial inju ry occu rred , inclu d ing the lum bar
sp ine, the fu nctional, stru ctu ral and chem ical changes in the
brain associated w ith chronic pain place it into the realm of
d isease state. Fu rtherm ore, a sum m ary point in a report from
the Institute of Med icine (2011, p 39) states ‘chronic pain
can be a d isease itself’. A nal exam p le that exem p li es the

cu rrent state of affairs com es from the w ebsite of the Eu rop ean
Fed eration of the International Association for the Stu d y
of Pain (IASP), w hich states that, althou gh acu te p ain m ay
reasonably be consid ered a sym ptom of d isease or inju ry,
chronic and recu rrent p ain is a sp eci c healthcare p roblem – a
d isease in its ow n right (http:/ / w w w.e c.org/ ind ex.asp ?sub=
724B97A2EjBu1C).
The p athophysiology of cLBP rem ains poorly u nd erstood .
As pointed ou t earlier, chronology is u sed to d istinguish acute
from chronic stages; how ever, the exact point w hen back p ain
m oves from an acu te (sym p tom ) to a chronic (d isease) stage
looks less likely to be a sim p le m atter of tim e. The lack of a
d evelopm ental perspective in cLBP creates a chasm in the
u nd erstand ing of biological changes taking p lace betw een
acu te and chronic p ain stages. Thu s, the targeting of biological
changes to p revent the ‘chroni cation’ of acu te low back p ain
rem ains an unattainable goal. In the follow ing sections, w e
w ill d iscu ss insights and d iscoveries from tw o eld s of
research being applied to cLBP: qu antitative sensory testing
(QST) and neuroim aging. These eld s have shed som e light
onto neu robiological d ifferences that exist in ind ivid u als w ith
persistent p ain com pared w ith ind ivid u als w ho are not exp e-
riencing p ain. Fu rther research is need ed to d eterm ine w hether
these d ifferences are ind eed changes that evolve and contrib-
u te to p ain p ersistence.
Altered Nociceptive Transmission in
Chronic Low Back Pain
Qu antitative sensory testing is the ap p lication of a qu anti a-
ble am ou nt of a sensory m od ality to d ifferent tissu es of the
bod y, su ch as skin, m uscle and viscera (Arend t-N ielsen &
Yarnitsky 2009; Arend t-N ielsen & Graven-N ielsen 2011). Dif-
ferent sensory m od alities can be u sed , su ch as therm al,
m echanical, chem ical, electrical and ischaem ia. Pain sensitiv-
ity testing is a su bcategory of QST, and record s a p sycho-
physical response to a qu anti able am ount of stim u lu s.
Psychop hysical resp onses inclu d e the m inim al am ou nt of a
stim u lu s to generate p ain (threshold ) the m axim u m am ou nt
of stim u lu s that is tolerable (tolerance) and / or the change in
perceived intensity of pain to repeated stim u lations (tem p oral
su m m ation) or m u ltip le locations of stim u lation (sp atial
su m m ation).
Pain sensitivity tests can d istingu ish grou p s of p atients
w ith cLBP from groups of p ain-free subjects. Patients w ith
cLBP d isp lay increased sensitivity to stim u lation of lu m bar
tissu es (Clau w et al 1999; Kobayashi et al 2009; Blu m enstiel
et al 2011) and tissues d istant from the site of pain – that is,
the leg or the thu m b (Giesecke et al 2004; O’N eill et al 2007).
The rationale behind perform ing pain sensitivity tests in
rem ote locations (i.e. ou tsid e the prim ary painful area) is that
pain hyp ersensitivity d etected after stim u lation of healthy
tissu e is consid ered a consequ ence of alterations in central
processing (Cu ratolo 2011). The increased sensitivity over
both the lum bar spine and rem ote locations su ggest cLBP is
associated w ith w id espread central hyp ersensitivity, w hich is
abnorm al central nervous system (CN S) processing of pain
(Latrem oliere & Woolf 2009). As m easures of d iscrim ination,
several p ain sensitivity tests have fair receiver-op erating char-
acteristics (ROC) and likelihood ratios. Those tests that m ay
Neuroimaging in chronic low back pain  237
be u seful includ e: pressure p ain threshold at the site of m ost
severe p ain ( tted area u nd er the ROC, 0.87), electrical stim u-
lation p ain threshold (ROC 0.87), pressure pain tolerance at
the site of m ost severe pain (ROC 0.81), p ressu re pain thresh-
old at rem ote (su prascapular) region (ROC 0.80) and tem poral
su m m ation of pain (ROC 0.80) (N eziri et al 2012).
QST can also assess kinaesthesia (e.g. bod y aw areness). For
kinaesthesia, psychophysical responses are record ed to quan-
ti able am ou nts of stim u lu s, bu t these resp onses are not
related to the perception of pain. Exam p les inclu d e the am ount
of vibration or p ressu re that is rst p erceivable (d etection
threshold ), the m inim u m d istance at w hich tw o sep arate
stim u li can be id enti ed (tw o-p oint d iscrim ination) and the
p ercentage agreem ent betw een the locations of a stim u lu s
w ith reference to a m arked bod y chart (localization).
Peop le w ith cLBP have been show n to exhibit higher d etec-
tion threshold s in the low back com p ared w ith a p ain-free
p op u lation (Blum enstiel et al 2011; Pu ta et al 2013). In loca-
tions rem ote from the low back, som e have fou nd higher
d etection threshold s (Pu ta et al 2013), w hereas others have
fou nd no d ifferences betw een healthy controls and cLBP (Blu -
m enstiel et al 2011). For tw o-point d iscrim ination, cLBP
p atients have been show n to requ ire larger d istances to p er-
ceive tw o stim u li being ap p lied to the lu m ber sp ine as being
d istinct, com pared w ith healthy controls (Wand et al 2010). In
ad d ition, cLBP patients are m ore likely to m islocalize sensory
inform ation d elivered to the back than pain-free controls
(Wand et al 2013). Although these sensory tests have been
able to d istingu ish cLBP patients from healthy controls, none
of the investigations fou nd a relationship betw een the sensory
tests and clinical p ro les (Wand et al 2010, 2013; Blu m enstiel
et al 2011; Puta et al 2013).
Another subcategory of QST com prises electrophysiologi-
cal re exive tests, su ch as the nocicep tive w ithd raw al re ex
(N WR) and re ex receptive eld s (RRF). These tests are u sed
to assess nocicep tive hyp erexcitability. Decreases in the
am ount of stim u lus to ind u ce a w ithd raw al re ex and enlarge-
m ent of the RRF are ind icative of sp inal cord hyp erexcitabil-
ity. The spinal hyperexcitability could be a consequ ence of an
increased nu m ber of responsive spinal neu rons or an expan-
sion of the recep tive eld s of sp inal neu rons as a resu lt of
increased synaptic sensitivity.
Patients w ith cLBP d isp lay low er N WR threshold s to single
and repeated electrical stim u lation (Biu rru n Manresa et al
2013). The d iscrim inative ability of the single electrical stim u -
lation re ex threshold is ad equate, w ith an ROC of 0.83 (N eziri
et al 2012). Com pared w ith pain-free volu nteers, patients w ith
cLBP have d em onstrated enlarged RRF in areas d istant from
the site of exp ected tissu e d am age, w hich ind icates w id e-
sp read sp inal hyp erexcitability (Biu rru n Manresa et al 2013).
An unexpected result is that patients w ith acute low er back
p ain d em onstrate sim ilar N WR and RFR d ifferences com -
p ared w ith p ain-free volu nteers and no d ifferences com p ared
w ith patients w ith cLBP (Biu rru n Manresa et al 2013).
Neuroimaging in Chronic Low
Back Pain
Research from the eld of neu roscience has p rovid ed evi-
d ence that subtle neurobiological d ifferences exist betw een
 238 PART 3 • 21 • Chronic low back pain
p eop le w ith cLBP and pain-free volu nteers. N eu robiology
inclu d es the stu d y of the nervou s system and how it is organ-
ized into fu nctional circu its that p rocess inform ation and
m ed iate behaviou r. Differences in neu robiology betw een
cLBP p op u lations and p ain-free volu nteers have been inves-
tigated w ith ad vanced neu roim aging techniqu es su ch as m ag-
netic resonance im aging (MRI) (Grachev et al 2000, 2002;
Ap karian et al 2004; Giesecke et al 2004; Kobayashi et al 2009;
Baliki et al 2011), positron em ission tom ography (PET) (Der-
byshire et al 2002), m agnetoencephalograp hy (MEG) (Flor
et al 1997) and a com bination of transcranial m agnetic stim u-
lation (TMS) and intram u scu lar ne-w ire electrom yograp hy
(EMG) (Tsao et al 2008). These techniques have d em onstrated
d ifferences in both cortical stru cture and function betw een
cLBP p op u lations and p ain-free controls.
Differences in cortical stru ctu re have been assessed using
MRI w ith tw o ou tcom e m easu res: voxel-based m orp hom etry
(VBM) and d iffu sion tensor im aging (DTI). VBM estim ates
cortical and su bcortical grey m atter (GM) thickness and
volu m e by p arcellating stru ctu ral MRI im ages; w hereas DTI
estim ates fractional anisotrop hy (FA), w hich is d erived from
a com bination of intravoxel isotrop y and intervoxel stru ctu ral
sim ilarity. Using FA, a p robability of m ovem ent is estim ated
and inform ation on w hite m atter (WM) tracts and stru ctu ral
connectivity is inferred (Basser & Pierp aoli 2011).
When com p aring pop u lations su ffering cLBP w ith p ain-
free volu nteers, structural d ifferences have been fou nd . Using
VBM, both global (w hole-brain) (Ap karian et al 2004) and
regional (brain regions) (Apkarian et al 2004; Sem inow icz
et al 2011) GM d ifferences have been found . In general, cLBP
su bjects show a d ecreased global GM volu m e (Apkarian et al
2004). Regional app roaches in cLBP subjects have show n GM
red uctions in the left d orsal lateral p refrontal cortex, bilateral
anterior insu la, left frontal op ercu lu m , left p osterior insula,
left p rim ary som atosensory cortex, left m ed ial tem p oral lobe,
bilateral thalam i and right anterior cingu late cortex com -
p ared w ith age-m atched control su bjects (Apkarian et al
2004; Sem inow icz et al 2011). DTI has also show n d ifferences
in the stru ctu ral integrity of WM w ithin regions of the su p e-
rior and inferior longitud inal fascicu lus and regions of the
anterior and p osterior cingu late cortices (Mansou r et al 2013).
These d ifferences w ere fou nd w hen com paring a grou p of 46
su bacu te low back p ain su bjects; in the cohort w ho continu ed
to experience low back pain 1 year later, there w ere low er FA
valu es in those regions of WM p reviou sly id enti ed .
H ow ever, the range of FA valu es in healthy controls inclu d es
both of the FA valu es in the su bacu te p opulation. The extent
to w hich the stru ctu ral integrity of these WM regions p red is-
p oses ind ivid u als to a greater risk of chronicity need s fu rther
research.
Differences in cortical function have been assessed u sing
MEG, a com bination of TMS and intram u scu lar ne-
w ire EMG and fu nctional MRI (fMRI). MEG has been used to
assess the cortical rep resentation of bod y areas in the prim ary
som atosensory cortex. Using MEG, Flor et al (1997) show ed
that the cortical rep resentation of the lu m bar sp ine w as shifted
m ed ially in cLBP su bjects com p ared w ith that in p ain-free
volu nteers. Using a com bination of TMS and EMG, Tsao et al
(2008) assessed the cortical representation (volum e and centre
of gravity) of the transverse abd om inis m u scle w ithin the
m otor cortex in cLBP su bjects. They fou nd that cortical rep re-
sentation w as larger (volu m e) and shifted p osteriorly and
laterally (centre of gravity) in cLBP su bjects com p ared w ith
p ain-free volu nteers. Researchers have sp ecu lated that these
shifts in sensory and m otor rep resentations are rep resentative
of cortical reorganization – that is, neurop lasticity (Flor et al
1997; Tsao et al 2008).
Functional MRI has also been used to investigate d iffer-
ences in cortical fu nction. fMRI m easu res the blood -
oxygenation-level-d ep end ent (BOLD) signal. This signal can
be used to estim ate cortical function, as neuronal activity is
associated w ith local changes in cerebral blood ow, blood
volu m e and blood oxygenation, term ed the d ynam ic resp onse
(Kw ong et al 1992). The haem od ynam ic response generates a
typ ical change in the BOLD signal, the key link being the d if-
ference in m agnetic properties betw een the oxygen-rich and
oxygen-p oor blood (Kw ong et al 1992; Miezin et al 2000; Log-
othetis 2002).
To investigate cortical fu nction, tw o analytical ap p roaches
are com m only u sed w ith fMRI BOLD signals. The rst
ap proach u ses the tim ing of events to estim ate w hereabouts
in the brain a haem od ynam ic response is occu rring. To assess
cortical regions involved in the p rocessing and m od u lation of
the p ain exp erience, the event is typ ically the ap p lication of a
noxiou s stim u lu s. An alternative ap p roach is to take the tim e
series of the BOLD signal from a cortical region and estim ate
the correlation (fu nctional connectivity) w ith that in other
cortical regions. This ap p roach estim ates the relationship of
BOLD signal u ctu ations betw een sp atially d istinct brain
regions w hile at rest or d u ring a task. Both ap proaches have
been u sed in cLBP popu lations.
Using the rst approach m entioned above, researchers
have tailored the noxiou s stim u lu s in tw o d ifferent w ays.
The rst m ethod tailors the intensity of the stim ulus to
create equ al sensations across su bjects. The second m ethod
u ses a stand ard am ou nt of stim u lu s across su bjects, w hich
inevitably creates d ifferences in the perceived intensity and
u np leasantness. Tailoring the intensity of the stim u lu s to
create equ al sensations resu lts in sim ilar haem od ynam ic
responses in activated brain regions betw een cLBP subjects
and pain-free su bjects; how ever, for the cLBP su bjects the
average stim ulus intensity w as signi cantly low er. When a
stand ard stim u lu s w as ap p lied to all su bjects, a greater
haem od ynam ic resp onse w as seen in the brain regions of
cLBP su bjects com p ared w ith p ain-free controls. In cLBP
su bjects, an increased BOLD signal w as rep orted in the con-
tralateral p rim ary som atosensory cortex, second ary som ato-
sensory cortex, inferior p artial lobe, insu la, anterior
cingu late cortex and the ip silateral second ary som atosen-
sory cortex and cerebellu m (Giesecke et al 2004; Gracely
et al 2004; Kobayashi et al 2009). Researchers conclu d ed that
the au gm ented cortical activity is rep resentative of sensitiza-
tion of brain regions involved in nocicep tion p rocessing and
m od u lation.
Using the second approach, researchers have found fu nc-
tional connectivity d ifferences betw een cLBP su bjects and
p ain-free controls d u ring a cognitive task and at rest (Baliki
et al 2008; Tagliazucchi et al 2010). During a cognitive task,
cLBP su bjects had less d eactivation of the d efau lt m od e
netw ork (DMN ); in these ind ivid u als a region of the DMN ,
the m ed ial p refrontal cortex, show ed increased connectivity
w ith brain regions that w ere active d u ring the cognitive task
com p ared w ith the control grou p (Baliki et al 2008). In another
stu d y, cLBP su bjects at rest show ed greater connectivity

betw een the sam e DMN and the insular cortex bilaterally
(Tagliazu cchi et al 2010). Researchers have suggested these
nd ings are rep resentative of altered cortical fu nction in su b-
jects w ith cLBP.
Althou gh there is clear evid ence that brain fu nction,
stru ctu re and chem istry are am iss in p eop le w ith cLBP, the
extent to w hich they are m od i able to treatm ent is d irectly
relevant for clinician-scientists. In cLBP su bjects, brain stru c-
tu re has been show n to change and be m ore re ective of
p ain-free control subjects follow ing su ccessful pharm acolog-
ical, injection and surgical interventions (Sem inow icz et al
2011; You nger et al 2011); how ever, in those su bjects w here
no im p rovem ent w as seen, no change in stru ctu re w as
fou nd . Functional brain changes have also been show n to
recover in su bjects after a therapeu tic intervention. Sensory
and m otor rep resentations in the cortex have been show n to
shift follow ing a cou rse of sp ecialized sensory d iscrim ina-
tion and m otor training; these interventions ind u ce changes
su ch that the cortical rep resentations becom e m ore like
those of p ain-free controls (Flor & Diers 2009; Tsao et al
2010; Moseley & Flor 2012). Lastly, the haem od ynam ic
resp onse to noxiou s stim u lus has been show n to change in
cortical regions over tim e follow ing a behaviou ral interven-
tion (Jensen et al 2012). Thus, it can be stated that d iffer-
ences in brain stru ctu re and function id enti ed in cLBP
p atients are reversible (i.e. d o not re ect irreversible brain
d am age) and that the stru ctural and functional d ifferences
ap p ear to norm alize w hen an ind ivid u al’s p ain experience is
ad equ ately treated .
The transition of back p ain from acu te (sym ptom ) to chronic
(d isease) stages rem ains poorly u nd erstood , and is an interest-
ing research area that w ill hopefu lly be fru itfu l. H ow ever,
taken together, the resu lts from the eld s of QST and neu roim -
aging p rovid e a grow ing bod y of evid ence suggesting that
abnorm alities of the nervous system are salient featu res of
cLBP. Thu s, classi cation of back p ain by tim e alone ap p ears
overly sim p listic and reliance on this ap p roach ap p ears to be
a consequ ence of inad equate pathophysiological inform ation.
It is plausible that altered self-p erception is m alad ap tive and
contribu tes to the m aintenance of cLBP, and m ay hence be a
target for treatm ent.
Manual Interventions or Chronic
Low Back Pain
In the United States, The N ational Center for Com plem entary
and Alternative Med icine (N CCAM) has established catego-
ries for m any non-p harm acological and non-su rgical inter-
ventions for cLBP includ ing m ind –bod y m ed icine and
m anip u lative and bod y-based interventions. Mind –bod y
interventions pertinent in the context of the m anual therapies
are d iscu ssed in m ore d etail in Chap ter 6, w hereas d ifferent
sp inal joint m anip u lation and m obilization interventions are
d escribed in Chap ter 22; therefore, the focu s of this chap ter
w ill be application of m anipu lative and bod y-based interven-
tions by p ractitioners of m anu al therap ies. Manu al therap ies
includ e techniques that focus prim arily on the structu res and
system s of the bod y, inclu d ing the bones and joints (joint
biased ), the soft tissu es (soft tissu e biased ), and the neu rovas-
cu lar system (nerve biased ).
Manual interventions for chronic low back pain  239
Joint-biased manual therapies
Joint-biased interventions includ e treatm ents such as spinal
m anip u lation and m obilization ap p lied either m anu ally by
p ractitioners or w ith the assistance of d evices. These tech-
niqu es p rovid e p assive m ovem ent of joints beyond their
norm al range of m otion in the case of sp inal m anip u lation and
w ithin its norm al range of m otion for spinal joint m obiliza-
tion. In the United States of Am erica, it is estim ated that
ap proxim ately 8.6% of the pop u lation see a p ractitioner p ro-
vid ing this form of m anu al therap y, sp end ing a total close to
$3.9 billion annually (N ahin et al 2009); in fact, the m ost
com m on cond ition or com p laint for these visits w as low back
p ain (17.8%). Lin et al (2011) fou nd evid ence su p p orting the
cost effectiveness of sp inal joint m anip u lation for cLBP.
Several large system atic review s and m eta-analyses have
been perform ed of the effectiveness of m anual therapies used
to treat ind ivid u als w ith cLBP (Chou et al 2007; Ru binstein
et al 2010; van Mid d elkoop et al 2011). One review for the
Cochrane grou p , for exam p le, focu sed on joint-biased tech-
niqu es (Rubinstein et al 2011). The review grou p id enti ed 26
clinical trials of su f cient qu ality to be inclu d ed in the m eta-
analyses. (Meta-analysis is a m ethod that allow s the results of
m u ltip le stu d ies to be com bined to increase the statistical
p ow er to nd real effects.) In this review the analyses inclu d ed
stu d ies that u sed high-velocity low -am p litu d e techniqu es and
low -am plitud e low -velocity oscillation techniqu es to m anage
cLBP (Ru binstein et al 2011). The resu lts of this m eta-analysis
ind icated there w as high-quality evid ence that joint-biased
techniqu es used alone have a short-term effect (1-m onth
follow -up) on both pain relief and fu nctional status com pared
w ith sham interventions and other therapeu tic m od alities.
The m ean d ifference (MD) betw een changes in pain for the
joint-biased technique and the change in p ain for the other
interventions w as −4.16 (95% CI −6.97 to −1.36). This ind icates
that for the joint-biased techniqu e the average red u ction in
pain w as 4.16 greater than w ith the other interventions
(Rubinstein et al 2011). Mean d ifferences are used w hen all
the stu d ies inclu d ed in the m eta-analysis u se the sam e m eas-
u rem ent, in this case for p ain intensity. When d ifferent scales
are u sed (e.g. the Osw estry Disability Ind ex or the Roland
Morris Disability Scale for d isability), stand ard ized m ean d if-
ferences are calcu lated (SMD) instead for m eta-analysis pu r-
p oses. For fu nctional statu s, the SMD in the above review w as
−0.22 (95% CI −0.36 to −0.07) w hen com p ared w ith other inter-
ventions, ind icating that the joint-biased techniqu es show ed
a 0.22 stand ard d eviation im p rovem ent com p ared w ith the
other interventions (Rubinstein et al 2011).
For pain, w hen a joint-biased techniqu e w as used alone,
statistically signi cantly better p ain relief w as noted com -
p ared w ith other interventions at follow -u p period s of both 1
and 6 m onths (MD −2.76, 95% CI −5.19 to −0.32 and MD −3.07,
95% CI −5.42 to −0.71, respectively). For fu nctional statu s,
there w as high-qu ality evid ence that joint-biased techniqu es
alone provid e statistically signi cantly better fu nctional
im provem ent at 1-m onth than d o other interventions (SMD
−0.17, 95% CI −0.29 to −0.06); how ever, this bene t is not
app arent 3 and 6 m onths later. There w as varying qu ality of
evid ence that a joint-biased techniqu e has a signi cant short-
term effect on p ain relief and fu nctional statu s w hen ad d ed
to another intervention. H ow ever, there is little evid ence that
sp eci c joint-biased techniqu es are su p erior to sham m anu al
 240 PART 3 • 21 • Chronic low back pain
therap ies w hen u sed in p atients w ith cLBP in the long term
(Ru binstein et al 2011).
Many read ers m ay argu e that the sp eci cs of the tech-
niqu es (thru st versu s oscillation) shou ld be consid ered
because these categories of techniqu e are theorized to effect
change in p ain throu gh d ifferent m echanism s (Pickar 2002;
Triano 2001). H ow ever, m echanistic theories of action alone
cannot exp lain clinical im p rovem ent in p atients w ith cLBP
and m ore recent literatu re has focu sed on the neu rological
system (George et al 2006; Bialosky et al 2009). Speci c analy-
ses w ere also p erform ed in the review to ad d ress the extent
to w hich the typ e of techniqu e (thru st or oscillatory m obiliza-
tion) or typ e of p ractitioner m ight have m od i ed the effects
d etected . H ow ever, those analyses show ed that the techniqu e
or the p ractitioner had no in u ence on the p ooled effects
calcu lated , ind icating sim ilar effects both w hen com p aring
techniqu es and w hen com p aring p rovid ers (Ru binstein et al
2011).
William s et al (2007) com pleted a separate m eta-analysis of
trials that focu sed on the effect of joint-biased interventions
on p sychological factors su ch as d ep ression, anxiety, self-
ef cacy and fear-avoid ance beliefs as the outcom es of treat-
m ent. These au thors rep orted that treatm ent w ith joint-biased
techniqu es resu lted in su p erior ou tcom es com p ared w ith a
‘verbal intervention’ (pred om inantly ed u cation interventions)
at both short-term (SMD −0.33, 95% CI −0.47 to −0.19) and
longer-term follow -u p p eriod s (SMD −0.27, 95% CI −0.40 to
−0.14). Joint-biased interventions w ere also su perior to sim ple
exercises and to acu pu nctu re (SMD −0.13, 95% CI −0.24 to
−0.01 at 1–5 m onths and SMD −0.11, 95% CI −0.25 to −0.02 at
6–12 m onths) (William s et al 2007). Sim ilar to pain and fu nc-
tional statu s ou tcom es, there w as no d ifference betw een the
effects of joint-biased interventions and sham interventions
w hen com pared d irectly (William s et al 2007).
It shou ld be noted that all these reported effects w ere noted
across heterogeneou s grou p s of p articipants. Su bgrou p ing of
p atients, to m atch treatm ents to patient signs and sym ptom s,
is ind icated to be an im p ortant factor to consid er in acu te low
back p ain episod es (Child s et al 2004). Whether this is also the
case in cLBP has not been established ; how ever, recent w ork
by Cook et al (2013) w ou ld su ggest that it is not. In su m m ary,
joint-biased techniqu es provid e greater p ain relief and better
im p rovem ents in fu nction than other therap eu tic m od alities
and other interventions in the short term , suggesting faster
rates of recovery in p atients w ith cLBP.
So t-tissue-biased manual therapies
Soft-tissu e-biased therap ies inclu d e techniqu es su ch as
Sw ed ish m assage, d eep tissu e m assage, trigger p oint therap y,
shiatsu m assage and variou s form s of m yofascial treatm ents.
These therapies are often m anu ally applied , but can also be
p erform ed w ith instru m ents. In the United States ap proxi-
m ately 8.3% of the p op ulation w ill see a p ractitioner w ho
p rovid es a soft-tissu e-biased intervention, sp end ing close to
$4.2 billion annu ally (N ahin et al 2009). The m ost com m on
cond ition / com p laint for these visits is low back pain (17.3%).
A system atic review d evelop ed Ottaw a Panel evid ence-
based clinical practice guid elines on therapeu tic m assage for
low back p ain (Brosseau et al 2012). The interventions consid -
ered inclu d ed m u scle-biased m anu al therap ies (Sw ed ish
m assage, fascial or connective tissu e release techniqu es,
cross- bre friction and m yofascial trigger p oint techniqu es).
The inclu d ed stu d ies had to com pare m u scle-biased m anu al
therap ies w ith a control grou p that received no intervention,
p lacebo (sham laser treatm ent), u su al care, self-care ed u ca-
tion, relaxation therap y, sham m anu al therap y or exercise. In
this review there w ere no d irect com p arisons of m u scle-biased
m anu al therap ies to joint-biased techniqu es (Brosseau et al
2012). The Ottaw a Panel w as able to d em onstrate that m u scle-
biased m anual therapies w ere effective at provid ing short-
term im p rovem ent of cLBP sym p tom s and d ecreasing
d isability im m ed iately post treatm ent, and short-term relief
w hen m u scle-biased m anual therapy w as com bined w ith
therap eu tic exercise and ed u cation. In fact, this conclu sion
w as previou sly suggested by the Cochrane system atic review
that conclu d ed m assage can be bene cial in the m anagem ent
of non-sp eci c low back p ain (Furlan et al 2008).
Cherkin et al (2011) investigated stru ctu ral m assage (m yo-
fascial, neu rom u scular and other soft tissue techniques) com -
p ared w ith u su al care (no m assage interventions) and
d em onstrated clinically im portant bene ts, w ith d ecreases in
both d isability and sym p tom bothersom eness. The strongest
evid ence of bene t w as at the end of treatm ent at 10 w eeks
(MD −2.5, 95% CI −3.56 to −1.44), w ith little evid ence of
longer-term bene ts at 16 or 42 w eeks after the intervention.
When relaxation m assage (ef eurage, petrissage, circu lar fric-
tion, vibration, rocking and jostling, and hold ing) w as com -
p ared w ith control (u su al care), clinically im p ortant bene ts
w ere d em onstrated at 10 w eeks for im p roved sym p tom s
(sym ptom bothersom eness score) and d ecreased d isability
w as d em onstrated at 10, 16 and 42 w eeks after treatm ent.
Little et al (2008) investigated therap eu tic m assage tech-
niqu es (p ractitioners cou ld choose from ef eu rage, knead ing,
p etrissage, p ercu ssion, and neu rom u scu lar trigger p oint
release) versu s norm al care (no m assage). This stu d y d em on-
strated clinically im p ortant bene ts in term s of d ecreased d is-
ability at 12 w eeks bu t not at 40 w eeks. Preyd e (2000) com p ared
soft-tissu e m anip u lation w ith sham laser treatm ent in p atients
w ith subacute low back pain. This author show ed there w ere
clinically im p ortant bene ts d em onstrated for the im p rove-
m ent of p ain intensity and qu ality, and d ecreased d isability,
in subjects treated w ith the soft tissu e techniques. This stud y
also com pared com prehensive m assage therapy (m assage,
rem ed ial exercise and p osture ed ucation) to exercise and
p ostu re ed u cation. There w ere also clinically im p ortant ben-
e ts d em onstrated for the im provem ent of pain and qu ality,
and d ecreased d isability. Read ers can nd several soft-tissu e
biased interventions targeted to m yofascial trigger points in
Chapter 60. In su m m ary, soft-tissu e-biased m anu al therapies
p rovid e greater bene ts to p atients w ith cLBP com p ared w ith
u su al care and p ostu ral exercises.
Nerve-biased manual therapies
N erve-biased techniques u se passive, active or a com bined
m ovem ent of the sp ine and / or extrem ities w ithin their
norm al range of m otion, in w ays to elongate, slid e, glid e,
stretch or tension neu ral stru ctu res. These techniqu es are
often referred to as neu ral m obilization. Unlike m u scle- and
joint-biased therap ies, w here professions are som ew hat
linked w ith those treatm ents (m assage therapists for soft
tissu e biased and chirop ractors for joint biased ), nerve-biased
therap ies are often incorp orated along w ith other m anu al
 Factors associated with ef cacy of interventions in chronic low back pain
therap ies. As su ch there is a lack of d ata on the u sage of or
expend itu res on nerve-biased therap ies. (Read ers are referred
to Chs 64 and 65 for m ore d etails on clinical neu rod ynam ic
ap p lications.)
N o system atic review s or m eta-analyses related to nerve-
biased interventions for cLBP have been id enti ed . Cleland
et al (2006) fou nd that the ad d ition of slu m p stretching (a
form of neural m obilization) to a treatm ent regim en of sp inal
m obilization and exercise tw ice per w eek for 3 w eeks in
p atients w ith non-rad icu lar low back pain and m ild to m od er-
ate neu ral m echanosensitivity (n = 16) p rod u ced greater
im provem ents at the end of the treatm ent in d isability, pain
red u ction and centralization of sym ptom s com pared w ith
p atients w ho d id not receive neural m obilization (n = 14). A
recent stu d y by Schäfer et al (2011) ind icated that, in p atients
w ith peripheral nerve sensitization, neural m obilizations
(slid ing techniqu es) m ay provid e bene t in red u cing p ain and
d isability, com pared w ith other patients w ith back and leg
p ain. Using a sim ilar stu d y d esign as Cleland et al (2006) bu t
a larger sam p le (n  = 60), N agrale et al (2012) fou nd that the
ad d ition of slu m p stretching to a regim en of spinal m obiliza-
tion and exercise for p atients w ith non-rad icu lar low back
p ain w ith d u ration > 3 m onths resu lted in greater im p rove-
m ent at 3 and 6 w eeks in d isability, pain red u ction and fear-
avoid ance belief attenu ation com pared w ith patients receiving
only sp inal m obilization and exercise.
Factors Associated with E f cacy o
Interventions in Chronic Low Back Pain
Stu d ies investigating the effectiveness of interventions for
ind ivid u als experiencing cLBP often conclud e that treatm ent
is better than no treatm ent; how ever, the effects of ind ivid u al
interventions have not been d istingu ished (Chou et al 2007)
and are associated w ith sm all-to-m od erate effect sizes (Keller
et al 2007; Machad o et al 2009). This is consistent w ith the
research presented above. Speci cally in m anual therapy
stu d ies, sim ilar clinical ou tcom es are observed in resp onse to
d iffering techniqu es (Kent et al 2005) and variable physical
param eters of the sam e technique (H essell et al 1990; N gan
et al 2005). Collectively, these nd ings su ggest that the treat-
m ent p rocess m ay be m ore im p ortant than the sp eci c m anu al
therap y intervention for ind ivid u als exp eriencing cLBP.
Factors related to the treatm ent process includ e ind ivid u al
preference, exp ectation of treatm ent effectiveness, and the
relationship betw een p atient and healthcare provid er (Prefer-
ence Collaborative Review Group 2008). These factors are all
in uential in the effectiveness of all interventions for pain. For
exam ple, pain m ed ication is signi cantly m ore effective w hen
provid ed by a healthcare p rovid er w ho is visible to a p atient
than w hen the p atient is u naw are that he or she is receiving
the m ed ication (Colloca et al 2004). Treatm ent contextual
factors m ay be m anipulated to in u ence clinical ou tcom es;
sp eci cally, p ain red u ction in resp onse to p lacebo is signi -
cantly enhanced w hen ind ivid u als are instru cted to exp ect
pain relief (Vase et al 2009, Kap tchu k et al 2008a) or w hen
accom p anied by an augm ented interaction w ith the treating
healthcare p rovid er (Kaptchu k et al 2008b). Fu rtherm ore,
the analgesic effect of a m ed ication m ay be abolished w hen
an ind ivid u al expects m ore p ain (Bingel et al 2011). The
241
follow ing sections w ill review the literature related to speci c
contextu al factors w ith the p otential to in u ence treatm ent
responses to interventions for ind ivid u als presenting w ith
cLBP.
Expectation
Expectation is w hat a patient believes w ill occur and is p rog-
nostic for LBP-related ou tcom es. For exam p le, system atic
review s have conclud ed expectations are pred ictive of w ork-
related outcom es (Iles et al 2008) and functional outcom es
(Iles et al 2009) in ind ivid uals w ith non-chronic LBP. Speci c
to cLBP, exp ectations are p red ictive of m issed w ork tim e
(Kuijer et al 2006) and resp onse to conservative interventions
(Goossens et al 2005; Lind e et al 2007; Sm eets et al 2008).
Expectation m ay also m ed iate outcom es of speci c interven-
tions. Kalauokalani et al (2001) rand om ly assigned 135 ind i-
vid u als w ith cLBP to receive either acu p u nctu re or m assage.
Grou p -related d ifferences w ere not observed in the p rim ary
ou tcom e related to fu nction; how ever, p articip ants w ith
greater expectation for acu pu nctu re w ho received acupu nc-
tu re exhibited signi cantly better ou tcom es than those w ith
higher exp ectation for m assage w ho received acu p u nctu re
and vice versa. The placebo literature su ggests these typ es of
exp ectations m ay be m anip ulated to in u ence pain. The effect
size of p lacebo analgesia is sm all in p lacebo control stu d ies in
w hich participants are told to expect a 50% chance of receiv-
ing a placebo – that is, ‘you are going to receive the active
treatm ent or a p lacebo’ (Vase et al 2009). In contrast, placebo
analgesia is m u ch larger in stu d ies of placebo in w hich an
instru ctional set aim ed at enhancing expectation is used (Vase
et al 2009); for exam p le, saline provid ed along w ith the
instru ctional set, ‘the agent you have ju st been given is know n
to signi cantly red u ce p ain in som e p atients’, w as as effective
as lid ocaine in red u cing p ain sensitivity in participants w ith
irritable bow el synd rom e (Vase et al 2003). Collectively, this
bod y of literature suggests that exp ectation is a prognostic
factor for cLBP, m ay m ed iate the results of treatm ent for cLBP
and is p erhap s a treatm ent target itself for enhancing the
effectiveness of rehabilitation interventions.
Patient pre erence
Patient p references are closely related to exp ectations (Lu rie
et al 2008; Sherm an et al 2010), and preference for a given
intervention enhances the likelihood of su ccess in response to
that intervention. A system atic review and m eta-analysis con-
clu d ed that better ou tcom es occu rred in ind ivid u als receiving
a preferred treatm ent than in those w ith no p reference and in
those not receiving their p referred treatm ent (Preference Col-
laborative Review Group 2008). H ow ever, ind ivid u al stu d ies
have not consistently d eterm ined p reference as in u ential in
clinical ou tcom es for su bjects w ith low back p ain. Donald son
et al (2013) rand om ly assigned 149 patients w ith low back
p ain to receive either thru st m anip u lation w ith exercise
or non-thru st m anip u lation w ith exercise. Particip ant p refer-
ence for thru st or non-thrust m anipulation w as not associated
w ith any of the stud ied ou tcom es. Generally, the literatu re
su ggests that p atient p reference is a sim ilar constru ct
to exp ectation. Althou gh not investigated as extensively,
p atient p reference is associated w ith ou tcom es related to
 242 PART 3 • 21 • Chronic low back pain
m u scu loskeletal p ain; how ever, it is not consistently associ-
ated w ith ou tcom es related to low back p ain.
Patient–clinician relationship
The relationship betw een the patient and healthcare provid er
m ay also in u ence clinical ou tcom es (Di Blasi et al 2001; H all
et al 2010). For exam p le, in one stud y 200 p rim ary care
p atients p resenting w ith sym p tom s w ithou t signs w ere ran-
d om ly assigned to receive a positive consultation (physician
p rovid ed a d iagnosis and assu rance of rap id im provem ent)
or a negative consu ltation (p hysician exp ressed u ncertainty
as to the d iagnosis and u ncertainty as to the likely resp onse
to treatm ent). Sixty-fou r p er cent of the p articip ants receiving
the p ositive consu ltation w ere better in 2 w eeks, w hereas only
39% of p articipants receiving the negative consu ltation w ere
better w ithin the sam e tim e (Thom as 1987). Sim ilarly, a sys-
tem atic review conclu d ed ‘Physicians w ho ad op t a w arm ,
friend ly, and reassuring m anner are m ore effective than those
w ho keep consu ltations form al and d o not offer reassu rance’
(Di Blasi et al 2001). The placebo literatu re su ggests that the
clinician–p atient relationship m ay be m anipu lated so as to
enhance clinical ou tcom es. A stu d y of 262 ind ivid uals w ith
irritable bow el synd rom e rand om ly assigned p articip ants to
a w aiting list, p lacebo acup unctu re w ith lim ited clinician–
p atient interaction, and a w aiting list w ith au gm ented patient–
clinician interaction (Kap tchu k et al 2008a). The augm ented
interaction consisted of several qu estions related to sym p -
tom s, interference w ith d aily activities and relationship s, and
the p atient’s u nd erstand ing of the cond ition. The au gm ented
interaction w as p rovid ed in a w arm m anner w ith active lis-
tening and exp ression of em p athy by the healthcare p rovid er
along w ith com m u nication of con d ence in the patient’s like-
lihood of bene ting from the intervention. Particip ants receiv-
ing the p lacebo w ith au gm ented interaction d em onstrated
signi cantly better clinical ou tcom es at 3 w eeks than those on
the w aiting list and those receiving the p lacebo w ith lim ited
interaction (Kap tchu k et al 2008b). In a stu d y of low back
p ain, the relationship betw een the physical therap ist and the
p atient as m easured at the second treatm ent session w as pre-
d ictive of the clinical ou tcom e at 8 w eeks (Ferreira et al 2013).
Furtherm ore, the clinical ef cacy of interferential electrical
stim u lation is signi cantly greater w hen p rovid ed w ith an
au gm ented interaction than w hen provid ed w ith lim ited
clinician–p atient interaction. Collectively, this bod y of scien-
ti c literatu re suggests that the patient–clinician interaction
affects clinical ou tcom es and m ay be m anipu lated to enhance
the effectiveness of interventions for p ain.
Conclusion
As m entioned previously, low back p ain is a heterogeneous
cond ition often lacking an id enti able anatom ical basis (Deyo
2002). Su bsequently, a pathoanatom ical d iagnosis is generally
not help fu l for d irecting treatm ent, necessitating treatm ent
app roaches focu sed u pon id entifying those ind ivid uals likely
to resp ond p ositively to a p articu lar intervention (Deyo et al
2009). Also relatively sm all effect sizes are associated w ith
treatm ents for cLBP (Keller et al 2007; Machad o et al 2009)
and so there is u ncertainty about w hich intervention is best
for w hich patient w ith cLBP. As ind icated above, m anu al
therap ies targeting d ifferent tissu es m ay have sim ilar overall
effects w hen com pared w ith inert interventions, but no one
ou tp erform s the others. In other w ord s, choosing to p erform
a m anu al therapy for a patient w ith cLBP provid es better
ou tcom es than not p erform ing any m anu al therap y; how ever,
the p articu lar therap y chosen m ay not be as im p ortant. In
ad d ition, consid eration and m anagem ent of treatm ent contex-
tu al factors are w arranted , su ch as the p atient’s p reference
and expectations for the interventions p rovid ed , and the ther-
ap eutic relationship betw een patient and therap ist. Consid -
eration of these factors m ay both enhance outcom es to speci c
interventions and aid in d eterm ining the best intervention for
a given patient.
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 PART 3 •  Lumbar Spine Pain Syndromes
Joint Mobilization and Manipulation of the Lumbar Spine
CHAP TER CONTENTS
Towards standardizing nomenclature  245
Evidence  or spinal manipulative therapy  246
Clinical prediction rules  246
The audible pop  248
Spinal positioning and locking  248
Sa ety and manipulative techniques  249
Contraindications and precautions  249
Spinal mobilization and manipulation techniques  250
Central posterior-to-anterior mobilization  250
Unilateral posterior-to-anterior mobilization  250
Lumbar rotation mobilization: grades I–IV  251
Lumbopelvic regional manipulation  251
Lumbar rotation in neutral or extension manipulation  252
Lumbar rotation in f exion manipulation  252
Conclusion  253
Towards Standardizing Nomenclature
Sp inal m anip u lative therap y (SMT) has a very rich and d iverse
history. It has long been p ractised by a w id e variety of clini-
cians inclu d ing p hysical therap ists, p hysicians, osteop athic
physicians, chirop ractors, and even m assage therap ists and
laypersons. The p roblem is that there are m any and varied
d e nitions for the term ‘spinal m anipu lative therap y’. To
som e extent, the d e nitions u sed have d ep end ed u p on the
practitioner ap p lying the technique: the chiropractic pro-
fession has trad itionally called it ‘spinal ad justm ent’, the
osteop athic p rofession has u sed the term ‘high-velocity low -
am p litu d e (H VLA) thru st m anipu lation’, and physical thera-
pists have called it either ‘sp inal m anipu lation’ or ‘grad e V
sp inal m obilization’. Descrip tions of the actu al SMT tech-
niqu es p erform ed by the variou s p rofessions have also been
extrem ely d iverse and often based u pon each ind ivid u al pro-
fession’s theoretical constru cts and schem ata.
This confu sion su rrou nd ing m anipu lation term inology led
to a call for a m ore stand ard ized nom enclatu re in the p hysical
therap y profession, and in 2008 the Am erican Acad em y of
Orthop ed ic Manu al Physical Therap ists (AAOMPT) form ed a
task force to d evelop a m od el for stand ard izing m anip u lation
Chapter  22  
Em ilio J . P u e n te d u ra
term inology in p hysical therap y p ractice (Mintken et al 2008).
The task force proposed that orthop aed ic m anual physical
therap ists u se six characteristics w hen d escribing a m anip u la-
tive techniqu e. These inclu d ed :
1. Rate of force ap plication – a d escrip tion of the rate at
w hich the force shou ld be ap plied
2. Location in range of the available m ovem ent – a
d escription of the point in the range at w hich the
m otion is intend ed to occu r, e.g. at the beginning,
tow ard s the m id d le or at the end p oint of the available
range of m ovem ent
3. Direction of the force – a d escrip tion of the d irection in
w hich the therapist im parts the force
4. Target of the force – a d escription of the location at
w hich the therapist intend s to apply the force; this
m ay be a speci c sp inal level, or m ore generally
across a p articu lar region of the sp ine, e.g. low er
lu m bar
5. Relative stru ctu ral m ovem ent – a d escrip tion of w hich
stru ctu re (or region) is intend ed to rem ain stable and
w hich structure (or region) is intend ed to m ove; the
m oving stru cture (or region) is d escribed rst and the
stable segm ent second , sep arated by the w ord ‘on’, e.g.
low er cervical sp ine on the u p p er thoracic sp ine
6. Patient position – a d escrip tion of the p osition of the
patient, e.g. su pine, left sid e-lying, or p rone.
Although the m od el prop osed by the AAOMPT task force
provid ed a step in the right d irection tow ard s im p roving
accu racy and consistency in d escribing these interventions
w ithin the physical therapy profession, it rem ains to be seen
w hether it w ill serve as a brid ge for im proving d escriptions
of these interventions betw een the variou s p rofessions.
Most clinicians w ou ld agree that there is a d ifference
betw een spinal m anip ulation and sp inal m obilization. Manip-
ulation of the sp ine is said to d iffer from m obilization becau se,
theoretically, d u ring a m anip u lation the rate of vertebral joint
d isp lacem ent d oes not allow the p atient to p revent joint
m ovem ent (Maitland 1986). Mobilization of the spine involves
cyclic, rhythm ic, low -velocity (non-thru st) p assive m otion
that can be stop p ed by the p atient (Maitland 1986). Therefore,
the sp eed of the techniqu e (not necessarily the am ou nt of
force) is w hat shou ld d ifferentiate a m anipulative technique
from a m obilization techniqu e.
 246 PART 3 • 22 • Joint mobilization and manipulation o  the lumbar spine
Evidence for Spinal
Manipulative Therapy
Despite a recent u psurge in clinical research into the ef cacy
of SMT for m echanical low back p ain (LBP), resu lts rem ain
equivocal at best. It is sad to note that there is still a persistent
m yth w ithin the m ed ical com m u nity that ‘m ost p eop le w ith
LBP w ill get better no m atter w hat you d o’. This has been
based up on clinical experience, w here fam ily physicians
w ou ld note that 9 ou t of 10 p atients w ith an acu te ep isod e of
non-sp eci c LBP w ou ld recover (no m atter w hat treatm ent
w as ad m inistered ) w ithin a m onth or tw o. H ow ever, a British
stu d y involving 490 ind ivid u als consu lting their general prac-
titioner (fam ily p hysician) w ith LBP found that, w hereas 92%
of the ind ivid u als d iscontinu ed consu ltation w ithin 3 m onths,
only 20% had fu lly recovered w ithin 12 m onths (Croft et al
1998). Another sim ilar stu d y follow ed 323 patients w ith LBP
receiving physical therapy or chiropractic treatm ent. The
stu d y fou nd that only 18% of p atients reported no recu rrence
of sym ptom s over 1 year, and 58% sou ght ad d itional health-
care (Skargren et al 1998). These, and sim ilar stu d ies, shou ld
effectively d isp el the m yth that LBP is a self-lim iting cond i-
tion and ind icate that it d eserves early attention in ord er to
avoid longer-term d isability. There is now a com m on consen-
su s am ong healthcare p rovid ers that: (a) w e can d iagnose
d e nite p athology in only abou t 15% of p atients w ith LBP, (b)
there is very little relationship betw een p hysical p athology
and associated p ain and d isability, (c) w e continu e to regard
LBP as an inju ry – how ever, m ost episod es occur spontane-
ou sly w ith norm al everyd ay activities, (d ) high-tech im aging
su ch as m agnetic resonance im aging (MRI) tells u s very little
abou t sim p le LBP, and ind eed it ap pears to contribu te to the
p roblem of u nw anted and u nnecessary su rgical p roced u res,
and (e) the exact p athoanatom ical lesion rem ains resistant to
trad itional clinical triage in the m ajority of p atients w ith LBP.
(Read ers are referred to Chs 16 and 21 for fu rther inform ation
on m echanical LBP and chronic LBP ad vances.)
Arou nd the turn of this century, there w as grow ing evi-
d ence for SMT bu t the conclusions w ere often con icting.
There w ere ju st as m any rand om ized controlled trials in
su p p ort of m anip u lation as there w ere against, and system atic
review s w ere evenly sp lit on the evid ence. Ad d ing to the
confu sion, there w ere a variety of conclu sions being d raw n in
national p ractice gu id elines for the m anagem ent of LBP (Koes
et al 2001). A review of the research into SMT for LBP around
the tim e nd s that m ost stu d ies had signi cant aw s in d esign
m ethod ology in that an incorrect assu m p tion w as being m ad e
that su bjects w ith LBP w ere a hom ogeneou s sam p le grou p .
One exam p le of su ch stu d ies is the United Kingd om back p ain
exercise and m anipulation (UK BEAM) rand om ized trial on
the effectiveness of p hysical treatm ents for LBP in p rim ary
care (UK BEAM Trial Team 2004). In that stud y, 1334 patients
w ith LBP w ere rand om ized into four group s and received
‘best care’ in general practice, ‘best care’ plu s exercise classes,
‘best care’ plu s spinal m anipulation, or ‘best care’ plu s spinal
m anip u lation follow ed by exercise classes. The ou tcom e
m easu re u sed in the stu d y w as the Roland Morris d isability
questionnaire at 3 and 12 m onths, com p ared w ith baseline.
The results d em onstrated that all grou ps im proved over tim e
and that the ad d ition of m anipulation and / or exercise
p rovid ed only sm all to m od erate bene ts over ‘best care’ at 3
m onths and only a sm all bene t over ‘best care’ at 12 m onths.
The signi cant aw w ith this stu d y (and m any others at the
tim e) w as that its u se of broad inclu sion criteria (i.e. LBP)
resulted in a heterogeneous sam p le that m ay have inclu d ed
m any p atients for w hom no bene t w ith m anip u lation w ou ld
have been exp ected , thu s m asking the intervention’s tru e
valu e (Child s & Flynn 2004). The take-hom e m essage w as that
not all p atients w ith LBP are the sam e, and this w as som e-
thing that certainly resonated w ith clinicians, w ho w ere w ell
aw are that certain patients w ith LBP w ere m ore likely to
bene t from a m anipu lative techniqu e, w hereas other patients
w ould not.
A classi cation-based ap p roach w as therefore p rop osed so
that p atients w ith LBP cou ld be classi ed into m ore hom oge-
neou s su bgrou p s. Classi cation system s for p atients w ith LBP
have been rep orted in the literatu re since the m id 1980s, w ith
som e system s d esigned to aid in p rognosis, som e d esigned to
id entify pathology and others d esigned to d eterm ine the m ost
ap prop riate treatm ent (Rid d le 1998). A treatm ent-based clas-
si cation ap p roach w as p rop osed by p hysical therap y
researchers in 1995, w ith one su bgrou p d e ned as those w ith
LBP m ore likely to resp ond to m anip u lation (Delitto et al
1995); how ever, the criteria for m em bership of that LBP su b-
grou p had not been d eterm ined through research. This
becam e the 1997 agend a for prim ary care research on LBP:
id entifying the d ifferent varieties and subgrou ps of LBP
w ithin the treatm ent-based classi cation system and d eter-
m ining the criteria for m em bership . In other w ord s, the
treatm ent-based classi cation ap p roach w ou ld be a w ay of
know ing ahead of tim e w hich patients w ou ld be help ed by
w hich treatm ent interventions. As w ell as a classi cation
system for p atients w ith LBP, signi cant strid es have also
been m ad e tow ard s d eveloping a sim ilar classi cation system
for patients w ith neck pain (Child s et al 2004a). (Ch 16
d etails the treatm ent-based classi cation app roach for
m echanical LBP.)
Clinical Prediction Rules
Clinical p red iction ru les (CPR) have been u tilized w ithin the
healthcare com m u nity for m any years. They are sim p ly tools
to assist in the clinical d ecision-m aking p rocess. They can be
d esigned to im prove d iagnostic accuracy or to pred ict a par-
ticu lar ou tcom e, and exam p les of CPR in the m ed ical litera-
tu re inclu d e: accu racy of d iagnosing ankle fractu res (Ottaw a
ankle ru le) (Stiell et al 1992), w hen to ord er cervical spine
rad iographs (Canad ian C-spine ru le) (Stiell et al 2001) and
how to d iagnose cervical rad icu lop athy (Wainner et al 2003).
A CPR for classifying p atients w ith LBP w ho d em onstrate
short-term im provem ent w ith SMT w as d evelop ed in 2002
(Flynn et al 2002). This w as a p rosp ective, cohort stu d y of
p atients w ith non-rad icu lar LBP referred to p hysical therap y.
In sim ple term s, the researchers ad m itted 71 consecutive
p atients w ith LBP w ho d id not p resent w ith any exclu sion
criteria (factors that w ou ld p resent p recau tions or contraind i-
cations for m anip u lation), and cond u cted a stand ard ized
battery of subjective and objective (p hysical) tests. Upon com -
p letion of the testing, and regard less of the nd ings or the
testing, all p atients u nd erw ent a stand ard ized SMT treatm ent

p rogram m e. Using the m od el for stand ard ized m anipu lation
term inology d iscu ssed earlier in this chap ter, clinicians gave
all p articip ants a ‘high-velocity, end -range rotational m anipu -
lation to the lu m bar sp ine on the low er thoracic sp ine w ith
the p atient in su p ine w ith contralateral lateral exion’.
Su bjects w ere then asked to return after 48 hou rs and com -
p lete a p ost-treatm ent Osw estry Disability Ind ex (ODI); if
there w as an im p rovem ent of at least 50% com pared w ith the
p re-treatm ent ODI score, p atients w ere classi ed as having
experienced su ccess w ith the m anipu lation. If they d id not
rep ort an im p rovem ent of at least 50% in their ODI, they w ere
given a second m anipu lation treatm ent session and asked to
return after another 48 hours, w hereu pon they com pleted a
third ODI and w ere nally classi ed as having exp erienced
success or not. The researchers d iscovered that 32 (45%) of the
su bjects had exp erienced su ccess w ith the m anip u lation inter-
vention (Flynn et al 2002). Their next task w as to d eterm ine
the d ifferent characteristics (exam ination variables) existing
betw een the grou ps. Each of the exam ination variables col-
lected w as analysed for u nivariate accuracy in pred icting
su ccess, and these w ere then com bined into a m u ltivariate
CPR. A CPR w ith ve variables (sym p tom d u ration, fear-
avoid ance beliefs score, lu m bar hypom obility, hip internal
rotation range of m otion, and no sym p tom s d istal to the knee)
w as id enti ed . When fou r or m ore of these variables w ere
p resent in a su bject w ith LBP, the p ositive likelihood ratio w as
24.38, w hich raised the p re-test p robability of experiencing
success from 45% to a p ost-test probability of su ccess of 95%
(Flynn et al 2002). This w as a signi cant nd ing that w ou ld
greatly change the land scap e of SMT for LBP. The next step
requ ired w as to cond u ct a rand om ized controlled clinical trial
to valid ate the ru le.
That valid ation stu d y w as p u blished in 2004 (Child s et al
2004b). In that stu d y, 131 consecu tive patients w ith LBP, aged
18 to 60 years, w ere rand om ly assigned to receive either
m anip u lation p lu s exercise or exercise alone by a p hysical
therap ist for 4 w eeks. Once allocated to the treatm ent grou ps,
all subjects w ere exam ined accord ing to the CPR criteria
(sym p tom d uration, sym ptom location, fear-avoid ance beliefs,
lum bar m obility and hip rotation range of m otion) and clas-
si ed as being either positive (at least 4 ou t of 5) or negative
accord ing to the ru le (less than 4 ou t of 5). Ou tcom e m easu res
w ere d isability (ODI) and p ain at 1 w eek, 4 w eeks and 6
m onths com p ared w ith baseline. There w as a signi cant d if-
ference in ou tcom es betw een patients w ho w ere positive on
the ru le and received m anip u lation com p ared w ith p atients
w ho w ere either negative on the rule and received m anip ula-
tion, p ositive on the ru le and received exercise only, or nega-
tive on the ru le and received exercise only. A p atient w ho w as
p ositive on the ru le and received m anip u lation w as found to
have a 92% chance of a su ccessful outcom e, w ith an associated
nu m ber need ed to treat (N N T) for bene t at 4 w eeks of 1.9
(95% CI 1.4–3.5) (Child s et al 2004b). This m eant that only tw o
p atients w ith LBP w ho are positive on the ru le need be treated
w ith m anip ulation in ord er to p revent one patient from failing
to achieve a su ccessfu l ou tcom e. It is w id ely accep ted that
p atients w ith p ersistent d isability are at increased risk of
chronic, d isabling ep isod es of LBP, and this stu d y d em on-
strated that d ecision m aking based on the CPR cou ld help
p revent p rogression to chronic d isability. In a follow -u p anal-
ysis of the stu d y, it w as fou nd that p atients w ith LBP w ho
w ere positive on the ru le and com pleted the exercise
Clinical prediction rules 247
intervention w ithou t m anipu lation w ere eight (95% CI 1.1,
63.5) tim es m ore likely to experience a w orsening in d isability
at 1 w eek than p atients w ho actu ally received m anip u lation
(Child s et al 2006). The authors noted that the risks associated
w ith harm d u e to lu m bop elvic m anipu lation w ere alm ost
negligible and conclu d ed that the risk of not offering m anip u -
lation w as real, and a m ore proactive ap proach seem ed to be
w arranted (Child s et al 2006).
Som e researchers im m ed iately qu estioned the valid ity of
the new ly valid ated CPR for LBP. H ancock et al (2008) p er-
form ed a second ary analysis of a rand om ized controlled trial
investigating the ef cacy of SMT in 239 patients w ith non-
sp eci c LBP. Patients received SMT or p lacebo tw o to three
tim es per w eek for up to 4 w eeks, and outcom es w ere p ain
and d isability m easu red at 1, 2, 4 and 12 w eeks. These
researchers reported that the CPR d id no better than chance
in id entifying patients w ith LBP m ost likely to bene t from
SMT, and they conclu d ed (incorrectly, as w e shall see) that
the CPR p rop osed by Child s et al (2004b) d id not generalize
to p atients p resenting to p rim ary care w ith acu te LBP w ho
received a course of SMT. H ow ever, it is im portant to recog-
nize that these au thors d e ned SMT as either thru st m anip u la-
tion or non-thru st m obilization. Fu rtherm ore, they rep orted
that the m ajority of the patients in their stud y (97%) received
a variety of non-thru st m obilization and only a sm all p rop or-
tion (3%) actu ally received thrust m anip ulation techniqu es. In
a follow -up letter to the ed itor, H ebert and Perle (2008)
p ointed ou t the p roblem w ith the au thors’ d e nition of SMT
and m ad e the argu m ent that the nd ings in the above stu d y
d id not actu ally test the valid ity of the CPR; instead they
m ad e the case for the im p lem entation of the ru le in the sam e
m anner as it w as d evelop ed , valid ated and exam ined in other
clinical settings.
The issue of d ifferences in ou tcom e betw een thru st m anip-
u lation and non-thru st m obilizations w as brou ght to fu rther
light by a m ore recent stu d y. Cook et al (2013) fou nd no sig-
ni cant d ifference in ou tcom es (i.e. p ain, d isability, rep orted
rate of recovery, total visits, or d ays of care) betw een early
u se of m anip u lation (thru st) and m obilization (non-thru st) in
149 su bjects w ith LBP. H ow ever, to qu alify for the stu d y,
p atients w ith LBP had to d em onstrate a w ithin-session change
(im provem ent in pain and / or range of m otion) d uring the
assessm ent p hase of the clinical exam ination – sp eci cally
d uring the passive accessory exam ination. The exam ination
requ ired the therapist to localize the m ost com p arable
response (reprod u ction of the chief com plaint of the sym p -
tom s id enti ed by the p atient) d u ring a p assive accessory
m obilization (either u nilateral or central) to a sp eci c level of
the lu m bar sp ine. Only p atients w ith an id enti able com p a-
rable level and a w ithin-session change w ere able to continu e
in the stud y. This m ay w ell have biased the resu lts of the
stu d y in favou r of non-thru st m obilization as only those
p atients w ho d em onstrated im p rovem ent (albeit w ithin-
session) w ith m obilization (non-thru st) w ere allow ed to con-
tinu e in the stu d y. The au thors ad m itted that ‘this p rocess
m ay have self-selected su bjects for non-thru st m obilization
since the p roced u re u sed to d e ne a w ithin-session change is
also sim ilar to the non-thrust m obilization used d u ring treat-
m ent’ (Cook et al 2013, p 197).
It w ould appear therefore that, for the tim e being, the d eci-
sion to u se either thru st m anip u lation or non-thru st m obiliza-
tion m ight w ell be left to therap ists (w ho m ay be m ore
 248 PART 3 • 22 • Joint mobilization and manipulation o  the lumbar spine
skilled / com fortable w ith one over the other) and p atients
w ith LBP (w ho m ay have a preference or belief that one w ill
be m ore effective than the other).
The Audible Pop
For m ost practitioners of SMT, the aim of the technique is to
achieve joint cavitation, w hich is accom p anied by a ‘popping’
or ‘cracking’ sou nd (Gibbons & Tehan 2004). Despite the
m any theories, there is cu rrently no evid ence abou t w hat
cau ses the characteristic ‘cracking’ sou nd or ‘au d ible release’.
Brod eu r (1995) com p leted a review of the literatu re on the
au d ible release associated w ith m anipu lation and reported
that it is theorized that the au d ible release is cau sed by a
cavitation p rocess w hereby a su d d en d ecrease in intracap su -
lar p ressu re cau ses d issolved gasses w ithin the synovial u id
to be released into the joint cavity. H ow ever, a clinical trial
investigating the effect of m anip u lation on the size and
d ensity of cervical zygap ophyseal joint sp aces in 22 asym pto-
m atic su bjects u sing CT and p lain lm rad iograp hy fou nd
no evid ence of gas in the joint sp ace, or of an obviou s increase
in zygap op hyseal joint sp ace w id th im m ed iately after the
m anip u lation (Cascioli et al 2003). Sim ilar stud ies have
failed to supp ort such a theory of gas in the joint (Cram er
et al 2011).
Another review of the literatu re (Evans 2002) to ‘critically
d iscu ss previou s theories and research of spinal H VLA thrust
m anip u lation, highlighting rep orted neu rop hysiological
effects that seem to be uniquely associated w ith cavitation of
synovial u id ’ fou nd that there ap p eared to be tw o sep arate
m od es of action from zygap op hyseal H VLA thru st m anip u la-
tion: ‘m echanical’ effects and ‘neu rop hysiological’ effects.
Evans (2002) also rep orted that the intra-articu lar ‘m echani-
cal’ effects of zygap op hyseal H VLA thru st m anip u lation
seem ed to be absolu tely sep arate from , and irrelevant to, the
occu rrence of rep orted ‘neu rop hysiological’ effects (Evans
2002). It is safe to say that, currently, w e d o not know how or
w hy m anipu lation m ight w ork in patients w ith LBP. What w e
d o know, how ever, is that there are som e patients w ith LBP
w ho d o bene t from m anipu lation, and the d evelopm ent and
valid ation of CPRs is help ing u s to d eterm ine in ad vance w ho
those p atients are.
Most clinicians w ho u tilize SMT consid er that their m anip -
u lative techniqu e has been correctly p erform ed w hen there is
an au d ible release or p op in the targeted joint. H ow ever, sci-
enti c research has suggested that this au d ible release m ay
not m atter. Flynn et al (2006) cond u cted a second ary analysis
of their CPR stu d ies to d eterm ine the relationship betw een an
au d ible p op w ith spinal m anip ulation and the im provem ent
in p ain and fu nction noted in p atients w ith LBP. Therap ists
record ed w hether an aud ible p op w as heard by either the
p atient or the therap ist d u ring the treatm ent interventions,
and an au d ible pop w as perceived in 59 (84%) of the patients.
H ow ever, no d ifferences w ere d etected at baseline, or at any
follow -u p period , in the level of pain, the Osw estry score, or
lu m bop elvic range of m otion based on w hether a p op w as
achieved . The resu lts suggested that a p erceived au d ible pop
m ay not relate to im p roved ou tcom es from high-velocity
thru st m anip u lation for p atients w ith non-rad icu lar LBP at
either an im m ed iate or a longer term follow -up.
Clinicians also seek to localize their m anip u lative tech-
niqu es to sp eci c joint(s) that requ ire them and avoid
u nw anted stress on ad jacent joints. Sp inal m anip u lative tech-
niqu es are tau ght and then p erform ed w ith a sp eci c (som e-
tim es biom echanical) intent. H ow ever, an evalu ation stu d y
(Ross et al 2004) u sing accelerom eters to locate the joints that
p rod u ced an au d ible sou nd in resp onse to m anip u lation
(cavitation) d uring spinal m anipu lative techniqu es fou nd that
both the accu racy and the speci city of the m anipu lation w ere
p oor. In this particu lar stud y, 64 asym ptom atic su bjects
received thoracic and lu m bar spinal m anip ulative proced ures
from 28 clinicians (all w ere Canad ian chirop ractors w ith a
range of clinical exp erience from 1 to 43 years); its nd ings
w ere that, for the lum bar spine, SMT w as accu rate ‘abou t half
the tim e’ (57 / 124) and , for the thoracic sp ine, SMT ap p eared
to be m ore accurate (29 / 54) (Ross et al 2004). H ow ever, m ost
of the p roced u res w ere associated w ith m u ltip le cavitations,
and , in m ost cases, at least one cavitation em anated from the
target joint. This m ay have skew ed resu lts tow ard s greater
accu racy.
Som e au thors have qu estioned w hether SMT need be sp e-
ci c in term s of localization of m otion (Cleland & Child s 2005;
Flynn 2006). Several stu d ies u sing posterior-to-anterior (PA)
non-thru st m obilization techniqu es rep orted that there w as
no d ifference in ou tcom es for p ain based on w hether the m ost
p ainfu l segm ent w as treated , or w hether a rand om ly selected
segm ent w as treated (Beneck et al 2005; Land el et al 2008;
Aquino et al 2009). H ow ever, cau tion shou ld be u sed w hen
generalizing the resu lts of such stud ies to all SMT techniqu es.
If clinicians w ere to accept that it is neither necessary nor pos-
sible to be sp eci c w ith SMT techniqu es, then one p ossible
consequ ence m ight be u nw anted ad verse resp onses. As noted
p reviou sly, p oorly localized and excessively forcefu l m anip u -
lative techniqu es m ay provoke ad verse responses. Therefore,
to m inim ize risks associated w ith SMT, the clinician shou ld
either carefu lly select patients w hen d ecid ing to u se less spe-
ci c m anip u lative techniqu es or u se techniqu es that attem p t
to be m ore sp eci c and localized .
Spinal Positioning and Locking
In both p hysical therap y and osteopathic m anipulative tech-
niqu es, sp inal locking can be u sed in ord er to localize forces
and achieve cavitation at a sp eci c vertebral segm ent (Stod -
d ard 1972; Dow ning 1985; Beal 1989; Kappler 1989; N yberg
1993; Greenm an 1996; H artm an 1997a). This locking can be
achieved by facet ap p osition, ligam entou s m yofascial tension,
or a com bination of the tw o (Stod d ard 1972; Dow ning 1985;
Beal 1989; N yberg 1993; Greenm an 1996; H artm an 1997a).
This principle is used to position the spine in such a w ay as
to localize the leverage or force m om ent to one joint w ithou t
p lacing u nd u e strain on ad jacent segm ents. The osteop athic
p rofession u ses the follow ing nom enclatu re to classify sp inal
m otion based u p on the cou p ling of sid e-bend ing and rotation
m ovem ents (Gibbons & Tehan 2004): in type 1 movement, sid e-
bend ing and rotation occur in opposite d irections; in type 2
movement, sid e-bend ing and rotation occu r in the sam e d irec-
tion. It is p rop osed that locking by facet ap p osition can be
achieved w hen the sp ine is p laced in a p osition op posite to
that of norm al cou p ling behaviou r.

A system atic review of the literatu re on cou p ling behav-
iou r of the cervical sp ine found that there w as 100% agree-
m ent in cou p ling d irection in the low er cervical vertebral
segm ents (C2–C3 and below ) (Cook et al 2006). N orm al cou -
p ling behaviou r is typ e 2 (i.e. left sid e-bend ing coup led w ith
left rotation, and vice versa) and therefore facet locking can
be achieved by p rod ucing typ e 1 m ovem ent (i.e. left sid e-
bend ing cou pled w ith right rotation and vice versa) (Cook
et al 2006).
The available research relating to cou p led m ovem ents of
sid e-bend ing and rotation in the thoracic and lu m bar sp ine is
inconsistent (Panjabi et al 1989; Oxland et al 1992; Steffen et al
1997; H arrison et al 1999; Plau gher & Bu rrow 1999; Feip el
et al 2001; Keller et al 2003; Legasp i & Ed m ond 2007). There
is som e evid ence that sp inal posture and p ositioning alter
cou p ling behaviou r in the thoracic and lu m bar sp ine (Panjabi
et al 1989; Steffen et al 1997; H arrison et al 1999). Speci cally
in the exed p osition, the cou pling of sid e-bend ing and rota-
tion is to the sam e sid e, and in the neu tral / extend ed p osition
the cou p ling of sid e-bend ing and rotation occu rs to the op p o-
site sid es. Althou gh the research d oesn’t valid ate any single
m od el for sp inal p ositioning and locking in the thoracic and
lum bar spine, m any ed u cators continu e to nd this m od el
u sefu l for learning and m otor skill acqu isition w ith m anip u la-
tive therap y techniqu es.
For neutral / extension positioning, norm al coupling
behaviou r of sid e-bend ing and rotation are to the op posite
sid e (typ e 1). Therefore, facet app osition locking can be
achieved throu gh sid e-bend ing and rotation to the sam e sid e.
For exion positioning, norm al coup ling behaviou r of sid e-
bend ing and rotation are to the sam e sid e (type 2); therefore,
facet apposition locking can be achieved throu gh sid e-bend ing
and rotation to the opp osite sid e.
Safety and Manipulative Techniques
Stu d ies show that, w hen it com es to m anip u lation in the
lum bar sp ine, seriou s risks are very m inim al. H ald em an and
Ru binstein (1992) com p leted a review of the literatu re and ,
over a p eriod of 77 years, fou nd just 10 episod es of caud a
equina synd rom e follow ing lum bar spinal m anipulation. This
equ ates to an estim ated risk of less than 1 p er 10 m illion
m anip u lations. Shekelle et al (1992) estim ated the rate of
occu rrence of cau d a equ ina synd rom e as a com p lication of
lum bar sp inal m anipu lation to be in the ord er of less than 1
case p er 100 m illion m anipu lations. Finally, Bronfort (1999)
reported that overall seriou s com plications of lum bar spinal
m anip u lation seem ed to be rare.
Possible cau ses of com p lications from sp inal m anip u lative
techniqu es to the lu m bar sp ine p rim arily involve one of tw o
factors: (1) incorrect p atient selection, and (2) poor m anipu la-
tive techniqu e. The clinician p rovid ing sp inal m anip u lation
for a patient w ith LBP should have:
• a m echanical or clinical-reasoning d iagnosis for the u se of
m anip u lation
• an aw areness of the p ossible com p lications
• cond u cted an ad equ ate p alp ation assessm ent
• ap p rop riately and ad equ ately p rogressed throu gh
m obilization grad es before com ing to m anip u lation
• p atient consent.
Sa ety and manipulative techniques 249
To avoid com p lications associated w ith p oor m anip u lative
techniqu e, the clinician shou ld :
• avoid excessive force
• avoid excessive am plitu d e of m ovem ent
• avoid excessive leverage of forces
• avoid inapprop riate com bination of leverages
• u se the correct plane of thru st
• u se correct patient p ositioning
• u se correct therapist positioning
• obtain patient feed back in the pre-thrust positioning.
Sp inal m anip u lative techniqu es requ ire a level of skill and
care that can be obtained only throu gh ap p rop riate and ad e-
qu ate clinical p ractice.
Contraindications and precautions
As w ith any therapeutic intervention, d ue consid eration m u st
be given to the risk–bene t ratio; that is, the bene t to the
p atient of p rovid ing the therap eu tic intervention m u st ou t-
w eigh any potential risk associated w ith the intervention.
Clinicians shou ld alw ays be aw are of any contraind ications
and precau tions for SMT. Is there a d ifference betw een a
contraind ication and a p recau tion? A contraind ication m eans
that a m anip u lative techniqu e shou ld not be u sed u nd er
any circu m stances, w hereas a p recaution m eans that, d ep end -
ing u pon the skill, experience and training of the p ractitioner,
the typ e of techniqu e selected , the am ou nt of leverage and
force used , and the age, general health and p hysical cond ition
of the p atient, it m ay not be the w isest choice to u se a m anip u-
lative technique. Boxes 22.1 and 22.2 provid e som e of the
better-know n and com m only accepted contraind ications and
Bo x 2 2 .1 C o n tra in d ic a tio n s fo r s p in a l
m a n ip u la tive th e ra p y
Bo ny is s ue s
Any pathology that may have led to bony compromise:
• Tumour, e.g. metastas es
• Infection, e.g. tuberculos is, osteomyelitis
• Metabolic, e.g. osteomalacia, os teoporosis
• Congenital, e.g. dysplas ia
• Iatrogenic, e.g. long-term corticos teroid medication
• In ammatory, e.g. severe rheumatoid arthritis
• Traumatic, e.g. fracture
Ne uro lo g ic al is s ue s
• Cervical myelopathy
• Cord compress ion
• Cauda equina syndrome
• Nerve root compress ion with increasing neurological de cit
Vas c ular is s ue s
• Diagnos ed vertebrobas ilar insuf ciency
• Aortic aneurysm
• Bleeding diatheses, e.g. severe haemophilia
• Lack of mechanical or clinical-reasoning diagnos is
• Lack of patient consent
 250 PART 3 • 22 • Joint mobilization and manipulation o  the lumbar spine

Bo x 2 2 .2 P re c a u tio n s fo r s p in a l m a n ip u la tive
th e ra p y

• Adverse reaction to previous manual therapy

• Disc herniation or prolapse
• Pregnancy
• Spondylolis thes is
• Psychological dependence upon manipulative techniques
• Ligamentous laxity
As a general rule, s afety in manipulation is bes t provided by
gradual progres sion of the strength of the technique (grades
of mobilization) coupled with continual as sessment and
reassess ment (Maitland, 1986).
Ho w c an we  make  manipulative  te c hnique s  s afe r?
• Appropriate clinician training
• Take a thorough patient history
• Perform a thorough physical examination
• Use as tute clinical reasoning s kills
• Using graded mobilizations prior to the application of any
Figure 22.1 Central posterior-to-anterior mobilization.
manipulative procedure

p recau tions for m anipulative techniqu es and offer som e

ad vice on m aking m anip u lation safer.

Spinal Mobilization and Manipulation

Techniques
The techniques presented w ithin this chapter are d eveloped
from Geoff Maitland , PT (Maitland 1986) and also from tech-
niqu es tau ght by Lau rie H artm an, DO, PhD (H artm an 1997b).
The em phasis w ith any m anu al therapy techniqu e should be
to m inim ize the occu rrence of m od erate to severe ad verse
resp onse as presented by Carnes et al (2010) and m axim ize
ou tcom es in term s of d ecreased p ain and increased fu nction.
These interventions can be su bd ivid ed into passive accessory
intervertebral m otions and p assive p hysiological interverte-
bral m otions.
Figure 22.2 Unilateral posterior-to-anterior mobilization.
Central posterior-to-anterior mobilization
The patient is prone in a p osition of greatest com fort w here Unilateral posterior-to-anterior
signs and sym p tom s are m inim ized . The therap ist shou ld mobilization
assu m e a com fortable stance and ad ju st the treatm ent table to
a com fortable height and then assu m e a p isiform contact on The patient is prone in as com fortable a position as possible
the d esired sp inou s p rocess (Fig. 22.1). The m obilization tech- to m inim ize signs and sym p tom s. The therap ist assu m es a
niqu e m ay be grad ed throu gh forces as d escribed by Maitland com fortable stance w ith the treatm ent table correctly ad ju sted ,
(1986). The force is d irected tow ard s the treatm ent table by and m akes contact w ith both thu m b pad s d irectly over the
the therap ist shifting his / her w eight forw ard s throu gh the m u lti d u s m u scle and u nd erlying zygap op hyseal joint (Fig.
arm s and hand s, and the m otion im parted shou ld be slow, 22.2). The m obilization technique is sim ilarly grad ed throu gh
rhythm ic and through a relatively short range. Most clinicians forces, as d escribed by Maitland (1986). The force is usually
w ill use either a larger am plitud e grad e III oscillation or a d irected d ow nw ard s tow ard s the treatm ent table, bu t can also
sm aller am p litu d e grad e IV oscillation, and p erform the m obi- be ap plied in a m ed ial / lateral or cephalad / caud ad d irection
lization for rep eated bouts of 45 to 60 second s, then reassess based on patient feed back and resp onse. As w ith the central
the p atient for w ithin-session changes to sym p tom s and range PA m obilizations, they are generally ap plied as a larger
of m otion. am plitud e grad e III oscillation or a sm aller am plitu d e grad e
 Spinal mobilization and manipulation techniques 251

Figure 22.3 Lumbar rotation mobilization grade I. Figure 22.4 Lumbar rotation mobilization grade II.

IV oscillation for rep eated bou ts of 45 to 60 second s, then the

p atient shou ld be reassessed for w ithin-session changes to
sym p tom s and range of m otion.

Lumbar rotation mobilization: grades I–IV

The patient is in sid e-lying w ith hips and knees exed to
m axim u m com fort. This techniqu e is also grad ed throu gh
forces as d escribed by Maitland (1986), so that grad e I m obi-
lization is p erform ed w ith the lu m bar spine in neutral rotation
(Fig. 22.3). The therapist assum es a com fortable strid e stance
and p laces both hand s above the p atient’s greater trochanter
and im m ed iately posterior to the anterior su p erior iliac spine
(ASIS). Very few clinicians w ould u se a grad e I m obilization;
how ever, it m ay be ap p rop riate for a p atient in severe d iscom -
fort as a gentle non-threatening m obilization that can then be
progressed throu gh a larger range of m otion.
The grad e II m obilization requ ires a larger am plitu d e
m otion and can be assisted by the p atient p lacing the elbow
behind the trunk (Fig. 22.4). During oscillations, the pelvis
and shou ld er gird les can be rhythm ically m oved in a com fort- Figure 22.5 Lumbar rotation mobilization grade III.
ing and hopefu lly pain-free range. To progress to a grad e III
rotation m obilization, the therapist can now apply forces
throu gh the hip and sam e-sid e shou ld er (Fig. 22.5). This is
typ ically p erform ed throu gh larger am p litu d e and kep t short p atient shou ld be reassessed for w ithin-session changes to
of end -range lu m bar (tru nk) rotation. sym p tom s and range of m otion.
Grad e IV m obilization is best p erform ed facing the p atient.
The patient is placed in sid e-lying and rotation of the lu m bar Lumbopelvic regional manipulation
sp ine (tru nk) is introd u ced (Fig. 22.6). The therapist takes u p
an axillary hold w ith the left forearm and u ses the left hand Using the term inology as recom m end ed by Mintken et al
to p alp ate and p rovid e som e ‘ xation’ at the d esired level. H e (2008), this can be d escribed as a high-velocity end -range rota-
or she can then u se the right forearm and hand to ap p ly the tion thru st to the lu m bop elvic region, p elvis on lu m bar sp ine
rotation force u p to the ‘ xated ’ level. The rotation oscillations w ith patient su pine. It has trad itionally been d escribed as the
are generated through the therap ist’s bod y rather than the anterior innom inate techniqu e (Fig. 22.7). The patient lies
arm s throu gh tru nk rotation w hile in a com fortable strid e su p ine and the therap ist m oves the p atient’s p elvis tow ard s
stance. him / her, then m oves the feet and shou ld ers in the op p osite
As w ith all other non-thru st m obilizations, oscillations are d irection to introd u ce left sid e-bend ing of the trunk. The
provid ed in tw o or three bou ts of 45 to 60 second s, then the therap ist then p laces the p atient’s left foot and ankle on top
 252 PART 3 • 22 •
Figure 22.6 Lumbar rotation mobilization grade IV.
Figure 22.7 Lumbopelvic regional manipulation.
of the right ankle and asks the p atient to clasp the ngers
behind the neck, or asks patient to fold the arm s across the
chest (based on com fort for p atient). The therap ist then rotates
the p atient’s tru nk to the right w hile m aintaining left tru nk
sid e-bend ing (it is im p ortant not to lose this sid e-bend ing).
The therapist then grasps the patient’s left scapu lar and thorax
w ith the left hand and places the palm of the right hand
d irectly over the ASIS. At this point, any necessary ad just-
m ents to achieve p re-thru st tension can be m ad e.
The thru st is applied throu gh the ASIS in a cu rved plane
tow ard s the cou ch. The therap ist’s left forearm , w rist and
hand over the p atient’s scap u la and thorax d o not ap p ly a
thru st, bu t rather act as stabilizers only.
Joint mobilization and manipulation o  the lumbar spine
Lumbar rotation in neutral
or extension manipulation
Using the term inology as recom m end ed by Mintken et al
(2008), this can be d escribed as a high-velocity end -range
rotation thrust to upp er lu m bar spine on low er lum bar sp ine
w ith patient sid e-lying and lu m bar spine in neu tral or slightly
extend ed . It has trad itionally been d escribed as the sid e-lying
rotation techniqu e or rotation glid ing thru st in neutral p osi-
tioning (Fig. 22.8A). The patient is in right sid e-lying, and
the therap ist p laces the p atient’s right leg and sp ine in a
straight line to achieve neu tral / extension p ositioning. The
left hip is exed to ap p roxim ately 90° so that the left knee is
also exed and the d orsum of left foot can be p laced ju st
behind the right calf / knee. The therap ist begins by introd uc-
ing left rotation of the u pper bod y d ow n to d esired level
w hile avoid ing the introd u ction of any spine exion, and then
takes u p axillary hold w ith the left forearm and hand (Fig.
22.8B). Stand ing close to the cou ch, feet spread and w ith one
leg behind the other, the therapist m aintains an u pright
p ostu re facing the p atient’s u p p er bod y then p laces the right
forearm in the region betw een the glu teus m ed ius and
m axim u s to rotate the p atient’s p elvis and lu m bar sp ine
tow ard s him / her u ntil m otion is p alp ated at the d esired
segm ent (p re-tension). The therap ist then rotates the p atient’s
u p p er bod y aw ay u ntil tension is sensed at the d esired
segm ent, and then rolls the patient about 10–15° tow ard s
him / her and can m ake any necessary ad ju stm ents to achieve
p re-thru st tension.
The thrust is applied w ith the right forearm against the
p elvis and the d irection is d ow n tow ard s the cou ch by ap p ly-
ing exaggerated pelvic rotation tow ard s him / her. The left
arm against the patient’s axillary region d oes not app ly a
thru st, bu t rather acts as stabilizer only.
Lumbar rotation in exion manipulation
Using the term inology as recom m end ed by Mintken et al
(2008), this can be d escribed as a high-velocity end -range rota-
tion thru st to u p p er lu m bar sp ine on low er lu m bar sp ine w ith
p atient sid e-lying and lu m bar sp ine in slight exion (Fig.
22.9). This u ses the osteopathic principles w here the lu m bar
sp ine, in exion, has ip silateral cou p ling m otions and , there-
fore, facet apposition locking can be achieved by com bining
lateral exion w ith contralateral rotation. The patient is in
right sid e-lying and a rolled tow el is placed u nd er the lum bar
sp ine to introd u ce lateral exion to the right. The lu m bar rota-
tion w ill be to the left, thereby p rovid ing contralateral m otions
to cou nter the norm al ip silateral cou p ling behaviou r. The
therap ist p laces the p atient’s right leg and hip in slight exion
to achieve lu m bar exion p ositioning. The left hip is exed to
ap proxim ately 90° so that the left knee is also exed and the
d orsum of the left foot can be placed ju st behind the right
calf / knee. The therap ist begins by introd u cing left rotation
of the u p p er bod y d ow n to d esired level w hile avoid ing the
introd uction of any spine exion, and then takes u p axillary
hold w ith the left forearm and hand . Stand ing close to the
cou ch, feet sp read and w ith one leg behind the other, the
therap ist m aintains an u p right p ostu re facing the p atient’s
u p p er bod y, then p laces the right forearm in the region

A B
Figure 22.8 Lumbar rotation in neutral or extension manipulation: (A) caudal view, (B) cranial view.
Figure 22.9 Lumbar rotation in exion manipulation.
betw een glu teus m ed ius and m axim us to rotate the p atient’s
pelvis and lu m bar sp ine tow ard s him / her u ntil m otion is
palp ated at the d esired segm ent (pre-tension). The therapist
then rotates the p atient’s u p p er bod y aw ay u ntil tension is
sensed at the d esired segm ent, and nally rolls the p atient
abou t 10–15° tow ard s him / her and can m ake any necessary
ad justm ents to achieve pre-thru st tension.
The thru st is applied w ith the right forearm against the
pelvis and the d irection is d ow n tow ard s the cou ch by ap ply-
ing exaggerated pelvic rotation tow ard s him / her. The left
arm against the p atient’s axillary region d oes not apply a
thru st, bu t rather acts as stabilizer only.
Conclusion 253
Conclusion
Great strid es have been m ad e in recent years in ou r u nd er-
stand ing of the variou s factors that are associated w ith su c-
cessfu l m anagem ent of LBP throu gh the u se of m anip u lation
and non-thru st m obilization. A signi cant ad vancem ent has
been the acknow led gem ent that not all p atients w ith LBP are
the sam e and , accord ingly, not all w ill resp ond favou rably to
one sp eci c treatm ent intervention. Use of the classi cation-
based approach w hen evalu ating an ind ivid u al w ith LBP can
help the clinician in d eterm ining the m ost bene cial treatm ent
ap proach, and clinical p red iction ru les m ay also be u sefu l.
Ultim ately, sound clinical reasoning w ill be requ ired so that
the therap ist can p rovid e the m ost ap p rop riate intervention
for the speci c patient w ith LBP in the clinic.
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 PART 3 •  Lumbar Spine Pain Syndromes
Therapeutic Exercise for Mechanical Low Back Pain
CHAP TER CONTENTS
Evidence for exercise in low back pain  255
Mobility exercises  256
Motor control: stabilization, motor pattern retraining, strength  259
Exercises  259
Abdominal draw-in manoeuvre  259
Adding lower limb challenges  260
Abdominal curl-up  260
Multi dus activation exercises  261
Bridge exercises in supine  262
Quadruped  262
Side plank / horizontal side support  263
Front plank / prone bridge  264
Exercises on unstable surfaces  264
Motor pattern retraining / functional integration  266
Pilates / yoga  267
Balance / proprioception  268
Higher level strengthening exercises  269
Exercise parameters  270
Conclusion  271
Evidence for Exercise in Low Back Pain
Exercise therap y is a com m only u sed intervention in the con-
servative m anagem ent of m echanical low back p ain (LBP). A
Cochrane review cond u cted by H ayd en et al (2005) fou nd that
exercise therapy signi cantly red u ced pain and im proved
function in ad ults w ith chronic LBP. A m ore recent system atic
review also fou nd evid ence for the effectiveness of exercise
therap y com p ared w ith ‘u su al care’ for red u cing chronic p ain
intensity and d isability at short-term follow -up (van Mid d elk-
oop et al 2010). System atic review s and clinical p ractice
guid elines on the m anagem ent of acu te LBP d o not, how ever,
recom m end exercise therapy and they have found strong evi-
d ence that exercise therap y is no m ore effective than no treat-
m ent or other conservative treatm ent for acu te LBP (van
Mid d elkoop et al 2010; Delitto et al 2012).
Various types of low back exercises have been d escribed in
the literatu re inclu d ing m obility, stretching, stabilization,
m u scle strengthening from low load to high load , m otor
Chapter 
23  
C a ro l Ke n n e d y, Le n e rd e n e Le ve s q u e
control, balance / coord ination, grad ed activity and aerobic.
Van Mid d elkoop et al (2010) found no evid ence that one par-
ticu lar typ e of exercise is m ore effective than any other. In an
earlier system atic review of 14 rand om ized controlled trials,
how ever, Maced o et al (2009) fou nd m otor control exercises
to be m ore effective than m inim al intervention and bene cial
w hen ad d ed to another intervention in red ucing pain and
d isability for p eople w ith p ersistent LBP. A m ore recent m eta-
analysis conclud ed that, in patients w ith chronic or recu rring
LBP, m otor control exercises w ere su perior to general exer-
cise, m anu al therap y and m inim al intervention w ith regard
to d isability and p ain (Bystrom et al 2013). H alad ay et al
(2013) evalu ated the quality of system atic review s on speci c
stabilization exercises for chronic LBP and fou nd several
high-qu ality review s ind icating that they are bene cial and
shou ld be consid ered as p art of the treatm ent p lan for this
p op u lation.
Classi cation system s have been p rop osed , throu ghou t the
literatu re, su ggesting that subgrou ps of p atients m ay respond
d ifferently to various types of exercise program m es; how ever,
it rem ains u nclear as to w hich patients bene t m ost from
w hich type of exercise (van Mid d elkoop et al 2010). H icks
et al (2005) d erived a clinical p red iction ru le (CPR) to assist
in id entifying those patients w ho m ay respond to a
stabilization-focu sed exercise p rogram m e. The fou r clinical
variables includ ed : (1) age < 40 years, (2) positive prone insta-
bility test, (3) straight leg raise > 91° and (4) p resence of aber-
rant tru nk m ovem ents w ith lu m bar exion. Rabin et al (2014)
w ere u nable to valid ate the rule in a recent rand om ized con-
trolled trial, bu t d id nd that a m od i ed version of the CPR
containing only tw o of the original fou r item s (p resence of
aberrant m ovem ent and a p ositive p rone instability test) d em -
onstrated better p red ictive valid ity in id entifying those m ost
likely to succeed w ith a stabilization program m e.
Choi et al (2010) cond u cted a Cochrane review evalu ating
the effectiveness of exercises on the p revention of recu rrence
of LBP and rep orted m od erate-qu ality evid ence that p ost-
d ischarge exercise program m es can prevent the num ber of
recu rrences of LBP. The Am erican Physical Therap y Associa-
tion (APTA) Low Back Pain Clinical Practice Gu id elines rec-
om m end ‘that clinicians shou ld consid er u sing tru nk
coord ination, strengthening and end u rance exercises to
red u ce LBP and d isability in patients w ith su bacu te and
chronic LBP w ith m ovem ent im p airm ents’ (Delitto et al 2012,
p A2).
 256 PART 3 • 23 • Therapeutic exercise for mechanical low back pain
The effectiveness of stretching in the managem ent of LBP
has received little attention. Many of the stu d ies that have
investigated the u se of stretching exercises for LBP also
inclu d e other form s of exercise, m ost often stabilization.
Althou gh this is consistent w ith cu rrent p ractice, it d oes m ake
it d if cu lt to d eterm ine the effectiveness of stretching as an
isolated intervention. Pu rep ong et al (2012) fou nd a signi -
cant im p rovem ent in p ain and d isability along w ith increased
lu m bar m obility follow ing 2 w eeks of exibility exercises
inclu d ing exion, extension and rotation. Franca et al (2012)
com pared tw o typ es of exercise in the treatm ent of LBP –
stretching and segm ental stabilization – and fou nd that,
althou gh both resu lted in pain relief and im p roved d isability,
the segm ental stabilization grou p exhibited signi cantly
higher gains in the variables associated w ith LBP than the
stretching grou p . In a stu d y investigating stretching in the
m anagem ent of LBP in nu rses, 81% of the exp erim ental group
experienced a m od erate to high level of back pain relief (Chen
et al 2012). In the system atic review by H ayd en et al (2005),
both stretching and strengthening exercise program m es d em -
onstrated the largest im p rovem ent over other com p arisons.
Clinical Practice Gu id elines recom m end that p atient p ref-
erences shou ld be consid ered and that exercises should be
ind ivid u alized and su p ervised (Delitto et al 2012). In a recent
system atic review of 15 qu alitative stu d ies, Slad e et al (2014)
fou nd that the participants consid ered supervision of exercise
p rogram m es to be im p ortant, and that therap ists shou ld d em -
onstrate exercises and observe and p rovid e feed back and cor-
rections rather than sim ply p rovid e a p rinted list of exercises.
The patient’s feelings of self-ef cacy w ith respect to exercising
and fear-avoid ance beliefs w ere associated w ith d ecisions
w hether to exercise or not, and patients felt that the ongoing
su p p ort of the healthcare p rofessional encou raged them to
ad here to exercises. In a recent prosp ective stu d y, Cecchi et al
(2014) attem p ted to id entify p red ictors of resp onse to exercise
therap y for chronic LBP. They conclu d ed that ind ivid u ally
d esigned exercise program m es w ere associated w ith clinically
signi cant fu nctional im p rovem ent both on d ischarge and at
1 year. Severe baseline pain intensity w as associated w ith an
u nfavou rable ou tcom e and w as consid ered a p oor p rognostic
ind icator. At 1 year after d ischarge, you nger age and better
m ental health p red icted im p roved ou tcome, w hereas the u se
of m ed ications and p reviou s LBP treatm ents w ere associated
w ith a poor response. Most im p ortantly, these au thors noted
that ad herence to an ind ivid u ally d esigned exercise p ro-
gram m e im proved long-term fu nctional outcom e (Cecchi et al
2014).
N evertheless, the p aram eters for exercise prescription –
intensity, d u ration and frequ ency – have not been w ell estab-
lished in the literatu re, althou gh som e gu id elines w ill be
d iscu ssed later in this chapter.
Mobility Exercises
A d ecrease in sp inal m obility is a com m on featu re in the
p resentation of LBP. There are several w ays to approach an
exercise prescription that is m eant to ad d ress an im pairm ent
of lu m bar m obility. Mobility exercises can inclu d e rep eated
m ovem ents in a p articu lar d irection, sp eci c articu lar m obil-
ity exercises and / or m u scle stretching. Ad verse tension in the
neu rom eningeal system can also red u ce m obility in the
lum bar spine. This topic is ad d ressed in Chap ter 65, and the
read er is d irected to that chapter for further inform ation. Fu ll
m obility of the sacroiliac and hip joints as w ell as the thorax
is also essential for optim al function, but exercises for these
regions are beyond the scope of this chapter (see Chs 24 and
38 respectively).
McKenzie p op u larized the u se of rep eated m ovem ents to
evalu ate the response of sym ptom s to m echanical load ing
(McKenzie & May 2003). A centralization phenom enon occu rs
w hen repeated m ovem ents cause the pain either to m ove
p roxim ally tow ard s the m id line of the sp ine or to d ecrease
p erip herally. Directional p reference is the d irection that
results in either centralization or a red uction in sym p tom s.
The m ost com m on d irectional preference is extension, w ith
80% of subjects falling into that category (Long et al 2004). A
recent system atic review reported m ixed resu lts for the ef -
cacy of the McKenzie ap p roach for treatm ent of LBP, bu t
conclu d ed that there w as som e evid ence in the short and
interm ed iate term for those presenting w ith a d irectional pref-
erence (Su rkitt et al 2012). For patients w ith acute or su bacu te
LBP, if there is a clear d irectional p reference, and esp ecially
w hen a centralization phenom enon also occu rs, the use of
sp eci c m obility exercises in that p referred d irection ap p ears
to be m ore effective, at least in the short term (Aina et al 2004;
Clare et al 2004; Long et al 2004). Delitto et al (2012, p A2), in
their Clinical Practice Gu id elines for Low Back Pain, con-
clu d ed that there w as strong evid ence that ‘Clinicians shou ld
consid er u sing rep eated exercises in a sp eci c d irection d eter-
m ined by treatm ent resp onse to im p rove m obility and red u ce
sym p tom s in p atients w ith acu te, su bacu te, or chronic low
back pain w ith m obility d e cits’. (Read ers are referred to Ch
7 for further d iscu ssion on McKenzie m ethod .)
Extension exercises are su ggested for those w ho p resent
w ith back pain w ith or w ithou t leg pain that is red u ced w ith
repeated extension or w orsened w ith exion, or those w ho
have a lim itation of the extension m otion (Fig. 23.1). Usu ally
this p atient grou p p refers stand ing and w alking over sitting.
Flexion exercises are ind icated for those w ith a restriction of
this m otion, p articu larly if the exed p osition or rep eated
m ovem ents im p rove the p ain (Fig. 23.2). Patients w ith lu m bar
stenosis or sp ond ylolisthesis com m only fall into this category.
They prefer to sit or pelvic tilt and tend to respond better if
m anu al therap y is inclu d ed as a com p onent of treatm ent
(Whitm an et al 2006). Lateral shift, sid e- exion or rotation
exercises are used w hen there is a visible lateral shift present
or to restore a loss of those sp eci c m ovem ents (Figs 23.3,
23.4). Box 23.1 illu strates variou s op tions for restoring lu m bar
sp inal m obility.
A m u ltim od al ap p roach to the treatm ent of LBP w ou ld
includ e the u se of various m obilization and m anip ulation
techniqu es along w ith exercise p rogram m es. Mobility exer-
cises can be general or localized , and tailored to m aintain or
to fu rther increase the sp inal m obility gained w ith the m anu al
therap y com p onent of the treatm ent. Self-m obilization tech-
niqu es as p op u larized by Mu lligan can be u sed to reinforce
the segm ental sp inal m obility gained d u ring treatm ent
(Mu lligan 2004; Vicenzino et al 2011). A self-m obilization
exercise requires the use of a belt, strap or hand ; the purp ose
of this is to localize to the involved segm ent by the p atient
p u lling u p on the strap in a vertical d irection along the p lane
of the facet joints. Self-m obilizations can be p erform ed in

Figure 23.1 Extension self-mobilization. A belt is used to lift up to unload the
affected level and the patient extends back over that support. The movement should
be pain free.
Figure 23.2 Jackknife. The patient bends over, exing at the hips and knees,
grasps the ankles and then extends the knees until they feel a stretch in either the
lumber spine or posterior leg. This exercise can be used as a lumbar exion
exibility exercise, erector spinae or hamstring muscle stretch.
variou s p ositions and d irections (see Fig. 23.1). The exercise
is u su ally rep eated 10 tim es up to 10 tim es per d ay once it has
been d eterm ined to be of bene t.
Jand a (1987) su ggested that the follow ing m u scles tend to
tighten in su bjects w ith LBP: the lu m bar extensors, qu ad ratu s
lum boru m (QL), hip exors, hip ad d uctors, ham strings, d eep
Mobility exercises 257
Figure 23.3 Child’s pose with side- exion. The patient sits back on the heels
from the quadruped position with the arms forward and then moves the arms to one
side to add a side- exion component. This exercise can be used to regain lumbar
side- exion mobility and to obtain an erector spinae stretch, as well as stretching
the quadratus lumborum, preferentially on the convex side.
Figure 23.4 Thread the needle. From the quadruped position, the arm is threaded
under the body to reach through to the opposite side. This creates a rotational
stretch of the spine and can also be used to stretch the latissimus dorsi.
hip external rotators and tensor fasciae latae (TFL) / iliotibial
band (ITB). In the literature, there is a lack of stud ies investi-
gating the presence of m u scle tightness speci cally in su bjects
w ith LBP. Ku jala et al (1992) investigated the association
betw een various characteristics such as spinal m obility,
general m obility, m u scle length and strength and LBP in
12-year-old s and found an association only betw een LBP and
tightness of the hip exors. Bach et al (1985) fou nd that,
althou gh ru nners had tighter ham strings than non-ru nners,
there w as no correlation betw een hip m u scle tightness and
LBP in the runners.
With any stretching exercise it is im p ortant to m onitor
the p ostu ral control of other ad jacent regions. It is com m on
that, if one region is tight, an ad jacent region m ay becom e
relatively m ore m obile to com pensate for that lack of
m otion; Sahrm ann (2002) u ses the p hrase ‘relative exibility’
to d escribe this p henom enon. Lengthening of a m u scle
becom es m ore focu sed if the relatively m obile section is con-
trolled throu gh either active m u scu lar effort or sp eci c
 258 PART 3 • 23 •
Bo x 2 3 .1 M o b ility e xe rc is e o p tio n s
A. Exte ns io n
• Prone press-up
elbows → full pres s -up (s loppy pus h-up)
symmetrical → as ymmetrical (unilateral / diagonal)
• Prone unilateral leg lift
• Supine anterior pelvic tilt
• Quadruped extens ion
• Standing back arch
from above / from below
• Forward lean at wall – extend from below
+ s ide- exion for unilateral
• Self-mobilization
us e of hand / strap to localize
B. Fle xio n
• Supine knee to chest
double / s ingle
• Pelvic tilt
supine → to full curl-up bridge
standing
• Forward curl
sitting (use therapy ball as roll-out)
standing (one leg up for unilateral)
• Jackknife
• Quadruped – exion cat curl
• Quadruped s it-back (prayer stretch / child’s pose)
us e ball roll-out
add s ide- exion for unilateral
• Flexion over end of bed
utilize contract–relax
p ositioning w hile the m u scle is being stretched . Patients m u st
be taught how to id entify and control any u nw anted m ove-
m ent to ensu re an op tim al stretch.
Sp eci c m yofascial extensibility exercises for the erector
sp inae (ES) m u scle cou ld inclu d e any of the exion exercises
listed in Box 23.1B. Using clinical reasoning, the choice of the
op tim al exercise w ou ld be d ep end ent on the featu res of the
p atient’s LBP. The jackknife stretch (see Fig. 23.2) for exam ple,
cou ld ad d ress both the ES and the ham strings length, bu t is
p erform ed in a p osition that w ou ld create su bstantial load on
the lu m bar sp ine as w ell as increase neu rom eningeal tension.
If spinal com pression intolerance w as a concern, a su pine
knee-to-chest stretch for the ES m u scle and stretch of the
ham strings in su p ine w ou ld lessen the load ing and therefore
be m ore app ropriate. Child ’s pose (see Fig 23.3) could be
another op tion for stretching the ES m u scle and ad d ing sid e-
exion provid es a unilateral focus in cases of asym m etrical
tightness and w ou ld also lengthen a tight QL. Du ring length-
ening proced u res for m uscles attaching to the lum bar spine
and p elvis, lu m bop elvic stability m u st be m onitored and
m aintained . Shortening of the latissim u s d orsi m u scle tend s
to p u ll the lu m bar sp ine into a lord otic p ostu re, and this
Therapeutic exercise for mechanical low back pain
• Self-mobilization
us e of hand / s trap to localize
C. S ide -f e xio n / late ral g lide
• Standing lateral glide automobilization / s tretch
• Side-lean into wall
• Side- exion back to wall (more extens ion)
reach rather than collapse
• Side- exion in child’s pose (more exion)
• Pole s ide- exion
• Lateral pelvic tilt / hip hike-drop
supine / standing
• Side-lying
legs drop over the edge of bed
over a roll / bolster
with arms overhead
• Yoga triangle pos e
D. Ro tatio n
• Quadruped – thread the needle (more exion)
• Pole rotation
• Spinal twis t
supine
side-lying
rotation with chair / wall assis t
diagonal rotation in standing
into exion (towards oor)
into extension (overhead)
• Yoga pose – warrior 2
lord osis m u st be controlled d u ring any lengthening exercise
for this m uscle. Again the sid e- exed child ’s p ose position
w ill prevent that tend ency to lord ose and having the arm s
overhead in a p osition of external rotation w ou ld fu rther
stretch the latissim u s d orsi.
Although there are several stud ies that have com pared
d ifferent types of ham string-stretching exercises (i.e. p assive,
active, static, d ynam ic, p ropriocep tive neu rom u scu lar facilita-
tion (PN F)), there is no clear ind ication as to w hich typ e is
su p erior (Fasen et al 2009; Pu ented u ra et al 2011; Ayala et al
2013). PN F stretching m ay resu lt in earlier increases in length,
bu t a passive stretch m ay be m ore effective over tim e. Borm an
et al (2011) d eterm ined that, d esp ite signi cant increases in
ham string m u scle length follow ing stretching regim ens, there
w as no change in lu m bar m obility or curvature. Kang et al
(2013) observed an im m ed iate increase in hip exion and
d ecrease in lu m bar exion in the preparation phase of stooped
lifting in su bjects follow ing therapist-assisted ham string
stretching. Sairyo et al (2013), in a pilot stu d y, fou nd the jack-
knife ham string stretch exercise (see Fig. 23.2) to be effective
for increasing ham string length in both healthy ad u lts and
young athletes w ith LBP.

Winters et al (2004) rep orted that a passive stretch exercise
(lunge and prop ped prone hip extension) w as equ al to an
active exercise (prone active hip extension w ith knee exed
and knee extend ed ) in lengthening tight hip exors in su bjects
w ith LBP or low er extrem ity inju ries.
Stretching of the TFL can be achieved u sing either the
exed or bent knee Ober ’s position, w ith con icting rep orts
as to w hich p osition is m ore effective (Gajd osik et al 2003;
Wang et al 2006). Ad d ing an overhead arm stretch to the
op p osite sid e seem s to ad d fu rther stretch w hen the trad i-
tional stand ing cross-leg stretch is u sed (Fred ericson et al
2002). (See Ch 38 for fu rther d etails on stretching the m u scles
of the hip .)
Motor Control: Stabilization, Motor
Pattern Retraining, Strength
Sp eci c stabilization or recru itm ent exercises are based on
Panjabi’s theoretical m od el that sp inal stability d ep end s on
three system s: the p assive osseoligam entou s system , an active
m u scu lar system and a neu ral control system (Panjabi 1992).
Bergm ark (1989) d ivid ed the m u scu lar system into a local
(d eep) system , controlling intervertebral m otion, and a global
(su per cial) system , responsible for generating spinal m otion.
For the lum bosacral spine, the local m uscles that have been
id enti ed as having a m ajor role in spinal stability inclu d e the
transversu s abd om inis (TrA), m u lti d u s, p elvic oor and d ia-
phragm . The evid ence suggests that the fu nction and stru c-
tu re of these m u scles are altered in p atients w ith LBP. The
anticipatory contraction of the TrA and lu m bar m u lti d us has
been observed to be d elayed , and m orp hological changes
su ch as fatty in ltration and typ e I and II m u scle bre atrop hy
have been rep orted in the m u lti d u s m u scle, in ind ivid u als
w ith LBP (H id es et al 1994; H od ges 2001; MacDonald et al
2009).
Motor control exercises have been d evelop ed to retrain
op tim al m ovem ent p atterns and control of sp inal m otion.
H ow ever, it has yet to be established w hich subgrou p of
patients w ould be m ost likely to bene t from this typ e of
exercise. Debate rem ains over w hether m otor control exer-
cises shou ld focu s on isolated contraction of the local m u scles
or w hether exercises shou ld aim at engaging all abd om inal
and back extensor m uscles to ensu re sp inal stability (Bystrom
et al 2013). H od ges (2011) postulated that isolated activation
of the local m u scu latu re ap p ears to be necessary to restore
op tim al control of m ovem ent and p ostu re. The w ork by Tsao
et al (2010) reported im proved recru itm ent of the lu m bar
m u lti d u s m u scu latu re w ith red u ced coactivation of the
su p er cial tru nk m u scles after skilled m otor control training.
The intervention involved cognitive attention to the activation
of the m u lti d u s and also inclu d ed techniqu es su ch as m otor
im agery, anatom ical d escrip tion, palpation and coactivation
w ith the pelvic oor m uscu latu re. An im portant observation
m ad e by these au thors w as that m otor control exercises
app ear to be d ep end ent on consciou s and precise correction
of m ovem ent (Tsao et al 2010).
Motor control exercise p rogram m es have often been
d escribed in tw o stages (Costa et al 2009; Maced o et al 2012).
Exercises 259
The rst stage involves training the coord inated activity of the
tru nk m u scles inclu d ing isolated activation of the d eep er
m u scles (TrA and m u lti d u s) w hile red u cing the overactivity
of the su p er cial m u scles. Stage tw o focu ses on the p rogres-
sion of the exercises throu gh a range of fu nctional activities
u sing static and d ynam ic tasks: coord ination / d issociation of
tru nk and lim b m ovem ent, m aintenance of op tim al tru ck sta-
bility, postu ral correction and im provem ent of m ovem ent
p atterns. H id es et al (1996) fou nd that local activation strate-
gies could reverse the atrophy of m u lti d us in patients w ith
acute LBP. Danneels et al (2001) su ggested that, in chronic
LBP patients, progressive strengthening involving high-load
exercise w as necessary to cause hypertrophy of m ulti d us,
w hich w as then associated w ith a d ecrease in pain.
Exercises
The follow ing section is an evid ence-inform ed d escription of
com m only p rescribed stabilization and m otor control exer-
cises for m echanical LBP. Many of the electrom yograp hic
(EMG) and real-tim e ultrasou nd stud ies reported here have
been perform ed on norm al su bjects and this shou ld be con-
sid ered w hen generalizing these observations to clinical p rac-
tice. Fu rther stu d ies on m u scle activation d u ring these variou s
exercises in subjects w ith LBP w ould give m ore guid ance for
exercise choices in this patient p op ulation.
Abdominal draw-in manoeuvre
The abd om inal d raw -in m anoeu vre is one of the essential
exercises used to isolate / activate the TrA m uscle (Fig. 23.5).
Teyhen et al (2008), u sing u ltrasou nd im aging in a grou p of
healthy su bjects, fou nd that the abd om inal d raw -in m anoeu -
vre p referentially activated the TrA w ith m inim al changes in
the internal obliqu e (IO). Ind ivid u als w ith u nilateral lu m -
bopelvic p ain d em onstrated a 20.9% sm aller increase in the
Figure 23.5 Abdominal draw-in manoeuvre. In supine the patient palpates the
abdominal muscle activity and monitors for any substitution errors. On expiration,
the patient is instructed to ‘hollow’ the abdomen; a pelvic oor activation cue may
also be used to facilitate the isolated activation of the deep stability muscles.
 260 PART 3 • 23 • Therapeutic exercise for mechanical low back pain

thickness of the TrA m u scle d u ring the abd om inal d raw -in
m anoeu vre, com p ared w ith controls (Teyhen et al 2009).
Other investigators have fou nd that those w ho m et the criteria
for the stabilization classi cation of LBP (Fritz et al 2007)
d em onstrated a 50% increase in thickness d u ring the contrac-
tion (Kiesel et al 2007). Variou s strategies have been su g-
gested to facilitate the activation of TrA d u ring this exercise,
inclu d ing p alp ation, contraction on exp iration along w ith the
instru ction to ‘hollow ’, and id enti cation and correction of
su bstitu tion strategies su ch as exaggeration of a p osterior
p elvic tilt. Co-contraction of the p elvic oor m u scles, an inte-
gral com ponent of the d eep stabilization m uscle system , can
also be u sed to facilitate contraction of the TrA (Sap sford et al
2001). After a brief period of hollow ing instruction, Bjerkefors
et al (2010), u sing EMG record ings, fou nd that a grou p of A
healthy su bjects w ere able to activate the TrA ind ep end ently
of the rectu s abd om inis (RA). They w ere also able to integrate
the TrA activation into basic exercises p erform ed in su p ine,
brid ging and qu ad ru ped positions. This exercise can be per-
form ed in variou s positions and Mew (2009) fou nd signi -
cantly greater thickness of the TrA w ith greater sp eci city in
relation to IO and external obliqu e (EO) w hen the abd om inal
d raw -in m anoeu vre w as perform ed in stand ing.
Chon et al (2010) exam ined the effect of an irrad iation tech-
niqu e, a form of p rop riocep tive neu rom u scu lar facilitation
u sed to increase selectively the nu m ber of active m otor u nit
recruitm ents. They applied resistance to strong ankle d orsi-
exion in com bination w ith the abd om inal d raw -in m anoeu -
vre, p rop osing that the irrad iation techniqu e m ay stim u late
the d eep target m u scle TrA. Using EMG and u ltrasou nd
im aging, they fou nd that the ad d ition of resisted ankle d orsi-
B
exion enhanced TrA m uscle activity, w ith associated
increased thickness. Althou gh this stu d y p rovid es em p irical
evid ence, perhaps in those ind ivid u als w ho have d if culty in
recruiting the TrA this cou ld have im portant clinical
im p lications.
The p ressu re biofeed back u nit (PBU) has been u sed as a
clinical tool to p rovid e feed back for a su ccessfu l abd om inal
d raw -in m anoeu vre in the prone or sup ine positions. In the
p rone p osition, the p ressure sensor is p laced u nd er the low er
abd om en, the low er ed ge in line w ith the anterior su perior
iliac sp ine, and is in ated to 70 m m H g. The p atient is
instru cted to d raw the low er abd om en gently off the PBU and
hold the p osition. When the correct isolated contraction is
p erform ed , the p ressu re should d ecrease by ap proxim ately
6–8 m m H g u p to a m axim um of 10 m m H g in the hold ing
p osition (Richard son et al 1999). In sup ine crook lying, the
p ressu re biofeed back u nit is p laced in the lu m bar lord osis C
and in ated to a base p ressu re of 40 m m H g w here an
isolated contraction can be p erform ed and the p ressu re Figure 23.6 Limb load progressions. Various lower and upper limb movements
changes m onitored . As a p rogression, the p atient can be asked can be added to challenge the ability of the deep muscles to maintain the lumbar
to p erform a low er lim b challenge w hile m aintaining the p res- neutral posture. All limb movements are preceded by the abdominal draw-in
manoeuvre and this is maintained throughout the exercise.(A) In crook-lying, one
su re, for exam p le a bent knee fall-ou t. A p ressu re increase of
leg is lifted to 90° hip exion and then returned to the start position, alternating
m ore than 10 m m H g ind icates posterior tilt and u ncontrolled between legs. (B) Starting in crook-lying, one leg is lifted to 90° hip exion and
exion. held there. The second leg is also lifted to 90° and then extended and returned
without touching the supporting surface. Legs are alternated for the number of
repetitions that can be performed without losing control of spinal neutral. (C) A
Adding lower limb challenges modi ed ‘dead bug’ exercise can be performed on a foam roller to increase the
abdominal muscle activation and stability challenge.
Accord ing to Sahrm ann (2002), the m ost im p ortant asp ect of
abd om inal m u scle p erform ance is achieving the control that
is necessary to: (1) ap p ropriately stabilize the spine, (2)
 Exercises 261

m aintain op tim al alignm ent and m ovem ent relationship s
betw een the p elvis and sp ine, and (3) prevent excessive stress
and com p ensatory m otions of the p elvis d uring m ovem ents
of the extrem ities.
Various exercises have been d escribed by Sahrm ann (2002)
based on the concept of leg load ing to challenge lu m bopelvic
control. These exercises requ ire the d eep and su p er cial
m u scles to w ork synergistically in a static su p p orting role
(Richard son et al 1999). The patient begins in a position of hip
and knee exion in su pine-lying and prior to each exercise
p erform s the abd om inal d raw -in m anoeu vre. Initially low -
load challenges such as a bent knee fall-ou t, lifting one foot
w ith the other foot on the oor (Fig. 23.6A) or hold ing one
knee to the chest and lifting the other foot can be introd uced .
The exercises then becom e progressively m ore d if cu lt involv-
ing higher load s, such as unsu pported extension of one leg
(Fig. 23.6B) or ad d ing arm and leg m ovem ents on an u nstable
su rface (Fig. 23.6C). The p atient shou ld aim to perform 10
repetitions correctly before m oving on to the next level. A
neu tral sp ine p osition shou ld be m aintained throu ghou t the
exercise and the p atient should breathe norm ally. As d escribed
earlier, a PBU cou ld be u tilized to assist the patient in m onitor-
ing this w hile p ractising in the clinic. In cases w here patients
are having d if cu lty w ith the patterning, they can be instru cted
to p lace their hand s su ch that their p alm s rest over the ante-
rior su perior iliac spine (ASIS) and ngers rest on the low er
abd om inal w all. This allow s them to m onitor both the d eep
abd om inal m u scle contraction and any p elvic m otion that
cou ld ind icate loss of sp inal neu tral.
p lacing the hand s on the forehead (Fig. 23.7B) or forw ard
reaching, pre-bracing the abd om inal w all and breathing
d eeply d uring the exercise (McGill & Karpow icz 2009). Teyhen
et al (2008) investigated six com m on abd om inal strengthen-
ing exercises using u ltrasou nd im aging and found the great-
est changes in m uscle thickness of the TrA d u ring the sid e
brid ge and the abd om inal cu rl-u p.
The trad itional bent knee sit-up (Fig. 23.8) requiring m ore
than 30° of lum bar exion has been show n to increase the
com p ressive load throu gh the lu m bar sp ine, w ith p otential
risk of inju ry, and m ay not be ap propriate for ind ivid u als w ho
need to m inim ize the am ou nt of lu m bar exion or com p res-
sive forces. Several stu d ies have show n higher EO m u scle
activity d u ring the bent knee sit-up com p ared w ith the cu rl-
u p , w hich m ay be ind icated for higher intensity strength
training, bu t there w as also greater activity of the rectu s
fem oris (Escam illa et al 2006a, 2006b, 2010). Escam illa et al
(2010) rep orted that the cu rl-u p generated relatively low
rectu s fem oris and lum bar paraspinal activity and relatively
high RA, EO and IO activity, p erhap s m aking it a better choice
for som e ind ivid uals.

Abdominal curl-up
The abd om inal curl-up has been fou nd to have the highest
abd om inal m u scu lar challenge w ith the least am ou nt of spinal
com p ression (Axler & McGill 1997). In the supine position,
w ith hand s placed und er the lu m bar spine to m aintain a
neu tral p osition and one knee exed , the p atient is instru cted
to p ivot abou t the sternu m and lift the shou ld er blad es off of
the m at w hile m aintaining a neu tral neck p osition and to hold Figure 23.8 Bent knee sit-up. The traditional abdominal-strengthening exercise
for 5 second s (Fig. 23.7A) (McGill & Karp ow icz 2009). This can be performed with hands by the head, reaching forward or across the chest to
exercise is progressed by elevating the elbow s from the table, modify the dif culty.

A B

Figure 23.7 Abdominal curl-up progressions. (A) The initial curl-up position is shown ensuring the patient pivots about the sternum as the shoulder blades are lifted off of
the mat. (B) The exercise can be progressed by reaching with the arms, or putting hands on the forehead.
 262 PART 3 • 23 •
Multi dus activation exercises
Researchers u sing real-tim e u ltrasou nd and m agnetic reso-
nance im aging (MRI) d em onstrated d ecreased cross-sectional
area of the m u lti d u s m uscle in p atients w ith chronic LBP
(Danneels et al 2000; Barker et al 2004; H id es et al 2008b). In
ind ivid u als w ith u nilateral chronic LBP, H id es et al (2008a)
d ocu m ented asym m etry, w ith the sm aller m u lti d u s m u scle
being found ipsilateral to the sym ptom s. This atrophy
app eared to be localized , suggesting that exercises should
ad d ress this speci c localized m u scle im p airm ent. Exercises
to activate the m u lti d u s selectively continu e to be a challeng-
ing task for both clinicians and p atients. Using u ltrasou nd
im aging in ind ivid u als w ith chronic LBP, H id es et al (2011)
d em onstrated that the ability to contract the m ulti d u s w as
related to the ability to contract the TrA, w ith the od d s of a
good m u lti d u s contraction being 4.5 tim es higher for patients
w ho had a good contraction of the TrA. Palpation can be u sed
as a facilitation technique and d u ring a contraction of the
m u lti d u s a sym m etrical d eep tensioning shou ld be p alp ated
close to the m id line (Richard son et al 2004). As illustrated in
Figu re 23.9A–C, variou s p ositions can be u tilized in an attem p t
to target activation of the m u lti d u s m u scle. The m u lti d u s
has also been show n to contribu te to p rop riocep tion and rep o-
sitioning accu racy (Bru m agne et al 2000). Visu al / m otor
im agery, a p rocess in w hich the ind ivid u al im agines p erform -
ing a m otor task w ithou t any ap p arent m otion of the bod y
segm ents, m ay be a u sefu l tool in retraining activation of the
m u lti d u s (H od ges et al 2013). Diane Lee (Lee & Lee 2011)
su ggests u sing the follow ing cu es:
Imagine a line connecting your groin (or back o your pubic
bone) to the part o multif dus in your low back you are trying
to train (wake up). Connect along this line and then gently think
about suspending (li ting) the lumbar vertebra 1 mm above the
one below.
Accord ing to Lee, the therap ist shou ld observe and correct
com p ensation strategies su ch as rotation of the p elvis, ante-
rior tilting, hiking of the hip or gripp ing w ith the buttock
m u scles. Variou s facilitation and correction techniqu es are
ou tlined in Box 23.2 and can be ap p lied to all of the
exercises.
Bo x 2 3 .2 M o to r c o n tro l fa c ilita tio n te c h n iq u e s
• Palpation / observation / identi cation of compensation
s trategies
• Maintain neutral s pine position – control lumbopelvic-trunk
rotation
• Co-contract with other mus cles – TrA with pelvic oor and
multi dus with TrA
• Incorporate relaxed breathing
• Reduce activity of overactive or dominant muscles
• Manual facilitation / taping
• Feedback – ultrasound, pres sure biofeedback unit
• Visual / motor imagery
• Correct faulty movement patterns
• Incorporate mus cle activation into functional movements
and postures
Therapeutic exercise for mechanical low back pain
Bridge exercises in supine
Brid ging exercises are com m only u sed in stabilization p ro-
gram m es to im prove m otor control and to enhance trunk
stability and glu teal m u scle activity. The p atient is instru cted
to p erform the abd om inal d raw -in m anoeu vre initially and to
squ eeze the glu teal m u scles p rior to lifting the p elvis. It is
im p ortant to elim inate ham string d om inance; McGill (2010)
su ggests p alp ating the ham strings and , if active, the p atient
can be cu ed to u se knee extension to p u sh the feet into the
su rface to d ecrease ham strings activation and u se slight hip
external rotation to ensure gluteal activation. It has been d ocu-
m ented that m u lti d u s activity m easu red by su rface EMG is
high d u ring a back-brid ge exercise (Ekstrom et al 2007; Oku bo
et al 2010). Oku bo et al (2010) rep orted relatively high bilat-
eral activation of the ES d uring the basic brid ge exercise and
the brid ge w ith one leg extend ed (Fig. 23.10). These au thors
p rop osed that the need to extend the sp ine against gravity
d u ring the brid ging exercise m ight accou nt for this higher
activity. In a recent EMG stu d y, Kim et al (2013) investigated
w hether incorporating arm m ovem ents into brid ge exercises
on the oor or on a therap eu tic ball changed the EMG activity
of selected tru nk m u scles (Fig. 23.11). They found increased
IO activity d u ring brid ging on a therapeu tic ball and w hen
arm m ovem ents w ere integrated into the exercise. Elevation
of one leg d u ring the trad itional back brid ge elicited the
largest increase in IO activity on the sid e of the raised leg to
control the tend ency of the p elvis to rotate d ow nw ard s
(Garcia-Vaqu ero et al 2012). Progression of the brid ge exercise
to can inclu d e the ad d ition of u nstable su rfaces su ch as lying
on a foam roll, and lim b challenges w ith or w ithou t resistance,
su ch as elastic resistance arou nd the knees (Fig. 23.12) (Jeon
et al 2013).
Quadruped
Patients are tau ght to activate the stability m u scles to m ain-
tain a neu tral sp ine p ostu re w hile p erform ing variou s lim b
load challenges in the qu ad ruped position. Teyhen et al
(2009) fou nd that the quad ru ped opposite arm and leg lift
exercise generated preferential changes in TrA w ith m inim al
changes in IO thickness. Stevens et al (2007) u sing EMG
m easu rem ents d u ring single-leg extension and op p osite arm
and leg extension in the qu ad ru p ed position fou nd the
highest m u scle activity (> 20% m axim al volu ntary contrac-
tion MVC) in the ip silateral m u lti d u s and glu teu s
m axim u s. Garcia-Vaqu ero et al (2012) found that, in this
p osition, the IO on the sid e of the raised arm p aired w ith
the contralateral EO to stabilize, w hereas ES activity w as
higher on the sid e corresp ond ing to the elevated leg; they
conclu d ed that this w as likely to be d u e to the increased
torqu e p rod u ced w ith elevation of the leg. Du ring the p er-
form ance of this exercise, it is im portant that the patient
m aintains a neu tral sp ine p osition and that the m otion takes
p lace abou t the shou ld er and the hip , avoid ing tru nk rota-
tion. Progressions cou ld inclu d e op p osite arm and leg eleva-
tion, qu ick short arc m ovem ents of the lim bs, d raw ing
im aginary patterns w ith the hand or foot (McGill & Karp o-
w icz 2009), ad d ing resistance (free w eights / elastic) (Fig.
23.13A) and the u se of an unstable su rface (e.g. foam roll,
sizzle, BOSU®, Sw iss ball; Fig. 23.13B).
 Exercises 263

C B

Figure 23.9 Multi dus activation exercises. Isolation of the multi dus can be performed in various positions and facilitated through palpation of muscle tension
developing at the desired spinal segment. (A) Side-lying: the patient palpates for a tensioning of the muscle while performing a clam shell (lifting the top knee). (B)
Standing: the patient palpates and accentuates the muscle tensioning while transferring load by pushing off to the forward leg in step stance. (C) Prone: a single-leg lift is
performed to activate a multi dus contraction.

Figure 23.10 Supine bridge with leg lift. Maintaining a neutral lumbopelvic Figure 23.11 Supine bridge with arm load. Incorporating arm movements with or
posture, one leg is lifted off the supporting surface in the bridge position. The without resistance during a supine-bridge exercise increases activation of the
exercise would be made more dif cult by bringing the arms off the oor; the hands abdominal muscles.
can be placed on the pelvis to monitor that position.

Side plank / horizontal side support
The sid e-plank exercise has been fou nd to activate the IO, the
EO and the QL w ith low lu m bar load ing (McGill et al 1996;
McGill 1997). As illu strated in Figu re 23.14, there are various
progressions to this exercise: (1) sid e brid ge w ith the knees on
the grou nd and the hand on the d eltoid to stabilize the shou l-
d er (Fig. 23.14A); (2) knees on the grou nd and the hand on
the w aist / pelvis; (3) full sid e p lank, knees extend ed (Fig.
23.14B); (4) single leg su pp ort – ad d ing hip exion, extension
or abd u ction of the u p p erm ost leg (Fig. 23.14C); (5) rolling
from the sid e brid ge into the front plank and then back into
the op p osite sid e brid ge, ensu ring m inim al rotation betw een
the p elvis and the rib cage (McGill & Karpow icz 2009). McGill
em phasizes that this exercise shou ld be initiated w ith a ‘hip-
hinge’ m ovem ent in w hich the hip s are extend ed in a
 264 PART 3 • 23 •
squ at-like m anner to neu tral and the tru nk shou ld m aintain
a neu tral alignm ent.
A nu m ber of investigators have d em onstrated the highest
activation of the obliqu e abd om inals (42–57% MVC) d uring
this exercise (Kavcic et al 2004; Lehm an et al 2005). Garcia-
Vaqu ero et al (2012) d em onstrated sim ilar resu lts, bu t also
fou nd the highest activation levels (14–30% MVC) on the
low er sid e com p ared w ith the up p erm ost sid e (3–10% MVC).
These authors postu lated that the lateral orientation of the
obliqu e m u scles offers the greatest su p p ort to the tru nk
d u ring a sid e-brid ge exercise. They d id , how ever, nd that
RA and ES on the low er sid e w ere also active (16% MVC),
su ggesting coactivation of m u scles on the low er sid e so as to
stabilize. Elevation of the leg d u ring the sid e brid ge w ith the
hip exed / extend ed resu lted in the highest m u scle activa-
tion, w ith IO on the su pp ort sid e increasing as m u ch as 20%
MVC com p ared w ith the conventional sid e brid ge. H im es
et al (2012) com p ared the activation of TrA d u ring the sid e-
brid ge exercise progressions in healthy controls and in ind i-
vid u als w ith recu rrent LBP, and fou nd that TrA contracted
sim ilarly d u ring the exercise in both grou p s. These au thors
recom m end ed that this exercise could be used in patients w ith
Figure 23.12 Supine bridge with leg load. Elastic resistance around the legs for
hip external rotation will encourage increased gluteal muscle activity.
A B
Figure 23.13 Quadruped exercises. (A) Resisted leg lift: elastic resistance can be added to a leg-lift challenge in the quadruped position. (B) The BOSU® provides an
unstable base to increase further the challenge of an opposite arm and leg lift exercise.
Therapeutic exercise for mechanical low back pain
LBP as long as the p rogressions rem ained p ain free and ad e-
qu ate tim e w as sp ent on instru ction and cu eing p rop er
techniqu e.
Front plank / prone bridge
The front p lank or prone brid ge is u sed to activate and
strengthen both the d eep and the su p er cial abd om inal w all
m u scles. The easiest form of this exercise w ou ld have the
p atient p erform ing it w ith the knees bent and the shou ld er
su p p orted , as illu strated in Figu re 23.15. The m ain m u scle
m aintaining p ostu re and stability d u ring the p rone brid ge
exercise is the RA (25–47% MVC) along w ith activation of the
EO, w hich varies anyw here betw een 16% and 50% MVC
(Lehm an et al 2005; Ekstrom et al 2007; Im ai et al 2010; Garcia-
Vaqu ero et al 2012). Garcia-Vaquero et al (2012) d escribed
changes in the m u scle recru itm ent p atterns w hen single-leg
su p p ort w as ad d ed to conventional brid ging exercises. Eleva-
tion of the leg d u ring the front brid ge (Fig. 23.16) resulted in
slight low ering of RA activation, w hereas the IO on the op p o-
site sid e of the raised leg and the EO on the sid e of the raised
leg increased slightly (3–4% MVC) to control the rotational
torqu e (Garcia-Vaqu ero et al 2012). Although creating a higher
challenge, the com bination of the increased rotational torqu e
and high trunk m u scle activation m ay generate increased
com p ressive load s on the sp ine and so this shou ld be consid -
ered w hen prescribing this exercise w ith ind ivid u als w ith
LBP.
Exercises on unstable surfaces
Ad d itions of u nstable surfaces, such as a Sw iss ball or a
BOSU®, are com m only u sed to increase the m u scu lar d em and
requ ired to m aintain tru nk stability (Im ai et al 2010). The
Sw iss ball shou ld be ap p rop riately sized for the p atient and
in ated accord ing to the p atient’s w eight so that w hen he / she
is sitting erect and centred on the ball w ith feet together and
at on the oor, the hips and knees shou ld be exed ap proxi-
m ately 90° and thighs p arallel to the oor. Som e au thors have
show n enhanced activity of the global tru nk m u scu latu re
su ch as the EO and RA, com p ared w ith the local stabilizers

C brid ges on a stable su rface, BOSU® or Sw iss ball. There are
Figure 23.14 Side plank. (A) The easiest form of side plank is with bent knees
and the arm supporting the opposite shoulder. (B) The side plank is progressed on
to extended legs. (C) Adding a leg and arm lift in the full side-plank position further
challenges stability and increases activation of the abdominal muscles.
(Im ai et al 2010). The prone brid ge exercise on a Sw iss ball
(Fig. 23.17A) p rod u ces the highest RA and EO activity
(Lehm an et al 2005; Im ai et al 2010; Czap row ski et al 2014).
The introd uction of a BOSU® (Fig. 23.17B) or Sw iss ball to the
sid e-brid ge exercise has been fou nd to lead to a signi cant
increase in TrA and EO activity (Im ai et al 2010; Czap row ski
et al 2014). Im ai et al (2010) propose that the unstable su rface
requ ires greater m u scle activity to control the rotation and
Exercises 265
Figure 23.15 Front plank. The easiest form of the front plank is performed by
lifting the hips off the supporting surface with the knees on the ground.
Figure 23.16 Front plank with leg lift. Adding a hip extension leg lift to the full
front plank will challenge stability control and increase activity in the oblique
abdominals.
lateral exion torque generated throu gh the trunk w ith this
exercise. In contrast, for the back-brid ge exercise, several
au thors have fou nd that tru nk m u scle activity is not in u -
enced by su rface stability (Stevens et al 2006; Ekstrom et al
2008; Im ai et al 2010). Czap row ski et al (2014) analysed EMG
activity levels as w ell as relative activation of the d eep to
su p er cial abd om inal m u scles d u ring p rone, su p ine and sid e
several clinical im p lications arising from their research nd -
ings. If the goal is to use a low -load exercise generating low
m u scle activity, the su p ine brid ge on a stable or u nstable
su rface is ap p rop riate, w hereas if the aim is to strengthen the
entire abd om inal w all then the p rone-brid ge exercise on a
Sw iss ball is a good choice. Abd om inal m u scle activity d u ring
the sid e brid ge is signi cantly higher than the activity d u ring
any of the supine-brid ge exercises. Alternatively, if the goal is
to m axim ize the activity of the d eep abd om inal m u scles rela-
tive to the RA, then the p rone and sid e brid ge on the BOSU®
or a stable su rface w ou ld be the best choice.
There are several higher level Sw iss ball exercises that m ay
be used for athletic ind ivid uals or in the later stages of m otor
control training (Fig. 23.18A–B). Escam illa et al (2010)
 266 PART 3 • 23 • Therapeutic exercise for mechanical low back pain

A B

Figure 23.17 Adding unstable surfaces. The additional of unstable surfaces increases the muscular demand required for trunk stability. (A) A supine bridge performed with
both legs on a Swiss ball. (B) Side bridge on a BOSU® and a sizzle.

investigated the effect of eight ad vanced Sw iss ball exercises

(roll-ou t, pike, skier, hip extension, d ecline pu sh-u p and
sitting m arch) and tw o trad itional abd om inal exercises (cru nch
and bent knee sit-u p ) on activation of the lu m bopelvic–hip
m u scu latu re. These au thors fou nd that the p ike and the roll-
ou t w ere the m ost effective in recru iting the core m u scles bu t
that they also requ ired the greatest effort and w ere the m ost
d if cu lt (Escam illa et al 2010). Exercises that generated m ore
than 60% MVC (roll-out and pike) w ere suggested to be m ore
cond u cive to d evelop ing m u scle strength, w hereas those that
generated less than 20% MVC (sitting m arch, cru nch) w ou ld
be m ore ap propriate for end u rance training.

Motor Pattern Retraining / Functional A

Integration
Motor p attern retraining involves id entifying fau lty m ove-
m ent p atterns, isolating the com p onent of the m ovem ent and
then p ractising the corrected p attern. Retraining into fu nc-
tional tasks sp eci c to the p atient’s ind ivid u al need s is then
incorp orated (O’Su llivan 2000). Motor learning strategies
have been ap p lied to the m anagem ent of chronic LBP and
involve the transition throu gh three p hases p rop osed by Fitts
and Posner (1967): (1) cognitive, (2) associative, and (3) au ton-
om ou s (O’Sullivan 2000; H od ges et al 2013).
The cognitive phase requires a high level of aw areness in
ord er to isolate the co-contraction of the d eep local system
w ithou t sup er cial global m u scle activation (O’Sullivan 2000).
Du ring this tim e, the patient is im proving the p erception of
the skill w ith consciou s attention to d etail and correction of
errors (H od ges et al 2013). Variou s facilitation techniqu es can
be u sed such as instructions, feed back, visu al cu es, m ental B
im agery and op tim al p ostu res (H od ges et al 2013).
In the associative phase, the focu s is on re ning a p articu - Figure 23.18 High-level Swiss ball exercises. (A) Roll-out: in a front-plank
lar m ovem ent p attern (O’Su llivan 2000). Tw o or three fau lty position the patient rolls the ball forwards and backwards while maintaining trunk
and pain-p rovocative m ovem ent p atterns are id enti ed and control. (B) Pike: performing a pike motion with feet on the ball is a high-end
challenge for the stability musculature, movement pattern control and balance.
broken d ow n into com ponent m ovem ents (O’Su llivan 2000).
In this phase, repeated practice of the skill for thousand s of
repetitions is requ ired to d evelop and solid ify a m otor p attern.
Initially sim ple tasks are perform ed in unload ed p ositions,
 Pilates / yoga 267

w ith grad ual p rogression to m ore-d em and ing com plex fu nc-
tional tasks ad d ing load and sp eed . Patients are encou raged
to focu s on consistency of p erform ance (H od ges et al 2013).
The nal p hase is the autonomous phase, in w hich the
objective of the exercises is to facilitate au tom atic correction
of m ovem ent / p ostu ral fau lts w ith m inim al consciou s effort.
This w ould prom ote d ynam ic stabilization of the spine in an
au tom atic m anner d u ring fu nctional activities (O’Su llivan
2000; H od ges et al 2013).
Evalu ation and correction / training of p ostu re is an inte-
gral com ponent of the rehabilitation of m echanical LBP and
cou ld be consid ered the rst step in d evelop ing m ovem ent
p attern exercises. Prolonged sitting m ay p rod u ce increased
m echanical stress and has been rep orted as a p otential factor
related to the d evelop m ent of LBP. Dankaerts et al (2006)
investigated the sitting postures of asym ptom atic ind ivid u als
and chronic LBP patients and fou nd that patients w ith LBP
have a tend ency to ad op t p ostu res near the end range of
sp inal m otion aw ay from the neu tral p osition w ith less ability
to change their p ostu re. O’Sullivan (2000) classi ed tw o d if-
ferent su bgrou ps: those w ho sit w ith a m ore kyp hotic lu m bar
sp ine assu m ing an end -range exion p ostu re and those w ith
a hyperlord otic sitting strategy. H e also reported that LBP
p atients d em onstrate a red uced ability to ad op t and m aintain
Figure 23.19 Waiter’s bow. To practise hip–trunk dissociation patterning, the
a neu tral (m id -range) position. LBP patients d em onstrate patient nds and maintains the neutral spine position and then hinges at the hips to
greater neu tral-spine-repositioning d e cits and higher bring the trunk forward without losing control of the neutral spine position.
abd om inal activity com pared w ith healthy su bjects (O’Su llivan
et al 2006; Sheeran et al 2012).
There is little consensu s in the literatu re as to the best d issociation tasks can be ad d ed . The sitting-forw ard lean can
sitting p ostu re. It has been p rop osed that an op tim al sitting be used to train d issociation of spinal and hip exion. After
p ostu re for su bjects w ith LBP is a neu tral sp ine position nd ing the neu tral sp ine p osition, the p atient is instru cted to
involving slight lu m bar lord osis and a relaxed thorax hinge at the hip s to bring the tru nk forw ard s w hile m aintain-
(O’Su llivan et al 2006). This ‘id eal postu re’ is associated w ith ing the neutral spine posture (Lee & Lee 2011). The ‘w aiter ’s
less overactivation of the sup er cial m u scles and encou rages bow ’ exercise (Fig. 23.19), execu ted in a sim ilar m anner in
greater activity of the d eeper tru nk m u scles along w ith a m ore stand ing, cou ld be u sed as a p rogression (Sahrm ann 2002).
relaxed breathing pattern (Clau s et al 2009; Lee et al 2010; In the qu ad ruped position, patients can be tau ght to m ain-
O’Su llivan et al 2012, H od ges et al 2013). This w ill obviou sly tain a neu tral lu m bop elvic region w hile exing and extend ing
vary betw een ind ivid u als and so, w hen d eterm ining the best the thoracic sp ine in a slow and controlled m anner. The op p o-
sitting p ostu re for an ind ivid u al w ith LBP, the clinician need s site d issociation p attern can also be p ractised : m aintaining
to consid er a nu m ber of factors su ch as the u nd erlying p athol- thoracic neu tral w hile exing and extend ing the lu m bop elvic
ogy, sp inal m obility, p ain and p rovocative p ostu res. Verbal region, initiating throu gh anterior and posterior pelvic rota-
instru ctions su ch as ‘grow tall’ or ‘roll forw ard s on you r sit tion. This lu m bar / thoracic d issociation p attern can also be
bones’ to increase lu m bar lord osis, or ‘im agine lengthening p ractised in the sitting p osition, initially on the stable su rface
your spine’ to red uce thoracic kyphosis can be u sed to facili- of a chair, then p rogressing to a Sw iss ball. Fu rther p rogres-
tate p ostu ral correction (Lee & Lee 2011). As an exercise, the sions m ay inclu d e p ostu ral control in m ore d if cu lt p ositions
p atient m ay be asked to u se their op tim al cu es to achieve a or increased load ing, as w ell as integrating the p ostu ral
neutral spine, to hold that postu re for the cou nt of 10 and control into m ore com p licated m ovem ent p atterns, som e of
rep eat 10 tim es, and to perform this every hou r throughou t w hich have alread y been d iscu ssed (quad rup ed op posite arm
the d ay to assist in habitu ation. and leg, planks, variou s brid ging exercises). From here,
In a recent EMG stu d y, Park et al (2013) fou nd altered further sp eci c functional integration exercises shou ld relate
d istribution of EMG activity betw een the ES, QL and psoas d irectly to the patient’s need s regard ing occu pation, hobby
m ajor (PM) in p atients w ith LBP. Those su bjects p resenting and sp ort activities.
w ith high ES EMG activity in a slight lord otic sitting posture
had low er PM and QL activity, w hereas those w ith low er ES
activity in this p ostu re had greater PM and QL activity. This Pilates / Yoga
p relim inary inform ation w ou ld su ggest that, in som e p atients
w ith LBP, the PM and QL m uscles m ay need to be d ow n- Both pilates and yoga can be u sed to incorporate fu ll-bod y
trained or stretched , w hereas in others PM and QL recru it- activity integrating m otor patterning into fu nctional m ove-
m ent exercises w ou ld be m ore ap p rop riate. m ents. Pilates-based therap eu tic exercise, often referred to as
Patients w ith LBP often m ove their w hole sp ine as a block, clinical p ilates, is becom ing m ore com m on as an intervention
being u nable to isolate and d issociate m ovem ent betw een for patients w ith LBP. Wells et al (2012), throu gh a system atic
regions. Once the neu tral spine postu re has been achieved , review of the literature, d eveloped a d e nition for p ilates as
 268 PART 3 • 23 • Therapeutic exercise for mechanical low back pain

a ‘m ind –bod y exercise that focu ses on strength, core stability, p ostu ral ad ju stm ents (H od ges et al 2013). A recent system atic
exibility, m u scle control, posture and breathing’. To d ate, the review by Mazaheri et al (2013) exam ined LBP and p ostu ral
research nd ings for the bene t of clinical pilates in the treat- sw ay and conclu d ed that increased sw ay is p resent in som e,
m ent of LBP are inconsistent in their results and conclu sions bu t not all, LBP patients. Incorporation of trunk balance and
(Lim et al 2011; Pereira et al 2011; Posad zki et al 2011; p rop riocep tive retraining m ay be requ ired to restore op tim al
Wajsw elner et al 2012; Alad ro-Gonzalvo et al 2013; Wells et al function in patients w ith chronic LBP. Gatti et al (2011), in a
2013). A recent m eta-analysis conclu d ed that, in subjects w ith rand om ized controlled trial, investigated the ef cacy of tru nk
chronic LBP, p ilates w as m od erately su p erior to other p hysi- balance training in patients w ith chronic LBP. The balance
otherap eu tic interventions in red u cing d isability bu t not p ain, exercises w ere perform ed in sitting, kneeling, qu ad ru ped and
and also p rovid ed m od erate to su p erior pain relief com pared su p ine p ositions. The p articip ants w ere asked to m aintain the
w ith m inim al intervention (Alad ro-Gonzalvo et al 2013). p osition for a period ranging from 30 second s to 2 m inu tes.
H ow ever, d u e to the sm all volum e, poor qu ality and presence Once achieved the exercise w as p rogressed in d if cu lty by
of co-interventions in m any stu d ies, the evid ence su p p orting changing the base of su p p ort, closing the eyes or by ad d ing
the u se of p ilates to red u ce p ain and d isability in chronic LBP head or u p p er lim b m ovem ent (Fig. 23.20A). The authors
is inconclu sive and the au thors w arn that any conclu sions conclu d ed that tru nk balance exercises com bined w ith
shou ld be m et w ith caution (Alad ro-Gonzalvo et al 2013;
Wells et al 2013).
One rand om ized clinical trial fou nd that the u se of a
p ilates-based exercise program m e in patients w ith non-
stru ctu ral scoliosis red u ced the d egree of cu rvatu re, increased
exibility and d ecreased p ain, com p ared w ith controls (Alves
d e Arau jo et al 2012). Stolze et al (2012) d eveloped a p relim i-
nary CPR to id entify those p atients m ost likely to bene t from
a p ilates-based exercise program m e for LBP. Five variables
w ere id enti ed : total tru nk exion of 70° or less, cu rrent
sym p tom d uration of 6 m onths or less, no leg sym p tom s in
the past w eek, bod y m ass ind ex of 25 kg / m 2 or m ore, and
left or right average hip rotation of 25° or greater. If three or
m ore of the ve variables w ere p resent, the p robability of a
successfu l ou tcom e increased from 54% to 93%. This ru le has
yet to be valid ated .
Yoga inclu d es a num ber of com ponents that theoretically
cou ld bene t the p atient w ith LBP. Strengthening, stretching,
balance, breathing and relaxation, as w ell as attention to
alignm ent and p ostu ral control, could all contribute to the
p ositive resp onse that som e patients receive from p articipat-
ing in this exercise ap p roach. Sherm an et al (2013) exp lored
the factors that m ed iated the resp onse to either yoga or an
intensive stretching p rogram m e in LBP. Participation in exer-
cise and self-ef cacy w ere the strongest m ed iators for both A
typ es of exercise. Relaxation, aw areness and the bene ts
of breathing w ere also im p ortant m ed iators for the yoga
grou p. Teku r et al (2012) found greater red uction in p ain,
anxiety and d ep ression and larger im provem ent of sp inal
m obility follow ing a 7-d ay intensive resid ential yoga pro-
gram m e com pared w ith physiotherapeutic exercises. Posad zki
and Ernst (2011), in their system atic review, fou nd that the
m ajority of the stu d ies w ere p ositive for the u se of yoga in the
treatm ent of LBP, bu t felt that d e nitive claim s need ed to be
treated w ith cau tion becau se of the sm all nu m ber of stu d ies
and the inconsistency of resu lts, as w ell as the m any d ifferent
typ es of yoga.

Balance / Proprioception B

Balance d e cits and p oor p osition sense have been rep orted
to be p resent in ind ivid u als w ith chronic LBP (Bru m agne et al
2000; N ew com er et al 2000; H od ges et al 2013). Balance m ay
be com prom ised as a resu lt of sensory or m otor im p airm ents
su ch as visu al, vestibu lar or som atosensory d e cits, p oor
coord ination and an inability to m ove or involve the tru nk in
Figure 23.20 Balance exercises. (A) Sizzel sitting balance: a sizzle can provide
an unstable sitting base; the patient can provide further challenge by closing the
eyes, lifting the arm and extending the head backwards. (B) Single leg balance-
reach: standing on one leg, the patient maintains lumbopelvic neutral and good
alignment of the lower extremity while exing forward at the hip to reach and pick
up an object, challenging balance and motor control..

exibility exercises w ere m ore effective than a com bination of
strength and exibility exercises in red u cing p ain and im p rov-
ing the physical com ponent of the qu ality of life in patients
w ith chronic LBP (Gatti et al 2011). Other choices of balance
exercises shou ld take into consid eration the speci c require-
m ents of the p articu lar p atient and cou ld inclu d e fu nctional
p atterns (Fig. 23.20B).
Higher Level Strengthening Exercises
For those patients w ith LBP w ho are retu rning to high-level
sp ort or p hysically d em and ing w ork situ ations, higher load
strengthening exercise p rogressions for both the anterior
and p osterior m u scle grou p s shou ld be includ ed w hen bu ild -
ing a com prehensive rehabilitation exercise p rogram m e.
Although im pairm ent of the d eeper m u scle system w ith inhi-
bition and altered recru itm ent strategies has been id enti ed
in response to LBP, the su per cial system can also becom e
w eak and , as su ch, targeted strength training m ay be requ ired
to regain op tim al fu nction. Strength training requ ires m u scle
overload and resistance and , other than the w eight of the
bod y against gravity, this can be achieved by using free
w eights or elastic tu bing. Specialized equ ipm ent su ch as iso-
kinetic m achines and Rom an chairs can also be used , althou gh
the lack of evid ence of su p eriority m akes it d if cu lt to ju stify
the cost of som e of this equ ip m ent (Mayer et al 2008). This
stage of the rehabilitation p rogram m e shou ld be reserved for
the p eriod after p ain has su bsid ed and fau lty p atterning has
been ad d ressed . Strength can be trained by u tilizing func-
tional activities su ch as p u shing, p u lling, lifting, carrying and
tw isting.
McGill (2010) su ggests that asym m etric kettlebell or su it-
case carrying challenges the lateral m u scu latu re (QL and
obliqu e m u scles) as w ell as the op p osite glu teal m u scles.
Although McGill and Marshall (2012) fou nd uniqu e m uscle
recruitm ent patterns d uring kettlebell sw ing exercises, he d id
recom m end cau tion in u sing these exercises w ith p atients
because of the high shear forces generated .
Chop and lift exercises (Fig. 23.21) utilize functional PN F
patterns and can be ad ap ted to half kneeling, tall kneeling and
stand ing w ith p rogressive increases in resistance, and can also
Figure 23.21 Chop exercises. A chop exercise against elastic resistance can be
performed in a lunge position to challenge stability and balance further.
Higher level strengthening exercises 269
be m od i ed to corresp ond to patterns required for a speci c
sp ort or occu p ation. The m ovem ent p atterns, both u p and
across into extension and d ow n and across into exion,
encou rage core and trunk stabilization w ith a triplanar rota-
tional control and strengthening com p onent.
Squ ats and lu nges can be load ed w ith a w eighted barbell
to p rovid e a sym m etrical load , or w ith a single-sid ed kettle-
bell (Fig. 23.22) to increase the sid e- exion and rotational
control challenge. The u se of strap s w hile p erform ing inverted
row s or pu sh-u ps also creates a higher level of stability chal-
lenge d uring the strengthening exercise. A w eight held w hile
p erform ing sp inal rotation from a su p ine on ball brid ge p osi-
tion (Fig. 23.23) increases the strength and stability challenge.
Pu ll-u p s, chin-u p s and d ead lifts are op tions for strengthen-
ing, but it is im portant to use clinical reasoning to d eterm ine
w hich exercises are ap propriate choices for a certain patient,
taking into accou nt the p athology, stage of healing, irritability
and level of m otor p atterning control.
Many exercises m ay ap p ear qu ite strenu ou s and yet
create only m od erate-intensity m u scle contraction – as d em -
onstrated for the oor w alk-ou t, sid e w alk-ou t and bow ler ’s
squ at exercises (McGill et al 2009). Much of the d if cu lty is in
the coord ination and control and , althou gh this cou ld still
be quite u seful in the m anagem ent of LBP, it w ill not neces-
sarily p rovid e the m u scle overload stim u lu s requ ired for
strengthening.
Although Mayer et al (2008) fou nd in their system atic
review that, in the short term , lum bar extensor strengthening
exercises w ere m ore effective than no treatm ent in im proving
p ain and d isability, there w as no clear bene t of lu m bar exten-
sor strengthening exercises com p ared w ith other exercise p ro-
gram m es. H igh-intensity lum bar strengthening appears to be
su p erior to low intensity in im p roving m u scu lar strength and
end u rance. Slad e and Keating (2006) in their system atic
Figure 23.22 Kettlebell lift exercise. An overhead lift exercise can be performed
in a lunge position using a kettlebell to provide resistance. Attention is given to
proper form throughout the movement pattern.
 270 PART 3 •
Figure 23.23 Trunk rotation control. In a supine bridge with shoulders supported
on a Swiss ball and extended arms holding a weight, the patient rotates the trunk in
a controlled pattern, maintaining optimal spinal alignment.
review reported sim ilar resu lts, but also stated that higher
intensity p rogram m es and those that inclu d ed m otivational
strategies ap p eared to be of greater bene t than d id less-
intensive p rogram m es. De Rid d er et al (2013) fou nd higher
levels of lu m bar extensor EMG activity d u ring tru nk exten-
sion exercises com p ared w ith leg extension exercises. There
w as no d ifference in the level of recruitment betw een d eep
and su p er cial m u scles and also no d ifference in recru itm ent
p atterns w ith d ifferent types of contraction (i.e. isom etric, con-
centric, eccentric). Strengthening throu gh the fu ll range
beyond neu tral into hyp erextension d oes not seem to give any
ad d ed bene t for strength or pain and d isability, and so it
m ay be safer to lim it the range of lu m bar extension w hen
p erform ing these exercises (Mayer et al 2008; Steele et al
2013). Danneels et al (2001) fou nd that the lu m bar extensor
cross-sectional area signi cantly increased in the lu m bar
strengthening grou p s (p rone back extension exercises) bu t not
in the stabilization grou p . When p rogressing to higher inten-
sity strength exercises, the m agnitu d e of load ing on the sp ine
m u st also be consid ered relative to the cu rrent statu s of the
p atient’s cond ition. In quad ru ped position, a single leg lift
creates arou nd 2000 N ew ton (N ) of com pression, an opp osite
arm and leg lift creates 3000 N , w hile a prone sim u ltaneou s
bilateral arm and leg lift im p oses over 4000 N of com pressive
force on the spine (Callagan et al 1998).
Exercise Parameters
The p aram eters for exercise prescrip tion–intensity, d u ration,
frequ ency, etc–have not been w ell established in the literatu re.
The d osage of a speci c exercise d epend s on several factors
inclu d ing the aim of the exercise (recru itm ent / p atterning,
strength, end u rance, m obility, stretching), the ability to
p erform the exercise prop erly, the patient’s tolerance (age),
and the p resence of p ain and irritability of the cond ition.
In 2011 the Am erican College of Sport Med icine (ACSM)
u p d ated their gu id elines for exercise p rescrip tion (Garber
et al 2011). Based on the available research, they grad e the
strength of evid ence gu id ing the choice of d oses for d ifferent
types of exercise. They suggest that 2–4 sets of 8–12 repetitions
23 • Therapeutic exercise for mechanical low back pain
(rep s) at 60–70% of 1rep etition m axim u m (RM), perform ed
2–3 tim es per w eek w ith 2–3 m inu tes rest betw een sets, is
op tim al for d evelop ing m u scle strength. The intensity shou ld
be increased for m ore exp erienced strength trainers and
d ecreased for sed entary or old er ad u lts. Tw o sets of 15–20 rep s
at 50% 1 RM, 2–3 tim es per w eek is consid ered to be m ore
ap prop riate for im proving end u rance. McGill (2007) su ggests
bu ild ing u p to a 10-second hold and then increasing rep eti-
tions rather than the d u ration of the hold to im p rove end u r-
ance. McGill also ad vocates u sing the ‘Ru ssian d escend ing
p yram id ’ to d esign sets and rep etitions, p rop osing that the
p yram id p rovid es a w ay for the p atient to bu ild end u rance
w ithou t becom ing fatigu ed , w hich could then result in poor
m otor patterning. Postu res are held for 8–10 second s. If X
rep etitions are perform ed in set 1, X − 1 reps are perform ed in
set 2, X − 2 reps are p erform ed in set 3, and so on.
For exibility, d aily stretching (w ith a m inim u m of 3–4
d ays / w eek) to the point of slight d iscom fort, p erform ing 2–4
rep s held for 10–30 second s (30–60 for old er ad u lts) for a total
stretching tim e of 60 second s is proposed , althou gh there is
not as m u ch evid ence available to gu id e these su ggestions as
there is for strength training (Garber et al 2011). Stretching
w ill be m ore effective if perform ed follow ing a light- to
m od erate-intensity w arm -u p . Flexibility exercises inclu d ing
static (active or p assive), d ynam ic, ballistic or PN F stretching
(contract–relax, hold –relax, reciprocal inhibition) have all
been show n to be effective. For PN F stretching, the ACSM
su ggest a 20–75% m axim um volu ntary contraction held for
3–6 second s, follow ed by a 10–30-second passive stretch. A
review article by Sharm an et al (2006) conclu d ed that PN F
w as su perior to other stretching m ethod s. They suggested
that the evid ence sup p orts a sequ ence of a 3–15-second low -
intensity (< 20% MVC) static contraction of the target m u scle,
follow ed by an active stretch prod u ced by the antagonist u ntil
the stretch sensation abates. They state that a m inim u m of one
repetition perform ed tw ice a w eek is required to gain range.
Regard less of the typ e of stretching u sed , any gains in range
are quickly lost w hen stretching is stopped . Althou gh it has
been suggested in the scienti c literature that stretching per-
form ed ju st prior to activity resu lts in d ecreased perform ance,
Kay and Blazevich (2011), in a system atic review of 106
stu d ies, d eterm ined that the d etrim ental effects of stretching
w ere m ainly lim ited to longer d u ration stretches of greater
than 60 second s.
There is no speci c research to guid e the d osage for
articu lar m obility exercises. Clinically, 10–15 repetitions held
from 2 to 10 second s are com m only u sed . If the aim is for a
capsu lar stretch, the hold tim e could be increased tow ard s 30
second s. A rocking m otion cou ld be u sed at end of range to
m im ic a joint m obilization techniqu e, if that w as fou nd to be
m ore effective. For self-m obilization exercises, the Mu lligan
ap proach suggests using 3 sets of 10 repetitions d aily to gain
m obility at a sp eci c sp inal segm ent (H ing et al 2008). The
McKenzie p rogram m e su ggests 1–2 sets of 8–15 rep etitions
p erform ed rhythm ically w ithou t a su stained hold , to the p oint
of p ain onset, and attem p ting to increase that range w ith each
rep etition. This is d one every 1–2 hou rs for a m inim u m of 6
tim es p er d ay (Ford et al 2011).
The ACSM fou nd m inim al evid ence to guid e the prescrip-
tion of neu rom otor exercises. Qu ality and p recision in the
perform ance of these exercises is consid ered m ore im p ortant
than the qu antity in a single session. Initially p atients are
 Conclusion 271

Table 23.1 Exe rcis e parame te rs

Mod e of e xe rcis e Inte ns ity Se ts Re p s Dura tion Re s t Fre q ue ncy

Recruitment / is olation Low load 1–3 10 10 s hold 2 min multiple × / day

motor patterning
Strength 60–70% MVC 2–4 8–12 2–3 min 2–3 × / week
Endurance 50% MVC 2 15–20 10 s hold 2–3 min 2–3 × / week
Stretch Slight dis comfort 1 2–4 10–30 s hold minimum 3–4 × / week
or total stretch time = 60 s
30–60 s hold for older adults
PNF stretch 20–75% MVC for resis tance 1 3–15 s contraction 2 × / week
10–30 s pass ive stretch
Mobility exercises : Stretch sens ation 1 10–15 2–10 (up to 30) s hold > 1× / day
articular
Mulligan Pain-free 3 10 Overpres sure Daily
McKenzie To point of pain ons et 1–2 8–15 Rhythmically Every 2 hours – minimum
6× / day

instru cted to perform only the nu m ber of exercises they can
com plete correctly and this cou ld be as few as 3–5 repetitions.
Cu es shou ld therefore be given to ensu re that they are accu -
rately m onitoring their m ovem ent patterns. Motor learning
princip les su ggest that m u ltip le rep etitions are need ed to
retrain and solid ify new m otor patterns. Id entifying recurring
activities in the d ay that could p rovid e a cu e to rem ind
patients to p erform at least a cou ple of rep etitions of an exer-
cise m ay assist in accom p lishing this. Exp erts in this eld
recom m end grad u ally bu ild ing up to 1–3 sets of 10 repetitions
held for 10-second hold s w ith 2-m inute rests betw een sets,
perform ed m u ltip le tim es a d ay (Tsao & H od ges 2007; Lee &
Lee 2011). Table 23.1 p rovid es a su m m ary of su ggested
param eters for exercise p rescrip tion.
Conclusion
Exercise therap y is bene cial for p atients w ith chronic LBP.
H ow ever, fu rther research is requ ired to d eterm ine w hich
su bgrou p s w ill bene t from w hich typ e of exercise. Exercise
d osage, intensity and frequ ency have yet to be fu lly d eter-
m ined in the literatu re. A sou nd clinical reasoning fram ew ork
w ithin a bio-p sychosocial m od el shou ld be applied and exer-
cise p rescrip tion shou ld consid er the ind ivid u al need s and
clinical featu res of the LBP p atient. In this chap ter, w e have
provid ed an evid ence-inform ed overview of cu rrent exercise
app roaches w ith variou s exam ples for clinicians to consid er.
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 PART 3 •  Lumbar Spine Pain Syndromes
24
Sacroiliac Joint as a Source of Pain:
 Chapter 
Diagnosis and Management
Ke n n e th E. Le a rm a n
CHAP TER CONTENTS
Introduction  274
Prevalence  274
Economic impact  275
Anatomy and biomechanics  275
Pathology and pathomechanics  277
Diagnosis  277
Medical diagnosis  277
Clinical diagnosis: subjective examination  278
Clinical diagnosis: physical examination  278
Clinical examination summary  283
Prognosis  283
Treatment  284
Exercise therapy  284
Manual therapy  286
Sacroiliac belts  288
Conclusion  288
Introduction
The sacroiliac joint (SIJ) as a source o low back pain has been
enigm atic, although the capacity o the SIJ to be a pain genera-
tor has been know n or m ore than 100 years. The controversy
su rrou nd s the typ es o p athom echanical p roblem s related to
the SIJ, the m ethod s to treat those p roblem s and the p reva-
lence rates o SIJ p athology. The SIJ m eets the requ irem ents
or pain generation as the joint is innervated . H ow ever, the
exact natu re and extent o that innervation is not conclu sively
know n currently (Bogd uk 2005), d u e in p art to the lack o
extensive stu d y, the potential variability and the m ultiseg-
m ental contribu tions. It is believed that u nencap su lated and
encapsulated f bres innervate the joint itsel and the surround -
ing stru ctu res in a m u ltisegm ental ashion, and it has been
p rop osed that these are f bres originating rom low er lu m bar
(Iked a 1991) and sacral nerve roots (Grob et al 1995) , w ith
p ossible contribu tion rom m ore proxim al root levels (Zelle
et al 2005). Moreover, the com plexity o the innervation m akes
the u se o nerve blocks or u rther exp loration o SIJ p athology
exceed ingly d i f cult. More conclusively, how ever, injections
o the SIJ can p rod u ce p ain w ith contrast m ed iu m and elim i-
nate p ain w ith lid ocaine (Xylocaine) (Fortin et al 1994a). Early
w ork by Gold tw ait and Osgood (1905) su ggested that the SIJ
cou ld contribu te to p ain in the low back and legs. Fu rther-
m ore, as early as 1920, a rad iographic stu d y w as pu blished
id enti ying m ovem ent and pain d u ring pregnancy as the
result o p elvic ring p athology (Lynch 1920).
Low back and low er extrem ity p ain that is associated w ith
p athology o the SIJs can be d ivid ed into tw o m ain classif ca-
tions: those o non-m echanical and those o m echanical origin
(Cook 2012). The orm er pathology can be u rther broken
d ow n into m any su bgroup s, such as in ectious cond itions
(bacterial or u ngal), in am m atory pathologies o m any sub-
typ es, tu m ou rs, m etabolic d isord ers and ractu res (H u ijbregts
2004). The exam ination and treatm ent o in am m atory and
in ectious pathologies related to m ed ical d iagnoses are beyond
the scop e o this text. The p rim ary goal or the orthop aed ic
m anu al clinician is to be able to id enti y those p atients w ho
m ay have non-m echanical p athology so as to re er them or
ap prop riate d iagnostic testing. As w ill be d iscu ssed u rther,
this can be a d i f cu lt task.
Mechanical d isord ers o the SIJ can also be u rther catego-
rized into sacroiliac joint pain (SIJP) synd rom es and sacroiliac
joint d ys u nctions (SIJD). Several au thors have p roposed a
w orking d ef nition o SIJD as a state w here aberrant m obility
w ithin the joint’s range o m otion results in positional au lts
betw een the sacru m and the ilium (Drey u ss et al 1994; van
d er Wu r et al 2000a; Laslett 2008). SIJP can be d ef ned as any
p ain cond ition arising rom the SIJ itsel or su rrou nd ing stru c-
tu res. In ad d ition, p elvic gird le p ain (PGP) exp and s ou r
w orking d ef nition o SIJP to inclu d e p athology associated
w ith the pu bic sym physis anteriorly or com binations o the
SIJ and p u bic sym p hysis.
Prevalence
The reported prevalence estim ates o SIJ pathology have
p roven to be an ep id em iological challenge. Tw o m ajor m eth-
od ological p roblem s w ith p revalence stu d ies or SIJ p athol-
ogy are a lack o a u niversally accep ted d iagnostic stand ard
and subject sam p ling strategies. Current d iagnostic stand ard s

includ e a pred eterm ined response to a u oroscopic-gu id ed
intra-articu lar injection (IAI). Using this d iagnostic stand ard ,
stu d ies m ight su ggest that SIJ p athology occu rs in 13–30% o
chronic low back p ain. A stu d y o 54 p atients w ith clinical
presentation consid ered to be consistent w ith SIJ ound that
18.5% (w ith a 95% CI o 9–26%) respond ed to an SIJ d ou ble
IAI (Maigne et al 1996). Schw arzer et al (1995) ou nd that u p
to 30% o low back pain m ay be the result o the SIJ, w ith a
m ore conservative estim ate o at least 13%. You ng et al (2003)
ou nd that 22 o 81 patients w ith chronic low back p ain
resp ond ed to an SIJ IAI, yield ing a prevalence rate o 27%.
Irw in et al (2007) exam ined 158 patients w ith chronic low
back p ain and ou nd that 26.6% resp ond ed to a d u al IAI. A
recent stu d y ou nd that 41% o all p atients w ith low back and
leg pain had m echanical p ain o the SIJ (Visser et al 2013).
Drey u ss et al (1996) used a single-IAI techniqu e on 85 su b-
jects w ith p ossible SIJP and ou nd a 53% resp onse rate. In
contrast, one stu d y w ith m ore broad ly ap p lied inclu sion cri-
teria d eterm ined throu gh IAIs that SIJ p revalence rates w ere
as low as 2% (Manchikanti et al 2001).
Several stu d ies have u sed clinically d erived d iagnostic cri-
teria or d eterm ining the p resence o SIJ p athology. Schm id
(1985) ound a prevalence rate o 35% w hen 467 o 1344 patient
cases d em onstrated p ositive clinical criteria or SIJ p athology.
This stu d y benchm arked 7 ou t o 14 clinical pred ictors to
d eterm ine SIJ pathology. Cibu lka and Kold eho (1999) stu d ied
the d iagnostic accu racy o a clu ster o tests u sed or d iagnos-
ing SIJD and ou nd that 86 o 105 patients (81.9%) w ith acu te
to su bacu te low back p ain tested p ositive. A recent cross-
sectional stu d y revealed that 72.3% o subjects w ith im aging-
conf rm ed herniated d isc p athology also d isp layed clinical
signs and sym p tom s consistent w ith SIJ p athology (Mad ani
et al 2013). This stu d y used a stand ard o at least our ana-
tom ical and tw o p ain p rovocation tests as a d iagnostic thresh-
old (Mad ani et al 2013).
The clinical p revalence rates m ight be d ep end ent u p on the
types o p atients w e exam ine. A stu d y o 1460 p regnant
Danish w om en ou nd that 20.1% had pregnancy-related PGP.
The 293 w om en w ith p elvic p ain cou ld be u rther broken
d ow n into ou r d istinct categories: single-sid ed SIJP (5.5%),
bilateral SIJP (6.3%), sym p hysiolysis (2.3%), and pelvic gird le
synd rom e (p ain in all three pelvic joints 6.0%) and a m iscel-
laneous category o m ixed presentation (Albert et al 2002).
This stud y attem pted to categorize PGP into hom ogeneous
grou ps rom a heterogeneous population. Fu rtherm ore, a
recent cross-sectional stu d y su ggests that the p revalence o
PGP related to p regnancy could be m u ch higher, at 60.4%,
w ith 20% o the su bjects reporting severe p ain o > 5 on the
N u m eric Pain Rating Scale (Mens et al 2012).
As previously stated , there have been signif cant m ethod o-
logical d i erences w ithin ep id em iological research, inclu d ing
the d iagnostic benchm ark u sed . Even w ithin the u se o d iag-
nostic blocks there have been m ethod ological d i erences,
inclu d ing variable threshold s o p ain relie u sed to d eterm ine
resu lts; these d i erences w ill be u rther d ef ned later in this
chap ter u nd er d iagnostic p roced u res. There have also been
variations in su bject selection betw een d iagnostic stu d ies
(Manchikanti et al 2001). A com m on selection bias is to id en-
ti y and stu d y p atients w ho are alread y su sp ected to have SIJ
pathology, w hich m ay artif cially in ate the p revalence rate.
Manchikanti et al (2001) report selecting ind ivid uals w ith
clinical p resentation typ ical o SIJ p athology as ap p rop riate
Anatomy and biomechanics 275
cand id ates or the SIJ d iagnostic block and byp assing this
d iagnostic test in those w ho d id not satis y those criteria.
Many stu d ies u sing d iagnostic blocks or d eterm ining cau sa-
tion o low back p ain have em p loyed a strategy that assu m es
low back pain cou ld be caused by only a single pathology
(Manchikanti et al 2001). N evertheless, m ulti actorial pain
generation is theoretically possible w hen less than com plete
resolution o sym ptom s is the d iagnostic stand ard , even
thou gh stu d ies su ggest that it m ay be a rare occu rrence
(Schw arzer et al 1994; Laslett et al 2005b). Finally, m ost
stu d ies that have attem p ted to id enti y the sou rce o low back
p ain have ocu sed on su bjects w ith chronic or p ersistent p ain
as one w ould not w ish to subject patients w ith acu te, p oten-
tially benign p ain to invasive interventional rad iological p ro-
ced u res. There ore, little is know n abou t the p revalence o SIJ
in acu te low back and leg pain and there are still gaps in our
know led ge about chronic low back p ain.
Economic impact
The econom ic and societal costs o SIJP are also d i f cu lt to
estim ate. With great variation in the estim ates o the contribu-
tion o SIJP to overall low back p ain, the econom ic bu rd en to
society is essentially u nknow n, even thou gh the econom ic
burd en o low back pain in general is w ell know n. I w e can
conservatively estim ate, how ever, that betw een 5% and 10%
o chronic low back p ain is SIJP in origin, it becom es evid ent
that, based on a recent system atic review o the literatu re on
healthcare costs related to low back p ain (Dagenais et al
2008), SIJP m ay cost Western nations m ore than $10 billion
annually.
Anatomy and Biomechanics
The p elvic ring is com p osed o the tw o innom inates and the
sacru m . Each innom inate is com p osed o the iliu m , ischiu m
and pu bis bones, w hich begin u sing d u ring p u berty w ith
com p letion o this p rocess by an ind ivid u al’s m id tw enties.
The sacru m com prises f ve vertebrae, w hich also begin
using in p uberty, but this com pletes only in the ourth
d ecad e o li e. The innom inates are held together anteriorly
throu gh a strong joint, the p ubic sym physis – a cartilagi-
nou s joint w ith a f brocartilaginou s d isc inter acing the joint
su r aces. The su p erior, in erior and p osterior p u bic liga-
m ents stabilize the joint throu gh their connections across the
joint line. Anteriorly, the pu bic sym physis is su pported by
expansions rom the rectus abd om inis, the internal obliques,
the transversu s abd om inis su p eriorly and the ad d u ctor
longus in eriorly.
Posteriorly, the ring is orm ed by the w ed ge-shap ed sacru m
acting as a keystone betw een the innom inates through the SIJ.
The SIJ is a hybrid joint w ith synovial and synd esm otic por-
tions. The anterior, synovial com p onent o the SIJ is an irregu -
lar, L-shap ed joint w ith urrow s and rid ges w ithin the articu lar
su r aces them selves that serve to encou rage stability u rther
(Snijd ers et al 1993a, 1993b). The pattern o rid ges w ithin the
joint and the general shape o the joint itsel can be highly
variable betw een ind ivid u als, bu t there are consistently irreg-
u larities that serve to lim it the m obility o these synovial
joints. In you th, the articu lar su r aces are generally sm ooth,
 276 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management
bu t w ith irregularity to the pattern o u rrow s and rid ges
beginning in the second to third d ecad e and continu ing to
d evelop throu ghout li e. Furtherm ore, it has been id entif ed
that anterior bony brid ges m ay d evelop w ith age, u rther
red ucing SIJ m ovem ent rom spontaneous u sion (Dar et al
2008). Posteriorly, the SIJ is a synd esm otic joint w here strong
ligam ents extend rom the sacral to the iliac tu berosities.
There are nu m erou s ligam ents that assist in p rovid ing sta-
bility to the SIJ. Anteriorly, the broad anterior sacroiliac liga-
m ent assists in p reventing joint su r ace sep aration o the SIJ.
Posteriorly, the interosseou s sacroiliac ligam ent (ISL) ru ns
betw een the ventrom ed ial su r ace o the p osterior sup erior
iliac sp ine (PSIS) and the d orsolateral su r ace o the sacru m ,
creating the synd esm osis. The ligam ent itsel is very d ense
and thick and lies d orsal to the SIJ. The size and position o
the ligam ent allow it to su p p ort congru ency o the joint su r-
aces, thereby resisting m ovem ent o the SIJ in all planes o
m otion.
Su p erf cial to the interosseou s ligam ent ru ns the p osterior
sacroiliac ligam ent (PSL). This has three d istinct band s that
d i er in length. The longer band , also know n as the long
d orsal ligam ent, ru ns rom the in erior tip o PSIS to the third
and ourth segm ents o the sacru m (Vleem ing et al 1996). Its
f bres becom e tau t d u ring anterior rotation o the innom inate
(sacral cou nternutation). The short band o the PSL assists the
ISL in su pporting bony congru ency o the SIJ.
The sacrosp inou s ligam ent ru ns rom the lateral m argin o
the sacru m to the iliac sp ine. The sacrotu berou s ligam ent ru ns
rom the low er sacral tu bercles, the PSIS and the lateral
m argin o the sacru m to the m ed ial p ortion o the ischial
tu berosity. The sacrosp inou s and sacrotu berou s ligam ents
becom e taut d u ring posterior rotation o the innom inate
(sacral nu tation). The sacrotuberous ligam ent’s su perior
attachm ent is consistent w ith the long d orsal ligam ent, and
its d eep p ortion is consistent w ith the sacrosp inou s ligam ent.
These interconnections create an interd epend ence o unction:
w hen one ligam ent becom es taut, it increases tension in the
other ligam ent (Vleem ing et al 1996). This tension m od u lation
system p revents one ligam ent rom becom ing lax d u ring SIJ
load ing, w hich w ou ld com p rom ise stability (Pool-Goud zw aard
et al 1998).
The su p erf cial f bres o the sacrotu berou s ligam ent attach
at the ischial tu berosity and are consistent w ith the long head
o bicep s em oris m u scle. In ad d ition to the bicep s em oris,
the glu teu s, latissim u s d orsi and m u ltif d u s m u scles have
attachm ents w ith the ligam entous com p lex arou nd the SIJ and
lu m bosacral ju nction throu gh the thoracolu m bar ascia; this
p rovid es d ynam ic stability d u ring unctional m ovem ent
(Mens et al 2000). Anteriorly, the transversu s abd om inis and
internal obliqu es p u ll m ed ially on the ASIS and increase
tension throu gh the thoracod orsal ascia to increase tension
throu ghou t the p elvic system (Vleem ing et al 1995).
There is variability in SIJ anatom y, w hich has been d em on-
strated by CT scan (Prassopou los et al 1999). Pelvic m orphol-
ogy itsel has been rep eated ly d em onstrated to be variable;
asym m etries in the p elvis have been rep orted u sing CT scan
(Bad ii et al 2003), cad averic assessm ent o bony land m ark
angles (Preece et al 2008) and via instrum ented p alpation
(Petrone et al 2003). The angle created by a straight line taken
rom ASIS throu gh the PSIS w ith a straight line rom the
anterior p u bis throu gh the ASIS has been noted to vary
betw een p elvises by as m u ch as 23° (Preece et al 2008). When
 
these angles are com p ared bilaterally w ithin a p elvis, variabil-
ity o up to 11° has been observed , w ith u p to 16 m m d i er-
ence in innom inate height (Preece et al 2008).
Biom echanically, the SIJ rotates and translates in three
planes, each arou nd an instantaneou s axis o rotation that lies
m id w ay betw een the p osterior su p erior iliac sp ines (Sm id t
et al 1995). Becau se the SIJ both rotates and translates in each
o three d istinct p lanes, it is said to have six d egrees o reed om
or m ovem ent. The x-axis is transverse and ru ns m ed iolater-
ally throu gh the bilateral PSIS and is the axis or nu tation and
cou nternu tation o the sacru m . The y-axis is vertical and is the
axis or the sacrum to rotate in the transverse plane, and
w ould accou nt or anterior translation o one SIJ w ith con-
com itant p osterior translation or the contralateral SIJ. The
z-axis runs anterior to posterior through the m id -sacrum and
serves as the axis o sacral rotation in the rontal p lane. Com -
bination axes such as the right and le t obliqu e axes have also
been prop osed (Mitchell 1958) and serve as the theoretical
basis or a nu m ber o the p roposed SIJD categories su ch as
sacral torsions. To d ate, how ever, this au thor is u naw are o
any im aging d ata that valid ate these theories, and DeSte ano
(2011) acknow led ges that their biom echanics are u nknow n
and their existence is largely hypothetical. Axes o m otion are
com p licated , and that w hich is tau ght is oversim p lif ed ,
m aking it d i f cu lt to ap p ly the p rop osed m echanics to the
clinical assessm ent and treatm ent o SIJ p athology (H arrison
et al 1997).
The SIJ has m inim al m ovem ent exhibited by a system atic
review reporting that seven m anu scripts conf rm ed that rota-
tional m ovem ents w ere −1.1° / 2.2° o m ovem ent along the
x-axis, −0.8° / 4.0° along the y-axis and −0.5° / 8.0° along the
z-axis (Good e et al 2008). In term s o translation, the m ove-
m ents averaged −0.3 / 8.0 m m in the x-axis, −0.2 / 7.0m m in
the y-axis and −0.3 / 6.0 m m in the z-axis (Good e et al 2008).
Data d erived rom roentgen stereophotogram m etric analysis
(RSA), the m ost reliable and valid technique, tend to avou r
the low er end o the rep orted range. Movem ent is m ore
restricted in w eight-bearing (Stu resson et al 2000) than in
non-w eight-bearing, w hich is likely to be a resu lt o the
ad d itional com pressive orces placed u pon the SIJ throu gh
tru nk-load ing in orm and orce closu re (Pool-Gou d zw aard
et al 1998). Du ring u nction, m ovem ent o the pu bic sym phy-
sis occu rs and is accom p anied by d e orm ation o the innom i-
nates (Pool-Goud zw aard et al 2012). This, in act, probably
com p licates all attem p ts to id enti y m echanical and p ositional
abnorm alities in the low back pain pop u lation i they are
ind eed p resent.
Functionally, the SIJ has no m u scular attachm ents that
cou ld resu lt in active m ovem ent at the joint. N evertheless,
m ovem ent at the SIJ d oes occu r p assively. The SIJ and p u bic
sym p hysis are p rim arily joints that p rovid e an avenu e or
orce translation and d issipation (Snijd ers et al 1993a) betw een
the low er bod y and tru nk. The sm all am ou nts o m ovem ent
ou tlined above w ou ld su ggest that m ovem ent o these joints
is not im portant or bod y positioning bu t rather orces attenu -
ation. It has been hypothesized that the SIJ is necessary to
d issipate orces trans erring throu gh the ring and hence
p revent ractu res. Sacral insu f ciency ractu res have been
noted in p op u lations that either have red u ced natu ral m ove-
m ent throu gh age and / or w eakened bony stru ctu res o the
sacru m (Grasland et al 1996). Eld erly w om en, and those that
repetitively load the pelvic ring at high levels w ith a

w eakened sacru m (Mybu rgh et al 1990), such as high-m ileage
ru nning em ales (Wentz et al 2011) are exam ples.
There w ou ld ap p ear to be tw o typ es o stabilization in the
p elvic ring: orm closure and orce closu re (Vleem ing et al
1990a, 1990b; Snijd ers et al 1993a, 1993b). Form closu re is the
com p onent o stabilization that is p rovid ed by the p assive
stru ctu res o the stabilization system . The w ed ge-shap ed
sacru m orces d ow n into the ilia stru ctu rally as a keystone,
evid enced by a red uction in SIJ m ovem ent d u ring w eight-
bearing activities (Stu resson et al 2000). The posteriorly acing
acets that articu late w ith the f th lum bar vertebra assist in
p reventing anterior shearing o the lum bar sp ine on the
nu tated sacru m . The strong ligam entou s system resists the
sep aration o the ilia as the sacru m w ed ges in betw een them .
The grou nd reaction orces translate proxim ally throu gh the
em u rs, orcing the ilia together and stabilizing the pu bic sym -
p hysis. It w ould seem that the greatest am ount o stability
w ou ld occur d uring equ al w eight-bearing. Alternatively,
som e o the highest SIJ load s occu r d u ring u nilateral ju m p ing
and land ing, m aking ad d itional system s o stabilization
necessary.
Force closu re is the external stabilization being prod u ced
on the SIJ by m u scles that can increase tension in the stabiliz-
ing system . Any m u scle that can d irectly im p act tension
throu gh the thoracolu m bar ascia or the stabilizing ligam ents
o the SIJ or p u bic sym p hysis can p rod u ce greater stability in
the SIJ. There have been rep orted to be tw o slings that assist
w ith orce closu re: a posterior sling and an anterior sling
(Vleem ing et al 1995). The p osterior sling is m ad e u p o the
ham string m u scle, the ip silateral glu teu s m axim u s and the
contralateral m u ltif d i and latissim u s d orsi m u scles. Anteri-
orly, the sling com p rises the internal obliqu e and transversu s
abd om inis and the contralateral ad d u ctor m u scle grou p .
These tw o slings w ork in concert to create ad d itional tension
in the SIJ as need ed . More recent evid ence suggests that a
sim p le co-contraction o the m u ltif d i and the transversu s
abd om inis w ill sti en the SIJ to a greater extent than targeting
the d iagonal p attern m u scle o the p elvic slings (Richard son
et al 2002). N evertheless, an ad d itional orce or stabilization
has been id entif ed and is available and p rovid ed throu gh the
anterior (Richard son et al 2002) and posterior slings (van
Wingerd en et al 2004). Becau se o the anatom ical interd e-
p end ence o attachm ents ou tlined above, it becom es apparent
that orm and orce closu re are not m u tu ally exclu sive system s.
As the sacrum rocks orw ard s into nutation tightening, the
m ajority o the ligam ents arou nd the SIJ and the m u scu lar
com p onents o the lu m bop elvic system p rovid e greater stabi-
lizing orce closure by pulling the stru ctu res together and
increasing orm closure by increasing tension throu gh the
ligam ents.
Pathology and Pathomechanics
It has long been proposed that large external orces placed
u p on the SIJ can cau se the joint to m ove internally and p erhap s
becom e stuck in a aulty position. The clinician w ou ld care-
ully exam ine the patient’s posture and eel or abnorm alities
in p osition or m ovem ent – o ten a p osition that w ou ld pre-
su m ably alter the stress p laced on the SIJ, thereby cau sing a
change in segm ental p ositioning based on changing stress. It
Diagnosis 277
w as believed that the u rrow s and rid ges w ithin the joint
w ould provid e a m echanism or the joint to get ‘stuck’ in an
altered p osition, thereby creating pain. This p hilosop hy has
been tau ght and practised by num erous m anu al therap y pro-
essions. H ow ever, even thou gh this hypothesis seem s reason-
able and is theoretically p ossible, there has not been a single
biom echanical stu d y pu blished to this author ’s know led ge
that has id entif ed p ositional au lts o the SIJ, nor has a single
article been p ublished to suggest that SIJ m anip u lation can
and w ill change the position o the joint su r aces. On the
contrary, m ore evid ence has been p rod u ced to su ggest that
this is highly u nlikely (Laslett 2008), and one stu d y has p ro-
vid ed evid ence to re u te this theory by id enti ying that
SIJ m anip u lation d oes not alter the joint p osition (Tu llberg
et al 1998).
More recently, it has been su rm ised that m ost m echanical
p ain is related to som e asym m etry o stabilization o the SIJ
and / or p ubic sym physis. This theory m ight su ggest that,
w ith altered stability, there w ould be pathological m ovem ent
in the SIJ. This has not been show n to be the case, how ever.
Stu resson (1999) id entif ed that there w as no m easurable d i -
erence in m ovem ent betw een the sym ptom atic and asym p-
tom atic sid es. PGP is m ore associated w ith asym m etrical
laxity o the pelvis, not generalized laxity o the SIJs (Vleem -
ing et al 1996, 2008; Pool-Gou d zw aard et al 1998; Dam en et al
2001, 2002; Richard son et al 2002). When excessive asym m et-
ric laxity is ou nd in an SIJ throu gh the active straight leg raise
test (ASLR) or Dop p ler u ltrasou nd (Dam en et al 2001), excess
m ovem ent is noted anteriorly at the p u bic sym p hysis and not
p osteriorly in the ip silateral SIJ (Mens et al 1999). Asym m etri-
cal stability m ay be the resu lt o altered m u scle recru itm ent
o the stabilizers on the sid e o p athology as evid enced by
electrom yographic stu d y (H u nger ord et al 2003).
Diagnosis
Medical diagnosis
As w ith any presu m ed neu ro-m u sculoskeletal pathology, the
f rst d iagnostic qu estion to answ er is w hether or not there is
a serious or sinister m ed ical p roblem that m ay be the sou rce
o the p atient’s p ain (Murp hy & H u rw itz 2007). Appropriate
screening or m ed ical, non-m echanical p athology m u st be
p er orm ed (H u ijbregts 2004; Sizer et al 2007).
As previou sly stated , the best external evid ence or d iag-
nosis o SIJP is a u oroscop ically gu id ed IAI that resu lts in at
least an 80% red u ction in pain as the gold stand ard (Chou
et al 2004). This test is sim ply not routinely d one in clinical
p ractice, bu t is reserved or ind ivid u als w ith recalcitrant back
p ain re erred or interventional rad iology; there ore, only a
select ew w ill have the ad vantage o these test resu lts. This
p roced u re is not w ithou t its lim itations, how ever. Intra-
articu lar injections shou ld only d iagnose intra-articu lar p rob-
lem s, and not pain com ing rom periarticular structu res su ch
as the long d orsal ligam ent (Mu rakam i et al 2007). There is
also evid ence that the reliability o the anaesthetic inf ltrating
the joint m ay be lim ited and that som e m ay leak ou t into the
su rrou nd ing tissu es, con ou nd ing the d iagnosis o a sp ecif c
stru ctu re (Berthelot et al 2006). Conversely, periarticu lar
stru ctu res m ay not be im p acted by the injection i the
 278 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management
anaesthetic d oesn’t leak ou t. Bearing these lim itations m ind ,
it is clear that alse p ositives and alse negatives exist w ith the
IAI. Ad d itionally, d i erent threshold s o pain relie to d ichot-
om ize test resu lts have ranged rom 50% p ain relie (van d er
Wu r et al 2006) to ≥ 90% (Drey u ss et al 1996; Broad hu rst &
Bond 1998). Other requ ently u sed threshold s includ e 70%
(Broad hu rst & Bond , 1998), 75% (Schw arzer et al 1995; Maigne
et al 1996) and 80% (Slipm an et al 2000; Fu ku i & N osaka 2002;
Laslett et al 2003, 2005a). N evertheless, consid ering the lim ita-
tions o im aging and other orm s o d iagnostic tests, althou gh
the injection m ay not be id eal it is better than any o the other
available op tions or d iagnosing p ain arising rom the SIJ
region.
Im aging can be used to d iagnose sacroiliitis; how ever,
there are lim itations to this techniqu e. A recent MRI stu d y
exam ined 691 patients w ith suspected sacroiliitis and ou nd
that 41% show ed no abnorm al f nd ings. Sacroiliitis appeared
in 36%, bu t other p athologies o the lu m bar sp ine and hip , SIJ
d egeneration and m ore p roblem atic d iagnoses su ch as
tu m ou rs (1.6%), ractures (1.2%) and in ections (0.6%) w ere
also p resent (Jans et al 2013). An im portant point to note is
that the belie o clinical sacroiliitis w as not p articu larly d is-
crim inative, w hich m ay be consid ered as consistent w ith
other stu d ies that have attem p ted to isolate historical and
clinical eatu res o SIJ p athology.
Clinical diagnosis: subjective examination
A care u l history assists the clinician in id enti ying p otential
cond itions o the SIJ that are non-m echanical in natu re. Un or-
tu nately, m any o the sym p tom s associated w ith in am m a-
tory and in ectiou s p athologies p resent w ith com p laints
sim ilar to those associated w ith m echanical p athologies
(Peloso & Brau n 2004). There are no particular sym p tom s
associated w ith the m echanical p ain p atterns in the SIJ, and
this m ay be d u e in p art to the basic p roblem o id enti ying
m echanical p athologies as either SIJP or SIJD (Laslett 2008).
The low back pain literature requ ently uses the term s SIJP
and d ys u nction interchangeably, althou gh w e have little evi-
d ence to su ggest that it is conceptu ally valid (Laslett 2008).
The inability to d i erentiate the SIJP accu rately as being o
either m echanical origin or rom an in am m atory process
m akes the clinical exam ination challenging. SIJP associated
w ith m echanical cau ses m ay respond to conservative care. A
ailu re to d o so m ay be an ind ication or m ed ical physician
re erral (Cook 2012).
Researchers have exp lored the u se o p ain m ap s to id enti y
p articu lar p atterns associated w ith SIJ pathology. A rectangu -
lar area o app roxim ately 3 cm w id e × 10 cm long ju st d istal
to the PSIS has been p rop osed to be a p rim ary area o p ain
or SIJ (Fortin et al 1994a, 1994b). This p ain m ap w as id enti-
f ed by injecting the joint o healthy su bjects w ith contrast
m ed ia to stim u late d iscom ort, ollow ed by Xylocaine, and
id enti ying the local region d em onstrating hyp eraesthesia to
light tou ch. This sam e region has also been id entif ed by other
investigators (Broad hu rst et al 2004). Contrad ictory f nd ings
have also been rep orted , how ever. Slipm an et al (2000) ou nd
that there w as no sp ecif c p ain p atterning or SIJ. Ad d ition-
ally, van d er Wu r et al (2006) ou nd that pain areas w ere not
selective or SIJ p athology bu t that intensity o p ain m ay be
m ore selective; su bjects w ho resp ond ed to a local anaesthetic
 
block reported the greatest pain intensity in Fortin’s region
just in erior to the PSIS w hereas non-resp ond ers had m ost
p ain over the region o the ischial tu berosity. In ad d ition, p ain
red u ction responses to anaesthetic injections, althou gh usually
localized to Fortin’s area (94%), have also d em onstrated re er-
ral to other regions o the low er quarter extend ing rom the
u pp er lu m bar area (6%) and abd om en (2%) to the oot (12%)
(Slip m an et al 2000). This variability in som atic pain re erral,
w ith signif cant overlap in lum bar pathologies, is likely d ue
to the com p lex and variable innervation noted earlier, w ith a
p rop osed contribu tion o both lu m bar and sacral roots (Vleem -
ing et al 2012). The long d orsal ligam ent, w hich courses
throu gh Fortin’s area, is requ ently p ain u l in p atients w ith
low back pain. Vleem ing et al (1996) ound that 44% o w om en
and 47% o m en w ith non-specif c low back p ain rep orted this
area to be very tend er to palp ation; how ever, it is not d iag-
nostically sp ecif c to SIJP.
You ng et al (2003) ou nd that p ain that is elt on rising rom
sitting w as signif cantly associated w ith SIJP, as w as an
absence o m id line p ain and u nilateral pain below the L5
sp inous process. Patients w ere 28 tim es m ore likely to have
SIJP w hen they had concu rrent p ain u p on rising and a p osi-
tive clu ster o three o ou t o f ve p ain p rovocation tests. When
exam ined specif cally or d iagnostic accu racy, p ain on rising
rom sitting w as ou nd to be poor (Cook et al 2007). There ore,
historical actors associated w ith SIJ p athology are cu rrently
lacking in d iagnostic accuracy. H istorical eatu res, as p art o
a com p rehensive exam ination, m ay be help ul in id enti ying
SIJ p athology bu t are not conclu sive in and o them selves
(H u ijbregts 2004).
Clinical diagnosis: physical examination
There are a nu m ber o categories o tests u sed to classi y
d i erent m u scu loskeletal pathologies. Active and p assive
ranges o m otion are o ten used , as w ell as special tests. The
latter can be u rther su bclassif ed into three d istinct orm s
o tests: p ositional p alp ation tests, tests or sym m etry or p re-
d ictable m otion, and sym ptom provocation tests (H u ijbregts
2004). Each o these classes o exam ination w ill be
d iscussed .
Active p hysiological m ovem ents are requ ently u sed in the
exam ination o axial skeletal d isord ers. Active m ovem ents
su ch as w alking have been rep orted ly associated w ith p elvic
p ain associated w ith p regnancy (Rost et al 2004). H ow ever,
other au thors have su ggested that active m ovem ents are not
associated w ith SIJ p athology (Schw arzer et al 1995; Maigne
et al 1996). Repeated active m ovem ents shou ld be per orm ed
in an e ort to id enti y the presence o the centralization phe-
nom enon. When centralization is p resent a d iscogenic p roblem
is ind icated , lessening the likelihood that SIJP is the problem
even though sym p tom provocation tests or SIJP are positive
(Laslett et al 2005c).
Passive p hysiological tests are also requ ently u sed in the
exam ination o prop osed SIJ p athology. Passive innom inate
rotations into end range have the capacity to stretch intra- and
periarticu lar structu res into end range. Pain p rovocation w ith
these tests m ay ind icate SIJ p athology. Exact id entif cation o
the stru ctu re involved is highly u nlikely, bu t the behaviou r
o the sym p tom s w ith single and rep eated p assive rotations
m ay ind icate a p ossible m ethod o treatm ent.

One stu d y su ggested that the p resence o asym m etry o hip
rotation w as associated w ith SIJD (Cibu lka et al 1998). An
ad d itional stu d y d em onstrated that hip range o m otion could
be enhanced ollow ing an SIJ m anipu lation (Pollard & Ward
1998). Interestingly, hip internal rotation (IR) o at least 35° in
at least one hip w as one o the p red ictor variables o w ho
w ou ld d o w ell w ith an SIJ m anipulation (Flynn et al 2002).
N evertheless, in that stu d y no specif c SIJ test pred icted
su ccess, red u cing the likelihood that SIJP w as the p roblem .
Passive accessory techniqu es are also requ ently u sed in
the d iagnosis o low back p ain and SIJP. Cu rrently, there are
no stu d ies exam ining the benef t o p assive accessory tech-
niqu es or SIJ p athology (Cook 2012). A proposed d iagnostic
eatu re o p assive accessory techniques m ay be to help rule
in / ou t lum bar p athology. I the patient has the prim ary pain
around the L5 sp inous process or higher and the prim ary p ain
can be p rovoked by either a central or u nilateral p osterior–
anterior (PA) glid e, it is less likely to be SIJ in origin. I the
p atient’s sym ptom s can be centralized w ith repeated PA p res-
su res in the lu m bar sp ine, lu m bar p athology is likely. I PA
glid es on the sacrum are app lied and result in alteration o
sym p tom s, SIJ p athology m ay be ru led in and a p otential
treatm ent op tion is id entif ed (Cook 2012).
Positional p alp ation tests are clinical tests u sed to d iagnose
SIJD that rely heavily u p on the p ercep tion o asym m etrical
bony alignm ent, w hereas tests or sym m etrical or p red ictable
m otion are sp ecial tests that attem p t to assess SIJ m ovem ent
qu alitatively. Palp atory exam ination o the p elvis is the ou n-
d ation o the osteopathic approach to treatm ent o pelvic p ain
(DeSte ano 2011). In ad d ition, m any clinicians rom various
healthcare p ro essions have ad op ted this m ethod ology or
assessm ent and treatm ent o pelvic and SIJ d isord ers. A un-
d am ental lim itation o this m ethod ology, how ever, is the low
d egree o both reliability and d iagnostic accu racy. The d iag-
nosis o SIJ p athology based on p alp ation and m ovem ent tests
and their sym m etry u nd am entally d epend s on the philoso-
p hy that there is easily p alp able or m easu reable m ovem ent in
the SIJ and that bony land m arks w ithin the p elvic ring are
d irectly palpable and sym m etrical. As stated previou sly,
how ever, this clinical p rem ise ap p ears to be inaccu rate; as the
m ovem ent o the SIJ is no m ore than a ew d egrees o rotation
or a cou p le o m illim etres o translation, it w ou ld ap p ear that
the SIJ is not a typ ical joint. Recognition o this p hilosop hical
lim itation m akes it easy to see w hy the d iagnostic accu racy o
clinical d iagnostic tests or m ovem ent and sym m etry is p oor.
N u m erous stu d ies have exam ined the intra-rater and inter-
rater reliability o tests per orm ed to establish sym m etry o
bony land m arks and SIJ m ovem ent, and have ound the
resu lts to range rom ‘only slightly better than chance’ to ‘ air ’
(van d er Wu r et al 2000b; H uijbregts 2004). Fu rtherm ore,
althou gh it w ou ld seem reasonable that greater training
w ou ld im prove reliability, this hypothesis has been re u ted
by tw o stu d ies that ound better reliability am ong novice
clinicians (H erzog et al 1989; Mior et al 1990). There are other
m ore-com p rehensive review s o the literatu re that p rovid e
m ore d etailed d ata regard ing these acts and the read er is
re erred to these (H u ijbregts 2004; Stovall & Kum ar 2010;
Cook 2013). A recent stu d y rep orted that the assessm ent o
p elvic m otion reliability can be enhanced to ≥ 0.97 w ith the
u se o an electrom agnetic tracking d evice, bu t this typ e o
instru m entation is not read ily available to the clinician (Ad hia
et al 2012).
Diagnosis 279
The valid ity o a clinical test can be d ef ned as the extent
to w hich the test m easu res the intend ed constru ct. Tests or
SIJ sym m etry o m otion and p alp ation ail to achieve m ean-
ing u l reliability – an u nd erlying principle o valid ity; there-
ore, they cannot be consid ered as clinically valid (H uijbregts
2004; Laslett 2008). In ad d ition, nu m erous stud ies have exam -
ined the valid ity o palp atory and m otion sym m etry tests and
have consistently ou nd it to be lim ited (H uijbregts 2004).
Tu llberg et al (1998) exam ined concu rrent valid ity by having
three investigators exam ine 10 ind ivid u als be ore and a ter an
SIJ m anip u lation or sym m etry o iliac crest, ASIS and PSIS in
stand ing, su p ine and p rone. There w as su bstantial agreem ent
that m ost ind ivid u als exp erienced correction o asym m etry
ollow ing the SIJ m anipu lation; how ever, the RSA d eterm ined
that no observable change in SIJ p osition occu rred . Another
stu d y u sing RSA that exam ined SIJ m ovem ent d u ring the
stand ing exion test in 22 patients w ith single-sid ed SIJD
ound that the m otions o the SIJ w ere too sm all to be d etected
m anually – cau sing the authors to conclu d e that the test w as
not clinically u se u l (Sturesson et al 2000). This suggests that
the asym m etrical p ositions o ten associated w ith SIJD are
likely to be the p rod u ct o local m u scular orces p rod u cing
strain on the p elvis, w hich gives the illu sion o SIJ p ositional
aults (Tu llberg et al 1998).
Anatom ical asym m etry in orm (Preece et al 2008) and
usion (Dar et al 2008) u rther challenge the valid ity o p osi-
tion- and m ovem ent-based tests. Bony asym m etry w ill
p rod u ce alse p ositives, w hich has been show n clinically by
asym p tom atic ind ivid uals d em onstrating p ositive clinical
tests (Drey uss et al 1994). Fu rtherm ore, the establishm ent o
d iagnostic accu racy in these tests is a challenge. Currently,
there is no established benchm ark stand ard or d iagnosing
SIJD. Diagnostic blocks can establish SIJP, bu t p ain m ay be
d ue to actors other than d ys unction, thus contributing to
p oor d iagnostic accu racy (Laslett 2008). Becau se o these d iag-
nostic lim itations, McGrath (2006) qu estioned their clinical
u se and su ggested the need to teach tests or sym m etry o
p osition and m ovem ent w ithin the osteop athic ed u cational
system .
Clinicians o ten clu ster tests in an attem p t to enhance the
clinical m eaning o the resu lts. Most tests w hen consid ered
ind ep end ently lack su f cient d iagnostic accu racy to d eter-
m ine the ap p rop riate clinical cou rse o action. Clinical reason-
ing su ggests that interpretation o the m eaning o all available
clinical d ata in an interd ep end ent m anner enhances the
p rocess. One test item clu ster o sym m etry tests – the stand ing
exion test, sitting PSIS sym m etry test, su pine to sit test or
m ed ial m alleoli sym m etry and prone knee exion test – has
show n m od erately strong d iagnostic p ow er (LR+ 6.83), bu t
the stu d y ailed to u se a benchm ark stand ard in conf rm ing
the SIJ d iagnosis (Cibu lka & Kold eho 1999). The d iagnostic
accu racy in this stud y w as based on the presence or absence
o low back p ain, w hich cannot be d iscrim inatively d ef ned
as SIJD.
Sym p tom p rovocation tests requ ire an alteration o the
p atient’s p erceived p ain. Provocation tests have also d em on-
strated variability in both intra-rater and inter-rater reliability,
w hich ranged rom poor to su bstantial (H u ijbregts 2004). The
reliability o provocational tests is nevertheless greater than
that o tests o sym m etry, p rovid ing a stronger ou nd ation or
d iagnostic accu racy (Laslett & William s 1994). A recent sys-
tem atic review su ggested that the d iagnostic accu racy o
 280 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management 

Figure 24.1 Thigh thrust test. Figure 24.2 Sacroiliac distraction test.

p rovocation testing or SIJ d ys unction is air (Sim op ou los

et al 2012). N o single provocation test is very d iagnostic
thou gh; there ore, clu sters o tests have been p rop osed to
enhance the likelihood o com ing to a reliable conclu sion. In
ad d ition, an earlier system atic review o the criteria or SIJP
as d eterm ined by the International Association Society or the
Stu d y o Pain (IASP) su ggested that clu stering p rovocational
tests yield s satis actory d iagnostic accuracy (Szad ek et al
2009).
Laslett et al (2003) f rst p rop osed a f ve-test-item clu ster in
w hich three o the f ve tests should be ound positive in ord er
to provid e a p ositive likelihood ration o 4.16; the f ve tests in
qu estion inclu d ed the thigh thru st test, the com p ression test,
the d istraction test, the torsional stress test (Gaenslen’s test)
and the sacral stress test. The reliability o this f ve-test-item
clu ster has been ou nd to be satis actory, at kap p a = 0.70 Figure 24.3 Sacroiliac compression test.
(Laslett & William s 1994; Kokm eyer et al 2002). Subsequ ent
research id entif ed that sim ilar d iagnostic accuracy cou ld be
obtained w ith only ou r tests (i.e. w hen the Gaenslen’s test
w as rem oved rom the original test-item cluster) w ith at least
tw o being p ositive (Laslett et al 2005a). The d etailed d escrip-
tions o these tests are as ollow s:
• Thigh thrust test: The p atient lies in supine w ith the hip
exed to 90° and ad d u cted su f ciently to control hip
rotation. The exam iner places one hand u nd er the
sacru m , avoid ing the PSIS o the testing sid e, and p laces
a orce p osteriorly throu gh the thigh to stress the SIJ
(Fig. 24.1).
• D istraction test: The patient lies su p ine w hile the
exam iner applies an equ al orce posteriorly throu gh both
ASISs (Fig. 24.2).
• Compression test: The patient lies in sid e-lying w ith hips
and knees com ortably exed or positioning. The
exam iner applies a orce tow ard s the table throu gh the Figure 24.4 Sacral thrust test.
u p p erm ost iliac crest (Fig. 24.3).
• Sacral thrust: The patient lies in prone w hile the
exam iner per orm s a p osterior-to-anterior orce tow ard s throu gh both legs. This test is rep eated on the
the table throu gh the centre o the sacru m (Fig. 24.4). contralateral sid e (Fig. 24.5).
• Gaenslen’s test: The p atient lies sup ine w ith one leg in Any o these tests are positive i they reprod uce the p atient’s
m axim u m hip and knee exion and the other hip in com p arable, am iliar sym p tom s. The p atient is instru cted to
extension. Pelvic torsion is created w ith overp ressu re ignore d iscom ort related to the exam iner ’s hand placem ent
 Diagnosis 281

Figure 24.5 Gaenslen’s test.

d u ring the test. A p otential sou rce o variability has been

reported w hen orces are applied asym m etrically so care
shou ld be taken to m aintain equ al orces sid e to sid e or tests
that requ ire bilateral contact (Levin et al 2001). A second
p otential sou rce o error m ay occu r i the orce applied is not
m aintained or a su f cient p eriod o tim e to create irritation
in the SIJ. Levin and Stenstrom (2003) ou nd that it took up
to 20 second s to p rovoke p ain in ind ivid u als w ith SIJP, w hich
m ay be exp lained by the large size, relative stability and
general u nctional requ irem ent o the SIJ to trans er large
load s d u ring w eight-bearing activities.
As stated earlier, PGP can be subgrou ped into ou r d istinct B
categories w ith a f th category o m ixed p resentation (Albert
et al 2002). This classif cation system has been ound to be
Figure 24.6 Active straight leg raise test: (A) without and (B) with compression
reliable, w ith a kap p a coe f cient o 0.78 (Cook et al 2007). PGP by the therapist.
is also best classif ed w ith the u se o clu sters o provocational
tests. Albert et al (2000) ou nd that SIJP w as best classif ed
• Active straight leg raise: The p atient lies su p ine and
w ith the use o the thigh thru st, Patrick’s test and Menell’s
attem pts to raise the heel o the involved leg 6 inches o
test, w hereas the p u bic sym p hysis classes w ere best id entif ed
the m at (Fig. 24.6A). The exam iner then com presses the
u sing p alp ation o the p u bic sym p hysis and Trend elenbu rg’s
pelvis and the test is repeated (Fig. 24.6B). The test is
test. A sm all stu d y exam ining the d iagnostic accu racy o sp e-
positive i the p atient reports prim ary pain w hile raising
cif c exam ination p roced u res ou nd the best single test to be
the heel on the f rst attem p t, then red u ced or elim inated
the active straight leg raise, w ith a LR+ o 3.2 (Cook et al 2007);
pain on the second attem pt.
how ever, w hen the researchers clu stered the ASLR w ith
Gaenslen’s test and the thigh thru st, w ith the requ irem ent that • Lunge test: The stand ing patient steps orw ard w ith the
at least tw o o the tests be p ositive, they ound this raised the involved leg, then lunges u ntil the trailing knee reaches
LR+ only slightly, to 3.5. From this stu d y, the best clu stering the oor. The test is rep eated on the other sid e. A
o exam ination f nd ings w as ou nd to be a single p ositive positive test is reprod u ction o the prim ary com p laint o
p rovocative test rom a lu nge, hip m anu al m u scle test, or hip pain (Fig. 24.7).
range o m otion, w hich p rod u ced an LR+ o 4.2 (Cook et al • Patrick’s test: The p atient lies su p ine and the involved
2007); this stud y sam p le w as too sm all, how ever, to su bclas- leg is exed and externally rotated . The exam iner then
si y d iagnostic accu racy based on PGP class and d oing so stabilizes the op p osite ASIS and ap p lies a d ow nw ard
m ight im p rove the d iagnostic accu racy o the exam ination orce throu gh the exed knee (Fig. 24.8).
f nd ings. • Trendelenburg’s test: The p atient stand s on the involved
Kristiansson et al (1996) ou nd that p rovocational tests or leg and the exam iner observes or a d rop o the non-
the p elvic gird le p rod u ced ad equ ate d iagnostic accu racy or w eight-bearing hip. The test is positive i the p rim ary
p regnancy-related PGP in a sam ple o 200 w om en. The pain is also provoked (Fig. 24.9).
Patrick’s test and p alp ation o the long d orsal ligam ent w ere • Resisted hip abduction provocation test: This test is
includ ed in this stu d y. Ad d itionally, sym p tom provocation carried ou t as the stand ard m anu al m u scle test or hip
w ith resisted hip abd u ction has been associated w ith aberrant abd u ction. The test is positive i it rep rod u ces the
m ovem ent o the SIJ and sym p hysis p u bis (Rost et al 2004). patient’s p rim ary com p laint o pain (Fig. 24.10).
The ollow ing are d escriptions o the ad d itional provocational • Pubic symphysis compression test: The patient lies
tests or PGP: su p ine and d irect AP p ressu re is ap p lied over the
 282 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management 

Figure 24.7 Lunge test. Figure 24.10 Hip abduction manual muscle test.

Figure 24.8 Patrick’s test. Figure 24.11 Pubic compression test.

sym p hysis. A p ositive test is p rovocation o

sym p tom s com p arable to the p atient’s p rim ary com p laint
(Fig. 24.11).
• Palpation of the long dorsal ligament: The patient lies
in p rone and the exam iner p alp ates ju st d istally and
slightly m ed ially to the PSIS and u ses m ed ial-to-lateral
stru m m ing across the ligam ent, looking or tend erness
and rep rod u ction o the patient’s p rim ary com p laint o
pain (Fig. 24.12).
• Palpation of the sacrotuberous ligament: The p atient
lies in p rone and the in erior lateral angles (ILAs) o
the sacru m are p alp ated . The exam iner d rop s slightly
in eriorly and laterally to the ILAs and p alp ates d eep ly
into the so t tissu e to d eterm ine w hether it rep rod u ces
the com p arable p ain (Fig. 24.13).
Bearing these issu es in m ind , it seem s reasonable or the
clinician to attem p t to id enti y ind ivid u als w ho are exp erienc-
ing SIJP, rather than patients w ho m ight have SIJD (van d er
Wur et al 2000b; Laslett 2006). To id enti y patients w ith SIJP,
a strategy o p ain p rovocation tests is ad vocated . Once it has
been d eterm ined that the low back pain is arising rom the
Figure 24.9 Modif ed Trendelenburg’s test.
SIJ, the therap ist shou ld then ad op t a strategy to id enti y

Figure 24.12 Long dorsal ligament palpation.
Figure 24.13 Sacrotuberous ligament palpation.
w hich d irectional m ovem ent m ight be the source o irritation,
thereby elu cid ating a p otential intervention ap p roach to the
cond ition (Laslett 2006). In ad d ition, a precu rsor to provoking
the SIJ m ay be to ru le ou t lu m bar sp ine p athology as m ore
low back pain can be attribu ted to the lu m bar spine than to
the SIJ and SIJ p rovocational tests m ay be p ositive in ind ivid u -
als w ho have low back p ain d em onstrating the centralization
phenom enon. Several stu d ies have su ggested that the cen-
tralization p henom enon is p ecu liar and highly sp ecif c to d is-
cogenic p athology (You ng et al 2003; Laslett et al 2005c; Laslett
2006), so it can be assum ed that positive SIJ provocational
tests in the p resence o centralization can be classif ed as alse
positives. I m echanical provocation o the lu m bar spine
reprod uces the patient’s pain, it w ould seem m ore likely that
the lu m bar sp ine is the region o choice or d irecting the inter-
vention. Only a ter ru ling ou t the lu m bar sp ine, and sp ecif -
cally the centralization p henom enon, d oes it m ake sense to
attem p t to ru le in the SIJ (Laslett et al 2005c; Cook 2012). In a
system atic review to evalu ate the clinical u se u lness o sp ine
sp ecial tests, H ancock et al (2007) ou nd the only test that w as
u se u l or id enti ying d iscogenic p athology w as centraliza-
tion. In ad d ition, clu sters o p rovocation tests w ere the only
m ethod o id enti ying SIJ p athology. There ore, the d ecision
process p resented here is consistent w ith these f nd ings.
Prognosis 283
Clinical examination summary
During history taking, the ind ivid ual w ith SIJ-related p ain
o ten reports p rim ary sym p tom s d istal to the L5 sp inou s
p rocess that are both u nilateral and o ten ocu sed in the region
just d istal to the PSIS. These sym ptom s requ ently re er to the
leg and m ay be present all the w ay d ow n to the oot or even
on occasion re er into the groin, lu m bar sp ine or abd om en
(Slip m an et al 2000). Old er patients w ith a history o sym p-
tom s below the knee are ar less likely to have SIJP. The history
m ay inclu d e a u nilateral trau m a, inclu d ing a all on the
buttock or a m is-step on the sid e o pain. Further, the patient
m ay rep ort that sym p tom s increase w hen they rise rom
sitting. These historical eatu res enhance the likelihood o SIJ
p athology, bu t certainly are ar rom d iagnostic.
The objective exam ination shou ld thorou ghly rule out the
p resence o lu m bar p athology, sp ecif cally targeting centrali-
zation because, as m entioned above, su bjects w ith d iscogenic
back pain are know n to d em onstrate a positive response to
the p ain p rovocation m anoeu vres recom m end ed or ru ling in
SIJ p athology. Asid e rom assessing or the centralization p he-
nom enon, active range o m otion testing ad d s little d iagnostic
valu e to the objective exam ination (H u ijbregts 2004). Passive
p hysiological and p assive accessory m otions o the lu m bar
sp ine can be u sed to ru le in / ou t lu m bar involvem ent. Posi-
tional p alp atory tests and tests or m otion sym m etry are not
cu rrently recom m end ed or d iagnosing SIJD since they have
lim ited reliability, valid ity or d iagnostic accu racy. Once
lum bar p athology has been ru led ou t, how ever, a cluster o
sym p tom p rovocation tests is recom m end ed to assist the clini-
cian in p otentially ru ling in SIJP.
Once SIJP has been ou nd to be likely, p assive p hysiologi-
cal m otions o the innom inates and p assive accessories arou nd
the sacru m can be u sed to id enti y p otential m anu al therap y
treatm ent op tions. I these tests are equ ivocal, stabilization
asym m etry m ay be an issue. The PGP p rovocational tests then
cou ld be p er orm ed to ru le in p elvic instability.
The recom m end ations above are consistent w ith the three
criteria the IASP d escribed to d iagnose SIJ pathology – that is,
the p ain need s to be near the SIJ, p rovocational tests or p ain
in the SIJ are positive and the pain can be relieved throu gh
the u se o intra-articu lar injections (Merskey & Bogd u k 1994).
Prognosis
Few stu d ies have ocu sed on p rognosis or SIJP. Stu d ies that
have ad d ressed the p rognosis o low back p ain in general
report that m ost low back pain resolves satis actorily w ithin
a relatively short period o tim e. Bearing this in m ind , it
w ould seem that acu te SIJP w ou ld be includ ed in these statis-
tics i it had not been d i erentiated in the d iagnosis. H ow ever,
m ost stu d ies that have ad d ressed SIJ p athology inclu d e
p atients w ith chronic low back p ain, ind icating a p oorer p rog-
nosis since the cond ition has alread y becom e p ersistent in
natu re.
Pregnancy-related p elvic p ain has been exam ined in a large
trial w hich ou nd that 62.5% o w om en had no p ain w ithin a
m onth a ter d elivery and 91.4% w ere pain ree at 2 years
(Albert et al 2001). H ow ever, the longitud inal ollow -u p o
341 patients revealed that d i erences betw een classif cation
 284 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management 

grou ps existed , as no subjects rom the grou p w ith sym physi-
olysis p ain still had p ain a ter 6 m onths post d elivery, yet 21%
o su bjects in the p elvic gird le synd rom e grou p (w ith d aily
p ain in all three p elvic joints) still had sym ptom s a ter 2 years.
The stud y’s conclusion w as that post-partu m PGP had an
excellent prognosis or recovery in every grou p except the
p elvic gird le synd rom e grou p, w hich had a m uch poorer
p rognosis since over three tim es m ore su bjects had pain in
that grou p than in the other ou r grou p s com bined (Albert
et al 2001).
I all conservative care ails to provid e ad equate pain relie ,
su rgical u sion o the SIJ is an available op tion. N u m erou s
stu d ies have d em onstrated that su rgical correction o recalci-
trant SIJP is e ective in p rovid ing ad equ ate relie allow ing
return to norm al unction (Belanger & Dall 2001; Rud ol 2012;
Cu m m ings & Cap obianco 2013; Sachs & Cap obianco 2013;
Sm ith et al 2013); how ever, the proced ure is not w ithout its
critics, w ho cite high com p lication and resid u al p ain rates in
p atients receiving SIJ u sions (Sha rey & Sm ith 2013). Sachs
and Cap obianco (2013), in contrast, reported ew p ostopera-
tive com p lications in 40 p atients having a m inim ally invasive
SIJ usion, and a 7.8-p oint im provem ent in the m ean low back
p ain score, w hich d ecreased rom 8.7 pre-su rgery to 0.9 at
1-year ollow -u p . The m inim ally invasive su rgical app roach
requ ires less recovery tim e and results in better pain and d is-
ability relie ollow ing surgery than the op en app roach – as
id entif ed by a retrospective exam ination o 263 p atients
treated by seven su rgeons (Sm ith et al 2013). A recent stu d y
reported that the cost o m inim ally invasive SIJ usions com -
p ares avou rably w ith the li etim e cost o non-op erative con-
servative care (Ackerm an et al 2013).
exercise p rogram m e that em p hasized the d iagonal m u scle
p atterns o the anterior sling (Mens et al 2000). Conversely,
there is evid ence that stabilization m ay be e ective in treating
p elvic p ain. Eld en et al (2005) ou nd that a stabilization
ap proach incorporating m od if ed m u ltif d i and transversu s
abd om inis m u scles w as clinically m ore e ective than stand -
ard , non-exercising conservative care alone – althou gh this
stu d y also ou nd that acu p u nctu re w as also clinically m ore
e ective than stand ard care alone and w as slightly m ore
e ective than the stabilization exercises. Stuge et al (2004a)
exam ined the e ects o a stabilization exercise program m e in
a sam ple o 81 su bjects w ith PGP that ocused on a com bina-
tion o local m u scle stabilizers, the m u ltif d i (Fig. 24.14) and
transversu s abd om inis (Fig. 24.15) m uscles, and p rogressed to
includ e global prim e m overs. Figs 24.16–24.22 p rovid e som e
exam ples o global stabilization exercises. This stud y com -
p ared stabilization exercises w ith a control grou p over a
20-w eek program m e and ou nd that the stabilization grou p
exp erienced im proved pain and u nctional ou tcom es, w hich
w ere m aintained at both 1-year (Stu ge et al 2004a) and 2-year
ollow -u ps (Stu ge et al 2004b). A com p arison o the contrad ic-
tory resu lts obtained betw een this and an earlier rand om ized

Treatment
Intra-articular injections are the d iagnostic re erence stand ard
or SIJ pathology, bu t are also a treatm ent technique. The u se
o IAI or the treatm ent o SIJ p athology is technically d em and -
ing so it is gu id ed by an im aging techniqu e to ensu re p rop er
p lacem ent o the m ed ication into the SIJ. One stu d y ou nd
that, d esp ite a low rate o actu al SIJ joint inf ltration, there
Figure 24.14 Multif dus muscle isolation contraction exercise.
w ere sim ilar ou tcom es or pain relie betw een those patients
in w hom the injection p enetrated the joint and those in w hom
the injection w as noted to have m issed the joint (H artung et al
2010).

Exercise therapy
There are tw o m ain types o active exercise prescribed or SIJ
p athology: stabilization exercises and exercise or m ovem ent
enhancem ent. Stabilization exercises are u sed to create tension
w ithin the thoracolu m bar ascia and the other ligam ents that
stabilize the SIJ. This enhances the band -like tension in the
p osterior asp ect o the sacral region, increasing orce tension
in the p elvic ring. Movem ent-based exercises are u sed to
stretch the innom inate in one d irection or another so as to
im p rove m obility and energy load trans er.
Mu ltip le stu d ies have qu estioned the benef t o a stabiliza-
tion exercise p rogram m e or the treatm ent o SIJP or p elvic
ring instability (Mens et al 2000; N ilsson-Wikm ar et al 2005).
One stu d y ou nd no betw een-grou p d i erences or an Figure 24.15 Transversus abdominis muscle isolation contraction exercise.
 Treatment 285

Figure 24.16 Single-leg, sling-supported bridge exercise. Figure 24.19 Sling-supported orward trunk lean exercise.

Figure 24.17 Single-leg, sling-supported bridge with active hip abduction Figure 24.20 Sling-supported trunk extension exercise.
exercise.

Figure 24.18 Sling-supported side-plank exercise. Figure 24.21 Standard plank exercise.
 286 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management 

Figure 24.22 Standard side-plank exercise.

Figure 24.23 Non-thrust or thrust manipulation to rotate the innominate

controlled trial rep orting no e ect (Mens et al 2000) id entif ed
anteriorly.
several key d i erences in the m ethod s u sed , inclu d ing the
training and the su p ervision o the exercises p rovid ed (Stu ge
et al 2006a). Another potential key d i erence involved the
theoretical im p lication o the exercises chosen. As p reviou sly
stated , a stu d y by Richard son et al (2002) id entif ed that an
isolated contraction o transversu s abd om inis and the m u lti-
f d i p rod u ced greater sti ening o the SIJ than the other id enti-
f ed stabilizers o both the anterior and p osterior p elvic slings.
The stud ies by Eld en et al (2005) and Stu ge et al (2004a)
em phasized the isolated m uscle grou ps, w hereas Mens et al
(2000) had ocu sed on the anterior sling m u scles only. The
im p ortance o the d eep er stabilizers has been id entif ed in an
observational stu d y by Stuge et al (2006b). This sstu d y id enti-
f ed key d i erences in the d eep stabilizer m u scles betw een
w om en w ho had recovered rom PGP and w om en currently
experiencing PGP, inclu d ing the ability to contract the pelvic
oor m uscles and the thickness o the transversus abd om inis
and internal obliqu es d u ring a contraction.
Figure 24.24 Non-thrust or thrust manipulation to rotate the innominate
posteriorly.
Manual therapy
Manu al therap y can be broad ly d ivid ed into tw o su bcatego- and Franz (2007) ou nd that exercise therap y involving rota-
ries o treatm ent: thru st m anipulation and non-thru st m anip- tional m obilization o the innom inate in the d irection o p re -
u lation. Thru st m anip u lation involves p lacing the joint in erence (anteriorly in this case) red u ced p ain and d isability in
end -range position and applying high-velocity low -am p litu d e a patient w ho had f rst been id entif ed as having SIJP by
thru sts in the d esired d irection so as to increase available ru ling ou t centralization throu gh a m echanical d iagnosis
m ovem ent. N on-thru st m anip u lation involves p lacing the therap y exam ination and ru ling in SIJP throu gh a test-item
segm ent in the d esired p osition and ap p lying either an oscil- clu ster. Figures 24.23–24.24 sum m arize potential rotational
latory orce or a su stained orce in the d esired d irection or a non-thru st / thru st m anip u lation techniqu es u sed in the clinic,
sp ecif ed p eriod o tim e. Marshall and Mu rp hy (2006) ou nd and Figure 24.25 show s a hom e exercise p rogram m e u su ally
that an SIJ m anip u lation p rod u ced an im m ed iate and signif - u sed in com bination w ith SIJ m anip u lation. Althou gh in
cant increase in eed - orw ard activity o the d eep tru nk stabi- neither o the above case rep orts w as SIJP d iagnosed by IAI,
lizers in those w ith im p aired eed - orw ard resp onse tim es. the clinical exam inations certainly m et the stand ard s set ou t
The exact im pact o this alteration in eed - orw ard m echa- by m any investigators.
nism s in term s o im p rovem ent in p ain and d isability rem ain A sm all rand om ized clinical trial has exam ined the e ect
u nknow n, how ever. Mu ltip le case rep orts have nevertheless o tw o d i erent thru st m anip u lation techniqu es on a sam p le
su ggested that m anu al therap y or p robable SIJP m ay be o su bjects d iagnosed w ith SIJ u sing a test-item clu ster o
e ective. p rovocational tests (Kam ali & Shokri 2012). The m anipu lation
Bashir (2011) ound that m u ltip le sessions o rotational techniqu es inclu d ed the SIJ thru st (Fig. 24.26) (Flynn et al
m anip u lation o the SIJ red u ced p ain and d isability in a 2002) and a neu tral-gapping (Fig. 24.27) technique (Cook et al
38-year-old p atient w ith probable SIJP. In this p articu lar stud y, 2013). The ou tcom es w ould su ggest that a com bination o the
the investigator ap p rop riately ap p lied clinical tests o p rovo- tw o techniqu es resu lts in im p roved ou tcom es over an inter-
cation and p er orm ed m u ltip le m ovem ent tests to ru le ou t vention u sing the SIJ m anip u lation techniqu e alone. The
lu m bar p athology be ore testing or SIJP. Sim ilarly, H orton results also su ggest that both proced u res prod uced signif cant

Figure 24.25 Sel -correction exercise to achieve posterior rotation o the
innominate.
Figure 24.26 Sacroiliac thrust manipulation.
Figure 24.27 Rotational neutral-gapping manipulation.
Treatment 287
Figure 24.28 Long-leg distraction manipulation or the sacroiliac joint.
and clinically m eaning ul changes in both pain and d isability
ollow ing a single session o m anipu lative therapy or su b-
jects w ith clinically d iagnosed SIJP (Kam ali & Shokri 2012).
An ad d itional thrust m anipulation technique that has been
p u rp orted to im p act the SIJ is a long-leg d istraction w ith the
hip in end -range internal rotation to red u ce p assive hip m ove-
m ent (Fig. 24.28).
A sm all rand om ized clinical trial com p aring orthop aed ic
m anu al therap y, exercise therap y and neu roem otional train-
ing or the treatm ent o p regnancy-related pelvic pain d em -
onstrated a trend tow ard s greater im p rovem ent in both
m anu al therap y and exercise therap y than in neu roem otional
training, bu t the betw een-grou p d i erences w ere not signif -
cant (Peterson et al 2012). The au thors conclud ed that a larger
trial w as w arranted based on the encou raging resu lts o the
stu d y as 50% o all the p atients rep orted a clinically m eaning-
ul change in pain and d isability.
Many p ro essions have ad op ted the osteop athic ap p roach
to m anaging SIJ. Osteop athic treatm ent involves p lacing the
segm ent in the d esired p osition to em p hasize isolation o the
SIJ to available m ovem ent in a single or sp ecif c p lane. A
m u scle energy techniqu e or a d irect techniqu e w ith im p u lse
is then ap plied to m obilize the segm ent in the d irection o the
lost m otion. This orm o treatm ent is guid ed by the p alpatory
exam ination used to id enti y the asym m etry in the lum bosac-
ral region that the technique pu rports to correct. There are a
nu m ber o nam ed d iagnostic categories o d ys u nction and
there ore p ositions or treatm ent id entif ed u sing this system
(see Ch 62 or d etails o m uscle energy techniques). Since
rotational m otions or the innom inates can requently be p ro-
vocative, a techniqu e that em p hasizes rotation m ay red u ce
p ain; there ore, p lacing p atients in Gaenslen’s test p osition
(see Fig. 24.5) and having them resist the overpressu re m ay
be an e ective treatm ent. A p otential problem w ith this system
or treating SIJ pathology is the lack o specif city o the pro-
p osed treatm ent, as isolated treatm ents to the SIJ m ay be a
allacious assu m ption (Laslett 2008). A large, w ell-d one d eri-
vation stu d y or a clinical p red iction ru le to d eterm ine treat-
m ent su ccess p rescrip tively w ith an SIJ m anip u lation
d eterm ined that not one o the SIJ tests pred icted clinical
su ccess (Flynn et al 2002). These resu lts m ay su ggest that
either the tests d on’t id enti y SIJ pathology or the SIJ m anipu-
lation proced u re im pacts m ore than ju st the SIJ (Laslett 2008);
 288 PART 3 • 24 • Sacroiliac joint as a source of pain: diagnosis and management
given the act that lu m bar hyp om obility d id pred ict treatm ent
su ccess (Flynn et al 2002), the latter seem s m ore plau sible. To
d ate, this author is u naw are o a single stu d y that strongly
su p p orts the u se o the exam ination and treatm ent techniqu es
or the correction o SIJD as conf rm ed by IAI.
N onetheless, this exam ination and treatm ent p rocess is
su p p orted anecd otally by su bjective rep orts o p ain red u ction
a ter su ch treatm ent, the clinicians taking this as conf rm ation
that the d iagnostic system w as ind eed correct w hen the treat-
m ent has never been conf rm ed to im p act the p osition o the
SIJ and cou ld ju st as easily be im p acting the lu m bar sp ine.
The pain relie observed ollow ing SIJ m anipulation, m obili-
zation and m u scle energy techniqu es is likely to be the resu lt
o the w ell-d ocu m ented neu rop hysiological and re exogenic
changes that occu r p rod u cing short-term p ain relie (Bialosky
et al 2009; Coronad o et al 2010).
Sacroiliac belts
Sacroiliac belts have been ou nd to red u ce p regnancy-related
p elvic p ain signif cantly w hen app lied ju st in erior to the ASIS
rather than over the level o p ubic sym p hysis (Mens et al
2006). A review article su ggests that there is m od erate evi-
d ence rom 18 articles to su pp ort the u se o external su pport
or the pelvic ring or pain red u ction, altered recruitm ent o
stabilizers and altered kinem atics o the lu m bop elvic region
(Aru m u gam et al 2012). One EMG stu d y o 17 su bjects ou nd
that ap p lication o the sacroiliac belt red u ced m u scle recru it-
m ent o the transversu s abd om inis and abd om inal obliqu es
d u ring the active straight leg raise and tread m ill w alking tests
(H u et al 2010). A second stu d y o 17 su bjects u sing EMG
d u ring abd om inal exercises on an unstable su r ace ou nd that
activity o the rectu s abd om inis, and both internal and exter-
nal obliqu es, w as red u ced ollow ing the ap p lication o this
belt (Kim et al 2013). These stu d ies w ould su ggest that the
sacroiliac belt p rovid ed orce closu re to the system thu s allow -
ing the u su al stabilizers to relax d u ring the attem p ted exercise
or u nctional activity.
Conclusion
SIJ p athology involves p ain, instability or asym m etrical stabil-
ity o the p elvic ring, or alteration / asym m etrical m otion.
Pain and / or stability issu es are the ar m ost likely and read ily
id entif able p athologies. Trad itional exam ination and treat-
m ent based on notable p elvic asym m etries ou nd d u ring a
p alp atory and visu al exam ination cannot be recom m end ed
or the ollow ing reasons. First, the pathology has not been
verif ed by any benchm ark gold stand ard su ch as rad io-
graphic evid ence. Second ly, the tests used to id enti y the
p athology clinically are generally unreliable, w ith a ew tests
having reliability coe f cients no better than chance agree-
m ent. N evertheless, w e cannot conclu d e that the treatm ents
p u rp orted to correct these au lts are ine ective because it is
entirely possible that they d em onstrate a general neurophysi-
ological e ect that m ay red u ce d iscom ort. Likew ise, im p rove-
m ents in p atients’ com p laints o p ain cannot be u sed to
d eterm ine that the exam ination principles are valid .
The best evid ence or clinical d iagnosis o SIJ p athology
com es rom tests that are classif ed as p rovocative in natu re.
 
Most o these tests lack su f cient d iagnostic accu racy as
stand -alone tests, bu t their clinical u tility is greatly enhanced
w hen per orm ed in clu sters ollow ing the exclu sion o likely
lum bar pathology through clinical screening. Use o a d iag-
nostic and treatm ent algorithm p rop osed by Cook (2012) is
consistent w ith cu rrent gu id elines and is based on consid er-
able research.
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 P AR T 4
The Shoulder Region in
Upper Extremity Pain
Syndromes
25 Acromioclavicular Joint 293
Janette W. Powell, Ian Shrier and Peter A. Huijbregts
26 Sternoclavicular Joint 302
Erland Pettman
27 Rotator Cuff Lesions: Shoulder Impingement 309
Peter A. Huijbregts and Carel Bron
28 Glenohumeral Instability 321
Steven C. Allen, Russell S. VanderWilde and Peter A. Huijbregts
29 Superior Labrum Anterior-to-Posterior (SLAP) Lesions 333
Janette W. Powell and Peter A. Huijbregts
30 Frozen Shoulder 344
Carel Bron, Arthur de Gast and Jo L.M. Franssen
31 Joint Mobilization of the Shoulder 350
Wayne Hing, Jack Miller and César Fernández-de-las-Peñas
32 Motor Control of the Shoulder Region 358
Mary E. Magarey, Mark A. Jones and Samuel R. Baida
33 Therapeutic Exercises for the Shoulder Region 373
Johnson McEvoy, Kieran O’Sullivan and Carel Bron
This pa ge inte ntiona lly le ft bla nk
 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
CHAP TER CONTENTS
Introduction  293
Anatomy of the acromioclavicular joint  293
Biomechanics of the acromioclavicular joint  293
Pathology of the acromioclavicular joint  294
Diagnosis of the acromioclavicular joint  295
Management of the acromioclavicular joint  298
Conclusion  299
Introduction
Shou ld er p ain is the third m ost com m on cau se for m u scu -
loskeletal consu ltation in prim ary care (Docim o et al 2008).
Acrom ioclavicu lar joint (ACJ) pathology and d ysfunction is
a com m on com p onent of should er p ain (H utchinson & Ahuja
1996; Magee & Reid 1996; Au ge & Fischer 1998; Shaffer 1999;
Debski et al 2001; Garretson & William s 2003; Renfree &
Wright 2003; Kiner 2004; Walton et al 2004; Pow ell &
H u ijbregts 2006; Cod si 2007; Docim o et al 2008; Sim ovitch
et al 2009). The ACJ accounts for ap p roxim ately 9–12% of
shou ld er inju ries p resenting for general m ed ical care (Ru d zki
et al 2003; Docim o et al 2008; Fraser-Mood ie et al 2008; Mac-
d onald & Lap ointe 2008; White et al 2008) and is one of the
m ost frequently injured joints in certain sports – for exam ple,
in football, ice hockey, skiing, snow board ing, skating and
ru gby (Magee & Reid 1996; Renfree & Wright 2003; Pow ell &
H u ijbregts 2006; Petron & H anson 2007; Fraser-Mood ie et al
2008; White et al 2008). Overall, ACJ sprains / separations
have been d escribed as accounting for 40–50% of all athletic
shou ld er inju ries (Debski et al 2001; Petron & H anson 2007;
Sim ovitch et al 2009) and are noted to be tw ice as com m on as
com p lete ACJ d isru p tions (Petron & H anson 2007; Fraser-
Mood ie et al 2008), w hich accou nt for 12% of all d islocations
affecting the shou ld er gird le (Magee & Reid 1996). In ad d ition
to the ACJ, the clavicle is frequ ently inju red w ith an incid ence
of 23 p er 1000 athletic exp osu res for ice hockey and 17 p er
1000 athletic exp osu res for lacrosse (H utchinson & Ahu ja
1996). The prevalence of atraum atic osteolysis of the d istal
clavicle has been reported to be as high as 27% in w eightlifters
(Au ge & Fischer 1998). These nu m bers probably und eresti-
m ate the tru e p revalence, as ind ivid u als w ith m inor inju ries
or d ysfu nction m ight not seek m ed ical care (Mehrberg et al
 
Chapter  25Acromioclavicular Joint
J a n e tte W. Po w e ll, Ia n S h rie r, P e te r A. Hu ijb re g ts
2004; Fraser-Mood ie et al 2008). ACJ inju ries are m ore com m on
in m ales (Beim 2000; Mehrberg et al 2004; Petron & H anson
2007; White et al 2008; Fraser-Mood ie et al 2008) and over half
occu r in the und er-30-years age grou p (Kiner 2004; Mehrberg
et al 2004).
Anatomy of the Acromioclavicular Joint
Fraser-Mood ie et al (2008) d escribed the ACJ as the ‘keystone’
link betw een the scapu la and the clavicle. It su spend s the
u p p er extrem ity from the axial skeleton (Shaffer 1999; Bu ss &
Watts 2003; N u ber & Bow en 2003; Renfree & Wright 2003). A
thin cap su le su rrou nd s the d iarthrod ial ACJ, w hich typ ically
contains a brocartilaginou s d isc (Lem os 1998; Shaffer 1999;
Beim 2000; Buss & Watts 2003; Garretson & William s 2003;
Renfree & Wright 2003; Docim o et al 2008; Fraser-Mood ie
et al 2008; Macd onald & Lapointe 2008; Rios & Mazzocca
2008; White et al 2008; Sim ovitch et al 2009). This intra-
articu lar d isc is variable in size and shape and m ay som etim es
u nd ergo rap id d egeneration, beginning as early as the second
d ecad e of life (Beim 2000; Renfree & Wright 2003; Mehrberg
et al 2004; Docim o et al 2008; White et al 2008; Sim ovitch et al
2009). The ACJ is reinforced by the acrom ioclavicular (AC)
ligam ents (su perior, inferior, anterior and posterior), the
robust coracoclavicular (CC) ligam ents (conoid and trape-
zoid ), the coracoacrom ial ligam ent, and the d eltotrapeziu s
ap oneu rosis (Fig. 25.1) (Lem os 1998; Shaffer 1999; Beim 2000;
Buss & Watts 2003; Garretson & William s 2003; Renfree &
Wright 2003; Petron & H anson 2007; Docim o et al 2008;
Fraser-Mood ie et al 2008; Macd onald & Lap ointe 2008; Rios
& Mazzocca 2008; White et al 2008; Sim ovitch et al 2009).
Dynam ic stabilization is provid ed by the d eltoid and trape-
zius m uscles (Lizau r et al 1994; Beim 2000; Bu ss & Watts 2003;
Renfree & Wright 2003; Garretson & William s 2003; Petron &
H anson 2007; Docim o et al 2008; Macd onald & Lap ointe 2008;
Rios & Mazzocca 2008; White et al 2008; Sim ovitch et al 2009).
Biomechanics of the Acromioclavicular
Joint
Few stu d ies have been pu blished on ACJ kinem atics (Teece
et al 2008) bu t m ore recent three-d im ensional im aging
 294 PART 4 •
Coracoclavicular ligament
Trapezoid Conoid
ligament ligament
Coracoacromial
ligament
Lesser tuberosity
Bicipital groove
Coracoid process
Figure 25.1 Normal anatomy of the acromioclavicular joint.
stu d ies qu antifying its m otion su ggest that the extent of
m ovem ent has historically been u nd erestim ated (Sahara et al
2006, 2007; Fraser-Mood ie et al 2008; Teece et al 2008). Sahara
et al (2007) have noted that d u ring abd uction of the should er
there is signi cant rotation of the clavicle and w ithin the ACJ,
w ith the clavicle acting as a screw axis (Sahara 2006). For
exam ple, in the anterior–p osterior (AP) d irection, the clavicle
translated m ost p osteriorly (1.9 ± 1.3 m m ) at 90° of abd u ction
and m ost anteriorly (1.6 ± 2.7 m m ) at m axim u m abd u ction.
When d e ning m otion of the scap u la w ith respect to the clavi-
cle, this stu d y noted that the scap u la generally rotated abou t
a sp eci c screw axis passing throu gh the insertions of both
the AC and the CC ligam ents on the coracoid p rocess (Sahara
et al 2006). Teece et al (2008) fou nd that signi cant m otion
(internal rotation, upw ard rotation and p osterior tilting)
occu rs at the ACJ d u ring active hu m eral elevation, and d is-
cu ssed how abnorm al m otions at the ACJ w ill affect the p osi-
tion of the scap u la on the thorax, and contribu te to shou ld er
p athology and d ysfu nction. The sam e researchers observed ,
d u ring active scap u lar p lane abd uction from rest to 90°, that
average ACJ angu lar valu es d em onstrated increased internal
rotation (ap p roxim ately 4.3°), increased u pw ard rotation
(ap p roxim ately 14.6°) and increased p osterior tilting (ap proxi-
m ately 6.7°). That stu d y d id not analyse m otion beyond 90°
abd u ction, ow ing to technical lim itations w ith clavicular
tracking. These ACJ m otions are of su f cient m agnitu d e to
w arrant clinical attention w ith m anu al m obilization w hen
these m otions are abnorm al or d ysfu nctional.
Pathology of the Acromioclavicular
Joint
Box 25.1 su m m arizes the p athologies that m ay affect the ACJ
(H u tchinson & Ahu ja 1996; Magee & Reid 1996; Au ge &
Fischer 1998; Lem os 1998; Lehtinen et al 1999; Shaffer 1999;
Debski et al 2001; Santis et al 2001; Garretson & William s
2003; Renfree & Wright 2003; Kiner 2004; Walton et al 2004;
Sim ovitch et al 2009). The ACJ can be acutely inju red by d irect
blow s to the shou ld er or falls onto an u pper extrem ity
25 • Acromioclavicular joint
Bo x 2 5 .1 P a th o lo g ie s / d ys fu n c tio n s a ffe c tin g th e
a c ro m io c la vic u la r jo in t
Traumatic  c o nditio ns
• Separation / dis location (types I–VI)
• Fracture
• Subacromial bursitis
• Rotator cuff pathology
In e c tio us  c o nditio ns
• Septic arthritis
Inf ammato ry c o nditio ns
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Ankylosing spondylitis
• Gout
De g e ne rative  jo int dis e as e
• Osteoarthritis
• Osteolysis
(ligam ent sp rain / separations / d islocations). The ACJ is also
vu lnerable to rep etitive overu se (osteolysis and d egenerative
joint d isease) (Lem os 1998; Debski et al 2001; N uber & Bow en
2003; Kiner 2004; Petron & H anson 2007; Macd onald &
Lap ointe 2008; Rios & Mazzocca 2008; Sim ovitch et al 2009).
Acu te inju ries to the ACJ typ ically involve a d irect fall onto
the ou ter asp ect of the shou ld er, u su ally w ith the arm ad d u cted
(Beim 2000; Buss & Watts 2003; Garretson & William s 2003;
Ru d zki et al 2003; Petron & H anson 2007; Fraser-Mood ie et al
2008; Sim ovitch 2009). This force d rives the acrom ion inferi-
orly u nd er the clavicle. The greater stability of the sternocla-
vicu lar joint (d iscu ssed in Ch 26) resu lts in the m ajority of the
im p act d issipated in the ACJ stru ctu res, w hich lead s to a
system atic failu re of stabilizing stru ctu res w ith p rogressive
force (Beim 2000; Brad ley & Elkou sy 2003; Rud zki et al 2003;
Petron & H anson 2007; Fraser-Mood ie et al 2008; Macd onald
& Lapointe 2008; Rios & Mazzocca 2008; Sim ovitch et al 2009).
The d ow nw ard force w ith this injury initially stretches the AC
ligam ents; then, as the force continu es, the AC ligam ents tear
and the CC ligam ents are stressed (Tom et al 2009). As the
d ow nw ard force continu es the CC ligam ents tear, follow ed
by the m u scle attachm ents of the d eltoid and trapeziu s
m u scles, resu lting in a com p lete d isru p tion to the ACJ (Tom
et al 2009).
These sequ ential acute injuries have been d e ned and
d escribed by Tossy et al (1963). Rockw ood et al (1996) m od i-
ed and exp and ed these inju ry typ es to the system that is
com m only u sed tod ay (Fig. 25.2):
• type I: AC ligam ent sp rain, CC ligam ent intact, d eltoid
and trapeziu s m u scles intact
• type II: AC ligam ents and ACJ d isru p ted , CC ligam ent
sp rain, d eltoid and trap eziu s m u scles intact
• type III: AC ligam ents and ACJ d isru p ted and d isp laced ,
CC ligam ents d isru pted w ith CC interspace 25–100%
larger than norm al shou ld er, d eltoid and trap eziu s
m u scles u su ally d etached
• type IV: AC ligam ents d isru p ted and ACJ d isp laced ,
clavicle d isp laced p osteriorly, CC ligam ents d isru p ted

Normal
Type I Type II
Type III Type IV
Conjoined tendon
of biceps and
Type V Type VI coracobrachialis
Figure 25.2 Types I–VI acromioclavicular joint sprain.
w ith w id er CC interspace, d eltoid and trapezius m uscles
d etached
• type V: AC and CC ligam ents d isru p ted , ACJ grossly
d isplaced (100–300% m ore than norm al shou ld er), d eltoid
and trapeziu s m u scles d etached
• type VI: AC and CC ligam ents d isru p ted and ACJ
d isplaced , clavicle d isplaced inferiorly, d eltoid and
trap eziu s m u scles d etached (Tossy et al 1963; Sim ovitch
et al 2009; Tom et al 2009).
A less com m on m echanism of acu te inju ry to the ACJ w ou ld
involve a fall onto an outstretched hand , or a d irect blow to
the elbow. These m echanism s d rive the hu m eral head su p e-
riorly into the acrom ion (Beim 2000; Garretson & William s
2003; Petron & H anson 2007; White et al 2008). These ind irect
forces m ay resu lt in the sam e injury p atterns d escribed above
(Sim ovitch et al 2009), or m ay spare the CC ligam ents w hen
the scap u la is d riven su p eriorly and m ed ially, inju ring the AC
ligam ents in isolation (Mehrberg et al 2004; White et al 2008).
Ad d itionally the ACJ m ay be injured by a traction force
ap p lied to the u p p er extrem ity (Beim 2000; Garretson &
William s 2003).
Diagnosis of the acromioclavicular joint 295
Rios and Mazzocca (2008) describe an acute ‘internal derange-
m ent’ w hereby the intra-articu lar d isc is torn. Magee and Reid
(1996) p rop ose that intra-articu lar d isc inju ries are im p licated
in the ‘clicking’ that is som etim es heard and in som e of the
p ost-trau m atic p ain synd rom es follow ing ACJ inju ries.
Although m any ACJ injuries are d ue to a sud d en force,
repetitive load s m ay also cau se injury to the region. N on-
contact sp orts su ch as cycling, baseball and w eightlifting have
been associated w ith d egenerative ACJ inju ries (Bow en &
N uber 2003). For exam ple, the com pressive forces across the
ACJ that are created d uring rep eated forceful contraction
by the d eltoid , trapezius and p ectoralis m ajor m uscles m ay
contribu te to osteolysis of the d istal clavicle (N uber & Bow en
2003; Renfree & Wright 2003). This repetitive stress to the
su bchond ral bone can cau se fatigu e fractu res and a hyp ervas-
cu lar resp onse lead ing to absorp tion of bone and an eventu al
clinically relevant osteolysis. The sequ elae inclu d e d em iner-
alization, osteopenia, su bchond ral cyst form ation and d istal
clavicle erosion (N uber & Bow en 2003). It is often noted that
the ACJ is requ ired to transm it large load s across a very sm all
su rface area and this m ay contribu te to failu re w ith rep etitive
activity and overu se (Shaffer 1999; Beim 2000; N u ber & Bow en
2003; Renfree & Wright 2003; Docim o et al 2008).
In ad d ition, d egeneration of the ACJ intra-articular d isc
com m ences in the second d ecad e of life and m ay be signi -
cant by the fou rth d ecad e (Garretson & William s 2003). An
incom plete brocartilaginou s d isc m ay play a signi cant
role in the d evelopm ent of arthrosis (Beim 2000; Pow ell &
H uijbregts 2006; Docim o et al 2008). Prim ary osteoarthritis
and post-traum atic arthritis are noted to be p revalent in
50–60% of asym p tom atic eld erly ind ivid uals (Shaffer 1999;
Docim o et al 2008; Rios & Mazzocca 2008). ACJ arthrosis, joint
d egrad ation, m ay be id iopathic, or resu lt from inju ry and / or
instability of this joint (Rios & Mazzocca 2008). The ACJ is
also p rone to in am m atory, sep tic and crystalline arthrop athy
(Garretson & William s 2003; Renfree & Wright 2003).
Diagnosis of the Acromioclavicular
Joint
The clinical presentation of an ind ivid ual w ith acu te ACJ
injury typ ically involves a history of one of the m echanism s
of inju ry d escribed above: d irect trau m a to the shou ld er w ith
the arm ad d u cted , fall onto an ou tstretched hand or elbow, or
a traction inju ry to the upp er extrem ity (H utchinson & Ahuja
1996; Lem os 1998; Beim 2000; Bu ss & Watts 2003; Garretson
& William s 2003; Petron & H anson 2007; Macd onald &
Lap ointe 2008; Rios & Mazzocca 2008; White et al 2008; Sim o-
vitch et al 2009). Ind ivid uals w ith isolated ACJ lesions typi-
cally note p ain over the anterior and / or su p erior asp ect of
the shou ld er. Althou gh the p ain is often localized to the
region d irectly over the ACJ, it m ay rad iate to the anterola-
teral neck, the trapezius–su praspinatus region and the antero-
lateral d eltoid (Gerber et al 1998; Shaffer 1999; Petron &
H anson 2007; Fraser-Mood ie et al 2008; Macd onald & Lapointe
2008; Rios & Mazzocca 2008).
Sw elling, ecchym osis / erythem a and d eform ity, if
p resent, are easily observed as the ACJ is ju st u nd er the
skin (H u tchinson & Ahu ja 1996; Shaffer 1999; Beim 2000;
Mehrberg et al 2004; Petron & H anson 2007; Fraser-Mood ie
 296 PART 4 • 25 • Acromioclavicular joint

et al 2008; Macd onald & Lap ointe 2008; White et al 2008;

Sim ovitch et al 2009; Tom et al 2009). Tend erness on palp a-
tion of the ACJ is rep orted as a com m on clinical nd ing asso-
ciated w ith ACJ d ysfu nction (H u tchinson & Ahu ja 1996;
Magee & Reid 1996; Shaffer 1999; Beim 2000; Tallia & Card one
2003; Bu ss & Watts 2003; N u ber & Bow en 2003; Mehrberg et al
2004; Walton et al 2004; Bru kner & Khan 2006; Petron &
H anson 2007; White et al 2008; Docim o et al 2008; Fraser-
Mood ie et al 2008; Macd onald & Lapointe 2008; Rios & Maz-
zocca 2008; Park et al 2009; Sim ovitch et al 2009; Tom et al
2009). A num ber of physical exam ination tests have been pro-
p osed to stress the stru ctu res of the ACJ and assist in the
clinical d iagnosis of ACJ p athology. These inclu d e the active
com p ression test (also know n as O’Brien’s sign) (Fig. 25.3)
(O’Brien et al 1998; Maritz & Oosthuizen 2002; Chronop ou los
et al 2004; Walton et al 2004), cross-bod y ad d uction test
(also know n as Scarf sign) (Fig. 25.4) (Maritz & Oosthu izen
2002; Chronopou los et al 2004), acrom ioclavicular resisted
extension test (Fig. 25.5) (Chronopoulos et al 2004), ACJ ten-
A
d erness test (Maritz & Oosthu izen 2002; Walton et al 2004)
and Paxinos sign (Fig. 25.6) (Walton et al 2004; Bru kner &
Khan 2006). Table 25.1 provid es psychom etric d ata on these
clinical tests.
Pow ell and H u ijbregts (2006) noted that research evid ence
su p p orts the inclu sion of the follow ing tests, w ith the
follow ing interpretation, for the d iagnosis of painfu l ACJ
d ysfunction:
• A negative nd ing on any of the follow ing tests w ould
rule out ACJ d ysfu nction: cross-bod y ad d u ction test,
tend erness on p alp ation of the ACJ, or Paxinos sign.
• A p ositive nd ing on any of the follow ing tests w ou ld
rule in ACJ d ysfu nction: active com p ression test, the
cross-bod y ad d u ction test, or acrom ioclavicu lar resisted
extension test.
• A p ositive nd ing on all three tests u sed to rule in ACJ
d ysfu nction (i.e. the cross-bod y ad d u ction stress, active
com p ression, and resisted acrom ioclavicu lar extension
tests) may be relevant w hen consid ering a m ed ical–surgical
referral and associated higher risk interventions.
B
A nu m ber of au thors note the valu e of ACJ local anaesthetic
injections to assist and / or con rm the involvem ent of ACJ
Figure 25.3 Active compression test: (A) Maximal internal rotation: the client
d ysfunction in the clinical presentation w hen other associated stands with the involved arm straight and orward f exed to 90°. The arm is then
shou ld er inju ries m ay be p resent (Parlington & Broom e 1998; horizontally adducted 10–15° and maximally internally rotated. The client then
Shaffer 1999; Maritz & Oosthu izen 2002; N uber & Bow en resists a downward orce applied by the examiner to the distal arm. (B) Maximal
2003; Tallia & Card one 2003; Walton et al 2004; Chronop ou los external rotation: the test is then repeated in the same position with the arm
et al 2004; Cod si 2007; Docim o et al 2008; Rios & Mazzocca maximally externally rotated; O’Brien et al (1998) did not quanti y the amount o
2008; Park et al 2009), and som e consid er it the criterion refer- orce used. This test is considered positive or ACJ dys unction i the pain is
localized to the ACJ on the rst position and relieved or eliminated on the second
ence (gold stand ard ) for the d iagnosis of ACJ inju ry / pathol- position. Pain ‘deep inside the shoulder’, with or without a click, in the rst position
ogy (Parlington & Broom e 1998; Maritz & Oosthu izen 2002; and eliminated or reduced in the second position is considered indicative o a
Chronop ou los et al 2004; Walton et al 2004). If p ain ceases glenoid labrum tear. (From Powell & Huijbregts 2006, with permission.)
w ith injection then only the ACJ is involved ; if pain d ecreases
w ith injection then other pathologies probably coexist; if
p ain is u naffected then the ACJ is p robably not involved
(Parlington & Broom e 1998; Shaffer 1999; Maritz & Oosthu i- w hen d im inished by osteophyte form ation (Parlington &
zen 2002; Tallia & Card one 2003; Chronop ou los et al 2004; Broom e 1998; Shaffer 1999; Bisbinas et al 2006; Cod si 2007;
Walton et al 2004; Cod si 2007; Docim o et al 2008; Rios & Maz- Rios & Mazzocca 2008). Parlington and Broom e (1998) noted
zocca 2008; Park et al 2009). H ow ever, injection into the ACJ that non-im age-gu id ed intra-articu lar in ltrations w ere
is noted to have its challenges. It m ay be u nsu ccessfu l, p ar- p laced su ccessfu lly in the ACJ in only 16 / 24 (67%) of cad av-
ticu larly w ith regard s injection targeting, d u e to the variabil- eric shou ld ers. Bisbinas et al (2006) fou nd that only 40% of
ity in ACJ anatom y, the obliqu ity of the joint, the sm all ACJ injections w ill be placed in the joint if perform ed w ithout
intra-articu lar region, and su bstantial joint sp ace narrow ing im aging gu id ance.

Figure 25.4 Cross-body adduction test. The client’s arm is orward f exed to 90°
and then horizontally adducted across the body. The literature is unclear on whether
this test is active or passive. This test is considered positive i it causes pain
localized to the ACJ. (From Powell & Huijbregts 2006, with permission.)
Figure 25.5 Acromioclavicular resisted extension test. The client’s shoulder
is f exed to 90°, then combined with maximal internal rotation and 90° o elbow
f exion. The client is then asked to abduct the arm horizontally against resistance.
This test is considered positive i it causes pain at the ACJ. (From Powell &
Huijbregts 2006, with permission.)
As a general p rinciple, im aging is only necessary w hen it
w ill change m anagem ent. For acu te injuries, history and clini-
cal exam ination w ill u su ally ru le ou t a fractu re or an ACJ
inju ry severe enou gh to requ ire su rgical intervention, and
therefore im aging is often not recom m end ed . If a fractu re
cannot be ru led ou t, or if the inju ry m ay bene t from su rgery,
stand ard ized rad iograp hs are essential to both the d iagnosis
and the classi cation (Shaffer 1999; Fraser-Mood ie et al
2008; N u ber & Bow en 2003; Docim o et al 2008; White et al
2008; Sim ovitch et al 2009). These rou tine im ages includ e: true
AP view s, axillary view s and the Zanca view (10–15° cep halic
tilt) (Shaffer 1999; Beim 2000; Garretson & William s 2003;
N u ber & Bow en 2003; Mehrberg et al 2004; Docim o et al 2008;
Diagnosis of the acromioclavicular joint 297
Figure 25.6 Paxinos sign. The patient sits with the arm relaxed by his / her side.
The examiner’s thumb is placed under the posterolateral aspect o the acromion;
the index and long ngers (same or contralateral hand) are then placed superior to
the mid-portion o the ipsilateral clavicle. The thumb applies an anterosuperior
orce concurrently while the ngers apply an in erior orce. This test is considered
positive i it causes or increases pain localized to the ACJ. (From Powell &
Huijbregts, 2006 with permission.)
Fraser-Mood ie et al 2008; Macd onald & Lap ointe 2008; Rios
& Mazzocca 2008; White et al 2008; Sim ovitch et al 2009).
View s w ou ld id eally be taken of the u ninvolved shou ld er to
p rovid e norm ative com p arison im ages (Shaffer 1999; Beim
2000; Garretson & William s 2003; Sim ovitch et al 2009).
Although stress view s of the ACJ have been d escribed to d if-
ferentiate betw een type II and typ e III inju ries, they are costly,
u ncom fortable, rarely ad d d iagnostic inform ation, d o not
affect m anagem ent and are thus no longer recom m end ed
for routine u se (Shaffer 1999; Beim 2000; Buss & Watts 2003;
Garretson & William s 2003; Petron & H anson 2007; Rios &
Mazzocca 2008; White et al 2008; Sim ovitch et al 2009). Rios
and Mazzocca (2008) p rop osed the u se of an AP rad iograp h
of the involved shou ld er w ith the arm ad d u cted across the
chest as a p rognostic tool. N orm al p ositioning, w here the
acrom ion d oes not overlap the clavicle, ind icates a stable joint
and d irects the clinician to non-su rgical m anagem ent. Sup er-
im position of the acrom ion and d istal clavicle suggests insta-
bility and m ay ind icate the need for su rgical intervention
(Rios & Mazzocca 2008).
In contrast to acute injuries, stand ard ized rad iographs
are often essential to both the d iagnosis and the classi cation
of non-acu te inju ries (Shaffer 1999; N u ber & Bow en 2003;
Docim o et al 2008; Fraser-Mood ie et al 2008; White et al
2008; Sim ovitch et al 2009). Com pu ted tom ography (CT)
can be u tilized w hen investigating arthritic osseou s changes
(e.g. joint narrow ing, erosions, su bchond ral cysts) (Docim o
et al 2008; Macd onald & Lapointe 2008). Som e au thors recom -
m end m agnetic resonance im aging (MRI) and u ltrasou nd
w hen investigating capsular hypertrophy, effu sions, su bchon-
d ral oed em a, subchond ral fractures and ligam entou s /
 298 PART 4 • 25 •
Table 25.1 Ps ychome tric data for ACJ phys ical e xamina tion te s ts
Active compre s s ion
Accuracy 0.53 1; 0.92 2; 0.97 3
Sens itivity 0.16 1; 0.41 2; 0.68 4; 1.0 3
Speci city 0.90 1; 0.93 3; 0.95 2
Pos itive predictive value 0.29 2; 0.62 1; 0.92 3
Negative predictive value 0.52 1; 0.97 2; 1.03
Pos itive likelihood ratio 1.61; 8.2 2; 13.3 3
Negative likelihood ratio 0.03; 0.6 2; 0.9 1
(Powell & Huijbregts 2006.)
1 Walton & Sadi (2008).
2 Chronopoulos et al (2004).
3 O’Brien et al (1998).
4 Maritz & Oos thuizen (2002).
ap oneu rosis inju ry (Shaffer 1999; N u ber & Bow en 2003;
Petron & H anson 2007; Docim o et al 2008; Fraser-Mood ie et al
2008; Macd onald & Lap ointe 2008). A recent stu d y u tilized
u ltrasou nd to id entify abnorm al m ovem ents in an inju red
ACJ that w ere not id enti ed on stand ard im aging or stress
rad iographs (Peetrons & Béd ard 2007; Rios & Mazzocca 2008).
Isotope bone scanning m ay be u sefu l in d iscrim inating the
sou rce of sym p tom s (Shaffer 1999; N uber & Bow en 2003;
Fraser-Mood ie et al 2008). Walton et al (2004) fou nd that bone
scans had relatively high sensitivity (82%) and speci city
(70%) in the d iagnosis of ACJ-related p ain.
Management of the Acromioclavicular
Joint
The goals of treatm ent for ACJ inju ries are achieving painless
range of m otion of the should er, obtaining fu ll strength
and exhibiting no lim itation in activity (Fraser-Mood ie et al
2008; Macd onald & Lapointe 2008; White et al 2008). Con-
servative m anagem ent is consid ered the stand ard of care for
non-acu te ACJ d ysfu nction and for typ es I and II ACJ inju ries
(Magee & Reid 1996; Brad ley & Elkousy 2003; Bu ss & Watts
2003; H ootm an 2004; Mehrberg et al 2004; Petron & H anson
2007; Sp encer 2007; Ceccarelli et al 2008; Docim o et al 2008;
Fraser-Mood ie et al 2008; Macd onald & Lapointe 2008; Rios
& Mazzocca 2008; White et al 2008; Tom et al 2009). Although
there is som e controversy over the treatm ents of typ e III
inju ries, m ost au thors now favou r non-su rgical intervention
(Magee & Reid 1996; Brad ley & Elkousy 2003; Bu ss & Watts
2003; Ru d zki et al 2003; H ootm an 2004; Mehrberg et al 2004;
Brukner & Khan 2006; Petron & H anson 2007; Sp encer 2007;
Ceccarelli et al 2008; Fraser-Mood ie et al 2008; Macd onald &
Lapointe 2008; Rios & Mazzocca 2008; White et al 2008;
Mu rena et al 2009; Sim ovitch et al 2009; Tom et al 2009).
Treatm ent of typ e III ACJ inju ries is d ep end ent on the inju ry
severity and activity level of the p atient. Su rgical intervention
is recom m end ed for typ es IV, V and VI and for p rotracted
p ain / d isability w ith ACJ d ysfu nction (Urist 1963; Brad ley &
Elkou sy 2003; H ootm an 2004; Mehrberg et al 2004; Petron &
Acromioclavicular joint
Cros s -b od y AC re s is te d ACJ te nde rne s s Pa xinos s ign
a dd uction e xte ns ion
0.792 0.84 2 0.531 0.651
0.772;1.0 4 0.72 2 0.954; 0.961 0.7 1
0.792 0.85 2 0.1 1 0.5 1
0.2 2 0.22 0.521 0.611
0.982 0.98 2 0.711 0.7 1
3.7 2 4.82 1.1 1 1.6 1
0.3 2 0.32 0.4 1 0.4 1
H anson 2007; Rabalais & McCarty 2007; Macd onald &
Lap ointe 2008; Rios & Mazzocca 2008; White et al 2008;
Sim ovitch et al 2009).
Conservative m anagem ent can involve rest, sp linting /
bracing, physical therapy (includ ing bu t not lim ited to m anu al
therap y, active rehabilitation, tap ing, m od alities inclu d ing
cold , heat, u ltrasou nd , laser, electrical stim u lation and ionto-
p horesis), ACJ corticosteroid injections and anti-in am m atory
and / or analgesic m ed ication (Magee & Reid 1996; Shaffer
1999; Brad ley & Elkou sy 2003; Bu ss & Watts 2003; Lem os &
Tolo 2003; Rud zki et al 2003; Bu ttaci et al 2004; Mehrberg et al
2004; Bru kner & Khan 2006; Cod si 2007; Petron & H anson
2007; Spencer 2007; Docim o et al 2008; Fraser-Mood ie et al
2008; Macd onald & Lapointe 2008; Rios & Mazzocca 2008;
White et al 2008; Sim ovitch et al 2009; Tom et al 2009). A
stru ctu red active rehabilitation p rogram m e that involves the
strengthening of the shou ld er gird le m u scles, inclu d ing the
d eltoid , trapeziu s, sternocleid om astoid and su bclaviu s as
w ell as the rotator cuff and p eriscapu lar stabilizers, is recom -
m end ed to p revent ongoing d isability in ind ivid u als w ith AJC
d ysfu nction / inju ry (Shaffer 1999; Brad ley & Elkou sy 2003;
Bu ss & Watts 2003; Fraser-Mood ie et al 2008; Sim ovitch
et al 2009).
The literatu re suggests that 80–90% of conservatively
m anaged ind ivid u als have good / satisfactory ou tcom es w ith
regard s to strength, m otion and retu rn to pre-inju ry levels of
function (Ru d zki et al 2003; H ootm an 2004; Macd onald
& Lap ointe 2008; Rios & Mazzocca 2008; White et al 2008;
Sim ovitch et al 2009). These stud ies u sed a variety of ‘con-
servative treatm ents’. Sim ovitch et al (2009) prop osed that
non-su rgical m anagem ent often translates into benign neglect
and su ggested that inad equate rehabilitation explains som e
of the failu res seen in non-su rgical m anagem ent. First, a
good / satisfactory ou tcom e in 80–90% of ind ivid u als d oes not
necessarily m ean that these su bjects are free of p ain or d ys-
function (Bjerneld et al 1983; Raw es & Dias 1996; Schlegel et al
2001); u p to one-third of those w ith typ e I and type II ACJ
injuries had pain on activity at longer term follow -up (Galp iri
et al 1985; Raw es & Dias 1996). Bergfeld et al (1978) fou nd that
30% of ind ivid u als w ith type I ACJ inju ry and 42% of ind i-
vid u als w ith typ e II ACJ inju ry rep orted clicking and p ain

w ith p u sh-u ps and d ips. An ad d itional 9% and 23% of ind i-
vid u als w ith typ e I and II inju ries resp ectively rep orted severe
p ain and lim itation of activities. Mou hsine et al (2003) reported
sim ilar resu lts, noting that 27% of ind ivid u als w ith type I and
II ACJ inju ries treated non-su rgically d eveloped chronic ACJ
sym ptom s at a m ean of 26 m onths p ost inju ry and required
su bsequ ent su rgery. Unsatisfactory resu lts have been rep orted
in 10–50% of ind ivid uals u nd ergoing conservative m anage-
m ent, at tim es lead ing to a change of job and / or m od i cation
of recreational activities, even p otentially requ iring su bse-
qu ent su rgery (Fraser-Mood ie et al 2008). These resu lts und er-
score the need for investigators and clinicians to p rovid e
d etailed inform ation about ‘conservative m anagem ent’ w hen
reporting their resu lts, ju st as a p roper evaluation of stu d ies
on p harm aceu ticals requ ires d etails on typ e, d ose and
frequency.
The im portance of ad equate rehabilitation w as show n in a
stu d y of the non-su rgical m anagem ent of typ e III ACJ inju ries
(Sim ovitch et al 2009). Glick et al (1977) investigated 35 u nre-
d u ced ACJ d islocations that w ere m anaged conservatively in
a professional and com p etitive recreational athletic popu la-
tion and noted that all ind ivid u als w ho had a su p ervised
rehabilitation program m e w ere pain free. They conclud ed
that the p red om inant reason for p ersistent p ain and d isability
after a typ e III ACJ inju ry m anaged conservatively w as inad -
equate rehabilitation. This prop osition is supp orted by Gu rd
(1941) w ho noted that the should er can fu nction norm ally
d espite an absent clavicle, as long as the should er gird le
m u scles are strengthened and m aintained .
Despite the success of conservative treatm ent for the vast
m ajority of inju ries, there are ind ications for su rgery. These
inclu d e: ACJ tend erness w ith (1) evid ent abnorm al signs on
ACJ im aging results such as those seen in types IV, V and VI
ACJ inju ries, (2) a lack of resp onse to conservative m anage-
m ent and (3) an u nw illingness or inability to m od ify, or
refrain from , d em and ing physical activity (e.g. overhead
sp orts, w eight-training, m anu al labou r) (Shaffer 1999;
Schw arzkop f et al 2008; White et al 2008). When ind icated ,
su rgical ou tcom es are also su ccessfu l bu t tend to have higher
rates of com plications, longer convalescence and longer
p eriod s aw ay from w ork and sports (Petron & H anson 2007;
Spencer 2007). There are m any surgical options for m anaging
ACJ d ysfu nction and inju ry, includ ing bu t not lim ited to open
or arthroscop ic p roced u res, d istal clavicle resection, p rim ary
xation of the ACJ, second ary stabilization of the ACJ via a
linkage betw een the clavicle and coracoid p rocess, d ynam ic
stabilization of the ACJ via a m u scu lotend inou s (inferiorly
d irected force) transfer from d istal clavicle to the coracoid
p rocess, ligam ent transfers and soft tissu e reconstru ctions,
and anatom ical reconstru ction (Magee & Reid 1996; Shaffer
1999; Brad ley & Elkousy 2003; Bu ss & Watts 2003; Kw on
& Iannotti 2003; N u ber & Bow en 2003; Bu ttaci et al 2004;
Mehrberg et al 2004; Petron & H anson 2007; Rabalais &
McCarty 2007; Docim o et al 2008; Macd onald & Lap ointe
2008; White et al 2008; Sim ovitch et al 2009; Murena et al 2009;
Tom et al 2009).
A w id e variety of su rgical techniqu es have been d e -
scribed , bu t none has been show n to be signi cantly su p erior
(Fraser-Mood ie et al 2008). The later m inim ally invasive tech-
niqu es are rep orted to show p rom ise, bu t w ell-d esigned p ro-
sp ective stu d ies need to be p erform ed (Fraser-Mood ie et al
2008; White et al 2008). Tim ing of su rgery is controversial,
Conclusion 299
w ith som e authors ad vocating early reconstru ction and others
ad vocating that su rgery be reserved for chronic sym ptom atic
p atients (Weinstein et al 1995; Brad ley & Elkou sy 2003; Bu ss
& Watts 2003). Weinstein et al (1995) noted a trend to better
ou tcom es w hen ligam ent reconstru ction w as d one w ithin the
rst 3 w eeks after inju ry. Du m ontier et al (1995) fou nd no
d ifference betw een early (< 3 w eeks) and late ligam entou s
reconstruction.
The evalu ation of su ccess or failure for a surgical interven-
tion m u st inclu d e com p lications. Su rgical com p lications
inclu d e bu t are not lim ited to: hard w are failu re and m igra-
tion, neu rovascu lar inju ry, infection, fractu re and osteolysis
(Shaffer 1999; Brad ley & Elkou sy 2003; Kw on & Iannotti 2003;
Lem os & Tolo 2003; N u ber & Bow en 2003; Ru d zki 2003;
Petron & H anson 2007; Fraser-Mood ie et al 2008; Rios &
Mazzocca 2008; White et al 2008; Sim ovitch et al 2009). Many
su rgical op tions exist for the ACJ region and their goal is to
m inim ize sym p tom s and m axim ize long-term fu nction
(Brad ley & Elkousy 2003; Kw on & Iannotti 2003). Brad ley and
Elkou sy (2003) rep orted that there is no correlation in the
literatu re betw een anatom ical red uction and im provem ents in
p ain, strength or m otion. Fraser-Mood ie et al (2008) note that,
even though the m any varied su rgical techniqu es record a low
rate of failu re, the m ultiplicity of p roced ures, the lack of a
generally accepted surgical m ethod and the num ber of reports
ou tlining the sp eci c su rgical com p lications infer that all ACJ
su rgical techniqu es carry a su bstantial risk of failu re of the
im plant, lead ing to resu blu xation of the joint. Partial resu b-
luxation is not necessarily associated w ith poor ou tcom es and
is often m anaged conservatively (Fraser-Mood ie et al 2008).
Com p lete resu blu xation is associated w ith resid u al sym p -
tom s, and there are rep orts of su ccessfu l revision op erations
(Fraser-Mood ie et al 2008).
Conclusion
The vast m ajority of ACJ inju ries are m inor (grad es I–II, w ith
CC ligam ents intact) and recover fu lly w ith ad equ ate con-
servative m anagem ent. Stu d ies com p aring ad equ ate rehabili-
tation w ith su rgery for grad e III inju ries (CC ligam ents
d isrup ted ) also sup port the role of ad equate rehabilitation as
the p rim ary treatm ent. The m ore severe inju ries (e.g. p osterior
or inferior d isp lacem ent of the clavicle) are rarer and there is
som e research su ggesting these inju ries shou ld be treated su r-
gically. Areas that are m ost likely to bene t from m ore
research includ e:
• long-term prognosis: stu d ying the sequelae of ACJ
injury w ith valid ated relevant outcom e m easu res
(H ootm an 2004)
• diagnostic testing: stu d y of the valid ity of new er
d iagnostic m anoeuvres su ch as Paxinos sign and cross-
arm ad d u ction AP rad iographs (Rios & Mazzocca 2008)
and und erstand ing how best to com bine the resu lts of
d ifferent tests for m aking m anagem ent d ecisions
• conservative treatment: the com parison of d ifferent
typ es of su p ervised rehabilitation in the m anagem ent
of typ es I, II and III ACJ inju ry and in chronic ACJ
d ysfunction (H ootm an 2004; Spencer 2007; Ceccarelli
et al 2008; Macd onald & Lapointe 2008; Sim ovitch et al
2009)
 300 PART 4 • 25 • Acromioclavicular joint
• surgical treatment: the tim ing of surgical interventions,
inclu d ing w hether there are som etim es ind ications for
early su rgical intervention w ith typ e III ACJ injury (Rios
& Mazzocca 2008).
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Sternoclavicular Joint
26  Chapter 
Erla n d P e ttm a n
CHAP TER CONTENTS
Introduction  302
Anatomy of the sternoclavicular joint  302
Biomechanics of the sternoclavicular joint  304
Pathology of the sternoclavicular joint  304
Patients requiring a medical / surgical consultation  304
Patients with indication for physical therapy intervention  305
Diagnosis of the sternoclavicular joint  305
Management of the sternoclavicular joint  306
Anterior disc / manubrial rotation mobilization (left shoulder)  306
Posterior disc / manubrial rotation mobilization (left shoulder)  306
Inferior clavicular / disc glide (right shoulder)  306
Posterior clavicular / disc glide (right shoulder)  306
Adjunct exercises  307
Conclusion  307
Introduction
A literatu re search on the sternoclavicu lar joint rap id ly m akes
the read er aw are that there are a very lim ited nu m ber of
p u blications on this joint and these p red om inantly cover
m ed ical and su rgical concerns. Anatom ical and biom echani-
cal references are d esigned , m ost often, to su p p ort m ed ical or
su rgical interventions. From a p hysical therap y p ersp ective,
this joint w ou ld therefore ap p ear to be the ‘p oor cou sin’ of the
shou ld er gird le in both interest and research. H ow ever, w hilst
bem oaning this fact, the reason alm ost certainly lies in the
joint’s inherent strength and stability. These factors w ill be
covered in the sections on anatom y and biom echanics.
What is m ost interesting to the w riter, how ever, is this
joint’s proposed ability to w ork in concert w ith the thoracic
sp ine to facilitate the fu nction of elevation throu gh exion /
abd u ction w ithou t com p rom ise to the neu rovascu lar stru c-
tu res that su p p ly the u p p er lim b. With resp ect to ou r u p p er
lim bs, w e m u st accep t the fact that they enable u s to be
p rim ate ‘brachiates’ (i.e. w e are able to locom ote w ith ou r
u p p er lim bs). Althou gh as w e get old er and heavier this
seem s an u nlikely p rem ise, w e need m erely to view child ren
at a playgrou nd or to stu d y gym nasts to realize this is at least
one of the fu nctions of the hu m an u p p er lim b and som ething
w e have in com m on w ith all other prim ates.
 
All anatom y texts that the au thor has read d escribe the
shou ld er gird le as ‘end ing’ at the m anu briu m . Em p hasis is,
therefore, p laced on how the clavicle m oves at the sternom an-
u brial articu lation. The au thor ’s p ap er entitled ‘The fu nctional
shou ld er gird le’ (Pettm an 1984) inferred that, d uring fu nc-
tional m ovem ents of the shou ld er gird le, there is ind eed
another biom echanical com ponent to this joint that need s to
be consid ered – manubriosternal m otion (i.e. that d ictated by
the thoracic sp ine). Given the d earth of biom echanical research
regard ing this joint, this chapter m u st rst present a p roposed
biom echanical m od el, based on observation and palpation,
w hich m ight lead to further research. Within this p roposal
w ill be a clinically reasoned explanation of how thoracic
and / or sternoclavicu lar d ysfunction m ay d irectly affect
glenohu m eral joint fu nction.
Anatomy of the Sternoclavicular Joint
Descriptive anatom y of this joint is w ell covered in texts such
as Gray’s anatomy (Stand ring 2008). Therefore, the em phasis
here shou ld be on fu nctional and com p arative anatom y. In
em bryological d evelopm ent the clavicle is present in alm ost
all m am m als. H ow ever, in qu ad rup ed s the clavicle becom es
a vestigial or ru d im entary stru ctu re help ing to p rovid e m u scle
attachm ents that prod u ce a m u scular ‘sling’ to su pp ort the
w eight of the thorax, neck and head . A fu lly d eveloped ,
osseou s clavicle that connects the scap u la to the m anu briu m
only exists in p rim ates. This bony stru t enables p rim ates to
enjoy a very large range of up per lim b m otion, especially
aw ay from the m id line of the bod y. Such m otion gives pri-
m ates the fu nctional ad vantages of grasp ing, thru sting
(throw ing or pu nching) and brachiation (sw inging).
Sp ecialization of fu nction w ithin d ifferent p rim ate grou p s
ap pears to d epend u pon the position of the scapu la bone
(lateral or posterior to the thorax) (Chan 2007) and the
cu rvatu re(s) of the clavicle (Voisin 2006). The d istinctive ‘S’
shap e of the hu m an clavicle has been likened to a ‘crank’. This
enables our m u scles to su pport a relatively heavy bod y w eight
d u ring brachiation, but also to increase the pow er and veloc-
ity of upp er lim b m ovem ents su ch as throw ing. H ow ever,
that sam e ‘S’-shap ed clavicle d oes p oorly w ith resp ect to com -
p ressive load ing – its w eak spot being the ju nction betw een
the m ed ial convexity and its lateral concavity. This fact is
u nd erscored by the nd ing that this m id -shaft region is the

m ost p revalent site for clavicu lar fractu res d u ring com p res-
sive load ing, su ch as a fall d irectly onto the shou ld er or the
ou tstretched hand (Denard et al 2005). Most fractures of this
region are u ncom p licated , but on rare occasion m ay lead to
brachial plexu s involvem ent, p ulm onary d ysfunction or even
d eath (Kend all et al 2000).
The m ed ial end of the clavicle bone p resents a large,
bu lbous head . Its su rface is concave horizontally and convex
vertically, giving it a sad d le-shap ed ap p earance. H istological
analysis of the clavicu lar head (Ellis & Carlson 1986), at
least d evelop m entally, show s p lates of cartilage w ithin the
bone; this is a d irect com p arison w ith the head of the m and i-
ble (Wolford et al 1994) – as both are presum ably d esigned
to absorb extrem e stresses and strains. The corresp ond ing
su rface of the sternu m has, recip rocally, an obviou s concave
su rface vertically and a slight convexity horizontally. Since
the articu lating su rface of the clavicu lar head is over tw ice
that of the m anu brial su rface, this ap p arent incongru ence,
although enabling large am p litud e of m otion, m akes the
joint potentially very unstable. It is the role of the joint’s liga-
m entou s stru ctu res to m aintain stability (Iannotti & William s
1999). Ligam ents of the sternoclavicu lar joint includ e the
intra-articu lar ligam ent or d isc, the interclavicu lar ligam ent,
the cap su lar (su p erior) ligam ent and the costoclavicu lar
ligam ent.
There is som e d isagreem ent over w hether this intra-
articular ligam ent serves prim arily as a ligam ent or as an
intra-articu lar d isc, and this w ill be d iscussed later. The
d ense brous stru ctu re has a strong peripheral capsu lar
attachm ent that com p letely d ivid es the joint into sep arate
cavities (DePalm a 1959), w hich in itself hints at a d iscrete
fu nction for each of the joint’s cavities. Occasionally, there
m ay be som e central connection betw een the tw o joint cavi-
ties, bu t this is believed to be second ary to w ear and tear.
Inferiorly, the d isc arises from the synchond rosis of the rst
rib cartilage and the m anu briu m . Su periorly, it attaches to the
su p erior and m ed ial asp ects of the m ed ial clavicle at the
lateral joint m argin, bu t blend s w ith the bres of the capsular
(su perior) ligam ent.
The interclavicu lar ligam ent, as its nam e suggests, blend s
w ith the sam e ligam ent of the opposite sid e. Also, it is attached
to the su p erior p art of the m anu briu m and blend s w ith the
ipsilateral cap su lar (su perior) ligam ent.
The cap su lar (sup erior) ligam ent, w hich is perhaps the
strongest of the sternoclavicu lar joint ligam ents, really rep re-
sents anterosu p erior and p osterior reinforcem ent (or thicken-
ing) of the articular capsu le, the anterosuperior being the
thickest.
Working in concert, these above three ligam ents afford
both strength and static stability to the sternoclavicular joint
w ith the shou ld er gird les in a resting, w eight-d epend ent
position. This has been referred to as ‘shou ld er p oise’ w here
the d istal end of the clavicle is p assively su p p orted slightly
higher than its m ed ial end . As a p assive su p p ort m echanism ,
this rep resents a signi cant saving in m u scu lar energy
expend itu re to help carry objects either on the should er
gird les (e.g. a yoke, satchel and even a child ) or by hand (e.g.
hu nted gam e, w ater containers and su itcases). Also, this
passive shou ld er poise is essential for ef ciency d uring
m anu al activities that requ ire m inim al shou ld er gird le excu r-
sion (e.g. m ou ld ing clay, cooking and u sing the com p u ter
m ou se). With regard to stability, the m ost im p ortant of the
Anatomy of the sternoclavicular joint 303
above three ligam ents ap pears to be the capsu lar (su p erior)
ligam ent. Cad averic experim ents (Bearn 1967) have clearly
d em onstrated that static ‘clavicu lar poise’ is ind epend ent
of m yofascial su p p ort, or even su p p ort from the interclavicu -
lar and intra-articu lar d isc ligam ents. Once the cap su lar
ligam ent is torn, m inim al force is need ed to tear the intra-
articu lar ligam ent, lead ing to su perior d islocation and d isru p-
tion of the sternoclavicu lar joint. If the p osterior p art of the
cap su lar ligam ent also fails then p osterior d islocation is p os-
sible, w hich m ay lead to m ore seriou s health or even life-
threatening com p lications d u e to com p ression of m ed iastinal
stru ctu res.
The costoclavicu lar ligam ent is also called the rhom boid
ligam ent becau se of the orientation of its bres. For this liga-
m ent, there ap p ears to be som e d isagreem ent as to its actu al
m orp hology (Tu bbs et al 2009). Trad itionally the ligam ent has
been d escribed as a ‘ attened ’ cone. The best w ay to visualize
this is to take a p olystyrene p ap er cu p and d raw obliqu e p ar-
allel lines arou nd its p erim eter. If it w ere then squ ashed at,
the d raw n lines w ou ld resem ble a rhom boid if view ed from
anterior and p osterior; how ever, the lateral and m ed ial
m argins of the cu p w ou ld ap p ear to continu e the sp iralling
lines originally d raw n. As su ch, the bres of the ligam ent
w ould ind eed be cap able of resisting clavicu lar m otion in all
d irections and planes except for one: d epression of the clavicle
in neutral. The argum ent w ithin the literature regard ing its
m orp hology is abou t w hether there is an interp osing bu rsa
(or sp ace) betw een the anterior and posterior sets of bres or
w hether they form one solid m ass. Regard less of the orienta-
tion, this ligam ent’s bres are clearly d esigned to resist any
m otion of the clavicle aw ay from its neu tral ‘p oise’. The ante-
rior bres appear p articularly vulnerable to excessive eleva-
tion and p rotraction of the shou ld er gird le, w hich this au thor
believes, from cad averic observation, is consid ered the close-
p acked p osition of the sternoclavicu lar joint.
Du ring fu ll elevation of the hum eru s (throu gh exion /
abd u ction) the should er gird le (scapu la and clavicle) m oves
into d epression and retraction. The d isagreem ent over
w hether the clavicle elevates or d epresses (Lu d ew ig et al
2004) is probably the resu lt of d ifferent instru ctions given to
the observed m od els. If the m od el is asked to elevate their
hand as high as he / she can then elevation of the clavicle w ill
result; how ever, this au thor believes that functional elevation
requ ires a stable, d epressed clavicle.
Du ring full elevation, recru itm ent of the low er trapeziu s
m u scle coincid es w ith activation of su bclaviu s m u scle
(Konstant et al 1982). This w ould m ake sense as the m otion
p robably coincid es w ith the greatest stress p laced on the ster-
noclavicu lar joint for either throw ing or brachiation. The
‘shu nt’ action of su bclaviu s w ou ld now be m ost approp riate
in term s of stability of the sternoclavicu lar joint. In this
au thor ’s exp erience, m ost costoclavicu lar ligam ent inju ries
(treatable by physical therap y) occur w hen there is a forceful
elevation thrust of the arm together w ith a correspond ing
elevation and protraction of the shou ld er gird le. In this cir-
cu m stance, the forced lateral d isp lacem ent of the clavicle
w ould not be resisted by the appropriate re ex shunt action
of su bclaviu s, rend ering the anterior bres su scep tible to
d am age. Ind ivid u als w ho m ight perform su ch an action are
lim ited to certain athletes (e.g. shot p utters, javelin throw ers,
racqu et p layers), bu t also those perform ing hou sehold tasks
(e.g. cleaning a bathtub, painters).
 304 PART 4 • 26 • Sternoclavicular joint
Biomechanics of the Sternoclavicular
Joint
At the sternoclavicular joint, the clavicle is clearly cap able of
m oving throu gh at least tw o card inal p lanes – that is, the
horizontal (35° of com bined p rotraction and retraction) and
vertical (30–35° d egrees of elevation) p lanes (Iannotti &
William s 1999). The joint is therefore consid ered to p ossess
tw o d egrees of freed om , w hich are both p u re sw ings. The
largest d isp lacem ent, how ever, is 45–50° of rotation (Iannotti
& William s 1999; Lu d ew ig et al 2004) arou nd the long axis of
the clavicle (i.e. m otion throu gh a sagittal p lane), bu t this
au thor w ond ers w hether this can tru ly be consid ered a d egree
of freed om ?
As m entioned earlier, the joint is clearly d ivid ed into tw o
sep arate anatom ical com p artm ents, su ggesting tw o sep arate
fu nctions (sim ilar to the tem porom and ibular joint). If the pos-
terior ed ge of the lateral end of the clavicle is p alp ated d u ring
insp iration and exp iration, rotation of the bone is clearly felt.
This is because the clavicle is ‘crank’ shaped , and , as the
m anu briu m rises w ith insp iration, elevation of the m ed ial end
of the clavicle p rod u ces a p osterior rotation arou nd its longi-
tu d inal axis. Since there is no other obviou s d isp lacem ent of
the clavicle (shou ld er gird le), it is assu m ed that the rotational
m otion at the sternoclavicu lar joint occu rs w ithin the m ed ial
com p onent (d isc / m anu briu m ) of the joint. So it cou ld w ell
be argu ed that the sternoclavicular joint com p lex has, ind eed ,
three d egrees of freed om of m otion.
The large, su p er cial head of the clavicle is easily p alp ated
d u ring m otion of the shou ld er gird le on a relatively stationary
m anu briu m . From fu ll retraction tow ard s p rotraction, the
m ost obviou s m otion initially ap p ears as a p osterior m ale
(convex on concave) glid e, but this glid e occu rs only throu gh
the rst tw o-third s of the range (from fu ll retraction to
neu tral p oise). After that p oint, as p rotraction continu es an
anterior rotation is ap parent, rep resenting a fem ale (concave
on convex) glid e.
A sim ilar change in glid es is ap p arent w hen the joint
is p alp ated from fu ll d ep ression to fu ll elevation of the
shou ld er gird le – w here there is an initial inferior m ale glid e
follow ed by a sup erior anterior fem ale glid e. Und erstand ing
that the m ale m otion occu rs at the d isc / clavicle com p onent
and the fem ale m otion arises from the d isc / m anu brium com -
p onent allow s the clinician to u se a very sim p le p alpatory
assessm ent techniqu e to d iscern w hich com p onent is in d ys-
fu nction, or ind eed w hether the w hole com plex m ight be
d eranged .
Consid ering the d earth of biom echanical research relevant
to p hysical therap y, at this p oint the au thor sees t to p rop ose
the follow ing interaction betw een clavicu lar m otion and
m anu brial m otion d u ring elevation of the arm throu gh exion
and abd u ction, based on clinical experience and extrap olation
of anatom ical know led ge. As the arm is elevated throu gh
exion / abd u ction, the initial m otion appears to occur at the
glenohu m eral and acrom ioclavicular joints on a relatively
xed clavicle. The inferior angle of the scap u la d isp laces later-
ally and anteriorly to p rod u ce an u pw ard rotation of the
scap u la and its glenoid su rface, the m otion occu rring at
the acrom ioclavicu lar joint. At abou t 150° of elevation, the
inferior angle stops m oving. Presu m ably xated by an isom et-
ric contraction of the low er serratu s anterior m u scle, the axis
of shou ld er gird le m otion now shifts from the acrom iocla-
vicu lar joint to the sternoclavicu lar joint and the shou ld er
gird le is seen to d epress and retract in the last 30–50° of arm
elevation. It m ight be reasonably assu m ed that the clavicle
shou ld signi cantly rotate p osteriorly. H ow ever, if the clavi-
cle is p alp ated d u ring this term inal range then m inim al, if
any, rotation is sensed . To solve this app arent conu nd ru m ,
one m u st now stu d y w hat is occu rring at the m anu briu m .
As the arm is elevated beyond 150°, u pper thoracic m otion
can be both seen and p alp ated . The u p p er thoracic sp ine
extend s, ipsilaterally rotates and sid e-bend s tow ard s the
m oving arm . The rst thoracic vertebra, rst rib and m anu -
brium now all m ove in concert, d ictated by thoracic spine
m otion. This is easily felt at the m anu briu m by p alp ating
bilaterally ju st below the rst rib cartilage. The m anu briu m
also sid e-bend s and rotates tow ard s the elevating arm . So the
m anu briu m is now m oving u nd er the clavicle, p rod u cing a
relative anterior rotation of the sternoclavicular joint. This
sim u ltaneou s m otion of both the clavicle and the m anu briu m
ensures that there is no resu ltant p osterior rotation of the
clavicle. The m ain qu estion now is: w hy w ou ld this be
necessary?
The d eep cervical fascia blend s w ith the posterior and
su p erior p eriosteu m of the clavicle. If the clavicle w ere to
rotate posteriorly u p to 45°, as has been su ggested , the d eep
cervical fascia w ou ld u nd ergo an extrem e increase in tension,
p otentially com p rom ising the neu rovascu lar tissu e p assing
throu gh it – a d istinct d isad vantage for a brachiator.
Although not strictly a sternoclavicular joint d isru ption or
injury, an inability of the thoracic spine to m ove approp riately
d u ring the nal stages of arm elevation w ould p revent the
d isc / m anubrium com ponent of the sternoclavicular joint
from d erotating the clavicle. Clinically, ind ivid u als w ho
p erform habitu al or su stained arm elevation in their recrea-
tional or w ork environm ent w ou ld p otentially com p lain of
signs or sym p tom s of abnorm al neu ral tension w ithin the arm
and / or d am age to d istal shou ld er gird le structu res from
m echanical com p ensation. For this reason, assessm ent of tho-
racic and m anu brial m otion should be a rou tine part of shou l-
d er gird le assessm ent.
Pathology of the Sternoclavicular Joint
For the physical therapist, pathologies of the sternoclavicu lar
joint are best d ivid ed into tw o m ain sections: those requ iring
a m ed ical / su rgical consultation and those w ith an ind ication
for p hysical therapy intervention.
Patients requiring a medical / surgical
consultation
The sternoclavicu lar joint is su sceptible to any of the patholo-
gies that affect synovial joints (Iannotti & William s 1999;
H igginbotham & Khun 2005). Whilst not attem pting an exact
m ed ical d iagnosis, the therap ist need s nevertheless to be able
to id entify p atients su ffering from seriou s trau m atic inju ries
and non-trau m atic or d egenerative arthritic cond itions.

Dislocations, although u ncom m on, represent the greatest
threat to articu lar fu nction. They can occu r in anterior, su p e-
rior and p osterior d irections. Dislocations can be the resu lt of
d irect trau m a to the clavicle or m anu briu m , as m ay occur in
m otor vehicle accid ents or sp orts. They can also resu lt from
ind irect traum a, especially to the posterolateral should er
(su perior and p osterior d islocations) and anterolateral shou l-
d er (anterior d islocations) (Iannotti & William s 1999).
The posterior d islocation is of greatest concern becau se
of the threat to retrosternal stru ctu res su ch as the trachea
and m ajor blood vessels (Rod rigu es 1843; Worm an & Laegu s
1967; Coop er et al 1992). If these stru ctu res are involved
the p atient m ay w ell be observed as having breathing p rob-
lem s and changes in skin colour d u e to vascu lar or airw ay
com p rom ise.
Dislocations tend not to be su btle. The therapist m ay
su sp ect them from a history of extrem e trau m a, a gross loss
of m otion of the u p p er lim b, and an obviou s observable and
p alpable change in the natural contours of the sternoclavicu-
lar joint. Du ring palp ation of m otion (d escribed later) the
therap ist m ay d etect gross d isru p tion of the anticip ated (m ale-
to-fem ale) m otion sequ ence.
Althou gh the clavicle is the rst long bone to begin ossi ca-
tion, it is the last to com p lete it. The ep ip hysis of the m ed ial
end of the clavicle ossi es in the 18th–20th year and fuses
w ith the shaft betw een the 23rd and 25th years. Direct and
ind irect traum a to the m ed ial end of the clavicle m ay result
in epiphyseal d isrup tion, even fracture; these closely resem ble
the p resentation of a d islocation, and only m ed ical exam ina-
tion can p rovid e an accu rate d ifferential d iagnosis (Iannotti &
William s 1999).
H yperostosis at the sternoclavicular joint (Dihlm ann et al
1993; N oble 2003), felt initially by the therapist as an apparent
bony hypertrophy of either the clavicu lar head or the m anu -
brium , could signify seriou s pathology and a m ed ical consu lt
is certainly w arranted (Fritz et al 1992). H ow ever, the au thor
has seen tw o cases of p hyseal trau m a w here fractu re or d is-
ru p tion w ere ru led ou t bu t the trau m a resu lted in benign
hyp erostosis of the head of the clavicle. Ap art from the d is-
tressing cosm etic ap p earance, joint fu nction and stability in
these tw o cases ap p eared norm al.
The sternoclavicu lar joint has been show n to suffer from
alm ost all p otential cau ses of non-trau m atic arthritis, the m ore
com m on of these inclu d ing sep tic arthritis, rheu m atoid arthri-
tis, tu bercu losis and ankylosing sp ond ylitis. The au thor has
rarely seen gouty arthritis as is m entioned in the literature
(Kearn et al 1999), bu t clearly it cannot be ru led out. H ow ever,
the p resentation of a p ainfu l, hot and sw ollen joint w ith no
history of inju ry shou ld im m ed iately raise enou gh concern for
the therap ist to requ est a m ed ical consu ltation.
Patients with indication for physical
therapy intervention
These p atients w ill includ e those w ith sprains and strains of
the sternoclavicu lar joint. Acu te trau m atic arthritis m ay
present w ith enough p ain, sw elling and d ysfu nction that a
m ed ical consu lt shou ld be sou ght. They are m ost effectively
treated w ith a resting sling and su bsequ ent referral to p hysi-
cal therap y.
Diagnosis of the sternoclavicular joint 305
The location of pain from sternoclavicu lar joint inju ry is
m ost com m only w ithin the joint itself, bu t d istal referral
(e.g. to the neck, shou ld er and arm ) is also p ossible (H assett
& Barnsley 2001). With subacute and chronic (traum atic)
arthritis, the therapist’s m ain concern is w hether joint m otion
has been lost, and if so assess w hich com p onent of the joint
is resp onsible.
Another concern w ould be the possibility of a ligam entou s
sp rain. The au thor is u naw are of any con rm ed d iscrete
tests for the intra-articu lar d isc ligam ent, cap su lar ligam ent
or interclavicu lar ligam ent. H ow ever, if articu lar m otion is
norm al bu t localized p ain is rep rod u ced by overp ressu re of
shou ld er gird le m ovem ents, a ligam entou s inju ry m u st be
su sp ected . Accu rate p alp ation follow ed by d eep transverse
friction m assage (DTFM) and u ltrasou nd w ou ld app ear to be
the treatm ent of choice.
Unlike the other ligam ents, the costoclavicular ligam ent
can be stressed d iscretely. With the p atient in contralateral
sid e-lying, the therap ist m oves the (affected sid e) gleno-
hu meral joint into extension and ad d u ction. Ap p lying p res-
su re throu gh the elbow, the therap ist then p u shes the shou ld er
gird le into full elevation and protraction. Continu ed pressu re
throu gh the p atient’s elbow now p rovid es a lateral d istractive
force to the sternoclavicu lar joint, m axim ally stressing the
costoclavicu lar ligam ent. In this au thor ’s op inion and exp eri-
ence, the anterior bres are those m ost likely to be inju red .
They are accessible to DTFM if the shou ld er gird le is p osi-
tioned into d ep ression and retraction (p osterior rotation of
the clavicle).
Osteoarthrosis is su sp ected w hen crep itation or even
‘clunking’ is d etected d uring m otion palpation. One p aper on
cad averic d issection of the sternoclavicu lar joints (H agem ann
& Ruttner 1979) su ggested that 80% of people over 50 m ay
have osteoarthrosis of this joint. H ow ever, as cad averic d is-
section can rarely be correlated w ith sym p tom s, it is u nclear
for how m u ch sym ptom atology this cond ition is responsible.
In the au thor ’s experience, m inor, asym ptom atic joint crepita-
tion is com m on in the p resence of norm al joint fu nction and
shou ld p robably be ignored . H ow ever, if the crep itation or
clu nking is signi cant, or corresp ond s to the rep rod u ction of
the p atient’s sym p tom s, then a m ed ical consu lt shou ld be
sought. The d egenerative state of the joint m ay help in an
eventu al prognosis, bu t also in d eterm ining the appropriate
m agnitu d e of force u sed in p hysical therap y p roced u res (Frosi
et al 2004). It is w orth rem em bering that all resisted forces on
the u p p er lim b m u st u ltim ately be transferred to the sterno-
clavicu lar joint.
Diagnosis of the Sternoclavicular Joint
As w as inferred earlier, the size of the clavicu lar head , cou pled
w ith the fact it is located so su per cially, enables the therapist
to p alp ate sternoclavicu lar joint m otion easily. Follow ing the
taking of a history and observation, the therap ist p alp ates the
anterior surface of the head of the clavicle.
From a p osition of fu ll retraction, the patient is instructed
to p u ll the shou ld er gird les into p rotraction. In norm al
m otion, the therap ist shou ld be able to feel the head of the
clavicle m ove initially p osteriorly (m ale clavicu lar / d isc
 306 PART 4 • 26 •
Figure 26.1 Mobilization for anterior rotation of the female component
(elevation and protraction).
m otion). At the p osition of neu tral ‘p oise’ the m otion shou ld
be felt to change to a fem ale (d isc / m anubrial m otion) ante-
rior glid e (roll). From a position of fu ll d epression, the patient
is instru cted to lift the shou ld er gird les into elevation. In
norm al m otion, the therap ist shou ld be able to feel the head
of the clavicle m ove initially inferiorly (m ale clavicu lar / d isc
m otion). At m id -range this m otion is felt to change to a fem ale
su p erior / anterior roll. This sim p le test enables the therap ist
to d ecid e w hich articu lar com p onent is lacking.
Management of the Sternoclavicular
Joint
Op tions for p hysical therap y m anagem ent have been p ro-
vid ed above in the section on p athology. The em p hasis in this
section w ill be on m anu al therap y intervention and ad ju nct
exercises for patients w ith m echanical sternoclavicular joint
d ysfunction. Techniques ad d ress either d isc / m anu brial
restrictions (anterior and posterior rotation) or clavicular / d isc
restrictions (inferior glid e and posterior glid e).
Anterior disc / manubrial rotation
mobilization (left shoulder)
The patient is placed on the right sid e lying facing the thera-
p ist. The therap ist stand s facing the p atient. The therapist’s
left m id d le and ring nger tip s are tu cked p osterior and infe-
rior to the lateral ed ge of the patient’s left clavicle. The thera-
p ist’s right hand grasp s the inferior angle of the scapu la; the
left hand p assively d raw s the p atient’s left shou ld er gird le
into elevation and p rotraction u ntil anterior rotation is sensed
to cease (Fig. 26.1).
The therap ist instru cts the p atient to take a short in-breath,
follow ed by a long ou t-breath. As the p atient breathes out,
increased anterior rotation of the clavicle is taken u p by p as-
sively increasing elevation and p rotraction, and also by the
therap ist’s left hand p u lling the p osterior ed ge of the clavicle
u p w ard and forw ard . The p roced u re is rep eated u ntil no
fu rther m otion can be elicited .
Sternoclavicular joint
Figure 26.2 Mobilization of posterior rotation of the female component
(depression and retraction).
Posterior disc / manubrial rotation
mobilization (left shoulder)
The patient’s starting position is the sam e as d escribed above.
In this techniqu e, and in contrast to the above technique for
anterior rotation, the therapist’s m id d le and ring ngers are
over the su p erior asp ect of the p osterior ed ge of the lateral
clavicle. The therap ist m oves the shou ld er gird le into d ep res-
sion and retraction u ntil p osterior rotation of the clavicle
ceases (Fig. 26.2).
The patient is instru cted to take a short out-breath follow ed
by a long in-breath. As increased posterior rotation of the
clavicle is d etected , the therap ist p u shes the p atient’s shou l-
d er gird le into fu rther d epression and retraction w ith an
accom panying p ush on the posterior ed ge of the clavicle infe-
riorly by the therapist’s left ngers. This proced u re is repeated
u ntil no fu rther m otion can be elicited .
Inferior clavicular / disc glide (right shoulder)
The p atient is su pine. The therapist is stand ing ad jacent to the
p atient’s op p osite shou ld er gird le. The therap ist’s left thu m b
p ad or thenar em inence is p laced over the su p erior asp ect of
the head of the p atient’s right clavicle. The therap ist’s right
hand d raw s the p atient’s right shou ld er gird le into elevation
u ntil the inferior glid e of the clavicu lar head ceases (Fig. 26.3).
The therapist then instru cts the patient to resist an attem pt
to p u sh the right shou ld er gird le into d ep ression. An inferior
glid e of the right clavicular head w ill be d etected and this
m otion slack is taken u p by p ressu re from the therap ist’s left
thu m b. Any slack in right gird le elevation is now taken u p by
the therap ist’s right hand . This p roced u re is rep eated u ntil no
further m otion is perceived .
Posterior clavicular / disc glide
(right shoulder)
The patient is su pine. The therap ist stand s on the opposite
sid e to the joint being treated , then grasp s the p atient’s right
shou ld er w ith the left hand and instru cts the p atient to p lace

Figure 26.3 Mobilization of the inferior male glide (elevation).
Figure 26.4 Mobilization of the posterior male glide (protraction).
his / her right hand on the therap ist’s left arm . The therap ist’s
right thu m b or thenar em inence is placed over the anterior
su rface of the head of the p atient’s right clavicle (Fig. 26.4).
The p atient is instructed to resist the therap ist’s attem pt to
pu sh the p atient’s right shou ld er gird le into retraction. A
posterior m otion of the clavicular head w ill be noted and the
therap ist’s right thu m b takes u p the slack. Any increased
protraction is taken up by therap ist’s left hand . This p roce-
d u re is repeated u ntil no further m otion is perceived .
Adjunct exercises
Active exercises to m aintain the range of m otion of the ster-
noclavicu lar joint gained by p assive m obilizations shou ld
sim ply be instru cted in fu nctional sets – that is, they should
have an em p hasis either on a com bination of elevation
and protraction or on a com bination of d ep ression and retrac-
tion. With regard to norm al sternoclavicu lar joint fu nction,
how ever, the au thor cannot overem p hasize the need for
norm al thoracic joint m otion. Manu al m obilization and
m anip u lation techniqu es to restore m obility in this region
have been d escribed in Chapter 13 and shou ld be review ed
and inclu d ed for optim al m anagem ent of p atients w ith
sternoclavicu lar joint d ysfu nction as ind icated by the
Conclusion 307
exam ination nd ings. Ad d ressing this com ponent of sterno-
clavicu lar joint d ysfu nction m ay also necessitate the p atient
to p erform ad d itional thoracic sp ine exercises to facilitate
shou ld er gird le d ep ression and retraction (extension and ip si-
lateral sid e-bend ing / rotation of the thoracic spine) or gird le
elevation and protraction ( exion and contralateral sid e-
bend ing / rotation of the thoracic spine).
Conclusion
The sternoclavicu lar joint seem s to be poorly u nd erstood and
m ore p oorly researched , bu t it is accep ted that this is, in p art,
d ue to the rarity of signi cant injury to the joint. H ow ever, as
p hysical therap ists continu e to gain the p rivilege of d irect
access to patients, it is essential they becom e aw are of how to
d ifferentiate betw een pathological cond itions of this joint that
m ay be either health or life threatening d em and ing a m ed ical
consu lt and those that requ ire a p hysical therap y intervention.
Also, m u ch m ore w ork is required by all interested parties to
investigate the biom echanical role of the thorax in sternocla-
vicu lar joint fu nction and its p otential p atho-biom echanical
interaction w ith upper lim b fu nction.
References
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Denard PJ, Koval KJ, Cantu RV, et al. 2005. Managem ent of m id shaft clavicle
fractu res in ad u lts. Am J Orthop 34 (11): 527–536.
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from isolated clavicle fracture. Trau m a 42: 316–318.
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Rod rigu es H . 1843. Case of d islocation, inw ard s, of the internal extrem ity of
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Voisin JL. 2006. Clavicle, a neglected bone: m orphology and relation to arm
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Wolford LM, Cottrell DA, H enry C. 1994. Sterno-clavicular grafts for tem po-
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Rotator Cuff Lesions: Shoulder Impingement
CHAP TER CONTENTS
Introduction  309
Anatomy  309
Biomechanics  310
Pathology of the rotator cuff  311
Diagnosis of shoulder impingement  313
Prognosis  315
Management  315
Conclusion  318
Introduction
Shou ld er com p laints are com m on. A Du tch stu d y ind icated a
point-prevalence of 20.9% in the general pop u lation (Picavet
et al 2000). Another Dutch stu d y ind icated a yearly incid ence
of 11.2 p er 1000 p atients in general m ed ical p ractice, w ith 41%
of the p atients seeking care for shou ld er com p laints d iag-
nosed w ith im p ingem ent (van d er Wind t et al 1995). A UK
stu d y fou nd that, at 16%, shou ld er p roblem s w ere the third
m ost com m on cau se of m u scu loskeletal d isease in p rim ary
care (Urw in et al 1998). Should er com plaints are also a
com m on reason for p atients to seek therap y. In a su rvey of
US outp atient physical therapy services (Boissonnau lt 1999),
11% of 1258 patients ind icated the should er as their chief area
of com p laints.
Althou gh d escriptions of rotator cu ff tears can be fou nd in
the m ed ical literature as early as the 18th centu ry (Lim b
& Collier 2000), and Cod m an (1906, 1934) and Gold thw ait
(1909) in the early 20th centu ry had m ad e signi cant contribu -
tions to ou r u nd erstand ing of anatom y and p athology of
the su bacrom ial region, it w as the d escrip tion and classi ca-
tion by N eer (1972) into stage I (oed em a and haem orrhage),
stage II (tend onitis w ith brosis) and stage III (p artial- to
full-thickness rotator cu ff tears) im p ingem ent that truly
brought su bacrom ial im pingem ent to the d iagnostic fore-
front. H ow ever, the d evelopm ent in ou r u nd erstand ing of
im pingem ent has not stopped there and tod ay, in ad d ition to
prim ary or su bacrom ial im pingem ent, w e recognize second -
ary, internal and coracoid im pingem ent as d istinct and rele-
vant clinical p resentations. Sim ilarly, an u nd erstand ing of
 
Chapter 
27  
P e te r A. Hu ijb re g ts , C a re l Bro n
relevant intrinsic pathological m echanism s has com plem ented
the sole em p hasis on extrinsic aetiology by N eer (1972).
Together w ith this increased know led ge has com e an increas-
ing role for conservative m anagem ent of p atients w ith these
cond itions.
Anatomy
Anatom ical structures relevant to the variou s types of
im pingem ent are the rotator cuff tend ons, the tend on of the
long head of the biceps, the subacrom ial / subd eltoid bursa,
the coracoacrom ial arch, the glenohu m eral cap su loligam en-
tou s stru ctu res (Ch 28) and the glenoid labru m (Ch 29). (As
the m ovem ent of the shou ld er is d ep end ent on the other com -
p onents of the shou ld er gird le as w ell as the cervical and
thoracic sp ine, the read er is also referred to the other relevant
chap ters of this text for m ore d etails on anatom y.)
The rotator cu ff consists of the su prasp inatu s, infrasp ina-
tu s, teres m inor and su bscap u laris m u scles. Even m acroscop i-
cally, the tend ons of these m u scles can be seen to fu se into a
single stru ctu re. The su p rasp inatu s and infrasp inatu s m u scles
join som e 1.5 cm proxim al to their insertion, w hereas the
infraspinatu s in turn m erges w ith the teres m inor proxim al to
their m u scu lotend inou s ju nction (Clark & H arrym an 1992).
Even thou gh the anterior p ortion of the su praspinatus and the
su p erior p ortion of the su bscap u laris are sep arated by the
rotator interval, throu gh w hich the coracoid process projects
m ed ially, the bres from the su p rasp inatu s and su bscap u laris
also m erge and interw eave to form a sheath arou nd the biceps
tend on (Clark & H arrym an 1992; Carr & H arvie 2005). These
interconnected bres from the su bscapularis and su prasp ina-
tu s tend ons, together w ith the su p erior glenohu m eral and
coracohu m eral ligam ent, form a tenoligam entou s sling, called
the bicep s p u lley, that keep s the long head of the bicep s
tend on stabilized as it cou rses across the glenohu m eral joint
to the bicip ital su lcu s (Choi et al 2004; H aberm eyer et al 2004).
Microscop ically, an even greater anatom ical interd ep end -
ence becom es ap parent. At the level of the su praspinatus,
infraspinatu s and subjacent capsuloligam entou s stru ctu res,
there are ve d istinct layers to the cu ff–cap su le com plex
(Clark & H arrym an 1992):
1. The m ost su p er cial layer is 1 m m thick and consists of
bres of the coracohu m eral ligam ent, cou rsing throu gh
 310 PART 4 • 27 • Rotator cuff lesions: shoulder impingement
the rotator interval and oriented obliqu ely to the axis of
each m u scle.
2. The second layer is 3–5 m m thick and consists of closely
p acked p arallel tend on bres grou p ed in large bu nd les
that also form the roof of the bicep s tend on sheath.
3. The third layer is 3 m m thick and consists of sm aller
tend on fascicles w ith a less u niform orientation, w here
bre bu nd les intersect at a 45° angle and extensive
interd igitations occur betw een the supraspinatus and
infraspinatu s tend ons.
4. The fou rth layer consists of loose connective tissu e w ith
som e thick collagen bre band s located m ostly on the
extra-articu lar sid e of this layer.
5. The d eep est layer is only 1.5–2 m m thick and is m ad e
u p of interw oven collagen brils that m ake u p the ‘tru e’
glenohu m eral capsu le.
The su bscap u laris tend on consists of 4–6 thick collagen bre
bu nd les. The m ost proxim al of these bu nd les passes und er the
biceps tend on to form the oor of its sheath interw oven w ith
som e bres from the su p rasp inatu s. In this groove, these
interw oven tend ons becom e brocartilaginou s. The su perior
and m id d le glenohu m eral ligam ents run und er the su bscapu -
laris tend on and sep arate the tend on from the capsu le w ith a
stru ctu re sim ilar to that d escribed for the fou rth layer of the
su p rasp inatu s region above (Clark & H arrym an 1992).
Althou gh extensively interw oven w ith the other local
stru ctu res, as d escribed above, the tend inou s segm ents of the
rotator cuff are thickened along the axes of the four m u scles
(Clark & H arrym an 1992). Clinically m ost relevant is that the
strong central tend on of the bip ennate su p rasp inatu s m u scle
along its cou rse m igrates anteriorly, leaving a stress riser at
the ju nction betw een its thick lead ing ed ge and the w eaker
p osterior tw o-third s, w hich is w here 96% of all rotator cu ff
tears initiate (Bu nker 2002).
The vascu lar anatom y of the rotator cu ff has been a conten-
tiou s issu e. Rathbu n and Macnab (1970) rep orted an avascu lar
area near the su p raspinatus insertion, especially w ith ad d u c-
tion, that corresp ond s w ith the area w here tears rst occu r.
Biberthaler et al (2003) also noted a signi cant red u ction in
cap illary d ensity at the ed ge of d egenerative rotator cu ff
lesions. Other sou rces have rep orted no such hyp ovascu larity
(Moseley & Gold ie 1963; Bu nker 2002; Carr & H arvie 2005),
or have even show n hyp ervascu larity in patients w ith sym p -
tom atic im p ingem ent (Chansky & Iannotti 1991). An im paired ,
bu t also increased , blood sup ply m ay be a second ary event
rather than a factor in the aetiology of rotator cu ff lesions
(Carr & H arvie 2005).
The coracoacrom ial arch d e nes the su bacrom ial sp ace and
consists of the acrom ion and coracoid p rocesses w ith, sp anned
betw een them , the coracoacrom ial ligam ent. Betw een the
head of the hu m eru s and the coracoacrom ial arch, in a sp ace
m easu ring 1–1.5 cm on rad iographs taken in the anatom ical
p osition, are located the su bacrom ial bu rsa, the rotator cu ff
tend ons and the tend on of the long head of the bicep s (Lim b
& Collier 2000). Apart from having a m echanical role, varia-
tions in the anatom y of the long head of the bicep s have been
associated w ith the aetiology of rotator cuff lesions. Dierickx
et al (2009) noted the role of the d ouble-origin biceps variant
in cau sing im p ingem ent and tears in young p atients. Varia-
tions in the shap e of the acrom ion have been su ggested as
p laying a role in im p ingem ent; Bigliani et al (1986) d escribed
a at (type I), a cu rved (typ e II), and a hooked (type III)
acrom ion and related these typ es w ith increasing occu rrence
of im p ingem ent.
Biomechanics
Although a sim pli cation, w ithin the context of im pingem ent
w e can d ivid e the m u scles of the glenohum eral joint into
p rim e m overs and stabilizers. N orm al glenohu m eral m otion
consists of a roll–glid ing com bination that keeps the hu m eral
head centred on the glenoid . Du e to their orientation, the large
p rim e m over m u scles im p art not only rolling bu t also signi -
cant translational forces on the head of the hu m eru s. The latis-
sim u s d orsi and the teres m ajor, for exam p le, can im p art an
inferior glid e (H ald er et al 2001), w hereas the d eltoid w ill
cau se a su p erior glid e (Lim b & Collier 2000). Althou gh a
su p erior translation of the hu m eral head can be easily seen to
cau se narrow ing of the su bacrom ial sp ace and su bsequ ent
im p ingem ent, d ecentring of the hum eral head on the glenoid
in any d irection w ill cause excessive tensile, com pressive and
shear forces in active and p assive stru ctu res that p red isp ose
the p atient to eventu al p athology.
Described in m ore d etail in Chap ter 28, the glenohu m eral
cap su loligam entou s stru ctu res serve as stabilizers m ainly
near or at the end range of m otions. N egative intra-articu lar
p ressu re, w hich is lost in the case of a fu ll-thickness rotator
cu ff tear, fu rther contribu tes to glenohu m eral stability (H ur-
schler et al 2000). H ow ever, the m ain stabilizers of the gleno-
hu m eral joint are the rotator cu ff m u scles. In the context of
this m u scu lar stabilization, tw o force cou p les are relevant
(Parsons et al 2002). In the coronal plane both the d eltoid and
su p rasp inatu s m u scles contribu te to abd u ction. Whereas the
su p rasp inatu s throu ghou t abd u ction has a p red om inant
vector com p ressing the hu m eral head into the glenoid , this
com p onent increases for the d eltoid as abd u ction p rogresses
(Fig. 27.1). H ow ever, d u ring early abd uction the pred om inant
vector for the d eltoid m u scle is d irected cranially, thu s com -
p ressing the hu m eral head against the su bacrom ial stru ctu res
and the coracoacrom ial arch. Most relevant to keep ing the
hu m eral head centred throu ghout m otion – and likely explain-
ing the noted prevalence of asym p tom atic rotator cuff tears
involving solely the su praspinatus (Sher et al 1995) – is the
transverse p lane force cou p le form ed by the su bscap u laris,
infraspinatu s and teres m inor m u scles (Fig. 27.2). The frontal
Deltoid and SSP
JRF
Deltoid SSP
Figure 27.1 Frontal plane force couple. SSP = supraspinatus; JRF= joint reaction
force.

Subscapularis
JRF
Infraspinatus
Figure 27.2 Transverse plane force couple. JRF= joint reaction force.
and coronal p lane force coup les together cou nteract the crani-
ally d irected force im p osed by the d eltoid m u scle (Lo & Bu r-
khart 2002).
Trad itionally, the rotator cu ff m u scles w ere thou ght of as
hu m eral head d ep ressors m aintaining a p hysiological su bac-
rom ial sp ace against m ainly the d eltoid im p arting superior
translation. H ow ever, the rotator cu ff m u scles are p oorly
p ositioned to p rod uce effective d ep ression of the hu m eral
head (H ald er et al 2001). More likely, their tru e or m ain role
is in prod u cing the com pressive forces requ ired for concavity
com p ression. Concavity com p ression is a m echanism in
w hich com pression of the convex hu m eral head into the
concave glenoid fossa stabilizes it against translating forces.
Glenohu m eral stability is thereby related to the d ep th of the
concavity as w ell as the m agnitu d e of the com p ressive force.
This clari es the im p ortant role in stability not only of the
rotator cuff but also of glenoid m orp hology and an intact
glenoid rim , labrum and closely associated capsu loligam en-
tou s stru ctu res resp onsible for the glenoid concavity (Lip p itt
et al 1993).
Althou gh the tend on of the long head of the bicep s is often
fu nctionally consid ered part of the rotator cu ff, research evi-
d ence w ith regard to its biom echanical role is equivocal,
ranging from it having no role at the should er to it being a
m ajor d ep ressor of the hu m eral head (Kru pp et al 2009). The
m ost likely role of the bicep s tend on (as w ell as the coracoac-
rom ial arch) is that of a static restraint to superior translation
of the hu m eral head . In norm al shou ld ers the active role in
stability for the bicep s tend on seem s lim ited to a p osition of
abd u ction and m axim al external rotation – as occu rs in the
late cocking p hase of an overhead -throw ing m otion w here
contraction of the bicep s ad d s to torsional stiffness of the
glenohu m eral joint and red u ces anterior translation (Itoi et al
1993; Rod osky et al 1994). H ow ever, con rm ing both au thors’
clinical observations, the bicep s tend on m ay have a greater
role in shou ld ers w ith rotator cuff d e ciency: Kid o et al (2000)
show ed that it acted as a hu m eral head d ep ressor lim iting
u p w ard translation not ju st at 90° bu t also at 0° and 45° of
abd u ction in p atients w ith a rotator cuff tear.
Clinically, fu nction and biom echanics of the glenohu m eral
joint cannot be d iscussed in isolation. The glenohu m eral joint
assu m es the requ ired p ositions in sp ace by the grace of scapu-
lar m ovem ent. Scapulothoracic m ovem ent in tu rn is m ad e
Pathology of the rotator cuff 311
p ossible by ad equ ate m obility and neu rom u scu lar fu nction in
the acrom ioclavicu lar, sternoclavicu lar and u p p er thoracic
joints, d iscu ssed in greater d etail in Chap ters 25 and 26. Ad e-
qu ate neu rom u scu lar fu nction of the scap u lothoracic joint,
thoracic p ostu re and the d egree of thoracic kyp hosis also
d eterm ine scapu lar m ovem ent (Lu d ew ig & Reynold s 2009).
In the context of scapu lothoracic contribu tion to should er
m otion, clinicians often refer to the scap u lothoracic rhythm .
At its least com plex, a norm al scapu lothoracic rhythm has
been d e ned as a scapula that rem ains stable d u ring the initial
30° of should er abd u ction or 60° of exion and then sm oothly
and continuou sly rotates u pw ard s d u ring elevation, follow ed
by a sm ooth and continu ous d ow nw ard rotation w hen the
arm m oves back to neu tral w ithou t evid ence of scap u lar
w inging (Kelley 1995; McClu re et al 2009). N orm al relative
contribu tion of glenohu m eral and scap u lothoracic m otion to
elevation m otions of the shou ld er are su ggested to be 2 : 1,
m eaning that 120° occu rs in the glenohum eral joint versu s 60°
in the scapu lothoracic joint (Kelley 1995). H ow ever, research
has show n that the exact contribu tion throu ghou t m otion has
high inter-ind ivid u al variability, is affected by ad d ing resist-
ance to m otion and d iffers betw een active and p assive m otions
(Kelley 1995; Lu d ew ig & Reynold s 2009). This m akes a relia-
ble and valid clinical d iagnosis of relevant scapu lothoracic
d yskinesis problem atic. Using a m ore three-d im ensional
orthogonal biom echanical rather than a clinical p ersp ective to
d escribe m otion, one can d escribe norm al should er fu nction
as d ep end ing on the ability of the scapu la to p rod u ce suf -
cient frontal p lane u p w ard rotation and sagittal p lane p oste-
rior tilt d u ring elevation m otions (Fig. 27.3); in a transverse
p lane initially the scap u la m ay internally rotate to som e extent
but in end range it is externally rotated (Lu d ew ig & Reynold s
2009).
Pathology of the Rotator Cuff
When N eer (1972) classi ed im pingem ent into stages I–III he
d escribed w hat is now know n as prim ary im pingem ent. In
p rim ary im p ingem ent the com bination of rep etitive overhead
activity and external narrow ing of the su bacrom ial sp ace is
thou ght to be resp onsible for tend on inju ry. Mechanical com -
p ression occu rs betw een the tend ons and the coracoacrom ial
arch. Cau ses of subacrom ial narrow ing inclu d e acrom ial vari-
ants su ch as an unfu sed anterior acrom ial epip hysis or os
acrom iale, m alunion or non-u nion after acrom ial fracture, and
acrom ioclavicu lar separation or d egeneration w ith inferior
osteop hytic sp u rring (Pyne 2004). Although acrom ial m or-
p hology, esp ecially a typ e II or III acrom ion, has been su g-
gested as a cau se of prim ary im pingem ent, p revalence of
these variants increases w ith age and it has been su ggested
that they are traction sp u rs d u e to tension in the coracoacro-
m ial ligam ent resu lting from rather than cau sing im p inge-
m ent (Shah et al 2001; Bu nker 2002).
Second ary im p ingem ent is associated w ith glenohu m eral
instability. This p rim ary instability has to be thou ght of as a
continu u m that ranges from m inor or fu nctional instability
often ind icated only by history nd ings to m ore p ronou nced
instability that presents w ith physical exam ination and at
tim es even im aging nd ings (Belling Sørensen & Jørgensen
2000). Congenital laxity, labral and rotator cuff tears, and
 312 PART 4 • 27 • Rotator cuff lesions: shoulder impingement
External
rotation
Downward
rotation Upward
rotation
Figure 27.3 Scapular motions.
p osterior glenohu m eral cap su lar tightness have all been
im p licated in second ary im p ingem ent (Pyne 2004). N eu -
rom u scular insuf ciency (initially w ithout m u sculotend inou s
lesions) can lead to d ecreased ef ciency of the concavity com -
p ression m echanism . Probably ind icative of insu f cient active
stabilization, glenohu m eral p rop riocep tive acu ity is d ecreased
in p atients w ith im p ingem ent (Machner et al 2003) but
also w ith m u scle fatigue in asym ptom atic su bjects, esp ecially
in the inju ry-p rone late cocking p osition (Carp enter et al
1998; Trip p et al 2004). N eurom u scu lar insu f ciency m ay go
beyond d ecreased propriocep tion, coord ination and end ur-
ance. Ganssen and Irlenbu sch (2002) show ed selective fast-
tw itch m u scle bre atrop hy in the su p rasp inatu s m ore than
in the d eltoid m u scle w ith p rogressively w orse rotator cu ff
lesions. Esp ecially relevant for the active old er p op u lation is
that w ith age there seem s to be an increase in m u scle activity
in the rotator cu ff (infrasp inatu s and su p rasp inatu s) and
d eltoid m u scles requ ired for shou ld er m otions (Gau r et al
2007). H igher d em and m ay lead to earlier fatigue and im paired
active stabilization in the eld erly com pared w ith you nger
su bjects.
Re ecting the role of the glenohu m eral joint as p art of the
m u ltijoint shou ld er gird le, scap u lar d yskinesis has been su g-
gested as a cau se for second ary bu t also internal im pingem ent
(Lu d ew ig & Reynold s 2009). We have d iscu ssed above the
role of the acrom ioclavicular, sternoclavicu lar and u pper tho-
racic joints and the in uence of increased thoracic kyphosis
and thoracic exion p ostu res. Soft tissue tightness – as often
fou nd in, for exam p le, the pectoralis m inor m u scle and the
levator scap u lae m u scle – m ight resu lt in inad equ ate posterior
scap u lar tilt. We also need to consid er the role of scap u lotho-
racic neurom u scular fatigue and d yscoord ination. Lu d ew ig
and Reynold s (2009) d escribed d ecreased serratu s anterior
and increased u p p er trap eziu s m u scle activity. External
rotator fatigue signi cantly red uced scapu lar u pw ard rota-
tion, p osterior tilt and external rotation d u ring shou ld er ele-
vation, thereby d ecreasing the am ou nt of su bacrom ial sp ace
(Tsai et al 2003). Cools et al (2003) show ed signi cant d elays
in m u scle activation of the m id d le and low er trap eziu s m u scle
in su bjects w ith im p ingem ent com p ared w ith asym p tom atic
controls. Ind icating the p ossible role of p ain-related inhibition
Posterior Anterior
tilting tilting
Internal
rotation
Figure 27.4 Posterosuperior glenoid impingement.
in scapular d yskinesis, Falla et al (2007) d em onstrated that an
acute bout of u pper trap ezius p ain w as su f cient to resu lt
in altered m otor control of this m uscle, not only locally at
the site of p ain bu t also in non-p ainfu l regions w ithin the
m u scle and on the contralateral sid e. A m od i cation of
m otor strategy that resu lts in com p ensatory m u scle activity is
likely to lead to m u scle overload and p erpetuate pain and
d yskinesis.
The m ost com m on type of internal im p ingem ent is postero-
su p erior internal im p ingem ent w hereby the articu lar sid e of
the su p rasp inatu s tend on is im p inged betw een the p ostero-
su p erior labru m and glenoid and the greater tu berosity
(Fig. 27.4) (Belling Sørensen & Jørgensen 2000). This contact
betw een the su prasp inatu s and the posterosu perior structures
is actu ally a norm al and p hysiological occu rrence d u ring
abd uction–external rotation, bu t it is likely that in higher level
throw ing athletes – perhaps second ary to concu rrent m inor
instability or scapu lar d yskinesis – it m ay lead to fraying of
the tend on and labru m , and sym p tom s are esp ecially located
in the posterior should er d u ring the late cocking phase of
throw ing (Pyne 2004). It is of d ifferential d iagnostic relevance
that shou ld er p ain in the late cocking p hase m ay also be d u e
to the overstretching of the su bscap u laris m u scle. Myofascial
trigger p oints in the su bscap u laris m ay p rod u ce referred p ain
in the posterior should er. Trigger points in the posterior
d eltoid and the teres m inor m u scle m ay also prod u ce

p osterior shou ld er p ain ow ing to their concentric contraction
in a shortened position d uring late cocking (Sim ons et al
1999).
Althou gh very infrequ ently encou ntered in both authors’
clinical p ractice, w ith anterosu p erior internal im p ingem ent
there is contact occu rring betw een the bicep s p u lley and the
anterosu p erior labru m w hen the shou ld er is exed and inter-
nally rotated . This cau ses d am age to the anterosu p erior
labru m , the tend on of the long head of the bicep s, the biceps
p u lley, the su p erior p art of the insertion of the su bscapu laris
and som etim es the anterior bres of the insertion of su p rasp-
inatu s that are norm ally unaffected in d egenerative or tensile
rotator cu ff lesions. Anterosuperior internal im pingem ent
m ay be resp onsible for the infrequ ent (4%) anterosu perior
rotator cuff tear (Bu nker 2002; H aberm eyer et al 2004).
With coracoid im p ingem ent, the tend on of the su bscap u la-
ris (and occasionally the long head of the biceps tend on) is
im p inged betw een the lesser tu berosity and the coracoid
p rocess. This im p ingem ent occu rs esp ecially d uring exion,
internal rotation and cross-bod y ad d u ction of the shou ld er.
Coracoid im p ingem ent m ay occu r after arthroscop y, gleno-
p lasty, tenod esis of the long head of the biceps, acrom io-
p lasty, coracoid or glenoid fractu re w ith m alu nion, bu t can
also be related to congenital or acqu ired d eform ities of the
hu m eral head or coracoid ap op hysis, anterior glenohu m eral
instability, and chronic overu se in a exion–ad d u ction–
internal rotation p osition (Ferrick 2000; Rad as & Pieper 2004).
Im pingem ent can prod u ce or contribu te to lesions that
vary across a sp ectru m ranging from in am m atory tend oni-
tis, bu rsitis and d egenerative tend inosis to p artial- or fu ll-
thickness rotator cu ff tears. We d iscu ssed earlier the stress
riser at the junction of the thick lead ing ed ge and the w eaker
p osterior tw o-third s of the su praspinatu s tend on, w here m ost
tears d u e to p rim ary im p ingem ent initiate. Located som e
7 m m behind the bicep s p u lley, an articular sid e rim -rent tear
starts at this w eak p oint and grad u ally p eels back fu rther off
its insertion into the su perior facet of the greater tu berosity
u ntil it em erges on the bu rsal sid e – and has thu s evolved
from a partial-thickness to a full-thickness tear. Decreased
concavity com p ression allow s for su p erior su blu xation of the
hu m eral head and second ary im p ingem ent. The cu ff tear
can either extend slow ly over tim e or give w ay m ore su d -
d enly w ith traum a, progressing from a sm all (< 1 cm ) to a
m od erate tear (1–3 cm ). The su perior cap sule loosened from
its hum eral insertion contracts and pu lls the cu ff to w hich it
is m erged back tow ard s the glenoid . As the coracohu m eral
ligam ent, w hich reinforces the sup erior capsule, retracts
tow ard s the coracoid it p u lls the strong lead ing ed ge of the
su p rasp inatu s tend on w ith it. As the tear thu s evolves into a
large (3–5 cm ) tear, the hu m eral head ‘p ops’ u p throu gh the
hole and cau ses an inferior su blu xation of the lead ing ed ge of
the su p rasp inatu s tend on anteriorly and the infrasp inatu s
tend on p osteriorly.
Althou gh the infraspinatu s tend on rarely tears, it is hard
to retrieve, even su rgically, from behind the acrom ion and
therefore m any su rgeons often assu m e it to be torn. Either
w ay, in its new m echanically d isad vantageou s position and
d u e to atrop hy it becom es non-functional – m aking the qu es-
tion of w hether or not it really tears a m oot p oint. The tend on
of the long head of the bicep s starts to hyp ertrop hy and
fray. As the lesion extend s into a m assive tear (> 5 cm ), in
som e 16% of p atients w ith cuff tearing the biceps p ulley
Diagnosis of shoulder impingement 313
and the su perior m argin of the subscapu laris also give
w ay, w hich can lead to biceps tend on subluxation or even
tearing, w hich thu s rem oves one m ore stabilizing force in the
rotator-cuff-d e cient should er. As the hu m eral head su blu xes
anteriorly and sup eriorly throu gh the now m assive tear,
arthritic changes betw een the hum eral head and acrom ion
m ay ensu e. This lead s to the end stage of cu ff tear arthrop a-
thy, or Milw au kee shou ld er, w hich is id enti ed on a rad io-
graph by m assive rotator cu ff calci cations (Bu nker 2002;
H ughes & Bolton-Maggs 2002). Isolated su bscapu laris tend on
tears are very rare and m ay be solely associated w ith antero-
su p erior internal im p ingem ent (Bu nker 2002) – althou gh one
m ight, w ith its im p ingem ent of the su bscap u laris, im p licate
coracoid im p ingem ent as w ell.
Although all above types of im pingem ent w ould seem to
strongly favou r an extrinsic m echanical aetiology for rotator
cu ff lesions, intrinsic m echanism s are likely to also p lay a role,
especially in the m ore chronic d egenerative tend inopathies.
As w e have d iscussed , evid ence for the role of hypovascular-
ity as an intrinsic factor is equ ivocal. H ow ever, im m obiliza-
tion, age-related changes, genetic d isord ers, end ocrine and
m etabolic in u ences, rheu m atic d iseases, nu tritional d e cien-
cies and tensile overload all need to be consid ered as relevant
intrinsic factors in the aetiology of rotator cuff inju ries. As
these factors im p act on p rognosis they w ill be d iscu ssed in
m ore d etail in that section.
Diagnosis of Shoulder Impingement
Shou ld er im p ingem ent often p resents w ith a p oorly localized
p ain in the anterior to lateral shou ld er. The p ain m ay be
p resent at rest or at night, bu t is m ost p ronou nced w ith m ove-
m ent, esp ecially overhead . Associated sym p tom s m ay inclu d e
w eakness, crepitus and stiffness. A history of repetitive over-
head u se in sp orts or w ork (e.g. throw ing, p ainting, carp en-
try) m ay be elicited (Pyne 2004; Boyles et al 2009). Second ary
and posterosuperior internal im pingem ents occu r m ostly in
athletes und er 35 years of age engaging in overhead activity,
su ch as throw ing or racket sp orts, gym nastics and sw im m ing
(Belling Sørensen & Jørgensen 2000). Anterosu perior internal
im pingem ent is m ore prevalent in m id d le-aged m en w ho are
still active in sp orts, w ith p ain esp ecially on exion and inter-
nal rotation m ovem ents (Bu nker 2002). Chronic overuse in a
exion–ad d uction–internal rotation position, p ain m ore con-
sistently in m id range than in end range of shou ld er exion
and tend erness ind icated over the coracoid m ay all su ggest
coracoid im p ingem ent (Ferrick 2000).
N orthover et al (2007) stu d ied risk factors for p rim ary
im pingem ent. Activities that increased the risk of p rim ary
im pingem ent inclu d ed occu pations w ith heavy m anu al
labour (OR 3.81; 95% CI 1.93–7.51) and / or overhead w ork
(OR 3.83; 95% CI 2.15–6.84), w eight-training (OR 2.39; 95% CI
1.07–5.05) and sw im m ing (OR 1.98; 95% CI 1.11–3.53). Work
involving ham m ering (OR 2.47; 95% CI 1.12–5.44) and u sing
vibrating tools (OR 1.95; 95% CI 0.973–3.93) also increased the
likelihood of im p ingem ent, bu t these risk factors m ay have
not been ind ep end ent risk factors bu t rather associated w ith
heavy labou r. A m ed ical history that inclu d ed d iabetes (OR
3.34; 95% CI 1.26–8.85) and generalized osteoarthritis (OR
2.39; 95% CI 1.41–4.07) also served as a risk factor.
 314 PART 4 • 27 • Rotator cuff lesions: shoulder impingement
Generally, p ain levels in p atients w ith im p ingem ent are
at best m od erate and severe p ain m ay ind icate p athology
requ iring referral for m ed ical d iagnosis and (co)m anagem ent,
if for no other reason than ad equ ate p ain control. A bu ild -u p
of calciu m hyd roxyap atite crystals w ithin the tend on is char-
acteristic of calcifying tend inopathy. In the shou ld er, the
su p rasp inatu s tend on is m ost com m only affected , w ith d ep os-
its located 1–1.5 cm p roxim al to its hu m eral insertion.
Although calci c d eposits in the rotator cuff tend ons are often
asym p tom atic, in cases of su d d en-onset severe pain w here
the p atient is relu ctant to m ove the shou ld er actively or
p assively and w here increased tem p erature is noted on
p alp ation the clinician need s to consid er calcifying tend inopa-
thy d u ring its resorp tion p hase. Sym p tom s are d u e to exu d a-
tion of cells, ru p tu re of the calci c d eposit into the bu rsa,
and vascu lar p roliferation. This acu te ep isod e can last up
to 2 w eeks, w hereas the su bsequent su bacu te episod e w ith
p ain and restricted m ovem ent lasts 3–8 w eeks (H ughes &
Bolton-Maggs 2002).
As d ata on d iagnostic accuracy of history item s are not
available and the above-m entioned history item s are obvi-
ou sly not very sp eci c, the clinician need s to d ep end to a
greater extent on physical exam ination. Patients w ith pathol-
ogy ranging from im p ingem ent to m assive tears have noted
d ecreases in shou ld er exion and external rotation (at 0° and
90°) range of m otion com p ared w ith the contralateral shou l-
d er (McCabe et al 2005). Clinically both au thors have also
noted p ainfu lly d ecreased m obility in the hand -behind -the
back test for the full spectru m of im pingem ent.
A p ainfu l arc sign is d e ned as p ain on active frontal or
scap u lar p lane elevation that is m ost p ronou nced d u ring m id -
range (60–120°). Sensitivity of the p ainfu l arc sign in the d iag-
nosis of rotator cu ff tears w as 0.45–0.98 and for im pingem ent
the sensitivity w as 0.33–0.71. Speci city for rotator cu ff tears
w as 0.10–0.79 and for im p ingem ent it w as 0.47–0.81 (Çalis
et al 2000; Litaker et al 2000; Park et al 2005). Consid ering the
w id e range of d iagnostic accuracy statistics, this sign can
hard ly be consid ered (as it often is) p athognom onic for rotator
cu ff lesions.
Rotator cu ff lesions can affect nd ings on strength tests d u e
to p ain and / or tearing. Patients w ith the fu ll sp ectru m of
im p ingem ent have signi cant d ecreases in shou ld er strength
in abd u ction (at 10° and 90°), external rotation (at 90°) and on
the em p ty can test (resisted scap u lar p lane elevation w ith
internal rotation) w hen com p ared w ith the contralateral
shou ld er. N ote that w eakness of greater than 50% com pared
w ith the other arm for abd u ction at 10° is ind icative of a large
or m assive rotator cu ff tear (McCabe et al 2005). Weakness on
the em p ty can test, w eakness on external rotation and a p osi-
tive im pingem ent sign provid e a 98% (95% CI 89–100%) prob-
ability that a (p artial- or fu ll-thickness) rotator cuff tear is
p resent. Any tw o of three positive tests in a patient aged over
60 also p rovid e the exact sam e post-test p robability of a
rotator cuff tear (Mu rrell & Walton 2001).
Althou gh N eer im p ingem ent test w as originally d escribed
(N eer 1972) w ith a retest after subacrom ial anaesthetic in ltra-
tion (N orthover et al 2007), in physical therapy literatu re this
test is generally d escribed as the clinician p reventing scap u lar
rotation w ith one hand w hile passively elevating the patient’s
arm in the scap u lar of sagittal plane. Pain at end range is
consid ered to be a p ositive nd ing. The H aw kins–Kenned y
im p ingem ent test involves the clinician facing the p atient and
raising the arm to 90° exion, follow ed by internal rotation,
w ith pain again consid ered a positive nd ing. H eged u s et al
(2008) p erform ed a m eta-analysis of these tests and p rovid ed
a p ooled sensitivity of 0.79 (95% CI 0.75–0.82) and a pooled
sp eci city of 0.53 (95% CI 0.48–0.58) for the N eer test; for the
H aw kins–Kenned y test the pooled sensitivity and speci city
w ere 0.79 (95% CI 0.75–0.82) and 0.59 (95% CI 0.53–0.64)
respectively. As Dinnes et al (2003) also have ind icated , this
m eans that these sp ecial tests can be help fu l in ru ling ou t a
d iagnosis of im pingem ent w hen negative, bu t not in d iagnos-
ing it w hen positive.
After elim inating d iagnostic accuracy stu d ies of insu f -
cient m ethod ological qu ality, H eged u s et al (2008) noted the
external rotation lag sign as a speci c test for infraspinatus
tears (98%) (althou gh, as noted above, the infraspinatu s p rob-
ably d oes not tru ly tear bu t rather subluxes and atrop hies) or
any rotator cuff tear (98%). For the external rotation lag sign
the p atient is seated and the clinician stand s behind the
p atient. The p atient’s elbow is passively exed to 90° w ith the
shou ld er at 90° of scapu lar plane elevation. The shou ld er is
p laced in m axim al external rotation, less 5° (to avoid elastic
recoil in the joint). The p atient is asked to m aintain this posi-
tion actively as the clinician releases the w rist w hile m aintain-
ing supp ort of the arm at the elbow. The test is positive w hen
lag or angu lar d rop occu rs.
The H ornblow er or Patte sign w as noted as sp eci c (92%)
for absence or severe d egeneration of the teres m inor (H eged us
et al 2008). For this test, the clinician supp orts the p atient’s
arm at 90° of scapu lar plane elevation w ith the elbow also
exed to 90°. The p atient is asked to rotate the forearm exter-
nally against the resistance of the clinician’s hand . If he / she
is u nable to d o this, the test is consid ered to be positive.
H eged u s et al (2008) noted the bear hu g (92%) and belly
p ress test (98%) as speci c for subscapu laris tears. For the bear
hu g test, the p atient p laces the p alm of the involved sid e on
the op p osite shou ld er, w ith the ngers extend ed so that
he / she cannot resist by grabbing the shou ld er. The p atient is
asked to keep the hand on the opposite should er as the clini-
cian then attem p ts to p u ll the hand off the shou ld er w ith an
external rotation force app lied perp end icu lar to the forearm .
The test is positive if the patient cannot hold the hand against
the should er; a 20% d e cit w ith a 5-second static strength test
com p ared w ith the op p osite sid e m easu red w ith a tensiom -
eter has also been d escribed as a positive nd ing (Barth et al
2006). The belly press test has the p atient p ress a at hand on
the abd om en w hile m aintaining m axim al internal rotation at
the shou ld er. If the p atient is u nable to m aintain active inter-
nal rotation and the elbow d rop s back behind the frontal
p lane, the test is consid ered p ositive.
With bicip ital inju ry d e ned as a tear, instability or
intrasubstance tend inopathy, Kibler et al (2009) reported the
bear hug (79%) and u pper cut test (73%) as the m ost sensitive.
The belly press test w as noted as the m ost speci c (85%). The
u p p er cu t test also p rod u ced the highest p ositive likelihood
ratio (3.38). The up per cut test is perform ed w ith the involved
shou ld er in a neu tral p osition, the elbow exed 90°, the
forearm su pinated and the patient m aking a st. The patient
is then asked to rapid ly bring the hand up and tow ard s the
chin, m im icking an u p p er cu t p u nch, as the clinician resists
this m otion w ith his / her hand on the p atient’s st. Pain or a
p ainfu l p op over the anterior p ortion of the shou ld er ind icates
a p ositive test.

In you ng athletes w ith shou ld er pain, Meister et al (2004)
valid ated the p osterior im p ingem ent sign w hereby the shou l-
d er is brou ght into 90–110° of abd u ction, 10–15° of extension
and m axim al external rotation. Pain reprod u ced in the poste-
rior should er constitu tes a positive nd ing. In this stu d y, sen-
sitivity and sp eci city for the d iagnosis of a p osterior labral
and / or articu lar sid e rotator cu ff tear w ere 75.5% and 85%,
resp ectively. When only athletes w ith a grad u al onset of pain
w ere consid ered , sensitivity increased to 95% and speci city
to 100%, m aking this the only test d escribed in the literatu re
w ith established d iagnostic accuracy relevant to internal
im pingem ent. Although ad m itted ly not valid ated and solely
based on biom echanical extrapolation and clinical experience,
the rst au thor attached fu rther d iagnostic relevance to relief
of p osterior shou ld er sym p tom s on ad d ing a p osterior glid e
(relocation) to the test position.
Med ical d iagnostic op tions inclu d e d iagnostic anaesthetic
in ltration and im aging (Pyne 2004). Im aging relevant for
p atients w ith im p ingem ent inclu d es plain rad iography, ultra-
sonograp hy, m agnetic resonance im aging (MRI) and m agnetic
resonance arthrography (MRA). Plain rad iography show s cal-
ci c d ep osits in the rotator cuff tend ons in 2.7–20% of asym p -
tom atic ad u lts. Calci c d ep osits at the ed ge of som e
full-thickness rotator cuff tears ind icate poor prognosis.
Massive calci cations, as in Milw au kee shou ld er or cu ff
arthrop athy, ind icate end -stage rotator cu ff d isease and severe
glenohu m eral osteoarthritis (Bu nker 2002; H ughes & Bolton-
Maggs 2002). Sclerosis of the u nd ersid e of the acrom ion and
u pp er greater tu berosity together w ith su p erior m igration of
the hu m eral head m ay ind icate the p resence of a large-
to-m assive rotator cu ff tear. Lesions associated w ith frank
instability such as a H ill–Sachs lesion, acrom ioclavicular
abnorm alities narrow ing the su bacrom ial space, acrom ial or
coracoid abnorm alities and acrom ial shap e can all be id enti-
ed w ith p lain rad iograp hy (Lim b & Collier 2000; Pyne 2004).
Ultrasonography is portable and offers high resolu tion, the
op tion of d ynam ic im aging and the ability to correlate im aging
d irectly w ith physical nd ings, all at a relatively low cost
(Pyne 2004). Dinnes et al (2003) d id a system atic review of the
literature on d iagnostic accuracy of tests for soft tissue d isor-
d ers of the should er inclu d ing the rotator cu ff. If partial- and
full-thickness cu ff tears w ere com bined , sensitivity for u ltra-
sound w as 0.33–1.00 and sp eci city w as 0.43–1.00. For fu ll-
thickness tears, both sensitivity and sp eci city w ere higher
than for d iagnosis of all tears com bined , bu t ranges w ere still
w id e w ith sensitivity at 0.58–1.00 and sp eci city at 0.78–1.00.
For d etection of partial-thickness tears, the pooled sensitivity
of ultrasonograp hy w as low (0.67; 95% CI 0.61–0.73) bu t sp e-
ci city rem ained high (0.94; 95% CI 0.92–0.96). Ultrasou nd ,
therefore, can be u sed w ith greater con d ence for d iagnosing
than for ru ling ou t p artial- and fu ll-thickness rotator cu ff
tears.
For any tear, pooled sensitivity of MRI w as 0.83 (95% CI
0.79–0.86) and sp eci city w as 0.86 (95% CI 0.83–0.88). For
d iagnosis of p artial-thickness tears, the pooled sensitivity w as
low (0.44; 95% CI 0.36–0.51) bu t speci city rem ained high
(0.90; 95% CI 0.87–0.92) (Dinnes et al 2003). MRI can be used
w ith con d ence for d iagnosing partial- and fu ll-thickness
tears and for ru ling ou t fu ll- bu t not p artial-thickness tears.
H ow ever, it should be noted that MRI prod uces m any false
p ositives. For exam ple, Sher et al (1995) fou nd that in asym p-
tom atic ind ivid u als u nd er the age of 40 nobod y had a tear,
Management 315
w hereas 4% of those betw een the ages of 40 and 60 years had
a tear, and 24% of those over the age of 60 years had a tear.
Milgrom et al (1995) show ed a sim ilar correlation betw een age
and the incid ence of asym ptom atic rotator cuff tears. Fu rther
qu estioning the d iagnostic relevance of MRI, Krief and H u gu et
(2006) rep orted no correlation betw een p ain or fu nction and
size or location of rotator cu ff tears on MRI.
In the d iagnosis of full-thickness tears, MRA had a pooled
sensitivity of 0.95 (95% CI 0.82–0.98) and a speci city of 0.93
(95% CI 0.84–0.97) – m aking it a u sefu l tool both to d iagnose
and to rule ou t full-thickness tears. Despite lim ited research
evid ence, Dinnes et al (2003) noted that, for p artial tears, the
d iagnostic accuracy of MRA exceed ed that of u ltrasonogra-
p hy or MRI.
Prognosis
Research on p rognostic ind icators for p atients w ith im p inge-
m ent synd rome is very limited . Brox and Brevik (1996) reported
on ind icators for su ccess or failu re w ith treatm ent in p atients
w ith stage II im pingem ent. The best ind epend ent p rognostic
ind icators for success w ere active treatm ent in the sense of
arthroscopic su rgery or su pervised exercise (4.8; 95% CI 1.7–
13.6), not being on sick leave (4.4; 95% CI 1.6–12.1) and not
being on regu lar m ed ication (OR 4.2; 95% CI 1.5–11.1).
Rep orted shou ld er-related w ork d em and s d id not im p act on
sick leave. Taking regu lar m ed ication w as a p rognostic factor
for treatm ent failu re that w as particularly high in those
p atients w ho had no d isease ap art from the p ainfu l shou ld er
(OR 17.0), w hich ind icates the need for careful pharm acologi-
cal m anagem ent.
Und er pathology w e brie y d iscu ssed intrinsic causes for
rotator cu ff tend on pathology. In ad d ition to a role in aetiol-
ogy, these cau ses p red isp osing the rotator cu ff to d egenera-
tive tend on lesions w ill p robably also affect p rognosis and
m anagem ent choices, althou gh sp eci c qu antitative stu d y
into their prognostic relevance has not been d one. Box 27.1
lists d iseases and cond itions associated w ith tend on d egen-
eration relevant not only to the rotator cuff tend ons bu t also
to all tend ons (Lead better 1992; Archam bau lt et al 1995; Bu ck-
w alter 1995; Jósza & Kannu s 1997; Cu rw in 1998; Alm ekind ers
& Deol 1999; Dahners & Mu llis 2004; Virchenko et al 2004;
Brou ghton et al 2006; H ansen et al 2008).
Management
Physical therap y m anagem ent op tions for p atients w ith
im pingem ent synd rom e inclu d e ed ucation, m od alities,
exercise, m anual therapy and also taping interventions.
Com m on m ed ical m anagem ent inclu d es non-steroid al anti-
in am m atory m ed ication (N SAIDs), su bacrom ial steroid
in ltration and arthroscopic or open su bacrom ial d ecom pres-
sion su rgery.
Given the role of thoracic exion on scap u lothoracic
m otion, ed u cation w ith regard to ap p rop riate p ostu re seem s
to be an obviou s com p onent of p atient ed u cation. Bu llock
et al (2005) noted a signi cant increase in p atients w ith
im pingem ent for shou ld er exion range, althou gh not pain
intensity, w ith erect com pared w ith slou ched sitting p osture.
 316 PART 4 • 27 • Rotator cuff lesions: shoulder impingement

Tap ing p atients m ay su p p ort retraining of correct m ove-

Bo x 2 7 .1 P ro g n o s tic fa c to rs : d is e a s e s a n d m ent p atterns. H ow ever, u sing asym p tom atic su bjects Cools
c o n d itio n s a s s o c ia te d w ith te n d o n d e g e n e ra tio n et al (2002) show ed that tap e ap p lication intend ed to inhibit
• Genetic disorders the u p p er and facilitate the low er trap eziu s had no effect on
electrom yographic activity in the serratus anterior, or all three
• Ehlers –Danlos syndrome
p ortions of the trap eziu s, w ith resisted or u nresisted exion
• Marfan syndrome and abd u ction of the should er. The authors suggested altered
• Osteogenesis imperfecta tim ing as a p ossible exp lanation for the clinically observed
• Homocystinuria effects of tap ing. In contrast, Selkow itz et al (2007) d id show
• Hypercholes terolaemia in patients w ith su bacrom ial im pingem ent that sim ilar taping
• Hypertriglyceridaemia d ecreased u pper trapeziu s and increased low er trapezius
• As partylglycosaminuria activity d u ring a functional overhead -reaching task, and that
• Haemochromatos is
it d ecreased u pper trapezius activity d u ring shou ld er abd u c-
tion in the scap u lar p lane. Mechanism s su ggested to be
• Menke s yndrome
involved in taping inclu d e facilitation or au gm entation of
• Larsen syndrome p rop riocep tive cu taneou s inp u t, tension w hen m ovem ent
• Congenital muscle dystrophies occu rs ou tsid e of the m ovem ent p attern allow ed by the tap ing
• Endocrine and metabolic diseas es / conditions ap plication, and inhibition or facilitation by tap ing shortened
• Diabetes mellitus overactive m u scles in a lengthened p osition, w hereas the tap e
• Stress m ight be u sed to hold lengthened u nd eractive m u scles in a
• Overtraining shortened p osition. Variou s tap ing techniqu es ap p rop riate for
p atients w ith im p ingem ent have been d escribed in the litera-
• Premature menopause
tu re (Morrissey 2000; Kneeshaw 2002) (Fig. 27.5). Morrissey
• Diminis hed oes trogen levels
(2000) su ggested that, w hen the p ositive effect on the m ove-
• Premenopausal hysterectomy m ent p attern or on sym p tom s w as m aintained , tap ing cou ld
• Oral contraceptive use (increased es tradiol) be d iscontinued .
• Hyperthyroidis m Laser therap y w as not d em onstrated to be su p erior to
• Hyperparathyroidism p lacebo for p atients w ith rotator cu ff tend inop athy (Green
• Renal diseas e et al 2003). Ultrasou nd (RR 1.81; 95% CI 1.26–2.60) and p u lsed
• Dialys is electrom agnetic eld therapy (RR 19; 95% CI 1.16–12.43)
resulted in im p rovem ent com pared w ith placebo in alleviat-
• Rheumatic dis eases
ing pain in p atients w ith calci c tend inopathy. There is no
• Rheumatoid arthritis evid ence of an effect for u ltrasou nd in patients w ith other
• Seronegative spondylarthropathies tend inop athies, how ever. Ultrasou nd also p rovid ed no ad d i-
• Nutritional de ciencies tional bene t w hen u sed in com bination w ith exercise inter-
• Decreas ed levels of vitamin A ventions over that obtained w ith exercise alone (Green et al
• Decreas ed levels of vitamin C 2003). There also is strong evid ence that extracorporeal shock-
• Decreas ed levels of copper w ave therapy is no m ore effective than p lacebo in patients
• Medications w ith im pingem ent, w ith regard to fu nctional lim itations
(Faber et al 2006).
• Corticosteroids
Exercise therap y interventions for p atients w ith im p inge-
• Indometacin m ent are intend ed to restore the frontal and transverse p lane
• Naproxen glenohu m eral force cou ples and norm alize scapular m otion.
• Parecoxib used during early tendon healing Generally they consist of p rogressive resistive exercises for
• Immobilization the rotator cu ff and scap u lar m u scles and stretching of tight
• Ageing stru ctu res, bu t they shou ld also ad d ress the m otor control
d e cits id enti ed in patients w ith im pingem ent. More d etail
on shou ld er exercises is p rovid ed in Chapters 32 and 33. Exer-
cise interventions have been su p p orted in a nu m ber of recent
rand om ized trials (Werner et al 2002; Walther et al 2004; Lom -
Visu al, m anu al and verbal feed back com bined w ith ed u cation bard i et al 2008) and system atic literatu re review s for prod uc-
on fau lty m ovem ent p atterns p rovid ed signi cantly d ecreased ing im p rovem ents in both pain and fu nction (Green et al 2003;
electrom yographic activity in the u pper and m id d le trap e- Faber et al 2006; Tram pas & Kitsios 2006). In a Cochrane
ziu s, infrasp inatu s, serratu s anterior, and anterior and m id d le review (Green et al 2003), exercise w as noted as effective in
d eltoid m u scles of patients w ith im p ingem ent both im m ed i- term s of short-term recovery in rotator cuff d isease (RR 7.74;
ately after and 24 hou rs after m ovem ent training, w hereas 95% CI 1.97–30.32) and of longer term bene t w ith regard to
tru nk, shou ld er and clavicu lar kinem atics im p roved d u ring function (RR 2.45; 95% CI 1.24–4.86). It shou ld be noted that
and im m ed iately after training, especially in the su bset of in patients w ith N eer stage I–II im p ingem ent there are no
p atients w ith elevated clavicu lar position; this su pports the signi cant betw een-group d ifferences (at 6 and 12 w eeks)
role of ed ucating patients on correct m ovem ent patterns (Roy w ith regard to pain and function for patients treated w ith a
et al 2009). su p ervised exercise p rogram m e or a hom e p rogram m e in

A B C the shoulder girdle, (B) retraction / upward rotation, (C) retraction of
D E F
w hich they are instru cted by a p hysical therap ist (Werner et al
2002; Walther et al 2004).
The p resence and size of a fu ll-thickness rotator cu ff tear
m ay lim it p otential for m anagem ent w ith exercise and this
u nd erscores the im p ortance of correct d iagnosis. H ow ever,
at least in a su bset of p atients w ith im p ingem ent, non-
op erative m anagem ent is equ ally effective as op en or arthro-
scop ic d ecom p ression (Coghlan et al 2008). H aahr et al (2005)
noted no betw een-group d ifferences at 12 m onths for p ain
and fu nction in patients treated w ith su bacrom ial arthro-
scopic d ecom p ression or 19 sessions of rotator cu ff and scapu -
lar strengthening au gm ented by therm otherapy and m assage.
Faber et al (2006) rep orted no signi cant d ifference betw een
su p ervised exercise therap y and arthroscop ic acrom iop lasty
w ith regard to retu rn to w ork statu s either at 6 m onths or at
2.5 years.
Som e system atic review s (Green et al 2003; Faber et al
2006) have su pported a com bination of m anual therapy and
exercise for patients w ith im pingem ent in term s of im prove-
m ents in p ain and fu nction. Manu al therap y interventions
m ay be ap p rop riate for restrictions in the glenohu m eral
joint, shou ld er gird le, cervical and thoracic spine, and ribs;
these are d iscu ssed in m ore d etail in Chap ters 13, 14, 26
and 31.
Senbu rsa et al (2007) com p ared a hom e p rogram m e of
rotator cu ff and scapular strengthening exercises, active range
of m otion and stretching w ith 12 sessions of glenohu m eral
Management 317
Figure 27.5 Taping techniques for the shoulder: (A) elevation of
the shoulder, (D) upper trapezius inhibition, (E) serratus anterior
facilitation and inferior angle abduction, (F) acromioclavicular joint
relocation.
soft tissu e and joint m obilization, ice ap p lication, stretching
and strengthening exercises in p atients w ith im pingem ent. At
4 w eeks there w ere signi cant betw een-grou p d ifferences
w ith regard to pain and function in favou r of the m anual
therap y grou p . Kachingw e et al (2008) show ed signi cant
changes w ith regard to p ain, p ain-free range of m otion, and
function in patients w ith im pingem ent treated w ith six ses-
sions of su p ervised exercise only, su p ervised exercise w ith
glenohu m eral grad e I–IV glid e and traction m obilizations
from m id range, supervised exercise w ith a Mulligan m obili-
zation w ith m ovem ent (MWM) shou ld er exion techniqu e, or
a control grou p receiving only physician ad vice; there w ere
no betw een-grou p d ifferences. Althou gh the statistical p ow er
in this pilot stu d y w as extrem ely lim ited , the three interven-
tion grou p s had a greater im p rovem ent in fu nction, and both
m anu al therap y grou p s im p roved m ore w ith regard to p ain
m easu res. The active range of m otion increased m ost for the
MWM and least for the m obilization grou p .
Bergm an et al (2004) com p ared m ed ical care (consisting of
oral analgesics or N SAIDs, ed u cation, ad vice, corticosteroid
in ltrations and p hysical therap y referral for exercise, m od ali-
ties, m assage after 6 w eeks) to m ed ical care w ith up to six
treatm ents of thru st and non-thru st m anip u lative interven-
tions to the ribs and cervicothoracic spine over 12 w eeks in
p atients w ith shou ld er sym p tom s and d ysfu nction of cervico-
thoracic spine and ad jacent ribs. At 12 w eeks, 43% of the
m anipu lation grou p and 21% of the m ed ical care grou p
 318 PART 4 • 27 • Rotator cuff lesions: shoulder impingement
reported fu ll recovery. A 17-p ercentage p oint d ifference
favouring m anip u lation still existed at 52 w eeks. Du ring
intervention and at follow -u p , consistent betw een-grou p d if-
ferences in severity of the m ain com plaint, shou ld er pain and
d isability and general health favoured the m anual therapy
grou p.
Bang and Deyle (2000) show ed signi cant betw een-grou p
d ifferences in function, pain and isom etric strength of the
shou ld er in p atients w ith im p ingem ent for a p atient grou p
that received thru st and non-thru st techniqu es to the gleno-
hu m eral joint, shou ld er gird le, cervical and thoracic sp ine and
ribs plu s m anu al m u scle stretching, m assage and su pervised
exercise com p ared w ith a grou p receiving only the exercise
intervention. Boyles et al (2009) show ed signi cant w ithin-
grou p im p rovem ents at 48 hou rs for pain (m easu red w ith
p rovocative shou ld er and resisted tests and fu nctional scores)
in p atients w ith im p ingem ent after receiving only m id -
thoracic, cervicothoracic and rib thru st m anip u lation.
With regard to m ed ical m anagem ent, Green et al (2003)
reported that, for rotator cu ff d isease, corticosteroid injections
m ight at tim es be su p erior to p hysical therap y. Bu chbind er
et al (2003) noted that, for rotator cu ff d isease, subacrom ial
steroid injection d em onstrated a sm all bene t over p lacebo in
som e trials. The p ooled resu lts of three trials show ed no
bene t of su bacrom ial steroid injection over N SAIDs. In the
context of su rgery, it shou ld be noted that no signi cant d if-
ferences have been reported in outcom e betw een arthroscopic
and op en su bacrom ial d ecom p ression, althou gh four trials
d id report earlier recovery w ith arthroscopic d ecom pression
(Coghlan et al 2008).
Conclusion
H eged u s et al (2008) called im p ingem ent the nal com m on
p athw ay for all shou ld er d isord ers, and w e agree. It is not the
d iagnosis of im pingem ent p er se that is challenging, but
rather elucid ating the und erlying aetiology. This requires a
com bination of clinical reasoning based on p athop hysiologi-
cal and p atho-biom echanical extrap olation and a good
com m and of relevant research know led ge, thereby ep itom iz-
ing the evid ence-inform ed p arad igm . Fu tu re research is
requ ired w ith regard to clinical d iagnosis of the various types
of im p ingem ent d iscu ssed in this chap ter, bu t also into im p li-
cations of these variou s typ es on op tim al p atient m anagem ent
and on p rognostic factors that can gu id e m anagem ent d eci-
sions for p atients at variou s p oints along the im p ingem ent
sp ectru m .
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 320 PART 4 • 27 • Rotator cuff lesions: shoulder impingement

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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Chapter  28
S te ve n C . Alle n , Ru s s e ll S . Va n d e rW ild e , P e te r A. Hu ijb re g ts
CHAP TER CONTENTS
Introduction  321
Anatomy  321
Biomechanics  322
Pathology  323
Diagnosis of glenohumeral instability  325
History  325
Examination  325
Stability tests  326
Laxity tests  326
Imaging  328
Prognosis  329
Clinical risk factors  329
Anatomical risk factors  330
Management of glenohumeral instability  330
Conclusion  331
Introduction
In Chap ter 27, glenohu m eral instability w as d iscu ssed in the
context of second ary im p ingem ent. In the au thors’ com bined
experience, patients presenting w ith shou ld er pain often have
u nd erlying instability of the glenohu m eral joint. H ow ever,
glenohu m eral instability presents a w id e spectru m . At the one
end of this spectru m is the m inor instability (m ore app ropri-
ately classi ed as atrau m atic, involuntary, recurrent, m ostly
anterior–inferior su blu xation) w ith often only the history
nd ings ind icating its p resence that resp ond s w ell to con-
servative m anagem ent. At the other end of the sp ectru m is
the trau m atic d islocation, at tim es w ith associated fractu res
and neu rovascu lar or soft tissue d am age, w hich often p oses
a su rgical ind ication.
With regard to d islocation, Krøner et al (1989) rep orted an
incid ence of 0.17 p er 1000 p erson-years in a general urban
popu lation. Ow ens et al (2009) reported an incid ence in the
general p op u lation of 0.08, versu s 1.69 per 1000 p erson-years
for m ilitary p ersonnel. In abou t 98% of patients the should er
d islocates anteriorly, w hereas less than 2% of d islocations are
posterior and only 0.5% are inferior (Walton et al 2002; Cicak
2004; Cam ard a et al 2009).
 
Glenohumeral Instability
The glenohu m eral joint can be u nstable in anterior, poste-
rior or m u ltiple d irections. Mu ltid irectional instability (MDI)
is sym ptom atic laxity in tw o or m ore d irections, one of w hich
is alw ays inferior (Cap lan et al 2007). It is im portant to d istin-
gu ish instability from laxity, as the great m ajority of lax shoul-
d ers are not unstable (McFarland et al 2010). Objectively,
laxity d escribes the extent to w hich the hu m eral head can
be translated on the glenoid (Schenk & Brem s 1998). In con-
trast, instability is an abnorm al increase in glenohu m eral
translation that cau ses sym p tom s related to su blu xation or
d islocation. Should er instability becom es a clinically relevant
p athology in the p resence of: (a) abnorm al and u su ally asym -
m etric laxity, (b) correlating sym p tom s, and (c) correlating
p athological anatom y. When these three elem ents are p resent,
an im balance of the static and d ynam ic glenohu m eral joint
stabilizers occu rs and the resu lt is instability. Probably d u e to
p roblem s w ith d e nitive d iagnosis, ep id em iological d ata on
shou ld er instability are not available.
Many you ng athletic p atients p resent to p hysical therap y
w ith shou ld er pain d u e to atrau m atic, involuntary, recurrent,
m ostly anterior–inferior su bluxation. H ow ever, therapists in
a d irect access role m ay also be confronted w ith p atients w ith
comp laints at the other end of the sp ectru m and therefore
need to be fam iliar also w ith the p resentation of frank d isloca-
tions, so that they m ay recognize a p atient in need of m ed ical–
su rgical evalu ation.
Anatomy
The anterior shou ld er joint cap su le has d istinct band s,
d escribed as the su perior (SGH L), m id d le (MGH L) and infe-
rior (IGH L) glenohu m eral ligam ents. The hu m eral attach-
m ent of the SGLH lies ju st su p erior to the lesser tu berosity
near the bicip ital groove. The ligam ent cou rses anterior to the
biceps tend on to attach to the anterosup erior labrum (Levine
& Flatow 2000). The MGH L, the m ost variable (and at tim es
absent) of the glenohu m eral ligam ents, arises from the
hu m eru s at the lesser tu berosity in association w ith the su b-
scap u laris tend on; its labral attachm ent lies ju st inferior to
that of the SGH L. The hu m eral attachm ent of the inferior
cap su le or axillary p ou ch, w hich contains the anterior (AB-
IGH L) and p osterior (PB-IGH L) band s of the IGH L, ru ns from
the 4 to the 8 o’clock position of the hu m eral head to attach
 322 PART 4 • 28 •
Coracohumeral Coracoacromial
ligament ligament
Falx
Figure 28.1 Falx attaching f bres o coracoacromial ligament directly to the
conjoint tendon o the rotator cu .
to the inferior labru m (Su galski et al 2005). The p osterior
cap su le extend s from the PB-IGH L to the p osterior band of
the tend on of the long head of the bicep s. It has been su bd i-
vid ed into the su p erior (SC), m id d le and p osterior cap su les.
Although often assu m ed of m inor biom echanical im portance,
it shou ld be noted that the SC has a tissue thickness sim ilar
to that of the AB-IGH L (Bey et al 2005).
The coracohu m eral ligam ent (CH L) arises from the lateral
asp ect of the coracoid p rocess, and traverses horizontally
beneath the coracoacrom ial ligam ent (CAL). It attaches to the
greater and lesser tu berosities on each sid e of the bicipital
groove. In the rotator interval betw een the inferior m argin of
the su p rasp inatu s and the su p erior m argin of the su bscap u -
laris, the CH L blend s w ith the ad jacent tend ons and the
u nd erlying joint cap su le. At the anterior joint cap su le the
anterior band of this ligam ent is su p er cial to and overlies
the SGH L.
The CAL sp ans the su p erior asp ect of the shou ld er, ru nning
from the coracoid process to the anterior and inferior acrom ial
p rocesses. Lee et al (2001) d escribed a falx or band of tissu e
that d irectly connects the bres of the CAL to the conjoint
tend on of the rotator cu ff w ithou t attaching to the coracoid
p rocess (Fig. 28.1). In the rotator interval, the CH L is also con-
nected via this falx to the CAL, and laxity or d am age (also
iatrogenic, as occu rs d u ring acrom iop lasty) to the CAL m ay
com p rom ise the tension in the CH L.
The intact labru m (d iscu ssed in d etail in Ch 29) is brou s
throu ghou t w ith a brocartilaginou s transition zone at its
attachm ent w ith the glenoid articu lar cartilage (Abboud &
Soslow sky 2002). Firm ly attached inferiorly and fou nd to be
looser su p eriorly and anteriorly, the labru m increases the
d epth of the glenohu m eral socket by 50% (Cooper et al 1992).
As noted above, it serves as the attachm ent sites for the gleno-
hu m eral ligam ents and bicep s tend on.
Biomechanics
All three band s of the glenohu m eral joint cap su le serve as the
p rim ary p assive restraints to external rotation (Tu rkel et al
Glenohumeral instability
1981; O’Connell et al 1990). The SGH L contribu tes a prim ary
restraint to external rotation in 0° of abd uction. The CH L,
intim ate anatom ically to the SGH L, also contributes a prim ary
sou rce of p assive restraint to external rotation in this p osition
(N eer et al 1992; Kuhn et al 2005). The MGH L is believed to
be a m ore im p ortant contribu tor to anterior should er stability
in 45° of abd u ction, p ossibly im plicating it in m id range shoul-
d er instability (O’Connell et al 1990; Ku hn et al 2005). Together
the SGH L and CH L also lim it inferior translation and p oste-
rior translation in the exed , ad d u cted and internally rotated
shou ld er (Levine & Flatow 2000).
The inferior portion of joint cap su le acts as a ‘ham m ock’
that checks u nd u e translation of the hu m eral head on the
glenoid . In abd uction, this entire com plex m oves beneath the
hu m eral head and becom es tau t. The AB-IGH L com es u nd er
the greatest tension in 90° of abd uction, 10° of extension and
end -range external rotation. The inferior com plex m oves ante-
riorly beneath the hu m eral head w ith external rotation lim it-
ing anterior translation (Levine & Flatow 2000). In cad aver
tests of the AB-IGH L com plex, the anterior d raw er test at 60°
abd u ction prod u ced high strain at the insertion sites on both
the hu m eru s and glenoid . These tw o sites corresp ond to the
m ost p revalent failu re sites d u ring tensile testing of the
AB-IGH L; speci cally the insertion site on the glenoid is a
com m on site for an anterior labral tear (Bankart lesion). Ku hn
et al (2005) rep orted that the entire IGH L, inclu d ing the axil-
lary p ou ch, w as the m ost im portant restraint for external rota-
tion in both positions of 15° and 60° abd uction.
The PB-IGH L of the inferior recess com es u nd er tension
w ith abd uction and internal rotation, as the com plex m oves
p osteriorly beneath the hu m eral head (Levine & Flatow 2000).
The PB-IGH L has been im plicated in the clinically observed
stiff p osterior shou ld er. After the PB-IGH L, in the exed and
internally rotated shou ld er the greatest tension is fou nd in the
p osterior shou ld er cap su le, w hich ind icates its role as another
p osterior stabilizer (Urayam a 2001).
The CAL is a signi cant static stabilizer of the glenohum eral
joint at low er elevations (Lee et al 2001). Previou sly it w as
thou ght to have no fu nctional im p ortance and su rgically
released d uring acrom iop lasty; how ever, com prom ise of the
CAL allow s for increased anterior and inferior translation of
the internally and externally rotated should er in 0° and 30° of
abd u ction, w hich ind icates the potential for iatrogenic insta-
bility after acrom ioplasty.
The intact labrum contributes to the centring of the hu m eral
head on the glenoid , and d am age to the anteroinferior labru m
allow s m igration of the hu m eral head tow ard s the site of
lesion. Fehringer et al (2003) conclu d ed that precise centric
p osition of the glenohu m eral joint is w ell served by an intact
labru m , especially in the m id ranges w here the m ajority of
ligam ents are lax. The glenohu m eral labrum elevates the
glenoid ed ge, contribu ting to should er stability by effectively
d ou bling the d epth of the glenoid socket and serving as a
‘chock block’ to translation (Walton et al 2002), ad d ing as
m u ch as 20% to the resistance to translation forces (Abbou d
& Soslow sky 2002). (In Chap ter 27 the role of the labru m in
the concavity com p ression m echanism contribu ting to gleno-
hu m eral stability w as d iscu ssed .)
Stability, of cou rse, is not solely p rovid ed by p assive
restraints. The transverse (subscap ularis, infraspinatu s and
teres m inor) and frontal p lane (su p rasp inatu s and d eltoid )
force coup les of the concavity com pression m echanism

function as local stabilizers (Parsons et al 2002). Both the
rotator cu ff m u scles and the prim e m overs of the should er
p rovid e m uscle force vectors to the glenohu m eral joint that
have com p ressive and shear com p onents (Lee et al 2000). The
d irections of these force vectors change substantially from 0°
to 90° abd u ction, although the com p ressive com ponent p ro-
vid ed by the rotator cu ff is consistently m u ch larger than its
shear com p onent. The shear com p onent can p otentially stabi-
lize or d estabilize the joint, d epend ing on its d irection. The
infraspinatu s and teres m inor generate a posterior shear in the
late cocking phase of throw ing, thereby contributing to ante-
rior should er stabilization, w hereas the su praspinatus gener-
ates a large anterior shear force in end range, thu s d estabilizing
the joint in the anterior d irection (Lee et al 2000). The pecto-
ralis m ajor sim ilarly provid es an anterior d estabilizing force
in the late cocking position (Labriola et al 2005). The latis-
sim u s d orsi and teres m ajor p rod u ce m ore effective inferior
shear forces than d o infrasp inatu s and su bscap u laris; the role
of the su p rasp inatu s in this regard is only m inim al (H ald er
et al 2001b). (In Chap ter 27 the equ ivocal evid ence on the role
of the long head of the bicep s tend on in stabilization w as
d iscussed .) The d eltoid is a signi cant contributor to anterior
stability in the p osition of ap p rehension, w ith all three head s
contribu ting equ ally to stabilization (Kid o et al 2003). The
lateral d eltoid is a key m uscle restraint to inferior gleno-
hu m eral instability (H ald er et al 2001a).
Pathology
Avu lsion of the glenoid labru m in the anteroinferior qu ad -
rant, called a Bankart or Perthes lesion, is the m ost com m on
pathology seen in anterior shou ld er d islocation. It is d isrup-
tion of the IGH L, and not solely the Bankart lesion, that
is thought to allow for d islocation (Robinson & Dobson
2004). Bigliani et al (1992) show ed that an intrasubstance liga-
m ent inju ry occu rs before labral avu lsion. An isolated IGH L
injury rend ers the glenohu m eral joint very unstable, even
w ith intact d ynam ic stabilizers. The typical m echanism
for anterior d islocation in the younger patient is ind irect
trau m a to the abd u cted , extend ed and externally rotated arm ,
w hich occu rs m ost com m only in overhead sports activities
(Bohnsack & Wu lker 2002). Prim ary anterior d islocation of the
shou ld er occu rs com m only after low -energy falls in the
eld erly (Robinson & Dobson 2004). An im p ression fractu re of
the p osterolateral hu m eral head , called a H ill–Sachs lesion, is
also p resent in m ost p atients w ith anterior instability (Cicak
2004; Robinson & Dobson 2004).
At less than 2% of all d islocations, d islocation in a p osterior
d irection is u ncom m on. Posterior d islocation can be cau sed
by a fall onto the ou tstretched arm , a w eight ‘getting aw ay’
from a w eightlifter at term inal extension of a bench press, a
football linem an unable to hold off an opponent w ith forces
axially transm itted throu gh the forw ard exed arm s, or a
hockey p layer attem p ting to slow d ow n velocity of a hit into
the board s. It m ay also resu lt from ep ilep tic seizu re or electric
shock. Posterior d islocation m ay be associated w ith fractu res
of the su rgical neck of the hu m eru s or fractu res of the tu ber-
osities. Posterior shou ld er d islocations w ith p osterior labral
d etachm ent (reverse Bankart lesion) and a hum eral anterom e-
d ial im p ression fractu re (reverse H ill–Sachs lesion) need to be
Pathology 323
consid ered for su rgery. Ind ications for su rgical rep air inclu d e
recu rrent su blu xations or d islocations, or m echanical sym p-
tom s d esp ite ad equ ate rehabilitation (Seebau er & Keyl 1998;
Cicak 2004; Kim et al 2005).
At 0.5% of all d islocations, inferior d islocations are even
less com m on. Mechanism s of injury includ e d irect axial
load ing through the hum erus – as m ight occu r w hen the
p atient tries to catch hold of som ething overhead w hen falling
from a height. The other m echanism is violent forced abd u c-
tion of an alread y-abd u cted shou ld er. Im p ingem ent of the
neck or p roxim al shaft of the hu m eru s against the acrom ion
levers the hum eral head inferiorly out of the glenoid . The
term ‘lu xatio erecta’ refers to the p resentation of p atient w ith
the arm abd u cted , elbow exed , forearm s p ronated and hand
above the head u nable to low er the arm to the sid e. Associated
injuries m ay inclu d e fractu res of the acrom ion, clavicle, cora-
coid p rocess, greater tu berosity and hu m eral head . Associ-
ated vascular injuries to the axillary vessels are often seriou s
and requ ire su rgery, bu t are less com m on than axillary, rad ial
or u lnar nerve, or brachial p lexu s inju ries that m ostly recover
w ell, ind icating their neu ropraxic nature (Baba et al 2007;
Cam ard a et al 2009). Mallon et al (1990) review ed 80 cases
and reported greater tuberosity fractu re or rotator cu ff inju -
ries in 80%, neu rological involvem ent in 60% and vascu lar
com p rom ise in 3.3% of cases.
Posterior su blu xation is attribu ted to p osterior com p ressive
or tensile load ing and forced hyp erad d u ction (Robinson &
Dobson 2004; Kim et al 2005) w ith pain attributed to excessive
translation into the p osterior recess. Recu rrent p osterior
shou ld er su blu xation as a clinical entity has becom e increas-
ingly recognized as a less com m on (2–5%) but im p ortant con-
tribu tor to shou ld er instability (Eckenrod e et al 2009). A single
trau m atic event or rep etitive cu m u lative trau m a, as m ay
occu r in contact sp orts w ith high-energy forces d irected to the
p osterior cap su le, m ay lead to p osterior glenohu m eral insta-
bility. Glenoid retroversion and w eakness of the external rota-
tors have also been id enti ed as p otential contribu tors
(Eckenrod e et al 2009).
Excessive anterior translation of the hu m eral head d u ring
abd uction–external rotation lead s to plastic d eform ation of
the AB-IGH L and anterior glenohu m eral joint su blu xation.
This w ould also ind icate that the d egree of excessive laxity
com m only fou nd in the shou ld er of throw ing athletes m ight
be on a progressive track of excessive m otion and translation
lead ing to sym ptom s that eventu ally m anifest in labral inju ry
and / or partial-thickness rotator cu ff tears (Ku hn et al 2003).
H ow ever, laxity and hyperm obility are not instability and in
fact are prerequ isites for achieving higher d egrees of speed
and torqu e in the throw ing should er (H u ijbregts 1998). Con-
sid ering its frequ ent association w ith anterior shou ld er insta-
bility and sublu xation, w e believe it is im portant to review
the variou s p hases of overhead throw ing and ap p ly clinical
reasoning to the kinetic chain to allow for the d iagnosis of
p ossible relevant p atho-biom echanical fau lts.
The overhead throw (e.g. of a cricket ball) has ve phases:
w ind -u p, early cocking, late cocking phase, acceleration
and follow -throu gh (Fig. 28.2). The w ind -up phase in the
overhead baseball p itch is a p rep aratory p hase, centred on
exion. A right-hand ed throw er has a exion p attern of the
left low er extrem ity w ith consid erable hip and knee exion.
There also w ill be a exion m ovem ent of the spine. Both
hand s are in contact w ith the ball and the shou ld ers are in
 324 PART 4 • 28 •
Wind-up Early cocking Late cocking
Figure 28.2 Five phases o the overhead-throwing motion.
an internal rotation–ad d uction p osition w ith bilateral elbow
exion. The pitcher is facing the batter w ith the left sid e of the
bod y. Early cocking starts w hen the left hand loses contact
w ith the ball. The right should er m oves from ad d u ction and
internal rotation to abd u ction and external rotation. The
p itcher step s w ith the p reviously exed left leg in the d irec-
tion of the batter, and the tru nk m oves into extension, right
rotation and left sid e-bend ing. The late-cocking phase starts
w hen the left foot of the pitcher hits the ground . This is the
start of a d erotation m ovem ent of the tru nk and legs that
w ill contribute to accelerating the ball. The right arm and ball
still m ove in the sam e d irection of horizontal abd u ction and
external rotation.
Acceleration starts w ith the sw itch-over from shou ld er
external rotation to shou ld er internal rotation. This rotation is
the m ost im p ortant m ovem ent of the acceleration p hase. In
this p hase, the shou ld er also m oves from horizontal abd u c-
tion to horizontal ad d u ction and back in the d irection of hori-
zontal abd u ction ju st p rior to ball release. Ball release by the
right hand m arks the end of acceleration. The arm , w hich has
been im m ensely accelerated for the throw ing m otion, now
has to be d ecelerated . The left low er extrem ity m oves into
exion and the tru nk into exion and left rotation. The right
arm is m oving into ad d uction and internal rotation. The rst
p art (d eceleration) of the follow -throu gh phase is m arked by
high activity in the m u scle com p lex of the right shou ld er, w ith
the second p art of follow -throu gh requ iring ad equ ate tru nk
and low er extrem ity m ovem ent to d ecrease the force requ ire-
m ents abou t the shou ld er and red u ce the p otential for inju ry
(H u ijbregts 1998). The overhead throw is an extrem ely fast
activity. Fleisig et al (1995) m easu red an average tim e of
0.139 ± 0.017 s from foot contact to ball release, a p eriod that
corresp ond s to the late cocking and acceleration p hases
com bined .
Tw o critical instants are id enti ed in the overhead throw
that p lace u nu su ally high d em and s on the shou ld er com p lex.
The rst phase id enti ed in late cocking reveals high torsional
and com p ressive load s to the shou ld er that m ay w ell exceed
the p lastic lim it of the anteroinferior cap su loligam entou s
com p lex, resu lting in p ain and instability in this qu ad rant.
The second critical instant occu rs ju st after ball release in the
early d eceleration phase. Although torsional load ing is sig-
ni cantly red u ced and shear forces to the anterior restraints
Glenohumeral instability
Acceleration Deceleration Follow-through
are low in this p hase of throw ing, the com p ressive load ing to
the shou ld er joint is highest at 1100 N , constitu ting a m ore
than 100% increase from com pression d uring the rst critical
instant. Any u nw anted translation of the hu m eral head in the
p resence of these com p ressive forces has the p otential to
p rod u ce d am age to the cap su le, the closely associated rotator
cu ff tend ons and the labru m . Enorm ou s d em and s are p laced
on both the active and p assive restraints of the shou ld er
w ith – in ad d ition to these high torqu es and forces – an exter-
nal rotation range of m otion of 140° at the end of late cocking,
an internal rotation angu lar velocity of 7000° / s d u ring accel-
eration and an angular d eceleration of 500 000° / s 2 d u ring
d eceleration (H u ijbregts 1998).
In a throw ing athlete w ith glenohum eral instability, the
clinician shou ld not lim it the search for cau sative or contribu -
tory d ysfu nctions to the shou ld er joint or even the shou ld er
gird le. As an exam ple of relevant low er quad rant d ysfu nc-
tions, a right sacral torsion p resent at left foot contact in the
acceleration p hase m ay lead to excessive com p ensation in the
shou ld er to attain the requ ired arm velocity for comp etitive
throw ing. Also m axim al lu m bar extension and right-sid e
bend ing are requ ired in this phase of throw ing, im p lying that
an u nresolved , chronic right p osterolateral d isc lesion m ay
also p lace excessive d em and on the shou ld er gird le, as tru nk
m otion in this qu ad rant m ay be lim ited . This sam e d isc lesion
in a m ore irritable back problem w ou ld com prom ise the d ero-
tation and d eceleration of the throw ing arm w here exion and
left rotation of the trunk are requ ired .
The overhead athlete m ay also be vulnerable in cases
of lu m bar instability or an increase in the neu tral zone of a
sp inal m otion segm ent (Panjabi 1992). If this instability is in
a rotational plane to the right in the overhead throw er, the
critical zone of acceleration m ay resu lt in com p ensation higher
u p in the kinetic chain and su bsequ ent inju ry to the gleno-
hu m eral joint. Unilateral w eakness of the m u lti d u s mu scles
of the lu m bar sp ine m ay lead to su bsequ ent atrop hy in
p atients w ith u nilateral back p ain (H id es et al 1996). Asym -
m etrical contraction of this grou p of segm ental m u scles w ou ld
result in torsional load ing w ith excessive translation of the
sp inal m otion segm ent and loss of form closu re in the lu m -
bosacral region (Lee 1989) – again exp osing the glenohu m eral
joint higher u p the kinetic chain to excessive shear or com -
p ression. A higher incid ence of osteoarthrosis in the op p osite

hip from the throw ing sid e in retired javelin throw ers (Schm itt
et al 2004) su ggests the need to tolerate high torsional forces
on the left hip in the right-hand ed overhead athlete. Weakness
in the d eep left hip rotators or gluteu s m ed iu s in the d ecelera-
tion p hase of throw ing or lim ited hip rotation m obility w ou ld
be likely to com p rom ise the safety m argin for attenuating
force requirem ents on the throw ing shou ld er that
the contribu tion of the hip m u scles in this p hase w ou ld oth-
erw ise offer.
With regard to u p p er qu ad rant d ysfu nctions, scap u lar
d ynam ics require ad equ ate u pw ard rotation, abd u ction and
p osterior tilting for optim al shou ld er fu nction in the throw ing
athlete (Magarey & Jones 1992). Muscle im balances betw een
the u p p er trap eziu s and serratu s anterior m ay m anifest
in scapu lar w inging ow ing to serratus anterior inhibition
(Sahrm ann 2002), thus com prom ising the w ell-coord inated
m ovem ent of the scap u la and hu m eru s and the m aintenance
of centric p osition of the hu m eral head on the labru m . A
hyp ertonic or stiff levator scap ulae m uscle, d u e to C4 facilita-
tion from a cervical sp ine joint d ysfu nction, w ou ld tilt the
scap u la into d ow nw ard rotation and inhibit the ‘chock-block’
m echanism offered by the labru m (Fow ler & Pettm an 1992;
Walton et al 2002). This w ould increase strain in the struc-
tu res, lim iting inferior and anterior translation of the hu m eral
head . The u p p er thoracic sp ine requ ires ad equ ate rotation
and sid e-bend ing to the right in a right-hand ed throw er.
H ypom obility in this region of the thoracic sp ine is com m on
and w ill d irectly im p act the d egree of stress placed on the
anterior restraints to the glenohu m eral joint.
Diagnosis o Glenohumeral Instability
Although it w ould be hard to im agine that a clinician w ou ld
not recognize a lu xatio erecta, the m u ch m ore com m on p atient
w ith m inor instability is m uch hard er to d iagnose, and even
m ost p osterior d islocations are m issed on initial exam ination
(Cicak 2004).
History
Patients w ith shou ld er instability m ost often p resent w ith
pain as their p rim ary com plaint. Som atic pain d escribed as
d eep , aching and interm ittent and located in the anterior or
posterior shou ld er joint is com m on. Traum a m ay su ggest d is-
location that m ay have spontaneou sly red uced , especially
w hen in an anterior d irection. In the section on pathology, w e
d iscussed m echanism s of injury that shou ld m ake the clini-
cian consid er anterior, p osterior and inferior d islocations. As
noted above, p osterior d islocations are often m issed on initial
exam ination, w ith the patient com plaining only of subjective
instability and pain w ith exion, ad d u ction and internal rota-
tion (Cicak 2004).
In the introd u ction, w e d iscussed how in physical therapy
the com m only u sed d iagnosis of m inor instability w ou ld be
m ore ap p rop riately classi ed as atrau m atic, involu ntary,
recu rrent, m ostly anterior–inferior sublu xation. This type of
instability is m u ch m ore com m on, but hard to d iagnose d e n-
itively. It is m ost often seen in you ng overhead -throw ing
athletes or gym nasts. Trau m a m ay p lay a role, but is often
m ore of a cu m u lative typ e w ith p reviou s m inor ep isod es
Diagnosis of glenohumeral instability 325
of inju ry. Magarey and Jones (1992) have su ggested the fol-
low ing (non-valid ated ) history nd ings as ind icative of m inor
shou ld er instability: (1) app rehension w ith certain m ove-
m ents, (2) sensation of the joint slip ping in and ou t, (3) pain
w orse w ith overhead activity, (4) painfu l catches throu gh
range, (5) painfu l intra-articu lar clicking or ‘d ead arm syn-
d rom e’ d u ring late cocking, (6) w eakness in the late cocking
p osition. N ote, how ever, that at least som e of these sym p tom s
can hard ly be consid ered sp eci c; Schenk and Brem s (1998)
noted that p atients w ith MDI m ight also p resent w ith p ain in
m id range p ositions.
Examination
As ind icated above, the exam ination of a patient w ith shoul-
d er instability shou ld not be lim ited to the shou ld er gird le but
also inclu d e a search for cau sative or contribu tory d ysfu nc-
tions throu ghou t the kinetic chain in the u p p er and low er
qu ad rants. Sp eci c to the shou ld er, thou gh, a scanning exam i-
nation m u st inclu d e assessm ent of three-d im ensional p ostu re.
Winging of the scapu la at rest and in 90° abd uction can be
ap preciated w ith a posterior view and it ind icates the need
for speci c m u scle strength and exibility tests. A sid e view
m ay su ggest m u scle length restriction in the p ectoralis m inor,
as evid enced by a shou ld er held in protraction and elevation
w ith scapu lar inferior bord er w inging. A patient w ith an unre-
d uced anterior or inferior d islocation m ay present w ith the
hu m eral head visible and p alp able on the chest w all ou t of
the glenoid socket. Patients w ith u nred u ced p osterior d isloca-
tion m ay p resent w ith the arm held and xed in ad d u ction
and internal rotation.
Active range of m otion in card inal planes w ith overp res-
su re and d iscrete resistance to m u scles w hile on stretch
(Cyriax 1978), as w ell as com bined m otions, are initial tests
for provocation and assessing integrity. Easy to spot are
p atients w ith lu xatio erecta, w ho are not able to low er their
arm s from the elevated position (Cam ard a et al 2009). Patients
w ith posterior d islocation m ay have the hum eral head caught
on the p osterior glenoid rim , thu s locking the shou ld er
betw een 10° and 60° of internal rotation w ith no external rota-
tion p ossible from this p osition (Cicak 2004). Should this
initial screen not provoke the patient’s sym ptom s, the clini-
cian m ay su sp ect a rem ote sou rce, inclu d ing referred m echan-
ical pain from the cervical spine or a non-m echanical aetiology.
N ote that, unless there has been recent trau m a, there m ay w ell
be a fu ll or nearly fu ll range of m otion in the should er gird le.
A neu rovascu lar exam ination for com p rom ise, esp ecially in
the p atient w ith a p ossible d islocation, w ill com p lete the
seated exam ination. Close insp ection of the scap u la from a
p osterior view p oint d u ring arm elevation w ill be help fu l in
the investigation of abnorm al rhythm , lack of u p w ard rotation
and abd u ction, or m ed ial bord er w inging, as d iscu ssed in
Chapter 32.
Magarey and Jones (1992) have su ggested the follow ing
(non-valid ated ) physical exam ination nd ings as ind icative of
m inor instability: (1) excessive m obility or loss of norm al end
feel on instability tests w ith or w ithout ap prehension or intra-
articu lar click, (2) full or excessive range of m otion w ith end -
range pain, (3) loose end feel w ith less of a ligam entou s
character, (4) external rotation at 90° abd u ction that is either
lim ited by spasm or show s excessive range, (5) p ain-free and
 326 PART 4 • 28 • Glenohumeral instability
strong rotator cu ff contractions w ith the excep tion of an often-
w eak bu t pain-free infraspinatus. Again, though, note that
m any of these nd ings m ay not be very sp eci c.
Stability tests
Sp ecial tests for clinical instability of the glenohu m eral joint
fall into tw o categories (Levy et al 1999; Ellenbecker et al 2002;
Tibone et al 2002). Stability tests use provocation, app rehen-
sion and end feel to d eterm ine joint integrity tow ard s end
range, w hereas laxity tests exam ine the m obility of a joint in
fu nctional and m id ranges of m otion. Bahk et al (2007) con-
clu d ed that sp ecial tests can ad d signi cantly to ou r assess-
m ent of the u nstable shou ld er bu t nd ings on clinical laxity
exam ination and relevance to instability m u st be placed in
p ersp ective. If nd ings ‘ t’ they con rm and solid ify the d iag-
nosis. If nd ings on these tests d o not t w ith other history
and exam ination nd ings, laxity alone m eans nothing excep t
a ‘loose shou ld er ’, w hich is not a d iagnosis bu t rather a physi-
cal exam nd ing. In the clinic of the second au thor, throw ing-
related MDI is often su perim posed up on an alread y genetically
loose shou ld er cap su le that su bsequ ently becom es too loose
and ‘d ecom p ensates’. An im p ortant parad ox is that it is p artly
the genetic laxity that initially allow s these athletes to su cceed
at a high level in overhead athletic events su ch as throw ing.
Once they d ecom p ensate, how ever, the original ad vantage
becom es a d isad vantage.
Apprehension test
The patient is sup ine on the table, w ith the glenohu m eral joint
at the ed ge of the table bu t the scapu la su p ported by the table.
The patient’s shou ld er is at 90° of abd u ction, the elbow is
exed to 90° and the exam iner ’s knee su p ports the elbow to
p revent extension of the shou ld er. The exam iner then applies
external rotation progressively u ntil the patient can tolerate
no fu rther rotation, and the d egree of rotation is record ed . In
p atients w ith anterior instability, a patient’s report of appre-
hension and a feeling that the shou ld er w ill com e ou t of joint
is consid ered to be a p ositive test. Som e au thors note that p ain
in this m anoeu vre m ay be ind icative of m ore su btle anterior
instability. Sensitivity for this test for the d iagnosis of trau -
m atic anterior instability has been established at 52.78% and
sp eci city at 98.91% (Lo et al 2004).
Relocation test
First d escribed by Jobe et al (1989), the relocation test com -
p rises the ap p lication of a posterior force to the hum eral head
in the p osition of ap p rehension as record ed in the above test;
it is p ositive if it relieves the sym p tom s of ap p rehension.
Although Lo et al (2004) proposed this test to d ifferentiate a
su btle instability in the overhead athlete from rotator cu ff
im p ingem ent, if p ain w as exp erienced in the ap p rehension
test and im p roved w ith the relocation test the sensitivity and
sp eci city w ith p rod u ction and su bsequ ent red u ction of p ain
w ere both low – at 40% and 42.65% respectively. H ow ever,
w hen consid ering solely d im inished ap prehension as a posi-
tive test nd ing, sp eci city w as 100% for anterior should er
instability – althou gh sensitivity stayed low at 31.94%. Red uc-
tion of sym p tom s is u su ally associated w ith an increase in
external rotation range.
Surprise (release) test
In this test, w hile hold ing the nal position of the relocation
test, the exam iner ’s hand is qu ickly rem oved from the p roxi-
m al hu m eru s and the p atient’s resp onse elicited . A p ositive
test is ind icated by a su d d en retu rn of the sym p tom s noted
w ith the apprehension test. The surprise test w as reported to
have a sensitivity of 63.89% and speci city of 98.91% for the
d iagnosis of anterior instability (Lo et al 2004). N ote, thou gh,
that the su rp rise test p u ts the shou ld er into a m ore vu lnerable
p osition of greater external rotation than d oes the ap p rehen-
sion test. For this reason, to p erform the su rp rise test safely
and accu rately w e recom m end that the apprehension and
relocation tests be perform ed rst. This w ill give the exam iner
an initial im pression of w here the patient feels vu lnerable and
thu s allow s carefu l p lacem ent of the p osterior-d irected force
so as to ap p ly and release it w ithin the p atient’s com fort level.
If the clinician perform s a surprise test im m ed iately this m ay
not only startle the p atient bu t also can acu tely d islocate the
shou ld er.
Posterior shou ld er instability has typ ically been exam ined
w ith a load -and -shift test prod u cing posterior translation, or
by posterior joint line tend erness (Eckenrod e et al 2009).
Patients m ay also have a p ositive jerk test. This test is p er-
form ed w ith the patient su pine, and the arm to be tested in
90° abd u ction and internal rotation. An axial load is then
ap plied as the arm is brought into horizontal ad d u ction. The
test is p ositive if the m anoeu vre p rod u ces a p alp able or
au d ible clunk, as w ell as pain. Sensitivity and sp eci city w ere
rep orted to be 73% and 98% resp ectively, in the d iagnosis of
a p ostero-inferior labral lesion (Kim et al 2005).
Laxity tests
Motion in any sim p le p lane of the glenohu m eral joint resu lts
in coupled m otion in tw o ad d itional planes. A strain-gauge
analysis of the glenohum eral ligam ents show ed that, for
each ligam ent tested , a tension-sharing relationship existed
w ith transfer of tension am ong all ligam ents (Terry 1991).
Still, Fow ler & Pettm an et al (1992), in their teaching at the
N orth Am erican Institute of Orthopaed ic Manu al Therapy
(N AIOMT), have proposed that the capsuloligam entou s
com p lex of the glenohu m eral joint be tested in serial fashion
to d iscrim inate the p red om inant site of inju ry or loss of integ-
rity. Using an electronic d igital ruler, Sharp and Kisser
(unpu blished research 2009), in a p hysical therap y d octoral
cap stone research p roject at And rew s University in Berrien
Sp rings, Michigan, p rovid ed p relim inary valid ation for the
selective tensioning su ggested as the rationale for the follow -
ing N AIOMT tests for the SGH L, MGH L and AB-IGH L.
NAIOMT SGHL / CHL test
With the p atient su p ine, and the shou ld er to be tested at the
ed ge of the exam ination table w ith the scapu la sup ported on
the table, the shou ld er is p laced in 0° abd uction and end -
range external rotation is follow ed by an anterior glid e of the
p roxim al hu m eru s (Fig. 28.3) so as to test the SGH L and the
p osterior or lateral band of the CH L. If the arm is now allow ed
to m ove into 10° extension, the anterior or m ed ial band of the
CH L com es m ore u nd er tension (Fig. 28.4).
 Diagnosis of glenohumeral instability 327

Figure 28.3 NAIOMT SGHL / posterior CHL test.

Figure 28.5 NAIOMT MGHL test.

Figure 28.4 NAIOMT SGHL / anterior CHL test.

NAIOMT MGHL test

From the test p osition of 0° abd uction, 10° extension and end -
Figure 28.6 NAIOMT AB-IGHL test.
range external rotation, the exam iner now m oves the arm to
45° abd u ction and then app lies an anterior m ed ial glid e in the
plane of the glenohum eral joint su rface (Fig. 28.5) to test the
MGH L.

NAIOMT IGHL test

From the MGH L test position, the exam iner now m oves the
arm to 90° abd u ction and applies an anterior m ed ial glid e to
the p roxim al hu m eru s to test the AB-IGH L (Fig. 28.6). The
PB-IGH L is tested w ith the arm m aintained in this p osition of
90° abd u ction and 10° extension, bu t now w ith full internal
rotation, and a posterior lateral glid e applied to the gleno-
hu m eral joint (Fig. 28.7) (Fow ler & Pettm an 1992; Levine &
Flatow 2000).

NAIOMT posterior capsule test

The exam iner brings the arm to 90° exion, follow ed by full
internal rotation, then end -range horizontal ad d uction, and
nally ap p lies an axial stress to the p roxim al hu m eru s in a
postero- lateral d irection to test the p osterior capsule (Fig.
28.8) (Fow ler & Pettm an 1992; Urayam a 2001). Figure 28.7 NAIOMT PB-IGHL test.
 328 PART 4 • 28 • Glenohumeral instability

Figure 28.8 NAIOMT posterior capsule test. Figure 28.9 NAIOMT sulcus sign in external rotation.

NAIOMT sulcus stability test for AB- / PB-IGHL

and inferior labrum
A su lcu s sign or d im p le created beneath the acrom ion w hen
the su bject’s arm is axially tractioned inferiorly, u su ally in a
seated p osition, w as rst d escribed as the hallm ark test for
MDI if it also rep rod u ces the p atient’s characteristic sym p -
tom s (N eer & Foster 1980). H ow ever, Bahk et al (2007)
reported the test as provocative of a p atient’s sym ptom s in
only a sm all nu m ber of sym p tom atic p atients. The d egree of
laxity consid ered to be relevant has also been arbitrary, and
McFarland et al (2003) su ggested that the su lcu s sign m ight
lead to an overd iagnosis of MDI. Pettm an (p ersonal com m u -
nication 2009) has su ggested a m od i cation of the su lcu s sign.
In this test, the exam iner stabilizes the scapula by hold ing
one hand in the axilla. With the other hand the exam iner
rotates the arm into external rotation and , w hile hold ing this
p osition, ap p lies an inferior force to assess for a su lcus sign,
w hich is su ggested as consistent w ith a p ossible labral lesion Figure 28.10 NAIOMT sulcus sign in internal rotation.
in the AB-IGH L com p lex (Fig. 28.9). If this sulcus sign is
p resent in the sam e test w ith the arm in fu ll internal rotation, p osterior d islocations it is p osterior (Workm an et al 1992;
a p ossible labral lesion in the PB-IGH L com p lex is su ggested Cicak 2004).
(Fig. 28.10). With a sensitivity of 97% and sp eci city of 91%, m agnetic
resonance im aging (MRI) has been show to have greater accu -
Imaging racy than plain rad iography and arthroscopy in the d iagnosis
of H ill–Sachs lesions (Workm an et al 1992). MRI is m ost
From a m ed ical–su rgical p erspective, in the vast m ajority of u sefu l for visu alizing the rotator cu ff in eld erly p atients w ho
p atients the d iagnosis of instability is based on the history and have su stained a d islocation and are at risk for a rotator cu ff
p hysical exam ination in com bination w ith plane rad iographs. tear as a resu lt of the d islocation. The second au thor consid ers
Plain rad iograp hs are also im p ortant in ru ling ou t fractu res, m agnetic resonance arthrograp hy (MRA), w ith gad oliniu m
w hich are often associated w ith d islocations. Whereas a contrast injected into the joint, to be the im aging stu d y of
stand ard anterop osterior view of the u ncom p licated u nstable choice for p atients w ith m echanical sym p tom s w here there is
shou ld er m ay p rod u ce equ ivocal nd ings or m ay be hard to a clinical concern for labral or intra-articu lar pathology. MRA
interp ret, an axillary lateral view is help fu l to visu alize the can be p articu larly valu able in the you ng athlete w ho is su s-
p resence and extent of a (reverse) H ill–Sachs lesion, bu t m ay p ected of a d islocation, bu t w ho m ay clinically have su ffered
be near im possible to obtain in a p atient w hose abd u ction is only a su blu xation. In the op inion of the second au thor, in the
severely lim ited ow ing to the p ain. The lateral scap u lar p lane young overhand athlete, a clear labral d etachm ent (either an
view is p articu larly help fu l in d eterm ining the relationship of anterior or posterior Bankart tear) and a clear H ill–Sachs
the hu m eral head to the glenoid . In anterior d islocations of lesion on MRA (Fig. 28.11) w ould serve to con rm a d isloca-
the shou ld er, the hu m eral head lies anterior to the glenoid ; in tion and steer the treating p hysician tow ard s a su rgical

Figure 28.11 Hill–Sachs lesion on MRI.
repair – ow ing to the high risk of recu rrent instability w ith
non-op erative m anagem ent. Com p u ted tom ograp hy (CT) can
be a very u seful tool for im aging bony d efects su ch as a H ill–
Sachs lesion or an anterior glenoid bone d e ciency (Cicak
2004). This can be usefu l in su rgical planning and for help ing
to d eterm ine the need for alternative p roced u res to ad d ress
bony d efects.
Prognosis
The challenge to the orthopaed ic physical therapist is to d eter-
m ine w hich p atients p resenting w ith instability can be best
Prognosis 329
m anaged on a conservative basis w ith a w ell-ou tlined and
carefu lly m anaged p rogram m e, and w hich p atients are best
referred for further d iagnostic testing and orthop aed ic su rgery
consu ltation. Patients w ho m ay requ ire su rgical stabilization
m u st not be d elayed or m issed as the long-term ou tlook for
recu rrence and m orbid ity associated w ith further insult to the
articu lar cartilage is of prim ary concern. Althou gh the au thors
d id not stu d y the possibly m itigating effect of conservative or
su rgical intervention, based on a case–control stu d y Marx
et al (2002) rep orted that the risk of d evelop ing severe arthro-
sis of the shou ld er is betw een 10 and 20 tim es greater for
p atients w ho have had a p reviou s d islocation.
In the clinical opinion of the second author, the you ng
p atient (less than 20 years of age) w ith a rst-tim e trau m atic
anterior d islocation w ith a Bankart tear and H ill–Sachs lesion
is the m ost obviou s high-risk patient, and probably the only
clear cand id ate for early su rgery after a single instability
ep isod e (Arciero et al 1994). In ad d ition, the eld erly p atient
w ith a rotator cu ff tear and w eakness shou ld be consid ered
for su rgery ow ing to the risk of pain and w eakness, rather
than risk of recu rrent d islocation. All others shou ld be con-
sid ered for su rgery w hen they fail non-op erative m anage-
m ent w ith p ersisting sym p tom s, or if they have recu rrent
d islocations or subluxation sym p tom s. Althou gh the exact
risk of recu rrent instability is im possible to d eterm ine for any
ind ivid u al, risk factors have been id enti ed that help u s clas-
sify those ind ivid u als w ho are at increased risk of recu rrent
instability. Risks of recurrence can be broken d ow n into the
follow ing clinical and anatom ical risk factors.
Clinical risk actors
The age at w hich the rst d islocation occu rs is a very pow erful
p rognosticator. In you ng p atients aged less than 20 years,
recu rrence rates have ranged from 55% to 94%. Te Slaa et al
(2004) reported 26% recurrence w ithin 4 years; in this stu d y,
age w as the m ost signi cant p rognostic factor w ith recu rrence
in 64% of p atients less than 20 years of age, versu s only 6% of
those old er than 40 years. Kralinger et al (2002) also rep orted
an age betw een 21 and 30 as the only factor associated w ith
recu rrence. N ote that ad vancing age is, how ever, associated
w ith an increased risk of falling lead ing to recu rrent d isloca-
tion and an increasing incid ence of rotator cu ff tears.
Chronicity refers to the nu m ber of tim es that a p atient has
su ffered a d islocation. Althou gh rare, a tru ly chronically d is-
located shou ld er is one that has d islocated and rem ains d is-
located . An acute d islocation is a shou ld er that has just
d islocated and is in need of red uction. More com m on clini-
cally is the recu rrent d islocation. The recu rrent d islocator is
the p atient w ho rep orts both p rior d islocations and su bse-
qu ent red u ctions. The m ore often a p atient has su ffered w ith
an instability episod e, the m ore likely it is that a su bsequ ent
recu rrence w ill take place. There is, how ever, no consensu s on
the nu m ber of instability ep isod es beyond w hich the risk
becom es a certainty.
A trau m atic aetiology is associated w ith a higher recu r-
rence risk than either m icrotrau m atic / overu se or atraum atic
instability. Atrau m atic instability, especially w hen associated
w ith generalized ligam entous laxity, is in fact a risk factor for
su rgical failu re. Volition is the p atient’s ability to rep rod u ce
the sym p tom or d islocation at w ill; som e d escribe their ‘trick
 330 PART 4 • 28 • Glenohumeral instability
shou ld er ’ and can volu ntarily d em onstrate the ability to d is-
locate or su blu xate their joint. These volu ntary d islocators
need carefu l screening for em otional and m ental health issu es,
as althou gh not an absolute su rgical contraind ication, su rgery
in this su bset of p atients need s to be very carefu lly consid ered
only after failu re of non-op erative m anagem ent and carefu l
cou nselling of the p atient and fam ily.
Althou gh p erhaps consid ered by som e as an ind ication of
likely failu re w ith conservative m anagem ent, p atients w ith
MDI m ay bene t from conservative m anagem ent. In ad d ition,
in a su bset of p atients w ith MDI, the natu ral history even
w ithou t conservative intervention seem s benign. Ku rod a et al
(2001) rep orted sp ontaneous recovery in 43 of 476 shou ld ers
of p atients follow ed for 3 years or longer. Althou gh shou ld er
kinem atics m ay not be restored w ith physical therapy in all
p atients w ith MDI, som e of w hom m ay rather requ ire surgical
intervention and p ostop erative p hysical therap y (Kiss et al
2010), conservative m anagem ent has been show n to be effec-
tive in an as-yet not clearly id enti ed su bset of these p atients
and u ltim ately m ay be the key to a successfu l ou tcom e. Gleno-
hu m eral instability can occu r as a com p lete sep aration of the
hu m eru s from the glenoid socket, or as a p artial sep aration or
su blu xation. Dislocations carry a higher risk of associated
inju ry and recu rrence.
Anatomical risk actors
Anatom ical risk factors for recu rrence inclu d e soft tissu e and
bony d efects. Soft tissue d efects inclu d e rotator cu ff, labral
and capsu lar tears. Bony d efects inclu d e glenoid rim fractures
and (reverse) H ill–Sachs lesions. A H ill–Sachs lesion is basi-
cally a d ent in the hu m eral head cau sed by an im p action
fracture that occurs as the head d islocates and im pacts the
anterior or posterior glenoid rim . An engaging H ill–Sachs
lesion is a d ent that hooks over the ed ge of the glenoid in a
fu nctional range of m otion and , by levering, creates a high
risk for recurrent anterior or posterior glenohum eral d isloca-
tion (Fig. 28.12). A large or engaging H ill–Sachs lesion consti-
tu tes a higher risk for recu rrent d islocation.
Figure 28.12 Hill–Sachs lesion.
Management o Glenohumeral
Instability
Inferior and anterior d islocations are generally ad d ressed
w ith closed red u ction, w ith the patient sed ated (Baba et al
2007; Cam ard a et al 2009). Cicak (2004) suggested that closed
red u ction und er general anaesthesia of a p osterior d islocation
is m ost likely to be su ccessful in patients w ith a hu m eral head
d efect of less than 25% of the articu lar surface w here the d is-
location is present for less than 3 w eeks. If closed red u ction
is u nsu ccessful the surgeon m ay have to progress to an open
red u ction. Althou gh in som e ju risd ictions, su ch as m ost prov-
inces in Canad a, it is w ithin the physical therapy scope of
p ractice to red u ce acu te d islocations of extrem ity joints; nev-
ertheless, the risk of associated fractu res and neurovascu lar
and other soft tissue d am age, the lack of access to im aging
and the inability to provid e sed ation clearly ind icate the need
for m ed ical–su rgical referral and m anagem ent w here p ossi-
ble. Su rgical m anagem ent m ay also inclu d e ad d ressing the
p ossibly p resent anatom ical risk factors for recu rrence
ad d ressed above.
In the p ast, patients post d islocation have often been tem -
p orarily im m obilized w ith a sling that keep s the arm in
ad d uction and internal rotation. Althou gh bracing the lim b in
15–20° of external rotation has been su ggested as being ana-
tom ically m ore bene cial and lead ing to d ecreased recu rrence
(Itoi et al 2001, 2003; Fu nk & Sm ith 2005), m ore recent research
has p ointed ou t that the evid ence is insu f cient to su p p ort u se
of one im m obilization m ethod over the other, or even to
su p p ort im m obilization at all (Kralinger et al 2002; H and oll
et al 2006; Sm ith 2006; Finestone et al 2009). It should also be
noted that patient com pliance w ith the required 3 w eeks of
full-tim e bracing is often lim ited , irrespective of the m ethod
u sed .
Although not provid ing su f cient operational d e nitions
of sp eci c interventions, Kralinger et al (2002) rep orted that
p articip ation of p atients in p hysical therap y d id not red u ce
risk of recu rrence. In general, insu f cient evid ence is available
to gu id e p hysical therap y m anagem ent after closed red u ction
of trau m atic anterior d islocation, w hich is p erhap s re ective
of insu f cient m ethod ological qu ality of stu d ies in this area
(H and oll et al 2006). A Cochrane review reported no d iffer-
ences, w ith regard to renew ed inju ry or function, betw een
op en and arthroscop ic stabilizing su rgery for anterior shou l-
d er instability in ad u lts (Pulavarti et al 2009). Scheibel (2007)
d iscussed the possibility of subscapu laris d ysfunction after
op en rep airs and , consid ering the im p ortant role of this
m u scle in the transverse p lane stabilizing force cou p le, this
m ay p resent another reason to choose arthroscop ic over op en
techniqu es. Lim ited evid ence su p p orts su rgery in you ng,
p red om inantly m ale ad u lts w ith a rst acu te trau m atic d islo-
cation w ho are engaged in highly d em and ing p hysical activi-
ties for red u cing recu rrent d islocation or su blu xation;
how ever, no evid ence is available to d eterm ine the best
treatm ent for other p atient grou p s (H and oll & Al-Maiyah
2004).
In the absence of research to gu id e conservative m anage-
m ent of p atients p ost d islocation, bu t also those p atients
w ith (m inor) instability, therapists have had to d epend on

clinical reasoning and extrap olation from basic science
research. Te Slaa et al (2004) d id not report sports participa-
tion as a risk factor for d islocation, yet Ku rod a et al (2001)
reported an 8.7-fold increase in incid ence of spontaneous
recovery for those patients w ith atraum atic shou ld er instabil-
ity w ho d iscontinued playing overhead sports. Provision of
ed u cation regard ing ad aptation in high-risk m ovem ents in
sp orts seem s a logical intervention. In athletes, this inclu d es
m od i cation of the often ancillary w eight-training activities.
Fees et al (1998) su ggested a grip w id th d uring the bench
press of less than 1.5 tim es the biacrom ial d istance in p atients
w ith anterior shou ld er instability. Other su ggested m od i ca-
tions inclu d ed requ ired assistance w hen lifting the bar from
and onto the rack, d ecrease of the shou ld er abd u ction angle
d u ring the bench press, alternation of at and d ecline bench
press to red u ce the chance of m icrotrau m atic injury, and elim i-
nation of the incline bench p ress and the behind -the-neck
press and p u ll-d ow n exercises, as w ell as the back-squ at posi-
tion, w here the hand s stabilize the bar on the shou ld ers. In
patients w ith p osterior shou ld er instability, Fees et al (1998)
su ggested a grip w id th d u ring the bench p ress of > 2 tim es
the biacrom ial w id th, u se of a shou ld er abd u ction angle > 80°,
horizontal abd u ction > 15° at the start and horizontal ad d u c-
tion < 20° at the nish of the bench p ress m otion. They also
prop osed m and atory assists w ith (u n)racking the bar and
u se of the at bench p ress only, or p referably no bench p ress
at all.
As d iscu ssed in Chapter 28, p rop riocep tive d e cits have
also been id enti ed in p atients w ith anterior glenohu m eral
joint instability as w ell as altered m u scle activation (Myers
et al 2004). Decreased rotator cuff coactivation and slow er
biceps brachii and pectoralis m ajor activation w ere id enti ed
and restoration of their norm al fu nction, and thu s shou ld be
part of any targeted rehabilitation program m e for anterior
instability. A d efect in proprioception also m ay be a factor in
the p athop hysiology of MDI (Schenk & Brem s 1998). Dynam ic
exercises incorporating propriocep tive neurom uscu lar facili-
tation (PN F) have been fou nd to be effective in the early
phases of shou ld er rehabilitation (Pad u a et al 2004). Utilizing
w ell-established principles of PN F to the up per qu ad rant such
as rhythm ic stabilization, eccentric-to-concentric load ing and
continu ou s m ovem ents associated w ith rotation (Knott &
Voss 1968), therapists can easily im plem ent and progress a
program m e even in the early stages. Closed kinetic chain
exercises, initially on stable and later on unstable su rfaces, can
increase the accu racy of joint position sense and enhance
stim u lation of m echanorecep tors (N au ghton et al 2005; Eck-
enrod e et al 2009). Op en-chain oscillatory exercises w ith the
Bod yblad e® can be u sed to p rovid e m ore ad vanced op en-
chain d ynam ic stabilization (Bu teau et al 2007). Exercises for
m u scu lar end u rance and strength need to ad d ress both the
local stabilizers in an attem pt to restore at least the active (if
not the p assive) contribu tion to the concavity com p ression
m echanism , as w ell as the p rim e m overs requ ired for fu nc-
tional m ovem ent and know n to have an effect on gleno-
hu m eral stability. A carefu l p rogression need s to be both
ad ap ted to the p atient’s fu nctional d em and s and rehabilita-
tion goals and also based on a carefu l and ed u cated im p res-
sion of the therap ist w ith regard to rehabilitation p otential.
Chap ters 32 and 33 provid e exam ples of exercises for m otor
control and other exercises relevant to the shou ld er.
Conclusion 331
Conclusion
Shou ld er instability can p resent a challenge to the orthop ae-
d ic p hysical therapist in d ifferential d iagnosis and m anage-
m ent. Id enti cation of p atients at high risk for recu rrence of
shou ld er d islocation ind icates the need for referral to a shou l-
d er specialist for likely su rgical intervention. Further research
on d iagnostic and p rognostic valid ity of ou r clinical tests,
su ch as those ou tlined above, is necessary and w ou ld help
d rive outcom e stu d ies of conservative versu s surgical m an-
agem ent for possible su bgrou ps of p atients id enti ed on the
basis of ou r clinical tests. A clear ind ication of glenohu m eral
instability shou ld not lim it the therapists to m anagem ent of
the shou ld er area alone. Patients w ith a history of shou ld er
instability should be exam ined for u nd erlying biom echanical
faults in both the u pper and low er qu ad rants that m ay con-
tribu te to the instability in m ore d ynam ic activities.
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Superior Labrum Anterior-to-Posterior (SLAP) Lesions
CHAP TER CONTENTS
Introduction  333
Anatomy  334
Biomechanics  335
Pathology  336
Diagnosis  337
Management  340
Prognosis  341
Conclusion  341
Introduction
Su p erior labru m anterior-to-p osterior (SLAP) lesions have
been d iscussed and investigated since And rew s et al f rst
d escribed this p athology in 1985. SLAP lesions involve the
su p erior glenoid labru m extend ing anteriorly and p osteriorly
(And rew s et al 1985; Snyd er et al 1990; D’Alessand ro et al
2000; Kim et al 2003; Bed i & Allen 2008; Dod son & Altchek
2009). SLAP lesions not only involve the su perior glenoid
labru m , bu t can also a ect the bicep s tend on and gleno-
hu m eral ligam ent attachm ents (D’Alessand ro et al 2000;
Dessau r & Magarey 2008). SLAP lesions are o ten com plex
injuries w ith a spectrum o locations and varied typ es o
tissu e d e ects in the glenoid labru m and its associated stru c-
tu res (D’Alessand ro et al 2000; Lebolt et al 2006; Bed i & Allen
2008).
These variants, in ad d ition to age-related changes in the
su p erior labru m , have thw arted an u nd erstand ing o the
precise ep id em iology o SLAP lesions (Bed i & Allen 2008).
Their prevalence has been reported in the literature to range
betw een 6% and 76% o all should er inju ries evalu ated arthro-
scop ically, bu t even ind ep end ent o their large range the rel-
evance o this reported prevalence to prim ary care settings
is u nclear (Snyd er et al 1990; Liu et al 1996a; Mileski &
Snyd er 1998; D’Alessand ro et al 2000; H iggins & Warner 2001;
H u ijbregts 2001; Mu sgrave & Rod osky 2001; Kim et al 2002,
2003; Gu anche & Jones 2003; Wilk et al 2005; Lebolt et al 2006;
Barber et al 2007; Funk & Snow 2007; Bed i & Allen 2008;
Walsw orth et al 2008; Dod son & Altchek 2009). Without sup-
plying sp ecif c qu antitative d ata, these lesions have been
d escribed as com m on occu rrences in the athletic popu lation,
particu larly in overhead / throw ing athletes (Lebolt et al 2006;
 
Chapter  29  
J a n e tte W. Po w e ll, P e te r A. Hu ijb re g ts
Fu nk & Snow 2007; Bed i & Allen 2008; Dod son & Altchek
2009). H ow ever, a num ber o au thors note the challenge o
d eterm ining the clinical relevance o a SLAP lesion w hen
there are coexisting lesions in the shou ld er (Mu sgrave &
Rod osky 2001; Stetson & Tem p lin 2002; McFarland et al 2002;
Kim et al 2003, 2007; Dod son & Altchek 2009). Di f cu lties
associated w ith investigations o SLAP lesions inclu d e the
variability o p athological f nd ings, clinical eatu res and the
p revalence – all o w hich can vary d epend ing on the p op ula-
tion stu d ied (Kim et al 2003).
SLAP lesions have been classif ed into typ es on the basis
o their m orp hological p attern. Snyd er et al (1990) classif ed
these p athological variations into ou r typ es (Fig. 29.1):
• type I: d egenerative raying w ith no d etachm ent o the
biceps insertion
• type II: d etachm ent o the bicep s insertion
• type III: a bucket-hand le tear o the su perior asp ect
o the labru m w ith an intact bicep s tend on insertion
to bone
• type IV: an intrasu bstance tear o the biceps tend on w ith
a bu cket-hand le tear o the superior aspect o the labru m .
The type II SLAP lesions have been urther d ivid ed into three
su btyp es (Fig. 29.2) d ep end ing on w hether the d etachm ent o
the labru m involves solely the anterior asp ect o the labru m ,
solely the p osterior asp ect, or both asp ects. The above classi-
f cation system has been exp and ed to inclu d e an ad d itional
three typ es (D’Alessand ro et al 2000; H iggins & Warner 2001;
H uijbregts 2001; Musgrave & Rod osky 2001; Parentis et al
2002; Kim et al 2003; N am & Snyd er 2003; Wilk et al 2005), as
ollow s:
• type V: a Bankart lesion that extend s superiorly to
includ e a type II SLAP lesion
• type VI: an u nstable ap tear o the labru m in
conju nction w ith a bicep s tend on sep aration
• type VII: a sup erior labrum and bicep s tend on separation
that extend s anteriorly, in erior to the m id d le
glenohu m eral ligam ent.
The prevalence o the various types o SLAP lesions as
reported in the literatu re again show s w id e ranges: type I
20–74%, type II 21–70%, type III 1–9%, and typ e IV 4–10%
(Snyd er et al 1995; Kim et al 2003; Kam pa & Clasp er 2005).
The p revalence o associated pathology, w ith other intra-
articu lar lesions, has been reported to range rom 62% to 88%
(Snyd er et al 1995; Mileski & Snyd er 1998; Kim et al 2003).
 334 PART 4 • 29 •
A B
Figure 29.1 Classi cation of superior glenoid or superior labrum and biceps anchor (SLAP) lesions: (A) type I, degenerative raying o the superior labrum with the
edge still f rmly attached to the glenoid; (B) type II, detachment o the superior labrum and biceps tendon rom the glenoid with resultant destabilization o the biceps
anchor; (C) type III, bucket-handle tear o superior labrum. The remaining labrum and biceps anchor are stable; (D) type IV, bucket-handle tear o superior labrum with
extension into the biceps tendon.
A B C
Anatomy
The glenoid labrum is a triangular f brocartilaginous structu re
that sits on the p erip hery o the glenoid rim . It is a transitional
connective tissu e, typ ically an ovoid circu m erential rim , that
lies betw een the articu lar su r ace o the glenoid ossa and the
f brou s cap su le o the glenohu m eral joint (D’Alessand ro et al
2000; H iggins & Warner 2001; Mu sgrave & Rod osky 2001;
Wilk et al 2005). Mu sgrave and Rod osky (2001) d escribe this
labral rim as being approxim ately 3 m m high and 4 m m
w id e. The d epth o the glenoid ossa is d oubled w ith the
labru m and the su r ace contact area betw een the hu m eral
head , and the glenoid is greatly enhanced by the labru m
(H iggins & Warner 2001; H u ijbregts 2001; Mu sgrave &
Rod osky 2001, Wilk et al 2005). The su perior labru m is trian-
gular in cross-section, is ‘loosely’ attached to the glenoid w ith
a ree ed ge and is com m only d escribed as ‘m eniscal’ in its
m orp hology (H u ijbregts 2001; Mu sgrave & Rod osky 2001;
N am & Snyd er 2003; Wilk et al 2005; Dessaur & Magarey
2008). The in erior labrum , in contrast, is rou nd ed and f rm ly
attached (H u ijbregts 2001; Mu sgrave & Rod osky 2001; N am
& Snyd er 2003; Wilk et al 2005).
The blood su p p ly to the labru m arises m ostly rom its
p eripheral attachm ent to the capsu le and is rom a com bina-
tion o the su p rascap u lar artery, the circu m ex scap u lar
branch o the su bscapu lar artery and the p osterior circum ex
hu m eral arteries (H u ijbregts 2001; N am & Snyd er 2003; Wilk
et al 2005). The literatu re on the extent and localization o
Superior labrum anterior-to-posterior (SLAP) lesions
C D
Figure 29.2 Subtypes of type II SLAP lesions: (A) anterior,
(B) posterior, (C) combined anterior–posterior.
vascu larization o the glenoid labru m is contrad ictory, w ith
som e au thors d escribing only vascu larization o the p erip h-
eral labrum , w hich in ad d ition is m ore extensive posteriorly
and in eriorly than (antero)sup eriorly (Cooper et al 1992; H u i-
jbregts 2001; N am & Snyd er 2003; Wilk et al 2005, Dessau r &
Magarey 2008), w hereas other au thors have d escribed m ore
global vascu larization (Prod rom os et al 1990). The qu estion o
w hether the su perior labru m is ind eed a vascu lar structure
has im p ortant im p lications in term s o the healing p otential
o a SLAP lesion (D’Alessand ro et al 2000; Dessau r & Magarey
2008); vascu larity o the labrum appears to d ecrease w ith
increasing age (H uijbregts 2001; N am & Snyd er 2003; Wilk
et al 2005).
Other glenohu m eral stru ctu res, inclu d ing the su p erior and
m id d le glenohu m eral ligam ents and the bicep s tend on, are
noted to be continu ou s and intim ately related w ith the
su p erior labru m (D’Alessand ro et al 2000; H u ijbregts 2001;
Mu sgrave & Rod osky 2001; Parentis et al 2002; Wilk et al
2005; Dessaur & Magarey 2008). The anterosu perior labrum
is one o the m ost variable areas o glenohum eral anatom y
(Fig. 29.3). It is im p ortant that norm al variants o this anatom y
are recognized as non-p athological (D’Alessand ro et al 2000;
H iggins & Warner 2001; H u ijbregts 2001; Mu sgrave &
Rod osky 2001; Kim et al 2003; Wilk et al 2005). A sublabral
recess or oram en has been reported in up to 73% o norm al
shou ld ers and consists o an op ening or hole betw een the
labru m and glenoid rim (Mu sgrave & Rod osky 2001). Its size
can vary rom only a ew m illim etres to sp anning the entire
anterosup erior qu ad rant (Fig. 29.4A) (D’Alessand ro et al

2000; H u ijbregts 2001; Mu sgrave & Rod osky 2001; N am &
Snyd er 2003; Wilk et al 2005). The Bu ord com plex represents
another anatom ical variant and is d escribed as a cord -like
thickening o the m id d le glenohu m eral ligam ent and absence
o the anterosu p erior labru m (Fig. 29.4C). This com plex is
reported to be less com m on, w ith prevalence ranging betw een
1.5% and 5% (Mu sgrave & Rod osky 2001; Bents & Skeete 2005;
Wilk et al 2005). Relevant to accu rate d iagnosis is the f nd ing
that, in norm al variants, the ed ges o both the labru m and
glenoid can be expected to be sm ooth w ithou t the raying or
haem orrhage that w hen noted on arthroscop y w ou ld be m ore
su ggestive o a p athological d etachm ent (D’Alessand ro et al
2000; H iggins & Warner 2001; H u ijbregts 2001; Mu sgrave &
Rod osky 2001; Wilk et al 2005).
The anatom y o the origin o the tend on o the long
head o bicep s (LH B) is noted to be highly variable (Barber
et al 2007; Ghalayini et al 2007; Dierickx et al 2009). Stu d ies
have rep orted that betw een 25% and 60% o LH B tend ons
originate rom the su p raglenoid tu bercle, w ith the rem aind er
originating rom the su p erior glenoid labru m (Pal et al 1991;
Vangsness et al 1994; Ghalayini et al 2007; Kru p p et al 2009).
Other variations that have been d escribed inclu d e a sp lit
tend on rom a single origin, a d ou ble tend on origin rom the
cap su le, labru m or tu berosity, m ed ial and / or lateral tend on–
cap su lar ad hesions, m ed ial and / or lateral tend on–rotator
cu ad hesions, and even a com p lete absence o the LH B
tend on (Dierickx et al 2009). It is ad d itionally noted that a
greater portion o the LH B attachm ent to the labrum is to the
Acromion Supraspinatus muscle
Coracoid process
Articular capsule
Long head of the
biceps tendon
Superior glenohumeral
ligament
Infraspinatus muscle Subscapular recess
Glenoid cavity
Subscapularis tendon
Glenoid labrum
Teres minor muscle
Middle glenohumeral
ligament
Inferior glenohumeral
ligament complex
Figure 29.3 Arthroscopic anatomy of the glenohumeral joint.
A B C
Biomechanics 335
p osterior labru m (Vangsness et al 1994; Dierickx et al 2009).
The variable attachm ent o this biceps anchor m ay m ake it
d i f cu lt to d i erentiate pathological d etachm ent o the biceps
anchor rom a norm al m eniscoid labru m w ith a su blabral
recess or a Bu ord com plex (D’Alessand ro et al 2000; H iggins
& Warner 2001; H uijbregts 2001; Mu sgrave & Rod osky 2001;
Kim et al 2003; N am & Snyd er 2003; Wilk et al 2005; Barber
et al 2007).
Biomechanics
The labrum appears to serve as a buttress assisting in control-
ling glenohu m eral translation, sim ilar to a ‘chock-block’ (Wilk
et al 1997, 2005; H uijbregts 2001). Labral d am age d isru pts the
circu lar conf gu ration and the hoop stresses, rend ering this
‘chock-block’ m echanism less e ective (H ow ell & Galinat
1989; H uijbregts 2001). Resection o the labru m has been
show n to red u ce the concavity-com p ression stabilization o
the glenohu m eral joint by 10–20% (Lip pitt et al 1993; Wilk
et al 1997; H ald er et al 2001). The labru m has also been
d escribed as u nctioning like a seal, w hereby labral injury
results in a loss o negative intra-articu lar pressu re thereby
d im inishing glenohu m eral joint stability (H u ijbregts 2001).
The biceps–labru m com plex has been show n to be an
im portant stabilizer o the glenohum eral joint (Bed i & Allen
2008). And rew s et al (1985) noted that electrical stim u lation
o the bicep s d u ring arthroscop y led to hu m eral head com -
p ression w ithin the glenoid . Increased glenohu m eral transla-
tion has been d em onstrated w hen the long head o the bicep s
tend on has been d estabilized (Pagnani et al 1995; Warner &
McMahon 1995; Prad han et al 2001). Warner and McMahon
(1995) observed u p to 6 m m o su perior hu m eral m igration
d uring active abd u ction in ind ivid u als w ith isolated LH B
tend on tears com p ared w ith their intact contralateral shou l-
d ers. Kim et al (2001) reported that m axim al bicep s activity
occu rred w hen the shou ld er w as in the abd u cted and exter-
nally rotated p osition in p atients w ith anterior instability.
SLAP lesions resu lt in signif cant increases in strain o the
anterior band o the glenohu m eral ligam ent w ith shou ld er
abd u ction and external rotation, suggesting a key role o the
su p erior labru m in glenohu m eral stability (Rod osky et al
1994). Pagnani et al (1995) ou nd that a com plete lesion o the
su p erior p ortion o the labru m w as associated w ith signif cant
increases in glenohum eral translation and that a sim ulated
SLAP lesion resu lted in a 6 m m increase in anterior gleno-
hu m eral translation. Rod osky et al (1994) observed that a
SLAP lesion contribu ted to anterior shou ld er instability by
Figure 29.4 Normal anatomical variants of the anterosuperior
glenoid labrum and glenohumeral ligaments: (A) sublabral
oramen, (B) cord-like middle glenohumeral ligament, (C) Bu ord
complex (cord-like middle glenohumeral ligament with absence o
anterosuperior labral tissue).
 336 PART 4 • 29 • Superior labrum anterior-to-posterior (SLAP) lesions
d ecreasing the shou ld er ’s resistance to torsion and placing a
greater strain on the in erior glenohu m eral ligam ent. Panos-
sian et al (2005) d em onstrated how a type II SLAP lesion
increased total glenohu m eral range o m otion, in ad d ition to
anteroposterior and in erior translation.
Pathology
Associated pathology is com m only encou ntered w ith SLAP
lesions, m ost notably concom itant rotator cu tears and other
labral p athology (Dod son & Altchek 2009). And rew s and
Carson (1984) noted that 45% o ind ivid u als (and 73% o base-
ball pitchers) w ith SLAP lesions also had partial-thickness
tears o the su p rasp inatu s. Mileski and Snyd er (1998) rep orted
that 29% o their ind ivid u als w ith SLAP lesions had partial-
thickness rotator cu tears, 11% com plete rotator cu tears,
and 22% Bankart lesions. They also noted that typ e I lesions
w ere typically associated w ith rotator cu pathology, w hile
typ es III and IV w ere associated w ith trau m atic instability.
Ad d itionally they observed that, in p atients w ith type II
lesions, old er ind ivid u als tend ed to have associated rotator
cu p athology w hile you nger ind ivid u als had associated
anterior instability.
Dod son and Altcheck (2009) explained how recognition o
these associated lesions acilitates insight into the biom echani-
cal aetiology o SLAP lesions. There are several p rop osed
m echanism s or SLAP lesions. These m echanism s can be
d ivid ed into acute traum atic events and chronic repetitive
inju ries that lead to ailu re (Dod son & Altchek 2009). Acute
trau m atic events, su ch as alling onto an ou tstretched arm or
a d irect lateral blow to the shou ld er, m ay resu lt in a SLAP
lesion rom im p action o the hu m eral head against the su p e-
rior labrum and the biceps anchor (D’Alessand ro et al 2000;
Funk & Snow 2007; Bed i & Allen 2008; Dod son & Altchek
2009). Sud d en in erior p ulls on the arm , su ch as w hen losing
control o a heavy object, anterior traction w hile w ater skiing,
or su p erior traction w hen grasp ing overhead to stop a all, are
trau m atic m echanism s o inju ry d escribed in the literatu re
(Ma et et al 1995; D’Alessand ro et al 2000; Barber et al 2007;
Bed i & Allen 2008). SLAP lesions in the throw ing athlete have
also been p ostu lated to be traction inju ries o the biceps–
labru m com p lex (H iggins & Warner 2001; Fu nk & Snow 2007).
And rew s and Carson (1984) theorized that SLAP lesions in
overhead -throw ing athletes w ere the resu lt o the high eccen-
tric activity o the bicep s m u scle, creating tension on the long
head o the bicep s tend on d u ring the arm d eceleration and
ollow -throu gh p hases o throw ing. The sud d en tensile load
on the bicep s w as su ggested to avu lse the bicep s–labrum
com p lex (And rew s & Carson 1984; H iggins & Warner 2001).
Su bsequ ent research w ith electrical stim u lation ap p lied to the
biceps d uring arthroscopy have, ind eed , noted that biceps
activation cau sed the bicep s anchor to sep arate rom the
glenoid (And rew s et al 1985). Electrom yographic stud ies
show ing increased bicep s activity a ter ball release su p p ort
this theory (Jobe et al 1984; Glou sm an et al 1988; D’Alessand ro
et al 2000).
Rep etitive overhead activity has been hyp othesized as a
com m on m echanism or p rod u cing SLAP lesions (Funk &
Snow 2007; Dod son & Altchek 2009). The traction injury
m echanism d escribed above has also been p ostu lated to resu lt
in repetitive m icro- rather than m acrotrau m a (avu lsion), pro-
gressively lead ing to stru ctu ral ailu re o the biceps–labru m
com p lex (D’Alessand ro et al 2000). Bu rkhart and Morgan
(1998) hyp othesized that a ‘p eel-back’ m echanism m ay
p rod u ce a SLAP lesion in the overhead athlete. They theorized
that, w hen the shou ld er is p laced in abd u ction and m axim al
external rotation, the rotation causes a torsional orce at the
base o the biceps. Prad han et al (2001) m easu red superior
labral strain d uring each phase o the throw ing m otion and
reported increased su perior labral strain d u ring the late
cocking p hase o throw ing, w hich su p p orts the concep t o the
‘peel-back’ m echanism .
Ad d itional authors (Walch et al 1992; Jobe 1995) have d em -
onstrated contact betw een the posterior–superior labru m and
the rotator cu w hen the arm is in an abd u cted and externally
rotated p osition, w hich sim u lates the late cocking phase o
throw ing. Shep ard et al (2004) sim u lated each o the a ore-
m entioned m echanism s in nine p airs o cad averic shou ld ers
that w ere load ed to bicep s anchor ailu re in either a p osition
o inline load ing (sim ilar to the d eceleration p hase o throw -
ing) or in a sim u lated peel-back m echanism (sim ilar to the late
cocking p hase o throw ing). Their resu lts show ed that all o
the sim u lated p eel-back grou p ailu res resu lted in a typ e II
SLAP lesion, w hereas the m ajority o the sim u lated inline-
load ing grou p ailu res occurred in the m id -substance o the
biceps tend on. Ad d itionally, the biceps anchor d em onstrated
a signif cantly higher strength w ith inline load ing as opp osed
to the u ltim ate strength d u ring the ‘p eel-back’ m echanism .
These results sup port the theory o peel-back as the pred om i-
nant m echanism , bu t d oes not exclu d e a com bination o
m echanism s in the aetiology o SLAP lesions (Dod son &
Altchek 2009).
A nu m ber o au thors have rep orted an association betw een
SLAP lesions and glenohu m eral instability (Cord asco et al
1993; Rod osky et al 1994; Pagnani et al 1995; D’Alessand ro
et al 2000; H iggins & Warner 2001; Kim et al 2001; Prad han
et al 2001; Parentis et al 2002; Panossian et al 2005; Bed i &
Allen 2008; Dod son & Altchek 2009). H ow ever, the exact
cau se-and -e ect relationship o instability and SLAP lesions
is still unclear (Liu et al 1996b; H iggins & Warner 2001;
Parentis et al 2002). It m ay be that instability allow s or a
p athological range o m otion that acilitates the p eel-back
m echanism , or conversely that SLAP lesions allow or exces-
sive glenohu m eral translation, w hich then lead s to instability
(H u ijbregts 2001; Parentis et al 2002; Dod son & Altchek 2009).
Internal im pingem ent is another proposed m echanism
w hereby the su perior labrum is subjected to shear and d irect
contact, in the p osition o m axim al shou ld er abd u ction and
external rotation, betw een the greater tu bercle o the hum eru s
and the posterosu perior rim o the glenoid (Bed i & Allen 2008;
Cools et al 2008; H eyw orth & William s 2009). Recurrent abut-
m ent, betw een the articu lar sid e o the rotator cu , the p os-
terosu p erior labru m and the glenoid rim , u ltim ately
p recip itates articu lar-sid ed rotator cu tears and p osterosu -
p erior labral lesions (H iggins & Warner 2001; D’Alessand ro
et al 2000; Bed i & Allen 2008; H eyw orth & William s 2009). A
range o theories has been proposed regard ing internal
im p ingem ent and the role that this p lays in should er d ys u nc-
tion and SLAP lesions (Wilk et al 2005; H eyw orth & William s
2009). Also a num ber o clinical f nd ings have been associated
w ith internal im pingem ent inclu d ing glenohum eral internal
rotation d ef cit, SICK scapu la synd rom e, posterior hu m eral

head lesions, p osterior glenoid bony inju ry and Bankart
and in erior glenohu m eral ligam ent lesions (H eyw orth & Wil-
liam s 2009).
A variety o aetiological m echanism s have been im p licated
or SLAP lesions (D’Alessand ro et al 2000; H iggins & Warner
2001; H u ijbregts 2001; Mu sgrave & Rod osky 2001; Parentis
et al 2002; Burkhart et al 2003; N am & Snyd er 2003; Wilk
et al 2005; Bed i & Allen 2008; H eyw orth & William s 2009).
Mu sgrave and Rod osky (2001) su ggested that d i erent m ech-
anism s o inju ry w ere likely to be op erational in the variou s
SLAP-lesion typ es. It is p robable that the varied p athoanat-
om y and / or p athom echanics o these d i erent typ es o SLAP
lesions signif cantly alter the clinical presentation (Kim et al
2003; Wilk et al 2005). Kim et al (2003) noted how the rarity
o som e o the typ es o SLAP lesions lim its the statistical
evaluation o som e actors that m ight be im portant in und er-
stand ing the p athop hysiology o su ch lesions. Kim et al (2003)
and Rao et al (2003) rep orted a p ositive association betw een
anterosu p erior labral anatom ical variants and anterosu perior
labral raying. These authors postu lated that anatom ical vari-
ants in u enced glenohu m eral biom echanics and p red isposed
the shou ld er to SLAP lesions (Kim et al 2003; Rao et al 2003;
Bed i & Allen 2008). A retrospective review by Bents and
Skeete (2005) su p p orted this p ostu lation: they ou nd the p res-
ence o a Bu ord com plex correlated w ith the presence o a
SLAP lesion in p atients. Ad d itionally, a sp lit bicep s tend on
has been associated w ith a d isp laced su p erior labru m in a
typ e IV lesion (Parentis et al 2002, N am & Snyd er 2003).
Diagnosis
Clinical d iagnosis o the SLAP lesion is d i f cu lt (Mu sgrave &
Rod osky 2001; Dod son & Altchek 2009). The clinical presenta-
tion and correct d iagnosis, even w hen u sing arthroscop y f nd -
ings as a gold stand ard , are com plicated by the variability o
‘norm al’ anatom y o the superior labrum (D’Alessand ro et al
2000; H iggins & Warner 2001; H u ijbregts 2001; Mu sgrave &
Rod osky 2001; Kim et al 2003; N am & Snyd er 2003; Wilk et al
2005). Ad d ing to these intrinsic com plexities, these lesions are
o ten associated w ith ad d itional concom itant shou ld er p athol-
ogy that in u ences p atient p resentation (Mileski & Snyd er
1998; Mu sgrave & Rod osky 2001; H u ijbregts 2001; Parentis
et al 2002; Kim et al 2003; Wilk et al 2005). A num ber o
au thors note the d i f cu lty in clinically d i erentiating, via
exam ination, a SLAP lesion rom concom itant pathology; they
report that, d espite e orts seen in literatu re to f nd clinical
tests or the id entif cation o SLAP lesions, a signif cant
nu m ber o p atients w ith su ch lesions are d iscovered only at
arthroscop y (D’Alessand ro et al 2000; Kim et al 2003; Wilk
et al 2005). Thu s, extra- and intra-articu lar shou ld er patholo-
gies con use the clinical d iagnostic process (Mu sgrave &
Rod osky 2001).
Fu nk and Snow (2007) noted that the m ost com m on p re-
senting clinical sym p tom s w ith SLAP inju ries w ere m echani-
cal sym p tom s su ch as ‘locking, catching, p op p ing, or snap p ing’
in the shou ld er. Walsw orth et al (2008) investigated the d iag-
nostic yield o history f nd ings or glenoid labral tears (inclu d -
ing SLAP lesions); a com bined patient report o popping or
catching and a p ositive crank (sp ecif city 91%, +LR3.0) or
anterior slid e test (specif city 100%, +LR∞) suggested the
Diagnosis 337
p resence o a labral tear. In the absence o a p atient rep ort o
p op p ing or clicking, having a negative anterior slid e test or a
negative crank test su ggested absence o a labral tear (−LR0.31
and 0.33, respectively). Age as a p red ictor or su ch lesions has
been investigated by Liu et al (1996a) and Walsw orth et al
(2008) bu t has not been noted to be o d iagnostic u tility,
althou gh Liu et al (1996a) noted a tend ency or you nger ind i-
vid u als (< 35 years) to have such lesions.
From a retrospective stu d y, Kam pa and Clasp er (2005)
reported that ind ivid u als w ith a history o trau m a or sym p-
tom s o instability w ere m ore likely to have a SLAP lesion
than those p resenting w ith atrau m atic aetiologies (p < 0.0001).
Withou t p rovid ing research d ata, Barber et al (2007) su g-
gested that clinically relevant SLAP injuries w ere m ost o ten
ou nd in the d om inant arm o m en < 40 years o age w ho had
p articip ated in high-p er orm ance overhead activities or
m any years, p atients w ith a sp ecif c history o shou ld er
trau m a, or p atients w ith shou ld er instability. Barber et al
(2007) ad d itionally noted that a all onto an ou tstretched hand
or a p rior m otor vehicle accid ent in w hich the p atient w as
w earing a seat-belt w as su ggestive o a SLAP injury.
As m any as 21 d i erent clinical tests have been d escribed
and investigated or their valu e in the d iagnosis o SLAP
lesions. There exists a large variation in the positions and
m ovem ents u sed to rep rod u ce sym p tom s and m any au thors
report that no clinical test is sensitive and specif c enough or
the accu rate d iagnosis o SLAP lesions, noting the need or
arthroscopic visu alization or d iagnosis (Mirkovic et al 2005;
Bed i & Allen 2008; Dessau r & Magarey 2008; Pow ell et al
2008; McCau ghey et al 2009). In ad d ition, m ethod ological
inad equacies have been prevalent in research o SLAP lesion
clinical tests (Dessau r & Magarey 2008; Meserve et al 2008;
Pow ell et al 2008; Walsw orth et al 2008; Walton & Sad i 2008;
Mu nro & H ealy 2009).
It is p ossible, and m aybe even probable, that the varied
p athoanatom y and / or p athom echanics o the d i ering typ es
o SLAP lesions signif cantly alter the clinical p resentation
and clinical f nd ings (D’Alessand ro et al 2000; H u ijbregts
2001; Mu sgrave & Rod osky 2001; Parentis et al 2002; N am &
Snyd er 2003; Wilk et al 2005; Dessaur & Magarey 2008;
Ebinger et al 2008; Dod son & Altchek 2009; Kibler et al 2009).
Ebinger et al (2008) p rop osed that the exion resistance test
has high sp ecif city or typ e II SLAP lesions. The sp eed test
and O’Brien test have been rep orted to be highly sp ecif c or
anterior type II SLAP lesions, w hereas the m od if ed Jobe relo-
cation test has been rep orted as highly sensitive and highly
sp ecif c or p osterior SLAP lesions (D’Alessand ro et al 2000;
Burkhart & Morgan 2001; Burkhart et al 2003; Wilk et al 2005).
The anterior scap ular slid e test has been reported to be u se u l
or d etecting anterior SLAP lesions (Burkhart & Morgan 2001;
Burkhart et al 2003). H u ijbregts (2001) reported that the SLAP-
p rehension test show ed greater sensitivity or id enti ying
types II–IV SLAP lesions and that the active com p ression
(O’Brien) test, the provocation test and the biceps load test
w ere u se u l or d istingu ishing betw een stable and u nstable
SLAP lesions. H ow ever, typ e-sp ecif c d iagnostic u tility statis-
tics have yet to be rep orted (Pow ell et al 2008).
The clinical recom m end ations or the utilization o clinical
SLAP lesion tests are varied . There are inconsistencies in the
recom m end ations based on the variou s review s available on
this top ic. H eged us et al (2008) p rop osed , w ith cau tion, that
the bicep s load II test ap p eared d iagnostic or SLAP lesions.
 338 PART 4 • 29 • Superior labrum anterior-to-posterior (SLAP) lesions

Cools et al (2008) p rop osed the inclu sion o the sp eed test, the
active com p ression test and the bicep s load II test w hen inves-
tigating SLAP lesions. Meserve et al (2008) p rop osed that the
active com p ression test shou ld be u tilized to ru le ou t a SLAP
lesion and that the sp eed test shou ld be u sed to ru le in a SLAP
lesion w hen the active com p ression test or crank test have
p ositive f nd ings. Meserve et al (2008) reported that a positive
sign on all three tests (active com p ression test, crank test,
sp eed test) increases the p robability that a SLAP lesion is
p resent. Meserve et al (2008) and Pand ya et al (2008) claim ed
the active com p ression test to be one o the best tests or d iag-
nosing SLAP lesions. Oh et al (2008) conclu d ed rom a stud y
o m u ltitest regim ens that com binations o tw o relatively sen-
sitive clinical tests and one relatively sp ecif c clinical test
increase the d iagnostic e f cacy o su p erior labru m anterior
and p osterior lesions.
Based on their system atic review o the d iagnostic accu racy
research, the cu rrent au thors recently recom m end ed the
inclusion o the ollow ing clinical tests w ith the ollow ing
interpretation or the d iagnosis o SLAP lesion (w ith d iagnos-
tic accu racy d ata in Table 29.1):
• a negative f nd ing on the passive com pression test
(Fig. 29.5) to rule out a SLAP lesion;
• a positive f nd ing on the anterior app rehension
m anoeu vre (Fig. 29.6) (Gu anche & Jones 2003), the
anterior slid e test (Fig. 29.7) (Kibler 1995; Pow ell et al
2008), the Jobe relocation test (Fig. 29.8) (Cook &
H eged u s 2007), the p assive com pression test, the speed
test and the Yergason test, or on a com bination o p ositive
f nd ings on the Jobe relocation test and the active
com p ression test or the Jobe relocation test and the
anterior apprehension m anoeu vre, to rule in a SLAP
lesion.
The active com pression test has been d escribed in Chap ter 28.
In contrast to pain localized to the top o the shou ld er in the

Table 29.1 Ps ychome tric data for SLAP-le s ion clinica l e xa mination te s ts
Pa s s ive Ante rior Ante rior J obe Sp e e d Ye rga s on Active
comp re s s ion a p p re he ns ion s lide re loca tion compre s s ion

Accuracy 0.84 0.59 0.54–0.86 0.56 0.56–0.57 0.61–0.63 0.54–0.98

Sensitivity 0.82 0.4–0.83 0.05–0.78 0.44–1.0 0.04–0.48 0.09–0.43 0.47–1.0
Specif city 0.86 0.4–0.87 0.81–0.93 0.4–0.87 0.67–1.0 0.79–1.0 0.1–0.98
Pos itive predictive value 0.87 0.53–0.9 0.05–0.64 0.32–0.91 0.35–1.0 0.46–1.0 0.1–0.94
Negative predictive value 0.8 0.33–0.75 0.56–0.90 0.34–0.71 0.26–0.72 0.25–0.71 0.1–1.0
Pos itive likelihood ratio 5.72 1.38–3.07 0.50–9.22 1.07–3.39 0.0–1.47 0.0–2.05 0.78–66
Negative likelihood ratio 0.21 0.43–0.72 0.24–1.10 0.63–0.94 0.6–0.94 0.72–1.29 0.0–2.0
(From: Kibler 1995; O’Brien et al 1998; Hamner et al 2000; McFarland et al 2002; Stets on & Templin 2002; Guanche & Jones 2003; Holtby & Razmjou 2004; Myers et al
2005; Nakagawa et al 2005; Parentis et al 2006; Kim et al 2007; Powell et al 2008.)

Figure 29.5 Passive compression

test: (A) start position: the clinician
rotates the patient’s involved arm
externally with 30° o abduction and
pushes the arm proximally while
extending the shoulder, which results in
the passive compression o the superior
labrum onto the glenoid; (B) end
position. (From Powell et al 2008, with
permission.)

A B
 Diagnosis 339

Figure 29.6 Anterior apprehension manoeuvre. The patient is supine and the
examiner abducts the arm to 90° with the elbow in 90° o exion and then
progressively externally rotates the involved shoulder. A positive test is indicated by
a look or eeling o apprehension or alarm on the patient’s ace and the patient’s
resistance to urther motion. The patient might also state that the eeling
experienced is what it elt like when the shoulder was previously dislocated. (From
Powell et al 2008, with permission.)
Figure 29.7 Anterior slide test. The patient is examined standing or sitting with
hands on hips and the thumbs pointing posteriorly. One o the examiner’s hands is
positioned at the top o the shoulder rom the posterior direction, with the last
segment o the index f nger extending over the anterior aspect o the acromion at
the glenohumeral joint. The examiner’s other hand is placed behind the elbow and
a orward and a slightly superiorly directed orce is applied to the elbow and upper
arm. The patient is asked to push back against the clinician’s orce. Pain localized
to the ront o the shoulder under the examiner’s hand and / or a pop or click in the
same area is considered a positive result. This test is also considered positive i the
patient reported this testing manoeuvre reproduces their presenting symptoms as
associated with overhead activity. (From Powell et al 2008, with permission.)

A B

Figure 29.8 Jobe relocation test: (A) The patient is supine and the test per ormed at 90° o shoulder abduction with the involved shoulder in maximal external rotation.
Initially an anterior orce is applied to the proximal humerus. (B) A posterior orce is applied to the proximal humerus. Pain that occurs with the anterior orce and is relieved
or diminished pain with the posterior orce is considered a positive test f nding. (From Powell et al 2008, with permission.)
 340 PART 4 • 29 • Superior labrum anterior-to-posterior (SLAP) lesions

internally rotated p osition that is relieved in the externally

rotated position, w hich is consid ered ind icative o acrom io-
clavicu lar d ys u nction, p ain ‘d eep insid e the shou ld er,’ w ith
or w ithou t a click in the f rst p osition and elim inated or
red uced in the second position, is consid ered ind icative o a
glenoid labrum tear (O’Brien et al 1998; Pow ell & H uijbregts
2006). In the context o d iagnosis, the greatest value should
be p laced on a positive f nd ing on the p assive com p ression
test ow ing to the strength o its p ositive likelihood ratio
(Pow ell et al 2008).
Di erent im aging tests (m agnetic resonance im aging
(MRI), ultrasonography or com pu ted tom ography) m ay be
u se u l in conf rm ing the p resence o a SLAP lesion, bu t they
are rep orted to have a sensitivity o only 60–90%. The value
o im aging stu d ies has been qu estioned in the orthop aed ic
literatu re (Lu im e et al 2004). App roxim ately 10–20% o
p atients w ith a norm al read ing on should er MRI or u ltra-
sonograp hy m ay still have a SLAP lesion (Mileski & Snyd er
1998; Mim ori et al 1999; D’Alessand ro et al 2000; Bu rkhart &
Morgan 2001; Parentis et al 2002; Stetson & Tem p lin 2002;
Bu rkhart et al 2003; N am & Snyd er 2003; H oltby & Razm jou
2004; Lu im e et al 2004; Mirkovic et al 2005; N akagaw a et al
2005; Wilk et al 2005; Parentis et al 2006; Sw earingen et al
2006; Jones & Gallu ch 2007; Dessau r & Magarey 2008; Calvert
et al 2009). There ore, d ef nitive d iagnosis requ ires arthros-
cop y (D’Alessand ro et al 2000; Bu rkhart & Morgan 2001; N am
& Snyd er 2003; Bed i & Allen 2008). Figure 29.9 Coronal T1-weighted image of a SLAP lesion from an MR
Stand ard m u ltip lanar T1- and T2-w eighted MRI im ages arthrogram. Contrast material is interposed between the superior labrum and the
can d etect su p raglenoid cysts, w hich have been associated glenoid (arrow). The labrum is displaced (arrowhead). (From Powell et al 2008,
w ith type II SLAP lesions. These cysts can arise as a result o with permission.)
labral inju ry w ith a com m u nication throu gh the cap su le (N am
& Snyd er 2003). MR arthrography w ith gad oliniu m m ay o er
im p roved visu alization (N am & Snyd er 2003; Cli ord 2007; lesions is o ten unclear, rad iograp hic and im aging stud ies are
Bed i & Allen 2008; Magee 2009). Bencard ino et al (2000) requently used to aid in the d iagnosis. Im aging options
reported 89% sensitivity, 91% sp ecif city and 90% accu racy or enhance the d iagnostic ‘pictu re’ by enabling the clinician to
the d iagnosis o SLAP lesions w ith gad oliniu m -enhanced MR d eterm ine the presence or absence o com m on concom itant
arthrograp hy com p ared w ith a gold stand ard o arthroscopic p athology or SLAP lesions. The clinical valu e o these d iag-
f nd ings. H ow ever, alse-p ositive and alse-negative resu lts nostic tools shou ld not be u nd erestim ated in the clinically
d o occu r (Bu rkhart & Morgan 2001; Parentis et al 2002; N am com p lex SLAP lesions.
& Snyd er 2003; Cli ord 2007).
SLAP lesions m ay be visu alized on the coronal obliqu e
sequ ence as a d eep cle t betw een the su p erior labru m and the Management
glenoid that extend s w ell arou nd and below the biceps anchor
(Fig. 29.9). O ten the contrast m ed ium w ill d issipate into the Di erent types o SLAP lesions seem to respond to d i erent
labral ragm ent, cau sing it to ap p ear ragged / rayed or ind is- typ es o interventions (D’Alessand ro et al 2000; H u ijbregts
tinct. The axial view is som etim es help u l to view the d is- 2001; Parentis et al 2002, 2006; N am & Snyd er 2003; Wilk et al
p laced su p erior labral ragm ent. N orm al labral variants m ust 2005). Som e au thors (D’Alessand ro et al 2000; Bed i & Allen
be kept in m ind w hen view ing these labral im ages, as these 2008) propose an initial trial o conservative m anagem ent or
congenital variations o the anterosu p erior labru m can be SLAP lesions, w hereas others (Mileski & Snyd er 1998; Wilk
m islead ing and can com p licate resu lts (Parentis et al 2002; et al 2005; Dod son & Altchek 2009) propose that conservative
Cli ord 2007). I there is an associated labral split or biceps m anagem ent w ill be u nsu ccess u l. H ow ever, the natu ral
tear, as seen in a typ e III or IV lesion, the d isp laced ragm ent history o SLAP lesions is u nknow n and d ata regard ing the
m ay be d i f cu lt to visu alize u nless the su p erior labral area is e f cacy o conservative treatm ents or SLAP lesions are not
care u lly exam ined . available (D’Alessand ro et al 2000). Vascularization, and
Stand ard rad iograp hs (AP, axillary and ou tlet view s) thereby healing p otential, is a p rerequ isite or op tim al con-
cannot id enti y a SLAP lesion, bu t assessm ent o the acrom ial servative m anagem ent (Pow ell et al 2008; H uijbregts 2001).
m orp hology and the acrom ioclavicu lar joint are u se u l w hen Treatm ent goals or conservative m anagem ent w ou ld
the clinician is consid ering associated d isord ers (D’Alessand ro includ e the red uction o pain and m echanical sym ptom s, and
et al 2000; Bed i & Allen 2008; Dod son & Altchek 2009). the restoring and op tim izing o glenohu m eral and also
Although rad iographs are u sually norm al in isolated SLAP scap u lothoracic, acrom ioclavicu lar, sternoclavicu lar and
lesions, other p otential sou rces o abnorm alities can be evalu - thoracic m otion, strength and u nction. Dod son and Altcheck
ated (Wilk et al 2005). As the clinical presentation o SLAP (2009) d escribe conservative m anagem ent as inclu d ing
 Conclusion 341

relative rest rom aggravating activities; anti-in am m atory et al 2002; Wilk et al 2005; Bed i & Allen 2008). Su ture anchor
m ed ication; restoration o norm al shou ld er m otion – includ - repair is pre erred over biod egrad able sutu reless im p lants,
ing ad d ressing glenohu m eral internal rotation d ef cit, i w hich have been associated w ith com plications su ch as syno-
p resent; strengthening o the shou ld er gird le m uscu latu re to vitis, chond ral inju ry and m echanical ailu re (Bed i & Allen
restore norm al scapu lothoracic m otion; and progression to 2008).
ad vanced cond itioning activities that inclu d e trunk, core, SLAP lesions that are com p lex, su ch as those involving
rotator cu and scap ulothoracic m u sculature and sp ort / acro- rotator cu tears, those associated w ith glenohu m eral joint
batic / unctional skills. instability, or those w ith concom itant bicep s tend on pathol-
Cord asco et al (1993) stated that SLAP lesions are the resu lt ogy, are likely to resp ond to d i erent m anagem ent strategies
o instability and shou ld not be consid ered isolated lesions. rom isolated SLAP lesions (D’Alessand ro et al 2000; Kim et al
Shear orces at the glenohu m eral joint have been hyp othe- 2003; N am & Snyd er 2003; Panossian et al 2005, Wilk et al
sized to p lay a role in p rod u cing the labral lesion (Snyd er et al 2005). Concom itant shou ld er d isord ers shou ld be ad d ressed
1990; Bey et al 1998). Mu scle orce has been hyp othesized to and their m anagem ent m ay even be critical to ensu re a suc-
com p ress the hu m eral head into the labru m , w hich norm ally cess u l ou tcom e (Mileski & Snyd er 1998; H iggins & Warner
p revents it rom rolling u p and over the labru m (H ow ell & 2001, Dod son & Altchek 2009). SLAP lesions id entif ed at
Galinat 1989) but in the case o instability im p arts excessive arthroscopy m ay not be p athological or clinically signif cant,
shear and com p ressive orces to the labru m . Ad d ressing but rather are part o a constellation o generalized d egenera-
glenohu m eral instability w ould there ore be a treatm ent tive changes (Lebolt et al 2006; Bed i & Allen 2008).
p riority (H u ijbregts 2001). Liu et al (1996a) su ggested an
intensive 3-m onth p rogram m e o activity m od if cation, non-
steroid al anti-in am m atory m ed ications and physical therapy
or p atients w ith m ild instability and labral tears. The physical
Prognosis
therap y p rogram m e they d escribed involves p assive range o
In orm ation on the natu ral history o SLAP lesions is lacking.
m otion ollow ed by active range o m otion o the shou ld er,
Ou tcom e d ata, and there ore p rognosis, or conservatively
strengthening o the rotator cu and scap u lar stabilizers, and
m anaged SLAP lesions are also u nknow n. Conservative m an-
f nally u nctional and sp ort-sp ecif c activities. Patients w ho
agem ent o SLAP lesions (regard less o type) is o ten rep orted
experience relie are thou ght to have had pain as a resu lt o
to be u nsu ccess u l, bu t ou tcom e d ata are not p rovid ed (Mileski
the instability. It has been qu estioned w hether the p ain that
& Snyd er 1998; Wilk et al 2005; Dod son & Altchek 2009).
ind ivid u als w ith a SLAP lesion com plain o is the result o the
Fu rther, long-term results w ith sim p le d ebrid em ent o lesions
labral tear itsel or the instability (Liu et al 1996b; H u ijbregts
are o ten reported to be p oor, bu t again ou tcom e d ata are
2001).
rarely p rovid ed (Mileski & Snyd er 1998; Wilk et al 2005).
Mu sgrave and Rod osky (2001) rep orted that SLAP lesions
Cord asco et al (1993) rep orted d eterioration o clinical ou t-
shou ld be treated based on the typ e w ith w hich an ind ivid u al
com es w ith longer ollow -u p (78% p ain relie at 1 year, 63%
p resents. They proposed d ebrid em ent o type I lesions w ith
at 2 years) a ter SLAP lesion d ebrid em ent, w ith only 45% o
p reservation o the bicep s anchor, w hereas Wilk et al (2005)
ind ivid u als retu rning to their preoperative level o unction.
su ggested conservative m anagem ent or typ e I lesions. Typ e
Abbot et al (2009) rep orted that, in old er patients (> 45 years)
II lesions, d u e to the d isrup tion o the biceps attachm ent and
w ho presented or m anagem ent o rotator cu inju ry and type
consequ ent glenohu m eral instability, com m only requ ire su r-
II SLAP lesion, those w ho had d ebrid em ent rather than SLAP
gical repair or op tim al stabilization and restoration o u nc-
repair w ith concom itant rotator cu repair had signif cantly
tion (D’Alessand ro et al 2000; Musgrave & Rod osky 2001;
better unction, pain relie and range o m otion.
Parentis et al 2002, 2006; N am & Snyd er 2003; Panossian et al
The m ajority o the SLAP lesion su rgical ou tcom es pu b-
2005; Wilk et al 2005; Bed i & Allen 2008; Dod son & Altchek
lished report that 80–90% o ind ivid u als have good or excel-
2009). The bu cket-hand le tear o a type III lesion is typically
lent resu lts, at short-term or interm ed iate ollow -up a ter
excised , w ith care taken to avoid d estabilization o the m id d le
su rgical rep air o typ e II SLAP lesions (D’Alessand ro et al
glenohu m eral ligam ent, particularly i a cord -like m id d le
2000; Bed i & Allen 2008; Dod son & Altchek 2009). Dod son and
glenohu m eral ligam ent is present (D’Alessand ro et al 2000;
Alcheck (2009) noted a lack o long-term ollow -u p stu d ies
H iggins & Warner 2001; Mu sgrave & Rod osky 2001; Bed i &
ollow ing type II SLAP lesion repairs and suggested that sur-
Allen 2008; Dod son & Altchek 2009). Managem ent o type IV
gical repair o type II SLAP lesions in overhead athletes w ith
lesions is som ew hat d epend ent on the extent o injury to the
a non-trau m atic incid ent m ay be less success u l than in other
biceps tend on. When the biceps involvem ent is less than 30%
ind ivid u als. Bed i and Allen (2008) reported that ind ivid uals
then the torn tissu e is excised and the su p erior labru m
w ith trau m atic-onset, isolated type II SLAP lesions w ho then
repaired ; i the biceps involvem ent is m ore extensive then
had su rgical rep air rep orted greater su bjective satis action
either it is repaired or a tenod esis is per orm ed (Mileski &
than d id ind ivid u als w ith insid iou s SLAP inju ry.
Snyd er 1998; D’Alessand ro et al 2000; H iggins & Warner 2001;
Mu sgrave & Rod osky 2001; Parentis et al 2002; Wilk et al
2005; Bed i & Allen 2008; Dod son & Altchek 2009). SLAP lesion
typ es V, VI and VII are treated sim ilarly to typ es I to IV, bu t Conclusion
there is ad d itional treatm ent or the associated p athology
(type V – Bankart rep air and bicep s anchor stabilization, typ e In su m m ary, ind ivid u als w ho present w ith pain or d ys u nc-
VI – ap d ebrid em ent and biceps anchor stabilization, typ e tion o the shou ld er m ay have su stained an inju ry to the
VII – rep air o m id d le glenohu m eral ligam ent and biceps su p erior labru m . I p resent, the severity o a SLAP lesion is
anchor stabilization) (Musgrave & Rod osky 2001; Parentis w id ely variable and m ay, or m ay not, be clinically signif cant.
 342 PART 4 • 29 • Superior labrum anterior-to-posterior (SLAP) lesions
SLAP lesions are o ten associated w ith other intra-articu lar
shou ld er inju ries, and the exam ining clinician shou ld have
a high ind ex o su spicion or coexisting p athology. SLAP
lesions are d i f cu lt to id enti y clinically. There is a p au city o
evid ence-based guid ance or the clinical exam ination and the
op tim al m anagem ent strategy to em p loy. There is w id esp read
agreem ent that a trau m atic labral inju ry w here the biceps
origin is d isru p ted (typ es II, IV, V, VI and VII) need s su rgical
m anagem ent, yet long-term ou tcom e stu d ies have not been
p u blished to su pp ort this. Fu rther stud ies are need ed to gain
a better u nd erstand ing o the cau ses o SLAP lesions, to
im p rove clinical d iagnoses and to d eterm ine the op tim al m an-
agem ent strategy or su ch lesions. Areas that are m ost likely
to benef t rom m ore research inclu d e:
• long-term prognosis: stu d ying the sequ elae o SLAP
inju ry w ith valid ated relevant ou tcom e m easu res
• diagnostic testing: (a) stu d y o the d iagnostic utility or
typ e-sp ecif c clinical tests w ou ld allow the clinician to
d i erentiate w ithin SLAP lesions those best m anaged
conservatively rom those best m anaged su rgically
(H u ijbregts 2001; Pow ell et al 2008); (b) u rther d iagnostic
accu racy investigation into m ore recently p roposed
clinical tests or SLAP lesions inclu d ing the bicep s load II,
p assive com p ression and resisted su p ination external
rotation tests (Dessau r & Magarey 2008; Meserve et al
2008); (c) stu d y o the com bination(s) or clustering o
history com p onents and clinical tests or d eterm ining the
p resence or absence o type-specif c SLAP lesions
(Dessau r & Magarey 2008; Meserve et al 2008; Walsw orth
et al 2008)
• conservative treatment: the com parison o d i erent typ es
o su p ervised rehabilitation in the m anagem ent o the
varied typ es o SLAP lesions (H u ijbregts 2001)
• surgical treatment: stud y o the long-term ou tcom es o
su rgically m anaged SLAP lesions.
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Frozen Shoulder
30  Chapter 
C a re l Bro n , Arth u r d e G a s t, J o L.M . Fra n s s e n
CHAP TER CONTENTS
Introduction  344
Incidence  344
Pathology  344
Natural history and prognosis  345
Diagnosis  346
History  346
Physical examination  347
Treatment  347
Recalcitrant frozen shoulders  348
Prevention of frozen shoulder  348
Conclusion  348
Introduction
Frozen should er (FS) or ad hesive capsulitis is, althou gh
know n for m ore than a centu ry, still an enigm atic and poorly
d e ned shou ld er d isord er. The earliest case report w as pub-
lished in 1872 by the French su rgeon Du p lay (1872), w ho u sed
the term ‘p eri-arthrite scap u lo-hu m erale’ w hen he d escribed
a d isord er sim ilar to the cond ition w e know now ad ays as
frozen shou ld er. This latter term w as introd u ced several
d ecad es later by Cod m an (1934). Finally, N eviaser (1945), an
orthop aed ic su rgeon also u sed the term ‘ad hesive cap su litis’
based on his arthrographic and intra-articu lar nd ings.
Cod m an (1934) stated that the frozen shou ld er w as ‘d if -
cu lt to d e ne, d if cu lt to treat, and d if cu lt to exp lain from
the p oint of view of p athology’. Obviou sly, not m u ch has
changed as the years have p assed . The three term s ‘frozen
shou ld er ’, ‘ad hesive cap su litis’ and ‘p eri-arthrite scap u lo-
hu m erale’ (althou gh the last one from Du p lay is now som e-
w hat ou td ated ) are all u sed to d escribe a clinical cond ition of
p ain and severe (m ore than 50%) restricted passive range of
m otion (PROM) of the glenohu m eral joint in all d irections
( exion, extension, abd uction, ad d u ction and internal–
external rotations). The aetiology of FS is u su ally u nknow n.
Patients occasionally m ention a variety of activities or circu m -
stances that they associate w ith the start of their com p laints.
Still, the exact cau se of FS rem ains to be established .
It is com m on u sage to d ifferentiate betw een a prim ary and
a second ary frozen shou ld er (Lu nd berg 1969). Prim ary FS is
 
id iopathic and not related to other d iseases, w hereas second -
ary FS is d e ned as being related to know n system ic p athol-
ogy, su ch as d iabetes m ellitu s, thyroid d isease or Parkinson’s
d isease, or occu rring post su rgery, post trau m a or after a
p eriod of im m obilization. It is d if cu lt to d ifferentiate, bu t one
m ight su ffer from p ost-su rgical shou ld er stiffness, w hich is
not the sam e as second ary p ost-su rgical FS.
In this chap ter w e w ill focu s on prim ary FS, w hich encom -
p asses the follow ing clinical criteria: (1) restriction of shou ld er
m otion w ithou t m ajor shou ld er inju ry; (2) global stiffness of
the shou ld er joint in all d irections, w ithou t the loss of strength,
joint stability, or joint surface integrity; and (3) plain should er
rad iographs d em onstrating a norm al glenohu m eral joint
sp ace and no p eriarticu lar abnorm alities, althou gh som e oste-
op enia of the p roxim al hu m eru s and glenoid m ay be seen.
Incidence
FS has an incid ence of 3–5% in the general p op u lation, and is
a com m on should er d isord er in orthopaed ic p ractice. In the
N etherland s it is calculated that 1 in 105 shou ld er p atients
w ho consu lt a general p ractitioner is d iagnosed w ith p rim ary
FS. FS is m ore com m on am ong patients w ith d iabetes, affect-
ing 20% or m ore of su ch p atients (Balci et al 1999; Kord ella
2002; Tighe & Oakley 2008).
Pathology
N orm al fu nctional lim its of the glenohum eral joint are d eter-
m ined by skeletal m orp hology, articu lar su rface area and the
exibility of the connection joint capsu le, ligam ents, m uscu lo-
tend inou s u nits and integu m ent. In a glenohu m eral joint w ith
sm ooth articu lar su rfaces, shou ld er stiffness occu rs as a resu lt
of (1) stiffening of the joint cap sule, ligam ents or m u scle–
tend on units, (2) ad hesions along the glid ing su rfaces betw een
the rotator cu ff and its su rrou nd ings, ad hesions in the bicep s
tend on m echanism and (3) extra-articular ad hesions. These
restrictions can occu r ind epend ently or in com bination. In
p rim ary FS the glenohu m eral fu nctional restriction m ost
p robably starts in the glenohu m eral joint cap su le, and d u ring
the cou rse of the d isease the stiffness m ay encom p ass soft
tissu e stru ctu res ou tsid e the joint.
 Natural history and prognosis 345

The p athological p rocess in p rim ary FS is not clear, althou gh

several au thors have tried to elu cid ate it (H anna n & Chiaia
2000; Cleland & Durall 2002; Uhthoff & Boileau 2007;
Schu ltheis et al 2008). It is generally accepted that und erlying A
FS is an in am m atory process of the synovial m em brane,
w hich is subsequ ently follow ed by a brotic reaction of the
brou s layer. There is still d isagreem ent over w hether or not
the u nd erlying p athology is an in am m atory p rocess, bu t
arthroscop y show s a hyp eraem ic and sw ollen synovial m em -
brane. The recent d iscovery of several cytokines in the joint
capsu le in p atients w ith FS su p p orts the in am m ation theory. I
The synovial reaction (or in am m ation) eventually lead s to
brosis of the u nd erlying layer of the glenohu m eral cap su le
( brous m em brane). Especially in the area of the coraco- II C
hu m eral ligam ent (CH L) and the rotator cu ff interval, scar
form ation and contractu re form ation are initiated by the
expression of vim entin (a cytocontractile p rotein that is
u su ally seen in brom yocytes), w hile in the entire joint
capsu le there is brop lasia (thickening of the joint cap su le)
bu t w ithout contraction.
Another im portant outcom e is the need for a d istinction
betw een broplasia and contracture. Uhthoff and Boileau
(2007) found that, althou gh brop lasia involves the entire
capsu le, the p resence of cytocontractile p roteins is lim ited to Figure 30.1 The coracohumeral ligament (II) shown in a normal cadaveric
the anterior cap su lar p art. Fu rther, brop lasia involves the right shoulder. Other visible structures are the coracoacromial ligament (I), the
entire joint capsule to an alm ost id entical d egree, w ith no acromion (A) and the coracoid process (C). (From Yang et al 2009, with
p referential involvem ent of the anterior capsu le. From this, it permission.)
follow s that the red u ced range of m otion of the p rim ary FS is
p rim arily attribu table to the contracture of anterior capsu lar
stru ctu res, p articu larly the CH L and the cap su le at the rotator
interval as seen by the selective expression of the cytocontrac- d egeneration in the low er regions of the cervical spine, (6)
tile p rotein vim entin. The above nd ing also con rm s the thyroid d isord ers, (7) d iabetes m ellitu s and (8) card iac and
clinical exp erience that su rgical d ivision of these stru ctu res is p u lm onary d isease.
u su ally su f cient to restore the lost range of m otion. Yang et al Prim ary FS seem s to be strongly associated w ith
(2009) stu d ied the anatom ical relationship of the CH L in 14 Dupu ytren’s d isease (Bu nker & Anthony 1995; Sm ith et al
norm al cad averic shou ld ers. In m ost of the cases (11 of 14) the 2001). Sm ith et al (2001) con rm ed that Dupu ytren’s d isease
CH L (Fig. 30.1) inserted into the rotator cu ff interval and the w as com m only seen in p atients w ith frozen shou ld er (52%),
su p rasp inatu s tend on, w hile in fou r the tend on of the su b- and this nd ing su ggests that the tw o cond itions m ay share
scap u laris w as also involved . The d issim ilarity in the inser- a com m on biochem ical p athw ay that lead s to contractu re.
tion of the CH L m ay be one of the reasons for d ifferent clinical Bunker and Anthony (1995) fou nd that the histological
p ictu res seen w ith, for exam p le, m ore or less lim itation of ap pearances of the tissues excised from p rim ary FS patients
external rotation. and those from patients w ith Du p uytren’s contractu res of the
Althou gh it is still controversial w hether the CH L is a sepa- hand w ere sim ilar.
rate entity or ju st a thickening of the glenohu m eral cap su le, Som e au thors also recognize sim ilarities w ith re ex d ystro-
Yang et al (2009) conclu d ed , based u p on their nd ings, that p hy (Su d eck’s d ystrop hy, or com p lex regional p ain syn-
the CH L p osition, m orp hology and origin are relatively d rom e typ e I, as it is referred to now ad ays) (H ertel 2000;
u nchanged , bu t that its insertion varies greatly and that the Mu ller et al 2000).
CH L is a m ore cap su lar than a ligam entou s stru ctu re based
on its histological featu res. Finally, althou gh N eviaser (1945)
w as convinced of the form ation of intra-articular ad hesion Natural History and Prognosis
betw een parts of the joint capsu le (especially in the axillary
recess) and the articu lar cartilage, there is nevertheless no Know led ge of the natu ral history of p rim ary FS is cru cial for
scienti c evid ence that this really exists. m aking treatm ent d ecisions. The natu ral history of FS is not
Despite all the scienti c w ork that has been d one on fully u nd erstood and rem ains controversial, as m any reports
p rim ary FS, the qu estion still rem ains as to w hat is the trigger of long-term follow -u p concern the evalu ation of p atient
for the cascad e of in am m atory and brogenetic processes. grou ps w ho have received particu lar treatm ent regim ens.
There is, how ever, som e know led ge about factors that pred is- Som e au thors have d escribed FS as a self-lim iting d isease
p ose to shou ld er stiffness, inclu d ing: (1) age, (2) m inor inju ries w ith an average d u ration of 1–3 years, bu t a substantial p art
w ith no d etectable stru ctu ral d am age to the glenohu m eral of the p op u lation p resents w ith su bstantial lim itations in
joint, (3) non-shou ld er su rgery (e.g. cervical neck d issection, glenohu m eral passive range of m otion for up to 10 years after
thoracotom y, sternotom y and intervention card iology), (4) the onset of their FS (Miller et al 1996). N evertheless, som e
im m obility, (5) cervical d isease su ch as intervertebral d isc d iscrep ancy m ay exist betw een the patient’s recognition of
 346 PART 4 • 30 •
Bo x 3 0 .1 S ta g e s o f fro z e n s h o u ld e r
S tag e  1: Fre e zing , s yno vitis  (duratio n 3–9 mo nths )
There is increas ing pain during res t and movement. As the
patient is often not able to lie down on the affected side,
sleep may be disturbed. When the patient makes a sudden
movement (this may often be called a ‘wrong movement’) it
can take s everal minutes (up to 15) before the pain s ubs ides .
The pain is very severe and is often scored on a visual
analogue s cale as reaching 9 or 10.
In this phas e it might be quite dif cult to diagnos e the primary
FS, becaus e of the abs ence of PROM limitation. Therefore
in this stage patients are often diagnosed with subacromial
tendinitis or bursitis. At the end of the freezing phas e, the
limitation of PROM becomes progress ively wors e.
S tag e  2: Fro ze n (duratio n 4–12 mo nths )
There is hypertrophy of the glenohumeral joint capsule and
contracture of the coracohumeral ligament and the rotator cuff
interval (Omari & Bunker 2001; Uhthoff & Boileau 2007).
In this phas e, pain will diminis h gradually, owing to the
recovery of the in ammatory proces s. Pain may be completely
abs ent during res t but pain felt at the end of the (s igni cantly
limited) range of motion is still present. Sleeping is s till
dis turbed becaus e lying on either side is still not poss ible
owing to the severe res triction of PROM (Cleland & Durall
2002). Although there is s ome mus cular atrophy due to
inactivity of the shoulder, severe loss of strength will not occur
during the cours e of FS. The PROM is limited by about 50% or
even more in all directions.
S tag e  3: Thawing  (be twe e n 12 and 42 mo nths )
This stage is characterized by gradually improving PROM.
fu nctional lim itation and the clinically m easu red objective
restrictions of the PROM. This can be explained by the fact
that shou ld er p ain is u su ally m ore incap acitating than is
restriction of glenohu m eral PROM as su ch.
To ou r know led ge, recu rrence of p rim ary FS in the sam e
shou ld er joint d oes not occu r, althou gh one case rep ort has
been pu blished (Cam eron et al 2000). In this case the patient
fu lly recovered w ithin 6 w eeks, w hich is very u nu su al for a
FS. Therefore w e d ou bt that this is ind eed the rst case report
of a recu rrent FS; m ost p robably, it is an exam p le of m istaking
a shou ld er com p laint for FS, w hich often hap pens. In a large
(269 shou ld ers) retrospective stud y on the long-term (5 years)
ou tcom e in p rim ary FS, H and et al (2008) reported no recu r-
rences. Sim u ltaneou s bilateral presentation of FS is rare, but
an FS d evelop ing over tim e in the opp osite shou ld er m ay be
seen in u p to ap p roxim ately 35% of cases.
FS is classically characterized by three clinical p hases:
(1) freezing p hase, (2) frozen phase, and (3) thaw ing phase
(N eviaser 1945) (Box 30.1). H ow ever, som e au thors use a
classi cation of fou r stages, w here the rst stage is d ivid ed
into a p ainfu l p re-freezing stage and a freezing stage w here
the PROM grad u ally d ecreases (N eviaser & N eviaser 1987;
H anna n & Chiaia 2000; Sherid an & H anna n 2006; Schu ltheis
et al 2008).
Patient ed u cation is one of the im p ortant asp ects of the
treatm ent. The clinician exp laining the benign natu re of the
Frozen shoulder
y
t
Pain Stiffness
i
s
n
e
t
n
I
Time (months)
Figure 30.2 The natural history of the self-limiting form of primary frozen
shoulder according to Hertel. (From Hertel R, 2000. Orthopäde 29: 845–851,
with permission.)
p rim ary FS help s to reassu re the p atient. Althou gh p rim ary
FS is seen as a self-lim iting d isease, this is p robably especially
tru e for the in am m atory p rocesses d u ring the rst stages.
H ow ever, the PROM restriction occasionally p ersists for
several years and m ight resu lt in m ajor lim itations in d aily
activities. Therefore it m ight be u seful for therap ist to instru ct
p atients to p erform gentle stretching exercises in the thaw ing
p hase. Very few cases w ill resu lt in a refractory p rim ary
frozen should er in w hich m ore rigorous interventions are
need ed . Accord ing to Tasto and Elias (2007), abou t 10–15%
of p atients continu e to su ffer from continu ou s p ain and
lim ited m otion, need ing up to 10 years to recover fu lly. Figu re
30.2 show s the natu ral history of the self-lim iting form of
p rim ary FS.
Diagnosis
The d iagnosis of a p rim ary FS should be easy. The history is
generally clear, p hysical exam ination only requires few d iag-
nostic shou ld er tests, and even few er ad d itional d iagnostic
tools are necessary. Still, FS is chosen as the m ost frequ ently
m isd iagnosed shou ld er com p laint in p atients referred for a
second op inion. FS is characterized by three p hases, and the
p ractitioner ’s clinical challenge consists of d iscrim inating the
exact phase and appropriate d uration of sym ptom s or signs.
(For d etails of these p hases see Box 30.1.)
History
Patients w ho p resent at the clinic are u su ally aged betw een
40 and 70 years, and w om en are m ore frequently affected than
m en (H anna n & Chiaia 2000). The right and left shou ld ers
are involved w ith equal frequency. Even w hen patients w ithin
the typ ical age grou p p resent them selves w ith a p ainfu l and
stiff shou ld er, and the d iagnosis of FS seem s obviou s, never-
theless other d iagnoses, su ch as neop lasias (Qu an et al 2005;
Sano et al 2010), glenohum eral infection, calci c bu rsitis or
tend initis, rotator cu ff lesions and glenohu m eral osteoarthri-
tis, have to be consid ered .
The pain is usually exp erienced in the should er region, the
d eltoid insertion and up per arm , bu t it often rad iates to the
neck and to m ore d istal regions of the u p p er extrem ity. In
the freezing p hase the p ain is felt d u ring rest and intensi ed
d u ring both m ovem ent and sleep. The am ount of pain strongly
d ep end s on the clinical phase of the d isease.

Physical examination
Exam ination starts w ith both shou ld ers exp osed . The align-
m ent and sym m etry of both shou ld er gird les and the cervical
sp ine are assessed . The cervical sp ine is assessed for m u scle
sp asm and local tend erness. Both shou ld ers are checked for
signs of m u scle atrop hy, form er trau m a and p athological
sw elling. N ext, the affected shou ld er is p alp ated . Patients w ith
FS typically d em onstrate tend erness in the region of the rotator
cu ff and su bacrom ial bu rsa, d eltoid insertion and along the
cou rse of the bicep s tend on. A p ainfu l bicep s tend on is often
confou nd ed w ith a tau t band in the anterior d eltoid , w hich is
m u ch m ore accessible to p alp ation than the bicep s tend on,
w hich lies d eep in the biceps groove und erneath a tight trans-
verse ligam ent. Myofascial trigger p oints (TrPs) m ay be fou nd
in alm ost all shou ld er m uscles, bu t m ost often in the su bscapu-
laris, infraspinatu s, teres m inor, teres m ajor, d eltoid and tra-
pezius m u scles. Accord ing to Sim ons et al (1999), the shou ld er
becom es m ore restricted in external rotation (up to 45% or
m ore) w hen TrPs in the su bscap u laris m u scle becom e p rogres-
sively active, w hereas TrPs in the teres m ajor m u scle m ay be
resp onsible for a restriction in abd u ction. It is unclear w hether
TrPs in the su bscap u laris m im ic a p rim ary FS, or w hether they
initiate it. Sim ons et al (1999) propose to m ake a d istinction
betw een severely restricted m otion d u e to active TrPs in the
shou ld er m u scu latu re and ad hesive cap su litis as a resu lt of
tru e brosis (see Ch 59 for m uscle TrPs).
Du ring assessm ent of the m obility of the shou ld er, particu -
lar attention shou ld be paid to the contribu tion of the gleno-
hu m eral joint to the total active and p assive range of m otion
(Fig. 30.3). Only then can FS be clinically d istinguished from
other d iseases that lim it shou ld er m obility.
In the pre-freezing and freezing phases, pain is the m ost
lim iting factor and the characteristic global restriction of the
glenohu m eral joint m ay be less clear. In the frozen phase, the
characteristic global lim itation of PROM of the glenohu m eral
joint is present. In the thaw ing phase, the global lim itation
fad es ou t and usu ally the contractu re of the rotator interval
cau ses a m arked lim itation of external rotation.
Figure 30.3 Patient with frozen left shoulder during shoulder abduction.
Treatment 347
Isom etric strength testing of the should er m u scles in a
p ain-free shou ld er p osition w ith the arm at the sid e of the
bod y is usually non-provocative and reveals nearly norm al
strength.
Treatment
Treatm ent regim ens d ep end on the stage of the FS. In the p re-
freezing ( rst phase) or freezing phase (second phase), the
chief com p laint of the p atient is the extrem e p ain. Treatm ent
therefore has to be aim ed at p ain relief u sing intra-articu lar
injections of corticosteroid s (Bu chbind er et al 2003), oral non-
steroid al anti-in am m atory d ru gs (N SAIDs) or su p rascap u lar
nerve block (H arm on & H earty, 2007), or treating the TrPs
in the surround ing shou ld er m uscles (Sim ons et al 1999;
Jankovic & van Zu nd ert 2006).
In one stud y (Bru e et al 2007), the use of corticosteroid s d id
not m ake any d ifference in long-term ou tcom e com p ared w ith
p hysiotherap y, althou gh it cou ld p rovid e som e p ain relief in
the early stages. Myofascial TrPs m ay occu r in rotator cu ff
m u scles, esp ecially in the su bscap u laris m u scle and in the
thoracoscap u lar m u scles; how ever, m anu al treatm ent of the
su bscap u laris m u scle m ay be d if cu lt becau se the m u scle is
p oorly accessible in severely restricted shou ld er joints. There-
fore TrP d ry need ling using a Jap anese need le plu nger to
p osition the need le d eep into the m u scle is a good op tion (Fig.
30.4). The other shou ld er m u scles can be treated either m anu-
ally or by TrP d ry need ling (see Ch 61 for TrP d ry need ling).
In som e cases, the ap plication of cold -packs or hot-packs (or
hot show er) m ay be bene cial. The p atient can ap p ly this
several tim es a d ay, as often as necessary.
In the freezing phase, it is not usefu l to perform gleno-
hu m eral joint m obilization – either becau se of the lack of
PROM restriction (in the p re-freezing p hase) or becau se the
p atient w ill resp ond w ith increasing p ain d u ring m obilization
Figure 30.4 Dry needling of subscapularis muscle using a Japanese needle
plunger.
 348 PART 4 • 30 • Frozen shoulder
and su bsequ ently w ith increasing joint lim itation. It is essen-
tial to exp lain to p atients the natu re of the d isease and ad vise
them to stop exercising. They have to be encou raged to d o
everything that d im inishes the pain, as less p ain m ay lead to
d im inishing of the in am m ation process and hence probably
to less brosis (H anna n et al 1994; Marx et al 2007).
In the frozen p hase, the pain w ill rapid ly d ecrease as the
in am m atory p rocess reced es and anti-in am m atory d ru gs
are no longer ind icated . Over-the-cou nter p ainkillers m ay be
taken on an irregu lar basis. H ow ever, there is great variety in
the treatm ent op tions that have been ad vised for im p roving
the PROM, w hich re ects the p oor consensu s of op inions
over the best-available treatm ent. Du e to the benign natu ral
cou rse, the au thors consid er that the best choice is to start
w ith a conservative, non-su rgical intervention. A sup ervised
p hysical therap y treatm ent or a gentle hom e stretching pro-
gram m e m ay be suf cient. End -range m obilization has been
show n to be m ore effective, bu t the bene ts are sm all
(Verm eu len et al 2006), and rigorous m obilization or stretch-
ing is not m ore bene cial p er se than gentle m obilization. In
the frozen p hase one m ight p refer a m ild er m obilization tech-
niqu e as this p rod u ces less p ain d u ring and after the treat-
m ent sessions. Occasionally new treatm ent op tions are
invented . Ru iz (2009) p resented a single case rep ort in w hich
he d escribed p ositional stretching of the CH L; the p atient
regained consid erable glenohum eral range of m otion w ithin
4 w eeks, w hich cou ld not be d u e to natu ral recovery alone.
Gasp ar and Willis (2009) p resented in a controlled , cohort
stu d y a new intervention, called d ynam ic sp linting; d u e
to m ethod ological aw s, how ever, rm conclu sions cannot
be m ad e.
In the thaw ing phase, gentle m obilization m ay be app lied
(Diercks & Stevens 2004; Verm eulen et al 2006). In this phase
the recovery is m ostly d u e to the natu ral cou rse of recovery
and it is the op inion of the au thors that m obilization d oes not
ad d m u ch bene t (Miller et al 1996; Diercks & Stevens 2004).
Recently, Kelley et al (2009) p rop osed a m od el for gu id ing
rehabilitation. Becau se of the lack of evid ence to d eterm ine
w hich patients m ay need form al su pervised therapy rather
than sim p ly a hom e p rogram m e, the researchers p rop ose a
p atient-centred ap p roach in w hich the d ecision is m ad e based
on the p hysician’s and p atient’s p reference, w ith inp u t from
the therap ist after initial evalu ation (Yang et al 2008).
As range of m otion is grad u ally regained , the patient w ill
carefu lly start to u se the affected arm in d aily activities. This
in itself w ill help to exercise the shou ld er and arm m u scles
and hence ad d itional exercises are rarely need ed .
Recalcitrant frozen shoulders
Although m ost cases of p rim ary FS recover w ithin m onths, it
m ight be necessary in a very few cases (esp ecially w hen the
p atient or his / her p hysician or physical therapist is im p a-
tient) to u se m ore rigorou s treatm ent op tions. These interven-
tions inclu d e m anip u lation u nd er anaesthesia, glenohu m eral
joint d istension and arthroscopic capsu lar release.
Closed m anip u lation u nd er anaesthesia m ay be effective in
term s of joint m obilization; how ever, the m ethod can cau se
iatrogenic d am age, w hich inclu d es haem arthrosis, ru p tu re of
the glenohu m eral capsu le, sup erior labru m anterior–posterior
(SLAP) lesions, Bankart lesions, tend inou s or ligam entou s
ru p tu res, fractu res of the hu m eru s and axillary nerve lesions
(Loew et al 2005). Also closed m anipu lation und er anaesthe-
sia is contraind icated in p atients w ith signi cant osteop enia,
recent su rgical repair of soft tissu e about the shou ld er,
fractu res, neu rological inju ry or instability (H anna n &
Chiaia 2000).
Glenohu m eral joint d istension u sing saline either in com -
bination w ith or w ithout corticosteroid s seem s to be bene cial
only in the short term . The techniqu e is also often p oorly toler-
ated becau se of the pain that is experienced d u ring the p ro-
ced u re (Manske & Prohaska 2008).
More recently, arthroscop y has been ad vocated for con r-
m ation of d iagnosis as w ell as for selective release of the
contracted p arts of the cap su le (Brue et al 2007). Release of the
CH L and the rotator cu ff interval is p articu larly effective in
increasing the range of m otion in external rotation, abd uction
and elevation. In cases w ith a d ecreased internal rotation and
ad d uction (cross-bod y ad d u ction), release of the p osterior
cap su le is p erform ed . Arthroscop ic release p rior to or follow -
ing a closed m anipu lation is consid ered to be an effective and
relatively safe proced ure, w ith less iatrogenic d am age than
that seen after closed m anip u lation u nd er anaesthesia.
Prevention of frozen shoulder
Patients w ith severe shou ld er com p laints are often ad vised to
p erform m obilizing or stretching exercises to p revent the
d evelopm ent of FS. H ow ever, the authors strongly believe
that it is im p ossible for the p atient to su cceed in this, or even
to slow d ow n the d evelop m ent of FS, by p erform ing exercises.
If d octors or therapists insist on an exercise regim en, patients
w ill then feel a responsibility for their FS that they should not.
Conclusion
The frozen shou ld er is still a challenge for p hysicians, thera-
p ists and researchers as there is still controversy over the
aetiology, the p athophysiology, the d iagnosis and the op tim al
treatm ent strategy. Most im p ortant, thou gh, is that the p rog-
nosis in m ost cases is good . Abou t 80–90% of all p atients w ill
eventu ally fu lly recover, although im p rovem ent m ay take u p
to 10 years. Recu rrence of the p rim ary frozen shou ld er in the
sam e shou ld er d oes not occu r. Patient ed u cation abou t the
natu ral history and good p rognosis is an im p ortant asp ect of
the treatm ent. The treatm ent is m ainly conservative and
d ep end s largely on the stage of the frozen shou ld er. In the
freezing stage the treatm ent is aim ed at inhibiting the pain
and d im inishing the in am m ation, w hereas in the frozen
stage it is aim ed at regaining the range of m otion. It is the
au thors’ p referred treatm ent to search for the least painfu l
ap proach. Recalcitrant frozen should ers are very rare and
p atience has to be exercised before su rgery is consid ered . If
necessary, arthroscop ic release of carefu lly selected stru ctu res
seem s to be bene cial in restoring the range of m otion in
refractory frozen should er. Recently, new stretching tech-
niqu es and d evices have been p u blished , bu t fu rther research
is need ed to see w hether these can be of ad d itional valu e. The
bottom -line m essage for therapists, physicians and patients
shou ld be to rem ain p atient d u ring the natu ral cou rse of the
p rim ary frozen shou ld er.

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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Joint Mobilization of the Shoulder
31  
Chapter 
W a yn e Hin g , J a c k M ille r, C é s a r Fe rn á n d e z - d e - la s - P e ñ a s
CHAP TER CONTENTS
Introduction  350
Passive mobilization interventions o  the glenohumeral joint  350
In erior glide  351
Posterior glide  351
Posterior glide in f exion  352
In erior and anterior glide  352
Anteroposterior or lateral–medial glide at end-o -range elevation  352
Mobilization with movement o  the shoulder complex  352
Overhead elevation mobilizations with movement   353
Overhead elevation: progression o  range o  motion  354
Hand behind back  355
Horizontal adduction motion  356
Conclusion  357
Introduction
A fu lly fu nctional u p p er lim b is d ep end ent on the op tim al
p ain-free m obility of the shou ld er gird le. Shou ld er pain and
d ysfunction lim it our ability to utilize the up per extrem ity in
activities of d aily living, resu lting in recreational, occupa-
tional and societal d isabilities. This chap ter has been organ-
ized to highlight the concep t of the restoration of u p p er lim b
fu nctional tasks through a continuum of manual therapy inter-
ventions to the shou ld er joint and shou ld er gird le com p lex.
The techniques d em onstrated in this chapter are focu sed on
achieving the op tim ization of u p per lim b fu nctional activities
inclu d ing p assive m obilizations, and m obilization w ith m ove-
m ent (MWM) focu sing on overhead elevation, cross-bod y
m otion and p lacing the hand behind the back. The p rogres-
sion of the techniqu es, by involving active p articip ation of the
p atient, w ill be d eterm ined by key subjective and objective
p aram eters su ch as p atient irritability, severity of p ain, stage
of p athology and recovery, the available range of m otion and
the effect of u p p er lim b load -bearing forces (H ing et al 2003).
Manu al therap y p roced u res u sed to restore m obility and
fu nction of the shou ld er gird le have been d eveloped and
d escribed by a variety of au thors (Kaltenborn et al 2002;
Mu lligan 2003; H engeveld et al 2005). A d ispassionate p er-
sp ective on these ap p arently d iverse ap p roaches reveals that,
 
althou gh each m ay have highly original com ponents, they are
invariably progressions of previously established w ork and
form an evolu tionary continu um (Miller 1999). This chapter
w ill highlight d ifferent m obilizations of the shou ld er joint that
have been d em onstrated clinically to be safe and effective and
are, at least partially, evid ence based .
Passive Mobilization Interventions of
the Glenohumeral Joint
Translatoric accessory joint m obilization techniqu es are w ell
established and form the basis of m u ch of the cu rriculum of
both entry level and postgrad u ate m anu al therap y training
p rogram m es. Originally d evelop ed by p hysical therap ists
su ch as Kaltenborn and Evjenth from N orw ay (Kaltenborn
et al 2002), orthopaed ic m anu al therapy (OMT) utilizes a
clinical-reasoning p arad igm based on the m anu al therap ist’s
p ercep tion of joint restriction as revealed by p assive m ove-
m ent exam ination and the ap plication of the concave–convex
ru le. Accord ing to the concave–convex ru le, the d irection of
the glid e is d eterm ined by consid ering the geom etry of the
m oving articu lar su rfaces. In su ch a m anner, w hen the convex
su rface m oves, it glid es in the op p osite d irection to the concave
su rface. In the glenohu m eral joint, the glenoid fossa (concave
su rface) is consid ered to be stable w hile the hu m eral head
(convex su rface) is u su ally m obilized d uring a physiological
shou ld er m ovem ent. N evertheless, the valid ity of this ru le has
been qu estioned (Brand t et al 2007).
In ad d ition, passive translatoric accessory m obilizations
can be p erform ed p arallel to or p erp end icu lar to the treatm ent
plane as d eterm ined by the speci c orientation of the joint
su rfaces. Mobilizations are grad ed in their range and su s-
tained for sp eci c d u rations accord ing to their intend ed
therap eu tic goal(s), inclu d ing p ain relief and im p rovem ent of
joint m obility. In fact, a cad averic stud y fou nd that greater
gain in m obility is obtained at the end -range p osition d u ring
axial d istraction m obilization of the glenohu m eral joint
(H su et al 2009). This w ou ld be im portant for clinical p ractice
if the aim of the treatm ent w ere to increase available range
of m otion.
The conceptu al m od el is that joint capsule contractu re
m u st be p assively elongated throu gh tissu e creep , effected by
 Passive mobilization interventions o  the glenohumeral joint 351

su stained p assive m obilization techniqu es into the tissu e

barrier. This hyp othesis is sup ported by an anim al stud y
w here im m obilization of the rat shou ld er ind u ced synovial
hyp erp lasia of the joint cap su le, ad hesion of su bscap u lar
bu rsa and an increase of the cap su lar content of typ es I and
III collagen (Liu et al 2011). Therefore, technique repetition
and an ap p rop riate self-treatm ent regim en along w ith consid -
eration of associated soft tissue d ysfunction, neurop hysiologi-
cal and m otor control factors are p rop osed to p rovid e
short- and long-term p ositive ou tcom es. There is little evi-
d ence d em onstrating the ef cacy of passive m obilization
interventions in the should er region. Verm eulen et al (2006)
fou nd that application of shou ld er joint m obilization tech-
niqu es w as effective for im p roving glenohu m eral joint m obil-
ity and red ucing d isability in su bjects w ith ad hesive capsulitis
of the shou ld er.
Maricar et al (2009) d em onstrated that the inclu sion of
Maitland accessory glenohu m eral m obilizations inclu d ing
anterior–posterior m obilization in should er exion and longi-
tu d inal cau d al m obilization in shou ld er abd u ction ind u ced
better ou tcom es w hen ad d ed to an exercise p rogram m e.
Su renkok et al (2009) rep orted that m anu al m obilization of Figure 31.1 Inferior glide of the glenohumeral joint (humeral head).
the shou ld er com p lex increased the range of m otion and
d ecreased pain intensity in patients w ith shou ld er p ain.
Passive m obilization p roced u res d irected at the shou ld er
region are d esigned to increase the accessory and physiologi-
cal ranges of joint m obility, w ith the therap eu tic goals of
im proving the patient’s range of m otion and fu nction. The
shou ld er joint generally resp ond s w ell to OMT p roced u res;
how ever, it m ay also react p oorly in cases of high irritability.
The inability to sleep on the affected should er, continu al pain
at rest and p ain of shou ld er origin rad iating below the elbow
are generally accep ted ind icators of high levels of irritability
and m ay ind icate the need to app roach the p atient w ith
cau tion.
In the follow ing sections w e d escribe som e of the passive
m obilization interventions targeted to the glenohu m eral joint
that are m ost com m only u sed in clinical p ractice.

Inferior glide (Fig. 31.1)

This glenohu m eral m obilization is ind icated to increase the
range of passive caud al glid e of the head of the hum eru s on
the glenoid fossa and to d ecrease p ain related to a su p eriorly
positioned hu m eral head . Su bacrom ial im pingem ent syn-
d rom es that are im proved by a caud al glid e of the hum erus
d u ring overhead lifting (Flatow et al 1994) m ay respond w ell
to this m obilization. For this p u rp ose, the p atient is su p ine
lying close to the ed ge of the bed . The hu m erus is m aintained
in neu tral internal / external rotation. The therapist grasp s the
arm close to the joint line w ith the w eb space of one hand
cu p p ing the su p erior asp ect of the hu m eral head , w hile
the other hand su p p orts the w eight of the extrem ity. A
cau d al / inferior glid e is im p arted to the hu m eru s along joint
plane of glenoid fossa. The glenoid can be stabilized by a
tow el u nd er the scap u la and / or a harness. In irritable cases
the therap ist m ay w ant to begin w ith the p atient’s arm by the
sid e in m inim al abd u ction. Progression to increasing ranges
of abd u ction m ay be attem p ted in non-irritable cases. As
reported by H su et al (2009), the m obilization shou ld be con-
d u cted at the pain-free end -range position.
Figure 31.2 Posterior glide of the glenohumeral joint (humeral head).
Posterior glide (Fig. 31.2)
This m obilization is ind icated to increase the available range
of p assive p osterior glid e of the head of the hu m eru s and to
d ecrease pain related to an anteriorly positioned hum eral
head (Dashottar & Borstad 2012). For this technique, the
p atient is su p ine w ith the arm in neu tral internal / external
rotation and the cervical spine neutral. The therapist is stand -
ing at the sid e of the bed . The cephalic hand cu ps the hu m eral
head w ith the p alm , and the cau d al hand su p p orts the u p p er
arm / forearm in a slightly exed and abd ucted p osition. The
therapist applies a posterior–lateral glid e of the hu m eru s head
along the joint plane of glenoid fossa. Clinicians shou ld ensu re
the glid e is translatoric by m oving both hand s equ ally in a
p osterior–lateral d irection, avoid ing contact w ith the coracoid
p rocess.
 352 PART 4 • 31 • Joint mobilization o  the shoulder

Figure 31.3 Posterior glide of the glenohumeral joint in exion (humeral head). Figure 31.4 Inferior and anterior glide of the glenohumeral joint (humeral
head).

Posterior glide in exion (Fig. 31.3)

This m obilization is ind icated for non-irritable patients w ith
internal im p ingem ent synd rom e and loss of cross-bod y m ove-
m ent. It can be also effective for p atients w ith p osterior
cap su le tightening. For this p u rp ose, the p atient is su p ine
close to the ed ge of the bed ; the scap u la m ay be stabilized by
a fold ed tow el p laced on the bed . The arm is exed to 90° and
internally rotated su ch that the therap ist’s hand rests on the
p atient’s sternu m . The therap ist then grasps the patient’s arm
close to the hu m eral head and stabilizes the elbow w ith
his / her sternu m . A p osterior glid e of the hu m eru s m ay now
be perform ed w ith both hand s. Ad d itional ranges of arm
ad d u ction m ay be u sed as the p atient’s range of cross-bod y
m ovem ent im p roves.

Inferior and anterior glide (Fig. 31.4)

This m obilization is ind icated in cases w here restoration of
internal rotation is the d esired rehabilitation goal. The p atient
is sid e-lying w ith the arm in 45° of abd u ction and 80° of inter-
nal rotation (w hen p ossible) w ith the hand resting on the
abd om en. The therap ist stand s behind the p atient clasping
the hu m eru s p roxim ally and u sing the abd om en to stabilize
the d istal end . The therap ist m ay next ind u ce an inferior and
anterior translatoric glid e to the hu m eral head w hile m onitor-
ing and varying the am ou nt of abd u ction / ad d u ction of the
arm , accord ing to p atient irritability.
Anteroposterior or lateral–medial glide at
end-of-range elevation (Fig. 31.5)
This m obilization is ind icated for recovery of end -range eleva-
tion in non-irritable cases. The p atient lies p rone w ith the arm
resting on the bed in m axim u m pain-free overhead elevation.
The am ount of internal / external rotation m ay be varied
d epend ing on the goals of treatm ent. The therap ist stand s
by the sid e of the bed stabilizing the scapula and controlling
Figure 31.5 Anteroposterior or lateral–medial glide of the glenohumeral joint
(humeral head) at end-of-range elevation.
the p osition of the hu m eru s w ith the p alm s of the hand s.
The thu m b pad s are placed over the posterior aspect of the
hu m eral head and an anterior–posterior or lateral–m ed ial
m obilization force can be ap p lied . The beginning range of
arm elevation m ay be p rogressed as d eterm ined by p atient
irritability. Yang et al (2012) reported that end -range m obili-
zations w ere m ore effective than a stand ard ized p hysical
therap y p rogram m e in a su bgrou p of su bjects w ith frozen
shou ld er.
Mobilization with Movement of the
Shoulder Complex
A grow ing bod y of evid ence has d em onstrated the valu e of
com bining trad itional OMT therap y m obilizations concu r-
rently w ith patients’ pain-lim ited physiological m ovem ents.

Term ed ‘m obilizations w ith m ovem ent’ (MWMs), this concep t
w as d evelop ed by Brian Mu lligan of N ew Zealand (Mu lligan
2003) and bu ilt on the fou nd ations of OMT. Within the Mul-
ligan concept, the m anagem ent of the patient requires the
id enti cation of a com parable sign or client-speci c im pair-
m ent m easu re (CSIM) as a baseline m easu re to evalu ate treat-
m ent effectiveness, often m easu red as a fu nctionally lim ited
m otor activity. This clinically m easu rable fu nctional d e cit
becom es the benchm ark against w hich the effectiveness of the
intervention(s) is continually reassessed (Vicenzino et al 2011).
The clinical-reasoning p arad igm of selection and p rogres-
sion of MWMs rests on the p atient’s ind ivid u al resp onse to
selected trial m obilizations as m easu red by p ain-free im p rove-
m ent in the id enti ed CSIM. The therap ist m u st continu ou sly
m onitor the p atient’s reaction to ensu re that m inim al to no
pain is recreated . Utilizing their know led ge of joint arthrol-
ogy, a w ell-d evelop ed sense of tissu e tension and active clini-
cal reasoning, the therap ist investigates variou s com binations
of m obilization d irections to nd the id eal treatm ent p lane
and grad e of m ovem ent. While su staining the pain-free acces-
sory m obilization, the p atient is requ ested to p erform the
previou sly id enti ed p ain-restricted CSIM. The CSIM m ay
now be signi cantly im proved – that is, increased range of
m otion, and a signi cant d ecrease in, or id eally absence of,
the original p ain. Failu re to im p rove the CSIM w ou ld ind icate
that the therap ist has not fou nd the correct contact p oint,
treatm ent p lane, grad e or d irection of m obilization, or sp inal
segm ent, or that the techniqu e is not ind icated . The p revi-
ou sly restricted and / or p ainfu l CSIM is rep eated by the
patient, initially as a trial treatm ent p rogressing up to sets
of 10, w hile the therap ist continues to m aintain the ap pro-
priate accessory glid e. Fu rther gains are exp ected w ith repeti-
tion d u ring a treatm ent session, w hich typ ically involves
three to fou r sets of 10 repetitions. Repetition of the CSIM
and pain-free end -range load ing in the form of passive over-
pressu re ap p ears to be critical to achieve d u rable resu lts
(Miller 1999; Mu lligan 2003; H ing et al 2008). As w ith all
m anu al therap y concep ts, a p rop erly stru ctu red su bjective
and objective assessm ent of the p atient and continu ous re ec-
tive clinical reasoning (Jones & Rivett 2004) are m and atory
both w ithin the patient’s assessm ent and d uring treatm ent
sessions.
The theoretical m od el of the effect of MWMs is that either
a p ositional fau lt of bony positional m alalignm ent or a neu-
rom echanical d ysfu nction is corrected or affected by the
m obilization com p onent of the p roced u res. N evertheless, the
biom echanical hypothesis that MWM reverses positional
faults requires fu rther investigation (Vicenzino et al 2007). In
place of the therap ist’s p ercep tion of passive accessory m ove-
m ent restriction and the concave–convex ru le, the speci c
d irection and grad e of m obilization are d eterm ined by the
patient’s rep orts of an accessory d irection of p reference of
pain abolition and objective im provem ents in CSIM fu nction
(Miller 2006; H ing et al 2009). Self-treatm ent proced u res along
w ith the ap plication of sports ad hesive tape are often u sed to
m aintain gains achieved in the clinical setting.
Som e case rep orts have d em onstrated that the ap p lication
of MWM over the shou ld er com p lex w as effective for red u c-
ing should er pain and d isability in su bjects w ith should er
pain (Scaringe et al 2002) or subacrom ial im pingem ent
(DeSantis & H asson 2006). Other rand om ized controlled trials
reported im m ed iate p ositive effects in range of m otion and
pressu re p ain sensitivity in subjects w ith should er pain
Mobilization with movement o  the shoulder complex 353
(Kachingw e 2008; Teys et al 2008) or frozen shou ld er (Yang
et al 2007) after the application of MWM over the shou ld er
com p lex. Doner et al (2013) d em onstrated that MWM lead s to
better im p rovem ents in term s of pain, range of m otion, shoul-
d er scores, and p atient and physiotherapist satisfaction than
p assive stretching for ad hesive cap su litis. A system atic review
conclu d ed that the ef cacy of MWM at p erip heral joints is
w ell established for various joints and p athologies, d em on-
strating p ositive effects (H ing et al 2009).
Overhead elevation mobilizations
with movement
Ind ivid u als w ith should er d ysfu nction u su ally rep ort that
regaining a functional range of overhead elevation is often of
p rim e im p ortance. In highly irritable and restricted cases the
p atient m ay initially need to be treated in a non-gravity-
d epend ent, recu m bent position w ith a grad uated progression
to u p right gravity-d ep end ent p ostu res and resisted load -
bearing environm ents. The clinical selection of the ap propri-
ate initial p roced u re and the appropriate progression of load s
w ill alw ays be d epend ent on the nd ings at assessm ent,
ongoing re-evalu ation and active clinical reasoning.
Mobilization with movement – elevation (Fig. 31.6)
This m obilization is ind icated to reposition the hu m eral head
in the glenoid fossa w hile restoring fu nctional range of over-
head elevation, and to increase active range of p ain-free eleva-
tion d u ring a trial treatm ent. The p atient is sitting or stand ing,
d epend ing on the height of the therapist and patient w ith the
cervical sp ine neu tral. The therap ist stand s on the contralat-
eral sid e of the patient, then w ith one hand m akes m anu al
contact w ith the anterior hu m eral head w ith the cu p of the
hand , w hile the other hand stabilizes the scap u la p osteriorly.
The technique consists of the ap plication of a p osterior–lateral
glid e along the joint p lane of the glenoid fossa w hile the
p atient is asked to p erform a sim u ltaneou s active shou ld er
elevation throu gh the scaption p lane (30° from frontal p lane).
It is im p ortant to allow norm al scapu lothoracic m ovem ent
throu ghou t the techniqu e to ensu re that the p atient elevates
the arm fu lly to achieve end -range load ing, and p rogressing
to resistance load ing w ith the u se of soft w eights or
elastic tu bing as tissu e irritability d ecreases. H su et al (2000),
in a cad averic stud y, found that the ap plication of an
Figure 31.6 Mobilization with movement – elevation.
 354 PART 4 • 31 •
Figure 31.7 Mobilization with movement – elevation, belt assisted.
anterior–p osterior glid e tow ard s the end of range of abd uc-
tion w as effective in im p roving the range of glenohu m eral
abd u ction. In a p osterior cad averic stu d y, the sam e authors
reported that this MWM techniqu e is effective in changing the
joint kinem atic characteristics d uring glenohum eral abd u c-
tion (H o & H su 2009).
Mobilization with movement – elevation, belt
assisted (Fig. 31.7)
This m obilization is ind icated in larger patients w ho require
a greater m obilization force than is available throu gh a m anu al
m obilization techniqu e. The aim of the m obilization is to rep o-
sition the hu m eral head in the glenoid fossa w hile restoring
the fu nctional range of overhead elevation and to increase the
active range of p ain-free elevation. The p atient is sitting on
the chair w ith the sp ine fu lly su p p orted bu t the scap u la
exposed and the cervical spine in neutral. The therap ist stand s
p osterior to the p atient. The m obilization belt is loop ed arou nd
the therap ist’s bu ttocks and over the hu m eral head of the
p atient. One hand is placed over the scap u la, thu s stabilizing
the scap u la to the chest w all bu t allow ing norm al scap u lotho-
racic m ovem ent. The techniqu e consists of the ap plication of
a p osterior–lateral glid e along the joint plane of the glenoid
fossa, w hile the p atient is asked to perform a sim ultaneous
active shou ld er elevation throu gh the scap tion plane (30°
from frontal p lane). N ote: the clinician shou ld ensu re the belt
is on the hu m eral head and d oes not im p ed e elevation of the
arm , and also ensu re the p atient elevates the arm fu lly to
achieve end -range load ing. The m obilization progresses to
resistance load ing w ith the use of soft w eights or elastic
tu bing as tissu e irritability d ecreases.
Overhead elevation: progression of
range of motion
Du ring norm al arm elevation the hu m eru s u nd ergoes a
conju nct external rotation, w hich is often referred to as
Cod m an’s p arad ox (Cheng 2006). In ord er to accom p lish full
Joint mobilization o  the shoulder
Figure 31.8 Mobilization with movement – end-range elevation (external
rotation).
overhead elevation it m ay be necessary to ensu re the recov-
ery of external rotation of the glenohum eral joint, rst in
neu tral, then in increasing d egrees of elevation and cu lm i-
nating in the position originally d escribed by Maitland
(H engeveld et al 2005) as ‘the u pper quad rant’. Ad d itionally,
in ord er to achieve full elevation, the therapist m ay need to
p rogress into an inferior glid e of the hu m eru s (see Fig. 31.1)
and consid er the signi cant involvem ent of the fu ll shou ld er
gird le com plex.
Mobilization with movement – end-range elevation
(external rotation) (Fig. 31.8)
This m obilization is ind icated w here the patient presents w ith
a loss of functional range of external rotation or restriction of
elevation d ue to loss of conjunct external rotation at or above
90° elevation. The p atient is lying sup ine w ith the shou ld er
slightly abd u cted to the com fortable range, w ith the elbow
exed to 90° and the cervical sp ine neu tral. The therap ist
stand s at the sid e of the p atient, and w ith the cep halic hand
cu p s the head of the hu m eru s w ith the p alm , w hile the cau d al
hand su p p orts the u p p er arm . The m obilization consists of the
ap plication of a posterior–lateral glid e in the treatm ent p lane
of the scap u la by the cep halic hand . Ad d itional inferior glid e
can be ap p lied w ith the cau d al hand of the therap ist, allow ing
the hu m eru s to translate p osteriorly. The p atient p erform s
p assive external rotation u sing the u naffected hand to p as-
sively p u sh the hand of the affected arm laterally w ith a short
stick w hile the therap ist m aintains the p atient’s elbow at their
sid e, creating a ‘sp in’ of the hu m eru s into external rotation.
Clinicians shou ld ensu re that the p osterior m obilization force
is m aintained u ntil the patient returns to a neu tral position.
The techniqu e can progress into greater ranges of abd uc-
tion / elevation (the qu ad rant p osition).
Mobilization with movement – end-range elevation
(inferior glide) (Fig. 31.9)
This m obilization is ind icated for patients w ith end -range loss
of elevation. The p atient is lying su p ine w ith the scap u la

Figure 31.9 Mobilization with movement – end-range elevation (inferior glide).
Figure 31.10 Mobilization with movement – elevation (shoulder girdle).
su p p orted by the bed su rface or a sm all fold ed tow el. The
therap ist is stand ing at the head of the bed . The therap ist grip s
the anterior forearm and p osterior hu m eru s in ord er to control
elbow exion. The technique consists of applying a posterior–
cau d al glid e at the end -of-range elevation. The p atient is
asked to p erform active arm elevation through scap tion. The
clinician shou ld ensu re that the hu m eru s is in external rota-
tion, and d oes not allow the elbow to bend / ex.
Mobilization with movement – elevation (shoulder
girdle) (Fig. 31.10)
This m obilization is ind icated in patients w ith observable
w inging or d yskinesis of scap ulohum eral rhythm , or those
w ith persistent should er p ain w ith active elevation not
resp ond ing to treatm ent of the glenohu m eral joint. The patient
is sitting on a chair w ith a low back and the cervical spine in
neu tral. The therap ist is stand ing on the contralateral sid e of
the p atient. The p osterior hand contacts the su p erior ed ge of
the lateral one-third of the sp ine of the scap u la w hile the
anterior hand p rovid es stability to the m ed ial half of the clavi-
cle. The techniqu e consists of glid ing the scap u la inferom ed i-
ally, rotating the scap u la externally and controlling any
w inging of the scapula bone. The patient is asked to p erform
Mobilization with movement o  the shoulder complex 355
a sim u ltaneou s active arm elevation throu gh scaption. Finally,
an assistant m ay also provid e an ad d itional posterior–cau d al
glid e of the hum erus d u ring elevation. Lew is (2015) reported
that this p articu lar p roced u re exerts a signi cant bene t in the
recovery of m otion in patients w ith frozen shou ld er. Som e
im portant points are: (a) progression into a closed chain posi-
tion m ay be accom p lished by having the p atient ad op t a fou r-
p oint kneeling stance, and (b) having the p atient sit back on
the heels w ill recreate controlled w eight-bearing forces on the
shou ld er gird le d u ring the ap p lication of a m obilization w ith
m ovem ent, w hich shou ld now rend er the activity p ain free.
Hand behind back
This m ovem ent is a m ultiplane m ovem ent requiring a com bi-
nation of shou ld er extension, internal rotation and ad d u ction
com p onents. Occasionally lim ited by signi cant p ain, this
m otion is often avoid ed by p atients w ith im p airm ents of the
shou ld er w ith a resu lting loss of fu nction inclu d ing the ability
to effectively d ress, reach for a w allet and u nd ertake p ersonal
hygiene.
Mobilization with movement – hand behind back
(Fig. 31.11)
This m obilization is ind icated in patients w ith pain or w ith a
loss of the hand -behind -back m ovem ent. The patient is stand -
ing w ith the contralateral hip su pported by a treatm ent plinth
to cou nteract the ad d u ctory forces. A m obilization belt is
d raped over the contralateral should er, and is held anteriorly
by the free hand and p osteriorly by the involved arm hand .
The therapist stand s at the sid e of the patient, placing the
p osterior hand high in the axilla w ith the p alm facing aw ay
from the patient, w hile the anterior hand is su pinated fully to
grip the d istal hu m eru s w ith the thu m b hooked into the
cu bital fossa of the p atient. For this techniqu e, the therap ist
stabilizes the scap u la w ith the cep halic hand and m ed ially
d irected force from the posterior hand . The m obilization con-
sists of an inferior glid e of the hu m eru s w ith the thu m b of the
anterior hand in the cubital fossa. The patient sim u ltaneou sly
m oves the hand behind the back by p u lling on the belt. Clini-
cians shou ld ensu re the p atient d oes not attem p t to lift the
hand aw ay from the back and ensu re that the p osterior hand
force in the axilla is ad d u ctory and cephalic so as to stabilize
the scap u la.
Mobilization with movement – hand behind back,
belt assisted (Fig. 31.12)
This techniqu e is ind icated in larger patients, or w ith sm aller
therap ists, and in those p atients w ith p ain or loss of hand -
behind -back m ovem ent. The patient is stand ing w ith the con-
tralateral hip su p p orted by a treatm ent p linth to cou nteract
ad d uctory forces. The m obilization belt is d rap ed over the
contralateral shou ld er and held anteriorly by the free hand
and posteriorly by the involved -sid e hand . One of the thera-
p ist’s hand s is p laced high in the axilla w ith the p alm s facing
aw ay from patient. The m obilization belt is fold ed in half and
hooked into the cu bital fossa of the p atient, and the heel of
one of the therap ist’s feet in the belt loop w ith the toe on the
oor so as to control the belt force. For this technique, the
therap ist stabilizes the scap u la w ith the cep halic hand and a
 356 PART 4 • 31 •
A B
Figure 31.11 Mobilization with movement – hand behind back: (A) posterior view, (B) anterior view.
Figure 31.12 Mobilization with movement – hand behind back, belt assisted.
m ed ially d irected force from the p osterior hand . The m obili-
zation consists of an inferior glid e of the hu m erus, d one by
p u lling on the belt by d orsal exing the foot. The p atient
sim u ltaneou sly m oves the hand behind the back by p u lling
on the belt. The clinician shou ld ensu re that the p atient d oes
not attem p t to lift the hand aw ay from the back. Som e im p or-
tant p oints are: (a) to ensu re that the hand force in the axilla
is ad d u ctory and cep halic to stabilize the scap u la, and (b) to
u se gentle p ressu re from the belt w ith the heel on the oor for
control.
Horizontal adduction motion
Reaching across the bod y to the op p osite shou ld er is an
activity involving m ultiple articulations in ad d ition to the
Joint mobilization o  the shoulder
glenohu m eral joint. Optim al fu nctioning of the acrom iocla-
vicu lar (AC) and the sternoclavicu lar (SC) joints is intim ately
associated w ith norm al pain-free perform ance of cross-bod y
m otion. Sp inal m obilizations w ith u p p er extrem ity m ovem ent
m ay rend er shou ld er m ovem ents p ain free and restore fu nc-
tional m obility w hen the neck is involved in d ysfu nction of
the u p p er qu ad rant.
Mobilization with movement – horizontal adduction
(AC / SC joints) (Fig. 31.13)
This techniqu e is ind icated w hen there is pain reaching across
the bod y tow ard s the contralateral shou ld er in the transverse
p lane. The p atient is seated on a low -back chair w ith the cervi-
cal sp ine neu tral. The therap ist stand s behind the p atient w ith
the hyp othenar p ortion of the hand on the su p erior su rface of
the p atient’s d istal clavicle bone. The techniqu e consists of an
inferior glid e of the clavicle, w hile the patient is asked to
p erform a sim u ltaneou s cross-bod y m ovem ent tow ard s the
contralateral shou ld er or rib cage. Som e im p ortant p oints are:
(a) the presence of m od erate pain-free crepitu s is norm al, and
(b) the therapist should begin w ith gentle active m ovem ent,
p rogressing to m ore vigorou s m otion as irritability d ecreases.
Spinal mobilization with upper extremity
movement – horizontal adduction (Fig. 31.14)
This techniqu e is ind icated w hen there is pain w ith cross-
bod y m ovem ent related to cervical d ysfu nction. The patient
is seated w ith cervical sp ine in neu tral. The therapist stand s
behind the patient, w ith the sid e of one thu m b contacting the
lateral slop e of the involved cervical vertebrae spinou s
p rocess. This thu m b m ay be reinforced by the contralateral
thu m b or ind ex ngertip . The m obilization intervention con-
sists of ap p lying a m ed ial translation / rotation of the targeted
cervical vertebrae, w hile the p atient is asked to p erform a
sim u ltaneou s cross-bod y m ovem ent tow ard s the contralateral
shou ld er or rib cage. Som e im p ortant p oints are: (a) that the
m obilization force controls, bu t d oes not block, the norm al
ipsilateral rotation of the cervical vertebrae and spinous
p rocess, and (b) the therap ist shou ld begin w ith gentle active

Figure 31.13 Mobilization with movement – horizontal adduction (AC/ SC
joints).
Figure 31.14 Spinal mobilization with upper extremity movement – horizontal
adduction.
m ovem ent, p rogressing to m ore vigorou s m otion as irritabil-
ity d ecreases.
Conclusion
The inclusion of passive intra-articu lar m obilizations and
m obilization w ith m ovem ent interventions of the shou ld er
region into a m u ltim od al ap proach in patients w ith neck and
arm p ain synd rom es should be consid ered in ord er to im prove
the fu nction and d ecrease the d isability of the p atient. The
intensity and progression of the m obilizations should be
ad ap ted to the irritability of the tissu e of the p atient.
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
32
Motor Control of the Shoulder Region
Chapter 
M a ry E. M a g a re y, M a rk A. J o n e s , S a m u e l R . Ba id a
CHAP TER CONTENTS
Introduction  358
Motor control  358
Motor control and joint stability  358
Evidence o  altered motor control around the scapula  359
Evidence o  altered motor control around the glenohumeral joint  360
Evaluation o  motor control around the shoulder girdle  360
Postural assessment  360
Evaluation o  isolated motor control around the shoulder  366
Management o  motor control impairments around the   sp ecify the p aram eters related to the p articu lar w ay the p ro-
shoulder girdle  367
Management o  shoulder motor control through   (Schm id t & Lee 2005). Targeted m otor training can be u sed to
patient examples  368
Conclusion  371
Introduction
Motor control arou nd the shou ld er, its exam ination and m an-
agem ent, are vast and com plex top ics. In this chap ter w e
p rovid e a brief background of m otor control theory and the
evid ence in su pport of im pairm ents in m otor control arou nd
the shou ld er, together w ith a su m m ary of the p rincip les of
m otor learning in the context of shou ld er rehabilitation. The
focus is on control asp ects of the scapu lothoracic and gleno-
hu m eral joints as d irectly relevant to shou ld er fu nction.
Although the focus is on evalu ation and m anagem ent associ-
ated w ith m otor control abilities and im pairm ents, evaluation
for and m anagem ent of im pairm ents in pain, range of m ove-
m ent, strength, end u rance, p ow er and techniqu e m u st also be
ad d ressed in a holistic context, w ith app ropriate d iagnostic
consid erations and a thorou gh bio-p sychosocial ap p roach.
The in uence of the rem aind er of the kinetic chain on shoul-
d er fu nction and of shou ld er gird le in u ence on arm function
shou ld also be acknow led ged and consid ered in both exam i-
nation and m anagem ent.
Motor Control
Motor control theories exp lain the central nervou s system ’s
ability to organize m echanism s and system s essential for
 
regulating m ovem ent, posture and stability. These ad d ress
both sensory (particu larly, vision, au d ition and prop riocep-
tion) and m otor system s w ith consid eration of the com p lex
interaction betw een the ind ivid ual, the task and the environ-
m ent (Schm id t & Lee 2005; Shu m w ay-Cook & Woollacott
2012). Motor behaviou r is consid ered to be p re-stru ctu red
generalized neu ronal cod ing about the ord er of events, their
relative tim ing and the relative force requ ired across d ifferent
tasks. For exam p le, the sequ encing of m u scle activity and joint
m otion for shou ld er elevation is inclu d ed in a m otor p ro-
gram m e of elevation, w hich is supp lem ented by ru les that
gram m e is executed accord ing to the task, such as speed
strengthen, m od ify or reacqu ire su ch m otor p atterns. In ord er
for the brain to encod e new or m od i ed m ovem ent it m u st
continu ally rem od el its neu ral circu itry for behaviou ral
changes to take p lace (Kleim & Jones 2008). Pain and / or
p erceived threat can also d rive m otor behaviou ral changes.
Ad aptation involves a protective process that helps prevent
injury by generating a w ithd raw al re ex from the noxiou s
stim u lu s and / or an u np leasant sensation that resu lts in
com p lex behaviou ral strategies u sed to avoid rep lication of
that sensation (Latrem oliere & Woolf 2009). With regard s to
rehabilitation program m es, approaches to m otor control and
learning m ust recognize the bread th of potential neural
changes, both short and long term and in d ifferent tasks and
environm ents (H od ges 2011; Shu m w ay-Cook & Woollacott
2012). A prim ary goal of rehabilitation is to prom ote neuro-
p lasticity, su ch that long-lasting and ad vantageou s m od i ca-
tions in m otor control strategies can be achieved (Bou d reau
et al 2010a). This m u st be balanced w ith treatm ent interven-
tions to ad d ress p otential p sychosocial factors contribu ting to
a p ain and / or d isability experience.
Motor control and joint stability
Motor control and joint stability are closely linked and shou ld
be consid ered as a d ynam ic p rocess of controlling static posi-
tion w hile allow ing m ovem ent w ith control (H od ges 2004).
Panjabi’s now -fam iliar m od el of three inter-related system s
responsible for control of the neutral zone (Panjabi 1992a,
1992b, 1996) form s the basis for m uch recent w ork in relation
to fu nction and d ifferences in behaviou r of d ifferent typ es of

m u scles. As a resu lt, tw o grou p s of m u scles have been id enti-
ed that fu l l d ifferent roles – ‘stabilizers’ or ‘local system ’
and ‘m obilizers’ or ‘global system ’ (H od ges 2004; Magee &
Zachazew ski 2007). Althou gh this categorization is d ebated
(McGill 2007) and fu rther research is need ed to clarify this
d istinction and its clinical ef cacy, w e nd this construct
help fu l in focu sing assessm ent and treatm ent p roced u res,
w ith excellent resu lts.
It has been established that m otor coord ination can be
altered w ith m u sculoskeletal p ain synd rom es (Ko er et al
1998; Tsao et al 2010). H od ges (2011) has p u t forw ard a m od el
com p rising ve key p rincip les, w hich help s better u nd erstand
the relationship betw een m otor control, p ain and neu ral
plasticity. This m od el provid es explanation of the m u ltip le
m echanical ad ap tation strategies that m ay be im p lem ented by
the brain d ep end ing on the ind ivid u al (exp erience, anthrop o-
m etrics, p ostu re) and the task (H od ges & Tu cker 2011). The
m ajority of changes are d riven from reorganization of m ove-
m ent rep resentations in the p rim ary m otor cortex (H od ges
2011). Exam ination is recom m end ed of all com ponents of the
neu rom u scu lar system inclu d ing d ysfu nction of synergistic
control, tim ing of m u scle activation, p atterns of co-contraction
and p rop riocep tive control in patients w ith m uscu loskeletal
pain, esp ecially p ain of long d u ration and / or intensity. This
recom m end ation, bu ilt on the hypothesis related to the rela-
tionship betw een afferent nocicep tive inp u t and m otor control
and the p rincip les of m otor learning, form s the fou nd ation of
ou r ap p roach to evalu ation and m anagem ent of p atients w ith
shou ld er d ysfu nction.
Evidence of altered motor control
around the scapula
Alterations to m u scle function arou nd the scapu la have been
d em onstrated in the presence of cervical pain or head aches
(N ed erhand et al 2000; Falla 2004; Szeto et al 2005, 2009; Falla
et al 2007; Ju ll et al 2008). With respect to the shou ld er, a
consistent recru itm ent p attern has been d em onstrated in
asym p tom atic shou ld ers that is related to active abd uction
in the scapu lar plane (Wad sw orth & Bu llock-Saxton 1997;
Moraes et al 2008) or response to sud d en release from an
abd u cted p osition (Cools et al 2002, 2003) and reaching tasks
(Roy et al 2008). The up per trapeziu s m uscle is activated rst,
follow ed by the serratus anterior, the m id d le trapezius and
nally the low er trap eziu s m u scles. The tem p oral character-
istics are d elayed but not changed by fatigue in asym ptom atic
su bjects (Moraes et al 2008).
A reasonably consistent p attern of d ecreased activity has
been d em onstrated in both the low er trapeziu s and the ser-
ratu s anterior, and increased activity in the upper trapezius
in p atients exp eriencing shou ld er p ain or p athology d u ring
d ifferent tasks (Glou sm an et al 1988; Scovazzo et al 1991; Pink
et al 1993; Lu d ew ig & Cook 2000; Cools et al 2003, 2004, 2005;
McClu re et al 2006; Cools et al 2007a; Roy et al 2008). Kibler
(1998) and Kibler et al (2013) observed that inhibition of the
low er trapeziu s and serratu s anterior m uscles app ears to be
a non-sp eci c response to shou ld er pain irrespective of the
pathology. The low er trapezius has a p red om inance of typ e I
bres, w hereas the u p p er trap eziu s has p red om inantly typ e
II (Sim ons et al 1999); this im plies that the low er trapeziu s is
best su ited for postu ral and stabilizing roles and the up per
Motor control 359
trap eziu s for p hasic activity. Find ings of d elayed and / or
red u ced activity in the low er trapeziu s and serratu s anterior
in response to shou ld er pain coupled w ith increased activity
in the upp er trapezius, althou gh not universally reported ,
lend su pport to this hypothesis. These results su pport nd -
ings from other bod y regions of a neu rom uscu lar im pairm ent
associated w ith pain in an ad jacent joint (Cow an et al 2001,
2002, 2003; H od ges 2004; Colné & Thou m ie 2006; H ertel &
Olm sted -Kram er 2007; Ju ll et al 2008).
Altered scapu lar position is com m on in association w ith
shou ld er p ain, w ith typ ical p atterns id enti ed and given
variou s nam es. A very com m on p attern is the ‘scap u lar d ow n-
w ard ly rotated synd rom e’ (Sahrm ann 2002), also term ed
‘type 1 scapu lar d yskinesis’ (Kibler et al 2002, 2003) – one of
the im p airm ent p atterns id enti ed u nd er the acronym of
‘SICK’ scap ula (Scap u lar m alp osition, Inferior m ed ial bord er
prom inence, Coracoid p ain and m alp osition and d ysKinesis
of scap u lar m ovem ent) (Burkhart et al 2003). This pattern
ap pears to be associated w ith insu f ciency of the u pw ard
rotation force coup le and overactivity or increased tone in the
antagonist m uscles, in particu lar levator scap u lae, rhom boid s
and p ectoralis m inor (Kibler & McMu llen 2003). Kibler et al
(2013), su m m arizing the nd ings of a recent ‘scap u lar su m m it’,
observed that contem p orary thinking is that scap u lar static
p osition is of less signi cance than im p aired scap u lar m ove-
m ent p atterns d u ring arm m ovem ent, su ch that the focu s on
nam ing d ifferent static p ositions and taking objective m eas-
u res is d ow n-p layed .
The serratus anterior and low er trapeziu s m uscles are
im portant com ponents of the scapu lar u pw ard rotation force
couple, particularly above 60° of arm elevation (Bagg &
Forrest 1986, 1988). Decreased activity in the low er trap ezius
and serratu s anterior associated w ith arm elevation (Lu d ew ig
& Cook 2000; Cools et al 2007a) in patients w ith su bacrom ial
p ain su p p orts the observation of d elayed or red u ced u p w ard
rotation in the clinical setting. Increased up per trap ezius
activity u nd er a heavier load (Lud ew ig & Cook 2000) and in
the u p p er ranges of elevation (Cools et al 2007a) p ossibly
re ects a com pensation for d ecreased activity in the low er
trap eziu s and serratu s anterior and / or an attem p t to over-
com e the increased tone in the antagonists.
A second altered scap u lar p ostu re, an elevated scap u la, is
d escribed as type III scapular d yskinesis (Kibler et al 2002,
2003). This pattern appears to p resent in association w ith
either should er stiffness into elevation or m ajor rotator cu ff
d ysfu nction, such that the d eltoid / rotator cu ff force couple
is d isrup ted and the hum eral head translates su periorly to
abut against the u nd ersurface of the acrom ion. Increased
activity in the up p er trapezius and levator scap u lae is
d om inant.
N ot all responses to should er p ain are consistent (Cools
et al 2003, 2004, 2005, 2007a), w hich possibly re ects the d if-
ferent patterns d em onstrated in subgrou ps w ithin sam ple
p op u lations w ith the sam e d iagnosis (Graichen et al 2001;
H ébert et al 2002; Roy et al 2008). The observation of varia-
tions in p atterns of m u scle activity su p p orts the need to
ad d ress each patient’s im pairm ent ind ivid u ally d uring assess-
m ent and m anagem ent.
Altered scapu lar positioning and scapu lar plane elevation
are frequ ently associated w ith increased thoracic kyphosis,
cervical exion or forw ard head p ostu re (Craw ford & Ju ll
1993; Green eld et al 1995; Lu d ew ig & Cook 1996; Bu llock
 360 PART 4 • 32 • Motor control o  the shoulder region
et al 2005), w hich su pports the kinem atic relationship of
sp inal p ostu re, scap u lar p ostu re and shou ld er elevation.
Although spinal postu re m ay not be correlated w ith speci c
shou ld er p athology (Lew is et al 2005a, 2005b), its relationship
to shou ld er elevation im p airm ent w arrants attention in
rehabilitation.
Clearly, w hen consid ering rehabilitation of the shou ld er,
attention to the scap u lar m uscle im p airm ents, p articularly
those related to m otor control, is im p erative (Ebau gh et al
2005; Kibler et al 2013). Equ ally the shou ld er shou ld not be
consid ered in isolation from the cervical and thoracic sp ine
(Ju ll et al 2008) and the control and m ovem ent patterns of the
lu m bar sp ine, p elvis and low er lim bs (Kibler 1998, 2013).
Although the focu s in this chapter is on m otor control of the
shou ld er, the im p ortant contribu tions of these other areas
m u st not be forgotten.
Evidence of altered motor control around
the glenohumeral joint
Evid ence related to local stabilizing m u scle fu nction arou nd
the glenohu m eral joint is less robu st, w ith only tw o stu d ies
reporting on sp eci c rotator cu ff control. David et al (2000)
d em onstrated that, d uring isokinetic glenohum eral rotation,
the rotator cu ff and bicep s brachii w hen consid ered as a grou p
w ere alw ays activated prior to the su per cial m u scles, d eltoid
and pectoralis m ajor in asym ptom atic shou ld ers and there
w as alw ays an elem ent of co-contraction, regard less of d irec-
tion or sp eed of rotation. The rotator cu ff grou p w as also
alw ays activated before m ovem ent of the isokinetic d evice’s
lever arm . This nd ing su p p orts the hyp othesis that the
rotator cuff fu nctions in a joint-stabilizing role. Delayed acti-
vation of the rotator cu ff / bicep s in ind ivid u als w ith u nstable
shou ld ers w as also d em onstrated in a clinical bu t not a
research setting.
H ess et al (2005) d em onstrated d elayed activation of the
su bscap u laris d u ring a reaction tim e test into external rotation
in throw ers w ith p ainfu l shou ld ers com p ared w ith a m atched
grou p of asym ptom atic volu nteers, hypothesizing that su b-
scap u laris fu l lled a joint stabilization role. H ow ever, their
testing p rotocol requ ired u se of the infrasp inatu s as a p rim e
m over. Lu m bar sp ine research d em onstrates that com p eting
d em and s on the central nervou s system lead to an alteration
in m u scle u se (H od ges 2004) so that, w hen required to fu nc-
tion in its p rim ary role, a m u scle’s second ary stabilizing role
is com p rom ised .
Ginn et al (2009) d em onstrated from EMG research that the
rotator cu ff d oes not function at equ al load s through all activi-
ties; rather, the m ajority of activation is d irection sp eci c. The
antagonist cuff m u scle w as activated at ap proxim ately 6%
m axim al volu ntary contraction (MVC) d u ring each of the
m ovem ents. H ow ever, given that only 1–3% MVC is required
to stiffen a joint (Cholew icki & McGill 1996), their nd ings d o
not d isp rove the stabilization role. There is also a w ealth of
biom echanical literature that sup ports a stabilization role for
the rotator cu ff (Clark & H arrym an 1992; Wuelker et al 1995;
Bu rkhart 1996; Kibler 1998; Lee et al 2000), particularly the
su bscap u laris and infrasp inatu s / teres m inor m u scles
(Burkhart 1996). Given that the low er bres of the su bscapu-
laris attach d irectly to the m ed ial lip of the bicip ital groove
(Morag et al 2011) and those of the teres m inor m uscle attach
to the lateral lip (Drake et al 2009), these tw o m u scles are
id eally placed biom echanically to fu l l a stabilization role.
Ind epend ent innervation for these m u scles (the low er su b-
scap u laris nerve for the low er su bscap u laris and the axillary
nerve for the teres m inor, the m ost com m on d erivation of the
low er subscapu lar being the axillary nerve) also ind icates the
p otential for their fu nction to d iffer from that of the infrasp -
inatu s (su prascapular nerve) and u pper subscapu laris (u pper
su bscap u laris nerve) (Kasp er et al 2008; Morag et al 2011).
Evaluation of Motor Control around
the Shoulder Girdle
The assessm ents d escribed below are u sed to guid e m otor
control retraining. Im p airm ents in m otor control exist w ithin
a continuu m and m anifest as poor postu ral aw areness com -
bined w ith an inability to p rod u ce sm ooth, kinem atically
correct m ovem ents throu gh a fu ll range w ithou t com p ensa-
tion u nd er varying d em and s of p ostu re, load and sp eed .
Whereas severe im pairm ents w ill be ap p arent even in gravity-
elim inated p ositions, lesser im pairm ents w ill often be evid ent
only in certain ranges of m ovem ent, load s (Lu d ew ig & Cook
2000; McClu re et al 2001, 2006) and sp eed s (Roy et al 2008)
and d u ring d istracting tasks (H od ges 2004). Equ ally, sid e-to-
sid e com p arison p rovid es evid ence of bilateral m ovem ent
d ysfu nction, possibly ind icating a pred isp osition to im pair-
m ent (H ébert et al 2002; McClure et al 2006), and / or physi-
ological p rocesses occu rring throu ghou t higher p rocessing
centres in the central nervou s system (Sterling et al 2001;
Kleim & Jones 2008; Shum w ay-Cook & Woollacott 2012), and
a poorer prognosis w ith respect to change. With the aim of
converting id enti ed m otor control im p airm ents into retrain-
ing exercises, each assessm ent evalu ates w here (range,
p ostu re, load , sp eed ) the p atient has control and w here that
control is lost, and attend s to all com p onents in the kinetic
chain (u p p er and low er tru nk, scap u la, glenohu m eral). The
assessm ent is varied w ith respect to position (against gravity
versu s gravity elim inated or assisted ) to id entify the p osi-
tion / fu nction in w hich control is su f cient to initiate
retraining.
Postural assessment
Detailed evalu ation of postu re allow s form ation of initial
hyp otheses in relation to p otential im p airm ents in m otor
control. Postu ral abnorm alities m ay be associated w ith m ove-
m ent and control im p airm ents, althou gh an association m u st
not be assu m ed . Su ch hyp otheses m u st be tested w ith m ove-
m ent, resistive and p alp atory assessm ent and sp eci c p os-
tu ral im p airm ent correction d u ring p rovocative active
m ovem ents to ascertain the effect (Lew is et al 2005a). Static
p ostu re shou ld be assessed in p ositions relevant to the
p atient’s fu nction and sym p tom p rod u ction, not ju st in a
stand ard ized starting p osition. In ad d ition to visu al assess-
m ent, the scap u lar slid e test (Kibler 1998, 2003) is a valid ated
m easure of scapu lar resting position – althou gh resting
p osition is not necessarily correlated w ith fu nction and
m ore objective m easu res of sp inal p ostu re are available (Ju ll
et al 2008).
 Evaluation o  motor control around the shoulder girdle  361

If an apparent postural im p airm ent is id enti ed , its asso- u p w ard rotation or p assive p osterior translation for an ante-
ciation w ith the p atient’s p resenting cond ition shou ld be riorly placed hu m eral head w ill, for exam p le, often im p rove
tested to d eterm ine its d irect or ind irect relevance by assess- m ovem ent and lessen sym p tom s.
ing w hether alteration of the im p airm ent, either p assively or
actively, in u ences the patient’s sym p tom s or sense of ‘nor-
m alcy’. Althou gh not con rm atory, alteration in resp onse to
p ostu ral correction and the ability to achieve a corrected p osi-
tion p rovid e an ind ication of the signi cance of the p ositional
fault to their sym ptom presentation, level of aw areness or
control im p airm ent.

Evaluation o movement impairments

and awareness
The focu s of this m ovem ent assessm ent is not ‘d iagnostic’ of
stru ctu ral sym p tom sou rces, bu t rather on im p airm ents of
aw areness, m ovem ent and control; how ever, this shou ld
alw ays be u nd ertaken w ith ap propriate cau tion and m onitor-
ing of sym ptom p rovocation.
All active m ovem ents of the should er gird le provid e an
ind ication of m otor control, in ad d ition to m ovem ent aw are-
ness, d issociation, relative activity w ithin and betw een force
cou p les, m ore so than sp eci c strength or end u rance. There-
fore, all active should er m ovem ents shou ld be exam ined as
part of an evalu ation of m otor control. Any m ovem ent im p air-
m ents are evalu ated for their relevance to p rovocation of
sym p tom s. Assistance w ith active m ovem ent, su ch as the
scap u lar assistance test (SAT) (Kibler et al 2002, 2006; Kibler Figure 32.1 Scapular assistance test. (From Kibler 2003; Kibler et al 2002,
2003; Cools et al 2008) (Fig. 32.1, Box 32.1) to facilitate scap ular 2006, with permission.)

Bo x 3 2 .1 De s c rip tio n / d is c u s s io n o f te s ts

Fig ure  32.1
The scapular ass istance tes t involves the therapist providing
manual as s is tance to upward rotation o the s capula during
glenohumeral elevation through f exion, abduction or scapular
plane abduction.
Fig ure  32.2
Strength o the rotator cu mus cles is more accurately
evaluated when the scapula is s upported in a retracted pos ition,
such that it provides a s table bas e rom which the rotator cu
can work. The therapist maintains the s capula in a retracted
pos ition with manual press ure while providing manual
res istance to the arm or the relevant rotator cu test.
Fig ure  32.3
A shoulder s hrug in standing with the arms by the side
demons trates the patient’s ability to elevate the shoulder girdles
to ull pass ive range, the pattern o activation as sociated with
the movement and s ymmetry between s ides. Shoulder s hrug is
requently accompanied by signi cant low cervical f exion and
upper cervical extension, scapular elevation combined with
protraction and apparent glenohumeral internal rotation,
pos sibly repres enting a dominance o the levator scapulae over
the upper trapezius , as the orward-poking head lengthens the
upper component o the muscle, thus allowing it more leverage
to complete the movement at its dis tal end. The accompanying
scapular movement is ref ective o the dominance o the levator
scapulae and pectoralis minor. Correction o this movement
pattern leads to an inability to rais e the s capulae to their ull
pas s ive range. A tape or ruler can be us ed to meas ure vertical
dis tance between the ear lobe and the s houlder girdle to
provide an objective outcome meas ure.
The hypothes ized bas is or this tes t is that, in the elevated arm
pos ition, the upper trapezius is in its maximally s hortened
pos ition, s o i lengthened in its res ting pos ture, as with a
downwardly rotated s capula, attaining the s ame level o
s houlder shrug as with the arms by the side will be di cult.
Lack o pas s ive f exibility or overactivity in the levator s capulae,
rhomboids or latis s imus dors i will limit the pas s ive range o
s houlder shrug in this pos ition. An equivalent measure may be
taken to compare the range in the two pos itions .
Fig ure  32.4
Glenohumeral rotations , particularly in 90° o abduction / f exion,
demons trate the ability to move the glenohumeral joint on a
s table scapula and an awarenes s o diss ociation o the arm
rom the scapula. Di erences in the ability to diss ociate in
s tanding and in prone / supine provide indication o the e ect
o load on the scapular stabilizers and rotator cu during
this task.
This analys is can be made more objective by measuring the
dis tance moved by the acromion rom its neutral start position
during the arm movement. Ideally, movement should be
minimal. Exces s ive s capular movement leads to greater
acromial movement rom its res ting pos ition.

Continued
362 PART 4 • 32 •
Bo x 3 2 .1 De s c rip tio n / d is c u s s io n o f te s ts —c o n t’d
Fig ure  32.5
Evaluation o awarenes s o s capular movement can be
undertaken using scapular proprioceptive neuromuscular
acilitation (PNF) patterns . Given that the movements involved
are un amiliar to the patient, s everal s teps are taken in this
evaluation:
• Explain the direction o movement required, us ing cues such
as ‘Take the point o your shoulder towards the corner o
your eye’, while at the same time touching the corres ponding
acromial angle and outer corner o the eye and doing the
movement with the patient pas s ively, us ing traditional PNF
hand-holds and principles . For the oppos ite direction, cue
‘Take the point o your s houlder blade (while touching it with
your ngers) down towards the opposite hip / back pocket’
and again guide the patient in the appropriate movement
direction.
• Talk the patient through the movement while per orming it
pas s ively, ens uring availability o ull pas s ive range.
• As k the patient to assis t with the movement, ollowing which
unas s is ted per ormance determines the patient’s ability to
replicate it.
• I the patient has di culty gras ping the eel o the movement,
urther acilitation can be given by means o verbal
encouragement, res is tance to the movement through range,
holds at end o range with s low eccentric contraction and
revers als , etc. (Fig. 32.5A).
• In patients with poor awareness or control, the s capula tends
to ollow a curvilinear path rather than a diagonal one, with
jerky uncoordinated movement. Frequently, the s capula
moves into exces s ive protraction and anterior tilt when
attempting the ‘up-and- orward’ direction in particular, as
demons trated in Figure 32.5B. Such an inability to control the
movement in a direct diagonal and to the des ired end point
is an indication that us e o PNF as a hands-on acilitation
may be indicated in the early s tages o rehabilitation.
Fig ure  32.6
The test is per ormed in side-lying, with tested arm uppermos t
and s upported on the therapis t’s arm in approximately 120°
elevation, such that the therapist can apply progress ively
increased resistance into scapular protraction, glenohumeral
elevation and external rotation, with the heel o the other hand
agains t the lateral border o the s capula us ed to as s es s and
res ist s capular upward rotation. The activation can be tested
isometrically, isotonically both concentrically and, at higher
levels, eccentrically. Poor activation is elt as a s luggish
res pons e o the s capula to res istance and / or more ‘give’ to the
movement. The tes t may be progres s ed rom s imply holding
the arm while applying res istance to the scapula to resisting
protraction and elevation / external rotation on the arm
concurrent with upward rotation on the s capula.
Fig ure  32.7
Evaluation in our-point kneeling:
• Initially, spontaneous posture is noted with respect to spinal,
s capular, s houlder and hip alignments and the position
maintained or an arbitrary period (e.g. 2 minutes ) while
obs erving or atigue. Typical compens ation s trategies
Motor control o  the shoulder region
include locking the elbows into ull extension; arms into
end-range rotation; dropping the trunk orward, leading to a
pass ive scapular retraction and thoracic extension, increased
lumbar lordos is, orward head posture and cervical f exion;
elevation o the s houlder girdle towards the ears; s capular
winging or tremor o the arm and / or s houlder girdle
mus cles . As ymmetries rom neutral are highlighted to the
patient and correction is acilitated by pas s ive guidance i
necess ary. In this context, neutral re ers to normal spinal
curves and scapular pos ture, taking account o the patient’s
individual s pinal mobility. The patient’s abilities and
impairments are then recorded.
• The patient is ins tructed to shi t the weight onto one hand,
initially without li ting the other arm and then in conjunction
with arm elevation s o that the pattern o head on neck, trunk,
s capular and arm control can be urther evaluated. Again,
impairments are recorded. This ass ess ment may be taken
through urther s teps to increas e the challenge to match
relevant s porting requirements. Raising the diagonally
oppos ite arm and leg, in a ull pus h-up pos ition, undertaking
the as s es s ment with the legs and trunk on an uns table
s ur ace, such as a gym ball, or the hand balancing on an
uns table s ur ace, s uch as a s lide mat, s pin dis k or ball, all
provide additional challenge to the s ys tem and may highlight
impairments. These s teps also integrate the whole kinetic
chain s o impairments more dis tant to the shoulder may be
identi ed.
Fig ure  32.8
Evaluation in our-point kneeling:
• During evaluation o spinal dis sociation, a requent nding is
an inability to pos ition the head in neutral without
concomitant thoracic and lumbar extension. An instruction to
extend the neck requently leads to a whole-s pine extens ion
pattern. A reques t or pelvic neutral may have a s imilar e ect,
with the patient unable to is olate the lumbar s pine
movement.
• With pro / retraction o the scapula, the chest ‘drops through’
the s capulae on retraction and is elevated between them on
protraction. Typically, a patient with s houlder pain is unable
to per orm this movement independently o thoracic
f exion / extension. An inability to protract (i.e. push-up plus
pos ition) is als o o ten obs erved. Education about the
impairment and acilitation o an improved movement is
undertaken to determine how ‘ xed’ the impairment is in the
patient’s motor patterning and, there ore, how s igni cant it
might be in the context o the pres enting problem.
Fig ure  32.9
The therapis t palpates the humeral head with one hand,
ens uring no res traint o humeral head movement. This hand
eels or humeral head trans lation or altered quality o
movement through each s tage o the test. The therapist als o
obs erves s capular and s pinal control and movement, and
enquires about provocation o s ymptoms .
• With the patient’s arm by the side, elbow f exed to 90° and
neutral orearm rotation, manual res istance is applied slowly
through the wris t to an is ometric contraction. This contraction
is repeated in as many positions as appropriate or the

Bo x 3 2 .1 De s c rip tio n / d is c u s s io n o f te s ts —c o n t’d
particular patient’s pres entation. Do not s top in the s equence
o pos itions when an impairment is noted, as activity
regularly per ormed at higher range, s uch as throwing, may
lead to better unction in this range. The movement is
repeated rom the neutral s tart pos ition into the oppos ite
rotation.
• In most instances, at least three elevation positions are
tested: neutral, 45–60° elevation and an end position relevant
to unction (e.g. 110° elevation in the s capular plane or a
thrower or ull elevation or a s wimmer, mimicking the ‘catch’
pos ition).
• The test procedures are repeated using an is otonic
contraction through the ull available range, rst in one
rotation and then the other, ens uring that the movement is
one o pure rotation.
• I no impairment is detected through any part o the test, it is
repeated at higher s peed, with an eccentric component,
quick revers als or with increas ed load. Occas ionally, the
res is tance o the therapis t’s hand is s u cient to acilitate
co-contraction. Asking the patient to repeat the tes t
movements with a small weight in the hand may lead to
altered humeral head control, or the patient may be able to
eel when control is lost even i the therapis t cannot.
• Once a pos ition o impairment is detected, whether
is ometrically or dynamically, small variations o pos itions are
evaluated until a pos ition o control is ound as clos e to
where control is los t as pos s ible. I impairment on the
dynamic rotary s tability tes t (DRST) is prioritized or inclus ion
in a management plan, this would be the position where
training is commenced.
Fig ure  32.10
• The s tart pos ition is usually s itting with the arm supported in
60–90° scapular plane elevation, neutral rotation. The s tart
pos ition mus t be pain ree, with a relaxed s capula and
relatively neutral s pinal pos ition. The therapis t palpates the
axillary aspect o subscapularis with the tips o the middle
two ngers , us ually rom a pos terior direction, with the pads
adjacent to the latissimus dors i on the posterior axillary wall.
Concurrently, the therapis t places the pad o the thumb
vertically along the tendon o the in raspinatus / teres minor
s o that activation o both components o the orce couple
can be palpated simultaneous ly. Finding the s ubscapularis
tendon may be di cult on s ome people, es pecially thos e
with a s uperiorly trans lated humeral head or hypertrophy o
either the latis s imus dors i or pectoralis major. Con rmation o
correct positioning is made by gentle resistance into rs t one
rotation and then the other while the therapis t eels or
increased tone in the relevant tendon.
• Very gentle traction is applied to the humerus and the patient
asked to ‘draw the arm into the s ocket’. The therapis t
palpates both tendons to evaluate levels o contraction while
monitoring unwanted activation in other mus cles . Manual
acilitation by press ure on the tendons may be us e ul,
rein orced by verbal encouragement and vis ual imagery. This
is an un amiliar task, so initial as ses sment should be on the
non-a ected s ide.
Evaluation o  motor control around the shoulder girdle  363
• I co-contraction can be elt but only in as sociation with
s uper cial muscle activity, training is undertaken to reduce
the extraneous activity. I no co-contraction can be acilitated,
urther tactile stimulation and / or imagery may help. For
example, the anteriorly uns table s houlder may res pond to
ins truction to ‘draw the arm up and back’ in ass ociation with
a traction orce combined with gentle internal rotation, thus
biasing the acilitation to the external rotators . The superiorly
placed humeral head may res pond better to a s ugges tion to
‘draw in and gently pus h down on my nger in your armpit’
in conjunction with pressure on the subs capularis, although
exces s ive activation o latis s imus dors i and pectoralis major
may be the res ult o this s ugges tion. Pers is tence with
acilitation and multiple trials may be needed to achieve
s ucces s. In the uture, bio eedback with real-time ultras ound
is planned to acilitate training.
• Once the co-contraction can be achieved, a benchmark is
es tablis hed to orm the bas is or a home programme and
urther training, during which the patient must be able to nd
the s ubs capularis tendon and co-contract without the
traction acilitation. An arbitrary 10 repeats o 10-s econd
holds with s low, s mooth build-up and releas e o contraction
is us ed as a goal be ore progression. Once this can be
achieved, the direction o progression depends on the
pres entation o the patient. I an athlete whos e primary range
o poor control is in elevation, progres s ion is quickly made
into positions within the DRST where control was lost,
whereas the patient with pathology o the rotator cu or
s ubacromial bursa may need much slower and more
deliberate co-contraction training be ore any load is applied
to the arm.
Fig ure  32.11
The patient drives the hands orwards and upwards in a
pos ition o elevation, external rotation and elbow extens ion, thus
acilitating the upward rotation component o the movement.
Slight tens ion maintained on a lighter weight Theraband® into
glenohumeral external rotation ens ures that the patient does not
dri t into internal rotation and s capular pos ition o downward
rotation / anterior tilt. The lumbar and cervical s pines mus t be
maintained in a neutral position.
Fig ure  32.12
The Theraband® is looped over the s houlder and under the
oppos ite oot. The patient catches hold o the Theraband® and
s teps through the loop. Placing the oot behind in a walk–s tand
pos ition provides a downward-and-backward orce on the
s houlder, which acilitates correct movement o the acromion
towards the corner o the eye. Maintenance o a chin tuck, arm
external rotation and a neutral lumbar s pine will all as s is t correct
movement o the s capula.
The revers e ‘downward-and-backward’ pattern can als o be
trained by placing the Theraband® over a door and s hutting
the door while looping the Theraband® under the axilla. A s mall
towel placed in the axilla makes this more com ortable. The
patient s tands acing the door s o that the Theraband® pulls the
s houlder girdle up and orwards and works the s capula down
and back towards the oppos ite hip.
 364 PART 4 • 32 • Motor control o  the shoulder region

Active physiological glenohu m eral m ovem ents that are
m ost u sefu l from a m otor control p ersp ective inclu d e:
• f exion, abduction, scapular plane abduction: all p rovid e
an ind ication of relative scap u lar to glenohum eral
contribu tion, tim ing of m ovem ent of each com p onent and
a visu al im pression of activation of the key m u scle
grou ps
• glenohumeral rotations, particularly in 90°
abduction / f exion: these d em onstrate the ability to
m ove the glenohu m eral joint on a stable scap u la and
an aw areness of d issociation of the arm from the
scap u la.
Trad itional m anu al m u scle tests p rovid e an ind ication of the
strength of sp eci c m ovem ent d irections, bu t not ind ivid u al
m uscles, as both stabilizer and m obilizer m u scles contribu te
to the generation of force. Observation of relative control of
the scap u la and glenohu m eral joint d u ring m axim al
strength tests is u sefu l, bu t it d oes not id entify sp eci c ind i-
vid u al m u scle d ysfu nction, only a fau lty m ovem ent p attern
u nd er load . Evalu ation and p ossible correction of scap u lar
p osition, for exam p le w ith the scap ular retraction test
(Kibler et al 2006), d uring m anual m u scle testing is essential
to d eterm ine w hether the scap u la is fu l lling its stabilizing
role (Fig. 32.2).
Shoulder shrug (Roberts 2009)
A shou ld er shru g in stand ing p osition w ith the arm s both by
the sid e and overhead d em onstrates the p atient’s ability to
elevate the shou ld er gird les to the fu ll passive range, the
p attern of activation and m ovem ent sym m etry and the effect
of the altered m u scle balance in d ifferent arm p ositions. A tap e
or ru ler can be u sed to m easu re the vertical d istance betw een
the ear lobe and the shou ld er gird le to p rovid e an objective
ou tcom e m easu re (Fig. 32.3A,B).
Scapular control through glenohumeral rotations in prone
and supine (Sahrmann 2002)
Glenohum eral rotations in 90° abd uction or exion d em on-
strate the ability to m ove the glenohu m eral joint on a stable
scap u la and an aw areness of d issociation betw een arm and
scap u lar m ovem ent (Fig. 32.4). Poor aw areness lead s to exces-
sive scap u lar elevation, anterior tilt and p rotraction d u ring

Evaluation o specif c motor control impairments

around the scapula
On the basis of the evid ence and clinical exp erience, w e u se
the follow ing key m ovem ent im p airm ent tests to gain a broad
p ictu re of the ability and level of im pairm ent of the axioscapu-
lar m u scles. If m ovem ent im p airm ent is noted , its signi cance
is evalu ated u sing the p rincip les as ou tlined above. These
assessm ents are by no m eans exhau stive, but representative
of those com m only fou nd u sefu l. Figure 32.2 Scapular retraction test.

A B

Figure 32.3 Shoulder shrug: (A) with arms by the side, (B) with arms in full elevation.
 Evaluation o  motor control around the shoulder girdle  365

Figure 32.4 Glenohumeral rotation on a stable scapula.

A

internal rotation and the reverse on external rotation, or

sim p ly an inability to m aintain a stable p osition. Measu re-
m ent of acrom ial m ovem ent from neu tral start p osition d u ring
the arm m ovem ent m akes the test m ore objective. Su ch testing
shou ld be initiated from the least-challenging p osition (u p p er
arm su p p orted ) and progressed throu gh m ore challenging
positions to id entify w here control exists and w here it is lost.
If later chosen as part of a retraining p rogram m e, the task
m u st be controlled w hile still having su f cient challenge and
variability to op tim ize m otor learning.

Scapular PNF patterns (Voss et al 1985)

B
Aw areness of m ovem ent of the scap u la in isolation from the
arm is d if cu lt. Use of the scapu lar com ponent of the trad i-
tional PN F d iagonal arm p atterns p rovid es u sefu l inform ation Figure 32.5 Evaluation of scapular movement awareness using scapular PNF
on the kinaesthetic aw areness of the scap u la (Fig. 32.5). Given patterns: (A) manual correction and guidance into a more normal movement
pattern, (B) poor movement pattern during scapular movement in an up-and-
that this is an u nfam iliar m ovem ent, it is u nreasonable to forward direction.
expect a p atient to perform it w ithout som e facilitation and
ed u cation. More d etailed d escription of these tests can be
fou nd in Magarey and Jones (2003a).

Evaluation of range and control of scapular

upward rotation
Scap u lar u p w ard rotation occu rs actively in conju nction w ith
elevation of the arm . Therefore, the op tim al p osition in w hich
to evalu ate activity in the u p w ard rotation force cou p les is
w ith the arm in elevation greater than 90°, w ith resistance
app lied throu gh the arm to glenohu m eral elevation and exter-
nal rotation and throu gh the lateral bord er and inferior angle
of the scap u la against u p w ard rotation (Fig. 32.6). The stage
of the assessm ent, the qu ality of contraction of this im p ortant
force couple, the load applied throu gh the arm and the
nu m ber of rep etitions are all u sefu l clinical ou tcom e
m easu res.

Evaluation in four-point kneeling

Four-point kneeling, althou gh not particularly functional in
itself, is u seful for assessing patients’ d issociation and control
cap abilities. The evalu ation step s can also be ap p lied in p rone
position on the elbow s, or m od i ed plantigrad e (i.e. stand ing
w ith hand s su pported on table or w all) w ith the aim of id en-
tifying w here the p atient has control and w here that control Figure 32.6 Evaluation of scapular upward rotation in glenohumeral elevation.
 366 PART 4 • 32 •
is lost, thereby p rovid ing an effective starting p osition for
retraining. Positional and m ovem ent im pairm ents of the
scap u la and hu m eru s are observed and loss of control / p osi-
tion from either id enti ed as the lim iting factor.
Step s in the evalu ation inclu d e:
• observation of sp ontaneou s p ostu re and m u scu lar
end urance w ith a su stained hold
• scap u lar and glenohu m eral control d uring w eight shift
from one arm to the other (Fig. 32.7)
• d issociation (the ability to isolate m ovem ent of one bod y
part from another) of d ifferent regions of the sp ine and
betw een spine and scapu la (Fig. 32.8)
• control of scap u lar and cervical m ovements
• end u rance of p ro / retraction w hile w eight-bearing on one
or both hand s and w ith tru nk m ovem ent on a xed hand .
All com p onents can be progressed to m ore challenging situ -
ations, su ch as w ith the trunk on a gym ball or hand on an
Figure 32.7 Evaluation in four point kneeling. Scapular and glenohumeral
control in a single arm loaded position.
Figure 32.8 Dissociation evaluation in four-point kneeling. Scapular protraction in
a spinal neutral position.
Motor control o  the shoulder region
u nstable su rface, as ap p rop riate for the p atient. More d etailed
d escription of these tests can be found in Magarey and Jones
(2003a). In ad d ition, Ellenbecker and Cools (2010) have p ro-
vid ed an excellent su m m ary of recent research related to
evalu ation of scapular m u scle function, w hich is fu rther d is-
cu ssed in the rep ort of the recent scap u lar su m m it (Kibler et al
2013). Read ers are encou raged to review these papers for
further su ggestions.
Evaluation o thoracic extension and control
o scapular retraction
The patient’s ability to perform thoracic extension in a rela-
tively segm ental fashion p rovid es an ind ication of the p riority
for its retraining d u ring rehabilitation. One effective evalua-
tion is facilitated intersegm ental extension from C7 to T7 / T8
over a gym ball, the p atient’s tru nk rem aining in contact
w ith the ball to red u ce the lu m bar spine contribu tion. Once
relative segm ental thoracic extension is achieved , assessm ent
is progressed by ad d ition of scapu lar retraction and arm
m ovem ents.
Evaluation of isolated motor control
around the shoulder
Dynamic rotary stability test (Magarey & Jones
2003a, 2003b)
The DRST is used to evalu ate the rotator cu ff’s ability to
m aintain the hu m eral head centred in the glenoid w hen
load ed through rotation. The DRST is pred icated on the
know led ge that the hum eral head should rem ain centred in
the glenoid throu ghou t the range of rotation in any p osition
of elevation, excep t at end range, w here cou p led translation
forces the hu m eral head to translate (H arrym an et al 1990;
Terry et al 1991). When d ynam ic control is lacking, the
hu m eral head is felt to translate anteriorly, p osteriorly or
su p eriorly w hen the rotator cu ff is load ed . In m ore su btle situ -
ations, any sym ptom p rovocation, alteration in the contrac-
tion qu ality or com p ensation elsew here alerts the exam iner to
d ysfu nction w ithout the sensation of hum eral head transla-
tion. The p atient’s su bjective sensation of ‘stability’ d u ring
testing is also inform ative.
The DRST is u nd ertaken in d ifferent p arts of the elevation
range starting from neutral and p rogressing tow ard s the
p atient’s sym p tom atic fu nctional p osition(s) (Fig. 32.9A–B).
The nu m ber of positions in w hich the test is perform ed
d ep end s on the irritability of the cond ition, the general p hysi-
cal statu s of the p atient, the clarity w ith w hich the p atient can
id entify the sym p tom atic p osition(s) and the d em and s placed
on the shou ld er by the p atient. The aim is to nd the p osition(s)
in range w here the p atient has hum eral head control as close
as possible to the position at w hich control is lost w hen an
isom etric and p rogressively challenging d ynam ic load is
ap plied to the arm . The am ou nt of resistance ad d ed is
light / m od erate, as the assessm ent is of the ability to stabilize,
rather than of rotation strength. All m ovem ents are perform ed
in one d irection rst rather than alternately, as patients nd
this easier. If lack of control is id enti ed , rehabilitation can be
u nd ertaken starting from p ositions of control to facilitate acti-
vation of the rotator cu ff and then p rogressing to m ore
 Management o  motor control impairments around the shoulder girdle  367

Figure 32.9 Dynamic rotary stability

test: (A) evaluation of humeral head
movement during isometric rotation in
low range of elevation, (B) evaluation of
humeral head movement during isometric
rotation in high range of elevation. (From
Magarey & Jones 2003a, 2003b.)

A B

challenging p ositions. More d etailed d escrip tion of this test

m ay be fou nd in Magarey and Jones (2003b).

Dynamic relocation test (Magarey & Jones

2003a, 2003b)
The DRT is a test of the ability of the rotator cu ff, particularly
the low er elem ents, to stabilize the hu m eral head in the
glenoid by m eans of co-contraction against a d estabilizing
load . Once the ability to isolate the co-contraction has been
d eterm ined in an optim al position, it can be evalu ated in d if-
ferent positions and d uring d ifferent tasks. If a patient is
u nable to achieve m ore than the very basic levels of the DRST,
assessm ent shou ld start w ith the DRT. The p rinciples of
testing are sim ilar to those for the craniocervical exion
test (Ju ll et al 2008) and transversus abd om inis activation
(H od ges 2004). Figure 32.10 Dynamic relocation test. (From Magarey & Jones 2003a, 2003b.)
Patient ed u cation abou t test p erform ance is im p ortant as it
is an unfam iliar task. Use of d iagram s and / or anatom ical
m od els / ap p s is help fu l so that the p atient u nd erstand s that
p rocesses of m otor learning are d istribu ted throu ghou t m any
the m ovem ent requ ired is one of a su btle ‘d raw ing in’ of the
d ifferent brain structures involving m u ltiple p rocessing
hu m eral head to the glenoid via co-contraction of the infra-
levels. The neural m od i ability can be seen as a continu um
sp inatu s / teres m inor and low er su bscap u laris w ith m inim al
from short-term to long-term changes that lead to the (re)
involvem ent of the sup er cial m u scles, in response to a gentle
acqu isition of relatively perm anent m ovem ent cap ability
longitud inal m ovem ent app lied to the arm (Fig. 32.10). Occa-
(Schm id t & Lee 2005; Shu m w ay-Cook & Woollcott 2012).
sionally, a p atient’s ability to co-contract is enhanced in a
Rehabilitation strategies shou ld be tailored to the ind ivid u al’s
load ed , closed kinetic chain position. More d etailed d escrip-
sp eci c neu rom u scu lar im p airm ents and m otor control cap a-
tion of this test m ay be fou nd in Magarey and Jones (2003b).
bilities, w hich m ay vary in d ifferent bod y segm ents and over
d ifferent tasks, together w ith consid eration of their goals and
any potential p sychosocial issues that m ay increase the brain’s
Management of Motor Control threat ap p raisal (Latrem oliere & Woolf 2009; H od ges 2011).
Impairments around the Although the Fitts and Posner (1967) (cognitive, associa-
tive, au tonom ou s) m od el of m otor learning is p erhap s m ore
Shoulder Girdle fam iliar, Vereijken et al (1992) d escribed another three-stage
(novice, ad vanced , exp ert) theory of m otor learning that
Motor learning refers to the acqu isition or m od i cation of accounts for red u ctions in bod y d egrees of freed om seen in
m ovem ent (Shu m w ay-Cook & Woollcott 2012). This process child d evelop m ent and new skill acqu isition in general. Given
has been d em onstrated in both sensory and m otor areas of that m u ch research arou nd d isru p tions to m otor control
the hu m an cortex as a resu lt of m anip u lation of p ractice or relates to freezing of d egrees of freed om (Cow an et al 2001,
experience (Boniface & Ziem ann 2003). The physiological 2002, 2003; H od ges 2004; Colné & Thou m ie 2006; H ertel &
 368 PART 4 • 32 • Motor control o  the shoulder region
Olm sted -Kram er 2007; Ju ll et al 2008; H od ges et al 2009), w e
feel that this m od el com plem ents and ad d s to the u sefu l
m od el of Fitts and Posner (1967). The novice stage involves
the learner freezing d egrees of freed om by co-contracting ago-
nists and antagonists to constrain a joint so as to sim p lify the
m ovem ent, as w ith the rigid bracing of the w rist w hen rst
learning to u se a ham m er. Degrees of freed om are p rogres-
sively released throu gh the ad vanced and exp ert stages, thu s
enabling m ovem ent at m ore joints and m ore sop histicated
m u scle synergies across m u ltip le joints until sm ooth, coord i-
nated m ovem ents are p erform ed . This theory offers a ration-
ale for the clinical effectiveness of strategic posturing and
external su pport that is com m only used in early stages of
rehabilitation, su ch as retraining the co-contraction of the
low er su bscap u laris and infrasp inatu s / teres m inor w ith the
arm initially su p p orted in a stabilized scap ular and gleno-
hu m eral neu tral p osition. Decreasing the d egrees of freed om
requ ired at the scapu la through external su pport of the table
and neu tral positioning sim pli es the task, allow ing the
p atient to focu s on the correct activation.
Shou ld er com p lex rehabilitation exercises shou ld be ind i-
vid u alized to sp eci c im p airm ents id enti ed from the exam i-
nation as p otentially contribu ting to the patient’s activity (e.g.
shou ld er elevation or throw ing) (as d escribed in Case Rep ort
1) and p articip ation lim itations (e.g. in activities of d aily living
or sport) (as d escribed in Case Rep ort 2) (Graichen et al 2001;
H ébert et al 2002; Roy et al 2008). The focu s in relation to
m otor learning theory and research in this chap ter is lim ited
to retraining of skills w ith w hich p atients are alread y fam iliar,
rather than learning new skills. Although this focu s im plies
com m encing w ith the associative / ad vanced stage of m otor
skill d evelop m ent, p re-existing im p airm ents in p ostu re and
m ovem ent p atterns com m only requ ire that attention be given
to the cognitive / novice stage to ensu re u nd erstand ing and
correct p erform ance (e.g. retraining shou ld er elevation w ith
less scap u lar p rotraction). Su ch im p airm ents are com m only
the resu lt of short-term m otor ad ap tations that can occu r p ost
inju ry and , if m aintained , m ay com p rom ise the qu ality of
m ovem ent, d ecrease the variability of m ovem ent and increase
the load on sp eci c stru ctu res / tissu es (H od ges 2011). Aw are-
ness training is generally started in neu tral p ositions, w hereas
control training is com m enced from neu tral or a p osition close
to the p osition of im p airm ent w here the action / hold can be
p erform ed correctly.
Patients’ u nd erstand ing and m otivation, goal setting,
qu ality p ractice, rep etition and feed back (Mon ls et al 2005;
Schm id t & Lee 2005; Sou sa 2006; Kleim & Jones 2008;
Shu m w ay-Cook & Woollacott 2012) all facilitate m otor learn-
ing. Und erstand ing, w here exp lanations are m eaningfu l to the
ind ivid u al, enhances p atient m otivation, attention and learn-
ing. The m ore thorou ghly the inform ation is p rocessed , the
d eeper is the learning and m ore likely the transfer to new situ -
ations outside the therapeutic setting (Sousa 2006). Explanations
of assessm ent nd ings and m anagem ent recom m end ations,
linked to research and su ccessfu l clinical ou tcom es, u se of
anatom ical p ictu res, m od els and app s, and op portunities to
ask qu estions and su m m arize m ain points all prom ote d eeper
learning.
Goal setting also facilitates m otivation and learning. Sp e-
ci c, absolu te goals of m od erate d if cu lty p rod u ce better p er-
form ance than either vagu e (e.g. ‘d o you r best’) (Kyllo &
Land ers 1995; Schm id t & Lee 2005) or no goals. Speci c goals,
both short and long term , assist patient focu s and facilitate
p erform ance w hile p rovid ing a reference for m onitoring
p rogress (Kyllo & Land ers 1995).
Practice is recognized as the single m ost im p ortant variable
in uencing learning, w ith changes occu rring rapid ly (w ithin
15 m inutes) and continu ing to evolve w ith extend ed training
(Schm id t & Lee 2005; Boud reau et al 2010b; Shu m w ay-Cook
& Woollacott 2012). Whereas synaptic connections are
strengthened throu gh exp erience, com p lexity of task, varia-
bility, level of attention and repetition (Spitzer 1999; Perez
et al 2004; Bou d reau et al 2010b), success d u ring exercise
enhances learning; this necessitates the choosing of exercises
that can be su ccessfu lly achieved w ith good kinem atic control
and no sym p tom aggravation (H od ges 2011). Motor ad ap ta-
tions need to continu e beyond the resolu tion of p ain and
therefore, to restore op tim al control, interventions m u st con-
tinu e to incorp orate the above strategies that target higher
levels of processing (H od ges & Tu cker 2011).
Au gm ented feed back regard ing p erform ance of a m ove-
m ent or exercise is consid ered to be critical to m otor learning,
second only to p ractice itself (Schm id t & Lee 2005; H od ges
& Tucker 2011). Perform ance feed back can be provid ed visu-
ally, as w ith vid eo, real-tim e u ltrasou nd , through EMG-based
biofeed back, throu gh tactile reinforcem ent or verbally, typi-
cally highlighting som e asp ect of the m ovem ent p attern that
is d if cult to perceive (e.g. recognition of spinal postu re / m ove-
m ent d u ring shou ld er elevation). Inherent feed back refers to
sensory inform ation d irectly available to the ind ivid u al
d u ring or resulting from the execution of a m ovem ent. Und er-
stand ing w hen control is lost is essential for hom e m otor
control exercises to ensu re that exercises are not continu ed
p ast this p oint, w hich w ou ld p otentially reinforce incorrect
m ovem ent p atterns. For exam p le, althou gh p atients cannot
see the loss of scap u lar control, by d raw ing their attention to
their scap u la the therap ist can teach them to recognize the
local sensation associated w ith control and loss of control;
they thereby learn to continu e the exercise only to the p oint
w here that sensation occu rs. Use of facilitatory tap ing w ith a
p rod u ct su ch as Dynam ic Tap e® (w w w.d ynam ictape.com )
can enhance learning of new scap u lar m otor p atterns.
Management of shoulder motor control
through patient examples
Tw o p atient case stu d ies are p resented below as exam p les of
im p lem entation of the suggestions above and to highlight
clinical reasoning and im p lem entation of m otor learning
p rincip les.
Case Report 1
Tom – baseball player with shoulder pain
Tom w as a 19-year-old left-hand -d om inant elite baseball
player w ith painfu l shou ld er w ith throw ing. H e p resented
w ith d eep, m od erately severe su p erior should er p ain
associated p rim arily w ith the late cocking phase of a throw.
The onset w as grad u al throu gh the p reviou s baseball season
and he w as keen to ad d ress it in the off-season. There w ere
no red ag issues to consid er, no app arent frank rotator cu ff
or labral pathology, cervical or neu rod ynam ic involvem ent.
 Management o  motor control impairments around the shoulder girdle  369
Tom had a good range of m ovem ent bu t p oor aw areness of
d issociation of d ifferent regions of his sp ine and betw een the
sp ine and scap u la, lead ing to p oor ability to stabilize the
scap u la or arm . H e stood w ith poor sp inal p ostu re,
p articu larly thoracic kyp hosis and a forw ard head p osture.
Active assisted correction w as possible bu t could not be
m aintained . H is scap u la w as d ow nw ard ly rotated and
anteriorly tilted (typ e I / III d yskinesis com bined ) (Kibler
et al 2002) so that his arm hu ng in m ed ial rotation. H is
ability to d issociate in fou r-p oint kneeling w as inad equ ate as
he w as u nable to su stain good scap u lar p osition w ithou t
fatigu e-related com pensations. Increased ‘give’ to resistance
on the lateral scap u lar bord er w as evid ent on u p w ard
rotation to his u naffected sid e. A DRST d em onstrated poor
isom etric control of his hu m eral head in 110° scap ular
elevation w ith both rotations, the p osition relevant to his
throw ing, and at 90° w ith slow isotonic rotations. With
facilitation, Tom w as able to achieve good contraction and
control in neu tral w ith the DRT.
Tom ’s m anagem ent consisted of ed u cation abou t the
relevance of his postu ral and m ovem ent im pairm ents to his
throw ing p ain, follow ed by sp inal and scap ular p ostu ral
correction and d issociation training in both sitting and
fou r-point kneeling, w hich w as later p rogressed to stand ing
and p ositions relevant for throw ing. Retraining of the
u p w ard rotation of his scap ula, w ith hand s-on
facilitation / feed back, w as follow ed by a hom e p rogram m e
ensu ring the m aintenance of a neu tral sp ine, glenohu m eral
external rotation and elbow extension as he d rove forw ard s
through his hand s (Fig. 32.11). As Tom im p roved , the
training w as progressed to closed kinetic chain activities
su ch as a slid e board in fou r-p oint kneeling and p u sh-u p
p osition, concentric and eccentric load , alw ays focu sing on
good positioning.
Figure 32.11 Home exercise for retraining scapular upward rotation.
Isolation training for glenohum eral stabilization w as not
w arranted as Tom w as able to learn the techniqu e qu ickly
and integrate it into the DRST, to w hich training w as
d irected im m ed iately close to p ositions of lost control, both
isom etrically and isotonically, and stop ping w hen he felt
hu m eral head translation or lost control of his scap u lar
position – both of w hich requ ired explicit sensory
recognition training for him to recognize. Over tim e, he
increased the speed and range of movem ent, as requ ired for
throw ing, and later increased the load .
Attention to Tom ’s throw ing techniqu e and the rest of his
kinetic chain w as an integral part of his m anagem ent, w ith
strengthening and skill training built around d ynam ic
control. If any given strengthening exercise resulted in loss
of control, the task w as jud ged too challenging and m od i ed
in p osition or load . For each task, frequent practice in as
m any d ifferent environm ents as p ractical w as encou raged to
facilitate m otor learning (Schm id t & Lee 2005). Based on
research by Bou d reau et al (2010b), changes in cortical
plasticity have been show n to occu r over short intervals
(60 w ithin-session task repetitions over a period of 10–15
m inu tes). If Tom w as not able to m aintain control over any
parameters of a speci c task, the achievem ent of these w as
set as a short-term goal. Once achieved , these param eters
w ere then p rogressively m ad e m ore challenging w ith
lengths of hold , sequ ence of m ovem ents, comp lexity of
tasks, load , rep etitions and other cognitively d istracting
tasks ad d ed to challenge the neu rom uscular system fu rther.
Tom w as p rovid ed w ith thoracic extension facilitation
training over the gym ball, learning intersegm ental thoracic
extension and then load ed end urance exercises into
extension. As a resu lt of the postu ral training and
m aintenance of good cervical p ostu re throu ghou t these
exercises, inclu sion of form al craniocervical exor training
w as not necessary. Later p rogressions w ere ad d ed to
challenge his sp inal control and end u rance fu rther in
conju nction w ith arm m ovem ents.
The need to lose co-contraction is p art of the
au tonom ou s / exp ert stage of learning associated w ith skilled
activity (Shu m w ay-Cook & Woollacott 2012) su ch that the
task becom es a feed -forw ard m echanism not a feed back one.
As Tom ’s control of the DRST p osition im proved and he
retu rned to throw ing, it is likely that he lost the m ajority of
the co-contraction inclu d ed w hile re ning his technique.
Loss of co-contraction in skilled p itchers (Glou sm an et al
1988) and elite sw im m ers (Carr et al 1998) com p ared w ith
u ntrained controls su pports the need to increase d egrees of
freed om w ith d evelop m ent of skill (Vereijken et al 1992).
H ow ever, interm ittent bu t regu lar co-contraction training is
recomm end ed , as clinical exp erience d em onstrates a
tend ency to lose this ability w ith the potential to lead to
higher risk of injury. Su ch control is still requ ired for
activities requiring high d egrees of accu racy (Gribble
et al 2003).
Case Report 2
Joan – o f ce worker with  ull-thickness rotator cu  tear
Joan w as a 59-year-old right-hand -d om inant of ce w orker
w ith MRI-con rm ed fu ll-thickness rotator cu ff tear involving
370 PART 4 • 32 • Motor control o  the shoulder region

the sup rasp inatu s and a sm all portion of the infrasp inatus,
cou pled w ith a thickened sw ollen su bacrom ial bu rsa. She
p resented w ith sharp severe left su bacrom ial p ain on qu ick
m ovem ents, an inability to raise her arm above 90° elevation
becau se ‘it w on’t go’ and d if cu lty in sleep ing becau se of
p ain. Three w eeks p reviou sly, her d og had p u lled sud d enly
on the leash and she felt som ething ‘give’ in her shou ld er.
Joan had a history of ‘nu isance valu e’ d iscom fort in her
shou ld er and neck p ain w ith p rolonged com p u ter u se. She
had d if cu lty w ith hand -behind -back activities, bru shing her
hair and reaching to the top cu p board becau se of p ainfu l
lim itation of m ovem ent. H ow ever, the p ain settled qu ickly.
There w ere no neurological sym p tom s, vertebrobasilar
insu f ciency issu es or red ags. As a result of p ainfu l
restricted range, Joan’s m otor control assessm ent w as
lim ited .
Joan’s key p ostu ral im p airm ents inclu d ed increased thoracic
kyphosis, a forw ard head p ostu re, elevation of her left
acrom ion comp ared w ith the right, ap p arent increased tone
in both the levator scap u lae and up p er trap eziu s, and
w asting of the su p raspinatu s. Correction of sp inal p ostu re
w as im p ossible ow ing to low cervical / u p p er thoracic
stiffness on extension. Active shou ld er elevation of 80° led to
im m ed iate hu m eral sup erior translation and scapu lar Figure 32.12 Home exercise for retraining scapular movement awareness in
elevation, w hile assistance to scap ular u p w ard rotation the PNF pattern of ‘up & forward’.
gained a fu rther 30° before p ain increased . Pain and
w eakness p revented Joan from hold ing this p osition.
Training w as then p rogressed into increased ranges of
Joan’s m ovem ent aw areness on scap u lar PN F p atterns w as
elevation, alw ays w ith the arm sup p orted and pain free.
p oor, even w ith facilitation. DRT w as tau ght initially on her
Only w hen Joan cou ld perform 10 sets of 10 hold s in each
right shou ld er w here she cou ld activate the rotator cu ff w ell;
position w as she p rogressed to taking the w eight of her arm .
how ever, she had great d if cu lty in the left shou ld er, and
Grad u ally, she w as able to su p port her arm in each training
w as eventu ally able to create only a w eak p ain-free
position and cou ld start to w ork into functional positions
co-contraction, su stained for 3–4 second s.
through elevation w ith controlled scapulohum eral and
Joan’s rotator cu ff tear w as not large bu t extend ed into the glenohu m eral m ovem ent. To optim ize im p rovem ents in
infrasp inatu s, su ch that it d isru p ted the biom echanics of the perform ance, it is vital that control is trained w ith skilled ,
shou ld er (Bu rkhart 1996). Therefore, the low er rotator cuff precise tasks prior to re-integration of higher load exercises
force cou p le w as u nable to control su p erior hu m eral (Remp le et al 2001; Bou d reau et al 2010b).
m igration d u ring active elevation. The m otor control
Once Joan cou ld perform the PN F p atterns w ell, sid e-lying
ap proach requ ired focu sing on the scapu la and rotator cuff
scap u lar u p w ard rotation training w as instigated in the
concu rrently as the m ovement imp airm ent w as so closely
increased range available, initially w ith no load throu gh the
linked . Joan’s accessory m ovem ent of the low er cervical and
arm , then later ad d ing a p rotraction load bu t u pw ard
u p per thoracic sp ine revealed signi cant stiffness, w hich
rotation stim u lu s only to the lateral scapu lar bord er, w ith
also contributed to her loss of should er elevation.
progression focu sed on increased elevation range rather than
The p riorities for Joan’s treatm ent w ere very d ifferent to load , again w ith an associated hom e programm e.
those for Tom . Isolated rotator cu ff training w ith the
Concurrently, Joan w orked w ith a series of scapu lar
d ynam ic relocation m anoeu vre w as ap p rop riate in
retraining exercises focused on facilitating low er
conju nction w ith retraining scap ular m ovem ent p atterns.
trapezius / low er serratu s anterior activity w hile red u cing
Passive m obilization and m obility exercises im proved her
activation of the u p per trapeziu s m u scle (Kibler et al 2008).
sp inal range, follow ing w hich aw areness and intersegm ental
‘Low row ’ and ‘law n m ow er ’ exercises cou ld be perform ed
control w ere facilitated w ith training. Joan’s p oor cervical
pain free w ithou t loss of scapu lar or hu m eral head control
p ostu re and previou s cervical p ain m eant that craniocervical
qu ite early in the p rogram m e.
exor evalu ation and training w ere appropriate and
integrated (Ju ll et al 2008).
Tom ’s p roblem s w ere largely a resu lt of p oor m ovem ent
Scap u lar PN F p atterns w ere u sed to facilitate im p roved
aw areness and techniqu e com bined w ith inad equate postu ral
scap u lar aw areness and m ovem ent. Tactile and verbal
aw areness, end urance and exp losive p ow er for throw ing.
stim u lation of correct m ovem ent w as com p lem ented w ith a
Joan’s poor m ovem ent patterns, how ever, w ere m u ch m ore
hom e p rogram m e (Fig. 32.12).
entrenched and associated w ith spinal stiffness, pathology
Dynam ic relocation training w as initiated in a p ain-free w ithin the tissues and provocation of pain. Red u ction in pain
neutral position, and she grad u ally bu ilt u p her capacity to and increase in range p robably resu lted at least in p art from
10 sets of 10-second hold s of good -qu ality contraction. im proved spinal and shou ld er gird le m ovem ent patterns plus

red u ced sup erior hum eral translation, red u cing the com pres-
sive force throu gh the irritated su bacrom ial bu rsa. As a resu lt
of her initial p oor ability to control the hu m eral head p osition,
isolation training of the rotator cu ff w as w arranted , com bined
w ith p rogressive scapu lar training. Progression w as slow for
Joan, w hereas for Tom it w as quick.
The training p rogram m es chosen incorporated exercises
from or w ere sim ilar to those recom m end ed by Cools et al
(2007b) and Kibler et al (2006, 2008). While not exhau stive,
this ap p roach to m anagem ent of p oor m otor control is effec-
tive and ap p licable across a range of p resentations of p atients
w ith shou ld er p ain.
Conclusion
Ou r ap p roach to m otor control evalu ation and m anagem ent
has not been valid ated in form al research bu t is based on
strong evid ence, sou nd clinical reasoning and exp erience.
Although w e read ily acknow led ge that m otor control retrain-
ing extend s beyond regaining control of the neutral zone, for
the p u rp oses of this chap ter the m ain focu s has been on the
early stages as p rogressive load ing is covered in Chapter 33.
Bu ild ing m ore fu nctional retraining on the basis of sou nd
m otor control enhances the bene ts of m ore ad vanced train-
ing and im p roves chances of su ccessful m anagem ent.
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 PART 4 •  The Shoulder Region in Upper Extremity Pain Syndromes
Therapeutic Exercises for the Shoulder Region
CHAP TER CONTENTS
Introduction  373
Clinical background  373
Shoulder exercise: evidence  374
Principles of exercise  374
Posture  376
Stretching  376
Isometric exercise of the shoulder  378
Isotonic exercises of the shoulder  378
Supraspinatus muscle  379
Infraspinatus and teres minor muscles  379
Subscapularis muscle  380
Trapezius muscle  380
Serratus anterior muscle  381
Functional exercises  381
Conclusion  383
Introduction
Therap eutic exercise is a cornerstone o physiotherapy prac-
tice and w as initially re erred to as medical gymnastics. The
d evelopm ent o m ed ical gym nastics in physical therapy has
had m any d iverse in u ences inclu d ing Dr Francis Fu ller,
au thor o M edicina gymnasticia (1740), Sw ed ish gym nast Per
H enrik Ling (1776–1839) and the Du tch p hysical ed u cation
teacher and physician Dr Johann Georg Mezger (1838–1909)
(Barclay 1994; Terlou w 2007). More recently Kend all (2002)
su m m ed u p the role o therap eu tic exercise in p hysical
therap y: ‘Central to the p ractice o p hysical therap y is the
prevention o m ovem ent d ys u nction and the rehabilitation
throu gh restoration and m aintenance o active m ovem ent – in
other w ord s, therap eu tic exercise in its broad est sense’. The
ocus o this chapter is to introd u ce general principles o
therap eu tic exercise or the shou ld er, and to stim u late
clinical reasoning and rational rehabilitation. The chap ter w ill
brie y d iscu ss p osture, stretching and strengthening o a
 
Chapter 
33  
J o h n s o n M c Evo y, Kie ra n O ’S u lliva n , C a re l Bro n
selection o m u scles, w ithou t ocu sing on one sp ecif c clinical
p op u lation.
Clinical Background
Essential to an u nd erstand ing o therapeutic exercise is an
in-d epth know led ge o anatom y, physiology and u nction,
sp ecif cally related to the neu rom u scu lar and m u scu loskeletal
system s (Kend all 2002). The should er is a com plex unctional
system p rod u cing m ovem ent o the arm on the tru nk and
allow ing the u pper lim b and hand to be d ynam ically m oved
and positioned or u nction. The shou ld er consists o the
scap u la, clavicle and hu m eru s, giving rise to the sternocla-
vicu lar, clavicu lar, hu m eral and scap u lothoracic joints, and
has a close relationship to the neck, thorax and ribs. The
shou ld er is su p p orted by cap su lar, ligam entou s and m u scu lar
system s w ith com p lex neu rom u scu lar p rocessing that o er a
w id e range o m otion, but w ith a subsequ ent com prom ise in
joint stability. This trad e-o in stability m akes the shou ld er
p otentially vu lnerable to d ys u nction and inju ry, and stability
is o ten the m ain ocus o therapeu tic exercise or the shou ld er
com p lex. Read ers shou ld re er to the ap p rop riate chap ters
o this book and other texts or a com p rehensive review o
shou ld er anatom y, biom echanics, kinesiology and p athom e-
chanics (Donatelli 2004a; Oatis 2004). Fu rther, know led ge o
connective tissu e p rop erties, orce ap p lications, tissu e inju ry
(bone, ligam ent, tend on, m u scle, ascia, nerve, etc.) and tissu e-
healing concep ts and tim elines (in am m ation, p roli eration,
m atu ration) is an im p ortant p recu rsor to the d evelop m ent o
a suitable and sa e therapeutic exercise program m e (Tippet &
Voight 1995; Paris & Loubert 1999; H ouglu m 2005).
Prior to the d evelop m ent o a rehabilitation p rogram m e or
the shou ld er com p lex a com p rehensive assessm ent and p hysi-
cal exam ination shou ld be p er orm ed w ith re erence to the
p rincip les o p hysical therap y p ractice so as to ascertain p er-
tinent in orm ation and p hysical characteristics o the ind i-
vid u al p atient. Ind ications or therap eu tic exercise o the
shou ld er are listed in Box 33.1 and are d iverse; they includ e
sp ecif c and non-sp ecif c m u scu loskeletal, orthop aed ic, su rgi-
cal and neu rological cond itions and d ys u nctions, and also
p ostu ral and p er orm ance enhancem ent and inju ry p reven-
tion strategy.
 374 PART 4 • 33 •
Bo x 3 3 .1 In d ic a tio n s fo r th e ra p e u tic s h o u ld e r
e xe rc is e s
• Glenohumeral joint lesions, dys functions and ins tability
• Rotator cuff les ions and dysfunctions
• Subacromial impingement syndrome
• Acromioclavicular joint les ions and dysfunctions
• Sternoclavicular joint les ions and dysfunctions
• Superior labrum anterior-to-posterior (SLAP) lesions
• Adhesive capsulitis (frozen s houlder)
• Arthropathies: arthros is, arthritis, rheumatoid arthritis
• Pos t fracture and trauma
• Soft tiss ue injuries and syndromes
• Sports injuries
• Myofascial pain and dys function from trigger points
• Hypermobility syndromes
• Pos tural dysfunction
• Movement disorders
• Performance enhancement and performance optimization
• Injury prevention
• Pos t shoulder s urgery and arthroscopy
• Shoulder replacement
• Thoracic surgery with s houlder involvement (e.g.
mas tectomy)
• Spinal cord injuries and nerve root s yndromes
• Peripheral nerve injuries
• Central nervous system disorders (e.g. hemiplegia)
Shoulder Exercise: Evidence
A w id e variety o shou ld er d isord ers have d em onstrated
alterations in shou ld er range o m otion (H all & Elvey 1999;
Verm eu len et al 2002; McClu re et al 2006), scapu lar kinem at-
ics (Lu kasiew icz et al 1999; Lu d ew ig & Cook 2000; McClu re
et al 2006; Roy et al 2009; Tate et al 2009), scap ular and rotator
cu m u scle activation (Lu d ew ig & Cook 2000; Cools et al
2007; Moraes et al 2008; Myers et al 2009), hu m eral translation
(Chen et al 1999; Lu d ew ig & Cook 2002), repositioning sense
(N au ghton et al 2005) and should er strength (McClu re et al
2006; Lom bard i et al 2008; Bayd ar et al 2009; Bigoni et al
2009). There ore, therapeu tic exercises are com m only ad vo-
cated to ad d ress these d ys u nctions in m obility, p ostu re,
m u scle activation, p rop riocep tion and strength.
Overall, the evid ence that therap eu tic exercise is e ective
or non-specif c should er p ain is m ixed (Sm id t et al 2005),
sim ilar to other ap p roaches inclu d ing m anu al therap y (H o
et al 2009) and acup unctu re (Green et al 2005). H ow ever,
exercise ap pears to be as e ective or non-specif c shou ld er
p ain as m ore expensive treatm ents su ch as m u ltid iscip linary
bio-psychosocial rehabilitation (Karjalainen et al 2001). Fur-
therm ore, w hen sp ecif c shou ld er d isord ers are consid ered
there is little evid ence that alternative ap p roaches are su p e-
rior to therapeu tic exercise. For exam ple m ed iu m - and long-
term ou tcom es a ter therap eu tic exercise in ad hesive cap su litis
are sim ilar to those a ter other treatm ents inclu d ing arthro-
graphic d istension (Buchbind er et al 2008) and corticosteroid
Therapeutic exercises for the shoulder region
injection (Winters et al 1997, 1999; Buchbind er et al 2003).
There is also evid ence that com bining corticosteroid injection
w ith physiotherapy includ ing therapeutic exercise resu lts in
greater im p rovem ent than either treatm ent in isolation
(Carette et al 2003).
The use o therapeu tic exercise in the m anagem ent o
sp ecif c d isord ers inclu d ing su bacrom ial im p ingem ent syn-
d rom e (SAIS) and rotator cu lesions is sup ported by m u ch
research (Bang & Deyle 2000; Desm eules et al 2003; Green
et al 2003; Michener et al 2004; Dickens et al 2005; Jonsson
et al 2006; Tram pas & Kitsios 2006; Senbu rsa et al 2007;
Lom bard i et al 2008; Bayd ar et al 2009; Chen et al 2009; Ku hn
2009; Roy et al 2009). Furtherm ore, ou tcom es ollow ing con-
servative treatm ent (incorp orating therap eu tic exercise)
ap pear to be sim ilar to those a ter su rgical intervention in
SAIS and rotator cu lesions (H aahr & And ersen 2006;
Dorrestijn et al 2009). This key role o therapeu tic exercise in
shou ld er rehabilitation is em p hasized by the act that good
clinical ou tcom es have been associated w ith norm alization o
scap u lar kinem atics (Roy et al 2009) and recovery o strength
(N ho et al 2009).
Principles of Exercise
A clinical assessm ent shou ld be com p leted p rior to exercise
p rescrip tion and clinicians shou ld rem ain cognisant o the
variou s acets o an exercise p rogram m e and su it the need s
to the ind ivid u al p atient: p ostu re, exibility and stretching,
stability, strengthening, p rop riocep tion and u nctional p ro-
gression (Tip p et & Voight 1995; Lep hart & Fu 2000; Alter
2004; Donatelli 2004b, 2006; Kraem er & Ratam ess 2004;
Weerapong et al 2004; H ouglu m 2005; Kend all et al 2005;
MacIntosh et al 2006). It is im p ortant or the clinician to gather
in orm ation includ ing the su bjective history, objective exam i-
nation, sp ecial tests, u nctional ability, im p airm ent, d ys u nc-
tions, d iagnosis and any other p ertinent in orm ation. Tw o-w ay
com m u nication w ith other team m em bers (e.g. m ed ical, su r-
gical, psychological, coach, strength and cond itioning, etc.)
is essential in ord er to enhance the overall physical therap y
p lan o care, and set ap p rop riate and sa e goals. Clinicians
shou ld em p loy evid ence-based p ractice and clinical reasoning
w ith respect to current research, and patient-orientated
goals as the basis or rational rehabilitation (Cicerone 2005).
Sa ety is o p aram ou nt im p ortance and clinicians shou ld
ensure that exercises are suitable and sa e or ind ivid ual
p atients. Fu rtherm ore, since p ain u l sensory inp u t m ay alter
m otor ou tp u t d u ring exercise, red u ction o the p ain w here
p ossible w ith ap p rop riate p hysical, p harm acological and / or
p sychological strategies is an im p ortant p art o the rehabilita-
tion p rocess.
There are three phases o a therapeu tic exercise pro-
gram m e, w hich are w orked throu gh progressively based on
the requ irem ents o the ind ivid ual patient; these inclu d e: (1)
p osture, joint range o m otion and exibility, (2) m u scle
strength and end u rance, and (3) u nctional asp ects includ ing
p rop riocep tion, coord ination and agility (H ou glu m 2005).
For exam ple, the exercise prescription and goals o a patient
w ith ad hesive cap su litis w ill d i er signif cantly rom those
o a p atient w ith hu m eral instability. Princip les or gu id ing
rehabilitation inclu d e avoid ance o aggravation, tim ing o
 Principles of exercise 375

Therapeutic exercise programme

Patient assessment Rehabilitation principles Phases of exercise programme (1–3)

(Houglum 2005) (Houglum 2005)
Patient characteristics
Clinical information Monitor and reassess
Avoid aggravation – adapt accordingly
Impairments /Dysfunctions /Diagnosis
Safety/Suitability/Goals Suitable exercise within clinical limits Safety
Treatment Monitor for aggravation
Communication with team members
Timing
1 Range of motion
Time within clinical limits
Anatomy/Physiology Start early as appropriate Posture
Function Monitor and progress Flexibility
Range of motion
Biomechanics-pathomechanics
Compliance
Pathology
Education, demonstration
Healing pathway Set goals 2 Muscle strength
1. Inflammation Reduce fear avoidance Muscle strength and endurance
2. Proliferation Avoid over-exertion
3. Maturation
Individualization
3 Functional
Prescribe individual programme
Guiding principles Proprioception
Relate to specific needs and goals
Evidence-based practice Coordination
Suitability and safety Agility
Specific sequencing
Wolff’s law/Davis’s law Function
Specific Adaptation to Progress as indicated
Imposed Demands (SAID) Elements of exercise programme (1–3)
Concentric/Eccentric
Intensity Aggravation–red flags
Open and closed chain exercise
(adapted from Tippet &Voight 1995)
Address healing pathway
Technique (Tippet &Voight 1995) Consider tissues Change in/presence of
Carriage /Confidence /Control Need to challenge patient 1. Swelling
2. Pain
Tools Total patient 3. Range
Elastic bands, weights, machines, Injured and uninjured body parts 4. Loss of strength
pulleys, mirror and biofeedback Psychology 5. Function
therapy, EMG, aquatherapy etc. General fitness and cardiovascular 6. Specific clinical tests

Figure 33.1 Principles of therapeutic exercise.

exercise, com pliance, ind ivid ualization, specif c sequ encing,
intensity and total patient ap proach (H ou glum 2005); these
p rincip les are p resented in Figu re 33.1.
Exercise p rogram m es shou ld be p rogressive and grad ed
accord ing to the stage o healing and shou ld not aggravate
p ain, sw elling or result in d eterioration in other clinical
signs su ch as range o m otion, strength and u nction (see
Fig. 33.1) (Tip p et & Voight 1995). The ability to per orm
exercises w ith appropriate skill should be m onitored closely
(Tipp et & Voight 1995). These au thors re erred to the three
‘C’s: (1) carriage – ap p ropriate w eight shi t, w eight accep t-
ance and sym m etry o m ovem ent, (2) conf d ence – verbal
and non-verbal com m u nication, sp eed and d eliberateness o
exercise p er orm ed , and (3) control – sm ooth u nrestricted
au tom atic m ovem ents w ith skilled task p er orm ance (Tip pet
& Voight 1995).
Bone and so t tissu es ad ap t accord ing to the stresses p laced
u p on them , w hich highlights the im p ortance o ap p rop riate
load ing o tissue in a grad ed progressive m anner to enhance
healing, and has been d escribed by Wol ’s law and Davis’s
law respectively (Wol 1986; Tippet & Voight 1995). These
p rincip les also ap p ly to the hyp ertrophy o uninju red tissu es;
or exam ple, it has been d em onstrated that baseball athletes
have thicker bicep s and su p rasp inatu s tend ons com p ared
w ith non-athletes (Wang et al 2005). On the other hand , over-
load ing o bone and so t tissu e can result in inju ry su ch as
bone stress racture or tend on ailure.
The p rinciple o specif c ad aptations to im posed d em and s
(SAID) re ers to the bod y’s ability to change accord ing to
sp ecif c d em and s p laced u p on it and there ore has im p lica-
tions or rehabilitation d esign in that exercises shou ld m im ic
the exp ected u nctional stressors o the ind ivid u al p atient as
m u ch as p ossible (H ou glum 2005). Im plem enting variance o
activities and rest phases is im p ortant so as to allow ad apta-
tion. An exam p le o the relevance o these p rincip les is w hen
consid ering the introd u ction o eccentric strength training
into the rehabilitation program m e. Eccentric strength training
p rogram m es ap p ear to be e ective in the m anagem ent o
knee and ankle tend on pathology (Al red son et al 1998; Young
et al 2005). There has been less research on eccentric pro-
gram m es or rotator cu tend on pathology; how ever, initial
results are encou raging (Jonsson et al 2006). Eccentric pro-
gram m es are, how ever, associated w ith m u scle d am age
(Clarkson & H u bal 2002). Be ore p lacing su ch high stresses on
p reviou sly inju red tissu es, basic isom etric and isotonic
strength p rogram m es shou ld be alread y in p lace. Fu rther, the
introd uction o su ch eccentric training p rogram m es should be
p rogressed .
 376 PART 4 • 33 • Therapeutic exercises for the shoulder region
Shou ld er m u scle balance ratios have been rep orted , inclu d -
ing ratios betw een the external and internal rotators o 1.5 : 1
(66%) or both ast and slow isokinetic torqu e arm speed in
norm al su bjects (Ivey et al 1985). Ratios have also been pre-
sented or p ro essional baseball p itchers (Ellenbecker &
Mattalino 1997). Clinicians should consid er these ratios in
exercise program m e d esign. A d iscu ssion o isokinetics is
beyond the scope o this chap ter, bu t has been review ed by
Ellenbecker and Davies (2000).
The ollow ing sections w ill d iscu ss, p ostu re, stretching and
strengthening (isom etric and isotonic) and brie y m ention
u nctional exercise. Specif c param eters or tim ing and repeti-
tions o stretching and strengthening w ill be covered u nd er
each appropriate section.
Posture
Postu ral assessm ent is an im p ortant p art o the objective eval-
u ation and id eal static p ostu ral alignm ents have been su g-
gested (Kend all et al 2005). H ow ever, it is im portant to assess
both static and d ynam ic p ostures to ascertain the patient’s
u nctional m ovem ent and ability to sel -correct a static habitus.
An exam ple o this is a boxer, w ho enhances a hyperkyphotic
and rou nd ed shou ld er postu re to red u ce his target size or
strategic ad vantage, bu t w hen d ynam ically tested m ay be able
to sel -correct the seem ingly p oor p ostu re.
It is im portant to assess or m u scle length, joint m obility
and m uscle control. Altered p ostu re m ay be related to m uscle
im balances and altered joint p osition, w hich u ltim ately cou ld
resu lt in m ovem ent d ys u nction and pain. Deviations in
norm al u p right p ositions m ay inclu d e a orw ard head p osi-
tion, an exaggerated cu rve in the thoracic kyp hosis, and
round ed should ers. Deviations in scapu lar kinem atics m ay
p resent in m u ltiple planes, inclu d ing changes in scapular
elevation, protraction, tilt and rotation, a ecting the size o
the su bacrom ial sp ace (Solem -Berto t et al 1993), as w ell as
both activation (Roy et al 2009) and m echanical ad vantage
(Kibler et al 2006) o m uscu lar stru ctures. It has been d em on-
strated that the size o the su bacrom ial sp ace is red u ced in the
p resence o thoracic hyp erkyp hosis (Raine & Tw om ey 1997;
Gu m ina et al 2008) and should er protraction (Solem -Berto t
et al 1993). It is, how ever, u ncertain w hether a strong correla-
tion exists betw een narrow ing o the su bacrom ial sp ace and
shou ld er sym p tom s (Graichen et al 2001; Roberts et al 2002;
H interw im m er et al 2003; Lew is et al 2005; Mayerhoe er et al
2009). In act, althou gh it has been assu m ed that there is a
d ef nitive association betw een these postu ral d eviations, a
stu d y o 160 asym p tom atic su bjects ou nd no su ch correlation
(Raine & Tw om ey 1997). There ore, although there m ay be a
relationship betw een posture and su bacrom ial space, this is
not yet u lly u nd erstood .
Thoracic kyp hosis and orw ard shou ld er p osition in u ence
the length o the u p p er back and scap u lar m u scles and p lace
the intervertebral joints in an end -range p osition (Griegel-
Morris et al 1992). The su stained strain on these so t tissues
m ay lead to u p p er back p ain or shou ld er p ain. In the ront o
the bod y the p ectoral m u scles m ay shorten (Borstad &
Lu d ew ig 2006; Mu raki et al 2009). Su stained m u scle shorten-
ing m ay lead to the d evelop m ent or activation o m yo ascial
trigger p oints (Sim ons et al 1999). Re erred pain rom the
p ectorals m ay be elt in the ront o the shou ld er and arm
(Sim ons et al 1999) and som etim es even in the u pper back
region (Deju ng et al 2003). (See Ch 59 or a review o these
m echanism s and m u scle re erral p atterns.)
Su stained contractions im p air norm al blood ow in skel-
etal m u scles. Optim al postu re allow s m uscles the opportunity
to relax in betw een contractions, w hich p erm its and acilitates
recovery o circulation (Otten 1988; Sjogaard & Sogaard 1998;
Palm erud et al 2000). Com bining p ostural exercises w ith
m yo eed back / EMG is help u l w hen teaching p atients how to
u se their m u scles in an econom ic and healthy m anner (Pep er
et al 2003; Voerm an et al 2006). Thou gh there is a w id e range
o p ostu res, clinicians shou ld consid er the op tim al p ostu re or
each patient and ind ivid u alize exercise program m es, rather
than ocu sing on an id ealized p ostu re su itable or all. Assu m p -
tion o an ap p rop riate u p right tru nk p ostu re can change
m u scle activation and m od i y range o m otion and sym p tom s
(Bullock et al 2005). Scapu lar taping can be u sed as a tem po-
rary m eans o altering scapu lar m uscle activation (Selkow itz
et al 2007). Furtherm ore, Lucas et al (2004) d em onstrated that
latent trigger points can alter m u scle activation patterns o the
shou ld er as assessed by EMG and su bsequ ently rep orted that
d ry need ling and stretch, w hen com pared w ith p lacebo ultra-
sou nd , w as ou nd to im p rove the m u scle activation p atterns
signif cantly and sim ilar to controls.
Treatm ent or p ostu ral d ys u nctions m ay inclu d e m anu al
therap ies, inclu d ing: joint m obilization and m anip u lation,
m assage and m yo ascial trigger p oint release, m yo ascial
release techniqu es, trigger point d ry need ling, bio eed back
and EMG, stretching, stability and strengthening and cogni-
tive and behaviou ral strategies.
Stretching
Flexibility and stretching is a broad topic w ith con icting
op inions in the literatu re, and a u ll d iscu ssion o this top ic is
beyond the scope o this chapter. Read ers are re erred else-
w here or a com prehensive review o stretching (Alter 1996;
Weerapong et al 2004). A rehabilitation program m e o the
shou ld er m ay incorp orate a m u scle-stretching p rogram m e,
w hich is u su ally em p loyed or m uscle lengthening and associ-
ated clinical im p lications, p ain inhibition and p otential inju ry
p revention.
It has been reported that alterations in scap ular m ovem ent
are related to changes in m yo ascial length (Borstad &
Lu d ew ig 2005; Borstad 2006). The ad d ition o ap propriate
m anu al therap y techniqu es m ay increase the e ectiveness o
therap eu tic exercise (Winters et al 1997; Conroy & H ayes
1998; Bang & Deyle 2000; Desm eules et al 2003; Bergm an et al
2004; Michener et al 2004; Senbursa et al 2007; Boyles et al
2009). These techniqu es m ay inclu d e so t tissu e techniques,
p assive stretching and joint m obilization, and m ay increase
range o m otion in subjects w ith shou ld er pain (Verm eu len
et al 2006; Johnson et al 2007). Therapeu tic exercise alone,
how ever, m ay be as e ective as ad d ing p assive joint m obiliza-
tions to therap eu tic exercise (Tram pas & Kitsios 2006; Chen
et al 2009). (Di erent joint m obilization techniqu es are
d escribed in d etail in Ch 31.)
A m u scle-stretching p rogram m e shou ld be based on assess-
m ent o m u scle length and end eel. Mu scles and ascia m ay

Figure 33.2 Levator scapula stretch. Ipsilateral arm-elevated position is
proposed to assist in isolating the levator scapula from the upper trapezius.
present w ith neu rom u scu lar, viscoelastic or connective tissue
alterations (Chaitow & Liebenson 2001). It is im portant to
evaluate m u scle length, and its in uence on the length–
tension relationship shou ld not be overlooked (Jand a 1993;
Sahrm ann 2002; Ekstrom & Osborn 2004; Kend all et al 2005).
Thou gh ind ivid u al patients w ill present w ith varying d egrees
o m u scle length, the ollow ing p atterns, as ou tlined by Jand a
and others, are o ten seen in clinic practice (Chaitow &
Liebenson 2001):
• short muscles and often facilitated: pectoralis m ajor and
m inor, latissim u s d orsi, levator scap u la, u p p er trap eziu s
(at tim es)
• long muscles and often inhibited: serratu s anterior,
low er and m id d le trap eziu s.
A stretch or the levator scap u la and a clinician-assisted
stretch or the p ectorals and latissim u s d orsi m u scles are p re-
sented in Figu res 33.2 and 33.3 respectively. Other sel -stretch
exercises or the pectorals and latissim u s d orsi m ay includ e
the d oorw ay stretch and one-sid ed u nilateral sel -stretch o
the p ectoralis m inor, w hich has been show n to be su p erior to
a su p ine m anu al stretch and a sitting m anu al stretch (Borstad
& Lu d ew ig 2006).
Mu scle-stretching techniqu es inclu d e static, ballistic,
d ynam ic and proprioceptive neu rom uscu lar acilitation
(Weerap ong et al 2004; H ou glum 2005). Other techniqu es
have been d escribed inclu d ing p ost-isom etric relaxation
(Lew it & Sim ons 1984; Lew it 1986, 1999), m u scle energy tech-
niqu e (Greenm an 1989; Chaitow & Crenshaw 2006), activated
isolated stretching (Mattes 1995) and spray and stretch (Travell
& Sim ons 1983; Sim ons et al 1999; Kostop ou los & Rizop ou los
2008). Stretching has been em ployed or the treatm ent o p ain,
especially in relation to the treatm ent o m yo ascial trigger
points (Sim ons et al 1999).
Stretching 377
Figure 33.3 Pectoral and latissimus dorsi, clinician-assisted stretch. The
patient maintains a neutral lumbar spine and a towel can be used to reduce thoracic
kyphosis. The clinician applies a low-grade smooth stretch against soft tissue
barrier. For appropriate modesty, the patient’s opposite hand can be placed across
the chest and the clinician’s hand can be placed on top. Contract relax application
can also be added to augment stretch.
The recom m end ed d u ration o static stretching varies, but
it is reasonable to recom m end a 15–30-second hold w ith 3–5
repetitions (Taylor et al 1990; H ou glum 2005) repeated d aily
or several tim es / d ay. Good orm shou ld be m aintained
d uring stretching techniqu e, w hich shou ld be sm ooth and
w ithin the clinical lim its o the presenting problem . Longer
hold tim es u p to and beyond 5 m inu tes have been recom -
m end ed or ascial tissu e release (Barnes 1999).
Patients w ith a history o su blu xation, d islocation, hyp er-
m obility o the shou ld er or general hyp erm obility synd rom e
need to be id entif ed , as a stretching p rogram m e m ay be inap -
p rop riate and p otentially d etrim ental in these ind ivid u als.
The p atient history, m u scle length tests, joint end eel, p assive
joint tests and the Beigthon score (Alter 1996) m ay assist the
clinician in id enti ying hyp erm obility and instability. Up to
11.7% o p eop le have som e orm o joint hyperm obility, and
this has been rep orted to be u p to three tim es m ore p revalent
in em ales than in m ales (H akim & Graham e 2003; Seckin
et al 2005).
The m ajority o current research d oes not su pport the
hypothesis that stretching p revents inju ry (Shrier 1999;
Weerapong et al 2004). H ow ever, there is som e evid ence to
su ggest that low er lim b stretching can red u ce the risk o
injury (H artig & H end erson 1999; Am ako et al 2003; Jam tved t
et al 2009), or the rate o return rom inju ry (Malliarop ou los
et al 2004). Interestingly, thou gh, review ed research on
stretching has d em onstrated a negative e ect on m u scle
strength and u nctional p er orm ance (Weerap ong et al 2004).
Fu rther, the act that m ost research has ocused on the low er
extrem ities raises valid ity issues about the valid ity o extrap o-
lating the f nd ings to the u pper extrem ity. H ow ever, clinicians
shou ld consid er these issu es w hen p rescribing exibility p ro-
gram m es, especially in relation to per orm ance athletes and
p layers. More research is requ ired to assist in a better u nd er-
stand ing o the role o stretching in inju ry m anagem ent and
p revention.
External rotation is u nd am ental or elevation and shou l-
d er u nction and it is im portant to restore p assive and active
external rotation (Donatelli 2004a). External rotation is
 378 PART 4 • 33 • Therapeutic exercises for the shoulder region
Figure 33.4 Subscapularis stretch, self-assisted stretch with cane. The supine
position offers stability of the scapula while external rotation of the glenohumeral
joint is assisted with self-control using the cane. A towel is placed under the elbow
to maintain alignment of the humerus.
p rim arily lim ited at 0° by the subscapu laris, at 45° o abd u c-
tion by the su bscap u laris, m id d le and in erior hu m eral liga-
m ent and at 90° o abd u ction by the in erior hu m eral ligam ent
(Tu rkel et al 1981). Muscle length testing o the su bscapu laris
is carried ou t w ith the arm in neu tral and testing into external
rotation (Donatelli 2004b). An auto-assisted stretch or the
su bscap u laris, u sing a cane, is p resented in Figu re 33.4. The
stretching p osition, or exam ple at 0°, 45°, 90° abd uction, etc.,
shou ld be based on any restrictions o the su bscap u laris and
hu m eral cap su le and ligam ents id entif ed rom the p hysical
assessm ent. The contribu tion o the hum eral joint capsu le
(and other posterior so t tissu e stru ctures inclu d ing the in ra-
sp inatu s, teres m inor and d eltoid ) to shou ld er m ovem ent
shou ld not be overlooked and has been p rop osed to be p ar-
ticu larly im p ortant in certain shou ld er d isord ers, inclu d ing
SAIS (Donatelli 2004a). Red u ced cross-bod y ad d uction has
been linked to tightness o the posterior capsu le, and associ-
ated w ith abnorm al hu m eral translation (Lu d ew ig & Cook
2002). Cross-bod y ad d u ction and the ‘sleeper stretch’ (internal
rotation o the shou ld er in 90° o shou ld er exion) have been
recom m end ed as stretches or posterior should er capsular
tightness (Coop er et al 2004; McClu re et al 2007; Lau d ner
et al 2008). The ‘sleep er stretch’ is presented in Figu re 33.5.
H ow ever, m od if cation into less shou ld er exion m ay be nec-
essary i sym ptom s are aggravated in this position.
Isometric Exercise of the Shoulder
Isom etric exercise is u su ally u tilized in the early p hase o
rehabilitation to m inim ize m u scle atrophy w hen m ovem ent
o the shou ld er is lim ited . Stu d ies have d em onstrated u p to
a 41% d ecrease in isom etric strength a ter im m obilization
o the u p p er extrem ity or 5–6 w eeks, w ith signif cant
d ecreases in m u scle f bre area by 33% and 25% or ast- and
Figure 33.5 Sleeper stretch. The 90° position stabilizes the scapula and
downward pressure is applied with a self-stretch to the opposite hand into internal
rotation.
slow -tw itch f bres resp ectively (MacDougall et al 1980).
Du ring im m obilization o the u pper lim b, strength training
w ith m axim al isom etric exercise 5 d ays / w eek o the ree lim b
m ay p revent atrop hy o the im m obilized lim b (Farthing et al
2009). Fu rther research has suggested that ad d ing a 0.5 kg
w eight to the ipsilateral hand d u ring isom etric and d ynam ic
shou ld er exertions increases shou ld er m uscle activity by 4%
m axim u m volu ntary excitation (Antony & Keir 2010). Static
exercises or the shou ld er are presented in Figure 33.6. A belt
is em ployed to allow m u ltid irectional static exercises;
how ever, other op tions inclu d e resistance against a w all. A
hand -held w eight o 0.5 kg is u sed to assist in increasing
shou ld er m u scle activity (Antony & Keir 2010). Suggested
p aram eters or isom etric exercises inclu d e pain- ree 5- to
10-second hold s w ith 10 repetitions, grad ed to m axim al con-
traction and rep eated several tim es p er d ay w ith p rogression
as ind icated (H ouglu m 2005).
Isotonic Exercises of the Shoulder
There is a plethora o exercises or the shou ld er gird le, and
research em ploying EMG has aim ed at id enti ying exercises
that target sp ecif c shou ld er m u scles; here w e brie y review
a selection o exercises that target the rotator cu , trap eziu s
and serratus anterior m u scles. For a u rther expansion o
this, read ers are recom m end ed to review other p u blications
(Ekstrom & Osborn 2004; H ou glu m 2005; Reinold et al 2009).
When d esigning a strengthening p rogram m e, the clinician
shou ld target m u scles id entif ed as w eak d u ring the evalu a-
tion and , on the basis o this, p rescribe su itable exercises.
The clinician should prescribe the specif c exercise, resist-
ance (or none), repetitions, sets and requency o the pro-
gram m e. This p rogram m e should be m onitored , ad justed
and ad vanced progressively. A program m e can be initiated
w ith or w ithout w eight, as app ropriate. Recom m end ations
have been m ad e in relation to exercise rep etitions (rep s) and
includ e 1–6 reps or strength, 6–12 or hyp ertrophy and
12–15 or end u rance (Kraem er & Ratam ess 2004). The w eight
u sed is ap p rop riate to cau se atigu e tow ard s the end o
the stated nu m ber o rep etitions. It has been ou nd that tw o

to six sets p er exercise p rod u ced signif cant increases in
m u scu lar strength in both trained and u ntrained ind ivid u als
(Kraem er & Ratam ess 2004).
Other recom m end ations inclu d e 6–15 repetitions o tw o
sets w here the p atient can control the w eight, p rogressing to
20–25 rep etitions o three sets (H ou glum 2005). When this is
reached , the w eight then is progressed accord ingly and the
p rocess started again w ith 6–15 repetitions o tw o sets, etc.
(H ou glu m 2005). There are various exercise progressions that
can be consid ered inclu d ing that o Delorm e and Watkins
(1948), Ox ord techniqu e (Zinovie 1951) and d aily ad justed
p rogressive resistive exercise (Knight 1985; H ou glum 2005).
The clinician shou ld consid er the principles o exercise as
ou tlined in Figu re 33.1 w hen prescribing strength pro-
gram m es. The rotator cu m u scles are im portant stabilizers
o the hu m eral joint and assist in stabilizing the hu m eru s in
the glenoid by com p ression and p reventing shear and u p w ard
m ovem ent o the hu m eral head d u ring arm m ovem ents (Oatis
2004). Other m u scles assist in stabilizing the scapu lothoracic
com p lex and in d ynam ic stability (Oatis 2004) and these
m u scle-sp ecif c exercises are covered below. For m u scles su ch
as the d eltoid , levator scapu lae and rhom boid s, and ind ica-
tions or strengthening, read ers are recom m end ed to review
the article by Reinold et al (2009).
Supraspinatus muscle
The sup raspinatu s is the m ost sup erior o the rotator cu
m u scles and lies d eep to the su bacrom ial bu rsa and the cora-
coacrom ial ligam ent w ithin the su bacrom ial sp ace (Oatis
2004). The reported actions o this m u scle inclu d e abd u ction,
external rotation and stabilization o the should er (Oatis
2004). Activity o the su prasp inatu s increases w ith increased
Isotonic exercises of the shoulder 379
Figure 33.6 Isometric exercises for
the shoulder. The use of a belt allows
the patient to perform isometric exercise
in multiple directions. This can be also
done against a wall. Internal and
external rotation is performed with
self-assisted resistance. The use of a
hand-held weight of 0.5 kg has been
shown to assist in increasing shoulder
muscle EMG by 4%. The arrows indicate
direction of force, but as an isometric
exercise there is no movement.
load ing d u ring abd uction and scaption m ovem ents, peaking
at 30–60° o elevation (Reinold et al 2009). Reinold et al (2007)
d em onstrated that EMG activity w as sim ilar across three exer-
cises: u ll can, em p ty can and p rone u ll can. The u ll-can
exercise results in signif cantly less activity o the m id d le and
p osterior d eltoid , w hich m ay red u ce harm u l shear orce on
the hu m eral joint rom d eltoid activity (Reinold et al 2007,
2009). In ad d ition, it red uces the potential or su bacrom ial
im pingem ent because o the external rotation com ponent
(Ekstrom & Osborn 2004). Moreover, this exercise has been
recom m end ed by previou s research (Kelly et al 1996). The
ull-can exercise in the plane o the scapula w ith external rota-
tion o the shou ld er is p resented in Figure 33.7.
Infraspinatus and teres minor muscles
The actions o the in raspinatu s and teres m inor are prim arily
external rotation and u nctionally assisting the stability o the
hu m eral joint d u ring elevation m ovem ents (Reinold et al
2009). Stabilization o the shou ld er by these m u scles is also
achieved by opposing sup erior and anterior hu m eral head
translation (Reinold et al 2009). The in raspinatus has poten-
tially a role in abd u ction and horizontal abd u ction, w ith the
teres m inor involved in ad d u ction, the d i erence ap p arently
being d ue to d i erent m om ent arm s (Oatis 2004). EMG analy-
sis d em onstrated the best isolation o the in rasp inatu s in 0°
abd uction w ith 45° o m ed ial rotation rom neu tral (Kelly et al
1996), and Reinold et al (2009) su ggested incorp orating this
p osition as an exercise to any rehabilitation p rogram m e w hen
ocusing on increasing external rotation strength. Ad d ition o
a roll sup port betw een the arm and the trunk (Fig. 33.8) has
been show n to increase EMG activity in the in rasp inatu s and
teres m inor m u scles by u p to 25% (Reinold et al 2004, 2009).
 380 PART 4 • 33 • Therapeutic exercises for the shoulder region
Figure 33.7 Supraspinatus full-can strengthening. This is carried out in the
plane of the scapula, slowly and controlled with the thumb up to ensure a degree of
external rotation.
Figure 33.8 Infraspinatus and teres minor muscles strengthening. In side-lying,
the arm is brought from internal into external rotation. A towel positioned between
the arm and trunk has been shown to increase EMG of the muscles by 25%.
A second exercise w orth consid ering is stand ing external rota-
tion in the scap u lar p lane (45° o abd u ction) (Fig. 33.9) as this
has d em onstrated good EMG activation o the in rasp inatu s
and teres m inor (Reinold et al 2004), and isokinetic external
rotational strength valu es in the plane o the scapula have
been reported to be signif cantly higher than in the rontal
p lane (Greenf eld et al 1990).
Other exercises or external rotation have been recom -
m end ed that p lace the shou ld er in a m ore com p rom ised p osi-
tion (e.g. external rotation in 90° abd u ction) and clinicians
shou ld care u lly consid er the ap p rop riateness o these exer-
cises in the p resence o cap su lolabral d ys u nction and p athol-
ogy (Reinold et al 2009).
Figure 33.9 External rotation in the plane of the scapula. The shoulder is
rotated from internal to external rotation.
Figure 33.10 Subscapularis strengthening (Gerber’s lift-off test). The hand is
raised upwards from the trunk.
Subscapularis muscle
The subscap ularis is the largest o the rotator cu m u scles and
acts to rotate internally, ex, extend , abd u ct, ad d u ct, ad d u ct
horizontally and stabilize the shou ld er, w ith broad agreem ent
that internal rotation and stabilization are the p rim ary roles
(Oatis 2004). Subscap ularis w eakness lead s to signif cant
d ecrease in internal rotation strength and m ay contribu te to
anterior instability o the should er (Oatis 2004). The li t-o
test as d escribed by Gerber and Krushell (1991) has been
d em onstrated to isolate the subscapu laris (Greis et al 1996;
Kelly et al 1996). The li t-o exercise or the su bscapu laris
m u scle is p resented in Figu re 33.10.
Trapezius muscle
The trap eziu s is an expansive m u scle that has three d istinct
m u scle sections: u p p er, m id d le and low er, w ith each having

Figure 33.11 Trapezius strengthening. This targets the upper, middle and lower
sections of the trapezius muscle. The thumb is maintained in an upright position.
a d istinct u nction and com bining to assist in the overall u nc-
tion o the trap eziu s (Oatis 2004). The actions o the three
sections have been rep orted as ollow s (Oatis 2004): up per
trap eziu s – elevation o the scapu la, ad d u ction and upw ard
rotation o the scap u la; m id d le trapeziu s – ad d u ction o the
scap u la; and low er trapeziu s – d ep ression, ad d u ction and
u p w ard rotation o the scap u la. In p articu lar, the u p p er and
low er trapeziu s orm an anatom ical orce cou ple that assists
in stabilizing the scapu la, and m aintaining a balance betw een
these m u scle segm ents is im p ortant or op tim al u nction
(Oatis 2004). Furtherm ore, the low er f bres have been reported
to p lay an im p ortant role in p osterior tilt and u p w ard rotation
o the scap u la d u ring shou ld er elevation (Lu d ew ig et al 1996).
There ore, the low er trap ezius and serratu s anterior com prise
an im p ortant target or rehabilitation and p revention o shoul-
d er d ys u nction and im pingem ent synd rom es (Lu d ew ig &
Cook 2000). With regard to exercises or the u pper trapeziu s,
the shou ld er shru g has been rep orted to p rod u ce the greatest
EMG activity (Ekstrom et al 2003). H ow ever, it has been
urther reported that the shru g exercise also highly activates
the levator scap u la and so i this need s to be avoid ed , ow ing
to the levator scap u lae action o scap u lar d ow nw ard rotation,
the m ilitary p ress m ay be m ore ap p rop riate (Ekstrom &
Osborn 2004).
For the m id d le trap ezius, abd u ction and external rotation
o the shou ld er at 90° in p rone (Fig. 33.11) has been show n to
ind u ce good EMG activity and is consid ered a suitable exer-
cise (Moseley et al 1992; Ekstrom & Osborn 2004; Reinold et al
2009). This exercise has also been recom m end ed or strength-
ening the trapeziu s as a w hole, ow ing to high EMG activity
in the upp er, m id d le and low er m u scle segm ents (Ekstrom
et al 2003; Ekstrom & Osborn 2004).
The low er trap eziu s has been show n to be best activated
w ith the arm raise overhead exercise in the prone position,
p er orm ed at app roxim ately 120° (Reinold et al 2009) to 135°
o abd u ction or w ith the arm p ositioned in line w ith the low er
f bres o trap eziu s (Fig. 33.12) (Ekstrom et al 2003; Ekstrom &
Osborn 2004).
Functional exercises 381
Figure 33.12 Trapezius strengthening. This targets mainly the lower bres of
trapezius performed at approximately 120–135° of abduction or with the arm
positioned in line with the lower bres of the trapezius.
Serratus anterior muscle
The serratu s anterior m u scle action has been reported as pro-
traction, abd u ction, u p w ard rotation and elevation o the
scap u la; the m u scle u nctions in actions su ch as p u shing a
revolving d oor and w eakness m ay lead to w inging o the
scap u la and d i f cu lty w ith overhead activities (Oatis 2004).
Shou ld er abd uction in the p lane o the scap u la above 120° (to
avoid p ain ul arc) in the stand ing position has d em onstrated
m ore EMG activity in the serratu s anterior than d oes straight
scap u lar p rotraction (Fig. 33.13). The increased serratu s ante-
rior activation shou ld , how ever, be balanced against the
increased risk o im pingem ent w hen exercises are per orm ed
in elevation (Roberts et al 2002). Other recom m end ed exer-
cises or the serratu s anterior inclu d e the d ynam ic hu g,
p u sh-u p w ith a p lu s and p u nch exercises (Decker et al 1999;
Reinold et al 2009).
Functional Exercises
The d aily tasks and m ovem ents per orm ed by the ind ivid u al
shou ld be consid ered w hen p rescribing therap eu tic exercise,
so that the exercises take into accou nt the sp ecif c u nctional
d em and s o that person. Fu nctional progression m ay includ e
m ovem ent rom isolated p lane to m u ltip lane strengthening
(Fig. 33.14) and eventually plyom etric exercise (H ou glu m
2005). Up per lim b tasks are com m only open kinetic chain
m ovem ents. In athlete su bjects w ith recu rrent anterior shou l-
d er d islocation, rehabilitation near / in the zone o instability
is ind icated in late-stage rehabilitation and there ore tasks that
load the rotator cu in sem i-com p rom ised positions m ay help
replicate the stability action requ ired on return to sport.
Closed chain and stability exercises (Figs 33.15 and 33.16) or
the shou ld er gird le are im p ortant to assist in m otor control
and re-ed u cation (H ou glu m 2005) and are d iscu ssed in
Chapter 32. The should er gird le relationship to the kinetic
 382 PART 4 • 33 • Therapeutic exercises for the shoulder region

Figure 33.13 Serratus anterior strengthening. Shoulder abduction is performed in the plane of the scapula above 120° (to avoid painful arc) in the standing position.

Figure 33.14 Proprioceptive neuromuscular facilitation with elastic band.

Elastic bands can assist with creating open chain coordinated movements that
mimic functional patterns.
Figure 33.15 Shoulder dip. This is a closed chain kinetic loading and
proprioceptive exercise.

Figure 33.16 Prone knee, single-arm raise. The abdominals are primed prior to
the lift. This offers a closed chain exercise for weight-bearing shoulder and a
dynamic open chain exercise for the opposite arm. This exercise can be advanced
to alternative arm and leg lift for stability.
chain shou ld be consid ered in the overall m anagem ent o the
patient and exercise program m es m ay incorp orate stand ing
balance and eye–hand coord ination tasks, etc. (Donatelli
2006). A com m on barrier to shou ld er rehabilitation is d i f -
cu lty in rep licating the therap eu tic exercise correctly at hom e,
possibly ow ing to red uced p ositional sense (N au ghton et al
2005). Tasks that challenge the prop rioceptive acu ity and
load -bearing ability o the shou ld er region m ay help to restore
positional sense aw areness (see Figs 33.14–33.16). Clinicians
can also incorp orate the u se o exercise equ ip m ent to assist in
unctional p rogression, includ ing elastic band s, pu lleys,
Theraballs, w obble board s, prop rioceptive exercise d evices
and eed back d evices such as m irrors, etc.
Conclusion
Therap eutic exercises can p lay an im portant role in the m an-
agem ent o shou ld er p ain. This chapter has ou tlined som e
basic principles on the type o exercise that m ay be ind icated
in the clinical setting, esp ecially in relation to strength o the
rotator cu and stabilizers o the scapu la. Clinicians should
rem ain cognisant o the need or a com prehensive assessm ent
and ensu re sa e and suitable exercise p rescrip tion and p ro-
gression. The nature, intensity and volum e o exercise pre-
scribed m u st be m atched to the clinical p resentation.
Ind ivid u al therapists m ay u se the p rinciples ou tlined in this
chap ter as a gu id e w hen p rescribing a therap eu tic exercise
program m e that is su itable or the need s o each ind ivid ual
patient or athlete. Fu rther research is requ ired and shou ld
ocus on id enti ying exercises to suit the specif c p atient
presentation.
Acknowledgements
Thank you to the p hotograp hic volunteers: Derek Malone,
Irish Paralym pic athlete and S.M.
Conclusion 383
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This pa ge inte ntiona lly le ft bla nk
 P AR T 5
The Hip Region in Lower
Extremity Pain Syndromes
34 Hip Osteoarthritis 389
Alexis A. Wright
35 Other Hip Disorders: Muscle, Labrum and Bursa 397
John Dewitt and David Kohlrieser
36 Postoperative Management of Hip Disorders 413
Robert C. Manske and Erik Meira
37 Joint Mobilization and Manipulation of the Hip 421
Jack Miller and Wayne Hing
38 Therapeutic Exercises for the Lower Quadrant 426
Carol Kennedy and Lenerdene Levesque
This pa ge inte ntiona lly le ft bla nk
 PART 5 •  The Hip Region in Lower Extremity Pain Syndromes
CHAP TER CONTENTS
Introduction  389
Prevalence  389
Economic impact  390
Anatomy  390
Pathomechanics  390
Diagnosis  390
Risk factors  391
Clinical presentation  392
Prognosis  392
Treatment  392
Non-pharmacological treatment  392
Introduction
Osteoarthritis (OA), or d egenerative joint d isease, is the m ost
com m on form of arthritis, and rem ains one of the few chronic
d iseases of ageing for w hich there is little effective treatm ent
(Lane 2007; Felson 2009). OA accou nts for m ore m obility d is-
ability in the eld erly than any other d isease, and ranks as one
of the lead ing sou rces of d isability as m easu red by d isability
ad justed life years (DALYs) and years lived w ith d isability
(YLDs) in people from the United States (Michaud et al 2006;
Felson 2009).
OA is characterized by joint p ain and d ysfu nction and , in
its ad vanced stages, joint contractures, m u scle atrophy and
lim b d eform ity (Bu ckw alter & Martin 2006). Although pain,
red u ced fu nction and p articip ation restriction can be im por-
tant consequ ences of OA, stru ctu ral changes com m only occu r
w ithou t accom panying sym p tom s (N ational Institute for
H ealth and Clinical Excellence (N ICE) 2008).
Any synovial joint can d evelop osteoarthritis, bu t the
knees, hips and sm all hand joints are the p eripheral sites
m ost com m only affected (N ICE 2008). OA d evelops m ost
com m only in the absence of a know n cau se of joint d egenera-
tion – a cond ition referred to as p rim ary or id iopathic OA.
Less frequ ently, it d evelop s as a resu lt of joint d egeneration
cau sed by inju ry or a variety of hered itary, congenital, m eta-
 
Chapter  34  
Hip Osteoarthritis
Ale xis A. W rig h t
bolic, neu ropathic, in am m atory or other m ed ical cau ses –
referred to as second ary OA (Bu ckw alter et al 2004).
Although there is no cu rrently know n cure for OA,
d isease-related factors such as im paired m uscle strength and
d ecreased function are potentially am enable to intervention
(Fransen et al 2003). H ow ever, the frequency and chronicity
of OA, cou p led w ith the lack of effective p reventive m easu res
or cu res, m ake this d isease a su bstantial econom ic bu rd en
for patients, healthcare system s, businesses and nations
(Buckw alter & Martin 2006).
Prevalence
Epid em iological research in OA faces som e speci c problem s
relative to prevalence estim ates, w hich are prim arily d u e to
the d if cu lty of m aking a correct d iagnosis given the range of
signs and sym p tom s associated w ith OA. In fact, m u ltip le
d e nitions of OA are in existence, inclu d ing rad iographic OA,
sym p tom atic OA and self-rep orted OA. Based on a recent
system atic review (Pereira et al 2011), the overall p revalence
of hip OA has been reported as 10.9%. Using only rad io-
graphic criteria, prevalence estim ates ranged from 1% in
China and Japan to 45% in Tasm ania. Using sym p tom atic
criteria, p revalence estim ates ranged from 0.9% in Greece to
7.4% in Sp ain. In the United States of Am erica (USA) alone,
cru d e p revalence of sym p tom atic rad iograp hic hip OA has
been reported as in the range of 4–18% d epend ing on age and
gend er (Jord an et al 2009).
The prevalence of OA increases w ith age and recent esti-
m ates su ggest that, if the p revalence of OA rem ains stable,
the nu m ber of old er ad u lts w ith arthritis or other chronic
m u sculoskeletal joint sym ptom s is p rojected to reach 41.1
m illion by 2030 (N ho et al 2013). Gend er prevalence rates are
contrad ictory in the literatu re, how ever, w ith som e stu d ies
reporting higher rates in w om en and others higher rates in
m en (Law rence et al 2008; Dagenais et al 2009). It has recently
been su ggested that m en have a higher prevalence of hip OA
before the age of 50 years, after w hich w om en have a higher
p revalence (Dagenais et al 2009). It has also been su ggested
that the higher incid ence of hip OA in old er w om en m ay be
a resu lt of horm onal changes after m enopau se (Dagenais
et al 2009).
 390 PART 5 • 34 • Hip osteoarthritis
Economic Impact
Available ap p roxim ations rank OA as a m ajor w orld w id e
cau se of econom ic loss (Buckw alter et al 2004). It has been
estim ated that the ageing popu lation w ill give rise to a higher
p revalence of d isabling OA, as the num ber of people aged
over 65 years is exp ected to nearly d ou ble from 12.9% to 20.0%
by 2030 (Croft 2005; N ho et al 2013). An ageing p op ulation,
along w ith escalations in obesity and p hysical inactivity
(Felson 2000; Yelin et al 2007), w ou ld increase the econom ic
bu rd en to society of d isablem ent d u e to OA.
In the USA, the annu al cost to society in m ed ical care and
lost w ages attribu table to arthritis and other rheu m atic cond i-
tions is cu rrently estim ated at US $128 billion ($80.8 billion in
d irect costs and $47.0 billion in ind irect costs), w hich is equ iv-
alent to 1.2% of the 2003 US gross d om estic p rod uct (Centers
for Disease Control and Prevention 2007). OA is su ggested to
be resp onsible for greater than US $65 billion of the total costs
ind icated (Eld ers 2000). Direct costs inclu d e d iagnostic serv-
ices, p harm acological and non-p harm acological therap ies,
visits to healthcare p rofessionals, su rgical interventions and
the p u rchase of ad ap tive equ ip m ent (Maetzel et al 2004; Yelin
et al 2007; Loza et al 2009). Ind irect m ed ical costs includ e
com p ensation p aym ents for lost labou r / p rod u ctivity, care
seeking and care by non-p rofessionals and fam ily m em bers
(Loza et al 2009; N ho et al 2013). Estim ated total annual
d isease costs are ap p roxim ately $5700 p er patient (US d ollars
scal year 2000) (Maetzel et al 2004). Med ical costs w ere 30%
higher am ong OA p atients than non-arthritic controls, w hich
highlights the increasing econom ic bu rd en of OA in society
(Maetzel et al 2004). Estim ated costs of job-related OA are $3.4
to $13.2 billion p er year (Bu ckw alter & Martin 2006).
Direct costs appear to account for the m ajority of the total
cost associated w ith OA (Loza et al 2009). It also ap pears that
higher total costs w ere associated w ith increasing age, increas-
ing nu m bers of com orbid ities, p oor health-related qu ality of
life and w orsening global health statu s (Maetzel et al 2004;
Gu pta et al 2005; Yelin et al 2007; Loza et al 2009).
The ability to p revent the onset of variou s typ es of arthritis
is qu ite lim ited , therefore the blu nting of this grow ing eco-
nom ic im p act w ill requ ire cost-effective efforts to d ecrease
m ean m ed ical exp end itu res and to red u ce the p rop ortion of
ad u lts w ho are lim ited in their ability to w ork for p ay. The
latter m ay be achieved w ith greater u se of cu rrently u nd er-
u tilized interventions, su ch as p hysiotherap y, w hich have
been show n to red u ce the d isability associated w ith arthritis
(Yelin et al 2007).
Anatomy
Osteoarthritis can be d e ned as a p athological d isease p rocess
affecting the synovial joints that is characterized by focal areas
of articu lar cartilage d egrad ation follow ed by su bsequ ent
thickening of the su bchond ral bone, new bony ou tgrow ths at
joint m argins (osteophytes), m ild to m od erate synovial in am -
m ation and thickening of the cap su le (Lane 2007; Felson 2009).
Contrary to p op u lar belief, OA is not cau sed by ageing and
d oes not necessarily progress (Felson 2009). Rather, it is a
m etabolically active, d ynam ic p rocess that involves all joint
tissu es (cartilage, bone, synoviu m / cap su le, ligam ents and
m u scles) and fu nction. Fibrocartilage d egeneration inclu d ing
the labru m is integral to the d isease, and changes in the load -
d istributing fu nction of this brocartilage m ay ind u ce injury
to ad jacent hyaline cartilage (Felson 2009). This com bination
of tissu e loss and new tissu e synthesis su p p orts the view of
OA as a rep air p rocess of synovial joints (N ICE 2008). A
variety of joint trau m as m ay trigger the need to rep air. OA
has a slow bu t ef cient rep air p rocess that often com p ensates
for the initial trau m a, resulting in a stru ctu rally altered bu t
sym p tom -free joint (N ICE 2008; Felson 2009). In som e peop le,
either becau se of overw helm ing traum a or com prom ised
repair potential, the process cannot com pensate, resu lting in
continu ing tissu e d am age and eventu al p resentation w ith
sym p tom atic OA. This exp lains the extrem e variability in
clinical p resentation and ou tcom e that can be observed
betw een ind ivid u als (N ICE 2008).
Pathomechanics
It has been proposed that OA is alm ost alw ays cau sed by
increased forces across a local area of a joint from : (1) abnor-
m al anatom y (congenital or acqu ired ) lead ing to increased
focal stress, (2) excess overall load from either an acu te inju ry
or a chronic obesity, or (3) a com bination of both anatom y and
excess load (Felson 2013). Tw o exam ples of anatom ical abnor-
m alities associated w ith d evelop m ent of hip OA inclu d e con-
genital d ysplasia and fem oroacetabular im pingem ent (FAI).
Congenital d ysp lasia increases the risk of hip OA by p lacing
increased focal stress on a sm all area of the acetabu lum , w hich
p rovid es insu f cient coverage of the fem u r. The anatom ical
abnorm alities associated w ith FAI (w hich includ e cam and
p incer d eform ities) are m ajor risk factors p red isp osing to later
life hip OA, suggesting m echanical abnorm alities as causes of
this d isease.
Generally, once joint inju ry has occu rred , a viciou s cycle of
joint d am age follow s. Typically, the area of focal stress is
su bjected to increased load s lead ing to increased cartilage
d am age, releasing d ebris into the joint space, w hich is ingested
by the synovium causing second ary in am m ation and excess
uid release (Felson 2013). This is follow ed by u nd erlying
bone rem od elling and d am age, w hich m ay create ad d itional
and m ore severe areas of increased stress that place the joint
at risk of m ore d am age (Felson 2013).
Diagnosis
Physicians frequ ently d iagnose OA based on the p atient’s
history and p hysical nd ings, w hich is then con rm ed by
rad iography, as rad iographs represent the cu rrent gold stand -
ard for d iagnosing hip OA (Reijm an et al 2004). The fu nd a-
m ental rad iological and p athological characteristic of OA of
the hip is joint sp ace narrow ing; consequ ently, the best rad io-
logical criterion used to d etect OA of the hip is the m easu re-
m ent of joint sp ace w id th (Reijm an et al 2004).
Rad iograp hs, thou gh u su ally help fu l in the d iagnosis of
severe hip OA, are not alw ays bene cial in the d iagnosis of
m ild or m od erate hip OA. In p atients w ith severe hip OA,
rad iographs typ ically show joint space narrow ing, sclerosis or

osteop hytes; how ever, p atients w ith early OA often d o not
show these kind s of rad iograp hic changes (Cibu lka &
Threlkeld 2004). The correlation betw een rad iographic
changes and the clinical p resentation of the d isease varies
consid erably am ong p atients (Bu ckw alter & Martin 2006).
Som e p eop le w ith m inim al rad iograp hic changes have severe
sym p tom s, w hereas other p eop le w ith rad iograp hic evid ence
of ad vanced joint d egeneration have m inim al sym p tom s
(Birrell et al 2005; Bu ckw alter & Martin 2006; Dieppe et al
2009). Changes in p ain and function appear to have little rela-
tion to the trajectory of stru ctu ral p rogression as evid enced
by rad iology (Felson 2009). Thu s, sole reliance on rad iograp hs
to d eterm ine OA of the hip , esp ecially in p atients w ith early
or m ild hip OA, can resu lt in false-negative d iagnosis (Cibu lka
& Threlkeld 2004).
In ad d ition to changes in the synovial joint, w hich are
u su ally observed by p lain rad iograp hs, d iagnosis of the clini-
cal synd rom e of OA requ ires the p resence of chronic joint
p ain (Bu ckw alter & Martin 2006). Clinical criteria for the clas-
si cation of p atients w ith hip p ain associated w ith OA w ere
d eveloped by the Am erican College of Rheum atology (Altm an
et al 1991). Clinical d iagnosis of hip OA is con rm ed w hen
p atients p resent w ith either one of the follow ing cluster of
clinical nd ings: (1) hip pain, hip exion less than 115°
d egrees, and hip internal rotation less than 15° d egrees, or (2)
hip p ain w ith internal rotation of the hip , d u ration of m orning
stiffness of the hip less than or equ al to 60 m inu tes, and age
greater than 50 years (sensitivity 86%, sp eci city 75%) (Altm an
et al 1991; Cibulka & Threlkeld 2004). Cibu lka et al (2009)
su ggested that the follow ing clinical criteria are typ ically
p resent in ind ivid u als w ho have rad iograp hic nd ings con-
sistent w ith hip OA: rep orts of m od erate p ain in the lateral or
anterior hip w ith w eight-bearing, age greater than 50 years,
lim ited passive hip joint range of m otion in at least tw o of six
d irections ( exion, extension, abd uction, ad d uction, internal
rotation and external rotation) and m orning stiffness that
im p roves in less than 1 hou r.
Althou gh clinical exam ination nd ings are often used to
d eterm ine the location and irritability of a patient’s sym p-
tom s, the d iagnostic accu racy of several com m only u sed
exam ination proced ures has not been thorou ghly stud ied for
d iagnosing OA of the hip in patients w ith hip pain (Su tlive
et al 2008). The im portance of id entifying key clinical exam i-
nation nd ings that are d iagnostic of hip OA assists health-
care p rovid ers in initiating early m anagem ent, and m aking
referrals to app ropriate provid ers w hen need ed (Su tlive et al
2008). A recent stu d y of patients w ith hip sym ptom s id enti-
ed ve p ossible clinical p red ictors for a d iagnosis of hip OA
as d e ned by a Kellgren and Law rence score of ≥ 2: pain w ith
squ atting, a p ositive scou r test, p ain w ith active hip exion,
p ain w ith active hip extension and p assive range of hip inter-
nal rotation less than 25° (Su tlive et al 2008). The Kellgren and
Law rence scale is u sed to grad e the severity of rad iograp hy-
con rm ed OA. A score of ≥ 2 w ould ind icate at least d e nitive
narrow ing of joint sp ace w ith associated osteop hytes. The
higher the grad e (u p to grad e 4), the m ore severe is the joint
sp ace narrow ing and p resence of osteop hytes The p ositive
likelihood ratio (LR+) w hen at least three ou t of the ve sym p-
tom s w ere p resent w as fou nd to be 5.2 (Su tlive et al 2008),
w hich increases the p robability of having hip OA from a pre-
test p robability of 29% (21 / 72) to a post-test p robability
of 68% – su ggesting that clinical exam ination nd ings are
Diagnosis 391
cap able of id entifying p atients w ith hip p ain w ho are likely
to have hip OA. Pre-test p robability in this stu d y w as based
on the nu m ber of p atients p resenting w ith a chief com p laint
of u nilateral p ain in the bu ttock, groin or anterior thigh, w ith
corresp ond ing rad iograp hic con rm ation of hip OA, d e ned
as a Kellgren and Law rence score of 2 of higher (Su tlive
et al 2008).
A clinical m ethod for d etecting early OA of the hip gives
the clinician an op p ortu nity for early intervention, thu s
im p roving the chances of clinical su ccess and potentially
lim iting or d elaying progression. Im provem ent in the
clinical d iagnosis of hip OA m ay also m inim ize the costs
associated w ith u nnecessary rad iographic p roced ures and ,
im p ortantly, avoid the risks of rad iation exposu re (Su tlive
et al 2008). Currently, rad iographs are still consid ered the
gold stand ard for prop er d iagnosis of hip OA. H ow ever,
ad d itional valid ation stu d ies of the cu rrent clinical p red ic-
tion ru le for d iagnosing hip OA cou ld eventu ally lead to
red u ced costs associated w ith rad iography if it is d eter-
m ined that clinical d iagnosis of hip OA is su f cient for
referral for early treatm ent m anagem ent strategies, such as
p hysiotherap y. Perhap s rad iograp hy cou ld be sp ared u ntil
conservative treatm ent m anagem ent strategies have failed ,
d eem ing su rgery a viable option.
Risk factors
Osteoarthritis can be d e ned as a com p lex d isord er w ith
m u ltip le risk factors. Su ch risk factors are d ivisible into
genetic factors (genetic pred isp osition), constitutional factors
(ageing, gend er, greater bone d ensity) and biom echanical
factors (joint laxity, m u scle w eakness, joint m alalignm ent,
joint inju ry, occu pational / recreational u sage) (Felson 2000;
N ICE 2008). Age, hip d evelopm ental d isord ers and previou s
hip joint inju ry show the strongest evid ence as risk factors for
hip OA. A nu m ber of stu d ies have d em onstrated an associa-
tion betw een d evelop m ental d isord ers, inclu d ing Legg–
Calve–Perthes d isease, congenital hip d islocation, or slip p ed
cap ital fem oral ep ip hysis, and p rem atu re OA of the hip
(Felson 2000; Jacobsen & Sonne-H olm 2005; Cibu lka et al
2009; N ovais & Millis 2012; Kim 2012). There is lim ited evi-
d ence suggesting that acetabu lar d ysplasia and fem oroacetab-
u lar im p ingem ent are associated w ith hip OA (H arris-H ayes
& Royer 2011). Participation in w eight-bearing sp orts, occu-
p ations that requ ire p rolonged stand ing, lifting or m oving of
heavy objects, m ajor m u scu loskeletal inju ries and vitam in D
d e ciency have also been id enti ed as potential risk factors
(Cooper et al 1998; Tanzer & N oiseux 2004; Lane 2007; Das &
Farooqi 2008; Juhakoski et al 2009; Su lsky et al 2012). A recent
system atic review w ith m eta-analysis rep orted a sm all bu t
signi cant association (relative risk (RR) 1.11; 95% CI 1.07,
1.16; p < 0.01) betw een bod y m ass ind ex (BMI) and the d evel-
op m ent of hip OA (Jiang et al 2011). The authors found that
a 5-u nit increase (5 kg / m 2) in BMI w as signi cantly associ-
ated w ith an 11% increased risk of hip OA (Jiang et al 2011).
H ow ever, the m ost im portant and over-rid ing risk factor for
hip OA in all p op u lations is age (Bu ckw alter & Martin 2006;
Cibulka et al 2009). OA of the hip prim arily affects m id d le-
aged and eld erly people, m ost often those over 60 years
(Tepper & H ochberg 1993; Buckw alter & Martin 2006;
Quintana et al 2008).
 392 PART 5 • 34 • Hip osteoarthritis
Im portantly, m any environm ental / lifestyle risk factors are
m od i able (m u scle w eakness) or avoid able (recreational joint
trau m a), w hich has im p ortant im p lications for second ary and
p rim ary p revention (N ICE 2008).
Clinical presentation
Clinical p resentation of OA of the hip is characterized by p ain,
stiffness, red u ced m ovem ent or fu nction, and variable d egrees
of local in am m ation (H u nter & Felson 2006; Juhakoski et al
2008). Most people w ith OA seek m ed ical attention becau se
of joint p ain (Bu ckw alter & Martin 2006); the pain is often
d escribed as a d eep, aching, poorly localized d iscom fort
that has been p resent for years (Bu ckw alter & Martin 2006).
Early on in d isease, p atients typ ically rep ort a grad u al onset
of hip p ain that is ep isod ic, w ith know n p recip itants and
self-lim iting p ain ep isod es (Lane 2007). As OA p rogresses,
p ain becom es m ore constant, w ith u nanticipated ep isod es of
sharp p ain. Consistent p ain tend s to occu r w hen stru ctu ral
d isease is ad vanced . Progressive OA is also associated w ith
m orning stiffness, p ain at rest or at night, d ecreased active
joint m ovem ent, low er lim b w eakness, slow er gait, red uced
aerobic cap acity and d ecreased m obility (Vogels et al 2003;
Bu ckw alter & Martin 2006; Lane 2007; Arnold & Fau lkner
2009). Existing literatu re has id enti ed consistent evid ence of
generalized m u scle strength d e cit of 20% of the affected
low er extrem ity in ind ivid u als w ith u nilateral hip OA relative
to the contralateral leg and healthy controls (Lou reiro et al
2013). These variou s im pairm ents can lead to d iverse d isabili-
ties associated w ith w alking, clim bing stairs, getting in and
ou t of a car, cycling, p u tting on shoes, and social p articip ation
(Vogels et al 2003).
Further, d isability is associated w ith the ability to cope w ith
p ain and p sychological w ell-being (van Baar et al 1998a).
Patients su ffering from p ainfu l OA are su bject to p sychologi-
cal d istress, d ep ression, sleep d isord ers and p ossible neu ro-
p athic elem ents, all of w hich have im p lications for treatm ent.
Depressive sym ptom s are far m ore com m on in patients w ith
p ainfu l hip OA than w as previou sly recognized (Felson 2009).
N egative affect is hypothesized to enhance a vicious circle
consisting of avoid ance of p ain-related activities, m u scle
w eakness, instability of joints, pain and d isability (Dekker
et al 1993). Patients m ay feel w ithd raw n and express general
d isinterest in social activities (Dosanjh et al 2009). This is exac-
erbated as old er patients are m ore likely to believe that arthri-
tis is a natu ral p art of grow ing old , that p eop le shou ld exp ect
that w hen they get old er they w ill not be able to w alk as w ell,
and that p eop le should expect to live w ith pain as they grow
old er (Ap p elt et al 2007). These beliefs that m ed ical cond itions
are a natu ral p art of ageing are associated w ith d ecreased
u tilization of p reventative healthcare services, w hich in
tu rn im p acts on fu nctional health and longevity (Good w in
et al 1999).
Prognosis
Although physicians and patients com m only regard OA as
relentlessly progressive, the d isease d oes not necessarily
follow this cou rse (Bu ckw alter & Martin 2006). Som e patients
w ith hip OA experience little change in pain or fu nction and
little stru ctu ral progression, w hereas others note a rap id
d ow nhill cou rse to the p oint w here the patient is d isabled
w ithin a few years of the onset of the d isease (Buckw alter &
Martin 2006). In contrast, som e hips heal spontaneou sly w ith
restoration of rad iographic cartilage space and d ecreased pain
(Guyton & Brand 2002; N ICE 2008). There is lim ited evid ence
that fu nctional statu s and p ain in hip OA d o not change
d u ring the rst 3 years of follow -u p (van Dijk et al 2006).
H ow ever, at the ind ivid ual level, consid erable variation
occu rs. Prognostic factors for w orsening of lim itations in
activities in patients w ith hip OA inclu d e avoid ance of activ-
ity, red u ced range of m otion at 1 year, increased p ain, higher
com orbid ity cou nt, higher age, higher ed u cational level,
red u ced range of m otion at baseline, the presence of m od erate
to severe card iac d isease, and p oor cognitive fu nctioning
(Dekker et al 2009; van Dijk et al 2010; Pisters et al 2012). A
recent trial id enti ed that higher ed ucational level, absence
of knee OA and com orbid ities, su p ervised exercise training
and habitual cond itioning physical activity p red icted a low er
p resence of p ain and better fu nctional statu s in p atients w ith
hip OA (Juhakoski et al 2013).
Progression of hip OA is com m only associated w ith m igra-
tion of the fem oral head in a sup erior–lateral d irection, sm aller
joint space w id th at entry and atrophic bone response
(Lievense et al 2002; Cheng et al 2010). Con icting evid ence
exists for the association betw een progression of hip OA and
old er age at entry, fem ale gend er, BMI and p rogression of
yearly m ean narrow ing (Lievense et al 2002; Cheng et al
2010). There is strong evid ence for no relationship betw een
BMI or w eight and p rogression, and lim ited evid ence for no
relationship betw een hip d ysp lasia and progression of hip OA
(Lievense et al 2002).
A few stu d ies have attem p ted to id entify variables associ-
ated w ith resp onse to physical therap y interventions.
Although the resu lts are m ixed , the variables of fem ale gend er,
absence of d epressive sym ptom s, history of com p lem entary
m ed icine u se, low com orbid ity cou nt, u nilateral hip p ain, age
≤ 58 years, pain severity ≥ 6 / 10, 40-m etre self-paced w alk test
≤ 25.9 second s and d uration of sym ptom s ≤ 1 year have been
id enti ed as positive pred ictors of ou tcom e (Weigl et al 2006;
Wright et al 2011).
Treatment
Pain relief and p reservation of fu nction rem ain the p rim ary
treatm ent objectives for p atients w ith OA of the hip . Manage-
m ent of OA shou ld be ad m inistered on an ind ivid u al basis
and m od i ed accord ing to the resp onse obtained (H unter
& Felson 2006; Bennell et al 2011; Fernand es et al 2013). A
nu m ber of international clinical gu id elines ad vocate non-
p harm acological treatm ents as the rst line of m anagem ent,
follow ed by pharm acological treatm ent and nally surgery
(Am erican College of Rheum atology Subcom m ittee on
Osteoarthritis Gu id elines 2000; Ottow a Panel 2005; Zhang
et al 2005, 2008; N ICE 2008).
Non-pharmacological treatment
A variety of interventions have been d escribed for the treat-
m ent of hip OA w ith fair evid ence to su p p ort the bene ts of

p hysiotherap y intervention in these patients. Recently, the
Eu rop ean Leagu e of Associations for Rheu m atology (EULAR)
convened a grou p of exp erts p rod u cing an evid ence-based
clinical gu id eline for non-p harm acological m anagem ent of
p eop le w ith hip or knee OA (Fernand es et al 2013). A com -
bined treatm ent approach inclu d ing the follow ing core
non-p harm acological interventions for m anaging p atients
w ith hip and knee OA has been recom m end ed (Fernand es
et al 2013): (1) inform ation and ed u cation regard ing OA,
(2) ad d ressing a regu lar ind ivid u alized exercise regim en and
(3) ad d ressing w eight loss if the patient is overw eight or
obese. Fu rther, the UK clinical gu id elines for m anagem ent
of hip OA recom m end inclu sion of m anu al therap y in con-
servative treatm ent p rogram m es, w hich are d escribed below
(N ICE 2008).
Patient education
Stu d ies have show n the bene t of p atient ed u cation in the
self-m anagem ent of p atients w ith arthritis in d ecreasing p ain,
im proving function, and red ucing stiffness, fatigue and m ed i-
cation u sage (H u ghes et al 2004, 2006; Walsh et al 2006;
Fernand es et al 2010, 2013). Ed u cation m ay com e in the form
of H ip School (Klassbo et al 2003), w hich highlights the need
for ed u cating patients w ith hip OA, especially their u nd er-
stand ing abou t the im p ortance of p reserving hip range of
m otion and m u scle fu nction, w hat therap y is effective and
w hat is not, and w hen su rgery is likely to be ind icated
(Cibu lka et al 2009; Bennell et al 2011). Ad d itional ed u ca-
tional ad vice shou ld focu s on activity and lifestyle changes,
includ ing both exercise and w eight loss. Clinicians m ay w ant
to consid er behaviou ral change strategies su ch as goal setting
for physical activity, w eight changes and regular exercise
(Fernand es et al 2010). Intervention strategies regard ing ed u -
cation on w eight loss m ay inclu d e strategies on red u cing
caloric intake throu gh u se of m eal p lans, red u ction of fats and
su gars, red u ced p ortion sizes, and self-m onitoring strategies
(Fernand es et al 2010).
Exercise therapy
Typ ically, exercise therap y consists of a com bination of
range of m otion / exibility exercises, m uscle strengthening
exercises and aerobic cond itioning / end u rance exercises
(Cibu lka et al 2009). The goals of prescribed exercise shou ld
be ind ivid u alized and agreed betw een the p atient and the
healthcare p rofessional. In general, the goal here is to increase
hip range of m otion and strengthen both the hip and knee
m u scu latu re so as to d ecrease the excess load absorbed by the
joint w hen hip / knee m u sculature is w eak. Treatm ent typ i-
cally involves one to three sessions per w eek, for 30 m inutes
d u ration for u p to 12 w eeks (van Baar et al 1998b; Bennell et al
2011). One im portant aspect of therapy in patients w ith OA of
the hip or knee lies in encou raging the continu ation of
exercise both d u ring and after treatm ent (Vogels et al 2003;
N ICE 2008).
Many of the p u blished articles rep orting on the bene ts of
exercise therap y in low er extrem ity OA inclu d e both stu d ies
w here particip ants have either hip or knee OA and those
presenting results of joint-speci c exercise speci c to patients
w ith hip OA alone. A recent system atic review w ith m eta-
analysis id enti ed 60 trials (44 knee, 2 hip , 14 m ixed ) stud ying
Treatment 393
the effectiveness of exercise in low er lim b OA (Uthm an et al
2013). Based on their nd ings, the au thors reported that there
is rm evid ence for a bene cial effect of exercise intervention
over no exercise for both p ain and fu nction in p eop le w ith
low er lim b OA, althou gh a m ajority of the evid ence w as from
trials in p atients w ith knee OA. The au thors also fou nd inter-
ventions com bining strengthening w ith exibility and aerobic
exercise to be the m ost effective in term s of im proving both
p ain and fu nction (Uthm an et al 2013).
There is con icting evid ence, how ever, w ith regard s the
effectiveness of exercise in red ucing pain and im proving func-
tion and overall qu ality of life in p eop le w ith hip OA
(H ernand ez-Molina et al 2008; Fransen et al 2009, 2014;
McN air et al 2009). A Cochrane system atic review (Fransen
et al 2009) fou nd that, in peop le w ith hip OA, land -based
exercise m ay red u ce pain slightly but m ay not im prove p hysi-
cal fu nction. An ad d itional system atic review (McN air et al
2009) w as in agreem ent w ith these nd ings, suggesting there
is insu f cient evid ence to su pport the u se of land -based exer-
cise therap y as a treatm ent for d ecreasing p ain, im p roving
function or enhancing qu ality of life in patients w ith OA of
the hip . H ow ever, a m eta-analysis by H ernand ez-Molina et al
(2008) rep orted the effectiveness of range of m otion and
strengthening exercises (inclu d ing hyd rotherap y) in p atients
w ith OA of the hip, follow ing d ata extraction on patients w ith
hip OA from trials w here hip and knee OA w ere originally
com bined (H ernand ez-Molina et al 2008). These au thors
fou nd hip-strengthening exercises to have a bene cial effect
(effect size −0.46; 95% CI −0.64, −0.28; p < 0.001) in red u cing
p ain and im p roving fu nction in p atients w ith hip OA (Pisters
et al 2007; H ernand ez-Molina et al 2008). Pisters et al
(2010) further suggested that a behaviou ral grad ed activity
p rogram m e consisting of grad u al reintegration of activity,
ind ivid u alized treatm ents and ad d itional booster sessions fol-
low ing cessation of treatm ent m ay red u ce the risk for joint
replacem ent su rgery in the long term in patients w ith hip OA.
Tw o ad d itional rand om ized controlled trials (Abbott et al
2013; French et al 2013) further su pport the u se of exercise
therap y in im p roving p ain, fu nction and p atient-p erceived
im provem ent am ongst patients w ith hip OA.
Manual therapy
Manu al therap y techniqu es are d esigned to im p rove the
m obility of restricted joints, connective tissu e or skeletal
m u scles, and are d irected at in u encing joint fu nction and
p ain. They inclu d e m obilization, m anip u lation, soft tissu e
techniqu es and su stained stretches (N ICE 2008; Bennell et al
2011). There is fair evid ence for m anual therapy for short-term
and long-term treatm ent of hip OA to increase hip joint range
of m otion, im p rove fu nction and red u ce p ain in p atients w ith
m ild hip OA (H oeksm a et al 2004; MacDonald et al 2006;
Cibulka et al 2009; Brantingham et al 2009; Abbott et al 2013;
French et al 2013). One stud y reported on the bene ts of
m anu al therap y over exercise therap y in term s of general
im provem ent, hip fu nction and p ain in som e patients w ith
m ild hip OA (H oeksm a et al 2004). Speci cally, follow ing
treatm ent the su ccess rate of m anu al therapy w as 81%, versu s
50% for exercise therap y. Tw o recent rand om ized controlled
trials rep orted on the bene ts of m anu al therap y, either alone
or in com bination w ith exercise, w ith effects lasting u p to 1
year (Abbott et al 2013; French et al 2013). In a recent
 394 PART 5 • 34 • Hip osteoarthritis

Figure 34.1 Indirect distraction manipulation. Figure 34.2 Posterior-to-anterior mobilization of the hip.

rand om ized controlled trial (Abbott et al 2013), m anu al

therap y d em onstrated the greatest bene t, com p ared w ith
exercise therapy or a com bination of exercise therapy and
m anu al therap y, over u su al care in term s of p ain and fu nction
as rep orted by the Western Ontario and McMaster Osteo-
arthritis Ind ex (WOMAC). Speci cally, WOMAC scores
im p roved by 22.9 p oints (170-point scale) in the m anu al
therap y only grou p as com pared w ith 12.4 p oints and 7.9
p oints for the exercise therap y and com bined treatm ent grou p
resp ectively (Abbott et al 2013). Bene ts w ere seen at the
9-w eek follow -u p and w ere m aintained to 6 m onths and 1
year. In another recent rand om ized controlled trial (French
et al 2013), im p rovem ents in hip function, hip range of m otion
and patient-p erceived change w ere noted in both the exercise
alone grou p and exercise plu s m anu al therapy group, w ith
higher p atient satisfaction w ith ou tcom e rep orted by the exer-
cise p lu s m anu al therap y grou p . Given these resu lts, m anu al Figure 34.3 Posterior-to-anterior mobilization in a ‘ gure 4’ position.
therap y has been recom m end ed to p rovid e both short-term
and long-term p ain relief, and to im p rove hip m obility and
fu nction in patients w ith hip OA; how ever, the grad e of rec- Posterior-to-anterior mobilization –
om m end ation rem ains m od erate given that cu rrently only a ‘ gure 4’ position (Fig. 34.3)
few high-qu ality rand om ized controlled trials (H oeksm a et al This techniqu e is a m od i cation of the posterior-to-anterior
2004; Abbott et al 2013; French et al 2013) su pport the recom - glid e m obilization. The patient assu m es a prone position w ith
m end ation. H ere w e d escribe som e hip m obilization tech- p re-p ositioning inclu d ing exion, abd u ction and external
niqu es com m only ap p lied on p atients w ith hip OA. (See Ch rotation of the hip. The clinician then app lies a passive glid e
37 for fu rther m anu al therap ies targeted to the hip joint.) of the hip joint u sing the heel of the hand to ap p ly the force
in a posterior–anterior d irection.
Indirect distraction manipulation (Fig. 34.1)
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 PART 5 •  The Hip Region in Lower Extremity Pain Syndromes
Other Hip Disorders: Muscle, Labrum and Bursa
CHAP TER CONTENTS
Introduction  397
Iliotibial band syndrome  397
Epidemiology  397
Pathomechanics  397
Diagnosis and clinical examination  398
Manual therapy treatment  398
Prognosis  399
Summary  399
Hip f exor tendinopathy (internal snapping hip syndrome)  400
Epidemiology  400
Pathomechanics  400
Diagnosis and clinical examination  400
Treatment  400
Prognosis  401
Summary  401
Gluteus medius tendinopathy  401
Epidemiology  401
Pathomechanics  401
Patient history  402
Diagnosis and clinical examination  402
Treatment  403
Prognosis  404
Summary  405
Adductor tendinopathy  405
Epidemiology  405
Pathomechanics  405
Patient history  405
Diagnosis  406
Treatment  406
Summary  407
Sports hernia  407
Epidemiology  407
Pathomechanics  408
Diagnosis and clinical examination  408
Treatment  409
Prognosis  409
Summary  409
Conclusion  409
 
Chapter 
35  
J o h n De w itt, Da vid Ko h lrie s e r
Introduction
Pain and d iscom ort exp erienced arou nd the hip joint can be
re erred rom m any extra-articular structures. The anatom ical
and biom echanical com plexity o this region can pose a sig-
nif cant challenge to p ro essionals in d iagnosing and treating
these p athologies e ectively ow ing to overlap p ing sym p tom s
or coexisting cond itions. Extra-articu lar d isord ers can p rod u ce
signif cant p ain and d isability, m aking a p rom p t and accu rate
d iagnosis im perative. Know led ge o best practice im proves
treatm ent e f ciency and p atient qu ality o li e.
Iliotibial Band Syndrome
Epidemiology
Iliotibial band synd rom e (ITBS) is a com m on knee inju ry in
athletes. The m ost com m only rep orted sym ptom is lateral
knee p ain d u e to in am m ation o the d istal aspect o the ili-
otibial band (ITB). The ITB is a thick ascia band that crosses
both the hip and knee joints. In som e athletes, the repetitive
m ovem ent o the knee p rod u ces in am m ation resu lting in
p ain (Khaund & Flynn 2005). ITBS is m ore com m on in
end u rance athletes and is the m ost com m on ru nning inju ry
occu rring at the lateral knee, w ith rep orted incid ence rates
betw een 1.6% and 12% (Lavine 2010). In cyclists, ITBS has
been reported as accou nting or 15% o all overuse inju ries
at the knee (H olm es et al 1993; Lavine 2010). It there ore is
im portant or m ed ical pro essionals treating these ind ivid u-
als to u nd erstand the risk actors, pathom echanics and
m ost e ective / e f cient treatm ent p ractices related to this
cond ition.
Pathomechanics
Injury is thought to occu r rom excessive riction betw een the
ITB and lateral em oral cond yle as the knee is exed beyond
30° (Fred ericson & Wol 2005). There is som e d ebate over
w hether the sym ptom s are rom riction or com pression o
stru ctu res arou nd the lateral em oral cond yle. Anatom ical
 398 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa
stu d ies su p p ort the id ea that the ITB is not a sep arate band ,
bu t rather a thickening o the lateral ascia f rm ly connected
to the linea asp era (Fairclou gh et al 2007), and it has been
p rop osed that the perception o ITB m ovement is d u e to rep et-
itive cycles o tightening, w hich cau ses repetitive com p ression
on the tissu es d eep to the ITB (Lavine 2010).
Both intrinsic and extrinsic actors have been id entif ed that
m ay be associated w ith d evelop m ent o ITBS. Anatom ical
actors, inclu d ing tightness o the ITB–TFL (tensor ascia lata)
com p lex, hip abd u ctor w eakness, increased Q-angle, leg
length d i erences, and altered knee, hind oot and ore oot
alignm ent have been associated w ith increased risk o ITBS.
These actors are theorized to increase strain or riction at
the d istal ITB and em oral cond yle d u ring rep etitive activi-
ties (Fred ericson & Wol 2005; Baker et al 2011; Saikia &
Tep e 2012).
Strength d ef cits throu ghou t the hip abd u ctor com p lex can
also have a role in d evelopm ent o this cond ition. Weakness
o this m u scle grou p resu lts in contralateral p elvic d rop ,
increased ip silateral hip ad d u ction and internal rotation,
w hich potentially increase the strain on the ITB. Fred ericson
et al (2000a, 2000b) ound that ind ivid u als w ho com p leted a
glu teal-strengthening program m e not only increased their
hip abd u ction strength, bu t also rep orted d ecreased p ain and
im p roved ability to retu rn to activity. Ru nners w ith ITBS had
d ecreased hip abd uctor strength in their a ected low er
extrem ity com pared w ith their u ninvolved low er extrem ity
and w ith a control grou p (Fred ericson et al 2000a). In another
stu d y (Fred ericson & Weir 2006), 50 m arathon ru nners w ere
evaluated at the beginning o their training p rogram m e and
it w as ou nd that those 7 ru nners w ho d evelop ed ITBS had
increased p eak hip ad d u ction com p ared w ith the u ninju red
ru nners; the increased hip ad d u ction range o m otion d u ring
stance p hase w as theorized to occu r rom d ecreased hip
abd u ctor strength and the d ecreased eccentric control o this
m otion.
The alignm ent o the low er extrem ity and / or w eakness o
the abd u ctor com p lex m ay p red isp ose the ind ivid u al to
d eveloping ITBS. A Trend elenburg gait pattern m ay lead
to excessive tension throu gh the lateral hip and ITB, d u e to
increased varu s torqu e at the knee region (Baker et al 2011).
A second observable m ovem ent p attern that m ay increase
stress throu gh the ITB is a contralateral p elvic d rop w ith
increased em oral ad d u ction and valgu s p ositioning at the
knee o the stance leg (Baker et al 2011).
Patients a ected by ITBS rep ort sharp and occasionally
bu rning p ain localized to the lateral aspect o the knee. The
m ajority o these p atients are active and involved in end u r-
ance sports su ch as ru nning and / or cycling (Barber & Su tker
1992; Fred ericson & Wol 2005). Several training actors asso-
ciated w ith ITBS inclu d e alw ays ru nning in one d irection on
a track, increased w eekly m ileage, and routes that inclu d e
d ow nhill running. Dow nhill ru nning places an ind ivid u al at
risk or d eveloping ITBS d u e to d ecreased knee exion at oot
strike, w hich increases riction betw een the d istal iliotibial
band and lateral em oral cond yle (Lind erbu rg et al 1984;
Barber & Su tker 1992; Fred ericson & Wol 2005).
Diagnosis and clinical examination
Patients m ay exhibit occasional sw elling and localized tend er-
ness along the d istal ITB. Palp able tend erness is localized to
an area 2–3 cm p roxim al to lateral joint line. This is the region
w here the ITB m oves d irectly over, or prod uces com pression
at, the lateral em oral cond yle w ith exion and extension o
the knee joint. I p resent, p itting oed em a and com p laints
o snap p ing are localized to this area (Fred ericson & Wol
2005). Pain and / or paraesthesia is also localized in this area,
bu t less com m only can extend along the length o the ITB
(Fred ericson & Wol 2005).
The clinician should assess the presence o any m yo ascial
restrictions and / or trigger points. Trigger points m ay be the
cau se or the resu lt o the ITBS and are typ ically ou nd in the
vastu s lateralis, glu teu s m inim u s, p iri orm is and d istal bicep s
em oris m uscles (Fred ricson et al 2000a; Fred ericson &
Wol 2005).
Pes p lanu s d e orm ity can contribu te to the d evelop m ent o
ITBS rom increasing strain on ITBS d ue to increased internal
rotation o the low er leg and thigh. This au lt m ay exaggerate
the e ects o glu teal m u scle w eakness, lead ing to excessive
ad d uction and internal rotation o the low er extrem ity d u ring
single-leg activities (Fred ericson & Wol 2005; Bau er & Du ke
2012). I any asym m etries are id entif ed betw een anatom ical
land m arks at the pelvis or low er extrem ities, the exam iner
m u st ru le ou t a leg length d iscrep ancy.
Extensibility o the gastrocnem iu s / soleu s com p lex m u st
be assessed , as tightness throu ghout this com plex can cause
d ecreased ankle d orsi exion, w hich prod uces increased knee
exion and ankle p ronation d u ring ru nning or closed kinetic
chain activities (Baker et al 2011). The m od if ed Thom as test
and Ober test are includ ed to d eterm ine tightness o the ante-
rior and lateral hip m uscles.
Further special testing should includ e the N oble com pres-
sion test, w hich is u sed d eterm ine w hether the p ain associated
w ith ITBS can be reprod uced p roxim al to the lateral em oral
cond yle (Magee 2002; Fred ericson & Weir 2006). Un ortu -
nately none o these tests have been exam ined or their d iag-
nostic u tility in id enti ying ITBS. Strength testing o the hip
m u scu latu re shou ld also be p er orm ed .
The Trend elenbu rg test is per orm ed by having the patient
stand on one leg w hile the op p osite oot is li ted o the
grou nd . Once the patient is balanced he / she is asked to hike
the non-stance p elvis as high as p ossible. This p osition is then
m aintained or 30 second s. A test is consid ered positive i the
p atient is u nable to assu m e the start p osition or the p elvis
begins to d rop; this ind icates w eakness o the hip abd uctors
on the stance lim b (H ard castle & N ad e 1985; You d as et al
2007). Any increased lateral trunk exion, contralateral pelvic
d rop, or increased knee valgu s or ankle / oot pronation cou ld
ind icate d ecreased u nctional hip and core strength and so
p red isp ose the athlete to inju ry (You d as et al 2007; H ollm an
et al 2009; Baker et al 2011).
It is recom m end ed that u rther u nctional testing (e.g. a
step -d ow n test, an anterior ip silateral reach test and a rontal
plane overhead reach test) be inclu d ed in the evalu ation o an
ind ivid u al w ith sym ptom s consistent w ith ITBS. Fu nctional
tests su ch as the orw ard step -d ow n test m ay id enti y w eak-
ness or com p ensatory p atterns that the p atient is able to see
and u nd erstand (Baker et al 2011).
Manual therapy treatment
Fred ericson and Wol (2005) recom m end ed d ivid ing the
rehabilitation program m e into phases, consisting o acute,

su bacu te, recovery and strengthening, and f nally retu rn to
ru nning p hases. The goal o the acu te p hase is to red u ce the
in am m ation that is creating pain and sym ptom s at the d istal
ITB (Fred ericson & Wol 2005). The u se o oral non-steroid al
anti-in am m atory d ru gs (N SAIDs), so t tissue m obilization,
and stretching is recom m end ed in the acu te phase o injury
and treatm ent (Fred ericson & Wol 2005; Baker et al 2011).
The u se o ice m assage has also been ou nd to be benef cial in
this early p eriod o inju ry and recovery (Fred ericson & Wol
2005). The m ost im p ortant asp ect o the acu te phase o m an-
agem ent is p atient ed u cation and activity m od if cation.
Withou t avoid ance or signif cant red u ction in the volu m e o
aggravating activities, m easu res to d ecrease pain and in am -
m ation w ill be ine ective. The p atient shou ld be recom -
m end ed to exercise below the rep eatable tim e that p rovokes
sym p tom s. In m ore severe cases, it is recom m end ed that the
only exercise an athlete m ay p er orm is sw im m ing. A local
corticosteroid injection is recom m end ed i visible sw elling
rem ains a ter 3 d ays and is not respond ing to physical therap y,
other m od alities and N SAIDs (Fred ericson & Wol 2005;
Baker et al 2011). H ow ever, no stud ies to d ate have exam ined
the e ectiveness o this ap p roach in a p op u lation o p atients
w ith ITBS.
As the acu te in am m ation and pain resolve, the athlete
shou ld be p rogressed into the su bacu te p hase. The goals o
this p hase are to im prove exibility throu ghou t the ITB–TFL
com p lex, allow ing athletes to p er orm strengthening exercises
w ithou t exacerbation o sym ptom s (Fred ericson & Wol 2005;
Baker et al 2011). Various stu d ies recom m end u sing stand ing
ITB stretches (Fred ericson et al 2002; Fred ericson & Wol
2005). The clinician shou ld also ad d ress any m yo ascial restric-
tions and / or trigger p oints at the lateral hip or thigh. Con-
tractu res, ad hesions or trigger p oints shou ld be ad d ressed
be ore initiating strengthening exercises. There are a variety
o treatm ent techniqu es that can be u sed to target restrictions
(see Chs 59–63). In act, a com bination o so t tissu e tech-
niqu es w ith isolated stretching and a oam roll has been rec-
om m end ed (Fred ericson & Weir 2006).
The recovery or strengthening phase should be initiated
once m yo ascial restrictions have been ad d ressed and norm al
exibility has been established (Fred ericson & Weir 2006;
Baker et al 2011). The goal o the strengthening phase is to
im prove the glu teus m ed ius and m axim u s strength in ord er
to increase d ynam ic control o the low er extrem ity d u ring
unctional activities (Baker et al 2011). All strengthening exer-
cises shou ld be p ain ree and the volu m e o p rogressive resist-
ance exercises shou ld be progressed rom 5–8 repetitions o
each up to 2–3 sets o 8–15 rep etitions. Exercises shou ld be
p er orm ed bilaterally, even i the p atient is sym ptom atic only
on one leg (Fred ericson & Wol 2005; Fred ericson & Weir
2006). A hip abd u ctor strengthening program m e, progressing
rom op en chain sid e-lying leg li ts to closed chain single-leg
orw ard step-d ow ns and lateral pelvic d rop exercises, allow ed
22 o 24 ru nners w ith ITBS to retu rn to their p reviou s activity
levels a ter 6 m onths (Fred ericson et al 2000a). Benef cial
resu lts have been reported rom the inclu sion o trip lanar and
unctional m ovem ents into the rehabilitation program m es so
as to p lace greater eccentric d em and s on the gluteal m u scu -
latu re (Fred ericson & Weir 2006). A recent EMG stud y
(Selkow itz et al 2013) has provid ed d irection to gluteal
strengthening program m es; 11 exercises w ere com pared and
the resu lts su p p orted the inclu sion o u nilateral and bilateral
Iliotibial band syndrome 399
brid ges, qu ad ru ped hip extension w ith knee exed and
extend ed , clam shells, sid e-stepping w ith band , and squ ats in
a gluteal strengthening exercise program m e. (See Ch 38 or
urther d etail on m uscle strengthening o the low er extrem ity
m u scu latu re.)
The return to sport p articip ation is initiated once the athlete
can p er orm all the above exercises w ithou t p ain and w ith
p rop er techniqu e and orm . The clinician shou ld ensu re that
the athlete has u ll range o m otion, norm alized and sym -
m etrical glu teal m u scle strength, and norm alized exibility.
It is recom m end ed that there is a negative N oble com pression
test p rior to attem p ting any retu rn to sp ort activities. Ru nners
and cyclists should be ed ucated to return to training every
other d ay and only on level grou nd . They shou ld increase the
d istance and requency o training increm entally w hile m oni-
toring or any signs or sym p tom s o ITBS (Fred ericson & Wol
2005; Baker et al 2011). Athletes should ru n no m ore than
every other d ay d uring the f rst w eek o their return to ru nning
p rogression, and shou ld be instru cted to begin w ith easy
sp rints on level grou nd w hile avoid ing any d ow nhill ru nning
d uring the f rst couple o w eeks. Faster paced running has
been show n to increase the knee exion angle beyond the
zone o im p ingem ent at oot strike, w hich d ecreases the
chance o re-inju ry. The athlete is then cou nselled to increase
the d istance and requ ency o ru nning grad u ally over the next
3–4 w eeks. It has been reported that the m ajority o p atients
are able to retu rn to their previou s level o activity at 6 w eeks
(Fred ericson & Weir 2006).
Prognosis
I an athlete is w illing to m od i y the training rou tine and has
ad d ressed the actors associated w ith ITBS, a u ll retu rn to
sp ort p articip ation is likely. The m ajority o athletes w ith ITBS
are able to retu rn to ru nning or p laying sports a ter ollow ing
a stru ctu red rehabilitation plan (Fred ericson & Weir 2006).
Fred ericson et al (2000a) provid ed evid ence to su pport an
athlete’s ability to retu rn to p reviou s level o activity w ithin
6 m onths a ter com pleting a gluteal-m u scle-strengthening
p rogram m e.
Summary
The d iagnosis o ITBS is u sually based on the history and
clinical exam . A thorou gh m u scu loskeletal exam is inclu d ed
to id enti y any im p airm ent that m ay be contribu ting to
sym p tom s (Fred ericson & Weir 2006). Overall, the literatu re
su p p orts conservative m anagem ent o ITBS in ru nners,
inclu d ing anti-in am m atory m ed ication, corticosteroid injec-
tion, stretching, glu teal-m u scle-strengthening exercises and
p atient ed u cation abou t training p aram eters (Van d er Worp
et al 2012). Many actors associated w ith training program m es,
su ch as d ow nhill ru nning, ru nning on a track and rap id
increase in m ileage, m ay pred ispose an athlete to injury and
shou ld be ad d ressed . A stru ctu red rehabilitation p rogram m e
broken up into phases is recom m end ed . The m ajority o
p atients are able to retu rn to p reviou s level o activity w ith
conservative m anagem ent alone. In rare, u nresp onsive or
recu rring cases surgery m ay be consid ered (Fred ericson &
Weir 2006).
 400 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa

p henom enon in 14 o 18 snap ping hip synd rom e cases, w hile

Hip Flexor Tendinopathy (Internal
Snapping Hip Syndrome)
Epidemiology
The iliopsoas m uscle w ill o ten create m echanical snap ping
sensations, w hich are re erred to as ‘internal’ snap p ing hip
synd rom e. Sym p tom s m ay range rom a non-p ain u l annoy-
ance to p ain and snapp ing. N on-p ain ul snapp ing hip syn-
d rom e occu rs in ap proxim ately 5–10% o the population;
how ever, this p rop ortion m ay increase in p op u lations o ath-
letes w ho m u st m ake excessive hip m otions (Teitz et al 1997;
Byrd 2005). Snapping hip synd rom e has been rep orted in
athletic p op u lations inclu d ing soccer players, w eightli ters
and ru nners (Keskula et al 1999; Gru en et al 2002; Konczak &
Am es 2005). Fem ales tend to be at higher risk or snapping
hip synd rom e, w ith reports ranging rom 62% to 86%, w hich
m ay be attribu ted to the greater requ ency o associated labral
p athology (Pelsser et al 2001; H oskins et al 2004; Lew is 2010).
Snap p ing hip synd rom e seem s to have the greatest requ ency
w ithin the elite ballet com m u nity; a stud y by Winston et al
(2007) rep orted a p revalence o as high as 90% in pro essional
ballet d ancers, w ith m ost com plaining o bilateral sym ptom s.
Volu ntary rep rod u ction o snap p ing w as ou nd in 60% o
conf rm ed cases, w ith the m ajority stem m ing rom the ilio-
p soas tend on (Winston et al 2007).
Pathomechanics
Internal snap ping hip synd rom e is attributed to the iliopsoas
tend on su blu xing over tw o com m on bony land m arks as it
crosses the anterior hip : the em oral head / joint cap su le and
the iliop ectineal em inence (Byrd 2005). Snapping typically
occu rs w ith hip m otion rom a exed , abd u cted and exter-
nally rotation p osition into extension, ad d u ction and internal
rotation. The snapp ing is o ten au d ible and can be reprod u c-
ible volu ntarily (Winston et al 2007). An alternative so t tissue
theory has been d escribed , w hich su ggests that the iliop soas
tend on actu ally ip s arou nd the iliacu s m u scle as the hip is
m oved rom an abd u cted , exed and externally rotated p osi-
tion to neu tral (Fig. 35.1) (Desland es et al 2008). An im aging
stu d y by Desland es et al (2008) id entif ed this ‘ ipping’
the rem aining ou r w ere d u e to a bif d iliop soas. Other less
com m on cau ses inclu d e one p art o a bif d iliop soas tend on
head ip p ing over the other, as ar as w ell over a p aralabral
cyst (Desland es et al 2008), stenosing tenosynovitis o the ilio-
p soas insertion (Micheli 1983) and a bony rid ge at the lesser
tu bercle (Schaberg et al 1984).
Acu te in am m ation and chronic d egeneration associated
w ith tend inopathy w ill o ten cause pain d u ring resisted hip
exion; how ever, this is not a consistent f nd ing (Winston et al
2007; Tibor & Sekiya 2008). Patients typically report d i f cu lty
in stand ing rom a seated position, running, cycling or getting
into and out o a car (Taylor & Clarke 1995; Keskula et al 1999;
Gruen et al 2002; Little & Mansoor 2008).
Diagnosis and clinical examination
Rep rod u ction o iliop soas snap p ing is com m only p er orm ed
w hen the leg is brou ght into extension rom a exed , abd u cted
and externally rotated position (FABER) (Gruen et al 2002;
H oskins et al 2004; Wahl et al 2004). Subluxation o the ilio-
p soas at the iliop ectineal em inence can o ten be elt and
red u ced w ith m anu al pressu re ap plied d uring the m ovem ent
so as to p revent the lateral to m ed ial m ovem ent (Gru en et al
2002). Althou gh the d iagnostic accuracy o special tests has
not been rep orted , Winston et al (2007) rep orted snap p ing in
24% o ballet d ancers m oving in extension rom a FABER
p osition; interestingly, these p atients w ere able to su blu x the
iliopsoas volu ntarily m ore than 90% o the tim e.
Treatment
Managem ent or internal snap p ing hip synd rom e initially
includ es rest, activity m od if cation and oral N SAIDs. Periten-
d on and intrabursal injections ollow ed by physical therapy
m ay be w arranted i sym p tom s p ersist (Wahl et al 2004).
Favou rable ou tcom es have been reported w ith iliopsoas
stretching (Jacobson & Allen 1990; Taylor & Clarke 1995;
Gruen et al 2002), u ltrasound (Taylor & Clarke 1995) and
strengthening o hip m u scles (Gru en et al 2002). Gru en et al
(2002) rep orted a 63% su ccess rate by u tilizing concentric hip
rotator strengthening and eccentric training o the hip exors
and extensors. N eu rom u scular activation and m yo ascial

Anterior Anterior Anterior

Lateral Medial Lateral Medial Lateral Medial
Posterior Posterior Posterior

T
m
m m T
T

A SPR B C

Figure 35.1 Causation of snapping iliopsoas tendon, transverse oblique view above the level of the hip joint: (A) As the hip is f exed, abducted, and externally rotated,
the iliopsoas tendon (T) rolls laterally over part o the iliac muscle (m) that becomes interposed between the tendon and superior pubic ramus (SPR). (B) As the hip joint is
brought back to neutral position, the tendon (T) ollows a reverse path (medially and posteriorly) and part o its muscle (m) becomes trapped between its tendon and the
superior pubic ramus. (C) At one point, the muscle (m) is suddenly released laterally, allowing abrupt return o the tendon (T) against the pubic bone, producing an audible
snap.

release techniqu es to im p aired tissu e can help resolve sym p-
tom s and enhance retu rn to p re-inju ry activity (Konczak &
Am es 2005). Althou gh good results have been reported , ew
rand om ized clinical trials exist.
I conservative m anagem ent ails then su rgical interven-
tion m ay be w arranted . Arthroscop ic release or lengthening
o the iliop soas is o ten u sed to correct sym p tom atic snap p ing
(Ilizalitu rri et al 2005). A com plete release o the iliopsoas
tend on m ay be p er orm ed at the p elvic brim , em oral head
(transcapsular) or lesser trochanter, w ith exception o the
iliacu s m u scle f bres that d irectly insert into the lesser tro-
chanter (Ilizalitu rri et al 2009). N o d i erences have been
reported betw een locations, and good u nctional resu lts are
obtained at ollow -u p regard less o the release site (Ilizalitu rri
et al 2009). Fractional lengthening o the iliopsoas tend on has
also been rep orted w ith good ou tcom es (Gruen et al 2002).
Active hip exion is restricted or the f rst 4 w eeks ollow ing
surgery. Isom etric hip exion strengthening can begin at 6
w eeks ollow ing release, w ith grad u al progression and resto-
ration o hip strength and neu rom uscu lar stability.
Com p lications ollow ing su rgical correction m ay inclu d e
recu rrent snapping, heterotrophic ossif cation, em oral nerve
p alsy, p ersistent anterior hip p ain, hip exor w eakness and
w ou nd in ection (Gru en et al 2002; Ilizaliturri et al 2005, 2009;
McCu lloch & Bu sh-Josep h 2006; Flanu m et al 2007). O these,
long-term hip exor w eakness is the m ost com m only reported
im pairm ent. Because labral pathology m ay be present w ith
internal snapping hip synd rom e, an intra-articular evalu ation
shou ld be p er orm ed to d eterm ine the need or su rgical cor-
rection (Taylor & Clarke 1995; Gru en et al 2002; Ilizalitu rri
et al 2005; Flanu m et al 2007).
Prognosis
Su ccess rates betw een 36% and 63% have been rep orted or
non-op erative m anagem ent u sing p hysical therap y (Taylor &
Clarke 1995; Flanu m et al 2007). A com bination o a hip exor
stability p rogram m e and steroid injections in eight cases
resu lted in relie lasting betw een 2 and 8 m onths (Vaccaro
et al 1995). Although optim al ou tcom es w ere reported , it
shou ld be noted that 50% o the cases eventu ally und erw ent
su rgical intervention (Vaccaro et al 1995). A case stud y by
Wahl et al (2004) d em onstrated high success rates w ith use o
injections in pro essional athletes. Ad d itionally, H oskins et al
(2004) rep orted an overall patient satis action o 89% at an
average o 6 m onths p ost su rgery in 92 patients. Althou gh
these ou tcom es ap p ear p ositive, com p lications occu rred in
40% o cases. Flanu m et al (2007) also rep orted signif cant
im provem ent ollow ing an end oscop ic release, w ith im proved
hip scores as high as 90–96 p oints and no recu rrence o snap-
ping in a case series o six patients.
Summary
Internal snapping hip synd rom e can be a com m on hip com -
plication in you ng, active ind ivid uals, esp ecially elite ballet
d ancers; how ever, m ost cases are asym ptom atic and d o not
a ect u nctional activity (Winston et al 2007). I pain is present
and u nction is lim ited , non-operative m anagem ent is u sually
e ective, inclu d ing hip exor stretching, neurom u scular acti-
vation, rotational strengthening and activity m od if cation
Gluteus medius tendinopathy 401
(Lew is 2010). I sym ptom s continu e to persist a ter 2–3 m onths
o conservative m anagem ent, su rgical intervention is recom -
m end ed . Im aging techniqu es, esp ecially d ynam ic u ltrasonog-
raphy, are use u l to id enti y the location and cause o
su blu xation. Care u l insp ection o the intra-articu lar anatom y
shou ld be p er orm ed to ru le ou t labral p athology as the sou rce
o m echanical sym p tom s. Follow ing end oscop ic correction,
good ou tcom es are expected ; how ever, care u l m onitoring
d uring rehabilitation should be utilized so as to avoid com -
p lications, esp ecially chronic hip exion w eakness (Ilizaliturri
et al 2009).
Gluteus Medius Tendinopathy
Epidemiology
Pain exp erienced at the greater trochanter is a com m on cond i-
tion that m ay be re erred rom intra-articu lar or extra-articu lar
stru ctu res. Previou sly d iagnosed as trochanteric bu rsitis, the
term ‘greater trochanteric p ain synd rom e’ better encom p asses
the array o problem s in this region, w hich a ects 10–25% o
the p op u lation (William s & Cohen 2009). The incid ence peaks
betw een the ou rth and sixth d ecad es o li e, m ore em ales
being a ected than m ales (Bird et al 2001). Gluteal tend inopa-
thies, inclu d ing overu se o inju ry to glu teu s m ed iu s and / or
m inim u s tend ons, are com m on cau ses o greater trochanteric
p ain (Klauser et al 2013). In the past, treatm ent consisted o
p hysical therap y and local corticosteroid injection targeting
the trochanteric bu rsa, w hich w as believed to be the sou rce o
the rep orted p ain and sym p tom s. H ow ever, the ad vancem ent
and inclu sion o m agnetic resonance im aging (MRI) in d iag-
nosis o greater trochanteric p ain synd rom e has id entif ed
glu teus m ed iu s injury to be present in a large proportion o
these ind ivid u als, w hereas bu rsitis is not p resent in isolation
(Bird et al 2001). Lateral hip pain or greater trochanteric pain
synd rom e can be d u e to tend initis and / or bu rsitis related
to the glu teu s m ed iu s and m inim u s tend ons (Lequ esne
et al 2008).
Pathomechanics
The specif c cau se o gluteal m u scle tend inopathy is not com -
p letely u nd erstood , bu t local m icro-trau m a and inju ry are
o ten p resent (Connell et al 2003; Klau ser et al 2013). Tend in-
op athy is o ten the resu lt o overload ; how ever, it is not ju st
repetitive tensile load s that can lead to inju ry. Com pressive
load ing can also lead to inju ry o tend ons (Docking et al 2013).
The gluteal tend ons can be com pressed beneath the iliotibial
band w hen the hip is ad d u cted ; the am ou nt o com pression
increases w ith a com bination o exion and internal or exter-
nal rotation o the hip (Goom 2013). The com bination o
tensile and com p ressive load ing o the tend on can lead to the
p ain and d ys u nction associated w ith tend inop athy (Docking
et al 2013). Mu scle im balances d ue to w eakness or abnorm al
tightness throu ghou t the hip region can p red isp ose to inju ry;
a com m only seen im balance and / or abnorm al m ovem ent
p attern in su ch ind ivid u als is com p ensation w ith the TFL or
hip abd u ction m ovem ents, w hich lead s to w eakness and
atrophy o the p osterior portion o gluteu s m ed iu s (Bew yer &
Bew yer 2003). Clinically this p attern presents as a w eakened
 402 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa

or lengthened p osterior glu teu s m ed iu s and a shortened
strong TFL m u scle.
Overu se inju ries m ay occu r rom a low -m agnitu d e stress
over a long p eriod o tim e – as in w eight gain, p ostu ral habits
and / or sleep ing p osition (Bew yer & Bew yer 2003). Weight
gain increases the d em and on the glu teus m ed iu s d uring
w alking / ru nning and stand ing. Postural habits, such as shi t-
ing the w eight onto one leg w ith contralateral p elvic d rop
and / or p rolonged sid e-lying p ositioning w ith the top leg
ad d u cted in ront o other leg, can lead to ad ap tive lengthen-
ing o the p osterior glu teu s m ed iu s (Bew yer & Bew yer 2003).
This pattern can resu lt in bu rsal irritation and com p ression o
glu teal tend ons (Bew yer & Bew yer 2003). Other actors that
have been linked to lateral hip p ain in the athlete inclu d e a
w id e p elvis, leg-length d iscrepancy, excessive oot pronation
and p oor ru nning su r aces (Robertson et al 2008). I excessive
com p ression or tension continu es w ithout allow ing a signif -
cant p eriod or tissu e rep air and recovery, the tend on m ay
begin to d egenerate.
Patient history
Typ ically p atients p resent w ith rep orts o non-sp ecif c hip and
bu ttock pain that intensif es w ith p rolonged stand ing, pro-
longed sitting, longer bou ts o w alking, stair negotiation and
lying on the involved sid e (Bew yer & Bew yer 2003). Occasion-
ally patients rep ort early atigue w hile w alking, or w alking
w ith a lim p (Lequesne et al 2008). The p ain is d escribed as an
‘aching pain’ at the lateral aspect o the hip (Bird et al 2001).
Pain less com m only rad iates into the groin and lateral thigh,
and this re erral pattern can p otentially lead to patients being
m isd iagnosed w ith ip silateral hip or lu m bar sp ine p athology
(Kingzett-Taylor et al 1999).
the a ected sid e in an attem p t to u nload the involved abd u c-
tors (Poultsid es et al 2012). I the single-leg stance can be held
or 30 second s, a reported sensitivity and specif city o 100%
and 97.3% resp ectively have been id entif ed (Lequ esne et al
2008). The Trend elenbu rg test also provid es value to the
exam ination as it has been reported to have a sensitivity o
72.7% and a sp ecif city o 76.9% in pred icting a tend on tear
(Bird et al 2001). There are m any variations o single-leg
balance testing recom m end ed , but the intent o all o these
tests is to evalu ate the p atient’s p rop riocep tion and abd u ctor
m u scle u nctioning (Pou ltsid es et al 2012). Ad d itionally, the
single-leg stance test, single-leg squ at test (Fig. 35.2) and star
excursion balance test (Fig. 35.3) are recom m end ed to assess
hip abd u ctor m u scle u nctioning in a you ng athletic p op u la-
tion w ith hip p ain (Kivlan & Martin 2012).
Active and p assive range o m otion o the hip and tru nk
shou ld be inclu d ed to assist w ith the d i erential d iagnosis by
ru ling in or ou t lu m bar sp ine or intra-articu lar hip p atholo-
gies. The hip range o m otion is typically norm al in patients
w ith abd u ctor tend inopathy. Passive elongation o involved
tend ons w ill increase p ain and shou ld be kep t in m ind as the

Diagnosis and clinical examination

Clinicians need to rely on the p atient history and the clinical
signs and sym p tom s in ord er to m ake an accu rate d iagnosis
that w ill gu id e treatm ent (Wood ley et al 2008). The clinical
exam shou ld includ e observation, unctional m ovem ent tests, Figure 35.2 Single-leg squat test to assess hip abductor muscle functioning.
p alp ation, range o m otion, resisted testing and special tests
(Gru m et et al 2010).
The clinician shou ld id enti y w hether any atrop hy is
p resent throu ghou t the glu teal m u scu latu re, w hich could be
d u e to com pensatory patterns second ary to pain, injury, or
entrapm ent o neu ral stru ctu res involving the sciatic, su perior
glu teal or in erior glu teal nerve. A retrospective evalu ation o
su bjects w ith glu teu s m ed iu s m u scle atrop hy ind icated that
ou r ou t o f ve su bjects had gluteu s m ed ius tend on p athology
as d iagnosed w ith MRI (Wood ley et al 2008).

Functional movement testing

Beyond the static p ostu ral assessm ent, the clinician shou ld
observe the p atient com p leting a series o u nctional m ove-
m ents. These shou ld inclu d e, bu t are not lim ited to, single-leg
balance testing and gait. The patient’s gait cycle is assessed in
ord er to id enti y an antalgic or an abd u ctor d ef cient p attern.
A Trend elenbu rg gait p attern is characterized by a w eak or
d ys unctional abd u ctor m u scle com plex. As the w eakness Figure 35.3 Star excursion balance test to assess hip abductor muscle
p rogresses, a com pensatory w eight shi t m ay occu r tow ard s functioning.

Figure 35.4 Hip abduction strength testing with a dynamometer.
range o m otion is assessed . Passive external rotation w ith the
hip in 90° o exion is typ ically the only provocative m ove-
m ent d u ring hip range o m otion testing (Lequesne et al 2008).
Occasionally, hip ad d u ction beyond neu tral increases sym p -
tom s ow ing to com p ression o the involved tend ons.
Resisted hip abd u ction and resisted hip internal rotation
are com m only recom m end ed to assist in the d iagnosis o
greater trochanteric pain synd rom e or glu teal tend inop athy.
H ow ever, the sensitivity o resisted abd uction test has been
rep orted as 72.5%, and as 54.5% or resisted internal rotation
(Bird et al 2001). The exam iner should closely m onitor the
p atient d u ring hip abd u ction strength testing (Fig. 35.4) as
m any w ill com p ensate or glu teal m u scu latu re w eakness w ith
the TFL or the qu ad ratu s lu m boru m (Fred ericson & Wol
2005). The glu teus m axim us strength is com m only assessed
in the p rone p osition w ith the knee p ositioned in 90° o exion
and neu tral hip rotation (Baker et al 2011). General hip inter-
nal and external rotation strength can be m easu red in a variety
o p ositions. The external d erotation test is p er orm ed by
having the p atient lie in a su p ine p osition w ith the hip and
knee exed to 90°; the hip is then placed in external rotation.
This p osition is typically pain ul in patients w ith glu teal tend -
inopathy, so the d egree o external rotation shou ld be red uced
u ntil the p ain d isap p ears. Patients are then instru cted to inter-
nally rotate their leg against resistance; any rep rod u ction o
their p ain is consid ered to be a p ositive test or glu teal tend i-
nop athy or trochanteric bu rsitis. The sensitivity and sp ecif -
city o this test have been rep orted to be 88% and 97.3%
resp ectively (Lequ esne et al 2008). The clinician should note
any w eakness, reprod u ction o pain and / or asym m etry
betw een the low er extrem ities.
Beyond the balance and u nctional m ovem ent testing,
several sp ecial tests p rovid e in orm ation that can assist w ith
d i erential d iagnosis o lateral hip pain. The Patrick FABER
test and the Ober test shou ld be inclu d ed in the exam . The
FABER test is u sed to d i erentiate sacroiliac joint rom
hip joint p ain in an abd u cted p osition (Gru m et et al 2010;
Poultsid es et al 2012). The Ober test w ill allow the clinician to
assess the tightness throughou t the TFL / ITB com plex that is
p otentially contribu ting to com p ression or irritation o the
glu teal tend ons w ith u nctional activities.
Gluteus medius tendinopathy 403
Palp ation to the trochanter w as rep orted to be the m ost
p rovocative test inclu d ed in clinical exam or lateral hip p ain
(Wood ley et al 2008). Sp ecif cally, tend erness along the pos-
terior asp ect o the trochanter m ay be ind icative o glu teu s
m ed iu s involvem ent, w hereas tend erness anterior to the tro-
chanter m ay be attribu ted to glu teu s m inim u s p athology
(Gru m et et al 2010).
Treatment
Su ccess u l treatm ent o tend inop athy is d ep end ent on accu -
rate staging o the acu teness or chronicity o inju ry. In the
early or reactive tend inopathy stage o inju ry, em phasis
shou ld be p laced on red u cing the p hysical d em and s p laced
on the involved tend on to allow healing and to p revent u rther
p rogression o inju ry. Activity m od if cation, inclu d ing p lacing
p illow s betw een the knees w hile in a sid e-lying p osition,
not crossing legs w hile sitting, and ensu ring equ al w eight
d istribution w hile stand ing, have been recom m end ed to
red u ce the am ount o com pression or tension placed through
the involved tend ons and m u scu latu re (Bew yer & Bew yer
2003). The u se o a cane in the contralateral hand and carrying
o external load s on the ip silateral sid e are recom m end ed in
ord er to d ecrease d em and s on the glu teu s m ed iu s d u ring the
stance p hase o gait (N eu m ann & Cook 1985; Bew yer &
Bew yer 2003). Although there is d ebate over w hether or
not tend inop athy is an in am m atory p athology, N SAIDs
m ay nevertheless help to red u ce tend on sw elling (Cook &
Pu rd am 2009).
Managem ent o glu teu s-m ed iu s-associated p ain shou ld
inclu d e an initial period o 1–2 w eeks o physical therap y. I
sym p tom s d o not im prove a ter 2 w eeks then an injection
shou ld be consid ered (Bew yer & Bew yer 2003), w hich has also
been show n to be benef cial (William s & Cohen 2009). I injec-
tion red u ces sym p tom s then p hysical therap y shou ld be con-
tinu ed . I no clear im p rovem ent is rep orted and no signif cant
strength im p rovem ent is noted w ith continu ed p hysical
therapy at 6 w eeks, re erral or u rther d iagnostic im aging
inclu d ing MRI is recom m end ed so as to d eterm ine the pres-
ence or severity o abd u ctor tend on pathology (Bew yer &
Bew yer 2003).
Strengthening exercises shou ld be inclu d ed in the initial
m anagem ent o this cond ition, bu t tailored to the stage o the
injury, w ith load s that are appropriate to the strength as d eter-
m ined in the clinical exam . Strengthening exercises shou ld be
d one w ith the m uscle in shortened positions to acilitate
norm al m u scle length in ord er to correct u nd erlying im bal-
ances and com pensatory m ovem ent patterns (Bew yer &
Bew yer 2003). Isom etric exercises m ay be benef cial in the
reactive stage o tend on pathology. The clinician need s to
m onitor p er orm ance o these exercises to ensu re that the
p atient is not com p ensating w ith the TFL. Du e to increased
com p ression o the glu teal tend ons w ith hip exion com bined
w ith internal or external rotation, the clinician should con-
sid er avoid ing certain com m on exercises, su ch as the clam -
shell, in the early p hases (Goom 2013).
As p ain and sym ptom s progress w ith early activity avoid -
ance or / and red uced load ing o the involved tend ons, the
strengthening com p onent o the rehabilitation p rogram m e
becom es m ore im portant. The p er orm ance o each p rescribed
exercise should be m onitored to prevent any abnorm al
 404 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa
Figure 35.5 The clam exercise with knee exed.
Figure 35.6 Unilateral bridge.
m ovem ents or com p ensatory m otions that cou ld aggravate
sym p tom s or lim it strength gains in these ind ivid u als. Som e
stu d ies have analysed com m on hip strengthening exercises in
ord er to help gu id e the clinician in selecting the m ost ap p ro-
p riate or benef cial exercises in these patients. Bolgla and Uhl
(2005) ou nd that w eight-bearing exercises requ ired greater
m u scle activation; the resu lts also ind icated that sid e-lying
hip abd u ction exercises generated greater m u scle activation
than stand ing non-w eight-bearing hip abd u ction exercises.
The au thors conclud ed that, althou gh the non-w eight-bearing
exercises p rod u ced less m u scle activation, they m ay neverthe-
less benef t those p atients w ho are u nable to p er orm the
w eight-bearing or sid e-lying abd u ction exercises (Bolgla &
Uhl 2005). A stu d y com pleted by Selkow itz et al (2013) com -
p ared 11 com m on exercises in ord er to d eterm ine w hich exer-
cises p re erentially activated the glu teal m u scu latu re w hile
m inim izing TFL activity. The au thors rep orted that the clam
(Fig. 35.5), sid e-stepp ing, u nilateral brid ge (Fig. 35.6), quad -
ru p ed hip extension w ith knee extend ed (Fig. 35.7) and quad -
ru p ed hip extension w ith knee exed (Fig. 35.8) w ere the m ost
benef cial or m axim izing glu teal activation w ith m inim al TFL
activity (Selkow itz et al 2013).
Figure 35.7 Quadruped hip extension with knee extended.
Figure 35.8 Quadruped hip extension with knee exed.
In the late tend on d isrepair or d egeneration stage, eccentric
exercise should be used to load the tend on su f ciently. Eccen-
tric exercise p rogram m es have been show n to red u ce p ain
levels, a ecting tend on stru ctu re, and im prove an ind ivid u -
al’s ability to retu rn to orm er activity (Cook & Purd am 2009).
In patients w ho ail conservative treatm ent, surgical inter-
vention is recom m end ed (William s & Cohen 2009). There are
a variety o su rgical interventions u tilized to ad d ress recu r-
ring or lateral hip pain that is u nresp onsive to conservative
m easu res; these inclu d e bu rsectom y, d irect lengthening o the
iliotibial band , trochanteric red u ction osteotom y and gluteal
tend on rep airs.
Prognosis
The m ajority o greater trochanteric pain synd rom e cases
resolve w ith proper conservative treatm ent (William s &
Cohen 2009). H ow ever, it is d i f cult to d eterm ine prognosis
or ou tcom es sp ecif c to glu teal tend inop athy ow ing to the
challenging natu re o clinical d i erential d iagnosis in those
p resenting w ith lateral hip p ain (Klauser et al 2013).

Conservative m anagem ent inclu d ing rest, p hysical therap y, a
corticosteroid injection and variou s other m od alities allow ed
66% o those d iagnosed w ith trochanteric bursitis to retu rn to
sport and 83% to retu rn to m anu al labou r a ter 3 m onths
(Lu stenberger et al 2011). In patients w ho ail conservative
treatm ent, su rgical intervention has been recom m end ed
(William s & Cohen 2009). Com parisons betw een surgical
interventions are d i f cult ow ing to the large nu m ber o
p athologies that m ay re er p ain to the lateral hip, lim ited
am ount o high-qu ality evid ence available and large variabil-
ity in outcom e m easu res u sed (Lu stenberger et al 2011).
Summary
Greater trochanteric p ain synd rom e is a com m only rep orted
cond ition that w as p reviou sly term ed trochanteric bu rsitis.
The pain and d isability rep orted m ay be d ue to a variety o
stru ctu res throu ghou t the lateral hip . With ad vances in
im aging techniques, gluteu s m ed ius and m inim us tend inop a-
thy has been id entif ed as a p rim ary cau se o p ain in these
ind ivid u als. The exam iner should take a thorough history and
exam to help assist w ith this challenging clinical d iagnosis
and d eterm ine the u nctioning o the hip abd uctor com plex.
There is little evid ence available to support best practice and
guid e physical therapy interventions. Generally treatm ent
shou ld ocu s on relative rest and avoid ance o aggravating
actors early on and then progress tow ard s ad d ressing low er
extrem ity m u scular im balances contributing to the sym p -
tom s. Fu tu re research shou ld be d irected tow ard the d evelop -
m ent o p revention strategies and the e ectiveness o sp ecif c
rehabilitation program m es a ter accurate d iagnosis o glu teal
tend inop athy.
Adductor Tendinopathy
Epidemiology
Inju ry to the ad d u ctor m uscle group is seen am ongst sports
that incorp orate qu ick m ovem ents and changes o d irection.
Sp orts su ch as ice hockey, soccer and Au stralian-ru les ootball
app ear to have som e o the highest p revalences o ad d uctor
stains (Ekstrand & Gillquist 1983; Molsa et al 1997; Em ery
et al 1999; Tyler et al 2001; Klu in et al 2004; Crow et al 2010).
Ten p er cent o all inju ries in Sw ed ish hockey p layers involve
an ad d u ctor m u scle strain and a prevalence o 43% has been
reported in Finnish ice hockey (Molsa et al 1997; Klu in et al
2004). Sim ilarly, Tyler et al (2001) d em onstrated an incid ence
o 3.2 strains p er 1000 p layer-gam e exposu res in the N ational
H ockey Leagu e (N H L). Rates as high as 13–20 inju ries p er
1000 p layers p er year have also been reported in the N H L,
w ith an increased risk o groin and abd om inal inju ries d uring
the p re-season p eriod (Em ery et al 1999). Within the soccer
pop u lation, p revalences ranging as high as 31% have been
reported (Ekstrand & Gillqu ist 1983). A recent stud y by
H olm ich et al (2013) review ed groin-related injuries in su b-
elite m ale soccer players and id entif ed ad d u ctor-related groin
pain as the m ost com m on cau se o prolonged recovery, espe-
cially w hen com bined w ith abd om inal-related inju ries.
Flexibility and strength have both been reported as risk
actors or ad d uctor inju ry. Stud ies in soccer players have
Adductor tendinopathy 405
show n a d ecrease in hip abd u ction m otion to be a risk
actor or groin strains (Ekstrand & Ringborg 2001; Arnason
et al 2004). Despite this, other stud ies have ound no relation-
ship betw een hip abd u ction m obility and risk o groin
injury (Tegner & Lorentzon 1991; Em ery et al 1999; Em ery &
Meeu w isse 2001). Def cits in hip ad d uction strength have
been d em onstrated in athletes both be ore and a ter a groin-
related injury. Tyler et al (2001) ou nd that an 18% hip ad d u c-
tor strength d ef cit in N H L hockey p layers increased the risk
o a u tu re groin strain com p ared w ith u ninju red p layers. In
the sam e stu d y, a d ecreased hip ad d u ction to abd u ction
strength ratio w as also ou nd in p layers su ering a groin-
related injury. Ad d u ction strength w as 95% o abd uction
strength in u ninju red p layers, bu t only 78% o abd uction
strength in inju red p layers (Tyler et al 2001). Sim ilarly, Crow
et al (2010) show ed d ecreased ad d u ctor strength im m ed iately
be ore and a ter the onset o groin pain in Australian ootball
p layers. In contrast to these f nd ings, a stu d y o elite soccer
p layers ou nd no association w ith hip ad d u ctor strength and
groin injury (Em ery & Meeu w isse 2001). A p revious history
and / or p resence o ad d u ctor injury are associated w ith recu r-
rence o groin pain (Tyler et al 2001).
Pathomechanics
The cau se o ad d uctor strain or tend inop athy is o ten m u lti-
actorial, w ith tw o or m ore actors in 27% o cases (Ibrahim
et al 2007). A thorough d i erential d iagnosis is essential to
d eterm ine the pain generator and rule ou t pathology o the
hip , lu m bosacral sp ine and abd om inal region, as p resence o
groin pain is com m on w ith these cond itions (Clohisy et al
2009). Qu ick m ovem ents in sports requiring eccentric activa-
tion o the ad d u ctor m u scles m ay p rod u ce inju ry i strength
or m obility d ef cits are p resent (Tyler et al 2001; Crow et al
2010). Im balances in exibility and strength have show n an
association w ith m u scle strains in the low er extrem ity. Def -
cits in general strength and exibility have also been associ-
ated w ith injury in em ale collegiate athletes, althou gh specif c
m u scle grou p s w ere not id entif ed (Knap ik et al 1991). Con-
versely, Orchard et al (1997) d em onstrated a relationship w ith
strength d ef cits, bu t not exibility, w ith ham string inju ry.
Sp ecif c to ad d u ctor inju ries, Tyler et al (2001) d em onstrated
a relationship w ith inju ry and strength, noting a 17 tim es
greater risk o injury i the ad d uctor strength w as less than
80% o the abd u ctor strength. In pro essional hockey p layers,
the incid ence rates o ad d u ctor strains w ere red u ced throu gh
an ad d uctor-strengthening program m e (Tyler et al 2002).
Core m u scu latu re w eakness and d elayed onset o transversu s
abd om inis m u scle recru itm ent m ay also increase low er
extrem ity and ad d u ctor injuries; how ever, d ebate still exists
and ad d itional research is need ed to id enti y the cau sation
(Ma ey & Em ery 2007; H rysom allis 2009; Labella et al 2011;
H erm an et al 2012).
Patient history
Ad d u ctor strains are m ost com m only associated w ith ice
hockey, ru gby, soccer and Au stralian-ru les ootball – sp orts
that involve qu ick d eceleration and changes o d irection.
Many o these athletes w ill rep ort a chie com p laint o groin
p ain a ter inju ry (Tyler et al 2001; Jansen et al 2008; Top ol &
 406 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa
Reeves 2008) and can result rom a single event or rom
repetitive m icro-trau m a (Avraham i & Chou d u r 2010). So t
tissu e d isru p tion m ay be p resent, d ep end ing on extent o the
inju ry, and athletes w ill o ten com p lain o p ain w ith sp orts-
related activities that requ ire ad d uctor involvem ent (Lynch &
Renstrom 1999).
Diagnosis
Diagnosis o an ad d u ctor strain is o ten orm u lated a ter a
thorou gh history, clinical exam and im aging to ensu re p rop er
id entif cation o the p athology. Clinical assessm ent o strength
and exibility o the ad d uctors, iliop soas and abd om inal
m u scles shou ld be highlighted , ow ing to alterations in antici-
p atory longstand ing groin p ain (Jansen et al 2010). H olm ich
et al (2004) d em onstrated good (> 0.60) intra- and inter-rater
reliability o m obility and strength testing, w ith the excep tion
o inter-rater reliability d u ring iliop soas strength testing,
w hich w as d eem ed u nacceptable. One o the m ost valid and
reliable clinical exam s or id enti ying groin pain is the ad d u c-
tor squ eeze test (Verrall et al 2007a). This is a reliable m easure
or ad d uctor m uscle strength and is the only m easu re to d is-
crim inate betw een athletes w ith and those w ithou t groin p ain
(Malliaras et al 2009). The test is reliable in the positions o 0°,
45° and 90° o hip exion; how ever, Delahu nt et al (2011)
d em onstrated the 45° p osition as op tim al or eliciting ad d uc-
tor m u scle activity.
MRI can be u se u l in id enti ying the location and d egree o
an ad d u ctor strain. This com m only occu rs at the m yotend i-
nou s ju nction; how ever, tend on avu lsions m ay also be p resent
(Lischu k et al 2010). Although not specif c to the ad d u ctors,
MRI resu lts have been associated w ith u nctional ou tcom es,
id enti ying longer recovery tim e based on cross-sectional
involvem ent and u id accu m u lation (Pom eranz & H eid t
1993). MRI m ay also be use u l or id enti ying non-ad d u ctor-
related causes o groin pain (Robinson et al 2004; Lischu k
et al 2010). Conventional rad iographs can be used to id enti y
stress ractu res, avu lsion inju ries and osseou s abnorm alities
(Bencard ino et al 2003).
Treatment
Initial m anagem ent o ad d u ctor tend inop athy is ocu sed on
activity m od if cation, rest, steroid injection, prolotherap y,
lu m bosacral strengthening and p assive therap y m od alities
(Topol et al 2005; Tyler & N icholas 2007; Top ol & Reeves
2008). H olm ich et al (1999) ou nd signif cantly better ou t-
com es u tilizing a p rogram m e ocu sed on active p elvic stabi-
lization com p ared w ith one consisting o p assive interventions
inclu d ing laser, cross- riction m assage, stretching and trans-
cu taneou s electrical nerve stim ulation. A ter a 7-m onth
ollow -u p , 79% o p atients com p leting the active stability pro-
gram m e w ere able to return to sp orts at the sam e or higher
level, com p ared w ith only 14% in the p assive treatm ent grou p
(H olm ich et al 1999). Verrall et al (2007b) d em onstrated an
89% retu rn to sp ort success rate a ter a p rogram m e u sing both
p assive m od alities and exercise p rogression; how ever, alm ost
hal o p atients w ere still sym p tom atic a ter their retu rn.
Inclu sion o m anual therap y m ay be benef cial as a com -
p onent o a m u ltim od al therapy p rogram m e; Weir et al
(2010) reported short- and m id -term im provem ents using a
com bination o joint m obilizations and exercise, w ith a 77%
su ccess rate. They ou nd that the inclu sion o m anu al therap y
m ay p rovid e qu icker resu lts com p ared w ith a p rogram m e
w ithou t this intervention; how ever, in this stud y the long-
term ou tcom es and p ain d u ring sp ort w ere no d i erent
betw een grou ps. Tyler et al (2002) d em onstrated an e ective
ad d uctor strain p revention program m e u tilizing an ad d u ctor-
strengthening p rogram m e. In this stu d y, 33 out o 58 p ro es-
sional hockey p layers w ere d eterm ined to be at risk or
ad d uctor strain based on an ad d u ctor : abd u ctor strength ratio
o less than 80%. The prevention program m e consisted o
concentric, eccentric and u nctional strengthening exercise
p er orm ed three tim es per w eek or 6 w eeks (Box 35.1). Fol-
low ing the prevention program m e, the incid ence rate o
ad d uctor inju ries d ecreased rom 3.2 to 0.71 per 1000 player-
gam e exposu res.
Injection at the pu bic cle t has been show n to im prove
ou tcom es in com p etitive and recreational athletes w ith
ad d uctor-related groin pain (Schild ers et al 2007, 2009).
Although all com petitive athletes d em onstrated im m ed iate
relie ollow ing the injection, only those w ith norm al MRI
f nd ings had no recurrence o pain at 1-year ollow -u p
(Schild ers et al 2007). Alm ost the entire grou p w ith abnorm al
f nd ings (16 o 17 cases) rep orted recu rrence, on average
at 5 w eeks ollow ing the injection; how ever, w hen the
sam e p rotocol w as ap p lied to recreational athletes, all
Bo x 3 5 .1 Ad d u c to r m u s c le s tra in in ju ry p re ve n tio n
p ro g ra m m e s
Warm-up
• Bike
• Adductor stretching
• Sumo squats
• Side lunges
• Kneeling pelvic tilts
S tre ng the ning  pro g ramme
• Ball squeezes (legs bent to legs straight) with different ball
sizes
• Concentric adduction with weight against gravity
• Adduction in standing on cable column or elastic resis tance
• Seated adduction machine
• Standing with involved foot on sliding board moving in
sagittal plane
• Bilateral adduction on s liding board moving in frontal plane
(i.e. bilateral adduction s imultaneous ly)
• Unilateral lunges with reciprocal arm movements
S po rts -s pe c if c  training
• On ice kneeling adductor pull together
• Standing resis ted stride lengths on cable column to
simulate skating
• Slide s kating
• Cable column cross over pulls
Clinic al g o al
• Adduction strength at least 80% of the abduction strength
(From Tyler et al 2002.)

d em onstrated good resu lts w ithou t recu rrence at 1 year
(Schild ers et al 2009).
Su rgery m ay be w arranted in cases o chronic ad d u ctor-
related groin p ain that d o not im prove. Due to lim ited out-
com es w ith conservative m anagem ent, su rgical interventions
shou ld be consid ered i sym p tom s d o not im p rove and there
is no p rogression. Du e to the com p lexity o the stresses
that cau se groin p ain, the ad d u ctor m u scle grou p , abd om inal
m u scu latu re, hip and p elvic oor shou ld all be evalu ated so
as to d eterm ine the true cau se o p ain (Meyers et al 2000; Bed i
et al 2011; Mei-Dan et al 2013). In particular, the ad d uctor
m u scle grou p and rectu s abd om inis seem to be the com m on-
est cau ses o abnorm al stress through the groin (Bed i et al
2011). A stud y by Dojcinovic et al (2012) id entif ed the pres-
ence o ad d u ctor tend initis in 24% o cases w ith sports hernia.
Ad d u ctor tenotom y, hernioplasty and pelvic oor repair
have all been ad vocated to treat the associated p athology,
w ith good ou tcom es, but again the id entif cation o the tru e
u nd erlying cau se o p athom echanics is p aram ou nt (Mei-Dan
et al 2013).
Isolated ad d u ctor tenotom y has been d em onstrated
to yield good resu lts in athletes su ering rom chronic
ad d u ctor-related p ain (Akerm ark & Johansson 1992; Atkinson
et al 2010; Robertson et al 2011). Schild ers et al (2013) per-
orm ed selective ad d u ctor release on 43 p ro essional athletes
(39 soccer p layers and 4 ru gby players). A ter an average
ollow -u p o 40 m onths, all bu t one retu rned to pre-injury
level o sp ort an average o 9 w eeks post-op (Schild ers
et al 2013). Bilateral tenotom ies have also been show n to be
e ective in treating u nilateral ad d u ctor-related groin pain.
Ma u lli et al (2012) per orm ed bilateral ad d uctor tenotom ies
on 29 athletes w ith unilateral ad d uctor longus tend inopathy.
At ollow -u p, 86% reported return to pre-inju ry activity level,
or higher, w ith a m ed ian tim e to retu rn at 11 w eeks (Ma u lli
et al 2012).
I d iagnosed quickly, conservative treatm ent m ay be e ec-
tive or correcting m u scle im balances, esp ecially ad d u ctor
strength d ef cits, and allow ing retu rn to p re-inju ry activity
(Tyler et al 2001; Machotka et al 2009; Weir et al 2010). Despite
encouraging ou tcom es, long-term recu rrence rates are high
(25–50%) ollow ing conservative m anagem ent (Verrall et al
2007b; Weir et al 2010). I conservative treatm ent ails, su rgi-
cal m anagem ent d em onstrates excellent ou tcom es w ith > 80%
return to pre-inju ry levels w ithin 3 m onths (Jansen et al 2008;
Mei-Dan et al 2013).
Summary
Ad d u ctor tend inopathy is a com m on inju ry in sports, espe-
cially in ice hockey, Au stralian-ru les ootball, soccer and
ru gby (Ekstrand & Gillqu ist 1983; Molsa et al 1997; Em ery
et al 1999; Tyler et al 2001; Klu in et al 2004; Crow et al 2010).
Several risk actors inclu d ing sp ort, m obility d ef cits, m u scle
im balance and ad d uctor w eakness m ay lead to ad d u ctor-
related groin pain (Ekstrand & Gillquist 1983; Molsa et al
1997; Em ery et al 1999; Tyler et al 2001; Klu in et al 2004; Crow
et al 2010). Ad d u ctor w eakness in particular has been show n
prior to and at the tim e o inju ry (Tyler et al 2001; Crow et al
2010). N on-operative m anagem ent o ad d uctor tend inopathy
shou ld be u tilized to correct u nd erlying im p airm ents;
how ever, recu rrence is com m on, ind icating the need or
Sports hernia 407
urther research regard ing pathom echanics and e f cacious
treatm ent strategies. I conservative m anagem ent ails, su rgi-
cal treatm ent has been show n to be e ective in retu rning
athletes to sp ort at pre-inju ry levels (Jansen et al 2008; Mei-
Dan et al 2013). Further research is w arranted to enhance
p reventative strategies and m anagem ent o ad d u ctor tend in-
op athy and chronic groin p ain.
Sports Hernia
Epidemiology
Sp orts hernia is a highly d ebated and controversial cau se o
low er abd om inal and groin pain in athletes. The resulting
chronic groin p ain can lead to signif cant tim e aw ay rom
w ork or participation in sp orts. Groin injuries accou nt or
5% o all sp orts-related injuries (Moeller 2003). The incid ence
o sp orts hernia is reported to be betw een 0.5% and 6.2%
(Cam panelli 2010). In a retrospective review o 189 p atients
w ith chronic groin p ain, Lovell (1995) reported that the cond i-
tion w as present in 50% o cases. Despite the reported preva-
lence o this cond ition, there is a lack o consistency o
in orm ation regard ing typical presentation, d iagnosis and
m ost e ective treatm ent ap p roach in this p op u lation
(Kachingw e & Grech 2008).
The term ‘athletic hernia’ or ‘sports hernia’ has been used
to d escribe the cond ition o a w eakened p osterior w all o the
ingu inal canal w ithou t palp able hernia, w hich resu lts in
chronic activity-related groin p ain (Ahu m ad a et al 2005; Sw an
& Wolcott 2007). The m echanism o inju ry, stru ctu res involved
and term inology used to d escribe this cond ition vary am ong
clinicians and w ithin the literatu re (Sw an & Wolcott 2007).
There are num erous term s u sed to d escribe this cond ition,
inclu d ing ootballers’ hernia, ingu inal insu f ciency, conjoined
tend on tear, hockey p layers’ groin, Gilm ore’s groin and ath-
letic pu balgia (Unverzagt et al 2008). The term athletic pu bal-
gia has been u sed to d escribe this p athology ow ing to the
absence o a palpable hernia. Pubalgia in ers that there is an
inconclusive physical exam w ith no id entif able cause o
the p ersisting activity-related groin p ain (Albers et al 2001;
Kachingw e & Grech 2008). It is generally accepted that a
sp orts hernia resu lts rom inju ry to m u scu lar and / or ascial
attachm ents at the anterior pu bis, but there is m u ch d isagree-
m ent as to w hich sp ecif c anatom ical stru ctu res are involved
(Leblanc & Leblanc 2003; Ahum ad a et al 2005; Sw an & Wolcott
2007). Groin pain related to sports hernia m ay be d ue to
tears o the transversalis ascia, p osterior ingu inal w all, d istal
rectu s abd om inis insertion, conjoined tend on or external
obliqu e ap oneu rosis (Albers et al 2001; LeBlanc & LeBlanc
2003; Kachingw e & Grech 2008) (Fig. 35.9). It w as reported
that only 6–8% o p atients u nd ergoing a sports hernia su rgical
repair had an isolated tear o the rectu s abd om inis (Meyers
et al 2000; Ahu m ad a et al 2005). Operative or su rgical exp lo-
ration com m only reveals m ultiple stru ctu res involved , all
contribu ting to a w eakened p osterior ingu inal w all (Diaco
et al 2005; Van Veen et al 2007). For a m ore thorou gh review
o the sp ecif c anatom ical stru ctu res com m only involved in
hip and groin inju ries in an athletic p op u lation, read ers are
re erred to the review ‘H ip and groin inju ries in athletes’ by
And erson et al (2001).
 408 PART 5 • 35 •
Figure 35.9 Different tissues related to the presence of sports hernia.
Pathomechanics
Overu se has been rep orted as the p rim ary cau se o sp orts
hernia. Inju ry m ay occu r rom shearing orces that are p ro-
d u ced at the pu bic sym physis d uring sport-related activities,
sp ecif cally those involving thigh hyp erabd u ction and tru nk
hyp erextension (Farber & Wilckens 2007). The resu ltant pelvic
m otion rom higher intensity and increased range o m otions
involving hip ad d u ction / abd u ction and exion / extension
p rod uces shearing orces across the pu bic sym physis, w hich
lead s to abnorm al stresses on the so t tissu es o the ingu inal
w all perpend icu lar to the f bres o the ascia and m u scles
(And erson et al 2001). This m ay also help explain w hy osteitis
p u bis and ad d u ctor tenop eriostitis coexist in these p atients
(H ackney 1993). Mu scu lar im balances and d ecreased hip
range o m otion m ay increase the risk o injury in these ind i-
vid u als (Verrall et al 2007a).
Few stu d ies look specif cally at risk actors or sp orts
hernia inju ries; how ever, there have been several stu d ies
id enti ying p otential risk actors or d evelop m ent o groin
p ain in athletes. A stu d y p er orm ed by Engebretsen et al
(2010) id entif ed p reviou s history o acu te groin inju ry and
w eakness o the ad d uctor m u scle group as signif cant intrin-
sic risk actors or d evelop ing new groin inju ries in m ale
soccer p layers.
Patients p resenting w ith sp orts hernia sym p tom s are typ i-
cally m ales engaging in athletic-typ e activities (Albers et al
2001). Most p atients w ill rep ort u nilateral d eep groin, severe
low er abd om inal or p u bic p ain w ith exertion that is relieved
by rest (Joesting 2002; Ahu m ad a et al 2005; Kachingw e &
Grech 2008). The pain is typically d escribed as m ore proxim al
and d eep er than a hip exor or ad d u ctor m u scle strain (Lynch
& Renstrom 1999; Kachingw e & Grech 2008). The onset is
m ore com m only insid iou s, bu t occasionally p atients m ay
report an acute event or specif c m ovem ent that prod uced
their sym p tom s once the p ain w as alread y p resent (Lynch &
Renstrom 1999; Meyers et al 2002; Moeller 2007). Activities
Other hip disorders: muscle, labrum and bursa
External oblique muscle
Internal oblique muscle
Transversus abdominis muscle
Rectus abdominis muscle
Lateral border of
rectus abdominis muscle
Deep inguinal ring
Conjoined tendon
Superficial inguinal ring
includ ing kicking, sprinting, cutting and per orm ing sit-u p
typ e m otions are o ten rep orted to increase sym p tom s (Joest-
ing 2002; Ahu m ad a et al 2005; Kachingw e & Grech 2008).
Occasionally, sym p tom s m ay be rep rod u ced w ith cou ghing
and sneezing (LeBlanc & LeBlanc 2003; Diaco et al 2005;
Kachingw e & Grech 2008).
Diagnosis and clinical examination
The d iagnosis o a sports hernia is m ad e throu gh exclusion
w ithou t a d ef nite d iagnostic test. Patients w ill typically
p resent w ith a norm al p hysical exam , no p alp able hernia and
w ith all other pathologies ruled ou t (Joesting 2002; Ahu m ad a
et al 2005; Unverzagt et al 2008). The d i erential d iagnosis o
groin pain is challenging ow ing to the natu re o overlap ping
sym p tom s and requ ent coexisting cond itions (Morelli &
Sm ith 2001; Van Veen et al 2007; Kachingw e & Grech 2008).
N u m erou s m u sculoskeletal cond itions cou ld prod uce ante-
rior hip and groin pain. Di erential d iagnoses should inclu d e,
bu t are not lim ited to: osteitis p ubis, acetabu lar labral tears,
ad d uctor / hip exor m u scles tend inopathy and stress rac-
tu re o p u bic ram u s (Lacroix 2000; And erson et al 2001;
Johnson & Briner 2005; Unverzagt et al 2008). Possible nerve
entrapm ent rom the ilioingu inal, iliohypogastric, obtu rator,
genito em oral and lateral em oral cutaneou s nerves could
also prod u ce d eep groin p ain in these ind ivid u als (H ackney
1993; Lacroix 2000; And erson et al 2001; Unverzagt et al 2008).
Urological d iseases inclu d ing prostatis, epid id ym itis, u rethri-
tis, hyd rocoele and varicocoele can also re er p ain to the
inguinal region (Unverzagt et al 2008; Sw an & Wolcott 2007).
Fu rther evalu ation o em ale p atients w ith sim ilar sym ptom s
o ten ind icate gynaecological sou rce o sym p tom s (Ahu m ad a
et al 2005; Moeller 2007; Kachingw e & Grech 2008). Once a
thorou gh history and su bjective d escrip tion o the cond ition
has been gathered rom the p atient and any p ossible system ic
or non-m u scu loskeletal cond itions have been consid ered , a
m ore sp ecif c clinical exam can be com p leted .

Palp ation shou ld be u sed to exclu d e the p resence o a
tru e ingu inal hernia (Minnich et al 2011). Resisted testing
w ill o ten reprod u ce sym p tom s w ith resisted cu rl-up and
resisted hip ad d uction at 0°, 45° and / or 90° o exion
(Minnich et al 2011). The clinician shou ld includ e range o
m otion testing at both hip s. As p reviou sly m entioned ,
red u ced hip range o m otion is a risk actor or d eveloping
chronic groin p ain in athletes (And erson et al 2001; Verrall
et al 2007a). H am m ou d et al (2012) rep orted a high inci-
d ence o sports hernia sym ptom s in athletes w ith em oroa-
cetabu lar im p ingem ent (FAI). The au thors recom m end
cau tion in d iagnosing and treating an athlete or a sp orts
hernia in isolation i signs or sym p tom s consistent w ith FAI
are present (H am m ou d et al 2012).
Sp ecif c m u scle length and exibility tests shou ld be
inclu d ed in the clinical exam to id enti y m u scu lar im balances
throu ghou t the lu m bop elvic region and low er extrem ities.
The clinician shou ld assess the length o the iliopsoas, ad d uc-
tors, tensor asciae latae / iliotibial band and glu teal and
p iri orm is m u scles. Resisted testing w ill allow the clinician
to elim inate or id enti y the p resence o m u scle strains or
tend inop athy as a p otential sou rce o p ain. The clinician
shou ld consid er d ynam om eter testing o the hip ad d u ctors
and abd u ctors. The objective valu es allow the ad d u ctor-to-
abd u ctor strength ratio to be calculated ; as previou sly d is-
cussed , a valu e o less than 80% increases an athlete’s risk o
groin strain (Tyler et al 2001).
Kachingw e and Grech (2008) clu stered f ve signs and
sym p tom s that w ere m ost ind icative o sp orts hernia, inclu d -
ing: su bjective rep orts o d eep groin or low er abd om inal p ain;
p ain that is w orse w ith activity and relieved by rest; tend er-
ness to p alp ation at the p u bic ram u s; insertion o the con-
joined tend on or rectu s abd om inis; pain w ith resisted hip
ad d u ction at 0°, 45° and / or 90° o hip exion; and pain w ith
resisted curl-up .
Treatment
Initial m anagem ent inclu d es non-su rgical m od alities such
as anti-in am m atory m ed ications, so t tissu e m obilization,
ice and prolonged or relative rest rom pain-provoking
activities, ollow ed by grad u al retu rn to and progression
o activity. An initial trial o 6–8 w eeks o p hysical therap y
has been recom m end ed to d eterm ine w hether the p atient
w ill respond avou rably w ithout need or surgical interven-
tion (Kachingw e & Grech 2008). There is little evid ence
in the literature to supp ort conservative treatm ent includ ing
physical therap y in the m anagem ent o sp orts hernia,
how ever. The em p hasis o an initial rehabilitation p ro-
gram m e should be on core m uscles strengthening and correc-
tion o any id entif ed m u scu lar im balances throu ghou t
the hip , p elvis and low er extrem ities (Ahu m ad a et al 2005;
Farber & Wilckens 2007). Ekstrand and Ringborg (2001)
per orm ed a stu d y on soccer p layers w ith sp orts hernia,
w ho w ere rand om ized into ou r groups: a su rgical grou p,
physical therap y grou p , d aily strength-training grou p and a
control grou p . The p hysical therap y grou p received treatm ent
three tim es a w eek or 4 w eeks that includ ed low er-
abd om inal-strengthening exercises and anti-in am m atory
m ed ications. The d aily strength-training grou p p articip ated
in three low er-abd om inal-strengthening exercises each d ay.
The authors rep orted that only the su rgical grou p had red u ced
Conclusion 409
sym p tom s d u ring athletic activities at 6 m onths (Ekstrand &
Ringborg 2001).
Su rgical intervention is recom m end ed w hen: (a) conserva-
tive m anagem ent has ailed , (b) the athlete can recall a sp ecif c
acute tearing or ripping sensation in the pu bic m u sculature
and / or (c) the patient is a higher level athlete w ho is u nable
to have an extend ed tim e p eriod to try a rehabilitation p ro-
gram m e (Kachingw e & Grech 2008). A proposed algorithm
or m anagem ent o sp orts hernia p u blished in 2008 stated
that, i an athlete p resented w ith the clu ster o sym p tom s
p reviou sly d iscu ssed , elt a tearing sensation d u ring activity
and is not expected to retu rn to sport or 4 m onths, then the
athlete shou ld consid er su rgical rep air. I the athlete is
expected to retu rn to particip ation w ithin 4 m onths, a 3–4-
w eek trial o p hysical therapy shou ld be consid ered . A ter the
3–4-w eek trial period , i the athlete rep orts ≥ 80% su bjective
im provem ent, then the patient shou ld continu e w ith rehabili-
tation. I the athlete rep orts ≤ 80% im p rovem ent a ter the trial
p eriod then su rgical consu ltation is recom m end ed . I there
w as no tearing sensation elt by the athlete, then an initial
6-w eek trial o p hysical therapy is recom m end ed (Kachingw e
& Grech 2008).
Prognosis
Rehabilitation p rotocols and retu rn to sp ort tim es vary,
d epend ing on the d i erent structures repaired and surgical
techniqu es u sed . Meyers et al (2008) rep orted that p ostop era-
tive rehabilitation protocols recom m end retu rn to p lay at 3
d ays to 3 m onths, d ep end ing on the su rgical techniqu e,
injured stru ctu res, sport and sp ecif c position o the athlete.
The m ajority o athletes are able to return to sport p articip a-
tion 2–6 w eeks a ter laparoscop ic repair and betw een 1 and 4
w eeks a ter the op eration i an open su rgical repair w as per-
orm ed (Farber & Wilckens 2007).
Summary
Sp orts hernia or athletic p u balgia is a d isord er that a ects
athletes at all levels w ith increasing requ ency, ow ing to
increased sport participation. It is vital or the clinician to
id enti y potential risk actors that can pred ispose an athlete
to d evelop ing chronic groin p ain, w hich cou ld be p otentially
d etrim ental to an athlete’s career. The d iagnosis is generally
m ad e by exclu d ing all other p ossible cond itions, stressing the
im portance o com pleting a d etailed and thorou gh history
and exam ination o the athlete. With increasing aw areness o
the cond ition and greater am ou nts o literatu re available, it is
im portant or any m ed ical pro essional w orking w ith these
athletes to id enti y sym ptom s p rom ptly. Clinicians shou ld
u nd erstand the recom m end ed best p ractices or m anagem ent
o this cond ition so as to retu rn an athlete to activity sa ely
and quickly, and w ithou t risk o urther inju ry.
Conclusion
Injuries involving so t tissu e stru ctu res su pporting the hip
and p elvis are com m on cond itions seen by rehabilitation spe-
cialists. Increased u nd erstand ing o the anatom ical stru ctu res,
m echanism s o inju ry and m eaning u l clinical exam ination
 410 PART 5 • 35 • Other hip disorders: muscle, labrum and bursa
f nd ings has im p roved d i erential d iagnosis in this region. As
evid enced by this section, the m ost e ective and e f cient
d iagnosis / treatm ent o these cond itions includ es the exper-
tise o a m u ltid iscip linary team ap p roach or ap p rop riate
m anagem ent o these com p lex inju ries.
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 PART 5 •  The Hip Region in Lower Extremity Pain Syndromes
Postoperative Management of Hip Disorders
CHAP TER CONTENTS
Introduction and overview  413
Hip disorders and arthroscopic surgical procedures  413
Femoroacetabular impingement  413
Chondral defects  414
Capsular and ligamentous structures  414
Postoperative considerations  415
Precautions  415
Phases of rehabilitation of hip disorders  416
Maximum protection phase: day of surgery (day 0) to   and tness, age, previous m ed ical and su rgical history, other
postoperative day 14  416
Moderate protection phase: 2–6 weeks postoperative  416
Minimal protection phase: 6–12 weeks postoperative  417
Return to sport or daily life activities phase: 12–24 weeks 
postoperative  418
An example acetabular labral repair with femoroplasty  
postoperative progression  418
Introduction and Overview
The hip joint has becom e the knee of the 1970s and 1980s – that
is, d ue to ad vancem ent of arthroscopic instru m entation tech
niqu e and recognition of intra articu lar cond itions, the inci
d ence of hip arthroscopic proced ures has surged (Boyd
et al 1997; Byrd & Jones 2001, 2011; Byrd 2005, 2007). This is
occu rring in higher nu m bers esp ecially in new ly trained su r
geons in the United States (Montgom ery et al 2013). Bozic
et al (2013) recently reported that the overall incid ence of hip
arthroscop y p roced u res p erform ed by Am erican Board of
Orthop ed ic Su rgeons Exam inees has increased by arou nd
600% over a 5 year p eriod . Ad d itionally, enhanced d escrip
tions of p atient ind ications as cand id ates for hip arthroscop y
have been p rop osed (Farjo et al 1999; Philipp on et al 2007a).
Therefore, hip arthroscopic proced ures have necessitated
hip rehabilitation p roced u res requ ired for op tim al p ost
su rgical resu lts. The science of hip rehabilitation continu es to
evolve. H ow ever, there is still m inim al high level evid ence to
su p p ort rehabilitation gu id elines. Ju st as p ost su rgical early
rehabilitation proced u res in the knee and shou ld er have both
seen d ram atic d evelop m ents, so too w ill early p ost su rgical
 
Chapter 
36  
R o b e rt C . M a n s ke , Erik M e ira
rehabilitation for the hip . This chapter w ill be based up on
the evid ence to d ate; how ever, one need s to extrap olate
from the basic science, biom echanical and cad averic research
and ou tcom e stu d ies to m ake clinical d ecisions regard ing
hip biom echanics and consid erations related to soft tissu e
healing constraints. Ad d itionally, gu id elines and rehabilita
tion m ethod s em p loyed follow ing m inim ally invasive p ro
ced u res for the knee, shou ld er, elbow and ankle w ill be
ap plied to the m anagem ent of post su rgical hip d isord ers
w hen appropriate. The phases of rehabilitation can further be
ind ivid u alized based on patients’ pre surgical level of activity
p athologies and , of cou rse, their goals and p references.
Hip Disorders and Arthroscopic
Surgical Procedures
Femoroacetabular impingement
Several form s of p athology that m ay requ ire su rgical arthros
cop y are related to bony overgrow th in the hip joint. These
form s of pathology re ect the abutm ent of the acetabu lar
rim and the fem oral neck and are associated w ith abnorm ali
ties of the p roxim al fem u r and the acetabu lu m (Reynold s
et al 1999; Ito et al 2001; N otzi et al 2002; Ganz et al 2003;
Siebenrock et al 2003). The cam type fem oroacetabu lar
im pingem ent (FAI) occurs w hen there is a d ecrease in fem oral
head –neck offset. This offset w ill contribu te to irregu lar abu t
m ent at the anterosu p erior acetabu lar rim w ith rep etitive
activities. If this cond ition p rogresses, it can resu lt in early
chond ral d elam ination and labral p athology (Beck et al 2005;
Philipp on et al 2007b; Ganz et al 2008; Byrd 2010a, 2010b).
There are several types of FAI, inclu d ing a pincer type, a cam
typ e and a com bined im p ingem ent (Ganz et al 2003).
Pincer-type impingement: def nition
and arthroscopic intervention
The pincer type of im pingem ent is caused by an excessive
p rom inence of the anterolateral rim of the acetabu lu m . Several
cau ses of this im p ingem ent have been hyp othesized , inclu d
ing a d ecreased am ount of acetabular anteversion or relative
 414 PART 5 • 36 • Postoperative management of hip disorders
retroversion of the acetabu lum , w here the face of the acetabu
lu m tilts slightly backw ard s rather than ad op ting its norm al
anterior forw ard p osition (Ganz et al 2008). Pincer im p inge
m ent can also occu r from an overgrow th of the anterior
ed ge of the acetabu lu m . The d om inant feature w ith pincer
im p ingem ent is that of a d eep or retroverted socket in w hich
the range of hip m ovem ent is lim ited by the overgrow ing
anterior acetabular rim . At the lim it of m ovem ent the fem oral
neck abu ts against the labru m , w hich acts like a bu m p er. The
labru m is com p ressed betw een the u nd erlying bone and
the fem oral neck and this force is transmitted fu rther to the
acetabular cartilage. The labru m w ill d em onstrate intrasub
stance ssu ring and intrasu bstance ganglion form ation. With
tim e, bone ap p osition occu rs on the osseou s rim next to the
labru m , p u shing the labru m forw ard . The labru m itself
becom es progressively thinner u ntil nally it is no longer
d istinguishable (Ganz et al 2008). The transm ission force to
the u nd erlying articu lar cartilage is restricted to a narrow
band along the acetabu lar rim . In pincer im pingem ent,
alterations of the labru m are m ore circu m ferential and
are m axim ally betw een the 11 and 1 o’clock p ositions (Beck
et al 2005).
The p incer typ e im p ingem ent p rod uces a rather slow
p rocess of d egeneration that occu rs m ore often in w om en
betw een 30 and 40 years of age. Activities w ith high d em and s
su ch as yoga and aerobics are likely to be those that create
exacerbations (Ganz et al 2008).
The arthroscop ic intervention for p incer lesions involves
clear assessm ent of the anterior labral p athology. With good
labral tissu e, p reservation is p referred . Once the labru m is
d etected , it can be d issected to expose the pincer lesion. Rim
d ecom pression can be perform ed in the central com partm ent
or the p erip heral com p artm ent. The acetabu lu m can be recon
tou red w ith a m otorized high sp eed bur. Follow ing recon
tou ring of the acetabu lu m , the d am aged labru m can be
d ebrid ed or re xed w ith su ture anchors if p ossible.
Cam-type impingement: def nition and
arthroscopic intervention
Cam typ e im p ingem ent is cau sed by the cam effect of a non
sp herical fem oral head rotating insid e the acetabu lu m (Ganz
et al 2003). With m otions su ch as exion of the hip, the non
sp herical p ortion of the head rotates into the acetabu lu m , thu s
creating a signi cant shear force on the anterolateral ed ge of
the acetabu lu m . This rep etitive activity can eventu ally lead to
m ore signi cant d elam ination and articu lar cartilage break
d ow n than that fou nd w ith pincer im pingem ent (Byrd 2010a).
With cam typ e im p ingem ent m ost of the d am age is located
anterosu p eriorly, at the 1 o’clock position accord ing to previ
ou s arthroscop ic stu d ies d em onstrating lesions in this area
(Beyers et al 1970; Fitzgerald 1995; Byrd 1996; Lage et al 1996;
McCarthy et al 2001). The cam type im pingem ent w ill typ i
cally be seen in athletic m en w hose average age is betw een 20
and 30 years. Unlike pincer type im p ingem ent, sym ptom s
of cam typ e im p ingem ent m ay ap p ear m ore acu tely (Ganz
et al 2008).
The arthroscop ic m anagem ent of cam im p ingem ent begins
w ith carefu l evalu ation of the anterolateral acetabulum . If
overlying soft tissu es, inclu d ing brou s and brocartilagi
nou s, are fou nd they are rem oved . The cam lesion is rem oved
by reshaping the bone so recreating a m ore norm al concave
relationship at the junction of the articu lar surface, and elim i
nating the lesion (Byrd 2010a). The surgeon should resect only
enough bone to relieve the FAI as d eterm ined by previou s CT
stu d ies or p eriod ic d ynam ic exam ination (Philip p on et al
2007a). It is im p ortant not to resect m ore than 30% of the
head –neck ju nction because the load bearing capacity of the
fem oral neck need s to be preserved (Mard ones et al 2005;
Gau nche & Bare 2006; Su ssm ann et al 2007).
In som e ind ivid u als a com bined pincer and cam im pinge
m ent can occu r. In fact, Beck et al (2005) rep orted that rarely
d o these tw o lesions occur in isolation. In their stu d y of 149
hips, only 26 presented w ith an isolated aspherical head ,
w hile ju st 16 p resented w ith an isolated coxa p rofu nd a; m ost
had a com bination of the tw o basic typ es (Beck et al 2005).
Any patient w ith both types is classi ed as m ixed cam –p incer
im p ingem ent.
Chondral defects
Chond ral d efects can occu r on the acetabu lar sid e as the resu lt
of axial load ing or shear inju ry of the cam shap ed head w ithin
the acetabu lu m . This can occu r w ith su blu xation or d isloca
tion of the hip . One m ethod of m anaging this arthroscop ically
is w ith m icro fractu re techniques to exp osed bone, and stabi
lization or d ebrid em ent of loose articular cartilage, w hich is
sim ilar to p roced u res in the tibiofem oral joint.
A recent system atic review has ind icated several nd ings
w hen com paring d ifferent treatm ent approaches for FAI
(H arris et al 2013); this d em onstrated that, in m ost cases,
su rgical treatm ent for FAI w as su p erior to non op erative
treatm ent. Fu rther, it fou nd that there w ere d ifferences in
clinical ou tcom es betw een d ifferent su rgical techniqu es. Tw o
years follow ing surgery, patients u nd ergoing m ini open
techniqu es and arthroscop y and m ini op en techniqu es had
signi cantly higher su bjective scores than those u nd ergoing
arthroscopy. Labral re xation and rep air resu lted in better
ou tcom es than labral d ebrid em ent, and re op erations and
com p lications w ere higher follow ing op en su rgical d isloca
tion and m ini op en techniqu es com p ared w ith arthroscop ic
techniqu es (H arris et al 2013).
Capsular and ligamentous structures
The goal of arthroscopic treatm ent of hip instability d u e to
cap su lar and ligam entou s laxity is to red u ce the volu m e of
the hip joint cap su le d irectly or to tighten lax ligam ents so as
to red u ce cap su lar red u nd ancy and enhance joint stability
(Philippon 2001; Philippon & Schenker 2005; Philip p on et al
2007c). Therm al capsulorrap hy uses a exible probe to m ove
across the tissue in a striped , corn row pattern, w atching
carefu l resp onse and colou r of tissu e. It is very im p ortant not
to exceed tissu e heating tim es or tem p eratu res (Philip p on
2006). When capsu lorraphy is u nable to correct the cap su lar
red u nd ancy, a capsu lar plication can be perform ed . Plication
is d one by passing a sutu re through m ore proxim al cap su lar
tissu e. The su tu re is grasp ed by p iercing the d istal cap su lar
tissu e, bringing the su tu re loop to the skin and p assing ante
riorly and or p osteriorly throu gh the tissu e, resulting in
cap su lar tightening (Philippon & Schenker 2005; Philipp on
et al 2007c).

Postoperative considerations
Com p lications after hip arthroscop y have been show n to be
as low as 1.5% of cases (Lynch et al 2013). They typ ically
involve traction related nerve inju ries, u id m anagem ent
issues and iatrogenic chond ral inju ries. H eterotopic ossi ca
tion frequ ency after hip arthroscop y has been historically
observed to be as high as 1.6%, bu t prop hylactic u se of
stronger non steroid al anti in am m atories su ch as ind om et
acin p ostop eratively has been show n alm ost to elim inate the
incid ence (Rand elli et al 2010).
When m anaging a p atient after hip arthroscopy, it is im por
tant to take note of the stru ctu res that w ere involved d u ring
the su rgery. It is alw ays a good id ea to have a cop y of the fu ll
op erative rep ort before initiating care, as the p atient is often
u nclear on the sp eci c d etails of su rgery. Since there are no
rand om ized clinical trials published to d ate on postoperative
m anagem ent of hip arthroscop y, it is also a good id ea for the
m ed ical, su rgical and rehabilitation team s to d iscu ss goals
and concerns u niqu e to their p references, su rgical technique
and p atient p opu lation to ensu re that there is a consistent and
agreed u p on p lan of care am ong the provid ers and p atients.
Although there is som e variation in provid er preferences,
there are som e gu id elines and p recau tions that can be fol
low ed for each proced ure.
Precautions
Labral debridement with / without rim trimming
and arthroscopy in general
A p atient w ho has u nd ergone d ebrid em ent of the acetabu lar
labru m w ith or w ithout osteop lasty of the acetabu lum (rim
trim m ing) has no rep air to p rotect. With this typ e of p roce
d u re, m ost activity is lim ited to that tolerated . The patient
typically u ses cru tches for u p to 2 w eeks to allow the joint to
recover from the trau m a of surgery. Range of m otion activi
ties are p erm itted w ithin p ain free p ositions to avoid irritation
of the joint.
All patients w ho have und ergone hip arthroscopy shou ld
be encou raged to m inim ize use of their hip exor m uscles
d u ring the rst 6 w eeks after su rgery. H ip exor recru itm ent
app lies p ressu re to the anterior hip joint w here m ost su rgeries
are p erform ed (Martin et al 2010). Since chronic anterior hip
irritation is a com m on com plication of hip arthroscopy, m ini
m ization d iscom fort in the early p hases is id eal. N on w eight
bearing is rarely recom m end ed in cases of hip arthroscopy as
this encou rages excessive u se of the hip exor.
Precautions for acetabular labral debridement
• Weight bearing as tolerated (WBAT).
• Lim it range of m otion to 90° of exion for the rst 2
w eeks. Do not pu sh into other d irections m ore than
tolerated for the rst 2 w eeks.
• N o active range of m otion for the rst 2 w eeks. N o active
exion for the rst 6 w eeks.
Femoroplasty
Rem oval of a cam lesion (fem orop lasty) requ ires au gm enta
tion to the stru ctu re of the fem oral neck. H istorically there has
Hip disorders and arthroscopic surgical procedures 415
been concern that this proced u re w ould cau se signi cant d is
ru p tion to the vascu lar su p p ly and / or the stru ctu ral integrity
of the fem oral neck (Philippon et al 2007b) and , d ue to this,
earlier recom m end ations have been for only partial w eight
bearing (lim iting it to 20 pound s / 9 kg) for u p to 6 w eeks after
su rgery (Philipp on et al 2007b). H ow ever, this concern has
not been su p p orted by m ore recent literatu re. Fractu res asso
ciated w ith norm al activities of d aily living after fem orop lasty
have been d ocu m ented only in cases involving stu m bling
(Rothen u h et al 2012).
Som e su rgeons recom m end cru tch u se as tolerated for the
rst 1–2 w eeks after surgery not only to red uce in am m ation
after su rgery, bu t also to give early protection to the fem oral
neck. When p atients can tolerate their fu ll w eight on the leg
w ithou t the u se of painkillers, cru tches m ay be d iscontinued .
Im pact load s are typ ically perm itted as tolerated after
8 w eeks.
Precautions for femoroplasty
• 50% partial w eight bearing (PWB) for the rst 2 w eeks
bu t m ay be WBAT.
• Lim it range of m otion to 90° of exion for the rst 2
w eeks. Do not p ush into other d irections m ore than
tolerated for the rst 2 w eeks.
• N o active range of m otion for the rst 2 w eeks. N o active
exion for the rst 6 w eeks.
Acetabular labral repair
In cases of acetabu lar labral repair, the repaired stru ctu re
requ ires p rotection as biological healing is achieved . It has
been su ggested that the patient shou ld be lim ited to partial
w eight bearing for up to 6 w eeks to p rotect the rep aired
labru m , bu t load s to the labral in patients w ithou t d ysplasia
have been show n to be only 1–2% of the total w eight of
the hip (H enak et al 2011). This sm all am ou nt of load m ay
actually be helpfu l for stim u lating a stronger biological bond
over tim e.
Since the anterior zone of the labru m contains the highest
relative concentration of sensory bres (Gerhard t et al 2012),
som e su rgeons have felt that w eight bearing as tolerated
shou ld be ad opted . Sim ilar to fem oroplasty, 1–2 w eeks of
cru tch u se m ay be help fu l for red u cing in am m ation and
allow ing the involved stru ctu res to tolerate progressively
heavier norm al load s d u ring typ ical activities of d aily
living. Im pact activities typically begin as tolerated after
12 w eeks.
Precautions for acetabular labral repair
• WBAT, bu t m ay be 50% PWB for rst 2 w eeks.
• Lim it range of m otion to 90° of exion for the rst 2
w eeks. Do not p ush into other d irections m ore than
tolerated for the rst 2 w eeks.
• N o active range of m otion for the rst 2 w eeks. N o active
exion for the rst 6 w eeks.
• N o im pact load ing (jum ping, running, sw inging a
racqu et / club / bat, etc.) until at least 12 w eeks p ost op .
Capsular modif cation
Cap su lar m od i cation to the hip joint alm ost alw ays involves
the anterior cap su le or iliofem oral ligam ent (Dom b et al 2013).
 416 PART 5 • 36 • Postoperative management of hip disorders
H ence lim itation of extension and external rotation for the
rst 4 w eeks is clearly recom m end ed to avoid excessive
tension to the affected cap su lar tissu e. Patients are typ ically
lim ited to p artial w eight bearing for the rst 2 w eeks, but
continu ing to u se crutches for another 2 w eeks is also ad vised
in ord er to assist the p atient in ad hering to the range of m otion
restriction.
After 4 w eeks, p rogressive stretching to the anterior cap su le
is ad vised so as to achieve and m aintain a norm al range
of m otion. Im p act activities typ ically begin as tolerated after
12 w eeks.
Precautions for capsular modi cation
• PWB for rst 2 w eeks.
• Lim it external rotation (ER) range of m otion for
4 w eeks.
• N o active range of m otion for the rst 2 w eeks. N o
active exion for the rst 6 w eeks.
• N o im p act load ing (ju m p ing, ru nning, sw inging a
racquet / clu b / bat, etc.) u ntil at least 12 w eeks p ost
op eration.
Micro- racture
When m icro fractu re is p erform ed on a w eight bearing
su rface of the hip joint, tou chd ow n w eight bearing (TDWB)
is ad vised for 6 to 8 w eeks to p rotect the new ly form ing brin
clot (Byrd & Jones 2011). Typically, the presence of a m icro
fractu re w ill d elay the rehabilitation p rogress by 6–8 w eeks
across all p hases. Depend ing on su rgeon preference, im pact
activities are p erm itted betw een 16 and 24 w eeks.
Precautions for micro-fracture
• TDWB for the rst 6–8 w eeks.
• N o im p act load ing (ju m p ing, ru nning, sw inging a
racquet / clu b / bat, etc.) u ntil at least 18 w eeks p ost op.
Phases of Rehabilitation
of Hip Disorders
Although there are sp eci c concerns for each structure that
cou ld be involved , there are also som e general gu id elines that
shou ld be follow ed for all p atients that have u nd ergone hip
arthroscop y. The rehabilitation can be d ivid ed into fou r
p hases: m axim al p rotection, m od erate protection, m inim al
p rotection and retu rn to sp ort or d aily activities. These p hases
follow a tim eline based on tissue healing consid erations of
the involved stru ctu res. This section is a sam p le p rogression
of an acetabu lar labral rep air w ith fem orop lasty, as this is
the m ost com m only p erform ed p roced u re u nd er hip
arthroscop y.
Maximum protection phase: day of surgery
(day 0) to postoperative day 14
The goals of the p hase are to control postoperative in am m a
tion and p ain, to lim it w eight bearing so as to p rotect affected
tissu es w hile op tim izing healing, to regain range of m otion as
tolerated and to begin hip isom etrics.
Figure 36.1 Prone heel squeeze. The patient lies prone with knees slightly apart
and bent to 90°, heels touching, then pushes the heels together, creating an
isometric contraction of the gluteus medius.
Du ring the m axim um protection phase, the focus shou ld
be on m inim izing postoperative in am m ation and d iscom
fort. Sp ecial care shou ld be taken to encou rage rest, anti
in am m atory and cryotherap y use, and observance of
w eight bearing restrictions. In fact, any increase in ‘as
tolerated ’ activities is u su ally d iscou raged u ntil after p ain
killer use d u ring norm al activities of d aily life has ceased .
The patient m ay begin gentle isom etrics as tolerated as
early as postoperative d ay tw o. Gluteal and qu ad riceps
sets are encou raged , as is isom etric ad d u ction in a hook
lying position. The p rone heel squeeze (Fig. 36.1) is an
isom etric exercise that generates high activity in the glu teus
m ed iu s w ith low activity of the iliop soas m u scle (Philip p on
et al 2011).
Gentle p assive range of m otion m ay also start as early as
postop erative d ay tw o, though the patient shou ld be carefu l
to avoid extrem es of m otion as this m ay stress involved stru c
tu res (Enseki et al 2006). Passive exion is usually lim ited to
90°. A caregiver m ay be trained to p erform passive range of
m otion, bu t som e p atients m ay p refer to p erform this them
selves u sing a rop e to achieve greater p ersonal control. When
tolerated , the p atient m ay rid e on an u p right exercise bike
w ith the seat elevated to avoid breaking the 90° of exion
restriction.
Since even high load m obilizations have been show n to
have very little m echanical effect on the hip joint (Lou bert
et al 2013), the focus of m anu al therap y interventions d u ring
this p hase shou ld be p erform ed solely to help w ith d iscom
fort. Anecd otally, patients typically prefer long d istraction,
p osterior glid es and lateral glid es at 90° of exion (Fig. 36.2).
If these interventions are causing ad d itional d iscom fort to the
p atient, how ever, they shou ld be d iscontinu ed .
After 2 w eeks have p assed and all goals from the m axim al
p rotection p hase have been achieved , the p atient m ay p rogress
to the m od erate p rotection p hase.
Moderate protection phase: 2–6 weeks
postoperative
The goals of the phase are to achieve full w eight bearing as
tolerated , to norm alize gait, to restore fu ll active range of

Figure 36.2 Lateral glide at 90° of exion. With the patient in supine and their
hip exed to 90°, wrap a mobilization strap around the provider’s body and the
patient’s proximal femur. A lateral force is applied to the hip by the provider shifting
his / her weight back against the strap while applying a slight adduction force at the
knee to stabilize.
Figure 36.3 Caudal glide self-mobilization. The patient lies supine with the hip
exed as far as comfortably tolerated, and then places the ipsilateral hand into the
proximal femur, applying a caudal glide with that hand while attempting additional
hip exion with the contralateral hand as tolerated.
m otion as tolerated , to increase soft tissu e exibility / toler
ance, to begin balance and p ropriocep tion activities and sup
p orted d ou ble leg squatting as tolerated , and to m aintain
and / or im p rove m uscle strength and coord ination of trunk
and low er leg.
Du ring the m od erate protection phase, the focus should be
on norm alizing gait m echanics and increasing m u scle activa
tion. Most activities of d aily living can be safely resu m ed as
tolerated d u ring this p hase, althou gh the p atient shou ld take
care to avoid im p act load s, qu ick tw isting m otions and d eep
squ atting.
Continu e gentle p assive range of m otion exercise as toler
ated . Anecd otally, w hen trying to p rogress passive hip exion,
the p atient m ay tolerate fu rther m otion w hile p erform ing a
cau d al glid e self m obilization (Fig. 36.3). Patients u su ally
p rogress w ell w ith gentle stretching into external rotation and
abd u ction if su p p orted by a p illow to m inim ize m uscle gu ard
ing of the joint. Gentle stretching to the hip exors can be
Phases of rehabilitation of hip disorders  417
Figure 36.4 Clamshells. The patient is in side-lying, with knees bent to 90° and
hips exed to approximately 60°, then raises the top knee while externally rotating
and abducting the top hip, and maintaining contact at the feet. The patient should
avoid compensating by rotating the trunk posteriorly during the motion.
initiated at this point in the rehabilitation program m e. Inter
nal rotation m ovem ent m ay be slow to retu rn as it p laces
stress on the su rgical rep air and m ay not be w ell tolerated .
Du ring this p hase, full active range of m otion should be
encou raged w ith the exception of active hip exion. Active
hip exion is u nlikely to cau se any d am age to the su rgical site,
but it can com m only cause irritation to the anterior hip region.
All other m otions should be perform ed as tolerated .
Strengthening exercises shou ld focu s on activation of the
hip abd u ctors, sp eci cally the glu teu s m ed iu s (Philip p on et al
2011). Clam shells (Fig. 36.4) and brid ging have been show n
to p rod u ce high activation of the glu teu s m ed iu s w ith low
activation of the tensor fascia lata (Selkow itz et al 2013).
Clam shells are m ost effective at 60° of hip exion w hile m ain
taining a neu tral p elvis, and not allow ing the top of the p elvis
to roll back d u ring the m otion (Willcox & Bu rd en 2013). Per-
form ance of stand ing op en kinetic chain band exercises into
extension, abd u ction and ad d uction can also be initiated
d uring the beginning of this phase.
Tow ard s the end of the m od erate p rotection p hase, the
p atient can begin band w alking and single leg brid ging activi
ties as tolerated . Ball squ ats can be initiated to p rogress squ at
d epth in a safe, controlled m anner w hile encou raging prop er
squ at m echanics.
After 6 w eeks have passed and all goals from the m od erate
p rotection p hase have been achieved , the p atient m ay p rogress
to the m inim al p rotection p hase.
Minimal protection phase: 6–12 weeks
postoperative
The goals of this phase are to achieve full squat d epth as toler
ated , to equ alize strength betw een the involved and u nin
volved lim bs, to be able to p erform single leg squ at, to
m aintain or im p rove m u scle strength and coord ination of the
tru nk and low er leg, and to be read y to initiate im p act activi
ties su ch as ru nning and ju m p ing.
Du ring the m inim al protection phase, the focu s shou ld be
on retu rning the p atient to equ al lim b strength. By the end of
 418 PART 5 • 36 • Postoperative management of hip disorders
Figure 36.5 Single-leg squat with physioball. Standing upright on one leg while
leaning back slightly on the physioball, the patient performs a squat while shifting
the hips underneath the ball and while maintaining proper knee position. The patient
should avoid excessive anterior knee translation, knee valgus, hip internal rotation
and hip adduction.
the p hase, the p atient shou ld be able to tolerate all activities
of d aily living and m ost w eight room activities that d o not
requ ire im pact load s or qu ick tw isting m ovem ents.
Flexion, abd uction, extension and external rotation range
of m otion shou ld all be close to norm al by 6 w eeks. Any
resid ual d e cit into internal rotation can be pu rsu ed m ore
aggressively at this point if tolerated . Also, if tolerated , active
hip exion strength can be p rogressed . Stretching to the hip
exors and ad d u ctors shou ld be continued .
Once fu ll d ep th p hysioball squ ats are tolerated , the p atient
can be p rogressed to box squ ats from a bench or chair. Resist
ance can be ad d ed as need ed . Athletes can then p rogress to
front squ ats and d ead lifts. Single leg presses shou ld also be
initiated to encou rage each low er extrem ity to fu nction ind e
p end ently. When tolerated , single leg squats can begin, u sing
a physioball for su p p ort and taking care to avoid hip ad d u c
tion, internal rotation or knee valgu s (Fig. 36.5). These can be
p rogressed w ith athletes in a Sm ith m achine, increasing the
resistance as tolerated .
After 12 w eeks have p assed and all goals from the m inim al
p rotection p hase have been achieved , the patient m ay p rogress
to the retu rn to sp ort p hase.
Return to sport or daily life activities phase:
12–24 weeks postoperative
The goals of this last phase are to be able to run as need ed for
training, to achieve hop p erform ance in the affected lim b at
90% that of the u ninvolved lim b, to retu rn to fu ll w eight room
activities, and to return to sp ort participation
The focu s of the retu rn to sp ort p hase is to increase toler
ance of im p act and other sport sp eci c activities. After 12
w eeks, the surgically repaired stru ctures have m ost likely
achieved biological healing and can be tested against increas
ing load s. H ow ever, as all patients heal at d ifferent rates, care
shou ld nevertheless be taken to p rogress system atically only
as per patient toleration.
Before p assing into this p hase, the p atient shou ld have
alread y achieved sym m etry in strength throu ghou t the low er
extrem ity. At this point, the patient can begin ru nning as
tolerated . As sym p tom s of lim itations can ap p ear several
hours after running, w e recom m end starting w ith only 10
m inu tes and assessing the resp onse of the joint over the next
24 hours. If there is no change in sym ptom s, running can then
be increased by 5 m inu tes. As long as sym p tom s continu e to
rem ain und er control, running m ay progress in 5 m inu te
increm ents u ntil the d esired ru nning tim e is achieved . If
sym p tom s increase at any p oint, w e recom m end that the
p atient stop ru nning u ntil sym p tom s resolve, then continu e
w ithou t increasing the tim e. Progress m ay then continu e as
sym p tom s p erm it.
Once light ru nning is tolerated , w e ad vise p rogressing to a
vertical d rop ju m p , as failing this test has been show n to be a
p red ictor of low er extrem ity inju ry in athletes (H ew ett et al
2005; Paterno et al 2010). If this d rop is tolerated , the patient
can then p rogress to hop testing, as this has been show n to be
a p red ictor of perform ance lim itations in athletes retu rning
from inju ry (Logersted t et al 2012).
As the patient passes these tests, fu rther testing speci c
to the p atient’s sp orts can be u sed . The p atient can then
return to sp orts in a grad ed fashion. If sym ptom s increase,
w e recom m end hold ing further activity until the sym ptom s
resolve.
An Example Acetabular Labral Repair
with Femoroplasty Postoperative
Progression
The clinician shou ld alw ays observe the above precau tions for
sp eci c p roced u res. This section sets ou t an exam p le rehabili
tation p rogram m e follow ing an acetabu lar labral rep air p ro
ced u re. Patients w ho have u nd ergone only acetabu lar labral
d ebrid em ent m ay progress as tolerated once precau tions have
been m et. In general, they shou ld progress no faster than
tolerated . For exam p le, range of m otion w ill u su ally p rogress
w ell once in am m ation is red u ced .
Weeks 0–2
• Passive range of m otion in all planes per p recautions.
• Isom etrics in all planes as tolerated .
• Exercise bike – u pright bike only w ith seat elevated one
step higher than norm al. Begin at 5 m inu tes, then
progress by 5 m inu tes each session as tolerated .
• Gait training as p er precautions.
• Use ice and painkillers as need ed .
Weeks 2–4
• Progress to full passive range of m otion as tolerated .
• May begin fu ll active range of m otion.
 An example acetabular labral repair with femoroplasty postoperative progression
• Begin stretching into ER, abd u ction and extension as
tolerated .
• May ad d resistance to active range of m otion if tolerated .
Focus on hip abd u ctor strength – no resistance to hip
f exion.
• May begin d ou ble leg brid ging.
• Exercise bike – m ay bring seat back d ow n to norm al
p osition. Up to 45 m inu tes as tolerated . N o stand ing
d u ring ped alling.
• Continu e gait training as p er p recau tions.
• Continu e u sing ice and p ainkillers as need ed .
Weeks 4–6
• Fu ll w eight bearing.
• Progress stretching into ER, abd u ction and extension.
• Balance training as tolerated .
• Begin ball squ ats and other short range closed kinetic
chain exercises as tolerated .
• May begin ellip tical exercise as tolerated .
• Progress hip abd u ctor training.
Weeks 6–12
• Continu e w ith ellip tical training.
• Begin p rogressing squ atting activities as tolerated
– p rogress d ep th of squat before ad d ing resistance.
• Progress tow ard single leg activities.
• Progress p rop riocep tion activities as tolerated in a
m inim al im p act environm ent.
• By the end of w eek 12, the patient shou ld have strength
in involved sid e w ithin 90% that of uninvolved sid e.
Weeks 12–24
• May begin ru nning activities as tolerated .
• Begin retu rn to sp ort p rogram m e sp eci c to the need s of
the p atient.
• Progressively retu rn to im p act activities (ju m p ing,
ru nning, sw inging a racqu et / clu b / bat, etc.).
• Progress only as tolerated .
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 PART 5 •  The Hip Region in Lower Extremity Pain Syndromes
Joint Mobilization and Manipulation of the Hip
CHAP TER CONTENTS
Introduction  421
Joint mobilization/manipulation of the hip joint  421
Longitudinal traction mobilization / manipulation  422
Lateral distraction mobilization  422
Flexion / adduction mobilization: mobilization with movement  
internal rotation non-weight-bearing  423
Flexion / adduction mobilization: mobilization with  
movement internal rotation weight-bearing   423
Mobilization with movement in  exion  424
Mobilization with movement in extension weight-bearing   424
Introduction
The Am erican Acad em y of Orthop aed ic Surgeons (2008)
ranks loss of m obility and d egenerative changes of the hip
joint as the m ost com m on cau se of hip p ain in old er ad ults.
The prevalence of hip pain appears to be p op ulation d epend -
ent, bu t it has been estim ated to be as high as 27% (Dagenais
et al 2009). H ip pain and d ysfunction m ay result in signi cant
personal m obility im pairm ents and su bsequent recreational,
occu p ational and societal d isabilities. A loss of hip range of
m otion, p articu larly internal rotation, has been id enti ed as
being highly p red ictive of hip osteoarthritis by Altm an et al
(1991), Sutlive et al (2008) and Birrell et al (2000, 2001). It is
theorized that a loss of joint m obility im p ed es the norm al
com pression–d ecom p ression cycle requ ired to op tim ize joint
cartilage synovial u id exchange, thereby accelerating the
d egenerative process. Manual therapy has been d em onstrated
to increase joint sp ace by up to 7 m m d uring the ap plication
of a lateral d istraction p roced u re (H ard ing et al 2003) and to
positively im pact on hip pain, m obility and fu nction (H oeksm a
et al 2004; MacDonald et al 2006; Abbott et al 2013). Ortho-
paed ic Manu al Therap y (OMT) has been recognized to be of
bene t to p atient fu nctional statu s and is includ ed in the
Am erican Physical Therapy Association’s Clinical Practice
Gu id elines for both arthritic and non-arthritic hip p ain
(Cibulka et al 2009; Keelan et al 2014).
This chapter focuses on restoration of low er lim b functional
tasks thou gh a continu u m of m anu al therap y interventions
to the hip joint. Joint m obilizations inclu d ing both
arthrokinem atics-based translatoric glid es and fu nction-based
 
Chapter 
37  
J a c k M ille r, W a yn e Hin g
m obilizations w ith m ovem ent have been selected to p rovid e
clinicians w ith a rep ertoire of tools to u se in clinical p ractice.
The application of these techniqu es w ill be d ep end ent on the
ind ivid u al clinical presentation of the p atient and app ropriate
clinical reasoning on the p art of the therap ist.
Joint Mobilization/Manipulation of
the Hip Joint
Manu al therap y p roced u res to restore m obility and fu nction
of the p elvic gird le have been d evelop ed and d escribed by a
variety of au thors (Kaltenborn et al 2002; Mu lligan 2003;
H engeveld et al 2005). Translatoric accessory joint m obiliza-
tion techniqu es are w ell established and form the basis of
m u ch of the cu rricu lu m of both entry level and p ostgrad u ate
m anu al therap y training p rogram m es internationally. Origi-
nally d evelop ed by contribu tors su ch as Kaltenborn and
Evjenth from N orw ay (Kaltenborn et al 2002), OMT utilizes a
clinical-reasoning p arad igm based on the m anu al therap ist’s
p ercep tion of joint restriction as revealed by p assive m ove-
m ent exam ination and the application of the concave–convex
ru le. (See Ch 31 for fu rther d etail on OMT.)
Passive translatoric accessory m obilizations are p erform ed
p arallel or p erp end icu lar to the treatm ent p lane as d eter-
m ined by the sp eci c orientation of the joint su rfaces. Mobi-
lizations are grad ed in their range and sustained for speci c
d urations accord ing to their intend ed therapeu tic goal(s)
inclu d ing p ain relief and im proving joint m obility. The theo-
retical conceptual m od el of OMT is the presence of joint
cap su le contractu re, w hich m u st be p assively elongated
throu gh tissu e creep effected by su staining the p assive m obi-
lization techniqu es; how ever, this hyp othesis has not yet been
scienti cally con rm ed . Techniqu e rep etition and an ap p ro-
p riate self-treatm ent regim en along w ith consid eration of
associated periarticu lar soft tissu e d ysfu nction, neu rop hysi-
ological and m otor control factors are p rop osed to p rovid e
short- and long-term p ositive ou tcom es (Vicenzino et al
2007, 2011).
A grow ing bod y of evid ence has d em onstrated the valu e
of com bining trad itional OMT m anu al therap y m obilizations
concu rrently w ith the p atient’s p ain-lim ited p hysiological
m ovem ents. Term ed ‘m obilization w ith m ovem ent’ (MWM),
this concep t w as d evelop ed by Brian Mu lligan of N ew Zealand
 422 PART 5 • 37 • Joint mobilization and manipulation of the hip

(Mu lligan 2003) and bu ilt on the fou nd ations of OMT. Within
the Mu lligan concep t, the m anagem ent of the p atient requ ires
the id enti cation of a com p arable sign or client-sp eci c
im p airm ent m easu re (CSIM) that is u sed to evalu ate treat-
m ent effectiveness, often a lim ited fu nctional activity. This
clinically m easu rable fu nctional d e cit then becom es the
benchm ark against w hich the effectiveness of the intervention(s)
is continu ally reassessed (Vicenzino et al 2007, 2011).
The clinical-reasoning p arad igm of selection and p rogres-
sion of MWMs is based u p on the p atient’s ind ivid u al resp onse
to the selected m obilizations as m easu red by the p ain-free
im p rovem ent in the id enti ed CSIM. The therap ist m u st con-
tinu ou sly m onitor the p atient’s resp onse to ensu re that no
p ain is created . Utilizing his / her know led ge of joint arthrol-
ogy, a w ell-d evelop ed sense of tissu e tension and clinical
reasoning, the therap ist investigates various com binations of
m obilization d irections to nd the correct treatm ent p lane and
grad e of m ovem ent. While sustaining the pain-free accessory
m obilization, the p atient is requ ested to p erform the p revi- Figure 37.1 Longitudinal traction mobilization / manipulation from the ankle.
ou sly id enti ed p ain-restricted CSIM. The CSIM shou ld now
be signi cantly im proved – that is, increased range of m otion,
and a signi cant d ecrease in, or id eally absence of, the original
p ain. Failu re to im p rove the CSIM w ould ind icate that the
therap ist has not fou nd the correct contact p oint, treatm ent
p lane, grad e or d irection of m obilization, or spinal segm ent,
or that the techniqu e is not ind icated . The previou sly restricted
and / or p ainfu l CSIM is repeated by the patient, initially as a
trial treatm ent p rogressing u p to sets of 10, w hile the therap ist
continu es to m aintain the ap p rop riate accessory glid e. Fu rther
gains are expected w ith repetition d u ring a treatm ent session,
w hich typ ically involves three to four sets of 10 rep etitions.
Rep etition of the CSIM and p ain-free end -range load ing in the
form of passive overp ressu re appears to be critical for achiev-
ing d u rable resu lts (Miller 1999; Mu lligan 2003; H ing et al
2008). As w ith all m anu al therapy concepts, a properly stru c-
tu red su bjective and objective assessm ent of the p atient and
continu ou s re ective clinical reasoning (Jones & Rivett 2004)
are m and atory both w ithin the patient’s assessm ent and
d u ring treatm ent sessions.
The theoretical m od el of the effect of MWMs is that either Figure 37.2 Longitudinal traction mobilization / manipulation from the knee.
a p ositional fau lt of bony positional m alalignm ent and / or a
neu rom echanical d ysfu nction is corrected by the m obilization
com p onent of the p roced u res (Vicenzino et al 2011). In p lace m obilization consists of an inferior glid e of the fem u r along
of the therap ist’s p ercep tion of p assive accessory m ovem ent the joint p lane of the acetabu lu m . The therap ist shou ld allow
restriction and the concave–convex ru le, the sp eci c d irection the belt to p erform the m obilization by relaxing arm s
and grad e of m obilization are d eterm ined by the patient and hand s.
reports of p ain abolition and objective im provem ents in CSIM N ote: A second belt or treatm ent table stabilization p ost can
fu nction (Miller 2006; H ing et al 2009; Vicenzino et al 2011). be p laced in the groin and xed to the bed to stabilize the
(See Ch 31 for fu rther d etail on MWM.) p elvis. The belt can be p u t arou nd the p atient’s low er leg
above the ankle or, if the patient has knee pathology, above
the knee (Fig. 37.2).
Longitudinal traction
mobilization / manipulation Lateral distraction mobilization
The objective of this techniqu e is to increase the available The objective of this techniqu e is to increase the available
range of p assive longitu d inal cau d al glid e of the head of the range of passive lateral glid e of the head of the fem u r and to
fem u r and to red uce hip p ain. The patient lies su pine w ith the d ecrease hip pain. The patient lies su pine w ith the hip exed
hip in the resting p osition of 30° of exion, slight abd u ction to 90°, in neu tral abd u ction / ad d u ction and neutral inter-
and external rotation. The therapist is stand ing at end of bed nal / external rotation. The therap ist stand s at sid e of bed in a
in a w alk / strid e stance. The m obilization belt is loop ed over w alk / strid e stance. The m obilization belt is loop ed arou nd
shou ld ers in a ‘ gure 8’ p osition w ith hand s insid e the belt the therap ist’s hip s and insid e the p atient’s u p p er thigh w ith
loop and p laced over the ankle of the p atient (Fig. 37.1). The p ad d ing as requ ired for com fort (Fig. 37.3). The m obilization

Figure 37.3 Lateral distraction mobilization of the hip.
Figure 37.4 Lateral distraction mobilization of the hip. Lateral view showing the
detail of the hand of the therapist on the lateral aspect of the pelvis.
consists of a lateral glid e of the fem u r throu gh the m obiliza-
tion belt (Fig. 37.4).
N ote: A treatm ent table stabilization post or second belt
m ay be p laced arou nd the p elvis and xated to the bed to
stabilize the p elvis.
Flexion / adduction mobilization: mobilization
with movement internal rotation
non-weight-bearing
The objective of this techniqu e is to red uce pain and to
im prove loss of hip internal rotation. The patient is su pine
w ith hip exed to 90° and in neu tral abd u ction / ad d u ction.
The therapist stand s at sid e of bed in a w alk / strid e stance,
placing the cep halic hand on the iliac crest of the patient
insid e the belt loop for lateral xation of the pelvis (Fig. 37.5).
The m obilization consists of a lateral glid e of the fem u r
throu gh the m obilization belt. The internal hip rotation is
im parted by the cau d al hand of the therap ist (Fig. 37.6).
Joint mobilization/manipulation of the hip joint  423
Figure 37.5 Flexion / adduction mobilization. Mobilization with movement internal
rotation non-weight-bearing.
Figure 37.6 Flexion / adduction mobilization. Mobilization with movement internal
rotation non-weight-bearing – lateral view showing the detail of the contact on the
internal side of the knee of the patient.
N ote: It is im p ortant to ensu re that both m obilization and
m ovem ent com p onents are p ain free d u ring all end -range
m ovem ent. The techniqu e is held for 5–10 second s and
rep eated in sets of 10 repetitions.
Flexion / adduction mobilization: mobilization
with movement internal rotation
weight-bearing
This technique is ind icated w hen there is p ain and / or loss of
hip internal rotation and it shou ld be consid ered as a p rogres-
sion of the p reviou s one. The p atient stand s w ith the hip in
neu tral exion / extension and neu tral abd u ction / ad d u ction.
The p atient can hold the treatm ent table for safety. The thera-
p ist stand s in a w alk / strid e stance. The cep halic hand of the
therap ist is then p laced on the iliac crest for lateral xation of
the p elvis. The m obilization consists of a lateral glid e of the
 424 PART 5 • 37 •
Figure 37.7 Flexion / adduction mobilization. Mobilization with movement internal
rotation weight-bearing.
Figure 37.8 Mobilization with movement in exion. Posterior view showing the
detail of the belt position.
fem u r throu gh the m obilization belt (Fig. 37.7). The techniqu e
focuses on internal hip rotation by the patient’s rotation of the
p elvis arou nd the w eight-bearing leg.
N ote: It is im p ortant to ensu re that both m obilization and
m ovem ent com p onents are p ain free and to achieve m axim u m
end -range m ovem ent. The techniqu e is held for 5–10 second s
and rep eated in sets of 10 rep etitions.
Mobilization with movement in exion
This techniqu e is ind icated w hen there is pain and / or loss of
hip exion. The p atient lies sup ine w ith the hip exed to 90°
and in neu tral abd uction / ad d u ction. The therap ist stand s at
the sid e of bed in a w alk / strid e stance. The cep halic hand
of the therap ist is p laced on the iliac crest of the p atient insid e
the belt loop for lateral xation of the p elvis (Fig. 37.8). The
Joint mobilization and manipulation of the hip
Figure 37.9 Mobilization with movement in exion.
Figure 37.10 Mobilization with movement in extension weight-bearing.
Posterior view showing the detail of both hands of the therapist on the lateral aspect
of the pelvis.
m obilization consists of a lateral glid e of the fem u r throu gh
the m obilization belt. The exion of the hip is im p arted by the
cau d al hand of the therap ist (Fig. 37.9).
N ote: It is im p ortant to ensu re that both m obilization and
m ovem ent com p onents are p ain free and to achieve m axim u m
end -range m ovem ent. The techniqu e is held for 5–10 second s
and repeated in sets of 10 repetitions.
Mobilization with movement in extension
weight-bearing
This techniqu e is ind icated w hen there is pain and / or loss of
hip extension. The p atient is stand ing w ith contralateral hip

Figure 37.11 Mobilization with movement in extension weight-bearing. Lateral
view.
and knee exed via the foot on a chair, and in neu tral abd uc-
tion / ad d u ction. The therap ist stand s at the sid e of the p atient
in a w alk / strid e stance, w ith both hand s insid e the belt loop
xating the lateral p elvis (Fig. 37.10). The m obilization con-
sists of a lateral glid e of fem u r throu gh m obilization belt. The
extension of the hip is p erform ed via forw ard lunge of the
patient (Fig. 37.11).
N ote: It is im p ortant to ensu re that both m obilization and
m ovem ent com p onents are p ain free and to achieve m axim u m
end -range m ovem ent. In ad d ition, the patient should avoid
an extension of the lum bar sp ine d uring the techniqu e. The
techniqu e is held for 5–10 second s and repeated in sets of 10
repetitions.
References
Abbott H , Robertson M, Chapple C, et al. 2013. Manual therapy, exercise
therapy, or both, in ad d ition to usual care, for osteoarthritis of the hip or
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Altm an R, Alarcon G, Applerou th D, et al. 1991. The Am erican College of
Rheum atology criteria for the classi cation and reporting of osteoarthritis
of the hip. Arthritis Rheum 34: 505–514.
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a com pend iu m of evid ence-based inform ation and resources. Online.
Available: w w w.aaos.org/ hom e.asp.
Birrell F, Croft P, Coop er C, et al. 2000. Pred icting rad iographic hip osteoar-
thritis from range of m ovem ent. Rheum atology 40: 506–512.
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presenters in prim ary care w ith hip pain. PCR H ip Stud y Group. Rheum a-
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Cibu lka M, White D, Woehrle J, et al. 2009. H ip pain and m obility d e cits – hip
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H ard ing L, Barbe M, Shepard K, et al. 2003. Postero-antero glid e of the fem oral
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m ent: a review of the tenets and p rescription of MWMs. N Z Physiother J
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H ing WA, Bigalow R, Brem ner T. 2009. Mu lligan’s m obilisation w ith m ove-
m ent: a system atic review. J Manu al Manipu l Ther 17: E39–E66.
H oeksm a H , Dekker J, Rond ay H K, et al. 2004. Com parison of m anu al therapy
and exercise therapy of the hip: a rand om ized clinical trial. Arthritis
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Jones MA, Rivett DA. 2004. Clinical reasoning for m anu al therapists.
Ed inburgh: Butterw orth-H einem ann.
Kaltenborn FM, Evjenth O, Kaltenborn TB, et al. 2002. Manual m obilisation of
the joints: the Kaltenborn m ethod of joint exam ination and treatm ent: the
extrem ities, 6th ed n. Oslo: Olaf N orlis Bokhand el.
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Miller J. 1999. The Mu lligan concept: the next step in the evolu tion of m anu al
therapy. Canad ian Physiotherapy Association Orthopaed ic Division
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pain. J Orthop Sport Phys Ther 38: 542–555.
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 PART 5 •  The Hip Region in Lower Extremity Pain Syndromes
38
Therapeutic Exercises or the Lower Quadrant
 Chapter 
C a ro l Ke n n e d y, Le n e rd e n e Le ve s q u e
CHAP TER CONTENTS
Introduction  426
Muscle performance: activation, endurance and strength  427
Neuromotor control: balance, proprioception, movement   H e rep orted that the onset of the p ain ap p eared to be related
repatterning and functional integration  431
Mobility, myofascial and articular impairments  432
Designing an evidence-informed exercise programme  434
Mobility exercises  435
Muscle performance and neuromuscular control  
exercises  437
Exercise parameters  440
Conclusion  441
Introduction
Exercise p rescrip tion is an integral com p onent of rehabilita-
tion of low er extrem ity cond itions. Op tim al neu rom u scu lar
fu nction is m u ltifaceted and non-linear, as illu strated in
Figu re 38.1, and p rop er d evelop m ent of effective therap eu tic
exercise program m es m u st consid er all these elem ents and
their relationship s. There is a grow ing bod y of evid ence
linking these variou s com p onents and their effect on the bio-
m echanics of the low er extrem ity. As it is im p ossible to
d escribe all the p ossible exercises for the low er qu ad rant, this
chap ter w ill focu s on exercise interventions to ad d ress hip
d ysfunction related to m u scle im balance, as d em onstrated
throu gh a case-based p resentation of a ru nner w ith anterior
hip and p osterolateral thigh p ain.
First this chapter w ill explore the scienti c evid ence as it
relates to exercises that can be used to ad d ress each of the
ind ivid u al elem ents requ ired for op tim al neu rom u scu lar
fu nction. The second section w ill d em onstrate how the evi-
d ence can inform ou r exercise p rescrip tion for this particu lar
p atient, rem em bering that evid ence-inform ed p ractice also
encom passes the patient’s perspective and the clinical exper-
tise of the clinician. The read er is d irected to Chapter 23 for a
d etailed d escrip tion of lum bopelvic exercises that w ould be
incorp orated into a low er qu ad rant exercise p rogram m e, p ar-
ticu larly one focu sing on the hip .
 
Case report
A 28-year-old p hysiotherap ist presented w ith a 2-year
history of right anterior hip and posterior–lateral thigh pain.
to an increase in his training volum e for a half-m arathon at
that tim e. Running, squ atting activities and cross-cou ntry
skiing aggravated his cu rrent sym p tom s. The pain w as
alleviated w hen he d iscontinu ed the activity bu t it could
take u p to 2 d ays to resolve com p letely. H is sym ptom s w ere
lim iting his ability to ru n and his goal w as to be able to
resum e his previou s training sched ule. The patient rated his
baseline pain on a nu m erical pain rating scale (N PRS) as
3 / 10 bu t it cou ld reach as high as 8 / 10 after a 10 km ru n.
The p atient’s score on the Low er Extrem ity Fu nctional Scale
w as 60 / 80 w ith 80 representing m axim u m function (Binkley
et al 1999).
Physical examination
• Lumbar spine: N o articular restrictions w ere noted on
biom echanical evaluation and neu rological cond u ction
and neural m echanosensitivity testing w as norm al.
• Sacroiliac joint: Laslett et al (2006) clu ster of p ain
p rovocation tests w as negative for rep rod uction of his
sym p tom s.
• Hip joint: Decreased internal rotation at both 0° and 90°
of hip exion, hip exion / ad d u ction qu ad rant w as
p ositive for anterior hip pain and restriction of m otion,
exion / abd u ction / extension / external rotation (FABER)
test revealed a lim itation of range of m otion on the right
w ith a m yofascial end feel. Anterior translation of the
fem oral head w as noted w ith a straight leg raise (SLR)
m anoeu vre – p assive accessory testing revealed a red u ced
p osterolateral glid e of the fem oral head w ith a capsu lar
end feel.
• Muscle strength: H ip extensors grad e 3+ / 5, hip
abd u ctors 3+ / 5, hip external rotators 4 / 5.
• Muscle f exibility: Mod i ed Thom as test revealed
tightness of the hip exors and iliotibial band (ITB), Ober
test w as positive for d ecreased ITB length, ham string
m uscle tightness w as noted at 70° hip exion – biasing
w ith tibial m ed ial rotation revealed greater tightness of
bicep s fem oris, piriform is tightness w as noted w ith
internal rotation at both 0° and 90° hip exion.
 Muscle performance: activation, endurance and strength
Muscle activation/
endurance
Strength low load
to high load
Optimal
Balance/
neuromuscular
function
proprioception
Mobility
myofascial/articular
Motor patterning
functional integration
Figure 38.1 Optimal neuromuscular control.
Dynamic / functional assessment
Observation of the p atient’s gait revealed d ecreased hip
extension at term inal stance, an increased hip
ad d u ction / internal rotation m om ent d u ring the load ing
resp onse and a slight trunk lean to the right d u ring single
leg su p port. A p attern of ham string d om inance relative to
the glu teal m uscles w as noted d uring prone active leg
extension. Du ring the p erform ance of a single-leg squ at, a
hip ad d u ction / internal rotation m om ent w as evid ent w ith
p oor control. Du ring a step -d ow n m anoeu vre (Souza &
Pow ers 2009), the p atient revealed a contralateral p elvic
d rop and increased hip ad d u ction and internal rotation. H e
also rep orted an increase in his sym ptom s (N PRS 6 / 10)
d u ring both the single-leg squ at and the step -d ow n.
Within the clinical d ecision-m aking p rocess, the clinician
m ay consid er the follow ing qu estions to gu id e the d evelop -
m ent of an ind ivid u alized therap eu tic exercise p rogram m e.
The constru cts w ithin the bio-psychosocial fram ew ork m u st
all be consid ered and how they inter-relate: the im pairm ent
ad d ressed w ith exercise m u st be linked to an activity lim ita-
tion or p articip ation restriction, and consid eration of the
contextu al factors (p ersonal and environm ental) is key to
a su ccessfu l ou tcom e (Brod y 2012). Designing an effective
exercise program m e requ ires ‘equ al parts science and art’
(Brod y 2012).
• What is the clinical hyp othesis generated and w hat
im p airm ents need to be ad d ressed w ith exercise?
• What m u scles d o w e w ant to target initially in this
rehabilitation program m e?
• Are there certain m u scle grou p s that w ill requ ire
lengthening p roced u res and others that w ill requ ire
activation, end u rance, or strengthening?
• What is m ost im p ortant to this p atient in relation to his
activity lim itation and p articipation restrictions and how
d o w e incorp orate this into his exercises?
• H ow can the evid ence assist u s in choosing the m ost
ap p rop riate exercises for this case?
• What are the p aram eters to consid er in p rescribing the
exercises?
• H ow d o w e p rogress the exercises and incorp orate m otor
retraining and fu nctional integration into his
rehabilitation program m e?
427
Muscle Performance: Activation,
Endurance and Strength
The glu teal m u scles are im portant in stabilizing the pelvis and
controlling fem oral ad d u ction and internal rotation d u ring
functional m ovem ents. Mu scle w eakness can contribu te to
low er extrem ity d ysfunction and has been reported in patel-
lofem oral pain, iliotibial band synd rom e and chronic ankle
instability (Baker et al 2011; Barton et al 2013; Webster &
Gribble 2013; N oehern et al 2014). H ip abd uction and external
rotation w eakness can lead to knee valgus, hip ad d uction and
internal rotation creating stress on the joints in the low er
extrem ity (Pow ers 2003).
Designing exercises for the glu teal m uscles requires the
therap ist to consid er carefu lly a nu m ber of factors inclu d ing
biom echanical principles, such as plane of the m ovem ent,
p atient p ositioning, effect of gravity, length of the m om ent
arm , sp eed of the m otion, base of su p port, load , volu m e and
the typ e of m u scle contractions (Reim an et al 2012). Exercises
shou ld p rogress from less challenging to m ore challenging, to
functional integration and task speci c.
Ward et al (2010) investigated the architectu re of the glu teal
m u scles and the im p ortance of consid ering this w hen assess-
ing and targeting these m uscles. The glu teus m ed iu s m u scle
(GMed ) has a large physiological cross-sectional area and
relatively short bres and appears to be d esigned to stabilize
the hip by generating large forces over a narrow range of
lengths. It is capable of prod u cing an exceptional am ount of
force given its size. It is not d esigned to prod uce very large
forces over a w id e range of lengths or hip positions. The
glu teus m axim u s (GMax), on the other hand , has a large phys-
iological cross-sectional area and long bres – suggesting that
it is cap able of generating large forces over a w id e range. The
ham strings have the p otential to generate a m ajor p art of hip
extensor torqu e.
The GMed consists of three d istinct portions: anterior,
m id d le and p osterior, w ith sep arate innervation from the
su p erior glu teal nerve. The p rim ary role of this m u scle is to
stabilize the p elvis and control fem oral m otion d u ring w eight-
bearing activities, w ith the greatest activation d u ring the
stance p hase of gait (Gottschalk et al 1989; Gow d a et al 2014).
The phasic activity of the three parts is based on the bre
orientation. The anterior and m id d le p ortions of the m u scle
initiate hip abd u ction. Acting in isolation, the anterior portion
abd u cts, m ed ially rotates, assists w ith hip exion and is active
w hen the base of su pport is m inim al (e.g. brid ges, u nilateral
squ at, lateral step -u p ) (Boud reau et al 2009). The posterior
p ortion of the m u scle extend s, abd u cts and laterally rotates
the hip . The p osterior bres have been d escribed as the
p rim ary stabilizers of the fem oral head in the acetabu lu m
d uring w eight transfer (Gottschalk et al 1989; Gow d a et al
2014). The posterior segm ent of GMed is im portant in lunging
and ju m ping tasks (N eum ann 2010; Gow d a et al 2014). With
hip exion angles greater than 60°, there is a shift of the ante-
rior bres of GMax anterior to the hip joint axis of rotation,
tu rning it into an internal rotator; in this situ ation the p osterior
bres of GMed act w ith the d eep external rotators to p rovid e
control (N eum ann 2010; Pow ers 2010; Gow d a et al 2014).
A com m on exercise u sed in the early stages of hip abd u c-
tion strengthening is the ‘clam shell’ (Fig. 38.2). Several stud ies
 428 PART 5 • 38 • Therapeutic exercises for the lower quadrant

Figure 38.2 Clam shell. In the side-lying position with the knees f exed to 30° or
60°, the patient is instructed to raise his knee up and back while keeping the ankles
together. He is cued to ocus the motion at the hip (abduction and external rotation)
and to avoid pelvis / trunk rotation. Elastic resistance can be added to increase the
muscle demand.

have investigated the m u scle activation of GMax and GMed

Figure 38.3 Lateral side-step. In a partial squat position with an elastic band
d u ring m od i cations to this exercise. Wilcox and Bu rd en around the thighs, the patient steps to the side maintaining good alignment o the
(2013) fou nd that a neutral pelvis position optim ized recru it- knees over the toes. This can be done as single or multiple strides in one direction
m ent of both m u scles and increasing the hip exion angle and then in the opposite direction, or per ormed as strides while walking orward.
increased the activation of GMed . The tensor fascia lata (TFL)
activity w as relatively low and unaffected by these variations
to the exercise. Selkow itz et al (2013) w anted to d eterm ine
w hich exercises w ere best for activating the GMed and the
su p erior p ortion of GMax w hile m inim izing the activity of the
TFL. A com m on strategy utilized by patients w ith hip abd u c-
tor w eakness is to com p ensate w ith the TFL m u scle, w hich
contribu tes to excessive hip internal rotation. If the goal is to
activate the glu teal m uscles preferentially then these au thors
fou nd that the clam shell, lateral sid e-step (Fig. 38.3), unilat-
eral brid ge and qu ad ru ped hip extension exercises w ith either
the knee exed or extend ed all achieved this.
O’Su llivan et al (2010) evalu ated the activation of all three
su bd ivisions of GMed d u ring three w eight-bearing exercises:
the w all squ at (Fig. 38.4), the p elvic d rop (Fig. 38.5) and the
w all p ress (Fig. 38.6) and fou nd that the activation levels of
GMed varied signi cantly across each of the su bd ivisions. All
three exercises cau sed greater activation of the m id d le and
p osterior su bd ivisions than the anterior, w ith the w all press
p articu larly increasing the activation of the p osterior su bd ivi-
sion. Across all three su bd ivisions, the exercises w ere p rogres-
sively m ore d em and ing from w all squ at to p elvic d rop to w all
p ress. These au thors p roposed that the w all press exercise
tend s to cau se hip internal rotation on the w eight-bearing leg,
thu s increasing the hip external rotation force requ ired to
m aintain p elvic and hip p ostu re. Based on these resu lts, the Figure 38.4 Single-leg wall squat. Standing on the a ected leg with the back
au thors su ggest that the w all press is an effective isom etric resting against the wall with hip and knee f exed to approximately 30°, the patient
strengthening exercise for the GMed , especially the p osterior slowly lowers himsel towards the ground. He is instructed to keep his knee over
the second toe to prevent a valgus position o the knee.
su bd ivision. The w all squ at and p elvic d rop m ay be u sefu l in
the early stages of rehabilitation to im p rove end u rance, stabil-
ity and m otor control. exercises. It has been theorized that exercises requiring greater
Table 38.1 su m m arizes the results of a system atic review electrom yographic (EMG) activity (> 40% MVC) w ill resu lt in
by Reim an et al (2012) evaluating the activation of GMax and strength gains and clinicians cou ld ap p ly this inform ation
GMed m u scles, as a p ercentage of the m axim al volu ntary w hen d esigning exercise program m es. Although the m ajority
contraction (MVC) during commonly prescribed rehabilitation of the stu d ies w ere cond u cted on sam p les of healthy su bjects
 Muscle performance: activation, endurance and strength 429

Figure 38.5 Pelvic drop. Standing with the a ected leg on the edge o a step,
maintaining a slightly f exed position o both knees, the patient slowly lowers one
side o the pelvis towards the f oor and then returns the pelvis to a level position.
Figure 38.6 Wall press. Standing sideways to the wall on the a ected leg in a
single-leg stance position, the patient per orms an isometric hip abduction / external
rotation press against the wall with the una ected non-weight-bearing leg, while
maintaining proper alignment o the knee over the oot using hip external rotation o
the stance leg. The trunk is kept vertical and the pelvis level throughout the
exercise.

Table 38.1 Activa tion le ve ls of glute us me dius a nd glute us ma ximus during various the ra peutic e xe rcis e s
Low-le ve l a ctiva tion Mod e ra te -le ve l a ctiva tion Hig h-le ve l a ctiva tion Ve ry-hig h-le ve l
(0–20% MVC) (21–40% MVC) (41–60% MVC) a ctiva tion (> 60%
MVC)

Gluteus Prone bridge plank (27%) Lateral step-up (41%) Single-limb squat (64%)
medius Bridging on stable sur ace (28%) Quadruped with contralateral Side bridge to neutral
arm and leg li t (42%) s pine position (74%)
Lunge – neutral trunk position (34%) Forward s tep-up (44%)
Unilateral mini-squat (36%) Unilateral bridge (47%)
Retro s tep-up (37%) Transvers e lunge (48%)
Clam s hell at 60° (38%) Wall squat (52%)
Clam s hell at 30° (40%) Side-lying hip abduction (56%)
Sideways lunge (39%) Pelvic drop (57%)
Single-limb deadli t (58%)
Gluteus Prone bridge / plank (9%) Side-lying hip abduction (21%) Sideways lunge (41%) Forward step-up (74%)
maximus Lunge with backward Lunge with orward trunk lean (22%) Lateral step-up (41%)
trunk lean (12%)
Bridging on a Swiss ball Bridging on a s table s ur ace (25%) Trans verse lunge (49%)
(20%)
Clam s hell with 30° hip f exion Quadruped with contralateral
(34%) arm / leg li t (56%)
Lunge neutral trunk pos ition (36%) Unilateral mini-s quat (57%)
Clam shell with 60 0 hip f exion Retro step-up (59%)
(39%)
Unilateral bridge (40%) Wall squat (59%)
Single-limb s quat (59%)
Single-limb dead-li t (59%)
(From Reiman et al 2012.)
 430 PART 5 •
Figure 38.7 Prone heel squeeze. In prone lying with the hips slightly abducted
and externally rotated, knees f exed to 45°–90° and heels touching, the patient
presses the heels together. Slight hip extension can be added by raising the thighs
o the table.
and the resu lts m ay d iffer in people w ith m u scu loskeletal
d isord ers, the know led ge of m uscle activation d uring various
exercises contribu tes to u nd erstand ing neurom u scu lar control
and is valuable inform ation to consid er w hen d evelop ing
exercise program m es for ind ivid u al p atients.
Gip hart et al (2012), u sing EMG, record ed the activation of
p ectineu s and piriform is m u scles d uring hip rehabilitation
exercises in a grou p of 10 healthy volunteers. They found the
highest activation of p ectineu s m u scle w as w ith su p ine active
hip exion (62.8% MVC concentrically, 55.4% eccentrically).
Mod erate to low activation w as also record ed d u ring both hip
internal and external rotation. The single- and d ou ble-legged
brid ge exercises, w hich requ ire static rotation stabilization in
a neu trally p ositioned hip and incorporate w eight-bearing,
m od erately activated the p ectineu s m u scle. These au thors
p rop ose that, fu nctionally, p ectineus is activated as a stabiliz-
ing m u scle for rotational control of the hip in activities involv-
ing even slight w eight-bearing. Based on their observations,
the p ectineu s m u scle p robably stabilizes the hip in d ynam ic
activities requ iring p ivoting m ovem ents and exp losive accel-
erations (e.g. sprinting). H igh piriform is m uscle activation
w as observed d uring resisted hip extension exercise, single-
legged brid ge, p rone heel squ eeze (Fig. 38.7) and sid e-lying
abd u ction in external rotation, all of w hich requ ire hip exten-
sion. They su ggest that the m ost likely function of p iriform is
is as an external rotation stabilizer p reventing internal rota-
tion w ith the hip in a neu tral-to-extend ed p osition. This
w ou ld translate to activities su ch as ju mp ing, skating strid e
or the toe-off p hase of ru nning, w hich requ ire the m u scle to
p rod u ce a d egree of external rotation to control hip internal
rotation. Weakness of the p iriform is cou ld potentially resu lt
in increased valgu s forces on the knee ow ing to the lack of
stabilization need ed to m aintain hip external rotation. It
w ou ld appear therefore that both of these d eep hip m u scles
have an im p ortant role in hip stability in activities of d aily
living and sp orting activities.
Com p rehensive rehabilitation p rogramm es shou ld inclu d e
both concentric and eccentric training, and clinicians shou ld
have an aw areness of how to d esign exercises to have a greater
eccentric em phasis and consid er how eccentric exercise
38 • Therapeutic exercises for the lower quadrant
Figure 38.8 Eccentric lowers (Nordic hamstring). Starting in a kneeling position
with the eet xed, the patient alls orward using the hamstrings to control the
descent and then catches himsel with the hands. Initially assistance can be
provided with an elastic band.
shou ld be p art of a system atic ap p roach to p ost-inju ry retrain-
ing (Lorenz & Reim an 2011). Althou gh not d irectly app licable
to the case p resented above, there is evid ence in the literatu re
for the u se of eccentric exercise for the rehabilitation of low er
extrem ity d ysfu nctions, m ostly relating to rehabilitation after
ham string inju ries or Achilles tend inop athy (Lorenz & Reim an
2011). (Read ers are also referred to other chapters for exercises
ap plied to particu lar d isord ers of the low er extrem ity.)
Several au thors have p rop osed rehabilitation strategies to
regain ham string function, bu t m ost are related to recovery
from m u scle strain inju ries (Com fort et al 2009; H eid erscheit
et al 2010; Lorenz & Reim an 2011). H eid erscheit et al (2010)
su ggest that early rehabilitation consists of isom etrics of the
lum bopelvic m u sculatu re, single-lim b balance exercises and
short-strid e frontal p lane step p ing d rills w hile avoid ing
heavier isolated resistance training of the inju red ham string
m u scle. H am string-sp eci c strengthening exercises can be
im p lem ented in non-w eight-bearing and open kinetic chain,
p ain free and w ith intensity p rogressing from light to m od er-
ate as tolerated . Exercises w ould progress to low -velocity
eccentric activities at low to m id d le ranges su ch as stiff leg
d ead lifts, w alking lu nges, eccentric ham string low ers (also
referred to as N ord ic ham string exercise) and split squ ats.
Lorenz and Reim an (2011) recom m end p erform ing the eccen-
tric low ers initially w ith elastic-band assistance (Fig. 38.8),
as the elasticity of the band can assist in both the concentric
and eccentric portions of the exercise. Finally, sp ort-speci c
exercises involving qu ick d irection changes, functional m ove-
m ent p atterns, p lyom etrics and eccentric exercises p rogress-
ing to end range are ad d ed to com plete the rehab. When
consid ering intensity of ham string m u scle activity, McAllister
et al (2014) fou nd that, w hen com p aring fou r exercises inclu d -
ing the glute-ham raise, good m orning, Rom an d ead lift and
 Neuromotor control: balance, proprioception, movement repatterning and functional integration
Figure 38.9 Treadmill running. Verbal and visual cues can be utilized as the
patient runs on a treadmill with mirror eedback. This can improve trans erence o
improvement in impairments to unctional goals.
p rone leg cu rl exercises, the concentric activity w as highest
d u ring the glute-ham raise and eccentric d uring the Rom an
d ead lift.
Neuromotor Control: Balance,
Proprioception, Movement
Repatterning and Functional
Integration
Willy and Davis (2011) cond u cted a rand om ized controlled
trial to investigate w hether a strengthening and m ovem ent
ed u cation p rogram m e targeting the hip abd uctor and external
rotator m u scles altered hip m echanics d uring running and
d u ring a single-leg squat in a group of healthy fem ales. They
fou nd im p rovem ent in the single-leg squat m echanics, but the
training p rogram m e d id not alter the abnorm al hip m echanics
d u ring ru nning. These au thors therefore su ggested that clini-
cians shou ld consid er incorp orating activity-sp eci c neu ro-
m u scu lar training into therap eu tic p rogram m es.
Willy et al (2012) evalu ated a sim p le gait retraining tech-
niqu e u sing visu al and verbal feed back in a grou p of fem ale
ru nners w ith p atellofem oral p ain and abnorm al hip m echan-
ics. The gait retraining consisted of p rovid ing visual feed back
w ith a full-length m irror p laced in front of the tread m ill w hile
ru nning and verbal cu eing – that is, ‘ru n w ith you r knees
apart and you r knee caps pointing straight ahead ’ and
‘squ eeze your bu ttocks’ (Fig. 38.9). These au thors found that
the training w as effective in im p roving m echanics d u ring
ru nning and m easu res of p ain and fu nction. They also noted
that the skill transferred to u ntrained tasks (i.e. squ atting and
431
Figure 38.10 Star excursion balance exercise. In a partial single-leg squat, the
patient is instructed to reach as ar as possible with the contralateral limb in various
directions ( orward, orward diagonal, lateral, backward and backward diagonal).
step d escent) and p ostu lated that a higher level of m otor
learning had occu rred .
Dynam ic postu ral control is essential for return to fu nction
and sport after a low er extrem ity m u scu loskeletal inju ry / d ys-
function. Unilateral w eight-bearing exercises are often used
to train d ynam ic p ostu ral control and p rop riocep tion. Proxi-
m al stability of the lu m bop elvic region is requ ired for coord i-
nated m ovem ent in the low er extrem ity. The star excu rsion
balance test (SEBT) is a test of d ynam ic postural control in
w hich the ind ivid ual balances on one leg w hile reaching w ith
the other in eight d ifferent d irections (Kinzey & Arm strong
1998; H ertel et al 2000). The SEBT is a usefu l tool for training
d ynam ic balance and prop rioception (Fig. 38.10). N eurom us-
cu lar control d u ring the test is re ected by the d istance
reached in each d irection, w ith an increase in the d istance
ind icating greater neurom u scular control had been achieved .
N orris and Tru d elle-Jackson (2011) investigated activation of
the p roxim al m u scu latu re (i.e. GMed , GMax, vastu s m ed ialis
(VM) ) d u ring the eccentric phase of the low er extrem ity
reaching in the anterior, m ed ial and posterom ed ial d irections
of the SEBT. They fou nd the level of GMed m u scle recru it-
m ent to be greater in the anterior and m ed ial d irections (38%
MVC and 48% MVC) and su ggested that, w hen p rescribing
the SEBT as an exercise to ad d ress GMed sp eci cally, the
p osterior–m ed ial d irection m ay be m ore app rop riate d u ring
the early stages, p rogressing to the anterior d irection and
then, as m otor control im p roves, the m ed ial d irection m ay be
ad d ed as a strengthening stim u lu s. In their stu d y, the GMax
EMG am plitu d e w as below the 40–60% threshold in all three
d irections, suggesting that the SEBT m ay not be an appropri-
ate strengthening exercise for GMax; how ever, it m ay be u sed
to p rom ote m u scle end u rance in the early p hases of rehabilita-
tion before p rogressing to exercises requ iring higher level of
 432 PART 5 • 38 •
m u scle activity. The VM am plitu d es w ere above the 40–60%
threshold su ggesting that the three d irections w ere equ ally
effective for VM strengthening and , given the high level of
recruitm ent, m ay be m ore appropriate in the later stages of
rehabilitation for that m u scle.
Altered frontal plane hip and knee m echanics m ay contrib-
u te to the aetiology of m any com m on ru nning inju ries su ch
as p atellofem oral p ain, tibial stress fractu res and iliotibial
band synd rom e. Wou ters et al (2012) hypothesized that hip
m u scle strengthening alone m ay not be su f cient to red u ce
hip or knee frontal p lane m otion and p eak m om ents d u ring
the stance p hase of ru nning. These au thors p ostu lated that
rehabilitation program m es should em phasize neu rom uscu lar
control elem ents, su ch as gu id ed p ractice of m ovem ent p er-
form ance and visu al, verbal and tactile feed back, rather than
hip strengthening alone. In their qu asi-exp erim ental d esign
stud y, su bjects p articip ated in a 4-w eek m ovem ent-training
p rogram m e u sing visu al feed back (use of a m irror) and
w eekly instru ction inclu d ing cu es such as keeping the knee
in line w ith the hip and foot in the frontal p lane, the p elvis
p arallel w ith the oor, increasing hip exion to avoid anterior
m otion of the knee beyond the foot d u ring the squ at exercise
and m aintaining a neu tral lu m bar sp ine. Manu al facilitation
techniqu es su ch as tap p ing over the glu teal m u scles or
tactile feed back to the lateral knee to p rom ote hip abd u ction
w ere also u sed . The exercise progression utilized in their
neu rom otor-retraining p rogram m e is ou tlined in Table 38.2.
At the end of the 4-w eek training p rogram m e, p articip ants
d isplayed red u ced frontal plane hip and knee joints m echan-
ics that m ay p otentially contribu te to and exacerbate ru nning
related inju ries. These resu lts supp ort the concept that strate-
gies to correct low er extrem ity alignm ent and m otor pattern-
ing in fu nctional m ovem ents are a cru cial com p onent in
exercise program m es, in ad d ition to strengthening.
Moresid e and McGill (2012a) analysed the transference of
increased p assive hip range of m otion (throu gh stretching),
m otor control (throu gh hip –spine d issociation exercises) and
core end u rance to fu nctional m ovem ent in a cohort of 24
young healthy m ales w ith lim ited hip m obility. The d ynam ic
activities that w ere analysed includ ed active hip extension,
lu nge, a stand ing tw ist / reach m anoeu vre and exercising on
Table 38.2 Ne uromotor re training programme
Exe rcis e s Volume (s e ts /
re p s )
Week 1 Wall s quat 3 / 10
Forward lunge 3 / 10
Lateral s tep down (4” / 10 cm) 3 / 10
Single leg s tance with ball toss 3 / 30 s hold
Week 2 Lateral s tep-down (7” / 18 cm) 3 / 10
Forward step-up (7” / 18 cm) 3 / 10
Single-leg dead-li t 3 / 10
Lateral s hu f es with band 3 / 40 eet (12 m)
Week 3–4 Forward step-down (7” / 18 cm) 3 / 10
Balance lunge 3 / 10
Single-leg multidirectional reach 3/5
Single-leg squat with band 3 / 10
(As per Wouters et al 2012.)
Therapeutic exercises for the lower quadrant
an elliptical trainer. They found that, althou gh both exibility
and end u rance im proved over a 6-w eek intervention, there
w as m inim al evid ence that these changes transferred to fu nc-
tional m ovem ent p atterns. The nd ings su ggest that exercise
p rogram m es m ay requ ire sim u ltaneou s m ovem ent rep attern-
ing and practising the d esired m ovem ent patterning to ensure
that the increased m obility and strength / end u rance are
incorp orated into fu nctional m ovem ent patterns.
Mobility, Myofascial and Articular
Impairments
It is d if cult to obtain optim al function of the low er quad rant
w ithou t ad equ ate m obility, w hich can be red u ced by a num ber
of factors – inclu d ing articu lar restriction and m yofascial
extensibility (length), as w ell as neu rom eningeal m obility. A
variety of m anu al therap y techniqu es can be u tilized to regain
articu lar m obility in the low er qu ad rant at the hip. It is then
im p ortant to augm ent or m aintain the gains achieved by uti-
lizing joint m obility exercises. There is an absence of research
regard ing these types of hip exercises to gu id e that portion of
the exercise d esign.
As suggested by Jand a (1987), the follow ing m u scles tend
to tighten arou nd the hip : the hip exors, hip ad d u ctors, ham -
strings, d eep hip external rotators and TFL / ITB; these shou ld
therefore be consid ered and ad d ressed as requ ired .
A system atic review by O’Su llivan et al (2012) conclu d ed
that there is consistent, strong evid ence that eccentric training
can im p rove low er extrem ity exibility. This w as tru e for the
ham strings, qu ad riceps and gastrocnem iu s–soleu s m uscu la-
tu re exibility. Althou gh eccentric training resu lted in signi -
cant im p rovem ent in exibility com p ared w ith controls, the
one stu d y that com p ared eccentric exercise w ith static stretch-
ing fou nd sim ilar gains in range of m otion w ith either
ap proach. One stu d y w ithin the review (N elson & Band y
2004) incorporated a static stretch at the end of range w ithin
low -load eccentric training and found this resu lted in higher
range gains than those found in other stu d ies that utilized
eccentric training alone. When com paring the effect of eccen-
tric versu s concentric exercises on m u scle exibility, tw o of
the stu d ies rep orted in the O’Su llivan et al (2012) review had
d ifferent resu lts – one favou ring the eccentric m od e and the
other nd ing no d ifference. An ad d itional rand om ized con-
trolled trial cond u cted by Patel and Yad av (2013) reached the
conclu sion that, althou gh both static stretching and eccentric
exercise signi cantly im p roved ham string exibility, static
stretching w as statistically m ore effective. At this p oint in
tim e, althou gh it is im p ossible to say w hether eccentric exer-
cise training is as effective as static stretching in im p roving
exibility, as eccentric exercise also enhances other perform -
ance variables it shou ld be consid ered an im portant com p o-
nent in a low er extrem ity exercise p rogram m e.
There are m any d ifferent exercises d esigned to increase the
length of the ham string m u scles. A system atic review by
Decoster et al (2005) conclu d ed that evid ence su p p orts the u se
of ham string stretching for increasing exibility, w ith a variety
of stretching techniqu es, p ositions and d u rations. Ayala et al
(2013) also found that im provem ent in ham string length
occu rred w ith stretching in both those w ith norm al (> 80°) and
those w ith lim ited ham string length (< 80°). Several of the
 Mobility, myofascial and articular impairments 433

p aram eters (i.e. position, m od e, d osage) of various exercises

have been investigated , w ith varying resu lts. Althou gh there
d o appear to be som e consistent nd ings that m ight guid e ou r
choice of exercise, the sp eci c p atient p resentation shou ld be
consid ered d u ring the clinical-reasoning p rocess to d eterm ine
w hich exercise w ould be op tim al for that p articu lar patient.
Several stu d ies have com p ared d ifferent typ es of ham -
string stretching exercises: p assive, active, static, d ynam ic
and p rop riocep tive neu rom u scular facilitation (PN F) / m uscle
energy techniques (MET). In a group of asym ptom atic ind i-
vid u als, Fasen et al (2009) fou nd that, at 4 w eeks, active-
stretching m ethod s w ere signi cantly su p erior to p assive,
bu t this d ifference reversed at the 8-w eek point, at w hich the
p assive SLR stretch exercise resu lted in the greatest im p rove-
m ent in ham string length. Davis et al (2005) found static
stretching to be su perior at 4 w eeks. Pu ented u ra et al (2011)
fou nd that, althou gh there w as an im m ed iate increase in Figure 38.11 90 / 90 active hamstring muscle stretch. In supine the patient
ham string length follow ing both static and active (PN F) stabilizes the upper leg with his hands holding the hip at 90°. He then actively
stretching, there w as no d ifference betw een the tw o grou p s. straightens the knee until a stretch discom ort is elt in the hamstrings muscles.
Covert et al (2010) reported that both ballistic and static
stretching increased ham string length com p ared w ith con-
trols, bu t the static grou p m ad e signi cantly m ore gains.
Becau se of these inconsistent resu lts across stu d ies, there is
no clear ind ication as to w hich typ e of ham string stretch is
su p erior, althou gh a static version seem s to be p referred .
Su bjects d id rep ort that the active exercises w ere m ore engag-
ing than passive exercises, w hich cou ld be a factor in ad her-
ence (Fasen et al 2009).
There d oes not ap p ear to be a clinically signi cant d iffer-
ence betw een a contract–relax exercise as com p ared w ith a
reciprocal inhibition techniqu e used d uring an MET / PN F
stretching exercise (Youd as et al 2010). The d uration of the
p assive stretch com p onent (30 second s versu s 3 second s) has
no signi cant im p act on the ef cacy of MET / PN F for short-
term increases in ham string extensibility (Sm ith & Fryer
2008). Also, ham string stretches appear to be equally effective
regard less of the position: su pine, sitting or stand ing (Decoster
et al 2005; Borm an et al 2011). Sairyo et al (2013), in a p ilot
stu d y, fou nd the stand ing jackknife ham string stretch exercise
to be effective for increasing ham string length. Fasen et al
(2009) com pared variou s su p ine exercises and found that a
p assive straight leg stretch w ith the leg su pported u p the w all
w as su p erior to a 90 / 90 p assive stretch w ith a strap ; the
active 90 / 90 stretch (Fig. 38.11) w as superior to the passive
90 / 90 stretch, bu t not as effective in the longer term as the Figure 38.12 Hamstring muscle wall stretch. At a corner or through a door,
p assive straight leg stretch u p the w all (Fig. 38.12). the patient lies with the tight leg up the wall in a straight leg position to achieve
Su bjects u sing an ‘aw areness throu gh m ovem ent’ exercise, a passive stretch. The stretch can be increased by bringing the hips closer to
the wall.
consisting of controlled lengthening m ovem ents w ith no end -
range stretch or hold , increased ham string exibility com -
p ared w ith controls (Step hens et al 2006). Ballantyne et al Chapter 65 for m ore d etailed inform ation regard ing neu rod y-
(2003) fou nd that, although there w as a signi cant increase in nam ics in the low er qu ad rant.)
range to the p oint of d iscom fort follow ing a MET stretch, d e Weijer et al (2003) fou nd that the ad d ition of a w arm -u p
there w as no change in range w hen an id entical force w as exercise prior to stretching d id not signi cantly increase the
u sed to retest the exibility. They conclu d ed that the d iffer- effectiveness of static ham string stretching. O’Su llivan et al
ences in range fou nd post stretch m ay be m ore related to an (2009) fou nd that, althou gh an active aerobic w arm -u p signi -
increase in stretch sensation tolerance than to any biom e- cantly increased ham string exibility, the su bsequ ent ad d ition
chanical or viscoelastic change in the m u scle. of static stretching fu rther increased exibility, w hereas
Incorporating a sciatic nerve ‘slid er ’ exercise in ad d ition to d ynam ic stretching red u ced ham string exibility. Their con-
either usual ham string stretching and w arm -u p or sustained clu sion w as that if the aim w as to increase ham string length
ham string stretching m ay resu lt in greater increase in low er then static stretching shou ld be em p loyed . Fu rther, a recent
qu ad rant exibility (Fasen et al 2009; Mend ez-Sanchez et al stu d y fou nd that d ynam ic ham string stretching p re-activity
2010; Castellote-Caballero et al 2013). (Read ers are d irected to red u ced concentric and eccentric ham string strength; this
 434 PART 5 •
Figure 38.13 Standing iliotibial band stretch. The a ected leg is extended and
adducted behind the standing leg and then the patient reaches overhead side-
f exing away rom the sti side.
su ggests that clinicians need to be cau tiou s w hen recom -
m end ing d ynam ic rather than static stretching so as to p revent
this p ost-stretch loss of m u scle force (Costa et al 2014).
A stretch of the ITB can be achieved u sing either the exed
or the extend ed knee in Ober ’s sid e-lying p osition, w ith con-
icting reports as to w hich position is m ore effective. Wang
et al (2006) fou nd that either p osition resu lted in a sim ilar
stretch w hen the leg w as d rop p ed p assively into ad d u ction,
bu t if a w eight w as ad d ed then the extend ed knee p osition
resu lted in m ore stretch. Conversely, Gajd osik et al (2003)
fou nd there w as less range of ad d uction in the bent knee p osi-
tion com p ared w ith the extend ed p osition, w hich su ggests
that a stretch of the ITB w ou ld be am p li ed in the exed
p osition. Fred ericson et al (2002) com p ared three stand ing
stretches and fou nd op tim al ITB lengthening occu rred w hen
an overhead arm stretch w as ad d ed to the trad itional stand ing
stretch of sid e-bend ing aw ay w ith the tight leg extend ed and
ad d u cted behind the stand ing leg (Fig. 38.13).
The p iriform is m u scle is generally regard ed as an external
rotator of the hip, bu t it also acts as a hip abd uctor. As su ch,
exion / ad d u ction / internal rotation of the hip w ou ld be
consid ered the p osition of stretch for the p iriform is (H ulbert
& Deyle 2009; Fishm an et al 2002). In contrast to this, Gu lled ge
et al (2014) com bined hip exion, ad d u ction and external
rotation in their investigation into the optim al stretching pro-
tocol for the piriform is. They found that, at 90° hip exion,
p iriform is elongation is sim ilar (ap proxim ately 12%) regard -
less of the ord er of sequ ence of ad d ing the tw o other m ove-
m ents (external rotation or ad d u ction) to the stretch. We can
infer from this that either of these stretches w ou ld be equ ally
effective, and the choice of stretch w ould be best d eterm ined
by the position w ith the strongest stretch sensation bu t also
the m ost com fort. Throu gh com p u ter m od elling these au thors
also d eterm ined that increasing the hip exion com ponent to
38 • Therapeutic exercises for the lower quadrant
115° or to 120° elongates the p iriform is m u scle by ap p roxi-
m ately 15%, and so m oving fu rther into hip exion could
op tim ize the stretch as long as this d oes not cau se sym p tom s
of im p ingem ent.
Wright and Drysd ale (2008) fou nd that both contract–relax
and reciprocal inhibition MET / PN F stretch techniqu es in
p rone resu lted in signi cant increase in p iriform is length, as
m easu red by p rone hip internal rotation range, bu t there w as
no d ifference betw een the tw o typ es of contraction u sed .
Winters et al (2004) found that a passive stretch exercise
(lu nge and propped prone hip extension) w as equ ally effec-
tive as an active exercise (p rone active hip extension w ith knee
exed and knee extend ed ) in lengthening tight hip exors in
su bjects w ith low back p ain or low er extrem ity inju ries.
God ges et al (1989) found that three sets of a 2-m inute static
stretch of the hip exors resu lted in increased hip extension
as w ell as im provem ent in gait (w alking and running)
econom y as m easu red by subm axim al oxygen consu m ption.
Moresid e and McGill (2012b) proposed that stretching
w ould be m ore effective in regaining hip m obility if the ad ja-
cent stru ctu res w ere incorp orated into the stretch to tension
the involved m yofascial connections m axim ally, and that
tru nk stability m ight also in u ence exibility of the low er
extrem ity. They analysed the effect of three d ifferent exercise
interventions: (1) stretching, (2) stretching w ith m otor control
exercises and (3) core end u rance w ith m otor control exercises
(no stretching), versus a control grou p on passive hip range
of m otion, sp eci cally extension and rotation. The stretching
com p onent inclu d ed trad itional exercises as w ell as w hole-
bod y m yofascial lengthening, w ith an overhead arm position
and tru nk rotation ad d ed to optim ize lengthening of ad jacent
tissu es (Fig. 38.14). They also inclu d ed a com bination of static
(30-second hold ) and ballistic stretches. The m otor control
exercises focu sed on im p roving hip–spine d issociation,
w hereas the core end u rance program m e focused on tru nk
m u scle activation. H ip extension and rotation m obility w ere
d ram atically im p roved in both grou ps 1 and 2, bu t the ad d i-
tion of the m otor control exercises d id not resu lt in greater
exibility. A m od erate increase in hip rotation range of m otion
w as also noted in the grou p receiving core end urance and
m otor control exercises w ith no active stretching. As su g-
gested by the au thors, this highlights the role of inclu d ing
core stabilization in rehabilitation p rogram m es for the low er
extrem ity (see Ch 23).
Designing an Evidence-informed
Exercise Programme
Consid ering both the su bjective and objective d ata, ou r initial
hyp othesis is that the p atient in the exam p le Case Rep ort
d em onstrated m obility and m u scle p erform ance im pairm ents
sp eci c to the hip region. H e p resented w ith restricted hip
joint m obility, d ecreased length of the ITB, ham string and
p iriform is, w eakness of the hip extensors, abd u ctors and
external rotators and an inability to control the hip and pelvis
d u ring fu nctional m ovem ents of the low er extrem ity. Poor
neu rom u scu lar control and abnorm al m ovem ent p atterning
contribu ted to the fau lty low er lim b m echanics d u ring fu nc-
tional tasks (squ at, step -d ow ns). The p atient’s goal w as to be
able to return to ru nning w ith m inim al pain. Exercises
 Designing an evidence-informed exercise programme 435

increasing m obility of the hip joint, ad d ressing the m u scle
im balance (length and strength) around the hip, and correct-
ing abnorm al m ovem ent patterning of the low er extrem ity
w ou ld therefore be the focus of the program m e. Balance, pro-
priocep tion, m ovem ent repatterning and fu nctional integra-
tion exercises are critical to ensu re transference of the
im provem ent in ind ivid u al im p airm ents into fu nctional activ-
ities, sp eci cally the goal of running.
Figure 38.14 Hip myofascial stretch. In standing the patient places the oot onto
a bench placing the hip in a FABER stretch position. An extended myo ascial stretch
o adjacent tissues is obtained by adding the ipsilateral overhead reach as well as
incorporating trunk rotation and / or side-f exion.
The exercise p rogression m od el proposed by Brod y (2012)
and m od i ed in Figu re 38.15 p rovid es a conceptual fram e-
w ork of the variables to consid er in exercise program m e
d esign.
Mobility exercises
As is often seen clinically, the cause of red u ced joint m otion
can be m u ltifactorial. The restriction of hip m obility that this
p atient p resents w ith m ay be related to articu lar hyp om obility
as ind icated by the early capsu lar end feel w ith a p osterola-
teral glid e. It m ay also be a re ection of m u scle im balance, the
lack of extensibility fou nd on length testing as w ell as the
w eakness of the glu teal m u scles and p oor m otor control.
Ad d ressing these im pairm ents cou ld potentially resolve hip
hyp om obility. In d esigning the therap eu tic exercise p ro-
gram m e, clinical reasoning m u st be u sed to d eterm ine w hen
it w ou ld be m ost ap propriate to ad d m obility exercises. In this
case, a focu s on the im p airm ents of m u scle p erform ance and
m otor control w ou ld be a p riority and m ay actu ally d ecrease
the d om inance of som e of the tight m u scle grou p s. Reassess-
m ent of length testing m ay w ell d em onstrate norm al m u scle
extensibility and , at that point, stretching exercises for m u scles
that continu e to test short can be ad d ed .
In this p articu lar case, the hip joint m obility restriction w ill
have also been ad d ressed w ith m anu al therap y to restore the
p osterolateral glid e, and hom e exercises can then be given to
m aintain the range that has been gained w ith m anu al therap y.
The qu ad ru ped sit-back exercise can be u sed to m obilize the
hip , controlling lu m bop elvic neu tral and rocking back into
hip exion only as far as is p ain free (Sahrm ann 2002). This
exercise encourages hip exion, stretches the p osterior hip
m u scu latu re and encou rages p osterior glid e of the fem oral
head , all issu es that need to be ad d ressed w ith this case. It
also encourages a d issociation p attern betw een the hip and
the lu m bop elvic u nit. If the p atient nd s it d if cu lt to gain

Activity/
participation goal
Running

Exercise challenges
Increase difficulty Increase repetitions
Sport-specific tasks Change muscle contraction type Add more sets
Change the exercise speed Increase the frequency
Functional Change the exercise mode Continually
integration Alter base of support expand the
motor Add unstable surfaces/perturbations exercise Figure 38.15 Exercise progression
patterning Reduce visual and verbal feedback volume model. (Modi ed rom Brody 2012.)
Alter the environment Add more exercises
Complex tasks
Alter the exercise sequence Increase the resistance
Dissociation activities
Vary the start and end position Decrease the rest interval
Reduce cognitive control/add distraction

Contextual
factors
Environmental
Personal
 436 PART 5 • 38 • Therapeutic exercises for the lower quadrant
Figure 38.16 Quadruped sit-back exercise. In the quadruped position the patient
adopts a neutral spine posture and maintains this throughout the exercise. Focusing
on hip joint motion, the patient then sits back into hip f exion as ar as he can
without losing the neutral spine posture or experiencing any impingement at the
anterior hip. A strap or heavy elastic band can be used to produce a lateral
distraction to decrease impingement.
range of m otion w ithou t prod u cing anterior im pingem ent, a
Mu lligan m obilization w ith m ovem ent (MWM) techniqu e can
be m od i ed to use as a hom e exercise (Mulligan 2004). A strap
or heavy elastic band can be anchored on a p ost, loop ed
around the right u pp er thigh as close to the groin as is com -
fortable and then u sed to apply either a lateral or p osterior
glid e, w hile the subject m oves into hip exion in either quad -
ru p ed or stand ing (Fig. 38.16). The patient is cautioned that
there shou ld be no rep rod u ction of the anterior hip p ain as he
rocks back into exion. One to three sets of 10 repetitions
shou ld be d one d aily (H ing et al 2008). (Read ers are referred
to Ch 37 for m ore m anu al therap ies targeted to restore range
of m otion of the hip .)
In m any cases there m ay be an overlap betw een exercises
p rescribed to increase joint range and those that stretch
m u scle. As there is often better ad herence to exercise p ro-
gram m es w hen there are a lim ited num ber of exercises, it
w ou ld be pru d ent to attem pt to achieve both goals sim u ltane-
ou sly (Med ina-Mirap eix et al 2009). Lying prone w ith knees
exed to 90° and d ropp ing the feet out to obtain end -range
hip internal rotation is an exercise that w ill lengthen the artic-
u lar cap su le as w ell as obtain a stretch of p iriform is and the
other d eep hip external rotators. This w ill also avoid the
exion–ad d uction position that is often used as a piriform is
stretch as this p osition rep rod u ced the anterior hip p ain in
this p atient. Once the anterior im p ingem ent p ain eases, the
p iriform is stretch can be progressed by m oving into exion
in su p ine. As a sim ilar intensity of stretch w as fou nd if exter-
nal rotation w as ad d ed p rior to ad d u ction, this m ight be the
best sequence to m inim ize reprod u ction of pain (Gu lled ge
et al 2014). A ‘ gu re 4’ position can be used to perform this
stretch (Fig. 38.17). At a later point, it m ay be bene cial to
inclu d e an internal rotation com p onent via a cross-knees-to-
chest or single-leg com bined exion / internal rotation / ad d u c-
tion stretch to ensu re all p ortions of the d eep lateral rotators
along w ith p ortions of the glu teal m uscles are lengthened .
The research has su ggested that a PN F or active ham string
stretch m ay be m ore bene cial in the short term . Consid ering
Figure 38.17 Figure 4 stretch. In supine the patient places the ankle o the
a ected side on the opposite knee and drops the a ected leg into external rotation
without allowing the pelvis to tilt. He then pulls the non-a ected leg up towards the
chest to produce the stretch.
this, our p atient cou ld start w ith the 90 / 90 active knee exten-
sion exercise (see Fig. 38.11) and then inclu d e the passive SLR
stretch u p the w all (see Fig. 38.12), w hich has show n better
long-term results (Davis et al 2005; Fasen et al 2009). Ad d ing
tibial m ed ial rotation p rior to knee extension m ay bias the
stretch to the lateral ham string, as w as fou nd on initial assess-
m ent. As there ap p ears to be no su p erior p osition in w hich to
stretch the ham string, he w ou ld also bene t from instru ction
on the correct form of a stand ing stretch to u se p re- and p ost-
ru nning (Decoster et al 2005; Borm an et al 2011). The p atient
shou ld also be ed u cated that aggressive stretching p re-activity
m ay negatively im p act his p erform ance; how ever, gentle
stretching of 1–3 repetitions of a 30-second hold w ou ld be
accep table (Johnson et al 2014).
A FABER p osition stretch cou ld be given in either su p ine
or sitting p osition w ith the back against the w all, and the
knees can be pushed d ow n passively to increase the stretch.
This is best perform ed bilaterally to p revent pelvic torsion. In
su p ine or stand ing, ad d itional stretch m ay be obtained by
sim u ltaneou sly elevating the right arm overhead and incor-
porating trunk rotation to exp and the m yofascial lengthening
throu gh ad jacent stru ctu res (Moresid e & McGill 2012b) (see
Fig. 38.14).
The TFL / ITB can be stretched in sid e-lying, bu t the clini-
cian shou ld ensu re verbal cu eing is given to avoid com p ensa-
tory m otions throu gh the lu m bop elvic region. The p ressu re
biofeed back u nit can facilitate prop er control, and this could
be utilized to assist w ith this training in the clinic. Either the
bent or extend ed knee p osition m ight be u sed , d ep end ing on
w hich achieved the best stretch sensation. This p osition m ay
be d if cu lt to control, how ever, and a stand ing stretch m ay
be preferred and also m ore easily p erform ed pre- and post-
ru nning. The m ost effective stretch in stand ing has been
show n to be the ad d ition of a right-arm overhead stretch into
sid e- exion w ith the right leg back and crossed behind the
left (see Fig 38.13). A foam roller m ay be u sed to achieve a
m ore d irect soft tissu e release of the tight ITB.
Stretching the tight hip exor m u scles u sing hyp erexten-
sion of the hip tend s to create anterior translation of the
fem oral head and so should be avoid ed , at least initially. As

m otor control and rep atterning im p rove, the hip exors m ay
in any case regain their norm al length w ithout the need for
sp eci c stretching exercises.
Muscle performance and neuromuscular
control exercises
This portion of the patient’s exercise program m e w ill focus
prim arily on strengthening of the GMed and GMax m uscles
and neu rom u scular retraining of prop er low er extrem ity
alignm ent d uring d ynam ic fu nctional m ovem ents. Several
au thors have su ggested p rogressing the exercises throu gh
three d istinct p hases: phase 1 – isolated m u scle recru itm ent;
phase 2 – w eight-bearing strengthening; and p hase 3 – func-
tional training (Mascal et al 2003; Tonley et al 2010; Wagner
et al 2010).
Phase 1
In the initial phase, non-w eight-bearing recruitm ent exercises
requ iring m od erate level activation of GMed and GMax
m u scles (see Table 38.1) w ith m inim al TFL activation w ould
be m ost appropriate. Lu m bopelvic control w ould need to be
established and em phasized d uring the p erform ance of the
low er extrem ity exercises. Possible options in this initial p hase
includ e the clam shell (see Fig. 38.2), brid ging / u nilateral
brid ging, sid e-lying leg lift w ith leg u p against the w all, hip
extension in prone lying (isom etric w ith foot against the w all
or concentric), resisted hip external rotation in sitting (Fig.
38.18) or qu ad ru ped hip extension. In selecting the exercises
for this particular patient, consid eration of the TFL and ham -
string d om inance and the anterior translation of the fem oral
Figure 38.18 Resisted hip external rotation. The patient sits on the edge o the
bed with the eet o the ground, holding the upper thigh to maintain control with an
elastic band around the oot. Keeping the knee at 90°, he slowly moves the oot in
against the elastic resistance. The patient is instructed to tighten his buttock
muscles as he per orms the movement.
Designing an evidence-informed exercise programme 437
head w ou ld in u ence the choices. The GMax and ham string
m u scles are agonists and d u ring the ru nning cycle they d ecel-
erate the thigh d u ring term inal sw ing and resist hip exion
d uring early stance (Lieberm an et al 2006). H am string d om i-
nance w as observed in ou r p atient, along w ith w eakness of
the glu teal m u scles, p rovid ing su p p ort for ou r d ecision to
focus ou r interventions on strengthening and neu rom u scular
control. The exercises are initially p erform ed w ithou t resist-
ance and once the p atient is able to p erform three sets of 15
repetitions the exercises can be progressed by ad d ing resist-
ance w ith elastic tu bing (Tonley et al 2010).
N eu rom uscu lar control exercises in w eight-bearing can be
introd uced in this initial phase to facilitate prop er low er
extrem ity alignm ent and prom ote activation of the target
m u scles in a m ore fu nctional p attern. As recom m end ed by
O’Su llivan et al (2010), the w all p ress (see Fig. 38.6) is an effec-
tive isom etric strengthening exercise for the p osterior d ivision
of the GMed m u scles; the w all squ at (see Fig. 38.4) and p elvic
d rop (see Fig. 38.5) m ay also be usefu l in the early rehab
stages. Wou ters et al (2012) used the w all squat, forw ard
lunge and step-d ow ns (Fig. 38.19) early in their neu rom otor
retraining program m e, w hile p rovid ing both visu al and
verbal feed back to m onitor alignm ent and low er extrem ity
p attern control.
Phase 2
Isolation exercises cou ld be progressed to w eight-bearing
su ch as hip external rotation kneeling w ith the affected hip
on a stool, w hich w ou ld also challenge balance and p rop rio-
cep tion as w ell as d issociation (Fig. 38.20). Many exercise
p rogram m es incorp orate squ atting-based exercises as this
Figure 38.19 Forward step-down. The patient stands on the step and squats with
the a ected leg, slowly lowering the heel o the non-weight-bearing leg toward the
f oor while ensuring proper lower extremity alignment. This can be per ormed
initially with upper extremity support i required.
 438 PART 5 • 38 • Therapeutic exercises for the lower quadrant

Figure 38.20 Weight-bearing resisted hip rotation. The patient stands with the Figure 38.21 Single-leg squat with resistance. The patient stands on the a ected
a ected knee on a swivel stool and elastic resistance is attached at the lower leg. leg, keeping the trunk and pelvis level with elastic resistance applied in the
Isolated hip external rotation is per ormed against the elastic resistance, ensuring direction o hip adduction, requiring the patient to resist with hip abduction and
good pelvic control. external rotation while per orming a single-leg squat.

m ovem ent strategy transfers to other fu nctional activities

su ch as d escend ing stairs, sit to stand and ru nning. Exercises
in phase 2 can begin w ith d ouble-leg w eight-bearing and
p rogress to single leg to increase the m u scu lar d em and as w ell
as to challenge balance and p rop rioception. Squ atting exer-
cises can also be u sed to target other low er extrem ity m u scu -
lature in ad d ition to the gluteal m u scles. Single-legged squat
exercises p rod u ce a high level of GMax and GMed activation
(> 40% MVC) (see Table 38.1), and w ill therefore facilitate
strength gains.
Single-leg squ ats can be p rogressed in front of a m irror,
initially w ith one hand su p p ort if requ ired , then u nsu p p orted ,
and nally fu rther challenge to the hip abd uctors can be
achieved by ad d ition of a resistance band (Fig. 38.21) applied
in the d irection of hip ad d u ction (Willy & Davis 2011). Proper
low er extrem ity alignm ent shou ld be em p hasized d u ring the
w eight-bearing exercises, and verbal cu es su ch as ‘keep the Figure 38.22 Controlled sit to stand. Starting in a stride oot position with elastic
centre of the p atella in line w ith both the anterior su p erior resistance around the lower legs, the patient rises rom the sitting position,
iliac sp ine p roxim ally and w ith the second toe d istally’ or maintaining proper lower extremity alignment in the rontal and transverse planes.
‘keep the patella pointing straight ahead to control hip inter- The exercise can be progressed by lowering the height o the sitting sur ace,
nal rotation’ can be u sed . increasing elastic resistance, adding an unstable sur ace under the oot or changing
The forw ard step -d ow n exercise can be p rogressed by the base o support.
ad d ing 5 cm increm ents to the height of the step (see Fig.
38.19). Prop er alignm ent of the low er extrem ity d u ring the p atient w ith a d om inant TFL / ITB, as Selkow itz et al (2013)
d escent should be m onitored to ensu re control in the frontal have fou nd that this exercise p rod u ces high activation levels
and transverse p lanes. Controlled sit to stand is a fu nctional of GMed and the su p erior p ortion of GMax m u scles w hile
m ovem ent that can be challenged by changing the base of m inim izing activation of the TFL. In the qu ad ru p ed p osition,
su p p ort or ad d ing resistance (Fig. 38.22). Mu ltip lanar lu nges a triplanar exercise incorporating hip abd uction, extension
or lateral, transverse or backw ard tru nk lean (Fig. 38.23) can and external rotation against elastic resistance w ou ld target
be ad d ed as all these exercises w ere show n to prod u ce high the GMed (Fig. 38.24). Challenges to forw ard and backw ard
activation of GMed and GMax m uscles. The d ynam ic sid e lunges can includ e ad d ing an unstable base of sup port such
step in a squ at p osition w ith elastic resistance arou nd the as a BOSU ® ball, or ad d ing elastic resistance. H igher level
thighs (see Fig. 38.3) w ou ld be particularly bene cial for this activation exercises such as the sid e p lank and front p lank

Figure 38.23 Lunge backward lean. Starting in standing with the hips and knees
extended, arms overhead, leaning slightly backwards with the trunk and eet
pointing straight orward, the patient lunges orward with the a ected leg to a
position o 90° o hip and knee f exion, with the other leg at 90° o knee f exion and
0° o hip extension.
Figure 38.24 Quadruped gluteus medius strengthening. With the hip and knee in
90° o f exion, a triplanar movement o the hip into extension, abduction and
external rotation is per ormed, while maintaining neutral spine and controlling
compensatory rotation through pelvis. Elastic resistance can be used as a
progression.
cou ld be inclu d ed in p hase 2, and progressions for these spe-
ci c exercises can be fou nd in Chap ter 23. From this patient’s
p ersp ective, his activity lim itation and goal is ru nning, thu s
the choice of exercises and attention to m otor p atterning
d u ring the p erform ance of these exercises in positions rele-
vant to this sp eci c task w ill be m eaningfu l to him and facili-
tate transfer to his fu nctional activities.
The star excu rsion balance exercise can be u sed as a
d ynam ic m otor control exercise that requ ires strength, exibil-
ity and p roprioception (see Fig 38.10). Other balance and pro-
p riocep tion challenges can inclu d e single- or d ou ble-leg
Designing an evidence-informed exercise programme 439
Figure 38.25 BOSU squat with ball toss. The patient stands on the BOSU® in a
squat position, maintaining proper lower extremity alignment while the distraction o
a ball toss is added.
Figure 38.26 Single-leg dead lift. The patient balances on one leg with hip and
knee f exed approximately 30°, slowly f exes the hip and trunk to touch down
towards the ground beside the support oot and then returns to the starting position.
The knee should be kept f exed at 30° to primarily obtain trunk and hip f exion and
to keep the knee over the toes.
stance on an u nstable su rface (BOSU ®) w ith a ball toss (Fig.
38.25), single-leg d ead lifts (Fig. 38.26) or the bow ler ’s squ at
(Fig. 38.27).
Phase 3
Once ad equ ate low er extrem ity alignm ent and control have
been established , p hase 3 em phasizes fu nctional integration.
Practising the m ovem ent p atterns requ ired for the ind ivid u -
al’s sport or speci c tasks constitu tes an essential elem ent in
this p hase of the rehabilitation p rogram m e. Many of the
 440 PART 5 • 38 • Therapeutic exercises for the lower quadrant
Figure 38.27 Bowler’s squat. Standing on the a ected leg in a semi-squat
position, the patient reaches back with the opposite leg as he hinges orward at the
hips, reaching orward and slightly across the body with the arm on the una ected
side. A light dumbbell can be added to that hand as a progression.
Figure 38.28 Single-leg vertical jump landing. The patient is instructed in proper
single-leg landing technique, maintaining proper lower extremity alignment.
p reviou sly d escribed p roprioception / balance exercises can
be integrated into sp orts-speci c tasks and progressed by
increasing the challenge throu gh altering the base of su p p ort,
ad d ing resistance and rem oving visu al cu es. For this p articu -
lar p atient, exercises sim u lating the p hases of the ru nning
cycle, d ou ble- and single-leg vertical ju m p ing (Fig. 38.28),
Figure 38.29 Functional integration / dissociation task. In a single-leg squat
position, the patient maintains proper lower extremity alignment and lumbopelvic
control while reaching and twisting with the thoracic spine against pulley resistance.
tasks involving qu ick m u ltid irectional m ovem ents and d is-
sociation tasks (Fig. 38.29) w ould be includ ed . Increasing the
sp eed , altering the base of su p p ort, ad d ing p lyom etric activi-
ties and d ecreasing cognitive control cou ld all be ad d ed ele-
m ents to achieve p rogression.
The u ltim ate goal from the patient’s perspective is running,
and tread m ill ru nning w ith m irror feed back is an excellent
training d evice that encou rages transference of gains m ad e
w ith speci c strengthening exercises into m ore optim al low er
extrem ity m echanics (see Fig. 38.9).
Exercise Parameters
Throughou t the d evelopm ent and progression of the exercise
p rogram m e, the d osage p rescribed d ep end s on several factors
su ch as the aim of the exercise (recru itm ent / p atterning,
strength, end u rance, m obility, stretching), the ability to
p erform the exercise p rop erly, p atient tness level and toler-
ance, the presence of p ain or sw elling and the irritability of
the cond ition.
In the rst p hase, w ith an em p hasis on isolated m u scle
recruitm ent, 1–2 sets of 10 repetitions w ith a 2-m inu te rest
w ould be com pleted d aily, lim iting the num ber to the am ount
that can be p erform ed w ithou t substitu tion. As phase 2
focu ses on w eight-bearing strengthening, 2–4 sets of 8–12 rep-
etitions w ould be ind icated w ith 2–3 m inu te rest, p erform ed
at least 3 tim es a w eek. In the functional training p hase 3, the
end u rance function w ou ld be achieved w ith 2 sets of 20 rep-
etitions w ith a 2-m inute rest. N eu rom otor retraining, inclu d -
ing balance and p roprioception, w ou ld progress throu gh
grad u ated challenges for 1–3 rep etitions of 30-second hold s
w ith 1-m inute rest perform ed d aily. Again, precision of m ove-
m ent p attern is a p riority w ith all exercises and w ou ld assist

Table 38.3 Exe rcis e parame te rs
Pha s e Goa l Loa d
Phas e 1 Muscle recruitment low
Phas e 2 Muscle hypertrophy 60–70% MVC
Phas e 3 Muscle endurance 50% MVC
Neuromotor retraining Progres sive challenge
Balance / proprioception Progres sive challenge
Mobility Articular mobility Stretch s ensation
Muscle lengthening Stretch dis com ort
in d eterm ining the exact nu m bers of repetitions and load .
Daily articu lar m obility (1 × 10–15 rep etitions) and m u scle
extensibility (3 × 30-second hold ) exercises w ou ld be inclu d ed
as requ ired throu ghou t these p hases.
Table 38.3 provid es a su m m ary of su ggested param eters
for exercise prescription, bu t m ore d etailed inform ation is
available from the Am erican College of Sport Med icine’s
u p d ated gu id elines (Garber et al 2011) and can also be fou nd
in Chap ter 23.
Conclusion
Therap eutic exercise is an integral com ponent of rehabilita-
tion of low er extrem ity cond itions. The p u rp ose of this chap ter
has been to p resent an evid ence-inform ed ap p roach to exer-
cise p rescrip tion in the low er qu ad rant, focu sing on hip d ys-
function. Using sou nd clinical reasoning, the practitioner
m u st u tilize the available scienti c research as w ell as clinical
experience in d esigning effective exercise program m es. Over-
arching this is a continu al consid eration of the p atient’s ind i-
vid u al p ersp ective and their u ltim ate goals.
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Se ts x / re p s Re s t Fre q ue ncy
1–3 / 10 2 min Multiple × / day
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2 / 15–20 2–3 min 2–3 × / week
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 P AR T 6
The Elbow Region In
Upper Extremity Pain
Syndromes
39 Elbow Tendinopathy: Lateral Epicondylalgia 445
Bill Vicenzino
40 Other Elbow Disorders: Elbow Instability, Arthritic Conditions 451
Chris A. Sebelski
41 Joint Mobilization and Manipulation of the Elbow 458
Helen Slater and César Fernández-de-las-Peñas
This pa ge inte ntiona lly le ft bla nk
 PART 6 •  The Elbow Region In Upper Extremity Pain Syndromes
Elbow Tendinopathy: Lateral Epicondylalgia
CHAP TER CONTENTS
Introduction  445
Diagnostic considerations  445
Pathological considerations  446
Prognostic considerations  447
Considerations in conservative treatment  447
Conclusion  448
Introduction
The com m on tend on o the extensor m u scles o the w rist and
f ngers is the m ost requ ently im p licated tend on in elbow
tend inop athy and w ill be the ocu s o this chap ter. There is
contention as to the correct nom enclatu re or the tend inop a-
thy o the extensor m u scles o the w rist and f ngers. A nu m ber
o term s are u sed in re erence to this tend inop athy, su ch as
tennis elbow, lateral ep icond ylitis, lateral ep icond ylosis and
lateral ep icond ylalgia. ‘Tennis elbow ’ is requently u sed
colloqu ially, bu t this term con u ses m any p atients, as the
cond ition is also very p revalent in those p atients w ho d o not
play tennis. Fu rther, ‘ep icond ylitis’ in ers in am m ation,
w hich has long been show n not to be the case (N irschl &
Pettrone 1979; Regan et al 1992; Potter et al 1995; Krau shaar
& N irschl 1999; Al red son et al 2000). ‘Epicond ylosis’ or ‘tend -
inosis’ connotes a d egenerative change – but, althou gh ele-
m ents o d isarray, breakd ow n or d egeneration o collagen
f brils have been id entif ed in su ch tend ons (Regan et al 1992;
Krau shaar & N irschl 1999), the relationship o these to p re-
senting p ain sym p tom s and associated clinical signs is not
clear (Khan & Cook 2000).
‘Lateral ep icond ylalgia’ ind icates that there is pain over the
lateral ep icond yle, w hich m ay be an accu rate term to use or
the p atient p resenting w ith p ain over the lateral ep icond yle;
how ever, it p rovid es little in orm ation abou t the u nd erlying
pathology. Recent reports o neovascularization and associ-
ated increased concentrations o algogenic m ed iators such as
glu tam ate, su bstance P and calcitonin gene-related pep tid e
(Lju ng et al 1999, 2004; Al red son et al 2000; Zeisig et al 2006;
d u Toit et al 2008) su ggest that tend inop athy is ar m ore
com p lex than any o the above com m only u sed term s su ggest.
In this chapter, the term ‘lateral epicond ylalgia’ w ill be u sed
to d escribe the p atient w ho attend s the clinic w ith p ain over
the lateral ep icond yle; as w ill be highlighted , this m ay be d u e
to som e p athology in the tend on (i.e. tend inop athy), bu t the
Chapter 
39  
Bill Vic e n z in o
p ain m ay also be associated w ith other cond itions, w hich
need to be consid ered to rehabilitate the p atient u lly.
Although there is no d ef nitive evid ence, the incid ence o
lateral epicond ylalgia varies rom 1% to 3% in the general
p op u lation (Alland er 1974; Verhaar 1994), w hich contrasts
w ith rep orts o prevalence rates as high as 35–64% in occup a-
tions requ iring rep etitive m anu al tasks (Kivi 1982; Dim berg
1987; Feu erstein et al 1998), w here it is one o the m ost
costly o all w ork-related inju ries (Kivi 1982; Dim berg 1987;
Feu erstein et al 1998). A su rvey o United States o Am erica
Departm ent o Labor, O f ce o Worker ’s Com pensation
Program s, accep ted claim s o occu p ational u p p er extrem ity
d isord ers d em onstrated that lateral ep icond ylalgia w as
responsible or app roxim ately 27% and 48% o all w ork-
related claim s or u pper lim b tend inopathies and enthesopa-
thies, resp ectively (Feu erstein et al 1998). This chapter ocu ses
on the m ost com m on tend inop athy abou t the elbow, lateral
ep icond ylalgia, w ith specif c consid eration o the evid ence in
regard s to d iagnosis, pathology, conservative m anagem ent
and p rognosis.
Diagnostic Considerations
Lateral epicond ylalgia is u sually id entif ed or d iagnosed on
the basis o a clinical exam ination. Classically, the p atient
p resents w ith p ain over the lateral elbow and m ay sp read into
the d orsal orearm as ar as the w rist, bu t no u rther than the
w rist and not proxim ally to the elbow (see Slater et al (2003,
2005) or p atterns o p ain m ap s). Those w ith p ain and sym p -
tom s into the hand and f ngers or p roxim al to the elbow
shou ld be consid ered to have concom itant p roblem s (e.g. cer-
vical sp ine re erral, neu rop athy) in ad d ition to, or instead o ,
lateral ep icond ylalgia. Patients w ith lateral epicond ylalgia
w ill have p ain and w eakness w ith tests that challenge the
w rist extensor m uscles – or exam ple, m uscle contraction
tasks o grip p ing, w rist extension and m id d le f nger extension
(clinically d escribed as a test o extensor carpi rad ialis brevis,
largely d u e to the insertion o that tend on at the w rist). It is
com m only rep orted that stretch o the w rist and f nger exten-
sors is p resent in these p atients; how ever, althou gh p ain m ay
be reprod u ced on stretching, it is not an u ncom m on observa-
tion by this au thor that p atients exhibit increased length in
these m u scles (i.e. increased range o exion o the w rist and
f ngers) associated w ith p ain rep rod u ction in those w ith
chronic cond itions. The p ain rep rod u ction is lim ited to the
 446 PART 6 • 39 • Elbow tendinopathy: lateral epicondylalgia
lateral ep icond yle and , at m ost, som e spread d ow n into the
d orsal orearm . Palpation w ill id enti y areas o hyp eralgesia
in and arou nd the lateral ep icond yle, at the site o the com m on
extensor tend on as w ell as in som e cases p ain into the d orsal
orearm m u scles. These p alpation f nd ings need to be present
w ith im p airm ent in m u scle contraction; otherw ise it is m ore
likely that the sym p tom s cou ld be largely re erred rom other
regions su ch as the cervical spine.
Typ ically, p atients attend ing general p ractice w ith lateral
ep icond ylalgia w ill be in their 4th or 5th d ecad e o li e. There
is u p p er lim b d om inance bias, bu t no sex bias. Patients w ho
p er orm rep etitive tasks requ iring su stained or repeated grip-
p ing o an im p lem ent or tool, su ch as those playing tennis or
u nd ertaking m anu al labou r, m ay be younger than 40 years,
bu t in su ch cases there shou ld be a higher d egree o su spicion
o an alternative u nd erlying cau se and d iagnosis. For exam p le,
in you nger p eop le consid eration need s to be given to osteo-
chond ritis d issecans o the cap itellu m and rad iu s in cases w ith
insid iou s onset, and bu rsitis, rad iohu m eral joint synovitis and
other so t tissu e sp rains w here there is m ore acu te onset p ain
and sw elling; in m ore eld erly p atients the practitioner w ill
need also to consid er d egenerative cond itions o the rad io-
hu m eral joint and re erral rom the cervical sp ine (Bru kner &
Khan 2007).
Lateral ep icond ylalgia is by d ef nition a clinical entity not
u su ally requ iring conf rm atory d iagnostic im aging or other
m ed ical p athology tests. Diagnostic im aging is likely m ore
help u l or exclu d ing d i erential d iagnoses. For exam p le,
rad iographs m ay be u sed to id enti y bone injuries, su ch as
ractures, apophysitis and su bchond ral arthritic changes.
Ultrasound has taken on a greater role in the d irect id entif ca-
tion o grey-scale hyp oechoic lesions, w hich im p ly d ys u nc-
tion in the connective tissu es. These grey-scale changes are
not necessarily linked to p ain in the tend on (Cook et al 2001,
2004; d u Toit et al 2008) and so they cou ld be legitim ately
term ed tend inop athy, m eaning som e p athology in the tend on,
and are m ost likely d u e to d egenerative breakd ow n o colla-
gen f brils (epicond ylosis) – thou gh u si orm sw elling m ay be
m ore ind icative o cellu lar and m atrix d ys u nction (Cook &
Pu rd am 2009). Increasing evid ence points tow ard s a link
betw een neovascu larization and sym ptom s su ch as pain
(Cook et al 2001, 2004; d u Toit et al 2008), w ith a recent stud y
show ing that, in a p atient w ith longstand ing lateral elbow
p ain that had ailed to resp ond to treatment, the lack o neo-
vascu larization strongly ind icated that the p ain w as not d u e
to tend inop athy, p rom p ting the p ractitioner to consid er other
d iagnoses (d u Toit et al 2008). Magnetic resonance im aging
m ay be u sed to ollow u p recalcitrant cases w here there are
no rad iograp hic or u ltrasonograp hic changes p resent, bu t
these cases w ill be in the m inority.
Pathological Considerations
N irschl and Pettrone (1979) d escribed the u nd erlying p athol-
ogy o lateral ep icond ylalgia to be one o angiof broblastic
hyp erp lasia w ith the ollow ing id entif ed histological changes:
(a) proli eration in the nu m ber o cells and in grou nd su b-
stance, (b) neovascu larization or vascu lar hyp erp lasia, (c)
higher levels o algogenic su bstances, as w ell as (d ) d isorgan-
ized im m atu re collagen (N irschl & Pettrone 1979; N irschl
1992; Regan et al 1992; Fred berg et al 2008). In an e ort to
exp lain d i erent clinical presentations m ore ad equ ately, Cook
and Pu rd am (2009) have recently p rop osed a clinical m od el
o histop athological changes across a continu u m rom : (a)
reactive tend inopathy and (b) tend on d isrepair, to (c) d egen-
erative tend inop athy. A brie su m m ary o their proposed clini-
cal m od el ollow s and the read er is re erred to their p ap er or
m ore d etail.
Reactive tend inop athy is a non-in am m atory p roli erative
cellu lar and m atrix resp onse to either an acu te tensile over-
load , as m ay occu r w ith a bout o unaccustom ed physical
activity, or a com p ressive overload , or instance that d u e to a
d irect contact inju ry. This is likely to occu r in the you nger
athlete w ho rapid ly increases the intensity or volu m e o physi-
cal activity and is m anaged w ell w ith a short p eriod o absence
rom the increased load ing activities be ore restoring pain- ree
unction. Consequently the classic presentation o lateral ep i-
cond ylalgia is not likely to all into this category, thou gh it is
im p ortant to keep this category in m ind or younger athletes
su ch as tennis p layers or m anu al labou rers, as w ell as p atients
w ho p resent w ith pain a ter an acu te trau m atic blow to the
com m on extensor origin at the elbow. At the other end o the
sp ectru m , the d egenerative p hase is characterized by angiof -
broblastic hyperplasia changes, w ith consid erable breakd ow n
in the collagen ram ew ork and neovascu larization. This tend s
to occu r w ith chronic overload ing in the old er p erson; hence
it m ore approp riately f ts the likely presentation in a classical
p resentation o lateral ep icond ylalgia. There is a sou nd argu -
m ent that exercises need to be a u nd am ental inclu sion in
the treatm ent p lan or d egenerative tend inop athy (Cook &
Pu rd am 2009; Khan & Scott 2009).
As w ell as local tend on changes, clinicians need also to
consid er evid ence that im p licates the central nervou s system
in the clinical presentation o lateral epicond ylalgia. This is
especially im p ortant, as local tend on changes are not read ily
ap preciated in the clinic, even w ith the assistance o d iagnos-
tic im aging. There are stu d ies rep orting w id esp read m echani-
cal p ain hyperalgesia – that is, red uced pressu re p ain threshold
in the una ected elbow and in the leg (Fernánd ez-Carnero
et al 2009a, 2009b; Coom bes et al 2012), as w ell as evid ence o
sp inal cord hyp erexcitability – that is, red u ced nociceptive
exion re ex threshold (Lim et al 2012) and red uced capacity
to m od u late nocicep tive stim u li (Lim 2013). These f nd ings
im p licate the central nervous system in the pain experienced
in those patients w ith u nilateral lateral epicond ylalgia. Ind i-
vid u als w ith severe cases o u nilateral ep icond ylalgia exp ress
cold hyp eralgesia bilaterally (i.e. on the u na ected sid e as
w ell) in ad d ition to w id espread m echanical pain hyperalgesia
(Coom bes et al 2012). This m ight have im plications in the
m anagem ent ap p roach or the m ore severe cases. As w ell as
this sensory system involvem ent, there ap p ear to be m otor
system changes. Patients w ith u nilateral lateral ep icond ylal-
gia have bilaterally red u ced reaction tim e o w hole u pper
lim b m ovem ents (Pienim aki et al 1997; Bisset et al 2009) and
less extension on gripping (Bisset et al 2009). They also have
w eakness o m ost o the m u scles on the a ected up per lim b,
w ith the exception o the long f nger extensors, w hich retain
their strength (Alizad ehkhaiyat et al 2009). It is interesting to
sp ecu late that the long f nger extensors are increasingly u sed
as w rist stabilizers w hen the w rist stabilizers (i.e. extensor
carp i rad ialis brevis and longu s) are im p aired throu gh the
tend inop athy, w hich m ight exp lain the red u ced extension on
grip ping. These sensory and m otor system changes are

im portant to consid er w hen planning a physical therap y
p rogram m e.
Prognostic Considerations
Lateral ep icond ylalgia is w id ely regard ed as being sel -
lim iting and resolving w ithin 6 m onths to 2 years; how ever,
this is low -level evid ence as the natu ral history o this cond i-
tion has not been d ef nitively d eterm ined . N otw ithstand ing
this, a nu m ber o rand om ized clinical trials have ollow ed
cases over 12 m onths (Sm id t et al 2002; Bisset et al 2006, 2007;
Sm id t & van d er Wind t 2006) and provid e d ata that m ay be
u sed in d eterm ining p rognosis.
The evid ence rom tw o rand om ized clinical trials (n = 383)
(Sm id t et al 2002; Bisset et al 2006) that inclu d ed rand om izing
a group o patients to ollow ing a w ait-and -see policy ind i-
cates that 87% o p atients sel -reported being m uch im proved
or com p letely recovered 12 m onths a ter inclusion into the
stu d y (Bisset et al 2007). When consid ering that patients had
on average ap p roxim ately 6 m onths’ d uration o p ain at inclu-
sion into the stu d y (Bisset et al 2007), an approxim ate ind ica-
tive natu ral history o the cond ition is in the ord er o 18
m onths or the m ajority o su erers. It is im p ortant to keep in
m ind that the p atients allocated to the grou p ollow ing the
w ait-and -see policy w ere given ad vice on avoid ing aggravat-
ing activities (e.g. ergonom ic ad vice on how to li t objects and
m anip u late im p lem ents w ithou t aggravating p ain) as w ell as
being closely m onitored in a clinical trial (and thereby prone
to the H aw thorne e ect), w hich is not necessarily the sam e as
a person w ith lateral epicond ylalgia not seeking out ad vice
and d oing nothing about the cond ition. Fu rtherm ore, Bisset
et al (2006) rep orted that those in the grou p allocated to w ait-
and -see p olicy w ere 2.7 tim es m ore likely to seek ou t other
treatm ents than those allocated to a m obilization w ith m ove-
m ent and exercise grou p (OR 4.7, 95% CI 2.1–10.3), w hich is
not the sam e as d oing nothing abou t the lateral ep icond ylal-
gia. On the contrary, it tend s to ind icate that, d espite being
recruited into a clinical trial and being closely m onitored ,
patients d o not eel com ortable d oing nothing about their
cond ition.
Sm id t et al (2006) p rospectively ollow ed 349 p atients rom
tw o rand om ized clinical trials (H ay et al 1999; Sm id t et al
2002) over a 12-m onth p eriod and ou nd that those w ho had
m ore severe p ain o longer d u ration also had greater likeli-
hood o a w orse outcom e (m ore severe p ain) at 12 m onths.
Another prognostic actor o p oor outcom e w as concom itant
neck p ain (Sm id t et al 2006). This f nd ing is interesting because
it ind icates that the p atient pool recru ited in this stu d y had a
heterogenic p ain p resentation, inclu d ing cases w ith m ore
com p lex p resentations (e.g. lateral ep icond ylalgia p lu s neck
pain) and d id not consist solely o patients w ith isolated
lateral epicond ylalgia.
Considerations in Conservative
Treatment
A w id e range o conservative treatm ents, su ch as m ed ication,
electrophysical agents, exercise and m anu al therapy, are
Considerations in conservative treatment 447
ad vocated or lateral ep icond ylalgia, w hich is usu ally an ind i-
cation that no one treatm ent has p roven su p eriority, bu t also
in part a prod u ct o an inconclu sive u nd erstand ing o the
u nd erlying p athology o the cond ition.
Corticosteroid injections are the m ost com m on conserva-
tive m ed ical intervention or lateral ep icond ylalgia and
accord ingly they have been the m ost stu d ied in high-qu ality
rigorous clinical trials. There is level 1 evid ence rom a nu m ber
o rand om ized clinical trials o short-term e f cacy, w ith
su ccess rates over 80% in the f rst 4–6 w eeks (H ay et al 1999;
Sm id t et al 2002; Bisset et al 2006, 2007; Sm id t & van d er
Wind t 2006), but this need s to be consid ered in light o post-
6-w eeks poorer ou tcom es in the orm o low er success rates
com p ared w ith the ad op tion o a w ait-and -see p olicy (Sm id t
et al 2002; Bisset et al 2006, 2007; Sm id t & van d er Wind t
2006), higher recurrence rates (70% versus 8%) and greater u se
o other not-per-p rotocol co-interventions (49% versu s 21%)
com p ared w ith those p atients u nd ergoing m obilization w ith
m ovem ents and exercise intervention (Bisset et al 2006, 2007).
The poorer d ow nstream e ects are su f cient to prom pt
cau tion in their u se and som e have ad vocated against their
u se in lateral ep icond ylalgia (Young et al 1954; Osborne 2010;
Vicenzino 2009), at least in the f rst instance, w ithou t a con-
certed attem p t at other interventions that d o not have su ch a
p oor longer term e ect on the cond ition. Other researchers
have p rop osed com bining the u se o these injections w ith
p hysiotherap y (Coom bes et al 2009a; Olau ssen et al 2009) in
ord er to overcom e the relatively p oorer long-term e ects. A
recent rand om ized clinical trial evaluated the proposition o
com bining the m obilization w ith m ovem ent techniqu e and
exercise program m e w ith a corticosteroid injection (Coom bes
et al 2013). H ow ever, this trial show ed that this com bination
o therap ies d id not p revent the higher recu rrence rates and
d elayed recovery ollow ing corticosteroid injections.
There is a sound level o evid ence in su pport o exercise
or treating lateral epicond ylalgia; how ever, u nlike in low er
lim b tend inopathy, eccentric exercise is not necessarily better
than concentric exercise (Wood ley et al 2007). Perhaps the
m ost illu strative evid ence com es rom a rand om ized clinical
trial com p aring an exercise p rogram m e w ith u ltrasou nd in
a grou p o patients w ho had recalcitrant lateral ep icond ylal-
gia, having ailed other treatm ents inclu d ing corticosteroid
injections and other com m on m od alities (Pienim aki et al
1996). Follow -u p som e 3 years later revealed that the exercise
grou p requ ired ew er m ed ical consultations, and had less
su rgery (N N T = 3) and 586 ew er sick d ays than the grou p
receiving u ltrasou nd (Pienim aki et al 1998). The exercise pro-
gram m e w as grad uated and progressive rom isom etric to
isotonic contractions o the w rist and orearm m uscles, cu lm i-
nating in p ragm atic exercises that rep licated a p atient’s
requ ired unction. It w as sup ervised tw ice a w eek or approxi-
m ately 8 w eeks. A m ore-recent stu d y has show n that su p ervi-
sion o the exercise p rogram m e retu rns su p erior e ects
com p ared w ith a hom e-based p rogram m e (Stasinop ou los
et al 2010), w hich shou ld be consid ered w hen prescribing
exercise.
Electrop hysical agents su ch as LASER, u ltrasou nd and
extracorporeal shock-w ave therap y (ESWT) have attracted
attention. Low -level LASER therap y has been show n to be
e ective in im proving p ain levels in the short term com pared
w ith control, but only at a w avelength o 908 nm (Bjord al et al
2008). There appears to be less conclusive evid ence and som e
 448 PART 6 • 39 • Elbow tendinopathy: lateral epicondylalgia
contention over the u se o u ltrasou nd and ESWT in the treat-
m ent o lateral ep icond ylalgia, p erhap s becau se o a lack o
sp ecif cation and stratif cation o d osage p aram eters.
Elbow orthotics or tennis elbow band s that f t abou t the
p roxim al orearm are requ ently u sed , o ten on a sel -selection
basis by p atients. H ow ever, system atic review s have been
u nable to f nd su f cient high-qu ality clinical trials to su p p ort
or re u te their u se (Struijs et al 2001, 2002, 2004).
Joint (high- and low -velocity) and so t tissu e m anipu la-
tions have been p rop osed or u se in treatm ent o lateral
epicond ylalgia (Lee 1986; Vicenzino et al 2007a). The initial
e ects o elbow m obilizations w ith m ovem ent (Vicenzino
2003) u sed as a single m od ality have been show n in a num ber
o stu d ies (Vicenzino et al 1996, 2001, 2007b; Abbott et al 2001;
Pau ngm ali et al 2003) and been show n to be e ective w hen
u sed in com bination w ith exercise (Kochar & Dogra 2002;
Bisset et al 2006). There are con icting interpretations o
the literatu re regard ing the u se o Mill’s m anip u lation and
riction m assage, also re erred to as Cyriax physiotherapy
(Vicenzino et al 2007a; Kohia et al 2008), w hich m ay be in
p art d u e to the lack o high-quality clinical trials (Bisset et al
2005). There is also a rand om ized clinical trial that has ou nd
w rist m anipu lation to be e f caciou s com pared w ith ultra-
sou nd , riction m assage and exercise (Stru ijs et al 2003).
As id entif ed in a prognostic analysis, patients w ith neck
p ain as w ell as lateral epicond ylitis have a poorer ou tcom e
(Sm id t et al 2006), bu t as in this stu d y the neck w as not treated
it is not p ossible to d eterm ine w hether it w ou ld have been
benef cial to have ad d ed neck treatm ent to the elbow treat-
m ent given. H ow ever, there are several other stu d ies that
show benef ts o ad d ing treatm ent o the cervical sp ine to
elbow treatm ent (Gu nn & Milbrand t 1976; Cleland et al 2004,
2005). Gu nn and Milbrand t (1976) treated 50 recalcitrant cases
o lateral ep icond ylalgia w ith non-thru st m anip u lation and
traction o the cervical sp ine and show ed an 86% success rate
a ter treatm ent that p ersisted at 6 m onths. In a retrospective
case aud it o 112 cases, Cleland et al (2004) show ed that sig-
nif cantly ew er treatm ents w ere requ ired or those (n = 51)
w ho received ad d itional m anu al therapy to the cervical spine
in the orm o non-thru st oscillatory m anip u lations, m obiliza-
tion w ith m ovem ents and / or m u scle energy techniqu es.
More recently, in a p ilot trial o 10 cases, Cleland et al (2005)
reported a better result on pain- ree grip orce and the Disabil-
ity o the Arm , Shou ld er and H and qu estionnaire. Fu rther-
m ore, a nu m ber o stu d ies show both high- and low -velocity
m anip u lations o the cervical sp ine to p rod u ce an initial
im p rovem ent in p ain at the elbow (Vicenzino et al 1996, 1998;
Fernánd ez-Carnero et al 2008). This evid ence provid es a basis
or the cervical sp ine to be treated i it is ound on physical
exam ination to be im plicated , especially since there have been
reported signif cant d i erences in pain provocation on m anual
exam ination o the cervical spine and signif cant red uctions
in sagittal p lane m otion in p atients w ith lateral ep icond ylalgia
w hen com p ared w ith age-m atched controls (Wau gh et al
2004; Berglu nd et al 2008).
The challenge acing the p ractitioner is how to best select
a treatm ent ap p roach or each ind ivid u al patient, as each
p erson is likely to be som ew hat d i erent in their ind ivid ual
clinical p resentation. The continu u m m od el o p resentation
o tend inop athy (Cook & Purd am 2009) ou tlined above
along w ith the proposed integrative m od el o lateral
epicond ylalgia (Coom bes et al 2009b) m ay provid e som e
gu id ance on how the practitioner m ay w ish to select rom the
m any p rop osed treatm ents. In brie , Coom bes et al (2009b)
p rop ose that each p atient p resents w ith a d i erent p rop or-
tional rep resentation o d ys u nction in the p ain and m otor
system s as w ell as in tend on stru ctu re and p hysiology, w hich
cou ld be u sed to select sp ecif c interventions. For exam p le,
i a patient p resents w ith relatively greater pain system
im p ed im ent – as w ould be seen clinically w ith large d ef cits
in p ressu re pain threshold s and high pain severity scores –
then p ain-relieving m ed ications, electrop hysical agents and
m anu al therap y shou ld be avou red . In contrast, a p atient
w ho presents w ith a progressed stage o d egenerative
tend inop athy w ith m od erate to low levels o p ain cou ld be
better m anaged m ore w ith specif c exercise (Coom bes et al
2009b; Khan & Scott 2009) and possibly injections o m ed ica-
tion / m aterials (Rabago et al 2009) or glyceryl trinitrate
transd erm al p atches (Paoloni et al 2003, 2009; Mu rrell 2007)
that p rom ote collagen synthesis. Fu rther d etail regard ing the
integrative m od el o lateral epicond ylalgia can be ou nd in
Coom bes et al (2009b).
Conclusion
Tend inop athy at the elbow is com m only exp erienced over the
lateral epicond yle. Over the past d ecad e there has been an
increase in ou r know led ge and u nd erstand ing o the u nd erly-
ing p athology, conservative m anagem ent and prognosis o
this p ain cond ition. Althou gh this has p rovid ed m ore in or-
m ation and d ata or p ractitioners to consid er w hen treating
p atients w ith lateral ep icond ylalgia, the challenge still rem ains
over how to ap p ly sp ecif c treatm ents to ind ivid u al p atients
in ord er to achieve optim al outcom es. This chapter provid es
a synopsis o the recent evid ence and som e ind ication o pos-
sible m eans by w hich to ap p ly su ch evid ence clinically.
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 PART 6 •  The Elbow Region In Upper Extremity Pain Syndromes
Other Elbow Disorders: Elbow Instability, Arthritic Conditions
CHAP TER CONTENTS
Introduction  451
Elbow instability  451
Anatomy review for elbow instability  451
General treatment planning guidelines for elbow instability  451
Lateral elbow instability  452
Medial elbow instability  454
Arthritic conditions  455
Anatomy review for arthritic conditions of the elbow  455
Incidence / prevalence of arthritic conditions of the elbow  455
Pathology / pathoanatomy of arthritic conditions of the elbow  456
Diagnosis of arthritic conditions of the elbow  456
Prognosis and treatment planning for patients with   rad iu s or the coronoid . In the progression of stages, stage I
arthritic conditions of the elbow  456
Conclusion  457
Introduction
This chapter w ill present tw o speci c cond itions of the
elbow : elbow instability and arthritic cond itions. Each section
presents a short introd u ction w ith relevant anatom y, inci-
d ence / prevalence, pathology, clinical exam ination inform a-
tion and , nally, non-op erative treatm ent. The read er is
encouraged to rem em ber that elbow d ysfu nction rarely occurs
in isolation (Royle 1991; Walker-Bone et al 2004). When
app roaching a clinical case involving elbow pathology, the
clinician m u st d eterm ine the u nd erlying p rim ary aetiology,
the p otential second ary aetiologies, the associated im p air-
m ents and nally the role of regional interd ep end ence for
d eterm ination of the appropriate plan of care.
Elbow Instability
Overall, the elbow is the second m ost com m only d islocated
joint in ad u lts, w ith posterior d islocation being the m ost
com m on (Royle 1991). It is the m ost com m only d islocated
joint in the paed iatric age group (Ku hn & Ross 2008). In the
very you ng or those of ad vanced age, associated inju ries su ch
Chapter  40  
C h ris A. S e b e ls ki
as fractures occu r, w hereas non-com plex d islocations m ost
com m only occu r w ithin you ng athletic p op u lations (Mehta &
Bain 2004). There are ve criteria (O’Driscoll et al 2001a) to
assist in classifying elbow instability:
• the involved articu lation(s)
• the d irection of d isplacem ent
• the d egree of d isplacem ent
• the d u ration (acute, chronic or recu rrent)
• the presence / absence of associated fractures.
Injury progression is represented throu gh the circle of H orii
w here the inju ry progresses from lateral to m ed ial through
soft tissu e, bone or both. Du e to the energy absorp tion by a
fractu re, one m ay see ligam ent sparing w ith a fracture of the
d em onstrates d isru ption of the lateral collateral ligam ent
(LCL) w ith a presentation of p osterolateral instability, stage
II signi es d isru ption of the capsu le w ith anterior and poste-
rior instability and stage III d em onstrates d isru p tion of the
p ortions of the m ed ial collateral ligam ent. Stage III is fu rther
d ivid ed into subp arts A, B and C (O’Driscoll et al 2001a).
Anatomy review for elbow instability
There are three prim ary constraints for elbow stability: the
u lnohu m eral joint, the m ed ial collateral ligam ent and the
lateral ulnar collateral ligam ent. Althou gh O’Driscoll (2000)
originally nam ed the lateral u lnar collateral ligam ent as a
p rim ary constraint, there is controversy regard ing its im p or-
tance, as cad aver stu d ies have d em onstrated elbow p ostero-
lateral rotatory instability (PLRI) w ith arti cially ind u ced
d ivision of variou s ligam ents in the LCL com plex (Olsen
et al 1996; Singleton & Conw ay 2004). Second ary constraints
inclu d e: the rad ial head , the com m on exor origin, the
com m on extensor origin, and the joint cap su le. Dynam ic
constraints p rod u ce com p ressive forces at the joint inclu d ing
the bicep s brachii, tricep s and anconeu s (O’Driscoll 2000).
General treatment planning guidelines
for elbow instability
Treatm ent varies accord ing to the severity of the inju ry. In an
acute d islocation w ithou t an associated elbow fractu re, the
recom m end ed treatm ent is a closed red u ction follow ed by
 452 PART 6 • 40 • Other elbow disorders: elbow instability, arthritic conditions
bracing for a short p eriod of tim e. The patient is typ ically
d irected to u se the u pper extrem ity for d aily function w ithin
sym p tom tolerance after the brace is rem oved . Sim p le elbow
d islocations have a good p rognosis, w ith u p to 95% of the
p ersons affected retu rning to their previou s level of activity
(H ild ebrand et al 1999). H ow ever, if sym ptom s persist, the
intervention p lan m u st be ad ap ted accord ing to the inju ry and
the sym p tom s rep orted . The p resence of fractu re w ith a d is-
location / su blu xation changes the cou rse of treatm ent, as
typ ically there is su rgical intervention for the fractu re. If an
acu te ligam ent inju ry is su stained in conju nction w ith a frac-
tu re of the rad iu s or the coronoid , a rep air of that ligam ent is
necessary to assist w ith the stability of the joint (O’Driscoll
et al 2001a). In the sections that follow, elbow instability is
fu rther d iscussed by injury to the lateral or m ed ial ligam ent
stru ctu res.
Lateral elbow instability
Anatomy review for lateral elbow instability
The lateral collateral ligam ent (LCL) com p lex originates from
the hu m eru s at the trochlea and cap itellu m and continu es
d istally to blend w ith the annu lar ligam ent inserting at the
p roxim al u lna (Cohen & Bru no 2001). This com plex consists
of u p to fou r stru ctu res: the annu lar ligam ent, the u lnar
p ortion of the LCL, the rad ial portion of the LCL, and the
accessory LCL (w hich is not alw ays present). The lateral liga-
m ent com p lex is tau t throu ghou t elbow exion and extension.
Ligam ent tension is increased w ith the forearm p ositioned in
su p ination.
Incidence / prevalence of lateral elbow instability
PLRI, an inju ry to the lateral collateral ligam ent and the soft
tissu e stabilizers, is the m ost com m on typ e of chronic
instability at the elbow. In contrast, isolated varus instability
from the laxity of the LCL is not as com m on as an
isolated m ed ial collateral ligam ent inju ry (Charalam bou s &
Stanley 2008).
Pathology / pathoanatomy of lateral elbow instability
There are three typical scenarios that m ay lead to lateral col-
lateral ligam ent inju ry: elbow d islocation, varu s stress insu f-
ciency / chronic attenu ation and iatrogenic cau ses (Singleton
& Conw ay 2004). Typically, elbow d islocation is an acute
occu rrence; O’Driscoll et al (1992) p rop osed that elbow PLRI
m ay be the initial step tow ard s elbow laxity. PLRI m ay p resent
as an ind ep end ent pathology, or it m ay be p art of a continuu m
lead ing to d islocation (Sm ith et al 2001). PLRI has also been
cited as the m ost com m on cau se of recu rrent sym p tom s fol-
low ing d islocation (O’Driscoll et al 2001a). Chronic attenu a-
tion and / or varu s insu f ciency m ay occu r w ith overu se
– su ch as in the cases of p atients w ith signi cant w eight-
bearing activities on the upper extrem ities (e.g. crutch am bu-
lation) – or in those p ersons w ith generalized ligam ent laxity.
A cau sal relationship of cu bitu s varu s and recu rrent elbow
instability in the form of PLRI has been rep orted by several
au thors, w ith sym p tom s that m ay not ap pear until m ore than
tw o d ecad es p ost inju ry (O’Driscoll et al 2001a, 2001b;
Arrigoni & Kam ineni 2009). It has been theorized that these
sym p tom s m ay be second ary to the attenu ation of the liga-
m ent from the rep etitive torqu e on the LCL and the inap p ro-
p riate p u ll of second ary stabilizers. Iatrogenic d isru p tion of
the integrity of the LCL m ay resu lt from su rgical ap p roaches
that involve the lateral elbow stru ctu res, su ch as a lateral
ep icond ylar release proced u re or an approach to access the
rad ial head (O’Driscoll 2000).
PLRI affects the articu lation betw een the u lna and the
hu m eru s w hile the p roxim al rad iou lnar joint rem ains intact.
This d iffers from a sim p le posterior d islocation of the rad ial
head , w here the u lnohu m eral joint rem ains intact and the
p roxim al rad iou lnar joint is d isru p ted . With PLRI, the forearm
externally rotates (supinates) aw ay from the hu m erus, effec-
tively ‘p ivoting’ on the intact m ed ial collateral ligam ents
and allow ing the rad ial head to su blu xate in a p osterior
d irection.
These m echanics provid e support for the u se of orthopae-
d ic tests that pay special attention to the position of the
forearm . Trad itionally, varus stress testing is u tilized w hen
exam ining a patient w ith probable d isru ption of the lateral
ligam ents of the elbow. Valgus stress testing is u sed to d eter-
m ine the laxity of the m ed ial collateral ligam ent. Ind ications
of p robable m ed ial collateral ligam ent laxity w ou ld be the
p resence of laxity / ap p rehension w ith the forearm in p rona-
tion and ap p lication of a valgu s stress. The p ronated forearm
p osition and m ed ially d irected stress tension the m ed ial col-
lateral ligam ent. Du ring forearm pronation, the lateral stru c-
tu res of the elbow are tensioned , stabilizing the rad ial head .
H ow ever, if the forearm is positioned in sup ination and a
valgu s stress is ap p lied , the lateral stru ctu res are u nable to
stabilize the rad ial head ap p rop riately. Therefore, if the
p atient d em onstrates laxity or ap p ears ap p rehensive w hen
the forearm is su p inated and tensioned in the valgu s d irec-
tion, PLRI shou ld be su sp ected (Sm ith et al 2001).
Diagnosis of lateral elbow instability
In a search for lateral collateral laxity, history taking should
includ e inqu iring abou t the three potential m echanism s,
includ ing both acu te d islocations and a history of d islocation
if a patient’s rep ort lead s the tester to suspect chronic recu r-
ring instability. Questioning should includ e positions of the
u p p er extrem ity that p lace the elbow at risk of chronic attenu -
ation, inclu d ing a history of elbow fractu re as a you th. Ad d i-
tionally, a m ed ical history that m ay contribu te to generalized
ligam ent laxity shou ld be explored .
Patient concerns m ay inclu d e ‘vagu e’ aching abou t the
elbow joint, p ain, clicking, snapping or clu nking that is w orse
w ith a su pinated position of the forearm . Patients m ay
com m ent on ‘som ething not right’ w hen extend ing their arm
w ith the forearm in sup ination (Lee & Rosenw asser 1999;
O’Driscoll 2000). Unless there is an associated traum atic
event, how ever, the p atient w ill only rarely be able to isolate
the onset of the sym p tom s.
Physical exam m easu res inclu d e observation for a cu bitu s
varu s d eform ity, range of m otion (ROM) and sp ecial ortho-
p aed ic testing (Table 40.1), w hich m ay be passive and / or
active. Reporting of the statistical evid ence for orthop aed ic
tests is lim ited and , d u e to the su p p ortive roles of the second -
ary soft tissue constraints, it is often recom m end ed that
p assive exam techniqu es be com p leted w ith the p atient u nd er
 Elbow instability 453

Table 40.1 Orthopae dic e xamination te chnique s for late ral e lbow ins ta bility
Na me of te s t Phys ica l e xa m te chniq ue Outcome to ind ica te a pos itive te s t
for pa thology

Varus stress tes t
Lateral pivot s hi t test
Pos terolateral instability tes t
Push-up sign ( rom f oor)
(Arvind & Hargreaves 2006)
Table-top relocation tes t
(Arvind & Hargreaves 2006)
Application o a laterally directed orce applied in both Greater laxity is elt by therapis t
ull extension and at approximately 30° o elbow compared with the contralateral side.
f exion to allow the olecranon to move out o the
olecranon oss a. It is recommended to per orm this
test with the humerus ully internally rotated (O’Dris coll
et al 2001b).
Patient lies s upine with the shoulder pas sively f exed Pos terolateral displacement o radius
pas t 90°. With the elbow in extens ion, the examiner occurs, ollowed by reduction as elbow
applies axial compres sion through the ulna and radius f exion progres ses to 90° (O’Dris coll
towards the humerus with a s upination and valgus et al 1991). The apprehens ion test
orce, causing the elbow to s ubluxate at ~ 40–70° o would have the patient report
elbow f exion. I the patient allows the pas sive apprehension prior to the subluxation.
examination to continue, an obs ervable clunk occurs
with continued f exion as the elbow reduces
(O’Driscoll et al 1991, 1992; O’Driscoll, 2000).
The examiner f exes the elbow to 40°, with the orearm Subluxation o the orearm away rom
in external rotation; an anteropos terior orce is applied the humerus.
to the ulna and radius (O’Driscoll et al 2001b).
Patient pus hes up rom the f oor with shoulders in Apprehens ion and voluntary / involuntary
abduction, orearms s upinated. guarding as involved elbow moves
towards terminal extension.
Three-step tes t: Firs t outcome: pain and apprehens ion.
1. Patient per orms a pres s-up rom a table top with Second outcome: pain and
the orearm in s upination. apprehension are reduced. Third
2. With ons et o s ymptoms (approximately 40° o outcome: pain / apprehens ion returns .
f exion) examiner applies a orce through their
thumb at the patient’s radial head.
3. Then the examiner removes the orce at the radial
head.

anaesthesia for best resu lts (O’Driscoll et al 2001b). In the case
of a varu s-d irected stress test a false negative m ay be rep orted ,
as the u lnohu m eral articu lation is the m ain constraint to varu s
m ovem ents (Charalam bou s & Stanley 2008). As ind icated
above, the exam ination techniqu e for m ed ial collateral laxity
via the valgu s stress test m ay give the exam iner clu es to a
potential PLRI p athology if com p leted w ith the forearm in
su p ination (Olsen et al 1998). H ow ever, for d etection of PLRI
the m ost u tilized exam ination techniqu e is the PLRI test. It
has also been ad vocated that the p ositive resp onse of the PLRI
test be changed to ‘p atient ap p rehension’ rather than ‘a visible
clu nk’ has also been ad vocated (Charalam bou s & Stanley
2008). Su ggested im aging inclu d es stress rad iographs, arthro-
gram or, for PLRI, MRI – for w hich a speci c p u lse sequ ence
is d escribed (Potter et al 1997).
Prognosis and treatment planning for patients
with lateral elbow instability
Despite its high prevalence for d islocation, the elbow is con-
sid ered to be one of the m ost stable joints in the bod y. The
philosop hy of treatm ent of elbow instability w ith associated
fractu res is rst to stabilize the osseous–articu lar inju ries.
With the achievem ent of osseou s stabilization, the next step
is to ad d ress ligam entous inju ry. Although w ith m ore com plex
injuries the prognosis for fu ll functional return d eclines, the
intervention and m anagem ent of a d islocation w ithout frac-
tu re has d em onstrated good ou tcom es overall (O’Driscoll
et al 2001b; Ku hn & Ross 2008).
In general, non-operative care for patients w ho d em on-
strate sym p tom -p rod u cing recu rrent instability, su ch as that
fou nd w ith PLRI or varus insu f ciency, is not com m on.
H ow ever, the u se of bracing to assist in avoid ance of forearm
su p ination w ith valgu s load ing m ay be ad vocated for those
p atients w ith m ild sym p tom s. In cases of recu rrent sym p -
tom s, op erative m anagem ent m ay be u nd ertaken via d irect
repair or reattachm ent of the ligam ent or in ord er to recon-
stru ct the lateral ligam ent com p lex w ith a tend on graft
reconstruction. The resu lts follow ing su rgical reconstru ction,
though lim ited , are prom ising – w ith stud ies reporting resolu -
tion of sym p tom s, fu ll range of m otion and a retu rn to activity
(N estor et al 1992; Lee & Teo 2003). Operative care m ay also
be ad vocated for correction of cu bitu s varus in those patients
w ho d em onstrate positive physical exam signs for PLRI
(O’Driscoll et al 2001a).
 454 PART 6 • 40 • Other elbow disorders: elbow instability, arthritic conditions
Medial elbow instability
Anatomy review for medial elbow instability
There are three ligam ents of the m ed ial collateral ligam ent
(MCL) com plex, nam ely the anterior oblique / bu nd le, the
p osterior obliqu e / band and the transverse ligam ent / band .
The origin of the MCL is slightly p osterior to the elbow joint,
and so it d em onstrates greater tension w ith increasing exion.
The anterior bund le of the MCL is the strongest of the three
and it attaches the m ed ial ep icond yle to the m ed ial coronoid
p rocess. H istologically, this bund le m ay be fu rther d ivid ed
into anterior and p osterior band s (Safran & Baillargeon 2005).
The anterior band is p rim arily taut from fu ll extension to 60°
of exion, w hereas the p osterior band of the anterior bu nd le
is tau t from 60° to 120° of exion (Cohen & Bru no 2001; Safran
2004; Safran & Baillargeon 2005). The p osterior oblique portion
of the MCL com p lex is a thickening of the cap su le that has
the greatest restraint at 90° of elbow exion. It arises from the
m ed ial ep icond yle and inserts onto the m ed ial sid e of the
sem ilu nar notch. The third p ortion of the MCL is the trans-
verse ligam ent, arising from the m ed ial olecranon and the
inferior m ed ial coronoid p rocess. It has lim ited im p act, is not
alw ays p resent, and is often ind istingu ishable from the
cap su le (Cohen & Bru no 2001; Safran & Baillargeon 2005).
Ad d itional stabilizers of the elbow includ e the rad iocapitel-
lar joint and the regional m u scles. The rad iocap itellar joint
contribu tes u p to 30% of the stability against valgu s stress.
The regional m uscles of the pronator and the exors m ay
also have a role; how ever, the signi cance of their contribu-
tion is not yet com p letely u nd erstood (Cohen & Bru no 2001;
Safran 2004).
Incidence / prevalence of medial elbow instability
Inju ry to the MCL is m ore com m on in the overhead -throw ing
athlete p op u lation than in the non-throw er popu lation. In the
throw ing athlete, the consequ ences of su ch instability m ay
inclu d e the inability to com p ete at the d esired level. In the
general popu lation it rarely affects the activities of d aily living
(Grace & Field 2008), asid e from particular job tasks w ithin
the w ork environm ent. Bennett et al (1992) provid e one
exam ple, of ind u strial w orkers w ho d em onstrated sym ptom s
of chronic m ed ial ligam ent instability d u ring sp eci c w ork
tasks w ho eventu ally requ ired su rgical intervention in ord er
to retu rn to w ork.
Pathology / pathoanatomy of medial
elbow instability
There are tw o m echanism s for MCL laxity: acu te or spontane-
ou s occu rrence and chronic attenu ation. The sym p tom s that
the p atient w ill rep ort m ay d ifferentiate the tw o incid ences.
A ‘p op ’ m ay be heard in the m ore acu te cases ,w hereas there
m ay be a rep ort of vagu e elbow d iscom fort that becom es m ore
p revalent over a length of tim e in a m echanism that involves
chronic attenu ation.
The m echanics of throw ing have been stu d ied to d eterm ine
its contribu tion to m ed ial collateral laxity. Of note, the MCL
(p rim arily the anterior bu nd le) p rovid es up to 54% of the
varu s torqu e to resist the valgu s strain in the elbow d u ring
the late cocking and early d eceleration p hases of throw ing
(Fleisig et al 1995). The u ltim ate failure load of the MCL is
calcu lated to be less (34 N m ) than the load s to w hich it is
exp osed d uring the m ajority of overhead sports (52–120 N m )
(Fleisig et al 1995). Therefore, it is hypothesized that there is
a signi cant in u ence from the proxim al segm ents and core
of the u p p er extrem ity to generate second ary constraints for
control of these forces (Kibler & Sciascia 2004); the su ggestion
is that an im balance of the contribution from local stru ctures
and / or inad equ ate contribu tion from the p roxim al segm ents
and core w ou ld create an environm ent of excessive strain,
w hich w ould resu lt in attenu ation over tim e.
Typ ically w ith a chronic cond ition, the MCL laxity m ay
represent only one aspect of a constellation of inju ries that
contribu te to the m ed ial elbow p ain. For exam p le, the liga-
m ent inju ry m ay be a p art of valgu s extension overload syn-
d rom e, w hich involves the com pression of the olecranon of
the u lna against the hu m eru s w ith a valgu s stress. Associated
injuries m ay inclu d e: capitellar w ear, posterom ed ial osteo-
p hytes, u lnar neu ritis and d egenerative or trau m atic arthritis
of the elbow. Fu rtherm ore, d u e to the d ynam ic natu re of the
p op u lation this p athology is often associated w ith, it is im p or-
tant to consid er the in u ence of the kinetic chain. In tw o d if-
ferent reports, nd ings ind icated that professional baseball
p layers p resenting w ith both m ed ial elbow sym p tom s of
insuf ciency and signi cant glenohu m eral internal rotation
d e cits d em onstrate a kinetic chain relationship w hereby
im p airm ents ou tsid e of the local region m ay have a causal
relationship to the sym ptom s reported at the elbow (Kibler &
Sciascia 2004; Dines et al 2009).
Diagnosis of medial elbow instability
The patient history shou ld inclu d e not only location, d uration
of sym p tom s and the m echanism of inju ry bu t also the d etails
of a throw ing or overhead m ovem ent history if the p atient is
an athlete (Safran 2004). The patient presentation m ay be com -
p licated by com p laints from the second ary stru ctu res involved
in the overload m echanism , inclu d ing m uscu lar strain, in am -
m ation or tend inosis, that m ay be associated w ith the u nd er-
lying instability.
Physical exam inclu d es p alp ation, observation for a cu bitu s
varu s d eform ity, range of m otion and sp ecial orthop aed ic
testing, w hich m ay be p assive or active (Table 40.2). On p alpa-
tion, the clinician m ay nd tend erness app roxim ately 2 cm
d istal from the m ed ial epicond yle at the ulnar insertion of
MCL. This tend erness has been reported in as m any as 80%
of those p atients u nd ergoing MCL reconstru ction. ROM lim i-
tations m ay often inclu d e a exion contractu re (Thom pson
et al 2001).
For sp eci c physical exam m easu res su ch as the valgus
stress test and the m ilking m anoeu vre statistical evid ence is
lim ited . Sim ilar to the sp ecial testing of the lateral ligam ents
of the elbow, consid eration m u st be p aid to the su p p ortive
roles of the second ary soft tissu e constraints. For exam ple,
d u ring the valgu s stress test, it has been stated that the p osi-
tion of su p ination for the forearm shou ld p rovid e a greater
bias of the MCL over the contribu tion from the LCL (Sm ith
et al 2001). H ow ever, in a cad averic stud y by Safran et al
(2005) w here both the anterior and p osterior band s of the
anterior bu nd le of the MCL w ere sectioned and tested at
variou s angles of exion and forearm p osition, the neu tral
p osition of the forearm in relationship to the horizontal,
 Arthritic conditions 455

Table 40.2 Orthopae dic e xamination te chnique s for me dial e lbow ins tability
Na me of te s t Phys ica l e xa m te chniq ue Outcome to ind ica te a p os itive te s t
for pa thology

Valgus s tress tes t
Milking test (Grace & Field 2008)
Moving valgus stress tes t
(O’Dris coll et al 2005)
Application o a medial directed orce applied at the Greater laxity is elt by therapist in
elbow in both ull extension and at 30–40° elbow comparis on to contralateral side.
f exion to allow the olecranon to move out o the
olecranon os sa. The humeral pos ition is s uggested
to be in external rotation.
A valgus orce is applied by the patient with the Medial elbow pain with this manoeuvre
elbow f exed. This is done by the patient holding the indicates a positive result.
thumb on the involved s ide with the contralateral
upper extremity. The contralateral upper extremity
must reach under the elbow o the involved side to
grasp the thumb.
Therapis t pass ively moves the involved elbow The test is positive i the medial elbow pain
through range o motion f exion to extension while is reproduced at the medial collateral
simultaneously applying a valgus orce. ligament. Maximum symptoms s hould be
elt at 120–70° during f exion and extens ion.

regard less of the d egree of elbow exion, assessed the integ-
rity of the MCL m ore clearly than any other position. It should
be noted , thou gh, that this alteration in the proced ure of the
valgu s stress test has not been tested in hu m ans; therefore the
inform ation m u st be view ed cau tiously.
For d etection of m ed ial ligam ent instability, su ch as com -
m only seen w ith p artial tearing or attenu ation in the throw -
ing athlete, the m oving valgus stress test as d escribed by
O’Driscoll et al (2005) is the m ost w id ely used , w ith sup port-
ive statistical evid ence of sensitivity of 1.0 and speci city of
0.75. Im aging techniqu es such as static im aging, stress rad io-
graphs, MRI, CT scan and arthroscopic valgu s stress testing
have all been u tilized w ith varying d egrees of su ccess
(O’Driscoll et al 2005).
Prognosis and treatment planning for patients
with medial elbow instability
Treatm ent of non-throw ers and the general p op u lation is via
a non-op erative rehabilitation program m e w ith reported suc-
cessfu l retu rn to the activities of d aily living w ithou t sym p -
tom s (Grace & Field 2008). For that su bset of patients w ishing
to retu rn to high d em and throw ing, non-op erative therap y is
attem p ted initially and only w ith a failu re to retu rn is op era-
tive m anagem ent consid ered .
In a single stud y by Rettig et al (2001), throw ers w ith
chronic m ed ial instability w ere treated non-op eratively. They
achieved a 42% su ccess rate in retu rning the athlete to sp ort
w ithin an average of 24.5 w eeks. The rehabilitation w as
d ivid ed into tw o phases. The rst phase involved a rest from
throw ing for u p to 3 m onths, resolu tion of in am m ation
includ ing w earing of a brace and achievem ent of fu ll range of
m otion. The second p hase inclu d ed a p rogressive strengthen-
ing program m e and step w ise progression tow ard s a retu rn
to throw ing.
Inform ation gained from cad averic stu d ies can provid e
cu es for rehabilitation. Arm strong et al (2000) stu d ied the
MCL in cad averic elbow s and conclu d ed that active m obiliza-
tion of the elbow in the vertical p osition w ith either a fu lly
su p inated or p ronated forearm p osition is safe for d ecreased
stress at the ligam ent. With tension in the m ed ial stru ctu res,
one m ight constru ct a rehabilitation p rogram m e that incorp o-
rates lim ited hu m eral external rotation in com bination w ith
neu tral forearm p ositioning and avoid ance of valgu s stresses,
especially d uring 70–120° of elbow exion. In a cad averic
stu d y by Bernas et al (2009), the im m ed iate p ost-rehabilitative
p hase w as conclu d ed to be an ap p rop riate tim e to introd u ce
isom etric exion and extension below 90° of exion and to
lim it m otion from fu ll extension to 50° of exion to p rotect
the MCL.
Arthritic Conditions
Anatomy review for arthritic conditions
of the elbow
The elbow com prises three articulations: the ulna articulating
w ith the hu m eru s, the ulna articulating w ith the rad iu s and
the rad iu s articu lating w ith the hu m eru s. There are tw o
d egrees of freed om in the elbow joint: exion / extension and
p ronation / su p ination. The fu nctional arc of m otion of the
elbow is 30–130°. A total range of less than 100° in the sagittal
p lane or the transverse p lane w ill generate signi cant fu nc-
tional lim itations (Morrey et al 1981).
Incidence / prevalence of arthritic conditions
of the elbow
Arthritis of the elbow is relatively uncom m on. It typically falls
into three categories: rheum atoid arthritis (RA), post-traum atic
arthritis or p rim ary d egenerative osteoarthritis (OA). In the
p atient population w ith RA, it has been fou nd that 25–66% of
the p atients m ay have the p resence of d isease in one or both
elbow s (Porter et al 1974; Lehtinen et al 2001). Prim ary d egen-
erative arthritis of the elbow has been reported to affect less
 456 PART 6 • 40 • Other elbow disorders: elbow instability, arthritic conditions
Table 40.3 Patie nt pre s e ntation with a rthritic conditions of the e lbow
Und e rlying d is e a s e Pa tie nt re p ort
Rheumatoid arthritis Pain throughout the ROM
Pos t-traumatic arthritis Sti nes s and pain with inadequate end ROM
Primary degenerative Initially, pain only at the terminal ROM
os teoarthritis In later stages , pain throughout the ROM
Catching / locking may be reported
than 2% of the p op u lation (Antu na et al 2002). Though the
theory rem ains som ew hat controversial, it is generally
accepted that p rim ary OA of the elbow affects m ales w ith a
history of ‘heavy u se of the u p p er extrem ity’ su ch as ind u s-
trial labou r, w eightlifting, etc. (Gram stad & Galatz 2006;
Kokkalis et al 2009). These patients are typically not less than
40 years of age (Gram stad & Galatz 2006).
Pathology / pathoanatomy of arthritic
conditions of the elbow
RA is an in am m atory d isease p rocess that affects m u ltip le
joints. It is characterized by sym m etric joint narrow ing, d isu se
osteop enia and p eriarticu lar erosions, w hich w ill be seen on
rad iographic im aging (Kokkalis et al 2009). The course and
natu ral history of OA are not w ell u nd erstood , how ever; it is
typ ically characterized by d estru ction of the articu lar cartilage
(Gram stad & Galatz 2006). Prim ary OA of the elbow d em on-
strates u niqu e featu res su ch as sp aring of the articu lar su r-
faces w ith preservation of the joint spaces and hypertrophic
form ation of osteophytes and cap su lar constriction (Cheu ng
et al 2008). OA begins on the lateral asp ect of the joint at the
rad iocapitellar joint (Good fellow & Bu llou gh 1967). In the
younger population w ith a presentation of elbow stiffness,
p ost-trau m atic arthritis shou ld be su spected . Associated d is-
ord ers to this p athology inclu d e: trau m a, osteochond ritis
d issecans, synovial chond rom atosis and valgu s extension
overload synd rom e (Gram stad & Galatz 2006).
Diagnosis of arthritic conditions of the elbow
Generally, p atients rep ort p ain, stiffness and p otential w eak-
ness. Fu nctionally, they often have sym p tom s w hen attem p t-
ing to carry a w eighted object next to the bod y w hen the
elbow is extend ed . Depend ing on the u nd erlying cau se of the
arthritis, p atient rep orts m ay vary, how ever. For exam ple, a
p atient w ith elbow p ain second ary to RA m ay com plain of
p ain throu ghou t the ROM (Soojian & Kw on 2007), a patient
w ith OA m ay have concerns of ‘p inching’ or ‘sharp pain’ w ith
term inal exion or extension d u ring the earlier stages of the
d isease (Cheu ng et al 2008), w hereas p atients w ith a d iagnosis
of p ost-trau m atic arthritis m ay be you nger and healthier than
those w ith RA or OA, w ith less involvem ent of other bod y
regions. The last group of patients m ay also possess an
Comme nts
Loss o rotation
Exces sive motion in the coronal plane (Soojian & Kwon
2007)
Possible underlying instability
His tory o trauma, s urgery to joint
Possible underlying instability
Need to monitor progress ion o diseas e as this impacts
treatment
exp ectation of higher d em and of the elbow (Am irfeyz &
Blew itt 2009). In Table 40.3, speci c features of each of the
m ost com m on p athologies associated w ith elbow arthritis are
highlighted .
A d etailed interview of the p atient to note the onset of
sym p tom s, cou rse of associated d isease p rocess or p rior su rgi-
cal / trau m atic history is necessary. Prior treatm ent, either for
the arthritic d isease or sp eci cally to the elbow, shou ld be
asked abou t, inclu d ing the u se of p harm acological therap ies.
Rad iograp hs are the stand ard to d eterm ine the p hase of
the d isease p rocess and the p otential p lan of care. Of sp ecial
note, one shou ld recognize p otential d ifferential d iagnoses
that m ay p rod u ce sim ilar p atient concerns inclu d ing sep tic
arthritis, crystalline arthrop athy, haem ophilia and ochronosis
(Soojian & Kw on 2007).
Prognosis and treatment planning for patients
with arthritic conditions of the elbow
The u nd erlying aetiology, functional lim itations includ ing
the cu rrent ROM of the elbow and the age of the p atient all
signi cantly in uence the treatment course. The current stand -
ard is non-operative treatment, w hich may includ e phar-
macological management, corticosteroid injections, dynamic
splinting and physical therapy (Gram stad & Galatz 2006;
Kokkalis et al 2009). With the ad vent of im proved and m ore
aggressive treatm ent of RA, one report (Brasington 2009)
stated that early m anagem ent has the p otential for com p lete
resolution of sym p tom s in 10% of p atients treated . For p atients
w ith prim ary OA at the elbow, activity m od i cation is typ i-
cally su ggested , bu t w ith varying resu lts.
If su ch non-operative m easu res fail to resolve the patient’s
functional lim itations or sym ptom s, there is a w id e variety of
su rgical op tions inclu d ing arthroscop y and arthrop lasty. The
best results for m anagem ent of OA and post-traum atic OA
w ithin the younger patient p op ulation have been reported
after arthroscopy for a capsu lar release and clearing of osteo-
p hytes (Gram stad & Galatz 2006). The total elbow arthro-
p lasty is typ ically reserved for the p op u lation of ind ivid u als
over 60 years of age, w ho have low er physical d em and s
and w ho are m ore likely to com ply w ith the postoperative
rehabilitative and long-term physical restrictions (Moro &
King 2000).

Conclusion
In recent years, there has been a signi cant gain in und er-
stand ing the anatom y and p athologies of the elbow that cau se
instability and stiffness. Bu ild ing u pon this new inform ation,
researchers now need to com plete the d evelopm ent rehabili-
tation gu id elines that w ill p rod u ce su ccessfu l ou tcom es.
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 PART 6 •  The Elbow Region In Upper Extremity Pain Syndromes
41
Joint Mobilization and Manipulation o the Elbow
Chapter 
He le n S la te r, C é s a r Fe rn á n d e z - d e - la s - P e ñ a s
CHAP TER CONTENTS
Introduction  458
Evidence-based decision making  458
Def nitions and clinical applications  459
Mobilization and manipulation techniques  460
Mobilization in extension combined with adduction   In choosing joint m obilization as part of m ultim od al m anage
(varus mobilization)  460
Mobilization in adduction and abduction   the clinical (p atient) m anifestations of p erip heral and central
(varus to valgus mobilization)  460
Mobilization in pronation / supination combined with  exion  461
Mobilization o  the radiohumeral joint  461
Lateral glide mobilization with movement  462
Manipulation in lateral glide o  the elbow  
(varus thrust manipulation)   462
Conclusion  462
Introduction
Mobilization and m anip u lation interventions of the elbow
joint are frequently u sed in clinical p ractice, and although
the evid ence for their u se is as yet insu f cient, it is grow ing
(Vicenzino et al 2007). System atic review s in relation to the
elbow refer m ainly to speci c elbow cond itions su ch as
lateral ep icond ylalgia (Sm id t et al 2003; Assend elft et al 2004;
Vicenzino et al 2007). Despite the large num ber of stud ies,
there is still insu f cient evid ence for m ost p hysiotherap y
interventions ow ing to contrad icting resu lts, insu f cient sta
tistical p ow er and the low nu m ber of stu d ies p er intervention
(Sm id t et al 2003). More recent high qu ality stud ies provid e
evid ence that joint m anipu lation / m obilization d irected at the
elbow and w rist results in bene cial alterations in pain and
the m otor system (Vicenzino et al 2007). A m eta analysis of
tw o rand om ized controlled trials show ed that elbow m obili
zation im p roved p ain free grip strength and p ressure p ain
threshold in com p arison w ith p lacebo at short term follow u p
(Bisset et al 2005). A few cases reporting the use of speci c
m obilization interventions for elbow d isord ers have also been
p u blished , inclu d ing a p atient w ith ulnar tu nnel synd rom e
(Law rence & H u m p hreys 1997) and a patient w ith lateral
epicond ylalgia (Kau fm an 2000). Given the low level of
evid ence for single case stu d ies, clinicians are cau tioned
against m aking any conclu sions from case stu d ies alone.
Evidence-based Decision Making
m ent, the therap ist m u st give consid eration to interp reting
sensitization p rocesses involved in m u scu loskeletal d isord ers.
For exam ple, in patients w ith u nilateral lateral epicon
d ylalgia, evid ence of bilateral m anifestations of d eep tissu e
hyp eralgesia ind icates that p erip heral sensitization alone is
u nlikely to exp lain the clinical p resentation (Slater et al 2005;
Fernánd ez Carnero et al 2008, 2009). In the stu d y by Slater
et al (2005), evid ence of w id espread pain, referred pain and
changes in som atosensory sensitivity raised the ind ex of su s
p icion that p atients w ith lateral ep icond ylalgia d em onstrated
alterations in the w ay that the nervou s system p rocesses noci
cep tive and non nocicep tive inform ation. Therefore, clinical
m anagem ent of p atients w ith lateral ep icond ylalgia m ay need
to extend beyond local tissu e based p athology to incorp orate
strategies d irected at norm alizing nervou s system sensitivity.
Changes in som atosensory fu nction, w hich are m anifested
clinically by p ersistent m u scu loskeletal p ain (Graven-N ielsen
2006), also im p act on m otor system s as changes in the d rive
to m u scle and altered m otor control (Arend t-N ielsen &
Graven N ielsen 2008). Managem ent cannot therefore focu s
just on the sim p le biom echanics of joint m obilization,
bu t m u st also incorp orate the m ore recent nd ings on
sensory–m otor interactions in persistent m u sculoskeletal
p ain d isord ers.
In consid ering the choice of joint m obilization as an inter
vention, clinicians shou ld also consid er the p otential neu ro
p hysiological and tissu e m echanism s u nd erlying the effects
(positive and negative) of m obilization. Mu ltiple interacting
tissu e and p ain m echanism s are likely to contribu te to the
p ain m od u latory effects of m obilization (Slater et al 2006;
Vicenzino et al 2007). For a com prehensive review of pu tative
m echanism s u nd erlying the effects of m obilization, read ers
are referred to Pau ngm ali et al (2003), Bisset et al (2006),
Vicenzino et al (2007) and Chapter 39.
Where a patient’s elbow d isord er ap p ears m ed iated
prim arily by peripheral nociceptive m echanism s (d om inantly

perip heral sensitization), early and app ropriate p hysiological
m ovem ents and fu nctional activity shou ld be encou raged . In
su ch cases, althou gh joint m obilization m ay offer bene ts in
term s of p ain relief and restoration of joint m obility, the u lti
m ate aim of su ch techniqu es is the restoration of fu nction,
lim iting the chance of sustained central nervous system facili
tation (central sensitization). Seld om in clinical p ractice w ou ld
a u nim od al ap p roach using m obilization alone be consid ered
app ropriate for the m anagem ent of elbow d isord ers. More
com m only, m obilization w ou ld be incorp orated into a m u lti
m od al ap p roach. For exam p le, d ep end ing on the chronicity
of the d isord er and the associated level of im p airm ent and
d isability, patients w ou ld be ed ucated about optim izing
norm al fu nctional m ovem ents and u nd ertaking active and
sp eci c exercises to m aintain gains in p ain free joint ranges.
The use of appropriate soft tissu es techniqu es to ad d ress soft
tissu e contribu tions at the elbow m ay also be exp lored (see
Chs 59–63). If requ ired , help m ay be sought throu gh the
patient’s d octor in regard to u se of approp riate analgesics
(e.g. acetam inophen, non steroid al anti in am m atories), the
prim ary p u rp ose of analgesia being to provid e a therap eu tic
w ind ow for the p atient to regain function.
Ad d itional consid erations m ay also be required w hen the
elbow cond ition is com prom ised by contribu ting factors such
as a loss of the norm al d ynam ic control of the shou ld er joint
(see Chs 28, 29 and 32) or a com prom ise of w rist stability (see
Ch 49). Such contributing factors need to be ad d ressed in the
overall m anagem ent of the p atient w ith elbow d isord ers if an
op tim al ou tcom e is to be achieved . Equ ally, the p ossibility of
intra articu lar p athologies, includ ing loose bod ies, osteochon
d ritis and other cond itions such as osteoarthritis, valgu s insta
bility w ith u lnar nerve trau m a in patients involved in throw ing
sp orts, or a covert p osterolateral p athology follow ing a fall
onto an ou tstretched hand , shou ld all be given d u e consid era
tion p rior to any d ecision that m anu al techniqu es are ind i
cated in m anagem ent (see Ch 40).
For all patients, reassessm ent of the ou tcom e of any inter
vention, inclu d ing joint m obilization, shou ld inclu d e a su bjec
tive inqu iry into the treatm ent effects (p ositive and negative),
re exam ination of key initial physical nd ings (e.g. loss of
joint range and associated p ain p rovocation, m echanical
hyp eralgesia) and fu nctional lim itations. Where p ossible, the
parallel u se of relevant ou tcom e m easu res to assess the
resp onse to treatm ent is consistent w ith cu rrent best clinical
practice. Exam p les of outcom e m easu res that could be used
for elbow d isord ers inclu d e the Patient Speci c Functional
Scale (PSFS) and the Disability of Arm , Shou ld er and H and
(DASH ) tool.
Def nitions and Clinical Applications
Joint m obilization is usually d e ned as low velocity, high
am p litu d e p assive m otion ind u cing intracap su lar m ovem ent
at d ifferent am p litu d es (H engeveld et al 2005; Takei 2005),
w hereas joint m anipulation is d e ned as a high velocity, low
am p litu d e thru st m otion. Maitland (1986) had d escribed d if
ferent grad es of m obilization accord ing to the am plitu d e of
the m otion and resistance offered by the su rrou nd ing tissu es
(H engeveld et al 2005). In Maitland ’s (1986) classi cation,
there w ere fou r d ifferent stand ard oscillatory grad es of
Def nitions and clinical applications 459
m ovem ent relating to am p litu d e, in w hich grad es I and IV
referred to sm all am plitu d e oscillations, w hile II and III ind i
cated large am p litu d e oscillations. Conventionally, m obiliza
tions of grad es I–II are usu ally used in patients w here the pain
is the d om inant sym ptom and a patient’s d isord er is consid
ered irritable in nature. In contrast, grad es III–IV are u sually
u sed in p atients w here the m ain sym p tom resp onse relates to
lim itation of elbow joint range and this restriction is associ
ated w ith som e pain p rovocation. Grad e V refers to high
velocity m anip u lation.
In ord er to regain range, joint m obilization is provid ed at
the lim it of the range, and the therap ist exp ects a p ain resp onse;
this shou ld settle im m ed iately after or w ithin second s of the
m obilization being com p leted . In cu rrent clinical p ractice, the
u se of a grad e I m obilization is rare. More com m only, acu te
nocicep tive elbow p ain is m anaged u sing a com bination of
sim p le analgesia if requ ired and ap p rop riate early active
m ovem ent to regain fu nction and m inim ize p rolonged sensi
tization. If p assive m ovem ent is ind icated in su ch a p resenta
tion, then large am p litu d e m obilization p erform ed short of
p ain p rovocation (grad e II or III-) offers the patient the ad van
tage of increasing range and red u cing p ain. Patients are
encou raged to continu e w ith ap propriate analgesia and m ain
tain gains in range w ith active m ovem ents. Where p atients
p resent w ith p ersistent elbow p ain (e.g. tend inop athy or oste
oarthritis), m anagem ent w ill requ ire a com bined ap p roach,
w ith joint m obilization offering only lim ited bene t w hen
u sed as a u nim od al intervention. Treatm ent ‘d ose’ (how long
and how m any) is d ecid ed based on the clinical presentation;
30–60 second s follow ed by reassessm ent are typ ical for m ore
acute d isord ers (2–3 repetitions), and 60–180 second s (4–5
repetitions) for m ore chronic hypom obility d isord ers.
When choosing to m obilize the elbow joint, a skilled thera
p ist typ ically u ses a clinically reasoned p rocess rather than a
d octrinal or d id actic approach. For exam ple, the grad e of a
techniqu e is typ ically gu id ed by the p atient’s clinical p resen
tation, w ith d u e consid eration of irritability (i.e. severity of
d isord er; natu re of associated pathology or system ic d isease
if appropriate; the acu te, su bacu te or chronic stage of the
d isord er; how easy it is to trigger sym p tom s; how long these
sym p tom s then take to resolve or red u ce to baseline; and any
p recau tions or contraind ications to m anu al interventions
su ch as p osterolateral joint instability or signi cant neu ro
p athic p ain).
Typ ically, sym p tom s that are localized , m echanically p at
terned (nocicep tive) and w ith clearly id enti able aggravating
factors and easing factors appear to be the m ost am enable to
m obilization techniqu es. In su ch p resentations, the choice of
the techniqu e is m ad e by consid ering w hich articu lation of
the elbow joint is p roblem atic (rad iohu m eral, rad iou lnar or
hu m erou lnar) and at w hat p oint in the joint range the sym p
tom s occu r. Most com m only, m obilization w ill be u sed at the
p oint in range w here loss of m obility occu rs. Where an elbow
d isord er is m ore acute and hypom obility is evid ent throu gh
a large p art of the joint range, physiological m obilization
m ay be u sefu l w hen p erform ed throu ghou t larger am p litu d es
of joint range. A good clinical exam p le is the u ncom p licated
p ost fractu re (ou t of cast) elbow, w here large am p litu d e
p hysiological joint m obilization help s to encou rage joint
m obility w ithou t com p rom ising the fractu re or exacerbating
p ain. Conversely, w here joint m obility is lost at term inal
extension or exion, or into abd uction or ad d uction at
 460 PART 6 • 41 • Joint mobilization and manipulation o  the elbow
term inal elbow extension, p assive accessory joint m obiliza
tion p erform ed at the p oint in the range of restriction is m ost
likely to be bene cial in restoring fu nction. In su m m ary, the
u se of clinical reasoning and cu rrent neu robiology of m u scu
loskeletal p ain to p roblem solve and assist in d ecision m aking
shou ld be central to clinical p ractice. For a com p rehensive
review of clinical reasoning in physiotherapy practice see
Jones et al (2004).
In the next part of the chapter, w e w ill d escribe som e of the
m ore com m only p erform ed elbow m obilization / m anip u la
tion interventions. For each techniqu e, the op tim al p ositions
for patient relaxation and for the therapist are d escribed ;
how ever, as w ith all m anu al techniqu es, ap p rop riate p osi
tional m od i cations are to be consid ered and ap p lied as
requ ired . For convenience, all techniqu e d escriptions relate to
the right elbow. The com bination of m obilization techniqu es
w ith active m ovem ent (an approach d escribed by Mu lligan
in 1989 as ‘m obilization w ith m ovem ent’ (MWM)) m ay also
offer alternatives to or p rogressions of the basic techniqu es
d escribed here.
The techniqu es ou tlined are not exhau stive. As w ith any
techniqu e, m od i cations and variations are w orthy of consid
eration if a logical and scienti c rationale can be provid ed .
Ad d itionally, given the bony con gu ration of the elbow joint,
m ost clinical p resentations w here joint m obilization is ind i
cated as p art of m anagem ent involve p ain p rovocation associ
ated w ith hyp om obility tow ard s the end of joint ranges. These
restrictions typically occur at term inal extension associated
w ith a restriction of abd u ction and ad d u ction, term inal exten
sion w ith lim itation of end range su p ination or p ronation,
and exion lim itation w ith restriction of pronation and su pi
nation. Often these p atterns of restriction are associated w ith
soft tissu e lim itations or heightened d eep tissu e sensitivity or
trigger p oints (see Ch 59). For exam p le, in patients w ith lateral
epicond ylalgia, term inal extension and ad d u ction / abd uction
can be p rovocative for p ain; how ever, su p ination p erform ed
in extension is also frequ ently lim ited .
Carefu l exam ination m ay reveal a loss of tissu e extensibil
ity of the exor and p ronator m u scle grou p , and trigger p oints
m ay exist in these tissu es as w ell as in the extensor m u scles.
Techniqu es d irected at norm alizing this soft tissu e lim itation
or heightened sensitivity shou ld assist in restoring su p ination
in extension (see Chs 59–63). Given the intim ate anatom ical
and functional relationship s in the up per lim b kinetic chain,
the techniqu es d escribed in this chap ter are com p lem ented by
the techniqu es d escribed in Chapters 31, 39 and 52.
Mobilization and Manipulation
Techniques
Mobilization in extension combined with
adduction (varus mobilization)
The aim of this m obilization techniqu e is to im prove the
lateral glid e of the elbow region, p articu larly of the rad io
hu m eral joint, w here p ain or restriction is associated w ith
active extension. Therefore, the clinical p resentation w ou ld
requ ire lim itation of term inal elbow extension and ad d uction;
p ain provocation in this p osition is also likely and p robably
Figure 41.1 Mobilization in extension combined with adduction (varus
mobilization). Black arrows show the stabilizations at the shoulder and the elbow o
the patient; the white arrow shows the direction o the mobilization orce.
m ost evid ent at the lateral elbow, althou gh m ed ial joint p ain
can also be elicited .
For this technique, the patient lies su pine w ith the elbow
extend ed (Fig. 41.1). To m axim ize stabilization, the therap ist’s
left elbow contacts the anterior part of the patient’s should er.
Med ial rotation of the w hole arm allow s the u se of a gravity
assisted m ed ial (varus) m obilization. The therap ist’s left
hand su p p orts the p atient’s elbow im m ed iately p roxim al and
m ed ial to the elbow joint. The therap ist’s right hand grasp s
the p atient’s w rist, w ith the therap ist’s ngers p laced over the
d orsum of the hand . The techniqu e consists of applying an
ap prop riately grad ed oscillatory m obilization into ad d u ction
(varus). The techniqu e w ould be p erform ed at the point
in the range p rior to the onset of p ain (acu te, grad e II or III)
or at the lim itation of range (chronic, grad e III–IV). Sym ptom s
shou ld be m onitored and the grad e of m ovem ent ad ju sted if
requ ired .
Mobilization in adduction and abduction
(varus to valgus mobilization)
The aim of this m obilization techniqu e is to im prove the
lateral glid e of the elbow region, speci cally the rad iohum eral
and hu m erou lnar joints, at the lim itation of extension range.
Therefore, the clinical patient presentation w ou ld requ ire
lim itation of term inal elbow extension and abd uction. Pain
p rovocation in this p osition is likely and p robably m ost
evid ent at the m ed ial elbow, althou gh lateral joint sym ptom s
m ay also occu r.
For this technique, the patient lies su pine w ith the elbow
extend ed (Fig. 41.2). The therapist w ith both hand s grasps the
forearm of the patient in close proxim ity to the elbow, w ith
stabilization p rovid ed m ed ially and laterally at the elbow ; the
tip s of both thu m bs are p laced against the p atient’s rad ial
head anteriorly, w hereas the rem aining ngers sp read m ed i
ally / laterally around the p atient’s forearm . The techniqu e
consists of ap p lying a grad ed oscillatory lateral m obilization
into abd u ction (valgus) or ad d uction (varu s). The techniqu e
 Mobilization and manipulation techniques 461

Figure 41.2 Mobilization in adduction and abduction (varus to valgus Figure 41.3 Mobilization in pronation combined with exion. The white arrow
mobilization). White arrows show the direction o the medial or lateral mobilization shows the direction o the f exion orce. A rotational mobilization in pronation o the
orce. orearm is applied with the other hand placed over the radiohumeral joint.

w ou ld be perform ed at the point in the range prior to the

onset of p ain (acu te, grad e II or III) or at the lim itation of range
(chronic, grad e III–IV). Sym ptom s should be m onitored as the
grad e of m ovem ent ad justed if required .

Mobilization in pronation / supination

combined with exion
The aim of this m obilization techniqu e is to im prove the pro
nation / su p ination rotational glid e / sp in of the rad iohu m eral
joint w here the lim itation occu rs in a exion p osition. There
fore, the clinical presentation w ou ld requ ire lim itation of
elbow exion and p ronation – w hich is fu nctionally one of the
m ost im p ortant p ositions to be able to attain. Pain p rovocation
in this p osition is likely and is probably m ost evid ent at the
rad iohu m eral joint laterally or at the anterior joint line (w hich
is com m on post fractu re).
For this techniqu e, the patient lies su pine w ith the right
elbow exed and the forearm p ronated . The therapist’s left Figure 41.4 Mobilization in supination combined with exion. The white arrow
shows the direction o the f exion orce. A rotational mobilization in supination o
hand is p ositioned w ith the d orsu m of the ngers lying p roxi the orearm is applied with the other hand over the radiohumeral joint.
m al to the elbow joint and the thu m b d istal to the elbow and
m aking contact w ith the rad ial head . The p roxim al contact
help s control the internal rotation of the p atient’s hu m eru s
that occu rs w ith forearm p ronation. The therap ist’s right hand associated joint restriction and pain provocation. Rad iou lnar
grasp s the patient’s right w rist at the d orsum of the d istal joint m obilization in the p osterior–anterior m ed ial d irection
rad iou lnar joint. The techniqu e consists of applying an oscil can be p erform ed effectively at 60° to 90° of exion.
latory m obilization force com bining pronation and exion For this technique, the patient is su pine w ith the right
(Fig. 41.3). This technique m ay be also p erform ed w ith the elbow exed to the point of restriction (Fig. 41.5). The forearm
forearm in supination and at the lim itation of exion (Fig. m ay be su p inated or p ronated at the p oint in the range w here
41.4), although this is less com m only u sed in clinical practice. there is p ain p rovocation or joint hyp om obility. The therap ist
Sym p tom s shou ld be m onitored and the grad e of m ovem ent p laces the p ad s of both thu m bs against the rad ial head p oste
ad justed if requ ired . riorly, w hereas the rem aining ngers spread com fortably
p roxim ally and d istally arou nd the p atient’s forearm . The
Mobilization o the radiohumeral joint techniqu e consists of ap plying oscillatory posterior–anterior
glid es of the rad ial head using an approp riate grad e of m ove
The aim of this technique is to im prove the anterior glid e m ent. Sym p tom s shou ld be m onitored and the grad e of m ove
of the rad iohu m eral joint (Ed m ond 2006) w here there is m ent ad ju sted if requ ired .
 462 PART 6 • 41 •
Figure 41.5 Mobilization o the radiohumeral joint. The white arrow shows the
posteroanterior glide applied over the radial head laterally.
Lateral glide mobilization with movement
Despite the nd ings of hum an and anim al stu d ies, the speci c
m echanism s u nd erlying the effects associated w ith the m obi
lization / m anip u lation techniqu es rem ain largely p u tative.
The bene cial effects associated w ith the speci c lateral glid e
MWM are likely to relate to m u ltip le and p otentially interact
ing m echanism s and these are d iscu ssed in m ore d etail else
w here (Slater et al 2006; Vicenzino et al 2007). (For a d etailed
d escription of this technique, see Ch 39.)
Manipulation in lateral glide o the elbow
(varus thrust manipulation)
The patient is sup ine or seated w ith the elbow extend ed . For
p atients w here no contraind ications exist, joint m anipu lation
can be an effective treatm ent p rogression. As w ith any m anip
u lative techniqu e, d u e care m u st be taken to exclu d e any
contraind ication to high velocity thru st. Screening qu estions
that contraind icate joint m anip u lation inclu d e evid ence of, or
su sp icion of, intra articu lar p athologies, fractu re, com p ro
m ised bone d ensity, p rolonged u se of corticosteroid s or anti
coagu lant m ed ication, p ain d om inant d isord ers and , in you ng
child ren, incom p lete bone m atu rity. Once the d ecision is
m ad e to p roceed to m anip u lation, clear su ccinct inform ation
shou ld be p rovid ed to the p atient w ith risks and bene ts
d iscu ssed . As a m inim u m , verbal consent and a record in the
p atient notes ind icating agreem ent to p roceed w ith m anip ula
tion is recom m end ed .
The therap ist’s left hand is p laced ju st d istal to the p atient’s
right rad iohu m eral joint, extend ing over the lateral part of the
elbow joint (Fig. 41.6). The therapist’s right hand grasps the
p atient’s forearm m ed ially at the elbow. Slight external rota
tion of the p atient’s w hole arm allow s a gravity assisted
thru st. The therap ist shou ld ensu re that the elbow joint is not
locked in fu ll extension bu t approxim ately 5° short of fu ll
extension, as this avoid s a painfu l and u nsuccessful thrust,
and then exam ine the position of restriction to establish the
Joint mobilization and manipulation o  the elbow
Figure 41.6 Manipulation in lateral glide o the elbow (varus thrust
manipulation). The black arrow shows the therapist’s lateral stabilizing hand placed
distal to the radiohumeral joint. The white arrow shows the varus direction o the
high-velocity low-amplitude thrust.
d irection that is restricted by gently guid ing the joint laterally
(varus force). It is im portant that the therap ist’s right (thrust
ing) arm is placed perpend icular to the patient’s elbow joint.
The therapist then inform s the patient to soften the arm and
relax, and that he / she w ill now provid e a rap id thrust, w hich
m ay be associated w ith an au d ible clicking or p op p ing sou nd .
Reassu rance that this p op p ing sou nd is exp ected and sim p ly
ind icates a joint cavitation is helpfu l ad vice for patients. The
techniqu e then consists of ap p lying a high velocity low
am plitud e thru st (grad e V) force d irected in a m ed iolateral
d irection. Post m anipu lation, joint range and pain provoca
tion shou ld be reassessed .
Conclusion
There is increasing evid ence that, w hen used ap propriately,
joint m obilization and m anipu lation techniques can help to
alleviate pain and assist in restoring function in patients w ith
m u scu loskeletal elbow d isord ers. Clinicians need to u nd er
stand the p u tative neu rop hysiological and tissu e m echanism s
u nd erlying elbow joint m obilization (inclu d ing p lacebo anal
gesia) and recognize that these techniqu es typically form only
a sm all p art of a m ore com prehensive evid ence based m an
agem ent ap proach.
Re erences
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and interaction w ith m otor control. Clin J Pain 24: 291–298.
Assend elft W, Green S, Buchbind er R, et al. 2004. Tennis elbow. Clin Evid 11:
1633–1644.
Bisset L, Paungm ali A, Vicenzino B, et al. 2005. A system atic review and m eta
analysis of clinical trials on physical interventions for lateral epicond ylal
gia. Br J Sports Med 39: 411–422.
Bisset L, Beller E, Jull G, et al. 2006. Mobilisation w ith m ovem ent and exercise,
corticosteroid injection, or w ait and see for tennis elbow : rand om ised trial.
BMJ 333: 939.
Ed m ond SL. 2006. Joint m obilization / m anipu lation, 2nd ed n. Lond on: Mosby
Elsevier, pp 86–87.

Fernánd ez Carnero J, Fernánd ez d e las Peñas C, d e la Llave Rincon AI, et al.
2008. Bilateral m yofascial trigger points in the forearm m uscles in p atients
w ith chronic u nilateral lateral ep icond ylalgia: a blind ed , controlled stu d y.
Clin J Pain 24: 802–807.
Fernánd ez Carnero J, Fernánd ez d e las Peñas C, d e la Llave Rincon AI, et al.
2009. Wid espread m echanical pain hyp ersensitivity as sign of central sen
sitization in u nilateral ep icond ylalgia: a blind ed , controlled stu d y. Clin J
Pain 25: 555–561.
Graven N ielsen T. 2006. Fund am entals of m uscle p ain, referred pain, and d eep
tissue hyperalgesia. Scand J Rheum atol 122: 1–43.
H engeveld E, Banks K, Wells P. 2005. Maitland ’s peripheral m anipulation,
4th ed n. Lond on: Elsevier H ealth Sciences.
Jones MA, Rivett DA, Tw om ey L. 2004. Clinical reasoning for m anual thera
pists. Lond on: Elsevier Science Ltd , Bu tterw orth H einem ann.
Kau fm an RL. 2000. Conservative chiropractic care of lateral epicond ylitis.
J Manipu lative Physiol Ther 23: 619–622.
Law rence DJ, H um phreys CR. 1997. Cu bital tu nnel synd rom e: a case report.
Chiropractic Techniqu es 9: 27–31.
Maitland GD. 1986. Vertebral m anip ulation, 5th ed n. Lond on: Butterw orth
H einem ann.
Conclusion 463
Mu lligan B. 1989. Manu al therapy ‘N AGS’, ‘SN AGS’, ‘MWMs’, etc.
Wellington, N Z: Plane View Services.
Pau ngm ali A, Vicenzino B, Sm ith M. 2003. H ypoalgesia ind uced by elbow
m anipu lation in lateral epicond ylalgia d oes not exhibit tolerance. J Pain
4: 448–454.
Slater H , Arend t N ielsen L, Wright A, et al. 2005. Sensory and m otor effects
of experim ental m uscle pain in patients w ith lateral epicond ylalgia and
controls w ith d elayed onset m uscle soreness. Pain 114: 118–130.
Slater H , Arend t N ielsen L, Wright A, et al. 2006. Effects of a m anu al therapy
techniqu e in experim ental lateral epicond ylalgia. Man Ther 11: 107–117.
Sm id t N , Assend elft WJ, Arola H , et al. 2003. Effectiveness of physiotherapy
for lateral epicond ylitis: a system atic review. Ann Med 35: 51–62.
Takei H . 2005. Joint m obilization for bone and joint d isease. Phys Ther Sci 20:
219–225.
Vicenzino B, Cleland JA, Bisset L. 2007. Joint m anipulation in the m anagem ent
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50–56.
This pa ge inte ntiona lly le ft bla nk
 P AR T 7
The Knee Region
In Lower Extremity
Pain Syndromes
42 Ligamentous and Meniscal Injuries of the Knee 467
Carol A. Courtney and Craig P. Hensley
43 Knee Osteoarthritis 482
Lars Arendt-Nielsen and César Fernández-de-las-Peñas
44 Patellofemoral Pain Syndrome 493
Johnson McEvoy and Caroline MacManus
45 Postoperative Management of the Knee: Ligamentous, Meniscal and Total
Joint Replacement 514
Jodi Young and Ellen Pong
46 Joint Mobilization and Manipulation of the Knee 525
Cody Weisbach, William Egan, Paul E. Glynn and Joshua A. Cleland
47 Tendinopathy of the Knee 531
Ellen Pong
This pa ge inte ntiona lly le ft bla nk
 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
Ligamentous and Meniscal Injuries of the Knee
CHAP TER CONTENTS
Introduction  467
Anterior cruciate ligament  467
Anatomy  467
Biomechanics  467
Incidence / prevalence of injury  468
Biomechanical / neuromuscular risk factors  468
Posterior cruciate ligament  470
Anatomy  470
Biomechanics  470
Incidence / prevalence of injury  470
Mechanism of injury/risk factors  470
Lateral collateral ligament  471
Anatomy  471
Biomechanics  471
Incidence / prevalence of injury  471
Mechanism of injury / risk factors  471
Medial collateral ligament  471
Anatomy  471
Biomechanics  471
Incidence / prevalence of injury  471
Mechanism of injury / risk factors  471
Meniscus  471
Anatomy  471
Biomechanics  472
Incidence/prevalence of injury  472
Mechanism of injury/risk factors  472
Management of knee ligament rupture and meniscal tear  473
Conservative versus surgical management  473
Conservative management  474
Surgical management  477
Conclusion  477
Introduction
Articular stru ctu res of the knee, includ ing ligam ents and
m enisci, are com m only d am aged d u ring knee joint trau m a.
Consid ering the frequ ency of knee trau m a in the hu m an bod y
(Lou w et al 2008), and that post traum atic knee osteoarthritis
Chapter 
42  
C a ro l A. C o u rtn e y, C ra ig P. He n s le y
(OA) is often a consequ ence (Brow n et al 2006), it is not sur
p rising that consid erable research has ad d ressed the aetiology
and m anagem ent of knee injury. Three joints – the p atellofem
oral, the tibio bular and tibiofem oral – encom pass the knee,
but acu te injury usually occurs at the articu lar stru ctures of
the tibiofem oral joint. There are fou r m ajor ligam ents of the
tibiofem oral joint: the anterior and p osterior cru ciate liga
m ents, and the m ed ial and lateral collateral ligam ents. Tw o
brocartilaginou s m enisci are situ ated betw een the tibia and
fem u r. These stru ctu res, in conju nction w ith the periarticu lar
m u scu latu re, p rovid e stability to the knee, yet allow m u ltip la
nar m obility requ ired for static and d ynam ic resp onses. As a
result, the hu m an bod y is capable of rem arkable bip ed al
agility and speed , and is also m ore su sceptible to m u scu lo
skeletal insu lt.
Anterior Cruciate Ligament
Anatomy
The anterior cru ciate ligam ent (ACL) consists of tw o fu nc
tional u nits: the anterom ed ial and p osterolateral bu nd les. It
originates on the lateral intercond ylar rid ge on the m ed ial
w all of the lateral fem oral cond yle (H ensler et al 2012). The
bund les travel parallel to each other anteriorly and m ed ially,
tw isting to insert in a fossa anterolateral to the tibial sp ine,
and blend ing w ith the anterior p ortion of the lateral m eniscu s
(Markatos et al 2013). The ACL receives its nerve and blood
su p p ly from the tibial nerve and m id d le genicu lar artery from
the p op liteal artery resp ectively (Woo et al 2006).
Biomechanics
The ACL is generally consid ered to be isom etric, m eaning that
it m aintains a d egree of tautness throu ghout the physiological
knee range of m otion (ROM) (Am is & Daw kins 1991). The
tw o bu nd les w ork synergistically to control and lim it ante
rior / posterior translation and rotation of the tibia as the knee
exes (Jord an et al 2007). In full knee extension, both bund les
are u nd er tension, w ith the posterolateral bu nd le und er
m axim al lengthening (H ensler et al 2012). The anterom ed ial
bund le achieves m axim al tension betw een 45° and 90° of knee
exion (Jord an et al 2007; Markatos et al 2013). As the knee
 468 PART 7 • 42 • Ligamentous and meniscal injuries of the knee

extend s, the ACL assists in guid ing the screw hom e m echa
nism of the knee by internally rotating the fem u r and p revent Bo x 4 2 .1 Ris k fa c to rs fo r a n te rio r c ru c ia te
ing internal rotation of the tibia in the closed chain (Papp as lig a m e n t o r m e d ia l m e n is c u s in ju ry
et al 2013). This fu nction becom es critical in sporting events Ante rio r c ruc iate  lig ame nt
that requ ire cu tting and p ivoting.
The m axim u m tensile strength of the ACL is ap p roxim ately • Competitive game (versus training)
1725 ± 270 N , w hich is signi cantly less than the m axim u m • Playing s urface
forces occu rring d uring vigorou s athletic activities (Markatos Dry s urface
et al 2013). H ow ever, other passive and d ynam ic stabilizers Cold temperature
contribu te to p reventing inju ry. For m u scles to assist in stabi As troturf or rubber
lization of the knee, effective p rop riocep tive feed back is • Athletes (versus non-athletes )
requ ired (Markatos et al 2013). Althou gh it has been su g • Gender
gested that the ACL m ay p lay a role in proprioceptive feed
Male: higher absolute ris k
back, ow ing to its rich su pply of m echanoreceptors and free
nerve end ings (Markatos et al 2013), it is generally accepted Female: higher injury rate
that the m u scle sp ind le is the m ain m ed iator of p rop riocep tive • Age: 15–25 years
acu ity (Gand evia & McCloskey 1976; Sharm a 1999). Thu s, • Elevated body mass
althou gh loss of p rop riocep tive acu ity has been rep orted fol • Increas ed joint laxity
low ing ACL ru p tu re (Barrack et al 1989; Roberts et al 2007), • Posture
the m echanism s behind this som atosensory change are not Genu recurvatum
fu lly u nd erstood and are probably m ore com plex than sim ple
Navicular drop
p erip heral recep tor d am age (Cou rtney et al 2013).
Subtalar pronation
• Sex hormone variation
Incidence / prevalence of injury First half of menstrual cycle
During the menstrual cycle
Globally, the annu al incid ence of ACL inju ries is estim ated to
• Fatigue
be 0.01–0.05%, or 10–50 per every 100 000 p eop le (Moses et al
2012), w ith ap p roxim ately 70% sustained as non contact inju • Proprioceptive de cits knee
ries (Bod en et al 2000; H ew ett et al 2006a). Many potential risk • Proprioceptive de cits lumbar s pine
factors for ACL inju ry have been id enti ed (Box 42.1). • Previous ACL injury
• Previous low back pain
• Genetics
Biomechanical / neuromuscular risk factors COL5A1 gene
It has been su ggested that ACL injury occu rs w ithin 10–40 m s Chromos omal region 11q22
of initial contact betw een the foot and the grou nd d u ring • Range of motion limitations
m ovem ents su ch as cu tting, land ing, d eceleration and p ivot Trans verse plane: hip
ing (Krosshau g et al 2007; Koga et al 2010). A great d eal of Ankle dorsi exion
research has been cond ucted to elu cid ate the role of biom e Me dial me nis c us
chanics and the neu rom u scu lar system in risk for ACL inju ry,
p articu larly that of non contact origin. Find ings lend su pport • Increas ed body mass
to the id ea that p oor control in all card inal p lanes from the • Caucasians / African
tru nk to the ankle d u ring d ynam ic m ovem ents is a m ajor risk • Americans in US military
factor for d eveloping ACL injury. • Occupation
Sports requiring cutting and twis ting
Trunk Prolonged kneeling
Altered tru nk position has a large im pact on force attenuation • Previous knee injury
and low er extrem ity kinem atics. The perform ance of athletic • Generalized os teoarthritis
m anoeu vres, su ch as land ing or cu tting, w ith d ecreased tru nk • Posture – knee varus
exion is a risk factor for ACL inju ry, probably d ue to greater
knee extensor effort (Ku las et al 2008) and rectus fem oris
activity (Zazu lak et al 2005), w hich m ay increase anterior erating from d rop jum ps (Pollard et al 2010), hence accentuat
shear force on the knee and stress on the ACL (Mend igu chia ing the risk of ACL injury.
et al 2011). Furtherm ore, it m ay lead to d ecreased hip extensor In the coronal plane, trunk d isplacem ent has also been
effort (Ku las et al 2008), gluteu s m axim u s activity (Zazu lak im p licated w ith ACL inju ry. Placing the ground reaction force
et al 2005) and shock absorption at the hip (Decker et al 2003). (GRF) lateral to the knee m ay increase knee valgus angle and
Fem ales, w ho are at higher relative risk for ACL injury than torqu e (Pollard et al 2007; Dem p sey et al 2009), a know n risk
m ales, tend to have higher knee to hip m om ent ratios d u ring factor for ACL inju ry (Fig. 42.2). In a prospective stud y,
vertical d rop ju m p s (Ford et al 2010), and those w ho exhibit Zazu lak et al (2007) fou nd that increased lateral tru nk d is
higher knee valgu s angles (Fig. 42.1) and m om ents have low er p lacem ent after a su d d en force release p red icted knee liga
hip extensor m om ents and less shock absorp tion w hile d ecel m ent inju ry. When cou p ling tru nk d isp lacem ent w ith p oor

Figure 42.1 Anterior cruciate ligament injury risk factor: increased knee
valgus angle.
Figure 42.2 Anterior cruciate ligament injury risk factor: lateral trunk
displacement.
tru nk p rop riocep tion and history of low back p ain, ACL
inju ry w as p red icted w ith 91% accu racy in fem ales. Du ring in
vivo analysis of ACL inju ry, H ew ett et al (2009) fou nd that
fem ales m oved their tru nks lateral to the ACL inju red lim b,
w hich w as uncom m on am ong m ales.
Lim ited research has been rep orted on the relationship
betw een transverse p lane tru nk kinem atics and ACL injury.
Anterior cruciate ligament 469
Figure 42.3 Anterior cruciate ligament injury risk factor: increased hip
adduction angle.
Ireland (1999) d escribed a ‘p osition of no retu rn’ in w hich
rotating the trunk to the opp osite sid e potentially increases
hip ad d u ction and internal rotation angles, thereby lead ing to
greater knee abd u ction angles and m om ents.
Hip
As w ith sagittal plane tru nk p osture, stu d ies have d em on
strated that fem ales tend to land (Salci et al 2004; Schm itz et al
2007) and cut (Mclean et al 2004; Land ry et al 2007) w ith
low er hip exion angles com pared w ith m ales, resulting in
ACL injury (Bod en et al 2009) – althou gh this evid ence is
controversial (H ew ett et al 2006b).
In the coronal plane, peak hip ad d u ction angles (Fig. 42.3)
have been fou nd to be greater in fem ales d u ring ru nning
(Chappell et al 2007; Chu m anov et al 2008), single leg hop
tasks (H ew ett et al 2006a) and cu tting (McLean et al 2005;
Land ry et al 2007). The hip ad d u ction angle w as reported as
the only signi cant p red ictor of higher knee abd u ction angle,
a risk factor for ACL injury (H ew ett et al 2005), d uring an
u nanticip ated cu tting m anoeu vre (Im w alle et al 2009). Con-
versely, Sigw ard and Pow ers (2007) found that fem ales w ith
greater knee valgu s m om ent d u ring sid e step cu tting had
larger hip abd uction angles at initial contact; these au thors
sp ecu lated that this strategy m oved the centre of p ressu re
laterally to the centre of m ass of the tibia, thus increasing the
valgu s m om ent.
H ip strength d e cits have also been im plicated w ith ACL
injury. Weakness in both hip extension (H ollm an et al 2013)
and external rotation and abd u ction (Claiborne et al 2006)
correlated w ith knee abd u ction angle and m om ent, althou gh
other stu d ies have challenged this notion (Sigw ard & Pow ers
2006; Sigw ard et al 2008). In one stud y, d e cits in hip external
rotation torque d uring a land ing task w ere ind epend ently
 470 PART 7 • 42 • Ligamentous and meniscal injuries of the knee
p red ictive of ACL re ru ptu re (Paterno et al 2010). Lastly,
Law rence et al (2008) rep orted that the greatest knee anterior
shear force in a land ing task w as d em onstrated by the grou p
w ith the w eakest hip external rotation strength.
Knee
Strain on the ACL has been show n to be highest w hen trans
verse and coronal p lane load s at the knee are ap p lied at less
than 40° of knee exion (Dürselen et al 1995; Markolf et al
1995). At low er knee exion angles, the quad riceps exerts a
higher anteriorly d irected force on the tibia that is p oorly
cou nteracted by the ACL and ham strings (Blackbu rn & Pad u a
2008). Therefore, it seem s p lau sible that m anoeu vres resu lting
in low knee exion angles increase the risk of ACL inju ry. In
a system atic review, Shim okochi and Schu ltz (2008) fou nd
that ACL inju ries com m only occu rred at or near fu ll knee
extension.
Altered quad riceps and ham string m u scle activation p at
terns m ay change anterior shear forces and knee extensor
m om ents, hence m aking the ind ivid u al m ore su scep tible to
ACL inju ry. Fem ales tend ed to perform athletic m anoeuvres
w ith increased qu ad riceps activation (Malinzak et al 2001;
Zazu lak et al 2005; Sigw ard & Pow ers 2006; Yu et al 2006;
Chap p ell et al 2007), prod ucing greater anterior shear forces
on the tibia and ACL (DeMorat et al 2004). Paterno et al (2010)
fou nd a 4.1 tim es greater asym m etry in knee extensor m om ent
in those w ith re ru p tu red ACLs in d ynam ic tasks. In a recent
review, H ew ett et al (2012) noted altered qu ad riceps and
low ered ham string activation strategies, along w ith low ered
ham string to qu ad ricep s torqu e ratios in fem ales.
Dynam ic valgus torqu es on the knee m ay signi cantly
increase anterior tibial translation and load on the ACL
(Fu ku d a et al 2003). Fem ales d em onstrated m ore knee abd u c
tion m om ents and angles com p ared w ith m ales d u ring ath
letic m anoeu vres (Carson & Ford 2011). H ew ett et al (2005)
p rospectively fou nd that fem ale athletes w ho suffered ACL
inju ry had 2.5 tim es larger knee abd u ction m om ents, 8° m ore
knee abd u ction angles at land ing, and 20% higher GRF com
p ared w ith u ninju red athletes. Other stu d ies have su pported
these nd ings (Olsen et al 2004; Paterno et al 2010).
Ankle  /  foot
In the sagittal plane, the ability of the ankle to absorb shock
and p revent anterior tibial translation is critical to m aintain
ing the stability of the ACL. Self and Paine (2001) fou nd that
land ing w ith the largest ankle p lantar exion p osition at initial
contact d em onstrated the greatest shock absorp tion and least
GRF. In p reventing anterior tibial translation, the gastrocne
m iu s and soleu s p rovid e a signi cant p osterior force of the
tibia d u ring a land ing task in healthy m ales (Mokhtarzad eh
et al 2013).
Posterior Cruciate Ligament
Anatomy
The posterior cruciate ligam ent (PCL) consists of tw o bu nd les:
an anterolateral and a posterom ed ial bu nd le (Mejia et al 2002).
The PCL travels in a lateral to med ial d irection (Amis et al
2006; Bowman & Sekiya 2010) along the anterolateral asp ect of
the m ed ial fem oral cond yle (Fanelli et al 2010) in the inter-
cond ylar notch. The PCL receives its nerve and blood su p p ly
from the p opliteal plexu s, d erived from the posterior articular
nerve off the tibial nerve and obtu rator nerve (Kenned y et al
1982) and m id d le genicu lar artery respectively.
Biomechanics
In cad aver stu d ies the PCL has been show n to have the
greatest tensile strength of the knee ligam ents, the m ajor con
tribu tor being the anterolateral bu nd le (Race & Am is 1996).
The PCL’s p rim ary fu nction is to resist posterior translation
of the tibia, w ith the second ary fu nction of lim iting external
rotation of the tibia (Bu tler et al 1980; Gollehon et al 1987;
Grood et al 1988) and varus stress (Bow m an & Sekiya 2010)
in greater d egrees of knee exion. Whereas sectioning the
PCL alone resu lted in only a sm all am ou nt of laxity in the
coronal and transverse p lane (Gollehon et al 1987; Grood et al
1988), cutting other posterolateral stru ctu res as w ell greatly
increased the am ount of laxity in these planes (Gollehon
et al 1987; Grood et al 1988). This m ay be of clinical im por
tance becau se p osterolateral corner inju ries m ay occu r con
currently w ith PCL inju ry in u p to 60% of inju ries (Fanelli &
Ed son 1995). Posterolateral corner inju ries m ay includ e the
iliotibial band , biceps fem oris tend on, qu ad riceps retinacu
lum , lateral p atellofem oral ligam ent, lateral collateral liga
m ent (LCL), p op liteo bu lar ligam ent, p op liteu s m u scle and
tend on, arcu ate ligam ent com p lex, p osterolateral cap su le
and / or lateral capsu lar ligam ent (Quarles & H osey 2004;
Pacheco et al 2011).
Restraint of p osterior translation by the PCL increases w ith
increasing knee exion, p rovid ing app roxim ately 90–95% of
p osterior stability betw een 30° and 90° (Butler et al 1980; Race
& Am is 1996; Covey et al 2008). Research has su ggested that
nearly 75% of posterior stability is accou nted for by the ante
rolateral bu nd le betw een 40° and 120° knee exion, bu t 57%
is provid ed by the p osterom ed ial bu nd le beyond 120° of
exion (Bu tler et al 1980). In PCL d e cient knees u nd er
load ing w ith a leg press, the m ed ial tibiofem oral contact point
is m ore anterior than in healthy knees, a nd ing that hints at
the im p ortance of the PCL in sagittal p lane biom echanics
(Fu kagaw a et al 2010; Chand rasekaran et al 2012). Stu d ies
have also su ggested that ind ivid u als w ith PCL inju ry typ i
cally have m ore m ed ial fem oral cond yle cartilage d egenera
tion (Strobel et al 2003).
Incidence / prevalence of injury
The reported incid ence of PCL d am age has ranged from 1%
to 40% in acu te knee inju ries (O’Donoghu e 1955; Degenhard t
& H u ghston 1981; Clancy et al 1983; Parolie & Bergfeld 1986;
Fanelli 1993), w ith the vast m ajority of su ch d am age occurring
d u ring trau m a (Fanelli 1993; Fanelli et al 2010) and in com bi-
nation w ith other ligam entous inju ry (48–94%) at the knee
(Fanelli & Ed son 1995, 2010; Schu lz et al 2003).
Mechanism of injury / risk factors
The m ajority of PCL inju ries occu r in a hyper exed knee from
a p osterior d irected force on the tibia, su ch as, for exam p le, a
d ashboard inju ry d u ring a m otor vehicle accid ent, or a fall
onto a exed knee (Fanelli et al 2010).

Lateral Collateral Ligament
Anatomy
The extracap su lar lateral collateral ligam ent (LCL), or bu lar
collateral ligam ent, extend s ap proxim ately 6.5 cm in knee
extension, connecting the posterior and su perior aspect of the
fem oral lateral ep icond ylar rid ge to the bu lar head (Meister
et al 2000; LaPrad e et al 2004a). As the knee m oves from
extension to exion, the trajectory of the ligam ent m oves from
an 11° p osterior to a 19° anterior slop e (Meister et al 2000).
The biceps fem oris bu rsa encapsu lates the d istal 25% of the
LCL (LaPrad e & H am ilton 1997). The average w id th of the
LCL is 36.6 m m (Terry & LaPrad e 1996; LaPrad e et al 2003).
Biomechanics
With increasing knee exion the LCL slackens (Meister et al
2000). The LCL serves as the prim ary lim itation to varu s
op ening (Sanchez et al 2006), p articularly at 0–30° of knee
exion. LCL load ing resp onses w ere fou nd to be highest at
30° of knee exion (Laprad e et al 2004b), becom ing slightly
lax w ith exion beyond 30° (LaPrad e & Wentorf 2002).
In the transverse plane, the LCL is the prim ary restraint to
external rotation of the tibia from 0° to 30° of knee exion,
w ith the popliteus m u scle serving as the prim ary restraint
beyond 60° (LaPrad e et al 2004b). The LCL m ay also p rovid e
resistance to internal rotation of the tibia at 15° and beyond
60° of knee exion (Meister et al 2000). H ence the LCL seem s
m ost su scep tible to inju ry at 30° of knee exion.
Incidence / prevalence of injury
Isolated injury to the LCL is rare. In patients w ith knee liga
m ent inju ries, only 7–16% had isolated LCL inju ry (DeLee
et al 1983; Grana & Janssen 1987). Kru khaug et al (1998)
reported that only 25–30% of lateral knee inju ries w ere sports
related , w hereas 52% w ere d u e to traf c accid ents. When the
LCL is inju red , other stru ctu res of the p osterolateral corner
are often d am aged as w ell.
Mechanism of injury / risk factors
The m ost com m on cause of LCL and / or PLC inju ry in sport
is a blow to the anterom ed ial knee near full extension, m ost
typ ically in football, soccer or skiing on snow (Qu arles &
H osey 2004). External rotation of the tibia w hile cu tting or
pivoting w ith hyp erextension of the knee m ay increase the
risk (Qu arles & H osey 2004).
Medial Collateral Ligament
Anatomy
The m ed ial or tibial collateral ligam ent (MCL) is d ivid ed into
tw o stru ctu ral com p onents: the su p er cial and the d eep MCL.
The su per cial MCL attaches to the d istal fem ur slightly prox
im al and p osterior to the m ed ial epicond yle (LaPrad e &
Wijd icks 2012) and has tw o tibial attachm ents: the proxim al
Meniscus 471
attachm ent, w hich blend s w ith the sem im em branosu s tend on
fascia and attaches 1 cm d istal to the tibiofem oral joint line,
and the d istal, w hich attaches broad ly to the p osterom ed ial
tibia 6 cm below the joint line (LaPrad e & Wijd icks 2012;
Schein et al 2012). Most of the d istal attachm ent is w ithin the
p es anserine bu rsa and is the stronger of the tw o (Schein et al
2012). The d eep MCL is a thickening of the joint capsu le
(LaPrad e & Wijd icks 2012) and is attached to the m ed ial
m eniscu s (Laprad e & Wijd icks 2012). A bu rsa lies betw een the
d eep and su per cial MCL (Schein et al 2012).
Biomechanics
The MCL provid es valgu s stability to the knee. The p roxim al
d ivision of the su per cial MCL has been show n to be the
p rim ary valgu s stabilizer, w hereas the d eep MCL serves a
second ary role (Grif th et al 2009; Wijd icks et al 2009). The
MCL also contribu tes to transverse stability of the knee. The
d istal segm ent of the sup er cial MCL is critical for external
rotation stability, particularly at 30° of knee exion (LaPrad e
& Wijd icks 2012). The contribution of the super cial MCL to
internal rotation stability is greatest at 45–90° of exion
(Kenned y et al 1976). One role of the d eep MCL is to control
anterior tibial translation w hen the knee is exed and exter
nally rotated (Grif th et al 2009).
Incidence / prevalence of injury
The MCL and associated m ed ial knee stabilizers are the m ost
frequently inju red ligam ents of the knee (Schein et al 2012).
The m ajority of these tears are isolated inju ries (LaPrad e &
Wijd icks 2012). The MCL is injured in at least 42% of knees
w ith ligam entous injuries and the yearly incid ence of m ed ial
knee injury in the USA is abou t 0.24 p er 1000 peop le – rou ghly
am ou nting to 74 000 inju ries per year (Schein et al 2012).
Mechanism of injury / risk factors
The m echanism of MCL inju ry typically involves valgu s knee
load ing, tibial external rotation or a com bination of the tw o
in knee exion (Qu arles & H osey 2004), w hich m ay resu lt
from a contact injury su ch as a clip in Am erican football. One
stu d y fou nd that up to 70% of MCL injuries in p rofessional
soccer w ere contact inju ries (Lu nd blad et al 2013). Med ial
knee injuries are m ore com m on in you th than in old er age,
and tw ice as likely in m ales as in fem ales (LaPrad e & Wijd icks
2012; Schein et al 2012).
Meniscus
Anatomy
The knee m enisci are crescent shaped brocartilaginous
tissu es located in the m ed ial and lateral com p artm ents of the
tibiofem oral joint (Fox et al 2012). The peripheral 10–30% is
vascu larized and the rem aining area receives nu trition via
synovial u id (Stärke et al 2009). The inner bord ers taper
m ed ially to a thin free ed ge (Fox et al 2012). The m enisci are
d istally at and p roxim ally concave so as to accept the convex
fem oral cond yles (Englu nd et al 2012). They are connected at
 472 PART 7 • 42 • Ligamentous and meniscal injuries of the knee
their resp ective anterior horns via the transverse ligam ent.
The nerve su pply travels w ith the vascu latu re to the periph
ery and horns of the m enisci (Kenned y et al 1982); hence pain
is not typ ically elicited from m echanical stim u lu s of the inner
region of the m enisci (Dye et al 1998).
Medial  meniscus
The m ed ial m eniscu s is sem icircular in shape, w ith the poste
rior horn broad er in w id th than the anterior horn (Greis et al
2002). The horns d em onstrate broad er attachm ent com pared
w ith the lateral m eniscu s (Fox et al 2012). The coronary liga
m ent is the tibial p ortion of the cap su lar attachm ent (Fox et al
2012). The m ed ial m eniscu s is anchored at its m id point to the
fem u r via the d eep MCL (Fox et al 2012).
Lateral  meniscus
The lateral m eniscus is nearly circular in shape. It covers a
larger area of the tibia (Arnoczky & Warren 1982), and the
anterior and p osterior horns attach m u ch closer to each other,
com p ared w ith the m ed ial m eniscu s (Fox et al 2012). The
p osterior horn attaches to the m ed ial fem oral cond yle via
anterior (H u m p hrey) and p osterior (Wisberg) m eniscofem o
ral ligam ents that originate near the PCL attachm ent on the
fem u r, althou gh their presence is variable (Ku sayam a et al
1994) and their fu nction u nknow n.
Biomechanics
Besid es nu trition and lu brication to the joint (Renström &
Johnson 1990), the prim ary fu nctions of the m enisci are to
transm it load (Ahm ed & Bu rke 1983) and absorb shock
(Fithian et al 1990). The m enisci transm it ap proxim ately 50%
of the com p ressive load in knee extension, and 85% at 90° of
exion, m ostly through the posterior horn (Walker & Erkm an
1975). For every 30° of knee exion, the contact su rface
betw een the tibiofem oral su rfaces d ecreases by 4% (Walker &
H ajek 1972), m aking com pressive load s m ore focal. Rem oval
of the m enisci resu lts in a signi cant red u ction in fem oral
contact area (Ahm ed & Burke 1983), increasing the risk of
d egenerative changes at the tibiofem oral joint (Englu nd et al
2012). It has been d em onstrated that norm al knees have a 20%
greater capacity to absorb shock com pared w ith those that
u nd ergone m eniscectom y (Voloshin & Wosk 1983).
Stu d ies have show n that, w hereas the lateral m eniscu s
m oves anyw here from 9 m m to 11 m m in anterior–p osterior
d isplacem ent w ith knee exion, the m ed ial m eniscu s m oves
only abou t 2–5 m m (Thom pson et al 1991). This lack of m ove
m ent m ay p lace the m ed ial m eniscu s at m ore risk of inju ry,
p articu larly in the p osterom ed ial corner, w hich m oves the
least (Thom p son et al 1991). With the ACL intact, the m ed ial
m eniscu s has little effect on anterior–posterior translation;
how ever, follow ing ACL ru p tu re the p osterior horn of the
m ed ial m eniscu s becom es the m ost im p ortant anterior trans
lation resistor (Shoem aker & Markolf 1986). Both m enisci are
im p ortant in knee joint stability (Levy et al 1989).
Incidence / prevalence of injury
In the US, m eniscal injuries are the m ost com m on intra
articu lar knee lesions and are the m ost frequ ent cause of
orthop aed ic su rgery (Salata et al 2010). The cum ulative risk
of m eniscal inju ry that necessitates su rgery in p atients betw een
the ages of 10 and 64 years is as high as 15% (Lohm and er et al
2007). The m ean annual incid ence of m eniscal lesions has
been reported to be betw een 61 and 70 per 100 000, 61 of w hich
result in m eniscectom y (Baker et al 1985; H ed e et al 1990;
N ielsen & Yd e 1991). Meniscal injury incid ence rates in physi
cally active populations have ranged betw een 0.33 and 0.61
p er 1000 (Baker et al 1985; Laud er et al 2000). In one stu d y in
the US m ilitary, the m ed ial m eniscu s w as tw ice as likely to be
injured relative to the lateral m eniscus (Jones et al 2012).
The p revalence of m eniscal lesions in p atients w ith clinical
and rad iographic nd ings of OA is 68–90% (Bhattacharyya
et al 2003; Englund et al 2007). The m ost frequent location
is the posterior horn of the m ed ial m eniscus (Bhattacharyya
et al 2003).
Mechanism of injury / risk factors
Gender
The ratio of m ale to fem ale m eniscal inju ry has ranged
betw een 2.5 : 1 and 4 : 1 (Baker et al 1985; Steinbrü ck 1999). In
a stu d y in the US m ilitary, m en w ere nearly 20% m ore likely
than w om en to su stain a m eniscal inju ry (Jones et al 2012);
how ever, after ad ju sting for sp orts related inju ry, m ales and
fem ales w ere show n to have sim ilar risk. H ow ever, there
is contrad ictory evid ence suggesting that fem ales are
m ore likely than m ales to su stain m ed ial m eniscu s inju ry,
p articu larly at the p osterior horn (Ozkoc et al 2008; H w ang
et al 2012).
Age
Som e stu d ies have su ggested that the inju ry risk p eaks
betw een the ages of 20 and 29 (Baker et al 1985; Steinbrü ck
1999). In the US m ilitary, increasing age w as show n to be an
ind ep end ent risk factor, w ith those over the age of 40 having
fou r tim es the risk com p ared w ith those you nger than 20
(Jones et al 2012). Increasing age w as also show n to be a risk
factor in posterior horn m ed ial m eniscus tears (Ozkoc et al
2008; H w ang et al 2012). In professional basketball players,
lateral m eniscus tears w ere m ore com m on in those younger
than 30, w hereas in old er players the m ed ial m eniscus inju ries
w ere m ore prevalent (Yeh et al 2012). In youth, 1 / 3 of m enis
cu s inju ries are sp orts related (Baker et al 1985); the m echa-
nism of inju ry typ ically involves cu tting or tw isting m ovem ents
w ith or w ithou t knee exion (Greis et al 2002). Interestingly
thou gh, in p rofessional basketball p layers the m ost com m on
m echanism of inju ry is insid iou s (Yeh et al 2012). An increased
incid ence of m eniscal tearing has been observed in skeletally
im m atu re child ren, as a grow ing nu m ber of ind ivid u als
w ithin this category are particip ating in athletics (Makris
et al 2011). Motor vehicle accid ents also account for a large
m ajority of m eniscal tears in the you ngest age grou p (Baker
et al 1985).
In m id d le aged and eld erly patients, m eniscu s tears are
u sually d egenerative. In those aged 50–90 years, the preva
lence of m eniscal tears increases w ith age, ranging from 19%
in w om en aged 50–59 years to over 50% in m en aged 70–90
years (Englu nd et al 2008). It is im p ortant to note that m any
of these tears w ere asym p tom atic. In a recent system atic
 Management of knee ligament rupture and meniscal tear 473

review, age over 60 years w as associated w ith increased risk Table 42.1 Spe cia l te s ts for liga me nt and me nis cal injury
for d egenerative tears (Snoeker et al 2013). Other risk factors
are noted in Box 42.1. Te s t Se ns itivity (%) Spe cif city(%)

Ante rio r c ruc iate  lig ame nt

Management of Knee Ligament Lachman’s testa 85 94

Rupture and Meniscal Tear Pivot-shifta 24 98

Anterior drawera 92 91
Prop er m anagem ent of knee joint trau m a shou ld entail a thor Po s te rio r c ruc iate  lig ame nt
ou gh su bjective and objective exam ination, inclu d ing a
d etailed accou nt of the m echanism of inju ry w hen joint Posterior drawerb 90 99
trau m a has occu rred . Previou s m ed ical history, inclu d ing Posterior sag b 79 100
prior injuries, w ill aid in d eterm ining p rognosis and treat
Quadriceps active b 98, 54 97–100
m ent p lan. Su bjective screening for aberrant p ain p rocessing
m ay help the clinician gain a m ore holistic u nd erstand ing of Me nis c us
the client’s cond ition. Sp eci cally, p sychosocial ‘d rivers’, su ch Apley’s c 60 70
as d ep ression, hyp ervigilance, catastrophization and fear
avoid ance m ay facilitate p rogression to chronic p ain (Esteves McMurray’s c 70 71
et al 2013). In certain athletic settings, these contributing Joint line palpation c 63 77
factors m ay be m ore prevalent becau se of the pressure or
d esire to retu rn to sport (Clem ent et al 2013). Su bjective ques Thes salys d 90 98
tioning and u se of w ritten clinical ou tcom e m easu res m ay Ege’s tes te 67 81
help to d eterm ine fu nctional d e cits. Objectively, both p hysi
Co llate ral lig ame nts
ological and accessory joint ROM shou ld be exam ined to
d eterm ine aberrant joint m ovem ent, inclu d ing hypo and Valgus s tres s test (MCL)f 86 Not reported
hyp erm obility. Mu scle p erform ance assessm ent, inclu d ing Varus s tress tes t (LCL)f 25 Not reported
strength and m otor control, is critical, w ith a strength at least a
Benjamins e et al 2006; b Malanga et al 2003; c Hegedus et al 2007; d Harris on et al
90% of that in the u naffected lim b u sed as the typical stand ard 2009; e Aks eki et al 2004; fHarilainen 1987.
for successfu l ou tcom e (Thom eé et al 2012). Special tests aid
in d ifferential d iagnosis, hence it is im portant to u tilize tests
that are both sp eci c and sensitive (Table 42.1). Objective
functional m easures (Bru m itt et al 2013) aid in d eterm ining Prop riocep tive loss can be consid ered another exam p le of
prognosis and p rovid e a baseline for d eveloping return to hyp oaesthesia, and m ay also be related to nocicep tive sensi
sp ort skills and activities. Recent recom m end ations su ggest tization (Cou rtney et al 2013); how ever, this has not been
restricting the u se of d iagnostic im aging to cases w hen frac investigated .
tu re is su sp ected based on the Ottaw a Knee ru les, or w hen
the p hysical exam ination is p ositive for m eniscal or ligam en Conservative versus surgical management
tou s d am age (Jackson et al 2003). These gu id elines have been
con rm ed by the Am erican College of Rad iology Ap p rop ri The d ata on the best therapeu tic options follow ing ACL injury
ateness Criteria for acu te knee inju ry (Tuite et al 2012). are inconclusive. A Cochrane review conclu d ed that there is
Another clinical m easu re – qu antitative sensory testing – insuf cient evid ence from rand om ized clinical trials to d eter
m ay help to d eterm ine the effect of the joint trau m a on m ine w hether su rgery or conservative m anagem ent is best
nocicep tive p rocessing (Arend t N ielsen & Yarnitzsky 2009; follow ing ACL injury (Linko et al 2005). In a retrospective
Courtney et al 2010a). The pressu re pain threshold can stu d y, Streich et al (2011) fou nd no d ifferences in self rep orted
provid e an objective m easure of m u scu loskeletal tissue ten m easu res and the incid ence of knee OA w hen com p aring
d erness (hyperalgesia) at the site of inju ry, such as the m ed ial ind ivid u als u nd ergoing ACL reconstru ction w ith those
joint line; it also ind icates expansion of nociceptive sensitivity receiving conservative p hysical therapy at 15 year follow up .
throu gh m easu rem ent at sites rem ote from the inju ry, su ch as Sim ilarly, Meu ffels et al (2009) reported no statistical d iffer
the tibialis anterior m u scle, the contralateral knee, or even ences betw een conservative and operative treatm ent in those
sites in the u p p er extrem ity (Cou rtney et al 2010a; Graven- w ith ACL inju ry w ith respect to knee OA, m eniscal lesions of
N ielsen & Arend t N ielsen 2010). The cutaneous m echanical the knee, activity level, or objective and su bjective fu nctional
d etection threshold and vibration d etection threshold m ay be ou tcom es after 10 years; how ever, better m echanical stability
u sed to id entify loss of sensory fu nction or hyp oaesthesia. w as observed in the surgical grou p. It is im portant to rem em
Although loss of these m od alities m ay occur w ith frank nerve ber that these stu d ies u tilized m u ltim od al rehabilitation pro
injury, this sensory loss m ay also occur as a consequ ence gram m es inclu d ing m anual therapy and exercise program m es.
of altered p ain p rocessing (Apkarian et al 1994). Clinically, Regard ing the PCL, a Cochrane review fou nd no rand om ized
prop riocep tion is not com m only m easu red at the knee; controlled clinical trials that com p ared op erative and con
how ever, d e cits have been id enti ed in ind ivid u als follow servative interventions for PCL inju ry (Peccin et al 2012).
ing ACL injury (Barrack et al 1989; Roberts et al 2007) and Meniscal inju ry has been im p licated as a m ajor contribu tor
m ay contribu te to the aberrant m otor control that is som e to early onset p ost trau m atic knee OA (Roos 2005). Som e
tim es d em onstrated in this p op u lation (H u rley 1997). stu d ies have su ggested that early onset OA follow ing ACL
 474 PART 7 • 42 • Ligamentous and meniscal injuries of the knee
inju ry m ay be a consequ ence of the concom itant m eniscal
inju ry rather than ligam entou s inju ry (Lou bou tin et al 2009).
N evertheless, a system atic review conclud ed that those ind i
vid u als w ith an isolated ACL tear or an ACL tear w ith an
associated m eniscal inju ry reported good short and long
term knee fu nction w ith conservative treatm ent (Myklebu st
& Bahr 2005). H errlin et al (2007) fou nd that arthroscop ic
p artial m ed ial m eniscectom y follow ed by su p ervised exercise
w as not su perior to su pervised exercise alone in term s of
im p rovem ents in knee p ain, knee fu nction and qu ality of life
in p atients w ith non trau m atic m ed ial m eniscal tears. Sim i
larly, a recent sm all rand om ized clinical trial also observed no
d ifferences betw een a conservative physical therapy pro
gram m e (e.g. high repetition, high d osage exercises) and
arthroscop ic surgery in ind ivid u als w ith d egenerative m enis
cu s p athology (Ø sterås et al 2012).
Therefore, althou gh p atients m ay w ish to retu rn to their
p rior level of sp ort and requ est that everything p ossible be
d one to prolong their athletic careers, they should be inform ed
that the risk of fu rther knee lesions and knee OA rem ains
high, w hatever the treatm ent they receive, su rgical or con
servative (Delincé & Gha l 2012).
Althou gh conservative rehabilitation program m es and sur
gical proced u res seem to be equ ally effective, up to one third
of the ind ivid u als receiving conservative treatm ent of ACL
inju ry requ ire late ligam ent reconstru ction, ap p roxim ately
20% retu rn to their pre inju ry level of activity w ithou t any
restriction, and 35–68% requ ire su bsequent m eniscal su rgery
(Ireland 2002). Therefore, d espite all the d ata available for the
m anagem ent of knee joint inju ry, and p articu larly ACL inju
ries, a proced u re for id entifying w hich ind ivid uals m ay be
better cand id ates for either conservative or surgical interven
tion is yet to be established . N evertheless, som e attem p ts have
been m ad e at categorizing those ind ivid uals w ith ACL inju
ries w ho w ill bene t from either intervention. For instance,
‘copers’ are those ind ivid uals w ho are able to retu rn to pre
inju ry activities, inclu d ing sp orts, w ithou t ep isod es of the
knee giving w ay and w ho d o not require su rgical m anage
m ent, w hereas ‘non-copers’ are those w ho either d id not
return to their previou s activity level or exp erienced giving
w ay ep isod es on resum ption of p re injury activities (Kap lan
2011). Fithian et al (2005) su ggested that cop ers are able to
retu rn to sp orts su ccessfu lly for at least 6 m onths w ithou t
ACL surgical intervention. H ow ever, this d istinction seem s to
be arbitrary, since it is p ossible that a signi cant proportion
of ind ivid u als w ho are initially consid ered as p otential non
cop ers m ay, w ith p rop er rehabilitation p rogram m es, be able
to regain d ynam ic knee stability sim ilar to that of p otential
cop ers (Mu aid i et al 2007). Several stud ies have d eveloped
algorithm s to id entify those w ith the p otential to return to
p re injury activity level (Kostogiannis et al 2007; Mu aid i et al
2007; H u rd et al 2008); how ever, Eitzen et al (2010) su ggested
that cond u cting a screening exam ination after a series of reha
bilitation sessions gave the best overall ind ications of fu nc
tional ou tcom es follow ing ACL inju ry.
Conservative management
The goals of conservative m anagem ent follow ing ligam en
tou s or m eniscal inju ry are to p rotect the joint from fu rther
stru ctu ral d am age, to d elay knee osteoarthritic changes and
to re establish fu ll ROM, m u scle strength and neu rom u scu lar
control so as to retu rn to p re inju ry levels of fu nction (Micheo
et al 2010). Joint traum a is a know n risk factor for knee OA
(Felson 2004; Roos 2005), w hich m ay lead to a d ecrease in
function and d im inished quality of life. Su rgery m ay be con
sid ered as a second ary insu lt to the joint, and thu s it can
p rom ote knee OA d isease p rogression. ACL reconstru ction
m ay aid in restoring m echanical stability to the joint and
p revent m eniscal d am age that m ay occu r d u e to excessive
accessory joint m otion in an ACL d e cient knee, althou gh this
p rem ise has been qu estioned (Kaplan 2011). Therefore, a con
servative ap p roach is u tilized w hen overall rehabilitative
goals can be properly m et and long term prognosis is best
enhanced .
Of all knee stru ctu res, the ACL has been researched by far
the m ost extensively, inclu d ing the ef cacy of conservative
rehabilitation. Strehl and Eggli (2007) fou nd that all patients
given successfu l conservative treatm ent w ere able to p erform
low risk pivoting sports and that, in 1 / 3 of the ind ivid u als,
conservative treatm ent led to good or very good clinical
results. The goals of conservative treatm ent are achieved
throu gh a p rogressive rehabilitation p rogram m es d ivid ed
into acu te, recovery and functional phases that could be
p erfectly ap p lied either to treatm ent of ind ivid u als w ho d o
not u nd ergo an op eration or to those treated w ith su rgical
reconstruction. Other au thors have su ggested a six stage
rehabilitation program m e through w hich an ind ivid ual
shou ld p rogress follow ing ACL reconstru ction (H errington
et al 2013), and these stages can be also app lied to conserva
tive m anagem ent of other joint inju ries. Dep end ing on
w hether or not the p atient has received surgical treatm ent, the
stages m ay inclu d e: p reop erative, p ostop erative, p rogressive
lim b load ing, u nilateral load acceptance, sport speci c task
training and u nrestricted sp ort sp eci c training. Progression
throu gh a p rotocol shou ld be gu id ed by the p atient’s resp onse
to treatm ent, and treatm ent techniqu es shou ld not elicit a
are up of p ain and in am m ation. In this section w e w ill
focus on conservative treatm ent, and read ers are referred to
Chapter 45 for postoperative m anagem ent of knee inju ries.
Acute   phase   after   ligamentous  and   meniscal   injury
The overall goal throu ghout the rehabilitation process is to
m ake stead y p rogress in fu nction w hile lim iting concom itant
p ain and sw elling, and to p revent re inju ry. Whereas acceler
ated rehabilitation p rotocols have previou sly been d eem ed
su ccessfu l, recent research consid ering long term ou tcom es
has su ggested that su ch p rotocols m ay, in p art, p rom ote oste
oarthritic d egeneration (Elsaid et al 2012). In the acu te phase
of rehabilitation, the goals therefore inclu d e the red u ction of
p ain and sw elling, regaining of the p hysiological ROM, in
p articu lar achievem ent of fu ll knee extension and p rop er
m obility of the p atella, and early p ain free w eight bearing. In
p articu lar, regaining fu ll knee extension is an im p ortant
m ilestone in rehabilitation and is essential for norm al gait.
H yperexcitability of central nociceptive p rocessing has been
d em onstrated follow ing ACL ruptu re (Cou rtney et al 2011),
ind icating that in am m ation and pain shou ld be carefu lly
m onitored to avoid facilitation of aberrant p ain m echanism s.
Although less researched in acu te knee inju ry, m anu al therapy
techniqu es ap p lied at the joint m ay increase knee joint m obil
ity, d ecrease p ain and facilitate nociceptive processing (Deyle
et al 2005; Cou rtney et al 2010b). Ind ivid uals shou ld start w ith
 Management of knee ligament rupture and meniscal tear 475

isom etric and isotonic contraction of the qu ad riceps and ham

string m u scles w ithou t resistance to p revent atrop hy.

Recovery   phase   of   ligamentous   and    

meniscal  injury
As p ain and in am m ation d im inish, m uscu lar strength, coor
d ination and norm alization of fu nction can be ad d ressed . Gait
retraining, m u scle activation and regaining of fu ll pain free
physiological knee m otion shou ld be em p hasized in this stage
of the rehabilitation p rocess. Also in this recovery p hase, the
goals are to achieve ad equate m otor control and strength in
the low er extrem ity, im p rove p rop riocep tion and balance,
and begin the integration of fu nctional activities. Precau tions
at this stage of the rehabilitative process w ill d epend up on the
injured tissu e, and m ay inclu d e avoid ance of rotational
stresses w ith m eniscal inju ry or valgu s stresses w ith MCL
injury.
Qu ad ricep s m u scle strengthening is an im p ortant m ile
stone in this stage and can be achieved throu gh a com bination
of op en kinetic chain exercises and closed kinetic chain exer Figure 42.4 Leg press exercise for strengthening the quadriceps muscle.
cises. Clinical gu id elines on ACL inju ry from the Du tch
Orthop aed ic Association fou nd m od erate (level 2) evid ence
that op en chain strength training had a p ositive effect on
m u scle strength of qu ad ricep s and ham string m u scu latu re
and on knee fu nctional recovery (Meu ffels et al 2012). Knee
extension in sitting is one of the m ost com m on open kinetic
chain exercises u sed for strengthening the qu ad ricep s m u scle
(H olm et al 1995). H ow ever, this exercise shou ld be perform ed
in a m anner that avoid s knee joint pain and in am m ation.
There is d ebate abou t w hich exercise prescription w ith resp ect
to the nu m ber of rep etitions and sets; it has been p ostu lated
that a high nu m ber of rep etitions (25–30) of each set are m ore
bene cial than sets containing a low er nu m ber of rep etitions
(12–15) (Ø sterås et al 2012). In clinical practice, a norm al pre
scrip tion inclu d es three sets of 10–12 rep etitions for each exer
cise, althou gh this d ep end s on the p hysical d em and s on the
patient.
Closed kinetic chain exercises m ay be m ore bene cial than
op en kinetic chain exercises becau se they are thou ght to
be m ore functional, provid e knee com pression forces and
prom ote qu ad ricep s / ham strings co contraction, thu s red u c
ing anterior tibial translation w ith activity. H ow ever, closed
kinetic chain exercises should be used in a m anner that m ini
m izes stress on vu lnerable tissu es (Fig. 42.4). For exam ple,
greater angles of knee exion can place increased stress on the
m enisci. Therefore, conservative rehabilitation p rogram m es
Figure 42.5 Bilateral squat exercise with less than 60° of knee exion.
shou ld incorp orate both op en kinetic chain and closed kinetic
chain strength training as soon as the stability of the knee and
pain p erm its this. w eight bearing w as noted on the injured lim b in norm al
Most closed kinetic chain exercises are cond u cted in stance as w ell as hyp erexcitable nocicep tive resp onses, even
w eight bearing p ositions since w eight bearing is encou raged thou gh all the ind ivid u als d enied resting p ain. It w as hyp oth
in rehabilitation program m es after knee injuries (Kvist 2004). esized that this pain sensitivity m ay in p art und erlie asym
The clinician m ust ad vance the patient throu gh progressive m etries noted in fu nctional activities p ost knee inju ry
low er lim b load ing from bilateral (Fig. 42.5) to unilateral (Fig. (Cou rtney et al 2011). (See Ch 38 for fu rther inform ation on
42.6) load acceptance. Du ring these exercises, carefu l m onitor exercises of the low er extrem ity.)
ing of the p atient’s overall activity level is essential, as w ell Finally, in ad d ition to w eight bearing strengthening exer
as analysis of exercise perform ance and fu nctional skills, so cises, neu rom u scu lar training p rogram m es (i.e. p rop riocep
as to avoid the d evelop m ent of aberrant m ovem ent patterns. tion p rogram m es) have been show n to be su p erior to
Su btle d ifferences in w eight bearing m ay p ersist thou gh strength training p rogram m es alone for p atients w ith ACL
u nrecognized by the clinician. In fact, in ACL d e cient su b injuries (Risberg et al 2007). These exercises are used to
jects (18 ± 19 m onths since inju ry), signi cantly d im inished d ecrease im balances in qu ad riceps and ham strings m u scles’
 476 PART 7 •
Figure 42.6 Split squat exercise with less than 60° of knee exion.
Figure 42.7 Proprioceptive training on unstable surface in single-leg stance.
strength and to p rom ote their coactivation for knee stabiliza
tion (Wilk et al 2003). Further, proprioceptive and neu rom u s
cu lar interventions can be effective for the p revention of
recu rrent knee injuries (Zech et al 2009). Som e exercises
inclu d e w eight shifts on stable and u nstable su rfaces (Fig.
42.7), perturbation training (Fig. 42.8), plyom etric exercises
(Fig. 42.9) and land ing strategies (Wilk et al 2003). In fact,
clinical gu id elines on ACL inju ry from the Du tch Orthop aed ic
Association fou nd level 1 evid ence that balance and proprio
cep tion training has a p ositive effect on joint p osition sense,
m u scle strength, knee fu nction, fu nctional ou tcom es and
return to fu ll activity in ind ivid uals w ith ACL inju ry
(Meu ffels et al 2012).
42 • Ligamentous and meniscal injuries of the knee
Figure 42.8 Perturbation training induced by the therapist on unstable surface
in single-leg stance.
Figure 42.9 Plyometric exercise: lateral box jumping.
Du ring the recovery phase other fu nctional exercises, su ch
as cycling on a stationary bike or stair w alking, should be
progressively includ ed . At the end of the recovery phase m ore
functional w eight bearing exercises, su ch as jogging, ju m p ing
and land ing, can also be initiated as tolerated .
Exercise p rogram m es can be cond u cted in a clinical setting
u nd er the su p ervision of the p hysical therap ist (clinic based ,
su p ervised ) or at hom e (hom e based , self m onitored ).
Although there are no evid ence based argum ents to recom
m end either one of these su p ervision regim ens (Risberg et al
2007), the clinical guid eline on ACL inju ry of the Du tch Ortho
p aed ic Association su p p orts su p ervised training as being

m ore effective than non su p ervised training (Meu ffels et al
2012). In ad d ition, supervised training p rogram m es can lead
to a low er risk of d am age or excessive tension of the affected
and su rrou nd ing stru ctu res.
Functional  phase  of  ligamentous     Peroneal nerve trau m a m ay occu r concom itantly w ith these
and   meniscal   injury
The goals of the fu nctional phase inclu d e m axim al strength
ening, d eveloping pow er and returning to sp orts. Clinical
d ecision m aking on the retu rn to norm al sport speci c skills
m u st inclu d e u nd erstand ing of the p hysiological m echanism s
behind healing of d am aged and / or repaired tissu es and the
potential joint stresses involved in the activity. Safety in pro
gression to m ore challenging w eight bearing tasks and sport
sp eci c activities is essential. Motor learning p rincip les are
carefu lly u tilized in this p hase of rehabilitation. Vid eo analy
sis, for exam p le, m ay aid in p rovid ing visu al term inal feed
back to the patient. Throughou t the rehabilitation p rocess,
ed u cation on p roper neu rom uscu lar m ovem ent strategies that
serve to p revent p otential re inju ry is necessary. A retu rn to
prop er aerobic tness shou ld be em p hasized throu ghou t all
phases (Della Villa et al 2012). Recent stud ies have recognized
that the nal stage of rehabilitation p rogram m es is often
lim ited or not inclu d ed in the plan of care (Della Villa et al
2012; H errington et al 2013). N otably, these stud ies em phasize
the im p ortance of sp ort sp eci c p erform ance criteria since
prop er fu nctional rehabilitation p rogram m es m ay help
prevent re inju ries in the fu ture.
Surgical management
Anterior   and   posterior   cruciate  ligament
Unlike other ligam ents of the knee, p rim ary repair of the ACL,
either surgical or non surgical, has not been consid ered as a
viable treatm ent op tion in recent years (Feagin & Cu rl 1976).
Rather, the stand ard su rgical m anagem ent follow ing ACL
ru p tu re has been the ACL reconstru ction, w hich is p erform ed
on ap proxim ately 200 000 knees per year in the US (Brophy
et al 2009). In this su rgery, a ‘new ’ ligam ent is harvested from
the p atient’s m id d le third of their p atellar tend on, ham string
tend on, cad aver graft, or another stru ctu re; how ever, the
reported sup erior outcom es w ith any one of these su rgical
op tions is controversial (Foster et al 2010). The p rem ise behind
this su rgical intervention is to p rom ote retu rn to fu nction,
prevent inju ry to other knee joint stru ctu res, in particu lar the
m enisci, and to im p ed e the onset of p ost trau m atic OA (Fu &
Lin 2013). H ow ever, recent estim ates have suggested that 62%
of ind ivid u als u nd ergoing ACL reconstru ction w ill neverthe
less d em onstrate osteoarthritic changes w ithin 10–15 years
follow ing su rgery (Oiestad et al 2010). A recent system atic
review reported that, w hereas ACL reconstruction offered
greater objective tibiofem oral stability, there w as only lim ited
evid ence d em onstrating an increased bene t of either recon
stru ction or non su rgical m anagem ent in term s of fu nctional
ou tcom es (Sm ith et al 2014).
Posterior cru ciate ligam ent inju ries are typ ically treated
non op eratively w hen less severe, su ch as isolated grad e I or
II injury, w ith m ost patients retu rning to sp ort (Petrigliano &
McAllister 2006). Su rgical reconstruction of the PCL has been
Conclusion 477
recom m end ed in acu te inju ries w ith severe posterior tibia
su blu xation and instability (Margheritini et al 2002; Iw am oto
et al 2004). The p osterolateral corner inju ry can be easily
m issed on clinical exam , and su rgical m anagem ent has been
the recom m end ed cou rse of treatm ent (Pacheco et al 2011).
injuries, so thorough neu rological exam m ay be critical in
these ind ivid u als. (See Ch 45 for post su rgery rehabilitation
of ACL and PCL.)
Medial   and   lateral   collateral   ligament
Isolated MCL injuries are generally treated conservatively,
and m ost have a su ccessfu l ou tcom e (LaPrad e & Wijd icks
2012). Grad e III injuries, d e ned as a com p lete tear of the liga
m ent, are m ore likely than other grad es to be associated w ith
d am age to other knee stru ctu res. For exam ple, a general pro
tocol for m anagem ent of com bined grad e III MCL and ACL
injury is to rehabilitate the m ed ial knee inju ry rst, allow ing
it to heal accord ing to the guid elines for isolated m ed ial knee
inju ries, and then to reconstru ct the ACL 5–7 w eeks after
injury once there is good clinical and / or objective evid ence
of healing of the m ed ial knee inju ry (Wijd icks et al 2010).
Typ ical m anagem ent follow ing LCL inju ry is d irected
tow ard conservative rather than su rgical care. H ow ever, fol
low ing high im pact inju ry, isolated LCL ru ptu re is rare, ind i
cating that su rgical d ecision m aking algorithm s m ay change
(Levy et al 2011). Bu shnell et al (2010) stu d ied LCL inju ries in
p rofessional football p layers and fou nd that non op erative
m anagem ent of isolated grad e III inju ries resu lted in m ore
rapid retu rn to p lay and an equ al likelihood of retu rn to p lay
at the professional level com p ared w ith op erative m anage
m ent. (See Ch 45 for post surgery rehabilitation.)
Meniscal   injury
Meniscal su rgery has a long history, w ith total m eniscectom y
serving as the treatm ent of choice u ntil the latter p art of the
20th centu ry, u ntil it w as d iscovered that com p lete rem oval
of the m eniscu s accelerated the rate of osteoarthritic d egen
eration (Englu nd et al 2012). Since then both partial m eniscec
tom y, p reserving as m u ch tissu e p ossible, and m eniscal rep air
have been u tilized in su rgical m anagem ent (Englu nd et al
2012). Repair of the m eniscus has been ad vocated w hen the
ind ivid u al is in the second to fourth d ecad e of life and can
com p ly w ith p ostop erative p recau tions for the p rescribed
tim e fram e, w hen the tear is sym p tom atic and greater than
10–12 m m in length, and w hen the tear is located in the
p erip heral asp ect of the m eniscu s and is red u cible (N oyes &
Barber Westin 2010). A system atic review has d em onstrated
better long term outcom es w ith m eniscal repair than w ith
m eniscectom y (Xu & Zhao 2013). (See Ch 45 for p ost su rgery
rehabilitation of m eniscal inju ries.)
Conclusion
Knee joint trau m a is com m on p articu larly in the you ng sp ort
ing popu lation, and has been the topic of consid erable
research. Recent stu d ies have su ggested that speci c exercise
p rogram m es m ay aid in p reventing these inju ries. In those
ind ivid u als w ho have sustained joint inju ry, the goals of
 478 PART 7 • 42 • Ligamentous and meniscal injuries of the knee
su rgical and non su rgical m anagem ent are to restore joint
stability for the p revention of d am age of other joint stru ctu res,
to regain fu nction and to p revent early onset of osteoarthritic
d egeneration at the joint. Recent evid ence has placed a
renew ed focu s on the im portance of m onitoring and lim iting
joint effu sion, pain and in am m ation d u ring the reha
bilitation process to prevent facilitation of aberrant p ain
m echanism s.
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 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
Knee Osteoarthritis
43  Chapter 
La rs Are n d t- N ie ls e n , C é s a r Fe rn á n d e z - d e - la s - P e ñ a s
CHAP TER CONTENTS
Introduction  482
Sensory manifestations in osteoarthritis  482
Sensitization in osteoarthritis  483
Speci c pain mechanisms in knee osteoarthritis  483
Pathophysiology and biochemistry of osteoarthritis  483
Biomechanics of knee osteoarthritis  484
Challenges in the management of osteoarthritis-related pain  484
Pharmacological management  484
Non-pharmacological management  485
Arthroplasty  488
Conclusion  489
Introduction
Osteoarthritis (OA) is the m ost requ ent m u scu loskeletal
d iagnosis in the eld erly population and the m ost com m on
cau se o d isability (Peat et al 2001); 40% o em ales and 25%
o m ales aged 60–70 years are d iagnosed w ith OA (Van Saase
et al 1989), in w hich knee OA is the m ost prevalent. With the
expected global grow th in the eld erly p op ulation and con-
com itant rise in stationary li estyle choices, the incid ence o
OA is p red icted to increase in the com ing years.
Sensory Mani estations
in Osteoarthritis
At the ind ivid u al patient level, severe knee joint d am age m ay
cau se little p ain, w hereas that w ith m inor / no rad iological
changes m ay cau se severe p ain (Davis et al 1992; H annan et al
2000; N eogi et al 2009). H ow ever, at a population basis this
d iscord ance is less evid ent (Bed son & Cro t 2008). A total o
10–20% o ind ivid u als w ith regional p ain su bsequently
d evelop w id espread pain (Mourão et al 2010; Atzeni et al
2011; Sarzi-Pu ttini et al 2011), as is o ten seen in m uscu loskel-
etal p ain synd rom es.
The su bjective sensory m ani estations o m u scu loskeletal
p ain in hu m ans inclu d e cram p-like, d i u se aching p ain and
p ain re erred to d istant som atic stru ctu res, as w ell as m od if -
cations in the su p erf cial and d eep p ain sensitivity in the
re erred pain areas (Arend t-N ielsen & Graven-N ielsen 2002,
2003). These m ani estations are d i erent rom cu taneous p ain,
w hich is norm ally su perf cial, localized arou nd the inju ry and
exhibits a sharp and burning quality. Pain localization is poor
rom m uscu loskeletal stru ctures, and it is d i f cult to d i eren-
tiate it rom p ain originating rom tend ons, ligam ents and
bones as w ell as rom joints and their cap su les.
Mu scle-re erred p ain is typ ically d escribed as a sensation
rom d eep structures, in contrast to visceral-re erred pain,
w hich is both su perf cially and d eep ly located . Muscle-
re erred pain has been know n and d escribed or m ore than a
centu ry and it is u sed extensively as a d iagnostic tool. The
re erred pain p attern m ore requently ollow s the d istribution
o sclerotom es (m u scle, ascia and bone) than that o the clas-
sical d erm atom es. A d istinction betw een sp read o p ain and
re erred pain is not possible, and these p henom ena m ay share
com m on p athop hysiological m echanism s. Firm neu rop hysi-
ologically based exp lanations or re erred p ain d o not exist,
bu t it has been show n that w id e-d ynam ic-range neu rons and
nocicep tive sp ecif c neu rons in the sp inal cord and the brain-
stem o anim als receive convergent a erent inp u ts rom the
m u cosa, skin, m u scles, joints and viscera. This m ay cau se a
m isinterp retation o the a erent in orm ation com ing rom
m u scle a erents and reaching high levels in the central
nervou s system , and hence it be one reason or the d i u se and
re erred characteristics.
Re erred p ain has been show n to be m ainly a central p he-
nom enon, as it is p ossible to ind u ce re erred p ain to lim bs
w ith com plete sensory loss d u e to spinal inju ry or anaesthetic
blockad e (Laursen et al 1997). The size o the re erred pain
area to exp erim ental joint p ain stim u lation has been ound to
d ep end on both the intensity and the d uration o the nocicep-
tive m u scu loskeletal inp u t (O’N eill et al 2009). OA patients
d em onstrating m ore than one location o pain o ten express
p ain sym p tom s extend ing rom the knee to other locations
(Thom p son et al 2010), w hich su pports the notion that spread -
ing o pain and o sensitization are present in these patients
(Arend t-N ielsen et al 2010b). Finally, anim al m od els o OA
(intra-articu lar injection o m onosod iu m iod oacetate in the
knee joint) have id entif ed spread ing sensitization through
m itogen-activated p rotein kinases (MAPKs), sp ecif cally ERK
and p 38 p hosphorylation (Lee et al 2011) w ith associated
m echanical allod ynia o the contralateral lim b.

Sensitization in Osteoarthritis
Treating knee OA p ain is challenging as the p athology is
d ecou p led rom the p ain and (1) the und erlying p ain m echa-
nism s are not u lly u nd erstood and , hence, (2) e f cient phar-
m acological and non-p harm acological treatm ents are not
su f ciently d evelop ed . Pain in knee OA is highly ind ivid u al
and no eatu res (e.g. on rad iology) have d em onstrated a
robust correlation w ith pain m ani estations. In recent years, a
variety o new qu antitative p ain assessm ent tools have been
d eveloped or prof ling o patients w ith OA accord ing to the
m echanism s involved , w hich in the u tu re m ay help d evelop -
ing ind ivid ualized pain m anagem ent program m es (Mal ait &
Schnitzer 2013).
There is am ple evid ence that the sensitization in OA is
cau sed by the nocicep tive inp u t rom the joint, as su ccess u l
joint rep lacem ent w ith total pain alleviation resets the
sensitization (Graven-N ielsen et al 2012; Arand a-Villalobos
et al 2013). The sensitization process in m u sculoskeletal
pain is cod ed not only by p ain intensity but also by pain
d u ration, as a variety o stu d ies have show n an association
betw een pain d u ration and level o local and sp read ing
sensitization (Arend t-N ielsen et al 2010a, 2010b). In knee OA,
the p ain intensity / d u ration cod es or the d egree o extraseg-
m ental p ressu re p ain hyp eralgesia (Arend t-N ielsen et al
2010b), sim ilar to tem porom and ibular joint d isord er (TMD)
(Fernánd ez-d e-las-Peñas et al 2009) and chronic tension-type
head ache (Fernánd ez-d e-las-Peñas et al 2008). Fu rtherm ore,
the nu m ber o OA locations is im p ortant w ith resp ect to how
d i usely the OA knee pain is p erceived (Thom pson et al
2010), and the m ore m yo ascial trigger points involved the
m ore generalized is the sensitization (Xu et al 2010). There-
ore, it has becom e increasingly evid ent that sensitization o
the nocicep tive p ain system p lays a role in the clinical p res-
entation o knee OA p ain (Kid d 2012). Peripheral and central
sensitization m echanism s are p resent in p atients w ith
OA (Arend t-N ielsen et al 2010b), neuropathic d escriptors
app ly to su bu nits o p atients w ith OA (Finan et al 2013;
H ochm an et al 2013) and w id espread hyperalgesia has been
d ocu m ented in a nu m ber o stu d ies (Im am u ra et al 2008;
Arend t-N ielsen et al 2010b; Graven-N ielsen et al 2012).
Becau se o the role o sensitization, it has also been argu ed
that p atients w ith OA in w ill general benef t rom ‘d esensitiz-
ing’ d ru gs, su ch as d u loxetine (Citrom e & Weiss-Citrom e
2012) or pregabalin, w hich have been show n e f cacy in anim al
m od els o OA (Rahm an et al 2009).
Specif c Pain Mechanisms
in Knee Osteoarthritis
I the anterior tibialis m u scle in patients w ith OA is tested by
pressu re pain threshold s, this m u scle show s pressu re pain
sensitization as a resu lt o sp read ing sensitization (Su okas
et al 2012). A m ethod has been d eveloped or m app ing
pressu re p ain sensitization in OA as a tool or m onitoring,
or exam ple, d isease progression or the e ect o treatm ent.
In this, pressure is applied to a nu m ber o pred ef ned loca-
tions over the knee and the p ressu re p ain threshold s are d eter-
m ined , w hich are, in tu rn, trans erred onto a three-d im ensional
Pathophysiology and biochemistry of osteoarthritis  483
representation o ind ivid u al knee sur ace contours estim ated
rom MRI scans o the knee (Arend t-N ielsen et al 2010b).
Courtney et al (2009) observed signif cantly red u ced cu rrent
am plitu d e and latency o re ex responses at exion w ith-
d raw al re exes threshold in ind ivid uals w ith knee OA,
inclu d ing those su bjects w ithout resting pain, com pared w ith
control su bjects, w hich su p p orts the p resence o central sen-
sitization in this p op u lation.
One actor su ggested to be im p ortant or sp read ing o p ain
is the statu s o the d escend ing pain control. In several chronic
m u scu loskeletal p ain cond itions (e.g. OA, TMD, f brom yal-
gia) the potency o the d escend ing inhibitory control is
red u ced , thus m aking the entire neu roaxis m ore vu lnerable
to p ain (Arend t-N ielsen & Yarnitsky 2009).
Another actor that seem s to play an im portant role in OA
is central tem poral su m m ation (enhanced pain response to
repeated experim ental stim uli), w hich has been show n to be
acilitated in patients w ith OA (Arend t-N ielsen et al 2010b)
– and is sim ilar to observations in m any other patient pop u la-
tions w ith chronic m u scu loskeletal p ain su ch as f brom yalgia
(Sörensen et al 1998) and w hiplash (Cu ratolo et al 2001). A
recent large knee OA cohort stud y (n = 2126) show ed that the
p ressu re p ain threshold and the tem p oral su m m ation w ere
associated w ith OA-related pain intensity, bu t not w ith rad io-
graphic evid ence o OA (N eogi et al 2013).
Finally, re erred m uscle pain areas evoked by intram uscu -
lar injection o hypertonic saline are signif cantly enlarged in
p atients w ith p ain u l OA (Bajaj et al 2001), again su pporting
the concep tion that re erred p ain and central sensitization are
closely related (Arend t-N ielsen & Graven-N ielsen 2002).
Pathophysiology and Biochemistry
o Osteoarthritis
Pain is a central p art o the clinical p resentation o OA and
the m ain reason or p atients to seek consu ltation. Many and
d iverse stru ctu ral eatures o the joint have been su ggested to
be involved in OA-associated pain inclu d ing, but not lim ited
to, the p resence o osteop hytes in the p atello em oral com p art-
m ent, ocal or d i u se cartilaginou s abnorm alities, su bchon-
d ral cysts, bone m arrow oed em a, su blu xation o the m eniscus,
m eniscal tears and Baker cysts (Read & Dray 2008). H ow ever,
p ain p ercep tion is o ten highly ind ivid u al, and so ar none o
these eatu res have d em onstrated a robu st correlation w ith
p ain. It has alw ays been a p u zzle w hy rad iological joint
changes d o not correlate w ith the clinical p ain intensity
(Lanyon et al 1998; Felson 2005), although a m ore-recent large
clinical trial has show n a relationship betw een Kellgren and
Law rence severity o OA and the intensity o clinical pain
(Laxa oss et al 2010).
H u m an articu lar cartilage has been thou ght to be avascu lar
and aneu ral, bu t recently sym p athetic and sensory nerves
have been id entif ed as p resent w ithin vascu lar channels in
the articu lar cartilage in both m ild and severe OA. Perivascu -
lar and ree nerve f bres and nerve tru nks have also been
observed both w ithin the su bchond ral bone m arrow and
w ithin the m arrow cavities o osteophytes. The f nd ing o
nerve end ings localized in d am aged hu m an articu lar cartilage
by Suri et al (2007) suggests that vascu larization and the asso-
ciated innervation o articu lar cartilage m ay contribu te to
 484 PART 7 • 43 • Knee osteoarthritis
tibio em oral p ain in OA across a w id e range o stru ctu ral
d isease severity. The im plications o these f nd ings are that
the m u scu loskeletal p ain associated w ith OA m ay resu lt rom
a com bination o the hereto-accep ted central and bone-d erived
e ects. A hallm ark o OA d isease is progressive d egeneration
o articu lar cartilage and su bsequ ent joint sp ace narrow ing.
In the m ajority o patients, the aetiology o OA is not know n.
Am ong the know n risk actors are age, signif cant trau m a,
obesity, altered gait, altered biom echanics (e.g. varu s or
valgu s d e orm ity) and excessive load ing.
Exp erim ental and clinical observations su ggest that the
stru ctu ral integrity o articu lar cartilage is d ep end ent on
norm al su bchond ral bone tu rnover, intact chond rocyte u nc-
tion and ord inary biom echanical stresses (H ayam i et al 2004).
An increasing line o evid ence su ggests that there is strong
com m u nication and interaction betw een the su bchond ral
bone and the articular cartilage (Karsd al et al 2008). As bone
and cartilage are closely inter-related , interventions a ecting
p ain related to bone tu rnover m ight in ad d ition be related to
the OA relevant p ain. Changes in the cartilage m atrix tu rno-
ver m ay re ect early alterations in cartilage stru ctu re accou nt-
ing d irectly or ind irectly or knee p ain (Ishijim a et al 2011).
Du ring early-stage OA, the presence and progression o oste-
op hytosis are, or exam p le, accom p anied by increased levels
o cartilage and in am m atory biom arkers (Attur et al 2013;
Ku m m et al 2013). Stu d ies have ind icated that sp ecif c p ain
m echanism s in OA m ay relate to biom arkers associated w ith
cartilage and bone d egrad ation (Ku m m et al 2013). Articu lar
cartilage and su bchond ral bone d am age are key actors in OA
and can be assessed by a variety o new biom arkers (Dam et al
2011) such as u rinary C-term inal telop eptid es o type I colla-
gen (CTX-I), CTX-II, type III collagen N -p ropeptid e (PIIIN P),
and m atrix m etallop roteinase (MMP)-m ed iated d egrad ation
ragm ents o typ e I, II and III collagen (C1M, C2M and C3M
resp ectively) (Garnero 2001). Ishijim a et al (2011) show ed typ e
II collagen d egrad ation (sC2C and u CTX-II) and orm ation
(sCPII), bone resorption (u N Tx) and hence, or exam p le, syno-
vitis m ay contribu te to joint p ain.
Arthroscop ic evalu ations o knee joints reveal that abou t
25% o su bjects w ith knee OA have in am ed synovial tissu e
(synovitis), resulting in sym ptom atic OA (i.e. joint sw elling,
p ain and joint sti ness). These p atients have increased risk o
rad iographic progression (Gold ring & Otero 2011; Scanzello
et al 2011). As in am m ation is consid ered as one actor
involved at som e stages in the p rogression o OA, the in am -
m atory p rocess m ay be associated w ith alterations in the
p rof le o cytokines (e.g. interleu kin-6, IL-6) (Livshits et al
2009). Som e cytokines m ay act as biochem ical m arkers o
OA severity and p ain (Saetan et al 2011) – the m ost com m only
m easu red cytokines in knee OA are IL-6 and tu m ou r necrosis
actor α (TN F-α ) (Pearle et al 2007; Livshits et al 2009;
Scanzello et al 2009). Various stud ies have id entif ed a corre-
lation betw een knee OA severity and higher levels o seru m
cytokines, su ch as TN F-α solu ble receptors sTN FR1 and
sTN FR2, and C-reactive p rotein (CRP) (Pelletier et al 2001;
Miller et al 2008). IL-1 and IL-1R inhibitors have been tested
in clinical OA trials, bu t both anakinra and AMG-108 have
been reported to have lim ited benef cial e ects on sym ptom s
and signs in knee OA (Chevalier et al 2009; Cohen et al
2011). H ow ever, these stud ies w ere d one in a m ixed p op ula-
tion o OA p atients. Sim ilar e ects on joint m etabolism
have been attribu ted to TN F-α , m aking it another target or
anti-in am m atory treatm ent. Un ortu nately none o these
therap ies has yet p roven e ective in OA, althou gh a sm aller
stu d y d em onstrated trend s tow ard s im p rovem ent o joint
health u p on treatm ent w ith ad alim u m ab (Magnano et al
2007). IL-6 is receiving increased interest in the OA f eld . TN F
has been com p ared w ith other p ro-in am m atory cytokines
and has been show n to be elevated in eld erly p atients w ith
knee OA (Stannu s et al 2010).
Stu d ies have d escribed the association o d isability
(WOMAC) and higher levels o p ro-in am m atory cytokines
(Ferraro & Booth 1999; Ferru cci et al 2002; Miller et al 2008).
In ad d ition, specif c cytokines m ay provoke d am age o the
extracellu lar m atrix o the joint tissu e (Gold ring et al 2011). A
novel biom arker sp ecif c to MMP cleavage is the CRPM,
w hich re ects local in am m ation, w hereas circulating,
u ncleaved CRP re ects system ic in am m ation (Vigu shin et al
1993). It is there ore o relevance to investigate how joint
d am age, m easu red by these novel d isease-related biom arkers,
is related to pain m echanism s. Fu rther, m any authors have
reported on the e ects o d i erent variables, such as u nc-
tional p er orm ance (Ferrucci et al 2002), obesity (Miller et al
2008), clinical aspects (Penninx et al 2004) and rad iological
severity o OA (Livshits et al 2009) on the seru m or intra-
articu lar levels o cytokines. In obese p atients, m ore and m ore
stu d ies have show n hyp ersensitivity to p ain and also that
these ind ivid u als are m ore vu lnerable to d evelop ing p ain,
p ossibly ow ing to the low -level in am m atory p rocesses
initiated by cytokine release rom ad ipose tissu e (Deere
et al 2012).
Biomechanics o Knee Osteoarthritis
Abnorm al knee load ing is an im p ortant actor in OA progres-
sion (And riacchi et al 2004; H u nter & Felson 2006). The m ed ial
knee com partm ent is u su ally m ore a ected than the lateral
com p artm ent as the m ed ial p art norm ally bears the m ajority
o the load s across the knee d u ring gait (H u rw itz et al 1998).
Extrinsic m easu res o m u scu loskeletal load ing d u ring gait
p lay a m ajor role in the id entif cation o inju ry m echanism s,
as m ed ial knee OA is associated w ith changes in gait p atterns
attributed to m ovem ent-ind u ced nociception (Mü nd erm ann
et al 2005; H enriksen et al 2006). The entire low er extrem ity
acts as a linked kinetic u nit w ith ad ap tations in d istal bod y
segm ents having signif cant e ects on load ing p atterns
throu ghou t the extrem ity, inclu d ing the knee (Mü nd erm ann
et al 2005; Lid tke et al 2010). N o correlation betw een plantar
load ing and Kellgren-Law rence grad e has been ound (Lid tke
et al 2010).
Few stud ies have investigated oot pronation in p atients
w ith knee OA, but they d em onstrated that patients w ith
m ed ial knee OA exhibit a m ore p ronated oot com p ared
w ith controls (Reilly et al 2009; Barton et al 2010; Levinger
et al 2010).
Challenges in the Management o
Osteoarthritis-related Pain
Pharmacological management
For m any years, oral analgesics su ch as acetam inophen
and N SAIDs have been the m ainstream treatm ent or
 Challenges in the management of osteoarthritis-related pain
sym p tom atic OA. In act, p harm acological m od alities cond i-
tionally recom m end ed or the initial m anagem ent o ind i-
vid u als w ith knee OA inclu d e acetam inop hen, oral and top ical
N SAIDs, tram ad ol, and intra-articu lar corticosteroid injec-
tions, intra-articu lar hyalu ronate injections and d u loxetine,
w hereas opioid s are cond itionally recom m end ed in patients
w ho had an inad equ ate response to initial therap y (H ochberg
et al 2012).
The increased aw areness o N SAID toxicity has changed
treatm ent recom m end ations to m ove aw ay rom the long-
term u se o these agents in sym p tom atic OA. System atic
review s and m eta-analyses o rand om ized placebo-controlled
trials have been p u blished to estim ate the analgesic e f cacy
o N SAIDs, inclu d ing selective cyclo-oxygenase-2 inhibitors
(coxibs) in ind ivid u als w ith knee OA (Bjord al et al 2004, 2005,
2007b). The stu d ies conclud ed that N SAIDs red uced short-
term p ain in OA o the knee slightly better than p lacebo.
H ow ever, the su bsequent analysis d id not su pport long-term
u se o N SAIDs or this cond ition, as seriou s ad verse e ects
can be associated w ith oral N SAIDs. Another m eta-analysis
evaluated rand om ized controlled trials o short-term (less
than 4 w eeks) e f cacy o topical N SAIDs in OA and reported
that a ter 2 w eeks there w as no evid ence o their e f cacy as
being su perior to placebo (Lin et al 2004).
Cu rrent recom m end ations or sym p tom atic treatm ent o
OA list p aracetam ol (4 g per d ay) as the f rst-line analgesic
d espite its lim ited analgesic e ect in this cond ition. It is
obviou s that cu rrent OA m anagem ent regim ens d o not at all
ocus on p ossible perip heral and central m ani estation o this
chronic p ain cond ition. One reason or this is the lack o
u nd erstand ing o the u nd erlying cau ses o p ain in OA in
com bination w ith a shortage o e ective d ru g cand id ates.
Com bination therap ies are also u sed w id ely to treat p ain
in OA, as is the case in all other pain cond itions. Stronger
op ioid s su ch as oxycod one and transd erm al entanyl /
bu prenorphine have been show n to be e ective in red ucing
p ain scores and im p roving unction in patients w ith knee and
hip OA (Lang ord et al 2006; Breivik et al 2010). Overall,
how ever, the relative lack o e f cacy and the m any sa ety
issues su rrou nd ing both N SAIDs and opioid s have led the
p harm aceu tical ind u stry to invest in f nd ing new and m ore
e ective com p ou nd s or m anaging OA pain, or exam ple, and
p rom ising resu lts have been published u sing, or exam p le,
m onoclonal nerve grow th actor (N GF) antibod y in OA p ain
(Katz et al 2011; Seid el & Lane 2012; Sanga et al 2013). Un or-
tu nately the anti-N GF treatm ent cau sed osteonecrosis in
p atients on ad d itional N SAIDs, and hence the au thorities
tem p orarily term inated the clinical trials. H ow ever, the N GF
target is o signif cant interest as a treatm ent or the u tu re.
Other p harm acological ap p roaches inclu d e the u se o
top ical therap ies su ch as N SAID cream s and gels as they seem
to show a better sa ety record (ad verse events < 1.5%) com -
p ared w ith oral ad m inistration. In a lim ited num ber o trials,
top ically ap p lied cap saicin has been show n benef t or reliev-
ing pain in patients w ith OA (Mason et al 2004).
Intra-articular steroid injections are w id ely u sed to red uce
OA p ain, althou gh the d u ration o relie m ay last only a ew
w eeks (Bellam y et al 2005). Intra-articu lar hyalu ronic acid
(hylu ronan) has sym ptom atic benef ts sim ilar to those o
intra-articu lar steroid s and , althou gh the onset o action is
d elayed , the e ect m ay last u p to 12 m onths (Lo et al 2003).
Glu cosam ine and chond roitin su l ate have been p op u lar
or the treatm ent o OA ow ing to the avou rable early
485
reports. H ow ever a large-scale m u lticentre and placebo-
controlled trial cou ld show no benef t over p lacebo (Clegg
et al 2006).
The pharm aceu tical ind u stry has a strong interest in d evel-
op ing new analgesic com p ou nd s or OA p ain. Com p ou nd s
su ch as TrkA / B recep tor blockers, anti-N GF m onoclonal
antibod ies, CB2 agonists, FAAH inhibitors, d i erent inhibi-
tors o the p rostagland in cascad e, d i erent coxibs, P2X7
recep tor antagonists and TRPV1 antagonists are currently
u nd er investigation in clinical trials or the treatm ent o p ain
in OA. The role o calcitonin in OA has also attracted renew ed
interest (Arend t-N ielsen et al 2009).
Non-pharmacological management
Several non-p harm acological m od alities are clinically
em ployed or rehabilitation o patients w ith knee OA. The
Am erican College o Rheu m atology (ACR) recently con-
clu d ed that non-p harm acological m od alities strongly recom -
m end ed or the m anagem ent o knee OA p ain inclu d e aerobic,
aquatic and / or resistance exercise, as w ell as w eight loss or
overw eight p atients (H ochberg et al 2012). In ad d ition, non-
p harm acological m od alities cond itionally recom m end ed or
knee OA includ e m ed ial w ed ge insoles or valgu s knee OA,
su btalar strap p ed lateral insoles or varu s knee OA, m ed ially
d irected patellar tap ing, m anual physical therapy, w alking
aid s, therm al agents, tai chi, sel -m anagem ent p rogram m es
and psychosocial interventions (H ochberg et al 2012). These
recom m end ations have been u rther su pported in other
review s (Roos & Juhl 2012; Segal 2012; Ad am s et al 2013;
Uthm an et al 2013). Fu rther, the European League against
Rheu m atism (EULAR) has recently proposed 11 recom m en-
d ations or the m anagem ent o ind ivid u als w ith hip and knee
OA inclu d ing rehabilitation p rogram m es as w ell as ed u ca-
tional teaching activities to m od i y u nhealthy li estyle habits
(Fernand es et al 2013). N evertheless, clinicians shou ld be
aw are that the choice o therapy shou ld be d eterm ined by
p atient characteristics and p atient choice.
Therapeutic exercise
Therapeutic exercise is probably the m ost recom m end ed ther-
ap eutic intervention or ind ivid uals w ith knee OA, given its
benef cial e ects, ease o application, ew ad verse e ects and
relatively low costs. Regular exercise can red uce physical
im pairm ents, im prove m obility, d ecrease the risk o alls,
acilitate loss o bod y w eight and im prove qu ality o li e by
increasing participation in occupational, social and recrea-
tional activities (Rod d y et al 2005; Bartels et al 2007; Fransen
& McConnell 2008, 2009; Bennell & H inm an 2011). Beckw ée
et al (2013) su ggested that exercise cou ld achieve im p rove-
m ent in f ve categories: neu rom u scu lar, p eriarticu lar, intra-
articu lar, psychosocial com p onents, and general f tness and
health.
Several review s and clinical gu id elines recom m end both
strengthening and aerobic exercise, bu t there are m u ltip le
other ap p roaches su ch as stretching / exibility, end u rance
training, aqu atic exercise and increasing general p hysical
activity that have also show n prom ising resu lts (Rod d y et al
2005; Bartels et al 2007; Fransen & McConnell 2008, 2009;
Bennell & H inm an 2011).
Fransen and McConnell (2008), in their Cochrane review,
conclu d ed that land -based therap eu tic exercise had
 486 PART 7 • 43 • Knee osteoarthritis

signif cant benef ts in term s o p ain (stand ard ized m ean d i -

erence (SMD) 0.40, 95% CI 0.30–0.50) and u nction (0.37, 95%
CI 0.25–0.49) com p ared w ith a control grou p. This review d id
not f nd signif cant d i erences in the m agnitu d e o treatm ent
e ects betw een d i erence types o exercise program m es, in
agreem ent w ith other review s (Rod d y et al 2005; Bartels et al
2007; Jam tved t et al 2008; Fransen & McConnell 2009). Another
Cochrane review conclu d ed that aqu atic exercise interven-
tions had sm all-to-m od erate e ects on u nction (SMD 0.26,
95% CI 0.11–0.42) and large e ect on pain (0.86, 95% CI 0.25–
1.47) or com bined hip and knee OA (Bartels et al 2007).
A m ore recent review ou nd strong evid ence or aerobic
and strengthening exercise p rogram m es, both land and
w ater based , or im proving p ain and physical u nction in
ad u lts w ith m ild -to-m od erate knee and hip OA (Golightly Figure 43.1 Active straight leg raise as non-weight-bearing exercise or
et al 2012). strengthening the quadriceps muscle.
Contrary to p reviou s review s that conclu d ed no clear su p e-
riority o one orm o exercise over another in im proving p ain
and u nction, a recent m eta-analysis p rovid ed tentative evi-
d ence about the m ost e ective exercise interventions or
p atients w ith low er lim b OA (Uthm an et al 2013). The overall
d i erence betw een exercise and control in pain intensity w as
−2.03 cm (95% CI –2.82 to −1.26 cm , large e ect size) or
strengthening-only exercise, −1.26 cm (95% CI −2.12 to
−0.40 cm , m ed iu m e ect size) or exibility plu s strengthen-
ing exercise, −1.74 cm (95% CI −2.60 to −0.88 cm , m ed ium
e ect size) or exibility plu s strengthening plu s aerobic,
−1.87 cm (95% CI −3.56 to −0.17, m ed iu m e ect size) or
aqu atic strengthening, and −1.87 cm (95% CI −4.11 to −0.68 cm ,
large e ect size) or aqu atic exibility p lu s strengthening
exercise. The overall d i erence in u nction or the com bina-
tion o strengthening, exibility and aerobic exercise versu s
no control w as −1.32 units (95% CI −2.44 to −0.21 units,
m ed iu m e ect size). This review conclu d ed that exercise
interventions com bining strengthening w ith exibility and
aerobic exercise (either land or w ater based ) seem ed to be the
m ost e ective intervention w hen one consid ered m easu res o
both pain and u nction in low er lim b OA (SMD −0.63, 95% CI
−1.16 to −0.10) (Uthm an et al 2013).
Another recent system atic review conclu d ed that m u scle-
strengthening exercises w ith / w ithou t w eight-bearing and
aerobic exercises are e ective or p ain relie in people w ith
knee OA (Tanaka et al 2013). The m ost e ective exercise o
the three typ es is non-w eight-bearing strengthening exercise
(Tanaka et al 2013).
Based on available d ata, regu lar therap eu tic exercise shou ld Figure 43.2 One-leg standing exercise with the knee bent or proprioceptive
be early includ ed in the treatm ent o knee OA pain. Patients training in close kinetic chain.
shou ld p rogress rom non-w eight-bearing exercises w ithou t
(Fig. 43.1) or w ith resistance to w eight-bearing exercises, par-
ticu larly those in close kinetic chain (Fig. 43.2). In act, there exercise or OA by such actors as age, sex and obesity
is som e evid ence ind icating the e ectiveness o p rop riocep - (Golightly et al 2012).
tive exercises cond u cted in close kinetic chain com p ared w ith
general strengthening exercises in unctional outcom es; Manual therapy
how ever, m ore research in this area is clearly need ed (Sm ith
et al 2012). Som e p u blished clinical gu id elines on the m anagem ent o
Finally, areas related to exercise program m es as therapeu - OA recom m end ed m anu al therap y as an ad ju nctive therap y
tic interventions or knee OA that requ ire u rther research to exercise or OA (N ational Institute o H ealth and Clinical
inclu d e exam ination o the long-term e ects o exercise Excellence (N ICE) 2008; Royal Au stralian College o General
p rogram m es, balance training or OA, exercise p rogram m es Practitioners (RACGP) 2009); how ever, these recom m end a-
or severe knee OA, the e ect o exercise program m es on tions w ere based on lim ited evid ence since ew stu d ies
p rogression o OA, the e ectiveness o exercise or joint had been p u blished at that tim e (French et al 2011). A qu es-
sites other than the knee or hip , and the e ectiveness o tionnaire su rvey o p hysiotherap ists based on clinical
 Challenges in the management of osteoarthritis-related pain 487

recom m end ations rom N ICE (2008) revealed that exercise

w as u sed by 100% o therapists, o ten su pp lem ented w ith
electrotherap eu tic m od alities (66%), m anu al therapy (64%)
and acu p u nctu re (60%) (Walsh & H u rley 2009). In act, the
app lication o exercise therapy or m anu al therap y w as m ore
cost e ective than u su al care at p olicy-relevant valu es o
w illingness-to-pay rom the perspective o both the health
system and society (Pinto et al 2013). N evertheless, there is a
lack o clear d escription o w hat constitu tes m anu al therapy
or knee OA in the literatu re, since it includ es joint-biased
techniqu es, so t-tissu e-biased interventions, therap eu tic exer-
cise, p ostu ral corrections, etc.
Few system atic review s on the e ectiveness o m anu al
therap y in knee OA have been p u blished . French et al (2011)
conclu d ed that there is inconclu sive (silver level) evid ence
that m anu al therap y is e ective or d ecreasing p ain and u nc-
tion in ind ivid u als w ith knee OA. Brantingham et al (2012)
also ou nd m od erate evid ence (level B) or short-term and
inconclu sive evid ence (level C) or long-term treatm ent o
knee OA w ith m anipu lative therap y.
The reasoning or includ ing m anu al therapies into the
m anagem ent o p atients w ith knee OA is that som e stu d ies
have d em onstrated analgesic e ects and m od u lation o sp inal
excitability w ith u se o m anual therapy techniqu es, w ith clini-
cal ou tcom es o im p roved gait and u nctional ability (Cou rt-
ney et al 2011). Moss et al (2007) observed a d ecrease o
pressu re p ain sensitivity both at the m ed ial joint line and at a
d istal non-p ain u l site (ankle) ollow ing a 9-m inute bou t o
accessory m obilization o the tibio em oral joint in patients Figure 43.3 Posterior-to-anterior accessory mobilization technique applied on
the tibio emoral joint.
w ith knee OA. Cou rtney et al (2010) reported d im inished
exor w ithd raw al re ex responses ollow ing the application
o a 6-m inu te bou t o oscillatory joint m obilization in p atients
w ith knee OA, ind icating that analgesic e ects o knee m obi-
lization includ e m od u lation o segm ental spinal cord excita-
bility or d escend ing inhibition rom the brainstem . This
hyp othesis is su p p orted by an anim al stu d y w here knee joint
m obilization red u ced cap saicin-ind u ced hyp eralgesia at the
ankle (Slu ka & Wright 2001). The m obilization interventions
per orm ed in these stu d ies consists o large-am plitud e, acces-
sory m obilization techniqu e to the knee in the p osterior-to-
anterior d irection (Fig. 43.3). In these stud ies, the knee joint
m obilization w as ap plied at a rate o approxim ately 45 oscil-
lations p er m inu te or 6–9 m inutes (Moss et al 2007; Cou rtney
et al 2010).
Another m anu al therapy generally u sed in the m anage-
m ent o chronic p ain is m assage. Perlm an et al (2006) ou nd
that 8 w eeks o m assage therapy signif cantly im proved pain
and u nction in the short term in patients w ith knee OA;
how ever, the au thors recognized that the m assage therap y
w as not stand ard ized . In a ollow -up stu d y, the sam e au thors
stand ard ized a p rotocol o m assage or knee OA o 60-m inute
session inclu d ing e eu rage, p etrissage, tap otem ent, vibra-
tion, riction and skin rolling ap p lied m ainly to the low er
extrem ities (Fig. 43.4), bu t also to the u pper extrem ity and
d iscretionally (Ali et al 2012). A recent rand om ized controlled
trial conf rm ed that this p rotocol o m assage w as e ective or
red u cing p ain and increasing u nction in patients w ith knee
OA and that the best resu lts w ere observed in those su bjects
receiving a greater d ose (i.e. m ore sessions o 60 m inutes) o
m assage (Perlm an et al 2012).
N evertheless, it has been suggested that m anual therapy,
althou gh not to be used as a stand -alone treatm ent, m ay be Figure 43.4 Skin rolling over the knee area as massage intervention.
 488 PART 7 • 43 • Knee osteoarthritis
benef cial or patients w ith knee OA (Page et al 2011). Deyle
et al (2005) reported that ad d ing som e clinical visits or the
ap p lication o m anu al therap y and su pervised exercise ad d s
greater sym ptom atic relie to hom e exercise program m es or
knee OA. The system atic review cond u cted by Jansen et al
(2011) ou nd that exercise therapy plu s m anual m obilization
show ed a m od erate e ect size (0.69, 95% CI 0.42–0.96) on p ain
com p ared w ith the sm all e ect sizes or strength training
(0.38, 95% CI 0.23–0.54) or exercise therap y alone (0.34, 95%
CI 0.19–0.49). In act, a com bination o exercise and m anual
therap y is recom m end ed in the Du tch p hysiotherap y p ractice
guid eline in hip and knee OA (Peter et al 2011). H ow ever,
these assu m p tions are not su p p orted by a recent rand om ized
controlled trial, w hich ou nd that m anu al therap y w as m ore
e ective than u su al care at long-term ollow -u p (1 year) and
w as sim ilarly e ective as exercise or relie pain and to increase
u nction in knee and hip OA, although there w as no ad d ed
benef t rom a com bination o m anual therap y and exercise
(Abbott et al 2013).
Inconsistency w ithin the results o e ectiveness o m anu al
therap y or therap eu tic exercise can be related to the act that
not all p atients w ith knee OA w ill benef t rom these interven-
tions. In this line, Deyle et al (2012) su ggested that the pres-
ence o patello em oral pain, anterior cruciate ligam ent laxity
and height > 1.71 m w ere variables associated w ith non-
su ccess u l ou tcom es a ter m anu al therap y in p atients w ith
knee OA (overall p rognostic accu racy o 96%). It is there ore
im p ortant that clinicians id enti y the clinical eatu res o those
p atients w ith knee OA w ho w ill benef t rom any p articu lar
intervention.
Acupuncture
Som e clinical gu id elines recom m end acu p u nctu re or ind i-
vid u als w ith knee OA, p articu larly or those p atients w ith
m od erate-to-severe p ain w ho are u nable or u nw illing to
u nd ergo knee arthrop lasty (Zhang et al 2008; H ochberg et al
2012). H ow ever, other guid elines d o not recom m end its u se
(Jord an et al 2003; N ICE 2008). A Cochrane review reported
signif cant im p rovem ent in p ain rom acu p u nctu re versu s
w aiting list (SMD −0.96, 95% CI −1.19 to −0.72) or sham acu -
p u nctu re (SMD −0.35, 95% CI −0.55 to −0.15) (Manheim er et al
2010); how ever, the au thors o the review consid ered that the
benef ts w ere sm all, not clinically relevant and probably d ue,
at least p artially, to p lacebo e ects rom incom plete blind ing.
The m ost u p-to-d ate m eta-analysis conclu d ed that acu punc-
tu re cou ld be consid ered as a p ossible e ective p hysical treat-
m ent or alleviating OA-related knee p ain in the short term ;
how ever, m u ch o the evid ence in this area o research is o
p oor qu ality (Corbett et al 2013). In this m eta-analysis, a sen-
sitivity analysis o satis actory- and good -qu ality stu d ies
revealed that m ost stu d ies w ere o acup u nctu re (11 trials) or
m uscle-strengthening exercise (9 trials). The resu lts show ed
that both interventions w ere signif cantly better than stand ard
care treatm ent, w ith acu p u nctu re being better than m u scle-
strengthening exercise (SMD 0.49, 95% CI 0.00–0.98).
Other therapeutic modalities
There are other therap eutic m od alities that are cu rrently u sed
or knee OA includ ing tai chi, neurom uscu lar electrical
stim u lation (N MES), transcu taneou s electrical nerve stim u la-
tion (TEN S) and short-w ave d iatherm y (SWD).
A recent system atic review ou nd m od erate evid ence or
short-term im p rovem ent o OA-related p ain, p hysical u nc-
tion and sti ness in p atients w ith knee OA p ractising tai chi
(Lauche et al 2013). The analysis revealed m od erate evid ence
or short-term e ects on pain (SMD −0.72, 95% CI −1.00 to
−0.44), p hysical unction (SMD −0.72, −1.01 to −0.44) and
sti ness (SMD −0.59, −0.99 to −0.19). H ow ever, no evid ence
w as ound or long-term e ects (Lau che et al 2013). The
au thors conclu d ed that, assu m ing that tai chi is a short-term
e ective and sa e intervention, it m ight be prelim inarily rec-
om m end ed as an ad ju vant treatm ent or ind ivid u als w ith
knee OA; how ever, m ore high-qu ality rand om ized controlled
trials are need ed to conf rm these resu lts (Lau che et al 2013).
A recent system atic review show ed m od erate evid ence in
avour o N MES alone or com bined w ith exercise or isom etric
qu ad ricep s strengthening in eld erly w ith OA (d e Oliveira
Melo et al 2013); how ever, the quality o the stud ies w as low.
In ad d ition, variation in param eters (pulse requ encies, pu lse
d u ration, cu rrent type and tim e o application) m akes it
extrem ely d i f cult to reach any clinical conclu sions. Despite
this variation in p aram eters, the u se o bip hasic-p u lsed cu r-
rents o 100–400 m s d elivered at stim u lation requ encies
ranging rom 50 to 100 H z at the highest tolerated cu rrent
intensity are suggested as id eal or m u scle strengthening, con-
sid ering the ind ivid u al variations w ithin the p op u lation (d e
Oliveira Melo et al 2013).
The review cond u cted by Bjord al et al (2007a) conclud ed
that TEN S, electroacu p u nctu re and low -level laser therap y
w ere m ore e ective than placebo or relieving p ain in the
m anagem ent o knee OA. In a su bgrou p analysis o rand -
om ized clinical trials w ith assu m ed op tim al d oses, the short-
term e f cacy on pain w as 22.2 m m (95% CI 18.1–26.3) or
TEN S and 24.2 m m (95% CI 17.3–31.3) or laser therapy
(Bjord al et al 2007a). In contrast, the Cochrane review ound
little evid ence or the use o TEN S in ind ivid u als w ith knee
OA (Ru tjes et al 2009); this review observed a sm all SMD or
p ain intensity (SMD −0.07, 95% CI −0.46 to 0.32) in avou r o
TEN S versu s a control grou p .
Finally, the m eta-analysis pu blished by Lau er and Dar
(2012) ou nd sm all, signif cant e ects on p ain and m u scle
per orm ance or SWD, but only w hen treatm ent evoked a
local therm al sensation in the p atient (SMD −0.334, 95% CI
−0.643 to −0.0256).
Arthroplasty
Knee arthrop lasty in one o the gold -stand ard su rgical p roce-
d u res or severe end -stage pain ul knee OA; how ever, approx-
im ately 13% o the p atients a ter total knee replacem ent su er
rom severe chronic postoperative pain (H ard en et al 2003).
For total hip replacem ent the range is 14–32% (Jud ge et al
2010). Fu rther, 44% o f brom yalgia patients w ith signif cant
signs o sensitization su er rom chronic p ostop erative p ain
a ter total knee rep lacem ent (D’Apuzzo et al 2012).
The possible im p ortance o sensitization in total knee
arthroplasty is su pported by the f nd ings that p re- and p ost-
op erative treatm ent o p atients w ith OA w ith p regabalin
red u ces the d evelopm ent o chronic p ostop erative pain a ter
knee replacem ent (Bu vanend ran et al 2010). In ad d ition, as

m any p atients w ith knee OA su er rom p ain a ter total knee
replacem ent, revisions are o ten p er orm ed even or u nex-
plained p ain. An early m eta-analysis show ed that the rate o
revision o knee arthroplasty w as 3.8% at a 4-year ollow -u p
(Callahan et al 1994). Su ch revisions are associated w ith a low
probability o su ccess, o ten leaving the p atients in m ore pain,
w ith m ore im paired u nction (Brow n et al 2006) and w ith
m ore sensitization (Skou et al 2013).
Finally, it is im portant to consid er that short-term and
long-term ou tcom es a ter total knee rep lacem ent are related
to the p ostop erative rehabilitation p rogram m es that the
patient w ill receive (Petterson et al 2009; Bad e & Stevens-
Lap sley 2011). The relevance o rehabilitation a ter total knee
replacem ent is related to qu ad riceps w eakness observed a ter
the su rgical p roced u re. In act, qu ad ricep s m u scle strength is
the strongest p red ictor o u nctional p er orm ance ollow ing
total knee arthrop lasty (Petterson et al 2009). Bad e and
Stevens-Lap sley (2012) su ggested that u se o N MES ap p lied
to the su rgical lim b’s qu ad ricep s m u scle or the f rst 6 w eeks
ollow ing knee replacem ent im proved the sp eed recovery o
qu ad ricep s m u scle strength and led to long-term increases in
strength and u nctional p er orm ance.
A recent system atic review id entif ed ou r categories o
postop erative rehabilitation interventions: (1) strengthening
exercises, (2) aqu atic therapy, (3) balance training and (4)
clinical environm ent (e.g. grou p -based ou tp atient p ro-
gram m e) (Pozzi et al 2013). This review conclud ed that out-
patient rehabilitation u nd er the su pervision o trained physical
therap ists p rovid es the best long-term ou tcom e a ter total
knee arthrop lasty and should inclu d e ind ivid ualized and pro-
gressive strengthening and unctional exercises based on
land -based or aquatic program m es (Pozzi et al 2013). In act,
the rehabilitation p rogram m es shou ld inclu d e higher inten-
sity and p rogressive resistive exercises targeting all m ajor
m u scle grou p s o the low er extrem ity (Bad e & Stevens-Lap sley
2012). N evertheless, in orm ation about the d ose, requency,
intensity and d uration o the rehabilitation p rotocols rem ains
u nknow n.
Conclusion
Du e to d em ograp hic and li estyle changes, the prevalence o
knee OA is orecast to increase d ram atically in the utu re.
Knee OA w ill eventu ally p rogress into a p ain u l cond ition
bu t, or the ind ivid u al patient, no relationship can be estab-
lished betw een joint d am age and the intensity o the p ain. In
chronic OA p ain p atients, p erip heral and sp read ing sensitiza-
tion d evelop ed , cau sing the p ain to be u rther acilitated . This
can be m ed iated by actors su ch as localized in am m atory
m echanism s, enhanced tem p oral integration, or im p aired
d escend ing pain m od ulation. Du e to sa ety issu es and lack
o long-term e f cacy, there is a need to rep lace oral N SAIDs
w ith new, better and sa er pharm acological d ru gs. Several
conservative interventions are claim ed to be e ective or
knee OA, therapeutic exercise being the m ost e ective one at
both short- and long-term ollow -u p. Knee OA can d evelop
into a d isabling cond ition that requires total knee arthroplasty.
Un ortunately m any patients w ill experience chronic p ostop-
erative pain that is o ten u rther aggravated by rep eated knee
su rgeries.
Conclusion 489
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 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
CHAP TER CONTENTS
Introduction  493
Anatomy of the patellofemoral joint  493
Patellofemoral pain  496
Pathophysiology of patellofemoral pain  498
Risk factors for patellofemoral pain  498
Remote and local factors in patellofemoral pain  499
Clinical assessment  499
Conservative treatment  502
Multimodal treatment  503
Balance training and neuromuscular control  506
Soft tissue massage and trigger point therapy  507
Trigger point dry needling and botulinum toxin injection  508
Selected electrophysical modalities  509
In-shoe orthoses  510
Conclusion  510
Introduction
Knee p ain is com m on, accou nting for ap p roxim ately one-
third of m u scu loskeletal p resentations seen in p rim ary care
(Calm bach & H u tchens 2003). The 1-year prevalence of knee
pain in athletes has been estim ated to be as high as 54%
(Rosenblatt et al 1983). In a stu d y of ad ult recreational athletes
(n = 1089), knee p ain accou nted for the m ost com m on sp orts-
related inju ry, at alm ost 25%, and w as m ore com m on than
shou ld er, low back or ankle inju ries, each of w hich accou nts
for ap p roxim ately 10% of injuries (Ralph & Garrick 1996).
Estim ates of knee inju ry rates per 1000 hours of recreational
sport are app roxim ately 4.4 and 10.7 in non-ru nning and
ru nning sp orts resp ectively (Ralp h & Garrick 1996). The inci-
d ence of ru nning-related knee injuries is estim ated to be
betw een 7.2% and 50%, and it is the m ost likely ru nning-
related inju ry (van Gent et al 2007). A 12-m onth stu d y of
athletes p resenting to an Australian sp orts m ed icine centre
(n = 2429) rep orted knee inju ries to be the m ost com m on con-
d ition (27.5%) (Baqu ie & Bru kner 1997). Patellofem oral pain
(PFP) w as the m ost frequently p resenting sports inju ry, fol-
low ed by lum bar and should er rotator cu ff cond itions (Baqu ie
& Bru kner 1997). PFP has been estim ated to affect 7–9% of the
general population (Post 2005). (See Ch 2 for ep id em iology.)
Chapter  44
Patellofemoral Pain Syndrome
J o h n s o n M c Evo y, C a ro lin e M a c M a n u s
Anterior knee pain is a com m on subset of knee pain d isor-
d ers and is a term used to grou p together a nu m ber of d iffer-
ent potential cond itions related to the anterior knee (Post
2005). The term patellofemoral pain is the preferred ‘u m brella’
term to d escribe p ain in and arou nd the p atella in the absence
of other p athologies (Crossley et al 2009), w hereas the term
patellofemoral pain syndrome (PFPS) is u sed in physical
rehabilitation to d escribe pain or d ysfunction of the p atel-
lofem oral joint (PFJ). Patellar nom enclature is varied and con-
troversial, and consensu s on d e nitions is lacking (Grelsam er
2005). This chapter offers a clinically focu sed evid enced -
inform ed brief overview of PFP in term s of anatom y, patho-
p hysiology, assessm ent and com m on p hysical treatm ents.
Anatomy of the Patellofemoral Joint
The patella is the largest sesam oid bone in the bod y and is
em bed d ed in the qu ad riceps tend on on the anterior knee
(William s et al 1995). The patella is an inverted triangular
shap ed bone w ith an anterior and p osterior su rface and a
d istal pointed ap ex. The patella articulates w ith the fem oral
cond yles and form s the PFJ. The intrinsic bony stru ctu re of
the p atella consists of u niform d ense trabecu lar bone covered
by a thin lam ina. The trabecular pattern is parallel on the
anterior su rface and rad ial on the articu lar su rface (William s
et al 1995). Ossi cation d evelops from one to three centres
betw een the third and sixth years of age (Prakask et al 1979).
The convex anterior su rface is covered by the qu ad ricep s
tend on and p rep atellar bu rsa and skin. Blood vessels p ierce
the anterior su rface to su p p ly the bone via vascu lar foram ina
(William s et al 1995; N em schak & Pretterklieber 2012). The
thick su p erior bord er p rovid es attachm ents for the rectu s
fem oris and vastus interm ed ius m u scles. The m ed ial and
lateral retinacu la insert onto the m ed ial and lateral bord ers of
the p atella bone. The retinacu la are band s of brou s tissu e
that assist in stabilizing the p atella as p art of the PFJ. The
m ed ial retinacu lu m exp and s from the vastu s m ed ialis
m u scle / tend on, the m ed ial knee cap su le and som e trans-
verse bres of the m ed ial fem oral ep icond yle. The lateral reti-
nacu lu m arises from the vastu s lateralis m u scle / tend on, the
lateral knee cap su le and receives som e expansion of bres
from the iliotibial tract laterally. Distally the patellar ligam ent
arises from the ap ex of the p atella and , in reality, it is a
 494 PART 7 • 44 • Patellofemoral pain syndrome
continu ation of the qu ad ricep s tend on and inserts into the
tibial tu berosity of the tibia. The p osterior su rface articu lates
as part of the PFJ (William s et al 1995). It has a sm ooth articu -
lar cartilage su rface that contacts the fem oral cond yles w ith
m ed ial and lateral p atellar facets, w hich are sep arated by a
sm ooth rid ge. The lateral facet is larger than the m ed ial facet.
Med ial to the m ed ial facet is a sm all sem ilu nar area, w hich is
term ed the ‘od d facet’ (Good fellow et al 1976; William s et al
1995). The proxim al attachm ent of the p atellar ligam ent arises
from the apex of the patella.
The p atellofem oral joint is a synovial joint that m akes u p
p art of the knee joint (William s et al 1995). The articu lar
su rface of the p atella is ad ap ted to t the articu lar su rfaces of
the m ed ial and lateral fem oral cond yles. The synovial m em -
brane of the knee is the m ost extensive in the bod y. It extend s
above the p atella to form the sup rap atellar bu rsa betw een the
qu ad ricep s fem oris and shaft of the fem ur; extend ing u nd er
the vastu s m ed ially and laterally and d istal to the p atella it
lies u nd erneath the infrap atellar fat p ad (Fig. 44.1).
The arterial su p p ly of the knee joint inclu d es the d escend -
ing genicu lar branches of the fem oral artery, su p erior, m id d le
and inferior genicu lar branches of the p op liteal artery, ante-
rior and p osterior recurrent branches of the anterior tibial
artery, the circu m ex bular artery and the d escend ing branch
of the lateral circu m ex fem oral artery (William s et al 1995).
The nerve sup ply to the knee includ es the fem oral, obturator,
tibial and com m on p eroneal nerves (William s et al 1995).
The op en-p acked p osition of the PFJ is extension and the
close-p acked one is exion (H ouglu m 2005). The patella
increases the m om ent arm of the qu ad ricep s and p atellar
com p lex (i.e. the bony congru ence, m u scles and retinacu la)
m aintaining the qu ad ricep s tend on in alignm ent (Oatis 2004;
H ou glu m 2005). Du ring knee exion, the patella glid es d is-
tally 5–7 cm (H ehne 1990). The PFJ can be subjected to load s
estim ated to be 0.5 to 8 tim es the bod y w eight or m ore
(Mathew s et al 1977). As an exam ple of functional activity, the
PFJ load ings for w alking, stair clim bing and squ atting are 0.5,
3.3 and 7.6 tim es the bod y w eight respectively (Reilly &
Quadriceps femoris
muscle
Femur
Quadriceps femoris
tendon
Suprapatellar bursa
Bursa under lateral head
of gastrocnemius
Joint capsule Prepatellar bursa
Joint cavity Patella
Synovial membrane
Articular cartilage Infrapatellar fat pad
Superficial infrapatellar bursa
Deep infrapatellar bursa
Meniscus
Tibia
Martens 1972). For the straight leg raise exercise in full exten-
sion, the load estim ate is 0.5 tim es the bod y w eight (Reilly &
Martens 1972). Proper m ovem ent of the PFJ is im portant for
norm al fu nction of the knee, and an u nd erstand ing of PFJ
m otion is clinically im p ortant and has been eloqu ently
review ed (Grelsam er & Klein 1998; Oatis 2004; H ou glu m
2005; Crossley et al 2009).
In fu ll extension the p atella has little contact w ith the fem ur
and is therefore relatively m obile, and w ith relaxation the
qu ad ricep s m u scle is restrained by the p assive resistance of
the retinacu la (Grelsam er & Klein 1998; Oatis 2004). During
initial exion the patella enters the fem oral trochlea and
m obility becom es restricted . The area of contact on the p atella
increases and m oves proxim ally as the knee exes (Oatis
2004). N orm al patellar m otion is characterized by m ed ial
m ovem ent from 45° to 18° and lateral d isp lacem ent from 18°
to 0° at fu ll extension (Pow ers et al 1998). Abnorm al stresses
d u ring these m ovem ents, from local and rem ote kinetic chain
in uences, m ay lead to PFP (Oatis 2004; Crossley et al 2009;
McConnell 2009).
Stability of the PFJ is d ep end ent on p assive and d ynam ic
restraints. The quad riceps m uscles attach to the patella and
act to m ove and stabilize the p atella locally on the fem ur, w ith
the vastu s m ed ialis obliqu e (VMO) being an im p ortant in u -
ence on m ed ial PFJ stability (Oatis 2004; Kend all et al 2005)
(Fig. 44.2). The fem u r is in u enced , stabilized and m oved by
m any m u scles, notably the hip abd u ctors (glu teu s m ed iu s,
glu teus m inim u s and tensor fasciae latae) and the external
rotators of the hip joint (piriform is, gem ellu s su perior, obtu ra-
tor internu s, gem ellu s inferior, obtu rator externu s and qu ad -
ratu s fem oris). These m u scles play an im p ortant role in
stability and control of the hip (Oatis 2004; Kend all et al 2005).
H ip abd u ctor and external rotator w eakness are associated
w ith PFP and therefore are of im portance in rehabilitation
(Lankhorst et al 2013).
The m ed ial–lateral position of the patella is assessed in fu ll
extension and has been stu d ied by m agnetic resonance
im aging (MRI) (Pow ers et al 1999). Clinical assessm ent
Figure 44.1 Lateral view of the knee.

Resultant
force
Vastus Rectus
intermedius femoris
Vastus Vastus
lateralis medialis
Figure 44.2 Muscular forces around the patella.
overestim ates the m ed ial–lateral position by m ore than
tw ofold com p ared w ith MRI. Excessive m ed ial, or m ore com -
m only lateral, p osition of the p atella is term ed m ed ial or
lateral tracking (Oatis 2004). The p roxim al–d istal position of
the p atella is the ratio of the p atellar tend on length and the
length of the patella. This can be m easu red on lateral knee
X-ray or MRI (Shabshin et al 2004). Patella alta (high) is d eter-
m ined as a ratio > 1.5 and p atella baja (low ) as < 0.74 (Shabshin
et al 2004). Both p atella alta and baja are related to PFP and
abnorm al p atellar tracking, w hereas p atella baja is also
associated w ith recu rrent d islocations (H olm es & Clancy
1998; Oatis 2004).
The quad riceps angle (Q-angle) is the angle form ed by a
line from the anterior su perior iliac spine to the m id d le patella
and a line from the m id -p atella to the tibial tu berosity
(H ou glu m 2005). The Q-angle is often associated w ith PFP
(Sm ith et al 2008). There is som e d isagreem ent as to the reli-
ability and valid ity of the clinical m easu rem ent of the Q-angle
(Sm ith et al 2008). Despite this controversy, the Q-angle is
associated w ith PFP, bu t is not cu rrently con rm ed as a risk
factor for futu re d evelop m ent (Lankhorst et al 2012, 2013).
The Q-angle can vary, w ith estim ates ranging from 10° to 15°,
w ith a rep orted average of 12.73°, and w ith sm all variance
from the left to the right sid e. The Q-angle is usually higher
in fem ales than in m ales (Fig. 44.3) and is an average of 20°
in PFP patients (Aglietti et al 1983; H ou glum 2005; Raveen-
d ranath et al 2011). The Q-angle can change from non-w eight-
bearing to w eight-bearing ow ing to, for exam p le, tibial
rotation, p ronation and w eakness of the VMO especially
(H ou glu m 2005), or possibly joint laxity. It is therefore im por-
tant to assess the fu nctional kinetic chain and resp onses to
w eight-bearing w ith such tests as the u nilateral single-leg
knee bend (Fig. 44.4), bilateral and u nilateral knee-d rop tests.
The patellar tilt angle (PT-angle) is the angle betw een a line
d raw n throu gh the largest w id th of the patella and a line
tou ching the m ost anterior su rfaces of the m ed ial and lateral
fem oral cond yles (Fig. 44.5) and is associated w ith PFP (Oatis
2004; Lankhorst et al 2013). Assessm ent of the PT-angle by an
experienced exam iner has been show n to have strong crite-
rion valid ity and intra-tester reliability (McEw an et al 2007).
Anatomy of the patellofemoral joint 495
12° 16°
Male Female
Figure 44.3 Q-angle of the knee. Comparison between male and female.
N orm al ind ivid u als have a PT-angle of betw een 0° and 20°
w hen m oving from 0° to 60° of knee exion (Pinar et al 1994).
Qu ad ricep s m u scle contraction cau ses a slight increase in
PT-angle, bu t this is not signi cant (Pinar et al 1994). In norm al
su bjects, a clinically d eterm ined laterally tilted p atella corre-
lates w ell w ith MRI d eterm ination in extension (McEw an et al
2007). Su bjects w ith a PT-angle < 5° on clinical exam ination
w ere assessed as having no d egree of patellar tilt (McEw an
et al 2007). Ultrasound im aging and MRI are reliable m ethod s
of assessing p atellar p osition. Ultrasou nd has the ad d ed
ad vantage of easier access and low er cost (H errington et al
2006a). Taping, m anual therapy and quad riceps m u scle
strengthening aim to in u ence PT-angle for therap eu tic
bene t.
The su lcu s angle (S-angle) is the angle form ed by lines
d raw n from the d eepest point of the fem oral sulcu s to the
highest p oint on the m ed ial and lateral fem oral cond yles
(Oatis 2004). Rep orted S-angle values range from 125° to 155°,
w ith sim ilar m easu rem ents reported in m en and w om en
(Oatis 2004). A shallow S-angle is associated w ith recu rrent
su blu xation (Aglietti et al 1983). S-angle can be m easured
from rad iographs.
The congru ence angle (C-angle) is form ed by a line bisect-
ing the S-angle and a line from the base of the su lcu s angle to
the m ost p rom inent p eak of the p atellar rid ge (Oatis 2004).
The average C-angle has been reported as −8°, but is −2° in PFP
patients and +16° in recurrent subluxation patients (Aglietti
et al 1983). The C-angle is a d eterm inant of the how w ell the
p atella sits into the fem oral trochlear notch (Oatis 2004).
 496 PART 7 • 44 • Patellofemoral pain syndrome

Figure 44.4 Dynamic Q-angle. step-down test or

single-leg squat: (A) Positive test with valgus knee
position with increased Q-angle during dynamic test.
(B) Negative test with controlled and normal dynamic
Q-angle. This can also be used as an exercise when
appropriate.

A B

of typ e IV recep tor nerve end ings m ay lead to the exp erience
of p ain (Wyke 1967; Warm erd am 1999). Patellar articu lar car-
tilage is not a sou rce of p ain (Dye et al 1998), bu t m ay ind i-
rectly affect other structu res such as the synovial m em brane
ow ing to chem ical or m echanical sensitization (Insall et al
1976; Warm erd am 1999; Fulkerson 2002; Crossley et al 2009).
Congruence Ultrasound im aging of the lateral retinacu lum of PFP
angle patients (n = 10) and controls (n = 10) revealed a trend tow ard s
a larger thickness and neovascularization as m easu red by
Patellar tilt
colou r Dop p ler u ltrasou nd (Schoots et al 2013); the m ean and
stand ard d eviation of PFP p atients versus controls w ere 4.0
Sulcus angle (1.4 m m , 95% CI 1.2–6.8) and 3.7 (0.8 m m , 95% CI 2.1–5.3)
respectively, althou gh this w as not statistically signi cant. In
the sam e stu d y, Dop p ler u ltrasou nd w as p ositive in fou r ou t
of ten of the PFP p atients, bu t in none of the controls. The
Distal femur increased lateral retinaculum thickness w as present in both
knees of PFP patients com pared w ith controls. Further
research is required to id entify the role of the lateral retinacu -
lum in PFP.
In a novel ap proach, neurosensory m app ing of the internal
stru ctu res of the knee w as carried ou t w ithou t intra-articu lar
anaesthesia on the consciou s senior au thor of the stud y (Dye
et al 1998). Both asym ptom atic knees w ere inspected arthro-
scop ically w ith only local skin anaesthesia. Pressu re w as
ap plied by w ay of a stand ard straight arthroscop ic probe w ith
a d istal tip size of 1 × 3 m m attached to a spring-load ed d evice
Figure 44.5 Patella angles. (See text for explanation of each angle.)
d esigned to m easu re force. Pain w as grad ed 0–4 (no sensation
to severe p ain) and localized w ith A or B for accu rate or p oor
sp atial localization resp ectively. Resu lts ranged from no sen-
sation (0) on the patellar articu lar cartilage to 4A on the ante-
Patellofemoral Pain rior synovial m em brane, capsule and fat pad (Table 44.1). It
m u st be noted that this stu d y d escribed the p ain resp onse in
PFP can arise from m any stru ctu res inclu d ing intra-articu lar one su bject of both asym p tom atic knees only.
or periarticu lar tissu es – for exam ple, the p atella bone, reti- Referred p ain from other stru ctu res shou ld be consid ered
nacu la, m u scles, cap su le, synovial m em brane, infrap atellar in d ifferential d iagnosis su ch as low back, p elvic gird le, hip
fat p ad , etc. (H ou glum 2005; Crossley et al 2009). Sensitization joint and stru ctu res, pu bic and ad d uctor areas, and also
 Patellofemoral pain 497

Table 44.1 Ne uros e ns ory ma pping o the human kne e

Structure te s te d Re s ult* Force (gra ms ) Summa ry

Patellar articular cartilage medial facet 0 500 No s ensation

Patellar articular cartilage lateral facet 0 500 No s ensation
Patellar articular cartilage central ridge** 0 500 No s ensation
Patellar articular cartilage odd facet 1B 500 Non-painful awarenes s poorly localized
Menisci (medial and lateral) inner rims 1B 500 Non painful awareness poorly localized
Femoral condyles articular cartilage s urface 1B–2B 500 Non-painful to s light dis comfort poorly localized
Trochlea 1B–2B 500 Non-painful to s light dis comfort poorly localized
Tibial plateau 1B–2B 500 Non-painful to s light dis comfort poorly localized
ACL mid-region 1B–2B 500 Non-painful to s light dis comfort poorly localized
PCL mid-region 1B–2B 500 Non-painful to s light dis comfort poorly localized
Menisci (medial and lateral) capsular margin 2B–3B 300–500 Slight discomfort to moderate dis comfort poorly localized
Menisci (medial and lateral) anterior / 2B–3B 300–500 Slight discomfort to moderate discomfort poorly localized
posterior horn
ACL tibial and femoral ends 3B–4B 500 Moderate dis comfort to servere pain poorly localis ed
PCL tibial and femoral ends 3B–4B 500 Moderate dis comfort to servere pain poorly localized
Medial and lateral retinacula 3A–4A < 100 Moderate dis comfort to severe pain accurately localized
Suprapatellar pouch s ynovial membrane 3A–4A < 100 Moderate dis comfort to severe pain accurately localized
Capsule 3A–4A < 100 Moderate dis comfort to severe pain accurately localized
Fat pad 4A Severe pain accurately localized
*0: no s ens ation; 1: non-painful awarenes s ; 2: slight discomfort; 3: moderate dis comfort; 4: severe pain; A: accurate localization; B: poor localization.
**Central ridge as ymptomatic grade II or III chondromalacia was identi ed on both patellas.
(Modi ed from Dye et al 1998.)

m yofascial trigger p oints (TrPs), w hich are com m on in knee
p ain and other m uscu loskeletal cond itions (Crossley et al
2009). (Read ers are referred to other relevant chapters.)
Mu scles that refer to the anterior knee area inclu d e, bu t are
not lim ited to, the qu ad ricep s, glu teu s m inim u s and ad d u c-
tors am ongst others (Travell & Rinzler 1952; Travell & Sim ons
1992; Deju ng et al 2003). Reliable id enti cation of TrPs
d ep end s on system atic p alpation of accessible m u scles by
exam iners w ho are know led geable and trained (McEvoy &
H u ijbregts 2011). (See Ch 59 for a review of m yofascial p ain
in the low er extrem ity m u sculature.)
Ad d itionally, several local knee cond itions need also to
be consid ered – su ch as osteoarthritis, rheum atoid and con-
nective tissu e d isord ers, bony lesions su ch as stress frac-
tu res, osteochond ritis d issecans, bip artite p atella, Perthes’
d isease and tum ours, w hich thou gh not com m on are m ore
likely in the young (Good m an et al 2003; Crossley et al 2009;
Boissonnau lt 2010).
Clinical classi cation system s for PFP have been p resented ,
tw o of note being p u blished sim u ltaneou sly: those by Wilk
et al (1998) and H olm es and Clancy (1998). Read ers are
encouraged to review these classi cation system s (available
free at w w w.jospt.org). H olm es and Clancy (1998) selected a
triclassi cation system : p atellofem oral instability, p atellofem -
oral p ain w ith m alalignm ent and p atellofem oral p ain w ithou t
m alalignm ent. In contrast, bu t w ith som e sim ilarities, Wilk
et al (1998) op ted for a w id er eight-system classi cation (Table
44.2): p atellar com pression synd rom es, patellar instability,
biom echanical d ysfu nction, d irect patellar trau m a, soft tissue
lesions, overu se synd rom es, osteochond ritis d iseases and
neu rological d isord ers. Sp ecial consid eration shou ld be given
to the child or ad olescent p atient ow ing to age-related cond i-
tions su ch as bip artite p atella p ain, grow th p late issu es of the
hip and knee and Osgood –Schlatter d isease, etc. (H olm es &
Clancy 1998).
For clinicians, classi cation of PFP can assist in planning a
treatm ent strategy p ertinent to the need s of the ind ivid u al
p atient id enti ed from the assessm ent. Accu racy of the
w orking d iagnosis / classi cation is im portant for gu id ing
safe and effective rehabilitation. It is therefore im p ortant to
carry ou t a com p rehensive assessm ent on each p atient to
gu id e the plan of care (see Clinical Assessm ent below ).
Sym p tom s of PFP inclu d e p ain arou nd the p atella or su r-
round ing area, sw elling, crep itus, catching of the knee and
giving w ay (w hich m ay suggest patellar instability / subluxa-
tion). Pain can be m ild to severe and can be local or d iffu se.
Behaviour of the sym p tom s often inclu d es aggravation w ith
load ing of the joint su ch as stairs, knee bend ing, especially
beyond 20–30° as the PFJ starts articu lating, and sitting,
especially w ith knee exion. PFP is not a self-lim iting cond i-
tion and efforts to correct kinetic chain factors, both local and
rem ote, are im portant (McConnell 2009).
 498 PART 7 • 44 •
Table 44.2 Clas s if cation s ys te ms o pate llo e moral pain
dis orde rs
Holme s & Cla ncy (1998) Wilk e t a l (1998)
1. Patellofemoral instability 1. Patellar compress ion
2. Patellofemoral pain with syndromes
malalignment 2. Patellar ins tability
3. Patellofemoral pain without 3. Biomechanical dysfunction
malalignment 4. Direct patellar trauma
5. Soft tis sue lesions
6. Overus e s yndromes
7. Os teochondritis diseas es
8. Neurological disorders
Special consideration for
children or adolescents:
Bipartite patella
Growth plates (hip, knee)
Osgood–Schlatter’s
Pathophysiology of Patellofemoral Pain
The p athophysiology of PFP is not w ell und erstood and the
general consensus is that the aetiology is m ultifactorial
(Pow ers et al 2012). Tissu e overload and stress m ay be ind uced
by biom echanical alterations from local and rem ote areas, and
p assive and active kinetic chain in uences (Crossley et al
2009). Su ch forces includ e joint shearing. There is a general
consensu s that p athom echanics contribu tes to p ain and d ys-
fu nction of the PFJ and surround ing tissu es via instability or
m alalignm ent (H olm es & Clancy 1998; Wilk et al 1998; Oatis
2004; Dye 2005; H ou glum 2005; Crossley et al 2009). These
stresses m ay ind u ce sym p tom atic loss of tissu e hom eostasis
(Dye 2005). As an exam ple, PFJ pain has been associated w ith
a change in PT-angle (Witonski & Goraj 1999) and increases
in the C- and S-angles (Aglietti et al 1983), w hich is also linked
w ith su blu xations (Aglietti et al 1983). Pathom echanical stress
on tissu es, su ch as id enti ed by Dye et al (1998) (see Table
44.1), m ay activate and sensitize grou p IV nociceptive nerve
end ings, resu lting in altered m otor p atterning and d ysfunc-
tion related to ongoing p ain stim u lu s. This m ay ind u ce
p eripheral and central sensitization and lead to hyp eralgesia
and allod ynia.
Ischaem ia has been p roposed as a potential PFJ pain m ech-
anism by ind ucing loss of tissu e hom eostasis (Selfe et al 2003;
Dye 2005). Sim ilar hom eostatic m echanism s have been
reported in m uscle, tend on, bone and cartilage (N aslund et al
2007) and card iac ischaem ia, a w ell-recognized cau se of
card iac p ain. In chond rom alacia p atellae and knee osteoar-
thritis there is evid ence of cap illary ingrow th into the osteo-
chond ral ju nction and cartilage w ith coexisting increase of
nerves containing su bstance P (Bad alam ente & Cherney 1989).
Tissue hypoxia is a w ell-recognized trigger for substance P
and neural grow th factor lead ing to nerve hyperinnervation
(N aslu nd et al 2007).
In a novel stu d y, the pu lsatile blood ow to the patella w as
m easu red by p hotop lethysm ography in zero extension, 20°
and 90° exion in p atients w ith PFP (n = 22) and in controls
(n  = 33) (N aslu nd et al 2007). The PFP patients had red u ced
blood ow after p assive knee exion of 20–90° w hereas no
Patellofemoral pain syndrome
Table 44.3 Ris k a nd a s s ociate d actors or pate llo e mora l pain
Ris k fa ctors for Fa ctors a s s ocia te d with
p a te llofe mora l p a in pa te llofe mora l p a in
Knee extens ion s trength Q-angle
Female gender S-angle
Patellar tilt
Reduced hip abduction strength
Reduced hip external strength
Reduced knee extension peak torque
su ch resp onse w as noted in the control grou p . This m ay, at
least in part, exp lain the m oviegoer ’s sign, w hich is seen often
in PFP patients w hen sitting w ith knee exion for sustained
p eriod s. Fu therm ore, p atients’ p ercep tion of cold ness of their
legs in w arm surround ings correlated w ith a poor ou tcom e in
PFP rehabilitation (Selfe et al 2003), and fem ales w ere m ore
likely to be affected by cold (Selfe et al 2010). Selfe et al (2010)
p ostu lated that, in a su bset of PFP p atients, re ex sym p athetic
d ystrophy (com p lex regional pain synd rom e) m ay play a role.
In su m m ary, there is a variable m osaic of processes affect-
ing tissue hom eostasis and neu ral activation (Dye 2005;
N aslu nd et al 2007), w ith new evid ence that ischaem ia m ay
p lay a role in PFP. Fu rther research is clearly requ ired . These
nd ings m ay im p act on the clinical m anagem ent of p atients.
Risk Factors for Patellofemoral Pain
The id enti cation of risk factors is im portant in prevention
and rehabilitation of m uscu loskeletal d isord ers. Risk factors
can be consid ered intrinsic or extrinsic, and m od i able or
non-m od i able. A recent system atic review of p rosp ective
risk factors for the d evelop m ent of PFP (Lankhorst et al 2012)
reported that red u ced knee extension strength and fem ale
gend er w ere associated w ith d evelopm ent of PFP, althou gh
there w as con icting evid ence on the onset tim ing of VMO
versu s vastu s lateralis as a risk factor for fu tu re PFP based
u p on tw o stu d ies. The Q-angle and the p rotective role of
p rior sp ort activity w ere not associated as a risk (Lankhorst
et al 2012).
In a subsequ ent review of factors associated w ith PFP by
the sam e researchers (Lankhorst et al 2013), 47 stu d ies w ere
evalu ated w ith a staggering 523 variables. Pooling w as p os-
sible for eight variables only and six of these w ere associated
w ith PFP com p ared w ith controls – larger Q-angle, sulcu s
angle and patellar tilt, less hip abd u ction strength, w eaker hip
external rotation and less knee extension p eak torqu e (Table
44.3) – w hereas foot arch height and C-angle had no su ch
association (Lankhorst et al 2013). Other factors w ere also
related w ith PFP in the 47 stu d ies review ed , bu t p ooling for
analysis w as not possible as these w ere w ere based u p on
single stu d ies only. Read ers are encou raged to refer to
Lankhorst et al (2013) for further review of these factors.
In patients w ith PFP, the presence of anxiety and fear-
avoid ance beliefs about w ork and physical activity w ere asso-
ciated w ith fu nction, w hereas only fear-avoid ance beliefs
abou t w ork and p hysical activity w ere associated w ith pain
(Piva et al 2009a). Fu rtherm ore, in patients und ergoing PFP
rehabilitation (n = 74), a change in fear-avoid ance beliefs abou t

p hysical activity w as the strongest p red ictor of recovery in
term s of both p ain and fu nction (Piva et al 2009b). This nd ing
u nd erp ins the im p ortance of strategies to target fear-avoid ence
beliefs in patients w ith PFP.
In general, low er extrem ity injury risk is often associated
w ith neu rom u sclar kinetic chain d ysfu nction. The fu nctional
m ovem ent screen is a clinical assessm ent tool that assesses
functional m ovem ent over seven m ovem ent tests, scored on
a scale of 0–3 per test, to a m axim um total of 21 (Cook 2010).
Good to excellent reliability (intra-class correlation (ICC)
0.66–0.92) has been d em onstrated w ith resp ect to intra-rater
reliability; how ever, the test is poor for inter-rater reliability
(ICC 0.38) (Shu ltz et al 2013). Prelim inary m od erate-quality
evid ence su ggests that the fu nctional m ovem ent screen can
assist in accu rately id entifying ind ivid u als at greater risk of
m u scu loskeletal inju ry am ongst m ale p rofessional football
p layers, fem ale collegiate basketball, soccer and volleyball
p layers, and m ale m arine trainee of cers (Kru m rei et al
2014). The functional m ovem ent screen m ay also be help ful
in clinical practice for assessing m otor skills, screening for risk
of inju ry, m easu ring im p rovem ent and for retu rn-to-p lay
p rotocol.
An ad d itional clinical tool is the star excursion balance test
(SEBT), w hich assesses d ynam ic single-stance balance in
eight-point reach or a m od i ed three-point reach (Kinzey &
Arm strong 1998; H ertel et al 2006) and has been show n to
have good reliability (ICC 0.67–0.92) (Kinzey & Arm strong
1998; Plisky et al 2006; Mu nro & H errington 2010; Gribble
et al 2013). This test w as a pred ictor of inju ry in high-school
basketballer players (Plisky et al 2006) and is recom m end ed
as part of screening for p red icting low er extrem ity inju ries in
team sp orts p layers (Dallinga et al 2012).
Remote and Local Factors in
Patellofemoral Pain
When PFJ force ap p lication exceed s the capabilities of the
joint and related structu res, tissu e stress lead s to loss of
hom eostasis w hereby activation of p erip heral nocicep tors
lead s to pain and d ysfu nction. Fu rtherm ore, PFJ pain and
d ysfunction in u ence m ovem ent in the local and kinetic
chain. Force ap p lications inclu d e tension, com p ression, shear
and torsion. In reality, how ever, these force ap p lications m ay
act in m ore than one m od e – for exam p le, com p resssion on
the lateral joint d u e to increased tilt and tension in the lateral
retinacu lum w ith coexisting PFJ shear d u e to lack of VMO
activation.
Load ing can be su d d en or accu m u lative. Acu te load ing is
exem pli ed by a d irect-blow injury to the anterior lateral
patella, lead ing to shear–com p ression of the lateral patellar
and tension ap p lication w ith physiological-stress-ind u ced
strain on the lateral retinacu lu m . An exam p le of accu m u lative
load ing is a runner w ith increased w eekly m ileage superim -
posed u p on kinetic chain factors su ch as increased valgu s
knee position, overp ronation of the subtalar joint and w eak-
ness in the lateral hip rotators and hip abd u ctors / stabilizers.
In another exam ple, accu m ulative load ing m ay occur from
static activities su ch as sitting for long p eriod s w ith the knee
in a bent position (com pression–tension force). This m ay lead
to loss of hom eostasis and therefore p ain. Ischaem ia m ay p lay
Clinical assessment 499
a role in this m od e, as previou sly d escribed , and fu rther
research is ind icated (N aslund et al 2007).
Crossley et al (2009) su ggested a usefu l strategy by consid -
ering local and rem ote factors id enti ed in the assessm ent that
m ay contribu te to PFP. Su ch a tactic aim s at d esigning ind i-
vid u alized p atient rehabilitation p rogram m es. Clinicians
shou ld be aw are of intrinsic (e.g. hip w eakness) and extrinsic
(e.g. playing surface) risk factors and w hether these factors
are m od i able (e.g. neu rom u scular control or strength) or
non-m od i able (e.g. age or sex). Local factors inclu d e p atellar
p osition, soft tissu e and qu ad ricep s neu rom u scu lar control;
rem ote factors inclu d e increased fem oral internal rotation,
increased knee valgu s, subtalar pronation and m u scle exibil-
ity (Crossley et al 2009).
Clinical Assessment
There is no consensu s gold stand ard or consistent usage of
clinical or fu nctional tests for the d iagnosis of PFP (Cook et al
2012). Moreover, PFP is regard ed as a m u ltifactorial clinical
d iagnosis m ad e by the clinical assessm ent of the presenting
com p laint, assessm ent of p otential p ain-p rod u cing stru ctu res,
assessm ent of kinetic chain in uences, fu nctional tests and
d iagnostic im aging as ap propriate (Cook et al 2012). In a sys-
tem atic review, stu d ies that u sed a d iagnosis of exclu sion as
p art of the d e nition of PFP w ere fou nd to have the highest
m ethod ological qu ality (N aslu nd et al 2006; Cook et al 2012).
The d iagnosis of exclusion approach u sed im aging or arthro-
scop ic su rgery evalu ation to elim inate com p eting d iagnoses
in patents w ith suspected PFP (Cook et al 2012). Cook et al
(2010) consid ered this to im p rove the accu racy of d iagnosis in
su sp ected PFP. In su m m ary, there is no cu rrent reference
test(s) for the d iagnosis of PFP. Clinical assessm ent, clinical
reasoning and im aging cou pled w ith patient response to reha-
bilitation are a reasonable clinical approach in p ractice.
The role of the assessm ent is to screen and id entify a w orking
d iagnosis / classi cation w ith consid eration of d ifferential
d iagnosis. Subjective, history, objective and im aging (w here
ind icated ) d ata are gathered to assist in form ing a w orking
im pression. Pertinent factors id enti ed from the assessm ent
d rive the rehabilitation program m e and goals of treatm ent.
Due to m u ltifactorial in uences of local and rem ote contribu -
tors in PFP, the assessm ent need s to ad d ress the kinetic chain
and also id entify pertinent factors in u encing the PFJ. Referred
p ain and d ysfu nction contribu tors, as exem p li ed by w eak-
ness of the hip , TrPs, benign hyp erm obility synd rom e and
sacroiliac joint d ysfu nction, and local factors, su ch as tightness
of the retinacu lu m , VMO w eakness, etc., requ ire p rioritization
in the plan of care. Such a strategy is likely to optim ize the
ou tcom es. Princip les of assessm ent have been p resented in
this book for other relevant areas. H istory taking for p atients
w ith low er extrem ity d isord ers, self-reported outcom e m eas-
u res for p atients w ith low er extrem ity p ain synd rom es and red
ags are presented in Chap ter 4. Im aging is help fu l for d iffer-
ential d iagnosis and m ay inclu d e X-ray, ultrasound im aging,
MRI, CT and bone scan. Blood tests m ay be requ ired to assist
in d ifferential d iagnosis of other system ic d iseases (Crossley
et al 2009; Boissonnau lt 2010).
The patient interview inclu d es subjective presentation
(Table 44.4), history of present com plaint (Table 44.5), patient
p ro le and m ed ical history (Table 44.6). Objective assessm ent
500 PART 7 • 44 • Patellofemoral pain syndrome

Table 44.4 Subje ctive complaint or patie nts with pate llo e mora l pain
Re fe re nce to curre nt Pe rtine nt is s ue s Comme nts
comp la int

What is the problem / are
the symptoms?
Location of complaint?
Characteris tics of the
complaint?
Aggravating factors
Relieving factors
Respons e to exercis e
Pain, s tiffnes s, crepitus , clicking, giving way, swelling, De ne what exactly are the s ymptoms and the
weaknes s, functional changes. nature.
Nature of the complaint (e.g. pain – s harp, dull ache,
throb, dull, etc.)?
De ne the area. Local pain may s uggest s peci c local caus e
Local / diffuse / remote? (e.g. infrapatellar fat pad).
Kinetic chain s ymptoms ? Diffuse pain may s uggest referral pain (e.g. L3
Other limb or body s ymptoms? type referral may sugges t referral from hip).
Unilateral / bilateral? Burning or electrical type pain may s uggest
neuropathy.
Intermittent / constant? This may allow an understanding of the
Frequency? Irritability? dimens ions of the problem.
Speci c / local / diffus e?
Activities that provoke symptoms? Important as this may ass ist in an
Sitting, s tanding, walking, running, s tairs (up & down). unders tanding of the potential
Sus tained pos itions ? tiss ues / stres ses provoking the pain.
Moviegoers sign?
What relieves the symptoms? Important as assis ts in plan of care and
Res t, exercis e (speci c or general), positions of management of s ymptoms and als o an
comfort, heat, medications . unders tanding of potential
tiss ues / mechanisms / stresses involved in
the complaint.
Do the s ymptoms come on with exercis e and what is Improvement with warm up phase may
the nature? sugges t increased blood ow and gating of
None, warm up only, after activity, provokes but remains pain mechanisms for example.
at tolerable level, gets worse and have to stop. Pain that is severe and summates may
Speci c activities walk, run (up or down), jump, uneven sugges t, for example, bone reaction.
ground, etc.

Table 44.5 His tory o compla int or patie nts with pa te llo e moral pa in
His tory of curre nt Pe rtine nt is s ue s Comme nts
comp la int

When did the What was the date or time frame of the Often the longer the time frame the more complex due to
complaint start? complaint? movement pattern changes, for example.
Is the complaint acute, subacute or chronic? Acute s ymptoms may s ettle naturally.
Is the complaint recurring? The focus of the plan of care may change in relation to
acute or chronic pres entation.
When not s ettling in expected natural course, etc., imaging
may play a role in ass isting differential diagnos is.
Cause? Was the complaint traumatic or non-traumatic? Forces ass ociated with speci c trauma (e.g. kick to knee,
Speci c incident remembered? knee impact to das hboard in road traf c accident) may
Did complaint ‘just come on’? require routine imaging X-ray or MRI.
What was the development of the complaint? Was there any incident of s ubluxation, dislocation, traumatic
Was there anything new or changed in the or non-traumatic?
time frame before the start of the complaint? Identi es the precipitating factor(s).
Intrins ic, extrinsic and modi able or non-modi able factors .
Identi es speci c or overus e causality.
 Clinical assessment 501

Table 44.6 Patie nt prof le , de mogra phics and clinical his tory or pa tie nts with pate llo e mora l pain

Patient Age, s ex, etc. Age and s ex are non-modi able factors.
demographics Weight, height, body mass index Chronological age may be different from
functional / phys iological age.
If overweight or obes e may in uence kinetic chain forces .
If underweight may in uence repair capabilities .
Female triad?
Medical his tory Medical, s urgical and s port injury his tory The presence of comorbidities may in uence plan of care
Presence of medical conditions may in uence and healing pathway (e.g. diabetes , obes ity, vas cular
outcome and plan of care disease, os teoporos is, etc.).
Pregnancy, children, etc. Previous s ports injuries may in uence plan of care, e.g.
for previous ACL injury, Achilles rupture and surgical
repair, etc.
Medication Current and his tory Medication may be us ed as part of the rehabilitation
process with pos itive effects on pain control, es pecially
in acute phase.
Medication may lead to undesirable side effects (e.g.
corticosteroid-injection-induced soft tiss ue atrophy,
s teroid induced myopathy, statin-induced muscle pain).
Medication may draw awareness to a medical condition
not reported, e.g. diabetes, etc.
Medical Has the patient had medical review with a s pecialist? The patient may require a medical review for medical
ass ess ment / Did the patient attend emergency room due to diseas e, e.g. rheumatoid conditions (Reiter’s s yndrome,
tests trauma or s uspected dislocation? seronegative arthropathy, pigmented villonodular
The patient may require physician follow-up or synovitis, neoplas m, etc.).
re-review? Specialist review may be required with s ports medicine,
Blood tes ts? orthopaedic or rheumatology.
Imaging, special X-ray, MRI, ultrasound, CT scan, bone scan, vas cular Imaging may ass ist in differential diagnosis and would be
tests indicated especially with traumatic injury, dis location
and persis tent problem not responding.
Red ags Are red ags pres ent? Presence of red ags indicates referral to primary care
Current or past his tory of cancer physician or emergency room.
Other medical condition
Fatigue
Malaise
Acute medical condition
Severe pain
Pain unrelated to movement
Unexplained weight los s / gain
Bowel or bladder habit changes
Numbness , los s of feeling
Change in mood
Cauda equina symptoms
Suspected fracture or dis location
Employment / What does the patient work at? Habitual habits s uch as prolonged s itting or driving may
lifestyle Nature of work? require attention in the plan of care.
Sitting, s tanding and occupational positions, e.g. Ergonomic ass ess ment may be indicated.
kneeling, etc. Change of habits , micro-breaks and rotation of activities
What are the hobbies ? may be required.
Sports and As certain s ports demographics ? Know the sport, demands , biomechanics and
exercise Type of sport? requirements .
Contact or non-contact? Technique and coaching input may be required.
Speci cs of sport? Regulation of training frequency.
Biomechanics of sport? Specialized equipment s uch as braces , orthotics may be
Equipment? required.
Surface being used? Ass ess for overtraining.
Enquire about frequency of competition, training and
periodicity, s eas on and sports speci c demands
Consider overtraining
 502 PART 7 • 44 • Patellofemoral pain syndrome

Table 44.7 Obje ctive a s s e s s me nt or pa tie nts with

pate llo e mora l pain
Ob s e rva tion of Sta nding, wa lking , lying s upine
lowe r kine tic cha in

Functional Squat, s tep-up, s tep-down, s ingle-leg

squat
Jump, drop jump, lunge
Balance ass ess ment (e.g. BESS, SEBT)
Functional movement screen
Range of motion Low back, hip, knee, ankle areas
Access ory joint motion
Flexibility tes ts Hip exors (iliopsoas / rectus femoris)
Thomas ’s test
External and internal rotation
Figure 44.6 Patellar mobility tests. The patella is moved lateral to medial, Lateral hip (abductors / TFL)
superior to inferior and tilted from lateral to medial (lateral border lifted anteriorly). TFL / ITB – Ober’s test
Palpate for mobility, end feel and pain. Compare with other side. Adductors, quadriceps , hamstring, calf
muscles
Ankle lunge tes t
is im p ortant and inclu d es local and rem ote kinetic chain con- Strength Hip abductors 0° and 30° (gluteus
tribu ting factors. A tem p late for su ch an assessm ent is inclu d ed Manual mus cle testing medius anterior and posterior bres)
in Table 44.7. Dynamometery External hip rotators , adductors ,
The overall d iagnostic accu racy of p atellar m obility and (handheld) quadriceps , hamstrings
p alp atory tests and the d iagnostic accuracy of gross pain Is okinetic Calf, trunk muscles
p rovocation m easu res w ere system atically review ed by Cook
Inspection PFJ and Swelling, temperature, deformity,
et al (2012), w ho reported sensitivities, speci cities, positive
knee congruency, colour
likelihood ratios (+LR) and negative likelihood ratios (−LR).
Overall, resu lts for m ost tests w ere low w ith resp ect to +LR Palpation for Borders of the patella
and there w as som e variance of the tests across stu d ies (Cook tendernes s Medial and lateral retinaculum
et al 2012). One of the review ed stu d ies rep orted higher +LR Mus cle attachments (vastus medialis
w ith positive pain on the Clarke grind test (+LR 7.4), pain and lateralis )
d u ring stair clim bing (+LR 11.6) and p ain w ith p rolonged Patellar tendon
sitting or exion (+LR 7.4) (Elton et al 1985; Cook et al 2012). Knee joint
It m ust be noted , how ever, that these resu lts w ere in con ict Tibial tuberosity
w ith other stud ies that reported +LR of less than 2.0 (Cook Palpation of medial and lateral under
et al 2012). surface of patella (as access ible)
The assessm ent consists of elem ents as requ ired , inclu d ing Myofascial trigger points
observation, fu nction, range of m otion, exibility, strength, PFJ Observation of position s tatic pos ition
insp ection, p alp ation, PFJ m obility testing (Fig. 44.6), PFJ Tenderness and pain Pass ive mobility: medial glide, lateral
sp ecial tests, other factors and screening of kinetic chain as provocation glide, superior glide, inferior glide, tilt
ind icated (see Table 44.7). Clinical assessm ent is a d ynam ic Mobility Patellar mobility with movement
p rocess and not all tests m ay be necessary, or ind eed app ro- Compare left and right
p riate. If the patient’s p ain is reprod u ced w ith a speci c test,
this is of signi cant valu e. PFJ s pecial tests Clarke’s grind tes t
The evalu ation p rocess shou ld d irect the clinician to high- Apprehension tes t
light sp eci c concerns and need s of the ind ivid u al p atient. Q-angle measurement (supine and
Plan of care shou ld ad d ress these need s and m onitor p rogress. observation in s ingle leg squat)
Differential d iagnosis shou ld alw ays be consid ered and , Other Knee joint ass ess ment
if ap p rop riate, a m u ltid iscip linary team ap p roach m ay be Low back s creen (McKenzie
requ ired . ass es sment, sacroiliac joint, active
straight leg raise)
Hip
Conservative Treatment Ankle
Hypermobility scale test (Beighton)
There is evid ence that m u ltim od al physiotherap y program m es Functional test scales
are effective for PFJ (Crossley et al 2009; McConnell 2009). The Other s pecial tests Imaging (X-ray, ultrasound, MRI, CT,
d evelopm ent of a plan of care for PFP is based u pon the nd - bone scan, etc.)
ings from the assessm ent. Differential d iagnosis need s to be Blood tests , etc.
consid ered . N eu rom u scu lar control d e cits or d ysfu nctions

in the rem ote or local kinetic chain need to be treated . Fu r-
therm ore, treatm ent of id enti ed p ainfu l stru ctu res shou ld be
consid ered , for exam p le the synovial m em brane, fat p ad ,
TrPs, etc. Given the d iverse natu re of PFP, m u ltim od al treat-
m ent, and esp ecially exercise-based rehabilitation, is likely to
potentiate ou tcom es as is sim ilarly seen in cond itions su ch as
neck and low back p ain (Boyling & Ju ll 2005; McConnell
2009). There is a general consensu s that surgery shou ld be
avoid ed in PFP, especially w hen there is evid ence of ef cacy
for conservative rehabilitation treatm ent (Crossley et al 2009;
McConnell 2009). N evertheless, there m ay be a role for su rgery
in a select cohort of PFP patients, but u su ally conservative
m easu res shou ld be exhau sted rst (Crossley et al 2009).
There is a p lethora of treatm ents p rop osed for PFJ p ain.
Cu rrent best p ractice recom m end s a conservative m u ltim od al
rehabilitation app roach for im proved ou tcom es (McConnell
2009). Due to the m ultifactorial nature of PFJ, no one treat-
m ent is likely to be fu lly su ccessfu l for PFP (McConnell 2009).
Targeting of fear-avoid ance beliefs m ay be an im p ortant treat-
m ent strategy and p sychological intervention shou ld be
sou ght as requ ired (Piva et al 2009a, 2009b).
Fou r clinical pred iction ru les (CPRs) for PFP have been
reported in patellar taping (Lesher et al 2006), lum bar m anip-
u lation (Iverson et al 2008) and the u se of orthotics (Su tlive
et al 2004; Vicenzino et al 2008). The application of CPRs in
clinical p ractice m ay help w ith d ecision m aking and shou ld
be used in conju nction w ith cu rrent existing evid ence, patient
preferences and clinical exp erience (Glynn & Weisbach 2011).
Cau tion shou ld be noted w ith CPRs, how ever, and they
shou ld not be u sed in isolation (Glynn & Weisbach 2011).
(These CPRs are reported u nd er each relevant treatm ent
section.)
Patient lifestyle, ergonom ic and sp orts factors shou ld also
be taken into accou nt and m ay need to be ad d ressed in the
plan of care. Exam p les inclu d e habitual sitting p ostu res w ith
knees bent, u se of high heels and sports footw ear, and sad d le
height for cyclists. Ergonom ic evalu ation of the w orkp lace
and habitu al postu res or positions m ay requ ire assessm ent,
su ch as kneeling p ositions. Cyclists m ay requ ire a p rofessional
bike- tting and m od i cation service. Sports-speci c tech-
niqu es m ay inclu d e coaching inp u t and sp ecialist equ ip m ent
(e.g. kneepad s, etc.). Ad vice and ed u cation is vital to the p lan
of care.
Multimodal treatment
Evid ence is in favou r of m u ltim od al treatm ent for PFJ.
McConnell (2009) review ed stu d ies (n = 8) of therapies for PFJ
and conclu d ed that a m u ltim od al physical therap y pro-
gram m e w as effective. A McConnell-based m ultim od al physi-
cal therap y p rogram m e, consisting of p atellar tap ing, p atellar
m obilizations, sp eci c qu ad ricep s and glu teal m u scle exer-
cises and stretching for the anterior hip and ham strings, w as
fou nd to be su ccessful for the treatm ent of PFJ (Cow an et al
2002; Crossley et al 2002; McConnell 2009).
Patellar taping
The aim of taping is to im prove patellar position. Evid ence
su ggests an im m ed iate effect on p ain, and short-term effects
on the onset tim ing of the VMO relative to the VL m u scle
and on the effect on functional gait, bu t the exact m echanism
Conservative treatment 503
Figure 44.7 Patellar taping. The tape is placed in a direction to reduce lateral or
lateral tilt position of the patella. This depends on the ndings from the patellar
mobility testing. Several layers of tape may be used and underlining tape may be
required. Precautions for taping are noted.
of effect is still u nd er investigation (Crossley et al 2009;
McConnell 2009). MRI assessm ent of lateral patellar d isplace-
m ent, w ith no tap e versu s tap e, show ed lateral p atellar d is-
p lacem ent red uctions of 0.4 m m , 1.1 m m and 0.7 m m at 0°,
10° and 20° of knee exion resp ectively (H errington 2006).
Thou gh these changes are sm all, the qu estion rem ains of
w hether they are statistically signi cant enou gh to be respon-
sible for changes in p ain and fu nction.
Tap ing is recom m end ed as a m easu re to relieve p ain
w hile strategies are applied to correct contributing factors
and d u ring exercises in the early stage (Crossley et al 2009;
McConnell 2009). Rigid zinc oxid e typ e tape w ith an und erlin-
ing tap e, to red uce allergic skin reaction, is applied on pre-
p ared shaved skin w here ap p rop riate w ith norm al p recau tions.
The tap e is often applied w ith a m ed ial glid e, and the tape
p osition varied so as to correct the abnorm al tilt (e.g. lateral
or inferior tilt) (Fig. 44.7).
A CPR for p atellar tap ing for PFJ w as d evelop ed w ith a
m ethod ological qu ality that w as d eem ed accep table (Lesher
et al 2006; Glynn & Weisbach 2011). The presence of one or
m ore of tw o p red ictor variables, inclu d ing tibial varu m > 5°
and p ositive patellar tilt test, led to a +LR of 4.4. This repre-
sents a sm all, bu t som etim es clinically im p ortant, shift in the
p robability of bene t from tap ing (Lesher et al 2006; Glynn &
Weisbach 2011). Success w as d e ned as p erceived global
im provem ent and / or a ≥ 50% red u ction in pain w ith p atellar
tap ing (Lesher et al 2006).
Patellar mobilizations and lumbar manipulation
Manu al therap y for PFP has evid ence for im p roving p ain,
range of m otion and fu nction as part of a m ultim od al therap y
p rogram m e. A literatu re review of the effects of m anu al
therap y as p art of a m u ltim od al-based p rogram m e in ind i-
vid u als w ith low er kinetic chain d isord ers, inclu d ing PFP,
rated it as ‘level B’ (fair) evid ence (Brantingham et al 2009).
(For a m ore d etailed d iscu ssion of m anu al therapy for PFP
and exam ple of m obilization glid es (cephalad and cau d al,
lateral and m ed ial) see Ch 46.)
A CPR for the u se of lu m bar m anip u lation in PFP has also
been published (Iverson et al 2008). It encom passed the pres-
ence of three or m ore of ve p otential pred ictor variables – (1)
 504 PART 7 • 44 •
sid e-to-sid e hip internal rotation d ifference of > 14°, (2) ankle
d orsi exion w ith knee exed > 16°, (3) navicu lar d rop test > 3°,
(4) no self-rep orted stiffness w ith sitting > 20 m inutes and (5)
squ atting rep orted as the m ost painfu l activity – led to a +LR
18.4 of p ositive change (Iverson et al 2008; Glynn & Weisbach
2011). This w as a large probability shift of su ccess and w as
d e ned as a bene t in perceived global im provem ent and / or
p ain w ith fu nctional testing and lu m bar m anip u lation (Iverson
et al 2008; Glynn & Weisbach 2011).
Stretching
There is little research on the effects of stretching alone as an
intervention for PFP (Crossley et al 2009). One stu d y assessed
the effects of a 3-w eek w eight-bearing (stand ing) static-
stretching p rogram m e for the qu ad ricep s m u scle (Fig. 44.8) in
p atients w ith PFP (Peeler & And erson 2007); the stretching
im p roved PFP p ain and fu nction, bu t there w as a p oor cor-
relation betw een qu ad ricep s exibility and the severity of
knee p ain.
The p atella p osition (lateral d isp lacem ent as d escribed by
McConnell) had a p oor correlation w ith iliotibial band length
as m easu red by Ober ’s test, but a m od erate correlation w ith
the m od i ed Ober ’s test (H errington et al 2006b). Mu scle
length tests from the assessm ent w ill reveal p otential soft
tissu e length challenges to the kinetic chain. Mu scles involved
m ay inclu d e the anterior hip exors (iliop soas, rectu s fem oris),
hip rotators, qu ad ricep s (rectu s fem oris and vastu s m ed ialis
and lateralis), ham strings and lateral hip stru ctures, p articu -
larly the tensor fasciae latae and the calf. A stretching p ro-
gram m e m ay be of valu e to optim ize kinetic chain in u ences;
how ever, other asp ects of the m u ltim od al p rogram m e shou ld
not be neglected .
Over exibility m ay be an issu e and sp ecial consid eration
shou ld be p aid to ind ivid u als w ith a history of su blu xation,
Figure 44.8 Standing quadriceps stretch. Stretches are held for 30 seconds for
three repeats with normal precautions. Avoid anterior tilt of pelvis. Avoid pain and
ensure safe stability.
Patellofemoral pain syndrome
d islocation and hyperm obility synd rom es so as to avoid inap-
p rop riate stretching. Prevalence estim ates of hyp erm obility
range from 4% to 7% in the norm al pop u lation, 9.5% in ballet
d ancers and 11.7% in high-school stud ents, and hyp erm obil-
ity is m ore com m on in girls and w om en than in boys and m en
(Klem p et al 1984; Alter 1996; H akim & Graham e 2003; Seckin
et al 2005). The Beighton score has been u sed to id entify su b-
jects w ith hyperm obility and is com m only u sed in sports
m ed icine, orthop aed ics and rheu m atology (Beighton et al
1973; Alter 1996).
Strengthening exercises
Strengthening is one of the m ain p illars of PFP rehabilitation.
Local p atellar stability is in u enced by the qu ad ricep s grou p ,
especially the VMO, w hich cou nteracts lateral p atellar tilt.
The m ain op en chain kinetic exercises u tilized are the isom et-
ric qu ad ricep s set at 0°, term inal knee extension and the
straight leg raise, w ith all three exercises w orking in less than
30° of knee exion, therefore m inim izing PFJ contact stress
(McConnell 2009). These three open chain exercises d o not
p referentially activate the VMO, and variants of the exercises
(e.g. external hip rotation d uring straight leg raise) d o not
confer greater VMO activity (Karst & Jew ett 1993; Cerny 1995;
Cu d d eford et al 1996; Mirzabeigi et al 1999). There have been
m ixed resu lts w ith resp ect to w hether ad d itional hip ad d u c-
tion in u ences VMO / VL activation (McConnell 2009).
In contrast, in one stu d y closed chain kinetic exercises p ro-
m oted balanced initial qu ad ricep s activation and a larger
am plitud e of m axim al volu ntary contraction than d id op en
chain exercises (Stensd otter et al 2003). In another, open chain
kinetic exercises prod uced m ore rectu s fem oris activity
w hereas closed chain kinetic exercises prod u ced m ore vastu s
m u scle activity (Escam illa et al 1998). Fu rtherm ore, PFJ com -
p ressive force w as greatest in closed chain exercises in near
full exion and in the m id -range knee-extend ing phase than
in open chain kinetic exercises (Escam illa et al 1998).
These stu d ies w ill in uence the choice of exercises for PFP
rehabilitation p rogram m es. When patients are read y and it is
app rop riate, closed chain kinetic exercises shou ld be initiated
ow ing to the ad vantages of targeting the kinetic chain for
oor-to-core and the ad d itional neu rom u scular balance aspect
(McConnell 2009).
A com p rehensive stu d y of electrom yograp hic (EMG)
activity of eight kinetic chain core, tru nk, hip and thigh
m u scles d u ring nine rehabilitation exercises has been p u b-
lished (Ekstrom et al 2007). The results in u ence the choice
of exercises in low er kinetic chain rehabilitation, inclu d ing
PFP. The nine exercises assessed w ere active hip abd u ction in
sid e-lying, su p ine tru nk brid ge, u nilateral brid ge w ith one
knee extend ed , sid e brid ge, p rone brid ge, quad rup ed alter-
native arm and leg lift, lateral step-u p to a 20 cm (8 inch)
step , stand ing lu nge and d ynam ic ed ge exercise m achine. As
p art of the assessm ent, these exercises cou ld be u sed as
functional tests to exam ine the ind ivid ual’s neu rom u scular
control. This m ay be of im p ortance in d esigning training p ro-
gram m es aim ed at control of the active local and rem ote
factors in uencing the PFJ in ind ivid ual patients. The m uscles
tested w ith EMG in the above stu d y inclu d ed the glu teu s
m ed iu s, glu teu s m axim u s, VMO, ham strings, longissim u s
thoracis, lu m bar m u lti d u s, external obliqu e and rectu s
abd om inis (Table 44.8).
 Conservative treatment 505

Table 44.8 Exe rcis e s re comme nde d or a ctivation o s e le cte d hip and core mus cle s *
Exe rcis e Glute us Glute us Va s tus Ha ms tring s Long is s imus Lumba r Exte rna l Re ctus
me d ius ma ximus me d ia lis thora cis multi d us ob liq ue a bdominis

Side bridge 1 2 3 1 2
Unilateral bridge 2 2 1 1 2
Lateral s tep-up 3 1
Quadruped arm / lower 4 1 2 4 1
extremity lift
Active hip abduction 5
(s ide-lying)
Lunge 3 2
Bridge 3 4
Prone bridge 2 1
*Numbering refers to priority of exercis es bas ed on EMG activation.
(Adapted from Eks trom et al 2007.)

Figure 44.9 Clam exercise. An exercise to target the gluteus medius muscle
especially. Make sure hips are stacked and avoid rotation of the trunk.

Other exercise regim ens have been also recom m end ed

includ ing VMO retraining, step -up / step-d ow n, hip abd uc-
tion and external rotation strengthening and lu nges (Crossley
et al 2009, McConnell 2009), and qu ad riceps and ham string,
w all squats, p lies, lunges, m ini-squ ats, step -u p / step -d ow n,
lateral step-up s and m achine and free-w eight exercises
(H ou glu m 2005). Caution shou ld be noted w hen using exer-
cises that cau se p ain, esp ecially w ith excessive load ing in
exion beyond 30° w here PFJ forces increase substantially
(H ou glu m 2005). The knee extension m achine, w hich is an
op en chain kinetic exercise, shou ld not be u sed or only be
u sed w ith signi cant cau tion ow ing to p otential for high PFJ
com p ressive and shear forces (H ou glu m 2005).
Box 44.1 su m m arizes the typ es of exercise that target sp e-
ci c m u scles, and Figures 44.9–44.15 present som e exam ples
of su itable exercises. As w ith any exercise p rogram m e, exer-
cise p rescrip tion shou ld be m onitored for tolerance and
ap p rop riateness. (Read ers are referred to other chap ters for
further inform ation on therapeu tic exercise principles.)
Figure 44.10 Standing hip abduction in 0° abduction and also with abduction
in 30° extension to target the posterior gluteus medius muscle. Weight can be
added for progression. Keep spine and trunk stable during exercise.
In a stud y that investigated the effect of low -load exercises
targeting glu teal m u scles on low er lim b fu nction / p erform -
ance (Crow et al 2012), a neu rom uscu lar w arm -u p routine
w as id enti ed . It inclu d ed seven exercises: the d ou ble-leg
brid ge, qu ad ruped low er extrem ity lift, quad rup ed hip abd uc-
tion, sid e-lying clam in 60° hip exion, sid e-lying hip abd u c-
tion, p rone single-leg hip extension and d ou ble-leg stability
ball squat. Although the precise m echanism for activation w as
not id enti ed , the au thors p ostu lated that it m ight be a resu lt
of altered m otor cortical activity. H ow ever, it w as clear from
the stu d y that there w as an increase in low er lim b p erform -
ance, a cou nter-m ovem ent ju m p increase resu lting from the
 506 PART 7 • 44 • Patellofemoral pain syndrome

Bo x 4 4 .1 Exa m p le s o f re h a b ilita tio n e xe rc is e s *

Lo c al kne e  o pe n c hain

Static quadriceps sets
Terminal knee extens ions
Straight leg raises
Kne e  c lo s e d c hain
Wall squats / mini-s quats etc
Lateral step-up
Lunge
Step-downs / step-ups
Unilateral bridge
Hip
Clam exercis e
Standing hip abduction 0° abduction and 30° Figure 44.11 Side-lying hip abduction in 0° abduction and also with abduction
abduction / extens ion (pos terior gluteus medius ) in 30° extension to target the posterior gluteus medius muscle. Weight can be
added for progression. Trunk should be stable during exercise with hips stacked.
Lying hip abduction 0° abduction and 30° abduction / extension
(pos terior gluteus medius )
External rotation of the hip in s ide-lying
Side bridge
Unilateral bridge
Lateral step-up
Quadruped arm / lower extremity lift
Step-downs / step-ups
Trunk
Side bridge
Unilateral bridge
Quadruped arm / lower extremity lift
Bridge
Prone bridge
Ne uro mus c ular and balanc e
Single-leg s tand
Single-leg s tand foam / cushion / balance board, etc. Figure 44.12 External rotation of the hip in side-lying. Target leg is lower leg on
table. Rotate hip as foot moves up to ceiling in concentric mode and then lowers in
Single-leg s tand with eyes clos ed eccentric. Weight can be added for progression. Trunk should be stable during
Single-leg s tand foam / cushion / balance board, etc. with eyes exercise with hips stacked.
clos ed
Star excursion balance exercise
Dynamic combined, e.g. balance cus hion and medicine ball sp orts activity in p atients p resenting w ith PFPs, or w hen su ch
rebounder, shuttle balance p atients are retu rning to sp ort.
Step-down exercis es
Multidirectional exercis es (bounding, hopping, etc.) Balance training and neuromuscular control
Plyo me tric
N eu rom u scu lar control and balance training and retraining of
Various as able and appropriate at end-stage rehabilitation
the visu al, vestibu lar and neu rom u scu lar control system s
and s ports -s peci c exercis es
shou ld be consid ered in low er kinetic chain rehabilitation
*Exercises s hould be pres cribed based upon individual needs and appropriatenes s . p rogram m es (H ou glu m 2005; Kenji 2010). Prop rioception
Monitor for ability to perform with good form and function and s afety. im p airm ent has been reported in PFP p atients, m ost notably
on the affected sid e bu t also on the u ninvolved sid e, w hen
com p ared w ith controls (Akseki et al 2008). One-leg static
balance is d ecreased on the sym ptom atic sid e in PFP p atients
low er level glu teal activation exercises. There ap p ears to be and a correlation w ith w eakness of the qu ad ricep s and ham -
an exp ected transfer of m u scle activation w ithin the targeted strings exists, w ith no correlation to severity of p ain or low er
m u scle grou p , w hich fu rther enhances activation d ow n the extrem ity alignm ent and Q-angle (Citaker et al 2012). Variou s
kinetic chain. This d oes need valid ation w ith EMG, how ever. tools can be u sed to assess neu rom u scu lar control and balance
Extrap olating the resu lts, these exercises m ay be an easy, non- – for exam p le, the balance error scoring system (BESS), w hich
fatigu ing m ethod of activating hip and thigh m u scles before is an easy clinical test to ad m inister and requires only a level

Figure 44.13 Step-down exercise. Dynamic lowering and raise from a step. Also
use lateral step-up exercise as an alternative. Improve control and avoid increasing
dynamic Q-angle by maintaining hip, knee and foot alignment.
Figure 44.14 Side bridge. Trunk and hip muscle exercise. Hold for 5–10 seconds
and repeat as indicated.
su rface and p iece of foam (Kenji 2010; Bell et al 2011). The
average error score in controls is nine, w here a low score signi-
es good neu rom u scu lar control (Kenji 2010). The reliability
of the BESS is rep orted as m od erate to good , esp ecially w hen
large balance d e cits exist in su ch cases as fatigu e and concu s-
sion (Riem ann & Gu skiew icz 2000; Valovich et al 2003; Wilkins
et al 2004; Docherty et al 2006; Bell et al 2011). When sm aller
su btle d e cits are p resent the reliability w ill be low er (Bell
et al 2011). BESS scores increase w ith age, ankle instability and
external ankle bracing for 20 m inu tes after exertion and
im prove after neurom u scular control balance training
(Riem ann & Gu skiew icz 2000; Su sco et al 2004; Bell et al 2011).
Whereas the BESS is a static balance test, the SEBT can be
em ployed for d ynam ic clinical testing. Factors lead ing
Conservative treatment 507
Figure 44.15 Quadruped arm / lower extremity lift. Maintain stability of trunk and
avoid excessive trunk rotation.
to p oor neu rom u scu lar control and balance need to be
id enti ed . This w ill allow su itable rehabilitation exercise p ro-
gram m es to be properly d esigned . Closed chain kinetic exer-
cises, as d escribed above, m ay also assist in fu nctional
im provem ent of neurom uscu lar control, balance and strength
in m u scles related to the kinetic chain.
For treatm ent, balance retraining can consist of d eveloping
exercises based up on errors id enti ed in the BESS test. The
SEBT can also be ad op ted as an exercise. It is ad vised to start
at the m inim u m challenging level and ad vance in a progres-
sive grad ed m anner. Balance exercise equ ip m ent can be
em ployed to p rogress exercises, su ch as foam , air cushions,
balance board s, beam s and specialized equ ip m ent su ch as the
Y-Balance System , Shu ttle Balance System and a m ed icine ball
rebound er, etc. Other treatm ent regim ens includ e the Jand a
ap proach for m uscle im balance and sensorim otor training
(Page et al 2010). A sim ple set of Jand a balance sand als has
been show n to facilitate volum e and tim ing of EMG of glu teal
m u scles in norm al su bjects d u ring w alking (Bu llock-Saxton
et al 1993; Page et al 2010). Som e exam ples of neurom u scular
and balance exercises are show n in Figures 44.16–44.18.
Soft tissue massage and trigger point therapy
There is a lack of research on the effect of soft tissu e m assage
for PFP. One trial reported higher bilateral prevalence of TrPs
in the gluteu s m ed iu s and qu ad ratu s lu m borum m u scles,
w ith a corresp ond ing low er hip abd u ction strength in PFP
p atients (n = 26), com pared w ith controls (n = 26) (Roach et al
2013). H ow ever, TrP pressu re release therapy had no effect
on strength in the PFP su bjects (Roach et al 2013). This stu d y
d id not evalu ate the vastus m ed ialis or lateralis m u scles (Fig.
44.19), w hich is a very clinically relevant grou p of m uscles
ow ing to their local effect on the PFJ, and esp ecially the vastu s
lateralis and VMO, ow ing to their d irect effect on lateral patel-
lar tilt.
There are con icting recom m end ations for soft tissu e
m assage in other knee cond itions su ch as osteoarthritis
(Perlm an et al 2006, 2012; Zhang et al 2007; Peter et al 2011;
Atkins & Eichler 2013). Further research is need ed to d eter-
m ine the effects, if any, of soft tissu e techniqu e inclu d ing TrP
therap y on PFP.
 508 PART 7 • 44 • Patellofemoral pain syndrome
Figure 44.16 Balance exercise. Example of single-leg stand balance on foam.
Maintain safety.
Figure 44.17 Balance exercise. Example of star excursion balance test used as
an exercise. Here it is carried out on the Y-Balance tester. Reaching is carried out in
anterior, lateral and medial direction repeated for 10–20 times in single-leg stand
and repeated on opposite side.
Trigger point dry needling and botulinum
toxin injection
Trigger p oint d ry need ling (TrP-DN ) has becom e a com m on
treatm ent in m u scu loskeletal and m yofascial p ain d isord ers
(Dom m erholt & Fernand ez-d e-las-Peñas 2013), and the
Figure 44.18 Dynamic balance incorporating vestibular, visual and
neuromuscular components carried out on the shuttle balance system with a
medicine ball rebounder. (Shuttle Balance Systems, WA, USA).
Figure 44.19 Massage and myofascial trigger point release to the lateral thigh
and vastus lateralis trigger points.
Am erican Acad em y of Orthopaed ic Manual Therapists
(AAOMPT) has pu blished a supp ort statem ent for TrP-DN
(AAOMPT 2009). TrP-DN is a safe proced ure w hen carried
ou t by ap p rop riately trained clinicians (Brad y et al 2014), and
gu id elines for safe practice have been pu blished (Irish Society
of Chartered Physiotherapists (ISCP) 2012; McEvoy 2013).
Dry need ling is a neu rophysiological evid ence-based treat-
m ent techniqu e that requ ires effective m anu al assessm ent of
the neu rom u scu lar system . Physical therap ists are w ell trained
to u tilize d ry need ling in conju nction w ith m anu al p hysical
therap y interventions. Research su p p orts the p rop osition that
d ry need ling im proves pain control, red u ces m u scle tension,
norm alizes biochem ical and electrical d ysfu nction of m otor
end plates, and facilitates an accelerated retu rn to active reha-
bilitation (AAOMPT 2009).
Read ers are referred to Chapter 59 of this textbook for
relevant review of TrPs. Althou gh no stu d y has assessed the

effect of TrP-DN on PFP, TrP-DN targeted to m uscles d eter-
m ined to contain clinically relevant TrPs su ch as the qu ad ri-
cep s, esp ecially the vastu s lateralis, glu teal m u scles and
qu ad ratu s lu m boru m , m ay be help fu l as p art of a m u ltim od al
p rogram m e. In p atients w ith PFP, the glu teu s m ed ius and
qu ad ratu s lu m boru m TrPs w ere m ore p revalent bilaterally,
and correspond ed to low er hip abd u ction strength (Roach
et al 2013). Clinicians should be trained ad equ ately to im prove
the accu racy of TrP p alp ation testing (McEvoy & H u ijbregts
2011). Althou gh need ling therapies seem to be effective for
p ain control (Cu m m ings & White 2001), no rand om placebo-
controlled trial existed u ntil recently (Mayoral et al 2013); in
this trial, p atients w ho w ou ld be receiving total knee arthro-
p lasty w ere exam ined for TrPs before su rgery (n  = 40). While
u nd er anaesthesia in the op erating room , and before the
su rgery started , they w ere rand om ized to TrP-DN or p lacebo
grou p and treated accord ingly. Blind ing w as m aintained by
anaesthesia. The stu d y au thors conclu d ed that a single
TrP-DN treatm ent u nd er anaesthesia red u ced p ain in the rst
m onth after total knee arthrop lasty com p ared w ith p lacebo
(Mayoral et al 2013). In another prelim inary rand om ized
controlled trial, old er p atients w ith knee osteoarthritis
(n = 30) w ere treated w ith TrP-DN , trad itional acu pu nctu re
or sham at TrPs; the resu lts d em onstrated signi cant
im provem ent w ith TrP-DN over acupu ncture and sham for
p ain and fu nction. (See Ch 61 for d iscu ssion on TrP-DN
techniqu es.)
Botu linu m toxin typ e A (Botox) has been tested in an op en
label pilot stud y of subjects w ith refractory anterior knee pain
w ith relative overactivity of the VL, w ith encouraging resu lts
(Singer et al 2006). This initial stu d y by a group of Australian
researchers p rovoked interest. In a fu rther stu d y of Botox
injection, for anterior knee p ain associated w ith quad riceps
m u scles im balance, su bjects (n = 24) w ere rand om ized to
either Botox or saline injection to the vastu s lateralis w ith all
su bjects p rescribed a hom e p rogram m e for vastu s m ed ialis
retraining (Singer et al 2011). Quad riceps m uscle im balance
w as assessed by EMG. Results at 12 w eeks w ere signi cantly
in favou r of the Botox treatm ent grou p in term s of pain on
kneeling, squatting and level w alking and anterior knee pain
scale. In a retrosp ective cohort stu d y of su bjects w ith refrac-
tory anterior knee p ain, a single Botox injection to the VL
resu lted in relief of knee pain and im provem ent in function
in 57 of 65 su bjects, w ith an average bene t of 34 m onths in
44 ou t of the 57 cases (Silbert et al 2012).
In com bination, these stu d ies suggest that altering the
vastu s lateralis fu nction by Botox injection has an effect on
PFJ p ain and d ysfu nction. This m ay act by altering vastu s
lateralis m u scle activation, lateral knee tension and p atellar
tilt. This is sim ilar in essence to the aim of other strategies
su ch as m anu al therap y, soft tissu e therap y and su rgical
release. It is w orth noting that none of these stu d ies strategi-
cally targeted TrP sp eci cally, or com p ared TrP-DN w ith
Botox. Areas of stiffness have been id enti ed in TrP zones
in stu d ies u sing MRI elastograp hy and u ltrasou nd elastogra-
p hy (Chen et al 2007, 2008; Sikd ar et al 2008, 2009). Fu rther-
m ore, TrP-DN has been show n to red u ce p alp able m u scle
stiffness u sing u ltrasou nd shear-w ave elastograp hy (Maher
et al 2013) w hen tested using ultrasound . It is feasible that
TrP-DN cou ld be an effective ad ju nctive treatm ent to the m u l-
tim od al p rogram m e in PFP rehabilitation. Fu rther research is
ind icated to d irect best p ractice.
Conservative treatment 509
Selected electrophysical modalities
A fu ll d iscu ssion of electrop hysical m od alities is beyond the
scop e of this chap ter; the m ain aim of this section is to stim u -
late the read er to consid er electrophysical m od alities as part
of PFJ m u ltim od al p rogram m e. Mod alities m ay p lay a role for
sp eci c biological effects. The choice of m od ality w ill d ep end
on clinical reasoning and evid ence-inform ed research and
goals. There is a lack of quality research on electrophysical
m od alities for PFJ. A system atic review of electrop hysical
m od alities for PFP, based on 12 stu d ies, conclud ed that som e
electrop hysical m od alities, w hen com bined w ith other treat-
m ent, m ay confer an effect on p ain, bu t w hen u sed alone had
no bene cial effect (Lake & Wofford 2011). The electrophysical
m od alities review ed w ere a com bination stu d y (u ltrasou nd ,
ice m assage, p honophoresis and iontophoresis), neurom u scu-
lar electrical stim ulation, EMG biofeed back and low -intensity
laser, and m ost stud ies w ere of low to m od erate qu ality
m aking conclu sions d if cu lt (Lake & Wofford 2011). Transcu -
taneou s electrical nerve stim u lation (TEN S), interferential
therap y and shockw ave w ere not covered in this stu d y. Fu tu re
basic biological and rand om ized controlled trials are required
to d elineate best p ractice. Slu ka and her grou p from the Uni-
versity of Iow a are investigating the p erip heral and central
m echanism s of chronic m u scu loskeletal p ain and also the
neu robiology of TEN S analgesia in anim al m od els w ith a
focus on translating these stu d ies to knee osteoarthritis in
hu m ans (Slu ka 2014). Slu ka has pu blished a book on the
m echanism s and m anagem ent of p ain for p hysical therap ists
and this is a valu able resource (Slu ka 2009). Other helpfu l
resou rces on electrophysical m od alities and tissue repair are
offered by Watson (2008).
Often m od alities, su ch as su p er cial heat, TEN S and inter-
ferential therapy, are em ployed as supp ortive treatm ents for
m u scu loskeletal p ain. As an exam p le, interferential therap y
has been rep orted to be help fu l for knee osteoarthritis, w ith
noxiou s and innocu ou s stim u lation signi cantly d ecreasing
chronic p ain and m orning stiffness, and signi cantly increas-
ing pain threshold and range of m otion com p ared w ith the
control grou p s (Defrin et al 2005). In this stu d y, noxiou s stim -
u lation d ecreased p ain intensity and increased p ain threshold
signi cantly m ore than innocu ou s stim u lation. Mod alities
m ay help to red u ce p ain and m ed ication u se, as d em onstrated
in osteoarthritis knee pain and low back pain (Facci et al 2011;
Atam az et al 2012).
Shockw ave is em p loyed for effectively treating p atellar
tend on knee p ain, am ongst other p athologies (van Leeu w en
et al 2009). There m ay be a role for shockw ave therap y as a
targeted therap y for stru ctu res involved in PFJ (see Table
44.1), su ch as the vastu s lateralis tend on com plex (Fig. 44.20),
retinacu lu m and fat pad , thou gh no stud ies have ad d ressed
this to d ate. In term s of TrPs, shockw ave m ay be a p rom ising
therap y (Gleitz & H ornig 2012). It has ef ciency for pain
red u ction and im p roving knee fu nction over p lacebo in knee
osteoarthritis p atients (Zhao et al 2013). In anim al stu d ies,
shockw ave therap y has d em onstrated a chond rop rotective
effect and regression of osteoarthritis in the rat knee (Wang
et al 2011, 2013a, 2013b). In term s of peripheral and central
p ain effects, the ap p lication of shockw aves led to a signi cant
d ecrease in the m ean nu m ber of neu rons im m unoreactive for
su bstance P w ithin the d orsal root ganglion of L5 in rabbits
exposed to high-energy shockw aves to the ventral sid e of the
 510 PART 7 • 44 •
Figure 44.20 Shockwave therapy to the vastus lateralis muscle and tendon.
d istal fem ur, w hereas no su ch change w as seen in the contral-
ateral u ntreated sid e (H ausd orf et al 2008b). Ad d itionally,
shockw ave therap y ind u ced selective loss of u nm yelinated
nocicep tive nerve bres in a rabbit m od el (H ausd orf et al
2008a), a nd ing that m ay p artially explain the red uction in
p ain by d enervation of sensory nerves.
In su m m ary, electrophysical m od alities m ay play a role for
p ain relief in a m u ltim od al p rogram m e for PFP. Clinicians are
encouraged at least to consid er these m od alities as part of the
p lan of care for p otential sym p tom atic relief. Fu ture research
is need ed , how ever.
In-shoe orthoses
In-shoe foot orthoses are often prescribed for PFP to im prove
kinetic chain fu nction through p otential biom echanical
and / or neu rom u scu lar effects. Soft and hard orthoses m ay
change foot biom echanics and grou nd reaction forces, bu t the
effects on knee, hip and p elvic kinem atics are generally
lim ited (N ester et al 2003; Barton et al 2010). Orthoses m ay
have an effect on the p assive and active soft tissu es (N ester
et al 2003; McConnell 2009) and neurom u scular control
(Crossley et al 2009).
Orthoses m ay be help fu l for a select p op u lation, for exam p le
forefoot varus and excessive su btalar pronation, w hich can be
associated w ith PFP (Eng & Pierrynow ski 1993; Saxena &
H ad d ad 2003; Johnston & Gross 2004; McConnell 2009;
Mu nu era & Mazoteras-Pard o 2011; Rixe et al 2013). Foot
orthoses m ay p rod u ce an im p rovem ent in p ain sym p tom s
w hen used as part of a m u ltim od al program m e (Barton et al
2010; Rixe et al 2013).
Tw o CPRs ad d ress orthoses and PFP. The rst p relim inary
stu d y (Vicenzino et al 2008) reported a +LR of 8.8 of ‘m arked
im p rovem ent’ on a 5-p oint Likert scale if three or m ore vari-
ables w ere p resent ou t of fou r pred ictor variables: (1) age > 25
Patellofemoral pain syndrome
years, (2) height < 165 cm , (3) w orst p ain < 53.25 m m on
100 m m visual analogue scale, and (4) m id -foot w id th d is-
tance > 10.96 m m . Cau tion shou ld be exercised w hen ap ply-
ing this research, thou gh, as it is a prelim inary stud y and
the m ethod ological qu ality has been rep orted as below
su ggested stand ard (50%) (Vicenzino et al 2008; Glynn &
Weisbach 2011).
The second p relim inary stu d y looked at prefabricated
orthotics and m od i ed activity for PFP p atients, and the
m ethod ological score for this stu d y w as d eem ed accep table
(61%) (Sutlive et al 2004). The presence of one or m ore vari-
ables creates a sm all bu t som etim es clinically relevant shift in
p robability that p atient’s p ain w ill d ecrease by ≥ 50%. The
p red ictor variables and related p ositive likelihood ratios w ere
rep orted as follow s: (1) forefoot valgus ≥ 2° / +LR 4.0; (2) great
toe extension ≤ 78° / +LR 4.0; and (3) navicular d rop
≤ 3 m m / +LR 2.3 (Su tlive et al. 2004; Glynn & Weisbach 2011).
Conclusion
PFP is a com m on cau se of m u scu loskeletal p ain and is m u lti-
factorial in natu re. Both local and rem ote kinetic chain in u-
ences can p lace stress on the PFJ and lead to pain and
d ysfu nction. The pathop hysiology of PFP is not fully und er-
stood , bu t tissu e stress w ith loss of tissu e hom eostasis is
thou ght to p lay a role in the d evelop m ent of p ain and d ys-
function. Recent evid ence su ggests that ischaem ia m ay play
a role in pain. Assessm ent of p atients w ith PFP relies on a
com p rehensive assessm ent of the kinetic chain and local knee
stru ctu res. Mu ltim od al p hysiotherap y p rogram m es ap p ear to
be effective in patients w ith PFP, w hereas surgery shou ld be
avoid ed . Ad d itional research is required to assist in fu rther
u nd erstand ing of the m echanism s, cau ses, p revention of and
op tim u m treatm ents for PFP p atients.
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 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
45
Postoperative Management of the Knee: Ligamentous,
 Chapter 
Meniscal and Total Joint Replacement
J o d i Yo u n g , Elle n Po n g
CHAP TER CONTENTS
Introduction  514
Anterior / posterior cruciate ligament reconstruction  514
Modalities  514
Bracing / weight-bearing 
Range of motion exercises 
514
515
Therapeutic exercise  516
Neuromuscular re-education  516
Medial collateral ligament repair / reconstruction  516
Bracing / weight-bearing  516
Range of motion exercises  516
Therapeutic exercise  516
Meniscus  517
Meniscal repair / transplantation  517
Partial meniscectomy  519
Total knee arthroplasty  520
Procedures  520
Treatment  521
Arthro brosis of the knee  522
Conclusion  523
Introduction
This chap ter introd u ces evid ence-based p hysical therap y
interventions for p atients u nd ergoing su rgery for ligam en-
tou s or m eniscal inju ries or total knee arthrop lasty. Postop era-
tive rehabilitation w ill vary d ep end ing on the severity of
inju ry, the su rgical ap p roach and other tissu es inju red . The
goals of rehabilitation after anterior cru ciate ligam ent (ACL),
p osterior cru ciate ligam ent (PCL) and m ed ial collateral liga-
m ent (MCL) reconstru ction, m eniscal rep air, transp lantation
and p artial m eniscectom y all inclu d e m inim izing sw elling
and pain, restoring the knee range of m otion and joint m obil-
ity, norm alizing low er extrem ity strength, d ynam ic stability,
gait and knee biom echanics, and enhancing proprioception
and neu rom u scu lar control (Logersted t et al 2010b; Wijd icks
2010; Escam illa et al 2012; LaPrad e & Wijd icks 2012; N oyes
et al 2012; Rosenthal et al 2012; Yvas et al 2012). Provision
of evid ence-based interventions to ad d ress these goals w ill
be the em p hasis of this chapter. (See Ch 42 for fu rther
inform ation on risk factors and conservative treatm ent of
knee inju ries.)
Anterior / Posterior Cruciate
Ligament Reconstruction
Initial rehabilitation principles for ACL reconstru ction em pha-
size fu ll p assive knee extension, im m ed iate range of m otion
and p artial w eight-bearing (Wright et al 2008; Logersted t et al
2010b; Wilk et al 2012). Au tograft tissu es, either bone–patellar,
tend on–bone or ham string tend on, are consid ered the gold
stand ard s in ACL reconstru ction and have been show n to
d ecrease tim e in su rgery and red u ce postoperative pain
(Manske et al 2012; N and ra et al 2013). The m ost com m on
au tograft in PCL reconstruction is the bone–patellar–tend on–
bone (Rosenthal et al 2012). Becau se cu rrent surgical practice
favours the u se of au tografts, the focu s on rehabilitation tech-
niqu es after au tograft su rgical p roced u res for ACL / PCL
reconstruction w ill be d iscu ssed . See Table 45.1 for rehabilita-
tion goals.
Modalities
The u se of cryotherapy, in conjunction w ith elevation and
com p ression, shou ld be u tilized in p atients im m ed iately after
su rgery to assist in p ain red u ction and sw elling (Logersted t
et al 2010b; Manske et al 2012; Rosenthal et al 2012; Wilk et al
2012). Patients can also be prescribed neurom uscu lar electro-
stim u lation (N MES) for red u ction of sw elling and assistance
of qu ad ricep s facilitation (Manske et al 2012; Rosenthal et al
2012). In recent stud ies, those w ho received N MES tw o to
three tim es p er w eek for u p to 12 w eeks had im p roved qu ad -
riceps strength com pared w ith those w ho d id not receive the
intervention (Logersted t et al 2010b).
Bracing / weight-bearing
H inged braces locked into 0° extension shou ld be u sed d u ring
am bu lation for up to 2 w eeks after ACL or PCL reconstru c-
tion. Patients w ill often be allow ed to u nlock the brace w hile
sitting, p erform ing knee range of m otion and strengthening
 Anterior / posterior cruciate ligament reconstruction  515

Table 45.1 ACL / PCL re cons truction re habilita tion goals

Time fra me Clinica l g oa ls

Weeks 0–2 ACL

ROM 0–90°
Quadriceps control
Full weight-bearing
PCL
AROM / PROM: 90–0° / 0–90°
Quadriceps control
Weeks 2–6 ACL
Knee f exion within 10° o uninvolved limb
Implement neuromus cular re-education
programme
Figure 45.1 Passive knee exion stretch with the patient prone.
PCL
ROM to 120°
Full weight-bearing
Weeks 6–12 ACL and especially knee extension (Manske et al 2012). Early
Full ROM (by 8 weeks) m obilization also help s to red u ce p ain and lim it p ossible soft
Normal gait (by 8 weeks) tissu e restrictions (Logersted t et al 2010b). Those w ho receive
a PCL reconstru ction m ay need to be im m obilized for 2–4
PCL
w eeks (H arner & H oher 1998). Therapist interventions to
Full ROM (by 12 weeks)
assist w ith gaining fu ll knee extension can includ e m anu al
Normal gait (by 12 weeks )
p assive range of m otion into hyp erextension (Manske et al
Implement clos ed kinetic chain exercises
2012), su pine ham string stretches w ith a w ed ge u nd er the
(week 6)
heel (Wilk et al 2012) or gravity-assisted extension (Manske
Weeks 12–16 ACL et al 2012).
Begin s port-speci c and agility exercis es To increase knee exion, w all slid es and active heels slid es
(week 12) can be u tilized . Active heel slid es shou ld not be p erform ed
PCL
for PCL reconstru ction, or ACL reconstru ction if a ham string
Begin basic agility exercis es
tend on graft w as u sed (Manske et al 2012; Rosenthal et al
2012). Care shou ld be taken in ind ivid u als u nd ergoing PCL
Weeks 16–24 ACL reconstruction to lim it exion to 90° u ntil after w eek 2; this
Continue sport-speci c, agility and can be d one throu gh p assive knee exion w ith p atients in a
plyometric training p rone p osition, or w ith p atients hold ing a strap and p erform -
Return to sport (i cleared) ing the stretch them selves (Fig. 45.1) (Rosenthal et al 2012).
PCL Progression p ast 90° of knee exion can begin after 2 w eeks,
Begin s port-speci c exercis es / plyometrics but shou ld be restricted to 120° u ntil 6 w eeks after a PCL
reconstruction (Wilk 1994; Rosenthal et al 2012).
Weeks > 24 PCL Return to s port Patellar m obilizations shou ld be u sed im m ed iately after
AROM= active range o motion; PROM= pass ive range o motion; ROM= range su rgery for those ind ivid u als w ho have u nd ergone either an
o motion.
ACL or a PCL reconstru ction. Su perior, inferior, m ed ial and
lateral patellar m obilizations should be u sed both as a thera-
p eu tic intervention and as a hom e exercise p rogram m e
(Rosenthal et al 2012; Wilk et al 2012). Tibiofem oral m obiliza-
tions can be p erform ed w ith care to increase knee extension
exercises. Weight-bearing status w ill d ep end on su rgeon and exion. Little has been stu d ied on joint m obilizations in
sp eci cation and range from p artial to total w eight-bearing as those u nd ergoing ACL or PCL reconstru ction, so therap ist
tolerated (Rosenthal et al 2012; Wilk et al 2012). Ind ivid uals d iscretion is necessary w hen d eterm ining the type and grad e
u nd ergoing ACL reconstru ction shou ld be fu ll w eight-bearing of m obilization to u tilize. Ad am s et al (2012) recom m end the
by 2 w eeks, w hereas full w eight-bearing m ay take u p to 4–6 u se of tibiofem oral joint m obilizations w ith rotation at 4
w eeks after PCL reconstru ction (Manske et al 2012; Rosenthal w eeks, and Rosenthal et al (2012) ad vocate that tibiofem oral
et al 2012; Wilk et al 2012). Dep end ing on physician prefer- m obilizations be ad d ed im m ed iately p ost su rgery for PCL
ence, the patient shou ld continue to w ear a brace for several reconstruction. (See Ch 46 for a d escrip tion of joint m obiliza-
w eeks. tion interventions of the knee joint.) H unt et al (2010) d escribed
the u se of one-tim e grad e fou r anterior tibiofem oral joint
Range of motion exercises m obilizations in 12 p atients p ost ACL reconstru ction. The
results ind icate that there w as an increase in knee exion after
Im m ed iate m obilization for those und ergoing ACL recon- anterior glid es; how ever, the results w ere tem porary, so
stru ction is im p ortant so as to regain knee range of m otion, p erhap s m ore than one session is ap p rop riate.
 516 PART 7 • 45 •  Postoperative management of the knee
Therapeutic exercise
Therapeu tic exercise for those u nd ergoing PCL reconstru c-
tion is sim ilar to those u nd ergoing ACL reconstru ction, excep t
for the use of active knee exion and active ham string-
strengthening exercises in the latter. In PCL it is im p ortant to
u se p assive knee exion rather than active assisted or active
knee exion in the rst 2 w eeks after surgery so as to prevent
p osterior shear forces on the PCL from the ham string
(Rosenthal et al 2012).
General therap eu tic exercises in the early stages of rehabili-
tation for both reconstru ctions shou ld inclu d e isom etric qu ad -
riceps sets, straight leg raises, w eight shifts, leg press and
squ ats in sp eci c ranges of m otion and op en kinetic chain
knee extension, w ith and w ithou t the u se of w eights (van
Grinsven et al 2010; Manske et al 2012; Rosenthal et al 2012;
Wilk et al 2012).
Closed kinetic chain exercises m ay begin at w eek 6 for
those w ith a PCL reconstru ction if p erform ed in the range 0°
to 45°, bu t resisted knee exion or active ham string contrac-
tions shou ld not be p erform ed u ntil w eek 8 ow ing to p osterior
tibial shear (Wilk 1994; Pand y & Shelbu rne 1997). Closed
kinetic chain exercises can begin earlier in the rehabilitation
p hase, betw een 1 and 4 w eeks (Manske et al 2012). Typically,
p atients u nd ergoing ACL reconstru ction have been ad vised
not to p erform closed kinetic chain exercises from 0° to 45°
and op en kinetic chain exercises betw een 90° and 0°, bu t
recent evid ence ind icates that there m ay be little harm in
w orking in these ranges (Manske et al 2012). Eccentric
strengthening has been stu d ied in recent years, and the con-
sensu s is that p hysical therap ists shou ld integrate eccentric
squ ats in PCL reconstru ction rehabilitation and u se an eccen-
tric exercise ergom eter for those follow ing ACL reconstru c-
tion (Logersted t et al 2010b).
Arou nd w eek 6, p atients can u se a stair clim ber, elliptical
or tread m ill, as w ell as p rogress w ith balance / p rop riocep tion
exercises (van Grinsven et al 2010; Manske et al 2012;
Rosenthal et al 2012). This cou ld inclu d e starting w ith squats
on a stable su rface and p rogressing to having the p atient
p erform them on a rocker board , w ith the p hysical therap ist
p rovid ing m anual p ertu bations (Manske et al 2012; Wilk
et al 2012).
Starting arou nd w eek 12, patients can incorp orate fu nc-
tional d ynam ic balance activities, p lyom etrics, agility exer-
cises and w ork on sp ort-sp eci c activities (van Grinsven et al
2010; Ad am s et al 2012; Manske et al 2012). To assess for a
p atient’s retu rn to sp ort, activities su ch as sid e shu f ing,
cu tting, start and stop s, zig-zags, gu re eights and cariocas
can be integrated (Wilk et al 2012). It is recom m end ed that
those u nd ergoing a PCL reconstru ction w ait u ntil w eek 16
to begin sp ort-sp eci c exercises and p lyom etrics (Rosenthal
et al 2012).
Neuromuscular re-education
N eu rom uscu lar re-ed u cation shou ld be started w hen a p atient
is am bu lating w ithou t an assistive d evice (van Grinsven et al
2010). DiStasi et al (2013) d iscu ssed the im p ortance of neu -
rom u scular training after ACL reconstruction to prevent a
second inju ry. It has been fou nd that m u scle w eakness,
im p aired neu rom u scu lar control and d e cits in a su ccessfu l
retu rn to high-level sports rem ain after an initial ACL recon-
stru ction (DiStasi et al 2013). Unid irectional single-leg activi-
ties, d ou ble- to single-leg exercises w ith d ecreasing base of
su p p ort, p ertu rbations d u ring single-leg activities and m u lti-
d irectional tasks need ing plyom etric and qu ick rep etitions on
u nstable su rfaces are ju st som e of the activities that shou ld be
includ ed (DiStasi et al 2013).
Medial Collateral Ligament
Repair / Reconstruction
In patients w ith severe acute MCL injuries, surgery typically
occu rs only w hen there is a m u ltiligam ent inju ry or knee
d islocation involving the MCL. Direct rep air w ith sutu res,
acute reconstru ction or a repair w ith a ham string graft m ay
occu r, bu t there is a risk for arthro brosis or heterotop ic bone
form ation w ith these proced u res (LaPrad e & Wijd icks 2012).
Patients w ith chronic m ed ial knee inju ries w ill have su rgery
w hen rotatory instability becom es an issu e (LaPrad e &
Wijd icks 2012).
Bracing / weight-bearing
Ind ivid u als u nd ergoing an MCL reconstruction w ill be non-
w eight-bearing or toe-tou ch w eight-bearing and w ear a brace
for up to 6 w eeks after su rgery (LaPrad e & Wijd icks 2012);
those u nd ergoing an MCL rep air w ill be non-w earing for 3
w eeks in a brace that allow s 30–90° of m otion (Qu arles &
H osey 2004). The knee brace should be rem oved only w hen
the p atient is u nd ergoing p assive range of m otion for the rst
2 w eeks after su rgery; after that, the brace should be w orn
w hile sleep ing or w hen the patient is m oving around . When
the p atient achieves fu ll w eight-bearing statu s and has no gait
d eviation, the brace can be d iscontinued .
Range of motion exercises
Early range of m otion is necessary to red u ce the chances of
arthro brosis or ad hesions. Fu ll knee extension is the goal by
the end of 2 w eeks, bu t care shou ld be taken to avoid hyper-
extension, w hich w ou ld place tension on the graft (Wijd icks
et al 2010). Passive or passive assisted knee exion from 0° to
90° shou ld occu r w ithin the rst 2 w eeks after su rgery
(LaPrad e & Wijd icks 2012). Range of m otion should im prove
to at least 130° exion by 6 w eeks after surgery. To assist in
increasing the knee range of m otion, patellofem oral joint
m obilizations can be p erform ed aggressively im m ed iately
after su rgery.
Therapeutic exercise
Im m ed iately follow ing su rgery, p atients recovering from an
MCL reconstru ction can p erform strengthening exercises su ch
as quad riceps sets, straight leg raise, hip extension and abd u c-
tion exercises (LaPrad e & Wijd icks 2012), all w hile w earing a
knee brace.
Closed kinetic chain exercises can be introd u ced at 6 w eeks
for functional strengthening, bu t if a leg press or d ouble-lim b
squ atting is p erform ed then knee exion shou ld be lim ited to
 Meniscus 517

70° to m inim ize extrem e joint m ovem ent (Wijd icks et al 2010;
LaPrad e & Wijd icks 2012). It is also ad vised that no resistive
or rep etitive ham string exercises be perform ed u ntil 4 m onths
after su rgery (LaPrad e & Wijd icks 2012).
N orm alizing gait m echanics shou ld be em p hasized w hen
incorporating closed kinetic chain exercises (Wijd icks et al
2010; LaPrad e & Wijd icks 2012). Close attention shou ld be
p aid to the ind ivid u al’s tolerance to full w eight-bearing and
gait to avoid joint effusion, w hich can affect qu ad ricep s
strength, range of m otion and p ain levels (Wijd icks et al 2010;
LaPrad e & Wijd icks 2012). The therap ist shou ld also observe
the p atient for a qu ad ricep s avoid ance gait, as it cou ld cau se
knee hyperextension d u ring stance (Wijd icks et al 2010).
Lastly, p atients shou ld avoid any gait p attern that exhibits
excessive knee valgu s or internal or external rotation at the
tibiofem oral joint so as to lim it stress on grafts (LaPrad e &
Wijd icks 2012).
Sixteen w eeks after su rgery, the p hysical therap ist m ay
incorporate the u se of plyom etrics and agility training if
the p atient has p rogressed w ith strengthening, balance and
p rop riocep tion (LaPrad e & Wijd icks 2012). Exam ples of exer-
cises m ay inclu d e m u ltip lanar d irectional lu nges (Fig. 45.2A–
C), footw ork d rills for agility w ith a lad d er, d ouble-leg
p lyom etric d rills and m anu al p ertu rbations from the p hysical
therap ist to challenge p rop riocep tion and balance. If the
p atient is able to tolerate 1–2 m iles (≈1.5–3 km ) of am bu lating
w ithou t antalgia at a brisk pace and show s controlled single-
leg squ atting, an interval-jogging program m e m ay then
be im plem ented (Wijd icks et al 2010; LaPrad e & Wijd icks
2012). Retu rn to sport or recreational activity m ay occu r
w hen the physician and physical therapist d eterm ine objec-
tively that the p atient is able to d o so safely (LaPrad e &
Wijd icks 2012).
Meniscus
Meniscal inju ries are often treated su rgically w ith a p artial
m eniscectom y or a m eniscal rep air, both of w hich are p re-
ferred to a total m eniscectom y (Barber 1994). A new er su rgical
op tion is m eniscal transp lantation, w hich u ses hu m an allo-
graft tissue (H eckm ann et al 2006; N oyes et al 2012). Rehabili-
tation p rogression after m eniscal rep air, transp lantation and
total m eniscectom y is slow er than p artial m eniscectom y, bu t,
as w ith every patient, the progression is d epend ent on m any
factors. Table 45.2 su m m arizes the p ostop erative m anage-
m ent intervention strategies.
Meniscal repair / transplantation
Modalities
Early postoperative m anagem ent inclu d es cryotherapy
and com pression, w ith ed ucation of patients to elevate their
low er extrem ity as often as possible (H eckm ann et al 2006;
N oyes et al 2012). N MES for pain m anagem ent and qu ad ri-
cep s re-ed u cation for increasing qu ad ricep s strength (Bax
et al 2005; H eckm ann et al 2006; N oyes et al 2012) can be
incorp orated .

Table 45.2 Pos tope rative  inte rve ntion s trate gie s   or me nis cal re pair / tra ns plantation
Inte rve ntion Evide nce -ba s e d re comme nd a tion

Modalities Cryotherapy and compress ion (Heckmann et al 2006; Noyes et al 2012)

Bracing / weight-bearing
Range o motion
Therapeutic exercis e
Neuromus cular re-education
NMES or pain management and quadriceps re-education (Bax et al 2005; Heckmann et al 2006; Noyes
et al 2012)
Brace allowing 0–90° immediately a ter surgery but locked in 0° extension at night or the rst 2 weeks
(Heckmann et al 2006; Logerstedt et al 2010b; Noyes et al 2012)
Immediate weight-bearing at tolerance (Shelbourne et al 1996a; Logers tedt et al 2010b)
Pass ive f exion and active / active ass isted and pass ive knee extension rom 0° to 90° immediately a ter
surgery (Heckmann et al 2006; Cavanaugh & Killian 2012)
Patellar mobilizations in superior, in erior, medial and lateral directions (Noyes et al 2012)
Early postsurgical quadriceps sets , s traight leg raise and active assis ted knee extens ion (Heckmann et al
2006; Cavanaugh & Killian 2012; Noyes et al 2012)
Clos ed kinetic chain exercis es when knee f exion improved to 85° and / or patients are 50% weight-bearing
or meniscal repair and at weeks 7–8 or menis cal transplant (Heckmann et al 2006)
Open kinetic chain non-weight-bearing exercises or those undergoing menis cal repair (Heckmann et al
2006; Noyes et al 2012)
Step-up / step-down programme around weeks 6–14 depending on repair or trans plant (Cavanaugh &
Killian 2012)
Plyometric / agility training at week 14 (Cavanaugh & Killian 2012)
Return to s port activities at weeks 16–20 (Cavanaugh & Killian 2012) or repair and at 1 year or menis cal
transplant
Balance and proprioceptive exercis es beginning when patient is 50% weight-bearing or menis cal repair
(Heckmann et al 2006; Cavanaugh & Killian 2012; Noyes et al 2012)
Rocker board, Airex, Bosu, mini trampoline, oam roll, BAPS or Biodex progressions or advanced
neuromus cular re-education (Heckmann et al 2006; Noyes et al 2012)
 518 PART 7 •
A B
Figure 45.2 Multiplanar directional lunges: (A) anterior lunge; (B) lateral lunge; (C) posterior–lateral lunge.
Bracing / weight-bearing
To red u ce effu sion and p ain, su bjects u nd ergoing m eniscal
repair / transp lantation shou ld w ear a brace for u p to 6 w eeks
after su rgery, d ep end ing on the severity of the repair / trans-
p lant (Cavanau gh & Killian 2012; N oyes et al 2012). Su bjects
w ill be allow ed range of m otion from 0° to 90° im m ed iately
after su rgery, bu t a brace shou ld be locked at 0° extension for
the rst 2 w eeks at night (H eckm ann et al 2006; Logersted t
et al 2010a; N oyes et al 2012).
Weight-bearing statu s is d ep end ent on the severity of the
repair / transplant; how ever, ind ivid uals should be fully
w eight-bearing by 9 w eeks after the op eration (H eckm ann
et al 2006; Logersted t et al 2010a; N oyes et al 2012). A stu d y
on accelerated rehabilitation allow ed im m ed iate w eight-
bearing at tolerance, early m obilization and a return to sport
w hen a fu ll range of m otion had been regained . Ind ivid u als
in the accelerated rehabilitation grou p had a fu ll range of
m otion m ore qu ickly, w ith better qu ad ricep s strength and an
accelerated retu rn to sp ort (Shelbou rne et al 1996a; Logersted t
et al 2010a). Early m obilization m ay be the best option for
those u nd ergoing a m eniscal rep air.
Range of motion exercises
H eckm ann et al (2006) and Cavanau gh and Killian (2012) rec-
om m end p assive exion and active / active assisted and
p assive knee extension exercises from 0° to 90° im m ed iately
after surgery. Overp ressu re for knee extension can be ad d ed
throu gh the u se of a w eight over the d istal thigh and knee
(H eckm ann et al 2006) or by self-overpressure as ed ucated by
the p hysical therap ist. Active knee exion shou ld be avoid ed
im m ed iately p ost su rgery to red u ce ham string strain on the
p osterior–m ed ial joint (H eckm ann et al 2006), the sem im em -
branosu s m ed ially and the p op liteu s laterally (Cavanau gh &
Killian 2012).
45 •  Postoperative management of the knee
C
Figure 45.3 Straight leg hip abduction exercise.
Patellar joint m obilizations shou ld begin in the rst w eek
of p hysical therap y after m eniscal rep air / transp lant. Mobili-
zations in all d irections should be perform ed (N oyes et al
2012). To assist in fu rthering the range of m otion, ham string
and gastrocnem iu s / soleu s stretching should be initiated 1
d ay postoperatively (H eckm ann et al 2006; N oyes et al 2012).
Therapeutic exercise
Early strengthening exercises shou ld inclu d e qu ad ricep s sets,
straight leg raise and active assisted knee extension (H eck-
m ann et al 2006; Cavanau gh & Killian 2012; N oyes et al 2012).
Straight leg raise shou ld be p erform ed in the sagittal p lane
only u ntil any extensor lag is elim inated (H eckm ann et al
2006; N oyes et al 2012); fu rther straight leg raise for extension
and abd uction can be ad d ed (Fig. 45.3) w hen any lag is elim i-
nated (Cavanaugh & Killian 2012).
When exion im proves to greater than 85° and / or p atients
are 50% w eight-bearing (around 3–4 w eeks postop erative) in
those u nd ergoing a m eniscal rep air, closed kinetic chain exer-
cises can be ad d ed (N oyes et al 2012). Mini-squats, w all sits
and bilateral leg p resses can be incorp orated w ithin a 0° to
60° exion range (H eckm ann et al 2006; Cavanau gh & Killian

Figure 45.4 Squat with the use of a physioball and Theraband®.
2012). Ind ivid uals having a m eniscal transplant m u st w ait
u ntil w eeks 7–8 to perform w all sits and m ini-squ ats
(H eckm ann et al 2006). At 5–6 w eeks after m eniscal rep air and
9–12 w eeks after m eniscal transplant, leg p ress exercises can
be p erform ed in the range of 70° to 10°. Open kinetic chain
non-w eight-bearing exercises can be u tilized in those p atients
u nd ergoing a m eniscal rep air arou nd 5–6 w eeks after su rgery,
includ ing ham string cu rls and quad riceps exercises w ithout
w eight until the patient tolerates w eight-bearing (H eckm ann
et al 2006; N oyes et al 2012).
As the patient resum es norm al range of m otion and d em -
onstrates a norm al gait pattern (arou nd 6–14 w eeks), fu rther
exercises can be ad d ed . Bilateral and unilateral eccentric leg
p ress can be ad d ed w hen the knee exion range of m otion
increases to greater than 120° (Cavanaugh & Killian 2012).
Squ ats w ith p rogressive resistance w ith the u se of a p hysio-
ball initially and then Theraband ® or tubing can be ad d ed
(Fig. 45.4) (H eckm ann et al 2006; Cavanaugh & Killian 2012).
Four-inch (10 cm ) step -up s p rogressing to 6 and then 8 inches
(15 and 20 cm ) are ap p rop riate at this tim e, and shou ld be
im plem ented prior to a forw ard step-d ow n program m e
(Cavanau gh & Killian 2012). The goal is to d em onstrate a
forw ard step -d ow n on an 8-inch step w ithou t p ain and any
d eviations in low er extrem ity control (Cavanau gh & Killian
2012). N oyes et al (2012) ad vocate the u se of lateral step-ups
at arou nd 7–8 w eeks. The stair clim ber, ellip tical and retro-
grad e tread m ill can all be used in this phase, based on patient
sym p tom s (Cavanau gh & Killian 2012).
The nal phase of rehabilitation for m eniscal rep air involves
op tim ization of fu nction and p rep aration for a safe retu rn to
sp ort (Cavanau gh & Killian 2012). Running program m es can
Meniscus 519
be im plem ented at 16–20 w eeks postoperatively u sing retro-
grad e ru nning p rior to forw ard ru nning (Cavanau gh & Killian
2012). Ind ivid uals u nd ergoing a m eniscal transplant should
w ait until 1 year to start a ru nning program m e, and if a
com p lex m eniscal rep air has been p erform ed then ap p roxi-
m ately 30 w eeks is approp riate (N oyes et al 2012).
Plyom etric and agility training can begin at ap p roxim ately
w eek 14. Agility lad d ers can incorporate d eceleration, cu tting,
sp rinting, p ivoting (Cavanau gh & Killian 2012) or lateral
carioca or gu re-of-eight exercises (N oyes et al 2012). To
ensure that an ind ivid ual is appropriate for retu rn to sport,
functional testing shou ld be u sed . The single-lim b single-hop
test, the single-lim b trip le-hop test and the single-lim b
crossover-hop test have a rep orted reliability of 0.92, 0.88 and
0.84 for those having und ergone an ACL reconstru ction, bu t
they can also be safely u sed in those u nd ergoing m eniscal
repairs (Logersted t et al 2010a). Cavanau gh and Killian (2012)
rep ort a goal of achieving an 85% lim b sym m etry score on the
single-lim b single-hop and single-lim b crossover-hop tests
before the patient retu rns to sport.
Neuromuscular re-education
Balance, proprioceptive and neurom u scu lar exercises can
be ad d ed to the rehabilitation program m e w hen patients
are 50% w eight-bearing (arou nd 3–4 w eeks p ostoperatively)
after m eniscal rep air (H eckm ann et al 2006; Cavanau gh &
Killian 2012; N oyes et al 2012). Initial exercises should inclu d e
sim p le w eight shifts in the sagittal and frontal p lanes, tand em
stance balance and cone w alking (H eckm ann et al 2006;
N oyes et al 2012). Other p rogressions includ e using a rocker
board w ith bilateral su pport for sagittal and coronal plane
m ovem ents (Cavanau gh & Killian 2012), ad vancing to u nilat-
eral su pport on a rocker board . Single-leg balance is utilized
for challenging the patient’s proprioceptive capabilities
(H eckm ann et al 2006; N oyes et al 2012) w ith progression to
m anu al p ertu rbations by the p hysical therap ist or single-leg
balance perform ed on an Airex, Bosu , m ini-tram p oline, foam
roll, biom echanical ankle p latform system (BAPS) or a Biod ex
balance system .
Partial meniscectomy
Postop erative rehabilitation for p artial m eniscectom y has
little evid ence-based research to exam ine its ef cacy, so there
is controversy over w hat constitutes best practice (Kelln et al
2009). Dias et al (2013) recently cond u cted a system atic review
on p ostop erative treatm ent for p atients u nd ergoing p artial
m eniscectom y, and fou nd that p hysical therap y w ith a hom e
exercise p rogram m e is effective in im proving self-rep orted
knee fu nction and range of m otion; how ever, the quality
of evid ence analysed had a m od erate to high risk of bias.
H ence, this section w ill present the best-available evid ence at
this tim e.
Modalities
Cryotherap y, lim b elevation and N MES, as d iscu ssed w ith
p reviou s su rgical p roced u res, can be u tilized for p ain, oed em a
and qu ad riceps strength (Good w in et al 2003; Bax et al 2005;
H eckm ann et al 2006; N oyes et al 2012).
 520 PART 7 • 45 •  Postoperative management of the knee
Range of motion exercises
Weight-bearing statu s d iffers from m eniscal rep air / trans-
p lantation in that ind ivid u als are im m ed iately w eight-bearing
at tolerance, starting w ith the u se of tw o crutches bu t d ecreas-
ing their u se u ntil there is fu ll w eight-bearing. Kelln et al
(2009) stu d ied cycle ergom etry and its effect on several objec-
tive m easu res, inclu d ing range of m otion and gait; gait p at-
terns and knee exion range of m otion valu es im p roved in
the exp erim ental grou p signi cantly com p ared w ith the
control grou p , thu s p rovid ing evid ence that early range of
m otion is bene cial for those u nd ergoing p artial m eniscec-
tom y. Passive and active range of m otion exercise is rarely
lim ited in range, u nlike in p atients u nd ergoing m eniscal
repair or transplantation (Brotzm an & Wilk 2003). Early range
of m otion shou ld inclu d e the em p hasis of fu ll knee extension
and exion to tolerance.
Manu al therap y for p atients follow ing a p artial m eniscec-
tom y can be m ore freely u sed than in m eniscal rep air or
transp lantation. Patellar m obilizations in all d irections can be
u tilized , and tibiofem oral m obilizations in the card inal p lane
d irections, as w ell as com bined m otions, can also be im ple-
m ented u ntil p atients are p ain free and / or the fu ll range of
m otion is achieved (Good w in et al 2003).
Therapeutic exercise
Therapeu tic exercise inclu d es m any of the previou s d escribed
exercises for postoperative knee m anagem ent, bu t can be uti-
lized earlier on in the treatm ent p hase than w ith other su rgical
p roced u res. Good w in et al (2003) stu d ied early p hysical
therap y after an arthroscop ic p artial m eniscectom y. The inter-
vention grou p p erform ed calf raises, step -u p s, hip abd u ctor,
ad d u ctor and extensor exercises, bicycle ergom etry and m ini-
tram p oline and w obble-board activities. In the later p hases of
the stu d y, the ind ivid u als p erform ed bilateral lateral hop s
and zig-zag hop s, then progressed to single-leg hops (Good w in
et al 2003). Althou gh the ind ivid u als in the intervention grou p
exhibited no signi cant d ifference from those in the control
grou p, the inform ation p rovid ed by this stu d y d oes give reha-
bilitation id eas for clinical practice.
Lateral and front lu nges, lateral step -u p s, leg p ress and
stair clim ber or the ellip tical can be introd u ced around 2
w eeks postoperatively. Return to sport / fu nctional activities
can occu r arou nd 4 w eeks and m ay last u p to 8 w eeks, w ith
sim ilar exercises to those d escribed above being u sed in this
p hase (Brotzm an & Wilk 2003).
Total Knee Arthroplasty
The knee is a pivotal hinge joint, perm itting exion, extension
and rotation w ith the knee exed . Biped al creatures, such as
hu m ans, load the w eight of the entire bod y throu gh the knee
joints. It is therefore a site of frequent injury and d egeneration.
There are tw o types of cartilage in the knee joints: brous
cartilage, contained in a large m eniscu s that sep arates the tibia
and fem u r in w eight-bearing to som e d egree, and hyaline
cartilage, fou nd on the bone end s. The m eniscu s p rotects the
end s of the w eight-bearing bones and prevents bone erosion.
When the m eniscu s is torn or w orn, the bone end s are exposed
to degenerative forces and advanced joint arthrosis occurs. Oste-
oarthritis (OA), both primary and secondary, and rheu m atoid
arthritis (RA) are prim ary cau ses of joint d estru ction (Sarw ark
2010). (See Ch 43 for fu rther inform ation on knee OA.) The
total and p artial (tricom p artm ental, bicom p artm ental and
u nicom p artm ental) knee arthrop lasties are u sed to restore
function and m obility in ad vanced cases.
Clinical sym p tom s of knee OA inclu d e p ain w ith w eight-
bearing, pain at rest in ad vanced cases, bu ckling or giving
w ay of the knee, d if cu lty in traversing stairs, and episod es
of locking. Physical exam ination u su ally reveals a varu s or
valgu s d eform ity of the knee. There m ay be d iffu se tend erness
along the joint lines. Loss of range of m otion, both p assive and
active, as w ell as joint crepitus m ay be p resent (Sarw ark 2010).
Diagnostic tests prim arily inclu d e rad iographs. A w eight-
bearing anteroposterior view of both knees in full available
extension w ill show narrow ing of the joint space. Degenera-
tive arthritis w ill be evid enced as asym m etric joint narrow ing,
bone sclerosis, periarticu lar cysts and osteophytes. In am m a-
tory arthritis w ill d em onstrate sym m etric joint narrow ing,
d isu se osteopenia and bony erosions at the articu lar m argins.
Lateral and axial p atellofem oral view w ill fu rther show the
d egeneration of the tibiofem oral joint and p atellofem oral
joint. The tunnel view w ill typ ically exhibit osteophytes and
osteochond ral loose bod ies, if p resent (Sarw ark 2010).
Procedures
The total knee arthrop lasty (TKA) is ind icated for d isability,
p ain and lim ited fu nction from OA, RA or any typ e of arthritic
d eform ity abou t the knee. The goals of TKA inclu d e red ucing
p ain, retu rning to activities of d aily living, restoring m echani-
cal alignm ent, p reserving the joint line, balancing the liga-
m ents and restoring a norm al Q-angle (Van Manen et al 2012).
There is no stand ard of severity ind icated from rad iographic
nd ings becau se the d ecision to u nd ergo the TKA is at least
p artially su bjective, based on the p atient’s resp onse to non-
op erative treatm ent, tolerance for p ain and p hysical d em and
of d aily activities (Van Manen et al 2012).
The u nicom partm ental arthroplasty is often presented as a
m eans of transition betw een end -stage OA and TKA. Other
physicians prefer u se of the high tibial osteotom y for the sam e
pu rpose. A com p rehensive review of the literature in 2010 d id
not nd m arked ad vantages of one m ethod over the other:
‘With the correct ind ications, both treatm ents prod uce d u rable
and p red ictable ou tcom es in the treatm ent of m ed ial u nicom -
partm ental arthrosis of the knee. There is no evid ence of su p e-
rior resu lts of one treatm ent over the other ’ (Dettoni et al
2010, p 131).
Ind ications for unicom partm ental knee arthroplasty
includ e u nicom partm ental OA, rad iographic evid ence of
p reservation of op p osite com p artm ent, absence of or only
m ild p atellofem oral d egeneration, a range of m otion greater
than 90°, exion contractu re < 5°, angu lar d eform ity < 15° and
a relatively sed entary lifestyle (Iorio & H ealy 2003; Boru s &
Thornhill 2008). Contraind ications to the proced ure are op po-
site com p artm ent or p atellofem oral arthritis, xed varu s or
valgus d eform ity greater than 5°, signi cantly restricted range
of m otion inclu d ing xed contractu re, ACL d e ciency (rela-
tive contraind ication for m ed ial com p artm ent, contraind ica-
tion for lateral com p artm ent) and sym p tom atic instability.
Certain m ed ical cond itions m ay also be consid ered to be con-
traind ications (Iorio & H ealy 2003; Borus & Thornhill 2008).
Com p lications of all TKA p roced u res inclu d e tibial p lateau
fractu re, m ed ial collateral ligam ent avulsion / tear, stiffness or

arthro brosis, infection, d eep vein throm bosis / p ulm onary
em bolism , and hard w are failure. Com plications u niqu e to the
u nicom p artm ent p roced u re inclu d e ACL ru p tu re and ad ja-
cent com p artm ent d egeneration (H ealy et al 2013).
Innovations in the arthrop lasty proced u re as a w hole
inclu d e m inim ally invasive su rgery techniqu es, gend er-
sp eci c p rosthetics and com p u ter-assisted navigation system s
(Zanasi 2011).
Treatment
Minns Low e et al (2007) com pared outcom es of fu nctional
physical therap y exercises provid ed in clinic after acute care
w ith sim ple at-hom e continu ation of a basic exercise pro-
gram m e provid ed in acute care after prim ary elective knee
arthrop lasty. Their conclu sion w as that the clinically pro-
vid ed fu nctional exercises su bacu tely had greater short-term
bene t; how ever, there w ere no d ifferences betw een the tw o
program m es at 1 year after surgery (Minns Low e et al 2007).
N evertheless, ad equate and even intensive rehabilitation is
com m only consid ered an im p ortant requ irem ent for su ccess-
ful TKA ou tcom es (Kisner & Colby 2007; Lenssen et al 2008).
Physical therap y rehabilitation after TKA has ve essential
com p onents: therap eu tic exercise, m anu al therap y, transfer
training, gait training and instru ction in the activities of d aily
living. Rehabilitation varies as to w here, how and w hen it is
d elivered . There is grow ing sup p ort for p re-rehabilitation –
that is, p hysical therap y beginning w eeks p rior to the exp ected
TKA (Desm eu les et al 2013). Trad itionally, the patient w ill
receive basic physical therap y w hile in acute care, consisting
of am bu lation, transfer training and exercises for p revention
of d eep vein throm bosis as w ell as range of m otion. After d is-
charge from the acu te care hosp ital, p atients m ay receive m ore
extensive inpatient physical therapy, w hich includ es skilled
nu rsing facilities and su bacu te rehabilitation facilities, or they
m ay continu e treatm ent on an ou tp atient basis, either at hom e
or at an ou tp atient clinic (H ealth Qu ality Ontario 2005).
Modalities
Mod alities su ch as ice, heat, and transcu taneou s electric stim -
u lation (TEN S) are u tilized to m od u late p ain and im p rove
treatm ent tolerance (Kisner & Colby 2007). Continuou s
passive m otion (CPM) is initiated in acu te care and m ay or
m ay not be continu ed after 3–5 d ays. Prolonged CPM u se m ay
increase short-term range of m otion gains; how ever, long-
term bene ts to both range of m otion and fu nction have not
been proven (Lenssen et al 2008).
Gait training and transfer training
Initially the patient learns to am bu late w ith a stand ard or
rolling w alker w hile in acu te care (Beaup ré et al 2001).
Cru tches m ay be u sed , bu t som e p atients, esp ecially the
eld erly, m ay nd a w alker safer to hand le (Kisner & Colby
2007). The type of prosthesis im p lanted , type of xation u sed
and other p ersonal variables d eterm ine the p rogress of
w eight-bearing. With biological / cem entless xation, w eight-
bearing m ay vary from tou ch-d ow n only for 4–8 w eeks to
w eight-bearing as tolerated w ithin a few d ays after surgery.
Cem ented xation typ ically allow s w eight-bearing as toler-
ated w ith a w alker or cru tches, w eaning the p atient to full
w eight-bearing over 6 w eeks (Kisner & Colby 2007).
Total knee arthroplasty 521
When the patient is able to tolerate cane use w ith at least
a fair gait pattern, the w alker is grad u ally exchanged for a
straight cane. Before d iscontinu ing the assistive d evice alto-
gether, the patient should be able to activate the lock-hom e
m echanism of the knee w ith su f cient active extension, and
d em onstrate a good gait p attern w ithou t evid ence of a
p ainfu l lim p or signi cant d e cits in range of m otion (Kisner
& Colby 2007).
Manual therapy and range of
motion expectations
Range-of-m otion goals are p rogressive and m ay vary accord -
ing to the su rgeon’s protocol. Generally, the expectations are
0–90° in w eeks 1–4 and 0–110° or greater in w eeks 4–8. After
w eek 8 the goal is to obtain an easy and p ainless range of
m otion from 0° to 110° or m ore (Kisner & Colby 2007).
Patellar m obilizations begin at grad es I and II d u ring w eeks
1–4. They are continu ed through to w eek 8 and after as
need ed . Tibiofem oral joint m obilization techniqu es, inclu d ing
hold ing a d istraction force w hile p erform ing p assive or active
assisted exion, m ay be allow ed . It is ad visable to d iscu ss this
treatm ent w ith the su rgeon before im p lem enting this,
how ever, as the d esign of the p rosthetic com p onent m ay p ro-
hibit m obilization of this typ e (Kisner & Colby 2007).
Therapeutic exercise
The patient is instru cted in antithrom botic exercises acutely
(Beaup ré et al 2001). Ankle p um ps, quad riceps setting and
glu teal setting in rep etition are p erform ed for the rst 2 w eeks
after surgery. With the leg elevated , and knee in extension,
these exercises are also help fu l for red u cing sw elling. In the
su bacu te p hase and beyond , exercises u tilized to increase the
range of m otion, strength and fu nction vary w id ely based on
experience and preference of the physical therapist. Basic
exercises includ e straight leg raises, heel slid es, short-arc knee
extensions, long arc knee extensions and ham string curls
(Beaup ré et al 2001). Progressive resistance exercises m ay be
initiated in the 4- to 8-w eek p hase, d epend ing up on the ind i-
vid u al p atient and su rgeon. Cu ff w eights are often ad d ed to
the basic exercises for p rogressive resistance exercises. Aqu atic
p hysical therap y m ay com m ence once the incision is fu lly
closed . The recu m bent bicycle m ay im p rove both range of
m otion and strength.
Several sp eci c exercises are lim ited initially after knee
arthrop lasty. Sid e-lying straight leg raises (abd u ction / ad d u c-
tion) shou ld be avoid ed early on ow ing to the varu s and
valgu s stresses on the knee. The therap ist shou ld also d elay
initiation of u nsu pported w eight-bearing exercises until there
is suf cient strength in the qu ad riceps and ham strings to
stabilize the knee.
Activities of daily living: return to function
In ad d ition to basic range of m otion exercises and progressive
resistance exercise, rehabilitation shou ld inclu d e balance
training, lim ited fu nctional squ atting, stabilization and p rop -
riocep tive exercises, step -u ps / d ow ns and stair training (Piva
et al 2010). The patient shou ld achieve suf cient easy knee
exion to allow norm al functional activities su ch as tying of
shoelaces, safe au tom obile transfers, and p rop er p ositioning
of the leg and foot for sit-to-stand transfers.
 522 PART 7 • 45 •  Postoperative management of the knee

Arthro brosis of the Knee
Arthro brosis is an abnorm al proliferation of brotic tissu e or
scarring in and arou nd a joint (Freem an et al 2009; Biggs-
Kinzer et al 2010), and is often id iopathic. Id iopathic types
m ay d evelop tissu e m etap lasia w ith abnorm al form ation of
d ense brous tissu e, w ith surgical intervention and revision
arthroplasty lead ing to w orsening of the cond ition and d isa-
bility (Freem an et al 2009). The incid ence of arthro brosis of
the knee is rep orted as 1.3–13.5% (Sharm a et al 2008).
H ow ever, a m ore blanket d iagnosis of joint stiffness follow ing
surgery or traum a is pu rp orted ly as high as 54% (Sharm a et al
2008). The aetiology of knee arthro brosis is m u ltifactorial
and m ay inclu d e infection, prolonged p ostop erative im m obil-
ity of the knee, overly aggressive rehabilitation, incorrectly
sized or p laced com p onents of the TKA, rep eated su rgeries,
au toim m u ne d iseases inclu d ing d iabetes, and preop erative
d eform ities (Schiavone Panni et al 2009; Kim & Joo 2013).
Arthro brosis of the knee has no of cial classi cation
system ; how ever, it has been classi ed in ind ivid u al stu d ies
(Shelbou rne et al 1996b). An exam p le of this is the fou r-typ e
m od el u sed by Shelbou rne et al (1996b): typ e 1, < 10° exten-
sion loss and norm al exion; type 2, > 10° extension loss and
norm al exion; typ e 3, > 10° extension loss and > 25° exion
loss w ith a tight p atella; and typ e 4, > 10° extension loss, 30°
or m ore exion loss and p atella infera w ith m arked p atellar
tightness.
Arthro brosis d em onstrates brogenesis w hich is charac-
terized by broblast p roliferation, excessive synthesis and
accum u lation of extracellu lar m atrix com p onents and red uced
extracellu lar m atrix rem od elling (Bosch et al 2001; Freem an
et al 2010; Monu m ent et al 2012). Freem an et al (2010)
su ggested that tissu e m etap lasia in arthro brosis resu lts from
increased in am m ation-associated oxid ative stress, w hich ini-
tiates a chain of events inclu d ing an accu m u lation of m ast
cells (secreting broblast grow th factor), d riving broblast
p roliferation and creating avascu lar regions of hyp oxia. The
hyp oxia and associated oxid ative stress together ind u ce a
m etap lastic conversion of brotic tissu e to brocartilage, and
then, in instances of brosis of longer d u rations, su bsequ ent
bone form ation by end ochond ral ossi cation.
In d iagnosing knee arthro brosis, other causes of joint stiff-
ness m u st be exclu d ed , su ch as m u scle inhibition, u id in the
joint (includ ing infection), m echanical factors, such as a loose
bod y or bucket-hand le tear of the m eniscu s, joint bones out
of alignm ent, interru p tion to the extensor m echanism , im p rop -
erly placed ligam ent graft, and d am aged nerves. H ow ever,
these cond itions m ay trigger or be p resent in com bination
w ith the arthro brosis (N oyes et al 1991).
There are no speci c d iagnostic tests for knee arthro bro-
sis; rather, the m ed ical team looks for inability to m eet norm al
range of m otion expectations, and alert signals su ch as exed
knee gait, w orsening pain, p ersisting w arm th in the joint and
continu ed tissu e sw elling. Objective signs inclu d e restricted
p atellar m obility and / or d ow nw ard m igration of the p atella,
as w ell as restricted and / or w orsening active and p assive
range of m otion (N oyes et al 1991). Serial m easu rem ent of
p atellar height on a lateral p lain lm of both knees is recom -
m end ed , as it has been show n that the p rogression of arthro -
brosis can trigger d ow nw ard m igration of the patella as
early as a few w eeks after the original tissue trau m a (N oyes
et al 1991).
Treatm ent of arthro brosis of the knee is extrem ely chal-
lenging and m ay utilize conservative and / or su rgical tech-
niqu es (Table 45.3).

Table 45.3 Tre a tme nt  or arthrof bros is  o  the  kne e  a te r total kne e  arthroplas ty

Co ns e rvative  tre atme nts

Sustained low-load s tretching recommended over high-load brie stretch (typical manual pas sive (Light et al 1984; Papotto & Mills 2012)
range o motion).
Home s tatic and dynamic s tretching devices recommended over s erial cas ting. (Jans en et al 1996; Biggs -Kinzer et al
2010; Papotto & Mills 2012)
Ins trument-as sis ted so t tiss ue mobilization techniques or brosis outside o the joint, (Black 2010)
accompanying standard treatment.
Manual therapy, including mobilization, and mobilization with movement. (Millett et al 2003)
Intra-articular injection o anakinra, an interleukin-1 (IL-1) antagonist targeting the inf ammatory (Brown et al 2010)
respons e mediated by IL-1.
S urg ic al tre atme nts
Traditional surgical releas es: quadricepsplas ty, caps ulotomy, excis ion o scar tiss ue in the (Farid et al 2013; Kim & Joo 2013)
patello emoral joint and anterior part o the tibio emoral joint, and release o the retinacula and
the sliding mechanism on the medial and lateral s ides o the joint.
Manipulation under anaes thesia (MUA), arthroscopic release (pre erred by Kim and Joo), open (Ghani et al 2012; Farid et al 2013;
surgical releas e (pre erred by Ghani) and revision TKA. Kim & Joo 2013)
Capsular dis tension with arthros copic releas e. (Millett & Steadman 2001)
Intra-articular injection o local anaesthetic and steroid given at the time o MUA. (Sharma et al 2008)
Preoperative low-dos e irradiation and cons trained condylar or rotating-hinge revis ion or severe, (Farid et al 2013)
idiopathic arthro bros is.

Conclusion
Many of the interventions d escribed in this chap ter have
been show n to be effective. Clinical practice gu id elines con-
tinu e to evolve and w ill change frequ ently. Thu s, read ers
shou ld note that best clinical p ractice encom p asses u sing
cu rrent evid ence, as w ell as incorp orating p atient valu es and
clinician exp erience, w hich w ill p rovid e the best overall
patient ou tcom es.
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 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
Joint Mobilization and Manipulation of the Knee
C o d y W e is b a c h , W illia m Eg a n , P a u l E. G lyn n , J o s h u a A. C le la n d
CHAP TER CONTENTS
Evidence of manual therapy in the knee  525
Mobilization interventions of the knee joint  527
Tibiofemoral posterior accessory glide  527
Tibiofemoral anterior accessory glide  527
Tibiofemoral knee  exion physiological mobilization  527
Tibiofemoral knee extension physiological mobilization  528
Tibiofemoral knee extension physiological mobilization variation  528
Tibiofemoral long-axis distraction manipulation  528
Tibiofemoral mobilization with movement  528
Proximal tibio bular thrust manipulation   529
Patellofemoral mobilization: caudal and cephalad  529
Patellofemoral mobilization: medial and lateral  529
Evidence o Manual Therapy in
the Knee
Disord ers of the knee are a com m on reason for ind ivid u als to
seek ou t the consu ltation of a p hysical therap ist. Patellofem o-
ral p ain synd rom e (PFPS) is estim ated to affect 7–40% of ad o-
lescents and active you ng ad ults, m aking it a highly p revalent
cond ition of the anterior knee (Alm eid a et al 1999). Knee
osteo arthritis (OA) is another highly p revalent cau se of knee
pain for w hich ind ivid u als w ould seek consu ltation. It is esti-
m ated that, in ad ults aged over 45 years, the prevalence of
rad iograp hic knee OA is 28% and for sym ptom atic knee OA
it is betw een 7% and 19%. With the ageing popu lation and
increasing obesity levels, these num bers are expected to con-
tinu e to increase in the fu tu re (N agoi 2013).
Manu al therap y is one of m any p otential conservative
treatm ent op tions that cou ld be a p art of the intervention
package for ind ivid u als w ith knee pain. The goals of m anu al
therap y are to im p rove range of m otion and m od u late p ain
throu gh m echanical, neu rop hysiological and non-sp eci c
effects on the ind ivid u al (Moss et al 2007; Bialosky et al 2009).
Mobilization and m anip u lation are typ es of m anu al therap y
that ap p ear to have strong su p p ort for im p roving range of
m otion, p ain and fu nction for tw o of the m ore p revalent con-
d itions of the knee: knee OA and PFPS. (These cond itions are
covered in Chs 43 and 44 resp ectively.)
Chapter 
46  
Brantingham et al (2009) cond u cted a literatu re review on
the effects of m anu al therap y w ith a m u ltim od al care p ackage
in ind ivid u als w ith low er extrem ity d isord ers. In this review
they ju d ged that there w as ‘level B’ evid ence of m anu al
therap y d irected at the knee in p atients w ith PFPS. The tech-
niqu es m ost frequ ently u sed in this p op u lation tend to be
d irected at the patellofem oral joint and the proxim al tibio bu-
lar joint. Van d en Dold er and Roberts (2006) sou ght to assess
the ef cacy of m anu al therapy in PFPS. They rand om ized 38
ind ivid u als w ith PFPS into tw o group s. The control grou p
w as p ut on a 2-w eek w aiting list, w hile the intervention grou p
received six sessions of m anu al therapy, inclu d ing friction
m assage, p atellar m obilizations and su stained m ed ial glid es
w ith knee exion and extension. After the six sessions, results
ind icated the experim ental group had greater im provem ents
comp ared w ith the w aiting list grou p in p ain, p ain on stair
clim bing, knee exion and the nu m ber of step -u p s they w ere
able to com p lete in 60 second s. The researchers conclu d ed
that an ap p roach incorp orating m anu al therap y w as su p erior
to no treatm ent.
Crossley et al (2002) cond u cted a rand om ized controlled
trial, bu ild ing on the van d en Dold er resu lts by com p aring
the sam e intervention w ith a p lacebo treatm ent. They enrolled
67 ind ivid u als w ith PFPS and rand om ized them into tw o
grou ps. The control grou p received placebo tap ing and su b-
therap eu tic u ltrasou nd . The treatm ent grou p received a m u l-
timod al treatm ent p rogram m e of low er bod y stretching,
strengthening, patellar tap ing and m ed ial patellar glid es (60
second s rep eated three tim es). This grou p w as seen once a
w eek for 6 w eeks. After treatm ent, the exp erim ental grou p
im proved in pain and function, and w as able to d o m ore step-
u ps, step -d ow ns and squ ats, in com p arison w ith the p lacebo
grou p.
Both the Crossley et al (2002) and van d en Dold er and
Roberts (2006) stu d ies w ere constru cted in su ch a w ay that all
ind ivid u als received the sam e treatm ents regard less of exam i-
nation nd ings, bu t interventions w ere selected clinically
based on ind ivid u al exam ination nd ings. Thereafter, Low ry
et al (2008) p u blished a case series to d escribe the exam ination
and m anagem ent of ve ind ivid u als, aged betw een 14 and
50 years of age, w ho had been d iagnosed w ith PFPS. Each
p atient u nd erw ent a d etailed , ind ivid u alized exam ination
and received a custom ized treatm ent program m e d ep end ing
on the exam ination nd ings and resp onses to treatm ent.
Treatm ents inclu d ed m anu al therap y to the lu m bar sp ine, hip ,
 526 PART 7 • 46 • Joint mobilization and manipulation of the knee
p atellofem oral joint and proxim al tibio bu lar joint. Other
com p onents of the treatm ent p rogram m e inclu d ed McCon-
nell tap ing, cu stom orthoses, over-the-cou nter orthoses and
an exercise p rogram m e for core, hip and knee stretching and
strengthening w ith a p rogression from non-w eight-bearing to
w eight-bearing exercise. Su bjects w ere seen for betw een 8 and
14 treatm ents over a 6- to 14-w eek p eriod . Ou tcom es of pain,
self-rep ort fu nction of the low er extrem ity and global im p rove-
m ent w ere assessed at baseline, third visit, d ischarge and
6-m onth follow -u p . The au thors fou nd that fou r of the ve
su bjects had clinically m eaningfu l im p rovem ents on all ou t-
com es m easu red at d ischarge and 6-m onth follow -u p.
As d etailed by Brantingham et al (2009), ‘level B’ evid ence
exists for the use of m anual therapy in the PFPS popu lation
and the d iscu ssion of the stu d ies above w ill hopefu lly help
the read er to u nd erstand better the cu rrent state of the evi-
d ence as w ell as provid ing id eas and clinical-reasoning
ap p roaches for these p atients. Selected techniqu es from these
stu d ies are ou tlined later in this chap ter.
Knee OA is another cond ition for w hich m anu al therap y
has been p rop osed as an effective treatment ap p roach. The
literatu re review by Brantingham et al (2009) also fou nd that
‘level B’ evid ence existed for m anual therapy in knee OA;
since that review, ad d itional stu d ies have been p u blished that
fu rther su pport the u se of m anual therapy in knee OA.
Several stu d ies have been p u blished that d escribe the u se
of m anu al therap y techniqu es to the tibiofem oral joint in su b-
jects w ith knee OA as a stand -alone treatm ent (H illerm an et al
2006; Moss et al 2007; Pollard et al 2008; Takasaki et al 2013).
French et al (2011) published a system atic review on the u se
of m anu al therap y only in p atients w ith knee and hip OA;
they fou nd that em p loying m anu al therap y in isolation w as
not su p p orted . Therefore, these stu d ies are m entioned since
the techniqu es d escribed show p rom ise; how ever, the m ajor-
ity of the d iscu ssion w ill focu s on stu d ies that inclu d e m anu al
therap y as a p art of a m u ltim od al treatm ent p lan, for w hich
stronger evid ence exists. Techniqu es su ch as long-axis tibio-
fem oral m anipu lation (H illerm an et al 2006), long-d uration
anterior–p osterior tibiofem oral m obilizations (Moss et al
2007) and m obilization w ith m ovem ents applied in open or
closed chain (Takasaki et al 2013) w ill all probably be usefu l
in certain situ ations in the m anagem ent of ind ivid u als w ith
knee OA and are d escribed in su bsequ ent sections. H ow ever,
in the au thors’ op inion, the techniqu es d escribed in the stu d ies
below shou ld m ake u p the fou nd ation of a m anu al therapy
ap p roach to this p op u lation, based on the strength of the best
cu rrent evid ence.
Deyle et al (2000) sou ght to investigate the effects of a m u l-
tim od al p hysical therap y p rogram m e in p atients w ith knee
OA. They rand om ized 69 ind ivid uals w ith knee OA into a
treatm ent and a p lacebo grou p . The treatment grou p received
eight sessions of m anu al re-exam ination and m anu al therap y
to the knee, hip , ankle and lu m bar sp ine ind ivid u alized to
each patient based on the therapist’s assessm ent. Manu al
therap y techniqu es u sed w ere sim ilar to those d escribed later
in this chap ter. Ad d itionally this grou p p articip ated in a
stand ard ized , su p ervised exercise p rogram m e, w hich con-
sisted of knee active range of m otion, aerobic exercise, low er
extrem ity stretching p lus hip and knee strengthening that
p rogressed from op en to closed chain. This grou p also p er-
form ed a sim ilar hom e exercise program m e on off d ays. The
p lacebo grou p received the sam e m anu al re-exam ination at
each session as w ell as 10 m inutes of d etu ned u ltrasou nd .
Ou tcom es w ere assessed w ith the Western Ontario and
McMaster Universities Arthritis Ind ex (WOMAC) and
6-m inu te w alk test, at 4 w eeks, 8 w eeks and 1 year. They
fou nd signi cant im p rovem ents in both WOMAC and
6-m inu te w alk test at 4 w eeks and 8 w eeks w ithin the m anu al
therapy grou p . At 1 year, su bjects in the placebo grou p
rep orted a higher incid ence of knee su rgery (20%) com p ared
w ith the treatm ent grou p (5%).
Deyle et al (2005) perform ed a follow -u p rand om ized
controlled trial to exp and on the resu lts of their p reviou s
w ork. In this, 120 ind ivid u als w ith knee OA w ere rand om ized
to a m u ltim od al treatm ent grou p or a hom e exercise p ro-
gram m e only grou p. The hom e exercise group received the
sam e p rogram m e as the m u ltim od al grou p , bu t w ith only one
session of initial instru ction, d etailed hand ou ts and one m ore
session of instru ction after 2 w eeks. Again, the WOMAC and
6-m inu te w alk test w ere assessed at 4 w eeks, 8 w eeks and 1
year. Results ind icated that both group s im proved at 4 and 8
w eeks, bu t that the group that also received m anu al therap y
im p roved signi cantly m ore than the exercise-only group. At
1 year, the d ifference in WOMAC scores w as no longer sig-
ni cant betw een grou p s, bu t those in the m anu al therap y
grou p reported signi cantly greater satisfaction w ith their
treatm ent.
This line of inqu iry w as fu rther p u rsued in 2012, w hen a
second ary analysis of the d ata from both of the above trials
w as perform ed to create a clinical pred iction rule (CPR) that
w ould help d eterm ine w hich of the patients w ou ld not bene t
from the m anu al therapy approach (Deyle et al 2012). This
analysis fou nd that three variables w ere inclu d ed in the CPR
and that ind ivid u als w ith tw o or m ore of those variables
w ould be less likely to bene t from m anu al therap y. The vari-
ables w ere height greater than 5’ 7”(1.7 m ), p ain w ith p atellar
glid es, and anterior cruciate ligam ent laxity. The au thors
noted that w as a d erivation-level CPR and that valid ation w as
necessary to increase the con d ence that these nd ings are
not d u e to chance, so an u nd erstand ing of these d esign lim ita-
tions shou ld be u nd erstood p rior to the rou tine ap p lication of
these resu lts in clinical p ractice.
Recent stu d ies have stu d ied the ef cacy and cost-
effectiveness of exercise and m anu al therapy in both hip and
knee OA (Abbott et al 2013; Pinto et al 2013). They recruited
206 subjects, rand om ized to one of four arm s. The rst arm
consisted of rou tine care, w hich w as d irected by the p atient’s
general p ractitioner. The second arm w as a m anu al therapy
ap proach and a range-of-m otion-based hom e program m e
ad ap ted to the ind ivid ual exam ination nd ings. The third
arm w as an exercise grou p w here subjects received an ind i-
vid u alized p rogram m e inclu d ing strengthening and aerobic
exercise. The fou rth arm w as a com bination m anual therap y
and exercise approach. The prim ary outcom e m easu re w as
the WOMAC score for the clinical effectiveness analysis. The
Osteoarthritis Costs and Consequ ences Qu estionnaire, cost of
care and qu ality of life m easu res w ere u sed in the econom ic
analysis. The effectiveness analysis (Abbott et al 2013) fou nd
that, at 1 year, those w ho received m anual therap y had sig-
ni cantly greater im p rovem ent on their WOMAC score com -
p ared w ith those w ho d id not receive m anu al therap y. Those
w ho received exercises w ere not signi cantly better than those
w ho received m anual therapy; interestingly though, they
fou nd an antagonistic effect in the m anu al therap y plus
 Mobilization interventions of the knee joint  527

exercise grou p, ind icating that this group actually fared w orse
than the others. Overall, those in the m anu al therap y grou p
w ere signi cantly better com pared w ith those in the general
p ractitioner care grou p, exercise grou p or com bination grou p
at 1 year. These results w ere sim ilar w hen hip OA and knee
OA w ere consid ered ind ivid u ally. The econom ic analysis
(Pinto et al 2013) found that those in the general practitioner
grou p had m ore visits to the em ergency d epartm ent and
rheu m atologist, and received m ore m eals on w heels, hom e
health help and hou se-cleaning services. From a societal
p ersp ective, w hich takes into accou nt cost of care and ind i-
vid u al health, com bination care w as su p erior to u su al care
only in those w ho d id not receive a joint rep lacem ent. They
fou nd that the exercise group w as m ore costly than general
p ractitioner care and that m anu al therapy w as less costly
than general p ractitioner care. Overall, this analysis seem s to
ind icate that the ap proach in the m anu al therapy grou p led
to the best balance betw een cost of care and health of
ind ivid u als, regard less of w hether or not they had a joint
replacem ent.
The above ind icates that m anu al therap y is w ell sup ported
as a com p onent of the care in p atients w ith knee pain. What
follow s is the au thors’ interp retation of a selection of the tech-
niqu es from the above stu d ies.
Tibio emoral anterior accessory glide
The patient’s knee is placed in approxim ately at 20° of exion.
The clinician places one hand on the anterior aspect of the
d istal fem ur to stabilize. The other hand is placed on the pos-
terior asp ect of the p roxim al tibia to ap p ly a grad ed , non-
thru st oscillatory m anip u lation anteriorly (Fig. 46.2). This
techniqu e can be p rogressed by increasing the am ou nt of knee
extension.
Tibio emoral knee f exion physiological
mobilization
The patient is positioned in su pine. The clinician exes the
p atient’s hip to app roxim ately 90° and p laces one hand on
the lateral asp ect of the fem u r to control its p osition. The
other hand grasp s the low er leg ju st p roxim al to the m alleoli.
The clinician stabilizes the fem ur and u ses the other hand
to ex the knee to the restrictive barrier (Fig. 46.3). Tibiofem o-
ral internal rotation or external rotation can be ad d ed to
re ne the barrier. The clinician then u ses the cau d al hand

Mobilization Interventions o
the Knee Joint
Tibio emoral posterior accessory glide
The p atient’s knee is p laced in ap proxim ately at 20° of exion.
This can be accom plished u sing a rolled tow el, a bolster or by
resting the patient’s knee over the clinician’s knee. The clini-
cian p laces one hand on the p osterior asp ect of the d istal
fem u r to stabilize and the w eb-space of the other hand on the
anterior asp ect of the p roxim al tibia to ap ply a grad ed , non-
thru st oscillatory m anip u lation p osteriorly (Fig. 46.1). This
techniqu e can be p rogressed by increasing the d egree of knee
exion by positioning the p atient in sitting w ith the legs off
the sid e of the treatm ent table. Figure 46.2 Tibio emoral anterior accessory glide.

Figure 46.1 Tibio emoral posterior accessory glide. Figure 46.3 Tibio emoral knee f exion physiological mobilization.
 528 PART 7 • 46 •
Figure 46.4 Tibio emoral knee extension physiological mobilization.
to ap p ly a grad ed , non-thru st oscillatory m anip u lation into
exion.
Tibio emoral knee extension physiological
mobilization
The patient is positioned in su pine, w ith the patient’s knee
over the clinician’s knee. The clinician grasp s the p atient’s
knee at the m ed ial and lateral joint line w hile stabilizing
the low er leg w ith the bod y and u p p er arm (Fig. 46.4). The
clinician u ses both hand s to extend the p atient’s knee to
the restrictive barrier. Varu s or valgu s forces can be ad d ed
to re ne the barrier. The clinician then u ses the hand s to
app ly a grad ed , non-thru st oscillatory m anipu lation into
extension.
Tibio emoral knee extension physiological
mobilization variation
The p atient is positioned in su pine. The clinician grasp s the
p atient’s d istal leg behind the m alleoli w ith one hand to sta-
bilize. The heel of the other hand is placed on the tibial tu ber-
osity, the ngers facing d istally and p ressu re is ap p lied into
extension to reach the restrictive barrier (Fig. 46.5). The clini-
cian then ap p lies a grad ed , non-thru st oscillatory m anip u la-
tion into extension.
Tibio emoral long-axis distraction
manipulation
The p atient is p ositioned in su pine, near the ed ge of the table.
The leg to be treated is off of the ed ge of the table. The clini-
cian p laces the d istal leg betw een his / her knees su ch that
they hold the p atient’s low er leg ju st p roxim al to the m alleoli.
The clinician hold s the knee at the joint line w ith both hand s
in slight exion (Fig. 46.6), and then lets the knee d rop into
fu ll extension w hile sim u ltaneou sly perform ing rapid exten-
sion of the p atient’s knees to ap p ly a high-velocity, low -
am p litud e thru st in the d irection of tibiofem oral d istraction.
Varu s or valgu s forces can be ad d ed to re ne ind uce lateral
m obilization of the tibiofem oral joint.
Joint mobilization and manipulation of the knee
Figure 46.5 Tibio emoral knee extension physiological mobilization variation.
Figure 46.6 Tibio emoral long-axis distraction manipulation.
Tibio emoral mobilization with movement
The p atient is p ositioned in su pine and perform s active knee
extension and exion. If either of those is painfu l, the clinician
then ap p lies test glid es d u ring active range of m otion to d eter-
m ine the treatm ent d irection. The test glid es inclu d e m ed ial,
lateral, anterior, p osterior, and m ed ial and lateral rotation. For
a lateral glid e, the clinician stabilizes the proxim al tibia m ed i-
ally, places the m obilizing hand on the lateral fem u r and
ap plies a su stained force m ed ially (relative tibiofem oral lateral
glid e; Fig. 46.7A) w hile the p atient perform s active knee
exion and extension m otions. For a m ed ial glid e, the clini-
cian stabilizes the p roxim al tibia laterally, p laces the m obiliz-
ing hand on the m ed ial fem ur and applies a sustained force
m ed ially. For an anterior glid e, the clinician stabilizes the
p osterior asp ect of the p roxim al tibia, w hile the m obilizing
hand is p laced anteriorly on the d istal fem u r w ith a su stained
p osterior force to create a tibiofem oral anterior glid e. For a
p osterior glid e, the clinician stabilizes the anterior asp ect of
the p roxim al tibia, w hile the m obilizing hand is p laced p os-
teriorly on the d istal fem u r w ith a su stained anterior force to
create a tibiofem oral anterior glid e. For a m ed ial and lateral
rotational glid e, the hand s are p laced on the m ed ial and lateral

A B
Figure 46.7 Tibio emoral mobilization with movement: (A) in supine, and (B) in standing position with the knee over a supporting table.
Figure 46.8 Proximal tibio bular thrust manipulation.
asp ect of the p roxim al tibia; to create a m ed ial glid e, a poste-
rior force is applied m ed ially and an anterior force is ap plied
laterally; for a lateral glid e, an anterior force is app lied m ed i-
ally and a p osterior force is applied laterally. The d irection
that creates the greatest p ain relief is rep eated for tw o sets of
10. If no p ain is felt in the su p ine p osition, then the sam e
proced u re is follow ed w ith the p atient in a stand ing p osition
and the knee over a su p porting table (Fig. 46.7B).
Proximal tibio bular thrust manipulation
The clinician places his / her second m etacarpophalangeal in
the p atient’s p op liteal fossa and p u lls the soft tissu e laterally
u ntil the m etacarp op halangeal is rm ly stabilized behind the
patient’s bu lar head . The clinician uses the op posite hand to
grasp the foot and ankle. The clinician externally rotates the
leg and exes the knee to the restrictive barrier (Fig. 46.8).
Once the restrictive barrier is m et, the clinician ap p lies a high-
velocity, low -am p litu d e force throu gh the tibia (d irecting the
patient’s heel tow ard the ipsilateral buttock). Prior to per-
form ing this m anip ulation, the clinician shou ld d eterm ine
Mobilization interventions of the knee joint  529
w hether the patient can safely and com fortably achieve the
d egree of knee exion requ ired .
Patello emoral mobilization:
caudal and cephalad
The patient’s knee is placed in approxim ately at 20° of exion.
This can be accom plished u sing a rolled tow el or a bolster, or
by resting the patient’s knee over the clinician’s knee. The
clinician d istracts the p atella w ith the non-m obilizing hand
by gently cu pping around the p atella w ith the palm . Using
the heel of the other hand the clinician ap p lies grad ed , oscil-
latory m obilizations in a caud al (Fig. 46.9A) or cephalad (Fig.
46.9B) d irection. The clinician’s forearm shou ld be placed in
line w ith the d irection of the m anipu lation and care is taken
to avoid com p ression of the p atella into the fem u r. This tech-
niqu e can be p rogressed by increasing the d egree of knee
exion either in sup ine or by having the patient sitting w ith
the legs off the sid e of the treatm ent table.
Patello emoral mobilization:
medial and lateral
The patient’s knee is placed in approxim ately at 20° of exion.
The clinician places the thum bs of both hand s on the lateral
sid e of the p atellar and the second and third ngers of both
hand s on the m ed ial sid e of the p atella (Fig. 46.10). The clini-
cian p erform s grad ed , oscillatory m obilizations of the p atella
on the fem u r in a m ed ial or lateral d irection. Care is taken to
avoid com p ression of the p atella into the fem u r. To progress
the m ed ial glid e techniqu e, the p atient is p ositioned in sid e-
lying. The clinician places the patient’s top leg in approxi-
m ately 10° of hip extension and ad d uction to p ut the lateral
leg soft tissu es, includ ing the lateral patellar retinacu lum , on
stretch. Using the heel of the hand the clinician ap p lies a
grad ed , oscillatory, non-thru st m obilization of the patellar on
the fem u r in a m ed ial d irection. The p atient’s top leg shou ld
be su pported on the m ed ial sid e to avoid placing a valgu s
stress on the knee d u ring the m anip u lation.
 530 PART 7 • 46 • Joint mobilization and manipulation of the knee
A B
Figure 46.9 Patello emoral mobilization: (A) in caudal, and (B) in cephalad, direction.
Figure 46.10 Patello emoral mobilization in medial and lateral direction.
Re erences
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therapy, or both, in ad d ition to u sual care, for osteoarthritis of the hip or
knee: a rand om ized controlled trial. clinical effectiveness. Osteoarthritis
Cartilage 21: 525–534.
Alm eid a SA, William s KM, Shaffer RA, et al. 1999. Epid em iological patterns
of m u scu loskeletal injuries and p hysical training. Med Sci Sports Exerc 31:
1176–1182.
Bialosky JE, Bishop MD, Price DD, et al. 2009. The m echanism s of m anu al
therapy in the treatm ent of m u sculoskeletal pain: a com prehensive m od el.
Man Ther 14: 531–538.
Brantingham JW, Globe G, Pollard H , et al. 2009. Manipu lative therapy for
low er extrem ity cond itions: exp ansion of literatu re review. J Manip u lative
Physiol Ther 32: 53–71.
Crossley K, Bennell K, Green S, et al. 2002. Physical therapy for patellofem oral
p ain: a rand om ized , d ouble-blind ed , placebo-controlled trial. Am J Sports
Med 30: 857–865.
Deyle GD, Allison SC, Matekel RL, et al. 2005. Physical therapy treatm ent
effectiveness for osteoarthritis of the knee: a rand om ized com parison of
sup ervised clinical exercise and m anual therapy proced u res versus a hom e
exercise program . Phys Ther 85: 1301–1317.
Deyle GD, H end erson N E, Matekel RL, et al. 2000. Effectiveness of m anu al
p hysical therapy and exercise in osteoarthritis of the knee: a rand om ized ,
controlled trial. Ann Int Med 132: 173–181.
Deyle GD, Gill N W, Allison SC, et al. 2012. Which patients are u nlikely to
bene t from m anual PT and exercise? J Fam Pract 61: E1–E8.
French, H P, Brennan A, White B, et al. 2011. Manu al therapy for osteoarthritis
of the hip or knee: a system atic review. Man Ther 16: 109–117.
H illerm ann B, Gom es AN , Korporaal C, et al. 2006. A pilot stud y com paring
the effects of spinal m anipu lative therapy w ith those of extra-spinal m anip -
u lative therapy on quad riceps m uscle strength. J Manipu lative Physiol
Ther 29: 145–149.
Low ry CD, Cleland JA, Dyke K. 2008. Managem ent of patients w ith p atello-
fem oral p ain synd rom e u sing a m u ltim od al ap p roach: a case series. J
Orthop Sports Phys Ther 38: 691–702.
Moss P, Sluka K, Wright A. 2007. The initial effects of knee joint m obilization
on osteoarthritic hyperalgesia. Man Ther 12: 109–118.
N agoi T. 2013. The ep id em iology and im pact of pain in osteoarthritis. Osteo-
arthritis Cartilage 21: 1145–1153.
Pinto D, Robertson MC, Abbott JH , et al. 2013. Manu al therap y, exercise
therapy, or both, in ad d ition to usual care, for osteoarthritis of the hip or
knee: econom ic evalu ation alongsid e a rand om ized controlled trial. Osteo-
arthritis Cartilage 21: 525–534.
Pollard H , Ward G, H oskins W, et al. 2008. The effect of a m anual therap y
knee protocol on osteoarthritic knee pain: a rand om ized controlled trial.
J Can Chiropr Assoc 52: 229–242.
Takasaki H , H all T, Ju ll G. 2013. Im m ed iate and short-term effects of Mu lli-
gan’s m obilization w ith m ovem ent on knee pain and d isability associated
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87–95.
van d en Dold er PA, Roberts DL. 2006. Six sessions of m anual therapy increase
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 PART 7 •  The Knee Region In Lower Extremity Pain Syndromes
Chapter  47
CHAP TER CONTENTS
Introduction  531
Tendinopathies of the hamstrings  531
Background  531
Semimembranosus tendinopathy  532
Background  532
Anatomy  532
Pathology and patho-biomechanics  532
Diagnosis  532
Treatment and prognosis  532
Iliotibial band syndrome  532
Background  532
Anatomy  533
Pathology and patho-biomechanics  534
Diagnosis  534
Conservative treatment and prognosis  534
Patellar tendinopathy  535
Background  535
Anatomy  535
Pathology and patho-biomechanics  535
Diagnosis  535
Conservative treatment and prognosis  536
Popliteal tendinopathy  537
Background  537
Anatomy  537
Pathology and patho-biomechanics  538
Diagnosis  538
Conservative treatment and prognosis  538
Quadriceps tendinopathy  538
Background  538
Anatomy  538
Pathology and patho-biomechanics  538
Diagnosis  539
Conservative treatment and prognosis  539
Conclusion  539
Tendinopathy of the Knee
Elle n Po n g
Introduction
Tend inop athies o the knee can have d evastating e ects both
unctionally and f nancially w hether the patient has a sed en-
tary li estyle or is a p ro essional athlete. Basic cau ses su ch as
overu se and ailed healing, along w ith histop athology inclu d -
ing hypovascularity and m u coid d egeneration, are present in
knee tend inopathies as they are present in tend inopathies
throu ghou t the bod y. Essential com p onents o treatm ent are
also sim ilar: rest, physical m od alities and particu larly eccen-
tric load ing o the recovering tend on. Sp ecif c rehabilitation
is tailored to f t the u nction and biom echanics o the patho-
logical tend on. Although there is greater agreem ent on general
characteristics o a tend inop athy in cu rrent literatu re, op inion
and evid ence still vary w id ely on anatom ical variations, sp e-
cif c p atho-biom echanics and com p onents o treatm ent.
Tendinopathies of the Hamstrings
Background
Although a m u ltitu d e o anecd otal in orm ation on tend inop a-
thies o the bicep s em oris and sem itend inosu s exists on
sp orts m ed icine and f tness w ebsites, and there is an occa-
sional general re erence to non-sp ecif c ham string tend in-
op athies in textbooks, rep orts o these cond itions in the
p eer-review ed literatu re are extrem ely rare, and they gener-
ally d iscu ss su rgical m anagem ent (Longo et al 2008). In orm a-
tion on inju ries to the ham strings is centred on m u scle strain,
tend on avu lsion and ru p tu re, w hich can be consid ered m ore-
com m on inju ries to these stru ctu res than tend inop athies
(Voight et al 2007; Sarw ark 2010; Kisner & Colby 2010). Snap -
p ing o the bicep s em oris and sem itend inosu s tend ons
is d escribed in the literatu re; how ever, this cond ition is nor-
m ally treated su rgically (Lyu & Wu 1989; Lokiec et al 1992;
Bae & Kw on 1997; Karataglis et al 2008; Bernhard son &
LaPrad e 2010; Date et al 2012) and is not consid ered a d egen-
erative or overu se tend inopathy, bu t rather a m echanical
p roblem .
 532 PART 7 • 47 • Tendinopathy of the knee
Semimembranosus Tendinopathy
Background
Sem im em branosu s tend inop athy (SMT) is a rare cau se o p ain
in the posterior–m ed ial knee. It w as scantily ad d ressed in the
literature rom the 1970s to the 1990s, but no new know led ge
o the cond ition or how to treat it is in evid ence tod ay
(Ray et al 1988; Sa ran & Fu 1995; Bylu nd & d e Weber 2010).
The incid ence is unknow n; how ever, it d oes appear to be
m ore p revalent in old er p atients w ith ad d itional knee
p athologies than in young athletes as an overu se synd rom e
(Bylu nd & d e Weber 2010). SMT u su ally presents as local
tend erness at the d istal sem im em branosu s tend on and p atient
com p laints o aching posterior–m ed ial knee p ain (Bylu nd &
d e Weber 2010).
Anatomy
The sem im em branosu s m uscle originates rom the lateral
aspect o the ischial tuberosity, ollow s a path d ow n the
p osterior–m ed ial asp ect o the thigh and inserts at the
p osterior–m ed ial asp ect o the knee, w here it acts as a knee
exor. The m u scle orm s a thick rou nd ed tend on d istally,
w hich p asses m ed ial to the m ed ial head o the gastrocnem iu s
and lateral to the sm aller sem itend inosu s tend on. The m ain
insertions inclu d e the p osterior–m ed ial tibial plateau , just
p osterior to the m ed ial collateral ligam ent (MCL), and the
m ost anterior insertion (p ars re exa), w hich tu rns anteriorly
alm ost 90° and p asses beneath the MCL to insert on the tibia
just d istal to the m ed ial joint line. A U-shaped bu rsa sur-
round s the d istal sem im em branosus tend on, w hich separates
the d istal asp ects o the tend on rom the m ed ial tibial p lateau ,
MCL and sem itend inosu s tend on. Tend inop athy norm ally
d evelops at the m ain (d irect) head , re ected insertions or
d istal tend on (Bylund & d e Weber 2010).
Pathology and patho-biomechanics
The sem im em branosu s tend on is subjected to increased ric-
tion rom the ad jacent joint cap su le, m ed ial em oral cond yle,
m ed ial tibial p lateau and sem itend inosu s tend on d u ring
repetitive knee exion. This overu se load ing and riction are
thou ght to p rod u ce d egenerative changes in the tend on and
its insertions, as w ell as irritation o the bu rsa (Bylu nd &
d e Weber 2010).
An im portant p art o the cau se o this tend inopathy m ay
be the association w ith coexisting ad d itional knee patholo-
gies. The m ost requently seen concom itant pathologies are
chond rom alacia and d egenerative m ed ial m eniscal tears.
Osteop hytes rom osteoarthritis m ay cau se SMT w hen im p ing-
ing on the nearby tend on at the joint line. Pes anserine tend o-
nitis is an ad d itional associated p athology. Im p ingem ent rom
total knee arthrop lasty com p onents m ay also cau se second ary
SMT. Other hyp othesized in u ences on SMT d evelop m ent
are increased knee valgu s stress, increased Q-angle and over-
p ronation o the oot – all o w hich m ay increase riction
betw een the m ed ial em oral cond yle and the sem im em brano-
su s tend on (Bylu nd & d e Weber 2010).
Diagnosis
The presentation o SMT can be variable and m isd iagnosed
because o the requ ency o concom itant pathologies. On its
ow n, p resentation consists o an insid iou s, p rogressive ache
in the posterior–m ed ial knee area that m ay rad iate p roxim ally
along the posterior–m ed ial thigh or d istally to the m ed ial cal
(Bylund & d e Weber 2010).
Clinically, there is tend erness to p alp ation o the sem im em -
branosu s tend on, either near its tibial insertion site or slightly
p roxim al to that. Passive d eep exion o the knee and p assive
internal tibial rotation o the knee w hile exed to 90° m ay be
u sed as p rovocative tests. As coexisting p athologies are
com m on, the joints o the entire low er extrem ity shou ld be
evalu ated or biom echanical eatu res, such as those previ-
ou sly listed , that can contribu te or p red isp ose to sem im em -
branosu s tend on im pingem ent or overu se (Bylu nd & d e
Weber 2010).
Im aging m ay be help ul in som e cases. Bone scans can
show increased rad iotracer u p take at the area o tend inop a-
thy. Magnetic resonance im aging (MRI) has p oor ability to
d ep ict accu rately any pathology o the posterior horn o the
m ed ial m eniscu s; how ever, it is u se u l or ru ling ou t other
cau ses o knee p ain in this area. Visu alization via u ltrasou nd
m ay assist d iagnosis w ith f nd ings o thickening o the tend on,
d egenerative tend inop athy at the site o clinical tend erness
and su rround ing bu rsal u id (Bylund & d e Weber 2010).
Treatment and prognosis
Conservative treatm ent shou ld be attem p ted initially w ith
relative rest, ice, m od alities to red uce pain, possibly non-
steroid al anti-in am m atory d ru gs and p hysical therap y. The
exercises w ill ocu s on strengthening and stretching o the
ham strings, and ad d ressing any cau sal actors that can be
im p roved w ith therapy. As w ith all tend inopathies, the exer-
cise p rogram m e shou ld p rogress rom concentric to eccentric
contraction o the m u scle. Prognosis or recovery w ith con-
servative treatm ent is good , based on the d ata cu rrently avail-
able; in m ore than 90% o reported cases the cond ition resolves
w ith treatm ent d escribed above. I sym ptom s are not resolved
or im p roved w ithin at least 3 m onths, su rgical rerou ting o
the tend on or other su rgical techniqu es m ay be consid ered
(H alperin et al 1987; Bylund & d e Weber 2010).
Iliotibial Band Syndrome
Background
Iliotibial band synd rom e (ITBS) (see also Ch 35) is an overu se
injury m ost o ten occu rring in the active athletic popu lation
(H ong & Kim 2013). Most patients com plain o lateral sid e
knee pain associated w ith repetitive activities. ITBS is cited as
a com m on cause o lateral knee p ain am ong runners, cyclists,
row ers and other athletes, inclu d ing m ilitary personnel, w ith
a rep orted incid ence ranging rom 1.6% to 14% (van d er Worp
et al 2012; H ong & Kim 2013) to as great as 52% d ep end ing
on the p op u lation stu d ied (Kirk et al 2000).
 Iliotibial band syndrome 533

Pelvis

Tensor fasciae
Gluteus maximus latae muscle
muscle

Biceps femoris muscle Figure 47.1 General anatomy of the iliotibial band.
(hamstrings) Iliotibial band

Patella

Lateral view Anterior view

Anatomy
The iliotibial band or tract (ITB) is a lateral thickening o the
ascia lata in the thigh (Fig. 47.1). It originates along the
m argin o the iliac crest w ith d om inant f bres cond ensing on
the iliac tu bercle (Sher et al 2011). The ITB sp lits into a su per-
f cial and a d eep p ortion, w hich covers the tensor asciae latae
and anchors it to the iliac crest (Fairclou gh et al 2006). The
tensor asciae latae itsel has an insertion on the ITB. Continu -
Tendinous
ing in the d istal d irection along the em u r, the ITB passes over
region
the greater trochanter w ithou t d evelop ing a f xation to the
bone (Birnbau m et al 2004). The ITB encom passes m ost o
the tend on o the glu teu s m axim u s (Birnbaum et al 2004; Ligamentous
Fairclou gh et al 2006). It then passes over the vastus lateralis region
and inserts at the u pp er bord er o the lateral epicond yle
throu gh strong f brou s strand s that are o ten obliqu ely orien-
tated . These strand s occasionally attach to the ep icond yle
itsel ; how ever, they are m ore usu ally attached im m ed iately
proxim al to this site and an ou t as they ap proach the bone.
A region o ad ip ose tissu e is closely associated w ith the f brou s Figure 47.2 Two regions of the ITB tract: a tendinous part proximal to the
strand s and intervenes betw een the ITB itsel and the em u r lateral femoral epicondyle and a ‘ligamentous’ part between the epicondyle and
(Fairclou gh et al 2006). Distal insertions o the ITB inclu d e Gerdy’s tubercle.
the transverse and longitu d inal retinacu lu m o the p atella, the
in racond ylar tubercle o the tibia or Gerd y’s tu bercle, the em oral cond yle, w hile the ligam entous part o the ITB is
head o the f bu la and the lateral interm u scu lar sep tu m tensioned in tu rn as the tibia m oves p osteriorly (Fairclou gh
(Fairclou gh et al 2006; Vieira et al 2007). et al 2006).
Stu d ies have d i erentiated tw o u nctional regions o the In su m m ary, there are several im portant consid erations in
ITB: a tend inou s part that is proxim al to the lateral em oral the anatom y o the ITB that w ere p reviou sly overlooked . It is
epicond yle, and a ligam entou s part that lies betw een the epi- not a d iscrete stru ctu re, bu t rather a thickened p art o the
cond yle and Gerd y’s tu bercle (Fig. 47.2) (Fairclough et al tensor asciae latae that envelop s the thigh. Ad d itionally, it is
2006). The ITB is tense w hen the lim b is load ed , both in the connected to the linea asp era by an interm u scu lar sep tu m and
neu tral p osition and w hen the tibia is internally or externally to the su p racond ylar region o the em u r, inclu d ing the ep i-
rotated . As the knee exes, tension shi ts rom the anterior to cond yle, by coarse f brou s band s that are not p athological
the p osterior f bre bu nd les o the ITB. The band s o the asciae ad hesions. Finally, a bursa is rarely p resent, bu t this m ay
latae, w hich are contigu ou s w ith the ITB and attached to the be m istaken or the lateral recess o the knee (Fairclou gh
patella, com e u nd er tension as the patella m oves arou nd the et al 2007).
 534 PART 7 • 47 • Tendinopathy of the knee
Pathology and patho-biomechanics
Several aetiologies have been consid ered and d ebated or
ITBS, w ith little evid ence that a pathological change such as
in am m ation takes p lace in the ITB itsel (H ong & Kim 2013).
In act, the id ea that ‘ riction’ and ‘in am m ation’ play a role
in w hat som e call ‘iliotibial riction synd rom e’ is d isp u ted
based on cu rrent know led ge o the anatom y (Fairclou gh et al
2007). Proposed aetiologies inclu d e one subtype that involves
irritation o a cyst, bu rsa or lateral synovial recess, and a
second su btyp e arising rom com p ression by the ITB o the
connective tissu es that u nd erlie the p ortion o the band
betw een the lateral epicond yle and the knee joint line (Lavine
2010; Strau ss et al 2011). There m ay or m ay not be any actual
anterior–p osterior riction-prod u cing m otion o the ITB
(Lavine 2010).
Patho-biom echanics o ITBS are also controversial. Som e
au thors attribu te ITBS to w eakness o the hip abd u ctors. Weak
hip abd u ctors cou ld conceivably cau se increased hip ad d u c-
tion d u ring the stance p hase o gait, w ith a consequ ent
increase strain o the iliotibial band and a greater tend ency
or it to com press the tissu es u nd erneath (Lavine 2010).
Ind eed , som e stud ies noted the presence o abd u ctor w eak-
ness or increased hip ad d u ction d u ring the stance p hase o
gait, w hich cou ld be interpreted as a resu lt o abd uctor w eak-
ness (Fred ericson et al 2000; MacMahon et al 2000; N oehren
et al 2007). Grau et al (2008) rep orted d i erent f nd ings,
how ever; hip abd u ctor w eakness, m easu red by a m echani-
cally stabilized d ynam om eter, w as not ou nd in their stu d y
o 10 ru nners.
Tightness versus laxity o the ITB is another d isputed actor
in ITBS. Early stu d ies (Gose & Schw eizer 1989) correlated
tightness o the ITB w ith ITBS, w ith the theory that a tighter
band w ould lead to greater com p ression o the und erlying
tissu es w ith each gait cycle. More recently researchers have
show n that som e ru nners w ith ITBS had a ‘looser ’ ITB, exhib-
iting increased strain (i.e. it elongated m ore w hen su bject to
an external load ) and a statistically signif cant increased strain
rate (i.e. it elongated m ore rapid ly) d u ring ru nning (H am ill
et al 2008).
A p red om inance o stu d ies assessing p atho-biom echanical
cau ses o ITBS had ocu sed on the athletic ru nner p op u lation.
H ence angle o knee exion d u ring stance phase (Orchard
et al 1996), an increased angle o exion o the knee at heel
strike d u e to atigu e (Miller et al 2007), excessive rear oot
eversion (Bu sseu il et al 1998), red uced rear oot eversion
(N oehren et al 2007), increased land ing orces, increased knee
internal rotation, low ham string to qu ad ricep s strength ratio,
genu recurvatu m and a narrow step w id th are all thou ght to
contribu te to ITBS (Devan et al 2004; N oehren et al 2007;
Meard on et al 2012).
Diagnosis
The case history and physical exam ination are u su ally su f -
cient or d iagnosis, althou gh re ractory cases m ay ind icate the
need or an MRI scan to sp eci y involved tissu es or to ru le ou t
another d isord er in the region (Lavine 2010). The patient
u su ally, bu t not alw ays, com p lains o p ain in the area o the
lateral em oral ep icond yle or slightly below it, w hich p resents
a ter repetitive exion and extension o the knee (H ong &
Kim 2013).
Three special tests are u sed to evid ence restriction o the
iliotibial band or to reprod u ce the sym ptom s o ITBS: the
N oble com pression test, Ober ’s test and the Thom as test
(H ong & Kim 2013). It shou ld be noted that tw o o the tests
ind icate only ITB tightness; there ore, in patients w ith ITBS
w ho d o not have ITB tightness, the tests m ay give a alse
negative w hen u sed sp ecif cally or d iagnosing ITBS (H am ill
et al 2008).
In the N oble com pression test, as d escribed by N oble
(1979), the p atient lies in the su p ine p osition and the exam iner
brings the p atient’s knee into 90° o exion w ith sim u ltaneou s
hip exion. The exam iner then ap p lies d irect p ressu re over
the lateral em oral epicond yle, or 1–2 cm proxim al to it, w hile
p assively extend ing the knee. For a p ositive test, the p atient’s
p ain w ill be rep rod u ced at the site o com p ression at ap p roxi-
m ately 30° o knee exion (Magee 2008). The sensitivity and
sp ecif city o this test or d etecting ITBS are not know n.
Ober ’s test assesses tightness o the ITB (Magee 2008; H ong
& Kim 2013). The exam iner per orm s the test w hile stand ing
behind the sid e-lying patient. The exam iner m anu ally stabi-
lizes the patient’s pelvis w ith one hand , passively exes the
p atient’s u p p erm ost thigh and then brings it into m axim al
abd u ction. The exam iner then m aintains that abd uction w hile
p assively m oving the thigh into extension. The tested lim b is
then low ered into ad d u ction u ntil it stop s, or u ntil the p elvis
starts to tilt. I tightness is p resent, the p atient’s thigh rem ains
above the horizontal p lane and d oes not reach the table
(Magee 2008). The test, as originally d escribed by Ober, w as
p er orm ed w ith the tested leg’s knee exed (Wang et al 2006).
To avoid stress on the em oral nerve and to show the e ect o
greater stretch on the ITB, the test is now com m only per-
orm ed as d escribed above, w ith the knee extend ed (Wang
et al 2006; Magee 2008). The sensitivity and specif city o this
test to d iagnose ITBS are not know n.
The Thom as test is used to assess the tightness o iliopsoas
m u scle, rectu s em oris and ITB. The p atient lies su p ine w hile
the exam iner p assively exes the non-tested hip , bringing the
knee to the p atient’s chest (Magee 2008). The patient then
hold s the knee to the chest. The tested straight leg w ill stay
on the table; how ever, it w ill abd u ct at the hip . This is called
the ‘J’ sign, and ind icates tightness o the ITB (Magee 2008).
The sensitivity and specif city o this test or d eterm ining ITBS
are not know n, how ever.
Conservative treatment and prognosis
Initially, in the acute p hase, treatm ent w ill inclu d e activity
m od if cation, ice and non-steroid al anti-in am m atory m ed i-
cation (Fred ericson & Wol 2005; Fred ericson & Weir 2006;
Ellis et al 2007). Use o corticosteroid injection in cases o
severe p ain or sw elling is d ebated . Althou gh corticosteroid
injections have been show n to red u ce sym ptom s in the acute
p hase o ITBS, they m ay actu ally d elay the eventu al retu rn to
ull pain- ree activity becau se long-term cortisone e ects
includ e inhibition o collagen synthesis (Gu nter et al 2004).
Most, i not all, p u blished p rotocols ap p ear to agree that
treatm ent in the su bacu te p hase entails a ocu s on stretching
o the ITB and so t tissu e therap y or any m yo ascial restric-
tions (Fred ericson & Wol 2005; Fred ericson & Weir 2006; Ellis
et al 2007). H ow ever, as research has show n that not all
p atients w ith ITBS have ITB tightness (H am ill et al 2008), a

m ore ind ivid u alized ap p roach based on exam ination f nd ings
is recom m end ed . (See also Ch 35 or u rther d iscu ssion on
m anu al therap y ap p roaches ocu sing on the role o the ITB in
the hip .)
The recovery p hase incorporates ad vanced exercises
includ ing eccentric m uscle contractions to strengthen the hip
abd u ctors, as w ell as trip lanar m otions and integrated m ove-
m ent p atterns (Fred ericson & Weir 2006). For patients w ho
are running athletes, the f nal retu rn to ru nning phase starts
w ith easy sprints and avoid ance o hill training, w ith a grad u al
increase in requ ency and intensity (Fred ericson & Weir 2006).
There is lim ited evid ence o research quality to supp ort
that the conservative treatm ents d iscu ssed above o er any
signif cant benef t in the m anagem ent o ITBS (Ellis et al 2007).
Despite this, the prognosis or recovery u sing a com p rehen-
sive conservative treatm ent p lan is consid ered to be good and
estim ated to occu r w ithin 6 w eeks o onset in m ost patients
(Fred ericson & Wol 2005; Beers et al 2008).
Patellar Tendinopathy
Background
Patellar tend inop athy d escribes both acu te and chronic ante-
rior knee pain associated w ith tend erness at the in erior pole
o the p atella, in w hich u ltrasou nd exam ination and MRI
reveal abnorm al signals at the junction o the patella and the
patellar tend on (Khan et al 1998). Other nam es or this vari-
able cond ition inclu d e ‘jum per ’s knee’, ‘patellar tend inosis’,
‘patellar tend initis’, ‘patellar tend onitis’, ‘patella tend on d is-
ord er ’, ‘insertion tend initis o the p atellar tend on’, ‘p artial
ru p tu re o the p atellar tend on’ and ‘p atellar ap icitis’ (Khan
et al 1998). Patellar tend inopathy has an estim ated incid ence
o 2.5% to 14% in athletes w hose sports involve repetitive,
su d d en ballistic m ovem ents o the knee (Zw erver et al 2011;
Ackerm ann & Renström 2012).
Both intrinsic and extrinsic actors contribu te to p atellar
tend inop athy. Intrinsic actors inclu d e strength im balance,
postu ral alignm ent, oot stru ctu re, red u ced ankle d orsi exion
and m u scle w eakness or tightness (Ru tland et al 2010). The
prim ary cau se is attributed to the extrinsic actor o overuse
(Ru tland et al 2010; Rod rigu ez-Merchan 2013).
Anatomy
The patellar tend on, d escribed by Khan et al (1998), is the
extension o the com m on tend on o insertion o the qu ad ri-
cep s em oris m u scle. It extend s rom the in erior p ole o the
patella to the tibial tu berosity. The patellar tend on is rou ghly
3 cm w id e in the coronal plane and 4 to 5 m m d eep in the
sagittal p lane.
The blood su pply to the p atellar tend on is thou ght to con-
tribu te to p atellar tend inop athy. Accord ing to Khan et al
(1998), an anastom otic ring that lies in the thin layers o loose
connective tissu e covering the d ense f brou s exp ansion o the
rectu s em oris is resp onsible or vascu larization o the patellar
tend on. The m ain contribu tors to this ring are the m ed ial
in erior genicular, lateral superior genicular, lateral in erior
gen icu lar and an terior tibial recu rren t arteries. Th e p oste-
rior asp ect o the tend on is m ost com m only a ected by
Patellar tendinopathy 535
tend inop athy, and it is here that the blood su p p ly to the p roxi-
m al p ortion o the p atellar tend on enters (Khan et al 1998).
The qu ad riceps and patellar tend ons are continu ou s w ith
each other over the anterior su r ace o the patella (Tou m i et al
2006). The d eep sur ace o the patellar tend on is closely associ-
ated w ith the in rap atellar (H o a’s) at p ad across its entire
w id th, and the at pad orm s interd igitations w ith the p roxi-
m al p art o the tend on that are m ore obviou s on the m ed ial
sid e than on the lateral sid e (Toum i et al 2006).
Pathology and patho-biomechanics
The patellar tend ons o patients w ith chronic patellar tend in-
op athy contain m u coid d egeneration and occasional hyaline
d egeneration, w hich is characterized by hard ness rather than
the so tness norm ally inherent in m u coid d egeneration (Khan
et al 1998; Ru tland et al 2010). There is abnorm al collagen,
tenocytes and vascu latu re (Ku lig et al 2013). The tend on d oes
not consist o tight p arallel collagen bu nd les, as is norm al, bu t
rather ap p ears d isorganized w ith collagen replaced by d egen-
erative and necrotic tissue. Micro-tearing in the collagen is
su sp ected (Khan et al 1998; Kulig et al 2013).
The presence o in am m atory cells in the tend on is d ebated .
One theory is that f broblasts, m ore p lenti u l in the p athologi-
cal tend on than in the norm al, m ay have been m istaken or
in am m atory cells early on (Khan et al 1998; Ru tland et al
2010). Kulig et al (2013) ou nd thicker proxim al patellar
tend ons in both sym p tom atic and non-sym p tom atic basket-
ball athletes com pared w ith non-athletes, w hich they su g-
gested w as a norm al ad aptation to training load s. In am m ation
w as previou sly believed to be a central d riving orce to the
p athological p rocess; how ever, cu rrent histop athological evi-
d ence has not su pported this, and a f rm ed that these cond i-
tions are instead d u e to a ailed healing resp onse (Ku lig et al
2013; Rod riguez-Merchan 2013).
Excessive or inap p rop riate load ing o the m u scu lotend i-
nou s u nit is believed to be a m ain actor in the d isease p rocess
in the ollow ing m anner. The norm al crim ped conf guration
o collagen f bres and f brils in norm al tend on at rest d isap-
p ears w hen the tend on is stretched by abou t 2%. When the
stretch reaches 5% elongation, tend on f bres becom e m ore
p arallel. Beyond 5% elongation, tend on m icro- ailu res occu r
(Khan et al 1998; Ru tland et al 2010). The vertical com ponent
o each grou nd reaction orce in a ju m p is arou nd six to eight
bod y w eights, and a basketball player jum ps an average o 70
tim es p er gam e. With the orces on the p atellar tend on in
activities ranging rom level w alking at 0.5 kN to 14.5 kN
d uring com petitive w eightli ting, it is clear that sports activi-
ties im p ose stresses su f cient to cau se tend on f bre ailu re
(Khan et al 1998).
Diagnosis
Patellar tend inop athy is d iagnosed clinically by history, knee
exam ination and palpation o the tend on and its attachm ents
(Cook et al 2001; Ru tland et al 2010). An im p ortant physical
f nd ing in p atellar tend inop athy is tend erness at the in erior
p ole o the p atella or in the m ain bod y o the tend on w hen
the knee is u lly extend ed and the qu ad ricep s is relaxed . Both
p atellae shou ld be tested . The u p p er p ole o the p atella is
grasped by the exam iner so as to anteriorize the ap ex o the
 536 PART 7 • 47 • Tendinopathy of the knee
p atella (Fig. 47.3). Using f nger pressure on the p atellar
tend on im m ed iately below the in erior p ole o the p atella,
the exam iner w ill elicit rom the p atient the test resp onse o
p ain or no p ain (Ram os et al 2009). The tend erness d ecreases
or d isap p ears w hen the knee is exed to 90° (Khan et al
1998). Cook et al (2001) ou nd p alp ation to be a m od erately
sensitive bu t not sp ecif c test in sym p tom atic tend ons. Other
researchers have reported high sensitivity and m od erate
sp ecif city or d iagnosing p atellar tend inop athy (Ram os
et al 2009).
The d iagnosis m ay be conf rm ed w ith im aging, com m only
u ltrasonograp hy and MRI (Khan et al 1998; Ram os et al 2009).
Patellar tend on p ain and tend erness, as w ell as im aging
changes, are m ost o ten ou nd to be p resent at the ju nction o
the in erior p ole o the p atella and the tend on attachm ent
(Cook et al 2001; Ram os et al 2009). Pain in the patellar tend on
m ay also be rep rod u ced w ith resisted knee extension and
u nctional tests, includ ing ascend ing or d escend ing stairs,
p er orm ing single-leg d eclining squ ats, and ju m p ing or
hop p ing (Ru tland et al 2010).
There are several system s o grad ing ju m p er ’s knee accord -
ing to the severity and tim ing o knee p ain, inclu d ing Blazi-
na’s knee scale, Kenned y’s scale and the Victorian Institu te o
Sp ort Assessm ent (VISA) scale or p atellar tend inop athy
(VISA-P) and others. Accord ing to Khan et al (1998), the reli-
ability o m ost o these scales has never been tested , and they
m ay be incap able o d iscrim inating betw een p atients w ith
w id ely d i ering sym ptom s. Som e clinicians u se the scales to
d eterm ine w hen to ad vance the patient to the next stage o
rehabilitation. For exam ple, Blazina’s scale presents the ol-
low ing stages (Panni et al 2000; Ru tland et al 2010):
• stage 1: pain p resent only a ter athletic participation; no
app arent u nctional im pairm ent (n = 0)
• stage 2: pain d u ring and a ter activity; per orm ance is
still at a satis actory level (n = 26)
Figure 47.3 Palpation for tenderness of
the inferior pole of the patella.
• stage 3: pain p resent d u ring and a ter activity bu t is m ore
prolonged ; progressive d i f cu lties w ith per orm ing at a
satis actory level (n = 16).
O these scales, the VISA-P is the m ost w ell know n and w id ely
u sed . It is a short qu estionnaire assessing sym p tom s, sim p le
tests o u nction and ability to p lay sp ort (Visentini et al 1998).
Creators o the VISA-P scale rep orted excellent short-term
test–retest and inter-tester reliabilities (both r > 0.95), as w ell
as good short-term (1-w eek) stability (Visentini et al 1998).
More-recent variou s langu age translations o the VISA-P scale
have also show n good test–retest reliability and valid u se as
a tool to evalu ate sym p tom s, knee u nction and ability to
p lay sp orts in athletes w ith p atellar tend inop athy (Frohm
et al 2004; Ma u lli et al 2008; Zw erver et al 2009; Lohrer &
N au ck 2011).
Conservative treatment and prognosis
Conservative treatm ent p rogram m es or p atellar tend inop a-
thy are varied , and are o ten p rogressed in stages based on
the p atient’s su bjective rep ort o p ain, u tilizing the scales d is-
cu ssed p reviou sly (Khan et al 1998; Panni et al 2000; Ru tland
et al 2010). Com ponents o each stage are d ebated , and no
single com p onent has strong evid ence-based su p p ort. Con-
servative treatm ent in general inclu d es correction o any
noted p red isp osing actors, relative or absolu te rest rom
aggravating high-load activities (Bahr et al 2006; Frohm et al
2007; Ru tland et al 2010) and stretching and strengthening.
Eccentric load ing is ad vocated by m ost (Panni et al 2000;
Cannell et al 2001) but not all (Visnes et al 2005) clinicians.
For ad vocates o eccentric load ing, the eccentric d ecline squ at,
either bilateral (Fig. 47.4A) or u nilateral (Fig. 47.4B), is specif -
cally recom m end ed (Pu rd am et al 2004; You ng et al 2005;
Ru tland et al 2010). Recent research (Saithna et al 2012) has

A B
d ispu ted the practice o w ithd raw ing the athlete rom sport
w hile engaged in eccentric exercise protocols, citing ‘signif -
cant p sychological, p hysiological and f nancial im p lications’
(p 554), and re erring to several stu d ies in w hich athletes
benef ted rom an eccentric exercise protocol w hile they con-
tinu ed to p articip ate in sp ort.
Other conservative therap y treatm ents inclu d ing trans-
verse riction m assage (Stasinopou los & Stasinopou los 2004),
ice and N SAIDs or local anaesthetics (Gam m aitoni et al 2013)
w ith or w ithout m od alities m ay be help ul to red u ce pain and
any in am m ation p resent, as w ell as increase treatm ent toler-
ance. Less requently incorporated are bracing (Khan et al
1998), u se o an in rapatellar strap (Lavagnino et al 2011) and
novel m od alities that have show n inconsistent clinical resu lts,
su ch as extracorp oreal shockw ave treatm ent (ESWT) (van d er
Worp et al 2013).
The m ost recent d irection o treatm ent research or p atellar
tend inop athy is injection o the tend on w ith p latelet-rich
p lasm a (Ferrero et al 2012; Gosens et al 2012; Vetrano et al
2013) or w ith au tologous bone m arrow stem cells (Pascu al-
Garrid o et al 2012). The reasoning is that trad itional conserva-
tive treatm ent d oes not ad d ress the biological state o the
cond ition, w hich is hyp ovascu larity and p rogram m ed cell
d eath (Gosens et al 2012). These treatm ents are recom m end ed
as an alternative treatm ent or those p atients w ho have ailed
6–8 m onths o non-operative treatm ent, bu t be ore su rgical
intervention is consid ered . Au thors have reported signif cant
long-term im p rovem ent o clinical sym ptom s, and the
p ossibility o recovery o the tend on m atrix (Ferrero et al
2012; Gosens et al 2012; Pascu al-Garrid o et al 2012; Vetrano
et al 2013).
Prognosis or u ll recovery w ithou t sym p tom recu rrence
u tilizing conservative treatm ent alone is p oor. The natu ral
history o p atellar tend inop athy is that o chronic p ain and
Popliteal tendinopathy 537
Figure 47.4 Eccentric decline squat: (A) bilateral,
(B) unilateral.
red u ced u nction, w hich o ten severely lim its or even end s an
athletic career. Signif cant p ain and lim itation w ill continu e
beyond 6 m onths a ter onset o pain in u p to one-third o
p atients, w hile the m ajority o p atients w ill have som e level
o sym p tom s or m any years (Saithna et al 2012). Patients w ho
continu e to experience d isabling sym p tom s a ter 6 m onths
m ay elect su rgery. Prognosis or u ll recovery w ithou t
sym p tom recu rrence a ter su rgery is u nknow n, based on the
variety o su rgical m ethod s available and p ostop erative p ro-
tocols ollow ed (Khan et al 1998; Cu cu ru lo et al 2009; Maier
et al 2013).
Popliteal Tendinopathy
Background
Pop liteal tend inop athy is an u ncom m on cau se o anterior–
lateral knee pain and has been presented in the m ed ical litera-
tu re as rare cases o acu te calcif c tend onitis (Tibrew al 2002)
and as p op liteal tenosynovitis (Blake & Treble 2005). Ru pture
o the tend on is m ore com m on than tend inop athy.
Anatomy
The popliteus m uscle originates rom the lateral em oral
cond yle, the p roxim al f bu la and the p osterior horn o the
lateral m eniscu s, althou gh variations have been reported in
the lateral m eniscu s p oint o origin. The em oral origin is
consid ered to be the strongest p oint o origin. The p op liteu s
m u scle itsel inserts into the p osterior su r ace o the p roxim al
tibia su p erior to the soleal line. The p op liteu s tend on lies d eep
to the lateral collateral ligam ent and p asses throu gh a hiatu s
 538 PART 7 • 47 • Tendinopathy of the knee
in the coronary ligam ent to attach to the lateral em oral
cond yle (N ielsen & H elm ig 1986; Blake & Treble 2005).
Pathology and patho-biomechanics
In the case o acu te calcif c tend onitis, the acu tely p ain ul
p hase is believed to occu r as the organic m atrix bind ing the
calcif c d ep osit d isintegrates and stim u lates an in am m atory
resp onse and phagocytosis (Tibrew al 2002). The m echanism
o the origin and resolu tion o the calciu m d ep osit m ay inclu d e
resp onse to tissu e insu lt and healing by calcif cation, local
stress necrosis and local hyp oxia second ary either to m echani-
cal actors or hyp ovascu larity (Tibrew al 2002). It has been
su ggested that d ystrop hic calcif cation o d egenerative tend on
m atrix is a d i erent p athological entity rom cell-m ed iated
calci ying tend initis (Tibrew al 2002). The exact pathogenesis
rem ains u ncertain, how ever: in tenosynovitis it is thou ght to
involve in am m ation w ithin the tend on sheath (Vu illem in
et al 2012), bu t in a reported case o popliteal tenosynovitis
(Blake & Treble 2005) the p athogenesis w as not d escribed .
Althou gh the prim ary u nction o the pop liteu s is to
rotate the tibia m ed ially on the em ur, the popliteal tend on
also e ectively restrains varu s instability rom 0° to 90° o
exion (N ielsen & H elm ig 1986; Blake & Treble 2005). It has
also been stated that m arked posterior–lateral instability
is im p ossible w ith an intact p op liteal tend on (N ielsen &
H elm ig 1986).
Diagnosis
In the case o acu te calcif c tend onitis, history and clinical
exam ination m ay reveal an acu te onset o pain, localized
sw elling w ith red ness, and tend erness to p alp ation over the
lateral sid e o the knee at the insertion o the p op liteu s tend on
(Tibrew al 2002). A history o inju ry or pred isposing actors
m ay not be p resent. There w ill be d i f cu lty or inability to bear
w eight on the a ected leg. The knee cannot be u lly extend ed
ow ing to p ain and p ossibly sw elling or m u scle sp asm . There
m ay be a p alp able tend er nod u le at the site o the p op liteu s
tend on (Tibrew al 2002). Calcif c changes in the popliteal
tend on m ay be noted on the p lain rad iograp h and MRI
(Tibrew al 2002).
In the case o popliteal tenosynovitis, there w ill be sim ilar
p alp able tend erness and d i f cu lty extend ing the knee.
Arthroscopy has been u tilized or both d iagnosis and treat-
m ent (Blake & Treble 2005).
Conservative treatment and prognosis
Su ccess u l treatm ent o calcif c tend onitis has been achieved
by injection o 4 m l o 0.5% Marcaine and Depo-Med rone
(20 m g) at the pain ul site, ollow ed by anti-in am m atory
m ed ication (d iclo enac 50 m g td s) or 2 w eeks and physical
therap y, as w ell as u se o so t knee sp lints (Tibrew al 2002).
Prognosis based on the little evid ence available is good w ith
conservative treatm ent as d escribed (Tibrew al 2002).
Rep orted treatm ent or p op liteal tenosynovitis other than
arthroscop y is u nknow n; how ever, u nreported cases m ay
have been treated w ith a stand ard p rotocol or tenosyno-
vitis consisting o corticosteroid injection and rest (Peters-
Velu tham aningal et al 2009).
Quadriceps Tendinopathy
Background
Qu ad ricep s tend inop athy is sim ilar to that o the p atellar
tend on, w hich is m u coid d egeneration in resp onse to rep eti-
tive overload (Aru m illi et al 2009). H ow ever, a signif cant
d i erence is that, w hereas patellar tend inop athy cau ses sig-
nif cant p ain, qu ad ricep s tend inop athy is o ten clinically
silent u ntil com p lete ru p tu re occu rs. H ence the f rst m ani es-
tation o qu ad ricep s tend inop athy m ay be a ru p tu re, althou gh
it m ay also coexist w ith sym ptom atic paratend inopathy
(Aru m illi et al 2009). Even the ruptu re itsel is o ten m isd iag-
nosed or d iagnosed late ow ing to being m istaken or other
p athologies su ch as stroke, rheu m atoid arthritis, d isc p rolap se
and neuropathy (Aru m illi et al 2009). This is especially true
in cases o bilateral spontaneou s ruptu re.
Anatomy
It is com m only accepted that the our m uscu lar elem ents o
the qu ad ricep s gather d istally to create the qu ad ricep s tend on
in three layers that conjoin app roxim ately 2 cm p roxim al to
the p atella. Som e researchers, how ever, su p p ort the id ea that
the three layers o the qu ad ricep s tend on rem ain d istinct u ntil
their insertion into the p atella (Waligora et al 2009). In ad d i-
tion, MRI has show n that the tend on has m ore lam ination in
its m id line and m ed ially than it d oes laterally. The qu ad riceps
tend on is layered w ith a su p erf cial contribu tion rom the
rectu s em oris, interm ed iate ad d itions rom the vastu s m ed ia-
lis and vastu s lateralis, and d eeply rom the vastu s interm e-
d ius. An ad d itional d eviation rom the stand ard d escription
o the qu ad ricep s tend on is that ap p arently not all contain
three f bre p lanes (Waligora et al 2009). Based on MRI stu d y,
it is p ossible that a signif cant p roportion o quad riceps
tend ons contain only tw o f bre p lanes, w ith a sm aller nu m ber
o tend ons classif ed as one layer or ou r layers (Waligora et al
2009). This m ay help to und erstand w hy there are cases
reported o healthy active ind ivid u als, younger than the
stand ard or this inju ry, w ho su stain seem ingly sp ontaneou s
qu ad ricep s tend on ru p tu res.
Pathology and patho-biomechanics
It is believed that, u nd er norm al cond itions, the qu ad riceps
tend on is resistant to tensile strain orces, and sp ontaneou s
ru p tu res occu r only in abnorm al tend ons w ith evid ence o
hyp ovascu lar changes inclu d ing narrow ing and obliteration
o sm all arteries, hyp ertrop hy o the intim a and m ed ia w alls
(Aru m illi et al 2009; Ma ulli et al 2012). Trobisch et al (2010)
p er orm ed a histological analysis o ru p tu red qu ad ricep s
tend ons and observed an increasing ratio o d egenerative
to non-d egenerative tend ons w ith increasing p atient age.
Ma u lli et al (2012), how ever, rep orted a higher incid ence o
d egenerative tend on changes in the ru ptu red quad riceps
tend ons o you nger age p atients, w hich d isp u tes the notion
that old er p atients are m ore p rone to hyp ovascu lar qu ad ri-
cep s tend inop athy lead ing to ru p tu re.
The com m on m echanism s o injury includ e orced contrac-
tion o the qu ad ricep s w ith the knee exed and the oot f xed

to the grou nd ; u nctionally sp eaking, this resu lts rom a
stu m ble, a sim p le all, or alling d ow n the stairs or rom a
height (Arum illi et al 2009; Ma ulli et al 2012). Qu ad riceps
ru p tu res tend to occu r com m only w hen the knee is exed
m ore than 60° ow ing to high orces transm itted throu gh
the extensor m echanism w ith an eccentric contraction o
the qu ad ricep s against the w eight o the bod y (Ma u lli
et al 2012).
Pathogenesis is consid ered m u lti actorial, how ever, as a
signif cant nu m ber o ru p tu res occu r w ith no evid ence o
hyp ovascu lar tend inop athy, and m any are associated w ith
d isord ers su ch as renal insu f ciency, p rim ary or second ary
hyp erp arathyroid ism and other cond itions that im p air and
w eaken the osteotend inous junction (Aru m illi et al 2009,
Ma u lli et al 2012). Obesity, repeated corticosteroid injections,
and u se o anabolic steroid s or statins m ay also be p red ispos-
ing actors (Ma u lli et al 2012).
Diagnosis
Missed d iagnosis and m isd iagnosis are com m on both or
qu ad ricep s tend inop athy and or qu ad ricep s tend on ru p tu re
(Aru m illi et al 2009; Ma u lli et al 2012; Volk et al 2014). Phys-
ical exam ination w ill reveal sup rapatellar pain on palpation.
In the case o a ru pture, a su prapatellar gap m ay be palpated .
There m ay be d i f culty in achieving u ll knee extension
against gravity. With a ru ptu re there w ill be an inability to
m aintain u ll active extension. Gait abnorm alities inclu d e sti
knee gait or exaggerated hip elevation or sw ing throu gh
circu m d u ction w hen the qu ad ricep s tend on is ru p tu red
(Aru m illi et al 2009; Volk et al 2014). In silent tend inopathies,
there m ay be no clinical signs or sym p tom s. Rad iograp hs
reveal abnorm al patella height (patella baja) in the case o
qu ad ricep s tend on ru p tu re; MRI and u ltrasou nd are u se u l
or view ing degenerative changes in the unruptured tendon as
w ell as or visualizing the ruptured tend on (Volk et al 2014).
In som e cases the retinacu lu m is intact bu t the quad riceps
tend on is ru p tu red . The p atient is able to p er orm w eak
straight leg raise w ith the aid o the intact retinacu lu m ;
how ever, the qu ad ricep s tend on is com p letely torn. Care u l
physical exam ination is recom m end ed , inclu d ing checking
the extensor lag and , i necessary, asp irating blood rom the
knee and injecting w ith lid ocaine be ore re-exam ining it (Volk
et al 2014).
Conservative treatment and prognosis
Conservative treatm ent or qu ad ricep s tend inop athy is not
established in the literature as d i erent to that or patellar
tend inop athy. This m ay be d u e to the in requ ent d iagnosis
and m ore com m on presentation as a rup tu re rather than a
tend inop athy w ith an intact tend on. Ru p tu re o the qu ad ri-
cep s is a su rgical ind ication, and the best ou tcom es occu r
w hen su rgery is p er orm ed quickly, ollow ed by im m obiliza-
tion p er p rotocol and intensive rehabilitation (Arum illi et al
2009; Grim et al 2010; Ma u lli et al 2012; Saragaglia et al 2013;
Bou d issa et al 2014; Volk et al 2014).
Prognosis or u ll recovery rom qu ad ricep s tend inop athy
is u nknow n; in act, the evid ence p oints to eventu al ru p tu re
in m ost cases (Aru m illi et al 2009; Ma u lli et al 2012). Prog-
nosis or u nctionally good recovery rom a su rgically rep aired
Conclusion 539
ru p tu red qu ad ricep s tend on is consid ered good i the d iagno-
sis and su rgery are not d elayed (Grim et al 2010; Saragaglia
et al 2013; Bou d issa et al 2014).
Conclusion
Clinicians and researchers continu e to qu estion p reviou s
assum ptions regard ing the cau se, pathology, d iagnosis and
treatm ent o tend inop athies in the knee. The trend has m oved
aw ay rom view ing tend inopathy as an acute cond ition in
w hich in am m ation is the only pathological actor. Ou r
cu rrent u nd erstand ing o tend inop athy p athology is that o
m u coid d egeneration associated w ith hyp ovascu larity and
overu se w ith ailed healing. Sp ecif c conservative treatm ents
attem pt to ad d ress replacem ent o the d egeneration in the
tend on w ith healthy collagen, o ten u tilizing eccentric exer-
cises to engend er this trans orm ation. At the sam e tim e, novel
treatm ents, inclu d ing injection o the tend on w ith p latelet-
rich plasm a or w ith au tologou s bone m arrow stem cells,
attem pt to ad d ress cau sative actors su ch as hyp ovascu larity,
w hile other p roposed treatm ents such as extracorporeal
shockw ave treatm ent have not as yet p roven them selves clini-
cally. A conclu sion across the sp an o knee tend inop athies is
that early d iagnosis and p rom p t, thorou gh, evid ence-based
treatm ents w ill p rovid e the best p ossibility o a good p rogno-
sis or recovery.
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This pa ge inte ntiona lly le ft bla nk
 P AR T 8
The Wrist and Hand
Regions in Upper
Extremity Pain
Syndromes
48 Tendinopathies of the Wrist and Hand 545
C. Joseph Yelvington and Ellen Pong
49 Carpal Instability 558
Ellen Pong
50 Carpal Tunnel Syndrome 566
Luca Padua, Daniele Coraci and César Fernández-de-las-Peñas
51 Other Entrapment Neuropathies 575
Joy C. MacDermid and David M. Walton
52 Joint Mobilization and Manipulation 584
Peter A. Huijbregts, Freddy M. Kaltenborn and Traudi Baldauf Kaltenborn
53 Finger and Thumb Pathology 594
Joy C. MacDermid, Ruby Grewal and B. Jane Freure
This pa ge inte ntiona lly le ft bla nk
 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
Tendinopathies o the Wrist and Hand
CHAP TER CONTENTS
Introduction  545
Def nition o  tendinopathy  545
Aetiology  546
Anatomy o  the tendon  546
Basic components  546
Blood and nerve supply  546
Pathoanatomy  547
Tendinopathy classif cation  548
Tendinosis  548
Tendinitis  548
Paratenonitis  548
Combined paratenonitis and tendinosis  548
Examination and diagnosis  549
Clinical tests  549
Diagnostic imaging and invasive testing  549
Tendinopathic entities o  the hand and wrist  550
Flexor carpi ulnaris  550
Extensor carpi ulnaris  550
Extensor carpi radialis longus and brevis (distal tendons)  551
Extensor indicis proprius  551
Extensor digiti minimi  551
Abductor pollicis longus and extensor pollicis brevis  552
Extensor pollicis longus  552
Flexor carpi radialis  553
Treatment and prognosis  553
Conservative treatment  553
Non-conservative treatment  554
Prognosis 
Conclusion 
555
555
Introduction
A large p rop ortion o hand and w rist tend inop athies occu r in
ind ivid u als w ho per orm highly repetitive and orce ul jobs
(Eld er & H arvey 2005). The Departm ent o Labor, Bu reau o
Labor Statistics (1999) reported incid ence o hand and w rist
tend initis (tend inop athy not sp eci ed ) as 3.66% o u pp er
extrem ity w orkplace inju ries record ed in 1999, resu lting in a
m ean o 6 lost w ork d ays or all hand / w rist inju ries.
 
Chapter  48
C . J o s e p h Ye lvin g to n , Elle n Po n g
Patients and p ractitioners had d iscovered that, once tend i-
nopathy is established , resolving sym p tom s cou ld be d i cu lt.
Treatm ent typ ically consists o resting in a sp lint, m od i ying
activities or ergonom ic correction, taking non-steroid al
anti-inf am m atory m ed ications (N SAIDs), and receiving cor-
ticosteroid injections, o ten w ith p ositive resu lts (Fred berg
& Stengaard -Ped ersen 2008). Deep tissue riction m assage
(DTFM), e f eu rage, connective tissu e release and Rol ng
have been u tilized on tend ons, w ith the p rem ise that they w ill
release scar tissu e restrictions and allow im p roved collagen
alignm ent. H ow ever, stud ies d o not reliably con rm the p osi-
tive bene t o these conservative treatm ents (Brou sseau et al
2002). This d em onstrates a typical problem : rand om ized clini-
cal trials o m anu al therap y to the tend ons o the hand and
w rist are scarcely, i at all, available.
Investigators have continued to look m ore closely at
tend ons, d iscovering p rocesses that m ay exp lain w hy ou t-
comes are not m ore p ositive. Ad equ ate anim al m od els or in
vivo stu d ies have only recently been d evelop ed (Soslow sky
et al 2000). Tend inopathy has been classi ed and red e ned .
Cu rrent stu d ies attem p t to exp lain w hy rep etitive m otion and
strain cau se tend on p athologies (Backm an et al 2005). This
d eveloping know led ge o tend on pathology has shed new
light on treatm ent rationale (Khan et al 2000).
This chapter ollow s the trend o cu rrent stu d ies and
expand ing know led ge, inclu d ing a review o the tend inopa-
thy p rocess rom a m olecu lar level. This review p rovid es a
know led ge base or the ensu ing d iscu ssion o exam ination,
d iagnosis, categorization o tend inop athy and treatm ent.
De nition of Tendinopathy
The lack o m ore positive resu lts w ith conservative treatm ent
m ay be d u e to m islabelling tend inosis as tend initis (Khan et al
2000). Tend initis m u st be qu ali ed . Stu d ies are now consist-
ently show ing w hat w as norm ally d iagnosed as tendonitis
m ay rep resent only one classi cation o tendinopathy (Fu tam i
& Itom an 1995). Tend inopathy rep resents histological nd -
ings that d i er signi cantly rom the generally accepted
cond ition o tend onitis. This is d u e p rim arily to the lack o
evid ence o inf am m atory precu rsors and cells in the tend on
itsel (Gabel et al 1994; Yuan et al 2003; Cu rw in 2005;
Fred berg & Stengaard -Ped ersen 2008). Khan et al (2006)
 546 PART 8 • 48 •
su p p orted Bonar ’s classi cation o tend inop athy, w hich
d e ned ou r classi cations, each w ith d istinct histological
nd ings. Clinicians have yet to ap p ly this know led ge to
su p p ort sp eci c conservative treatm ent use (Cannon 2001). A
ou rth ed ition m anu al o u pper extrem ity rehabilitation
p rinted in 2001 d id not u se the w ord s tend inosis or tend in-
op athy, bu t instead u sed the term s tendinitis and paratend-
initis or all related cond itions o u p p er extrem ity p ain cau sed
by tend on pathology (Cannon 2001).
One reason or the continu ed consid eration o tend on
p athologies as tend onitis m ay be the initially p ositive ou t-
com es w ith corticosteroid s in sym p tom atic tend ons (Fred berg
& Stengaard -Ped ersen 2008). The presence o an ‘-itis’ or
inf am m ation in the orm o neu rogenic inf am m ation m ay
also su pp ort p ersistence o the old term inology. Fred berg and
Stengaard -Ped ersen (2008) conclu d ed that som e com bination
o classic inf am m ation and neu rogenic inf am m ation d oes
m ean that tend onitis is not a com p lete m isnom er. It is the
histological d i erence in tend inop athies stem m ing rom tend -
initis, tend inosis and p aratenonitis that m ay d ictate d i erent
treatm ents, p articu larly in m anu al therap y.
There continu e to be areas o need ed research into this
su bject. Find ings rom anim al stu d ies and rom tend on stu d ies
p er orm ed on other areas o the bod y w ill be u sed in this
chap ter to p rovid e d ata that m ay be extrap olated to ap p ly to
the hand and w rist, d esp ite d i erences betw een w eight-
bearing versus positional tend ons (Sm ith et al 1997).
Aetiology
Researchers rep ort that know led ge o the aetiology o tend i-
nop athy is evolving (Sharm a & Ma u lli 2005; Fred berg &
Stengaard -Ped ersen 2008). Many actors contribute to tend in-
op athy, both intrinsic and extrinsic (Riley 2004). Renstrom and
H ach (2005) su m m arized extrinsic actors as: m alalignm ents,
red uced f exibility, m uscle w eakness or im balance, overu se
and excessive bod y w eight. H art et al (2005) ad d ed genetics,
gend er and tness level, w hile H am m er (2007a) reported bio-
m echanical au lts. Intrinsic actors that a ect ap op tosis can
lead to tend on d egeneration. This p rocess o p rogram m ed cell
d eath can be exacerbated by intrinsic oxid ative or m echanical
stresses (Yu an et al 2003; Sharm a & Ma u lli 2005). Theories
Tendon
Epitendon
Endotendon
Fascicle bundles
Fascicle Tropocollagen fibre
Tendinopathies o  the wrist and hand
on tend on ru p tu re have been sep arated into tw o categories:
vascu lar and m echanical (Riley 2004). The read er is encou r-
aged to read the w ork o Riley (2004) to exp lore this top ic
urther.
Anatomy of the Tendon
Basic components
The tend on is the attachm ent site o a m uscle to bone. It is
d esigned to trans er tension rom the m uscle to the bone,
thereby cau sing m otion to take p lace (Kannus 2000).
The basic bu ild ing block o the tend on, tropocollagen, is
orm ed by broblasts (O’Brien 2005). These are assem bled
into brils, w hich are arranged into bres, w hich are organ-
ized into fascicles and bou nd together w ith a loose connective
tissu e called endotendon (end otenon) (Kannus 2000; Sharm a
& Ma ulli 2005). The end otend on is the p athw ay or blood
vessels, nerves and lym p hatics (Riley 2004). Bund les o asci-
cles are bou nd together by another layer o connective tissu e
called the epitendon (epitenon), w hich is continu ous w ith the
end otend on (Kannu s 2000) (Fig. 48.1).
Synovial tend on sheaths, also called paratendon (p ara-
tenon), are ou nd in areas su bjected to increased m echanical
stress, su ch as the tend ons o the hand s and eet, w here e -
cient lu brication is requ ired (Sharm a & Ma ulli 2005). Fibre
bund les are pred om inantly aligned w ith the long axis o the
tend on and these are resp onsible or the tensile strength o
the tend on (Riley 2004). A sm all proportion o bres ru n
transversely, and there are even sp irals and p lait-like orm a-
tions (Kannu s 2000). This com plex ultrastructu re provid es
resistance against transverse, shear and rotational orces
acting on the tend on (Riley 2004).
Blood and nerve supply
Tend on vascu lar su p p ort com es rom three sou rces: at the
m yotend inou s ju nction, the osteotend inou s ju nction, and the
extrinsic system throu gh the p aratend on (Benjam in & Ralp hs
1996; Sharm a & Ma ulli 2005; Scott et al 2007). Innervation
accom panies vascu lar pathw ays through the paratenon (H art
Figure 48.1 Basic tendon structure.
Tropocollagen fibril

et al 2005). The nerve receptors that su pply tend ons can
term inate in the vicinity o m ast cells, w here neu rop ep tid es
are involved in norm al tend on regu latory control (H art
et al 2005).
Pathoanatomy
Tenocytes and tenoblasts are the cells involved in tend on
healing (Sharm a & Ma ulli 2005, 2006). Tenocytes are sparse
in tend on tissu e but have extensions that create an extensive
netw ork insid e the m atrix (O’Brien 2005). They are responsi-
ble or m aintenance o m atrix and collagen (H arley & Bergm an
2008). Tenocytes are crucially responsive to environm ental
cond itions. Mechanical d em and s p laced on tend on tissu e
w ill p rom ote changes in the m icroarchitectu re o the tissue
(Magra et al 2007). Strain applied to a tend on can change its
stru ctu re; these changes can be d am aging, or they can be
reparative i appropriately and p urpose u lly applied in
treatm ent.
Scott’s research (Scott et al 2007) provid ed evid ence that it
is stim ulation o the tenocytes rather than intrinsic inf am m a-
tion that is associated w ith tend inosis. Alterations in cell activ-
ity lead to tend on changes rom m echanical stress, rather than
the converse (Riley 2004). The local stim ulation o tenocytes,
w hich is a load -d riven cellular resp onse, rather than inf am -
m ation or ap op tosis, is the tru e m echanism in tend inosis
(Scott et al 2007). Apoptosis plays a role later in the tend ino-
pathic p rocess (Scott et al 2007). Localized hypoxia rom vig-
orou s exercise can lead to tenocyte d eath (Sharm a & Ma u lli
2005) and tend inop athic changes.
Tenocyte m etabolism is regu lated p artly by m echanical
stim u lation (Maed a et al 2009). Maed a et al (2009) show ed
that cyclic strain w ill change gene exp ression in tend on cells.
Force ap plied to a tend on changes cellu lar process via m ech-
anotransd u ction, the process in w hich a cell converts biom e-
chanical stim u li into chem ical signals (Ma ulli & Longo 2008).
Mechanotransd u ction u tilizes gap ju nctions, stretch-activated
channels (Wall & Banes 2005), voltage-operated calciu m chan-
nels (VOCC) and tand em p ore d om ain p otassiu m channels
(TPDPC) to com m u nicate w ith ad joining tenocytes (Wall &
Banes 2005; Magra et al 2007). Tension on su r ace proteins,
called integrins, em bed d ed in the cell m em brane is transm it-
ted to the cell’s cytoskeleton. This orce is transm itted via the
intracellu lar netw ork to the nu cleu s o the cell and can alter
protein exp ression (Chiqu et 1999). H uang et al (2004) observed
that m echanical load ing is essential or hom eostasis o the
bone, cartilage and skin. Ad d itionally, external orces are
cap able o p rod u cing changes in intracellu lar reactions. Teno-
cytes are resp onsible or changing stru ctu re in resp onse to
d em and by altering, ‘gene expression patterns, protein syn-
thesis and cell p henotyp e’ (Ma u lli & Longo 2008). This
alteration is susp ected o being the link to overu se and tend i-
nop athic changes (Scott et al 2007). Im portantly rom a m anu al
therap y p ersp ective, Ma u lli and Longo (2008) su p p orted
that an alteration o m echanical orces m ay au gm ent the
healing p rocess. Conversely, u nd erstim u lation can cau se
tend inop athic changes (Arnoczky et al 2006).
The tend on m atrix is resp onsible or m aintenance o
the tend on. Its d am age, accord ing to Riley (2004), is the
lead ing event in tend inop athy. The grou nd su bstance o the
extracellu lar m atrix netw ork su rrou nd ing the collagen and
Anatomy o  the tendon 547
the tenocytes contains p roteoglycans, glycosam inoglycans,
glycoproteins, as w ell as several other sm all m olecu les
(O’Brien 2005). Water m akes u p 60–80% o the grou nd su b-
stance (O’Brien 2005). Proteoglycans are strongly hyd rophilic,
enabling rapid d i u sion o w ater-solu ble m olecu les and the
m igration o cells (Sharm a & Ma ulli 2005). They, along w ith
glycoproteins, have a role in organization o collagen into
brils and bres (O’Brien 2005). When rep etitive d am age
becom es extensive it overw helm s the ability to heal (Riley
2004). Arnoczky et al (2007) cred ited extracellular m atrix
d egeneration as a precu rsor o tend on w eakness. Riley (2004)
d escribed the possibility that changes in cellu lar activity in the
m atrix d u e to m echanical strain can inf u ence the stru ctu ral
p rop erties o tend ons.
Tendon injury
Riley su m m arized overu se tend inop athy as the p henom enon
cau sed by rep eated strains below the ailu re threshold
that ou tstrip s the cell’s ability to heal (Riley 2004). Tissu e
injury rom repetitive strain is thou ght to be a cellular event
(Arnoczky et al 2006). Recent stu d ies in anim al m od elling
have p rod u ced resu lts o tend inop athy that corresp ond to
those ou nd in non-exp erim ental tend inop athies in hu m ans.
Soslow ky’s m od el o rep etitive m otion id enti ed tend ino-
p athic changes in su p rasp inatu s tend ons in rats (Soslow sky
et al 2000). These changes m im ic those ound in id iopathic
tend inop athies in hu m ans, inclu d ing red u ced m echanical
p rop erties (Lavagnino et al 2006; Arnoczky et al 2007).
Glazebrook et al (2007) ou nd sim ilar changes in rats a ter
overu se ind u ced by rep etitive ru nning. Backm an et al (2005)
p rod u ced sim ilar resu lts w ith rabbits.
Post-inju ry d isu se o a tend on, throu gh im m obilization or
com p ensation, can also have d etrim ental e ects. The concep t
o stress shield ing can be ap p lied to tend ons. An exam p le o
this in term s o bone is the ap p lication o Wol ’s law w ith
red u ced bone d ensity ollow ing racture im m obilization. Woo
et al (1981) observed that, a ter ractu re healing, reap plied
w eight-bearing w ill increase bone d ensity. Kannu s and Jozsa
(1991) show ed that u nd erstim u lation o tend on cells p ost-
injury p rod u ced d egenerative nd ings in the investigation o
tend inop athy. De Boer et al (2007) su pported this w ith his
d em onstration o tend on p rotein synthesis rates d ecreasing
p rogressively through 10 d ays o im m obilization. Lavagnino
et al (2006) ind uced m echanical injury in rat-tail tend ons, ol-
low ed by im m obilization, w hich revealed an u p-regulation o
collagenase m RN A and p rotein synthesis in this d am aged
area. Even und am aged ascicles show ed sim ilar u p -regu lation
d uring the im m obilization portion o this stu d y. In an earlier
stu d y the sam e researchers ou nd that these ad verse e ects
cou ld be controlled in vitro w ith cyclic stretching (Lavagnino
et al 2003). Screen et al (2005) rep orted sim ilar resu lts w ith
cyclic stretching in non-inju red tend on ascicles. With regard
to the treatm ent o tend inop athy, attem p ting to im m obilize
a tend inosis via splinting or casting thus ap pears to be
d etrim ental.
Tendon healing
The phases o tend on healing ollow ing inju ry resem ble that
o other connective tissu es in the bod y, that is: (1) acu te
inf am m atory phase, lasting 1–2 d ays, (2) repair-regeneration
 548 PART 8 • 48 • Tendinopathies o  the wrist and hand
or proli erative p hase, lasting u p to 6 w eeks, and (3) m atura-
tion or rem od elling p hase, lasting 3 w eeks to a year (Lead bet-
ter 1992; Sharm a & Ma u lli 2005). Each o these phases in
tend inop athy has u niqu e cellu lar p rogression that shou ld be
consid ered w hen p rep aring a treatm ent p lan. Tenocytes begin
new collagen synthesis around d ay 5 a ter injury and continu e
synthesis or 5 w eeks (Ma ulli & Moller 2005). Intrinsic teno-
cytes begin p roli erating at w eek 4 and are involved in rem od -
elling throu gh to w eek 8 (Ma ulli & Moller 2005). Attem pts
to ap p ly stand ard bu t sp eci c treatm ents in a global ashion
to all tend inop athies w ithou t ad d ressing the stage o healing
cou ld be ine ective. Cook and Purd am (2009) recom m end ed
that interventions shou ld be tailored to the su sp ected
p athology.
Tendinopathy Classi cation
Tend inop athy actu ally rep resents several d i erent m ixed and
som etim es overlap p ing d egenerative p rocesses. H istologi-
cally there are m ixed nd ings. H ow ever, there is evid ence o
the absence o inf am m atory cells, increased grou nd su b-
stance, increased vascu larity and cellu larity w ith collagen
d isorganization (Khan et al 2006). Each o these can d isru pt
som e tend on bres and w eaken the rem aining ones (Ma u lli
& Moller 2005). The role o the tenocyte in tend on changes
has alread y been d iscu ssed . Murrell (2002) stated that ap op -
tosis, or p rogram m ed cell d eath, m ay have a roll in tend in-
op athy. Oystein et al (2007) show ed apoptosis to be enhanced
in p atellar tend inop athy biop sies com p ared w ith controls.
Inf am m ation is partially controlled by a neurogenic
p rocess. Su bstance P and calcitonin-related gene peptid e are
sensory neu rop ep tid es (H art et al 2005). These, am ong other
su bstances, are ou nd in sym p tom atic tend ons (And ersson
et al 2008) and d irectly stim u late nociceptor end ings (Ued a
1999). H art et al (2005) hyp othesized that neu ropeptid es are
involved via m ast cells in tissu e in norm al tend on regu latory
control; also, a d ys u nctional regu latory loop p rod u ces an
inad equ ate rep air resp onse. This d i ers rom classic inf am -
m ation. Riley (2004, p 137) observed , ‘nerve end ings and m ast
cells m ay u nction as u nits to m od u late tend on hom eostasis
and m ed iate ad aptive responses to m echanical strain’. H e also
stated that ‘excessive stim u lation as a resu lt o overu se m ay
resu lt in pathological changes to the tend on m atrix’. There is
a grow ing bod y o evid ence that p ain associated w ith tend i-
nop athy m ay be neu rogenic.
Tend inop athy severity is grad ed accord ing to histological
eatu res d istinguished u nd er light m icroscopy (Ma u lli et al
2008). Various scales have been proposed . Tw o early scales
w ere originally d eveloped or low er extrem ity research. The
Movar scale and the Bonar scale have each since their d evel-
op m ent been ap p lied su ccess u lly to research o the u p p er
extrem ity (Ma u lli et al 2008). Each scale consid ers the m icro-
scop ic ap p earance o ve to seven actors, and each actor is
given a grad e ranging rom the low est nu m ber (norm al
tend on) to the highest nu m ber (m arked ly abnorm al tend on).
The sam p le is grad ed cu m ulatively, w ith com bined scores
rom each actor (Ma u lli et al 2008). Scott et al (2007) u sed
a m od i ed Bonar scale to assess tend inosis sp eci cally.
This scale consid ers ve histological changes: (1) tenocyte
m orp hology, (2) tenocyte proli eration, (3) collagen changes,
(4) glycosam inoglycans and (5) neovascu larization (Scott
et al 2007).
A lack o com m on d escrip tion o these histological tissu e
changes, w hich vary rom scale to scale to m od i ed scale, has
lim ited a clear classi cation and und erstand ing o tend inop a-
thy w ith its u nd erlying cau ses. Khan et al (2006) cited Clancy
as having initially m ad e a classi cation o tend inopathy types,
w hich w as later m od i ed by Bonar and now inclu d es: tendi-
nosis, tendinitis (tend onitis) or partial ru ptu re, paratenonitis
(p aratend onitis / p araten d initis / ten osyn ovitis / tenovagin-
itis) and paratenonitis w ith tendinosis. The ollow ing sec-
tions p rovid e d etails o these typ es.
Tendinosis
Tend inosis is d e ned by Ma u lli et al (2003a) as intratend i-
nou s d egeneration typ ical w ith ageing or d evascu larization.
It is characterized by bre d isorientation, hypercellularity
and ocal necrosis and calci cation (Ma u lli et al 2003a).
Krau shaar and N irschl (1999) d e ned the three nd ings in
tend inosis as broblastic hyp erp lasia, hyp ervascu larity and
abnorm al collagen prod uction, w ith the orm er being the rst
response. Kannu s and Jozsa (1991) exam ined 891 sp ontane-
ou sly ru p tu red tend ons in the u p p er and low er extrem ity.
H istopathological exam ination show ed that 97% o these had
d egenerative changes. These w ere su bclassi ed into hypoxic
d egeneration (44%), m ucoid d egeneration (21%), tend ol-
ipom atosis (8%) and calci c tend inopathy (5%) (Kannu s &
Jozsa 1991) There is m ultiple cell / tissu e involvem ent and this
m ay be d i cu lt to d iscern rom other classi cations.
Tendinitis
Tend initis and p artial ru p tu re are grou p ed together in this
classi cation. An active inf am m atory resp onse, sym p tom atic
d egeneration and tru e vascular d isru ption are characteristic
nd ings (Khan et al 2006). Lym phocytes and neutrop hils are
seen (Krau shaar & N irschl 1999). It has sim ilar characteristics
to tend inosis bu t histop athologically w ill also d em onstrate
broblastic p roli eration, haem orrhage and granu lation tissu e
(Ma ulli et al 2003a). H am m er (2007a) stated that isolated
active inf am m ation is not com m on bu t is u su ally associated
w ith som e d egree o ru ptu re, w hich im p lies that this classi -
cation is alsely overd iagnosed .
Paratenonitis
Paratenonitis, also term ed p aratend initis or tenosynovitis, is
evid enced as rank inf am m ation o the outer layer o the
tend on (Khan et al 2006). Microscopically this w ill reveal in l-
trate that p ossibly inclu d es brin d ep osition, exu d ate and
areolar tissu e d egeneration, w hich could exp lain the palp able
crep itation at certain stages o its p rogression (Khan et al
2000; Ma ulli et al 2003a).
Combined paratenonitis and tendinosis
This ou rth classi cation (Khan et al 2006), originally d escribed
by Clancy, includ es characteristics o tend inosis w ith an over-
lying paratenonitis as d escribed above. Most clinicians,
includ ing prim ary care physicians, w ould not be able to

d i erentiate w hich o these w as m ost prom inent in a patient
p resenting w ith general hand / w rist pain, as the signs and
sym p tom s are sim ilar to those o isolated p aratenonitis.
O the above categories, only tend initis and p aratenonitis
have an inf am m atory com p onent and w ou ld conceivably
resp ond to an anti-inf am m atory regim en, and likew ise w ould
not logically resp ond to d eep tissu e riction m assage.
Examination and Diagnosis
A com p rehensive assessm ent is the m ost im p ortant step to
d eterm ining appropriate treatm ent o m ost m u scu loskeletal
d isord ers. H istory, clinical tests and im aging w ill contribu te
to a d i erential d iagnosis. (See Chs 3–5 or a d iscu ssion o
history taking and p hysical exam ination.) Clinical testing or
tend inop athy can inclu d e p alp ation, selective tissu e testing
and provocation testing. It is theorized that clinical tests w ill
help to d i erentiate the stru ctu re involved , yet reliability and
valid ity are still being researched . Ind eed , this is only one p art
o the d iagnostic equ ation. Id enti ying the typ e o tend on
involvem ent and stage o pathology is another actor o
greater d i cu lty.
The d iagnosis o tend inopathy w ill be the result rom a
com p rehensive exam ination, bu t d istingu ishing betw een
tend inosis and tend initis can be d i cu lt (Khan et al 2000).
Ma u lli et al (2003a) id enti ed tend inop athy clinically as
localized tend on sw elling and pain w ith im paired u nction.
Cu rw in (2005) stated that w e m u st assu m e the level o tend on
involvem ent can be correlated w ith the level o d ys u nction
and p ain, although the d egree o inju ry cannot be ascertained
acu tely. Eld er and H arvey (2005) m aintained that the sp eci c
area is u su ally easy to isolate w hen acute. Lead better (1992)
d e ned acute inju ry as having a su d d en speci c onset ol-
low ed by grad ually d ecreasing pain. Id enti ying an acu te
onset d u ring history taking shou ld help to d i erentiate a
cu rrent stage o acu te or su bacu te inf am m atory p rocess
rom a chronic stage w hen inhibiting pain occurs d u ring activ-
ity or a terw ard s (Lead better 1992), and w ill help gu id e
treatm ent.
One com p licating actor in isolating a sp eci c involved
stru ctu re is that m ost tend ons to be id enti ed w ill have ana-
tom ical variations or su p ernu m erary insertions. These vary
too m u ch or inclu sion here. Another com p lication is the p os-
sibility that a trigger p oint (TrP) is resp onsible or all or a
portion o the sym p tom s. TrPs in the u pp er qu arter can re er
pain to the w rist area. The su bscapu laris, bicep s brachii and
brachialis are som e o the m u scles that can re er pain to the
w rist (Finand o & Finand o 2005). Failu re to clear these
points / areas o p otential contribu tion w ill d elay approp riate
treatm ent. It cannot be overem p hasized that su sp ected
TrPs shou ld be cleared as p art o the initial exam ination. (See
Ch 59 or ad d itional in orm ation on re erred p ain rom
m u scle / m yo ascial trigger p oints in arm p ain synd rom es.)
Clinical tests
Regard ing general p alp ation, evid ence o oed em a and hyp er-
aem ia o the p aratenon m ay be ou nd clinically. A brinou s
exu d ate accu m ulates w ithin the tend on sheath, and crep itus
m ay be elt on clinical exam ination (Khan et al 2000; Sharm a
Examination and diagnosis 549
& Ma ulli 2005). This m ay be im portant in d i erentiating
p aratenonitis rom tend inop athy; how ever, the p resence o
crep itis to p alp ation d oes not p rove that p aratenonitis is
p resent (Khan et al 2000; Sharm a & Ma u lli 2005).
Palp ation or tend erness is a com m on tool or clinical d iag-
nosis and d i erential testing in tend inop athy. Cook et al
(2001) assessed the valu e o p alp ation to id enti y p atellar
tend inopathy in a grou p o 326 young athletes. Intra-rater
reliability w as good at 82%. Palp ation o tend ons in patients
w ith sym p tom s resulted in sensitivity o 68% and sp eci city
o 9% (Cook et al 2001). H ow ever, applicability to the w rist is
lim ited since the patellar tend on is larger than those o the
hand / w rist.
Ma u lli et al (2003b) ou nd a high positive pred ictive valu e
in palpation, w hen com bined w ith the Royal Lond on H ospital
test and a p ain u l arc sign to d eterm ine Achilles tend inop athy.
The pain u l arc sign is theorized to d i erentiate pathology
w ithin the tend on itsel versus that o the paratend on. I the
p athology is con ned to the tend on stru ctu re, a p alp able area
o thickness and tend erness w ill m ove w ith the tend on as the
ankle is m oved ; i the p ain u l, thickened area stays in a xed
p osition regard less o ankle m ovem ent then the p athology is
w ithin the paratend on (Easley & Le 2009). The sensitivity and
sp eci city o this test w ere 52% and 83% respectively (Ma ulli
et al 2003b). The Royal Lond on H osp ital test id enti es tend i-
nop athy by eliciting local tend erness w ith p alp ation o the
tend on in neu tral or slightly on slack. The test is p ositive i
the tend erness d ecreases signi cantly or d isap p ears w ith the
tend on on stretch. The sensitivity and sp eci city o this test
w ere 54% and 91% resp ectively. The sensitivity and sp eci city
o d irect palpation w ere 58% and 74% respectively. When the
three tests w ere com bined , the sensitivity w as 58% and the
sp eci city w as 83% (Ma u lli et al 2003b). There is a d earth o
evid ence-based research ap plication o these clinical tests to
tend ons o the w rist and hand .
Cyriax su p p orted selective tissu e tension testing (STT)
(H am m er 2007b). STT is utilized to com pare non-contractile
w ith contractile tissu e involvem ent (H am m er 2007b). The
tend on is isolated as m u ch as p ossible based on p lanes o
m otion p er orm ed : either isolated or overlap p ed w ith other
tend ons. The exam iner attem p ts to ad m inister a m inim al iso-
m etric orce to the tend on / m u scle w hile the p atient resists.
Elicitation o p ain is a positive test (H am m er 2007b). H anchard
et al (2005) ou nd the agreem ent (0.71–0.79, kap p a and 95%
con d ence interval) am ong Cyriax-trained assessors u sing
STT com bined w ith clinical history w hen assessing tend in-
op athy o the rotator cu . Reliability has yet to be established
or any u pper extrem ity tend on app lication (Stasinop ou los &
Johnson 2007).
Provocation tests (sp ecial tests) are u sed w ith varying
evid ence-based su pport o reliability, sensitivity and speci -
city. These tests are inclu d ed , as available and relevant, in the
ou tlined d iscu ssion o tend inop athies u niqu e to sp eci c
tend ons o the w rist and hand ollow ing d iagnostic im aging
and invasive testing.
Diagnostic imaging and invasive testing
Due to the d i cu lty in reliably d iagnosing tend inop athy,
Fred berg and Stengaard -Ped ersen (2008) recom m end ed u ltra-
sou nd or m agnetic resonance im aging (MRI) i there is no
 550 PART 8 • 48 •
Flexor carpi
radialis
Flexor carpi
ulnaris
Figure 48.2 Tendiopathic entities: exor tendons.
resp onse to conservative treatm ent or i rad icu lar pain is
p resent. Fred berg and Stengaard -Ped ersen (2008) d escribed
the e cacy o u ltrasou nd versu s MRI. These inclu d e m ore
d etailed visualization o tend on m icrostru ctu re, better tend on
bord er d e nition and its interactive nature. A ocal thicken-
ing, visu alized w ith u ltrasou nd , is associated w ith tend initis
in tend ons w ithou t sheaths. This m ay corresp ond to angio -
broblastic areas associated w ith m icro-ru ptures (Daenen et al
2003). Furtherm ore, the tend on or tend on sheath, as view ed
via u ltrasou nd , w ill be thickened on m ore chronically involved
tend ons (Daenen et al 2003). Ultrasound can be per orm ed
d irectly over the subjectively pain u l area and even d u ring
range o m otion (Fred berg & Stengaard -Ped ersen 2008).
McN ee and Teh (2007) consid ered ultrasou nd to be the ‘inves-
tigation o choice’ in tend on p athology. Bed d i and Bagga
(2007) stated that u ltrasou nd is the gold stand ard or tend on
exam ination.
Isolated id enti cation o the involved structu re can be
assessed by rem oving sensation rom speci c areas, and con-
tinu ing u ntil the p atient’s sym p tom s are resolved . Selective
anaesthetic injections, usu ally w ith lid ocaine, are supp orted
by Eld er and H arvey (2005) as ‘the best d iagnostic test’ or
tend inop athy o the hand and w rist, bu t they o er no stu d ies
to back u p this recom m end ation.
Tendinopathic Entities of the Hand
and Wrist
This section w ill d escribe com m on areas o tend on pain in the
w rist. Areas o rare involvem ent are not inclu d ed .
Flexor carpi ulnaris
Pathology o the f exor carp i u lnaris (FCU) m u scle (Fig. 48.2)
m ay inclu d e tend initis, tend inosis, or a com bination o these
tw o. This is the m ost com m on w rist f exor tend inop athy
(Eld er & H arvey 2005) and o ten occu rs in those w ho play
racqu et sports and gol (Rettig 2001). The FCU inserts
into the p isi orm , the hook o the ham ate and the th m eta-
carp al (Moore 1992). It is not held in place by the f exor
Tendinopathies o  the wrist and hand
Extensor digiti minimi
Extensor
indicis proprius
Extensor carpi
radialis brevis
Extensor carpi ulnaris and longus
Figure 48.3 Tendiopathic entities: extensor tendons.
retinacu lu m , bu t instead relies on its ow n tend on sheath
(Eld er & H arvey 2005).
Testing
• Characterized by pain u l palpation o the pisi orm and
the FCU tend on, p resence o angio broblastic hyp erp lasia
is o ten evid enced by p alp able sw elling and thickening in
sym p tom atic FCU tend ons (Bu d o et al 2005).
• Pain w ith resisted w rist f exion and u lnar d eviation.
• Shuck test i pisotriquetral involvem ent is suspected
(Rettig 2001).
• Passive w rist extension and rad ial d eviation w ill provoke
sym p tom s (Eld er & H arvey 2005).
Differential diagnosis
Rettig (2001) recom m end ed the pisotriqu etral grind test to
im p licate the pisotriqu etral joint pain over an FCU tend inop a-
thy. Cam p bell (2001) and Bu rke (1996) d escribe the test as
grasping the pisi orm and com pressing it onto the triquetrum
and rotating the pisi orm u nd er p ressure. Palp ation alone
m ay im p licate the tend on w ith p ain and crep itu s, w hereas
p ain w ith com p ression im p licates the p isotriqu etral joint. Pis-
otriqu etral com p ression synd rom e (Rettig 2001), arthritis, cal-
ci c tend onitis and u lnar neu ritis, p isi orm ligam ent com p lex
synd rom e, p isotriqu etral arthrosis (Rayan 2005) and Guyon’s
canal synd rom e (Eld er & H arvey 2005) are ad d itional d i er-
ential d iagnoses.
Extensor carpi ulnaris
Tend inop athy o the extensor carp i u lnaris (ECU) (Fig. 48.3)
m ay com m only inclu d e a tend initis, tend inosis, or a com bina-
tion o these. The joint is also su bject to su blu xation (Eld er &
H arvey 2005). Activities su ch as racqu et sp orts and baseball
batting w ill cau se rap id and repetitive supination, f exion and
u lnar d eviation, w hich have been cited as p rom oting actors
(Eld er & H arvey 2005; H am m er 2007c). Rettig (2001) noted
that ECU tend inop athy o ten involved the non-d om inant

hand in tennis p layers w ho u sed a tw o-hand ed backhand
stroke. Fu tam i and Itom an (1995) ou nd that, o 155 p atients
w ith d orsal w rist pain, 53 had p ain possibly cau sed by teno-
vaginitis (p aratenonitis) o the ECU ind u ced by overu se.
Bencard ino and Rosenbu rg (2006) associated subluxations o
the ECU w ith tenosynovitis and recom m end ed testing su p i-
nation and volar f exion or u lnar su blu xation o the tend on.
Montalvan et al (2007) stu d ied 28 clinical cases o ECU-related
p ain w ith three clinical patterns d escribed : (a) acu te trau m atic
instability o the ECU in the bro-osseu s groove (12 cases);
(b) tend inop athy (14 cases); and (c) com plete ECU rup tu re
(4 cases).
Testing
• Sym p tom s are p rovoked by com bined active su p ination
and w rist extension (Eld er & H arvey 2005) and com bined
resisted u lnar d eviation and extension (Eld er & H arvey
2005; You ng et al 2007).
• Dislocation can be rep rod u ced by a clicking on
su p ination and extension actively, bu t not p assively
(Eld er & H arvey 2005).
• Tend erness to p alp ation over the sixth d orsal
com p artm ent (Rettig 2001) at the ECU tend on and u lnar
head (Eld er & H arvey 2005).
Differential diagnosis
Ru p tu re, su blu xation, d islocation, triangu lar brocartilage
com plex (TFCC) p ain, triqu etru m –lu nate ligam ent lesion,
pisi orm –lu nate joint p ain, and ractu res o the lu nate, tri-
qu etru m and p isi orm are d i erential d iagnoses (Futam i
& Itom an 1995). Ad d itional d iagnoses to be exclud ed are
extensor d igiti m inim i tenosynovitis, TFCC tears (Eld er &
H arvey 2005) and stenosing tenosynovitis in the u lnar w rist
(Rettig 2001).
Extensor carpi radialis longus and brevis
(distal tendons)
A com m on com bined p athology o the extensor carp i rad ialis
longu s (ECRL) and brevis (ECRB) tend ons (see Fig. 48.3) d is-
tally is know n as intersection synd rom e. This is also term ed
peritendinitis crepitans (You ng et al 2007), crossover tend-
initis and squeaker’s w rist (Rettig 2001). The synd rom e m ay
includ e tend initis, tend inosis and / or bu rsitis. It is com m on
am ong racqu et p layers, w eightli ters and canoeists (H am m er
2007c). Ski pole and ham m er u sage can also provoke this
particu lar synd rom e (Eld er & H arvey 2005).
Intersection synd rom e is associated w ith riction rom the
crossing o the rst d orsal com p artm ent abd u ctor p ollicis
longu s (APL) and the extensor pollicis brevis (EPB) over the
second d orsal com p artm ent (ECRL and ECRB) (You ng et al
2007). It is a paratenonitis (tenosynovitis) that can result in
stenosis o the a ected tend ons.
Cvitanic (2007) noted a natu ral oram en betw een the exten-
sor p ollicis longu s (EPL) and ECRB in cad avers at the site o
the intersection. This cou ld exp lain the areas o m u ltip le
sym p tom s in the d orsal orearm and cou ld m ake d i erential
d iagnoses m ore com p licated . Inf am m atory cond itions o the
ECRB and ECRL at their insertions m ay be associated w ith
Tendinopathic entities o  the hand and wrist  551
bony protu berances at the capitate, second or third m etacar-
p als, or trap ezoid (Daenen et al 2003).
Testing
• Pain to palpation and visible sw elling m ay be evid enced
in the tend ons proxim al to the rst com partm ent
(Plancher et al 1996; Bencard ino & Rosenbu rg 2006).
• Thickening and interstitial f u id collection arou nd both
tend ons app roxim ately 4 to 8 cm proxim al to Lister ’s
tu bercle w ill show on MRI (Bencard ino & Rosenbu rg
2006; Plancher et al 1996).
• Crepitation betw een the APL / EPB and ECRL / ECRB
w ith w rist f exion or extension m ay be palp able (Eld er &
H arvey 2005).
Differential diagnosis
Finkelstein’s test w ill be positive bu t in a m ore proxim al
region o the d orsal orearm than w ou ld be the case in
De Qu ervain’s tenosynovitis (Eld er & H arvey 2005; You ng
et al 2007).
Extensor indicis proprius
Pain and swelling over the ourth dorsal compartment is the
most common nding in extensor ind icis proprius (EIP) (see
Fig. 48.3) synd rome (Plancher et al 1996). This synd rome
involves an irritation o the tenosynovium near the extensor
retinaculum (Elder & Harvey 2005). Plancher et al (1996) attrib-
uted symptoms o EIP tendinopathy to overuse hypertrophy, or
to synovitis secondary to overuse. The ormer could lead to the
latter i symptoms w ere not ad d ressed in a timely ashion. Ana-
tomical variations (75%) are common, complicating the exact
structure involved (Plancher et al 1996; Soejima et al 2002).
Testing
• Evid ence o pain and sw elling in the ou rth d orsal
com p artm ent d istal to the u lnar head w ith su p ination
(Plancher et al 1996).
• Resisted ind ex extension (H am m er 2007c) w ith the w rist
u lly f exed (Eld er & H arvey 2005) provokes sym ptom s.
Differential diagnosis
Extensor d igitorum com m u nis (EDC) or EPL tenosynovitis,
d orsorad ial ganglion, Klebock’s d isease, extensor d igitorum
com m u nis tend inop athy and ou rth-com p artm ent synd rom e
are d iagnoses to be exclu d ed (Eld er & H arvey 2005).
Extensor digiti minimi
The extensor d igiti m inim i (EDM) (see Fig. 48.3) occupies the
th d orsal com p artm ent. The p athology m ost o ten occu rring
here is a tenosynovitis (Eld er & H arvey 2005). Du plication o
the tend on is com m on com p licating im p lication o the p rop er
stru ctu re (You ng et al 2007). Eld er and H arvey (2005) stated
that continu ou s hand u sage su ch as hand w riting w ill p rovoke
sym p tom s. H am m er (2007c) rep orted a lack o p ain w ith
resisted testing, w hich is unusu al or tend inopathy, but no
reason or this p henom enon w as given.
 552 PART 8 • 48 •
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Figure 48.4 Tendiopathic entities: thumb tendons.
Testing
• Grip is p ain u l (Eld er & H arvey 2005).
• Lim itation in th-d igit extension is seen (Eld er &
H arvey 2005).
• Wrist f exion a ter st closu re or f exing a st is p ain u l
(Eld er & H arvey 2005).
• Tend erness to p alp ation is p resent ju st d istal to the u lnar
head (Plancher et al 1996).
Differential diagnosis
Exten sor carp i u ln aris (ECU) ten osyn ovitis, TFCC p ath ol-
ogy and u lnar im p action shou ld be ru led ou t (Eld er &
H arvey 2005).
Abductor pollicis longus and
extensor pollicis brevis
Together the abd u ctor p ollicis longu s (APL) and extensor p ol-
licis brevis (EPB) (Fig. 48.4) contribute to De Qu ervain’s teno-
synovitis. These tend ons norm ally p ass together throu gh a
single bro-osseou s tu nnel to insert on the rst m etacarp al
and rst p roxim al p halanx respectively (Plancher et al 1996).
De Quervain’s tenosynovitis o ten results rom excessive
p inching or rad ial d eviation (H am m er 2007c). This synd rom e
is a com m on occu rrence in gol , racqu et sp orts and shing
(Rettig 2001).
Testing
• Finkelstein’s test (Fig. 48.5A): Ahu ja and Chu ng (2004)
d etailed the true test and variations, as the test is
m isrep resented vigorou sly in the literatu re. The original
test that Finkelstein (1930) d escribed w as com pletely
p assive: the clinician grasps the p atient’s thu m b and
qu ickly pu lls the w rist into u lnar d eviation via the
thu m b. A p ositive resu lt is rep rod u ction o p ain at the
u lnar styloid . The su rgeon Eichho d escribed a test or
d e Qu ervain’s d isease that is o ten m istaken or
Finkelstein’s test (Fig. 48.5B). H is test consisted o the
p atient actively p lacing the thu m b into the palm and
old ing the ngers d ow n, hold ing the thum b in place
w hile the clinician passively m oves the w rist into ulnar
Tendinopathies o  the wrist and hand
A
Figure 48.5 (A) Finkelstein’s test. The clinician grasps the patient’s thumb, uses
it to quickly and passively place the wrist into ulnar deviation, causing pain at the
radial styloid process.(B) Eichhoff test.The patient actively grips the thumb in the
f st and then the clinician passively places the wrist into ulnar deviation, which
causes pain at the radial styloid process (Ater Ahuja & Chung 2004.)
d eviation. A positive test is the sam e as d escribed above
or Finkelstein’s test. This test, w hich m any believe to be
the Finkelstein test, has been criticized as giving alse-
positive results. Bru nelli d escribed a test in 2003 that he
claim ed w as m ore accu rate than the tru e Finkelstein’s
test. Bru nelli criticized Finkelstein’s test or alse-p ositive
resu lts d ue to the stretch o the rad ial collateral ligam ent,
the scap hotrap ezial ligam ent, or the thu m b
carp om etacarp al ligam ent cau sed by the APL and EPB
tend ons being m oved aw ay rom the p u lley, and
d escribed a test in w hich the w rist is held in rad ial
d eviation w hile orcibly abd ucting the thu m b (Ahu ja &
Chu ng 2004). Psychom etric properties o these tests have
not been established (Eld er & H arvey 2005).
• The EPB entrapm ent test id enti es separate
com p artm ents and resu lting stenosis; this test w as
reported to have a sensitivity o 81% and sp eci city o
50% (Alexand er et al 2002).
• Tend erness on palp ation and sw elling over the rad ial
styloid (Eld er & H arvey 2005) and rst d orsal
com p artm ent (Rettig 2001) are p resent.
• Resisted thu m b extension is pain u l (Eld er &
H arvey 2005).
Differential diagnosis
Intersection synd rom e (Eld er & H arvey 2005), scap hoid rac-
tu re, f exor carp i rad ialis (FCR) tend inop athy, rst carp om eta-
carp al (CMC) joint arthritis and Wartenbu rg’s synd rom e
(Plancher et al 1996) are d i erential d iagnoses.
Extensor pollicis longus
The extensor pollicis longus (EPL) (see Fig. 48.4) o ten exhibits
a tenosynovitis com m on in racqu et sports players. A history

o rep etitive trau m a as occu rs in racqu et sp orts, p ain, crep itu s
and sw elling arou nd Lister ’s tu bercle w ill narrow the list o
su sp ected d iagnoses (Plancher et al 1996). Triggering o the
thu m b m ay be seen in severe cases.
Testing
• There is evid ence o p ain, sw elling and crep itu s along
the EPL tend on at the third d orsal com p artm ent
(Plancher et al 1996) and at Lister ’s tu bercle (Eld er &
H arvey 2005).
• Pain is elicited w ith resisted thu m b extension or p assive
f exion (Eld er & H arvey 2005).
• Passive interp halangeal joint f exion can rep rod u ce the
p ain (Eld er & H arvey 2005).
Differential diagnosis
Di erential d iagnoses have not been established as necessary
or this tend on pathology.
Flexor carpi radialis
Flexor carpi rad ialis (FCR) (see Fig. 48.2) tend inopathy is
com m on in p eop le w ho p lay racqu et sp orts, gol and baseball
(Rettig 2001). Eld er and H arvey (2005) rep orted an o ten-
insid iou s onset w ithou t know n trau m a. A prim ary sym ptom
is pain near the proxim al asp ect o the trapezium (Gabel et al
1994). This is o ten a resu lt o overu se w ith repeated f exion
o the w rist, o com p lication a ter scap hoid ractu re or d istal
rad ius racture, or o other d irect trau m a (Gabel et al 1994).
The FCR is su bject to trau m atic injury ow ing to its position.
The FCR lies in d irect contact w ith the roughened sur ace
o the trap eziu m . Its insertion onto the trap eziu m is only
20% o the entire insertion. Ad d itional insertions includ e the
second and third m etacarp als (Bishop et al 1994) and the joint
cap su le o the trap ezioscap hoid joint itsel (Schm id t 1987).
The tend on occu p ies 90% o the bro-osseou s tu nnel, m aking
it vulnerable to com pression (Bishop et al 1994; Eld er &
H arvey 2005). FCR tend inopathy is also associated w ith
scap hotrap ezial joint osteoarthritis, m alu nion o the trap e-
ziu m or a scap hoid cyst (Soejim a et al 2002).
Testing
• Sym p tom s are exacerbated by resisted f exion and
rad ial d eviation o the w rist (Eld er & H arvey 2005;
Rayan 2005) and by resisted f exion (Rettig 2001);
w rist hyp erextension or resisted w rist f exion w ith
rad ial d eviation can reprod u ce sym ptom s (Young
et al 2007).
• There is evid ence o p ain and notable sw elling at the
level o the d istal w rist crease along its cou rse (Eld er &
H arvey 2005) and near the bro-osseous tunnel (Young
et al 2007).
Differential diagnosis
Di erential d iagnoses inclu d e osteoarthritis o the rst CMC
joint, scaphoid cysts, ractu res, ganglion cysts, De Quervain’s
synd rom e and Lind bu rg’s synd rom e (Eld er & H arvey
2005).
Treatment and prognosis 553
Treatment and Prognosis
Conservative treatment
Conservative treatm ent or tend inop athy inclu d es m od alities
su ch as u ltrasou nd , electric stim u lation, ice and laser (Cu rw in
2005), as w ell as injections and splinting (Plancher et al 1996).
Konijnenberg et al (2001) attem pted a m eta-analysis o ou t-
com es o rep etitive strain inju ries. Many bod y areas w ere
inclu d ed in the analysis. They ou nd no strong evid ence or
any conservative treatm ent option (Konijnenberg et al 2001).
Conservative treatm ents inclu d ed p hysiotherap y involving
m u ltip le typ es o interventions, bu t none inclu d ed the hand
or w rist.
Manu al therap y, in p articu lar d eep tissu e riction m assage
(DTFM), is a conservative treatm ent or tend inopathy that is
u tilized by som e clinicians; how ever, e cacy has not been
p roven. This cou ld be d u e at least in p art to stu d y d esign.
DTFM or tend on pain w as rst popu larized by Jam es Cyriax.
Cyriax d id not p er orm ou tcom e stu d ies, bu t stu d ies d one by
Stasinop ou los and Johnson (2007) conclud ed that e ective-
ness o DTFM or lateral ep icond ylitis cou ld not be assessed
rom the stu d ies they review ed . Stasinop ou los d id not stud y
ou tcom es o the w rist.
Cyriax techniqu es o DTFM or treatm ent o so t tissu e
lesions are per orm ed w ith d irect p ressu re on the pain u l area.
The clinician’s nger ru bs rm ly transversely to the bres o
the tissu e, w hich inclu d es tend on. Recom m end ed d u ration
and requency are 20-m inu te sessions or 6–12 treatm ents
w ith at least 48 hours betw een treatm ents (Cyriax 1983).
Cyriax (1983) theorized that the treatm ent erod ed scar tissu e
betw een m u scle bres via abrasive contact; in tenosynovitis
the rolling w as theorized to sm ooth rou ghened synovial su r-
aces. More recent w ork has speci ed the optim al tim e o
ap plication or tend on strain based on the p reviou sly d is-
cu ssed stage o p athology. Research by Zeichen et al (2000)
su bjected broblasts to strain or varying tim es, m onitoring
or proli eration o broblasts as a response to a biaxial strain
over subsequent hours. The resu lts show ed that 15 m inu tes
o strain resu lted in increased p roli eration com p ared w ith
controls at 6 and 24 hou rs (Zeichen et al 2000).
The 48 hours o recom m end ed m inim um accepted tim e
ram e betw een treatm ents roughly equ als the end ing o the
acute stage o inf am m ation, w hen rem od elling begins (Lead -
better 1992). The rm er pressu re, as recom m end ed by Cyriax
(1983), m ay be ju sti ed by a stu d y by Gehlsen et al (1999)
show ing that rm er p ressu re had m ore p ositive e ects than
lighter pressu re.
H am m er (2007d ) applied so t tissu e m obilization w ith
greater p recision w ith respect to the stage o tend on p athol-
ogy. Althou gh he generally concu rred w ith treatm ent in the
5–15-m inu te d u ration tw ice a w eek lasting 2 w eeks to 2
m onths, he recom m end ed no m anu al treatm ent u ntil the p ro-
li erative p hase, w hich w as d escribed as 7–14 d ays a ter origi-
nal inju ry. Treatm ent d u ring the acu te p hase w hen rest is
recom m end ed shou ld be light, so as to aid broblastic p roli -
eration and break d ow n im m atu re collagen. In the m atu ration
p hase the treatm ent cou ld be m ore vigorou s in ord er to red u ce
brosis (H am m er 2007c).
Khan and Scott (2009) and Krau shaar and N irschl (1999)
theorized that m echanical d isru p tion m ay trans orm a ailed
 554 PART 8 • 48 • Tendinopathies o  the wrist and hand

intrinsic healing into a therap eu tic extrinsic healing m echa- Normal tendon tissue
nism . The stu d y by Brousseau et al (2002) on DTFM and tend -
initis (not tend inosis) consid ered cross- riction treatm ent as
only cross- riction and not other techniqu es, inclu d ing a
Repetitive strain Submaximal strain
stroke along the m u scle. This cou ld be one exp lanation or the
lack o m ore p ositive ou tcom es: im p rop er or non-u ni orm
d irection o orce. Another reason could be lack o prop er
selection o the su bcategory o tend inop athy as classi ed Excessive Excessive Excessive
earlier in this section. Som e classi cations, such as acu te frequency duration intensity
inf am m ation, in theory cannot be a ected by m anip u lation.
Despite the lack o rand om ized controlled trials o tend on
pain and DTFM, other research is em erging. These stud ies
Matrix/cell changes
provid e, on a sm all scale, a pathoanatom ical link betw een
m anual therapy and reversal o tend inopathic changes. Meltzer
and Stand ley (2007) d em onstrated that a m od elled ind irect Conservative
Fibre damage
osteop athic m anipu lative techniqu e (IOMT) signi cantly treatment:
stress shielding
red uced pro-inf am matory secretions com pared w ith controls rest, ice, immobilization
24 hours a ter application, and conclud ed that the m od elled
IOMT can reverse some o the e ects o repetitive strain
(Meltzer & Stand ley 2007). Stand ley and Meltzer (2008) stud ied No treatment
the e ect o mod elled m anu al therapy on cellular response.
Im proved range o m otion, red uced analgesic requirem ents
and d ecreased oed em a post-m yo ascial release w as theorized Symptom reduction Fibre weakening No treatment
to be a resu lt o anti-inf am m atory cytokines rom strain
ind u cem ent o m yo ascial release (Stand ley & Meltzer 2008).
Eccentric exercise is a m ore recently ap p lied orm o con- Eccentrics Treatment Rupture
servative treatm ent that is theorized as reversing d egenera-
tion via sp eci c load ap p lication. This treatm ent has show n
p ositive ou tcom es (Ohberg et al 2004). Eccentric exercise No relief
involves contraction o a m u scle to control or d ecelerate a load
w hile that m u scle and tend on are lengthening or in a length-
ened position. Eccentric exercises have been proven e ective Manual tendon
at changing u ltrasonic nd ings in involved Achilles tend ons Surgery
release
w ithin 12 w eeks (Ohberg et al 2004); the stu d y ollow -up
show ed red u ction in tend on d iam eter and retu rn o norm al
Figure 48.6 Selected treatment algorithm.
tend on stru ctu re in a m ajority (19 o 26) o tend ons. The
u nchanged tend ons had u nd e ned resid u al d e ects (Ohberg
et al 2004).
Wood ley et al (2006) review ed 11 stu d ies o eccentric The research by Kannus and Josza (1991) illum inated how
exercises that m et the inclu sion criteria o m ethod ological stress red u ction can lead to d egenerative changes in the
qu ality and levels o evid ence. They covered both u p p er and tend on, inclu d ing a red u ction in m echanical p rop erties. This
low er extrem ity tend inop athies. Eccentric exercise w as m ore m ay be w hy eccentric exercises are e ective in som e cases in
e ective than other treatm ents that includ ed rictions, stretch- red u cing the e ects o im m obilization. So t tissue m obiliza-
ing, sp linting and u ltrasou nd in treating tend on p ain and tion along the tend on cou ld also red u ce the e ects o im m o-
im p roving p atient satis action and retu rn-to-w ork ou tcom es bilization, bu t only to a localized p ortion o that tend on. Any
(Wood ley et al 2006). orce, includ ing eccentrics, w ill not a ect the tend on equ ally.
Curw in (2005) ou tlined an eccentric program m e that con- Und am aged ascicles w ill accept and transm it that orce nor-
sisted o w arm -u p activities, stretching, three sets o 10 eccen- m ally, w hile d am aged ascicles, accord ing to Arnoczky et al
tric exercises, rep eated stretching and ice ap p lication. This (2007), w ill not trans er that orce to all ascicles, w hich lead s
w as continu ed or 6 w eeks u nless sym p tom s resolved be ore to d egeneration o the involved ascicles. This w ill be a neces-
then. The p rotocol w as p er orm ed by 200 p atients w ith chronic sary su bject o u tu re stu d ies. An algorithm (Fig. 48.6) ou tlines
tend inop athy that ailed conservative therap y. Marked or a prop osed p athw ay o m anu al treatm ent and eccentrics in
com plete relie o sym ptom s w as reported in 90% o patients tend inop athy.
w ho com p leted the program m e. H ow ever, d espite the large
sam p le size there w as no control grou p or rand om ization Non-conservative treatment
(Cu rw in 2005).
Knobloch (2008) su p p orted eccentric training on the w rist Review o the recent literatu re on su rgeries or w rist tend in-
to be equ ally e ective as that on the Achilles tend on in op athy reveals a consistent u se o the term s ‘tend initis’ and
d ecreasing abnorm al capillary tend on f ow (angiogenesis) ‘tenosynovitis’ in su rgical cases. This u sage is there ore con-
seen in tend inop athy. Khan and Scott (2009) p rom oted the tinu ed in the rep ort o su rgical interventions.
theory that e ects o eccentric m u scle contraction on the De Quervain’s tenosynovitis that d oes not respond to
tend on ap p ear to stim u late tissu e healing. conservative therap y m ay u nd ergo su rgery. This involves

d ecom pression o the rst d orsal com partm ent and is not
w ithou t risks (Plancher et al 1996). Rettig (2001) rep orted that,
a ter 7–10 d ays o splinting, return to sp orts can be exp ected
in 6–9 w eeks.
Flexor carpi u lnaris surgery o ten involves excision o the
pisi orm (Rettig 2001). The expected retu rn to sports averages
8 w eeks (Rettig 2001).
As the f exor carpi rad ialis occu p ies 90% o the available
sp ace in its synovial tu nnel, su rgery here involves d ecom p res-
sion o the tu nnel (Plancher et al 1996).
Plancher et al (1996) stated that extensor carp i u lnaris su b-
luxation d oes not alw ays respond to conservative care. The
sixth d orsal com p artm ent is released in extensor carp i u lnaris
tend initis. Du e to the chance o su blu xation, som e au thors
recom m end release o the bro-osseu s tu nnel that it occu pies
(Plancher et al 1996). Rettig (2001) reported that, a ter 4–6
w eeks o cast w earing, retu rn to sports requ ired a m inim u m
o 8 w eeks.
Su rgery or intersection synd rom e, accord ing to Plancher
et al (1996), involves release o the second com p artm ent w ith
synovectom y. Rettig (2001) m entioned bu rsectom y betw een
the involved tend ons. Release o the third d orsal com p art-
m ent is also p er orm ed on non-resp onsive cases o extensor
pollicis longu s tend initis.
Prognosis
Prognosis w ith conservative treatm ent or sp eci c tend inop a-
thies or synd rom es is not w id ely available in evid ence-based
stu d ies. Regard ing conservative treatm ent or DeQu ervain’s
tenosynovitis, H arvey et al (1990) reported 80% resolu tion o
sym p tom s w ith injections alone. Lane et al (2001) conclu d ed
that classi ying these p atients be ore conservative treatm ent
w as initiated im p roved ou tcom es; 17 o 18 p atients w ith clas-
si ed m ild sym p tom s im p roved w ith sp linting and non-
steroid al anti-inf am m atory m ed ications, w hereas those w ith
sym p tom s classi ed as m od erate to severe resp ond ed m ost
avourably to injections (76%). Richie and Briner (2003)
review ed seven d escriptive stu d ies com paring conservative
treatm ents or De Qu ervain’s tenosynovitis. They rep orted an
overall cu re rate o 83% or injection alone, 61% or injection
and sp lint, 14% or sp lint alone and 0% or treatm ents that
consisted solely o non-steroid al anti-inf am m atory m ed ica-
tions and rest. Tend inop athies o the other stru ctu res o the
w rist have not been as w id ely stu d ied .
Conclusion
Although m uch m ore is now know n abou t tenocyte and
m atrix d ys u nction, su ccess u l ap p lication o these concep ts
or treatm ent o tend inop athy in the w rist and hand has not
been proven. Stud ies continue to be ham pered by sam ple size,
lack o m eaning u l ou tcom es, sm all popu lation selection and
lack o rand om ization. Ad equate stu d ies regard ing conserva-
tive treatm ent o non-inf am m atory tend inop athies d o not
app ear to exist at p resent.
Eccentrics show p rom ise or treating tend inop athy in a
m ajority o w eight-bearing tend ons. Su ccess u l ap p lication o
this into tend inop athies o the u p p er extrem ity has yet to be
accom p lished .
Conclusion 555
Manu al therap y’s p lace in treatm ent o w rist tend inop athy
has not been established . I the e cacy o m anu al ap p lied
eccentrics or w hat som e au thors call ‘active release’ could be
likew ise established in the u pper extrem ity, they could easily
be per orm ed ad apting Curw in’s (2005) gu id elines or eccen-
tric exercises. A stu d y that reveals the e ects o m anu al
therap y on tend inop athy w ill require the ollow ing: (1) selec-
tion o ap p rop riate tend on p athology, w hich w ill p ose its ow n
d i cu lties, (2) so t tissu e m obilization such as ‘active release’
along the tend on bres, (3) continu ed sel -range o m otion
routinely or 48 hou rs, to red u ce the e ect o im m obilization,
and (4) the repetition o criteria (2) every 48 hou rs or up to 6
w eeks u ntil unction has retu rned . A d esign incorporating
these actors m ay be able to d iscern the tru e w orth o DTFM
in tend inop athy.
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 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
Carpal Instability
49  Chapter 
Elle n Po n g
CHAP TER CONTENTS
Introduction to wrist instability  558
Functional stability  558
De ning wrist instability  558
Incidence and aetiology of carpal instability  558
Anatomy and biomechanics  559
Anatomy  559
Biomechanics  560
Aetiopathogenesis  560
Patterns and classi cation  560
Pathogenesis  561
Examination and diagnosis  561
Diagnostic considerations  561
Clinical tests  561
Radiological tests, diagnostic dynamic ultrasound and   logical load s. Taking this fu rther, De Filip po et al (2006) speci-
arthroscopy  563
Treatment and prognosis  563
Conservative treatment and prognosis  563
Surgical treatment and prognosis   564
Conclusion  564
Introduction to Wrist Instability
Functional stability
The hum an w rist is a necessary link betw een the pow er of the
forearm and the p recision of the hand . It has been proposed
that there w as a su rvival ad vantage in hu m an evolu tion to
having a carp u s w hose stability as a stationary p latform
enhanced precise u se of instru m ents, w eapons and tools
(Wolfe et al 2006). Sim ple grasp of an object relies on at least
fou r m echanism s of carpal stabilization. They includ e the
p roxim al carpal row, the d istal carp al row, the m id -carpal
joint and the rad iocarpal joint (Garcia-Elias 1997a). Althou gh
stability of the rad ial sid e is clearly a necessary com p onent of
op p osable thu m b u se, stability of the d istal rad iou lnar joint is
just as im portant for p rovision of the rotational forearm in
tool u se and carrying (Dobbs 2003).
 
De ning wrist instability
Linscheid and associates are cred ited as the rst to d e ne
carpal instability in 1972 (Schm itt et al 2006), but references to
cond itions of instability are record ed as early as 1923
(Linscheid et al 1972; Lichtm an & Wroten 2006). Linscheid
and Dobyns (2002) set forth sp eci c concep ts in d e ning typ es
of instability as w ell as p rovid ing an overall d e nition;
how ever, this d e nition has continu ed to evolve w ith tim e
(Carlsen & Shin 2008).
There is d isagreem ent am ong researchers regard ing aetiol-
ogy and p athom echanics, resu lting in variou s accep ted view s
of term inology and treatm ent for instability of the w rist and
its speci c joints (Lichtm an & Wroten 2006). Linscheid and
Dobyns (2002) d e ned w rist instability as a w rist having
altered kinem atics and / or being unable to su p port p hysio-
ed : carp al instability occu rs from all u ntreated d islocations
and d isplaced or m alu nited fractures, integrity of interos-
seou s ligam ents and joint cap su le d eterm ine stability, con-
genital ligam entou s laxity (su ch as Ehlers–Danlos synd rom e)
is not consid ered to be pathological w rist / carpal instability,
and p ain m ay not be present as a d iagnostic sym ptom in the
initial stages of som e carpal instabilities.
Four joints are grossly consid ered in the presentation of
w rist instability: the carpom etacarpal joint, the m id -carpal
joint, the rad iocarpal joint and the d istal rad iou lnar joint
(DRUJ), w ith DRUJ stability in uenced by stability of the asso-
ciated triangular brocartilage complex (TFCC) (Dumontier
1996). This chapter w ill focu s on m id -carpal, rad iocarpal and
DRUJ instability.
Incidence and aetiology of carpal instability
Exact gu res of carp al instability incid ence and econom ic
im p act are d if cu lt to obtain, p rim arily because m any insta-
bilities are not d iagnosed early, or even revealed for treatm ent
at all, ow ing to lack of p ain in som e cases and poor recogni-
tion and follow -u p in others (Perron et al 2001; Dias & Garcia-
Elias 2006).
The m ost w id ely recognized cause of carp al instability is
trau m a, w ith w rist hyp erextension and variou s forearm rota-
tions; how ever, the exact com bination of joint p osition varies

along w ith the resu lting instability location (De Filip po et al
2006; Garcia-Elias 2006; Schm itt et al 2006). Linscheid et al
(1972) fou nd that instability w as a com p lication in 10% of all
reported carpal injuries. The m ost com m on carpal instability
(up to 19% of w rist inju ries) is w ithin the m id -carpal joint,
betw een the scaphoid and lunate (Bozentka 1999; Su rd ziel &
Lu biatow ski 2006).
The m alu nited d istal rad ius fractu re is recognized as a
cau se of carp al m alalignm ent, d evelop ing d u ring the p eriod
of im m obilization and w orsening grad u ally after fractu re
healing ow ing to continu ed stress and load ing of the w rist
(Gu p ta et al 2002). The incid ence of carp al instability from this
type of injury is p ossibly as high as 30% (Tang 1992). Rheu -
m atoid arthritis and calciu m p yrop hosp hate d ep osition
d isease (CPPD) are ad d itional cau ses of w rist instability in the
intercarpal, d istal u lna and rad iocarpal joints (Resnick &
N iw ayam a 1977; Schm itt et al 2006). Avascu lar osteonecrosis,
neu rological d isord ers, neop lastic d isease and sp eci c con-
genital m alform ations have also been attributed as causes (De
Filip po et al 2006; Schm itt et al 2006).
Anatomy and Biomechanics
Anatomy
This review is pertinent to w rist instability. The read er is
encouraged to u tilize other resources to revisit the basic
anatom y of the d istal forearm , w rist and hand , if need ed .
Osseous anatomy
The osseous anatom y is im portant in consid ering carpal and
w rist stability. Pathologies such as in am m atory arthritis,
infection and fractu re can change the shap e of the carpal
bones su f ciently to alter bony balance and prod uce instabil-
ity (Garcia-Elias 2006). Yet, even after ligam entou s injury, the
bony anatom ical featu res of the d istal rad iu s and proxim al
scap hoid have som e ability to stabilize the carp u s. Werner
et al (2007) d em onstrated this concep t of bony geom etry pro-
vid ing scap holu nate stability in the p resence of a torn scap ho-
lunate interosseous ligam ent.
Discu ssion begins w ith the d istal rad iu s and ulna. The
rad ius w id ens d istally to form a large articu lar su rface for the
scap hoid and lu nate, creating the rad iocarp al joint (Wad sw orth
1988). The d istal end s of the rad ius and u lna betw een them
form the d istal rad iou lnar joint. The d istal ulna has an articu -
lar su rface w ith the d istal rad ius and another w ith the TFCC
(Dobbs 2003). The articu lar su rfaces of the DRUJ are incongru -
ou s and therefore vu lnerable to translational d orsal and volar
instability (Kleinm an 2007).
The bones of the proxim al carpal row are the scaphoid ,
lunate, triqu etru m and pisiform . These carpals m ove w ith
greater d egrees of rotation to each other than d o the carp als
of the d istal row. The lu nate, w hich is coronally w ed ge
shap ed , has a tend ency to d islocate into the d orsal d irection
from the scaphoid ; it is ad d itionally the m ost frequ ently d is-
located carpal (Wad sw orth 1988; Schm itt et al 2006).
The d istal carp al row consists of the trap eziu m , trap ezoid ,
cap itate and ham ate. This is a m ore solid fu nctional u nit
than the p roxim al row, and w ith less intercarp al m ovem ent.
The d istal and proxim al carpal row s articulate throu gh the
Anatomy and biomechanics 559
m id -carp al joint. The m id -carp al joint is a com bination
of three joints: the scaphotrap ezoid –trap ezial (STT) w ith
scap hocap itate com p onents in the lateral com p artm ent, the
cap itolu nate central com p artm ent and the ham atotriqu etral
m ed ial com p artm ent (Schm itt et al 2006). Carlsen and Shin
(2008) d escribed the anatom y of the m id -carp al joint som e-
w hat d ifferently, in term s of the scaphocapitate / lunocapitate
central articu lation and the triqu etroham ate m ed ial articu la-
tion. This m id -carp al joint, as a w hole, is com p ared to a ball
and socket joint, w ith the capitate often intru d ing into the
scap holu nate gap (Schm itt et al 2006).
Ligamentous anatomy and stabilization
The ligam ents of the w rist are classi ed as intra-articu lar
or intracap su lar. Intracap su lar ligam ents are integrated in
the cap su lar sheaths and are either intrinsic or extrinsic to the
carp u s (Schm itt et al 2006). Schm itt et al (2006) d escribed the
interosseous scapholu nate ligam ent (SLL, SLIL), interosseous
lunotriqu etral ligam ent (LTL) and m id -carpal ligam ents as
intra-articu lar. Carlsen and Shin (2008), in contrast, stated that
all w rist ligam ents are intracapsu lar w ith the excep tion of the
transverse carp al ligam ent, the p isoham ate ligam ent and the
p isom etacarp al ligam ent. They based this d escrip tion on
the intracap su lar ligam ents being contained in ‘loose connec-
tive tissu e and fat’ (Carlsen & Shin 2008), w hich w as previ-
ou sly p oorly visu alized w ith op en su rgical insp ection.
The SLL (Fig. 49.1) is consid ered to be the m ost im portant
and is the one m ost often inju red . Each of the three SLL seg-
m ents p erform s d ifferent biom echanical fu nctions. It is cen-
trally com p osed of brocartilage that m erges w ith the articu lar
cartilage of the scap hoid and the lu nate (Linscheid & Dobyns
2002). The brocartilage section, or m id d le segm ent, lacks
stabilizing fu nction and is p rone to d egenerative inju ry
(Ozcelik et al 2005; Schm itt et al 2006). It is the d orsal segm ent
that is vital to scap holu nate com p artm ent stability. Rotary
su blu xation of the scap hoid and sym p tom atic scap holu nate
d issociation d evelops w ith the ru pture of this segm ent
(Schm itt et al 2006).
The LTL (see Fig. 49.1) plays a role in the stability of the
lunotriqu etral com partm ent sim ilar to that of the SLL in the
scap holu nate com p artm ent. It is sm aller than the SLL bu t
Triquetrocapitatoscaphoid
ligament
Radioscaphocapitate
ligament
Lunotriquetral
ligament
Scapholunate Radioscapholunate
ligament ligament
Figure 49.1 Critical volar stabilizing ligaments (right hand).
 560 PART 8 • 49 • Carpal instability
sim ilarly shap ed , and the central or m id d le segm ent, w hich
is also p rone to d egeneration, has no stabilizing fu nction. It is
the volar segm ent, how ever, rather than the d orsal segm ent
that m aintains fu nctional stability of the lu notriqu etral com -
p artm ent (Schm itt et al 2006).
Whereas the SLL and the LTL are intrinsic stabilizers of the
p roxim al carp al row, three short extrinsic interosseou s liga-
m ents stabilize the scap hoid and lu nate. The rad ioscap holu -
nate ligam ent (RSLL) (see Fig. 49.1) is uniqu e in that it has
been proposed to carry an anterior interosseous nerve and
artery to the p roxim al p ole of the scap hoid (Schm itt et al
2006). These interosseous ligam ents are d eep and transverse,
w hereas the su per cial and obliqu e com plex is term ed the
V-ligament system (Schm itt et al 2006). This system inclu d es
the im p ortant volar su p p ort band or rad ioscap hocap itate liga-
m ent (RSCL) (see Fig. 49.1), w hich helps to stabilize the rad io-
carp al joint w ith an obliqu e orientation that p revents carp u s
translocation (Schm itt et al 2006). Disrup tion of the RSCL is a
p rim ary cau se of scapholunate and capitolu nate d issociation
(Ozcelik et al 2005). The triqu etrocapitatoscaphoid ligam ent
(TCSL) (see Fig. 49.1) has a loose triqu etrocap itate section,
w hich is called the ulnar link, and a tight cap itoscap hoid
p ortion. This is an im p ortant stabilizer of the m id -carpal joint.
The RSCL and TCSL together w ith others that m ake up the
volar V-shap ed com p lex are stronger and m ore su p p ortive
than the d orsal com p lex (Schm itt et al 2006). In the proxim al
p ortion of the volar V-ligam ent, d isru ption of the rad iolu no-
triqu etral ligam ent w ill resu lt in lu notriqu etral d issociation
(Ozcelik et al 2005).
Prevention of axial (colu m nar) instability is the task of the
transverse intercarp al ligam ents and the exor retinacu lu m
(Schm itt et al 2006). These m ake u p the supp ort of the d istal
carp al row.
Stability of the DRUJ is m inim ally su p p orted extrinsically
by the interosseous m id -forearm ligam ent. The TFCC intrinsic
rad iou lnar d orsal and p alm er ligam ents provid e effective
ligam entou s stability (Kleinm an 2007).
Muscular anatomy
The m ost relevant contribution of the m uscu lar anatom y to
stability of the carp u s concerns the nd ing that both w rist
exors and extensors generate their m axim um forces w ith the
w rist fu lly extend ed (Lieber & Frid en 1998). Ind eed , there is
an alm ost constant ratio of exor to extensor torqu e over the
w rist range of m otion (Lieber & Frid en 1998). This is p ossible,
d espite the exors having a larger physiological cross-section
area, becau se of the su p erior extensor m om ent over the exor
m om ent. Thu s the w rist is m ost stable in extension and its
d esign is biased tow ard s balance and control instead of
m axim u m torqu e (Lieber & Frid en 1998).
Kleinm an (2007) ad d itionally d escribed the tension of the
extensor carpi ulnaris tend on across the u lna d istal head w ith
the su p er cial and d eep head s of the p ronator qu ad ratu s as
im p ortant to d ynam ic stability of the DRUJ.
Biomechanics
An im portant consid eration in u nd erstand ing forces across
the w rist is that there are no tend ons attaching d irectly to the
carp al bones, exclu d ing the p isiform ; how ever, the p isiform
is a sesam oid bone w ithin the tend on of the exor carp i
u lnaris, and this relationship is not consid ered to be signi -
cant in carp al stability (Bed nar & Osterm an 1993). The forces
are su m m ed across the carp us as the m ovem ent of the w rist
begins d istally w ith tend ons inserted at the base of the m eta-
carp als. The m otion of the carp u s is initiated at the d istal row
w ith forces proceed ing from the d istal to the p roxim al carpal
row. The forces at the scap hoid –lunate–capitate com p artm ent
com p rise 60% of the total force, w ith the rem aind er d istribu t-
ing at the rad iu s–lu nate joint and u lnocarp al com p artm ent,
accord ing to Schm itt et al (2006). Thu s m ovem ent of the p roxi-
m al carp al row d ep end s on the com p ressive forces of the
d istal row as w ell as the supp ort of the ligam entous attach-
m ents (Bozentka 1999).
Flexion–extension and rad ial–u lnar d eviation are the tw o
p lanes of m otion p rod u ced by the carp al joints. Flexion–
extension total m ovem ent is an average of 121–150° (Bed nar
& Osterm an 1993; De Filipp o et al 2006). This m otion is split
betw een the rad iocarpal and m id -carpal joints. The rad ial–
u lnar d eviation total m ovem ent is an average of 45–50°, w ith
a d istribu tion of 60% at the m id -carpal joint and 40% at
the rad iocarp al joint (Bed nar & Osterm an 1993; De Filipp o
et al 2006).
The scaphoid and lu nate m ove d orsally and rad ially d u ring
w rist extension. Volar and ulnar m ovem ent of the scaphoid
and lunate occu r w ith w rist exion. This scapholu nate m ove-
m ent is three tim es greater than the lu notriqu etral m ovem ent.
With the scap hoid having the w id est arc of rotation, both
exion and extension of the w rist effect a spatial change
am ong the carpu s elem ents. This intricate and sp eci c m echa-
nism m u st be intact to ensu re carp al stability (De Filippo
et al 2006).
The TFCC central articular d isc rep orted ly bears the
bu rd en of load transm ission from the m ed ial carpus to the
forearm w hen the w rist is ulnarly d eviated (Kleinm an 2007).
With the forearm in neu tral rad iou lnar d eviation, the load
passes from the m id -carpus to the d istal rad iu s interfossal
rid ge w ith a d istribu tion of 84% to the rad iu s and 16% to the
TFCC d isc (Kleinm an 2007). The read er is referred to the w ork
of Kleinm an (2007) for an extensive d iscu ssion of DRUJ
biom echanics.
Aetiopathogenesis
An und erstand ing of patterns and classi cation of instability
in the w rist is necessary to the d iscussion of aetiopathogen-
esis. Each ad vance in the evolving project of the classi cation
of instability is accom p anied by fu rther u nd erstand ing of
com m on cau se and effect on sp eci c tissu e or stru ctu re.
Patterns and classi cation
Recognized patterns and areas o carpal
and wrist instability
There are three basic patterns of instability to consid er,
althou gh each of these p atterns has ad d itional classi cation,
w hich w ill be d elineated later in this section. The patterns are
based on rad iological appearance. Predynamic instability
refers to a clinical d iagnosis w ithou t supp ort of abnorm alities
seen on a rad iograp h. D ynamic instability has a clinical

d iagnosis plu s altered kinem atics view ed on sp ecial but not
stand ard rad iograp hs; it occu rs, bu t inconsistently, w hen the
carp als are load ed u nd er certain cond itions. Static instability
is su pported by clinical d iagnosis and altered kinem atics
ap p earing on conventional rad iographs; the m alalignm ent is
evid ent w ith any am ou nt of load applied (Garcia-Elias 1997b;
Van Rooyen 2005).
Classif cation o carpal and wrist instability
Linscheid et al (1972) are cred ited w ith the rst classi cation
of carp al instability. Their w ork id enti ed tw o general typ es:
d orsal and volar (Linscheid et al 1972), of w hich dorsal inter-
calary segment instability (DISI) is the m ore com m on. De
Filip po et al (2006) attribu ted DISI to scaphotrapezoid al liga-
m ent inju ry, a non-u nion or bad ly healed trans-scap hoid frac-
tu re, or scap holu nate ligam ent inju ry. DISI is d etected w ith a
lateral view plain lm in w hich a d orsal tilt of the lunate is
seen, along w ith aberrant cap itolu nate and scap holu nate
angles (De Filip p o et al 2006). With the sam e plain lm view,
a volar intercalary segment (VISI) m alalignm ent is evid ent
w ith a volar tilt to the lu nate (Garcia-Elias 1997a). VISI is
d escribed as caused by d issociation of the lunotriqu etral, rad i-
otriqu etral or scap hotriqu etral joints, as w ell as by bad ly
healed and / or d isp laced fractu res of these carp als (De Filippo
et al 2006).
The Mayo Clinic system is cu rrently the m ost w id ely
know n and u sed classi cation (Carlsen & Shin 2008). This
system grou p s instabilities accord ing to p attern: carpal insta-
bility dissociative (CID), carpal instability non-dissociative
(CIN D), carpal instability combined (CIC) and adaptive
carpal instability (CIA).
Instability betw een ind ivid ual carpals in the sam e row and
involving the intrinsic ligam ents is CID. An exam p le of this
is scap holu nate d issociation. Progressive scap holu nate d is-
sociation (CID) becom es DISI before end ing in severe d egen-
erative arthritis, w hich is d escribed as scap holu nate ad vanced
collap se (SLAC) (Bozentka 1999).
Instability that cau ses aberration of the entire proxim al row
at the rad iocarpal and m id -carp al joints and involves the
extrinsic ligam ents is CIN D (Garcia-Elias 1997b; Van Rooyen
2005). Perilu nate instability results in CIN D ow ing to the
com p lex p athology at the rad iocarp al and intercarp al levels.
Instability w ith com bined involvem ent of the intra-row
and inter-row intrinsic and extrinsic ligam ents is CIC. De
Filip po et al (2006) listed lu nate d islocation as a typical
exam ple of CIC.
CIA is best d escribed as instability of the carp als cau sed by
pathology that is either d istal or p roxim al to the carpals, bu t
not w ithin the w rist. An exam p le of this is p athology at the
d istal rad iu s from either a m alunited fracture or Mad elung’s
d eform ity (Van Rooyen 2005; Schm itt et al 2006; Carlsen &
Shin 2008).
Discu ssion of DRUJ instability fu nctionally inclu d es the
triangu lar brocartilage com p lex (TFCC). TFCC tears are clas-
si ed by the Mayo Clinic system as trau m atic tears and d egen-
erative tears. Traum atic tears are classed as: (I) rad ial rim
d etachm ent, (II) central tears, (III) ulnar tears, and (IV) palm ar
tears. Degenerative tears are classed as: (I) central tears, (II)
central tear w ith u lnocarp al im p ingem ent, (III) central tear
w ith im pingem ent and lu notriqu etral ligam ent tear, and (IV)
central tear, w ith im p ingem ent and lu notriqu etral arthritis
Examination and diagnosis 561
(Van Rooyen 2005). TFCC p athology can result from d egen-
erative changes w ithou t causing DRUJ instability, how ever
(Van Rooyen 2005).
Ad d itional read ing is recom m end ed to follow the evolving
classi cations as know led ge of carp al biom echanics exp and ed ,
to inclu d e the view s of Lichtm an (Van Rooyen 2005; Lichtm an
& Wroten 2006) and Am ad io (De Filip po et al 2006). Carlsen
and Shin (2008) d escribe the Mayo system in greater d etail,
inclu d ing the su bd ivisions.
Pathogenesis
Destruction of the w rist ligam ents, throu gh traum a or d egen-
eration, and alteration of the bony articular su rfaces are
responsible for w rist instability. Tw o frequ ent types of insta-
bility d ue to m alunited d istal rad ius fractures are noted : m id -
carp al and rad iocarp al. Ad ap tive m id -carp al m alalignm ents
occu r w ith the bod y’s attem p t to realign the hand to the
m alu nion. Carp al ligam ents and rad iocarp al cap su le are not
d isrup ted . Pathological rad iocarp al m alalignm ents occu r
from inju ry to the rad iocarpal ligam ents and joint capsu le
d uring the fracture incid ent and resu lt in instability of the
rad iolu nate joint (Gu pta et al 2002).
Pathological abnorm alities of intra-articu lar ligam ents
in rheum atoid arthritis occu r as a result of p annus invasion
and d estruction, w hile the abnorm alities in calciu m p yro-
p hosp hate d ep osition d isease occu r resu lt from calci c
d ep osition and cystic d egeneration (Resnick & N iw ayam a
1977).
An ad d itional cause of w rist instability at the scap holu nate
interval w as rep orted by Mehd ian and McKee (2005) to be
excision of a d orsal w rist ganglion; the p ostulated reason for
this occu rring w as that m anip u lation u nd er anaesthesia of the
w rist to recover from the ganglion-ind u ced stiffness had trig-
gered the instability.
Examination and Diagnosis
Diagnostic considerations
Cooney et al (1990) d escribed an algorithm for d iagnosis that
inclu d ed clinical exam ination, report of the p atient’s sym p-
tom s and u se of p rovocative stress testing that w ou ld together
d eterm ine, in absence of p athological stand ard rad iographic
exam ination results, an appropriate portal of entry for ad d i-
tional tests (e.g. arthrogram or arthroscop y). (See Chs 3–5 for
the basic initial exam ination and history taking.)
Clinical tests
General mid-carpal tests
The m id -carpal shift test w as d escribed by Feinstein et al
(1999) as a valid and u sefu l clinical d iagnostic test for ind icat-
ing m id -carpal non-d issociative carpal instability. The exam -
iner stabilizes the patient’s forearm in pronation w ith one
hand and , w ith the other, p laces a thu m b over the p atient’s
d orsal d istal capitate. The thu m b d irects a palm ar force via
the cap itate, allow ing translation to occu r. Maintaining this
 562 PART 8 • 49 •
p ressu re, the exam iner provid es passive u lnar d eviation to
the p atient’s w rist. A p ositive test consists of a d egree of
clu nking and / or laxity d u ring the u lnar d eviation. Dysfu nc-
tion of stabilizing ligam ents is thou ght to cau se a loss of
norm al joint reaction forces betw een the p roxim al and d istal
carp al row s, resu lting in loss of sm ooth translation (Feinstein
et al 1999). The test w as review ed und er vid eo u oroscop y,
w hich show ed that the p roxim al carpal row m aintained a
exed volar position rather than m oving sm oothly from
exion to extension as the w rist w as m oved into ulnar d evia-
tion. Instead , the p roxim al row then su d d enly snap p ed into
extension once the u lnar d eviation w as achieved , hence the
‘clunk’ (Lichtm an & Wroten 2006).
Scapholunate, second and third carpometacarpal
joints and capitolunate tests
The scaphoid stress test (scap hoid shift test, Watson’s test,
SST, m od i ed scap hoid shear test) is the m ost com m only u sed
clinical test for the d etection of scap holu nate instability
(Christod ou lou & Bainbrid ge 1999). Rod ner and Weiss (2008)
noted that it m ight be d if cu lt to p erform the test w ell initially
w here there is sw elling and pain. The exam iner places a
thu m b on the scap hoid tu bercle, ap p lying p ressu re volar to
d orsal, and p assively m oves the p atient’s w rist from ulnar
d eviation and slight extension into rad ial d eviation w ith
slight exion (Fig. 49.2). The scaphoid w ill becom e prom inent
u nd er the exam iner ’s thu m b w ith the m ovem ent to rad ial
d eviation. When the thum b p ressu re is rem oved , a positive
test w ill d em onstrate the scap hoid retu rning to p osition w ith
an often p ainfu l and palp able ‘clu nk’. The clu nk is thou ght to
occu r w hen, d u e to laxity or p athology, the p roxim al p ole of
the scap hoid shifts onto the d orsal rim of the rad iu s w ith
thu m b p ressu re; then it retu rns w ith a clu nk w hen the p res-
su re is rem oved (Skirven 1996). The test is also m eaningfu l
w hen it reprod uces p ain over the scapholunate interval
(Rod ner & Weiss 2008). Accord ing to LaStayo and H ow ell
(1995), this test w as found to have a sensitivity of 69%, a spe-
ci city of 66%, a p ositive pred ictive valu e of 48% and a nega-
tive p red ictive valu e of 78% relative to arthroscopic nd ings
in 50 p ainfu l w rists.
B tests that have been rep orted to be sp eci c to LT inju ry (Dobbs
A
Figure 49.2 Scaphoid stress test: (A) The examiner applies pressure to scaphoid
with wrist in ulnar deviation and extension. (B) The examiner maintains pressure
while per orming radial deviation and f exion o the wrist, noting any ‘clunk’ or pain.
Carpal instability
Watson d escribed the w rist- exion nger-extension
m anoeu vre as an ad d itional test of scap holu nate instability
(Skirven 1996). Truong et al (1994) includ ed this test in their
screening criteria that, in com bination, had a sensitivity of
88.5% and a speci city of 84%. The patient’s w rist is p osi-
tioned in exion w hile the exam iner ap p lies resistance against
nger extension, the test being p ositive if this cau ses p ain in
the scap holu nate region (Truong et al 1994).
The synovial irritation sign of the scaphoid has high sensi-
tivity bu t low sp eci city for d etecting scap hoid instability.
Van Bu u l et al (1993) found that a positive synovial irritation
sign test had signi cantly higher incid ence in p atients w ith
su sp ected carp al instability. A p ositive test consists of p ain
elicited w hen the exam iner provid es pressu re on the scaphoid
throu gh the anatom ical snu ffbox (van Buu l et al 1993).
Still assessing the rad ial w rist, the Linscheid test p rod u ces
pain in the second and third carpom etacarpal joints w hen
positive (Skirven 1996). The exam iner supports the patient’s
m etacarp al shafts w hile p ressing into the d istal m etacarp al
head s in both d orsal and volar d irections (Skirven 1996).
The d orsal cap itate–d isplacem ent test w as fou nd clinically
to rep rod u ce su ccessfu lly a d orsal su blu xation of the cap itolu -
nate or the cap itolu nate and rad iolu nate joints (Lichtm an &
Wroten 2006). A capitolu nate instability pattern w as d escribed
and tested in this w ay by Louis et al (1984) u nd er vid eo u or-
oscopy in a series of 11 patients (Lichtm an & Wroten 2006).
The exam iner applied pressure to the scaphoid tu berosity in
a d orsal d irection w hile sim u ltaneou sly perform ing longitu-
d inal traction and passive exion to the p atient’s w rist. This
p rod u ced nearly com p lete d orsal su blu xation of the cap itate
from the lu nate and reprod u ced the patient’s p ain in that area
(Lou is et al 1984). Instability w as cred ited to d ynam ic laxity
of the rad iolu nate ligam ents and extrinsic scap hoid stabiliz-
ers, along w ith laxity of the d orsal cap itolunate ligam ent
com p lex (Lou is et al 1984).
Lunotriquetral tests
The lunotriqu etral (LT) ballottem ent test (Reagan’s test) ind i-
cates LT instability w ith p rod u ction of p ain and / or excessive
m otion as the exam iner translates the p isiform and triqu etru m
(together) volarly and d orsally relative to the stabilized lunate
(Rod ner & Weiss 2008). The test is perform ed w ith the exam -
iner u sing the thum b and ind ex nger of one hand to hold the
p atient’s lu nate w hile hold ing the triqu etru m in the contral-
ateral hand and provid ing sim u ltaneous m ovem ent of the
tw o bones against each other (Dobbs 2003) (Fig. 49.3). A posi-
tive resu lt is w here there is rep rod u ction of p ain, crep itu s or
excessive laxity. A sensitivity of 64%, a speci city of 44%, a
p ositive p red ictive valu e of 24% and a negative p red ictive
valu e of 81% w ere reported by LaStayo and H ow ell (1995) for
this test, althou gh Dobbs (2003) later d escribed an inconsist-
ent sensitivity of 33–100% (Dobbs 2003).
Kleinm an’s shear test d oes not stabilize the lu nate bu t d oes,
sim ilarly to Reagan’s test, ap p ly d orsal translation to the p isi-
form and concu rrent volar translation to the lunate for sym p-
tom s ind icating LT instability, and it is one of three clinical
2003). The exam iner places several ngers d orsal to the
p atient’s lu nate w ith a thu m b on the latter ’s p isotriqu etral
joint (Skirven 1996), though other authors have d escribed the
u se of the exam iner ’s thu m b on the lu nate w ith the

Figure 49.3 Lunotriquetral ballottement test. The examiner uses the thumb (not
shown) and index nger o one hand to hold the patient’s lunate while holding the
triquetrum in the contralateral hand and providing simultaneous movement o these
bones against one another, looking or pain, crepitus or excessive laxity.
contralateral thu m b on the p isotriqu etral joint (Dobbs 2003).
While the lunate is stabilized , the thu m b p rovid es a volar-to-
d orsal d irection of force that creates a shear across the LT joint.
The exam iner then d eviates the w rist rst in the ulnar and
then in the rad ial d irection. Elicitation of p ain or clicking
d em onstrates a p ositive test (Skirven 1996).
Dobbs (2003) also d escribed the u lnar snu ffbox com p res-
sion test (Linscheid ’s test, LT com p ression test) as p oorly sp e-
ci c for LT instability. The test is p ositive if p ain is rep rod u ced
as the exam iner p u shes the p atient’s triqu etrum into the
lunate from the u lnar w rist, sp eci cally in the su lcu s, or snuff-
box, w hich is form ed by the extensor carpi u lnaris and exor
carp i u lnaris tend ons (Skirven 1996; Rod ner & Weiss 2008).
Distal radioulnar joint and triangular
f brocartilage complex tests
The piano-key test is a variation of the piano-key sign, and is
u sed to assess for d istal rad iou lnar joint DRUJ instability. The
exam iner stabilizes the rad iu s w ith one hand w hile the other
hand grasp s the p atient’s d istal u lna and m oves it in d orsal
and volar d irections, w ith the forearm positioned in various
d egrees of pronation and su pination. A p ositive test includ es
reprod uction of pain, tend erness and hyp erm obility com -
pared w ith the u ninvolved sid e (Skirven 1996).
As m entioned earlier, the triangular brocartilage com plex
(TFCC) contribu tes to DRUJ stability, bu t it is not know n
w hether clinical tests for DRUJ instability accurately d em on-
strate instability cau sed from tears of the triangu lar ligam ent
of the TFCC (Moriya et al 2009). The biom echanical stu d y of
Moriya et al (2009), althou gh lim ited , su p p orted the DRUJ
ballottem ent test but not the piano-key test or the ulnocarpal
abu tm ent test as having a statistically signi cant d egree of
accu racy in d em onstrating this concept.
LaStayo and H ow ell (1995) exam ined the ulnom eniscotri-
qu etral (UMT) d orsal glid e test for p athology of the TFCC.
The technique for this test has the patient’s elbow resting on
a table w ith forearm in neu tral and vertical p osition. The
patient’s d istal rad iu s is stabilized by a golfer ’s grip of the
exam iner ’s hand . With the other hand , the exam iner places
his ind ex nger (d igit 2) cu rled su ch that the rad ial sid e of the
Treatment and prognosis 563
p roxim al interp halangeal joint contacts the p atient’s volar p is-
otriqu etral com p lex. With this nger p rovid ing d orsal p res-
su re, the exam iner sim u ltaneou sly u ses the thu m b to ap p ly
volar p ressu re against the d orsal d istal u lna, p rod u cing a
d orsal glid e of the pisotriquetral com plex on the d istal u lnar
head . A p ositive test resu lts in rep rod u ction of the p atient’s
p ain and / or laxity in the UMT area (H ertling & Kessler 1996).
LaStayo and H ow ell (1995) reported a sensitivity of 66%, a
sp eci city of 64%, a p ositive pred ictive value of 58% and a
negative pred ictive valu e of 69% for this test.
Radiological tests, diagnostic dynamic
ultrasound and arthroscopy
Rad iograp hic exam ination of the w rist ranges from stand ard
static view s to sp ecial d ynam ic p ositions and load ing cond i-
tions, as w ell as com p lex lm s su ch as vid eo u oroscop y and
arthrogram (Garcia-Elias 2006), in w hich the u ltim ate goal is
to d isp lay the gap betw een d issociated bones. Tom s et al
(2009), in a sm all bu t relevant stu d y, ind icated that d ynam ic
u ltrasou nd m ay con rm m id -carp al instability via a triqu etral
catch-u p clu nk. H ow ever, it is w rist arthroscop y that is
becom ing the gold stand ard , althou gh clinical tests are w id ely
u sed to regionalize the p ertinent area (Reynold s et al 1998;
Garcia-Elias 2006). Arthroscopy versu s open arthrotom y
avoid s su spension of the w rist u nd er traction, enabling oth-
erw ise occult d ifferences in ligam ent app earance to be
revealed (Cooney et al 1990).
Treatment and Prognosis
Conservative treatment and prognosis
Ad d itional research is need ed to d eterm ine true ef cacy of
conservative treatm ent, inclu d ing m anu al therap y of soft
tissu e and joint, for w rist instability. Most available inform a-
tion for m anu al therap y treatm ent of the w rist has focu sed on
treatm ent of carp al tu nnel synd rom e, w ith p ositive ou tcom es
noted (Bu rke et al 2007; O’Conner et al 2003).
The literatu re sup ports carpal m anipu lation for w rist insta-
bility as a d iagnostic rather than a treatm ent tool. Manipu la-
tion is u sed to evoke signs w hereas p alp ation is u sed to evoke
sym p tom s d u ring p hysical exam ination of the w rist (Dobbs
2003; You ng et al 2007). Conservative treatm ent d escribed in
the literatu re has em p hasized p atient ed u cation, sp linting and
exercises (H ofm eister et al 2006; Lichtm an & Wroten 2006;
Prosser et al 2007).
H ofm eister et al (2006) reported tem porary pain relief, at
best, w ith conservative treatm ents inclu d ing im m obilization,
sp linting, non-steroid al m ed ications and intra-articu lar injec-
tions. Most sp linting consists of general im m obilization after
acute inju ry su ch as sp rain or d islocation. Sp lints are often
cu stom -m ad e for best t, and are d orsal or volar, thu m b free
or p rotected , d ep end ing on the location of the inju red stru c-
tu re (Cop pard & Lohm an 2001).
Weiss et al (2000) recom m end ed tap ing, sp linting and anti-
in am m atory m ed ications for the athlete w ith a p artial or
com p lete m em branou s central tear of the LT ligam ent (w ith
no VISI). The sp lint shou ld be carefu lly m ou ld ed w ith a p ad
u nd er the p isiform to attem p t op tim al alignm ent (Shin et al
 564 PART 8 • 49 • Carpal instability
Figure 49.4 DISI custom splint.
2000). Patients w ith this type of inju ry and protocol are esti-
m ated to require 3–6 m onths for recovery (Weiss et al 2000).
Lichtm an and Wroten (2006) su p p orted a trial of conserva-
tive treatm ent as u sefu l in only one of fou r instability typ es:
that of d orsal m id -carp al instability. Garcia-Elias (1997a) con-
cu rred , w ith the ad d ed sp eci cation of a d orsal m id -carp al
typ e term ed the ‘cap itate lu nate instability p attern’ (CLIP),
w hich is u su ally d ue to congenital laxity. A cu stom -m ad e
d orsal sp lint w ith a d ynam ic com p onent, term ed a D ISI
splint or Lichtman splint (Fig. 49.4), is the only orthotic sp e-
ci cally su p p orted for this ap p lication (S. Kam al, p ersonal
com m u nication, 2009).
Sp eci c statistics for p rognosis follow ing conservative
treatm ent are u navailable. The literatu re d oes agree, how ever,
that p rognosis has an increased chance of being favou rable
(not requiring su rgery for restoration of fu nction) if the inju ry
is conservatively treated in the acu te p hase (Israeli et al 1981;
Bed nar & Osterm an 1993; Garcia-Elias 1997a; Shin et al 2000;
Lichtm an & Wroten 2006). H ow ever, conservative treatm ent
is not recom m end ed for chronic w rist instability.
Surgical treatment and prognosis
Su rgical interventions are p erform ed w hen p ain is intractable
and affects quality of life. Carlsen and Shin (2008) listed the
p rim ary consid erations that d eterm ine cou rse of treatm ent as:
arthritic changes, inju ry onset (chronicity), probability of the
tissu es, based on qu ality, to w ithstand su rgical rep air, and the
ability of the su rgeon to red uce the d eform ity. An id eal can-
d id ate for su rgical repair w ou ld have an acu te inju ry w ith
red ucible d eform ity and tissu es of good quality (Carlsen &
Shin 2008).
Decisions for choices of su rgical p roced u re – su ch as Kir-
shner w ire (K-w ire), bone–ligam ent–bone graft, p artial carp al
fu sion or arthrod esis, m id -carpal or four corner fusion and
p roxim al row carp ectom y – are based on the consid erations
above, as w ell as d egree and location of injury (Garcia-Elias
2006). Other surgical options inclu d e: arthroscopic or op en
d ebrid em ent includ ing ligam ent and synovectom y, capsulod -
esis, and ligam ent repair or reconstru ction; there is also ante-
rior and posterior interosseou s neurectom y (H ofm eister et al
2006; Johnston et al 2009). Prognosis is as w id ely varied as are
the factors of cau se, sp eci c p athology, techniqu e and skill of
the su rgeon.
Conclusion
Wrist instability is only now becom ing accu rately and su c-
cessfu lly id enti ed , classi ed and treated , ow ing to recent
im p rovem ents in technology and a d evelop m ent of the know l-
ed ge base over the last 25 years. Arthroscopy in particu lar has
allow ed a relatively u nd istu rbed view of the anatom y, biom e-
chanics and p athology of the w rist that has been incorp orated
into the bod y of classi cations, clinical tests, form al d iagnoses
and treatm ents.
The current literatu re su pports m anu al interventions by
the clinician for clinical tests, bu t not for conservative treat-
m ent in chronic w rist instability. Conservative treatm ent, con-
sisting p rim arily of p atient ed u cation, sp linting and exercises
is m ost ef caciou s w hen applied acu tely.
Ad d itional research is necessary to im prove the reliability
and valid ity of clinical testing as the aforem entioned know l-
ed ge base of w rist anatom y and biom echanics im proves. Tai-
loring of splint applications to speci c pathological and
functional need s w ill probably im prove conservative treat-
m ent ou tcom es, bu t this m u st be d iligently p u rsu ed and
record ed in ord er to d evelop evid ence-based treatm ent.
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 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
Carpal Tunnel Syndrome
50  Chapter 
Lu c a P a d u a , Da n ie le C o ra c i, C é s a r Fe rn á n d e z - d e - la s - P e ñ a s
CHAP TER CONTENTS
Introduction  566
Anatomy  566
Patho-biomechanism of carpal tunnel syndrome  567
Sensory and motor aspects in carpal tunnel syndrome  568
Diagnosis of carpal tunnel syndrome  568
Clinical examination  568
Questionnaires  569
Electrodiagnostic evaluation  569
Ultrasound assessment  569
Prognosis  570
Prognosis of untreated carpal tunnel syndrome  570
Therapy  571
Carpal tunnel syndrome and pregnancy  571
Conclusion  572
Introduction
Carp al tu nnel synd rom e (CTS) is characterized by com p res-
sion of the m ed ian nerve in the carp al tu nnel. It is a com m on
p athology affecting an estim ated 10% of the p op u lation,
accord ing to the Am erican Acad em y of N eu rology (AAN
1993a, 1993b; Olney 2001). It is consid ered the m ost com m on
nerve com p ression d isord er of the arm , w ith rep orted p reva-
lence rates of 3.8% (95% con d ence interval (CI) 3.1–4.6%) for
w om en and 2.7% (95% CI 2.1–3.4%) for m en (Atroshi et al
1999). Bland and Ru d olfer (2003) fou nd an annu al incid ence
of 139.4 cases p er 100 000 fem ales and 67.2 cases p er 100 000
m ales, w ith a fem ale : m ale ratio of 2 : 1. Bongers et al (2007)
have rep orted an incid ence rate of CTS of 1.8 / 1000 (95% CI
1.7–2.0). In fem ales the incid ence w as 2.8 (95% CI 2.6–3.1) and
in m ales 0.9 (95% CI 0.8–1.0), show ing a fem ale : m ale ratio of
3 : 1 (Bongers et al 2007). Ad d itionally, this stud y show ed that
in 2001 the incid ence of CTS w as calcu lated to be 1.5 tim es
higher than in 1987 (how ever, this d ifference d isappeared
after su bd ivid ing p atients by age and sex) (Bongers et al
2007). A m ore recent stud y has reported an annual p revalence
of 3.1% for CTS on active w orkers, representing 4.8 m illion
p eop le in the United States (USA) (Lu ckhau pt et al 2013).
This stu d y also found an overall lifetim e prevalence of CTS
 
of 6.7% in w orkers (Luckhaupt et al 2013). Dale et al (2013)
p ooled the ep id em iological d ata of CTS and rep orted an
overall prevalence rate of 7.8% and an incid ence rate of
2.3 / 100 p ersons / year. Analysis of the literature raises the
d if cu lty of accurately estim ating the incid ence and p reva-
lence of CTS becau se it is a com m on pathology and , as w e
d iscuss below, can be associated w ith m anual and repetitive
w ork. This last controversial association m eans that the inci-
d ence and prevalence of CTS are often calcu lated in a speci c
w ork p op ulation, as in the stud y by Lu ckhau pt et al (2013).
Moreover, another confou nd ing factor cou ld be the m ethod
u sed to d iagnose CTS, as Atroshi et al (1999) rep orted ; in their
stu d y, the com bination of clinical and neu rop hysiological
evalu ations contributed to physicians d iagnosing CTS in one
of ve sym p tom atic su bjects from the general p op u lation.
Tw o d ecad es ago, it w as been estim ated that in the USA
arou nd 1 m illion people requ ired care for CTS, arou nd 200 000
su rgical interventions w ere need ed and that the social costs
w ere in the range of m illions of d ollars (Tanaka et al 1995). A
d ecad e later, a stud y by Stap leton (2006) fou nd that CTS
aggregated health costs of app roxim ately US$ 2 billion annu -
ally in the USA.
Anatomy
In the carpal tu nnel the m ed ian nerve is su rrou nd ed by
bones on three sid es w ith the transverse carp al ligam ent on
the top . The transverse carp al ligam ent is a brou s stru ctu re
constitu ted by d ense connective tissu e (Fig. 50.1), w ith a clear
p red om inance of transverse bres (61%) in the p isiform –
trap eziu m and scaphoid –ham ate d irection (Prantil et al 2012).
Fu rtherm ore, the transverse carp al ligam ent exhibits high
neu ral nocicep tive innervation (Mashoof et al 2001). The
m ed ian nerve lies w ithin the nine exor tend ons of the
hand , and su p p lies fu nction, feeling and m ovem ent to
the rst three d igits of the hand and one-half of the ring nger
(Fig. 50.2).
The m ed ian branches for the nger and w rist exors origi-
nate in the forearm , w hereas the m otor branches that control
the thu m b exor and ad d u ctor m u scles, and the sensory
branches that provid e over half the hand w ith the sense of
tou ch, u su ally originate at the end of the tu nnel. Com p ression
of the nerve can be d u e to a d ecrease in the size of the canal,
an increase of the size of tend ons, or both.

Figure 50.1 Dissection of a right hand in a human cadaver. The gure shows
the connective tissue of the transverse carpal ligament and the transverse
disposition of the bres.
Tenosynovium Flexor tendons
Transverse
carpal ligament
Flexor tendons
Carpal bones Median nerve
Figure 50.2 Scheme of the carpal tunnel.
Patho-biomechanism of Carpal
Tunnel Syndrome
In m ost cases CTS is id iopathic (Sternbach 1999) bu t som e-
tim es it is associated w ith trau m a, p regnancy, hyp othy-
roid ism , m u ltip le m yelom a, am yloid osis, rheum atoid arthritis
or acrom egaly (Stevens et al 1992). Som e risk factors includ e
fem ale gend er (od d s ratio (OR) 3.7, 95% CI 2.6–5.2), m id d le
age (OR 2.2, 95% CI 0.9–4.9), d iabetes m ellitu s (OR 5.3, 95% CI
1.6–16.8) and excessive alcohol abu se (OR 2.3, 95% CI 0.7–2.3)
(Spahn et al 2012). Peru m al and Stringer (2014) have recently
reported that right hand s from fem ale cad avers exhibited sig-
ni cant red u ction in the intrinsic arterial vascu larity of the
m ed ian nerve at the entrance to the carp al tu nnel. Gend er
d ifferences in the intrinsic arterial sup ply of the m ed ian nerve
m ay be a factor p red isp osing to CTS (Peru m al & Stringer
2014). Obesity has been also found to be a risk factor (OR 2.7,
95% CI 1.9–3.9) for im paired m ed ian nerve fu nction (Coggon
et al 2013). For instance, a BMI of > 29 (obese subjects) increases
Patho-biomechanism of carpal tunnel syndrome  567
the risk by 2.5 com pared w ith a BMI of < 20 (slend er ind ivid u-
als) (Werner et al 1994).
As d iscussed above, anatom ical changes occu rring in the
carp al tu nnel d u e to u nd erlying m ed ical cond itions are
responsible for the m ed ian com p ression. For exam ple:
• Rheum atoid arthritis cau ses in am m ation of the exor
tend ons d eterm ining m ed ian nerve com p ression
(Karad ag et al 2012).
• Pregnancy and hyp othyroid ism cau se uid retention
in tissu es, w hich sw ells the tenosynoviu m (w e d iscu ss
the role of p regnancy in m ore d etails later in this
chap ter).
• Acrom egaly causes the com pression of the nerve becau se
of the abnorm al grow th of bones arou nd the hand and
w rist.
• Tum ours (u su ally benign), such as a ganglion or a
lipom a, can protru d e into the carpal tunnel, red ucing the
am ount of sp ace, althou gh this is exceed ingly rare (< 1%).
Carp al tu nnel tu m ou rs can m im ic CTS (Pad u a et al 2006)
and in these cases the use of u ltrasou nd evalu ation has
been crucial. This top ic w ill be d iscussed in further d etail
below (Granata et al 2008).
• Dou ble-cru sh synd rom e is a sp eculative and d ebated
theory, w hich p ostu lates that, w hen there is com p ression
or irritation of nerve branches contribu ting to the m ed ian
nerve in the neck or anyw here above the w rist, this
increases the liability of the nerve to becom e com pressed
in the w rist. Pierre-Jerom e and Bekkelu nd (2005) rep orted
that p atients w ith CTS exp erienced a higher incid ence of
narrow ing of the cervical foram en com p ared w ith
controls; these au thors hyp othesized that the
com p rom ised neu ral foram en cou ld p otentially lead to
nerve com p ression and p ossibly a d ou ble-cru sh
synd rom e in p atients w ith CTS. H ow ever, there is a little
evid ence that this synd rom e actu ally exists in CTS
(Wilbou rn & Gilliatt 1997; Ru ssell 2008).
• There are a great nu m ber of traum atic inju ries of the
forearm cau sing CTS (Colles fractu re, d islocation of one
of the carp al bones of the w rist, haem atom a form ing
insid e the w rist, etc.) (Zylu k & Waśków 2011).
• A recent stud y has d em onstrated that the presence of the
Val158Met (rs4680) polym orp hism in the COM T gene
that cod es the enzym e catechol-O-m ethyltransferase
seem s not to be a risk factor for d evelop m ent of CTS;
how ever, Val158Met (rs4680) p olym orphism w as
associated w ith increased perception of p ain and higher
d isability scores, suggesting a p otential genetic effect in
clinical m anifestations of this synd rom e (Fernánd ez-d e-
las-Peñas et al 2013).
• The role of m anu al activities and CTS is still a m atter of
d ebate. A num ber of au thors found that there is strong
relationship betw een hand positions and increased
pressu re on the carp al tu nnel (Keir et al 1998; Lu chetti
et al 1998) and this strongly su pports the hyp othesis that
forceful u se of the hand s, repetitive u se of the hand s and
hand –arm vibration m ay all cau se or contribute to CTS.
H ow ever, other stu d ies d o not su pport the relationship
betw een m anual activity and CTS (Chiang et al 1993;
Moore & Garg 1994) and so, d espite researchers’ efforts,
the d ebate is still far from over. Read ers are referred to
other texts for a greater u nd erstand ing of these
 568 PART 8 • 50 • Carpal tunnel syndrome
m echanism s (Werner 2006; van Rijn et al 2009; Jenkins
et al 2013).
Sensory and Motor Aspects in Carpal
Tunnel Syndrome
Although the aetiology of CTS is not com pletely und erstood ,
there is som e evid ence involving the w hole nocicep tive
system (De-la-Llave-Rincón et al 2012). Previous stu d ies have
investigated the fu nction of nocicep tive therm orecep tive
bres in CTS. Different stu d ies fou nd elevated therm al p ain
threshold s in the ngers and the p alm w ithin the affected
hand in p atients (Arend t-N ielsen et al 1991; Westerm an &
Delaney 1991; Goad sby & Bu rke 1994). Lang et al (1995) su g-
gested that pain intensity in CTS d epend s on alterations of
p eripheral and central nervou s fu nction.
More recent stu d ies fou nd that 45% of p atients w ith CTS
also rep orted sp read ing p roxim al sym p tom s, w hich m ight be
related to central nervou s system m echanism s (Zanette et al
2006, 2007). Chow et al (2005) fou nd that neck p ain w as
p resent in 14% of p atients w ith CTS. Tu cker et al (2007) fou nd
bilateral generalized increases in vibration threshold s in CTS,
w hich su ggested a generalized d isturbance of som atosensory
fu nctions rather than the existence of an isolated p eripheral
neu rop athy. In fact, tw o im aging stu d ies have show n cortical
rem app ing in the p rim ary som atosensory cortex (S1) in
p atients w ith CTS, su p porting the p ossible involvem ent
of central m echanism s in CTS (Tecchio et al 2002; N apad ow
et al 2006).
Ad d itionally, d ifferent clinical stu d ies also su pport the
p resence of both p erip heral and central sensitization m echa-
nism s in CTS. Fernánd ez-d e-las-Peñas et al (2009a) fou nd
bilateral w id espread d ecrease in pressure pain threshold s
(PPT) in w om en su ffering from u nilateral CTS (clinically and
neu rop hysiological) com p ared w ith healthy controls. This
stu d y rep orted bilateral low er PPTs over the m ed ian, rad ial
and u lnar nerve, the carp al tu nnel, the C5–C6 zygapophyseal
joint and the tibialis anterior m uscle. A signi cant d ecrease in
PPT over the C5–C6 joint m ay represent the existence of seg-
m ental sensitization of the nocicep tive system in CTS, w hereas
a bilateral d ecrease in PPT over the tibialis anterior m uscle
m ay ind icate m u ltisegm ental sensory sensitization or sensiti-
zation of the central nervou s system in CTS p atients (Fernán-
d ez-d e-las-Peñas et al 2009a). Another stud y has revealed that
bilateral p ressu re pain hyp ersensitivity w as heterogeneously
d istribu ted over the hand region in CTS, w ith som e areas
being m ore sensitive to pressu re than others (Fernánd ez-d e-
las-Peñas et al 2010a). Zanette et al (2010) observed that ind i-
vid u als w ith CTS w ith extram ed ian sym p tom s exhibited
p ressu re p ain hyp eralgesia and enhanced w ind -u p pain in the
territories innervated by the m ed ian, u lnar and rad ial nerves,
w hich further con rm s a w id espread sensitization process.
All these stud ies su pport the concep t that pain sensitivity to
p ressu re is a featu re of CTS. This hyp othesis has been con-
rm ed in a stu d y w here w om en w ith m inim al, m od erate or
severe CTS exhibited sim ilar w id esp read p ressu re p ain hyp er-
algesia (De-la-Llave-Rincón et al 2011a).
Sim ilar resu lts have also been rep orted for therm al p ain
sensitivity in CTS. De-la-Llave Rincón et al (2009) fou nd that
w om en w ith unilateral m od erate CTS exhibit bilaterally
therm al hyp eralgesia (red u ced heat and cold therm al p ain
threshold ), bu t not hyp o-aesthesia (norm al heat and cold
therm al d etection threshold s) com p ared w ith healthy con-
trols. Zanette et al (2010) also show ed that su bjects w ith CTS
w ith extram ed ian sym p tom s exhibit therm al hyperalgesia in
the territories related to the m ed ian, u lnar and rad ial nerves.
Bilateral sensory changes in ind ivid u als w ith u nilateral d iag-
nosis (clinical and neu rop hysiological) of CTS re ect the p res-
ence of central sensitization m echanism s. As w ith pressure
p ain sensitivity, heat and cold therm al hyp eralgesia, bu t not
hyp o-aesthesia, w as sim ilar in w om en w ith m inim al, m od er-
ate or severe CTS (De-la-Llave-Rincón et al 2011a). These
clinical nd ings are su p p orted by anim al stu d ies w here
p erip heral neu ral p athology in one local area cau ses w id e-
sp read effects inclu d ing in the u ninvolved lim bs (Koltzenbu rg
et al 1999; Kleinschnitz et al 2005).
In ad d ition to sensory sym ptom s, includ ing pain and
nu m bness, p atients w ith CTS u su ally d escribe self-p erceived
pinch-strength d e cits, sensations of clum siness d u ring their
activities of d aily living and som e d if culty in grasp ing sm all
objects. Som e stu d ies have also d em onstrated the relevance
of m otor d istu rbances in this p op u lation. A stu d y investigat-
ing im pairm ents in ne m otor control skills revealed bilateral
d e cits in ne m otor control ability and pinch-grip force in
w om en w ith u nilateral CTS (Fernánd ez-d e-las-Peñas et al
2009b). The p resence of bilateral m otor im p airm ents and
p inch-grip force d e cits in p atients w ith u nilateral sensory
sym p tom s re ects a reorganization of the m otor control strat-
egy of the central nervous system that occu rs as a conse-
qu ence of the p ain (Tam bu rin et al 2008). In fact, another
stu d y con rm ed also that the d e cits in ne m otor control
and pinch-grip force w ere sim ilar in p atients w ith m inim al,
m od erate or severe CTS; this resu lt su ggests that m otor d is-
tu rbances m ay be p resent from the onset of the p ain cond ition
(De-la-Llave-Rincón et al 2011b).
Finally, these stu d ies also d em onstrated that bilateral
sensory and m otor d e cits w ere related to the intensity and
d u ration of pain sym ptom s, su pporting the theory that the
perip heral nervou s system has a role in initiating and m ain-
taining the central sensitization m echanism (De-la-Llave-
Rincón et al 2009, 2011a, 2011b; Fernánd ez-d e-las-Peñas et al
2009a, 2009b). Gracely et al (1992) p rop osed a m od el of neu -
ropathic pain in w hich an ongoing nociceptive afferent inpu t
from a p eripheral nociceptive focu s d ynam ically m aintains
altered central processing. In fact, Tecchio et al (2002) su g-
gested that the continuou s sensory bom bard m ent from the
m ed ian nerve m ight trigger cortical p lastic changes fou nd in
these p atients. In su ch instances, it can be su ggested the
p ainful cond ition – that is, the ischaem ia of the nervi nervo-
rum (Watkins & Maier 2004) (the nerves innervating the con-
nective tissu e layers of the nerve itself) sensitized by the
com p ression of the m ed ian nerve in the carp al tu nnel (H all &
Elvey 1999) – m ay as su ch act as a trigger for grad u al sensiti-
zation of nocicep tive pathw ays in CTS patients. N ew stu d ies
shou ld investigate the role of these sensitization m echanism s
in the evolu tion of CTS.
Diagnosis of Carpal Tunnel Syndrome
Clinical examination
The gold stand ard for the d iagnosis of CTS is consid ered to
be the follow ing clinical presentation, accord ing to the AAN

(1993a, 1993b) d iagnostic criteria: paraesthesia, pain, sw elling,
w eakness or clum siness of the hand p rovoked or w orsened
by sleep, sustained hand or arm position, repetitive action of
the hand or w rist that is m itigated by changing p ostu res or
by shaking of the hand , sensory d e cits in the m ed ian inner-
vated region of the hand and m otor d e cits in, or hyp otrop hy
of, the m ed ian innervated thenar m u scles. Wainner et al
(2005) d eveloped a clinical pred iction rule for the d iagnosis
of CTS. The ru le id enti ed consisted of one qu estion (d oes
shaking hand s give sym p tom relief?), a w rist-ratio ind ex
> 0.67, a sym p tom severity scale score > 1.9, a red uced m ed ian
sensory eld of the rst d igit, and age > 45 years (LR 18.3).
Som e stu d ies have id enti ed the relationship betw een the
d istribu tion of sensory sym ptom s and the severity of CTS
accord ing to the neu rop hysiological classi cation. Patients
w ith low er severity of pathology com plain of sensory sym p-
tom s w ith a glove d istribu tion, w hereas p atients w ith higher
severity of p athology com p lain of sensory sym p tom s w ith the
‘classical’ m ed ian d istribution (Caliand ro et al 2006).
The p atient history is extrem ely im p ortant for the d ifferen-
tial d iagnosis, esp ecially as CTS can be second ary to end o-
crinal and m etabolic p athologies, and so therap y for the
p rim ary p athology can p rod uce CTS rem ission. In the clinical
exam ination, it is ad d itionally possible to u se a su bjective and
objective scale of CTS that inclu d es tw o m easu res (Giannini
et al 2002). The rst m easure (historical–objective, or H i-Ob)
includ es a clinical history and the follow ing objective sub-
scores: (1) noctu rnal paraesthesia only, (2) nocturnal and
d iu rnal p araesthesia, (3) sensory d e cit, (4) hyp otrophy or
m otor d e cit of the m ed ian innervated thenar m u scles and (5)
p legia of the m ed ian thenar em inence m u scles. The second
m easu re evalu ates categorically, by p atient qu estioning, the
p resence or absence of p ain w ith a forced -choice answ er (i.e.
‘yes’ or ‘no’). Therefore, the historical–objective–d istribution
(H i-Ob-Db) score com prises a num ber (H i-Ob) w ith or w ithout
the variable m easu ring p ain or the d istribu tion of p araesthe-
siae (Db) (Giannini et al 2002; Caliand ro et al 2010).
The p hysical exam ination inclu d es the Phalen test (Fig.
50.3), p erform ed by a prolonged (1-m inu te) p assive forced
exion of the w rist, the Tinel test, consisting of a p ercussion
of the m ed ian nerve trop hism of the thenar em inence, and
evaluations of m otor fu nction of the m ed ian innervated
m u scles and the sensory fu nction (cotton w ool is u sed as a
stand ard m aterial for skin stim u lation). Bilkis et al (2012)
d eveloped a m od i ed Phalen test, w hich has show n a higher
sensitivity (84.4%) than the trad itional Phalen test (50%); this
test com bines the classic Phalen test, obtained by w rist exion
Figure 50.3 The Phalen test.
Ultrasound assessment 569
for 1 m inu te, w ith the ap p lication of a Sem m es–Weinstein
2.83-u nit m ono lam ent to the palm ar and lateral su rface of
the ve ngers. The test is p ositive if the su bject d oes not refer
to the tou ch in at least one nger of the m ed ian nerve
territory.
Questionnaires
As d octors w ant to help patients, the assessm ent of the
p atient’s p ersp ective is also u sefu l in the com p rehensive eval-
u ation of CTS. The m ost com m only u sed qu estionnaire is the
Boston Carp al Tunnel Questionnaire (BCTQ) (Levine et al
1993). The BCTQ evaluates tw o d om ains of CTS: ‘sym p tom s’
(SYMPT = patient-oriented sym ptom ), assessed on an 11-step
scale, and ‘fu nctional statu s’ (FUN CT = p atient-oriented fu nc-
tion), assessed on an 8-step scale. Each item inclu d es ve
p ossible resp onses, and the score for each section (SYMPT or
FUN CT) is calcu lated as the m ean of the responses to the
ind ivid u al item s. The use of this questionnaire in several m u l-
ticentre stu d ies on CTS show ed interesting resu lts; w hereas
function has a linear signi cant correlation w hen assessed
both by physicians and patients, the sym ptom s d o not d em -
onstrate a clear linear correlation (Pad u a et al 2002). Patients
w ith m ild -to-m od erate CTS seem ed to function w ell, althou gh
severe sym p tom s m ay be rep orted by the p atient. H ow ever,
w hen nerve im pairm ent becom es severe, the p atient’s hand
function is extrem ely im paired although sym ptom s m ay be
m ild er. The d ata also show that the p atient’s p oint of view is
reliable (Pad u a et al 2002).
Electrodiagnostic evaluation
Electrod iagnostic evaluation is very im portant to d e ne the
im pairm ent of the m ed ian nerve. It is now accep ted that, in
ord er to increase the sensitivity of conventional nerve cond u c-
tion stu d ies (sensory d igit–w rist and m otor w rist–thenar),
segm ental nerve assessm ent and / or com p arative tests shou ld
be u sed (see below ) as stated in AAN and AAEM recom m en-
d ations (AAN 1993a, 1993b). When the stand ard tests yield
norm al resu lts (‘stand ard negative’ hand s), the follow ing
stu d ies increase the electrod iagnostic sensitivity:
• segm ental m otor or sensory cond u ction tests in the
palm –w rist segm ent
• com parative stud ies (m ed ian–u lnar or m ed ian–rad ial)
• segm ental / com parative stu d ies (as d istal : p roxim al
ratio).
A stu d y cond u cted on p atients w ith CTS show ed that the
sensitivity of stand ard tests can reach 83.5%, and com p ara-
tive / segm ental tests can d isclose abnorm al nd ings in a
further 11.4% of cases, provid ing CTS electrod iagnosis in
abou t 7 of 10 ‘stand ard negative’ cases. The overall sensitivity
of the protocol thu s reaches 94.9% (Pad u a et al 1999). The
severity of neu rop hysiological CTS im p airm ent can be
assessed and scored accord ing to a pu blished neu rop hysio-
logical classi cation (Pad u a et al 1997a, 1997b).
Ultrasound Assessment
Thanks to the ad vances in technology (re nem ent of high-
frequency broad band linear-array transd u cers, and sensitive
 570 PART 8 • 50 •
Median nerve
2
A B
Median nerve
C D
colou r and p ow er Dop p ler technology), low cost, w id e avail-
ability and ease of u se, u ltrasound (US) has recently been
ap p lied to the stu d y of tend ons and nerves.
In tend on and nerve im aging, US can assess a great nu m ber
of p athologies su ch as d islocations, d egenerative changes and
extrinsic or intrinsic focal com pression. Moreover, it can
su p p ort clinical and electrop hysiological testing and , in m ost
cases, a focu sed US exam ination can be p erform ed m ore
rapid ly and ef ciently than MRI (Martinoli et al 2002).
From a technical point of view, althou gh tend ons and
nerves share sim ilar characteristics (d im ensions, tu bu lar
conform ation and striated ap p earance), US can easily d iffer-
entiate them . Tend ons have a brillar pattern of parallel
hyp erechoic lines in the longitu d inal p lane becau se of the
collagen bu nd les and end otend ineu m sep ta, w ith a hyp er-
echoic rou nd -to-ovoid im age containing bright d ots (Fornage
& Rifkin 1988; Martinoli et al 1993); in contrast, nerves have
a fascicular p attern d u e to hypoechoic parallel linear areas –
the neu ronal fascicles – separated by hyp erechoic band s (the
interfascicu lar ep ineu riu m ) (Graif et al 1991; Silvestri et al
1995). On transverse scans, nerves assum e a honeycom b-like
ap p earance, w ith hypoechoic d ots su rrou nd ed by a hyper-
echoic background (Fig. 50.4).
Ultrasou nd has been m ainly tested in the evaluation of
CTS becau se of the com p lem entary p ersp ective it p rovid es
(Beekm an & Visser 2003; H obson-Webb & Pad u a 2009; Sm ith
et al 2009; Karad ağ et al 2010). CTS can be assessed u sing
the follow ing m easu res: cross-sectional area (CSA), sw elling
ratio, retinacu lar bow ing, retinacu lar thickness and attening
ratio. Several stud ies have show n that the m ost u seful d iag-
nostic criterion is the CSA, w hich is the area of m ed ian nerve
calcu lated at the w rist, either by u sing the ellip se form u la or
by m anu al tracing; the best cu t-off valu e is a CSA of
≥ 9.875 m m 2 at the pisiform level (Wang et al 2008). A m eta-
analysis conclu d ed that a CSA of the m ed ian nerve betw een
9.5 and 10.5 m m 2 has a pooled sensitivity of 0.84 (95% CI
0.81–0.87), a speci city of 0.78 (95% CI 0.69–0.88), a likeli-
hood ratio for a negative test of 0.21 (95% CI 0.17–0.27), and
Carpal tunnel syndrome
Median nerve
Figure 50.4 The median nerve at the
wrist (in the carpal tunnel). Note the
change in shape and position between
the nerve and the tendons (1, 2) in
Median nerve relation to the different wrist angle:
(A) neutral position, (B) 45° wrist
exion, (C) 90° wrist exion, and
(D) maximal wrist extension.
2
a likelihood ratio for a p ositive test of 3.74 (95% CI 2.30–6.10)
(Descatha et al 2012).
More sensitive tests have been d evelop ed in ord er to obtain
the best sensitivity and sp eci city. For exam p le, the w rist-to-
forearm ratio of the m ed ian nerve area can be consid ered
m ore sensitive than a m easu re of m ed ian nerve area at the
w rist alone (H obson-Webb et al 2008). The sensitivity of the
com bination of US and neu rop hysiology is higher than that
of either neu rop hysiology or US alone. Ultrasou nd is there-
fore a p otential u seful com plem entary tool for CTS assess-
m ent, w ith p ositive correlation betw een US nd ings and
conventional m easu res of CTS severity (clinical, neu rop hysi-
ological and p atient oriented ) (Pad u a et al 2008).
Ultrasound allow s clinicians to collaborate ef ciently w ith
su rgeons becau se it is able to show the anatom y before the
su rgery (e.g. show ing bi d m ed ian nerve). Fu rtherm ore, w ith
resp ect to d ecision m aking, US is able to show extrinsic (ana-
tom ical variant as m u scles) or intrinsic (nerve tu m ou r) nerve
com p ression, p rovid ing cru cial inform ation for the choice of
treatm ent.
In conclu sion, there is increasing evid ence that US is a
u sefu l com p lem ent in a neu rop hysiology laboratory; it greatly
increases the d iagnostic pow er and therap eutic w ork-u p of
p atients w ith m ononeu rop athies (Pad ua et al 2007), and the
m orp hological evalu ation of nerves help s the clinician to
avoid severe m isd iagnoses (e.g. a m ed ian nerve tu m ou r that
m ay m im ic CTS), esp ecially in cases w ith atyp ical neu rop hys-
iological nd ings (Pad ua & Martinoli 2008).
Prognosis
Prognosis of untreated carpal
tunnel syndrome
The know led ge and evolution of untreated CTS is very im p or-
tant in ord er to ad m inister the best therap eu tic ap p roach.

Only a few stu d ies have evalu ated this top ic (Pad ua et al 1998,
2001; Resend e et al 2003; Ortiz-Corred or et al 2008; Pensy et al
2011) and all agreed that m any patients im prove spontane-
ou sly. When the evolu tion is analysed accord ing to the initial
clinical p ictu re, it is observed that CTS hand s w ith initial low
severity tend to get w orse w hile CTS hand s w ith initial high
severe im p airm ent tend to im p rove (this is observed in all
CTS m easu rem ents, either p atient oriented or neu rop hysio-
logical). H ow ever, Kiylioglu et al (2009) fou nd that treatm ent
w as su perior to spontaneou s im provem ent in su bjects w ith
id iopathic CTS.
The factor that is m ost pred ictive of untreated CTS evolu-
tion is the d u ration of sym p tom s. In p articu lar, a long d u ra-
tion of sym p tom s is a p oor p rognostic factor accord ing to all
p atient-oriented m easurem ents. Conversely, a long d uration
of sym p tom s is not signi cantly associated w ith a bad neu ro-
p hysiological or clinical exam ination ou tcom e. With regard to
the p ositive p rognostic valu e of hand stress at the baseline, it
shou ld be noted that this valu e is p robably d u e to the inter-
ru p tion of the stress. In this sense, it is interesting to note that
in the entrap m ent synd rom e the ‘natu ral history’ can be in u -
enced by the physician giving an explanation of the patho-
p hysiology of CTS. Therefore if d octors, w hile giving patients
this d iagnosis, also p rovid e p ractical inform ation abou t the
hand p ositions to be avoid ed , they can alter the natu ral cou rse
of the p athology.
Therapy
Scienti c evid ence for the m anagem ent of CTS is con icting.
With regard to the conservative op tions of CTS therap y, a
review by Piazzini et al (2007), inclu d ing 33 rand om ized con-
trolled trials, show ed that there is a strong evid ence (level 1)
for the ef cacy of local and oral steroid s; m od erate evid ence
(level 2) that vitam in B6 is ineffective but that splints are effec-
tive, and lim ited and / or con icting evid ence that N SAIDs,
d iuretics, yoga, laser and US are effective, w hereas exercise
therap y and botu linu m toxin B injection are ineffective. An
ad d itional system atic review, w hich focu sed on neu ral m obi-
lization interventions for the m anagem ent of CTS, includ ed
six stu d ies and fou nd w eak-to-strong effects of neu ral-glid ing
exercises, w ith bene ts seen across d ifferent outcom e m eas-
u res (Med ina McKeon & Yancosek 2008). N evertheless, the
au thors p rop osed that the bene t of neu ral glid ing m ay be
best id enti ed w ithin a speci c su bpopu lation of patients
w ith CTS – that is, it is p ossible that neu ral glid ing m ay
be m ore effective in those w ith m inim al or m ild CTS or
w ith low er central sensitization. Fernánd ez-d e-las-Peñas et al
(2010b) fou nd that p eripheral sensitization, rather than central
sensitization, w as related to a p ositive p hysical therap y
resp onse in w om en w ith CTS. These authors found that pres-
su re hyp eralgesia over the cervical sp ine and heat hyp eralge-
sia over the carp al tu nnel, bu t not w id esp read p ressu re p ain
or cold p ain hyp eralgesia, w ere associated w ith a su ccessfu l
ou tcom e after the ap p lication of p hysical therap y (Fernánd ez-
d e-las-Peñas et al 2010b). In a follow -u p review, H uissted e
et al (2010) fou nd strong and m od erate evid ence for the effec-
tiveness of oral steroid , steroid injections, US, electrom agnetic
eld therap y, noctu rnal sp linting, and trad itional cu p p ing
versu s heat p ad s in the short term bu t sp arse evid ence on
their bene ts in the m id - and long-term m anagem ent
of CTS. N evertheless, the m ost recent Cochrane review
Carpal tunnel syndrome and pregnancy  571
conclu d ed that there is only lim ited and low -qu ality evid ence
of bene t for interventions su ch as exercise and m obilization
in CTS (Page et al 2012).
Regard ing su rgical intervention, the Cochrane review con-
clu d ed that su rgical treatm ent relieves sym p tom s signi -
cantly better than sp linting, bu t fu rther research is need ed to
d eterm ine w hether this conclu sion ap plies to ind ivid uals w ith
m ild sym p tom s and or w hether su rgical treatm ent is better
than steroid injection (Verd u go et al 2008). In fact, a rand -
om ized controlled trial d em onstrated that hand su rgery and
p hysical therap y exhibited sim ilar p ain relief in p atients w ith
CTS, and that 61% of patients w ith CTS w ill try to avoid
su rgery (Jarvick et al 2009). The m ost u pd ated review analys-
ing su rgical versu s conservative m anagem ent in CTS show ed
that both interventions had bene ts for CTS bu t that su rgical
treatm ent had a su p erior bene t, in term s of red u ction of
sym p tom s and fu nction, at 6 and 12 m onths com p ared w ith
conservative treatm ent (Shi & MacDem id 2011). In ad d ition,
this review conclu d ed that p atients w ith su rgical release
w ere tw ice as likely to have norm al nerve cond u ction
stu d ies, bu t also exp erienced m ore com p lications and sid e
effects than those receiving conservative treatm ent (Shi &
MacDem id 2011).
A nu m ber of stu d ies have been p erform ed analysing the
factors that in u ence the su rgical results in d ifferent popu la-
tions; for exam p le, the resu lts of su rgical d ecom p ression w ere
fou nd to be sim ilar in m en and w om en (Mond elli et al 2004a).
Fu rtherm ore, eld erly patients show ed less im provem ent com -
p ared w ith you nger p atients, w hich w as p resu m ably d u e to
greater preoperative d am age and a red u ced repair capacity of
the com p ressed nerve, althou gh this asp ect w as not a con-
traind ication for su rgical release in eld erly p atients (Mond elli
et al 2004b). The p resence of com orbid ity has also been inves-
tigated ; for exam p le, p atients w ith d iabetes have the sam e
p robability of p ositive su rgical ou tcom e as those w ith id io-
p athic CTS (Mond elli et al 2004a).
Along the sam e lines, an analysis of the cost-effectiveness
of non-su rgical versu s su rgical treatm ent has show n that
su rgery, rather than non-su rgical care, shou ld be consid ered
as the initial form of treatm ent w hen p atients are d iagnosed
w ith CTS (con rm ed by nerve cond uction stu d ies), as this
op tion p rovid es sym p tom resolu tion at a favou rable cost–
bene t (Pom erance et al 2009).
Carpal Tunnel Syndrome
and Pregnancy
Carp al tu nnel synd rom e is frequ ent d u ring p regnancy
(PRCTS) bu t can be consid ered as a d istinct entity. The inci-
d ence of CTS in pregnant w om en rep orted in the literature
ranges from 2% up to 70% (Pad u a et al 2010; Zylu k 2013).
H orm onal uctu ation, u id accu m u lation w ith tend ency to
oed em a, nerve hyp ersensitivity and u ctu ations in blood
glu cose level are factors that pred ispose pregnant w om en to
the d evelop m ent of sym p tom s. Stu d ies have show n that
PRCTS d oes not d isap p ear after d elivery (it m ay im p rove, bu t
on the contrary m ay also p ersist, and the p rolonged com p res-
sion can resu lt in m ed ian nerve d efect) so CTS sym p tom s
m u st be accu rately assessed in p regnant w om en. When
p resent they m u st be m onitored either clinically or
 572 PART 8 • 50 • Carpal tunnel syndrome
neu rop hysiologically (also, the role of US in PRCTS is not w ell
know n and this m u st be assessed as it could be a non-invasive
m onitoring tool). In fact, m ost cases w ith p regnancy-related
CTS u su ally im p rove sp ontaneou sly w ithou t treatm ent, bu t
sym p tom s can persist in m ore than 50% of the p atients after
1 year and in abou t 30% after 3 years (Pazzaglia et al 2005;
Pad u a et al 2010).
In cases of early CTS appearance (i.e. before the last
trim ester), the m ed ian com p ression m u st be thorou ghly
assessed as it m ay resu lt in acute or d isabling CTS, in w hich
im p rovem ent is less frequ ent. In cases of severe CTS w ith
early onset, su rgical d ecom pression d uring pregnancy m ay
p revent nerve d am age and a negative psychological in u ence
after d elivery.
Appearance of CTS sym ptom s in the last trim ester is the
m ore u su al occu rrence and has a higher p robability of
im p rovem ent after d elivery; nevertheless, arou nd half of
these w om en m ay com p lain of CTS sym p tom s for a long tim e
p ost p artu m , so clinical and neurop hysiological m onitoring is
ad vised . N ote that in one stu d y (Mond elli et al 2007), d espite
im p rovem ent of sym p tom s, the d istal sensory cond u ction
velocity of the m ed ian nerve im p roved bu t rem ained d elayed
in 84% of w om en w ell after the d elivery.
Apart from acu te CTS, w hich m ay be an em ergency (w ith
the need for rap id su rgical d ecom p ression), the rst line in
app roaching PRCTS shou ld be conservative therap y. Bu t
in absence of im p rovem ent and the p resence of severe
neu rop hysiological CTS (d isap p earance of sensory or m otor
resp onses), or d isabling sym ptom s, su rgical d ecom pression
before d elivery m u st be consid ered in ord er to p revent not
only m ed ian nerve d am age (Osterm an et al 2012) bu t also
d eterioration of quality of life d ue to d if cu lty and anxiety in
hand ling the baby.
Conclusion
Although CTS has been d e ned as ‘com plex issu es w ith a
“sim p le” cond ition’ (Olney 2001), and this has been con rm ed
by the high nu m ber of pu blications concerning all asp ects of
CTS, in recent years there have been m any efforts to im p rove
know led ge of this cond ition. Tools im ported from other eld s,
su ch as u ltrasou nd , have been com m only accep ted as m ethod s
to im p roving the d iagnostic accu racy, althou gh the gold
stand ard for d iagnosis rem ains the clinical p resentation. The
natu ral history of the p athology show s that som e u ntreated
p atients w ith CTS can im prove, bu t this is p robably d u e to
the d octor exp laining to the p atient how to avoid w rong hand
p ostu res and thu s red u ce the stresses on the neu ral tissu es.
Conservative therap ies are often u sed for the m anagem ent
of CTS and have been d em onstrated to be effective, bu t
su rgical d ecom p ression, also u sed in eld erly or d iabetic
p atients, rem ains a d e nite cure and is ef cient from the cost-
effectiveness p oint of view. N evertheless, it is possible that
p atients w ith m inim al or m ild CTS can bene t from conserva-
tive intervention, p articu larly p hysical therap y, as a rst ther-
apeu tic op tion.
The op inion of the au thors concerning su rgical d ecom p res-
sion, based on clinical exp erience and on u np u blished d ata
on the natu ral history of CTS, is that su rgery m ay be su g-
gested in severe cases (either neu rophysiologically or clini-
cally) w ith d u ration of sym p tom s longer than 1 year and for
p atients over 50 years of age. A brief period of conservative
therap y can be tried in cases of acu te CTS, bu t in cases w here
w e suspect acu te CTS that is not second ary to a particularly
stressing event – a very rare bu t very severe cond ition – u rgent
d ecom p ression m ust be consid ered , together w ith a com p re-
hensive assessm ent of a p ossible p rim ary su bclinical cau se.
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 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
Chapter  51
Other Entrapment Neuropathies
CHAP TER CONTENTS
Epidemiology  575
Anatomy  575
Ulnar nerve  575
Radial nerve  576
Median nerve  577
Pathology  577
Diagnosis  577
Ulnar nerve  578
Radial nerve  580
Median nerve  580
Prognosis  581
Conservative treatment  581
General treatment principles  581
Ulnar nerve  581
Radial nerve  582
Median nerve  582
Conclusion  582
Epidemiology
Com p ression neu rop athy can exist anyw here along the cou rse
of a nerve, althou gh all rep orted sites are u ncom m on com -
pared w ith the carpal tu nnel. The second m ost com m on site
of u p p er extrem ity com p ression involves the u lnar nerve at
the cu bital tu nnel (Mond elli et al 2005). The u lnar nerve
m ay also be com p rom ised at Gu yon’s canal. The annu al inci-
d ence of cu bital tu nnel com pression in w orkers p erform ing
repetitive w ork has been estim ated at 0.8% p er person-year
(Descatha et al 2004). A single large stu d y (Pascarelli & H su
2001) su ggested that the rate of electrophysiological abnor-
m ality in the m ed ian nerve at the u p p er extrem ity is tw ice
that of the u lnar nerve, and affected m ed ian nerves are tw ice
as likely to be sym p tom atic, thus resulting in a ratio of carpal
to cu bital tu nnel synd rom es of 4 : 1(Seror & N athan 1993).
Entrap m ent of the m ed ian nerve in the p roxim al forearm
is relatively u ncom m on, bu t is an im p ortant com p onent of
d ifferential d iagnosis and a potential explanation for failed
treatm ent of carp al tu nnel synd rom e. The m ost-rep orted com -
pression synd rom es are p ronator teres synd rom e and anterior
interosseou s nerve (Kiloh–N evin) synd rom e. In a large series,
 
J o y C . M a c De rm id , Da vid M . W a lto n
these contribu ted 1% of the com pression synd rom es of the
u p p er lim b (Pascarelli & H su 2001).
The rad ial nerve has m u ltip le sites of com pression in the
forearm , w ith ‘rad ial tu nnel’ the m ost com m on. Since there is
little agreem ent on d iagnostic ap proaches or criteria for rad ial
nerve com p ressions of the forearm , incid ence / p revalence
rates have not been clearly d e ned . In a large series of
p atients w ith w ork-related u pper extrem ity d isord ers, 7%
w ere d iagnosed as having rad ial tu nnel synd rom e (Pascarelli
& H su 2001).
Risk factors for d evelop ing nerve com p ression in the
forearm are related to both activity and the ind ivid ual.
‘H old ing a tool in position’ w as pred ictive of risk for cu bital
tu nnel (od d s ratio (OR) 4.1). Obesity (OR 4.3) had a sim ilar
risk, and the p resence of concom itant u pp er extrem ity tend i-
nosis also increased the risk (Descatha et al 2004). A gend er
effect has been established for cu bital tunnel synd rom e w ith
m ales at greater risk (Richard son et al 2001). A system atic
review exam ined the exposu re–response relationships
betw een w ork-related p hysical and psychosocial factors
inclu d ing cu bital tunnel synd rom e and rad ial tunnel syn-
d rom e in occu pational popu lations (van Rijn et al 2009). The
occu rrence of cu bital tu nnel synd rom e w as associated w ith
the factor ‘hold ing a tool in position’ (OR 3.5), w hereas han-
d ling load s > 1 kg (OR 9), static w ork of the hand d uring the
m ajority of the cycle tim e (OR 5.9) and fu ll extension (0–45°)
of the elbow (OR 4.9) w ere associated w ith rad ial tu nnel syn-
d rom e. Roqu elaure et al (2000) had p reviou sly fou nd sim ilar
risk factors: exertion of force of over 1 kg (OR 9.1), p rolonged
static load ing of the hand (OR 6) and w orking w ith the elbow
extend ed (OR 5).
Anatomy
Ulnar nerve
The u lnar nerve is vulnerable because of its location, its p ath
throu gh the forearm and the effects of p osition and m ove-
m ent. The C8 and T1 nerve roots give rise to the m ed ial cord
of the brachial p lexu s, w hich branches into the u lnar nerve
and the m ed ial com ponent of the m ed ian nerve. The u lnar
nerve travels on the m ed ial sid e of the brachial artery in the
u p p er arm , and at the m id u p p er arm it p ierces the
 576 PART 8 • 51 • Other entrapment neuropathies
interm u scu lar sep tu m to continu e on the m ed ial head of the
tricep s. At the elbow, it p asses throu gh the cu bital tu nnel, a
groove betw een the m ed ial hum eral epicond yle and the ole-
cranon. The nerve then travels betw een the tw o head s of the
exor carpi u lnaris and d ow n the forearm betw een the d eep
and su per cial nger exors. Just below the elbow, it send s
branches to the exor carpi ulnaris and the u lnar half of the
exor digitorum pro undus. There are ve p otential entrap-
m ent sites:
1. The arcad e of Struthers, a brou s band from the m ed ial
head of the tricep s to the m ed ial interm u scu lar sep tu m
(the brou s band occurs in only 70% of peop le)
2. The m ed ial interm u scular sep tum
3. The cubital tunnel (m ost com m on site) w here the
m ed ial collateral ligam ent of the elbow form s the oor
and the arcu ate ligam ent (cu bital tu nnel retinacu lu m )
the roof
4. The ap oneurosis betw een the tw o head s of the exor
carp i u lnaris (Osborne band )
5. The ap oneurotic covering betw een the exors d igitoru m
p rofu nd u s and su p er cialis, w hich is occasionally a site
of com p ression. Anatom ical variants are com m only
reported in case stu d ies as u nusual causes of nerve
com p ression.
An average of 5 m m of u lnar nerve excursion is requ ired at
the elbow to accom m od ate should er m otion from 30° to 110°
of abd uction, or elbow m otion from 10° to 90°. When the w rist
is m oved from 60° of extension to 65° of exion, 14 m m excur-
sion of the u lnar nerve are requ ired at the w rist. When all the
m otions of the w rist, ngers, elbow and shou ld er are com -
bined , 22 m m of u lnar nerve excu rsion are requ ired at the
elbow and 23 m m at the w rist. Ulnar nerve strain of 15% or
m ore occu rs at the elbow w ith elbow exion and at the w rist
w ith w rist extension and rad ial d eviation (Wright et al 2001).
Ultrasonograp hy of 200 norm al ind ivid uals revealed that the
u lnar nerve changes its cou rse at the brou s band region
11.5 m m d istal to the m ed ial ep icond yle. Dynam ic stud ies
show ed that, d u ring elbow exion, the nerve m oved to the
tip of the ep icond yle in 27% of ind ivid u als, w hereas it d islo-
cated anteriorly in 20% (Okam oto et al 2000). Som e believe
that su blu xation of the nerve d u ring m ovem ent can contrib-
u te to cu bital tu nnel synd rom e.
At the w rist, the u lnar nerve ru ns above the exor retinacu-
lu m lateral to the exor carp i u lnaris tend on and m ed ial to
the u lnar artery. At the p roxim al carp al bones, it cou rses
betw een the pisiform and the hook of the ham ate at the
entrance to the Gu yon canal (the roof of the canal is form ed
by an extension of the transverse carpal ligament, w hich links
these tw o bones). Three zones of the u lnar nerve w ithin the
d istal u lnar tunnel have been d e ned , as follow s:
• zone 1: u lnar nerve p roxim al to the bifu rcation
• zone 2: the d eep branch
• zone 3: the su per cial branch or branches.
The d eep (m otor) branch supp lies the abd u ctor d igiti m inim i
(ADM), then crosses und er one head of the exor d igiti
m inim i (FDM), su p p lies this m u scle and then crosses over to
su p p ly the op p onens d igiti m inim i (ODM) before rou nd ing
the hook of the ham ate bone to enter the m id -p alm ar sp ace
and su p p ly other hand m u scles. These anatom ical zones cor-
relate w ith the clinical sym ptom atology. After zone 1 the
nerve bifu rcates into su p er cial and d eep branches. These
terminal branches inclu d e the su per cial cu taneous branch
to the u lnar p ortion of the p alm and volar su rfaces of u lnar
1 1 2 ngers, the d eep m otor branch that p asses ad jacent to the
hook of ham ate bone, and the d eep branch that innervates the
hypothenar m u scles, third and fou rth lu m bricales, ad d u ctor
p ollicis, all the interossei and d eep head of the exor pollicis
brevis. Dep end ing on the exact site of com p ression w ithin the
Gu yon canal, the ADM or both the ADM and the FDM m ay
be spared . The ODM is alw ays affected , together w ith the
interossei, lu m bricals 3 and 4, and the ad d u ctor p ollicis.
Patients w ith zone 1 com pression can p resent w ith m otor,
sensory or m ixed lesions, those w ith zone 2 only m otor
lesions, and zone 3 only sensory lesions. Com pression of the
d eep branch is the m ost com m on and u sually occurs at the
level of the brou s arch of the hypothenar m u scles. The d istal
canal is also the com m onest site for ganglions arising from
the w rist.
Radial nerve
The rad ial nerve is the largest branch of the brachial plexus
(posterior cord ) and receives bres from C6, C7 and C8 (som e-
tim es T1). Its crosses the latissim us d orsi d eep to the axillary
artery, p asses the inferior bord er of the teres m ajor, w ind s
around the hu m eru s and then enters the tricep s m uscle
betw een the long and m ed ial head s. It progresses along the
sp iral groove of the hu m eru s to p ierce the lateral interm u scu -
lar septu m and runs betw een the brachialis and brachiorad ia-
lis to lie anterior to the lateral cond yle of the hu m eru s.
Branches to the brachiorad ialis and extensor carp i rad ialis
longus are given off just proxim al to the elbow. The anconeu s
receives a branch, and the nerve then d ivid es into a super cial
branch and a d eep branch. The extensor carp i rad ialis brevis
(ECRB) receives its innervation either from the rad ial nerve
p rop er or from the p osterior interosseou s nerve. The su p er -
cial branch, w hich is p u rely sensory, ru ns u nd er the cover of
the brachiorad ialis in the forearm . Eight centim etres p roxim al
to the tip of the rad ial styloid , the nerve p ierces the fascia
m ed ial to the brachiorad ialis to lie d orsal to the extensor
tend ons. It d ivid es into a m ed ial branch and a lateral branch
to innervate the rad ial w rist (w ith som e variable overlap from
the lateral antebrachial cu taneou s nerve), d orsal rad ial hand ,
and d orsum of the rad ial 3 1 2 d igits to approxim ately the
m id d le p halanx level.
The d eep branch, or posterior interosseou s nerve (PIN ),
w ind s to the d orsum of the forearm , around the lateral sid e
of the rad iu s and throu gh the m u scle bres of the su p inator.
It then d ivid es into m ed ial and lateral branches, each of w hich
su p p lies d ifferent extensor m uscles. The PIN su p p lies the
ECRB and su p inator before entering the arcad e of Frohse.
This arcad e is a brotend inous stru ctu re at the proxim al
origin of the su p inator and the m ost com m on site for entrap -
m ent of the rad ial nerve. In 25% of ind ivid u als, the PIN actu-
ally touches the d orsal asp ect of the rad iu s opp osite the
bicip ital tu berosity; thu s fractu re xation (plates) placed high
on the d orsal su rface of rad iu s m ay trap the nerve u nd er-
neath. The m ost com m on com pression site is at the su p inator
m u scle. H ow ever, p roxim al lesions shou ld be su sp ected
w ith hu m eral fractu res. Rad ial nerve palsy associated w ith
fractu re is m ore com m on after fracture of the m id d le third of
the hu m eru s (H olstein–Lew is fractu re) or at the ju nction of
the m id d le and d istal third s. The nerve also can be com -
p ressed by the lateral interm u scu lar sep tu m . Less-com m on

com p ression sites inclu d e the brou s arch of the lateral head
of the tricep s m u scle and the accessory subscapu laris–teres–
latissim u s m uscle.
The aetiology of PIN synd rom e is sim ilar to that of rad ial
tu nnel synd rom e. PIN com p ression is m ost com m only associ-
ated w ith tend inou s hypertrophy of the arcad e of Frohse and
brou s thickening of the rad iocap itellar joint cap su le. Lesions,
su ch as lip om a, synovial cyst, rheu m atoid synovitis or vascu -
lar aneurysm , m ay be cau sative and should be consid ered
w here sym p tom s d o not respond pred ictably to m echanical
forces. H obbies or occu pations associated w ith repetitive and
forceful su pination pred ispose the ind ivid u al to PIN neu ropa-
thy. Chronic trau m a to the exion su rface of the forearm can
also create p roblem s. Cru tches that inclu d e forearm rings,
inappropriately placed forearm braces (e.g. for tennis elbow )
or tight clothing can p rovid e su ch external com p ression.
Com p ression affects branches innervating the rad ial w rist
extensors and the rad ial sensory nerve (RSN ). After em erging
from the sup inator, the nerve m ay be com pressed before it
bifurcates into m ed ial and lateral branches, causing a com -
p lete p aralysis of the d igital extensors and d orsorad ial d evia-
tion of the w rist second ary to p aralysis of the extensor carpi
ulnaris (ECU). If com p ression occu rs after the nerve bifu r-
cates, selective p aralysis of m u scles occu rs, d ep end ing on
w hich branch is involved . Com p ression of the m ed ial branch
cau ses p aralysis of the ECU, extensor digitorum minimi
(EDM), and extensor digitorum communis (EDC). Com pres-
sion of the lateral branch cau ses p aralysis of the abductor
pollicis longus, extensor pollicis longus and extensor
indices. Other possible aetiologies for posterior interosseou s
nerve d ysfu nction inclu d e trau m a (Monteggia fractu res), syn-
ovitis (rheu m atoid ), tu m ou rs and iatrogenic inju ries.
Wartenberg synd rom e, or RSN entrap m ent, is u niqu e in
that it has isolated sensory sym p tom s. Insid iou s onset m ay
occu r in association w ith d e Qu ervain tenosynovitis. Acu te
onset can occu r follow ing p ost-su rgical inju ry, external com -
p ression or trau m a on the rad ial aspect of the w rist. The
anatom ical site of com pression corresp ond s to the transit of
the nerve from its su bm u scu lar p osition beneath the brachio-
rad ialis to its su bcu taneous position on the ECRL. With pro-
nation, these tw o m u scles can create a scissor-like effect,
com p ressing the RSN .
Median nerve
The m ed ian nerve arises from both the lateral and m ed ial
cord s of the brachial p lexu s and travels w ith the brachial
artery on the m ed ial sid e of the arm betw een the bicep s brachii
and brachialis. In the u p per arm it is lateral to the artery, bu t
then crosses anteriorly to ru n m ed ial to the artery insid e the
cu bital fossa, in front of the p oint of insertion of the brachialis
m u scle and d eep to the bicep s. The m ed ian nerve gives off an
articular branch in the u p per arm as it p asses the elbow joint,
and then p asses betw een the tw o head s of p ronator teres. It
innervates the pronator teres (PT), exor carpi radialis (FCR)
and exor digitorum superf cialis (FDS), then travels betw een
the FDS and exor digitorum pro undus (FDP) before em erg-
ing betw een the FDS and FCR. The m ed ian nerve gives off
tw o branches as it cou rses throu gh the forearm : the anterior
interosseou s branch cou rses w ith the anterior interosseous
artery and innervates the exor pollicis longu s (FPL), the FDP
to the second and third ngers and end s w ith its innervation
of p ronator qu ad ratu s. The p alm ar cu taneou s branch of the
Diagnosis 577
m ed ian nerve arises at the d istal p art of the forearm and su p -
p lies sensory innervation to the lateral asp ect of the skin of
the p alm (bu t not the d igits).
Com p ression of the m ed ian nerve in the forearm can arise
as a resu lt of anatom ical variations (supracond ylar p rocess,
Stru thers ligam ent, lacertu s brosu s) at the bicep s brachii, or
overu se / tightness of the p ronator teres m u scle or exor
su p er cialis. With low er frequ ency, an anom alou s accessory
head of the exor p ollicis longu s (Ganzer ’s m u scle) or p ersist-
ent m ed ian artery can be fou nd . Rarer cau ses of extrinsic
com p ression of the m ed ian nerve are chronic com p artm ent
synd rom e or p artial ru p tu re of the d istal bicep s tend on (or
bicip ital tend on bursitis). The m ost com m on site of com pres-
sion of the m ed ian nerve is the tend inou s origin of d eep head
of p ronator teres.
Pathology
N erve com pression can occur d irectly from anatom ical stru c-
tu res, as highlighted above. Also, rep etitive or acu te trau m a
to a nerve m ay resu lt in m icrovascu lar (ischaem ic) changes,
oed em a, or inju ry to the m yelin sheath and stru ctu ral altera-
tions in m em branes in both the m yelin sheath and the nerve
axon. Wallerian d egeneration of the axons and p erm anent
brotic changes in the neu rom u scu lar ju nction m ay p revent
full re-innervation after com pression is relieved . Sed d on has
classi ed nerve inju ries into three categories:
• N europraxia: A transient ep isod e w ithou t d isru p tion of
the nerve or its sheath – com plete recovery is expected .
• Axonotmesis: Disruption of the axon but m aintenance of
the Schw ann sheath. In this case, m otor, sensory and
au tonom ic effects are expected and recovery m ay be
com p lete or incom p lete.
• N eurotmesis: N erve and sheath d am age and incom p lete
recovery are usual.
N erve bres are not affected uniform ly bu t accord ing to their
p roxim ity to the sou rce of com p ression. Su p er cially located
bres tend to bear the bru nt of com p ression, w hereas central
bres are relatively sp ared . As large-d iam eter, heavily m yeli-
nated bres are m ore sensitive to com p ression than p oorly
m yelinated bres, they are m ore affected . This exp lains the
earlier and m ore pronou nced im p airm ent of light tou ch
(vibration) sensibility in nerve com pression d isord ers. Mild
com p ression p rod u ces a transient cond u ction and d isru p tion
of axop lasm ic ow that m ay be evid ent only w ith p rovocative
m anoeu vres. In chronic com p ression, segm ental d em yelina-
tion resu lts in slow ing of cond u ction and m ore p ersistent
sym p tom s. With p rogression, axolysis occu rs in com p ressed
segm ents and Wallerian d egeneration occu rs d istally. The
critical threshold p ressu re for initiating changes in nerve has
been reported to be 30 m m H g (Mackinnon 2002).
Diagnosis
N erve com pression p resents w ith loss of sensory and m otor
function w here m ixed nerves are involved . Rad ial tunnel and
d istal sensory nerve com pressions are exam p les of w here
these sym p tom s m ay occu r sep arately. In general, p rogression
of m otor sym p tom s m ay start w ith a feeling of clu m siness or
aching, then p rogress to su bstantial loss of m u scu lar strength
 578 PART 8 • 51 • Other entrapment neuropathies

and end u rance. By the tim e that patients have id enti ed
w eakness a su bstantial loss in grip strength is u sually m easu r-
able. Mu scle atrop hy is typically a late nd ing. Sensory abnor-
m alities tend to p rogress from p ositional- or activity-based
p araesthesiae, w hich be associated w ith p ain, to persistent
sym p tom s. In later stages, nu m bness m ay be so p rofou nd
that neither p ain nor p araesthesiae is as p ronou nced as
earlier. Sensory abnorm alities are rst d etected in vibration
or tou ch threshold s and later ap p ear in d iscrim inative tou ch
tests, su ch as tw o-p oint d iscrim ination. Tables 51.1–51.3
show resp ectively the clinical signs, the sp ecial tests and
com m on d ifferential d iagnosis d ep end ing on the site of nerve
entrapm ent.
Ulnar nerve
The presenting sym p tom s w ith ulnar nerve are num bness
and / or tingling, m ost noted by the p atient in the little nger,

Table 51.1 Symptoms and s igns de pe nding on the s ite of ne rve e ntrapme nt
Ulna r ne rve Me d ia n ne rve Ra dia l ne rve
Cub ita l tunne l Guyon’s tunne l Ante rior Ra dia l tunne l Pos te rior Dis ta l s e ns ory
s yndrome s yndrome inte ros s e us ne rve s ynd rome inte ros s e us ne rve ra dia l ne rve
s yndrome s ynd rome s ynd rome
(Wa rte nbe rg’s
s ynd rome )

Area of Medial elbow Palmar as pect Poorly localized to Approximately Over arcade of Dorsal as pect of
s ymptoms All of 5th and of 4th and 5th the volar 5 cm (2″) Frohse the radial 3 12
ulnar half of 4th digits only – proximal distal to the digits , as far
digits sensation forearm lateral distally as the
should be epicondyle proximal
spared over interphalangeal
dors al as pect joints . The
subungual
region a should
be s pared
Nature of Pain, numbnes s or Could be any or Pain and / or Pain and fatigue, Weaknes s Pain, numbnes s or
s ymptoms tingling, all of pain, weaknes s weakness tingling
weaknes s numbness or
tingling,
weakness
Motor s igns Grip and / or pinch Froment’s sign b Weakness of No obvious With complete No obvious muscle
weaknes s Wartenberg’s exor pollicis mus cle palsy, patients weakness should
Pos sible sign c longus and weakness in will be unable to be pres ent
Froment’s s ign b Weakness of the exor digitorum early stages e extend the
Pos sible dors al and profundus of thumb or ngers
Wartenberg’s palmar the 2nd digit at the metacar-
s ign c interos sei and Affected pophalangeal
May have dif culty hypothenar individuals will joints
cros sing 2nd mus cles d be unable to Will also have
and 3rd digits form a circle by dif culty or be
Speci c weaknes s pinching the unable to extend
of 1s t dorsal tips of the the wris t in
interos seous , thumb and 2nd neutral or ulnar
abductor digiti digit together positions f
minimi and
exor digitorum
profundus of
the 4th and 5th
digits
a
The region directly under the nail.
b
Usually tested by as king the patient to pinch a piece of paper between the thumb and index nger, then the examiner pulls it away. Inability to hold the paper, or excess ive
exion of the median innervated exor pollicis longus ( exion of the 1s t interphalangeal joint) is considered pos itive for ulnar nerve pals y.
c
Abduction and extens ion of the 5th digit.
d
Opponens digiti minimi, abductor digiti minimi, exor digiti minimi brevis.
e
Prolonged compres s ion of the radial nerve may lead to weakness of the radially innervated muscles of the forearm including extens or digitorum, extensor pollicis longus
and brevis and extens or carpi ulnaris . If weaknes s is pres ent the condition is usually referred to as pos terior interos s eous nerve s yndrome.
f
Branches supplying ECRB and ECRL us ually come off the radial nerve prior to entering the arcade of Frohs e and therefore are s pared.
 Diagnosis 579

Table 51.2 Spe cia l te s ts de pe nding on the s ite of ne rve e ntrapme nt

Ulna r ne rve Me d ia n ne rve Ra d ia l ne rve
Cubita l tunne l Guyon’s tunne l Ante rior Ra dia l tunne l Pos te rior Dis ta l s e ns ory
s yndrome s yndrome inte ros s e us s yndrome inte ros s e us ne rve ra dia l ne rve
ne rve s yndrome s ynd rome s ynd rome
(Wa rte nbe rg’s
s ynd rome )
Pos itive upper limb Positive upper limb Pos itive upper limb Positive upper limb Pos itive upper limb Positive upper limb
neurodynamic neurodynamic neurodynamic neurodynamic testing neurodynamic neurodynamic
testing with ulnar testing with ulnar testing with with radial nerve bias testing with radial tes ting with radial
nerve bias nerve bias median nerve Tenderness over the nerve bias nerve bias
Pos itive Tinel’s sign Positive Tinel’s sign bias radial tunneld Pain with extreme Positive Tinel’s s ign
at the cubital over Guyon’s May reproduce Pain with resis ted pronation over the s ite of
tunnela tunnel s ymptoms with extension of the Tenderness over the exit of the SRNe
Pos itive elbow exion deep palpation 3rd digit radial tunnel Symptoms increase
testb of the two heads Pain may be Pain with resis ted when tightly
Tenderness or of pronator teres reproduced with extens ion of the pinching the
hyperalges ia over active or res isted 3rd digit thumb and 2nd
the cubital tunnelc forearm supination Pain may be digit together
with wrist exion reproduced with Pain may be
active or resis ted reproduced with
forearm s upination extreme
with wris t exion pronation
a
Positive Tinel’s s ign at the cubital tunnel is not an uncommon nding in asymptomatic people.
b
Flex elbow pas t 90°, supinate forearm and extend wris ts. Pos itive tes t is reproduction of pain or discomfort within 60 s econds. Shoulder abduction can be added to
increas e the s ymptoms .
c
Between the medial epicondyle and olecranon.
d
Approximately 5 cm (2″) distal to the lateral epicondyle.
e
Between the brachioradialis and extens or carpi radialis tendons, approximately two thirds of the way down the forearm. SRN = s ens ory radial nerve branch.

Table 51.3 Common diffe re ntial diagnos is de pe nding on the s ite of ne rve e ntra pme nt
Ulna r ne rve Me d ia n ne rve Ra d ia l ne rve
Cubita l tunne l Guyon’s tunne l Ante rior Ra dia l tunne l Pos te rior Dis ta l s e ns ory
s yndrome s ynd rome inte ros s e us s ynd rome inte ros s e us ne rve ra dia l ne rve
ne rve s yndrome s ynd rome s ynd rome
(Wa rte nbe rg’s
s ynd rome )

C8 / T1 root lesions C8 / T1 root les ions Flexor digitorum Lateral epicondylitis C5–C8 radiculopathy De Quervain’s
Guyon’s tunnel Carpal tunnel profundus Brachial plexus injury Lateral epicondylitis tenosynovitis
syndrome syndrome avuls ion C5–C6 radiculopathy Extensor digitorum Brachial plexus injury
Thoracic outlet Thoracic outlet Lateral cord les ion rupture C5–C8 radiculopathy
syndrome syndrome C8 radiculopathy
Valgus ligament Systemic – diabetes, (rare)
ins tability alcoholis m Pars onage–Turner
Systemic – diabetes, Pancoas t tumour s yndrome
alcoholis m
Pancoast tumour
Medial epicondyle
fracture

bu t a loss of sensory fu nction throughou t the nerve d istribu-
tion. Aching p ain and loss of hand fu nction are u su ally
reported . Sym p tom s are aggravated in positions of exion
(and at night). Sensory and m otor im pairm ents can be vari-
able, and electrod iagnosis is recom m end ed before proceed ing
to su rgery (N akazu m i & H am asaki 2001). Patients w ith an
u lnar neu rop athy w ith a grad u al non-trau m atic onset m ay
report a history of rep etitive elbow exion or prolonged
resting of the elbow on a hard su rface. Elbow exion creates
narrow ing of the cu bital tu nnel as a resu lt of traction on the
arcu ate ligam ent and bu lging of the m ed ial collateral liga-
m ent. Elbow exion m ay also contribu te to the inju ry by
increasing the intraneu ral pressure. With scarring and ad he-
sion of the ep ineu riu m , elongation accentu ates the tethering
effect on the axons. These effects m ay be accentuated at night
w hen the patient sleep s w ith the elbow in exion.
 580 PART 8 • 51 • Other entrapment neuropathies
Sensory and m otor exam inations of the hand reveal w eak-
ness of grip , atrop hy of the thenar m u scles and w eakness of
p inch (ad d u ctor p ollicis m u scle). Atrop hy of affected m u scles
is m ost easily observable in the rst d orsal interosseou s area.
Inability to cross ngers m ay ind icate interosseous w eakness,
althou gh m anu al m u scle testing m ay also be used . The FCU
and FDP to the ring and little nger are u su ally not affected .
Sp ecial tests inclu d e From ent’s sign, w here p ronou nced
thu m b interp halangeal (IP) exion is observed w hen grasp ing
a p iece of p ap er betw een thu m b and ind ex nger, as the FPL
is u sed to stabilize the p ap er su bstitu ting for the absent
ad d u ctor force. If the u lnar nerve is affected below the m id -
forearm , an ulnar claw (hand of bened iction) d eform ity m ay
be prod u ced , as the m etacarpophalangeal joints of the fou rth
and fth ngers are hyperextend ed by the long extensors
(ow ing to a lack of balance because of w eak lu m bricals to
these ngers) w ith a length-resid u al FDP tension p rod u cing
exion of the IP joints. If the ulnar nerve is com prom ised
above the m id -forearm , claw ing d oes not occu r because the
FDP is also affected . Deform ity u su ally ind icates m ore pro-
fou nd com pression.
Sensory evalu ation shou ld inclu d e tou ch threshold or
vibration exam ination to d etect m ild er com p ression. A Tinel’s
(p ercussion) test can also be u sed , but, given the su per cial
natu re of the nerve, a p ositive test in isolation shou ld not be
consid ered d e nitive p roof of u lnar neu rop athy as it has been
rep orted in 24% of asym ptom atic peop le (Rayan et al 1992).
A com p ression test ( ngertip p ressu re over the u lnar nerve)
m ay be m ore accu rate, althou gh evid ence is lim ited . In a sm all
stu d y, it w as rep orted that the m ost sensitive p rovocative test
in the d iagnosis of cu bital tu nnel synd rom e w as elbow exion
w hen com bined w ith pressu re on the u lnar nerve. Provoca-
tive tests inclu d e su stained elbow exion, w hich is p ositive if
it rep rod u ces sym p tom s w ithin 1 m inu te. A stu d y of the
elbow exion test in 216 elbow s u sing Rayan’s fou r positions
ind icated that the false positive rate w as 3.6% at 1 m inu te and
16.2% at 3 m inutes (Rosati et al 1998).
If the ulnar nerve is com prom ised at the w rist then a Tinel’s
response (electrical, shooting or tingling into the nerve d istri-
bu tion) m ay be obtained by percu ssing at Gu yon’s canal. A
w rist exion test (usu ally u sed for carpal tu nnel synd rom e)
that p rod u ces p araesthesiae in the ring and sm all ngers is
also a p ositive nd ing. Both p alpation and observation shou ld
be u sed to look for abnorm alities at the ham ate hook or for
sw elling that ind icates ganglia or m asses. A history of ‘ham -
m ering’ or rep eated trau m a to the p alm is not u ncom m on.
The classic presentation is a young m an w ith painless atrophy
of the hyp othenar m u scles and interossei w ith sp aring of the
thenar grou p . Sensory loss and p ain involving the u lnar 1 1 2
d igits m ay be present. Distal ulnar com pression can be d if-
ferentiated as the d orsum of the hand is spared , w hereas in
cu bital tu nnel com p ression sensation is affected over both the
d orsum of the ulnar half of the ring nger and the little nger.
This is becau se the d orsal cutaneous branch, w hich leaves the
u lnar nerve p rior to entering Gu yon canal, w ou ld be sp ared
if the com p ression w ere in Gu yon’s canal alone.
Radial nerve
Rad ial tu nnel synd rom e is characterized by p ain over the
anterolateral p roxim al forearm in the region of the rad ial head
that can be aggravated by rep etitive elbow extension or
forearm rotation. The sym p tom s of rad ial tunnel synd rom e
can ap p ear sim ilar to those of lateral ep icond ylitis (H enry &
Stu tz 2006), although the m axim u m tend erness is u su ally
located fou r ngerbread ths d istal to the lateral epicond yle, as
op p osed to d irectly over the top of it. Based on a cad averic
stu d y, a clinical test for rad ial tu nnel w as p rop osed that
involved constru cting nine equal squ ares on the anterior
aspect of the forearm , and noting squares in w hich tend erness
is elicited ; in rad ial tunnel synd rom e the tend erness (d ue to
PIN com p ression) is con ned to the lateral colu m n (crossing
tw o or three of the lateral squ ares) (Loh et al 2004). Sym ptom s
can be rep rod u ced by extend ing the elbow and p ronating the
forearm . In ad d ition, resisted active su pination and extension
of the long nger cau se p ain (m id d le nger test). A com p res-
sion test, w here the thu m b is u sed to com p ress over the rad ial
tu nnel (sim ilar to that u sed for carp al com p ression), is p osi-
tive if it rep rod u ces sym p tom s or aching m u scle p ain. This
has been rep orted as the m ost consistent nd ing in rad ial
tu nnel synd rom e (Rinker et al 2004).
Posterior interosseou s nerve synd rom e p resents w ith
w eakness or p aralysis of the w rist and d igital extensors.
Pain m ay be p resent, bu t u su ally is not a p rim ary sym p tom .
Attem pts at active w rist extension often resu lt in w eak
d orsorad ial d eviation, ow ing to p reservation of the rad ial
w rist extensors bu t involvem ent of the ECU m u scle and
extensor d igitoru m com m u nis. These patients d o not have a
sensory d e cit. Mu scle testing shou ld inclu d e extension of the
m etacarp op halangeal joints, w hich w ill be w eak, w hereas IP
extension rem ains intact because innervation to the lum bri-
cals w ill be sp ared (u lnar nerve). Since the extensor ind icis
propriu s (EIP) and EDM are ind epend ent from the EDC and
sep arately innervated , the ind ex and sm all ngers are less
affected than the extension of the third and fou rth d igits. An
extension lag in the m id d le tw o ngers, w hereas the ind ex
and little ngers extend (‘sign of horns’) is suggestive of PIN
com p ression.
Patients w ith com p ression of the RSN com p lain of p ain
over the d istal rad ial forearm associated w ith p araesthesiae
over the d orsal rad ial hand . They frequ ently rep ort sym p tom
m agni cation w ith w rist m ovem ent or w hen tightly p inching
the thu m b and ind ex d igit. These ind ivid u als d em onstrate a
positive Tinel sign over the RSN as w ell as local tend erness.
H yperpronation of the forearm can cause a positive Tinel
sign. A high p ercentage of these p atients reveal exam ination
nd ings consistent w ith d e Qu ervain tenosynovitis, and the
synovitis m ay be a contribu ting factor in the com p ression of
the nerve. Thu s carefu l exam ination is requ ired to d istingu ish
isolated d iagnosis of either cond ition from coexistent p athol-
ogy. Finkelstein’s test m ay be p ositive in both cases, bu t qu an-
titative sensory testing w ill reveal d e cit w hen the RSN has
been com prom ised .
Median nerve
Patients w ith p ronator synd rom e u su ally com p lain of p ain in
the anterior forearm aggravated by forearm rotation. Unlike
carp al tu nnel p atients, the sym p tom s are not w orse at night.
Com p ression of the m ed ian nerve is ind icated by sensory
m otor d istu rbances affecting the thu m b, ind ex and long
ngers, and occasionally ‘ring-sp litting’ p henom ena, w here
the lateral sid e of the ring nger is noted as d ifferent from the
m ed ial sid e. If the p alm is also affected then con d ence is
increased that com pression is proxim al to the carpal tu nnel.
Mu scle testing shou ld attem p t to d ifferentiate betw een

p otential com pressive stru ctu res includ ing the lacertus bro-
su s (resisted su p ination and exion), FDS (ind ep end ent
exion of the m id d le nger localizes the level of entrap m ent
to the brou s arcad e of the FDS) and p ronator teres (p rona-
tion and w rist exion). A com p ression test w here the thu m b
is u sed to create pressure over the p ronator m u scle that repro-
d u ces p araesthesia w ithin 30 second s is d iagnostic. A d iffer-
ential d iagnosis for C6 / C7 rad icu lopathy can be d eterm ined
by exam ining the fu nction of the m u scles innervated by the
C6 / C7 p ortions of the rad ial nerve (i.e. the w rist extensors
and the tricep s).
Involvem ent of the anterior interosseou s nerve (AIN ) can
be d istingu ished from the m ed ian nerve proper because it is
p rim arily a m otor nerve excep t for som e sensory branches to
the d istal rad iou lnar and carp al joints. The latter m ay contrib-
u te to p ain in the w rist w ith this synd rom e; how ever, p araes-
thesia is absent. The AIN su p p lies the FPL, the lateral half of
the FDP, and the p ronator qu ad ratu s. A m ore com m on m is-
d iagnosis is FDP avu lsion, as loss of term inal joint exion m ay
be interpreted as a loss of tend on integrity. Patients w ith AIN
synd rom e p rim arily com p lain of w eakness, w hereas those
w ith p ronator synd rom e m ay present w ith sym ptom s of pain
and paraesthesia that can be confu sed w ith those in carp al
tu nnel synd rom e.
Prognosis
The extent of nerve d am age affects sym ptom s and prognosis
as d iscu ssed above. In general, severe com pression d etected
by electrod iagnosis, atrophy, changes in tw o-point d iscrim i-
nation and p ersistent nu m bness ind icates m ore-severe nerve
d am age and thus poorer prognosis. Dellon et al (1993) fol-
low ed a cohort of 128 patients treated non-operatively for
cubital tu nnel synd rom e. At 5 years, 89% of p atients w ith
sym p tom s only, 67% of those w ith abnorm al sensorim otor
threshold s and 38% of those w ith abnorm al sensorim otor
innervation d ensity had not progressed to su rgery. A history
of elbow inju ry signi cantly w orsened ou tcom e (p < 0.02), but
the resu lts of the p retreatm ent electrod iagnosis d id not. For
patients w ho d o p roceed to cubital tunnel release, ou tcom es
are better if p hysical therap y is initiated w ithin 3 d ays rather
being d elayed for 14 d ays (Warw ick & Serad ge 1995).
Conservative Treatment
General treatment principles
As the m ajority of nerve com pression synd rom es d iscu ssed
in this chapter are rare, speci c high-qu ality evid ence on
best m anagem ent approaches is virtually lacking. Therefore,
extrapolation of the ef cacies of speci c techniqu es stu d ied in
the com m oner com p ression neu rop athies (e.g. carp al tu nnel
synd rom e) has of necessity been u sed , resu lting in low er con-
d ence in these recom m end ations. A treatm ent p rogram m e
generally selects a variety of techniques that ad d ress speci c
objectives su ch as: to alter factors that are contribu ting to
com p ression or com p rom ise of the nerve, to p rom ote nerve
recovery, to enhance nerve glid ing and to facilitate norm al-
ized cortical reorganization.
Conservative treatment 581
Techniqu es are rou tinely u sed to red u ce static (com p res-
sive) p ostu res, rep etitive trau m a or external forces. The sp e-
ci c p ositions / activities to avoid are d iscu ssed by each
synd rom e below. Carefu l exam ination of contractile versu s
insert stru ctu res m ay d elineate the sou rce of com pression.
Where m u scu lotend inous hyp ertrop hy is a contribu ting
factor, strengthening of these m u scles m ay w orsen sym p-
tom s. H ow ever, strengthening of m u scles for p ostu ral rea-
lignm ent is need ed to red uce positional nerve com p ression.
Mu scle end u rance m ay be im p ortant to p revent oed em a w ith
activity or abnorm al m ovem ent patterns that contribu te to
comp ression. Rest m ay be requ ired to red u ce com p ression
related to in am m ation, bu t lack of m uscle extensibility is
likely to w orsen sym ptom s. Therefore, carefu l exam ination of
p otential sites / aetiologies is requ ired so as to cu stom ize the
rest / m obilization / realignm ent strategy for each patient. A
generalized progression of activity w ould m ove from rest and
gentle nerve-glid ing exercises to red uce sym ptom s, to treat-
m ent focu sing on restoring m u scle and nerve length extensi-
bility, and nally to functional / postu ral restrengthening /
rebalancing. An im portant goal throu ghout treatm ent is to
ensure that prop er bod y m echanics and m u scle recru itm ent
are u sed d u ring functional and occu p ational tasks.
N erve recovery is p rim arily p rom oted by rem oval of com -
p rom ising / com p ressive forces and allow ing the bod y to heal
nerve bres that rem ain viable. Facilitation of this recovery
w ith ad junctive physical agents m ay prom ote this process or
be used to facilitate m obilization of the nerve. Low -d ose ultra-
sound (1.0 W / cm 2), of long d u ration (15-m inu te sessions –
5× / w eek for 2 w eeks, then 2× / w eek for 5 w eeks), resu lted
in better nerve cond u ction velocity in carp al tu nnel synd rom e
p atients both im m ed iately after the end of treatm ent and 6
m onths later (Ebenbichler et al 1998). In contrast, higher d oses
at shorter intervals have not show n effectiveness. Iontophore-
sis w ith d exam ethasone and lid ocaine w as u sed in one sm all
trial of p atients w ho failed sp linting for p atients w ith carp al
tu nnel synd rom e, and 11 / 19 recovered (Banta 1994). Another
trial su ggested that, in m ild to m od erate cases, 10 treatm ents
of iontop horesis and u ltrasou nd w as effective in red u cing
sym p tom s (Dakow icz & Latosiew icz 2005).
The ability of the nerve to glid e betw een d ifferent stru c-
tu res in the forearm has been highlighted in the section above
on anatom y. Consequ ently, there have been su ggestions that
‘nerve-slid ing’ techniques m ay enhance the m obility of the
nerve, w hile p rod ucing less strain (Cop p ieters & Alsham i
2007). An app roach that encourages nerve m obility has been
su ggested as bene cial, bu t cu rrent clinical trials are lim ited
to those u sing su ch exercises as an ad ju nct to sp linting and
these trials tend to be u nd erp ow ered (Cop pieters et al 2004;
Pinar et al 2005; Baysal et al 2006; Svernlov et al 2009). (See
Ch 64 for a d iscu ssion of nerve neu rod ynam ics.) There is
rationale (level 5 evid ence) to su ggest that a d etailed exam ina-
tion of m u scle m obility, activation and p ositional effects on
sym p tom s that are characteristic of p hysical therap y exp ertise
m ay id entify stru ctu res that requ ire sp eci c m obilization,
althou gh this w ill rem ain inherently d if cu lt to stu d y in clini-
cal trials.
Ulnar nerve
The m ainstay of treating cu bital tu nnel synd rom e has been
night p ositioning, activity m od i cation (Pad u a et al 2002),
sp linting the elbow in extension and nerve-glid ing exercise.
 582 PART 8 • 51 • Other entrapment neuropathies
Although cu stom -m ad e hard therm oplastic splints are
com m on, com p liance can be a p roblem and soft versions that
restrict full exion m ay be m ore acceptable to patients. These
can range from inexp ensive off-the shelf (neop rene and other
m aterials) or hom em ad e ap p roaches (e.g. a p air of socks u sed
to create a sleeve and exion block) to cu stom -m ad e ind i-
vid u al p ad d ed orthoses.
Behaviou ral changes shou ld inclu d e avoid ing com p ression
(e.g. resting on the elbow s, elbow exion, external pressu re
on the elbow s) and rep etitive exion or any activity in
extrem es of position. Of ce w orkers m ay need w ork-station
evaluation, and postural and ergonom ic training.
N erve m obilization if slow ly progressed m ay be u sefu l,
bu t care shou ld be taken to avoid overaggressive m obiliza-
tion that contribu tes to the p roblem throu gh tractioning the
u lnar nerve. There is em p irical evid ence that ‘slid ing tech-
niqu es’ resu lt in a su bstantially larger excu rsion of the u lnar
nerve at the elbow than ‘tensioning techniqu es’ (8.3 m m
versu s 3.8 m m ) and that this larger excu rsion is associated
w ith a m u ch sm aller change in strain (Cop p ieters & Bu tler
2008). Differential stretching of sp eci c m u scles (FDS) m ay
also increase m obility. Although strength m ay be com p ro-
m ised , and fu nctional goals m ay su ggest the need for
im p roved strength, therap ists shou ld exercise cau tion as
strengthening exercise has the p otential to increase com p res-
sive factors.
The evid ence for conservative m anagem ent is sp arse and
inconclu sive. A recent sm all trial su ggested that 75% of
p atients w ith m ild to m od erate u lnar neurop athy im prove
w ithin 6 m onths, bu t that splinting and nerve glid ing provid e
no ad d itional bene t over activity m od i cation (Svernlov
et al 2009); the p otential for lack of pow er in this trial of 70
p atients is su bstantial, bu t it d oes ind icate the need for m ore
evid ence. The potential for natural history of recovery w ith
m inor changes (Szabo & Kw ak 2007) su ggests that activity
m od i cation and evalu ation of a recovery p athw ay shou ld be
im p lem ented as a rst ap p roach. Failu re to resp ond to a m ore
com p rehensive p hysical therap y p rogram m e ind icates a need
for surgical release (Robertson & Saratsiotis 2005; Lu nd &
Am ad io 2006).
Radial nerve
Evid ence for the effectiveness of conservative m anagem ent
and rad ial tu nnel is lacking (H u issted e et al 2008). Mobiliza-
tion of the p otential com p ressive stru ctu res and d ifferential
m ovem ent of both m u scle and tend on m ay be u sefu l. Ergo-
nom ic changes to w orkstations m ay inclu d e tilting / sp lit or
m od i ed keyboard s to red u ce excessive rotation or extrem e
w rist positioning. Tissu e pressu res su ggest that positions of
elbow exion, supination and w rist extension place the least
stress and strain on the rad ial tu nnel. This is not fu nctional,
bu t patients m ay bene t from a w rist support that places the
w rist in m od erate w rist extension and being given ad vice on
avoid ing forearm rotation and elbow -extend ed positions
d u ring activity. Given that rad ial nerve sym ptom s can be
confu sed w ith lateral ep icond ylitis, p atients w hose sym p tom s
are u nim p roved or are w orsened by a tennis elbow cou nter-
force bracing should be re-evalu ated for potential rad ial
tu nnel synd rom e and sw itched if necessary to a w rist exten-
sion sp lint.
Median nerve
Changes in activity to red u ce m ed ian nerve irritation inclu d e
p revention of rep etitive forearm rotation and excessive force-
ful grip. A rest splint that m aintains m id -rotation is som etim es
u sed for a short p eriod , althou gh the necessity of this has not
been proven (Lee & LaStayo 2004). The natural history of
com p ressive d isord ers w ou ld su ggest that activity m od i ca-
tion is m ore im p ortant. Stretching of the p ronator teres and
nerve glid ing m ay be u sefu l.
Conclusion
N erves can be com p rom ised in the forearm as a resu lt of
anatom ic, biom echanical or external forces. Mu scle testing
and sensory exam ination should reveal the nerve affected and
the m ost likely site of com p ression. Qu antitative m easu res of
m u scle strength and sensory d etection threshold are im p era-
tive for accu rate d iagnosis and m onitoring p rogress in treat-
m ent. A treatm ent p rogram m e that m itigates the com p ressive
forces, facilitates nerve healing, restores norm al glid ing, u ses
p ostu ral and cortical retraining to norm alize anatom ical
balance and interp retation of nerve responses, and teaches
p atients to be p roactive in id entifying p otential sou rces of
com p ression in their w ork and behaviou r (and how to m od ify
these ap p rop riately) shou ld be su ccessfu l for m ild to m od er-
ate cases of nerve com p ression. Ad vanced com pression m ay
requ ire su rgical release, w ith early p hysical therapy being
ind icated . Both the qu ality and qu antity of evid ence on p hysi-
cal therap y techniqu es or p rogram m es are insu f cient, and
stu d ies that look at the im m ed iate im p act of sp eci c interven-
tions on nerve fu nction and the m ore global fu nctional im p acts
of p hysical therap y p rogram m es over the longer term are
need ed .
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Warw ick L, Serad ge H . 1995. Early versus late range of m otion follow ing
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H and Su rg Am 26: 655–662.
 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
52
Joint Mobilization and Manipulation
Chapter 
P e te r A. Hu ijb re g ts , Fre d d y M . Ka lte n b o rn , Tra u d i Ba ld a u f Ka lte n b o rn
CHAP TER CONTENTS
Introduction  584
Scientif c evidence  or mobilization o  the wrist and hand  585
Mobilization / manipulation o  the wrist and hand  586
Distal radioulnar joint dorsal glide radius  587
Distal radioulnar joint ventral glide radius  587
Distal radioulnar joint MWM  587
Radiocarpal traction  587
Radiocarpal palmar glide  588
Radiocarpal dorsal glide  588
Radiocarpal radial glide  588
Radiocarpal ulnar glide  588
Radiocarpal MWM  589
Opponens roll  589
Transverse carpal extension  589
Radial carpal palmar glides  589
Central carpal palmar glides  590
Ulnar carpal palmar glides  590
Radial carpal dorsal glides  590
Central carpal dorsal glides  590
Ulnar carpal dorsal glides  590
Carpal glide manipulation with proximal f xation  590
Carpal glide manipulation with distal f xation  591
Carpometacarpal I traction  591
Carpometacarpal I glides  592
Metacarpophalangeal I MWM  592
Finger joint traction  592
Finger-joint glides  592
Finger joint MWM  592
Introduction
Therapists use m obilization and m anipu lation techniques to
red uce pain and increase range of m otion (ROM) (Kaltenborn
et al 2007). Kaltenborn et al (2007) classify joint restrictions as
p eriarticu lar, extra-articu lar, intra-articular, or com bined in
aetiology. Periarticu lar restrictions d ue to ad ap tive shorten-
ing of neu rom u scu lar and inert stru ctu res (inclu d ing skin,
retinacu la and scar tissu e) and extra-articular structu res
 
(capsule and ligam ents) are best treated w ith su stained m obi-
lization techniqu es, w hereas periarticu lar restriction d ue to
m u scle hyp ertonicity resp ond s best to neu rop hysiological
inhibitory techniqu es. Intra-articu lar restrictions are best
treated w ith (traction) m anip u lation initiated from the actu al
resting position (Kaltenborn et al 2008).
Gu id ing both d iagnosis and m anagem ent, Kaltenborn et al
(2007) have d escribed grad es of m ovem ent (Fig. 52.1):
• Grade I is a very sm all traction force that elim inates the
norm al com p ressive forces across the joint.
• Grade II takes u p the slack w ith initially very little
resistance to passive m ovem ent (slack zone), then m ore
resistance as tissu es are tightened (transition zone), and
nally a m arked resistance called the rst stop .
• Grade III occurs after the rst stop : as tissues becom e
tau t, resistance to m ovem ent rap id ly increases w ithin this
range.
In joint d ysfu nction both the expected norm al excu rsion and
resistance to m ovem ent for the various grad es w ill be altered .
Grad e I traction m ovem ents facilitate glid ing m ovem ents
u sed d u ring exam ination, m obilization and m anip u lation and
are applied d u ring all techniques d escribed later. Treatm ent
to relieve p ain occu rs in the grad e I and grad e II slack zone
ranges. Lim ited m ovem ent in the absence of shortened tissu es
can be treated by joint m obilization techniqu es throu ghou t
grad e II (Kaltenborn et al 2007). Extra-articu lar restrictions
d u e to capsu loligam entous connective tissue shortening are
best treated w ith non-thru st grad e III m obilization tech-
niqu es. Thru st m anipu lation techniques are used both for
d iagnosis and for m anagem ent of intra-articular restrictions
(Kaltenborn et al 2008). To d ate, the sp eci c natu re of these
intra-articu lar restrictions rem ains unknow n bu t clinically
they m ay p resent w ith restricted ROM, an earlier rst stop ,
abnorm al end feel and altered throu gh-range resistance
(perhaps d ue to sm all positional fau lts or synovial u id
changes w ith resu ltant alterations in cohesion and ad hesion)
w ith traction and glid ing joint p lay m otions, and p ain on
com p ression d u e to p ossible intra-articu lar entrap m ent of
sensitive stru ctu res.
Withou t p rop osing the location of the tissu e at fau lt,
Mu lligan (2004) has su ggested ‘m inor p ositional fau lts’ as
an alternate aetiology for joint d ysfu nction that w ill resp ond
to m obilization w ith m ovem ent (MWM). With an MWM
the therap ist ap p lies a su stained accessory glid e, long-axis

Slack taken up
Grade I Grade II
Loosening Take up the slack Tighten slack
SZ TZ
e
c
n
a
t
s
i
s
e
R
Movement range
rotation, or com bination of these w hile the patient actively
perform s a p reviously painfu l m ovem ent. (See Ch 31 for
further d iscussion of MWM in the shou ld er.) Central to both
the Kaltenborn and the Mu lligan ap p roach is the em p hasis on
restoration of the glid ing com p onent of the norm al joint roll-
glid ing m ovem ent (Exelby 1996). Central also to both is the
treatm ent p lane d e ned as the p lane across the concave joint
su rface. Translatoric techniqu es encom p assing traction, com -
pression and glid ing techniqu es, traction and com pression are
perform ed p erp end icu lar to this treatm ent p lane, w hereas
glid ing techniques ind uce m ovem ent parallel to this p lane
(Kaltenborn et al 2007).
The d ifference betw een the Kaltenborn and Mu lligan tech-
niqu es is that, w hereas Kaltenborn em p hasizes glid ing tech-
niqu es in the d irection norm ally associated w ith the restricted
physiological m otion, Mu lligan often starts w ith a su stained
glid e at a right angle to this physiological glid e. An iterative
process then tests glid es in d ifferent d irections or long-axis
rotation before settling on the m ost effective d irection allow -
ing for p ain-free active range of m otion or isom etric m u scle
contraction constitu ting the MWM (Exelby 1996; H sieh et al
2002). Tw o to three sets of 6–10 repetitions are p erform ed ,
su p p orted by a hom e p rogram m e of self-m obilization and
corrective tap ing (Mu lligan 2004). An ad d itional d ifference
betw een the tw o techniques is that the Kaltenborn concept
u ses only straight-lined (linear) glid ing techniqu es p arallel to
the treatm ent p lane for joint m obilization, w hereas Mu lligan
ad ap ts continu ou sly to the contou r of the joint su rface w ith
cu rvilinear glid ing techniqu es. It shou ld be noted , thou gh,
that the Kaltenborn techniqu e has also trad itionally u sed cu r-
vilinear glid ing techniqu es, albeit for assisted active m ove-
m ents and solely accord ing to the convex–concave ru le.
Scienti c Evidence for Mobilization of
the Wrist and Hand
Research evid ence for the u se of m obilization and m anip u la-
tion techniqu es in the w rist and hand region is lim ited bu t
em erging. Using anim al research, Olson (1987) show ed
increased p assive ROM and ROM d u ring gait in d ogs w ith
im m obilization-ind uced rad iocarp al hypom obility receiving
end -range oscillatory traction and glid ing m obilization, com -
pared w ith controls not receiving this intervention.
Scientif c evidence  or mobilization o  the wrist and hand 585
First stop
Grade III
Figure 52.1 Kaltenborn grades of movement. SZ= slack zone;
TZ= transition zone. (Redrawn from Kaltenborn et al 2007, with
permission.)
Su cher (1994) provid ed p relim inary clinical evid ence for
m anu al therap y for p atients w ith carp al tu nnel synd rom e
(CTS) in the form of an uncontrolled case series show ing
d ecreased severity of sym ptom s and norm alization of electro-
d iagnostic nd ings. Sucher et al (2005) also p rovid ed basic
science evid ence in cad avers for the u se of su stained m anu al
techniqu es, inclu d ing variations of the op p onens roll and
transverse carp al extension m anoeu vres intend ed to stretch
the exor retinacu lu m . H ow ever, althou gh noting signi cant
w ithin-group im provem ent for self-rep orted p hysical and
m ental d istress, nerve cond u ction stu d ies and nger sensa-
tion for both stu d y grou p s, Davis et al (1998) found no sig-
ni cant betw een-grou p d ifferences in their rand om ized
controlled trial (RCT) of 91 subjects w ith CTS treated either
w ith 16 sessions over 9 w eeks of chirop ractic cervicothoracic
sp ine and u p p er extrem ity joint and soft tissu e m anip u lation,
u ltrasou nd and night sp linting or w ith m ed ical m anagem ent
consisting of ibuprofen and sp linting. In 21 p atients w ith CTS
sched u led for su rgery, Tal-Akabi and Ru shton (2000) com -
p ared 3 w eeks of treatm ent u sing neu rod ynam ic m obilization
or p alm ar and d orsal carp al glid ing m obilization and exor
retinacu lu m stretching w ith a control group . They rep orted
signi cant w ithin-grou p im p rovem ents w ith regard to p ain
and active w rist extension ROM for both m obilization group s
and signi cant betw een-group d ifferences favou ring both
exp erim ental group s over the control group w ith regard to
p ain. Six of seven su bjects in the control grou p p roceed ed
w ith su rgery, w hereas 11 of 14 in the m obilization grou p s
cancelled su rgery. Tw o system atic review s (O’Connor et al
2003; Mu ller et al 2004) have recom m end ed carpal bone m obi-
lization for the m anagem ent of p atients w ith CTS.
In an RCT w ith 52 patients, Taylor and Bennell (1994) com -
p ared m anagem ent of p atients su ffering from Colles fractu re
consisting of ad vice, heat and a hom e p rogram m e w ith the
sam e p rogram m e p lu s m anu al m obilization; they rep orted no
betw een-group d ifference in w rist extension ROM. In an RCT
w ith 32 p atients, McPhate and Robertson (1998) looked at the
effects of a hom e p rogram m e w ith or w ithout m anu al m obi-
lization and also fou nd no betw een-grou p d ifference for w rist
extension ROM or grip strength, bu t they d id note signi -
cantly low er p ain scores in the m obilization grou p . Kay et al
(2000) rand om ly assigned 39 patients w ith cast and / or inter-
nal xation p ost-Colles fractu re to a hom e p rogram m e w ith
or w ithou t Maitland grad e 1–2 accessory m obilization of the
d istal rad iou lnar and carpal joints, p rogressing to grad e 3–4
 586 PART 8 • 52 • Joint mobilization and manipulation
p hysiological techniqu es. They rep orted signi cant w ithin-
grou p d ifferences on pain, ROM, grip strength and fu nction
for both grou ps, but only one statistically (but not clinically)
signi cant d ifference in w rist exion ROM favou ring the
m obilization grou p . Using a single-su bject d esign for eight
su bjects w ith stable (typ e I or III) Colles fractu res, Coyle and
Robertson (2002) com pared six sessions of various com bina-
tions of tw o 60-second end -range oscillatory and su stained
p alm ar glid ing rad iocarp al m obilization in m axim u m p ain-
free extension; they noted im provem ent in w rist extension
ROM in both grou p s. They also noted that oscillation w as
m ost effective in increasing ROM if u sed rst in treatm ent
session and in the p resence of p ain, w hereas the su stained
techniqu e w as m ore effective in later treatm ent sessions and
w hen used as a second techniqu e for increasing ROM. A sys-
tem atic review re ected these equ ivocal nd ings in stating
that m anu al m obilization for Colles fractu re w as not su p -
p orted by an RCT, bu t d id show p ositive ou tcom es in a case
series d esign (Michlovitz et al 2004).
Rand all et al (1992) rand om ly assigned 18 subjects after at
least 2 w eeks of im m obilization for a m etacarpal fractu re to
an active ROM hom e program m e or a hom e p rogram m e com -
bined w ith three sessions of end -range oscillatory m etacar-
p ophalangeal (MCP) traction and glid ing m obilization. Over
the course of 1 w eek, the m obilization grou p im proved sig-
ni cantly w ith regard to joint stiffness and ROM com p ared
w ith the control grou p. Tw o case reports have also lent
su p p ort to the u se of long-axis rotation MWM in p ost-fall
MCP I d ysfu nction, althou gh one rep ort u sing MRI d id not
su p p ort Mu lligan’s hyp othesis of resolu tion of a ‘m inor p osi-
tional fau lt’ (Folk 2001; H sieh et al 2002).
One case rep ort ind icated the p ossible bene t of a m u lti-
m od al m anagem ent ap p roach in a p atient w ith d e Qu ervain
synd rom e consisting of neu ral m obilization and joint m obili-
zation of the cervicothoracic sp ine, should er and w rist includ -
ing p alm ar and d orsal glid ing m obilization of the cap itate and
lu nate bone (And erson & Tichenor 1994). Backstrom (2002)
reported positive ou tcom es in a patient w ith d e Quervain
synd rom e u sing a m u ltim od al p rogram me inclu d ing p alm ar
m anip u lation of the cap itate, ‘conventional’ joint m obilization
and MWM techniqu es inclu d ing rad ial glid e of the proxim al
carp al row d u ring thu m b and w rist m otion and u lnar glid e
of the trap eziu m and trap ezoid bones d u ring active thu m b
m otion.
Re ecting the role of the w rist in the u p p er extrem ity
kinetic chain, Stru ijs et al (2003) com pared (a m axim u m of)
nine treatm ents over 6 w eeks of 15–20 minu tes of rep eated
p alm ar scap hoid glid ing m anipu lation and p assive w rist
ROM w ith a control treatm ent of friction m assage, u ltrasou nd
and strengthening in an RCT on 28 p atients w ith lateral ep i-
cond ylalgia. They rep orted a signi cant betw een-grou p d if-
ference on a global m easu re of im provement at 3 w eeks and
on pain at 6 w eeks, both results being in favour of the m anipu -
lation grou p .
Mobilization / Manipulation
of the Wrist and Hand
In the Kaltenborn concept, traction m obilization and m anipu-
lation are sp eci c translatoric techniqu es alw ays p erform ed
p erp end icu lar to the treatm ent p lane. When choosing a trans-
latoric glid ing m obilization techniqu e, clinicians need to con-
sid er the Kaltenborn convex–concave rule d escribing the
arthrokinem atic roll-glid ing com binations (Kaltenborn et al
2007). When the m oving joint partner has a convex joint
su rface, glid ing m obilization occurs in the d irection opposite
to the d irection of restricted bone movem ent. When the m oving
joint partner has a concave joint surface, glid ing m obilization
(in both cases w ith concurrent grad e I traction) occurs in the
sam e d irection as the restricted bone m ovement. Know led ge
of joint su rface geometry (Mink et al 1990) is, therefore, a
necessary prerequisite for appropriate glid ing m obilization
technique choice. It shou ld be noted that Mulligan MWM tech-
niques generally apply glid es perpend icular to, or even oppo-
site to, the d irections p roposed by the convex–concave ru le
– assum ing the presence of und e ned ‘minor positional faults’
interfering w ith norm al arthrokinem atic m ovem ent behav-
iou r. Unless otherw ise ind icated , all techniques d escribed in
this section are taken from Kaltenborn et al (2007).
In the d istal rad ioulnar joint, the rad iu s is the concave joint
partner and the u lna has the convex joint surface. Sup ination
requ ires a d orsal glid e of the d istal rad iu s and pronation a
palm ar glid e in relation to the d istal ulna.
The proxim al row of carpal bones offers a convex articular
su rface to the concave rad ius–triangu lar brocartilage
com p lex. This m eans that roll and glid e occu r in op p osite
d irections d uring rad iocarpal m ovem ents.
The situation is m ore com p lex in the articulation betw een
the p roxim al and d istal carp al row. The concave su rface on
trap eziu m and trap ezoid articu lates w ith a convex su rface on
the (biconvex) scap hoid . This m eans that, d u ring w rist exten-
sion, the trap eziu m and trap ezoid roll d orsally and also glid e
in a d orsal d irection and that, d u ring w rist exion, roll and
glid e of the trapezium and trap ezoid are both in a p alm ar
d irection. In ad d ition, w ith the trapeziu m –trapezoid com p lex
able to assu m e a m ore d orsal position, rad ial d eviation is
m ad e p ossible. In the central (lu nate / cap itate) and u lnar (tri-
qu etru m and ham ate) carp al bones, the p roxim al row has the
concave joint su rfaces, w hereas the d istal carp als have convex
joint su rfaces. That m eans that d u ring w rist extension the roll
of the cap itate and ham ate is d orsal, bu t their glid es are in a
p alm ar d irection. Du ring w rist exion, the ham ate and cap i-
tate roll p alm ar, bu t glid e d orsally. Du ring w rist extension,
the rad ial carp al bones lock early, bu t an ad d itional 52° occu rs
lunate and capitate. This requ ires the presence of a large
am ount of m obility betw een the scap hoid and the ad jacent
lunate.
The carp om etacarp al (CMC) II–IV joints are alm ost at
joints but the CMC V joint is a sellar joint. The concave su rface
on the fth m etacarpal ru ns m ed ial–lateral and the convex
su rface ru ns d orsal–p alm ar. The CMC I joint is also a sellar
joint. The concave d istal surface is involved in exion and
extension of the thu m b; the convex d istal surface is involved
in abd u ction and ad d u ction of the thu m b (i.e. roll and glid e
are in the sam e d irection for exion and extension), w hereas
for abd uction and ad d uction the roll is in the sam e d irection
to and the glid e is in the op p osite d irection to the bone
m ovem ent.
The d istal end of the m etacarpals I–V is biconvex; the p rox-
im al end of the proxim al phalanx is biconcave. Therefore, in
the MCP II–V joints, roll and glid e of the proxim al p halanx
are in the sam e d irection, w ith both exion–extension and
 Mobilization / manipulation o  the wrist and hand  587

Figure 52.2 Distal radioulnar joint dorsal glide radius. Figure 52.3 Radiocarpal traction.

rad ial–u lnar d eviations. The interp halangeal joints I–V are
hinge joints w ith the convexity p roxim al and the concavity
d istal, resu lting in roll and glid e in the sam e d irection d u ring
exion and extension.

Distal radioulnar joint dorsal glide radius

(Fig. 52.2)
This technique is ind icated in patients w ith restricted sup ina-
tion. The p atient is sitting w ith the arm by the sid e, and the
forearm su pported on table and supinated . The therapist
stand s facing the p alm ar sid e of the p atient’s forearm . The
stabilizing hand of the therap ist xates the d istal u lna on its
palm ar asp ect w ith the thenar and on its d orsal asp ect w ith
the ngertip s. The thenar p ortion of therap ist’s m obilizing
hand p rovid es d orsal glid ing m obilization to the d istal rad iu s.
This techniqu e can be perform ed in various p ositions of su pi-
nation u p to p athological end range.
Distal radioulnar joint ventral glide radius
This techniqu e is ind icated in p atients w ith restricted prona-
tion. The p atient is sitting w ith arm abd u cted at shou ld er,
forearm su pported on the table and pronated . The therapist
stand s facing the d orsal sid e of the p atient’s forearm . The
stabilizing hand of the therap ist xates the d istal u lna on its
palm ar asp ect w ith the ngertips and on its d orsal asp ect w ith
thenar or thu m b. The thenar p ortion of therap ist’s m obilizing
hand p rovid es ventral glid ing m obilization to the d istal
rad ius. This m obilization can be perform ed in variou s posi-
tions of p ronation u p to the p athological end range.
Distal radioulnar joint MWM
(Mulligan 2004)
This technique is ind icated in patients w ith restricted sup ina-
tion d u e to a m inor p ositional fau lt (note that the d irection of
glid e is opposite to norm al arthrokinem atic glid ing). The
patient is sitting, should er exed , elbow bent and forearm
su p inated . The therap ist is stand ing d orsal to the hand . The
therap ist p laces the ngers of the ip silateral hand on the
Figure 52.4 Radiocarpal traction in exion.
p alm ar asp ect of the d istal rad iu s and then covers these w ith
the ngers of the contralateral hand . The ip silateral thu m b is
p laced over the contralateral thu m b on the d istal d orsal asp ect
of the rad iu s. The ngers ap p ly d orsal glid ing to u lna and ,
m aintaining this, the p atient actively su p inates (w ith therap ist-
ap plied overpressure).
Radiocarpal traction
This techniqu e serves as a non-speci c joint m obilization. The
p atient is sitting, w ith arm p ronated and resting on w ed ge or
table. The therap ist stand s d istal to p atient’s w rist. The d istal
forearm is xated against a w ed ge by the therapist’s stabiliz-
ing hand ; the thenar portion stabilizes just proxim al to the
w rist. The m obilizing hand grasps the carpal bones ju st d istal
to the w rist joint and p erform s traction (Fig. 52.3).
This techniqu e can be m ad e m ore effective by various
d egrees of w rist exion (Fig. 52.4), extension (Fig. 52.5), rad ial
d eviation or u lnar d eviation; shifting the stabilizing and
m obilizing hand s d istally allow s for traction betw een the
d istal and proxim al carpal row s. This m obilization can be
m ad e m ore sp eci c w hen the m obilizing hand grasp s
one carp al bone w ith the thu m b d orsal and ind ex ngertip
ventral.
 588 PART 8 • 52 • Joint mobilization and manipulation
Figure 52.5 Radiocarpal traction in extension.
Figure 52.6 Radiocarpal palmar glide.
Radiocarpal palmar glide
This techniqu e is ind icated in patients w ith restricted w rist
extension. The patient is sitting, w ith arm pronated and
resting on a w ed ge or table. The therap ist is stand ing at the
u lnar sid e of the p atient’s w rist. The d istal forearm is xated
against a w ed ge by the therapist’s stabilizing hand ; the thenar
p ortion stabilizes ju st p roxim al to the w rist. The m obilizing
hand grasp s the p atient’s carp al bones ju st d istal to the w rist
joint and perform s the palm ar glid e (Fig. 52.6).
This m obilization can be also d one in variou s d egrees of
w rist extension (Fig. 52.7); shifting stabilizing and m obilizing
hand s d istally allow s for glid e betw een the d istal and p roxi-
m al carp al row s. It can be m ad e m ore sp eci c w hen the
head of m etacarp al II of the m obilizing hand is p laced on one
carp al bone.
Radiocarpal dorsal glide
This techniqu e is ind icated in patients w ith restricted w rist
exion. The patient is sitting, w ith arm supinated and resting
on a w ed ge. The therap ist is stand ing at the rad ial sid e of the
w rist. The d istal forearm is xated against the w ed ge by the
therap ist’s stabilizing hand ; the thenar p ortion stabilizes ju st
p roxim al to the w rist. The m obilizing hand grasps the carpal
Figure 52.7 Radiocarpal palmar glide in extension.
Figure 52.8 Radiocarpal dorsal glide.
bones ju st d istal to w rist joint and perform s the d orsal glid e
(Fig. 52.8).
This techniqu e can be also d one in various d egrees of w rist
exion (Fig. 52.9); shifting stabilizing and m obilizing hand s
d istally allow s for glid e betw een the d istal and proxim al
carp al row.
Radiocarpal radial glide (Fig. 52.10)
This technique is ind icated in patients w ith restricted ulnar
d eviation. The patient is sitting, w ith shou ld er abd ucted ,
forearm pronated and resting on a w ed ge, or can be also
su p ine, w ith shou ld er elevated and externally rotated . The
therap ist is stand ing at the p alm ar sid e of the w rist. The
p atient’s d istal forearm is xed against a w ed ge by the thera-
p ist’s stabilizing hand ju st p roxim al to w rist. The m obilizing
hand grasp s the carp al bones from the u lnar sid e, ju st d istal
to the w rist joint, and p erform s the rad ial glid e. This m obiliza-
tion can be d one in variou s d egrees of w rist u lnar d eviation.
Radiocarpal ulnar glide (Fig. 52.11)
This technique is ind icated in p atients w ith restricted rad ial
d eviation. The patient is sitting, w ith arm supinated and
resting w ith the ulnar aspect on a w ed ge. The therap ist is

Figure 52.9 Radiocarpal dorsal glide in exion.
Figure 52.10 Radiocarpal radial glide.
Figure 52.11 Radiocarpal ulnar glide.
stand ing at the d orsal sid e of the w rist. The d istal forearm is
xated against the w ed ge by the therap ist’s stabilizing hand
just proxim al to the w rist. The m obilizing hand grasps the
carp al bones from the rad ial sid e ju st d istal to the w rist joint
and p erform s the u lnar glid e. The m obilization can be also
d one in variou s d egrees of w rist rad ial d eviation.
Mobilization / manipulation o  the wrist and hand  589
Radiocarpal MWM (Mulligan 2004)
This techniqu e is ind icated in patients w ith restricted w rist
extension or exion d u e to a m inor positional fau lt (note the
d irection of glid e is perp end icular to norm al arthrokinem atic
glid ing). The patient is sitting. The therapist is stand ing proxi-
m al to the p atient’s w rist, and grasp s the latter ’s d istal forearm
w ith one hand so that the w eb betw een ind ex nger and
thu m b lies over the d istal rad iu s. The other hand grasp s the
p roxim al carp al row from the u lnar asp ect so that the w eb
sp ace is now over the triqu etru m . Rad ial translation is ap p lied
to the p roxim al carp al row u ntil a d irection is fou nd that
allow s the p atient to perform previously p ainfu l active w rist
exion or extension.
Opponens roll (Sucher 1994)
This techniqu e is ind icated in patients w ith d ecreased length
of the exor retinacu lu m im p licated in the aetiology of CTS.
The patient is sitting, w ith arm supinated and resting on the
table. The therap ist is stand ing d istal to p atient’s hand . The
thu m b and thenar p ortion of the ip silateral hand stabilize
the u lnar p alm ar asp ect of the hand . The thu m b is then
brought into abd u ction w ith slight extension and su pination
along the axis of the rst m etacarpal bone by the contralateral
hand of the therap ist.
Transverse carpal extension
(Sucher et al 2005)
This techniqu e is ind icated in patients w ith d ecreased length
of the exor retinacu lu m im p licated in the aetiology of CTS.
The patient is sitting, w ith arm supinated and resting on the
table. The therap ist is stand ing d istal to the p atient’s hand .
The m obilization consists of a three-p oint bend ing techniqu e
w hereby the therap ist hooks his / her thum bs on the inner
p alm ar ed ge of the carp al bones (trap eziu m and ham ate d is-
tally, scap hoid and p isiform p roxim ally) w hile his / her
ngers w rap arou nd d orsally to converge on the centre of the
p atient’s w rist, p rovid ing a cou nterforce. The techniqu e can
be d one com bined w ith passive thu m b and little nger abd u c-
tion and extension or w ith the op p onens roll techniqu e.
Sim ilar three-p oint techniqu es over the m etacarp al bones
cau sing concave and convex m ovem ents of the m etacarp al
arch can be d one as a general m obilization for the interm eta-
carp al connections.
Radial carpal palmar glides
This techniqu e is ind icated in patients w ith restricted w rist
extension and rad ial d eviation. The patient is sitting, w ith arm
p ronated and resting on a w ed ge. The therap ist is stand ing at
the u lnar sid e of the p atient’s w rist, and the d istal rad iu s is
xed against the w ed ge by the therap ist’s stabilizing hand ;
the thenar p ortion stabilizes d orsally ju st p roxim al to w rist
w ith the ngers p alm ar. The m obilizing hand grasps the
p atient’s hand from the rad ial sid e; w ith the thenar em inence
d orsal against the scaphoid , the therapist glid es the scaphoid
p alm ar. Movem ent of the xation d istally to inclu d e the
scap hoid and m obilization of the trap eziu m and trap ezoid in
 590 PART 8 • 52 • Joint mobilization and manipulation
Figure 52.12 Central carpal palmar glides.
a p alm ar d irection increase restricted exion and u lnar
d eviation.
Central carpal palmar glides (Fig. 52.12)
This techniqu e is ind icated in patients w ith restricted w rist
extension. The patient is sitting, w ith arm pronated and
resting on a w ed ge. The therapist is stand ing d istal to the
p atient’s w rist, and the d istal rad iu s is xed against the w ed ge
by a xation belt. The therapist, w ith one hand , grasps the
p atient’s hand from the rad ial sid e w ith the thum b d orsal and
ind ex nger p alm ar over the lu nate; the hyp othenar of the
other hand p laced over his / her ow n thu m b glid es the lu nate
p alm ar. Movem ent of the xation d istally to includ e the
lu nate and m obilization of the cap itate in a p alm ar d irection
increase restricted extension.
Ulnar carpal palmar glides
This techniqu e is ind icated in patients w ith restricted w rist
extension. The patient is sitting, w ith arm pronated and
resting on a w ed ge. The therapist is stand ing d istal to the
p atient’s w rist, and the d istal u lna is xed against the w ed ge
by a xation belt. The therapist grasp s the patient’s hand from
the u lnar sid e w ith the thu m b d orsal and ind ex nger p alm ar
over the triqu etru m ; the hyp othenar of the other hand p laced
over his / her ow n thu m b glid es the triqu etru m p alm ar.
Movem ent of the xation d istally to inclu d e the triqu etru m
and m obilization of the ham ate in a p alm ar d irection increase
restricted extension.
Radial carpal dorsal glides
This techniqu e is ind icated in patients w ith restricted w rist
exion and u lnar d eviation. The patient is sitting, w ith arm
su p inated and resting on a w ed ge. The therap ist stand s d istal
to the p atient’s w rist, and the d istal rad iu s is xated d orsally
against the w ed ge by a xation belt. With one hand the thera-
p ist grasp s the p atient’s hand from the rad ial sid e w ith the
thu m b p alm ar on the scap hoid and ngers d orsal; the hyp oth-
enar of the other hand is p laced on his / her ow n thu m b and
p rod uces the d orsal glid e. Movem ent of the xation d istally
Figure 52.13 Carpal glide manipulation with proximal xation.
to inclu d e the scap hoid and then m obilization of the trap e-
zium and trap ezoid in a d orsal d irection w ill increase restricted
extension and rad ial d eviation. With all carpal d orsal glid es,
the therap ist m ay need to ‘soften’ contact on the often-p ainfu l
p alm ar asp ect of the carp al bones, for exam p le by u sing the
head of the second m etacarp al rather than the thu m b as a
p alm ar contact.
Central carpal dorsal glides
This m obilization is ind icated in patients w ith restricted w rist
exion. The patient is sitting, w ith arm sup inated and resting
on a w ed ge. The therap ist stand s d istal to the p atient’s w rist,
and the d istal rad iu s is xated d orsally against the w ed ge by
a xation belt. The therapist w ith one hand grasp s the hand
from the rad ial sid e w ith the thu m b (or ‘softer ’ contact) p alm ar
on the lu nate and the ind ex nger d orsal; the other hand
p laces the hyp othenar on his / her ow n thu m b and p rod u ces
a d orsal glid e. Movem ent of the xation d istally to inclu d e
the lu nate and m obilization of the cap itate in a d orsal d irec-
tion increase restricted exion.
Ulnar carpal dorsal glides
This m obilization is ind icated in patients w ith restricted w rist
exion. The patient is sitting, w ith arm sup inated and resting
on a w ed ge. The therap ist stand s d istal to the p atient’s w rist,
and the d istal u lna is xated d orsally against the w ed ge by a
xation belt. The therap ist’s hand grasp s the hand from the
u lnar sid e w ith thu m b (or ‘softer ’ contact) p alm ar on the tri-
qu etru m and ind ex nger d orsal; the other hand p laces the
hyp othenar on his / her ow n thu m b and p rod u ces a d orsal
glid e. Movem ent of the xation d istally to includ e the tri-
qu etru m and m obilization of the ham ate in a d orsal d irection
increase restricted exion.
Carpal glide manipulation with proximal
xation (Fig. 52.13)
This m anipu lation is ind icated in patients w ith restricted
w rist extension (in the p resence of norm al rad ial and u lnar
d eviation). The patient stand s w ith the arm exed forw ard at
 Mobilization / manipulation o  the wrist and hand  591

the shou ld er. The therap ist stand s in front of the p atient and
grips the latter ’s hand from both sid es. The ind ex ngers on
top of each other stabilize the lu nate on its p alm ar asp ect. The
cap itate bone is contacted w ith the p ad s of thu m bs on top of
each other on its d orsal aspect. Slack is taken up and tightened
betw een the ind ex ngers and thu m bs. The im p ulse consists
of a qu ick d ow nw ard m ovem ent of the p atient’s arm and
w rist from a slightly exed position. The m ovem ent stops
su d d enly, w hen the w rist is in the zero p osition (not in exten-
sion). A traction com p onent is m aintained throu ghou t the
w hole p roced u re. This techniqu e can be app lied for w rist
extension restrictions resulting from joint restrictions betw een
rad ius and lunate, lu nate and capitate (d escribed above) and
rad ius and scap hoid . The site of restriction in case of restricted
extension and rad ial d eviation is m ostly betw een the rad iu s
and scap hoid , and / or the scap hoid and trapezoid –trapezium
com p lex. (A m anip u lation to restore m ovem ent betw een the
scap hoid and trap ezoid –trap eziu m com p lex in case of
restricted extension and rad ial d eviation is d escribed not here
bu t und er the next techniqu e.) N ote that proxim al xation on
the p alm ar asp ect of the scap hoid w ith a thru st ap p lied to the
d orsal asp ect of the trapezoid –trapeziu m com plex serves to
increase w rist exion.
the p roxim al bone is m oved in a p alm ar d irection, resu lting
in relative d orsal m ovem ent of the d istal bone. This techniqu e
can be u sed for all bones in the p roxim al and d istal row. N ote
that carp al glid e m anip u lation of the scap hoid w ith d istal
xation of the trapezoid –trapezium com plex is u sed for
restricted w rist extension and rad ial d eviation.
Carpometacarpal I traction
The patient is sitting, w ith the arm stabilized w ith its u lnar
aspect against the table. The therap ist is stand ing p roxim al to
the p atient’s hand . The stabilizing hand of the therap ist xates
the trap eziu m w ith the thu m b p alm ar and ngers d orsal. The
therap ist’s m obilizing hand grasp s the rst m etacarp al w ith
the thenar d orsal (rad ial) and nger p alm ar and ap p lies trac-
tion (Fig. 52.15). Sim ilar techniqu es w ith the hand pronated
on the table, the p roxim al joint p artner stabilized , and the
m etacarp al bone tractioned can be u sed for the CMC II–V
joints (Fig. 52.16).

Carpal glide manipulation with distal xation

(Fig. 52.14)
This m anipu lation is ind icated in patients w ith restricted
w rist exion. The patient stand s w ith the arm exed forw ard
at the shou ld er. The therapist stand s in front of the p atient
and grip s the latter ’s hand from both sid es. The ind ex ngers
on top of each other stabilize the cap itate on its p alm ar asp ect.
The lunate is contacted w ith the pad s of the thum bs on top of
each other on its d orsal aspect. Slack is taken up and tightened
betw een the ind ex ngers and thu m bs. The im p ulse consists
of a qu ick d ow nw ard m ovem ent of the p atient’s arm and
w rist from a slightly exed position. The m ovem ent stops
su d d enly, w hen the w rist is in the zero p osition (not in exten-
sion). A traction com p onent is m aintained throu ghou t the
w hole proced ure. Often the palm ar aspects of the carp al Figure 52.15 Carpometacarpal I traction.
bones are too sensitive to have a thru st applied to them .
Therefore, w ith d istal xation, the d istal bone is stabilized and

Figure 52.14 Carpal glide manipulation with distal xation. Figure 52.16 Carpometacarpal II–V traction.
 592 PART 8 • 52 • Joint mobilization and manipulation
Figure 52.17 Carpometacarpal I glides.
Carpometacarpal I glides
(Fig. 52.17)
These techniqu es are ind icated in patients w ith restricted
thu m b m ovem ents. The stabilizing hand grasp s the trap e-
ziu m w ith the thu m b d orsal and ind ex nger p alm ar, and
xes it in a p osition m axim ally rotated tow ard s the p alm . The
m obilizing hand grasp s the rst m etacarp al ju st d istal to the
CMC I joint sp ace and ap p lies the glid es:
1. For restricted abd uction and ad d u ction, the patient sits
w ith the u lnar sid e of the hand against the therap ist’s
bod y (Fig. 52.17). For restricted abd u ction, the glid e is in
a d orsal d irection. For restricted ad d u ction, the glid e is
in a palm ar d irection (convex ru le).
2. For restricted extension and exion, the patient’s hand
is tu rned , so that the d orsal sid e is against the
therap ist’s bod y (not p ictu red ). For restricted extension,
the glid e is in a rad ial d irection. For restricted exion,
the glid e d irection is u lnar (concave ru le).
Metacarpophalangeal I MWM
(Folk 2001; Hsieh et al 2002)
This m obilization in ind icated in patients w ith restricted MCP
I m otion d ue to a m inor positional fau lt (m ed ial or lateral
glid e is perp end icu lar to norm al arthrokinem atic glid ing).
The patient is sitting, w ith elbow bent and forearm su pinated .
The therap ist is stand ing or sitting at the rad ial aspect of the
p atient’s w rist. The therap ist stabilizes the rst m etacarpal
bone betw een ind ex nger and thu m b and applies a lateral or
m ed ial glid e or long-axis rotation that allow s the p atient to
p erform a p reviou sly p ainfu l m otion.
Finger joint traction (Fig. 52.18)
The patient is sitting, w ith arm su pinated , w ith the d orsu m
of his / her hand resting on a w ed ge or table. The therap ist
is sitting or stand ing at the d istal asp ect of the p atient’s
Figure 52.18 Finger-joint traction.
hand . The thenar em inence of the therap ist’s stabilizing hand
xates the p roxim al joint p artner; the m obilizing hand then
grip s the d istal joint partner and applies traction. The tech-
niqu e can be d one in variou s nger joint p ositions; shifting
xation d istally allow s for traction to rst MCP, then p roxim al
interphalangeal (PIP), then d istal interphalangeal (DIP) joints.
Finger-joint glides
This technique in ind icated in patients w ith restricted MCP,
PIP or DIP extension. The p atient is sitting, w ith arm su p i-
nated , and the d orsu m of his / her hand resting on the w ed ge
or table. The therap ist is sitting or stand ing at u lnar asp ect of
the p atient’s hand . The thenar em inence of the therap ist’s
stabilizing hand xates the p roxim al joint p artner; the m obi-
lizing hand then grip s the d istal joint partner and applies a
d orsal glid e. With the hand pronated , a palm ar glid e can be
ap plied to m obilize exion. Rad ial and u lnar glid es can also
be used at the MCP joints to restore rad ial and u lnar d evia-
tion, resp ectively.
Finger joint MWM (Mulligan 2004)
This technique is ind icated in patients w ith restricted PIP or
DIP exion d u e to m inor positional fault (the d irection of
glid e is p erpend icu lar to norm al arthrokinem atic glid ing).
The patient is sitting, and the therap ist is stand ing to the sid e
of the p atient. The therap ist xes the p roxim al p artner betw een
the thu m b and ind ex nger. A m ed ial or lateral glid e is
ap plied to the d istal joint p artner u ntil a d irection is fou nd
that allow s the p atient to p erform p reviou sly p ainfu l active
PIP or DIP nger exion.
Acknowledgements
The au thors w ould like to gratefully acknow led ge the librar-
ian of the Physical Therapy Association of British Colu m bia,
Ms. Deb Monkm an, MLS, BSc, for her help in retrieving the
references u sed in this chapter.

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 PART 8 •  The Wrist and Hand Regions in Upper Extremity Pain Syndromes
Finger and Thumb Pathology
53  Chapter 
J o y C . M a c De rm id , Ru b y G re w a l, B. J a n e Fre u re
CHAP TER CONTENTS
Introduction  594
Digital fractures  594
Epidemiology: incidence, prevalence, economic impact  594
Anatomy  594
Pathology  595
Diagnosis of digital fractures  596
Prognosis for digital fractures  596
Conservative treatment of digital fractures  596
Ulnar collateral ligament injury of the thumb  598
Epidemiology  598
Anatomy  598
Pathology  599
Diagnosis  599
Prognosis  600
Conservative treatment of UCL injury  600
Other digital tendon injuries  600
Osteoarthritis of the digits  600
Epidemiology  600
Anatomy  600
Pathology  600
Diagnosis  601
Prognosis  601
Conservative treatment of digital arthritis  601
Rheumatoid arthritis affecting the digits  601
Conclusion  601
Introduction
Physical therap y for the hand m u st em brace an u nd erstand -
ing of the hand as an ‘organ’ that interfaces the p erson w ith
their w orld by bringing in sensory inform ation, and allow ing
the p erson to engage in activity that d eterm ines fu nction and
qu ality of life. The hand has intricate anatom ical stru ctu res in
close p roxim ity that contract, glid e and heal follow ing
inju ry. Maintenance of joint m obility and stability w hile the
stru ctu res in the p roxim ity rem ain free to glid e and resist
 
contractile forces is critical to hand m otor p erform ance. Issu es
of m otor control and sensory m otor integration are critical to
the fu nctionality of the hand . Exqu isitely innervated , the hand
can serve as a sensory organ or contribu te p ainfu l stim u li that
alter the cortex and p rod u ce chronic pain. Manu al therap y
techniqu es can contribu te to norm alizing the neu rosensori-
m otor fu nction of the hand , in com bination w ith other tech-
niqu es. In this chap ter w e highlight the m ost p revalent
cond itions affecting the d igits.
Digital Fractures
Epidemiology: incidence, prevalence
and economic impact
H and fractu res are com m on traum atic inju ries, u su ally arising
d u ring w orkplace, sp orting or recreational activities. Frac-
tu res of the m etacarp als and p halanges are m ost com m on
(H ove 1993; van Onselen et al 2003; Aitken & Cou rt-Brow n
2008; Feehan & Shep s 2008), and in particular the ou ter d igits
(i.e. thum b / sm all nger). The m ajorities are treated conserv-
atively (Feehan & Shep s 2008). Metacarpal fractu res represent
35% of hand fractures.
Anatomy
To u nd erstand hand fractu res better, one m u st rst u nd er-
stand the relationship betw een soft tissu e and bony factors
that contribu te to both soft tissu e and skeletal stability. We
su ggest that read ers consu lt a stand ard anatom y text or The
electronic textbook of hand surgery (http:/ / w w w.eatonhand .com /
hom / hom 033.htm ) w ebsite for d etails of hand / w rist anatom y
as this chapter w ill highlight only the key elem ents. The
w ebsite has prim al pictures (u sed w ith perm ission), som e
rad iographic im ages of anatom y and pathology and inform a-
tion on variou s bony and soft tissu es, p rovid ing accessible
and clearly visualized aspects of key anatom ical featu res.
More-d etailed d escrip tions of anatom ical featu res are availa-
ble in the classic anatom y textbooks.

Pathology
Bone fractu res resu lt from excessive force, in com p arison
to bone strength. Fractu re angu lation is d eterm ined by the
forces exerted by the soft tissu es on both the proxim al and
the d istal fragm ents. Movem ent recovery follow ing fractu re
can be affected by the natu re and severity of the original
fracture, associated soft tissu e inju ries and the extent of
m alalignm ent in bony stru ctu re that occu rs follow ing bone
healing.
The m echanism of injury p lays a role in the typ e of frac-
tu res that shou ld be anticip ated . A d irect blow w ill resu lt
in a transverse fractu re, a tw isting inju ry w ill cau se a spiral
fracture and com bination of torque and axial force w ill resu lt
in a short oblique fractu re. Fractures are fu rther classi ed
accord ing to the location (e.g. head , neck, shaft or base of a
sp eci c hand bone) and any associated soft tissu e inju ry.
All fractu res are associated w ith soft tissue injury. The
natu re of these inju ries can be d if cu lt to d eterm ine even w ith
im aging and clinical exam ination. Mu scle and ligam ent inju-
ries can be im portant asp ects of the fracture and m ay becom e
m ore evid ent as the fractu re heals and sw elling su bsid es,
or w hen m ovem ent is initiated . Scar healing of inju red soft
tissu e can be a su bstantial com p onent of active m ovem ent
lim itation.
Metacarpal fractures
The m etacarpal bones have intrinsic stability p rovid ed by
strong interosseu s ligam ents bind ing them to the carp al
bones, and proxim ally by the transverse m etacarp al ligam ent,
w hich links all the m etacarpal head s. The ligam ents tend to
prevent excessive d isp lacem ent w ith inju ry. The fth m eta-
carp al is com m only fractu red d u ring a ‘p u nch’ m echanism
(the m ajority of these inju ries occur in m ales) and is treated
conservatively since fu ll m otion / fu nction is often obtained
d espite m alrotation. There is generally a good blood supp ly,
w hich su p p orts high rates of healing, usually w ithin 4–6
w eeks. The m ost im portant soft tissu e concerns are to pre-
serve m id d le p halanx (MP) joint exion and m aintain exten-
sor d igitoru m com m u nis (EDC) glid e.
Fractu res of the base of m etacarp als are intra-articu lar frac-
tu res that u su ally resu lt from high forces d isru p ting the rigid
carp al ligam ents of the ind ex and m id d le nger or over-
w helm ing the norm al exibility of the ulnar m etacarpals.
Shaft fractu res are extra-articu lar fractu res that u su ally arise
d u ring a fall or blow and usually angulate d orsally (w ith
com p onents of shortening or rotation). They are d escribed as
transverse, obliqu e or sp iral. Intrinsic m u scle tension w ill
cau se both end s of the m etacarp al bone to ex into an ap ex
d orsal presentation. This causes a shortening, w hich com pro-
m ises the extensor m echanism by altering the m u scle length
relationship. Metacarpal neck fractu res are the m ost com m on
m etacarp al fractu re (‘boxer ’s fractu re’). The im p act of a closed
st cau ses a break at the extra-articu lar neck. If associated
w ith a bite, infection is a potential com p lication that can su b-
stantially increase tissu e d am age. Metacarp al head fractu res
are intra-articu lar fractures caused by high axial load ing that
m ay involve collateral ligam ents and su bstantial com m inu -
tion. These fractu res can lead to chronic p ain and joint
instability.
Digital fractures 595
Phalangeal fractures
Phalangeal fractu res have greater tend ency tow ard s instabil-
ity as the phalanges lack intrinsic m uscle sup port and are
ad versely affected by the m echanical forces of the extrinsic
exors and extensors. H ow ever, these fractu res are also m ore
likely to becom e stiff w ith im m obilization (Shehad i 1991);
the pred icted m otion retu rn is 84%, bu t if the p eriod of
im m obilization is longer than 4 w eeks, the p red icted m otion
is 66%.
Intra-articular fractures of the base of the proxim al phalanx
(PP) u su ally occu r follow ing an abd u ction force, w hich is
m ost com m only seen in sp orts inju ries or a fall. Disp laced
fractu res m ay not be red u cible conservatively because of col-
lateral ligam ent avulsion, w hich w orsens the fracture d is-
p lacem ent w ith MP exion. This can lead to higher rates of
non-u nion if m anaged conservatively (Shew ring & Thom as
2006). PP shaft fractu res have the poorest prognosis for regain-
ing of fu ll ability as they occu r in exor zone II. As 90% of the
PP su rface is covered by glid ing stru ctu res, these can easily
becom e ad hered to the fracture callus. PP cond yle fractu res
u su ally occu r w ith the lateral d eviation force and m ay be
associated w ith collateral ligam ent inju ry. This is a com m on
sp orts inju ry, and a com m only m issed d iagnosis.
The interossei and lu m bricals m u scles are the prim e MCP
exors. The lum bricals originate from the tend ons of the
exor d igitorum profu nd us tend on, and the three palm ar and
fou r d orsal interossei m u scles originate from the volar and
d orsal surfaces of the m etacarp al respectively (Sm ith 1975).
The interossei insert onto the anterolateral base of the PP
and the extensor m echanism form ing part of the lateral band
w ith the lu m bricals, w hich also inserts d orsally into the exten-
sor ap p aratu s. These intrinsic m u scles, along w ith the extrin-
sic exor tend ons, create d eform ing forces on the fractu red
m etacarp al shaft that resu lt in ap ex d orsal angu lation (Flatt
1996). A PP fractu re w ill typically angu late w ith an apex volar
d eform ity because the interossei w ill ex the proxim al frag-
m ent, ow ing to their insertion at the PP base, w hile the d istal
fragm ent is p ulled into hyp erextension by the central slip ,
w hich inserts at the base of the m id d le phalanx and acts to
extend the d istal fragm ent.
Fractu res of the shaft of the MP occu r less com m only, and
m ay d isp lace either d orsally or volarly. Intra-articu lar frac-
tu res at the base of the MP occu r com m only from a fall or
d irect force. These m ay be associated w ith proxim al inter-
p halangeal (PIP) joint d islocation and d am age to the volar
p late and / or central slip . If the com p ression trau m a is severe,
a com m inu ted fractu re of the articular surface occu rs, w ith
d epression of the fragm ents into the bone shaft or ‘p ilon’
fractu re. MP fractures of the d istal third tend to angu late w ith
an apex volar d eform ity as the exor d igitoru m su p er cialis
(FDS) acts to ex the p roxim al fragm ent. A proxim al third
fractu re usu ally angulates w ith an apex d orsal d eform ity as
the FDS w ill ex the d istal fragm ent w hile the central slip
extend s the proxim al fragm ent.
Distal phalanx (DP) fractu res are com m on d u ring cru sh
injuries and m ay not d isplace signi cantly because the p res-
ence of a rigid nail plate d orsally help s to p reserve alignm ent.
H ow ever, d ue to the space restrictions inherent in the nger-
tip anatom ical stru ctu res and their d ense innervations, these
inju ries can be p articu larly p ainfu l. The DP accou nts for 50%
of hand fractu res, w hich m ay be attribu ted to its vu lnerability
 596 PART 8 • 53 • Finger and thumb pathology
as the ngertip. Tend on avu lsion can occu r either alone or
w ith a variable am ou nt of the articu lar surface ‘chip fractu re’.
This com m only occu rs in sports and hence the existence
of sp ort-related nam es for these inju ries (‘jersey’ = exor
avulsed from the volar base of the DP; ‘baseball’ = avu lsion of
the term inal extensor tend on from the DP). PP shaft fractu res
are proxim al to the nail bed and u su ally resu lt from d irect
trau m a. PP tu ft fractu res are the m ost d istal fractu re and can
be qu ite painful and d if cult to m anage since union m ay
be slow.
Thumb fractures
The rst carpom etacarpal (CMC) joint is a d ou ble sad d le-
joint, w hich allow s m ovem ent both in the exion / extension
p lane and in abd u ction / ad d u ction. Becau se of the w id e
range of m otion (ROM) present at the thu m b CMC joint,
angu lation of u p to 30° is w ell tolerated , allow ing full function
to be achieved in rehabilitation even w hen p re-m orbid joint
m obility is not attained . In extra-articu lar fractu res, d orsal
angu lation occurs because the abd u ctor p ollicu s brevis,
ad d u ctor p ollicis and exor p ollicis brevis m u scles attaching
at the base of the PP act to ex the d istal fragm ent w hile the
abd u ctor p ollicus longu s m u scle (w hich attaches to the m eta-
carp al base) extend s the p roxim al fragm ent. A Bennett frac-
tu re is an intra-articu lar fractu re involving the m etacarp al
base. The fractu re fragm ent involves the volar–u lnar portion
of the m etacarp al base. This fragm ent is held u nd isp laced by
the anterior obliqu e ligam ent. The rem aind er of the thu m b
m etacarp al u su ally su blu xes rad ially, p roxim ally and d orsally
by the forces exerted by the abd uctor pollicu s longus.
Diagnosis of digital fractures
The focus of assessm ent d ep end s on the stage of healing.
Clinical and rad iograp hic assessm ent of fractu re u nion shou ld
be perform ed u ntil u nion is established . Clinical signs of non-
u nion inclu d e exqu isite local p ain at the fractu re site and
m ovem ent of the fractu red com p onents. Com p u ted tom ogra-
p hy can be a u sefu l ad ju nct to rad iograp hs as it can help to
d elineate accurately the d egree of articu lar d isplacem ent and
can id entify other associated inju ries. Rad iograp hs are rou -
tinely u sed to id entify fractu res and to d eterm ine the d egree
of d isp lacem ent; how ever, X-ray cannot be u sed to ru le ou t a
rotational d eform ity. Patients can be asked to ex their d igits
actively to d eterm ine w hether there is any scissoring of the
d igits (i.e. overlap). If pain from the acute inju ry preclu d es an
active exion effort, passive w rist exion and extension w ill
p lace a exion m om ent across the ngers, w ith the tenod esis
effect allow ing an assessm ent of rotation to be m ad e. A thor-
ou gh clinical assessm ent shou ld be m ad e to d eterm ine
w hether there is any associated soft tissu e or neurovascular
inju ry and to id entify any rotational d eform ity. Assessm ent
shou ld inclu d e evalu ation of im p airm ents and d isabilities
arising from fractu re com p lications or treatm ent sequ elae. A
su m m ary of these and p otential treatm ent ap p roaches are
d escribed in Table 53.1.
Prognosis for digital fractures
Prognosis varies accord ing to the ou tcom e of interest. Su ccess-
fu l union of the fractu re and restoration of norm al anatom y,
p re-inju ry m ovem ent / grip strength and fu nction are typ ical
goals and outcom es evalu ated . Union is d ep end ent on the
p erson’s ind ivid u al cap acity for bone healing and is thu s
affected by p rognostic factors that affect bone healing in a
generic sense, inclu d ing ind ivid ual p hysical factors (nu trition,
com orbid ity, age, bone qu ality), the bone affected (com p osi-
tion, blood su p p ly, biom echanics), behaviou r (com p liance
w ith xation, im m obilization, rem obilization, rehabilitation,
activity levels), inju ry (type of fractu re, size of d efect, soft
tissu e com p onents, associated inju ries) and com p lications
(nerve com pression, infection, loss of red u ction).
Op tim al anatom ical ou tcom es and fu nctional ou tcom es are
m od erately related , in that m alu nion can lead to d ecreased
p ain, grip strength, scissoring, or loss of joint m otion (Synn
et al 2009). H ow ever, poor fu nctional ou tcom es can occur in
the p resence of good anatom ical restoration, p articu larly
w here pronou nced joint stiffness, chronic pain, or chronic
regional pain synd rom e exist (Field et al 1992; Field & Atkins
1997). Conversely, ad equ ate fu nctional outcom es are attained
in old er sed entary ind ivid u als d espite lack of restoration of
norm al anatom y (Grew al & MacDerm id 2007). When fractu re
m alu nion resu lts in scissoring, a corrective rotational osteot-
om y m ay be requ ired .
Evid ence on p rognosis and fractu res is generally sp arse
and of p oor qu ality (level IV stud ies). One stud y found that
functional (DASH ), aesthetic and fracture u nion ou tcom es in
m etacarp al shaft and neck fractu res w ere not affected by
p alm ar angu lar d eform ity, bu t fu nctional and aesthetic ou t-
com es w ere better in non-op eratively m anaged p atients
(Westbrook et al 2008). Spiral / long obliqu e fractures of the
shaft of the m etacarp al are at risk of shortening and resu ltant
extension lag and red u ced grip strength. H ow ever, there m ay
be p rogressive recovery of the extension lag by 1 year and a
m ean of 94% of the contralateral hand m otion by 1 year after
injury (Al-Qattan 2008). In 51 u nstable m etaphyseal MP and
PP fractu res w here xation w as m aintained w ith m iniatu re
titaniu m p lates u nion, the nal range of total active m otion
(% TAM) w as excellent (> 85%) for 26, good (70–84%) for 17,
fair (50–69%) for 5, and poor (< 49%) for 3 (Om okaw a et al
2008). Postoperative com plications includ ed loss of red u ction
(2 cases), cond ylar head collap ses (2 cases) and one sup er cial
infection. Plates w ere rem oved in 30 cases, and ad d itional
su rgery w as required in 20 cases. Postoperative grip strength
averaged 87% that of the contralateral sid e. Old er age, intra-
articu lar fractu re, phalangeal bone involvem ent and soft
tissu e inju ry w ere associated w ith a p oorer range of nger
m otion follow ing fractu re (Om okaw a et al 2008). A level IIb
stud y of 120 MC and PP em ergency room fractures ind icated
that infection, increased bony d efect and associated soft tissu e
injury increased the risk of non-u nion (Ali et al 2007). In
another stu d y, 36% of MC or PP fractures show ed d ifferent
com p lications; PP and op en fractu res w ere at higher risk for
stiffness, non-u nion, p late p rom inence, infection and tend on
ru p tu re (Page & Stern 1998).
Conservative treatment of digital fractures
The general p rinciples of fractu re m anagem ent are to red uce
the fractu re (op en or closed ) in a m anner that w ill restore
norm al anatom y and to m aintain the red u ced p osition
throu gh an im m obilization / xation technique that is su f -
cient to w ithstand the p otential for loss of red u ction throu gh
 Digital fractures 597

Table 53.1 Summary of tre a tme nt proble ms a nd a s s ociate d tre a tme nt te chniques for ha nd fracture s
Prob le m Phys iothe ra p e utic tre a tme nt s tra te g ie s

Fracture protection (Fes s et al Custom-made or off-the-shelf orthoses

2004)
Pain Frequent, low-intens ity active exercis e of unaffected joints and affected joints when s table
Adequate fracture protection and oedema management
Desensitization programme
Electrothermal agents
Coordinate pharmacological management and therapy
Nerve irritation / neuroma Desensitization programme (Robinson & McPhee 1986; Waylett-Rendall 1988)
Iontophoresis with lidocaine – evidence in other conditions (Fedorczyk 1997; Bas kurt et al 2003;
Bolin 2003; Yarrobino et al 2006; Polomano et al 2008)
Mirror box therapy (Alts chuler & Hu 2008; Ezendam et al 2009) – limited evidence
Visualization exercis es – limited evidence
Nerve-gliding / neurodynamic techniques focus ed on at-ris k or s ymptomatic nerve bias
Oedema Exercise in elevation
Compres sion (compress ive gloves, retrograde mass age, Coban wrap, s tring wrapping (Flowers
1988) (especially for digits )
Thermal agents (cold in acute stages for those who can tolerate; heat s hould be us ed only in
elevation with monitoring of volume)
Phys ical agents (high-voltage stimulation) (Stralka et al 1998)
Loss of joint motion (Michlovitz Active exercise of affected joints (s table xation or healed)
et al 2004) Phys iological and acces sory joint mobilization
Static progress ive splinting
Dynamic s plinting
Continuous pass ive motion (Soffer & Yahiro 1990) (low evidence in other upper extremity joints)
Constrained movement therapy (blocking or casting of adjacent mobile digits to enforce
movement of stiff joints)
Loss of power Progress ive resis ted exercis e (Hos tler et al 2001; Bautmans et al 2009)
Loss of endurance Progress ive resis ted exercis e
Progress ive functional activity
Scissoring Buddy tape to adjacent digit
May require osteotomy
Joint Instability Buddy taping, taping, cus tom or premade orthoses
Activity modi cation to avoid lateral s tres s
Non-union Low-dos e ultrasound (Buss e et al 2002; Grif n et al 2008)
Abnormal s ens orimotor integration Sensorimotor retraining (focused, progress ive retraining of normal sensory responses )
or motor control Motor control exercises
Dexterity training / functional activity
Prevention of future fractures Ass ess ris k for future fracture (bas ed on age mechanism of injury and comorbid s tatus)
Manage modi able ris k factors (safety training, activity modi cation, protective devices, fall
prevention, balance training as needed)
General In s imple, clos ed metacarpal fractures, early motion has the potential to res ult in earlier recovery of
mobility and s trength, facilitate an earlier return to work, and not affect fracture alignment
(Feehan & Bas sett 2004)
Dors al s kin s car contracture Silicone gel / topical agents to s uper cial s cars
Scar mas sage / mobilization for adherence
Simultaneous heat, s tretch and tendon-gliding exercises (Wehbe 1987)
Scar mobilization with hand-held s uction device
Ultras ound
Laser
MP joint contracted an extens ion Early pos itioning MP joint at 70°
Later dynamic or s tatic progres sive s plinting of MP
Continued
 598 PART 8 • 53 • Finger and thumb pathology

Table 53.1 Summary of tre a tme nt proble ms a nd a s s ociate d tre atme nt te chnique s for ha nd fracture s —cont’d
Prob le m Phys iothe ra p e utic tre a tme nt s tra te g ie s

Intrins ic mus cle contracture Early – active intrinsic minus exercises; blocking exercise
Later – dynamic splinting; muscle stimulation
Abs ence of MP head Educate patient about s hortening of metacarpal; as ses s whether any functional implications (may
not affect functional outcome)
Ass ess functionality of extensors ; if redundancy is apparent s plinting extens ion at night and
s trengthen intrinsic
Ass ess alignment – volar prominence = volar angulation and may require adaptive
padding / gloves / positioning or os teotomy
Communicate with health care team
Loss of IP extens ion Blocking exercis es
MP block extension splint during the day
PIP extension splint thing at night
Neuromuscular s timulation to EDC and inter-ross ei
Joint mobilizations
Loss of IP exion FDP / FDS tendon glide exercis es
Daytime MP exion blocks blunting
Dynamic or static progress ive nights splinting
Heat and composite stretching
Joint mobilizations
Stretch of oblique retinacular ligament
Boutonniere deformity Early – DIP active exion to maintain length of lateral bands
Later – s plinting
Swan neck deformity Orthotic to hold MP joint in exion
(From: Freeland et al 2003; Hardy 2004.)

d eform ing or external forces. Since im m obilization lead s
to com orbid stiffness / w eakness, early m obilization is
p referable w here it d oes not com prom ise red uction. In
keeping w ith these goals (Fig. 53.1), the general principles
of rehabilitation of fractu res are d ivid ed into tw o stages
(MacDerm id 2004):
• Stage 1 – early rehabilitation, w hich inclu d es protecting
the healing fractu re, m inim izing p ain and oed em a,
restoring norm al m otion and tissue extensibility,
m onitoring p atients for associated inju ries or
com p lications, p reventing therap y-ind u ced com p lications,
assisting p atients in d ealing w ith their inju ry u sing
app rop riate coping m echanism s and avoid ance of
patterns that increase the risk of d evelop ing chronic
pain / d isability synd rom es and help ing p atients
to u nd erstand their inju ry, the role of healthcare
provid ers, and how to take an active role in their
rehabilitation.
• Stage 2 – later rehabilitation, w hich includ es amelioration
of joint contracture, restoration of hand and arm strength,
ad aptation to resid ual physical impairments, transition
into normal w ork or activity and teaching prevention
strategies to reduce the risk of further fractu re.
There is a lack of clinical trials com p aring d ifferent treatm ent
ap proaches for d igital fractu res. A single sm all low -quality
trial su ggested that the u se of a com p ression glove avoid ed
the loss of fu nction im p osed by sp linting and w as associated
w ith a greater range of m ovem ent d u ring the second and
third w eeks follow ing a m etacarp al fractu re (McMahon
et al 1994). Managem ent is based on the stage of bone
healing and p resenting fractu re sequ elae (see treatm ents
based on presenting problem s in Table 53.1). Poor-qu ality
stu d ies su p p ort the u se of m etacarp al bracing for early
m obilization.
Ulnar Collateral Ligament Injury of
the Thumb
Epidemiology
Ulnar collateral ligam ent (UCL) inju ries can be acute or
chronic. Acu te inju ries are m u ch m ore com m on and are the
result of an acu te valgu s stress rup turing the ligam ent. Chronic
injuries are referred to as ‘gam ekeeper ’s thu m b’, as it w as
trad itionally noticed in Scottish gam ekeep ers w ho fractu red
the necks of the rabbits betw een their thu m bs and ind ex
ngers. This is also an inju ry of the UCL; how ever, it is the
result of attenuation of the ligam ent d u e to a chronic, rep eti-
tive rad ially d irected force on the u lnar sid e of the thu m b.
Anatomy
The thum b MP joint has both static and d ynam ic stabilizers.
The static restraints includ e the volar p late and the proper and
accessory collateral ligam ents. The prop er collateral ligam ent
acts as the prim ary stabilizer of the MP joint in exion; in
 Ulnar collateral ligament injury of the thumb 599

Callus New bone growth

Fracture Normal bone

Week 1
• Immobilization
• Early (safe) mobilization

Weeks 2–6
• Manage pain and oedema
• ROMunaffected joints
• Safe active motion if fracture stable (closed
undisplaced or rigid fixation)

Figure 53.1 Progression in the rehabilitation process.

Weeks 4–6+ (graduated mobilization – with clinical union)

• Progressive active, gentle passive techniques
• Assess and treat specific emerging impairments
within safety margins (see Table 53.1)

Weeks 8–12+ (remodelling and functional restoration)

• Passive techniques and joint mobilization
• Progressive strength and function programme
• Dynamic or progressive static orthotics
• Manage residual disability and future fracture risk

extension, the accessory collateral ligam ent and the volar
p late are the prim ary joint stabilizers (Minam i et al 1984;
H eym an et al 1993). The d ynam ic stabilizers includ e both the
thu m b extrinsic (EPL, EPB and FPL) and the intrinsic (APB,
FPB and ad d u ctor pollicis m u scles) structures. The ad d uctor
p ollicis is the m ost im p ortant d ynam ic stabilizer of the thu m b
MP joint. It inserts into the extensor hood (throu gh its ap oneu -
rosis) and lies super cial to the joint and the UCL.
Pathology
When a valgu s stress is app lied to the thu m b (i.e. a fall onto
the abd u cted thu m b) the d ynam ic and static stabilizers fail
sequ entially d ep end ing on the m agnitu d e of the force. When
the inju ry is lim ited to the d ynam ic stabilizers, the thu m b w ill
be stable on valgus stress testing. When the p roper collateral
ligam ent ru ptu res valgu s instability w ill be present in MP
exion. When the accessory collateral is also torn, there w ill
be valgu s instability in both exion and extension, ind icating
a com p lete tear (H eym an et al 1993). At tim es, the ru ptu red
d istal end of the ligam ent can becom e d isplaced su ch that it
lies super cial and p roxim al to the ad d u ctor aponeu rosis; this
entity w as rst d escribed in 1962 by Stener and so the lesion
bears his nam e (Stener 1962). Du e to interposition of the
ad d u ctor ap oneu rosis, this injury w ill not heal w ithou t opera-
tive intervention.
Diagnosis
Patients w ill rep ort a history of a valgu s inju ry and com p lain
of p ain and sw elling over the u lnar asp ect of the MP joint.
Pain w ill be exacerbated by forcefu l p inch and activities su ch
as u nscrew ing jar top s and hold ing large objects because of a
lack of p ow er d ue to the thu m b’s inability to generate counter-
p ressu re on the object. Occasionally a Stener lesion m ay be
evid ent, as a palpable m ass on the ulnar aspect of the joint;
how ever, lack of su ch a m ass d oes not ru le ou t a Stener lesion.
Rad iograp hs shou ld be obtained and view ed p rior to stress
testing of the ligam ent to ru le ou t an avu lsion fractu re, thereby
avoid ing potential d isplacem ent of the fracture fragm ent.
Stress testing of the UCL is p erform ed by p lacing a valgu s
stress across the MP joint in 30° of exion and then in exten-
sion. If there is m ore than 30° of laxity (or 15° m ore than the
contralateral sid e) in exion (30° of MP exion) then ru p tu re
of the p rop er collateral ligam ent is likely. The valgu s stress is
then ap plied in extension; if there is less than 30° of valgu s
laxity then the accessory collateral is intact, preclud ing a
Stener lesion. If there is greater than 30° of laxity in both
exion and extension, the accessory collateral ligam ent is also
ru p tu red and the p robability of an u nd erlying Stener lesion
is then approxim ately 80% (Stener 1962). Rad iograp hs d em -
onstrate rad ial d eviation at the MP joint and p ossible volar
su blu xation.
 600 PART 8 • 53 • Finger and thumb pathology
Prognosis
There are no sp eci c prognostic stu d ies on this topic. Inad e-
qu ate m obilization or failu re to d etect a Stener lesion can lead
to chronic instability and p ain.
Conservative treatment of UCL injury
Managem ent consists p rim arily of im m obilization that is su f-
cient to p erm it ligam ent reattachm ent / healing. Althou gh
biom echanical evid ence suggests early control of m obilization
m ight be feasible (H arley et al 2004), this has not been tested
in clinical trials. Casting or cu stom ized sp linting can be u sed
for m obilization, but rem ovable sp lints are best reserved for
com p liant p atients. A Stener lesion or failu re to achieve a
stable thu m b w ith m inim al p ain d u ring p inch is an ind ication
for surgery (Dinow itz et al 1997) – that is, early rep air or late
ligam ent reconstru ction. Progressive strengthening and p ro-
tection from lateral stress (fu nctional sp linting / tap ing) w ill
allow rem od elling of the collagen bres to ligam ent orienta-
tions that p rovid e tensile strength. Stretching the UCL p rem a-
tu rely can lead to chronic instability, how ever.
Other Digital Tendon Injuries
Other tend on inju ries that affect the d igits can occu r throu gh
lacerations, avu lsion inju ries (e.g. m allet / jersey nger),
acute bou tonniere and p u lley ru ptures. Lacerations of the
exor tend ons that ruptu re in zones I or II requ ire su rgical
repair and speci c tend on rehabilitation protocols (Groth
2005; N ew p ort & Tu cker 2005; Libberecht et al 2006; Kou l
et al 2008; Soni et al 2009). These m ay involve active (pro-
tected ) early m obilization in sp ecially selected cases w here
repair strength is suf cient. Early passive m obilization proto-
cols rem ain m ore com m on. Consu ltation w ith the referring
su rgeon and aw areness of hand therap y rehabilitation p roto-
cols are requ ired (Klein 2003; Chai & Wong 2005; Su eoka &
LaStayo 2008; Yen et al 2008). Extensor tend on ru ptu re or
lacerations in the d igits require extension splinting (4–6
w eeks), and in som e cases surgical repair. Grad u ally pro-
gressed , protected active ROM protocols institu ted w ithin
the safety m argins allow able by the sp eci c rep air are
requ ired to ensure that tend on glid e is restored w ithout com -
p rom ising rep air (tend on ru ptu re or gapp ing). Active m otion
w ith d ifferential glid ing is em phasized d u ring rehabilitation.
When tend on scarring lim its d ifferential glid ing, tenolysis
m ay be requ ired .
Osteoarthritis of the Digits
Epidemiology
Digital osteoarthritis (OA) is the m ost prevalent form of
d egenerative arthritis, althou gh functional consequences vary
(Doherty et al 2000; H unter et al 2004). The d istal interphalan-
geal (DIP) joint is the m ost affected , althou gh fu nctional con-
sequ ences tend to be m ore severe in the CMC joint of the
thum b, w hich affects 1 in 4 w om en and 1 in 12 m en. In p atients
old er than 75 years the prevalence of rad iograp hic CMC
d egeneration increases to 40% in w om en and 25% in m en
(Arm strong et al 1994; Doherty et al 2000; Caspi et al 2001).
Anatomy
The CMC joint acts as a u niversal joint, allow ing m otion in
extension, exion, ad d u ction and abd u ction. Together, these
m ovem ents allow the com p lex m ovem ents of the thu m b su ch
as opp osition, retropu lsion, palm ar and rad ial abd u ction, and
ad d uction. The CMC joint has little intrinsic stability and
relies on static ligam entous restraints to lim it translation of
the m etacarp al base d u ring these m ovem ents. There are three
ligam ents that help to stabilize the CMC joint. The prim ary
stabilizer is the anterior obliqu e ligam ent, or volar beak liga-
m ent. It is an intracap su lar stru ctu re that originates from the
p alm ar tu bercle of the trap eziu m and inserts on the u lnar sid e
of the m etacarp al base, along the articu lar m argin. It resists
abd u ction, extension and pronation forces. The second ary sta-
bilizers inclu d e the d orsorad ial and interm etacarpal liga-
m ents. The d orsorad ial ligam ent resists d orsal and rad ial
translation of the CMC joint and is the m ost robu st of the
CMC joint ligam ents. The interm etacarp al ligam ent lies
betw een the base of the rst and second m etacarpals and
p revents rad ial translation of the base of the rst m etacarp al
(Bettinger et al 1999). The thenar m u scles also play a role as
d ynam ic stabilizers of the CMC joint. These m u scles w ork in
concert, stabilizing the thu m b in p osition to allow activities
su ch as p inching.
Pathology
OA is a d egenerative cond ition characterized by p ain,
interm ittent in am m ation and cartilage d egeneration. The
p athological p rocesses that u nd erlie this d egeneration are
m u ltifactorial and not fu lly d e ned , bu t inclu d e both genetic
and biom echanical factors. Loss of joint space, su bchond ral
sclerosis, loss of cartilage, osteop hytes and joint d eform ities
occu r. The DIP joint can also be affected w ith m u cou s
cysts that occu r d u ring the early stages of d egenerative joint
d isease.
Doerschuk et al (1999) cond u cted a cad averic stu d y and
d em onstrated that the d egree of d egeneration in the anterior
obliqu e ligam ent w as correlated w ith the stage of the OA.
Eaton and Littler (1973) also d em onstrated a strong associa-
tion betw een excessive laxity at the thu m b CMC joint
and prem ature d egenerative changes. Laxity com bined w ith
repetitive load ing m ay pred ispose certain ind ivid uals to syno-
vitis and , w ith continu ed load ing, the articu lar su rfaces grad -
u ally w ear resu lting in joint sp ace narrow ing and OA.
Orsorad ial su blu xation occu rs at the base of the thu m b m eta-
carp al, w hile d istally the ad d u ctor p ollicis p u lls the thu m b
into an ad d ucted position (Blank & Feld on 1997). This
ad d ucted p ostu ring of the thum b lead s to d if cu lty in spread -
ing the hand arou nd objects for grasping and lead s to com -
p ensatory, p rogressive hyp erextension of the MP joint. The
aetiology of CMC joint laxity has been attribu ted to horm onal
in uences (i.e. prolactin, relaxin and oestrogen), w hich poten-
tially exp lains the increased incid ence of CMC OA seen in
w om en.

Diagnosis
H and OA is d iagnosed by its clinical featu res along w ith
rad iographic su bstantiation (Zhang et al 2009). H eberd en
and Bou chard nod es are clinically d e ned p osterolateral
rm / hard sw ellings of the IP and PIP joints resp ectively.
N od al OA exists in the presence of these nod es, plu s und erly-
ing IP joint arthritis d e ned clinically and / or rad iologically.
N on-nod al OA is d e ned by IP joint OA in the absence of
nod es. Erosive OA is d e ned rad iograp hically by su bcortical
erosion, cortical d estru ction and su bsequent reparative
change, and m ay inclu d e bony ankylosis. Generalized OA is
hand arthritis existing in com bination w ith OA at other sites.
Thu m b base OA is w hen the rst CMC joint is involved and
the scap hotrap ezial joint.
Typ ical hand OA sym p tom s are p ain on u se, m ild m orning
pain and inactivity stiffness, p articu larly w hen affecting only
single or a few consistent joints. Lateral d eviation of IPs, su b-
luxation and ad d u ction of the thum b base are the com m on
d eform ities.
The d iagnosis of CMC OA is based on history and clinical
exam . The typ ical presentation is a w om an in her 50s to 70s
w ith rad ial-sid ed hand or thu m b pain. Clinical exam ination
w ill reveal tend erness localized to the CMC joint, w ith a posi-
tive grind test (axial com p ression of the thu m b) rep rod u cing
pain and crepitu s. Rad iograp hs are u sed to con rm the d iag-
nosis. Variou s stages of joint involvem ent can be seen, ranging
from a w id ened joint space (joint effu sion or synovitis) to joint
sp ace narrow ing, su blu xation, sclerosis and osteop hyte for-
m ation. The d ifferential d iagnosis inclu d es p soriatic arthritis,
rheu m atoid arthritis, gou t and haem ochrom atosis, each of
w hich tend s to have d ifferent target sites of involvem ent that
can be u sed to assist w ith d ifferentiation (Zhang et al 2009).
Prognosis
Genetic factors, fem ale gend er, age over 40, m enop au sal
statu s, obesity, higher bone d ensity, greater forearm m u scle
strength, joint laxity, p rior hand inju ry and higher occu p a-
tional recreational u se are all associated w ith increased
risk of hand OA and its severity and progression (Zhang
et al 2009).
Conservative treatment of digital arthritis
H and OA is a m u ltijoint problem and treatm ent approach.
Eu rop ean Leagu e Against Rheu m atism (EULAR) evid ence-
based recom m end ations for m anagem ent suggest that a
com bination of p harm acological and non-p harm acological
treatm ent be ind ivid u alized to the p atient (Klein 2003; Chai
& Wong 2005; Su eoka & LaStayo 2008; Yen et al 2008). Ed uca-
tion abou t joint p rotection and exercise are recom m end ed for
all patients. Local app lication of heat, especially p rior to exer-
cise, sp lints for thu m b OA and orthotics to p revent or correct
lateral angu lation exion d eform ities are also recom m end ed .
Local treatm ents are p referred over system ic ones for m ild to
m od erate p ain and w hen only a few joints are affected . Top ical
N SAIDs and capsaicin are effective and safe treatm ents. Phar-
m acological and su rgical interventions shou ld be consid ered
in patients w ith m arked pain or d isability, or w hen conserva-
tive treatm ents have failed . There is insu f cient evid ence
Conclusion 601
to choose betw een d ifferent orthotics op tions (off-the-shelf /
cu stom t, long / short op p onens, d orsal / volar, therm op las-
tic / neop rene / other m aterials). Orthotics shou ld be cu stom -
ized accord ing to the joint d eform ity / d am age, fu nctional
requ irem ents and patient preferences. It is com m on for
p atients w ith hand arthritis to have m u ltip le orthoses to su it
d ifferent activities or levels of d isease activity. Exercise and
ed ucation have been show n to be m ore ef cacious than OA
inform ation alone (Moe et al 2009).
Rheumatoid Arthritis
Affecting the Digits
Rheu m atoid arthritis is an in am m atory arthritis that has
d iffu se d igital and other involvem ent. In the past, severe hand
d eform ities w ere com m on, bu t are now uncom m on because
of p harm acological ad vances in the m anagem ent of the
d isease. H ow ever, old er p atients m ay continu e to p resent
w ith severe d eform ity and for surgical reconstruction. Rheu -
m atoid arthritis hand d eform ity can inclu d e bou tonniere,
sw an neck, u lnar d rift, cap u t u lna, tend on ru p tu re and sagit-
tal band / tend on su blu xation.
Conclusion
Injuries to the joints, tend ons, ligam ents and nerves in the
d igits are com m on and attention to d etail is requ ired d u ring
rehabilitation so as to restore the ne precision m ovem ent that
is essential to their fu nction. Rehabilitation principles suggest
that the requ irem ents inclu d e p rotected m otion d u ring
healing / joint irritability, p rogressive active m ovem ent and
strengthening that incorp orates fu nctional activities and
selected u se of joint m obilization techniqu es to enhance joint
kinem atics. Oed em a m anagem ent and integration of sensory
and m otor assessm ent / retraining are p articu larly im portant.
Reliance on these p rincip les is essential, given the d earth of
p hysical therap y evid ence for d igital d isord ers and the sp e-
ci c lack of attention to this area w ithin m anu al therap y
literatu re.
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 P AR T 9
The Foot and Ankle in
Lower Extremity Pain
Syndromes
54 Ankle Sprains 605
Thomas Denninger and Gary Austin
55 Plantar Heel Pain 616
Matthew P. Cotchett
56 Postoperative Management of Foot and Ankle Disorders 623
Stephanie Albin, Mark W. Cornwall and Thomas G. McPoil
57 Manipulation of the Foot and Ankle 637
William Egan, Wayne Hing, Jack Miller and Joshua A. Cleland
58 Tendinopathy of the Foot and Ankle 646
Ellen Pong
This pa ge inte ntiona lly le ft bla nk
 PART 9 •  The Foot and Ankle in Lower Extremity Pain Syndromes
CHAP TER CONTENTS
Introduction  605
Anatomy and physiology  605
Distal tibiof bular joint  605
Talocrural joint  606
Subtalar joint  606
Biomechanics o  the ankle  606
Lateral ankle sprains  607
Medial ankle sprains / syndesmotic injuries  607
Chronic ankle instability  608
Examination  608
Ottawa ankle rules  608
Subjective history  608
Ankle range o  motion  609
Anterior drawer test  609
Medial talar tilt test  609
Figure-o -eight test  609
Functional testing  610
Conservative treatment  610
Thrust and non-thrust joint mobilization  610
Therapeutic exercise  613
Introduction
App roxim ately 10% to 34% of all sports inju ries are related to
the ankle (Su rve et al 1994; Trop p & Gillquist 1985), w ith
lateral ankle sprains accou nting for 77–83% of these inju ries
(Broglio et al 2009). A review of em ergency d epartm ent
record s in the United States betw een 2002 and 2006 estim ated
the incid ence of an ankle sprain to be 2.15 p er 1000 person-
years in the general p opu lation (Waterm an et al 2010). This
incid ence, how ever, is m ost probably u nd erestim ated as
McKay et al (2001) fou nd that 56.8% of basketball players
w ho sustained an ankle sprain d id not seek treatm ent. N early
half of all ankle sprains (49.3%) occu rred d u ring athletic
activity, w ith baseball (41.1%), football (9.3%) and soccer
(7.9%) associated w ith the highest percentages of ankle
sp rains (Waterm an et al 2010). In d ynam ic sp orts, ankle
sprains rep resent 25% of all lost-tim e injuries (Reid 1992).
The incid ence rate of ankle sprains for m ale soccer players is
 
Chapter  54  
Ankle Sprains
Th o m a s De n n in g e r, G a ry Au s tin
0.46 for every 1000 hou rs of p laying tim e and 0.86 for every
1000 hours of p laying tim e for those w ith a previou s history
of an ankle sp rain (Surve et al 1994). In other d ynam ic sp orts,
su ch as basketball, a p reviou s history of ankle inju ry resu lted
in a re-occurrence rate of ve tim es the norm al sprain rate of
3.85 p er 1000 p articipants (McKay et al 2001). Ankle sprains
have been show n to be 2.4 tim es m ore com m on in the d om i-
nant leg, and they have a high (73.5%) prevalence of reoccu r-
rence (Yeung et al 1994).
Most basketball p layers w ho su stained an ankle sp rain
em ployed som e form of self-treatm ent, su ch as ice, com pres-
sion and / or elevation (McKay et al 2001). Am ong those w ho
sought p rofessional treatm ent, 62.5% received m ed ical atten-
tion and 56.3% saw a p hysical therap ist (McKay et al 2001).
This is of concern as the clinical cou rse of ankle sprains su g-
gests that, although there is a rapid red uction in pain d uring
the rst 14 d ays, u p to 33% of patients still exp erience p ersist-
ent p ain and instability at 1 year (Gerber et al 1998; Van Rijn
et al 2008).
Anatomy and Physiology
Distal tibio bular joint
The ankle joint com plex encom passes m ultiple joints inclu d -
ing the d istal tibio bu lar joint, talocrural joint, subtalar joint
and talonavicu lar joint. The d istal tibio bular joint is the syn-
d esm otic union of the d istal extents of the tibia and bula.
The synd esm osis is created by the follow ing ligam ents: the
anterior inferior tibio bu lar ligam ent (AITFL), the posterior
inferior tibio bu lar ligam ent (PITFL), the interosseu s liga-
m ent and the transverse ligam ent.
The PITFL ru ns from the p osterior tibial m alleolus to the
p osterior tu bercle of the bu la. It is d ense and strong and
w hen stressed is m ore likely to result in an avulsion fractu re
than in failu re (Van d e Perre et al 2004). The inferior trans-
verse ligam ent is located p osteriorly and d eep to the PITFL,
and often blend ing w ith the PITFL to form the interm alleolar
ligam ent and form ing a labral-like stru cture (H erm ans et al
2010). The interm alleolar ligam ent m ay contribu te to poste-
rior im p ingem ent synd rom e in patients w ho frequ ently
p erform extrem e p lantar exion (Rosenberg et al 1995; Oh
et al 2006). The AITFL is the w eakest of the synd esm otic liga-
m ents, and is the rst to fail u nd er external rotation forces
 606 PART 9 • 54 • Ankle sprains
(H erm ans et al 2010). Distal to the AITFL is the intra-articu lar
accessory anterior–inferior tibio bu lar ligam ent, also know n
as Bassett’s ligam ent, w hich contacts the lateral aspect of the
trochlea d u ring ankle d orsi exion (H erm ans et al 2010), pos-
sibly contribu ting to anterolateral ankle im p ingem ent.
The interosseou s m em brane cou rses betw een the length of
the tibia and bu la, and the d istal asp ect transitions into the
interosseou s ligam ent, u ltim ately blend ing w ith the AITFL
and PITFL (H erm ans et al 2010). The interosseou s ligam ent,
along w ith fatty and synovial tissu e, m ay ad d a spring-like
effect to the m ortise, accom m od ating the w ed ge-shaped talu s
d u ring ankle d orsi exion (H erm ans et al 2010). Fu rtherm ore,
the interosseou s ligam ent ap p ears to p lay a role in stabilizing
the talocru ral joint d u ring load ing (H ermans et al 2010).
Talocrural joint
The talocru ral joint is the articu lation betw een the bod y of the
talu s, inclu d ing the trochlear su rface, and the m alleoli of the
tibia and bu la. The slightly concave tibial su rface articu lates
w ith the plane to convex (Du tton 2004) triangular-shaped
d istal end of the bu la. The structure of the m ortise consists
of the tibia su p eriorly, the m ed ial m alleolu s m ed ially and the
lateral m alleolu s of the bu la laterally. The m ed ial su rface of
the bu lar m alleolu s articu lates w ith the lateral facet of the
talar bod y to create the bu lotalar joint. Sim ilarly, the lateral
su rface of the tibial m alleolu s articu lates w ith the m ed ial facet
of the talar bod y to create the tibiotalar joint (Moore 1985).
The m ortise fu nctions as a concave su rface to accep t the
convex su rface of the talar bod y. The trochlea of the talu s is
u p to 6 m illim etres (m m ) w id er anteriorly than p osteriorly,
cau sing the talu s to act as a w ed ge w ithin the ankle m ortise,
enhancing the congruence and static stability of the talocrural
joint in d orsi exion. The tibiotalar joint, bu lotalar joint and
d istal position of the tibio bu lar joint resid e in the sam e
cap su le and m ake u p the synovial hinge joint know n as the
talo-cru ral joint (Moore 1985).
Ligam ents su p p orting the talocru ral joint inclu d e the ante-
rior and posterior talo bular ligam ents (ATFL and PTFL
resp ectively), calcaneo bu lar ligam ent laterally and the
d eltoid ligam ent m ed ially. The ATFL is frequently sprained
d u ring an uncontrolled inversion m ovem ent, typically in the
p lantar exed p osition (H osea et al 2000). When com pared
w ith other ligam ents, ATFL sprains occu r relatively easily
second ary to low load to failu re and high sp rain to failu re
rates (Attarian et al 1985).
Subtalar joint
The subtalar joint is irregularly shaped and can be classi ed
as a synovial bicond ylar joint. There are tw o articulating su r-
faces betw een the talu s and the calcaneus. The anterior articu-
lation is convex on the talu s and concave on the calcaneu s,
w hereas the posterior articu lation is concave on the talus and
convex on the calcaneu s. Betw een these tw o articu lations is
the interosseu s m em brane, also referred to as the axial liga-
m ent, w hich assists in stabilization of an eversion m ovem ent
(Kap anji 1970). With the anterior articulation lying m ed ial to
the p osterior articu lation and w ith irregu lar joint su rfaces, the
su btalar joint w ill m ove in op p osite d irections d u ring fu nc-
tional w eight-bearing (Du tton 2004).
Ligam ents are p resent to m aintain integrity of the su btalar
joint. They includ e the m ed ial and lateral interosseus, the
calcaneo bu lar ligam ents (CFL), the d eltoid ligam ents (DL)
and the lateral talocalcaneal ligam ents (LTCL). The m ed ial
talocalcaneal interosseu s ligam ents p roject from the m ed ial
tu bercle of the talu s p osteriorly to ju st behind the su stentacu -
lum tali of the calcaneus and serves to protect the talus from
anterior translation on the calcaneu s. The lateral talocalcaneal
interosseus ligam ents (cervical ligam ents) project from the
sinu s tarsi p osteriorly to the calcaneu s and serve to p revent
the excess sep aration of the talu s from the calcaneu s d u ring
inversion m om ents. These ligam ents are typically inju red
w hen an excessive m om ent is app lied in inversion and
cou p led w ith d orsi exion (Dutton 2004). The cervical liga-
m ent is fu rther forti ed in p reventing su btalar inversion by
the d eep bres of the extensor retinacu lu m . Med ially, the
d eltoid and calcaneonavicular ligam ents prevent excessive
eversion. Laxity of the ligam ents in the lateral com partm ents
is im plicated frequ ently in lateral instability ow ing to an
excess of active and passive ranges of m otion. Laxity
in the m ed ial com partm ent is pred om inately less frequ ent,
bu t m ay be functionally m ore problem atic since this type
of sp rain is associated w ith a higher incid ence of cartilage
d am age and concom itant lateral ligam entou s d am age (Cook
2007). Table 54.1 su m m arizes the role of the ligam ents in
ankle stability.
Biomechanics of the ankle
As in all joints, the ankle com plex has tw o types of p ossible
m otion: translator m ovem ent, also know n as arthrokine-
m atic m ovem ent, and rotational m ovem ent, also know n as
osteokinem atic m ovem ent. Osteokinem atic m ovem ent incor-
p orates translatory m otion in ord er to stabilize the instantane-
ou s axis of rotation. This is im p ortant to translate forces over
a larger su rface area w ithin the joint, as w ell as to p revent
u nnatu ral forces d u ring the end ranges, w hich m ay d am age
the p assive stru ctu res of the joint.
The collective m ovem ent patterns and p assive and active
control of ankle m otion allow for transfer of force throu ghou t
the ankle com p lex d u ring fu nctional m ovem ent. This p rocess
involves the ind ivid ual range of m otions provid ed at each
articu lation.
Table 54.1 Role of collate ra l liga me nts in ankle s tability
Move me nt Controlle d b y
Abduction o the talus Tibiocalcaneal and tibionavicular
bands
Adduction o the talus Calcaneo bular ligament
Plantarf exion ATFL and anterior tibiotalar
ligament
Dors if exion Pos terior tibiotalar band and
PTFL
External rotation o the talus Anterior tibiotalar and
tibionavicular bands
Internal rotation o the talus ATFL, anterior tibiotalar and
tibionavicular bands

Althou gh the talocrural joint is typ ically d escribed as a
u nip lanar ginglym u s or hinge joint, the anatom y w ou ld
su ggest otherw ise.
Range of motion
The talocru ral joint d em onstrates approxim ately 50° of
plantar exion and 20° of d orsi exion. The su btalar joint is
reported to have 40° of inversion and 20° of eversion. The
tarsal joints are rep orted to have 10° of pronation and 20° of
su p ination (Cook 2007).
Open-packed and closed-packed positions
The term s open-packed and closed -packed positions of the
ankle refer to the theoretical su p p osition that selected m ove-
m ents w ill increase the com p ression (closed -p acked ) or d is-
traction (op en-p acked ) betw een the joints of the ankle. With
resp ect to the m echanics of articu lation, the closed -packed
position refers to the sp eci c joint p osition w hen the articular
su rfaces are at the m axim u m p oint of congru ency, w hereas
the op en-p acked p osition is the op p osite of this situ ation.
Unfortunately, no stu d ies yet exist to su pport this assu m p -
tion, and hence the valid ity behind the theory of op en- and
closed -p acked p ositions is essentially u nknow n (Cook 2007).
Axes of rotation / osteokinematics
The talocrural joint axis travels pred om inately in the m ed ial–
lateral d irection, w ith sm aller com ponents in the anterior–
posterior and su p erior–inferior d irections. The longer and
m ore p osterior lateral m alleolu s contribu tes to the d ep artu re
of the talocru ral joint axis from a pu re m ed ial–lateral axis in
the frontal p lane (abou t 10°) and transverse p lane (abou t 6°).
Su ch an orientation allow s for large am ou nts of m otion in
the sagittal p lane (d orsi exion / p lantar exion) and sm aller
am ounts of m otion in the frontal (inversion / eversion) and
transverse (abd u ction / ad d u ction) p lanes. The su btalar joint
axis is oriented 42° from the transverse plane, travelling
nearly m id w ay betw een anterior–posterior and su perior–
inferior d irections, w ith a m inor com ponent in the m ed ial–
lateral d irection. It has been d escribed that the axis of rotation
is 42° from the horizontal p lane and 16° from the sagittal
plane, ru nning in an anterior, m ed ial and su p erior d irection.
Su ch an orientation allow s for large am ou nts of m otion in
the frontal (inversion / eversion) and transverse (abd u ction /
ad d u ction) p lanes and sm aller am ou nts of m otion in the sagit-
tal p lane (d orsi exion / p lantar exion). At the ankle, m ost
m otions are cou p led and trip lanar in natu re. At the talocru ral
joint sm aller bu t signi cant am ou nts of eversion and abd uc-
tion accom p any d orsi exion (p ronation), w hereas sm aller bu t
signi cant am ou nts of inversion and ad d u ction accom p any
plantar exion (su p ination). At the su btalar joint, larger
am ounts of eversion and abd u ction are accom panied by sm all
bu t signi cant am ounts of d orsi exion, w hereas inversion
and ad d u ction are accom panied by sm all but signi cant
am ounts of p lantar exion.
The closed - and open-packed positions in the hind foot
w ork in concert w ith the axes of m otion to create coupled and
functional m ovem ent patterns in the low er extrem ity (Du tton
2004). Subtalar joint supination assists in locking the m id -
tarsal joint, creating a m echanically ad vantageou s rigid lever
d u ring propu lsion. Pronation at the su btalar joint unlocks the
Medial ankle sprains / syndesmotic injuries  607
m id -tarsal joint, p rom oting a exible foot that is able to accom -
m od ate u neven su rfaces and absorb the shock of grou nd reac-
tion forces.
Arthrokinematics
During d orsi exion at the talocrural joint, the su perior su rface
of the talu s rolls anteriorly w ithin the m ortise w hile sim u lta-
neou sly slid ing p osteriorly. Du ring p lantar exion, the talu s
rolls posteriorly w hile sim u ltaneously slid ing anteriorly
(Dutton 2004). The m otion, how ever, is not pu rely in the sagit-
tal p lane as it has sm aller, bu t im p ortant, m ovem ents in the
frontal and transverse planes.
The articulation of the subtalar joint is m ore com plex, w ith
p ronation and su p ination resu lting, p rim arily, from relative
slid ing m otions betw een the calcaneu s and talu s at the su bta-
lar facets (anterior, m ed ial and posterior) (Cook 2007). The
relative slid ing m otion can occur from a m obile calcaneus
m oving on a xed talu s, a m obile talu s m oving on a xed
calcaneu s or m otion betw een a m obile talu s and calcaneu s.
Lateral Ankle Sprains
Acute lateral ankle sp rains are often d escribed accord ing to
the severity of the inju ry. Trad itionally, lateral ankle sp rains
are assigned grad es of I to III to represent the extent and
severity of ligam ent d am age, w ith grad e I being the least
involved and grad e III being the m ost severe type of inju ry
(Martin et al 2013). Grad ing scales often incorp orate m ultiple
static and d ynam ic m easu res to d escribe the severity of the
injury. Static m easu res includ e an assessm ent of ligam ent
laxity, haem orrhaging, sw elling and tend erness. Dynam ic
m easu res have inclu d ed range of m otion, strength and ability
to p erform fu nctional tests.
A com m only u tilized m ethod to grad e acu te lateral
ankle sprains has been d e ned as follow s (H ockenbu ry &
Sam m arco 2001):
• grade I: no loss of fu nction, no ligam entou s laxity, little
or no haem orrhaging, no p oint tend erness, d ecreased
total ankle m otion of ≤ 5°, and sw elling ≤ 0.5 cm or less
• grade II: som e loss of function, positive anterior d raw er
test (ATFL), negative talar tilt (CFL), haem orrhaging,
point tend erness, d ecrease in total ankle m otion betw een
5° and 10° and sw elling betw een 0.5 and 2.0 cm
• grade III: near-total loss of fu nction, p ositive anterior
d raw er test (ATFL) and talar tilt tests (CFL),
haem orrhaging, extrem e p oint tend erness, d ecreased total
ankle m otion > 10° and sw elling > 2.0 cm . Grad e III
injuries have been further d ivid ed accord ing to stress
rad iograph resu lts, w ith anterior d raw er m ovem ent of
≤ 3 m m being IIIA and > 3 m m of m ovem ent being IIIB.
Medial Ankle Sprains /
Syndesmotic Injuries
Med ial ankle sp rains occu r m u ch less frequ ently than lateral
ankle sp rains, accounting for ap proxim ately 5–10% of all
ankle sprains (Broglio et al 2009). The DL is often not injured
 608 PART 9 • 54 • Ankle sprains
second ary to its strong internal stru ctu re and ligam entou s
connections. Isolated DL inju ry is rare, typ ically occu rring
w ith an avu lsion fractu re of the m ed ial m alleolus (Pott frac-
tu re). The m echanism of inju ry for an isolated d eltoid inju ry
is p lantar exion and eversion. Ind ivid u als w ith this rare
inju ry w ill rep ort p ain on the m ed ial asp ect of the foot and
reprod u ction of pain up on subtalar inversion and eversion.
Synd esm otic inju ries can occu r concom itantly to m ed ial ankle
sp rains second ary to gap p ing of the d istal tibio bu lar joint
d u e to w ed ging to the talu s that occu rs w ith d orsi exion ever-
sion and rotation inju ries. This can inclu d e inju ry to the ante-
rior tibio bular ligam ent, interosseus m em brane and DL. This
can resu lt in w id ening of the ankle m ortise as a resu lt of
d am age to the tibio bu lar ligam ents (Brosky et al 1995).
Initial m anagem ent of m ed ial ankle sprain and synd esm otic
inju ry is m ore conservative than w ith lateral ankle sp rains,
often requ iring a longer p eriod of im m obilization w ith non-
w eight-bearing. Progressive w eight-bearing and rehabilita-
tion are su ggested for grad u al resu m p tion of norm al and
u ltim ately athletic activity (Lin et al 2006).
Chronic Ankle Instability
When sym p tom s of instability continu e after a lateral ankle
inju ry, p atients are com m only d iagnosed as having m echani-
cal or fu nctional ankle instability. Chronic ankle instability
has been d e ned as the p resence of p ersistent p ost-acu te
sym p tom s su ch as occasional sw elling, im p aired strength,
instability and im p aired balance resp onses. This has been
op erationalized as sym p tom s of giving w ay for greater than
6 m onths follow ing the initial inju ry (O’Lou ghlin et al 2009)
This d iagnosis has been fu rther broken d ow n in to patients
w ith fu nctional ankle instability and those w ith m echanical
ankle instability.
Functional ankle instability has been d e ned as recu rrent
ankle sp rains or ongoing sensations of the ankle giving w ay
w ith norm al ankle m otion and the absence of objective joint
laxity. In a stu d y of 80 ind ivid uals w ith functional ankle insta-
bility, sid e-to-sid e com parisons of ankle laxity w ere m ad e
betw een the ankle w ith functional ankle instability and the
u ninvolved ankle (H irai et al 2009). This stud y su ggests that
fu nctional ankle instability is not associated w ith joint laxity.
Factors that m ay contribu te to functional ankle instability
app ear to inclu d e m u scle w eakness, m u scle recru itm ent pat-
terns, d ecreased ankle range of m otion, balance d e cits and
joint p roprioception. A m eta-analysis conclu d ed that patients
w ith fu nctional ankle instability have poor balance com pared
w ith subjects w ithou t ankle instability (Arnold et al 2009).
Ad d itionally there are d ocum ented d e cits in sensorim otor
p erform ance in su bjects w ith fu nctional ankle instability
(Konrad sen et al 1998; O’Driscoll & Delahu nt 2011). Patients
w ith functional ankle instability have d em onstrated im proved
balance and red u ctions in d isability throu gh balance pro-
gram m es u tilizing stable and u nstable su rfaces.
Mechanical ankle instability is d istingu ished from fu nc-
tional ankle instability by the p resence of ankle ligam entou s
laxity (Cau l eld 2000). Persistent ligam entous laxity occu rs in
app roxim ately 30% of patients p ost inversion ankle sprain 1
year after initial inju ry (H ubbard et al 2004). Rehabilitation of
m echanical instability d oes not d iffer from that of fu nctional
ankle instability. For m ost p atients, rehabilitation includ ing
bracing and fu nctional training lead s to recovery (Broglio et al
2009; H ale et al 2007; d e Vries et al 2011). Persistent nd ings
of u nilateral ligam entou s laxity via clinical or rad iograp hic
exam ination m ay be associated w ith w orse p rognosis, and if
com p laints p ersist follow ing a com p rehensive conservative
treatm ent ap p roach then the literatu re su ggests that su rgical
intervention m ay be required (H interm ann et al 2002). It is
im p ortant to note that d ichotom izing ankle instability into
m echanical or fu nctional is d if cu lt, as p atients m ay p resent
w ith a m ixture of m echanical and fu nctional instability.
Examination
Ottawa ankle rules
The Ottaw a ankle ru les w ere d evelop ed in 1992 to red uce the
frequency of rad iographic im agery follow ing ankle sp rain.
Prior to the onset of these ru les, p lain rad iograp hs w ere cu s-
tom arily ord ered for su sp ected ankle sp rains, even thou gh
less than 15% of ankle sp rains resu lt in a fractu re (Bachm ann
et al 2003). The ru les d ictate that, in the presence of a trau -
m atic inju ry to the foot and / or ankle, there is a need for an
ankle rad iographic series if a p atient d em onstrates: (1) tend er-
ness at the p osterior ed ge or tip of the lateral m alleolu s, (2)
tend erness at the p osterior ed ge or tip of the m ed ial m alleo-
lus, and / or (3) inability to bear w eight both im m ed iately post
injury and in the em ergency room for fou r steps (includ ing
lim ping). The rules also d ictate the need for a foot rad io-
graphic series if the p atient d em onstrates: (1) tend erness at
the base of the fth m etatarsal bone, (2) tend erness at the
navicu lar, and / or (3) inability to bear w eight im m ed iately
p ost inju ry and in the em ergency room for fou r step s (inclu d -
ing lim ping). A sum m ary of several stud ies d em onstrated
that the absence of these factors is excellent in ru ling ou t the
p resence of fractu re (−LR 0.07; 95% CI 0.03–0.18) (Bachm ann
et al 2003) and can sup port a d ecision to proceed w ith treat-
m ent w ithou t obtaining rad iograp hs. The ru les lack su f cient
sp eci city and p ositive likelihood ratios (LRs) to ru le in a
fractu re; thu s the presence of these factors prevents the ability
to ru le ou t a fractu re, and a p lain foot or ankle rad iograp h is
su ggested . The sp eci city and p ositive likelihood ratio are
su f ciently d iagnostic w ith the ad d ition of a tu ning fork
ap plied to the d istal bu la shaft (Dissm an & H an 2006).
Subjective history
Im portant history item s collected d u ring the su bjective exam -
ination includ e the presence of com orbid ities, any relevant
p ast history of ankle d isord ers (inclu d ing the nu m ber and
d egree of previous ankle sprains), a history of p revious
su rgery, and occu p ational and avocational d em and s. The
m echanism of inju ry can assist in d eterm ining the likelihood
of the p resence of a fractu re. H igh-im p act inju ries or p rofou nd
ankle sp rains should au tom atically initiate the assessm ent of
the Ottaw a ankle ru les.
The behaviou r of the sym ptom s m ay help to ou tline the
cau se of the d isord er and to ru le ou t m ore seriou s p athology.
Locking d isord ers that exhibit an interm ittent p attern m ay be
ind icative of osteochond ritis d issecans of the talar d om e

(Cook 2007). Pain associated w ith osteochond ritis d issecans
shou ld be rep resented so as to d ifferentiate from anterior
im pingem ent at the anterolateral ankle joint line; anterior
im pingem ent is consistently triggered d u ring d orsi exion at
end range, w hereas osteochond ritis d issecans m ay occu r
interm ittently and d u ring d ifferent planes of m otion. Signi -
cant d orsolateral ankle p ain m ay su ggest cu boid synd rom e.
Paraesthesiae along the d orsu m or d orsolateral asp ect of the
foot m ay ind icate potential neurod ynam ic involvem ent
of the p eroneal and su ral nerves resp ectively (Jennings &
Davies 2005).
Ankle range of motion
Goniom etric m easu rem ent of p assive and active ankle range
of m otion in the non-w eight-bearing p osition has been u sed
to assess p hysiological m otion of the ankle joint. Com m on
m easu rem ents are d orsi exion m easu red in p rone both w ith
the knee extend ed and w ith it exed to 45°, p lantar exion in
su p ine, and eversion / inversion in su p ine. A reliability is
established for intra-tester reliability of > 0.90 and an inter-
tester reliability of 0.70 (Martin & McPoil 2005; Menad u e et al
2006). The reliability of plantar exion is consistently low er
than that for d orsi exion. Ankle d orsi exion can also be reli-
ably m easured in a w eight-bearing lu nge p osition using either
an inclinom eter or a tap e m easu re (Bennell et al 1998).
Anterior drawer test
The anterior d raw er test is utilized to assess the integrity of
the ATFL. The am ou nt of anterior talar translation in relation
to the ankle m ortise is qu anti ed (Croy et al 2013). The p atient
is sitting in 90° of knee exion, w ith the leg relaxed and
u nsu p p orted and w ith the ankle p ositioned in 10–20° of
plantar exion. One hand of the exam iner is p laced on the
d istal tibia w hile p alpating the articulation betw een the lateral
su rface of the talu s and the anterior asp ect of the d istal bu la.
The second hand grasps the posterior aspect of the calcaneu s.
The test is perform ed by pu lling the calcaneu s and su bse-
qu ently the talu s in an anterior d irection w ith the d istal tibia
stabilized (Fig. 54.1). To assess the ATFL properly in the
Figure 54.1 Anterior drawer test.
Examination 609
p resence of an intact anterior tibiotalar and tibionavicu lar
ligam ents and avoid a false negative, the exam iner then intro-
d uces abd u ction of the foot (Tohyam a et al 2003). The d iag-
nostic accu racy w as established in one stu d y (Croy et al 2013)
as: sensitivity 0.74 (95% CI 0.58–0.86), sp eci city 0.38 (95% CI
0.24–0.56), +LR 1.2–1.4 and −LR 0.41–0.60. In another stu d y
(van Dijk et al 1996), the com bination of pain w ith palp ation
of the ATFL, lateral haem atom a and a p ositive anterior d raw er
on exam ination 5 d ays after injury had a sensitivity of 100%,
sp eci city of 75%, +LR of 4.13 and −LR of 0.01 for id entifying
lateral ligam ent ru p tu res. H ow ever, the sam e test p erform ed
less than 48 hours follow ing injury w as not inform ative,
show ing a sensitivity of 0.71, sp eci city of 0.33, −LR of 1.06
and +LR of 0.88. Inter-tester reliability ranged betw een 0.5 and
1.0. The test is m ost u seful for both ru ling in and ru ling ou t
anterior talo bu lar ligam ent laxity w hen p erform ed at least 5
d ays follow ing injury.
Medial talar tilt test
The m ed ial talar tilt test is utilized to assess the am ount of
talar inversion occu rring w ithin the ankle m ortise, testing the
integrity of the CFL. The test is perform ed w ith the patient
sitting in 90° of knee exion, w ith the leg relaxed and u nsu p-
p orted . One hand of the exam iner grasp s the d istal tibia and
bu la w hile the second hand grasp s the calcaneu s, hold ing
the ankle in a neu tral p osition. The test is p erform ed by
inverting the calcaneus and subsequ ently the talus, relative
to the ankle m ortise. Variations of the test have been d escribed
in sup ine, sid e-lying (Fig. 54.2) and prone. Diagnostic accu-
racy has been established w ith sensitivity of 0.50 (95% CI
0.25–0.75), speci city of 0.88 (95% CI 0.53–0.98), +LR of 4.00
(95% CI 0.59–27.25) and −LR of 0.57 (95% CI 0.31–1.07)
(H ertel et al 1999). The test is m ost u sefu l for ru ling in CFL
laxity.
Figure-of-eight test
The gure-of-eight test has been utilized to m easu re ankle
circu m ference as an ind ication of the am ou nt of ankle oed em a
follow ing trau m atic inju ry (Maw d sley et al 2000). The ankle
Figure 54.2 Talar tilt test with the patient in side-lying.
 610 PART 9 • 54 • Ankle sprains
Figure 54.3 Figure-of-eight test.
is positioned in either neu tral com fortable or 20° of p lantar-
exion. The zero end point of a tape m easure is positioned at
the groove on the ed ge of the lateral m alleolu s, m id w ay
betw een the p rom inence of the lateral m alleolus and tibialis
anterior tend on. The tap e is d raw n m ed ially around the foot
to cross the p lantar asp ect to and behind the base of the fth
m etatarsal. The tap e is then d raw n tow ard s and u nd er the
m ed ial m alleolu s, across the Achilles tend on, to and u nd er the
lateral m alleolu s of the bu la, and nally to m eet the original
zero p oint (Fig. 54.3). Inter-tester reliability has been fou nd to
be excellent (intraclass correlation coef cients (ICC) 0.93–0.99)
w ith a m inim al d etectable change of 6.8 m m w hen m easu red
in 20° (Rohner-Sp engler et al 2007).
Functional testing
Single-limb balance
Single-lim b balance shou ld be assessed as a baseline m easu re
of fu nctional ankle stability p rior to the p rogression to
d ynam ic activity (Akbari et al 2006). Testing shou ld be com -
p leted w ith patient safety in m ind and therefore should either
be gu ard ed or have a close hand -hold to gu ard against loss
of balance. Tim ed d u ration of single lim b stance shou ld be
com p leted w ith eyes op en and eyes closed , on both the
affected and u naffected lim bs. Alternatively, patients m ay be
tim ed for 1-m inu te d u rations in both testing cond itions,
cou nting the nu m ber of tou ches w ith the contralateral leg or
u p p er extrem ity. N orm ative d ata (Bohannon et al 1984)
su ggest that the average lim b balance tim e for ind ivid u als
betw een 20 and 49 years of age ranges betw een 29.76 and 30.0
second s w ith eyes op en and betw een 24.2 and 28.8 second s
w ith eyes closed ; for those betw een the ages of 50 and 79 years
of age the average tim es d ecrease to betw een 14.2 and 29.4
second s w ith eyes open and 4.3 to 21.0 second s w ith eyes
closed .
Star excursion balance test
The star excursion balance test layout consists of eight lines
from a centre p oint arranged at 45° angles. The lines can be
labelled accord ing to their position in a cou nterclockw ise
d irection w ith reference to the tested lim b as follow s: anterior,
anterolateral, lateral, posterolateral, p osterior, p osterom ed ial,
m ed ial and anterior–m ed ial. The test consists of having the
su bject stand w ith the low er extrem ity being tested in the
centre w hile the exam iner m easu res the m axim u m reach d is-
tance of the contralateral low er extrem ity achieved along
each of the d irections. Patients are not allow ed to m ove the
su p p ort foot and shou ld keep their hand s on hip s. The reach
d istance can be norm alized by d ivid ing the excursion d istance
by the low er extrem ity length. The test–retest reliability in
healthy ind ivid uals has been found to be good (ICC 0.67–0.96)
(Buchanan et al 2008), w hereas inter-tester reliability has been
d em onstrated as p oor to excellent (ICC 0.35–0.94) (H ertel et al
2009). The Y-Balance test is an ad ap tation of the star excu rsion
balance test that is instru m ented and involves only three
d irections (anterior, posterolateral and p osterom ed ial) (H ertel
et al 2006; Plisky et al 2006).
Conservative Treatment
Mobility is essential in the recovery of lateral ankle sp rains.
For grad e I and grad e II inju ries, early m obilization has been
show n to be m ore effective than im m obilization. In a grou p
of 82 patients w ith lateral ankle sprains, 87% w ho w ere im m o-
bilized w ith a p laster cast for 10 d ays rep orted the presence
of p ain at 3 w eeks. This com pared w ith 57% of patients w ho
received early m obilization in the form of an elastic strap fol-
low ed by a functional brace for 8 d ays (Eiff et al 1994). Stud ies
generally favou r m obilization, com pared w ith im m obiliza-
tion, in ou tcom e m easu res re ecting retu rn to sp ort (w eighted
m ean d ifference 4.6 d ays; 95% CI 1.5–7.6 d ays), retu rn to w ork
(w eighted m ean d ifference 2.1 d ays; 95% CI 5.6–8.7 d ays) and
instability (w eighted m ean d ifference 2.5 d ays; 95% CI 1.3–3.6
d ays) (Kerkhoffs et al 2001). There w ere also sm all effect sizes
of treatm ent that favou red the early m obilization grou p for
ankle range of m otion and sw elling.
Thrust and non-thrust joint mobilization
Several stu d ies have d em onstrated the effectiveness of early
m anu al therap y in d ecreasing p ain, d ecreasing oed em a and
red u cing recovery tim e (N ield et al 1993; Green et al 2001;
Pellow & Brantingham 2001; Fryer et al 2002; Eisenhart et al
2003; Whitm an et al 2005; van d er Wees et al 2006). Most
recently, Cleland et al (2013) d em onstrated superior short-
and long-term ou tcom es in a grou p receiving m anual therap y
and exercise as com pared w ith a group receiving hom e exer-
cise p rogram m e in isolation. Other stu d ies have d em onstrated
sim ilar resu lts com p ared w ith tru e control and in-clinic exer-
cise alone. Whitm an et al (2009) d evelop ed a clinical p red ic-
tion ru le for p atients likely to resp ond to m anu al therap y
d irected at the foot–ankle com plex for patients post lateral
ankle sp rain. Pred ictors of success includ ed sym p tom s w orse
w hile stand ing, sym ptom s w orse in the evening, navicu lar
d rop test greater than 5 m m and d istal tibio bu lar hypom o-
bility. Presence of three of the pred ictors w as associated w ith
a positive likelihood of 5.90 (95% CI 1.08–41.60), increasing
p ost-test p robability of success to 95%. It is w orthw hile noting
that 75% of the p atients had a su ccessfu l ou tcom e w ith the
 Conservative treatment 611

treatm ent, qu estioning w hether a clinical p red iction ru le is

need ed to d eterm ine the ef cacy of m anu al therap y d irected
to the foot and ankle for p atients p ost lateral ankle sp rain.
H ere w e sum m arize som e of the m ost com m only u sed tech-
niqu es for ankle sp rains. (See also Ch 57 for m ore joint m obi-
lization and m anipulation techniqu es targeted to the ankle.)

Anterior–posterior non-thrust mobilization

(see Fig. 57.2)
The therapist uses one hand to stabilize the low er leg rm ly
at the level of the m alleoli. The therapist grasps the anterior,
m ed ial and lateral talu s w ith the m obilizing hand , ju st d istal
to the m alleoli, being carefu l to avoid p ainfu l and sensitive
injured tissues. The therapist then applies a low -velocity,
anterior–posterior oscillatory force to the talus. The therapist
m ay u se his / her thigh to stabilize the foot and p rogressively
increase the am ou nt of ankle d orsi exion. Fine ad justm ents Figure 54.4 Non-thrust lateral glide mobilization of the subtalar joint.
in su pination and p ronation m ay help optim ize the technique.
Lastly, the introd u ction of an anterior roll m ay im p rove the
arthrokinem atics and facilitate the restoration of ankle d orsi-
exion range of m otion (Maitland 2005).

Lateral–medial non-thrust mobilization

(see also Figs 57.3–57.5)
Talocrural joint lateral glide
The therapist grasps the m alleoli ju st proxim al to the talocru -
ral joint w ith the ind ex nger / thu m b of the cephalad hand
and u ses the forearm to stabilize the p atient’s leg against the
table. The therap ist p laces the thenar em inence on the talu s
just d istal to the m alleoli and grasps the rearfoot. The thera-
pist then u ses his / her bod y to im part a low -velocity oscilla-
tory force to the talu s throu gh the extend ed arm and thenar
em inence (Maitland 2005).

Subtalar joint lateral glide

The therap ist shifts the cephalad hand / forearm d istally and Figure 54.5 Rearfoot (subtalar) distraction thrust manipulation set-up.
grasp s the talu s w ith the ind ex nger / thu m b. The therapist
places the thenar em inence on the p atient’s m ed ial aspect of
the calcaneu s and grasp s the rearfoot (Fig. 54.4). The therapist
u ses his / her bod y to im p art a low -velocity oscillatory force
to the calcaneu s throu gh the extend ed arm and thenar em i-
nence (Maitland 2005).

Rearfoot distraction thrust manipulation

(see also Fig. 57.1)
The therapist grasps the d orsum of the patient’s foot im m e-
d iately d istal to the talocru ral joint line w ith interlaced ngers
and p laces the foot into d orsi exion. Firm p ressu re, w ith both
thu m bs, is ap p lied to the m id d le of the p lantar su rface of the
foot (Fig. 54.5). The therapist engages the restrictive barrier
by passively d orsi exing and everting the ankle (protecting
the inju red ATFL) and ap p lying a long-axis d istraction. The
therap ist everts and d orsi exes the foot to ne-tu ne the
barrier. The therapist ap plies a high-velocity, low -am plitu d e
force in the cau d al d irection (Fig. 54.6) (Whitm an et al 2009). Figure 54.6 Rearfoot (subtalar) distraction thrust manipulation.
 612 PART 9 • 54 • Ankle sprains

Figure 54.7 Proximal tibio bular joint thrust manipulation set-up. Figure 54.8 Proximal tibio bular joint thrust manipulation.

Distal tibio bular joint non-thrust mobilization

(see Fig. 57.7)
The therapist grasps and stabilizes the d istal tibia w ith one
hand p laced p osterior to the m ed ial m alleolu s. The therap ist
then p laces the thenar em inence of the op p osite hand over the
anterior asp ect of the lateral m alleolu s and u ses his / her bod y
to im p art a low -velocity, oscillatory, anterior-to-p osterior
force to the bu la on the tibia (Mu lligan 1995).

Proximal tibio bular joint thrust manipulation

(see also Fig. 57.6)
The therapist places the second m etacarp op halangeal joint in
the p op liteal fossa, p u lling the soft tissu e laterally u ntil the
m etacarp op halangeal joint is rm ly stabilized behind the
p atient’s bu lar head (Fig. 54.7). The therapist u ses the oppo-
site hand to grasp the foot and ankle. The therap ist externally
rotates the leg and exes the knee to the restrictive barrier
(Fig. 54.8). The therapist d elivers a high-velocity, low -
am p litud e force throu gh the tibia, d irecting the patient’s
heel to the ip silateral bu ttock (Whitm an et al 2009; Beazell
et al 2012).
Weight-bearing dorsi exion mobilization with
movement (see also Fig. 57.4B)
The therapist supp orts the arch of the foot w ith the m ed ial
hand and app lies a stabilizing force (anterior–p osterior) over
the anterior talu s. A belt is p laced arou nd the p atient’s d istal
p osterior tibia and bula and arou nd the therapist’s buttock
region. The p atient is gu id ed into d orsi exion of the involved
ankle w hile the therap ist applies a p osterior-to-anterior-
d irected force to the d istal leg by leaning backw ard / p ulling
on the belt. As the p atient d orsi exes m ore, the therap ist
squ ats d ow n w hile leaning back in ord er to m aintain a p er-
p end icular orientation to the low er leg and thu s app ly a
d irect p osterior–anterior force at the talocru ral joint (Fig. 54.9)
(Mu lligan 1995; Collins et al 2004; Vincenzino et al 2006).
Figure 54.9 Weight-bearing dorsi exion mobilization with movement.
Cuboid whip thrust manipulation
(see also Fig. 57.8)
Patients p ost inversion ankle sp rain w ith p ersistent p ain
located over the lateral d orsum of the foot associated w ith
m id -foot hyp om obility m ay bene t from a cu boid w hip tech-
niqu e. Care shou ld be taken w ith u se of the techniqu e in
p atients w ith high acu ity and inju ry of the ATFL, given the
end p osition of the technique. The patient is positioned in
p rone. The exam iner grasp s the p atient’s foot w ith the knee
p ositioned in exion. The therap ist interlocks the ngers of
both hand s over the d orsum of the foot, w ith both thu m bs
ap plying rm pressu re to the p lantar surface of the cuboid
d irected in a d orsal and slightly lateral d irection (Fig. 54.10).
The therap ist then app lies a high velocity, low -am plitud e
force, m oving the ankle in the plantar exed and inverted
p osition w ith sim u ltaneou s knee extension (Jennings &
Davies 2005).

Figure 54.10 Cuboid whip thrust manipulation.
Therapeutic exercise
Mobility exercise
After initial ankle sprain w ith resp ect to protection, early
active m obilization is recom m end ed for increasing extracel-
lular u id exchange, d ecreasing sw elling, increasing range
of m otion, d ecreasing stiffness and restoring norm al joint
m echanics (van d er Wees et al 2006). For lateral ankle sprains,
em phasis is placed on restoration of m otion to pre-existing or
contralateral m easu res; how ever, p articu lar note is p laced on
restoration of subtalar eversion and d orsi exion given the
tend ency for red u ctions in range, w hich m ay p lay a role
in recurrence or other low er extrem ity injury (Denegar
et al 2002).
This can inclu d e static and d ynam ic stretching of the ankle
plantar exor and also non-w eight-bearing and w eight-
bearing m obilizations into com bined pronation (Etnyre &
Abraham 1986). An exam p le of this is a split kneel into w eight-
bearing d orsi exion; this m ay be com bined w ith an elastic
posteriorly d irected force to serve as a self-m obilization
sim ilar to the w eight-bearing d orsi exion m obilization w ith
m ovem ent.
Strengthening
Early strengthening exercises for p atients recovering from
ankle sp rains often includ e isom etric or concentric and / or
eccentric contractions, u sing elastic resistance in non-w eight-
bearing p ositions. Card inal planes of m ovem ents shou ld
be u tilized inclu d ing d orsi exion, plantar exion, inversion
and eversion (Uh et al 2000; Bassett & Prapavessis 2007;
Kem ler et al 2011).
In ord er to avoid exercise tolerance, patients should transi-
tion to w eight-bearing exercises as p ain and sw elling d ecrease
w ith respect to physiological healing tim es, esp ecially in cases
of m ore severe ligam entou s inju ry. This m ay inclu d e w eight-
shifting and p rogression to active heel rising throu gh p artial
and eventu ally fu ll ranges of m otion. Gentle and grad u al
progressive squ atting can p rom ote talocru ral and subtalar
joint p ronation. Gait-restorative exercises utilizing the full
Conservative treatment 613
functional range of m otion of the ankle shou ld be im ple-
m ented early on so as to p revent com p ensatory p atterns
(Wilson & Gansned er 2000).
Proprioceptive exercises
Prop riocep tive exercises have w ell-established im p ortance for
p atients retu rning to p reviou s fu nction. De cits related to
joint proprioception are thou ght to be associated w ith chronic
ankle instability and recu rrence (Lentell et al 1995). Proprio-
cep tive exercises have taken m any form s: on stable versu s
u nstable su rfaces, op en versu s closed eye circu m stances,
single- versu s d ou ble-lim b stance, and static versu s d ynam ic
activities. Com m on exam ples of these exercises inclu d e static
single-lim b stance w ith the d egree of d if cu lty p rogressed
w ith the ad d ition of d ecreased visu al inpu t, an u nstable
su rface, or contralateral low er extrem ity and u p p er extrem ity
m otion (H ess et al 2001; Osborne et al 2001). These ad vances
serve to challenge the neu rom u scu loskeletal system to
im prove joint proprioception and m u scle recru itm ent and
reaction tim es (H an et al 2009; Wester et al 1996).
More-ad vanced m od i cations inclu d e the ad d ition of ball
throw ing w ith a p artner or on a tram p oline. Esp ecially in
retu rn-to-sport cases, jum ping and bound ing exercises are
essential for restoring function and d ecreasing the likelihood
of recu rrence (H olm e et al 1999; H u pperets et al 2009). Uni-
p lanar m otion shou ld begin w ith an em p hasis on rep etitions
and speed of land ing to take off, w ith p rogressions m ad e by
increasing height or d istance, and incorp orating m u ltiple
d irections in a pattern or at rand om . Read ers are referred to
other chap ters of the cu rrent textbook for fu rther d iscu ssion
and progression of exercises in relation to p rop riocep tive
rehabilitation.
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 PART 9 •  The Foot and Ankle in Lower Extremity Pain Syndromes
Plantar Heel Pain
55  Chapter 
M a tth e w P. C o tc h e tt
CHAP TER CONTENTS
Introduction  616
Prevalence  616
Origin of plantar heel pain  616
Anatomical considerations  616
Pathology of plantar heel pain  616
Diagnosis  617
Symptoms  617
Signs  617
Imaging  617
Risk factors  618
Prognosis  618
Management strategies for plantar heel pain  618
Non-invasive manual therapy for plantar heel pain  618
Invasive manual therapy for plantar heel pain –  
dry needling  620
Conclusion and recommendations  621
Introduction
Prevalence
Plantar heel p ain is a com m on sou rce of p ain and d isability,
w ith an estim ated prevalence of 3.6–7.5% in the general popu -
lation (Du nn et al 2004; Menz et al 2006; H ill et al 2008). In
the United States, an estim ated 1 m illion p atient visits to
of ce-based p hysicians and hosp ital ou tp atient d ep artm ents
p er year w ere for p lantar heel p ain (Rid d le & Schap p ert
2004). Plantar heel pain pred om inantly affects m id d le-aged as
w ell as old er ad u lts (Dunn et al 2004), and is estim ated to
contribu te 8.0% of all ru nning-related injuries (Tau nton et al
2002). The d isord er ap pears to be m ore com m on in fem ales
(Davis et al 1994; Rano et al 2001; Land orf et al 2006;
Rad ford et al 2006, 2007; Cleland et al 2009, Kalaci et al 2009;
Labovitz et al 2011; Renan-Ord ine et al 2011; McMillan et al
2012; Saban et al 2014), although there are few high-quality
epid em iological stud ies available. The high prevalence of
p lantar heel p ain is associated w ith a large econom ic bu rd en
to the com m u nity. Tong & Fu ria (2010) p rojected that in 2007
the annu al econom ic cost of p lantar heel p ain w as betw een
$US192 and $US376 m illion to third p arty p ayers.
 
Origin of plantar heel pain
Pain beneath the heel can be neu rological, vascu lar, arthritic,
neop lastic or trau m atic in origin (Thom as et al 2010).
H ow ever, it is generally accepted that a m echanical overload
of the p lantar fascia is the m ost com m on sou rce of p ain in
this region. An overload of the p lantar fascia, and associated
changes to its connective tissu e stru ctu re, is m ost often
referred to as plantar fasciitis (McPoil et al 2008). The term
plantar heel pain is also u sed frequ ently in the literatu re, as
it highlights the involvem ent of other stru ctu res and tissu es
(e.g. m u scle and bone), w hich m ight be associated w ith an
overload of the p lantar fascia in p eop le w ith p lantar
fasciitis.
Anatomical considerations
The plantar heel region com prises the calcaneu s, m u scle and
tend ons (sp read over tw o layers) and three neu rovascu lar
bu nd les. Overlying and intertw ined w ithin the plantar heel
intrinsic m u scles is a thickened band of connective tissue
called the p lantar fascia (Fig. 55.1). The central band of the
p lantar fascia attaches to the m ed ial tu bercle of the p lantar
su rface of the calcaneu s and is ad jacent to other stru ctu res that
attach to this region, inclu d ing the m u scles and tend ons of
abd u ctor hallu cis, exor d igitoru m brevis and quad ratus
p lantae (Fig. 55.2). Evid ence from com p arative cross-sectional
stu d ies rep orts that the thickness of the p lantar fascia ranges
from 2.4 m m to 3.6 m m (Crofts et al 2014).
Pathology of Plantar Heel Pain
Pathological changes w ithin the p lantar fascia are com m on in
p eop le w ith p lantar heel p ain. H istological exam ination of
sp ecim ens obtained from the p roxim al attachm ent of the
p lantar fascia in p eop le w ith p lantar heel p ain show s collagen
necrosis, increased m u coid grou nd su bstance, angio broblas-
tic hyp erp lasia, chond roid m etap lasia and m atrix calci cation
(Wearing et al 2006). Su ch nd ings su ggest a loss of organized
tissu e stru ctu re, w hich is consistent w ith a d egenerative
fasciosis (Lem ont et al 2003), althou gh som e stu d ies have
reported evid ence of local non-sp eci c in am m atory changes.
Pathological changes w ithin the p lantar intrinsic m u scu la-
tu re have also been rep orted in p eop le w ith p lantar heel p ain.
 Diagnosis 617

w ill highlight the key sym ptom s and signs of p lantar

heel p ain. The read er is also referred to an excellent review
on the d ifferential d iagnosis of p ain beneath the heel
(Buchbind er 2004).

Symptoms
Patients w ith p lantar heel p ain typ ically p resent w ith an
insid iou s onset of p ain in the m ed ial plantar heel region.
Sym p tom s are u su ally u nilateral, bu t they can p resent bilater-
ally in ap p roxim ately 40% of cases (Lap id u s & Gu id otti 1965;
Land orf et al 2006; Rad ford et al 2006, 2007; Labovitz et al
Plantar fascia: Plantar fascia:
lateral component medial component
2011). Bilateral sym ptom s shou ld raise su sp icion of a spond y-
loarthrop athy (e.g. Reiter ’s synd rom e, psoriatic arthrop athy,
Plantar fascia: ankylosing spond ylitis) (Bu chbind er 2004). The type of pain
central component can vary from sym p tom s that are initially sharp and localized
to p ain that is d eep , d u ll and p oorly localized . Sym p tom s are
w orse up on w eight-bearing after period s of rest and often
im prove w ith initial activity, although it is also com m on for
sym p tom s to be w orse at the end of the d ay, p articu larly fol-
low ing prolonged period s of stand ing and w alking. N octur-
nal sym p tom s are u ncom m on, and shou ld alert the clinician
Figure 55.1 Anatomical diagram highlighting the various bands of the plantar to other cond itions inclu d ing cancer, infection and neu ro-
fascia. p athic p ain (Bu chbind er 2004). The onset of plantar heel pain
often coincid es w ith a change in the typ e and level of activity,
or a change in footw ear (McPoil et al 2008).

Abductor hallucis
Quadratis plantae
Flexor digitorum
Abductor digiti brevis
minimi
Figure 55.2 Anatomical diagram highlighting the intrinsic muscles within
layers one and two of the heel.
Cross-sectional stu d ies have revealed atrop hy of the abd u ctor
d igiti m inim i (Chund ru et al 2008) and atrophy of the forefoot
intrinsic m u scles (Chang et al 2012), nd ings that have been
hyp othesized to exacerbate the load p laced on a sw ollen or
d egenerative plantar fascia (Chang et al 2012).
Diagnosis
A d iagnosis of p lantar heel p ain is u su ally m ad e on the basis
of a thorou gh history and p hysical exam ination. This section
Signs
The physical exam ination shou ld be cond ucted w ith the
p atient both non-w eight-bearing and w eight-bearing and
inclu d e active and passive m ovem ents, m uscle tests, nerve
tests, p alp ation and other sp ecial tests, for exam p le the
tarsal tu nnel synd rom e test, the w ind lass test, m ed ial and
lateral squ eeze test of the calcaneu s, and an assessm ent of
foot postu re using a reliable and valid m easu re such as
the Foot Postu re Ind ex (Red m ond et al 2006). The key d iag-
nostic featu re of p lantar heel p ain is localized tend erness
at the proxim al insertion of the plantar fascia (McPoil
et al 2008).
Imaging
Diagnostic im aging for plantar heel pain is generally used
only w hen the assessm ent is inconclu sive. Diagnostic m u scu -
loskeletal ultrasound (MSKUS) is the m od ality of choice for
the assessm ent of soft tissu e stru ctu res beneath the heel,
althou gh m agnetic resonance im aging (MRI) and plain rad io-
graphs can be u sed w hen there is a need to ru le out other
p ossible cau ses of heel p ain (McPoil et al 2008). MSKUS often
reveals fu siform sw elling of the plantar fascia that is greater
than 4 m m in thickness (McMillan et al 2009) w ith su rrou nd -
ing local or d iffuse areas of hyp oechogenicity. MRI often
show s increased intrafascial oed em a on T1- and T2-w eighted
im ages, and perifascial oed em a at the insertion of the plantar
fascia, w hich is m ore com m on in p atients w ith longstand ing
sym p tom s (Chim u tengw end e-Gord on et al 2010). Finally, it
is com m on to id entify su bcalcaneal spu rs on plain rad io-
graphs in patients w ith plantar heel p ain (McMillan et al
2009). The presence of a spu r is of no d iagnostic value,
althou gh it m ight alert the clinician to the p ossibility of an
 618 PART 9 • 55 • Plantar heel pain
u nd erlying sp ond yloarthrop athy if the sp u r is ill d e ned
(Bu chbind er 2004).
Risk Factors
Despite the p revalence of plantar heel pain, the aetiology
rem ains uncertain. The highest level of evid ence, w hich has
evaluated p hysical and fu nctional associates of plantar heel
p ain, is d erived from a system atic review by Irving et al (2006)
that fou nd increased bod y w eight in a non-athletic p op u lation
to have a strong association w ith p lantar heel p ain. Weak
evid ence w as also fou nd for an association betw een plantar
heel p ain and increased bod y m ass ind ex in an athletic p op u -
lation, as w ell as increased age, d ecreased ankle d orsi exion,
d ecreased rst m etatarsop halangeal joint d orsi exion and
p rolonged stand ing. The association betw een p lantar heel
p ain and foot p ostu re, foot m otion and foot fu nction w as
inconclu sive, how ever (Irving et al 2006).
Prognosis
Plantar heel p ain is consid ered a self-lim iting cond ition
(Buchbind er 2004). This statem ent is su pported by the fact
that sym p tom s norm ally resolve w ithin 12 m onths regard less
of the intervention im p lem ented (Lap id u s & Gu id otti 1965;
Davis et al 1994; Wolgin et al 1994; Martin et al 1998;
Craw ford & Thom son 2003). An increased risk of persistent
p ain has been rep orted in those patients that are obese, and
have bilateral sym p tom s (Wolgin et al 1994).
Management Strategies for Plantar
Heel Pain
N u m erous interventions are used to treat plantar heel pain;
how ever, tw o system atic review s have conclu d ed that
there are few interventions that are su p p orted by good evi-
d ence (Craw ford & Thom son 2003; Land orf & Menz 2008).
An evid enced -based m anagem ent algorithm provid ed by
the Am erican College of Foot and Ankle Su rgeons (ACFAS)
recom m end s a m ultifaceted , tiered treatm ent app roach
(Thom as et al 2010). Initial op tions inclu d e p ad d ing and
strap p ing, stretching exercises, over-the-cou nter foot orthoses,
shoe recom m end ations, and oral and / or injectable anti-
in am m atories. Second -tier op tions for p atients w ith m inim al
im p rovem ent at 6 w eeks inclu d e night splints, custom
orthoses, cast or boot im m obilization, or a p rogram m e of
m anual therap y for a fu rther 4–6 w eeks. Su rgery is recom -
m end ed as a last resort and u su ally only after failu re of at
least 6 m onths of conservative therap y (Thom as et al 2010).
The p u rp ose of the follow ing section is to review the evi-
d ence for the effectiveness of m anu al therapy for p lantar heel
p ain u nd er the categories of non-invasive m anual therapy
and invasive m anu al therapy (i.e. d ry need ling). The focus
w ill be on stud ies that have u sed rand om ized controlled trial
m ethod ology, w hich is consid ered the gold stand ard for a
clinical trial to evalu ate the effectiveness of an intervention
(Portney & Watkins 2009).
Figure 55.3 Soft tissue mobilization of the plantar fascia. The patient is prone
with the knee extended. With the ankle and rst metatarsophalangeal joints in
dorsi exion, the clinician applies deep pressure along the length of the plantar
fascia. The technique is performed for approximately 3 minutes, and the depth of
mobilization is dependent on the patient’s tolerance.
Non-invasive manual therapy
for plantar heel pain
Three rand om ized controlled trials have evalu ated the effec-
tiveness of m anu al therap y for p lantar heel p ain, althou gh
each trial d iffered in regard s to the type of m anu al therapy
im p lem ented , com parator intervention, ou tcom e m easu res,
follow -u p and frequ ency of treatm ent. As su ch, each trial w ill
be d iscussed separately below, and all are su m m arized in
Table 55.1.
Cleland et al (2009) evaluated the effectiveness of m anu al
therap y and exercise in com p arison to electrop hysical agents
and exercise. A sam ple size of 60 participants w as rand om ly
allocated to tw o equ al grou ps: one group receiving electro-
p hysical agents (iontop horesis and d exam ethasone) and the
other grou p receiving m anual therapy (i.e. 5 m inutes of
aggressive soft tissue m obilization of the Achilles and inser-
tion of the p lantar fascia (Fig. 55.3), and rearfoot eversion
m obilization). In ad d ition, p articip ants in the m anu al therap y
grou p received joint m obilization and / or m anipu lation of
the foot and ankle, d ep end ing on the p resentation of that
p atient. Su ch m otions inclu d ed su btalar joint lateral glid es,
talocru ral anterior–posterior glid es, rearfoot d istraction
m anip u lation, cu boid m anip u lation, intertarsal m obilization
and d istal tibio bu lar m obilization. Manual therap y tech-
niqu es w ere also ap p lied to the hip and knee at the d iscretion
of the clinician. The m anu al therap y grou p w as also ad vised
to p erform self-m obilization of the su btalar joint, and p assive
m anu al soft tissu e m obilization of the p lantar fascia at hom e.
Both grou p s u nd ertook a p rogram m e of calf and p lantar
fascia stretching. Participants in both grou ps received six
treatm ents over a 4-w eek period . Changes in p hysical fu nc-
tion w ere assessed at baseline, at 4 w eeks and at 6 m onths,
u sing the Low er Extrem ity Fu nction Scale (LEFS), w hile foot
p ain w as assessed u sing the N u m eric Pain Rating Scale
(N PRS). At 4 w eeks and 6 m onths, signi cant effects favou red
the grou p receiving m anu al therap y. For low er extrem ity
function, the betw een-group d ifference w as 13.5 p oints (95%
CI 6.3–20.8) at 4 w eeks and 9.9 points (95% CI 1.2–18.6) at
 Management strategies for plantar heel pain 619

Table 55.1 Evide nce for the e ffe ctive ne s s of non-invas ive ma nua l the rapy for planta r he e l pain
Author(s ) Prima ry inte rve ntion(s ) Compa ra tor inte rve ntion(s ) Ma jor re s ults

Renan-Ordine et al
(2011)
Saban et al (2014)
Cleland et al (2009)
Trigger point pres sure releas e
technique of the gas trocnemius
(us ually 3 repetitions by 90
s econds) – 4 days a week for 4
weeks
Three longitudinal s trokes (dis tal to
proximal) over the gastrocnemius –
4 days a week for 4 weeks
Self-s tretching of the calf and plantar
fascia (20-second holds followed
by 20 s econds rest for a total of 3
minutes, 2× / day)
10 minutes of deep, forceful
mas sage to painful incompliant
areas of the calf (1–2 times a week
for 6 weeks – total of 8 treatments )
Pas sive s traight leg rais e exercise (20
s econds by 5 repetitions , 3× a day)
Self-s tretching of the calf (20
s econds by 5 repetitions , 3× a day)
5 minutes of aggress ive soft tiss ue
mobilization of the Achilles and
ins ertion of the plantar fascia, and
rearfoot evers ion mobilization (6
treatments over 4 weeks )
Impairments based manual therapy
approach (subtalar joint lateral
glides, talocrural anterior / posterior
glides, rearfoot dis traction
manipulation, cuboid manipulation,
intertarsal mobilization, dis tal
tibio bular mobilization, hip, knee,
patellofemoral and bula–tibia joint
mobilization) – (6 treatments over 4
weeks)
Self-mobilization of the plantar fascia
and s ubtalar joint into evers ion
Self-s tretching of the calf and plantar
fascia
Self-s tretching of the calf and
plantar fascia (20-second
holds followed by 20
seconds res t for a total of 3
minutes , 2× a day)
Self-stretching of the calf (20
seconds by 5 repetitions,
3× a day)
Ultrasound (1 MHz; 1.0
W / cm 2, continuous dos e)
– (1–2 times a week for 6
weeks for a total of 8
treatments)
Ultrasound followed by:
electrophys ical agents
(iontophores is and
dexamethas one) and ice
application pos t treatment
(6 treatments over 4
weeks)
Intrins ic foot s trengthening
Self-s tretching of the calf and
plantar fascia
At 4 weeks, signi cant reductions
in pain favoured the group
receiving trigger point press ure
releas e (between-group
difference 7.8 points, 95% CI
2.5–13.3, p < 0.05)
At 4 weeks, signi cant
improvements in phys ical
function favoured the group
receiving trigger point release
(between-group difference 9.3,
95% CI 3.9–14.8, p < 0.05)
At 6 weeks, phys ical function
improved s igni cantly more in
the group receiving deep
mass age therapy (between-
group difference 9, 95% CI
0.7–16, p = 0.034).
No signi cant differences between
groups for pain
At 4 weeks, phys ical function was
signi cantly improved in favour
of the group receiving manual
therapy (between-group
difference 13.5 points, 95% CI
6.3–20.8, p = 0.001). Foot pain
was s igni cantly more reduced
in the manual therapy group
(between-group difference −1.5,
95% CI −0.4 to −2.5, p = 0.008).
At 6 months, physical function
was s igni cantly more reduced
in the manual therapy group
(between-group difference 9.9,
95% CI 1.2–18.6), p = 0.027).
No signi cant between-group
difference in pain was reported
at 6 months

6 m onths. At both tim e points, the betw een-grou p d ifference
w as greater than the m inim al im p ortant d ifference of 9 p oints,
w hich su ggests that the results are of clinical im portance.
For pain, the grou p receiving m anual therapy had signi -
cantly larger im provem ents in pain at 4 w eeks w ith a betw een-
grou p d ifference of −1.5 points (95% CI −0.4 to −2.5). There
w ere no signi cant nd ings for pain at 6 m onths. Althou gh
these nd ings are p rom ising for the u se of m anu al therap y
for p lantar heel pain, it is not possible to ascertain w hich
com p onent(s) of this m u ltim od al treatm ent p rogram m e w ere
resp onsible for the im provem ent in pain and fu nction (Cleland
et al 2009).
Renan-Ord ine et al (2011) cond u cted a rand om ized con-
trolled trial to evalu ate the effectiveness of trigger p oint
therap y for p lantar heel p ain. Sixty p articip ants w ere ran-
d om ly allocated to a grou p that received either self-
stretch in g of the p lantar fascia and calf m u scles (soleu s and
gastrocnem iu s speci c stretches) or to one that received the
sam e stretching p rogram m e in conju nction w ith m anu al
therap y (trigger p oint p ressu re release of the gastrocnem iu s
m u scle and a neu rom u scu lar techniqu e involving longitu d i-
nal strokes d irected over the calf m u scu latu re). The exact
m echanism for the ef cacy of trigger p oint m anu al therap y is
u ncertain, althou gh trigger p oints in the soleu s m u scle have
been p roposed as a sou rce of pain in people w ith plantar heel
p ain (Travell & Sim ons 1992). In this regard , trigger point
m anu al therap y m ight d eactivate trigger p oints by norm al-
izing the length of contracted sarcom eres in the affected
region. All participants in the trial w ere treated fou r tim es a
w eek for 4 w eeks. The p rim ary outcom e m easu res inclu d ed
the bod ily p ain and p hysical fu nction d om ains of the Short-
Form 36 H ealth Su rvey (SF-36) and w ere record ed at baseline
and at 4 w eeks. Both group s show ed d ecreased p ain at 4
w eeks; how ever, there w ere signi cant betw een-group effects
 620 PART 9 • 55 • Plantar heel pain
that favou red the grou p receiving trigger p oint m anu al
therap y. For bod ily p ain, the betw een-grou p d ifference w as
7.8 points (95% CI 2.5–13.3), w hereas for physical fu nction the
betw een-group d ifference w as 9.3 p oints (95% CI 3.9–14.8).
For both ou tcom es, the results w ere also clinically signi cant.
It is im portant to note, how ever, that the m ethod ological
qu ality of the trial m ight have been com p rom ised as there w as
no evid ence that the allocation sequ ence w as concealed or
w hether the d ata w as analysed on an intention-to-treat basis.
In ad d ition, the follow -u p p eriod w as short (i.e. 4 w eeks) so
it is u nclear w hether the treatm ent is effective in the long term
(Renan-Ord ine et al 2011).
In a sim ilar stu d y that evaluated m anu al therap y for
p lantar heel p ain, Saban et al (2014) investigated w hether
d eep m assage of the calf, neu ral m obilization exercises and a
self-stretch p rogram m e w as m ore effective than u ltrasou nd
therap y p lu s the sam e self-stretch p rogram m e. Sixty-nine p ar-
ticip ants w ith a d iagnosis of p lantar heel p ain w ere rand om ly
allocated to tw o grou p s; one grou p received 10 m inu tes of
forcefu l, d eep m assage therapy to p ainful incom pliant areas
of the calf. The techniqu e w as ap p lied u sing the clinician’s
thu m b or elbow in a m ed ial and lateral d irection, across the
bres of the gastrocnem iu s and soleu s. In ad d ition, this grou p
p erform ed a p assive straight leg raise exercise, w ith d orsi ex-
ion of the ankle, u sing a long belt. Each exercise w as held for
20 second s, rep eated ve tim es, and cond u cted three tim es a
d ay. In com p arison, the stretching and u ltrasou nd grou p
received 3 m inutes of u ltrasou nd (frequency of 1 MH z and
intensity of 1.0 W / cm 2, continu ou s d ose). Both grou p s w ere
asked to p erform gastrocnem iu s and soleu s sp eci c stretches,
at the sam e d osage as in the neu ral m obilization exercise
grou p. All patients w ere treated tw ice a w eek, w ith a total of
eight treatm ents over a 6-w eek period . Ou tcom e m easures
inclu d ed fu nctional statu s, assessed u sing the Foot and Ankle
Com p u terized Ad ap tive Test (CAT), as w ell as the change in
foot p ain d eterm ined w ith a 10 cm visu al analogu e scale. All
ou tcom e m easu res w ere assessed at baseline and at 6 w eeks.
At the 6-w eek follow -up, both group s rep orted a signi cant
im p rovem ent in fu nction and p ain. H ow ever, signi cant
effects favou red the grou p receiving d eep m assage therap y,
w ith a betw een-group d ifference in fu nction of 9 p oints (95%
CI 0.7–16), a resu lt that w as also clinically im p ortant (Saban
et al 2014). Changes in foot pain w ere less convincing, w ith
betw een-group d ifferences of −0.1 cm (95% CI −0.7, 1.7) that
w ere not statistically signi cant. It is im portant to note,
how ever, that a large percentage of p atients d rop p ed ou t in
the stu d y (28% in the d eep m assage therapy grou p , 24% in
the stretching and u ltrasou nd grou p ), w hich m ight have
yield ed biased estim ates of treatm ent effects (Bell et al 2013).
In ad d ition, the short-term ou tcom es preclu d e any assu m p-
tion abou t the long-term effectiveness of d eep m assage
therap y for p lantar heel p ain (Saban et al 2014).
In su m m ary, the evid ence for the effectiveness of m anual
therap y for p lantar heel p ain is lim ited to three stu d ies w ith
su bstantial m ethod ological heterogeneity. N evertheless, there
is m od erate evid ence that: (i) a m u ltim od al m anu al p hysical
therap y ap p roach that com bines soft tissu e m obilization of
the p lantar fascia, m obilization and / or m anip u lation of
low er extrem ity joints and self-stretching is su p erior to a com -
bination of iontophoresis, ultrasound and self-stretching exer-
cises, (ii) m yofascial trigger p oint m anu al therap y of the calf,
in com bination w ith self-stretching of the calf and p lantar
fascia, is superior to the sole app lication of self-stretching, and
(iii) d eep m assage therap y of the calf in com bination w ith
neu ral m obilization exercises and calf stretching is su p erior
to a com bination of u ltrasou nd and calf stretching. Fu tu re
w ork is required to: (i) d eterm ine w hether trigger point
m anu al therap y, d eep m assage therap y or aggressive soft
tissu e m obilization of the p lantar fascia is m ore effective than
a sham treatm ent, (ii) d eterm ine the am ou nt of force that
need s to be ap p lied d u ring m anu al therap y of the calf or
p lantar fascia to obtain a clinically w orthw hile im p rovem ent,
(iii) d eterm ine w hich speci c joint m obilization techniqu es, or
com bination of techniqu es, is m ost effective for p lantar heel
p ain, and (iv) com p are the effectiveness of non-invasive
m anu al therap y techniqu es against other com m on treatm ents
for p lantar heel p ain (e.g. foot orthoses).
Invasive manual therapy for plantar heel
pain – dry needling
In ad d ition to stand ard therap ies, d ry need ling is increasingly
u sed by p ractitioners to treat m yofascial p ain w ithin all p arts
of the bod y, inclu d ing the p lantar heel region. Dry need ling
for plantar heel pain is m ost often gu id ed by the trigger point
m od el (Cotchett et al 2011), w hich involves the insertion of
need les into a trigger p oint to red u ce p ain and im p rove fu nc-
tion (Dom m erholt & Fernánd ez-d e-las-Peñas 2013). The
m u scles m ost com m only d ry need led , w hen gu id ed by the
trigger p oint m od el for p lantar heel p ain, inclu d e the soleu s,
gastrocnem ius, qu ad ratu s p lantae (Fig. 55.4), abd u ctor hal-
lucis and exor d igitoru m brevis (Cotchett et al 2011),
althou gh it is also not u ncom m on for som e practitioners to
d ry-need le the gluteu s m ed ius, gluteu s m inim u s and erector
sp inae if their treatm ent is gu id ed by the rad icu lop athy m od el
(i.e. a m od el that su ggests m yofascial pain is second ary to a
sp inal nerve d ysfu nction) (Cotchett et al 2011).
Evid ence to su p p ort the u se of d ry need ling for p lantar heel
pain is lim ited to tw o case series and a single rand om ized
controlled trial (Cotchett et al 2010). Tillu and Gup ta (1998)
fou nd a signi cant im p rovem ent in 18 ad ults w ith plantar
heel pain (68% im provem ent) after 2 w eeks (1 treatm ent
p er w eek) of d ry need ling of the calf and heel regions,
follow ing a 4-w eek p eriod of trad itional Chinese acu p u nc-
tu re. Perez-Millan and Foster (2001) also d em onstrated a
Figure 55.4 Trigger point dry needling of the quadratus plantae muscle.

signi cant red u ction in pain (46% im p rovem ent) in 18 partici-
pants w ith p lantar heel p ain after a 6-w eek (1 treatm ent per
w eek) program m e of trad itional Chinese acup unctu re and
d ry need ling of the heel and arch. H ow ever, these trials w ere
case series of p oor m ethod ological qu ality, w hich lacked
control grou p s. Therefore, the effects of the trigger p oint treat-
m ent are likely to have been overestim ated ow ing to con-
fou nd ing and possible bias.
Based on the resu lts of the system atic review, a trial to
evaluate the effectiveness of trigger point d ry need ling for
plantar heel pain w as cond u cted (Cotchett et al 2014). The
protocol, inclu d ing need ling d etails and treatm ent regim en,
w as form ulated by general consensu s (u sing the Delphi
research m ethod ) u sing 30 exp erts w orld w id e w ho com m only
u se d ry need ling for p lantar heel p ain (Cotchett et al 2011a).
Read ers are referred to another text for m ore d etails on d ry
need ling of these m u scles (Dom m erholt & Fernánd ez-d e-las-
Peñas 2013).
The resu lts of the rand om ized controlled trial revealed that,
at the p rim ary end -point (i.e. 6 w eeks), signi cant effects
favoured real d ry need ling over sham d ry need ling for
pain (ad ju sted m ean d ifference: visu al analog rst-step pain
−14.4 m m , 95% CI −23.5 to −5.2, p = 0.002; Foot H ealth Status
Qu estionnaire foot pain 10.0 points, 95% CI 1.0 to 19.1,
p = 0.029), althou gh the betw een-grou p d ifference w as low er
than the m inim al im p ortant d ifference. The nu m ber need ed
to treat at 6 w eeks w as 4 (95% CI 2 to 12) (Cotchett et al 2014).
Conclusion and Recommendations
Plantar heel p ain is one of the m ost com m on m u scu loskeletal
d isord ers of the low er extrem ity and has a negative im pact
on health-related qu ality of life. The cond ition p rim arily
effects m id d le-aged and old er ad ults, and is a com m on sou rce
of p ain in athletes. Plantar heel p ain is not consid ered an
in am m atory cond ition bu t rather a d egenerative fasciosis.
The d isord er is d iagnosed based on a thorou gh history and
physical exam ination to help d istinguish the cond ition from
pain beneath the heel that m ight be arthritic, neurological,
trau m atic or the resu lt of other system ic cond itions. Key d iag-
nostic featu res inclu d e p ain in the p lantar m ed ial heel region
that is w orse u p on w eight-bearing after p eriod s of rest, and
pain u p on p alp ation of the plantar fascia insertion.
N u m erous interventions are u sed to m anage plantar heel
pain, althou gh there are few interventions that are su pp orted
by good evid ence. Despite the lim ited evid ence, clinical prac-
tice gu id elines, w ritten by the ACFAS in 2011, recom m end an
initial low cost and m inim al risk approach, w hich inclu d es
pad d ing and strapp ing, calf and plantar fascia stretching,
footw ear ad vice, over-the-counter arch supp orts, activity
m od i cation and oral or injectable anti-in am m atories.
Second -tier op tions inclu d e night sp lints, cast and boot im m o-
bilization, a repeat cortisone injection and a cou rse of m anu al
therap y. Su rgery shou ld be consid ered only after 6 m onths of
failed conservative care.
The recom m end ation by the ACFAS to includ e m anu al
therap y as a second -tier op tion m ay need to be revised based
on recent evid ence p u blished after the ACFAS gu id elines
w ere w ritten. This chapter has highlighted that there is
m od erate evid ence to recom m end the inclu sion of non-
invasive m anual therapies for plantar heel p ain in the short
Conclusion and recommendations 621
term , p articu larly as a rst-tier op tion. Su ch m anu al therap y
techniqu es inclu d e: (i) trigger p oint m anu al therap y and lon-
gitu d inal m assage strokes of the calf in com bination w ith calf
and plantar fascia stretching, (ii) d eep m assage to the calf in
com bination w ith neu ral m obilization exercises and calf
stretching, and (iii) a m u ltim od al m anu al therap y p rogram m e
inclu d ing aggressive soft tissu e m obilization of the plantar
fascia, joint m obilization w ithin the foot and low er extrem ity,
and calf stretching.
Whereas there is m od erate evid ence from three trials rec-
om m end ing non-invasive m anu al therap ies for p lantar heel
p ain, there is only m od erate evid ence from a single rand -
om ized controlled trial su p p orting the u se of invasive m anu al
therap ies (i.e. d ry need ling) for p lantar heel p ain.
Despite the p rom ising evid ence for the u se of m anu al ther-
ap ies for p lantar heel pain, m ore rigorou s rand om ized con-
trolled trials are need ed . Fu tu re trials shou ld evalu ate these
interventions w hen u sed alone, and in com parison w ith a
sham intervention, inclu d ing ap p rop riate blind ing p roce-
d ures. Fu rtherm ore, it is recom m end ed that fu ture trials
com p are m anu al therap y techniqu es against other com m on
treatm ents for p lantar heel p ain.
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 PART 9 •  The Foot and Ankle in Lower Extremity Pain Syndromes
Postoperative Management o Foot and Ankle Disorders
Chapter  56
S te p h a n ie Alb in , M a rk W. C o rn w a ll, Th o m a s G . M c Po il
CHAP TER CONTENTS
Introduction  623
Total ankle arthroplasty  623
Introduction  623
Ankle arthrodesis versus arthroplasty  624
Surgical procedures  624
Postoperative rehabilitation treatment  625
Ef cacy of rehabilitation treatment  627
Achilles tendon ruptures  628
Introduction  628
Epidemiology  629
Risk factors  629
Diagnosis  629
Surgical versus non-surgical treatment  630
Early range of motion versus immobilization  631
Early weight-bearing versus late weight-bearing  632
Post-surgical rehabilitation treatment  632
Conclusion  635
Introduction
The effectiveness of m anu al therapy has been d ocu m ented in
patients w ith acu te and chronic foot and ankle cond itions
(Vicenzino et al 2006; Cleland et al 2009, 2013; Whitm an et al
2009; H ensley & Kavchak 2012). H ow ever, literatu re assessing
the effectiveness after su rgical p roced u res is som ew hat rare,
and alm ost non-existent in the foot and ankle. This chapter
focuses on m anu al therapy and rehabilitation after surgical
repair of the Achilles tend on and after total ankle arthro-
plasty. As literatu re is sparse in these areas, m uch of the
treatm ent recom m end ations are based on clinical exp erience
and p rincip les of best practice. A p roper d escrip tion proce-
d u re and clinical outcom es have been provid ed for both su rgi-
cal p roced u res so as to p rovid e insight into areas w here w e
cou ld p otentially im p rove treatm ent and the p otential for
m anu al therap y to serve as an ad ju nct in the m anagem ent of
these p atient p op u lations.
 
 
Total Ankle Arthroplasty
Introduction
Total ankle arthrop lasty began increasing in p op u larity in the
1970s w ith approxim ately 23 d ifferent p roced u res being
d eveloped d u ring the 1970s and 1980s (Gittins & Mann 2002;
H interm ann & Vald errabano 2003; Clarid ge & Sagherian
2009). By the m id 1980s, arthroplasty for end -stage arthritis of
the ankle w as nearly aband oned ow ing to high failu re rates
of these early-p rosthetic-generation d esigns. These rst-
generation ankle p rostheses d id not fu lly take into account
the biom echanics of the ankle joint (Gittins & Mann 2002).
Poor ou tcom es of these early p rosthetic d esigns led som e
au thors to qu estion w hether it w as even p ossible to rep licate
the ankle joint (H interm ann & Vald errabano 2003). H ow ever,
d ue to the high su ccess rates of total hip and total knee
replacem ents along w ith new prosthetic d esigns, ankle arthro-
p lasty is again regaining p op u larity. These new p rostheses
cu rrently being d evelop ed d o accou nt for the com p lexity of
ankle biom echanics and assist w ith preserving m ore bone
stock than d id the p reviou s generations of rep lacem ents
(Gittins & Mann 2002).
As w ith other joint replacem ent surgeries, osteoarthritis
(OA) is the m ain reason for joint rep lacem ent. OA of the
ankle joint lead s to joint stiffness, pain, d ecreases in p hysical
and sporting activities, and lim itations in activities of d aily
living, and often restricts w ork-related activities (Clarid ge &
Sagherian 2009; H orisberger et al 2009). During norm al d aily
activities, extrem e com pressive load s are p laced on the tal-
ocru ral joint. For exam p le, d u ring norm al gait, com p ressive
forces through the talocrural joint reach 5.5 tim es the bod y
w eight (H interm ann & Vald errabano 2003). Su rprisingly
though, less than 1% of the general popu lation su ffers from
ankle OA (H orisberger et al 2009). Prim ary OA occurs pre-
d om inately in the hip and knee, and only rarely in the ankle
joint (H interm ann & Vald errabano 2003). About 65–80% of
ankle OA occu rs second ary to a traum atic event (H interm ann
& Vald errabano 2003; H orisberger et al 2009; H u bbard et al
2009). In com parison, only about 9.8% of knee OA and 1.6%
of hip OA occu r after a trau m atic event (H orisberger et al
 624 PART 9 • 56 • Postoperative management of foot and ankle disorders

2009). Patients w ith ankle OA are often younger than those
w ith hip and / or knee OA (H interm ann & Vald errabano
2003; H orisberger et al 2009).
The exact m echanism of the d evelop m ent of p ost-trau m atic
ankle OA is u nclear. Possible cau ses includ e severity or type
of fractu re, the am ou nt of cartilage d am age related to the
inju ry, age, obesity and joint congru ency after red u ction
(H orisberger et al 2009). Fracture type has been related to the
onset of p ost-trau m atic OA, w ith m alleolar fractu res being the
m ost com m on fractu re typ e cau sing ankle OA, follow ed by
p ilon fractu res and then talu s fractu res (H orisberger et al
2009). Malleolar fractures occur m uch m ore frequ ently than
p ilon fractu res, w hich accou nt for less than 1% of all low er
extrem ity fractu res, and m ay lead to the increased rate of OA
(H orisberger et al 2009).
The average latency tim e betw een fractu res and the d evel-
op m ent of end -stage ankle OA has been rep orted to be, on
average, betw een 10 and 20 years (H orisberger et al 2009).
Coetzee (2010) fou nd 39% of patients w ith p ilon fractu res
d eveloped ankle arthritis, d em onstrated rad iographically,
w ithin 2–3 years of the tim e of inju ry. Another stu d y rep orted
that the incid ence rate of p ost-trau m atic OA after talar frac-
tu res ranged from 47% to 97% (Thom as & Daniels 2003).
Patients w ith intra-articu lar fractu res d evelop end -stage
ankle arthritis m ore qu ickly than d o those w ith extra-articular
fractures (H orisberger et al 2009). In ad d ition, it appears the
old er a p atient is at the tim e they su stain an ankle fractu re,
the m ore qu ickly this end -stage OA p rogresses (H orisberger
et al 2009). Due to the traum a involved , it is believed that the
soft tissu e envelop e arou nd the ankle is involved in the
p rocess (H interm ann & Vald errabano 2003). This thin soft
tissu e envelop e becom es scarred and elasticity is com p ro-
m ised (H interm ann & Vald errabano 2003). In ad d ition to
bony inju ries, ligam entou s inju ries are also a signi cant cau se
of p ost-trau m atic OA, w ith 66–78% of p atients w ith chronic
ankle instability eventu ally d evelop ing ankle OA (H u bbard
et al 2009). Surgeries m ore proxim al to the ankle, su ch as a
total knee rep lacem ent, that change the alignm ent at the tal-
ocru ral joint have been show n to increase the incid ence of
ankle OA (Lee & Jeong 2012).
Stu d ies have d em onstrated gait d eviations betw een
p atients w ith ankle arthritis com p ared w ith a grou p of age-
and gend er-m atched controls (Dyrby et al 2004). Patients w ith
ankle arthritis d em onstrate d ecreased w alking sp eed s,
d ecreased strid e length and increased cad ence (Dyrby et al
2004). Sim ilarly, patients post ankle arthrod esis d em onstrated
a d ecreased gait velocity of 16%, an increase in oxygen con-
sum p tion of 3% and signi cant d ifferences in static balance
variables com p ared w ith m atched controls (H interm ann &
Vald errabano 2003; H u bbard et al 2009). Su bjects w ith ankle
OA rep orted signi cantly m ore centre of p ressu re total
d isplacem ent and centre of pressu re total velocity (H u bbard
et al 2009).
Patients w ith end -stage OA are often m anaged conserva-
tively w ith bracing, assistive d evices, anti-in am m atories,
shoe m od i cations (su ch as a rocker-bottom shoe) and foot
orthoses (Clarid ge & Sagherian 2009). In ad d ition, physical
therap y m ay be p rescribed to assist w ith stretching, joint
m obilization and strengthening as ind icated , althou gh
research on the bene ts of physical therap y in this patient
p opu lation is lim ited (Clarid ge & Sagherian 2009). Although
the au thors cou ld nd no research on m anu al therap y
techniqu es in the m anagem ent of p atients w ith ankle OA,
joint m obilizations m ay bene t this popu lation since m anu al
therap y techniqu es have been fou nd to be bene cial in
other p op u lations w ith low er extrem ity OA (Deyle et al 2005;
MacDonald et al 2006; H and o et al 2012). If conservative treat-
m ent fails, the tw o m ost com m only p erform ed op erative p ro-
ced u res for end -stage ankle arthritis are arthrod esis and
arthroplasty (Clarid ge & Sagherian 2009).
Ankle arthrodesis versus arthroplasty
Ankle arthrod esis w as rst introd u ced in 1879, and has
long since been consid ered the gold stand ard for treatm ent
of ankle OA (Coester et al 2001). H ow ever, this p roced u re
is not w ithout shortcom ings. Problem s after fusion inclu d e
su btalar and m id foot arthritis, p ain w ith w eight-bearing
activities, the long-term need for assistive d evices, perm a-
nent shoe m od i cations and d ecreased fu nctional ability
(Thom as & Daniels 2003). Stress fractures of the tibia, non-
u nion, m alu nion, infection and neu rovascu lar inju ry are
other com p lications associated w ith ankle fu sion (Thom as &
Daniels 2003). In response, arthroplasty w as introd uced as an
alternative. Due to the lack of consistently good long-term
p atient ou tcom es follow ing arthrop lasty, ap p rop riate p atient
selection is critical and shou ld be consid ered only after con-
servative treatm ent has failed . Unlike p atients u nd ergoing
total knee and total hip su rgery, the id eal cand id ate for a
total ankle is not com p letely u nd erstood . Ind ications for
arthrop lasty are su rgeon d epend ent, but generally inclu d e
norm al vascu lar statu s, good hind foot–ankle alignm ent, no
im m u nosupp ression, w ell-p reserved ankle joint m otion, su f-
cient m ed ial and lateral ankle stability and low -d em and
sp orting activities (cycling, sw im m ing, w alking, gol ng)
(H interm ann & Vald errabano 2003). In ad d ition, ind ivid u als
w ith bilateral ankle arthritis w ou ld bene t from arthroplasty,
as bilateral ankle fusions often exhibit p oor functional ou t-
com es (Saltzm an et al 2000). Som e contraind ications for
receiving an ankle arthrop lasty includ e neuroarthropathic
d egenerative d isease (Charcot arthrop athy), avascu lar necro-
sis of the talu s, non-reconstru ctable m isalignm ent, severe
joint hyperm obility, active or recurrent infection, sensory or
m otor d ysfu nction of the foot or leg, and high-d em and ing
sp ort activities (ru nning, contact sp orts) (H interm ann &
Vald errabano 2003; Thom as & Daniels 2003).
Surgical procedures
Total ankle arthrop lasty su rgical p roced u res are com p lex and
d ep end ent up on the type of p rosthesis used . Details of each
p roced u re are beyond the scop e of this chap ter. H ow ever,
som e of the p roced u res and p rostheses u sed affect rehabilita-
tion and are therefore w orth m entioning here. In the United
States, three m ain p rosthetic d evices are u sed : the Agility
Ankle® (d ePuy Inc., Wau sau , IN ), the STAR® (Link Inc.,
H amburg, Germany) and the Salto-Talaris® (Tornier, Grenoble,
France). All of these prosthetic d evices rely on bony ingrow th
for stability of the implant instead of cement (Saltzman et al
2000). The ad vantages of relying on bony ingrow th rather
than cem ent are threefold . First, less bone resection is need ed
ow ing to a d ecrease in the sp ace betw een the bone and the
im p lant need ed for cem ent. Second ly, the d am age to soft

tissu e stru ctu res is m inim ized as high levels of heat p rod u ced
from the exotherm ic process of cu ring the acrylic cem ent are
d ecreased . Lastly, the risk of inad vertent sp illage or d isplace-
m ent of the cem ent is elim inated (Saltzm an et al 2000). Bony
ingrow th of the prosthesis occurs as a result of a bead ed
su rface along the interface w ith the bone, a hyd roxyap atite
layer, or a com bination of the tw o (Saltzm an et al 2000). The
ingrow th for the bead ed su rface occu rs over a 6–12-w eek
period , d u ring w hich tim e any m otion shou ld be lim ited , as
it is believed that m otion betw een the prosthesis and bone can
d isrupt the bony ingrow th, w hich m ay lead to m igration of
the p rosthesis and failu re of the im p lant. The hyd roxyap atite
coating takes only 3–6 w eeks to becom e bond ed . H ow ever,
this layer eventu ally resorbs, creating p otential long-term
xation issu es (Saltzm an et al 2000). Cu rrently, the m ain pros-
thetic d evices u sed in the United States all u se a bead ed
su rface for xation. Im p lications of the bead ed p rosthetic
d evices shou ld be incorporated into an early rehabilitation
protocol. For exam p le, talocru ral joint m obilization m ay be
best im p lem ented at 12 w eeks p ostoperatively to ensure that
bony ingrow th has occurred .
Postoperative rehabilitation treatment
History and physical examination
A thorou gh p atient history is critical after total ankle arthro-
plasty since it w ill gu id e p atient m anagem ent. To begin, it is
im portant to id entify w hether there is a history of p revious
trau m a. For exam p le, a stable ankle after arthrop lasty is
im perative for preserving the life of the im plant; therefore it
w ou ld be im p ortant to know w hether the patient has a history
of chronic ankle instability. Another im p ortant qu estion to ask
the p atient is how long sym p tom s have p ersisted p rior to
receiving total ankle arthroplasty. Patients w ith previou s
history of ankle arthritis w ill often exhibit gait d eviations and ,
w ith tim e, m uscle atrophy (Vald errabano et al 2007). The
process of rehabilitation for these p atients m ay therefore be
m ore extensive. Therap y w ill thu s need an increased focu s on
balance and proprioceptive retraining after ankle replacem ent
to ensu re that the p atient is safe w ith w eight-bearing p recau -
tions early in the p ost-su rgical p hase (Coetzee 2010). Find ing
ou t w hether a p atient has a history of d iabetes is also im p or-
tant to the rehabilitation p rocess, as m any p atients p resent
w ith neu ropathies and im p aired proprioceptive aw areness. It
is also im p ortant to ask the patients w hether they cu rrently
sm oke cigarettes, as ad d itional attention w ill need to be
d evoted to w ound com p lications in this popu lation (Saltzm an
et al 2000). Probably one of the m ost im portant questions after
ankle arthrop lasty d eals w ith the patient’s long-term expecta-
tions, and setting realistic obtainable goals in this p op u lation
is cru cial to help preserve the life of the im plant.
Immediate postoperative phase (weeks 0–6)
Postop erative p rotocols vary based on su rgeon p reference,
the typ e of p rosthetic im p lant u sed and the concu rrent p roce-
d u res p erform ed . Physical therapy is often seen as a necessary
ad junct to p atients receiving total hip and total knee rep lace-
m ents; how ever, this has not historically been the case after
total ankle arthrop lasty. Vald errabano et al (2007, p 290) state
that p atients w ho have u nd ergone a total ankle arthrop lasty
Total ankle arthroplasty 625
‘shou ld have an intensive physiotherapeutic rehabilitation
p rogram m e and be encou raged to p erform regu lar m u scle
strengthening and stretching exercises even 1 year after ankle
arthrop lasty’. Saltzm an et al (2000, p 66), how ever, stated ‘in
ou r cu rrent p ractice, approxim ately 20% of patients requ ire
p hysical therap y to m ake satisfactory p ostop erative p rogress’.
The evid ence for form al rehabilitation after total ankle arthro-
p lasty is lacking and fu tu re stu d ies are need ed to assess the
effect on patient outcom es.
Ad d ressing com orbid d eform ities either prior to or at the
tim e of total ankle arthrop lasty is cru cial for p reserving the
com p onent and d ecreasing p rem atu re w ear. Som e ad d itional
p roced u res com m only p erform ed in this p atient p op u lation
inclu d e osteotom ies, tend on transfers, tend on- or m u scle-
lengthening proced u res and fu sions (e.g. m id foot, su btalar
joint or trip le arthrod esis). Intraoperative fractures (particu-
larly those involving the m ed ial m alleolu s) are not uncom -
m on d u ring ankle rep lacem ent su rgery. Du e to these
aforem entioned issu es, obtaining an operative rep ort is highly
recom m end ed before initiating any physical therapy pro-
gram m e follow ing total ankle arthrop lasty.
In the initial postoperative phase, w ound healing w ithou t
com p lication, solid xation of the im p lant and ad equ ate ankle
m otion are the m ain goals (Saltzm an et al 2000). The p atient
is often placed in a splint for the rst 2–3 w eeks after su rgery
u ntil the su tu res are rem oved (Coetzee 2010). The patient is
sp linted in a neu tral p osition so as to avoid p lantar exion
contractu re, and the splint typically rem ains on the full 2–3
w eeks to m inim ize the chance of infection. After su tures are
rem oved , the patient is often placed in a rem ovable w alking
boot, w hich again helps to prevent plantar exion contrac-
tu res, and is encou raged to w ear the boot as m u ch as p ossible
u ntil beginning active range of m otion. If p roced u res su ch as
a m id foot fu sion are d one in concu rrence w ith the total ankle
arthrop lasty, the p atient m ay be casted for the rst 6 w eeks
after su rgery. Patients typ ically rem ain non-w eight-bearing
for ap proxim ately 3–6 w eeks to ensu re bony xation of the
im plant. Patients w ith an Agility® im plant are often held to
6 w eeks of non-w eight-bearing d u e to the synd esm otic fu sion
at the tim e of the replacem ent. Patients receiving a Salto-
Talaris® im p lant are often allow ed to begin p artial w eight-
bearing app roxim ately 3 w eeks after surgery. Again, these
gu id elines assu m e no other proced u res su ch as su btalar joint
or m id foot fu sions have been p erform ed .
App roxim ately 25–30° of total d orsi exion and p lantar ex-
ion range of m otion can be expected after total ankle arthro-
p lasty. Du e to the m otion lim itations of the arthritic talocru ral
joint, this am ou nt of m otion is often m ore than patients had
p rior to total ankle arthrop lasty. Most of the range of m otion
w ill be gained in the rst 3 m onths after su rgery, bu t patients
can exp ect to continu e to gain m ore range of m otion for u p to
12 m onths after su rgery (Saltzm an et al 2000). There is current
d ebate am ongst su rgeons regard ing w hether to allow early
initiation of range of m otion after total ankle arthroplasty,
because this m ay inhibit solid bony xation of the im plant
(Saltzm an et al 2000). Active d orsi exion range of m otion is
lim ited for the rst 6 w eeks after su rgery as the extensor reti-
nacu lu m is cu t at the tim e of the joint rep lacem ent (Fig. 56.1).
Fu ture stu d ies are need ed to assess the effects of early range
of m otion follow ing total ankle arthrop lasty.
Du ring the rst 6 w eeks after su rgery, the m ain goals of
rehabilitation are to m aintain the patient’s w eight-bearing
 626 PART 9 • 56 •
Figure 56.1 Right total ankle using Salto-Talaris® implant visible through
transected extensor retinaculum.
statu s, p revent any w ou nd com p lications, p revent p lantar-
exion contractures and m anage sw elling. Elevation is cru cial
for these p atients in ord er to m inim ize sw elling, as the u se of
cryotherap y is lim ited for the rst 2–3 w eeks w hile w earing
the sp lint. Also, ad d ressing p roxim al strength is im p ortant at
this stage in the rehabilitation p rocess. Mu scles su ch as the
glu teus m ed ius act as d ynam ic stabilizers of the p elvis;
how ever, d u ring this non-w eight-bearing p eriod they tend
to atrop hy. Ad d ressing su ch issu es early on in rehabilitation
can help to d ecrease com m on p roblem s su ch as hip and low
back pain as the patient begins w eight-bearing in the boot.
(See other chapters for d etails on strengthening of the hip
m u scles.)
Intermediate postoperative phase (weeks 6–12)
Arou nd 6 w eeks after su rgery, the extensor retinaculu m
shou ld be healed enou gh to begin active d orsi exion range of
m otion. Early in this p rocess, it is im p ortant to ed u cate
p atients regard ing how m uch range of m otion they can expect
in the long term . After ankle arthrop lasty, it is often felt that
stability is m ore im p ortant than m obility of the foot and ankle.
H ow ever, the art in the rehabilitation p rocess is to achieve a
balance of stability w ith m obility. For this reason, subtalar
joint m obility should possibly be lim ited in ord er to create a
stable base for the im p lant, p otentially increasing the longev-
ity of the total ankle arthrop lasty. After the w ou nd is com -
p letely healed and bony xation of the im plant has occurred
(around w eek 12), p osterior glid es of the talocru ral joint m ay
be initiated (see Ch 57). Previous literatu re in a non-operative
p atient p opu lation d em onstrates that p osterior glid es of the
talu s im p rove d orsi exion range of m otion (Lou d on et al
2014). Many p atients w ill com p lain of m etatarsal–phalangeal
joint pain after being im m obilized in the w alking boot. Since
joints receive their nutrition throu gh m otion, m anu al therap y
techniqu es ad d ressing the im p airm ents at the m etatarsal–
p halangeal joints m ay im p rove patient’s p ain levels w hile
w earing the boot and also aid a m ore norm al gait p attern as
the p atient transitions ou t of the boot. Again, the im p ortance
of know ing abou t concu rrent su rgical p roced u res that w ere
Postoperative management of foot and ankle disorders
p erform ed is im p erative before initiating any m anu al therap y
p rogram m es.
From w eeks 6 to 12, the patient progresses to fu ll w eight-
bearing and then from w earing the boot, w ith p ain as the
u ltim ate gu id e. Gait training shou ld be em p hasized in this
p eriod of rehabilitation p rocess as p atients w ith ankle arthritis
have d em onstrated altered gait p atterns (H orisberger et al
2009). Becau se su ch ind ivid u als typ ically d evelop ed abnor-
m al gait p atterns p rior to their ankle arthrop lasty, correcting
these p atterns can be challenging, esp ecially in light of
ad d itional su rgical p roced u res su ch as a triple arthrod esis
or m id foot fu sion. After nearly fu ll ankle m otion is restored ,
strengthening exercises can be initiated . Many of these
p atients receive a tend o-Achilles lengthening concu rrently
w ith the ankle replacem ent, so aggressive m u scular strength-
ening shou ld be avoid ed for app roxim ately 12 w eeks after a
tend o-Achilles lengthening p roced u re. In ad d ition, if the
p atient has had an Agility® ankle rep lacem ent w here the
synd esm osis is fu sed , it is critical to avoid forced d orsi exion
activities at an early stage, so as to encou rage healing of the
fusion. Several previous stu d ies have d em onstrated changes
in balance and proprioception after m anual therapy technique
(Lóp ez-Rod rigu ez et al 2007; Alburqu erqu e-Send in et al 2009;
H och & McKeon 2011); how ever, these stud ies w ere d one in
non-su rgical p atient p op u lations, and so fu tu re research is
need ed to exam ine the effectiveness of m anu al therap y tech-
niqu es in p atients w ith ankle arthrop lasty. N evertheless, once
the p atient is w eight-bearing, balance and p rop riocep tion
exercises should be initiated .
Pain m anagem ent is an im p ortant com p onent d u ring this
p hase of the rehabilitation p rocess. Patient ed u cation regard -
ing activities that d o not increase pain can aid in im proving
long-term outcom es. Again, m anual therapy m ay play a role
in aid ing in p ain m anagem ent. One stu d y of non-surgical
p atients has su ggested that p osterior glid es of the talu s for 1
m inu te rep eated three tim es w ith a 30-second rest interval
im p rove pain tolerance (Yeo & Wright 2011). As su ch, althou gh
not su bstantiated in a p ost-su rgical p op u lation, m anu al
therap y techniqu es m ay p lay a bene cial role d u ring this
p hase of rehabilitation.
Later postoperative phase (weeks 12–24)
From 3 to 6 m onths, althou gh an em phasis shou ld still be
p laced on continu ed com p liance w ith a hom e p rogram m e,
p atients shou ld begin transitioning to a m ore ind ep end ent
therap y p rogram m e. At this stage, the balance and p rop rio-
cep tion shou ld be sim ilar to that on the contralateral sid e. Gait
p atterns shou ld be sim ilar to age- and gend er-m atched norm s,
thou gh this w ill d ep end on the ad d itional su rgical p roced u res
p erform ed . More w ork- and sp ort-sp eci c activities shou ld be
incorp orated into the rehab p rogram m e at this stage. N ever-
theless, avoid ance of high-im p act activities shou ld be stressed
in ord er to preserve the integrity of the im plant. Cycling,
sw im m ing, hiking and gol ng are all safe activities for clini-
cians to encou rage p atients to u nd ertake (Vald errabano et al
2006; Bonnin et al 2009). As patients becom e m ore active, they
shou ld also be ed u cated abou t signs of com p onent loosening.
Sim ilar to com p onent loosening at the hip and knee, p atients
w ill often d escribe start-up pain, or pain w ith the rst few
step s after p rolonged p eriod s of inactivity. The p ain is typ i-
cally d escribed as ‘d eep in the joint’. If com p onent loosening

is su spected , the patient should be referred back to the surgeon
for follow -u p rad iographs. Box 56.1 p rovid es a gu id e for reha-
bilitation of ind ivid uals follow ing total ankle arthroplasty. It
is im portant to bear in m ind , how ever, that rehabilitation is
patient sp eci c and d epend s on several factors. These inclu d e,
bu t are not lim ited to, concom itant su rgical proced ures, type
of im p lant u sed , p atient history, fu nctional d e cits and p atient
goals. A d e nite need exists for ad d itional cohort stud ies
and clinical trials exam ining the role of rehabilitation pro-
gram m es after total ankle arthroplasty, and the m ost effective
treatm ents.
E cacy o rehabilitation treatment
As p reviously m entioned , appropriate patient selection for an
ankle arthrop lasty is cru cial to achieving su ccessful ou tcom es.
The nu m ber of long-term outcom e stud ies after total ankle
arthrop lasty is relatively lim ited com p ared w ith knee and
total hip rep lacem ents.
Changes in range of motion
Although a full ankle range of m otion is not restored after
ankle arthrop lasty, patients often have an increase in m otion
com p ared w ith before su rgery. Several stu d ies have com -
pared the total d orsi exion-to-plantar exion range of m otion
prior to su rgery versu s after ankle rep lacem ent. Preop era-
tively, total ankle range of m otion ranges from 15.2° to 23°
(Wood & Deakin 2003; Bonnin et al 2004; San Giovanni et al
2006; Doets et al 2007; Vald errabano et al 2007). Postopera-
tively, the total ankle range of m otion ranges from 23° to 36°
(Pyevich et al 1998; Bu echel et al 2003; Wood & Deakin 2003;
Bonnin et al 2004; San Giovanni et al 2006; Doets et al 2007;
Vald errabano et al 2007).
Gait
H istorically, patients w ith ankle arthrod esis have problem s
w ith stair clim bing, getting up from a chair and w alking on
u neven grou nd . As m otion is lost at the talocru ral joint after
ankle fu sion, the ad jacent joints are u nd er increased stresses
to m ake u p for som e of the lost m otion. A total ankle arthro-
plasty, in theory, shou ld d ecrease the stress of the ad jacent
joints and create a m ore norm al w alking pattern. After fusion,
it has been show n that gait velocity d ecreases by app roxi-
m ately 16% (Vald errabano et al 2003). H ow ever, after ankle
arthrop lasty the gait velocity d ecreases by only 6% (Doets
et al 2007). Du ring gait, the range of m otion of the norm al
ankle joint has been rep orted to be 14.7° + 0.9° of d orsi exion
and 28.2° + 0.8° of p lantar exion (Vald errabano et al 2003).
Patients w ho had u nd ergone ankle fu sion exhibited only
4.4° + 0.4° of d orsi exion and 8.1° + 0.2° of p lantar exion,
although this m otion originated from the subtalar joint and
not from the talocru ral joint. Patients w ith arthrop lasty, in
contrast, d em onstrated 10.0–11.1° of d orsi exion and 22.7–
30.0° of p lantar exion (Vald errabano et al 2003). Although
patients w ith a fu sion com pensated w ith som e m otion, this
slight am ou nt of m otion w ou ld m ake activities su ch as going
d ow n stairs d if cu lt.
Overall, it ap p ears that total ankle arthrop lasty rep rod u ces
a m ore-norm al ankle range of m otion com p ared w ith an ankle
fusion, w hich in tu rn shou ld lead to less stress throu gh
Total ankle arthroplasty 627
Bo x 5 6 .1 Re h a b ilita tio n p ro to c o l fo r to ta l a n kle
a rth ro p la s ty
0–6 we e ks  po s t-o p
Goals
1. Minimize s welling.
2. Prevent wound complications .
3. Prevent plantarf exion contractures .
4. Patient avoiding weight-bearing s tatus .
Tre atm e nt
1. Elevation / compres s ion s tockings .
2. Suture removal at 2–3 weeks a ter surgery.
3. Patient placed in walking boot at 2–3 weeks a ter surgery in
neutral pos ition (unles s casting or mid oot usion, etc.
required).
6–12 we e ks  po s t-o p
Goals
1. Active range o motion.
2. Full weight-bearing and out o boot.
3. Work toward s ymmetrical balance and proprioception.
4. Normalize gait pattern.
Tre atm e nt
1. Initiate active range o motion at 6 weeks (goal: 80% o
operative range o motion by 3 months a ter surgery).
2. Manual therapy (as s es s bas ed on limitations and
concomitant procedures . Avoid talocrural joint mobilization
or 12 weeks a ter s urgery).
3. Progres s to ull weight-bearing and weaning the patient out
o boot during this time bas ed on type o implant – Agility®
implant will be slower, due to time or syndesmotic us ion.
4. Balance and proprioception retraining.
5. Gait training (may be modi ed bas ed on additional s urgical
procedures).
6. May initiate light s trengthening avoiding aggres s ive
gas trocnemius strengthening.
3–6 mo nths  po s t-o p
Goals
1. Increas e unctional s trength.
2. Normal or near-normal proprioception and balance.
3. Initiate work or s port-s peci c activities .
4. Begin trans ition to an independent programme.
Tre atm e nt
1. Ens ure dors if exion and plantarf exion range o motion is
near 25–30°.
2. Progres s balance and proprioception exercis es s o that
balance is s ymmetrical or near-s ymmetrical to contralateral
side.
3. Increas e unctional s trength; may now begin increas ing
intensity o gastrocnemius s trengthening i TAL per ormed.
4. Begin work- / s port-s peci c training with an emphas is on
avoiding high-impact activities .
5. Set up long-term independent programme to meet patient’s
goals / expectations. Emphasis on continued unctional
strengthening or at least 12 months a ter surgery.
 628 PART 9 • 56 • Postoperative management of foot and ankle disorders
ad jacent joints. Fu rther, in arthroplasty the increased w eight-
bearing m otion m ay lead to im provem ents in fu nctional activ-
ities com p ared w ith p atients u nd ergoing an ankle fu sion.
Balance and proprioception
There is no consistent scale for assessing balance and prop rio-
cep tion after total ankle arthrop lasty rep orted in the literatu re;
how ever, both static p rop riocep tion (the ability to sense joint
p osition) and kinaesthesia (the ability to sense joint m ove-
m ent) seem to p lay a critical role in su ccessfu l ou tcom e after
ankle arthrop lasty (Conti et al 2008).
Prior to total ankle rep lacem ent, ind ivid u als w ith ankle
arthritis d em onstrate lim itations in both m echanical and sen-
sorim otor characteristics (H u bbard et al 2009). Patients d em -
onstrate signi cant increases in m echanical stiffness and
increases in centre-of-p ressu re d isp lacem ent (H u bbard et al
2009). These changes are consistent w ith patients w ho have
knee OA and d em onstrate increased p ostural sw ay (Masu i
et al 2006). Conti et al (2008) reported that, 2 years after ankle
arthroplasty, there w ere no signi cant d ifferences in joint
p osition sense for the surgical ankle versus the unaffected
sid e. It is p ossible that the ad d ition of m anu al therap y m ay
accelerate this norm alization of joint position sense after total
ankle arthrop lasty; how ever, futu re research in this area is
w arranted .
Self-reported outcomes
Self-rep orted fu nctional ou tcom es follow ing a total ankle
arthroplasty seem p rom ising. Patients consistently report
d ecreases in pain as w ell as im proved function. Vald errabano
et al (2006) rep orted , at a 3-year follow -up , that 70% of patients
reported no pain after their ankle arthroplasty. H ow ever,
other stu d ies have stressed that ind ivid u als rep ort a d ecrease
in p ain after ankle arthrop lasty, bu t not necessarily a resolu -
tion of their p ain (Kim et al 2013). Kim et al (2013) stated that
it w as im p ortant, both for the p atients and for the su rgeons,
to u nd erstand that som e resid u al p ain is to be exp ected . Table
56.1 p rovid es a sum m ary of the literatu re regard ing fu nctional
outcom es. As can be seen in the table, of 778 patients from 9
d ifferent stu d ies, the m ean AOFAS (Am erican Orthopaed ic
Foot and Ankle Society) score prior to su rgery w as 41 / 100
and it increased to 81 / 100 follow ing surgery (m ean follow -up
of 4.3 years).
Table 56.1 Functiona l outcome s be fore a nd a fte r total ankle arthroplas ty
Stud y (ye a r) Numb e r of
p a tie nts
Pyevich et al (1998) 85
Bonnin et al (2004) 91
Doets et al (2006) 93
San Giovanni et al (2006) 28
Valderrabano et al (2006) 147
Claridge & Sagherian (2009) 28
Kim et al (2013) 120
Sproule et al (2013) 85
Achilles Tendon Ruptures
Introduction
Form ed by the gastrocnem iu s and soleus m u scles, the Achil-
les tend on is the largest and strongest tend on in the hum an
bod y and is a trad em ark of the biped al hu m an (Deangelis
et al 2009; Jiang et al 2012). Althou gh the Achilles tend on is
the largest and strongest tend on in the hu m an bod y, it is also
the m ost frequ ently ru p tu red tend on (Kongsgaard et al 2005;
Maffu lli et al 2011; Maqu irriain 2011; Garras et al 2012; H and o
et al 2012; H orstm ann et al 2012; Jiang et al 2012). Unlike
other tend ons, w hich are su rrou nd ed by a synovial sheath,
the Achilles tend on is encased by a thinner p aratenon
(Mortensen et al 1999; Strom & Casillas 2009). The m id d le
layer of the paratenon, the m esotenon, supp lies m ost of the
blood to the tend on. During a m u scle contraction, the blood
ow to the tend on is greatly d im inished or can even cease
com p letely (Strom & Casillas 2009). When d am aged , the
Achilles tend on is slow to heal, as it is a hypocellu lar and
hyp ovascu lar tissu e (God bout et al 2006). These anatom ical
and physiological featu res create signi cant challenges in the
m anagem ent of Achilles tend on ru p tu res.
With ageing, low er rates of collagen regeneration and
replacem ent occu r, along w ith d ecreases in vascular sup ply
and red u ced w ater content. These changes can result in altera-
tions to the m olecu lar p rop erties of the collagen, w hich is
responsible for w ithstand ing the tensile forces placed on the
Achilles tend on (White et al 2007; Strom & Casillas 2009). As
the collagen becom es stiffer, the tensile strength of the tend on
d ecreases, m aking it m ore su scep tible to tears (White et al
2007). In ad d ition, as a person ages, the blood supp ly to the
extrem ities d ecreases and collagen regeneration m ay be
u nable to occu r at an ad equ ate rate, thereby leaving the
tend on su scep tible to failu re (Deangelis et al 2009; Strom &
Casillas 2009). Tend on failures can also occu r as a result of
chronic d egeneration of the tend on or failu re of the inhibitory
m echanism of the m u scu lotend inou s u nit (Deangelis et al
2009; Strom & Casillas 2009; Jiang et al 2012). Finally, tend on
failu res m ay also occur as the result of d irect or ind irect
trau m a (Strom & Casillas 2009). Approxim ately 80% of Achil-
les tend on ru ptures occur 3–6 cm above the insertion of the
Achilles tend on onto the calcaneu s, w hich is the sm allest
Me a n follow-up AOFAS s core AOFAS s core
ye a rs (ra ng e ) p re -s urg e ry p os t-s urge ry
(ra nge )
4.8 (2.8–12.3) NA 85 (40–100)
3.9 (2–5.6) 32.3 83.1
7.2 (0.4–16.3) NA 77 (73.2–80.8)
8.3 (5–12.2) NA 81 (40–92)
2.8 (2–4) 36 (10–74) 84 (28–100)
1.8 34.9 76.4
3.3 (1.2–7) 59.3 (21–89) 83 (49–100)
3.3 (2.5–5) 38.2 (12–59) 74.8 (46–100)

cross-sectional area of the tend on (Deangelis et al 2009;
Maqu irriain 2011).
Epidemiology
It is w ell d ocum ented that the incid ence of Achilles tend on
ru p tu res is stead ily increasing (Suchak et al 2005; Costa
et al 2006; Clayton & Cou rt-Brow n 2008; Deangelis et al 2009;
Mu llaney et al 2011; Garras et al 2012; Jiang et al 2012). Su chak
et al (2005) reported that the total incid ence increased from
5.5 ru p tu res p er 100 000 in 1998 to 9.9 ru p tures per 100 000 in
2002. Clayton and Court-Brow n (2008) rep orted an increase
in incid ence rates in Denm ark betw een 1984 and 1996 of 18.2
per 100 000 to 37.3 p er 100 000. In ad d ition, incid ence rates
d iffer based on gend er, w ith m ales ranging from 8.8 to 14
ru p tu res p er 100 000 m ales, and fem ales ranging from 2.1 to
6.1 ru p tu res p er 100 000 fem ales (Suchak et al 2005). The m ale
to fem ale ratio for these ru ptures is reported to be 4 : 1 (Su chak
et al 2005; White et al 2007; Jiang et al 2012). The increased
rate of ru ptu res d u ring participation in athletic activities
by m id d le-aged ind ivid uals is felt to contribute to the
increasing incid ence of Achilles ru ptu res (Su chak et al 2005;
Deangelis et al 2009). Achilles tend on ruptu res are m ost
frequ ently seen in m ales aged 30–39 years (Ow ens et al 2007;
Jiang et al 2012).
Risk actors
Several risk factors have been im p licated in Achilles tend on
ru p tu res. These inclu d e: p reviou s Achilles tend on changes
d u e to tend inopathy, participation in athletic activities involv-
ing repetitive load ing of the tend on, m ed ication use, hered i-
tary factors and race (Deangelis et al 2009).
It has been suggested that people w ith a history of Achilles
tend inop athy are m ore su scep tible to Achilles ru p tu re, since
a p athological continu um exists from a healthy tend on to a
thickened tend on associated w ith neovascu larization and
neoneu ralization (Kraem er et al 2012). Perhap s this d eterio-
rated tend on is m ore su sceptible to com plete ru pture than a
healthy tend on to stresses that w ou ld otherw ise not resu lt in
injury (Strom & Casillas 2009; Kraem er et al 2012).
Stu d ies have rep orted that 60–75% of all Achilles tend on
ru p tu res occu r d u ring athletic activities, w ith the greatest risk
for athletes w ho participate in jumping, cutting and/ or making
qu ick acceleration or d eceleration m ovem ents (Su chak et al
2005; Deangelis et al 2009; Maffu lli et al 2011; Kearney &
Costa 2012). On the other hand , it has been estim ated that 11%
of Achilles ru p tu res occu r from accid ents, and ap p roxim ately
5% occu r from activities of d aily living (Su chak et al 2005).
Su chak et al (2005) rep orted that p atients betw een the ages of
20 and 30 years w ere m ore likely to ru p tu re the Achilles
tend on d u ring sp orting activities, w hereas old er p atients
(50–60 years) w ere m ore likely to ru p tu re it d u ring activities
of d aily living su ch as trip p ing on the stairs or step p ing in a
hole. Deangelis et al (2009) estim ate that m ost tend ons in the
hum an bod y have a failu re stress p oint of 100 MPa and that
the typ ical stress placed up on them is below 30 MPa. The
Achilles tend on, how ever, often experiences u p to 70 MPa of
stress d u ring a m axim al eccentric p lantar exion contractu re
(Deangelis et al 2009). This increased stress placed on the
Achilles tendon ruptures 629
Achilles m ay therefore p lay a role in the ultim ate failure of
the tend on.
Med ications su ch as u oroqu inolone antibiotics have
been im plicated in increased Achilles tend on ruptu re rates
(Deangelis et al 2009; Kraem er et al 2012). These m ed ications
are often used in the treatm ent of serious bacterial infections,
especially hosp ital-acqu ired infections such as pneu m onia. It
is theorized the uorinated qu inolone com pou nd s m ay alter
the collagenases and m atrix m etallop roteinases, w hich cou ld
lead to an increased risk of tend on ru pture (White et al 2007).
H ered itary factors m ay also play a role in the incid ence of
Achilles tend on rup tu res. Ind ivid u als w ho have sustained a
p revious Achilles tend on ru ptu re are 200 tim es m ore likely
to ru p tu re the contralateral one (Kongsgaard et al 2005;
Deangelis et al 2009). In ad d ition, in one stud y (Deangelis
et al 2009) ind ivid uals w ith ABO blood group O have been
linked to a higher risk of Achilles tend on ru ptures, although
other stu d ies failed to d em onstrate su ch an association
(Ow ens et al 2007).
In a stud y d one looking at tend on ruptu res in US service
m em bers, the ad ju sted rate ratio for African-Am erican service
m em bers com p ared w ith Cau casian service m em bers for
Achilles tend on ru ptu res w as 3.85 (95% CI 3.31–3.88) (Ow ens
et al 2007). The authors of this stu d y offered a potential bio-
m echanical exp lanation, citing stu d ies that show ed the vis-
coelastic p rop erties of the Achilles tend on had a higher
stiffness in African-Am erican athletes. The increased stiffness
m ay resu lt in tend on ru p tu re w ith su f cient trau m a (Ow ens
et al 2007).
Diagnosis
The m echanism of an Achilles tend on ru pture generally
occu rs from a su d d en p lantar exion or ‘p u shing off’ from
a w eight-bearing forefoot w ith the knee extend ed , or from
u nexp ected d orsi exion of the ankle, for exam p le step p ing in
a hole (Strom & Casillas 2009; Jiang et al 2012). Som e stud ies
su ggest m isd iagnosis of an Achilles tend on ru p tu re occu rs in
20% to 36% of all cases (Deangelis et al 2009; Garras et al
2012). A d elay in the d iagnosis, and therefore treatm ent, of an
Achilles ru pture (be it surgical or non-surgical) can resu lt in
an u nfavou rable outcom e (Deangelis et al 2009; Garras et al
2012). As su ch, m aking an accurate d iagnosis early on can
have a signi cant im p act on p atient ou tcom es.
Su bjectively, ind ivid u als w ill often rep ort they heard or felt
a loud ‘p op’. In ad d ition, ind ivid uals w ill also rep ort feeling
like they w ere kicked or hit in the back of the leg (Deangelis
et al 2009; Kearney & Costa 2012). Many of these subjects
report d if cu lty in w alking im m ed iately after the injury. Clin-
ically, three m ain tests are u sed to d iagnosis a ru ptu re of the
Achilles tend on: the Thom p son test, the Matles test and the
p resence of a p alp able d efect. An abnorm al Thom p son test is
d escribed as d im inished or absent plantar exion of the ankle
joint w hen the exam iner squ eezes the p atient’s calf m uscle,
ind icating an Achilles ru ptu re. The sensitivity and speci city
of the Thom p son test are 0.96 and 0.93 respectively (Garras
et al 2012). The Matles test assesses the norm al resting tension
of the Achilles tend on. The norm al resting tension of the ankle
is app roxim ately 20° to 30° of plantar exion (Garras et al
2012). The patient is tested in p rone w ith the knee bent to 90°.
If the affected sid e has an increased d orsi exion angle
 630 PART 9 • 56 •
Figure 56.2 Positive Matles test. Increased resting dorsif exion o right ankle a ter
Achilles tendon rupture.
com p ared w ith the u naffected sid e, this constitu tes a p ositive
test (Fig. 56.2). The sensitivity and sp eci city of the Matles test
are 0.88 and 0.85 respectively (Garras et al 2012). The third test
is d e ned as being able to p alp ate a gap in the Achilles tend on.
The sensitivity of this test is 0.73 and the speci city is 0.85
(Deangelis et al 2009; Garras et al 2012).
Garras et al (2012) rep orted that the com bination of these
three clinical tests w as m ore accu rate than MRI in d iagnosing
an Achilles tend on ru ptu re. In ad d ition, those patients in this
stu d y w ho u nd erw ent MRI had d elayed tim es betw een initial
inju ry and tim e to su rgical intervention. The m ean tim e
betw een ru pture and su rgery w as 12.4 d ays (95% CI 10.5–14.3)
for the grou p of p atients receiving MRI com pared w ith 5.6
d ays (95% CI 5.0–6.2) for the grou p of p atients w ho received
only the three clinical tests to m ake the d iagnosis of Achilles
tend on ru p tu re (Garras et al 2012). As previously m entioned ,
p atients w ith longer tim es betw een d iagnosis and su rgical
repair of the Achilles tend on often p resent w ith inferior out-
com es The p atients in this stu d y w ho w ere d iagnosed w ith
clinical tests requ ired no ad d itional proced u res, w hereas
alm ost 30% of the patients w ho w ere in the MRI group
received ad d itional su rgical proced u res su ch as a exor hal-
lu cis longu s transfer (Garras et al 2012). Therefore, it w ou ld
seem that MRI shou ld be u sed ju d iciou sly in the d iagnosis of
Achilles tend on rup ture. One reason a d elayed d iagnosis
m akes su rgical rep air m ore challenging is that, like rotator
cu ff tears, the Achilles tend on w ill start to retract and ad here
to u nd erlying stru ctu res w ith scar tissu e, requ iring ad d itional
p roced u res su ch as tend on transfers (Fig. 56.3). Other m ed ical
im aging su ch as a p lain rad iograp h is ind icated if an avu lsion
fracture is su spected (Deangelis et al 2009).
Surgical versus non-surgical treatment
There is controversy su rrou nd ing the best m anagem ent of
Achilles tend on ru ptu res. With a m ajority of US states having
d irect access, physical therapists are often the rst m ed ical
p rovid ers to cou nsel patients w ith an Achilles tend on repair
on the variou s op tions that are available. These inju ries can
Postoperative management of foot and ankle disorders
Figure 56.3 Right chronic Achilles tendon repair with plantaris tendon trans er.
be m anaged both surgically and non-su rgically. Surgical
repair for Achilles tend on ru ptures accounts for approxi-
m ately 40% of all op eratively repaired tend ons (Garras et al
2012). Cu rrently, there is no clear consensus on the best m an-
agem ent strategy. Som e consid erations for su rgical versu s
non-su rgical m anagem ent inclu d e: age, associated m ed ical
cond itions and athletic activity (Strom & Casillas 2009). As
p reviou sly d iscu ssed , ageing d irectly affects the healing
p rocess at a cellu lar level and less-aggressive form s of treat-
m ent m ay be ind icated (Strom & Casillas 2009). Associated
m ed ical cond itions inclu d e sm oking, as it lead s to im p ed ance
of cu taneou s blood ow, d ecreased p roliferation of red blood
cells, broblasts and m acrop hages, w hich are essential to the
healing p rocess. Also system ic d iseases su ch as rheu m atoid
arthritis and system ic lupu s erythem atosu s can w eaken col-
lagen and d am aged joint surfaces, im ped ing the healing of
the Achilles tend on (Strom & Casillas 2009). It is also sp ecu -
lated that patients w ho are m ore active m ay achieve better
ou tcom es ow ing to increased self-m otivation (Strom &
Casillas 2009).
There are several d ifferent w ays to repair an Achilles
tend on ru p tu re su rgically, inclu d ing: op en rep air, p ercu tane-
ou s rep air and m ini-op en p roced u res. Each of these p roce-
d u res has its ad vantages and d isad vantages. For exam ple,
som e stu d ies rep ort increased w ou nd com p lications in op en
repairs com pared w ith percu taneous proced u res; how ever,
stu d ies also d em onstrate that p ercu taneou s p roced u res
p resent w ith m ore su ral nerve inju ries (Deangelis et al 2009).
Different su ture techniqu es such as the Kessler, Bu nnell and
Krackow techniqu es have been stu d ied in the literatu re, and
the Krackow su tu ring techniqu e ap p ears to have a biom e-
chanical ad vantage over both the Bu nnell and Kessler tech-
niqu es (Deangelis et al 2009). Ep itend inou s sutu ring plays
tw o im p ortant roles. First, it increases the resistance to gap p ing
and , second ly, it im p roves the load to failure com p ared w ith
su tu ring of ju st the core of the Achilles tend on (Deangelis et al
2009; Maqu irriain 2011).
Su rgical rep air of the Achilles tend on lead s to shorter sick-
leave d u ration, d ecreased re-ru ptu re rate and higher rates of
infections. H ow ever, patients treated op eratively also have
higher risks of d evelop ing w ou nd com p lications than p atients
w ho are m anaged conservatively (Deangelis et al 2009;
Maquirriain 2011; Kearney & Costa 2012). The m ost com m on
w ound problem s follow ing an Achilles tend on repair inclu d e

infection, w ou nd d ehiscence and scarring. Wou nd com plica-
tions greatly increase in this p op u lation if p atients are d ia-
betic, or use tobacco or steroid s (Deangelis et al 2009). The
chance of d evelop ing a w ou nd com p lication after an Achilles
tend on rep air is arou nd 6%; how ever, if one or m ore of the
above risk factors is present, the chance of d eveloping a
w ou nd com p lication increases to 40% (Deangelis et al 2009).
Patients u nd ergoing su rgical rep air of the Achilles tend on
return to w ork m ore quickly and have a shorter m ean sick
tim e than d o those treated non-op eratively. A m eta-analysis
p u blished by Jiang et al (2012) reported that patients und er-
going su rgically treated Achilles ru ptures returned to w ork
on average of 23.8 d ays (95% CI −41.6 to −5.9) sooner than
those w ho w ere treated non-su rgically. This is consistent
w ith another stu d y that reported an average of 19.2 d ays
(95% CI 3.9 to 34.0) less d ays for retu rn to w ork (Soroceanu
et al 2012).
Re-ru p tu re rates for p atients w ith su rgically rep aired
tend ons are also low er com p ared w ith p atients treated non-
su rgically (Maqu irriain 2011). A recent m eta-analysis found
that p atients treated su rgically had 8.8% less risk of re-ru ptu re,
and that the nu m ber of patients need ed to treat in ord er to
p revent one re-ru ptu re w as 12 (Soroceanu et al 2012). In the
m eta-analysis p erform ed by Jiang et al (2012), 4.3% (19 of 441)
of p atients in the op erative grou p re-ru p tu red the Achilles
tend on w hereas 9.7% (44 of 453) in the non-operative grou p
rep orted re-ru p tu re of this tend on (relative risk (RR) 0.44, 95%
CI 0.26–0.74). Interestingly, som e research su ggests that
p atients treated conservatively w ho begin an early functional
rehabilitation program m e, m ay have sim ilar re-ru pture rates
to those treated op eratively (Soroceanu et al 2012). H istori-
cally, p atients treated conservatively w ere often casted (Strom
& Casillas 2009). More recent protocols are now allow ing for
earlier functional rehabilitation in this conservative popu la-
tion, w hich m ay resu lt in re-ru p tu re rates sim ilar to those in
p atients treated op eratively.
Early range o motion versus immobilization
Tw o m ain concerns of early range of m otion after an Achilles
tend on rep air inclu d e increased incid ence of re-ru p tu re and
overstretching of the rep aired tend on, m aking it d if cu lt to
regain functional strength (Sorrenti 2006; Deangelis et al 2009;
Strom & Casillas 2009). Im m obilization usually inclu d es
placing the patient in a cast w ith the foot placed in equ inu s
as the tend on rep air heals for 6–8 w eeks (Strom & Casillas
2009). This im m obilization p eriod is often follow ed by a
su p ervised rehabilitation p rogram m e (Strom & Casillas 2009).
Early m obilization often inclu d es p lacing the p atient in a
rem ovable w alking boot. Again, the foot is initially positioned
in equ inus to p lace less tension on the healing tend on.
Although there are several bene ts to a rem ovable boot com -
pared w ith a cast w ith respect to perform ing activities of d aily
living such as bathing, a rem ovable d evice relies heavily on
patient com p liance in ord er to p revent com plications and
d elayed healing.
Prolonged im m obilization is associated w ith joint stiffness,
m u scle atrop hy, soft tissu e ad hesions, d eep venou s throm bo-
sis and u lceration of joint cartilage (Sorrenti 2006). An im m o-
bilized joint u nd ergoes d egrad ative and d estructive changes
to the joint su rfaces (Sorrenti 2006; Strom & Casillas 2009). In
Achilles tendon ruptures 631
an im m obilized tend on, the new ly form ed collagen brils
m ay not be rem od elled p rop erly (Sorrenti 2006). In a sim ilar
vein, one stu d y looking at Achilles tend on ru p tu res in rats
fou nd that prolonged im m obilization im ped ed the healing
p rocess, becau se it com p rom ised the u p -regu lation of rep air
gene expression in the healing Achilles tend on (Bring et al
2010). The au thors of this stud y su ggested that a shorter
p eriod of im m obilization, such as 1 w eek, w ou ld not im pair
the healing p rocess of the tend on. In ad d ition, these au thors
fou nd that early m obilization post Achilles tend on rup ture
ind u ced a higher d ensity of blood vessels. Fu rther, broblasts
w ere m ore d ifferentiated and there w as a higher d egree of
collagen organization com p ared w ith an im m obilized grou p
(Bring et al 2010).
The concern for tend on elongation after Achilles repair
p rohibits som e therap ists from allow ing early range of m otion.
This elongation often occurs as a result of gap ping betw een
the end s of the tend on after su rgical xation. If a gap is p resent
then granu lation tissu e, ad hesions and d elayed collagen m at-
u ration m ay occu r, resu lting in a w eaker rep air (Maqu irriain
2011). Kangas et al (2007) assessed d ifferences in tend on sepa-
ration betw een a group of patients beginning early range of
m otion and those p laced in a below -knee cast w ith the foot in
a neu tral position for 6 w eeks. Early range of m otion allow ed
for fu ll plantar exion range of m otion, bu t d orsi exion only
to a neu tral p osition. Both grou p s w ere allow ed fu ll w eight-
bearing by 3 w eeks p ostoperatively (Kangas et al 2007).
Markers w ere p laced w ithin the tend on and p lain rad iograp hs
w ere taken at follow -u p visits to m easure the am ou nt of sepa-
ration. At a m ean of 60 w eeks postoperatively, the au thors
fou nd that elongation occu rred to a lesser extent in the group
starting early range of m otion (2 m m ) than in the im m obilized
grou p (5 m m ) (Kangas et al 2007). Mortensen et al (1999)
fou nd sim ilar resu lts; they also com pared a grou p of patients
beginning early range of m otion w ith a grou p im m obilized in
a cast for 8 w eeks and fou nd no signi cant d ifference in sep a-
ration of the intratend inous m arkers in the Achilles tend on at
12 w eeks postoperatively. In ad d ition, patients w ho w ere in
the early m obilization grou p w ere able to retu rn to w ork m ore
qu ickly com p ared w ith the grou p that w as im m obilized
(Mortensen et al 1999).
The second concern w ith initiating early m obilization after
an Achilles repair is re-ruptu re. A m eta-analysis p erform ed
by Su chak et al (2006) ind icated that no signi cant d ifference
in re-ru ptu re existed betw een p atients w ho initiated early
m obilization and those su bjects w ho w ere im m obilized after
Achilles tend on repair. Ind ivid uals w ho initiated early m obi-
lization incurred a re-ruptu re rate of 2.5%, w hereas those w ho
w ere im m obilized rep orted a re-ru pture rate of 3.8% (Su chak
et al 2006).
Based on the literatu re, it therefore ap p ears that early fu nc-
tional rehabilitation d oes not increase the risk of re-ru p tu re
after su rgical repair of the Achilles tend on, nor d oes it increase
the length of the tend on after the rep air. In ad d ition, w ou nd
com p lications (su p er cial or d eep infections) w ere not
m ore p rom inent in those w ho initiated early m obilization
com p ared w ith those w ho w ere im m obilized . The average
infection rates for the early m obilization group versu s the
im m obilization grou p w ere 2.6% and 3.9% respectively
(Su chak et al 2006). Finally, p atients w ho initiated early m obi-
lization also reported greater satisfaction than patients w ho
w ere im m obilized after surgery (88% and 62% respectively)
 632 PART 9 • 56 • Postoperative management of foot and ankle disorders
(Su chak et al 2006). Based on these nd ings, early m obiliza-
tion after Achilles tend on ru p tu re can be consid ered bene cial
to this p atient p op u lation.
Early weight-bearing versus late
weight-bearing
It w as form erly com m on p ractice for clinicians to ad vise 6–8
w eeks of non-w eight-bearing after an Achilles tend on rep air.
H ow ever, m ore-recent stu d ies have suggested that early
w eight-bearing is not d etrim ental to the repair and ind eed
m ay have several bene ts. Su chak et al (2008) fou nd early
bene ts for a grou p of patients w ho initiated w eight-bearing
as tolerated at the rst p ostoperative visit 2 w eeks after
su rgery com p ared w ith a grou p of p atients w ho rem ained
non-w eight-bearing u ntil 6 w eeks after su rgery. At 6 w eeks
after su rgery, the early-w eight-bearing grou p rep orted sig-
ni cantly im p roved ou tcom es on p hysical fu nctioning, vital-
ity, social fu nctioning and role-em otional m easu res (Su chak
et al 2008). By 6 m onths, d ifferences no longer existed betw een
the tw o grou p s and there w ere no re-ru p tu res in either grou p
(Su chak et al 2008). Costa et al (2006) fou nd sim ilar resu lts in
a stud y com p aring im m ed iate w eight-bearing versu s a group
that w as initially non-w eight-bearing. Patients initiating
im m ed iate w eight-bearing retu rned to norm al w alking and
stair clim bing m ore quickly (12.5 versus 18 w eeks for w alking
and 13 versu s 22 w eeks for stair clim bing). Tw o p atients
re-ruptu red in the im m ed iate w eight-bearing group ; how ever,
both of these w ere perform ing strenuous activities in breach
of the stu d y’s p rotocol at the tim e of re-ru p tu re (Costa et al
2006). It app ears from the cu rrent literature that functional
ad vantages exist for p atients w ho initiate early w eight-bearing
after a su rgical rep air of an Achilles tend on ru p ture. Patients
w ho bore w eight early also reported feeling that they could
p erform activities that w ere not in line w ith accepted p rinci-
p les of tissu e healing, ind icating the im p ortance of stressing
p rotocol com p liance.
Post-surgical rehabilitation treatment
The rst clinical gu id elines for the treatm ent of acute Achilles
tend on ru p tu re w ere pu blished in 2010 by the Am erican
Acad em y of Orthopaed ic Surgeons and the Am erican Foot
and Ankle Society (Kearney & Costa 2012). The guid elines
w ere as follow s: (1) the u se of early p ostop erative w eight-
bearing (w ithin 2 w eeks) and (2) the u se of a ‘protective
d evice’ allow ing for early m obilization (Kearney & Costa
2012). It seem s a ‘protective d evice’ should be used w ith this
p atient p opu lation; how ever, there is no consensus on w hich
d evices shou ld be used , and w hat d egree of ankle p lantar ex-
ion the p atient shou ld be in. There is also a lack of evid ence
for the optim al tim e these d evices shou ld be w orn. Rehabilita-
tion p rotocols ap p ear to follow this trend of u ncertainty; con-
troversy still exists on an op tim al p hysical therap y p rotocol
for Achilles tend on rup tures, w hether m anaged su rgically or
conservatively (Deangelis et al 2009).
The p hases of tend on healing shou ld be kep t in m ind w hen
d esigning a rehabilitation p rotocol. The three phases of tend on
healing are in am m ation (occu rs d u ring the rst w eek), p ro-
liferation (occu rs betw een w eeks 2 and 8), and rem od elling
(can take u p to 12 m onths) (Kearney & Costa 2012). When
d eveloping a protocol for treatm ent of Achilles tend on rup-
tu res, early lim ited range of m otion and w eight-bearing are
bene cial. As previously d iscu ssed , the range of m otion
shou ld be in a p rotected range so as to avoid tend on elonga-
tion. Most of the im m ed iate w eight-bearing p rotocols involve
u sing a rem ovable p rotective d evice su ch as a w alking boot.
Fu rther, stu d ies consistently d em onstrate that one m ain goal
in recovering strength after an Achilles tend on ru ptu re is to
p revent tend on elongation. H ow ever, the op tim al tim e to
begin functional strengthening or balance and proprioception
exercises after an Achilles tend on ru ptu re is also unclear.
Ru p tu re of the Achilles tend on can resu lt in p erm anent loss
of p lantar exion strength, gait d eviations, and d if cu lties
w ith activities of d aily living such as stair clim bing and retu rn
to sp orts (Garras et al 2012). After an Achilles tend on rup ture,
it is often d if cu lt to achieve full fu nction as only m inor
im p rovem ents are seen after the rst 12 m onths follow ing
su rgery (Maqu irriain 2011). For exam ple, ap proxim ately 30%
of US N ational Football Leagu e p layers are u nable to retu rn
to p rofessional football after an Achilles ru p tu re (Kraem er
et al 2012). Therefore, regard less of the lack of ou r com p lete
u nd erstand ing of tend on healing, it is clear that tend on-
training exercises shou ld be p art of the rehabilitation p rotocol.
Rep etitive load ing of the Achilles tend on orients the collagen
bres p arallel to the longitu d inal axis of the tend on, w hich
increases tend on strength, im proves vascularity and increases
the nu m ber of collagen lam ents (Sorrenti 2006). One such
exercise inclu d es p lantar exion w ith an elastic band (Fig.
56.4). H ow ever, care shou ld be taken w hen p erform ing su ch
p lantar exion to p revent the ankle d orsi exion going p ast
neu tral, w hich w ou ld p lace u nd u e stress on the Achilles
tend on. Cycling is another tend on-training exercise. Early in
the rehabilitation p rocess, p atients can begin cycling ou t of
the w alking boot and in a shoe w ith heel lifts to m aintain the
p lantar exed p osition of the foot and red u ce strain on the
Achilles tend on. This again allow s the patient to begin tend on
training early on in the rehabilitation p rocess. The exact tim e
fram e, how ever, is su rgeon d ep end ent. There is no research
to su p p ort d u ration or frequ ency of these tend on-training
exercises after Achilles tend on repairs, bu t it seem s pru d ent
to let p ain be a gu id e. Patients often rep ort m inim al p ain after
an Achilles tend on ru ptu re, so it is im p ortant to stress not
p u shing into p ain d u ring this p hase of the rehabilitation
p rocess.
Figure 56.4 Tendon training exercise with elastic band a ter Achilles tendon
repair, avoiding stretching into dorsif exion.

Figure 56.5 Scar tissue mobilization a ter Achilles tendon incision has healed.
Scar tissu e bu ild s rap id ly in p atients w ho have had a su rgi-
cal rep air of an Achilles tend on ru p tu re. The literatu re su g-
gests that p atients w ill u ltim ately end up w ith a tend on that
is 45–50% thicker than the u naffected sid e (Mortensen et al
1999). Once the incision is healed , scar tissue m obilization
shou ld be initiated to d ecrease ad hesions (Fig. 56.5). Patients
initiating range of m otion early tend to d evelop few er
scar ad hesions than those w ho are im m obilized or casted
(Mortensen et al 1999).
Sw elling shou ld be ad d ressed early after an Achilles tend on
ru p tu res. Sw elling can be m anaged in a variety of w ays
inclu d ing cryotherap y, elevation and com p ression stockings.
Manu al therap y techniqu es aim ed at d ecreasing sw elling,
su ch as ef eu rage, can be im p lem ented im m ed iately after the
p atient is ou t of the sp lint and p laced into a rem ovable w alking
boot. Care should be taken to avoid stressing the incision site.
Long-term lim itations in p rop riocep tion p ersist after Achil-
les tend on ru ptures. Bressel et al (2004) cond u cted a stu d y of
p ropriocep tion in patients 5.8 years after Achilles tend on
injury by m easu ring the errors in m atching joint position.
Errors for the involved lim b and u ninvolved lim b w ere m eas-
u red and com p ared w ith an age- and gend er-m atched control
grou p. The resu lts of the stu d y ind icated that signi cantly
greater errors existed for both the involved (27%) and unin-
volved (31%) lim bs com p ared w ith the control grou p (Bressel
et al 2004). H ow ever, as patients w ere analysed only after
Achilles ru ptu re, it is not p ossible to know w hether there w ere
d e cits prior to Achilles inju ry that m ay have m ad e them
m ore su scep tible to tearing the Achilles. It shou ld be noted
that only 45% of p atients in this stu d y reported they w ere
p rescribed an organized physical therapy p rogram m e (Bressel
et al 2004). As su ch, w hen clinicians are d esigning a rehabilita-
tion p rogram m e for p atients after an Achilles tend on ru p tu re,
ad d ressing p rop rioception for both the ip silateral and contral-
ateral sid es is w arranted ; how ever, no clear consensu s exists
for the id eal tim e to initiate balance and proprioception exer-
cises after an Achilles tend on ru p tu re. Stu d ies u tilizing elec-
trom yograp hic (EMG) analysis have show n that som e balance
exercises activate the gastrocnem iu s less than sim ple plantar-
exion using an elastic band (Mullaney et al 2011). Therefore,
initiation of balance exercises early in the rehabilitation
Achilles tendon ruptures 633
Figure 56.6 Subtalar lateral glide joint mobilization.
p rocess w hile the p atient is in the boot seem s to be a safe and
bene cial activity after an Achilles repair. Although there is
cu rrently no research to su p p ort the effectiveness of m anu al
therap y techniqu es aim ed at the talocru ral joint to im p rove
balance and propriocep tion in this population, it m ay be a
u sefu l ad ju nct once the tend on has ad equ ately healed .
Although the trend is for starting early range of m otion
exercises, p atients typically spend app roxim ately 10–12 w eeks
in a w alking boot after Achilles tend on ru ptures and joint
stiffness often p ersists. Since joints receive nu trition throu gh
m ovem ent, the thou sand s of step s w e take throu ghou t the
d ay provid e this nu trition. H ow ever, being im m obilized in a
w alking boot d oes not allow for the sam e m otion of the joints
as norm al gait. As su ch, patients often com plain of m etatarsal–
p halangeal joint stiffness along w ith su btalar joint stiffness.
Manu al therap y m ay p lay an im p ortant role in im p roving
joint m obility prior to the p atient beginning to be w eaned ou t
of the w alking boot in ord er to d ecrease gait d eviations,
althou gh care should be taken not to stress the incision site.
Sorrenti (2006) p u blished a typ ical p hysical therap y p rotocol.
This protocol inclu d ed joint m obilization to the subtalar joint
(Fig. 56.6) and the forefoot beginning as early as 2–6 w eeks
p ostop eratively After a p eriod of w eight-bearing in the boot
w ith heel lifts, patients com m only com plain of low back p ain,
hip and knee p ain. Manu al therap y techniqu es aim ed at p rox-
im al stru ctu res seem to bene t this patient popu lation.
Although there are cu rrently no research stud ies at this tim e
sp eci cally ad d ressing the effectiveness of m anu al therap y
after Achilles tend on ru ptures, clinical experience su ggests a
bene t for m any of the patients w ho stru ggle w ith joint stiff-
ness after a p eriod of im m obilization. Fu tu re research shou ld
exam ine the effects of incorporating m anu al therapy into a
p ostop erative rehabilitation p rotocol follow ing Achilles
tend on rep air.
Although no evid ence-based protocols exist w hen rehabili-
tating p atients after su rgical rep air of an Achilles ru p tu re,
consid eration of the forces ap p lied to the Achilles tend on
d uring com m on activities or exercises is pertinent to safely
p rogress these p atients. This tend on transm its m ore force
than any other tend on in the hu m an bod y, and stu d ies
su ggest that its rep air m ay fail at forces ranging from 45 to
 634 PART 9 • 56 •
Table 56.2 EMG activity of the trice ps s ura e mus cle for he althy
individuals
Ta s k MVIC (%)
Balance board 23.4
Ankle pumps 36.7
Plantarf exion red elas tic band 43.2
Walking 43.2
Lateral step-up 59
Heel rise 112.6
Hopping 128.9
MVIC: maximal voluntary is ometric contractions .
250 N ew tons (N ) (Maqu irriain 2011; Mullaney et al 2011).
Mu llaney et al (2011) p erform ed a stud y on healthy ind ivid u -
als assessing the p ercentage of m axim al voluntary isom etric
contractions (MVICs) of the calf d u ring com m only p rescribed
therap eu tic exercises. A single-lim b heel rise and hop p ing
elicited the highest p ercentages of MVIC (112.6% and 128.9%
resp ectively), w hereas balance and ankle pu m ps elicited
low er percentages of MVIC com pared w ith w alking (23.4%
and 36.7% respectively) (Mullaney et al 2011). The resu lts are
su m m arized in Table 56.2.
Patients im m obilized in a w alking boot after an Achilles
tend on ru p tu re are often p laced in p lantar exion to red u ce
stress on the tend on as it heals. This is u su ally d one w ith
heel lifts. Ap p roxim ately 80% of norm al plantar exion con-
tractile activity is exerted d u ring w alking w ith the foot im m o-
bilized in a neu tral position (Maquirriain 2011). H ow ever,
ad d ing a 1-inch (2.5 cm ) heel lift red u ces the p lantar exion
contractile activity to 57% (Maqu irriain 2011). As the tend on
heals, the lifts are grad u ally rem oved from the boot in ord er
to p rep are the tend on to accep t tensile stress d u ring w alking
ou t of the boot. There ap p ears to be a su bset of p atients w ho
natu rally stretch ou t the rep aired tend on m ore qu ickly com -
p ared w ith others. These patients p resent w ith a d ecreased
resting plantar exion position of the foot w ith the knee
bent to 90°. It m ay therefore be bene cial for this su bset of
p atients to w ean them selves off of the heel lifts m ore slow ly.
These patients m ay also bene t from a sm all lift in the shoe
w hen transitioning ou t of the w alking boot. The larger the
d egree of p lantar exion the ankle is imm obilized in, the
greater is the resultant atrophy (Maqu irriain 2011). H ow ever,
too m u ch stress on the tend on d u ring w eight-bearing activi-
ties in the boot m ay jeop ard ize the rep air and im p ed e fu nc-
tional ou tcom es. The goal of the therap ist m anaging p atients
after an Achilles tend on rep air is to nd the balance betw een
lim iting m u scle atrop hy and u nd u ly stressing the healing
tend on. This goal is m ore easily accom p lished w hen the clini-
cian u nd erstand s the stresses p laced on the healing tend on
w ith variou s activities. Strengthening the p lantar exed
m u scles in a range that avoid s increased d orsi exion of the
ankle is therefore p ru d ent so as to avoid overlengthening of
the tend on (Maqu irriain 2011). Serial sarcom ere ad aptation
d u ring this phase of rehabilitation can be im proved by com -
bining eccentric exercises w hile avoid ing the end range of
d orsi exion (Maqu irriain 2011).
Postoperative management of foot and ankle disorders
Available rehabilitation p rotocols p rovid e only a general
guid eline and should be m od i ed based on the patient’s
goals and ability. Protocols shou ld also be d eveloped or m od i-
ed in consu ltation w ith su rgeons based on several factors.
First, it is im portant to consid er the natu re of the ru pture.
The tim e from initial d iagnosis u ntil surgery is an im portant
factor to consid er. Patients w ho present w ith chronic rup tures
often have ad d itional p roced u res su ch as a exor hallu cis
longus au gm entation or plantaris tend on transfer (see Fig.
56.3). Another im portant factor to consid er is w hether the
ru p tu re w as p rim ary or recu rrent. Re-ru p tu res are d if cu lt
injuries to m anage ow ing to w ou nd com p lications. Therefore,
therap y shou ld be m od i ed to re ect these ad d itional con-
sid erations. The age and health of the p atient w ill re ect
p atient goals and u ltim ately rehabilitation consid erations.
For exam ple, patients w ho present w ith d iseases su ch as d ia-
betes w ill have sp ecial w ound - and tissue-healing consid era-
tions. In ad d ition, high-level recreational athletes shou ld be
m oved throu gh a p rotocol very d ifferently to a non-athletic
p op u lation.
Manu al therap y techniqu es m ay be of bene t in ord er to
im p rove m obility to joints m ore proxim al and d istal to the
ankle joint, to d ecrease sw elling and to im prove balance and
p rop riocep tion. Assessm ent of the bene ts of incorp orating
m anu al therap y techniqu es into rehabilitation p rotocols after
Achilles tend on ru ptu res still requires futu re research. A
general protocol for patients und ergoing Achilles tend on
repair, w hich should be m od i ed based on the above factors,
has been inclu d ed in Table 56.3.
It has been d em onstrated that, after Achilles tend on repair,
elongation of the tend on occu rs, resu lting in suboptim al out-
com es inclu d ing both m u scle w eakness and p erm anent fu nc-
tional im p airm ent (Mortensen et al 1999; Maqu irriain 2011;
Mu llaney et al 2011; H orstm ann et al 2012; Silbernagel et al
2012). This lengthening has tw o prim ary causes: rst is a lack
of p rop er tensioning at the tim e of op erative rep air, and
second is a p rogressive tend on lengthening d u ring the p ost-
op erative p eriod (Maqu irriain 2011), since the lengthened
Achilles tend on has a com prom ised capacity to prod uce force
at a given ankle angle (H orstm ann et al 2012). Silbernagel et al
(2012) fou nd signi cant sid e-to-sid e d ifferences in heel-rise
height and tend on length at 6 m onths and 12 m onths. The
au thors of this stud y found that the m ajority of the tend on
elongation occu rred d u ring the rst 3 m onths after surgery.
Although the sam ple size w as sm all, a signi cant negative
correlation w as still fou nd betw een the d egree of tend on elon-
gation and the sid e-to-sid e d ifference in heel-rise height at 6
m onths and 12 m onths after su rgical rep air (Silbernagel et al
2012). So, as tend on elongation increased , patients’ ability to
p erform p lantar exion at end range of m otion d im inished
(Silbernagel et al 2012). Clinical outcom es also signi cantly
correlate w ith tend on elongation; Maqu irriain (2011) show ed
that p atient ou tcom es im p roved as tend on elongation
d ecreased and stated that gapp ing greater than 5 m m w as
consid ered to be a clinical failu re. Managing these p atients
becom es m uch m ore d if cult once the elongation becom es
p erm anent (Maqu irriain 2011).
Both calf m u scle strength and end u rance are lim ited after
Achilles tend on rup tu re. On average, at 1 year after inju ry,
m u scle end u rance recovers to only 52–88% of the unaffected
sid e as m easu red by the m axim u m nu m ber of heel raises
p erform ed in a fu ll-w eight-bearing p osition (Bostick et al
 Conclusion 635

Table 56.3 Achille s te ndon re pair re ha bilita tion protocol

Time p e riod Tre a tme nt
(p os top e ra tive ly)

0–6 weeks Ankle pumps (limited dors if exion to neutral)

Weight-bearing with crutches in walking boot with ankle in plantarf exion (s hould be ull weight-bearing by
6 weeks pos toperatively)
Swelling management (ice, elevation, compress ion s tocking, manual therapy techniques)
Plantar f exion against light resis tance or tendon training
Bilateral balance and proprioception in the boot
Joint mobilization (s ubtalar joint, ore oot, metatarsal–phalangeal joints , and proximal joints as needed)
6–12 weeks Scar tissue mobilization (once wound is healed)
Continue swelling management
Continue joint mobilization as needed
Slowly reduce heel li ts in boot until in neutral pos ition
Balance and proprioception (progres sing to unilateral on both contralateral and ipsilateral s ides)
Stationary bike (in shoe with heel li ts to maintain plantarf exion)
At 10–12 weeks – wean patient out o boot
Gait training
Bilateral heel raise (s tarting with increas ed weight on contralateral s ide and increas ing to equal weight bilaterally)
12–16 weeks Increas ed plantarf exion strength – adding in eccentric work in weight-bearing
Progress to unilateral heel rais e
Focus on end range o motion plantarf exion strength
Continue balance and proprioception exercis es
16 weeks May begin jogging i able to per orm unilateral heel rais e with only 2- nger light touch or balance at 75% o
endurance o contralateral s ide (measured by number o unilateral heel raises )
6 months Progress to sprinting and plyometric work in order to return to ull s port activity

2010). Perm anent strength d e cits of 10–30% can com m only
be seen after Achilles tend on ru ptu res (Silbernagel et al 2012).
One stu d y show ed that calf circu m ference rem ains signi -
cantly sm aller even 10 years after Achilles tend on rup tu re
(H orstm ann et al 2012). In ad d ition, the au thors of this stu d y
reported signi cantly d ecreased heel raise height com p ared
w ith the contralateral lim b. Patients in this 10-year follow -u p
stu d y had d ecreased eccentric p lantar exion strength and
increased m u scle activation com pared w ith the contralateral
lim b, ow ing to the d ecreased force prod uction of the plantar-
exors (H orstm ann et al 2012). It is of note that only abou t
tw o-third s of p atients in this stu d y received form al p hysical
therap y (H orstm ann et al 2012).
Tw o years after an Achilles ru p tu re, p atients typ ically still
have gait d eviations (Silbernagel et al 2012). Strength d e cits
of the calf m u scles m ay help to exp lain these d eviations in the
norm al gait p attern, w hich in tu rn m ay increase stress on the
Achilles (H orstm ann et al 2012).
Conclusion
Although the effectiveness of m anual therapy has been show n
to be of bene t to p atients w ith acu te and chronic foot and
ankle cond itions, little evid ence sup ports the u se of m anual
therap y in a p op u lation of p atients w ho have u nd ergone
su rgery to the foot or ankle. There is great p otential for fu tu re
research supporting the jud iciou s u se of m anu al therapies in
patients w ho have und ergone a total ankle arthroplasty or
w ho have sustained an Achilles tend on rup tu re.
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 PART 9 •  The Foot and Ankle in Lower Extremity Pain Syndromes 

Chapter  57
Manipulation of the Foot and Ankle
 

W illia m Eg a n , W a yn e Hin g , J a c k M ille r, J o s h u a A. C le la n d

p otentially am enable to joint m obilization or m anip u lation.

CHAP TER CONTENTS
Introduction  637
Manipulation / mobilizations  637
Ankle sprains  637
Ankle fractures  638
Plantar heel pain  638
Cuboid syndrome  638
Foot and ankle tendinopathies  639
Other disorders of the forefoot  639
Clinical decision making for manipulation of foot and ankle   inclu d e: ankle sprains, ankle fractures, plantar heel pain and
disorders  639
Passive joint manipulation / mobilization techniques of the   of the evid ence and rationale for m anip u lation in the m anage-
talocrural joint  639
Talocrural distraction thrust manipulation  639
Talocrural posterior glide non-thrust manipulation  640
Talocrural lateral glide non-thrust manipulation  640
Mobilization with movement techniques of the   concerning d ifferential d iagnosis and fu rther m anagem ent of
talocrural joint  640
Non-weight-bearing talocrural posterior glide mobilization   ters in this book that cover these top ics in d etail.)
with movement  641
Weight-bearing talocrural posterior glide mobilization with  
movement 
Passive manipulation / mobilization techniques of other ankle  
641
and foot joints  641
Subtalar joint lateral glide non-thrust manipulation  641
Proximal tibio bular thrust manipulation  642
Distal tibio bular non-thrust manipulation  642
Cuboid thrust manipulation  642
First metatarsal phalangeal non-thrust and thrust manipulation  643
Distal tibio bular mobilization with movement: ‘sprained ankle’  643
Self-mobilization interventions  643
Weight-bearing dorsi exion mobility assessment  643
Talocrural dorsi exion self-mobilization  644
Subtalar lateral glide self-mobilization  644
Introduction
Disord ers involving the ankle and foot are com m on in both
athletic and non-athletic p op u lations. Patients w ith these d is-
ord ers often p resent w ith joint m obility im p airm ents that are
Practitioners of m anu al therap y and m anu al therap y text-
books have d escribed techniqu es of m anipu lation for foot
and ankle d isord ers for som e tim e (H engeveld & Banks 2005;
Mu lligan 2010; Boyles et al 2013). H ow ever, m anipu lation for
foot and ankle d isord ers is an area that has only recently
becom e m ore stud ied in the literatu re. Em erging, high-quality
evid ence su ggests that m anip ulation can be an effective inter-
vention as p art of a m u ltim od al p rogram m e involving ed u ca-
tion and therap eu tic exercise for several d ifferent foot and
ankle d isord ers (Brantingham et al 2012). These d isord ers
forefoot pain. In this chapter w e w ill rst provid e an overview
m ent of foot and ankle d isord ers. Follow ing this, d escrip tions
and gures of the m ore com m only u sed foot and ankle
m anip u lation techniqu es w ill be p rovid ed , based on the litera-
tu re and the au thors’ clinical exp erience. (For inform ation
foot and ankle d isord ers, the read er is d irected to other chap-
Manipulation / Mobilizations
Ankle sprains
Lateral ankle sprains are one of the m ost com m on traum atic
low er extrem ity inju ries in athletic and active pop ulations.
Ind ivid u als w ith acute to chronic lateral ankle sprains often
p resent w ith im p airm ents in ankle m obility. The m ost com -
m only rep orted m obility im p airm ent is a lim itation in ankle
d orsi exion m obility (Denegar et al 2002). A lim itation of the
accessory joint glid e of the talu s w ithin the ankle m ortise has
been p roposed to lead to a lim itation in ankle d orsi exion
m obility. Sp eci cally the talu s is p rop osed to glid e p osteriorly
w ithin the m ortise d uring ankle d orsi exion and a lim itation
of this glid e cou ld lead to a red u ction in d orsi exion m obility.
Motion occu rring at the p roxim al and d istal articu lation
betw een the bu la and tibia also contributes to ankle d orsi-
exion m obility. Lim itations in m obility at these articulations
resulting from the consequences of an ankle sp rain injury
cou ld also theoretically lead to a d ecrease in ankle d orsi ex-
ion m obility. As a result of these im pairm ents, m anu al therapy
 638 PART 9 • 57 • Manipulation of the foot and ankle
techniqu es for ind ivid u als w ith ankle sp rains have often been
d irected tow ard s the talocrural joint and the p roxim al and
d istal tibio bular joints in attem pts to im p rove ankle joint
d orsi exion range of m otion. Evid ence from several stud ies,
sum m arized in a system atic review by Lou d on et al (2014),
ind icates that m anip u lation lead s to an im p rovem ent in ankle
joint range of m otion includ ing d orsi exion. In ad d ition to an
im p rovem ent in ankle d orsi exion m obility, m anip u lation,
com bined w ith an im p airm ent-based exercise p rogram m e,
lead s to a clinically m eaningfu l im p rovem ent in self-rep orted
fu nction and a d ecrease in p ain for ind ivid u als w ith acu te,
su bacu te and chronic lateral ankle sp rains (Brantingham et al
2012; Lou d on et al 2014).
In one of the best-qu ality stud ies to d ate, Cleland et al
(2013) reported the resu lts of eight sessions of m anual therapy
and su p ervised exercise com p ared w ith a control p rogram m e
of fou r sessions of therapist-tau ght hom e exercises for 74 ind i-
vid u als w ith inversion ankle sp rain inju ries. Ind ivid u als
betw een the ages of 16 and 60 years w ho had su stained a
grad e I or II inversion ankle sp rain and w ho reported at least
a 3 ou t 10 on the N u m erical Rating of Pain Scale (N RPS) w ere
inclu d ed . Ind ivid u als w ith fractu res, grad e III sp rains or con-
traind ications to m anu al therap y w ere exclu d ed . The m anu al
therap y techniqu es inclu d ed the follow ing: ankle d istraction
thru st m anip u lation (see Fig. 57.1), talocru ral p osterior glid e
non-thru st m anip u lation (w eight-bearing and non-w eight-
bearing; see Figs 57.2–57.4), talocru ral and subtalar lateral
glid e non-thru st m anipu lation (see Figs 57.3–57.5), a proxim al
tibio bu lar thru st m anip u lation (see Fig. 57.6) and a d istal
tibio bu lar anterior–posterior non-thru st m anipu lation (see
Fig. 57.7). The m anip ulations w ere d elivered once p er session
and the non-thru st m anipu lation w ere typically d osed as
Maitland grad es III–IV and p rovid ed for ve bouts of 30
second s each. Ind ivid u als in the m anu al therap y grou p w ere
also provid ed w ith self-m obilization exercises targeting the
talocru ral (see Fig. 57.12) and su btalar joints (see Fig. 57.13).
The exercise program m e w as id entical for both grou ps and
consisted of m obility, strengthening, balance and coord ina-
tion exercises that w ere p rogressed over tim e. Both grou p s
rep orted d ecreased pain and im p roved fu nction at 4-w eek
and 6-m onth follow -u p. H ow ever, the m anu al therap y grou p
reported a clinically signi cant d ifference in p ain and fu nction
com pared w ith the control grou p at 4-w eek and 6-m onth
follow -u ps. Although there w ere som e lim itations, inclu d ing
a potential attention bias for the m anu al therap y grou p , this
stu d y ad d s to the evid ence for the effectiveness of m anip u la-
tion for ind ivid u als w ith lateral ankle sp rains. (See Ch 54 for
m ore d iscu ssion on m anagem ent of ankle sp rains.)
Ankle fractures
Ankle fractu res are a com m on d isord er lead ing to signi cant
loss of fu nction and d isability. Sim ilar to and m ore severe than
ankle sp rains, ankle fractures often result in a loss of ankle
m obility as a resu lt of the p rolonged im m obilization follow -
ing the fractu re and / or su rgery (Lin et al 2010). Manu al
therap y in the m anagem ent of ankle fractu res has not been
w ell stu d ied , but som e literature d oes exist. In a rand om ized
clinical trial, Lin et al (2008) reported that grad e III anterior–
p osterior talocru ral joint non-thru st m anip ulation com bined
w ith a su pervised exercise p rogram m e d id not enhance
p atient ou tcom es com pared w ith exercise alone for patients
w ho w ere post im m obilization for ankle fractu res of varying
severity. In a pilot stu d y involving 10 patients, Wilson (1991)
reported that ad d ing a variety of non-thru st m anipu lation
techniqu es targeting the talocru ral, su btalar and ad d itional
low er extrem ity joints to a stand ard exercise program m e led
to an im p rovem ent in ankle d orsi exion range of m otion, bu t
not fu nction, com p ared w ith exercise alone. Ad d itional
research investigating the use of a variety of m anipu lation
techniqu es for ind ivid u als w ith ankle fractu res is requ ired
before d e nitive conclu sions can be reached .
Plantar heel pain
Plantar heel p ain is a very com m on non-trau m atic foot d isor-
d er. Typical treatm ent involves rest, m ed ication, stretching
exercises, soft tissue m obilization, electrotherm al m od alities
and foot orthotics (McPoil et al 2008). Plantar heel p ain can be
associated w ith m obility im pairm ents in the ankle and foot
joints, and a lim itation in ankle d orsi exion is a risk factor for
d eveloping plantar heel pain. Given these m obility im pair-
m ents, m anip u lation cou ld p otentially have a role in the m an-
agem ent of plantar heel p ain. In a case series by You ng et al
(2004) and in rand om ized clinical trials by Cleland et al (2009)
and Dim ou et al (2004), m anual therapy d irected to the foot
and ankle w as show n to lead to both short- and long-term
im p rovem ent in pain and self-rep orted fu nction. In the
Cleland et al (2009) stu d y, p atients w ere rand om ized to
receive either six treatm ents of m anu al therap y, inclu d ing soft
tissu e m obilization and im p airm ent-based low er extrem ity
joint m anipu lation com bined w ith exercise, or electrotherm al
m od alities and exercise. At 4-w eek and 6-m onth follow -u p
there w as a clinically m eaningfu l d ifference in p ain and
p atient-rep orted fu nction in favou r of the m anu al therap y
intervention. Manipu lation techniques com m on to all of these
stu d ies inclu d ed talocru ral joint d istraction thru st m anip u la-
tion (see Fig. 57.1), talocru ral joint posterior glid e non-thrust
m anip u lation (see Fig. 57.2) and su btalar lateral glid e non-
thru st m anip u lation (see Fig. 57.5). Proposed m echanism s for
m anip u lation in the m anagem ent of p lantar heel p ain inclu d e
biom echanical, w ith an increase in ankle and rearfoot m obil-
ity, and neu rop hysiological, via d escend ing pain m od u lation
(Bialosky et al 2009). (See Ch 55 for m ore d iscussion on the
m anagem ent of p lantar heel p ain.)
Cuboid syndrome
Cu boid synd rom e is an u ncom m on bu t p otentially very
p ainfu l and d isabling d isord er (Jennings & Davies 2005;
Ad am s & Mad d en 2009). It is proposed to be cau sed by a
forceful contraction of the bularis longus tend on p ulling on
the cu boid bone, either in reaction to an inversion ankle sp rain
or d u ring an end -range p lantar exion m anoeu vre su ch as in
ballet d ancing. The resu lt is plantar–lateral foot pain located
in the vicinity of the cuboid bone and its articulations. Clinical
exam ination nd ings includ e point tend erness on the d orsal,
lateral or plantar asp ect of the cu boid bone along w ith
sym p tom rep rod u ction d u ring m anu al accessory glid ing of
the cu boid . It is p rop osed that the cu boid m obility becom es
lim ited , particularly in a plantar to d orsal d irection, and that
m anip u lation of the cu boid (see Fig. 57.8) can be effective in
relieving p ain from this d isord er. Observational case series
 Passive joint manipulation / mobilization techniques of the talocrural joint
stu d ies have rep orted an im m ed iate and lasting im p rovem ent
in p ain and function follow ing a plantar–d orsal cu boid
m anip u lation.
Foot and ankle tendinopathies
There is no cu rrent evid ence that m anipu lation can be
effective in the m anagem ent of foot or ankle tend inop athies
su ch as Achilles tend on or p osterior tibial tend inop athy.
H ow ever, u sing an im pairm ent-based ap proach the clinician
m ay nd a lim itation in ankle and foot joint m obility, su ch
as lim ited ankle d orsi exion, and u se m anipu lation as p art
of an intervention p rogram m e in the m anagem ent of these
d isord ers. Fu rther research is need ed to investigate this
prop osal.
Other disorders of the forefoot
Com m on d isord ers of the forefoot inclu d e m etatarsalgia,
hallu x valgu s and hallu x rigid u s. These d isord ers m ay involve
m obility restrictions of the ankle, rearfoot, m id foot, and inter-
m etatarsal and m etatarsal p halangeal joints. In a system atic
review, Brantingham et al (2012) reported that there w as
grad e C or lim ited evid ence for m anip ulation in the m anage-
m ent of these d isord ers based on p oor-to-m od erate-qu ality
stu d ies. Du Plessis et al (2011) d escribed a progressive m anip-
u lation techniqu e d irected to the rst m etatarsal p halangeal
joint in the m anagem ent of hallu x valgu s (see Fig. 57.9). Ad d i-
tional high-qu ality research is need ed to investigate the u se
of m anip u lation in the m anagem ent of forefoot d isord ers.
Clinical Decision Making for
Manipulation of Foot and
Ankle Disorders
When d eterm ining w hich techniqu es or w hat grad es of
m anip u lation to ap p ly in a p atient w ith a foot or ankle d isor-
d er, the au thors recom m end that clinicians take into accou nt
all relevant variables that m ay affect clinical d ecision m aking.
The clinician shou ld also consid er any contraind ications to
m anip u lation for p atients w ith foot and ankle d isord ers. For
exam ple, in the Cleland et al (2013) stu d y on m anip u lation
for patients w ith inversion ankle sprains, the follow ing
w ere exclusion criteria for being enrolled in the stud y: grad e
III sprain, tu m ou r, fractu re, rheum atoid arthritis, osteoporo-
sis, p rolonged history of steroid u se, and severe vascu lar
d isease. Selection of the techniques is based on the relevant
im pairm ents fou nd by the clinician d u ring the physical exam -
ination. For exam ple, a therap ist m ay d ecid e to utilize a talo-
cru ral p osterior glid e non-thru st m anip u lation techniqu e for
a patient w ith an acu te ankle sp rain w ho has a lim itation in
ankle d orsi exion w ith a restricted posterior talar glid e.
Dosage of the m anual therapy technique, includ ing the grad e
of m obilization, d u ration, frequ ency and nu m ber of bou ts,
w ill d epend on the patient’s response in ad d ition to the clini-
cian’s d eterm ination of the p atient’s irritability (H engeveld &
Banks 2005). It is suggested that clinicians attem pt to use the
m ost com fortable techniqu e w ith the least am ou nt of force to
639
accom plish the d esired goal and to progress the vigou r of any
techniqu e over tim e u sing the p atient’s resp onse as a gu id e.
The u se of a functional asterisk or concord ant sign can be very
help fu l in gu id ing techniqu e selection and p rogression. An
exam ple of a com m only u sed functional asterisk sign is a
lunge (see Fig. 57.11), w hich gau ges the patient’s ability to
p erform w eight-bearing ankle d orsi exion (Chisholm et al
2012). The clinician cou ld u tilize this as a fu nctional assess-
m ent before and after m anip u lation to d eterm ine w hether a
w ithin-session change in that fu nctional im pairm ent has
occu rred . Techniqu es p roven to be su ccessfu l w ithin session
shou ld then be au gm ented w ith a sp eci c exercise that targets
the sam e im p airm ent as the m anu al therap y techniqu e. For
exam ple, if a talocru ral posterior glid e non-thrust m anipu la-
tion led to a w ithin-session im p rovem ent in w eight-bearing
d orsi exion su ch as d uring a lu nge, the p atient w ould be
instru cted in an ankle d orsi exion self-m obilization (see Fig.
57.12). Another self-m obilization technique com m on am ong
several of the research stu d ies d escribed in this chap ter is the
su btalar lateral glid e self-m obilization (see Fig. 57.13). It is
im portant to reiterate that m anip ulation w ould form only a
single p art of a com p rehensive rehabilitation p rogram m e for
p atients w ith foot and ankle d isord ers. It has been p rop osed
that m anu al therap y lead ing to d ecreased p ain and im p roved
m obility serves as a catalyst to the p atient actively engaging
in rehabilitation (Bialosky et al 2009). The follow ing sections
of this chap ter d escribe som e of the m ore com m only u tilized
m anip u lation techniqu es, based on research evid ence and
clinical exp erience. For ad d itional techniqu es and d etailed
inform ation, read ers are referred to variou s m anu al therapy
texts (e.g. H engeveld & Banks 2005; Mulligan 2010; Boyles
et al 2013).
Passive Joint Manipulation / Mobilization
Techniques of the Talocrural Joint
Talocrural distraction thrust
manipulation (Fig. 57.1)
This technique is ind icated w hen there is lim ited ankle d orsi-
exion and restricted posterior accessory glid e of the talu s.
The patient is sup ine-lying, w ith the ankle off the end of
the treatm ent table. The therap ist is stand ing at end of bed
in a w alk / strid e stance. The clinician uses both hand s to
grasp the patient’s ankle / foot w ith the ngers interlaced
around the d orsu m of the foot and the thum bs on the plantar
aspect. The therapist ind u ces pronation and d orsi exion
of the p atient’s foot and takes u p the slack in a cau d al /
d istraction d irection. The clinician applies a high-velocity, low
am plitud e force in a caud al d irection.
N otes: For ind ivid u als w ith lateral ankle sp rains, the lateral
ligam ents and soft tissu e structu res are protected by d orsi ex-
ion and eversion / pronation of the foot / ankle. The m anipu -
lation shou ld not be perform ed if a patient rep orts an increase
in pain d u ring the set-up. A m od i cation w here the thru st is
d elivered in a com bined cau d al and posterior d irection
(J-stroke) m ay be u seful if initial attem pts d o not achieve an
im provem ent in ankle d orsi exion.
 640 PART 9 • 57 • Manipulation of the foot and ankle

Figure 57.1 Talocrural distraction thrust manipulation. Figure 57.2 Talocrural posterior glide non-thrust manipulation.

Talocrural posterior glide non-thrust

manipulation (Fig. 57.2)
This techniqu e is ind icated w hen the patient exhibits lim ited
ankle d orsi exion, and restricted p osterior accessory glid e of
the talu s. The p atient is su p ine-lying, w ith the ankle off the
end of the treatm ent table. The therapist is stand ing at end of
bed in a w alk / strid e stance. The clinician uses one hand to
stabilize the low er leg rm ly at the m alleoli and grasp s the
anterior, m ed ial and lateral talu s w ith the w eb space of the
op p osite hand . The therap ist now ap p lies a low -velocity,
anterior–p osterior oscillatory force to the talus.
N otes: The clinician can use his / her thigh to help stabi-
lize the foot and to increase the am ou nt of ankle d orsi-
exion progressively, and m ay need to ad just the am ount
of foot / ankle su p ination / p ronation to op tim ize the
techniqu e.

Talocrural lateral glide non-thrust

manipulation (Fig. 57.3)
This techniqu e is ind icated w hen the patient exhibits restricted
talocru ral inversion or eversion. The p atient is sid e-lying on
the involved sid e, w ith the ankle / foot off the end of the treat-
m ent p linth. The therap ist is stand ing over the p atient’s
ankle / foot. The clinician grasp s the p atient’s m ed ial m alleoli
just proxim al to the talocrural joint w ith the ind ex nger /
thu m b and u ses the forearm to stabilize the p atient’s leg
against the table. The clinician also p laces the thenar em inence
of the op p osite hand on the talu s ju st d istal to the m ed ial
m alleoli and grasp s the rearfoot. The clinician u ses his / her
bod y to im part a low -velocity oscillatory force to the talu s
throu gh the arm and thenar em inence.
N otes: It m ay be usefu l for the therapist to apply slight
d istraction of the talu s w ith the m obilizing hand prior to
app lying the lateral glid e. The p atient’s ankle / foot can be
stabilized in neu tral by the therap ist’s thigh.
Figure 57.3 Talocrural lateral glide non-thrust manipulation.
Mobilization with Movement
Techniques of the Talocrural Joint
Both w eight-bearing and non-w eight-bearing m obilization
w ith m ovem ent techniques have been d em onstrated to be of
signi cant valu e in the restoration of ankle d orsi exion range
w hen m easured in fu nctional w eight-bearing (Collins et al
2004; Reid et al 2007). Early research ind icates that m obiliza-
tion w ith m ovem ent m ay also be effective in the m anagem ent
of a d istal tibia– bular d erangem ent p ost ankle inversion
sp rain (H u bbard et al 2006; Vincenzino et al 2006; H u bbard &
H ertel 2008).
 Passive manipulation / mobilization techniques of other ankle and foot joints  641

Figure 57.4 Talocrural posterior glide mobilization

with movement: (A) non-weight-bearing, (B)
weight-bearing.

A B

Non-weight-bearing talocrural posterior glide

mobilization with movement (Fig. 57.4A)
This techniqu e is ind icated w hen the patient exhibits lim ited
ankle d orsi exion and restricted p osterior accessory glid e of
the talu s. The p atient is su p ine-lying, w ith the ankle off the
end of the treatm ent table. The therapist is stand ing at end of
bed in a w alk / strid e stance. The clinician grasps the talus
w ith one hand and the calcaneu s w ith the other. The talus is
glid ed p osterior–m ed ially in the p lane of the ankle joint w ith
no p ain rep rod u ction. While m aintaining the p osterior glid e,
the p atient is requ ested to assist in the p erform ance of ankle
d orsi exion through the pull of a m obilization belt, bu t not
active d orsi exion.
N ote: If this passive d orsi exion is also p ain free, overp res-
su re of d orsi exion m ay be ap p lied by p ressu re from the
therap ist’s thigh on the sole of the foot.

Weight-bearing talocrural posterior glide

mobilization with movement (Fig. 57.4B) Figure 57.5 Subtalar joint lateral glide non-thrust manipulation.
This technique is ind icated w hen there is lim ited ankle d orsi-
exion and restricted posterior accessory glid e of the talus.
The p atient is in step-kneeling on the treatm ent plinth. The
therap ist stand s at the end of the treatm ent p linth w ith a
Passive Manipulation / Mobilization
m obilization belt loop ed arou nd the therap ist’s hip s and Techniques of Other Ankle and
arou nd the p atient’s p osterior tibia. The patient’s talu s and
m id foot are stabilized by the therap ist’s hand s. The clinician
Foot Joints
u ses a m obilization belt ap p lied to the p osterior tibia to effect
a p ain-free anterior, lateral glid e of the tibia. The patient is Subtalar joint lateral glide non-thrust
requ ested to lu nge forw ard s, effecting p assive pain-free ankle manipulation (Fig. 57.5)
d orsi exion. The therap ist m u st p erform a partial squ at to
m aintain the belt p arallel to the d ynam ic tibial joint treatm ent This techniqu e is ind icated w hen the p atient exhibits restricted
plane. talocalcaneal (su btalar) inversion or eversion. The p atient is
N ote: Pain-free passive overpressu re m ay be applied by the sid e-lying on the involved sid e, w ith the ankle / foot off the
patient’s hand s on the knee. end of the treatm ent p linth. The therapist is stand ing over the
 642 PART 9 • 57 •
Figure 57.6 Proximal tibio bular thrust manipulation.
p atient’s ankle / foot, then grasp s the p atient’s talu s just proxi-
m al to the su btalar joint w ith the ind ex nger / thu m b and
u ses the forearm to stabilize the p atient’s leg against the table.
The clinician places the thenar em inence of the opp osite hand
on the calcaneu s ju st d istal to the talu s. The clinician then u ses
his / her bod y to im p art a low -velocity oscillatory force to the
calcaneu s throu gh the arm and thenar em inence.
N otes: It m ay be usefu l for the therapist to apply slight
d istraction of the calcaneu s w ith the m obilizing hand p rior to
ap p lying the lateral glid e. The patient’s ankle / foot can be
stabilized in neu tral by the therap ist’s thigh. The therap ist
reassesses the patient’s rearfoot range of m otion pre and post
m anip u lation to d eterm ine w hich of the p reviou s tw o tech-
niqu es (talocru ral versu s su btalar) creates the greatest change
in rearfoot m obility.
Proximal tibio bular thrust
manipulation (Fig. 57.6)
This techniqu e is ind icated w hen there is restricted ankle d or-
si exion and restricted accessory glid e of the p roxim al tibi-
o bu lar joint. The p atient is su p ine lying w ith the involved
leg exed at the knee. The therap ist stand s at the sid e of the
treatm ent p linth in a w alk / strid e stance. The clinician p laces
his / her second m etacarp op halangeal in the p op liteal fossa
and p u lls the soft tissue laterally u ntil the m etacarp op halan-
geal is rm ly stabilized behind the patient’s bu lar head . The
clinician u ses the op p osite hand to grasp the foot and ankle.
The clinician externally rotates the leg and exes the knee to
the restrictive barrier. Once the restrictive barrier is m et, a
high-velocity, low -am p litu d e force is ap p lied throu gh the
tibia (d irecting the p atient’s heel tow ard his/ her ip silateral
bu ttock).
N ote: If the p atient has a knee d isord er, the clinician shou ld
u se cau tion w hen consid ering ap p lying this techniqu e,
Manipulation of the foot and ankle
Figure 57.7 Distal tibio bular non-thrust manipulation.
althou gh it can also be u sed in the treatm ent of p atients w ith
knee pain.
Distal tibio bular non-thrust
manipulation (Fig. 57.7)
This technique is ind icated w hen there is restricted ankle
d orsi exion and restricted accessory glid e of the d istal
tibio bu lar joint. The p atient is su p ine-lying, w ith the involved
ankle / foot off the end of the treatm ent plinth. The therapist
is stand ing at the end of the treatm ent plinth, then grasps and
stabilizes the d istal tibia w ith one hand and p laces the thenar
em inence over the lateral m alleolus. The clinician uses his / her
bod y to im p art a low -velocity, oscillatory, anterior–p osterior
force to the bula on the tibia.
N otes: If the lateral m alleolu s is tend er the clinician can u se
a tow el or foam p ad d ing over the lateral m alleolus for p atient
com fort. The clinician can p rogress the techniqu e by u sing
his / her thigh to d orsi ex the p atient’s ankle.
Cuboid thrust manipulation (Fig. 57.8)
This techniqu e is ind icated w hen there is cuboid synd rom e
and restricted accessory glid e of the cu boid . The p atient lies
p rone and the therap ist stand s at the end of the treatm ent
p linth. The clinician p laces the tip s of the thu m bs over the
m ed ial p lantar su rface of the p atient’s cu boid . The p atient’s
knee is exed to 90°, w ith the ankle in neu tral. The p atient’s
knee is then passively extend ed as the ankle is p lantar exed
w ith slight sup ination of the su btalar joint. The therapist
ap plies a high-velocity thru st force to the cu boid w ith both
thu m bs in a d orsal lateral d irection.
N ote: For p atients w ith concom itant lateral ankle sp rains, it
is im portant to avoid p lacing the ankle in end -range plantar-
exion and inversion d uring the m anipu lation.
 Self-mobilization interventions 643

Figure 57.8 Cuboid thrust manipulation. Figure 57.9 First metatarsal phalangeal non-thrust and thrust manipulation.

First metatarsal phalangeal non-thrust and

thrust manipulation (Fig. 57.9)
This techniqu e is ind icated w hen the patient exhibits restricted
rst m etatarsal p halangeal joint extension. The p atient is
su p ine-lying, w ith the ankle / foot off the end of treatm ent
plinth. The therapist stand s at the end of the treatm ent p linth.
H e / she stabilizes the patient’s foot and rst m etatarsal w ith
one hand then, u sing the second and third ngers of the
op p osite hand , grasp s the p atient’s rst p roxim al p halanx
on the p lantar and d orsal asp ects. The clinician u ses grad ed ,
low -velocity oscillatory force in a d irection of longitu d inal
traction.
N otes: For patients w ith hallux valgus, traction force can be
com bined a slight m ed ial glid e / ad d u ction of the p halanx and
lateral glid e / abd u ction of the rst m etatarsal. Based on the
patient’s tolerance and resp onse to the non-thru st m anip ula-
tion, the clinician m ay im p art a high-velocity thru st.

Distal Tibio bular Mobilization with
Movement: ‘Sprained Ankle’ (Fig. 57.10)
This technique is ind icated in lateral ankle sprains and
painful / restricted ankle plantar exion and inversion. The
patient is sup ine-lying w ith the involved ankle / foot off the
end of the treatm ent p linth. The therapist is stand ing at the
end of the treatm ent p linth, then contacts the lateral m alleolu s
of the p atient w ith his / her thenar em inence and stabilizes the
d istal tibia w ith the other hand . The therapist uses the thenar
em inence contact on the lateral m alleolu s to glid e the bula
posteriorly in relation to the stabilized tibia. The foot / ankle
w ill passively d orsi ex and evert d uring this m obilization
second ary to the increased tension in the anterior tibio bu lar
ligam ent. While m aintaining the pain-free posterior bular
glid e, the patient is requested to perform com bined plantar-
exion and inversion that should now be fu lly pain free.
Figure 57.10 Distal tibio bular mobilization with movement: ‘sprained ankle’.
N otes: If the lateral m alleolus is tend er, the clinician can u se
a tow el or foam pad d ing over the lateral m alleolu s for patient
com fort. Pain-free p assive overp ressu re of the inversion force
m ay be p rovid ed by the p atient p u lling on a m obilization belt
and / or the therap ist’s m anu al force.
Self-mobilization Interventions
Weight-bearing dorsi exion mobility
assessment (Fig. 57.11)
The patient faces a w all in a lu nge position w ith the involved
foot forw ard . The clinician instructs the p atient to lu nge
 644 PART 9 • 57 •
Figure 57.11 Weight-bearing dorsi exion mobility assessment.
Figure 57.12 Talocrural dorsi exion self-mobilization.
forw ard s w hile attem pting to tou ch the knee of the involved
sid e to the w all. The m axim u m d istance betw een the rst toe
and the w all in w hich the patient is able to contact the knee
to the w all is record ed . The clinician shou ld ensu re that the
p atient lu nges forw ard s through the talocru ral joint and d oes
not com p ensate by u tilizing m id foot p ronation.
Talocrural dorsi exion
self-mobilization (Fig. 57.12)
The p atient faces a w all w ith the hand s on the w all and places
the foot / ankle to be m obilized behind the other, as show n in
Figu re 57.12. With the foot p ointing straight forw ard s, the
p atient is instru cted to bring the knee forw ard s w hile ‘d riving’
the heel d ow n and back. The heel shou ld be kep t in contact
Manipulation of the foot and ankle
Figure 57.13 Subtalar lateral glide self-mobilization.
w ith the oor. If the patient reports pain in the anterior area
of the ankle, he/ she can ad ju st the foot p osition to m inim ize
the p ain and m axim ize the stretch. The p atient is instru cted
to perform the exercise in an oscillatory fashion for 30 second s
repeating up to three tim es.
Subtalar lateral glide
self-mobilization (Fig. 57.13)
The patient sits and crosses the involved leg over the opposite
leg. The patient stabilizes the talu s w ith one hand and grasps
the calcaneu s w ith the other hand . The p atient is instru cted
to p u sh the calcaneu s tow ard s the oor, and is also instru cted
to perform the exercise in an oscillatory fashion for 30 second s,
repeating up to three tim es.
References
Ad am s E, Mad d en C. 2009. Cuboid subluxation: a case stud y and review of
the literature. Cu rr Sports Med Rep 8: 300–307.
Bialosky JE, Bishop MD, Price DD, et al. 2009. The m echanism s of m anual
therapy in the treatm ent of m u sculoskeletal pain: a com prehensive m od el.
Man Ther 14(5): 531–538. d oi: 10.1016/ j.m ath.2008.09.001.
Boyles R, Flynn T, Whitm an J, et al. 2013. Spinal and extrem ity m anipu lation:
the basic skill set, 2nd ed n. Louisville, KY: Evid ence in Motion.
Brantingham JW, Bonne n D, Perle SM, et al. 2012. Manipulative therapy for
low er extrem ity cond itions: an u p d ate of a literatu re review. J Manip u lat
Physiol Ther 35: 128–166.
Chisholm MD, Birm ingham TB, Brow n J, et al. 2012. Reliability and valid ity
of a w eight-bearing m easure of ankle d orsi exion range of m otion. Physi-
other Can 64: 347–355.
Cleland JA, Mintken PE, McDevitt A, et al. 2013. Manual physical therapy and
exercise versus su pervised hom e exercise in the m anagem ent of patients
w ith inversion ankle sprain: a m u lticenter rand om ized clinical trial.
J Orthop Sports Phys Ther 43: 443–455.
Cleland JA, Abbott JH , Kid d MO, et al. 2009. Manu al physical therapy and
exercise versus electro-physical agents and exercise in the m anagem ent of
p lantar heel pain: a m ulticenter rand om ized clinical trial. J Orthop Sports
Phys Ther 39: 573–585.
Collins N , Teys P, Vincenzino B. 2004. The initial effects of a Mulligan’s Mobi-
lization w ith Movem ent techniqu e on d orsi exion and p ain in su b acu te
ankle sprains. Man Ther 9: 77–82.

Denegar CR, H ertel J, Fonseca J. 2002. The effect of lateral ankle sprain on
d orsi exion range of m otion, p osterior talar glid e, and joint laxity. J Orthop
Sports Phys Ther 32: 166–173.
Dim ou E, Brantingham J, Wood T. 2004. A rand om ized controlled trial (w ith
blind ed observer) of chirop ractic m anip u lation and Achilles stretching vs.
orthotics for the treatm ent of plantar fasciitis. J Am Chiropr Assoc 41:
32–42.
d u Plessis M, Zipfe B, Brantingham JW. 2011. Manu al and m anip ulative
therapy com pared to night splint for sym ptom atic hallux abd uctor valgu s:
an exp loratory rand om ised clinical trial. Foot 21: 71–78.
H engeveld E, Banks K. 2005. Maitland ’s peripheral m anipulation, 4th ed n.
Ed inbu rgh: Elsevier Bu tterw orth-H einem ann.
H u bbard T, H ertel J. 2008. Anterior positional fault of the bula after sub-acute
lateral ankle sp rains. Man Ther 13: 63–67.
H u bbard T, H ertel J, Sherbond y P. 2006. Fibular position in ind ivid uals
w ith self-rep orted chronic ankle instability. J Orthop Sp orts Phys Ther
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Jennings J, Davies GJ. 2005. Treatm ent of cuboid synd rom e second ary to
lateral ankle sprains: a case series. J Orthop Sports Phys Ther 35:
409–415.
Lin CW, Moseley AM, H aas M, et al. 2008. Manu al therapy in ad d ition to
physiotherapy d oes not im prove clinical or econom ic ou tcom es after ankle
fracture. J Rehabil Med 40: 433–439.
Lin CW, H iller CE, d e Bie R. 2010. Evid ence-based treatm ent for ankle inju ries:
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Loud on JK, Reim an MP, Sylvain J. 2014. The ef cacy of m anu al joint m obilisa-
tion / m anipu lation in treatm ent of lateral ankle sprains: a system atic
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McPoil TG, Martin RL, Cornw all MW, et al. 2008. H eel pain-plantar fasciitis:
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Reid A, Brim ingham T, Alcock G. 2007. Ef cacy of m obilization w ith m ove-
m ent for p atients w ith lim ited d orsi exion after ankle sprain: a crossover
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Vincenzino B, Branjerd porn M, Teys P, et al. 2006. Initial changes in p osterior
talar glid e and d orsi exion of the ankle after m obilization w ith m ovem ent
in ind ivid u als w ith recu rrent ankle sprain. J Orthop Sp orts Phys Ther 36:
464–471.
Wilson F. 1991. Manual therapy versu s trad itional exercises in m obilization of
the ankle post fracture: a pilot stu d y. N Z J Physiother 19: 11–16.
Young B, Walker MJ, Strunce J, et al. 2004. A com bined treatm ent ap proach
em phasizing im pairm ent-based m anual physical therapy for p lantar
heel pain: a case series. A com bined treatm ent approach em p hasizing
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 PART 9 •  The Foot and Ankle in Lower Extremity Pain Syndromes
58
Tendinopathy o the Foot and Ankle
 Chapter 
Elle n Po n g
CHAP TER CONTENTS
Introduction  646
Achilles tendinopathy  646
Background  646
Anatomy  647
Pathology and patho-biomechanics  647
Diagnosis  647
Treatment and prognosis  648
Peroneal tendinopathy  649
Background  649
Anatomy  649
Pathology and patho-biomechanics  650
Diagnosis  650
Treatment and prognosis  651
Tibialis anterior tendinopathy  651
Background  651
Anatomy  652
Pathology and patho-biomechanics  652
Diagnosis  652
Treatment and prognosis  652
Tibialis posterior tendinopathy  653
Background  653
Anatomy  653
Pathology and patho-biomechanics  653
Diagnosis  653
Treatment and prognosis  654
Other tendinopathies of the foot and ankle  654
Background  654
Anatomy  654
Pathology and patho-biomechanics  654
Diagnosis  654
Treatment and prognosis  655
Conclusion  655
Introduction
Tend inop athies o the oot and ankle rep resent an incred ibly
d iverse and com plex group o pathologies. The causes inclu d e
system ic d isease cau sing p athological tissu e changes, intrinsic
aulty biomechanics o the individual patient causing improper
 
use, and d aily habits and activities cau sing overu se or acu te
trau m a The sp ectru m o tend inop athies com m only seen in the
oot and ankle includ es inf am m atory and d egenerative
insults to the tend on and , w ith seem ingly greater requ ency
than anyw here else in the bod y, tend on ru p tu res. These
p athologies can end an athlete’s career, or create a nu m ber o
all hazard s in an eld erly person’s d aily rou tine. The propor-
tion o tend inop athies requ iring su rgical intervention either
ou tright or a ter ailed conservative treatm ent ap p ears highest
in the oot and ankle. It is im portant to know the speci c
characteristics o each tend on’s p athological p resentation and
need s in treatm ent in ord er to best serve this p atient
p op u lation.
Achilles Tendinopathy
Background
Achilles tend inop athy is a prevalent cond ition in sports
involving ru nning and ju m p ing (van Sterkenbu rg & van
Dijk 2011). The risk o long-d istance runners or d eveloping
an Achilles tend inop athy is estim ated to be 52% (van
Sterkenbu rg & van Dijk 2011). The risk is not con ned to
athletes, how ever. One-third o patients w ith Achilles tend i-
nop athies have sed entary li estyles (van Sterkenbu rg & van
Dijk 2011; Papa 2012). People in their m id d le years (aged
30–50), regard less o p hysical activity level, are the m ost
a ected (van Sterkenbu rg & van Dijk 2011; Papa 2012). Physi-
cal d econd itioning, acu te inju ry, rep eated overu se, com or-
bid ities, corticosteroid injection and intrinsic risk actors are
all im plicated in d evelopm ent o Achilles tend inopathies
(H art 2011; van Sterkenburg & van Dijk 2011; Pap a 2012).
Achilles tend inopathies are rep resented in the literatu re
u nd er a con u sion o nam es. Van Dijk et al (2011) p rop osed a
new term inology w ith sp eci c locations, sym p tom s, clinical
nd ings and histop athology; m id -p ortion Achilles tend inop a-
thy; Achilles p aratend inop athy, acu te and chronic; insertional
Achilles tend inopathy; retrocalcaneal bursitis involving the
anterior in erior aspect o the Achilles tend on; and su p er cial
calcaneal bu rsitis com p rise the list o cu rrently p re erred ter-
m inology. Ad d itionally, there is also a recom m end ation to
aband on previou s term s su ch as H aglu nd ’s d isease, H aglu nd ’s
synd rom e, H aglu nd ’s d e orm ity, and p u m p bu m p (calcaneu s
altus, high-prow heels, knobbly heels, cu cu m ber heel) (van
Dijk et al 2011).

Anatomy
The Achilles tend on is a com bined tend on o tw o m u scle
origins: the soleu s and the gastrocnem iu s (van Sterkenbu rg &
van Dijk 2011). Both the gastrocnem iu s and the soleu s orm
an ap oneu rosis, rom w hich the tw o tend ons o the com bined
Achilles tend on originate. The gastrocnem ius m u scle origi-
nates rom the p osterior m ed ial and lateral em oral cond yles,
crosses the knee, su btalar and ankle joints, and inserts w ithin
the com bined tend on onto the calcaneu s. The soleu s m u scle
originates rom the p roxim al tibia, bu la and interosseou s
m em brane, crosses the ankle and su btalar joints, and also
inserts w ithin the com bined tend on onto the calcaneu s (van
Sterkenbu rg & van Dijk 2011).
The Achilles tend on begins to rotate and becom es m ore
m arked 2–7 cm p roxim al to its insertion. Within the tend on,
the gastrocnem iu s bres rotate to the lateral sid e and the
soleu s bres are rotated to the m ed ial sid e o the tend on’s
insertion. The Achilles tend on, via the gastrocnem ius and
soleu s m u scles, is the p rim ary p lantarf exor o the ankle.
Insertional shap es or the Achilles tend on have been d escribed
as ‘oval’ in m any anatom y texts. Lohrer et al (2008) view ed
im ages o the insertion rom the transverse plane, and reported
a slightly bent or u nbow ed tend on insertion.
Pathology and patho-biomechanics
Basic rep resentation o the p athogenesis o Achilles tend in-
op athy begins w ith a change in the m od e, intensity or
d u ration o physical activity that im poses an abnorm al bio-
m echanical d em and (Pap a 2012). Usu ally a com bination o
intrinsic and extrinsic actors is ou nd . Malalignm ent o the
oot and hyp erpronation place abnorm al strains on the
tend on (van Sterkenbu rg & van Dijk 2011) Chronic d isease
prod u ces blood f ow changes to the tend on and bres o
the tend on itsel . Ad d itionally, the elastic p rop erties o the
tend on d ecrease w ith age; this d em and s m ore w ork o the
m u scle and resu lts in local tem p eratu re increase and su bse-
qu ent p athological tend on changes (van Sterkenbu rg &
van Dijk 2011).
Incom plete recovery tim e engend ers breakd ow n o the
tend on at a cellu lar level (van Sterkenbu rg & van Dijk 2011;
Pap a 2012); this incom plete healing response m ay be d u e to
hyp ovascu larity and / or continu ed m echanical orces on the
tend on. Degenerative changes to the tend on inclu d e brin
d ep osition, red u ction o neu trophils and m acrophages, neo-
vascu larization and collagen bre d isorganization (van
Sterkenbu rg & van Dijk 2011; Pap a 2012). The neovasculariza-
tion w ithin the p athological tend on is believed to cau se, at
least in part, the pain o this cond ition, w hich resu lts rom
ingrow th o nerve ascicles (Papa 2012). Van Sterkenburg and
van Dijk (2011), how ever, m ake a d istinction betw een the
aetiology o d egenerative changes described above and tendon
neovascularization speci c to mid-portion Achilles tendinopa-
thy. The ull aetiology o pain accompanying neovasculariza-
tion is not ully known. An add itional consideration to this
aetiology is the recent nd ing o nerves accompanying the
peritendinous neovascularization rom the paratenon into the
tend on itsel . These nerves contain high concentrations o
nocicep tive su bstances (glu tam ate, su bstance P, calcitonin
gene-related p eptid e) (van Sterkenburg & van Dijk 2011). The
Achilles tendinopathy 647
healthy Achilles tend on has su p er cial innervations by the
p aratenon, bu t is norm ally consid ered a non-neu ronal tissu e.
Chronically p ain u l tend ons, how ever, d em onstrate this new
ingrow th o nerve bres along w ith the pathological changes
o neovascu larization (van Sterkenbu rg & van Dijk 2011).
Diagnosis
The d iagnosis o Achilles tend inopathy is m ad e based on
history and p hysical exam ination; how ever, sp eci cation
o the typ e o tend inop athy is assisted by m agnetic reso-
nance im aging (MRI) and u ltrasonograp hy (Scott et al 2011;
van Sterkenbu rg & van Dijk 2011; H u tchison et al 2013).
The m ost valid clinical d iagnostic tests or Achilles tend i-
nop athies are: p ain w ith p alp ation o the tend on (sensitivity
84%, speci city 73%) and su bjective localization o p ain
2–6 cm above the insertion into the calcaneus (sensitivity 78%,
sp eci city 77%) (H u tchison et al 2013). Yet patients w ith
Achilles tend inopathy m ay or m ay not exhibit and report pain
(van Sterkenburg & van Dijk 2011). Tend inopathy and para-
tend inop athy m ay coexist, w ith the p aratend inop athy p ro-
d ucing pain w hile the intratend inou s changes rem ain silent.
A p alpable sw elling, u su ally located 2–7 cm rom the inser-
tion on the calcaneu s m ed ially, m ay be p ainless or p ain u l;
this m ay be the only clinical p hysical nd ing (Figs 58.1–58.2).
Ankle d orsif exion and p lantarf exion w ill prod uce m ove-
m ent o the sw ollen area i tend inop athy is p resent w ithou t
involvem ent o the paratenon. There is local thickening o the
p aratenon, w hich w ill not m ove w ith ankle d orsif exion
and plantarf exion i tend inop athy is not also p resent (van
Sterkenbu rg & van Dijk 2011).
Pain u l p eritend inou s crep itu s m ay be p resent as the
tend on glid es w ithin the inf am ed sheath in acu te cond itions
(van Sterkenbu rg & van Dijk 2011). The clinician m ay also
note localized heat, increased erythem a and p alp able tend on
nod u les. In chronic cond itions, these signs o inf am m ation
d im inish, but pain is reprod uced w ith active plantarf exion o
the ankle (van Sterkenbu rg & van Dijk 2011).
The Victorian Institute o Sports Assessm ent – Achilles
(VISA-A) qu estionnaire is used to d eterm ine clinical severity
Figure 58.1 Seemingly normal appearance o Achilles tendinosis rom bilateral
tendon width comparison.
 648 PART 9 • 58 •
Figure 58.2 Pathological nodule on the Achilles tendon revealed with ankle
dorsif exed.
o the cond ition and p rovid e a gu id eline or treatm ent, as w ell
as m onitor the e ect o treatm ent. Cu rrently, the VISA-A is
consid ered the only valid , reliable and d isease-sp eci c assess-
m ent tool or m easu ring the cond ition o the Achilles tend on
(Lohrer & N au ck 2009).
Treatment and prognosis
Conservative and su rgical treatm ent op tions or Achilles
tend inop athies are w id ely varied (van Sterkenbu rg & van
Dijk 2011; Wiegerinck et al 2013). Both treatm ent types nor-
m ally ad d ress the intratend inou s d egenerative changes w hen
they are p resent (van Sterkenbu rg & van Dijk 2011). N on-
insertional Achilles tend inop athies are m ost o ten m anaged
conservatively (Wiegerinck et al 2013). Although conserva-
tive treatm ent is recom m end ed as the initial treatm ent or
insertional Achilles tend inop athies, it is generally recognized
that su rgical treatm ents m ay be m ore su ccess u l (Wiegerinck
et al 2013). Both conservative and su rgical treatm ent out-
com es are less avou rable in non-athletic p op u lations and in
those w ith insertional tend inop athy versu s m id -p ortion tend -
inop athy (Pap a 2012).
Su rgical p roced u res m ay be op en or m inim ally invasive
w ith both typ es attem pting d ebrid em ent o the tend on or
tenotom y (van Sterkenbu rg & van Dijk 2011). This also
involves release or rem oval o the p aratenon. Althou gh p ara-
tend inop athy and tend inop athy o ten coexist, som e su rgical
p roced u res ad d ress only the peritend inou s stru ctu res. Exam -
p les o this are the op en or m inim ally invasive p aratenectom y
as w ell as Achilles tend oscop y, in w hich the p aratenon is
released and the p lantaris tend on is cu t to relieve sym p tom s
(van Sterkenbu rg & van Dijk 2011). The prognosis or good
recovery a ter su rgical treatm ent in 6 w eeks to 6 m onths is
good . When the surgery ad d resses the tend on itsel rather
than the p aratenon in isolation, the tend on is initially w eak-
ened . Recovery rom this p roced u re m ay requ ire 3–18 m onths
be ore sp orts and ru nning / jum ping activities can be resum ed
again (van Sterkenbu rg & van Dijk 2011).
Most conservative treatm ents or Achilles tend inop athies,
like other tend inop athies, d o not d em onstrate strong evid ence
Tendinopathy of the foot and ankle
Figure 58.3 The concentric portion o bilateral eccentric heel raises. The
patient pushes up into ull plantarf exion using either the una ected leg or both legs
to per orm this concentric portion o the exercise.
o a treatment e ect in randomized controlled trials (Magnussen
et al 2009; Scott et al 2011). Extracorporeal shockw ave therapy,
local corticosteroid treatm ents, injections o sclerosing agents,
p olid ocanol, glycosam inoglycan p olysu l ate, p latelet-rich
p lasm a or d ep roteinized haem od ialysate, as w ell as top ical
glyceryl nitrate application, m ay be part o a conservative
treatm ent p rotocol or Achilles tend inop athies; how ever,
urther investigation is need ed in ord er to ascertain their e -
cacy (Magnu ssen et al 2009; Scott et al 2011).
Ice, transverse riction m assage, therapeu tic ultrasound ,
m ed ical acu p u nctu re and the Graston Techniqu e® o so t
tissu e treatm ent are u tilized and regard ed as bene cial by
physical therap ists and chirop ractors; how ever, these treat-
m ents have a sim ilar lack o evid ence base at this tim e
(Magnussen et al 2009; Scott et al 2011; Papa 2012). Althou gh
cu stom orthotics m ay be help u l w hen accom p anied by other
orm s o treatm ent, to be o bene t the patient m u st have an
id enti able m alalignm ent that the orthotic corrects (Scott et al
2011). Air braces and night sp lints are not su pported as e ec-
tive treatm ents or Achilles tend inop athy (Scott et al 2011).
The single conservative intervention w ith strong supp ort-
ing evid ence in the m ed ical literatu re is heavy-load exercise,
u su ally in the orm o eccentric exercise (Magnu ssen et al
2009; Scott et al 2011; Pap a 2012). For exam p le, bilateral and
u nilateral eccentric heel raises or d rop s are p er orm ed or
both the soleu s m uscle and the gastrocnem ius m u scle actions.
For bilateral eccentric heel raises, the patient pu shes up into
ull p lantarf exion u sing the u na ected leg or both legs to
p er orm this concentric p ortion o the exercise (Fig. 58.3). The
a ected oot is then placed on the grou nd in the sam e p osition
next to the u na ected sid e, and both lim bs p er orm the slow,
controlled eccentric low ering the ankle into neu tral. I this
exercise is per orm ed rom the ed ge o a step this changes the
heel raise to a heel d rop , w ith the eccentric p ortion continu ing
p ast neu tral and into ankle d orsif exion. Unilateral heel
raises / d rops are p er orm ed in a sim ilar ashion, w ith the
exception that the a ected low er extrem ity alone per orm s the

Figure 58.4 When per orming unilateral heel raises / drops, the a ected lower
extremity alone controls the eccentric lowering portion o the exercise.
eccentric portion o the exercise (Papa 2012) (Fig 58.4). (See
Ch 38 or u rther exercises or the low er extrem ity.)
Prognosis or recovery rom chronic Achilles tend inop a-
thies, like chronic tend inop athies located elsew here in the
bod y, rem ains poor to air w ith conservative treatm ent
(Magnu ssen et al 2009; Scott et al 2011). Long-term prognosis
or recovery rom acu te to su bacu te Achilles tend inopathies
is rep orted ly m ore avou rable, how ever, as 71–100% o
p atients are able to retu rn to their p rior level o u nction w ith
m inim al to no com p laints (Pap a 2012).
Peroneal Tendinopathy
Background
Peroneal tend inop athy is a com m on cau se o lateral ankle
pain w hen ankle trau m a has occu rred that is o ten m isd iag-
nosed as a lateral ligam ent inju ry (Scanlan & Gehl 2002). Pero-
neal tend inop athies m ay occu r as a resu lt o d irect or ind irect
trau m a or overu se. Direct trau m a p rod u ces acu te cond itions,
su ch as cu tting w ith a sharp object, w hereas m echanism s
o ind irect inju ry, inclu d ing overu se, are m u lti actorial
(Palm anovich et al 2012). Anatom ical location, vascu larity,
skeletal m atu rity and the m agnitu d e o orces are actors
that p rod u ce p eroneal tend inop athies (Scanlan & Gehl 2002;
Palm anovich et al 2012).
Peroneal longu s and brevis inju ry m ay ap p ear together or
sep arately. Stenosing tenosynovitis m ay occu r in the p er-
oneu s brevis tend on, in isolation o any inju ry to the p eroneu s
longu s (Boya & Pinar 2010). Reports o chronic tend initis
and stenosing tenosynovitis occu rring w ithou t a tear o
the p eroneu s longu s tend on are m ore com m on than p resenta-
Peroneal tendinopathy 649
tion o non-trau m atic ru p tu res (Sim pson & H ow ard 2009;
Palm anovich et al 2012). Trau m atic rup tures at the m u sculo-
tend inou s ju nction and avu lsion ractu res are m ore com m on
than m id -su bstance tend on ru p tu res. The estim ated incid ence
o peroneal tend on tears ranges rom 11% to 37%, based on
cad aver d issection nd ings (Palm anovich et al 2012). Pero-
neal tend on tears are also associated w ith signi cant lateral
ankle instability. Tears o the peroneu s longu s u su ally occu r
in three anatom ical zones: the lateral m alleolus, the peroneal
tu bercle o the calcaneu s and the cu boid notch (Palm anovich
et al 2012). The m ost com m on tears occu r in the rst three
p eroneals: the longu s, the brevis and the tertiu s. O ten there
are existing tears o the longu s and the brevis at the sam e tim e.
Another m od e o tend inopathy is tend on su blu xation, w hich
is also term ed d islocation, o the peroneu s longus and brevis
tend ons snap p ing over the lateral m alleolu s (Oliva et al 2006).
More rarely, intrasheath p eroneal tend on su blu xation occu rs
(Michels et al 2013).
Anatomy
The m id d le third o the lateral sur ace o the calcaneus
eatures a bony p rotrusion in eriorly, called the em inentia
retrotrochearis (retrotrochearis em inence) (Palm anovich et al
2012). The peroneal tu bercle, w hich is reported ly ound
in 50–90% o the pop ulation, lies anterior to this stru ctu re
(H yer et al 2005; Sau pe et al 2007; H eller & Robinson 2010;
Palm anovich et al 2012). This tubercle, w hen present, sepa-
rates the peroneus longu s tend on rom the peroneu s brevis
tend on (Palm anovich et al 2012); it is situ ated below the angle
orm ed by the lateral bord er o the sinu s tarsi and the lateral
bord er o the posterior articu lar acet on the talus. The pero-
neal tu bercle shap e is classi ed into three grou p s: grou p α is
an oval orm , group β is a rid ge orm , and grou p γ is an
im per ectly d eveloped orm (Palm anovich et al 2012).
Sp eci c location o the tu bercle is rep resented in ou r clas-
si cations; how ever, these w ere orm ed long ago rom the
nd ings o a single stu d y. Typ e I has a single p eroneal tu ber-
cle located anteroin erior to the tu bercle o insertion, the cal-
caneo bu lar ligam ent, typ e II consists o a single p eroneal
tu bercle incom p letely d ivid ed into anterior and p osterior
p arts by a sm ooth groove, typ e III eatu res tw o p eroneal
tu bercles com p letely sep arated by a rou ghened area in the
m id d le and typ e IV is a nu ll classi cation in w hich the p ero-
neal tu bercle is com p letely absent (Agarw al et al 1984).
The d im ensions o the peroneal tu bercle are im portant, as
hyp ertrop hy o this stru ctu re is rep eated ly associated w ith
p eroneal tend inop athy (Ochoa & Banerjee 2007; Taki et al
2007; Boya & Pinar 2010; Taneja et al 2013). The peroneal
tu bercle on average m easu res rom 2 to 17 m m in length, rom
2 to 10 m m in base w id th and rom 1 to 7 m m in height (Sau p e
et al 2007; Palm anovich et al 2012). Another im portant bony
eature p red isposing to the d evelopm ent o peroneal tend in-
op athy near the cu boid tu nnel is the os p erineu m , w hich
is present in rou ghly 20% o the p op ulation. This ossi ed
sesam oid bone, w hen p resent, lies near the calcaneocu boid
joint.
Both p eroneal tend ons are gu id ed by the in erior retinacu -
lum , w hich is attached to the calcaneus both superior and
in erior to the trochlear process. The m uscle o the p eroneus
longus tend on originates rom the lateral cond yle o the tibia,
and the head o the bula then tu rns at the cu boid groove
 650 PART 9 • 58 • Tendinopathy of the foot and ankle
be ore inserting into the p lantar–lateral asp ect o the rst
m etatarsal and m ed ial cu nei orm . Originating rom the
m id d le third o the bu la, the p eroneu s brevis m u scle inserts
into the base o the th m etatarsal bone. Both tend ons have
m u scu lotend inou s ju nctions p roxim al to the su p erior p ero-
neal retinacu lu m .
The p eroneu s tertiu s is a u niqu e m u scle, w hich is p resent
only in hu m ans and varies in its sp eci c cou rse and attach-
m ents (Joshi et al 2006; Ellis 2007). It originates rom the d istal
third o the anterior su r ace o bu la, the interosseou s m argin,
and is o ten u sed w ith the d istal portion o the extensor d igi-
toru m longu s. The p eroneu s tertiu s inserts on the d orsal
su r ace o the base o the th m etatarsal, althou gh there
are variants o this. The p eroneu s qu artus is a norm al variant
that can occu r in 13–25% o patients and has been associated
w ith chronic p ain and sw elling at the lateral ankle / oot
(Mu rlim anju et al 2012). Som e au thors eel that it m ay be
sym p tom atic becau se o the m ass e ect o the m u scle. It can
be con used w ith a so t tissu e m ass, or the third tend on m ay
m im ic the ap p earance o a sp lit tear in the p eroneu s brevis
(Bilgili et al 2014). Its origin m ay includ e the d istal lateral
p ortion o the bula as w ell as the peroneus brevis or longu s
m u scle. Insertion locations o the p eroneu s qu artu s inclu d e
the p halanges or m etatarsal bone o the th toe, the cal-
caneu s, the cu boid bone and the lateral retinacu lu m o the
ankle (Mu rlim anju et al 2012; Bilgili et al 2014).
The innervation o the p eroneu s brevis and longu s is via
the su p er cial p eroneal nerve, and both receive their blood
su p p ly rom the p osterior p eroneal artery and branches o the
m ed ial tarsal artery (Palm anovich et al 2012). Avascular zones
corresp ond w ith requ ent locations o tend inop athy. The p er-
oneu s longu s has an avascu lar zone arou nd the lateral m alleo-
lu s, w hich extend s to the p eroneal tu bercle, and another
avascu lar zone arou nd the cu boid (Petersen et al 2000;
Palm anovich et al 2012).
Pathology and patho-biomechanics
Tend inop athy o the p eroneal tend ons occu rs as a resu lt o
m any actors, both acu te and chronic. Peroneal tend inop athy
has been associated w ith occu rrence o the variant p eroneu s
qu artu s m u scle, osteochond rom a, ractu re, f at oot, p es cavu s,
congenital d e ciency o the su p erior p eroneal retinacu lu m
and a shallow bu lar groove (Oliva et al 2006; Lee et al 2013).
The p eroneu s longu s together w ith the p eroneu s brevis
p rovid e lateral ankle stability in ad d ition to the lateral liga-
m ents, esp ecially d u ring the m id -stance and heel rise o the
gait cycle (Palm anovich et al 2012). Muscu lotend inou s ju nc-
tion tears o ten occu r ow ing to an acu te, violent contraction
beneath the superior peroneal retinacu lu m or at its d istal
ed ge (Palm anovich et al 2012). Su blu xation represents another
tend inop athy. The p eroneu s longu s and brevis share a
com m on tend on sheath p roxim ally, w hereas each tend on lies
d istally in its ow n sheath (Oliva et al 2006). The com m on
sheath is p roxim al to the d istal tip o the bu la and contains
the p eroneu s brevis lying m ed ial and anterior to the p eroneu s
longu s. The bu lar groove on the posterior–lateral aspect o
the bu la contains the com m on sheath. Along w ith the su p e-
rior peroneal retinacu lu m , the groove prevents su blu xation o
the com m on tend on sheath. The bu lar groove is norm ally
5–10 m m w id e and 3 m m d eep . The su perior peroneal reti-
nacu lu m originates on the p osterior–lateral asp ect o the
bu la and inserts onto the lateral asp ect o the calcaneu s.
Acute subluxation is less com m on than chronic subluxation
(Oliva 2006).
Mechanically, the cavovaru s oot is id enti ed as a p red is-
p osing actor or p eroneal longu s tend inop athy (Red ern &
Myerson 2004; Lee et al 2006). The altered placem ent, and
there ore red u ction o the m om ent arm o the tend on in cond i-
tions o the cavernou s oot, increases rictional orces on the
tend on in three locations; the p eroneal longu s tend on is at
high risk or p athological riction at the level o the lateral
m alleolu s, at the p eroneal tu bercle and at the cu boid notch
(Red ern & Myerson 2004; Lee et al 2006).
Another source o m echanically ind uced tend inop athy is
the p resence o an enlarged p eroneal tu bercle (Boya & Pinar
2010; H eller & Robinson 2010; Schu bert 2013). An enlarged or
hyp ertrop hied p eroneal tu bercle can p rod u ce chronic riction
at the anterior aspect o the peroneu s longu s tend on as it
passes over the bony p rom inence o the enlarged tu bercle.
The norm al unction o the peroneal tubercle inclu d es: (1)
insertion o the in erior p eroneal retinaculum , (2) p hysical
sep aration o the com m on p eroneal sheath into sep arate
sheaths or the p eroneu s longus and brevis, and (3) serving
as second u lcru m or pu lley or the peroneal tend ons (H eller
& Robinson 2010; Schu bert 2013). Alterations o the p eroneal
tu bercle’s norm al m orp hology cou ld a ect any or all o
these u nctions, hence p u tting the tend ons at risk o inju ry
(Schu bert 2013).
Diagnosis
Diagnosis o p eroneal tend inopathies varies as the speci c
d isord ers p resent in variable w ays. Tend inop athy w ithout
tend on su blu xation, ru p tu re, longitu d inal tear, stenosing ten-
osynovitis and su blu xation m ay each p resent d i erently, w ith
the p otential or any one or m ore o ou r tend on involvem ents
(Table 58.1). A ull m ed ical history m u st also includ e com or-
bid ities a ecting tissu e, su ch as rheu m atoid arthritis or d ia-
betes. The exam iner m u st also note patient reports o any local
steroid injections or trau m a to the area, inclu d ing p reviou s
sp rains or ractu res (Palm anovich et al 2012).
Peroneal tend initis p resents as p atient rep orts o a grad u al
onset o p ain, sw elling and w arm th in the posterior–lateral
ankle (van Dijk & Kort 1998). There m ay be a d ecline in unc-
tion d u e to the p ain (van Dijk & Kort 1998; Palm anovich et al
2012). This p ain is reprod uced w ith p assive hind oot inver-
sion, w ith ankle p lantarf exion and by active hind oot ever-
sion and ankle d orsif exion (Karageanes 2005; Magee 2008).
Physical exam ination m ay reveal sw elling p osterior to the
lateral m alleolu s. Tend erness to p alpation m ay exist along the
p eroneal tend on trajectory. Pain or tend on ru p tu re m ay
p rod u ce a m arked loss o strength; how ever, a tend on tear or
ru p tu re can exist even in the p resence o a seem ingly strong
p lane o m ovem ent, su ch as eversion. The exam iner shou ld
note a p robable d ys u nction o the p eroneu s longu s tend on in
the p resence o lim ited p lantarf exion o the rst ray. Weak-
ness and sym p tom s o chronic tend inop athy cou ld rep resent
a longitud inal tear o the p eroneu s longus. An app arent teno-
synovitis that d oes not resp ond to conservative treatm ent
cou ld instead be a p artial tear o the tend on (Palm anovich
et al 2012).
Sp ecial tests sp eci c to p eroneal tend on d ys u nction are
ew, and those d escribed closely resem ble one another. The
 Tibialis anterior tendinopathy 651

Table 58.1 Pre s e ntation of pain a nd dys function in pe rone al te ndinopathie s

Pe rone a l te nd inop a thy typ e Pre s e nta tion of p a in a nd d ys function

Peroneal tendinitis
Peroneal tendon s ubluxation
Peroneal tendon tears
Anomalous peroneus brevis
mus cle injury
(Adapted from van Dijk & Kort 1998.)
Symptoms of pain behind and dis tal to the lateral malleolus when the patient returns to activity after a
period of res t.
Swelling and tendernes s may als o be present.
A painful snapping along the lateral ankle is pres ent, with a s ens e of weaknes s or pain.
Pain at the lateral ankle when walking on the toes .
In acute injury, pain and swelling are present over the pos terior–lateral as pect of the ankle.
In chronic injury, subluxation may be present, along with lateral ankle ins tability.
In acute injury, there is a decreas e in strength as well as pain and s welling located inferior and
pos terior to the lateral malleolus.
Chronic injury demons trates a s ubtle, ins idious onset of pain at the posterior to lateral malleolus. This
condition progres sively wors ens in both pain and decreas ed function.
The patient may report acute or chronic debilitating pain while performing the pus h-off portion of the
stance, with or without a history of ankle injury.

test or p eroneal d islocation is p er orm ed w ith the p atient
p ositioned in p rone, w ith the knee f exed to 90°. The exam iner
rst insp ects the posterior–lateral region o the ankle or
sw elling. The p atient is then asked to d orsif ex actively and
p lantarf ex w ith eversion w hile the exam iner p rovid es a
resisting orce. Su blu xation o the tend on rom behind the
lateral m alleolus is consid ered to be a positive test (Magee
2008). The peroneal tend on stability test is per orm ed w ith the
p atient sitting, w ith legs hanging over the ed ge o the table
and knee f exed to 90°. The exam iner hold s the patient’s oot
w ith one hand , w hile u sing the opposite hand gently to locate
the p eroneal tend ons ju st p osterior to the lateral m alleolu s.
The exam iner m oves the oot into end -range inversion, and
then asks the p atient to evert against resistance. I the exam -
iner eels a palp able snap or translation o the tend on, the
test is consid ered p ositive (Karageanes 2005). Reliability,
sp eci city and sensitivity are not cu rrently established or
these tests.
Rad iograp hy or com p u ted tom ograp hy (CT) in the H arris
heel view can d em onstrate the p eroneal tu bercle, w hich m ay
be hypertrophied , as w ell as associated ractu res and the os
p erineu m . Recent reports ind icate that three-d im ensional
colou r volu m e-rend ered im aging p rovid es su p erior d iagnos-
tic resu lts com p ared w ith trad itional CT (Ohashi et al 2015).
Ultrasou nd is rep orted ly both accurate (90–94%) and sp eci c
(85–90%) in d iagnosis o p eroneal tend inop athies (Park et al
2010; Vu illem in et al 2012). MRI m ay ind icate tenosynovitis,
tend inosis or a tear w ith areas o increased signal on
T2-w eighted and STIR im ages, as w ell as loss o hom ogene-
ou s signal. Researchers have agreed that, althou gh MRI is a
u se u l tool or revealing p eroneal tend inop athies, it is o ten
vagu e and shou ld be u tilized only as an ad ju nct to a thorou gh
p hysical exam ination (Park et al 2010).
Treatment and prognosis
Although acu te peroneal tend inopathies m ay be conserva-
tively treated , chronic tend on inju ries have d em onstrated
poor resp onse to conservative treatm ent and are o ten consid -
ered surgical ind ications (Scanlan & Gehl 2002). Conservative
treatm ent or p eroneal tend on su blu xation, even w hen acu te,
has a low rate o su ccess or the p revention o recu rrent
su blu xation (Roth et al 2010). A classi cation system based on
the transverse (cross-sectional) area o viable tend on that
rem ains a ter d ebrid em ent o the d am aged p ortion o the
tend on m ay be u sed to gu id e su rgical d ecision m aking in
cases o p eroneal tend on tears, assu m ing that the retained
p ortion o the tend on has no sp lit tears (Krau se & Brod sky
1998). Tend on repair is ind icated w ith grad e I lesions, w hich
are less than 50% o the cross-sectional area, w hereas teno-
d esis is recom m end ed w ith grad e II lesions, w hich are m ore
than 50% o the tend on’s cross-sectional area (Krau se &
Brod sky 1998). Postoperative treatm ent p rotocols are based
on the typ e o su rgery p er orm ed , and m ay inclu d e non-
w eight-bearing, casting, range o m otion and initiation o
p hysical therapy at 6 w eeks (Palm anovich et al 2012).
Anti-inf am m atory treatm ent, rest, activity m od i cation
and cast im m obilization are attem pted in conservative treat-
m ent (Palm anovich et al 2012; Tzoanos et al 2012). Exercises
and m anu al therapy techniqu es, inclu d ing the lateral calca-
neal glid e, are recom m end ed as p art o a com p rehensive
p hysical therap y p rogram m e (H ensley & Kavchak 2012). (See
Ch 57 or u rther in orm ation on m anu al therap ies targeted
to the ankle and oot.)
With su ch a varied list o p athologies encom p assed in
p eroneal tend inop athies, the m ajority o w hich are consid ered
to be su rgical ind ications, a single statem ent o p rognosis is
not easible. I the p athology is w ell m atched to the su rgical
techniqu e, and the p atient is com p liant, it is generally consid -
ered that return to m axim um activity a ter su rgery is pro-
longed , bu t that good -to-excellent results can be expected
(Krause & Brod sky 1998; Dom bek et al 2001; Scanlan & Gehl
2002). Prognosis or conservative treatm ent in chronic cond i-
tions is consid ered to be o ten p oor, and in acu te cond itions
air to variable (Roth et al 2010; H ensley & Kavchak 2012;
Palm anovich et al 2012; Tzoanos et al 2012).
Tibialis Anterior Tendinopathy
Background
Sp ontaneou s ru p tu re o the tibialis anterior tend on is con-
sid ered to be w ell recognized by som e and an u nu su al
 652 PART 9 • 58 • Tendinopathy of the foot and ankle
occu rrence by others (N egrine 2007; Beischer et al 2009).
Tend inop athy o the tibialis anterior tend on, how ever, is gen-
erally acknow led ged to be a rare clinical p resentation (Beischer
et al 2009; Waizy et al 2011). Inju ry to the tibialis anterior
tend on occu rs w ith orced d orsif exion against resistance o a
p lantarf exed oot (eccentric stress on tibialis anterior tend on),
u su ally in ru nning athletes, or m inim al to norm al stresses on
a d egenerated tend on, ow ing to chronic overu se, in eld erly
p atients (Sim p son & H ow ard 2009). Degenerative tend inosis
is m ore p revalent in eld erly, overw eight em ales, w hereas
sp ontaneou s tend on ru p tu re is ou nd m ore o ten in eld erly
m ales w ith a history o m inor trau m a (N egrine 2007; Beischer
et al 2009).
Anatomy
The tibialis anterior m uscle has ou r com m on points o origin:
the lateral cond yle and u p p er hal to tw o-third s o the lateral
su r ace o the bod y o the tibia, the ad joining p art o the inter-
osseou s m em brane, the d eep su r ace o the ascia, and the
interm u scu lar sep tu m that sep arates it rom the extensor d igi-
toru m longu s (Wheeless 2011).
The tibialis anterior tend on, view ed p rom inently on the
anterior–m ed ial d orsal asp ect o the oot close to the ankle,
p rovid es an insertion or the m u scle at the m ed ial su r ace and
u nd ersu r ace o the m ed ial cu nei orm bone and the base o
the rst m etatarsal bone (Wheeless 2011).
Pathology and patho-biomechanics
The tibialis anterior tend on passes throu gh three tu nnels,
orm ed by the superior extensor retinaculum , obliqu e su pero-
m ed ial and obliqu e in erom ed ial lim bs o the in erior extensor
retinacu lum (Lee et al 2006). In partial tears, the level o the
tear corresp ond s to the ap p roxim ate level o the obliqu e
su p erior–m ed ial lim b. In com plete tears, the proxim al end s o
torn tend ons are retracted so as to lie below the obliqu e
su p erior–m ed ial lim b. In all tears, the obliqu e su p erior–m ed ial
lim b su rrou nd ing the torn tend on is thickened , and there is a
f uid collection w ithin the tend on sheath in tend on tears (Lee
et al 2006).
Tend inosis o the tibialis anterior is d escribed as typ ical o
a d egenerative tend inosis w ith m acroscop ic thickening and
loss o norm al brillary ap p earance (Beischer et al 2009).
Sw elling over the tibialis tend on is p resent, and longitu d inal
sp lit tears are o ten ou nd . Chond ral thinning, and / or osteo-
p hyte orm ation at the rst tarsom etatarsal or m ed ial navicu -
locu nei orm joints, is observed in som e cases (Beischer et al
2009; Waizy et al 2011).
Tibialis anterior tend inopathy has been linked to system ic
d isease (e.g. d iabetes), m echanical stress (e.g. tight shoelaces),
accum u lated overu se traum a and both orce ul d orsif exion
and p assive hyp er-p lantarf exion (Beischer et al 2009; Gru nd y
et al 2010; H art 2011; N egrine 2007).
Diagnosis
The p resenting patient is u sually eld erly, and som etim es
overw eight, w ith o ten a history o m inor trau m a to the
tend on. Bu rning m ed ial m id oot p ain that is w orse at night is
o ten rep orted (Gru nd y et al 2010). There w ill be tend erness
w ith d irect palpation over the tend on, and a gap m ay be
ou nd in the case o com p lete ruptu res (Gru nd y et al 2010).
Pain and / or w eakness w ith resisted d orsif exion and inver-
sion m ay ind icate a tend inop athy or tear. In chronic cases,
active d orsif exion m ay lack 10–15° rom norm al. The exam -
iner can ask the patient to per orm a heel w alk (toes li ted ) in
ord er to d em onstrate the d egree o d e ect and d isability
(Jerom e et al 2010). A steppage-typ e gait is apparent in com -
p lete ru p tu re, w ith active d orsif exion d em onstrating concu r-
rent eversion as the peroneu s tertiu s provid es assistance
(Wheeless 2011). A classic triad in the p resentation o tibialis
anterior tend on ru p tu re includ es: (1) pseu d otu m ou r at the
anterior p art o the ankle that correspond s w ith the rup tu red
tend on end , (2) loss o the norm al contour o the tend on and
(3) w eak d orsif exion (Sam m arco et al 2009).
Ad d itional d iagnostic tests includ e ultrasou nd and MRI
(Lee et al 2006; Jerom e et al 2010). MRI nd ings w ill show
d iscontinuity o the tend on, thickening o the retracted
p ortion o the tend on, and excess f u id in the tend on sheath
in the case o com plete ru ptures. Tend inopathies inclu d ing
p artial tears w ill m ani est as an attenu ated tend on
w ith increased su rrou nd ing f u id (Lee et al 2006; Jerom e
et al 2010).
Treatment and prognosis
In cases o ruptu re, partial tear and tend inosis, conservative
treatm ent is recom m end ed and m ay be su ccess u l; how ever,
it m ay not restore com plete unction, especially in cases o
chronic com p lete ru p tu re and eld erly p atient (Jerom e et al
2010; Waizy et al 2011). With conservative treatm ent attem p ted
rst, cond itions o p artial tear m ay d em onstrate good u nc-
tional ou tcom es w hile com p lete ru p tu res reveal them selves
w ith poor response. Research has show n, how ever, that con-
servatively treated p atients m ay d evelop late sequ elae su ch
as oot d rop, m ild -to-m od erate f at oot d e orm ity and ankle
arthrosis (Jerom e et al 2010).
Conservative treatm ent is not d etailed in the literatu re;
how ever, the stand ard treatm ent ap p ears to be a p rotocol
sim ilar to that or d egenerative tend inop athies in other
tend ons o the low er extrem ities (Sim pson & H ow ard 2009).
Tibialis anterior eccentric exercises m ay provid e a challenge
regard ing load ing technique, ow ing to the u nctional u se o
the m u scle in norm al activity. Tools that p rovid e elastic resist-
ance in both isotonic and eccentric m ovem ents o ankle
d orsif exion w ith inversion are recom m end ed (Sim p son &
H ow ard 2009). When surgery is not an option or high-risk
patients, an ankle– oot orthosis can m echanically su pp ort the
oot d u ring gait in ord er to prevent or red uce risk o alls d u e
to oot d rop (N egrine 2007). Other stand ard treatm ent m ay
includ e any o the ollow ing: short-term im m obilization, pro-
tection, relative rest, ice, com p ression, elevation, m ed ication
and rehabilitative exercise m od alities (Beischer et al 2009;
Sim p son & H ow ard 2009; Gru nd y et al 2010).
Su rgical op tions or ad vanced tend inosis and tend on tears
includ e sim ple tend on d ebrid em ent and rein orcem ent w ith
a su tu re anchor (Grund y et al 2010; Waizy et al 2011). Chronic
com p lete ru p tu res o the tibialis anterior tend on m ay be au g-
m ented w ith an extensor hallu cis longu s trans er into the
m ed ial cu nei orm (Gru nd y et al 2010; Jerom e et al 2010).
This p roced u re can engend er som e sym ptom atic hallu x

interphalangeal joint extensor lag and / or u nsa e toe-catching
w hen the patient is am bu lating w ithout shoes (Gru nd y et al
2010; Waizy et al 2011).
Postop erative p rognosis or u nctional recovery is rep orted
to be good to excellent. Patients w ith a low -d em and li estyle
m ay d em onstrate a good ou tcom e w ith conservative treat-
m ent alone, w ith tend inosis, p artial tear and com p lete ru p tu re
(Jerom e et al 2010). Acute rup tu re su rgical treatm ent w ill have
the op tim al ou tcom e w hen p rovid ed w ithou t d elay (Gru nd y
et al 2010; Jerom e et al 2010).
Tibialis Posterior Tendinopathy
Background
Tibialis p osterior tend inopathy is a com m on and w ell-
recognized sou rce o pain and w alking d ys u nction, and is
cited as one o the lead ing cau ses o acqu ired f at oot d e orm -
ity in the ad u lt popu lation (Kulig et al 2009; Sim p son &
H ow ard 2009). Factors associated w ith tibialis posterior tend i-
nop athy inclu d e age-related d egeneration, inf am m atory
arthritis, hyp ertension, d iabetes m ellitus, obesity, valgus f at-
eet and , less requ ently, acute trau m atic ru pture (Sim p son &
H ow ard 2009; Bu rks 2014). Speci c tend inopathies inclu d e
chronic tend inosis w ith p rogressive ru p tu re, tenosynovitis,
tend on d islocation and acu te ru p tu res (Lhoste-Trou illou d
2012).
Anatomy
The tibialis posterior is the largest, m ost anterior-lying tend on
on the m ed ial asp ect o the ankle. The tibialis p osterior tend on
m u scle originates at three locations: the tibia, the interosseou s
m em brane and the bu la (Lhoste-Trou illou d 2012). It d escend s
w ithin the p osterior com partm ent o the leg, betw een the
f exor d igitoru m longus and the f exor hallucis longus m uscles,
w ith a central lam ina that continues d ow nw ard s w ith the
d istal tend on. The d istal tend on term inates at ankle level w ith
a nearly 90° change in d irection arou nd the m ed ial m alleolus.
The insertion on the plantar oot is com plex; there are m ulti-
ple insertions on the navicu lar tu berosity as w ell as m ain
tend on insertions on all o the tarsal bones, w ith the excep tion
o the astragalu s, and the second , third and ou rth m etatarsals
(Lhoste-Trou illou d 2012). The tibialis posterior tend on, along
w ith the calcaneonavicu lar ligam ent, provid es signi cant
su p p ort or the m ed ial arch o the oot. It is also a p ow er u l
plantar and su p inator o the ankle (Lhoste-Trou illou d
2012).
Pathology and patho-biomechanics
The tibialis p osterior m uscle and tend on together as a unit
provid e the prim ary stabilization o the m ed ial longitud inal
arch (Bek et al 2012; Lhoste-Trou illou d 2012). They achieve
this by li ting the m ed ial longitu d inal arch w ith its active
plantarf exion and inversion m ovem ent, thus locking the
m id -tarsal articu lation and stabilizing the hind oot (Bek et al
2012). When the m id d le and p osterior oot are stable in this
m anner, the gastrocnem iu s and soleu s m u scles are e ectively
Tibialis posterior tendinopathy 653
activated . H ow ever, w hen the m id d le oot cannot be locked
in the orw ard phase o w alking, excessive orce is applied on
the m id -tarsal joint by the gastrocnem iu s and soleu s m u scles.
In turn, this causes a collapse o the m ed ial arch and eversion
o the su btalar articu lation. Tibialis p osterior tend inop athy
w ith strength insu ciency cau ses a posterior shi t o the
centre o gravity o the oot and p rod u ces an abnorm al load
on its m ed ial stru ctu res (Bek et al 2012).
The pathological process lead ing to chronic tend inop athies
o the tibialis p osterior d evelop s as a resu lt o d egenerative or
inf am m atory cau ses or repeated m icro-trau m a. Di erent
stages o this p rocess m ay p rod u ce rigid stru ctu ral oot
d e orm ities and d egenerative changes (Bek et al 2012). Previ-
ou s rep orts su ggested that the d ys u nction arises rom an
inf am m atory process such as tend initis or tenosynovitis;
how ever, cu rrent histological stu d ies show that the changes
associated w ith this tend inopathy are m ore consistent w ith a
d egenerative process as d escribed above (Bek et al 2012;
Lhoste-Trou illoud 2012).
Diagnosis
Three stages, also term ed ‘grad es’, o tibialis posterior tend i-
nop athy are d escribed in the literatu re, and treatm ent d eci-
sions are based u p on this classi cation (Ku lig et al 2009;
Sim p son & H ow ard 2009; Bek et al 2012; Lhoste-Trou illou d
2012). Stage 1 is characterized by m ild sw elling, m ed ial ankle
p ain and norm al bu t p ossibly p ain u l single heel raise, bu t no
d e orm ity. Stage 2 eatu res progressive f attening o the arch,
p es p lanu s and m id oot abd u ction; how ever, the su btalar
joint is still f exible. The tend on at this point is u nctionally
incom petent or rup tured ; the patient is u nable to per orm a
heel raise. Stage 3 incorporates all o the eatures o stage 2,
except that the su btalar joint has becom e xed (Ku lig et al
2009; Sim pson & H ow ard 2009; Bek et al 2012; Lhoste-
Trou illou d 2012). A ou rth stage w as later ad d ed to encom -
p ass p rogression to valgu s tilt o the talu s in the ankle
m ortise, lead ing to lateral tibiotalar d egeneration (Ku lig
et al 2009).
An excellent p hysical exam ination w ill inclu d e a num ber
o tests, inclu d ing the single-lim b rise, rst-m etatarsal rise
sign and the ‘too-m any-toes’ sign (Churchill & S erra 1998;
Sim p son & H ow ard 2009). The rst-m etatarsal rise test has
excellent sensitivity, bu t u nknow n sp eci city, or d iagnosis o
tibialis p osterior tend on d ys u nction. Patients are tested w hile
in stand ing w ith ull w eight-bearing bilaterally. The exam iner
hold s the shank o the a ected oot w ith one hand and exter-
nally rotates it, or, w hen the heel o the a ected oot is held
by the exam iner ’s hand and brou ght passively into a varus
p osition, the head o the rst m etatarsal li ts or raises in the
case o tibialis p osterior tend on d ys u nction bu t rem ains on
the f oor w hen the tend on is u nctioning norm ally (Chu rchill
& S erra 1998).
The too-m any-toes sign, w ith a reported sensitivity o
65–80%, is a com m only used test to id enti y tibialis p osterior
tend on tend inop athy (Chu rchill & S erra 1998; Sim p son &
H ow ard , 2009). To per orm this test, the exam iner w ill view
the p atient’s oot rom behind ; a p ositive test w ill be ind icated
by the exam iner view ing m ore toes exp osed on the lateral
aspect o the involved oot, along w ith f attening o the
arch (Churchill & S erra 1998; Ku lig et al 2009; Sim p son &
H ow ard 2009).
 654 PART 9 • 58 • Tendinopathy of the foot and ankle
Other p hysical nd ings inclu d e excessive p ronation o the
inju red oot, relative w eakness o the p osterior tibial tend on
and abnorm al heel varus w hen the p atient is asked to stand
on tip toe (Chu rchill & S erra 1998; Sim p son & H ow ard , 2009).
The patient w ill have d i cu lty and pain w hen per orm ing
a single-leg heel raise (Chu rchill & S erra 1998; Ku lig et al
2009; Sim p son & H ow ard 2009). Frank ru pture o the tibialis
p osterior tend on is ind icated by an inability to initiate and
m aintain p lantarf exion w ith a single-leg heel raise or the
p resence o abnorm al heel varus w ith this m anoeuvre (Ku lig
et al 2009).
Ultrasou nd and w ill reveal a thickened retinacu lu m
and / or tend on. The classic pictu re consists o an irregular
cortical bone p ro le, heterogeneity o the tend on insertion
and hyp eraem ia on colou r Dop pler u ltrasou nd (Prem ku m ar
et al 2002; Lhoste-Trou illou d 2012). The sensitivity and
sp eci city o u ltrasou nd or d iagnosing tibialis p osterior
tend inop athy are 80% and 90% resp ectively; or d iagnosing
tibialis p osterior p eritend inosis they are 90% and 80% resp ec-
tively (Prem ku m ar et al 2002). H igh-resolu tion sonography
w ith colou r and p ow er Doppler im aging is nearly as accurate
as MRI or d iagnosing tibialis p osterior tend inopathy
(Prem ku m ar et al 2002).
Treatment and prognosis
There is no agreem ent or strong evid ence in the litera-
tu re regard ing the e cacy o conservative treatm ent ap -
p roaches or tibialis posterior tend inopathy (Bow ringa &
Chockalingam 2010). General recom m end ations are or rela-
tive rest, p ain m ed ication, p hysical therap y and w alking cast
or ankle oot orthosis in stage 1, w ith the ad d ition o re erral
to an orthop aed ic su rgeon in stage 2 (Ku lig et al 2009;
Sim pson & H ow ard 2009). Surgical rep air is the p rescribed
treatm ent or stage 3 or 4 (Ku lig et al 2009; Sim p son &
H ow ard 2009).
Focusing on the su pposed tend on pathogenesis o d egen-
eration, physical therapy p rogram m es in the early stages o
tibialis p osterior tend inop athy attem p t to su p p ort the f at-
tened arch m echanically so as to p revent u rther tend on
lengthening and oot d e orm ity (Ku lig et al 2009). Exercises
to strengthen the w eakened tibialis p osterior m u scu lotend i-
nou s com p lex, albeit in the p resence o p ain u l tend on d ys-
u nction, are strongly recom m end ed (Sim p son & H ow ard
2009); a closed -chain resisted oot ad d u ction exercise per-
orm ed bare oot m ost e ectively and selectively activated the
tibialis p osterior m u scle in p eop le w ith a norm al arch ind ex.
Gastrocnem iu s and soleu s m u scle stretching and the ad d ition
o eccentric tend on load ing w hen tolerated are ad d itional
d etails o rehabilitation strategies (Ku lig et al 2009).
Su rgical op tions, w hich are p re erred in the later stages o
tend inop athy, inclu d e tend on trans ers, osteotom ies, arthro-
d eses and their variou s com binations. Overcorrection and
u nd ercorrection are com p lications sp eci c to the tend on-
trans er p roced u re (Bek et al 2012).
Prognosis or u ll u nctional recovery a ter conservative
treatm ent or su rgery is based on treatm ent op tions accord ing
to the tend on’s p athological stage. Provid ed that the recom -
m end ations or treatm ent are ollow ed accord ing to the stage
as d iscu ssed above, ou tcom es o both op tions are good to
excellent (Ku lig et al 2009; Bek et al 2012).
Other Tendinopathies o the Foot
and Ankle
Background
Most tend inop athies in the oot and ankle other than those
d iscussed earlier in this chapter involve the f exor hallu cis
longus (FH L) tend on, althou gh literally any tend on in the oot
and ankle could present pathologically. Restricted m ovem ent
o the FH L tend on cau ses tend inop athies m ost o ten in
ru nners, ballet d ancers and other athletes; how ever, this con-
d ition presents in the sed entary popu lation as w ell. Tend in-
op athy o the f exor FH L tend on is o ten m isd iagnosed as
p lantar asciitis, w hich then p roves recalcitrant to treatm ent
(Michelson & Du nn 2005; Sim pson & H ow ard 2009). Chronic
tend inop athy o the FH L cau ses chronic p ain, early arthritis,
brosis w ith d ecreased range o m otion, and p ossibly an
early end to a d ancer ’s or athlete’s career (Sim p son &
H ow ard 2009).
Anatomy
The FH L originates rom at least ou r sites: the in erior tw o-
third s o the p osterior su r ace o the bod y o the bu la, the
low er part o the interosseous m em brane, an interm uscu lar
sep tu m betw een it and the p eroneals laterally, and the ascia
covering the tibialis p osterior m ed ially (Magee 2008). The
tend on o the FH L occu p ies nearly the entire length o the
p osterior su r ace o the m u scle. Grooves on the talu s and
calcaneu s contain the FH L tend on. The groove crosses the
p osterior su r ace o the d istal tibia, the p osterior talu s and
u nd ersu r ace o the su stentacu lu m tali o the calcaneu s. The
tend on p asses betw een the m ed ial and lateral sesam oid bones
at the m etatarsophalangeal joint, then ru ns orw ard s in the
sole o the oot betw een the tw o head s o the f exor hallu cis
brevis m u scle, and nally inserts into the base o the last
p halanx o the great toe (Magee 2008; Wheeless 2012).
Pathology and patho-biomechanics
The FH L tend on m ovem ent can be restricted at the level o
the p osterior ankle and at its p assage betw een the tw o sesa-
m oid s (Michelson & Dunn 2005; Sim p son & H ow ard 2009).
This is not alw ays a stenosing type o tenosynovitis. Tend in-
op athy o the FH L is also cau sed by p osterior im p ingem ent
by the talus. In som e cases, how ever, the m echanism o inju ry
is trau m a that m ay or m ay not be com p ou nd ed later w ith
chronic d egeneration (Michelson & Du nn 2005; Sim p son &
H ow ard 2009; Corte-Real et al 2012).
Diagnosis
Patients m ay rep ort p ain w ith p alp ation at the p osterior–
m ed ial ankle, the p lantar heel, the p lantar m id oot, and m u l-
tip le other locations (Michelson & Dunn 2005; Sim p son &
H ow ard 2009). In short, the p ain m ay m ani est itsel any-
w here rom the p osterior leg to the p lantar oot and the
hallu x. Length testing o the FH L m uscle and tend on reveals

restriction by lim ited hallu x m etatarsophalangeal joint d orsi-
f exion w hen the ankle is d orsif exed (Michelson & Du nn
2005). MRI o the FH L m ay reveal synovitis, d egenerative
tend on changes, or tears (Michelson & Dunn 2005; Corte-Real
et al 2012).
Treatment and prognosis
Conservative treatm ent inclu d es stretching, short-term im m o-
bilization and m od alities or pain. Surgery includ ing open
or arthroscop ic release o the FH L tend on yield s good
resu lts w hen conservative treatm ent ails (Corte-Real et al
2012). In orm ation on prognosis is lim ited . An estim ated
50–64% o those treated conservatively w ill have su ccess u l
resu lts. Prognosis reported or su rgical intervention is excel-
lent (Michelson & Du nn 2005; Sim pson & H ow ard 2009;
Corte-Real et al 2012).
Conclusion
Tend inop athies o the ankle and oot vary w id ely and o ten
requ ire su rgical intervention or ru pture or severe d egrad a-
tion. Conservative treatm ents, both novel and trad itional, are
largely unsu pported by reports o e cacy in the m ed ical lit-
eratu re (Magnu ssen et al 2009; Bow ringa & Chockalingam
2010; Pap a 2012; Scott et al 2013). A general rehabilitation p lan
m ay be ollow ed , bu t w ith less than op tim al resu lts (Bek et al
2012). The d evelopm ent o an e ective rehabilitation treat-
m ent p lan or con rm ed sym p tom atic tend inop athy requ ires
not only cognizance o evid ence-based treatm ent bu t also
pathoanatom ical know led ge, as w ell as com plex clinical rea-
soning (Kulig et al 2009; H ensley & Kavchak 2012). Tend on
pathology in the oot and ankle varies greatly rom tend on to
tend on and accord ing to the m echanism o inju ry. Conserva-
tive treatm ent shou ld be tailored to the site o p athology, the
stage o the tend inop athy, the u nctional assessm ent, the
activity statu s o the p erson, any contribu ting issu es throu gh-
ou t the kinetic chain and com orbid ities (Scott et al 2011, 2013;
Pap a 2012). N either evid ence-based m ed icine nor the practi-
tioner ’s clinical reasoning and exp erience shou ld stand alone
as ‘best p ractice’ or the treatm ent o tend inop athies in
the oot and ankle (Kulig et al 2009; Scott et al 2011, 2013;
Pap a 2012).
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 P AR T 10
Soft Tissues in the Upper
and Lower Quadrants
59 Referred Pain from Myofascial Trigger Points 659
César Fernández-de-las-Peñas, Hong-You Ge, Lars Arendt-Nielsen and
Jan Dommerholt
60 Manual Treatment of Myofascial Trigger Points 678
César Fernández-de-las-Peñas, Jaime Salom-Moreno, Hong-You Ge and
Jan Dommerholt
61 Dry Needling of Trigger Points 690
Jan Dommerholt and Erik H. Wijtmans
62 Muscle Energy Approaches 710
Gary Fryer
63 Myofascial Induction Approaches 729
Andrzej Pilat
This pa ge inte ntiona lly le ft bla nk
 PART 10 •  Soft Tissues in the Upper and Lower Quadrants

Chapter 

Referred Pain from Myofascial Trigger Points

59  

C é s a r Fe rn á n d e z - d e - la s - P e ñ a s , Ho n g -Yo u G e , La rs Are n d t- N ie ls e n , J a n Do m m e rh o lt

CHAP TER CONTENTS
Introduction  659
Myofascial trigger points  660
De nition of a trigger point  660
Characteristics of the referred pain elicited by muscle  
trigger points  660
Manual identi cation of myofascial trigger points  660
Neurophysiological basis of trigger points  661
Exploration of trigger points related to upper quadrant   p ain m ay refer to the contralateral sid e (Carli et al 2002).
pain syndromes  662
Neck–shoulder muscles  662
Scalene muscles  663
Pectoralis minor muscle  663
Supraspinatus muscle  664
Infraspinatus muscle  664
Teres minor and major muscles  665
Subscapularis muscle  665
Pectoralis major muscle  665
Deltoid muscle  666
Biceps brachii muscle  666
Triceps brachii muscle  666
Brachioradialis muscle  667
Supinator muscle  667
Wrist / hand extensor muscles  667
Pronator teres muscle  669
Wrist / hand  exor muscles  669
Other muscles of the upper quadrant  670
Exploration of trigger points related to lower quadrant   d eep pain in the posterior part of the leg sp read ing to the
pain syndromes  670
Quadratus lumborum muscle  670
Psoas major muscle  670
Piriformis muscle  671
Gluteus medius muscle  671
Gluteus minimus muscle  671
Quadriceps muscle  672
Adductor muscles  672
Gastrocnemius and soleus muscles  672
Tibialis anterior, extensor digitorum longus and extensor   the p rop er d iagnosis. This chap ter w ill d escribe the clinical
hallucis longus muscles  673
Other muscles of the lower quadrant  673
Conclusion  673
Introduction
Referred p ain (p ain felt in a region rem ote from the sou rce
of p ain) has been know n and d escribed for m ore than a
centu ry and has been u sed extensively as a d iagnostic clini-
cal tool. In clinical p ractice, it is very com m on to see
p atients w ith neck or shou ld er p ain that refers to the u p p er
arm , the forearm or hand , or p atients w ith low back or hip
p ain that sp read s to the thigh, knee or leg. Occasionally,
Pain from d eep tissu es, su ch as m u scles, joints, ligam ents,
tend ons and viscera is often d escribed as d eep and d iffu se
and d if cu lt to locate precisely (Mense 1994). The term
‘referred pain’ is actually only p artially correct, how ever, as
referred pain is not necessarily lim ited to p ain bu t can also
inclu d e other referred sensations or paraesthesiae. Referred
p ain sym p tom s can be involved in u p p er and low er qu ad -
rant p ain synd rom es in w hich there is no clear d iagnosis
(Gerw in 1997). For instance, patients w ith d eep pain in the
shou ld er and p osterior d eltoid region sp read ing to the
u p p er arm m ay be d iagnosed as a non-sp eci c arm p ain
synd rom e, since they com p lain of d iffu se arm p ain and ten-
d erness w ith loss of function but lack objective physical
signs (Macfarlane et al 2000). Sim ons et al (1999) d escribed
com m on referred p ain p atterns from the infrasp inatu s
trigger p oints (TrPs), w hich m ay resem ble the clinical
p ictu re of these p atients. What w as consid ered to be a non-
sp eci c arm p ain synd rom e m ay in fact originate from infra-
sp inatu s TrPs. Another exam p le w ou ld be a p atient w ith
p osterior p art of the knee or the low er leg. In this case, the
p atient m ay be d iagnosed w ith sciatic nerve p ain. H ow ever,
TrPs w ithin the p iriform is m u scle can m im ic sim ilar sym p -
tom s (Sim ons et al 1999). Sim ilarly, w hat w as consid ered to
be sciatic nerve com pression m ay in fact originate from piri-
form is TrPs.
An ad d itional clinical reasoning challenge is that, in ind i-
vid u als w ith m u scu loskeletal p ain, the sym p tom s m ay be the
su m m ation of referred p ain from m u ltip le m u scle TrPs and
from joints and viscera, m aking it m ore d if cu lt to establish
and the neurop hysiological basis of m yofascial TrPs w ith
referred pain patterns spread ing to the u pper and low er
qu ad rants.
 660 PART 10 • 59 • Referred pain from myofascial trigger points
Myo ascial Trigger Points
Def nition o a trigger point
Although there are d ifferent d e nitions of TrPs, the m ost
com m only accep ted d e nition states that a TrP is a hyp er-
irritable sp ot w ithin a tau t band of a skeletal m u scle that
is p ainfu l on com p ression, stretch, overload or contraction,
w hich cau ses a referred pain that is p erceived d istant from the
sp ot (Sim ons et al 1999). From a clinical point of view, w e can
d istinguish betw een active and latent TrPs. Active TrPs are
those in w hich local and referred p ain rep rod u ce sensory or
m otor sym p tom s rep orted by the p atient, and the p ain is
recognized by the patient as a usu al pain (Sim ons et al 1999).
Latent m u scle TrPs are those in w hich local and referred p ain
d o not reprod u ce any sym ptom that is fam iliar or u su al for
the su bject (Sim ons et al 1999). Active and latent TrPs have
sim ilar p hysical nd ings. The d ifference is that latent TrPs d o
not rep rod u ce any sp ontaneou s sym p tom s. In ad d ition, active
TrPs are bigger and ind u ce larger referred p ain areas and
higher p ain intensities than d o latent TrPs (H ong et al 1997;
Ballyns et al 2011). For instance, a patient w ith lateral epi-
cond ylalgia can have active TrPs, w hich rep rod u ce the sym p -
tom s w ithin the affected arm (Fernánd ez-Carnero et al 2007),
bu t this patient m ay also have latent TrPs on the non-affected
sid e, as the local and referred p ain is not u su ally p erceived in
this arm (Fernánd ez-Carnero et al 2008). Sim ilarly, Ge et al
(2008a) found that ind ivid uals w ith u nilateral shou ld er pain
exhibit active TrPs in the infraspinatu s m uscle w ithin the
sym p tom atic sid e, bu t also latent TrPs in the sam e m u scle on
the non-sym p tom atic sid e. Ad d itionally, both active and
latent TrPs p rovoke m otor d ysfu nctions, for exam p le m u scle
w eakness, inhibition, increased m otor irritability, m uscle
im balance and altered m otor recru itm ent (Lucas et al 2004),
in either the affected m u scle or in fu nctionally related m u scles
(Sim ons et al 1999). Lu cas et al (2010) d em onstrated that
latent TrPs w ere associated w ith an im p aired m otor activation
p attern and that the elim ination of these latent TrPs ind uces
norm alization of the im p aired m otor activation p attern.
Du ring the past d ecad e, an increasing num ber of researchers
have show n an interest in the aetiology and clinical relevance
of latent TrPs (Ge & Arend t-N ielsen 2011).
Characteristics o the re erred pain elicited
by muscle trigger points
• The d u ration of referred p ain cou ld last for as short as
a few second s or as long as a few hours, d ays, w eeks
or som etim es ind e nitely, d ep end ing u p on the TrP
activity.
• The referred p ain is d escribed as d eep , d iffu se,
bu rning, tightening or p ressing pain, w hich is
com p letely d ifferent from neu rop athic or su p er cial
(skin) p ain.
• The referred p ain can sp read cranial / cau d al or
ventral / d orsal, d ep end ing on the TrP.
• The referred p ain intensity and sp read ing area are
p ositively correlated w ith the d egree of TrP activity
(irritability of the nervous system ).
• The referred pain can be accom panied by other
sym p tom s, su ch as nu m bness, cold ness, stiffness,
w eakness, fatigue and m otor d ysfunction, w hich su ggests
that the term ‘referred sensation’ m ay be a m ore
app ropriate and accu rate d escription.
• Inactivation of active TrPs should effectively relieve the
referred pain.
• TrP referred pain patterns m ay be sim ilar to joint referred
pain patterns (Bogd u k 2004).
Manual identif cation o myo ascial
trigger points
Com p etent TrP d iagnosis requ ires ad equ ate m anu al skills,
training and clinical p ractice to d evelop a high d egree of reli-
ability in the exam ination (Gerw in et al 1997; Sim ons et al
1999; Sciotti et al 2001). There are several signs and sym ptom s
that m ay be u sed for the TrP d iagnosis: (a) p resence of a p al-
p able tau t band in a skeletal m u scle w hen accessible to p alp a-
tion, (b) p resence of a hyp erirritable sp ot in the tau t band , (c)
p alp able local tw itch resp onse on snap p ing p alp ation (or nee-
d ling) of the TrP, and (d ) presence of referred pain elicited by
stim u lation or p alp ation of the hyp erirritable sp ot (Sim ons
et al 1999). Ad d itional helpfu l signs for d iagnosis are m uscle
w eakness, pain on contraction in the shortened or lengthening
p osition, or a ju m p sign. H ow ever, d ifferent review s investi-
gating the reliability of TrP d iagnosis have conclu d ed that
further high-quality investigations are need ed of the currently
u sed clinical d iagnostic criteria in d ifferent p op u lations
(Tou gh et al 2007; Mybu rgh et al 2008; Lu cas et al 2009).
Factors that m ay have contribu ted to the varying reliability of
the resu lts from stu d ies are lack of id enti cation of tau t band s,
inexperienced exam iners in assessing m uscle TrPs, incorrect
p ositioning of the p atient or the assessor, incorrect p alp ation
techniqu es, and variations in the am ou nt of m anu al force
exerted on the palpated point and the d u ration of force
ap plied . N evertheless, it has been reported that in som e
m u scles a TrP m ay consistently be m ore reliably exam ined
than others (Gerw in et al 1997; Sciotti et al 2001). Read ers
are referred to other texts for d iscussion on the reliability of
d iagnosing TrP (Tough et al 2007; Mybu rgh et al 2008;
Fernánd ez-d e-las-Peñas et al 2009b; Lu cas et al 2009; Bron &
Dom m erholt 2012).
In clinical practice, Sim ons et al (1999) and Gerw in et al
(1997) recom m end that the minimum accep table criteria for
TrP d iagnosis are the p resence of a hyp erirritable sp ot w ithin
a palpable tau t band of a skeletal m u scle com bined w ith
the p atient’s recognition of the referred p ain elicited by the
TrP. When ap p lied by an exp erienced assessor, these
criteria have obtained good inter-exam iner reliability (kap p a)
ranging from 0.84 to 0.88 (Gerw in et al 1997). More-recent
stu d ies fou nd that tau t band s and TrPs can be visu alized
u sing m agnetic resonance and sonograp hic elastograp hy
(Chen et al 2007, 2008; Sikd ar et al 2008, 2009), althou gh fu ture
stu d ies are need ed to op tim ize these p roced u res. These
stu d ies have d em onstrated that tau t band s exhibit higher
stiffness (Chen et al 2007), red uced vibration am plitud e
(Sikd ar et al 2009), higher peak systolic velocities and nega-
tive d iastolic velocities (Sikd ar et al 2010) com pared w ith
norm al m u scle sites.

Neurophysiological basis o myo ascial
trigger points
TrP referred p ain is a p rocess of central sensitization, w hich
is m ed iated by peripheral nociceptive activity and w hich can
be facilitated by sym p athetic activity or altered d escend ing
inhibition.
TrPs: are they a focus of peripheral sensitization?
Mu scle p ain is d ep end ent u p on activation of m u scle
nocicep tors by end ogenou s su bstances (e.g. neu rop ep tid es or
in am m atory m ed iators). Different algogenic su bstances are
com m only u sed in exp erim ental p ain m od els for eliciting
both local and referred pain from m uscle tissues, includ ing
hyp ertonic saline (Arend t-N ielsen & Svensson 2001; Graven-
N ielsen 2006), brad ykinin and serotonin (Babenko et al 1999a),
cap saicin (Witting et al 2000), substance P (Babenko et al
1999b), glu tam ate (Svensson et al 2003a), nerve grow th factor
(Svensson et al 2003b) and acid ic saline (Sluka et al 2001). It
is interesting to note that the referred p ain patterns reported
w ith injection of these su bstances are sim ilar to the referred
pain p atterns d escribed in the trigger point m anuals (Sim ons
et al 1999).
The p ressu re sensitivity is low er at TrPs than at control
points su ggesting an increased nociceptive sensitivity at TrPs
and p erip heral sensitization. In fact, active TrPs and their
overlying cu taneou s and su bcu taneou s tissu es are u su ally
m ore sensitive to p ressu re and electrical stim u lation than are
latent TrPs (Vecchiet et al 1990, 1994).
Microd ialysis stu d ies show ed that the concentrations of
brad ykinin, calcitonin gene-related peptid e, substance P,
tu m ou r necrosis factor-α , interleukin-1β, serotonin and nor-
epinep hrine w ere signi cantly higher in active m uscle TrPs
com p ared w ith latent TrP or control non-TrP p oints (Shah
et al 2005, 2008). A m ore recent anim al rabbit stu d y con rm ed
the increased concentrations of β-end orphin, substance P,
tu m or necrosis factor α (TN F-α ), cyclo-oxygenase-2 (COX-2),
hyp oxia-ind u cible factor 1α , ind u cible nitric oxid e synthase,
and vascu lar end othelial grow th factor (H sieh et al 2012).
These stu d ies establish the p resence of nocicep tive hyp er-
sensitivity in active TrPs and valid ate that TrPs are a focu s of
persistent perip heral sensitization. Li et al (2009) reported
nocicep tive (hyp eralgesia) and non-nocicep tive (allod ynia)
hyp ersensitivity at TrPs, su ggesting that TrPs sensitize both
nocicep tive and non-nocicep tive nerve end ings. N evertheless,
painful stim u lation ind u ces higher p ain resp onse than non-
noxiou s stim u lation at TrPs (Li et al 2009). Ad d itionally,
Wang et al (2010) observed that ischaem ic com pression,
w hich m ainly blocked large-d iam eter m yelinated m uscle
afferents, ind u ced increased p ressu re p ain and referred pain
threshold s at the TrP, bu t not at non-TrP regions. All these
stu d ies su p p ort the id ea that TrPs constitu te a focu s of
sensitization of both nocicep tive and non-nocicep tive
nerve end ings.
TrPs and central sensitization mechanisms
When m u scles are in a state of sensitization, m u scle nocicep-
tors are m ore easily activated and m ay resp ond to norm al
innocuou s or w eak stim u li su ch as light pressu re and
m u scle m ovem ent. The p resence of m u ltip le TrPs (sp atial
Myofascial trigger points 661
su m m ation), or of TrPs d u ring p rolonged p eriod s of tim e
(tem p oral su m m ation), w ou ld sensitize the spinal cord and
su p rasp inal stru ctu res by continu ed nocicep tive afferent
barrage into the central nervou s system (Fernánd ez-d e-
las-Peñas et al 2009a). In these sensitization m echanism s,
new recep tive eld s w ou ld ap p ear and cau se referred p ain
(Mense 1994).
Em erging research su ggests a p hysiological link betw een
the clinical m anifestations of TrPs, su ch as hyp eralgesia
and consistently referred pain, and the p henom enon of
central sensitization, althou gh the cau sal relationship s and
m echanism s are still u nclear (Fernánd ez-d e-las-Peñas &
Dom m erholt 2014). Several stud ies have con rm ed that the
area of referred p ain correlates w ith the intensity and d u ration
of the m u scle p ain (Graven-N ielsen et al 1997; Lau rsen et al
1997). These stud ies su ggest that m u scle-referred pain is
m aintained by p erip heral sensitization m echanism s. Ku an
et al (2007) reported that spinal cord connections of TrPs w ere
m ore effective than non-TrPs in ind u cing neu rop lastic changes
in the d orsal horn neurons. Im aging stud ies have d em on-
strated that active TrP p ain is, at least p artially, p rocessed at
su p rasp inal levels as TrP hyp eralgesia is p rocessed in variou s
brain areas; enhanced som atosensory activity w as observed
in the prim ary and second ary som atosensory cortex, inferior
p arietal, m id -insu la and lim bic system (N id d am et al 2007,
2008; N id d am , 2009).
Som e clinical stu d ies have d em onstrated that sensitization
m echanism s related to TrPs m ay be reversible w ith p rop er
m anagem ent (Mellick & Mellick 2003; H sieh et al 2007). For
instance, d ry need ling inactivation of prim ary TrPs inhibits
the activity in satellite TrPs situ ated in their zone of referred
p ain (H sieh et al 2007). TrP injection into neck m u scles p ro-
d uces rapid relief of p alpable scalp or facial tend erness and
also alleviates associated sym ptom s of nau sea, photop hobia
and phonophobia in m igraine (Carlson et al 1993; Mellick &
Mellick 2003). Anaesthetic injections of active TrPs have been
show n to d ecrease m echanical hyp eralgesia, allod ynia and
referred pain signi cantly in patients su ffering from m igraine
(Giam berard ino et al 2007), brom yalgia (Affaitati et al 2011)
and w hiplash (Freem an et al 2009). It is conceivable that the
d egree of central sensitization m ay in uence w hether a p atient
w ill respond to TrP treatm ent. In fact, in clinical p ractice it is
com m on that ind ivid u als w ith less central sensitization
requ ire few er treatm ents. Multiple factors can hence in u ence
the d egree of sensitization, inclu d ing altered d escend ing
inhibitory system s, sym pathetic activity and neuropathic acti-
vation, and therefore increase the likelihood that m yofascial
p ain synd rom es m ay be reversible.
TrPs and the sympathetic nervous system
There is a grow ing interest in the association betw een m u scle
TrPs and the sym p athetic nervou s system . Stu d ies in rabbits
(Chen et al 1998b) and hu m ans (McN u lty et al 1994; Chu ng
et al 2004) have show n evid ence of a sym p athetic contribu tion
to the m od u lation of sp ontaneou s electrical activity at TrPs.
In these stud ies, increased sym p athetic efferent d ischarge
increased both the frequency and the am p litu d e of spontane-
ou s electrical activity of m u scle TrPs, w hereas sym p athetic
blockers d ecreased the frequency and am plitud e of spontane-
ou s electrical activity. Ge et al (2006) found increased referred
p ain intensity and tend erness w ith sym p athetic hyp eractivity
 662 PART 10 • 59 • Referred pain from myofascial trigger points
at TrPs, w hich su ggests a sym p athetic contribu tion to the
m echanism s resp onsible for the generation of referred p ain.
A later stu d y fou nd an attenu ated skin blood ow resp onse
after painfu l stim u lation of latent m uscle TrPs com p ared
w ith control non-TrPs, su ggesting that there w as increased
sym p athetic vasoconstriction activity at latent TrPs (Zhang
et al 2009).
Since both p erip heral and central sensitization m echanism s
p articip ate in the d evelop m ent of m u scle-referred p ain (for a
m ore com p lete review see Arend t-N ielsen et al 2000), sym pa-
thetic facilitation can involve p erip heral, sp inal and / or
su p rasp inal sym p athetic stru ctu res. The interactions betw een
sym p athetic and central nervou s system s, and betw een the
sym p athetic–sensory and sym pathetic–m otor coup ling at
TrPs, are still u nknow n (for a review see Arend t-N ielsen &
Ge 2009). Gerw in et al (2004) su ggested that the p resence of
α - and β-ad renergic receptors at the end plate m ight provid e
a p ossible m echanism for au tonom ic interaction (Maekaw a
et al 2002). Stim u lation of the α - and β-ad renergic receptors
stim u lated the release of ACh (acetylcholine) in the p hrenic
nerve of rod ents (Bow m an et al 1988).
TrPs: the integrated hypothesis
To exp lain the variou s p otential hyp otheses of the p athogen-
esis of TrPs is beyond the scop e of this chapter, bu t a su m m ary
of cu rrent d ata w ill be review ed . The activation of a TrP m ay
resu lt from a variety of factors (e.g. repetitive m u scle overu se,
acute or su stained overload , p sychological stress or other key
m yofascial TrPs). Particu lar attention has been p aid to inju red
or overload ed m u scle bres in the p athogenesis of TrPs (Chen
et al 2000; Gerw in et al 2004; Itoh et al 2004; Treaster et al
2006). Som e authors have hyp othesized that m u scle traum a,
repetitive low -intensity m u scle overload or intense eccentric
contractions m ay create a viciou s cycle of events. Dam age to
the sarcop lasm ic reticu lu m or the cell m em brane m ay lead to
an increase of the calcium concentration, an activation of actin
and m yosin lam ents, a relative shortage of ad enosine tri-
p hosp hate (ATP) and an im paired calciu m p um p (Sim ons
et al 1999; Gerw in et al 2004).
Based on these events, Sim ons and Travell p rop osed the
so-called ‘energy crisis hypothesis’ introd u ced in 1981 and
enhanced by subsequent research, lead ing to the integrated
hypothesis (Sim ons 2004). This hyp othesis proposes that
abnorm al d ep olarization of the post-junctional m em brane of
m otor end p lates enhanced by su stained m u scu lar contraction
gives rise to a localized hypoxic energy crisis associated w ith
sensory and au tonom ic re ex arcs that are su stained by sen-
sitization m echanism s (McPartland & Sim ons 2006). The
notion that d am age to the sarcop lasm ic reticu lu m w ou ld be
an initiating event has now been aband oned in favou r of less
biom echanical explanations. H ypoxia red u ces the pH of
m u scle tissu e, w hich w ill activate acid -sensing ion channels
and transient recep tor p otential vanilloid recep tors, w hich in
tu rn lead s to the antid rom ic release of m u ltip le sensitizing
chem icals (Dom m erholt 2011). Qeram a et al (2004) fou nd
higher p ain intensity and p ain characteristics sim ilar to m u scle
TrPs w hen noxiou s stim u li w ere ap p lied to m otor end -p late
regions, com p ared w ith silent m uscle sites. Further, end -plate
noise and end -p late sp ikes (EMG signals from d ysfu nctional
m otor end -p late regions) have been signi cantly associated
w ith m uscle TrPs in both hu m an and anim al stu d ies (Chen
et al 1998a; H ong & Yu 1998; Cou pp é et al 2001; Sim ons 2001;
Ku an et al 2002; Macgregor et al 2006; Chang et al 2008). Find -
ings from these stu d ies support the theory that TrPs are su b-
sequ ently associated w ith d ysfu nctional m otor end p lates
(Sim ons et al 2002). Althou gh there is evid ence to sup port the
integrated hypothesis as an aetiological p athogenesis of TrPs,
the hyp othesis still has som e w eak links that need to be
ad d ressed in fu ture stu d ies to solid ify the theoretical fou nd a-
tions fu rther. As new research is p u blished , the hyp othesis of
the form ation of TrPs is becom ing increasingly com p lex
(Gerw in 2005; Dom m erholt et al 2006; McPartland & Sim ons
2006; Bron & Dom m erholt 2012). Ad d itionally, although
cu rrent evid ence su p p orts the theory that d ysfu nctional m otor
end plates are clearly associated w ith TrPs, p relim inary evi-
d ence su ggests that m u scle spind les m ay also be involved in
this com p lex p rocess (Ge et al 2009).
Exploration o Trigger Points Related to
Upper Quadrant Pain Syndromes
Clinical history, exam ination of active and p assive m ovem ent
p atterns, qu ality and area of p ain and sym p tom s, and consid -
eration of referred pain patterns assist clinicians in d eterm in-
ing w hich m u scles m ay be clinically relevant for up per
qu ad rant p ain synd rom es. There are cu rrently no laboratory
or im aging tests available that can con rm the p resence of
TrPs; how ever, new em erging im aging techniqu es are p rom is-
ing (Sikd ar et al 2009).
TrP p alp ation starts w ith the id enti cation of a tau t band
w ithin the skeletal m uscle by p alpating perpend icular to the
bre d irection. Patients m ay be asked to contract the m u scle
so as to locate the bres better. Mu scles m ay be p laced in a
relaxed or slightly pre-stretched position for p alpation,
d ep end ing on the patient’s clinical presentation. Once the tau t
band is located , a hypersensitive spot w ithin that band is
id enti ed , w hich by d e nition is a TrP. If the exam iner m anu -
ally strum s the tau t band , a local tw itch response (LTR) can
be elicited , w hich is a sud d en involuntary contraction of the
tau t band . The LTR and referred p ain increase the certainty
of the TrP d iagnosis. Clinicians shou ld be w ary of p recon-
ceived exp ectations of the location and referred p ain p atterns
of TrPs, althou gh m ost textbooks w ill u se som e kind of stand -
ard m arks for d id actic purp oses.
TrP can be id enti ed throu gh (a) at p alp ation, in w hich
the therap ist ap p lies nger or thu m b p ressu re to the m u scle
against und erlying bone tissue (Fig. 59.1), and (b) pincer pal-
pation, w here the m uscle is rolled betw een the tips of the
d igits (Fig. 59.2). In the follow ing section, w e w ill d escribe the
m u scles m ost com m only involved in the genesis of u p p er
qu ad rant p ain synd rom es.
Neck–shoulder muscles
There are several neck–shou ld er m u scles (i.e. the u pp er tra-
p eziu s, sternocleid om astoid , levator scap u lae, rhom boid ,
serratu s p osterior su p erior, sp leniu s cap itis and sp leniu s
cervicis) from w hich TrP-referred p ain can contribu te to arm
p ain synd rom es (Sku bick et al 1993; Sim ons et al 1999).
For instance, Fernánd ez-d e-las-Peñas et al (2007a) d em on-
strated that the referred p ain elicited by the u p p er trap eziu s,
 Exploration of trigger points related to upper quadrant pain syndromes
Figure 59.1 Flat palpation o a taut band within the extensor wrist muscles.
Figure 59.2 Pincer palpation o a taut band within the biceps brachii muscle.
sternocleid om astoid , su boccip ital and levator scap u lae TrPs
reprod uced the p ain pattern in p atients w ith id iopathic
neck p ain. The referred p ain from these m u scles often sp read s
to the head and the neck, for instance the u p p er trap eziu s
(Fernánd ez-d e-las-Peñas et al 2007b) or sternocleid om astoid
(Fernánd ez-d e-las-Peñas et al 2006) in ind ivid uals w ith
chronic tension-typ e head ache. The levator scap u lae and
rhom boid TrPs refer pain to the angle of the neck, along the
vertebral bord er of the scap u la bone and to the p osterior p art
of the shou ld er (Sim ons et al 1999). Read ers are referred to
other texts for the exp loration of neck–shou ld er m u scles from
w hich TrPs refer pain to the head and the neck (Sim ons et al
1999; Gerw in 2005; Fernánd ez-d e-las-Peñas et al 2009c).
Scalene muscles
TrPs m ay be located in either the anterior, m ed ial or p osterior
scalene m u scle. The referred p ain sp read s anteriorly to the
chest (over the p ectoral region), to the anterior shou ld er
663
Figure 59.3 Re erred pain elicited by myo ascial trigger points in the scalene
muscle.
area, to the lateral (rad ial) bord er of the u pp er extrem ity
reaching the thu m b and / or ind ex nger, and posteriorly to
the m ed ial scap u lar bord er and interscap u lar region (Fig.
59.3). Spanos (2005) suggested that scalene m u scle TrPs are
one of the m ost ignored cau ses of interscap u lar d orsal p ain.
Active TrPs w ithin the scalene m u scle have been fou nd in
p atients w ith m echanical neck p ain (Mu ñoz-Mu ñoz et al
2012), w hiplash neck p ain (Fernánd ez-Pérez et al 2012), non-
sp eci c arm p ain (Fernánd ez-d e-las-Peñas et al 2012), breast
cancer (Fernánd ez-Lao et al 2010) and brom yalgia (Alonso-
Blanco et al 2011). Fu rther, since the brachial p lexu s anatom i-
cally ru ns betw een the anterior and the m ed ial scalene
m u scles, TrPs in either scalene m u scle m ay be related to
entrapm ent of peripheral nerves (Chen et al 1998a), contribut-
ing to d ifferent arm p ain synd rom es, for exam ple carpal
tu nnel synd rom e (Sim ons et al 1999) and thoracic ou tlet syn-
d rom e (Fergu son & Gerw in 2005). In ad d ition, shortening of
these m u scles ind u ced by TrP tau t band s m ay be related to
u p w ard d ysfu nctions of the rst rib (Fergu son & Gerw in
2005). It seem s that scalene m u scle TrPs can have repercu s-
sions in both neu ral and joint tissu es in u p p er qu ad rant p ain
synd rom es.
Pectoralis minor muscle
The pectoralis m inor m u scle pu lls the coracoid process ante-
rior and d ow nw ard s, prod u cing a protracted shou ld er p osi-
tion (Fergu son & Gerw in 2005). TrPs w ithin the pectoralis
m inor m u scle refer p ain to the anterior p art of the chest, the
anterior p art of the shou ld er (coracoid p rocess) and u sually
to the u lnar asp ect of the arm and forearm (Fig. 59.4). Law son
et al (2011) d em onstrated that active TrPs in the pectoralis
m inor m u scle cou ld m im ic angina sym p tom s. In ad d ition,
since the brachial p lexu s ru ns anatom ically u nd er the p ecto-
ralis m inor m uscle, an increased tension of this m u scle can
trap the low er trunk (C7–C8 nerve tru nks) of the brachial
p lexu s, resu lting in an u lnar rad icu lop athy (Sim ons 1991;
Vem u ri et al 2013). Langley (1997) su ggested that patients
exhibiting sym ptom s of brachial p lexu s irritation and other
com p ression neu rop athies shou ld be exam ined for the
 664 PART 10 • 59 •
Figure 59.4 Re erred pain elicited by myo ascial trigger points in the pectoralis
minor muscle.
Figure 59.5 Re erred pain elicited by myo ascial trigger points in the
supraspinatus muscle.
p resence of TrPs w ithin the p ectoralis m inor m u scle. H ong
and Sim ons (1993) d em onstrated that p atients w ith chronic
w hip lash exhibit active TrPs in the p ectoralis m inor reprod uc-
ing their arm p ain sym p tom atology.
Supraspinatus muscle
The sup raspinatu s m u scle assists abd u ction of the arm and
stabilization of the hu m eral head d u ring arm m ovem ents.
Stability p revents su p erior translation of the hu m eral head
and is accom p lished throu gh com p ressive forces applied to
the convex hu m eral head into the concave glenoid fossa. TrPs
w ithin the su praspinatus m uscle elicit a referred pain that is
felt as d eep pain in and around the shou ld er, particularly
over the m id -d eltoid region. Deep p ain over the m id -d eltoid
area m ay be m istaken for subd eltoid bu rsitis (Sim ons et al
1999). The referred pain m ay also spread d ow n to the arm
and the forearm , and som etim es over the lateral epicond yle
(Fig. 59.5).
Referred pain from myofascial trigger points
Figure 59.6 Re erred pain elicited by myo ascial trigger points in the
in raspinatus muscle.
Active TrPs in the su praspinatus m uscle have been found
in patients w ith should er im pingem ent (H id algo-Lozano
et al 2010), shou ld er pain (Bron et al 2011) and non-speci c
arm pain (Fernánd ez-d e-las-Peñas et al 2012). Jacobson et al
(1989) reported that repetitive strain inju ry over the should er
joint m ay be a p recipitating factor for su prasp inatu s TrPs.
Chaitow and Delany (2008) su ggested that su prasp inatu s TrPs
m ay lead to im balance or d ysfu nction of this m u scle, ind u cing
non-p rop er fu nctioning of the hu m eral head stabilization
d u ring arm elevations. This situation could lead to a com pres-
sion of su p rasp inatu s tend on against the acrom ion (Chaitow
& Delany 2008). Em p irically, TrPs in the supraspinatus m u scle
can contribu te to m u scle im balances observed in ind ivid u als
w ith su bacrom ial pain synd rom e.
Srbely et al (2008) reported that treatm ent of the infrasp-
inatu s TrPs red u ced the sensitivity of the su praspinatus TrP,
w hich probably occu rs becau se both m uscles receive their
innervation from the su p rascapu lar nerve (C5 nerve root).
This stud y sup ported the su ggestion that all scapu lar gird le
m u scles m ay contribu te to sym p tom s of shou ld er / arm p ain.
In raspinatus muscle
The infraspinatus m uscle assists external rotation of the arm
and stabilization of the hu m eral head d u ring arm m ovem ents.
Sim ons et al (1999) su ggested that TrPs in the infrasp inatu s
m u scle m ay be am ong the m ost ignored cau ses of shou ld er
and arm pain. Lu cas et al (2004) fou nd that the presence of
latent TrPs w ithin the infrasp inatu s m uscle ind uced early acti-
vation of the m u scle, althou gh the au thors recognized that the
grou p m u scle activation pattern w as inconsistent in that
stu d y.
The referred pain from this m uscle is perceived as d eep
joint pain in the anterior part of the shou ld er area and d ow n-
w ard s to the anterior–lateral (rad ial) aspect of the arm ,
forearm and ngers (Fig. 59.6). Infraspinatu s m u scle TrPs can
ind u ce restriction of shou ld er internal rotation (Sim ons et al
1999). Bron et al (2007) fou nd that infrasp inatu s m u scle TrPs
show ed a better inter-rater reliability (p air-w ise agreem ent
69–80%) than either the bicep s or the d eltoid m u scles.
 Exploration of trigger points related to upper quadrant pain syndromes
Qeram a et al (2009) d em onstrated that 49% of su bjects w ith
norm al electrop hysiological nd ings of the m ed ian nerve, bu t
sym p tom s m im icking carp al tu nnel synd rom e, p resented
w ith active TrP in the infrasp inatu s m u scle associated w ith
p araesthesia and referred p ain to the arm and ngers. In the
sam e stu d y, p atients w ith m ild electrop hysiological signs of
carp al tu nnel synd rom e show ed a signi cantly higher occu r-
rence of infraspinatu s m u scle TrPs w ithin the sym ptom atic
arm , com p ared w ith p atients w ith m od erate to severe electro-
p hysiological signs (33% versu s 20%).
Ge et al (2008a) fou nd m u ltiple, rather than single, active
TrPs in the infrasp inatu s m u scle on the p ainfu l sid e in p atients
w ith shou ld er–arm p ain, w ith the m ajority of TrPs located in
the m id - bre region of the m u scle belly. Active TrPs in the
infraspinatu s m u scle have also been fou nd in subjects w ith
shou ld er im p ingem ent (H id algo-Lozano et al 2010), shou ld er
p ain (Bron et al 2011) and non-speci c arm pain (Fernánd ez-
d e-las-Peñas et al 2012). Ohm ori et al (2013) recently rep orted
that TrPs in the su p rasp inatu s and infrasp inatu s m u scles con-
tribu ted to shou ld er p ain w ith ip silateral u p p er extrem ity
elevation after m u scle-sparing thoracotom y.
H ong (1994) su ggested that infrasp inatu s m u scle TrPs m ay
be consid ered as p rim ary (key) TrPs of d eltoid m uscle TrPs.
H sieh et al (2007) con rm ed that treating infraspinatus TrPs
can inactivate TrPs in the anterior d eltoid m u scle, w hereas
other au thors have observed electrom yograp hically that
infraspinatu s TrPs can inhibit use of the anterior d eltoid
m u scle, w ith fu ll fu nctional recovery after inactivation of
these TrP. Infrasp inatu s TrPs are the m ost im p ortant TrPs to
consid er in p atients w ith u p p er qu ad rant p ain synd rom es,
p articu larly scap u lar gird le p ain.
Teres minor and major muscles
TrPs in the teres m inor m u scle elicit referred p ain in the
posterior p art of the d eltoid region, m im icking a ‘painful bu r-
sitis’ in the p osterior p art of the shou ld er joint (Escobar &
Ballesteros 1988) (Fig. 59.7A). TrPs w ithin the teres m ajor refer
pain to the p osterior d eltoid area and shou ld er joint, w hich
A B
Figure 59.7 Re erred pain elicited by myo ascial trigger points in the teres
minor (A) and major (B) muscles.
665
can occasionally sp read to the d orsal forearm (Fig 59.7B).
Active TrPs in the teres m inor and m ajor m uscles have been
fou nd in p atients w ith non-speci c shou ld er p ain (Bron
et al 2011).
Subscapularis muscle
Su bscap u laris TrPs cau se severe p ain at rest and d u ring
m otion. The referred p ain sp read s to the p osterior asp ect of
the shou ld er joint and the scap u la, extend ing d ow n to the
p osterior asp ect of the arm and the volar su rface of the w rist
(Fig. 59.8). The insertion of the subscapu laris tend on is u su ally
d escribed on the lesser tuberosity of the hu m eru s; how ever,
it seem s that this m uscle also expand s its insertion to the
anterior part of the shou ld er joint (Cash et al 2009). In ad d i-
tion, the su bscap u laris m u scle has a d estabilizing inferior
shear p otential over the shou ld er joint (Ackland & Pand y
2009). Therefore, shortening of this m uscle m ay be im plicated
in shou ld er retraction p athologies su ch as the ‘frozen shoul-
d er ’ (Sim ons et al 1999; Ferguson & Gerw in 2005); Jankovic
and Van Zu nd ert (2006) rep orted that ve p atients w ith frozen
shou ld er synd rom e exp erienced p ain relief after injections
into TrPs in the subscapu laris m u scle. This m uscle is one of
the m ost com m only involved m u scles in shou ld er d ysfu nc-
tion and p ain synd rom es and , as it serves as an antagonist to
m ost of the other shou ld er joint stabilizers, its d ysfu nction
encou rages the d evelopm ent of TrPs in other m u sculature. In
fact, TrPs in the su bscapu laris m uscle have been fou nd to be
involved in elite sw im m ers w ith shou ld er pain (H id algo-
Lozano et al 2013). Therefore, this m uscle should not be over-
looked in TrP exam ination, w hich d oes requ ire consid erable
m anu al skill.
Pectoralis major muscle
Shortening of the p ectoralis m ajor m u scle has been linked
clinically to the u p p er cross synd rom e (Jand a 1996). TrPs
w ithin the pectoralis m ajor m u scle refer pain particularly to
the anterior p art of the chest and to the u lnar asp ect of the
arm (Fig. 59.9). Active TrPs in the pectoralis m ajor m u scle
have been stu d ied in d ifferent p op u lations and w ere fou nd to
reprod uce non-speci c arm pain in blu e-collar and w hite-
collar w orkers (Fernánd ez-d e-las-Peñas et al 2012), as w ell as
in w om en w ith brom yalgia (Alonso-Blanco et al 2011). The
Figure 59.8 Re erred pain elicited by myo ascial trigger points in the
subscapularis muscle.
 666 PART 10 • 59 •
referred pain from the left pectoralis m ajor m uscle m ay sim u -
late angina p ectoris (Sim ons et al 1999). Fu rther, it is conceiv-
able that angina p ectoris m ay be a precip itating factor for
activation of p ectoralis m ajor TrPs. In fact, ind ivid u als w ith
know n or suspected angina p ectoris u su ally p resent w ith pain
and tend erness in this m u scle (Ku m arathu rai et al 2008).
Rinzler and Travell (1948) reported that patients w ith pain
com p laints of coronary insu f ciency w ith no history or
evid ence of card iac d isease are often af icted w ith active
p ectoralis m ajor TrPs. Som e stu d ies have fou nd that post-
m astectom y p ain is also related to active TrPs in the p ectoralis
m ajor, latissim u s d orsi and serratu s anterior m u scles (Fernán-
d ez-Lao et al 2010; Torres Lacom ba et al 2010). Active TrPs in
the right p ectoralis m ajor have also been d escribed in p atients
w ith tachycard ia (Sim ons et al 1999).
Deltoid muscle
The d eltoid is a m uscle that com m only d evelops TrPs in any
of its bellies (anterior, m id d le or p osterior). The m id d le and
Figure 59.9 Re erred pain elicited by myo ascial trigger points in the pectoralis
major muscle.
A B C
Referred pain from myofascial trigger points
anterior parts of this m u scle can contribute signi cantly to
su p erior shear forces of the hu m eral head (Ackland & Pand y
2009); therefore, d eltoid m u scle TrPs m ay contribu te to shoul-
d er m u scle im balance (Sim ons et al 1999). Ibarra et al (2011)
fou nd that the presence of latent TrPs in the posterior d eltoid
m u scle red u ced antagonist recip rocal inhibition d u ring arm
elevation. TrPs in the d eltoid m u scle could contribute to a
d elayed and incom plete m uscle relaxation follow ing exercise,
d isord ered ne m ovem ent control and unbalanced m otor
activation of the should er gird le com plex. Deltoid TrPs typ i-
cally refer a bu rning and d eep p ain to the region w here the
m u scle is located : (a) TrPs in the anterior p art of the d eltoid
refer pain to the anterior and m id d le should er regions (Fig.
59.10A), (b) TrPs in the m id d le part of the m u scle refer pain
over the m id d le and p osterior areas (Fig. 59.10B) and (c) TrPs
in the posterior part refer p ain to the posterior area of the
shou ld er (Fig. 59.10C). H su eh et al (1998) reported that C5–C6
d isc lesions w ere associated w ith active TrPs in the d eltoid
m u scle, su ggesting the clinical relevance of assessing cervical
segm ents related to the innervation of the affected m u scle.
Biceps brachii muscle
The referred p ain elicited by TrPs in the biceps brachii m u scle
sp read s u p the m u scle into the anterior region of the shou ld er.
Referred p ain in the region of the bicep s tend on can be m is-
d iagnosed as bicipital tend onitis (Sim ons et al 1999). The
referred pain can also spread d ow n the m u scle to the anterior
area of the elbow region (Fig. 59.11). It is im portant to note
that the m ed ian nerve ru ns anatom ically m ed ial to the m u scle
belly of the biceps brachii (Maed a et al 2009). Therefore,
tension ind u ced by TrP tau t band s or abnorm al m u scle band s
(Paraskevas et al 2008) located over the biceps brachii m uscle
m ay lead to m ed ian nerve tension.
Triceps brachii muscle
As the rad ial nerve ru ns d eep to the lateral head of the triceps
m u scle (Rezzou k et al 2002), TrPs in this m u scle m ay contrib-
u te to rad ial nerve entrap m ent (Sim ons et al 1999). TrPs can
be located in any of the head s of this m u scle: (a) TrPs w ithin
Figure 59.10 Re erred pain elicited by myo ascial
trigger points in the anterior (A), middle (B) and
posterior (C) deltoid muscle.
 Exploration of trigger points related to upper quadrant pain syndromes
the long head of the m u scle refer p ain u p w ard s to the p oste-
rior area of the shou ld er joint, spread ing occasionally to the
u p p er trap eziu s region, and som etim es d ow n the d orsu m of
the forearm , skip p ing the elbow (Fig. 59.12A, right arm ); (b)
TrPs over the lateral head of the m u scle refer p ain to the p os-
terior p art of the arm , som etim es sp read ing to the d orsu m of
the forearm or the fou rth and fth d igits (Fig. 59.12B, right
arm ); (c) the referred p ain elicited by TrPs w ithin the m ed ial
head of the m u scle is p rojected to the lateral ep icond yle and
to the olecranon p rocess (Fig. 59.12B, left arm ). Janssens (1991)
fou nd , in a stu d y w ith d ogs, that treatm ent of TrPs in the
tricep s brachii m u scle w as critical for the recovery of norm al
w alking and ru nning.
Brachioradialis muscle
The brachiorad ialis is an elbow exor m uscle w ith the forearm
in neutral position ind ucing sym ptom s in the forearm or
w rist (Sim ons et al 1999). A recent case report d em onstrated
that the rad ial nerve cou ld becom e trap p ed at the hu m eral
origin of the brachiorad ialis m u scle (Cherchel et al 2013).
Figure 59.11 Re erred pain elicited by myo ascial trigger points in the biceps
brachii muscle.
A B
667
Brachiorad ialis TrPs project their referred pain to the lateral
ep icond yle, the rad ial aspect of the forearm , the w rist and the
base of the thum b, in the w eb betw een the thu m b and ind ex
nger (Fig. 59.13). Referred pain from TrPs in this m u scle can
m im ic d e Qu ervain’s synd rom e. Som e stu d ies have observed
that the brachiorad ialis m u scle w as m ore irritable than other
elbow m u scles, ow ing to the presence of latent TrPs in both
child ren (H an et al 2012) and ad u lts (Kao et al 2007).
Fernánd ez-Carnero et al (2007) found that 50% of p atients
w ith u nilateral lateral ep icond ylalgia show ed active TrPs
w ithin the brachiorad ialis m uscle, w hich su pports its role in
this p ain cond ition. Finally, shortening of the brachiorad ialis
m ay cau se an entrap m ent of the rad ial nerve (Mekhail
et al 1999).
Supinator muscle
The su pinator m uscle is extrem ely im p ortant for a properly
functioning elbow joint. It is know n that the rad ial nerve
crosses the brou s arch of the su p inator m u scle, called the
arcad e of Frohse, the m ain region of entrapm ent of this nerve
(Tatar et al 2009; Tubbs et al 2013). Therefore, m u scle tension
ind u ced by TrP tau t band s in this m u scle can trap the rad ial
nerve, p articu larly its m otor branch (p osterior interosseu s)
(Sim ons et al 1999; Schneid er 2005). TrPs in the sup inator
m u scle refer p ain to the lateral ep icond yle, the lateral area of
the elbow, and som etim es can p roject sp illover p ain to the
d orsal aspect of the w eb of the thu m b (Fig. 59.14).
Sim ons et al (1999) su ggested that su pinator m u scle TrPs
sim u late sym p tom s exp erienced by ind ivid u als w ith lateral
ep icond ylalgia. Slater et al (2003) con rm ed that hyp ertonic
saline injected into the su p inator m u scle sim u lated sensory
and m otor m anifestations of lateral ep icond ylalgia patients.
In a su bsequent stu d y, Slater et al (2005) fou nd that the injec-
tion of hyp ertonic saline into the su p inator m u scle in p atients
w ith lateral epicond ylalgia increased the referred p ain areas
and m otor d istu rbances.
Wrist / hand extensor muscles
The w rist extensor m uscu lature is located over the rad ial
aspect of the forearm . These m u scles have com p lex
Figure 59.12 Re erred pain elicited by myo ascial trigger
points in the triceps brachii muscle.
 668 PART 10 • 59 •
agonist–antagonist fu nction, w hich m akes them vu lnerable
for repetitive strain and overload situ ations. For instance, the
extensor carpi rad ialis longu s m u scle ind u ces w rist extension
and rad ial d eviation and the extensor carp i ulnaris m u scle
exerts w rist extension and u lnar d eviation (Livingston et al
2001). Chen et al (2000) found that piano stu d ents exhibited
signi cantly d ecreased p ressu re threshold s over latent TrPs in
the w rist extensor m u scles after only 20 m inu tes of piano
p laying. Latent TrPs m ay transition into active TrPs and com -
p rom ise m otor fu nction. The w rist extensor m uscu latu re is
innervated by the d eep branch of the rad ial nerve (p osterior
interosseou s nerve). The rad ial nerve m ay becom e trap p ed in
the su p erior–lateral asp ect of the extensor carp i rad ialis brevis
m u scle (Clavert et al 2009; Cho et al 2013).
In general, referred pain p atterns elicited by w rist extensor
m u scle TrPs sp read u p w ard s to the lateral ep icond yle and
d ow nw ard s along the m u scle belly tow ard s their insertion in
the w rist / hand : (a) TrPs in the extensor carpi radialis longus
m u scle refer p ain to the lateral ep icond yle and to the d orsu m
Figure 59.13 Re erred pain elicited by myo ascial trigger points in the
brachioradialis muscle.
A B C D
Referred pain from myofascial trigger points
of the hand next to the thu m b (Fig. 59.15A), (b) TrPs in the
extensor carpi radialis brevis m u scle p roject pain to the rad ial
and posterior aspects of the hand and the w rist (Fig. 59.15B),
(c) extensor digitorum communis TrPs refer p ain d ow nw ard s
to the forearm , reaching the sam e d igit that the bres activate
(Fig. 59.15C), and (d ) referred pain from the extensor carpi
ulnaris muscle TrPs is p erceived on the u lnar sid e of the back
of the w rist (Fig. 59.15D).
Fernánd ez-Carnero et al (2007) fou nd that active TrPs
w ithin these m uscles (65% extensor carp i rad ialis brevis, 55%
extensor carpi rad ialis longu s and 25% extensor d igitoru m
com m u nis) rep rod u ced the p ain p attern exp erienced by ind i-
vid u als w ith lateral ep icond ylalgia. Interestingly, these sam e
m u scles d evelop ed latent TrPs on the non-sym p tom atic sid e
in ind ivid uals w ith unilateral elbow pain (Fernánd ez-Carnero
et al 2008). It is rem arkable to note that the extensor carpi
rad ialis brevis, the m uscle m ost affected by active TrPs in
su bjects w ith lateral ep icond ylalgia, seem s to be the m ost
relevant for tend on changes in elbow p ain (Ljung et al 1999).
Therefore, clinicians should exam ine the w rist extensor
m u scles in p atients w ith lateral ep icond ylalgia.
Figure 59.14 Re erred pain elicited by myo ascial trigger points in the
supinator muscle.
Figure 59.15 Re erred pain elicited by myo ascial
trigger points in the extensor carpi radialis longus (A),
extensor carpi radialis brevis (B), the extensor digitorum
communis (C) and extensor carpi ulnaris (D) muscles.
 Exploration of trigger points related to upper quadrant pain syndromes 669

A B C
Figure 59.16 Re erred pain elicited by myo ascial trigger points in the pronator
teres muscle. Figure 59.17 Re erred pain elicited by myo ascial trigger points in the
exor carpi radialis (A), palmaris longus (B) and exor carpi ulnaris
(C) muscles.

Pronator teres muscle

The pronator teres m u scle is the m ain pronator of the forearm .
The m ed ian nerve passes betw een the tw o head s of the prona-
tor teres m u scle, m aking this m u scle a com m on entrap m ent
region of the nerve (Bilecenoglu et al 2005; Dem irci et al 2007).
An entrapm ent of the m ed ian nerve in the p ronator teres
m u scle is know n as p ronator synd rom e (Lee & LaStayo 2004).
Tension ind u ced by TrP tau t band s in this m u scle m ay be
relevant for sym p tom s associated w ith m ed ian nerve com -
pression (Sim ons et al 1999). Pronator teres TrPs refer p ain
d ow nw ard s to the forearm and the volar rad ial region of
the w rist (Fig. 59.16). H ains et al (2010) found that com p res-
sion at TrPs located in the p ronator teres m u scle w as effective
for red ucing sym ptom s in patients w ith carpal tu nnel
synd rom e.

Wrist / hand exor muscles

The w rist exor m uscu latu re has a sim ilar com p lex agonist–
antagonist fu nction as the w rist extensors. For instance, the
exor carpi rad ialis ind uces w rist exion and rad ial d eviation,
w hereas the exor carpi ulnaris m u scle exerts w rist exion
and u lnar d eviation. In general, referred pain patterns elicited
from w rist exor m u scle TrPs u su ally spread d ow nw ard s
along the m u scle belly tow ard s their insertion in the w rist: (a)
TrPs in the exor carpi radialis refer p ain to the volar asp ect
of the w rist (Fig. 59.17A); (b) palmaris longus muscle TrPs
project sup er cial, need le-like pain over the volar area of the
palm (Fig. 59.17B), thou gh the palm aris longus m u scle is not
present in all subjects; (c) referred p ain from the exor carpi
ulnaris muscle TrPs is p erceived in the u lnar sid e of the volar
asp ect of the w rist (Fig. 59.17C). Finally, no easy d istinction
can be m ad e betw een referred p ain p atterns of the exors
digitorum super cialis and those of the profundus m u scles
(Sim ons et al 1999) as, in these m u scles, TrPs w ill refer pain
to the sam e d igit that the bres activate (Fig. 59.18). For
instance, TrPs in the bres of the m id d le nger exor m uscle
Figure 59.18 Re erred pain elicited by myo ascial trigger points in the exors
digitorum superf cialis and pro undus muscles.
refer pain throu gh the length of the m id d le nger, sim ilarly
to the extensor d igitoru m com m u nis m u scle.
Wrist exor m u scles are innervated by the m ed ian and
u lnar nerves. Du e to their anatom ical relationship s, the
m ed ian nerve can becom e trap p ed by the exor d igitoru m
p rofu nd u s and su p er cialis m u scles, w hereas the u lnar
nerve can becom e trap p ed by the exor carp i u lnaris and
exor d igitorum profu nd us m u scles (Chaitow & Delany
2008; Pap pas et al 2010). Clinicians should exam ine and treat
TrPs in this m u scu latu re in p atients w ith p ain sym p tom s
in either u lnar or m ed ian nerve territories, for exam p le
carp al tu nnel synd rom e or u lnar neu rop athy (Ferguson &
Gerw in 2005).
 670 PART 10 • 59 • Referred pain from myofascial trigger points

Other muscles o the upper quadrant

Finally, clinicians shou ld be aw are that there is a greater
nu m ber of m u scle TrPs w ith their ow n sp eci c referred p ain
p atterns contribu ting to u p per qu ad rant pain synd rom es. For
exam ple, the brachialis, coracobrachialis, latissim u s d orsi, ser-
ratu s anterior and su bclaviu s m uscles also refer p ain to the
arm or the forearm (Sim ons et al 1999). Several stu d ies have
d escribed referred pain from other m u scles, su ch as the pro-
nator qu ad ratu s (H w ang et al 2005a) or the abd u ctor p ollicis
longu s (H w ang et al 2005b), w hich w ere includ ed in the com -
p rehensive book by Sim ons et al (1999). In this chap ter w e
have also not inclu d ed any hand m u scu latu re, su ch as the
exor pollicis longu s, ad d uctor pollicis, abd u ctor pollicis,
op p onens p ollicis, thu m b exor or interosseou s m u scles,
w hich also can be involved in hand pain synd rom es (Sim ons Figure 59.19 Re erred pain elicited by myo ascial trigger points in the
et al 1999). quadratus lumborum muscle.

Exploration o Trigger Points Related to

Lower Quadrant Pain Syndromes
The clinical exam ination of TrPs in p atients w ith low er quad -
rant synd rom es, particularly those w ith low back p ain, can be
com p lex. There is a consid erable overlap of referred p ain p at-
terns and , becau se m any of the m u scles are d eep , p alp ation
of the tau t band and the ability to elicit a local tw itch resp onse
are m ore d if cu lt. Clinicians shou ld be w ary of preconceived
expectations of the location and referred pain patterns of TrPs,
although m ost textbooks u se som e kind of stand ard m arks for
d id actic purp oses. In this section, w e w ill d escribe the m u scles
m ost com m only involved in the genesis of low er qu ad rant
p ain synd rom es.

Quadratus lumborum muscle
The quad ratu s lum boru m m u scle is the m ain stabilizer of the
tw elfth rib and the low er attachm ents of the d iap hragm . It
assists w ith insp iration, bu t its m ain role is related to m ove-
m ent of the sp ine. When the m u scle contracts u nilaterally, it
controls contralateral sid e-bend ing (eccentric contraction)
and it p erform s ipsilateral sid e-bend ing of the spine (w hen
the p elvis is xed ). When acting bilaterally, it assists w ith
facilitation of spine extension. The referred p ain can spread
to the iliac crest, the greater trochanter, the lateral thigh, the
low er p ortion of the abd om en, the sacroiliac joint, the low er
bu ttock (Fig. 59.19) and , som etim es, to the groin, labia and
testicles.
Several stu d ies have d em onstrated that active TrPs in the
qu ad ratu s lu m boru m m u scle are p resent in p atients w ith low
back pain. Teixera et al (2011) id enti ed that active TrPs
w ithin the quad ratu s lu m borum and glu teus m ed iu s m u scles
w ere p resent in 85.7% of p atients w ith post-lam inectom y pain
synd rom e. Chen and N izar (2011) fou nd that 63.5% of p atients
w ith chronic back pain exhibited TrPs in the piriform is and
qu ad ratu s lu m boru m m u scles, and these p atients exp erienced
a favou rable outcom e follow ing TrP-d ry-need ling interven-
tion. A recent stu d y (Iglesias-González et al 2013) supp orted
the role of active TrPs in non-sp eci c low back p ain, as the
p resence of TrPs in the qu ad ratus lu m boru m , iliocostalis lu m -
borum and glu teus m ed ius m uscles w as associated w ith
Figure 59.20 Re erred pain elicited by myo ascial trigger points in the
iliopsoas muscle.
higher p ain intensity and w orse sleep qu ality. It is p ossible
that the p resence of active TrPs in this m u scle can be related
to the m u scle atrop hy fou nd in p atients w ith d egenerative
d isc d isease (Ploum is et al 2011), or w ith the changes in m otor
control strategies observed in p atients w ith low back p ain
(Park et al 2013).
Psoas major muscle
The psoas m ajor m u scle is one of the m ain stabilizers of the
lum bar spine (Penning 2000). TrPs in the psoas m ajor m u scle
refer pain to the groin area, su perior p art of the thigh and
lum bar spine (Fig. 59.20). This is an im portant m uscle since it
is anatom ically related to several u rogenital stru ctu res and
the lu m bar p lexu s (Step nik et al 2006; Petchp rap a et al 2010).
Entrap m ent of the fem oral nerve in the p soas m ajor m u scle
can ind u ce p aralysis of the qu ad ricep s m u scle (Lefevre et al
2015). Sim ilarly, the lateral fem oral cu taneou s nerve em erges
from the lateral bord er of the psoas and crosses the iliacu s
m u scles before em erging from the p elvis m ed ial to the ante-
rior su perior iliac spine u nd er the ingu inal ligam ent and so
it is especially vu lnerable to injury in this area (Craig
2013). Therefore, taut band s in the psoas m ajor m uscle can
 Exploration of trigger points related to lower quadrant pain syndromes
contribu te to p ossible entrap m ents of the lu m bar p lexu s.
Cu m m ings (2003) d escribed a case w here TrPs in the iliop soas
m u scle rep rod u ced knee p ain sym p tom s.
Patients w ith low back p ain exhibit increased activity
d u ring fu nctional tasks (Arbanas et al 2013) and d ecreased
m u scle size at the lu m bar level (Lee et al 2011) of the p soas
m ajor m u scle. TrPs in this m u scle m ay be also related to the
m u scle activity changes observed in p atients w ith low back
p ain. One of the p roblem s w ith id entifying TrPs in this m u scle
is that it is not easily accessible to prop er palpation, as the
reliability of TrP id enti cation is low (H sieh et al 2000).
Piri ormis muscle
The piriform is m u scle is the m ain stabilizer betw een the
sacru m and the fem u r. The sciatic nerve anatom ically ru ns
d eep to the piriform is; how ever, variations exist and the nerve
m ay exit either above or throu gh the m u scle (N atsis et al
2014). The referred pain travels along the path of the sciatic
nerve, w hich m ay inclu d e the sacroiliac region and the p roxi-
m al tw o-third s of the thigh (Fig. 59.21). Du e to the anatom ical
relationship betw een the sciatic nerve and the p iriform is
m u scle, TrPs in this m u scle m ay be related to entrap m ent of
the nerve, w hich is com m only referred to as p iriform is syn-
d rom e. Piriform is synd rom e continu es to be a som ew hat
Figure 59.21 Re erred pain elicited by myo ascial trigger points in the
piri ormis muscle.
671
controversial d iagnosis for sciatic p ain (Jankovic et al 2013).
Active TrPs in the p iriform is m u scle have been fou nd in
p atients w ith non-sp eci c low back p ain (Iglesias-González
et al 2013) and w ith brom yalgia synd rom e (Alonso-Blanco
et al 2011).
Gluteus medius muscle
The gluteu s m ed iu s is the m ain hip abd uctor and lateral
stabilizer of the p elvis. Insu f ciency of this m u scle resu lts
in a positive Trend elenbu rg test. Burnet and Pid coe (2009)
observed that low er isom etric glu teu s m ed iu s torqu e w as a
p oor p red ictor of frontal p lane p elvic d rop d u ring ru nning.
TrPs in this m u scle m ainly refer p ain to the sacroiliac joint,
glu teal and lum bosacral regions (Fig. 59.22). Since it is not
p ossible to sep arate referred p ain p attern from the glu teu s
m inim u s m u scle in the area w here the tw o m u scles overlap ,
it is likely that glu teus m ed ius TrPs also refer pain to the ili-
otibial tract, the p osterior thigh and p osterior low er leg.
Active TrPs in the glu teu s m ed iu s m u scle have been found
in patients w ith non-speci c low back pain (Iglesias-González
et al 2013), lu m bar d isc prolap se (Sam u el et al 2007) and bro-
m yalgia synd rom e (Ge et al 2011). Sam u el et al (2007) fou nd
that active TrPs in the glu teu s m ed iu s m u scle w ere related to
an L5–S1 d isc prolapse. It is possible that TrPs in this m u scle
are intrinsically related to d isc p rolap ses at the innervation-
related segm ent. Ad d itionally, a recent stud y found that
p atients w ith p atellofem oral p ain synd rom e also exhibited
bilateral TrPs in the glu teus m ed ius m u scle (Roach et al 2013).
Rainey (2013) rep orted that m anagem ent of TrPs in the glu teu s
m ed iu s and m axim u s m u scles w ere effective for a single
p atient w ith chronic low back p ain.
Gluteus minimus muscle
This m u scle is found d eep to the gluteu s m ed ius. It has a
bursa betw een the tend on and its insertion at the greater tro-
chanter (Flack et al 2012). The gluteu s m inim us assists the
glu teus m ed iu s w ith hip abd uction and it is a lateral stabilizer
of the hip . It su p p orts the bod y in single-leg stance w ith the
tensor fascia lata m u scle (Bew yer & Bew yer 2003). Referred
p ain from glu teu s m inim u s m u scle TrPs sp read s to the ilio-
tibial tract, glu teal region, p osterior thigh and p osterior third
of the low er leg (Fig. 59.23). It is not possible to separate its
Figure 59.22 Re erred pain elicited by myo ascial trigger points in
the gluteus medius muscle.
 672 PART 10 • 59 •
Figure 59.23 Re erred pain elicited by myo ascial trigger points in the gluteus
minimus muscle.
referred pain patterns from those of the glu teu s m ed ius
m u scle in the area w here the tw o m u scles overlap .
Quadriceps muscle
This m u scle is form ed by fou r m ain bellies: the rectu s fem oris,
vastu s m ed ialis, vastu s lateralis and vastu s interm ed iu s
m u scles. The m u scles insert at the base of the p atella via the
thick at qu ad ricep s fem oris tend on. The p atellar tend on is a
continu ation of the qu ad ricep s fem oris m ain tend on and con-
nects the m u scle to the tibial tu berosity.
The p rim ary fu nction of the qu ad ricep s m u scle is knee
extension. The rectus fem oris also assists w ith hip exion,
w hereas the vastus lateralis and vastus m ed ialis m uscles play
an im portant role in m aintaining p atella tracking. The referred
p ain elicited by TrPs in the qu ad riceps m u scle sp read s to the
anterior thigh and knee pain (rectus femoris; Fig. 59.24A),
to the lateral sid e of the thigh from the iliac crest to m id w ay
d ow n the low er leg (vastus lateralis), and to the anterior–
m ed ial asp ect of the thigh d ow n to the m ed ial asp ect of the
knee area (vastus medialis; Fig. 59.24B). Active TrPs in any of
these m u scles m ay ind u ce m otor d istu rbances and p ain
in the knee area. H enry et al (2012) rep orted that p atients
w ith knee osteoarthritis aw aiting knee arthroplasty exhibited
TrPs in the vastu s m ed ialis and gastrocnem iu s m u scles. In
ad d ition, H u ang et al (2013) d em onstrated in an anim al m od el
that active TrPs in the vastu s m ed ialis m u scle cou ld be p ro-
voked by rep eated blu nt inju ry. Ad d itionally, active TrPs in
these m u scles can be p resent after knee su rgery (e.g. restora-
tion of anterior cru ciate ligam ent or arthroscop y after a
m eniscectom y).
Adductor muscles
The ad d u ctor grou p includ es the ad d uctor longus, ad d uctor
brevis and ad d u ctor m agnu s m u scles. Their m ain fu nction
is ad d u ction and m ed ial rotation of the thigh as w ell as hip
Referred pain from myofascial trigger points
A B
Figure 59.24 Re erred pain elicited by myo ascial trigger points in the rectus
emoris (A) and vastus medialis (B) muscles.
A B C
Figure 59.25 Re erred pain elicited by myo ascial trigger points in the
adductor longus and brevis (A), adductor magnus (B) and gracilis (C) muscles.
exion w hen the hip is extend ed . TrPs can be located in
any of these m uscles along their m u scle bellies. The referred
p ain extend s from the fem oral triangle to the knee (adductor
longus and brevis; Fig. 59.25A), from the pelvic oor and
genitals to the internal sid e of the leg (adductor magnus; Fig.
59.25B), and along a line w ithin the m ed ial aspect of the thigh
(gracilis; Fig. 59.25C). TrPs from the ad d uctor m u scles can
also refer pain to the intrapelvic area (Longbottom 2009). Kim
et al (2013) have recently d em onstrated that TrP injection of
the hip exors, ad d u ctors and low er abd om inal m u scles
resulted in excellent outcom es relative to groin pain in patients
w ith chronic prostatitis / chronic p elvic pain synd rom e.
Finally, since the obtu rator nerve m erges several m otor and
sensory branches to the ad d u ctor grou p m u scles, this nerve
can becom e trap p ed as it enters the thigh in the ad d u ctor
canal (Craig 2013).
Gastrocnemius and soleus muscles
The gastrocnem iu s and the soleus m uscles insert into the
Achilles tend on, w hich attaches to the posterior surface of the

Figure 59.26 Re erred pain elicited by myo ascial trigger points in the
gastrocnemius muscles.
calcaneu s bone. Their m ain fu nction is p lantar exion and
stabilization of the knee (gastrocnem iu s) and ankle. Most TrPs
in the gastrocnemius muscles refer pain locally d eep in the
leg (Fig. 59.26). TrPs in the belly of the m ed ial head tend to
refer pain to the instep of the foot, som etim es spread ing to the
low er posterior thigh, the back of the knee and the posterior–
m ed ial asp ect of leg and ankle. The soleus muscle refers pain
to the d istal p art of the Achilles tend on and the p osterior and
plantar su rfaces of the heel. TrPs in the p roxim al part of the
gastrocnem ius m u scles are resp onsible for p osterior knee
pain in p atients before (Mayoral et al 2013) and after (H enry
et al 2012) total knee replacem ent su rgery, and after knee
arthroscop y (Rod ríguez et al 2005). These TrPs can also con-
tribu te to calf p ain (Grieve et al 2013). Ind eed , TrPs in the
gastrocnem ius m u scles seem to be im portant contribu tors
to m u scle cram p s (Ge et al 2008b). In a sm all clinical trial,
Prateep avanich et al (1999) d em onstrated that injections of
gastrocnem ius m u scle TrPs resulted in better long-term ef -
cacy on calf cram p s com p ared w ith oral qu inine.
Plantar heel p ain, w hich is often d iagnosed as p lantar fas-
ciitis, can be also related to TrPs in the calf and foot m u scu -
latu re. Several reports have d em onstrated that conservative
treatm ent of TrPs in calf m u scles is u sefu l in the treatm ent of
plantar heel p ain and plantar fasciitis (N gu yen 2010; Renan-
Ord ine et al 2011). Althou gh there is no solid evid ence of the
effectiveness of invasive treatm ents (Cotchett et al 2010),
som e rep orts su ggest that need ling and injections of TrPs in
the calf and foot m u scles can help the m anagem ent of this
cond ition (Im am u ra et al 1998; Ku shner & Fergu son 2005;
Scon enza et al 2011).
Tibialis anterior, extensor digitorum longus
and extensor hallucis longus muscles
These m u scles have their insertion in the anterior–lateral part
of leg betw een the tibia and the bu la. Their com bined m ain
function is ankle d orsal exion and stabilization. Of cou rse,
the extensor m u scles are also resp onsible for extension of the
toes. The extensor hallucis longus brevis m u scle sp read s p ain
to the d istal asp ect of the d orsu m of the rst m etatarsal, som e-
tim es sp read ing d istally to the tip of the great toe (Fig. 59.27A);
Conclusion 673
A B C
Figure 59.27 Re erred pain elicited by myo ascial trigger points in the
extensor hallucis longus brevis (A), tibialis anterior (B) and extensor digitorum
longus (C) muscles.
the tibialis anterior muscle refers pain to the anterior–m ed ial
aspect of the ankle and over the great toe (Fig. 59.27B); the
extensor digitorum longus muscle refers pain to the d orsum
of the foot and toes (Fig. 59.27C).
There is general agreem ent that active TrPs in the tibialis
anterior and intrinsic foot m u scles can contribu te to heel pain
(Cotchett et al 2011). In ad d ition, Sam u el et al (2007) found an
association betw een the presence of TrPs in the m u scles inner-
vated by the corresp ond ing affected segm ental level – for
exam ple L4–L5 d isc lesion and tibialis anterior TrPs – in ind i-
vid u als w ith lu m bar d isc p rolap se.
Other muscles o the lower quadrant
Finally, clinicians shou ld be aw are that there are m any m ore
TrPs w ith referred p ain p atterns contribu ting to low er qu ad -
rant p ain synd rom es. For instance, the glu teu s m axim u s,
tensor fascia lata, bicep s fem oris, sartoriu s, tibialis p osterior,
p eroneu s longu s and intrinsic foot m u scles also refer p ain to
the thigh, knee, leg or foot (Sim ons et al 1999).
Conclusion
In su m m ary, there are num erous m u scles of the neck / upper
extrem ity and the tru nk / low er extrem ity w ith TrPs and spe-
ci c referred p ain p atterns that can contribu te to the initiation
and m aintenance of sym ptom s in several u pp er and low er
qu ad rant p ain synd rom es. Clinicians shou ld exam ine clini-
cally relevant m u scles and TrPs to characterize and m anage
better the variou s upp er and low er qu ad rant pain synd rom es.
Although m u ch progress has been m ad e, fu rther stu d ies are
requ ired in ord er to elu cid ate further the role of m u scle TrPs
in the clinical evolution of these synd rom es.
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 PART 10 •  Soft Tissues in the Upper and Lower Quadrants 

60
Manual Treatment of Myofascial Trigger Points
 Chapter 

C é s a r Fe rn á n d e z - d e - la s - P e ñ a s , J a im e S a lo m - M o re n o , Ho n g -Yo u G e , J a n Do m m e rh o lt

Stretching longitudinal massage of adductor muscle taut bands  687
CHAP TER CONTENTS
Stretching compression of gastrocnemius muscle taut bands  687
Introduction  678 Compression and contraction of anterior–lateral leg muscles  687
Treatment interventions for myofascial trigger points  678 Conclusion  688
Best evidence of manual therapies for myofascial  
trigger points  679
Manual therapies for the management of myofascial  
trigger points  679 Introduction
Compression interventions  679
Massage therapies  680 Treatment interventions for myofascial
Stretching interventions  680 trigger points
Dynamic interventions  680
Clinical applications of manual therapies over myofascial TrPs  681 In clinical practice, there are several intervention m od alities
Stretching compression of levator scapulae muscle   aim ed at elim inating m yofascial trigger p oints (TrPs): d ry
taut band  681 need ling therap ies (Cu m m ings & White 2001; Dom m erholt
Longitudinal strokes of scalene muscle taut band  681 et al 2006a; Tou gh et al 2009; Dom m erholt & Fernánd ez-
Compression and contraction of supraspinatus muscle  681 d e-las-Peñas 2013; Kietrys et al 2013), ultrasound (Gam et al
Stretching strokes of infraspinatus muscle taut band  682 1998; Majlesi & Unalan 2004; Srbely & Dickey 2007; Srbely
et al 2008; Kim et al 2014), therm otherapy (Lee et al 1997),
Stretching longitudinal strokes of infraspinatus muscle  
laser therapy (Pöntinen & Airaksinen 1995; Altan et al
taut band  682
2005; Du nd ar et al 2007; Uem oto et al 2013), electrotherapy
Stretching compression of teres major muscle taut band  682
(Tanriku t et al 2003), m agnetic therapy (Brow n et al 2002;
Stretching compression of subscapularis muscle   Sm ania et al 2005), extracorporeal shockw ave therap y (Gleitz
taut band  683
& H ornig 2012; Jeon et al 2012) and m anual therap ies (Sim ons
Dynamic transverse strokes of deltoid muscle   et al 1999; Lew it 1999). Am ong these interventions, m anu al
trigger points  683 therap ies are the basic treatm ent op tions (Dom m erholt
Dynamic longitudinal strokes of biceps / triceps brachii   et al 2006b).
muscle taut band  683 This chap ter w ill focu s on d ifferent m anu al app roaches
Dynamic longitudinal strokes of hand / wrist extensor   that can be u sed for inactivating m yofascial TrPs. Several
muscle taut band  684 m anu al therap ies are su ggested in the literatu re: m assage
Transverse massage of hand / wrist  exor muscle   (Sim ons et al 1999), ischaem ic com p ression or TrP p ressu re
trigger points  684 release (H ong et al 1993; Sim ons et al 1999; Fryer & H od gson
Stretching compression of thumb muscles taut bands  684 2005; Fernánd ez-d e-las-Peñas et al 2006b; Gem m ell et al 2008;
Transverse massage of quadratus lumborum muscle   Dom m erholt & McEvoy 2011; Bod es-Pard o et al 2013),
taut bands  685 m yofascial ind u ction (Pilat 2009), spray and stretch (Jaeger &
Post-isometric relaxation of quadratus lumborum muscle   Reeves 1986; H ong et al 1993; Sim ons et al 1999), passive
taut bands  685 stretching (H anten et al 2000), m uscle energy or p ost-
Stretching compression of psoas major muscle   isom etric relaxation techniqu es (Lew it 1999; Rod rígu ez-
taut bands  686 Blanco et al 2006; Oliveira-Cam p elo et al 2013), neu rom us cular
Stretching longitudinal stroke / dynamic longitudinal stroke   ap proaches (Ibáñez-García et al 2009), active head retraction–
of gluteus medius muscle taut bands  686 extension (H anten et al 1997), strain / counterstrain
Stretching longitudinal stroke of quadriceps muscle   (Dard zinski et al 2000) and spinal m anipu lation (Ru iz-Sáez
taut bands  687 et al 2007; Fernánd ez-d e-las-Peñas 2009; Srbely et al 2013).
 Manual therapies for the management of myofascial trigger points  679
Best evidence of manual therapies for
myofascial trigger points
The rst system atic review of m anu al therapies in the m an-
agem ent of TrPs fou nd inconclu sive evid ence since few
stu d ies had investigated m anu al therap y ap p roaches for the
m anagem ent of TrPs (Fernánd ez-d e-las-Peñas et al 2005a).
Later stu d ies rep orted that the ischaem ic com p ression
techniqu e is effective in red u cing p ain sensitivity of latent
(Fryer & H ogson 2005) and active (Fernánd ez-d e-las-Peñas
et al 2006b) TrPs. N o signi cant d ifferences w ere found
betw een ischaem ic com pression and transverse friction
m assage in the red u ction of self-p erceived p ain and p ressu re
pain sensitivity over the u p p er trap eziu s m u scle TrPs
(Fernánd ez-d e-las-Peñas et al 2006b). A later system atic
review analysing the effectiveness of non-invasive treatm ents
for active TrPs revealed that there is evid ence of the short-
term effectiveness of m anu al therap ies, bu t no conclu sions
can be m ad e relating to m ed iu m - and long-term follow -
u p s (Rickard s 2006). One stud y not includ ed in these review s
fou nd that neurom u scular approaches w ere also effective
for red u cing pressu re pain sensitivity of latent TrPs (Ibáñez-
García et al 2009). Other stu d ies rep orted im provem ents
in range of m otion after treatm ent w ith ischaem ic com pres-
sion (Fernánd ez-d e-las-Peñas et al 2004) or p ost-isom etric
relaxation technique of latent TrPs in the m asseter m uscle
(Rod rígu ez-Blanco et al 2006; H ered ia-Rizo et al 2013). A su b-
sequ ent review su m m arized m od erately strong evid ence su p -
porting the u se of ischaem ic p ressu re for im m ed iate p ain
relief of TrPs, but only lim ited evid ence for long-term pain
relief (Vernon & Schneid er 2009). A recent m eta-analysis con-
clu d ed that m u scle m anu al therap ies had a favou rable effect
on p ressu re p ain threshold s w hen com p ared w ith no-treatm ent
and sham / inert grou ps and com parable effects w ere also
observed w hen com p ared w ith those of other active treat-
m ents (Gay et al 2013).
Further, there is p relim inary evid ence investigating
changes in m u scle sensitivity after sp inal m anip u lations.
Ru iz-Sáez et al (2007) show ed that a m anipu lation d irected at
the C3–C4 segm ent evoked changes in pressu re p ain sensitiv-
ity of latent TrPs in the up per trapezius m uscle. A recent
stu d y has observed that sp inal m anip u lation evokes short-
term regional increases in p ressu re p ain threshold s w ithin
m yofascial tissu es in healthy you ng ad u lts (Srbely et al
2013). N evertheless, althou gh a clinical relationship betw een
m yofascial TrPs and joint im p airm ents has been su ggested
by som e au thors (Lew it 1999; Fernánd ez-d e-las-Peñas et al
2005b, 2006a; Fernánd ez-d e-las-Peñas 2009), the clinical effects
of sp inal m anip u lations on active TrP sensitivity rem ain
u nclear.
Therefore, it is d if cult to d raw clinical conclu sions from
cu rrent scienti c evid ence as m ost stu d ies had investigated
single m od alities, w hereas m u ltim od al ap p roaches are
u su ally p ractised by m any clinicians. Clinical stu d ies investi-
gating m ultim od al interventions includ ing the treatm ent of
m yofascial TrPs w ith m anu al therap ies are need ed . There
are som e clinical stu d ies d em onstrating the effectiveness of
the inclu sion of m yofascial TrP techniqu es into m u ltim od al
m anu al therap y p rotocol for the m anagem ent of heel p ain
(Renan-Ord ine et al 2011), should er pain (Bron et al 2011),
ankle sp rain (Truyols-Dom íngu ez et al 2013) or chronic pelvic
p ain (And erson et al 2005). The inclusion of m anu al therapies
targeted at inactivating TrPs can p otentiate the therap eu tic
effects of other physical therapy interventions.
Manual Therapies for the
Management of Myofascial
Trigger Points
Compression interventions
There are d ifferent com pression techniqu es d ep end ing on the
am ou nt of pressure ap plied , the d u ration of ap p lication, the
p osition of the tissu e (shortened / lengthened ) and the p res-
ence / absence of pain. In clinical practice, the p ressu re level,
d uration of application and position of the m uscle are d eter-
m ined based on the sensitization m echanism s of the p atient
and the d egree of irritability of the tissu e.
Sim ons (2002) prop osed that com pression of the sarcom -
eres by d irect pressu re in a vertical or perpend icu lar m anner
com bined w ith active contraction of the involved m u scle m ay
equalize the length of the m uscle sarcom eres in the involved
TrP and consequ ently d ecrease the p ain; how ever, this notion
has not been scienti cally investigated (Dom m erholt & Shah
2010). Other au thors have suggested that pain relief from
d irect pressure m ay result from reactive hyperaem ia w ithin
the TrP or a sp inal re ex m echanism for the relief of m u scle
tension (H ou et al 2002).
One of the com p ression techniqu es ap p lied over TrPs is the
so-called ischaemic compression technique (Sim ons et al
1999). In this techniqu e, w ith the m uscle in a lengthened posi-
tion, the therap ist grad u ally ap p lies m anu al p ressu re to the
TrP u ntil the sensation of p ressu re becom es p ainfu l, at w hich
m om ent the p ressu re is m aintained u ntil the d iscom fort / p ain
is eased by arou nd 50–75% as perceived by the p atient u nd er
treatm ent; at that p oint the p ressu re is increased once m ore
u ntil the d iscom fort / p ain reap p ears. This p rocess is u su ally
rep eated for 90 second s (Sim ons et al 1999), w ith tw o or three
repetitions (H ains et al 2010).
Fryer and H od gson (2005) recom m end ed com p ression u p
to 7 / 10 on a N u m erical Pain Rating Scale; how ever, particu -
larly for patients w ith chronic p ain, this level of p ain m ay be
excessive. H ou et al (2002) p rovid ed alternative com p ression
ap proaches using either low p ressu re below the p ain thresh-
old for p rolonged period s (90 second s) or high pressu re above
the pain threshold (p ain tolerance) for a short period (30
second s). In clinical p ractice, the p ressu re level d ep end s on
the m echanism s of p ain sensitization in the ind ivid u al p atient
and the d egree of irritability of the TrP. For instance, in the
case of a high-level athlete, the techniqu e can inclu d e short-
d uration high pressu re, w hereas in a patient d iagnosed w ith
brom yalgia it w ou ld be p referable to u se p rolonged low
p ressu re.
The ischaem ic com pression technique has now been
replaced by the TrP pressure release technique, w hich con-
sists of an ap p lication of p ressu re over the TrP u ntil an
increase in m u scle resistance (tissu e barrier) is perceived by
the therap ist (Lew it 1999). That p ressu re is then m aintained
u ntil the therap ist p erceives a release of the tau t band . At this
stage the p ressu re is increased to retu rn the p atient to the
 680 PART 10 • 60 • Manual treatment of myofascial trigger points
p reviou s level of m u scle tension; the above process is then
rep eated for 90 second s (u sually there are tw o to three repeti-
tions). In m ost p atients the m om ent of increased m u scle
tension is not p ainfu l, bu t in som e the increase in tissu e
resistance m ay correlate w ith m od erate d iscom fort (Grieve
et al 2011).
Another com pression intervention that can be applied to
a TrP is the strain / counterstrain technique (Jones 1981;
D’Am brogio & Roth 1997). In this techniqu e, the therap ist
ap p lies p ressu re u ntil reaching the p atient’s pain threshold .
At that m om ent, the patient’s involved bod y part is passively
p laced in a p osition that red u ces the tension u nd er the p alpat-
ing ngers and cau ses a su bjective red u ction of p ain by
around 90–100%. This position is m aintained for 90 second s
(Jones 1981). This technique w as d esigned for the m anage-
m ent of tend er p oints; how ever, there is no evid ence that
these tend er p oints as d escribed by Jones (1981) are ind eed
the sam e entity as TrPs. The relationship betw een tend er
p oints and TrPs has not been investigated . Dard zinski et al
(2000) reported a positive im m ed iate im provem ent in sym p-
tom s of 50–75% in a patient after the application of a p rotocol
inclu d ing strain / cou nterstrain interventions and bod y exer-
cises. Rod rígu ez-Blanco et al (2006) d em onstrated that the
ap p lication of a single session of strain / cou nterstrain tech-
niqu e over latent TrPs in the m asseter m u scle p rod u ced a
sm all increase in active m ou th op ening.
Massage therapies
The ap plication of m assage for inactivating TrPs w as d is-
cu ssed by Sim ons (2002). Bu ttagat et al (2011) show ed that
trad itional Thai m assage increased heart rate variability and
im p roved stress-related p aram eters in p atients p resenting
w ith back p ain associated w ith TrPs. Massage can be d one
along the tau t band (longitu d inal strokes) or across the tau t
band (transverse m assage or strokes). H ong et al (1993)
reported that d eep tissu e m assage w as m ore effective in
d ecreasing pressure pain sensitivity than spray and stretch
and other m anu al therapies. Ibáñez-García et al (2009) show ed
that neu rom u scu lar ap p roaches w ere effective for red u cing
p ressu re p ain sensitivity in latent m u scle TrPs. Fernánd ez-d e-
las-Peñas et al (2006b) fou nd that transverse m assage w as as
effective as the ischaem ic com pression for red u cing TrP pres-
su re p ain sensitivity. FitzGerald et al (2012) observed that
app lication of TrP m assage therap y w as m ore effective than
global therapeutic m assage in w om en w ith interstitial cysti-
tis / p ainfu l blad d er synd rom e.
Sim ons (2002) and H ong et al (1993) have p rop osed that
m assage m ay exert a lengthening effect sim ilar to com p res-
sion techniqu es. For instance, transverse friction m assage m ay
offer a transverse m obilization to the tau t band , w hereas
stroking m ay offer a longitu d inal m obilization of the tau t
band . In som e m uscles, particu larly those w here clinicians
can u se p incer p alp ation, the therap ist’s ngers can grasp
the tau t band from both sid es of the m u scle TrP, stroking it
centrifu gally and elongating it aw ay from the TrP (Sim ons
2002). Bod es-Pard o et al (2013) recently d em onstrated that
m assage therap y targeted to active TrPs in the sternocleid o-
m astoid m u scle w as effective for red u cing head ache and neck
p ain intensity and for increasing m otor perform ance of the
d eep cervical exors, pressure pain threshold s and active
cervical range of m otion in ind ivid u als w ith cervicogenic
head ache.
Stretching interventions
There are several applications of stretching approaches:
p assive stretching (w here the therap ist p assively stretches the
m u scle w ithou t p articip ation of the p atient), active stretching
(w here the patient actively stretches the m uscle w ithou t the
p articip ation of the therap ist), sp ray and stretch (H ong et al
1993; Sim ons et al 1999) and post-isom etric relaxation (Lew it
1999). Fryer (2000) su ggested that the therap eu tic m echanism
of stretching interventions m ay be the com bination of ‘creep ’
(i.e. tem porary elongation of connective tissu e d u ring the
stretch) and p lastic changes in the connective tissu es cau sed
by the stretch. There is, how ever, little evid ence show ing that
stretching is bene cial for TrP treatm ent. Fu rther, p atients
w ith benign hyperm obility or Ehlers–Danlos synd rom e
shou ld not p artake in any stretching exercises, as stretching
w ill m ost likely contribu te to increased laxity of connective
tissu es and ligam ents w ithou t any p ositive effect on m u scles,
tau t band s and TrPs.
Jaeger and Reeves (1986), in a low -qu ality stu d y, fou nd that
sp ray and stretch w as effective for red u cing p ain sensitivity
and sym ptom s in active TrPs. H ong et al (1993) d em onstrated
that sp ray and stretch show ed im m ed iate p ositive effects on
p ressu re p ain sensitivity and w as m ore effective w hen com -
bined w ith d eep pressu re m assage. H ou et al (2002) fou nd
that the ap p lication of sp ray and stretch in com bination w ith
other m od alities w as m ore effective than hot-p acks for inac-
tivating TrPs. Em ad et al (2012) show ed that TrP injections
p lu s stretching w ere signi cantly m ore effective in red u cing
p ain than TrP injections alone. It shou ld be noted , how ever,
that the com m ercially available sp rays have a consid erable
environm ental im pact, inclu d ing ozone d epletion and
increased global w arm ing.
Dynamic interventions
As m yofascial TrPs are located in m uscle tissue, it is im p ortant
to inclu d e d ynam ic interventions, in w hich clinicians ap p ly
m anu al techniqu es, su ch as TrP p ressu re release or longitu d i-
nal stroking, com bined w ith contraction or stretching of
the affected m u scle. For instance, d u ring TrP m anu al com -
p ression, the p atient is asked to contract the affected
m u scle actively throu gh a sm all range of m otion (Gröbli &
Dom m erholt 1997; Gröbli & Dejung 2003). The active m u scle
contraction is thou ght to stretch the shortened sarcom eres
against the com p ression (Sim ons 2002). The m echanism s of
these techniqu es are still u nknow n, bu t m ay be related to
activation of the intrafascial p acinian / paciniform and Ruf ni
m echanorecep tors, w hich are fou nd in all typ es of d ense
p rop er connective tissu es (Schleip 2003). Ruf ni end ings are
especially responsive to tangential forces and lateral stretch
(Kru ger 1987), and stim u lation of Ru f ni corpuscles is
assu m ed to resu lt in a low ering of sym pathetic nervou s
system activity (Van d en Berg & Cabri 1999). Du ring m anu al
com p ression or longitu d inal stroking, the p atient m ay also be
asked to m ove the segm ent actively through a p articu lar
range (Gröbli & Deju ng 2003).
 Clinical applications of manual therapies over myofascial TrPs
Clinical Applications of Manual
Therapies over Myofascial TrPs
In this section, d ifferent m anu al TrP therapies are d escribed
in m uscles w ith referred pain patterns into the u pper and
low er qu ad rants. The featured techniqu es are not exclu sive
and are not the only p ossible op tions. Clinicians are encour-
aged to d evelop other techniques based on established prin-
cip les. The selection of techniqu es w ill d ep end p artially on
the irritability of TrPs and the sensitization of the p atient’s
central nervou s system .
Stretching compression of levator scapulae
muscle taut band
A stretching com p ression techniqu e com bines com p ression
(TrP p ressu re release or ischaem ic com pression) w ith passive
or active stretching of the TrP tau t band . In ou r clinical p rac-
tice, w e ap p ly this techniqu e for inactivating levator scap u lae
TrPs located at the angle of the neck w here the levator scap u -
lae m uscle em erges from the anterior bord er of the u pper
trap eziu s. For this techniqu e, the p atient is seated w ith the
torso resting against the backrest. The therap ist brings the
u p p er trap eziu s m u scle in a relaxed p osition to achieve good
contact w ith the levator scap u lae TrP. In that p osition, a com -
pression techniqu e is app lied . When the therapist p erceives a
slight relaxation of the TrP, the p atient’s neck is gently tu rned ,
either passively or actively, tow ard s the op posite sid e to
increase the tension w ithin the taut band (Fig. 60.1). This
proced u re is rep eated until a relaxation w ithin the tau t band
is perceived or until the referred pain d isappears.
Figure 60.1 Stretching compression of levator scapulae muscle taut band.
681
Longitudinal strokes of scalene muscle
taut band
TrP tau t band s in the anterior or m ed ial scalene m u scles can
trap the brachial p lexu s (Chen et al 1998). In ad d ition, tension
ind u ced by TrP tau t band s w ithin the scalene m uscles m ay be
related to u pw ard d ysfu nctions of the rst rib (Fergu son &
Gerw in, 2005). In our clinical practice, the application of lon-
gitu d inal strokes to both anterior and m ed ial scalene m uscles
is u sefu l for relaxing TrP tau t band s w ithout increasing
tension w ithin the brachial p lexu s.
The anterior scalene is easily palpated below the posterior
bord er of the clavicu lar d ivision of the sternocleid om astoid
m u scle. The m ed ial scalene lies d eep and lateral to the ante-
rior scalene and anterior to the d eep bres of the levator
scap u lae m u scle.
Longitu d inal strokes are u su ally p erform ed u sing one
thu m b in a cranial–cau d al d irection (Fig. 60.2). The d egree of
p ressu re ap p lied is d eterm ined by the feed back rep orted by
the p atient, or the tension felt w ithin the p atient’s tissu e.
Compression and contraction
of supraspinatus muscle
This techniqu e com bines a m anu al com pression w ith an
active contraction of the com p ressed m uscle (Gröbli & Deju ng
2003). For the techniqu e, the patient lies prone w ith the shoul-
d er abd ucted 90°. The therapist places the up p er trap eziu s
m u scle in a relaxed p osition to ap p roxim ate the su p rasp inatu s
fossa of the scapu la. In that position, he / she app lies m anual
com p ression over the su p rasp inatu s TrPs w ith both thu m bs.
When the therap ist perceives a slight relaxation of the tissu e,
the p atient is asked to contract the m u scle abd u cting the
Figure 60.2 Longitudinal stroke of scalene muscle taut band. The black arrow
shows the direction of the stroke.
 682 PART 10 • 60 • Manual treatment of myofascial trigger points

Figure 60.3 Compression and contraction of supraspinatus muscle. The black Figure 60.4 Stretching strokes of infraspinatus muscle taut band. The black
arrow shows the compression of the therapist and the white arrow shows the arrow shows the direction of the stroke.
direction of the contraction force by the patient (abduction).

shou ld er for 5 second s. The therap ist offers resistance w ith

the leg p u shing against the p atient’s arm in ord er to achieve
an isom etric contraction (Fig. 60.3). This techniqu e is rep eated
u ntil the referred p ain d isap p ears.

Stretching strokes of infraspinatus muscle

taut band
A stretching stroke consists of a longitu d inal stroke ap p lied
over a m u scle p laced in a stretched p osition. With the p atient
seated , the infrasp inatu s m u scle is stretched by bringing the
hand and the arm across the front of the chest to grasp the far
arm rest of the chair. In this stretched position, the therapist
p erform s longitud inal strokes u sing one thum b in a m ed ial
(thoracic spine) to lateral (sp ine of the scapu la) d irection
(Fig. 60.4).
Figure 60.5 Stretching longitudinal strokes of infraspinatus muscle taut band.
The black arrows show the centrifugal direction of the stroke.
Stretching longitudinal strokes
of infraspinatus muscle taut band
This technique consists of a com bination of com p ression and
longitu d inal strokes along the TrP tau t band . The p atient lies p incer p alp ation of the axillary fold a few centim etres below
p rone w ith the shou ld er in 90° of abd u ction. The ngers of the arm , the therap ist locates the teres m ajor m u scle and the
the therap ist com p ress the infrasp inatu s TrPs, grasp the tau t lateral bord er of the scapu la. With one hand he / she then
band from both sid es of the TrP and stroke centrifugally aw ay p inches the teres m ajor TrP and w ith the other hand grasp s
from the TrP (Fig. 60.5). the forearm of the p atient. The therap ist p assively abd u cts the
p atient’s shou ld er u ntil a tension w ithin the TrP tau t band
is perceived (Fig. 60.6). The tension is usually perceived
Stretching compression of teres major w hen the should er joint reaches app roxim ately 60° of abd u c-
muscle taut band tion. The therap ist shou ld avoid any com p ensatory m ove-
m ent of the scap u la. The techniqu e is rhythm ically rep eated
With the p atient lying on the op p osite sid e, the teres u ntil a relaxation in the teres m ajor m u scle tau t band is
m ajor m u scle can be easily located by p incer p alp ation. Using p erceived .
 Clinical applications of manual therapies over myofascial TrPs
Figure 60.6 Stretching compression of teres major muscle taut band. The black
arrow shows the shoulder abduction and the white arrow shows the stabilization
force of the therapist.
Figure 60.7 Stretching compression of subscapularis muscle taut band. The
black arrow shows the compression over the subscapularis whereas the white arrow
shows the external rotation and abduction movement.
Stretching compression of subscapularis
muscle taut band
The p atient is sup ine w ith the shou ld er abd u cted betw een 30°
and 60°. The therapist hold s on to the m ed ial bord er of the
scap u la and m anu ally m oves the scap u la laterally. Manu al
com p ression is ap p lied cep halad and tow ard s the sp ine of the
scap u la. From that p osition, the therap ist d ynam ically exter-
nally rotates and abd u cts the p atient’s shou ld er u ntil m u scle
tension is p erceived (Fig. 60.7).
Dynamic transverse strokes of deltoid muscle
trigger points
This techniqu e com bines a transverse stroke w ith passive
rotation of the shou ld er joint. With the patient supine and the
shou ld er in 90° of abd u ction, the therap ist grasps the anterior
or p osterior p art of the d eltoid m u scle. The thu m b of the
therap ist’s hand shou ld be p laced over the TrP tau t band . The
683
Figure 60.8 Dynamic transverse strokes of anterior deltoid muscle trigger
points. The black arrow shows the anterior to posterior stroke of the deltoid and the
white arrow shows the internal rotation movement.
therap ist’s other hand grasp s the forearm . In ord er to rotate
the shou ld er joint, the p atient’s elbow shou ld be extend ed .
For anterior d eltoid m u scle TrP, the therapist p assively inter-
nally rotates the shou ld er joint and at the sam e tim e intro-
d u ces an anterior–posterior transverse stroke to the anterior
p art of the d eltoid m u scle (Fig. 60.8). For p osterior d eltoid
m u scle TrPs, the therap ist p assively externally rotates the
shou ld er and at the sam e tim e introd u ces a posterior–anterior
transverse stroke to the p osterior p art of the m u scle (Fig. 60.9).
Dynamic longitudinal strokes of
biceps / triceps brachii muscle taut band
This techniqu e com bines longitu d inal m anu al strokes w ith
the p atient being asked to contract the m u scle and m ove the
forearm throu gh its range of m otion. For the biceps brachii
m u scle, the p atient lies su p ine w ith the shou ld er at on the
table, the elbow extend ed (if p ossible) and the forearm su p i-
nated . The therap ist ap p lies longitu d inal strokes over the TrP
tau t band w ith both thu m bs from a cranial (shou ld er) to
cau d al (elbow ) d irection and at the sam e tim e the p atient
exes the elbow by contracting the biceps brachii m uscle
(Fig. 60.10).
For the triceps brachii m uscle, the patient lies p rone w ith
the shou ld er at on the table, the elbow exed (if p ossible)
and the hand in neu tral position. The therapist app lies longi-
tu d inal strokes over the tau t band w ith both thu m bs from a
cranial (shou ld er) to cau d al (olecranon) d irection and at the
sam e tim e the p atient extend s the elbow by contracting
the tricep s brachii (Fig. 60.11). It is perceived clinically that
the strokes shou ld be ap p lied sim u ltaneou sly w ith the m u scle
contraction.
 684 PART 10 • 60 • Manual treatment of myofascial trigger points
Figure 60.9 Dynamic transverse strokes of posterior deltoid muscle trigger
points. The black arrow shows the posterior to anterior stroke of the deltoid and the
white arrow shows the external rotation movement.
Figure 60.10 Dynamic longitudinal strokes of biceps brachii muscle taut band.
The black arrow shows the longitudinal stroke and the white arrow shows the elbow
exion motion.
Dynamic longitudinal strokes of hand / wrist
extensor muscle taut band
This techniqu e is the sam e as that d escribed for the
biceps / triceps brachii m u scle. The patient is seated w ith the
elbow at 90° of exion, and the hand pronated and closed .
Figure 60.11 Dynamic longitudinal strokes of triceps brachii muscle taut band.
The black arrow shows the longitudinal stroke and the white arrow shows the elbow
extension motion.
The therapist applies longitu d inal strokes over TrP tau t band s
w ith both thu m bs from a cranial (elbow ) to caud al (w rist)
d irection and at the sam e tim e the patient extend s the w rist
by contracting the hand / w rist extensor m u scles. Since these
m u scles ru n longitu d inally along the forearm , the therap ist
can focu s the stroke over each hand / w rist extensor m u scle
(i.e. extensor carpi rad ialis longu s or brevis, extensor d igito-
ru m com m u nis or extensor carp i u lnaris m u scle).
Transverse massage of hand / wrist exor
muscle trigger points
This techniqu e com bines a transverse m assage w ith or w ithout
the p atient m oving the forearm throu gh its range of m otion.
The patient is asked to actively contract the hand / w rist exor
m u scles. The patient is seated w ith the elbow at 90° of exion,
and the hand su pinated and opened . The therap ist app lies a
transverse friction m assage over the TrP tau t band of the
affected m u scle. The patient has tw o op tions: (a) to op en and
close the hand by contracting the hand exor m u scles (Fig.
60.12); (b) to close the hand and to ex the w rist by contracting
both the hand and w rist exors (Fig. 60.13). Since these
m u scles also ru n longitu d inally along the forearm , the thera-
p ist can focu s the transverse m assage over the tau t band of
each hand / w rist exor m uscle (i.e. the palm aris longu s,
exor carpi rad ialis or u lnaris, exor d igitoru m su per cialis
or p rofu nd u s m u scle).
Stretching compression of thumb
muscles taut bands
Any m u scle located in the thenar em inence can d evelop TrPs.
For instance, a TrP w ithin the ad d uctor pollicis m u scle refers
 Clinical applications of manual therapies over myofascial TrPs
Figure 60.12 Transverse massage of hand exor muscle trigger points.
Figure 60.13 Transverse massage of hand / wrist exor muscle trigger points.
The black arrow shows the transverse friction massage and the white arrow shows
the wrist and nger exion motion.
an aching and d eep p ain along the thu m b and to the rad ial
styloid . TrPs in the op p onens p ollicis m u scle refer p ain to the
p alm ar su rface of the thu m b and to the rad ial sid e of the
p alm ar asp ect of the w rist.
The stretching com pression technique for thenar em inence
m u scle TrPs consists of the therap ist ap p lying com p ression to
the TrP w ith the thu m b w hilst p assively and rhythm ically
stretching the m u scle. Figu re 60.14 show s the techniqu e
ap p lied over the op ponens pollicis m u scle TrPs.
Transverse massage of quadratus lumborum
muscle taut bands
This techniqu e com bines a transverse m assage w ith or w ithou t
m oving the legs of the p atient to ind u ce lateral exion of the
bod y. The patient is lying on the unaffected / non-sym ptom atic
sid e w ith the therap ist stand ing in front of the p atient. The
u lnar asp ect of the therap ist’s forearm shou ld be p laced over
the tau t band of the m u scle. The techniqu e consists of ap p ly-
ing a sm ooth and slow transverse m assage over the TrP tau t
685
Figure 60.14 Stretching compression of opponens pollicis muscle.
Figure 60.15 Transverse massage of quadratus lumborum muscle taut bands.
band (Fig. 60.15). If the therapist w ants to cond u ct a d ynam ic
intervention, the feet of the p atient are placed ou tsid e of the
table and the p atient lifts the feet to the horizontal level. This
action provokes an isom etric contraction of the qu ad ratu s
lum boru m m uscle by ind u cing sid e-bend ing of the trunk.
Post-isometric relaxation of quadratus
lumborum muscle taut bands
This techniqu e can be applied w hen the m u scle is very tight
and d irect palpation of the m u scle is too p ainfu l for the
p atient. The p atient is sid e-lying on the u naffected / non-
sym p tom atic sid e w ith the su p erior leg arranged in front of
the other leg. A p illow can be p laced u nd er the w aist to
increase the lateral convexity of the lu m bar sp ine. The thera-
p ist’s cau d al hand stabilizes the iliac bone, and the cranial
hand is p laced on the rib cage of the p atient. The rib cage is
 686 PART 10 • 60 • Manual treatment of myofascial trigger points

Figure 60.17 Stretching compression of psoas major muscle taut bands

in exion.

Figure 60.16 Post-isometric relaxation of quadratus lumborum muscle taut

bands. The black arrows show the centrifugal direction of the stroke.

stretched aw ay from the iliac bone u ntil tension is p erceived

(Fig. 60.16).
In that position, the patient actively contracts the m uscle
by lifting the leg for 4–8 second s, and then releases it. When
the therap ist feels that the contraction has ceased and the
m u scle is becom ing m ore relaxed , an increase in m u scle
stretch is slow ly introd u ced . The p atient can actively p ar-
ticip ate by gently lengthening the leg at the start of the
stretch.
Figure 60.18 Stretching compression of psoas major taut bands in extension.
Stretching compression of psoas major
muscle taut bands
Managem ent of the p soas m ajor m u scle is im p ortant since this
m u scle is anatom ically related to several u rogenital stru ctu res
and the lu m bar p lexu s (Step nik et al 2006). A stretching com -
p ression techniqu e com bines a com p ression intervention w ith
p assive or active stretching of the TrP tau t band . The patient
is su p ine w ith the knee and hip exed , and the foot on the
table. The therap ist com p resses the TrP (w hich is u su ally
located w ithin the m u scle belly, reached throu gh the overly-
ing abd om inal m u scles) w ith the tip s of the ngers of one or
both hand s (Fig. 60.17). At the tim e that he / she perceives a
relaxation of the tau t band , the patient is asked to straighten
the knee and the hip , either p assively or actively, to increase
the tension in the tau t band (Fig. 60.18). The aim of this tech-
niqu e is for the p atient to achieve p ain-free extension of the
hip and knee at the sam e tim e that the therap ist m aintains the
com p ression.
Figure 60.19 Stretching longitudinal stroke / dynamic longitudinal stroke of
Stretching longitudinal stroke / dynamic gluteus medius muscle taut bands. The black arrow shows the direction of the
stroke.
longitudinal stroke of gluteus medius muscle
taut bands
p osition, longitu d inal strokes can be p erform ed w ith the u lnar
A stretching stroke consists of a longitu d inal stroke ap p lied aspect of the therap ist’s forearm , from a p osterior to an ante-
over a m u scle tau t band p laced in a stretched p osition. With rior d irection (Fig. 60.19). When the patient lifts the knee, the
the p atient sid e-lying, the glu teu s m ed iu s can be stretched by techniqu e w ill be converted into a d ynam ic longitu d inal
ad d u ction of the leg w ith the knee exed . In this stretched stroke of the glu teu s m ed iu s m u scle.
 Clinical applications of manual therapies over myofascial TrPs
Figure 60.20 Stretching longitudinal stroke of quadriceps muscle taut bands.
The black arrow shows the direction of the stroke.
Figure 60.21 Stretching longitudinal massage of adductor muscle taut bands.
Stretching longitudinal stroke of quadriceps
muscle taut bands
With the p atient in su p ine, the qu ad ricep s m u scle can be
stretched by exing the knee w ith the hip extend ed . In this
stretched p osition, longitu d inal strokes can be p erform ed
w ith the therap ist’s thum b–ind ex ngers or knu ckles, from a
cau d al to a cranial d irection (Fig. 60.20). When the patient lifts
the knee, the techniqu e w ill be converted into a d ynam ic
longitud inal stroke of the qu ad ricep s m uscle.
Stretching longitudinal massage of adductor
muscle taut bands
The aim of this techniqu e is lengthen the m uscle taut band by
app lying a p incer stroke. The patient is su pine or sid e-lying.
Once the therap ist locates a TrP in any of the ad d u ctor
m u scles, a p incer p alp ation of the TrP tau t band is rm ly
app lied . The therap ist’s ngers grasp the tau t band from both
sid es, and strokes are ap p lied centrifu gally aw ay from the
TrP. This techniqu e is p articu larly effective for the ad d u ctor
m agnu s and longu s m u scles (Fig. 60.21).
687
Figure 60.22 Stretching compression of gastrocnemius and soleus muscles
taut bands.
Figure 60.23 Compression and contraction of anterior–lateral leg muscles.
Stretching compression of gastrocnemius
muscle taut bands
The stretching com pression technique com bines any TrP com -
p ression w ith p assive or active stretching of the TrP tau t band .
The p atient lies prone w ith the knee at 90° of exion. The
stretching com p ression techniqu e for gastrocnem iu s m u scle
TrPs consists of com p ression of the TrP w ith a p incer p alp a-
tion, w hich the therap ist can com bine w ith p assive and rhyth-
m ical stretching of the m u scle by ind u cing p assive ankle
d orsi exion (Fig. 60.22). The proced u re is rep eated u ntil a
relaxation w ithin the tau t band is perceived or u ntil the
referred pain d isapp ears.
Compression and contraction
of anterior–lateral leg muscles
For this technique, the patient is su pine. With the thu m b, the
therapist com presses the TrP on the anterior–lateral leg
m u scles (tibialis anterior, extensor d igitoru m longu s or exten-
sor hallu cis longu s m u scle). When the therap ist p erceives a
slight relaxation of the tissu e, the p atient is asked to contract
the m u scles by ind u cing active d orsi exion and p lantar
exion of the ankle (Fig. 60.23). This techniqu e is rep eated
u ntil the referred p ain d isap p ears, w hich u su ally hap p ens
w ithin 10–12 rep etitions.
 688 PART 10 • 60 • Manual treatment of myofascial trigger points
Conclusion
There are several m anu al therapies that can be u sed for inac-
tivating m u scle TrPs in the u p p er and low er qu ad rant m u s-
cu latu re. Cu rrent scienti c evid ence has investigated single
app lications of a few m anu al therap ies (i.e. ischaem ic contrac-
tion, neu rom u scu lar ap p roach and m u scle energy); how ever,
m anu al therap ies are u su ally p art of a m u ltim od al ap p roach
for pain relief. Som e clinical stud ies have d em onstrated the
effectiveness of the inclu sion of TrP m anual therapies into
d ifferent m u ltim od al ap proaches for the m anagem ent of
low er qu ad rant p ain synd rom es, su ch as heel p ain or ankle
sp rains. N ew stu d ies are need ed to elu cid ate the neu rop hysi-
ological m echanism s of m anu al therap ies ap p lied to m yofas-
cial TrPs. In ad d ition, the inclu sion of m anu al therap ies aim ed
at inactivating TrPs in m u ltim od al app roaches of patients
w ith d ifferent u pper quad rant p ain synd rom es should be
investigated .
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 PART 10 •  Soft Tissues in the Upper and Lower Quadrants
Dry Needling o Trigger Points
61  
Chapter 
J a n Do m m e rh o lt, Erik H. W ijtm a n s
CHAP TER CONTENTS
Introduction to trigger point dry needling  690
Scienti c evidence of dry needling  691
General guidelines for dry needling  692
Dry needling of selected neck, shoulder and arm muscles  693
Scalene muscles  693
Pectoralis minor muscle  693
Pectoralis major muscle  693
Supraspinatus muscle 
Infraspinatus / teres major / teres minor muscles 
693
694
Rhomboid major and minor muscles  694
Subscapularis muscle  694
Latissimus dorsi muscle  695
Deltoid muscle  695
Biceps brachii muscle  696
Brachialis muscle  696
Brachioradialis muscle  696
Supinator muscle  696
Wrist and  nger extensor muscles  697
Dry needling of selected trunk muscles  697
Thoracic and lumbar multi dus muscles  697
Longissimus thoracis muscle  698
Quadratus lumborum muscle  698
Rectus abdominis muscle  698
External and internal oblique muscles  699
Dry needling of selected hip and leg muscles  700
Gluteus maximus muscle  700
Gluteus medius muscle  700
Gluteus minimus muscle  700
Piriformis muscle  700
Adductor longus muscle  701
Adductor brevis muscle  701
Adductor magnus muscle  701
Pectineus muscle  702
Psoas major muscle  702
Iliacus muscle  703
Quadriceps femoris muscle group  703
Biceps femoris muscle  704
Semimembranosus muscle  705
Semitendinosus muscle  705
 
Tibialis anterior muscle  705
Gastrocnemius muscle  705
Soleus muscle  706
Flexor digitorum longus muscle  706
Fibularis (peroneus) longus and brevis muscles  707
Introduction to Trigger Point
Dry Needling
Treating clinically relevant trigger p oints (TrPs) w ith invasive
p roced u res requ ires a thorou gh know led ge o the u nctional
anatom y o m u scles and their d irect environm ent. TrPs are
id enti ed w ith m anual palpation u sing either a f at or a
p incher p alp ation techniqu e (see Ch 59). TrPs eatu re increased
m u scle tension (Bu chm ann et al 2014) and can be palpated
accu rately in m ost m u scles. Once a TrP is id enti ed , the
clinician m u st visu alize its location in a three-d im ensional
p ersp ective and ap p reciate the d ep th and p resence o neigh-
bou ring structures, includ ing arteries, veins, nerves and inter-
nal organs. For m ost m u scles, the need le shou ld not be u sed
to locate the TrP, as this w ou ld m ake inactivating TrPs a rather
rand om process (Dom m erholt et al 2006). Most m uscles can
be palp ated m anually, bu t there are several excep tions. Parts
o the su bscap u laris and serratu s anterior m u scles, or
exam ple, are partially in betw een the scapu la and the rib cage.
The iliacu s m u scle is on the insid e o the p elvis and the m u scle
is inaccessible to m anu al palpation. In those cases, the clini-
cian can u se a need le to locate and treat these TrPs ap p roach-
ing the m u scles rom the m ed ial bord er o the scapu la and
d irectly over the ed ge o the ilia respectively. Inactivating TrPs
w ith a need le requires an excellent kinaesthetic sense and
aw areness, based on training, exp erience and anatom ical
know led ge (N oë 2004). At any tim e, the clinician m ust know
w hereabouts in the bod y the tip o the need le is and w hich
stru ctu res w ill be encou ntered . Well-d evelop ed kinaesthetic
p ercep tion m akes need ling p roced u res sa e and accu rate, as
the clinician w ill be able to ap p reciate changes in stru ctu res
and accu rately id enti y w hen the need le penetrates the skin,
the su bcu taneou s connective tissu e and ascial layers, the
m u scle, and u ltim ately the tau t band and the TrP (Mayoral
d el Moral 2005).

Invasive TrP therapies can be d ivid ed into injections and
d ry need ling. TrP injections are ad m inistered w ith a hypod er-
m ic syringe; TrP d ry need ling is ad m inistered w ith a solid
lam ent need le. Dry need ling can be d ivid ed into su p er cial
and d eep d ry need ling (Dom m erholt et al 2006). Som e old er
stud ies su ggested that d ry need ling w ou ld cau se m ore p ost-
need ling soreness (H ong 1994; Kam anli et al 2005), but in
these stu d ies injections w ere com p ared w ith d ry need ling
u sing a syringe. In a m ore recent stu d y com p aring injections
w ith d ry need ling u sing a solid lam ent need le, there w as no
signi cant d i erence betw een the tw o ap p roaches (Ga et al
2007). Dry need ling p rovid ed longer-lasting relie , how ever
(Ga et al 2007). This chapter ocu ses on d eep d ry-need ling
techniqu es and d oes not inclu d e sp eci c in orm ation abou t
su p er cial d ry need ling or TrP injections, althou gh injection
techniqu es are not all that d i erent rom d eep d ry need ling.
Read ers are re erred to other textbooks or this in orm ation
(Dom m erholt & Fernánd ez-d e-las-Peñas 2013). The chapter
also d oes not inclu d e any in orm ation abou t d ry need ling
o other stru ctu res, su ch as ligam ents, tend ons and tend on–
bone attachm ents, scar tissue or ascial ad hesions. In clinical
p ractice, d ry need ling can be ap plied to any o these entities
(Lew it 1979).
Dry need ling is w ithin the scope o practice o m ed icine,
acup u ncture, p hysical therapy, chiropractic, veterinary m ed i-
cine, d entistry and m yotherap y, d ep end ing on local ju risd ic-
tion. Each p ractitioner w ill u se d iscip line-sp eci c p hilosop hy
and m anagem ent approaches to d eterm ine w hen and how
d ry need ling techniques w ill be applied . Acup unctu re practi-
tioners m ay re er to d ry need ling as ‘TrP acu p u nctu re’, bu t
this d oes not im p ly that d ry need ling w ou ld be in the exclu -
sive d om ain o any d iscip line (Association o Social Work
Board s et al 2006). Although d ry need ling is generally p er-
orm ed w ith the sam e need le used in acu pu ncture, it d oes not
requ ire any know led ge o trad itional acu pu nctu re theory or
Chinese m ed icine (Bald ry 2005; Am aro 2007; White 2009).
Cu rrently, there are several com m ercially available need les
d esigned speci cally or the practice o d ry need ling. As
early as the 19th century, physicians used need les, includ ing
lad ies’ hat-pins, to treat tend er points in the low back region
(Chu rchill 1821, 1828; Elliotson 1827; Osler 1912). Dry nee-
d ling is an expansion o the TrP injection techniqu es pro-
m oted by Travell, Sim ons and others and is based on the
observation that the actu al m echanical stim u lation o a TrP by
the need le m ay be resp onsible or the therap eu tic bene ts
(Steinbrocker 1944; Travell & Sim ons 1992; Sim ons et al 1999).
H ow ever, d ry need ling is not w ithou t risk (Dom m erholt
et al 2006; Lee et al 2011; McCu tcheon & Yelland 2011; Usm an
et al 2011). Du e to the invasive natu re o the proced u re, there
is a risk o penetrating vital organs and other bod y structu res,
su ch as the lu ngs, intestines, kid neys, u rethra, nerves and
arteries, and the brainstem throu gh the oram en m agnum ,
am ong others. While the incid ence o acu pu nctu re-ind u ced
p neu m othorax is less than 1 / 10 000, the incid ence o d ry
need ling-ind u ced p neu m othorax is u nknow n. A p rosp ective
stud y o the risk o ad verse events o d ry need ling show ed
that the risk o a signi cant ad verse event w as less than 0.04%
in nearly 8000 d ry-need ling treatm ents by Irish physiothera-
p ists (Brad y et al 2014). Dry need ling should alw ays be
anatom y d riven; a thorou gh know led ge o anatom ical rela-
tions is requ ired or the techniqu e (Peu ker & Gronem eyer
2001; Yang & Mu llan 2011). In ad d ition, clinicians m u st ollow
Scienti c evidence of dry needling 691
established protocols or preventing the spread o blood -
borne pathogens and m aintain sou nd gu id elines or sa e
d ry-need ling practice, w hich inclu d es hand w ashing and
other hygienic m easu res (McEvoy et al 2011; Au stralian
Society o Acu pu ncture Physiotherapists (ASAP) 2013).
Scienti c Evidence of Dry Needling
One o the rst p rosp ective scienti c stu d ies o d ry need ling
w as pu blished in 1980 and show ed its e ectiveness in the
treatm ent o inju red w orkers w ith low back p ain (Gu nn et al
1980). An au thoritative Cochrane review ou nd that d ry nee-
d ling w as a p otentially u se ul ad junct in the treatm ent o
ind ivid u als w ith chronic low back pain, bu t agreed that m ore
high-qu ality stu d ies are need ed (Furlan et al 2005). A stu d y
o the e ects o latent TrPs on m u scle activation p atterns in
the shou ld er region d em onstrated that a com bination o TrP
d ry need ling and passive stretching restored norm al m uscle
activation patterns (Lu cas et al 2004). A p rospective, open-
label, rand om ized stud y on the e ect o d eep d ry need ling on
shou ld er pain in 101 patients ollow ing a cerebrovascu lar
accid ent show ed that, a ter only ou r d ry need ling treatm ents,
p atients w ho w ere treated w ith d ry need ling rep orted signi -
cantly less p ain d u ring sleep and d u ring p hysical therap y
treatm ents, had m ore rest u l sleep and exp erienced signi -
cantly less requ ent and less intense p ain. They red u ced their
u se o analgesic m ed ications and d em onstrated increased
com p liance w ith the rehabilitation p rogram m e com p ared
w ith patients w ho received the regu lar rehabilitation pro-
gram m e (Dilorenzo et al 2004). A ew stu d ies con rm ed the
p ositive e ects o d ry need ling on tem p orom and ibu lar p ain
(Fernánd ez-Carnero et al 2010; Dıraçoğlu et al 2012; Gonzalez-
Perez et al 2012; Itoh et al 2012).
A recent m eta-analysis o the e ectiveness o d ry need ling
or up per-qu arter m yo ascial pain conclu d ed that d ry nee-
d ling is an e ective treatm ent m od ality (Kietrys et al 2013).
Another stu d y ou nd that d ry need ling prod uced an im prove-
m ent in p ain intensity, p ain p ressu re threshold s and scores on
the Disabilities o the Arm , Shou ld er and H and (DASH ) test
and m ay be prescribed or subjects w ith TrPs in the u pp er
trap eziu s m u scles (Ziaei ar et al 2014). Maher et al (2013)
established objective im provem ents in postu re and pain ol-
low ing d ry need ling u sing u ltrasou nd shear-w ave elastogra-
p hy. Dry need ling can im p rove both m u scle blood f ow and
oxygenation (Cagnie et al 2012).
Single-case rep orts also su ggested that d ry need ling
w as u se u l in the treatm ent o : plantar asciitis (Akhbari
et al 2014), chest w all p ain (Westrick et al 2012), posterior
knee pain (Mason et al 2014), ad hesive capsu litis (Clew ley
et al 2014), ham strings tend inopathy (Jayaseelan et al 2014),
shou ld er inju ries (Osborne & Gatt 2010), tem porom and ibu lar
d isord er w hen com bined w ith other interventions (González-
Iglesias et al 2013), low back pain (Rainey 2013) and groin
p ain (Paantjens 2013). A ear o need les d oes not seem to
im pact the clinical outcom e (Joseph et al 2013).
In one stud y (H sieh et al 2007), TrP d ry need ling o the
in raspinatu s m uscle d ecreased the pain intensity o the
shou ld er, and increased active and p assive shou ld er internal
rotation and the pressure pain threshold o TrPs in the ipsi-
lateral anterior d eltoid and extensor carpi rad ialis longu s
 692 PART 10 • 61 • Dry needling of trigger points
m u scles. In another (Tsai et al 2010), d ry need ling o TrPs in
the extensor carp i rad ialis longu s red u ced the irritability o
TrPs in the ip silateral trap eziu s m u scle and the overall p ain
intensity, and im p roved cervical range o m otion. A sim ilar
stu d y (Chou et al 2009) o the e ect o need ling tw o acu pu nc-
tu re p oints in the extensor carp i rad ialis longu s and extensor
ind ices m u scles red u ced the p ain intensity and end -p late
noise associated w ith a TrP in the trap eziu s m u scle; the
au thors com p ared the resu lts w ith a sham -need ling proce-
d u re w hereby a need le w as inserted into a rubber connector
w ith d irect contact on the skin. Su bjects cou ld eel the sharp
need le tip , how ever, w hich m akes it qu estionable w hether
this w as a tru e sham p roced u re. Tekin et al (2013) d em on-
strated the p ositive e ects o d ry need ling, bu t in this stu d y
the sham need ling p roced u re w as in act a variation on su p er-
cial d ry need ling. Any need ling is likely to have a p hysio-
logical e ect, su ch as a release o end orp hins, a change in p ain
threshold s or an exp ectancy o a p ositive ou tcom e (Pariente
et al 2005; Birch 2006; Lu nd & Lu nd eberg 2006; Wang et al
2008). Both actu al need ling and so-called sham proced u res
can activate brain areas involved in sensorim otor p rocessing,
and d eactivate brain regions m ore active d u ring rest than
d u ring other tasks. Interestingly thou gh, in one stu d y the
areas associated w ith cognitive u nctioning w ere activated by
both real and sham need ling, but actual need ling evoked
a stronger resp onse. The au thors noted that som e o the
d i erences could be d u e to atypical stim u li rom d eep er, sub-
d erm al recep tors being stim u lated by need ling, as opp osed
to the cu taneou s recep tors stim u lated by sham p roced u res
(N ap ad ow et al 2009). Likew ise, a light tou ch o the skin has
been show n to be able to stim u late m echanoreceptors cou pled
to slow cond u cting u nm yelinated C- bre a erents, w hich in
tu rn can activate the insu lar region, bu t not necessarily the
som atosensory cortex (Olausson et al 2002). Kong et al (2006)
con rm ed that m ild and m od erate p ain stim u li w ere m ore
e ective at activating p articu lar areas o the brain than strong
p ain stim u li. The only true d ou ble-blind stu d y o the e ec-
tiveness o d ry need ling involved TrP d ry need ling p rior to
total knee rep lacem ent (Mayoral et al 2013). Forty su bjects
sched u led or a total knee rep lacem ent w ith TrPs in either the
tensor ascia lata, hip abd u ctors, ham strings, qu ad ricep s,
gastrocnem ius or popliteu s m u scles w ere rand om ly allocated
to either an intervention grou p , w ho received TrP d ry nee-
d ling, or a placebo-need ling grou p. A ter each su bject w as
anaesthetized , d ry need ling w as per orm ed . Obviou sly, the
su bjects w ere blind ed to the p roced u re. The stu d y d em on-
strated that a single treatm ent o TrPs p rod u ced a signi cant
d ecrease in p ain intensity over and above p lacebo 1 m onth
a ter knee rep lacem ent su rgery (Mayoral et al 2013).
Dry need ling m ay red u ce end -plate noise at TrPs (Chen
et al 2001) and the chem ical concentrations o several nocicep -
tive su bstances ou nd in the im m ed iate environm ent o active
TrPs (Shah et al 2005, 2008). A recent rabbit stud y show ed that
the e ects on chem ical concentrations w ith d ry need ling o
TrPs w ere actu ally d ose d ep end ent (H sieh et al 2012). Short-
term d ry need ling m od u lated the biochem icals associated
w ith pain and inf am m ation, su ch as substance P, β-end orphin
and tu m ou r necrosis actor α (TN F-α ). Im m ed iately a ter d ry
need ling the levels o β-end orphin and TN F-α increased ,
w hereas the levels o su bstance P d ecreased . The longer term
need ling also cau sed changes in the levels o cyclo-oxygenase-
2 (COX-2), vascu lar end othelial grow th actor (VEGF),
ind u cible nitric oxid e synthase (iN OS), and hypoxia-ind u cible
actor 1α (H IF-1α ). The increase in su bstance P, COX-2 and
TN F-α levels m ay be associated w ith m ore tissu e d am age
(H sieh et al 2012). Up-regu lation o H IF-1α m ay be associated
w ith hypoxia, as seen in TrPs, but can also be associated w ith
m echanical stress. It shou ld be noted that the exp ression o
H IF-1α , iN OS and VEGF proteins m ay be im p ortant actors
in im proving the local circu lation a ter intensive d ry
need ling.
Ind ivid uals w ith active TrPs d em onstrated abnorm al
central p rocessing and hyp eralgesia in resp onse to electrical
stim u lation and com p ression o the TrP (N id d am et al 2007,
2008). Enhanced brain activity w as observed in the som ato-
sensory and lim bic regions, and su p p ressed activity w as
noted in the hip p ocam p u s (N id d am et al 2008). There is
increasing evid ence that TrPs contribute to the d evelop m ent
o central sensitization (Fernánd ez-d e-las-Peñas et al 2007,
2009; Giam berard ino et al 2007; Fernánd ez-Carnero et al
2008). There is also som e evid ence rom anim al stu d ies that
need ling therap ies involve the d escend ing p ain inhibitory
system (Takeshige et al 1992a, 1992b). It is likely that
d ry need ling inf uences both peripheral and central pain
m echanism s (Dom m erholt 2011; Fernánd ez-d e-las-Peñas &
Dom m erholt 2014). The tissu e d am age cau sed by d ry nee-
d ling lasts only a ew d ays in a d ry-need ling m od el in m ice
(Dom ingo et al 2013).
General Guidelines for Dry Needling
This ollow ing section provid es basic guid ance to need ling
TrPs in the neck, shou ld er, arm , tru nk, hip and leg m u scles.
It shou ld be noted that the skills need ed to u se these tech-
niqu es sa ely and accu rately can be learned only throu gh
attend ing hand s-on cou rses o ered by quali ed and exp eri-
enced tutors. Read ing this chapter d oes not constitu te any
qu ali cation to u se d ry need ling in clinical p ractice. There are
general gu id elines, how ever, w hich shou ld be ad hered to. It
is recom m end ed that patients are lying d ow n d u ring any
need ling p roced u res, becau se o the risk o vasod ep ressive
syncop e. For every m u scle, anatom ical land m arks shou ld be
id enti ed , includ ing the m argins o the m uscle and any rel-
evant bony stru ctures (e.g. the m ed ial and lateral bord ers o
the scap u la and the scap u lar sp ine w hen need ling the su p rasp-
inatu s m u scle). Once a TrP is id enti ed , the land m arks are
once again veri ed to assu re sa e need ling. There is ongoing
d ebate over w hether d isin ection o the skin is necessary, and
gu id elines vary in d i erent countries and regions. For TrP d ry
need ling, u se o need les in tu bes is recom m end ed (White et al
2008). The tu be is placed on the skin overlying the TrP and
the need le is qu ickly tap p ed into the skin. The tu be is rem oved ,
and the need le is m oved in and ou t into the region o the TrP
by d raw ing the need le back to the subcutaneou s tissu e and
red irecting it. I the need le is not w ithd raw n su ciently, the
need le w ill ollow the sam e p athw ay and the clinician w ill not
be able to alter its d irection. The objective o need ling is to
elicit so-called local tw itch responses, w hich are an ind ication
that the TrP is ind eed inactivated (H ong 1994). Follow ing
need ling p roced u res, haem ostasis m u st be accom p lished to
p revent or m inim ize local bleed ing, help restore and m aintain
range o m otion, and acilitate a retu rn to norm al u nction.
 Dry needling of selected neck, shoulder and arm muscles
Figure 61.1 Dry needling of TrPs in the anterior scalene muscle.
Only very exp erienced clinicians shou ld u se need ling p roce-
d u res w ith p atients w ho rou tinely take w ar arin or anticoagu -
lants. Mu scles that are inaccessible to m anu al p alpation and
there ore to haem ostasis shou ld be avoid ed , su ch as the
p soas m ajor, iliacu s, lateral pterygoid , and parts o the sub-
scap u laris and serratu s m u scles, am ong others. The u se o
p latelet inhibitors is generally not an absolute contraind ica-
tion to need ling, bu t the therap ist need s to be care u l to
achieve haem ostasis.
Dry Needling of Selected Neck,
Shoulder and Arm Muscles
Scalene muscles
A natomy: The anterior and m id d le scalene m u scles originate
rom the rst rib; the posterior scalene m u scle com es rom the
second rib. The m u scles insert at the transverse p rocesses o
cervical vertebrae C3–C8.
N eedling technique: The p atient is lying either su p ine or in
the lateral d ecu bitu s p osition. The m ed ial scalene m u scle lies
anterior to the transverse processes o the cervical sp ine. The
need le is inserted into the belly o the m u scle (Fig. 61.1). The
anterior scalene m u scle is id enti ed by asking the p atient to
sni sharp ly (Katagiri et al 2003). The m u scle is ap proached
lateral to the clavicu lar head o the sternocleid om astoid
m u scle. The p osterior scalene m u scle is not need led , ow ing to
its close proxim ity to the apex o the lungs.
Precautions: The ju gu lar vein shou ld be id enti ed and
avoid ed . The scalene m u scles cannot be need led tow ard s the
lungs, because o the high risk o cau sing a pneum othorax.
Pectoralis minor muscle
A natomy: The m u scle originates rom the third , ou rth and
th ribs near their costal cartilages and inserts at the coracoid
process o the scapu la.
N eedling technique: The patient lies supine. The coracoid
process shou ld be id enti ed rst. The need le is inserted
693
Figure 61.2 Dry needling of TrPs in the pectoralis minor muscle.
throu gh the p ectoralis m ajor m u scle and d irected either
u p w ard s tow ard s the coracoid p rocess (Fig. 61.2) or tow ard
the thu m b o the p alp ating hand u sing a p incer p alp ation.
Precautions: Care m u st be taken to avoid pneum othorax.
Also, the neu rovascu lar bu nd le o the arm lies und er the
p ectoralis m inor m u scle close to the coracoid p rocess.
Pectoralis major muscle
A natomy: The pectoralis m ajor m u scle has our separate
origins: the rst arises rom the clavicle, the second rom the
sternu m , the third rom the ribs, and the ou rth is an abd om i-
nal attachm ent via the ap oneu roses o the external abd om inal
obliqu e and rectu s abd om inis m u scles. The m u scle inserts
over the greater tu bercle o the hu m eru s along the lateral lip
o the bicip ital groove.
N eedling technique: The p atient lies su pine. When treatm ent
is over the chest w all, need ling is alw ays d irected tow ard s
a rib w ith the therapist’s ind ex and m id d le ngers placed
in the intercostal sp ace to avoid cau sing p neu m othorax
(Fig. 61.3). Other portions o the m u scle can be need led via
a pincer p alp ation, w ith the need le d irected tow ard s the
ngers. The clavicu lar p art o the m u scle can be need led
either w ith a pincer palpation or shallow ly tow ard s the
hu m eru s.
Precautions: The ribs m u st be palpated and u sed as a gu id e-
line to avoid pneum othorax.
Supraspinatus muscle
A natomy: The m u scle arises rom the sup raspinatu s ossa and
attaches to the u pper part o the greater tu bercle o the
hu m eral head .
N eedling technique: The patient is in sid e-lying. The need le
is d irected slightly posteriorly tow ard s the u pper bord er o
the scap u la and scap u lar sp ine (Fig. 61.4).
Precautions: I the need le is d irected tow ard s the anterior
w all o the su praspinatu s ossa, there is a consid erable risk o
cau sing a p neu m othorax.
 694 PART 10 • 61 •
Figure 61.3 Dry needling of TrPs in the pectoralis major muscle. (Modif ed
rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Scapular spine
Figure 61.4 Dry needling of TrPs in the supraspinatus muscle.
Infraspinatus / teres major / teres
minor muscles
A natomy: The three m u scles originate rom d i erent asp ects
o the p osterior su r ace o the scap u la below the scap u lar
sp ine. The teres m ajor originates at the in erior angle o the
scap u la and inserts in ront o the hu m eru s to its lesser tu ber-
cle. The teres m inor originates rom a higher and m ore lateral
p oint than the teres m ajor m u scle near the axillary bord er o
the scap u la. The teres m inor inserts behind the hu m eru s to
the greater tu bercle.
N eedling technique: The patient lies in the prone position or
in sid e-lying w ith the arm su p p orted w ith a p illow. Bod y
land m arks m u st be p alp ated be ore each need le insertion. The
m ed ial and lateral bord er o the scap u la shou ld be p alp ated
p rior to the need le insertion. For the in raspinatu s, the need le
Dry needling of trigger points
Figure 61.5 Dry needling of TrPs in the infraspinatus muscle.
is inserted d irectly into the TrP (Fig. 61.5). When p ossible, the
teres m ajor and m inor are grasp ed betw een the thu m b and
the ind ex nger and the need le is inserted tow ard s the nger
or the scap u la. I the m u scles cannot be held in a p incer p alp a-
tion, care u l need ling in a lateral d irection tangential to the
cu rvatu re o the rib cage is ind icated .
Precautions: Ind ivid u als w ith osteoporosis m ay present
w ith thin and enestrated scapu lae. By d eveloping a good
kinaesthetic aw areness o need ling, clinicians shou ld notice
w hen the need le leaves the m u scle.
Rhomboid major and minor muscles
A natomy: The rhom boid m inor attaches rom the sp inou s
p rocesses o C7–T1 and reaches in erolaterally to the m ed ial
scap u lar bord er at the level o its sp ine. The rhom boid m ajor
m u scle originates rom the spinou s p rocesses o T2–T5 and
inserts over the m ed ial bord er o the scapula into its in erior
angle. Both m u scles also attach to the serratu s anterior m u scle.
N eedling technique: The m u scle is need led in sid e-lying or
p rone p osition. When need ling over the chest w all, the thera-
p ist shou ld alw ays d irect the need le tow ard s a rib, w ith the
ind ex and m id d le ngers placed in the intercostal space so as
to avoid cau sing a p neu m othorax. The need le is inserted in a
shallow angle tow ard s the rib in ord er to avoid p enetrating
the lu ng (Fig. 61.6).
Precautions: The rhom boid m u scle poses a relatively high
risk or pneu m othorax. The ribs m u st be palpated and the
need le shou ld alw ays be d irected tow ard s the ribs.
Subscapularis muscle
A natomy: The m uscle lies over the anterior sur ace o the
scap u la. It originates rom the inner su r ace o the scap u la and
attaches to the lesser tu berosity o the hu m erus.
N eedling technique I: To treat the m ore m ed ial TrPs, the
p atient is p laced in a sid e-lying p osition on the sid e that need s
to be treated . The p atient’s tru nk is p ositioned in su ch a w ay
that there is w inging o the scap u la, w hich m akes it p ossible
to need le trigger p oints in the su bscap u laris m u scle. The
need le is d irected tow ard s the u nd ersu r ace o the scap u la
tangential over the rib cage (Fig. 61.7).
 Dry needling of selected neck, shoulder and arm muscles
Rib
Intercostal space
Figure 61.6 Dry needling of TrPs in the rhomboid muscle.
Figure 61.7 Dry needling of TrPs in the subscapularis muscle.
N eedling technique II: The patient lies sup ine w ith the arm
held in ap p roxim ately 90° o abd u ction w ith the elbow bent.
The clinician m anu ally brings the scap ula into a protracted
and laterally d isp laced position, w hich w ill p rovid e greater
access to the lateral asp ect o the m u scle. The palpating hand
is placed against the rib cage and rests on the m u scle. The
need le is inserted betw een the p alp ating ngers tow ard s the
u nd ersu r ace o the scap u la (sim ilar to Fig. 61.8).
Precautions: When need ling the lateral asp ect o the m u scle,
the therap ist shou ld p rotect the lu ngs by keep ing the p alp at-
ing ngers against the chest w all to locate the rib cage accu -
rately. N eed ling tow ard s the ribs m u st be avoid ed or both
need le techniqu es.
Latissimus dorsi muscle
A natomy: The m u scle originates rom the sp inou s p rocess o
the low er six thoracic vertebrae, the thoracolu m bar ascia,
iliac crest and in erior three or our ribs. The insertion o the
m u scle is into the inter-tu bercu lar groove o the hu m eru s.
N eedling technique: The m u scle can be need led w ith the
patient in su p ine, p rone or sid e-lying. To need le the latissim us
d orsi in the axilla, the patient lies su pine w ith the arm
abd u cted at shou ld er level. The m uscle is then p alp ated w ith
695
Figure 61.8 Dry needling of TrPs in the latissimus dorsi muscle in the axilla.
Figure 61.9 Dry needling of TrPs in the mid-deltoid muscle.
a pincer p alpation and the need le is inserted perp end icu larly
to the skin (Fig. 61.8). N eed ling the latissim u s d orsi over the
tru nk requ ires a sim ilar ap p roach to that d escribed in the
section on the rhom boid m u scles. When p ossible, need ling
w ith a pincer palpation is pre erred over the tru nk.
Precautions: All need le insertions are m ad e in consid eration
o the chest w all and lu ngs.
Deltoid muscle
A natomy: The m uscle originates rom the anterior bord er o
the lateral third o the clavicle, the lateral bord er o the
acrom ion, the low er lip o scapular spine and the ascia over
the in rasp inatu s m u scle. The insertion is over the d eltoid
tu berosity at the hu m eru s.
N eedling technique: The patient is either in supine or sid e-
lying position. The need le is inserted perpend icularly throu gh
the skin d irectly into the tau t band (Fig. 61.9).
Precautions: N one.
 696 PART 10 • 61 • Dry needling of trigger points

Figure 61.11 Dry needling of TrPs in the brachialis muscle.

Figure 61.10 Dry needling of TrPs in the biceps brachii muscle.

Biceps brachii muscle

A natomy: The long head o the bicep s brachii m u scle origi-
nates rom the glenoid ossa w ith its tend on p assing throu gh
the glenohu m eral joint. The short head originates rom the
coracoid p rocess w ithou t p assing throu gh the glenohu m eral
joint. Both head s attach d istally to the lesser tu berosity o the
rad ius.
N eedling technique: The p atient lies in su p ine. The m u scle is
p alp ated and picked u p via a p incer p alp ation. The need le is
inserted p erp end icu lar to the skin and d irected tow ard s the
clinician’s nger (Fig. 61.10).
Precautions: The neu rovascu lar bu nd le, inclu d ing the
m ed ian nerve, the m u scu locu taneou s nerve, the u lnar nerve
and the brachial artery, is located m ed ial to the biceps brachii
m u scle and m u st be avoid ed .

Brachialis muscle
A natomy: The m u scle originates rom the d istal tw o-third s o
the hu m eru s and inserts at the coronoid p rocess o the u lnar
tu berosity. The m u scle extend s into the joint cap su le o
the elbow.
N eedling technique: The p atient lies su p ine w ith the elbow
su p p orted and relaxed in a slight f exion. The m u scle is p al-
p ated w ith a f at p alp ation techniqu e. The m u scle is need led
rom the lateral asp ect o the arm only so as to avoid hitting
the neu rovascu lar bu nd le. The need le is d irected m ed ially
(Fig. 61.11).
Precautions: The neu rovascu lar bu nd le shou ld be avoid ed
over the m ed ial head o the m u scle.
Brachioradialis muscle
A natomy: The m u scle starts rom the u p p er tw o-third s o
the su p racond ylar rid ge o the hu m eru s and attaches over
the d istal rad iu s at the styloid p rocess.
N eedling technique: The patient lies in supine position. The
TrPs are id enti ed via p incer p alp ation. The need le is inserted
and d irected tow ard s the p ractitioner ’s nger (Fig. 61.12).
Figure 61.12 Dry needling of TrPs in the brachioradialis muscle.
Precautions: The brachiorad ialis m u scle is the m ost su p er-
cial m u scle over the lateral elbow. The rad ial nerve p asses
close to it and shou ld be avoid ed .
Supinator muscle
A natomy: The m u scle originates rom the lateral hum eral epi-
cond yle, and rad ial collateral ligam ent, the annu lar ligam ent
and the su pinator crest o the u lna. The m u scle inserts over
the rad ial tu berosity and u p p er third o the rad ial sha t.
N eedling technique: The patient is in sup ine w ith the arm
su p inated . Flat p alp ation against the rad ial bone on the volar
sid e o the arm is u sed to id enti y the m u scle. The need le is
inserted pointing proxim ally tow ard s the hum eru s (Fig.
61.13). It is possible to need le the su pinator m uscle at the
d orsal aspect o the orearm , bu t there is a risk o hitting
the su p er cial rad ial nerve, w hich lies over the m u scle, or the
p osterior interosseu s nerve, w hich lies in betw een the tw o
head s o the m u scle.
 Dry needling of selected trunk muscles  697

Figure 61.14 Dry needling of TrPs in the extensor digitorum muscle.

Figure 61.13 Dry needling of TrPs in the supinator muscle.

Precautions: With the p osterior ap p roach, there is a risk o

hitting the sensory and m otor branches o the rad ial nerve.

Wrist and nger extensor muscles

A natomy: The w rist extensors (extensor carp i rad ialis longu s
and brevis m u scles) originate rom the lateral su pracond ylar
rid ge o the hum eru s, the lateral epicond yle, the rad ial liga-
m ent o the elbow and the interm u scu lar sep ta throu gh a
com m on tend on, w hich is shared w ith the extensor carp i
u lnaris m u scle and the extensor d igitoru m m u scle. The attach-
m ents are at the base o the second and third m etacarp al bone,
the u lnar sid e o the base o the th m etacarp al bone and the
d istal p halanx o the ngers respectively.
N eedling technique: The extensor carp i rad ialis longu s and
brevis can be need led w ith the m u scles held in a pincer palpa-
tion. The extensor carp i u lnaris and extensor d igitoru m
m u scles are treated w ith a f at p alp ation (Fig. 61.14).
Precautions: The rad ial nerve crosses over the extensor d igi-
toru m m u scle.
Dry Needling of Selected
Trunk Muscles
Thoracic and lumbar multi dus muscles
A natomy: These m u scles orm the d eep er p arasp inal m u scles
and consist o asciculi, w hich in the sacral area originate rom
the low er p ortion o the d orsal sacrum , the posterior–su perior
iliac sp ine and the d eep sur ace o tend inous origin o the
erector sp inae, in the lu m bar spine rom the m am m illary
processes o all lu m bar vertebrae, and in the thoracic spine
rom the transverse processes o all thoracic vertebrae. Each
Figure 61.15 The spinal safe-needling zone. (Modif ed rom Dommerholt J,
Fernández-de-las-Peñas C 2013.)
ascicu lu s runs sup erior and m ed ially to the base or the tip o
the sp inou s p rocess above. In the lu m bar sp ine they attach to
the ad jacent vertebra; in the thoracic sp ine they can skip one
to three segm ents.
N eedling technique: The p atient lies prone. Using a f at pal-
p ation techniqu e, the m u scle is id enti ed ju st lateral o the
sp inou s p rocesses. For need ling in the thoracic sp ine, it is
im portant to stay w ithin the so-called ‘sa e need ling zone’,
w hich is d e ned as the areas approxim ately one nger-breath
on each sid e o the sp inou s p rocesses (Fig. 61.15). The need le
is inserted perpend icu lar to the skin and d irected in an in e-
rior (cau d al)–m ed ial d irection tow ard s the lam ina (Fig. 61.16).
Precautions: Stay w ithin the sa e need ling zone to avoid the
p ossibility o a p neu m othorax in the thoracic sp ine. Direct the
need le in a cau d al–m ed ial d irection along the entire sp ine to
avoid penetrating the epid u ral space.
 698 PART 10 • 61 •
Figure 61.16 Dry needling of TrPs in the multi dus muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.17 Dry needling of TrPs in the longissimus muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
Longissimus thoracis muscle
A natomy: The m u scle originates rom a com m on tend inou s
origin in the sacru m , the iliac crest, and the sp inou s p rocesses
o low er thoracic and m ost lu m bar vertebrae. In the lu m bar
region, the m u scle blend s w ith the iliocostalis lu m borum
m u scle. It attaches to the tip s o the transverse p rocesses o all
thoracic vertebrae and ribs 3 or 4 to 12 betw een their tu bercles
and angles. Som e o its bres are attached to the entire poste-
rior su r ace o the transverse processes, to the accessory p roc-
esses o the lu m bar vertebrae and to the m id d le layer o the
thoracolu m bar ascia.
N eedling technique: The patient is prone. The tau t band is
id enti ed u sing a f at p alp ation p erp end icu lar to the d irection
o the m u scle bres. The need le is inserted p erp end icu lar to
the skin betw een tw o ngers, ju st su p erior to the trigger p oint.
The need le is then d irected tow ard s the TrP longitu d inally in
a shallow angle (Fig. 61.17).
Precautions: Maintain a shallow angle in ord er to avoid the
p ossibility o a p neu m othorax.
Dry needling of trigger points
Figure 61.18 Dry needling of TrPs in the quadratus lumborum muscle.
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Quadratus lumborum muscle
A natomy: The m u scle originates rom the m ed ial hal o the
low er bord er o the 12th rib, the transverse processes o L1–4,
and occasionally the transverse process or bod y o T12. It
inserts by aponeurotic bres to the iliolu m bar ligam ent and
the ad jacent p ortion o the internal lip o the iliac crest. Occa-
sionally a second m u scle layer is p resent; this attaches su p e-
riorly to the m ed ial low er bord er o the 12th rib, and in eriorly
to the transverse p rocesses o the low er three or ou r lu m bar
vertebrae.
N eedling technique: The patient lies in the sid e-lying position
w ith the a ected sid e up . The m u scle is id enti ed by f at
p alp ation ju st p osterior to the m id line betw een the 12th rib
and the iliac crest. I need ed , the therap ist can increase the
sp ace betw een the 12th rib and the iliac crest by placing a
tow el u nd er the p atient, by raising u p the p atient’s arm , or by
extend ing the u pper leg. The need le m ust be long enou gh to
reach the d epth o the transverse process. While giving ad e-
qu ate com p ression to the su bcu taneou s tissu e, the need le is
inserted betw een tw o ngers straight lateral–m ed ially, and is
d irected tow ard s the transverse process (Fig. 61.18).
Precautions: N eed le below L2 in ord er to avoid the kid ney,
the p leu ra and the d iap hragm . Do not need le in a cep halic
d irection so as to avoid the pleu ra.
Rectus abdominis muscle
A natomy: The m uscle originates in eriorly rom the pu bic crest
and the p ubic tu bercle, and interlaces w ith the contralateral
m u scle on the sym p hysis p u bis. Su p eriorly it inserts on the
costal cartilages o ribs 5–7 and the xiphoid process. The
p aired recti are sep arated by the linea alba in the m id line, and
are interru pted by three or ou r m ore or less com p lete trans-
verse tend inou s inscrip tions.
N eedling technique: The patient lies sup ine. For su perior and
in erior TrPs, the taut band and TrP are located u sing f at
p alp ation. The need le is inserted p erp end icu lar to the skin
and then d irected in a very shallow angle tow ard s the costal
cartilage (Fig. 61.19), or to the pubic bone (Fig. 61.20). For TrPs
in the m uscle belly, the operator sits on the contralateral sid e
o the p atient, and the TrP is id enti ed w ith f at p alp ation.

Figure 61.19 Dry needling of TrPs in the rectus abdominis muscle (at the rib
cage). (Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.20 Dry needling of TrPs in the rectus abdominis muscle (at the
pubic bone). (Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
The therapist d epresses the abd om inal w all ju st lateral o the
tau t band and p u lls it m ed ially w ith the TrP xated betw een
tw o ngers, thu s creating a ‘w all’, or a ‘shel ’; the need le is
inserted p erpend icu lar to the (now vertically oriented ) skin,
and is d irected m ed ially, thu s staying in the rontal p lane
(Fig. 61.21).
Precautions: Maintain a shallow angle in ord er to avoid
entering the abd om inal cavity; keep the need le parallel to the
rib m argin in ord er to avoid entering the pleural cavity and
thereby p ossibly cau sing a p neu m othorax.
External and internal oblique muscles
A natomy: The external obliqu e is the m ost sup er cial o the
lateral abd om inal m uscles. It originates rom eight d igitations
rom the external su r aces and in erior bord ers o ribs 5–12
near to w here they m eet the cartilages. The su p erior ve d igi-
tations interd igitate w ith the serratu s anterior, and the low er
three w ith the latissim u s d orsi. The bre d irection is rom
alm ost vertical in the lateral bres, to m ore and m ore obliqu e
Dry needling of selected trunk muscles  699
Figure 61.21 Dry needling of TrPs in the rectus abdominis muscle (shelf
technique). (Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.22 Dry needling of TrPs in the oblique abdominal muscles. (Modif ed
rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
in the m ore-m ed ial bres, all o w hich extend cau d ally. The
m ore-lateral bres attach to the anterior hal o the iliac crest,
w hereas the m ed ial bres join the abd om inal aponeurosis,
w hich attaches to the linea alba.
The internal oblique lies und erneath the external obliqu e
m u scle, and the bre d irection is o ten m ore or less p erp en-
d icu lar to the bre d irection o the latter. It originates on the
low er portion o the thoracolum bar ascia, the anterior tw o-
third s o the iliac crest, and the lateral hal o the ingu inal
ligam ent. The bre d irection is rom nearly vertical in the
lateral bres, to m ore and m ore obliqu e in the m ore-m ed ial
bres, all o w hich extend cep halically. The m ore-lateral bres
attach to the cartilages o the low er three or ou r ribs. The
m ore-m ed ial bres attach to the linea alba via the anterior and
p osterior rectu s sheath, and the m ost-m ed ial bres ru n m ore
horizontally and attach as a com m on tend on w ith the trans-
verse abd om inis to the p u bic crest and p ectineal line.
N eedling technique: The p atient is in sup ine or in sid e-lying
w ith the a ected sid e up . Using a pincher palpation, the
lateral portion o the abd om inal m u scles is grasped and
p u lled aw ay rom the abd om en. The therap ist need les the TrP
betw een tw o ngers tow ard s the opp osite thu m b or nger
w hile hold ing a rm grip (Fig. 61.22).
 700 PART 10 • 61 •
Figure 61.23 Dry needling of TrPs in the gluteus maximus muscle.
Precautions: Use o a p incer p alp ation w ill avoid the need le
going into the abd om inal cavity.
Dry Needling of Selected Hip
and Leg Muscles
Gluteus maximus muscle
A natomy: The m u scle originates rom the p osterior iliac crest,
the lateral sacru m and the coccyx. The bres ru n d iagonally
in erolaterally and insert onto the iliotibial band o the tensor
asciae latae and the glu teal tuberosity on the em ur betw een
the vastu s lateralis and ad d u ctor m agnu s.
N eedling technique: The patient is in prone position w ith a
p illow u nd er the abd om en, or in sid e-lying w ith the a ected
sid e u p . TrPs can be located and need led u sing f at p alp ation
p erp end icu lar to the m u scle, w hile the su bcu taneou s tissu e is
com p ressed ad equ ately (Fig. 61.23). I the TrP is located in the
in erior p art o the m u scle, o ten a p incer p alp ation can be
u sed : w hile xating the tau ght band betw een the ngers and
the thu m b, the therap ist d irects the need le tow ard s the op p o-
site nger.
Precautions: Avoid need ling the sciatic nerve by need ling
aw ay rom the nerve. The d epth o p enetration is also d epend -
ent on the am ou nt o subcutaneous tissu e.
Gluteus medius muscle
A natomy: The m u scle is ou nd betw een the glu teu s m axim u s
and the tensor asciae latae. It originates rom the anterior
three-qu arters o the iliac crest and inserts onto the greater
trochanter. The p osterior bres have a d iagonal d irection
tow ard s the in erior–lateral sid es, w hile the m ore-anterior
bres have a m ore vertical cou rse.
N eedling technique: The p atient is in p rone p osition or in
sid e-lying p osition w ith the a ected sid e u p . TrPs are
Dry needling of trigger points
Figure 61.24 Dry needling of TrPs in the gluteus medius muscle.
id enti ed w ith f at palpation perpend icular to the m u scle
bres (Fig. 61.24). Strong d epression o the su bcu taneou s
tissu e is requ ired . The need le d irection is p osterior to anterior.
N eed le contact at the periosteum is com m on.
Precautions: Avoid need ling the sciatic nerve by need ling
aw ay rom the nerve. The d epth o penetration is also d epend -
ent on the am ount o subcutaneous tissu e. In ad d ition, there
are d eep branches o the su perior glu teal vessels and nerve
betw een the gluteu s m ed ius and m inim u s, w hich should be
avoid ed .
Gluteus minimus muscle
A natomy: The m u scle is ound d eep to the gluteu s m ed ius. It
originates betw een the anterior and in erior glu teal lines on
the p osterior (d orsal) asp ect o the iliu m . It inserts onto the
anterior aspect o the greater trochanter.
N eedling technique: The p atient is in p rone or in sid e-lying
p osition w ith the a ected sid e u p . TrPs are id enti ed w ith
f at palpation perpend icular to the m uscle bres (Fig. 61.25).
Strong d ep ression o the su bcu taneou s tissu e is requ ired . The
need le d irection is p osterior to anterior. N eed le contact at the
p eriosteu m is com m on.
Precautions: There are d eep branches o the superior glu teal
vessels and nerve betw een the glu teu s m ed iu s and m inim u s,
w hich should be avoid ed . The d epth o penetration is also
d ep end ent on the am ou nt o subcutaneous tissu e.
Piriformis muscle
A natomy: The m u scle originates rom the anterior sur ace o
the sacru m at S2–S4. It exits the pelvis throu gh the greater
sciatic oram en. It inserts onto the u p p er bord er o the greater
trochanter o the em u r.
N eedling technique: The p atient is in p rone or in sid e-lying
p osition w ith the a ected sid e u p . The bony land m arks o
S2–S4 and the greater trochanter are recognized . TrPs are
id enti ed w ith f at palpation perpend icular to the m u scle

Figure 61.25 Dry needling of TrPs in the gluteus minimus muscle.
Figure 61.26 Dry needling of TrPs in the piriformis muscle.
bres. The need le d irection is d irectly into the m u scle throu gh
the glu teu s m axim u s m u scle (Fig. 61.26).
Precautions: Avoid need ling the sciatic nerve by need ling
aw ay rom the nerve, w hich is located in the m id d le third o
the m u scle. I need ling over the sciatic nerve is ind icated ,
ad vance the need le very slow ly to id enti y the exact location
o the nerve. The d ep th o p enetration is also d ep end ent on
the am ou nt o su bcu taneou s tissu e.
Adductor longus muscle
A natomy: The m u scle originates rom the su p erior p u bic
ram u s betw een the crest and the sym physis, and inserts onto
the linea asp era in the m id d le third o the em u r.
N eedling technique: The patient is in sup ine, w ith the knee
f exed and the hip f exed and externally rotated . Using a rm
Dry needling of selected hip and leg muscles  701
Figure 61.27 Dry needling of TrPs in the adductor longus and brevis muscles.
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
p incer p alp ation, the tau t band and the TrP are id enti ed . The
need le d irection is anterior to p osterior, p erp end icu lar to the
m u scle su r ace (Fig. 61.27). Som etim es, the ad d uctor longu s
and brevis can be need led at the sam e tim e.
Precautions: Avoid need ling the em oral nerve, artery and
vein, and the sciatic nerve.
Adductor brevis muscle
A natomy: The m u scle originates rom the anterior sur ace o
the in erior p u bic ram u s, in erior to the origin o the ad d u ctor
longus. It inserts onto the em ur at the p ectineal line and the
su p erior p art o the m ed ial lip o the linea asp era.
N eedling technique: The p atient is in sup ine position, w ith
the knee f exed and the hip f exed and externally rotated .
Using a f at palpation or a rm p incer palp ation, the therapist
id enti es the tau t band and the TrP in the u pper part o
the thigh betw een the ad d u ctor longu s and the p ectineu s. The
need le d irection is anterior–p osterior, perp end icular to the
m u scle su r ace and tow ard s the bu ttock crease. Som etim es
the ad d u ctor longu s and brevis can be need led at the sam e
tim e (see Fig. 61.27).
Precautions: Avoid need ling the em oral nerve, artery and
vein, and the sciatic nerve.
Adductor magnus muscle
A natomy: The m uscle is a large an-shaped m u scle w ith three
d i erent bre d irections. It originates rom the in erior ram u s
o the p u bis, the conjoined ischial ram u s, and the in erior–
lateral aspect o the ischial tuberosity. The short horizontal
bres insert onto the rou gh line o the em u r lead ing rom the
greater trochanter to the linea aspera, m ed ial to the glu teus
m axim u s. The obliqu e bres are oriented in erior–lateral and
insert by m eans o a broad ap oneu rosis into the linea aspera
and the u pp er part o its m ed ial prolongation below. The m ost
m ed ial p ortion, w hich is also called the ischiocond ylar p ortion,
has a vertical bre d irection, inserts into the ad d u ctor tu bercle
on the m ed ial cond yle o the em u r and is connected by a
 702 PART 10 • 61 •
Figure 61.28 Dry needling of TrPs in the adductor magnus muscle (supine).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.29 Dry needling of TrPs in the adductor magnus muscle (side-lying).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
brou s exp ansion to the line lead ing u p w ard s rom the tu ber-
cle to the linea asp era.
N eedling technique: The patient is in su pine position w ith
the knee f exed and the hip f exed and externally rotated (Fig.
61.28), or in sid e-lying position w ith the sid e to be treated
u nd erneath w hile the u p p er leg is f exed in ront o the low er
leg (Fig. 61.29) TrPs are id enti ed via f at palpation and the
need le is inserted p erp end icu lar to the m u scle su r ace. The
need le d irection is m ed ial–lateral.
Precautions: Avoid need ling the em oral nerve, artery and
vein along the ad d u ctor canal, and the sciatic nerve.
Pectineus muscle
A natomy: The m u scle is a f at, qu ad rangu lar m u scle. It origi-
nates rom the p ectin p u bis (the p ectineal line) and rom the
su r ace o the bone ju st anterior to it. It inserts at the lesser
trochanter d istally o the iliop soas. The bre d irection is
in erior–lateral.
Dry needling of trigger points
Figure 61.30 Dry needling of TrPs in the pectineus muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
N eedling technique: The patient is in supine position, w ith
the knee f exed and the hip f exed and slightly externally
rotated . The therapist should rst id enti y the em oral artery
lateral o the m uscle and then, w hile hold ing a nger on
this, id enti y the TrP via f at p alp ation ju st m ed ial o the
neu rovascu lar bu nd le. The need le is inserted p erp end icu lar
to the m u scle su r ace (Fig. 61.30). The need le d irection is
anterior–posterior.
Precautions: Avoid need ling the em oral artery, vein and
nerve lateral to the m u scle. Avoid need ling the obtu rator
nerve m ed ially, w hich lies d eep u nd er the m u scle next to the
tend on o the ad d u ctor longu s m u scle.
Psoas major muscle
A natomy: The p soas m ajor attaches at the 12th thoracic and all
lum bar vertebral bod ies, intervertebral d iscs, and the anterior
and in erior p ortions o the lum bar transverse p rocesses. It
p asses anterior to the sacroiliac joint. The m u scle shares a
com m on tend inou s insertion w ith the iliacu s m u scle at the
lesser trochanter on the posterom ed ial su r ace o the em u r.
N eedling technique: N eed ling o the belly o the psoas m u scle
is accom plished w ith the patient in the sid e-lying position.
There are tw o ap proaches. In the lateral approach, the qu ad -
ratu s lum boru m serves as the anatom ical land m ark. The
need le techniqu e is sim ilar to the techniqu e u sed or the qu ad -
ratu s lu m borum , but the need le is d irected at an anterior
angle o approxim ately 10–30° into the psoas m uscle (Fig.
61.31). A 75 m m need le m ay be u sed in m ost ind ivid u als o
average bu ild , bu t m ore-obese ind ivid u als m ay requ ire a
90 m m need le.
In the posterior app roach, the m u scle is approached at the
level o L3–L5, w ell below the kid ney, w hich is usu ally at
L1–L2. Palpate the sp inal processes o L3–L5 and the ad jacent
longissim u s m uscle. The need le is placed ju st lateral to the
lum bar longissim us m u scle into the iliocostalis m uscle. The
psoas lies alongsid e the vertebrae anterior to the transverse
processes. The need le is d irected parallel to the table w ith the
patient in the sid e-lying position (Fig. 61.32). I the need le hits
the transverse p rocess, the need le p lacem ent w as too m ed ial.
A 75 m m need le m ay be u sed in m ost ind ivid u als o average

Figure 61.31 Dry needling of TrPs in the psoas major muscle (lateral
approach).
Figure 61.32 Dry needling of TrPs in the psoas major muscle (posterior
approach). (Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
bu ild , but m ore-obese ind ivid uals w ill requ ire a 90 m m
need le.
Precautions: To avoid p enetration o the kid ney, as w ell as
the m ore cep halic d iap hragm and p leu ra, need le below the
level o L2.
Iliacus muscle
A natomy: The iliacu s m u scle com es rom the su p erior hal o
the iliac ossa, the inner lip o the iliac crest, the anterior liga-
m ents o the sacroiliac joint and the su p erior su r ace o the
lateral p ortion o the sacru m lling the lateral pelvic w all. It
shares a com m on tend inou s insertion w ith the p soas m ajor
m u scle at the lesser trochanter on the p osterom ed ial su r ace
o the em u r, w hile som e bres p ass below the trochanter onto
the m ed ial su r ace o the p roxim al em u r.
N eedling technique: The iliacu s m uscle m ay be approached
below the crest o the iliac bone w ith the patient in the sid e-
lying position. The therapist w raps the ngers o the non-
need ling hand arou nd the iliac crest to ‘hook on’ to the bone,
and inserts the need le ap proxim ately 5 m m rom the bone
into the abd om inal external obliqu e m u scle. The need le is
Dry needling of selected hip and leg muscles  703
Figure 61.33 Dry needling of TrPs in the iliacus muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.34 Dry needling of TrPs in the rectus femoris muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
d irected tow ard s the iliu m and kept close to the inner su r ace
o the iliu m so as to avoid p enetrating the abd om inal contents
(Fig. 61.33). For m ost patients, a 50–60 m m solid lam ent
need le is su cient, althou gh this m ay be d i cu lt to d o in
obese ind ivid uals. Use o a spinal need le or a 50–75 m m
need le allow s the d eep er p arts o the iliacu s to be reached
rom the iliac crest.
Precautions: To avoid penetration o the peritoneum , d irect
the need le tow ard s the inner su r ace o the iliu m .
Quadriceps femoris muscle group
Rectus femoris muscle
A natomy: The m uscle originates rom the anterior–in erior
iliac spine and the up per m argin o the acetabulum . It
inserts as a f at thick tend on at the base o the patella, w hich
eventu ally term inates via the patellar ligam ent on the tibial
tu berosity.
N eedling technique: The patient is in su pine position. The
need le is inserted perpend icu lar to the m uscle su r ace d irectly
into the tau t band , as id enti ed by f at p alp ation (Fig. 61.34).
 704 PART 10 • 61 •
Figure 61.35 Dry needling of TrPs in the vastus lateralis muscle (supine).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Posterior knee
Figure 61.36 Dry needling of TrPs in the vastus lateralis muscle (side-lying).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Precautions: Avoid need ling the lateral circu m f ex artery by
not need ling throu gh the m u scle.
Vastus lateralis muscle
A natomy: The m u scle originates rom a broad ap oneu rosis,
w hich is attached to the upp er part o the intertrochanteric
line, to the anterior and in erior bord ers o the greater tro-
chanter, to the lateral lip o the glu teal tu berosity and to the
u p p er hal o the lateral lip o the linea asp era; this ap oneu -
rosis covers the u pper three-qu arters o the m u scle, and m any
bres originate rom its d eep su r ace. It inserts via the com m on
f at tend on to the base and lateral bord er o the patella. It is
the largest m u scle o the qu ad ricep s em oris.
N eedling technique: TrPs in the anterior aspect o the m u scle
are need led w ith the patient in su pine p osition (Fig. 61.35);
TrPs in the lateral asp ect o the m u scle and in the p art o the
m u scle that is p osterior o the iliotract band are need led w ith
the p atient in sid e-lying or in p rone p osition (Fig. 61.36). The
Dry needling of trigger points
Figure 61.37 Dry needling of TrPs in the vastus medialis muscle. (Modif ed
rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
need le is inserted p erp end icu lar to the m u scle su r ace d irectly
into the tau t band , as id enti ed by f at palpation.
Precautions: N one.
Vastus medialis muscle
A natomy: The m u scle originates rom the ront and m id d le
sid es o the intertrochanteric line o the em u r, traversing
the p ectineal line, the m ed ial lip o the linea asp era, and the
m ed ial su p racond ylar line o the em u r. It inserts as all the
bres converge onto the m ed ial p art o the qu ad ricep s em oris
tend on and the m ed ial bord er o the p atella.
N eedling technique: The p atient is in su p ine p osition. The
need le is inserted p erpend icu lar to the m uscle sur ace d irectly
into the TrP, as id enti ed by f at p alp ation (Fig. 61.37).
Precautions: N one, althou gh it is possible to get close to the
sap henou s nerve and p op liteal artery.
Biceps femoris muscle
A natomy: The m u scle is com posed o tw o head s. The long
head originates rom the u p p er p art o the ischial tu berosity
via a tend on it shares w ith the sem itend inosu s m u scle, and
rom the low er parts o the sacrotuberous ligam ent. The short
head o the m u scle com es rom the lateral lip o the linea
aspera, bu t it m ay be totally absent. The tw o head s m erge
at the d istal end o the m u scle and attach to the bu lar head ,
the lateral cond yle o the tibia and the bu lar collateral
ligam ent.
N eedling technique: The p atient is in p rone p osition, w ith
the knee slightly f exed and the low er leg su p p orted by a
p illow. The need le is inserted p erp end icu lar to the m u scle
su r ace d irectly into the TrP, as id enti ed by f at p alp ation
(Fig. 61.38).
Precautions: Avoid need ling the sciatic nerve, w hich lies in
the m id line o the p osterior thigh, by inserting the need le
m ed ially w hen need ling the p roxim al p art o the m u scle, and
laterally w hen need ling the d istal part o the m u scle. When

Figure 61.38 Dry needling of TrPs in the biceps femoris muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.39 Dry needling of TrPs in the semi hamstrings muscle. (Modif ed
rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
need ling d irectly over the nerve, care u l exp loration o the
region w ith the need le w ill easily id enti y the exact location
o the nerve.
Semimembranosus muscle
A natomy: The m u scle originates, w ith a f at tend on it shares
w ith the biceps em oris and the sem itend inosu s m uscles, rom
the su p erior–lateral asp ect o the ischial tu berosity. It then
travels d eep to the sem itend inosu s m u scle and inserts at the
tu bercle o the m ed ial tibial cond yle, the m ed ial m argin o the
tibia, the ascia over the p op liteu s m u scle and the lateral
em oral cond yle w here it orm s m uch o the obliqu e p opliteal
ligam ent.
N eedling technique: The p atient is in p rone p osition, w ith the
knee slightly f exed and the low er leg su pported by a pillow.
The need le is inserted perpend icular to the m uscle su r ace
d irectly into the TrP, as id enti ed by f at palpation (Fig. 61.39).
Precautions: Avoid the sciatic nerve by need ling in a m ed ial
d irection.
Dry needling of selected hip and leg muscles  705
Figure 61.40 Dry needling of TrPs in the anterior tibialis muscle. (Modif ed
rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Semitendinosus muscle
A natomy: The sem itend inosus m u scle originates rom the
in erom ed ial p art o the ischial tu berosity via a tend on it
shares w ith the bicep s em oris and the sem im em branosu s
m u scles, and rom an ap oneu rosis connecting the m u scles. It
inserts via a long tend on overlying the sem im em branosu s
m u scle at the u p p er p art o the m ed ial su r ace o the tibia
behind the insertion o the sartoriu s and d istal to the insertion
o the gracilis (p es anserine).
N eedling technique: The p atient is in p rone p osition, w ith the
knee slightly f exed and the low er leg su pported by a p illow.
The need le is inserted perp end icu lar to the m uscle su r ace
d irectly into the TrP, as id enti ed by f at palpation, sim ilarly
to need ling the sem im em branosu s m u scle (see Fig. 61.39).
Precautions: Avoid need ling the sciatic nerve by need ling
in a m ed ial d irection.
Tibialis anterior muscle
A natomy: The m u scle originates rom the lateral cond yle o
the tibia and u p p er tw o-third s o the lateral su r ace o the
tibia. It inserts into the p lantar and m ed ial asp ects o the
m ed ial cu nei orm and the m ed ial asp ect o the base o the rst
m etatarsal bones.
N eedling technique: The patient is in su pine position. The
need le is inserted perpend icu lar to the m uscle su r ace, and
the need le is d irected slightly m ed ial to the tibia into the TrP,
as id enti ed by f at palpation (Fig. 61.40).
Precautions: Avoid need ling the neu rovascu lar bu nd le,
w hich is com posed o the anterior tibial artery and vein and
the d eep bu lar nerve, and w hich ru ns d irectly behind the
lateral asp ect o the m u scle, by need ling m ed ially tow ard s
the tibia or by initially need ling su p er cially w ith d eep er
ad vances w ith each need le m ovem ent u ntil the trigger p oint
has been reached .
Gastrocnemius muscle
A natomy: The m uscle is com posed o tw o head s. The m ed ial
and lateral head s originate rom each respective cond yle o
 706 PART 10 • 61 •
Figure 61.41 Dry needling of TrPs in the gastrocnemius muscle (medial head).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
Figure 61.42 Dry needling of TrPs in the gastrocnemius muscle (lateral head).
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
the em u r and attach to the cap su le o the knee joint. Distally,
the m u scle bres end on an ap oneu rosis that joins the soleu s
m u scle to orm the Achilles tend on, w hich su bsequ ently
attaches to the p osterior su r ace o the calcaneu s.
N eedling technique: The p atient is prone, w ith the knee
slightly f exed and the low er leg su p p orted by a p illow. For
TrPs in the central p art o the m ed ial head , a p incer p alp ation
is u sed to locate and x the tau t band and the TrP. The need le
is angled m ed ially, tow ard s the nger located at the op p osite
sid e (Fig. 61.41). For TrPs in the central part o the lateral
head , a f at p alp ation is m ore com m only u sed to locate and
x the tau t band and the TrPs. The need le is d irected p erp en-
d icu lar to the m u scle sur ace, aim ing tow ard s the TrP in a
p osterior–anterior d irection w ith a slightly lateral angu lation
(Fig. 61.42).
Precautions: When need ling the p roxim al head s o the
m u scle, care m u st be taken not to need le the neu rovascu lar
Dry needling of trigger points
Figure 61.43 Dry needling of TrPs in the soleus muscle. (Modif ed rom
Dommerholt J, Fernández-de-las-Peñas C 2013.)
bu nd le, w hich is com posed o the tibial nerve and the p op -
liteal artery and vein in the m id line o the popliteal ossa. In
ad d ition, care m u st be taken to avoid need ling the bu lar
nerve w hen need ling the lateral head , w hich lies ju st m ed ial
to the bicep s em oris tend on. There are m any anatom ical vari-
ations w ith regard s the location and sp lits o the nerves. It is
there ore im p erative that clinicians u se good clinical skills
and ju d gem ents in ord er to need le the TrPs in this area sa ely.
Fu rtherm ore, the posterior capsule o the knee should be
avoid ed . Lastly, w hen need ling the central bellies o both
head s, the neu rovascu lar bu nd le in the m id line shou ld be
avoid ed by need ling m ed ially w hen need ling the m ed ial
head , and by need ling laterally w hen need ling the lateral
head .
Soleus muscle
A natomy: The m u scle originates rom the posterior aspect o
the head and the m id d le third o the p osterior bord er o the
bu la and the soleal line, rom the m id d le third o the m ed ial
bord er o the tibia, and rom the tend inou s arch spanning
betw een the tw o bones. Distally, the m u scle bres attach to
the ap oneu rosis and join the gastrocnem iu s m u scle to orm
the Achilles tend on, w hich su bsequ ently attaches to the p os-
terior su r ace o the calcaneu s.
N eedling technique: Proxim al TrPs can be need led tow ard s
the bu la w ith the p atient lying on the u ninvolved sid e. The
need le is inserted p erp end icu lar to the m u scle su r ace d irectly
into the TrP, as id enti ed by f at palpation. For d istal m ed ial
or lateral TrPs, the w hole m u scle can be held in a p incer
betw een the thum b and tw o ngers, w ith the patient either in
a p rone or in a sid e-lying p osition. The need le is d irected
tow ard s the op p osite nger or thu m b (Fig. 61.43).
Precautions: When need ling the m ed ial p art o the m u scle,
care m u st be taken to avoid need ling the p osterior tibial nerve,
by avoid ing need ling the m id line.
Flexor digitorum longus muscle
A natomy: The m u scle originates rom the p osterior su r ace o
the m id d le tw o-qu arters o the tibia below the attachm ent o

Figure 61.44 Dry needling of TrPs in the exor digitorum longus muscle.
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
the soleu s m u scle, and the d eep layer o the interm u scu lar
sep tu m shared w ith the tibialis p osterior m u scle. Distally,
each o the ou r tend ons attaches to the correspond ing
base o the d istal phalanx o the second , third , ou rth and
th toes.
N eedling technique: The patient lies on the involved sid e,
w ith the hip s and knees bent at 90°. TrPs are id enti ed by f at
palp ation d irectly behind the p osterior su r ace o the tibia.
The need le is inserted perpend icular to the m uscle su r ace
and is d irected m ainly in a lateral bu t also slightly anterior
d irection (Fig. 61.44). The need le shou ld be kept close to the
posterior asp ect o the tibia. Alternatively, the m uscle can be
treated w ith the p atient in the p rone p osition.
Precautions: Avoid need ling the neu rovascu lar bu nd le,
w hich is com posed o the tibial nerve, the posterior tibial
artery and vein, and w hich lies d irectly behind the m u scle, by
keeping the need le close to the tibia.
Fibularis (peroneus) longus
and brevis muscles
A natomy: The bu laris longu s m u scle originates rom the
bu lar head , rom the p roxim al tw o-third s o the lateral
asp ect o the bu la, and rom the ad jacent m uscu lar septa. It
inserts onto the d orsal and lateral sid es o the m ed ial cu nei-
orm and the rst m etatarsal bones. The bu laris brevis origi-
nates rom the low er tw o-third s o the lateral asp ect o the
bu la and rom the ad jacent m u scu lar sep ta. It inserts onto
the lateral sid e o the base o the th m etatarsal bone. The
bu laris brevis is p artially covered by the longu s.
N eedling technique: The patient lies on the uninvolved sid e,
w ith the hip s and knees bent to 90°. TrPs are id enti ed by f at
palp ation. The need le is inserted laterally perpend icular to the
m u scle su r ace and is d irected in a m ed ial d irection tow ard s
the bu la (Fig. 61.45).
Precautions: Avoid need ling the com m on bu lar nerve,
w hich lies d eep to the proxim al third o the bu laris longu s
m u scle. Avoid need ling the su p er cial bu laris nerve, w hich
lies ju st anterior o the bularis brevis m u scle, by avoid ing
need ling in an anterior d irection, bu t instead d irecting the
need le aw ay rom the nerve.
Dry needling of selected hip and leg muscles  707
Figure 61.45 Dry needling of TrPs in the bularis longus and brevis muscles.
(Modif ed rom Dommerholt J, Fernández-de-las-Peñas C 2013.)
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 PART 10 •  Soft Tissues in the Upper and Lower Quadrants
Muscle Energy Approaches
62  
Chapter 
G a ry Frye r
CHAP TER CONTENTS
Introduction
Evidence of effectiveness
Physiological mechanisms
An integrated approach to muscle energy
Principles of muscle energy application
General principles
Cautions and contraindications
Techniques for the spine, rib cage and pelvis
Principles of application of muscle energy to the joints of   exist, su ch as the use o concentric contractions against a
the spine
Cervical spine
Thoracic spine
Rib cage
Lumbar spine
Pelvic girdle
Techniques for myofascial tissues
Principles of application of muscle energy to myofascial tissues
Muscles of the upper quadrant
Muscles of the lower quadrant
Introduction
Mu scle energy techniqu e (MET) is a system o m anu al p roce-
d u res that u tilizes active m uscle contraction e ort rom the
p atient, u su ally against a controlled m atching cou nter orce
rom the practitioner. The MET system w as d evelop ed by
osteopathic physician Fred Mitchell Sr in the 1950s, althou gh
techniqu es u sing resisted m u scle e ort to increase range o
m otion w ere d ocu m ented as early as 1919 (Sw art 1919). The
evolution o MET continued w ith contributions rom Fred
Mitchell Jr, w ho system atized and u rther d evelop ed the
m ethod s in techniqu e m anu als (Mitchell Jr & Mitchell 1995).
The MET ap proach has benef ted rom contribu tions by
m any ind ivid u als and is p ractised by clinicians in d i erent
m anu al therap y d iscip lines. MET has been u sed to lengthen
shortened m u scles, m obilize articu lations w ith restricted
m obility, strengthen w eakened m u scles and red u ce localized
oed em a and p assive congestion (Mitchell Jr & Mitchell 1995;
Good rid ge & Ku chera 1997; Chaitow 2013).
The m ost com m only d escribed MET is the p ost-isom etric
relaxation (or ‘contract–relax’) techniqu e, w hich is used
 
p articu larly w hen increasing m u scle length or joint range o
m otion. The nu m ber o rep etitions is in u enced by the
710 response o the involved tissu es, bu t three to f ve rep etitions
710 have been recom m end ed (Mitchell Jr & Mitchell 1995;
Good rid ge & Kuchera 1997; Chaitow 2013). The orce and
711
d u ration o isom etric e ort can vary, d epend ing on the aim
711
o the techniqu e and the tissu es involved . A gentle, controlled
712 isom etric e ort is u su ally su itable or treatm ent o sp ecif c
712 joint d ys u nctions, m yo ascial trigger p oints (TrPs), or acu te
712 m yo ascial p ain; a stronger contraction can be em p loyed or
712 f brotic, shortened m u scles. Other variations o this techniqu e
713 yield ing resistance to increase strength and recruitm ent o a
714 m u scle, or recip rocal inhibition techniqu es that acilitate
716 relaxation o a m u scle w hen app lied to the antagonist m u scle,
718 bu t these techniqu es w ill not be d etailed in this chapter.
720 Sim ilarities exist betw een MET and other orm s o p ost-
721 isom etric stretching, su ch as prop rioceptive neurom u scular
723 acilitation techniqu es, particu larly w hen the techniqu es are
ap plied to acilitate the lengthening o m u scle. H ow ever, MET
723
w as d eveloped along biom echanical principles or the treat-
724
m ent o sp inal and p elvic joint d ys u nction, w hich is evid ent
726 in m any MET texts (Mitchell Jr & Mitchell 1995). Thu s, it is
very d i erent rom other treatm ent system s that u se isom etric
contraction.
Evidence of effectiveness
As w ith m any m anual therapy approaches, robu st, high-
qu ality research investigating the clinical e ectiveness o MET
is lacking (Fryer 2013). More research is need ed or u sing MET
in patients w ith spinal p ain and d isability, but a num ber o
sm all rand om ized controlled trials o er low -qu ality su p p ort
or the e ectiveness o MET or acute and chronic low back
p ain (LBP) and or neck p ain. Ad d itionally, evid ence su ggests
there are short-term increases in sp inal range o m otion and
m u scle extensibility ollow ing treatm ent.
Regard ing acu te LBP, researchers have ou nd that MET
ap plied to spinal and pelvic joint or m u scle d ys u nctions
im p roved pain and d isability. Wilson et al (2003) assigned 19
p atients w ith acu te LBP to an MET grou p ( or treatm ent o a
sp ecif c lu m bar joint d ys u nction) or to a m atched control
grou p that received a sham treatm ent (sid e-lying passive
m otion); both grou p s also u nd ertook a hom e exercise p ro-
gram m e. The MET patients show ed a signif cantly higher
change in d isability scores than d id the control p atients, and

every MET p atient had a greater im provem ent than control
patients. Selkow et al (2009) applied MET to innom inate d ys-
u nction in p atients w ith a recent acu te ep isod e o lum bopel-
vic p ain and rep orted a signif cant d ecrease in p ain severity
in the MET grou p 24 hou rs a ter treatm ent com p ared w ith a
sham control grou p .
Several stu d ies rep orted im p rovem ents in acu te LBP ol-
low ing MET ap plied to the lu m bar and pelvic m uscu latu re.
Salvad or et al (2005) com p ared MET ap p lied to the p arasp i-
nal, qu ad ratu s lu m boru m , ham strings and p iri orm is m u scles
w ith transcu taneou s nerve stim ulation in 28 garbage w orkers
w ith acu te LBP. The au thors reported signif cant pain red u c-
tion and increased extensibility o m u scles in the MET grou p .
Sim ilarly, Patil et al (2010) rand om ized 20 su bjects w ith acu te
LBP p ain into tw o grou p s; both received inter erential therap y
bu t the MET grou p also received MET to stretch the qu ad ratu s
lum boru m m uscle. Although pain d ecreased in both grou ps,
a signif cant d ecrease in d isability and increase in spinal range
o m otion w as rep orted or the MET grou p .
Stu d ies also su ggest benef ts o MET or p atients w ith
chronic LBP. Rana et al (2009) rep orted large im p rovem ents
in pain and d isability in LBP patients w ho u nd erw ent six ses-
sions o MET or p assive m obilization ap p lied to sp ecif c p elvic
d ys unctions, but not in the control group . Dhinkaran et al
(2011) reported greater im p rovem ents in pain and d isability
in the group that received MET to a d iagnosed pelvic d ys u nc-
tion com p ared w ith those w ho received transcu taneou s elec-
trical stim u lation. These stu d ies u sed sm all sam p le sizes,
how ever, and the statistical analysis p roced u res w ere u nclear.
MET has been rep orted as help u l or neck p ain. Gu p ta et al
(2008) ou nd that MET (re erred to as p ost-isom etric relaxa-
tion) p rod u ced a greater im p rovem ent in p ain, d isability and
m otion in 38 p atients w ith non-specif c neck p ain com pared
w ith isom etric exercises over 3 w eeks. In a case series, Mu rp hy
et al (2006) rep orted p ositive resu lts u sing m u scle energy or
cervical m anip u lation in 27 patients w ith neck and / or arm
pain w ith f nd ings o cervical sp inal cord encroachm ent.
Regard less o the treatm ent, these p atients rep orted su bstan-
tial im p rovem ent in neck p ain and d isability w ithou t any
m ajor com p lications associated w ith the treatm ent.
MET (or sim ilar isom etric stretching techniqu es) has
increased the extensibility o m uscles m ore than by passive
stretching alone (Fryer 2013). MET has also increased the
range o neck and trunk m otion (Schenk et al 1994, 1997;
Lenehan et al 2003; Fryer & Ruszkow ski 2004; Bu rns & Wells
2006). H ow ever, these m otion and exibility stu d ies have
exam ined only the im m ed iate or short-term e ect o treat-
m ent, o ten in healthy p ain- ree p atients, bu t little evid ence
links im p rovem ents in exibility and m obility to p ositive
patient ou tcom es. Altogether, the research on MET supports
its u se or im p roving clinical ou tcom es, su ch as pain, d isabil-
ity and restricted m otion, but the stu d ies are generally o low
qu ality and u rther investigation is requ ired that u ses robu st
m ethod ology and larger sam p le sizes, inclu d ing m easu res o
the longevity o these e ects, in ord er to veri y the clinical
benef t o MET.
Physiological mechanisms
Although the m echanism s by w hich MET prod uces therapeu-
tic benef t are sp ecu lative, MET m ay p rod u ce neu rological
and biom echanical e ects, bu t possibly through m echanism s
Introduction 711
not typ ically d escribed in MET texts (Fryer & Fossu m 2010;
Fryer 2013). Trad itionally, MET w as thou ght to prod u ce
m u scle relaxation via Golgi tend on organ and m u scle sp ind le
re exes (Ku chera & Kuchera 1992; Mitchell Jr & Mitchell
1995), but this explanation seem s unlikely as stud ies had
reported increases in electrom yographic activity ollow ing
p ost-isom etric stretching techniqu es (Osternig et al 1987,
1990). MET has also been proposed to reset the neu rological
resting length o m u scles, bu t it appears that m otor
activity d oes not play a signif cant role in lim iting p assive
stretch o a m u scle, at least in healthy, u ninju red ind ivid u als
(Magnusson et al 1996a).
Increased exibility o m uscle group s ollow ing isom etric
contraction is largely attribu table to an increase in an ind i-
vid u al’s tolerance to stretch, rather than to lasting biom e-
chanical change in the tissu e (Magnu sson et al 1996b; Fryer
2013). Increased stretch tolerance m ay be a resu lt o a d ecrease
in pain perception (hypoalgesia) through the activation o
m u scle and joint m echanorecep tors involving centrally m ed i-
ated p athw ays, such as the p eriaqu ed u ctal grey in the m id -
brain region and non-opioid serotonergic and norad renergic
d escend ing inhibitory p athw ays (Souvlis et al 2004; Fryer &
Fossu m 2010). Ad d itionally, MET prod uces hypoalgesia via
p erip heral m echanism s associated w ith increased u id d rain-
age. Rhythm ic m u scle contractions increase m u scle blood and
lym ph ow rates (Coates et al 1993; H avas et al 1997).
Mechanical orces, su ch as load ing and stretching, acting on
f broblasts in connective tissu es m ay a ect f broblast m echan-
ical signal transd uction processes (Langevin et al 2004), thu s
changing the interstitial p ressu re and increasing transcap il-
lary blood ow (Langevin et al 2005). These actors m ay p lay
a role in the tissu e response to injury and in am m ation; MET
m ay su p p ort these p rocesses by red u cing the concentrations
o p ro-in am m atory cytokines, resu lting in d ecreased sensiti-
zation o peripheral nocicep tors.
In ad d ition to hypoalgesia, MET m ay involve neurological
m echanism s to enhance p rop riocep tion and m otor control in
p atients w ith p ain. Patients w ith sp inal p ain have d ecreased
aw areness o the d irection o sp inal m otion and p osition
(Leinonen et al 2002; Grip et al 2007; Lee et al 2007) and
changes in p arasp inal m u scle m otor strategies (Fryer et al
2004). For instance, high-velocity spinal m anipu lation
im proves head re-positioning in chronic neck pain p atients
(Rogers 1997; Palm gren et al 2006) and m otor recruitm ent
strategies in LBP p atients (Ferreira et al 2007). Malm strom
et al (2010) ound that a prolonged unilateral neck m u scle
contraction task increased the accu racy o head rep ositioning.
Although the su ggestion is specu lative, MET m ay enhance
p rop riocep tion, m otor control and m otor learning becau se it
involves active and precise recru itm ent o m uscle activity.
This area d eserves urther investigation.
An integrated approach to muscle energy
MET w as d evelop ed to be ap p lied in a holistic m anner, con-
sistent w ith osteop athic p rincip les. The osteop athic d iscip line
em phasizes the unity and interconnected ness o the bod y, the
inter-relationship o stru ctu re and unction, and the in uence
o the m u scu loskeletal system on other system s and general
health. The MET ap p roach w as based on a sp ecif c d iagnostic
m od el that em p hasized a global view o bod y biom echanics
and includ ed screening and scanning o global p ostu re,
 712 PART 10 • 62 • Muscle energy approaches
m ovem ent p atterns and gross and segm ental range o m otion
(Mitchell Jr & Mitchell 1995). For exam ple, in patients present-
ing w ith neck and arm p ain, the bod y m ay be exam ined rom
head to toe (p ostu re, static and d ynam ic sym m etry, and active
and passive range o m otion), and treatm ent m ay be d irected
at any or all o the regions that are believed to be problem atic
– low er lim b, p elvic, lum bar, thoracic, rib cage, neck, head and
u p p er extrem ity. Im p licit in this ap p roach are the concep ts
that d ys u nction in one region m ay cau se com p ensation and
strain in other regions and that treatm ent that ad d resses only
the sym p tom atic site is likely to achieve only short-term relie .
In recent years, researchers have reported that m anipu lative
treatm ent p rod u ces rem ote and system ic e ects; or instance,
cervical treatm ent im p roves shou ld er sym p tom s (Aparicio
et al 2009) and thoracic treatm ent im proves neck pain (Cleland
et al 2005; González-Iglesias et al 2009) and should er pain and
d isability (Boyles et al 2009).
Assessm ent and treatm ent o the thorax – inclu d ing the
spinal joints, ribs, and m u scles – are extrem ely im portant or
p atients w ith neck and arm com plaints. Treatm ent o this
region shou ld preced e treatm ent o the neck and up per
extrem ity becau se (in the author ’s exp erience) it o ten pro-
d u ces im provem ent o sym ptom s and physical f nd ings in the
neck and extrem ities.
MET m ay be ap p lied in com bination w ith other m anu al
techniqu es, su ch as so t tissu e m anip u lation, p assive joint
articulation, high-velocity thru st, and gentle ind irect tech-
niqu es su ch as u nctional techniqu e and cou nterstrain (w here
tissu es are held in a p osition o ease). There is no u niversal
agreem ent on the criteria or selection o a p articular tech-
niqu e or a given cond ition or p atient, bu t p ractitioner and
p atient p re erences are signif cant d eterm inants. Little evi-
d ence is available to gu id e clinicians regard ing the m ost e ec-
tive com bination o techniqu es. H ow ever, Tram pas et al (2010)
ou nd that the com bination o cross-f bre m assage w ith a
contract–relax technique p rod u ced signif cant im p rovem ents
in p ressu re p ain sensitivity o a TrP, w hich su p p orts p ersonal
experience that so t tissu e techniques w ork w ell w ith MET or
treating m u scle d ys u nction.
Techniqu es m ay be selected based on their likely therap eu -
tic m echanism s, d esp ite the sp ecu lative natu re o those m ech-
anism s. For exam p le, MET m ay be used w here uid d rainage
and im p roved p rop riocep tion are d esired , high-velocity thru st
m ay be u sed w here joint end eel is p articu larly hard , end -
range articu lation m ay be used w here joint m otion appears to
be restricted by f brotic changes in p eriarticular tissues, and
ind irect ap p roaches m ay be u sed w here signif cant in am m a-
tion and p ain are p resent. The integration o these d i erent
techniqu es m ay involve intu itive cu es rom p alp ation and the
p ragm atic u se o alternative techniqu es i the initial tech-
niqu es ail to achieve the intend ed tissu e and m otion changes.
Principles of Muscle
Energy Application
General principles
The elem ents com p rising the ap plication o MET – restrictive
barrier engagem ent, orce o contraction, d u ration o contrac-
tion and p ost-isom etric stretch, nu m ber o repetitions – can be
varied accord ing to the tissu e or joint, the aim o the techniqu e
and the response o tissu es to treatm ent. In general, the p recise
localization o leverages in one or m ore p lanes to a restrictive
joint barrier w ith a gentle contraction e ort is im p ortant or
the ap p lication o MET to a single joint d ys u nction. These
p rincip les m ay also be ap p lied to irritable or p ain u l m yo as-
cial tissu es, and the orce o stretch and contraction intensity
m ay be p rogressively increased or m u scles that are short and
f brotic w ithou t su bstantial tend erness. In all cases, the p racti-
tioner shou ld have a w ell-balanced p ostu re to p rovid e control
and resistance to the isom etric e ort in an econom ical m anner.
The patient should alw ays be com ortable; the proced u res
shou ld not be p ain u l even w hen the therap ist is u sing a m od -
erate stretching orce or large m uscles. This chap ter d escribes
techniqu es or a nu m ber o com m only encou ntered joint and
m u scle d ys u nctions; how ever, the p ractitioner w ith a clear
u nd erstand ing o m u scle anatom y, joint biom echanics and the
p rincip les o MET shou ld be able to m od i y the techniqu es to
ad d ress any joint restriction or shortened m u scle.
Cautions and contraindications
MET is a sa e techniqu e, and no rep orts o seriou s ad verse
reactions have been ou nd in the literatu re. Typically, very
gentle to m od erate applications o stretch or isom etric con-
traction are p er orm ed , so MET is also p erceived as a tech-
niqu e w ith little risk o seriou s inju ry. The cau tions and
contraind ications or MET are sim ilar to those o other so t
tissu e techniqu es and inclu d e cau tion w ith the u se o orce
and leverage w hen d ealing w ith acu te pain cond itions and
ind ivid u als w ith w eakened bone. When app lied to previously
injured , healing tissu es, the orces o contraction or stretch
shou ld be m atched to the stage o healing and rep air in ord er
to avoid u rther tissu e d am age and to p rom ote op tim al
healing (Led erm an 2005).
Cerebrovascu lar accid ents ollow ing high-velocity m anip -
u lation to the cervical sp ine have been rep orted as rare com -
p lications (Di Fabio 1999; H ald em an et al 2001). Although no
su ch incid ents have been rep orted or MET, cau tion shou ld be
taken w hen treating the cervical sp ine. Fortu nately, the lever-
ages ad vocated or MET ap plied to the cervical sp ine are
su btle and m inim al, and the avoid ance o end -range rotation
and extension leverages m ay u rther red uce risks p osed
by MET.
All techniqu es shou ld be app lied slow ly and care u lly w ith
p atient eed back. I the p atient exp eriences d iscom ort or any-
thing other than a p leasant stretching sensation, the p racti-
tioner shou ld stop the p roced u re im m ed iately and reassess
the p atient. The techniqu e shou ld also be stop p ed and the
p atient reassessed i there are any signs o vertebrobasilar
insu f ciency (Gibbons & Tehan 2006) such as vertigo, visual
d istu rbances, d ysphagia, d ysarthria, hoarseness, acial nu m b-
ness, p araesthesia, con u sion or syncop e (d rop attacks).
Techniques for the Spine,
Rib Cage and Pelvis
The ollow ing are d escriptions o techniqu es that illustrate the
ap plication o MET to ad d ress m otion restrictions at variou s
sp inal segm ents and to the joints o the rib cage and p elvis.

The techniques are intend ed to ad d ress specif c p hysical d iag-
nostic f nd ings, and a brie d escrip tion o d iagnostic
ap p roaches is p rovid ed . It is beyond the scop e o this chapter
to d escribe assessm ent p roced u res thorou ghly and it is
assu m ed that the clinician w ill alread y be skilled in assessing
the sp ine and p elvis. The listed techniqu es and d escrip tions
are not intend ed to be exhau stive, bu t rather to illustrate the
ap p lication in d i erent regions. Once the read er u nd erstand s
the p rincip les o ap p lication, techniqu es can be ad ap ted or
any com bination o m otion restrictions at any m otion segm ent.
Principles of application of muscle energy to
the joints of the spine
The app lication o MET to the intervertebral joints o the spine
d i ers rom its application to large m uscles in term s o the
need or localization, control and orce (Mitchell Jr & Mitchell
1995). The basic p rinciples o ap plication to intervertebral seg-
m ents to increase range o m otion inclu d e:
1. Localization: Care u l attention is requ ired to engage the
restrictive barrier accu rately at the involved level using
the initial sense o increasing resistance to m otion (‘f rst’
or ‘ eather ed ge’ o barrier) (Mitchell Jr & Mitchell 1995).
The p rim ary p lane o m otion restriction should be
engaged f rst, a ter w hich ‘f ne-tuning’ can be per orm ed
u sing second ary p lanes o m otion restriction (i
d etected ) and / or translation. The patient m u st be
relaxed , so that active m u scle contraction is not helping
or hind ering the engagem ent o the restrictive barrier.
2. Contraction and control: The patient is instructed to
p u sh actively bu t u sing a very gentle orce aw ay rom
the restrictive barrier against the p ractitioner ’s
controlled , u nyield ing counter orce or 3–5 second s. Too
strong a contraction w ill recru it larger, m u ltisegm ental
m u scles and create d i f cu lty in m aintaining accu rate
localization. The p ractitioner should give clear
instru ctions to the patient and be relaxed in ord er to
acilitate patient relaxation.
3. Relaxation: The patient should be allow ed to relax u lly
or several second s.
4. Re-engage the barrier: Usu ally the restrictive barrier is
p erceived to change or reced e, and the p ractitioner
shou ld take u p the slack to re-engage this barrier.
5. Repetition: The p roced u re is typically p er orm ed 2–4
tim es.
6. Re-examination: This w ill d eterm ine w hether the range
or qu ality o m otion has im p roved .
Box 62.1 show s com m on errors in MET ap plication.
Spinal coupled motion
Many texts on MET em p hasize the cou p led m otions that are
com m on in d i erent sp inal regions and d escribe a d iagnostic
and treatm ent app roach to ad d ress the planes o restricted
m otion in a segm ent (Mitchell Jr & Mitchell 1995; Greenm an
2003). The trad itional MET approach w as based on the bio-
m echanical p rincip les o sp inal cou p led m otion p rop osed by
Fryette (1954), w here typ e 1 ‘neutral’ cou p led m otion w as
d escribed as contralateral cou pling o rotation and lateral
exion, and typ e 2 ‘non-neutral’ cou p led m otion involved
Techniques for the spine, rib cage and pelvis  713
Bo x 6 2 .1 C o m m o n e rro rs in m u s c le e n e rg y
a p p lic a tio n
• Joint barrier is overlocked.
• Patient pushes too hard.
• Patient’s contraction duration is too s hort.
• The use of too few repetitions (wait for tiss ue change).
• Patient does not relax.
• Practitioner does not offer s table support of limb, region or
patient.
• Practitioner allows movement during contraction phas e.
• Practitioner is uncomfortable, awkward, poorly positioned,
unbalanced or tense.
ipsilateral coupling o rotation and lateral exion w hen the
sp ine w as in a non-neu tral ( exed or extend ed ) p ostu re. Som e
au thors ad vocate that the clinician shou ld assess the sp ine or
asym m etry o the transverse processes w hile the spine is in
d i erent p ostures (neutral, exed or extend ed ) and m ake
in erences about m otion restrictions rom the relative
p osition o these land m arks (Mitchell Jr & Mitchell 1995;
Greenm an 2003).
N evertheless, the u se o this m od el has been criticized or
its prescriptive d iagnostic labelling, w hich allow s only three
p ossible com binations o trip lanar m otion restriction: one
type 1 (sid e-bend ing and rotation to op posite sid es) and tw o
type 2 com binations (sid e-bend ing and rotation to the sam e
sid e w ith either exion or extension), and has qu estionable
in erences rom static positional assessm ent (Gibbons & Tehan
1998; Fryer 2000, 2009). Sp inal cou pled m otion in the lum bar
region app ears to be unpred ictable, w ith variability betw een
sp inal levels and betw een ind ivid u als (Gibbons & Tehan 1998;
Legaspi & Ed m ond 2007), and there is little evid ence to ind i-
cate consistent p atterns o thoracic m otion cou p ling, althou gh
m ore rigorou s stu d ies are requ ired (Sizer et al 2007). The
original Fryette m od el d escribed the cervical sp ine (C2–C7) as
having only typ e 2 cou pled m otion. This notion is consistent
w ith recent stu d ies (Cook et al 2006; Ishii et al 2006), bu t
others su ggest that variability in the am ou nt and d irection o
these m ovem ents is in u enced by gend er, age and cervical
p ostu re (Ed m ond ston et al 2005; Malm strom et al 2006).
Du e to the u npred ictability o coup led m otions in the
lum bar and thoracic regions and the possibility o variability
in the cervical spine, this au thor recom m end s ad d ressing
m otion restrictions that p resent on m otion testing, rather than
relying on assum ptions based on coup led m otion and static
p alp atory f nd ings. I m otion is introd u ced in the p rim ary
p lane o restricted m otion, sp inal cou p ling w ill occu r au to-
m atically and w ithou t the intervention o the p ractitioner.
There ore, the author recom m end s a pragm atic approach or
ad d ressing the p rim ary m otion restriction (in one or m ore
p lanes) and su ggests that associated cou p led m otions w ill
occu r w ithou t the p ractitioner intentionally ad d ressing them .
Variations of application
The com m on application o MET previou sly d escribed is a
p ost-isom etric techniqu e p rim arily u sed to increase range o
m otion in a sp inal segm ent. The au thor has u sed variations
 714 PART 10 • 62 • Muscle energy approaches
o MET to p rom ote u id d rainage and p ain relie in the acu te
joint and to p rom ote p roprioception and m otor control.
Applications for acute dysfunctions
For an acu tely pain u l joint w ith m arked ly restricted m otion,
the typ ical ap p lication o MET – w here a restrictive barrier is
engaged and an attem p t is m ad e to increase range o m otion
a ter each isom etric e ort – m ay be d i f cu lt becau se o patient
app rehension and ear o pain. Fu rther, su ch cond itions m ay
involve m inor trau m a to the sp inal segm ent and in am m a-
tion o the joint cap su le and su rrou nd ing tissu es (Fryer 2003,
2011), although evid ence o in am m ation or e usion in the
sp inal joint is lacking (Fryer & Ad am s 2011). In acu te cond i-
tions, the au thor has ou nd it e ective to u se gentle isom etric
contraction against the resistance o the p ractitioner, alternat-
ing the contraction rom right to le t, w ith the joint in the
neu tral region o m otion. Thu s the joint is not near the p ain u l
barrier, and the p atient can be relaxed and not ear u l o expe-
riencing pain. The repetitive contraction and relaxation phases
are theorized to prom ote trans-synovial ow (m oving u id
ou t o the e u sed joint by changing p ressu re grad ients) and
d rainage o tissu e uid rom around the joint. Ad d itionally,
the m u scle contraction m ay stim u late m u scle and joint m ech-
anorecep tors to p rom ote d escend ing inhibition o pain, as
p reviou sly d iscu ssed . As the patient becom es less ear u l, the
joint can be progressively p ositioned tow ard s the restrictive
barrier, and d ecrease in p ain m ay allow a stand ard end -range
MET to be p er orm ed .
Applications to promote proprioception
and control
For a chronically p ain ul joint or region, m any patients app ear
to lose op tim al p ositional sense and control and have d i f -
cu lty in allow ing the region to relax u lly or p assive m otion
to be ap p lied . The au thor has u sed variations o MET that m ay
be e ective in p rom oting im proved p roprioception and m otor
control, and p rom oting conf d ence in contracting the m u scles
and m oving the joint w here p atients are ear u l becau se o
ongoing or ep isod ic p ain. Initially, m otion restrictions shou ld
be treated u sing conventional MET. A plane o m otion should
be chosen that is easy to m anage and control (u sually rotation
is su itable) and gentle isom etric contraction e orts tow ard s
neu tral are p er orm ed throu gh ‘stages’ o ranges o m otion
(e.g. in neu tral, at 20°, at 40°, etc.). The p atient shou ld be
relaxed so that the contraction phases and p ositions d o not
cau se any p ain.
Follow ing success u l (and painless) application as d escribed
above, gentle controlled isotonic (i.e. concentric, allow ing
m otion and m u scle shortening) contraction p hases can be
em ployed . Initially, the joint is placed at the end range (in one
o the card inal p lanes o rotation, lateral exion, exion or
extension) and the p atient is instru cted to pu sh gently towards
the end-range barrier against the resistance o the p ractitioner.
The f rst contraction is an isom etric contraction, w here no
m ovem ent is allow ed to occu r. The joint is then rep ositioned
app roxim ately one-third o the range tow ard s neutral and
aw ay rom the barrier. The p atient is requ ested a gain to push
gently tow ard s the barrier against the resistance o the prac-
titioner and also to m ove slow ly tow ard s the end range u nd er
the control o the p ractitioner. This p rocess is then rep eated
w ith the starting position in neutral. Repetitions can be per-
orm ed w ith the patient progressively prod u cing stronger
contraction e orts. The p roced u re shou ld cau se no p ain and
p rod u ce a com ortable, consistent contraction and m ovem ent,
and the patient should be relaxed and not ap p rehensive. The
aim o the technique is or the p atient to p er orm isotonic
contractions o p rogressively increasing intensity against
resistance through the ull range o m otion w ithout p ain,
ap prehension or ear.
Cervical spine
Assessm ent o the cervical region should inclu d e inspection
o neck p ostu re and head carriage, active and p assive range
o m otion, p alp ation, orthop aed ic tests w here ap p rop riate,
and exam ination or segm ental pain and d ys u nction. Seg-
m ental exam ination m ay inclu d e p alp ation or tend erness,
tissu e abnorm ality and segm ental m otion. Passive lateral
translation (an accessory m otion analogou s to the p rim ary
m otion o lateral exion or sid e-bend ing) is a u se u l d iagnos-
tic p roced u re to id enti y segm ental m otion restriction. Palp a-
tion o tend erness, restricted m otion and abnorm al end eel
w ill all help to d eterm ine segm ental sid e-bend ing restriction.
Som e au thors recom m end assessing lateral translation w hen
the cervical sp ine is p assively exed and extend ed to assess
the contribu tion o exion and extension restriction; how ever,
these m otions can be assessed ind ep end ently. In ad d ition to
m otion assessm ent, translation m ay p rovoke tend erness and
am iliar pain rom a sym ptom atic joint, so care shou ld be
taken to avoid aggravating a sym p tom atic segm ent.
For treatm ent, sid e-bend ing m u scle activation orce is
easily controlled by the practitioner, althou gh other d irections
can be u sed at the p ractitioner ’s d iscretion. Many au thors
recom m end engaging the restrictive barriers in either cervical
exion or extension f rst, and then localizing sid e-bend ing
(d epend ing on w hether lateral translation is m ost restricted
in either o these positions d u ring assessm ent) because
this ord er o m otion introd u ction is easily controlled and
localized .
Typical cervical (C2–C7) segments
Although MET texts trad itionally d escribe only typ e 2 m u lti-
p lanar restrictions, p roced u res m ay be ad ap ted and ap p lied
to restrictions in a single p lane (sid e-bend ing, rotation, exion
or extension) or in m u ltip le p lanes, d ep end ing on the clinical
f nd ings. In general, the p ractitioner shou ld treat the typ ical
cervical segm ents be ore the u p per cervical com plex (C0–C2).
Procedure for restriction of exion, side-bending and
rotation (Fig. 62.1, main photo)
1. The patient is in sup ine p osition. Stand or sit at the
head o the table.
2. Place the 1st–3rd f ngertips o both hand s on the right
and le t articu lar pillars o the u pper segm ent (e.g. the
C3 pillars or a C3–C4 d ys u nction).
3. Flex the neck to the level o d ys u nction. Introd uce
sid e-bend ing / lateral translation u ntil the f rst barrier at
that segm ent is engaged . Fine-tu ne w ith very su btle
ad d itional leverage (i.e. rotation, m ore / less exion or
extension) as requ ired .

Figure 62.1 Muscle energy technique for the typical cervical (C2–C7)
segments. Main photo: or restriction o f exion, side-bending and rotation. The
restricted motion barriers are engaged in one or more planes, and the patient gently
pushes the head back towards the midline against the unyielding counter orce o
the practitioner. Inset photo: or restriction o extension, side-bending and rotation.
Note pincer hold on articular pillars producing segmental extension (dotted arrow).
4. Request the patient to pu sh the head gently tow ard s the
m id line (sid e-bend ing aw ay rom the restrictive barrier)
or extend against your u nyield ing resistance or 3–5
second s.
5. Allow the p atient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in
sid e-bend ing or extension that has d evelop ed since the
contraction and relaxation p hases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Procedure for restriction of extension, side-bending and
rotation (Fig. 62.1, inset photo)
1. The p atient is in supine position. Stand or sit at the
head o the table.
2. Tw o hand positions are su itable or introd ucing
segm ental extension:
a. Place the f ngertips (1st–3rd ) o both hand s on the
right and le t articular p illars o the upp er segm ent
(e.g. the C3 p illars or a C3–C4 d ys u nction).
b. Place the ind ex and m id d le f nger o one hand on
one articu lar p illar, w ith the thu m b on the op p osite
p illar o the low er segm ent. The other hand contacts
the p atient’s head . This ‘p incer ’ hold is u se u l or
introd ucing highly localized extension (w ithou t the
need to extend the neck) and lateral translation, as
w ell as or creating a local u lcru m or lateral
exion.
3. Extend the segm ent by li ting the f ngertips on the
p illars u ntil the extension barrier is p alp ated . Introd u ce
sid e-bend ing (u sing the cep halic hand to introd u ce
m otion and the f ngers or thu m b o the p incer hand as a
ulcru m ) and / or lateral translation (u sing the pincer
contact) u ntil the barrier is engaged . Fine-tu ne w ith very
su btle ad d itional leverage (i.e. rotation, m ore / less
exion or extension) as requ ired .
Techniques for the spine, rib cage and pelvis  715
Figure 62.2 Muscle energy technique for the C1–C2 segment. The neck is
f exed to minimize rotation below C1, and the C1 segment is rotated to the
restrictive barrier. The patient is instructed to rotate gently towards the midline
(arrow) against the unyielding counter orce o the practitioner.
4. Requ est the p atient to p u sh the head gently tow ard s the
m id line (sid e-bend ing aw ay rom the restrictive barrier)
or ex against your u nyield ing resistance or 3–5
second s.
5. Allow the p atient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in
sid e-bend ing or extension that has d evelop ed since the
contraction and relaxation p hases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Atlanto-axial (C1–C2) segment
The prim ary m ovem ent at the C1–C2 segm ent is rotation and ,
althou gh som e au thors ad vocate ad d ressing ad d itional planes
(Mitchell Jr & Mitchell 1995), in the experience o the au thor
the engagem ent o rotation alone is highly e ective. For exam -
ination and treatm ent, the neck can be placed in ull exion,
w hich relatively ‘locks’ the low er cervical joint segm ents
and localizes available rotation to the atlanto-axial segm ent
(Ogince et al 2006).
Procedure for restricted C1–C2 rotation (Fig. 62.2)
1. The p atient is in su p ine p osition. Stand or sit at the
head o the table.
2. The f ngertip s o both hand s are p laced on the articu lar
pillars o the up p er segm ent, w ith palm s crad ling the
head . The chest or abd om en can also be u sed to su pport
you r hand s.
3. Flex the p atient’s neck u lly (u ntil a sense o resistance)
to ‘lock’ the m id d le and low er cervical sp ine. Maintain
the exion and rotate the neck u ntil the barrier o
restricted rotation is engaged . Fine-tu ne w ith ad d itional
leverages (i.e. sid e-bend ing, exion, extension) as
d eterm ined w ith palpation.
 716 PART 10 • 62 • Muscle energy approaches
4. Request the patient to rotate the head gently tow ard s
the m id line (rotating aw ay rom the restrictive barrier)
against you r u nyield ing resistance or 3–5 second s.
5. Allow the p atient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in
rotation that has d eveloped since the contraction and
relaxation phases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Occipito-atlanto (C0–C1) segment
The prim ary m ovem ents at the C0–C1 segm ent are exion
and extension, bu t exam ination and treatm ent o the restricted
sid e-bend ing and rotation can be clinically rew ard ing. Tech-
niqu es can be u sed to ad d ress a single p lane (u su ally exion
or extension) or m u ltip le p lans (contralateral sid e-bend ing
and rotation, w ith exion or extension).
Procedure for single-plane restricted exion
(or extension) (Fig. 62.3, main photo)
1. The p atient is in supine position. Stand or sit at the
head o the table.
2. Place one hand u nd er the occipu t w ith the f ngertips
p alp ating the su boccip ital tissu es close to the occip ito-
atlanto joint line and the other hand resting on the
p atient’s orehead .
3. Gently ex (or extend ) the head w ithou t engaging
m ovem ent in the cervical sp ine u ntil the initial sense o
barrier at the C0–C1 segm ent is palpated .
4. Request the patient to extend (or ex) the head gently
by stating the instru ction to ‘nod the head u pw ard s’ or
Figure 62.3 Muscle energy technique for the C0–C1 segment. Main photo:
treatment o single-plane restricted f exion. The practitioner care ully f exes the head
to the barrier, and the patient gently extends the head (arrow) against the unyielding
counter orce o the practitioner. Inset photo above: treatment o single-plane
restriction, extension. The practitioner care ully extends the head to the barrier, and
the patient gently f exes the head (arrow). Inset photo below: multiple plane
restriction, emphasizing side-bending. The practitioner care ully f exes (or extends)
the head to the barrier, and then introduces side-bending, lateral translation and / or
rotation to address the motion barriers. The patient gently pushes away rom the
barrier in side-bending, f exion or extension.
‘look up w ard s’ (or d ow nw ard s) against you r u nyield ing
resistance or 3–5 second s.
5. Allow the patient to relax or several second s.
6. Re-engage the new barrier by taking u p any slack in
exion (or extension) that has d evelop ed since
contraction and relaxation p hases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Procedure for multiple-plane restriction: exion (or
extension), lateral exion and contralateral rotation
(Fig. 62.3, inset photo below)
1. The patient is in sup ine p osition. Stand or sit at the
head o the table.
2. Crad le the occipu t and head u sing both hand s, w ith the
f ngertips palpating the su boccip ital m u scles near the
occip ito-atlanto joint line.
3. Gently ex (or extend ) the head until the initial sense o
barrier is palp ated .
4. Introd u ce sid e-bend ing by a com bination o gentle
sid e-bend ing and lateral translation o the head on the
neck u ntil the barrier is engaged . Fine-tune w ith subtle
contralateral rotation, i requ ired .
5. Request the p atient to pu sh the head gently tow ard s the
m id line (sid e-bend ing aw ay rom the restrictive barrier)
against your unyield ing resistance or 3–5 second s.
Alternatively, a exion (or extension) activating orce
can be u sed .
6. Allow the patient to relax or several second s.
7. Re-engage the new barrier by taking u p any slack in
exion (or extension) or sid e-bend ing that has
d eveloped since the contraction and relaxation p hases.
8. Rep eat 2–4 tim es.
9. Re-exam ine.
Thoracic spine
Assessm ent o the thoracic region shou ld inclu d e inspection
o tru nk p ostu re w hen stand ing and seated , active and p assive
gross m otion, palpation or tend erness and tissu e texture
abnorm ality, orthopaed ic tests w here appropriate and exam i-
nation or segm ental p ain and d ys u nction. Assessm ent o
segm ental m otion can inclu d e short-lever, p osterior–anterior
accessory m otion (vertebral ‘springing’ w ith the p atient
p rone), as w ell as assessm ent o card inal p lane m otion ( exion,
extension, rotation, sid e-bend ing), w hich can be per orm ed
w ith the patient seated . When seated , the patient shou ld sit
u p right becau se a slu m p ed p ostu re w ill restrict p assive rota-
tion and sid e-bend ing.
The techniqu es d escribed below illustrate MET applica-
tions to the thoracic sp ine or segm ental m otion restriction,
bu t the principles can be applied to any com bination o m otion
restriction by m od i ying the techniqu e. Althou gh only seated
techniqu es are illu strated in this section, MET can also be
ap plied w ith the patient in the lateral recu m bent, p rone or
su p ine p ositions.
For m id –low thoracic techniques, the patient’s arm s are
best i old ed w ith the hand s on the opposite should ers.
Lateral and anterior–posterior translation o the patient’s
bod y is u se u l or p recise localization and f ne-tu ning

o sid e-bend ing, exion and extension barriers. For u p p er
thoracic segm ents (T1–T4), the patient’s head and neck or the
hand s interlocked arou nd the p atient’s neck are o ten u sed as
levers to prod u ce localization o m otion in the u pper thoracic
segm ents. Many cervical techniqu es can be m od if ed or the
u p p er thoracic region.
Restriction of exion combinations
Procedure for restriction of exion, with or without
concurrent restrictions of rotation and side-bending
(Fig. 62.4, mid–low thoracic segments; inset: upper
thoracic segments)
1. The p atient is seated w ith arm s old ed ; stand behind the
p atient. Palp ate the involved segm ent.
2. For m id –low thoracic segm ents, contact the patient’s
arm s or elbow s and gently gu id e the patient into trunk
exion until the involved segm ent starts to ex. For
u p p er thoracic segm ents, gently ex the head and neck
u ntil the involved segm ent starts to ex. Su btle
p osterior translation o the tru nk m ay be u sed to
localize exion m otion urther to the involved segm ent.
Sid e-bend ing and rotation to restricted barriers can also
be introd uced using a sm all am ount o lateral
translation.
3. Request the patient to try to straighten or extend the
tru nk (m id –low thoracic) or neck (u p p er thoracic) gently
against you r u nyield ing resistance or 3–5 second s.
Alternatively, a sid e-bend ing activating orce can be
u sed w hen sid e-bend ing restriction is ap p arent.
4. Allow the p atient to relax or several second s.
5. Re-engage the new barrier by taking u p any slack in
exion or sid e-bend ing that has d eveloped since the
contraction and relaxation p hases.
6. Rep eat 2–4 tim es.
7. Re-exam ine.
Figure 62.4 Muscle energy technique for restricted exion in the thoracic
spine. Main photo: treatment in the mid-low thoracic region. The practitioner
care ully f exes the trunk to the barrier, and the patient gently extends (arrow)
against the unyielding counter orce o the practitioner. Inset photo: treatment o the
upper thoracic region. The practitioner care ully f exes the head until motion is
palpated at the restricted segment, and the patient gently extends the neck (arrow)
against the unyielding counter orce o the practitioner.
Techniques for the spine, rib cage and pelvis  717
Restriction of extension combinations
Procedure for restriction of extension, with or without
concurrent restrictions of rotation and side-bending
(Fig. 62.5, mid–low thoracic segments; inset: upper
thoracic segments)
1. For m id –low thoracic segm ents, the patient is seated w ith
the arm s crossed and hand s resting on the op posite
should ers. For upper thoracic segm ents, the patient is
seated w ith the hand s interlocked around the neck. Stand
behind the p atient and palpate the involved segm ent.
2. Using the p atient’s elbow s as a lever, gently extend the
tru nk u ntil the involved segm ent starts to extend . Su btle
anterior translation m ay be used to localize extension to
the involved segm ent. Sid e-bend ing and rotation to
restricted barriers can be introd uced by using the head
and neck leverage, or by introd u cing a sm all am ou nt o
lateral translation.
3. Requ est the p atient to p u sh the tru nk gently orw ard s
( exion) against your u nyield ing resistance or 3–5
second s.
4. Allow the p atient to relax or several second s.
5. Re-engage the new barrier by taking u p any slack in
extension and sid e-bend ing that has d eveloped since the
contraction and relaxation p hases.
6. Rep eat 2–4 tim es.
7. Re-exam ine.
Alternative procedure for restriction of extension,
with or without concurrent restrictions of rotation and
side-bending (Fig. 62.6, mid–low thoracic segments;
inset: upper thoracic segments)
This proced ure is use u l w hen the p atient is bigger than the
p ractitioner and w hen the u p p er thoracic region is sti and
exed and requires stronger leverage to prod uce extension.
Figure 62.5 Muscle energy technique for restricted extension in the thoracic
spine. Main photo: treatment in the mid–low thoracic region. The practitioner
care ully extends the trunk to the barrier, and the patient gently f exes (arrow)
against the unyielding counter orce o the practitioner. Inset photo: treatment o the
upper thoracic region. The practitioner care ully extends the head and neck until
motion is palpated at the restricted segment, and the patient gently f exes the neck
(arrow) against the unyielding counter orce o the practitioner. Note the di erent
hand holds or each region.
 718 PART 10 • 62 • Muscle energy approaches
Figure 62.6 Muscle energy technique for restricted extension in the thoracic
spine (alternative procedure). This technique is use ul or small practitioners
and / or large patients. Main photo: treatment in the mid–low thoracic region. The
practitioner care ully extends the trunk to the barrier by drawing the segment
anteriorly, and the patient gently f exes (arrow) against the unyielding counter orce
o the practitioner. Inset photo: treatment o the upper thoracic region. The
practitioner care ully extends the upper thoracic segment by drawing the segment
anteriorly and elevating until extension motion is palpated at the restricted segment,
and the patient gently f exes the neck against their arms and the unyielding
counter orce o the practitioner. Note the di erent hand holds or each region.
1. For m id –low thoracic treatm ent, the p atient is seated on
a table acing the p ractitioner w ith the arm s either
old ed or resting on a pillow over the practitioner ’s
shou ld er. You r arm s shou ld link arou nd the p atient so
that you r f ngers contact each sid e o the involved
segm ent (Fig. 62.6, m ain p hoto).
2. For upp er thoracic segm ent treatm ent, the p atient is
seated on a low table or chair w ith the arm s old ed and
head resting on the orearm s. Stand in ront o p atient
and thread you r arm s u nd er the p atient’s orearm s so
that you r f ngers contact each sid e o the involved
segm ent (Fig. 62.6, inset p hoto).
3. Gently raise you r arm s and shi t your w eight onto your
back leg to translate the patient orw ard and prod u ce
localized extension at the involved segm ent. Your
f ngers can be u sed as a u lcru m to assist this
localization. Su btle sid e-bend ing and rotation to
restricted barriers can be introd uced by shi ting your
stance.
4. Request the patient to pu sh the head or tru nk gently
orw ard s ( exion) against you r unyield ing resistance or
3–5 second s.
5. Allow the p atient to relax or several second s.
6. Re-engage the new barrier by taking u p any slack in
extension and sid e-bend ing that has d eveloped since the
contraction and relaxation p hases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Rib cage
Assessm ent o the rib cage involves insp ection or thoracic
cage d e orm ity, p alp ation or thoracic cage contou r and sym -
m etrical exp ansion d u ring u ll inhalation and assessm ent o
Figure 62.7 Muscle energy technique for restricted rib inhalation or exhalation
motion. Main photo: treatment o mid–low ribs in supine. The practitioner stabilizes
(circle) either the rib below or inhalation restrictions or the involved rib or
exhalation restrictions. The patient’s arm is abducted and elevated until the tension
is palpated at the rib and intercostal and associated muscles are stretched. The
patient pushes the arm down against the unyielding counter orce o the practitioner
(arrow) against the unyielding counter orce o the practitioner. Inset photo below:
treatment o mid–low ribs in lateral recumbent position. Inset photo above:
treatment o upper ribs in supine.
rib m obility by accessory m otion or gentle ‘springing’ tech-
niqu es. Som e au thors d ivid e rib d ys u nction into tw o catego-
ries: ‘respiratory’ d ys unctions, w hich are restrictions o
inhalation or exhalation m otion, and ‘structural’ d ys u nc-
tions, w hich are claim ed to be rib ‘su blu xation’ and associated
w ith consid erable pain and lim ited m otion (Mitchell Jr &
Mitchell 1998; Greenm an 2003). The prop osed aetiology o
these stru ctu ral d ys u nctions is d u biou s, bu t m ay involve
sp rain o the costovertebral or costotransverse joints. In clini-
cal p ractice, MET is o ten e ective in red u cing p ain and
im p roving m otion. With the excep tion o an acu tely pain u l
rib d ys u nction, rib d ys u nctions should be treated ollow ing
treatm ent o thoracic sp ine d ys u nction, as rib restrictions
m ay occu r second arily to thoracic d ys u nction.
Restriction of inhalation
The ollow ing techniqu e is based on the principle o stretching
the intercostal m u scles below the restricted rib to p rom ote
greater m ovem ent o that rib d u ring inhalation. Arm exion
is u sed to encourage pum p hand le m otion o the u pper ribs,
and arm abd uction is used to encourage bu cket-hand le m otion
o the m id d le and low er ribs. The techniqu e can also be p er-
orm ed w ith the patient sitting or in the lateral recu m bent
p osition.
Procedure for restricted inhalation motion (Fig. 62.7)
1. The patient is in sup ine p osition. Stand at the sid e o the
table.
2. Fix on the anterior or lateral sha t o the rib below the
a ected rib (i.e. rib 9 w hen rib 8 is restricted ) w ith the
thenar or hyp othenar p art o you r hand (broad contact
is m ost com ortable; a tow el can be u sed or p ad d ing).
3. Elevate the rib u sing leverage on the patient’s ipsilateral
arm (u pp er ribs arm exion; m id d le and low er ribs –

arm abd u ction) to a position o com ortable stretch,
w hile m aintaining tension on the low er rib.
4. Request the patient to inhale ully and hold , and then to
p u sh the arm gently d ow n against you r u nyield ing
resistance or 3–5 second s.
5. Allow the p atient to breathe ou t and relax or several
second s.
6. Re-engage the new barrier by taking u p any slack in
abd u ction and tension on the low er rib that has
d eveloped since the contraction and relaxation phases.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Restriction of exhalation
This techniqu e u ses a m yo ascial ap proach based on the prin-
cip le o stretching the intercostal m u scles above the restricted
rib (in contrast to below the rib or restrictions o inhalation)
so as to p rom ote greater m ovem ent o that rib d u ring exhala-
tion. The sam e techniqu e is u sed to treat restricted inhalation
(see above), except that or exhalation restriction the practi-
tioner f xes the sha t o the involved rib to encou rage rib
d ep ression and stretch the intercostal m uscles superior to it
(see Fig. 62.7).
Elevated rst rib
Techniqu es have been d escribed or an elevated f rst rib, in
w hich the rib is held in an elevated position, has restriction
o exhalation m otion and is associated w ith m arked tissu e
hyp ertonicity and tend erness (Mitchell Jr & Mitchell 1998;
Greenm an 2003). This d ys u nction has been postu lated to
involve a sup erior subluxation o the joint w ith shortening o
the attaching scalene m u scles, bu t this aetiology is p u rely
sp ecu lative. The ollow ing techniqu e is p rop osed to op erate
by reciprocal inhibition o the scalene m u scles, but the guid ing
d ow nw ard pressure on the rib d uring patient relaxation m ay
contribu te to the su ccess o the techniqu e. It is help u l to
alternate the isom etric contraction w ith the p atient taking a
d eep breath, an exhalation and then relaxation.
Procedure for elevated rst rib (Fig. 62.8)
1. The p atient is seated . Stand behind the patient.
Alternatively, this technique m ay be per orm ed w ith the
p atient su p ine and the p ractitioner sitting at the head o
the table.
2. Contact the posterior sha t o the f rst rib throu gh the
trap eziu s m u scle w ith the thu m b and the su p erior
asp ect o the sha t w ith the f rst phalange or f ngers.
Exert a cau d al and anterior orce on the p osterior rib
sha t to gu id e it d ow nw ard s.
3. Sid e-bend the patient’s neck to the sid e o the involved
rib ju st be ore the m otion o the rib is sensed .
4. Request the patient to pu sh the head gently tow ard s the
m id line (sid e-bend ing aw ay rom the sid e o the rib)
against you r u nyield ing resistance or 3–5 second s.
5. Allow the p atient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in rib
d ep ression or sid e-bend ing w hile m aintaining the
cau d al and anterior orce on the p osterior rib sha t.
Techniques for the spine, rib cage and pelvis  719
Figure 62.8 Muscle energy technique for an elevated rst rib. Note the caudal
and anterior pressure applied to the posterior sha t o the rst rib (dotted arrow) and
the side-bending o the patient’s neck to relax the tissues around the rib. The
patient uses a gentle side-bending contraction away rom the side o the rib (arrow)
against the unyielding counter orce o the practitioner.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Acute rib dysfunction
Mu scle energy au thors have d escribed a nu m ber o ‘stru c-
tu ral’ rib d ys u nctions that are p rop osed to be ‘su blu xations’
w here the norm al joint apposition is d isru pted (Mitchell Jr &
Mitchell 1998; Greenm an 2003). The au thor suggests that the
u nd erlying p rocess m ay in act be joint sp rain, e u sion and
tissu e in am m ation. An acu te rib d ys u nction m ay p resent
w ith pain arou nd the costotransverse joint that becom es
intense on tru nk rotation and inhalation e ort. There is
o ten tissu e hyp ertonicity and tend erness o the iliocostalis
m u scles arou nd the rib angle, and there m ay be p ain and
restricted m otion on accessory m ovem ent testing (‘springing’)
o the rib.
In the author ’s experience, structural rib techniques are
u se u l or acu tely p ain u l rib d ys u nction. These techniqu es
m ay activate d escend ing p ain inhibition p athw ays and
im prove tissu e d rainage arou nd the in am ed joint (Fryer
2011). The au thor o ten com bines ind irect techniqu es
(Greenm an 2003) w ith MET w hen the joint is acutely pain u l.
The ollow ing p roced u re is a m od if cation o the ‘posteriorly
su blu xed ’ rib d ys u nction techniqu e (Mitchell Jr & Mitchell
1998; Greenm an 2003) (Fig. 62.9):
1. The p atient is seated w ith the hand o the involved sid e
resting on the opposite should er. Stand behind the
patient w ith one hand on the patient’s elbow and the
other p alp ating the angle o the involved rib throu gh
the iliocostalis m u scles.
2. Elevate the p atient’s elbow u ntil localization o m otion
is p alp ated at the rib angle. Then ap p ly m od erately f rm
pressure to the rib angle in a m ed ial and anterior
d irection.
3. Requ est the p atient to p u sh the elbow gently laterally
against you r unyield ing resistance or 3–5 second s.
Alternatively, the d irection m ay be u pw ard or m ed ially,
 720 PART 10 • 62 • Muscle energy approaches
Figure 62.9 Muscle energy technique for an acutely painful rib dysfunction.
The practitioner elevates the patient’s elbow until localization o motion is palpated
at the posterior rib angle o the involved rib. Moderately rm pressure is maintained
over the rib angle in a medial and anterior direction (dotted arrow). The patient
gently pushes the elbow laterally against the unyielding counter orce o the
practitioner (arrow).
d ep end ing on w hich d irection creates a sense o tissue
contraction and localization.
4. Allow the p atient to relax or several second s.
5. Re-engage the new barrier or tissue tension that has
d eveloped since the contraction and relaxation phases.
6. Rep eat 2–4 tim es.
7. Re-exam ine.
Lumbar spine
Assessm ent o the lum bar region shou ld includ e inspection
o tru nk p ostu re w hen the p atient is stand ing and seated ,
active m otion to d eterm ine range and pain, orthopaed ic and
neu rological tests w here ap p rop riate and exam ination or seg-
m ental p ain and d ys u nction w ith p alp ation. Segm ental
m otion testing is o ten p er orm ed w ith the p atient in the
lateral recu m bent p osition, and w ith the p ractitioner u sing
the exed hip s and legs as levers or exion and extension. In
the au thor ’s exp erience, assessm ent o accessory m otion or
acet glid e u sing p osterior–anterior overpressu re w hen the
p atient is in the ‘sp hinx’ p osition (i.e. prone, w ith the up per
bod y resting on the elbow s or straightened arm s to extend the
lu m bar sp ine) can also be u se u l to conf rm segm ental restric-
tion o extension.
The techniqu es below illu strate MET ap p lications to the
lu m bar sp ine or segm ental m otion restrictions o exion and
extension, bu t the principles can be ap plied to any com bina-
tion o m otion restriction by m od if cation o the techniqu e.
Although only lateral recu m bent techniqu es are illu strated in
this section, MET can be ap p lied w ith the p atient in the seated ,
p rone or su p ine p osition.
Restriction of uniplanar motion
Although m ost MET texts d escribe techniqu es or com bina-
tions o m otion restriction based on the Fryette m od el o
cou p led m otion, joint restrictions m ay be d etected in only a
Figure 62.10 Muscle energy technique for restriction of uniplanar motions in
the lumbar spine. Using the patient’s legs as a lever, the lumbar spine can be
positioned at the barrier o f exion, extension, or side-bending motion restrictions.
Main photo: treatment o restricted right side-bending. The patient is instructed to
push the legs gently down (arrow) against the unyielding resistance o the
practitioner. Inset photo: treatment o rotation restriction. The restricted segment is
positioned at the motion barrier, and the patient is instructed to ‘untwist’ gently
(arrows).
single p lane; how ever, techniqu es are easily d evelop ed or
these situ ations based on the p rincip les o ap p lication
d escribed above (Fig. 62.10).
Restriction of exion combinations
The ollow ing techniqu e is or restriction o exion, w ith con-
cu rrent restrictions o ip silateral rotation and sid e-bend ing.
Although the technique m ay appear aw kw ard , w ith practice
it is com ortable or both patient and practitioner, and allow s
good control and localization o exion and sid e-bend ing o
a lu m bar segm ent. The technique m ay be u se u l to prom ote
op tim al exion (u p w ard and orw ard glid ing) o the involved
acet joint.
Procedure for restriction of exion, rotation and
side-bending (Fig. 62.11)
1. The patient is in the prone position. Stand to the
sid e o the p atient, bend the p atient’s knees, and
m ove and rotate the patient’s hips to a sem i-Sim s
position.
2. Using the thighs and pelvis as levers, ex and extend
the sp ine u ntil the involved segm ent starts to ex.
Care u lly low er the legs to localize sid e-bend ing to
the segm ent (be care u l to su p p ort the p atient’s thigh
w ith you r thigh to avoid d iscom ort against the ed ge
o the table).
3. Request the p atient to li t the legs gently against you r
unyield ing resistance or 3–5 second s.
4. Allow the patient to relax or several second s.
5. Re-engage the new barrier by taking u p any slack in
exion or sid e-bend ing that has d evelop ed since the
contraction and relaxation p hases.
6. Rep eat 2–4 tim es.
7. Re-exam ine.

Figure 62.11 Muscle energy technique for restriction of exion combinations in
the lumbar spine. The technique illustrated is or restriction o segmental f exion,
le t rotation and le t side-bending. The patient is repositioned rom the prone
position to the semi-Sims position by f exion o the knees and rotation o the pelvis.
Flexion motion is localized to the involved segment by f exing the hips, ollowed by
side-bending by care ully lowering the legs. The patient gently li ts the legs (arrow)
against the unyielding counter orce o the practitioner.
Restriction of extension combinations
Restriction o segm ental extension in the lu m bar sp ine is con-
sid ered clinically relevant becau se it reverses the norm al
lum bar lord osis and shock absorption o the region. The ol-
low ing techniqu e is a proced ure or restriction o extension,
w ith or w ithout concu rrent restrictions o rotation and sid e-
bend ing. Li ting the p atient’s leg m ay som etim es be aw kw ard ,
so it m ay be help u l or the p ractitioner to hold the leg close
to their bod y (w ithou t allow ing hip and lu m bar exion) w hile
positioning the p atient in a d egree o sid e-bend ing w ith an
ad justable table or p illow s.
Procedure for restriction of extension, rotation and
side-bending (Fig. 62.12)
1. The p atient is in the lateral recu m bent position on
the sid e o the u ninvolved acet. Stand in ront o the
p atient.
2. Palp ate the involved segm ent and localize extension by
extend ing the leg on the table and glid ing the u pper
bod y posteriorly. Using the f ngertips o both hand s
(slid ing around the patient’s w aist), the involved
segm ent can be translated anteriorly u sing the f ngertip s
to localize extension u rther.
3. Rotation can be localized to the segm ent by posterior
translation o the shou ld er. I p ossible, the p atient can
hold the ed ge o the table to m aintain the rotated
p osition.
4. Sid e-bend ing can be localized to the segm ent by li ting
the p atient’s leg to p rod u ce m otion in the p elvis and
then sid e-bend ing o the lu m bar sp ine.
5. Request the patient to press the leg gently d ow nw ard
against you r u nyield ing resistance or 3–5 second s.
6. Allow the p atient to relax or several second s.
7. Re-engage the new barriers by taking up any slack in
extension or sid e-bend ing that has d eveloped since the
contraction and relaxation p hases.
Techniques for the spine, rib cage and pelvis  721
Figure 62.12 Muscle energy technique for restriction of extension
combinations in the lumbar spine. Localization o lumbar extension is produced by
extension o the leg and upper body, with urther extension obtained by translating
the segment anteriorly; localization o rotation is achieved by moving the shoulder
posteriorly to rotate the trunk, with the patient anchoring the shoulder by holding
the table; localization o side-bending is created by li ting the leg, being care ul not
to lose extension o the spine. The patient gently pushes the leg toward the f oor
(arrow) against the unyielding counter orce o the practitioner.
8. Rep eat 2–4 tim es.
9. Re-exam ine.
Pelvic girdle
Au thors o trad itional MET texts d escribed a large range o
p elvic som atic d ys u nctions – subd ivid ed into p u bic, sacroil-
iac and iliosacral d ys u nctions – based on a biom echanical
p elvic m od el p rop osed by Mitchell Sr (Mitchell Jr & Mitchell
1999; Greenm an 2003). The biom echanical m od el and associ-
ated d ys unctions w ere d evelop ed largely throu gh clinical
observation and have been a catalyst or the d evelop m ent o
MET. H ow ever, the valid ity o these d ys u nctions as real clini-
cal entities is d u biou s, and these d ys u nctions m ay instead
re ect the ind ivid u al variability o sacroiliac joint anatom y
and the sm all m otions available (Fryer 2000, 2011). Fu rther-
m ore, the reliability and valid ity o m ost m otion and static
sym m etry d iagnostic tests u sed to d etect p elvic d ys u nctions
are d u bious. For instance, pelvic gird le sym m etry m ay be
in uenced by pelvic m u scle tone (Bend ova et al 2007), and
m any techniqu es p u rp orted to ad d ress articu lar d ys u nction
m ight im p rove p elvic gird le sym m etry throu gh stretching or
activating m yo ascial tissu es.
The trad itional MET approach involves system atically
d etecting and treating pu bic, sacroiliac and iliosacral d ys unc-
tions to im p rove m otion and sym m etry o the p elvis. The
ocus has been on im proving m otion in d ys unctions w ith
restricted m otion; how ever, hyperm obility o sacroiliac joints
and lack o stabilizing m echanism s m ay be a greater contribu -
tor to p elvic p ain (H ossain & N okes 2005). The author there-
ore recom m end s a three-tiered ap proach to treating the pelvic
region: (1) treating m yo ascial im balance (treating m uscles or
length and strength and d eactivating TrPs), (2) treating articu-
lar d ys unction (w hen the joint app ears to be hypom obile or
p ain u l, gu id ed by the p lane o the joint as assessed w ith
p alp ation) and (3) im p roving p elvic stability (strength and
control o p elvic m u scles). It is beyond the scop e o this
 722 PART 10 • 62 •
chap ter to exp lore these issu es and treatm ent ap p roaches,
how ever.
Several techniqu es are d escribed below to correct ap p arent
articular d ys u nction (that m ay also be acting on m yo ascial
tissu es), w hich the au thor has ou nd u se u l in clinical p ractice.
It shou ld be noted that static pelvic torsion is com m on and
is typ ically u nrelated to d ys u nction or p ain; restriction o
m otion shou ld be consid ered only w here there are clinical
signs su ggesting d ys u nction other than asym m etry.
Restriction of innominate anterior rotation
A restriction o anterior rotation o the innom inate m ight be
consid ered w hen p elvic torsion is id entif ed w ith signs o
d ys unction (asym m etrical m otion on springing and acces-
sory m otion tests, p ain and p ositive p ain p rovocation tests)
and w hen the involved sid e appears to be p osteriorly rotated
(su perior anterior sup erior iliac sp ine (ASIS) and m ed ial
m alleoli relative to the other sid e w ith the p atient su p ine;
in erior p osterior su p erior iliac sp ine (PSIS) w ith the p atient
p rone). MET au thors re er to this d ys u nction as a ‘p osterior
innom inate,’ bu t the au thor recom m end s avoid ing term inol-
ogy that p rom otes obsolete ‘bone-ou t-o -p lace’ concep ts
because such term inology m ay prom ote inapp ropriate belie s,
ear and d epend ence on treatm ent in susceptible patients.
Care u l localization o m otion to the sacroiliac joint is rec-
om m end ed or the su ccess o the techniqu e and m ay stim u late
joint p roprioceptors and subsequ ent neu rological e ects.
H ow ever, in cases o long-term , pain- ree sti ness, the author
u ses stronger end -range m obilizing orces. The techniqu e can
also be per orm ed w ith the patient in the lateral recu m bent or
su p ine p osition.
Procedure for restriction of innominate anterior rotation
(Fig. 62.13)
1. The p atient is in the prone position. Stand on the sid e to
be treated .
2. Monitor the sacroiliac joint u sing three f ngers (one on
the PSIS and tw o m ed ial to it to cover the sacru m ).
Figure 62.13 Muscle energy technique for restriction of innominate anterior
rotation. The practitioner abducts the thigh slightly and then extends until
localization o motion is palpated at the sacroiliac region (be ore the sacrum starts
to move). The patient gently pushes the thigh towards the table (arrow) against the
unyielding counter orce o the practitioner.
Muscle energy approaches
3. Slightly abd u ct the thigh (to p rom ote a loose-packed
position), and then extend the thigh until localization is
palpated at the sacroiliac joint. Localize the m otion to
the p oint ju st be ore the sacru m begins to m ove.
4. Request the p atient to pu sh the thigh gently back to the
table against you r unyield ing cou nter orce or 3–5
second s.
5. Allow the patient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in hip
extension that has d evelop ed since contraction and
relaxation phases to localize to the sacroiliac joint again.
7. Rep eat 2–4 tim es.
8. Re-exam ine.
Restriction of innominate posterior rotation
A restriction o p osterior rotation o the innom inate m ight be
consid ered w hen p elvic torsion (static asym m etry) is id enti-
f ed w ith other signs o d ys u nction (e.g. regional p ain, p osi-
tive p ain p rovocation tests, asym m etrical m otion on sp ringing,
and accessory m otion tests) and w hen the involved sid e
ap pears to be anteriorly rotated (in erior ASIS and m ed ial
m alleoli relative to the other sid e w ith the p atient su p ine;
su p erior PSIS w ith the p atient p rone). This d ys u nction m ay
be clinically relevant becau se posterior rotation o the innom i-
nate is an im p ortant ad ap tation to the orces o gravity d u ring
one-legged stance and contribu tes to the sel -locking m echa-
nism o the p elvis (H u nger ord et al 2004). MET au thors re er
to this d ys u nction as an ‘anterior innom inate’, bu t the au thor
recom m end s avoid ing this term inology or the reasons
exp lained above. Care ul localization o m otion to the sacro-
iliac joint m ay be im portant or the su ccess o the techniqu e,
bu t, in cases o long-term , pain- ree sti ness, the au thor uses
stronger end -range m obilizing orces. The techniqu e can
also be p er orm ed w ith the patient in the prone or su p ine
p osition.
Procedure for restriction of innominate posterior rotation
(Fig. 62.14)
1. Patient is laterally recu m bent, lying on the u ninvolved
sid e. Stand acing the p atient.
2. Monitor the sacroiliac joint using three f ngers o one
hand (one on the PSIS and tw o m ed ial to it to cover the
sacru m ).
3. Slightly abd u ct the thigh (to p rom ote a loose-packed
position), and then ex the hip and knee u ntil
localization is p alp ated at the sacroiliac joint (being
care u l not to lose the slight abd u ction). Monitor the
joint w hile f ne-tuning hip exion and extension to
localize the m otion to the p oint ju st be ore the sacru m
begins to m ove. The patient’s knee or oot can be
stabilized against you r hip or stom ach.
4. Request the p atient to pu sh the thigh gently back
against you r unyield ing resistance to extend the hip or
3–5 second s.
5. Allow the patient to relax or a ew second s.
6. Re-engage the new barrier by taking u p any slack in hip
exion that has d evelop ed since contraction and
relaxation phases to localize to the sacroiliac joint again.
7. Rep eat 2–4 tim es.
8. Re-exam ine.

Figure 62.14 Muscle energy technique for restriction of innominate posterior
rotation. The practitioner f exes the hip until motion is localized at the sacroiliac
joint (be ore the sacrum starts to move). Main photo: the patient gently produces an
extension e ort o the hip by pushing the oot or thigh (arrow) against the
unyielding counter orce o the practitioner. Inset photo: alternative hand hold to
produce stronger articulatory orces or posterior rotation.
Sacroiliac ‘gapping’ technique
This techniqu e has been used to prom ote m otion and tissu e
relaxation around the sacroiliac joint. It is unlikely that tru e
joint gap ping or separation is possible u sing m anu al tech-
niqu es, bu t, in the au thor ’s exp erience, this techniqu e ap p ears
to have clinical u tility and m ay cau se tissu e relaxation and
pain red u ction by activating joint and m u scle m echanorecep-
tors and d escend ing p ain inhibitory p athw ays. The techniqu e
u tilizes the leverage o hip internal rotation to ‘gap ’ the p os-
terior asp ect o the joint (Fig. 62.15).
Techniques for Myofascial Tissues
The ollow ing sections d escribe MET or lengthening and
d esensitizing m yo ascial tissu e. Du e to space lim itations o
this chap ter, techniqu es w ill be d escribed only or m u scles
that are, in the op inion o the au thor, m ost clinically relevant.
H ow ever, the read er w ill be able to app ly the principles o
MET to any m u scle that w arrants treatm ent. (See Ch 59 or
d etailed d escrip tions o m yo ascial TrPs and associated d iag-
nostic f nd ings.)
Principles of application of muscle energy to
myofascial tissues
MET can be ap p lied to m u scles and so t tissu es to stretch and
lengthen the tissues, to d eactivate m u scle TrPs and to im prove
lym phatic d rainage. The m ain principles or app lication o
MET are d escribed below :
1. Stretch the involved muscle: The m u scle shou ld be
stretched to its barrier (sense o p alp ated resistance or
end range):
a. light stretching orce to the initial or ‘f rst barrier ’ i
the m u scle is acu tely p ain u l
Techniques for myofascial tissues 723
Figure 62.15 Muscle energy sacroiliac ‘gapping’ technique. The practitioner
palpates the sacroiliac region and internally rotates the hip until motion is localized
at the joint (just be ore the sacrum starts to move). The patient gently pushes the
oot and leg into external rotation (arrow) against the unyielding counter orce o the
practitioner.
b. m od erate stretching orce to a com ortable sensation
o stretch exp erienced by the p atient i the m u scle is
m ild ly pain u l or not pain ul.
2. Isometric contraction: Requ est the patient to contract
the targeted m u scle (p u sh aw ay rom the barrier)
against you r controlled , unyield ing resistance or 3–5
second s:
a. light contraction orce i the m uscle is pain ul or
contains active TrPs
b. m od erate contraction orce or pain- ree, f brotic
m u scles.
3. Muscle relaxation: The patient should ully relax or
several second s, w ith the stretch m aintained . A d eep
inhalation or exhalation m ay assist relaxation. Chaitow
(2013) recom m end s m aintaining this stretch or u p to 60
second s or chronically shortened m u scles (rem oving
the m u scle rom stretch or a rest p eriod ), bu t this long
period o stretch is probably ap propriate only or larger
m u scle grou ps. A stretch m aintained or approxim ately
10 second s is recom m end ed or neck, shou ld er and
upp er lim b m uscles that are shortened and f brotic and
are not provoked by stretching. A stretch m aintained or
only a ew second s is ap p rop riate or tend er and
irritable m u scles.
4. Re-engage barrier: The slack that has d evelop ed in the
tissu es ollow ing the contraction and relaxation p hases
is taken u p , and u su ally the m u scle can then be
stretched to a new barrier w ithou t u sing increased
orce.
5. Repetition: This process is repeated 2–4 tim es, or until a
change in length and tissu e textu re is noted .
6. Re-examine: To d eterm ine w hether the tissu es have
changed .
For op tim al localization and e ectiveness, m any o the m uscle
stretches requ ire su btle f ne-tu ning or each p atient. Practi-
tioners are encou raged to exp erim ent w ith sm all am ou nts o
 724 PART 10 • 62 • Muscle energy approaches
ad d itional leverage – exion, rotation, sid e-bend ing and trac-
tion – u sing p alp ation o tissu e stretch and p atient eed back
to m axim ize the localization o the techniqu es.
Muscles of the upper quadrant
Many o the m u scles o the chest and neck are su scep tible to
shortening and d ys u nction and m ay ad versely a ect p ostu re,
cau sing abnorm al stress and strain on other stru ctu res that
aggravate neck and u p p er extrem ity sym ptom s. Ad d itionally,
tw o m u scles – the scalenes and pectoralis m inor – m ay com -
p ress, trap and com prom ise neu rovascu lar structures that
p ass by these m u scles and aggravate u p per extrem ity sym p-
tom s (Sim ons et al 1999).
Upper trapezius and levator scapulae muscles
TrPs are com m only rep orted in the u p p er trap eziu s m u scle
and are an overlooked sou rce o neck pain and head aches
(Sim ons et al 1999; Fernánd ez-d e-las-Peñas et al 2007). The
levator scap u lae m u scle, w hich p rod u ces local p ain in the
ip silateral neck, w ill also be stretched d u ring treatm ent o
the trap eziu s. These m u scles can be stretched together, bu t
cervical rotation m ay selectively stretch p articu lar f bres.
There are d i erent view s abou t the am ou nt and d irection o
rotation that is need ed to select specif c parts o the m u scle
(Liebenson 2007; Chaitow 2013), so the author recom m end s
su btle f ne-tu ning o rotation u sing p alp atory and p atient
eed back to d eterm ine the m ost e ective p osition or each
ind ivid u al (Fig. 62.16).
Scalene muscles
The scalene m u scles (anterior, m id d le and posterior) are a
com m only overlooked sou rce o back, shou ld er and arm p ain.
TrPs in these m u scles m ay contribu te to sym p tom s in p atients
Figure 62.16 Muscle energy technique to lengthen the upper trapezius and
levator scapulae muscles. The shoulder is rmly depressed and stabilized, and the
neck is f exed and side-bent away rom the involved side, with rotation o the neck
dependent on the bre direction and sense o stretch. The patient’s isometric e ort
is either neck extension with side-bending towards the involved side (arrow) or
elevation o the shoulder (arrow) against the unyielding counter orce o the
practitioner.
w ith cervicogenic head ache (Sim ons et al 1999). Stretching
involves d epression o the should er and lateral exion o
the neck (Fig. 62.17). Opinions d i er on the d egree and
d irection o rotation required to stretch the scalene m u scles
(Gerw in 2005; Liebenson 2007; Chaitow 2013), so the au thor
recom m end s experim entation u sing p alpatory and patient
eed back.
Pectoralis major muscle
TrPs in the p ectoralis m ajor m u scle typ ically re er p ain to the
chest and arm (Sim ons et al 1999), and shortened m u scles can
p rod u ce a rou nd -shou ld ered , head - orw ard p ostu re that m ay
lead to ongoing strain in the should er and neck regions. Treat-
m ent o this m u scle shou ld be rein orced by exercises and
regular stretching at hom e to correct the head - orw ard posture.
This techniqu e is enhanced by the practitioner care u lly
anchoring the ascia over the sternu m and ap p lying traction
throu gh the length o the hu m eru s (Fig. 62.18).
Caution: This technique is not su itable or any p atient w ith
an u nstable shou ld er joint, a previou s shou ld er injury, or
lim ited shou ld er m ovem ent d u e to pain. Do not use external
rotation as the prim ary leverage because this w ill cause pain
and d iscom ort even in the healthy shou ld er joint.
Pectoralis minor muscle
The pectoralis m inor m uscle m ay re er p ain to the anterior
d eltoid region or to the ulnar sid e o the arm , hand and
f ngers; it m ay trap the axillary artery and brachial p lexu s to
m im ic cervical rad icu lop athy (Sim ons et al 1999). Like the
p ectoralis m ajor m u scle, shortened p ectoralis m inor m u scles
m ay a ect p ostu re, p rod u cing rou nd ed shou ld ers and a head -
orw ard posture, w hich m ay place strain on these stru ctu res.
A sm all tow el can be old ed and p laced on the p atient’s ante-
rior should er to cu shion the practitioner ’s hand i the patient
Figure 62.17 Muscle energy technique to lengthen the scalene muscles.
Main photo: the shoulder and upper ribs are stabilized by downward pressure on
the shoulder and clavicle (dotted line). Alternatively, the hand and thenar eminence
can be placed below the medial clavicle to stabilize the rst and second ribs. The
neck is slightly extended, laterally f exed, and rotated away rom the involved side.
The patient gently per orms an isometric e ort in lateral f exion towards the
involved side (arrow) against the unyielding counter orce o the practitioner.
Inset photo: alternative hold in which the arms are crossed.

Figure 62.18 Muscle energy technique to lengthen the pectoralis major
muscle. Note that the chest is rmly stabilized by the practitioner’s orearm and the
leverages applied to the shoulder are chief y horizontal extension and traction (long
dotted arrow). Pre-tension on the ascia over the sternum using a light compressive
and lateral orce (small dotted arrow) will help to minimize the amount o leverage
necessary or the shoulder. The patient li ts the arm (arrow) against the unyielding
counter orce o the practitioner. Note also that the applicator arm is straight and the
isometric orce is easily resisted by the practitioner’s body weight.
Figure 62.19 Muscle energy technique to lengthen the pectoralis minor
muscle. The tissues over the sternum are rmly stabilized by the practitioner’s
orearm, and a posterior and lateral orce is applied to the anterior shoulder (dotted
arrows). A small towel may be used or padding i the contact on the shoulder
is uncom ortable. The patient attempts to li t the shoulder (arrow) against the
unyielding counter orce o the practitioner. Note that the applicator arm is straight
and the isometric orce is easily resisted by the practitioner’s body weight.
exp eriences d iscom ort rom the pressu re o the contact
(Fig. 62.19).
Subscapularis muscle
TrPs in the su bscap u laris m u scle m ay p resent as d eep anterior
shou ld er p ain and m ay p rod u ce su bstantial lim itation o
external rotation, thu s m im icking ad hesive capsulitis (Sim ons
et al 1999). E ective stretch o this m u scle requires f rm stabi-
lization o the scap ula and m ay be per orm ed w ith the patient
in a supine or lateral recum bent position (Fig. 62.20).
Techniques for myofascial tissues 725
Figure 62.20 Muscle energy technique to lengthen the subscapularis muscle.
Inset photo: the arm is rst li ted to allow the practitioner’s hand to contact and
stabilize the lateral border o the scapula. Main photo: the scapula is rmly
stabilized using medial compression against the border o the scapular (small
dotted arrow) to prevent upward rotation. The shoulder is then abducted and
externally rotated with slight traction through the arm and wrist (dotted arrows). The
patient provides isometric e ort by li ting the arm (arrow) against the practitioner’s
unyielding counter orce.
Figure 62.21 Muscle energy technique to lengthen the latissimus dorsi muscle.
The patient is positioned on the una ected side with a pillow under the waist region
to promote lumbar side-bending. The patient’s iliac crest is stabilized with one
hand (dotted arrow), while the other hand links through the patient’s arm to apply
an abduction and traction orce (dotted arrow). The patient produces an isometric
e ort by attempting to push the arm down (arrow) against the unyielding
counter orce o the practitioner.
Caution: This techniqu e is contraind icated i the p atient has
an u nstable should er.
Latissimus dorsi muscle
The latissim us d orsi is a large sup erf cial m uscle that m ay
re er p ain to the in erior scapula, the m ed ial arm and orearm ,
and the ank and lu m bar regions (Sim ons et al 1999). Ad d i-
tionally, shortening o this m u scle m ay restrict u ll arm
elevation, and patients characteristically com pensate w hen
p er orm ing bilateral arm elevation by overextension o the
lum bar spine to achieve u ll elevation (Fig. 62.21).
 726 PART 10 • 62 • Muscle energy approaches
Muscles of the lower quadrant
Assessm ent o the key m uscles o the low er bod y by palpation
or TrPs and assessm ent o shortness and strength should be
p art o the p hysical exam ination o any patient w ith low er
back or low er extrem ity pain. In ad d ition, shortness o som e
m u scles m ay a ect p elvic tilt and sp inal cu rvatu re and there-
ore have p otential to d istu rb the static and d ynam ic equ ilib-
rium o other regions. In the case o back and low er extrem ity
p ain, re erral rom TrPs in these m u scles shou ld be care u lly
d i erentiated rom other causes o re erred pain, su ch as
rad icu lar pain.
Quadratus lumborum muscle
The qu ad ratus lum boru m m u scle is a d eep m uscle and a
requ ently overlooked sou rce o LBP. Re erred pain typically
sp read s to the iliac crest, sacral region and the greater tro-
chanter. The au thor f nd s this m u scle to be requ ently involved
in chronic LBP, w hich m ay be p resent concu rrently w ith d isc
and acet joint p ain. The ad d ition o slight traction throu gh
the leg o ten increases the e ectiveness o the stretch
(Fig. 62.22).
Hip exor muscle group
The exor m u scles o the hip that com m only present w ith
shortness or TrPs are the iliop soas, rectu s em oris, p ectineu s
and tensor ascia lata m u scles. The iliopsoas, rectu s em oris
and pectineu s m ay re er p ain to the anterior thigh and groin,
w hereas the tensor ascia lata re ers pain to the lateral thigh.
Ad d itionally, the iliopsoas m ay prod uce ipsilateral lu m bar
p ain (Travell & Sim ons 1992). When shortened , these m u scles
restrict hip extension and prom ote pelvic anteversion, w hich
Figure 62.22 Muscle energy technique to lengthen the quadratus lumborum
muscle. Main photo: the patient is positioned on the una ected side with a pillow
under the waist region to promote side-bending o the trunk and stretch o the
quadratus lumborum on the upper side. The leg on the upper side can be extended
slightly and adducted to assist this stretch, and the practitioner’s hip may contact
the patient to stabilize the pelvis to avoid rotation. One hand is used to x the lower
ribs with a com ortable broad contact (dotted arrows), while the other hand contacts
the leg to produce urther hip adduction and traction (dotted arrows). The patient
provides isometric e ort by attempting to li t the leg (arrow) or hitch up the hip
against the unyielding counter orce o the practitioner. Inset photo: alternative hand
contact on the iliac crest, which will avoid stretching the hip adductors.
m ay lead to u rther strain on the lu m bar sp ine. These m u scles
can be treated in the Thom as test p osition, u sing extension
and f ne-tu ning o knee exion, ad d uction or abd u ction to
localize the stretch to each m u scle (Fig. 62.23).
Gluteus medius and gluteus minimus muscles
The glu teu s m ed iu s and m inim u s m u scles are im portant hip
abd u ctors and they stabilize the pelvis d uring single-lim b
stance. TrPs in these m u scles m ay p rod u ce local p ain in the
sacroiliac and hip region (m ed iu s), or m ay re er p ain d ow n
the p osterior or lateral thigh and leg (m inim u s) (Travell &
Sim ons 1992). For treatm ent, the m u scle can be d ivid ed into
p osterior, m id d le and anterior p ortions. Stretching requ ires
the p rim ary leverage o hip ad d u ction, w ith hip exion or
extension to localize the stretch to the posterior and anterior
p ortions, resp ectively. These m u scles o ten have TrPs in
p atients w ith low back or sacroiliac p ain and instability, and
they p robably becom e a second ary sou rce o noxiou s inp u t in
these cases. The m u scles can be stretched and treated in d i -
erent positions, bu t the techniques that the au thor f nd s m ost
e f cient are illu strated in Figure 62.24.
Piriformis muscle
The piri orm is m ay be a com m on cause o pain and d istress,
and TrPs m ay re er pain to the sacroiliac region, laterally
across the bu ttock and over the hip region p osteriorly, and to
the p roxim al tw o-third s o the p osterior thigh (Travell &
Sim ons 1992). Ad d itionally, the piri orm is m ay prod uce an
entrapm ent synd rom e o the neu rovascular structures against
the rim o the greater sciatic oram en, althou gh tru e entrap -
m ent m ay actu ally be rare. This m u scle acts as an external
rotator o the hip w hen the hip is in a neu tral position, bu t
Figure 62.23 Muscle energy technique to lengthen the hip exor muscle group.
Patients are most e ectively treated in the Thomas test position, where they are
supine with the pelvis just on the end o the table. The untreated leg should be ully
f exed, held by the patient and stabilized by the practitioner’s body (dotted arrow) to
ensure stability o the pelvis and lumbar spine. Main photo: treatment o iliopsoas
muscle. An extension orce is applied to the treated thigh (dotted arrow) until a
barrier is palpated or a moderate stretching orce is perceived by the patient. The
patient pushes the thigh up (arrow) against the unyielding counter orce o the
practitioner. Inset top left photo: addition o abduction will localize the stretch to the
pectineus and short abductor muscles. Inset top right photo: addition o adduction
will localize the stretch to the tensor ascia lata muscle. Inset bottom photo:
addition o knee f exion will localize the stretch to the rectus emoris muscle.

Figure 62.24 Muscle energy technique to lengthen the gluteus medius and
gluteus minimus muscles. These two muscles are treated as one muscle, but they
can also be treated as posterior, middle and anterior portions. The anterior division
can be treated in the same way as the tensor ascia lata in Fig. 62.23. Main photo:
the posterior division requires hip f exion and adduction. The practitioner position
illustrated permits a very e ective stretch that requires little e ort to maintain.
The hip is f exed to approximately 30° and is then slightly adducted. A mild
compressive orce is placed down the axis o the emur (long dotted arrow) to
stabilize the pelvis. Minor shi ts in weight by the practitioner produce urther
adduction (short dotted arrow) or a localized and e ective stretch. The patient
provides isometric e ort by attempting to push the leg back to midline (arrow)
against the unyielding counter orce o the practitioner. Inset photo: treatment o the
middle bres o the le t hip using adduction. The uninvolved hip is f exed to create
room or the adducted treated leg and stabilized by the practitioner (dotted arrow).
The treated leg is abducted using the practitioner’s thigh (dotted arrow) and the
patient gently pushes the thigh in adduction (arrow).
Figure 62.25 Muscle energy technique to lengthen the piriformis muscle.
The practitioner position illustrated takes advantage o the abduction action o the
piri ormis when the hip is f exed and permits a very e ective stretch that requires
little e ort to maintain. The hip is f exed to approximately 90° and is then slightly
adducted. The practitioner should move close to the leg. A mild compressive orce
is placed down the axis o the emur (long dotted arrow) to stabilize the pelvis.
Minor shi ts in weight by the practitioner produce urther adduction and external
rotation (short dotted arrow) or a localized and e ective stretch. The patient
provides isometric e ort by attempting to push the leg back to the midline (arrow)
against the unyielding counter orce o the practitioner.
Techniques for myofascial tissues 727
becom es an abd uctor o the hip w hen the hip is exed . E ec-
tive stretching o this m u scle u sing internal rotation is d i f cu lt
because the hip joint lim its the available rotation, so the u se
o ad d u ction w hen the hip is exed at app roxim ately 90° is
m ore e ective (Fig. 62.25).
Acknowledgements
The au thor grate u lly acknow led ges the assistance o Rolena
Step henson as su bject o the p hotos, o Kelly Rogers, ATSU
p hotograp her, and o Deborah Goggin MA, Scientif c Writer,
A.T. Still Research Institute, A.T. Still University, or review ing
this chap ter.
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 PART 10 •  Soft Tissues in the Upper and Lower Quadrants

Chapter  63
Myo ascial Induction Approaches
 

An d rz e j P ila t

CHAP TER CONTENTS
Introduction
Introduction 729
Fascia and its dynamics  730 Bod y m ovem ent involves ascial activity. An extensive d ef ni-
Functions of the fascial system  730 tion o the ascia is need ed to analyse bod y biom echanics and
Information transmission process  730
p athom echanics. H ow ever, there is a lot d iscrep ancy in op in-
ions on and d ef nitions o w hat ascia is (Langevin & H u ijing
Anatomical considerations related to the continuity of the fascial  
2009; Ku m ka & Bonar 2012; Schleip et al 2012b; Sw anson
system of the neck and upper extremity  732
2013). Ku m ka and Bonar (2012) d ef ned ascia as an inner-
Fascial anatomy of the cervical region  732 vated , continu ou s, u nctional organ o stability and m otion
Fascial anatomy of the upper extremity  733 that is orm ed by three-d im ensional collagen m atrices. Fascia
Anatomical considerations related to the continuity of the fascial   can be d escribed as the bod y’s d ynam ic u ni ying stru ctu re; it
system of the pelvis and lower extremity  738 m ani ests as a continu u m o f bres im m ersed in the grou nd
Super cial and deep fascial anatomical links between the trunk   su bstance that accom p anies the bod y stru ctu res w ithou t
and lower limbs  738 any interruption (Pilat 2003). The ascial system represents
Deep fascial intermuscular links  740 a com plex com m u nicational architecture, w hich p rovid es
Theoretical aspects related to the treatment of myofascial   m echanorecep tive in orm ation; this p rocess occu rs as a resu lt
dysfunction syndrome  743 o not only its top ograp hic d istribu tion p er se, bu t also m ainly
Mechanics of myofascial dysfunction syndrome formation  743 the p attern o how it inter-relates w ith other bod y structu res,
Proposed neurophysiological mechanisms of myofascial   especially m u scles. Its f brou s construction allow s it to align
induction techniques  745 w ith and accom m od ate to both intrinsic and extrinsic ten-
Scienti c evidence related to the results in the myofascial   sional bod y requ irem ents. The tensional p aths, created ou tsid e
approach  747 the correct biom echanical m ovem ent p atterns, can thu s red i-
Research related to pathology  747 rect the bod y d ynam ics. The d ensity, the d istribu tion and the
Clinical research in healthy subjects  747 organolep tic characteristics o the system d i er across the
bod y, bu t its continu ity is essential, allow ing the ascia to act
Therapeutic strategies applied in the myofascial induction process  748
as a synergistic w hole, absorbing and d istribu ting local stim u li
General observations related to the therapeutic process  748 to the entire system . This inherent synergy o the stru ctu ral
De nition of the myofascial induction process  748 ascial system helps the hum an bod y to be relatively ind e-
Bases for clinical applications  748 p end ent o the gravitational orce, and also gives it a great
Examples of practical applications for upper quadrant disorders  749 cap acity to ad ap t accord ing to changing external and internal
Techniques related to the cervical spine  749 requ irem ents, or instance in relation to the availability o
Techniques related to the shoulder girdle  750 energy and nu trients in the im m ed iate environm ent. Besid es
Techniques related to the brachial and antebrachial fascia  752 its structural role, the ascial system also d istribu tes stim uli
Techniques related to the fascia of the hand  752 that the bod y receives: its sensor netw ork registers therm al,
chem ical, p ressu re, vibrational and m ovem ent im p u lses, and
Examples of practical applications for lower quadrant disorders  753
it analyses, categorizes and transm its them to the central
Techniques related to the lumbopelvic region  753
nervou s system . The central nervou s system then red irects
Techniques related to the thigh region  755 the im p u lses and send s instru ctions to the organs. We can
Techniques related to the knee and the leg region  756 conclu d e there ore that the ascial system is not a p assive
Contraindications  758 and m erely su p porting stru ctu re, bu t rather a d ynam ic and
Conclusion  758 m u table system (Sw anson 2013).
 730 PART 10 • 63 • Myofascial induction approaches
This chap ter d iscu sses basic concep ts involved in m yo as-
cial ind u ction therap y ap p lications to the m u scu loskeletal
p ain synd rom es o the u pp er and low er qu ad rants. Sp ecial
attention w ill be p laced on:
• p rincip les o ascial d ynam ics
• biom echanics
• innervations
• im pu lse (in orm ation) transm ission
• anatom ical continu ity along the u p p er and low er qu ad rants
• orm ation o ascial entrap m ent
• assessm ent p rincip les
• basic treatm ent p rincip les
• sam p les o treatm ent ap p lication
• ind ications and cou nterind ications.
Fascia and its Dynamics
Fascia com p rises the d ense (both regular and irregu lar) con-
nective tissu e that is involved in d i erent stru ctu res (e.g.
aponeu rosis, tend ons, ligam ents, joint capsu les and nerve
sheets) and orm s a continu ou s bond ing netw ork betw een the
elem ents o the m u sculoskeletal system , as w ell as the loose
connective tissu e that, by f lling all the interm ed iate sp aces o
the bod y, creates links betw een all the anatom ical com p onents
(vascular, nervou s and visceral) (Langevin & H u ijing 2009;
Schleip et al 2012a). These connections m ay even exist at the
cellu lar and intracellu lar levels (Chiqu et et al 2009).
Functions of the fascial system
The ascial system not only orm s anatom ical connections
throu gh its continu ou s com m u nication netw ork, bu t also has
a large variety o other unctions, inclu d ing (Pilat 2003):
• su sp ension
• su p p ort
• orm ation o u nctional u nits
• absorp tion and d istribu tion o local stim u li as a
synergistic w hole
• m echanical (pressu re, vibration, m ovem ent)
• chem ical
• therm al
• p rotection and au tonom y o the m u scles and viscera
• orm ation o com p artm ents
• m aintenance o bod y p ostu re (Langevin 2006)
• tissu e nu trition
• acilitation o bod y hom eostasis
• p articip ation in w ou nd healing
• im p lication in control o a erent stim u li transm ission.
Information transmission process
Som e au thors (Gerlach & Lierse 1990) have suggested an inte-
grated bod y m od el nam ed the ‘bone– ascia–tend on system ’
ascribing to the ascia the bond ing u nction o the m uscu lar
biom echanics. Such a com plex and m ultitask system requires
the ability to receive, p rocess and transm it in orm ation related
to bod y m ovem ent. The in orm ation can ow throu gh the
system , em p loying three d i erent connexion p atterns related
to a sp ecif c p u rp ose (Pilat & Testa 2009).
Mechanical (anatomical) pattern
These links are present at d i erent anatom ical levels ( rom
m acro- to m icroscop ic) and cou ld act hierarchically (Wang
et al 2009). At the m acroscopic level, observations o d issected
u nem balm ed cad avers (Vleem ing & Stoeckart 1997; Myers
2003; Stecco et al 2008; Pilat 2009) have d em onstrated m echan-
ical continu ity o the ascia w hereby all the m u scles attached
to a sp ecif c ascia act synergistically, creating m yokinetic
links (Stecco et al 2007; Pilat 2009). Recently Yam an et al
(2013) p resented evid ence show ing ep im u scu lar m yo ascial
orce transm ission throu gh und issected m uscles in situ , hence
conf rm ing the hyp othesis that, in vivo, m u scles are in
p rincip le not m echanically ind ep end ent. In another in vivo
exp erim ent, Carvalhais et al (2013) observed m yo ascial
orce transm ission betw een the latissim u s d orsi and glu teus
m axim u s m u scles across the thoracolu m bar ascia. Fu rther,
based on the observations m ad e d u ring end oscopic surgery,
Gu im berteau et al (2010) prop osed that ascia not only su r-
round s m uscle stru ctu res (epim ysiu m ), bu t also inf ltrates the
m u scu lar m ass and at (in a very ind ivid u al m anner in each
p erson), thu s creating a three-d im ensional interconnection
w ithin the bod y’s netw ork o m acro- and m icro-stru ctu res
(Sw artz et al 2001; Gu im berteau et al 2010). Gu im berteau et al
(2005) have d escribed the ascial system as an uninterru pted
netw ork, term ed the ‘m u ltim icrovacu olar collagen d ynam ic
absorption system ’ (MCDAS), that although seem ingly a ‘cha-
otic m atrix’ nevertheless m aintains its orm as a resu lt o the
actions o criss-crossing p hysical orces that im part a hierar-
chical and interd ep end ent com p lexity, inclu d ing both sp atial
and tem p oral relationships. This m echanical transverse orce
transm ission throu gh the ascia has also been extensively
stu d ied at m icroscop ic level (H uijing 2009; Purslow 2010;
Chi-Zhang & Gao 2012), w ith particu lar ocus on the inter-
m u scu lar ascia w here the m u scle f bres are inserted . Throu gh
these ascial connections, m u scle f bres can p articip ate in
m echanical action even w ithou t d irectly inserting into the
bone (Van d er Wal 2009).
A m echanical m od el to exp lain the interactions d escribed
above is the tensegrity (tensorial integrity) m od el, w hich w as
p rop osed by Ingber (1998). This theory su ggests a system o
shared tensions at m u ltip le bod y levels, and it can also exp lain
the global reaction o the ascial system w hen it receives a
m echanical stim u lu s (Chicu rel et al 1998; Khalsa et al 2000;
Ingber 2006). The research by Ingber (1998, 2003, 2005, 2006)
and others (Parker & Ingber 2007; Stam enovic et al 2007;
Wang et al 2009), on cellular d ynam ics and the active resp onse
o the cytoskeleton w hen m echanical orces are transm itted to
it rom the extracellular m atrix, d em onstrates the im portance
o tissu e rem od elling at both cellu lar and su bcellu lar levels.
This com m unication takes p lace throu gh the extracellu lar
m atrix via integrins (m olecu lar brid ges betw een the m atrix
and the cytoskeleton), by w hich the cell ‘senses’ its environ-
m ent and resp ond s as requ ired . The m echanical inp u t can
su bsequ ently trans er to the nu cleu s m em brane at the su bcel-
lular level (Maniotis et al 1997; H u et al 2003), and f nally can
also m od i y gene exp ression (Chiquet et al 2009). Consid ering
the act that the hu m an bod y is bu ilt u p as a hierarchical

d esign, these f nd ings w ould su ggest a sim ilar princip le in the
increasing bod y’s constru ction ord er. The d ynam ics o the
ascial system ’s m ovem ents at cellu lar level are associated
w ith contractions o m yof broblasts (a type o f broblast con-
taining d ynam ic actin m icrof lam ents that contract in the
m anner o sm ooth m u scle cells) (Gabbiani 2007).
Functional pattern
The ascia is consid ered to be a m echanosensitive structure
(Langevin 2006; Vaticón 2009; Langevin et al 2011); how ever,
neu roanatom ical stu d ies tend to ocu s m ainly on d iscs, acet
joints, m u scles f bres, tend ons or ligam ents so there is a little
in orm ation regard ing ascial innervation. Ou r interest here
ocuses on the u nctional connection, w hich m ainly takes
place throu gh the loose connective tissue stru ctu res betw een
its u niqu e netw ork o m echanoreceptors, particularly the
so-called interstitial m echanorecep tors (typ e III and IV ree
nerve end ings). Each recep tor has tw o su bgrou p s, w ith low
and high levels o m echanosensitivity related to the cell archi-
tectu re. The p resence o this kind o recep tor w as conf rm ed
in recent stu d ies:
• Grou p III m u scle a erents are ou nd in p erim u scu lar
ascia and the ad ventitia o m u scle blood vessels and
respond to a variety o stim u li, includ ing pressure and
stretch (w hich resu lts in m atrix d e orm ation a ter
m echanical im p u lse ap p lication (Lin et al 2009)).
• The thoracolu m bar ascia (TLF) is a highly innervated
tissu e (Tagu chi et al 2009).
• There is su bstantial innervation o non-sp ecialized
connective tissu e throu gh the Aδ and / or C-f bres
(Corey 2011).
• There is a strong link betw een ascia and the au tonom ic
nervou s system (H aou zi et al 1999).
• Many f bres – especially in the su p erf cial ascia – exp ress
tyrosine hyd roxylase, an enzym e characteristic o
p ostganglionic sym pathetic f bres (d op am ine secretion
control). This f nd ing m ay exp lain w hy p atients w ith low
back pain report increased intensities o pain w hen they
are u nd er p sychological stress (Chou & Shekelle 2010).
• N eu ral action p otential f ring throu gh nerve term inals is
linked to sp ecif c m echanical d e orm ation and
extracellu lar m atrix interactions (Lin et al 2009).
• Stim u lation o grou p III and IV m u scle a erents has been
show n to have im p ortant re ex e ects on both the
som atic and the au tonom ic nervou s system s. These
inclu d e an inhibitory e ect on α -m otor-neurons, an
excitatory e ect on γ-m otor-neurons and an excitatory
e ect on the sym pathetic nervou s system (Kau m an
et al 2002).
• Sp ecialized connective tissu e stru ctu res are related to
m u scle stru ctu re (end om ysiu m , p erim ysiu m , ep im ysiu m )
and other bod y system s: circulatory (arterial, venou s,
lym p hatic) and nervou s. Rem od elling o interstitial
connective tissu e m ay have im p ortant biom echanical,
vasom otor and neu rom od u latory e ects.
It is su ggested that the three-d im ensional ascial netw ork is
also involved in the pain transm ission p rocess. The pain exp e-
rienced in the extrem ities is o ten a re erred pain (i.e. it is
perceived in areas rem ote rom the site o noxious stim u la-
Fascia and its dynamics 731
tion). This kind o p ain d oes not alw ays ollow the segm ental
p ain p attern (Travell & Bigelow 1946). The central hyp erexcit-
ability theory (Mense 1994) explains the m echanism o pain
rom d eep structu res, bu t d oes not clari y the p resence o non-
segm ental p ain p atterns rom the su p erf cial m u scles su ch as
the neck, the latissim u s d orsi, the trap eziu s and lim b m u scles
(H an 2009). In the su bcu taneou s tissue close to the ou ter level
o the TLF, f bres are o ten ou nd in the p roxim ity o blood
vessels. The location o m ost f bres arou nd blood vessels su g-
gests that at least p arts o them are vasom otor f bres and ,
w hen activated , these f bres m ay cau se ischaem ic pain (Tesarz
et al 2011). Free nerve end ings have been ou nd in all layers
o the TLF (su p erf cial, m id d le and d eep ); how ever, no cor-
p u scu lar recep tors su ch as p acinian and p acini orm corp u s-
cles or Golgi tend on organs have been ou nd . Micro-inju ries
resulting rom irritation o nociceptive nerve end ings in the
TLF m ay lead d irectly to back pain (Willard et al 2012). Tissu e
d e orm ations d ue to inju ry, im m obility or excessive load ing
cou ld also im p air p rop riocep tive signalling, w hich m ay lead
to an increase in p ain sensitivity via an activity-d ep end ent
sensitization o w id e-d ynam ic-range neu rons (Willard et al
2012). The ‘barrier-d am ’ theory su ggests that re erred pain
rom the neck m u scle, the pectoral gird le and the arm is
p erip heral in origin and is m ani ested by irritation o the
p erip heral nerves (Farasyn 2007). Langevin et al (2009)
reported an abnorm al connective tissue stru ctu re in the
lum bar region in a grou p o su bjects w ith chronic or recu rrent
low back p ain, and suggested p ossible causes inclu d ing
abnorm al m ovem ent p atterns and chronic in am m ation. H an
(2009) has prop osed an alternative hypothesis – term ed the
‘connective tissu e theory’; consid ering the anatom ical exp an-
sions o the ascia and the orm ation o the m yokinetic links
and chains, he su ggests that the signalling m echanism s
p resent in the loose connective tissu e m ay be able to transm it
noxiou s stim u li rom the su r ace to the m u scles and other
d eep structu res, throu gh the cells o the vascular and neu ral
system s. H ence p erip heral p ain m ay also have a d irect origin
in the connective tissu e.
Chemical pattern
Cells are u nd am ental u nits o living beings and they are
im m ersed in the extracellu lar m atrix, w hich constitutes their
ecosystem . The extracellular m atrix o the connective tissue is
the m ed iu m in w hich the com p lex m echanotransd u ction
p rocess takes place – that is, the cells w ithin it react d ynam i-
cally, d etecting and interp reting m echanical signals and con-
verting them into chem ical changes and / or m od if cations in
gene expression (Ingber 2006; Ghosh & Ingber 2007; Parker &
Ingber 2007; Chiqu et 2009). Ingber (2006) consid ered the
m ed iating stru ctu res o the m echanotransd u ction p rocess to
inclu d e both m echanosensitive proteins and structural hierar-
chical netw orks, rom the organ d ow n to the cellu lar level, and
Vanacore et al (2009) id entif ed netw orks o collagen IV present
in the basem ent m em brane that provid ed structural integrity
to tissu es and served as ligand s or integrin cell-su r ace recep -
tors. These netw orks m ed iate cell ad hesion, m igration, grow th
and d i erentiation. Shoham and Ge en (2012) d em onstrated
that ad ip ocytes (also osteoblasts, chond roblasts and end othe-
lial cells) are ind eed m echanosensitive and m echanoreceptive.
These m echanism s cou ld help exp lain inju ry and d isease that
are related to changes in cell m echanics.
 732 PART 10 • 63 • Myofascial induction approaches

The ascial system is responsible or the transm ission o

Anatomical Considerations Related to
the Continuity of the Fascial System of
the Neck and Upper Extremity
In the introd u ction w e re erred to the continu ity o the bod y’s
ascial system . This continuou s ascial linking is present in the
m echanical connection betw een the head , the tru nk and the
u p p er lim b. In this region, there is no clear d ivision betw een
m u scu lar, nervou s and vascu lar stru ctu res related to a single
segm ent. Generally, rom an anatom ical p ersp ective, less
im p ortance is given to the ascia than to the tissu es related
to it; how ever, it is this ascial stru ctu re that ap p ears to
ensu re u nctional continu ity throu ghout the bod y (Pilat 2003;
Vanacore et al 2009).
Fascial anatomy of the cervical region
The ascial cervical system orm s several spaces w ith a longi-
tu d inal orientation (Bien ait 1987; Up led ger 1987; Bochenek &
Reicher 1997; Pilat 2003), w hich d ivid e, envelop , su pport and
connect the m u scles, bones, viscera, vascu lar vessels and
p erip heral nerves. They can be com p ared to a system o tu bes
concentrically p laced insid e one another, all o w hich are
interconnected at d i erent levels and in several w ays (Pilat
2003) (Fig. 63.1). These interconnections un old betw een the
m u scles, establishing m echanical links that d eterm ine the
d irection and the range o m otion (Bochenek & Reicher 1997).
The lubrication o these com p artm ents, w hich is a resu lt o
the greater am ou nt o atty tissu e or loose connective tissu e
p resent, allow s or greater reed om o m ovem ent (p articularly
slid ing) o the ascial system (Pilat 2009).
d ynam ic (active) orces betw een the craniu m , m and ible,
hyoid , sternu m , clavicles, scap u la, the f rst tw o ribs and the
cervical sp ine. It enables com m u nication betw een the end o-
craniu m and the end othorax, in u encing not only the m echan-
ics o the cervical region, the shou ld er com plex, the arm and
the tem p orom and ibu lar joint, bu t also the m echanics o the
respiratory system and transm ission in the vascu lar system
betw een the m echanical inp ut and the cephalic region
(Pilat 2009).
The precise rou te and connection betw een ascial layers is
d i erent or each ind ivid ual, and this is w hy it is d i f cu lt to
classi y its exact anatom y in relation to the transm ission
p athw ay and the inter-relations betw een variou s elem ents.
H ow ever, m ost anatom ists agree w ith the ollow ing classif ca-
tion and d istribu tion o the ascial system (Pilat 2009):
• sup erf cial ascia
• d eep ascia
• superf cial lam ina
• prevertebral lam ina.
This system orm s com plex links w ith the should er gird le and
has continu ity w ith the arm .
Super cial cervical fascia
The f rst structure in this continuity is the su perf cial ascia,
located und er the skin and orm ing a f rm link (Pilat 2009). It
closely su rrou nd s the entire stru ctu re o the cervical sp ine (see
Fig. 63.1A, Figs 63.2–63.3), varying in thickness, orm , elasti-
city, resistance and at content. It contains the p latysm a
m u scle, cu taneou s nerves, cap illaries and lym p hatic vessels,
and is an elastic stru ctu re. The d ynam ic activity o the sup er-
f cial ascia is related to the p latysm a m u scle, w hich exp and s

C D

x C D y

Front

A B

Figure 63.1 Scheme showing the continuity of the fascial system of the cervical region and its links with the scapular–thoracic region. (A) Sagittal projection.
(B) Horizontal projection. (C) The superf cial sheet o the deep cervical asciae communicating the craneal structures and the chewing system with the scapular–thoracic
region. (D) Prevertebral ascia creating the bond between the sub-occipital region and the shoulder girdle.
 Anatomical considerations related to the continuity of the fascial system of the neck and upper extremity
Figure 63.2 Continuity of the super cial fascia in the front part of the body,
from the cervical region to the arm, from unembalmed cadaver dissection. Note
the skin withdrawn at the level o the orearm as a glove. There is no independent
movement between the superf cial ascia and the skin.
Figure 63.3 Continuity of the super cial fascia of the cervical, scapular and
dorsal regions, from unembalmed cadaver dissection.
su p erf cially over the anterolateral neck region. On the u p p er
sid e, the su p erf cial ascia along the p latysm a m u scle envel-
op s the m and ible and continu es to the su p erf cial ace m u scles
(i.e. the d epressor angu li, d epressor labii in erioris and orbicu-
laris oris); on the low er sid e, it extend s beyond the level o the
clavicle and inserts into the second and third ribs; on the
lateral sid e, it continu es to the p latysm a insertions.
Deep cervical fascia
The d eep cervical ascia is located und er the skin, the su per-
f cial ascia and the p latysm a m u scle. It is a thin lam ina that
envelops the neck stru ctu res like a collar. At the upp er sid e
the ascia inserts onto the p eriosteu m o the occip ital external
protu berance, the m astoid process o the tem p oralis bone, the
external acou stic m eatu s, the in erior bord er o the zygom atic
arch and the m asseter ascia. It inserts p osteriorly onto the
733
sp inou s p rocesses o the cervical sp ine, and the nu chal and
su p rasp inou s ligam ents.
From its posterior insertions, the su perf cial lam ina o the
d eep cervical ascia d ivid es bilaterally into tw o com partm ents
envelop ing f rst the upper trapeziu s and next the sternoclei-
d om astoid m uscle (see Fig. 63.1A). At the anterior bord er o
the trap eziu s m u scle, the ascia exp and s into a f brotic lam ina
that attaches to the ascia o the scalene m u scles. The sterno-
cleid om astoid ascial envelop e is asym m etric, w ith a d eep
layer that is thin and there ore low -load resistant. Its superf -
cial layer is thicker and stronger, p articu larly at the su p erior
p art o the m u scle belly. At the su p erior bord er, the cervical
ascia o the sternocleid om astoid m uscle orm s several f brotic
trabecu lae that cross the su bcu taneou s tissu e and the d erm is.
The sternocleid om astoid and the u pper trapezius m uscles
envelop the bord ers o the neck region, establishing several
ree sp aces, w hich perm it access to the d eepest lam ina o the
cervical ascial system . Fu rtherm ore, on exam ination the
cranial and clavicle insertions o both m u scles ap p ear as only
one m u scle, w hich m ay be d u e to the act that both m u scles
arise rom the sam e em bryonic lam ina, and / or that they are
innervated by the sam e cranial nerve (XI). Finally, other struc-
tu res that are m echanically associated w ith the su p erf cial
lam ina o the d eep cervical ascia includ e the su bm and ibular
gland u le and the f brotic capsule o the parotid gland ule. This
sp an orm s a com p lex stru ctu re that integrates w ith the
d ynam ics o the shou ld er gird le.
The d eepest level o the cervical ascia system is repre-
sented by the p revertebral ascia (see Fig. 63.1B), w hich envel-
op s all the cervical m u scles exclu d ing the sternocleid om astoid ,
the u p p er trap eziu s and the in rahyoid . The in erior inser-
tions, at the third thoracic vertebra, join the thoracolu m bar
ascia and continue up to the lu m bar region. In its lateral
trajectory, the p revertebral ascia ru ns bilaterally to the axillar
ascia; at the anterior–in erior bord er, it continu es tow ard s the
vertebral anterior longitu d inal ligam ent and the p osterior
bord er o the m ed iastinu m . It covers the three scalene m uscles
laterally, and the longus collis and longus cervicis m u scles
anteriorly. Finally, it rests over the transverse processes o the
cervical vertebrae (Gallau d et 1931; Bochenek & Reicher 1997;
Pilat 2009).
Fascial anatomy of the upper extremity
The upper limb fascia super cial layer
On the su p erf cial level, the ascial continu ity betw een the
neck and the arm anatom ically is clear (Figs 63.4– 63.5). Along
the shou ld er and arm region the at content is high, p articu -
larly in w om en. In the orearm , this content d epend s on the
p hysical bu ild -u p o the ind ivid u al, thou gh it grad u ally
red u ces tow ard s the extrem ity (Fig. 63.6). In the hand , there
is a m arked d i erence betw een the d orsal and palm ar regions,
w hich probably resu lts rom the d i erent unctions assigned
to each su r ace. In the d orsal area the ascia is loose and thin,
w hich allow s or greater m obility d uring m anipu lation su ch
as f nger- exing (Fig. 63.7). The ascia o the p alm ar region is
m ore f rm ly ad hered to the skin (Fig. 63.8), although in the
thenar and hyp othenar em inence the su p erf cial ascia is
again m ore loose and thin, w hich acilitates m anip u lative and
grip ping actions in both these regions. The sup erf cial ascia
 734 PART 10 • 63 •
Figure 63.4 Super cial fascia of the cervical and pectoral region from
unembalmed cadaver dissection. Note the continuity o the ascial structure and
its considerable thickness with high at content. A. Skin. B. Superf cial ascia.
C. Deep ascia at a pectoral region.
Figure 63.5 Super cial fascia of the scapular–thoracic region, from
unembalmed cadaver dissection. Note the continuity o the ascial structure and
its smaller thickness in relation to the pectoral region. A. Skin. B. Superf cial ascia.
C. Deep ascia at the dorsal region.
Figure 63.6 Super cial fascia in the forearm, from unembalmed cadaver
dissection. Its thickness is smaller in comparison with the arm.
has been given variou s nam es: su bcu taneou s ascia (Rou viere
& Delm as 2005), cellu lar cu taneous tissu e (Testu t & Latarjet
2007) and su bcu taneou s ad ipo ascial tissu e (Avelar 1989). The
characteristics o the hand ascia have been analysed m ainly
in relation to p lastic su rgery and the skin-healing p rocess
Myofascial induction approaches
Figure 63.7 Areolar fascia in the dorsum of the hand, from unembalmed
cadaver dissection. Note how easy it separates rom the deep ascia.
Figure 63.8 Super cial fascia in the palm of the hand from unembalmed
cadaver dissection. Note how f rmly it adheres to the skin.
(Congd on et al 1946; Markm ann & Barton 1987; Avelar 1989).
N evertheless, althou gh the su perf cial ascia is a m ajor ana-
tom ical stru ctu re, the d earth o exhau stive anatom ical and
biom echanical stu d y m akes it d i f cult to clari y its precise
role in relation to bod y m ovem ents.
Arm fascia deep layer
The m ain d ynam ic ascial link betw een the cervical region and
the u p p er lim b is orm ed by the su p erf cial sheet o the d eep
cervical asciae (Fig. 63.9), w hich in its low er span extend s
along the length o the u pper lim b (Pilat 2003), orm s num er-
ou s bond s and continu es tow ard s the sp ine o the scap u la, the
acrom ion process and the clavicle. These then orm su r ace
links to the p ectoralis m ajor, the d eltoid , the trapezius, the
in raspinatu s, the teres m inor, the teres m ajor and the latis-
sim u s d orsi m u scles (Fig. 63.10). The interm ed iate and d eep
levels (Figs 63.11–63.12) involve the pectoralis m inor, the
su p rasp inatu s, the levator scap u lae, and the rhom boid and
 Anatomical considerations related to the continuity of the fascial system of the neck and upper extremity 735

C
A B

A
C
D

D
E B

Figure 63.9 The anterior and lateral aspect of the deep fascia from unembalmed
cadaver dissection. A. External lamina o the deep cervical ascia. B. Pectoral ascia.
C. Deltoid ascia. D. Serratus anterior muscle ascia. E. Superf cial ascia. The f rst
our (A–D) orm a continuous and thin lamina that inf ltrates the muscle mass
through f ne expansions in the orm o intramuscular septa.
Figure 63.12 Deep aspect of the scapular region, from unembalmed cadaver
dissection. A. Supraspinatus muscle. B. In raspinatus muscle. C. Levator scapulae
muscle. D. Rhomboid muscle is hidden under the scapula.

A
A
B

C D C

Figure 63.10 The posterior aspect of the deep fascia on the back, from
unembalmed cadaver dissection. A. Trapezius muscle. B. Latissimus dorsi muscle.
C. In raspinatus ascia. Note a large density o the f bres o the insertions o the
muscles on the spine o the scapula (D) and also the density, thickness and the
multidirectional span o the in raspinatus ascia (C).

Figure 63.13 Panoramic view of the axillar fossa, from unembalmed cadaver
dissection. A. Pectoralis major muscle. B. Latissimus dorsi muscle. C. Serratus
anterior muscles.

su bscap u laris m u scles. This sp an orm s a com p lex stru ctu re

that integrates w ith the d ynam ics o the shou ld er gird le. It can
A be d ivid ed into tw o grou ps:
B
C Front and anterior–lateral span
D • The p ectoralis ascia (Fig. 63.13) orm s a thin sheet
d ep loyed over the ront o the thorax, w hich in its
m ed iu m sp an is f rm ly inserted into the sternu m and
continu es, covering the ront o the p ectoralis m ajor, to
Figure 63.11 Clavipectoral fascia, from unembalmed cadaver dissection.
en old over its low er ed ge, supporting the inner ace.
A. Pectoralis minor muscle. B. Clavipectoral ascia. C. Serratus anterior muscle. Und er the pectoralis m ajor it is continu ou s w ith the ascia
D. The pectoralis major muscle is sectioned in its sternal and clavicular insertions, o the anterior abd om inal w all (Pilat 2003; Testu t &
turned and resting on the arm. Latarjet 2007).
 736 PART 10 •
A B
1 12
14
2 3 7 8
10
4 11
5 11 Superficial lamina of the axillar fascia
6 12 Subclavian muscle
Figure 63.14 Sagittal section of the axillar fossa, from fresh cadaver dissection.
• The d eltoid ascia (see Fig. 63.9) extend s as a d irect lateral
expansion o the p ectoralis ascia. It en old s the d eltoid
m u scle and , in the p osterior sp an, links to the
in rasp inatu s m u scle. The low er sp an continu es w ith the
brachial ascia.
• The clavip ectoral ascia is su sp end ed in the interm ed iate
p lane, starting at the ront ed ge o the clavicle, the
coracoid p rocess and the coracoclavicu lar ligam ent. It
en old s the subclavian m uscle, continues over the ront
p art o the sternum and joins the d eltoid ascia laterally.
It also expand s rom its low er ed ge to en old the
p ectoralis m inor. In its d eep sp an it is f rm ly integrated
w ith the intercostal m uscles and the ribs. Its low er end
continu es to the axillary ossa, w here it joins the
p ectoralis ascia (see Fig. 63.11) (Gallaud et 1931;
Bochenek & Reicher 1997).
• The serratu s anterior ascia is very thin, and covers the
m u scle’s entire su r ace (see Fig. 63.13).
Posterior and posterior–lateral span
• The trap eziu s ascia (see Fig. 63.10) is continu ous w ith
the su p erf cial sheet o the d eep cervical asciae in its
p osterior length; rom the sp ina o the scapu la it becom es
the trap eziu s ascia, covering its m id d le and low er f bres.
• The su p rasp inatu s ascia (see Fig. 63.12) en old s the
su p rasp inatu s m u scle, enclosing it together w ith the
osseou s channel o the su p rasp inatu s ossa w ithin an
osteo ascial com p artm ent (Rou viere & Delm as 2005).
• The in rasp inatu s ascia (see Fig. 63.12) is a very resistant
stru ctu re that throu ghou t its length, starting on the sp ine
o the scap u la, p rovid es su p p ort to the in rasp inatu s,
teres m inor and teres m ajor m u scles, ad joining them at
their insertions (Rou viere & Delm as 2005). It is f rm ly
u nited to the m ed ial and lateral bord ers o the scap u la,
w ith strong and m ultid irectional f bre connections.
• The latissim u s d orsi ascia (see Figs 63.10–63.13) is
continu ou s w ith the ascia o the teres m ajor m u scle and
is strengthened in eriorly by the d eep layer o the axillar
ascia.
63 • Myofascial induction approaches
A Scapula
B Cavicle
1 Trapezius muscle
2 Deltoid muscle
3 Infraspinatus muscle
13
4 Teres minor muscle
5 Teres major muscle
6 Latissimus dorsi muscle
9 7 Subscapularis muscle
8 Pectoralis minor muscle
9 Pectoralis major muscle
10 Deep lamina of the axillar fascia
13 Clavipectoral fascia
14 Supraspinatus muscle
• The ascia o the levator o the scapu lae m u scle (see Fig.
63.12) com prises a thin sheet that accom panies the m u scle
throu ghou t its length.
• The ascia o the subscap ularis m u scle covers the area
o the su bscap u laris ossa, sep arating the su bscap u laris
and the serratus m ajor m uscles.
• The rhom boid m u scle ascia (see Fig. 63.12) is m ore
robust in its span at the low er end , w here it is continu ou s
w ith the trapeziu s and the latissim u s d orsi m u scles.
• The axillary ascia (Figs 63.13–63.14) orm s the axillar
base. Throughou t its su r ace it reaches rom the low er
bord er o the pectoralis ascia to the low er end o the
teres m ajor and latissim u s d orsi m u scles. It orm s a sort
o squ are that is su sp end ed rom the low er bord er o the
pectoralis m inor m uscle, runs throu gh the axillary ed ge
o the scap u la, enters the insertions o the su bscap u laris,
teres m ajor and teres m inor m u scles and f nally
app roaches the glenoid cavity. In its m ed ial sp an, it
app roaches the anterior serratu s m u scle (Bochenek
& Reicher 1997; Rou viere & Delm as 2005; Testu t &
Latarjet 2007).
This very com plex d istribution o the m yo ascial system
enables e ective integration o the ascial stru ctu res o the
cervical region w ith the brachial ascia, the antebrachial ascia
and f nally the hand stru ctu res.
• The brachial ascia orm s a strong layer that envelop s the
stru ctu res o the arm like a glove. At the su p erior end , it
is continu ou s w ith the p ectoralis ascia (Fig. 63.15), the
d eltoid , the axillar and the d orsal asciae, and then w ith
the thoracolu m bar ascia (Rou viere & Delm as 2005; Testu t
& Latarjet 2007) – thu s linking the d ynam ics o the
scap u lar gird le w ith those o the u p p er lim b. Stecco et al
(2008) id entif ed these connections and ascial continuities
in resh cad aver sp ecim ens, and conclu d ed that they
cannot be assu m ed to be m erely anatom ical variations.
They also noted the p resence o a consid erable nu m ber o
m u scu lar f bres that w ere som ehow connected to the
intram u scu lar sep ta; these sep ta w ere continu ou s w ith
the ascia envelop ing the overlying m u scu lar ascia that
 Anatomical considerations related to the continuity of the fascial system of the neck and upper extremity
B Figure 63.17 Lacertus brosus. Note the continuity between the brachial and
Figure 63.15 Detail of the interlinking of the fascia pectoralis with the brachial
fascia, from unembalmed cadaver dissection. A. Pectoralis ascia. B. Brachial
ascia.
B
A
Figure 63.16 Fascial continuity of the anterior aspect of the upper limb,
from unembalmed cadaver dissection. A. Pectoralis ascia. B. Brachial ascia.
C. Antebrachial ascia.
connected to the brachial ascia. This f nd ing w as
conf rm ed in observations o transverse sections. When
there is m u scu lar contraction, som e bu nd les w ill tense
the intram u scu lar sep ta and ind irectly strengthen the
brachial ascia. Stecco et al (2008) urther su ggested that
these exp ansions and insertions strengthen the
anatom ical d esign o the brachial ascia and p lace it
u nd er selective tension, w hich m ay increase the
e ectiveness o arm m ovem ent. The brachial ascia
expand s tw o f brou s sheets that are transversally
oriented , orm ing the exor and extensor com p artm ents
(Rou viere & Delm as 2005), w hich m ainly involve the tw o
m ain m u scles o the arm : the tricep s and bicep s. In the
u p p er third o the arm , there is a third com p artm ent that
contains the coracobrachial m u scle.
• The antebrachial ascia arises as a d irect continu ation
o the in erior section o the brachial ascia (Fig. 63.16).
On the ventral su r ace, there is a very p articu lar
737
antebrachial ascia, rom unembalmed cadaver dissection.
A
Figure 63.18 Palmar fascia, from unembalmed cadaver dissection. Note a
dense and f rm f brotic union between the skin and the palmar ascia, evidenced by
the presence o longitudinal and transverse f bres. A. The tendon o the palmaris
longus muscle.
connection betw een the brachial and the antebrachial
asciae and the low er insertion o the brachial bicep s
m u scle throu gh the bicip ital ap oneu rosis or lacertu s
f brosu s (Fig. 63.17). This an-shaped stru ctu re (Testu t &
Latarjet 2007) extend s rom the low er tend on o the
biceps to continue over the antebrachial ascia in the
proxim al end . It then inserts into the cubital region o the
com m on m ass o the ep itrochlear m u scles (Blem ker et al
2005; Chew & Giu rè 2005). The lacertu s f brosu s
connection is p erhap s one o the best exam p les o the
d ynam ic linkage w hereby pow er is transm itted d irectly
rom ascia to ascia, rein orcing the bone–tend on
connection. On the p osterior o the lim b is a d irect link
betw een the tricep s m u scle and the antebrachial ascia.
One p art o the tricep s’ tend on is f rm ly inserted into the
olecranon and the other continu es to attach to the
antebrachial ascia.
• The p alm ar ascia extend s in a an pattern as a
continu ation o the antebrachial ascia. It is a thick
stru ctu re rein orced by the long p alm ar m u scle. It
continu es laterally to the thenar and hyp othenar
em inences (Fig. 63.18).
 738 PART 10 • 63 •
A
Figure 63.19 Dorsal fascia of the hand, from unembalmed cadaver dissection.
A. Extensor retinaculum.
• The d orsal ascia o the hand is continu ou s w ith that o
the orearm . It sp read s to cover the tend ons o the
extensor m uscles and then thickens to orm the extensor
retinaculum over a transverse span o the f bres (Fig.
63.19). The m ain u nction o the retinaculu m is f rst to
m aintain the p recise u nctional p ositioning o the
extensors’ tend ons, and also to stop them becom ing loose
w hen in contraction.
Anatomical Considerations Related to
the Continuity of the Fascial System of
the Pelvis and Lower Extremity
Trad itionally, the anatom ical d escrip tion o the ascia is related
to the top ograp hy o the m u scles attached to a sp ecif c p art o
the bod y. H ow ever, the ad op tion o a bip ed al p osition and
locom otion by hu m ans has orced the d evelop m ent o a com -
p lem entary su p p ort system or m aintaining bod y w eight and
op tim izing d aily activities to rationalize the u se o energy. For
this reason, the anatom ical analysis o the ascia o the low er
qu ad rant ocu ses on the anatom ical links com p rising this
system . The lu m bar sp ine, or instance, is not alone cap able
o su staining the norm al load s that it carries d aily (Crisco et al
1992; Willard et al 2012). Protecting the spine’s ragile stru c-
tu res is a m yo ascial com p lex that su rrou nd s the tru nk
(Bergm ark 1989; Cholew icki et al 1997; Schuenke et al 2012;
Willard et al 2012). The m ost im portant stru ctu re o this
com p lex is the thoracolu m bar ascia. Its p rincip al u nctions
are p articip ation in the exion and extension o the trunk
(Gatton et al 2010), m aintenance o upright bod y p osture and
also bip ed al locom otion (Gracovetsky 2008; Willard et al
2012). Anatom ically the thoracolum bar ascia appears as the
largest bod y ap oneu rotic stru ctu re and d ynam ic connection
brid ging the tru nk and lim bs. Wood Jones (1944) consid ers
that the top ograp hy and d ynam ics o ascia’s low er extrem ity
are linked to its ectoskeletal unction, w hich has a role in
m aintaining the u p right bod y p osition. H ence the architec-
tu ral orientation o the ascial system is d eterm ined by its
w eight-bearing u nction; or exam p le, the glu teus m axim us
Myofascial induction approaches
C
Figure 63.20 Back region from unembalmed cadaver dissection. A. Skin (inner
view). B. Superf cial ascia. C. Section line. Notes: Observe the di erences o the
vascularization intensity between the upper thoracic area (strongly vascularized),
lower thoracic area (weakly vascularized) and lumbar area (again strongly
vascularized). Note the mirror e ect between the skin and superf cial ascia areas.
C
B
A
Figure 63.21 The super cial and deep fascia levels on the back from
unembalmed cadaver dissection. A. Skin (inner view). B. Superf cial ascia (inner
view). C. Deep ascia.
and tensor asciae latae m uscles are m ainly inserted into the
d eep ascia rather than onto the bone so as to m axim ize their
m echanical e f ciency. Within this ram ew ork, in the next
section w e analyse the continu ity o the ascial system in
consecu tive layers o its constru ction and relate it to the orce
transm ission d u ring the basic tasks o the low er qu ad rant.
Super cial and deep fascial anatomical links
between the trunk and lower limbs
Super cial fascia ( rmly attached to the skin)
On the p osterior, the su p erf cial ascia covers the thoracic and
lum bar areas (see Fig. 63.3), then continu es to the iliac crest
(Figs 63.20–63.22) and ru ns w ithout interrup tion d ow n the
length o the entire low er extrem ity u p to the end o the oot
stru ctu re (Fig. 63.23). On the anterior, it continues rom the
cervical segm ent throu gh the p ectoral and abd om inal region
to the ingu inal area (see Fig. 63.2). There it becom es the ascia
 Anatomical considerations related to the continuity of the fascial system of the pelvis and lower extremity 739

o the thigh and leg, continu ing to the d orsu m o the oot (see
Figs 63.32, 63.38–63.39).

Deep fascia (located directly under

B
the super cial fascia)
On the p osterior, the d eep ascia ollow s the sam e p ath as the
A su p erf cial ascia rom the cervical segm ent to the iliac crest
C (see Fig. 63.21), w here it becom es the gluteal ascia and
attaches to the iliac crest, sacrum and coccyx (Fig. 63.24).
D On the anterior, the abd om inal ascia becom es the ascia
E
lata at the iliac crest, groin and pu bis levels (see Figs 63.32–
63.33, 63.39).
F
Below the iliac crest and the ingu inal area, the thoracolu m -
bar ascia and abd om inal ascia becom e the m ultilevel low er
extrem ity ascial system ( ascia lata, ascia o the leg, oot
Figure 63.22 Thoracolumbar fascia as a bridge structure (image from ascia).
unembalmed cadaver dissection). A. Thoracolumbar ascia (TLF). B. Trapezius
muscle. C. Latissimus dorsi muscle (LD). D. Gluteus maximus muscle (GM).
E. Deep ascia (inner view). F. Superf cial ascia (inner view). Note the continuity Deep fascia of the thigh segment
between the LD and opposite GM across the TLF.
The ascia lata surround s the thigh. On the posterior, it is
continu ou s w ith the glu teal ascia (Figs 63.24–63.25). On the
anterior, its origin is in the ingu inal ligam ent (see Figs 63.32–
63.33, 63.39); it continues along the thigh and is inserted into
the p atella and tibia (see Figs 63.32, 63.39).

Figure 63.23 The continuity of the super cial fascia on lower extremity from unembalmed cadaver dissection (posterior view). A. The superf cial ascia continuity.
B. The skin (inner view).

A
D

Figure 63.24 The continuity of the deep fascia on lower extremity from unembalmed cadaver dissection (posterior view). A. Back region. B. Gluteal region. C. Thigh
region. D. Leg region. E. Skin in conjunction with the superf cial ascia (inner view).
 740 PART 10 •
A
B
Figure 63.25 The continuity of the deep fascia on upper part of the lower
extremity from unembalmed cadaver dissection (close-up view). Observe the
f brous appearance o the deep ascial tissue. A. Back region. B. Gluteal region
(gluteal ascia). C. Thigh region ( ascia lata).
On the inner sid e o the ascia lata there originate several
f brou s exp ansions as the beginning o m u scle ascias ( ascial
sheets) (see Fig. 63.33). In som e places these sheets m erge w ith
ligam ents (e.g. the iliop soas ascia w ith the ingu inal ligam ent)
or tend ons (e.g. the ascia o the tensor asciae latae w ith its
tend inou s sheet).
Deep fascia of the leg segment
The ascia o the leg su rrou nd s the leg structure w ith a strong
insertion into the tibia m erging w ith the p eriosteu m (see Figs
63.39 and 63.75). On the p osterior, it is continu ou s w ith the
ascia lata (see Fig. 63.34). On the anterior, it attaches to f bula,
the cond yles and the tibial tu berosity (see Figs 63.39–63.40).
On the inner sid e o the ascia o the leg, an interm u scu lar
sep ta (anterior and su p erior) originates, w hich together w ith
the interosseou s m em brane orm com p artm ents that d ef ne
and control the p osition o the leg m u scles (see Fig. 63.70).
Deep fascia of the foot segment
At its low er end the leg ascia becom es ascia o the oot (see
Fig. 63.34). The d orsal sid e covers the tend ons o the long
extensor m u scles (see Fig. 63.39), w hereas the p lantar sid e
covers the su p erf cial m u scles o the oot (see Fig. 63.34).
Deep fascial intermuscular links
Thoracolumbar segment
In the thoracolum bar segm ent the m ost relevant tissu e is the
thoracolu m bar ascia and its connections. As m entioned
earlier, the thoracolu m bar ascia acts as a brid ge stru ctu re
betw een the m uscles o the tru nk and the extrem ities. At the
m ost su p erf cial level the m ost extensive connection is betw een
the latissim u s d orsi and glu teu s m axim u s m u scles (see Figs
63.22, 63.28), w hich is expressed in the activities o locom otion
and trunk stabilization (see Fig. 63.29). Recently, Carvalhais
et al (2013) d em onstrated in vivo that m anipulating the
tension o the latissim u s d orsi m u scle also m od if ed the
p assive hip variables, thu s provid ing evid ence o m yo ascial
orce transm ission betw een the gluteu s m axim u s and latis-
sim u s d orsi m u scles on the op p osite sid e. The d eep lam ina o
63 • Myofascial induction approaches
D
B
E
C
C
A
Figure 63.26 Cross-section of the gluteus maximus muscle from a
unembalmed cadaver dissection. A. Cranial portion o the gluteus maximus
muscle (inner view). B. Deep layer o the gluteal ascia. C. Caudal portion o the
gluteus maximus muscle. D. Sacrum. E. Superf cial layer o the gluteal ascia. Note
the f brous ascial connections.
A
B
D
C
E
Figure 63.27 The posterior aspect of the gluteal region and the thigh from a
unembalmed cadaver dissection. A. Sacrotuberous ligament. B. Tendon o the
long head o the biceps emoris muscle. C. Biceps emoris muscle belly. D. Sciatic
nerve. E. Gluteus maximus muscle (inner view). (Reproduced rom Chaitow &
Lovegrove Jones (2012). Chronic pelvic pain and dys unction: practical physical
medicine. Elsevier, with permission. Picture rom the same author.)
the glu teal ascia (Fig. 63.26) com m u nicates w ith the u nd erly-
ing m uscles inclu d ing the gluteu s m ed ius, piri orm is, supe-
rior and in erior gem ellu s, obtu ratoriu s externu s and
qu ad ratu s em oris. There is a link betw een the sacrotu berou s
ligam ent and the tend on o the long head o biceps em oris
m u scle; it creates a d eep connection betw een the bicep s
em oris and thoracolu m bar ascia (Figs 63.27–63.28). The com -
m u nication and transm ission o m echanical im p u lses w as
ou nd to be not only rom and through the thoracolum bar
ascia to the latissim us d orsi m u scle, bu t also to the trapezius
m u scle and throu gh both u p p er extrem ities (Fig. 63.29).
In relation to the balance o orce d istribution throu gh
the ascial p lanes related to the thoracolu m bar ascia, the
inter ascial lu m bar triangle (LIFT) is im portant (Schu enke
et al 2012; Willard et al 2012) (Fig. 63.30); this is the area
o intersection o the ascia corresp ond ing to the com m on
extensor lum bar m ass (i.e. the m ultif d u s, longissim us and
iliocostalis m u scles), the abd om inal m uscles (i.e. the transver-
su s abd om inis, internal obliqu e and external obliqu e), the
 Anatomical considerations related to the continuity of the fascial system of the pelvis and lower extremity 741

serratu s p osterior–in erior m u scle, the latissim u s d orsi and Leg and foot segment (Figs 63.34–63.39)
the qu ad ratu s lu m boru m . The au thors su ggested that this
triangle m ay act to d istribu te laterally m ed iated tension in In the posterior aspect o the leg can be observed the f brou s
ord er to balance variou s viscoelastic m od u les, along either the ap oneu rotic expansions o gastrocnem iu s m uscles and a long
m id d le or the p osterior layers o the thoracolu m bar ascia hau l o Achilles tend on, w ith p rogressive d ensif cation o the
(Schu enke et al 2012). f bres (see Fig. 63.35). Figu re 63.36 show s the ascial p lane
betw een the gastrocnem iu s and soleu s m u scles. In a d issec-
Thigh segment tion o the p lantar ascia (Fig. 63.37), the Achilles tend on and
p lantar ascia are seen to orm a continu u m interru p ted by the
The d eep ascia o the thigh initiates tw o interm uscu lar sep ta
(m ed ial and lateral), ord ering the large m u scles as w ell as the
em oral vessels in its longitu d inal path (see Fig. 63.31). It also
initiates the m u scle sheaths that d ef ne the p ositioning o ind i-
vid u al m u scles and their inter-relationship . On the p osterior,
it includ es the continu ity betw een the sacrotu berou s ligam ent
and the tend on o the long head o the biceps em oris
m u scle, as w ell as the p ath o the sciatic nerve (see Fig. 63.27).
On the anterior, the ascia rom the abd om inal region crosses
the ingu inal ligam ent and covers the anterior thigh (Fig.
63.32). N ote the f brou s appearance o the acial planes in Stretching
Figure 63.33.
Contraction

A
D C

B F
G

Figure 63.28 The posterior–lateral side of the back, pelvis and thigh from an
unembalmed cadaver dissection. Deep aspect. A. Trapezius muscle. B. Latissimus
dorsi muscle. C. Sacrotuberous ligament. D. Thoracolumbar ascia. E. Tendon o the
long head o the biceps emoris muscle. F. Sciatic nerve. G. Piri ormis muscle
belly. (Reproduced rom Chaitow & Lovegrove Jones (2012). Chronic pelvic pain Figure 63.29 The myofascial force transmission across the thoracolumbar
and dys unction: practical physical medicine. Elsevier, with permission. Picture rom fascia between the latissimus dorsi and gluteus maximus muscles during
the same author.) running.

Quadratus Lumbar
lumborum interfascial
muscle triangle
(LIFT)
External
abdominal
L3 oblique muscle
Internal
abdominal
oblique muscle
Transversus
abdominis
muscle
Latissimus
dorsi muscle
Multifidus Iliocostalis Serratus posterior
muscle muscle inferior muscle
Longissimus
muscle

Figure 63.30 Cross-section at the L3 level.

 742 PART 10 • 63 • Myofascial induction approaches

Figure 63.31 Cross-section of the third upper thigh from unembalmed cadaver dissection. A. Femur. B. Deep emoral artery. The circle shows the sciatic nerve.

B
A
C

A Figure 63.34 The deep fascia of the leg from an unembalmed cadaver
dissection. A. Skin along with the superf cial ascia and at nodules. B. The deep
ascia. C. The plantar ascia.

Figure 63.32 Close up of the fascial levels on the anterior aspect of the thigh
from an unembalmed cadaver dissection. A. Superf cial ascia (inner view).
B. Deep ascia ( ascia lata). (Reproduced rom Chaitow & Lovegrove Jones (2012).
B
Chronic pelvic pain and dys unction: practical physical medicine. Elsevier, with C
permission. Picture rom the same author.)
A

Figure 63.35 Muscles level of the posterior aspect of the leg from an
B unembalmed cadaver dissection. A. Medial gastrocnemius muscle. B. Lateral
gastrocnemius muscle. C. Achilles tendon.
D

B
A

Figure 63.33 Incision of the deep fascia of the thigh from an unembalmed
cadaver dissection. Note the aponeurotic expansion of the quadriceps muscle.
A. Pubis. B. Anterior superior iliac crest. C. Deep ascia ( ascia lata). D. Quadriceps
muscle. (Reproduced rom Chaitow & Lovegrove Jones (2012). Chronic pelvic pain Figure 63.36 Deep aspect of posterior leg from a fresh cadaver dissection.
and dys unction: practical physical medicine. Elsevier, with permission. Picture rom A. Soleus muscle. B. Gastrocnemius muscles (inner view). Arrow: ascial
the same author.) connection.
 Theoretical aspects related to the treatment of myofascial dysfunction syndrome 743

periosteu m o the calcaneus, w ith w hich both structu res are
m erged . A sim ilar p henom enon o u sion o the ascia w ith
the p eriosteu m can also be seen in the lateral asp ect o the leg
(see Fig. 63.75).
Knee joint and popliteal fossa segment
At the level o the knee joint, the f brou s stabilizing structure
o the p atella orm s a m u ltilevel and m u ltid irectional com p lex
w eb (Fig. 63.40). This netw ork u nctions m ainly in the posi-
tioning o the p atella in betw een the qu ad ricep s tend on, the
Figure 63.37 Plantar fascia from an unembalmed cadaver dissection. Observe
the continuity between the plantar ascia and deep ascia o the leg.
in rapatellar ligam ent and the ascia lata; it also help s to
control lateral p atella m ovem ents (Figs 63.41–63.42).
In the popliteal ossa, the ascia system acts as a protection
or the nerves and vessels passing throu gh it (Fig. 63.42; see
also Fig. 63.45). (N ote the presence o abund ant layer o loose
connective tissu e w ith a consid erable am ou nt o at nod u les
in Fig. 63.45.)
Theoretical Aspects Related to the
Treatment of Myofascial Dysfunction
Syndrome
Mechanics of myofascial dysfunction
syndrome formation
Fascial system d ys u nction is d ef ned as an alteration o the
highly organized w ave o sp ecialized m ovem ents and as the
incorrect trans er o in orm ation throu gh the m atrix (Pilat
2003). I there is im p airm ent o proper ascial d ynam ics (i.e.
glid ing betw een end o ascial f bres and inter ascial planes)
then op tim al bod y u nctioning m ay be a ected . This is con-
nected to a su bop tim al exchange o u id s; red u ction in m obil-
ity alters the qu ality o blood circu lation, w hich becom es slow
and heavy, and lead ing in extrem e cases to ischaem ia and

Figure 63.38 Super cial fascia path of the anterior aspect of lower extremity from an unembalmed cadaver dissection. A. Thigh region. B. Leg region.

Figure 63.39 Deep fascia path of the anterior aspect of lower extremity from an unembalmed cadaver dissection. A. Thigh region ( ascia lata). B. Leg region.
 744 PART 10 • 63 •
Figure 63.40 Close up of the anterior–lateral aspect of the knee joint from
unembalmed cadaver dissection. A. Patella. B. Patellar tendon. Note the quite
varied distribution o ascial f bres spread over the several levels.
A
B Figure 63.42 Cross-section over the patellofemoral joint from unembalmed
D
C
E Fascial entrapment areas
F ascial entrapm ent orm ation generally are:
Figure 63.41 Cross-section of the knee joint in the sagittal plane.
A. Suprapatellar at body over the quadriceps emoris tendon. B. Patella.
C. Femur. D. Patellar ligament. E. In rapatellar at pad. F. Tibia.
d eterioration o the qu ality o m u scular f bres. Further, exces-
sive stim u lation o collagen f bre p rod u ction acilitates the
d evelopm ent o f brosis in the m yo ascial system . The resu lt
is loss o m atrix qu ality and consequ ently orm ation o entrap -
m ent areas (i.e. areas w ith red u ced p hysiological m ovem ent
w ith respect to am plitud e, speed , resistance and coord ination)
(Pilat 2009).
Those ascial entrap m ents (Figs 63.43–63.44) prom ote the
orm ation o com pensatory (substitu te) m ovem ent patterns.
Regard less o the cau se o the entrap m ent, i it p ersists or
long p eriod s o tim e, this eventu ally lead s to excess load and
u ltim ately d ys u nction (Pilat 2003). These changes in uence
m ostly the loose connective tissu e stru ctu res and a ect the
sp ecialized stru ctu res (d ense regu lar and irregu lar connective
tissu e), p rod u cing overly d ense tissu e and reorientated f bres.
These specialized stru ctu res inclu d e the tend ons, ligam ents
and the articu lar cap sules. Short-term changes w ill a ect their
u nction locally, and long-term changes m ay potentially resu lt
in global d ys u nction p atterns.
Myofascial induction approaches
C
cadaver dissection. A. Femur. B. Patella. C. Femoral artery.
In the locom otor system , the areas that are m ost vu lnerable to
• Bond ing areas betw een ascial stru ctu res in places o
extensive load s – or exam p le, the bicipital aponeu rosis
(lacertu s f brosu s) (see Fig. 63.17), in w hich the contracted
m u scle orce is transm itted not only to the tend on and to
the bone at its insertion p oint bu t also throu gh the
intrinsic and extrinsic connective tissu e linked to the
m u scle (H u ijing et al 1998; H uijing & Baan 2001a, 2001b).
The bicipital aponeu rosis appears not only as a structure
that p rotects the neu rovascu lar bu nd le, bu t also as one
that d ynam ically stabilizes the bicep s’ tend on in its low er
insertion (Eam es et al 2007). It appears that it is because
the traction orce in the low er insertion o the bicep s is so
large – com pared w ith that received by its tw o su p erior
insertion tend ons – that it requ ires this rein orcem ent.
A sim ilar anatom ical d esign can be ou nd in nu m erou s
stru ctu res, su ch as in the tend on o the qu ad ricep s
m u scle w ith its insertion in p atella (see Figs 63.40–63.41).
• Areas w ith excessive riction (e.g. tend ons w ith tend inou s
sheaths rein orced by the retinacu lu m ) (see Fig. 63.19) –
an increase in the com p ression level betw een tend on
and retinaculu m lead s to f brocartilaginou s changes
(Benjam in 1995).
• Areas w ith nu m erous insertions o ascial stru ctu res w ith
greater d ensity o f bres (e.g. the scapu lar spine) (see Fig.
63.10) – these regions operate m echanically as m ovem ent
linkage and d istribu tion areas. When the entrap m ent
occu rs, this m ay resu lt in altered local m ovem ent and / or
a re erred com p ensation process (Pilat 2009).
 Theoretical aspects related to the treatment of myofascial dysfunction syndrome 745

Figure 63.43 Fascial entrapments between two sliding planes. A. Location o the ascial entrapment.

C G
D
E
F

B
A

Figure 63.45 The deep aspect of the popliteal fossa, from unembalmed
cadaver dissection. A. Skin. B. Superf cial ascia. C. Deep ascia. D. Sciatic nerve.
E. Loose connective tissue. F. Tibial nerve. G. Muscle ascia.

Figure 63.44 Fascial entrapment inside the movement plane. (Reproduced rom
Chaitow & Lovegrove Jones (2012). Chronic pelvic pain and dys unction: practical
physical medicine. Elsevier, with permission. Picture rom the same author.)
C

• Areas w ith p rolonged and / or repeated hyp om obility – A

or exam ple, as a result o ad ju sting to inad equate
p ostu res. D
• Bod y segm ents a ected by trau m atic or su rgical
p rocesses. B
• Stru ctu res involved in the p rotection o the neu rovascu lar
continu u m – or exam ple, the p op liteal ossa (Fig. 63.45).
• Transit areas o p er orating veins and nerves (Fig. 63.46).
• Places tend ing to bear excessive load s as a resu lt o
su stained and / or rep eated em otional stress.

Figure 63.46 Forearm of the fat from fatty cadaver from unembalmed cadaver
Proposed neurophysiological mechanisms of dissection. A. The skin. B. The superf cial ascia with at nodules. C. The deep
myofascial induction techniques ascia. D. Vein and cutaneous nerve. The le t part was previously dissected.
Normally both are embedded within the superf cial ascia and at tissue.
The ascia is prop osed to act as a m echanosensitive system .
Du ring a treatm ent, the clinician stretches or / and com presses
a sp ecif c bod y area in ord er to transm it a low -intensity
 746 PART 10 • 63 • Myofascial induction approaches
m echanical stim u lu s. This inp u t creates changes that sp read
throu gh the bod y system s u p to the m olecu lar level. The
ou tcom e is a recip rocal reaction rom the bod y, inclu d ing bio-
chem ical, m etabolic and f nally p hysiological resp onses (Pilat
2014). This outcom e m ay take place at any level o the sys-
tem ’s stru ctu re (i.e. m icro- or m acroscop ic) and resp onses
m ay occu r in any segm ent, and consequ ently the bod y’s reac-
tions can involve any m u scu loskeletal u nctional u nit, organ,
viscera or grou p o cells (Langevin 2006; Vaticón 2009).
Three m echanism s or the release and restru ctu ring o the
ascial system are p rop osed : (1) piezoelectricity, (2) the atti-
tu d e o the interstitial m echanorecep tors w ith the consequ en-
tial d ynam ics o the m yof broblasts and (3) viscoelasticity.
Piezoelectricity
Piezoelectricity is a p henom enon exhibited by certain crystals
that, w hen a m echanical orce is ap p lied , becom e p olarized
w ithin their structu re, resu lting in electrical potentials and
load s on their su r ace (Pilat 2003). The crystals in the hu m an
bod y are liqu id crystals (Szent-Gyorgyi 1941; Bou ligand 1978)
and , sim ilarly, their response to a m echanical inp u t is the
generation o a m inute electrical pulse; this occu rs particularly
in the m atrix o the connective tissu e, w hich becom es har-
m onic and oscillating. The in orm ation (im p u lse) is transm it-
ted electrically throu gh the m atrix (Oschm an 2003). As
collagen is a sem icond u ctor (Cop e 1975), it is capable o
orm ing an integrated electronic netw ork that enables the
interconnection o all the ascial system com p onents
(Bou ligand 1978; O’Connell 2003; Ahn & Grod zinsky 2009;
Rivard et al 2010). Thus, the basic prop erties o the system
(i.e. elasticity, exibility, elongation, resistance) w ill d epend to
a great extent u p on the ability to m aintain a continuous and
correct in orm ation ow.
Myo broblast dynamics
As the m u scle is a contractile tissue that enables the bod y to
m ove, the ascia shou ld also be consid ered an intram u scu lar
connective tissu e that orm s a u nctional u nit along w ith the
m u scu lar f bres. The ascial system is richly innervated by an
extensive netw ork o m echanorecep tors inclu d ed in the
bod y’s som atosensory system , as d iscussed above. It is
p rop osed (Vaticón 2009) that there are tw o categories o
reception / transm ission / interpretation o each m echanical
im p u lse:
• Epicritical sensitivity: This is know led ge, exp loration, or
qu antitative in orm ation, transm itted throu gh the
lem niscal p ath rom the p acinian and p acini orm
corp u scles, Golgi organs and Ru f ni corp u scles.
• Protopathic sensitivity: This is qu alitative and plastic
in orm ation, transm itted throu gh an extralem niscal p ath.
The interstitial recep tors ( ree nerves end ings) are in
charge o this sensitivity and act as a p rotection and
alarm system . They are p olym od al receptors that m ay
also act as nocicep tors.
Consequ ently, the m echanical im p u lse (e.g. m anu al p ressu re
or traction) received by the m echanorecep tors creates a broad
range o responses in the ascial system that m ay result in
m ovem ent at both m acro- and m icroscop ic levels.
The p ossibility o inherent m ovem ent w ithin the ascial
system is still controversial. Som e au thors (Stau besand & Li
1997; Schleip et al 2005, 2007) believe that this phenom enon
exists and is related to the d ynam ics o the m yof broblasts.
They su ggest that activation o actin m icrof lam ents is the
origin o m ovem ent, as d em onstrated in the lu m bar ascia o
rats (Schleip et al 2007). More research on the d ynam ics o
m yof broblasts in p athologies su ch as Du p u ytren’s contrac-
tu re, p lantar asciitis, rozen shou ld er or f brom yalgia, m ay
conf rm this observation. Several stu d ies ocu sing m ainly on
the skin-healing p rocess strongly su p p ort this line o reason-
ing (Fid zianska & Jablonska 2000; Gabbiani 2003, 2007;
Satish et al 2008). Chau d hry et al (2008) orm ulated a three-
d im ensional m athem atical m od el or d e orm ation in hum an
asciae, and reported that the m echanical orces applied
d u ring m anual techniques cannot m od i y the length o the
stru ctu res o the d ense connective tissu e (e.g. p lantar ascia),
bu t can create m echanical changes in the loose connective
tissu e (e.g. su p erf cial nasal ascia). The therap ist’s m anu al
techniqu e ap p lied to the p atient’s bod y m ay stim u late ascial
m echanorecep tors and triggers changes in skeletal m u scle
tone. This m ovem ent m ay be visible, or p erceived only by
care u lly p alp ation.
Viscoelasticity
Viscoelasticity (viscosity and elasticity) d ef nes the long-term
behaviou r o a m aterial. A orce applied to a m aterial w ith
viscoelastic p rop erties cau ses it to d e orm . Over tim e, d e or-
m ation can occu r w ithou t any need to ap p ly m ore orce.
The viscoelastic p roperties o the ascia have been observed
in num erou s stud ies analysing certain ascial structures o
the bod y – the TLF (Yahia et al 1993), ascia lata (Wright &
Rennels 1964), su bcu taneou s ascia o rats (Iatrid is et al 2003)
– or global concepts o practical ap plications (Barnes 1990;
Threlkeld 1992; Rol 1997; Cantu & Grod in 2001; Pilat 2003;
Schleip et al 2005, 2012b). Vaticón (2009) su ggested that local
m ed iators su ch as f broblast grow th actor (TGF-β1) p artici-
p ate in this p rocess, and Langevin and Yand ow (2002) pro-
p osed that m etallop rotease has a role in regu lating the collagen
d ep osit/ d egrad ation balance in the rem od elling o the ascial
stru ctu re.
Viscoelasticity is linked to the rem od elling p rocess o the
extracellu lar m atrix, to changes in d ensity and also to the cor-
rection orientation o the collagen f bres. Stud ies (ex vivo)
cond u cted by Chau d hry et al (2007) in ascia lata, plantar
ascia and nasal ascia conf rm the viscoelastic properties o
the tissu e. Som e o these observations are w orth noting:
• The viscoelastic response begins 60 second s a ter
app lying a constant traction or com pression orce.
• To avoid the blocking o the release response, it is
su ggested that the therap ist d oes not grad u ally increase
the ap p lied orce; rather, the orce shou ld be constant.
• Di erent ascial structures requ ire d i erent m agnitud es
o ap p lied orce; how ever, the tim e or resp onse
throu ghou t the m ovem ent rem ains the sam e.
The three types o response in the ascial system are the resu lt
o ap p lying a p rop er m echanical im p u lse, w ith the ad equ ate
orce, tim e and speed . These response types occu r at d i erent
levels o the bod y system (m icro and / or m acro) and also
have d i erent tim e scales (Langevin 2006; H u ijing 2009; Pilat
2009; Vaticón 2009). Any o these m echanism s have the p oten-
tial o in u encing the behaviou r o the other tw o (Langevin
 Scienti c evidence related to the results in the myofascial approach
2006). Accord ing to the response o the ascial system d u ring
the treatm ent, all the m echanism s m ay interact (Pilat 2003).
There ore, as a resu lt o the m yo ascial ind uction techniques
ap p lication, the clinician can:
• im p rove the circu lation o the antibod ies in the m atrix
• increase blood ow to the restriction areas by releasing
histam ine
• im p rove f broblast m echanics
• im p rove blood su p p ly to the nervou s tissu e and increase
the ow o m etabolites to and rom the tissu e, thu s
accelerating the healing p rocess (Evans 1980; Barnes 1990;
Barlow & Willoughby 1992; H am w ee 1999; Pilat 2003).
Scienti c Evidence Related to the
Results in the Myofascial Approach
(Pilat 2014)
A grow ing nu m ber o p u blications related to the clinical
resu lts o m yo ascial ind u ction techniques have been reported
in p atients w ith pain synd rom es com pared w ith healthy sub-
jects. A nu m ber o stu d ies have show n signif cant changes
linked to responses o the au tonom ic nervou s system , as
d etailed below.
Research related to pathology
• An objective m ethod or evalu ating the e ect o
m yo ascial ind u ction techniqu es ap p lied to m u scu lar
lesions w ith d ynam ic sonoelastograp hy w as rep orted by
Martínez and Galán-d el-Río (2013).
• Leonard et al (2009) rep orted that connective tissu e
m anip u lation im p roved p erip heral circu lation and
enhanced w ou nd -healing p rocesses in 20 p atients w ith
d iabetic oot ulcers.
• Signif cant d i erences betw een p re- and p ost-treatm ent
m easu rem ents o p ressu re p ain threshold s w ith
d ecreasing sensitivity to m yo ascial trigger points w as
reported in d i erent strained m uscles, includ ing the
ad d u ctor longu s (Robb & Pajaczkow ski, 2009), the up per
trap eziu s m u scle (Fryer & H od gson 2005) and cervical
m u scle (H ou et al 2002).
• Marshall et al (2009) conclud ed that m yo ascial release
help ed to red u ce the severity and intensity o m u scle
p ain in p eop le w ith chronic atigu e synd rom e.
• H icks et al (2009) rep orted that hum an f broblasts secrete
the solu ble m ed iators o m yoblast d i erentiation and that
m yo ascial release can regu late m u scle d evelop m ent.
• Tozzi et al (2012) investigated non-sp ecif c low back pain
in relation to kid ney m obility. Using real-tim e u ltrasou nd ,
this stu d y d em onstrated that osteop athic ascial
m anip u lation d ecreased p ain p ercep tion and im p roved
renal m obility.
• Useros and H ernand o (2008) conclu d ed that m yo ascial
ind u ction has benef cial e ects in p atients w ith brain
d am age, w ith special em phasis on au tom atic postu re
control.
• In p atients w ith u nilateral sp atial neglect (an alteration o
the head ’s p osition w ith resp ect to the m ed ian line),
747
Vaqu ero Rod rígu ez (2013) observed signif cant resu lts or
the sensitivity variable in the exp erim ental grou p treated
w ith m yo ascial ind u ction techniqu es, com pared w ith
those treated w ith Bobath therap y.
• Fernánd ez-Lao et al (2011) ap plied m yo ascial release
techniqu es in breast cancer su rvivors. The au thors
observed that m yo ascial release led to an im m ed iate
increase in salivary ow rates, su ggesting the
intervention had a parasym p athetic e ect.
• Vasqu ez (2011) reported the e ectiveness o m yo ascial
ind u ction techniques in treating sw im m ers’ shou ld ers
w ith respect to articular balance and p ain.
• Argu isuelas-Martínez (2010) d em onstrated the e ects o
lum bar spine m anipu lation and thoracolu m bar
m yo ascial ind u ction techniqu es on the sp inae erector
activation pattern.
• In a d ouble-blind stud y, Urresti-López (2011) ap p lied the
suboccipital ind uction techniqu e to 26 su bjects w ith
chronic neck p ain. Electroencep halograp hic (EEG)
changes w ere observed in latency red u ction in the
experim ental grou p com pared w ith the control grou p.
This resu lt suggests that im provem ents in cognitive
processes inclu d ing attention, m em ory activation and
associative states are associated w ith the P300 w ave. Lack
o changes in other EEG p aram eters d id not su p p ort the
in uence o vascu lar m od if cations.
Clinical research in healthy subjects
• Arroyo-Morales et al (2008a) reported that the heart rate
variability and blood p ressu re recovery a ter a p hysically
stress u l situ ation w ere im p roved by m yo ascial release,
com p ared w ith sham electrotherap y treatm ent.
• Arroyo-Morales et al (2008b) reported that ap plication o
an active recovery protocol u sing w hole-bod y m yo ascial
treatm ent red u ced EMG am p litu d e and vigou r w hen
app lied as a passive recovery technique a ter high-
intensity exercise.
• Toro Velasco et al (2009) reported that the ap plication o a
single session o m anu al therap y (inclu d ing m yo ascial
ind u ction techniques) prod uced an im m ed iate increase o
heart rate variability and a d ecrease in tension, anger
statu s and p erceived p ain in p atients w ith chronic
tension-typ e head ache.
• In a rand om ized single-blind placebo-controlled stud y,
Arroyo-Morales et al (2009) reported that m yo ascial
ind u ction techniques m ight encourage recovery rom a
transient im m u ne-su p p ressed state ind u ced by exercise in
healthy active w om en.
• H enley et al (2008) d em onstrated qu antitatively that
cervical m yo ascial release shi ted the sym p athovagal
balance rom the sym p athetic to the parasym pathetic
nervou s system .
• In a stu d y involving 41 healthy m ales rand om ly assigned
to exp erim ental or control grou p s, Fernand ez-Pérez et al
(2008) rep orted signif cantly d ecreased anxiety levels in
healthy you ng ad u lts a ter the ap p lication o m yo ascial
ind u ction treatm ent. Ad d itionally, signif cantly low er
systolic blood p ressu re valu es w ere observed , com p ared
w ith baseline levels.
 748 PART 10 • 63 • Myofascial induction approaches
• H ered ia-Rizo et al (2013) d em onstrated that ap plication
o su boccip ital m u scle inhibition techniqu e im m ed iately
im p roved the head p osition. Ad d itionally, it im m ed iately
d ecreased the m echanosensitivity o the greater occipital
nerve.
• Fernánd ez-Pérez et al (2013) observed m ajor
im m u nological m od u lations, w ith an increased
B-lym p hocyte count 20 m inu tes a ter the craniocervical
app lication o m yo ascial ind u ction techniqu es.
Therapeutic Strategies Applied in
the Myofascial Induction Process
General observations related to
the therapeutic process
There are various concepts related to the treatm ent o the
ascial system (Barnes 1990; Rol 1997; Paoletti & Som m er eld
1998; Cantu & Grod in 2001; Myers 2003; Chaitow & Delany
2002; Pilat 2003; Stecco 2004; Manheim 2008). Find ings arising
rom the basic sciences on the m echanical and p athom echani-
cal p henom ena related to the therap eu tic ind u ction o the
ascial system , as d iscu ssed above, provid e a solid theoretical
ram ew ork. H ow ever, there is a need to u ni y and valid ate
clinical p roced u res (Rem ving 2007). The applications o m yo-
ascial ind u ction techniques su ggested below are based on the
clinical exp erience o the au thor (Pilat 2003, 2007, 2009, 2011,
2012), and sup ported by the theoretical ram ew ork and
research d iscu ssed above. The m yo ascial ind uction process
m ay be com bined w ith other m anu al therap y strategies.
De nition of the myofascial induction
therapy process
Myo ascial ind u ction therap y is an assem blage o p roced u res
ocused on optim izing u nction and balance w ithin the ascial
system . The ap p roach aim s at local correction, recovery o
global d ynam ics and pain- ree bod y use. The treatm ent pro-
tocol is d ivid ed into tw o p hases: (i) su p erf ci
to p athom echanics o the locom otor system . We su ggest
ollow ing the sam e techniques or investigating m ovem ent
d ys u nctions in each area treated . The su ggested assessm ent
sequ ence com p rises:
• Anamnesis including the patient’s retrospective
pathology (Pilat 2007): Misu se – red uced coord ination
and / or stability; abu se – trau m a; overu se – rep etitive
m ovem ents and / or excess load , all three becom ing, in
tim e, the ou rth actor, that o d isu se – atrophy or
red uced load cap acity (the d isuse m ay becom e a
pathology in itsel ).
• Static evaluation of posture (observation): Attention
shou ld be ocu sed on the gravitational bod y behaviou r.
• D ynamic evaluation of posture: Any test p er orm ed in
m anu al therap y p ractice can be u se u l. It is also
recom m end ed that the exam iner u se global u nctional
tests ocu sing on a m ovem ent qu ality analysis or basic
d aily activities, w ith special attention paid to the presence
o any com p ensation m ovem ents. In ad d ition, sp ecif c
u nctional tests ocused on the specif c stru ctu re involved –
or exam ple, m uscle (strength, elasticity) inclu d ing tissue
palpation and com plem entary tests – shou ld be also
inclu d ed . (Ch 5 d iscusses clinical exam ination.)
Cu rrently there is no sp ecif c and objective test available to
isolate m yo ascial d ys u nction rom other m uscu loskeletal
pathologies. This issu e is con used by the close anatom ical
relationship betw een the m u scular f bres and the ascia.
H ow ever, recent research w ith high-resolution sonoelastogra-
phy techniques (Martínez Rod ríguez & Galán d el Río 2013)
anticip ates the u se o this proced ure. For instance, alterations
in m otion pattern and m od if cation o pain pattern w ill be
u se u l ind icators. Restrictions m ay occu r in variou s d irections
and planes; they m ay even occu r in d i erent d irections on the
sam e p lane, in the sam e d irection in variou s p lanes, or in d i -
erent planes in various d irections. There is no need or the
patient to p er orm active m uscu lar contractions. The patient
m ay be said to be in a state o active p assiveness.
Clinical procedure principles (Pilat 2003, 
2009, 2014)