Principles of Extremity
Adjusting:
An Overview
By Keith Rau, D.C., CCEP
he adjusting of extremities is an anathema to some and the key to practice to
others. This article hopes to shed some light on the foundational principles
of extremity adjusting. This article, the first of two, will look at extremities
from the local and regional perspective. The second article will examine the
integration of the extremities with the spine from a global perspective.
Basic Principles
In practice and as a faculty member at a chiropractic college, who adjusts extremities,
I am frequently asked “could you look at my wrist?” Most likely
they have gotten the wrist adjusted but without improvement. Beside the obvious
history questions (mechanism of injury, history, etc.), the questions I ask
are, “Have you gotten your spine checked?” and “Has anyone
checked your shoulder and elbow?” Typically the answer is no, at least
to the latter. The regularity of this experience demonstrates a remarkable degree
of forgetfulness of our foundational principles of extremity adjusting. We quickly
forget to look to the spine first and then compound the problem by only focusing
on the point of pain or symptom. Of course the point of pain or chief complaint
must be evaluated, but chiropractors have always looked to attempt to locate
the cause of the problem. This is the model we teach in extremity management
at Life University.
It is generally accepted that the chiropractor should adjust the spine before
adjusting the extremities to insure proper nerve supply to the extremities.
(We will explore a variation on that in the next article). Yet there is a sort
of “chicken or egg” relationship between the spine and extremities
with problems in the one contributing or causing problems in the other. First,
the large muscles that move the extremities also move the spine depended in
which serves as the origin and insertion. Second, the spine serves as the anchor
of extremities. While the lower extremity has muscle attachments up to L1/T12
via the psoas, the entire spine serves as the attachment upper extremity via
the trapezius and latissimus dorsi. Aberrant patterns in the extremities will
give feedback to the spine, providing a source of noxious biomechanical stress.
This is obviously very important as the nerve supply for extremities comes from
spine.
Selection or default
Dr. John Downes states the upper extremity is used by selection and the lower
by default. The lower extremity “does not complain.” When injured,
people continue to use it because of the need for locomotion. On the other hand
it is much easier for patients to alter or discontinue using their upper extremity
when problems present. The body will attempt to recruit other muscles through
substitutionary patterns to accomplish the tasks of the upper extremity and
if that is not possible, it will then abandon the tasks. Any substitutionary
patterns will affect the muscle attachments. This often gives rise to trigger
points. Additionally, irritation within either the upper or lower extremity
can affect both the mechanical and neurological systems.
How do extremity problems tend to present?
The symptoms of upper extremity problems tend to magnify distally. That is,
a dysfunction in the sternoclavicular joint (SC) may present as a glenohumeral
(GH), elbow or wrist symptoms/problem. Through experience I would estimation
that 75 percent of the patients I have checked with wrist pain had the primary
cause in the shoulder or elbow and little or nothing wrong in the wrist.
In the lower extremities, symptoms tend to magnify proximally. Foot and ankle
dysfunctions often present as knee pain or low back pain (LBp). The lower extremity
is most frequently injured and most commonly forgotten. Dr Downes states that
the most common manifestation of minor, initially unreported ankle sprains is
knee or LBp. Any changes in the foot and ankle will effect the transmission
of forces, through the kinetic chain, to the knee, hip and spine. It is therefore
recommended to start distally when looking at lower-extremity problems. In a
recent review of literature conducted by one of my classes, an amazing array
of problems was linked to hyperpronation of the foot including plantar fascitis,
ACL tears, meniscal degeneration, chrondromalacia patella (CMP), low back pain
and facet syndromes. In light of this, it has become very helpful to evaluate
and adjust the feet and knees of any patient with LBp. The result has been a
much faster recovery for the patients.
Part of this phenomenon is related to kinetic chain issues. The kinetic chain
is the linkage of bones, muscles, connective and neural tissues that makeup
an extremity and its linkage to the axillary skeleton. In the lower extremity
large strong ligaments provide much of the stability. The hip joint is an extremely
strong and stable joint even without musculature. There is little comparison
between the hip and shoulder other than their roles to transmit forces and attach
the extremity to the trunk. The upper extremity is suspended from the trunk
and driven by a force-coupled system where static and dynamic stability are
provided largely by the musculature. Here ligaments connect the chain but they
do not create stability. Scapular stabilizers attach to the spine and provide
the foundation for the glenohumeral joint. Even though scapular efficiency determines
glenohumeral efficiency the majority of care focuses on the rotatory cuff. This
unfortunate situation is slowing changing as practitioners catch up with the
research.
“The primary function of the shoulder is to place the upper extremity
in space so that the hand can perform its function.”. The upper extremity
is much more complex from a management standpoint because its stability and
function are muscle driven. If you were to stripping away the shoulder musculature
it would leave the entire joint suspended from the SC joint. Therefore the SC
is the key starting point to the care of the upper extremity. Additionally,
because of relationship to the spine through the attachment of the sternocleidomastoideus
muscle, there is a strong correlation between SC dysfunction and headaches,
neck pain, TMJ disorders. Additionally thoracic outlet syndrome and chronic
first rib problems are also related.
The elbow, wrist and hand are analogous to the knee, ankle and foot, respectively.
The elbow and knee are at the intersection of forces within the kinetic chain
with little ability to accommodate to aberrant forces. It is therefore essential
with elbow and knee complaints to evaluate not only the joint itself but to
look at the joints both proximal and distal to them.
Evaluation of Extremity Problems
The care of extremity problems begins, as does any care, with a good history.
The mechanism of injury is typically only remembered if significant trauma is
involved. In that case it is important to understand the position of joint at
the time of injury, the forces involved and the time of the episode, i.e. gradual,
abrupt, etc. This will guide coming to a conclusion regarding the injured tissue.
Many patients present with no apparent injury or trauma. Here is where you get
to practice your detective skills. Abrupt changes in training, sleep positions,
repetitive stress pattern, new or different shoes, activities of daily living
all can effectively be mechanisms of injury. You must often ask many questions
and use many brain cells to get to the cause of the complaint.
Downes frequently discusses facts, clues and patterns in this regard. Facts
are what the patient tells you. Clues are what the doctor gathers from what
is said, not said, how it is said, and observation of the patient. For instance
a powerful clue is given when a patient reports difficulty in fully extending
one arm in the last repetitions of a set of pushups or bench press. This is
indicative of a SC problem.
Doctors begin to develop patterns after seeing numbers of patients with the
same problems. Vladimir Janda’s upper and lower cross syndrome are classic
examples. It is my observation that doctors that are good at discerning many
different patterns are rare, gifted and think everyone sees the same patterns.
Examination of the extremities consists of standard procedures such as observation,
palpation, orthopedic testing and imaging as warranted. Before adjusting one
must be certain of safety, stability and subluxation. Safety is defined by the
absence of fracture, dislocation, other pathology(s) or underlying condition(s)
and pain tolerance. If too much pain is generated by the adjustment the patient
may be lost to future care, despite the obvious need and benefit. Stability
is assessed by orthopedic stress tests such as Lachman’s or valgus and
varus stress tests. The location of subluxation is largely technique driven.
Kevin Hearon did you a favor!
The adjusting of extremities follows several models. Historically, motion palpation
has been done to locate the areas of fixation and direct the adjustive forces.
Recently Drs. Mark Charette and Mitch Mally have recently developed systems
of analysis and adjusting. Dr. Kevin Hearon has developed a system using relative
muscle testing (RMT) to help locate the areas of dysfunction requiring adjustment.
Its virtue is its attempts to reveal interference in the nervous system as well
as altered arthrokinematics found with motion palpation. The concept uses Hilton’s
Law and the mechanoreceptor theory. Hilton’s law states that a nerve supplying
a joint also contains axons innervating muscles that cross that joint and the
skin overlying the articular attachments of those muscles. The mechanoreceptor
theory says that muscles are affected by dysfunction of the joint. This occurs
through the impact on the mechanoreceptors that accompanies joint dysfunction.
The result is dysafferentation and muscle “weakness.” I use quotes
because the muscle is not truly weak in terms of its ability to do work but
dysfunctional as evidenced by RMT. In terms of classical muscle testing, we
typically find a 3 or 4 out of 5 on the Kendal and Kendal scale. In simple terms
the body is protecting the joint from further damage by weakening the muscle(s)
around the joint.
Dr. Hearon found relationships between specific muscles and specific joints.
For instance, the Pectoralis Major, Clavicular division is found to be weak
with SC subluxations. The adjustment of the SC joint should result in strengthening
of the RMT. Hearon has found specific correlations for the major joints of the
upper extremity. In the lower extremity, the popliteus RMT correlates with dysfunction
of the tibiofemoral joint. There are several other RMTs but those associated
with the foot and ankle often yield false negatives. This is theorized to be
caused by plastic deformation of the capsule and or ligaments of the dysfunctional
joint resulting in alteration or resetting of “normal” for the mechanoreceptors.
Dr. Hearon’s model and methods are taught through
the Council on Extremity Adjusting affiliated with several of the colleges.
Completion of the seven modules and concomitant tests and the comprehensive
practical exam leads to the earning of the designation of Certified Chiropractic
Extremity Practitioner (CCEP). The faculty at Life University’s College
of Chiropractic teaches the model and methods as well in their extremity adjusting
classes and student seminars.
Sports and Extremity Adjusting
The use of extremity adjusting in conjunction with the adjustment of
the spine is a powerful tool when working with athletes. The use of muscle testing
gives further advantage in that the athlete has an immediate outcome assessment.
It is not just a matter of whether there was a cavitation of the joint or your
assurance of a benefit. When a “weak” muscle becomes strong, the
athlete has visible evidence of the result. Those of us who use RMT can report
case after case of athletes wildly impressed and amazed by the changes.
Other than the previous stated safety issues, one should be aware that the results
of spine and extremity adjusting can hugely impact the “skilled sport”
athletes such as jumpers in track and field, pitchers, golfers, etc. In my experience
at track meets I would always warn the athlete that they needed to recheck their
marks in the jumping events as stride length could change after an adjustment.
At the NAIA Indoor Track and Field Nationals one year, before adjusting the
eventual runner-up in the women’s high jump, in mid-competition due to
acute back pain developed during the competition, I asked if she had any jumps
to spare as her approach would probably change. I did not want her to blame
me (and more importantly chiropractic) for her failure if it happened. In her
case, she successful cleared the height she had previously missed on the very
next jump.
Over the last 10 years the doctors of the Department of Sports Chiropractic
adjusted hundreds, if not thousands of athletes in a myriad of sports and locations.
Extremities always played a huge role, whether it was women’s football,
the Arena Football League, hockey, rugby, road races, cheerleading, or Major
League Baseball. It is the author’s opinion that if you desire to care
for athletes you owe it to them to become an expert at extremity adjusting.
You will expand the number of complaints that will respond to your care and
will help the athletes avoid needless drugs and surgery.
Unfortunately due to the difficulties of conveying muscle testing and adjusting
techniques through the pages of a magazine the focus of this article has been
on the foundational principles upon which to build those techniques. If you
desire to learn the adjusting techniques, I suggest attendance at the seminars
mentioned previously. The addition of extremity adjusting to your practice,
no matter what type of patients you see, will only enhance your results.
The author is indebted to the work of Dr Hearon’s, which serves as
the foundation of Life University’s extremity classes. His books are available
at kevinhearon.com and include What You Should Know About Extremity Adjusting,
and both Advanced Principles of Upper Extremity Adjusting and Advanced Principles
of Lower Extremity Adjusting. Additionally the author is indebted to the work
of Life University’s Dr. John Downes, his lectures, classes and conversation.
Material used is with his permission. He assisted in editing the article as
well. Downes teaches several of the CCEP modules, including the one he developed
titled “Global Extremity Assessment,” in addition to other programs.
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