Symptom Localization in the Spine and in the Extremity Joints

Sytnptotn Localization in the Spine and the Extretnity Joints

O laf Evjenth, PT C hristian G loeck, PT

Distributed by OPTP Minneapolis, MN

800-367 -7393 www.optp.com

Forward The primary reason why patients seek a physician or a physical therapist is pain. Those working within the realm of manual therapy have always been searching for methods to treat pain. The focus has often been on joint dysfunction (hypomobility and/or hypermobility). However, the lack of success in treatment has been considerable, as many patients have failed to improve. Over the course of many years of practice, Olaf Evjenth has searched extensively for a means to determine the cause of pain. The systematic approach that he found and developed is very promising. For those inexperinced in manual therapy, this publication will provide a means with which to localize the area from which the symptoms are coming. For those trained in manual therapy, it will provide a means with which to localize the source of the symptoms more specifically through the use of special tests. During the past several years, we have often discussed these tests, and we believe that we now have a clear picture. I have attempted to write down OlafEvjenth' s thoughts, as well as the results of our di scussion, so as to help you understand and carry out these techniques. Naturally. an essentia l part of using these evaluation techniques is practice. As physical therapists, there are sufficient opportunities within the course of our daily practice to obtain the necessary skills.

Although this is only a small workbook, it has required a great deal of time which could otherwise have been spent with our families. Our families have endured sacrifices with patience. For this they deserve our gratitude. We thank Carolyn Hvistendahl for her excellent translation of the text and for her constructive comments. And finally. we thank the OPTP team for adding the finishing touches to the layout of our " little book".

Seehausen, August 2000 Christian G loeck

EvjenthlGloeck

Table of Contents Spine The Symptom Localization in the Spine Differentiation between the Muscles and the Passive Structure at the Involved Segment

3

Principles of Specific Symptom (pain) Localization

4

Regional Localization in the Cervical and in the Thoracic Spine

6

Specific Pain Localization in the Occiput/Atlas! Axis Joints

9

Specific Pain Localization in the Lower Cervical Spine

J0

Differentiation between the Ribs and the Thoracic Spine by Pain Localization

J3

Specific Pain Localization in the Thoracic Spine

14

Specific Pain Localization in the Costal Region

J7

Differentiation between Nerve and Mobile Segment in the Lumbar Spine and in the Sacro-iliac Joints

23

Regional and Specific Segmental Localization in the Lumbar Spine and Sacro-iliac Joints

24

Extremity Joints Specific Pain Localization in the Shoulder and in the Shoulder-Girdle

31

Specific Pain Localization in the Wrist

32

Specific Pain Localization in the Leg

34

Specific Pain Localization in the Foot

36

Evjenth/GJoeck

ii

Symptom Localization in the Spine The use of high-tech diagnostic instrumentation has pushed the use of manual investigation more and more into the background. As mentioned in the relevant literature, the use of high-tech diagnostic instruments is not without problems. The results obtained are subject to misinterpretation and sometimes the actual cause is not detected at all. When the patient is examined in a position where symptoms are not elicited, it is quite possible that no positive fmdings will be found even though the patient may have considerable pain in other positions. A reliable, but relatively simple manual examining procedure for identifying the source of pain is essential to the physical therapist. Specific mobility testing alone does not allow the physical therapist to accurately locate the source of the patient's symptoms. As physical therapists do not use anaesthetic medication, they must then use their brains and their hands to localize the source of the patient's symptoms. . The symptom provocation and alleviation tests are essential to the making of a differential diagnosis, as well as a biomechanical diagnosis. An accurate diagnosis requires that one thinks and proceeds in a logical manner. The effectiveness of the testing procedure is therefore dependent on the skills of the examiner. The use of instrumental examination and laboratory tests may well follow a Symptom Localization Test. Localizing the source ofthe symptoms prior to the use of instrumental testing can lead to greater costeffectiveness and spare the patient unnecessary testing. Localizing the source of the symptoms proceeds according to the following:

Symptom Localization Test Spine Regional Localization (Cervical - Thoracic - Lumbar - Sacro-iliac Joint)

Segment Localization

Structural Localization or Mobility (hypomobile, hypennobile or nonnal)

Evjenth/GJoeck

Page 1

We would like to present Olaf Evjenth's concept of Symptom Localization by using some examples of Pain Localization, In order to obtain the proper results from the applied tests, the following questions need to be answered: I.

Does the pain disappear at a specific point in the range of motion? If so, then the pain should be reproduced by the pain provocation test and alleviated by the pain alleviation test.

2.

If the pain is constant throughout the entire range of motion, is the pain increased in some positions and decreased in others? If so, then the pain should be increased by the pain provocation test and decreased by the pain alleviation test.

Legend:

®

e

Reproduction of pain or increase in pain

Decrease in pain or elimination of pain

Pressure against a vertebra or a rib

X

fl:j

® @

Pull on the rib

Fixation

Pain Alleviation

Pain Provocation

EvjentWGloeck

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Differentiation between the Muscles and the Passive Structures at the Involved Segment If an active movement is painful, the therapist must guide the movement passively through the full range of motion. A)

If pain is present during the passive movement, the pain may be caused either by the passive structures of the segment or by the muscles which are being stretched. Differentiation can be made by following the localization test described below.

B)

If pain is not elicited by passive movement, the pain is probably muscular in origin.

Localization Test The Specific Pain Localization techniques are used to identifY the source of the exact same pain which the patient complains of; hereafter, referred to as "the Pain". I.

The therapist gives resistance in a neutral position (static work). If static work elicits pain, then the pain is caused either by the actively contracting muscles, or by the compression occuring in the joint.

2 a) The patient moves actively to the verge of pain and maintains the position actively. The therapist then causes compression of the joint surfaces. Ifpain is elicited by joint compression, the pain is probably joint-related. 2 b) The patient moves actively to the verge of pain, and maintains the position actively. The therapist then applies traction to the joint. If pain is elicited by traction, the pain is most likely muscular in origin (i. e. the pain is probably not joint-related). 3 a) Moving actively, the patient moves slightly into the painful range of motion and maintains the position actively. The therapist then applies traction to the joint. If the pain is decreased or alleviated by the application of traction, then the cause is probably joint-related, disc-related or related to other passive structures. 3 b) Moving actively, the patient moves slightly into the painful range of motion, and maintains the position actively. The therapist then applies traction to the joint. Iftraction causes the pain to increase, the pain is most likely muscular in origin. 3 c) Moving actively, the patient moves slightly into the painful range of motion, and maintains the position actively. The therapist then causes compression of the joint surfaces. Ifthe pain is decreased or alleviated by joint compression, the pain is probably not joint-related.

EvjenthlGloeck

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Principles of Specific Symptom (pain) Localization Pain Provocation Test: 1.

The patient moves actively through the range of motion, in order to fmd where the pain starts (i.e., the borderline of pain). Ifnecessary, the therapist may assist the movement, or perform the movement passively.

2.

The patient then moves backwards in the range of motion, until the pain just subsides (i.e., at the verge of pain).

3.

The location of the borderline of pain is confmned.

4.

The patient then moves slightly backwards in the range of motion, and stops at the verge of pain (i.e., just before the pain starts).

Borderline of Pain

Painfree Range

Painful Range

I I I

(1 )

(2)

(3) ~(4)

(5 b)

I •~

5.

Pain Provocation: a) The patient, or the therapist, sustains the position b) The therapist performs the specific provocating movement (i.e., the therapist causes movement to occur in the joint being tested)

6.

If the provocating movement causes the same pain to occur, then the pain may be coming from the segment/joint being moved.

~>

Perform the Pain Alleviation test

Evj enthlGIoeck

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Pain Alleviation Test: 1.

The patient moves actively through the range of motion, in order to fmd where the pain starts (i.e., the borderline of pain). Ifnecessary, the therapist may assist the movement, or perform the movement passively.

2.

The patient then moves backwards in the range of motion, until the pain just subsides (i.e., at the verge of pain).

3.

The patient then moves just beyond the verge of pain (i.e., just into the painful range).

Borderline of Pain

Painfree Range

Painful Range

1 (1)

I ... I (3) I..... I

-

(2)

(4 b)

1 4.

Pain Alleviation: a) The patient, or the therapist, sustains the position. b) The therapist performs the specific alleviating movement (i.e., the therapist causes movement to occur in the joint being tested).

5.

If the alleviating movement causes the pain to disappear, then the cause of the pain is in the segment/joint being moved.

EvjeothlGloeck

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Regional Localization in the Cervical Spine (CS) and in the Thoracic Spine (TS) A. Flexion of the cervical spine is painful: A.1.Differentiation between CSITS Pain Provocation: The patient extends the thoracic spine. The therapist stabilizes this position through the shoulder girdle. The patient then flexes the cervical spine as far as possible.

If the patient's symptoms are provoked, the symptoms probably have their origin in the cervical spine. The localization should then be confirmed by using the alleviation test. Pain Alleviation: The patient flexes both the cervical and the thoracic spines until the pain begins. The therapist stabilizes the thoracic spine through the shoulder girdle. The patient then extends the cervical spine. If the pain subsides, the source of pain is probably in the cervical spine. One problem with this evaluation is the movement which occurs at the cervi co-thoracic junction. Movement in the cervical spine will cause movement to occur in the upper thoracic spine, even though the thoracic spine is stabilized through the shoulder girdle. To prevent movement in the thoracic spine, one must palpate for movement between the spinous processes ofTI and T2.

A.2.Differentiation between the upper and lower cervical spine Starting cranially, the patient flexes the cervical spine until the pain occurs. The chin is then protruded ventrally. Jutting of the chin causes extension to occur in the upper cervical spine.

If extension of the upper cervical spine causes the pain to subside, and the patient can flex the lower cervical spine further without eliciting the pain, then the origin of the pain is suspected to be in the upper cervical spine. If the pain remains and the patient cannot flex further, the probable origin of pain is suspected to be in the lower cervical spine. To confirm this, one allows the patient to extend the entire cervical spine. The patient then retracts the chin dorsally. The resulting head movement causes flexion to occur in the upper cervical spine. If the pain is provoked now, then the origin of the pain is in the upper cervical spine. If the pain is not provoked, then the origin is in the lower cervical spine.

EvjenthlGloeck

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B. Extension during the cervical movement is painful: Pain Provocation: The patient flexes the thoracic spine. The therapist fixates/stabilizes this position through the shoulder girdle. The patient then extends the cervical spine as far as possible. If the patient's symptoms are provoked, the origin of the pain is most probably in the region of the cervical spine. The localization should now be confirmed by using the pain alleviation test. Pain Alleviation: The patient extends until both the cervical and the thoracic spines are in extension, and the pain is provoked. The patient then flexes the cervical spine. If the pain subsides or is alleviated, then the origin of the pain is probably in the cervical spine. During this evaluation, movement at the cervi co-thoracic junction can present a problem. The therapist needs to take into consideration that movement in the thoracic spine can still occur even though the shoulder girdle is fixated. In order to control this, the therapist must palpate for movement between the spinous processes of T I and T2.

B.1.Differentiation between the upper and lower cervical spine Starting cranially, the patient extends the cervical spine until the pain is provoked. The patient then moves the chin dorsally, causing flexion to occur in the upper cervical spine. If the pain subsides, and the patient can extend the lower cervical spine further, then the origin of the pain is suspected to be in the region of the upper cervical spine.

If the pain remains, and the patient cannot extend further, then the probable origin of the pain is suspected to be in the lower cervical spine. To confirm this, the patient flexes the entire cervical spine. The patient then lifts the head while moving the chin ventrally, causing extension of the upper cervical sprne. If the symptoms are provoked, the origin of the pain is in the upper cervical spine. If the symptoms are not provoked, the origin of the pain is in the lower cervical spine.

EvjenthlGloeck

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C. Cervical rotation; e.g. to the right, is painful: I.

The patient rotates the cervical spine to the right until the pain is provoked. The therapist stabilizes the thoracic spine through the shoulder girdle. The patient then rotates the cervical spine to the left. If the pain is alleviated or subsides, the origin of the pain is in the region of the cervical spine.

2.

The patient actively rotates the thoracic spine to the right, while maintaining a neutral position in the cervical spine, relative to the thoracic spine (i.e., a relative left rotation of the cervical spine). If this does not cause the pain, then the origin of the pain is most likely in the cervical spine.

3.

The patient actively rotates the thoracic spine to the left. The therapist stabilizes this position through the shoulder girdle. The patient then rotates the cervical spine to the right. If this provokes the pain, then the origin of the pain is in the cervical spine.

C.1. Differentiation between the upper and lower cervical spine: The patient laterally flexes the entire cervical spine to the left, and then rotates the head to the right. If the pain is not provoked, then the origin of the pain is most likely to be in the region of the lower cervical spine, which is still in left rotation. If the pain is provoked, the patient should laterally flex the cervical spine to the right. If this is not painful, then the origin of the pain is in the region of the upper cervical spine.

EvjenthlGloeck

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Specific Pain Localization in the Occiput/Atlas/Axis Joints Rotation to the right causes pain: Pain Provocation: The patient rotates to the right, to the verge of pain; i.e., the patient rotates until the pain just occurs, and then rotates slightly to the left, just enough so that the pain subsides. The therapist stabilizes this position through the occiput. Testing is cranial to caudal (CI to C2). The therapist moves each individual vertebra into left rotation, using contact on either the right transverse process or on the posterior arch (the articulating process). If this provokes the pain, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of right rotation. In this way, the pain cannot be provoked from the more caudal segments, as these segments have been moved in the direction of left rotation. The advantage of testing from cranial to caudal is that the pain is only provoked when the caudal vertebra of the involved segment is moved. If one starts caudally with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

Pain Alleviation: The patient rotates to the right, just beyond the verge of pain (i.e., just slightly into the painful range). The therapist stabilizes this position through the occiput. Testing is cranial to caudal (C I to C 2). The therapist moves each individual vertebra into right rotation: A. Occiput/atlas by using contact at C I on the right transverse process and pull this one backward, B. Atlas/axis by pressing on the left transverse process of C2 or by pushing the spinous process of C2 to the left. If this alleviates the pain, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of left rotation. In this way, the pain cannot be alleviated prematurely from the more caudal segments, as these segments have been moved in the direction of right rotation. The advantage of testing from cranial to caudal is that the pain is only alleviated when the caudal vertebra of the involved segment is moved.

If one starts caudally with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely. EvjenthlGloeck

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Specific Pain Localization in the Lower Cervical Spine

Flexion causes pain: Pain Provocation:

The patient flexes until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (C 7 to C 2). The therapist moves each individual vertebra in a cranial-ventral direction. If this provokes the pain, the therapist has moved the more cranial vertebra in the involved ·segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of extension. The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

Pain Alleviation:

The patient flexes until the pain occurs (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from cranial to caudal (C 2 to C 7). The therapist moves each individual vertebra in a cranial-ventral direction. If this alleviates the pain, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of extension. In this way, the pain cannot be alleviated prematurely by the more caudal segments, as these segments have been moved in the direction of flexion. The advantage of testing from cranial to caudal is that the pain is only alleviated when the caudal vertebra of the involved segment is moved. If one starts caudally with this technique, it is quite possible that more than one segment will be moved at the same time, which could reduce the pain prematurely.

EvjenthlGloeck

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Extension causes pain: Pain Provocation: The patient extends the cervical spine until the pain occurs, then goes backwards until the pain is relieved (i.e., at the verge of pain). The therapist, or the patient, maintains this position as well as possible. Testing is from cranial to caudal (C 2 to C 7). The therapist moves each individual vertebra in a cranial-ventral direction. If the pain is provoked, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of extension. In this way, the pain cannot be provoked prematurely from the more caudal segments, as these segments have been moved in the direction of flexion. The advantage of testing from cranial to caudal is that the pain is only provoked when the caudal vertebra of the involved segment is moved. If one starts caudally with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

Pain Alleviation : The patient extends just beyond the verge of pain (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (C 7 to C 2). The therapist moves each individual vertebra in a cranial-ventral direction. If this alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be alleviated prematurely from the more cranial segments, as these segments have been moved in the direction of extension. The advantage oftesting from caudal to cranial is that the pain is only alleviated when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely.

Evjenth/Gloeck

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Rotation to the right causes pain: Pain Provocation: The patient rotates to the right until the pain just occurs, and then moves backwards in the range until the pain just subsides (i.e., at the verge ofpain). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (C 7 to C 2). The therapist moves each individual vertebra into right rotation, by contact on the spinous process. If the pain is provoked, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of right rotation. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of left rotation. The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

Pain Alleviation:

0----

The patient rotates to right, just beyond the verge of pain (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (C 7 to C 2). The therapist moves each individual vertebra into left rotation, by contact on the spinous process. If this alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction ofleft rotation. In this way, the pain cannot be alleviated prematurely from the more cranial segments, as these segments have been moved in the direction of right rotation.

The advantage of testing from caudal to cranial is that the pain is only alleviated when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely.

Pain with a Three Dimensional Movement: In this case, one can use the same approach as used with segmental localization with rotation. The segmental localization is thus achieved by rotation of the vertebra.

EvjentblGIoeck

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Differentiation between the Ribs and the Thoracic Spine by Pain Localization Active Tests The patient extends and breathes in simultaneously => Pain => The patient remains in the painful position and breathes out => If the patient can now go further into extension without pain, the ribs are probably the cause of the decreased mobility. The patient flexes and breathes in simultaneously => Pain => The patient remains in the painful position and breathes out => If the patient can now go further into flexion without pain, then the ribs are probably the cause of the decreased mobility. The patient side-bends and breathes in simultaneously => Pain => When the patient breathes out, the pain disappears and the patient can move further without pain, then the ribs are probably the cause of the decreased mobility. The problem can be on the convex or the concave side.

Evjenth/Gloeck

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Specific Pain Localization in the Thoracic Spine Flexion causes pain: Pain Provocation: The patient flexes until the pain just occurs, then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (Tl2 to Tl). The therapist moves each individual vertebra in a cranial-ventral direction. If this provokes the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of extension.

The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which might induce the pain prematurely. If movement in the cranial-ventral direction cannot be performed, testing can proceed from cranial to caudal by pushing against each individual spinous process, in a caudal direction. If this provokes the pain, the therapist has moved the caudal vertebra in the involved segment.

Pain Alleviation: The patient flexes until the pain occurs (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from cranial to caudal (Tl to Tl2). The therapist moves each individual vertebra in a cranial-ventral direction. If this alleviates the pain, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of extension.

In this way, the pain cannot be alleviated prematurely by the more caudal segments, as these segments have been moved in the direction of flexion. The advantage of testing from cranial to caudal is that the pain is only alleviated when the caudal vertebra of the involved segment is moved. If one starts caudally with this technique, then it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely. If movement in the cranial-ventral direction cannot be performed, testing can proceed from caudal to cranial by pushing against each individual spinous process in a caudal direction. If this alleviates the pain, the therapist has moved the cranial vertebra in the involved segment.

Evjenth/Gloeck

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Extension causes pain: Pain Provocation:

The patient extends until the pain just occurs, then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The therapist, or the patient, maintains this position as well as possible. Testing is from cranial to caudal (TI to Tl2). The therapist moves each individual vertebra in a cranial-ventral direction. If pain is provoked, the therapist has moved the caudal vertebra of the involved segment. The segment has been moved in the direction of extension. In this way, the pain cannot be provoked prematurely from the more caudal segments, as these segments have been moved in the direction of flexion. The advantage of testing from cranial to caudal is that the pain is only provoked when the caudal vertebra of the involved segment is moved. If one starts caudally with this technique, it is quite likely that more than one segment will be moved at the same time, which might induce the pain prematurely. If movement in the cranial-ventral direction cannot be performed, testing can proceed from caudal to cranial by pushing against each individual spinous process in a caudal direction. If this provokes the pain, the therapist has moved the cranial vertebra in the involved segment.

Pain Alleviation:

The patient extends just beyond the verge of pain (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (Tl2 to TI). The therapist moves each individual vertebra in a cranial-ventral direction. If this alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be alleviated prematurely from the more cranial segments, as these segments have been moved in the direction of extension.

The advantage of testing from caudal to cranial is that the pain is only alleviated when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely. If movement in the cranial-ventral direction cannot be performed, testing can proceed from cranial to caudal by pushing against each individual spinous process in a caudal direction. If this alleviates the pain, the therapist has moved the caudal vertebra in the involved segment.

EvjentWGloeck

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Rotation to the right causes pain: Pain Provocation: The patient rotates to the right until the pain just occurs, then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (Tl2 to TI). The therapist moves each individual vertebra into right rotation by pressing on the spinous process.

If the pain is provoked, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved further in the direction of right rotation. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of left rotation. The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

Pain Allevia tion: The patient rotates to the right until just beyond the verge of pain (i.e., just into the painful range). The therapist, or the patient, maintains this position as well as possible. Testing is from caudal to cranial (Tl2 to TI). The therapist moves each individual vertebra into left rotation by pressing on the spinous process. If this alleviates the pain, the therapist has moved the cranial vertebra ofthe involved segment. The segment has been moved in the direction of left rotation.

In this way, the pain cannot be alleviated prematurely from the more cranial segments, as these segments have been moved in the direction of right rotation. The advantage of testing from caudal to cranial is that the pain is only alleviated when the cranial vertebra of the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely. Pain with a Three Dimensional Movement: In this case, one can use the same approach as used with segmental localization with rotation. The segmental localization is thus achieved by rotation of the vertebra. The junction between the vertebra and the rib will be tested later (pages 21 and 22). EvjenthlGloeck

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Specific Pain Localization in the Costal Region

Pain with Flexion and Inspiration Pain Provocation: The patient flexes and breathes in simultaneously, until the pain just occurs, and then moves backwards in the range until the pain just disappears (Le., at the verge of pain). The therapist andlor the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from caudal to cranial. The therapist moves each individual rib cranially, by pressing on the rib in the region of the mammary line. If the pain is provoked, the therapist has moved the involved rib. As the therapist tests from caudal to cranial, the pain will only be provoked when the involved rib is moved.

Pain Alleviation: The patient flexes and breathes in simultaneously until the pain just begins (i.e., just into the painful range). The therapist andlor the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from cranial to caudal. The therapist moves each individual rib caudally, by pressing on the rib in the region of the mammary line. If the pain decreases, the therapist has moved the involved rib. As the therapist tests from cranial to caudal, the pain will only be decreased when the involved rib is moved.

Evjenth/Gloeck

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Pain with Flexion and Expiration Pain Provocation: The patient flexes and breathes out simultaneously, until the pain just occurs, and then moves backwards in the range until the pain just disappears (i.e. , at the verge of pain). The therapist and/or the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from cranial to caudal. The therapist moves each individual rib caudally, by pressing on the rib in the region of the mammary line. If the pain is provoked, the therapist has moved the involved rib. As the therapist tests from cranial to caudal, the pain will only be provoked when the involved rib is moved.

Pain Alleviation: The patient flexes and breathes out simultaneously until the pain just begins (i.e., just into the painful range). The therapist and/or the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from caudal to cranial. The therapist moves each individual rib cranially, by pressing on the rib in the region of the mammary line. If the pain decreases, the therapist has moved the involved rib. As the therapist tests from caudal to cranial, the pain will only be decreased when the involved rib is moved.

EvjenthlGloeck

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L Pain with Extension and Inspiration Pain Provocation: The patient extends and breathes in simultaneously, until the pain just occurs, and then moves backwards in the range until the pain just disappears (i.e., at the verge of pain). The therapist and/or the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from caudal to cranial. The therapist moves each individual rib cranially, by pressing on the rib in the region of the mammary line. If the pain is provoked, the therapist has moved the involved rib. As the therapist tests from caudal to cranial, the pain will only be provoked when the involved rib is moved.

Pain Alleviation: The patient extends and breathes in simultaneously, until the pain just begins (i.e., just into the painful range). The therapist and/or the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from cranial to caudal. The therapist moves each individual rib caudally, by pressing on the rib in the region of the mammary line. If the pain decreases, the therapist has moved the involved rib. As the therapist tests from cranial to caudal, the pain will only be decreased when the involved rib is moved.

Evjentb/Gloeck

Page 19

Pain with Extension and Expiration Pain Provocation: The patient extends and breathes out simultaneously until the pain just occurs, and then moves backwards in the range until the pain just disappears (i.e., at the verge of pain). The therapist andlor the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from cranial to caudal. The therapist moves each individual rib caudally, by pressing on the rib in the region of the mammary line. If the pain is provoked, the therapist has moved the involved rib. As the therapist tests from cranial to caudal, the pain will only be provoked when the involved rib is moved.

Pain Alleviation: The patient extends and breathes out simultaneously until the pain just begins (i.e., just into the painful range). The therapist andlor the patient maintain(s) this position as well as possible and simultaneously the patient holds the breath-position as well as possible. Testing is from caudal to cranial. The therapist moves each individual rib cranially, by pressing on the rib in the region of the mammary line.

If the pain decreases, the therapist has moved the involved rib. As the therapist tests from caudal to cranial, the pain will only be decreased when the involved rib is moved.

EvjenthlGloeck

Page 20

Pain on the Right Side with Right Rotation: Pain Provocation: The patient rotates to the right until the pain just occurs, and then moves backwards in the range until the pain just subsides (i,e., at the verge of pain). The therapist maintains the rotation in the painful segment by pressing against the right side of the spinous process. The therapist moves the rib ventrally, on the right side. If the pain is provoked, the rib must be the cause.

Pain Alleviation: The patient rotates to the right until the pain just occurs (Le., just into the painful range). The therapist maintains the positioning of the painful segment by pressing against the right side of the spinous process. The therapist moves the rib dorsally on the right side. If the pain decreases or disappears, the rib must be the cause.

If the therapist moves the rib dorsally without fixating the vertebra, and the pain still disappears, the cause must be the movement of the rib in relation to the vertebra, as the vertebra itself goes in the direction of increased right rotation .

•

x

= =

Pressure against the rib from dorsal to ventral Pull on the rib from ventral to dorsal

EvjentbiGloeck

Page 21

Pain on the Left Side with Right Rotation: Pain Provocation: The patient rotates to the right until the pain just occurs, and then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The therapist maintains the rotation in the painful segment by pressing against the right side of the spinous process. The therapist moves the rib dorsally, on the left side. If pain is provoked, the rib must be the cause.

Pain Alleviation: The patient rotates to the right until the pain just occurs (i.e., just into the painful range). The therapist maintains the positioning of the painful segment by pressing against the right side of the spinous process. The therapist moves the rib ventrally, on the left side. If the pain decreases or disappears, the rib must be the cause. If the therapist moves the rib ventrally without fixating the vertebra, and the pain still disappears, the cause must be the movement of the rib in relation to the vertebra, as the vertebra itself goes in the direction of increased right rotation .

•

= Pressure against the rib from dorsal to ventral

x

=

Pull on the rib from ventral to dorsal

EvjeothlGloeck

Page 22

--.

-------------------------------------

Differentiation between Nerve and Mobile Segment in the Lumbar Spine and in the Sacro-iliac Joints Flexion is painful

Fle~on

to thte,ge of pain

Cervical - Flexion

Pain provocation

Irritation OfliatiC ne",e

Pain unchanged

!

LS,SI,Hip

Diagnosis by flexion just into the pain, followed by neck extension with a decrease in the aggravation of pain Localization of region or segment

Possibly due to increased Flexion in the lumbar spine

EvjenthlGloeck

Page 23

Regional and Specific Segmental Localization in the Lumbar Spine and in the Sacro-iliac Joints

Flexion causes pain: Pain Provocation: The patient flexes lllltil pain occurs, then moves backwards in the range lllltil the pain just subsides (i.e., at the verge of pain). The patient needs to maintain this position as well as possible. The therapist stabilizes the pelvis ventrally, below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to 11). The therapist moves the sacrum into flexion by pressing on the sacral base. If this provokes the pain, the cause lies in the sacro-iliac joints, as the lumbar segments have been moved in the direction of extension.

If it is not possible to reproduce the pain by moving the sacrum, then the therapist moves each individual vertebra in a cranial-ventral direction by pressing on the spinous process, on the articular process or on the transverse process. If this provokes the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of extension.

The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which might induce the pain prematurely.

EvjenthlGloeck

Page 24

Pain Alleviation: The patient flexes until the pain occurs (i.e., just into the painful range). The patient maintains this position as well as possible. The therapist stabilizes the pelvis ventrally below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to L I). The therapist moves the sacrum into extension by pressing on the apex of the sacrum. If thi s decreases or alleviates the pain, the cause lies in the sacro-i1iac joints, as the lumbar segments have been moved in the direction of flexion.

If it is not possible to alleviate the pain by moving the sacrum, then the therapist moves each individual vertebra in a caudal direction by pressing on the spinous process, on the articular process or on the transverse process. If this decreases or alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of extension. In this way, the pain cannot be decreased prematurely from the more cranial segments, as these segments have been moved in the direction of flexion.

The advantage of testing from caudal to cranial is that the pain is only reduced or alleviated when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely.

EvjenthlGloeck

Page 25

Extension causes pain: Pain Provocation: The patient extends until the pain occurs, and then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The patient maintains this position as well as possible. The therapist stabilizes the pelvis ventrally below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to L 1). The therapist moves the sacrum into extension by pressing on the apex of the sacrum. If this provokes the pain, the cause lies in the sacro-iliac joints, as the lumbar segments have been moved in the direction of flexion.

If it is not possible to reproduce the pain by moving the sacrum, then the therapist moves each individual vertebra in a caudal direction by pressing on the spinous process, on the articular process or in direction of the transverse processes. If this provokes the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of extension.

In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have been moved in the direction of flexion.

The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

EvjentblGloeck

Page 26

Pain Alleviation: The patient extends until the pain occurs (i.e. , just into the painful range). The patient maintains this position as well as possible. The therapist stabilizes the pelvis ventrally below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to L I). The therapist moves the sacrum into flexion by pressing on the base of the sacrum.

If this decreases or alleviates the pain, the cause lies in the sacro-iliac joints, as the lumbar segments have been moved in the direction of extension.

If it is not possible to alleviate the pain by moving the sacrum, then the therapist moves each individual vertebra in a cranial-ventral direction by pressing on the spinous process, on the articular process or on the transverse process. If this decreases or alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of flexion. In this way, the pain cannot be decreased prematurely from the more cranial segments, as these segments have been moved in the direction of extension.

The advantage of testing from caudal to cranial is that the pain is only reduced or alleviated when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely.

EvjenthlGloeck

Page 27

Rotation to the right causes pain:

Pain Provocation: The patient rotates to the right until the pain occurs, and then moves backwards in the range until the pain just subsides (i.e., at the verge of pain). The patient maintains this position as well as possible. The therapist stabilizes the pelvis ventrally below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to L I). The therapist moves the sacrum into right rotation by pressing on the left side of the sacrum at the S I level. If this provokes the pain, the cause lies in the sacro-i1iac joints, as the lumbar segments have been moved in the direction of left rotation. In this way, the pain cannot be provoked prematurely from the more cranial segments, as these segments have

been moved in the direction of left rotation.

If it is not possible to reproduce the pain by moving the sacrum, then the therapist moves each individual vertebra in right rotation by pressing on the left transverse process or by pushing the spinous process to the left. If this provokes the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved in the direction of right rotation. In this way, the pain cannot be provoked prematurely from the more cranial segments,

as these segments have been moved in the direction of left rotation.

The advantage of testing from caudal to cranial is that the pain is only provoked when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could induce the pain prematurely.

EvjenthlGloeck

Page 28

Pain Alleviation: The patient rotates to the right until the pain occurs (i.e., just into the painful range). The patient maintains this position as well as possible. The therapist stabilizes the pelvis ventrally below the ASIS (anterior superior iliac spine). Testing is from caudal to cranial (Sacrum to L 1). The therapist moves the sacrum into left rotation by pressing on the right side of the sacrum at the S I level. If this decreases or alleviates the pain, the cause lies in the sacro-iliac joints, as the lumbar segments bave been moved in the direction of right rotation.

qop

If it is not possible to alleviate the pain by moving the sacrum, then the therapist moves each individual vertebra into left rotation by pressing on the right transverse process or by pushing the spinous process to the right.

c[TI:J

If this decreases or alleviates the pain, the therapist has moved the cranial vertebra of the involved segment. The segment has been moved into left rotation. In this way, the pain cannot be decreased prematurely from the more cranial segments, as these segments have been moved in the direction of right rotation.

The advantage of testing from caudal to cranial is that the pain is only reduced or alleviated when the cranial vertebra in the involved segment is moved. If one starts cranially with this technique, it is quite likely that more than one segment will be moved at the same time, which could reduce the pain prematurely.

Pain with a Three Dimensional Movement: In this case, one can use the same approach as used in segmental localization with rotation. The segmental localization is thus achieved by rotation of the vertebra.

EvjenthlGloeck

Page 29

SYMPTOM LOCALIZATION IN THE EXTREMIlY .JOINlS

Evjeoth/GJoeck

Page 30

Specific Pain Localization in the Shoulder and in the Shoulder-Girdle

Flexion causes pain: Pain Provocation: The patient flexes the shoulder until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist stabilizes this position as well as possible. The therapist moves the inferior angle of the scapula in a dorsal/medial direction. If this provokes the pain, then the cause of the pain is probably in the glenohumeral joint. In this way, the pain cannot be provoked prematurely from the acromioclavicular joint or the sternoclavicular joint, as the joints have been moved in the direction of the extension.

"-

"-

"-

"-

"-

"-

"- '-./

Pain Alleviation: The patient flexes the shoulder until the pain just occurs (i.e., just into the painful range). The therapist stabilizes this position as well as possible. The therapist moves the inferior angle of the scapula in a ventralllateral direction. ......

If this alleviates the pain, then the cause of the pain is in the glenohumeral joint.

\

, \

In this way, the pain cannot be alleviated prematurely from the acromioclavicular joint or the sternoclavicular joint, as the joints have been moved in the direction of the flexion.

Evjenth/Gloeck

'\

"-

"-

-') Page 31

- - --

-

-

- -----

- -- - --_

._ -

-

Specific Pain Localization in the Wrist Flexion causes pain: Pain Provocation: The patient flexes the wrist until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist stabilizes this position as well as possible. The therapist moves the lunate in dorsal direction. Ifthis provokes the pain, then the cause of the pain is probably in the joint between the radius and the lunate. In this way the pain cannot be provoked prematurely from the joint between the lunate and capitate, as this joint has been moved in the direction of extension.

Pain Alleviation: The patient flexes the wrist until the pain just occurs (i.e., just into the painful range). The therapist stabilizes this position as well as possible. The therapist moves the lunate in volar direction. If this alleviates the pain, then the cause of the pain is in the joint between radius and lunate. In this way, the pain cannot be alleviated prematurely from the joint between the lunate and the capitate, as this joint has been moved in the direction of flexion.

Evjenth/GJoeck

Page 32

Extension causes pain: Pain Provocation: The patient extends the wrist until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain).

CD\~ J.,

The therapist stabilizes this position as well as possible. The therapist moves the lunate in dorsal direction. If this provokes the pain, then the cause of the pain is probably in the joint between the lunate and the capitate.

il

_~----R

t

In this way the pain cannot be provoked prematurely from the joint between the radius and the lunate, as this joint has been moved in the direction of flexion.

Pain Alleviation: The patient extends the wrist until the pain just occurs (i.e., just into the painful range). The therapist stabilizes this position as well as possible.

-------

The therapist moves the lunate in a volar direction. If this alleviates the pain, then the cause of the pain is in the joint between lunate and capitate. In this way, the pain cannot be alleviated prematurely from the joint between the radius and the lunate, as this joint has been moved in the direction of extension.

Evjenth/Gloeck

Page 33

I

Specific Pain Localization in the Leg Loading of the leg causes pain: Pain Provocation in the Ankle Joint: The patient loads the leg until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the lower leg in a distal direction. If this provokes the pain, then the cause of the pain is probably in the ankle joint. As long as the patient keeps the position, the pain cannot be provoked prematurely from the more proximal joints, as the loading of these joints has been decreased.

Pain Alleviation in the Ankle Joint: The patient loads the leg until the pain just occurs (i.e., just into the painful range). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the lower leg in a proximal direction. If this alleviates the pain, then the cause of the pain is in the ankle joint. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as the loading of these joints has been increased.

Evjeoth/Gloeck

Page 34

Loading of the leg causes pain: Pain Provocation in tbe Foot: The patient loads the leg until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the talus in a distal direction.

If this provokes the pain, then the cause of the pain is probably in the foot. As long as the patient keeps the position, the pain cannot be provoked prematurely by the more proximal joints, as the loading of these joints has been decreased.

"

Pain Alleviation in the Foot: The patient loads the leg until the pain just occurs (i.e., just into the painful range). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the sustentaculum tali in a proximal direction. If this alleviates the pain, then the cause of the pain is in the foot.

In this way, the pain cannot be alleviated prematurely from the more proximal joints, as the loading of these joints has been increased. If it is not possible to alleviate the pain by moving the sustentaculum tali in a proximal direction, then the cause of the pain is in the subtalar joint.

EvjenthlGIoeck

Page 35

Specific Pain Localization in the Foot

Extension causes pain: Pain Provocation in the Joint between the 1" Metatarsal and the l"Cuneiform: The patient extends the foot until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e. at the verge of pain). The therapist stabilizes the position of the forefoot, as well as possible. Testing is distal to proximal. The therapist moves the I ~ cuneiform in a planta:r direction. If this provokes the pain, then the cause of the pain is in the joint between the I" metatarsal and the I ~ cuneiform. In this way, the pain cannot be provoked prematurely from the more proximal joints, as these joints have been moved in the direction of flexion.

Pain Alleviation in the Joint between the I" Metatarsal and the 1" Cuneiform: The patient extends the foot until the pain just occurs (i.e., just into the painful range). The therapist stabilizes the position of the forefoot, as well as possible. The therapist moves the I" cuneiform in a dorsal direction. If this alleviates the pain, then the cause of the pain is in the joint between the I" metatarsal and the I ~ cuneiform. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as these joints have been moved in the direction of extension.

Evjenth/GJoeck

Page 36

Extension causes pain: Pain Provocation in the Joint hetween the 1" Cuneiform and the Navicular: The patient extends the foot until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e. at the verge of pain). The therapist stabilizes the position of the forefoot, as well as possible.

~\

Testing is distal to proximal. The therapist moves the navicular in a plantar direction. If this provokes the pain, then the cause of the pain is in the joint between the 1~ cuneiform and the navicular. In this way, the pain cannot be provoked prematurely from the more proximal joints, as these joints have been moved in the direction of flexion.

Pain Alleviation in the Joint between the 1" Cuneiform and the Navicular: The patient extends the foot until the pain just occurs (i.e., just into the painful range). The therapist stabilizes the position about the forefoot as well as possible. The therapist moves the navicular in a dorsal direction. If this alleviates the pain, then the cause of the pain is in the joint between the I" cuneiform and the navicular. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as these joints have been moved in the direction of extension.

Evjenth/GIoeck

Page 37

Extension causes pain: Pain Provocation in the Joint between tbe Navicular and tbe Talus: The patient extends the foot until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (Le. at the verge of pain). The therapist stabilizes the position of the forefoot, as well as possible. Testing is distal to proximal. The therapist moves the talus in a plantar direction. If this provokes the pain, then the cause of the pain is probably in the joint between the navicular and the talus.

In this way, the pain cannot be provoked prematurely from the more proximal joints, as these joints have been moved in the direction of flexion .

Pain Alleviation in the Joint between the Navicular and tbe Talus: The patient extends the foot until the pain just occurs (i.e., just into the painful range). The therapist stabilizes the position of the forefoot, as well as possible. The therapist moves the talus in a dorsal direction. If this alleviates the pain, then the cause of the pain is in the joint between the navicular and the talus. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as these joints have been moved in the direction of extension.

-

EvjenthlGloeck

Page 38

Loading of the leg causes pain: Pain Provocation in the Foot: The patient loads the leg lIDtil the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e., at the verge of pain). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the talus in a distal direction. If this provokes the pain, then the cause of the pain is probably in the foot. As long as the patient keeps the position, the pain cannot be provoked prematurely by the more proximal joints, as the loading of these joints has been decreased.

Pain Alleviation in the Foot: The patient loads the leg lIDtil the pain just occurs (i.e., just into the painful range). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the sustentaculum tali in a proximal direction. If this alleviates the pain, then the cause of the pain is in the foot. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as the loading of these joints has been increased. If it is not possible to alleviate the pain by moving the sustentaculum tali in a proximal direction, then the cause of the pain is in the subtalar joint.

Evjenth/GJoeck

Page 39

b Loading of the leg causes pain: Pain Provocation in the Knee Joint: The patient loads the leg until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (i.e. at the verge of pain). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the thigh in a distal direction.

If this provokes the pain, then the cause of the pain is probably in the knee joint. As long as the patient keeps the position, the pain cannot be provoked prematurely by the more proximal joints, as the loading of these joints has been decreased.

Pain Alleviation in the Knee Joint: The patient loads the leg until the pain just occurs (i.e., just into the painful range). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the thigh in a proximal direction.

If this alleviates the pain, then the cause of the pain is in the knee joint. In this way, the pain cannot be alleviated prematurely from the more proximal joints, as the loading of these joints has been increased.

EvjenthlGloeck

Page 40

Loading of the leg causes pain: Pain Provocation in tbe Hip Joint: The patient loads the leg until the pain just occurs, and then moves slightly backwards in the range of motion, just until the pain subsides (Le. at the verge of pain). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the ilium in a caudal direction, by pressing on the iliac crest. If this provokes the pain, then the cause of the pain is probably in the hip joint. As long as the patient keeps the position, the pain cannot be provoked prematurely by the more proximal joints, as the loading of these joints has been decreased.

Pain Alleviation in tbe Hip Joint: The patient loads the leg until the pain just occurs (i.e., just into the painful range). The therapist, or the patient, stabilizes this position as well as possible. The therapist moves the ilium in a cranial direction, by pressing on the ischial tuberosity and the anterior superior iliac spine. If this alleviates the pain, then the cause of the pain is in the hip joint.

f

In this way, the pain cannot be alleviated prematurely from the more proximal joints, as the loading of these joints has been increased.

EvjenthlGIoeck

Page 41