Functional anatomy

Osseous Structures

Interestingly, although the ulna plays a highly significant role in the function of the elbow, it is secondary in the wrist, whereas the radius, having a secondary role in the elbow, has a dominant part in the wrist. The radius flares to become much larger at the distal end, terminating with a lateral extension, called the radial styloid process. The distal end of the ulna also ends in a styloid process, but it is much smaller in comparison with the radial styloid. The distal aspects of the radius and ulna form an articulation with the proximal row of carpal bones directly in the radius and indirectly via an intracapsular disc in the ulna. The eight carpal bones that make up the wrist are arranged in two rows that greatly enhance the hand’s mobility. The proximal row consists of the scaphoid, lunate, triquetrum, and pisiform (in order from medial to lateral). The pisiform overlies the triquetrum, which forms an articulation with the proximal ulna via the interarticular disc. The scaphoid and lunate articulate directly with the radius. The distal row of carpals consists of the trapezium, trapezoid, capitate, and hamate (in order from lateral to medial). The proximal and distal rows of carpal bones collectively form an intercarpal joint, although some movement also occurs between the individual carpal bones (Figure 6-102).

Figure 6-102 Palmar view of the osseous structures of the right wrist and hand.

The base of each of the five metacarpals articulates with the distal row of carpals. Five proximal phalanges articulate with each of the metacarpals, followed by a middle and distal phalanx for each of the fingers and a distal phalanx for the thumb.

Ligamentous Structures

The numerous ligaments of the wrist, many of which are unnamed, are not all separate entities. They form a crisscross pattern of connections between the radius and ulna to the carpals, between the carpals, from the carpals to the metacarpals, and between the metacarpals (Figure 6-103). The volar radiocarpal and radioulnar carpal ligaments strengthen the joint capsule and wrist anteriorly, while the dorsal radiocarpal ligament provides support posteriorly (Figure 6-104). Radial collateral and ulnar collateral ligaments stabilize the wrist laterally and medially, respectively. Collateral ligaments also support the MP and the interphalangeal joints (Figure 6-105).

Figure 6-103 Ligaments of the wrist. A, Palmar view. B, Dorsal view.

(Modified from Hertling D, Kessler RM: Management of common musculoskeletal disorders: Physical therapy principles and methods, ed 2, Philadelphia, 1990, JB Lippincott.)

Figure 6-104 Coronal section through right wrist, showing intercarpal joints and ligaments.

Figure 6-105 Lateral view of the ligaments of the finger.

Musculature

Extrinsic and intrinsic muscles function for the wrist and hand (Table 6-10). The wrist flexors and extensors are located in the forearm, attached to the epicondyles of the humerus. As the muscles head distally, their tendons are enclosed in sheaths that offer a smooth environment for sliding. Intrinsic muscles include the interosseous and lumbricales muscles, as well as those responsible for the movements of the thumb and little finger. Six passageways transport the extensor tendons through fibro-osseous tunnels. Fibrous bands running from the retinaculum to the carpal bones form the tunnels (Figure 6-106). The flexor retinaculum spans the scaphoid, trapezium, hamate, and pisiform. It forms a tunnel out of the carpal arch to allow passage of the median nerve and the flexor tendons (Figure 6-107).

TABLE 6-10 Actions of the Muscles of the Wrist and Hand

Actions	Muscles
Wrist flexion	Flexor carpi radialis, abductor pollicis longus, palmaris longus, flexor pollicis longus, flexor carpi ulnaris, and flexor digitorum superficialis and profundus
Wrist extension	Extensor carpi radialis, extensor digitorum, extensor carpi ulnaris, and extensor pollicis longus
Wrist adduction (ulnar deviation)	Extensor carpi ulnaris and flexor carpi ulnaris
Wrist abduction (radial deviation)	Extensor carpi radialis, abductor pollicis longus, and extensor pollicis longus and brevis
Finger flexion	Flexor digitorum superficialis and profundus
Finger extension	Extensor digitorum, extensor digiti minimi, and extensor indicis
Finger abduction	Interosseous muscles

Figure 6-106 Dorsal view of the left hand, showing the location of extensor tendons and dorsal interosseous muscles.

Figure 6-107 Palmar view of the left hand, showing flexor tendons.

Biomechanics

The complex movements of the wrist are accomplished by the distal radioulnar joint, the radiocarpal joint, and the midcarpal joint. The radiocarpal and midcarpal joints produce the motion at the wrist joint. Wrist flexion and extension, as well as radial and ulnar deviation, are thought to occur around an axis of movement that passes through the capitate (Figure 6-108). However, the multiplicity of wrist articulations and the complexity of joint motion make it difficult to calculate the precise instantaneous axis of motion.¹² The close-packed position for the wrist is full extension (Table 6-11). The wrist can undergo approximately 160 degrees of flexion and extension, with extension being slightly greater. Radial and ulnar deviation are possible to 60 degrees, and ulnar deviation is almost twice as great as radial deviation (Figure 6-109). Radial deviation is limited by contact of the scaphoid against the radial styloid process. ROMs for the wrist and hand are listed in Table 6-12.

Figure 6-108 Most wrist flexion occurs at the intercarpal joint, and most wrist extension occurs in the radiocarpal joint.

TABLE 6-11 Close-Packed and Loose-Packed (Rest) Positions for the Wrist and Hand Joints

Figure 6-109 Dorsal view of the right wrist. A, With ulnar deviation, some extension of proximal carpals occurs. B, With radial deviation, some flexion of the proximal carpal occurs. C, Capitate; H, hamate; L, lunate; S, scaphoid; TP, trapezium; TQ, triquetrum; TZ, trapezoid.

TABLE 6-12 Arthrokinematic and Osteokinematic Movements of the Wrist and Hand Joints

DIP, Distal interphalangeal joint; MCP, metacarpophalangeal joint; PIP, proximal interphalangeal joint.

With dorsiflexion of the wrist, a supinatory rotation of the carpal bones also occurs, which is mostly a result of the scaphoid moving more with respect to the radius while the lunate and triquetrum relate to the ulna. Furthermore, when moving from flexion to dorsiflexion, the distal row of carpals becomes close-packed with respect to the scaphoid first. This results in the scaphoid moving with the distal row into dorsiflexion, necessitating movement between the scaphoid and lunate as full dorsiflexion is approached. With extension of the wrist, the proximal row of carpals rolls and glides anteriorly with respect to the radius and ulna, and the distal row of carpals moves similarly with respect to the proximal row of carpals. The converse is true of wrist flexion; the proximal row moves posteriorly relative to the radius and ulna as the proximal row moves posteriorly relative to the proximal row of carpals.

Radial and ulnar deviation involve rotary movements between the proximal row of carpals and the radius, as well as between the proximal row and distal row of carpals. Moreover, during radial deviation, the proximal row combines pronation, flexion, and ulnar glide movements with respect to the radius as the distal row combines supination, extension, and ulnar glide movements with respect to the proximal row. Ulnar deviation has the opposite movements.^3,16

The hand must be able to change its shape to grasp objects. Three physiologic functional arches running in different directions provide the means for the wrist and hand to conform to a position for grasping (Figure 6-110). Transversely, an arch through the carpal region corresponds to the concavity of the wrist, and distally, the metacarpal arch is formed by the metacarpal heads. Longitudinal arches are formed along each finger by the corresponding metacarpal bone and phalanges. Obliquely, arches are formed by the thumb during opposition with the other fingers. These arches allow coordinating synergistic digital flexion and opposition of the thumb and little finger.

Figure 6-110 The three physiologic arches of the wrist and hand.

(Modified from Nordin M, Frankel VH: Basic biomechanics of the musculoskeletal system, ed 2, Philadelphia, 1989, Lea & Febiger.)

The wrist provides a stable base for the hand, and its position controls the length of the extrinsic muscles to the digits. The muscles stabilize the wrist, as well as provide for the fine movements of the hand, to place it in its functioning position. The positioning of the wrist has a significant influence on the strength of the fingers. For most effective action of the extrinsic muscles of the fingers, the wrist usually must move in a direction opposite the movement of the fingers.

The naturally assumed position of the hand to grasp an object, or the position from which optimal function is most likely to occur, is termed the functional position (Figure 6-111). The functional position occurs when the wrist is extended 20 degrees and the ulna is deviated 10 degrees, the fingers are flexed at all of their joints, and the thumb is in a midrange position, with the MP joint moderately flexed and the interphalangeal joints slightly flexed. Prehensile functions of the hand are unique and fundamental characteristics (Figure 6-112).

Figure 6-111 The functional position of the hand.

Figure 6-112 The fundamental patterns of prehensile hand function. A, Power grip. B, Precision maneuver.

Evaluation

The wrist and hand are prone to injuries from trauma, commonly a fall on the outstretched hand. The radial side of the wrist and hand tends to take the majority of the force from such a trauma. Displacement, instability, and rotary subluxation of the scaphoid often occur, creating pain on dorsiflexion of the wrist and limited ROM. Palpable tenderness will be present over the joint space between the scaphoid and the lunate. Occasionally, the scaphoid can be felt slipping as the wrist is moved, or a painful click may be perceived. A space of more than 3 mm between the scaphoid and lunate may be seen on a closed-fist supinated radiographic view of the wrist.

Trauma to an outstretched hand that is forcefully flexed or extended may cause a fracture to the radius. A Colles fracture occurs when the wrist is in dorsiflexion and the forearm is in pronation. Local pain and tenderness to palpation and vibration are important physical findings; however, the radiograph is the most important tool for determining the presence of a fracture. Manipulative therapy to this area is then contraindicated.

Singular trauma, such as a fall, or repetitive activities may lead to a sprain of the ligaments of the wrist. Moreover, when the wrist is subjected to sudden increases in workload, such as in gripping or lifting, or racquet games that require flexion and extension of the wrist, the tendons crossing the wrist can become inflamed, resulting in tendinitis. In addition, a possible response to repeated twisting and straining is a localized nodular swelling, called a ganglion. Likely a defense mechanism, the ganglion is characterized by a fibrous outer coat that covers a thick gelatinous fluid derived from the synovium lining the tendon sheaths.

Undoubtedly, the most noted condition affecting the wrist and hand is carpal tunnel syndrome, a peripheral entrapment neuropathy involving the median nerve. The median nerve lies superficial to the flexor tendons beneath the tense transverse carpal ligament (flexor retinaculum), making the carpal tunnel just barely adequate to accommodate these structures. In the act of grasping an object, particularly with the wrist in flexion, the flexor tendons are displaced forward and can compress the nerve against the unyielding ligament. Narrowing of the carpal tunnel can occur through bony deformity after fracture, degenerative joint disease, synovial swelling of a tendon or of the wrist joint ligaments, and thickening of the transverse carpal ligament (Figure 6-113). Most often, however, no definitive local cause for nerve compression can be detected. Moreover, Upton and McComas²⁰ has identified the possibility that peripheral nerves can be compressed at more than one spot along their course, creating “double-,” “triple-,” and “quadruple-crush” syndromes. Therefore, although the patient’s clinical picture may be defined as carpal tunnel syndrome, the nerve compression may not necessarily be at the wrist but may be at the elbow, shoulder, or neck. This syndrome occurs more often in women, with onset commonly between 40 and 50 years of age. Slight paresthesias may precede the onset of the acute symptoms for several months. Then, paroxysms of pain, paresthesia, and numbness occur in the area of the median nerve distribution. The patient is often awakened at night by numbness or pain that can be described as burning, aching, prickly, or pins-and-needles. Motor weakness of the thumb adductor or opposer may be found. The patient may describe relief from dangling the hand over the side of the bed, shaking the hand vigorously, or rubbing it.

Figure 6-113 Cross-section of the wrist, showing the relationship between the carpal bones, tendons, flexor retinaculum, and median nerve.

Because the wrist structures are innervated primarily from segments C6 through C8, lesions affecting structures of similar derivation may refer pain to the wrist and vice versa. Symptoms experienced at the wrist and hand must always be suspected as possibly having a more proximal origin (Figure 6-114).

Figure 6-114 Symptoms in the hand and wrist must be suspected of having a more proximal origin.

(From Magee DJ: Orthopedic Physical Assessment, ed 5, St Louis, 2008, Sauders.)

Observe the wrist and hand for general posture and attitude. In the resting attitude of the hand, the MP and interphalangeal joints are held in a position of slight flexion. Observe the arm and hand for natural swing when the patient walks. Also, note functional activities of the hand and wrist, including the firmness of the person’s handshake, as well as temperature and moisture of the hand. The dominant hand should be determined. Sometimes this can be done by noting the hand with more developed musculature, but is most easily done simply by asking the patient.

To begin the evaluation of the wrist and hand, osseous symmetry, bony relationships, and pain production are identified through static palpation of the wrist and hand (Figure 6-115). Palpate the radius and ulna distally, identifying each of their styloid processes. Just distal to the radial styloid and in the anatomic snuffbox, the scaphoid can be palpated. Wrist flexion will facilitate the palpation of the lunate, which lies next to the scaphoid. The triquetrum and pisiform overlie one another and are just distal to the ulnar styloid. The trapezium can be identified at the base of the first metacarpal. The trapezoid lies at the base of the second metacarpal. The capitate is found between the base of the third metacarpal and the lunate. The hook of the hamate, and hence the hamate, can be found on the palmar surface, just distal and to the thumb side of the pisiform. Then palpate the metacarpals through the palm of the hand, with the fingers along the shaft of the metacarpal on the palmar surface while the thumb is over the dorsal surface. Finally, palpate the 14 phalanges (2 for the thumb and 3 for each finger).

Figure 6-115 Localization of osseous structures of the left wrist.

Identify tone, texture, and tenderness changes through soft tissue palpation of the flexor and extensor tendons, the thenar eminence, and the hypothenar eminence. Determine patency of the radial and ulnar arteries (Allen test) and take a radial pulse.

Evaluate accessory joint motions for the wrist and hand articulations to determine the presence of joint dysfunction (Table 6-13). Assess A-P and P-A glide of the distal radioulnar joint with the patient supine or sitting. Grasp the distal radius with one hand and the distal ulna with the other. Apply an opposing A-P and P-A shearing stress between the radius and ulna (Figure 6-116).

TABLE 6-13 Accessory Joint Movements of the Wrist and Hand Joints

A-P, Anterior-to-posterior; L-M, lateral-to-medial; M-L, medial-to-lateral; P-A, posterior- to-anterior.

Figure 6-116 Assessment of anterior-to-posterior and posterior-to-anterior glide of the distal left radioulnar joint.

Conduct M-L compression of the distal radioulnar joint with the patient supine or sitting, and use both hands to encircle the distal radius and ulna. Use both hands to apply an M-L compression stress to the distal radius and ulna (Figure 6-117).

Figure 6-117 Assessment of medial-to-lateral compression of the distal left radioulnar joint.

In evaluating long-axis distraction of the intercarpal joint, the patient can be seated or supine. Grasp the distal forearm with one hand and the distal wrist with the other. While stabilizing the forearm, distract the wrist in the long axis (Figure 6-118).

Figure 6-118 Assessment of long-axis distraction of the left intercarpal joint.

Perform M-L tilt and glide of the intercarpal joints with the patient seated and the affected arm raised in forward flexion. Stand on the affected side, facing the lateral aspect of the arm. Grasp the distal radius and ulna with your proximal hand while grasping the patient’s distal wrist with your distal hand. Use both hands to create opposing forces, creating a shearing stress (M-L glide) (Figure 6-119) and radial and ulnar deviation stress (M-L tilt) (Figure 6-120).

Figure 6-119 Assessment of medial-to-lateral and lateral-to-medial glide of the left intercarpal joint.

Figure 6-120 Assessment of medial-to-lateral and lateral-to-medial tilt of the left intercarpal joint.

Assess A-P and P-A glide of the intercarpal joint, with the patient seated and arm raised in forward flexion. Stand on the affected side. Grasp the distal radius and ulna with your proximal hand while grasping the patient’s distal wrist with your distal hand. Using both hands to create opposing forces, stress the intercarpal joints in an A-P and P-A glide, looking for a springing joint play movement (Figure 6-121).

Figure 6-121 Assessment of anterior-to-posterior and posterior-to-anterior glide of the left intercarpal joint.

Assess A-P and P-A glide of the individual carpal bones with the patient seated and the affected arm raised in forward flexion. Stand and face the patient. Use your thumb and index or middle fingers to contact the anterior and posterior surfaces of the carpal bone to be evaluated while using your other hand to stabilize the rest of the wrist. Apply an A-P and P-A stress to each individual carpal bone, looking for a springing joint play movement (Figure 6-122, A and B).

Figure 6-122 Assessment of posterior-to-anterior (A) and anterior-to-posterior (B) glide of the individual carpals of the left wrist.

Assess A-P and P-A glide of the intermetacarpal joints with the patient seated and the affected arm raised in forward flexion. Stand and face the patient, grasp the adjacent metacarpals with both hands, and stress them in an A-P and P-A glide (Figure 6-123).

Figure 6-123 Assessment of anterior-to-posterior and posterior-to-anterior glide of the left intermetacarpal joints.

Evaluate the MP and interphalangeal joints in a similar fashion. With the patient seated, grasp the proximal member of the joint to be tested with one hand while grasping the distal member of the joint being tested with the other hand. Then stress each MP or interphalangeal joint with long-axis distraction, A-P and P-A glide, L-M and M-L glide, and internal and external rotation (Figures 6-124 and 6-125).

Figure 6-124 Assessment of long-axis distraction, internal and external rotation, and anterior-to-posterior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the left metacarpophalangeal joints.

Figure 6-125 Assessment of long-axis distraction, internal and external rotation, and anterior-to-posterior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the left interphalangeal joints.

Adjustive procedures

The application of an impulse thrust often can be performed using the accessory joint motion test procedure and adding the impulse thrust at the end. Although this is true of any joint in the body, fewer adjustive procedures are unique or different from the testing procedure for the wrist and hand. Box 6-8 identifies the adjustive procedures for the joints of the wrist and hand.

Wrist

Supine or Sitting:

Bimanual Thumb-Index Radius and Ulna Shear; Anterior-to-Posterior and Posterior-to-Anterior Glide (Figure 6-126)

IND: Loss of A-P or P-A glide of the radius and ulna.

PP: The patient is supine or sitting.

DP: Stand and face the patient on the involved side.

SCP: Distal radius and distal ulna.

CP: Grasp the distal radius with one hand and the distal ulna with the other.

P: Apply an opposing A-P and P-A shearing thrust between the radius and ulna.

Figure 6-126 Adjustment for anterior-to-posterior and posterior-to-anterior glide of the distal left radioulnar joint.

Sitting:

Reinforced Hypothenar/Radius; Medial-to-Lateral Compression (Figure 6-127)

IND: Loss of radial and ulnar compressibility.

PP: The patient is seated on the adjusting table, with the affected arm resting on the headrest so that the ulnar surface of the forearm is down and the radial aspect is up.

DP: Stand at the head end of the table, facing the patient.

SCP: Distal radius.

CP: Establish a pisiform contact with your cephalic hand over the patient’s distal radius.

IH: Place your caudal hand pisiform contact in the contact hand’s anatomic snuff box.

VEC: Compressive approximation.

P: With both arms, deliver an extension thrust, creating an impulse movement and compressing the radius and ulna. This procedure can be augmented with the use of a mechanical drop headpiece.

Hand Grasp Pull with Forearm Stabilization; Long-Axis Distraction (Figure 6-128)

IND: Loss of long-axis accessory movements.

PP: The patient is seated, with the affected arm raised in forward flexion.

DP: Stand and face the patient.

SCP: The hand.

CP: Using your inside hand, grasp the patient’s hand as though to give a handshake.

IH: Grasp the distal forearm with your outside hand.

VEC: Long-axis distraction.

P: While you stabilize the forearm with your IH, distract the wrist in the long axis with your contact hand.

Bimanual Palmar Grasp/Hand with Arm Axillary Stabilization; Long-Axis Distraction (Figure 6-129)

IND: Loss of long-axis accessory movements.

PP: The patient is seated, with the affected arm slightly flexed at the shoulder and slightly flexed at the elbow.

DP: Stand or sit on the affected side.

SCP: Proximal to the hypothenar and thenar eminences.

CP: Position your inside arm so that the inferior aspect of your arm rests in the patient’s antecubital fossa and a calcaneal contact can be placed just proximal to the patient’s hypothenar and thenar eminences.

IH: With your outside hand, place a calcaneal contact over the dorsal aspect of the metacarpal heads, with a palmar contact over the back of the patient’s hand.

VEC: Long-axis distraction.

P: Squeeze both the contact hand and the IH together to maintain contact while flexing the patient’s elbow. The lever action will create and maintain a long-axis distraction at the wrist.

Bimanual Grasp/Distal Forearm Hand; Medial-to-Lateral or Lateral-to-Medial Glide; Medial-to-Lateral or Lateral-to-Medial Tilt (Figure 6-130)

IND: Decreased M-L or L-M glide movements.

PP: The patient sits, with the affected arm raised in forward flexion.

DP: Stand on the affected side, facing the lateral aspect of the arm.

SCP: Distal radius and ulna.

CP: Using your proximal hand, grasp the distal radius and ulna.

IH: With your distal hand, grasp the patient’s distal wrist.

P: Use both hands to develop opposing forces and deliver an impulse thrust, creating a shearing stress (M-L glide) or radial and ulnar deviation stress (M-L tilt).

Bimanual Grasp/Distal Forearm Hand; Anterior-to-Posterior or Posterior-to-Anterior Glide (Figure 6-131)

IND: Loss of A-P and P-A accessory joint movements.

PP: The patient sits, with the affected arm raised in forward flexion.

DP: Stand on the affected side.

SCP: Distal radius and ulna.

CP: With your proximal hand, grasp the distal radius and ulna.

IH: With your distal hand, grasp the patient’s distal wrist over the metacarpal-carpal joints.

P: Using both hands to create opposing forces, deliver an impulse thrust, stressing the intercarpal joints in either an A-P or P-A direction.

Reinforced Thumbs/Carpal; Anterior-to-Posterior or Posterior-to-Anterior Glide (Figure 6-132)

IND: Restricted glide motions of the carpals, anterior or posterior misalignment of the individual carpals.

PP: The patient is seated, with the affected arm raised in slight forward flexion.

DP: Stand and face the patient.

SCP: Carpal bone.

CP: Establish a thumb contact over the affected carpal.

IH: Using your other hand, apply a thumb contact over the contact thumb to reinforce it.

VEC: A-P or P-A.

P: Use both hands to remove articular slack and deliver an impulse thrust with both thumbs to create A-P or P-A glide.

Figure 6-127 Adjustment for lateral-to-medial compression of the distal right radioulnar joint.

Figure 6-128 Adjustment for long-axis distraction of the right intercarpal joint.

Figure 6-129 Manipulation for sustained long-axis distraction of the right intercarpal joint.

Figure 6-130 Adjustment for medial-to-lateral and lateral-to-medial glide (A) and medial-to-lateral and lateral-to-medial tilt (B) of the left intercarpal joint.

Figure 6-131 Adjustment for anterior-to- posterior and posterior-to-anterior glide of the left intercarpal joint.

Figure 6-132 Adjustment for anterior-to-posterior (A) and posterior-to-anterior (B) glide of the individual carpals of the left wrist.

Hand

Sitting:

Bimanual Thumbs Digits/Metacarpals; Anterior-to-Posterior or Posterior-to-Anterior Glide (Figure 6-133)

IND: Restricted intermetacarpal glide movements.

PP: The patient is seated, with the affected arm in forward flexion and the elbow flexed so that the palm of the hand faces outward.

DP: Stand and face the patient.

SCP: Metacarpal bone.

CP: Establish a thumb contact on the palmar aspect of a metacarpal bone. With your fingers, hold the same metacarpal shaft on the dorsal surface of the hand.

IH: Make the same contacts on the adjacent metacarpal.

VEC: A-P or P-A.

P: Use both hands to create an A-P and P-A shear between the two metacarpals.

Thumb Index Grasp/Metacarpophalangeal (or Interphalangeal) with Hand Stabilization; Long-Axis Distraction; Internal or External Rotation; Anterior-to-Posterior or Posterior-to-Anterior Glide; Lateral-to-Medial or Medial-to-Lateral Glide (Figure 6-134)

IND: Lack of accessory joint movement in the finger joints, misalignment of the finger joints.

PP: The patient is seated.

DP: Stand and face the patient.

SCP: Distal component of the affected joint.

CP: Grasp the distal member of the joint to be adjusted with either hand.

IH: With your other hand, grasp the proximal member of the joint being adjusted.

VEC: Long-axis distraction, A-P and P-A glide, L-M and M-L glide, and internal and external rotation.

P: Apply an impulse thrust to the affected MP or interphalangeal joint, using long-axis distraction, A-P and P-A glide, L-M and M-Lglide, and internal and external rotation.

Figure 6-133 Adjustment for anterior-to-posterior and posterior-to-anterior glide of the left intermetacarpal joints.

Figure 6-134 Adjustment for long-axis distraction, internal and external rotation, and anterior-to-posterior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the left metacarpophalangeal joints (interphalangeal joints are adjusted in the same way).

Functional anatomy

Osseous Structures

The hip is a deep ball-and-socket joint with a spherical convex surface on the head of the femur and a concave articular surface formed by the acetabulum of the pelvis. The acetabulum is formed by a fusion of the three bones that make up the innominate: the ilium (superior), the ischium (posteroinferior), and the pubic bone (anteroinferior) (Figure 6-136). A fibrocartilaginous acetabular labrum surrounds the rim of the acetabulum, effectively deepening it and serving to protect the acetabulum against the impact of the femoral head in forceful movements. Hyaline cartilage lines the horseshoe-shaped surface of the acetabulum. The center of the acetabulum is filled in with a mass of fatty tissue covered by a synovial membrane. The cavity of the acetabulum is directed obliquely anteriorly, laterally, and inferiorly. The inferior component is important because of the transference of weight from the upper body through the sacroiliac joints into the head of the femur and down its shaft.

Figure 6-136 Structures of the innominate and acetabulum.

The femur is the longest bone in the body, as well as one of the strongest. It must withstand not only weight-transmission forces but also those forces developed through muscle contraction. The femoral head is completely covered with hyaline cartilage, except for a small pit near its center, known as the fovea capitis. The cartilage is thicker above and tapers to a thin edge at the circumference.

The femoral neck forms two angular relationships with the femoral shaft that influence hip function (Figure 6-137). The angle of inclination of the femoral neck to the shaft in the frontal plane (the neck-to-shaft angle) is approximately 125 degrees (90 to 135 degrees). This angle offsets the femoral shaft from the pelvis laterally and facilitates the freedom of motion for the hip joint. An angle of more than 125 degrees produces a coxa valga, whereas an angle of less than 125 degrees results in coxa vara. A deviation either way can alter the force relationships of the hip joint. The angle of anteversion is the second angle associated with the femoral neck and is formed as a projection of the long axis of the femoral head and the transverse axis of the femoral condyles. This angle should be approximately 12 degrees but has a great deal of variation, of which 10 to 30 degrees is considered within normal limits. Any increase in this anterior angulation is called excessive anteversion and results in a toe-in posture and gait. An angle that is less than ideal produces a retroversion and an externally rotated leg posture (toe-out) and gait.

Figure 6-137 The proximal femur. A, Coronal section, showing the trabecular patterns and the angle of inclination of the femoral neck. B, Apical view of left femur, showing the angle of anteversion.

The atmospheric pressure holding the head of the femur in the acetabulum is approximately 18 kg. This could support the entire limb without ligamentous or muscular assistance, although capsular ligament and muscular tension do help keep the head of the femur stable in the acetabulum.

A unique trabecular pattern corresponding to the lines of force through the pelvis, hip, and lower extremity are developed through the course of the femoral neck (Figure 6-138). Tension trabeculae are more superior and run from the femoral head to the trochanteric line. Compression trabeculae are inferior and run from the trochanteric area to the femoral head. The epiphyseal plates are at right angles to the tension trabeculae, which likely places them perpendicular to the joint reaction force on the femoral head. Aging produces degenerative changes that gradually cause the trabeculae to resorb, predisposing the femoral neck to fracture.

Figure 6-138 Hip joint, showing tension and compression trabeculation, as well as the forces transmitted from the ground and gravity.

(Modified from Kapandji IA: The physiology of the joints, ed 2, vol 1, Edinburgh, 1970, Churchill Livingstone.)

Ligamentous Structures

The hip joint is completely covered by an articular capsule that attaches to the rim of the acetabulum, to the femoral side of the intratrochanteric line, and to parts of the base of the neck and adjacent areas. The joint capsule is a cylindrical structure resembling a sleeve running between its attachment around the peripheral surface of the acetabular labrum to the femoral neck (Figure 6-139). It therefore encloses not only the head of the femur but the neck as well. From its femoral attachments, some of the fibers are reflected upward along the neck as longitudinal bands, termed retinacula. The capsule is thicker toward the upper and anterior part of the joint, where the greatest amount of resistance is required. Some deep fibers of the distal portion of the capsule are circular, coursing around the femoral neck and forming the zona orbicularis. They form somewhat of a sling, or collar, around the neck of the femur.

Figure 6-139 Diagrammatic representation of the cylindrical joint capsule, showing the orientation of fibers to resist stresses.

The joint capsule is reinforced and supported by strong ligaments named for the bony regions to which they are attached (Figure 6-140). The iliofemoral ligament lies anteriorly and superiorly and forms an inverted Y from the lower part of the anteroinferior iliac spine to the trochanteric line of the femur. It prevents posterior tilt of the pelvis during erect standing, limits extension of the hip joint, and is responsible for the so-called “balancing on the ligaments” maneuver that occurs in the absence of muscle contraction.

Figure 6-140 The ligamentous structure of the right hip. A, Anterior view. B, Posterior view.

The ischiofemoral ligament consists of a triangular band of strong fibers extending from the ischium below and behind the acetabulum to blend with the circular fibers of the joint capsule and attaching to the inner surface of the greater trochanter. It reinforces the posterior portion of the capsule and limits excessive medial rotation, abduction, and extension.

The pubofemoral ligament is attached above to the obturator crest and the superior ramus of the pubis, and below it blends with the capsule and with the deep surface of the vertical band of the iliofemoral ligament. It reinforces the medioinferior portion of the joint capsule and limits excessive abduction, lateral rotation, and extension.

The apex of the ligamentum teres attaches to the fovea capitis femoris, and its base attaches by two bands, one into either side of the acetabular notch (Figure 6-141). This ligament does not truly contribute to the support of the joint, although it becomes taut when the thigh is semiflexed and then adducted or externally rotated. It sometimes contains and offers some protection for a nutrient artery that supplies the femoral head. The ligamentum teres is lined with synovium and is believed to play a role in assisting with joint lubrication. As such, it may act somewhat like the meniscus in the knee by spreading a layer of synovial fluid over the articular surface of the head of the femur. The transverse ligament crosses the acetabular notch, converting the notch into a foramen through which the artery that supplies the head of the femur runs.

Figure 6-141 Ligamentum teres and transverse acetabular ligaments are not true supportive ligaments.

Biomechanics

The movements of the femur are similar to those of the humerus but not as free because of the depth of the acetabulum. In the standing position, the shaft of the femur slants somewhat in a medial direction and is not vertically straight. This places the center of motion of the knee joint more nearly under the center of motion of the hip joint. Therefore, the mechanical axis of the femur is almost vertical. The degree of slant of the femoral shaft depends on both the angle between the neck and the shaft and the width of the pelvis. Seen from the side, the shaft of the femur bows forward. These orientations of the femur are provisions for resisting the stresses and strains sustained in walking and jumping and for ensuring proper weight transmission.

Pelvic rotation about the hip accounts for a significant portion of forward bending. Trunk flexion from the erect posture through approximately the first 45 to 60 degrees involves primarily the lumbar spine, with further forward bending occurring because of the pelvis rotating about the hip (Figure 6-142). The iliofemoral and ischiofemoral ligaments twist as they go from the pelvic attachment to the femur. In the erect neutral position, these ligaments are under moderate tension. Thigh extension “winds” these ligaments around the neck of the femur and tightens them. Furthermore, during posterior tilting of the pelvis, these ligaments are taut and therefore are responsible for maintaining optimal pelvic position (Figure 6-143). Anterior hip and thigh pain may occur as a result of tension in these ligaments from excessive posterior pelvic tilting. In contrast, flexion of the hip “unwinds” these ligaments. Moreover, anterior pelvic tilting is not prevented by these ligaments, and the hip extensors must play an important role in stabilizing the pelvis in the anteroposterior direction. The twisting of these ligaments, as well as the twisting that occurs within the joint capsule, draws the joint surfaces into a close-packed position through a “screw-home” movement of the joint surfaces. The close-packed position of the hip is in extension, abduction, and internal rotation (Box 6-9). According to Kapandji,²¹ erect posture tilts the pelvis posteriorly, relative to the femur, causing these ligaments to become coiled around the femoral neck.

Figure 6-142 Trunk flexion begins with lumbar spine flexion, followed by pelvic flexion at the hip joints.

Figure 6-143 Diagrammatic representation of the effects of flexion and extension on the ischiofemoral and iliofemoral ligament. A, Right hip in the neutral position. B, Extension tightens ligaments. C, Flexion slackens ligaments.

During flexion, a forward movement of the femur occurs in the sagittal plane. If the knee is straight, the movement is restricted by the tension of the hamstrings. In extreme flexion, the pelvis tilt supplements the movement at the hip joint. Extension is a return movement from flexion. Hyperextension, however, is a backward movement of the femur in the sagittal plane. This movement is extremely limited. In most people, this is possible only when the femur is rotated outward. The restricting factor is the iliofemoral ligament at the front of the joint. The advantage of restriction of this movement is that it provides a stable joint for weight-bearing without the need for strong muscular contraction. The movements are mostly rotary actions. Abduction is described as a sideward movement of the femur in the frontal plane, with the thigh moving away from the midline of the body. A greater range of movement is possible when the femur is rotated outward. Adduction is a return movement from abduction, whereas hyperadduction is possible when the other leg is moved out of the way. Abduction and adduction motions are a combination of roll and glide. Internal rotation and external rotation are rotary movements of the femur around its longitudinal axis, resulting in the knee turning inward and outward, respectively (Figure 6-144). Circumduction is a combination of flexion, abduction, extension, and adduction performed sequentially in either direction (Table 6-15).

Figure 6-144 Hip joint movements.

TABLE 6-15 Arthrokinematic and Osteokinematic Movements of the Hip Joint

When the hip is externally rotated, the anterior ligaments become taut while the posterior ligaments relax. The converse is true when the hip is internally rotated (Figure 6-145). During adduction the inferior part of the joint capsule becomes slack while the superior portion becomes taut. The opposite is true during abduction; the inferior part of the capsule becomes taut, and the superior portion relaxes and folds on itself (Figure 6-146). During abduction the iliofemoral ligament becomes taut, and the pubofemoral ligament and ischiofemoral ligament slacken. Again, during adduction, the opposite occurs; the pubofemoral ligament and the ischiofemoral ligament become taut, and the iliofemoral ligament slackens.

Figure 6-145 Transverse section through the left hip, demonstrating effects of internal and external rotation on the ischiofemoral, iliofemoral, and pubofemoral ligaments. A, Neutral position. B, External rotation slackens posterior ligaments and stretches anterior ligaments. C, Internal rotation slackens anterior ligaments.

Figure 6-146 Coronal section through the right hip viewed from anterior to posterior, demonstrating the effects of abduction and adduction of the joint capsule. A, Neutral. B, Adduction tightens superior fibers and slackens inferior fibers. C, Abduction tightens inferior fibers and slackens superior fibers.

Pelvic stability in the coronal plane is secured by the simultaneous contraction of the ipsilateral and contralateral adductors and abductors. When these antagonistic actions are properly balanced, the pelvis is stabilized in the position of symmetry (Figure 6-147). If, however, an imbalance exists between the abductors and the adductors, the pelvis will tilt laterally to the side of adductor predominance. If the pelvis is supported by only one limb, stability is provided only by the action of the ipsilateral abductors. An insufficiency in the abductor muscles and, specifically, the gluteus medius results in the body weight not being counterbalanced, resulting in a pelvic tilt to the opposite side. The severity of muscular insufficiency relates directly to the degree of lateral pelvic tilting. Furthermore, during standing on one leg, the femoral head must support more than the weight of the body. The total force acting vertically at the femoral head is equal to the force produced by the pull of the abductors plus the force produced by the body weight or up to three times the body weight.³

Figure 6-147 Pelvic stability in the coronal plane is produced by a balance between the abductors and adductors.

The resting, or loose-packed, position of the hip, or that in which the joint capsule is totally slack, is 10 degrees of flexion, 10 degrees of abduction, and 10 degrees of external rotation. This position will often be assumed to accommodate swelling. Pathomechanical changes and degenerative processes can alter the resting position. A joint posture of flexion, adduction, and external rotation is the classic capsular pattern of the hip.

Evaluation

Although the hip joint exhibits 3 degrees of freedom of motion and is analogous to the glenohumeral joint, the hip is intrinsically a much more stable joint. The hip, however, is still quite prone to pathomechanic changes and, as such, is often overlooked as a source for mechanical joint dysfunction. Clinically, pain originating in the hip joint is primarily perceived as involving the L3 segment, although derivation of the hip joint is from segments L2 to S1. Hip pain can be the result of referral from the facets of the lower lumbar spine. Moreover, the knee also refers pain to the hip area, and the hip can refer pain to the knee (Figure 6-148).

Figure 6-148 Hip pain can be referred from the knee or lumbar spine, and hip disorders can refer pain to the lumbar spine and knee.

The muscles working across the hip joint are subject to strain, either through overuse (chronic strain) or overstress (acute strain or trauma). Tenderness is usually localized to the involved muscle, and the pain increases with resisted contraction. Commonly strained muscles include the sartorius, rectus femoris, iliopsoas, hamstrings, and adductors.

Trochanteric bursitis, a result of overuse or direct injury, presents as pain felt primarily over the lateral hip region, which is often aggravated by going up stairs. The pain is usually described as deep and aching pain that began insidiously. Getting in and out of a car is sometimes listed as a precipitating factor. Point tenderness is found over the inflamed bursa at the posterolateral aspect of the greater trochanter.

Entrapment of several peripheral nerves can occur in association with hip dysfunction. The femoral nerve lies close to the femoral head, and trauma or hematoma may produce entrapment, causing weakness of the hip flexors and local tenderness in the groin. The sciatic nerve, which passes deep to or through the piriformis muscle, may be compressed with contraction of the piriformis muscle. A sciatic radiculopathy with concomitant motor and sensory changes may result. The lateral femoral cutaneous nerve is prone to entrapment near the anterior superior iliac spine (ASIS), where the nerve passes through the lateral end of the inguinal ligament. Entrapment creates a condition called meralgia paresthetica and is characterized by a burning pain in the anterior and lateral portions of the thigh. The condition may be associated with a biomechanical dysfunction of the lumbopelvic complex and postural unleveling of the pelvis.²²

Use radiographic examination of children with hip pain (anteroposterior and frog leg) to evaluate the integrity of the capital femoral epiphysis. A slipped capital femoral epiphysis may occur, creating hip or knee pain. On examination, the hip will tend to swing into external rotation instead of flexion. A referral for a surgical consult is indicated.

An unrecognized or improperly treated slipped capital femoral epiphysis or a reactive synovitis may occlude the blood supply to the femoral head, and part or all of the femoral head may die as a result of avascular necrosis. These avascular changes usually involve the superoanterolateral weight-bearing part of the femoral head, and in later stages, this area becomes irregular, collapsed, and sclerotic. Examine radiographs for rarefaction of the femoral head, characteristic of Legg-Calvé-Perthes avascular necrosis.

To begin evaluation of the hip, observe the joint for the presence of any skin lesions associated with trauma, signs of inflammation, and the presence of pelvic obliquity. Observe gait patterns, although usually a pathomechanic hip dysfunction will not be severe enough to create a noticeable change in gait. However, toeing-in or toeing-out may be identified.

Note osseous symmetry and relationships between the greater trochanters, ASIS and posterior superior iliac spine, iliac crests, ischial tuberosities, and pubic symphysis. Identify tone, texture, and tenderness changes through soft tissue palpation of the bursa, inguinal ligament, hip flexors, hip extensors, hip adductors, and hip abductors.

Evaluate accessory joint motions for the hip joint for the presence of joint dysfunction (Box 6-10). Evaluate long-axis distraction of the iliofemoral joint, with the patient supine and the affected side close to the edge of the table. Straddle the patient’s distal thigh, grasping the area just proximal to the epicondyles with your knees. With your outside hand, palpate the greater trochanter while you stabilize the pelvis at the ASIS with your inside hand. By straightening your legs, you can induce a long-axis distraction into the hip joint and perceive a springing joint play movement with the contact on the greater trochanter (Figure 6-149).

Figure 6-149 Referred pain around the hip. Right side demonstrates referral to the hip. Left side shows referral from hip.

(Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2008, Saunders.)

Evaluate internal and external rotation, with the patient supine with the affected hip flexed to 90 degrees and the knee flexed to 90 degrees. Stand on the affected side, facing cephalad and using your outside hand to palpate the hip joint and greater trochanter while grasping the patient’s calf and thigh area with your inside arm. Then induce internal and external rotational stresses while evaluating for the presence of a springy end feel–type motion (Figure 6-150).

Figure 6-150 Assessment of external (A) and internal (B) rotation of the left hip joint.

Determine A-P and P-A glide movement, with the patient supine and the involved leg slightly abducted. Straddle the patient’s thigh just above the knee. Grasp the proximal thigh with both hands and induce an A-P and P-A stress, feeling for the presence of a springing joint play movement (Figure 6-151).

Figure 6-151 Assessment of anterior-to-posterior (A) and posterior-to-anterior (B) glide of the left hip joint.

Evaluate inferior glide of the hip in flexion, with the patient supine and the involved knee flexed to 90 degrees and the hip flexed to 90 degrees. Stand on the involved side, facing the patient and bending over so that the patient’s calf can rest over your shoulder. Grasp the anterior aspect of the proximal thigh and create a caudal stress toward the foot end of the table, evaluating for the presence of a springing end-feel movement (Figure 6-152).

Figure 6-152 Assessment of inferior glide in flexion of the left hip joint.

Adjustive procedures

The manipulative techniques used to treat hip disorders aim to restore normal joint mechanics, which will then ideally allow full pain-free functioning of the hip joint. Box 6-11 identifies the adjustive procedures for the hip.

Hip

Supine:

Bimanual Grasp/Distal Tibia Pull; Long-Axis Distraction (Figure 6-153)

IND: Loss of long-axis distraction accessory movement.

PP: The patient is supine, with the ischial tuberosities just cephalad of the slightly raised pelvic piece.

DP: Stand at the foot of the table.

SCP: Distal tibia.

CP: With both hands, grasp the distal tibia just above the ankle.

VEC: Long-axis distraction.

P: Use the raised pelvic piece to stabilize the patient’s pelvis on the table while using both hands to produce long-axis distraction at the hip joint. It is difficult to perceive whether the distraction has affected the hip, the knee, or the ankle, and it likely affects all three. A modification to this technique is made by wrapping a towel around the patient’s ankle and grasping the towel with both hands (Supine Towel Wrap Grasp/Distal Tibia Pull to Induce Long-Axis Distraction) [Figure 6-154]).

Bimanual Grasp/Proximal Femur; Internal Rotation (Figure 6-155)

IND: Loss of internal rotation accessory joint movement of the hip joint, external rotation misalignment of the proximal femur.

PP: The patient is supine, with the affected hip flexed to 90 degrees and the knee flexed to 90 degrees.

DP: Stand on the side of involvement, facing cephalad.

SCP: Femur midshaft.

CP: With your cephalic hand, grasp the proximal aspect of the affected femur.

IH: With your caudal hand, grasp the proximal aspect of the affected femur, reinforcing the CP.

VEC: Internal rotation.

P: Using your IH, induce internal rotation, then deliver an impulse-type thrust with the contact hand.

Bimanual Grasp/Proximal Femur; External Rotation (Figure 6-156)

IND: Loss of external rotational accessory joint movement or the hip joint, internal rotation misalignment of the proximal femur.

PP: The patient is supine, with the affected hip flexed to 90 degrees and abducted slightly and the knee flexed to 90 degrees.

DP: Stand on the side of involvement between the patient’s leg and the adjusting table, facing outward.

SCP: Medial aspect of the proximal femur.

CP: With your cephalic hand, grasp the medial aspect of the proximal femur.

IH: With your caudal hand, grasp the proximal aspect of the affected femur, reinforcing the CP.

VEC: External rotation.

P: Using your IH, stress the femur into external rotation, then supply an impulse thrust with the contact hand.

Hypothenar/Proximal Femur, Palmar/Distal Femur Grasp; Anterior-to-Posterior Glide (Figure 6-157)

IND: Loss of A-P glide accessory joint movements, anterior misalignment of the proximal femur.

PP: The patient is supine, with the hip and knee flexed slightly.

DP: Stand at the side of the table opposite the involved leg.

SCP: Anterior aspect of the proximal femur.

CP: With your cephalic hand, establish a knife-edge contact over the anterior aspect of the proximal femur.

IH: With your caudal hand, grasp the distal femur with the fingers in the popliteal fossa.

VEC: A-P.

P: Using your IH, flex the hip while delivering an A-P impulse thrust to the proximal femur with the contact hand.

Bimanual Grasp/Proximal Femur; Inferior Glide in Flexion (Figure 6-158)

IND: Loss of inferior glide in flexion accessory joint movements of the hip joint.

PP: The patient is supine, with the involved knee flexed to 90 degrees and the hip flexed to 90 degrees.

DP: Stand on the involved side, facing the patient, flexed forward, with the patient’s calf resting over your shoulder.

SCP: Anterior aspect of the proximal femur.

CP: Grasp the anterior aspect of the proximal thigh with both hands.

VEC: S-I.

P: With both hands, deliver an impulse thrust caudal.

Side Posture:

Hypothenar/Trochanter Push; Long-Axis Distraction (Figure 6-159)

IND: Loss of long-axis distraction accessory movement of the hip joint.

PP: The patient lies in a basic side-posture position, with the involved side up, the hip flexed to approximately 60 degrees, and the knee bent to 90 degrees, with the dorsum of the foot in the popliteal fossa of the other leg.

DP: Stand in front of the patient, straddling the patient’s involved leg.

SCP: Posterosuperior aspect of the greater trochanter.

CP: With your caudal hand, establish a pisiform hypothenar contact on the posterosuperior aspect of the greater trochanter.

IH: Use your cephalic hand to apply a palmar contact over the patient’s shoulder.

VEC: Long-axis distraction.

P: With your IH, stabilize the patient’s trunk while using your contact hand to create long-axis distraction to the hip joint. This same procedure can also be used for a loss of internal rotation and inferior glide in flexion.

Prone:

Hypothenar/Proximal Femur, Palmar Distal Femur Grasp; to Induce Posterior-to-Anterior Glide (Figure 6-160)

IND: Loss of P-A glide accessory joint movements, posterior misalignment of the proximal femur.

PP: The patient is prone.

DP: Stand at the side of the table on the involved side.

SCP: Posterior aspect of the proximal femur.

CP: With your cephalic hand, apply a knife-edge contact to the posterior aspect of the proximal femur.

IH: With your caudal hand, grasp the distal femur from the medial aspect (the patient’s knee can be bent and cradled against your IH and forearm).

VEC: P-A.

P: With your IH, draw the hip into extension by raising the knee off the table. Deliver a P-A impulse thrust with your contact hand.

Figure 6-153 Adjustment for long-axis distraction of the left hip joint.

Figure 6-154 Modification for long-axis distraction using a towel. A, Wrapping the towel. B, Grasping the towel to apply the thrust.

Figure 6-155 Adjustment for internal rotation of the left hip joint.

Figure 6-156 Adjustment for external rotation of the left hip joint.

Figure 6-157 Adjustment for anterior-to-posterior glide of the left hip joint.

Figure 6-158 Adjustment for inferior glide in flexion of the left hip joint.

Figure 6-159 Adjustment for long-axis distraction, as well as inferior glide in flexion or internal rotation, of the left hip joint in the side-posture position.

Figure 6-160 Adjustment for posterior-to-anterior glide of the left hip joint.

Functional anatomy

Osseous Structures

The femoral shaft lies in oblique alignment with the lower leg, which produces a physiologic valgus angle of approximately 170 to 175 degrees (Figure 6-161). The distal end of the femur is expanded to form a large, convex, U-shaped articular surface (Figure 6-162). The medial and lateral femoral condyles lie on the end of the U shape and are separated by the intercondylar fossa. Anteriorly, the articular surface of the femoral condyles forms the patellar groove. The proximal end of the tibia is flattened to create a plateau with a bifid, nonarticulating intracondylar eminence, dividing the plateau into medial and lateral sections to accommodate the medial and lateral femoral condyles. The tibial tuberosity projects from the anterior surface of the tibia, serving as the point of insertion of the quadriceps tendon (Figure 6-163). The patella, the largest sesamoid bone in the body, lies embedded within the quadriceps tendon. It is triangular in shape, with its apex directed inferiorly. The anterior surface is nearly flat, and a longitudinal ridge divides the posterior surface into medial and lateral articulating facets. The longitudinal ridge fits into the patellar groove of the femur. The proximal head of the fibula is expanded and contains a single facet that corresponds with a facet on the posterolateral aspect of the rim of the tibial condyle.

Figure 6-161 The physiologic valgus tilt of the lower extremity places the knee under the hip.

Figure 6-162 Osseous structures of the right knee. A, Anterior view. B, Articular surface of the distal femur. C, Articular surface of the proximal tibia.

Figure 6-163 Lateral view of the knee.

Ligamentous Structures

Internal to the joint are the cruciate ligaments, arranged in a crisscross manner, providing A-P, as well as M-L, stability at the knee. They prevent excessive medial rotation of the tibia and help maintain contact between the articular surfaces of the tibia and femur (Figures 6-164 to 6-167). The anterior cruciate ligament extends from the anterior aspect of the intercondylar eminence of the tibia and runs posteriorly and superiorly to the medial side of the lateral condyle of the femur. The posterior cruciate ligament attaches from the posterior intercondylar eminence of the tibia, extending anteriorly and superiorly to the lateral side of the medial condyle of the femur. The anterior cruciate ligament resists anterior displacement of the tibia and checks extension movements. In contrast, the posterior cruciate ligament primarily checks posterior displacement of the tibia and resists internal rotation of the tibia. The posterior cruciate ligament, lying medial to the anterior cruciate ligament, is the strongest of the knee ligaments. It is especially important for providing M-L stability of the knee when in extension.

Figure 6-164 Anterior view of the right knee ligaments.

Figure 6-165 Posterior view of the right knee ligaments.

Figure 6-166 Superior aspect of the proximal right tibia, showing origin of the cruciate ligaments.

Figure 6-167 A, Anterior cruciate ligament becomes taut while in flexion. B, Posterior cruciate ligament becomes taut on knee extension.

The collateral ligaments provide M-L stability and support for the knee while also preventing excessive external rotation of the tibia. The medial, or tibial, collateral ligament attaches from the medial epicondyle of the femur to the medial aspect of the shaft of the tibia. This ligament becomes taut on extension of the knee, abduction of the tibia on the femur, and external rotation of the tibia on the femur. The medial collateral ligament provides some help in preventing anterior displacement of the tibia on the femur. The lateral, or fibular, collateral ligament attaches from the lateral epicondyle of the femur to the head of the fibula. This ligament becomes taut on extension, adduction, and external rotation of the tibia on the femur. The tendon of the biceps femoris almost completely covers the lateral collateral ligament, and the popliteus tendon runs beneath it and separates it from the meniscus.

Surrounding the external aspect of the joint is the fibrous joint capsule attaching at the margins of the articular cartilage. The inferior portion of the capsule has been referred to as the coronary ligament. A substantial thickening in the medial portion of the joint capsule has fibrous attachments to the periphery of the medial meniscus, thereby binding it firmly to the femur and loosely to the tibia. The lateral aspect of the joint capsule has a similar thickening and has fibrous attachments to the lateral meniscus.

The posterior fibers of the medial collateral ligament blend with the joint capsule and the attachments to the medial meniscus. The patellofemoral ligaments form as thickenings of the anterior joint capsule and extend from the middle of the patella to the medial and lateral femoral condyles. Their function is to stabilize the patella in the patellar groove. The posterior thickening of the joint capsule arches over the popliteus tendon, attaches to the base of the fibular head, and becomes taut in hyperextension. Also blending with the posterior joint capsule is the oblique popliteal ligament, which forms as an expansion of the semimembranosus tendon and runs obliquely in a superior and lateral direction to attach to the lateral femoral condyle. It also becomes tight in hyperextension.

Lying between the femur and the tibia are the two semilunar cartilages called menisci (Figure 6-168). The menisci are shaped so that the more peripheral portions are thicker than the central portion. This serves to deepen the articular surface on the tibial plateau and provide additional stability to the joint. Because they increase the surface area of the joint, the menisci help to share the load in weight-bearing across the joint by distributing weight over a broader area. They also aid in the lubrication and nutrition of the joint and, coupled with their shock-absorbing capabilities, help to decrease cartilage wear. The periphery of each meniscus attaches to the joint capsule, and the inner edge remains free. The medial meniscus is C-shaped, and the posterior portion is larger than the anterior. The anterior horn inserts on the intercondylar area of the tibia, and the posterior horn inserts just anterior to the attachment of the posterior cruciate ligament. The lateral meniscus is almost a complete circle, with the tips of each horn quite close to one another. The lateral meniscus is more mobile than the medial meniscus.

Figure 6-168 Menisci of the right knee.

Musculature

Stabilizing the knee are the many muscles that cross it (Table 6-16). Laterally, the iliotibial band attaches to the lateral condyle of the tibia, providing anterolateral reinforcement and stabilization against excessive internal rotation of the tibia on the femur. Crossing the anterior aspect of the knee is the quadriceps tendon. It is formed by the junction of the four heads of the quadriceps muscle, which consist of the vastus lateralis, the vastus medius, the vastus medialis, and the rectus femoris. The quadriceps musculature functions to extend the knee. Balanced activity between the vastus medialis and lateralis maintains optimal orientation of the patella within the patellofemoral groove. The sartorius and gracilis muscles provide medial stability to the joint. The sartorius also assists in knee and hip flexion, external rotation of the femur, and internal rotation of the tibia, depending on whether the extremity is weight-bearing. The gracilis acts to adduct the femur and assists in knee flexion and internal rotation of the tibia. Posteromedial reinforcement of the joint is supplied by the pes anserinus tendons (semitendinosus, gracilis, and sartorius), and the semimembranosus tendon. These help to prevent external rotation, abduction, and anterior displacement of the tibia. Posterolateral support from the biceps femoris tendon helps to check excessive internal rotation and anterior displacement of the tibia. The hamstring muscle is the primary knee flexor; the biceps femoris also provides some external rotation. Posterior reinforcement of the knee joint is provided by the gastrocnemius muscle and the popliteus muscle (Figure 6-169). The gastrocnemius is a primary ankle plantar flexor but also assists in knee flexion. The popliteus internally rotates and flexes the tibia when the limb is not bearing weight. The converse occurs when the limb is bearing weight.

TABLE 6-16 Actions of the Muscles of the Knee Joint

Action	Muscles
Extension	Quadriceps
Flexion	Hamstrings, gracilis, sartorius, tensor fascia lata, and popliteus
Internal rotation	Sartorius, gracilis, semitendinosus, semimembranosus, and popliteus
External rotation	Biceps femoris and tensor fascia lata (iliotibial tract)

Figure 6-169 Lateral (A) and medial (B) aspects of the right knee, demonstrating muscular attachments.

Because the knee is exposed to a variety of demands in human locomotion, numerous bursae are located in relationship to the knee joint and to the synovial cavity. The synovial membrane of the knee joint is the most extensive of any in the body. The suprapatellar pouch, or quadriceps bursa, is actually an extension of the synovial sac that runs from the superior aspect of the patella upward beneath the quadriceps tendon and then folds back on itself to form a pouch inserting on the distal femur above the condyles (Figure 6-170). The prepatellar bursa is relatively large but superficial and lies between the skin and the patella. It can become inflamed with prolonged kneeling activities. The deep and superficial infrapatellar bursae lie just under and over the patellar tendon, respectively. Bursal sacs also lie between the semimembranosus tendon and the medial head of the gastrocnemius muscle, and two bursae separate the mediolateral heads of the gastrocnemius muscle from the joint capsule. (A Baker cyst occurs with effusion of the medial gastrocnemius and the semimembranosus bursae.) A bursa also lies under the pes anserine tendon, separating it from the tibial collateral ligament.

Figure 6-170 Sagittal section through the knee, demonstrating numerous bursae.

Biomechanics

The knee joint must provide a broad ROM while maintaining its stability. It must react to rotational forces, as well as absorb shock, and then immediately prepare for propulsion. The knee functions as a modified hinge joint, with flexion and extension being its primary motions. Limited rotation occurs, especially when the joint is not in the closed-packed position (extension) (Box 6-12). Flexion and extension of the knee are combinations of roll, slide, and spin movements, which effectively shift the axis of movement posteriorly as the knee moves from extension into flexion (Figure 6-171). Similar to elbow flexion, knee flexion is limited by soft tissue of the calf and posterior thigh, and extension is limited by the locking of the joint from bony and soft tissue elements in the joint’s close-packed position. Moreover, the so called screw-home mechanism, which is a combination of external rotation of the tibia occurring with knee extension, further approximates the osseous structures and tightens the ligamentous structures to stabilize the joint (Figure 6-172). The marked incongruent positions of the tibiofemoral joint are reduced by the fibrocartilaginous menisci. These also help to distribute the forces of compressive loading over a greater area and reduce compressive stresses to the joint surfaces of the knee. ROMs of the knee are listed in Table 6-17.

Figure 6-171 Flexion and extension movements are combinations of roll, slide, and spin.

Figure 6-172 “Screw-home” mechanism of the knee, combining external rotation with extension, which maximally approximates the joint surfaces.

(Modified from Nordin M, Frankel VH: Basic biomechanics of the musculoskeletal system, ed 2, Philadelphia, 1989, Lea & Febiger.)

TABLE 6-17 Arthrokinematic and Osteokinematic Movements of the Knee Joint

The patellofemoral joint plays an active role in flexion and extension of the knee joint. This joint has a gliding motion, moving caudal approximately 7 cm when going from full flexion to full extension. The articular surface of the patella never makes complete contact with the femoral condyles; the joint space decreases with flexion, and at full flexion, the patella sinks into the intracondylar groove (Figure 6-173). This characteristic is important in helping to increase weight-bearing capabilities in a flexed position (squatting). Therefore, the patella plays two important biomechanical roles for the knee. It primarily aids in knee extension by producing anterior displacement of the quadriceps tendon, thereby lengthening the lever arm of the quadriceps muscle force. In addition, it allows a wider distribution of compressive force on the femur, especially in a fully flexed position.

Figure 6-173 The relationship of the patella to the femur in extension (A) and flexion (B) of the knee.

The patella has an optimal position in relationship to the knee joint in both the vertical and sagittal planes. On a lateral view of the knee, the length of the patella is compared with the distance from the inferior pole of the patella to the tibial tubercle (Figure 6-174). If the difference of these two numbers is greater than 1 cm, the position of the patella is either high (alta) or low (baja), depending on which distance is greater. To determine if the patella is aligned properly in the femoral groove, the Q angle can be determined. After locating the center of the patella, extend a line up the center of the patellar tendon through the center point. Then draw a line from the center of the patella toward the ASIS (Figure 6-175). The resultant angle is the Q angle. The normal Q angle is 10 to 15 degrees, being slightly greater in females. Muscle imbalance and rotational disrelationships of the tibia and femur produce changes in the Q angle.

Figure 6-174 Identification of the position of the patella. If A–B is greater than 1 cm, a low (baja) patella exists; if B–A is greater than 1 cm, a high (alta) patella exists.

Figure 6-175 Q angle, the angle formed from the intersection of lines from the center of the patella to the anterior superior iliac spine and along the quadriceps tendon.

The superior tibiofibular joint is mechanically linked to the ankle, but a dysfunctional process in this joint presents clinically as pain in and about the knee. Therefore, inclusion of it in a discussion of the knee is clinically relevant. The superior tibiofibular joint allows superior and inferior movement, as well as internal and external rotation of the fibula. During ankle dorsiflexion the fibula internally rotates and rises superiorly. The addition of ankle eversion causes some posterior displacement of the fibular head. Ankle plantar flexion draws the fibula inferiorly and creates external rotation. The addition of ankle inversion draws the fibular head anteriorly.

Evaluation

The knee joint is affected by a wide variety of clinical syndromes. Trauma is by far the most common causative agent. Injuries to the collateral ligaments usually require some type of traumatic force. The mechanism of most medial collateral ligament injuries is a twisting external rotation strain while the knee is flexed or a valgus (abduction) blow to the knee. A lateral collateral ligament injury may occur with a varus (adduction) blow to the knee, and when internal rotation and hyperextension occur with this force, the fibular head may avulse.

The anterior cruciate ligament is commonly injured by forced internal rotation of the femur on a fixed tibia while the knee is abducted and flexed. The posterior cruciate ligament can be torn when a traumatic force is delivered to the front of the flexed tibia, driving it posteriorly under the femur. Forced external rotation of the femur on the tibia while the foot is fixed and the knee is abducted and flexed will also injure the posterior cruciate ligament.

After traumatic injuries to the knee causing ligamentous injury, joint instabilities are likely. The knee can undergo translational or rotational instabilities. Orthopedic stress tests are performed to identify the presence of joint instability.

The menisci are another site of possible injury. A trauma that couples rotation or violent extension of the knee may cause an isolated longitudinal or transverse tear in the meniscus.

Problems involving the patellofemoral joint complex are common and may be more frequent than ligamentous or meniscus disorders. A patient complaining of vague aching pain about the knee that is aggravated by going up or down stairs likely has patellofemoral joint dysfunction. Patellar tracking problems can occur primarily from injuries to the knee and quadriceps mechanism or secondarily in response to problems affecting the ankle or hip. Chondromalacia patella, an erosion and fragmentation of the subpatellar cartilage, may be secondary to trauma, recurrent subluxation, pronated feet, postural instability, short leg syndrome, or excessive femoral torsion with resultant irregular Q angle.

An avulsion fracture with resulting aseptic necrosis of the tibial tuberosity may occur from a sudden contraction of the quadriceps femoris. This condition is called Osgood-Schlatter’s disease and is more common in boys.

The knee joint is innervated by segments L3–S1, and therefore in cases of pain of nontraumatic onset, lesions situated elsewhere in segments L3–S2 must be ruled out. The lumbar spine, hip, and foot are sources of referred pain to the knee (Figure 6-176).

Figure 6-176 The ankle and hip can refer pain to the knee.

To begin the evaluation of the knee, observe the knee for evidence of swelling, asymmetry of contours, and postural changes (valgus, varus, or recurvatum). Movements of the knee during gait should be smooth and rhythmic, with the knee bent during the swing phase and fully extended at heel strike.

Identify osseous symmetry and pain production through static palpation of the tibial plateau, tibial tubercle, adductor tubercle, femoral condyles, femoral epicondyles, fibular head, patella, and trochlear groove (Figure 6-177). Determine the Q angle.

Figure 6-177 Patterns of referred pain to and from the knee.

(Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2008, Saunders.)

Identify tone, texture, and tenderness changes through soft tissue palpation of the quadriceps muscle, the infrapatellar tendon, the collateral ligaments, the pes anserine tendons, the peroneal nerve, the tibial nerve, the popliteal artery, the hamstring muscles, and the gastrocnemius and soleus muscles.

Evaluate accessory joint motions for the knee articulations to determine the presence of joint dysfunction (Table 6-18). Assess long-axis distraction with the patient supine and the affected leg slightly abducted. Stand and face the patient, straddling the affected leg so that your knees can grasp the patient’s distal leg just proximal to the malleoli. Use both hands to palpate the knee joint at its medial and lateral aspects and use your legs to create a long-axis distraction while palpating with your hands for a springy end feel (Figure 6-178). Alternatively, one hand may stabilize the patient’s femur on the table while the other hand palpates for end feel.

TABLE 6-18 Accessory Joint Movements of the Knee Joint

A-P, Anterior-to-posterior; I-S, inferior-to-superior; L-M, lateral-to-medial; M-L, medial-to-lateral; P-A, posterior-to-anterior; S-I, superior-to-inferior.

Figure 6-178 Assessment of long-axis distraction of the left tibiofemoral joint.

Evaluate A-P and P-A glide with the patient supine and the involved knee flexed to 90 degrees with the foot flat on the table. Either kneel or sit on the patient’s foot for stability while grasping the proximal tibia with both hands. Stress the proximal tibia in an A-P and P-A direction, looking for a springing end feel (Figure 6-179).

Figure 6-179 Assessment of anterior-to- posterior and posterior-to-anterior glide in flexion of the left tibiofemoral joint.

To evaluate internal and external rotation, use the same positions as for A-P and P-A glide. Stress the proximal tibia internally and externally to feel for a springing end feel (Figure 6-180).

Figure 6-180 Assessment of external and internal rotation in flexion of the left tibiofemoral joint.

Evaluate M-L and L-M glide with the patient supine and the involved leg abducted beyond the edge of the table. Then straddle the patient’s involved leg just proximal to the ankle while grasping the proximal tibia with both hands. Apply an M-L and L-M stress to the knee joint to identify a springing end feel. Alternatively, grasp the patient’s involved leg with the tibia held between your arm and body, with one hand on the tibia and one hand on the femur. The two hands can then create an M-L or L-M stress action (Figures 6-181 and 6-182).

Figure 6-181 Lateral-to-medial glide of the left tibiofemoral joint.

Figure 6-182 Assessment of medial-to-lateral glide of the left tibiofemoral joint.

Evaluate the patellofemoral articulation for M-L glide (Figure 6-183), L-M glide (Figure 6-184), S-I glide (Figure 6-185), and I-S glide (Figure 6-186), with the patient lying supine and the involved leg straight in passive knee extension. Contact the borders of the patella with both thumbs and apply a stress to the patella in M-L, L-M, S-I, and I-S directions, feeling for a comparative amount of movement from side to side, as well as a springing quality of movement.

Figure 6-183 Assessment of medial-to-lateral glide of the left patellofemoral joint.

Figure 6-184 Assessment of lateral-to-medial glide of the left patellofemoral joint.

Figure 6-185 Assessment of superior-to-inferior glide of the left patellofemoral joint.

Figure 6-186 Assessment of inferior-to-superior glide of the left patellofemoral joint.

Evaluate A-P and P-A glide of the tibiofibular articulation with the patient supine and the affected knee bent to 90 degrees and the foot flat on the table. Either kneel or sit on the patient’s foot to stabilize it and grasp the proximal fibula with the outside hand while stabilizing the proximal tibia with the inside hand. Then stress the fibula in P-A and A-P directions, looking for a springing end feel (Figures 6-187 and 6-188).

Figure 6-187 Assessment of posterior-to-anterior glide of the left tibiofibular joint.

Figure 6-188 Assessment of anterior-to-posterior glide of the left tibiofibular joint.

Perform I-S and S-I glide of the tibiofibular articulation with the patient supine, the affected leg straight, and the knee in the relaxed extension. Use a digital contact of the cephalic hand to palpate the proximal fibula while grasping the patient’s foot with your caudal hand. Then passively invert (with plantar flexion) and evert (with dorsiflexion) the patient’s ankle while palpating for the fibula to move it superiorly and inferiorly (Figures 6-189 and 6-190).

Figure 6-189 Assessment of superior-to-inferior glide of the left tibiofibular joint.

Figure 6-190 Assessment of inferior-to-superior glide of the left tibiofibular joint.

Adjustive procedures

The manipulative techniques used to treat knee disorders aim to restore normal joint mechanics, which will then ideally allow full pain-free functioning of the knee joints. The three joints associated with the knee should be evaluated for characteristics of dysfunction when there are knee symptoms present. Box 6-13 identifies the adjustive procedures for the joints of the knee.

Femorotibial Joint

Supine:

Bimanual Grasp/Proximal Tibia with Knee Extension; Long-Axis Distraction (Figure 6-191)

IND: Loss of long-axis distraction accessory movements of the femorotibial joint.

PP: The patient is supine, with the involved leg abducted beyond the edge of the adjusting table.

DP: Straddle the patient’s involved leg, grasping the patient’s distal tibia above the malleoli with your knees. If the adjusting table has an elevating pelvic piece, raise it to form a ledge for the patient’s buttocks.

SCP: Proximal tibia.

CP: Use both hands to grasp the proximal tibia.

VEC: Long-axis distraction.

P: Straighten your knees while simultaneously using your hands to pull the proximal tibia into a long-axis distraction movement.

Reinforced Web/Proximal Tibia Push; Anterior-to-Posterior Glide in Flexion (Figure 6-192)

IND: Loss of A-P tibial glide, anterior misalignment of the proximal tibia.

PP: The patient is supine, with the affected leg flexed to 90 degrees at the hip and the knee.

DP: Stand on the affected side, with your caudal foot placed on the table so that the patient’s affected leg will rest over your thigh.

SCP: Anterior aspect of the proximal tibia.

CP: Use your cephalic hand to apply a web contact over the anterior aspect of the proximal tibia.

IH: With your caudal hand, place a knife-edge contact, reinforcing the contact hand.

VEC: A-P.

P: Use both hands to create an A-P impulse thrust on the proximal tibia.

Bimanual Grasp/Proximal Tibia with Knee Extension; Internal or External Rotation in Extension (Figure 6-193)

IND: Loss of rotational accessory movements of the tibia, internal or external misalignment of the proximal tibia.

PP: The patient is supine, with the affected leg abducted off the edge of the table.

DP: Stand and face the patient, straddling the affected leg and grasping the patient’s ankle between the knees.

SCP: Proximal tibia.

CP: Using both hands, grasp the proximal tibia with the thumbs along the sides of the tibial tuberosity.

VEC: Rotation.

P: Extend your knees and hop caudal to create some long-axis distraction while simultaneously twisting the proximal tibia, either internally or externally, with your hands.

Hypothenar/Proximal Medial Tibia with Leg Stabilization; Medial-to-Lateral Glide (Figure 6-194)

IND: Loss of M-L glide movement, medial misalignment of the proximal tibia.

PP: The patient is supine, with the involved hip flexed to approximately 45 degrees.

DP: Stand on the side opposite the involved leg, grasping the distal tibia with your caudal arm and axilla.

SCP: Medial aspect of the proximal tibia.

CP: With your cephalic hand, establish a pisiform-hypothenar contact on the medial aspect of the proximal tibia.

IH: Use your caudal arm to grasp the proximal tibia and hold it against your torso.

VEC: M-L.

P: Create articular tension by using your body on the distal tibia as a lever, pivoting against the contact hand. When all joint movement is removed, deliver an M-L impulse thrust.

Hypothenar/Proximal Lateral Tibia with Leg Stabilization; Lateral-to-Medial Glide (Figure 6-195)

IND: Loss of L-M tibial glide movement, lateral misalignment of the proximal tibia.

PP: The patient is supine, with the involved hip flexed to approximately 45 degrees.

DP: Stand on the involved side, with your caudal arm grasping the patient’s distal tibia in the axilla.

SCP: Lateral aspect of the proximal tibia.

CP: Using your cephalic hand, apply a pisiform-hypothenar contact on the lateral aspect of the proximal tibia.

IH: Use your caudal arm to grasp the proximal tibia and hold it against your torso.

VEC: L-M.

P: Using your contact hand as a pivot, tilt the distal tibia with your indifferent arm to remove articular slack, and then use the contact hand to deliver an L-M impulse thrust to the proximal tibia.

Figure 6-191 Adjustment for long-axis distraction of the left tibiofemoral joint.

Figure 6-192 Adjustment for anterior-to- posterior glide of the right tibiofemoral joint.

Figure 6-193 Adjustment for external and internal rotation of the left tibiofemoral joint in the supine position.

Figure 6-194 Adjustment for medial-to-lateral glide of the left tibiofemoral joint.

Figure 6-195 Adjustment for lateral-to-medial glide of the right tibiofemoral joint.

Prone:

Reinforced Mid-Hypothenar (Knife-Edge)/Proximal Tibia Pull; Posterior-to-Anterior Glide in Flexion (Figure 6-196)

IND: Loss of P-A tibial glide, posterior misalignment of the proximal tibia.

PP: The patient is prone, with the involved leg flexed to just less than 90 degrees.

DP: Stand at the foot end of the table and bend over so that the patient’s dorsum of the foot can rest on your inside shoulder.

SCP: Posterior aspect of the proximal tibia.

CP: With your inside hand, establish a knife-edge contact on the posterior aspect of the proximal tibia.

IH: Using your outside hand, reinforce the contact hand.

VEC: P-A.

P: Use both hands to remove articular slack and thrust in the long axis of the femur, creating a P-A glide of the proximal tibia.

Bimanual Grasp/Distal Tibia with Knee Thigh Stabilization; Internal or External Rotation in Flexion (Figure 6-197)

IND: Loss of rotational accessory movements of the tibia, internal or external rotation misalignment of the proximal tibia.

PP: The patient is prone, with the affected leg flexed to just less than 90 degrees.

DP: Stand at the side of the table on the affected side, placing your cephalic proximal tibia on the patient’s distal femur.

SCP: Distal tibia.

CP: Using both hands, grasp the patient’s distal tibia with your fingers interlaced.

VEC: Rotation.

P: Stabilize the patient’s thigh on the table, use both hands to apply long-axis distraction, and then impart an impulse thrust, creating internal or external rotation of the tibia.

Figure 6-196 Adjustment for posterior-to- anterior glide of the left tibiofemoral joint.

Figure 6-197 Adjustment for external rotation of the left tibiofemoral joint in the prone position.

Patellofemoral Joint

Prone:

Bimanual Web/Patella; Superior Medial-to-Inferior Lateral Glide; Superior Lateral-to-Inferior Medial Glide; Inferior Medial-to-Superior Lateral Glide; Inferior Lateral-to-Superior Medial Glide (Figure 6-198)

IND: Patellar tracking problems, restricted patellar movements.

PP: The patient is supine, with the involved knee in relaxed extension.

DP: Stand on the involved side.

SCP: Patella.

CP: Use both hands to apply thumb web contacts over the borders of the patella.

VEC: Inferolateral, inferomedial, superolateral, and superomedial.

P: Depending on the direction of dysfunctional movement and involved soft tissues, give a thrust to the patella in a down-and-in, down-and-out, up-and-in, or up-and-out direction.

Figure 6-198 Adjustment for superior and medial (A) or inferior and lateral (B) glide of the right patellofemoral joint.

Tibiofibular Joint

Supine:

Index/Proximal Fibula, Palmar Ankle Push

IND: Loss of P-A fibular movement, posterior misalignment of the fibula. (Figure 6-199)

PP: The patient is supine, with the involved leg flexed at the hip and knee.

DP: Stand on the involved side.

SCP: Posterior aspect of the proximal fibula.

CP: Using your superior hand, apply the palmar aspect of the index contact on the posterior aspect of the proximal fibula.

IH: With your caudal hand, grasp the distal tibia.

VEC: P-A.

P: Use your IH to flex the leg, pushing the heel toward the buttock, while giving a lifting motion with the contact hand, creating P-A movement of the proximal fibula.

Reinforced Thumbs/Proximal Fibula; Anterior-to-Posterior Glide in Flexion (Figure 6-200)

IND: Loss of P-A fibular movement, anterior misalignment of the fibula.

PP: The patient is supine, with the affected knee bent to 90 degrees and the foot flat on the table.

DP: Either kneel or sit on the patient’s foot to stabilize it.

SCP: Anterior aspect of the proximal fibula.

CP: With your outside hand, establish a thumb or pisiform-hypothenar contact over the anterior aspect of the proximal fibula.

IH: With your inside hand, grasp the proximal tibia and reinforce your contact.

VEC: A-P.

P: Using your IH, stabilize the tibia while using the contact hand to deliver an A-P impulse thrust to the proximal fibula.

Prone:

Reinforced Mid-Hypothenar (Knife-Edge)/Proximal Fibula Pull; Posterior-to-Anterior Glide in Flexion (Figure 6-201)

IND: Loss of P-A fibular movement, posterior misalignment of the fibula.

PP: The patient is prone, with the knee flexed to just less than 90 degrees.

DP: Stand at the foot end of the table, flexed at the waist so the dorsum of the patient’s foot can rest on your inside shoulder.

SCP: Posterior aspect of the proximal fibula.

CP: With your outside hand, establish a pisiform-hypothenar contact on the posterior aspect of the proximal fibula.

IH: Use your inside hand to reinforce the contact.

VEC: P-A.

P: Using both hands, deliver a P-A impulse thrust to the proximal fibula.

Side Posture:

Reinforced Mid-Hypothenar (Knife-Edge)/Proximal Fibula Push; Inferior-to-Superior Glide in Eversion (Figure 6-202)

IND: Loss of I-S fibular movement, inferior misalignment of the fibula.

PP: The patient is side-lying, with the affected leg up and positioned anterior to the unaffected side. Both knees should be slightly flexed.

DP: Stand at the foot end of the table so that the patient’s involved foot rests against your thigh, maintaining the patient’s ankle in eversion.

SCP: Lateral and inferior aspect of the proximal fibula.

CP: Using your anterior hand, establish a knife-edge contact on the inferior aspect of the proximal fibular head.

IH: With your posterior hand, reinforce the contact hand.

VEC: I-S.

P: While maintaining the ankle in eversion, deliver a thrust to the proximal fibula in an I-S direction. This movement can be achieved in a similar fashion by placing a thenar contact under the inferior aspect of the lateral malleolus, reinforcing the contact with the other hand, and delivering an I-S thrust.

Reinforced Mid-Hypothenar (Knife-Edge)/Proximal Superior Fibula Push; Superior-to-Inferior to Glide in Inversion (Figure 6-203)

IND: Loss of S-I fibular movement, superior misalignment of the fibula.

PP: The patient is side-lying, with the involved side up and involved leg resting on the table behind the uninvolved leg so that the ankle of the involved leg can hang in inversion off the edge of the adjusting table.

DP: Stand at the side of the table behind the patient, facing caudal.

SCP: Posterosuperior aspect of the proximal fibula.

CP: With your outside hand, establish a knife-edge contact over the posterosuperior aspect of the proximal fibula.

IH: Using your inside hand, reinforce the contact hand.

VEC: S-I.

P: Using both hands, apply an S-I impulse thrust to the fibular head.

Figure 6-199 Adjustment for P–A glide of the left tibiofibular joint in the supine position.

Figure 6-200 Adjustment for anterior-to- posterior glide of the left tibiofibular joint.

Figure 6-201 Adjustment for posterior-to- anterior glide of the left tibiofibular joint in the prone position.

Figure 6-202 Adjustment for inferior-to- superior glide of the left tibiofibular joint.

Figure 6-203 Adjustment for superior-to-inferior glide of the left tibiofibular joint.

Functional anatomy

Osseous Structures

The distal tibia and fibula join with the talus to form a mortise-type hinge joint called the talocrural joint. The calcaneus, the largest tarsal bone, articulates with the talus, forming the subtalar joint. The navicular articulates with the talus proximally and cuneiforms distally. The cuboid articulates with the calcaneus proximally and with the fourth and fifth metatarsals distally (Figure 6-204). It also articulates with the navicular and third cuneiform medially. The first, or medial, cuneiform articulates with the first metatarsal; the second, or intermediate, cuneiform articulates with the second metatarsal; and the third, or lateral, cuneiform articulates with the third metatarsal. Two phalanges complete the structure of the great toe, and three phalanges complete the bony structures of each of the other four toes. The function of the tibia is to transmit most of the body weight to and from the foot, and although the fibula plays a very important role in ankle stability, it is not directly involved in the transmission of weight-bearing forces. Functionally, the talus serves as a link between the leg and the foot.

Figure 6-204 Osseous structures of the right foot and ankle. A, Medial aspect. B, Lateral aspect.

Ligamentous Structures

Although many ligaments and joint capsules are associated with the foot and the ankle, some are more important to localize, palpate, and functionally understand (Figures 6-205, 6-206 to 6-207). The deltoid ligament, composed of four parts, provides medial stability to the ankle by attaching from the medial malleolus to the talus anteriorly and posteriorly, as well as to the navicular and calcaneus. Laterally, the ankle is secondarily stabilized by five fibular ligaments: the anterior and posterior tibiofibular ligaments, the anterior and posterior talofibular ligaments, and the calcaneofibular ligament. The plantar calcaneonavicular (spring) ligament attaches from the sustentaculum tali to the navicular (Figure 6-208). The function of this ligament is to keep the medial aspect of the forefoot and hindfoot in apposition and, in so doing, help to maintain the arched configuration of the foot.

Figure 6-205 Ligaments on the lateral aspect of the right ankle.

Figure 6-206 Ligaments on the medial aspect of the left ankle.

Figure 6-207 Ligaments on the posterior aspect of the right ankle.

Figure 6-208 Ligaments on the plantar aspect of the left foot.

Biomechanics

The functional biomechanics of the foot and ankle must include the ability to bear weight and allow flexible locomotion. The ankle joint is a uniplanar hinge joint, with talus motion occurring primarily in the sagittal plane about a transverse axis. The lateral side of the transverse axis is skewed posteriorly from the frontal plane (Figure 6-209). The primary movement at the ankle mortise is dorsiflexion (20 to 30 degrees) and plantar flexion (30 to 50 degrees) (Table 6-20). Through the normal gait pattern, however, only 10 degrees of dorsiflexion and 20 degrees of plantar flexion are required.²⁴

Figure 6-209 Dorsiflexion and plantar flexion in the foot and ankle occur around an oblique axis, and eversion and inversion occur around the longitudinal axis.

(Modified from Wadsworth CT: Manual examination and treatment of the spine and extremities, Baltimore, 1988, Williams & Wilkins.)

TABLE 6-20 Arthrokinematic and Osteokinematic Movements of the Ankle and Foot Joints

The subtalar joint formed between the talus and calcaneus is also a hingelike joint. The axis of movement passes through all three cardinal planes of movement, thereby allowing movement to some extent in all three planes. Movement of this joint, then, includes the complex movement of supination and pronation of the calcaneus under the talus. Supination is a combination of inversion, adduction, and plantar flexion, whereas pronation is a combination of eversion, abduction, and dorsiflexion (Figure 6-210). The subtalar joint has the important function of absorbing shock at heel strike and rotating the lower extremity in the transverse plane during the stance phase of gait.

Figure 6-210 Pronation and supination movements in free swing action (open kinetic chain) (A) and with weight-bearing (closed kinetic chain) (B).

The transverse or midtarsal joint is composed of the talonavicular and calcaneal cuboid articulations. The amount of movement occurring at these joints, which function in unison, depends on whether the foot is in pronation or supination. The supinated position creates a divergence of the axes of movement, which decreases the amount of movement, setting up a rigid bony structure necessary for stability at the heel-strike stage of gait. Pronation, on the other hand, allows for the axes of motion to become aligned, which allows for increased mobility and decreased stability. The ligaments that run on the plantar surface between these tarsal bones are an essential component for absorbing stress and maintaining the longitudinal arch. Table 6-21 identifies the close-packed and loose-packed positions for the ankle and toe joints.

TABLE 6-21 Close-Packed and Loose-Packed (Rest) Positions for the Ankle and Foot Joints

The individual tarsal joints, metatarsal-tarsal joints, metatarsophalangeal joints, and interphalangeal joints enhance the foot’s stability or flexibility. They must provide a base for the stance phase, as well as the necessary hinges for flexion and extension during toe-off. Ligaments and tendons further enhance stability and flexibility by maintaining arches in the foot (Figure 6-211).

Figure 6-211 The longitudinal arch of the right foot formed by the tibialis anterior and posterior.

During the gait cycle, two main phases are described. The first occurs when the foot is on the ground and is called the stance phase, and the second occurs when the foot is not contacting the ground and is called the swing phase (Figure 6-212). The stance phase is further divided into a contact component, midstance component, and a propulsive component. Movements of the leg and foot change through the different components. Pronation of the subtalar joint occurs initially at heel strike while the tibia internally rotates. This is followed by supination of the subtalar joint and external rotation of the tibia through midstance and propulsive stages, as well as through the swing phase of gait. This creates a shifting area of weight-bearing across the foot, starting from the posterolateral aspect of the calcaneus and curving over to the first metatarsophalangeal joint. Abnormal supination or pronation of the subtalar joint will result in altered gait patterns, as well as weight-bearing stresses on the plantar surface of the foot.

Figure 6-212 Gait pattern demonstrating that 60% of the gait is the stance phase, and 40% is the swing phase. Also shown is the pattern of weight-bearing on the plantar surface of the foot normally and in pronation and supination.

Evaluation

With the concentrated stress that occurs to the foot and ankle during bipedal static and dynamic postures, these areas are susceptible to many injuries. Commonly, ankle injuries have an acute traumatic onset, whereas the foot is more likely to develop chronic and insidious onset disorders from stress overload. Pain and paresthesias arising from the lower lumbar or first sacral NRs should not be overlooked (Figure 6-213). Most foot and ankle pain, however, arises from local disease or pathomechanic processes.

Figure 6-213 The low back, hip, and knee can refer pain to the ankle and foot area.

The most common traumatic injury to this area is the inversion sprain of the ankle, causing a separation to the lateral compartment with damage to the anterior talofibular ligament and possibly to the calcaneofibular ligament. Rarely does inversion occur alone, because usually plantar flexion of the ankle, as well as external rotation of the leg, also occur.

An eversion sprain involving trauma to the medial aspect of the ankle and affecting the deltoid ligament usually occurs when the foot is fixed in an excessive amount of pronation and the individual turns forcefully toward the opposite foot. The stress is applied first to the anterior tibiofibular ligament.

Shin splints refer to a generalized, deep aching or, sometimes, sharp pain along the tibia. It is considered an overuse or abuse syndrome occurring commonly because of running or jumping on a hard surface. This activity causes the talus to be driven upward into the mortise, forcing the tibia and fibula to separate. Stress to the interosseous membrane results and may cause a periostitis. Furthermore, activity of the anterior tibialis may result in fluid becoming entrapped within the fascial covering, creating a compartment syndrome.

Plantar fasciitis results as a strain to the plantar fascia on the sole of the foot. This may be a result of standing on hard surfaces, quick acceleration or deceleration, repeated shocks, standing on ladders, or long periods of pronation. A calcaneal heel spur may eventually occur as the fasciitis continues or worsens. The fascia will pull the periosteum off the calcaneus, creating a painful periostitis, and bone will be laid down at the site of stress.

Hallux valgus is a lateral deviation of the big toe, usually with a concomitant metatarsal varum. Improperly fitting footwear, as well as an unstable and pronated foot, has been blamed for this condition.

The evaluation of the foot and ankle begins with observation during static posture, as well as gait for symmetry, arches, toe deformities, and soft tissue swelling. Inspect the plantar surface of the foot for signs of weight-bearing asymmetry in the form of callous formation. Identify osseous symmetry and pain production through static palpation of the distal tibia and fibula (malleoli), dome of the talus, navicular, cuboid, calcaneus, cuneiforms, metatarsals, and phalanges.

Identify tone, texture, and tenderness changes through soft tissue palpation of the medial and lateral ligaments, Achilles tendon, and plantar fascia, as well as the musculature that controls movement of the foot and ankle. Additionally, palpate the posterior tibial artery and dorsalis pedis artery.

Evaluate accessory joint movements for the foot and ankle articulations to determine the presence of joint dysfunction (Table 6-22). Assess long-axis distraction of the tibiotalar articulation or ankle mortise joint with the patient supine, the knee flexed to approximately 90 degrees, and the hip flexed and abducted. Sit on the table between the patient’s legs and face caudal. Place web contacts over the dome of the talus and superior aspect of the calcaneus, applying a distraction force through both hands (Figure 6-214).

TABLE 6-22 Accessory Joint Movements of the Foot and Ankle Joints

A-P, Anterior-to-posterior; L-M, lateral-to-medial; M-L, medial-to-lateral; P-A, posterior-to-anterior.

Figure 6-214 Patterns of referred pain to and from the ankle.

(Modified from Magee DJ: Orthopedic physical assessment, ed 5, St Louis, 2008, Saunders.)

Evaluate A-P and P-A glide of the ankle mortise joint with the patient supine and the hip and knee both slightly flexed so that the calcaneus rests on the table. Stand at the side of the table and place a web contact of your cephalic hand over the anterior aspect of the distal tibia while placing a web contact with your caudal hand over the anterior aspect of the dome of the talus. With both hands, grasp the respective structures and maintain the joint in its neutral position. Apply an A-P and P-A translational force through both hands, working in opposite directions, looking for a springing joint play movement (Figure 6-215).

Figure 6-215 Assessment of anterior-to- posterior and posterior-to-anterior glide of the right tibiotalar joint.

Assess M-L and L-M glide of the tibiotalar articulation with the patient supine. Stand at the foot of the table, facing cephalad. Grasp the dome of the talus with the fingers of both hands, using the thumbs to grasp under the plantar surface of the foot. Then stress the talus in an M-L and L-M direction, feeling for a springing joint play movement (Figure 6-216).

Figure 6-216 Assessment of medial-to-lateral (inversion) (A) and lateral-to-medial (eversion) (B) glide of the left tibiotalar joint.

Evaluate subtalar joint glide with the patient lying in the prone position and the knee flexed to approximately 60 degrees. Stand at the foot of the table, facing cephalad, with the plantar surface of the patient’s toes resting against your abdomen. Then grasp the calcaneus with palmar contacts while interlacing your fingers in a “praying-hands” position. Use both hands to create A-P and P-A glide, as well as M-L and L-M glide movements (Figure 6-217).

Figure 6-217 Assessment of anterior-to-posterior, posterior-to-anterior, medial-to-lateral, and lateral-to-medial glide of the right subtalar joint.

Perform A-P and P-A glide of the navicular, cuboid, and cuneiforms by grasping the specific tarsal bone while stabilizing the proximal tarsal and creating an A-P and P-A glide movement (Figure 6-218).

Figure 6-218 Assessment of anterior-to-posterior and posterior-to-anterior glide of the left cuboid (same procedure used for the navicular and cuneiforms).

Perform A-P and P-A shear of the intermetatarsals by grasping adjacent metatarsals with each hand and creating an A-P and P-A shear (Figure 6-219).

Figure 6-219 Assessment of anterior-to-posterior and posterior-to-anterior shear between the left metatarsals.

Evaluate the metatarsophalangeal and interphalangeal joints for A-P and P-A glide, M-L and L-M glide, axial rotation, and long-axis distraction by grasping the metatarsals with one hand for stabilization and placing the specific phalanx between the index and middle fingers of the other hand (Figure 6-220).

Figure 6-220 Assessment of long-axis distraction, internal and external rotation, and anterior-to-posterior, posterior-to-anterior, medial-to-lateral, and lateral-to-medial glide of the left metatarsophalangeal joints (same procedure for the interphalangeal joints).

Adjustive procedures

The manipulative techniques used to treat ankle and foot disorders aim to restore normal joint mechanics, which will then ideally allow full pain-free functioning of ankle and foot hip joints. Box 6-14 identifies the adjustive procedures for the ankle and foot.

Tibiotalar Joint

Supine:

Bimanual Reinforced Interphalangeal/Anterior Talus Pull; Long-Axis Distraction (Figure 6-221)

IND: Loss of long-axis distraction joint play movement of the tibiotalar joint.

PP: The patient is supine on the table, with the pelvic section raised and the buttocks resting against the raised pelvic piece.

DP: Stand at the foot end of the table, facing cephalad.

SCP: Dome of the talus.

CP: Use either hand to apply proximal interphalangeal contact, with the middle finger over the dome of the talus.

IH: With your other hand, use a middle finger contact over the contact hand to reinforce it. With the thumbs of both hands, grasp the plantar surface of the foot.

VEC: Long-axis distraction.

P: Maintain the ankle in dorsiflexion and apply a long-axis distraction with both hands. To induce subtalar long-axis distraction, move the knife-edge or web contact of your IH to the posterosuperior aspect of the calcaneus.

Reinforced Webs/Anterior Talus Push; Anterior-to-Posterior Glide (Figure 6-222)

IND: Loss of A-P glide tibiotalar joint, and anterior misalignment of the talus.

PP: The patient is supine on the table, with the heel just off the end of the table.

DP: Stand at the foot end of the table, facing cephalad.

SCP: Dome of the talus.

CP: With your outside hand, establish a web contact over the dome of the talus, grasping the foot with your thumb and fingers.

IH: With your other hand, either reinforce the contact hand or grasp the distal tibia for stabilization.

VEC: A-P.

P: Apply an A-P translational thrust to the talus.

Reinforced Middle Interphalangeal/Talus Pull; Lateral-to-Medial Glide (Eversion) or Medial to Lateral Glide (Inversion) with Long Axis Distraction (Figure 6-223)

IND: Loss of medial or lateral glide at the tibiotalar articulation, medial or lateral misalignment of the talus.

PP: The patient is supine, with the leg straight and the foot off the end of the table.

DP: Stand at the foot end of the table, facing cephalad.

SCP: Dome of the talus.

CP: To produce eversion, use your inside hand to establish a middle finger distal interphalangeal contact over the dome of the talus, drawing tissue and articular slack medially. To produce inversion, use your outside hand to apply the middle finger contact over the dome of the talus, drawing tissue and medial slack laterally.

IH: With your other hand, grasp the posterior aspect of the calcaneus.

VEC: L-M or M-L.

P: Use both hands to distract in the long axis and give a thrust, drawing the dome of the talus in an L-M or M-L direction.

Web/Talus, Mid-Hypothenar (Knife-Edge)/Calcaneus; Long-Axis Distraction with Either Inversion or Eversion (Figure 6-224)

IND: Loss of long-axis distraction joint play movement of the tibiotalar joint.

PP: The patient is supine on the table, with the pelvic section raised and the buttocks resting against the raised pelvic piece.

DP: Stand at the foot end of the table, facing the affected ankle.

SCP: Dome of the talus.

CP: Using your cephalic hand, establish a web contact over the dome of the talus with the forearm along the line of the tibia.

IH: With your caudal hand, grasp the distal tibia while applying a mid-hypothenar (knife-edge) contact over the superior aspect of the calcaneus.

VC: Long-axis distraction.

P: Use both hands to deliver an impulse thrust in the long axis of the tibia. M-L glide (inversion) or L-M glide (eversion) can be produced as well.

Figure 6-221 Adjustment for long-axis distraction of the left tibiotalar joint.

Figure 6-222 Adjustment for A-P glide of the left tibiotalar joint.

Figure 6-223 Adjustment for lateral-to- medial (A) and medial-to-lateral (B) glide of the right tibiotalar joint.

Figure 6-224 Adjustment for distraction of the left tibiotalar joint, which can combine either inversion or eversion.

Prone:

Reinforced Webs/Talus Push; Posterior-to-Anterior Glide (Figure 6-225)

IND: Loss of P-A glide movement, posterior misalignment of the talus.

PP: The patient is prone, positioned with the distal tibia at the edge of the table.

DP: Stand at the foot end of the table at the side of the table, facing the side of involvement.

SCP: Posterior aspect of the talus.

CP: With your caudal hand, establish a web contact over the posterior aspect of the talus.

IH: With your cephalic hand, grasp the distal tibia for stabilization.

VEC: P-A.

P: With your contact hand, apply a thrust, creating P-A glide of the talus.

Figure 6-225 Adjustment for posterior-to- anterior glide of the left tibiotalar joint.

Subtalar Joint

Prone:

Reinforced Web/Calcaneus; Long-Axis Distraction (Figure 6-226)

IND: Loss of subtalar long axis distraction.

PP: The patient lies prone, with the dorsum of the foot resting on the edge of the table, maintaining the ankle in plantar flexion.

DP: Stand on the affected side, facing caudal, in a lunge position.

SCP: Posterosuperior aspect of the calcaneus.

CP: With your cephalic hand, establish a calcaneal contact on the posterosuperior aspect of the calcaneus.

IH: With your caudal hand, reinforce the contact hand.

VEC: Distraction.

P: Use both hands to deliver a thrust caudal, drawing the calcaneus away from the talus.

Interlaced Bimanual Grasp/Calcaneus; Lateral-to-Medial Glide; Medial-to-Lateral Glide; Anterior-to-Posterior Glide; Posterior-to-Anterior Glide (Figure 6-227)

IND: Loss of subtalar glide movements (P-A, A-P, L-M, M-L), misalignment of the calcaneus (anterior, posterior, medial, or lateral).

PP: The patient lies prone, with the knee flexed to approximately 45 degrees.

DP: Stand at the foot end of the table, facing cephalad, so that the plantar aspect of the patient’s foot can rest against your abdomen.

SCP: Calcaneus.

CP: With both hands, grasp the calcaneus, interlacing the fingers in a “praying-hands” position.

VEC: A-P, P-A, L-M or M-L.

P: While stabilizing the patient’s foot against your abdomen, the calcaneus can be moved medially, laterally, anteriorly, or posteriorly.

Figure 6-226 Adjustment for distraction of the left subtalar joint.

Figure 6-227 Adjustment for lateral-to-medial glide of the left subtalar joint.

Tarsometatarsal Joint

Prone:

Hypothenar/Cuboid with Forefoot Distraction; Plantar-to-Dorsal Glide (Figure 6-228)

IND: Loss of plantar-to-dorsal movement of the cuboid, inferior misaligned cuboid.

PP: The patient is prone, with the knee bent to 90 degrees.

DP: Stand between the patient’s legs, facing the affected side at its medial aspect.

SCP: Plantar aspect of the cuboid.

CP: Use your cephalic hand to apply a pisiform/hypothenar contact over the plantar aspect of the cuboid, wrapping your fingers around the lateral aspect of the foot.

IH: With your caudal hand, cradle the dorsum of the foot or interlace the fingers with the contact hand.

VEC: Plantar-to-dorsal.

P: Use your IH to accentuate the longitudinal arch against the pressure applied to the plantar surface of the cuboid. Then give a thrust through the contact hand in a plantar-to-dorsal direction on the cuboid.

Hypothenar/Navicular (Cuneiforms) with Forefoot Distraction; Plantar-to-Dorsal Glide (Figure 6-229)

IND: Loss of plantar-to-dorsal accessory movement, inferior misalignment of the navicular.

PP: The patient is prone, with the knee bent to 90 degrees.

DP: Stand at the affected side, facing the lateral aspect of the foot.

SCP: Plantar aspect of the navicular.

CP: With your cephalic hand, establish a pisiform/hypothenar contact over the plantar aspect of the navicular, wrapping your fingers around the medial aspect of the foot.

IH: With your caudal hand, cradle the dorsum of the foot or interlace your fingers with the fingers of your contact hand.

VEC: Plantar-to-dorsal.

P: Using your IH, increase the longitudinal arch against the pressure applied to the navicular while applying a plantar-to-dorsal thrust to the navicular.

Reinforced Thumbs/Cuneiform (Cuboid, Navicular) with Forefoot Distraction; Plantar-to-Dorsal Glide (Figure 6-230)

IND: Loss of plantar-to-dorsal accessory joint movement of the cuneiforms, plantar misalignment of the cuneiforms.

PP: The patient is prone, with the knee flexed to approximately 45 degrees.

DP: Stand at the foot end of the table, facing cephalad.

SCP: Plantar aspect of a cuneiform.

CP: Use your inside hand to apply a thumb contact over the plantar aspect of the cuneiform, wrapping your fingers around the dorsum of the foot.

IH: With your outside thumb, reinforce the contact.

VEC: Plantar-to-dorsal.

P: With both thumbs, deliver a plantar-to-dorsal snapping-type thrust, being careful not to take the ankle into complete plantar flexion. This procedure can also be used for the navicular and cuboid.

Figure 6-228 Adjustment for plantar-to-dorsal glide of the left cuboid.

Figure 6-229 Adjustment for plantar-to-dorsal glide of the right navicular.

Figure 6-230 Adjustment for plantar-to-dorsal glide of the right first cuneiform.

Tarsometatarsal Joint

Supine:

Reinforced Hypothenar/Navicular (Cuboid, Cuneiforms); Anterior-to-Posterior Glide (Figure 6-231)

IND: Loss of dorsal-to-plantar accessory joint movement, dorsal misalignment of a tarsal bone.

PP: The patient is supine, with the knee and hip flexed so that the plantar aspect of the foot rests on the table.

DP: Stand at the foot of the table, facing cephalad.

SCP: Dorsal aspect of a tarsal bone (cuboid, navicular, or cuneiform).

CP: Use either hand to establish a pisiform contact over the dorsal aspect of the involved tarsal bone.

IH: With your other hand, reinforce the contact.

VEC: Dorsal-to-plantar.

P: Deliver a very quick dorsal-to-plantar impulse or recoil-type thrust. A mechanical drop section can be used to enhance this procedure.

Reinforced Middle Interphalangeal/Cuneiform (Navicular, Cuboid) Pull; Anterior-to-Posterior Glide (Figure 6-232)

IND: Loss of dorsal-to-plantar accessory joint movement, dorsal misalignment of a tarsal bone.

PP: The patient is supine, with the affected leg straight.

DP: Stand at the foot of the table, facing cephalad.

SCP: Dorsal aspect of a tarsal bone (cuboid, navicular, or cuneiform).

CP: Use either hand to apply a middle finger distal interphalangeal contact over the dorsal aspect of the affected tarsal.

IH: With your other hand, reinforce the contact, wrapping both hands around the plantar aspect of the foot with the thumbs just distal to the point of contact.

VEC: Dorsal-to-plantar.

P: Use both hands to apply a dorsal-to-plantar pressure, while the thumbs apply an opposite plantar-to-dorsal stress. Then apply a quick dorsal-to-plantar thrust through the contact hand.

Figure 6-231 Adjustment for dorsal-to-plantar glide of the tarsals (left navicular shown).

Figure 6-232 Adjustment for dorsal-to-plantar glide of the tarsals (right cuneiform shown).

Intertarsal Joint

Supine:

Bimanual Web/Tarsals; Long-Axis Distraction (Figure 6-233)

IND: Metatarsal varum, hypomobility of the medial tarsal articulations.

PP: The patient is supine, with the leg externally rotated and abducted off the table.

DP: Stand on the affected side, facing caudal, with the inside foot on the table so that the lateral aspect of the patient’s affected foot can rest on the doctor’s thigh.

SCP: Medial aspect of the navicular.

CP: With your inside hand, establish a web contact over the medial aspect of the navicular.

IH: Use your outside hand to apply a web contact over the medial aspect of the proximal metatarsal.

VEC: Distraction.

P: Using your thigh as a fulcrum, thrust both hands away from each other, effectively separating the navicular from the first cuneiform and the first cuneiform from the proximal metatarsal.

Figure 6-233 Distraction between the navicular, first cuneiform, and first metatarsal joints of the left foot.

Intermetatarsal Joint

Supine:

Bimanual Thenar/Metatarsal Grasp Shear; Anterior-to-Posterior and Posterior-to-Anterior Glide (Figure 6-234)

IND: Restricted intermetatarsal glide movements.

PP: The patient is supine, with the affected leg in slight flexion.

DP: Stand at the foot of the table, facing cephalad.

SCP: Metatarsal bone.

CP: Establish a thumb-thenar contact on the palmar aspect of a metatarsal bone, and with your fingers, hold the same metatarsal shaft on the dorsal surface of your hand.

IH: Make the same contacts on the adjacent metatarsal.

VEC: A-P or P-A.

P: Use both hands to create an A-P and P-A shear between the two metatarsals.

Figure 6-234 Adjustment for anterior-to-posterior and posterior-to-anterior glide between the right metatarsals.

Metatarsophalangeal Joint

Supine:

Thumb Metatarsal/Thumb Phalanx Shear; Plantar-to-Dorsal Glide (Figure 6-235)

IND: Loss of plantar-to-dorsal accessory joint movement of a metatarsal, plantar misalignment of a metatarsal.

PP: The patient is supine, with the leg straight and resting on the table.

DP: Stand at the foot of the table, facing cephalad.

SCP: Plantar aspect of a metatarsal bone.

CP: Use your outside hand to apply a thumb contact over the plantar aspect of the affected metatarsal.

IH: With your inside hand, establish a thumb contact over the dorsal aspect of the phalanx just distal to the metatarsal contact.

VEC: Plantar-to-dorsal.

P: Use both thumbs to create a simultaneous shear, emphasizing the plantar-to-dorsal component on the metatarsal.

Thumb Index Grasp/Phalanx; Long-Axis Distraction (Figure 6-236)

IND: Loss of long axis accessory joint movement in the metatarsophalangeal or interphalangeal joints.

PP: The patient is supine, with the affected foot extending off the end of the table.

DP: Stand at the foot of the table, facing cephalad.

SCP: Individual phalanges.

CP: Use either hand and loosely curl the index finger, applying its radial aspect against the plantar surface of the metatarsophalangeal joint. With the thumb, then grasp the phalanges from above (dorsal aspect) and distal to the index contact on the plantar surface.

IH: With the other hand, grasp the foot to stabilize it.

VEC: Long-axis distraction.

P: With the thumb, draw the phalanges over the index contact, and apply a dorsal-to-plantar distractive thrust.

Figure 6-235 Adjustment for plantar-to-dorsal glide of the right metatarsophalangeal joints.

Figure 6-236 Adjustment for long-axis distraction of the right metatarsophalangeal joints (same procedure for the interphalangeal joints).

First Metatarsophalangeal Joint

Supine:

Web Metatarsal/Finger Grasp Phalanx; Medial-to-Lateral Glide with Pendular Distraction (Figure 6-237)

IND: Hallux valgus, bunions, loss of M-L movement of the first metatarsophalangeal joint.

PP: The patient is supine, with the affected foot off the end of the table.

DP: Stand at the foot of the table, facing cephalad.

SCP: Proximal phalanx of the great toe.

CP: With your outside hand, grasp the proximal phalanx between your index and middle finger.

IH: Using your inside hand, apply a web contact over the medial aspect of the metatarsophalangeal joint.

VEC: M-L.

P: With the contact hand, elevate the foot, using gravity to create long-axis distraction at the metatarsophalangeal joint. Induce side-to-side rocking with the contact hand to mobilize the joint initially. A very shallow M-L thrust can then be applied by the IH.

Figure 6-237 Adjustment for medial-to-lateral glide of the right first metatarsophalangeal joint.

Interphalangeal Joint

Supine:

Thumb Index Grasp/Phalanx; Long-Axis Distraction; Internal or External Rotation; Anterior-to-Posterior or Posterior-to-Anterior Glide; Lateral-to-Medial or Medial-to-Lateral Glide (Figure 6-238).

IND: Loss of accessory joint movement in the toe joints, misalignment of the toes joints.

PP: The patient is supine.

DP: Stand and face the patient.

SCP: Distal component of the affected joint.

CP: Grasp the distal member of the joint to be adjusted with either hand.

IH: With the other hand, grasp the proximal member of the joint being adjusted.

VEC: A-P and P-A glide, L-M and M-L glide, and internal and external rotation.

P: Apply an impulse thrust to the affected metatarsophalangeal or interphalangeal joint, using A-P and P-A glide, L-M and M-L glide, and internal and external rotation.

Figure 6-238 Adjustment for internal and external rotation and anterior-to-posterior, posterior-to-anterior, lateral-to-medial, and medial-to-lateral glide of the right metatarsophalangeal joints (same procedure for the interphalangeal joints).

The use of manipulative or adjustive techniques with peripheral joint problems is a valuable aspect in chiropractic practice, requiring no more or no less skill than techniques for the spine.