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Page 1: Nicholas Ch14 BLT

14 Balanced Ligamentous Tension and Ligamentous Articular Strain TechniquesTechnique PrinciplesBalanced l i gamentous tens ion (BLT) and l i gamentous ar t icu la r s t ra in (LAS) techn iques may be

cons idered as two separa te techn iques or as one The h is tory o f the deve lopment o f these

techn iques probab ly s tar ted dur ing A T S t i l l s t ime bu t deve loped great l y th rough the work o f a

number o f os teopath ic phys ic ians inc lud ing bu t no t l im i ted to W G Suther land DO H A

L ipp incot t DO R L ipp incot t DO R Becker DO and A Wales DO ( 1 2 ) I t appears tha t a

geograph ic separa t ion and min imal contact be tween two groups may have caused the same

techn ique to be known by two names Those in the centra l Un i ted S ta tes ( i e Texas) eventua l ly

p romoted the te rm LAS and those in the nor theas tern Un i ted S ta tes ( i e New Jersey and New

Eng land) promoted the te rm BLT As the two names suggest some var iance in the techn iques

deve loped and the prac t i t ioners deve loped the i r own par t icu la r nuance fo r the app l i ca t ion o f the

t rea tment The te rm LAS seems to descr ibe the dysfunc t ion wh i le the te rm BLT descr ibes the

process or goa l o f the t rea tment

Suther land may have been mos t respons ib le fo r the techn ique be ing taught in ear l y osteopath ic

s tudy groups In the 1940s he began teach ing a method o f t rea tment o f the body and ex t remi t ies

wi th the pr inc ip les promoted fo r the t rea tment o f the c ran ium He ta lked about the jo in t s re la t ion

wi th i t s l i gaments fasc ia and so on ( l igamentous ar t i cu la r mechan ism ) and we can ex t rapo la te th i s

to i nc lude the potent ia l fo r mechanoreceptor exc i ta t ion in dys func t iona l s ta tes One o f Suther land s

ideas a key concept in th is a rea was tha t normal movements o f a jo in t o r a r t icu la t ion do not cause

asymmet r ic tens ions in the l igaments and tha t the tens ion d is t r ibu ted th rough the l igaments in any

g iven jo in t i s ba lanced ( 2 3 ) These tens ions can change when the l igament or jo in t is s t ressed

(st ra in o r un i t de format ion ) in the presence o f a l te red mechan ica l fo rce Today th is p r inc ip le is

s imi la r to the arch i tec tura l and b iomechan ica l (s t ruc tura l ) p r inc ip les o f tensegr i ty as seen in the

geodesic dome o f R Buckmins ter Fu l le r and the ar t o f Kenneth Sne lson h is s tudent ( 4 5 6 ) Th is

pr inc ip le is commonly promoted in the pos tu la te tha t an anter io r anatomic ( fasc ia l ) bowstr ing is

p resent in the body The theory is tha t the key dys func t ion may produce both prox imal and d is ta l

e f fec ts These e f fects can produce symptoms both anter io r ly and pos ter io r ly ( 1 )

One o f the aspects ment ioned in some osteopath ic manipu la t ive techn ique (OMT) s ty les is a re lease-

enhancing mechan ism Th is mechan ism may be isometr ic cont rac t ion o f a musc le a resp i ra tory

movement o f the d iaphragm eye and tongue movements o r in the case o f BLT or LAS the use o f

inherent fo rces such as c i rcu la tory (T raube-Her ing-Mayer ) l ymphat ic o r a var ie ty o f o ther fac tors

(e g p r imary resp i ra tory mechan ism) ( 2 ) The phys ic ian in t roduces a fo rce to pos i t ion the pat ien t so

tha t a fu lcrum may be se t Th is fu lc rum pa i red wi th the subsequent lever ac t ion o f the t i ssues

( l igaments ) combines wi th f l u id dynamics and o ther fac tors to produce a change in the dys func t iona l

s ta te In some cases the techn ique is used to a f fect the myofasc ia l s t ruc tures In the case o f

t rea t ing a myofasc ia l s t ruc ture the d i f fe rent ia t i ng fac tor be tween BLTLAS and myofasc ia l re lease

(MFR) is tha t an inherent fo rce ( f lu id mode l ) is the re lease-enhancing mechan ism in BLTLAS in

MFR the thermodynamic react ion to pressure is the pr imary re lease fac tor

Technique ClassificationIndirect TechniqueIn the case o f BLTLAS the phys ic ian pos i t ions the pat ien t s dys func t iona l a rea toward the ease

bar r ie r Th is

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ind i rec t pos i t ion ing is the c lass ic method o f t rea tment in th is techn ique However some LAS

techn iques are exact ly l i ke MFR d i rec t techn iques and those are inc luded in th is chapter ra ther than

Chapter 8 on myofasc ia l re lease ( 1 )

When beg inn ing the t rea tment the phys ic ian typ ica l ly a t tempts to produce some f ree p lay in the

ar t icu la t ion Th is a t tempt to a l low the most mot ion to occur w i thout res is tance i s te rmed

d isengagement I t can be produced by compress ion or t rac t ion ( 1 ) Exaggera t ion i s the second s tep

descr ibed I t i s p roduced by mov ing toward the ease or to what some re fer as the or ig ina l pos i t ion o f

in ju ry (1 ) P lac ing the t i ssues in an opt ima l ba lance o f tens ion a t the ar t icu la t ion or a rea o f

dys funct ion is the f ina l pos i t i on ing s tep o f th is techn ique Some re fer to th is po in t as the wobble

po in t Th is is s im i la r to the sensat ion o f ba lanc ing an ob ject on the f inger t ip The wobble po in t i s

cent ra l to a l l rad ia t ing tens ions and those tens ions fee l asymmet r ic when not a t the po in t Whi le

ho ld ing th is pos i t ion the phys ic ian awai ts a re lease Th is re lease has been descr ibed as a gent le

movement toward the ease and then a s low movement backward toward the ba lance po in t (ebb and

f low)

For example i f the dys func t ion be ing t rea ted is descr ibed as L4 F SL RL the ease or d i rec t ion o f

f reedom is in the fo l lowing d i rect ions f lex ion s ide bend ing le f t and ro ta t ion le f t Moving L4 (over a

s tab i l i zed L5) in th is d i rect ion is descr ibed as moving away f rom the res t r ic t i ve bar r ie r and there fore

def ines the techn ique as ind i rec t

Direct TechniqueLAS somet imes var ies i t can be per fo rmed as a d i rec t techn ique when the muscu la ture is caus ing a

vec tor o f tens ion in one d i rec t ion bu t to ba lance the ar t i cu la t ion i t fee ls tha t you are moving toward

the d i rect ( res t r i c t ive) bar r ie r I t fo l lows the d i rect s ty le o f MFR techn ique descr ibed in Chapter 8

Speece and Crow ( 1 ) i l lus t ra te th is in the i r book as techn iques used in dysfunct ions o f f i rs t r i b

i l i o t i b ia l band pe lv ic d iaphragm and so on

Technique StylesDiagnosis and Treatment with RespirationIn th is method the phys ic ian pa lpa tes the area invo lved and a t tempts to d iscern the pat te rn o f

dys funct ion wi th ext remely l igh t pa lpa tory techn ique Th is cou ld be descr ibed as nudg ing the

segment th rough the x - y - and z -axes wi th the movements caused by resp i ra t ion There fore the

movements used in the a t tempt to d iagnose and t rea t the dysfunct ion are ex t remely smal l

Diagnosis and Treatment with Intersegmental Motion Testing (Physician Active)In i n te rsegmenta l mot ion test ing t rea tment s ty le s l i gh t l y more mot ion andor fo rce can be used to

tes t mot ion parameters in the dysfunc t iona l s i te and to beg in to move the s i te in to the appropr ia te

ind i rec t pos i t ion o f ba lanced tens ions There may be more compress ion or t rac t ion in th is fo rm as

we l l depend ing on the dysfunc t iona l s ta te s i te o r p re ference o f the t rea t ing phys ic ian

Indications Somat ic dysfunct ions o f a r t icu la r bas is

Somat ic dysfunct ions o f myofasc ia l bas is

Areas o f lymphat ic conges t ion or l oca l edema

Relative Contraindications Frac ture d is locat ion o r g ross ins tab i l i t y i n a rea to be t rea ted

Mal ignancy in fect ion o r severe osteoporos is in a rea to be t rea ted

General Considerations and Rules

The techn ique is spec i f ic pa lpa tory ba lanc ing o f the t issues sur round ing and inherent to a jo in t o r

the myofasc ia l s t ruc tures re la ted to i t The ob jec t i s to ba lance the ar t icu la r sur faces or t i ssues in

the d i rect ions o f phys io log ic mot ion common to tha t a r t icu la t ion The phys ic ian i s no t so much

caus ing the change as he lp ing the body to he lp i tse l f In th is respect i t i s very osteopath ic as the

f lu id and o ther dynamics o f the neuromuscu loske le ta l sys tem f ind an overa l l normal iza t ion or

ba lance I t i s impor tan t no t to pu t too much pressure in to the techn ique the t issue must no t be taken

beyond i t s e last ic l im i ts and the phys ic ian mus t no t p roduce d iscomfor t to a leve l tha t causes

guard ing I t genera l l y shou ld be very to le rab le to the pat ien t

General Information for All DysfunctionsPositioning

The phys ic ian makes a d iagnos is o f somat i c dys funct ion in a l l p lanes o f perm i t ted mot ion

The phys ic ian pos i t ions the super io r (upper or p rox imal ) segment over the s tab i l i zed in fer io r

P 369

( lower or d i s ta l ) segment to a po in t o f ba lanced l i gamentous tens ion in a l l p lanes o f

permi t ted mot ion s imul taneous ly i f poss ib le

o This typ ica l ly means moving away f rom the bar r ie r (s ) to a loose (ease) s i te

o Al l p lanes must be f ine tuned to the most ba lanced po in t

Fine- tune Have pat ien t b reathe s lowly in and out to assess phase o f resp i ra t ion tha t fee ls

most loose ( re laxed so f t e tc ) pa t ien t ho lds breath a t the po in t ( i t may be on ly par t ia l ly

comple te inha la t ion or exha la t ion) where the ba lance is maximal

Treatment At the po in t o f ba lanced l igamentous tens ion the phys ic ian ad justs the re la t ive pos i t ion

between the super io r and in fer io r segments to main ta in ba lance

o This typ ica l ly means sh i f t ing the top segment cont inuous ly away f rom the d i rect

bar r ie r to prevent the t issues f rom t igh ten ing as they re lease

o The t issues as they re lease a re o f ten descr ibed as i f they are mel t ing or so f ten ing

o Tissue texture changes shou ld occur dur ing the re lease i f they are not pa lpa ted the

pos i t i on o f ba lanced l igamentous tens ion has not been se t

When a to ta l re lease i s no ted the phys ic ian reassesses the components o f somat ic

dys funct ion ( t issue tex ture abnormal i t y asymmetry o f pos i t ion rest r ic t ion o f mot ion

tenderness [TART] ) The phys ic ian repeats i f necessary

The shor thand ru les fo r th is a re as fo l lows ( 1 )

Disengagement

Exaggera t ion

Balance unt i l re lease occurs

P370

Cervical Region Occipitoatlantal (C0mdashC1 OA) Dysfunction Example C0-C1

ESLRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C1 transverse processes (Figs 141 and 142)

5 The physicians palpating fingers simultaneously carry the C1 transverse processes upward and cephalad (arrows Fig 143) toward the extension ease and toward side bending right rotation left under the occiput This should produce a relative side bending left rotation right effect at the occiput

6 As the physician introduces the vectored force the head is gently side-bent left and rotated right (arrows Fig 144) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may

Figure 141 Head and vertebral contact

Figure 142 Steps 3 and 4

Figure 143 Step 5

present itself and the physician will hold this position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 144 Step 6

P371

Cervical Region Atlantoaxial (C1mdashC2 AA) Dysfunction Example C1 RR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C2 articular processes (Figs 145 and Fig 146)

5 The physicians palpating fingers simultaneously carry the C2 articular processes

Figure 145 Palpation of C2 articular pillars

Figure 146 Steps 3 and 4

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 2: Nicholas Ch14 BLT

techn iques are exact ly l i ke MFR d i rec t techn iques and those are inc luded in th is chapter ra ther than

Chapter 8 on myofasc ia l re lease ( 1 )

When beg inn ing the t rea tment the phys ic ian typ ica l ly a t tempts to produce some f ree p lay in the

ar t icu la t ion Th is a t tempt to a l low the most mot ion to occur w i thout res is tance i s te rmed

d isengagement I t can be produced by compress ion or t rac t ion ( 1 ) Exaggera t ion i s the second s tep

descr ibed I t i s p roduced by mov ing toward the ease or to what some re fer as the or ig ina l pos i t ion o f

in ju ry (1 ) P lac ing the t i ssues in an opt ima l ba lance o f tens ion a t the ar t icu la t ion or a rea o f

dys funct ion is the f ina l pos i t i on ing s tep o f th is techn ique Some re fer to th is po in t as the wobble

po in t Th is is s im i la r to the sensat ion o f ba lanc ing an ob ject on the f inger t ip The wobble po in t i s

cent ra l to a l l rad ia t ing tens ions and those tens ions fee l asymmet r ic when not a t the po in t Whi le

ho ld ing th is pos i t ion the phys ic ian awai ts a re lease Th is re lease has been descr ibed as a gent le

movement toward the ease and then a s low movement backward toward the ba lance po in t (ebb and

f low)

For example i f the dys func t ion be ing t rea ted is descr ibed as L4 F SL RL the ease or d i rec t ion o f

f reedom is in the fo l lowing d i rect ions f lex ion s ide bend ing le f t and ro ta t ion le f t Moving L4 (over a

s tab i l i zed L5) in th is d i rect ion is descr ibed as moving away f rom the res t r ic t i ve bar r ie r and there fore

def ines the techn ique as ind i rec t

Direct TechniqueLAS somet imes var ies i t can be per fo rmed as a d i rec t techn ique when the muscu la ture is caus ing a

vec tor o f tens ion in one d i rec t ion bu t to ba lance the ar t i cu la t ion i t fee ls tha t you are moving toward

the d i rect ( res t r i c t ive) bar r ie r I t fo l lows the d i rect s ty le o f MFR techn ique descr ibed in Chapter 8

Speece and Crow ( 1 ) i l lus t ra te th is in the i r book as techn iques used in dysfunct ions o f f i rs t r i b

i l i o t i b ia l band pe lv ic d iaphragm and so on

Technique StylesDiagnosis and Treatment with RespirationIn th is method the phys ic ian pa lpa tes the area invo lved and a t tempts to d iscern the pat te rn o f

dys funct ion wi th ext remely l igh t pa lpa tory techn ique Th is cou ld be descr ibed as nudg ing the

segment th rough the x - y - and z -axes wi th the movements caused by resp i ra t ion There fore the

movements used in the a t tempt to d iagnose and t rea t the dysfunct ion are ex t remely smal l

Diagnosis and Treatment with Intersegmental Motion Testing (Physician Active)In i n te rsegmenta l mot ion test ing t rea tment s ty le s l i gh t l y more mot ion andor fo rce can be used to

tes t mot ion parameters in the dysfunc t iona l s i te and to beg in to move the s i te in to the appropr ia te

ind i rec t pos i t ion o f ba lanced tens ions There may be more compress ion or t rac t ion in th is fo rm as

we l l depend ing on the dysfunc t iona l s ta te s i te o r p re ference o f the t rea t ing phys ic ian

Indications Somat ic dysfunct ions o f a r t icu la r bas is

Somat ic dysfunct ions o f myofasc ia l bas is

Areas o f lymphat ic conges t ion or l oca l edema

Relative Contraindications Frac ture d is locat ion o r g ross ins tab i l i t y i n a rea to be t rea ted

Mal ignancy in fect ion o r severe osteoporos is in a rea to be t rea ted

General Considerations and Rules

The techn ique is spec i f ic pa lpa tory ba lanc ing o f the t issues sur round ing and inherent to a jo in t o r

the myofasc ia l s t ruc tures re la ted to i t The ob jec t i s to ba lance the ar t icu la r sur faces or t i ssues in

the d i rect ions o f phys io log ic mot ion common to tha t a r t icu la t ion The phys ic ian i s no t so much

caus ing the change as he lp ing the body to he lp i tse l f In th is respect i t i s very osteopath ic as the

f lu id and o ther dynamics o f the neuromuscu loske le ta l sys tem f ind an overa l l normal iza t ion or

ba lance I t i s impor tan t no t to pu t too much pressure in to the techn ique the t issue must no t be taken

beyond i t s e last ic l im i ts and the phys ic ian mus t no t p roduce d iscomfor t to a leve l tha t causes

guard ing I t genera l l y shou ld be very to le rab le to the pat ien t

General Information for All DysfunctionsPositioning

The phys ic ian makes a d iagnos is o f somat i c dys funct ion in a l l p lanes o f perm i t ted mot ion

The phys ic ian pos i t ions the super io r (upper or p rox imal ) segment over the s tab i l i zed in fer io r

P 369

( lower or d i s ta l ) segment to a po in t o f ba lanced l i gamentous tens ion in a l l p lanes o f

permi t ted mot ion s imul taneous ly i f poss ib le

o This typ ica l ly means moving away f rom the bar r ie r (s ) to a loose (ease) s i te

o Al l p lanes must be f ine tuned to the most ba lanced po in t

Fine- tune Have pat ien t b reathe s lowly in and out to assess phase o f resp i ra t ion tha t fee ls

most loose ( re laxed so f t e tc ) pa t ien t ho lds breath a t the po in t ( i t may be on ly par t ia l ly

comple te inha la t ion or exha la t ion) where the ba lance is maximal

Treatment At the po in t o f ba lanced l igamentous tens ion the phys ic ian ad justs the re la t ive pos i t ion

between the super io r and in fer io r segments to main ta in ba lance

o This typ ica l ly means sh i f t ing the top segment cont inuous ly away f rom the d i rect

bar r ie r to prevent the t issues f rom t igh ten ing as they re lease

o The t issues as they re lease a re o f ten descr ibed as i f they are mel t ing or so f ten ing

o Tissue texture changes shou ld occur dur ing the re lease i f they are not pa lpa ted the

pos i t i on o f ba lanced l igamentous tens ion has not been se t

When a to ta l re lease i s no ted the phys ic ian reassesses the components o f somat ic

dys funct ion ( t issue tex ture abnormal i t y asymmetry o f pos i t ion rest r ic t ion o f mot ion

tenderness [TART] ) The phys ic ian repeats i f necessary

The shor thand ru les fo r th is a re as fo l lows ( 1 )

Disengagement

Exaggera t ion

Balance unt i l re lease occurs

P370

Cervical Region Occipitoatlantal (C0mdashC1 OA) Dysfunction Example C0-C1

ESLRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C1 transverse processes (Figs 141 and 142)

5 The physicians palpating fingers simultaneously carry the C1 transverse processes upward and cephalad (arrows Fig 143) toward the extension ease and toward side bending right rotation left under the occiput This should produce a relative side bending left rotation right effect at the occiput

6 As the physician introduces the vectored force the head is gently side-bent left and rotated right (arrows Fig 144) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may

Figure 141 Head and vertebral contact

Figure 142 Steps 3 and 4

Figure 143 Step 5

present itself and the physician will hold this position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 144 Step 6

P371

Cervical Region Atlantoaxial (C1mdashC2 AA) Dysfunction Example C1 RR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C2 articular processes (Figs 145 and Fig 146)

5 The physicians palpating fingers simultaneously carry the C2 articular processes

Figure 145 Palpation of C2 articular pillars

Figure 146 Steps 3 and 4

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 3: Nicholas Ch14 BLT

The techn ique is spec i f ic pa lpa tory ba lanc ing o f the t issues sur round ing and inherent to a jo in t o r

the myofasc ia l s t ruc tures re la ted to i t The ob jec t i s to ba lance the ar t icu la r sur faces or t i ssues in

the d i rect ions o f phys io log ic mot ion common to tha t a r t icu la t ion The phys ic ian i s no t so much

caus ing the change as he lp ing the body to he lp i tse l f In th is respect i t i s very osteopath ic as the

f lu id and o ther dynamics o f the neuromuscu loske le ta l sys tem f ind an overa l l normal iza t ion or

ba lance I t i s impor tan t no t to pu t too much pressure in to the techn ique the t issue must no t be taken

beyond i t s e last ic l im i ts and the phys ic ian mus t no t p roduce d iscomfor t to a leve l tha t causes

guard ing I t genera l l y shou ld be very to le rab le to the pat ien t

General Information for All DysfunctionsPositioning

The phys ic ian makes a d iagnos is o f somat i c dys funct ion in a l l p lanes o f perm i t ted mot ion

The phys ic ian pos i t ions the super io r (upper or p rox imal ) segment over the s tab i l i zed in fer io r

P 369

( lower or d i s ta l ) segment to a po in t o f ba lanced l i gamentous tens ion in a l l p lanes o f

permi t ted mot ion s imul taneous ly i f poss ib le

o This typ ica l ly means moving away f rom the bar r ie r (s ) to a loose (ease) s i te

o Al l p lanes must be f ine tuned to the most ba lanced po in t

Fine- tune Have pat ien t b reathe s lowly in and out to assess phase o f resp i ra t ion tha t fee ls

most loose ( re laxed so f t e tc ) pa t ien t ho lds breath a t the po in t ( i t may be on ly par t ia l ly

comple te inha la t ion or exha la t ion) where the ba lance is maximal

Treatment At the po in t o f ba lanced l igamentous tens ion the phys ic ian ad justs the re la t ive pos i t ion

between the super io r and in fer io r segments to main ta in ba lance

o This typ ica l ly means sh i f t ing the top segment cont inuous ly away f rom the d i rect

bar r ie r to prevent the t issues f rom t igh ten ing as they re lease

o The t issues as they re lease a re o f ten descr ibed as i f they are mel t ing or so f ten ing

o Tissue texture changes shou ld occur dur ing the re lease i f they are not pa lpa ted the

pos i t i on o f ba lanced l igamentous tens ion has not been se t

When a to ta l re lease i s no ted the phys ic ian reassesses the components o f somat ic

dys funct ion ( t issue tex ture abnormal i t y asymmetry o f pos i t ion rest r ic t ion o f mot ion

tenderness [TART] ) The phys ic ian repeats i f necessary

The shor thand ru les fo r th is a re as fo l lows ( 1 )

Disengagement

Exaggera t ion

Balance unt i l re lease occurs

P370

Cervical Region Occipitoatlantal (C0mdashC1 OA) Dysfunction Example C0-C1

ESLRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C1 transverse processes (Figs 141 and 142)

5 The physicians palpating fingers simultaneously carry the C1 transverse processes upward and cephalad (arrows Fig 143) toward the extension ease and toward side bending right rotation left under the occiput This should produce a relative side bending left rotation right effect at the occiput

6 As the physician introduces the vectored force the head is gently side-bent left and rotated right (arrows Fig 144) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may

Figure 141 Head and vertebral contact

Figure 142 Steps 3 and 4

Figure 143 Step 5

present itself and the physician will hold this position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 144 Step 6

P371

Cervical Region Atlantoaxial (C1mdashC2 AA) Dysfunction Example C1 RR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C2 articular processes (Figs 145 and Fig 146)

5 The physicians palpating fingers simultaneously carry the C2 articular processes

Figure 145 Palpation of C2 articular pillars

Figure 146 Steps 3 and 4

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 4: Nicholas Ch14 BLT

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C1 transverse processes (Figs 141 and 142)

5 The physicians palpating fingers simultaneously carry the C1 transverse processes upward and cephalad (arrows Fig 143) toward the extension ease and toward side bending right rotation left under the occiput This should produce a relative side bending left rotation right effect at the occiput

6 As the physician introduces the vectored force the head is gently side-bent left and rotated right (arrows Fig 144) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may

Figure 141 Head and vertebral contact

Figure 142 Steps 3 and 4

Figure 143 Step 5

present itself and the physician will hold this position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 144 Step 6

P371

Cervical Region Atlantoaxial (C1mdashC2 AA) Dysfunction Example C1 RR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C2 articular processes (Figs 145 and Fig 146)

5 The physicians palpating fingers simultaneously carry the C2 articular processes

Figure 145 Palpation of C2 articular pillars

Figure 146 Steps 3 and 4

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 5: Nicholas Ch14 BLT

present itself and the physician will hold this position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 144 Step 6

P371

Cervical Region Atlantoaxial (C1mdashC2 AA) Dysfunction Example C1 RR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences

4 The physicians index or third fingers palpate the patients C2 articular processes (Figs 145 and Fig 146)

5 The physicians palpating fingers simultaneously carry the C2 articular processes

Figure 145 Palpation of C2 articular pillars

Figure 146 Steps 3 and 4

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 6: Nicholas Ch14 BLT

upward and cephalad to disengage C1-C2 while simultaneously rotating C2 left (sweep arrow) under C1 (curved arrow Fig 147) This should produce a relative C1 rotation right effect

6 As the physician introduces the vectored force the head with C1 may be minimally and gently rotated right (arrow Fig 148) until a balanced point of tension is met

7 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 147 Step 5 rotation right effect

Figure 148 Step 6

P372

Cervical Region Atlantoaxial (C1mdashC 2) Dysfunction Example C1 Right Lateral

Translation

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 7: Nicholas Ch14 BLT

1 The patient lies supine and the physician sits at the head of the table

2 The physicians hands cup the head by contouring over the parietotemporal regions

3 The physician places the index finger pads over the C1 transverse processes (Fig 149)

4 The physician gently and slowly introduces a translational force (arrow Fig 1410) that is directed from left to right toward the ease barrier The physician may have to go back and forth between left and right to determine the balanced position (Figs 1410 and 1411)

5 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician will hold the position against it until a release in the direction of ease occurs

6 This can be performed as a direct technique if preferred or indicated

7 The physician reassesses the components of the dysfunction (TART)

Figure 149 Steps 2 and 3 hand position

Figure 1410 Step 4 translation left to right

Figure 1411 Step 4 translation right to left

P373

Cervical Region C2 to C7 Dysfunction Example C4 ESRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 8: Nicholas Ch14 BLT

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients head so that the contact is made at the level of the tentorium cerebelli (1) mostly with the heel of the hands toward the hypothenar eminences (Fig 1412)

4 The physicians index or third fingers palpate the patients C5 articular processes (arrow Fig 1413)

5 The physicians palpating fingers simultaneously carry the C5 articular processes upward and cephalad to disengage C4-C5 while simultaneously rotating and side bending C5 left (sweep arrow) under C4 (curved arrow Fig 1414) This should produce a relative effect of C4 side bending and rotation right)

6 As the physician introduces the vectored force the head with C1 to C4 as a unit may be minimally and gently rotated right (arrow Fig 1415) until a balanced point of tension is met

7 When this balanced

Figure 1412 Steps 1 to 3 head contact

Figure 1413 Step 4

Figure 1414 Step 5 SRRR

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 9: Nicholas Ch14 BLT

position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1415 Step 6

P374

Thoracic Region T1 and T2 Dysfunctions Example T1 FSRRR

1 The patient lies supine and the physician sits at the head of the table

2 The patient is far enough away to permit the physicians forearms and elbows to rest on the table

3 The physician places the hands palms up under the patients cervical spine at the level of C2 or C3 so that the cervical spine rests comfortably on them

4 The physician places the index finger pads on the transverse processes of T1 and the third finger pads on the transverse processes of T2 (Figs 1416 and 1417)

5 The physicians palpating fingers lift the T2 transverse processes up and down (arrows

Figure 1416 Steps 3 and 4 hand and finger positioning

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 10: Nicholas Ch14 BLT

Fig 1418) to find a point of disengagement between the flexion and extension barriers

6 Using the third finger pads the physician gently side-bends (curved arrow) and rotates (sweep arrow) T2 to the left which causes a relative side bending right and rotation right at T1 (Fig 1419)

7 As the physician introduces the vectored force the index finger pads on the T1 segment may minimally and gently rotate and side-bend T1 to the right until a balanced point of tension is met (Fig 1420)

8 When this balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself and the physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

Figure 1417 Step 3 and 4 palpation of patient

Figure 1418 Step 5 neutral balance point

Figure 1419 Step 6 T2 SLRL

Figure 1420 Step 7 T1 SRRR

P375

Cervicothoracic Region Anterior Cervical Fascia Direct Technique

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 11: Nicholas Ch14 BLT

1 The patient lies supine and the physician sits or stands at the head of the table

2 The physician abducts the thumbs and places the thumbs and thenar eminences over the clavicles in the supraclavicular fossa immediately lateral to the sternocleidomastoid muscles (Fig 1421)

3 The physician applies a downward slightly posterior force (arrows Fig 1422) that is vectored toward the feet

4 The physician moves the hands back and forth from left to right (arrows Fig 1423) to engage the restrictive barrier

5 If there appears to be symmetric restriction both hands can be directed (arrows Fig 1424) toward the bilateral restriction

6 As the tension releases the thumb or thumbs can be pushed farther laterally

7 This pressure is maintained until no further improvement is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1421 Steps 1 and 2

Figure 1422 Step 3

Figure 1423 Step 4

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 12: Nicholas Ch14 BLT

Figure 1424 Step 5 bilateral tension if needed

P376

Thoracic And Lumbar Regions T3 to L4 Example T12 ESLRL

1 The patient lies prone and the physician stands beside the table

2 The physician places the left thumb over the left transverse process of T12 and the index and third finger pads of the left hand over the right transverse process of T12

3 The physician places the right thumb over the left transverse process of L1 and the index and third finger pads over the right transverse process of L1 (Fig 1425)

4 The patient inhales and exhales and on exhalation the physician follows the motion of these two segments

5 The physician adds a compression force (long arrows) approximating

Figure 1425 Steps 1 to 3

Figure 1426 Step 5

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 13: Nicholas Ch14 BLT

T12 and L1 and then directs a force downward (short arrows) toward the table to vector it to the extension barrier (Fig 1426)

6 Next the physicians thumbs approximate the left transverse processes of T12 and L1 which produces sidebending left (horizontal arrows Fig 1427) while simultaneously rotating T12 to the left (left index finger arrow) and L1 to the right (right thumb downward arrow) (Fig 1427)

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1427 Step 6

P377

Thoracic And Lumbar Regions T8 to L5 Example L5 FSRRR with Sacral Tethering

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 14: Nicholas Ch14 BLT

If no sacral component is present the hands may contact each segment of the vertebral unit involved in the dysfunction (eg L2 and L3)

1 The patient lies supine and the physician sits at the side of the patient

2 The physician places the caudad hand under the patients sacrum so that the finger pads are at the sacral base and the heel is toward the sacrococcygeal region

3 The physician places the cephalad hand across the spine at the level of the dysfunctional segment so that the heel of the hand and finger pads contact the left and right L5 transverse processes (Figs 1428 and 1429)

4 The sacral hand moves the sacrum cephalad and caudad (arrows Fig 1430) to find a point of ease as the lumbar contacting hand does the same

5 The lumbar hand may need to lift upward and downward (arrows Fig 1431) to balance between flexion and extension

6 The lumbar contacting hand then side-bends and rotates L5 to the right (arrows) to find balanced tension in these directions (Fig 1432)

7 When this total

Figure 1428 Steps 2 and 3 hand positioning

Figure 1429 Hand positioning with sacrum and lumbar vertebra

Figure 1430 Step 4

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 15: Nicholas Ch14 BLT

balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1431 Step 5

Figure 1432 Step 6 L5 SRRR

P378

Costal Region First Rib Dysfunction Example Left Posterior Elevated First Rib

(Nonphysiologic Nonrespiratory)

1 The patient sits or lies supine and the physician sits at the head of the table

2 The physician places the left thumb over the posterior aspect of the elevated left first rib at the costotransverse articulation (Fig 1433)

3 The physician directs a force caudally (arrow

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 16: Nicholas Ch14 BLT

Fig 1434) through the overlying tissues and into the elevated left first rib

4 The force applied should be moderate but not severe

5 The pressure is maintained until a release occurs as indicated by the thumb being permitted to move through the restrictive barrier

6 The physician reassesses the components of the dysfunction (TART)

Figure 1433 Step 2 thumb placement

Figure 1434 Step 3 caudal force

P379

Costal Region Dysfunction of the Respiratory Diaphragm andor Exhalation

Dysfunction of the Lower Ribs

1 The patient lies supine and the physician sits or stands at the side of the patient

2 The physician places one hand palm up with the fingers contouring the angle of the rib cage posteriorly

3 The other hand is placed palm down with the fingers contouring the angle of the rib cage anteriorly (Fig 1435)

4 The hands impart a moderated compression force (arrows Fig 1436) that is vectored toward the xiphoid process

Figure 1435 Steps 2 and 3 hand placement

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 17: Nicholas Ch14 BLT

5 This pressure is adjusted toward the ease of movement of the ribs and underlying tissues until a balance of tension is achieved

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1436 Step 4 compression force

P380

Upper Extremity Region Clavicle Left Sternoclavicular Dysfunction (Direct Method)

Symptom and DiagnosisThe symptom is pain at either end of the clavicle

Technique1 The patient sits on the

side of the table 2 The physician sits on a

slightly lower stool and faces the patient

3 The physicians left thumb is placed on the tip of the inferomedial sternal end of the clavicle immediately lateral to the sternoclavicular joint (Fig 1437)

4 The physician places the

Figure 1437 Step 3

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 18: Nicholas Ch14 BLT

right thumb on the lateral clavicle just medial and inferior to the acromioclavicular joint (Fig 1438)

5 The patient may drape the forearm of the dysfunctional arm over the physicians upper arm

6 The physician moves both thumbs (arrows Fig 1439) laterally superiorly and slightly posteriorly while the patient retracts (sweep arrow) the unaffected shoulder posteriorly

7 The physician maintains a balanced lateral superior and posterior pressure with both thumbs (arrows Fig 1440) until a release is noted

8 The physician reassesses the components of the dysfunction (TART)

Figure 1438 Step 4

Figure 1439 Step 6

Figure 1440 Step 7

P381

Upper Extremity Region Shoulder Spasm in the Teres Minor Muscle (Direct

Method)

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 19: Nicholas Ch14 BLT

Symptoms and DiagnosisThe indication is pain in the posterior axillary fold

Technique1 The patient lies in the

lateral recumbent (side-lying) position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician locates the teres minor muscle at the posterior axillary fold

4 The pad of the physicians thumbs are placed at a right angle to the fibers of the muscle (thumb pressure directed parallel to muscle) at the point of maximum hypertonicity (Fig 1441)

5 The physician maintains a steady pressure superiorly medially and slightly anteriorly (arrows Fig 1442) until a release of the spasm is noted

6 The physician reassesses the components of the dysfunction (TART)

Figure 1441 Step 4 thumbs at point of greatest tension

Figure 1442 Step 5

P382

Upper Extremity Region Shoulder Glenohumeral Dysfunction

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 20: Nicholas Ch14 BLT

Symptoms and DiagnosisThe indication is subdeltoid bursitis or frozen shoulder

Technique 1 The patient lies in the

lateral recumbent position with the injured shoulder up

2 The physician stands at the side of the table behind the patient

3 The physician places the olecranon process of the patients flexed and relaxed elbow in the palm of the distal hand and grasps the patients shoulder with the opposite hand (Fig 1443)

4 The physician controls the humerus from the patients elbow and compresses it into the glenoid fossa (arrow Fig 1444)

5 The physician draws the elbow laterally and slightly anteriorly or posteriorly (arrows Fig 1445) to bring balanced tension through the shoulder

6 The physician draws the shoulder anteriorly or posteriorly and simultaneously compresses it inferiorly (arrows Fig 1446) directing the vector into the opposite glenohumeral joint

7 The physician holds the position of balanced tension until a release is felt

Figure 1443 Step 3

Figure 1444 Step 4 compress toward glenoid

Figure 1445 Step 5 balancing tensions

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 21: Nicholas Ch14 BLT

8 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

9 The physician reassesses the components of the dysfunction (TART)

After the release the humerus may be carried superiorly and anteriorly making a sweep past the ear and down in front of the face (1)

Figure 1446 Step 6 point of balance

P383

Upper Extremity Region Forearm and Elbow Ulnohumeral and Radioulnar

Dysfunctions

Symptoms and DiagnosisThe indication is elbow pain or stiffness

Technique1 The patient lies supine

and the physician stands or sits at the side of the patient

2 The physician grasps the patients olecranon process with the thumb (lateral aspect) and index finger (medial aspect) at the proximal tip of the olecranon process at the grooves bilaterally

Figure 1447 Steps 2 and 3

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 22: Nicholas Ch14 BLT

3 The physicians other hand grasps the dorsum of the patients flexed wrist (Fig 1447)

4 The physician rotates the patients forearm into full pronation (curved arrow Fig 1448) and the hand into full flexion (short arrow)

5 The physicians hands compress (straight arrow Fig 1449) the patients forearm while slowly extending (curved arrow) the patients elbow

6 Steady balanced pressure is maintained against any barriers and until the elbow straightens and the physicians thumb and fingertip slide through the grooves on either side of the olecranon process

7 This treatment resolves any torsion of the radial head and any lateral or medial deviations of the olecranon process in the olecranon fossa (ie lateral or medial deviation of the ulna on the humerus)

8 The physician reassesses the components of the dysfunction (TART)

Figure 1448 Step 4 pronation and flexion

Figure 1449 Step 5 compression and extension

P384

Upper Extremity Region Wrist Carpal Tunnel Syndrome

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 23: Nicholas Ch14 BLT

1 The patient lies supine and the physician stands next to the outstretched arm of the dysfunctional wrist

2 The physicians medial hand controls the patients thumb and thenar eminence (Fig 1450)

3 The physicians other hand grasps the patients hypothenar eminence and then supinates the forearm (arrow Fig 1451)

4 At full supination the patients wrist is flexed to its tolerable limit (long arrow Fig 1452) and the thumb is pushed dorsally (short arrow)

5 The physician maintaining the forces slowly pronates the forearm to its comfortable limit and adds a force (arrow Fig 1453) vectored toward ulnar deviation

6 The physician reassesses the components of the dysfunction (TART)

Figure 1450 Steps 1 and 2

Figure 1451 Step 3 supination

Figure 1452 Step 4 wrist flexion

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 24: Nicholas Ch14 BLT

Figure 1453 Step 5 ulnar deviation

P385

Lower Extremity Region Hypertonicity of the External Hip Rotators and Abductors of

the Femur (Example Piriformis Hypertonicity and Fibrous Inelasticity)

1 The patient lies in the lateral recumbent position with symptomatic side up and both hips flexed to 90 to 120 degrees

2 The patients knees are flexed to approximately 100 degrees

3 The physician stands in front of the patient at the level of the patients hip facing the table

4 The physician locates the hypertonic or painful piriformis muscle slightly posterior and inferior to the superior portion of the greater trochanter

5 The physician maintains a firm pressure with the pad of the thumb medially (down toward the table) over the

Figure 1454 Steps 1 to 5

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 25: Nicholas Ch14 BLT

muscle until a release is palpated (Fig 1454)

6 Alternative The physician may use the olecranon process of the elbow instead of the thumbs (Fig 1455) The olecranon is sensitive to the pressure (arrow) and is able to determine the tendons resistance and the differential anatomy of the area It is also easier on the physician as this style of technique can fatigue the thumbs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1455 Step 6 alternate contact with elbow

P386

Lower Extremity Region Knee Posterior Fibular Head Dysfunction

1 The patient lies supine and the physician sits at the side of the dysfunctional leg

2 The patients hip and knee are both flexed to approximately 90 degrees

3 The thumb of the physicians cephalad hand is placed at the superolateral aspect of the fibular head

4 The physicians other hand controls the foot just inferior to the distal fibula (Fig 1456)

5 The physicians thumb

Figure 1456 Steps 1 to 4

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 26: Nicholas Ch14 BLT

adds pressure on the proximal fibula in a vector straight toward the foot (arrow at right Fig 1457) while the other hand (arrows at left) inverts the foot and ankle

6 The physician attempts to determine a point of balanced tension at the proximal fibula and maintains this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1457 Step 5

P387

Lower Extremity Region Knee Femorotibial Dysfunctions Example Sprain of the

Cruciate Ligaments

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 27: Nicholas Ch14 BLT

1 The patient lies supine and the physician stands at the side of the dysfunctional knee

2 The physician places the cephalad hand palm down over the anterior distal femur

3 The physician places the caudad hand palm down over the tibial tuberosity (Fig 1458)

4 The physician leans down onto the patients leg (arrows Fig 1459) directing a force toward the table

5 The physician adds a compressive force (arrows Fig 1460) in an attempt to approximate the femur and tibia

6 The physician adds internal or external rotation to the tibia (arrows Fig 1461) with the caudad hand to determine which is freer The physician attempts to maintain this position

7 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

8 The physician reassesses the components of the dysfunction (TART)

Figure 1458 Steps 1 to 3

Figure 1459 Step 4 downward force

Figure 1460 Step 5 joint compression

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 28: Nicholas Ch14 BLT

Figure 1461 Step 6 internal or external rotation

P388

Lower Extremity Region Gastrocnemius Hypertonicity Direct Method

1 The patient lies supine and the physician sits at the side of the table just distal to the patients calf facing the head of the table (Fig 1462)

2 The physician places both hands side by side under the gastrocnemius muscle The physicians fingers should be slightly bent (arrow Fig 1463) and the weight of the leg should rest on the physicians fingertips

3 The physicians fingers apply an upward force (arrow at left Fig 1464) into the muscle and then pull inferiorly (arrow at right) using the weight of the leg to compress the area

4 This pressure is maintained until a

Figure 1462 Step 1

Figure 1463 Step 2

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 29: Nicholas Ch14 BLT

release occurs

5 The physician reassesses the components of the dysfunction (TART)

Figure 1464 Step 3

P389

Lower Extremity Region Ankle Posterior Tibia on Talus

1 The patient lies supine with the heel of the foot on the table

2 The physician stands at the foot of the table on the side of symptomatic ankle

3 The physician places the proximal hand palm down across the distal tibia with the metacarpal-phalangeal joint of the index finger proximal to the distal tibia (Fig 1465)

4 The physician presses directly down (arrow Fig 1466) toward the table and balances the tension coming up through the heel and the tibiotalar joint

5 The physicians other hand can be placed on top of the treating hand to create more pressure

Figure 1465 Steps 1 to 3

Figure 1466 Step 4 pressing downward

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 30: Nicholas Ch14 BLT

The physician internally rotates (Fig 1467) or externally rotates (Fig 1468) the tibia slightly to bring the compression to a point of balanced tension

6 When this total balanced position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

Figure 1467 Step 5 internal rotation

Figure 1468 Step 5 external rotation

P390

Lower Extremity Region Foot and Ankle Example Left Calcaneus Dysfunction the Boot Jack Technique (1)

1 The patient lies supine and the physician stands on the left facing the foot of the table

2 The patients left lower thigh and knee are placed under the physicians right axilla and against the lateral rib cage for balance and control

3 The physician grasps

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 31: Nicholas Ch14 BLT

the patients left calcaneus with the right thumb and index finger (Fig 1469)

4 The physician flexes the patients left hip and knee approximately 90 degrees and gently externally rotates and abducts the patients femur (arrow Fig 1470)

5 The physicians right distal humerus and elbow touch the patients distal femur just above the popliteal fossa as a fulcrum to generate proximal pressure

6 The physician controls the patients left foot by wrapping the fingers around the lateral aspect of the foot

7 The physician leans back carrying the patients left hip and knee into further flexion while maintaining tight control of the patients left calcaneus This exerts a distraction effect (arrow Fig 1471) on the calcaneus from the talus

8 The physicians left hand induces slight plantarflexion (arrow Fig 1472) to a point of balanced tension in the metatarsals and tarsals of the patients left foot

9 When this total balanced position is achieved a slow rhythmic ebb and flow

Figure 1469 Steps 1 to 3

Figure 1470 Step 4 external rotation and abduction of femur

Figure 1471 Steps 5 to 7

Figure 1472 Step 8 plantar flexion to balance

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 32: Nicholas Ch14 BLT

of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

10 The physician reassesses the components of the dysfunction (TART)

P391

Lower Extremity Region Foot Dysfunction Metatarsalgia

1 The patient lies supine and the physician stands or is seated at the foot of the table

2 The physician grasps the foot with both hands the fingers on the plantar aspect of the distal metatarsals (Fig 1473) and the thumbs on the dorsal aspect of the foot (Fig 1474)

3 The physician flexes the distal forefoot (arrow Fig 1475) slightly by contracting the fingers on the plantar aspect of the foot

4 The physician then presses the thumbs downward into the metatarsals toward the table (arrow Fig 1476)

5 The physician attempts to position the foot at a point of balanced

Figure 1473 Steps 1 and 2 fingers on plantar surface

Figure 1474 Steps 1 and 2 thumbs on dorsal

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 33: Nicholas Ch14 BLT

tension 6 When this total balanced

position is achieved a slow rhythmic ebb and flow of pressure may present itself at the dysfunctional segment The physician holds the position against it until a release in the direction of ease occurs

7 The physician reassesses the components of the dysfunction (TART)

surface

Figure 1475 Step 3 flexion of forefoot

Figure 1476 Step 4 press toward table

P392

Lower Extremity Region Foot Plantar Fasciitis Direct Method

1 The patient lies supine and the physician sits at the foot of the table

2 The physicians thumbs are crossed making an X with the thumb pads over the area of concern (tarsal to distal metatarsal) at the plantar fascia

3 The thumbs impart an inward force (arrows

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57

Page 34: Nicholas Ch14 BLT

Fig 1477) that is vectored distal and lateral This pressure is continued until meeting the restrictive (bind) barrier

4 The pressure is held until a release is palpated

5 This is repeated with the foot alternately attempting plantarflexion (Fig 1478) and dorsiflexion (Fig 1479)

6 The physician reassesses the components of the dysfunction (TART)

Figure 1477 Steps 1 to 3

Figure 1478 Step 5 plantarflexion

Figure 1479 Step 5 dorsiflexion

P393

References1 Speece C Crow T L igamentous Ar t icu la r S t ra in Os teopath ic Techn iques fo r the Body Seat t l e

East land 2001

2 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine Ph i lade lph ia L ipp incot t Wi l l iams amp Wi l k ins

2003

3 Suther land WG Teach ings in the Sc ience o f Osteopathy Wales A (ed ) Por t land OR Rudra

1990

4 Fu l le r RB Synerget i cs New York Macmi l lan 1975

5 Sne lson K h t tp wwwkennethsne lsonnet Frequent ly Asked Quest ions (FAQ) and St ruc ture amp

Tensegr i t y Accessed February 4 2007

6 Ingber DE The arch i tec ture o f l i fe Sc i Am 199827848ndash57