Proximal Tendon, Distal Muscle; Proximal Muscle, Distal Tendon

By Joseph D. Kurnik, DC

The concept expressed in the title means that a hypertonic (overly contracted) muscle will shorten. In so doing, there will be a pull or tug at the origin and insertion points of the muscle: tendons. 
Sustained pulling of tendons can result in tendon irritation or inflammation, either proximally or distally.

Examples of this concept can apply to muscles associated with spinal, occipital and pelvic attachments. For example, consider the following muscles: 

1. levator scapula
2. sternocleidomastoid
3. trapezius
4. rhomboids

Each of these muscles has spinal attachments. At this point, the concept enlarges. Dr. Irvin Korr spoke of the concept of "segmental facilitation." Dr. Korr was a physiologist whose work involved the relationship of muscles to their spinal attachments. The results of his experiments showed that muscles attached to dysfunctional spinal vertebrae underwent changes in irritability and contractility, becoming more irritable and contracted. Thus, spinal fixation can cause shortening of attached muscles, causing symptoms in those muscles and their tendonous attachments, proximally or distally.

The levator scapula is a great example of this concept. It attaches to the first four vertebrae of the cervical spine and the upper medial scapula. Levator pain is a common finding in chiropractic practice. It is commonly related to occiput/C-1, C-1/C-2 and C-2/C-3 dysfunctions. Practicing doctors everywhere must have witnessed the frequent disappearance of levator symptoms with upper cervical adjusting. If, however, the problem of levator irritation has gone on too long, the levator may need more direct treatment to reduce muscular contraction and irritation/inflammation at the tendonous attachments. For example, the levator may have to be treated with electrotherapy, massage and ultrasound. Stretching may also be required.

Interestingly, problems with the infraspinatus muscle may accompany this hypertonic contraction of the levator scapula muscle. The infraspinatus also commonly presents with hypertonic status, requiring softening techniques to reduce muscle shortening. Trigger points with this hypertonic muscle can create a variety of symptoms, such as shoulder pain, shoulder stiffness/decreased ROM in several directions (especially lateral abduction and medial adduction), anterior shoulder pain, cervical pain, and arm and wrist pain.

Other common muscle reactions accompany AS ilium fixations. These reactions involve hypertonic and overly contracted muscles, causing muscle and associated tendon complaints. Examples of these are: gluteal muscles (hip extensors), hip flexors (especially the rectus femoris, TFL, and gracilis), and hamstrings.

The mechanisms of muscular hypertonicity with these muscles are different than with the muscles with spinal attachments. With these pelvis-attached muscles, the mechanism appears to reflect overuse: The muscle gets overused and begins to resist overusage by contracting. When the ilium does not rotate posteriorly during hip flexion (e.g., walking, running), a sequela of events occurs: 

1. Gluteals become overstretched, due to increased hip motion at the acetabulum. Eventually, complaints may develop in these gluteal tissues, in the muscle fibers or at the tendonous attachments on the ilium, sacrum or femur. Release of the muscular contraction through AS ilium correction, muscle massage, ultrasound or stretching will eliminate the complaints.
2. Hip crepitus can occur, due to increased compensatory femur head activity, leading to irritation/inflammation and increased wear of the hip joint. This irritation can spread to the tendonous attachments at the femur head, or a facilitation process of gluteal muscles may be involved.
3. Hip flexors develop hypertonicity, because their antagonists (the hip extensors, or gluteal muscles) have become shortened and resistant to relaxation during hip flexion. The common complaints seen here are:

1. anterior thigh pain, associated with rectus femoris strain;
2. anterior/medial thigh pain, associated with gracilis strain;
3. lateral pelvic pain, superior to the femur head, associated with the TFL;
4. lateral thigh complaints, associated with the TFL;
5. groin complaints, associated with the tendonous attachments of the rectus femoris and gracilis;
6. lateral knee complaints, associated with the TFL muscle tendon strain;
7. anterior knee compartment disorders, associated with strain of the tendonous extension of the rectus femoris;
8. hamstring strain, due to continued overstretch of the hamstring (due to the loss of posterior pelvic rotation);
9. ischial and posterior knee and upper calf complaints, as a result of overstretch and strain at the tendonous attachments of the hamstring muscles at the ischial tuberosity and posterior knee region (and upper leg); and
10. medial knee complaints, associated with the gracilis and sartorius tendonous attachments.

The concept of treatment with pelvis-attached dysfunctional muscles involves the following processes:

1. release of the AS ilium fixation, which may be due to: 

1. a real SI joint fixation;
2. a compensatory pseudo-fixation, reacting as a result of spinal dysfunctions, lumbar hyperlordosis, or thoracic hyperkyphosis (Spinal dysfunctions creating the AS fixation can be anywhere, but common areas are the T/L region, mid-thoracic region, and upper cervical region.);
3. lower extremity disorder;
4. lumbar disc disorder; or
5. cervical or thoracic disc disorder;

2. release of the tension and contraction in the muscles. For this, you may use any combination of: 

1. electrotherapy;
2. massage techniques;
3. ultrasound applied to muscles, not tendons; and
4. stretching (using caution not to irritate tendons at early stages).

The electrotherapy can be divided into two different types of application: 

1. Millicurrent, such as any standard contractile current, can be used to soften muscle regions and sedate sore tissues. Strong millicurrent contractile current is applied to hypertonic muscles, not tendons.
   
   
2. Microcurrent (or low intensity millicurrent, if microcurrent is not available.) can be applied to tendons and joints. Use: 

1. positive polarity to reduce any inflammation; or
2. alternating positive and negative polarity to induce healing.

Microcurrent is less overwhelming to injured joint tissues and tendons and has a great capacity to induce or quick-start tissues in the repair process. Repair appears to occur as a direct result of the current at the cellular level, as opposed to indirect effects of the millicurrent. If millicurrent is used on irritated tendons or joint regions, I have seen the best results with low intensity, which does not aggravate the sensitized tissues. When millicurrent is applied to muscle that is overly contracted, I try to induce some level of muscular contraction to loosen the contraction.

Medium-frequency (Russian) current is used by some to specifically soften tissues. Associated with long-term hypertonic tissues is the development of adhesions. These adhesions, within muscles, can be a continued source of irritation, but can be reduced with electrotherapy and massage techniques.

In each case presented in this article, I have tried to show interrelationships of spinal or pelvis-attached muscles and spinal/pelvic dysfunctions. I call these muscular/tendonous conditions "associated disorders." In my experience, the difficulties in solving associated disorder complaints fall into three categories:

Acute care: This is the process of correcting the spinal/pelvic dysfunctions and treating the involved tissues to reduce and eliminate the complaints.

Maintenance of the corrections: For example, consider a person with a hyperkyphotic thoracic spine and an associated hyperlordotic spine, leading to AS ilium fixations and shortened hamstrings. Ischial tuberosity tendon attachment irritation of the biceps femoris muscle will be associated with shortened hamstrings. The irritation to the tendon may be slight or may involve a significant tear or avulsion. The process of repair may take a short time - or longer - with significant injury. Following the protocol given can more easily relieve complaints. However, maintenance of those corrections and repairs also can make or break the process. Releasing the patient too soon can result in failure and frustration. Not evaluating the degree of tissue injury and underestimating repair time can result in failure, and not communicating these facts and concepts to the patient can lead to patient frustration and resignation from treatment.

Rehabilitation: If muscles or tendonous tissues have been significantly injured, cautious rehabilitation must be considered. Let me give you an example: I treated a middle-age woman who presented with right "ischial bursitis." She had been sitting with legs outstretched on the floor and heard a snap at the ischial region, followed by pain and limitation of right hip flexion. She had bilateral AS ilium fixations, a hyperlordotic lumbar spine, moderate thoracic kyphosis, and T/L extension fixations. I corrected the AS ilium on the right side by adjusting the T/L region and providing a direct right AS ilium fixation adjustment. Contractile current, massage, and ultrasound were applied to the biceps femoris, and a (+) microcurrent was applied to the ischial tuberosity. She received great and almost total relief immediately.

The patient followed up a few times for more treatment. After the third treatment, she decided to take a 30-minute walk and exacerbated the condition. I saw her again and told her that we would have to take smaller steps and that much more time would be required. I should have understood from the start that we were dealing with a more serious disorder, due to her history of hearing and feeling a "snap." I should have prepared the patient for a more lengthy and cautious approach. She had previously seen an orthopedist and physical therapist. The PT had given her stretching exercises too soon, which had exacerbated the pain. The patient's patience had been previously exhausted and underevaluated. In this case, a realistic explanation and plan should have been developed and communicated before undertaking rehabilitation.

Joseph D. Kurnik, DC
Torrance, California

Test Combinations in Patient Examination, Part 3: Testing by Indirect Method

By K. Jeffrey Miller, DC, DABCO

As discussed previously, most orthopedic and neurological tests are taught as individual entities and are then grouped into regions and/or categories of pathology, rather than being taught in patterns or sequences that consider efficiency in performance or clinical use.

In the first two articles in this series, we discussed test sequencing and testing for the same pathology, respectively. The third method of combining tests is testing by indirect method. This method involves obtaining clinical information without actually having to perform a test.

The Subtle Art of Indirect Observation

Many orthopedic and neurological tests are purely observations. The doctor simply watches the patient to obtain information. Another method is to perform a test that simultaneously allows for observations of other characteristics. The key is for the doctor to avoid making it obvious that they are watching the patient. The patient is distracted by the test being performed and the doctor obtains two pieces of clinical information while only performing one test.

A common example of the second concept occurs when recording pulse and respiration rates. A patient cannot (except in very rare situations) control their pulse rate; they can, however, control their respiration rate. Taking the pulse rate is easy, while taking the respiration rate can be more difficult if the patient is aware the doctor is watching them breathe. The patient may become self-conscious and alter their normal pattern and rate of breathing.

With this in mind, students are taught to take the pulse and once finished, continue to hold the wrist as though still taking the pulse, but instead begin counting the patient's breaths. The patient is unaware of the doctor's actions and the recorded breathing pattern and rate are more accurate. This is indirect observation of the patient.

This concept is very important in testing range of motion (ROM). Range of motion is very subjective. This is of particular concern in cases that may eventually involve litigation and financial reward. It does not take a great deal of intelligence for a patient with questionable ethics to realize that the less they move, the better their reward may be. This is one of the reasons ROM testing is now a secondary method of determining spine-related disability.

Orthopedic and neurological testing allow for observation of spinal and extremity ROM through indirect method. Most tests require the patient to move joints through specific ranges of motion. The examiner should look for the result of a particular test, but also note the patient's ROM during the test. The patient will be distracted by the performance of the test and the doctor's questions. It is interesting that in some cases, you can see the differences between ROM results from the indirect method versus standard ROM methods.

Combining Tests to Gather Additional Information

The maximal cervical compression test for radicular pathology requires rotation and extension of the cervical spine. L'Hermitte's test for spinal cord pathology requires flexion of the cervical spine. The shoulder depressor test of brachial plexus pathology requires lateral bending of the cervical spine. Three tests cover all four planes of cervical spine range of motion.

Here's another example: The slump test for neuromeningeal pathology requires flexion of the lumbar spine. The sphinx test for spinal extension requires extension of the lumbar spine. Kemp's test for disc and radicular pathology requires rotation and lateral bending of the lumbar spine. Again, three tests cover all four planes of lumbar range of motion.

A doctor will observe multiple ranges of motion during the course of an exam. This may be all the ROM testing necessary. Doctors can also perform ROM testing individually using instruments if clinical findings indicate instrumentation will be necessary. When more traditional methods are performed, the order of performance should be active movements followed by passive movements and finally resisted movements.

This method of test combining overlaps with the method of testing using tests with the same mechanism of performance that identify different pathologies, as discussed in parts 1 and 2 of this series. Only one mechanism is performed, yet the doctor is obtaining multiple pieces of clinical information. The patient is unaware of the doctor's purpose in both methods.

Remember, as I've stated before, always study tests individually before using them in combination. With knowledge of the tests enhanced, testing combinations will become more evident and examination procedures more practical. The whole point is to maximize clinical efficiency and your ability to gather information in the most reasonable period of time.

Test Combinations in Patient Examination: Test Sequencing

By K. Jeffrey Miller, DC, DABCO

Most orthopedic and neurological tests are taught as individual entities. They are then grouped into regions and/or categories of pathology. Seldom are they taught in patterns or sequences that consider efficiency in performance or clinical use.

There are a few exceptions to this: Bragard's test is almost always taught as an immediate follow-up to the straight-leg-raising (SLR) test, and Fajersztajn's test is almost always taught as an immediate follow-up to the crossed straight-leg-raising test (CSLR). These short sequences are effective, but they can be enhanced.

SLR and Bragard's tests are intended to detect radicular pathologies causing lower extremity pain. SLR is employed first to reproduce the pain of the chief complaint. Bragard's follows immediately after to confirm the SLR result. The SLR/Bragard's combination is usually considered diagnostic. However, there are a few instances in which they can miss the pathology they are intended to detect.

Most tests for radicular pathology typically use some combination of hip flexion and knee extension. Lasegue's test and SLR, for example, both use these maneuvers. The only difference in the tests is the order in which the maneuvers are performed. Lasegue's uses hip flexion first, followed by knee extension. SLR uses knee extension first, followed by hip flexion. This minor difference is the reason the names of the two tests are often used interchangeably.

Since Lasegue's and SLR both require hip flexion and knee extension to reproduce symptoms, it is logical that removing one of the movements would reduce symptoms. This would serve as a confirmatory test, just as Bragard's does. When using Lasegue's test, if symptoms produced by hip flexion and knee extension are reduced by flexing the knee back to its original position, the procedure is termed Lasegue's differential test.

Considering the above, SLR-Lasegue's, Bragard's and Lasegue's differential can be sequenced to improve clinical efficiency. This can be taken a step further by studying the mechanism of Bragard's test.

Bragard's test for radicular pathology and Homan's test for deep-vein thrombosis (DVT) both involve dorsiflexion of the foot. A second commonality is that the conditions these tests are intended to detect both cause pain in the lower leg and calf. This mandates differential diagnosis.

When the foot is dorsiflexed following SLR, reproducing lower leg and calf pain, the pain may be radicular or due to a DVT. Differential diagnosis can be accomplished by flexing the knee, as in the Lasegue's differential test, while maintaining the dorsiflexed position of the foot.

With flexion of the knee, tension in the nerve root is reduced. The dorsiflexed position of the foot does not elicit enough tension in the nerve tissue and symptoms should decrease. Flexing the knee would not affect a DVT and symptoms would persist.

Note that some authors recommend a quick, sudden dorsiflexion of the foot during Bragard's test. This is not recommended in practical assessment. The action may dislodge a DVT, making it subject to transport through the vascular system.

The sequence has now expanded to a series of four tests. The supine patient can be examined by raising the extended symptomatic leg to the point at which symptoms are reproduced. The leg is then lowered to just below the point symptoms were produced and the foot dorsiflexed. Reproduction of symptoms reinforces the initial SLR finding and is then followed by flexion of the knee while maintaining foot dorsiflexion.

Relief of symptoms with knee flexion further reinforces the SLR/Bragard's findings. Continued symptoms with knee flexion and continued dorsiflexion suggest the possibility of DVT. Moses' test (squeezing the calf muscles to reproduce the pain of DVT) is used as a confirmatory procedure when DVT is suspected. Squeeze cautiously to avoid dislodging the DVT.

Symptoms during SLR are typically produced between 35 and 70 degrees. Considering this, flexion of the knee for Lasegue's differential test should occur while maintaining the angle of hip flexion present when Bragard's test is performed. This allows the possibility of symptom relief and test interpretation without movement of the hip joint. Avoiding movement of the hip at this point is important, as it allows the sequence to expand further.

The "sign of the buttocks" test differentiates between radicular and hip joint pathologies. The test is performed by maintaining the position of the hip joint following a positive SLR. Flexing the knee (Lasegue's differential) and attempting to increase hip flexion provide the differential. If the hip flexes further, the condition is radicular/sciatic in nature. If the hip does not flex further, hip joint pathology is indicated. Hip joint pathology can be further evaluated by attempting to move the patient's leg into the figure-four position of Patrick's test.

The sequence has now expanded to a series of five tests. The supine patient can be examined by raising the extended symptomatic leg to the point at which symptoms are reproduced. The leg is then lowered just below the point symptoms were produced and the foot dorsiflexed. Reproduction of symptoms reinforces the initial SLR finding. This is followed by flexion of the knee while maintaining foot dorsiflexion. This position is held long enough to interpret results for Homan's test; the hip is then flexed further to complete the sequence with the sign of the buttocks maneuver.

The described sequence provides diagnostic information for identifying radicular problems, DVT and hip joint pathologies. The time spent performing the sequence is only seconds longer than the original SLR and Bragard's sequence. The result is improved efficiency and diagnostic information.

It is recommended that the reader study the tests listed here individually before using them in combination. After study of these and other tests, testing combinations will become more evident and their employment will enhance any examination.

Tibiofibular Joint

Proximal Tibiofibular Joint Dysfunction

By Manuel Duarte, DC, DABCO, DACBSP, CSCS

Patients who complain of lower extremity pain and dysfunction are commonly seen in chiropractic practice. General diagnoses of the lower extremity often fall into general categories of either traumatic or overuse etiologies.

Traumatic injuries have a clear mechanism of injury, leaving the doctor to decide type and degree of tissue damage based on clinical history and examination. Overuse injuries often involve a mechanism of repetitive activities, which have the effect of stressing the involved tissues to the point at which breakdown occurs faster than the body can repair.

Mechanism of Overuse Injuries

In the overuse mechanism, there is often an underlying deficit in the body structure or function leading to an overload situation. Forces can accumulate, not be properly dissipated or be misdirected into areas not intended to handle the load. Injury may occur secondary to the structure not being able to meet the demands placed upon it. For example, a runner with knee pain may be engaged in too much activity too early in training. (A general rule for runners is to not increase mileage more than 10 percent per week.) The patient could cut down on overall mileage and give the body enough rest and nutrition to recover before the next training session.

Overuse combined with biomechanical faults will almost certainly create an overuse injury.⁵During running, each leg repeatedly absorbs loads equaling 1.5 to 5 times body weight. It has been suggested that repetitive loading of this type and the associated impact shocks cause microtrauma to the underlying tissues and may eventually cause enough damage to impair function. The use of cushioned or shock-absorbing insoles has been suggested to reduce the impact forces associated with running.⁴

Common overuse injuries related to this repeated microtrauma include conditions such as plantar fascitis, medial tibial stress syndrome and metatarsalgia. As such, part of a reasonable treatment plan could involve decreasing mileage and offering the patient a custom-made, shock-absorbing orthotic to decrease impact forces.

Involvement of the PTF Joint

The posterolateral surface of the tibia and the head of the fibula form an arthrodial articulation known as the proximal tibiofibular (PTF) joint. The capsule surrounding the PTF joint, although reinforced by anterior and posterior ligaments, is thicker anteriorly. The popliteus tendon helps to reinforce the posterior aspect of the capsule as it crosses the joint. At the biceps femoris insertion, the proximal fibula is integral in providing lateral stability of the knee.

There are three distinct movements that occur between the proximal tibia and the fibular head: anteroposterior glide, superoinferior motion and rotation. The ability of the PTF joint to withstand longitudinal or axial stresses is a direct function of its anatomy. The proximal aspect of the fibula seems best able to undergo tensile and torsional stresses. Compressive forces appear best managed distally, where the interosseous membrane ensures lower leg function by actively involving the fibula in load transference. The fibula has been shown to bear one-sixth of axial loading on the leg, with a key role in dissipating torsional stresses produced by ankle motion.

The PTF joint acts primarily to reduce torsional stress at the ankle, minimize lateral bending of the tibia and decrease weight-bearing torsion.¹ Abnormal force accumulation and altered biomechanics or trauma frequently affect a joint that, when injured, can contribute to chronic pain and considerable disability. It is my opinion that the PTF joint is an underappreciated and infrequently diagnosed cause of chronic leg and foot pain.

Disruption of the PTF joint has been considered a rare injury. Usually it is an isolated injury, although certain underlying pathological conditions may predispose the proximal end of the fibula to dislocate in a small number of patients.² Although dislocation of the tibiofibular joint is considered rare, subluxations and biomechanical faults at this joint are common enough to be considered in every clinical case of lateral knee pain and neurological findings of numbness and tingling in the lateral leg and dorsum of the foot. It has been my experience that this is especially common in active individuals, particularly athletes.

There are two basic types of tibiofibular joints: horizontal and oblique. Horizontal joints have a fibular articular surface that is usually circular and planar (or slightly concave in some cases) and that articulates with a similar planar-circular surface on the tibia. These articular surfaces are under and behind a projection of the lateral edge of the tibia, which provides some stability by preventing forward displacement of the fibula.

The second type of tibiofibular joint is oblique. In general, the more oblique joints have the least area of articular surface. Because this type of joint is less able to rotate to accommodate torsional stresses than a horizontal joint, it may subluxate and dislocate more frequently.

Anterolateral subluxation is the most common subluxation of the PTF joint that occurs during athletic activity, especially actions involving violent twisting motion. This subluxation is best discerned by clinical examination, which will reveal a prominent mass over the lower anterolateral knee joint.

When a patient complains of pain and tenderness of the proximal part of the fibula, there may be associated symptoms in the lateral popliteal fossa along the stretched biceps tendon. In this case, pain can be accentuated by dorsiflexing and everting the foot. There may also be transient paresthesias along the distribution of the peroneal nerve. Movement of the knee is usually painless, with a deficit in range a few degrees short of full extension. The biceps tendon may be in a muscular spasm or may be palpated as hypertonic. Upon observation, the fibular head will appear as a prominent lateral mass. A typical mechanism of anterolateral subluxation may be the following:

• inversion and plantarflexion of the foot that causes tension in the peroneal muscle group, extensor digitorum longus and extensor hallucis longus, resulting in a forward-subluxating force of the proximal end of the fibula;
• simultaneous flexion of the knee, relaxing the biceps tendon and fibular collateral ligament;
• concomitant twisting of the body, transmitting the twist along the femur to the tibia, causing a relative external rotatory torque of the tibia on the foot, which is already fixed in inversion.⁶

The combination of points two and three above springs the proximal end of the fibula out laterally, at which point the violently contracting muscles (point 1) pull the fibula forward.

Tibiofibular subluxations occur under traumatic conditions such as twisting athletic injuries, a slipping injury in which the patient lands with their knee flexed under their body, or parachute landings. Anterolateral subluxations can be sustained from a wide variety of sports activities such as football, soccer, rugby, wrestling, gymnastics, judo, broad jumping and skiing Posterolateral subluxations are usually associated with violent trauma to the knee, with the proximal part of the fibula being pushed posteriorly and medially.

Severe disruption of the anterior and posterior capsular ligaments of the tibiofibular joint, probably with a significant tear of part of the fibular collateral ligament, allows the biceps to draw the unsupported proximal part of the fibula posteriorly. This type of dislocation is invariably associated with a fracture of the tibial shaft. The literature describes a variety of proximal fibula subluxations. I have provided a complete list of them with a description of the extra vertebral adjustment for each as follows:

Superior Fibula Subluxation

Subluxation: A superior fibula subluxation often allows eversion sprain of the ankle. Typical features include tenderness about the fibular collateral ligament due to jamming, restricted inferior fibula joint play, and possibly a slight foot-drop sign.

Adjustment: Place the patient supine with the knee extended and hip flexed at about 45 degrees. Stand at the end of the table with the patient's foot placed on the anterior aspect of your thigh. Grasp the patient's ankle with your lateral hand, and take a web or capitate contact at the proximal aspect of the lateral malleolus. With your medial hand, overlap the wrist of your contact hand for stability. Apply traction and simultaneously make a short, inferiorly directed thrust to correct the malposition.

Inferior Fibula Subluxation

Subluxation: An inferior fibula subluxation can be the result of inversion ankle sprain and is often associated with tenderness about the collateral ligament of the fibula and restricted superior fibula joint play.

Adjustment: Place the patient in the lateral recumbent position with the affected side upward and the medial aspect of the affected foot resting relaxed on the table. Stand at the foot of the table in line with the longitudinal axis of the patient's affected leg. Apply a capitate contact with your medial hand against the inferior aspect of the lateral malleolus, with your lateral hand grasping your contact wrist for stability. Apply pressure and simultaneously make a short thrust directed superiorly along the vertical axis of the fibula to correct the malposition.⁷

Anterolateral Fibula Subluxation

Subluxation: An anterolateral fibula subluxation is often the result of lateral hamstring strain, inversion ankle sprain or trauma to the posterolateral aspect of the knee. It is characterized by lateral hamstring tendon tenderness, genu varum, excessive ankle pronation, and restricted posteromedial fibula motion.

Adjustment: Place the patient prone with the involved knee flexed. Squat at the end of the table (facing the patient) so that the patient's leg can rest on your shoulder for stability. Grasp the involved leg and interlace your fingers around the posterior aspect of the patient's leg proximally. Direct a pisiform contact with your cephalad hand against the anterolateral aspect of the fibular head. Apply traction and simultaneously rotate the fibula posteromedially to correct the malposition.

Posteromedial Fibula Subluxation

Subluxation: A posteromedial subluxation of the fibula often follows inversion ankle sprain, violent hamstring pull, trauma to the anterolateral knee and genu valgum.

Adjustment: Place the patient prone with the involved leg fixed. Squat at the end of the table (facing the patient) so that the patient's leg rests on your shoulder for stability. Grasp the involved leg and interlace your fingers around the posterior aspect of the patient's leg proximally. Apply a specific pisiform contact with your lateral hand against the medial aspect of the involved fibular head. Apply traction, and simultaneously rotate the fibula impulsively anterolaterally to correct the malposition.

Postero-Inferior Fibula Subluxation

Subluxation: The typical physical features of a postero-inferior subluxation of the fibula include pain at the fibula head, lateral collateral ligament pain at the ankle, lateral hamstring complaints, and restricted anterosuperior fibula joint play. This subluxation is often the result of inversion ankle sprain.

Adjustment: Place the patient supine with the affected knee flexed. Stand lateral to the involved limb with your cephalad hand with the popliteal fossa. Apply a thenar-pad contact against the fibular head. For leverage, grasp the anterior aspect of the patient's lower leg with your caudad hand. Apply oblique pressure with your stabilizing hand to flex the knee and push the leg superiorly, while simultaneously briskly lifting the fibular head anteriorly with your contact hand to make the correction.³

Following the adjustment, application of physiologic therapeutics such as ultrasound or interferential and ice can be applied at the doctor's discretion. For overuse injuries and to correct biomechanical faults, I recommend custom-made, flexible orthotics to provide patients with a balanced, symmetrical foundation and relieve postural stress.

When pain allows, the patient should begin active care stretching and strengthening muscles. During the initial phases of treatment and during stressful activities, a wrap or tape could be applied as necessary to maintain joint integrity.

References

1. Bressler H, Deltoff M. Proximal tibiofibular joint dysfunction: an overlooked diagnosis.Chirop Sports Med, 1988;2(2).
2. Ogden JA. Subluxation and dislocation of the proximal tibiofibular joint. J Bone Joint Surg, 1974;56:145-54.
3. Schafer RC. Knee and Leg Trauma. 1997.
4. O'Leary K, Vorpahl KA, Heiderscheit B. Effect of cushioned insoles on impact forces during running. J Am Podiatr Med Assoc, Jan/Feb 2008;98(1).
5. Quinn E. Checklist for Running Overuse Injuries. About.com: Sports Medicine.
6. Ahmad R, Case R. Dislocation of the fibular head in an unusual sports injury: a case report. J Med Case Reports 2008;2:158.
7. Hatzokos I, Drakou A, Christodoulou A, et al. Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator. J Bone Joint Surg, 2004;86:1491-6.

Exercise Tubing

Joint Rehabilitation and the Use of Exercise Tubing

By Kim Christensen, DC, DACRB, CCSP, CSCS

Many professionals have found that exercise tubing is an effective tool in rehabilitating various joint injuries. There are several systems that are popular with chiropractors. One of these is comprised of surgical tubing with adjustable straps for the wrist/ankle and thigh and a retainer that attaches into the hinge side of a door. 
With this system, most patients can be instructed within minutes and then perform the prescribed exercises at home.

Experience has revealed that combining the chiropractic adjustment with the appropriate exercise will speed recovery, due to the increased ability of the musculoskeletal system to "hold" the adjustment. Other positive results have been shown to occur with the application of tubing exercise. Such results include: significant increase in both the size and strength of muscles exercised; reduction of muscle atrophy; pain relief; an increase in the facilitation and velocity of muscular contraction; enhancement of joint endurance; reduction in healing time required (due to improved vasodilation); and a decrease in new adhesions at the site of injury (allowing for more efficient and pain-free range of motion).

Using exercise tubing can increase muscle size and strength, reduce healing time, and offer pain relief.

Guidelines for Use

To achieve optimal results with exercise tubing, several guidelines must be followed. All exercises are to be pain-free; pain produced as a result of exercise is counterproductive and results in decreased strength, atrophy, swelling, etc. Straight single-plane motions are utilized prior to rotational motions. Short arc movements are prescribed prior to full-range movement. Prior to advancing to full-range exercise, the motion must also be able to be performed pain-free. Bilateral exercise is always preferred, and it is essential that the uninvolved side be exercised prior to the involved. This speeds the recovery process due to the cross-education afforded.^1,2

Exercise Phases

There are four phases which comprise the established protocols for utilizing resistive-motion exercise. Start with slow and short-range motion. Proceed to fast and short range. Progress to slow, full-range exercise; and finally to fast, full-range movement (see Table 1). The patient generally spends two weeks per phase. If the patient spends more than one week per phase, it is recommended that an every-other-day schedule be followed. The general rule to apply prior to advancing to a higher phase of exercise is the ability of the patient to perform the next phase pain-free.

Table 1: The four exercise phases using tubing.

Phase 1 -- Slow Pace, Short Range
Phase 2 -- Fast Pace, Short Range
Phase 3 -- Slow Pace, Full Range
Phase 4 -- Fast Pace, Full Range

Phase one's slow paced, short-range sessions generally provide benefits to the circulatory system. This is due to an improvement in venous and lymphatic drainage, thus increasing the muscular pump and ridding the area of excess fluid. The connective tissue starts to conform to Davis' law ("soft tissue models according to imposed demands"), as the fibroblasts align to tissue stress. Adhesions are less likely to form, and those that do form will produce a small but flexible scar.

Because of their fast-paced movements, phase two exercises improve collagen healing. They also facilitate the neurological pathway, as provided for in the law of facilitation: "When an impulse passes through a certain set of neurons to the exclusion of others, it will take the same course on future occasions; and each time it traverses this path, the resistance in the path will be less." This results in muscular tonus; joint integrity starts to improve because of the increase in joint lubrication. Along with nourishing the articular cartilage, further adhesions are prevented because of the quick movement. This integrity forms the basis for further strengthening and endurance training.

As the patient performs the daily living activities of work, home, sports, etc., the neuromuscular system is coordinated. This can be demonstrated by performing before-and-after manual muscle testing of the involved exercise motion. It will be generally found that, prior to the phase two exercise, the involved muscles providing the exercise motion will respond in abnormal tonus, whereas immediately after the phase two exercise the manual muscle test reveals a "normal" tonus.

When tonus is evaluated by manual muscle testing, there is a 10 degree overflow on each side of the tested position which would apply to the results obtained.³ For example, if one were to completely assess shoulder flexion from 0 to 180 degrees, the specific positions to perform manual muscle testing would have to be at 0, 20, 40, 60, 80, 100, 120, 140, 160 and 180 degrees. This would evaluate the neurologic tonus throughout the range-of-motion via manual muscle testing. It cannot be assumed a range-of-motion is in normal tonus by testing only at one point in the plane of motion. Manual muscle testing provides the clinician with neurological tonus information. The phase two exercise becomes the exercise to normalize every neuromuscular position through an entire range of motion.

These short-range exercises facilitate lubrication and fluid dynamics.⁴ Furthermore, short-range movement disperses the synovial fluid, helps nourish the cartilage, helps prevent its deterioration and prepares the joint for the demands of further exercise and rehabilitation.⁵

One of the many goals of the phase one and phase two exercise programs is to reduce strength loss as well as not allow decrease in the size of the muscle, which occurs during the atrophic process. In any neuromusculoskeletal condition entering the chiropractic office, the nervous system (due to the previously mentioned law of facilitation) will have set up abnormal facilitated pathways that are viciously cyclic, and are being manifest by muscle spasm, ischemia, hypoxia, pain, muscle weakness and joint instability. The facilitated pathways must be resolved with phase two exercise to obtain any degree of permanency in a rehabilitation program. Due to the law of facilitation, the neurological impulse will take the same course on each occasion; each time it traverses the path, the resistance will be less. Thus, we re-educate the pathway of muscle contraction.

Phase three begins the slow-pace, full-range exercise wherein we start to duplicate functional movements. Here we start to increase the strength and endurance capabilities of the particular joint. Phase four is the final phase and provides the full functional capabilities of strength, endurance and joint stability needed for daily living.

Muscular strength is described functionally as the greatest amount of peak tension a muscle group can generate dynamically during one contraction. Training the muscle for strength involves overloading the muscle through work-induced hypertrophy and hyperplasia. A muscle may be overloaded by fluctuating the amount of repetitions or the amount of resistance. By stretching the exercise tubing in phase three or phase four, the patient overloads the muscle by fluctuating the resistance and increases in strength are realized. Likewise, the velocity of limb movement may be held constant while increasing the number of repetitions. During phase three or phase four, the muscle can be overloaded by increasing the intensity of muscular work by the addition of more repetitions.

This principle of strength is a physiological law attempting to accomplish a greater amount of peak tension in the involved muscle group. This is accomplished by contracting the involved muscle on an every other day regimen to the point of complete peripheral fatigue. It is essential in strength training after seven weeks that the involved muscle not be contracted on consecutive days. This will simply deteriorate muscle tissue versus enlarging and strengthening.

It is recommended that at the completion of each session the patient routinely perform an ice massage for 10-15 minutes to reduce any joint irritation which might be caused by the prescribed movement.

References 

1. Wellock L. Development of bilateral muscular strength through ipsilateral exercise. Phys Ther Rev 1958;38:671-674.
2. Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sprts Exerc 1997;29:107-112.
3. Knapik JJ. Nonspecific effects of isometric and isokinetic strength training at a particular joint angle (abst.). Med Sci Sprts Ex 1980;12(2):120.
4. Larson R. Commentary. Am J Sprts Med 1981;9(3):148.
5. Zuckerman J. Effects of exercise on knee ligament separation force in rats. J App Physiol 1969; 26:716-719.

Kim D. Christensen, DC, DACRB, CCSP
Ridgefield, Washington 

Stretching

The Science of Stretching

To stretch or not to stretch? Impact on performance and injury rates in runners.

By Thomas Michaud, DC

In 1986, Rob DeCastella set a course record by running the Boston Marathon in 2:07:51, just 39 seconds off the world record.

A few days be-fore the race, I saw Rob in my office; when I checked his hamstring flexibility, I was shocked to see he could barely raise each leg 30 degrees off the table (even tight runners can raise their legs 60 degrees). Having never seen hamstrings that tight, I asked Rob if he ever stretched. He responded: "When I run, that's as far as my legs go forward, so that's as far as I want them to go forward."

At the time, it was just assumed that runners had to stretch to run fast and remain injury-free, but here was one of the world's fastest runners who not only didn't stretch regularly, but avoided stretching altogether!

According to conventional wisdom, I should have encouraged Rob to stretch, but I didn't. Besides being one of the world's fastest runners, Rob DeCastella knew a lot about exercise physiology and I trusted his judgment.

Years later, research appeared suggesting tight runners were metabolically more efficient than flexible runners. This is what DeCastella intuitively knew: Tight muscles can store and return energy in the form of elastic recoil, just like a rubber band can stretch and snap back with no effort. Because tight muscles provide free energy (i.e., the muscle fibers are not short-ening to produce force, so there is no metabolic expense), stiff muscles can significantly im-prove efficiency when running long distances.

Muscle Composition & Flexibility

To understand why muscles are able to store and return energy, just take a look at how muscles are made. To protect individual muscle fibers from developing too much tension, and to assist in the storage and return of energy, muscle fibers and fibrils are surrounded with perimysium and endomysium. These envelopes contain thousands of strong cross-links that traverse the entire muscle. (Fig. 1) These cross-links are essential for injury prevention be-cause they distribute tension generated on one side of the tendon evenly throughout the entire muscle.

Fig. 1. The components of a muscle. When the foot pronates (A), excessive tension is placed on the inner side of the Achilles tendon (arrow). Small cross-links present in the perimysium distribute pressure generated on one side of the tendon evenly throughout the entire muscle.If these cross-links were not present or were excessively flexible, the asymmetric tendon force would be transferred through the muscle fibers only on the side of the tendon being pulled. Because fewer muscle fibers would be tractioned, the involved fibers would be more prone to being injured because the pulling force would be distrib-uted over a smaller area.

The muscle itself would also be less able to store and return energy simply because fewer fibers would be stretched (the more fibers being pulled, the greater the return of energy). The tight cross-links present in the soft-tissue envelopes act as powerful reinforcements that distribute force over a broader area.

Given the improved efficiency associated with tightness, you would think that the world's fastest runners would all be extremely stiff. This isn't the case. Compared to the mid-to-late '80s, today's elite runners are significantly more flexible. The reason is that even though tight muscles can make you more efficient, they are easily strained and are more likely to produce delayed-onset muscle soreness after a hard workout.¹

Because the best runners often run a significant number of miles per week with grueling track workouts, increased delayed-onset muscle sore-ness would interfere with their ability to tolerate their rigorous training schedules and more than likely increase their potential for injury.

To prove that tight muscles are more prone to injury, researchers from Lenox Hill Hospital in New York classified subjects as either stiff or flex-ible before having them perform repeated hamstring curls to fatigue.¹ Following the workout, the stiffer subjects complained of greater muscle pain and weakness. The enzyme marker for muscle damage (CK) was also significantly higher in the stiff group after working out.

The authors of the study state that because flexible people are less susceptible to exercise-induced muscle damage, they are able to exercise at a higher intensity for a greater duration on the days following heavy workouts. The catch-22 to muscle tightness is that while a certain degree of tightness increas-es the storage and return of energy, excessive tightness can increase the potential for injury, especially with hard workouts.

Fig. 2. U-shaped curve of injuries versus flexibility.The vertical axis of the graph represents cumulative injury incidence as a percentage. There were the same number of people in each of the five groups.While excessively tight runners are injury prone, excessively loose runners are also prone to injury because their muscles have to work harder to stabilize joints that are moving through larger ranges of motion. Flexible muscles are also less able to store energy in their epimysium and perimysium, so their muscles have to work harder to generate the same force.

The end result is that overly flexible runners are just as likely to be injured as stiff run-ners. It turns out that if you make a graph of inju-ries associated with different degrees of flexibili-ty, it forms a U-shaped curve with the tightest and the loosest runners being injured.² (Fig. 2)

Too Tight or Too Loose? Avoiding Flexibility-Related Injuries

Because runners in the middle of the graph are typically not prone to flexibility-related injuries, the goal of a rehab program should be to get your runners away from the extreme ends of the curve. A simple test to quickly evaluate flexibility is to have the athlete bend their thumb back toward the wrist and measure the distance. (Fig. 3) Checking range of motion in the thumb is one of the easiest ways to evaluate overall flexibility because thumb flexibility is a marker for whole-body flexibility (just as grip strength is a marker for whole-body strength). If the thumb is overly flexible, consider adding resistance training and incorporating agility drills to improve strength and coordination.

Fig. 3. The thumb-to-radius index. The index (A) is measured with the wrist flexed and radially deviated.Hypermobility is present when the thumb can be positioned within 2 cm of the radius.⁶In contrast, if your runner happens to fall on the tight side of the flexibility spectrum, consider incorporating specific stretches into a daily routine. Keep in mind that improving flexibility is not that simple. Some great research has shown that when done for just a few weeks, stretching does not alter the ability of a muscle to absorb force because the improved stretch tolerance results from changes in the nervous system that allow the muscle to temporarily lengthen, with no corresponding changes in muscle stiffness and/or work absorption.³

Stretching and Injury Rates

The inability of short-term stretches to improve muscle flexibility explains why there are so many studies showing that stretching does not change injury rates. Because of compliance issues and time constraints, almost every study on stretching and injuries has evaluated stretches over a short duration (probably because so few people would stick with a long-term stretching regimen).

That being the case, it's not sur-prising that while some great research shows tight muscles are more likely to be injured,¹ relatively few studies have ever shown that stretching alters your potential for injury.

In order to produce real length gains, some experts suggest it is necessary to stretch regularly for four to six months. In theory, when a mus-cle is repeatedly stretched for several months, cellular changes take place within the muscle, allowing for a permanent increase in flexibility. Animal studies have shown that the increased flexibility associated with repeated stretching results from a lengthening of the connective tissue envelope surrounding the muscle fibers (especially the perimysium) and/or an increased number of sarcomeres being added to the ends of the muscle fibers.⁴

Although I typically suggest that stiff runners should stretch and flexible runners should strengthen, recent research suggests runners may intuitively know whether or not they should stretch. In the largest randomized control study of stretching to date, Daniel Pereles and colleagues⁵ randomly assigned 2,729 recreational runners to either a stretching or a non-stretch-ing pre-run routine. Not surprisingly, there was no significant difference in injury rates between the runners who stretched versus the runners who didn't stretch.

However, if a runner who routinely stretched was assigned to the non-stretch protocol, they were nearly twice as likely to sustain a running injury. This research confirms that regardless of their overall flexibility, the individual runner should always be the final judge of deciding whether or not a pre-exercise stretching routine is right for them.

References

1. Malachy P, McHugh M, Connolly D, et al. The role of passive muscle stiffness in symptoms of exercise-induced muscle damage. Am J Sports Med, 1999;27:594.
2. Jones B, Knapik J. Physical training and exercise-related injuries: surveillance, research and injury prevention in military populations. Sports Med, 1999;27:111-125.
3. La Roche D, Connolly D. Effects of stretching on passive muscle tension and response to eccentric exercise. Am J Sports Med, 2006;34:1000-1007.
4. Kubo K, Kanehisa H, Kawakami Y, Fukunaga T. Influence of static stretching on viscoelastic properties of human tendon structures in vivo. J Appl Physiol, 2001;90:520-527.
5. Pereles D, Roth A, Thompson D. "A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury on Teenage and Older Runners." USATF Press Release, 2012.
6. Bulbena A, Duro JC, Porta M, et al. Clinical assessment of hypermobility of joints: assembling criteria. J Rheumatol, 1992;19:115-122.

Graston Technique: A Necessary Piece of the Puzzle

By Warren Hammer, MS, DC, DABCO

For more than 40 years I have enjoyed considerable success in treating and resolving soft tissue lesions for patients across the spectrum. I have also seen numerous methods with extraordinary claims that have not been validated. 
Let's face it; I am a skeptic who doubts there is anything better than my hands for diagnosing and treating my patients. So, when I was contacted three months ago by a representative of the Graston technique about testing stainless steel instruments to resolve soft tissue lesions, you could imagine my answer: "No thanks, I'm a hands-on practitioner and do not want anything artificial between me and the patient's skin."

After they offered to send a PT, PhD candidate from Indiana to demonstrate the instrument-assisted technique, I relented. I thought that if they were willing to go to that expense, I have nothing to lose (except for a few patients, of course). The Graston technique was demonstrated on a variety of conditions, including a chronic lower back problem (Figure 1), a chronic cervical spine, a lateral epicondylopathy and a plantar fascitis to name a few. What I discovered has prompted me to reconsider my position concerning the use of my hands alone. All of the patients improved by the next visit. I have used the instruments for three months, and am forced to admit that these instruments allow me to palpate and treat soft tissue that cannot be accurately felt with the human hand.

While a stainless steel instrument cannot compare with the human hand in palpation of skin temperature, moisture, tissue layers and movement, such as skin rolling, there are definite advantages of these instruments over manual assessment. When we palpate using the pads of our fingers we feel for the usual nodules, restrictive barriers and tissue tensions, among other things. What surprised me most was that with the instruments the tissue feeling was greatly magnified. The fat pads of our fingers compress tissues, while the instrument, with a narrower surface area at its edge, has the ability to separate fibers. In a broader sense, it's as if we are running our fingers over the strings of a harp, except that the strings are much closer together. The feeling of the individual fibers is transmitted as a vibrating sensation through the stainless steel to our hands. The practitioner and the patient are together able to detect the abnormal gritty, sand-like restrictive collagen cross-links. Our fingers cannot duplicate this sensation. Interestingly, a bystander or the patient can hold on to the instrument as it glides over the fibers and experience the same "grizzly" or "grayish" abnormal fiber sensation. The instrument can then be moved nearby as a comparison to experience normal tissue sensation.

Another important feature of these instruments is the ability to penetrate and feel the texture of tissue at deeper levels. For anyone in the soft tissue world who works on knees, plantar fascia and carpal tunnel areas, to mention a few, a tremendous benefit is the saving of our own joints, muscles and tendons. There is no longer stress on our own appendages, which will allow us to work much easier in our later years. Forty years of pressure on my hands is totally relieved with these instruments!

A major reason for soft tissue technique is to palpate and eliminate both superficial and deep restrictive tissue due to collagen interfiber cross-links and diminished glycoaminoglycans (GAGs). The loss of GAGs creates a tissue dehydration and hardening of the gel. It is essential in many chronic cases to be able to remove all of the "grizzle" for complete tissue freedom. I regret to say that our fingers cannot penetrate to feel all of it. During the last few months I had treated several patients with chronic lateral epicondylosis and carpal tunnel syndrome (Figure 2) who improved but didn't completely resolve. I called them to return for treatment to see if these instruments would make a difference.

Instrument palpation of the lateral epicondylosis picked up several fibrous areas just off the anterior border of the lateral epicondyle, and in the belly of the extensor carpi radialis brevisthat I completely missed with my hands. This time I used the instruments to totally remove all of the "grizzle" I could find. I also treated and evaluated other areas of the kinetic chain such as the triceps, biceps, flexor and extensor forearm areas. There were plenty of restrictions to deal with, and the patient was amazed. Her symptoms were completely resolved! She regained the ability to function virtually pain free. Testing resistive wrist extension at least 10 times in a row, strong, passive wrist flexion was painless.

We must also understand that part of the resolution must deal with the rehabilitation of the tissues involved. In all cases, patients must be taught stretching and strengthening exercises so that tissue remodeling will continue to its normal termination. In the carpal tunnel patient (Figure 2) I found deep restrictions in the thenar, hypothenar, palm, forearm flexor and extensor areas that, when removed, completely resolved the problem.

I was so convinced at the efficacy of the instruments that New Jersey DC Gregory Doerr and I demonstrated the Graston technique on about 150 DCs at the recent Florida State convention. Admittedly, I am now a consultant for its developer, based upon what I have learned. One of the tests we performed was to ask them to palpate their own thenar eminence with their hands, then palpate it with the instrument. In nearly every case, the DCs remarked that they felt much more fiber restriction with the instrument than with their hands.

Good news for the friction massage practitioners is that with this technique you only should spend up to one minute on a local area. For the deep fascial areas, after treatment you can repalpate the tissue with the instrument and feel a significant difference. Restricted areas versus normal areas invariably turn red in a short time, due to the immediate breakdown of blood vessels, which are more fragile in abnormal adhesion-type tissue. The same theory of creating a new inflammatory cascade (fibroblastic proliferation) to promote a new healing, as discussed in past articles, still holds true. I still use my hands directly on patients, especially for superficial fascial areas throughout the body, and on the subscapularis belly and iliopsoas.

The ability to palpate, penetrate and treat deep fascial fibrotic adhesions by the use of this type of instrumentation immediately supplants the many fascial release techniques in use today. The following represents a few of the many case studies, positive outcome studies and research that lends support to this method.^1-5

References 

1. Graston D, Hall A. Graston Technique Manual, 2^nd ed., 1997. TherapyCare Resources, Inc.
2. TherapyCare Resources Clinic Outcomes (as of 12-98): Poster presentation: APTA combined sections meeting, Seattle, WA., Feb. 1999.
3. Davidson CJ, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine & Science in Sports & Exercise,1997:313-319.
4. Sevier TL, Gehlsen GM, Wilson JK, et al. Traditional physical therapy vs. Graston augmented soft tissue mobilization in treatment of lateralepicondylitis. JACSM 27(5), 1995.
5. Sevier TL, Wilson JK, Melham TJ, et al. A comparison of augmented softtissue mobilization vs traditional physical therapy for carpal tunnel syndrome. CTD News, Oct. 1997.