Muscle bellies

Friction is given to a healing muscle belly after contusion, in minor muscular tears and in so-called ‘myosynovitis’. In minor muscular tears the friction is often part of combined treatment because it is usually applied after an infiltration with local anaesthesia and is followed by active contractions.

The aim of treatment in muscular tears is to allow the torn fibres to heal in such a way that normal increase in breadth on contraction remains possible, a characteristic that can be disturbed by abnormal adhesion formation. Transverse friction aims to achieve a transverse sweeping movement over the longitudinal muscular fibres without pulling on the tear, so to prevent (in the early stage) or to break down (in the chronic stage) adhesion formation between the individual fibres and between individual fibres and the surrounding connective tissue. It is obvious that to break down crosslinks in a chronic stage, the friction can be given forcefully and for a duration of 15–20 minutes, whereas in more recent lesions the technique must be applied more gently and for a shorter duration. Friction to a muscle belly is always given with the muscle well relaxed.

In recent tears, especially in the large muscles of the lower limb, friction is followed by active or electrical contractions with the muscle in a position of maximal relaxation and without weight bearing, so that tension does not fall on the healing breach.

To avoid early recurrence, friction is given for 1 week after all clinical tests have become negative. During the period of treatment, all movements or activities that bring on pain should be avoided by the patient.

Theoretically, friction can be used for all muscle belly lesions. However, some lesions respond so well to local anaesthetic infiltration that friction is not used. This is the case in type IV tennis elbow (lesion at the muscle belly of the extensor carpi radialis). On the other hand, sometimes no alternatives exist to treatment with deep transverse friction (Box 5.1). A lesion of the subclavius or intercostal muscles for instance can be treated only by deep transverse friction.

Musculotendinous junctions

It is a common clinical experience that all musculotendinous junctions (containing both muscular and tendinous fibres) throughout the whole body can be treated only by deep transverse friction. It would seem that no alternatives exist: local anaesthetics, so curative for some lesions of muscle bellies, and steroids, so effective for tenoperiosteal lesions, have not the slightest effect on musculotendinous lesions, whereas deep transverse friction usually has.

Tendons

All overuse tendinitis can be treated by deep massage except for the tenoperiosteal origin of the extensor carpi radialis brevis (type II tennis elbow), which is best treated by an infiltration with corticosteroid or, in refractory circumstances, sometimes by manipulations.

Tenosynovitis also usually responds well to deep transverse massage. In this condition, occurring in long tendons with a sheath, inflammation and roughening of the gliding surfaces of both tendon and sheath give rise to pain and sometimes to crepitus. Friction rolls the sheath around the stretched tendon, so facilitating functional movement between the tendon and its sheath. The technique is useful in both acute and chronic lesions.

Lesions at the tenoperiosteal insertion can be treated either with corticosteroid infiltrations or with deep transverse massage. Corticosteroid suspension quickly converts an inflamed and painful scar into one free of inflammation. However, the recurrence rate is rather high, between 20% and 25%.³ The aim of the massage is to get rid of the self-perpetuating inflammation by breaking up the disorderly scar tissue and adhesion formation by converting it into properly arranged longitudinal connective fibres. This takes longer but once cure is achieved there will be less of a tendency towards recurrence. It may therefore be a policy to start treatment with infiltrations but if the trouble recurs after a few months to substitute with massage.

As a rule, however, friction is always selected as the treatment of choice in athletes or when the tendon is weakened (partial rupture). It cannot be denied that repeated use of corticosteroids, even in small doses and correctly applied, temporarily weakens a tendinous structure. Steroids also take away inflammation and pain, so giving the patient the false impression of being cured. The combination of a weakened tendon and abolition of pain can be disastrous – rupture may ensue.

There exist also a few conditions that seem to respond only to deep transverse friction. Steroid infiltrations are useless here. This is so in tendinous lesions of the interosseus in the hand and at the quadriceps expansion at the patella.

Lesions in the tendinous body, either traumatic or resulting from overuse, are contraindications for infiltration with corticosteroids. Ruptures have been reported after intralesional steroid infiltrations of long tendons and therefore deep frictions are the treatment of choice here.22,23

It is obvious that during the whole period of treatment of tendinitis, tenosynovitis or tenovaginitis, the patient must avoid all activities that provoke the pain, especially the loading of the affected contractile tissue.

Ligaments

Transverse massage is an excellent treatment in acutely sprained ligaments, especially in ligaments of the knee and ankle. The background, mode of action and technique differ considerably and depend on the stage of the lesion.

It has been explained (see Ch. 3) that early mobilization is extremely important for swift and full recovery of ligamentous sprains. However, in advocating this, one main difficulty is encountered: the intensity of the initial inflammatory reaction. The slightest movement causes pain which forces the patient to immobilize the joint and the ligaments. However, during immobilization, regenerating fibrils quickly start to form randomly organized scar tissue, leading to crosslinks and adhesion formation. This problem can be solved by gentle transverse frictions. Rhythmic movement across the inflamed ligament eases the pain and the tissue can be moved to and fro in an imitation of its normal behaviour.

In recent cases the friction need not last long nor be very vigorous – 1 or 2 minutes of daily gentle transverse sweeping movement over the regenerating fibrils is enough. As pain diminishes over subsequent days friction is progressively increased to about 4–5 minutes for 2 or 3 days and finally to a full duration of 15–20 minutes. From the third day, friction is followed by passive and active movements within the limits of pain to maintain normal gliding of the ligament over adjacent bones. When the lower limb is involved, the patient should be instructed to walk as normally as possible but without provoking too much pain.

In chronic ligamentous lesions, frictions are also used but in a totally different way. Here adherent scar tissue has formed abnormal attachments as the result of healing during a period of insufficient movement. As a result of the reduced mobility of the ligament, vigorous use of the joint re-sprains the ligament and in due course leads to recurrent sprains.

Treatment will consist of rupturing the adhesions by manipulation, for which vigorous deep friction to the site of the adhesions prepares the ligaments. The massage weakens and desensitizes the structure, making the forced movement practicable and painless.

Experience has shown that particular ligamentous lesions can be treated only by friction. This is the case for the posterior carpal ligaments at the wrist and the tibiotalar ligaments.

Joint capsules

Deep transverse friction can be applied to the capsules of the trapezium–first metacarpal joint, the temporomandibular joint and the cervical facet joints. The indication is traumatic arthritis or osteoarthrosis. Results are fair, provided the arthrosis is not too advanced. Indications and contraindications to friction are outlined in Table 5.1.

Ossification and calcification of soft tissues

Extensive ossification in muscles, tendons, ligaments or capsules is a bar to all active treatment. However the minor calcifications that may occur after a sprain can be managed by friction. In supraspinatus tendinitis, calcification is regarded as responsible for complaints when the insertion is very tender to touch and a radiograph shows calcification. These findings are a contraindication to friction. In contrast, when calcification is present in the absence of severe tenderness, transverse massage can be given.

Bacterial and rheumatoid-type tendinitis, tenosynovitis, tenovaginitis

All types of bacterial and rheumatoid disorders, no matter at what stage of inflammation, are absolute contraindications to friction.

Skin problems such as ulcers, psoriasis and blisters

When normal skin has been abraided – sometimes by friction – massage should not be given. In skin disorders, it must be abandoned when stable skin–finger contact becomes impossible and friction aggravates the skin problem.

Neighbouring bacterial infection

Because these may be reactivated by or may extend if friction is used, it must be postponed until the infection has resolved.

Bursitis and disorders of nerve structures

When bursitis is mistaken for a tendinous or ligamentous disorder and friction is given, the problem will either increase or, at best, the pain will remain unchanged – it certainly will not improve. Friction to a nerve is also harmful.

Haematoma

A haematoma in a muscle belly or after an ankle sprain is not a contraindication to friction. Even if the haematoma is the result of deep friction, treatment may be continued unless the effusion is large.

To-and-fro movements

These are used in the treatment of dense, round or flat collagenous bundles (tendons or ligaments) and in the treatment of tenosynovitis. The active phase is a sweep with the tip(s) of one or two digits across the tendinous structure. During the passive relaxation phase the finger is returned to the starting position, without losing contact between finger and skin. Movement is with the arm; friction is given by use of the pulpy part of the finger (Fig. 5.2). In large lesions, as in peroneal tendinitis, two or three adjacent fingers are used together. In deep-seated lesions as in tendinitis of the long head of biceps in the bicipital groove or at its insertion on the radius or in infraspinatus tendinitis, the thumb performs friction.

Counterpressure is usually provided to enable a good sweep. The finger(s) applying counterpressure and stabilization are most important in bringing those applying friction into the right position and also determining the direction of the friction. The thumb is used (to give counterpressure) when the sweep is performed by a movement of the index reinforced by the middle finger or the middle finger aided by the index finger. When the thumb does the massage, counterpressure is from the fingers (Fig. 5.3). The most common way of applying friction around a round edge on a flat surface is to use the index reinforced by the middle finger. Sometimes the opposite is done: the middle finger is reinforced by the index. Sometimes counterpressure is not given, for example in friction to the quadriceps expansion or intercostal muscles.

Pronation–supination

This technique is often used where the lesion is difficult to reach: the anterior aspect of the Achilles tendon, popliteus tendon and the dorsal interossei of the metacarpals. Massage is performed with the pulpy part of the third finger (long finger), reinforced by the index finger. The long finger is used because its long axis is the prolongation of the axis of pronation–supination rotation of the forearm (Fig. 5.4).

The active phase is usually on supination. No counterpressure is given. Caution is taken not to move the finger on the skin but rather to move the skin and the fingertip as a whole. The passive phase is the pronation movement that brings the frictioning finger back to the starting position without losing contact with the skin.

Pinch grip

This is the normal technique for a muscle belly. The pinch is between the thumb and the other fingers. The muscle is fully relaxed. The fingers are placed at one side of the affected area and the thumb at the opposite side (Fig. 5.5). By drawing the fingers upwards over the affected area, the therapist feels the muscle fibres escape from the grip until only skin and subcutaneous tissue remain.

During the passive phase the fingers are slightly relaxed and moved downwards into the previous deep position where the same movement starts again.

Sometimes the same technique is used in tendinous lesions, for example, at the sides of the Achilles tendon.

• The depth of the lesion: that friction must always reach sufficient depth to move the affected fibres in relation to their neighbours and sometimes the underlying bone or capsule, increased pressure must be applied to deeper structures.

• The ‘age’ of the lesion: recent sprains and injuries require only preventive friction because crosslinks or adhesions have not had time to form. In long-standing cases more pressure is needed to get rid of these. However, pressure should always be associated with movement and should not replace it because pressure alone is both painful and ineffective.

• The tenderness of the lesion: in severely inflamed lesions that are very tender to touch, friction with the usual amount of force may be very painful. Pain can be avoided by starting with a minimal amount of pressure – just enough to reach the lesion – and progressively increasing the force as treatment proceeds.

To promote healing of injured connective tissue

Passive movements within the pain-free range are usually called for in the treatment of injured connective tissue. A comprehensive literature evaluation and meta-analysis of experimental studies of the past several decades have demonstrated that regeneration of injured connective tissue is significantly better with the application of continuous passive motion. If the healing tissues are not loaded, regeneration results in unstructured scar tissue. Under functional load, the collagen fibres are oriented in a longitudinal direction and the mechanical properties are optimized.²⁴

Grade A mobilizations are therefore applied early in the treatment of sprained ligaments to promote orientation of the regenerating fibres. They are given in conjunction with gentle transverse massage and within the pain-free range. Care should be taken not to bring the fibres under longitudinal stress in order not to disrupt the healing breach. The movements are of short duration but repeated often.

Distractions at the shoulder

Grade A mobilizations are also used on the capsule of the shoulder in stage III arthritis when stretching and intra-articular steroids are contraindicated (see Ch. 14). In this condition, long-standing stimulation of the nociceptors has increased neuro-sympathetic activity, giving rise to vasoconstriction, muscle spasm and pain.

Gentle and rhythmical grade A movements are performed in such a way that the fibres are stretched longitudinally, stimulating the mechanosensor mechanisms in the joint and so inhibiting somatosympathetic reflexes that are co-responsible for the increased inflammation of the joint.

Deformity correction

Some cases of lumbago show persistent spinal deviation even after the pain has ceased. A quick thrust manipulation so effective in relief of pain is not effective in correcting the remaining deformity, but sustained translatory gliding in the opposite direction is most helpful. The movement is performed slowly and care is taken to keep the gliding within the pain-free range (see Ch. 40).

Reduction of an intra-articular displacement in a peripheral joint

When a meniscus or some other piece of intra-articular cartilage (with or without an osseous nucleus) becomes displaced and locks a joint, the logical treatment is either to remove it or manœuvre it into such a position that the joint can again move freely over a normal range. The technique needed for the latter is usually a series of manipulative movements which normally contain elements of traction combined with movements of rotation and flexion or extension. In general, these are first performed in the less painful direction of movement and repeated several times with progressively increasing force.

Unlike manipulations in the spine, the manœuvre to reduce an intra-articular loose body is not a grade C mobilization because the movement is not performed at the end of range nor does it contain a ‘thrust’ element. The flexion–extension movement is over a wide range and stops before the end-feel is reached. The rotation movements are performed to the end of range where end-feel is sensed by the therapist. The ‘manipulation of an intra-articular displacement in a peripheral joint’ is therefore a combination of grade A and grade B mobilizations.

To maintain a normal range at the joint

Paralysed muscles may lead to a loss of normal range of motion of the corresponding joint. This can be avoided by gently stretching the capsule, starting as soon as possible after the onset of paralysis. The approach should also be considered for joints that have been injured or subjected to surgery. In such circumstances, there may be the paradox that immobilization is needed for a fracture to heal but that movement is required to prevent loss of capsular elasticity. Often the problem can be solved by adapting the technique of capsular stretching so that it does not influence the site of the fracture.

To stretch the capsule of a joint

Grade B mobilizations may be required to stretch the joint capsule in non-acute arthritis and in early osteoarthrosis. The technique will be further referred to as capsular stretching. Capsular stretching is particularly useful in shoulder and hip joints but is applicable in all ‘non-irritable’ capsulitis. The condition is characterized by:

In the very beginning of arthritis, muscle spasm forces the joint to be held in a position of ease, so restricting movement in some directions more than in others (see Capsular pattern, Ch. 4). Immobilization and inflammation cause disordered deposition of collagen fibres in the joint capsule and lead to the formation of capsular adhesions, which in turn are responsible for more restriction of movement and pain. Stretching aims at restoring mobility and function by breaking micro-adhesions and producing elongation of the shortened capsule. To be applicable, however, the ligamentous end-feel must be reached before the protective muscle spasm begins. To be successful, the therapist should therefore be able to differentiate between an elastic and a spastic end-feel.

The technique is a slow and steady pressure, performed at the end of range over about 30 seconds to 1 minute with as much force as is reasonable for the patient to bear. Tension is slightly diminished for a few seconds, so affording the patient some respite, and then again increased. From time to time the procedure is completely interrupted. If tension is released too quickly, some pain may be felt and it is therefore wise to bring the limb back into neutral position under traction. The technique is not painless. The stretching causes some micro-ruptures, which result in an inflammatory response and after-pain that lasts for a few hours.

Normally, capsular stretching is given for 15–20 minutes, three times a week. The therapeutic effect is slow.

Capsular stretching can be preceded by application of heat, either through short-wave diathermy or ultrasound. This can relieve some pain and seems to lower the viscosity of the collagenous tissue, allowing more movement for less force. In vivo studies on the effects of heat on ligament extensibility have shown that sustained force applied after elevating tissue temperature produced significantly greater residual elongation.25,26

Manipulation of a joint capsule under anaesthesia is a grade C mobilization and is only considered for postoperative intra-articular adhesions. A joint that has been manipulated under anaesthesia requires daily intensive mobilization immediately afterwards in order to prevent the formation of new intra-articular adhesions.

To stretch a muscle

Children with short calf muscles can be helped by sustained stretching. The procedure consists of a series of alternating passive stretchings and active contractions. Stretching is maintained for about 8–10 seconds and is followed by full relaxation and active contraction of the muscle. These alternating movements are performed six to eight times per session, preferably daily but at a minimum of three times a week. The earlier the stretching is started, the better the result. Above the age of 15 not much improvement can be expected.

Traction

Traction is used to separate articular surfaces from each other and can be employed in two ways: as an accessory to manipulation or as the sole treatment. Reducing a displaced fragment is obviously easier when the bone ends between which it lies are pulled apart. If the fragment projects beyond the articular edge, tautening of the ligaments and capsule also provides a centripetal force. In that traction diminishes the pressure on the fragment, pain decreases, which allows the patient to relax the muscles more.¹⁸ In the cervical and thoracic spines, traction is a built-in safety measure for protecting the spinal cord during manipulation (see below) although the use of traction for this purpose and at these sites does not imply that manipulation can be performed on a basis of ‘try and see what happens’ without a proper diagnosis.²⁷

In the spine, traction is used as the sole treatment only in nuclear disc protrusions, which are rare at the cervical and thoracic levels but are more common in the lumbar area. Spinal traction is always mechanical and is performed with the help of a harness (lumbar or low thoracic) or a sling (cervical or upper thoracic). Spinal traction distracts the intervertebral disc spaces. It also pulls the apophysial joints apart and slightly widens the intervertebral foramina.27–31 At the same time, negative intradiscal pressure is produced with centripetal ‘suction’ on any protrusion. The posterior longitudinal ligament is tightened, which may help reduce a displaced fragment. All these elements are helpful in the progressive reduction of a nuclear disc protrusion. Reduction of herniated bulges has been demonstrated on epidurography^31–33 and on CT scan³⁴ during and after traction. The effect of traction depends on the amount of force applied, the length of time per session, the interval between each session and the total number of sessions.³⁵

Rupture of ligamentous adhesions

Small ligamentous adhesions sometimes develop between a healing ligament and bone. They usually result from a sprained ligament that has been immobilized during the healing process. The usual presentation is at the lateral ligaments of the ankle and at the medial collateral ligament of the knee. The clinical features are local pain during exertion and a small limitation of movement in one direction only. The adhesions can be ruptured by a high-velocity, small-amplitude thrust manipulation, after preparation of the affected ligament with intensive deep transverse friction.

The joint is stretched as far as possible in the limited direction and manipulated with a single firm thrust, during which a typical ‘snap’ is often heard. Harm is not caused to the ligament nor to the other parts of the joint because the adhesions bear the brunt of the force. The manipulation is almost painless and after-pain is not to be expected. A successful manipulation should achieve an immediate result. Active movements during the following days to maintain function should be highly encouraged.

Rupture of tenoperiosteal adhesions

In type II tennis elbow (tendinitis of the attachment of the extensor carpi radialis brevis), adherent and disorganized scar tissue causes a self-perpetuating inflammation. The manipulation aims to rupture the adhesions and produce a permanent elongation of the tendon. The high-velocity manœuvre is preceded by thorough deep transverse friction in order to numb and to weaken the spot. The manipulation is performed only once per session; 10–15 sessions may be required to achieve a result.

To reduce a bony subluxation

A subluxation of one of the carpal bones or of the cuboid bone can easily be reduced by digital pressure combined with translatory movement during traction.

Capsular inflammation

Forced movements should not be performed when signs and symptoms of capsular inflammatory activity are present. These are spontaneous pain, pain especially at night, wide reference of pain, inability to lie on the affected side at night or to bear weight on the affected side. Local warmth and effusion are other pointers of a highly inflamed joint. However, if these symptoms and signs are present but the rest of the clinical examination demonstrates internal derangement (e.g. knee, hip, ankle), manipulation is indicated and can safely be performed.

Muscle spasm

Grade C mobilizations should never be applied to a joint that is protected by a muscle spasm. Grade B mobilizations may be used unless the end-feel of the movement that is intended to be forced through is also spastic.

Severe osteoporosis

Grade B mobilizations, for instance stretching of the shoulder or hip joint in elderly people, should always be carried out with caution for fear of fracturing the humerus or the neck of the femur.

Joints and ligaments not under voluntary tension control

Mobilization is also contraindicated for those joints and ligaments on which the tension is not under voluntary control. This is the case for the acromioclavicular, the sternoclavicular and the sacroiliac joints and the sacrococcygeal ligament.

Even if you have a hammer in your hand not everything you see is a nail. Therefore indiscriminate use of spinal manipulative therapy must not be made if the criticisms that have been justifiably levelled at chiropractice and osteopathy are to be avoided. The development of postgraduate courses in manipulation is welcome, although some have overvalued the benefits of manipulative therapy. All who undertake manipulation have experienced the feeling of pride and joy in producing cure. It is the duty of those who have more experience of the benefits and limitations of manipulative therapy to moderate the understandable enthusiasm of those entering the field – a few successes may quickly lead to the temptation to manipulate every patient for any disorder.⁴¹

Osteopathy

The concept of osteopathy was introduced by A. T. Still (1828–1917) and developed out of frustration with traditional medicine. His ideas were based on two principles: (1) the body has within itself the processes to combat all disease, and (2) the cause of all disease is dislocated bones, abnormal ligaments or contracted muscles with consequent mechanical pressure on blood vessels and nerves.

Diagnosis is mainly based on palpation for restricted spinal mobility and treatment consists of a manipulative system in which joints are forced by a distant leverage. Cure is sought for all kinds of visceral and musculoskeletal disorders.²⁷

Chiropraxy

This method was started in 1885 by D. Palmer. It is based on a revision of techniques that originated with Hippocrates and is also influenced by osteopathy. Chiropraxy was long regarded as maintaining osteopathic dogma in its most primitive form and having a strong commercial character.

Chiropractors also claim to cure visceral diseases via the musculoskeletal system. Diagnosis is made on palpation for vertebral displacement and manipulative pressure is applied directly to the bone.

Orthopaedic medicine

This term describes the system of diagnosis and treatment of musculoskeletal lesions introduced by J.H. Cyriax. It is the system on which this book is based. Diagnosis rests on careful history and functional examination. Treatment depends mainly on the type of lesion, and manipulation is applied only when indicated. In spinal manipulation, Cyriax proposed a fixed set of high-velocity, small-amplitude thrusts performed at a certain distance from the lesion and, characteristically for this method, usually under strong traction. The objective of Cyriax’s spinal manipulative techniques is to alter the discodural or discoradicular interaction by moving a displaced cartilaginous fragment away from the sensitive dura mater and dural nerve sleeve. Spinal rotation manipulations apply a torsion stress throughout a whole part of the spine, not at just one level. With an intact posterior longitudinal ligament and annulus fibrosus, some of this torsion force exerts a centripetal force by suction on the protruding disc material.⁴² This effect is not confined to one level and full reduction is not absolutely necessary for pain relief, in that when contact between dura and disc has ceased the problem is frequently solved.

Manual therapy

Treatment is characterized by rhythmic repeated movements within the physiological range. Oscillatory techniques had already been used by E. Cyriax (father of J.H. Cyriax) but were more widely employed by Maitland and later slightly changed by the different schools of manual therapy (Cyriax:³ p. 40). Pressure is applied to what is believed to be the appropriate level.

Traction during manipulation

Most types of spinal manipulation in orthopaedic medicine are performed under traction. For the cervical and thoracic spine, traction is applied by the manipulator with the help of a fixing belt or by one or two assistants. At the lumbar level, traction is usually already built into the manœuvre. Traction facilitates the reduction of a displaced fragment and provides an important safety element against the possibility of a protrusion contacting the spinal cord during manipulation.

End-feel on taking up the ‘slack’

All spinal manipulations are performed over only a small amplitude. Therefore all ‘slack’ must be taken up by moving the vertebral joints passively to the end of the normal passive range of movement. At this stage it is absolutely necessary to have a clear idea of the end-feel, which is nominally elastic for the entire spine. An end-feel that does not correspond with this – muscle spasm, or hard or empty end-feel – is an absolute contraindication to any manipulation and the manœuvre is not continued.

Final thrust

Immediately after the slack has been taken up in the surrounding tissues, a minimal amplitude, high-velocity thrust is given to affect the target tissue. The velocity is of great importance because tissues loaded quickly are stiffer so that the manœuvre will affect only the displaced fragment of disc and will not damage the surrounding structures.⁴³

The amount of force used for the final thrust depends mainly on the patient and manipulator in that a tall manipulator will have to use less force in a small patient and vice versa.⁴⁴ The length of the lever (see later) is also important. The force should always be kept reasonable and may be progressively increased, according to the immediate result.

The manipulation thrust is often accompanied by an audible ‘pop’.29,45 Although it is a common belief that pops or clicks are provoked by the formation of a temporary vacuum, as occurs in small peripheral joints put under traction,^46–48 this is not definitely established for the spine. An alternative and more likely explanation is movement of cartilaginous fragments, as may be heard during manipulation for a loose body in the knee or hip. If the clicks were simply the result of the collapse of a vacuum they should also be – but are not – heard during mechanical traction, in which the traction force is much higher.

Leverage

The amount of force used depends on the length of the lever. If for example a rotation of the lumbar spine is forced via the shoulder and pelvis, the lever offered by the shoulder is the same length as that offered by the pelvis, so an equal amount of force must be used by both hands. But if the femur is used instead of the pelvis, the length of the pelvic lever doubles. The hand on the shoulder must apply double the amount of force that is used on the knee. The longer the lever, the less force is needed.

Reassessment

After each manœuvre the patient is assessed, the criteria of success being the absence of symptoms and the restoration of pain-free movement. The patient and not the manipulator is the arbiter.⁴⁹ Depending on the immediate outcome, the therapist decides whether to repeat the same manipulation, probably with increased strength, to try another manœuvre or to refrain from further manipulation.

It should be appreciated that after successful manipulation the anatomical lesion is still present: a piece of cartilage, although put back in place or into a neutral position, persists and may redisplace. For this reason, those who undertake manipulation should note the results obtained and what manipulations were used, in case of recurrence.

Figure 5.6 outlines the assessment of spinal lesions and their manipulation.

Selectivity of diagnosis

Osteopaths and manual therapists claim to have developed the clinical skills to localize by palpation the exact site of fixation, and are therefore able to perform the manipulation at the required level. Diagnosis is mainly based on segmental mobility tests: joint play, springing test or tests of passive physiological movements. Movement can be tested by exerting local pressure at one side of a vertebra while counterpressure is applied to the contralateral side of the vertebra above or below. For the lumbar spine, it can be done with the patient on the side with both hips flexed to 90°. Small movements of the thighs cause the lumbar spine to flex or extend which can be detected by palpation of the spinous processes.

Other practitioners look mainly for palpable soft tissue changes, such as local subcutaneous thickening or exquisite tender spots (trigger points) in muscles, ligaments (iliolumbar, sacroiliac) and over bony prominences. All these are considered to be important diagnostic and therapeutic factors.

The great variability in the extent of spinal stiffness between subjects, or at different levels within the one subject, makes the determination of areas of abnormally increased stiffness difficult. Increased stiffness may in fact be a normal variant and bear no relationship to the patient’s presenting symptoms. Few of those advocating segmental mobility tests have seriously examined the value of their tests. They have generally presumed that the tests were useful because their patients got better.⁵⁰ However, several studies have failed to demonstrate the reliability of these tests.^51–62 Therefore it must be made clear that judgement of small changes in the range of movement of a segment, in the absence of full restriction of movement, remains a very subjective finding, which depends mainly on the personal conviction of the examiner rather than on objective measurements. Moreover, in soundly based tests, findings must be reproducible and must show correspondence when performed by other investigators. In the establishment of ‘joint play’ the inter-observer discrepancy is too large to be acceptable.⁶³ In 1973, Cyriax attended a demonstration in which five therapists, all of whom specialized in mobility testing, examined over a period of a few minutes a patient with a neck problem. There was no agreement between these specialists about the level of the lesion (C2, C3, C4, C5, C6 or T2), or about the direction of restriction (see Cyriax:⁶⁴ p. 108). Similarly, a patient who had congenital fusion of the sacroiliac joints was examined by 10 manipulators. Each had his own diagnosis, such as left anterior sacrum, right anterior sacrum and bilateral posterior sacrum, although ‘the tests were very positive’ for all of them (see Maigne⁶⁵ and Cyriax:⁶⁴ p. 363).

Even if it were possible to identify with certainty localization of the hypomobile segment, the question remains as to whether this is also the site of the lesion. Studies have shown that frequently the lesion does not lie at the joint where motion is restricted but at one which appears to be normal.⁵⁵ Moreover, other disorders such as osteophytosis, congenital fusion and ankylosing spondylitis all give rise to restricted movement which is usually painless.

Selectivity of manipulation

Manipulation is often accompanied by immediate relief of symptoms and signs which, since success has been obtained, is logically taken as absolute confirmation of the precision of diagnosis and treatment. Such a deduction may be – and often is – totally wrong. The only thing proved is that the manipulation was efficacious. The erroneous reasoning that successful manipulation necessarily confirms the diagnosis has been and is still today an important argument for the false belief of some schools that manipulation can cure all kinds of disorders even including visceral diseases. A typical example is pectoral pain, resulting from a thoracic discodural interaction which is misdiagnosed as angina. The patient goes to an osteopath who manipulates the thoracic spine and the pectoral pain ceases immediately. Both patient and manipulator, misled by the wrong diagnosis, will believe that the manipulation has altered autonomic tone and cured the angina, whereas what it actually did was interrupt the discodural interaction.

In orthopaedic medicine most manœuvres used are non-specific long-lever manipulations. These include all procedures in which a force is exerted on a part of the body some distance away from the area where it is expected to have its beneficial effect. Levers may include the shoulder, transverse processes and parts of the skull, pelvis or thigh (Frymoyer et al:⁴⁵ p. 1594). Although some criticize the crudity of long-lever high-velocity manipulation it should be realized that it is not elegance, impressiveness, specificity or technical difficulty which count but effectiveness and safety. Furthermore, the use of a lever enables the manipulator to reach the lesion more effectively. During the preparative phase – on taking up the slack – all the normal joints are brought to their anatomical end position except for the joint that is blocked. When the additional thrust is given, the final extra pressure falls inevitably first and to the greatest degree on the deranged joint. The manœuvre thus becomes specific even though in general the techniques are regarded as non-specific.

Long-lever manipulations are in full contrast to what are called ‘specific’ short-lever high-velocity manipulations. Here the goal is to act specifically at what is believed to be the level of the lesion. The spinal segment and the facet joints adjacent to the lesion are locked by moving the spine to the physiological limit of passive movement and a high-velocity small-amplitude thrust is given to the short vertebral lever (transverse process or spinous process) in the specific direction that will liberate the restricted movement. However, it is technically not possible to lock all other joints and then to manipulate at just one level (Cyriax:⁶⁴ p. 108). It was even demonstrated that by mobilizing the sacroiliac joints after locking of the lumbar spine, the largest movement took place between L4 and L5.⁶⁶ Furthermore, if diagnosis fails to be absolutely right, how can there be certainty as to the exact level of the lesion to work on? Fortunately for those who employ ‘specific’ short-lever manipulations, these are much less specific than they think, because the manipulations actually cover a much larger part of the spine and so unintentionally also include the lesion.

Specificity is a false attribute. The methods that claim to lead to specific localization in both diagnosis and treatment are scientifically unacceptable. Claims of specificity are made in order to give prestige to manipulators who claim to feel something that cannot be felt. Manual therapists, chiropractors and osteopaths over-complicate their teaching and often create excessive patient dependency, instead of providing the patient with independence. Indeed, patients are encouraged to return at regular intervals for pointless prophylactic adjustment.⁴¹ We support R. McKenzie’s conclusion that demystification of spinal manipulative therapy is an urgent priority.⁴¹ Chiropraxy, manual therapy and osteopathy, however, thrive by creating the impression that there is something complex and exclusive about the practice of passive end-range motion that only experts in these practices can understand or have the skills to feel. The belief is strong that expertise in the understanding and delivery of spinal manipulative therapy requires 3 or 4 years’ training. The main advantages of the methods discussed in this book are that the manipulations are much simpler and at least as effective as those advocated by chiropractors, osteopaths and manual therapists. Non-specific long-lever manipulations are quickly effective, do not take long to perform and are simple to learn. Moreover, they can take only about 180 hours of tuition, provided that the student has already gained qualifications in medicine or physiotherapy.

Bleeding disorders and anticoagulant use

When normal clotting of blood is not guaranteed, as in congenital or acquired (liver disease) bleeding disorders or because of the administration of anticoagulants (Box 5.3), spinal manipulations are potentially dangerous. Disastrous results can follow, such as intraspinal haemorrhage with the formation of a haematoma that may lead to sensory and motor deficit, to paraplegia, quadriplegia or death.⁷⁸ For this reason, a coagulopathy is an absolute contraindication to spinal manipulations. Manipulation can be safely performed only after blood clotting tests have returned to normal.

Spinal tumours, unstable fractures, vertebral infections and severe osteoporosis (see Grieve:²⁷ p. 829)

These all result in weakening of bone with risk of further damage by manipulation. Long-lever manipulation is not safe in severe osteoporosis.

Rheumatoid arthritis, psoriatic arthritis, Reiter’s syndrome and ankylosing spondylitis

The first three of these may be associated with ligamentous laxity and gross destruction of the joint with subsequent instability. Manipulation must not be undertaken. The same applies for the inflammatory stage of ankylosing spondylitis. In the unlikely event of a patient with this disorder developing a disc lesion, manipulation is not at all safe, especially in the cervical spine, where luxations, fractures and cord compression have been described.⁷⁹

Neurological deficit and spinal cord compression

Segmental neurological deficit is characterized by disturbance of either motor function, with impaired reflexes and/or muscular weakness, or sensory function, with diminished sensibility. The two may be combined. Segmentally referred pins and needles due to compression of the sensory fibres of a nerve are not regarded as neurological deficit and are therefore not a contraindication. In neurological deficit, manipulation is usually without value because deficit suggests a large protrusion that cannot be reduced. This opinion is not universally supported,80,81 and some still manipulate when minor neurological signs are present. However, in all instances where progressive neurological deficit is present, manipulation must not be done.

A similar rule applies in cord compression or cauda equina syndrome when a very large posterocentral protrusion threatens the spinal cord or the cauda equina. This is true not only for obvious signs but also in the presence of even the slightest symptoms, such as extrasegmental pins and needles or pain in the S4 dermatome.

Hypermobility

In several schools of thought on manipulation, too much emphasis is placed on hypermobility. Although it is true that special attention must be given to hypermobility in the cervical spine, it is not important elsewhere. A hypermobile joint may move further than an ordinary joint, but once extreme range is reached it stops in exactly the same way as does an ordinary joint. More often the disc fragment itself is hypermobile, which may lead to frequent recurrences. This circumstance does not contraindicate manipulation but calls for extra measures to achieve stabilization, for example by infiltration with ligament sclerosant (see Cyriax:³ p. 38).

For the cervical spine a history of frequent disc problems, alternating from one side to another, may be suggestive of hypermobility. When doubt exists the following tests may be useful: spinal flexion with putting the palms flat on the floor with knees straight, passive apposition of the thumb to the flexion aspect of the forearm, passive hyperextension of the fingers parallel to the external surface of the forearm and hyperextension of the elbow and/or of the knee of 10° or more. If one or several of these are positive hypermobility is likely.⁸² Also, when the end-feel on passive rotation, extension or on preparation for a straight-pull manipulation is too elastic, further manipulation must cease.

Spinal manipulation under anaesthesia

Spinal manipulation should never be done in an unconscious patient. First, anaesthesia is unnecessary. Second, the final warning of potential danger offered by increased pain or abnormal end-feel on taking up the slack is completely lost, as is clinical assessment after each manœuvre. Consequently, complications are more frequent after manipulation under anaesthesia.⁸³

Patients who have difficulties in relaxing during manipulation may benefit from being given diazepam before a session.

General considerations

Manipulation is, as with anything in medicine, not without danger and it must be admitted that even in experienced hands accidents may happen. Therefore manipulative treatment must never be undertaken recklessly, or on a ‘hit or miss’ basis.³ Although it is probable that more accidents have occurred than have been reported, the risks must not be overstressed.^40,99 In 30 years of clinical practice Kirkaldy-Willis²⁹ (his p. 293) did not have one patient who was made worse by a manipulation. Dvorak and Orelli estimated that in 1 out of 400 000 manipulations severe neurological damage results, and in 1 out of 40 000 slight neurological signs appear.¹⁰⁰ It should not be forgotten that traditional treatment with non-steroidal anti-inflammatory drugs is also not without complications, in that they may give rise to severe gastrointestinal problems (mucosal bleeding, or reactivation of previous ulcers or initiation of new ones), haemolytic anaemia, leukopenia, thrombocytopenia and even fatal agranulocytosis, salt and water retention, albuminuria, nephritis, acute renal insufficiency, or to allergic reactions in all degrees of severity. No matter what treatment is given there will always be an inherent risk, but this should be reduced to a minimum by taking all necessary precautions.

Complications of manipulation can range from a temporary slight increase in pain to severe neurological deficit and death.

Risks in relation to level

The risks involved in manipulation differ at the cervical, thoracic and lumbar levels.

Measures to prevent complications

Although complications may occur and cannot be totally excluded by any means, each manipulator should try to reduce the eventuality to the lowest possible degree. It would be wrong to condemn the manipulator simply because a mishap or a complication occurred. If this was done it would mean that, instead of getting on with his work, the practitioner would forever be ‘looking over his shoulder’. It is not possible to arm oneself against unpredictable events. Even if they do occur occasionally, this argument should not be used to condemn manipulation.¹¹⁶

Obviously all measures must be taken to decrease the risks as far as possible. In orthopaedic medicine the necessary steps are taken during the whole procedure, starting with the history, through clinical examination, technical investigations and ending with the manipulation itself. Safety measures and acknowledged warning signs are incorporated in each stage. These are discussed in detail in the relevant chapters and are only briefly outlined here.

• Hand antisepsis

• Skin antisepsis at the site of insertion

• Disinfecting the rubber septum with alcohol prior to piercing it

• Using a new sterile syringe and sterile needle to draw up the fluid while preventing contact between the needle and the hands

• Removing the needle and using a fresh one for the injection

• Using a no-touch-technique: neither the tip of the needle, nor the skin at the site of insertion should be touched after skin antisepsis

• Using gloves? Gloves can only be used if an assistant handles the non-sterile packages and vials and prepares the syringes. In our opinion, the use of gloves does not add to aseptic safety, if the rules mentioned above are strictly followed.

Dynamic infiltration

This is used mainly when large amounts of product have to be administered in extensive lesions. Three different techniques are used, mainly conewise, fanwise and cylindrical infiltration. A further technique is used for static infiltration.

Static infiltration

This technique is mainly used to put a small amount of fluid into a well-delineated area. It is indicated for tendinous insertions and ligamentous attachments to bone. These offer considerable resistance to depression of the plunger. Hence the smallest syringe must be used to provide enough purchase to force the product into the structure. When the tip of the needle lies at the exact site, a typical counterpressure is felt during insertion, just before its point hits the bone. Now a few droplets are injected with the tip of the needle in bony contact. The needle is then five to ten times partly withdrawn and inserted at slightly different angles and depths (Fig. 5.10) until the full amount has been administered and the whole lesion has been treated. The technique is sometimes referred to as peppering. During the entire infiltration a typical resistance is felt, much more marked than during infiltration of a muscle belly or a bursa, where resistance is minimal.

Procaine

Procaine is an ester of para-aminobenzoic acid and was first synthesized in 1904 by Einhorn. Until 1943 it was the only anaesthetic available.¹⁴⁰ It is quickly and locally metabolized by an esterase, giving rise to the acid itself, which may act as an allergen. Its effect begins after 5–10 minutes and lasts approximately 45 minutes. The maximum dose used is 250 mg, which corresponds to 50 ml of a 0.5% concentration.

Although classical texts emphasize the hazard of allergic reactions, we have used procaine several times daily for over 20 years without any problems. Cyriax estimated the risk as 1 per 500 000 administrations.

The usual concentrations employed are 0.5 and 2%. Indications for 0.5% procaine are lesions of muscle bellies, most cases of chronic bursitis and caudal epidural injection. Procaine 2% is used to dissolve calcifications in tendons and bursae, and in sinuvertebral nerve blocks.

Amides

Newer local anaesthetics are the amides. They are metabolized in the liver and seldom give rise to allergic reactions. We use lidocaine (lignocaine) and prilocaine to anaesthetize only certain structures so allowing other interventions. For this reason, they are used to anaesthetize the skin and the intercornual ligament before inserting an epidural needle, and for skin and tenoperiosteal anaesthesia before a tenotomy in type II tennis elbow. Because their local anaesthetic effect is stronger and faster acting than that of procaine, they are also used for diagnostic infiltrations around nerves and in tendons, ligaments and bursae.

In countries where procaine is not available, or there is patient allergy, bupivacaine 0.125% is an alternative. The maximal dose used is 60 mg, which corresponds to about 50 ml of a concentration of 0.125%. The immediate effect starts after 2–5 minutes and continues over 3–6 hours.

• Psychogenic reactions

• Toxic side effects

• Allergy.

Types of reaction

Toxic side effects can be divided into two groups. They may be related to the central nervous system or to the cardiovascular system or to both.

Clinical appearance

Toxic side effects may clinically appear in two ways:¹⁴⁷

Treatment

The most important measures, even if only minor signs of CNS or cardiovascular involvement are present, are to stop further infiltration at once and to administer oxygen. These may be sufficient to stop further development towards more severe conditions. The rest of the treatment should be in relation to the degree of toxic reaction:

Treatment

Treatment is different for immediate and delayed allergic reactions. The treatment is outlined in Tables 5.5 and 5.6.

Joints

Beneficial effects occur in traumatic arthritis, monoarticular steroid-sensitive arthritis, rheumatoid arthritis, crystal-induced arthritis (gout and pseudogout), ankylosing spondylitis, lupus erythematosus and psoriasis.¹⁵³ Steroids are ineffective in Reiter’s disease (Cyriax:³ p. 52).

Monoarticular steroid-sensitive arthritis is of spontaneous onset without any other signs of rheumatological disorders and resolves equally spontaneously over months or years. The joints affected are the glenohumeral, the elbow, the knee, the hip, the ankle and the temporomandibular. The treatment of choice is intra-articular steroids. Usually, the joint must be kept under continuous anti-inflammatory influence for some time. Hence a specific sequence of injections must be observed.

Improvement is subjectively felt by the patient in that pain and stiffness diminishes, and objectively shown by a decrease of local heat and effusion together with improved function. Patients should be warned against overactivity at weight-bearing joints for the first days after injection to avoid further destruction of cartilage.¹⁶² Moreover, the efficacy of an injection is greater with relative rest.

In arthrosis, lasting improvement is not to be expected.¹⁶³ Some authors even suggest, although this has never been scientifically proven, that it may accelerate the degenerative process.¹⁶² If synovitis complicates arthrosis, intra-articular injection may well be beneficial.

Tendons

Steroids may be indicated in tendinitis, tenosynovitis and tenovaginitis. It is often used in tendinitis of the supra- and infraspinatus tendons and the subscapularis tendon at the shoulder. The same applies for type II tennis elbow and for golfer’s elbow at the tenoperiosteal insertion. In the lower limb, steroid injection is mainly used in supra- and infrapatellar tendinitis and for tendinitis of the peroneal tendon.

To avoid rupture, infiltration should be at the tenoperiosteal insertion or between tendon and tendon sheath, never into the body of the tendon.162,164–167 Ruptures have been reported mainly after intratendinous infiltration with agents of high anti-inflammatory effect or at too high a concentration or when too frequently administered. When the rules are respected as set out in this chapter, there should be no danger of rupture.

Ligaments

In the acute stage – within 24 hours of the injury – of a ligamentous sprain at the ankle or tarsus or of the medial and lateral collateral ligaments at the knee, a steroid infiltration quickly helps but should only be done at the ligamentous insertions. Because the inflammatory reaction ceases shortly after administration, the ligamentous lesion can heal in the presence of movement. This leads to better functional results and to absence of adhesions, which are later often the reason for chronic pain.

In sprain of the cruciate ligaments of the knee, steroid infiltration is the only possible treatment, no matter what the stage of inflammation. Steroid infiltration is also an important part of the treatment in sprains of the radial and ulnar collateral ligaments of the wrist and in plantar fasciitis.¹⁶⁸

Bursae

Depending on the type and location of bursitis, steroid is used at once or after an infiltration with procaine has been found to be unsuccessful. Pain, local tenderness and functional impairment are all reduced.¹⁶⁹

Nerves

Compression of the median nerve in the carpal tunnel of the ulnar nerve at the ulnar sulcus or of any nerve root by an unreducible disc protrusion all usually benefit from an infiltration with triamcinolone around the nerve.¹⁷⁰

Musculoskeletal side effects

There are a number of musculoskeletal side effects of local corticosteroid injection.

Neurovascular complications

Direct intrafascicular injection of steroid in peripheral nerves may provoke permanent damage, whereas extrafascicular injection does not appear to be harmful.¹⁹⁰ The mechanism of injury is multifactorial and can be related to direct trauma with the needle, to ischaemia and to a neurotoxic effect of the steroid or of the buffer agents and additives such as polyethylene glycol and benzyl alcohol. The first features are severe radiating pain and numbness or paraesthesia in the sensory territory of the nerve, together with motor deficit. The pain usually responds poorly to narcotics and may persist for many years.¹⁹¹ As to the steroid itself, triamcinolone hexacetonide and hydrocortisone are most hazardous and dexamethasone causes minimal damage, whereas triamcinolone acetonide is intermediate.^190,192

Damage to the nerve should be treated conservatively for about 12 weeks. If the neurological deficit does not improve after this time, neurological consultation is necessary.

Dermatological side effects

Fat necrosis, atrophy of skin and subcutaneous tissue and depigmentation of the skin may be encountered. These are due to a faulty injection technique or to leakage of the product after an intra-articular injection. The latter occurs often in smaller joints if the volume injected is excessive. Consequently, if resistance during the injection increases markedly, the injection should be stopped.

Endocrinological side effects

There are five categories of potential endocrinological side effects.

Musculoskeletal side effects

In addition to the local musculoskeletal side effects already mentioned, there can be systemic musculoskeletal effects.

Immunological side effects

Suppression of the inflammatory mechanism sometimes leads to a disappearance of symptoms in non-injected joints. Chronic use of steroids may increase the liability to infections.

An allergic reaction to steroids is not expected because they all have immunosuppressive and anti-inflammatory activity. However, a number of well-documented allergic anaphylactic (type I) reactions to corticosteroid medications have been reported.¹⁹⁹ Recent reports have warned of potential (though rare) anaphylactic reactions after intra-articular or intralesional injection of triamcinolone acetonide.^200–202

One recent study indicates that the triamcinolone acetonide component responsible for the patient’s reaction is the suspending agent carboxymethylcellulose.²⁰³ It is therefore suggested that care be taken and component testing eventually considered when patients experience allergic-type reactions to drugs.

Miscellaneous side effects

Central nervous system, gastrointestinal and ophthalmological side effects have been reported: