Radial head posterior

HVLA
Physician applies a handshake grip on the side of the
patients dysfunction and contacts the patients radius
Physician applies anterior pressure against the posterior
aspect of the radial head with the thumb of their other
hand
Physician extends the elbow to within several degrees of
full extension and supinates the hand to the restrictive
barrier
A high velocity, low amplitude thrust is applied
anteriorly to the radial head as the forearm is supinated

Reassess
---Radial head anterior
HVLA
Physician contacts the patients distal forearm and fully pronates the
forearm
Physician places the thumb or hypothenar eminence of their other
hand over the radial head
Physician flexes the elbow over the fulcrum to create a
posterior force on the radial head.
A high velocity, low amplitude thrust is applied by
increasing flexion and pronation
Reassess
---treatment position for an exhalation somatic dysfunction:
- patient lying supine and placing their ipsilateral hand on their
forehead (these two steps are the same in treating all rib exhalation
somatic dysfunctions) while the physician grasps the key rib angle
posteriorly
1st rib: anterior/middle scalenes

look straight ahead and lift her head anteriorly

2nd rib: posterior scalene
Turn her head 30 degrees away then lift it anteriorly
3rd 5th rib: pectoralis minor
Pt inhales fully and pushes her elbow towards her (contralateral) ASIS
as the physician lifts on the third rib
6th 9th rib: serratus anterior
push her bent ipsilateral arm anteriorly
10th- - 12th rib: latissimus dorsi
Pt is instructed to hold their breath in full inhalation and to adduct
their bent arm while the physician provides resistance and
simultaneously raises the key rib by pushing inferiorly on the rib angle
--CV4: to enhance CRI
CV4 is shorthand for compression of the fourth ventricle. Its done by
using the thenar eminences on each hand on the occipital bone and
drawing back on it during craniosacral flexion, thus resisting it. This is
done for a few cycles of flexion and extension, gently resisting flexion
until the inherent motion ceases and a still point is felt.
--Venous sinus drainage
With the thumbs on each hand crossing over the suture overlying the
sinus, the fascias are spread laterally awaiting a release. This is done
sequentially along the length of the suture.
--OM suture direct articulatory release: treatment for a sutural restriction
It is done by grasping the zygomatic arch of the temporal bone on the
side of dysfunction, and the occipital bone just medially to the OM
suture on the same side. While the patient inhales, the occiput is flexed
while the temporal is externally rotated. This may be repeated until
normal motion is felt at that suture
--Condylar decompression:
soft tissue technique performed by cradling the occiput with both
hands and extending the fingers from inion as far towards the foramen
magnum as possible. Then with slight flexion of the distal

interphalangeal joints, the distracting force is held until a release or

softening is felt and both sides of the occiput feel similar
--V Spread: sutural technique used to treat any restricted suture in the
skull
finger is placed on each side of the restricted suture (forming a V)
with gentle separation and distraction while the other hand is placed
opposite the suture on the other side of the head. Fluid is directed
back and forth between the 2 hands and is the activating force
in this technique.
--Myokymia: involuntary eyelid spasms
--L5 is rotated toward the deeper sacral sulcus in both type I and
type II dysfunctions
L5 = type I mechanics in forward torsions
L5 = type II mechanics in backward torsions
--hip drop test: used to evaluate sidebending of the lumbar spine
physician places hands on the iliac crest and asks the patient to bend
one knee without lifting the heel and to allow compensatory weight
shift and compares bilaterally. The iliac crest on the side of the bent
knee should drop more than 20 degrees. Less than 20 degrees
indicates restriction and is interpreted as a positive test.
--caliper ribs: move on vertical axis
bucket handle ribs: AP axis
Pump handle ribs: transverse axis
--dysfunction = position of ease
exhalation dysfunction = rib is stuck in exhalation and resists
inhalation
-rib is stuck caudad and resists cephalad movement with
inhalation
--Restriction = restriction of movement in that direction

Exhalation restriction: resists exhalation and is therefore stuck in

inhalation
Exhalation restriction = inhalation dysfunction
---Structural rib dysfunctions are the other class of rib somatic
dysfunctions, along with respiratory dysfunctions. Structural rib
dysfunctions generally have a respiratory restriction associated with
them, however the structural dysfunction should be addressed and this
likely will resolve the respiratory dysfunction. The categories of
structural rib dysfunctions are subluxations (anterior and posterior),
compressions (anteroposterior and lateral), and torsions (internal and
external).
Subluxations are a malposition of the rib compared to the rest of the
cage.
Anterior subluxations are named for position and will have a
prominence at the anterior (sternal) end of the rib, and a depression on
the posterior end as if the entire rib is shifted forwards.
Posterior subluxations are the opposite, and this position is what is
described in the question. Both anterior and posterior subluxations will
have tenderness at the rib angle secondary to iliocostalis tightness,
and because they put tension on the intercostal muscles, they are
often very painful and the patient may complain of intercostal
neuralgia.
Rib torsions are structural rib dysfunctions in which the rib twists on
itself. If present long enough, the rib can actually undergo intraosseus
changes due to the forces on it. They usually accompany non-neutral
dysfunctions in the thoracic spine and correcting the thoracic
dysfunction will often correct the rib torsion.
External torsions will have a prominent superior aspect and widened
intercostal space above it.
Internal torsions will have a prominent inferior aspect and a widened
intercostal space below.
Rib compressions are secondary to trauma and are classified as
either lateral (the force was from lateral, resulting in prominences at
the anterior and posterior aspects of the rib) or anteroposterior (the
force from anterior to posterior or posterior to anterior, resulting in
depressions on the anterior and posterior aspect and a prominent
lateral aspect).
---

Muscle energy to correct a bilateral sacral extension, like rib muscle

energy, is performed using respiratory assistance. The patient lies
prone while the physician abducts and internally rotates the patients
lower extremities to gap the sacroiliac joints. The physician places his
palm over the sacral base with the fingers pointing towards the
patients feet. The patient is instructed to hold their breath in
exhalation as the physician engages the new restrictive barrier with a
downward force. This technique is performed for 3-5 seconds and 3-5
times.
--(pronator teres compression syndrome) is a median nerve entrapment
due to a pronator teres spasm. The symptoms are similar to carpal
tunnel syndrome; however Tinels sign at the wrist is negative. Tapping
over the pronator teres muscle may reproduce symptoms.
---An exhalation somatic dysfunction with a second key rib is treated with
the patient lying supine, placing their hand on their forehead (these
two steps are the same in treating all rib exhalation somatic
dysfunctions), and turning their head 30 degrees away from the side of
the dysfunctional rib while the physician grasps the second rib angle
posteriorly. The patient is instructed to hold their breath in full
inhalation and to raise their turned head anteriorly for 3-5 seconds
while the physician provides resistance to the head and simultaneously
raises the depressed rib by pushing inferiorly on its angle. The
technique is repeated 3-5 times and then the ribs are rechecked for
symmetry.
Direct your treatment at the key rib.
Rib 1: anterior scalene
rib 2: posterior scalene
ribs 3-5: pectoralis minor
ribs 6-9: serratus anterior
ribs 10-11: latissimus dorsi
rib 12: quadratus lomborum
--Sacral Muscle energy position
Backward torsion: patient lies on side of axis, face up (BACK DOWN)
Forward torsion: patient lies on side of axis, face down (Sims
position)
---

The first step in treating group rib somatic dysfunctions with HVLA is to
identify the key rib with the mnemonic BITE (Below Inhalation; Top
Exhalation). To treat a rib somatic dysfunction with a rib 2-12 key rib,
the supine patient crosses their arms across their chest and the
patients body is flexed and sidebent away from the
dysfunctional rib. The physician stations themselves on the opposite
side of the dysfunctional rib and places the thenar eminence of their
hand over the posterior angle of the key rib.. An inhalation somatic
dysfunction is then treated with a caudal (downward) directed HVLA
thrust while an exhalation somatic dysfunction (ribs stuck down) is
treated with a thrust that is angled 45 degrees cephalad (upwards).
---Supraspinatusabduction
Infraspinatusexternal rotation
Teres minorexternal rotation
Subscapularisinternal rotation
--Chapmans point for the vagina is located just distal to the ischial
tuberosity, on the proximal posteromedial thigh
--Lumbar roll for type I somatic dysfunctionsif posterior transverse
process is pointing up, pull the inferior arm cephalad; if the posterior
transverse process is pointing down, pull the inferior arm caudally
(Type 1: up/up, down/down).
Lumbar roll for type 2 somatic dysfunctions if the posterior
transverse process is pointing up, pull the inferior arm caudally; if the
posterior transverse process is pointing down, pull the inferior arm
cephalad (Type 2: up/down, down/up)
--Order of lymph tx:
Open inlets/diaphragms from top to bottom lymphatic pump to
mobilize fluid local lymphatic tx which is dependent on symptom
--In reference to the ribcage, posterior tenderpoints are synonymous
with elevated ribs, while anterior tenderpoints are synonymous with
depressed ribs
anterior tenderpoint associated with rib three is on the third rib in the
anterior axillary line

--Trigger points are small points that radiate pain when pressed and are
treated differently than tenderpoints. One of the key differences is that
tenderpoints are non-radiating.
--The motion at the tibiotalar joint (also referred to as the superior
articulation of the talus, as well as the ankle mortise) is mainly
plantarflexion and dorsiflexion
-Motion of the talus at the mortise is anterior as the ankle
plantarflexes, and posterior in dorsiflexion
talar motion allowed by the subtalar joint is anteromedial and
posterolateral motion. Inversion of the calcaneus causes anteromedial
glide of the talus, while eversion of the calcaneus causes posterolateral
glide of the talus.
In an inversion or supination ankle sprain, the most common
dysfunction at the subtalar joint is dysfunction in posterolateral glide,
meaning it resists anteromedial glide.
--treatment position for performing muscle energy:
Upper thoracic: T1-4; use the head
Lower thoracic: (T5-12; use the raised elbow as a lever) vertebrae.
--Chapman's points are tender, rubbery nodules that form as a result of
visceral pathology. The thyroid gland, esophagus, myocardium, and
bronchi may cause Chapman's points at the 2nd intercostal space.
Choice B (4th intercostal space) indicates lung disease.
Choice C (periumbilical region) is the Chapman's point associated with
the bladder.
Choice D (6th intercostal space) is the point for stomach peristalsis (L),
liver, and gallbladder (R).
Choice E (7th intercostal space) is the point for the spleen (L) and
pancreas (R).
Other high yield Chapman's points are the following:
8-10th intercostal space: small intestine
1" superior and 1" lateral to the umbilicus: kidneys
1st intercostal space: tonsils

1st rib and clavicles, lateral to where they cross the first ribs: middle
ear
---Wallenbergs test is performed by having the patient hold their
head in six different planes of motion (i.e. flexion, extension, flexion
with left rotation, etc.) for ten second periods of time in each position
to detect vertebral artery insufficiency. A positive test is a test that
elicits neurological signs and symptoms, especially dizziness and visual
changes. Do not perform cervical HVLA on a patient with a positive
Wallenbergs test
--Bulb decompression is also known as the CV4 technique
(compression of ventricle 4) and it results in increased amplitude of
the cranial rhythmic impulse (CRI), increased flow cerebrospinal fluid
(CSF), and augments the bodys inherent ability to heal itself via the
stimulation of CSF flow out of the fourth ventricle. The CV4 technique is
performed on a supine patient with the physician sitting at the
patients head. The physician cups their hands with the thumbs on top
and then places them behind the patients head such that the weight
of the patients head is resting on the physicians thumbs. The
physician then gently augments craniosacral extension (physicians
hands rocking towards the physician) and resists craniosacral flexion
(hands rocking away). The amplitude of the patients CRI will decrease
until a still point is reached, at which point the amplitude of the CRI will
return and be increased versus its amplitude at the beginning of the
technique.
On the COMLEX, the CV4 technique can be useful in assisting women
in labor and can be used to augment the intrinsic ability of the body to
heal. Remember for the COMLEX that the physician resists flexion and
encourages extension until a still point is reached, at which point the
patients CRI will return with increased amplitude.
---Singultus, or hiccups, are caused by spasmodic contractions of the
diaphragm. Phrenic nerve (C3, 4, 5) stimulation has also been shown to
be helpful in chronic singultus.
--S5-9
L6-9
P 5 - 11
S 9 - 11
K 10 - 11
B 11 - 2
L 11 - 2

It should be remembered by splitting up the letters, first numbers, and

second numbers for memory's sake (i.e. SLPSKBL, 5/6/5/9/10/11/11,
9/9/11/11/11/2/2). Practice writing this on a piece of paper until you
have it down cold. You can use the mnemonic SLow ParaSympathetics
Kill BoweLs (SLPSKBL) to help memorize this. This will serve as an
EXCELLENT tool on test day. The letters stand for stomach/spleen, liver,
pancreas, small bowel (jejunum and ileum), kidney, bladder, lower
extremities (and the penis - "the 3rd leg") and the numbers are the
levels corresponding to each organ. The 11 - 2 for the last two are T11
- L2 and the others are all thoracic. This will cover about 90% of the
visceroscomatic questions and will save you a lot of time when used as
a reference during the test.
---C4 extended, sidebent right, rotated right;
the initial treatment position for HVLA with a sidebending thrust is
to flex the C4/5 joint, sidebend the joint to the left, and to rotate the
cervical spine to the RIGHT to lock out rotational motion of the cervical
spine. A sidebending thrust is then applied with the MCP joint of the
left hand to the left articular pillar of C4
The treatment C2-7 with HVLA using a rotational thrust is more
straightforward. Recall that C2-7 are pseudo type 2 vertebrae in which
sidebending and rotation occur to the same side. To treat C2-7 using
HVLA with a rotational thrust, the neck is flexed to the dysfunctional
segment and then the restrictive barrier is engaged in all three planes
(if it is a flexed segment, extension is induced locally by pushing the
dysfunctional segment anteriorly). The MCP of the thrusting hand is
placed on the articular pillar of the segment being treated and a
rotational HVLA thrust is applied in the direction of the patients
opposite eye.
TakeHomeMessage:
C27somaticdysfunctioncanbetreatedwithHVLAwitheitherarotationalthrustorasidebendingthrust.
Totreatwitharotationalthrust,engagetherestrictivebarrierinallthreeplanesandthendeliverthethrust
towardsthepatientsoppositeeye.
Totreatwithasidebendingthrust,engagetherestrictivebarrierinflexion/extension,sidebending,andthen
rotatethecervicalspineTOWARDSTHEPOSITIONOFEASEtolockoutcervicalrotation.The
sidebendingthrustisdirectedatthepatientsoppositeshoulder.

--Medical records must be made available within 5 working days after a

written request is made
--C5 biceps reflex

C6 brachioradialis reflex
C7 Triceps reflex
--L5 innervates tibialis anterior and extensor hallucis longus
-dorsiflexion of foot andextension of first toe
---External rotation of the temporal bone results in posterior
displacement of the mandibular fossa and the chin will be displaced
toward the side of temporal external rotation.
Temporal internal rotation results in anterior displacement of the
mandibular fossa and the chin will be displaced away from the rotation.
Internal rotation of the temporal bone also causes eustachian tube
obstruction which may cause ipsilateral chronic otitis media.
left temporal bone external rotation and right temporal bone internal
rotation would both cause manifest with the chin displaced to the left.
--(reciprocal inhibition) is the use of the reflex inhibition that occurs
when an antagonistic muscle is contracted, reflexively relaxing the
muscle on which muscle energy is being performed. An example of
reciprocal inhibition is contracting the biceps to allow a tight triceps to
be stretched.
(crossed extensor reflex) is the use of the contraction of the
contralateral muscle to relax the targeted muscle. For instance,
contraction of the right biceps can be used to reflexively cause
relaxation of the left biceps (and contraction of the left triceps).
----The mechanism of injury in a superior vertical strain is a centrally
located blow to the frontal bone. This causes traumatic flexion of the
sphenoid on the basilar portion of the occiput at the sphenobasilar
synchondrosis (SBS). Since the sphenoid will prefer flexion, it will resist
extension, and will also prevent the occiput from flexing. Vertical
strains, like all other cranial strain patterns, are given their name
based on the location of the sphenoid, not the occiput. Since the
sphenoid is flexed and the occiput extended, the sphenoidal portion of

the SBS is more superior than the basiocciput, hence why it is named a
superior vertical strain.
--Rib raising:
An upward motion of the fingertips is used to raise the rib angles
resulting in three effects: normalization of hyperactive
sympathetic tone, increased chest wall motion, and increased
lymphatic flow through the chest.
--Buzzword: CHF leads to classic nutmeg liver on COMLEX pathology
questions
--Patricks test is also known as the FABERE testFlexion,
ABduction, External Rotation, and Extension. It is performed by
crossing the supine patients leg over their contralateral lower
extremity such that the ipsilateral lower extremity forms a reversed
L. The physician then stabilizes the contralateral ASIS and exerts a
downward force on the patients raised ipsilateral knee. A positive test
elicits pain in the hip joint and is suggestive of hip pathology,
especially osteoarthritis.
Thomas test is a test of hip flexibility, which can be compromised by
inflexible or hypertonic iliopsoas muscles. The patient lies supine while
the physician flexes their hip until the patients thigh approximates to
their abdomen. A positive test is raising/flexion of the
contralateral lower extremity
Lasegues test is the eponym for the straight leg raise test
Braggards test can be added to a straight leg raise to increase its
specificity. Braggards test is performed after a positive straight leg
raise test by lowering the patients leg to just below the level at which
pain was elicited and then dorsiflexing the foot. If dorsiflexion of the
foot precipitates the same pain as the straight leg raise then the pain
is likely neurologic in etiology. If Braggards test does not incite the
pain, then the positive straight leg test raise is more likely to be due to
inflexible hamstrings.
--spurling test: cervical n root impingement
---

Hawkins-Kennedy impingement test:

The GH joint is at 90 of abduction and 30 of forward flexion; the
elbow is flexed to 90; the humerus is then internally rotated
Pain; indicates impingement of the rotator cuff tendons (usually
supraspinatus)
---Thomas test:
The patient is lying supine with the buttocks at the end of the table;
one knee is drawn up to the chest while the other leg (the one being
tested) remains passive
The knee of the tested leg is unable to flex to 90; indicates a tight
rectus femoris. The thigh of the tested leg raises off the table;
indicates a tight iliopsoas
--Trendelenburg test
While standing, the patient raises the leg opposite the side being
tested
The iliac crest of the nonweight-bearing side falls below the level of
the iliac crest on the standing leg; indicates weakness of the gluteus
medius of the standing leg
--Ober test
The patient is sidelying with the affected side up and both knees
and hips flexed to 90. The examiner stabilizes the pelvis with one
hand while lifting and extending the affected hip and returning it to
neutral. The hip is then allowed to drop (adduct) to the table
The knee does not drop to the table; indicates a tight ITB
---High Velocity, Low AmplitudeAnterior Fibular Head Dysfunction
The patient lies supine.
The physician stands by the table on the same side as the
dysfunction.
The physician grasps the patients foot on the side of the somatic
dysfunction with the nonthrusting hand.
The physician places the thenar eminence of their thrusting
hand on the
anterior superior aspect of the fibular head.
The patients knee is gently flexed.
The physician extends the patients knee rapidly, while
simultaneously

introducing a downward and medial thrust through the fibular

head.

--HVLA posterior fibular head

Use for posterior fibular head
Patient supine with knee and hip partially flexed
Stand at dysfunctional side
Place cephalad hand in popliteal area with thumb or thenar eminence
in contact with posterior aspect
Grasp ankle and foot with other hand to induce further flexion of knee
and external rotation of tibia
Direct thrust anterior and slightly lateral while flexing knee