HVLA WORKSHOP: EXTREMITIES & THORACIC SPINE

Kevin D. Treffer, D.O., FACOFP Associate Professor of OMM & Family Medicine Chair, Department of OMM KCU-COM Kansas City Campus OBJECTIVES

• At the end of the workshop the attendee will: • Be able to diagnose somatic dysfunction of the ankle and foot, tibia, glenohumeral, joint, and the thoracic spine. • Be able to demonstrate and explain the HVLA techniques for the ankle and foot in the supine posture. • Be able to demonstrate and explain the HVLA techniques for the ankle and foot in the prone posture. • Be able to demonstrate and explain the HVLA techniques for the fibular head, distal fibula, and tibia plateau. • Be able to demonstrate and explain the HVLA techniques for the Glenohumeral joint. • Be able to demonstrate and explain the HVLA techniques for the thoracic spine. THE REAL “OSTEOPATHIC” DEAL • Frederick A Treffer, D.O. • 1947 Graduate of KCU-COM (KCCOS) • Matriculated at Kirksville College of Osteopathic Medicine 1941 and 1942 • Drafted into WWII: Army Air Core - Bomber Pilot • Post War KCU (KCCOS) had an accelerated program. • Graduated Sept 1947 from KCU (KCCOS) • General Practitioner who incorporated OMM into his patient’s care for 42 years • Taught as adjunct faculty in OMM entire career until I was accepted at KCU • These are his techniques that he learned and taught to me and his many students. HINDFOOT Talus and Calcaneus TALUS: SUPINE

• Dysfunction Diagnosis • Plantar flexion 55-66 degrees • Dorsiflexion 15-20 degrees • Treatment • Patient supine, doc seated at foot of table • Interlock your fingers and place fingers over dorsum of foot with thumbs contacting the plantar fascia • Engage barrier by dorsiflexion and eversion followed by linear traction toward the doc until restrictive barrier fully engaged. • Apply traction thrust toward the doctor • Reassess CALCANEUS: PRONE • Diagnosis • Inversion: 5-10 degrees • Eversion : 5-10 degrees • Treatment patient supine with knee flexed 90 degrees, doc standing on ipsilateral side of table • Docs caudal hand envelopes the calcaneus while the forearm is contacting the plantar aspect of the foot. The cephalad hand reaches around to stabilize the distal tibia and hold the lower leg against the doc’s trunk • Doc shifts weight in a cephalad direction to engage dorsiflexion at the ankle until maximal load into restrictive barrier • Provide a thrust force in the dorsiflexion direction with the caudad forearm onto the plantar aspect of the foot. • Reassess CALCANEUS: SUPINE • Diagnosis • Inversion: 5-10 degrees • Eversion : 5-10 degrees • Treatment • Patient is supine with physician at foot of table • Doc cups the calcaneus with one hand with the other on dorsum of foot • Apply a distraction force on the calcaneus first then add more traction with the hand on the dorsum of foot to fully engage restrictive barrier • Apply a long axis traction thrust (gapping subtalar joint) • Reassess

MIDFOOT Navicular, Cuboid, Cuneiform • Diagnosis NAVICULAR: SUPINE • Plantar glide • Dorsal glide • Treatment • Patient is supine with doc standing at ipsilateral side of table • Abduct, flex, and externally rotate involved hip to place the lateral aspect of foot on table • Cephalad hand is placed over the Hindfoot to stabilize the foot to the table • Caudad hand contacts the navicular, 1st cuneiform and 1st MTP so that the finger tips are on the plantar aspect of these bones • Caudad hand everts the forefoot through above contacts into dorsal glide barrier while cephalad hand maintains stabilization forces • Thrust in direction of eversion • Reassess • Diagnosis NAVICULAR: PRONE • Plantar glide • Dorsal glide • Treatment “Golf Stroke” • Patient prone with doc standing on ipsilateral side • Flex knee on involved side to 90 degrees • Caudad hand contacts the dorsum of the foot with the middle finger on the navicular bone • The cephalad hand reaches over plantar aspect of foot with the thumb parallel to the 1st MTP keeping elbow fully extended • Imagine the ball is “teed up” on the contralateral hip and note where restrictive barrier is • Thrust by “swinging through the ball” inducing eversion upon the navicular bone The foot will cross over the patient’s midline • Reassess • Diagnosis CUBOID: SUPINE • Plantar Glide • Dorsal Glide • Treatment • Patient is supine with doc standing at ipsilateral side of table slightly facing the foot of the table • Doc externally rotates, abducts ipsilateral hip and flexes knee • With cephalad hand grasp the calcaneus and the caudad hand grasps the dorsum of the foot so the finger tips are on the plantar aspect of the cuboid and 5th MTP • Engage restrictive barrier with a “wringing motion” – inversion of forefoot with eversion of calcaneus • Apply a “wringing” thrust while simultaneously increasing the ER, abduction, and knee flexion • Reassess • Diagnosis CUBOID: PRONE • Plantar Glide • Dorsal Glide • Treatment • Patient is prone with doc standing at the ipsilateral side of table • Flex the ipsilateral knee to 90 degrees • Caudad middle finger contacts the plantar aspect of the cuboid then turn our body to face toward the patient head so that the same palm contacts the dorsum of the foot • Cephalad hand grasps the calcaneus • Invert the forefoot and plantar flex the ankle while stabilizing the calcaneus( with the cephalad hand) into the barrier • Thrust in a “wringing motion” – inversion of cuboid and forefoot with eversion of the calcaneus • Reassess. CUNEIFORM: HISS WHIP • Diagnosis • Plantar Glide • Dorsal Glide • Treatment • Patient prone with doc standing at the foot of the table. • Doc interlaces fingers and supports the dorsum of the foot and then places both thumbs on the plantar cuneiform • Engage barrier by increasing plantar flexion at the talus and dorsal glide upon the cuneiform • Apply a thrust by exaggerating the plantar flexion/dorsal glide with the addition of a simultaneous long axis traction • Reassess.

FOREFOOT Metatarsal Phalangeal Joints METATARSAL PHALANGEAL 2-5: SUPINE • Diagnosis • Plantar (distal point of reference) MTP joint prefers dorsiflexion • Treatment • Patient is supine with doc at ipsilateral aspect of table • Place foot into plantar flexion and inversion position • Cephalad hand stabilizes the Hindfoot • Caudad hand contacts the dorsal MTPs and the finger tips curl over the phalanges (2-5) contacting the plantar aspect of the distal metatarsals • Plantar flex MTP joints to engage barrier • Thrust with plantar flexion with dorsal pressure upon the plantar distal metatarsal bone • Reassess METATARSAL PHALANGEAL 2-5: PRONE • Diagnosis • Plantar (distal point of reference) MTP joint prefers dorsiflexion • Treatment • Patient prone with doc at ipsilateral side of table • Flex ipsilateral knee to approx. 80 degrees then plantar flex ankle and invert forefoot • One hand stabilizes the foot just distal to the calcaneus • Other hand contacts the dorsal MTPs and the finder tips curl over the phalanges (2-5) contacting the plantar aspect of the distal metatarsals; Plantar flex MTP joints to engage barrier • Thrust with plantar flexion with dorsal pressure upon the plantar distal metatarsal bone • Reassess 1ST METATARSAL PHALANGEAL JOINT • Diagnosis “BUNION”: SUPINE • Dosiflexed Hallux or 1st MTP joint • Treatment • Patient is spine with doc at ipsilateral aspect of table • Cephalad hand contacts the dorsum of the foot so the thenar eminence is on the proximal/dorsal aspect of the MTP 1 and fingers contact plantar aspect of MTP 1 • Caudad hand grasps the proximal phalanx of the great toe • Distract and Planar flex MTP 1 into barrier • Provide a plantar flexion thrust • Reassess 1ST METATARSAL PHALANGEAL JOINT • Diagnosis “BUNION”: PRONE • Dosiflexed Hallux or 1st MTP joint • Treatment • Patient is prone with doc at ipsilateral aspect of table • Flex knee 30-45 degrees • Caudad hand slides under dorsum to contact the 1st metatarsal, with fingers on the plantar aspect of the 1st Metatarsal • Cephalad hand grasps the proximal phalanx of great toe • Distract and Planar flex MTP 1 into barrier • Provide a plantar flexion thrust • Reassess RESETTING OF THE ARCHES Medial and Lateral Longitudinal RESETTING THE ARCHES

• Treatment • Patient is supine with doc at foot of table • One hand cradles the calcaneus while the other contacts the dorsum of the foot at the junction of the metatarsals and the tarsals • Plantar flex ankle to allow some laxity to the midfoot and forefoot • Provide a compression force from the hand on the dorsum toward the hand supporting the calcaneus • Apply a compression thrust with your hands

KNEE Tibia plateau & Fibular (Proximal & Distal) TIBIA ADDUCTED: SUPINE

• Diagnosis • Adducted Tibia • Treatment • Patient is supine with doc at ipsilateral side of table • Cephalad hand contact the lateral aspect of the proximal tibia plateau • Caudad hand grasps the distal tibia • Provide a valgus force at the knee by pushing your cephalad hand away from you and pulling the caudad hand toward you to engage barrier • Thrust medially on the proximal tibia • Reassess POSTERIOR FIBULAR HEAD: SUPINE • Diagnosis • Posterior fibular head • Treatment • Patient is supine with doc on ipsilateral side of table • Cephalad hand contacts the posterior aspect of the fibular head with the index MCP joint • The caudad hand grasps the ipsilateral ankle • Engage barrier by providing full flexion of the ipsilateral knee and hip • Provide flexion thrust at the knee • Reassess POSTERIOR FIBULAR HEAD: PRONE • Diagnosis • Posterior fibular head • Treatment • Patient is prone with doc at ipsilateral side of table • Place thumb of one hand at the insertion of the lateral hamstrings and the other hand flexes the knee to engage barrier • The thumb provides the fulcrum to the fibula • Provide a flexion thrust at the knee • Reassess DISTAL FIBULA : SUPINE • Diagnosis • Anterior Distal fibula • Treatment • Patient supine. Physician stands at the foot of the table • Stabilize patient’s foot, wrapping fingers around calcaneus and engage dorsiflexion RB. • Thumb of lateral hand contacts the anterior aspect of the distal fibula with other thumb on top, • Engage the RB and use a thrusting force through the RB. • Re-assess TART DISTAL FIBULA: PRONE

• Diagnosis • Posterior Distal fibula • Treatment • Patient prone. Physician stands at the foot of the table. • Stabilize patient’s foot, wrapping fingers around calcaneus and engage plantarflexion PB. • Thumb of lateral hand contacts the posterior aspect of the distal fibula with other thumb on top, • Engage the RB and use a thrusting force through the RB. • Re-assess TART

SHOULDER Glenohumeral GLENOHUMERAL: SEATED

• Diagnosis • Anterior/Inferior • Treatment • Patient seated with doc standing behind the patient • Doc reaches in front of the contralateral shoulder to grasp the ipsilateral olecranon process with the other hand, fingers interlaced together cradling the olecranon • Flex the GH then adduct and externally rotate the GH joint • Provide a compression force into the joint to engage barrier • Provide compression force thrust • Reassess THORACIC SPINE Upper and Lower THORACIC SPINE: T 1-2 SEATED

• Diagnosis • T1-2 Type 1 or Type 2 dysfunction • Treatment- linear distraction technique • Patient seated with doc standing behind • Doc reaches under each axilla to place the hands on the posterior aspect of the neck with the patient interlacing their fingers and placing the hands over the docs hands. • “Full Nelson” • Patient pulls elbows slightly anterior and inferior • Doc extends trunk to gain control of trunk • Doc engages the transverse and sagittal plan barrier • Doc provides a cephalad distraction thrust • Reassess THORACIC SPINE: T 3-4 SEATED • Diagnosis • T3-4 Type 1 or Type 2 dysfunction • Treatment- linear distraction technique • Patient seated with doc standing behind • The patient interlaces their fingers and plaices their hands behind their neck with Doc reaching under each axilla to place the hands on the posterior aspect of the patients hands. • “Full Nelson” • Patient pulls elbows slightly anterior and inferior • Doc extends trunk to gain control of trunk • Doc engages the transverse and sagittal plan barrier • Doc provides a cephalad distraction thrust • Reassess THORACIC SPINE: T 5-12 SEATED • Diagnose • T5-12 Type 1 or Type 2 dysfunction • Treatment • Patient seated with doc standing behind the patient • Doc places the dorsum of the patient's hands at the level of the thoracic PTP • Doc slides hands through the patient arms so as to contact the bilateral anterior aspects of the shoulders and “bellies” up to a pillow between the doc and patient trunk. • Doc extends trunk to gain control of trunk • Doc engages the transverse and sagittal plan barrier • Doc provides a cephalad distraction thrust • Reassess