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Home , Calcaneofibular ligament, Deltoid ligament, Femoral head, Iliofemoral ligament, Ischiofemoral ligament, Pubofemoral ligament

Slide 1 ______Manual Therapy for the and Lower Quarter ______

Techniques and Supporting Evidence ______

Mitchell Barber Scarlett Morris ______PT, MPT, CMT, OCS, FAAOMPT PT, DPT, CMT, OCS

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Slide 2 ______Disclosures: ______

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Slide 3 ______Session 1: The Hip ______

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______Slide 4 ______The Hip

Hip Anatomy ______

o Synovial ball-and socket o The head of the points in an ______anterior/medial/superior direction

o The faces lateral/inferior/anterior ______o Anteversion angle of the neck is 10-15 degrees ______

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Slide 5 ______The Hip Hip Anatomy ______

o articulates with acetabulum, which covers 50% of the femoral head ______o Attached to the rim of the acetabulum is the fibrocartilaginous labrum, deepening the socket

o Neck angle is 125-135 degrees ______

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Slide 6 ______The Hip

Ligamentous Stability ______

◦ Strong fibrous joint capsular extends from the bony rims and labrum of the ______acetabulum to the inter-trochanteric line just super to the inter-trochanteric crest ◦ Three , or thickenings, of the joint capsular provide stability to the hip joint ______

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______Slide 7 ______The Hip ______

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Slide 8 ______The Hip

Ischiofemoral ______

 Forms the posterior margins of the capsule ______ Extends from the ischial portion of the acetabulum to the superior ______

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Slide 9 ______The Hip

Pubofemoral Ligament ______

lies medially and inferiorly and extends from the inferior ______acetabular rib to the inferior femoral neck

 Helps to limit abduction and extension ______

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______Slide 10 ______The Hip ______

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Slide 11 ______The Hip

Iliofemoral Ligament ______

 Extends from the ventral edge of the to the inter-trochanteric line ______ It is taught in full extension and promotes stability of the on the femur in erect stance ______

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Slide 12 ______The Hip ______

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______Slide 13 ______The Hip

Ligamentum Teres ______

 From the acetabular notch to the head of the femur ______ Aids little in joint stability and helps to arrest abduction ______

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Slide 14 ______The Hip

 The anterior and posterior hip ligaments ______wind around the column in a clock-wise direction  Extension 'winds' or tightens these ______ligaments, while flexion, 'unwinds' or relaxes them

 In ER the anterior fibers are taut and in IR the posterior fibers are taut ______

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Slide 15 ______The Hip

Range of Motion ______

Flexion: • 120 deg w/ flexed ______• 30-40 deg abduction: 150 degrees

Abduction: 45 degrees ______

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______Slide 16 ______The Hip

Range of Motion ______

Adduction: 30 degrees Ext. Rotation: 45 degrees ______Int. Rotation: 30 degrees Extension: 20 degrees w/knee ______extended

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Slide 17 ______The Hip Joint Arthrokinematics ______Follows convex on concave rules – roll and glide are in opposite directions ______Flexion/extension: Spin movement of the head of the femur Abduction: Head of femur rolls superior, ______glides inferior ______

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Slide 18 ______The Hip Joint Arthrokinematics ______Adduction: Head of femur rolls inferior, glides superior ______External Rotation: Head of femur rolls posterior, glides anterior ______Internal Rotation: Head of femur rolls anterior, glides posterior ______

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______Slide 19 ______The Hip Joint Arthrokinematics ______Resting position: Flexion 30 degrees Abduction 30 degrees Ext. rotation 20 degrees ______Closed-packed: Full extension, abduction, internal rotation ______Capsular pattern: Flexion, abduction, internal rotation (order may vary) ______

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Slide 20 Joint Mobilizations ______Distraction

• Belt can be used. ______

• Be as close to the joint as possible.

• Hip should be placed in ______resting position – 30 flex, 30 abd, 20 ER.

• Lean away from patient gliding femoral ______head in lateral, inferior and posterior direction – “down and out”. ______

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Slide 21 ______Long axis distraction • Hip in open-packed position ______• Grasp above malleoli • Distract by leaning back

*Can also be a manipulation ______**Think about what is behind you/body mechanics! ______

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Slide 23 ______Anterior glide femoral head in prone ◦ Place cranial hand on proximal part femur. ______Caudal hand under distal part femur. Flex knee.

◦ Extend hip with caudal ______hand, while mobilizing the proximal femur in anterior direction. ______◦ >>> Increases extension

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Slide 24 ______Anterior glide of femoral head, hip extended

◦ Pt supine with stabilization pad ______under superoposterior iliac crest. ◦ PT on opposite side of table. ◦ Hand over hand on , elbows extended. ______◦ Mobilize by pushing down on which creates an anterior glide of the femoral head. ______◦ >>> Increases external rotation and extension. ______

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______Slide 25 ______Posterior glide of femoral head, hip extended ______◦ Pt prone, pillow under ASIS, and ankle off end of table. Therapist on opposite side of table. Hand over hand on greater trochanter, elbows ______extended. ◦ Push down on posterolateral aspect of trochanter, which creates a posterior glide of the femoral head. ______◦ >>> Increases internal rotation and flexion. ______

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Slide 26 ______Evidence ______

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Slide 27 Comparison of Manual Therapy and ______Exercise Therapy in Osteoarthritis of the Hip: A Randomized Clinical Trial[2] ______HUGO et. al, Arthritis & Rheumatism (Arthritis Care & Research) Vol. 51, No. 5, October 15, 2004, pp 722–729

◦ 109 hip OA patients, outpatient clinic of a large hospital. ◦ Treatment period: 5 weeks (9 sessions) ______◦ “The manual therapy program was found to be superior to the exercise therapy program.” ◦ “The effects […] lasted up to 6 months after the end of therapy.” ______◦ “traction of the hip joint was performed, followed by traction manipulation in each limited position” ______

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______Slide 28 ______Manual Therapy for the Hip and Lower Quarter ______

Techniques and Supporting Evidence ______

Mitchell Barber Scarlett Morris ______PT, MPT, CMT, OCS, FAAOMPT PT, DPT, CMT, OCS

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Slide 29 ______Session 2: The Knee ______

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Slide 30 ______The Knee ______◦ The knee is the most researched joint in the body[1] ◦ 1.3 million annual visits to the ER in USA due to knee trauma[1] ______◦ Comprised of the tibio-femoral joint and patello-femoral joint ______

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______Slide 31 ______The Knee ______• The superior tibio-fibular joint is non- weight-bearing but can be a source of dysfunction ______• is a large sesamoid embedded in the quadriceps tendon ______

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Slide 32 ______The Knee Anatomy ______• The distal femur has 2 facets, or , which are bi-concave

• The lateral is larger and juts out ______more anteriorly than the medial condyle • The condyles are not parallel but diverge ______posteriorly

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Slide 33 ______The Knee

Anatomy ______• The distal femur has a facet for articulation with the patella. • The medial tibial condyle is bi-concave but ______the lateral condyle is concave med/lat but convex ant/post. • The is attached to the edges of the tibial condyles. The capsule winds around ______the cruciate ligaments, which are therefore extra-capsular. ______

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______Slide 34 ______The Knee ______

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Slide 35 ______The Knee Ligamentous Stability ______Medial or Tibial Collateral Ligament • Arises from the medial epicondyle of the ______femur and extends to the medial condyle and medial surface of the • Blends with the joint capsule and has attachment to the medial ______• The MCL is the prime stabilizer against valgus stress in either flexion or extension ______

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Slide 36 ______The Knee ______Lateral or Fibular Collateral Ligament

• Arises from the lateral epicondyle of the femur and extends to the fibular head ______• The LCL of the knee is extra-articular in that it does not blend with the joint capsular or ______• Plays a role in defending the knee against varus stresses ______

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______Slide 37 ______The Knee ______Anterior Cruciate Ligament

• Arises from the anterio-medial tibia and extends to the posterior-medial aspect of the ______lateral femoral condyle • The anterior cruciate lies entirely within the joint capsule but is extra-synovial ______• The ACL is the prime restraint against anterior tibial displacement ______

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Slide 38 ______The Knee Posterior Cruciate Ligament ______

• The PCL is also extra-synovial but is contained within the joint capsule ______• Arises from the posterior-medial aspect of the tibial and extends to the lateral aspect of the medial femoral condyle • The PCL is the primary restraint against ______excessive posterior tibial translation ______

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Slide 39 ______The Knee Range of Motion ______

Active flexion w/ hip flexed: 140 degrees Active flexion w/ hip extended: 120 degrees Passive flexion: 160 degrees ______Passive Extension: 5-10 degrees ER in full extension: 5 degrees ER in flexion: 45 degrees ______IR in flexion: 30 degrees

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______Slide 40 ______The Knee ______Arthrokinematics

• Flexion and extension are a combination of rolling and gliding in the opposite ______direction (convex femur moving on concave tibia). • The initial phase of flexion is pure rolling. This corresponds to the normal knee ______ROM in walking.

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Slide 41 ______The Knee Arthrokinematics ______

• The terminal phase of extension is associated with a small amount of external rotation ______(around 20 deg).

• This is due to tension of the cruciate ligaments, the MCL is being tightened more rapidly ______than the LCL, and the lateral femoral condyle gliding more freely on the convex tibial surface. ______

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Slide 42 ______The Knee

• Resting position: 25 degrees of knee flexion ______

• Closed-packed: Full extension, external rotation of tibia ______

• Capsular pattern: Gross limitation of flexion, mild limitation of extension ______

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______Slide 43 ______Posterior glide of femur on tibia

◦ Pt supine with bolster under ______proximal tibia just distal to the joint line. ◦ Therapist standing at side of table. Distal hand stabilizes ______tibia just below the joint line. Keep elbow extended. Mobilizing hand is placed on femur just above the patella. >>> Increases extension Keep elbow extended and ______mobilize femur in posterior direction. ______

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Slide 44 ______Posterior glide of tibia on femur

◦ Pt supine with bolster under ______distal end of femur just proximal to joint line. ◦ Therapist places proximal hand on anterior distal femur. Mobilizing hand on ______tibial plateau just below patella. Keep elbow extended. Mobilize tibia in posterior direction. ______◦ >>>Increases flexion of the knee. ______

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Slide 45 ______Posterior glide tibia on femur, seated ◦ Alternate version of the supine technique. Allows you to apply distraction to the tibia ______while mobilizing in a posterior direction. ◦ PT seated in front of the patient. Come up on your toes and place your against the patient’s middle tibia/. When you gently drop your heels to the ground this will provide a mild distraction ______in the knee joint. Place both hands on the proximal lateral tibia and fibula and mobilize in posterior direction. ◦ Good technique to use in post op situations when patient status is still highly irritable. ______◦ >>> Improves flexion

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______Slide 46 ______Anterior glide of fibula at proximal tibiofibular joint ______◦ Pt on hands and knees with affected foot over edge of table. ◦ Therapist standing across table from affected leg. Tibia fixated against table by pt’s body ______weight and by right hand holding the medial side of the knee. Thenar eminence of left hand on pt’s posterior-medial fibular head. ______◦ Mobilize in anterior-lateral direction. ______

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______• 2015 - 75 participants, 65 retained at one year • Conclusion: • “Our results indicated that providing either manual therapy or booster sessions, in addition to exercise therapy, conferred ______incremental benefits over providing exercise therapy alone.” ______

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______Slide 49 ______Manual Therapy for the Hip and Lower Quarter ______Techniques and Supporting Evidence ______

Mitchell Barber Scarlett Morris ______PT, MPT, CMT, OCS, FAAOMPT PT, DPT, CMT, OCS

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Slide 50 ______Session 3: Adverse Neural Tension ______

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Slide 51 ______Pain Mechanisms

• Nociceptive Pain: pain from tissue at the end of a neuron ______. Nerve endings are excited by mechanical or chemical irritant. Chemical irritation: pro inflammatory chemicals. Inflammatory chemicals can cause excitability at ______the neuron. Ischemia or highly acidic tissues can cause excitability at the nerve ending ______

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______Slide 52 ______Pain Mechanisms

• Central Sensitivity/Pain: the neurons on the dorsal horn of the spinal cord become ______sensitized to impulses from the nerve. • Creating less activity to create an impulse to the brain. • The brain neurons become increasingly ______sensitized causing output from the brain which causes a sensation of sensitivity to movement etc. • Peripheral Neuropathic pain: Pain or lesion ______of the peripheral nervous system. ______

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Slide 53 ______LE Neurodynamics ______

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Slide 54 ______Clinical Neurodynamics • Neurodynamics involves mechanical ______and physiological alterations in the peripheral nervous system. ______• May manifest as limitation in range of movement or pain with movement. ______

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______Slide 55 ______Sensitizing Movements Maneuvers are used during neural tissue ______provocation tests to allow the clinician to differentiate between neural and non-neural origins of symptoms. ______

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Slide 56 ______Assessment of Neural Tissue Movement ______Neural provocation tests may be used to assess: ______1. irritability 2. range of motion (of the nerve) 3. reproduction of the familiar pain ______

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Slide 57 ______Adverse Neural Tension A positive neural provocation test will produce: ______1. a re-creation of familiar pain (and/or paresthesia)

2. a difference of 10% limitation in range ______of motion or more than the involved side

3. symptoms must be modifiable by a distant component change ______

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______Slide 58 ______Adverse Neural Tension

Beware of a False Positive: ______These tests may produce paresthesia, pain, or a stretching sensation in asymptomatic, “normal” people. ______

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Slide 59 ______

Adverse Neural Tension ______

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Slide 60 The Straight Leg Raise ______(SLR)

• Pillow or not – be consistent ______• Cervical flexion alters dural tube length • Ask for baseline first • Knee passively fully ______extended • Lift leg until symptoms are reproduced • Stop at first sign of ______symptoms before adding sensitization movements ______

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______Slide 61 Lower Extremity Nerve Bias Positions ______

• Sural nerve is biased with SLR + Inversion + DF (SID)

• Peroneal nerve is biased with SLR + Inversion + PF (PIP) ______• Can be positive in patients presenting with ankle

• Tibial nerve is biased with SLR + Eversion + DF (TED) ______

• Can be further sensitized with hip IR, hip add, cervical flexion and trunk SB away. ______

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Slide 62 ______The SLR

Tibial Nerve Bias: • Ankle DF ______• Foot Eversion • Knee Extension • Use head and hip movements to differentiate ______

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Palpation of the Tibial Nerve ______

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Slide 63 ______The SLR & Common Peroneal Nerve Bias

◦ Plantar flexion ◦ Inversion of the ankle ______

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______Slide 64 ______Prone Knee Bend Test – Femoral Nerve

Equivalent to the SLR ______for the upper lumbar.

1. Knee flexion 2. Hip extension 3. ~sensitize with ______Palpation of the Femoral Nerve cervical motion if needed or trunk SB ______

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Slide 65 ______Side-Lying Slump Test

◦ Testing the involved leg up ______◦ Hip extension with knee flexion

◦ Addition of cervical flexion and extension ______

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Slide 66 ______Adverse Neural Tension ◦ Patients with radiating pain ______◦ Numbness/tingling ◦ Heaviness

◦ Often involves a nerve root condition ______◦ Often distal pain is worse than proximal pain

◦ Would expect to find ______positive straight leg raise ◦ Positive Slump test ______

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______Slide 67 ______Adverse Neural Tension

Active Tests and Treatments ______

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Slide 68 ______Manual Therapy for the Hip and Lower Quarter ______Techniques and Supporting Evidence ______

Mitchell Barber Scarlett Morris ______PT, MPT, CMT, OCS, FAAOMPT PT, DPT, CMT, OCS

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Slide 69 ______Session 4: The Ankle ______

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______Slide 70 ______The Ankle

◦ The ankle is the most commonly injured weight-bearing ______joint in the body (McKinnis 2014)

◦ Consists of the talocrural and subtalar ______◦ Most injuries to the ankle are straight-forward, ligamentous injuries

◦ Subtle ankle/foot fractures can be missed on initial ______examination

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Slide 71 ______The Ankle Anatomy The ankle joint is formed by the ______articulation of the distal tibia and fibula with the talus. ______

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Slide 72 ______The Ankle

◦ The distal end of the fibula, the lateral ______malleolus, is slightly posterior and inferior to the level of the medial .

◦ The distal end of the tibia has a broad ______articular surface called the tibia plafond, the medial malleolus, an expanded process at the anteromedial aspect called the anterior tubercle, and a ______posterior marginal rim.

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______Slide 73 ______The Ankle

Ligamentous Stability ______

Three principal sets of ligaments stabilize the ankle joint ______

1. medial collateral ligament () 2. lateral collateral ligaments 3. distal tibiofibular syndesmotic complex ______

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Slide 74 ______The Ankle ______

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Slide 75 ______The Ankle

Ligamentous Stability ______

The medial collateral ligament consists of several superficial and deep bands ______expanding in a fan-like shape from the medial malleolus to the talus, the navicular, and the . ______

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______Slide 76 ______The Ankle

Ligamentous stability ______

The lateral collateral ligaments are three distinct bands extending the lateral malleolus to the talus and calcaneus. ______

The ligaments are the: ◦ anterior talofibular ligament (ATFL) ______◦ posterior talofibular ligament (PTFL) ◦ (CFL) ______

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Slide 77 ______The Ankle

The distal tibiofibular syndesmotic complex ______is considered to be among the most important stabilizing structures of the ankle and is comprised of the: ______◦ anterior tibiofibular ligamentous ◦ posterior tibiofibular ligamentous ◦ interosseous membrane ______

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Slide 78 ______The Ankle ______

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______Slide 79 ______The Ankle

Range of Motion: ______

Talocrural joint: DF: 20 degrees PF: 50 degrees ______

Subtalar joint: INV: 20 degrees EV: 10 degrees ______

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Slide 80 ______The Ankle

Arthrokinematics ______

◦ Talocrural joint: Allows plantarflexion and dorsiflexion and is a uniaxial modified ______hinge joint

◦ : Allows supination and pronation ______

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Slide 81 ______The Ankle

Talocrural Joint ______

◦ Resting position: 10 degrees plantar flexion, midway between ______inversion/eversion ◦ Close-packed position: Maximum dorsiflexion ◦ Capsular pattern: Plantar flexion greater ______than dorsiflexion ______

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______Slide 82 ______The Ankle

Subtalar Joint ______

◦ Resting position: Midway between eversion and inversion, 10 deg PF ______◦ Close-packed position: Supination ◦ Capsular pattern: Varus greater than ______valgus

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Slide 83 ______The Ankle

Talocrural Open-Chain Motion ______The relatively convex talus rolls and glides in an opposite direction on the relatively concave distal tib/fib. ______

Talocrural Closed-Chain Motion The distal tib/fib rolls and glides in the same ______direction on the talus. ______

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Slide 84 ______The Ankle Subtalar Open-Chain Motion ______◦ In supination the calcaneus moves distally, medially, and inverts ◦ In pronation the calcaneus moves proximally, laterally, and everts ______Subtalar Closed-Chain Motion

◦ Pronation consists of tibial IR, talar PF/adduction, and calcaneal eversion ______◦ Supination consists of tibial ER, talar DF/abduction, and calcaneal inversion ______

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______Slide 85 ______The Ankle Ankle Joint Mobilizations Distraction talocrural joint ______

• Little fingers catch neck of talus and thumbs rest over tarsals and metatarsals on ______dorsum of foot. • Keep elbows in sides, one foot in front of the other. • Distract by leaning back. • Manipulation done in the ______same manner

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Slide 86 ______Dorsal glide of talus in talocrural joint ______

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Mobilization with movement in WB ______

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Slide 87 ______Evidence ______

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◦ Link to pictures: ◦ manual-physical-therapy-and-exercise-versus-supervised- home-exercise-in-the-management-of-patients-with- ______inversion-ankle-sprain.pdf

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Slide 89 ______The efficacy of manual joint mobilization/manipulation in treatment of lateral ankle : a systematic review ______British Journal of Sports Medicine. March 2014; 48 (5): 365-370.[6] Loudon et al.

◦ No detrimental effects from the joint techniques were ______revealed in any of the studies reviewed. ◦ Conclusions: ◦ For acute ankle sprains, manual joint mobilization diminished pain and increased dorsiflexion range of motion. ______◦ For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of motion, decreased pain and improved function. ______

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Slide 90 ______Manual Therapy for the Hip and Lower Quarter ______Thank you for coming!

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Mitchell Barber Scarlett Morris ______PT, MPT, CMT, OCS, FAAOMPT PT, DPT, CMT, OCS

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______Slide 91 ______Acknowledgements ______◦ Manual Therapy Institute for pictures and adapted content – ◦ www.mtitx.com ______

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Slide 92 ______References 1. Lynn N. McKinnis PT, O. (2014). Fundamentals of Musculoskeletal Imaging (4th ed.). ______2. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of Manual Therapy and Exercise Therapy in Osteoarthritis of the Hip : A Randomized Clinical Trial. 2004;51(5):722-729. doi:10.1002/art.20685. 3. Carol A. Courtney, PT, PhD, Alana D. Steffen, PhD, César Fernández-de-las-Pñas, PT, PhD, John Kim, PT, DPT, Samuel J. Chmell, MD . 2016. Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. Journal of Orthopaedic & Sports Physical Therapy 46:3, 168-176. ______4. Abbott JH, Chapple FCM, Fitzgerald GK, et al. The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2015;45(12):975-984. doi:10.2519/jospt.2015.6015. 5. Cleland JA, Mintken P, Mcdevitt AMY, et al. Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. J Orthop Sports ______Phys Ther. 2013;43(7):443-455. doi:10.2519/jospt.2013.4792. 6. Loudon JK, Reiman MP, Sylvain J. The efficacy of manual joint mobilization/manipulation in treatment of lateral ankle sprains: a systematic review. British Journal of Sports Medicine. March 2014; 48(5): 365-370. ______

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