Workshop held from 13.04.06 – 15.04.

06
at Dolphin Institute of Physiotherapy

Conducted by

R. Ravi Kumar., MPT(Australia)

Manipulative therapist
[Link] was the first to study thoroughly and systematically soft tissue lesions
of the locomotor system.

The pillars of his system are:

A good understanding of the phenomenon "referred pain" The chief obstacle to
correct diagnosis in painful conditions is the fact that the symptom is often felt at a
distance from its source

The diagnosis will often turn on the assessment of the site and nature of the pain
and the manner in which it is projected and elicited.

In the Cyriax concept, referred pain obeys certain rules.

To a certain degree, referred pain can be compared with the refraction of light
when it falls on a water surface.
The observer does not see objects under the water surface at their exact localization.
Examination by Selective Tissue Tension

Cyriax had to begin somewhere, so he started with the simple assumption that if a
damaged tissue was pulled it would hurt ... tension on the structure would give rise
to pain, wherever that pain might be felt.

If each structure acting on or around a joint could be put under tension

independently and in turn, then the structure at fault could be identified.
This simple postulate turned out to be extremely effective.

He worked out that some tissues (the contractile tissues, the muscles with their
associated tendons, nerve and bony insertion) could be made to apply tension to
themselves by a simple strong isometric contraction.

The inert structures (joint capsule, ligaments, bursae) would not have been moved
during this contraction, but could, by contrast, be put under tension by being
stretched passively.

A logical system of Examination was developed, and which is known as

"Examination by Selective Tissue Tension".

Cyriax had three principles for examination by Selective Tissue Tension.

[Link] contractions tests the function of the contractile tissues.

[Link] movements test the function of the inert structures.
[Link] patterns differentiate between joint conditions and other inert structure
lesions.
Cyriax Treatment is based on 3 principles
1. All pain arises from a lesion
2. All treatment must reach the lesion
3. All treatment must exert a beneficial effect on the lesion

Theory & Practice of Massage

Massage is given in many ways for many purposes
Manual techniques, frictional & manipulative techniques

Types of Manual Treatment

1. Deep effleurage
2. Deep friction
3. Massage to dermatome
4. Massage with creams

Deep Friction - Effects

1. Traumatic hyperaemia
2. Movement
3. Increased tissue perfusion
4. Mechanoreceptor stimulation

Deep friction
Advantage of using deep friction – it applies therapeutic movement over only a very
small area

1. Deep friction for muscular lesion

2. Deep friction for ligamentous lesions
3. Deep friction for tendinous lesions

Deep friction for muscular lesion

Deep transverse friction restores mobility to muscle in the same way as
manipulation free a joint. The action of deep transverse friction may be summed up
as affording a mobilisation that passive stretching or active exercises cannot achieve

Deep friction for ligamentous lesions

When friction is started during the 1st day or 2 after a sprain – ligament need to be
moved only a few times
In chronic cases – deep friction is given to fibrous structures such as ligaments in
preparation for manipulation
Friction thins out the scar tissue by which the fibrous structure is held abnormally
Deep friction for tendinous lesions
• Manual rolling of the tendon sheath to & fro against the tendon serves to
smooth the gliding surfaces
• Causative overuse might be of longitudinal friction, the curative is transverse
friction

Technique of Deep Friction

Principles
a. The Right spot must be found
b. The Physiotherapist’s fingers & patient’s skin should move as one
c. The Friction must be given across the fibres composing the affected structure
d. The friction must be given with sufficient sweep
e. The friction must reach deeply enough
f. The patient must adopt a suitable position
g. Muscles must be kept relaxed while being given friction
h. Tendons with a sheath must be kept taut

Position of Physiotherapist hands

1. The index finger crossed over the middle finger
2. The middle finger crossed over index finger
3. Two finger-tips
4. The opposed fingers and thumb

Indication for & against Deep Friction

Indications
1. Muscular lesions
- Recent trauma
- Long standing scars
- Lesions at the musculoskeletal junction

2. Tendinous lesions
- Tendons with a sheath
- Tendons without a sheath

3. Ligamentous lesions
- Recent sprain
- Chronic sprain

Contra indications for Deep friction

1. Inflammation due to bacterial action
2. Traumatic arthritis of the elbow joint
3. Ossification or calcification in soft structures
 4. Bursitis
5. Rheumatoid types of arthritis
6. Pressure on nerves

Diagnosis of soft tissue lesions

1. Primary Fibrositis
2. Secondary Fibrositis
1. Traumatic fibrositis
2. Rheumatoid fibrositis
3. Infectious fibrositis
4. Parasitic fibrositis (Trichinella spiralis)
5. Myositis
3. Muscle tone
4. Muscle spasm
5. Muscle wasting
6. Limited movement & pain in arthritis

Different sites of lesion in a muscle

Point A – treatment by active exercise, local anesthesia & deep massage are effective
Point B – treatment by local anesthesia & deep friction are effective
Point C – treatment only by deep friction is effective

Referred Pain
Referred from where??
Pain felt elsewhere than its true site is termed “Referred”
Dermatomes

Pressure on nerves
- Pins & needles due to compression
- Small nerves
- Nerve trunk
- Nerve root
- Spinal cord

Stretching the nerve root

The different ways of stretching the root are given below
a. Straight Leg Raising
b. Prone knee flexion
c. Neck flexion & scapular approximation
Signs of pressure on a nerve
i.) Pain on stretching the nerve
ii.) Provocation of pins & needles
iii.) Tenderness & swelling of the nerve sheath
iv.) Postural deformity
v.) Cessation of symptoms for the duration of local anesthesia
vi.) Relief following steroid infiltration

General Principles of Diagnosis

Diagnostic Approach - Introduction
1. Inert & contractile structure
2. Active movements
3. Passive movements
4. Resisted movements

Inert structures – joint capsule, ligament, fasciae, bursae, dura mater, dural sheaths
to the nerve roots
Contractile structures – muscle and its attachments

Active Movements
- Used to prevent adhesions forming within or about a muscle
- Active movements of the muscle suffices for the formation of a supple scar
that becomes painless quickly
# active exercise are alone ineffective, but active movements in the required
direction strongly assisted by the physiotherapist are often successful

Passive movements
- inert structures are stretched

- no material strain borne to the contractile structures

- when a passive movement hurts, an inert structure is at fault.

The physiotherapist must be aware of the extreme of range at every joint in the
body feels like – “END FEEL”

1. Bone – to – bone
The movement stops abruptly with the sensation of two hard surfaces
engaging
2. Leather
The movement comes to a firm stop but can be pressed a little further by the
use of some strength, with the sensation of stretching a elastic tissue
3. Springy block
It is caused by internal derangement & is best felt when the meniscus is
displaced at the knee
4. Muscle spasm
When gentle forcing evokes muscle spasm coming on with a sudden vibrant
twang
5. Emptiness
There is no stop – e.g. flexion at elbow, hip or knee

Purpose of Passive Movement

• To break adhesions
• To stretch the capsule of a joint
• To reduce an intra-articular displacement
• To stretch a muscle
• To stretch a tendon
• To reduce a bony subluxation
• To correct a deformity
• To maintain range at joints whose muscles are paralysed
• To maintain movement at a joint soon after an operation

Resisted movements
- no material strain falls on the inert structures

- a particular muscle or muscle group attempted for a movement is put under

tension

Steroid Therapy
Until 1952, no alternative was available for deep friction in the treatment of
musculotendinous lesions
There are some “what – where – how – when” based on which steroid therapy can
be given

History
1. Listen
2. Findings based on history
3. Inspection
4. Palpation
Clinical examination
Resisted Movements
 Joint must be held at mid range to keep the inert structures off the stretch
 no movement should take place at the joint
 muscles other than tested must not be included
 patient must exert herself to the utmost

Findings on resisted movements

1. Strong and Painless
nothing wrong with the contractile structures
2. Strong and Painful
minor lesion of some parts of a muscle, tendon or
its attachments
3. Weak and Painless
complete rupture of relevant muscle or tendon,
impaired conduction along a nerve leads to
weakness
4. Weak and Painful
serious trouble is present
5. Painful on repetition
intermittent claudication is the probability if a movement is strong and
painless at first but hurts after a number of repetition
6. All the resisted movements hurts
gross lesion lying proximally, usually capsular and produced when joint
movement is not fully restrained

Passive Movements
 lesion of a contractile structure does not produce limitation on passive
movement
 if the movements show the lesion lies in an inert structure, primary issue is
whether the whole capsule or some other inert structure is involved
 whether it is capsular or non capsular
 non capsular – internal derangement, ligamentous sprain and bursitis

Findings on passive movements

1. Capsular lesions
2. Internal Derangement
3. Ligamentous sprains
4. End feel
5. Extra articular limitation
Capsular lesions
 If an entire capsule is inflamed, all or most passive movements of that joint
will strain a different part of the capsule.
 Arthritis is designated by the capsular pattern

Internal Derangement
 Lesions are capable of restricting the range, but not involving the entire
joint, have to be considered.
 Eg. Carpal capitate subluxation – painful but full passive flexion, painful
limited extension and painless full deviations. Whereas in capsular pattern –
equal limitation of flexion and extension

Ligamentous sprains

 sprained ligament will cause pain on one passive movement

 if pain is produced on passive wrist radial deviation, lesion of the ulnar
collateral ligament is suggested.

THE PERIPHERAL JOINTS

THE SHOULDER JOINT

EXAMINATION
ACTIVE & PASSIVE MOVEMENTS
RESISTED MOVEMENTS
FINDINGS
ACTIVE & PASSIVE MOVEMENTS
1. Active Elevation
2. Passive Elevation
3. Passive lateral/medial rotation
4. Passive abduction/adduction
5. Resisted lateral/medial rotation
6. Resisted elbow flexion/extension
7. Full passive arm elevation
8. Arm elevation

RESISTED MOVEMENTS
 Resisted abduction tests deltoid & supraspinatus
 Resisted adduction tests pectrolis major, latissmus dorsi & both teres
 Lateral rotation if painful – lesion with infraspinatus
 Medial rotation tests subscapularis
 Resisted elbow flexion assess biceps
 Resisted elbow extension tests triceps

FINDINGS
1. Capsular Lesions
2. Traumatic arthritis
3. Non Capsular Lesions
1. Acute Subdeltoid Bursitis
2. Chronic Subdeltoid Bursitis
3. Subluxation

Capsular Lesions
 limitation of movement

 hard end feel

 limitation with medial rotation, glenohumeral abduction, lateral rotation

Traumatic arthritis
Stage 1 and 3
• Relatively non-irritable phases
• Short wave diathermy or other appropriate modality followed by repeated
stretching towards extreme elevation in half lying position with counter
pressure on sternum
* Elastic end feel is a good prognostic sign

* If pain persists for a minute or more - injection or capsular distraction are

substituted.
Stage 2
• If untreated for 1st month – joint becomes too irritable to be stretched
• The following signs are noted
• Pain radiates below elbow
• Arm is painful even at rest
• Difficult to lie on the affected side at night
• If only 1 or 2 indicators are present, stretching can be tried cautiously
• Treatment – injection of steroid suspension – pain subsides in 36 hours

Physiotherapy treatment
Distraction with maintaining slight flexion and medial rotation (to keep the
joint capsule relaxed) avoiding abduction
Intermittent distraction pressure for about 1 cm
Sessions lasting for half an hour

Non Capsular Lesions

Acute Subdeltoid Bursitis

• Uncommon condition limits passive movement but not in capsular pattern

• whole bursa becomes inflamed – in due course loses the capacity to abduct
the arm
• pain may radiate as far as wrist
• resisted movements are painless

Stage 1
# acute pain lasts 7-10 days
# strong analgesic is injected as a preliminary measure
# 2nd injection may be required a few days later

Stage 2
# following the injection – nocturnal bandage is needed to stop the arm drifting into
painful range
# Non steroid anti-inflammatory agents provide a worthwhile alternative at either
stages

Chronic Subdeltoid Bursitis

 only a limited part of the bursa is affected
 calcium deposit may lead to recurrence
 may give rise to painful arc only or pain on several resisted movements, or
pain on some passive movements
  abducted arm into internal rotation may reproduce the pain
 tender spot must lie under the acromion

 Solution of 0.5% procaine 5-10ml is injected in droplets over the inflamed

area

 persistent recurrent impingement might require surgery to the coraco-

acromial ligament

Subluxation
• Recurrent transient anterior subluxation may occur in sports men
• Shoulder is laterally rotated and abducted to about 90 degree.
• Pressure on the posterior aspect of the humerus, forcing the head out of the
glenoid cavity, almost invariably produces apprehension suggestive of
diagnosis
• Treated with shoulder girdle muscle rehabilitation and rest from provoking
activities

Contractile structures
Supraspinatus Tendinitis

• Commonest tendinous lesion at the shoulder

• Noted with painful resisted abduction
• The musculotendinous site is treated by massage
• If calcification is seen on x-ray – contraindicated to massage
• Injection with 5 ml 2% procaine is administered

At the tenoperiosteal site

• Painful resisted abduction, accompanied by painful arc shows lesion to lie in
a pinchable position between the acromion and greater tuberosity
 • Momentary pain is caused as the inflamed area squeezes under the acromial
arch on arm elevation.
• Arm elevation with palm upwards, lesion lies at anterior aspect of the
tenoperiosteal junction
• If more pain is produced during palm downwards, the posterior aspect is
affected

Treatment
*Either massage or injection
*The lesion is accessible if the patient puts her
arm behind her back with elbow bent
*Medial rotation of shoulder brings the greater
tuberosity forwards and adduction as the arm
moves backwards exposes the tendon

Physio treatment
# For massage, patients positioned as mentioned earlier
# sessions last for 20 minutes twice weekly for 2-5 weeks
# counter pressure is supplied by the thumb on the deltoid

The distal end of the tendon

• Painful resisted abduction accompanied by both painful arc and pain on full
elevation indicates that the lesion lies superficial and deep aspect of the
tendon
• Massage and injection are effective.

The Musculotendinous junction

• If resisted abduction hurts with neither painful arc nor pain on full elevation,
attention is drawn to the proximal end of the tendon
• Palpation with arm supported horizontally may locate the tenderness deep
within the angle formed by the clavicle and the spine of the scapula

Massage is effective
• The operator stands behind and to one side of the patient
• Middle finger is pressed deeply into the above mentioned angle
• Friction is imparted by rotating the forearm to and fro
• 15 minute of treatment on alternate days.
SUPRASPINATUS – MUSCULOSKELETAL JUNCTION

Infraspinatus
• Pain on resisted lateral rotation
• Painful arc suggests lesion at superficial aspect of the distal end of the tendon
• Pain on full elevation focuses attention on the deep aspect of the distal end

For injection or massage

• The patient lies prone propped up on her elbows
• This retracts the scapula and uncovers the head of humerus.
*Infraspinatus is easily found just below the most lateral extent of the spine of the
scapula
*For massage – fingers supply counter-pressure, the thumb is alternately abducted
and adducted across the lesion.
*Treatment time – 20 minutes on alternating days
*Recovery can be anticipated in about 3 weeks.
Subcapularis

* Of all tendinous lesions at shoulder, this is probably the most difficult to locate as
the tendon is wafer thin, lies deeply and usually tender in normal person

Physical signs
- Resisted medial rotation is painful
- Painful arc exists (upper most part of the lesser tuberosity is affected)
- Full passive adduction hurts
- To palpate, the thumb is laid on the head of the humerus and guided laterally
until it encounters the bicipital groove
- The tendon is extremely thin and feels as hard as a bone
- Results are good for injection

For massage
The operator locates the tendon and hooks the thumb round the medial edge
of the upper part of the deltoid.
The belly is drawn laterally, letting the short head of the biceps slip under
the finger so the thumb can connect directly with the subscapular tendon
The thumb is then moved vertically up and down while counter pressure is
maintained by the fingers at the back of the shoulder.
Biceps
• Out of the five common sites, the coracoid origin of the short head may be at
fault
• Resisted elbow flexion and supination
Lesion
• Overuse or severe strain
• Mid part of the tendon of the long head is usually at fault

Physical signs
# Resisted flexion & supination of elbow hurts at the upper most part of arm
# Pain free & full range with passive movement at shoulder is present

Patient position – half lying, arm by the side

Technique
- Identify the biceps tendon lying in the groove on the humerus
- It can be felt by doing resisted elbow flexion
- Whole thumb is pressed flat on the tendon by applying counter pressure by
the fingers at the back
- Friction is given by adduction & abduction of thumb along with to & fro
over the tendon

Biceps Muscle - Belly

Strain during heavy lifting & a painful scar forms which hurts every time the
muscle contracts

Physical signs
- Pain is felt in mid arm
- Reproduced by resisted flexion & supination of the elbow

Patient’s position – half lying, arm & forearm supported by the couch & elbow held
in 90 degree of flexion

Technique
- Therapist sitting – facing the patient
- Grasp the affected area of muscle between fingers & thumb, interphalangeal
joints are held in flexed position
- While maintaining this grip, pull the whole bulk & impart friction

Biceps Tendon – Insertion at radial tuberosity

Physical signs
- Pain is front of the elbow & radiates along the front of the forearm to wrist
- Passive flexion, extension & supination at the elbow are full & painless
- Extreme of pronation hurts
 - Resisted flexion & supination at elbow provokes pain in the forearm

Patient position – half lying position on the couch, forearm fully supinated

Technique
- Thumb is flexed at the interphalangeal joint so that the tip is on the radial
tuberosity anteriorly
- Counter pressure is applied by the fingers at the back of her forearm
- Friction is imparted to the tendon at the tuberosity by means of the other
hand by pronation & supination of forearm

Serratus anterior muscle

Strain appears to occur only at the fibres of the insertion at the deep aspect of the
inner border of scapula

Physical signs
- Unilateral scapular pain unaltered by movement at cervical or thoracic joints
- Passive elevation & resisted abduction hurts

Patient position – prone lying, hand to back, arm medially rotated, lifts the medial
edge of scapula away from the chest wall

Technique
# grasp the medial edge of scapula using thumb
# fingers supply counter pressure at the dorsum of the scapula
# friction is applied by adduction & abduction movement of thumb

Pectoralis Major Muscle

As a result of overstrain during heavy lifting, sometimes directly from a blow.

Physical signs – unilateral pectoral pain brought on by full passive elevation of the
arm & on resisted abduction, medial rotation

Patient position – half lying on the couch, abduct the arm so as to bring the muscle
into prominence
Therapist sits by the patient – grasps the edge of the muscle – by maintaining the
grip – friction is imparted

Acromioclavicular joint
Commonly traumatic incidence – osteoarthrosis in elderly is a common radiological
finding but often symptomless.

Physical signs
• Pain is felt at the point of the shoulder at the extreme of scapular range
• Full passive adduction of the arm across the front of the chest – most painful
movement

Indication for massage

- Trauma to the joint followed by persistent symptoms
- Osteoarthrosis causing pain
Therapist stands behind the patient – press the index finger on the joint & give
friction horizontal to & fro movement in the sagittal plane

Shoulder joint – Forced Elevation

Lesion
1. Following injury – direct or indirect adhesion formation about the capsule
2. Osteoarthrotic capsular contracture
3. Non specific arthritis

Indication for Manipulation

# Limitation of movement in the capsular pattern
# Capsular adhesions causing movement limited in one direction
In established arthritis, stretching the shoulder joint is indicated when…
a.) Pain does not reach beyond elbow
b.) There is no pain except on movement
c.) Patient can lie on the affected side at night
d.) End feel is elastic
Patient position – supine lying with the upper body slightly raised – forearm is kept
over the forehead

Technique
# One hand over the lower end of sternum – to prevent arching of back
# Other hand presses hard against the elbow – forcing into shoulder elevation
# No jerk is given
# When bringing back slight traction is given to ease off the shoulder pain

Shoulder joint - Distraction

LESION – limitation of movement at the shoulder joint in the capsular i.e. arthritis
Indication for distraction
- When pain is constant & spreads below the elbow
- Patient cannot sleep on the affected side
- End feel is sudden spasm

Patient position – supine lying

Therapist position – facing the patient, holding arm in slight flexion, one hand to the
inner aspect of arm & accommodates the shaft of humerus with the other palm

Technique
> Distraction is attempted by pulling both with the hand in the axilla & with the
hand that lies on the lateral aspect of arm
> No abduction should occur
 THE ELBOW JOINT
Examination
• Passive movements
• Early arthritis is marked by limitation in the capsular pattern
• Later stage – limitation of pronation and supination
• Soft end feel on extension – loose body
• Hard end feel on flexion - arthritis

Resisted Movements

• Pain on resisted flexion – biceps at fault

• Pain on resisted extension – lesion at triceps
• Resisted pronation – strains the pronator teres
• Resisted supination – tests the supinator brevis and biceps

Findings – Capsular lesions

Capsular pattern - greater limitation of flexion than of extension.
Palpation may reveal warmth and synovial thickening.

Myositis Ossificans
Results from improper treatment of traumatic arthritis at the elbow.
Forced extension is ill advised.
The only conditions calling for manipulation are a loose body blocking extension.

Non capsular lesions - Displacements

A displaced loose body blocks the joint – limiting either flexion or extension.

The manipulator needs 2 assistants, one anchors the patients trunk, other secures
the patients humerus to the couch
Grip is at the lower forearm with elbow semi flexed, swings the patients elbow
towards further extension. Throughout the procedure, forearm is supinated and
pronated giving a final jerk

Contractile structures
Biceps
Lower musculotendinous junction
• Steroid injection is ineffective
• Massage – placing finger and thumb in opposition behind the structure and
pinching them together while the hand is drawn anteriorly across the
structure

Lateral epicondylitis
Lesion of the extensor carpi radialis longus and brevis
Any exercise involving repeated and forcible wrist extension can provoke the
condition
Resisted wrist extension with the elbow in full extension is painful and hurts at the
elbow
About 9 lesions out of 10 lie at the tenoperiosteal junction at its origin from the
lateral epicondyle

First patient receives strong deep friction for 15 minutes

Counter pressure is afforded by the fingers at the medial side of the joint while the
thumb crosses to and fro over the tendon

Mill’s manipulation immediately follows the preliminary massage

Operator takes up position behind the patient who lifts the arm to a right angle,
internally rotates shoulder and pronates the forearm
The operator clamps the patient’s wrist into fullest extension and rests the other
hand lightly on the patient’s flexed elbow
The elbow is then snapped smartly into full extension, provided the full wrist
extension has been maintained
The manipulation is extremely painful momentarily. It is repeated twice a week -
once on each visit for a month or more
Mill’s manipulation is dangerous if full extension is not attainable and strongly
contraindicated by signs of capsular disorder.
 Mills Manipulation

Medial epicondylitis
Less common and less disabling than tennis elbow
Affects the common flexor tendon at the medial epicondyle
Resisted wrist flexion is painful, although resisted pronation may be the only finding
in early stages

Pain is felt clearly at the inner side of the elbow and does not radiate. Patient’s
affected fall between 40-60 years
The lesion responds to either massage or steroid infiltration
For massage – the elbow is supported in full extension and supination – this
provides a firm bony foundation against which to rub the tendon
The thumb applies counter pressure on the outer side of the arm and finger
movement is not vertical but almost horizontal following the contour of the
epicondyle
The very strongest friction is scarcely powerful enough.
Sessions latest for 15 minutes on alternate days.

SUPINATOR MUSCLE
LESION – it is rare & always mistaken for tennis elbow
Physical signs
- Unlocalised pain is felt at the elbow
- Resisted supination is painful
Patient position – sitting – patient’s forearm is supported in full pronation

Technique
# therapist’s thumb is placed over the affected area of the muscle & pressed deeply,
slightly flexing the interphalangeal joint
# fingers supply counter pressure at the back of the elbow
# alternate abduction & adduction of the thumb gives deep friction
Duration of treatment – 15 minutes – 2 to 3 times a week

THE WRIST AND HAND

INSPECTION
 Tender, red and swollen joint suggests septic or gouty arthritis
 Swollen and tender joints suggests rheumatoid arthritis
 Skin contracture occur in scleroderma
 Atrophic changes in which the skin is smooth, shiny and thin occur in
sudeck’s atrophy and in shoulder hand syndrome
 Localised swelling may represent effusions into tendon sheaths.
 Wasting of thenar eminence suggests carpal tunnel syndrome

EXAMINATION – The radio ulnar joint

Passive pronation and supination – evaluate the capsule of inferior radio ulnar joint
Pain or limitation should be treated by mobilization of the joint or injection.
Passive wrist flexion and extension – tests the capsule, but passive flexion also
stretches the ligaments at the dorsum of the wrist.
Passive radial deviation puts strain on the ulnar collateral ligament and passive
ulnar deviation tensions the radial collateral ligament

Resisted wrist flexion tests the flexor tendon of both wrist and fingers
Resisted extension tensions the extensor tendons of both wrist and fingers
Resisted ulnar deviation assess ulnar deviators and resisted radial deviation tests
radial deviators

Thumb – passive extension stretches the anterior aspect of the capsule.

This always hurts in arthritis of the trapezio-first metacarpal joint

° Resisted thumb flexion puts strain on the flexor pollicis longus

° Resisted abduction tensions the abductor longus and extensor brevis
° Resisted adduction tests the adductor of the thumb

Fingers
 The intrinsic muscles of the fingers are examined by resisted finger
abduction and adduction
 A strained interosseous muscle can produce pain felt at the wrist if the
proximal part of the muscle is affected
 Resisted extension and flexion of each finger checks the integrity of the flexor
and extensor muscles in the palm and fingers, but for convenience all fingers
may be assessed simultaneously
 Passive flexion and extension can be treated for each joint of each digit.
 In arthritis both movements tend to be equally limited and painful.
 Throughout, the examiner listens and feels for crepitus, a sign of
tenosynovitis or osteoarthritis.

Carpal tunnel syndrome

Lesion
- Compression of the trunk of median nerve under the transverse carpal
ligament
- Idiopathic or frictional cause

Physical signs
- Paraesthesia felt at the palmar aspect of all four digits but not the little finger
- Keeping the wrist in flexed position for a minute & suddenly extending
causes pins & needles

EXTENSOR CARPI RADIALIS TENDONS

Lesion – overuse, lesion lies at the distal half inch of the tendons
Physical signs
- Pain is felt accurately at the dorsum of the wrist
- Resisted extension & radial deviation hurts

Patient position – sitting, arm rests by the side on a pillow over the edge of the couch

Technique
• One hand holding the wrist in flexed position (to stretch the tendon)
 • With the other hand, index finger tip identifies the affected tendon
• Middle finger reinforces the index finger
• Friction is imparted to the tendons by means of horizontal to & fro
movement of forearm & hand
Duration – 20 minutes – 3 times a week

EXTENSOR CARPI ULNARIS TENDON

Lesion – due to overuse, lesion occurs as a part of the tendon between the
metacarpal & cuneiform bones

Physical signs
- Pain is felt at the ulnar side of the wrist
- Reproduced by resisted extension & ulnar deviation
- Radial deviation may produce pain due to stretching of the tendon

Patient in sitting position with forearm placed pronated

Technique
õTherapist facing the patient in standing position
õOne hand grasp the fingers of patient & maintains in full radial deviation at the
wrist
õOther hand grasps the wrist in such a way that the index & middle fingers lie on
the affected tendon & the thumb on the side of the wrist
õFriction is imparted to & fro across the tendon which is attained by alternate
flexion & extension movement at wrist
WRIST JOINT – REDUCTION OF CARPAL SUBLUXATION-I
Lesion – persistent subluxation between the capitate & lunate bones
Physical signs
- Pain is localised to the dorsum of the wrist
- Passive flexion is full & painful
- Extension is 5-10 degrees & it hurts
Patient position – half lying – elbow at right angle, arm is fixed to the couch by an
assistant

Technique
- Therapist leans backwards while having a grasp of the patient’s forearm &
hand
- One thumb lying just above & other below the wrist joint
- By giving traction, the 2 hands are moved vertically up & down in opposite
direction

THE SACROILIAC, BUTTOCK AND HIP

EXAMINATION
 PASSIVE MOVEMENTS
 PASSIVE HIP FLEXION
 PASSIVE MEDIAL ROTATION
 PASSIVE LATERAL ROTATION
 PASSIVE HIP EXTENSION
 SIJ STRETCH – ANTERIOR LIGAMENT
 SIJ STRETCH – POSTERIOR LIGAMENT

RESISTED MOVEMENTS
 RESISTED HIP FLEXION
 RESISTED MEDIAL ROTATION
 RESISTED LATERAL ROTATION
 RESISTED HIP ABDUCTION
 RESISTED HIP EXTENSION
 RESISTED HIP ADDUCTION
  RESISTED KNEE EXTENSION
 RESISTED KNEE FLEXION

 Uncommon cause of pain at the front of the upper thigh

 Passive adduction in flexion is the most painful movement
 Passive lateral rotation usually hurts
 All resisted movements are painless
 The symptoms resembles a loose body in the hip
 Treatment – a solution of 0.5% procaine 50ml is injected

HIP JOINT – FORCED FLEXION

Lesion – Osteoarthrosis of the hip joint in a reasonable early stage

Physical signs
• Restricted movement in the capsular pattern
• There is no or little range for medial rotation & abduction
• Resisted movements are painless
• The more elastic the end feel the better the result of stretching
• In early stages, stretching the capsule often produces relief for many months
or years, but although the pain at night may be abolished, range is not
improved
• Treatment is repeated on return of the symptoms after some months
• Sessions are twice weekly for about a month
• First the joint is sedated by short wave diathermy or other appropriate
modality
• The hip is then flexed as far as it will comfortably go, whereupon it is forced
to further flexion by slowly increasing the pressure at the knee. No jerk is
given
ATo force extension, the patient’s good hip is then put into fullest possible flexion,
thereby raising the bad thigh slightly off the couch
AMaintaining pressure at the good knee, gentle repeated force is exerted
downwards at the lower end of the bad thigh
AWith pauses, physiotherapist keeps this up for 5-10 minutes

Displacements
• A loose body at hip is not always correctly identified
• Displacement is usually secondary to osteoarthrosis
• There is sudden twinges of pain shooting down the front of the thigh with the
leg giving away, often temporarily immobilizing the patient
Manipulation-1
• Patient lies face upwards on a low couch (supine lying)
• An assistant holds the patient’s pelvis down to stop it being lifted by traction
of the operator, who stands on top of the couch grasping the leg at the ankle.
• The manipulator leans back with all his weight and gradually steps off
backwards
• The patient’s leg is slowly extended and during repeated rotation
• The manoeuvre is concluded with a sharp jerk towards one extreme of
rotation range
This final over pressure is given in the direction found most beneficial and thus the
patient is usually manipulated at least 3 times, re-examination follows each attempt

Manipulation - 2
• Usually the last movements to stop hurting are full flexion and full lateral
rotation
• The patient lies face upwards on a low couch
• Pelvis is anchored by an assistant while the operator places the crook of the
patient’s knee over his knee
• The operator then plantiflexes his foot and presses down at the ankle over
the fulcrum of his thigh, thereby exerting traction on the hip

• A single smart rotation is then applied to the hip joint using the tibia as a
lever during continuing traction.

Hamstrings
• These may be affected at the ischial origin, the belly or the knee
• Direct trauma or sudden strain may be responsible and pain intensifies over
24 hours
• Resisted flexion at the knee hurts at the back of the thigh
• Massage is an uphill task because of the tendon’s size and density
• To render it palpable the hip must be supported in flexion
• 2 or 3 fingers exert strong transverse friction by flexion and extension of the
wrist

• On the next visit – massage is given

• The knee is kept flexed to relax the muscle
• The deep friction is extremely tiring and given 5 minutes and 5 minutes off –
over half an hour
• For the first week, sessions are daily and thereafter on alternate days
• The lesion is grasped between thumb and fingers of both hands and the
fingers are flexed and extended while the hands are drawn upwards

Quadriceps
 • Athletes sometimes strain the quadriceps, often the rectus femoris
• Although the vasti may be individually injured calling for deep friction
• Resisted extension of the knee is the primary painful movement
• Full passive flexion or rotation may also pinch or stretch the tissue
• Massage is the treatment of choice

Massage
• The patient half-lies to put the hip joint in flexion and relax overlying tissues
• The rectus femoris tendon is about 8cm below the anterior spine of the ilium
and 2 fingers are laid firmly on the lesion with friction applied using the
thumb for counter-pressure
• Treatment lasting for 20 minutes twice a week should ensure recovery in a
month or less

Adductor longus Muscle

Lesion – traumatic cause (sudden over contraction – during football, in case of

ballet dancers)

Physical signs
- Full passive abduction may hurt
- Resisted adduction is painful
- Tenderness +ve at tenoperiosteal junction, musculotendinous junction &
uppermost part of the belly

Patient position – half lying position, somewhat in abduction & lateral rotation

Technique
- One hand grasps the affected area of the muscle between his thumb & index
and middle fingers
- Friction is imparted by drawing the hand medially
Duration of Treatment – 20 minutes – twice a week – 3 to 4 weeks treatment may be
required

THE KNEE JOINT

PASSIVE MOVEMENTS
• PASSIVE FLEXION
• PASSIVE EXTENSION
• VALGUS STRAIN
• VARUS STRAIN
• PASSIVE LATERAL ROTATION
• MEDIAL ROTATION
• FORWARD SHEARING
• BACKWARDS SHEARING
• LATERAL SHEARING

 The 2 primary passive flexion and extension evaluates the joint capsule
 Capsular pattern is greater limitation of flexion than extension
 The normal end feel – on flexion it is soft and on extension fairly hard
 Seven passive movements following the above – tests the ligaments not only
for pain but also for laxity
 Valgus strain applied in slight flexion – opens the inner side of knee – pain
elicited indicates a sprain of the medial collateral ligament
 Varus strain – opens the outer side of the joint – testing lateral collateral
ligament

• Painful passive lateral rotation incriminates medial coronary ligament

• Pain on Passive medial rotation – suggests a lesion at the lateral coronary
ligament
• Pain on forwards shearing implicates anterior cruciate ligament lesion
• Straining the tibia backwards on the femur stretches the posterior cruciate
ligament

RESISTED MOVEMENTS

# RESISTED FLEXION
# RESISTED MEDIAL ROTATION
# RESISTED LATERAL ROTATION
# RESISTED EXTENSION

• Resisted flexion – tests the hamstrings

• Resisted medial rotation – suggests a lesion of semimembranosus,
semitendinosus or popliteus muscles
• Resisted extension – tests the quadriceps

Ligamentous lesions – general principles

Stage – 1
 a sprain to a ligament is accompanied by a secondary traumatic arthritis for
1-2 weeks
Stage – 2
traumatic arthritis has subsided, but the lesion must not be allowed to heal in
immobility, otherwise small adhesions build up at the site of tear, binding ligament
to bone. Lasts for a further 4-6 weeks
Stage – 3
- tear to the ligament is healed

- in this chronic stage, there are no symptoms on

normal use but attempts at exertion are frustrated by
recurrent pain and swelling

- minor laxity following a sprain seldom causes

disability in those with a sedentary lifestyle

- surgical opinion should be sought

Treatment
Stages 1 and 2
• Massage is given, gently moving the ligament over bone to inhibit the
formation of adhesions
• Forcing the joint towards extension is strongly contraindicated, but after the
first week or so the massage is given more strenuously and accompanied by
gentle encouragement of movement
Stage 3
Manipulative rupture of the adhesion is normally only necessary or feasible at the
collateral ligaments

Medial collateral ligament

• Commonest ligamentous disorder in the entire body
• History is of valgus strain
• At first patient can walk, but within half-an-hour he can only hobble with
assistance
• 2 weeks after injury the arthritis starts to abate and after 3 months-if
untreated the symptoms are of an ache following exertion
• Except in the chronic stage – treatment is deep friction
• The ligament is never injected with steroid

 The medial collateral ligament is first massaged in maximum comfortable

flexion
 Then massage is given in comfortable extension
 Massage in flexion is administered to the site of the lesion with strong
transverse pressure
  The ligament lies roughly in line with the longitudinal axis of the tibia and
accordingly the sweep of the fingers is diagonal rather than vertical
 For massage in extension the ligament is horizontal; the massage is thus
straight up and down
 Treatment lasts for 20-30 minutes given daily for the first few days

The coronary ligaments

• These attach the two menisci to the circumference of the tibial plateau
• Rotation strain may overstretch one of the coronaries with or without
accompanying tear on the meniscus
• Medial ligament is more frequently damaged than the lateral
• The precise location is sought by palpation for tenderness with the knee well
bent
• Massage is highly effective
• Sessions last 15-20 minutes daily for the first week and later on alternate
days
• The friction must be directed downwards onto the tibial plateau

• The finger is pulled to and fro across the site of the sprain with the index
fingernail lying horizontally and uppermost
Displacements
Manipulation – 1
In prone lying - Operator hooks the patient’s foot – pulls upwards while an assistant
presses heavily downwards on the thigh to open the joint

Distracting force is maintained as the operator removes the foot from the couch and
then smartly extends and repeatedly rotates the knee using the foot as a lever

Re-examination

Manipulation –2
If flexion remains limited, the next method to try is rocking the tibia on the femur
simultaneously forcing rotation (half lying) – assistant’s forearm is placed in the
popliteal space

Manipulation –3
The operator works single handed as before but omits rotation

Manipulation – 4
The patient half lies, with the leg in slight flexion and the operator applies varus
pressure.
The subject co-operates actively by extending her knee. A small jerk is encouraged
at full extension
 KNEE JOINT – REDUCTION OF IMPACTED LOSSE BODY

Contractile structures – the extensor mechanism

Painful resisted extension may stem from a lesion of the rectus femoris, the
quadriceps belly, the quadriceps expansions, the suprapatellar or infrapatellar
tendon
The last 2 may respond to both massage and injection

Suprapatellar tendon
• The patient relaxes her quadriceps
• One hand presses downwards on the lower pole of the patella – this lilts the
upper border of the patella upwards and raising the lesion into prominence
The principle of massage
• The web of 1 hand presses down on the lower edge of the patella while
transverse friction is administered by the other hand in supination
• The pressure is angled distally and anteriorly to catch the fibres against the
upper pole of the patella
• The hand must not be held in pronation pressing downwards only; this rubs
the wrong part of the tendon
• The massage is very tiring and is given for 20 minutes on alternate days with
recovery in under a month.
Infrapatellar tendon
• Strain of the infrapatellar tendon is commoner than that of suprapatellar
• The patient relaxes her quadriceps
• Alteration in the angle of the patella is again achieved by downwards
pressure of the operator’s free hand, but this time it is brought to bear on the
upper edge of the patella thus swinging the lower edge upwards

• The free hand tilts the patella while the operative finger, reinforced by its
neighbour, presses hard upwards against the tenoperiosteal junction
• The hand is in supination and the whole arm moves to and fro
• Sessions last about 20 minutes on alternate days and recovery takes
anywhere between 2 – 6 weeks

Quadriceps expansion
The lesion may lie either side of the patella at the junction between the patella and
the expansion
The only effective treatment is massage for 2 – 3 weeks on alternate days
The first step is for the operator to push the patella towards the affected side using
the thumb.
This allows the operative finger of the other hand to wedge itself right under the
now projecting edge; the hand is held upwards so that the fibres are massaged
against the posterior surface of the patella by drawing the finger back and forth
THE PLANTIFLEXORS
• Sprain of the gastrocenemius is the commonest muscle lesion in the leg
• Pain on resisted plantiflexion puts strain on both gastrocnemis and soleus
• But they can be distinguished by resisted plantiflexion with the knee flexed

Treatment consists of 3 co-ordinated measures – local anaethesia, massage and

raised heel

Treatment
The fingers are placed on the affected area and the friction imparted by drawing the
hand to and fro horizontally

In chronic cases relief may take up to a month

Meanwhile a heel raise is fitted to the inside of the sole to compensate for the
limitation of dorsiflexion

THE TENDO ACHILLIS

The pain is at the back of the heel

Standing tip toe hurts
Resisted plantiflexion is normally the only other painful movement

Massage is the treatment of choice

 
Sessions lasts for 20 minutes on alternate days with 3 week recovery in appropriate
cases 

For the lateral and medial aspects of the tendon the patient’s foot projects over the
edge of the couch and dorsiflexion is maintained by the operators knee

The tendo achillis is then squeezed firmly between finger and thumb and friction is
applied simultaneously to both sides by drawing the hand up and down

It is hard work and the operator may wish to change hands mid session
For the anterior aspect the foot is fully plantiflexed to relax the tendon so it can be
pushed sideways by the free hand
Friction is delivered by supination and pronation of the forearm with upwards
pressure maintained by elbow flexion.
 
The finger hand and forearm are held in line with the patient’s lower leg

THE EVERTOR MUSCLES - PERONEI

THE INVERTOR MUSCLE – TIBIALIS POSTERIOR

THE INVERTOR MUSCLE – TIBIALIS POSTERIOR (Distal part)

ANKLE & FOOT
PASSIVE DORSIFLEXION
PASSIVE PLANTIFLEXION
PASSIVE INVERSION
PASSIVE EVERSION
VARUS STRAIN – TALOCALCANEAN JOINT
VALGUS STRAIN

THE MID TARSAL JOINT

PASSIVE DORSIFLEXION
PLANTIFLEXION
ADDUCTION
ABDUCTION
MEDIAL ROTATION
LATERAL ROTATION

LIGAMENTOUS SPRAINS

• The anterior talofibular ligament

• Calcaneofibular ligament
• Anterior talofibular ligament
• Calcaneocuboid ligament
• Peroneal tendons
• Extensor longus digitorum
• Anterior talotibial ligament

The talocalcanean/sub-taloid joint and heel

Capsular lesions
Non capsular lesions
Dancer’s Heel
Immobilization limitation
Subcutaneous nodules
Plantar fascitis
SPRAINED ANKLE – FIBULAR COLLATERAL LIGAMENT

SPRAINED ANKLE – CALCANEO CUBOID JOINT

SPRAINED ANKLE - MANIPULATION

ANKLE JOINT – REDUCTION OF LOOSE BODY

 THE SPINE

PRINCIPLES OF EXAMINATION

MOBILITY

CONDUCTION

MOBILITY AND CONDUCTION

THE JOINTS

THE ZYGAPOPHYSEAL JOINTS

INTERVERTEBRAL PRESSURE

SPINAL MANIPULATION
THE CERVICAL SPINE
EXAMINATION
ACTIVE EXTENSION
BILATERAL ACTIVE SIDE FLEXION
BILATERAL ACTIVE ROTATION
ACTIVE FLEXION

PASSIVE EXTENSION/ SIDE FLEXION/ ROTATION

RESISTED MOVEMENTS
EXTENSION/SIDE FLEXION/ROTATIONS/FLEXION

OTHER EXAMINATION
ACTIVE SHOULDER GIRDLE ELEVATION
RESISTED SHOULDER GIRDLE ELEVATION
T1 & T2 STRETCH (RETRACTION)
DURAL STRETCH ( PROTRACTION)
ACTIVE ARM ELEVATION

RESISTED ABDUCTION
RESISTED ADDCUTION
RESISTED MEDIAL ROTATION
RESISTED LATERAL ROTATION
RESISTED ELBOW FLEXION
RESISTED ELBOW EXTENSION

MANIPULATION – STARIGHT PULL

MANIPULATION – CERVICAL ROTATION

MANIPULATION – CERVICAL LATERAL FLEXION

 MANIPULATION – AP GLIDE

THE THRORACIC SPINE

EXAMINATION
NECK FLEXION
SCAPULAR APPROXIMATION
T1 STRETCH
ACTIVE EXTENSION
ACTIVE SIDE FLEXION
ACTIVE ROTATION
ACTIVE FLEXION

RESISTED ROTATION
RESISTED SIDE FLEXION
RESISTED FLEXION
RESISTED EXTENSION

EXTENSION DURING TRACTION – Patient in prone, 2 assistants to apply

traction from either sides, therapist applying AP glide

ROTATION DURING TRACTION – patient in prone – 2 assistants to give traction

from either sides – therapists one hand on shoulder & other hand over the ASIS –
opposite trunk movement is performed
 THE LUMBAR SPINE

EXAMINATION CONDUCTED FOR

BONE SIGN
JOINT SIGN
DURAL SIGN
NERVE ROOT MOBILITY
NERVE ROOT CONDUCTION

LUMBAR SPINE – FORCED EXTENSION (CENTRAL)

LUMBAR SPINE – ROTATION STARIN

LUMBAR SPINE – REVERSE STRETCH