Manipulation (pgs found in E1 manual)

  • Treatment plane is ALWAYS referenced to the CONCAVE surface
  • Direction of force is either parallel(glide) or perpendicular(distraction) to the treatment plane
  • Forearm should be in line with the direction of force applied (applied w/gravity whenever possible)
  • Force needs to be as close to the joint line as possible
  • Convex on concave= glide is opposite direction of movement of limb
  • Concave on convex= glide is same direction as movement of limb
  • Distractions do not follow roll and glide rule (force always perpendicular to treatment plane)
  • To find sub-talar neutral (STN) 3 options. Palpate dome of talus and place thumb and index finger over lateral and medial edges to feel for congruency. 1. Grasp 5th ray and dorsi/plantar flex (sagittal). 2. Grasp calcaneus and move into inversion/eversion (frontal). 3. Grasp midfoot, move into pronation/supination.
  • Drape for every joint mob.

Grades for Glides(Oscillations)

  1. 0-25% avail range, small amp, beginning ROM
  2. 0-50% avail range, large amp, beginning to mid ROM
  3. 50-100% avail range, large amp, mid to end ROM
  4. 75-100% avail range, small amp, end ROM

Grades for Distractions

  1. Bunched skin
  2. Bunched skin and take up tension in capsule
  3. Bunched skin, take up tension, stretch

Normal End Feels

  1. Normal Capsule- Firm arrest, CREEP
  2. Normal ligament- Firm arrest, NO CREEP
  3. Normal cartilage- Hard/rigid, sudden stop
  4. Normal muscle S.T approx.- soft and spongy
  5. Normal muscle stretch- elastic, slow

Manipulation / Pt pos. and Loosepack
(3pts) / Ther pos. and palp jt alignment
(2pt) / Stabilize
Hand
(2pts) / Manip Hand
(2pts) / Force
Direction +Amount (3pts) / End feel/ Comm.
symptom
w/pt (3pts) / Use
Long Axis Distraction p208
/ Pt supine, no pillow, sock off, diaper drape. LP= 20-30 hip flexion, slight ABD / Therapist at foot of bed. Palpate knee for alignment. / Ask assistant to stand on opposite side and stabilize ASIS by first sliding skin down with palms and then push down and up. / With both hands, grasp lower leg (above malleoli) Forearm aligned with lower leg, tuck elbow and stagger stance (A/P) / Tug leg keeping forearms and direction of force in line with pt’s leg. / Normal capsule. Normal ROM / JP for all movements at hip.
Inferior Glide p212
/ Pt. supine at edge of table. Drape. / Rest pt’s posterior knee on your shoulder. Power AP stance. Pt hip flexed to 90. / Stabilize ASIS-(contact skin) / Slide hand down ant thigh close to hip jt (warn pt) and cradle thigh against body. Lumbrical grip. Keep elbow tucked / Pull thigh inferior. Drive with front leg (and shoulder slightly). Keep firm stabilization on ASIS. Keep hip flexed at 90. (Able to use both hands for bigger pt’s) / Normal capsule. Normal ROM / CM for hip flexion
Inferior-lateral stretch/glide p.213
/ Pt. supine at edge of table. Drape / Rest posterior knee on your shoulder. Power AP stance. Pt hip flexed to 90. / MUST Stabilize ASIS (contact skin) / Slide hand down ant thigh close to hip jt (warn pt) and cradle thigh against body. Lumbrical grip. Keep elbow tucked / Pull thigh inferior-lateral. Do not rotate body, use arm and drive with front leg. Maintain firm stabilization. / Normal capsule/ ROM / CM for hip ADD and flexion.
Inferior-medial stretch/glide p.214
/ Pt. side lying. 20-30 hip ABD and slight flexion. / Stand behind pt. (keep table low) / Hand under medial knee to support leg. / Manip hand on top of greater trochanter. / Push medial and inferior / Normal capsule/ ROM / CM for hip ABD and flexion.
Medial/lateral glide of patella p.145
/ Pt. supine. LP= 3 options hyperextend (towel roll under ankle), neutral (no roll), flexed (roll under knee) / Stand on lateral side of leg. / Four fingers of both hands above and below patella on anterior surface of leg. / Both thumbs on lateral surface of patella (medial surface for lateral glide) / Push medially/laterally keeping forearm in line with direction of force / Normal capsule/ ROM / JP for knee flexion, extension. Tibial IR and ER.
Superior/inferior glide of patella p.144
/ Same as medial/lateral glide / Stand facing pt for superior glide, facing foot for posterior glide / Hand/fist on table (optional) / Web space on inferior surface of patella for superior glide. (Superior surface for inferior glide) / Superior/inferior force keeping forearm in line with tibia. / Normal capsule/ ROM / Superior glide= CM for knee extension.
Inferior glide= CM for knee flexion
Tibio femoral distraction p.148 / Pt. supine, calcaneus over edge of table. LP= 20 knee flex(wedge/roll) / Stand at foot of table / Use aid to stabilize anterior distal femur. / Wrap hands around lower leg, above malleoli. TUCK ELBOWS / Pull inferiorly, forearms in line with tibia. / Normal capsule/ ROM / JP for knee flexion, extension. Tibial IR and ER
Posterior tibial glide p.152
/ Pt. supine, calcaneus over edge of table. LP= 20 flex(wedge/roll) / Stand at side of leg. / Stabilize anterior-distal surface of femur. / Web space over anterior tibia just below knee / Push posteriorly, position forearm // to treatment plane / Normal capsule/ ROM / CM for knee flexion
Anterior tibial glide p.157
/ Pt. PRONE. Hold in LP (20 knee flex). Wedge/towel under distal femur / Stand at side of leg / Stabilize and support by grasping anterior-distal tibia / Grasp proximal tibia (below knee) / Push anteriorly, position forearm // to treatment plane / Normal capsule/ ROM / CM for knee extension
Anterior glide of lateral tibial condyle p.158
/ Pt. PRONE. Thigh on wedge.
Hold in LP (20 knee flex). / Stand on opposite side of table / Stabilize/support lower leg in 20 flex. / Palm on lateral surface of tibia. / Push down (anteriorly) forearm // to treatment plane / Normal cap, normal ROM / CM for tibial IR and knee flexion
Anterior glide of medial tibial condyle p.159
/ Pt. PRONE. Thigh on wedge. Hold in LP (20 knee flex). / Stand on same side of table / Stabilize/support lower leg in 20 flex. / Palm on medial surface of tibia. / Push down (anteriorly) forearm // to treatment plane / Normal cap, normal ROM / CM for tibial ER and knee extension
Posterior glide of lateral tibial condyle p.155
/ Pt. supine. Thigh under wedge. Heel off table / Stand on opposite side of table / Stabilize anterior distal thigh / Palm on lateral surface of tibia / Push down (posteriorly) forearm // to treatment plane / Normal cap, normal ROM / CM for tibial ER and knee extension
Posterior glide of medial tibial condyle p.154
/ Pt. supine. Thigh under wedge. Heel off table / Stand on same side of table / Stabilize anterior distal thigh / Palm on medial surface of tibia / Push down (posteriorly) forearm // to treatment plane / Normal cap, normal ROM / CM for tibial IR and knee flexion
Anterior glide of talus p.175 / Pt. PRONE. Wedge under distal leg / Stand on same side of table / Find STN. Stabilize tib-fib (watch for knee bend during manip) / Web space around post. talus. Contact ant talus with thumb and fingers / Push down (anteriorly) through talus. Forearm // to treatment plane / Normal cap, normal ROM / CM for talocrural plantarflexion and rearfoot supination
Posterior glide of talus p.174
/ Pt. supine. Wedge under distal leg / Stand on same side of table / Find STN. Stabilize tib fib (watch for knee bend during manip) / Web space around anterior talus. / Push down (posteriorly) through talus. Forearm // to treatment plane. / Normal cap, normal ROM / CM for talocrural dorsiflexion and rearfoot pronation
Lateral glide of talus p.177
/ Pt. supine. Place foot on opposite shoulder of manip hand / Sit / Find STN. Block distal fibula / Thumb contacts medial neck of talus. Fingers relaxed on ankle. Keep elbow up / Push laterally, forearm in line with force / Normal cap, normal ROM / CM for talocrural plantarflexion and rearfoot supination
Medial glide of talus p.177 / Pt. supine. Place foot on opposite shoulder of manip hand / Sit / Find STN. Block distal tibia / Thumb contacts lateral neck of talus. Fingers relaxed on ankle. Keep elbow up / Push medially, forearm in line with force / Normal cap, normal ROM / CM for talocrural dorsiflexion and rearfoot pronation
Calcaneus medial arc glide
2:1 (medial = 2)
p. 178 / Supine, heel off table / Sit / Find STN. “thumbless” lumbrical grip on talus with pressure from middle and ring finger / Key pinch medial/lateral calcaneus. Start with elbow adducted. / Pull elbow out “chicken wing” / CM for rearfoot supination
Calcaneus lateral arc glide
2:1 (lateral = 1)
p.178 / Supine, heel off table / Sit / Find STN. “thumbless” lumbrical grip on talus with pressure from middle and ring finger / Key pinch medial/lateral calcaneus. Start with elbow adducted. / Pull elbow out “chicken wing” / CM for rearfoot pronation
Talus distraction p.171
/ Supine. Heel off table / Stand at foot of be and raise table / Ask aid to support anterior distal tibia. / Both little fingers contact anterior talus. Interlace other fingers (or lumbrical grips) around foot. Thumbs on plantar surface. Forearms tucked in. / Lean back using body weight / Normal cap, normal ROM / JP for all movements of talocrural and subtalar jt
Big toe MTP plantar/ dorsal glide p.195
/ Pt. supine. Foot flat on wedge, metatarsal head off wedge / Stand on same side as foot / Stabilize dorsal-distal foot / Place toe in extension. Thumb just distal to jt surface on dorsal toe. / Push down (plantar glide). Pull up (dorsal glide). Keep forearm // treatment plane / Cartilagenous end feel for posterior/ plantar glide / Plantar glide CM for MTP PF
Dorsal glide CM for MTP DF
Big toe MTP distraction p.194
/ Pt. supine. Foot flat on wedge, metatarsal head off wedge / Stand on same side as foot / Wrap fingers around mets. / Pinch grip big toe close to jt. / Bunch skin and pull. Forearm perp to jt / Normal cap, normal ROM / JP for all classical movements of MTP
1st TMT plantar/ dorsal glide p.184

USE WEDGE! / Pt. supine. Foot halfway on wedge (Cuneiform off wedge) / Stand on same side as foot / Slide fingers btwn wedge and arch of foot and stabilize / Thumb pad on dorsal surface of base of 1st met / Push down (plantar glide). Pull up (volar glide). Forearm // treatment plane / Normal cap, normal ROM

Special Tests- Pgs found in Magee

Special Test / Pt Position / Procedure / + sign / Tests for
Patrick’s (FABER) p.680
/ Supine / Cross affected leg over opposite knee (figure 4). Slowly lowers knee toward table, apply slight over-pressure. / Pain, knee remains above the straight leg. / Hip pathology (very general test)
Quadrant (Scouring)p.706
/ Supine / Passively fully flex hip and knee towards opposite shoulder (ADD). Hands on knee. Apply pressure through the femur. Rotate femur into ABD and back to ADD / Pain, apprehension, irregular movements “bumps” / Hip pathology(look for location of pain/irregular movements)
Craig Test p.681-682
/ Prone / Palpate greater trochanter. Flex knee to 90. IR hip (move tibia laterally). Feel where greater troch pops out on hand most. Measure angle. Fulcrum = knee. Stationary= perpendicular to table (vertical). Moving= tibia (between malleoli) / + = angle greater than 15 degrees / Femoral anteversion (NOT retroversion)
FADDIR Test p.681
/ Supine / Start pt in full hip flexion, ABD, ER (one hand around ankle, other on knee). Then take pt to full ADD and IR (maintain full hip flexion) / + = pain, clicking / Anterior/ superior impingement syndrome, anterior labral tear, iliopsoas tendinitis.
Posterior Labrum/Labral Test p681
/ Supine / Start pt in full flexion, ADD, IR (one hand around ankle, other on knee). Then take pt to full ABD and ER (maintain full hip flexion) / + = Groin pain, apprehension, clicking / Posterior labral tear, anterior hip instability, post/inferior impingement.
Valgus stress test p.763
/ Supine, hip and knee extended / One hand on lateral knee, other around medial ankle. Push knee medially while stabilizing ankle (counter force). If (-), flex knee to 30 by taking lower leg off table, keeping thigh on table. Repeat valgus stress to knee. / + = excessive medial knee deviation / Medial knee instability
Varus stress test p. 767
/ Supine, hip and knee extended / One hand on medial knee, other around lateral ankle (counter force). Push knee laterally while stabilize ankle. If (-), flex knee to 30 by taking lower leg off table, keeping thigh on table. Repeat varus stress to knee. / + = excessive lateral knee deviation / Lateral knee instability
Stable Lachman p.769
/ Supine with back of knee resting on therapists knee / Place your knee on table with pt’s leg resting on top. Stabilize top of distal femur. Other hand under proximal tibia (thumb on anterior tibia). Apply quick pull up on tibia (anterior stress). / + = excessive anterior knee deviation / ACL injury, especially posterolateral band
Anterior Drawer p.772
/ Supine w/foot flat on table / Sit on pt’s foot to stabilize. Wrap fingers around posterior knee, thumbs on anterior knee, Pull anteriorly quickly / + = tibia moves forward more than 6mm (coupled with negative posterior sag sign) / Anterior instability (one plane). ACL injury, especially anteromedial bundle. (Additional structures listed on pg 771)
Posterior Drawer p. 772
/ Supine w/foot flat on table / Same as anterior drawer except push tibia posteriorly. / + = excessive posterior deviation / Posteriorly instability (one-plane). PCL (Additional structures listed on pg 772)
Posterior sag sign p. 773
/ Supine with both feet flat on table / Visual observation. / + = tibia “drops back”/ sags on the femur / PCL instability, torn PCL
Godfrey test p.774
/ Supine / Hold both legs, hip 90 knee 90 / + = Posterior sag of the tibia / Posterior instability
Reverse Lachman p.774 / PRONE, knee flexed to 30 / Stabilize posterior-distal thigh. Grasp proximal tibia w/other hand and hold between arm and body. Pull up (posteriorly). / + = excessive posterior deviation / PCL instability
Lateral pivot shift p.776
/ Supine w/hip flexed and ABD 30, slight IR. Knee flexed 90. / Hold pt in test position by supporting foot (under calcaneus) with one hand, other hand behind fibula (heel of hand under lateral gastroc head) causing IR of leg. Hold tibia in IR as you extend knee. Then apply valgus stress to knee and flex knee to 30-40 / + = subluxation at extension. Tibia reduces/”jogs” backward when flexed. / ACL ruptures (3rd degree sprain), anterolateral rotary instability
McMurray test p.791
/ Supine w/knee fully flexed. Hip flexed 90. / IR tibia, then extend knee to test lateral meniscus. Repeat with ER of tibia to test medial meniscus. / Pain, snapping, clicking / Meniscus lesions
Apley’s Test p.791
/ PRONE w/knee flexed to 90. / Place your knee on pt’s thigh. Wrap both hands around ankle, lift (distract) and rotate medially and laterally. Then push down (compress) and rotate med/lat. / + = Pain / Meniscus lesion of + with compression. Ligamentous if + with distraction
Plica “stutter” test p.795 / Seated with leg off table / Place finger over medial patella. Instruct pt to slowly extend / + = patella stutters/jumps btwn 45-60 flexion / Presence of plica remnants
Brush test p796
/ Seated, knee extended / Sweep medial side of patella upward 3 times. Then downward on lateral side of patella w/opposite hand. / + = extra wave of fluid bulging on medial knee / Swelling in knee (minimal effusion)
Indentation test p.797 / Supine, knee extended. / Passively flex knee, watch for indentation on the lateral side of the patellar tendon to disappear (should not disappear in normal knee). Observe good leg 1st / + = indentation disappears (sooner indentation = greater the swelling / Swelling in knee
Patellar tap test p.798 / Supine, knee extended / Tap patella to push fluid down. / + = floating/dancing patella / Swelling in knee
Patellar grind/ compression test p.798 / Supine, knee extended / GENTLY press patella down. Have pt contract quad / Pain / Patellofemoral dysfunction
Noble compression test p.803
/ Supine / Passively flex knee to 90. With thumb, apply pressure 1 cm proximal to lateral femoral epicondyle and passively extend knee (maintaining pressure). / + = severe pain at 30 flexion (pt states same pain occurs w/activity) / IT band syndrome
Anterior drawer (ankle) p.888
/ Pt supine, heels off table. / Stabilize anterior distal tib-fib with one hand. Cup calcaneus with other. Quickly pull up on heel / + = pain, excessive anterior deviation / ATFL injury
Homan’s sign p.897
/ Supine, knee extended / Passively dorsiflex foot with hand under heel and bottom of foot against forearm. (make sure knee is extended) Stabilize distal tib fib. / + = pain in calf / DVT
Tinel’s sign p. 896 / Supine / Tap front of ankle (deep peroneal n.) Tap behind medial malleolus (posterior tibial n.)
/ + = tingling/ paresthesia / Deep peroneal n./ posterior tibial n.
Thompson’s test p.894
/ PRONE / Squeeze calf / Absence of PF / Achilles tendon tear (3rd degree)

Palpation

  • Use one finger to identify

Structure / Location / Confirmaiton
Greater trochanter / Pt prone. Flex knee and IR/ER leg to feel GT rotate (expose skin) / Moves with IR/ER of leg
Ischial tuberosity / Pt prone. Drape. Take heel of hand to gluteal fold and apply pressure.
ASIS / Supine. Drape. Have pt tuck towel and expose ASIS. Use thumbs and roll up in ASIS
Adductor tubercle / Superior attachment to MCL
Meniscus
ITB / Insertion at Gerdy’s tube. Runs up btwn VL and hams
Med/lat jt lines / Thin gap btwn tibia and femur
Patellar lig / Thick lig under patella
Tibial tubercle / Big bump just below patella femoral lig
Lateral tibial condyle / Have pt knee 90. On either side below patella
Medial tibial condyle / Have pt knee 90.
Gurdy’s tubercle / Bump on lateral tibial condyle
Fibular head / On lateral proximal portion of lower leg / IR/ER lower leg to feel fib head rotate
Biceps femoris / Only tendon on lateral side of posterior knee
Lateral/medial femoral condyle / Have pt knee 90. On either side of middle patella
Lateral/medial femoral epicondyle / Have pt knee 90. On either side superior to patella
LCL
MCL (stress at 0 and 30)
Lateral meniscus
Medial meniscus w/ IR/ER
Pes anserine tendon / On medial knee around where knee bends
ATFL / Btwn lateral malleolus and talus / Plantarflex and invert foot
CFL / Below and posterior to lateral malleolus
Dorsalis pedis a. / Btwn big toe and 2nd toe, just inferior to ankle jt
Neck of talus (med and lat) / Have pt PF. Btwn both malleolis
Sinus taris / Gap below lateral malleolus
Base of 5th met (peroneus brevis attachment site) / Bump on 5th met
Navicular tuberosity / High arch bone

MMT