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)

I. 0-25% avail range, small amp, beginning ROMII. 0-50% avail range, large amp, beginning to mid ROM

III. 50-100% avail range, large amp, mid to end ROMIV. 75-100% avail range, small amp, end ROM

Grades for DistractionsI. Bunched skin

II. Bunched skin and take up tension in capsuleIII. Bunched skin, take up tension, stretch

Normal End Feels1. Normal Capsule- Firm arrest, CREEP2. Normal ligament- Firm arrest, NO CREEP3. Normal cartilage- Hard/rigid, sudden stop4. Normal muscle S.T approx.- soft and spongy5. 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.symptomw/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

Pull thigh inferior-lateral. Do not rotate body, use arm and drive with front leg. Maintain firm

Normal capsule/ ROM

CM for hip ADD and flexion.

axis distr.

tucked stabilization.

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

Stand on same side of table

Stabilize/support lower leg in 20 flex.

Palm on medial surface of tibia.

Push down (anteriorly) forearm // to

Normal cap, normal

CM for tibial ER and knee extension

knee flex). treatment plane ROM

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 glide2:1 (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 glide2:1 (lateral = 1)p.178

Supine, heel off table

Sit Find STN. “thumbless” lumbrical grip on talus with pressure from middle and ring

Key pinch medial/lateral calcaneus. Start with elbow adducted.

Pull elbow out “chicken wing”

CM for rearfoot pronation

fingerTalus 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 forPatrick’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.772Supine 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

Anterior instability (one plane). ACL injury, especially anteromedial

sign) 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 ConfirmaitonGreater 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 MCLMeniscusITB Insertion at Gerdy’s tube. Runs up btwn VL and hamsMed/lat jt lines Thin gap btwn tibia and femurPatellar lig Thick lig under patellaTibial tubercle Big bump just below patella femoral ligLateral tibial condyle Have pt knee 90. On either side below patellaMedial tibial condyle Have pt knee 90. Gurdy’s tubercle Bump on lateral tibial condyleFibular head On lateral proximal portion of lower leg IR/ER lower leg to feel fib head rotateBiceps femoris Only tendon on lateral side of posterior kneeLateral/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

LCLMCL (stress at 0 and 30)Lateral meniscusMedial meniscus w/ IR/ERPes anserine tendon On medial knee around where knee bendsATFL Btwn lateral malleolus and talus Plantarflex and invert footCFL Below and posterior to lateral malleolusDorsalis pedis a. Btwn big toe and 2nd toe, just inferior to ankle jt

Neck of talus (med and lat) Have pt PF. Btwn both malleolisSinus taris Gap below lateral malleolusBase of 5th met (peroneus brevis attachment site)

Bump on 5th met

Navicular tuberosity High arch bone

MMT For knee flexors have pt seated, rest pt’s foot on your knee. LP= 20 knee flexion Same position for knee extensors, except move your leg before applying force

Loose packed position Therapist position

Contact Procedure

Knee flexors (medial/lateral hams, popliteus)

20 knee flexion Seated 2 finger contact to posterior mid/lower leg

Apply 3-5 lbs pressure/force toward extension

Lower leg ER (lateral hams) 20 knee flexion Seated 2 finger contact to lateral-posterior mid/lower leg

Apply 3-5 lbs pressure/force toward IR and

Lower leg IR (medial hams, popliteus)

20 knee flexion Seated 2 finger contact to medial-posterior mid/lower leg

Apply 3-5 lbs pressure/force toward ER and

Knee extensors (quads) 20 knee flexion Seated 2 finger contact to anterior mid/lower leg

Apply 3-5 lbs pressure/force toward flexion