THE LOW BACK and PELVIS Clinical Applications
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THE LOW BACK and PEVIS Clinical Appications AL Lga Sr rra Tq Ci J. utcn th a conuon by oseph W. Howe
Chris J Hutcheso, DC rivate Practice Aub. Cfoa
and Joseph W. Howe, DC, DACBR, FICC
AN ASPEN PUBCATIO� spn ublishers. nc Gaithersburg Maryland 197
rfessr o Radology Ls Aneles Cee o Chirpractc rvte ractice of Raiooy Ls Aneles n Sylmar Caoa
Lbay of Congss Caaloging-in-Puiaon Data Hutheson. Chis J The low bak and lvis nial aplatons/Chs J. utheson: with a ontruton by Joscph W owc p mAL Logan seres n hiopai ehnique) Inldes biiogahial eeenes and index SBN 0834206897 SineDseaseshropai treae 2 PevsDiseasesCho� eamen owe Joseh W ie eres [DNLM Snal Diseasesheray 2 Lmsaral Region 3 Choratimehos WE 25 93L 1996 RZ26S6488 996 6S 60620 DNLM/DLC for Lbay of Congss 96-2630 CP yih © by Asn lsh n Al ghs reseved Asen Puishes n, grants pemission for hotooying for imied persona o nena usc hs onsent dos not extnd to othe kinds o oying Udl as opying o geneal distibion o adverising or motional puroses o reatng new oetve woks or o resale For inormaion addess Aspen Pblshes. n . Pemssons Dartment 200 Ohad Rdge Div. Se 200 Gaithesbug Mayland 2088
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Member o he woldwide Wolers Kwer goup
he ahos have made evey efo ense the auray of the inomation herein artiary wh gad to ehnue and poede oweve aropiae informion soures shold e onsuled. ese iay fo new or namla roedures t s the responsiy o evey ratitone t evalue the apo raeness o U <riular opnon n the onext o atal inal siuatons and wth due onsidion 10 new develoments Ahos edtos and the blsher anno e held esponsie o any tyogahial o othe eos ound in his book
dtoal Resoures Rh loom by o Congess aog Cad Nmbe 96-2630 SN 08320689 Prie i the Unid Saes ofAmerc
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Anyone who has been o school can remember a leas one eacher whose nflu ence nspred him o learn more fully to apprecate he subect beng taught, and perhaps o reaize a lie's work. I have been orunae enough to have had severa such teachers In high school my bology teacher moved me into he scences, and a humanites teacher nstled in me he desire o hnk and reason Whie sudying chiropracic, I found Dr AL. Logan I frst met hm when he vounariy dd clnica rounds at he Los Angeles Colege of Chropracic (ACC). Roy ogan had a capacty o understand how he human body works and a cur osy about t hat kep hm consany searching and researchng or ways to hep hea it. The proesson s ul of personaiies teachng a variey o echnques some nsisting heirs s he ony way bu it has ew rue proessors who can cul the vari ous eachngs and presen to he suden a clear and concse way o approach a patient whou personaity and ego getng n he way. Roy had hese abiiies, and, ortunaely or us he had a desre o each others. He never mssed an opporunity He saw the need in our proesson or a way to ink the roe clncal sciences and the various ways o execung an adustmen He gave us an answer o he com monly asked quesion of when and where o adust. He was constantly pushng he proession o reaize the mporance o eecive cinca appcaion o chropracc princples a a me when here seemed o be more emphasis on ting ino he healh care ndustry by wearng a whe coat and using bg words Around the world sudents o Dr. Logan use his mehods of dagnoss and trea ment every day and are reminded of his wonderful conribuions o he professon. He ecured repeaedly before several state assocatons and taught an egh monh post-graduae course at LACC for egh years He was Chairman of he Technque Deparmen at the Anglo-European Colege o Chiropractc or ve years. In spie of hs many conrbutions Roys work remans unnshed. He passed away in Aprl o 1993 afer ghng a ermna lness. He was working hard on his exbooks up to the end hoping o ranser as much o his knowledge and wsdom to paper as he could. Dr. Logan has a number of sudens dedicated to continuing hs work and seeng t evolve n the way he envsioned There is no "A.. ogan Technique, but raher a complaon of varous teachngs, combined with a unique understanding o he nterdependences o the human srucure. We hope to do hs work jusce and see more sudens o chropracc become as eectve as possibe in the reatment of human dsorders
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Table of Contents
Series Preface ...........................................................................................................................................................................
ix
Preface
xi
Acknowledgments ..................... ........................ ........................ ........................ ........................ ........................ .......................
xiii
Chapte I-Anatomy ..............................................................................................................................................................
1
Boney Strctures.......................................................... Muscles ..... ..... . .............................................................. ... .......... Vasca Anaomy .................................................................................................... euroanatomy.. Viscea Anaomy Functiona Anaomy ............................. Concson . ..
1 0 6 7 9 9 33
Chapter 2Examination......................... ......................... .......................... .......................... ......................... .........................
35
Oseration istoy ..... ..................................................................................... . ...... ........ xamnaon
Chapter 3-maging the Low Back ........................ ......................... ........................ ......................... ........................ ............. Joseph W Howe
maging Mehods Spinogapy ............................... Anomales and Norma Varans........................................................... ... Fraces and Disocations .............................................................................. . .. ... . Spondylolysis and Spondyolshesis Degeneae Spnal Disease................................................................................... nammatoy Spnal Disease ....................................... Deposion Diseases Inolng he Spinal Coumn ........................................... .. .............. Dseases Casing Oseopena in the ower Spinal Coumn Tumos and TmorLike Conditions o Bone Sgncant ncidenal indings
Chapter 4MuscJe Testing ....................................................................................................................................................
35 35 36 63
63 66 70 75 80 82 92 95 97 7 23
Msce Examination 24 Conclsion 34 Chapter 5Adjustive Techniques ........................ ........................ ......................... ......................... ........................ ...............
135
Dersied Tecnqe 36 Pincples o ectie Adjusmen 37 Concuson 47
i
i
THE
L
BACK AND PELVIS
Chaper 6Condiions and Treamen..
naaton and Connectie Tisse ... Stain/Span njres Lodotc Lmba Syndrome Leg Lengt neqalty LL!) .. Te Unstable eis Scatica Qadrats Lmborm . Artitc Lbosacra Spine .... Hip Conditons . Chaper 7-Exercises
Abdomnal ... Gltes Maxms .. Gltes Medis ... Latea Hip Rotatos adrats Lbor . ............. ................. ....... ..... ..... ....... ... ............... ... ........ ........ ........................................ Tanserss eine ................................................................................................................................ Lowe L and Coccygea Fbes o te Gltes axims .................................................... Fit Segment o te soas .............................................................. ........................................ Hip and Waist xercses ................................................................................................................................... Lordotic Lbar xecse ......................... ....... ................................................................................................ ppendix Organc robems and he Low Back ...........................................................................................................
19
49 5 1 52 57 59 6 62 63 163 167
167 168 169 69 l70 70 l7 l7 l72 72 75
Fxation-Ogan Teory ................................................................................................................................ 175 Neroascar Dynacs (NVD) .................................................................................................................... 16 Ogansce Reationsps l77 Cnical rooMetodoogy i 77 Opinon .......................................................................................................................................................... 78 ppendx Bhysica Therapeucs
Cyoterapy ... . ........... Heat Hot/Cod ............................................................................................................................................................... Heat/Range o otion................................. ............................................... .................................................. lectrical StlatonSine Wa e ...................................................................................................... traond .................................................................................................................................................. .
ndex
.
.
181
8 1 8 8 182 82 82 183
Series Preface
" The apliatin f nile invlve higher mental pee an eir memizng; every tuden huld e given a hug drl n inial anay n whh e uld e made ee he reainhp wi exit eween e funda menal fat and tei lnal applan
Frm thi egnn ame ve 20 yea f eahng wa i he tat hi dea wud geneae ntined dalge and ineret n expanding the nia apiatn pra prinie. r gan dd lnia und a e L Angee Cllege f Cra ne he eary eventie He eued ten va ae aatin, and taugh a the Angl-Eupean Clege Chirpa ing thi me r Lgan nined lean and grw a a lnian and teahe H den t write a ere ex n the inal applatn hpra prnple ame t f experene n teahng undegadu ae enue a AECC and eeing te diiuly upper dvn udent had n undetanding wen whee and wy hey d adju Th erie f textk wl e a mpehenve refeene n hirpai lnal apan r gan eleved ti apprah d e te ai an ndegaduae ue n adtive and lnal tehniue i at te ame me a we me addtn te knwedge any patine
Francis M Pttenger, MD
Te eduatin tha a mdern hrat nderge n ude e na ene and he manipulave art A graduae d hipra a a tugh grap f te d agn and inial kl and aned n a manative tehnique Wh t knwedge, he ratiing dr egn t gain he exeiene hat make te appatin hi nwledge eul A ue d ne w nn e ean eynd wha minimaly reqred fr e r e i nany enewed and timaed A gan wa a ef hipa a d a like . Palmer ntinued t expand undertandng te human dy in heah and dieae He tuded e wk many f te hiati pren' leading eduar He reeared and deveped wn heie whh he apied in hi praie, and ke mt rprar deveed a eful diveried apa dagning and reang patient r gan regnzed te need fr a pratia way end a and advaned manpatve tenue wh lni al ki
Ptenge FM Symptms of Viseral Disease. S : My; 953. Chris Hutheson DC Aubu Cliorni
ix
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Preface
Ts is he trd in a seres o exs conceived by D A L Logan Te concep o ese works is based on D Logan's experence in eachng gaduate and undegaduae clncal echnque and ofers a beter way o approac he nucton of sudens. Tis series started with e knee and foowed wt he foo and anke and now moves up into e pelvis and spine is necessay o have an undesandng of te lower extremes and her nuence on the strucues above before beng abe o fuly compreend e clincal aspecs of te pel vs, spne, and upper exemes D Logan compeed he s wo texs even tough seri ously Befoe s passng e ouined the ideas o hs tird book on he lower back and pevs was honored a he asked me to cary on his work by completng hs text thereby con nung he work he so lovngy pusued have wien hs tex based on my undesandng o s wok and he exensve ecture maeras he ef in my custody have atempted o presen his work as e woud have done I ink Dr Logan woud be satised wh the outcome
Dr Logans work s mpotant because s an inelgen digeson of a diverse coecton of echnues handed down from he earlest days o the pofesson. s an excelent sta ing poin or researc nto he most effecive manipulatve echnues-a needed foundaton fo he scentic verifca ion of chropacic manpulaive teapy D Logans wok is a great contibution to te chopracc pofession. Tis sees s designed o be a woking manual of cincal aspects in e dagnoss and eatmen o musculoskeea con ditons s no easy task o eac manipuatve pocedures from a tex The ilusraons ae smpe on pupose. D Logan e a simple ]jne dawings can more accuraey focus te empasis inended. Moe sopstcaed photograpic ilusta ions may present too muc confusing nformaon ese exs are ou atempt to explan n wods and drawngs a dy namc process
-Chris Hutcheson
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Acknowledgments
Richad Wilcox C Maui Hawa, o providng me wh vdeoapes o one of Logan's as seminas. It poved invaluabe in veiyng much of Dr. Logan's lae wok. Joseph Howe, C, DABCR for contrbung his ime and knowledge of radioogy o his ext Hebet I. agee, Jr., C and Mer Coo, DC for he use of heir extensve lbraes fo reseach. Nehma G. Saab A LS Dector, Leaning Resource Cente Los Angees Coege of Chropacc, for her aid n esearching the teaue fo D. Logan and ysef
This book could not have been wrten without the ad and suppot of many people. woud lie to thank, especaly the folowng: My wife Rebecca for her encouagemen and advce. Judy A Logan, DC o he couageous reess suppo of Dr Logan in his efos o complete as much o hs series as he coud and fo he encouragement n my assumng D. Logan's wor Paula Regna Rodigues de Fras Hlenbrand fo her any hours o modelng fo phoogaphs, and he husband Stephen Hlenband for hs expertse n phoogaphy. The efots made the ilustaons possbe
x
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Chapter 1 Anomy
The anaoy of he ower ba and pevis enopasses h ore han he ve bar verebrae he nnonaes and reaed sof isses anno reay be separaed fro he nfene of he sondng srres n ndersanding he nraies of he bar/pev ehanis i is neessary o ndersand he infene of he ower exreiies as we as he pper body The os iporan anaoy o onsder n diagnosng and reaing disorders of he ower ba and pevis s nde he hp oins he dorsobar nion and he wefh ribs or he prpose of his ex he anaoy wi no neessariy be deaed or opee b w fos on erain iporan onsderaons and ha whh s pernen o a inia evaa ion and reaen of ower ba and pevi ds orders B RUCURS
h Pevis
The pevs is a basinie srre ha hods he pevi or gans and sppors he abdona rgans provides a sabe base for a oveabe spna on and ress pon he ower bs baanng over he hp oins ig 1 1 ) oprises for bones: he sar he wo nnoinaes and he oyx There are aso for joi ns : h e wo saro a oins he pbi syphysis and he sarooygea join ah inno nae bone is aay hree bones he i i s h and pbis ha by adhood have beoe fsed a he aeab he pshaped reepae for he head of he fer aera view of an inno inae ig 1 2) od re
F - Boey tructe of the low back ad peli
ind one wih a ie iagnaion of a wobaded arne propeer. The aeab is he hb of he prop The wide bades of he i ia for he sides of he pevi bow he ower b ade is a rng fored by he rai of he pbis and ish i and is ben inward iewed eday he ariar srfaes of he sar and pbis an be seen ig 13)
2
T w A AND EV
acrum blqe ad lateal ew
-2 nnminate be aeal ew
he sam s he en esul o he eveopmenal usion o ve semens o he spinal oumn iee aeon Fi. 1 ) loks ana h h e base a he op ha os a plaom he moveabe spnal olmn. he apex pons in ely an ailaes ih he oyx o ailbone aeal ve shs h e lae suae o he saoil ia aiulao n an he apex ha anles oa i 1 ).
1- nminate be, medial iew.
The oyx is usualy ome by o umenay spna semens apein o a mee noule as esbe n Gr's Anto I s a bpy l e bone povn aahen su aes o msl es an li aens ha sppo he pelvi loo. The sau is ee beeen he pelv bones on o omplex aiulaons he saoa jons on o Gr's Anto he eaJshape on s a ben o a ii synhonosis an a eey mov eable jo n ha aually eveops a synoval spae as pesons ae. Kapanji emphaszes he e suual vaiaons ha an be seen n he shape an symey o he saoia jons Opinons on he anaoy an non o he saoi ia jo ns vay eay In hopai he anaoy an nion o hese oins ae onsee o ey impoane. he sau s ee ah an sspene on iea ouoppns beeen he nnonaes an boun nenaly by pahy aeas o boalae. ompex aay o a mens aah he sau o he pe v bones. The poseo saola iamen Fi 15) s ompose o sevea ayes o bes unnin in ieen eons he os enal poon o he poseo laen has been abee he sho axa a men by apanji. I s onsee by some o be he axs o saola oveen. he saoubeous l amen 1 5) is a boa suue aisin o he poseo ineo l a spne sam an o yx ss upon se an aahes o he ishal beosy. The olmba liaen Fi. 16a) sabes he an somee s veebae unnin om h e ansvese poess an benin ih he aneo saola laen The aneo saoila laen F. 16b) s opose o o bans unnn obliqely aoss he aneo aspe o he jon The saospnos iamen F 16) a ana oup o bes uns o he laea boe o he sam an oyx o an apal aahen a he spne o he sha l beosy .
Antoy
a
b
c
3
eoeos lame h a eal le The ymphy bod by ames al plae. The aeo aspe ha a me ha ae oo h he apoeos o abdomal ad addo mses F. 1-). The aooyea aao s al o a aao jo ed by a dsle eosseo l ame alo ha a aay o lames suppo he aao aeoly poe oy ad laealy F. 1-8). exam he pelv mpoa palpao ladma o oe ae aeo speo l a spe 2 a es 3 pb ymphyss 4 poeo speo a spe
1-5 Pteri aciliac ligamen a ililumba lgament b pte aciliac ligamen c acuberu li gament
The pb ymphyss s he aeo oeo beee he pb boe ompe he m o he pev bo s a a lao jo a ymphy hh s a shy moveabe o Le he eveeba jo ha a ds a boaae
1-7 Pubc ymphyi arw depict iber blendng wih ab dmna and adductr mucle .
1-6 Anterir acri iac lgament a i ilu mba l igament b an teri acri iac l igament c. acrpinu ligamen t d. acrtuberu ligamen.
-8 acrcccygea ariculatn and ligament
4
TE L A AND EV
5 6 7 8.
chl tubrot cro c onts coccyx ltr crum
h ip Joins
Th h jo ns nrthod o bndsockt o nt Th ctbulum th sockt n th nnomnt cvs h hd o h mu th bll jon rovd so ld ound ton or th v s o blnc uon nd hv n tnv ng o moton Th mur g 19) s h ong songs bon n th body t t roxml nd th nc bnds mdly t n mot rgh ngl nd trmns n crg cod bl th hd Th nc gduly dcrs ng bcomng mor o ght ngl rsons grow om nncy to duthood Th cbuum g 19) hs mlunr sh to ts culr urc Wthn tht drson th cbu notch l d by t d nd covrd by syno vl mmbrn Th gt trochntr g 1 9) l rg romnnc roctng tly rom th bs o th mor nck t s h mot ltr bony romnnc o th h nd ov ds g urc or th tchmn o musc Th ssr ochntr nor nd md to h grr trochn on h oot d o th mor sht s stutd t th nn junct on o th nc nd sh o th mur Th l gmnts o th h l low vst rng o moon w h ng th bl mly n s oct t th sm tm th lg
mns suort th lvs chcng ostror rotton o h vs on th h ntrnlly most romnnt but unmor tnt gmn th lgmntum g 19), r om dsson n h hd o th mur th ov cs Th lgmntum ts srds ou ormng th bnds h tch to h ctbulr noch nd bnd wh th rnsv lgmn Th gmntum tr condd to b rudmnry nd though strong to hv ltl sgncnc n th stbl ty o th jo nt Th mos nson lcd on th gmnt s durng dducon o h h Th ctbulr lbrum s broctlgnous m th x nds nd dns th rm o th sockt t s contnuou wth h trnsvs gmnt ht brdgs th botom o th ctbur noch nd orms ormn o nurn r Th tcu lr csul s rong nd hckr rom y nd ntrorly bu thnn dtly nd oory Crculr bs h zon orbcu orm colr whch s rong otroy nd dst ly ound h nck o th mu Th longtud nl bs mor omnnt roxmly nd ntoly nd bnd wth ccssory lgmns Th rtculr csu s rnorcd by xtrnl gmnts tht wr clockws om ostror to nror round th h on Th schomorl omorl nd ubomorl lgmnts g 10) r tns n h rct oson bcomng tghtr wth urth xnson n lon hy r ncng y rd Ths scrwhom" mchnm uls th hd o th mu t ght no h cbul um nd vnt xcv otro otton o th v s
Geater rochate r
F -9 emoal head ad acetabulum ligametu m tee eeed)
F -0 gae of the hip oi t dotted areail opeieal bura).
Anatoy
Btwn h iiomora and pubomoa gamns, th ar ticuar capsu s thnn T iiopcna busa ovis is ara, cushoning t osoas musc ig 10 Th is o tn a comm unicaton bwn t capsu and burs a alpaon o h p s diicut as i i s d undr ays o musc and connciv tssu n vauating th ow back, pvs, and hs, t h gratr rochan is an i mtant ara to pa pa is th atachmnt pon or a nu mb o mportant muscs and can provd i normaton abou t uncion o t hs o nstanc, comparng tnsion b atray can rva th sta o musc ton, and aaion o musc nstions can povid normaion on t muscs o h hp he Lumbar Spne
T lumba spin, as a unctional unt, incuds iv umba vrbra, h twlth hoacic vtbra and h tw ibs T 2 s a ansiiona vrtba wih caracstcs o bot h hoacic and lumba vtbra T tanston bgns wt T as h body, pdics, and procsss bcom ag and avr T lumbar spin, vwd antrioy, s staght and aivly symmtca g 1 om 2 to on can s ha t vrbra and transvrs procsss bcom widr T 1 2 as divdd loyats and a pivoa o n th mcanca unc ion o t spin Th wh rbs, k h vnth, ar oat ing bs, ha vng no cosoansvs atcua tion Ths ibs a shor, ncin caudaly, and ar subjc to muc vaiaton n siz and sha
om a latal prsctv ig , th umba spn s cuvd anriory Th umbar ordoss is a commntay cuv o t thoracic kyphosis and crvica odosis Ths curvs ar a ncssay comonnt in g ving h umans h abi ly o stand ct and wa in baanc wih mnimal ot Ramamurt, among oths, consids h umbar lodosis to undri h human prdspostion to lo w bac pain aran dscibs anatom ca actors tat ncourag th lumba ordosis poins out tat bodis o h umbar vtbra a wdgd, h ghr antroy, and dcas posrory T dsks show smiar wdging This wdging shaps u mba curv Ohr actos that inunc th lodosis a t dg o vic tit and th sacra bas ang Cai dscrbs t spin a s an aggrgat o articul atd, suimposd sgmns ach o wich is a fnctona unt." div ds h unt nto an anior porton : wo vtbal bod is and th dis nbwn ts ro s that o wightbaring and soc absoption Th ostio porton consists o two vbal acs, aird aca jonts, and sinous and ransvs pocsss g 1 2 T osro porion, th moor/nual unt, ovds otcon or th dica nua strucurs and vs or th attacmnt muscs Th aca joints giv guidanc to t movmn o th vrtba as wl as barng som o h wigt o th body T umbar vtbra g 1 3 ar disting usd by svra anaomca actos T pdcs ar s higr oming a dp vrbra notc Th snous ocsss a boad, a, and ctangular Th body s wdr than it is d and alr antrioy an it is ostriory Th transvrs procsss a s vna to th atcuar procsss insad o dorsaly as n h hoacic spin Thy ar considrd to b rib vss T ar thr tubcs ratd to h tansvs procs s Th
( 0)
F Aterior ad lateral iew o lu ba pie ad ac
F 1-12 Vertebral fuctioa u i
6
THE w A AND EV
F 14 umba ai of otatio F -3 ypical umba eeba
no on considrd o b hooogous with th ctu rnsrs rocss s cd h ccssory rocss Th suio on, h mmiry rocss, s roinnt nd connctd wth th suor ricur rocss In ing h umbr sin i is th mmiy rocss nd not th rnsvrs rocss h s usd o t or unction Th nsvrs rocss s oo d to t ccuty Und r gn obs vton th ub c o nt s to hv both vrtc nd sgit n o rtcuion This woud gv h u mbr sin conto o xion nd xtnsion Th thocic s n hs ct rtc ur ns h ncoug tr lxion bu n h cvic sin ottion domns Frn dscibs h ct ricutio ns s hing mor comx sh with dirnt ros ttbutd to h ur T 2 to L3) nd owr 4 to S I) sgmnts Th u sgmnts h du ct join ns Th ostior twohirds o h joint hs n o h ongiudin xs o h sn Th ntior thid bnds t ost 90° to c osti oy Frn concuds tht his dsgn rstrcts orwrd discmnt o th rtb in xon Kndji tibuts to his sh gud o imitd ottion movmnt Th cn t xis o th rotion s h bs o th sinous rocss Fig 14) Th L45 nd L5S cts hv or r oundd sh in h rnsvrs n Thy so c in mor obiqu dicton md oY nd suoiniory Fn suggss h h momnt t th ct o int i s no g ding cton bu mor comx bndsock" on Ciit mntions in dscribng th ostor rt o th uncton unt th i is nonwghtbing Bg hs concudd rom hs rsrch ht owr umbr cts do br wgh rs o hs s th iod thory" Wigh is di dd btwn h ostrio sc o th rtbr body nd h ticu rocsss Fig 1 1 5 )
F -15 ipod weghtbeag cocept
Th invtbr disk is th mos romnnt srucu o tchmnt sn n th sn Th nio nrbr oin s cssd s symhy sis t s comosd o wo nd s nd h disk Th disks mk u roximty 25% o th hight o th sin coumn hthy disk is hydohyc drwing wtr n k song whn h od s o Cons qun y, h sn cn gin nd oos hght in 24 hours co sondng o riods o wight nd nonwighbrng Th strucur o th dsk s dsignd o bsorb shock ow or mtd momn nd rovid strong ttchmnt btwn vtbr Th mui contibut ons rom ch disk mk h sin zingy vsi in ts rng o moon Th dsk is uidid continr Th w o th con tnr th nnuus ibosis Fig 1 6) is hick mn o
Anatomy
a
7
d e
b c
F 1-16 chematic of a dik.
concntricly rrngd ibrs t vrying obliqu ngs Kndi dscribs th lyrs s bing vrticl t th rih ry, bcoming mor obiqu nd lmost horizontl t th cn tr Th nnuus is ttchd bov nd blow to th nd ts This comx ngmnt is wht givs th vtbr th ccity to x xtnd, bnd ltrly, rott, nd shr with strong limits nd stbility Ci it dscribs th dis s hvin g l th chctristics o hydrulic systm Th nucus ulosis ig 1 - 6) is gltinous substnc, mostly wtr, tht is tighty bound by th nnuus Th luid cn cct comrssiv orcs nd distribut thm vnly ing th vrtbr bodis srtd Th movmnt o on vrtbr uon th othr is ossibl du to th bility o th uid to shit in its smilstic continr Th lstic rortis o th dis r th rsut o nnulr lsticity n young, hlthy dis, th ibrs r rdominnty stic nd th nucus is hydrohilic s ging nd injury or both occur th nnur ibrs r rcd by mor ibous lss stic ons, nd th colo idl hydrohi ic rortis o th nucu s dcrs Th dis bcoms ss o shoc bsorbr Th dis so grdu ly loss its vsculr suy nd by th third dcd it is dndnt uon diusion, imbition nd movmnt or its nutrint nd wst xchng This rducs th dis s biity to rgnrt or h ctiv y Th sinl column is bound ntriorly by th ntrior ongi tudin igmnt (LL ig 7) t runs rom th occiut to th scrum nd is ttchd to th diss s wl s th vrtbrl bodis t cts s rinorcmnt or th dis in its control o orwrd shr nd lso chcs hyrxtnsion Th ostrior longitudinl igmnt (LL ig -7) courss rom th occi ut to th scr um on th ostrior sct o th vrtbr bodis t is dhrnt to th diss nd th surior nd in rior mrgins o th vrtbrl bodis rvrtbr vnous lxus is housd undr th LL in th midortion o th vrtbr body Th LL hs lssr rol in chcing xion thn th LL hs in chcing xtnsion s it is cosr
F -7 igae of the unciona uit a intertranere, b an terior ogitudia (A) c. poeior longitudinal (P, d upra piou, ad e ierpious
to th cntr o rottion Cillit nots tht th LL bgins to tr s it dscnds into th umbr sin nd is hl s wid whn i t rchs th scrum ttributs th rquncy o di s ruturs to thi s tring t oint whr mxi mu m movmnt nd strsss roducd Th vrtbr rchs r connctd by sgmnt l igm nts th lmin, by th igmntum vum thic igmnt tht mts its oosit in th midli n nd comlty ncloss th vrtbrl cnl n th lumbr sin this igmnt joi ns with th csulr ligmnt ntrotrly nd dns th surior rtic ur rocss t tnds to hyrtrohy nd cn crt stno sis nrrowing o th vrtbrl cn Th ohys or ct joints r dirthrodil joints with synovi mmbrn nd surounding csu rn dis missd th notion tht th ct csuls r oos contnds tht thy r no mor lx th n th i ntrhlngl oint csuls Th intrsinous ligmnt ig -7) rovids strong bond btwn th sinous rocsss but th tis o th rocsss r intrconnctd by th sursinous ligmnt Th sursinous igmnt is contiguous with th lumbodorsl s ci nd ccording to rn my not b ttchd to th L4 L5, or S sgmnts lving g rom S2 to L3 nd chc" igmnt with thin ttchmnts Th intrtrnsvrs igmnts r wll dvlod in th lumbr sin nd intrconnct th trnsvrs rocsss Th lumbodors sci ig -18) nvos th rctor sin muscs nd contributs to th ligmntous suort o th umbr sin t hs ttchmnts to th sinous nd trnsvrs rocsss th ilic crst nd scrum t is lso contiguous with bdomin muscls nd th ltissi mus dorsi t cts s chc ligmnt ginst xcssiv xion nd cn bsorb som o th shr strsss o lxion o r xtnsi on by th orcs xrtd by muscl contrctions in tight comrtmnt djcnt to th sin
HE D EV
8
a
b
F 18 a lamu dor . erratu poteror feror pote ro abdomnal d lmodora aa
he lobar lgaens (Fg 1 6) are poran sab lzers of he 4 and 5 segens apandj desrbes he olbar lgaens as rnnng nferolaeraly fro he ransverse proesses of 4 and 5 o he a res, wh an nferor slp down o and hen blendng no he aneror saroa ga ens Tese gaens ek fexon, exenson, and, os poranly laera fexon
Te sarola a aons are rregulary saped and ofen dfferen n er onfgraon fro rgh o lef When assess ng radographs of he low bak and pevs noe any sgnfan derenes ha g reqre soe nnovaon n a npuaon or gh expan a paen's sypos For nsane, one sde ay have a nohed onfgraon, bu e oppose sde ay be srag e sraghsded jon woud have a endeny o shf superonferorly (Fg 1 9) noaos faeal ons are oon n e bar spne araons fro he noral pane of arlaon o a ore saga, oronal, or orzona one an our (Fg 1 20) These varaons an be baera or naera Unlaeral asye res (F g 2 an be verfed by radograph and n soe ases by arae papaon Transona verebrae usal y nvolv e he 5 and S 1 segens brrng of he derene beween a separae verebra and a flly fused poron of he sar has neros varaons Te os naly sgnfan varees are ose w psedoaruaons a ause aberran oon (Fg 1 22) apaon an n a es e anoaes b a radograp s neessary o deerne e exa degree of anoay dre on of arular panes, and ow bes o adus he segen Spondyosess (Fg 123 s no an unoon fndng Mos oen found a he 5S level, as several auses blaeral defe n e pars de o a faure of ossfaon en ers o fuse has been he aeped expl anaon as beoe ore aeped o nk o f hese anoales as aa sress fraures raher han ongena defes wen hey are presen a an early age Oer anoalos faors ha ase a forward sp page of e verebrae are eongaed pedes or pars w no break egenerave anges n he onneve sses surroundng he segen an also alow a sppage Spondyoshess appears o have a eredary endeny, and eary degen erave anges are kely
Anomalous Anatomy
frs glane o anaoy sees syeral I s a won der ha n he developen of a huan beng fro a sngle el ha s neary perfe every e Upon loser sruny, however, we ofen see le flaws n he syery of e body Mos of hese are nsgn fan, and we have an aazng ably o adap and opensae so ha hese anoaes go unnoed s neresng ha an ndvdua w one anoaly wll ofen ave ore p aen w a bfd spnous proess a S ay aso ave a ransona verebra or faeal asyer y Boney anoales ha are oonly seen n prae and an nerfere wh nora boeana fnon or aler he approah o reaen nude ong or shor ransverse pro esses, asyeres n he sarola jons asyeres of he faea ons, ransona verebrae and le g lengh nsufeny xaggeraed derenes n e lengh of he ransverse proesses an aler e leverage produed on a parular ver ebra and ause aberran oveen or sresses
F -19 aroa aymmery.
Anamy
9
a
b
F -22 aalizaio wt pseudoariuaio
F -20 aeal arageme. a. ormal, b oroal, . sagttal.
a
F 23 podylolstesis a spodyolyt b degeeaive
b
F -2 aetal asymmety a omal ad sagittal b horizoa ad oma
eg eng nsfieny () is an poran faor in he fnon of e lower bak and sod be aserained n an evala ion. Tee has been dssson abo he effes of an anaoialy sor leg and onseqenly, gea onro vesy as o is porane sor leg wil ase an nleve ing of e pelvis and a series of opensaory ehanss. n evala ing a paen, i i s neessary o deenae beween an aal L and a fnional L
0
T BA AD EV
MUSCLES
To ly appeae he elaonship beween on and sle i s peaive o hooghly ndesand he anaoy and non o he sl es Msces of the H ip and Pevis
The Gluea Region
The bok s oposed o sessively deepe layes o ses. The os speiia h e ges axi s s o key ipoane s a lage oasely ibeed se paay ovesized n hans when opaed o ohe qadpeds. The gles axis (Fg. 2) pays a key oe in he ee sane ognaes o he poseo speio i (i nldng he es o a sho disane above he speio lia spne) he lowe poseio sae o he sa and sde o he oyx. also aahes o he aponeoss o he saospi nas sles he saobeos gaen and he gea apo neosis, whih oves he se The bes n neoaealy o a dal inseon. T he age poxial and speiia dsa bes beoe hk and end nos and bend no he lioibal band o he asa laa The deepe disal bes nse i no he e below he geae ohane. The aions o he ges axs i nl de exension and aea oaon o he hgh sabiaion o he knee hog h he asa laa and poseo oaon o he ia.
F -24 Glueus maxmus
The gles eds (Fg. 2) oig inaes ove a boad aea o he l nd ing os o he es hinning o o s he es aneoy. I also aises o he oveyng geal aponeosis Is bes onvege no a endon ha nses on he laeal aspe o he geae ohane wih a bsa nde i o shon he ohane. The poseioly oginang ibes aah aneoly and he aneo ibes inse poseoly This wisng o he se give s i a liple nion. The an aon s abdion o he high. The poseio ibes assis in laea oaion and ex ension and he aneo ibes ad edal oaion and exio n. This sle is ipoan n walking as i ho ds he pevs eve dng he swi ng phase o he oppose side The ges edi s has he abiiy o i sa neiis when inaed aoding o . Robe Kein a heaoogs a he Sans Media Cini n Sana Babaa Caona. The gles nis (Fg -26 is deep o he eds aahing boady aoss he nne aspe o he i i The ibes onvege n a endinos aahen o he aneo sae o he geae ohane s aon is is edial oaon hen abdion I an asss in exion as wel. The piois (Fig 1 -2) ns aos paale o he pose io bode o he ges edis. is la and pyada n shape he base oiginang o he aneo sa a he evel o he seond hd, and oh oaen and he aea ad jaen o he geae sia oaen I aso has aahens oginaing o he aneio sae o he saobeos iga en The se exis hogh he geae sai oaen and a is apex, os a onded endon ha inses ino he speio bode o he geae ohane s an aion s aeal oaon and abdon o he hgh. an also asss in exenson The piois is known o spass. s lose pox iiy o he sai neve as exis he sia noh akes ikey o iiae he neve asng saa n a sgnian
F 1-25 G ues medus.
Aatoy
F 26 Glutu mmu
-28 Obtuat tu ad xtu
a
b c
F -27 Latal tat a piifmi b mll fm
c.
quadatu
nuber o people he sia nerve passes hrough he pifo is This loaon an ake i even oe vulnerable o rria on The piforis wl beoe hyperoni opensang fo a weak glueus inius The oher aea roaores o he high ae arranged aound he obuao oaen They inude he obuao inernus (Fg -28) neresing or is inernal pelvi oigin igh ange u and puleyke aion as rides over he goove above he sha ubeosiy The oburaor inenus is anked by he geei (Fg -27), wo usles ha un above and below he inernus o aah no he geaer rohaner The
quadraus eois (Fg 127) is he owes in he goup a rangeen jus above he adduo group The obuaor exenus (Fg 1 -28) akes up he aneor wall o he pelvs The enso fasia laa (TF Fig -29) orginaes along he oue border of he aneio ilia es and spne I blends ino he asa laa over e geaer ohane in he h k i loibal ak The glueus axius aso nsers ino he rak a his evel The ensor usle papaes in lexion o he hgh and has a sal onibuon o edia oaion is aso e sponsble or ensing he asa aa whih helps sabilze he knee The reus feois (Fig 30) he os superfiial of he quadieps eors group osses wo ariuaions ogi naes on he aneo ineror ia spne and oins wih he oher usles o he quad goup o nse on h e anero aspe o he bia I pays a ole in fexing he high as we ll as ex ending he knee n he ee poson i assiss n inluening he la aneoy The sarorius and gralis (Fgs 30 and 3 ) have a oon nseon on he eda aspe of he proxia iba The saroius is e longes usle in he body oginaing ro he aneror superior a spine runs obiquey aross he high o is inseion I exes and ediay oaes he gh and aso exes e eg Wh he eg flexed i an assis in edial oaon of he bia The saorius pl ays a oe n i ia sab ili y weakness o he saroiu s an be a faor in a pose rior roaon of he la he saorus wee in a sae o hype oniiy ould pul he la aneriorly The grals (Fg 3 1 ) arises o h e pubi syphyss and arh oinng he sarorus o nser on he bia I is he os supera use o n he edal aspe of he hgh s an adduo of he hgh, exo of he le g and assss n eda roaion o he ibia wih he leg fexed
T B ND V
2
a b
c d a
h
e
f b
9 aea ew pelc ad thgh mucle a guteu a mu b bcep emo c. eo aca lata ) d. atou e. ecu emo f. atu ateal g. otbal tract
The pb shal a provdes srong aaen for he addor group whh add and edaly roae he hgh The group s ade up of e penes and he adduors on gs bevs and agns (Fg 30). Te hasrngs ae an poran usle grop o onsde wen evalan g he aons of e p and pelv s Tey oss wo jons e p and nee doublng e aons exng he nee and exendng e g In e ee poson, ey hep slghy) o e aneo oaon of e pelvs ore so wen he pevs a nd ba are flexed The asrngs ogeer provde laeal sably The beps feors (Fgs -29 and 3 1 ) s e aeral sng s sho head orgnaes on he fe e ong head fro he sal berosy Bo heads n ser on e head of e fba and laeal bal ondye Bes des exendng he hg and fexng e eg e beps an aealy
F 13 Ateo ew pelc ad thg mcle a lacu b poa c. gluteu medu d teo faca lata ) e atou f. ectu femo g. lotbal tact h. adduco goup.
oae e ba when e nee s fexed and an asss n aea roaon of he hg when s exended The beps as an nfuene on he fbula f hypeon an p l e fba s peory o f weak alow o shf nfero nder he nfluene of e opposng usles n he af? The eda hasrng Fg 3 1) s oposed of wo ses Te seendnoss ns oe aealy and he seebranosus oe edaly They orgnae fro e sal berosy Te endons jon he saorus and gras o nse on e aneoeda ba e eda hasrngs an edaly oae he ba wh he knee n fexon Te asrngs are ofen fond o be sorened espeay n paens wo end o be sedenay n he jobs and a hoe Two usles n e peneu he ransverss pene and oyges are nvoved n pev pobes The ansvesus perne Fg 1 -32) orgnae on e eda sha ubeosy and on a a enral endnous pon aneo o e anus Ter
nay
C
3
f
F 132 f viw f plvi bsin nsvsus pnus b yus
oy The fbes on and ose o he sa n in an aneo obliqe dieion. Keep in ind ha he difeen seions of he se an have d iffeen effes on he fnon of he i l a and sa The basi funon of he las is flexion of he hgh. I is aso a pnipal aneo oao of he il ia, and he oe aeal fibes ay oppose aeal flare of he ia The fibes wi h a saal oigin an in flene he base of he sa aneioy. uscs of h umbar Spin
F -3 s viw plv nd hih musls luus mi mus b lis h msins d luus mius . l l s smimmbnsus ddus
silaneos onaion xes he peine dawing he s hia edaly. ysfnion of hese ses an ase la flae o edia sh disor ions The oyges Fg -32) s a ang a fa, fbos s le. s apex ogin is fo he spne of he shi and he saospinos igaen . The i nse on s on he las saal and al he oygeal segens. They daw he oyx aneioy and an be a pnipal paye n oygea pobes The iias (Fig -33) is ofen fond o be invoved in ow bak and pev pobles I has a boad ogn aking p os of he inne sfae of he li The oign exends fo he aneio la spines aond he ia fossa and ono he aneio saal base. aso has aahens o he aneio saoi a and he iiolba igaens. The fibes onvege wih he psoas endon inseng ino he lesse ohane of he fe The se fibes of he ilias n in vaying deons dependng on he poin of oigi n The fibes ose o he aneo spines n in feoediall y The iddl e fbes n nfei
The psoas (Fg -33) is a ajo playe n he noa and abnoal fnion of he lowe bak apand desibes he psoas as beng oposed of wo shees, one oiginaing fo
F 1-33 An vw: dp musls. . qudus lu mbum b. i us . pss.
1
THE BA AND EV
the tasvese pocesses of he five uba vetebae The secod sheet is moe aeo oigia tig fo adjacet bod es ad diss fom T2 o 5 The usce desceds obiuey ad is efected ove the pevic b ude the iguia igame. The iiacus jois wih the psoas o se o he esse tochae. t has a vaiety of actios ( 1 ) fexig he high 2 fexig ad atea bedig the uba spie ad (3) uecig he uba odosis ad pevic it epedg o the posiio of the hip t ca eday o ateay otae the femu The psoas mo ofe abse) aises fo the sides of he veteba bodes fom T2 ad . t has a og tedo hat ises o the pubic boe a he iopectiea eece It exes the umba spi e ad posteioy otates th e pe vis . The uadatus umboum Q; igs 33 ad 1 3) s aothe ipoat but ofe goed musce owe bac dys fuctio. t is a thi oughy ecagua shaped usce u g betwee the iiac ces ad the ast ib wth sips to the asvese pocesses of he ubas Cose obsevaio show s he usce to have thee ayes The most poseo aye s ade up o f fbes u ig diecty fo the as ib to the iac cest The midde aye has fibes uig fom the as ib to he asvese pocesses of a five ubas. The aeo aye us fo he tasvese pocesses of the ft fou ubas to the ac ces The ost ofe descibed fuco is eated to he depesso of the ast bs ad atea fexio of the uba spe. Ths usce aso has mpota fuctos i the sabzaio of the umba spe ad pevis I hs eseach oga foud the Q to have a sgifca oe choic ow back stabities The musce goup sacospias o eecto spae ig 1 3 aes up th e oe supeficia of what ay co sdes the deep musce s of the sp ie The us ce goup aises fo a boad thc tedo atachig to the d de ces of he sacu ad the spious pocesses fo 5 to T . The goup aso has attachets o he atea ces of he sacu ad i e pose io iiac cest bedg with he sacoiac ad sacotubeous igamets ad og is of he guteus axiu s The ubodosa fasca coves he goup i he uba ad thoacic ego The sacospia s usces stat out th ad mosty tedous becoig thc ad feshy i the umba egio. The usce goup s dvded to thee distc goups gaduay hiig out aga as hey cot ue upwad. The eeco spiae es i he goove adacet to the vee ba coum. ts fucio is o exted ad ateay bed he veteba coum. The eda dvisio he spias thoacs ogiates fo the spous pocesses of the as wo hoacc ad s two umba vetebae Ru g supeioy i ataches by as may as egh sips to he uppe hoacic spious pocesses. The ogissimus thoacs s the agest dvisio its oigi i s beded wth the spas ad ocosas goups wih soe fibes atachg o the uba accessoy ad tasvese pocesses. Ths divso isets io the tips of the ho
d
e f b
F 134 Psei iew ee spine musles. semispinlis dsi, b qudus lmbum mlifids d. il islis dsi, e. spilis dsi f l issims hsis i isalis lmbum
acc tasvese pocesses ad ito the ast ie o e ibs. The iocosais uboum is he most atea goup ts fbes oigi ate fo the ac ces ad i se to he ages of the as six o seve ibs The deepe ayes of the spa usces ca be uped ogethe as he paaveeba usces. They a have veeba ogis ad isetos ad ae shot ug bewee oe to ve segets. They ca be fuhe diffeetated by he at achets ad basic fucto. The paaveebas icude the utifidus g. 1 3) tespiaes itetasvesaii ad the oatoes They exted ad otate the veteba cou i geea ad ove idivdua veebae o sevea at a tme upo each othe The abdo a usc es ae the ateo usces of the u ba spe The ectus abdoius g. 1 35) s the ateioos uig veticay o ehe sde of he mide t ogi aes by wide b ads fo the ffth sxh ad seveth b s a the ateio aches ad costa catages. The bads becoe aowe as hey desced to be atached o he pubc cest ad symphysis by a stig edo. The ect ae atached at the ide by the iea aba a potio of he abdoa apo euosis.
5
36 svesus bdinus muse. 1-35 Reus bdmnus mse
The tansvesus abdonus g 36 is th e deepest ayer oiginatng at the tps of the ub ar tansverse pocess Ts the catages of the ast six ibs the i i ac cest and the atea inguna igaent. The fibers run hoizontay to the anteior bending nto the aponeurosis of the ectus sheath onng ts opposite. The transves ake up the inner abdoina wa suroundng the viscea. The obiuus ntenus ig 1 37 s the aye anteior to the tansvesus ts fibes fan out fo its attachents aong the ac cest and the inguina igaent running superoediay The infeio fbers which attach to the i nguina gaent run horizontay and nferory to attach to the pubic cest and syphysis. The superor fibes un obiuey superoediay to attach nto the tps of the ast two ribs. The idde fibes run fo the ac crest bending nto an aponeu rosis that contrib utes to the inea aba and attaches to the tenth costa cariage and xiphoid pocess. The obiuus extenus g. 1 38 akes up the outerost ayer of the abdoina wa. The fibers run obuey supeonferoy and ateroediay oiginating fro the owe egh t ribs Th e ower segents run aost direc ty i nfe ior to i nset on the anteior haf of the i iac cest. The upper segents un obiuey inferoediay to bend wth a boad aponeurosis becoing the nea aba at the idine. When considerng the abdona usc es as a wh oe one can see that they support the viscea that they are invo ved i n fexion and rotation ofthe trunk and that they support the pev is anteiory pu ing t supeioy. Th e posteror fibes of the obiues attaching into th e posteior aspect of the iiac crest can produce posteio otaton or ao w anteo rotation of the i ia.
-37 Obus inenus se.
The serratus posteio nferio g 139 can infuence the uppe ubar spne. t aises fro the sp inous pocesses of the ast two thoacic and first three ubar vertebae. runs up ward obiue y and ateray to insert on the inferior bordes of the ast four ribs. Its ain action i s to draw the owe rbs out and down in oppos ition to the diaphag. The atiss us dorsi ig. 39 has attachents into the ubodosa fascia which gives t attachents aso to the spinous pocesses of the ower thoacic uba and sacra segents as we as the iiac crest t is conceivabe that the
16
TE BA AND EV
bra Th cra ad th orgs to h psoas trdgta ad ca b actd by ach ohr. VSCULR NTOMY
dtad stdy o th vascar systm s o rva o h prpos o ths x ho vr thr ar svra c ca vascar cosdratos hat d vaag wh xamg h owr bac ad pv s ahoogy o th aora s a vry m por a coradcato to orc mapato. Th aora h ma artry dscdg hrogh th abdom s aog h aror mbar sp Bor brcag at L gvs o mros vscra ad parta brachs Th brcao orms th wo commo ac arrs hch dvd o th tra ad xta ac artrs g. 0 Occs v ad
F 38 Obqus xnus mus
b
F 39 is smus ds b. ss psi ini . ps bmins d umbdsl s
atssms dors ca c co h ow bac ad pvs. Th daphragm has attachmts o th mbar sp . Is t d os cra ad m bocosa archs atach o th mbar vr
F 10 A xn nd in n i is nd vnus u
ammaoy diseases and aneuysm o he vesses can e mpoan consdeaions n deemining a couse o manpua ve heapy. The nena iac o hypogasic aey suppie s he pevc was vscea and epoducve ogans. aso suppes he uoc and media hgh. The exena ac aey descends aong he meda ode of he psoas and unde he inguna igamen a which poin i s na med he emoa aey The femoa iange g. ) is an anaomca andma mpoan in examining he cicuaoy sysem The aea o deed y he nguna gamen adduco ongus and saous aows papaon o he femoa vein aey and neve.
1
b c d e f
EUAATMY
h
The examnaion o he owe ac and pevs incudes an evauaion o he nevous sysem. Ths ex w ocus o n he cnca aspecs o neuoogy ahe han a deaed d iscu sso n o neuoanaomy. The spna neve ig. 2) oignaes om he sp na cod va wo oos he vena o moo oo and he age dosa o sensoy oo. The dosa oo conans he spina gangion whch is usu ay su aed in he ineveea foamen eyond he dua sheah. The wo oos join immedaey eyond he gangon The oos of he uma saca an d coccygea segmens ae ong descendng om he end of he cod n h e cauda equina The cod ends a he 2 eve Because he oos in he
c d e
1 em e i ui ie b TL c. fe vei d fem ey e fem eve f sius
-42 Spi eve spi cd b. ds c ve d. mee bch e ds i f symphec u i psei piy divisi h ei pmy divsi .
owe uma and eow oginae highe up anaomicay i has een found ha manipuaing h e spine a he oigin o he oos as we as whee hey ex may e efecive o n sance a weaness n he quadaus umoum innevaed y T 2 and neves oen esponds o adusing o he T9 1 0 1 1 segmens The spna neve spis no dosa and vena p imay divsons. The dosa divison s geneay smae. In he um osaca spne meda and aea anches suppy he deep paaveea and sacospinaes musces wih cuaneous anches suppying he uoc aea The vena pmay div so ns wi disiue neves o he es o he ody. In h e ho acic egon he vena pimaes emain segmena and in he cevica and umosaca aeas hey fom pexuses The pevis and owe exemy ae nnevaed y neves fom fou pexuses he uma saca pudenda and coc cygea. These pexuses ae fomed fom he vena pimay divis ions of he fve uma five saca he coccygea and a conuo fom he wefh hoacc spna neves. The uma pexus g. 1 3) i s fomed y he weh hoacic is hee and mos of he fouh uma dvis ions. The pexus ies agains he poseio adomna wa agains he psoas oen newined n he fascicui of he musce s emina anches ae as foows . iiohypogasic 2. iioinguina 3 geniofemoa
T1 2 2
THE BA AND PEV
18
2
LI
b
L2
L4 L
L3 -
SI L4
d
S2
d
L S3 -
e F 3 Lumb plexus. i iohyposi neves (l 2, L l ), b l ioinuinl neve (L ), enofemol neves (L I 2) d le emol uneous neve (L2, 3), e. femo neve (L2, 3, 4), f obu o neve (L2, 3 4) . lu mbosl un
laeral femoral cutaneos 5. otrator 6. femoral 7 moacral trn
4.
L23 L234 234 (to the sacra plexs
The irst hree nerves i nnervae the tsses of he o wer a domnal wall ncuding he musces and sn o he toc proxima thgh and groin. The atera emora cutaneous sup pes he s n ofh e aneroaera thig h to the nee The ourator nerve s he moor nerve for the adducors and grac is , w th an articuar ranch to the nee. The femora nerve supp ies sensory nerves to he anteromedia high and, va he saphenous ranch the media eg and foot Motor ranches sppy the sartorus pecineus and quadrceps grop Branches o he psoas eave he plexus at or near the eginn ng o he emora nerve The sacral plexs ig . 44 i s a comnaion o a poron of he forh a of the fith lmar and rst three sacra nerves. I l es aganst the piriformis on he poserior wa of the pelv is. The sacra pl exs converges on h e greaer sciatic foramen. The of he comned ers mae up the sciac nerve The sacral pexs has the fol owng ranches: I . o he qadrats femoris and gemels nferior
2. to the otraor internus and gemellus sperior 3 . o he piriorms no shown in ig. 144 4. sperior gleal 5 . inferior guteal
4 S S 2 S2 4 S S 2
F - Sl Plexus o lumb plexus, b supeio luel neve (L4 S ), . i neio l uel neve (L4, S I , 2), d poseo femol uneous (S , 2, 3), e ommon peone neve, ibil neve . o obuo inenus n emelus supeio (L S 2), h o qudus femois nd emellus infeio (L4, , S I ), i , in feio medil une neve (S2, 3), j o pudend plexus
6 poseror femora cuaneous 7 . perforang cutaneous 8 scaic ( g. 44 e f 9. o pudenda p exs 0. neror eda cunea
S 23 S23 L4 S 23 S234 S2S3
The first hree ranches are 3selfexplanaory as to heir unction The superior and nferior gueal nerves nnervae the gea musces The posterior emoral ctaneos nerve sppl es the sn of the poserior high eg and pernem. The peroraing ctaneous nerve suppies he sn over the meda and lower glteus maximus The scaic nerve is sud vided no the iial and common peronea which trav e together from he pi rforms o he ds ta hird o he posterior thgh efore spitng p The scatc nerve supp ies the sin of he foot and most of the eg a l he joi nts o the ower exremty the posteror hgh musces and a the msces of he eg and foo The tia porion of he scatic nerve conines down the ac o he eg spl ting no he media and aeral planar nerves as i ronds the medal ma eo s on is way o he nderside o he oo. The common peronea nerve crosses he popleal ossa wnds arond he nec of he a sp itn g no he s pecial and deep pero nea nerves. The pdenda and coccygea pexses (ig. 145 have ranches rom the ower four sacra and he coccygeal nerves. They suppy the perneal sructres
Anat
ange of Motion
S S3 S
-
S d C
19
F 5 Pudndl nd yl plu ss. b. . srl plus d pudndl nrv S2 3 lvrn yus sphnr ni us . h. nyJ nrvs.
ISCA AATOMY
The abdoina and pevic vscea ae contained and sppoed by he vaos pevic stces and scat e. vey paient shod have a viscea papaton exanation. Ths wi boaden exaines' diagnostic skis and incease he con dence in the abiity to ecognize abnoaties When s ng he oganc eex echnies knowing whee the ogans o eex pons ae ocaed can ake he dieence beween the sccess and ai e o teatent The ogans ae aeced by he condtion o he pevic stctes as we as the one and nction o the sc es. The psoas she sppots the kidneys ieoceca vave appendx etes and ena vens. The psoas can aect these stctes i i is dysnctiona. The abdoina sces hod he vscea n pace. weak sagging abdoen can case ptosis and ae he ncion o the ogans n aneo t o the pevis can en coage poss and ay aec he tes advesey .
The sac as descibed eaie s sspended between the i a. iet descbes t as oating" n the pevic ing passve n is oveents oowing aong wth the oveents o the i a and bas tation o the sac is he otationa ting o the sac ove the hoizona axis at he axia igaent. The sac can oate aond a vetica axis and tit obi ey ig. 16) t shod be noted that the sac has no diect sce atachents excep o a s a segent o the i iacs and is n essence a passive paye in the oveents o the pevis. The ia can otae posteoaneoy on the sac The posteio speio i iac spnes becoe cose to o the o the dne as he pane o otaton is angentia to the sagita pane. The ia can ae the ischia tbeosites conveging ediay g 7) and hey can sht neoy The pbis can shit ethe neioy o speioy. The hip jonts have a wide ange o otion inc ding exion exension abdction addcion cicdction an d otaion The vetebae have thee basi c oveents pon e ach othe anteio to poseio toP; exin/extenson atea exion and otaion The ba spne has a tota exion o appoxiaey 40° and an extenson o 30 Most o he ove en occs at he and 5 segens Kapandji notes that aea bendng is abot 30 oveens ae geate eay n e and diinish with age Kapandi aso consides the shape o the ba aceta aticatons and the esistance to sheang o he disk esictive to otaton and cites stdies hat gve the ota oaiona oveent o the bas as 1 0° in eithe diecton neestingy n these stdies it was ond
FUCOA AATOMY
To y appeciate he vaidity o d vesiied echne i t is necessay to deveop a copete enta oving picte o he nctona anatoy o he han body nc tiona anatoy s a cobination o bioechancs kinesioogy and anaoy. ot ony the ange o oion o individa atcaions bt the cobned acons o any joins st be ndesood. Mses oten have addiiona oes beyond thei ain actons. They can ncton i n synchonizaton b i atea y and aect the body one way o opeate niaeay in vaios cobnations that can copicate the cinica pice beyond the bascs I s easy to oveook potant bioechanica consdeations when exaning a patient; theeoe t is potan to ndestand the body s nctona anaoy.
F 6 Srl mvmns rin nd vri s b blqu r nfrr nun
20
THE BA AND PEV
Lordosis and Pevc Tt
17 Momt of t il ia a. AoP rotatio b. fla
tha the thoai spne has fo tmes he otatona aiy of the lma spine in sp ie of the i age Glet desies ma fexion and exenson as havng less fowad and awad glding than the dosa o evia spine. e also deses he omnaion of fexonotation nvolved in aea endng and saes that the ovet pnple s only ly pesent n the owe dosa and ma spne. odng to the ovett pinip le, h e otation of the veeae n aeal flexon s noma o posiv e if the ody otates owad he onvexiy and the spnos towad he onavy (ig 18)
he pevi s is a aned ove the hp oints The toP i of he pevs afes he lma odosis (g. 19) The nepay of he msles aove and elow has a vita oe n this aanng at ha aso indes a saolia omponent. The oP otaton of he i ia on he sam adds a sl igh degee o pev ilt, who affeting the odosis. Kenda deses the neta pevi posii on as havng he aneio speo iia spine (S S ) and the pi symph yss i n he same veta plan e Kapand efes to the intespnos ne etween he anteio and poseo ia spines as eve n a neal pevs Boh methods ae good ndaos. When the pevs ts aneoy, he lma vate s in eased and he hp jons ae fexed n a posteo til the ve s deeased and the hip ons ae exended. xessve posteio it s heked y the iiofemoa lgamens whh eome tat. In the eet stane, the adomi nas gltes maxms, and hamstings infene the pelv s posteioly (g. 1 50 he adominas an e thoght of as the aneio msles of he owe spine The es and he oliqe fies help sppo he pelv is p ng pw ad on the pis whi e he poseo fies p poseioy on the iia ess, edng the odoss as wel as the pev tit. he adomna oiqe and ansvese fes, espeal y he moe posteio fies ae often nvoved n low ak and pelv ondiions and ae ofen ovelooed in evaation and teatment he gltes maxm s wos wih the adominas to pl the pelv s posteioy in the eet sane Wth the legs planted the g es maxim s wth is atahments o the fem, i a es and sam eeps he pelvis fom itng too fa aneoy he hamsngs povide fhe p on he shia keepng them fom ding speoly. The gtes maxims is often
a
1 -8 Lumba latral flio with rotatioa opot.
b
-9 Pli il ad ordoti ur hag a. porior drad b tral atror irad ur.
Aaoy
21
b
b
c
F 50 Mcl tha luc h pli ptrly. a abdmial b. glut u mamu c hamtig F -5 Mcl that ilc t pli arly. a pa b. i iacu c artu T rct fi
fod o be wea or have wea potos The hastgs ae ote too shot ad ote cotracted The psoas i iacs ad to a esser exet the sartoris T ad ects eoris ilece the pelvis ateioy (Fig. 1 5 1 . The psoas fleces the ba spe to lordoss Bogdk ees that th e desig of the psoas adds a copressve foce o the bar spie icreasig he ordotc edecy. The i lacs pls the i lia ateiorly. It s picpaly the iddle fibers of the l iac fossa that are esposb le. The oe aterior fibes ea he SIS pll the iiac cres oe iward With her aachets o the ateio ad feior liac spi es he sarors ad ects eos p l fro their espec tive ee i setos ecoragig the pevi s o i t aeory. the erect stace he pelvis is baaced by a cocert of syegistic ad atagoistic actios by he above described sces Kedal beieves he erecor spiae cotrbes to odosis whe they ae chocally coacted The erectos ae ot as sigiica affectg he tl o he pelvs as he previosy etioed scles; however if cotraced they
are resposibe fo icreasig the ba crvatre withot i volvig he pelvs. Kapadji otes that with he sac fixed the erecors are powef extesors acig o he l bosacra ad thoacobar jots. This exesio wil cease the lordoss They a y also be coracted secodary o a chroc lodoic lbar sydroe see Chapter 6 o Codi tos ad Teatet) Trnsverse Pevi Stbility
I the optal eect stace the pelvs is level hoiotaly acoss the il iac crests ad a the posterior sperior iiac spies. The dyac actios traslated thogh the hips ad pevis i al l phases of oveet are he co tepart o th e stabil ty that he pelvis provides sppotig the body. The porat scles latera stabity icl de the addc os abdctos hastrigs obliqe abdoals qadrats
22
HE Lw A AND EV
lumboum psoas and the i iaus and tansversus perne (F g 52 n the eret position the gute us medius s the mao lateal stabiize. It is a very important muse in waling and un ning. ts funton s that of a hip abdutor but from anothe perspetve i t an be vewed as a latera flexor of the pev is on the hp. With a major weaness of the medus the pelvi s wi l drop on th e opposite side whe n the ontralateal le g s ifted (a postive Trendelenberg sign Fg I-53 he medius i s ofen found to be wea enough to ause adaptve problems without showing a positive rendelenbeg sgn he gluteus minmus
I-53 At fglt d ad Q i Trdlbrg tt. QL pprt lmbar pi righ ad i p lft
Fig. -52 Latral tabili y. a addr b hamtrig . abdtr d. bl abdmia l . QL f. ilipa g. ta prii
and the FL pay a sgnifiant role in supporting the medius The oblique abdominal s an l ft the pelvis The ipsi lateral inteal obique and the ontralateal exteal oblique wor together to it the la rest (Fig. 1 52). Fo instane n lf ng the le ft leg the right g uteus medus mini mus and external obique and the left n terna o blique abdominas ae ating in onert to eep the left side of the pel vis from doppng t the same time the quadatus lumboum is woring blateraly the left wil be ifting the lum and the rght will be stabiizing the lumbar spine eeping it from bending to the let (Fig . 153 he psoas on the right w l also be holdng the lumbars. If the weight remains on the ght eg and the pevis is ante rio or posterio of neutral thee s a euitment of additional abdutors In neutral the medius is the man musle With the pevis n a posteror tilt the FL and minimus an be aled into ation s the pel vis til ts anteriorly the maxmus then the pii foms obtuator extenus and quadat us femors will suessvey ome nto play eepng the pelvis evel The hamstings at as stablzers n the eet posture and assist in movng the pevis from side to side Standng wth both feet on the gound transverse stability s aomplshed by the synergsti/antagonisti he and baane o al these musles The transvese perne musles wl approximate the ishia tuberosities (Fg. 5. They at as a he to pevent the
Anam
23
F -5 Traneru peiei pl ichia medially caig ac flare aerio fibe of the liac pl iia medaly educig flare.
tuberosii es rom speadg too r apar Latera fe xo or fare of the ia o the sacrum s produced by he trasvese peiei pul g the tuberosties medialy ig 1 54) he atero fbers of the iliacus couer hs by pulig the lac crests medally which spreads the ubeoses ad ecouages a medial lexio of he il ia o the sacrum he teral obique abdomias led support pulig ward o he iiac cress Wih these musces acig cocer the pelvis emas ela ively balaced ad sabe he tasversus peiei eed to be srog o oppose he pull of the adductors hey coact frst beore the adductors ca beg to wor Gi let descrbes the mechais ms of lateral ad meda lex io of the iia ivolved i sttig ad sadig e describes the a as farg he schia cog togethe upo sadig Whe pesos si h e isch ia spead ou o provi de a wider base for distibuio o weigh he sye gstc acio s o the trasvesus peiei ad aero iiacus fibers are major stabiliers i this acio
F 55 "cewhome deig of he hip capule
opposie he hp s much moe sabe i extesio tha ay othe posto he muscles that ae i l e wih the femoal ec wor to hold the femur place he priformis obtuator exterus ad the gu teus med ius are oted by Kapadj to be he mai musces of hip appositio g 1 56). e otes hat the logiudial musces ie the adductors ca be a stog force to
Hip Actions
he hip oit s hed together by fbrous exesos of the aceabuum the labrum ad oa orbiculars he acetabulum is ot a deep eough socet aoe ts artcular surfaces ae irmy coaped by atmospherc pressure he head of the fe mu is very difficul to remove from the soce withou al owig a ito the joi t space Whie erect he weight of the body aso eeps he femora head place he ligame ts o the o t capsule wrap aroud he jot rom posteror to ateior ad become tau i exte sio checig further exe sio ad coversey posterio roatio o the pelvis he femora head is scewed" ito the acetabulum by hs ligametous cofgurato ig 55). t is ierestig to ote tha the aterior hip joit has heavy lga mets ad less musculaure bu the poseior aspec has the
F 56 Mucle o h p apoto a g uteu medu b. p riformi c obtato exeru
24
THE w BA AN PEV
disloate the hp. The hip is weakest in adduion wih fexon (ig 1 57. ip dysplasa or a shalow aetabulu an faili tate d sloaton as t he roof of he soke an be anged ore superorly. The exensor usles of he hip are priariy the gluteus axius and he hasrngs asssed by he ibers o he g u teus meius and inius and the adduors (osy he agnus ig 58 Kapandi dvides the extensors nto two groups The glueus axius aong wh the edius and nimus extend and abdut. The hasrings and adduor
agnus exend and addut. Pure exension requres a balane between hese wo ses of synergiss and anagonists The hasrings ross wo oins the hp and knee The ore ex ended he knee he ore efien ther extensor aton a he hp ip exion i s priariy the responsibi iy of the iopsoas. ssstng he iiopsoas are he sartorius T retus femors peineus adduor longus and graiis g 59). When these usles a n oner one sees pure fexon The indi vidua fexors are also apabe o abduton addution and edal and l aera roation The retus feors is a bariular usle flexing he hip and extending he knee. The ore the knee is flexed he ore effent the reus s a hip flexion obnation of fexionabduionmeda rotaion s a oplished wih the aid o the anteror ibers of the glueus edus and inus lexionadduonaera roation s produed wih he iliopsoas petineus and he adduor lon gus predoinatng In lexionaddutionmedial roaton he adduors and T predomin ae I The ain abduor of the hip is he gluteus edius ig 1 60) I t i s siuaed nearly perpendiuar to its lever ar. The nimus is essenially an abdutor and the T s a srong abduor n he eret sane. The most superior ibers of the axi us asss i n abdution and the pirforis a ain laera rotator kiks n wih the hip flexed g. 1 61 ) The prin ipa adduors are the addutor group he l arges beng he a gnus. t ies poseror to he aduors ongus and brevs and has soe extension apabiity but he longus and brevis an assis only n flexon Other iportant uses as sising in adduion are the hamstrings gueus axius
F 58 Mc of hip io. a. guu au, b gu iu ad i iu c. adduco agu, d hag.
F 59 Mc o hip fo. a. iiopoa b. aoi, TL c o, c. addco ogu, gaci i, pci
F 157 Hp adduco ad fiowak poiio fo diocao
Aatoy
25
F -60 G ueu medimain hip abdcor F 1-6 Mucle o adducion a adau eori pecneu, obaor, b adducor goup and glueu aximu, c amring, gacili
F 6 Laeal roaore a piormi oburao gemeli b pecineu, uadrau emori c glueu ediu maxmu d adduc or F -6 1 Wi hip lexed piiom ac a an abducor
quadratus femoris pectn eus boh obturators and the gracil s Fig. 62. atera rotaon is accomplshed by numerous powerul musces Fg 163 The pirforms the obturaors and ge mel are he princpal roaores and are asssted by the quadra tus femoris pectineus ibers of he gueus maximus medius, and adducor magnus The obturator exte rnus has some flexor infuence and is a more powerul atera rotator wth the hip in lexion The piriforms does more abduction wth he hip in flexion Medal rotaton is accomplished with ess orce and fewer muscles the TF and aneror fbers o he gue us med us and
most o the mini mus Fig -64 When the hip i s in extreme medal rotation he obturator externus and the pectineus be come medial rotatores. This is an example of wha Kapandj I calls inversion of muscular action s easy to see that the main funcion of a musce can become alered demonstrating secondary funcions or even be reversed dependng on the posiion o the oin noher example s he previously men toned secondary abducton uncion of the piriformis in hip flexion Fig 1 6 1 ). Wih extreme exion the pirorms be comes capabe of medial rotaton and exension ubar Mehais
The lumbar spine sits on the sacra base tang off a a for ward tit The ordotic curve is mainaned and influenced by
26
THE L BACK AND PELVS
Fi Medial roaores. a. TL b gluteus edus ad ius aerio bes
the pelvic ilt, he wedge o he 5S1 unctona unt, the sac ra base angle, and he action o the elated muscle s The paavetebra muscles, a the deep muscles coveng one o several segmens, ae responsbe or extending otat ing, and laeally bending ndivdua or groups o segents Ci nicaly, hey are considered in a genera conext when examinng and treang a bac condton They wi oen be ound to be hyperonic and nlamed n areas o dysunct on The last two vertebrae ae raher tghty bound to the i a by the ii olumbar l gamens and thereoe have a imi ted ange o moton compared o 3 and above apandji gives L3 a sg nican roe n the eec posture I t is at the apex o the odoss and is generay paalle o the horionta pane L3 has a beee arch, anchoring the ascending spnais ibes and the descendng i li ol umba ibes om he lats I s isel anchored and pu led ineorly by ereco spnae bes rom the sacu and li um Fig 1 65. T 2 is considered to be the point o nlexibit y between he u mba and thoracic spne It acts as a swvel and s bypassed by some o he veeba musces atachng above and below i When considerng the lumbar spne cin ical y, thee ae sevea imporan musces that need o be uy undestood o a cinician to be successu in treang he ow bac and pevs. The iacus, psoas, guteus maxm us, and quadratus u mboru are most oen nvoved in one combnaion or anoher in ow bac and pevic dysunctions In he erec stance, the umba spne and pelvs are suppored by the synegisic/anagon sic act ons o the suound ng musces nteriorly, he abdominals are poweru exos o the un They aso wor n he opposite d recton to i he pe vis, which can reduce the ordosis ig 66 This is an ac o lexon as wel wth a reversa o stabaton and a ected ponts The psoas muscles, principay hip lexors ac o compess the lumbas and end to increase he ordoss especaly the
Fi -65 L3: acor or lower bes o erecto r spia e ad asced ig bers o spas ad descedg aissius dors.
Fi -66 Abdo ia ls' eect o posteror peli c rotaio.
uppe r umba bes ig 1 67 L4 and 5 ae moe lexed by he psoas When he pelvis and umbar spine are in ul lexion, as n bendng ove beore he body can begn o aise L5 is uther exed by its psoas sp This hods 5 n lexion whch actates he extension o the rest o the lumba spne
Anatoy
27
i. -67 Psos effec o compesso o lums icesg lodosis
and pevis y increasing everage ig 1 68) The L5 psoas sip is oen fond o e dysfnciona, either hypo or hyperonic. Bending and lifting inuries coony invove he psoas, especiay the LS sip There is a reaionship etween the psoas and the abdoinas They work ogeher in an ac t sch as a sitp The abdoinas iniiae he act, and the psoas kicks in at the hafway poin They antagonize each other in the standing posiion he adoinals iing or infencing he pevis posteriory whie he copressive inence of he psoas increases he lordosis, and y fexing the hips, infuences the pelvis iting it aneriory ig. 1 69).
i -68 il sge of isg fom e posiio L psos slip cocs dkeepg L flexed eeco spi e cocs c gles mxmus cocs d msigs coc e. elxed ppe psos es
i -69 Ago sic cio of domi ls d psos i eec posue
Poseriory he erector spinae and the deep paravererals are iportant extensors. The guteus axis keeps the pevis i n check, faciitating extension by p ing the pelvis pose riory ig 70) The axius is considered the ost powerfu usce in the body yet it is often fond o e weak. The Q is a ch ore iportant sce than origina y hoght The Q runs etween the i li ac crest and he as r with two of its three ayers giv in g sip s to he rs for u not the fifth) transverse processes These sli ps rn in a ateral and si ghty anterior direction ig. 1 7 1 ). n the erect stance
�
i 7 Eec posuexesio of spi e d peli s y eeco spe d glueus mxmu s
28
TE L w A AD PEV
the QL helps the lumbars to ess the forward pul of the psoas g 17 1 The ndv idual slps fom the transvese processes can infuence the movement and posii on of he firs our umbas hese sip s play a pat n l umbar dysunction and subuxation he Q sip from he fourh lumbar s an impotant chec on a nteior otaton o the i um f he u mba spine is ixed by is suppor musces The QL s principal funcion s descbed as latera fexion of the spine In tandem, they ress the anteror pul on the lumbars They wor wih the abdominas psoas and paravertebras to rotate the spne an d tun One can see by ths mutude of seemingy confcting functons ha a muscle can opeae n a variety of diections dependng on the demands of the moment and he poston o ts origin or inseron The QL s oten found to have signfi can weaness, ofen unilatera which can have a sgnican mpac on spna and pelvc stabilty Stati an Dynami Postue
In evaluatng the bomechanical functon of a paient, the unil atera unction of the various musces mus be considered o urther complcate hings, each muscle s actualy a colec ion of smal e muscle b undles ha can be considered as sepa rate musces One must consider ha potions of a musc e may be dysfuncti ona It is poss ble o have pat of a muscl e hyper onc, part hypoonic, and par functoning normaly, and he musce may test normal ! ost lower bac and pelvc probems nvolve the muscles in various combnations of hyper and hypotonic staes n ooing at the mechani cs of the area, the examin er must con sde the muscua r nteactions and determne whch usce o muscles ae malfunctoning and if the nvolvemen s bil atera, uni aera obique di agona, or nterna
71 Aeolaea pul o QL ibes uees lia posteo ad esists ateio pul of psoas lae aows)
When invesigatng a paien s complaints the inesiology o he area shoud lead he examn er to loo at he muscles that poduce he peceived mba lance, those tha a low t and hose ha provide secondary suppot Carefu scruiny wil revea he muscles ost liely to be invoved They could be above below next o, dagonaly across, or oblquey above or be ow etemning whether the whoe or ony a porion of a musce is invo lved wl l help pinpon he problem which may even be caused by one of he more obscue muscles I no dscovered, any muscle dysfuncton wil preven a complee recovery Posture is manained by the coordinated efort of these muscles The coordnaton is provided by the proproceptve nevous system he paiens' basc posture wil reveal much about thei condtion and how thei body is adaping o stresses and dysuncton We mus vsua lie paiens biome chan cal y and mental y compare he mage o our undersand ing of idea funcion ey o successu teament, which in chiropactc involves the eduction of subuxatons is he co recton of any inesi opahoogy ea Posture
We often efer o normal postue, but rarely is the normal specimen found except in ex boos ven Kendal admis
-7 deal pum lie posue
Anaoy
tht they hd neve seen sube h i their rie or peret posture. s hroprtos we guide ou ptiens towrd xu heth. soohunioning bned usuoselet sys te s unden o the suessu eduion o subux ion s nd ther ees on the nervous syse Kend1 desrbes ide posue s t woud be seen upon exinon. gure n deonsrtes he de pub ine postue nd shoud be oe en stndd in pien evutons. When a oo spien snds eet he or she s us ing ni use powe nd the poproepive nevous syste o eep he bni ng together. we ope th e oo sp ens to othe pies we see th we hve hd to dp to the eet poston We hve hd to uve he spine in he sgt pne. The owe b sts on bse h ts orwd. Te ub spne hs o urve b nd hen goes nto yphot uve s sends to the ne whee uves nerory g in neessry o blne he body. The ubr odoss s dptive nd hee re usur d ptions s we ht re neessy to suppo te upgh posi ion. odng o Mhee in s boo liopsoas the eong ion o he iopsos is prry dpton o the uprigh sne e ontends ht it s oten nopete nd tht the iue o he use to uy eonge s piy or in ow b nd pevi pobes. r. Logn stressed the ipo tne o he us nd psos. oweve in h s sudes he on uded tht the two uses nnot be onsdeed s one e even stessed he ide o vewng the psos s ve disnt uses one o eh lub segent. I s ipotnt to reognize h porons o te u se n be hyperoni nd ohers hypooni. The psos nd us n be ou o bne whih w er he retonshp between the ub ordosis nd pevi t I he psos wee hypertoni nd e us no or hypooni he odosis woud be inresed wth the pevs neu r or ted poseroy (ig 1 73) I both e hyperon swyb n resut (g. 74) wih n nresed ordoss nd neor pe vi tt espeiy i the bdoins nd guteus xus re no be o opense. the psos nd the us wee hypoon (ig 1 75) n piure o b oud be seen with deesed odoss nd posterior pelv i t the psos s we nd he iius hypetoni (ig. 76) there oud be deesed o no odoss nd nteror pevi it exggered by we bdoins The neut idel stndng posture hs the eet ped eveny pr under the hp ons nd the pevis eve n he sgit nd oron pnes The nees re n sgh e xion ( not hyperexended nd oed) The hed s ove the shouders whh re in turn over he ib ge. The use o he pub ne s hepu bu i soud beoe esy to spot ibnes one he de ehn i ge s ngned. I he pevs s deved ro the ide l neut post on the di sorion n the owe b w rnse upwd no h e thor nd evi spine
29
F -7 Poa yptoic i lia cu waincad lodo wt plvi uta o poto.
F -7 Poa ad ili ac yptoiccad lodoi ato pi
F 75 Poa ad liacu hypotoicdcad odoi pv ua o potio
30
TH Lw BACK AN PV
76 Psoas hyoonic iiacus hyeoncdeceased lodoss anteio elis.
either exaggeratng or reduci ng the nora curvature accordingly entoned earler ucle fal ino one of hree categorie when anayzed for pecific oechanical funcion: ( 1 ) thoe ha alow an action (2) hoe that produce an acion and (3) thoe tha upport an acon. When a uce alow an action o occur it i reaxng or contracing eccentricaly (lengthening the ucle) agant the oppoing oad The con centric contraction of a ucle (cau ng the ucle o horten ) i a producer of an acton. The upport ucle are the yner git aiing in tailzing the eetal yte around the area of acion The upport ucle would e n a uained contracion during the acton. Loong a he toP aancing echan he ucle ha prode a poeror hift of ody weght are hoe that prodce a poterior ting of he pelvi priarily he glueu ax adona and o a leer degree he haring (ig 1 77 he uce ha alow th poeror hft are he poa lacu and the aroriu and rect feori hey u reax and le the producer tae over nerior hifin g i a reveral of the aove wih th e producer eng the poa il iacu and oher ynergit (g. 78) . Thoe that a lo w it are he guteu ax iu adoinal and ynergit Recall that the fourh egen of he quadratu lu or ha a ignifcant role in he oP tal ty of the il u ine of pul fro he tranvere proce of to he i iac cret give it the aii y o uppor he ii a when the luar pne fixed herefore i t can e i gnificanly in voved in the producton of poterior rotaion of he il a or all ow anterior roaton. he ala ncing ac of he pe vi in the erect ance i accoplihed y the nterplay of thee pelvic uce in he toP pane and y the l atera tail zer in he ranvere plane
1 77 Musc les ta oduce a osteo si. a gue us ax us b abdoinas c astings
-78 Musces ta oduce an anteo shift a soas i iacus b TL ectus feois saoius.
the pevi i nflue nced poterorly y the weigh of the ody it i checed y the poa iliacu and ulatey the iliofeora l gaen The adonal hold he pelvi u p and the erector pinae uppor the pine y exendng i The glueu axu pul ac on the pev countered y the ilacu and poa here are other ucle in he ower extreiie ha ao pay portan roe in aintaining the erec tance (ee text on The Knee and The oot and Anke y r Logan)
nay
3
Postural Fauls
Postural auls are requenty seen n lower bac patiens The ost coon is he ordoc ubar syndroe S) Ths s due to an exaggeraion o the ubar ordosis and aneror rotation o the il ia shi ing he body wegh orward ig 19 It is produced by hyperonc tight psoas and acus wea stretched gluteus axus and wea or nonuncioni ng abdoinas g 1 80 here ay or ay not be signican changes n the upper spnal curvatures. Such changes would include an ncreased horacic yphoss and anterior dispace ment o the head and ne c. atbac aul is the oppos te o the LS w th a posterior roaton o the pelvis with the gluteus axius being hyper onic and the psoas wea g 8 1 hs is seen ess oen clinicaly Uneveling o he pevs in the ransverse pane s anoher coon aut oen seen wih leg lengh nsucency I) ether anaoca or unctonal Opposng or unatera rota ions o he l a and correspondin g uscu ar adapaions occur n an aep o correc he unlevelng. Postue n Motion
F -80 Coic .
n dagnosng he echan cal cause o a low bac condii on, nowing what s occurring during specic acions that preciptae sympoms is via o a successu reaen oucoe or
F latback poure
F 79 odoc um ba ydome ()
exape a patent wih a n acute low bac episode wil oen arise wh wegh borne on one eg o reduce stress on he in ured area see Chaper 2 on xai nation)
32
THE Lo BA AD PEV
tandin on One oot
When he weigh in he sandng posion is paed on one oo, he ow bak and pevis s adap in order o ean eve and suppo he uppe body The pevis wi end o dop on he nonweghbeang side, and he bar spine w urve away ro he suppored side The horai spine wi opensae by rvng bak and h e nek od end i n he dreon o he ubars n a heahy body, hs s n iized The sppo uses w go o wok o see ha baane is ananed The gueus edus is a key use in his posiion The edus on he weighbeaing sde asssed by oher abduor uses w i be woking o keep he pev is as eve as possibe (g 82) sgnian weakness o he edis w be seen as a posiive Tendeenbeg es wih a signian dop o he pevi s on he ns uppored sde The QL wi be ave on boh sdes (Fig 182) On he weghbearng side he QL and psos wi be reain ng he ba spine eding is endeny o urve onvexy oward he unsuppored side On he resing side, he QL w be ing he pevis supeory aided by he obqe abdoinas Ciniay, any ak o baane or weak ness observed when evaang his non shod ead he exainer o invesigae hese ses and oe any dysnon Arising
The a o asng ro a seaed posion invoves any ses aing in oner Soe wi be ave, onrang
onenray (CC), poding he aion ohers wi be e enray onraing (C), aowng he aion and ohes w be supporve (S) The a o arsing an be broken down no o sages: ( 1 ) orwad oveen o he rnk, 2) i niaion o eevaon o he buoks ro he sea 3) idway o ere and ) ina oveen o ee xhibi 1 1 desibes he varos nions o he os sgnian ses in he sages o arisng In reviewing xhib 1 , he bold onenri onaons (CC) apons n he seond sage indiae ha he QL geus axi us and he qadieps eois are onaing hard and ae he os poran ses in he a o sandng p Arising on On e oot
The a o sandng p wh he weigh on he rgh oo ephaszes a naera hange n he eors o he QL and g es axi us and aivaes harder onaions ro ohe ses (see xhib 1 2) xh ibi ] 2 shows ha he QL us onra harde on he e side o i he nsppoed side whie he gues axs woks uh harde on he weghbearng side as does he qadrieps eors Boh xhbs 1 and 2 deonsae he gea poane o he QL and gues axiuswo uses h a shoud be onsdeed eary n he inve sigaon o ower bak disodes Bending and in
The ubapev rhyh is he oodinaed oveen o he uba spine and he pevis neessary or a sooh oveen ino exion as in bendng over, and a en o he pigh posi io n Ca ie desribes he rhyh as a preise aio o ba exion and aneio pev oaon over he hip
xhibit Mule Funi i Stage Ariig
Stag Mscl
eer inae a liau abdinaJ quadratus lumborum glutes maxms tranvere ereal iifi glueu eiu quadraceps femoris atrig addur garneeu
F -8 e me i an Q t ta g e f
EC CC CC CC C CC CC/S S S S EC
2
3
4
S S EC
CC EC/S C
CC C/S EC
S CC S EC S EC
CC CC S CC S CC EC S EC
CC/S CC
CC
Anatmy
33
xhbt \-2 Muscle Fnction in Sages of Arisig o Oe Foo Stage Muss
IL
R
2L
R
3L
R
4L
R
erecor spiae abdomials qadraus mborum psoas glutes maxms ransvese peroneus piriformis gluteus meius qadrceps emors hamsrigs
CC CC
EC CC CC CC
S S S CC CC S CC CC EC
CC CC CC S CC EC
CC CC EC CC S S S S EC
CC S CC EC S CC EC
CC EC EC CC S S S S EC
CC EC S EC S CC CC EC
o The lumba spe lexes maxmaly by he e he uk ed 45° The pevs, h h ha bee pp aeroly oues o l o omplee he proess The everse ao exaly he oppoe h s a omal rhyh, he pelv l resposble or probably 0% o he overall a o Kapadj desrbes he msular ao bed over as be h he paraverebral ad ereors oa hard s he uk oered, hee mus be a eer oao o he eeor adualy alo he body o lex The lues maxu ex he equee oa had he eealy loer he pelvs The hamsrs are he las o kk , loer he pelv s he e o he ay Ca ll e meo he mehaa advaae o lex he kees hh oras he uadeps emors he he o ba ra v he lues a bee purhase Ths s a advaae , ak he ress o he pe The a o a s essealy he oppoe, he hass he he lueals ora oealy , l he pelvs poeroly r Loa od ha he psoa lp rom L5 ll ora had o hod 5 lexo as he res o he psoa s elax ad he ereos ad paaveebras are exed he sp e above Th appears o provde beer leveae or ex es o Reclinin and Active tiht e Raisin
he upe poso, h he le exeded he eso o he psoas mue l aeuae he vaue o he lubar spe leav a ap beee he pe ad he able he poas mes are hypeo he ap a be a Ths poso a be uomorabe a bes By ex h e les al lo he pev s o roae poserorly, he es o a be edued lae he sp e ad b losr o he sae o he able he upe poso, a ave sah le ase (SLR) provde aoher ook a uua erao he l o bak ad pev s he rh le s avey rased he r h ha has o happe s a sablzao o he pelv ad loe bak
The e sde o he oer bak m be ppoed more aesve ly o ose he eh hae o he h as he e ed The e Q ooal l mbou ad seraus poeor eor oa The abdomas ora o sppor he pelvs preve om l aerorly The musle ha podue he l ae he psoas, aus saror, reu emor, ad TF exae plae her es o he lu mbar pous proesses hle he rh le rs he verebrae ll be el o roae o he e aay rom he ave le ase Th s a s ha he suppo mue ae play p aa he spe ad ouer he eh o he r le The maxm u deree o rse may be reed by horeed hamrs CONCLUSON
The sa ad uoal aaomy o he huma body o paramou porae he daos ad eae o mu ulokelea od os horouh dead o he ay muses aah ad operae he varous aulaos ll eable paoers o be ompee aalyz her paes ad ovave he approah o reame s ha bee demoraed, mos musles have aos beyod he r ma uo Sye aos, aao aos, ad suppor ao a be perormed by he same musle dee suao Reproal hbo, he euooa pheoeo here he oao o oe mule oupled h he hbo o s aao, a our a /P pae a spero/ero pa e or a d aoal pla e eher horzoaly or veraly Severa o he os omo sura dyso have also bee demoraed The vas majory o lo bak om pa s l be od o have oe o severa o hese ommo dysuo oever, here s o m o he vaey o pob l es ha ould our W h a kee kolede o srue ad uo, here ae o l o he able o he praoer
34
THE L BA AND PEV
REFERENCES
I Gray H Ana tomy oj the Hman Body. (29 A ) Plalpa, Pa: La Fbgr; 1973 Kpaji A. Te Phyioloy of the Joi. he rnk and Vertebrl Comn Nw York NY Crill ivigo; 974 3 Rari Orthopedic in Primary Care Bal, M Willia & Wk 1982 4 Fara HF echanical Diorde oj/he Low Back. Plalpa Pa: a Fbigr; 973 5 Caill R Low Bak Pain Syndrom 3r ) Pilapia Pa Davi 1981 6 Barg F ortipevi Davpor Iowa: Baw; 986
7 ga A he Knee: Cinial Apet. Garburg M: Ap; 199 8 Gl H Belian Chiroprati Reearch Not 1985 Huigo Ba, Calf Mi Palpao I; 1985 9 Kall H Potre an d Pain Malabar, Fla Rbr E. Krigr 1985 1 0 Bgk N Aaoy a biai of pa ajo Clin Bioech 19927 19- 1 9
I I Kapa A he Phyiooy oj the Joint Lowr Limb w Yr Y Curill ivg; 974: 1 2 Ml A liopoa Sprgfl ll: Carl C Toa; 96
Chapter 2 Exminion
Man pto in e uppe bod e fro probe in te lowe bak pelvi or lowe extrete. erefoe n o i ropati exaination oplete wiou deerinin te ondion oft e ower too. Wi a ea undetandin of e funiona anao of te aea of op lain t and it elaion to te bod a a woe i beoe eaier for e li nan to ob etif te uulokeletal fndn and develop a treaent pan
te. e ue of pan drawn and painratn ale an ep in aein e patie n peepion of i or er ondition and ow u eotona overla ext. ow and wen did te ondiion bein? t a rauati inur o doe t appea to ave no aual inident? I it an aute ubaute o roni onditon? Wa e onet udden or radua? Getin paien to relate a aurael a po ibl e te fato uoundin teir opla int an re ult in i portant lue about te nature of te inur ivn dietion to te exainaton f e patent wa bendin ove to i a box did te pain tat on e wa down o on e wa up? e anwer o tat queion wi ll lead te exaner to te ule l ike o be n volved o inane pain atin on te wa down woud oe li ke nvolve te luteu axiu but pain at e in itiation of te lif would involve te fift een of te poa Real a te luteu wi ll be eeniall ontatin w ie a peron bend in down bu upon arii n e fift eent of e poa will ontrat ad in order to tabilize 5 wie te et of te pine i exendin. nowin ow lon te patient a ad te ondition will i ndiate e tae of e onditon. If t a reent i nur e tan 8 ou nfaation will be nial f te ondtion i over 1 2 ou od weln wi l be advaned and teefoe an porant fato in te intal treatent A roni ondition wl ave tiue ane and adaptive ab tat wil op liate reaten an d eove e patient pat ito provide lue for better unde tandin of te urren oplaint. reviou epiode oud be diued Were e evere wore or ild in oparion? Are ere an reidual fro pat nuie? An uere? e
OBSRV A TIN
e exa ould bein wi e exane obervaton of te paient Doe e patent appear to be in pain? aial expreon an ve ipotant ue ow doe te paent poiion ielf? I e abe o t? Doe e t le ve o o to one de? How eal doe e are? Doe e arie wi we balaned equall on bot fee o wit o of te weit on one foot? tere an anali lean o te ide o ere an exaeraed flexon poture? Doe e need atane o od on to in fo uppor? Wi wat diffiut doe e le upon te exa tabe? I e able o extend e le o i one o bo kep ben? HISTORY
In takin a ito t i iportant to real wat and liten to te patent. ee an be an ube in al of dfunt ion tat wil l be evden if te pian i pain loe attention. Patient often tr to inize inifiant fator abou teir ealt o attept to diuie e fa to ake te look bet
35
T BK EV
rio illee ad fay hoy hold be expoed. The pae' ifeyle i poa. De exere habi ad re leve hod be aeed. Alway ak abo leepig hab. May peope are i he habi of leepg o he oah Th w l ofe ae ek ow bak hi p ad kee poble . he pa e ao elae a peif i de or aiviy ha prepaed h or her opa qire abo avie over he la ix o eigh week ofe fod ha a eve orig ha far bak od prepiae a rre epode o bak pai. A oofhape 5yearold a who goe dowhill kg ho ay aep o ge io hape wll ix week laer) have a oe o exriaig low bak pa whl e bedig ove r for a pei o he floor. kig p he pei ge he blae. Th ao i o realy he ae b he a raw i a bak ha ha ried o opeae fo daage doe eal er XAMNATON
The foa of a ial exaiao ay be aered by he eveiy of he pae ypo. A pae wih a ho ow bak ay o edre a deaed hory or yea evalao Thee wl be o way o poeed exep o ae he pa e or he o eeive way o eleve pa a qky a poibe Obvio ly oe he paie i oe oorable he exa a be opeed. Sanding am
The exaiao of a ow bak oplai hod ar wih he pae i he adig poio poeed o a eaed exa ad he o o a pe ad fialy o a proe aee. Thee wll be gifa vaiao i pore ad ra fd g bewee hee poio ha are dia ve of he derlyg pahology. Fir ak he pae o ad who ayg ha yo are obervig poe. No kowg wha yo are obevg he pae wl ae a poo of ofor Th a good way o ee how he pae arre h or heref ook a he poio of he fee Are he eg ar apar or oe ogeher hey hod be der he h p ) Ae he fee roaed o beyod he aeped 5° o 1 0° o oe roaed o arher ha he oher U aeral oego Fg. 2 1 ) i a oo fidg aa oal leg egh i fiey !) ad h p poble. The pae wh h a habi wll e he aaoialy orre poo eeg oforable Thi reiae a da o ha he pae ha opeaed fo he aboay adg a oreed poio w l ikely evea he re dioio To oie he exa who oreg he foo paee wod be a iake. Th alo apple o radiogaph poog i he weighbearg poo f poible he pae hold a d i he oreed poiio for a ea oe ie. ake ha log fo he le o
Fig. 2- Obseve f l el e Ne he h hws eer lel h le
read o he oal ae. A y ove e ho ld be oed a he pae aep o adap o he ae Ak he paie o derbe where he o he eel wegh dbed o he ole of he fee ae hold be red o o look dow b rea l ad h k abo how he fee are eg wegh d iribio. a oral ao pae hod o be able o dier ay aea wh a greae eaio of weighbearg. Wegh ha forward o he bal of he fee od be a g of aeo l ig of he pelvi oe de o hypero poa ad a weak ge ax or boh. f h foward weigh i laeral i old be de o a aerior roao o ha parila ia wh aoaed le dyo he weigh bakwad o he hee he oppoie a i kely fd g .e. a poero pelvi wih he gle ax hypero ad he poa weak. wegh el o he ode of he ee ook for a weak e he peroe e ad exeo digor og ha alow ivero of he foo. f wegh i fel o he edal ape of he foo i old be he aeo ibial orbg o poao Antalgic Posture
Noe ay aalg ea The pae ay be leag o ehe i de o have a flexed ae wh a fla bak oe kee be or a obia o of flexo ad laeral bedi g. Noe he degree ad opare he d reo of lea ad he loao of pai . For iae a preeao of lef laeal lea wh radag pai o he igh leg ay idiae a diopahy wih eve roo opeio o he rgh aed by a laeral dk prorio. Hoever if he adilar ypo are o he ef he ae ay lkey be a era proro Wih he paie adg i a oe a oplae wh he dered pore ar a he ee he pae o o ove ad o avod ri g o awer qeio . Th keep he paie fo h i g o of he "oa poe o d g g a. The oga approah o exag ay re o a wh he bae Ay baae wil prode a reao of
Examination
37
te trtre above eabig e body to opeae ad eai adig. eep i id te patiet foo poiio ad oe ay exeive otwad deviatio, epeialy i iaeal otra al ragig fo a ited ead or pelvi o leve ode or pia di orio ay be eie otr ib ig to or aed by a owe exreiy probe Pronation ofthe Cacaneus
ook for ig of proatio ad deterie if te alae i ivoved. Tee wi l be a obvio deviatio of te Ail e tedo Fig. 2-2). roatio iv olvi g te alae ede e diae fo te tib ia to e foo ad w il pode a fioa orteig of at eg aig oeqee above. f te proaio i i e foefoo ol y tere wi l be o efe o te leg egt. Uiatera poatio witot raa aly i diate poo body eai ad ol d lead to rer i ve tigatio. oaio ay i telf be adapive e re t of a lateraly rotated er aatoa leg leg ifiiey or a vag kee defority.
Fg. 2-3 Compa ee ol heh
Knee Fod Height
Copae kee old eig Fig 23) Wi bot eet e ae a ow kee fold ay idiae a poibe aatoialy ot ibia. FexionExtension of the Knee
Copare e kee for ay flexioexteio ibaae Fig. 24). Are te kee ypeexeded Uiaeal flexio old i diae a aatoial y log eg, a way to adap to pai or a adaptaio o pevi diorio A ilatera yperexeio old idiate daaged ligae a weak popie or pevi d iortio
Fg. 24 U lateal flexoexteo balac e
Gutea Folds
Copae te glteal old Fig 25) Ay evelig or i latera exaggeratio gget a evel pev i or ilateal rotatio Iiac Crests and Posterior Superior Iiac Sines (PSIS
Fig 22 ef Ach le eo ow ea c re ete of oato
Bri g te idex ige dow o te il ia et to deeie e evel of te pelvi Fig 2-6) alpatio old opae e level a tree poi aog te et. Te poteior idde ad aterior ret old be opared to obtai a opete idea of te ate of te ibalae. it a ifeiority or a rotatio of te ila or a obiatio Hook e tb der e poterior peior ilia pie ad opae leve Ueve level idiae a otatio of oe o te ote or bot iia i
38
T o BK EV
Fig. Cae lteal flds
Fig. Nte an nleven f shlders and scaplae
rve or ay ig of olo i . Note te poitio of te ap lae ad f tey ae eve Fg 2) Note ay ead ti lt. Note te degree of teo t e paravertebal ad if tee ae ay df feree from ide to ide Pelvic Tilt
Fom te ide ae te pevi tit ad weter te pia rvatre ae ormal dereaed or exaggerated I te abdo me protdg Note te poitio of te oder ad te ead wi i ofte et forward Fig. 2-8).
Fig. 26 alatn l ac crests and SIS
differet dreto At t i poit moto palpato of te a rola ot a be perfomed aive motio palpato of te pelv a provde more iformato ad i doe late wit te patiet i te pe exam. Spine and Upper Toro
Note ay obvio abormaiti e te pa vatre ei te a lo or ireae te aterior to poteo Ato
Fig. 28 Aner e vc t lt wh weak adnal s and anter head dsplaceent
Examination
ValgusNarus Deformity
the ft te if thee is ay valgus vaus deviat f the kee whih a tbute t a futal leg legth sufiiey ( g 29). uthe evalu ati f the kee shud be de with the patet i the supie exa. Ofte subuxat fixati i the kee a als afet leg legth.] Range of Moton (ROM
Deteig the age f ti (ROM) i the luba spe gves lues t the ehaial pesatis a patiet wil ake t ahieve veet. A auate easueet is as ptat i the lii al settig t pae fidgs du g the use teatet t satsy the eed t keep auate eds ad t ustify fidgs ad teatet a edial/legal settg. ROM Flexion Extension Lateral Bending Rotaion
Normal (in degees)
90 30 20 30
ueus ethds easueet ad difeees f pii abut the degee f veet s ideed al exst. Reety the use f ilietes has ade the auate deteiat f ROM ease with bette epduibity. Hweve age ti a b e deteied by bsevati ale if he exaie has uh expeiee Defeies i veet ae easy t spt t is iptat t duet the age ad be able t pae t with futue tests t dete ie a patiet's pgess. he best pas is with the patets abilty t aheve a ul (al f the) R O wthut pai vsi ble deiey pesati peeived li i tatis. t shuld be eebeed that tw peple w l have the sae degee blty what is a f e wuld be
39
hypeblity hypbilty athe Oe siple but auate assesset lex i s t easue the d stae the figes t the fl f the patiet at tuh the f his is a easy way t bety the patiets pgess If the patet uld eve tuh the f befe they at be expeted t d s whe they ae ued. Flexion. Ask the patiet t bed ad attept t tuh the f but t t g beyd the pit f pa te hw the patet beds s thee the appeaae f a sth lubpevi hyth D the kees bed sigifatly If s assess the age with the kees staight as well Wath the spe ad pelvis ad te ay aba ateal tatia vee ts Ofte a exai e a bseve a ateal deviati f the l ubas as i the spi e i s vi g aud a bstale as flex is attepted. Whe pai is peset te the lat f the pa ad ay adati. Extension Have the patiet exted bakwad t the pt f pa ad te the l at f pai te the degee f pste pelvi tlt Wath the ldsis ad te ay exaggeated iease suggestive f hypeextesi. Lateral Bending Wath f vaatis i the lateal tit the pevis. Nte the way the uba spe beds i bth dietis Ofte the degee f veet wl be al ad eq ual but the spie ay bed f deet eves diatg abeat ti ad ixat. Cside that a iequaity f side bedig ay idiate a weak stethed quadatus lu bu (QL) the exessive side Rotation eep the pevs f vig ad te the de gee f veet ad the lati f ay pai he shuldes ae the easiest t wath but it shud be kept i i d that ta t f the uppe ts ivves the thai spe ad the shude gdle. valuatg the age f t f the hips shud iude ative ad passve testg All ages shuld be sdeed lexi : the patiet shuld be able t bg the kee alst t the hest 1 35). xte s: aisi g f sittig tests extesi al extesi beyd eutal s 30° Abduti the stadig patiet speads the egs as apat as pssibe (g. 2l0). Na abduti is 45°. Adduti: ssig e leg ve the the shul d be at least 20° tea tati sh uld be appxiatey 35 ad exteal tati shuld be abut 45°. Havg the patiet ss the thighs i the seated psiti tests flex ad addut hav g the patie t plae the lateal side the t the ppste kee tests the b ed ve ets f fexi abduti ad exteal tati (Patiks test) Deeased age ti a be fud w th degeeative ditis ad usle tatues Siing and Arising Eam
Fig 2-9 Rh kneevls deor
ptat sgs ad sypts a be evealed duig the at f sittig dw ad aisig f the sttig psiti f the
40
TE Lw BK V
Fg. 2-0 ncn e sn p bdc
paient is able have the si n the exa table bseve the w bak and trs ibaanes D the findings n he standing psitin reain when the paten is siting r is there a hange r nstane a patient wih an anatia sht eg and a un lateral weakness f he QL r bth ay shw a w sapua n ne sde in he standing psure Bu when his patient sts he lw sapua wil palpate high Lk at he spna urves and the pevis rtatna evel hanges ave the patient stand wah r bvus dfiuy un balaned veents As the paient lifs the butk f the table nte whether ne sid e li s f firs and hee is any laea shiting f the trs f the paient an rse up stagh but wth diiuty have hi r he attept t rise with the weigh n ne leg and then the her f here is a uniatera weakness f he QL t wi l be re diffiut f the pai ent ase n the ppsie leg . Fr ns tane if he gh QL is weak the patent wil be abe ise easily n the ight but wi nt be able ise easily n the let ft T he rght QL ust wk harde raise he ight pevis when the bulk f the weght i s n t he ef. A paient wih a disk abnrality wll rse and lis ne sde r the ther and if ne butk is uh a patien annt rise straght beause this inreases he pressure n the disks A patien wih a faeta stran/sprain wil be abe t rse easly straight bu wi find it painfu t ise ne sde as there s re stess n the aetal ins. ide pain and weighbeang ae nt diely relaed in this evauain The analgi pstue a patient with a disk pbe is affeted by the psii n f he prrusin edial aeal (see Chapte 6 n Cnditins and Teaent) A aeal inury an ause a vaiety pensatry ehaniss a patient annt i se staight up w ithut pan r diffuty but an rise re easily wth the weight n the gh eg and ess n he e s pbabe that he rght QL s weak dysuntinng Grasp he gh QL and assis it ntra
whie the patien rses (g 21). f i s easier r less panu i is l ikel y the right QL is a ar fa n he paten s nditin n paients wih sai sypts suppr he pirfs duing rsng and siting (ig 2-12) he pai n s redued here is a greaer ease in the atins it s pbable ha hee s a pirfi s dysuntin at he rt the pble n t he sting pstin with he high lexed t 90°, the pirfrs is an abdut A s the paient rses wah r any in wad deviain f the knee Ths uld be a sign f a weakness n the prfr is Assist the pirris in its ntratin and nte any prveent i n the ease f rsi ng dereased pan Anther area hek is the stabl ty the shia tubeses n he at f arsng the ransversus perne ust nrat pu the ubesies inward They spread r a wider base in sitng and e gether in he standing pstn. an n stabilty s suspeed supp the ishial ubersites pushng he edialy as he paent stands (ig 213). Any reduin n pain r ease ain is a psitive indiatn and shud ead an evaluain f the uses invved A sevee nsta blty wth igaenus invveent ay beneft fr a rhante bet Supine Exam
valuatns i n he supi ne exainain inude general papain passve tn papatin the spine and pelvis papan f he abden thpaed and neurgi tess and a
Fig. 2 Ass s QL s pen eps rse
Exmnton
Fi 2-2 Spp pfs blaeall as paen aeps ase
4
kiesilgia eauati f ay sigfia usles lw bak ad peli fut. he supie psii is he st ideal palpati. ealuag he ete tissue usles ad atiulais he exaier shuld feel r edea hypetty esited bliy ad pa. Wih he pate as ftable as pssible gasp bth akes ad push y seeral ties i a ephalad direti Push hard eugh t ake the pels rtate psteriy (ig 214 his wil put a weightbearig stress he bdy ad reea ay balaes r pesatry adapatis I ealuaig fr ibaaes ad subluxais t ust be reebered that he exaier is easily led t subetie piis abut the fidigs It s iperatie tha the exaier ake eery efr t betify the fdgs eep i id that t s easy fr pis abut wha expet ad ake the fidgs fi thse expetais Reig as ay bstaes t a betie exaiat as pssble is i prtat i suh a i peise area as the esigati hua ales Durg a psgraduae sei ar Dr. Lga asked the partiipats i the lass t erify the eg legh f a subet He pupsely ad with feiged iadertee ade the lass aware f the wrg aswer. Al bu f the 32 pariipats gae the irret aswer. hey had satsfed thesees that their fidigs fi wha they thugh he istur waed t hear istead f usig what they had bee taught he frst thgs t sde i the ealuati the usulskeleta syste are the key ladarks. he aaial adarks f eauatig he lw bak ad pes are (g. 2-15: ifer alaeus 2 eda alelus 3 edia feral dyle 4 aerir superir iia spies (AI) 5 l a ress
he pub syphysis ad he greater trhaes ae e hepfu adaks as wel
Fi 2-3 Sppn sca l bese s as paen aeps ase
Fi 24 sh n cephala s ae wehean
42
E BK PEV
c
d e Fi 2 lon ndks c ces b ASS c medl femorl condes d edl mleo s e nfero clcnes
Hp Ealuaton
peteus ad se f the upper adduts ad pssbe degeeratve hages Mve the flexed thgh the ppsite dret t addut ig 27) Ths ati s redued i degeerat espealy wth aetabular r buldup Distrat the feur with a steady pul ad etest the rage f t g 21). This ay allw a tepray irease veet. Ths a be paful f the lpeteal bursa s faed. he petea bursa a be irrtated i ases f futa l lg leg ad th s rritat a affet the fexr uses wh h uld test weak due t pa Papate the bursa f pa Deretate betwee bursts ad a peteus hypetty by tig f the l a s aterrly rtated ad i f the i aus ad psas are hypert bth f whh a ause the petie us t shrte ad setes spas r udeg tature i e hr dts. edued extes is evdet with a degeeated hp but is as see w th psas spas r shrte ig ad wit h a aatialy shrt feur pesatry aterr rtat f the ila ad flexr ad ateal rtatr usle hypeti ty g 219) dea the hp a ause the leg t appea ge due t iterapsular swelg Cpress the flexed hip ad rehek f a derease legth that quiky ireases aga ig 220) Pa a be papated behi d the trhater supeir t
The hip ts shuld be exaed fr rage f t, aeas f pa edea ad sg s f degeerati . W th the pate t i the supie psiti brig the kee ad thgh t ex Attept t ful y flex the t hgh t the hest ad detere the edfee ad ask if ay pa is felt. he lpeteal busa ay be the sure f pa wth full flexi Plae the patet s ft the ppsite kee ad abdut the thigh g 2-6) Nte the degee f veet edfeel ad ay pa edued abduti ad a tight e dfee ae i d atve f trature f the
r
Fi 26 es or bdc on el oon exenson
F 2-7 Evln flexon nd dducon
Examination
43
Fi 2-20 Compress hp check for eema
Fi 2-8 Hp dsaco ma empoal mpove moveme deeerave codos
I
.
,• "
•
.
Fi Noma ad edced (doed ole) hp exeso
he piriris and anterateral he ischial tubersty he patent wl ften cpain lw back pan raher than hip pan D Abrsia describes the pain f h p athriis a s se tes icking sciaica and re ten radiatng dwn he aneredia thigh he knee here ay be n fnd ngs sug
gesive f leg ength nequalty in he standng psin he hip fexrs ay test weak Leg Length
he evauatin f eg length is a cn prcedure in chirpracic hwever t s the subect f uch cnrversy an d s ten isunderstd. he deterinatin f an L and wheher i s anaica r functnal is i ptant Anatica s und n apprxately 10% 15% he ppuatin but unctina L is uch re requently fund Because f ts prevaence the clncal deterinatin L is f ar prtance n the diagnsis and reaten f lw back and pevc disrders he derenial diagnss f anatical versus funcina L requres a cear cncse and cnsstent ethd t deterine he diference. he bechanica evidence avaabe des uch explan the causes and eans f crrectin f a funcinal L uch f the discussin by experts hwever revves aund he nuerus ethds f easuring the degree anaca dference n leg lengh. Mst the ethds are inaccurate and can nvlve cplicaed radigical prcedures. Nne f the have been clinicay saisfactry hus fa he ntrapressnal dscussn f a unctinal has been ited t he adissin ha here ay be se pelvic dstrtin that ight bear cl inic a sudy he ehds deveped by Dr gan hav e prved be accurate in d ierentat ing anatical r functinal L and have shwn an accuracy n easuring anatical d ifferences wth n 3 the st accepted easureent prcedure n iied clinica studies.
44
E Lw B PE
Initil determintion After sulating weighbearng stress us e the hubs w ith equal pressure against the in err edal alel the prxia tibia) Be sure n t use uh pressure whh ud aler the pstn and disrt the fndngs By sghtng dretly ver the alei deterne if they are even r nt ig 221 Drsiflex he eet and hek he leve f the heels g 222 nfir the fndings at the ft and ankes use the sae thub tehnque t press up under the nferr surae f he eda ndye he eur g 22
Fi 2-23 Cen lenh a eal feoa onyles
Fi 2-2 Cen le enh a ea a lleo
Wih these abve three heks an nta deternan leg ength an be ade. f he eda alel are uneven bu he feur hek shws n unevenness and if the heel hek as shws uneven eves he tiba ay be shr If he tba hek shws evenness and he heel hek shws unevenness lk fr prbes n he t r ankle A prnatn r fxatn f the ibtalaraaneus plex ay be at fault neven ale nfred by the heel and he feur hek ndiaes a pssibe shrt eur r hip and pev d strtn r bth ext hek the A evel s g 224 Press he hubs up under bh spnes wih equal pressue and sght dwn ver he An inerr AI s ndatve f an anterir rtan he iiu an A iiu) whih by wering the aeabulu wl inrease leg length A superir AI s a sign f a pste rir a ratn a PI iliu) rasing the aetabuu and shrtening he leg Bring the hands dwn n the ilia rests ingers extended and he ndex fngers resing n he rests g 225 ight dwn ver the area and deerine if there is any uevelng An in err rest ud be a psiive s gn f an in ferr il u r weak Q r bth wh h ud ause an n reased eg ength sign n he supne paten aera Rain fhe Femur
Fi. 222 Chen heel levels
Grasp he ankes and ift the legs f the abe. Rtae the legs inernaly and pare the degree f veen g. 2 26 f there s less veent n ne sde here ay be a atera rtatn fxain f he feur r hypertn ty f he at
Examinaion
45
Fi 224 Chec ASS leves Fi 2-26 Chec eal oao o fems, oe ecease oa o o e h
Drnial
Fi 2-2 Chec ac ces leve ls
The severa auses f funtinal leg egth nsuffieny disussed abve nude an A r P tatin f he iia an i nferr i lia a laera rain f the feur and knee and f dysfuntns These findngs an ur alne in any diffeen bnatins. Ofte an evauatn wil evea seveal binas that unterat eah he n an effrt t pesate and balane ut the sruure instane a latera tatin f he feur inea sing eg length s pe nsated by a P iiu n the sae side whh anels ut the lng leg ig. 22). Afte fnding and rretig al baanes and lstngs if here eains a eg lengh disepany it is highy lkey that there s an aaia LL. ordoic umbar Syndrom
era rtas An he sig n f atea an fxatin is a sig nfiant interna pstn atea tatn f the feur) f he leg wih axiu fexin f the hip and knee. Nraly if the fexed knee is u sed t fuly fle x the hp the ft shuld b e n agnen with he thgh. f thee is a atea tatn fixain f he hip r a least hypertni laeral tats the ft wil ve edaly as he hp is fuly flexed. Latera tatn fxain f he feur wil nrease the ength f the leg. is an in plee seatng f the head f he feur n he aetabul u . Any ie he eg ength and pelvis findings d nt ide suspe a laeraly aed feu. This s a n subluxatn. The ateral rtas sh uld b e heked fr hypetni ty and reated ardgly.
Mainanig he weightbearng stress exane the uba ldsis A nal di urve wil n the supine psin aw he hands easly sip in beween he sp ine and able N gap a all r diiulty in sli pping the hands unde the bak ndate a derease i he lrdsis wih a lkely weakness f he psas and i laus and hyperniiy f the guteus axi us bth f here i s a s gnifiant gap wi h peny f r t sl p hands under the spne a rdti l ubar syndre ( LL) s l ikely wi h hyperniity f he psas an d weakness f he guteus axius and abdnals. vauate the usles invved in prduing a nd allw ng t his disttin t u and teat ardngly see Chapte 4 n Muse Tesing) Anthe sgn f LL in the supine psitn is he leve f he pubi syphysis n elati t he AI n a nral stuatn
o BK PE
46
a
Fi 228 Acv e b laeral SLR Noe nceased lodoss and bc sphss oer han ASS ndcave o ea abdonas
b
i 2-27 a odcn shor le b l u and aeal oa on o eur equalzes e lenhs
(patie supe a rest) e sympysis is eve w e iia spies it a te sympyss s ound o be ower (ae rior pe vi tt ) is a beome even more evident by avg te paient do an aive bi aera srag eg raise ( R ig 228 Observe e degree o reased ordoss ad aneror pevi roaio a ours ere i s si gn ia exaggeraio n te abdomas soud be evauated or weakness or uderutoig Iius ad Pss Imbalace
e psoas an be eked or yperoniy by exig one ip bringig te kee to e est ad observg te opposie extended eg (ig 2-29. it is pued up o e exam abe tere s a yperoniity on a side Papation o te iiopsoas sertion or ederess a oirm irritato Papae te iiaus origs aog e ier iia rests ad determne te degree o sesitivity exessive i a ndiae rrtation A norma ordoti urve i e presee o marked i iaus orgi pain and aterior pevi it i e standng posto oud ndi ae yperoni i iaus muses Miee desribes e iia istory o psoas myostis He atributes "psois to ro aure to eongate durng e rapd growt pase He aso mentons e keiood o mis
Fi 229 soas heonc h homas es
taken diagosis o appediiis in ases o rgtsided psoas myosiis Burney s poin used i e diagnoss o apped tis a be onused aordg o iee wit myostis or ibrosii anges in e iiaus Have e paten do an ave uniaera stragt eg rase Papae te ubar spine and oe te movement o e spinous proesses e psoas muses are untoning propery te spious proesses wi move away om te sde beng rased s ndiates at e opposie suppor muses nudng e psoas are working propery supporig te spne aganst te weg o e rsig eg Quatus Lumboum Imbaace
Aer evauaing e pevi andmarks grasp e akes ad ask te patie o ompeey reax te bak ad ps ug sev era times wit equa ore a eror dreton (ig 230. ug ard enoug to pu te pev is dow amos moving te patie t Ree k e eg egt and e i ia ress or ay ange tere is a egteng o oe eg ad a ipsiatera in eror st o te ii a rest ere is a ke ood o a ui atera weakess Rese e wegbearig stress ad retes o onirm e i ndig xessve aterior movement o te pevs wen d strain g te egs s ndatve o abdoma weakess
Examiatio
47
nation te A and P iia are cecked by obseving te pos ton o te A i n te supine position Te AI wi be ine rior wit an A iium and superior wit a P iium (Fig 3). Te A iium wi poduce a unctona ong eg and a PI i iu m wi produce a sort eg Te musces tat aow and pro duce tese otatons need to be ev auated or weakness or ypetonicity Te musces tat produce a P iium (guteus maximus posteio abdominas amstrngsto a minor extent) are te musces tat aow an A ii um. Te musces tat aow a PI (iiacus tansverse abdomnas, TF, rectus emo is sartorius, gracii s) produce an A Medial Ichium Fi 2-30 n eor fo QL bl nce
Hatrig Imbalace
A passive stragt eg raise wt te patent reaxed wi e vea any ypertoncity o contracture o te amstings (Fg 3). Tey are commony too sort Te knee wi begin to ex as te eg is raised n a norma situation te eg soud appoac 90° wit no sign icant restrction. S ad PI Iiac Rotatio
One o te most common indings in a ciropractc examination s otation o te iia at te sacoiiac oint As mentoned above an A iium s an anterio rotation o te ia. Te A desgnation reers to te poston o te P, wic moves antero and superio in te A ds totion A P otaton sows a posteror ineror poston o te PI In te exam
Te media iscium (M) and te A and P ixatonsub uxation compexes ae te tree most commony ound m baances in te pevis Te I is a ared ium Te sca tuberosity wi be mediay positioned and possiby xed wi e te crest is ared out ateray (Fig 33). Te musces invoved ae te iacus posterior obique and transverse abdomn as, an d out segment o te usuay ound to be weak Te guteus medius and minmus tensor ascia ata (TF) and transverse peroneas are usuay ypertonic To test or an M reac unde te patient and grasp te media aspect o bot scia and pu ateray (Fig 34) t practice, it is easy to dierentate norma pay rom resticted or excessive movement n unstabe ow back patients a ypermobiity s oten ound at te isca tuberosites In ts case te musce mbaance wi be te opposite o te meda scia ixaton Te most mpotant musces to conside are te tansvese peonea musc es w ic are weak and wi need to be strengtened (see Capte 7 on xecises) Pubic Smphi
Pubic sympysis probems are uncommon Tey can be seen oen in pregnancy wt te eaxed igaments and te stesses on te gavid pevi s Papate te pubic sympysi s or
-.
Fi 23 hecn fo hsn concre oe o ln e sows ecese le ex enson
Fi 232 R PI Le AS
48
BK PE
Fg 2-33 Rh el sc h
Fg. 234 oo on of sc
te spie; wever it plaes abrmal sresses e verebrae tug pressure te ib age ad ieased ldti pressure te umbar spie as te pelvis rtates aterly Mi palpai s de i e stig pst wi a al ter e res e spie by reduig e uee impra supprt musl es ta are ative i te stadig psit Passve mt papat is permed te supie psit (ig 35) s el mi ates te pre mpessi te rib age wi igtes e trai vertebrae ad aei pevi rat wi ireases te rdsis tgeig te lu mbars ad all te wei gtbearig eets te sitti g ps t prvdes a pptuity palpate e bdy i a psure a s as l se as pss ibe t e eret psture wiu weig bearg stresses e paiet s i te supe pst wit te arms a res ad e gers iterlaed ver e es As desbed earlie grasp te ak les ad pus i a epalad d ret ad eug t rk e pelvis is puts a weigtbeaig stress e bdy ad ses te usual distrts dysutis mpesas ad adaptats it pae Palpai s amplsed by plaig te ads uder e paties bdy a te leves be examied e metaarppalagea its ae set agaist te exam abe aig as a ulrum ad e iger tps ae used t rk ad mve e idividual segmets e irmati gaied by palpati iludes a assessmet te sesiviy te tssues te sae musula e te relatve psti adae artuatis ad e degree it play ev aluatg te m ususkeleta sysem subluxat ixat ad musle dysut t is ees say t leay deie e ause ay abrmalte s i der t reat e diti wit ay eetveess A aged irpati quest s were we ad wy adus? PMP s a eeive r asweig is quest
tederess ad a ligmet By brig ig te tumbs dw te superi aspe e pubes it a be determied tey ae level subluxaed a super st a be see Passve Moon Palpaon
Passve mi papai (PMP) is bes deied as te m t palpati allege a artulat wiu te iuee wegtbearig i s is t t be used wit mt palpat develped by D Heri ilet ad widely used e rpati press Passive mt palpati was develped by Dr Raymd Brme ad Dr Alred ga w le auly members at te Aglupea Cllege Ci prat Dr. Brme develped metds r palpatg e exremities, espeialy e eet Dr ga bega t devep PMP r spial ad pevi palpat ater usig sa palpa ti ad mt palpat ad dig b t ave t may vaiables tat derease terexamer relablty at palpati is usualy permed wt e pate i e pre psiti w is veie die bservai
Fg 23 Bsc os on fo lo of low bc d elv s
Examiaio
Subuxaio/Fixaio
h subuxaon s unamna s on cons ir by ciopracor I as bn in n many in ways an as bn h subc o conovrsy om a c in ica as w as a phlosopical sanpon On in ion s a subuxaon i s any aicuaon ha ail s o run o s norma rsing pac. ion al rfrs o a subuxaion as a slgh chang in h rav posiion o coniguous vrba Dorlad 's ins i as an incomp o paa isocaion h nnaiona Chiropacc Associaon fns subux aon as "an aaion of biomchanica an physioogc ynamcs o coniguous spina srucurs causng nura is urbancs. hs xcus xaspna srucus Am can Chropacic Assocaion fns subuxaion as "an aban raionship bwn wo ajacn srucurs ha may av uncona or paologic squa causing an araion n h biomchanica or nuophysoogca rfcions o hs arcula sucus or boh, hr poxima srucurs o or boy sysms o boh ha may b icy or i nircy ac by m s ini ion s mo comphnsi v an incus xraspina srucurs n is achng s D. Logan pr rm fxai on ovr subuxaon an in i simpy as any aicuaon ha as o mov hrough i s ni noma rang of moon . Ors s bo fxaion as w as subuxa on o n s ons xam n s amp o agnos an corrc con si r a subuxa ion o b a ixaon ha s pahognomonic or h chropacic sion an abran vrba sgmn afcing nuroogca sucurs. No a fxaons a subuxaions bu som may conibu o causng subuxaions. An arcuaion may b rsic n is movmn hroughou is noma ang o moion by an i mbaanc of h muscu au h us o sa c palpaion (pa pao n fo pos on) ma y min a maposion; howvr wl no ifrna bwn a xaon an a maposion u o musc imbaanc. An aicuaon can b n pac bu fix, an PP wou b mor liy o c a probm han saic papaon I a maposon xiss an PP proucs movmn roug a noma ang, no xaion xiss an manipuaion wou b usss maposiion s prouc by musc ysuncon an shou b in vsiga an a accor ngy f PP shows h aculaon ang o mov normay a u fxaon xss an may b ga as olows
is n h vauaon procss an otn i s icul o r min wic cam fis PMP for Ilia Fixaio
h rmnaon of a fixaion is aciv by PP o calng a for an AS fixaon si h han fom h oppos si unr an conac h sacum jus ma o h sacoiac join. s a broa inx ingr an humb conac aong h iiac cs o b s y ocing h ilium n a posomial ircion an pusng upwar wih h ngrs on h sacrum h xamnr can f for movmn o lac o movmn. h um is fix, i wi no mov in o posrior oaion bu s fx anrory (AS Fig. 36) A P fixaon s s wh opposi manuvr. Pu may agains h spn o h sacrum whi ampng o roa iiac cs n an anroara ircion fng for o n pay. f non is c hr is a ixaon prvning h anor oaion of h a on h sacrum a P ixaion Fig 37) s ixaions may o may no conci wih sac papaon of h anrior supror ac spin s Ofn h ixaion w no ncu a maposon. For nsanc sac papaion may show a posio oaion of h righ il a (a high AS S or P a). PP may sow h g iia o hav no fixaion amp o pu iiac crs anoaay woul show no rsicion, which wou la o an invsigaion of h muscs ha aow an pouc a P PP o h f l um cou show a lac of movmn ino posrio roaion, sug gsng an AS fxaion ha wou iy n o b ajus
0 o movmn n con s 1 sv mora m na movmn 3 ml movs y as o mov hrough is n ir ang xaminr shou p in min ha a fxaion may av occur as a sul of musc i mbaanc or may hav cra musc ysfuncon. I is mpoan o cons bo possbii
49
Fig. 2-36 Passve moton palpato for AS um fxao
50
E K PV
tur of trvrtbra fucto . Roc h S jons and f for ratv poston (g. 2-38) hr shoud b a prcpib jo n pay and a quaiy h raonsh p of th atra sacra body and th posror supror iac spn. Commo xaons of th S jonts ar antror postror ad ob iu. Posterior Sacrum. PMP of h S oin w show no antror jot pay and h PSS and sacrum w papa mor vy (g. 2-39) Aterior Sacrum. PMP s not capab of assssg th movm t as t s o po ssb o nfuc h sacrum postr ory Th sacra body wi b mor arior n raon to th PSS (g. 2-39) Th idig of orma oint pay on h oppost sd s furthr carcaton. n th is cas th frs imprs
Fi 2-37 asse oton papaon o I m xa on
Tsting for AS ad P fxaons rurs practc ad patc. Th movmts ar subt ad tas tm to dvop a f for wha s norma and aborma. n gra, s com mon to fd mor antror fixatos (AS) du to h ndnc s of h la o rotat antrior y in h sad ng pos on. t s aso concivab to ind a utra po sto o th AS S o sac papato and a fai ur o postror or anror movm nt w h PMP suggstng an AS or P xato xporng h uncion of th pvs, t s possb o fnd may combnaons of fxations and musc mbaancs.
Fi 2-38 M o sacoa c j onts
M fthe aiia Jint and Luma pine
Th supi positon incrass h accuracy o dtrmnng spin al functo As mntond arr t s cosr o th sandig posion wthou wghtbarng n th oracc spn th rib cag is ss i y o dis tor nd gs by prssur o h rbs as in th pron postur h umbar spin s mor raxd as th pvs w not nd to roat antrory Sand to o sid of h patt and sd both hads, from oppos sids, undr th patit. Star a th sacroac onts and work upward to th thoracc spi. Wih h nucs against h tab acg as a vrag poi h gr ps prss upward on th rst sacra sgmn and on h mamary procsss o th umbars ad ransvrs procsss of h thoraccs. PMP ofthe Sacroiliac oits. rom a startng pac a th sacroi iac (S ) joins th sgms ca b movd n a dirc ons ad changd agans ach othr o oba a car pc
Fi. 2-39 Speo e w o sacm and pev s, ht posteo et anteo sbx aton
xamnaton
sion woud b a ossb ostrior ixaion, bu with vdnc o noma oint ay t s iy o b antrioy ixd on th oosi sd. PMP of the Lumbosacral Articulations. h umbosacra ons ar subct o antror osror an obiqu fxaions Th L5S 1 sgmns a otn subct o anomais, such as sacaiaton and faca asymmtry. Wth ractic, PP can b an ctv too in dtci ng ths anomal s w ih an accu acy hat mas radiogahic confrmaion a most sconary. Dr. Josh ow has statd hat bing surs by wha you in on th adiogah mans your xamin aton was robaby acing (sona communicaton to Dr. A Logan 989) ov th hands u to h L5 v an oc t n h sam ashion as h SI jons F fo oston and oi n ay. hn mov on han down to th S 1 sgmnt an rss uwa on both a th sam tim an oc on uon h othr (Fg 0) Thn rvs h osiion o th contac and ra (F ig 0) Ths aows you to ay on sgmnt again s h othr, on boh sids o dn any ixaion and th ircion of hat fxaton. L5 can subuxat antriory ostioy an nfioy. Anterior Fixation L5 on l Paaton of an antio 5 (Fg. 1 ) wi a drssio n g vin g a mor ostrior on h oost si. To conim, th osor sid shou b rocd anioy whi stabi i in g th S sg mn on h oosit si (Fg. 0) f joi n ay s ctd on h "ostro sd is y hat no osto fxation xsts and h oosi sd is ind ix antrioy. Pa ab an on h antrior si is oftn ound h fth sg mn of h soas may b hyronc on h anrior sd. Posterior Fation L5 on l Paaton of 5 wi show a mo ostro f o th si o fixaton and an obvious r ducton n th join ay whn ushing antriory (Fig. 1 ) Th oost sd wi b mo norma in ts oston an show a
ig 2 L5S 1 speo vew L5 s aneor on rt posteo on et
a mor norma gr oo n ay. Th ostor xa on w on b mor ainfu o aation h fith sgmnt o th soas may b wa or strain Oblique or nferior Fixation of L5 on l y taing a sta bi izi ng conact on th S sgmnt on on sid an ushin g th oost L5 mamary rocss suroy i s ossib to d c any rsricton in suroinfrior joint ay (Fg. ) This shoud b don for boh sids. t s ossib to hav an inor xation as w as an antrior o ostrior fxaton on th sam sd. Combination Fixations. n many insancs 5 coud b fixd b atra y antrior on on sid ostrio on th ohr t coud b fxd ostrior b aay or antrio biatray. P P wi i nicat th tru natur of th fxatons For instanc 5 is ixd anory on th righ an ostiory on th t aation fnd ngs woud i y show an biaray wih a d drssion on th right and a rgid ostior on th f n
b
ig 20 PMP LS a stabze t SI move L5 on let b e vese
51
ig 22 P MP or neor L5
52
T Lw BK PV
corectng these fxations, the posteor ixaton coud be ad sted and repapated. f the adjustment is successfu, thee wi be a return ojoi nt pay on the et with perhaps a decease in pain The deep depesson on the ght woud ndicate an anteio fixaton that wod be adsted next and epapated fo noa positon and play f there eans any papabe ds tortion, the ifth segment of the psoas sho d be checed or baance. As ones eve of si in papation becomes moe acute, it s easy to deterine these combinations Obviousy, knowing whet her a fixation s pesent, o erey a usc e i baance, greaty poves one's accracy in adjust ng Anomalous LS Articutions As one becomes moe adept at PMP, the sspicion of anomaous condtons s moe easiy confired A niatera sacraized 5 wi papate as rgd and noving perhaps more so than a fxation t w have no anteio/posteior or supeo/inferior jont pay f there is a psedoarticuaton, thee ay be a sight degree of supeior/i nferior p ay. Faceta asyetry adds a new dimension. A coona facet w have ess anteor/posteor pay wth sperorinerio pay n evdence. A sagttafacng facet wi key have ore of both, soeties to the degee of hypermobiity. n investgating these variatons, one ay expect to papate and adjust, then epapate and contine to corect sspected ixatons A picture w fo as to the unc tion of the artcat ons xperience and copason wth radographic ndngs w enhance one s conidence in assessng these compex fxations. Spinal Palpation Continue to papate the vertebra seg ents n the sae fashon, press upward on each segment, then roc each vertebra to deterine basc postion Th s w revea i the veteba s n neutra or rotated an d ixed. Next, ove down one eve on one side an d chaenge the vertebra beow against the spero one, pressng upwad sutaneosy on both sdes; reverse contacts and chaenge again Then, ove the i nerio contac t to the next veteba above and chaenge in the sae fashion on both sdes (Fg 23) These chaenges wi tel f the vetebra s ixed n respect to the segment above o beow. As an exape in papatng , frst press upwad on the ai ares o , and fee or a neuta, posteror, or anteior postion. Roc it bac and forth to deterne the degee o joint pay Then move the right contact nferor to the 5 aay Press upward siutaneousy feeng fo nora joi nt pay between the segents . Then reverse the contacts, L on the rght and L5 on the et, and repeat the pocess. Then sh the eft contact to L3 and chaenge 3 Reverse con tacts and chalenge again y repeating this process one can wor a the way p to T3 and obtain an accurate assessment o spina ixatons. Ths seems tedios at rst, but famiarity brngs speed n ost cases, the sgni fcant subxat ons stand ot. This techniue s seu in fnetuning the specifcty of sbuxation anays s especaly when oe genera man ipative procedures fa to copetey coect the probem.
c
Fig 2-43 Sqnt o vrt t tz on t mov ft v c mov u to nxt v nd
Mue Teng
The reatve strength of the usces invoved shod be tested Testng shod begin with the ost ipotant usces and poceed to the oe uniey sces t s not necessary to test a of the msces n evey case As one's expertise impoves, the e y musces wi becoe ease to detect n the supne position, the psoas, abdoina s, adratus boru, TF, uadiceps eors, sartoris grac s, and the abdctos and addctos of the hip can be tested The g tes medi s and ns ae better tested n the side poste. Prone xam
The pone poston gves the exaine a oo at the bac. The cond ito n of the sin an d the state of the posteior scate can be evauated Fn dngs fo previous sections of the exa can be conired Leg Lengh
Tae another oo at the eg ength by hooing the thbs under the eda maeoi and compare wth the spne exa.
Exminain
53
Pvi Rin
oo h thmbs r th postrior sprior iiac sps a sght ow ovr hm Compar hs fgs wih h spi valato Yor iigs shol b cosstt wih h ii gs i ohr pars of h xam. hr ar tims w h yo wl tha g lgh or pvc roaio or both wi rvrs wh th pat swichs from spi to pro. Dr ogas rsarch has o tha sblxatios of h alas ca cas ths to happ I hav cofirm his i igs i pracic Ajstg h atlas frst is lily o ihr imia h igs i h low bac or plvis alogthr or a cosiscy of figs w l sabl sh tsl from sp o pro W hav o clar bomchaica xplaao for this phomo howvr t i s a i icatio o th m porac of h aas mbaacs of h hma boy Aothr xampl of ths s h fg o a AS i l m wt h a short g o th sam si. I is ot commo to i his variaio whch mas o ss bomchacaly What sms to happ s hat a postror rotato a ixato o th ffh lmbar ca altr h c iic a apparac o a plv c mba ac. his appars to occr ar mor frqty wth a righ posrior roatio (spios lft) fixatio of 5 Wih ths th rgh i ia wi l palpa AS a th rgh lg isa of chcig og chcs short y ajstig 5 bor procig h tr ar of th p vc stortio wl b rval hr s o cosistcy to what shows x. I co pa pat as ormal or as a AS wh og g or PI wih a short g h phomo may b a mscar a proprocptv racto if c primariy by th fith sgmt of th psoas
F 2-44 R t fo o ob q
;/
Obiqu Sru
rg th thmbs p o ach si o h frior sacral apx. Sgh ow ovr h ara a loo or ay lvlg tha wol icat h sacrm has sht irorly o o s (ig. 2). A obi sacrm is ot fo w ih a frior im Mu Tn in h Hip
A assssm o th to of h glts maxi ms a pri orms ca b o by wo mthos irs by passivy xtg th paits h p by bi g th to 90° a fg h rlax thigh of th ab (ig 25) h pops ot laraly a h first par o h ift t is iy that th pir formis is hyproic. th rs o atraly as h x so s arig maxmm th gs maxims s hypr oc A h sam tim ot h gr of passv xtsio. I i i s rstric may ica a short psoas or rcs or gratv chags a is ot o wih a aatomca short lg to compsaory rotaio of h ia a mr h sco mtho is o by staig at th pa's shor facg footwar a cotactig th grar trocha rs with h figrs A xamr ca tct hyprtocity or wass i ihr h glts maxims or pirformis by mov
Fi Pv p xnont o k t pr o or t x hyprony
ig th rochatrs. y ps hi g th trochatrs ariorly (m ia roao) th priormis rsisac ca b assss. y pshi g a mor i rior rcio h glts maxim s ca b assss (g. 2 Mu Ting
Wth th patit i th pro posiio h gl ts maxi ms priorms a mia roators of h high a th hamstrgs ca b vaat Drniating Jint and Mu Dfunin
I th cors o th xam atio by carfl obsrvaio a palpaio tchiqs th xamir wll b abl o irtiat btw jot a mscl cass for a pat's compats h sittg a arisig xam mostrat h a of atmptig to ris trmiig if thr was ay pai or ffcly h spporig varios mscs vo v i h acio.
5
E Lw BK EV
Fi 6 apo o eae roae fo p fom a l e maxm ypeoy
Ay ipovt th sigs ad syptos woud idicat usc dysfuctio hs pici p ca b app id to oth aas ad ca b usd to ipovis ways to ivstigat a vaty of suspctd ibaacs o dysuctios. Fo stac wh xaato fidigs va a pobab ustab pvis (s Chapt o Co ditios ad att), papato o th SI jots poducs sigfcat pa. y suppotig th ii a i d it dictios it ay b possib to dt th y usc o uscs ivovd, o whth th coditio is ifaatoy, ad dsg a o spcic tatt pa. Suppot th vaous uscs th foow ig a Stad o sit to o sid of th sup i patit. S d th cphaad had ud th patt wth th igs cotact with th S joi t. s th oth had to p ut th i a though vaious auvs Fist push th scha tubosity diay, hod, ad chc fo ducd pai at th S I joi t. If th is ss o o pai , th tas vsus pi uscs a y wa ad at faut. u th tubosty atay, hod, ad chc fo p With ducd pai at th S joit, suspct th tasvs abdoias ad fouth sgt o th QL of big at faut. ush th tubosty atioy (postio otatio o th iia) Wth dcasd SI pa, suspct th gutus axius With a dcas S I pa whi pushig supioy o th ischa tubosity, cosid QL dysucto. Pu th iiac cst day If pa is ss d at th S joit th posto abdoa fbs ad thd ad fouth sgts o th QL ay b at faut. ths auvs duc pa, th caus of th pai is usc dysfuctio. o if is otd, a joi t pob with ifaatio , a sigi ficat facto, i s i y th caus. th supi positio, th activ SLR givs i dcatos as to th patt's abiity. s th pai o itato y assistig
th suppot uscs, dos th patit fid it as I this cas, th suppot cos o th oppost QL psoas ad bac us cs . Rach ud th sup patt gasp, ad hod th uscs as f thy w cotactd ad hav th patit attpt th ovt aga A biata actv SLR ca b ipad by wa abdoas. Pss dow o th ow abdo ad hav th patit pat th ov (F g. ). I th psc of wa o udfuctioig abdoas, this suppot by assistig th abdoias as t sigiicaty asi. his is a coo fidg i wo who hav had chid. h abdoias cas to fucti o as pgacy advacs t i s coo to id that thy do ot tu to oa actio v wo who a xcisg h ti abdoa copx ust b taid to fucto oay. I PP of th vtba I hav foud that th ocato of pai ca aid th dfta diagosis. Aft acut ifa atio has b ducd a fidig o p ov th ata aspcts of th vtba oto ut usuay suggsts a facta pob icudg th igats ad uscs atd to that sgt. Papab pai ov th spi ous ad abst o sgif caty ss atay ov th aiay pocss, is a sg of dis ivovt. It ay b a sta/spai o th dis, a itatd dgativ codti o, o a sig that coud id cat potuso o hatio. Futh cofato is of cous, cssay h pai with spious pssu s usuay dp ad iy to ivov th dp ivatio of th dis itsf ad th cut ssoy vs Othopaedc Testing
h fid of othopadic tstig is cotovsia. h a ay obscu tsts usua y ad fo so act dica pactitio As udstad th cocpt of othopadic tst
Fi 7 Ave b erl SLR w aboma ppo
Eaintion
ig t s a ampt o soa a sio ivovg artcuaios ad hr supporig stuctus May tss ova p ad ca b coimaory or ca coadict ad cofus h issu Thr a umrous actos tha ca atr h tst id gs, ic ud ig musc mbaacs ad subuxaio/fxatio is up o ach pracitor to dtrm which sts bs srv hs o hr ow xamaio procdurs gi vig o as ca a diagosic i mprssio as possb Orthopadic sig s impoa objcifyg a patit's compais spciay i mdca/ga portg udrsadg orhopadc tstg, is hpfu o ud stad th bomchacs o th ara Of a thorough papat o ad musc vauaio ca gv mor iformatio t s rcommdd ha bo prformig or aayig ohopadic ss th xami shoud horoughy x ami ad papat th aa From h cocpts psd Chap (Aaomy) t shud bcom asir o udrsad h rsu s o orthopadc tstg ad to sabis h fo os h vad y o f a paicu ar tst Duig h sig b su o obsrv th pait's ac tios Look for paiu racios hat ca ga th ts ad wach o compsatory racios ha atr th sus
55
Fg 248 Thos' es
Ortoaedi Tests for te Hi Trendelenberg's Test h pait is sadig ad ataty fts o oot of th oor Obsrv th pv ic v ad ot ay dop of h i iac cs o th sid big i td Ay doppi g of th crs s di caiv of a wakss of th wightbaig sid abducors prcipay th gutus mdius Thoms Test (Fg 28 Th pat is supi Fx h hig h (wth bt) o h abdom Obsrv h oppost xtdd g ad ot whhr h high ifs o th tab Aso ot ay posior pvc otaio ad f h umba odoss ad o whh it fats or rmas th sam dug th mauvr f th xtdd hig h s ifd by h xio o th oppos thigh, hr is y a xio coactu o ha (th xdd) hi p o at as a hypoc i iacu s o psoas o both A ack o fatig of h ordoss may aso b s A casd odoss may b a compsaio fo a xio coracur Prick 's Fbrere Test (Fg 29 h pai is supi Th hp s fxd abducd xay otatd ad xdd S mpy pac th ak o th sd b ig tstd o h oppost k ad prss dow o that (th sid big std) abducig h hip This tst s supposdy paiu wih dgratv hip dsas I may idicat a capsua iammato Ay rsico abductio ad xtra oao dmostrats pobab coractur or hyproiciy o h tra roaors ad uppr adducors picpay th pcius Ober 's Test h patt is y g o his o hr sid Grasp h a ad abduc ad xd th g wih th fxd o 90° f th thigh mas abductd with suppot wihdaw, i suggsts a hyptoicty or cotracu of h oiba bad hat is rad to th muscs atachg i o t , h TF ad h
Fig 2-49 Pck s bee es
gutus maximus vas sas tha Obs tst is postiv i cass o as syovts o th hip ad som cass of umbosacra di sodrs Ortoedic Tests for te Sacroiliac Joints lic Compression Test Th pati is sdyig Appy fm pssur dowward ov h i iac crs T hs ssss th sacroiiac igams spcay h postrior igams R sut ig crasd pa or ssato s dicaiv o a S dsor dr Goldthwit's Sign h pa is sup Pac o had udr th umbar sp ad passivy ras h actd g pai s ctd bor th umbas mov, suspc h SI , ih a spra o athtis f pai coms o atr th umbars mov it is pobaby a umbosaca pobm Rpa h st wih th
6
E L BK PEV
unaected leg. f the pan begns at abou the same eve suspect a lu mbosaca pobe m. f the unaffected eg can be ased fathe beoe pain s elicited the poblem s ikey wth he S joint Yeman 's Test he patien t s pone. Flex he afeced leg and extend the thi gh w hie a ppy ing a fim downwad pessue ove he suspeted S ont. pain s nceased in the S joint the es i s posi ve. he est pus pessue on he anteio sacoila igaments Ohopdi T ssjo h Lumb Spin Kemp 's Test hs test can be pefomed wih the patent eihe sttng o standng vans ecommends peoming the test n both posions e staes that he siting posion neases inadisca pessue maximizing sess on he dsk. Sandng neases weghtbeang stess to he aces. Stab ize the paten wth one hand on the iiac cest and wih the othe on he shoude Guide he paient into lexion and aound to the igh n to an oblque y exended posiio n. Repeat to he eft side he tes is positve f adicula symptoms ae el ted o aggavaed and i ndicate a pobable neve oo com pession low back pain s fet wth n o adiatng sympoms suspect a acetal eson Minr s Sign. Obseve as the paient ases om sittng. he paient suppos he weigh o the body on the un nvoved sde exing the knee and hip on the invoved sde. his s a genea indng and can be seen n a vaiety of ow back condi tons see Chapte 1 on Anatomy) Bhw's Ts. he paent is seated. Atemp to fuly extend one eg at a ime and then both egs smutaneousy Any esistance o aggavation of adcua pain is ind icaive of a pobabe dsk esion t can aso be ndic aive of infamma tion o subuxation that compomses the neve oo. Ofen the patient wll ean back in an attempt o educe he stetch on the neve Rasing both egs inceases intadiscal pessue. Stight eg Raise (SR he paient s supine wth the egs extended. he examne passively ases the afected eg to the point of pain o 90° xacebation of pain is a posive test and may ndicae sciaica fom umba o sacoac poblems dscopathy senosis o infammation he tenson developed by the SLR s sequentia. n the fist 30 o hee is li ttle o no tension on the neve oots and pan geneaed a ths leve s lkely due o a piios syn dome o saoil ac lesi on Pain e ic ted between and 70° s lkey to be due o a neve oot lesion such as a disk potu son aecting pimaly he L S l and S2 eves Past to 70°, ei ied pain w il be due to a lumba o nt pobem as the neve oots ae aleady maximaly stetched. he hamstngs ae ofen shotened wi h conactues. Note how fa the eg can be aised befoe the kn ee fexes Futhe infomation can be obained wth an acive staigh leg ase (ASLR. Ask the paient to atempt to ase the aected leg. Detemine the degee and whee pan is noed.
Wach fo sgns of anteio pevc otaion that sugges weak abdominals Suppot the abdominas and note if he paient can aise he eg futhe o notes less p an o both. f so atention shoud be paid to coecting he abdominal weakness Noe whethe he opposite QL seatus poseo neio and ilocostas umboum ae conacing o suppo the leg lt dysfunction s suspected suppot the musces by compessng hem whle the patent attempts o ase the eg Note any mpovemen in he patien s abiiy and decease n pain. Palpae the lumba veebae fo nomal oation away fom the side being aised to deemne f he psoas s functioning nomaly. oe inomaion can be asceaned by estng he flexo musces the psoas iliacus ectus femos satoius and FL. Weakness i n hese mu scles can afect the outcome o he SLR and ASLR n acua pactice he SLR is oten nconclusve. Combning the SLR ASLR and lexo esing can povde moe infomation wth which to om an opinon as o the patent s condiion ragard s Sign f he SLR is posi tive dop the eg to just below the po nt of pan and dosiflex the foot the pan is inceased o f thee is adiating pain poduced along the couse of the sciatc neve he est s posiive and ndicaes a l key neve oot itaton. Duble Straight eg Raise. he patent is sup ne and both legs ae aised togehe. f pain s elced ealie than duing the aising o one eg only the test s postve and s indcatve of lumbosaca joint pobems. Welleg Raising. Afte pefomng the SRL the unaffected side s tested wth the eg ased and the foot dosflexed. hee i s pan poduced on the symptomatc sde it s pobabe that a signifcant henation has occued. wstring Sign Rase the patent's leg above he exane's shoude and compess the hamstng musce and he popiteal ossa any adicula o lum ba pan s ec ied suspect a neve oot compesson. Femral Nerve Tractin Test he patent i es on the unafeced sde. he exane exends the knee and hen hypeexends the afected high o . A this pon flex he knee his stetches the femoal neve he test is posit ive i f pain is fel adiatng down the aneio thigh Pain n the goin and hp adiatng aong the anteomedial thgh indicates an L3 neve oo pobem and pan ext endn g o he mdib ia nd icates L. Ely's Sign he patent s pone. Fex he heel to he but tock and then hypeexend the thgh. his est wl elci ess tance o pain o both wth a hip pobem psoas conatue o neve oot iitaton. Nuologial Evauation
he umba spne and sacum distibute neves to he pevis and ow e exte mty . t s necessay to evauate the integty of he nevous sysem to ave at a complee diagnoss he
Examnatn
57
nrv spp ly fro h s ara can b dsrbd by n ros condons n ding nfaaon sc spas spacoccpyng sions sch as ds drangn or or snosis and dgnraiv ondons Th n iia nroogica worp shod nc d r sng scl srngh assssn and snsory vaaion Th s on nroogcal sng s al y dscrb h indin gs or a prc nrv roo dsrbanc n h clnca sing i s s aly a ddld picr ha dvops n y princ h or confd h findngs (wih no clarc nrv roo lson dscib) h prob is or l y o b a nroogcal disrbanc d o a sran/sprain injry involvng naaon and scl spas owv r a worng dagnosis can b cy discardd f niial ran als o iprov h condion On nial ran drcd a rdcing inlaaion and spas ay inn h sgns and sypos rvang a or obvios nrv roo sion Thr ar cass of ds hrniaions a svra vs ha can prsn a confsion o signs and sypos Whn h siaion warrans rhr or nsv nrological vaaon ay b ncssary
rfl is prdoinay L4 b ncl ds 2 and 3 Th rf can b sd n h spi n poson by s ighly li ng and spporng h n Th Achl s rf is sd wh h pan sing b can b oband wih h pan spn or pron Th oo s p no slgh dorsion o srch h ndon and a sharp rap on h Achl s ndon shod li ci a ic p lanar fion rspons Th Achis r is alos clsivy S L oppnfd dscribs a rfl s for h L5 vl b in dcas i o b dicl o lici Th s is on h posrior bials ndon wih h foo in slgh vrson and dorsif io n Sri h ndon on h dia sid of h foo j s bor is insron no h navicar Th noral rspons wold b planar lion wh invrsion Th pahological rfs n h lowr l b ar sa ly sn in cass o ppr oor nron lsions abinss sign s os ofn nio nd y sroi ng h boo of h oo wih a pn as f o icl nsion o h gra o and a anni ng o of h sal os is a posiiv sgn Th noral rspons wold b a ing of al h os
Reee
Whn hr s a nroogca copros i wil b iy o ac h sc s i nnrvad wani ng h T sing crain scls can hp n narowing down a nrv roo lson Aways s baraly and copar is poran o con sdr h nros rasons a sc wil s wa bsds a nrv roo sion; pan d o njry spna sbaion aricar sbai on or dysfncon yphaic congsion and js plain wanss Th T 2 hrogh 23 vs innrva h iliopsoas As hs is a ivd innrvaion i is no a vry accra sc s or si ons and carf assssn of al facors of ncion shold b don Tsng for h l iopsoas s bs don n h spn posion F o 65° and sighly rnaly roa h g Conac h pain s hgh s abov h n and as h pain o rsis yor for o nd and sighy abdc h high Ts svra is o drin h sana o h scl (s Chapr 4 on Mscl Tsing) Th adricps fors is nnrvad by 23 via h fora nrv Asss sng h srngh of n ns on can b achvd in svra ways Noing any dfficy in h siing pan s abily o fly nd h g s a si gn of nsion lag Th las 10° o nsion rr 50% or sc powr Tsng h scl can b don in h siin g or spn posons As h pain o rsis yor ap o fl h ndd lg n h siing posiion h lg s ly ndd n h spn posiion h high and n ar d o 90° Th pain rsiss h ainrs ap o frhr fl h lg Ts svra is o ascrain h saina of h scl Th hip addcors ar also L23 (obraor nrv) nnrvad av h sp in pain rsis yor ap o abdc h gs fo h id i n
Th ngriy of h rf arc can provid inforaon abo h ngriy of h arn/rn nrvs and hr cnra synapic conncion Th dp ndon rfls o h lowr ry ar h palar and Achils rfs A d cras or absnc o hs rfs ay indica a prphra nrv lson or a son n h spinal cord or crbar dsas aggrad rls can rs whn hr s a son in h ppr oor nrons or oor co As wh os all bodly fncions hr ar a wd vaiy of rsponss o slaing a dp ndon rfl So pans wl s o hav non a al y ncon noraly any way Ohrs wl la abo wih h sghs s aion wh no ohr vdnc o an ppr oor nron lson Cincal princ hlps o d irn a bwn a nor al an d paho ogcal rspons Th dgr o rspons i s copard bi laraly for syry Asyrca rsponss ar say in dicaiv of a prob Rfs ar gradd clinicaly as absn dnishd nora or aggrad On hy ar n brd: 1 ) ro qas absn (2) pls 1 als d in shd (3) pls 2 as noral (4) ps 3 als aggrad b no ncssarily pahoogc and (5) p s 4 as hypracv and l y pahoogic h rs ar dific o c h ndrass anvr s hp l av h pan hoo h fd ingrs oghr and p as i o spara h Ofn a di in ishd or absn r wi bco nora Th palar rf s say an wih h pain sad and h gs rad and f car o h floor A sharp rap on h palar ndon js blow h pala wll donsra a njr rspons (a ic nsion of h lg) Th palar
Muscle Strength
58
BK PV
h tibiais antrio is ainy innvatd by 4 and is a stong indicato of 4 radicoathy his msc can b assssd in th standi ng ositio n by havin g th atint attmt to hwa with th ft dorsifxd and invtd t can aso b tstd with th atint sin Dorsix and invrt th foot and hav th atint rsist fots to th foot into anta xion his is a owrf msc and shod b difict o iossib to bdg sing th oram against th dosm o th foot is a good way to xact a signifi cant tstin g oc (ig 250 5 is rrsntd by th xtnso ha cis on gs, th xtn sor scs of th tos and th gts dis h xtnso hacis is th ost asiy rcognid indicato of L5 radicoathy It is bst tstd with th atint sin Pac th grat to into xtnsion and hav th atint sist yo ffots to fx it (Fig 25 . B s r to contact th dista ha ang ony so as not to n ist th xtnsor ha cis bvis h xtnsor scs of th oth tos can aso b tstd in this ann hs sc s shod b vry had to bat hs tndons shod stand ot whn th atint is attmting to h wa withot invrsion h gts dis is tstd by tsting th strngth of abdction (s Chatr 4 on sc stng h ons ongs and bvi s, mao vtors of th foot, ar i nnrvatd rinciay by h atint can b asd to wal on th dia bord o th oot hy can b tstd by acing th foot into vrsion an d attmting to i nvt against th atints rsistanc (ig 252 and 2 i nnrvat th gastrocnis and sos mscs, owrf antar fxos too stong to tst mana y H av th atint towa onfd sggsts having th atint and down on t h bas o th ft on foot at a tim his ts nogh oc on th sc to ncov wanss 24 i nnrvat i ntins ic mscs of th foot that a diict to isoat hs nrv roots innvat th scs o th
\
Fg 2- Exensor ha c onL5
Fig 22 Perones ons an evsS
badd and any sig niicant radicoathy wi show i n baddr dysnction Sens Tesing
Fig 2-0 ba anero esL
Ctanos innrvation o th owr ib shod b tstd fo atrd snsation Inc rasd o dcrasd snsation shod b notd h most cint way to assss th snsory syst is to s dob inwhs and tst biatay a th dratos Figr 25 dmonstats th basic datom attrn I any discancis a notd a o dtaid assss
Eamination
Fi 23 Dermaome aern
ment an be done to diferentiae harp and l gh tou a w el a vib raory enation i neeary Viscera Examinan
he hroprator i the mot ikey phyiian to il ave he papatoy kil to perm a thoroug abdominal exami nation he modern phyiian ha ome o rely on aboratory e and highteh dagnoti proedure, and a e mot exreme eploraory urgey to iagnoe intenal pathoogy eem li key hat the "old oo door oud, wt h a k iled phya exam aurately iagnoe and dferentae inernal iorder, and woud u e ab and oter proedue to bak up ther fndng Modern phyiian wth e fear of malpratie on the mind have ome to rely heavily on highteh iagnoi proedue moving fare away fom ter trut in pyia exam and the nti nt tha make phyan heae oay, we tend to aume the wort probable diagnoi an wok bak to
59
e mot ike ly t a been a id ha today 80% of meial ot are for dagno a nd o nly 20% go oward teatment he imporane o te iroprator of being able to dieentae beween an organi pahology and a tuural ondi ion i lea e eteton an appoprae reamen of a patient ontion i he phyiian reponibility ndertanding the n teelation ip between vieral and trutural pathology make the iroprato an important prmary are pyiian and a qualifed gatekeeper in the managedare moe ere are many patient wo initialy eek treatment from hiropraor nderaning vieral anaomy and funtion i imporant in te onervaive management of inernal diorder here are many ondition tha are treatabe wthout medial inter vention or, by patent oe an be managed by mean other than radtiona interventon any ommon nterna diorder are reaily treatable by manipulaton, nutriional therapy an refex ehniue, w hi ae wi thin the ope of hi roprati he important onieration in being able to propery reognize te paient ondition and refer for appropriate treat ment, if warranted e eary deetion of eriou patology i often the iroprator reponibility rougout i eahing Dr Logan treed that every pa tient oul d ave a oroug abominal exami nation he ex perene gained om the papation of numerou abdomen epea ly noma abdomen prepare one or te eay reog niion of abnormaliy n hi inial experiene he detete everal tumor in early age, one hat ha been unnotied in previou meial workup e abdomen uualy ivie into four uadrant t i generaly oniered tat, in a normal abdomen, it i diffiult to itinguh mu of anything he viera that an ometime be itnguihe are he liver ege a i un aong the owe rg rb age he arge intetne and the pulating aor i and il a artere ig 254) he ower poe of te ight kdney an be fet however the left i up under the rib In palpang, e examiner ould be feeing for igidty of he abdominal mule, and any viera tuure that are di enible ould be dentifed and ondered fo any abnor malitie f a gnifiant gatrointetinal dorder i upeted auultation of te abdomen i important e abene of ound i a erou findn g and may be a medial emergeny Diffeenia Diagnsis
Organic VS. Structural
here are numerou organ ondition that manfe bak pain at ome tage uually eay n te oure of a dieae In onidering a patient ompaint it i eential to onder e age and ex of e paient a nd how thee fator an relate to te moe ommonly found ondtion For intane, he role of oeoporoi in verteba ompreion and emoral nek
60
TH E B PE
b
i r Zaary Cpe as emphasized te r nderstandn f te anatmy f he abdmen and pelvs He beleves a tere ae many anatmia relains between visera and strtre hat an be sed fr diansis. r insane hee are ften eaed iiains f adaent mses eie by dre r eflex means Te psas, Q, ateral abdminals pri frmis btratr n terns, a nd diapram an be affeed by viseal dsrders. Tey wil fen sw sins f spasm, ridy tendeness, w ineased sympms pn aemptn t streth them. Tis sd be kept n mind wen te patiens isty s nt lea as t a strtral ase f sympms. Dcoath v . Stan/San
f
Fig 24 V ppo po b lo l mo oo d o tr f bld
fraes n de pstmenpasal wmen r prstate ypetrphy in der men. Any irrearities in an fntin , s as destn, bwel, r nary habts and menstratin sd be ned idney nfetins ase w bak pain f a dll nare in he earie staes, bemin me pnned wit ter n mistakabe sins ater. A paten nrespnsive t intal trea ment based n te wkin danss shld ead te l niia n t fte investatin. Caner is a ma nern, and te nrespns ive patient w ts er rteia nside rin tei hisry, shd be arefl y evalated Te l assi sin f ntal bak pan s fnd in ases f melanma, prsai aner and te ikey metastass t te we spine. Te his try f a rada nset f pan wih itle evdene f likey srtral prblems isry f iny sd ase nern and aref assessment Referred pain paterns an hep in te dansis Te ass refered pan f renal r kidney inflammain te lwer bak, saly ve the msle is wel knwn, as is te refeal f pan te shlde in iver al badder, and panreai ndiinsessentially an iratin e diapam and te preni neve Reta and erine pain an be referred t the lmbsara aea
Te sins and symptms f srain/span and disk inries an be d if t diffeeniate amae t te nnet ve ts se spprtn he faea in s has been shwn ase radatin pan int he btk and pseri t tat an resembe radilpathy. It sally says abve te knee b a ds en radi lpaty w l l me ften ravel in he af f r bh. B types f nry an pesen wth analia exin and latea lean ae mmn Te lass anta ean away frm e side f siaia is indiatve f a ateral dsk ptrsn and a lean in te sde f saia is ikely de a enta be A srain/spran nry wll me ften eit palpaty pan either side f te spins sestive f faeal i nvl vement. A dsk inry wl me ften be panf with dret anerr presse ve te spins Ts pessre seems mre dretly nflene te disk and te rerrent nerve ta inne vaes te peristem and inner disk stes. A vereba frare, espeia ll y a mpressn frare, w l e li it an exaeaed pain reatn when dey palpated Ths type f respnse and a sty f a pa fall r sspeted steprsis sl d lead a srn ssp i n f vetebral fae Te elatn f ese findins wt te sty, rpaedi and neral fndns sd pvde an aae wrkin dianss A di sk an be strained spaned wit prrsin r heniatn, asin n dsernible nea symptms. Cnversely te swellin f a faea spran an mpress the sttres in the ntevetebal framen and ase nerve r iiain n determi ni n e se f teatmen in tese statns, he iniia terapy sld be dieted a redin te nflammain and are sd be exeised in te e f maniplatv e tenies A sspeted disk ny sld be hand led arefl y s as n t ase frte damae. Peripheal inres in te ip an als ase radiatn pan nt te e Te entrapmen f he sati neve in an nred prifms an ase siat symptms, te psas an entap lmbar neve s, and te atera femral tanes neve an be rapped ve the ip and anerr pelvi bnes. Obvsly, te inial pite wil sw fewe sins f spina n
Eamnaon
vovmn T gs mdus wn nd cn vy closy smbl scc dculopy, ncludng nuoog cl fndngs conssn w dscopy Ts mscl sold b xmnd n l css w scc sympoms In Dcmb 994 . Dpmn of blc l nd umn vcs vcs (D) publsd nw gdlns o ssssmn nd mn of c low bc k poblms o T Dpmn dfnd dfnd c s bn g psods of low bck pn sng lss n fou fou wks. s b os s low bck pn s s bn mc scny o clnc ppoc s w o o cn cn sds (suc s M ng po, po, C ndn sudy dmonsng cvnss o copcc mn n wokld low bck nus), s mo gnl gmn consvv ppoc, ncludng mnplon, n ssssmn nd mn mn of ow bck poblms p oblms s bs T DPHH gdlns cl fo mo consvv dgnosc ppoc. I clncl pcu s o "nonspcc bck sympoms nd no pon ly so sous us sgn s o sympoms xs, vod ggssv dgnosc wokps usng mgng o b sng Tmn Tmn s consv v w s mnp ul on nd smpl pn vs sc s spn Ts sms o v bs sls. Mos css wl solv wn o wks. T gudns pon o sv d lgs n n ssssmn. T "ponly sos spnl condon ncds umo c o mo nologc compoms sc s cud qn syndom d flgs o fc mo um (o vn m no n n old p n); fo fo mo o ncncon g (ov 5 o nd 2 soy of cnc consuonl sympoms sympoms (fv (fv,, c ls nxpnd wg oss) noc nl pn nd cn soy of sysmc nfcon Cd n sympoms woud sow sdd nss, bldd dysuncon o low xmy nuologc dc Ts sgns nd sympoms wod wn mo dld ssssmn ny c scc sympoms sggs nv oo compoms woud lso ndc mo sos suon nd mo ggssv wokp. Assessment of he "Ho Low Back
T pn wo s cd n o you of ofc c o psns w sv pn mks sndd modc soy nd xm dcu dcu bs, s on clngs ll pc pcons ons Ts pns cn by mov cnno s o snd nd fn fn d gonzng o g on xm bl Oopdc ss would b posv fo fo pn nd plpon s nly mpossb. nly s bs o g pn no supn poson wc bs smus wgbng poson Mo nfomon cn b obnd by xmnng n s poson s glow copcc b cn b lpfl; owv, g c sod b xcsd xcsd n low ng nd sn g pn s sd dn cngs n wgbng spclly sng pn
61
cn cus suddn xcucng pn I v fond fond bs o o l pn w yo wn m o do n d l m fg fg o ow o do do y clos o sss m, b l m mk movs n own wy nd n own m pl ow nd kns cn ofn ofn mk spn poson mo olb. olb. T soy soy s mpo mpon n How dd s ppn I s n xcbon o conc condon wc would suggs n mmon D d ppn w l pn ws mpng mpng o f o s down vy obc (cl ltng my n psos nd lowng s lky o n glus mxms) s pn s o sp/fl sp/fl o p ll ll s ny dng pn Mos pns psn psn s wy v d sddn ons of sv pn T lkly o b som smls of sgns nd sympoms n l o s nsncs no m m- w undlyng l son o pology. pology. By ddssng ddssng cu fcos s possbl o dc som of pn nd nxy nd gn pn s cond condnc nc W pn s comfo comfobl bl s possbl ssss bsc pvc lsngs ook o oon n m mg suggs lcs o psos s n spsm Pp nson on mdl g fo pn. lm my nvolv gls mxms. Comp lc ndngs w plpon fndngs n low xms xms Plp mxms ogn nd n son fo pn nd spsm. lp pfoms o bnom pn, contcon, nd ny scc nv npmn. Pp nd pvtbs nd dmn ss No umb lodoss n spn pn s ncsd sggsng yponc psos o s nd sggsng gl nd pvbl yptoncy Pp p ons o pn nd dm lp scoc ons nd n sppo l n vyng dcons s dscbd dscbd l (s scon on Df Df nng nng Jon nd M scl Dysn on). ducd scol scol c pn w s s cn povd nd cos fo fo wys o duc sv sympoms Obsv nd plp w pn mps o do n cv v cl n l concon of conl conl nd ld mscls occs s, folowd by bdomn bdo mn ls n od od o o fx plv s cl lfng of lg s ccomplsd by psos cus, sous, cs mos, nd TF Dung cv no f pvs ls noy n dcng wk o nonf nonfunconng unconng bdomns o f l m b spnoss o o wy fom fom cv sd ndcng noml fncon of conll sppot mscls No ny dvon of g mdy o lly s ss wc cod ndc poblm w ddcos o bdcos By suppo suppong ng muscls pp o b dysfncon dysfncon ng nd sng sng ny d dcd cd pn o ncsd s of ltng lg cn ndc ndc muscls nd non By cocng cocng s sgns of dysf dysfuncon uncon pn w ll lk ly xpnc ducon n p n s fs fs sp sp n vlu ng nd ng c o ow bck
6
T BK PE
REFERENCES I Loga A The Knee: Clinical Aspects. Gathebg, Ape; 994 D'Amboa R Musculoskeetal Disorders: Regional Examination and D rential Diagnosis Phaepha, Pa ppcott; 96
7 e 1. e Dorland's Illustrated Medical Dictiona. Phaepha a Sae; 974
3 aeo D Leg egh nequaty A teate evew. eete a the
va R Illustrated Essentials in Othopedic Physical Assessment. St ou, o oby 99
Seventh Ana Confeece of the Conom o Chopactc Re each Cafoa Chopactc Aocato; am Spng, Caf: Je
an d Etemities Etemities New 9 Hoppenfe S Physical Examination of the Spine and Yok NY Appeon-Cety-Cot; 976
9- 9 99 99 Aspects Gahebg, A 4 ogan A e Foot and Ankle: Clinical Aspects pen 994
0 Bate B A Guide to Physical Examination Phaepha Pa ppnco; 974
5 Mchee A Iliopsoas. Spge, Chae C Thoma 96
Early Diagnosis of of the Acute Abdomen Loo Oo I Co Cope pe Z The Early U vey e 97
6 Bon W Wee 8, Hoe R Chiropractic Principles and Technique Chcago I: Natona Coege of Chopactc 939
US Depatme of Heath a Huma Sevce Acute Lo w Back Poblems in the Adult: Assessment and Treatment. Rockve, 994
Capr 3 Imging the Low Bck seph W e DC DACBR CC
i ape aperr revew diagot agng o he ot oo aboraltie of he low bak Plai il radiograpy wll be the ajor iagig etod diued but appropriate uee of advaned u advaned iag ng w l a o be overed
pev of a large paiet, a x 7 wil ot alow the toraolubar jutio to be vualzed o te orona view. A A o he pel v wt e entral ray a a the top o he hi p o nt ad a eod oronal vew (a PA uig a 1 x 1 il pre ferred o ee the ubar pine to inlude he horaolubar unio te optal tudy Obl que vew are o o value ony under ertain iuaio and a lateral po o he lu boaral uton i oy rarey indiaed I ould be doe ony whe he ar arger ger laera laera view doe no alow adeq adequate uate viualizatio o he lub oa oara ra ju ton Col i aio l tg expoure to the the area area o tere tere ad ue o goad eding are portan beaue low bak radiograpy vove expoure of via orga ad gonad
MGG MHODS Pan Flm Radiography General Cns Cnsderatns deratns
Te n u radiograpi radiograpi exaiaio o he he l uboa uboara ra regio hould hou ld o t of oronal oronal and l atera vew, v ew, 2 the oroa vew udig te etire pelvi By onvenio he oroa view uualy doe for he ow ba i an ateropoeror (AP vie w. However, Howe ad other advoae advoae poito ng the paiet ag e fl a poteroanerior (A) proeio whh ha geoeri advaage ad for feale paiet redue he radiaio to te ovarie A agulaed oroa pot l o te te lub oa oaral ral ju io o uld eary alway be part o te route ub oa oaral ral erie.5 Whe i ud ng the e ntre
Uprght vs. vs . Reum Reumbent bent Radgraph Radgraph
ot hi hirop ropra rai i rad radog ograp rap h fai l i ie u uee a up upr r g g bu ky or grid ha habe berr and do ot ave the availab iiy of a radograph abe to alow reube radiography Beaue radograp of a tandig pate t have pe i radograp i value by de p itg the upright poure (ex ept for for hin pa en dago i deal i o a good good a uual y obaied whe e paiet i reubet When a radographi able i available, he optiu l ow bak erie ake advanage advanage of bot uprg ad re uben ube n radogra rad ograp p y perona per ona preferen e i o do 1 x 7 orona oronall ad agi agitta ttall vi view ew wi th he pa paie iett a d dng ng and te angulaed oronal pot fl (ad oblique whe done) o te tabe Wth thi proedure the poural nding ro te uprgh po ton and er er detail of boe boe ad joi fro the re ubet ube t i are b oth obta obtaied ied.. Al o o opa ri rion on of diferd iferee pa oour ad algne bewee uprgh ad reube poure wll be appreaed wen preen ad ay
Spei thk to Tery Tery R Yoh, DC, DAC BR for ow g he ue o eve utrtio fo fo h i boo book k En f R forr hrig wth e y fi for for y ehi ehi g fie, o oee of g fo whih re ued i hi hpe, d o hi oiu efot o behf o the proeo Thk o to Jeffrey Cooey, DC, DACBR or proo pr oor redig edig the uript dd kg uggetio tht wee hep My gtiude to y wie, Dee, for he ptee whi e I egete y projet he woud hve preferred derke Ad prur hk to Cg Sdberg, whoe efort otibute gety o y prtie d y oher hig y i e
T BACK A PV
contribut posura nformaton that may not b as as w l appr ciad othrwis othrwis Wn ony uprigt ms ar mad, us of a comprsson band o bo comprss sof tissus and o hp maintain stabty so ta no mot ion occurs durng xposur s hpfu and is nary mandatory n obs pants f aduat dagnostic da s to b obtand. s of h PA projcton wt th patin squzing against th grid chambr s aso pfu pfu I postura postura ino inormatio rmationn is t o b of au from uprgt radogradography it s mportan that th oor or paorm paorm upon wh ch th patnt stands, th grid chambr and th radographc tub (thrfor t tub coum) b pumb, suar, and It s quay important that th patint b carfuly posond to assur, as much as possib hat roaton of pis and torso is no prsn to caus gomtrc distorton whch may b mscnsrud as bomchanica abnormalty. h AP r PA V h
or a standing corona w th patn soud b pacd with h t t drcty undr t hp s aing th f f mor narnarrowy or broady sparatd wi caus a paralogram ffct tat may may produc p c un ing (i g. ) that that dos dos not not rct t actua stuation. Th wig shoud b baancd btwn t gs and th kns ockd n xnson f t kns ar bnt bnt unuay, a as un ng of t t pis w rsut wi h probab probab compsatory compsatory atrai on o spna agnm nt A s cosy as possb (mor asiy accompi sd wi a PA an an AP projction projction S posr posror or tubrc shou d b at f m mid in wih pc rot rotato atonn i mna mnatd td to h xtnt possb T nra ray (CR) shoud b at t approxmat oL,
prpndcuar to fm pan. Wn possb, th thoracoumbar un cion and th bottom o t bony p s shou d b on h i m. Us o a n or n TubmD isan isanc c (TD and a x m sz wl usua usuay y aow hs wr wras as wh a in (t usua sandard) TD in arg paints t s on no pos sb to ha boh rgons ncompassd on a x im Co imaton atrally to t dgs o t rocant rocantrs rs s optima. Ma gonad shiding soud b mpoyd. If ths radograph is don with th paint rcumbn t pron posi on comprsss th abdomn and gi s bttr go go mtrcc sua zat mtr zaton on of h spin f a supin position s usd kns sould b sighty bnt wi a ro pacd undr thm aowing som attning o t umbar cur. he Anguated Crn Spt Ve
Ths i w s most asi y accompi sd wh a PA PA pro procon bcaus th CR can b ocad at t asy papatd L spno us procss whras n an AP appoach t t postonng o h CR s ss prcs. A to ° ang of h CR is ndd (mor angulaton s ndd in a patnt wh an incrasd sacra bas angl) wt cauda ub tit for h PA and cphac tub ti for h AP pro projcion. jcion. An x fm sz is usuay sucn but on arg patnts or th obs wr papaory and marks ar ar no no as asy ocatd a xx may b ncs ncs sary. Th objct o ths iw is to s trough t disk spac at t u mbos mbosacra acra juncton. Tis w aso aows opima opima su aizaion of t sacroac sacroac joints Optma y t ara ara sn incuds L or n sig hty g r My prfr prfrnc nc i s to do his radograp wh h patint pron on h radograpic tab bcaus that gis bs radiographc ualty and aso a
g 3- f in poi oni ng a pain for an AP or PA v iw of h ow bac g bac ca no an an o b h hp ar ar irc y abov h f f ara ay of h boy ay boy i ca ca an appan appan n v ng a hip an pvi a hi figr a a. . B Wh h hip icy abov h f a
paraogam i fom o ha aa ay o no ca gomric nving a h hip or pv. Thrfor wh popr poionng hip abov f f an n o c any nv n g a hp an iac c n n on a corona v of h ow bac ho n fac inica a hor hor my on h o i
Imin the Bck
ow any potua diffnc rad to cumbncy a compad o ta n in t upigt PA or AP w to b nod Howr i can b aiy accomph d wih th pai nt tand ing (g 32)
xpinc h a y fw occaon wn t arg atra w do no ow t S juncton adquaty By minaing t ata pot iw h adaon burdn o h patn gaty rducd
he ter Vie
Obique Vies
A x fim z atray co imatd o ha th fd z i mtd o t bony pi my prfnc bcau t radiogap ou d aow iu aiz ation of th acrum and th ho racoumba unci on. Pacing h patin to aur ta tr i a it oation o f h body a po b from a tu ara po ton i imporant bcau ma amount of otaon g fa informaion rgarding pina aionhip T CR houd b a h ac crt. I i mporant o u a k ooag (kYp ig noug o pnrat t pi aowing adqua uazaton of t umboacra juncton. A kYp approxima ing 9 w do i and wi nary away mnat th nd for a po aa iw of th u mboaca un cio n. Th atra po w a coninud to b routiny ud in mo mdica adoogy facii and by a fw ciropractor n pit of iatur noting h futty of i u I wa ndd ya ago wn ow powrd quipmnt and owr kYp tchniqu woud not aow adquat agtta uaizaion of th umba pn and t umboaca juncton on h am fm n my
Obiqu w alow opima iuaizaion of t fac join pat intraticuari and g anoth prpc on th tba bod dik and parapina oft iu. 2 Th w ar warrantd wn it i mporan to tho tucur pcaly wn h corona and ata w uggt fact da o whn pa dfc ar upctd Thy a dom of au in young patn u n ndd to ru ou fracur2 In odr patn pciay ho howing dgnai cang thy may dmona fact dia fact imbcation mpingmnt of pa du o fac ubuxaton o o finding not adquaty apprcatd fom th corona and atra w Rotation of t patint ° with t CR at L i h appropiat potioning. Wr PA o AP obiqu ar ud i up to th prfrnc of t ph y cian I faor PA obqu bcau th poiioning i ai and th gomty i tortcay btr. U of 1 x fm i uua y adquat to capu h mag of h umbar tbra but x fi m ao a ow h acoiiac joint o b dmonad and wi incud h horacolumbar uncion. n thr ca ara co i maon i uuay adquat a in. or mo dtaid nformaon on pcific of th and otr radiograpic procdu p a otr ourc 79 dvancd maging
T u of adancd imagng procdur fo auation of ow back probm a gra au n p cfic tua tion . How r u houd b i mi td o ho ccumtanc wr pyca xamination and pain fim imaging do not g ufici n nformaion o form an adquat dia gno i and ratmnt pan T caat tat t jutifcation for any imagng tudyincuding pan fm radiogaphy be tat th findng fom th xam wi infunc h ratmn of th patnt. Thi ould b t cririon for ach and a dcion a to whthr maging hould b don and what xaminaton i bt for t ituaion. Cmputed mgrphy
Fg 3-2 Angua coona po fim. Thi fim gv oma v u
azaon o h acoi ac joi n Compar h apaanc o h ac roi ac jon onhi m o ha on Fg 33 a anar A v of h am pai n Th L/S i ac a o n on h v i an ony rary n on anar A or A umba fm.
Computd omogapy (CT of pcfic adanag in pn magng 11 Th acquition of axa mag and th abty to h ructur in boh bon and o u window aow auaion of h pna cana and inrrbra nr root cana (nba foamina th bordring bony ructur th jont and to om dgr th contnt of t cana 1 5 T finding canno b gand from pain fim CT gi xqu iit bon dta and dmontat frac tur and on da optmay. T abity o fomat t
T ow BACK A PV
xil iges to sgittl coro d obique pes s so o cosiderble vlue ost situtos 1 4 I recet ers CT hs gel bee eplced b getic resoce igg (RI) fo spe igg bu CT still hs defiite vlue especl ssesset of rcures d for evluio of o disese h ecoch upo eu suctures. Magnet Resnane Imagng
getc resoce igig (RI) hs becoe the crte io igig ethod for evluto of dis dsese bu be cuse o ts bi to llow vsulzto of sot tssues d o discie betwee vrious issues i hs vue i evu tio of erl l spi l diseses. 147 RI h s h e dvtge of oferig exquste iges i utple ples d with d eret puse sequeces to diferetite vrious sof tissues l wthout exposure to iozig rditio ie CT whee x ges re cquied d othe igig ples us be obied b reortig the digil dt RI c direct ige ple h s desired resutg i gete clrit d lc o soe dstortio heret i the efortg process. 41 s low vis uiztio o f the cotets o he s pil c d eur fori wth he bii usig soe puse se queces to discriite the thec sc o the epdurl sof tssues the erve roots wthi he sc d s he exi o t the cous edul is d he bo rgis bordeig the c l. tr d extdur sses potrusios d extusos of ds erl sovi csts ro fcet joits d other boriies tht cot othewise be iged c be deo strted though RI14 151719 Boe d joi disese borliies of prspl so tissues d evluo of he possurgicl bc b use of prgetc cors ed i re other prtcurl sigict dvtges o R of the ow bc. 14 15 1 Radnulde Sannng
Rdiouclde scig RN) hs uti i igig of he ow bc whe ifectio is suspected 419 2 whe he ge o copressio frctue is uceti 1 4 9 ( R is eve ore helpful i his stce 1 4 but is cosiderb ore expesve) i evutio o disseed boe o joi disese1 419 cet uos o deteie ctvit such s i the i sce of osteoid osteo o veif ipressio o pl ils 1 1 4 9 RN scg octes res of icesed o decesed bo etbolc ctivt d s ve sesiive o erl disese. 4 19 It i s ot t l l specic however d c o be used o locte disese or to evute disese ctivt b sequetil studes o to or digosis 1 1419 Techetiu is the dioucide usull used fo spl scg but whe iectio is suspeced gliu be used usul s ddio poce
dure folowg techeiu sc. 492 1 Both cotst edi re i jected i tveous d the res of upe re detected b scillo cer whch ows e te gg S gle phoo eissio copued oogrph SPCT) is oe sophsticted ehod o RN scig lowig D depctio of the seetl stuctues d gvg uch oe sophistcted dt ht esults ore discrete oclizto o subtle borliies. 4 9 lthough RN scig ivolves rveous ijecio of rdioctve te he dto burdes iposed re qute low Shot hlf ives of the rdioucldes d ow docivi result equl or lower overl diio o the ptet th s i cu ed i os ow bc ig g pocedures ht u se i oizg rdtio. 1 14 19 Megraph
CT d RI hve de ubr elogrph er out oded gg procedure I s ol ifequel used recet ers ore oe h ot t he equest o surgeo who hs bee cofotble wih is use o m es d wts the ressuce of fl procedue. Thee re ol ew stutos whee elogrph wil ed ifoto th is ot bete see b RI wthou the probles iheret i he vsive pocedue o ijecig iodted cotrs ediu to he subrchoid spce. Dsgph
Dscogrph te es of il use hs de coebc i ecet es.2223 I is provoctve procedure d is dvoces oe th t s he ol gig ethod th specicll isoles sptoproducg dis Ijecto of cots ediu (occsol t s doe wih sle her th cotrst substce) o ds whc h cuses eplicio of the p specicl oces he dis s) tht ccout for he piets sptos.2225 Rdiogrph fe he iecio (whe cotst ediu is used) gves chceistic idigs o dis wl show Hshped colecto o the co trst edu the uc eus of he dis wheres dl u tes d herio of ucler teril wil be depiced b extruso o the corst ediu fro the cet poto o the ds 142225 RI ote shows severl leves of ds dege eio or bugg o both o pousio d CT show ore th oe eve of dis protrusio Dscogph los he offedg eve o be specfed i these stces. 142225 goodl ube of peope wih o bc o leg sptos wl show bugig dis s o CT or R 32 Di scogrph due to is povocive ure is discritg pocedue lthough it s ivsve d is pful . SPOGPHY
Hstoicl c hiroprcic phsici s hve used dogrph to deterie posurl borities devtos o lge
Imaging the Bak
d speifi o oe or verf or both everebrl subluxios lhough hee re uber of spiogrph sstes dvoed b dheets of eti hiopri ehues d uh edo ev ide e of effetvee ss of hose tehiu es thee is ltle i he l terture to verif the oel to of dogrphi l deosted sub uxtos d spi l dstortos wih spos. d here is eve less pee e viewed pubished eil to show h suh fidigs be impoved b hiopri d uset or i pul o . No tep o be elopedi egrdig spogrph sis wil be de his hpter he folowig e o o epted esurtio proedues h hve soe sgfe i oeto wih phsi dgs d plpio i he evluto of low b disoders. he f h poedue is i uded shoul d o be te s defi tv e seet h he proedure hs pove i i l re eve. O he other hd the ois so of spiogrph poedue does ot e tht it o be eevt. Sacral Bas ngl SB Frgusons ngl
his i s esuee of the gl e of the sl bse to he hoiotl.272 It hs wide ge of vito i spto i idividuls. hee is o osesus egrdg he sgfi e of eithe resed o de resed SB but ov eio wisdo suggests ht sigif irese i he ge be ehi l for i low b p b esig he sess o fe oits. umbosacral ngl
he s bse gle s ofte properl refeed to s he ubosr gle Proper, he umbosrl gle is the ge of he ds t he ubosl juio d s esued b he itersetio of li es drw log th e gis of the ver eb ed pltes the ubos uio o he tel view Rowe2 properl refers o this s the ubosl ds ge. I rese hi s ge s ev idee of hperextesio of he verebr moio u it d hs bee l ed to low b p b bi io of he fe joi ts. With deese the ub lodoti oour due o tlgi his gle diish.
67
Graviy in Frgusons in)
Ferguso oted tht veril le fro the eer of verebl bod should tese he teor oe thid of the srl bse27 Feguso de his esuee fo lte l doe wih he piet eube. Oe stud3 howeve suggests tht i is irreev wheher the ptiet is i upigh o reubet posito Sgie is ributed whe this i e fls ore h erio o the sr prooor due to iesed sherig sess o he fe jos o whe i s shfted o the posterior whh suggests iresed weighbeig o the fes. 29 Hadlys S Curv
Curviler ies dw fro the iferior of he svese poess log the gi of the i feior tiul poess o the pophse joit spe d fo there otiuig og the oute gi o f the superior tiu poess of the su bj et veeb should resut sooh Sshped uve.2 dis o i uous l ie t the joi t spe is evide e of fet sublux to. 97 proposed tht o e ue deteri tio oud be de b vit io of his proedure us i g obique views, gi dwig uviler lie og he se pth di soti ui the joi spe beig ore redi v isu lied i this poje tio4 (Fig ) umbar Disk ngls
he ges de b iersetio of lies drw hrough he ub vetebl ed pl tes be esured d opred to sdrds oted ohus uthortive text ssentas f Skeletal Radilg he ges vr t eh level d re ffeted b lteos of posture suh s gi or usur ible. he folowig re the e vlues ited b Rowe29 Dis evel
e g le i degees
/
/:
/:
/S:
umbar ordosis
he ge betwee perpediulrs dw fo ies hrough the supeior e d ple d the superio S ed plte defies he ge of he lub lodoss. he rge of his ge i sptoi idividu s vies wde . Rowe29 suggess verge for this ge o be fo ° o 6° he sgie of viio fro the verge vue is oroversil opiios gig fo to osidebe i relto o ow b pi .
nrvrbral Disk High
Nol dis heigh ves dffeet evels. I he lubr spie he / iespe usull exhibits the getes height
BACK AD PV
68
d he itespe t L/S l he es heght. esueets e iext t best so opiio visul evluo is deute. Ptul t /S whee vito fo ol o is feuet, the pesee of ppet deesed dis height is espeill ueti sigfie uess op ed b degeeive ed pl e hges Myrdings Grading Sysm or Spondylolishsis
Fo his deetio, he sl bse s dvded to fou udts d he degee of teo tsto of the l st ub veteb s judged b the ud i wh h le dow the poseo gi of th vetebl bod fls. 3 gde oe spodlo ishes s the posteo gi of he veteb s i th e fst udt i gde fou t i s i he fouth Whe the ve ebl bod hs sipped beod the eo sl g i s e d spod oposis (so oted s gde fve). Prcnag o Slip in Spondylolishsis
A
Beuse ofliiios i eedgs gdig soe pefe to gde spodl olsthe sis b he peege of s ppge. he se udts used fo eedigs sse be used but peetge ssged. his llows oe ute diffeet o of the out of sl p beuse 0% o 24% slp woud boh be osdeed eedg Gde Oe 26% o 9% slp osdeed Gde Two e Saic nvrbra Malposiion
he Housto Cofeee i 972 ehed osesus egdig he diogphi evdee of iteveeb subluxios followg the ilusio of hiopi e edie ovege whih ded th subluxos be deosted dogphl37 lthough these lssfios hve eve bee uivesl eped i hopi o b edre he hve soe utlt. hee hs eve bee pee eviewed publshed doueio th hese l posios e elted to b pi o othe disodes o th the be oeted b hiopi dustet but edotl evdee of he sigifie bouds he folow e those os deostbe fo ouie diogph
B
Fig 3-3 Hdey' S cuve ) Th i n AP view of the e p ient Figue 32; the p defect een thee e o een hee Con Hdey' S cve i dwn in t the eft L3/4 fce jon deonting no ignent (8) Th ve w of the e ptien deontte the vion of Hdey' S cve hown on n obe.
Flexo isige: O the tel vew ies fo the e d ples divege posteiol the spous poesses d fet o its dvege. xeso slige: O the le vew les fo the ed ples ovege posteiol the fes ibe d he spous poesses ovege. Ltel Fexio islge: O he P (o P) vew ies fo the ed ptes ovege o oe sde d d vege o the opposie.
magng the Bak
•
•
•
Rotaioa isalget O the P (or P) vew he pedices are aseca he pedcle o the aterior sde beg ore aera he oe o the posteio side be ig oe ceal. he spious pocess s deviated o he sde o aterioi. eroisthess (Spod oishess): O the l atea view hee i s aeior dsplacee of a vetebra bod o the oe beow.
69
•
Retolishesis O the aea vew here is poseor ds paceet of a vereba bod o the oe beow the luba spie hs usual s due o cosdeable exte sio of he veteba otio u. atera ish esis O he P (or P) vew there s ateal dspaceet (overhag) o the verebal bod upo he oe below. his accopaies ared veebral roaio of he upper seget. Fig 3-4 Cobbs Msumns o Scooss. Th ins n o
Cobb's Masumn o Scoliosis
O he P (or P) view easue the agle foed b tersecio of perpedculars ereced to ies acoss he superor ed pate of he ost superior vertebra i he sco ios is ad he ieior ed pate o he os ieior seget he curva ue.3 t s porat ha he ed vetebrae be oted so ha for futue copaiso the sae segets ae chose. his is the preered ethod for scoiosis easureet whe the ed paes ae easi vsible (Fig 34)
msu h Cobb ng o scoioss mons on hs A viw o n nomlous spn (svn vb w umb chcsics n congni/vopmn wgng o L2. T n vb shou wys b inc whn pong Cobb ng. Th ng s msu by h inscion o ns wn fom h upp n p of sc supo vb n nfo n p o h sc ow vb. Th vb sc shou b os whch w pouc h gs ng Co Ths im cos Cobb ng of 9° (L2). Aso no h h is fxion n oonl subluxon L/6 n L6/.
npdicula Disanc issFguson Masumn o Scoliosis
O the P (o P) vew, easue he age ored b i er secto o li es draw fo the ceters of he superor ad i fero ed vetebae to he ceter of th e vetebra at t he a pex9 he ed verebrae ust be oted fo eferece i fuure evauaio s hs easureet gives valu es below those eached b he Cobb ehod but s used whe ed paes are ot easl see o alow l ies to be draw across the. isnsins Mhod o Sagial Spi nal C anal Masumn
Except at L5 a easoabl close approxiat io o the sagital diaee of the spial caal ca be ade b ea surig the dstace ro a ie daw coecig the superio ad ifeior ips of the aricula pocesses of the sae sege (repre seig the poseior of he spia caa) ad the idpoi o he posero o the verebral bod. L5 the easueet is ade ro the spoaia uctio o he posteio of the vetebra bod. Whe this easueet is less tha 4 i suggests steosis. ccurate deeriaio of seoss how eve equies axa iagg ehe C or R
O the P or P view he cooal de sio of he spial caa ca be deteed b easurig the dsta ce bewee the eos aspecs of he pedicles his easureet varies accordg o the patiets age aog ohe sigicat fac tors. I aduls Rowe29 cies the average/iiu diesos for his easureet o be 2 3 / 9 m at 2 252 a l 262 at L2 ad L3 272 m at 4 ad 3023 a L5 ecease o these easureets suggests possible seoss bu t i s best if his s cosdered i cobiatio wi th a sagital caa easuree. Sgica crease i the coroal caal easureet a idcate a space occupig leso he caal (Exhbit 3- ) Spinal Canabal Body aio
he hgher he aio the sale the spial caa possbl dicatig spial caa seosis. his ehod has ot bee show o be relable ncsal Lin
asvese lie s daw fro the op of oe iiu o the ohe hs is used o oe he eatioship of L4 ad 5 to the
70
T BACK A PVS
xhibt Spil Clrtbrl Body Rtio This ratio is derived by teformula
Block Vrbra
AxB were: CxD
A = ipdiulr dimso B gitl al dimion C tnsvs body dimnsio widt o th body rom th A viw) D = sgit body dimsion A dimsio o h body at mid poi rom th lar viw
oa ranges fo tis tio are : :
miimm 1:.0 1:.0 1
mximm 6.0 1:60
J :6
op of h plvi Row not ha th tia o pobab dvlopmnt of L/ dgnaion a . A hgh i nal i n paing hogh th upp haf of L 2 Log anv po Rudimn ay ib Tantona vba H itia fo pobab / dgnaion a . An i al l n pain g hough L 2. hot tanv po
ongmntaion o lmba vba no nommon Th a of gmnaion may b a h vbal bodi fa join t potio ah u o al o h Ay mmy o bo vtba i no nuual Th nongmnaon may b ompl on on id and i n omp on th oh Rgad h gmt n a bo vba anno mov on on anoh n ia ing tanf o h moto n tha wod odinaly a pa a hat vbal moion ni to ho abov o blow o both h altation o moon pan fqtly a aymm a o nuu al t o atiul aion abov o b ow h anomaly o boh w hi h ofn in pma d gnaton3 Chiopao adting a pin n whh h a blo vba mt hang th a appoah o a om odat o th dn n mobiiy tng om h no gmnaion (Fg ) Bury Vrbra
Th mo ommon y o u i n th hoa gion bt o aionay wil b fond in h lu mba pi n A bttfly vtba t fom nonnion o nompt dvlopmn o h pimodia fo h vbal body ult ng two hal vbal bod wh a t o paial lt a th nt4 Th appa an mb h wn g of a bty A hogh th appa an ting whn hi an ioatd anomay h gnfi an of a buly vba i ng igi b With p inal dyaphm th may b mupl buy vba h
No di mntay ib o aniona vba OM ES D OM V S
Th umboaal gion i a funt t o anomai and vaian fom nomal anaomy Mo o h do no ignif anly aff bo mhani o h o w b a bu t om do hav bomhan a igni fan Thi i paly u wh ana omi al vai aion au altation o movmn pan po du ng aymmti al t o anfing mob y o join oth tha th a loao h inan pop with ho anomali may b pditd towad pmatu dgnaion4 4 To hiopai phy i ian pin al anomal and vaan hav pala gnian in that hy may onu palpaoy di mnaion if th pn i no nown And with aymmta anomal o alaon of gmnaion aoad ald movmn pa may ntat a dif n appoah o pinal adjuting han i ony appid Th op of hi hap i no uh hat an nyopd viw of umboaal vaiant i aibl o ony h mo ommo n o tho hat may b da gnot a ly onfing o tho wih ponia bomhanial/ina ignifan wil b ovd
Fig 3-5 Boc Vbr. Tis b ock vrbr prsnng 5 s nrior nonsgmnion consricng nrior of v br bodi s poducng rivy ypic wspwis pprnc.
Imaging he ack
7
dyraphi probm bing of grat i ni al ignifi an Fig 36)
Hmvrbra
Abn o nondvopmn of pat of a vrtba body a lly on id b arly h antrio or vn mo raly th poior potion of th body rult in a igniant anomaly ha au a utura pinal urvaur57 Latral hmivrtbra au trutal oio Oaionaly a hift in gmnation wi l rt in latal h mivtba on oppoi id o h pin a difnt v that an ot th aymmry o that h ruling olio i i mi ni ma Potrior hmivtba au a loalizd kypho and an b mtakn fo pahologi al vrbal olap Th xtmy rar vntra hm ivrtbra a pinal dfomity than oth fom of hmivtbra and i vry aily mdiagnod a pahol ogy Hmi vrba ar known to oxi with b ok vtba and a alo fond in tho with diatmatomyia mningo and po ndylothoai dy paia Dora h mi v rtbra ar fond in ahondroplaia and othr vr form of dwarf im48 Fig 3-7 and 3-8) ransional Vrbra B Fig 3-5 B Boc vb poso nonsgmnon Ths ns boc vb hs posio nonsgmnon. Con Th c o spon o h pophys oin scs hs so sd in hypopsc dis
tba at th aniio n from on pinal rgion to anoth may a on haaii of th adjant gion Thora o umbar and umbo aal trani tiona gmn a l ati vy omm on anomali3344 Th may b inra o dra in th numb of vrtba with uual lumba hararii whn a tanitional gmnt i pnt at ithr nd of th lu mbar pin
ig 3-6 By vb. T 2 s by vb nd cosponding nom i s T nd L psn. L3 is pi by h cn c which podcs h by ppnc i s inc omp . No so h h ony o mb vb.
Low BACK AD PV
Fig 37 L h mvb. A l hmv b s psn T which is unusl n h hs bs psn b y . o h symmy of h T 12 bs. Cmm Th T hm iv b nd congni l y wdgd vb oh lv s poduc suc scoios s.
A he horcoub uncon Ll y hve sl ib pro cesses unlerly or blerly, rher hn yc lubr rnsvese pocesses nd conrwise T y hve lubr ye nsverse processes her hn sl ibs nson segens he T-L juncion re bioechncly nd clin cly nsignifcn uboscl rnsion verebre re coon nd y be eihe syecl or syercl When L5 ssues soe scl chcerscs scrzon) he efecive uboscr juncon is shfed cephlcly nd he slng echnis he uboscr uncon h s ffoded by he ilioub gens low ng unvers jon echns he juncion s no presen When S es on lu br chrceiscs ofen cled ubiion so ers boechncs he luboscrl juncion See "nercresl ne in he spnogphy secion of his chpe) Asyec nsonl segens hv e geer poenil o eing bioechnics hn do syercl ones3 I is quie coon for degeneve chnges o be ound n hose wih rnsiionl luboscrl segens especly hose h re syer cl) where ccessoy cuions re presen beween he suled rnsvese processes of he os cudl l ub veebr nd he subcen scrl l333 Fg 3-9) Fig 3 Vn hmvb L5 s nsonl sgmn wh
dvopmny now dis L5/S 1 L4 s vn hmvb, h poso ch sucus no hvng dvlopd. Su Rpnd wih pmssion fom T.R ochm a f Sa Rag © 9 Wiims Wins
gnsis or Hypognsis o a Pdcl
he bsence o pedcle s poeni ly s gnificn fndi ng Pedcul genesis o hyogenesis us be diferenied fo hologicl desrucon of he pedce Pedculr desucion
maging he ack
73
Fig 39 Ayric ti ubc vrtb. Th rg pt ft trvr pc fr ccry rtc ti with th ubjct c Com Crry, th th thr cir it t b r b wh cuig ch titi vbr t ipy ig th y tri t gt t i fcti chctriic, rth th try t tri whth i cri ubr g r ubri cr vtbr.
is no nfequen in crcino esic o one nd hs gve signficnce wheres congenil pediculr sence is usuly of le clncl signficnce5 When pedce fls o deveop or is rudieny hee is usul y hyperophy of is conle counerpr h is frequeny scleroic due o incresed omechnc sess plced upon i he congenl sence of pedce s so n fes y ge n erveerl foen5 (Fg ) Fac ropism
Mny yers go Ferguson27 2 posuled h he ur fces shoud e sgiJy fced excep L/S whee hey shoud e coon Alhough hs my e he de i is rrey ezed Asyery of fce fcngs whch hs een cled ropism is vey coon nd i n fc ruy sgil or coonl fce fcngs re exreey uncommon ecuse he fce jons re no pnr u re curvil ine he c inic significnce of ops is uncern nd emins conovesil
B Fig 3 Agi f pc. ( A vw B Obiu viw
Th rig ht 5 pic frir tic pc r gtic t h yprp th cr tctur Cury Dr. W E. L itrr, Eibth w Jry.
eension o he veel moon un nd my nefere wih oher inerveerl moons Fcen jons frequenly show degenerve chnges sceosis nd rregulriy of he rcu ing mgins nd when such chnges re presen hee re usuly ssoced sypos (Fig 3-) nraaricuar Ossicls
FacLamna Joins
Occsionly lrge nfero rculr processes orm ccessoy joins wih he sujcen mn5 Such nomies imi
Flue of union of ccessoy ossifcion cenes he superior o more commonly he inferio specs of in ferior r iculr processes hese hve een clled Oppenheer os
w BK VS
Fig 3- 1 Fce i jt A rge fcet i j i pre e t 4/ he right Such u jit fe bece egeertive i tue wih t h e i t b ty f he vertebr t u t t ete / e Comm Thi etrte tpi t 3/4 4/. The ght 3 fce cr y fce he ef gi t y fce. The ppie rieti i ee t 4/.
scles nd cn be isen for fcures of e ricu processes especiy n e posruc bc In e lb spne ey y be nlel or biler Fg 32 Spna Biida Occulta and Vra
Occul spn bifd (S BO ) s so coon S s o ofen be overlooed fro diogrps A oer levels spin bifd occ is oe noble b egrdless of locion i is nerly wys clincly insgnfcn Absence of spinos pro
cesses occsonly ccopnies SBO e orcolubr juncion nd oug no clincly sgnificn finding, o plp on e bsence of one or oe spnouses y be of concen n diogpy idenifes e bnorly Spn bfd ver (SB) s rely fond n e ow bc excep in cidren w sevee spn dysrpis nl e SBO wc s sl defec in e poseio rc due o congen lc of cose SB es pl ce wen fi e of closue of e poserior c exends over ore n one sege n esse n ly nroofing e spnl cnl o be lbeled SB ee s be proson of
Fi 312 Oppeheie ice. A uuite ccery ce i preet t the ifeir f the rght ferir rtcr prce f 3 Comen Thee ice re r vrit which y be itke fr fcture.
maging he ack
he conens of he cn hough he defec (Fig KniClasp Dormity
7
cue sge in chioprcc prcce ecuse mos wil presen o he emegency oom o o orhopedc surgeons A few howeve picul rly frcues of umr nsvese pocesses h hve no een pevousy dignosed n recenly um
hs eivey common nomly found he lumosc juncion hs been so nmed fo s resemnce o foded cknfe251 An enged spnous pocess is receved n o mulileve SBO defec n he poserio rch of S nd S occsonly even S he knife de he enged spinous pocess i s roby due o colescence of he L spno us w h he poseior uece(s) of he upper scrum evng gp in he scrl poserior ch where he uercles should h ve een When knfeclsp deformiy is ccompned y pin on eenson due o he prorusion of he nfe blde n o he sc spnl cn i s cled nfecsp syndome50 (Fig ) Bon sands nosomas
Bone snds e ci nicly nsign ifcn colecons of dense one found wihn medulry (cncelous) one nd e s ympomic hey my be sml or lge nd cn e found n ny one bu e frequen in he uppe femus pevic ones nd no uncommon in veebe555 Bone islnds cn be confused wih oseobsic esions hcescly, bone is lnds e homogenous nd hve serred o ush bode555 A few my increse n size nd hose h do my be ho on bone scns ming diffeenion from n oseobsic lesion dcu565 (Fg FCUS D DSOCOS
Fig 3-4 Kfecasp deoity. A classical nfeclasp deormty
rumcly induced frcues o dsocions in he lumb spne nd pelvs re no commony encounered n he
is preset at the lubosacral jucton. he eongated spin ous pro cess (actu ally that pocess fused with the tubercle o S 1) ext ends cau dally into the open posterior ach at S 1 and S2.
Fg 33 Partially unossifed posterio arch sulatig occult spa bda. Somewhat uusual appeaances simulating occult spna bifdas are
preset at S and S2 he posteior tubercles ae ossfied but there s adiol ucecy o both sides of those tubecles indic atn g that the posteior arches ae carti age which h as ot ossfied.
76
T L BK P
Fig 3-5 Ilac bone island. A hoogenos adopacy n he iim wh a "brush border represens a benign bone isandCommen I should not be msaken o an oseobasc lesion
tzd patnt may ncontrd y ch ropractc physcans. Spna and pvc acturs on th othr hand ar somthng that vry prmary car physcan nds to art to nd n odr patnts spcay postnopausa won thos who ar munocompromsd and thos who ar ongtrm usrs o cataoc strods such as thos wth dssmnatd ont dsas chronc rspratory dsordrs tc. hs chaptr w cov r ony thos racturs and ds ocatons n th umosacra spn and pvs that ar most ky to ncoun trd n c h ropractc practc. Pars n trartcu ar s racturs and spondyosthss w dat wth sparaty rom othr spna racturs. Fracurs o ransvrs Procsss
ransvrs procss (P) racturs ar th scond ost com mon racturs n th u mar spn ony compr sson racturs ng mor rqunt. Du to ovryng ntstna gas ssqnt to trama P racturs can as y ssd . h L and L Ps ar th most rqunty ractrd tp ractrs ng common.585 racturs o th L Ps otn accompany pvc ractrs or dsruptons o th sacroac ont. Whn horzonta P ractrs ar ound cos nspcton or a Chanc ractur s portant.58 Horrhag accopanyng P ractrs ay oscur th psoas shadow. Rna or urtra damag or oth may aso accompany ths racturs. Ea nato n o th ur n or occut or man st ood s mandatory n pat nts wt h P racturs58 (g. 3-6). Chanc La p Sa Bl Fracturs
[n 948 Dr. Chanc do cumntd a horz onta ractr copty throgh th vrra ody and nura arch rsut ng n
spttng th vrtra horzontay. Surprsngy ony aot 5% o thos who hav surd ths typ o ractur dvop nuroogca dct.58 h most comon st or ths ractur s rom L J . Bcas Chanc racturs most rqunty occr rom automo trauma n whch th njrd prson was warng a ap sat t thr ar usay russ or arasons or oth on th uppr adomn n th ara whr th satt was postond58 (Fg. 37). Lumbar Fractur Dislocaions
Most mar ractur d socatons ar sr ous and accopand y nuroogca anormats58 that mak th unky to ncountrd n ch ropractc practc cpt n a at stag staton. ractr dsocaton n th o ack s usuay n th thoracoumar ara o ow ng v on t trauma. h ony typ o ow ack ractur ds ocaton ky to prsnt to a chroprac tor n an acut stuaton s a ractr o an artcuar procss wth assocatd act dsocaton and vn that s unky Comprssion Fracurs
Coprsson ractrs ar not as comon n th uar spn as n th thoracc spn ut do occur rom on and aa coprsson orcs.5966 hy ar or commony ound n th gratrc popuaton spca y n thos wth ostopoross such as postmnopasa womn ut wth sucnt orcs can ound vn n young actv ndvduas h ost comon sts or ow ack comprsson racturs ar L and L.58 Radographc sgns o comprsson racturs ar: ) antror wdg dormty that may s t and may tak svra days oowng th traatc ncdnt to co apparnt () an antror stp dct whr thr s
an he Back
A
77
8
Fig. 3-16 ansvese pocess facues. A hee ae dsp aced actues o te L L2 and L3 ansvese processes on the eadng et 8 A subtle acue o the L3 ansvese pocess on te eadn g gt s sown o be a adoluce n l ne avesng he pocess om top o botom. ee s no d pacemen o he acue. Coutesy o D. John A . . ayo, Gesham, Oegon.
Fig3-7 Cance actue. he A and aea adogaphs sow sp t ng o e verteba houg te ped ces. Supeo angu aon o he supeo
poon o te actued veteba s bes seen by e sepaaton o he uppe and o we poons o the poseo ach sucues on te aea ve w e schematc depcs a hozontal spl t ng actue, a vaan o a Chance actue. Comm hese acues esu om a l ap sea be acng as a ulcum whee te oce om a sevee auto accdent sp t s e veeba mmob l ed by te sea bet Sou Repned wh pemsson om .R. Yocum, ssenals ofSlal Raolog © 19, Wams Wns
78
w BACK A PVS
voaon o th antror cortca n o th vrtbra body uu a y aocatd wth dpron o th nd pat 3) a nar zon (wht band) o condnaton adjacnt o th nd pa 4 nvagnaon o th nd pat, and () parapna da.8 t ar or coon or th copron to act th upror o th vrtbra body/nd pat bu thr ar rar occaon whn th copron dort ar ound at th antonror apct o th vrtbra. A bdona u u uay vdnt at and or o t oown g th raua aocatd wh h pan.8 h radographc antaton o copron ractur ar otn vry ub ary on and ay no b radographca y vdnt or a w day oowng th trauatc nc dnt. n a pn that vry otoporotc or othrw waknd by o pathoogca proc copron racur ay occur wth na traua or vn wth no apparnt raua.8 o dcu o drn whthr copron dorty o a vrtbra rprnt od or rcnt coap. h nar radopau n undr th daagd nd pat not a contant ndng, but whn prnt, dnt an ara o pacton o
A
h daagd rabcu a h bco or vdnt a cau oraon occur and dappar wth hang. h p dct ao an ary ndng hat no ongr vdnt atr ha n g tak pac. Boh th gn ar vdnc o a ractur hat than wo onth d.563 Whn hr a quon a to th ag o a copron dorty a radonucd bon can ay b hpu. h upak at h racur w b nc rad h can howng a "ho ocu, durng actv bony rpar bu h can ay ran potv (hot or war) or a ong a 8 onth to yar6 In a patnt who ha bn prvouy nu rd a bon can ay b conun g rathr than hpu (g 3] 8 and 39). Burs Fracurs
ont aa copron traua ay crat a burt ac tur. h vrtbra body tray " xpod wt h vr copron and on a vrtca racur n n on h corona vw64 Conuton o th vrtbra body wh arkd n vagnat on o upror and nror nd pat b apprc
B
Fi 3- arly L3 o mpresson ratre A sl igt anerior "bea, seen beter on e obi que ve w an on e latera, and assoiated serosis
wit s ig ly ti en ng of te superio r end pae are ev idene of a new ompression raure, subse uenty proven wen greaer deormiy was doumented a mont aer. Commn Tese l ms, of only ai r uaiy, onrm te need or exelen radiograp ualty e finding was not deteed from ese flm s bt wen frter fi ms not av aia ble to present) were done a mont aer te fratre was evden
magng the Back
Fig 3-19 There is compression deformty of the verebrl body
wth decresed nterior bu not posterior height. The superior end plte is mi ldly inv ginted nd here is "dome like invgnton of the inferior end pte. Al though the nteror verebrl body mrgin s lered in contour the bone is now norm n compostion This is n old heled compression frcture tht is now stble 3 lso shows mred nvgnion of its superior end plte representing c ol pse of trbecule in the spongios Co The ptent is 6 1yerold mle recovered lcoholc nd exhibis reltively dvnced osteopeni xtens ive therosclerotc ortic nd common i lic c lc fiction is obviou s, demonstrting ortic tortuosity Note he reion shi p of he ort to the spine Such dvnce d oric chnges re due to deposition of ccium in necrotic issues of the vessel Whi le the ppernce suggess vsculr rgidiy, n fc he vessel is "roten due to the necrosis nd cn be dmged by excessive force
atd on h latra v w. Posror dsp acnt o a ragn ay daag h cons or cada qna Fg. 320)
79
ig 3-20 Burst frcture 3 This yerold mle fel onto hi s but
tocs n ddito n to compression, there hs been frcure ompleely through the body from top o botom displcing the nterior frgment. ote l so ht there re compression deformite s of the verte br bodies bove indicng prtil collpse of these segmens Co The frcure t 3 probby represents refrcture of ver tebr th hd previously been frctured or hd prilly colpsed from osteoporosis.
Vrical Sacra Fracurs
hs ar rarly solad njrs and rama scnt to cas th s saly ndrct and so svr hat th pan s no aaory. Thy ar saly dtctd y notng dsrp ton o th sacra srs th ransvrs sacra orana ns. A corona tt vw ay donstrat h ractr t oography or CT ay ncssary. 6
Horzonal Sacral Fracurs
ransvrs ractrs o h dsta sacr ar ary coon o owng d rct raa to th sacr . hy ar otn vry d ct o vsa on corona vws d o ovryng gas and ca atra and th dagnoss s saly ad ro atra vws. A cansng na s say ncssary h racr s to adqaty apprcad ro a corona prspctv pp r sacral ransvrs ractrs ar ss coo n and sa y rs ro svr traa Fg. 32)
Coccygal Fracurs and Coccygal Dislocaion
Fractrs o h coccyx thos o h owr sacr, ar sally olqy transvrs. h atra vw as th dagnos s. hy ar rary apprcad ro h corona v w. Coc cyga dslocaton/sxaton s saly to th antror t postror dsocaon can occr. aratons n sacrococcyga orphoogy can consng and ay rs n sdagnoss y an nxprncd osrvr
80
w CK ND PELVIS
Fig 3-2 S rur di srupton o ormi n in s On th ront viw no dini rtur in s vdnt but th ormn rut ins r dis ruptd rows. h C sn shows th rur ns t th ormin nd so dmonsrts onrtr vi rtu n Cmmn Disrupion o ormin ins my b th ony rdogph sgn o sr rtur. Courtsy o John C . S izs Avd Coordo.
ac Wng Fracturs
hs sut rom dic trauma and a stabl.58 h actur n i s usua y bs appciatd om an obi qu vi w and dispacmn is minima du to th attachmns o arg muscs vulson Fractur o th ntri or nrior ac Spin S o th ntrior Suprior ac Spin SS and o th schial ubrosity
A vu son o th oigi n o th ctus mors causs a ractur a th AIlS but avusion o th sartorus oigin ractus th ASIS Hamstrng avusion causs ractus o th scha tubrsity hs a injuri s sud hough vari ous snuous ahtc actviis and hir dagnoss a staighoward (Fg )
o a cntra actabua actur maks it h igh y u n iky that a chropracto wi s on as h nta doco SPODYOYSS D SPODYOSHSS
Spondylolyss and spon dyoisthss a such common nts tha hy a cons idrd sparay in t his chap Th main hos who qusion whth som pas dcts (spondyl olyss) ar congnta o whth a a in act pas ractus78 Lt th qustion b aid to st bcaus no in sanc o pas dcts hav bn documntd i n th nwbon Wits who is cognd as th pminn auhoriy on spondyo is thsis has shown tha th thory tha h pas dc s du to non union o two spaat ossiication cns o du to a dc i n cartiagnous dvo pmnt i s a acous bcaus no vdnc has bn poducd o viy thos horis
ctabular Fracturs
Mos actabua acturs sut om automobl accidns or pdstrian vs auto tauma. Th mchanism o inury s usu ay om indirct tauma th moa had jammd nto h acabuum th posit ion o th mu at th ti m o njuy dctat ng th t yp o ractu. Fracus o th posto acabu ar rm on accompany posior hip dislocaton Anior coumn racturs disup th ischopubic n and mday dspac oh's tadop. Cnta acturs a th mos com mon actabua racturs and h most sv, h mora had punching though h actabuum, ctvy spiting th in nominat bon into uppr and ow potions Although on occasion a patn wit h an undiagnosd anio or postior coumn acu may consut a chiropaco th sviy
Fg 3-22 Avuson tus o th pvis his shmt dmonsts h th mos ommon sts o vusi on rturs o th pvis. S Rprintd wih prmisson rom .R. Yohum n a fSa Rag © 9, Wiims Wns.
Imagng h Back
h mos common poposd oogy gdng ps dcs s tt ty du to stss ctus Wts s posutd t ts occu s sut o cunt mchncl sss nd ts s suppod by n n vto sudy don n 978 by Cyon nd Huton On occsons n cut ps cu my occu om tum. hs s mo ly h bon s bt om dyspls such s osoposs o n dvncd os opooss. Spondyosss s uncommon n cs o unt spondyoyss nd h occsons whn t my b bt ps dcs wh no nolst ss. Obqu vws quny ndd to dquy vsuz ps dcts bu t s no uncommo n tht th dcs cn b sn wthout h ddton posu om oblqus. h d mnon s to whth obqu s shou d b don whn th s n obvous nosthss nd t o coonl vws o bot show vdnc ht ps dcts psnt, o pobb shoud (s soud b tu n ny dcson gdng whh dogphs shou d b don ) b bsd o n whh o not h ddton v ws w nunc tmn (Fgs. nd ).
81
Fig 3-24 Sponylolsthess RI san, sk extuson. l weghte an parasagttal ages o ierent patents wth an sponylosthess eonstrate assoate sk extruson. he sagttal age shows s atea extenng above the n eor L5 en plate but the parasagittal age shows huge extung sk ateral ex tenng ephay to the upper L5 en pate. he nterupte pote ro oon gaent s seen as a lnear ak struture extenng upwar o the posteror o the S 1 boy. Cn Posteror sk protrusion is a equent ning wt h syptoat sponylo sthe ss. hs ase s an extree exape, but RI shou be onsere when raular syptos aopany sponylol sthess Courtesy o D. Stephen .G Rothan, orane, Calorna.
most commonly usd c lsscon o spondyo s ss l sts v yps: Dyspstc: Ths du to congn bnomty
Fig 323 Pas eets, ultp le leve ls. In ths lateral vew pars e
ets are present at 2 3 an . here is a slght sponylo ist hes is o L5 on S 1
n h upp scum o th L nu c tt ows h ds pcm]nt o occu. . shmc: h h subctgos und h s csscon: () Lycps dcts du o stss o gu ctu. s s t most common typ o spondyo sthss. (b) Elongon o nct ps nttcus (c) D sp cmnt du o cu ps ctus . Dgntv: Ths ound m ny n womn n h sh dcd o lt nd du to conc dsk nd ct dgnton . ps ntc h mjoy o dgntv spondyostss ound t . Mny o ts no ptcully sympomtc, bu dspc mnt byond th usu 0% to 5% ) cn sut n spnl cnl stn oss wt h th ttndnt sympoms. umtc hs csscon s svd o thos ntolstss wh nul c ctu oth n
w BK PV
Fig 3-25 Degenerative pondylothei. A 25% degeneative pondyloi the o on 5 hown. There appear to be light elongation o he hu on thi adiogaph but obliqe l did not eontrae pa eect. Come he y po o degenera ive pondylo lihei ay be negigi be a in th i patien, bt entrapent o nerve ay lead to radc ula r or cauda equna y pto.
o that dgnav changs pay n spna bocancs Fro vwpont o th chropraco, atd spna uncton ha atnds spna dgnraton tanscnds h s p lsc quston o t aonshp o back pan to spna dgnraton. h concpt hat dysuncton n any poron o t usc ulosk a sy st has cs on a ohr body systs hrough atraton o nura ngaton s basc to chropactc hnkng and o at o othrs who spous a wolsc ap poach to any aspcs o hath and dsas t s no wtn t scop o ths captr o go nto ga dta gardng h paognss o spna dgnatv cangs bu so consdraon o at subjc cannot b avodd on atpts to rlat agng ndngs to c nca ccustancs. n ths dscusson o spna dgnaton, a uncona approac to t consquncs thro w b takn bcaus hs xplans or at ast posuats h rvanc o any thngs w can s tough agng Ths s aso n kp ng wh h concpts and achngs o Roy ogan ha hs book atpts o porray Atough a spna dgnratv changs a ntgatd wh on anoh thr a drncs n gn and chan ca consquncs o thos cangs that ak dscusson o dnt dgnav aspcts o th dgnratv pocss wortwh. Dgnraiv Di sk Disas
at th pas ntatcuars aows t dsplacnt hs ar vry ar n h ow back. 5. Patoogca: s occu w h bon dsas h o cazd or gnalzd wc aows h dspacnt o occur Th ost coon pathoogs to rs n such subuxaons ar tasac cacnoa Pags dsas and osoptoss. ochu nos hat a sxh yp ca d possugca or atrognc spondyosthss s aso asb .? Ths cou d su ro a sss acur o pas abov or bow an aa o spna uson o o sugy w too uch bon s ovd durng ancoy o actcoy causng n sabty DRVE SP DSS
Sp na dgnraton s an n vtab consqunc o agng, but t s accrad by aua, rpttv sss sysc dsas, nacvy wth rsuant wasng o supporv ssus and bon and probaby oth actors. t s so qunty s n n nonsyptoac nd vduas tat r s quson n t taur as to ts atonshp to hos wo do av back syptos. 7 7 h dba as to wtr dgnrav spna changs av rvanc to back pan xbts ack o undrsandng o sva portan aspcs ad to th gnss o th svra typs o spna dgnaon and t caus/ct
As h dsk oss wa ssurng o ntrna annu occus wt protruson o nuca atra no tos ssurs.5 MR has nabd nonnvasv n vvo donstraon o dsk dgnaon h dcrasd ydraon wtn th dsk bng sown as dcrasd sgna n nsty o wghd ags377 gu ). As th ydrostatc uncon o h dsk s ard subt atatons o nrvtbra ovnts occu Ths changs n bochancs rsut o dgnraon but aso c aus uthr dgnaon to occu at th prary st and aso a hos oth arcuatons tat ar actd by t atd obty nortunaty, ahough dgnrav changs can b donsatd by agng th sos subt bo chanca altaons that atnd such changs ar usuay not wl u ndrstood ro h ag s. n atr copracc ad bn ncudd n Mdcar wth t unorunat andat ha o rbursn o chopractc srvcs spna subuxatons ad o b donsratd by adogahy tstd to HCFA that ony about 0% o 5% o sub uxaons at coud b ound cncay coud b sown radograpcay. My opnon n ta rgard has not changd. Rsnck7 as cad dgnraton bgnnng n h nucus (ntrvtbra chondross) wch causs oss o sncy n t nu clar aa rsung n changs n t adacn bon, ntvrba ostochondoss and h cas dgnraton o th outr annuus wch s ansd by agna oso phyc changs, spondyoss doans (o coony spy cad spondyoss).
Imagng th Back
83
Fg 3-26 Disk degeneration, RI scan 2 weighted iages
through leves o the neural oraina and parasagita regions show seveely decreased disk sgna intensiy at L4/ and L/S whereas the othe visuaized disk inerspaces show brght signal inensty Commn he deceased sgnal intensity is evidence o decreased water conen wihi n the ds k associated wth poeoglyca n degenera tion hese iages show the protruding disk atera occludng the ineror poron o the L4/ neural oaen and extending into the lateal recess
Fig 3-2 Intervereba osteochondoss, L4/ and L/S he na row disk nterspaces he intadisca gas vacuu phenoenon at L/S l , and the subchondral sclerosis abuttng the end pates ae he sigata o hs type o disk degeneraion Comm A Schorl's node s seen in the inerior L3 end pate wih a very shaow Schor s node opposie i t indentng the supeior L4 end plate
Intvtbl Otchnd (IVOC
As nca dgnraton progrsss ssring o th innr ann s and igraion o nca ara i nto h ssrs, as w as ts convsion o ss asic ss rsts in progs siv narowng o th nspac. Gas nt y a ccas whn h issrs and is donsad adogaphca y as radocncy wihn h nspac.788 Th gas coctions a known as vac phnona. Ths ar say cnra within th dsk, b ay nd o h ot anns. Concotanty wih oss o disk hght, h anns bgs and acion on th atachn o h ann s to th vtbra a gn cass sa osophytc pping ig. 327). Spndy Dfman
Antior and antroatra osophyts (spondy ophys) a vtba body argns a h os coon adiogaphic ansaton o dsk dgnaion.788 Ths occ o disrpion o h atachns o th o ann s o h vrtba agns dcrasng anchoag o th disk to th vrtba body aowing dispacnt o th disk which cis bon oraton a h discovtba argns. Spondyotc hypr tophy is ainy sn wh th antrior ongdna gant
atachs o th dscovtbra ncton ths th anroata ocaion Spondyophys a orintd oghy para o h vrba nd pat at hi oigns bt as thy narg ay cv pward o th or nro vrtbra body agn or downwad o th argin o h or spror vrtba. Thi horizona o rgn d intas spondyophys ro th syndsophyts and paasyndsophyts o naaory spna disass (to b dscssd atr), which ar o vticay ontd, paang th o aspc o h dsk ann 808 (Fgs. 328 and 329 Th argina ostophyts o spondyosis dorans ar grat n s han th sa ostophyts that accopany th atr sags o OC. Howv, th dgnrativ pocss is a cont n and ths pocsss a no nry spaa.7880 ntrvrtbra Dsk Dsplacmnt
Dspacnt o dsk ata has bn caJd hrnaion b that s so nbos as o b consng rahr han hp. For prposs o this dscsson hrniation wiJ b
8
T w BK PV
g 3-2 Spondyl ophytes () , (, and ) hese are nonmarginal spondyophytes that are essenti aly orizontal i n orientation caled tracon osteophytes. hese "claw osteophyes, which neay brdge he ds k nterspace, are also usua ly nonmagina l, bt ae age, crve veicaly ,
and, as i n th s case, ma y approxmate one another and eve n se o mmobl ize te vertebral motion nit hi s is an axial C image o claw osteophytosis. Comme Spondylo tc canges, as h s m age demonstate s are found in the area where he antero longit udnal li gament ataces to he vetebral body hey ae raey ond poserolaterally Soue Reprinted with permisson from R Yochm, Esseas of Seea Radoog © 19, Wilams Wiins
usd n a gnc sns and o spcc rnoogy w b usd n a udn g to th sva yps and ss o ds k dspacn. Wth th cpton o Schos nods n so nsancs or dspacnt o dsk ata to occur so dgnav dsas ust b prsn n ght o th abov dscussons o IYO and spondyoss antor and antoata dsk prouson ro thos dsas procsss w not b rpatd. w atp wh bng sp sc n dscbng h varous othr typs o dsk d spacn o us rnoogy ha s wdy accptd avodng as uc h as possb h gnrc r hnaton.
Shms Ndes
Supo or nror dspacn s o dsk at�ra o boh ha hrnats hough th caragnous vrtba nd pa no h spongosa o a vrtba body ar dsgnatd as Schor' s nods•8 Schor s nods ay b dopahc usuay occung n c hdhood ay accopany Schuann s dsas ncon taboc or ndocrn dsas, nopas o ay rsu o aua 8 8 Thy ar rcognzd as radou cnt sons wthn th vrbra body usuay counca wth th dsk ntrspac and hav scoc bodrs ha ay b thck o h n (Fg. ).
maging he Back
ig 3-29 Intervetebrl osteochondos s nd spondyoss defor-
mns A L2/3 the nrrow ds nterspce, end ple scleross, nd vcuum phenomen e ndc tve of IVOC, but t L2/3 nd L4/ the spondylophytes re moe typcl o spondylos s deformns At L3/ the nd stncness nd regulry of end ples s su spc ous of nectous dsc ts, but more probby s smp y dvnced degenerton C hs cse s pesented o me the po nt ht spondyloss deormns nd IVOC re fequently found togethe nd n fc re smpl y d fferen mneston of the pocess of ds degenerton
imbu Bne
Protrson o dsk aal n ch ldhood, ntrrtng a o on o h l c aohyss and ds lac ng a agnt o on ro ha aohyss ss n a chaactrstc aaranc ha has n cald a ls vrra3344 t or oly shold rd a s on hs s ost coon at th antro sor conr o a vtra, ay occ anronoly and on a w nsancs ostroly Ls ons a saly ncdna ndngs n adls and, n adts, vn osro ls ons saly hav l tl cln ca s gn canc c n ndvdals w th congntaly sa l snal canals7882 (g 33 ). Pei and Peaea Dik Dipacemen
hat whch s sa ly d to as ds k hrnat on s osto o ostrolaal dsacnt o dsk atra o oth Any and all o th olowng hav n cald dsk hrnaton
85
ig 3- 30 Schmorls node A gnt Schmors node s present t th e nteosupero corner of L Co Schmorls nodes e n requently found t th e mgns o vetebr e nd pes, bu t when they do occur n those octon s n ths cse poron o he end ple mrgn my be dsplced hs occurs pro o seel mtuty nd he vulsed frgment o the lmb c pophyss becomes l mbu s bone (so known s mbus vertebr
n th l trat51 7 Mo scc rnoogy s ndd th svty and sgncanc o th dslacnt s o nd stood Th olow ng d scrv n onc lat s rrrd y so, 517 althogh h s no snt standad rnology •
•
Anna Dsk Blg Blgng o th anns ay d s and crcrnta, or ocazd n a g ng dsk, th annla rs an nact1743 athogh oth nc la and ann a dgnaon ar oaly nc ssay o lgng o occr. Howvr agntc rsonanc ags ay show dsk lgng wth nal dcas n dsk sgnal nt nsty 51743 Ann ar gs ay rord no th snal canal, atal csss, and ntrva nv oot canals (nra orana) and ac and occasonaly ng on na strcts Dsk Potrson (Polas): Whn ncar ara tnds hrogh at last so o h anns, t th ot annls s not voad, t s st rd to as ds rotrson.17 Sch rotrsons ay cntra, and, d
86
L B PLVS
Dsk Susrato (F Frag) Wh h potud g uca atra dachs ro th par dsk ad hr pats hrough h PLL to th pdura spac o ovs up o dow or so dsac udr h PLL, s trd a squsd or r dsk ragt 1513 Susrd dsk rags v hough ag a s hav show to rgss o v dsappa gv 1383 athough so o h appa grsso ay du to rsopo o horhag
Fac oin Dgnaion Fac rhrosis DD
Fact os ar arhroda (syova) atcuatos ad dgratv d sas actg t h dos o d r s pathoog ca progss o ha o dgatv jo d sas prpha jo ts h ha arks o scross o atcua suacs arga ostophyts ad vtua oy hyptophc chags that rsut ro th akdo o atcuar carag ad s cts o th co guo us o a dosra radogaph ca y th uar sp hs ar o tr apprcatd o oqu adogaphs ha o cooa ad aa vs Aa
Fig 33 Postior i mbs bons Postor limbus bons a dm onstatd at h inior nd pla ts o 3 and 4. Cmm Ths ar qit nommon Suh ndngs hav potnial o aus nurologial symptoms bu sh symptoms our in a surprsngy w n stans
•
pdg o th sz o h protruso ay ac or co prss th thca sac. Paada porusos ay aso dspac h g v oot. Postoatra protusos aga dpd o sz ay th ara css ad d to th trac o th rv roo caa Far atra potrusos to th rv oot caa that ay copss th rv roo or gago or oth hav dosrad y C ad MR ad pa why pror to th wh aa agg was avaa yography woud ot show such aorats 51 (Fg 332). Dsk Etruso: Ths a protrusos o uca aa hat hav copty prad h auus ut a s cotad y th posto ogtuda ga PLL) 151 Bcaus th PLL s a ctra structu ths casscao rs oy o ctra ad parada pro usos tudd dsks a usua y o such s hat h hca sac s coprssd ad o o oh g rv roots ay dspacd. Th potrudg ara ay d aov o ow th vrtra d pats o oth a h actd trspac 51
A Fig 332 Dis protsion and rativ maw dgnation, R sans (A) Sid by sid ist and sond ho proton dnsiy and T2 wghtd ) m dsagittal and us parasagttal i mags show svrly drasd disk hi gh and s gna int nsiy at /4 wih postror proru sion and wih ratv marrow hangs on boh sids o th inr spa Ds narrowng wih Shmors nods and drasd sgnal inns ity s also sn at /2 and 2/ Rmarkaby norma disk high ts and signa l i nnsty at 4/ and /S is most unsal w th th xnsv dgnraion abov Courtsy o Dr Stphn G. Rothman Torran Cai ona
main h Back
87
B Fg 333 Hypeophc degeneatve face jont d eae. ee e Fg 3-32 B l weghted pe and potgadol nu axal age a
e boaca jncon deonate te efcacy of obanng paa agnetc cona age n yptoatc pougca patent whee tee ueon whete ecuent d pouon o potu gca ca cae te pan Con he peage ow a lage a o atea encopang he le neve oot e potgado nu age how enhanceent of hat aea, ndcat ng tat te atea vaclazed and heefoe epeent ca ue ate tan dk whc wold not enhance Cotey of D Stepen L.G. Rothan oance, Cal foa.
vee hypetopc degeneatve acet ont d eae at L3/4, L4/ and LS, oe evee on he gt. Facetla na o n ae evdent at L 3 4 and patcla ly at L4, on te gh a bo leve . Con e bony bdgng a the laea apec of e 1 2/L d n epace an on te gh a L1/2 ugge ankylo whc confed on te lateal vew
Dius diopathic Sklal Hyprososis DSH Forrstirs Disas
imaging upeior o pan fl m radiography in demonraing facet dieae and addtionaly alow viualzaion of the lgamena fava w ic form pat of the joint capule and when ypertropic or buckled may poude ino the p nal cana or aeal rece uffciently o produce tenoi Synovial cy accompanying facet degeneraton may alo protrude into the pna cana or atea rece caung teno 7 8 Degeneative face dieae uualy aocated wih d degeneraion bu i occaonally found wihou obviou accompanying dk dieae olated o unilaeral face deae bepea peviou pecific trauma 38 More commonly facet artroi reu from prolonged tree uc a toe from chronic potural fault coioi o epeiive ta that impact he low back (Fg 3-33)
DSH a degeneraive pinal dieae which in ome apec reembe inflammatory deae. t caue unce tain7888 bu i i a bone fomin g pathology an enheopaty and i caracerized by hyperootc bony poiferaton at tendinou or ligamentou aachment (enhee). In te low back i i mot commonly found in the uppe lumbar region but may afec the entre umbar pne. 78881 The bony proiferation may be quie age. Renic' citeria for e diagnoi of DISH reuire ta four contiguou e gment be i nvol ved 78 However for practcal pupoe a mae area of pina in vovemen may til repreent DSH requenly ankyloi occur at te uperor portion of the acroiliac join 7888 a oppoed o anyloi of te lowe o ynovia porion wh ich i een n inflammatory pina l dieae (ig. 334)
T w BK PV
88
B A Fig 3-34 Dse dopatc seeal ypeososs DISH) A Hypeostoc bony canges at te aneo of e l 2 12L , L 12 and L3/4 wt lesse sm a canges a L2/3 ae evdence of DIS H Co Resn ck s ceon o DISH s nvol vemen at 4 congos leve s bt fo pacca pposes te dagnoss s vald wen ewe contgos segmens ae fond b te ypeososs s elatvey ypcal B xtensve
aneo ypeososs at L /2 3/4 L4/ and e sse canges at L/S ae compable w DISH al og te congos nate of te abnoma fndngs s nteped Com Scatteed adopaces n e so ss es aneo to e spne ae de o bam etaned n colonc dvecae esdal om a pevos gastonestna stdy
Neutphi Spndylpahy
NFMMTOY SPN DSESE
Neuoogc eficits ha cause loss o impaimen of pain senation o popioception o both may cause estructve athopathy which may affect the spine The majo seases causng neuotophc spina arthopahy ae tabes osali s an iabee mellitus0 n the spine, the hyperrophc patten of etucton i foun athe han the aophc fom which may occu in peipheal joints4 The umba spine is he mos common te fo spna neuoathopathy an the enstage etuction may be pectacua with efomity sevee ubluxaton ilocations an even factues occing make scleosi s being a hal lmak The eay si gns ae those of egeneaion with sk narrowing vacuum signs scleoss an osteophytes that may become exubeant This pogesses apily o he sevee estuctive stage n contast to peiphea neuoathopathy spinal isease may be accompanie by sgnfiant pain 5 ig 3-3
Infammaoy iseaes of the spine have vey eious clinical mpl ications These iseases w ill be pesente in t he oe of the severity of the pobems they cause nfecius Spinal Disease
Spina infection othe than aogenic is no common Infecton othe than tha which euls fom iect noculaton iatogenc o othewse) occus fom bloo bone pahogens o by ect exenson fom ajacent septic issues The vascua oute is moe feuent4 The pathogens oge n smal vessels in veteba boie usually close o vetebal en paes o occasionally subjacent o the sacoiiac joint su faces Because the enzymes that occu wih nfecion ae moe stongy chonolytic than oseoytic the sease moves apily to the isk o joint suface an esults in eosons an i
magng the Bak
ig 3-35 Neurotrophc uropathy tabes dorsals). xensve hy
pertrophic spondylophytes dsk narrowng at any e vels ult ple subluxations and a shor double scoli osis are presen in tis paten wih tabes dorsais Con Neurotrophic arthropathy in the spne as esewhere, is characterized by exensive jon destrction and i n stabilty
regurte of end plte or rticulr mrgin tht re rgged nd often mldly cerotc from the debr.886 Spreding cro the oint to in vove the other jon t urfce/end p lte nd the djcent bone common but not invrbe.886 Soft tue involvement frequenty occur n my produce prpn bcee tht my pred the nfecti on to dcent tiu e886 Prompt digno o tht tretment cn begn erly ex tremely importnt becue uppurtve nfection move rp dy with detruction proceeding over few dy to few month886 depending on the virulence of the pthogen the reitnce of the ptient n the efectvene of tretment Stphyococcu ureu ccount for 90% of uppurtive i nfection but n i mmunocompromied ndvi du other more exotc bcteri my be found More inolent infection uch tubercuo lthough lower in their ction my til cue rdiogrphicy vible chnge wth n few wee.8486 ubercuou pondylti mot commonly nvolve the lower thorcc or upper umbr vertebre or both n frequently cue prpin bce.8486 A po bce my low grvt tion of ceou mter cudlly in to the ingu n re or even nto the upper leg ig . 336 nd 337)
89
g 336 Infectos disc ts hs 62yearold an had been diag-
nosed as havi ng degenerative spinal disease he erosion of te verebra end plaes a 2/3 was seen and a diagnosis o infectous disciis ade.
he en reult of uppurtive pondyiti i nyloi.886 ubercuou ponylit however mot frequently cue vertebrl body collpe tht my reult in gbbu formtion8486 Rheumaid hiis and Rheumaid Vaiants ecing he Spine
Rheumtod rthiti RA) nvolveme nt of the umbr pine mot unnown Rheumtod rthriti ffect ynovl join t o tht i f i t i found n the um br pne the fcet ont wou be the ite of nvolvement er y rrely RA my fect croi ic join t n whc h ce the invo vement i u nlter where in other re of the body RA biter nd uuly ymetricl.88 Low bc involvement with the rheumtoid vrint: ytemic upu erythemtou SLE) progreive ytemic cle ro ceroderm) nd dertomyoit i o nfrequent tht they w l not be dicued n thi chpter The Seegaive Spndylpahies
he folowing inflmmtory pinl diee re chrcter ized by c of the rheumtoid fctor in the erum but hve
90
w BK V
Fi 337 l t lvl d st s xr as o nfous dsts aftng al lubar dsks. Co h dsk hghs appar o b
antand du to th svr roson of h aftd vrbral bods. Cousy: Dr. Stphn L.G Rohan Los An gls). Coursy of Dr. Stphn L.G. Rohan, oran Caorna
ncesed pbby hvng pstve HA B 27 90% n nysng spndys, 7 5 % n pstc thpthy nd -
-
Rei ter' s syn drome ).80,88-92 ky Sdy (S
Anysn g spndyl s s nt n fequently fund n pents wh see chprctc cre. Is usul nset s n yung dus, nd t s pedmnnty me dsder 3808990 he usu sgmt e btel nd reltvey symmecl scrlts, squng f veteb bdes ntery nd syndesmphyes th e thn nd usuly symmetc, nvlvng bth sdes f the spne. The scrlc nmmtn ffecs he synv ptns we tw hds he jnts nd my begn un ey b tely, bu nt symmetc y Hwever, ely n, he n mmtn w l becme b e nd symmetcl nd dvnced stges my nylse he bus prns f the jnts s we s the synv sectns 38090 seudwdenng f he jn spces due t ersns tcu surfces nd ben f the whe lne tht shud be und n the c sde f the jnt e ery sgns The prgessn thugh eguy nd sclerss f jn mgns evenul yl ss my e yes. he eles spn nvlvement s usu y
hclumbr r smetmes umbsc nd he chnges my pgress cudlly cephcy, n bh decns8 90 sns t he dscvetebl junctns the cners f he vertebrl bdes, he mnus esn, cuse the ppence f "squng f bdes80889 As he esns he, scess vetebl bdy cnes nwn s he "shny crne sgn be cmes evdent680 rgessn t sscn the uer nnuus cuses bny bdgng f the nerspce, hese shee ssfcns beng cled syndesmphytes, cntsted t spndylphytes th re due degenetve chnges t end plte mrgns Syndesmphytes re prllel t he ds bders, wheres spndyphytes re evey pl e t he end ptes Evenuly, the gmentus strucues t cet ns, temed he l ey tc sgn ,80 nd even he nte nd supspnus gments my ssy. hs dstnctve ppence hs been cled he "dgge sg n.80 he dsese my dvnce t nvve much he spn cumn, bu t my stp spnneusy t ny pnt n me338090 Anylss, f cuse, s ccmpned by hypmblty, nd steprss fm c f mvement s en prmnent nd my ccur ery. Bcncvy f veeb bdes n nylsed res s n nequent. Due t the fgty nysed prtns f the spne, fctues my ccu ht e chrctestcly trnsvese nd hve been clled "c stc fcures.8These e ess cmmn n the w bc hn n the cevc r thcc egns nd n he umb spne my n be ccmpned by sevee symptms.8090 ue t enylse fe such fctures ccurs nd esuls n pseudrthss tht my requre surgc stb zn.8090 Appxmtey 50% f AS ptents wl s devep thc chnges n perphe jnts, mst cmmnly n hps, shulders, nd he ccneus808890 These e esve nd enthespthc esns nd my be que destuctve gs 3 38 339 nd 30) e pahc Spdypahy
When dsese f the gsnesn ct s ccmpned by spnl chnges denc t thse AS, s ced enepthc spndyphy. he fndngs n he spne cnn be dsngushed frm thse f AS8 93 Pac hpahy
stc rthrts resembles heumd hts n sme especs n he pepher seen nd hs sme esembnc AS n the spnl c umn Scr s, whch s usuy bt er bu symmec, s und n 30% 50% f pepe wh pstc thrs.809 Occsny, unel nvvement s fund Spnl nvvement s me cmmn; up t 60% f hse wth sn esns exhb t sme spn dsese809 Asymmec nnmrgn syndesmphytc chnges e he ms cmmn mnfesttn nd ccur mst frequenty n the uppe lumbr nd thrcumb egn.809 These psyndesmphytes begn f m the verteb end pe nd ny ppe s flufy r thn cuvne pveeb clcfctns
Imaging the Low Back
A
B
c
D
91
Fig. 3-3 Ankylosng spondyis A Ahogh he patient ad cronic backace and s iness his lateral (AP ) vew sows no signs o he dsease except for early squarng of veebal bodes (8) No sacroi iac di sease or syndesmopyes are apparent at is ime C and (D are the same paent en years ater C In his laeal View Te ypcal stigmaa o Ankylosing spondyliis ae seen w syndesmophyc changes bridging the disk inerspaces roghou e lumba region. (D) The AP now is aso ypcal of he dsease, compete ankylos s o e sacoi iac joins avng occurred and he ypcal "bamboo spine appearanc e seen
9
T w K PES
Fg 339 Saroiiis vs osits onnsans ilii. It s sotis iful to irntiat bwn blatral sytal saoiits an ostis
onnsans l i his pts xtnsv b latal syral saroi its Both sis o th jons a at, h joint agins ar irrgular wih rosions, an soss as th saru as wl as th i i Ostiis onnsans i l i ay s u a saol iis bu only th l ia ss o th joins ar at Cmm h sross ay b floi or l, but is onn to th li, is usualy sytal an ypialy has a tangular onguraton. h joint argins ar not o. OCI is usualy oun n ultpaous won an n os insans rgsss a yars, sp ialy atr nopaus.
that vtaly bco raivy thick boy xcrscs aris ig fro th vrtbra body ar th d pats. Thy ay or ay ot bridg th disk i trspac A parasydsophyt that bridgs th irspac bt shows cavag btw islf ad th vrtbra bodis is cald a "B ywatr sDixo or floatig sydsophy Qit ifrqy psoriaic sydsophyts ay siat thos of AS bt th corr chags that ar fod i AS ar ot s with psoriatic spodyopathy (ig. 3). Rr Syndrm
A triad of cojctivitis rthritis ad poyarthritis is h critrio for Ritrs sydro Th svra titis that copris h sydro ay ot a b prs sitaosly. 9 Th sktal aifstatios of Ritr's ar fod i th thoracobar ad bar spia rgios i th sacroiiac joits ad i th owr xtritis. Sacroiiac ivolvt ay b prst i as ay as 50% of thos with th disas.2 Row ad och rport that radioisotop stdis hav idicad
tha p to 70% of hos with h disas hav sacroiiac i vovt tha ay rsov wihot visib pai fi fidigs Sacroiliac disas i Ritrs say is prdoiay iiac ad is s as rosios variab scrosis ad atratio of h joit spac vov ay b ilatra or biatra wih biatral ivolvt tdig to b asytrica. Akyosis is o as frqt as with AS Spia chags td to b parasydsophytic idisigishabl fro thos s i psoriaic spodyopathy S pi a iv ov is o as frqt as is sacroiiac disas 2 (igs 3 ad 33) DEOSTON DSESES NVOVNG THE SN OUMN Gu
Goy arthriis ifrqty afcts th spi or sacroiiac joits4 bt wh it dos th aifsatios ar siiar o thos i prodcs i othr aricaios. oi spacs ar s
magg he Back
Fig 3-40 Lae aylos ng spody iti s In lae stage AS there ay be
akyoss of faet joits ad spios proesses as is shown i this f. C he spnous aky osis has bee ale d the dagger sgn and when t is aopanied by faet ankylosis the ter "troley trak sign has bee used
ay preserved. Erosons adjacen o jons ha e venua y ay desroy he on so ssue or even nerosseous oph chondrocacn osis and sceross assocaed w h avascuar necross are radographc sgns accopanyng he dsease. Hydxyapaie Depsiin Disease HDD
Hydroxyapaie deposon n degeneraed or naed ssues or boh is coon n perphera jons accopanyng burss endns and necross n he spne ay occur n he nuceus puposus or annu us brosus.8 I s aso encoun ered n endons and gaens aachng o he pevs and he eora rochaners eposiion n he nuceus n chdren s usuay accopa ned by acue sypos o ever pan and resrced oon ncrease n he di sk space is usua and sypos usuay resove n abou wo onhs.8 Nucear caccaon n adus s usuay asypoac and osy s secondary o degeneraion sequesered dsk rag ens b ock verebrae or eaboc dse ase.8
93
Fig 3-4 Asyetra saroiltis (psoriati arhropathy. Anylosing spodyits is anfest by biaeral syetrial saroiii s, athough i the earl y sage he ndg a y be asyera . hi s radiograph of a person wt h psorai arhropahy l lustraes oderae y advaned asyetria sarol iis. his radiograph of a perso with psoriai arhropathy llsrates oderately advaned asyeria saroiitis.Asyetria saroitis beyond an early sage, however shold sgges oe of the oher seroegatve spondyoarhropahies. Psorat arhris and Reiers dsease boh frequety afes wih asyetrial saroa disease
Annuar caccaon s usuay degenerave and s ore coon han s nucear caccaon80 alcium Pyphsphae Dihydae Depsiin Disease PPD
Spna nvoveen wh CPP s nrequen The os coon ndngs ae dsk spac e narrowng vacu u pheno ena arked veebra body scerosis and oseophyes Annu ar caccaon ay resebe syndesophyes beng hn caccaons aong he argn s o he ds k Nucear cacica on s un coo n806 Caccaon o he gaena ava oc curs and ay be v sbe radographcay bu s beer seen on CT ages.8
94
THE Low K PV
Fig 3-42 Asymmetical sacroilitis (Reier's disease). There ae no radiographicaly dfferentating featres to distnguish sacroilitis fom
Reit er's d sease from hat of psoraic joint dseas e. Cl in cal fnd ings are the di fferenia ting factors
Fig 3-43 arasyndesmophytes () Thick osteophytic changes arising from above and below the veebral end plaes and paralel to the disk margins occ in psoriaic arhropahy and Reier s disease. C These may caus e ankyloss o may no completely bridge the interspace.
They differ from the spondylophytc changes of disk degeneraion whch ae parallel to he end pates and differ from he hinner syndesmophytes of ankylosng spondylitis which arse fom end plate margins and conform to the margns of the disks The floid parasyndesmophyes seen here were found n a paient wi h Reiters d isease alhough sp nal m anifestations are more commony found in psoratic disease than with Reiters () Occasional ly a parasyndesmophyte, such as s seen here, deveops whch is no atached to one or both vertebra bodes These may occur in eiher psoiatic arhropahy or Reit er s disease, but are more common wth psoriati c disease Comn nteresingy the patient depicted hee had Reiter s
Imaging he Back
Ohnsis
This is a rare heeditay disease i which absece of ho mogetisc acd oxidase resuts depositio of homogetisic acid i ti ssues causg oit di sease he spial maifestatos are characteistic8 Heavy plateie calcificatos with iterspaces parale l to the ed plates accompay vacuum pheomea, arowig of disc spaces, with ii ma margial osteophytc chages ultiple leves ae ivolved ad evetualy ayosis may ocur, whch may somewhat esembe AS, 8 although dis arrowig ad ac of sydesmophytes are dstgu ish g factors The sacoili ac joi ts are u affected acet it ad iterspious calcificatio are evetua fidigs Ex cretio of homogetsc acd i urie that turs blac with stadig is a id etifyig feature of the disease8 (g 3-4). SESES USNG OSTEOPEN N THE OWER SPN OUMN Osepsis
I the spie osteoporosis s characterized by decreased boe desity adolucecy per se, does ot coote os
Fg 344 Ohronoi. hi i rre dee in whih nkylo o ur de to liition o dk It rdiogrphi mnettion e oonl ly i lr to thoe o nky oi pondyl t but in mot intne hold no t be oned
95
teoporosis because osteomalaca, hyperparathyroidism, ad other diseases which diish boe mass are aso causes of radiolucecy he descrptve ter osteopeia s appropate as a geera desigatio of radoucecy with osteopoross reseved as a specifc diagostc tem Because of the extesive di scuss ios e eded to elaborate o the seveal causes of osteoporosis the imagig maifestatios wil be discussed a geeral maer, ot specificaly otig the severa causes, except i p assig Decease boe substace occurs with age ad wth di suse ad disease I osteoporosis boe uatity di m ishes, but the ualty of the remaiig boe remas ormal This is i cotrast to osteomalacia where the uatty of boe remais bu uaty is reduced Geeralized osteopoross s mos commoly a result of agg, especaly i postmeopausal females Geeraized osteopoosis may aso be foud maligay especaly mutple yeloma i which it may be the oly ra diographic maifestatio utl late i the disease, i prologed use of catabolic steroids, i Cushig's disease those o og\term hepai therapy, acromegaly ad aemas8 !OI Regoal osteopoross occurs with disuse, such as i mmobilizatio, ad i igratory ad traset osteopoross as wel as i refex sympathetic dystrophy (SD also ow as Sudes atrophy8 oca osteopoosis s see adacet o severe dseases such as ifecto iflammatoy arthtides, ad eoplasms8 osteopoross, the cortical margs, whie thied remai relatve y radiopaue as compared to the decreased cace lous tabecula boe i vertebal bodies As boe loss occurs ta becuar loss taes pace frst i the trabecuae that are ot uder (postural) stress he decrease i these trabeculae maes those remaig more vsibe he appearace of osteoporotic vertebral bodies is ofte somewhat pale or washed out with vertcal stiatos the spogiosa ad thi cortices that appear to be sceotc i cotast to the deceased opacity the bodies Bcocavty of vetebral bodies due to vagiato of ed plates s commo Compresso deformities with wedgig of vetebral bodes ad eve colapse to a vertebra plaa cofiguratio ca occur as osteoporosis progesses8 Isolated depressos of vertebral ed pates ae also foud due to ocalzed fractures with vagatio of di s material at t he fracture sites Spial cotours may also be altered, especially with thoracic vertebral colapse wich icreases the thoracc yphosis ad causes compesatory ateratio of the lumbar cofguratio Osteoporosis s maifested the pevis by esseti ally the same appearaces due to trabecuar loss ad elatvey greater cotical opacity (ig 3-5) t s im portat to remember that i cacellous boe it taes at least 30% ad sometimes moe that 50% oss of boe substace before i t is visib le radiographicay 8 or this reaso, it s risy to diagose osteopooss from adiographs uless it s blatat, rememberg that if the disease has progressed to the poit where it is obvious, it is uite ad
96
BK PV
racue are fequen. Hazy nebody cleo accompany ng compreon fracue due o hypeophc calu formaon moe common n hee deae han n verebra body co ape rom ohe caue o oeoporo80 A fndng n compeon fracure due o erod ue ha no ound n oher uaon an nerverebra vacuum cle gn here ga found whn he colaped verebral body.8 0 Hemlyic nemias
Fg 35 Avane osteoporosis. Deease boe ensiy whi h i s
not h geater tha t he opaty of he sof iss es a h i orties ae he spefi stigmaa of avane osteoporosis mmn It is important to ealize that at east 3%, an ofte greaer than %, loss of boe ensty is eessary befoe it is event fro raiographs herefore he agosis of osteopoosis fro aiographs anot be mae tl it i s fairl y far avane. Noe the exte nsiv e ath eoserot alifiato in the aora. It shol be reebere hat when thee s aheosleoti aiation a peripheral vessel the li kel hoo tha there is also s h i sease i oonary an/or eebral areries is qie high .
vanced Quancaon of bone ma by mean of ngle or dual phoon radonuc lde or adographc abopomery or by quanave C alow no ony comparon o he preen a u o bone quany bu alo by ea examnaon can race he proge or lac heeof wh paage o me58 Parculary n older women whee here clncal upcon o oeopoo peodc bone ma evauaon a worhwhle procedue.
he hemoly c anema ce cel anema haaema and heedary pherocyo, due o maow poeaon o ec ondary efec of he deae or boh, may caue vbe oeopen c pn al change. he change n halaem a ae he mo evere o hoe abued o hee deae. Generalzed oeoporo wh coaened abecuae and enaged vacula channel wden ng o he cancellou poron o he verebra bode wh hnnng of coce may progre o a "honey comb appearance affecng mulple egmen. he honey comb paern may alo be een n he pevc bone. 0 0 Pacularly n cle cel deae unque end pae deome wh cenal depreon poduce he H haped o fh veebra appeaance of vereba bode ha are neary pahogno monc of hee deae. nfarc n bone are common n he hemolyc an ema and n he pne ma ve n farcon may caue veebral body co l ape ha orunaey may be reored o norma hegh wh only mld edual clero eman ng 0 For unnown eaon hoe aced wh hemolyc anema have a predlecon for amonela oeomyel and pnal nvo vemen may occur. li and . iJuezae bone nfecon ha ao been documened (Fg. 36 Osemalacia
n cona o oeoporo oeomaaca characezed by decreaed bone quay bu peervaon of bone quany un l very lae n he deae. Oeomaaca due o nucen depoon of calcum n oeod ue and lealy mean of bone Oeomalaca n ch dren ce n adul here are many caue. Radogaphcally bone adolucen, and abecular paern are coae. here o of corcal defn on and peudofacue are no uncommon.83 Spnal maneaon ae conen wh bone ofenng adolu cency wh nvagnaed end pae verebral body colape, al eraon n pna conou due o veeba body deome. he dagno of oeomaaca rom pnal flm hazardou.
ushing's Dsease and Sed Osepenia
Cuhng deae and bone deae rom prolonged eod ue boh have al he uual manfeaon of oeoporo n Cuhng deae oeonecro no common bu n polonged herapeuc erod ue.8 Boh ene com mony caue bconcave verebal bode and compreon
Hypepaahyidism HPT/Renal Osedysphy
Hyperpaahyrodm acually a orm of oeomalaca. Pmay and econdary (enal oeodyrophy) hypepaahy rod m produce oeopena wh ch e ul fom nceaed oeocac acvy epecaly n ubperoeal ocaon Wd
main the Bak
ig. 3-6 Sike ell aneia he poleation of heatopoeti
aow ases oseopenia, and he esoption o vetial weighbeaing) tabeae alows nvaginaion and opaion of the end pates. he tabeae ae oase in appeaane. he ongaion of he vetebal bodis ay be aleed as i s i l saed hee, wth oss of height and d nease n hoizontal densons.
ening o acroi ac jon pace and irregu ar jo nt margn are reaive common nding in HPT and miar change ma be ound at the mphi pubi8 Lo o corica deini tion and accenuaion o trabecuae are common and nvaginaton o vertebra end plae occur in man ntance Sot iue calciication ma be preent and ma be extreme 8 0 Fg 37 and 38) TUMOS D TUMORKE ODTOS OF BOE
Fortunae pina tumor are not requen encountered in chiropractic pracce However ome patent wih uch pathoog w nvariab ee ch ropracic care and there wi l be ew practce ha do not ind at ea one over the ear Wh an aging popuation the requenc o uch incdent i near certan to increae n th preentaton there wi l be no atempt o dcu a nown umor or umorie procee hat can be ound in he ow bac n thoe tha are more
7
ig. 3-7 Hypepaathyoidis (H) gge esey spne. In hy
pepaathyodis esopton of ai in the veteba spongiosa and etention and even einfoeent adaen o he e nd pl ates ay est n the sped appeaane of veteba bodes ha has been alled the gge jesey spn e.
common wi l be covered t i alo worth tatng ha the ob o the chropracor a a primar heath provider i to ind no necear to mae a deiniti ve dagno o uch abnormai tie a umor and thoe entte reembin g them Maligna n Bne Tums Metastati Bne umrs
Approxmael 70% o all maigna nt bone umor are meta tatc50 uua ll rom carcinoma n t he pine he percenage o metaai probabl even higher becaue the pine i a major target region or o vcera magnancie The mot common prmar malignancie ha metaaie o the pne are brea protae ung idne throid and bowe 5 0 Sarcoma uch a Ewing and oteoarcoma on occaion ma alo metataize to the pine or pev 0 08 0 The dicover o metatai to he p ine i grave igning that he di eae i wel advanced Not in requen the t rea pai n aociated with a vicera carcnoma occur with metata to bone Bone pain i evere athough the umor in a vicu ma
T w BK PV
Fg 3 Hyprparathyroidis psdowidning of h sacroil iac
joints. In H piosal sopion of calciu may rsut n psudowdning oh sacroi iac joints a s s lu stratd h Anothr rqn finding wih H is xnsiv vascla calcification sn hr in plvc sot tissus.
au w ymptom unt ar avan In a bra ar noma aoun or up o % o bony aa wt pn t mot rqun 06 Tyro ny an utrn ma gnan ao unt or ot o rt 1 6 but a ung anr nra n womn mtata ro tat our w l ao nra About % o bon mata n ma rom pro a anr t lun g aount ng or abou % mor . 1 06 pn an pl v ar by r ot oo nly at ara. T mot rqun rou roug boo tra atat mbo po ng n v au ar/arrowr ara u a a vrtbra boy or t p v bon Otr paway or atat pra ar by rt xtnon or troug ymp at annl Matat on tn to b ulp an no nary n onguou ara o on b u ot ar axal. 06 Mtata o t pn wt xpton o a rom t protat narly away ooly106 n ma oo blat mtaa uualy rom t brat06 I mu b rmmbr ta w routn raograpy at la % an on mor an % o truton o anlou bon mut av tan pa bor t vb Coral ang ar v b wt mu l truton but oral nvolvnt n
mtata o not uualy our unt mulary a wl along Mtata o t ortx rty rar an t uual prmary tuor mtatazng to oral bon bronogn arnoma. 10610111 Wra raograpy no nv or v uaz ng arly bon ruon raonul (RN agng w l t u ang at an arly tag Rou n num bon an av bn a bng able o t % to % o alraon n bon abolm 106 1 1 1 PEC an ar v n mor n tv an mor unly n lon( Bau bon an a low wo boy magng wn aa up an partuary wn nown o xt RN an oul b u o ount t ara o nvovmnt CT uu n valua ton o tatat lon bng onrably or nv an raograpy n png on an mor p n n ng t n vovmn. M R vn mor ntv an RN a n a t avantag ta o tu nvo vmnt vry wll monrat. Howvr wol boy MR no prnly an opton o a RN magng mor appab o n an oa nvolvn wt MRI u to valuat p on y bon truon ta pa rom prur o tumor matral troyng t urrounng rabula w ooat atvy not parul ary nvolv 107 On raograp t rult n patrn o truton a av bn trm "oatn or "prav A otatn patrn aratrz by ragg ara o ruton ta rmb a woo lot ta a bn r by mo 11 patrn o ruton an alo b oun n oomyt appar an rb a pratv mor ub an mor ltal. Pra v an ta on a gon ar troug at bon t a bn ln o t apparan o many tny rl o troug t at ara may rult n mpl y a azy n n loo to t bon In bot moan an pratv truto n margn o on ar uualy poory n vn n tn t (al a on g zon o ranon bau umor matra nvang t aant bon (Fg. An unuua mantaton o mtaa to bon our o aonay w ung tyro or ny arnoma wn a arg xpan l bubbly bony on oun rar an utp poory n on ta ar mor ommo n ar a "bowout lon mlar apparng on may our w gant l tuor or wt a otary pamoytoma Ooba mata mu l ommon tan ooy a T nra bon ny n wt otoba matat a no a mantaton o tumor matra but rav lro n t at o o 106 (g. . Bau o t mx ooba an ooy on ar on n Inrang raopaty n a on or pra o otobla avy a gn o grat onrn n atng a n p o boy atmpt to rpar t a bon anr progr ng 1 06
magng he Bak
99
8 i 39 Oseoy mes no ( Oseoy esons e pesen n he e spe o he gh es nd hve desoyed he mgn o he lef pelv b. hee s so oseoy desuon n he ef pub body nd supeo us 8) In wo monhs he oseoy deson hs pogessed sgnfnly nd ef supebu desuon s now v sb le wh h ws quesonbe on he el e dogph
Bcs o th mchnsm o nvolvmnt i n mtsss o h sin thr r scfc rs of rlction for th l sons. Th mos common sit s th vrtbrl b bcs h s whr th grtst ccml ion of mrrow s fon n h vsclrt is grst. Mtssis o h vrtbrl bo m b ostoblsic or ostoltc; ostolsis is intl sn mor rntl. A svrl osoblstc vrbr bo hs
bn rm n "vo vrtbr 106 Fg. 3-5 1 ). In ton o msic crcinom vor vrbr m b to Pgts ss mhom (Hogkin s iss) mloscrosis or msoctosis.105 161 17 Anohr rnt si for mssis s icl. An fct cl m b ostoblstic or mor common osolic 105106 (Fg. 352 h bsnc of c is no crtn sgn of mtsttic os bcs
THE Low BACK AND PEVIS
B Fig -50 Osteobastc etasasis. () hs paten with prostate cacinoma shows osteoblasic foc in the ight ischum, the inetrochantrc potion of the right feur, and a uestionabl e focs in the l et i li m at the sacroil ac join B) sx months aer the lesions seen previously have advnced grossly and new lesions have appeared in nmeous locations.
agenei of pedcle occur t wi pedicular agene or ypogene tere i uualy eactve enlargemen and increaed radiopaciy of te oppote pedce (Fg . Wee a mng pedice i ound and reactive cange ae not een on te oppote ide, meatai mut e conideed nt diproven In paent under year o age pedicular de tuction may e due o aneuryma one cyt (ABC) or oteoatoma rate an to metatai A neura tumor extending trog a neura foramen i anoter poie cae fo a mi ing or eroded pedce.
Pimay Malignan Bne Tums Mltiple Myelm
M ulip e myeloma (M M te mo common prmary one umor 20 I raey found eore age 0, and t incidence increae maredy wt age Mutple myeoma occu more equently n male wt an appoxmate 2: raio 2 e caica adiogapic appearance of MM a een decred a multipe mal pnced o eon t n e pne punced ot leion are extremey ncommon In many
Imagng he Bak
01
diographs ha include the emora heads and necks esions may be visibe . Rarely (ess than 3% o those wih M M) scleroic lesions may occur. 5 1 hese may be singe o r muiple and the spine as been known to be invoved A single ivory vetebra as been seen wi MM and he dieenial diagnosis rom othe causes o ivory vertebra may be neay impossible withou biopsy. 5 1 Radionuclide scans ae not sensitive to esions o MM because the bone changes are oseolytic Excep in he rae instance o osteobasic MM the ony positive RN indings would be at racture sites. 5 1 11 C depicts lesions ha are not visible on plain im radiographs as well as those that are 55 1 MR ! due to its abiity to image marrow is very sensiive in detection oM M lesion s reveaing low signa intensity in marrow at on l weighted images and increased signal intensity wi weighting.55 Soiary plasacyoma is a locaized om o pasma cell proieraion that is much ess common than MM and hat re
F 3-51 Ivoy vetebra. Dese scleosis of a vertebra may occur with Pages dsease, osteoblasic metastass, lymphoma of boe, or idiopathic ally Wih Pagets tere s usa ly expasio of te vertebra ad the margis ae usually more sclerotc tha the ceter of the ve tebra body. With lymphoma fequely thee is scal opig of the a terio of te vertebra body due o pressure from earged ymp odes. Osteoblastc metastatic ad dopatic voy veebae av e o distguisig characteristcs e ivory verebra foud hs paet was id iopathic No pmay eopla sm was foud, there wee o other sites to sugges Pages , ad the paie did ot ave ymphoma. Biopsy was doe ad oly scleotc bo e was foud.
i not most cases he ony radiogapic indings may be os eopoosis wich at irst may be airly mi ni ma bu as he dis ease pogesses can b e severe eno ugh hat bone densi ty in veeba bodies i s not muc h geater han that o te di sks 5 (Fig 35. erebral colapse is inevitable and may occur a one o many ev els. he pedicl es are ess l ikely o be inv olved than he verebral bodies because they conain ite marow and wen hee is veteba body colapse withou pedice involvement it is known as he "pedice sign o multiple myeoma 15 (Fig 355) his is not an invariae siuaion many cases o pedice involvemen having be en repored.15 n te pevis sharply deined purey osteoyic esions o varying size but usualy smal and mutipe occur wi MM. Fe mus ae avored sies o MM esions and in lumbosacal ra
Fig 3-52 issig pedce ) he left pedice of L4 s mssig havig bee desroyed by osteolyic metastasis. is has bee descrbed as the oe eyed pedicle sig Cme. e pedce is a commo st e fo osteolytic meastasi s. e costictio of blood ve ssels a pedicle allows cacer cels the blood steam o lodge ad cause destucto as they pol iferate.
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Fig 352 8 and The oblque v ews show the nact pedces on the patents rght sde and he ms sng pedcle on the let.
Fg. 3-53 ssng pedcles, congena v s neoplasm. ( Oblteraton of the rght pedcle of L resultng from osteoytc metastass The lamna and spno us process have aso been desroyed Noe tha the oppost e pedcle sho ws no evden ce of reactve scleros s or hypertrophy 8 The lef pedc le s m ss ng, but the opposte ped cle s scle rotc and has hypertrophe d Th s s a reacve change due to the altered bomechanca stresses fro the longstan dng alteraon of anaomy Source: Reprnted wh permsson from TR Yochm Essentials ofSkeetal Radiology, © Wllas Wlns.
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8 Fig 354 Mutp yo M M ( Gnd osopn nd coprsson dforts t L nd L5 nonspcc fndngs n hs ptnt who hs utp yo Comn MM spcy n h spn coun oftn hs no rdogrphc nfston xcpt fo ostopn Th prsnc of Ut p co prsson fcturs prtc y f noncontg uous n n od r osopnc ptn shou d rs th possb ty of MM. 8 A v w of s pn
Fig. 3-55 Mutp yo th pdc sgn () nd 8) A nd t vws show cops of h vrbr body but th pdcs r prsrvd o ht vn h postro of th vrtbr body hs bn dstroyd wh th pdcs hv bn spd. o In MM row po frton y s n ths cs ds to bony cops Th pdc s, hvng n rrow rn vb Sour Rprnd wth prsson fo T.R oc hu Essn ofSk Rdioog © 19, Ws Wkns
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quenty ccu at an eaie age 051 2 (Fig 3-56. A patient with pamacytma i expected t hae the dieae pge t fu bwn MM e time with etha cnequence, athugh with adiatin teatment ugey bth a ma pecentage patient uie he ein f pamacytma i a itay gegaphic uuay expanie, teytic ein with ap bubbe chaacteit ic ten appeaing t be benig n The d iffeentia diagni incude aneuyma bne cyt the peudtum f hemphi ia fibu dypaia bwn t um f hypepaathyidim, and giant ce tum The pne i infequenty the ite thee ein the pei me cmmny affected Ostesara
teacma i a pimay mai gnant bne tum wi th fie ditinct cinica type (centa muticentic patea ecnd ay and extaeu) 1050702 f thee the centa and ec nday aietie ae the ny ne fund in the pina cumn with any fequency Centa teacma i the ecnd mt cmmn pimay maignant tum f bne 051071091 2 1 t c cu mainy by befe age but a ew cae pimay teacma hae been dcumented in de patient teacma in de patient i uuay ecnday, epeenting maignant degeneatn in a ein f Paget dieae, fibu dypaia in an techndma in an aea bne iadiated f anthe maignant tum. 15 107101 1 1 1 2 1 Cen ta teacma ny ey aey afect the pine ite but ha been fund i n the acum and the peic bne Becaue teacma i deied m undifeentiated cnnectie ti ue, the adigaphic appeaance aie accding t the pe
dminant tiue being pieated the hitgicay pe dminant ti ue i c agenbatic chndgenbatic, the ein wi be mainy teytic but if tebatic the ein wi be deney cetic Mixed teytic and tebatic ein ae cmmn Expanin the ein i apid and me tatai t the ung (cannnba metatai) i eay and etha. 05 10 10 2 Muticentic teacma i a ae manifetatin f thi tu m aiety. t i nt entiey cetain whethe the ein in thi fm the dieae ae ditinct imutaneu ci mutipe metatatic ein , athu gh thee ha been i nabii ty t identify a pimay ein fm which the the ae deied05 102 1 (Fig 3-57) n y a few cae f thi entity hae been epted but me hae ined the pine Chdrsarma
Chndacma may aie in any bne but i ditincty uncmmn in the pine 10507 1 2 1 2 Chndacma may be pimay ecnday and eithe centa (aiing in the medu ay ptin f bne) peiphea (aiing m the ctex) Raey, a chndacma may aie in extaeu t ti ue Mt c hndacma ccu afte age 40, and thee i a 2: I pedminance in mae 0510 2 1 23 The mt cmmn ite in ement f chndacma ae the pe i and pxima femu 1051072 bth f which ae uuay hwn n umbaca adigaph Secnday chndacma ccu in peexiti ng catiagin u tu m uch a enchndma aey techndma and a fm ein aget dieae ibu dypaia. hee i a much highe ate f maignant degeneatin t chndacma in benign catiaginu tu
Fg 3-56 amacytoma A arg ptatd radoucnt lion abov and mdia to th actabuum i a oitary pamacytoma a prcuror to
mu ti p my oma. Larg yi c l on ch a hi n old r patint vn though th margin appar to b dicr houd b condrd to hav grav potnial
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ig 3-7 Oteorcom Ti i rre ce of ml icentri c oeorcom Cmmnt Oteorcom re the mot poory diferentited eet
rcom nd proiferte one crtlge nd brou mteri cc ountin g for the vryi ng rdogrphic chrcerii c Courtey o Dr W im Litterer lizbet ew Jerey
os tat a n or nar axa ston tan os a ar o r al 5 1 7 1 1 Condrosarcoas a dstuc v roliatv sons and cacfcaton occurs in t uo a rx n wo ids of s uors 1 517 1 1 13 ig. 3-58 aaanc of "rings and acs n atrx s an nd cato n of a cariag uo and al catlag uors scaly in t axia skton, soud considrd ontialy algnant 5 1 7 1 1 Condoscoa scaly in coason to ososacoa and Ewings sacoa is faiy sow gowing ut astasis o t ungs is no un coon. ng ' Srm
Ewing 's is a gy aignan connciv issu tuor a s usuay ound n as al :a ratio twn t ags o 0 and . I s ar or 5 yars o ag or af 30, u a w cass av n rortd n t dly .15 1 71 1 1 t s classid as a "ound c uo along w MM an d non Hodgkins s lyoa Lsions n axa sklon ar o likly in tos ovr 157 1 is a rdicton fo at ons i nno inat ons a agt si, wi t sacu ss coonly invovd 5 1 71 a sions ar ar usua radograic snation s xd lytc and lastic and a aiv atrn i s frqunt F g 3-59 Escialy ci n cay difntaion fo ncton o lyoa ay a ol . " onion skn aaranc o rista roiraton w c s fqunly sn in long ons ay snt n t lv s E wing s is t os coon on tuor to as tasz to on w tastass o t sin c oon 1 57 11 Cannonal tastass to ungs ay occu.
g 3- Chondrorcom In condrorcom the neopic c-
ivity proliere ibrou wel crtilginou mteri rregur ccifiction wtin he neopltic crtige i freuent nd my be uite dene The rdiogrphic ppernce of "rc nd ring n he eion i chrcteritc of crige ed umor
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Fig 360 Fbrosrco hs xpsil rdoluct son th 4 vrrl body is brosrco mm Fbrosrcom is h
Fg 359 Ewings srco ) nd () A pl l d omo gm lustt ostolyc dstrucon o th 5 pdc nd porto o h vtl ody; mm wg s s ucommo th spi wn prst usully ctig th scu o ub spin Surc Rpntd with prisso ro R Yochu Essis fSk Rg © 9, Wlli s Wlks
Fbsaa ad Magat bus stta
Fbosacoa s a algnan or ha s osolyc b cas i polfas colagn s sally fond n ads and alhogh saly a pay o ay copica a prs ing bnign lsion 1502 2 is ncoon n h spn oc casonaly fond in h plvis Radiogaphcaly i pss as a paiv aa of dsrcon saly wih a so ss coponn ha ay b larg F g. 3-60). Scoday ibosa coa ay b fond n algnan dgnaon in Pags dis as fbros dysplasia and chonic incon 1 05 0 1 6 1212 Maignan fbos hsocyoa s a adographcaly ndsn gishabl "is cosn of fbrosacoa whch s own o occ in bon inacs 15 011 Fbosarcoas ar sa ly rla ivly slow n h pogss and asas a alhogh h a a w v y aggssv os ha asasz ay. Masasis o lg and vr s coon. Scv yphac asass aso occs.05 012 2
ost d td o th sk srcos produc g ign brous mril bu ot crlg or bo so tht its rdiogrphic p prnc is purly lyic s occurrnc i th spin s rr Surc Rpntd with pission rom R ochum Esis fSk Rig © 9, Wils Wlkins
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hordoa is a ra priay aignan bon o arsng fro noochoda rnans is a slowgowng ocaly ag grssv pans o ha saly has a larg assocad so ss coponn. Masasis s ncoon. Bcas is ogn is noochoda occs n h aia sklon p doany n h sacrococcyga and cvcocranal gons05012125 Fg. 36. s rpod o ak p a las 40% of saca ors1050 2 Mos chodoas a ond n psons bwn ags 0 and 70 b can occ a any ag. h s a 2 a pdcon.5 inicaly h o ay rach larg s bor bng dscovd. h sypos a sal y d o h fcs o h slowl y narging o on h adjacn s ss. Sacral os ay b ccnic b clas scaly shod b idlin h adiogaphic appaanc o a sacrococcyga chodoa s an pansil o conaining cacfcaon and ncopl spa wh aas of lyic dsc on and a consdab sot ss copo ha ay conain caccaon D o ca gas and fcs adqa vsaa io of h sacr/coccy s on dfic spcaly n a coronal projcon. lansing o h low ns pio o
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hve been epored n thoe bove O ye o ge. There i 2: e prepondernce 17 1 2 1 1 2 Pelv c bone nd verebe re oetie nvolved bt the oity o bone lypho re ond n exxil oction yphoto eion in bone re l y lytic w th peetive pen o derction bt y be blt ic erebrl or cl coll pe y occ he ete indiingihble o invoveen with ett or p cyo Up to 20% o ptient wi h Hodgkn y pho develop lyphoto bone diee prirly in the owe thocc nd pper lbr vertebe.1171 2 ot ch eon re oteolytc bt y b blic w th n vory vereb ppence Scllopng o he nteror or ltel pec o the nvolved veebr body chrcteritc bt n e re1 172 The pevc bone re occionly invol ved. Giant Cell Tumr GT the QuasiMalignant Tum f Bne
ig. 361 Chordo This pnsil tuor sn bov th opci fid blddr in this fil fro n ctory urogr hs id rdo pcty du o orphos clcicton wth in h tri C Chordos usuly ostolytc but frqnly contin ophous clcificton Th scrococcygl r is pdilctd si for ths r uors which ri fro noochordl nnts
rdiogphy or e o convenion or copted toogphy y be necery o deqtely evlte he tor ery rey verteb y be the te o chodo nd n vory vereb reled o chordo h been epoted 17 ete br chodo y be ethe lytc o bic nd hve no dioogc chrctertic o dtingih the o yeo or eti hodo one o very ew tor ht y nvolve contgo egen detroying the intevenng di. 117 Ndgkin 's ymphm fBn (Rtiulum Cll Scm nd dgkin s ymphm fBn
e yelo nd wng rco Hodgkn nd non Hodgkin ypho re rond cel or The oty o lypho ond in bone re econdry o ignnt ly pho n oher locion b l percenge re pr ily n bone.72 1 2 In nonHodgkn lypho o bone he ory o ce hve been ond n peron beoe ge 40 ptcrl y between ge 20 nd 40 b goody nber
Gint cel o etvely coon bone tor tht y ec the pine the c being he ot coon te GT i he ot coon bengn or o the cr 7 2 1 27 The bone o the pe v re occion l y eced nd rely vetebr y be i nvol ved Approxi ely 20% o GT hve ignnt chrcteriic nd hereoe l hod be condeed lgnnt nti l proven otherwie e pecy bece oe very benign ppering eion hve etized wih l ret 2 2 Biopy i necey o deterine ignncy o benignncy There i 3 : 2 ele predoinnce with benign GT b 3 predlection or le n he ignnt vriey 171 27 The l ge nge i 20 o 40 wih ew occrrng beore 20 or er 1712 1 27 Gint cel tor e expnle rdolcen eion wth thn cotce nd wi de zone o nitio n ro bnorl to no bone ggetng ignncy A "op bbbe ppernce i coon A in he exteite lc GT tend o be bicl occing ne the crolic oint or cebi17 2 1 27 Fg 362) The ore ggreive leion tend o be pely lytc nd ot te y be peen. erebl GT eeble oteobto o neyl bone cy nd rdiogrphclly cnnot be dieentted o thee. 17 1 27 Bengn Bne Tumrs
Ony thoe bengn o h re coonly ond in he pine nd pelvi w l be dced mngim
Hengio i he o coon benign pn bone t o 1 7 128 2 Mny l hengio cnno be deteced by pn il dogphy b T nd epecly re entve in her deection 1 171 2 Nerly l re ypto ic b with the rre expnile leion rcte or heor
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Fig 3-62 Maga ga ce umr f he acum Thi gr expaie epae umr a u be a maga gia ce umr Co GCT are reach h ze ahugh m ae expaie GCT i he m cmm beg umr he acrum bu GCT ae uai-
maga umr a he pbi f a maiga aure mu aa be ciere The acum i he m cmm ie r pa GCT. Cure D Wam E Lerer Ezabeh Ne Jere
rhge ympom my . 15 1 7 1 9 Mot pin eion re oitry but mutipe eion hve been epoted he rdio gphic ppernce c hceri c y rited or coduroy coth midy rdioucent veteb body or poron theeof bu occiony the neur rch tructue e ffeced ig. 363 nd 3-64) Other dee procee h reu in trted ppernce of bone imir to tht een in hemngiom re Pge diee nd modertey dvnced oteoporo. 99 5 1 i in gui h ng fetue re h the cortc hicenng nd bony epnion tht typify Pget re no ound n hemngiom nd oteoporoi i moe generized indng. emngiom cn be found nywhere n he pine nd occiony in the pev. Otechd d eedty Mutpe xtt M
Oeochondrom e eooe ri ing fom he urfce of bone They e compoed of bone wth crige cp nd repreent dipced gowh cige h polierte o orm benign tumor m Oteochondom re the mot common benign bone tumor bu e not common n the pne. hey e howeve no nrequen in pevc bone5 7 9 Fig 365 Athough oteochondom re n chdhood mot e not deected uni duthood Ecept n the pine une ge enough to cue n obviou defomity or ump or octed where they inteere with jo int functon they re uu y found eendipitouy. Spin oeochondrom uuy occur ner econdry oicion center nd my be rdiogrphcly pectcu but un e they er uncion o r cue neuolog c bnomity due to compreon re uuly nonympo
mc owever f rge hey my cue eiou vcur or neuroogic dmge or boh. 9 Mignnt degeneon o oitry oteochondom i rre 1 5 17 9 ig 366 Mutple hereditry eotoi o ced oteochon domt o o dphye ci i hereditry diorde whee oeochondom of vying ize occur n mny oction. There i no ml e or feme pepondernce but me eem o be more everey ected. 5 1 9 It uuy dicoveed n chi dhood ney wy beore ge , nd my be the cue o obvo u deformie o bnom jon uncion o both Pevic eon my be prtcury rge nd deorming. Spin eon my cue pn cord compeon. 1 5 7 19 Mignn degeneon my occur in up o 25% of hoe fected 15 1 7 1 1 9 Fg. 3-67. Oted Otem
Oteoid oteom (00) re bengn but fequenty vey pin fu bone tumo ht uu y occur in peon between the ge of 0 nd 25 but hve been nown to be preen n hoe beyond 30 Me re eced bout twice ten fe me 5 1713 00 n the pn e re oten dicu to be demon rted mny me equiing mutpe mging em. Pin rom 00 my pecede ny dioogi c mnfetton. he pin reed to 00 my be tibuted to mechnc poblem pn tin/pin or dik diee hu deying dignoi epeciy when the eon not ey pprecited rom rdiogrph 5 1 3 Spin 00 uu y ound n neur rch he pedce peferred e nd the u mbr pne i he mot common oction wth the crum the net mo common te 517 13 Pn fm e fequenty ndequte o demon
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Fig 3-63 Sm hmniom Th sion in th L2 vrtbr body is hrtristi of hmnom dispyn vti stitions wihin rdio un sion (th ordoy oth pprn. Cmmn Hmnioms, whn sm , my not b visib on pn fi m diophy nd r frun ty sn on CT nd R xm s whn not dttb on diorphs of th sm p tint. Hmnioms th most ommon bnin umors of h spin, pobby mor ommon thn s rizd sin mny r undttd rdiorphy
Fig. mniom. Anohr hmnom, s o found in L2. Th is oups rtr portion of th vrbr body nd is hfor mor s y sn
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. 365 Oochodro ii. Th chrcric of h rg c owr o r r ypic of crig d io wih rc d rg of ccfd r ixd wih rdioccy Comn: Th i d irrgr r o hi i o rhr i vigi o of poi gcy cry ic crgio io x cp or chodro i hd or hv ig poi
ate a te pina eion 1 1 (Fig CT i paiuay hepfu in oang he aiouent nu, whih may not e emontae with pain fm. he eo ounng he ni u i eaiv e athe than ue to umo one an may e mi o evee B Is (stem
Bone an ae no tuy tumo ut hei aiogaph appeaane eeme tumo aivity epeay oteoat metata o oteoi oteoma. Bone i an ae ete aea of ompat amea one in a oation whee hee hou e aneo one. Beaue they ae atuay noma one n an anoma oation, no ympom ae aoiate. Thei appeaane that of a homogenou eot fou S ize vay fom a few mi imete to poiy evea entimete epeiay in the pevi one, wit h vaiae hape ig an . he uh oe a eate o ighy piuate appeaane of he magn of the eion i haateii. They ae foun in a one, the vetea oy in the uma egion
Fg 366 Mig dgrio of oochodro A i oochodro rig fro f prior pc r h n idiic ordr priory d h pprc h op of h io gg ggrv r Cnt Thi w prov o dgrio of oochodro o chodrorco
eing he mot ommon pna oaton Neua ah an patiuay pee oaton may muae 00, t he ak of ympom make iffeentiaion fay oviou. Ostebst
hee ae ae te onefomng t umo an ae mot om mony foun in the pine 0 10 3 1 ioogiay ut not aiogaphiay, hey eeme 00 an fo many yea wee onee to e gian oteoi oteoma. hee ae painfu eion, ua y foun in t he neua ah. A hough the age ange ha een noe a to mot o eween 0 an 20 hee a 2: 1 mae peponeane 0 1 1 3 hee ae expane eion wih a thin ota magn. Mo ae puey aiouent, t a mote ai an yi appeaane may e foun. The a ie o m t ome ae age an have a oap ue appeaane, making he iffeenation fom aneuyma one yt ffiut 1031 Oteoatoma that ae mainy eoi o ou mang the iagnoi e toueome.
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th fs idtifictio of HME sy digos is. Th ggrssi v ppc of th righ isc hi s io d ir gur ccific io t th crtigious rgi of th so ifriory r ifsttios of high y gt trsfotio of this sio Comm Th pctg of ig t dgtio i H ME hs b rportd to b s hgh s 25%. () I ths CT sc of th s ptit th i gs dfi th sio d dpic ts gis d chctrisics bt th dos pi f diogrphy Not th xtt of t occfid crti g wi hi h so d th rdo distributio of th ccifid rs wih . Courtsy of D Stv o Woodd Hi s Cifor.
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codroa ar carlag bad or a dvop ro grow carlag ha dipacd. y ar hrfor oud ar py ad occr drig grow b o olary lio ar od i h hrd dcad r o al or f
a prpodrac.05107 codroa ar o od i h p b do occr i h pvic n.0507 Th apparac i a o a gograpic xpa radolc io w wldid arg ad a ac b pobly i corx. Fy prc how calcificaio ha ippd or pca Plvic lio wiho iral calcifcaio b driad fro fibro dyplaia ooblaoa ad gia cll
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Fg. 3-6 Sara sid sma This pan had pn pin pan in h righ pp sara aa. Th sn is sb and is indad by pni mas Th radi u n ara and h sma adipau nid us bnds wih h adjan ramn. Comnt Th usua hararisi s sid
smas in ubar bns a an aa aiv srsis ih a nids hih may b difiu visuaz. In a bns r in h anus prin ba bns h may b n ssis, maing h sns diiu dnify. Cursy Dr JF Winsin Lumbard Inis
or05 07 Oer deae or encondromao are tm ued wen tere are encondroma n mupe e Magnant degeneaon n encondromao a been tated o be a g a 50%11712132 Caragnou umor nea e axa eeton ave a greaer predecton fo magnant degenera ton tan toe a ae more perpera 05 07 Ane uysmal Bne Cyst (ABC
Aneu ma bone c ae not tue umo bu con of a cc cav t fe d wt bood e are expan e oap bubbe eon and were named for er radogapc appearance rae tan ter oog0507 Mo occu econdar n preextng or coexng eon 05 7 21 e radograpc appearance at of an eccentrc rapd expand ng adoucent eon wt a tn "bown out outer margn e corex n tac ertebra eon ae predomnan n e neura ac bu verebra bod eon do occur uua aocaed w a neura ac eon g 3-7 1 ) e adoogc appeaance ma make derena dagno om oteobaoma dfcu 0 07 Pev c ABC are pca bow ou eon and a be ver arge g 372). TumorLike Conditions of Bone Fg 3-69 Lag a bn sand. Th radipau sn n h f i m has disn bu srad margin s ypia a bn is and Comment Th i nian a sn f his s fm an sb as
us may b diiu . Th hmgn s maix and h s rrad margins a hpu i n maing h righ diagnss bu hn hr is unrainy a bn san may hp. [ mus b rmmbd hvr, ha in a sa prnag bn isands w i sh inrasd aiviy n adinuid xamnain.
Paget 's Dsease
Page' deae a comon deae o bone a vare n ncdence accodng to geograp and ma ave a fama predpoton erng potee for prevaence n ome geograpc regon and popuaon and pauc of cae n oer ave been advanced wout concuve anwer
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Fig 3-70 L4 vrtbra boy bo ia To tri wh thr a io o thi ort a bo a or a otobatic ocu ay b icut Th
rrat margi o th io uggt bo a but urthr imagig a poby a biopy may b cary to ak a t iagoi Coe Th hi tory a yptomatoogy ar vta to akg th ciio wht hr to proc with xtiv a xp iv urthr i vtiga tio. ompario with prviou i m i avaiab i vry impoat. Dpg o th c iic a pictur, a pro o watchu wait g ay b th wt approach
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Fg 371 L3 aurya bo cyt A) A xpai uct io i th potrior arch travr proc a potrior o th vrtbra
boy wa prov to b a A. ourty o Dr. Wiia . Littrr, izabth Nw Jry.
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w BK PV
Fg 72 Iia aeuryma be y A ae ai ue "bw u e te rht i ium mpre e the atea apet te paiie bae Commnt Te tuu brer with a ry expaie raiuet ei i haraeri a AC Curtey Dr Larry Cpetei ttbuh e yvaa
Ode pien e fected Pet' e n thoe unde 0 ye o e nd he ncidence e wth e. Thee : 1 me pepondence.15 16 Mot pten wth Pet d ee do not hve octed ymptom. In hoe who do the on o pin i mechnc octed wth the bony defomie nd otenin of bone Any bone my be fected nd invovement of mutpe bone uu thouh monotoic Pet doe occu he pine nd pevi e common e o invovement nd the dophc mnfeon e m o thoe in othe bone wth few ndn tht e typc of veebe nd pevi5 614 (F 7 The thd nd fouth u mb veebe eem to be pedleced te fo nvo veme nt e the pevic bone 15 Pevic nvovement my be o ne nnominte bone o he ente pev incudn the cum Sc Pet' whou nnomnte invovement evey common5 1 6 14 (Fi. 7 nd 7 In the um b pne "pc ue me veeb dit nct peentton whee he thicened cotex wth eltvey diolucent pono eu in the unuu ppence 5116 (F 7 Bony expnion i common wth qu in o the veteb body e peciy een on the el view Accentution of vetic t becue my mule the ppence o hemnom 5 6 Dene veeb ceo epeciy in monototc pn Pet my peent n ivoy veeb. n the few ntnce whee the Petic bone h not expnded the deenition o Petic ivoy veteb fom one due o oteobtc meti o odn ympho m when c opn of the veeb mn i not peent my be dfficut. 5 16 Due to the expne ntue of Peic bone pn tenoi my eventute wth eutn neuopthy 15 16 n the pev the "bm
in whee tbecu hicenn nd ceoi occu on he mn o the pevc im obtetn ohe' tedop i wenown mnifeton but i not pthonomonic o Pe' becue oteobic me my o ob ete he edop becul hicen in nd euiy with bony ex pnion e the h lm of Pet diee5 16 4 Pe' d ee nd fbou dyp i e nown the "et m tto of bone dee nd Pe' mut be coni deed n ney ny peentton of cleoc bone. 151 16 Pet' dee deene te mnntly n m pecente of thoe ficed he mlinn tnfomton my be o oeocom chondo com o bocom nd the ponoi i poo 15 1 1 1 Mnnt deenetion i indcted by viibe chne in Peic eion. he teton uuy ytc but my be ceoc o mxed nd ccompned by ocized pin. brus Dysplasa
Fibou dyp bone bnomty of unnown oiin whch my be monototic o poyototc It i elvey com mon ict on o bone but ely ect the p ne. 5 8 5 he pelvi howeve i occionly nvoved (F. 77 h my be monotoc ocu but pevc eion e moe e quen y ound n poyootc di ee he e n nce oveeb fbou dyp e ocited wih the poyotoc fom nd the veteb body fected the thn he neu ch.5 8 5 Monotoic fbou dyp uuy mne t bout e 4; poyootc dee wthout ocited endo cne dode t bout 1 , nd poyototc di ee wh endocne dode bou e Poyooic dee with octed endocne d ode i pedomnny eme ficion
Iagng the Ba
I 15
8
Fig 373 Pgt d. . xpo of t L2 vtb body wt goy gul tbc d ttd ppc wc xd to t poto c w t vtb body. Muc vdt tto wt t L3 d L4 vtb bod o p. Coent fd fd g cott cott wt Pg Pgt t d, bt t vtc tt tto o mct o mgom w Not t xtv ococ ococ cc fco t o d t dgtv dgtv dk ow ow g d ct ct to to 4/ 4/(8 T CT c of ot pt w Pgt d t u mb p pd to ow t bom tbcu tbcu to w t t f fctd vtb vtb body.
Fig. 3-7 3-7 Pg d omt bo Icd dopcty d co bculto cum d pub o t g om
fdg typc o Pgt.
6
THE Low BACK AND PVIS
Fig 3-5 Pa Pagets gets disease i omate boe vs. osteoblasti metasasis. Ireased radio radiopaity paity ad oarse tra trabeuato beuato i the i ium ad ishium of the right iomiate with obliterato o Kohler's eardrop as show i ths patiet oud represet either Pagets or oseobasti meastasis Cen The a k of boy expaso suggests metasasis metasasis but the distributio is mor moree typia of Pag Pages es Deter Determii mii g whether there there are are other areas are as of of ivove met ad f so he r haraterstis haraterstis is im potat ad may may deermie the diag osis wit hou further further ests ests The fia diagos s i thi s asee was Pa as Pages ges disease.
A
vertebra. L2 has thie ed s eroti trabeuae a the margi s o the vertebra body partiuary adaet adaet Fig 33-6 6 Pages di sease piure frame vertebra. to the ed pates a usig a "pure frame or eary "boe wt hi a boe appearaeCnt I a olde r patiet suh as is show here these d gs are dia tive of Pagets disease
magng he Ba
7
Fig 3-77 Firo dypaia innominat bon. A ptad radiocnt "moy or "grond ga apparanc in th triadia ara and pror pic ram o th t innominat bon prnt a ion o iro dypaa. Commen Not th da contrat mdim (pantopa in th acra pna cana rom a prvo myogram. antopa i no ong in a a myographic mdim d to i ow aorption aorp tion and h potntia to ca aachnoi aachnoi dit h nonionic conra mdia d today ar ar abord abord and xcrtd xcrtd in a hort im b id ct a i ncontrd ncontrd occaionay occaionay Wth th ophitic ation o MRI myogra myography phy now a pocdr pocdr ha i ony n nny ny d
u te oter orm of te eae have no mae or emae preponerance5 8 5 Caaulat kn manfetaton wt rregular orer (coat o Mane appearance) are frequen n frou yplaa hee fer rom te cafaua pot o neuroro neuro romato mato wh ch have mor moree mooh regua reguarr margn (coa o Cal Calforna forna appearance) 51 8 e raologc halmark of frou yplaa a wth al frou leon of one a raoucent moky or groun gla appearance wtn te leon Frou eon characertcaly ave a cerotc mar gn cale a rn o clero5 8 Area o cero a n area o gre greaer aer lucency w t n eo n o rou rou ypl aa may mulate the appearance of a mxe metatac ocu Sepaton wtn frou leon prouce a oap ue appearance Bony expanon not uncommon an can e fferenate from agec expanon y ack o coare raecular accenuaon an cortcal hckenng Becaue frou ue rep repacng acng one n h eae ony eormy eormy common 105 1 815 A wth aget eae rou ypaa mut e conere wh neary any clerotc ony anormalty an wth many raolucent leon Symptom n patent w ony ony manfeaton o rou ypaa are hoe ao cate wth mechancal ffcue ue to te one oftenng an eormty The leon temeve o no prouce ymptom une fracure occur Neur urjb jbrma
Neurofromao an nherte orer ta frequently afect he pne Cafaulat pot mutple of tue cuta neou tumor an one change charactere charactere e eae wt
0 of hoe aflce havng keleta anormale Aoug the anormalte are preent at rth they are uualy no covere untl early choo Neurofromato af 51 51 8 3 Spna man fec fec male an emale equal y manetaon etaon are kypocoo kypocoo uual ly n the lower hora horacc cc pne pot poteeror callopng o verteral oe an enargement of neura oramna o ramna oerocentral verter vertera a calo png may exten over evera egment ue to ura ectaa Eccentrc unlatera calopng occur rom neural tumor (umel tumor) tha are wthn te pna cana from nerve root an exten (Fg 7 through an enlarge neura oramna5 1 1 8 1 here are many exrapnal manfetaton of the eae wch wl no e e cue here here Sp nal n n ng oter than n the low ack are are more common han toe n the lu mopevc regon ere aout a ncence o malgnant egeneraton n neuro neuro rom romao ao 5 1 1813 SGNNT NDENT NDNGS
I mu alway e rememere tat prolem whch afec te low ack may e relate o vceral or vacular eae atoug te ymptom may eem to e of a muculokeeal nature Suc ente a aneurym of the aora or other veel colecytt or galtone or oth urnary tone or urnary trac trac eae or tumor l ver eae garonena deae or umor mut e conere n evau aton of low ack pan Some of ee may ave raographc manfetaon that can e een on raograp or oher mag ng tu e of he lumoacral regon (Fg 7 an 0 roper evaluaton
THE Low BACK AN EVIS
JJ8
A
c
of h L4 vtbral vtbral boy l to th CT a MR a a wh h rval a arg Fig Fi g 7 7 A Nurfiboma ( a ) Sa lop g at th potrior of ural tuor ("mbbl tmo hat ha o th vrtbral boy a arg h ura oam a t protru hough
magig he Ba
9
Fig 3-9 bdomal yst. ait yswall aifiatio in t lf
pp abdomn was fod s patt wos radogaps wr takn as pa of i s wokp fo bak pa in Cmmen ys was an iidntal fnding latd o t prsting symptoms b d madd frtr vala io was dmid to b a parat yst
o ow ck dioghs o othe imging exmntions must include ceu eusl of he visulzed soft tssues Susiious fndngs my eue uthe mgng o secl exmintons to ule out dsese ht my e o get sgn ficnce I s ncument u on the docto of chi ocic s ot of enty hysicin o e e o detect such nomiies nd if une o dequely dignose he olems o if the ien needs entve o comementy ce, to efe the tien fo such sevces
Fig 3-0 radopaity s in 2/3 a foamn ada o
postior of vtbal body was fond ata o t spi o P viw (ot avaial and rprstd a dy sto
B iomechnic o thologc olems in the his owe exemiie s eseci ly the feet nd nkles o n othe snl o musculoskeletl suctues s wel s system o neuolog diseses mct on he low ck nd mus e consdeed in evluon of ow ck olems ememe D ogn i n ogm on shoude nd ue extemity oems th we wee esenting egnning his ectue y sying: "Snce we e exmi nng ien o ue extemty oems we should egin he exminton t the logcl locionhe fee
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5 Yc u TR Gut G Kttn NW h tiltu vi w: cl l t t lubcl uctin App Diagn Iag. 1989 19
Hw W Fct flci yh & icncti i i nghy J inia ipi. chiv Ed 19 .
8. Jg S. A tas f Radigapi Psitioning a A natoY and Dvpnta Vaians Nwl Cn: t ng 1988
6 inbg R in R Hdgcc MW Sig wl ctd ll viw f h lbcl i: cd vw cy? AJR 199 1 1 ill A tas of Rngnogapi sition and Standad Radio gi Pd (th d S. Li : y 195
1
o BAC AND PV
9 Rowe Yochum TR Radogahic ositioig ad nomal aatomy. : Yochum R Rowe LJ eds Eni f Sk Rdigy d ed Baltimore Md Wi lliams Wilins; 1996 138 1 0 Howe JW Foeman SM Ge n WV J Advanced Imagi g Modalities In: Haldema S ed Pinip n d Pi f ipi d ed: Norwal Con: Aleto ange; 199 361 37 1389 I I Rothma SLG Glen WV Muipn f Spin Balimore Md: University Par Pess; 985. 1 Rascheig W Coelative mltilana comued tomogahc aatomy of the normal sine : Post D ed pud gpy f Spin Baltimoe Md: Williams Wilins; 1984: I-57. 13 Saio R Comuted tomogahic anatomy of the l umbosacal sie Post JD ed pud gpy f Spin Baltimoe Md: Williams Wilis; 1984 78-93 1 4 Kerbe CW Gle WV J Rothma SLG umba comuted tomoga y/Mltilaa reformatios A readig ime I Post ed pud gpy f Spin Baltimoe Md: Wiliams Wilins; 1984 155-1 74 1 5 Yochum R Bay MS Diagnostic imagig of the muscoseletal sys tem : Yochum TR Rowe LJ eds ni f Sk Rdigy nd ed. Baltimoe Md: Wiliams Wilins ; 1 996 373-545 6. Modic MT Masary TJ Ross S. Mgni Rn n Iging f Spin Chicago 1 Year Boo; 1 989 1 7 Edelma RR Hesseli JR eds ini Mgni Rnn Ig ing Philadelhia Pa Saudes; 1990 1 8 Sole W Geant HK Magetic resonace imaging of he lmbar sie In Weistei N Wiesel SW eds Lub Spin Philadel hia: WB Sades; 1 990: 30336 1 9 Ross S Masary TJ Modic M. Gadoini um DTPA-ehaced MR images o th e lumba sine Time couse and mechaism o enhance ment AJR 1989; 0:37. 0 Thall H Ziessman HA u Mdiin Rquii S ois Mo: Mosby; 1995 1 Lavede P Lowe Barer JR et a Galium67 cirate scanig i neolastic and inammatoy esios B J Rdi 1 9 7 1 ; 44: 36 Ghelman B Discograhy In: Kiu MR ed. Imging Mdii in Spin Did Philadelhia Pa Saudes; 1988: 538-556
33. Hadley LA Ani-Rngngpi Sudi f Spin 5th ed Sringfield II: Chales C homas 95 1 34. Howe W Deteminatio of lumbosacal facet sbluxations Rn gngi Bif Couci o Roentgenology Ameica Chioracic Assn. Aug 970 35 Yochm R Roe J. Eni f Sk Rdigy d e Balti moe Md: W ill iams Wilins; 1996. 36 Meyedig HW Sondylolisthesis. Sug Gyn Ob 193; 54:37 1 37 Bi ipi Pdu Mnu Des Moies Iowa: Ameic Chiroractic Ass; 1973 38 Cobb JR. Outlie fo the sdy of scoliosis A Ad Op Sug 1948; 561 39 Risse JC egso AB Scoliosis s rogosis. J Bn Jin Sug (A) 1936; 18:667 40 Eisenstein S Measemets in the lumbar sial caal in two racal grous in Op R R 1976; 1 15 4 4 1 Joes RAC Thomson JLG he aow lu mbar canal. J Bn Ji Sug (B) 1968; 50:595 4. MacGibbo B Fafa H A aiologic svey o various configations o the lu mbar sie Spin 1979; 4:58 43. Cox M Lw Bk Pin Mi, Digni nd 5 ed Baltimoe Md: Williams Wilins; 1990 44 Schmorl G Jugh anns H Hun Spin in H nd Di d ed New Yo Ny: Gne & Statto; 197 45 Estei BS SpinA Rdigi x nd A 4h ed Phila delhia Pa: Lea Febige; 976 46 M rray RO acobson HG Rdigy f Sk id New Yor y: Chuchill Lvigstone; 1977 47 Yochu m TR Hatley B Tomas DP et al A raiogahic anthology of vertebal ames J Mnipui Pyi 1985 8:87 48 Gou PA Dosal hemveebae A Op Snd 964; 35: 1 7. 49 Tii PG Wieser C Zin WM. The transioal verteba o the lm bosacral sine Its radiological classifcation incidece evalence ad cliical sgniicance Ru Rbi 1977 16 180
3 Aget Lae B magig of degeneative disc of the lumbar sie. Pgd Rdi 1987; 7:41
50. Gebe GM Yochu m R Rowe LJ Cogenial aomalies ad omal seletal vaiants In Yocum TR Rowe J eds. Eni f Skt Rdigy nd ed Baltimoe Md Williams Wilins; 1996: 197
4 Ninomiya M Man T. Pahoanatomy of lumbar disc eatio as dem ostated by comted omogahy/dscogahy Spin 199; 17 : 3 16
5 1 Rich EA. A f ini Rggy Idiaaois Id: RAE Pub lshig Co 1965
5 aharata H Sachs BL Siv ey MA et al he elatio shi of ain vocation to lumba disc deterioation as see by C/discogahy Spin 1987; :95
5. Nachemso A The umba sine-a orthoedic challege Spin 1976 1 :59
6 Weisel SW somas N Feff H et al. A study o comter asssted omogahy The icidence o ositive CA scans i an asymtomatic gou of atiets Spin 1984; 9:549 7. Fguso AB Rngn igni f Exii nd Spin New Yo Ny: Hoebner; 949. 8 Fergso AB The cl in ical and oetgeogahic iteetaio of lm bosacal aomalies Rdigy :934948 9 Rowe Yochum TR. Measuemets i seletal radology. In: Yochm R Rowe eds Eni f Sk Rdigy d ed Baltimoe Md Williams Wilins; 1996: 139196 30 Ban s S he use of sinogahc arameers i diag osis of lmbar ace ad disc abnormaiies J Mnipuiv Pyi Th 1983; 6: 11 3
53 Magora A Schwartz A. Relatio n betwee te low bac ai sydome and x-ay findings m. Sia bida occulta Snd J Rbi M 1980; 1:9 54 Oitsu a H Roentgeologic asects of boe slands Rdigy 1977; 13:67 55 Geesan A Steie G Knuz R Bone islad enostosis : Cli ical significance and adiologic ad athologic considertions Skt Rdi 1991 ; 0:85 56. Sic le EA Genan HK Hoffe PB. cresed ocalizaon o99M TE yooshae i a boe isand: Case reot J u Md 1976; 1 7: 1 3 57. Davies JA Hall FM Goldbeg RP et al. Positive boe scas in boe isads J Bn Ji Sug (A) 1979; 61 6
3 1 Hasson T Bigos S Beecher P et a. he lumba lodosis i acte ad chnic low ac ai Spin 1985; I 0: 54.
58. Rowe Yocum TR Trauma In Yochm R Rowe es E i f Sk Rdigy (nd ed Batimoe Md: Wlliams Wilis 1996: 653
3 Haley LA I ntevertebral joit s ubuxation bony imingemen a fo ramial ecachment wh neve oot changes AJR 1951 ; 65:377
59 Kiu M Kr iu R. Fractues o e lumba sie S/in Rngn 199; 7:6
Ian he Bak
60 Ch GQ Nots o typ of lxio frtur of spn Br J Rad 148 2 1 :452 6 1 Grtzn SD Sp upd: Clssfiion of hori nd lur r trs Sp 14 1:626 62 Ro R sdy o th his of spn injurs . J Bo Jo Surg Br 160 2:810 6 Ghwilr Oso R Bkr RF. T Radoog of Vrra raua Phidlph P: Sndrs 180 64 tls SW Rgogn Y Rogrs F t Th rdiogrphi hrtr ion of rst rtrs of th spin AJR 86 47:575. 65 kso' K rris Th srl rut is in uppr srl turs Radoog 182 145:5. 66 Rogrs LF. Radoog of Sa ua (2nd d) Nw York Ny: Chrhill Livingsto 12: I & 2. 67 Bokow SE Klgr B Spondyloisths s in th nwo: s rport rop. 1 7 1 8 1 : 7 68 Tur R Bno Spondyolysis nd spodyoisthss in h ldr nd tgrs. .I B Jo Srg A) 171 5 128 6 Wlts Wi dll E kson DW Ftigu frtu: Th si son i isthi spondyolisthss Bo Jo Surg A) 175 57: 1 7 70 Cyron B M, utto W. Th ftigu strngth o th lur nrl rh i spodylolysis J B Jo Surg Br 178 60:462. 7 1 Yoh TR, Row , By MS Nturl history of spodylolysis d spondylolisthsis n Yohu TR Row L ds. Ea of Sa Radoog (2nd d) Bltior Md: Wilis & Wilkis 16: 2772. 72 Fryoyr W Nwrg Pop M t l Spi rdiogrphs p tins wih low k p. J Bo IoSurg A 184 66 1048 7. Wddll G w l iil odl for h trtnt of low k p Wstn M Wisl SW ds Luar Sp Phildlphi, P: Sndrs 10: 8-56 7 Wisl SW Fffr L Rothn R. lur spi gorith n: Wistin M Wisl SW ds Luar Sp Phildlphi P: Sundrs 0: 58-68. 75 Grn SR rkowitz N. h intvrtrl dis n: Winstin M, Wisl SW ds Luar Sp Phildphi, P: Sndrs 10 6-80. 76 nsn MC, BrntZwdsji MW, Ohowski N t l Mgnti rso nn iging o th r sp in popl wihou k pin. N Eg .I Md 14 1 :6
12
85 Rsik D Nrorthropthy : Rsik D, Ni wy G ds Dag o of Bo ad Jo Dordr 2d d Phildphi P: Sundrs 1 88 5 : 1 54 1 85 86. Rsnik D Ni wy G Ostoylii s spti rthritis , nd so tissu ftion h xil sklto. : Rsik D, N iwy G, ds Dago of Bo ad Jo Dordr (2nd d) Phildlph P Sundrs 188 4 2647-2754 87 Rsnik D, Niwy G. Rhutoid rthritis: In Rsnik D Niwy G, ds Dago of Bo ad Jo Dordr (2d d.) Phildlphi P: Sundrs 1 88 2: 551067 88 Rsnik D, N iwy G Rhod rthri is nd h srongiv spodylorthropthis Rdiogrphi nd phologi opts. I: Rsnik D Niwy G, ds. Dago of Bo ad Jo Dordr (2d d) Phildphi P: Sudrs 188 2: 845. 8 il F i ll GS Bodr G Clini dignosis of kylosng spondyltis in won nd rion to th prs of B27 A Ru D 176 5:267 0 Rsik D, Niwy G nkylosig spodylitis : Rsk D Niwy G, ds. Dago of Bo ad .Io Dordr (2nd d) Phildphi P Sundrs 188 2 1 0-1 1 70 1 . Rsik D, Niwy G Psoriti rhris n Rsk D Niwy G. ds Dago of Bo ad Io Dordr (2nd d) Phidlph P Sudrs 1 88 2: 1 17 1-1 18 2 Rsik D Nwy G. Ritrs sydo In: Rsni k D Ni wy G ds Dago of Bo ad Jo Dordr (2nd d) Phildlphi P Sndrs 188 2: 1 1 -12 1 7. Rsnik D N iwy G E topth rhopthis . Rsik D Nwy G. ds. Dago of Bo ad Io Dordr (2d d) Phildlphi, P: Sudrs 188 2: 12 1 8 251 4 Rsnik D Niwy G Gouty rthrtis In Rsk D Ni wy G. ds. Dago of Bo ad Jo Dordr (2nd d) Phildlphi P Sudrs 1 88 : 16 1 8-167 1 5 Rsnik D Niwy G . Cliu hydoxypt rysl dposiio diss n Rsnik D Niwy G ds. Dago of Bo ad Jo Dordr (2nd d.) Phidlphi P: Sndrs 88 : 71 764 6 Rsnik D, Ni wy G Cliu pyrophospht dih ydr (CPP D) rys dpostion diss Rsik D N wy G ds Dago of Bo ad Jo Dordr 2nd d.) Phildlphi P: Sudrs 188 167-176
77 Gls GF Aaoa Ba of w Ba Pa Bltior, Md: Will is & Wilkis 18
7 Rsik D Niwy G l kptonuri Rsik D N wy G ds Dago of Bo ad Jo Dordr (2nd d) Phildlph P: Sudrs 1 88 : 787-1 80
78. Rsnik D Niwy G Dgrtiv disss o th spin n Rsik D Niwy G ds. Dago of Bo ad Io' Dordr 2nd d Phildlphi P Sudrs 1 88 1 481 56 1 .
8 Row L Yohu R Nutritionl toli nd dorin disordrs : Yohu R, Row L ds. Ea of Sa Radoog (2nd d) Btior Md: Wills & Wikins 6 127-170
7 Rsik D Niwy G Gurr t l Spl vu phon: ntoil study nd rviw Radoog 1 8 1 1 : 4 1
Rsnik D Niwy G Ostopooss : Rsnik D N iwy G ds Dago of Bo ad Io Dordr (2d d) Phildlphi P Sundrs 1 88 4 2022-2085
80 Row Yohu R rthriti disordrs : Yoh R, Row L. Ea of Sa Radoog (2nd d) Bltor Md: Wilis & Wilkins 16: 75-7. 8 1 Forsr DM Brown Radoog oJo Da Phildphi, P Sndrs 187 82. Row Yohu R ologil d vsl disordrs I Yoh R Row L Ea of S Raoog (2nd d) Blti or Md: Wllis & Wlkis 6 124-126
100 Rsnik D ogoinopthis d othr nis n: Rsik D Niwy G ds Dago of Bo ad Jo Dordr (2nd d Phidlphi, P: Sundrs 18 8 4: 22 1-257 10 Row Yoh R. ologi d vslr disordrs In Yohu TR, Row ds Ea of Sa Radoog 2nd d. Bltior MD: Wills & Wilkis 16 124-126
8 Bsh K Cown N Ktz DE t l Th ntrl hi story of sit ssoi td with ds pthoogy. Sp 2 17: 1205
1 02 Rsik D Disordrs of othr ndorin glnds d o prgnny Rsnik D Niwy G ds Dago of Bo ad Jo Dordr (2nd d) Phildlphi P: Sudrs 1 88 4: 2287-2 1 7
8. Row Yoh TR ftio n: Yohu TR Row L ds E a of Sa Radoog (2nd d) Bltio Md Wllis & Wilkins 16: 1 1- 241.
1 0 Pitt M Rikts nd ostoli I : Rs ik D Niwy G ds Dago of Bo ad Jo! Dordr (2nd d) Phildlphi P: Sundrs 1 88 4: 208721 26.
1 22
T Lw AC AD PV
14 Rei k D, iwayama arahyoid diorder and renal oeodyro phy Renik D Ni wayama , ed Dini f Bne nd Jint Dirder 2nd ed.) hiladephia a: Sauder 1 9; 4 221 9-225 1 05 ohum R Rowe LJ. Tmor ad umole proee I ohum R, Rowe ed etia f Skeet Radi 2nd ed) al imore M: William & Wlkin; 1 99; 95-1 1 9 10. Renik D Niwayama Skeea meaai n: Reni D, Ni wayama ed. Diani f Bne nd Jint Dirder 2d ed.) iladelpia a: Sauder; 19; 3945-4010 1 0 Reik D yriak M reenway D umor and umorike leio of bone: magig ad pahology of peifi eio Renk D, Niwayama ed Dii f Bn e nd Jint Dirder 2d ed) hiadelphia a: Sander 19 31 7-3 0. Wi ler D. wig aroma n: Wi ler D. ed Rdi f B e u r and id Dirder hiladelpia a: Saunder; 1 92; 3: 2422573 1 09 Wi e D. Oeogei aoma oeoaroma). In: W ler D ed. Radi f Be ur nd ied Dirder iladelpia a: Sauder; 192; 3: 1 9-2095 1 0. Deh A Renik D. Eenri orial meaae o he keleon form bohogei arioma Rdi 190; 137:49 endri RW Roger F Davi M Jr oral bone meaa Rdi 1 9 9 1 ; 1 1 : 40 9 1 1 2 MDogal lR . Skeeal ingraphy Weter J Med 199 130:503 13 Lerer WE Nulea boe anigSkeleal maging J in ir 190 3:7 1 14 odwik, W. The bone ad oin : ode ed n t f u r Radi hiago, I: Year ook; 1973 1 1 5 Reik D Tmor and morlie lei o of bone Radiographi pri iple. : Reik D Niwayama ed Dini f Bne n d Jint Dirdr 2n ed hiladelphia, a: Sauder; 1 9 : 303-3 5 1 1 . Renik D, Niwayama age dieae Reik D N wayama ed Diai f Bne d Ji Dirder hi ladelpha a: Sader 19 4 2 1 2210. 1 1 Reik D agighi . Myeloprolifeave diorder. : Rei D Niwayama , ed Dini f Bne n d Jint Dirder 2nd ed) hiladelpha, a: Sauder 9 4: 2459249. 1 1 Feldma F uberou ero i, eofibomaoi, ad fibro dypla ia. In: Rek D, Niwayama ed. Dini f Be nd Jint Di rder 2d ed) iladelphi a, a: Sauder 1 9; 40334072
I 1 9. Rek D lama el dyraia and dygammagloliemia Reik D, Niwayama ed Dini f Be ad Ji1 Dirder 2 e.) hiladelphia a: Sander; 19 4: 235-2403 1 20 Wier D. Myeloma : Wi e D ed. Rdi f Be ur d ied Dirder hladelphia a: Sander; 192; 3: 203925.
1 2 1 Mirra M Bne ur hiladelpha a: Lppio 190 1 22 udw g Kumpa W, Sin zger Radiography and oe iga phy in mlpe myeoma: A omparaive aayi Br J Radi 192 55: 13. 1 23 Wi lner D hondoaroma n W ile D ed Radi f Bne u r nd ied irder hladelphia, a: Sader 192 3: 210 220 1 24 Wi ler D. Fbroaroma. n: Wi le D ed Radi f B e ur and ied Dirder hiladepia, a: Sader 1 92 3: 221 -232 1 25 Wi e D hordoma : W ler D, ed Radi f Be Ur and ied Dirder hiladelpia, a: Saunder 192 3: 207-25 1 2 Wil er D. Maligna hemaologi and ymphod diordr of boe. n : Wilner D ed. Rdi f Bne ur a d ied Dirdr hia delphia a: Saunde 92 3: 259-2945 1 27 Wiln er D. Maigna gia el mor n Wi er D, ed. Radi f Bne ur nd ied Dirder hiadepha a: Sauner 192 3: 235-23 1 2 Wi lne D eig vaula mor ad allied dorde of bone. In : Wier D, ed Radi f Bne ur ad id Dirder hila delpia a Sader 1 92; : 02 1 29 W le D Oeohodoma In : Wi le D ed Radi f Be u r ad ied Dirder ilaelphia a Sader 1 92 : 2 3 1 30 Wil ner D Oeoid oeoma I Wilne D, ed Radi f Bne u r nd ied Dirder hiladelpia, a: Saunder; 92 : 1 44 21 3 1 Wilner D eig oeobaoma. I Wil ner D ed Rdi f Bne ur d ied Dirder hiladelphia, a: Sander 192 I : 21-20 1 32 Wilner D Enhodroma : Wil ne D, ed. Radi f Bne ur d ied Dirder hladelphia a Sauder 92 : 33 1 33 Wilner D Aeurymal bone y. I : W ler D, ed Radi f Bne ur and ied Dirder iladelphia a Sander 192 : 1 0031 1 03 1 34. Wil ner D age dieae of boe Oeii deforma) : Wil er D, ed Rdi f Bn e ur and ied Dirder iladelphia, a: Sauder; 1 92; 2: 1 4-1 750 1 35 Wi er D Fibrou dyplaia of boe : Wi er D, ed Radi f Be ur ad ied Dirder iladelphia, a Sander 192 2: 1443150 1 3 Wler D Neurofibomaoi. I: Wi lner D, ed Radi f Be u r and ied Dirder hladelphia, a: Sader 192 2: 155 1 1 45
Chapter 4
Muscle Testing
Msce esi ng is essenil in he exinin f ll sclskelel prbles A scle ibnce beces n ipr n becive inding wen i verifies sbecive cpins he bsevin f fncin ess nd plpin findings f scle weness is fnd be cs ive c i beces n i prn p he reen prcl . Tesing n individ sce is difficl if n ips sibe. When isling priry scle evling i wil inclde e secndry s ppr scles nd s bili zers f he p being esed The s deiniive ex n esing is Musles: Testing and Functon by endl. I Mscle esing is he cni nin f n ci ve veen by e pien wh ile he exine ses is r e ski l pvide esisnce Th resisnce shld be f diecin whee he pr being esed is in psiin h eicis he gees espnse f e priry scle The sk il led exin er hs cer ndesnding f he scles heir igins inseins nd fncin I is i prn bserve e pie n s er nd he bdy recin dring he es. Te veen f n r icl in eies pr iry nd secndry ves nd in sbilizers ecndy sppr scles sbiize he srcres pn wich he vers rigine A ck f nrl srengh in scles er hn he piy ve y res in cpensin dpin bnr recrien fr sbi izin by he eced persn. Tesing he piry ver y see nl ye be c cpnied by bvis s ifi ng f he b y give he secndy scles greer dvnge An bnl scle ecin sch s shking f he piry scle dri ng e es y be bserved Ofen in e presence f wek priry scle ere wil be n exggered ep sece he res e
bdy dring he es The prie ver y es wek in he presence f wek secndy scle h fils sece he priys igi n r exple esing he hip flexrs pss nd il ics wih wek i licsl is lbr n he ppsie side will esl in n ppren wekness. Observin f he pien will sw bnrl bdin veen dring he es T efecively es sce he pien s ndesnd w is being dne nd w is expeced f hi r her ce he pien in psiin gives he s cle bein g esed e grees dvnge. Hve e pien ld h psii n y sing n pen hnd if pssible pply esisnce he pien is bee ble discern he d iecin f e ppli ed frce Gsping he re be esed cn cnfse he p i en s he di recin in wi c resis. Apply ligh presse insrcing e pien esis nd deerine if ny pin is e licied in w il l nege he es T deerin e he reli ve sreng f he s ce pply frce i n grd nner nil y hve sisfied yrself h he sce hs sficien srengh gives wy. I is bes es he sce severl ies nd cpre bierly r wih is ngnis r b where pssibl e Cpring bh sides fr signs wekness r ibnce is essenil crec dignsis Mscle blnce n srengh is e key cf nd nrl fncin y esi ng he scle sevel ies i n rw re ccre ssessen cn be de. he scle ess wih in nr li is he firs i e b wekens n sbseqen eps i cn be ssed be dysncinl The bec f scle es ing is n vepwer e scl e b deemin e wheher he m scl e respnds i n nner h ppes nrml fr he pien Age sex nd generl bdy
23
1 2
T H L ND PVIS
ype of te pient s be consiere. ven srong tlee cn be ssesse wi proper ecniqe. Testng sces n is fsion c be resonbly objectve s long s t e exiner is crefl to keep ope no lowing oter evton fings o prece is or er expecions. xperence n prcice being cref o se conssen pressre n est setp g ve e ex er te bl ty o obecfy te procere. As stte prevosly pin neges te test. t s portn to observe te pient for signs of boily pin s wel s fcil expression in response to te es. Pties re often rectnt o report pi n ey so be i fore to relte ny syp os to te exiner t i s i porn o know te poin n te est were te pin is note. Te octon n fcionl point of pn wil be por in forio n e ignosis e png locte sc e ter teno ti s or brs iis. Pin wy fro te re being este y incte proble wit te spport strcres. Recrtent of oer sces my be necessry for te ptien o perfor e tes t. Most ov eens of te boy re crrie ot sootly wi ese n strengt gins vrying egrees of resstnce. n e presence of pin join ysfncion or wekess e boy co perfor nor ly n i s force to se lernve eos to cieve te esire fncton Te norly soo cion gives wy o n obvosly pive ct o. Te boy y s t o est bis new point of stbiiy. nsl ovee of oer scles y occr to provie beter sppor. Tere y be eviton n te recion of resisce wy fro e expecte irecion of e es. Te boy "cets n orer to cieve e esire ction or response Te cetng s qite nvilize n cn be sbtle. Te experence exiner knows wt to expec fro norl fnctoing oy n sol be be o re tese teps to cet. To etere weter seconry sce is t fl pply n ssisce to e sspece scle or o is job by sbil zng te strctre wle retesng te priry scle Wen sce ests wek go te orign insertio. Go ng i s rp eep osci lti ng pressre sing te finger or tb p witot lowing e cotct to slie over e sk. f e scle s l srec, i y not be wek wl respon o gong tt will stilte te Golgi ten o orgns n "rese te scle. ees sever ies. f e sce s rly wek i y see norl on e rst es bt weken qickly. Wen te wekness i s fon tere re n er of possible cses to cosier. A sce cn be wek fro ck of se y pie nt. A scle y be srece s reslt of oss of se n orl bi ptterns. or expe e bo in ls ri ng pregncy re srece n e ot of se. f tey re o elibertely resore by consstent exercise postprt tey y ren cronc lly wek. Tis i s co on fini ng in woen Anoer coon stt on is n overstrec g of te popltes scle w t excessive yperexten
sion of te knee s i n s tin g w t e eels o footsoo n te knees nsppore in yperexenson. A mscle y be wek fro loss of nor o lgne t cn ter te fcr of cton. Hypertoc sces wi l ofen test wek. p in sblxt on y weken te nerve spply o scle. ions c ni b scle fncton (see Appenix A. ixtons re spin rclios tt ve no oveet b re not ecessrily o of gnent. Dr. Logn fon in is clcl reserc wo fxion ptterns t cosstenty cse specfc scle recions. Oe is n nerior fixion of e s wi te occp csg wekness o f e orsifexors of e foo. Te oer s fixion of L5 csig wekness of e gltes xis. ixion teory s proven consstent in te clnicl setng. y ele explnion fro prely ntoc perspectve, bt is wort consi ering for frter reserc. Orgc probes cn ec scl e fncton (see Ap peni x A. nry to sce cn ffec streng. A ior str itot fiber mge cn cse prolonge nerfnctonig n y respon to il exercse. A l srin wi fber mge y test t 80% of norl wiot sgnfcnt pn. A oerte strn wl es wek or so l te fncton n eonsrte plpbe pn evere inries cn cse is rpio of te sce or eo n reqre srgcl repr. Mscle nry cn be ers n e bely of te sce t te sce/tenon inerfce or t te teno/bone terfce. n exning e sces bnor fcton wl e to n nvesigton of l te fctors ffecing teir fcio n o ignoss. MUSCLE EXAMINATION
Gluteus Maximus
Te g tes xi s (i g. 1 ) is e piry exensor of te ig n is teste wle e ptet is proe. Grsp te nke n flex e knee to 0 en li f e tig of e tbe (g. 2) Te exners oter n so stbiize te lboscrl re. Te ptent sol be rexe ecorge no o elp Ascerin f tere s ny i scofor n sk te ptent o tep o ol e leg in e eevte posiio. e e ptie i s secre es te sce by ppyng pres sre ginst te posterior g st bove te knee. Te pres sre is in e irecto of fexion. We n ifing te tg fro te tbe noe ny ler ev tion. An iee "poppng ot of te knee terly ctes probble pirifors ypertonicty (ig. 3). A ore gr l erl ev ion s te en poin t of i ft is rece sggests e xis iself y be yperonc. Wekness of e corterl qrts lbor (QL w rece e spport neee to sbilze e low bck n pevs lowig te xi s to fcion Grsp te Q L n ssst t w ie testng
Mue Tetng
12
assive ip exensnlaea flare f ee niaes pii fis r gles axs ypeiy
4- Ge axis lef sperfiial g eep aaets
posio otion fixion of L on h opposit sid. Wnss n lso b found with post o mnstu pobms s Appndix A. Gluteus Medius
Th mdius Fig 4) is mo bduto. Th ntio fibs ssist in mdi oion nd th postio fibs ssis in l ottion Th bs wy to isolt thi s musl is w ih h ptin lying on his o h sid H h pint bnd th und lg. Th xn should sbiJi th pli s wit h th fr hnd. Ts th sid ht is up by bduting th lg with sl ight
2 Glues axis es
th mxim us. If th is btt spns o h QL. Th gluus mximu s i s in nd by fibs fom L, S 1 nd S2 i h infio glut n. Fixion hoy finds bit wnss ssoitd wih n upp i xtion s Appndix A A u niltl wnss n b fftd by
Gtes es
126
T w
N
EV
extenson and lateal rotation. ppy pressue near he anke in the dietion of addution and lexion (Fig 4 5) This s the priay aeal stabili er of the pel s and sho uld be srong in orde to untion noally. luu nmus
The inus (Fig 46) is he prary abduor of the eg. The est is done wih the patent i n he sae posiion as or the edius est The upper eg s paed n neutral abdution (no exension or roaton) Pressue s di eted ino addution w ith sight exenson seond ethod of tesing s wih he paient supine The eg s abduted and ressane is appled aganst addution press e (Fig 4 )
7 Gteus minimus estpaen spine
Prformis and Laeral Roaors
The pirforis (Fg 48) is he ajo atera rotaor. I s ipos sibl e to isoae i fro h e oher u ses in th e goup the uadratus feors, obtuaors and geeli netunng a dagnosis of these usles an be done wth areful papaon solating orgins and inserions hat ae reate. The patien s pone. Flex the knee o 0 Use the open hand against the edia ankle Fig 4) . Graspng the anke an onfuse he paient Make sure the patien t undersands the di retion of fore that is ateral The laea oeent s au aly edaly rotating the thigh Kendall I deonsrates ths tes t with he paien n he sttng posii on howeer Kend all te sts the otaiona aspet when he u sle is ati ng ore as an abduor is ore auate o est is abdution aton in he sitng posiion (g 0) Testing roaion n this po st on ay reoe the pii fori s to an extent that b ngs ou ore of the ohe ateral rotatores funi on
4 Gles mes est
Glueus mmus.
48 atera rtatres a prfrmis b. emeli qaraus femrs
Muscl Ttng
1 2
mim are oed Te te i te oppote o te poe piriorm et wi retae prere direed medially agai te laeral akle (Fg . 1 1 ) T e ere upply to tee mue ome rom 25 ad S l . Tere a orga aoiao wt e ieoeal ale (ee ppedix ) djtig T 2 l affet te leoeal ae ad appedx . Sarorius and Gracilis
9 Piifis epatiet pe
(
Te artoriu (Fig. 1 2) i ioled lexg e p ad kee a medialy rotate te ig ad wt e kee ex io ait i frter medial rotatio of te kee t i alo re poble for ifueg te la aeriorly i e eret poito Te grai i (Fi g 1 2) te mot uperfial mle meda ly o te tg t a weak addtor ad ait e am trig i kee flexio a wel a tabi liz ig te kee we te body i ere. t ao work w t e artori i medal roaio of te kee Teig eiter mle aloe di ffiu lt Wi t te patet i te upie poi tio pae e eel aboe te oppote kee ad abdut e ig approximatey 0 ae te patiet old t po tio. lae a ope ad o e media ape t of te kee igalg o e paiet at a abdio ad lgt exteio fore will be applied lae e oter ope ad aga te eel ad ake galig tat a preure to exted te leg wit igt abdio w il be made te pate ret apply prere i mul taeoly at bot otat (Fg. 1 3) Te kee ota wil gage e grail ad t e ake otat wi l gage te artori Wat for p port me dyfuto Te ip may exted to pport e grai i wi te addtor or te i li a may rotate poteror to ppor e arori
10 Siig pirmi es.
Te prform i ierated by brae from e irt ad eod ara ere ad i aoiated wit bladder problem (ee ppedx ). Mdal Roaors
Tere i o way o iolate diidal mue Te addtor petie l au ad fber rom te ge medu ad
1 Meial are tespaie pe
28
TE Low
B N
EV
weakened sartoius ust be consideed n erssten osteio rotation fixaions of te iia It ay also be a sgn of adenal robles (see endix ) If adena weakness s susected te secifc area to adust is T. Te nee suly for bo u scles s 2 and 3 te femoa nee
a b c
Tensor Fasca Laa (TF) d h
e
Tis uscle (Fig. 1 stabiizes e ili otba tact and asssts in flexon edial roaion and abducion of e tig Ts uscle s tested wit e atent suine. ase and s igty abd uc e eg o aroxiately 0 wi s ig media rotaton of te ig ressure s aied wt e oen and a te ane n te direction of exension and adducton (ig 1 ) Suot te elis on te sae sde Suot muscles
g
c
a
e
-12 Anterir view pelvic a thg muscles. a liacus b. psas, c. glueus medius ens fascia laa, e saius, f. ecus fems, g liba tac, aduc grup
g
1 Sarus ad gacls est
- atea vew pevc ad g muscles. a glueus maxi mus b bceps emis c TF d. satrus e. ectus femis f vasus laerals, g ltial tact
Muse Tesng
129
4-6 Act p 4-15
ude e uadreps o keep he knee exeded, he ado als o keep e pei s ro il g aerorl y ad he QL and ohe luar paraeea uses o sale he spe The nee suppy s fo e superio guea nere L, and S Oga relaioshp s w e age inesine is ofe suluxaed olo poes Addutors
The adduors i g 2 ) are a age ad powerfu group o u ses oposed o e pein eus adduors agu s ogus ad es and he gas These a e esed i e supe posio ul aerally on e ankl es n e dieio o adu o Tee soud e o oee ig 6). ore speif es s deonsraed i Kenda 1 The pa en s paed o is o e side The uder eg is addued up o e ale, wi he exaer suppog he uppe eg and appl yn g pessure agas e er aspe o he unde eg owad aduio g 7) The inneao is i a he ouaor nee, L3 and s ogai asso aion s w ih he eoe a ae Spef adjusig soud e dieed oward .
e adduo es The egs ae adued appoxaely ° ad he paie resiss a aep o ue adu e legs g 9) The ansersus peinei us onra fs o sail e e sia ueosiies Tis onaion alow s a ee suppo fo e adduors The nere supply is i a e peiea anh o e pudeda ere
ransversus Perneus
Hamstrngs
These uses i g 8) are dif iu o isoae Thei a o s os piay i n i ni iag adduio ro an adued posio The os spe es s done in a s il ar ane o
The hasrigs ig 20) arse ro e is a uerosy wi h he ieps ong head as o aepig ies fro he saro eous gaes Te so head of e ieps origaes on
4-7 Ac i pi
30
T H ow B D PVI
4-8 Infi viw f plv a a av pi, ygu
I
4-19 av p
he posterior eur begig at the owest iseto o the gltes axis. The setedioss ors the edia border o the pop iea ossa ad isers o h e ateroedi a t ib a i th e aea kow as he pes aserius The seebraosus ies deep o he setedioss. The biceps os he atera boder o he popliea ossa ad serts geeray o the ba. cig ogeher he hasigs ex the ee ad exted th e hip. With the kee exed he bceps is a atea roaor o the tib ia ad he edia hastrgs ae edia otatos. The hastigs becoe posteior roaors o he pes oy i s exed orward assstig i returg he peis t o e tra . th e erect posure he hastri gs' eect o pe ic otaio is iial i were sigicat here wod be a arge uber o he shoteed hastrigs od cicay which wol prodce a pedoace o poserory otated pees
20 Pi viw plvi ad tgh mul a. glt max m gali, atig d gl md latral rat f mima, g addu.
ayhig he opposte is he case May cases o hastig coracte ae see cicay wth aeio peic rotaios. The hasigs act as aea stabers o he peis the erec sace ad ass st i sh itig he peis o sid e to side The biceps ca aec the ibua ad co seqet y p ays a oe kee oot ad ake pobes To test the hastrgs hae the patet i the proe posto ex the ee o 0° The suppot had shod coer the bel y o the usce. ppy extesio presse wih he back o he wrst or had (Fg. 42) a spas shod occ ediately exted the eg ad appy steady pressure ateray acoss he be y o the sce Do ot atept to retest Testg he usces w th the eg at aryg ages o exio o 45° to 0° ca elcit pobes wth arious suctres at he kee
Mu Ttng
131
-22 Gnal t r qac fm. -2 amg .
To ephas e he edia hasrngs rotate he hi gh ed aly (oe the foo laealy. Ths brings the edal uses into proi nene and redues the bieps effetieness The la t ea hasings an be brough to pronene by roaing he thigh atealy. The nere suppy oes fro he s iati nee L S and S2 The hastings ae assoaed wih the etu and an be weakened by saral fxatons Qadricep Femori
The uads (F ig 4 1 2) are he pay exensos of he leg The reus osses wo jon ts, he h ip and knee and has the added oe of fexng he hip The uads as a group an be esed and he reus an be soewha solaed fo he asus group as wel as fo the fexor group (psoas and laus. To es he uads lex the hp and knee boh to 0 (pa ien supne. Test he hip flexors fs by pushng nferiorly on he nee n he dreon of hp exension before applying flexon pessue a he anke (Fig 422) Th s w i gie he exainer a bas dea of he sength of the hip lexos. If they appea weak i wil be diffiut o deterine the staus of he retus and nerfee wh sabl ng he body fo testi ng of the uads. To furher isolae he eus appy nferor exenson pes sue a the nee a he sae ie as flexon pressure is appl ed a he ankle (Fig 423) I f he hp fexors are fun tion ing noaly hi s w l pu he retus to wo. U sual y if he hp fex os ae noral and he retus is weak thee w l be noiea ble oeent of he pe s and e xagerated abdo na effor o opensate. The asus ateral is an be eph asied by edial y roat ing he foo and apply ing a sl ghtl y edial down ward pressue on he ane. The asus edials an be ephased wih latera
-2 Qua mpazg rt fm
rotation and ateal downwad pessure The oblue fbers of he as us ed ia is (YMO ae the ost inferor fibes ru nn ng alost lateraly fro the feur o the paela ny weakness of he uadrieps shoud ause he ex ai ner o s uspe he YMO first as t s he ore oonly dysfun tional pa of he asus goup and pays an ipotan pa in nee pobles To test for he YMO, hook he hub o the suppot hand around he paela infuening i edialy and sig hty superor whil e retesting the uads. If proeen is noed the YMO s weak and n need of treaent o exerse or boh. The nere supply t o the uads s 2L4. The quads are used as an ndator for nere roo opoise espeially of L4 djusti ng T 1 01 2 and l has ore often affeted quad one in inal experiene I s heoried tha spna fixaons an affe he segens and soai inneaons aboe or blow he ste of fxations. nother heory s tha he aual origin of he nere oos fro the spn al od our high er up than he r site of ext though the i nte ertebra foraen ( IYF; real h a
132
T Low
BA AN P
e ord end at L2 n te fiu eri nale). djust ng hghe up e pine an aet the nerve root at is oigin. The uad are assoiated wth the sa l intes tine, espeial y the duodenu ee ppendix ). ny weakness in the presene of dgeve dsturbane an be elped by adusing the owe ix orais. Psoas
Te poa Fg 424) orignates ro the ansvere pro ee bode, and dsks of the ve uba vetebrae I an be een as ve dtin ule lp s ha join wih he i iaus to or a oon endon i nert ing on he esser trohante of he fe ur. It often neesary to onider e sl ps separatey as it is oon o fnd he do ng derent thn gs Fo insane the L4 l p ae oe ike y to be hypeton, but the upper l ip ay be noral o r weak. Te poa fgures signiany in low bak pobles It is th e prinipal fexo of he hip with i s orgn fxed. I also invoved n abduion a wel as aera and edia rotation, dependng on he postion o the hip. Wt the inseton fxed, t flexe te ubar pne, and ang uniatealy i an lateraly bend te pine. ting egentay, t supports he ind vdual vertebra in i oveen s entioned in Chapte 1 , the poa an nease e lodoss by a opessive ation. Te poa i oten hyperoni , and papaio n of the in eron ofen panful. In the supne posion, a ypertoni poas use wi l exaggeate the lodosi, a rhing the bak and podung a gap between the bak and exaination abe To e e poa, the paten shoud be supne The es wi l e t e genera one of te laus and psoa. ase the eg wih
he knee sraigt to appoxately 55 and plae i in igt abduton and atera rotation Stabl ie te pelvis on the oppo site ide and appy pesue, at the ankle or knee eihe is appoprae bu ontat shou ld be onten t), i n te dreton of exenion with ligh abduion Fig. 425) Te evera es, and wa for weakei ng. Te psoas s innervaed by the eond and third luba nerves via the ubar plexus. dusting the T1 01 seg ents often aets the nerve oo. The psoas is alo weak ened by latera otaton of te eur and ateral tara ixaions of he foo. Te psoas s reated o the kidney ee ppendx ). The psoas and i liaus an b e teted wih the patient n he sing positon. ave the paen flex the hip and resis a downward pessue on the knee Fig. 426) Te L sip and iiaus an be isoated by eaning forward, wih edue he upper ubar s ips nfluene lacus
The laus originaes on he nside of e la, a broad at taent fro the aneior superor iia pine SIS) to te saroiia S) oint. It joins te psoa to atah o the lesse trohaner t is no readiy tested and ontrbutes to te general atons assoiated wit the poa t anterior fbes aso pul te iiu edialy Te dde and poeio fbe pu the l u anerory T e saral fber an in fluene te au anerorly.
424 Aeir iew: deep ses a qadaus m, lias pa
4-25 Psas est
Muse Testig
133
4-7 lag au an lr pa b.
4-6 Sg pa .
The 4 and 5 psoas sips and the aus an be isoated by testng in the sittng position and hang the patient ean fo wad elinatng the uppe psoas sl ps (Fi g 427). Qarats mborm
The Q Fig 424) oiginates on the iia est and ii olubar lgaent and nserts on th e tweh rb w it h anothe aye insetng into the upper ou ubar tanserse po esses Anothe laye often arises fro the ist fou ubas and inserts nto the last rib Its bas unton s onsidered to be puling down on the ast ib and ateraly fl exng the ubar spine t has iportant funtions i n stabii in g the u bar er tebae ontolng anteio and otationa nfluenes The QL s not auatey tested The ost oon test is to hae the patien pone tation he eg in feioy and hae the patient attept to pu the pelis ephalad. There ae too any support uses that an as a weaness The Q is oten weaened in low ba dysfuntons Weaness is de teted n ts basi tone The os auate way to aess wea ness s to test o tone [f the pei s s lee and fee of fixaton or rotation s or both gasp the supine patients ans and tation audad with enough ore to ro the pes and aost pul the patient fro the tabe ul with eual foe on both legs (Fg 428) I thee is a uniateral weaness the wea side wil deon strate an elongaton of the eg and an nferio i i u The wea
4-8 ug ry Q ala
sde w be pued down due o the a of tone ush the legs ephaad and ehe fo eel a ests and egs etest se era tes to oni r If the weaness is due to subluxation adjustng the ower thoras wi eiinate the in feior shift upon tes ting Goad ng the nseton on the twelth ib an iproe funtion but only teporary the usle s in need o exerise The QL is assoiated with the appendx It is i nnerated by the T2 and Abominals
The abdonas are oten obsered to be wea n en ue to a a of exe ris e and eerineas ng abdoi na fat ayers
3
T HE Low B D PEVIS
29 Adml mucl t mpzg c
and n women de o the ovetrethn o enany and a o exerie otarm The re, oblqe and tanvere are neeary o mantain a able low ba and ot the vea Tet the abdomna wth the aen itin wh e extended and am roed ove the he. Have he aent ean ba i htly. Stabi l ze he e and onta he oed am Attem o h he atien t down (F 29) A noma reone hod be no mo vement. Te he obl iqe and tran vere iber by rnin the aient o one ide and hen the oher and eea he te (i. 30) No movement hold be noed. The abdomna are innevaed by the T8T2 inerota and the iioinna and iliohyoat neve Thi mle ro i aoiated with the dodenm.
4-30 Adml mpzg lq vr gp
CONCLUSION
The me died n th hater ae thoe mo detly and mot ommony nvoved n low ba and evi ondion hold be eonized hat mle in the ne, e ba and hol de dle or below t he nee and ino he oot an be a ato in ow ba and e v roblem When evalaion ai o eveal i nian indn i n the mmediate aea he nvetaton hod move o te above or below o le o aa aor or nane, the oa m le an be aeted by d ahamai dynt on The laiim dori an afet the thid mba i dta n eton and thereby afet he lowe eeor nae mle nein at L3 rom beow Foo mbalane de to tbiai aneror or erone m e an et l mboel vi nio n
REFERECE Kall H. Musl Teting and nctio (2nd d) Bltio M Wil im & Wilki 97
2. Log . Th Kn liial Apet Gihbug p 994
Chapte 5
Adjustve Technques
The maniuation of te human body for he exre ur oe of reorin health i doumented n he earle of re orded hory. orm of maniulaion were ued in anient yt and Greee and the healn ar of he Orien tl in lude maniuatve roedure. n the nited State in modern hitory, Andrew Stll lned manulaton to the rnie of oteoathy. He founded the ir hool in 874 n 895 D. Pal mer founded he rn e of hirorat. He did not laim o have diovered manulaion but did aim o be the frt to ue he vetebra roee a ever to adut eif ement. He referred to adut in al artiu laion o he body in lu din he in e, evi a nd extremte. Over he at one hundre d year he h rora rofeon ha evoved a vared hoohy and methodoloy, ye Pamer bai onethe idea ha ariuar dyfunon eei aly of he ine an interfere w ith he flow of nervou enery omromin heathreman. Sei maniula ion o retore norma funion an ree the nnate mehanm alow n the body to be a heath y a oib e The hitory o hirorat a livey ubet, ful of are eo and tron diferene of oinion a to the bet way to exan an d imlemen reament. The onrovery bean w th ome o the firt tuden o a throuh he P almer Co llee. Wi ard Carver wa a ontant riti of Palme r method and wen on to found four other hirorati intitui on. Muh of the ealy onrovery ha le ft th rofeion d vi ded and ev en fraionated by hi oohal and ehn ia di ferene. In ite of hee diferene hirorat ha erevered a a val aernative to raditional medne. Dete the efort of it detraor to eradiae hrorati, t oninue o ee
rowin oula r uor and a rowin body of va id reearh that uor t hyothee A we ener a new era, tha of manaed are, hrora need o ontinue it efort to va idate and tandardie i eva uaton and reatmen roool n order to artiiate a equal. My hoe i that hirorati wi l develo t own rotoo intead of bein fored i nto or aei n medial model. The l of notabe ontrbutor to hirorat tehniue i lare rom D.. and B.. Pamer hrouh oeh ane Ma or Dearnette and . Metzner to Geore Goodheart and Alan uher, the and iene of maniulation ha rown. Many of the ehnique are touted by thei r uorter a he only v al d method of analyi and orretion. Wthout vaid reearh, uh a lai m i l tle more than bombat. n udyin th e variou tehnque, one mu h more iey to fnd val id b it and iee tha eem to mae ene and a ear to be lnially onitent. Out o uh reearh he on e of dverfied ehnique ha develoed. Thi looey de fned amaam o adutive tehnique wa named dverifed ehnique by D . Metziner. He beieved n earnin from anyone and everyone, tetin for himelf, and oetin the roedure that wored or hm. he ditled eene o hi wor, and the oninued onribution of many, i he diveri fied aroah. Dr. Metzi ner tauht at wha i now the o Anele Col ee of Chirorat in the 94s and remembered for hi ommon ene aroah o adutin, baed on a thorouh ommand of anatomy and what we now all biomehan. e develoed many new ad utve ehn ique or he n e and i redied with ioneerin maniua ion o the rb and extremi e.
135
J 6
T Lw B ND PVS
Dr. .L. Loan was a student and rote of D. Metzner. The onets desribed in this text are the resut o a ontinuum fom those who tauht Dr Metziner throuh those who hve lerned from Dr. Loan, who ontinued to efne nd dd to the body of nowlede nown as diversifed teh niue thouhout hs areer. There is no one way to move bone. Many of the teh niues tauht today have exelent ways to orret osseous di srelati onshis. They rane in iation from nonore or more arortey ow fore to an essive dynam thrust. The adust ive roedures i nl uded in ths tex t are those we hve found to be the most effetve. Whee ossible, alter ntve methods are desrbed. n u sn th s text ny method of mniu tion tht the eader feels w ll eetive ly orret the subluxtions desribed is iey to be as vaid as those nluded oweve am of the oinon that the more aressve (not neessiy forefu) the adjustment the more efetve and rid the imrovement in the atient. Dr. Warren Hammer who hs witten extensv ely on h irorati adu stin said: The soalled ainless entle nonfore tehniues used by rttioners who deride the sna djustment n neve be as eetive as the hio rt thust. aso doubt that the use of the ativa tor instuments oud stmute the amount o mehnoreetors that a ood od ashioned d ust ment s able o stim ul tin. The hiroati dustment by hand s the main stay of ou rt nd sene. I ea that the a of rofiieny and onfidene resent in many hioratos auses them to see alternative methods of sna e. [n studyin the ntriies of the neurohysoloal system nd how the body leans, t my be that the soall ed nonfoe tehniues my show reate resuts in oetn lonterm orioetive irreulites due to hroni subuxation t tes. ywernt wrtin on the Fedenais method of un tionl interation ludes to the eater infomation nut fom entle maniulton than from foeul aohes. It s my exeriene that ressive ma niu lation the oe of assi hirorati is efetive in restorin normal funtion when there is sinfant xation o ontrature of tissue round the ont in question. owever I h ave hd suess n usn owfore tehniues. t may be that owfoe adjustin my be more eetive n reestablshn normal neuohysoo funt on whi h in voves reenin oesses. t ths time, m of the oinon that ombination o aressve and ente tehniues may be the most efetive. These are areas or future eseah. Jt is iely tht the arnoia ove erval manulaton based on the erroneous assumtion th t there is va ld e videne of ossible harm hs led some eduators nd shoos to disontnue the tehn o effetve ervia manulaton and
to substitute autious aroahes tht my be less effetive. This ution in my oinon seas to an element in hirorati that wishes to have the snton of the estabished medal owers with no oue to stand u o hroti as an alterntive hoie in helth re. Most ratitiones today ave deveoed thei own stye of manilaton based on ther undeaduate trainin nd what they hve ied u n ostrduate eduaton. diversfed aoah to dj ustv e roedues shoud ive the ratit ioner a vaiety of ways to et a subl uxa ton . D ifferent atients wi ll resond better to di ferent tehn iues. n elderly tient with advned osteoorosis shoud not be djusted with a dynam thrust. lowe fore aoah woud obv ousy be moe jud ous. I oten use the sme basi aroah s with more aessve tehniques but edue the fore. On some oasions I hve used an mat tool (oen reered to s an tivator) an wth the bs setu substitutin t he i mator instead of a thust. Lenin djustv e tehniues out o a textboo is inomlete. Thouhout the hstoy of mnilative hein ulm inati n n h roati the methods were handed down by oneonone nstution. Ths is obv ously the best method Most of the tehniue texts have onsulted hve seemed stt istn ontat and stabiization onts with lttle ese to ive feel in of the dynams of hysn nd tient nteton. n attemtn to desrbe adusti ve tehnues n this text wl lst the basis o setu nd oints of ontat. I wl aso ttemt to desibe the flow of movement as earned it. Ths may seem wordy but should hel to more uly onvey the sensaton of exeutn these moves. DVERSIFIED TECNIQUE
The basi onets of dvesifed tehniue e as oows 1 . l artu latons of the body e subjet to subluxton or dysun to n. It s neessy to be abe to adust l o them fom the num to the toes wth the sine obi ously the most i motant. 2 The aliation of arefuly ontoled fore wth the utmost seed, when exeutn the adjustment s fundamenta aset of efetive manulation Ths reu res u efexes nd een hand/eye ood ntion. This does not im y the use of ret oe but the ad sl tseond aition of a ontroled amp tude se fi al y di eted foe foe tht is determined by the situation the aea adjusted the e o the tent nd the deee o njury o deenertion. ndson alation touhi n one s atients een for hyer and hyomobi l ty muse tone and ateed sensaton is the rin anyti tool. our altoy nd i nia l exerene shoud eave ttl e room o suse when evewin radoahs.
Adjuive T echnqu
4 The reasn r gi v ng an adj ustmen t must have an ex panatn tha is cmpatbe with he anatmy and unctn he area being teated and t the vera un ctin f he bdy 5 The mprance msces and t hei eects n j in t dysunctn s undamena eectve asting cectn 6. The echnqe ms demnsae cinca cnsstency m physican t physic ian 7 The echnqe shd be adaptabe and aw f creatvty t shud be penended An mpran acr n sccessu adjustng is the cmft and cnidence the patient has n he physicia When psining he paen r an adusmen he practitner wi pace he bdy in a pstn hat aws access he pat bing adjused Tensin tractn s apped t he issues t ake up he sack in he acuatin and the adstment s made I he physcan s cnfdent and assetive n seting u p an adju smen it is far me key he patien w eax A eaxed cmtabe patent makes f an easy cmfrabe adjusment It s bvs t the experienced praciiers f handsn heapeuics s uch as massage chi pracic sepa thy and physica therapy hat he paient can ead he pactitner Unceran hands te he patent esis and ptec themseves. If he paien cannt eax any attemp t ads s me wth insincta a nd fen cnscs esstance ha means he physicia n s fghtng tgh msc es hat cnter he ad smen. n ths case he adjsment wi key be panf and ar ess efecive A ense patent can ten be ticked in t reaxi ng by dsractng ther atenn smetmes ny fr a sp t secnd The skied adjuse shud be abe t sense hat mmen bken cncenratn and execue wih speed an adjstmen tha is quick and cmfrabe Once a paten is cniden n he chirpact's handng he r she becmes ease ads. Thse that ae diic t get reax are canddates r wce adu stn g PRNCPE OF EFFECTIVE ADJUTMENT
The pr ncp es f an efecive adju smen are as f ws . siin ng. Caeu and cnfdent handing the patent s undamenta Pace he paent n he desred psitn exp an ng what is expected h m r he and what is gng be dne 2. Tacin Take up the sack n he tsse and srrundng srcures. Make sre he patien s cmr abe Any pain ned shd warn the physcian ha anther apprach may be necessary r hat t is sn t atempt tha patcar cectn Cnac pn/ine drive Accurae papatin and a keen sense anamy are via in de t make he
17
cnact pin t as precse as pssi be In umba and pelvic adjsng the pisifm cntact is ms effecve. W th a "p technque nger tp cnact wi be sed Cae n estabishng the ine f dive s that i cincdes w ith he pane artc uati n and naa ange mn s as impran The ine f drive s esabshed in dvesified echn iqe by the psiin ng f the eam The physician s bdy shd drp nt a pstn that ines p the rearm behind the pis rm and n ne wih he arcuar pane Thi s gives a sid drive t he adjustmen In dvesfied techniques a adjsmens shud be made wi th espect t the naura i nt pay and ange f mtn. n my pinn adjusive techniqes that "g aganst the gran ae ikey t prdce itain and pssiby cause igamen damage As an exampe the cervca break s a thrs pependcuar t the spi ne wih n respect t the pane aicuatin the cevca apphysea in ts T hs appach i s key verstrech he gaments and ead t int instabiiy 4 Sabiain Stabi ig s based arnd baancng the bdy s ha tracn can remve a sac k in the tis sues ha spprt the jin t and an end pint in jin pay can be reached n handng patents t is best utie the paent's bdy weight fr eveage whenever pssible. An efectve adjustmen can be deveed wih ess efft and fce the patent s eaxed baanced and paced in he ms advantages pstn If the paent s set up ppery he physic ian can beter use his her wn bdy me ecnmicay edcing he stress n he physcans wn bdy 5 The mpse xect ng he ad sment at the cu m natin f the setp shd be fas The depth the thrs s determned by he area being adj sed the bdy ype ad age the patent As a re he depth f hust shud aw ays be min imed If the setp s crrect and the paent is reaxed he need fr a deep thrust is n warraned Speed is he key There s an instncta tighteni ng f he bdy in respnse t stretching fces ike hse n makg an adusment The speed f he impu se can beat hs bi n cnacin respnse The adjustment is ve befe the bdy can respnd have nd hat a ec ethd wrs i cease he speed The idea s t back f as ast r faser than th e hrust 6. Repapae Ae making an adjustment recheck yur findngs t ascertan a crrecn has been made An audibe eease pp i s n a ways a c ear indicatr f crrectin Nt a paients wi make audibe reeases and sme pps may be icidenta fixans ther than the int being adusted. In cases chrnc subux atn whee phic changes have prgressed tward anky sis i may take a series adju smens reduce
1 38
TE Low BACK AND PEV1S
e adesos ad estoe orma moveme Atempig to beak dow a croc fixaio too qcky ca ceae iammatio ad ceased symptoms a ca comp icae a paiet s recovey. Tese steps settg p ad makg a adjstmet are a fr awkward, ad e stde of divers ied ad si g eeds to sped ime perfecig a smoo qck ad cofdet exec tio Te idea is to fow fom posiog o actioig to sig qcky I teacig ecqe, ave oiced tat e o ge oe foos aod settig p a adj ste, te more tese te paie becomes Te adjst me w e be d m ised by estace, may be paif ad w i key be iefec ive Mos diversied adjstig o te ow back ad pevs s doe wt te paie i e side postre posito i g 5 ) We propery posiioed te ps de kee ad p ae exed ad te dowsde ip d kee are exteded Tck e pside foot o e poptea ossa of e dowsde kee ad i sc te paiet o keep t ere. Te pevi s s otaed, ad e so ders sod remai reatve y fat o te tabe. Ma ke se a te pate s ot ced p or exed, bt reaxed ad exeded as if eect May patiets w cr p appoaci g te fea posii o i f yo e em Have e paiet i my terace ei fges ad re em o te ower pat of te psde rb cage We popery postioed e pai et w be baaced Te pysica sod stad to te sde fac g te paiet w i te cepaad eg agaist te tabe ad bacg e paiet Tis give e pate te eeg o be g seced o te abe as tey ae oed rter to take p sack g. 52). Te cadad eg is sed o coact e psde fexed ip ad kee Te pysicas kee s paced at approximatey te sca be osiy ad s o er ae a e pate s kee Tis sab a to coact s sed o compee taco ad, i cetai ad s mes, a sgt eg kick a rapid saow exesio o te pysicia eg) i se d o "gap e aricatio Te ppor ad sod comforaby coac te pside soder w a broad cotact te pate s arge o as oder patoogy, grasp te psde am s above e ebow remember o isrc e paiet o keep e figers irmy i teaced). Sabe e sode ad pper torso, keepg i as fa agaist te tabe a possibe
5-1 Sd
5-2 Sd at ad ac
Te pys ca ' s cadad eg is sed to frer rotae te ow back ad pevs by extedg te pysca') eg g 5) Te combia o of ppe oso sabiiatio ad toqig o e pevis w take p a sack i te patiets ow bac ad pevis Bo pyicia ad patet od be baaced ad re axed Te ad s g ad is ee o mae te approprate cotac Tis posiio ca be sed o adjs e sacrm, ia, ad a e mbars Wt oe exceptio, te pside te sde a is to be adsed Te excepo wi be dscssed i e secio o mbar ad sg To compete e emova o sack ad make te ad smet moe specifc, fte fexio o exteso of e pates p side p ca be efecivey doe by movig e paet's g wi e adjsters cadad eg cotac. Use te adsig ad
5-3 Pyca ' g x ca lvc a.
Adjive Thnq
t ppte the prverte musces he eve eng d used y fexng the upsde p un tensn s nted the pvete musces t e desed eve (Fg 54) A sc s emved up ne eve ew he segmen e mved Fr exmp e du stng wud e mre eectv e f e up sde hp s exed unt he prvere musce s 4 ecme u T djus ew 5 he hp s extended un n e sn s ned he 5 eve T dju st 5 ex he p unt ensn s fe te 5S eve When executng umpevc djustmen te w frm ng te ptent nt e sde psure tng sng nd dusve cntcts t ng te mpuse sud e smth mneuve Te ce the djustmen s rgted t rm he sude u rm drp f he physcn's ts Ts s me ecnmc use f e physcns dy ess ey t ed suder njury r prems fm epettve trum The wy ths ws s set up he pen nd test e pnt f tensn remve sc ) Brng he pvere musces up tgh (hp fexn). Te he djustve cnct Dp yu dy dwn qucy ve he pten (Fg 55) Wen yu rech te crec ne drve tht s yu rerm s n ne wh he specc pne nd nge f tcun fe yu mpuse Fg. 55) Wen ndcted smutneus eg c gps e n nd the djustmen s mde Ths dy dp nsers he wegt nd mmentum fm yu rs hrugh he sude nt he psrm Tee s n questn t d vesfed echnque s pysc ecnque h reques sme stengt nd gy. W me n chprctc e every s cpe f pctc ng d versed ecn que They en hve grete need t srengten her upper des n der t vd nung hemseves. We hve wys stessed ur sudens t cndtnng s mprn.
9
55 king up slck n eginning y rp
5-5 Cplein y p n nse menum in jusing m.
Mny physcns w pt fr ess senuus technques rher tn tn r wht cud er the prctte mre cm pete chprctc regmen. PI Ilium
5- Mng upsi e hip n ue exin enses lu peel muscles ge up e spne
en stn
sde psure
Sttn
upsde shuder m nd hg
Cntct nt:
psfm the pser super c spne
ne f Drve
ntete
14
w
AC AND
A pse tatn sbx atin f the i i s ned when the spne paient has a spei antei spe iac spne ASS; Fg 56) and passve mtn papain M) shws n ane mvement he saci ac SI ) pane f atican is anteaea/pseeda Adsing a I im, wi e qe an anteatea ne f dive he eam shd be agned wh the S jint pane As he adjste' s bdy dps nt he adstment the ea shd be weed pas he pste spe lac spne SIS) cnact s that he m pse s dieced aneateay Fig 57) se a eg kck AS Iu
aent stn:
sde pste
Sab atn nt:
psde sh de and hgh
Cntact int:
scha tbesiy
ne f ve
anteedia
An AS m is ndicated by an ne ASIS Fg 56) M shws a ack pse mveent When he i m s aney taed he ischa besy s ved pstei and sighy aea he ne f dve needs t be antei and s ghty meda d ths, he adj stes shde s be ntenay tated bing th e ps f n t cnact wth th e ischa tbesty he ebw w be pnted twad he ppse sde the paient and si ghy cephaad Fig 58) his i s ease t d the paien is ed fhe ve han h e I adjstmen. eg kick s sed An atenatve techn qe ha is sees eect ve s he se f bcks Fist sed by W ad Cave, wh stated c ectng pevc tains wth he paients shes, t was ppaed by Maj eanete n hs sacccpia techniqe SO)
-
56 Rg P lm lft AS l
_
57 P lm ajm
58 AS ilium jstm
have fnd he bcs efecve n ace cases whee he sde pste was cnta indcaed and as a wfce methd n vey a paiens have fnd tha a pecse setp and a eaxed paien make the sde pste adstmen easy wh vey g h fce. he b cks ae n aways efecve i he xain s se had I d nt w he SO ciein I pace the bcks nde the spne patent he I m s bcked nde th e pste i ac ces n ne wi th he SI jn t space he AS m is bcked nde he geae chante Fi g 59) t shd take ess than a mne see ess f n change s nted the ixain wi eqie a me dect ads en B cking s e efectiv e when hee s te n fixatn and the ain nvves msce mbaance he bcks ae ten eectve in acte cases as they e ten nvve widespead sce eactn I n a cases, the msces hat pdce and aw AS and a shd be evaaed see Chapte n Anamy) he ges maxs, hamsngs and pste abdmna and qadas bm can pdce a I and wi aw an AS
Adjusve Te hnques
]1
5 1 M plpi ichi
5-9 Blcg ig lf AS.
ium The iiacus and t a esser exten the satrus rectus emrs and ens asc a aa can prduce an AS and aw a PI um The chapter n cndiins and reamen w dscuss thi uther
A hypernic transvesus perneu can pu he cha tubesty meday When weak hey can alw excessve atea pay. Paient Pstn
sde pstue
Stabain Pn
upsde huder r arm
Cntac Pnt
ps ifrm n media sc hia tu ersty
ne rve
aera
Medal schium
A meda i sch ium M !) s fen descied as a aing f the iac cres g 5 1 ) I s ead y fund wth PMP f the s ch a ueste By graspng the meda aspect f the ube ses and attemptng t pu hem ateay, hee shud be a niceabe jn t pay g 5 1 ) Ofen there is papae pan in the SI in t due the faing f the a and a stann g the SI gamens The musces invved are the ransversus perne rgna ing n the media schia tuesiies and nseting in a cen ta endnus speta The musces are a maj suppr r he ectum and the pevs The aterams iacus ers ac t pu he ac crest mediay cunteing the atera are
5-0 Rig ml iscm.
Ths adusment equres the deepes bdy drp in rder rng the frearm in a crect ne f drive. The ebw shu d be p nted ams t tward he r s that a true aera hrus can be deivered The thus w be pactcay tward he ceing dependng n hw far the patient can be red g. 51 2a,b,c)
5 2 M jstbgnng by p
1 2
TE L BAC
AND
5 nfi rg t m
5- 2 MI adjmnmday n dy d
5- 2 MI admcml dy dr i h
The PI AS and M ia ae the mst cmmn pevic suuxains
we ex cept i hee ae AS ta ins. Adust he in ei ity is and echeck he cest and ASIS stngs. Ae seing he supine patien with cephaad ce int simuaed wegh beang he ii ac ces emans ine an adust ment an ine iium is indicaed The adjusment inei segmens n he pevs and uma spne equies a mdied side psue With he paient ed he side p lace he upsde am ve he paient' s head and the dwsde hand in the upside axlay aea The knee stabiiain is set with tensin elw he SI int This pstn accenuaes the ine dive which s cephaad Patent Pstn:
mded s de psue
Saatn int
upside axia ve patents hand
Ctact in
ps im n inei isch ial ubesty
Li e Dive
cephaad
The adjustes eam shud be paale he ale with he ebw pned caudad The thus is a supei thust n the scha tubesy. Tactin n he spine is accmpished by he aduse's dy shtng m caudad t cephalad wth a gid si am cact n the shude. By he aduste's shtg headwad w h im cnact ad sabiain pins he ce bdy mmen um can be taseed the paen A ina mpuse a the ischia cnac at he pea supei mvemen makes the adusmet This shud e a smth as shaw adjustment (g. 51).
nferior ium
An inei ilium (g. 5) is indicated y a w iac cest usualy accmpanied y an psatea ng eg and en asscaed wth a weak quadatus umum Q) is deteced y indng a pess tent w ac cest even ae weightbeaing simuatin. The ASS indings w e cnsisten as
Laeral oaion Subluxaion of he Femur
The hp jint is cmmny suuxaed nt deeced and cected, he suuxatn can cnuse he indngs in a diagnsis w back and pev ic cndiins The laealp ema atin (LR) subuxati s an ncmpee seang the
Adjusive Tecniques
3
oss o movement there may be an LRF or ony hyperoniciy o he atea otator msces pimariy he piiormis Another conrmatory chec is o ex the knee and hen he high as y as possbe. Wi h an LRF here w ll be a sgni cant meda deviaton o the oo as the hgh s lexed, whch s de o latera roation o the em A normal hip wil ex wth he oo emaning n ine wth the hgh A aeral otaton o the em wil oen ase hip pain, mos oen across the btoc o radaing down the aneror thgh Paten Posiion
spne wth hip and nee exed
Sablaton Pont:
none
Conact Pon
ineroced ngers over he nee
ne o Drive
in eor o ward he loor)
5- 4 fi ilim adsm
head o the emr in the acetabm The waparond design o the capslar gaments scews home he head nto he aceablm when he hip i s extended as n t he sanding posiio n Apparenty he necapslar at pad can become trapped be ween he head and im o he soce pevenng complee seatng The emr remains laeay rotaed and longe Thee ae common posta as hat case his sbxaton They incde siting crossegged sit ng wth one ane esng on the opposie thgh, and seep ing on one' s somach. The emr can also sbxae n compensation or ohe ow bac and pevc disotions (see Chapter 6 on Condtons and Treament) The detecton o an RF can b e made by is notn g any eg engh discepancy The LRF wi case he leg o appea onger This s oen an nreabe pmay i ndicaor ness a other cases o a eg engh neqaty ae ed ot nc dng an anaomical dierence A bete indicaor is to compare n erna roaton o boh egs Grasp the s pine paent s anes and inenaly rotate hem Fig 5 1 5) here s a noticeable
5- 5 Dcasd ial tai f g gsggss aa fmal ati slxa
This adjstmen s done wih a body dop The adster sands nex to he hip to be adsed acng cephaad The bac shod be saght A patia croch is done o conac he nee nteace yor ngers ove the nee and clamp the eg to yor body w ih yo cadad arm o shold be croched so that yo hands ae a shode eve and yor sholder shol d be eve wth the patien s rased nee se the leg o roae the thgh meday (p i aealy by otaing yo body). ll t to tenson, removng a sac A t this point a shor ampltde body drop maes he adsmen. eep yor n eaced hands ams and shoders gid or body shold drop as i i were a soid nit (Fg. 5 6).
5- Adjsm f aal tai slxai m
144
TE Low
BAC AN
EV
There s ofe a od adie reease arey omorae t sho d e sed wth atio i paies yo sspet o hav oseopoross ate athrt iammato, or rate A aeraive adsme t a e doe f this ad sme s oaidated The patet is spie Grasp he ake ad ta o the e adad ma se he patiet reaxes the hp ad ow a. Whe yo ae etai of eaxatio ad a sa s tratioed o a rapid adad t of shot amp ide w ap the joi ad sea he hp. Wih RF sxatio he atea otator mses are ofte hyperoi ad may eed o e strethed The seod mehod s safer if h p pathooy s evde t od aravae ay ow a pahooy have sed he is adsme may qestoae mstaes Ote a ete steh ad mid drop, o a rapid seres o ee dops wi ahieve a oeio wt h o dis omfot or rther ha to the pate Pstrir acrum
A poserior sam sxaio w papae as a dereased spae ewee the S S ad atea orde o the sam ( F 5-7. M wi show he sxaed S to have o aterio jot pay The sam may eve fee as if it is i a reaivey oma posto t i f M eveas a oss of aterio moveme it s i key o e xed. atet osiio
side postre
Saiiaio oit:
psde shoder or arm
Cota ot:
ps form o pside aera oder S 2
ie o Drve:
ateoaera ( ie wih joi spae
dve ei osiset wth the pae of the atato ei ad sted The sarm has a ie of dive ha is more ateror o posteio Ato ha he m (Fi. 518 Antrir acrum
A aeror sarm wi papate as a deepe spae etwee he S S ad he atera oder of the sam Fi . 517 t is o t posse o moto papate for a a ofposeior joit pay Comparso o he opposie S a aid i ofrm he ae or ixa io f the opposie S oi t is i a oma posto ad has oma ot pay the ehood of aeror ixaio is eat Adsi aeror fxatios i he sarm ad ma spie s doe wih the paiet i he side posre There s a reversa of staiiatio ad oat pos The dea s o ifee a aterioy fxed semet poseroy The oept o adj st aterioiies is o i teso i the paaverera mses p o the eve eow t he semet to e adj sed ad y hrsi poseory he semets aove the aeio semet, eease from i s fxatio. aiet osiio
sde posre
Staiiaio ot
psde im adae to S jo
Coat oit:
pside shode or arm
L e of Drve
poseror otaio o the sp e
This adstme is sm a i a espes to the ad m ar adjsme w th he exepo of the otat ad e o
The staiiaio of the m is doe wh psiom o dex otat o the i i m at the S o wih the orearm esaish the same posto as i f adjst i a Cota at he sho der or arm s whee he thst w e made Bi the paiet o tesio y roai the pe vs towad yo wi th e exte sio ad a im hod o the i i a. Ro he shoder away Whe a sa i s removed a rapi d hrs s ma de at the shoder o arm wh e the pevi s is hed frm This wi p he sam poste
5 7 Seri iew sacrm ad elis gt steir e aeir sacral sblxa.
58 Psei sacm adste.
Adjuve Technque
145
o along wth the et o the pne Th adjtment i apid and of hot ampl tde (Fig 5 9 The e to a comfotabe anteo adjtment patent eaxation and pece tenion lee et with the lexon/extenon mechanim of the patent pde leg. Cae hod be taen to aoid adjt ing igniicant mcle hpetonicit o pam o acte inj to pna egment i peent. Inferor or Oblique Sacrum
An neio o obiqe acm (Fig 520 i detected b binging the thmb p againt the lowe bode of the acm aboe the acococcgeal joint wth the pat ient pone t ea to pot an nleeling of the acm An nfeio acm oten ond aong wt h an ineio i l m on the ae ide n ome cae, coecti ng one coect the othe. f both ae peent, J wl al adt the lm ft and epapate befoe adjting the am Patent Poito n
ide pote ineio ide p
Stabization Pont
axi lla, patient' am oehead
Contact Pon t ine of Die :
5-20 g f r blqu sac
Posteror LI-LS
A poteo bxation of a mba eteba wil papate (Fig 52 a a ac of anteio joi nt pla when peing anteo on the mam ila poce, wth pine PMP t wil l a feel coe to the ace (Fig 522 Patient Poition:
pi om on ateal bode o acm
de pote, blxaton ide p
Stabi zation Poin t
p de hode o am
cephalad
Contact Point:
p ifom on pde maml a poce
Line o De
anteolateal
The etp and adjtment ae the ame a o the ineo i m (F g 5 1 . The contact i on the nfeoateal apect of the acm, with a cephaad ine o die An atenate method i to eee the de pote o that the neio ide down and pa tient i poitioned a fo a poteo fxaton The pi fom contact i on the downde ateal aca bode The l ne o die atea and ig ht peo which mean a deep bod dop w th the oeam l ned p a i n the M adjtment (Fig 51 2c.
The ine of de can a accoding to the pane of faceta atclation. PMP o adoogca edence o both how aceta ammet , coect the i ne of de a necea. U e a leg c. An effecte atenate o adjting a poteio bx ato n that i often effecte w th le foce and le toqi ng of
5-9 A sacum ajsm
52 Basc ps fr papa f w bac k a plvs
146
TE w B D PEV
5-23 Pll adj se luars
5-22 S 1 spir viw is ai igt sti f
te ody is a l adstmen. When settng p or a l ad stment, se he sde osre and t the poserority on he downside The saizaton and pside eg postons are e same The onta o nt s wi e ti s o e is wo nges on te downsde mami lay proess ig 523 . Tae tension n the same ashon t note at ess s neessary When he end ont s reaed l yor rigd hand ingers and arm toward yo T s is no a spno s pl Anothe way o onsid eing ow o mae this move is t o hink tat yo ae pokng te mamilary o move i aneorly A paten tat s in too mh an o tae m otation may e easily adjsted wi a ehnqe. Antrir LILS
exng te paen's sde eg Stailze hat segmen and mae e adj stment tr stng on te sde sode o am Infrir LILS
A vetera that is slxaed nerory wil no ave any speio jo nt pay w PMP he set is he same as or an ineror ilim or sarm Fig. 51). ex te sde eg o rng enson to the segmen elow he sl xaed segmen Paten Post on
side osre n eio side
Sal zaton oin
ax i lary, sde arm ovehead
Conat oint
s iom ndes i de mamay
L ne o rve:
seio
o
Cmbntin Subluxtins
An anterio sxation wi aae deepe eoe onta ng e mamilay roess ig 522 he oposte sde may eel osterior n omarson. atient Posiion
side oste slxaton sid e
Saiiaion oint
segmen elow s lx ated segment
Conta oint
sde solder or arm
ne o rve:
oserio hrst on psde shode/am
Adjstng lma anteorties s he same as or te sam ig. 5 1 9 Te onet is o ring the slxaed segmen oseror ng the ension p to te next lowest segmen y
is are o have a soltary slxaton. Mos oten yo wi ind vaos omnatons o sxaions. Any segmen an e iaeraly sxated posero on oh sdes o posero on one and aneio on e oe sde Tere s no a set way to disen wh one o adst irs. Te mos onsng omi nation s an anterio and osteror omnaton a he same leve Paaton w il el yo ta yo have a ostero ixaton, nil yo ads and ee yo annot e sre o he anteioity he es way to appoa oreting moevi s xations is to sa n adst reek, and adst te next nding. n some ases te rs adstmen wl oret other lstings. As a le sa ly ad st 5 rst as 5 sxatons have te ai lt y o mas or ater ohe s xai ons om hee se yo own method o nt ion
djutve Tehnqu es
A combi o o potoifrior ubl ux to on th m id c b dutd prly o by puting "pi on th piorm combtio of io thut wth upio torqu cn b ppld t th m im ot corrcig boh ubluxton. Thr r on vrl ovppg ubluxtion h d to b uvd or nc ini f dg t th i ic crt how igh fro i um w th qul g lgth whic h my b rottion of th lf fmur. Ttg or t otto o th mur i giv Chcking th AS S lvl how thm to b vl If h right liu m i nior h AS S hould b wll Chckg fo PI ixion o th right i potiv Th PI rottio h vd out h AS S d lvld out th lg y corcing h PI ixi o thr wl b mo ogic fd g of ong g o th igh t d corrcion of h i rior rgh iium wil bc out th plvi Thr r mny vri o of combid ixto/ubuxtion ptr h cn b foud y li m t g o othr lcorrc o bcom mo pprnt Pubic Syphysis
Th pubic ymphyi h itl movm but c hi upioly o on id g. 52). Th pub wil o b pinfu wh plptd. Sight dow ovr th pubic ymphyi whi prg vy wth th thumb on h upior pc of h pub I i y to drmi on ridig high Th djutmnt i bt do wih light forc. A riorcd piiorm th wb o th ohr hd ovr th writ of th contc hd bt with rpid hllow hrut Thi c b ucomfortbl to th ptit Th r i uuly iti v I fid th mpct oo ud i Activto chniqu fciv
5-24 e se pbsajsng wh mac
14
Coccyx
Th coccyx cn ubluxt tiorly. Th coccygu mucl c bcom hyprtoc puing h coccyx forwd. Pr fl cn m it orwrd. Wk o th coccyg ibr of h glutu mximu c low th coccyx o hif rory tl wkn c llow t to dvit to th oppoi id Th fit hing to do i o god th coccygl fibr of h glutu mximu Oftn hi timultio ough to c h problm. Adjuting h coccyx c b do wth rltv comfot. t i dj utd by rctlly cotcig t h trio ip o h coccyx d gntl y pu l ing w th tdy comforb orc fo priod up o o mu ig 525). A rl on ft h coccygu rx d mov potriory Som chqu fo th coccyx ch pid orcfu pul ht cn b vry pinful d i no ncry Th ggli on of imp i tutd t th uppr lv of th coccyx u o coct oly h owr gmt. Whil cotcting h coccyx no if i dvitd to on d Thi dict h th guu mximu fibr my b wk on h id oppoi th dvtio. rying th dirctio o pul towrd h midl i d godg h wk glutl ibr thi inrtio on h mur w il bing h r io b c. CONCLSON
I i wi to conid th im portnc of kowg wh nd whn ot o dj ut. t i robl o coidr djut ing whn thr i comp undrndg of th fctor tht wrrt djut v i trvntion d hr i ronb lik ihood of fvorb outcom bd on clinic xprc. It i wi o to dju t f hi undrn ding i not c r if frcur or othr pthoogy upcd or i th i ignifict nb i y of th riculto
5-25 Asng h e cccyx
48
TE Lw BAC AN PI
REFERENCE Hammer W Adjustment by han only. Motin Palpatin Institute 's Dynamic Chiroprati 99; 2:24
Ryweant Y. The Fedenki Mehod: Teaching by Hnding. New Yok, Y: Gi ninge; 983
Chapter 6 ondiions nd Tmn
The reame o varo codo o he omac ero mclokeeal) yem hold, my opo olow a pro oco o:
degeeave o deae, relaed o a od jry poor heal g, mlpe jre ad a hory o varo ml dcplary aemp o op he pa The mo commo cae o choc low back probem are dagoed aaomcal ad conal eg legh eqale ) a qadra mborm Q) ydrome ad lack o deph he vegao o e cae o he pae com plahow he ry occred ad wha acor he pae' leye ad work are aggravag he probem hee oe beg reame wl deped o he phyca dvdal appoach a d e age o he deae Ace jry wold bee om rapd alammaory heapy, ch a ce, proolyc enzyme, re calcm or pam o oher mo dae, ad pocede o ppleme a are el o oe dvda pracce Mapao hold be jdco A coc cae wold bee rom creaed crclaory exchage, c a ROM exerce o/cod applcao, raod ad mo mpoaly a maplave pogram o re ore jo con ad ably ee Appedx B ) Proper corol o e pae drg reame eea ad a he ame e dcl o acheve Pae are lkely o gore rco o home care So make hg a mple a poble Be clear a o wha yo expec rom pae ad make e ha hey derad he procedre ad e coe qece o o parcpag her recovery
. aeg ad coolg lammao ace or choc aeg ad correcg mcle mbalace, hype or ypooc 3. deermg arcar dyco ad corecng by maplao reablag he damaged arclao ad er r rodg coecve e compone by coecve maplao phycal erapy modale ad exerce o voved rce Coecve maplaon a adjve program deged o creae ad ormaze rage o moo ROM) ad redce coecve e reco eaed o chroc dyco Coervave maageme o omac pahopyoogy be g a varyg age Some pae pee whn hor o beg red ome wll come aer everal day week or ome eve moh laer Some wll have aemped erea me wh overecoer OC) pa ad aamma oy drg, hea lme, ad pobaby lle re Oer ave ee radoal medcal phyca ad have bee precrbed relaxa ad more powerl NSAID o erodal alammaory dg) or aggreve phycal heapy P) a ca acaly aggravae he codo ad ave ad o re oe wh a moe chroc lammaory proce wl lkey have degeerave chage he rrod g elaed rcre May pae pree wh gca
INFLAMMATION AND CONNECTIVE TISSUE
he gle, mo commo acor deag wh eromclokeeal pahoogy he ace ad chroc e ec ohe lammaory proce o he coecve e The 9
5
THE Low BACK AND PV
low bac hip ad pvis a mo iy to ba dow ad dgat tha atcuatios such as th a motis whch tas a mo pouds p squa ich oc with ay a complait. Th dg ad qucy o ammatoy cdts i a patits hstoy ad th dg o appopat tatmt o thos juis dtmi th thooughss o covy. [t sms to b th td to cosid lammatio as som thig to b stoppda udsiabl mt that ts wth pai. tu to th basic txts o huma physioogy wil mid o that iammatio s th haig pocss. To stop it could opadiz halig owv ducg th lvl o th acto could b advatagous Cosvativ maa gmt o iammato is ast dict ad has ittl ihood o sd cts. ammatio is th ist stagth acut stago haig. Swlg dss hat ad pai a th ou aspcts o ammatio. Th poblm wth ilammatio asptic stai/spai juis s th alloothig spos. t is ot dd. th s o that by oig ivads th s o d o a al out spos. Coctiv tssus a ss y to gat tha a oth tissus i th body. Thy a po to scag. Th paativ ot poducs a dsogaizd co stuctio o ibs that a wa ad ss astic tha th oigial ibs th swlig s couagd th is ly to b a mo wdspad volvmt o coctv tissu th s pottia dgatv pocss. Coctv tissu which cuds th igamts tdos ad ascia hods thigs togth. Th muscs ad s a spcaizd typs o coctiv tssu Th ibous tissus i th igamts tdos ad muscls td to pai stas ad tas wth colagous sca tissu. Th mmbaous tssus such as th ascia aso md i ths way ad td to om adhsos that bid tissus dow pvtg movmt. S mo ot tha ot wll gat ulss th damag is gat o th halg is slow o ituptd. Th scas a ly The Acute Phase
Wh th clua itgity is damagd uochmca actios tigg th lammatoy spos whch is a allo othg actio. t is dsigd to apidy potct th body om ctio by waig o th ijud aa ad ppag th tssu o pai s a pat o this mchasm th sous xudat th ud tissu bgs coagulatg omig co lag ibs that bd to om bous bais Thos bas bcom th scas ad adhsos that ca dgad coctiv tssu. The Subacute Phase
Th paativ pocss bgis i th subacut phas. Th mas o th damagd tssu a o th way out ad sh blood with oxyg ad utits is lowig . lammatio is
ss its. Coag ibs a big omd to md th to bs The Chronic Phase
Rsouto o th tssu to a·patchd up vsio o ts om s tas pac i th choc phas Th choc phas ca b shot wth complt pai ad a % tu o stgth ad ucto. O it ca b a og ad somtms icompt pocss adig to choic dysucto ad dgatv chags. my opio th pa o ijud coctv tssu s a gativ pocss wth a gic lowgad pai tissu. t s ss astic ad is ot so disogazd i ts costucto that t causs cotactos ad shiag i th tssu. dhsios i th asca shaths cotibut to ducg th plablty ad as o movmt o o tissu o aoth o pat o aoth. This pai pocss dos a miacuous ob o patchig up ad stog uctio With ou btt udstadg o huma physoogy ad th us o simp thaputics t is pos sib to cotol ad maxmiz th pa pocss. t is possib to com a cos to gato o tssu with th pop combiato o cosvativ tatmt ad hablitato. Th cosvativ appoach i th acut phas usig ic ad st s a supo i th log u. By popy cig a sigiicat sowig o swig will b accomplshd ducd low o bood though th capllas ov th ist 8 to 36 hous coupld with st ca madly duc th aa o vovd tissu (s ppdix B. th subacut ad choc phass wth ducd swlig a gaduatd itoductio o hat ag o motio xcis ad ic (to coto swllig th pogssg to toig xcss wil cat th bst vomt o maxmum pa. t has b show that movmt xcis itoducd y th subacut phas ca cat a btt ogazd sca Th colag ibs wi td to alg thmslvs with th dyamics o movmt. Thy bcom mo li th tssu thy a patch ig This wi gaty mpov th stgth ad slic o th pa. May patts a s o th ist tim wth choic ow bac poblms som o thm havg sud o yas. pooy hald juy o dgatv chags ad th ogtm tissu chags that su ca chalg th actito. Wth pop ca ad patc may cass o sious choic athitic ad myoascial ammato ca b cotold ad th stuctu stabizd. Coctv tissu disass a bcomg mo wdy u dstood ad accptd as a valid codto Th lumbosacal atcuatos th dosoumba ascia th sacolac, ad iolumba lgamts a ot oud to b choicaly ilamd dgatd ad ot sd to choc bosts myoasci tis o ibomyalgiali sydoms. hav oud ths to b
Conditions and Treatment
muc mor common n womn, bginnng in th arly 4s af tr chldbaing. hs disass ar lind accoding to som sach s achrs, rs, to cronic fatigu fatigu and pstinB pstinBarr arr vius (B syndoms synd oms and humatoid dsass hy ar oft n clinically nd to strain/sprain or ptitiv strss nuris t mas ma s t ducton of inlammaton inlammaton and th thooug rsolution of suc inurs impotant to th ongtrm halth of t patint T is a growing body of litatur on th subjct of cronic cron ic connctiv connctiv tissu pathology. t is bcomng cla tat w hav uc to larn about th fasca and th ntrrlatd nss of a vaity of pain mchansms that can b cratd by fascial iitaton• Ts conditons ar bnfitd graty by ciropractic ntvntion. Manpulation spcialy spinal ma nipulation, s a powfu tool, afcting what s a combination of igy ntgratd tissus nuroogcaly and bomchani caly. Manipulation coupld wit so tssu wo (myofascial and gamntous can afford pan contol and tssu stabiliza ton By maintanng that stabiity ovr a ong noug tim what s nown as dgnrativ oint disas (I may actu aly show sgns of rgnration. STRAIN/SPRAIN INJURIES
Tauma to th muscuoslta systm s classfid by t dg of inury inury and sgns and symptoms h tissus involvd aso nd to b dlnatd stan s gnraly considrd to b a dgr of tauma du to ovstrtching that causs in complt taring or ruptung of th connctiv tissus. sprain njury wil caus mor svr taring and disuption of tissu tiss u W gnr gnraly aly thin of straining muscls and sprain spraining ing joints Classifying stain/spain injurs is basd on an assssmnt of t svrity of of t injuy Considr th story and th cin cal findngs. W gnraly dfn an inury as acut subacut or conc dpndng on th tm of nuy and tim apsd bfo tratmnt. h fist 36 ours s th acut stag T subacut stag lasts from 3 to 4 days and th cronc phas can last for 2 to 8 ws or as ts nam impls it may nvr rsolv. h svrty of t injury s catgorizd as mid if it is a staining njuy with minimal vidnc of tissu damag or acton. modrat stain wl invov a largr ara of con nctiv tssu wt mild swllng and av som tssu clos to th brang point sprain would b diagnosd as md if valuaton finds ony t ilihood of a smal ta with n crasd pain and vidnc of swlling us th tm stain/ spran as most inurs byond ths v ar combnations of bot typs of damag modrat stran/sprain injuy woud find sgnificant dsrupton of tissu and vidnc of incrasd ont instability sv sprain is a mao disuption of liga mnt o tndinous structu wit srious joint instabiity that in t xtrmitis can lad to th nd fo major orthopadic ntvnton
15 1
n daing wit strain injurs aftr t inammaton s un dr control th muscls invovd can b valuatd fo wa nss Wn found wa goading th origin and nsrtion of th muscl wil wi l oftn brng t muscl up to nar noma func tion Goading is a apid oscllatng movmnt dp nough to affct th undrlying muscl/tndon tissu, witout t xaminrs contact bing allowd to sld ovr th sn. s n. Tis tchniqu can b don on patd tratmnts to hlp th body maintan as normal a function as possib during rcovry Th acut low bac ba c inuy inuy is commonly brought on by som typ of njuy such as a fall or twistng whil bnding o ift ng. suddn onst usually suggsts muscl strain and spasm mor gradua onst ovrnigt s mor ily to b a span owvr tr is no st s t rul tat t cannot b any combnation of factos T patint wl most oftn b awa of wat bougt on th pisod n som cass of spontanous low bac pan it was not bnding ovr t sin but th si trip two ws arl tat st up a dlayd action action Rcall that an in jury whi whi bnding down wil nvolv th glutu glutuss maxim maximus us mor oftn tan not (Fig. 6-1) Raising up o ifting will most oftn affct th psoas and spcialy th L4 sgmnts Fig 62
n xaminaton should rul out pathoogy suc as idny nfction, vascuar, o srious nurologi nurological cal probms h ag and any history of prvious low bac psods wil lp dtr min t ilhood of dgnrativ cangs Patints with acut low bac stain/sprain can usually ma it to your ofic and onto your tabl; howvr, somtims it may ta awhil hy may b antagic complain of low bac
Fg Eetr pe d ge xm rt eer
whe edg er The gte xm e tred eretr pe gte mxm
5
TE Lw BACK AND PEV
Fig 2 Te wer pss slips c e ied i te iii se f risi fm fm et psi pss slp ctrcs ctrcs hrd erecr spe crcs c es xis ccs d sis c trac, e ee ppe psoas fibers.
pi idctig t umboscrl r d o hv i buttoc o ig but do ot ot comi o i or mbss bow th or to t oot. hir rg o mo to is lmtd d tog urologc tstig s gtiv som o th orodic tsts c giv coictig rsts v wh i rs tt th my b v oot irttio t y mgm wod sill b md ductio o swlig rs, d judc judcious ious cocio cocio o muscost m blcs. l l umbr sti/sp sti/sp ijuris i juris shoud is is i cd possib possib discophy discophy i h worg digosis. my m y css rly urologicl symtoms wi sbsd s imm to is coolld. Plpio wil show rs o yroic muscs hypomobi jois d good idctio o t v o pi toc o t pt. Tt v w hl dtm how ggssv iit tmt shoud b modrttosv sp s suspctd mipulto durg h cut phs sould b igt wih rspc o t lrdy dmgd lgmt s d t pts pt s comot comot I t it tmt dcig msc ssm d thr o stri or protctv lgic yproiciy w ot provid oticb ri T most commo yptoc mscs ow bc/pvc s wi b o o mo o h sos guus mxims riomis ics d pvtb mscs. t t with w ith spsm o hyptocty o gtus d rcto mscs suy psts wth t bc Psos hyptocty wl cs icrsd ordosis d ror ror pl pl vis. Stchig c b ccompisd th cut stg wt lv comot d sty. T cut s bds ito t sbcut hs s pi sub sids d ROM is icrsd v v slightly Wth mmto mmto dow clrr id o ctu dmg is sr to ssss. ssss. M
iputio c bcom mor ggssv h us o combiios o t RO ROM M xrcis d ic og w y ysic rpy moditis c b ittd itt d s grl ru c rm sod iclud corrctig y musc mbcs by strtcig or godig s dd. Dyscto o h urd tiss d t dtiv cgs dd o rotct t r d sor t body cs rptd oogc "imprtg o sor brrt brr t uctio T ctio c bcom hbtul hbtul csg csg logrm dmg d i icompt compt hig. Rd corrcio o ts dysuctios "rmids t body o oml uco. T chroic hs is h tim o i i solutio. Il Ilmmmmtio sod b occsol d miml t mos wth stdy mrovm od subjctivly by th tt rporig ss pi d icrsd ucto. Tis shoud b cormd by ob jctiv sigs sc s dcsd i icrsd crsd oi mobiity mobiity d improvd idigs po orhopdc tstg. Pts s ss qty d sod b dctd s o popr itg hnqu nd vnv lyl hng Thy hld
b pogrssd ito xrcis progrm scc to i r c wsss but cotiig grid ow bc sgtig rogm (s pdx B). o wo ptts rspod to tr jis t sm wy s gl u most simp st/spri iris sod b rsovd our o sx ws My drg tiuds d opios xst bout ow mc mt is prop d how log th ttmt soud . hs idivid dcisos bsd o t pysicis udsdig o h ptit's cod to h tciqu t ciqu big sd d th idividu lig pro pro csss o th pt. Rct ttmps o d t protocos or tmt r dig i my opiio to lcig mdicly ccpb ccp b lmttos lmt tos o ciroprctic ciroprctic tmt cocts. grl g rl Mrcy guidis itrpo itrposso sso ttmt to stdrdz cicl chropcic protocols ccb to boh chropctos d mgd cr istttos r sobl bu lc y cosdtio o corctiv miiv rogms or rviv chcups. h mpss i ht i trditio mdc is o s imo o sympoms, whic to som s quivt o cr I my opiio t ci roprcic rooco shod provid or og trm mil tiv trmt ogms to coct coic sbluxto trs d xprss th bis o vv c. t is my xpric ht srs o djustms c m sgiic movmts i oi ucto. Th dicous s o spcc rptiiv dstms c br dow ibous dsos d cotctrs rstoig t t uco grty o h ois qusto Ths ducs rvous itrc rom brt ssoy pt p t d dict di ct iiio iiio o t spl rvs d my cotb to rgio rgi o o tiss. tiss. LORDOIC LUMBAR SYNDROME
T odoc lmbr sydom (LLS is commo dg i pts wt ow bc compits (Fg. 63. chroic it
Cndiins and Treament
53 5 3
Fg. 6 scles a prdce a aterr pev psas iiacs
recs fers fers sr sris is
Fig 3 Crc S
is ccompid ccompid by ogtm chgs i ucio d tsic tssu chgs cut iuy wt udryig LLS my v compicios rcovry du o brdow th dptv dp tv procss. procss. Tis c b good im to it it coctiv ivto bcus t jurd s op to mprovm ivto mprovm Od dhsios d cotctus cotctus r iy o b disuptd wic wi c c b dvtg dv tg T LLS is prsst tror tit o h pvs ivovg combitios o icrsd ordoss tio ii hyprtoc psos d cus d possiby h srtoius tso sci (TFL d rctus mois (Fg 6 Th gutus mxi mus o bdomis or or boh wil b wk or uductioig (Fg 6-5 Wgt is triory o th bs o t. Th pi w dscib t ibiity to std si wthout p Pts my comp o pi d sictd biiy o stight up upo arsig rom std postio. Bot psos ot i LS cotct wh pso s stig d wi ot x quicly oug du to iito d hyprocty P tts my hv p wh lyig supi d t gp btw t tb d th ow bc w b wd (Fig 6-6 Th sp ms chd by t igh muscuur Ptits wih LS wi commoy v mdy rottd mus wit irrittd prorms muscs compsig o h wk guus mxi mus s w s y y rottd ibs d chgs i th s pr o h compsory mcsms LLStyp posur is courgd by h shio dusy ht rquirs mods to pos svr swybck ostios
Fg. 5 sces a allw a ater pevs a es is
aias c ass
wich sm o b mutd by my youg wom Suc pos tu s so commo tos who v b gymsts t is so cusd by gigc vid i t dclig m py squ wih ag pduous bdom gi g ovr bdly rioy ppd pvis (Fg 6-7. LS howv cts mor wom h m Wom os d ot ot vr rgi rgi bdomi strgh prgcy Ty r courgd to coom to h shob stys h dmd high hl sos. Both o s ctos wi courg LS
154
THE w BACK AND PV
ydrome (S ig. rdc l mbar ydrome
g a a. Te gueus axius wi be wea ad seced. e piios ay be ypeoic, o ilaed ad wea. Te piois wi be aepg o copeae o e wea gueus axus Soe paies wi S ae soac seepes Poe seepig abis wi sess e ub spie aeoy iiaig e psoas a becoes coaced ceasg e odosis. Soac seepes oe ow oe o e oe eg ou, wc pe cpiaes a aea oao subuxaio o e eu (g. 68 Ts poduces a og eg wc wi se, be e subec o adapao ad ue copcaios. Te iia eae us epasize e educo o aao. Te ypeoic usces e psoas ad iiacus ad, ess iey e saoius T ad ecus eois soud be seced ad e pae soud be suced abou ow o peo oe seces o educe coc usce coacue Te soac seepe wi eed soe aid i aeig e seep posue. Oe eod s o use a be o od e ees ogee. I seep, w be possbe o seep poe. oe eod a ca be successu is o ape wo abes o eac side o e ubcus Lie e abe o e picess ad e pea os paies wi o say poe o og. aes abou 30 days o bea e poe seepig ab. Te use o a body pow a e paie ca seep ove s epu wi dcu cases.
ig. -77 Aerir elvi c i l wih weak abdomia ad aei aeirr ead diaceme
I bo e decg ae pysique ad oss o abdoia seg ae pegacy oe w id e psoas o e iiacus o bo i a sae o ypeoiciy w aed pa o papa io o o e bey o ogi/iseio. Te abdoias ae wea o seced ad e owe poseio bes oe ae o wo
g. -8 Smach leeig.
Condtons and Treatment
Stretching Technques
h a umrous mthods o strtchig muscls, rom rx mthods that us th sidl cs ad Golgi tdo o gas to rst th urological comots o th musc, to vaious combiatios o cotract/raxadstrtch mthods h atur o h cotractd musc wil dtrmi th bst mthod. acutly straid muscl may b mor comortably rlaxd by woig th ssory orgas ad avoidig uthr damag b ovrsttchig
1
4�
Popoceptve Adjustment
Chaitow dscribs sidl cl ad Gogi tdo wor as orioctiv adjusig but acow dgs its mo commo dscritio aid isioogy agr with his statmt ha th tight hytoic muscs shoud b dat with irst lid isiology strsss th wa muscs h coct is to ay light thumb ssu (two ouds toward th c tr o th muscl i th ara o th sidl c ls or away rom th ctr i th ara o th Gogi tdo orgas h sidl cls a locatd i th by o th musc ad th Golgi tdo orgas ar locatd ar th origi ad isr tio Sid cls d bac cotactio orcs. Pushig to wad th ct o h muscl stimulats th sid to siga h musc to rduc is to h Gogi tdo ssors moi to orcs at th tdious origi ad isrtio By stimuatig th aras o th muscl ar th origi ad istio, ushig away om th ctr th Golgi tdo orgas d bac th d to rlax h muscl (Fig. 69) By worig th sidl cls ad Golgi tdo orgas i th oosit mar it is os sibl to activat a ax muscl to icas its to hav usd ths mhods with icosistt rsuts hav oud th mthod o strtchig rcommdd by Robrt drso to b civ. commds a two has strtch h ist is th asy strtch at th tsio oit o th musc or 0 to 30 scods h a scod dvo mta sttch at a mild tsio or aothr 0 to 30 scods hr should b o boucig, ad ach strtch shoud b i a comortabl rag. Ovrstrtchig activats th strtch x which cotacts th musc, ad th musc ds u tightr. othr civ mhod, osisomtric laxatio (PR, uss muscular aciitatio ad ihibitio to rduc muscl to h muscl that is big strtchd is brought to its maxi mal gth without srtchig h atit is asd o cotact th muscl (wih miima orc agaist th xamirs sis tac or 0 scods h ati is th istructd to com ty ax ad wh th hysicia is crtai o comt laxatio, th muscl is ogatd urthr, byod th origial tsio oi o scods this is ot succssul th hass ca b icrasd to 30 scods, o th isomtic has shortd ad atd thr to iv tims Sttchig h soas ca b achivd by addig tsio to th homas tst or hyrtoicity (Fig. 6 0) By havig th
Fg. 9 Sile el S a Glgi te (G reure T rei rege e Btm ie i weake e
Fig 10 Pa et
atit do th xtdd lg o th tabl ito xtsio, hodig th oosit lxd tight to th abdom h hysicia ca ay xtsio rssur agaist th xtdd thigh h atit ca us this mthod to strtch at hom h iliacus ca b strtchd by holdig th sui atis isrtio ara o th ir mur ad alyig ostrio rs sur o th ilium. his is a ssitiv aa, ad th si is ot asily ovrstrtchd. B sur to hav lty o slac. h sartorius ca b achd i th sui atit at its bly ad origi o isrtio. dirct strtch is bst with a am cotact ovr th atrior surio iiac si (SS ad a idx cotact at th mdial asct o th wh th sarto rius asss o its way to th s asrius Pssig dow o
56
Lw BACK AND PELVIS
he ASS, ong he um poseror, nd pushng owrd he nseron he medl knee, he uscle s comfory sreched. he cn e sreched y plcng he hgh (pen supne no fleon, slgh ducon, nd slgh nernl roon, eg eended. Suppor he leg y holdng he nke. he cephld hu s used o srech he muscle fers owrd her orgn on he lc cres, s he hgh s lowered no eenson nd dducon. he recus emors cn e worked wh he pen n he supne poson y pushng nerory on he pe nd superory on he neror neror lc spne. he prorms, f hy peronc, cn e sreched y pplyng pressure owrd he scrl orgn whe he pen s n he sde posure (g 6 n LS, he we musces, he glueus mmus nd prforms nd, mos mporny, he domnls, wl need o e srenghened (see Chper 7 on ercses. s more common o nd n ny o cve he domnls n women. hey re ofen une o perfor pelvc rockng con nd ecoes necessry o rn hese pens o cve he pelvc rhy hm hs s ofen resu of he ncon o he domnls durng pregnncy. Wh he pen n he supne poson, sk he o rock he pelvs nerorly o poserory. hey cnno, sss hem y pcng one hnd over he lower domen nd he oher under he scrum nd cvey rock he pevs ck nd forh un he pen ecomes wre o he necessry con. hs s n eercse hey should do severl mes dy o reeslsh proper one nd ncon o he domns Sups my e necessry o compeey srenghen he uscles. Mnpuon n LLS s dreced correcng ny hul suluon perns. Aneror ons o he l re common. Aong wh correcng he musces h ow nd pro
duce LS, pssve oon ppon (M should e used o check for AS fon (g. 6 2. he condon y requre repeed djusmens due o hul chnges n he propro cepve mechnsms dpng o he mlnce, nd conrcul chnges n he connec ve ssue (g. 63. Aneror on suluns wll e common n he ower umrs he hyperonc psos sps o 4 nd 5 cn mnn verer nerores (g. 64. he knees nd fee shoud e checked or suuon perns. ercses shoud e sred s soon s he pen cn do he whou pn duce he pen on eer posurl hs. Somch seepers need o chnge her hs, or use sup
-Fig. 2 av e m alpati r AS i im ixati
Fi. - ri trech
Fig 3 AS lum admet
Coditio ad Treatmet
57
14 Aerior mbar admet
por pow under he somch, or seep ove body pow The pen's wok nd py hbs shoud be consdeed fo ny cors h e conrbung o he LLS pern
6-5 Papaio of ac cre ad poerior peror iiac pie
LEG LENGTH INEQUALITY (LL)
The em fndng of unequ eg engh s very common woud esme h 8% o pens w show uneven egs oweve only 8% o % e nomc The funcon shor eg s conroves A number o uhors wrng on he subec o LL seem nehe o rejec nor ccep he de h umb nd pevc dynmcs re cpbe of erng eg engh They wl dm o he need fo fuher sudy Mos echnques n use consde he unconl sho leg Logn dened cer se of uncon fcors h w cuse funcon eg engh nequy (LLn) e found n hs premnry cnc sudes h he could consseny dgnose by physc emnon n nomc LL nd be whn wo o hree mm of he mos cceped rdoogcl mehods n he emnon, number of fndngs w ed o n in vesgon of LL such s uneve c cress n he sndng em (g 5) nd glue folds nd knee fods (g Look for sgns of pronon (g 67) Check or hsory of eg fcue or hp dysps A pen wh LL w ofen snd wh he sho eg oed ouwd g 8. Ths s compensoy mechnism er roon cn ncrese he eg engh nd ofen he hp s chroncy subued ery Some pens wh LL w snd wh wde snce wh he ong eg roed ery, nohe emp o compens n he supne poson check cres nd ASS eves Check he eg eves he medl meo nd med femo condyes (see Chpe 2 on mnon) The bes wy s o hook he humbs up unde he bones on boh sdes wh equ
; )
6-6 Compari ee fod ei
7 ef Ace edo o meda cve etive o proatio.
158
TH w BACK AND EV
ig 6-18 Rh e roaed aeray o i creae e eh
pessre nd sgh down ove he Fg. 69) Check he heels for dscrepncy A long leg cn e fncony csed y: ) erly oed er, 2) n AS l, (3 n neror l (4 knee son nd (5) hgh rch n he oo A fncon sho leg cn e csed y ( 1) I l (2) nee son nd 3 pronon o dropped ch The knee cn sle lerly nd oe oe coony ely cn se eher long or sho eg dependng on nqe ndvdl vr ons. y enng he ncon cses sed ove he n ocoe shold e relvely eq eg enghs o re nocl dfference. Ths ehod o evon w povde
elvey ccre eseen o he dfference. I n y opnon s ccre enogh fo clnc pposes. The necessy of sng rdogrph fo he soe prpose of deernng he neqy s no cnicy necessy ecep n copced cses. A pen wh re wll oen cee copensoy chnges Coon ong hese e le oon sl on of he sho sde e Fg 620), AS on on he shor eg sde, or I on he ong eg sde. These e he se cos h cse nconl I (Fg. 621). The ponon of he long eg sde oo or he hgh rch on he shor eg sde cn e fncon dpons Anohe dpon cn cse he sho sde o se nfeoy wh reed Q sreching nd wekness In re noc hese nces e oen chronc nd wl reqe correcve nplon. The de s o nn ncon n he jons nvoved hogh npon nd sce ncng They wl en hehe nder he dded sess of dpng o n lnce. An n cn so nvove chronc dpve chnges h wl eqre progr of corecon. Fo nsnce chonc lerl roon of he e cod cse chronc I on h sde. The pen wh he pessen I h s wys coreced lwys hee on he ne pponen y hve er er h ps he l no I s soon s he pen s on hs o her ee. Soe pens hve very se dpons. I wold e nwse o ep o e nyhng n sch cse. se of o eps o sop dpve fncons y cee pn nd dys ncon where none esed. If deng wh ow c pen, e se he I s cly cse of he copln e ore peng wh The gener consenss s h n neqly o ore hn nch s consdered lkely o cse poes. n pcce hee
g20 Cecki era roaio o emr Noe decreaed roa ig 19 Ceci e e a meda maeoi
tio o r.
Conditions and Treatment
ig. 6-21 LLI and compenaon or a ri e decency pe vi c i and compenaory cooi i ac roaion nee and em roa ion , oot pronaon
re ome pen who hve ympoc dyncon wih le hn inch nd hoe who hve ble dpion wih inch o more. wold be nwe o nrodce oo ch chnge no be dpion. bee o ppo he body' efo by mnning nor jon dynic pobe nd bncing nd onng he ce o ccoode he dpion. Lifts
When n deermined nd l dpive imbnce hve been coreced i i poble o deermne he need or f. he body i doing ine who ppor, i cod be dro o dd lf oicly. Dr. ogn ed ehod preened by r. George Goodhe n he 970 direc chlenge o he erec mclokelel ppor ye The pen nd brefoo wh bnced pore nd oeched n fon hnd ogeher The exmine conc he hnd nd h he pien e he eo o ph he hnd down (Fg. ) Wch fo n obvo wekne n he pien eo The m wil no be ble o ei o he p en wl mke noceble efo o vod fling orwd. oo he fee. If he heel lif of he oor or he oe grip wih exggeed effor he ned fo if ndced. Sr wih i Y2 he neqiy rre o need ch more. ce nde he hor heel nd ee. he pien rence i impoved, i dmc poof o he need or lif. Add o bc fro he hegh of he l nl he on
159
ig 6-22 Strent e or determi naion.
ge repone i noed. By reoving he if eing nd epcng i, nd eng gin, he pien mde wel wre o he diference Thi wrene cn improve compince eriodic evlon of he i hold be done o be re ndced, or he correc hegh. i no ncommon o ee chnge over ime Where pronion pr of he dpion o or i fcor in uncion , i pobe h corecon of he ohe fcor or ppo o he ho eg wh lf my llow he foo o efcorrec. When conderng he e o ohoc be o ke re he chnge n he oo e pemnen nd no fncion in ne. ongem dpon o my inclde degenerve chnge in he hp pevi, nd ow bck. The need for correcve nipion w be likey. Chnge need o be gdl n oder o vod recion Al pien wl need o exece he ce h e wek nd rech hoe h re hyperonic nd conced The Q oen wek on he hor leg ide. The gle mxim wil how wekne wih n AS ilim. The bdoin e oen invoved The po nd ic my be hypeonic wih n AS ii THE UNSTABLE PEL VIS
The nbe pev he rel of xy of he coiic (S on. The coilc gen nd he overlying bodo fc e highy innerved wih enoy nerve. The nbe pelvi comon ce o evere ce low bck epiode Thi he pen who peen wih mjor
160
HE ow BACK AND EV
pan ann and ably bu de n neealy hw analg eanng a n a d ae. Mn papan n pbe and ue eng and hpaed eng ae panu gvng n ueul nan he hy ay be ha an undeyng hn ndn wh ped eaeban Anaal I an be a aue, a an a hy pegnane a pa al, he nuy ha daage he SI jn h ndn e n n wen beaue he eae pelv ubjeed he ee pegnany and devey. A he ay he pelv ga en enhaned by he hnal hange pegnany. I ee ha he pev uue neve uly eun pepegnany ably. ed an/pan njue an lead hnaly unable ue. I have und vey n n wen appahng 50 have euely panu lubaa aea. apan e wh a a pan epne and avdane ean. he n neve ue end bee hnally nvved wh b. h ue an be eveely panul he uh bu gve n ndan he paen eep dung eaeban. he upne pn be evaluang h ndn. Muh an be dveed by palpang he S jn and eeng hw epnd veen n al den ee hape 2 n anan. y puhng edaly n he hal ubey a neabe deeae n pan a he S jn ead he anveu peneu a a aual a A laeal pu n he ubey ha edue pan ndae ha he abdnal anveu and pe bque and he uh egen he Q ae epnble Ree wh ane peue ndae he glueu au wh upe peue he Q he pan geneaed by ule an nly hee aneuve wl neaby edue he pan. an naay nd n hee wl be le hange he pub yphy huld be palpaed hn pelv nably an ae he pub and hee ay be gn ubuan g 623 . pe he la and epapae ee hee any ele. I la pen wh a hane bel uld be hepul n evey. nng he addu and anveu peneu waaned. he ule ha ae nvved ae he ha alw a I pdue an AS pay he lau and he ue ha pdue a I allw an AS he glueu au pay Fg. 624. he ule nvved n a edal hu M ae he anveu pene and glueu edu whh pdue , and he lau ane be Q uh egen tanvee and pe abdnal whh alw Fg. 625 he p an al gue n an unabe pelv. Thee ae hee ue ha ae he au he gueu au he edal be he lau and he p. hee ule wl be ehe n ae hypeny wea. he ndn hn e he hypen ule ay have undegne naue and an hw gn y. he paen able uhe nan an be baned by
g 623 Left superio pubisadjusi ng i h impacor
d
a
e
C
ig 6-24 Muscles poducg a P o al owi g a AS ium: a. glu eus aximus, b quadaus lumboum ad poseo abdomas c hamsrigs Musces aog a P o producg a AS iu d i acus e TF saor us recus emoris
evauang he unn hee ule n he a ang and ng ee hape 2 n anan. Real ha he hal ubee wden n he eaed pn, and pull gehe a we and Supp he hane a he paen . h a he p and gueu au. Supp he ha ubee Suh upp help he anveu peneu and gueu edu Fg. 626. Redun n pan geae eae veen an help pnpn he pble.
Condions and Treament
Fig. 66-25 25 Tran Tranve ve perinei perinei pl ici m medally cang a me me
dial cim Anerir fier f he liac pll lac cre edally redcing il ia flare flare and M.
161
Arng on one oo wll be eer on he de o S nlm on. When he wegh borne on he good de he h e mce cion epeciy he Q on he nonberng, nvoved de wl e he ined S on. wl A een progm hold r wih he conro o nlmion The pen wih n ce ce hold be ordered o bed berng no wegh or wo o hree dy No dng o he S hold be done. Ading Ading he T9 T9 101 1 e help norlze he innervon o cr c mcle recl he cl oign o nerve oo on he pnl cod Adin Ad ingg o he S hold be dco, or hee on re nbe. Too ch djng cold ncree he nby. The be pproch o corec he pelvc blnce ch AS, P nd M. Ue block n he evere ge oher p proche proch e ee nwe ipon n he reen reen pn p n o ephie renghening exerci exercie e or he wek pevc mcle The igen y neve egn her orgn or gn gh gh ne ecy nd biiy o compeey compeey ppo ppo he S on on. . The ce becoe ipon econdry ppor Chonic ce y ke long e o bize Thee ly enogh edy mproveen mproveen o keep he pen mov moved ed SCIAICA
Spping ing i chial er erie ie a patient aemp aemp t arie Fig. 6-2 6-26 6 Spp
When obervng he pen pon ing, noe he knee The pien keepng he knee cloe ogehe ogehe y be ndcve o nvere peonel rin or piror wekne. The pro c n bdcor n he eed poon nd cve n he n c o rng h o ler roor role he hwy pon o nding reched. A pien who nd wh he knee r pr ly proecng bd br pne nd no n nbe pelvi.
Rding pn no he bock hgh or leg common preenng ypo o cc The exmnon wl oc on dierenng beween he vo ce o cc. nion n ion oen co n prodcng prodcng dclr ypom n he n een redcing weling cn oen re n rpidy dnhed ypo o cc When neroogcl ndng re ligh o nconclve, oen n nl perod o re, ce, nd crel niplon cn elne concen ove dcogenc cc Nevo ie lowe o ecove hn oher ie. imporn o ndernd h o jp oo oon o concion cn led o nnecery nnecery nvive procede Depending on he everiy o he nerologcl deici,, he pien hod be nome deici nomedd o vlble v lble opon Uly he medc me dcl l pproch o w nd provde pn, pn, ninory nd ce exn medcon, whch do no wy reeve ch o he dcoor Peripherl enpen o he cic nerve cn occ n he bock Poi yndroe he rion o he cc neve by dyncon o he piio. Th dyncon cn be de o p or overechng nd lxy. Check he prori or rengh nd hyperoniciy The pien w l hv hvee no gn or ypo o pnl involveen. Thee gn Th ee ly gncn ppble pin in he cic noch. A lerl roon blxion blx ion o he er cn be precping cor, cng rron in he er o ooe oe Treen hold be deced edcng he emor bxon Fg. 627 nd eiher reching o onng exece o norle cle ncion. Proceed wh con nl he every o he nerii h bded.
THE w w BACK
AND V
b aagd wh r, ic for for pa ad fammaio ad car car f aipaio y ha oo aggrv a approach wi wor h ypo rmi cadicaio ca ic ciaica rmi ciaica or pc odr ad i cary rad o acviy coig o wh wag ad o qick qicky y rvd r vd wih r r Discopahy
Adjstme jstme for e e ot otio io bxtio of femr femr Fig 27 Ad
Aohr ara whr h rv ca b irrad i h poa mc Th pia rv ha a p h bar px pa hrogh h poa ar a r orgi or gi o o h vrbra Wh h poa i hyproic or irrad ad amd h rv pag hrogh ar ar dagr of big irrad a w Thi cod ca radiaig pa io h aroara high Srchig ad corrcio o h facor ivovd i crag h hyprocy hyprocy ar idicad Th ara fmora cao rv ca bcom famd by compr compro o or rama ovr h arior hp ad ASS A SS ara Mraga parhica a i ow, ca iic arhrii of h hp jo ad a acor acor o coidr i i d dra diagoi Thr ar vra rrrd pai cha ha ca ca radiaig pa o h bock, poror hgh, ad rary h caf Th pa igam ik h gam fav ad h faca capar iga ca rfr pai wh iriad Th g md ca wh iad, iic caca proa commcao rom R K) hod b xaid or wak or amaio amaio or boh tenosis
Dgraiv podyoi ad hyprrophy of h igam m avm i parcar addd o dgrav chag i h di ca ak h paag or or h rv roo qi aow ai wih o w rr radicar yp ypo o ha ca
Th crad of compd omography (CT ca ad magic roac magg (MR) hav how may proro pro ro ha ar i cda, caig o ym ympo pom m Wh a dcogc radicopahy i pcd, i i impora o rcogz wh o rfr or rgica coaio f h roogica ig ar igica, wh vr wak o mc ad g of arophy, h pa hod b rrrd for poib rgry Sig o baddr or bow dirbac ar ao ri o ig f iia ram how o mprovm, i b o k aohr opo rag pai wih ac dik probm h r wo wk hod how om poiv prov h roogica ig ar vr, h ogr o hia, h mor iky hr wi b prma daag So pa hod b rfrrd righ away Thy may o away ak h advic o h rgo ad prr o avoid rgry by oghig i o wih corvaiv corvai v maag maag Ma Mayy dicopah dicopah ca b afac ory rovd wh m m r ad corvaiv ram, icdig rhabiiaio apaio hod b jdicio my opo i i o cary o avoid adjig b car hod b d o b a pcifc a poib ad forc hav od h fxio/racio chq piord by h oopahic profo ad carrid o i h chiropracc profo by Ja Cox, DC, o b civ i may ca i pcfc ad g mprovm hod b od wh h ir o 4 day improvm o od by hi m h probm may b a or rio hriaio ha may rqr rgry I hav od ha cra proro or rpr ar c cy rad by maipao Th pai who hav a aagc a o h id wh cac ympom or pr wih ard xio xio aagia a agia or ig o mp v o vovm may ao b rgica cadida QUADRATU LUMBORUM
hi ar rarch Dr oga ocd h aio o h qadra bor (Q; Fig 8 a a mpora mc i h cioa abiiy o h ow bac ad pv Dr oga cica ci ca di, h fod Q ivovm 9% o ab a b pvi ca A dcd dcd arr h Q i a mfcoa f coa c mai co ar ara ara bdg of h mbar p ad dprio o h h wfh rib rib v ho hogh gh i a hi c, xr gfca ifc o h baac
Conditions Conditio ns and Treatment
163
Fi 29 g feriory for QL imbaace
Fi. -28 28 Aerior vie of deep deep muce. a. uadra mboum b
iacu c poa
he mba n laea ably and la c pp he fh egmen check ane lac an and flae he ene mcle pp he a nflencng pely he Q en nd be eak fen naealy, n ch cndn a he nabe pev ncna and ana mcal l he pan hen pefmng a alava maneve hen cghng may be caed by Q an m cnac befe he daphagm h hld be cndeed n he dfeena dfeena dagn h mcle dffcl dffcl ae a e I nee can be deemned n deemned by acnng he leg nfely nfely h a pll ha ck he pev Fg 629 Ne f hee exceve pelvc ckng ckng a h ndcave abdmnal eakne If nee f he Q mce eak n e ak l h a a an ne ne a a and nge leg h h acn Q pbem can cae pa pable pan a a he 2 evel evel naeal al eakne fnd fnd adj 9 9 and e e a nae check Adjng h leve mlae he neve ppy a he eve n he pna cd hee he neve gnae f hee n mpvemen, he paen hld be gven a pecc exece ee Chape 7 n xece f he Q and nced d nlaealy f eek n m cae he eakne l be ceced he Q hld be checked a a mae f ne and any eakne ceced If h mcle velked may be dcl mpbe eec a cmplee ce
can be eavey e avey able and cae he paen le n pan daby In appachng he eamen f a paen h "ah e e can and lgh manpan nally f he paen ha been d by anhe phycan ha hey ndeed have ah hey ae en ef h he mpen ha hee nhng nhng ha can be dne hey ll have lve h l ge e and dange ampe h a hey ae n vey fage In acay hee paen can be eaed ccefy and h elave aggevene eamen deced a eng n mby and edcng abnmal e de dyfncnng mcle and elaed mbalance can affd e lef fm pan and mpve pefmance I mpan e edcae hee paen ee he cndn a cnllabe and n decae Ung mdale ch a hea land and eeccal mce mc e man man can ca n mpve mpve ccan ccan n agnan e Manplan hld he cndn cndn f he paen One h evee pndyl and nea ankyl hd be eaed h gene echnqe degned manan a mch mvemen and agnmen a pble, and aenn hld be pad he adapan he paen ha made he pacla an eepng he adapan baanced and fee f pblem he key Many de paen h ah need be encaged exece A ack ne en epnbe he fale f adapan and keep he degeneaed aea nfamed have ecmmended yga and a ch a genle, lmn fm f maal a a excelen exece exece ha ae genle and afe
ARTHRITC LUMBOSACRAL SPINE
Many paen ha peen eamen l have me de gee degeneave jn deae n he hp, aclac n and lmba pne pne In my expeence expeence hee n cnen cn en c ean beeen he degee f degenean and ympm Sme he degenean, a evdenced n adgaph
H COND CONDO O
he m cmmn hp pbem pbem een e en clncaly clncaly ae eaed anng nje n alay acaed h ama b elaed chnc dyfncn n he le back, pev, and le exeme exeme and degenea degeneave ve change
164
E w BACK AND EV
in in he in he hip cn come from fr om eer oce he bure of he hip cn be he ource o pin nd imion of moion he opecine b (Fig 630 cn be irred by chroncy ery oed emur he ochneric nd he ichioge be cn be nured nd inmed he on cpe my be noed nd chronic cpii wi cue conrce conr ce n educed moon Degen Degeneron eron o he jon will cue oc pin nd reered pin down he neromedi hgh ofen o he knee opecine buri w how ignifcn pn on direc ppion n f fexon wh dducion wil be reiced he hip fexor wi e wek due o pn, nd he pecne my become become hyperonic hyperonic reducng bdcon here oen n neor ii he fem chonicy blxed, blxed, i impor n o reuce i nd keep reduced Bede dng nd ice herpy her py inuc inuc he pen o o odd ng ng cro crol legged egged,, nd cuon he pen gn omch eeping n he exminon o he hp finding of reduced rnge rnge of moon h ncee er drc on i key wih degene degene e chnge remen of degenerie hip condiion houd
be dreced owrd conr conro o ng nfmmon nd corec corecng ng co h wil re he hip Any mucle imblnce whehe wheh e hyperonic hyperonic o wek w need o be dde ddeed ed dem of he hip cn ighy enghen he eg Compreon o he on wil empo emporiy riy reduce reduce he engh (Fg 63 1 in cn be eicie eiciedd upon p pi pion on behnd beh nd he ochne ochne peor o he pirifom pirifom nd n no oe e o he ch ch be beo o y Re nd ice hepy re ecommended Diferen dignoi Diferen dignoi i mpo mpon n n ch dren he hip hip cn be inoled in phoogc procee ch eggCe erh dee o cox pn nd ipped cpi femor epphy he ery preenon my be of md hp in wih gn o nfmmion nfmmion Rdogph hod be ordered ordered [n oder pen ge dee mergi prehec (n inmmion of he e femo cuneou nere o eoporoic rce inemen cdcon nd dcophy houd be condeed A rue ny nonmc hip pn hould be horoghy neged he hd n eldery p ien culy wlk no my oice wh femor neck rc ue
g 630 oe bs b ilopeie br l bus
g 6-31 Compess pek ing fo fo edem.
Condiions a d Tratmen
165
REFERENES I . Chatow . Soj Tisse Manipulatio. Wellingborough: Thosons Pub lishing Grop; 7 2 Back J Pimary Firomyalgia Syndrome. Ortho-iefs: Amerian College ofChipracti Orthopedists 3 40-0 3 Logan A Foot ad Ankle: Cliial Apet Gathersburg, Md Aspen; 4 Anderson R trething olinas Shelter Publications In 0
ea California Chiropracic Associaion alm Springs Calif: ne -2 , 7 ogan A The Knee Clinial Aspets Gaihesburg Md: Aspen 4 Gille H Belgian Chiroprati Reearh Nots, 1985 Hntington each Calif Motion Palpation nstitute Goodheart G Appl ied Kinesiol ogy Notes resented at Aplied nsiol ogy Seminars 6
HannonJ Scainge J New diretions in he management of mucloskel
Cox J ow back pain: ecent statisis and data on its mecansm diag
etal ondtions eture notes presented at the os Angeles Colege of Chiroprati iense enewal Progam Sacramento Cali f: Apri 23-24
nosis and teatment from hiroprati manplation Ja l of Chroprati Ae rian Chiroprati Aoiation ; 3 : - 3
4 6 Manello D. eg length ineqality: A lterare review Presented a he
Seent Annual Confeence of he Consortium for Chiropraic e-
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Chapter 7 Exciss
7 f a spose s avaable e o se ca be elised to e se compliace
ey faco i e sccess ocome of eatme s te eabtaive eecse ecessay o esoe omal msce co Getg pae complace tis pase o eamet is ley o be difclt Most paes ae coopeative as log as ey ae pai bt as pai sbsdes tei tees eabii tave pocesses dmises. some cases e best way o ese compiace is o ee e paie o a eab faciiy wit a pescpo eab ce e wil be stafed wi aed eapiss wo ca moo te patie esig pope compiace. ee is a gowg e est amog may pacoes i esablisg iose eab cetes s is a ecele way o cool te paties ee cise pogam ome paiets ae aleady membes o ea clbs wit ad eqaey eqipped gyms. ey ca be edcaed te oce ad eleased o tei ow ecogzace ose pates wo cao aod eab o gyms a be gve aiig i e oce ad povded wt iepesive essace eecise tbg ad ca wo ot a ome. ese paes ae e mos dfcl o cool oweve. o ese e eecises ae peomed ad peomed coecy e folowig ms be doe:
8 leay epla e mbe o epeiios ad mbe of sessos to be compleed pe day. 9 Revew te eecise ad cec mscles fo impove
me o sbseqe viss We elyig o te coopeao of e pae te smple e eecise pocess e easie is eeco te moe iey i wl be folowed stead o descbig e mbe o ses ad epeiios pe set ave od easie some cases to give te paet a me lie. Fo isace wil sc e paie to sat wt a oe o two mite se o i e mscle bs a few mies o es e epeat aga. e paie ca gadaly icease e ime as e mscle espods e ee o e pogam sold be ailoed o e paies codi o ad abily e eecise coceps descbed i tis cape ae ose deveoped ove may yeas o clcal epeiece ey ave poved to be te mos sccess eecses we elyg o te patie o comply e mscles cosdeed ae te mos com moy fod o be wea o dyscioal ee ae meos eoies ad metods o oig mscles. e eecise co ceps descibed ee ca be modiied o i ay pogam ad sold be a eample o ow to ige o ceaive ways o isolae ad toe paccaly ay mscle.
1 Gve a caef eplaatio i lay ems o eacly wa te pobem is 2 est e msce ad demosae to te patet ow wea s ad sess e mpoace o segeig it 3 emostate te eecise 4 ave e paet pem e eecise mag se ta ceatig (ecme o oe mscles does o occ
AONA
5. Povde wee possibe a diagam o te eecise as a emide.
ee ae coless ab eecise eciqes e evolio o e sit-p as pogessed om e old stag egged ll sitp to te moe coect ce cce oga de vsed is sp eecise to ly acvae e otal adoma
6 ae avaiabe eecise tbg f it s o be sed. o o ey o te pae to obta it o is o e ow.
167
18
TE Low BACK AND EVIS
grop y cses he ecs s he os ephsized, d he oiqes d sese grops ge iy wored es peciy he owe peic es he l s-p wil es he psos sces he secod hf of he oee ore cses h o he psos scles re redy oo gh d f sp wi exggee he ice ewee hese wo goisic sces "h sp h soes he doils d deces he psos is dgeos By pig he egs p oer chir wih he hips 90°, he psos sces e le o ssis wh y segh By iiig he sp o he s h (risig p oy o eee he shoder des fro he loo), he dois re sed fly he s e e feig he ow c o he oor which is he peis poseiory wors he owe do fiers Wih he s osreched rise p o och igiry poi o he exree e Fg 7), hold o co o wo d sowy er o he foor his is posio oe h ech sccesse sp, oe he giry po o he rgh pss g he cee poi (oe he ees d edig wih poi s r o he gh (Fig 7-2). The wor c o he le his si poi rdis of sips wors he oqe d rserse es he pie c e srced o ssess ech posio d dd exr repeiios o hose posos h see wee
72 St t 6
UU AXU Exercse
sc he pe o s o hds d nees Rise oe leg p d "psh he foo owrds he ceilg (Fig 7-3) o o oe he peis The hip jo does o orly eed eyod er ore h 0 Frher exesio wi e c . 73 Glts mxms xs
coplshed wih pelic roio h defes he prpose o he eecse. r wih 8 o 0 epeios o ech sde d co pre efos dd ex repeiios o he wee sde s segh ceses e weighs c e dded s wel s he er o epeios icresed Exercse
F. 71 St t
Usg esisce ig sdg execise c e doe d e o des or le d es he wegh-eig hip gs he edge o he e Fex he hip d ee o he side o e woed d secre he ig od he hee ecre he ohe ed gs he des wh oh hds sh he oo c gs he esisce o oe h eigh iches ps he ohe leg (Fig 7-4
Exercises
9
F7-5 Gls ms xs
AERA HIP ROAOR F7 Gls mxm x 2.
These eecises icde he pioris ad gea sces Exercise
epea 6 to 8 es ad eese to wor he othe sde o pae he eorts ad wor the weae side a te oe Exercse 3
This s a owegh-bearg posio hat is ease to do f he patie is abe to pefo he fis wo ethods he pa et ies spie with the hp ad ee eed to 90° The esis ace tbg is hooed aod the hee ad he hip s eteded o a 45° age hs is actay he sae as he stadig eer cise doe spie epeat 6 o 8 ties ad swch to the oppo sie side opae ad add epeos o the weaer sde
ece the esstace bg to the eg o a heay pece o ite to the side beig eecsed it i as reced a pos o as possbe wh the hp as eteded owad eta as is possibe (abo 30°reca that he pios becoes a ab dco as he hp is eed owad 90°) ook he tbg aod the oo ad p acoss toward the opposte eg whch oaes he hp ateay (Fg 7-6
GUEU EDU
Exercise 1
The mos sccess way o wor the ges eds s o istct the pae i sde ifs (abdcto with sigh ete sio) i he sae posiio as he es yg o oe side the he other (ig 75 cease epetitios o add ae weighs o boh Exercise 2
sadg eecse ca be acheed by spportig the body by hodg o o a wa or chai bac The eg is abdced ad sighy eteded whe he peis eas ee his e sebes a baet eecse
F 7-6 fm xs
170
TE BA AD PVIS
epet 8 o 0 ies f both sdes re to be wored co pe d dd epeitios o he weer sde Exercise
ig p stigh hoo the tubig round he hgh e he ee ecre he oher ed roud he oppose ee bduct he thigh o execise he pifors whch ths poso, cs s bduco Fig 7-7). QUADRATUS LUMBORUM
ecre he ubg t chest ee osg oted ed doo jb is coeet ehod o hoe se xed d "oc the nees They shod o bed drng he exercse oeet houd be fo the ws p Me sue the peis does ot shit e towrd he door d te esio o the tbig hodg he ed o he ches wth both hnds Fig 7-8 gist the resstce d do sde bed o he oppose sde Fig 7-9) Be sure the shoudes ren lne nd do ot ote to recu othe sces d "chet epe 8 o 10 tes epe the boe exercse firs wh oe oot to 8 ches behd d he o 8 iches rot o the othe foot o pre the effo d dd 8 o 0 ddonl epeitios to the weer oot posio Ths posto chge ephszes d ere portos o he sces beig wored
ig 7-8 Bennn n QL exere
ig 7-9 Q exee en pn
TRANSVERSUSPERlNEI
Fig. 77 Prm exece 2.
Ths sce s ctted to sbize he schi uberoses po o he cto of the dductors reug the hgh o bduced se
Exriss
he es way o perfor hs execse s to s sped i a cha wh the egs exteded o ad caped agas he egs of a facg chai i sight adcto soetc coracio to rg the egs ogeher w activate ad wor the rasve ss pere (Fig 7- ave the pae do a e secod so etrc cotactio 2 to 3 ies a day sadg execse ca e doe y sadg wih a wde stace ad isoetrcay coac the addctors which eces sates he a actio of he asverss perie (Fg 7- WE Q AND CCCYGEA FBES F THE GUTEUS AXI US
17
he patie s proe Fex the ee o 90° dc the hp as far as is cofotae he f he foot oward the ceig withot rotatig the eg (Fig 7- 2 Repea 8 to l tes Exercie
sig verso ca e doe wih tig he tg is se ced aod he ac of the ec ad hed tght o he oppo ste sde The oher ed is secred to the ee it o the edge of the chai ad adct ad flex the hp; tae p a sac he g ad ove he kee towad he foo, eepg he ee adcted (Fig 7- 3 FIFTH SEGENT F THEPSAS
Execie
The forth Q- sege ad posteror adoas are part of he syste tha ps he iiac crest eday coeig the asverss peie Whe wea hey wi aow a eda s ch The coccygea fiers of the ges axs re ofte wea with a ateior coccyx
Fg 7-10 Tanveu erne exece
Fg. 7 Stann exece fo anveu ene
he owe psoas ad iacs ca e isoated whe fod wea he fth seget of he psoas s ofe wea fo ftg iries that occr po isig p
Fg7-2 Execn e owe QL n coccyeal fe o the lu eu axu
Fg 7-3 Sn exece o lower QL an coccyeal bes o he lueu axLS.
172
E w BA AND ELVIS
[ he sg posito sece he tig oe the kee d the ohe ed der he oppose foot ke p l sck d he kee towrd he chest hs w work the whoe psos By edig fowrd frhe fexig he spie d hp the ower psos fes d the ics c e isoted (Fig 7- 4) hese st three exercses re the ost iportt the e hiio o f the ste pes HIP AD WA XCE
Adductors
he p is o d eyod he oppose eg ito ddctio (Fig 7 15 Wth ech epeitio oe he foo fowrd d he reerse diecio d oe posterory steppg oe the ig d pogessig hree o for ceets ito exesio (Fg 7 6) g 7-5 Aun exeeane an p Abdctors
td with the e secred t foo ee d sece firy rod he ke Wh the kee srgh dct he hip to coforte ed poit (Fg 7- 17) With ech sccesse ep eo oe he foo forwd hree or fo ceets d he ck to po hree o for crees ehd the oppo site foo seppig oer the g s yo pss erl epet his seqece wth he kee e d the wst sces ore ctied (Fig 7- 8)
g 76 Aun exeepe en pn
hese execses shod e doe ery y postios th see weke shod e sressed wth ex repetitios LODOC LMBA EXEC
g 7-4 Sn exee lwe a an lau
he ordotc r sydoe () is os coo dg chiroprctc prctice he sedety ifestye of the oder ge wl weke the sppot syse of the eect ody ess it s popey execised
Exeriss
73
Fig. 7-19 Atve blaeal SLR Noe eased odoss and pub symphyss owe than anteor seor a spe ndatve of weak abdonals
Fig 7-17 Abducton exerse
ors ca go o work roery They ae key weak a mos cases w e ysfuctiog rorocetey Whe hs fig s ose ress o he ower aome a suo the aomias The hae he atie atem a aea R (Fig 7-0 The ierece shou e sgi cat which ca e a goo exame for comace The oowig execse ca oe he guteas a aomias as we as reesaish orma oroetie uc tio. ae he atet ie sue a ace 5 to 10 s o wegh o the aome eow he umicus Be oe kee, a ace the foot o he foor. Raise he es o he foor wh ha eg (Fg 7 he same tme otae he eis oste ioy. o for 5 o 6 secos Reeat 6 to 8 mes a eerse ses eeig o he chocy o he case, seera ses sos a ay ca e rescie his woks oth the guteas a he aomas Whe srucg the atet ths execse it may e ec essary o coscousy reeucae the atiet o use the aomas to oseiory oae he es, rockg it ack a
Fg 7-18 Abduton exerse wh kee en
The atet wih has a chroic aerory otate eis wth streche a weakee aomias gueus maxmus a ossy the rforms musces he iiacus a soas wi e hyeoc a i ee o setchig Tes or aomia fuctio i atiets y haig them atemt a iaera staigh eg raise (R) he eis its ateory efoe he egs t o it is a sig ha the aomias are ot acag roery (Fg. 7- 19). They shou e cotracg a saiizg the eis so the hi ex
Fig 7-20 Atve ateal S wth abdonal supot
17
THE w BACK AND PELVIS
Fig 7-2 LLS exece wh weh
forth Place a hand on the supine paen's abdomen and the oher nder the lmba spne. ctivey wok the pevs and have the paient aten the lumba spine while atempting o pl he pbis oward the chin This pevic rocing exercse wil help he paient ndestand what is necessay to nomalize fncon Ths condition s most common in women who have had chden The mscles are weak nd oen have no ees ablshed norma poproceptive inegraton aer beng sreched and nonfnconal during pregnancy
Appendix A Orgac Poblms a h Low Back
Orgaic probem may prodce may g ad ympom whch may icde ieerece wh he cio o peciic mce. Mce weake he ow back ad hip hod wa he examie o he pobiiy o orgac problem Qeoig he paie a o oher eaed ympom wi ead o rhe veigao o e o ogaic pahology a a cae o coibo o he compai o ow back pevc o hp probem. The heore ad appicaio o eex ad ogamce echqe coovea. Ye here a growig awae ha a commo head ik he may appicaio o he viceoomac eex. he acie pracice o yoga demo ae a eaohip bewee orga ad mcle. The echg echqe o herapic yoga are deged o m ae peciic mce ha ca aec pecic ogac cio. The mce aeced by rechg ae rkigly imiia o he oga-mce eaohp odced by Geoge Good hear i he 960 The wok o Fak hapma Fraci Poege MD ad Terace ee D3 have odced cocep o o mac g ad ympom ha ca be deeced ad ed o diagoe ad iece he co o iera orga va re ex echqe Dr. oga pe may year dyg he vaio mehod ad became covced o he vaidy o ap pyig hem ciicay. Thee i e reeach hi area. The co o hee cocep hi eachig come rom h be ie hei vadiy d hi dere o pepeae hee hep mehod o eame ad perhap ecorage reearc o vai dae her ico acceped reame poocol i he e i p o each idivida praciioe o apply hee ech iqe ad deermie hey oer ay coe way o impove he heah o hei paie. have ed hee ech iqe ad od hem eecve
FIXA TON-ORGAN THEORY
From he begig chiropacic ha emphaized he eao o aea o ixao or bxao ad ogaic pobem. 895 D.D Palme camed o have eored he hearig o a paie by adig he dora pie o a paehe i chi ropacic pae May echiqe popoe have labeed varo aea o he pie a ogac pace. 199 io Wel ad oer i h P hq reer o he or gaic pace e by may chropracor a ha me he mo promie chiropacic yem o popoe ogac pace wa he Meric yem which reae orga o pecic pa eve he eve vay rom aho o aho b are ay o more ha oe or wo veeba eve apar. i ikey ha vaiaio i paie aaomy ad mehod o papao ac co o he dierece MR YM T l- 2
T4 - 5 T6-8 T7 8 T7- 1
T9 T9- 11
T2- 5
ea g Gabadder ve Pacrea mal ee Adea Kdey eoceca ave Appedx Uer Proae
ve hogh here are overappig aea i he i above pere ixao i he aea hod ae he paciioer o veigae he pobiiy o orgac probem aocaed wih ha area. Frhe veigao may be eceary o dierei
5
16
T
BK D PLVS
ae bewee a udeeced rucura au ad a ogaic obe NUROVASCLAR DYNAMCS (NVD)
Terree ee D eabed eex aea a e e ieved eaed o eac orga o e ody e caied cce oe ogac roe by uig e eexe a reae oi Te coac o o e vea race o e ody (Fg A ) ae ee over e ocao o e oga or a ee decied e reexe ro e oga or ce vave Te coac oi aog e ie Fg A-2) are aaed a
"
/
•
,i
I \ , . ' •
,
I
0 ' � It \ \ �
1 ntenal recta sphnce 2 locecal valve 3 appendx 4. sal testne 5 pyoc valve 6 panceas head panceas tal 8. al badde 9 lve 10 cadac sphncte 11 uteus
12 3 1 15 6 17 8 9 20 2 22
,"
ovaytestcle bladdepostate uethra adenals spleen boncluns boch cortc snus heat tone thyod kdney
v d f
v d
aea o uce eo or eiiviy or bo oe o ee ia coac coicde w e xao ace Teae ig ND co o aive odg o co ac a e aroiae doa ad vea o ecic o e orga or ye beig eaed Te yca od ad o e ig ide o e ae Te rg ad od coac e vera oi we e e coac e dora aog e aaveebra ue Prere ig Accodg o ee e o oud be ed i a uao i e ude e ve ra coac ad gyg a coeo o ao ad a orazao o e vicerooac away Ti aio i o away eay o deec oe cae ay ake evera eae o eore oay Te o od be ed o a ea 45 ecod o ue ave ad e wio ee g e uaio ee i o ao o o evde re ry reveg oo ad coac e ycia o e ae e de e ad o vea o, ig ad o doa coac Ti ay ae oary ewee ycia ad ae
ND a hep oo i decogeg orga or eaxg vcea mce ad phcer. hghy eecive camg dow a oveacive garoieia (G ac cae o pam o diarhea. i a amazig oo he reame o a coic Tacig he dgeve ac om he era eca phicer o he cadac phcer, ca qcky reax ad omae co The ame pae o eex eame ca acvae a ggh oga a we. The reame by eexe eem o ormalie he cio o he arge oga whehe i i ove or deacive. The cha or ND (Figre A- ad A-2) ae expaded o cde poi or he g, hear ad hyroid a Bee de crbed hem. my experece wih ND, have had moe coe re wh he po or abdomial vcea. OGANUSC ATIONSIPS
hapma, a oeopah, od ha pae wh ogac probem ay had eaed area o eiivy. ke Bee he od eaed dora ad vea aea o eiv y ahogh hey are o miar locaio. hapma caimed ce eag hee aea by goadg. George Goodhear, D, iodced o he proeo he imporace o mce baace ad cio a par o diago i ad eame. e od ha paie wih kow ogac pobem had pecic mce ha eed weak (Table A). e dicovered ha goadig o he hapma reex poi e aed o he oga reed i a icreaed repoe he mce' egh. Wh her eg, Goodhea od ha he peece o ogac probem he eexe wod be pee ad he mce wod be ihibied. he mce wa jed how eve here wa o ecproca orga dycio Goodhea
able A
heoied ha he eao wa va commo ymphaic drai age chae ha ae aeced by goadig. e oied he erm eoymphaic (N) eexe o decibe h dig. CLCAL PROOMODOLOG
The oegog decripio o ND ad N i a erpea io o he wok o hapma, Goodhea, ad ee ad doe o eceary eec he heoie a oigay pre eed. Frher dy he preogaive o he reader. The o lowg Dr oga acco o hi aemp o prove c caly, a he Agoopea oege o hiropacic, he heoe o ND mce weake, ixao ad ND. To prove o dprove he orgamce reaohp, i wa eceary o prove o dprove he ixaio ad ND heore. everal hg had o be codeed: •
•
•
•
a paie wih orgac ympom preeed wh a mce weake, wod he ixao be pree Wod he ND reex be pee a xao peie, rerg me ae ime ad ohe poa ad coa a have bee correced wod he mce eaed o he oga ha i eaed o he xaio be weak doro i he pore ca be eaed o oe mce o mce grop, wod vegao id ha he ixa io pree Wih rher ivegaio, wod he pa ie have ciica o bcica ympom o ogaic problem a mce i hibied rom ciog a a e o a orga dyco, wod he mce epod i he ND reexe wee ed
Organ/Muscle/Fixation Relationship
ymptms 1 2 3 4
Iveted foot Low back Eveted foot Knee poblems
Orgn
5 6 7 8. 9. 10. 11 12 13.
Low Back Bowel Menopause Appendicitis Bowel Uinay Digeston Digeston Digeston
Bladde Bladder Ueta Gal badde Small itestine Utes Colon Adrenal Appendix leocecal valve Kidey Stomach Pancreas Gall bladde
14 15. 16. 1.
Respiatio Shouldeheart Shouldehyoid ndonasa
Lug Heat Thyoid Edonasal
1
Musc Peoneus tetius Pirifomis Anteior tibialis opliteus Quad femois Glut. max and med Tenso fasca ata, liotibial tact Satoius Quadats lumboum Quadatus lumboum Psoas Pectoalis majoclavicula divisio aissimus dosi Popliteus Pecoalis majorsteral divisio Deltoids Subscapulais Infaspinaous tees mino Upper tapezius
ixtin L45 L45 L5S T45 T711 L5 L45 T9 9 1 67 8 T45 T45 T3 T1-2 CT1 C1
18
•
THE
Low BK D PLVIS
f a muse is inhbited rom unconing as a result o an organ dysuncon, woud he musce respond o adjust ment o he ixaion?
] used severa methods to ind he answers. tudens in sev era osgraduate casses were insruced o dine on scy Mexican or aan ood or lunch. Uon ther reurn o class a the musces reaed o digesion were tested and retested durng the remaining three hours aer he meal. Ths was no a scentific study because boh he sudens and examiners were aware o he es Nevertheless, each me his method was used the mory o he musces ha resened weak corre sponded wih the organ required o uncton a ha time durng digeson As the hree hours passed and he ood assed the musces associaed with he stomach reurned to norma, and hose associaed wth the pancreas smal inestne and so orth weaened and hen reued o normal woud seem reasonabe that, he musce s nhibed when he organ is overwored i shoud be aeced durng any dysunction A paiens wih known (or a eas dagnosed) organic symptoms were checked or xaion ND relexes and musce weaness Fxations were ound in the majoriy o he cases with oven organ problems (on urasound, radogra phy, omuted omagraphy ec). n severa cases where xa ons were not resen, invesgation proved he origna diag noss to be ncorrec wih he new diagnoss later being onrmed on surgery. The ND reexes were resen in most roven organic cases One excetion was the presence o sones n the gabadder The reex was no aways present without sympoms. A reasonabe expanaion is ha, where sones are presen and are no bocking he duc the relex woud no be rggered Galstones are present in many ind vduas who have never experienced symptoms and are an n cdenta inding on anoher investigaion or surgery The muses wre aeced n amos a the proven organc prob ems n he majority o the proven organic cases xation ND reex and musce inhbition were al presen. Patens who presened wh ersisen ixaons in an area reaed to an organ were nvestigated as horoughly as os sibe or oher srucura auls. the ixaions were sil perisen he aens were nvestigaed or organic problems. The number o cnica and subcinical robems was great enough to justiy he use o perssen ixaon as a major sign o organ disease. ome patiens whou obvous sgns and symoms mited this invesgaton The atiens could not ethcay be reerred or nvestgaion whout ustcaion Of course some persistent xatons coud have been and baby were, compensaory or robems not ound on the examnaon. One prcedure used on several occasions wh casses o boh sudens and docors o chiroracic in a worsho seing invoved he reex reationshp beween the popiteus musce
T4-5 and galbladder Whout expanaon he studens were insruced to examine each other in he erect posure or ex onhyerextenson o the nees and to examine in the suine posture with he legs suspended by he hees or hose hyer exended wthout weighbearng) Those with biatera hyer exenson were elimnated rom he test Usng only those cases wth unilateral hyerextended nees the sudents were instucted o test he popiteus musces biaeraly. Nnetysx ercen o he hyerextended knees (mosy e nees) ested wea compared with he oposie nee. Careul aaon in he sune poson ound xaon a T4-5 in al cases. n wo grous adused each suden in he supne position and n wo oher groups he sudens were adusted by he examiners both wth smlar resus eventyseven percent o hose ad jused revealed uon reexamnation that boh he weaness and he hyerextenson were eminated O he remainder six responded when ND was used. One aed o resond; he re ored ha he had receny had an injury o he nee. One can only concude hat i he galbadder s under stress •
•
•
•
•
•
a xaion wil be presen at T4-5 the popiteus musce wl test wea he afeced knee wil be hyperexended he ND relexes wl be resen by adjusting he T4-5 xaon a resonse may be ex peed by the weak poleus muscle wih no drect neu roogic expanation) most o the me use o the ND relex (passive) aer a ese as may produce imroved uncion of the opiteus muscle (wth no neurologica expanation) and possiby w he ga badder unction
The vaue o the above esng is proved oen. When an examnation reveals a hyperexended nee a tight, sensve area is usualy resen under the rgh rib cage, and a ersisen T45 ixaton is resent nquiry nto symptoms o gabadder dysunction many mes surprses paens because hey usuay do not beieve that a reaonshp exss beween he gabladder sympoms and heir srucura probems. Wih he use o organ muscle relaonshps and subsequen nvesigaon ino he or gan probems, the reamen program mus be imroved.
Nothing s absoute. ach reex ixation, and musce test requires udgemen on he examner's part o deermne he relex, he degree o ixation, or the oss o norma strength or boh. Accuracy again depends on the degree o experence and abiity o he examiner To cloud he ssue urther paen re action varies rom ndividua o individua
Mos sigs d symptoms cceped by the medic commu y so requre the judgeme o he exmer d piet reco Oe study i Autr (where, with ocized medi ce oe woud expect ewer eedes surgeries) howed tht oy 5% o the ppedces removed rom eme pets were pthoogic. Other stude Ciori howed eve ower percetge o ccurcy.7 The cceped sig o ue eevted temperture reboud ederess over McBurey' poit d eevted whie ce cout were h crieri ued to determie he ecey or surgery. he re o ixio (T2 hd bee ppted d oud sesitive d the qudrus umborum muce hd bee tesed d oud cg i its orm regh coud eedess urgery hve bee preveed? Woud he percetge o phoogic ppedcie be hgher No oe c wer those questios ter the c. the exmier h the dv tge o the dditio sigs d sympoms provded by the ixo ND d org-musce reioships however, the digosis must certiy be more ccure There deey vdy to the exisece o orgc pce, d his houd be ught ppo d exmio d s pr o dgois togeher wh cceped dgoc sgs sympom. ND reexes re vube he dgo ss d remet o orgc probems d shoud be ught s pr o digois s we s techque The org-muce retioship s suicey correc o icude it oe o the sgs d symptom o orgic dsese d prt o truc tur yss
REFERENCES I Owens C A Endocrine InTerpreTaTion of Chapman's Rexe. Colorado Sprgs, Coo: America Academy of Oseopahy; 937 2 Poege F SympToms of Viseral Disease S Lou Mo: Moby 53 3 Benet T A New Clinical Basis for The CorrcTion o f Abnral Physiol· ogy Des Moes Iowa: oudao for Chropacc Educao ad Reseach; 967
19
Usig he hree heories s crosschec, some o he muce proposed by ppied esoogsts proved cicy icorrect bu he mority proved correc. Oy those proved correc re dicued here. Mos o the ND pots coicied with the eced muces d xtos. he ixios were oud to be coistety correct i ow prove orgic probem Noe o the bove i eded o edorse or ds cred ppied eioogy. The euoymphtic reexes were ot used s prt o he tes becuse my teto ws o crochec D. hereore the vidy o tremet hrough the ue o the euroymphtic reexes ws o co iderio A owedge o orm musce ucto s ecessry o e be he exmer o detec mucio or dysucio or boh. Deermig the cue requres ivetgio d shoud cude orhopedc etig euroogc esg, pptio or ixo muce testig d esig o the reexes ow o be hepu i rrivg t correct dgois. he use o or gmuce retohps xtio d D reexes heps determig h org probem exs, pipoig he org voved d ddg o exisg ccepted medic dg oic igs d ymptoms. heir use c oy ehce he digoc by o our proessio. The exmpe ued bove re reted o musces ecig he ee. hey my so rete to musce ectig he ow bc hp d pevi. or istce, persse weess o he gueus mximu houd ed o ivesgtio o he repro ducve ystem. Kidey probems c ect he psos.
4. Pamer D he Scien, ArT and Philosophy of ChiropraTic ord, Oreg: Porad Prng House Co 90 5 ro W Wee B, Houser R ChiropraTi Priniples and ehnique. Chicago 1I: Naoa Coege of Chropracc 39 6 Goodhear G. Apped Kesoogy Noe Preseed a Apped Keso ogy Semar 7-76 7 Chag A. An Aay o he Pahoogy of 3003 Appedces AT NZ J r 8; 5 78
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Appndix B Phycal Thrauc
A
epening n he appach the nual pacttne he use teapeutc maltes can e emplye t enance he heaing pcess Be [ hae ste he malities tat gan an hae un cnsisteny eectie in cn ling the inlammay an epai pcesses This is nt in ene t e a cmpete lis t iscunt he maliies that ae in e use
Te use heat is est n suacue an cnic cnitns. ais in the elaxan tght muscles an nceases cula tin The use heat n t acute a case il ikey ncease selng Tee is sme cntesy e the use et y hea eee tat et heat l aect eepe tssues, ut he ie ence s paly insignican. Te use mst heat is en aka hme heapy an an eecca heating pa s usualy suicient n easy ay mst ea heapy a me is t micae a amp tel ea au minutes [ ecmmen heatng n me than minues u tiple sessins ae ecmmene hee shul e an hu eak eteen sessns t minme the pssiiity a ecuence selng
RYERAPY
The use e t cnt pain an inammatn is ecg ne as an eicien meth n the acute stage nuy Un unatey, many meica pacitnes cntnue ase pa tents t put heat n a esh stain/spain injuy hc il me en tan nt, cause an incease in selng ecmmen my patients use ice n any nuy they ae un sue unless tee is ius musce spasm. ess am il e ne. Mst pepe ant t use eat ecause i eels ette ce l euce cicuatn an cntl pan me eectely ith ee se eects tan meicatin ce s es use in te acue stage inammatnte ist us The ms ecent an eecte met is a mnue inteupt sessin (LO mnutes n, 10 an 0 n again) t s my unestaning tat his nteupte meth l maximie te ecease n empeatue te ngest me (e 6 minutes) Te equency shu ay it te see iy he inuy The mst equent appicatn ul a u eteen sessins Patens ih ess seee inuies sul appy ice hee t six times pe ay
HT/CD
Te aenatng eat an e is a ey eectie ay ceate a tissue lushng eect n e suacute chnc sages The altenate iatin an cnstictin esses in he nue tssue seems ai n he excange ase pucs an es xygen an epai mateas t s eecte in cn ling muscle spasm ie as eucing the ppensty seling n sme ticky acue stain/spain injuies hee he musces ae pne spasm
1
12
T ow BACK AND PVIS
The methd have used mst successfuy is alternate fr 10 mnues each, heat hen cd then heat agan. have he patien d ur O-minute heat sessins ih a Ominue ice sessin in beeen. n her rds, fu heat sessins th three ice sessins inersersed s ha he aent stars and ens ih hea. yu are cncerned abut nfammatn, have the aten end the sessn ih ice. Ths is a lengthy rcess taking aut 9 minutes. i have the patien d this ne t t tmes a day r t t five days. EARANGE F MIN
When he aient s arachng he end f the subacute stage an s beginning rehab exercises, the use f heat r mnues prr t a range f mn exercse can be eectve in increasng circuatn and reaxing gh musces. f he patien nices any increased pain ater such a rku have hem ce dn aerard.
EERIA SMUAN-SINE WAVE
There are a number f sphistcaed eectrca simuatn instruments avaabe, rm sine ave generatrs t nerfer entia and mcrcurent instrumens. have und he use simpe sne ave e hepfu n reducing musce ensn. [n sme cases f severe sasm have used etanzng sine a tgue musces hat uld n reax h manua echnques. The use nermitten sne ih heat is an xceen ay t r musces in injured areas ithu irraing damaged jints. URASUN
Urasund can e hepfu n the suacue and chrnc stages hen the need t break up cngesin and reduce the endency fr serus exudae caguate and egin the frma n f cagenus scar tssue.
I
A
Anerir acrum adumen, 44145 paive min palpan 50 -5 I Anerir uperir liac pine avulin racur80 Ara16 Apphyea jn7 Ariing32 39041 ne 3233 Aric lumbacral pin163 Acular capule 4-5
Abdminal muc 4 exrcie 167 -168 mucl ng, 33-134 Abducr, exerce 172 Aceabular acure80 Aceabular abrum, 4 Aceabulum, 4 Acive raigh leg raiing33 Adducr exercie72 mucle eing, 129 Adjumen adjuive echniue 35 -147 cnac pin/line drve137 divried echniue 36-137 mpule 137 piining, 37 principle, 137 -139 repalpain, 37 -38 ide pure38 abilizain137 racn, 37 Agenei, pedicle, 723 Anamical leg lngh inuciency 58 uncinal leg lengh derenial diagni, 45, 46 Aneurymal bne cy, 12, 3, I 14 Anying pndylii 90, 992, 93 Annuu bri, 67 Analgic pure, 337 Anerir nerr iliac pine, avun racure 80 Anrir ngudinal ligamen7 Anrir acriliac ligamen, 2, 3
B
Becherew e, 56 Bending 32-33 Bengn bne umr, 107 -12 Bicep emri, 1213 Blc veebrae70 Bne umr97-117 umrlie cndiin 97- 7 Bne iland, 75 76 0, I 2, 13 Bny anmaly 8 Bwring ign56 Bragard ign, 56 Bur racure78-79 Buery verebrae707
c
Calcaneu prnain 37 Calcum pyrpphae dihydrae depiin dieae, 93
183
14
HE w BAK A PS
vical di, 5 hac ac, 76 77 Chdacma 0405 Chdma, 0607 bb' mauemen clii 69 ccygal dicain, 79 Cccygal acu79 ccygal pu, 8, 9 Cccygu 2 -3 ccy, , 2 adumen 47 mbinan blxai adjume 46-47 mpi ace, 7678, 79 Cmpued mgaphy 65-66 Cnnciv iue nammay pce 49 -51 Cyeapy, 8 uing' diae 96
D
Dgnaive dik dieae 8283 Degneav pna dieae 8288. S al Specic ype Dpiin dieae pina clum 92-95 Dmam pae, 5859 Dinial dagni ganc ucural, 5 9 -60 Diu idpahc klal ypei 87, 88 Dcgaphy, 66 Dcpahy ain/pain difeenial dagni, 60 -61 Dveed cniq 136-37 Dubl agh leg aie, 56 Dynamic pu 28
Elcical imulain, 82 Ely ign 56 Enchndma - 2 Enchdmai 12 Enema, 0, I 2 3 Enma, 75, 76 Enepahic pndylpay 90 Ec pia, 4 Ewig' acma 05 06 Eamnain 38 -6 analgic pue 3637 aiig 3940, 4 nin39 ein, 39 einnin knee, 37 gleal ld 37, 3 iliac ce 37 38 kee ld high 37 laal bndig39 pevc i, 3 pe upei iliac pne 3738
pain f calcaeu 37 pe eam5254 ange f min 39 ai 39 iing, 3940, 4 pie 38 ading eam 36 upine eam 40-52 uppe 38 valgu defmi, 39 va dey, 39 Eece, 67-74 veview 167 Eenin 39 Eeal iliac aey67 7 F
Face ahi, 8687 Face jin degeneain, 8687 Face pim, 73 Faceal in7 amau 89 Facelamina ji 73 74 Fema neve acin e 56 Fema iange, 7 Fmu, 4 laeal ain 445 laeal ain ublain, adjuen 142 -44 Fegun angle67 Fegun line 67 Fibacma106 Fibu dypaia 147 Fiain, 49 Fainga hey 7576 clinical p, 17778 Flaback pue, 3 Flin 39 Fleineenin f kee 37 Feie dieae 87, 88 Funcinal anamy 1933 Funcinal leg egh, anamcal leg lngh inuciency dieenial diagni 4546 G
a cell um, 07, 08 ueal ld37 38 lueal egin, mucle, 03 lueu maimu0 eecie 168 -69 lwe QL and cccygeal be eecie 7 mucle ing12425 lueu mediu, 0 eece 6 mucle eig, 25-26
Glte minimu 0 I mue ting 26 Goldthwat ign, 55 -56 Gout, 92-93 Gaili I I 3 mule tting 27 -28 Gavity lin 67 Geate toant 4
Hadley S uve 67, 68 Haming 12 mule ting, 29 -3 aming mbalan, 47 Heat, 18 ange of motion, 82 emangioma, 07 -08 109 emiveteba 7 72 Hemolyti anemia, 96 Hditay phoytoi 96 ip aion 23-25 26 evaluation, 4243 exeie 172 hp poblm 63 -164 mule tone, 53 54 mule, 13 othopaedi ttng 55 Hip abdution, funtional teting, 39, 40 ip joint anatomy, 45 itoy 35 -36 Hodgin lymphoma of bon 107 Hoizontal aal fatue, 79 80 Hot low ba, aement 6 Hotold altnation 8-82 uman body, ntional anatomy 9 -33 ydoxyapatite dpoition diea, 93 Hypepaathyoidim 969798 H ypogati atey 7 Hypogene pedile, 72-73
liolumba igament, 3, 8 liopetineal ba 4 5 164 iopetneal biti 64 ium adutment 139 -4 maging advaned 65-66 ow ba 6319 ignfant indental nding, 117-8 method, 63 -66 nfetiou pinal diea, 88 -89 90 nfeio ili adjutment, 42, 43 nfeio aum, adjutment, 145 nammation, 149151 aute phae, 150 honi pae, 150-151 ubaute phae, 150 nflammatoy pinal dieae 88-92 nnomnate bone, 2 nteetal ine, 69-70 ntenal ila atey 16-1717 ntepediua ditane, 69, 70 ntepinou igament, 7 nteveeba di 67 nteveeba di diplaement 83-86 ntevetebal di eight 67-68 ntevetebal oteoondo, 83 ntaatila oile 73 -74 ha bua, 164 ha tubeoity, avuon ate 80
J
Jont dyuntion, mule dyntion diffntating, 53 -54
K
Kemp' tet, 56 Knee fold heigt, 37 Knielap defoity 75
L
lia movement, 920 S and otaion, 47 lia atey 16 lia ompion t 55 lia et 37 -38 la xaton, paive moton palpation, 49-50 ia wing fate, 80 lia 3 mle teting, 3233 ia imbalane, 46
I5 anteio adjtment, 146 ineio, adjtment, 146 potio, adjutment 145 -46 45 fae, 6 5 ombinaion xaion, 5 -52 antional veebae, 8, 9 5 on S I antio fixation 5 obliqe o infeo xation 5 poeio xation, I
1
w BAK AD PELVIS
LS I , anmalus aricuains, 52 L5S I face Lap sea bel fracture 7 77 Laral bnding, 39 Laral hip rar, exercises, 19 -170 Laeral rar, muscle esing, 12 -127 Laissimus drsi, 15 - Lg lngh evaluain 4344 45 xaminain 52 inial derminain, 44 Leg ng inequaiy, 157-59 examinain, 157 -158 funcinal facrs 157 Leg lngh insuciency, 9 31 cmpensary changes 158 159 funcinal causes, 157158 lis 159 sable adapains 158 Liing 3233 Lis, leg lengh insuciency, 159 Ligamnum res 4 Limbus bn 5 Lrdss 221 Lrdic umbar syndrme, 31152 -157 valuain, 454 erciss, 72 -174 iniial ramen 154 psur, 53 -154 prpricpive adjusmen, 1 55157 smac slping 154 srecing chniqus 155 -57 Lw back bny ucures 19 anmalus anamy 89 imaging, 3 119 signican incidenal ndings 117 118 rganic prblem 175 -179 papain landmars, 4142 Lw back pain acue, 1 Lumbar dis angle, 7 Lumbar xnsin, 20 Lumbar facal jin Lumbar lxin, 20 Lumbar racure dislcain, 7 Lumbar lrdsis , 297 Lumbar pxus, 17 -18 Lumbar spin anamy, 5 -8 fracurs and dislcains, 75 -80 mechanics, 252 muscls, 13 -1 rpadic esing, 5 passive min palpain 51-52 Lumbar vrbra 5 - Lumbdrsal ascia, 7 8 Lumbsacral angle 7 Lumbsacral ariculain, passive min palpain 51
Lumbsacral regin anmaies, 7075 nrmal varians 7075 Lumbsacral spine, arhriic, 13
M
Magneic resnance imaging Malignan bne umr, 97100101 102 Malignan brus isicyma, 10 Medial amsring, 2 3 Mdia ischium adjusen, 14-142 examinain 47 48 Media rar, muscle esing, 127 Measaic bne umr 97100 10 I 102 Meyerdings grading sysem, spndyllishesis, Minrs sign 5 Muliple erediary exssis, 108 I I Muliple myema 00-04 Muscle, anamy 101 Muscle dysncin, jin dysncin, difrniaing, 53-54 Musce srengh, examinain, 5758 Musc esing, 52 53 23134 prcedure, 123-24 Myelgraphy,
N
euranamy, 17-18 Neurbrmasis, 7 8 Neurgical evaluain 559 Neurrpic spndypay, 88 89 Neurvascular dynamics, 17177 clinical prf, 177178 NnHdgins lymphma f bne 107 Nucleus pulpsus, 7
o
Obers es, 55 Oblique sacrum 53 adjusmen, 45 Obliquus exeus 15 1 Obliquus ineus, Observain, 35 Oburar exernus, Oburar ramen, Oburar ineus 1 Ochrnsis, 95 Oliers disease, 1112 Organic prblem lw bac 75-179 Organmusce relainsips, 77 clinical prf, 177
Index
Orhopadi tsting 54-5 hip 55 lumbar spine 5 saroiia joint 55 -5 Osteoblastoma 0, I 2, 3 Oseohondroma 08, 09 Osoid ostoma 08 -09, 2 Oseomalaia 9 Oseopenia 95 -97 Osoporosis 95 -9 Oseosaoma 04, 05
p
Pagt's disas 2 -4, 5, 1 Paravrtebal musles 4 Passiv motio palpatio 48 antrior sarum 50-5 ilia ixation 49 -50 lumbar spin 51-52 lumbosaral artilatio 5 posterio saum 50 saroilia joint 505 Patriks Fabr st 55 Pedile agensis 72 -73 hypognsis 72-73 Pedile sign o multple myeloma 0 I 03 Pelvi rotation 53 Pelvi tit 20-2, 38 Pelvis anatomy 4 avlsion raue 80 bony suurs 9 anomalous anatomy 8 -9 raturs and dsloatons 7580 musles0 -3 palpation landmarks 442 transvrse pelvi stability 2 -23 unstable 59 - treatmen Perentage o slips spondylolisthesis 8 Physia theapeuts 8 -82 Priormis 0 musl testing 2127 unstable pevs 0 iriois syndrome Plain m radiography 3 -5 Pasmaytoma 0 I - I 04 Posterior disk dispaement 858 Posterior ongiudinal ligamet 7 Posterior saoilia ligamen 2, 3 osterior sarum adjustmnt 44 passive moion palpation 50 osrior superior lia spine 37 -38 oserolateral disk dispaement 85 -8
osture 28-33 dynami 28 ideal posture 28-30 lordoti lumbar syndrome 53 -54 postural auts 3 postre in motio 3-33 stati 28 rimay maignant bone umor 00 07 rone exam 52-54 soas 3-4 h segment exerises 772 mse tesig 132, 133 soas mbaane 4 sorai arhropathy 90-92, 93 ubi shial rami 12 ubi symphysis 3 adjustment 147 examiatio 4748 udendal plexus 819
Q Quadrats lumborum 3, 4, 2 -3 exerises 170 mse tesig 33 Quadrats Iborm imbalane 4, 47 Quadrieps emoris muse tsting 3 -32 R
Radiography 3-5 angulated orona spot view 4-5 view 4 laeal view 5 oblique views 5 P view 4 upright vs. reumbent 3 -4 Radionulide sanning Range o motion 920, 39 heat 82 Relinng 33 Retus abdominus 4, 5 Reus emors I I 2 Reex examnaion 57 Reier's syndrome 92, 94 Rena osteodystrophy 997, 98 Retuum el saroma 07 Rheumaoid ahiis 89 Rhumatoid variant 89 Rising. S ising Risseerguson measurement soliosis 9 Rotaton 39 s
S I ransitional vertebrae 8, 9 Saal base angle 7
187
188
TH ow BACK AND PELVIS
Sc plexs 8 Scococcygl icultion, 3 Scoilic, symmey8 Scoili joint othopic tesing, 5556 pssive motion plption, 5051 unstbl plvis 159 -160 Scospinlis, 14 Scospinous ligment 3 Scotubous igmen, , 3 Scum, hozonl scl cue 79, 80 sc movmns 19 veicl sc ctue 79 Sgittl spinl cnl mesuement Eisensteins method 69 Stoius I I , 1 muscl tsting 1718 Schmols no 84, 85 Sciic nv 18 Sciic 161 -16 discopthy, 6 stnosis 6 mnt, 161 6 Scoliosis Cobbs msemn, 69 Risseeguson mesuement 69 Sensoy tsting 5 8 -59 Seongtive spondylopty 899 Sus postio ineio I , 16 Sickle cll nemi 96, 97 Sin wv 18 Siting 390 41 Soty psmcyom 01 -104 Spin bid occult 7475 Spin bii v, 74 Spinl cnvtbl boy to 69 Spinl column deposition disese, 995 Spin nv 17 Spinogphy 66-70 mensution poceues 6770 Spondyloisthsis 8, 9 80 -8 Meyeing's gdng system, 68 pecng o slips 68 Spondylolysis 80-8 Sponylophy, 84 Sponylosis deons 83 84 85 Spin 151 15 Stning on oot 3 Sttc intevbl mlposiion 6869 Sttic postu 8 Steoi osopni 96
Stight g ise 56 Sin 151-5 Subluxtion 49
T
T T1 5 Tenso sci lt, I , 1 msce esing, 1819 Tlssemi 96 Toms test 55 Tocic kyphosis Tnsiionl veebe71-7 73 Tnsves plvic stbility 1-3 Tnsvese pocess ctue 76 Tnsvesus bdominus, 15 Tnsvesus peines, 1-13 execises, 170171 muscle esng 19130 Tendelenbeg's tes 55 Tochnteic bus 64 Tumo bon 97-17 Tumolike conditons o bone I 1 -117
u
Ultsound 18
v
Vscul ntomy 1617 Vteb, movements 90 Vetebl ch 7 Veticl sc ctue, 79 Viscel nomy, 19 Viscel exmintion 59 -60
w
Wist, execises, 17 Wellleg sing 56
Y
Yeomns test, 56
Notes
Notes
Noes
Noes
Noes
