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• Muscle Distributions
• Assessment
• Needling Therapy
• Electroneedling
• Kinesiology
• Movement Therapy
• Mobilization

Posterior Lateral Foot

Muscular Distribution
 Chinese Orthopedics

D.E. Kendall, OMD, PhD

6105 Lake Lindero Drive
Agoura Hills, California

April2009

This material is protected by U.S. Copyright Laws and

may not be reproduced or transmitted in any Form or by
any means, including electronic, digital, or Internet,
without the prior written permission of the author.
 Chinese Orthopedics

Table of Contents

1. Introduction and Principles.... ... .............. .... ............ .. . . . .............. .. .. . .... ..... .. ... .
Chinese Orthopedics 2
Early Beginnings 4
Introduction ofNeedling Therapy 13
Longitudinal Body Organization 16
Neurovascular Node Designations and Use 22
2. Chinese Muscular D istributions.. ....... ............ ................. ............. . .......... ... .. .. 31
View of Pathology 31
Longitudinal Muscular Organization 35
Needling Mechanisms 38
Longitudinal Distribution of Muscles 40
Posterior Lateral Foot (PLF) Muscles 41
Posterior Medial Foot (PMF) Muscles 45
Anterior Lateral Foot (ALF) Muscles 48
Anterior Medial Foot (AMF) Muscles 52
Lateral Foot (LF) Muscles 54
Medial Foot (MF) Muscles 57
Anterior Lateral Hand (ALH) Muscles 59
Anterior Medial Hand (AMH) Muscles 60
Lateral Hand (LH) Muscles 63
Medial Hand (MH) Muscles 64
Posterior Lateral Hand (PLH) Muscles 67
Posterior Medial Hand (PMH) Muscles 69
3. Basis o f Chinese Medicine Orthopedics .. .. . . . . .. .. .. . .. . .. . . . . . . . .. . . . . . . ... . . . .... .. . .. . . .. . . 71
Logical Process of Assessment and Diagnosis 71
Review Blood Vascular System 74
Review of Musculoskeletal System 76
Nervous System Review 84
4. History and Physical Examination . .......... . ............. ........ ......................... . . . .. .. 93
The History 96
Observation and Examination 104
Assessment Process 1 07
5. Treatment and Case Management...... ........... .................... ........ ..................... 125
Modes of Care 125
Medicines for Internal and External Use 130

D.E. Kendall, OMD, PhD ©2005-2009

 ii

Movement Therapy, Exercise, Prevention and Rehabilitation 1 32

Frequency and Duration of Care 142
Disability and Pennanent lmpainnent 150
6. Head and Face . . .. . . ......................................................................................... . 153
Head and Face Regional Anatomy 153
Head and Face Physiology 155
Disorders of Head and Face 159
Assessment of Face and Jaw 161
Management of Head and Face Problems 173
7. Cervical Spine ............ ...... ........................................................ ....... .............. . 177
Cervical Spine Physiology 179
Pathology of Cervical Spine 182
Assessment of Cervical Spine 186
Management of Cervical Spine Disorders 197
8. Scapula . . . . . . . . . . ...... . . . . . . . . . . . . . . . . . . .. . . . . . . . .... . . . .. . . . . .. . . . . . . . . . . . ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Scapular Physiology 207
Disorders Affecting Scapula 209
Examination of Scapula 2 12
Management of Scapular Problems 220
9. Shoulder ......................................................... . .............................................. . 225
Shoulder Physiology 226
Disorders Affecting Shoulder 227
Examination of Shoulder 235
Management of Shoulder Problems 25 1
10. Elbow and Forearm ............... ... ....... .......................... .......................... ..... . .... . 259
Elbow Physiology 259
Disorders Affecting Elbow 260
Examination ofElbow 262
Management of Elbow Disorders 269
11. Wrist and Hand ....................... ...................................................................... . 273
Physiology of Wrist and Fingers 273
Disorders of Wrist and Hand 275
Examination of Wrist and Hand 279
Management of Wrist and Hand Disorders 295
12. Thoracic Spine ....................... . .......... .... . .................. ..................................... . 305
Physiology of Thoracic Spine 307
Problems Affecting the Trunk and Back 309
Assessment of Thoracolumbar Spine 313
Management of Thoracic Spine Disorders 326

D.E. Kendall, OMD, PhD ©2005-2009

 iii

13. Lumbar Spi ne ... .. ... .. .. . . ........ .. . ..... ....... . . ... .. ... ... ... . .. .. . . . . ...... ... ... . . . ............ . ...... . 337
Disorders of Lumbar Spine 337
Assessment of Lumbar Spine 343
Management of Lumbar Spine Disorders 350
14. Pelvis ......... . . . . . .... . . . . . . .. . .. . . ....... . . . ........... . . . . . . . . . .. . . . . . . .................. . . ......... . . . . . . . . . . . . 357
Physiology of the Pelvis 357
Assessment of Sacroiliac Joint 359
Management of Sacroiliac Joint Disorders 364
15. Hip and Thigh ... . .. .. . .. .. . ... .. ......... .... ..... .. ......... .... . . .. ...... .. .. ............. ...... ..... . .... . 367
Hip Physiology 367
Disorders Affecting the Hip 368
Examination ofthe Hip 374
Management of Hip and Thigh Disorders 385
16. Knee ... ... .. ... .. ..... .... .. ...... .. .... .. .... .... ..... . ................ ..... ......... .... ..... . .. .. . . ....... . ..... 393
Physiology of the Knee 394
Disorders of the Knee 395
Assessment of the Knee 399
Management of Knee Disorders 412
I 7. Lo w er L eg, Ankle, and Foo t . ... ............. ....... ..... . .. . . .. .. .. .. .. . .. .. . . . ... .... ......... ..... . 4 17
Physiology of Lower Leg, Ankle, and Foot 4 17
Disorders of the Lower Leg, Ankle, and Foot 4 19
Assessment of the Leg, Ankle, and Toes 427
Management of Leg, Ankle, and Foot Disorders 440
A. Applicatio n o f E lectro stimulat ion . ... ...... .... ... ........... ....... ........ ...... . ............ . . 447
Early use o f electrostimulation 447
Features of Typical Unit 449
General Operational Guidelines 454
Precautions and Contraindications 458

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics

Forward
Chinese orthopedics is a unique approach to the assessment and treatment of pain and
musculoskeletal conditions commonly affecting the general population. It is based on a
modem science-based understanding of needling therapy as w ell as the longitudinal
organization of the musculoskeletal system. Both of these original discoveries w here
made by the Chinese in ancient times. Marco Polo's may have been the first European to
w itness the practice of needling during his stay in China from 1275 to 1292. European
Jesuits visitingChina some tw o centuries later wrote their reports in Latin and introduced
the term "acus punctura" to explain w hat the Chinese called "needling therapy." The term
acupuncture only means to puncture something w ith a needle and gives no hint as to its
therapeutic usefulness. By the early 201h Century, new but metaphysical ideas w ere
promoted in the West that acupuncture w as based on energy and blood circulating by
means of invisible meridians, instead of blood vessels originally described by the ancient
Chinese. These impossible ideas have permeated the Western training programs for both
lay practitioners and medical professionals alike.

Failure to provide evidenced-based training in the assessment and treatment of

pain and musculoskeletal problems, that affect some 70% of the population, has resulted
in many acupuncturists not being able to adequately serve the public's needs. This has
been unfortunate in California w here the acupuncture law recognizes needling to be a
physiologically based process and requires students to be trained in prim ary care
competencies. Acupuncturists have been marginalized by lack of this training and are not
able to communicate w ith the medical community. The author, along w ith a few others,
recognized very early on for the need in science-based training in applying acupuncture
in treating pain and common orthopedic problems. Few acupuncturists have been
interested in pursuing this type of training. How ever, those that have participated in this
program are very successful in helping a significant number of patients to resolve their
problems.

Fortunately, the Chinese provided the w orld w ith the unique treatment modality
of needling therapy that is based on know n anatomical relationships and physiological
processes of the body. These facts have been scientifically verified by a significant body
valid research w hich has been basically ignored. Instead, the Western w orld is still trying
to confirm the existence of invisible meridians w hich has w asted an enormous amount of
time and research funds. The other critical part of the story is the original Chinese
discovery in how the body is longitudinally organized. This involves spinal axial
pathw ays w ith segmental level dominance. The Chinese understood these relationships ca.
200 BCE based on observing certain phenomena including propagated sensation along
longitudinal routes provoked by needling, and organ referred pain. The ancient Chinese
also performed post mortem dissection studies as w ell.

Roots of Chinese medicine date back to the Neolithic period of human

development but the unique practice of needling therapy may have only occurred during
the latter half of the Zhou Dynasty (ca. 500 BCE). Millenniums before this the ancient
Chinese therapeutically used small stone points to prick and bleed certain locations on the
body. This gave the Chinese a very long period of time to figure out w hat locations or
nodes on the superficial body w ere most effective. Since they w ere bleeding these nodes

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics

it allowed th em to develop a keen appreciation for th e distribution of superficial blood

vessels. Metal needles were first described in the Chinese text called th e "Huangdi
Neijing (Yellow Emperor's Internal Classic" complied sometime before 200-100 BCE;
usually referred to as the Neijing. Th e oldest metal needles recovered so far date to 150
BCE.

The Neijing provides th e world's first description of th e lymph atic system along
with th e first complete description of continuous cardiovascular blood circulation of
inh aled air and absorbed nutrients by means of a branch ing system of out flowing arteries
and return flowing veins. All of the main longitudinal and collateral blood vessels to the
internal organs, extremities, head, brain, and trunk are described. Th e skeletal muscles
are also described in terms of six longitudinal distributions of th e arm and legs on each
side of th e body. Numerous approach es in treating pain and orth opedic conditions are
also provided in th e Neijing. Th is includes needling th erapy, massage, including hot
water massage, exercise, guided stretching, breath ing exercises, manipulation,
mobilization, pressure meth ods, traction, h eating for some conditions, and cupping.

Purpose of this text is to provide updated translations, by the author, on key

aspects of the Neijing th at are consistent with modern anatomical and physiological
science. Perh aps it would have been an easier approach to use existing Western texts to
train lay and medical acupuncturists in orthopedics except for th e fact of th e unique
Ch inese discoveries with regard to th e longitudinal body organization. This information
is presented for all of th e muscles including th e kinesiology involved in the articulation of
eachjoint. Needling t h erapy protocols are provided as well. Joint mobilization,
manipulation, and exercise reh abilitation are also provided. Orth opedic assessment
provided h erein is consistent with present day Western standards and meth ods including:
strength testing; range of motion; neurological assessment; and use of diagnostic imaging
and laboratory tests.

American acupuncturists h ave been schooled in th e common use of Chinese

pinyin (#fir) Romanization pronunciation guide syllables in place of th e actual Ch inese
ch aracters. Th ese terms are only used to teach non-Ch inese in h ow to pronounce Ch inese
characters, including their tone, much like th e ph onetic guides th at are used inEnglish
dictionaries. Pinyin (#f:ir) terms are nonsensical in absence of th e actual Chinese
ch aracter. Th is text is basically for individuals th at are eith er learn ing or practicing
Ch inese needling th erapy and therefore th e most commonly used pinyin em-ir) terms are
provided in Ch apter 1 along with th eir corresponding ch aracters to better understand th e
Ch inese concepts. Th e goal is to ph ase out th e practice of using pinyin (#fir) terms and
solely rely on modem medical and scientific terminology.

D.E. Kendall, 2009

D.E. Kendall. OMD. PhD ©2005-2009 ii

 Chinese Orthopedics Introduction and Principles 1

Introduction and Principles

Principles of Chinese orthopedics involve the assessment and treatment of

musculoskeletal conditions from the perspective of the ancient Chinese understanding of
the muscular system longitudinal organization along with modem orthopedic
assessments. This information ìs presented ìn modem Westem termìnology and
pathology affecting the musculoskeletal system， consìstent wìth primary c缸e medical
training and evidence based standards. This is essentìal to assure that practitioners are
able to communicate with maìnstream medìcal providers and services， including possible
specialist referral， to best serve the interest of their patients. Emphasìs is on developing a
21st century understanding on the key anatomical and physiological findings of the
ancìent Chinese. They performed postmortem dissections as early as the Spring and
Autumn period (770 BCE - 476 BCE) of theZhou dynasty. Early physicians mapped out
the entire cardiovascular system and identified al1 the main arteries and veins supplying
the superficial and intemal body regions. They correctly understood the role of the
intemal organs except for the spleen which was assigned digestive and metabolic
activities; since 1 889 these have been proven to be pancreactic functions.
Ancient Chinese identified twelve specific longitudinal regions on each side of
the body with six associated with each 缸m and leg. Neurovascular nodal pathways
(acupoints)，3 blood vessels， and skeletal muscle distributions were specifically identified
for these longitudinal regions. The brain and spinal cord were identified and they had a
rudimentary understanding of peripheral nerves. From this basic understanding the
Chinese discovered spinal cord longitudinal organization with segmental dominance. Use
of metal needles was introduced around 500 BCE. This led to the development of the
effective and repeatable practice of "needling therapy" (zhën辛十b needle: zhìi台to cure，
to heal). Assessment and treatment protocols for orthopedic conditions presented herein
盯e consistent with the Chinese longitudinal muscle distrìbutions and spinal relationships.
Orthopedics in Chinese is usual1y referred to as"straight bones (zhènggu正骨)"
but is also referred to as"orthopedics and traumatology (民shãng këxué 骨伤科学)"
which literally translates as"science specialty of bones and injuries."] The word
"orthopedics" was first used in the West by Nicolas Andry ( 1 658- 1 742)， derived 仕om the
Greek root "orthos，" meaning "straight，" and "pais，" meaning "child." Andry believed that
skeletal deformities were the result of muscular imbalances that occurred during
chìldhood. His treatise， Orthopedics or the Art 01Preyenting and Correcting in flη向nts
Dφrmities 01the Bo吵， was Íirst published in 1741.2 He d�fines an "orthopedist'; 出a
physician who prescrìbes corrective exercise. Andry's definition is far from what is now

a The ancient Chinese referred to the needling sites as nodes or critical junctures (jié节) where collateral
vessels branched什om the longitudinal vessels involving both nerves and blood vessels and best described
as "neurovascular nodes." Nodal sites are also referred to as: slight depression， cave， or hole (xué只).
b Chinese characters provided herein represent the simplitied character set of China and their pïnyïn (拼音)

pronunciation guide syllables and tone indicator.

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 2

practiced， however， many of his ideas are similar to movement and exercise approaches
promoted some 2，000 years prior by the ancient Chinese.�

Chinese Orthopedics
In addition to movement therapy including (tàijíquán太极拳)， guided stretching (dãoyln
导号[)， and exercise for rehabilitation (kãngfù康复)，4 the Chinese developed a wide range
of treatment modalities to address pain， musculoskeletal， and orthopedic conditions
which were common创nong ancient people just as they are today. These treatment
methods include the use of: needling therapy; mobilization; manipulation;' massage
(阳ïná推拿) 产 7 pressure methods; heat application; diet; breathing exercise (qìgõng
气功) 户 stress management; lifestyle counseling and electroneedling (EN) (See
Appendix A).
Needling therapy is usually referred to as "acupuncture" in the West. This term
was coined by early Jesuit missionaries to China frorn the Latin "acus" (needle) and
"punctura" (to puncture) to describe their observations of needling therapy.
Unfortunately， "acupuncture" only denotes puncturing something with a needle and
provides no clue to a highly sophisticated and effective therapeutic system. Marco Polo
(1254-1324) may have been one of the first Europeans to observe needling therapy
during his stay in China frorn 1 275 to 1292 some two centuries before the first Jesuits
arrived. Supposedly he referred to it as "needles that cure" in a now lost letter from the
Venetian archives to the Doge ofVenice. This information has not been verified and
Marco Polo did not mention Chinese needling therapy in his Travels. Medical
instruments of ancient Chinese referred to as needles included probes、pricking devices，
and knife-like devices that may have been used for reducing abscesses and minor surgery.
Chinese orthopedics employs the use of standard assessment methods for
evaluating orthopedic conditions. Muscular conditions are viewed in terms of the unique
Chinese view on the longitudinal organization of the skeletal muscular system.IO、CH 12
Twelve longitudinal muscle (jïngjïn经筋) pathways are considered to distribute along
each side of the body with six starting on the feet and six on the hands. Once assessrnent
is complete the condition is then treated with Chinese medical modalities. Most important
treatment approach relies on needling therapy (acupuncture) using the well established
neurovascular nodes (acupoints) discovered by the ancient Chinese. Needling is applied
consistent with established physiological mechanisms.
Needling protocols take advantage of spinal cord axial (longitudinal) relationships
as well as segmental dominance along with distal nodes usually on the terminal
extremities. Some proximal nodes are considered as well. In some clinical conditions
electrostimulation is applied to selected inserted needles (electroneedling: EN; See
Appendix A). Candidate treatment protocols are provided in Chapters 6 through 17 for
conditions affecting all joint articulations in the body. Perhaps the most important aspect
of Chinese orthopedics treatment and assessment is reliance on the longitudinal
organization of the musculoskeletal system as described by the ancient Chinese (See
Chapter 2).

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 3

Application
Problems addressed with Chinese orthopedics are 0丘en concemed with soft-tissue lesions
that result in dysfunction and pain in the muscles and joints of the body. Lesions to
muscles， tendons， tenosynovial sheaths， joint capsules， Iigaments， and bursae typically
arise from environmental， inflammatory， degenerative， and traumatic conditions.
Although these situations are quite common， they are often not adequately evaluated and
treated. Through the process of proper history taking， keen observation， and careful
clinical examination， the source of the problem can be localized so proper treatment and
management of the case can bring about a possible successful resolution. These same
assessment strategies can also be applied， using proper guides， to evaluate various
degrees of potential disability and impairment in situations where the problem cannot be
resolved by further medical intervention. In this situation the patient is considered to have
reached their maximum medical improvement (MMI).
Orthopedics can also involve the treatment of acute fractures， dislocations，
infections， tumors， and other abnormalities. In the West， Chinese medicine practitioners
are not presently trained in surgery， bone setting， or resolving dislocated j oints， as is done
in China. Consequently， these traumatic conditions need to be handled in modem
emergency care facilities. Likewise， significant infections and tumors are not normally
treated by needling therapy techniques. However， practitioners need to have sufficient
knowledge of these conditions to understand when a case must be referred to the proper
medical specialist. Specific treatment of these conditions is not covered in this text，
however， post recove叮or post surgical treatment is a normal part of Chinese medical
orthopedics.
Patient Care Responsibilities
The most important responsibility of a practitioner is to provide the best care possible
within the scope of their training and experience while respecting the patients'
sensitivities as well as all other ethical and legal aspects of practitioner-patient
interrelations. Critical to fulfilling the responsibilities of properly addressing patient
needs requires a present-day understanding of anatomy and physiology as well as
competency in the practice of needling therapy. In addition it requires employment of an
organized system of collecting and surnmarizing clinical findings， examination results，
Iaboratory results， diagnoses， treatment details， recommendations， and progress. Properly
coUected data then permits assessment of clinical trends and effectiveness of various
treatments. The pu叩ose of Chinese orthopedics training is to develop the necessary skills
and competencies in the assessment and treatment of orthopedic conditions including
pain and musculoskeletal problems. Specific objectives include:
•
Understanding of orthopedics consistent with the historic Chinese theories and
current medical science
•
Concentration on present understanding of anatomy and physiology of the
musculoskeletal system， including assessment and standard evaluation methods as
well as treatment strategies using needling therapy
•
Understand the medical and legal obligations of maintaining records， referral to
other specialists， and need for laboratory tests or other studies

D.E. Kendall. OMD. PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 4

•
Help practitioners integrate into mainstream medicine and improve
communication skills with other health care professionals
•
Prepare practitioners to be able to work within multiple disciplinary clinics

Early Beginnings
Chinese culture is very ancient dating back to the Neolithic period of human
development. Sometime around 9000 BCE the people moved north from the middle
Yangzi river valley to settling along the great basins of the Yellow River of China.
Transition to an agrarian society brought many challenges associated with living in fixed
locations that had an impact on health. Disease became prevalent resulting in the need to
develop a wide range of treatment modalities over time including the use of: herbal
remedies， heat packs (some that contained herbs)， radiant heat， moxibustion (direct heat
on skin or much later on needles)， cupping， therapeutic bathing弓diet， medicated diet，
exercise， movement therapy， guided stretching， breathing exercises， relaxation
techniques， pressure techniques， manipulation、massage， bone setting and splintinιand
limited surgery.'O，Cf-15 Present day practitioners in China still reduce and splint all types of
bone fractures. Neither bone setting nor surgery of any kind has yet to be included within
the scope of modem needling therapy practice in the West.
Ancient Chinese physicians also pricked the skin with small stone points called
"biãnshí (眨石)" to therapeutically release a few drops of blood. Stone points were used
for bloodletting， and also for reducing abscesses.3 The small points were employed for
several millenniurns before the metal needles were introduced. This gave the Chinese a
very long time to acquire a detailed understanding of the longitudinal pathways of main
blood vessels， skeletal muscles， spinal cord， and nerves. It also allowed them to also
identify the most effective neurovascular nodes along these pathways for pricking to
address pain， orthopedic conditions， and intemal organs problems.
Blood Vessel Theory
Sometime around the middle of the Zhou dynasty (700 BCE-500 BCE) the Chinese
developed a keen interest in studying the hurnan body. Eventually this led to postmortem
dissection studies. One of the main interests was the understanding of the blood vascular
system and its critical role in bodily function and sustaining life.'o The earliest reported
account of continuous blood circulation， including a description of human conception and
fetal developmental including that of the intemal and sensory organs， is found in the
Guanzi (ca. 3 7 5 BCE) in the essay on Water and Earth:
"Earth is the root source of all things and the foundation of all life and luxuriant growth."
Water is the blood (xuè 血) and breath (qì气) of earth in a similar manner to blood and
breath circulation through blood vessels and muscles."
From this time period forward， Chinese physicians participated in a text-based
alignment of knowledge eventually leading to detailed medical manuscripts. Oldest of the
ancient texts recovered so far were retrieved in 1 973 from tomb 3 at Mawangdui near the
city of Changsha， Hunan Province， China dated to 168 BCE. These medical manuscripts
were p盯t of a large collection and provide the first detailed infonnation about the
Chinese blood vessels (mài脉)川1 Similar vessel texts were also found in 1 983 at

D.E. Kendall， OMD， PhD @2005-2009

 Chínese Orthopedícs Introduction and Prínciples 5

Zhangjiashan in a tomb dated to 150 BCE. Collectively， these texts provide the first
universal model of pathology based on the blood vessel theory. Neither Chinese needling
therapy nor neurovascular nodes/acupoints (jié节/ x时穴) are mentioned in these
particular texts卢p39.p.87
First Comprehensive Text
The most important ancient text on Chinese medicine， including the first information on
needling therapy， is the Huangdi Neijing (Yellow Emperor￥/nternal Classic). It is 0白en
referred to as the "Ne ijing" and the date of its origin is unknown but other information
suggests it may have been compiled around 200- 1 00 BCE. The Neijing is obviously a
compilation of texts written much earlier but none of the originals have survived to date.
Efforts to place a fair copy of the Neijing in the Han Dynasty court library was initiated
by Liu Xiang after 26 BCE and completed by his son Liu Xin.1" Liu Xin was a1so an
author and astronomer and famous for having calculated the period of the solar year by
analyzing moon phases over a 19 year period. His value for the solar year only differs
仕om the present value by 14 minutes. The eaτliest recorded mention of the Neijing is
found in The History ofthe Former Han Dyn asty by Ban Gu (32-92 CE). He simply lists
the Ne 扩ing as consisting of 1 8 scrolls without comment.
By the 2nd and 3rd Cen阳ry CE the Ne 扩ing was viewed in terms of the Suwen
(Common Conversations) and the Zhen jing (Needling Classiο containing nine scrolls
each.13;14 The Ne ijing was then lost until 762 CE when a Tang dynasty minister named
Wang Bing set out to restore a recovered copy. He added text to lhe SUl1仰(SW) and
renamed the Zhenjing the Lingshu (LS) (Center ofKnowledge).13:14 Commentaries were
also made in 1 056- 1 066 CE during the Song Dynasty by Gao Baoheng.13:14 AdditionaJ
commentaries on the Suwen continued up to出e I 9lh century. 14
This incredible work provides a compilation of Chinese medical concepts that
demonstrate a profound understanding of anatomy and physiology that was superior to
the ancient Greek ideas of the same time period. The Chinese information is 80 to 90%
consistent with modern understanding including the first detailed description of the entire
cardiovascular system specifically identifying all the major arteries and veins of the
intemal and superficial body.'O They also identified the brain， spinal cord， some
peripheral nerves， heart， pericardium， lungs， stomach， spleen， liver， gallbladder， kidneys，
urinary bladder， lymphatic system， and the membrane systems of the thoracic， abdominal，
and lower abdominal cavities (sãnjião三焦); but， never specifically identified the
endocrine glands.
Reason for this level of knowledge is the fact that the ancient Chinese conducted
postmortem examinations to obtain quantitative information noted in L S 12 as follow:
"With regards to a person， even 8 Chinese feet tall (about 6 feet)， they can be examined
by a trained practitioner providing that the skin and flesh are still intact. Externally the
body can be completely measured in accordance with established standards. In case of
death， a dissection study can be pe斤。rmed to examine the condition of the internal
。rgans to determine the firmness or fragility of the viscera and the size of the bowels and
contents of the digestive system. The length of the vessels can be measured and
whether the blood is either clear or deep and thick. The total air content of the body can
be determined as well as the ratio of blood to air in the 12 main longitudinal vessels. It

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 6

can also be determined if the body contains considerable blood and air or if there is a
lesser amount of both. Quantitative measurements can be derived for all of these
parameters."
TheNe扩ing gives a complete description of the cardiovascular blood circulation
of: 1) a critical component in inhaled air (qì气) now known to be oxygen， absorbed in
the lungs and distributed in the arterial blood supply (LS 10); 2) nutrients (yíng营'j from
food stuff and water broken down in the stomach and absorbed by the small intestine fine
veins (LS 8 1) and directed to the liver by the portal vein; 3 ) defensive substances (wèi卫)
(immune cells) that can leave blood circulation to mount a defensive action and then
drained back into the blood supply via the lymphatic system (LS 18); and 4) refined
substances of vitality (jïngshén精冲) which mediate emotions (hormones and other
biologically active substances) (LS 8). The venous blood returns to the heart and lungs，
now known to transport cellar respiratory carbon dioxide (C02) which is exhaled along
with the nitrogen (N2) in the lungs as air (qì 气). 10 It was clearly understood that the
inhaled air and nutrients were critical to sustain life.
Cardiovascular Blood Circulation
A detailed and correct discussion of the entire cardiovascular system involving a11 main
blood vessels supplying the internal body as well as those supplying the extremities，
head， and brain is provided in the Ne扩ing. Vessel pathways are accurately described
along with the len!S1h of the longitudinal vessels. 10. C闸，CHIO，CHII The tliree main deep
singular vessels (jïmài奇脉) of the internal trunk were distinguished from the 12
longitudinal vessels (jïngmài 经 脉) supplying each side of the body. Deep vessels
inc1ude the aorta (chδng 冲thoroughfare vessel)， vena cava (rèn f圭allowance vessel)，
and veins of the posterior trunk (dü督governing vessel) consisting of the但ygos，
hemiazygos， and ascending lumbar veins (See Figure 1.1). Five other singular vessels
(jïmài奇脉) were also described which consist of superficial venous networks on each
side of the body. These vessels are in addition to the six longitudinal veins (jïngmài 经
脉) on each side of the body to account for the fact that the body has 80% more veins
than arteries due to the slow flow rate in veins.
The aorta receives oxygenated blood and nutrients， collectively referred to as
"essential substances (qì气and yÍng营)，" directly from the heart left ventricle. Here it is
circulated to the arteries (like a thoroughfare) supplying a11 the internal organs and brain
and a branching system of out flowing longitudinal arteries that supply the arms， legs，
head and face， and the body trunk. This clearly involves heart function producing a pulse
wave as noted in LS 62 (Pulsating Tran sport):
"Essential substances leave the heart (Ieft ventricle) suddenly， like shooting a cross bow
or like a wave hitting shore."
After the pulse wave reaches the thenar region (radial pulse) it declines and reverses flow
in the veins. The pulse was noted not to be able to transmit through the arterioles，
capillaries， and venules (fine vessels siinmài {rJ\ 腑 and hence veins do not have any
pulse.

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 7

The vena cava is the largest allowance vessel of the body and receives venous
blood from the liver弓kidneys， and the urinary bladder. Venous blood from the
gallbladder， stomach， spleen， pancreas弓and the intestines is directed to the liver by the
portal vein and is included with the blood of the liver. The vena cava also receives blood
from the retum f10wing longitudinal veins of arms， legs弓 head， brain， and face， and the
body trunk， including blood from the goveming (dll督) vessels. The vena cava cOJ1Ilects
to the right atrium ofthe heart. Vessels comprising the goveming vessels (veins) of the
posterior trunk receive venous blood from the intercostal and other veins of the back and
the bronchial veins of the lungs. Venous blood from the heart is drained 仕om within the
heart itself by the coronary sinus.

VEINS Sunmaí ARTERIES

Arteri，olles. Capilllaries，. Ve n ul es
Jingmaí
Jíngmaì Longitudinal Vessels
哽一一一- TQ:He自d， Neçk. Brain.
础EB 〉』帽aE 2」mE唱 Z曲。二

Upper Exlr，em刷es，
andT阳Ink

Lungs
百 E 20

R.，enmai Chongrnai
十畹〈d o国再N旦 E @Z d o四hN〈

Vena Cava Aorta

↑ 4一一一 Inlem.al 哇二一一-

O咱ans

To: Lower Exb"emiti，es

唔一一一
and Trunk
JingmaÎ

--Ì)> Blood Circulatìo n Diredion

Figure 1.1. Schematic view of Chinese cardiovascular system organization and vessel
branching
Pathology affecting the 12 longitudinal blood vessels Gïngmài 经 脉) includes
disorders resulting from blood circulation problems along each longitudinal vessel. The
longitudinal vessels are thought to have intemal connections with specific intemal
organs. Problems in c irculation could result in disorders associated with the
somatovisceral related intemal organ. Problems also result when blood circulation of
essential substance (oxygen from inhaled air， nutrients ， and water) along specific
longitudinal vessels is either in surplus (excess) or hollow (deficient). It is presently

D.E. Kendall. OMD. PhD @2005-2009

Chinese Orthopedics Introduction and Principles 8

understood that muscular problem， including pain and chronic pain， result when blood
flow is restricted. 1 5 In addition， restricted oxygen and nutrient flow to the internal organs
results in serious problems including heart attacks. All the above conditions affecting the
vessels and somatovisceral related organs are thought by the Chinese to reflect on both
the radial (related by the Chinese to the lungs) and carotid pulses (related to the stomach).
There are three sets of longitudinal arteries and veins that supply and drain each
arm， I吨， body truru豆、and head. These vessels Uïngmài经脉) branch into collateral
vessels (luòmài络脉) which in turn supply the fine vessels (sünmài孙脉)， now known
to be arterioles ， capillaries， and venules， that connect the arteries to the return flowing
veins. 10 This completes the circulation of blood "like a ring without end" (See Figure
1 . 1 ).
William Harvey provided the first experimental verification o f continuous blood
circulation in 1 6 1 6. He continued teaching on the cardiovascular system and published
16
his Exercitatio in 1 62 8 but did not veri命 how the arterial blood flowed to the veins.
This problem was resolved by M arcello Malpighi ( 1 628- 1 694) by discovering capillaries
in 1 66 1 . The work of Harvey and Malpighi confirmed the Chinese concepts of
continuous blood circulation "like and ring without end" through a complex branching
system of out flowing arteries and retum flowing veins postulated some 1 800 years
earlier by the ancient Chinese.
Despite也is， Harvey's contribution is rightly considered the single most important
Western discovery because it stimulated a science-based endeavor to understand the
human body. Ancient works always need to be viewed in terms of modern science. Here
we have a paradox where the ancient Chinese had a coπect understanding of the
cardiovascular system which was replaced with metaphysical concepts in the 20th
century. Chinese ideas of blood circulation were replaced with the misconception of
blood and energy circulating by means of invisible meridians by Georges Soulié de
Morant in 1 93 9 and 1 94 1 . 17 Adoption of this impossible "meridian theory" by the
m句ority of European and American practitioners has virtually precluded Chinese
needling therapy from being integrated into mainstream medicine.18;19 These incorrect
ideas have also impeded the development of valid treatment protocols and science-based
training for Chinese needling therapy programs in the West. This present text 1S based on
correct anatomic and physiologic terminology consistent with the ancient Chinese
discoveries and present day medical science.

Confusing the Spleen with the Pancreas

Had the ancient Chinese identified and understood the endocrine glands their
comprehension of anatomy and physiology would have been nearly complete. They did
assign certain vitalities and related emotions to the five main viscera that are obviously
mediated by hormones (LS 8: Root 01 Vitalitie s) (See Table 1 . 1 ). These organ
relationships are easily correlated with the main endocrine glands except for the spleen
being paired with the stomach. The stomach was considered to have the major
descending function of the body by breaking down food stuff and water and passing this
on to the small intestine. The spleen was wrongly considered to have the maj or ascending
function of the body by controlling digestion and absorption of nutrients via the small

D.E. Kendall， OMD， PhD @2005-2009

 Chìnese Orthopedìcs Introductìon and Prìncìples 9

intestine veins. Nutrients were noted to be directed upward (ascending) to the liver via
the portal vein and then onto the vena cava (r缸lmài任脉) and then heart.
Ancient Chinese， Greeks， and other cultures described diabetes being
characterized with symptoms of 仕equent urination， sweet tasting urine， wasting of the
body， and finally death. The Chinese thought the spleen caused diabetes however， Oskar
Minkowski serendipitously provided experimental evidence of the pancreatic (yí膜)
origin of diabetes in 1 889. 20; 21 The Greek physician and anatomist Herophilus (ca.335-
280 BCE) from Chalcedon in Asia Minor was first to identify the pancreas. Some four
hundred years later Ruphos ( 1 st or 2nd Century C时， an anatomist and surgeon of
Ephesus in Asia Minor coined the term "pancreas" which ìn Greek meant "all f1esh."
Galen ( 1 38-20 1 AD)， another physician and anatomist also bom in Asia Minor， thought
the pancreas served as a cushion or fatty pad below the stomach to protect the large blood
vessels lying immediately behind the pancreas (splenic artery with branches to the
pancreas). Considered the most famous physician in the World of his time， his word was
not to be challenged until the 1 8th Century.
It is interesting to note that the ancient Chinese measured the size and weight of
-
the viscera and bowels， and the capacity of the bowels. 10 ，p46 The spleen was noted in the
Nan jing (Classic o fDifficu lties) Question 42ωweigh 2 jïn (斤) and 3 li缸电 (两= 1 1 1 6
of a jïn 斤) along with another one half jïn (斤) o f distributed fat户;23 Weight of a jïn (斤)
during the Qin and Han dynasties was 220-253 grams. 24 An average of these two values
results in a weight for the spleen of 517 grams with the distributed fat weighing 1 1 8
grams. The weight of 5 1 7 gr缸ns for the spleen is actually twice the normal value while
the 1 1 8 gram weight for the distributed fat is consistent with the weìght of the pancreas.
The pancreas is a dual function organ that controls digestion as wel l as having a
critical endocrine role to maintain blood glucose levels. Since the spleen has no endocrine
function it would seem reasonable that the Chinese vita1ity of intent (yì意) is more
appropriately assigned to the pancreas (See Table 1 . 1 ). Anatomically， the spleen is
located in the upper left abdominal cavity， in contact with the stomach， tail of the
pancreas， the diaphragm， and the le白 kidney. The pancreas lies slightly below and behind
the stomach to reach the descending part of the duodenum where it curves left to meet the
large intestine. All these organs make intimate contact with each other which may have
contributed to missing the role of the pancreas. But ， the most likely problem may have
resulting by the Chinese following the large splenic artery route to its final destination at
the spleen and ignoring the fact that this arteη supplies small critical branches to the
pancreas before reaching the spleen.
The spleen is the l argest lymphatic organ in the body that targets pathogens that
infect the bloodstream. It also filters out and breaks down old red blood cells， recovers
lron 仕om the hemoglobin， and removes bile pigments for excretion as bile by the liver.
Toward the end of fetal development the spleen manufactures red blood cells and after
birth this function is taken over by the bone maπow. The spleen also acts as a blood
reservoir including the storage of about 25% of the body's platelets. During stress or at
other times when additional blood is needed， the spleen contracts， forcing stored blood
and platelets into circulation. The ancient Chinese should have assigned the spleen to the
heart which they considered responsible for blood and the vascular system.

D.E. Kenda"， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 10

Table 1.1. Characteristics of Chinese assigned organ vitalities and related endocrine glands.

Vitalities Vigor (pò魄) Mood (hún魂) Vitality (shén种) Intent (yi 意) Drive (zhì志)
1 2
Residence Air Blood Vessels Nutrients Essence3
Related Lungs Liver Heart Exocrine Kidneys
。rgan(s) Pancreas
Endocrine Thyroid Pineal Pituitary Endocrine Adrenal
Gland(s) Pancreas Glands
Characteristic Vigor; Physical Mood; Soul; Vitality; Intent; Desire; Drive; Will;
Strength; Spirit Mentality; Inclination; Aspiration
Animation; Life Expression; Thought; Idea
Natural Abilities;
Animal Spirit
Related Grief & Worry Anger Joy Pensiveness Fear & Fright
Emotions
Related Large Intestine Gallbladder Small Intestine Stomach Bladder
Bowel
1. I ndicates both blood vessels and nerves; 2. Nutrients (yíng营); 3. Refined substances Ú1ng精)

Muscle System Organization

All the skeletal muscles and the diaphragm are described in the LS 13: Longìtudinal
Muscle s GIngjIn经简. IO，OHZ One of the most unique organizational features of the
muscular system involves longitudinal association and grouping discovered by the
Chinese. Here the musculoskeletal system is organized into 1 2 distinct longitudinal
distributions related to the ne凹es and longitudinal blood vessels GIngmài 经 脉)
supplying the same regions， including related neurovascular nodes (acupoints). Each of
these twelve muscle distributions is discussed in detail in Chapter 2 including illustrations
and tabular information on: muscle name， function， origin， insertion， innervation， and
nerve root. In addition， the kinesiology associated with each major j oint (Chapter 6
through 1 7) is provided listing: each muscle， Chinese anatomical division， nerve root， and
the prime mover (PM) or accessory or assistant mover (AM) function involved each joint
articulation.
The Chinese noted that pain and pathology can reflect along the muscular
distributions， including the spontaneous development of sensitive locations (ahshì xué
啊是穴). Correlation of this information at each joint provides a quick assessment of
what longitudinal division may be involved in a patíent's condition príor to performing
any detailed assessrnent. Muscles were considered to represent the extemal body and
have no special relationships with the intemal organs. However， visceral referred pain
first mentioned in the Neijing can reflect ín the muscles of neck， shoulder， body trunk，
and buttocks but not usually in those of the extremities.
Muscle and tendon distributions were thought of as a linked systern passing over
one particular joint and then continuing on to the next muscle and joint in the vertical
pathway. Muscles in each distribution were determined by following the pathway of
propagated sensation (PS) to needling experienced by a srnall percentage of the
population. These phenornena are related to the axial organization of spinal cord
including the spinal afferent processing system mediated by the propriospinal system.

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 11

Muscle action potentials can be measured at neurovascular nodes in response to PS along

the muscle pathways户The Chinese described all the muscles for each of the 1 2
longitudinal divisions starting with the hand or foot and moving up along the vertical
pathways of the anηand legs. They were described mainly by noting the insertion and
origin of each individual muscle or related group. This approach was used by the ancient
Greeks as well. For some reason the ancient Chinese did provide actual names for three
skeletal muscles including the gastrocnemius， quadriceps， and the stemocleidomastoid.
The Chinese also described the diaphragm by name as well.

Basic Comprehension of Nerves

The earliest first-hand Westem account from Japanese and Chinese practitioners in Japan
that Chinese theories involved continuous blood circulation， a branching network of
arteries and veins， and nerves was provided by Willem ten Rhijne ( 1 647- 1 700) in 1683.26
The ancient Chinese used the character sUl (髓) to denote nerves and the spinal cord and
when used with the character jí (脊) for backbone， it refers to spinal nerves.27;28 Later sUl
髓was considered to mean "marrow" consistent with the Westem terminology of the
time that referred to the spinal cord as "spinal ma盯ow." The character sUl髓consists of
the two components of gu (骨) which means bone and suÍ (造) which serves as the
phonetic and means "to follow." So an obvious translation of sui髓would be:
"something that follows the bones" and that is what ne凹es do even distributing through
bone foramen as described in the Ne 扩ing.
The character gu (骨) also consist of two components， namely guã (问) which
means "skeleton or bones without flesh，，29 and ròu (肉) which means "flesh" referring to
the muscles that attach to the bones. The character guã (问) represents a bone which
contains marrow as does the bone represented by the character gu (骨). So， it does not
seem reasonable to use the character sUl髓to mean "marrow" just because it contains gu
(骨) as part of the character. One possible source in creating this confusion is from the
SWll where the Yellow Emperor asks:
"1 have heard from some physicians that perhaps the brain (nao脑) and the nerves (s山
髓) are considered to be viscera ... Qi 80 directly replied: The brain， nerves， bones (gu
骨)， blood vessels (mai脉)， gallbladder， and uterus are six organs generated by the
earth's environment."
This seems to indicate that sUl髓refers to nerves instead of marrow. Since sUl髓
immediately precedes gu骨in the later part of this discussion some have wrongly
assumed that sui髓means bone maπow. However， the initial part of the conversation is
about clarifying the classification of the brain and nerves. Furthermore all nerves were
considered to be connected to the brain as noted in SW 10:
"AII blood vessels relate to the eye5， all nerve5 (5山髓) join the brain (nao脑)， the
muscles and tendons belong to the joints， blood belongs to the hea此， essential breath (qi
气) belongs to the lungs and these provide function to the four extremities and eight
articulations from morning to night."

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 12

Additional indications that sui髓 means nerves is provided by the Yellow

Emperor in a discussion of embryonic and fetal development in response to being asked
about blood vessel development in LS10 as fol1ow:
"Life for the human first sta叫s when the reproductive essence combines (father's sperm
unites with the mother's egg). As result of this conception the brain (nao脑) and nerves
(sui髓) start to form and the bones (gu骨) develop to provide a framework for the body
The vessels (mai经) form to circulate nutrients (ying吉) and the muscles Uin筋)
develop to make the body strong. The flesh (rou肉) aevelops to form the body trunk and
the skin (pifu皮肤) becomes firm and the hair (mao毛) can grow long."
It is interesting to note that this quote is accurate in that the embryonic nerves
develop first and blood vessels develop by following the nerves. In addition， the possible
involvement of nerves in the function of neurovascular nodes Gié节) (acupoints) is
provided in LS1:
寸hat which we call nodes Uie节) are the places that vitality signals (shenqi神气)
transmit inward and outward (efferent and afferent nerve signal剖， and is not just skin，
flesh， muscles， and bones."
The character shén (神) can mean: vitality， mind， miraculous effect， or spirit. The
term sh白lqì神 气 can be used to indicate nerve signals and modem names for nerves and
the spinal cord are basically consistent with terminology of the Ne扩ing， namely:
•
Nerves: longitudinal nerves (shénjïng 神经i8
•
Spinal cord: backbone nerves Gísui脊髓)28
•
Spinal ne凹es: backbone longitudinal ne凹es Gísui sh句jïng脊髓神经) or Gí shénjïng
脊神经)28

Concepts of Pathology
Cause of human pathology was viewed by the ancient Chinese in terms of the total
environment of daily and annual existence involving: atmospheric and seasonal
conditions; physical wear and tear; emotions; stress of living in crowded cities; diet;
lifestyles; condition of one's residence (including its location and the tranquility among
the occupants); famine; epidemics; and pathogenic organisms. Collectively， the Chinese
called the disease causing (pathogenic) factors"xiéqì(邪气)." This view of pathogeneses
is still prevalent today with the addition of modem work loads， work place environments，
computers， intemet activities， television， cell phones， i-phones， and substance overuse.
Disease was viewed as an ongoing contention between physiological function (zhèngqì
E气) and pathogenic factors (xiéqì邪气). Normal health was considered to exist when
physiologicalhIICHorI Was optimum and external factors were in normal range-IO，FIE23
The Chinese concept of physiological function was highly sophisticated for its
time and involved the perfo口nance of all body systems. This idea embraces Cannon's30;3 1
concept of feedback control of"homeostasis" as well as the unstable feed-forward
aspects of hormone mediated vitalities and emotions (See Table 1 . 1 ) now called
"allostatis. ，，1 O，CHI3丑;33 A solid or substantial (shí实) condition was considered to exist
when physiological functionlbalance was optimum but extemal factors were abundant. A

D.E. Kendall. OMD. PhD @2005-2009

Chinese Orthopedics Introduction and Principles 13

hol1ow (xü虚) condition was considered to exist when extemal factors were in normal
range but physiological且mction was below normal. There is a constant waxing and
waning between extemal factors and intemal function and normal health can be
rnaintained as long as the body is resilient and capable of recovery. Chronic disease and
pain， including chronic pain， can result when physiological balance does not fully
recover.
Bodily function， including that contributed by the intemal organs， relies on a
continuous supply of oxygen (02) frorn inhaled air (qì句， nutrients (yíng营)， and water.
These are the potential energy sources that are converted by rnetabolic processes (zhënqì
真气) to fuel cellular function， and hence physiological function. The Chinese placed
emphasis on the idea that needling restored or stimulated rnetabolic processes; thereby
strengthening physiological function to dissipate pathogenic conditions.

Introduction of Needling Therapy

The srnall stone points (biãnshí眨石) were used several thousands years before the metal
needle was adopted as first described in the LS 1 (Nine Needle s and Twe lve Sources). The
inherent advantage of needles was the fact they could be inserted and retained for shorter
or longer periods of time depending on the desired therapeutic response. They could also
be rnanipulated after insertion to enhance certain aspects of the physiological response to
needling. Basically， the needles provide a better means of regulating and restoring bodily
function to address disease and dysfunction. Needles also caused less damage to the skin
and f1esh as did the stone points. The Yel10w Emperor explains why needling therapy
was preferred， as follow:
"1 supp。内all my people though 1 receive a tax from them. 1 am saddened when they do
not have adequate provisions or when their family members are sick. I wish they would
not use poisonous or toxic medical remedies and not use the stone points (bianshi
眨石). Instead， I prefer to use fine metal needles to communicate with the longitudinal
vessels to regulate blood and essential substance distribution in order to normalize the
inverse (venous) and outward (a同erial) flow of nutrients." (LS 1)

Oldest Needles and Confirmed Practitioner

The earliest received evidence of metal needles recovered so far was found in the tomb
belonging to Liu Sheng ( 1 54- 1 1 3 BCE)， King ofZhongshan.3;11 This information would
suggest that the unique Chinese treatment system involving the insertion of fine metal
needles may have developed around 250- 1 50 BCE. However， there are unsubstantiated
reports of legendary practitioners dating back to the time of the Yellow Emperor (ca.
2674 BCE) but they were app缸ently stiU using the stone points.
The first mention of Chinese needling therapy related to a known physician is
found in the Historical Records of the Han马masty (90 BC时， Chapter 105 of Sima Qian
(ca. 1 45-86 BCE). His name was Chunyu Yi (ca. 2 1 6-150 BCE)3;14 who treated patients
with herbs， moxibustion， and needling therapy. Chunyu Yi considered blood vessels to be
the most important structures compared to other constituents of the body. He was brought
before the Han court on a complaint by a well connected patient. Chunyu Yi provided
information on his teachers and presented 25 patient case histories. Despite these efforts
he was found guilty in 1 67 BCE of what could be called malpractice charges today. He

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 14

was sentenced to mutilation punishment but his youngest of five daughters Tiying
intervened on his behalf with the Emperor who commuted the sentence.
Given the sophisticated level of Chinese needling therapy at this point in time
suggests that this practice may have deveJoped much earlier. This is partly supported by
Sima Qian's report on other notable practitioners whose existence has yet to be verified.
The most famous of these is the legendary physician named Bian Que (ca.500 BCE) who
lived during the later part of the Spring and Autumn period (770 BCE - 476 BCE). Bian
Que used herbs， moxibustion， and needling therapy and is presently highly regarded as
one of the most important early practitioners. We know from this report that Bian Que
used metal needles suggesting they may have been used starting sometime before 500
BCE.

Metal Needles Replace Stone Points

The first treatise of the Lingshu (LS J : Nine Needles and Twefve Sources) provides a
detailed description of nine different needles， including their shape， length and use.
Additional information was also provided on the needles in LS 78 (Tre atise on Nine
Needle攻) indicating that each were used for specific conditions. Few details are provided
on how the needles were clinically utilized except for the fine needle which was further
described in LS 3 (Explanation oJthe Fine Needle) . It is clear 仕om the descriptions of the
needles that they were used for conditions that are still common today including pain and
musculoskeletal problems.
Current practice of needling therapy concentrates almost exclusively on the
modem equivalent of the ancient"fine" needle: "... used to treat cold and hot rheumatic
pains situated in the collateral vessels. Because this needle is so fine， it can be retained
for a long time to reduce pain， clear inflammation， and restore physiological balance
(zhèngqì 正 气). This is brought about by the influence on tissue metabolic processes
(zhënqì 真气) causing dissipation of the pathogenic conditions. "LS 78
Some practitioners still perform limited bleeding using the modem three-comered
equivalent of the ancient"lance tip" needle: " . used to drain off heat and let blood t。
. .

resolve chronic diseases including superficial ulcers， abscesses， carbuncles and heat
conditions. "
The ancient "sword-shaped" needle consisted of a blade device that could be used
for lancing large abscesses and possibly for minor surgery. The modem equivalent of this
needle is the ever present medical scalpel， which was: " .. used to treat large abscesses，
.

carbundes and accumulated pus， as well as hot diseases caused by contention between
hot and cold environmental conditions. "
Two of the ancient needles were actual1y non evasive probes including the
"round" needle which appears to be an instrument to possibly examine muscle and
tendon strains and sprains or to massage areas between the muscles: .. . used to treat
"

conditions of the flesh and applied to the spaces between the muscles without inju叩 to
the muscles."
The other probe was called the "spoon" needle possibly to massage specific blood
vessels: " used to treat blood and vascular system diseases by pressing down on or
. . .

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 15

massaging the vessels without causing their collapse. This stimulates metabolic
processes (zhënqì 真气) to dissipate pathogenic conditions."

Early Western Exposure

Marco Polo was the first European to observe needling therapy being practiced in China
during his long stay from 1 275 to 1 292 and may have brought the first reports to Europe.
However， he did not mention anything about needlíng in the story of his Travels. Some
two centuries later Jesuit missionaries visited China and were the first to introduce
Chinese acupuncture to Europe. They made use of needling therapy and moxibustion， and
taught it to others. Almost another century later the first European work on the subject
was published by Girolamo Cardano ( 1 508- 1 576)， a physician and medical teacher in
Milan.34 Cardano's information was based 011 reports by travelers who had been treated
with needling therapy and moxibustion in Asia. A Jesuit mission was already established
in Japan by 1 549 with missionaries being knowledgeable about needling therapy，
moxibustion， and Chinese and Japanese terms of anatomy and physiology.35 More
information on needling therapy was obtained during the late sixteenth and seventeenth
centuries. One mention was provided by Jakob de Bondt ( 1 598- 1 63 1 )， the surgeon
general to the Dutch East India Company， who observed acupuncture and moxibustion
being used in Java-36
The earliest first-hand account on the anatomical and physiological basis of
Chinese concepts was provided by the Westem science trained physician Willem ten
Rhijne ( 1 647- 1 700) in 1 683巧 He joined the Dutch East India Company for an
assignment in Java where he spent his first six months teaching anatomy to the surgeons
of Djakarta. Ten Rhijne then sailed to the island of Dej ima in Nagasaki Bay of Japan and
stayed 仕om October 1 674 to October 1 676. He sought to understand something about the
medicine of Asia and had obtained four longitudinal-collateral vessel Uïngluò 经绚
charts from local practitioners. These practitioners noted that Chinese concepts were
based on the continuous circulation of inhaled air and nutrients by means of the blood
vascular system. Furthermore， they explained that it involved the continued branching of
out flowing arteries into smaller vessels and then the reverse process for return flowing
veins essential to distribute blood throughout the body; they noted that ne凹es were
involved as well. Ten Rhijne even observed a hydraulic device that demonstrated how
blood continually circulates inhaled air and nutrients by means of the blood vascular
system. He conducted his own dissection studies to confirm progressive branching of
blood vessels suggesting that this was not understood by the West at the time. He
described the branching blood vessels as being similar to the veins on a leaf. Ten Rhijne
retumed to Java where he worked for the remainder of his life.
Herman Buschof， a Dutch minister and friend of ten Rhij ne wrote an account on
moxibustion in the treatment of gout and arthritis in 1 674. Andreas Cleyer， a German
physician， who served with ten Rhijne in Java， wrote a book on ac叩uncture and the
pulse in 1 682. Englebert Kaempfer (1 65 1-1 7 1 6)， a German physician who also worked at
Dejima island wrote the most comprehensive Western account of moxibustion， with
essays on acupuncture in 1 7 1 2 卢;3 8
By the start of the nÍneteenth century the practice of needling therapy in Europe
was in a state of ridicule until Louis Berlioz ( 1 776-1 848) of France discovered ten

D.E . Kendall ， OMD ， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 16

Rhij肘's report on acupuncture. Berlioz used this information to start experimenting with
neeciling in 1 8 1 0 and was perhaps the first physician in France to actually practice the
art.39 He published an article in 1 8 1 6 on the e f I日cacy o f ac upu ncture in treal i ng d i gest i v e
and nervous disorders.3 9 ;40 Another i m portan l contri butor was S a r l and ie re Ic C heva J i cr of
Paris who was the first to use an electrical device attached to i nserted need les in 1 82 5 :�1
This was the first known application of electroneedling.
Numerous French articles appeared in medical joumals shortly after the efforts of
Berlioz in 1 8 1 6， attesting to the utility of needling therapy. Its use continued in Italy
along with the publication of articles and books on the subject.34 Electroneedling was also
repo口ed by da Camino of Venice卢;43 Interest in needling therapy was also stimulated in
Germany and Sweden. A summaη of acupuncture practice in Europe during this time is
contained in the academic thesis of Gustaf Landgren ( 1 805 - 1 857) for his degree of
Medicine Doctor at Uppsala University， May 1 6: 1 829.39 By the year 1 900， �algesia by ，
electroneedling promoted by Sarlandiere le Chevalier and da Camino was already in
disreputeι It is interesting the note that after Soulié de Morant created his energy­
meridian concept he condemned all the above European work as being false
acupuncture. 1 7
Needling therapy was also imported to America where a few physicians tried their
hand at needling therapy as e町ly as 1 822卢 Ten Rhijne's report was first translated into
English in 1 826， and published in the North American Medical and Surgical Journal
( 1 826; 1 : 1 98-204).46 0ne of the most notable practitioners was the Canadian physician，
Sir William Osler (1 848-1 924). He practiced a variant form of acupuncture， and
recornmended its use for the treatment of lumbago and sciatica户 After Soulié de
Morant' s concept of energy flowing through rneridians gained a foothold in Europe
during the 1 940s and 1 950s， ten Rhijne's report on Chinese needling being based on
vessels， nerves， and blood circulation was discredited as eπoneous.

Longitud inal Body Organization

The ancient Chinese were perhaps first to develop a standard system for anatomical
reference to identify specific body locations. Instead of relative Westem or even Chinese
terms such as medial (nèi 内 and lateral (wài 州， or anterior and posterior the Chinese
used the adjectives yáng (阳) for anything that is extemal and yîn ( 阴 for intemal regions
except in situations where the two te口ns can be used in opposition to each other such as
comparing lateral to medial. The a口ns and legs were each divided into six easily
identified longitudinal regions contrasted by yîn (阴 for the medial aspect and yáng ( 阳 )
for the lateral aspect. However， there is confusion as to where the medial (yîn 阴 reglOns
transition onto the trunk proper since they are considered to traverse under the superficial
lateral (yáng 阳) areas. The Chinese also used yïn and yáng terms to describe the relative
location of the intemal organs.
The earliest received evidence showing that ancient Chinese used standard
anatomical nomenclature to describe the location of major blood vessels (mài 腑 running
lengthwise in the body was found in the medical texts recovered from a tomb in 1 973 at
Mawangdui， China previously noted户; 1 1 Three lateral (yáng 阳 ) blood vessels and three
medial (yîn 阴) blood vessels were identified that traversed each leg along with three

D.E. Kendall， OMD， PhD @2005-2009

 Chinese Orthopedics Introduction and Principles 17

lateral (yáng 阳 ) and two medial (yïn 阴 vessels that traversed both arms. No blood
vessel was identified for the hand transitional yin G 1均ïn 厥 阴 region in these texts， but
was included in the Neíjing (LS 10) descriptions of vessels.
Collectively， the three yáng ( 阳 ) longitudinal vessels of the hand and feet where
referred to as the lateral vessels of the hand and feet. Likewise， the three yïn ( 阴 )
longitudinal vessels of the hand and feet where referred to as the medial vessels of the
hand and feet. 1 4 .pp. 60-6 1 Each of the lateral and medial aspects of the arms and legs were
divided into three regions. For the lateral aspect of the hand and feet these consisted of
the anterior lateral， lateral， and posterior lateral regions. The medial aspect of the hand
and feet these were divided into the anterior medial， medial， and posterior medial regions.
This resulted in 1 2 specific longitudinal regions on both sides of the body. These regions
were named mostly by astronomical relationships to the sun， moon， stars， and planets as
noted later (See F igure 1 .2 and Table 1 .2).

Earl y Understanding of Longitudinal Relationships

The Ne 扩ing provides detailed information on the longitudinal organization of the body
with bilateral symmetry with respect to the skeJeton， brain， spinal cord and the
distribution of major blood vessels， skeletal muscles， and peripheral nerves. I O Most of
this knowledge was considered to have been handed down from ancient times (SW刀，
perhaps from the Warring States Period (475 BCE to 22 1 BCE) or even earlier. The ancient
Chinese discovered the phenomena of propagated sensation (PS) provoked by needling
that helped to identi句 which neurovascular nodes (acupoints) were related to each
specific longitudinal body division (LS26;LS75). 1 0，PP. 52 刃 They also discovered organ
U，p 4，+"9 some 2，000 years before
referred pain reflected on various body regions (LS74) 1' 0.0
William Head in 1 893 ι Postrnortem autopsies allowed correlation of possible
sornatovisceral relationships between some neurovascular nodes along specific
longitudinaJ vessel pathways and specific organs.
Other key discoveries included spinal segmental dominance and noting that
certain nodes of the posterior lateral foot (PLF) body region (Table 1 .2)， located on each
side of the spine， had influence on specific internal organs. They also noted that distal
nodes on the hand and feet evoked strong effects due to needling and other means of
stimulation. Understanding of the spinal cord longitudinal organization along with
segrnental dorninance and distal effects allowed the Chinese to develop the rational and
effective treatrnent system of needling therapy. Modern science-based needling makes
use of the longitudinal and segmental body organization. 1 0 ，CH I 4 刑 咱 。

Chinese longitudinal View

The Chinese term jïng (给 is used to mean "longitude" or things that run lengthwise. This
even applies to second character 气jing " in the word Neíjing generally translated as
"classical texts" referring to characters written on vertical bamboo strips that are bound
together in 10ngitudinaJ scrolls. The term jïng can also apply to the w盯p of a fabric， main
longitudinal arteries and veins of the body， and meridians. 2 9 三 1 1n the Neijing it refers to
longitudinal blood vessels， rivers， and muscle Gïn 筋 ) distributions as follow:
•
LS 10 Longitudinal Blood Ve sse ls Gïngmài 经 H部: provides an anatomically coηect
detailed description of the 1 2 main longitudinal blood vessels supplying the

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 18

longitudinal body regions of each side consisting of out f10wing arteries and retum
I 电 H 们
nowing veins O C
•
LS J 2 Longitudinal Waterways (Rivers) (jlngshul 经 圳: describes the 1 2 main rivers
of China that are considered to be similar to the 1 2 main longitudinal blood vessels on
each side of the body
•
LS J 3 Longitudinal Miωcles (jlngjln 经 盼 : provides an anatomically correct detailed
description of the skeletal muscles that distribute longitudinally through the 1 2 rnain
anatomical divisions on each side of the body l 0，C H l 2 (See Chapter 2)
Much confusion about Chinese historic medical facts has resulted from
inappropriate translation and use of the term 丁lng (��." This is used in both Chinese
terms for meridian (jlngxiàn 经 编 and longitude (jlngdù 经 由 But， serious problems
，
resulted by translating jingmai (longitudinal blood vessel) as "meridian. ， 1 7 ; 1 9 English
versions of acupuncture books from China 0白en repeat these misconceptions while the
Chinese versions of the same texts in Chinese are correct. The Chinese justi命 this
practice by noting they are just using the accepted Westem translation of Chinese
concepts.
The term jlng (经) is also applied to the wa甲 of a fabric causing some to think
that the term longitudinal and collateral vessels (jlngluò 经 络 was referring to an
invisible network. 5 2 Others have translated jlng (经) as "conduit" resulting in jlngmài
being translated as "conduit vessel" and the longitudinal muscle (jlngjln) distributions
would presumably be called "conduit muscles" which does not seem to provide the
clearest understandingf， l 4 ， 5 3

Fundamental Bod y Plan

The ancient Chinese unknowingly discovered longitudinal body organization which is
common to all other animals with some modifications. This feature first appeared in
unsegmented f1atworrns around 600-570 million years ago. Flatworms are longitudinally
organized with a head， body， and tail with bilateral symmet可. They are the simplest
animals to have a bilateral ne凹ous system involving longitudinal nerve cords which form
transverse branches to supply sensory and motor ne凹e 臼nction at specific intervals along
the body (segmental relationships).
Some 40-50 million years later the chordates appe盯ed that had a notochord，
which in vertebrates consists of an intemal skeletal rod that is replaced with interlocking
vertebrae during embryonic development. The earliest fossil chordate is the Yunanozoon
Lividum 仕om China and dates to the Early Cambrian Period some 525 Million years
ago. 54 The central nervous system of chordates distributes on the dorsal aspect of the
body opposite to the f1atworms. Anton Dohm proposed as early as 1 875 that vertebrates
inherited their central nervous system 丘om an annelid (worm) ancestor and simply
inverted their dorsoventral body axis during their evolution. 55 Recent molecular
architectural studies of the annelid neurodevelopment confirm the important aspects of
Dohm's ideas showing the homology (similarity in structure and in origin) of the annelid
6
and vertebrate trunk central nervous systems (CNS). 5J U Flat飞Nurms evolved by crawling on
the ground or the botlom of ponds. However， when they started swimming free they

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 19

automatically inverted their bodies due to the properties of water reversing their control
system effect.
The first fish then appeared during the Ordovian Period (5 1 0-439 million years
57
ago). Fishes quickly diversified and are the first known members of the Verbrata of the
Chordate subgroup which gave rise to a11 subsequent vertebrates including amphibians，
reptiles， birds， and mammals. The fundamental stages of longitudinal development and
segmental dominance that is important to understanding Chinese needling therapy is
clearly demonstrated by the careful study of either animal or human embryology.

Chinese Body Orientation

Standard notation systems were devised over time to provide a means to reference certain
features of the human body in order to relate information 仕om one practitioner to
another. The West eventually developed the idea of using irnaginary orthogonal planes as
a reference to describe body articulation (See Chapter 3 ) . The ancient Chinese may have
been the first to use a reference system by identi命ing twelve longitudinal regions on each
side of the body. This scheme describes six yïn ( 阴) and yáng (阳) longitudinal
anatomical divisions of the hands (shõu 韦 and feet (z白 局 on each side of the body as
noted earlier. Their view on the order of blood circulation， somatovisceral relationships，
and diumal relationships or chronobiology and was included in their nornenclature as
we11 (Table 1 .2， Cols.3 ， 4， & 5). This created a unique notation system that is not
consistent with any known Westem approach. Description for the twelve divisions in the
West is usuall y only provided in Chinese pinyin pronunciation guide terrns (Table 1 .2弓
Col . l ). These are properly translated in Westem terminology to provide a better
understanding and application of these concepts (Table 1 .2， Co1.2).

Table 1 .2. Chinese and modern anatomical notation scheme for 12 longitudinal Uing) body
regions， related vessels， and muscle distributions

2 3 4 5

Chinese Anatomical Longitudinal Region， Vessel， Vessel Somatovisceral Time

Divisions (pïnyïn) and Muscle Distributions Type Relationship Period

Shõu Tàiyïn Anterior Medial Hand (AMH) Artery Lungs 3am-5am

Shδu Yángmíng Anterior Lateral Hand (ALH) Vein Large Intestine 5am-7am
ZÚ Yàngm i ng Anterior Lateral Foot (ALF) Artery Stomach 7am-9am
Zú Tàiyïn Anterior Medial Foot (AMF) Vein Pancreas 9am-1 1 am

Shõu Shãoyïn Posterior Medial Hand (PMH) Artery Heart 1 1 am-1 pm

Shδu Tàiyáng Posterior Lateral Hand (PLH) Vein Small Intestine 1 pm-3pm
ZÚ Tàiyáng Posterior Lateral Foot (PLF) Artery 81adder 3pm-5pm
Zú Shãoyïn Posterior Medial Foot (PMF) Vein Kidneys 5pm-7pm

Shõu Juéyïn Medial Hand (MH) Artery Pericardium 7pm-9pm

Shõu Shãoyáng Lateral Hand (LH) Vein Internal Membranes 1 9pm- 1 1 pm
ZÚ Shãoyáng Lateral Foot (LF) Artery Gallbladder 1 1 pm-1am
ZÚ Juéyïn Medial Foot (MF) Vein Liver 1 am-3am

1 . sãnjião (三 匍

D.E. Kendall. OMD . PhD @2005-2009

Chinese Orthopedics Introduction and Principles 20

Sky and Earth Orientation

The position of the sun with respect to the earth' s daily rotation was used to divide the
day into three yáng ( 阳 ) periods of 4 hours each based on the sun's position or incident
angle with respect to a standing individual facing east with their hands to sides in the
neutral position (See Figure 1 .2). The three 4 hour periods between the yáng ( 阳 ) regions
were assigned to yïn (阴) classification. All six of the 4 hour periods were divided to
describe the vessel order of arteries first supplying the hands and then the fee1. The
Chinese understood that blood continually circulates in all the vessels at the same time by
the heart. This could be verified by examining arterial pulses at nine different locations
on the body.
The Chinese were first to introduce the idea of tracing blood distribution through
the linear pathway of the longitudinal blood vessels on one side of the body and then the
other side noted in LSI O. The circulation order starts with an out flowing artery supplying
the anterior medial aspect of the hand (AMH) which is drained by the veins associated
with anterior l ateral hand (ALH). A maj or branch of this vein also drains the anterior
lateral head and face where it associates with the anterior lateral foot (ALF) artery which
supplies the face， the body trunk， and the ALF region of the leg and foo1. The ALF artery
is drained by the anterior medial foot (AMF) veins directing venous blood back to the
heart. This order of circulation between the hands and feet then continues to arteries and
veins supplying and subsequently draining the posterior medial and lateral hand and foot
and then the medial and l ateral hand and foot (See Table 1 .2， Co1.3).

Circulation Order
The initial 4 hour yáng period of the hand and feet is from 5am to 9am and called the
sunrise or bright yáng ( 阳 明 (See Figure 1 .2). The second 4 hour yáng period from 1 pm
to 5pm is called the great y但g (太 阳 ) which is the name for the sun. The third 4 hour
yáng period is from 9pm to 1 am and called the lessor yáng (少 阳 ) which is the name for
the stars visible at this time period. The yáng body areas occupy the anterior lateral，
lateral， and posterior lateral aspect of the arms穹 legs， body， and head. Some neurovascular
nodes along the six yáng vessel pathways have somatovisceral relationships and
indications for the large intestine， stomach， small intestine， bladder， intemal membrane
systems (sãnjião 三 角 ， and the gallbladder.
The yïn body areas occupy the medial aspect of the arr口s and legs consisting of
the great yïn (referring to the moon)， the lessor yïn (referring to the planets)， and the
transitional or declining yïn (厥 阴 located between the greater and lessor yïn regions of
the arm and legs. The yïn regions on the trunk are considered to traverse under the
superficial yáng areas with neurovascular nodes on the anterior trunk which are
considered yïn in comparison to the posterior body. Some neurovascular nodes along the
six yïn vessel pathways have somatovisceral relationships and indications for the lungs电
pancreas， spleen， heart， kidneys， pericardium， and the l iver.

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 21

， 1 PM

Posterior Lateral Hand

(PLH)

\ / 3 PM

Anterior Lateral Foot

(ALF) Posterior Lateral Foot
( P LF)

、、，
7 AM �
5 PM

Anterior Lateral H and Great Yang (Taiyang )

(ALH) time period with sun

angles ind icated by
arrows

----司，
5 A. M .

Sunrise or Bright Yang

( Yangming ) time period
with sun angles ind icated
by arrows

Lesser Yang ( Shaoyang )

referring to stars visible at
this time with sun angles
\
9 P.M.
--1‘

indicated by arrows while

on opposite side of earth
Lateral H and
DE

(LH)

Lateral Foot
M

( L F)

Figure 1 . 2 . Standard Chinese anatom ical orientation with respect to sun (yáng) position over 24
hour period showing longitudinal body regions for distribution of blood vessels， skeletal muscles，
and neurovascular nodes (acupoints).

First Concept of Chronobiology

Each longitudinal vessel giving rise to superficial neurovascular nodes was considered to
have unique somatovisceral relationships involving blood vessels supplying each specific
intemal organ (See Table 1 .2， CoI.4). Furthermore， a specific 2 hour time period was
associated with each intemal organ and vessel creating the original concept of

D.E. Kendall， OMD ， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 22

chronobiology (See Table l .2， Cols 4 & 5). The Chinese attempted to show that organs
had certain functions or situations during certain diumal periods. This is mainly related to
intemal organ function but may also be associated with changes in blood flow needed to
support eating and digestion of food， and other activitìes. 1t was known at this time that
the liver and spleen stored blood during the night. The ancient Chinese also noted
seasonal effects foτ specific intemal organs that recovered during certain seasons or
became worse in other seasons.
The blood circulation order starts with the lung vessels (3am-5am)， since
inhalation of air (qì 句 now know to contain oxygen (02)， was understood to be most
essential to sustain life. The AMH vessels consist of the radial arteries of each a口n and
the wrist pulse is considered related to lung function. It is know that certain conditions
atI-ect the lungs during in the early hours including decreased peak expiratory function
(PEF). Next in order is the large intestine， related is the lung， which is usually active soon
after awaking between 5 am -7am (See Table 1 .2 ， Co1.5). Individuals often consume their
first meal which is broken down in the stomach (7am-9am). The stomach was considered
responsible for nutrients (yíng 营) and the carotid pulse located on the ALF anatomical
division. Partially digested food and water are passed on to the duodenum which triggers
the pancreas (9am- l l am) to neutralize stomach acid， provide digestive agents， and
release insulin for cellular uptake of glucose. This is followed by the heart ( 1 1 am- l pm)
during its most active time of the diumal cycle. The heart provides the greatest supply of
resistance vessels to the small intestine ( 1 pm-3pm) to support digestion which in tum
delivers absorbed nutrients to the small intestine veins connected to the portal vein. The
urinary bladder and kidneys are next in the order followed by pericardium and intemal
membrane system. F inally， the gallbladder collects and stores bile ( l l pm- l am) and the
liver stores blood ( 1 am-3pm).

Neurovascul ar Node Designations and Use

From ancient times the Chinese have used their yïn ( 阴 - y扭g ( 阳 ) longitudinal body
divisions to name the m句or blood vessels， neurovascu1ar node (acupoint) pathways， and
the skeletal muscle distributions (Table 1 .2， Col. l ). 咄咄en Soulié de Morant translated the
Chinese blood vessels as meridians in 1 939 they were named by their anatomical regions
in the yïn-yáng divisions. But， he thought 由at his meridians were also named for the
intemal organ for which the vessels have somatovisceral relationships. 1 7 ; 绍 ; 59 He further
complicated the problem by creating new nomenclature for the nodes by using the organ
name or abbreviation as a prefix to an assigned sequential number as the accepted name
for the specific nodes. Nodes along the ALF longitudinal division， for example， were
named Stomach (ST) nodes 1 through 45 . This nomenclature created a totally false
impression that any neurovascular node along a given organ-named meridian was useful
for treating condìtions of that particular organ. Unfortunately， Westem language
acupuncture texts all fol low this serious misdirection contributing to a further confusion
that negatively reflects on the credibility of the Chinese.

Location and Function of Neurovascular Nodes

Soulié de Morant' s new nomenclature was contraη to the Chinese practice which give
each node a specific Chinese n创口e that indicates its possible location or function. The
Chinese name for ST 1 is Chengqi (承 j岛 (Receive Tears) which is located directly

D.E. Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 23

below the pupil， between the eyeball and the lower infraorbital ridge. 61 This is obviously
a place that receives tears and has indications for eye disorders. One famous node of the
ALF anatomical region which is effective in resolving a wide range of gastrointestinal
problems is ST 3 6 Zusanli ( 足 三 岛 (Leg Three Miles). lts name indicates this node is
located three Chinese inches (cun) below a reference point which happens to be the node
Dubi (ST 3 5). Another example is DU 8 called Jïnsuõ (筋 缩) (Contracted Muscles)
located below the spinous process of the ninth thoracic vertebra. This is a special node
that is effective in treating spasms in back muscles. There are many such examples.
Because of spinal segmental dominance， node location basically dictates its main
clini cal utility or function except for distal nodes. As example， a11 eight ALF nodes on the
head (ST 1 to 8) only have indications for eye， teeth， face， j aw problems and headache
with ST 40 to 45 having related distal effects for these conditions.ov The ALF nodes ST 9
to 1 6 and 1 8 have indications for neck， upper chest， lungs弓 and breast disorders with ST
36 and ST 40 having related distal effects. Only the local and adjacent ALF nodes ST 1 9
to 2 5 overlying the stomach region are useful to address gastrointestinal problems， along
with distal nodes ST 36， 3 7， and 44. The ALF nodes ST 26 to 30 on the lower abdomen
have indication for urogenital， reproductive， lower abdominal problems， and hemia. In
addition， a11 the ALF nodes on the leg (ST3 1 to 45) also have musculoskeletal
indications.
One of the first step in trying to restore the original Chinese concepts and reduce
confusion is to replace the organ names or initials by the Chinese anatomical division
names and initials such as ALF 1 for ST 1 ， AMH 1 for LU 1 and so on (See Table 1 .3).
A11 neurovascular nodes referenced in this text， including those in treatment protocol
tables， 盯e identified by a prefix representíng an abbreviation for one of the hand or foot
longitudinal body regions as noted in Table 1 .2， Co1.2 and Table 1 .3 . The order for some
of the terminal nodes in the posterior medial foot (PMF) region has been changed to
correct another problem. However， these nodal names and theír locations are unchanged.
This involves changing the order of: KD 3 Taixi to PMF 6 Taixi; KD 4 Da址lOng to PMF
5 Dazhong; KD 5 Shuiquan to PMF 4 Shuiquan; and KD 6 Zhaohai to PMF 3 Zhaohai.

Table 1 . 3. Chinese anatomical division nomenclature for neurovascular nodes (acupoints) versus
(Vs) the usage introduced by Soulié de Morant.

Chinese French Chinese French

a rteries meridians velns 内leridians
AMH 1 to 1 1 Vs LU 1 to 1 1 ALH 1 to 20 Vs LI 1 to 20
ALF 1 to 45 Vs ST 1 to 45 AMF 1 to 2 1 Vs S P 1 to 2 1
PMH 1 to 9 Vs HT 1 to 9 PLH 1 to 1 9 Vs SI 1 to 1 9
PLF 1 to 67 Vs BL 1 to 67 PMF 1 to 27 Vs KD 1 to 2 7
M H 1 to 9 Vs PC 1 to 9 LH 1 to 23 Vs 1M ! 1 to 23
LF 1 to 44 Vs GB 1 to 44 MF 1 to 1 4 Vs LV 1 to 1 4
1 . Internal Membrane System (sãnjião 三 匍

Impact of Confusing Nomenclature

Naming a11 the nodes (acupoints) along a longitudinal division by a specific intemal
organ has created unnecessary con且lsion. As result， node selection for some practitioners

D.E . Kendall ， OMD ， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 24

may be a somewhat random process. This is especially troubling given the fact that only
the local and adj acent and appropriate distal nodes for any anatomical division have
consistent clinical utility. This is true whether it is for treating an intemal organ or
musculoskeletal problem. Basically， local and adj acent nodes take advantage of spinal
segmental (or cranial nerve) dominance with distal nodes selected also within the same
spinal level. Understanding these fundamental relationships provides a rational basis for
selecting nodes consi stent with achieving repeatable results. 1 0册 ; 50 The problem is further
complicated by practitioners adhering to the concept of non-existent meridians which
supposedly do not involve nerves. Lack of interest in understanding the known
mechanisms of needling is a m句or limiting factor as well. 10，CH 1 4 刑 ;62 The net effect of
these problems has been poor results in acupunc阳re research studies over the years and
finding that sham acupoints are 0自en as good as well known nodes. 63
Numerous articles on acupuncture have been listed in the Medline since the
1 970's but few involved clinical studies， and even fewer yet involved placebo-controlled
randomized clinical trials (RCT). There is an essential need for clinical evidence of
acupuncture if needling therapy is to be accepted by mainstream medicine. Lack of rigor
in the present literature database provides insignificant support to achieve this goa1. 64
Database searches may produce a large number of acupuncture references with titles that
are not fully consistent with the content. As it is with other clinical study repo口s the
abstracts of acupuncture reports may be drawing conclusions not supported by the
presented weak data. Some studies are presented in such a way that it is difficult to
duplicate the original data.
Additional problems involve a wide variety of concepts and techniques used by
different practitioners. This is especially true for those involving what is known in the
United States and Europe as Traditional Chinese Medicine (TCM) that rely on a
metaphysical understanding of acupuncture. 6S ; 66 They argue that TCM is so different
from Westem medicine that they cannot be held to using RCTs in clinical trials.

Correcting the Energy-Meridian View

1t is interesting to note that changing from the metaphysical application of Chinese
needling therapy to that of the real world only involves a shi丘 in one' s mind set. All
licensed or certified acupuncturists have invested considerable time and effort to leam the
location and indications for most of their meridian needling sites (acupoints). Many have
even sought to understand the dermatome or spinal cord segment that se凹es each of these
locations. Some must have realized that the pathways of acupoints (neurovascular nodes)
run longitudinally up and down the arms， legs、 and body. They have also leamed that:
"the muscle regions and cutaneous regions are the sites where the qì (气 inhaled breath
and yÍng 营 nutrients)， and blood (xuè 血) of the meridians nourish the muscles. tendons
and skin" S8 without realizing these are longitudinal distributions of actual skeletal
muscles (See Chapter 2). Changing to real world anatomy only requires the elimination
of the false terms "meridians or channels" and replacing them with the original Chinese
longitudinal body notation to name the vessels， acupoints， acupoint pathways， and
skeletal muscle distributions (See Tables 1 .2 and 1 .3). Everything else they have leamed
that is useful for treatment approaches is still applicable.

D.E . Kendall， OMD， PhD @2005-2009

Chinese Orthopedics Introduction and Principles 25

Developing Consistent Treatment Protocols

The Chinese longitudinal muscle distributions provide a means of developing rational,
effective, and consistent needling therapy treatment approaches. These are derived from
clinical experience and a science-based understanding of Chinese medical concepts, the
musculoskeletal system, physiological mechanisms of needling, and neurophysiology.
They provide a rational approach to obtain consistent results for clinical trials to verify
possible utility for needling therapy. This is essential since little valid research based
evidence has yet to be provided given the confusion and mystery associated with
acupuncture as previously noted.
Each joint of the arms and legs, including the shoulders and hips, are served by 6
muscle distributions. Pain and pathology of a given joint area typically reflects in one or
two muscle distributions, although more can also be involved. Treatment consists of
selecting possible Local and Adjacent, Proximal, and Distal (LAPD) nodes for any given
problem affecting specific longitudinal muscular distribution (See Figure 1 .3). Candidate
treatment protocols for pain and musculoskeletal problems are presented in Chapters 6
through 1 7 for all the main articulations of the body. They are presented in tabular form
and take advantage of spinal segmental dominance, proximal effects, and distal effect
provoked by the afferent nerve processing system. Suggested application of
electroneedling (EN) is also included.

Brain
Needle insertion along
Descending Stem
muscle/vessel pathway
Inhibition .......__
relative to problem
��
,,

-+
Proximal Area Proximal ... Segemental
Nodes ...
to Problem Level
Ascending
�� �Afferent
,,
Signals

� I
Local and
Region of Segemental
Adjacent
Problem
• Level
Nodes
��
,,

-+
Distal Area Distal ... Segemental
Nodes ...
to Problem Level

Figure 1 . 3. Schematic of neurovascu lar node selection that are local and adjacent (LA) to the
problem area that integrate at same spinal nerve level, along with proximal (P) nodes that
integrate at the same or h igher segmental region, and the distal (D) nodes on the extremity
associated with the affected muscle distribution, to direct descending restorative processes.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Introduction and Principles 26

One interesting approach by the Chinese was to only use neurovascular nodes
(acupoints) of the l ateral hand and foot distributions in treatment of muscular problems.
Part of the reason for this is the fact that the lateral distributions have better distal nodes
and also have more tonic type muscles. Another reason for this is that medial and lateral
regions of the hand and feet are related in terms of out flowing arteries and return flowing
veins and related nerves. The treatment protocols presented in tabular form in Chapters 6
through 1 7 generally follow this strategy. Early clinical studies indicated that the use of
only local and adjacent nodes did not resolve the problem. Adding distal nodes improved
clinical results. Maximum clinical effectiveness was only achieved by using local and
adjacent, proximal, and distal nodes together (See example of LAPD protocols in Table
1 .4).
Local and A djacent Nodes
Selecting nodes associated with the affected j oint simply involve considering those
located in or near the region of the problem. These represent the local and adj acent area
of the problem that take advantage of the segmental dominance features of the afferent
processing system. Basically, afferent nerve signals stimulated by needling the local and
adjacent area of the problem distribute to the same spinal region as the pain signals
emanating from the local and adj acent area of the presenting problem. This assures that
descending control and pain inhibition signals will be directed down to the same area as
the presenting problem (See Figure 1 .3).10·CHIS;so;sl The restorative effects involve
inhibition of pain, reducing inflammation, restoring blood flow the area, normalizing
homeostasis, and possibly restoring muscular function. An example for possible
candidate local and adjacent neurovascular nodes for a problem affecting the shoulder is
provided in Table 1 .4 . Suggested candidate nodes are based on the actual muscles or the
affected joint. The actual nodes selected depend on the specific location of the problem.
Four candidate nodes are listed in this example for problems in the anterior lateral aspect
of the shoulder involving the anterior medial hand and anterior lateral hand (AMH &
ALH) muscle distributions. Four other candidate nodes are listed for problems in the
anterior lateral aspect of the shoulder involving the anterior, medial, and posterior lateral
hand (ALH, LH & PLH) muscle distributions.

Table 1 .4. Candidate regional, proximal and distal nodes for pain and disorders of the shoulder
(See Chapter 9 Table 9.4).
Pain or Disorder of Candidate Local & MD* Proximal Nodes Distal Nodes
the Shoulder Adjacent Nodes
Anterior Lateral Yunmen (AMH 2) AMH Fengchi (LF 20) Hegu (ALH 4)
Jugu (ALH 1 6) ALH
Jianyu (ALH 1 5) Dazhu (PLF 1 1 )**
Jianliao (LH 1 4) Feishu (PLF 1 3)
Lateral Posterior Jugu (ALH 1 6) ALH Dazhu (PLF 1 1 ) Hegu (ALH 4)
Jianliao (LH 1 4) Feishu (PLF 1 3)
Jianzhen (PLH 9) LH Fengchi (LF 20) Zhongzhu (LH 3)
Naoshu (PLH 1 0) PLH Tianzhu (PLF 1 0) Houxi (PLH 3)
Jianzhongshu (PLH 15)
* Muscular d1stnbut1on
** Add if signs of subscapularis tendonitis or pain

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Introduction and Principles 27

Proximal Nodes
These nodes are selected that are usually at a higher spinal integration site than the local
and adjacent nodes selected to address the presenting problem. Proximal nodes are often
located on the posterior regions of the lumbar, thoracic, or upper neck depending on the
prime location of the problem. These nodes enhance the therapeutic effect ofthe local
and adjacent node or spread the restorative effects to a slightly higher level along the
spinal cord. In the case of sacraL lumbar, or thoracic problems, the proximal nodes are
represented by the local and adj acent nodes on the back. One possible proximal
neurovascular node is listed in Table 1 .4 for anterior lateral shoulder problems is Fengchi
(LF 20). The subscapularis muscle belongs to the anterior lateral hand (ALH) muscle
distribution. Any signs of subscapularis tendonitis or pain can be addressed by adding the
nodes Dazhu (PLF 11) and Feishu (PLF 13) even though these nodes are assigned to the
posterior lateral foot (PLF) vessel. The anterior lateral hand (ALH) muscle distribution
ties into the spine with the rhomboid muscles which include the nodes Dazhu (PLF 11)
and Feishu (PLF 13). Needling these two nodes along with other more distal ALF nodes,
including either Jianyu (ALH 15) or Jugu (ALH 15), and especially Hegu (ALF 4), will
address problem with the subscapularis muscle. Both nodes Dazhu (PLF 1 1) and Feishu
(PLF 1 3) are appropriate proximal nodes to address problems in the lateral posterior
shoulder involving the ALH muscle distribution; the proximal node Fengchi (LF 20) is
appropriate for lateral hand (LH) muscle distribution involvement; and both Tianzhu
(PLF 1 0) and Jianzhongshu (PLH 15) are appropriate proximal nodes for the posterior
lateral hand (PLH) muscle distribution.
Distal Nodes
These nodes are unique in that they are typically located on the hands or feet which have
a high density ofafferent sensory nerve fibers. As a consequence, distal nodes provoke
strong responses. Distal nodes are selected on the affected extremity associated with the
prime longitudinal muscle distribution involved in the presenting problem. Distal nodes
may also be selected on adj acent muscle distributions. Some have characterized these
nodes as being a window into the entire associated muscular distribution and therefore
are essential in treatment approaches. Selection of distal nodes in Table 1.4 for problems
affecting the anterior lateral shoulder only involve the anterior lateral hand (ALH) node
Hegu (ALH 4 ) even though the problem may also involve muscles in the anterior medial
hand (AMH) muscle distribution. Distal nodes for problems of the lateral posterior
shoulder involve: Hegu (ALH 4) for the anterior lateral hand (ALH) muscle distribution;
Zhongzhu (LH 3) for the lateral hand (LH) muscle distribution; and Houxi (PLH 3) for
the posterior lateral hand (PLH) muscle distribution.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Introduction and Principles 28

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 Chinese Orthopedics Muscular Distributions 31

Chinese Muscular Distributions

The most important and unique aspects of Chinese orthopedics involves a systematic
approach to treating musculoskeletal problems, once a proper assessment has been
completed. This relies on a physiological understanding of the principles of needling
therapy including spinal segmental dominance of neurovascular node ( acupoint)
indications and spinal axial organization. The other aspect of assessment and treatment
concerns application of the Chinese longitudinal muscular distributionsa that are
consistent with the neurovascular nodal (acupoint) pathways along the body. Six specific
muscle distributions are involved in the articulation of each joint in the extremities. All
twelve of the Chinese longitudinal muscle distributions are presented herein including the
muscle name, function, origin, insertion, and innervation including appropriate nerve
roots. In addition, Chapters 7 through 1 7 lists all muscles involved in the articulation of
each particular j oint providing their name, longitudinal muscle distribution identifier, and
nerve root. The kinesiology of the muscles is also provided in terms of muscle functions
in being prime movers (PM) or associate/assistant/ movers (AM) for each direction of
joint movement.
Rational treatment protocols involve selecting candidate nodes related to specific
muscle distributions that are: 1 ) local and adjacent (LA) to the problem that consider
spinal segmental dominance; 2) those that are proximal (P) to the problem that take
advantage of spinal axial relationships; and 3) distal (D) nodes that may be related to
either or both spinal segmental or axial relationships. This treatment approach provides a
rational strategy that is based on how the body and spinal afferent processing system is
organized. This approach also allows development of rational treatment protocols for
needling therapy research. Candidate needling therapy treatment protocols provided in
Chapters 6 through 1 7 is based on LAPD approach.

View of Patho logy

Western orthopedic disease terminology is exclusively applied in Chapters 3 through 1 7
since this is the world standard used by all other medical practitioners. Furthermore, it is
difficult to accurately correlate ancient Chinese descriptions of orthopedic conditions
with present day problems. However, it is important to examine some of the Chinese
ideas of physiological function or balance which do have a high degree of
correspondence with present day understanding. Cause of disease was viewed by the
ancient Chinese as a contention between normal physiological function and external
factors including atmospheric and climatic conditions, and possible infective agents.
Bodily physiological function also includes its normal resistance and recovering capacity.
Consequently, the body can tolerate a certain level in the variation of external factors
without becoming ill. However, when external factors are excessive, either by magnitude

a Description of the twelve muscular distributions provided in this chapter are derived from the author's
original translation of Treatise 13: Longitudinal Muscles from the Huangdi Neijing, Lingshu volume.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 32

or duration, the body will mount a strong defensive response. The Chinese considered
this to be an external cause disease tern1ed as solid or substantial condition. When
physiological function is strong the affected individual should normally recover. If bodily
function eventually weakens due to the external assault, the disease may become more
serious, and could potentially become fatal.
The Chinese also considered an opposite cause of disease which occurs when
external factors are in a normal non-pathogenic level but some aspect of bodily or
physiological function may be insufficient. This situation leads to an internal disease
condition termed a hollow or empty disorder. Internal insufficiencies could be result of
internal organ problems, vascular disease, emotional strain, disturbed vitalities mediated
by the endocrine glands, immune and defensive system problems, nutrition, lifestyle, and
other conditions. The Chinese considered emotions and vitalities to be an important
source of internal disorders.
There is a constant waxing and waning between external factors and internal
function, including emotional strain. If this situation persists eventually impairing the
body's normal resistance and recovering capacity, it can lead to chronic illness. This is
typically noted in orthopedic conditions of chronic pain, arthritis, rheumatism, and other
conditions. All humans (and animals) have a sophisticated endogenous control system
which provokes the sensation of pain when the skin, tissue, or bones are injured. The pain
normally subsides as the injuries heal. However, many people also develop pain and
dysfunction without any obvious history of significant injury, overstrain, or trauma. This
would indicate possible derangement of some aspect of physiological function. Many
orthopedic conditions are also the result of trauma and wear and tear. Properly directed
needling therapy is effective in addressing both categories of problems because it
facilitates tissue healing, mediates pain relief, restores local blood flow, and restores
sympathetic and parasympathetic balance, and hence homeostasis.

Orthopedic Conditions in the Neijing

Some twenty-one treatises of the Neijing Lingshu (LS) and Suwen (SUI) cover needling
therapy and the treatment of orthopedic conditions. The principal cause of pain and other
problems for the Chinese mainly related to enviornmental conditions, emotional strain,
diet, physical stress, wear and tear, and injury, much as it is in present times. The cause of
internal organ and external body pain is described in the SW 39 Pathogenesis ofPain
including how pain in one region or organ affects another part of the body. A specific
discussion on the cause of pain in the muscular system is noted as follows:
"When environmental cold remains in the external region of the vessels (and related
nerves and muscles) causing the vessels to be cold, it results in contractions and
inability to extend the legs, contractions and inability to extend the legs then causes
an acute insufficiency of the vessels. This acute insufficiency results in stretching
the small collateral vessels of the muscles resulting sudden pain. This pain can be
relieved by slight warming of the area; however, if the cold attacks again the pain
can persist for an extended period." (SW 39)

From this viewpoint most musculoskeletal problems are considered to be due to

environmental and other influences on the superficial and deep vessels, since these
structures supply all the oxygen from inhaled air and nutrients to the muscles and joints.

D . E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 33

The Suwen described additional orthopedic conditions including treatises: SW 41

Needling/or Low Back Pain; SW 43 Rheumatism; and SW 44 Flaccidity ofthe Four
Limbs. The Lingshu described other conditions including: LS 27 Circular Rheumatic Pain
(possibly referring to rheumatic fever) and LS 53 Individual Pain Tolerance. Cerebral
vascular accident (CVA) or stroke was described separately and noted to be the result of
major blockage of vessels in the brain.

Physiological Function
The first Western research into possible internal body balance was provided by the
renowned experimental medical researcher Claude Bernard (1813-1878). During post
mortem examination he discovered that the internal body conditions appeared normal and
showing no signs of disease. He referred to it as the balance of the milieu interieur and
considered this constancy of the internal environment to be responsible for a free and
independent life (Bernard, 1865). The American physiologist Walter B. Cannon (1871-
1945) extended Bernard's ideas by introducing the term "homeostasis" to indicate that
bodily systems actually have stable feedback control capability to maintain certain
functions or parametes at constant values (Cannon, 1914). Homeostasis basically means
to control something at the same (homeo) set point (stasis). Control of normal bodily
temperature at 98.6° Farenheight is one important example. However, there are some
serious conditions in which body temperature exceeds this level; such as in case of
illiness or hyperthermia or lower temperature due to hypothermia.

Homeostasis and Allostasis

Cannon explored the limits of homeostasis in animal research that led him discover that
sympathetic splanchnic nerve stimulation of the adrenal medulla released important
catecholamine hormones into the blood stream including epinephrine and norepinephrine.
Epinephrine increases heart and breathing rate, dilates the bronchi to increase air intake
capacity, increases blood flow to the legs, while restricting blood flow to the arms.
Cannon described this as the fight-or-flight emergency or defense reaction to allow an
animal or human to either escape danger or prepare the body for a life threatening battle.
Hans Selye (1936; 1950) coined the term "stress response" to explain the wear and tear
strain that causes pain and pathology for humans and animals alike.
Other endocrine glands come into play during this emergency reaction including
the pituitary, thyroid, parathyroid, and the endocrine pancreas. Inappropriate activity of
the pineal gland also leads to conditions that influence the body's control of pain. The
concept of homeostasis denotes stable, but essential, feedback control mechanisms
whereas the fight or flight response is a feed-forward unstable response. The feed­
forward response is designed to mediate a short duration emergency response, after
which the individual can relax and fully recover. However, the structure of so-called
civilized societies provides long duration stressful exposures that lead to many problems,
especially those that affect the musculoskeletal system resulting in pain and orthopedic
conditions.
Concepts of physiological function and regulation considers these feed-forward
aspects now referred to as allostasis, meaning stability through change first proposed by
Sterling and Eyer (1988). The idea of allostasis provides a broader insight into

D.E. Kendall. OMD. PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 34

understanding physiology and pathophysiology and the impact on health (Schulkin, 2003;
2004). As it turns out the ancient Chinese already touched on this problem and developed
the idea that each main viscera mediated one specific attribute of human vitality (See
Table 1 . 1 ). Vitalities mediate emotions and are clearly identifiable with the present
understanding of the endocrine glands (Kendall, 2002).

C h inese View of Physiological Function

The ancient Chinese had a clear understanding that some essential component in inhaled
air was circulated in the blood vascular system that was critical to sustain life. This has
long been verified to be oxygen. They also understood that certain refined substances
were circulated in the blood stream. This included nutrients absorbed by the small
intestine veins, defensive or immune substances, and substance of vitality that mediate
emotions now called hormones (See Figure 2. 1 ) . The Chinese were first to note that
defensive substances could leave arterial blood circulation to mount a defensive reaction
and then be drained back to the subclavian veins by the lymphatic vessels.
The Chinese also described several unique functional aspects including: nerve
signals; a concept referred to as ancestral function that included the combined function of
the heart and lungs; internal organ function; and first description of true function or
energy production which occurs within cellular mitochondria to fuel bodily function, now
referred to as cellular metabolism. The anatomical and physiological components of
physiological balance are clearly consistent with modern understanding including the
ideas of homeostasis and allostasis (See Figure 2 . 1 ).

Metabolic Anatomical & Physiological

}
Substrates Components

{
Plasma
Qi (Air) - Oxygen - & Cells
- Blood ( Xue)
Ying -Absorbed - Blood Vessels (Mai)
N utnents
Jing - Refined
Wei - Defensive -Lym phatics &
Substances Zhengqi or
Substances I m mune System
Shenj i ng - Hormones - Endocrine Glands Physiological
Shenqi - Nerve Signals - Brain & Nerves Function
Zongqi - Heart & Lung - Blood Circulation (Homeostasis
Functional (Qi) Function & Respiration + Allostasis)
Aspects Zangfuqi - Internal Organ - Digestion , Fluids,
Function & Eli m ination
Zhenqi - True Function or - Cellular Level
Energy Production Metabolism

Figure 2. 1 . Modern view of metabolic, functional, anatomical, and physiological aspects of

Chinese concept of physiological function regulated by homeostatic and allostatic means

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 35

Relationships of Organs, Endocrines, and Vitalities

The ancient Chinese were the first to systematically relate the impact of emotions on the
internal organ vitalities that lead to certain pathological manifestations (LS 8: Root of
Vitality). The vitalities assigned to each of the five viscera correlate well with the
function of the endocrine glands which have a corresponding influence on emotions (See
Table 1.1). However, emotions themselves also have an impact on the endocrine glands
that lead to many problems. The LS 8 notes that unresolved fear and dread can result in
aching bones, flaccid paralysis, and cold limbs. Fear and dread also impairs functional
activity that if not resolved could become fatal. Emotions that impact vitalities were
noted to cause damage to prominent muscles and wasting of muscle tissue. If this
condition persisted it could put the person at risk of dying early, usually before the age of
thirty. The Chinese were also the first to recognize the influence of daily, monthly, and
annual time periods on the function of the internal organs and on health that is now
referred to as chronobiology. Consistency in daily awake and sleep periods was noted to
be essential in maintaining health.

Impact of Diet on Musculoskeletal System

Since food intake is necessary for growth, development, and to sustain the body, it is
obvious that improper intake of certain foods would have an impact on health. The
Chinese categorized foods into five flavor or taste groups related to each viscus and
thought to dynamically interrelate in terms of the five earth phase relationships (See
Table 2.1). Evidence of these relationships has yet to be established. The sour flavor is
related to the liver, bitter to the heart, sweet to the pancreas (formerly thought to be the
spleen, See Chapter 1 ), pungent to the lungs, and salty to the kidneys. A neutral flavor is
also recognized. Some flavors were avoided in diseases of the muscles, tendons, flesh,
and bones. Excess consumption of specific flavors of food and herbs were considered to
harm the functional activity of related viscera; causing injury to muscles and tendons
resulting in flaccidity, bone related fatigue, and shortening of muscles. Excess
consumption of some flavors was considered to have a direct impact on bone pain and
musculoskeletal problems. In addition, certain flavors were used to counteract excess
consumption of other flavors.

Longitu d i n a l M uscu lar Orga n ization

The ancient Chinese carefully identified all the muscles of the human body, correctly
noting their origins and insertions. They further noted that muscles are longitudinally
organized in a manner similar to the longitudinal vessels that supply the muscles, and
related neurovascular nodal (acupoints) pathways. Muscle and tendon distributions are
viewed as a linked system starting at the extremities and passing over one particular joint
and then continuing up longitudinally to the next muscle and joint in line. Sensitive site
locations, propagated sensation pathways, and musculoskeletal pain and dysfunction
patterns, are consistent with these distributions. These relationships are mediated by the
propriospinal system, and somatovisceral and somatosomatic mechanisms and reflect the
organization of the spinal afferent processing system of the body.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 36

Table 2. 1 . Ancient Chinese view of harm to body by excess consumption of specific flavors
viewed in terms of the ancient Chinese 5 phase relationships.
Sour Bitter Sweet Pungent Salty
1 . Condition that Disease of Blood disease Diseases of flesh Disorders of Disease of
flavor is avoided muscles and essential breath bones
tendons
2. Harm of excess Accumulation of Failu re of Shortness of Injures muscles Bone related
consumption on liver fluids and pancreas to breath, heart and tendons fatigue and
functional activity exh austion of moisten, fullness with dark causmg shortening of the
pancreas rmparnng complexion, and flaccidity, and muscles,
functional activity stomach imbala nce of depletion of restraining of
function, causing kidney functional endocrine gland heart function
it to thicken activity hormones
3. Effect of excess Thickening of Withering of skin Pain in bones and Cramps in Stiffening of
consumption flesh and and body hair to falling out of hair tendons and blood vessels
protrusion of lips fall out on head m uscles and and change in
withering of their color
finger and toe
nails

4. Flavors used to Pungent, except Salty, except Sour, except when Bitter, except Sweet, except
counteract excess when liver when heart pancreas disease when lung when kidney
consumption disease present disease present present disease present disease present

In the Chinese anatomical and physiological view, muscles are organized in

longitudinal distributions patterns in the same twelve anatomical body regions as their
related distribution vessels (See Table 1.2 and Figure 1.2). Unlike the vessels, muscles do
not make physical connections with the internal organs, with the possible exception of the
diaphragm. Muscles can however, develop spasm, cramps, and pain as result organ
problems. The Chinese considered muscles to represent the external body. Most
musculoskeletal problems are usually external disorders, unless an internal organ is the
primary source of the problem, or if diet and emotions are the main cause of the problem.
Description of the twelve muscular distributions demonstrates a sophisticated
understanding of the muscular system. Muscles are supplied by specific longitudinal
distribution vessels and nerves associated with each longitudinal regions of the body.
Propagated sensation stimulated by needling travels along the superficial muscular and
vessel pathways.
Furthermore, development of sensitive locations due to musculoskeletal
pathology, usually distribute along these same muscular pathways. Sensitive sites can
reflect organ pathology as well. Palpation of sensitive sites is normally a part of the
examination process. This routine is repeated each time the patient returns for further
treatment, and disappearance of sensitive locations, indicate how well the treatment is
proceeding. Sensitive sites (ahshi nodes) were first investigated in the West by the
Huneke brothers in 1 928 where they developed a technique of injecting these areas with
local anesthetics. They called this practice "neural therapy" and a variation of the
technique is referred to as "trigger point" therapy (Huneke; Travell; Baldry; Dosch).

Aspects of Muscular Control

Voluntary control of the striated skeletal muscles is mainly accomplished by signals
originating in the motor cortex of the brain mediated by upper motor neurons that
distribute to various segmental levels on the opposite side of the spinal cord. Here they

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 37

synapse on lower motor neurons. The basal ganglia and cerebellum have important roles
related to providing signals to make the control of muscles and coordination a smooth
process. Problems in the basal ganglia system include Parkinson's disease and other
movement anomalies. The basal ganglia are influenced by and participate in responses to
needling therapy. Motor control relies on afferent feedback signals from the periphery
associated with the lower motor neurons that provide information on load, position and
acceleration, which are operative at the spinal segmental and brain levels.

Proprioceptive I nvolvement
Lower motor neurons require a feedback servo signal from the muscle tissue involving
afferent muscle spindles signals and efferent input via the gamma motor nerve control
loop. Voluntary signals from upper motor neurons have no effect in contracting the target
peripheral muscle unless there is a corresponding proprioceptive input from the target
muscle. This system provides a feedback control system to assure smooth, precise,
controlled, and safe contraction of the skeletal muscles. This system normally prevents
individuals from picking up excess loads or trying to put force on a structure when the
angular conditions at the particular joint are not proper.
Perhaps the most important aspect of the proprioceptive system is the mediation
of spinal reflexes that affect the target muscle at its specific spinal segmental level.
However, the afferent proprioceptive signals provide input to the propriospinal system
involving long and short neural loops in the spinal cord. These nerve fibers send
proprioceptive information to various muscles throughout the entire body, including to
the opposite side, in order to respond to ongoing conditions of normal and emergency
responses. Typical responses produce ipsilateral flexion of one limb and contralateral
extension of the limb on the opposite side of the body. Some propriospinal reflexes affect
the ipsilateral leg and the contralateral arm, and vise versa. Proprioceptive responses can
also provoke autonomic reflexes as well.

Propriospinal Communication
Most essential to Chinese treatment modalities, especially needling therapy is that the
propriospinal system provides the primary neural communication pathway to send spinal
cord dorsal root reflexes (DRR) to various parts of the body that participate in mediating
autonomic and somatic homeostasis. The net effect of this is to restore blood flow, reduce
muscle spasms, normalize visceral function, and reduce pain. If threshold conditions are
proper a propagated sensation (PS) can be experienced in some individuals that travels
along the vessel nodal path and muscular distribution. Group II static load muscle spindle
fibers are the responsible for mediating this phenomena. The group II muscle spindles are
affected by local pressure and temperature and hence environmental conditions have a
direct impact on orthopedic conditions. Both lower temperatures and mechanical pressure
can inhibit the group II fibers while the opposite conditions of lower atmospheric
pressure and higher ambient temperatures can enhance their participation. Surgical
procedures and injuries that produce scars across nodal pathways and muscular
distributions can potentially impair the normal communication of the proprioceptive
system that leads weakness, muscular dysfunction, and pain.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 38

The organization of the spinal afferent processing system, including the

propriospinal system, also provides the mechanisms to mediate important reflex
phenomena. Some of these reflexes are mediated at or near the same segmental level that
contains the structures involved. This is much the case for deep tendon reflexes. Other
reflexes involve the participation of higher levels of the CNS and therefore can be used in
conjunction with the tendon reflexes to help isolate a problem, such as determining if an
upper or lower motor neuron was involved in the problem.
Several well known and applied deep tendon reflexes have been in use for some
time, even including by the ancient Chinese. One involving the mandible is used to
determine proper supply to the temporalis muscle by the 5th cranial nerve motor fibers.
Other deep tendon reflexes involve both the brachial plexus (See Table 3.7) and the
plexuses of the low back (See Table 3.8). Deep tendon muscle reflexes that are below
normal indicate possible problems affecting lower motor neurons. Hyperactive deep
tendon reflexes indicate possible involvement of upper motor neurons.

Need ling Mec hanisms

Present research into the role of the spinal afferent processing and propriospinal neural
systems in needling stimulated reactions and viscerosomatic relationships are now
beginning to provide a clear understanding of the physiological means to explain how
needling the superficial body brings about beneficial and restorative processes (Kendall
2002, CH 14). Initiating and sustaining these reactions require participation of both
vascular and neural components at the site of needle insertion. Furthermore, many
indications for nodal sites display somatotopically organized somatovisceral
relationships. Basically, indications for nodal sites are mostly related to the spinal level
where their local afferent fibers distribute and integrate with visceral afferents at the same
spinal cord segment.

Initial Response to Needling

The critical feature of neurovascular nodes is the synergistic way the vascular and neural
components interact. Needle insertion causes production of bradykinin via blood
coagulation tissue reactions which stimulates the substance P containing afferent A()
nociceptive fibers that activate local, spinal and brainstem restorative processes. The
initial needling response is sustained by an axon reflex of the A() fibers by releasing
substance P directly on the capillary bed associated with the tissue that is damaged by the
inserted needle. The tissue reaction also produces immune complement C3 which
activates the immune complement system alternative pathway, which in turn causes
degranulation of mass cells in the local tissue and their plasma counterpart, the basophils,
attracted to the site affected by the needle micro trauma.
Kinin protease produced in these reactions serves to stimulate the tissue response
to preferentially produce more bradykinin which then further sustains the initial
activation of the A() fibers. The local vascular structures also participate in the needling
reaction processes to enhance outflow of immune cells that participate in the initial
reaction as well as in the restorative processes. If the A() nociceptive fibers are inhibited,
the needling reaction cannot be sustained. The somatic A() afferent fibers converge with
visceral afferents in the spinal dorsal horn to form somatovisceral connections, and also

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics M uscular Distributions 39

stimulate the spinal afferent processing system which ultimately results in descending
control signals from the brainstem back to the same spinal cord level that provided the
afferent signals.
Needling also activates the proprioceptive group II static load muscle spindle
fibers that bring the propriospinal system into play. When threshold conditions permit the
patient may feel a propagation sensation (PS) of an electrical type nature along the nodal
pathway represented by an organ-related distribution vessel. This PS travels from node to
node and seems to follow along the line that results from connecting the nodal location
for any one distribution vessel. Most individuals can feel the PS over one or two nodes,
while the rare sensitive responders can feel the signal traverse along the entire nodal
pathway and many collateral branches. The propriospinal system is activated by needling
even though the subj ect does not consciously feel the PS.

Directing Descending Control

Purpose of the PS signal is to activate many reflex responses, which can be remote to the
needling site, mainly involving the muscular system. The other role of PS is to direct the
descending control signals, from the brainstem via the dorsolateral funiculus of the cord.
to the correct spinal segmental levels to provide restorative effect. Descending control
signals to the spinal cord results in: inhibition of nociceptive fibers (pain signals);
restoration of blood flow and vascular tone in the periphery and in the viscera; relaxation
of residual muscular tension (antispasmodic feature); restoration of visceral homeostasis;
and control features of tissues responses to needling that enhances immune responses and
promotes tissue healing.

Somatotopic Indications
The indications and use of nodal sites are related to their local area of influence on the
body as well as relationships to muscle and vessel distributions and the internal organs.
Nodes also have influence on the underlying related vessels in the peripheral regions of
the arms and legs as well as other regions of the face, hands, feet and the auricle. Thus
many nodes in these areas have unique capabilities and some located below the elbows or
knees are considered to be special communication nodes. The historic indications for
nodes are based on their characteristics and location and are grouped as follows:
1. Indications involving vascular, circulatory, musculoskeletal, pain disorders, skin,
tissue or sensory organ problems, related to the node's physical location in
relation to regional anatomic features and the particular distribution vessel that
supplies the region.
2. Conditions involving pain and dysfunction in some portion of the muscular
distribution pathway to which the node and vessel belong, even though the
problem is remote (either distal or proximal) to the selected node.
3. Physiological effects, including the influence of vessel relationships, on one or
more organ systems due to the node' s relation to specific spinal segmental levels
(or brain stem) that converge with corresponding afferent signals from the related
v1scera.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese O rthopedics M uscular Distributions 40

4. Special known effects for certain nodes or conditions treated due to unique
communication pathways or relationships to the specific node.
Since muscular and visceral problems can often be viewed as a general category,
it is helpful to consider these indications separately from each other. This makes the task
of understanding the use of neurovascular nodes easier. Nodes of each distribution vessel
can be viewed separately with respect to their internal and musculoskeletal indications.
Visceral related indication show a good correspondence with the node location and its
potential influence on autonomic systems related to or mediating at the same spinal cord
segmental level or brainstem area. Musculoskeletal indications show a clear relationship
between the node and the underlying muscles and structure. These somatovisceral and
somatosomatic relationships hold true for all regions of the body including the face,
trunk, upper extremities, and lower extremities. Indications for some nodes show distal
effect that corresponds to an area of the body that is remote to the node in question. This
indicates the involvement of neural communication that is mediated by the spinal afferent
processing system, perhaps involving the propriospinal system.

Lon gitud i n a l Distrib ution of M uscles

Each specific longitudinal muscular distribution is served, both in terms of blood
circulation and neural innervation, by one of the twelve longitudinal distribution vessels.
The muscular pathways described in the LS 1 3 represent a clear depiction of all of the
skeletal muscles in the body. Some of these are identified by specific Chinese names for
the gastrocnemius, quadriceps, and sternocleidomastoid muscles, and the diaphragm.
Other muscles are accurately described throughout the body including the temporalis,
occipitalis, frontalis, pectoralis, deltoids, and trapezius. Location of particular muscles
and their area of insertion and origin are anatomically correct.
However, many of the muscles are only mentioned by their travel routes, insertion
site, and their origins. The ancients did not make the subtle distinction between the
insertion and origin related to place of attachment and area of action. They simply called
all the major sites of tendon and muscular attachment as either insertion, knotting, or
tying locations. This method of describing muscles is not unusual since the practice of
naming each specific muscle in the body did not come into use until the 19th century.
The presently understood Western name of each muscle is provided in the following
paragraphs for each of the twelve longitudinal body regions (See Figure 1 .2) of the upper
and lower extremities.
The muscular system, comprised mostly of muscle tissue, has several unique
features aside from the function of moving the body. First, many muscles have different
capabilities to perform their specific function, related to the speed of the muscle and its
inherent strength. It is now known that muscles are composed of different types of tissue
fibers to mediate their respective functions (Table 3.3). The ancient Chinese may have
appreciated the subtle differences between the muscles, borne out by the fact that nodal
sites in muscles are usually found in the slower muscles, and are not found in fast
muscles.
Muscles are arranged in longitudinal pathways, and sensitive sites within these
routes are useful for diagnosis and assessment of treatment. Temperature and color

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 41

variations i n the cutaneous regions that overlie the muscle and vessel distribution
pathways are also useful for diagnosis. The related pathology reflected along each
distribution is provided along with the description of the muscular distributions.
Treatment strategies were also provided for each longitudinal muscle distribution that
indicated the use of a preheated needle. It is known that needles were sharpened and
heated prior to treatment. It is not understood if the heating was a prophylactic process or
not, but the needles had to be cooled before insertion into patients.

Posterior Lateral Foot (PLF} Muscles

Muscles and related tendons belonging to the posterior lateral lower extremity generally
follow along the course of the distribution vessel neurovascular nodes pathways assigned
to the Chinese PLF anatomical division of the body (See Figure 2.2 and Table 2.2a and
2 .2b) as follow: The PLF muscular distribution starts at the small toe including the flexor
digiti minimi brevis (5th toe) and abductor minimi digiti and ties into the ankle (calcaneus
bone). From here the pathway deflects upward with the lateral soleus tying into the
posterior aspect of the knee (upper shaft of fibula). Another muscular pathway distributed
from the heel ties into the calcaneus and travels upward accompanying the former muscle
(lateral soleus) as the plantaris to tie into the back of the knee (lateral condyle of femur).
The plantaris overlies the popliteus muscle which is not mentioned. (LS 1 3)
Another branch from the lateral aspect of the heel forms the specifically named
lateral gastrocnemius muscle traveling above to the popliteal fossa (lateral condyle of
femur). From above the medial aspect of the popliteal fossa and former pathway on the
lateral popliteal fossa, the (PLF) muscular pathway distributes upward as the biceps
femoris long head and semitendinosus muscles tying into the buttocks (ischial
tuberosity). Starting from the ischial tuberosity this distribution includes the lateral hip
rotators to include the gemellus inferior, gemellus superior, quadratus femoris, obturator
intemus, and piriformis and muscles. The buttocks include the gluteus maximus muscles
that overlie the lateral hip rotators. (LS 1 3)
The PLF muscle distribution continues from the gluteus maximus to travel up
each side of the spine with the erector spinae muscles including: iliocostalis lumborum,
thoracis and cervicis; longissimus thoracis, cervicis and capitis; and spinalis thoracis,
cervicis and capitis to the nape of the neck. Here a branch enters into the root of the
tongue to include the styloglossal muscle. Also included are the serratus posterior
superior and inferior muscles. The distribution continues up the neck with the
semispinalis capitis, splenius capitis, splenius cervicis, longissimus capitis, and trapezius,
to insert into the occipital bone. As the distribution continues over the head in includes
the occipitalis and galea aponeurotica, and then descends to the nose with the procerus
muscle. Another branch enters below the axilla with the latissimus dorsi and then from
the supraclavicular fossa the distribution travels above to tie into the mastoid process
with the sternocleidomastoid. Another branch travels out from the supraclavicular fossa
slantingly upward toward the lower border of the zygoma with the platysma. (LS 13)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 42

Occipita lis
Semispinalis Capitis ---­

Splenius Capitis

Splenius Cervicis

Seratus Posterior
Superior

Spinalis Thoracis

Longissimus Thoracis ---

I liocostalis Thoracis
Latissimus Dorsi
Seratus Posterior -
I nferior

l l iocastalis Lumboru

P i riformis
Gemellus Superior
Obturator l nternus --­
Gemellus I nferior - Gluteus Maximus
Quadradus Femoris

0.: )
!f/j)) Biceps Femoris
(long head)

Semitendinous --

Plantans

Popliteus

Lateral Soleus --��--- Lateral Gastrocnemius

Muscles Not Shown: Platymus;

Procerus; Orbicularis Oculi Upper
Flexor Digiti Minimi Brevis
Portion; Styloglossal; Spinalis
Capitis and Cervicis; Longissimus
Capitis and Cervicis
- Abductor Digiti Minimi

Figure 2.2. Muscles of the posterior lateral foot (PLF) longitudinal body region

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese O rthopedics Muscular Distributions 43

Table 2 2 a. M usc �s o f th e poster!or latera l f00

�F) IO!!�ti!J_m al dtstr!button
I
..• _ _ _

r Muscle Function I Origin I nsertion Innervation & Root

Procerus Draws skin of
forehead down
Bridge of nose Skin over root of nose
�:I
Facial

l
- -

Orbicularis Closes eyelid Medial aspect of Encircles upper orbit

oculi, upper maxillary and frontal and pass across VII
- -

orbital and bones and medial eyelid to form lateral -

palpebral part palpebral ligament palpebral raphe

1-' - 1--':-
Acromion,
---

clavicle and
-

Lower border of Facial, cervical

--

Platysma Depresses jaw and

--

lower lip; wrinkles skin fascia over deltoid and mandible, risorius and branch
of neck and chest pectoralis major opposite platysma CN-VII
-

Occipitalis Draws scalp back Occipital bone and Galea aponeurotica Facial
mastoid part of C N VII
temporal bone --
-- -- - --- -

Sternocleido- One side rotates head Consist of two heads, Mastoid process and Spinal accessory
mastoid to opposite side; both one from sternum and lateral part of superior CN XI; C 1 , 2, 3
sides depresses head other from clavicle curved line of occipital
bone
--

Trapezius Raises and pulls Occipital bone; nuchal Acromion, scapular Spinal accessory
Shoulder back; rotates ligament; spinous spine and lateral third CN X I ; C2, 3, 4
scapula; extends or processes of 7th of clavicle (upper, middle, &
draws head to one cervical to 1 2th thoracic lower fibers)
side vertebrae
Styloglossal Pulls tongue backward Styloid process of Sides of tongue Hypoglossal
and upward temporal bone CN X I I
---

Splenius One side turns head to Lower half of nuchal Occipital bone; Branches of dorsal
capitis same side; both sides ligament; 7th cervical mastoid process of rami of middle
extend head and first three thoracic temporal bone cervical spinal
vertebrae nerves C4, 5. 6
Splenius Rotates and extends Spines of 3rd to 6th Transverse process of Branches of dorsal
cervicis head and neck thoracic vertebrae 1 st and 2nd cervical rami of cervical
vertebrae C6, 7, 8
Semispinalis Rotates and d raws Transverse processes Occipital bone, Branches of dorsal
capitis head backwards of lower four cervical between the inferior rami of cervical
and upper six thoracic and superior curved spinal nerves
vertebrae line C1 - 5
Latissimus Adducts, extends, Posterior crest of ilium, Bicipital groove of the Thoracodorsal
dorsi rotates ann medially; spinous processes of h umerus C6, 7, 8
raises trunk and pelvis lower 6 thoracic and
lumbar vertebrae, and
outer part of last 4 ribs
f--
Serratus Elevates the ribs Spines of 7th cervical Angles of 2nd to 5th Branches of ventral
posterior and 2 upper thoracic ribs rami of thoracic
superior vertebrae T1 - 4
r-
Serratus Draws ribs back and Spines of lower 2 Lower 4 ribs Branches of ventral
posterior down thoracic and 2 upper rami of thoracic
inferior lumbar vertebra T9 - 1 2
Spinalis capitis Extends head, or turns Spinous processes of Occipital bone Dorsal rami of
head slightly to one 7th cervical and upper cervical and thoracic
side thoracic vertebrae spinal C6, 7, 8
Spinalis Extends cervical spine Spinous processes of Spinous process of Dorsal rami of
cervicis 7th cervical and upper 2 axis cervical and thoracic
thoracic vertebrae spinal C6, 7, 8
Spinalis Un ilateral flexion of Spinous processes of Spines of thoracic Posterior rami of
thoracis spine; bilateral thoracic vertebrae T1 0, vertebrae T3 to 8, (9) thoracic nerves
extension and 1 1 , 1 2 and lumbar T4 - 1 2
hyperextension of vertebrae L 1 , 2
vertebral column --
-- - - -

Longissimus Keeps head erect, Transverse processes Mastoid process of Dorsal rami of lower
capitis extends head, or of lower cervical and temporal bone cervical spinal
draws back to same upper 4 or 5 thoracic C6, 7, 8
side vertebrae
� --

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 44

--r- - of the_posterior lateral foot {PLF lon itudinal

Table 2.2b. Muscles
.-
-- O �- -- - ( continued), .
-body region
. - --�- I
-- -----

Muscle Function rigi I nsertion Innervation & Root

- ·-- -
··

Semispinalis Bilateral extension and Transverse processes spinous processes of Posterior rami of
cerv1cis hyperextension of of 1 st to 6th, articular 2nd to 5th cervical cervical nerves
cervical spine; processes of 4th to 7th vertebrae C3, 4 , 5. 6
unilateral flexion of the cervical vertebrae

-�
neck and head --
Semispinalis Extends spine and Transverse process of Spinous process of 1 st Posterior rami of
thoracis rotates it toward 6th to 1 Oth thoracic to 4th thoracic and thoracic nerves
opposite side vertebrae 6th-7th cervical T1 to 6

---: . . - �rtebrae
Long1ss1mus Unilateral flexion of Transverse processes of Transverse processes Dorsal rami of lower
cerv1cis neck; bilateral 1 st to 4th, & sometimes of 2nd to 6th cervical cervical
extension and 5th thoracic vertebrae vertebrae and thoracic C6. 7. 8
hypertension of neck - ---:-
--
Longissimus Extends spinal column Transverse processes of Transverse processes Dorsal rami of
thoracis lumbar vertebrae and of thoracic vertebrae thoracic and lumbar
Thoracolumbar fascia and lower 9 to 1 0 ribs spinal T4 to L3 --
I liocostalis Extends cervical spine Angles of 3 rd to 6th ribs Transverse processes Dorsal rami of
cervicis of 4th to 6th cervical cervical spinal
vertebrae C6. 7 , 8
I liocostalis Keeps dorsal spine Angles of 7th to 1 2th 1 st to 6th ribs and 7th Dorsal rami of
thoracis erect ribs cervical vertebra thoracic spinal
T1 to 6
r- Broad tendon from Angles of 6th to 1 2th Branches of thoracic
Iliocostalis Bilateral extension and
lumborum hyperextension of sacrum, lumbar ribs and lumbar spinal
spine; unilateral flexion vertebrae spinous T5 to L3
of spine processes, and inner lip
of iliac crest
· -r- . -
Gluteus max. Extends and rotates Superior curved iliac line Iliotibial tract and lnfenor gluteal
Upper fibers thigh and crest, sacrum and fem u r below the L5, S 1 , 2
Lower fibers COCC X greater trochanter
P iriformis Abducts and rotates Great sacrosciatic notch Upper margin of Branch of sacral
thigh outward of ilium and margins of greater trochanter L(5), S 1 , S2
-- anterior sacral foramina -
Obturator
internus
Quadratus
I Rotates thigh outward
--
Rotates thigh outward
Pubis, ischium, obturator
foramen
Ischial tuberosity
Inner surface of
greater trochanter
Intertrochanteric ridge
Sacral plexus
L5, S 1 , 2
Sciatic
-- --
femoris - L4, 5,_§1___ ___

Gemellus Rotates thigh outward Ischial spine Greater trochanter Sacral plexus
superior
Ischial tuberosity
L5, S 1 , 2
-- -
Gemellus Rotates thigh outward Greater trochanter Sacral
inferior L4. 5 . S 1
Biceps femoris Flexes knee and Ischial tuberosity Lateral condyle of tibia Tibial portion of
�� head) rotates knee outward and head of fibula sciatic L5, S 1 , 2
Semitend inosus Extends thigh; flexes Ischial tuberosity On shaft of tibia below Tibial portion of
and rotates leg internal tuberosity sciatic L5, S 1 , 2
r----
Popliteus Rotates tibia medially Lateral condyle of femu r Posterior surface of Tibial
1-
or femu r laterally
- -- tibial shaft L4, 5, S 1
Gastrocnem ius Plantar flexes foot and Lateral condyle of femur Tendo calcaneus Tibial
wteral headl flexes leg --- S1 . 2
I
Plantaris Plantar flexes foot Lateral condyle of fem u r Calcaneus Tibial
-- L4, 5; S 1
Lateral Soleus Plantar flexes and Upper shaft of fibula Tendo calcaneus Tibial
rotates foot L5, S 1 , 2
Abductor digiti Abducts little toe Lateral tuberosity of Lateral side of 1 st Lateral plantar
minimi calcaneus; plantar fascia phalange of l ittle toe S1. 2
Flexor digiti Flexes little toe Base of 5th metatarsal Lateral side of 1 st External plantar
minimi brevis and sheath of peroneus phalange of little toe S1 , 2
-- longus

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 Chinese Orthopedics Muscular Distributions 45

PLF Muscle Pathology

When the posterior lateral foot (PLF) longitudinal muscular distribution pathway is
disordered it wil l result in pain and swelling in the small toe and the region of the heeL
contractions in the back of the knee, abnormal curvature in the back, muscular spasms in
the nape of the neck, inability to raise the shoulders due to pain, cramp like pain in the
axilla extending to the supraclavicular fossa, and inability to tum the upper body to the
left or to the right. (LS 13)

PLF Treatment Strategies

To treat the above disorders, quick insertion with a (previously) heated needle of
indefinite duration, should be employed. To understand the duration and frequency of
treatment involves assessing the effectiveness by palpation of painful and sensitive
neurovascular nodes and locations along the PLF muscular pathways. Symptoms
associated with this muscular distribution are called "midspring" rheumatism. (LS 13)

Posterior Med ial Foot (PMF) Muscles

Muscles and related tendons belonging to the posterior medial lower extremity generally
follow along the course of the distribution vessel neurovascular node pathway assigned to
the PMF longitudinal body region. The longitudinal distribution of the muscles and
related tendons belonging to the posterior medial lower extremity starts below the small
toe with the flexor digitorum brevis, plantar interosseous, and lumbricals (See Figure 2.3
and Table 2.3a and 2.3b). It then includes the quadratus plantae, adductor hallucis, flexor
hallucis brevis, and abductor digiti minimi muscles. From the calcaneous, this
distribution continues up the medial leg with the medial soleus and medial
gastrocnemius, to insert above at the medial aspect of the fibula. It then follows up along
the thigh with the semimembranosus, adductor magnus, adductor longus and adductor
brevis muscles. (LS 13)
From here it travels to region of the sexual organ to include the deep transverse
perineal and iliococcygeus muscles, and then follows along the inner aspect of the spine
with the coccygeus and quadratus lumborum muscles. Continuing up each side of the
back bone this distribution includes the transversospinal group of muscles including the
semispinalis cervicis and thoracis; rotatores thoracis; levatores costarum brevis and longi;
intertransversarii; and multifidi muscles. It then travels up to the nape of the neck with
the obliquus capitis inferior, obliquus capitis superior; rectus capitis posterior maj or and
minor; longus colli, longus capitis; and rectus capitis anterior and rectus capitis lateralis
muscles. (LS 13)

PMF Muscle Pathology

Disease manifestations of the PMF longitudinal muscular pathways include acute cramps
in the bottom of the feet as well as pain and cramps at the major insertion sites for these
muscles (ankle, heel, knee, pubic region, back and nape of neck). Diseases specifically
associated with this muscular distribution include epilepsy, alternating contraction and
relaxation of the l imbs leading to tetanus or convulsions. (LS I 3)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orth o pedics Muscular D i stributio n s 46

Obliquus Capitis . Rectus Capitis

Superior Posterior M i nor
Rectus Capitis
Obliquus Capitis
Posterior Major
I nferior
Longus Capitis
Semispinalis Cervicis
Longus Colli
Multifidus -

Semispinalis Thoracis

Levator Costarum
Brevis
Rotatores
Levator Costarum Thoracis
Longi

l ntertransversarii
(C 1 to Sacrum) Quadratus

I Lumborum
Multifidus

Coccygeus
l liococc geus

Adductor Brevis

'� Adductor Longus

Addu ctor Magnus
.. ,_
...
· Semimembranosus

Gastrocnemius
(Medial Head)
- Medial Soleus

Muscles Not Shown: Rectus Capitis

Anterior & Lateralis; Deep Transverse
Perineal; Flexor Halucis Brevis; Adductor
Hallucis; Quadratus Plantae; Lumbricals;
Plantar I nterosseous; & Flexor Digitorum
Brevis

Figure 2.3. Muscles of the posterior medial foot (PMF) longitudinal body region

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 47

j"' '"'
Table 2 . 3a. Muscles of the posterior medial foot (PMF) longitudinal body region
--
I
j Muscle
Longu s calli
_
cerv1c1s
Function
ood beod'
neck forward
I Origin
Transverse processes of
3rd to 5th cervical
Insertion
Anterior atlas; body
of 2nd to 4th and
I Innervation & Root
Branches of 2nd to 7th
cervical nerves
I

vertebrae transverse processes C2 - 7

of 5th & 6th cervical
--
Longus capitis 1 Flexes head Transverse processes of
3rd to 6th cervical
vertebrae
Occipital bone;
basilar process
Branches of 1 st to 3rd
cervical nerves
vertebrae -- - C 1 , 2. 3
Rectus capitis Rotates a nd Base of atlas Occipital bone; Betwee n 1 st and 2nd
� terior inclines head basilar process cervical nerves �
Rectus capitis
lateralis l Supports head;
inclines head

--- lat�_r:� � ---- -

Transverse processes of
atlas
- - - --
Occipital bone ju g u lar
process
Between 1 st and 2nd
cervical nerves
C1 , 2 -
Rectus capitis
posterior minor
I
Extends head Posterior tubercle of
atlas
Occipital bone Suboccipital nerve,
dorsal rami of C 1 ; I
I
C1 . 2
Rectus capitis Extends head, Spinous process of axis Occipital bone Suboccipital nerve ,
posterior major rotates to same dorsal rami of C 1 ;
side C1, 2
Obliquus capitis Extends head, Transverse processes of Occipital bone Suboccipital nerve,
superior flexes toward same atlas dorsal rami of C 1 ;
side 2 __
__f.1__ -
Obliquus capitis Turns face toward Spinous process of axis Transverse Suboccipital nerve,
inferior same side processes of atlas dorsal rami of C 1 ;

-'-- -� · 2 -
I nterspi nales: Extend neck and Upper border of spinous Lower border of Dorsal primary rami of
cervica l , thoracic, & trunk process (C3 to scarum) spinous process spinal nerves
lumbar above (C2 to L5) C2 - 8; T1 - 1 2 ; L 1 - 5
--- - ---
Rotatores: cervical , Rotates & extends Transverse processes of Lamina of next Dorsal rami of spinal
thoracic, & lumbar vertebral column to 3rd cervical to sacrum vertebrae above C2 - 8; T1 - 1 2 ; L 1 - 5
opposite side
Levatores Raises ribs and Transverse processes of Rib next below Ventral and dorsal
costarum brevis flexes vertebral 7th cervical to 1 1 th rami of spinal
column thoracic vertebrae T1 - 6
--- - -r-- ·-

Levatores Raises lower ribs Transverse processes of Second rib next Ventral and dorsal
costarum longi and flexes vertebral 9th and 1 Oth thoracic below rami of spinal
column vertebrae T6 - 1 0
lntertransversarii: Laterally bends Transverse processes of To next transverse Ventral and dorsal
cervical, thoracic, neck and trunk vertebral column process below, from rami of spinal
& lumbar C 1 to sacrum C2 - 8; T1 - 1 2; L 1 - 5
Multifidus: cervical, Rotates spinal Iliac spine; sacrum; Laminae and spinous Dorsal rami of spinal
thoracic, & lumbar column thoracic and cervical process of next 4 C2 - 8; T1 - 1 2; L 1 - 5
vertebrae vertebrae above
Quadratus Flexes trunk Iliac crest, iliolumbar Upper lumbar Branches of 1 2th
lumborum laterally and ligament, lower lumbar vertebrae and 1 2th thoracic and 1 st
forward vertebrae rib lumbar T 1 2 - L3---
-
Coccygeus S u pports coccyx, Sacrospinous ligament Lower part of sacrum 3rd and 4th sacral
closes pelvic outlet and ischial spine and coccyx S3, 4 -
l liococcygeus Supports pelvic Pelvic fascia, ischial Rectum, coccyx and Sacral and perineal
floor spine fibrous raphe of S3, 4
-1 -4erineum
Deep transverse Helps expel urine in Ischial rami Central tendon of Perineal branch of
perineal females and urine perineum pudendal
and semen in males
Adductor brevis Adducts a nd flexes I nferior ram is of pubis Upper part of linea Branch of obturator
thig h aspera of fem ur L2, 3, 4
Adductor longus Adducts a n d flexes Pubic crest Middle of linea Branch of obturator
thigh aspera of fem u r L2. 3, 4
Adductor magnus Adducts thigh and Ischiopubic ramus; Med ial condyle a n d Branch of obturator
upper & lower rotates it outward ischial tuberosity linea aspera of femu and sciatic L2 - 5, S 1 I

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 48

Table 2. 3b. M uscles of the posterior medial foot ( PMF) longitudinal distribution (continued)
-
I Fu nction I I nsertion
j
·-

1 Muscle Origin I n nervation & Root

Semimembra- I Extends thigh or trunk; Ischial tuberosity Medial condyle of j Tibial
- nosus ____J_ !!_exes leg ___ . ... fem u r �1 2 -
Soleus (medial I Plantar flexes and Oblique line of tibia and Tendo calcaneus Tibial
portionl_ rotates
---foot
-
upper fibula LS, � 1 . 2
_
Gastrocnemius Plantar flexes foot and Medial condyle of femur Tendo calcaneus Tibial
(Medial head) flexes leg__ __§1. 2
-
Flexor hallucis Flexes big toe Cuboid; 3rd cuneiform Base of big toe Medial plantar
brevis proximal phalanx L4, 5, S 1 --
Adductor Adducts big toe Tarsal terminations of Base of big toe 1 st Lateral plantar
haiiUCIS - middle metatarsal bones phalanx S1 , 2
Quadratus Assists in flexing toes I nferior os calsis by 2 Tendons of flexor Lateral plantar
plantae heads at inner and outer digitorum longus S1 , 2
--
borders - --
-:-- - --
--=-
Lumbricals Flex 1 st a nd extend Tendons of flexor First phalanx of External and internal

�
2nd and 3rd phalanges digitorum longus extensor tendon plantar L4, 5 ( 1 st) S1 ,
-f-..c:-
S2 (2nd-4th) ____
Plantar Adduct 3 outer toes 3rd , 4th and 5th First phalanx of E�em•l pl•
interossei metatarsal bones corresponding toe S1 , 2
Flexor d igitorum Flexes toes at proximal Medial tuberosity of Middle phalange of 4 j Med;l plantar
brevis inte�halan eal joint calcaneus: plantar fascia_ lateral toes L4. 5, S 1

If the (PMF) disorders involve the more superficial muscles in the back, the
patient will be unable to bend forward. If it involves the deeper muscles in the back, the
patient will be unable to bend their heads backwards. Hence, a more superficial PLF type
disorder will cause abnormal curvature in the lumbar region due to contraction of
superficial muscles, resulting in inability to bend forward. If it is a deeper PMF type
disorder, it will result in the inability to bend backwards due to contraction of the deeper
muscles. Symptoms associated with this muscular distribution are called "midautumn"
rheumatism. (LS 13)

PMF Treatment Strategies

To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive neurovascular
nodes along these muscular pathways. If disorders of the P MF muscular distribution
occur internally (deeper muscles of the back), they can be relieved by stretching exercises
and consuming herbal remedies. However, if the present muscles are in contraction and
seized, and the seized component is a very dominant feature (such as with tetanus) the
disease is considered incurable. (LS 13)

Anterior Lateral Foot (ALF) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the anterior
lateral lower extremity (ALF) starts in the region surrounding the third toe to include the
2nd and 3rd dorsal interosseous muscles (Figures 2.4 and 2.5, and Table 2.4a and b ). It
then inserts into the dorsum of the foot with the extensor hallucis brevis muscles
continuing up leg with the extensor digitorum longus, peroneus tertius, and tibialis
anterior muscles. Above the knee this distribution continues with the vastus intermedius
and rectus femoris muscles. From the femur it sends a branch to join the backbone with
the psoas major and minor, and iliacus muscles. Another branch consisting of the

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 49

obturator extemus distributes to gather around the sexual organs. This distribution then
travels above along the abdomen as the rectus abdominis muscles, and continuing above
the supraclavicular fossa to include the sternohyoid, sternothyroid and thyrohyoid
muscles and then the mylohyoid muscle. The anterior lateral foot (ALF) longitudinal
muscular distribution includes several important facial muscles i ncluding the mentalis,
depressor labii inferior, orbicularis oris, zygomaticus major, zygomaticus minor, levator
labii superioris alaeque nasi, lower orbicularis oculi (palpebral and orbital parts), and the
masseter (See Figure 2.5). (LS 13)

ALF Muscle Pathology

When the ALF muscular distribution is disordered it will result in acute cramps in the
middle toe and along the tibia, foot tremors, acute cramps in the rectus femoris muscle,
swelling and edema in the anterior aspect of the thigh, incarcerated hernia, contractions
of the abdomen (spasms), stretching sensation from the supraclavicular fossa reaching the
jaw (cheek), unexpected or sudden deviation of the mouth, with acute condition that the
eye cannot close (Bell's palsy). If the condition is caused by heat, the muscles will be
relaxed and the eye will not be able to open (ptosis of the eyelid). If the muscles of the
cheek have a cold sensation, it will cause acute drawing of the cheeks and alterations or
movements in the mouth. If heat conditions are present it will result in relaxation and
release of the muscles, with inability to contract and consequently will cause deviation of
the mouth. (LS 1 3)

ALF Treatment Strategies

To treat these conditions an ointment made from horse fats can be applied in case of
contractions (spasms and cramps), while white wine mixed with cinnamon can be used to
apply to the areas in the case where the muscles are relaxed. A hook made of mulberry
wood can be used to support the angle of the mouth. Mulberry wood coals can be placed
in a pit, whose depth and size is dictated by how long it takes to warm (radiant heat
application) the patient when they are seated. Apply the ointment like ironing the spastic
muscles of the cheeks, and the patient, just for the time being, can drink good wine and
eat roasted meat. Even if they do not normally drink, they can make an individual effort
to do so and thereby enhance the effect of massage that is applied to bring about a cure.
(LS 13)
To treat these disorders, quick insertion with a (previously) heated needle of
indefinite duration, should be employed. To understand the duration and frequency of
treatment involves assessing the effectiveness by palpation of painful and sensitive
neurovascular nodes along the ALF muscular pathways. Symptoms associated with the
ALF longitudinal muscle distribution are called "late spring" rheumatism. (LS 1 3)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 50

Levator Labii
S uperioris Orbicularis Oculi ( Lower Parts)
alaeque nasi - - .. Zygomaticus M inor
Levator Labii . Zygomaticus Major
Orbicularis Oris - Masseter
M entalis - - - ----- -- Depressor Labii Inferior
· Mylohyoid
Sternothyroid & Thyrohyoid

Psoas Obturator Externus

Vastus Intermedius -- - - Rectus Femoris

-Tibialis Anterior

Extensor Digitorum Longus

- Peroneus Tertius Tendon
--- --- Extensor Hallucis Brevis
-- 2nd and 3rd Dorsal I nterosseous

Figure 2.4. Muscles of the anterior lateral foot (ALF) longitudinal body region

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 51

Table 2 4a. M uscles of the anterior lateral foot (ALFL!Q_rl_gitudinal body region---
I I Tlnnervation & Root
- - ·----

Muscle Function Origin --

-
-- Insertion !

Orbicularis Close eyelid Medial aspect of Encircles lower orbit Facial

oculi, lower maxillary and frontal and pass across CN VII
palpebral and bones and medial eyelid to form lateral
orbital parts pa lpebral ligament
--
palpebral raphe
- _,
_ ___ --

Levator labii Elevates upper lip, Maxillary nasal process Nasal ala cartilage I Facial -

superions dilates nostrils and upper lip I CN VII, infraorbital

alaeque nasi -
branch
-

Zygomaticus Draws upper lip up Zygomatic bone Angle of mouth, Facta I

minor and out orbicularis oris CN VI I
- ·-
r- . -- - --
-
Zygomaticus Draws upper ltp Zygomatic bone Angle of mouth Facial
major upward, backward and CN V I I

r--
Orbicularis oris
outward
Closes and puckers
lips
J Nasal septum and
canine fossa of
B uccinator and skin at
angle of mouth
-
-
Facia l
C N VIl
mandible
r-- -- -

Menta l is Raises and protrudes I ncisive fossa of Skin of chin Facial

lower lip mandible CN VII
External oblique line of
--- -

Depressor labii Depresses lower ltp Lower lip and Facial

in ferior mandible orbicularis oris CN V I I
--
c----
Masseter Masltcalion Zygomatic arch and
--

Angle and lateral Bigeminal

malar process of surface of ramus CN V. mandibular
superior maxilla m a nd ib le division
--- --- --

Mylohyoid Depresses jaw, Mandible Body of hyoid T rig emi n a l

e�"tes flooc of mo"lh CN V
-

Sternohyoid
and hyoid
Depresses hyoid
----· --·------ -
---- - - --
FManubrium
- ---
---

Body of hyoid
--

Upper cervical
through ansa
-- -

hypoglOSSI
u
M a n b n um
-

Sternothyroid Depresses larynx Thyroid cartilage Upper cervtcal

through ansa
hypoglossi
Thyrohyoid Depresses hyoid or T h yroid cartilage Hyoid Ftrsl cervical
raises larynx through
hypoglossal -

Rectus Flexes or bends Crest of pubis and Cartilages of 5th, 6th Branches of
abdomims vertebral column to ligaments of pubtc and 7th ribs intercostal
one side; compresses symphysis T7-T 1 2
abdominal contents I
robturator Rotates thigh outward Pubis, ischium.
I Trochaneric fossa of Obturator
extern us (laterally) superficial su rface of fem ur L3. 4
obturator membrane
-

Psoas major Flexes thigh or trunk, Transverse processes Lessor trochanter of Lumbar plexus
adducts and rotates it of last thoracic and all femur L1 , 2 , 3, (4)
medially -
lumbar vertebrae
- -

Psoas minor Tenses iliac fascia Twelfth thoracic and 1 st Iliac fascia and Branch of lumbar
--
lumbar vertebrae iliopectineal tuberosity L1
Iliacus Flexes and rotates Margin of iliac fossa; Fibers converge into Branches of
thigh sacrum lateral side of psoas femoral
major tendon L( 1 ) , 2, 3, 4
-
f----- f-
Rectus femoris Extends leg, assists in Anterior inferior iliac Base of patella, Femoral

Vastus
flexing hip joint

Extends leg
spine

Ventral surface of femu r

tuberosity and
condyles of tibia
Base of patella,
I L2, 3, 4

Femoral
--

intermedius
--- --
tuberosity and
condyles of tibia
_j L2, 3 , 4

D.E. Kendall, OMD. PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 52

Table 2.4b. Muscles of the anterior lateral foot (ALF) longitudinal body region (continued).
I
i
-- -

Muscle I F unction I Origin lnsert1on I n nervation & Root

I Tibialis anterior Dorsiflex and invert

foot
Lateral condyle and
upper lateral portion of
Internal cuneiform
and base of 1 st
Deep peroneal
L4, 5, S 1
tibia metatarsal

r I
- -·- -

Peroneus Doriflexes foot Lower third of fibula, Base of 5th Deep peroneal
tertius medial su rface metatarsal L4, 5, S1
-- --c-
--- - --

Extensor Extends Lateral condyle of tibia, B y tendons t o the 2nd Peroneal I

dig ito rum metatarsophalangeal proximal three fourths - 5th digits L4, S, S 1
longus joints and assists in ! od anterior fibula.
extending !
interphalangeal joints

I
i
of 2nd .:... ?th d i g 1ts
hnterolateral upper
- - --

Extensor Extends big toe Proximal phalange of Deep peroneal

haiiUCIS breVIS surface of calcaneus 1-- b1g toe � : S, S1
2nd and 3rd Adducts 2nd. 3rd and Sh aft of 2nd, 3rd and First phalanges of the Lateral plantar
Dorsal 4th toes 4th metatarsals toes S1 ,2
Interosseous -- ---

Levator Labii Su perioris Orbicularis Oculi

alaeque nasi (Lower Parts)

Zygomaticus Minor

Levator Labii
Zygomaticus Major
Orbicularis Oris -
M asseter

Deppressor Labii
Mentalis I nferior

Sternohyoid, Sternothyroid, Mylohyoid

& Thyrohyoid

Figure 2.5. Muscles of the anterior lateral foot (ALF) on the face and upper neck.

Anterior Med ial Foot (AMF) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the anterior
medial lower extremity start at the medial aspect of the big toe with the abductor hallucis
(See Figure 2.6 and Table 2.5). Above this it continues to the knee with the tibialis
posterior and flexor digitorum longus, and to the medial aspect of the fibula with the
flexor hallucis longus muscle. This distribution travels above following along the inner
aspect of the thigh to include the vastus medialis and sartorius muscles, and then
distributes to the sexual organs to include the pectineus muscle. Above this it ties into the
umbilicus (linea alba) following interiorly along the abdomen to tie into the lower ribs
(hypochondrium). Here it spreads out into the chest with the internal intercostals muscles
and internally these travels around to connect to the spine with the external intercostals
muscles. (LS 13)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 53

External l ntercostals

Vastus Medius

Common Tendon of
Quad riceps Femoris
J

Tibialis Posterior

Flexor Digitorum
Longus

Flexor Halluc1s
Longus

, Abductor Hallucis

Figure 2_6_ Muscles of the anterior medial foot (AMF) longitudinal body region

AMF Muscle Pathology

Disease manifestations of the anterior medial foot (AMF) muscular distribution includes
pain in the big toe and medial ankle, acute cramps and pain in the medial knee and pain
in the upper medial fibula, a stretching pain sensation along the inner thigh, a cramping
pain around the genitalia, a stretching pain from below the umbilicus extending up

DE Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 54

through the ribs on each side (internal intercostals muscles), and a stretching pain
extending from the breast around to the spine (external intercostals muscles). Symptoms
associated with this muscular distribution are called "early autumn" rheumatism. (LS 1 3)

AMF Treatment Strategies

To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive neurovascular
nodes and other areas along the anterior medial foot (AMF) longitudinal muscular
pathway. Symptoms associated with this muscular distribution are called "early autumn"
rheumatism which corresponds to the month of August. (LS 1 3)

Table 2.5. Muscles of the anterior medial foot (AMF) longitudinal body region
Muscle F unction Origin I Insertion Inne rvation & Root
I

dI
External I Raises ribs during Lower border of a rib Upper border of a rib Intercostal
intercostals inspiration -- - below the---
origin T 1 -T 1 1
I
- - -
r- . . . .
R1dge on mner surface
f--:-:-
Upper border of a rib
1-:- -- ---
Intercostal
Internal Depresses nbs dunng
I intercostals forced expiration of a rib below the origin T1 -T 1 1
Pectineus Flexes, adducts thigh Pubic spine Femur distal to lessor Branch of obturator
trochanter & femoral l2, 3, 4
Sartonus

Vastus medius
Flexes and laterally
rotates thigh
Extends leg, draws
Anterior superior iliac
spine
I ntertrochanteric line;
Medial surface of
upper tibi a _
_
Common tendon of
Femoral
L2, 3, (4)
Branches of femoral
�
patella in medial lip of linea quadriceps femoris L2, 3, 4
aspera of femu r
-j
Tibialis Inverts foot; assists in I Shaft of tibia and fibula I nternal cu nieforrn, Tibial
posterior plantar flexion and interosseous cuboid, navicular and L5, S 1
I membrane 2nd-4th metatarsal
I
-- --

Flexor Plantar flexes foot, Posterior surface of Distal phalanges of Tibial

di g itorum flexes toes I tibial shaft 2nd-5th toe L4, 5, S 1
longus
Flexor hallucis Plantar flexes foot, Posterior surface of Base of big toe distal Tibial
longus flexes big toe fibula -+-'p h_ l a_
a_ nx
, ------r- L5, 5_ , 2
1.:... .
..,...-, ,- .... _
_

Abductor Abducts and flexes big Plantar fascia; medial Base of big toe distal Medial plantar
1_ hallucis toe tuberosity of calcaneus phalanx, medial L5, S 1 , 2
surface---

Lateral Foot (LF) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the lateral
lower extremity starts at the small and forth toe with the 4th dorsal interosseous muscle
(See Figure 2. 7 and Table 2.6). It continues to the lateral malleolus with the extensor
digitorum brevis muscle and fol lows up along the tibia with the peroneus brevis and
peroneus longus muscles. Above the knee it continues with the biceps femoris (short
head) and vastus lateralis traveling above the thigh including the iliotibial tract, tensor
fascia latae, and the gluteus medius and gluteus minimus. It continues above between the
iliac crest and hypochondrium to include the external oblique, internal oblique and
transverse abdominis muscles. This muscular pathway continues up to insert into the
supraclavicular fossa with the superior serratus anterior and subclavius muscles. Above
this the LF muscular distribution continues up to the neck with the scalenus anterior
muscle ending on the head to include the temporalis and frontalis muscles. (LS 1 3)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 55

Temporal is Frontalis

Scalenus Anterior

Superior Serratus Anterior

- External Oblique
(With Internal Oblique &
Transverse Abdominis deeper)

Gluteus Medius - Tensor Fascia Latae

- Gluteus Minimus

- Iliotibial Tract

Biceps Femoris �
- -- Vastus Lateralis
(Short Head)

Peroneus Longus

- Peroneus Brevis
�--�- Extensor Digitorum Brevis

'
4th Dorsal Interosseous

Figure 2.7. Muscles of the lateral foot (LF) longitudinal body region

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 56

Table 2.6. Muscles of the lateral foot ( LF) longitudinal body region
----

Muscle Function I nsertion I n nervation & Root

Frontalis Raises eyebrows, pulls Procerus, corrugator Galea aponeurotica Facial
scalp fqrward and orbicularis oculi
Temporalis Raises mandib� Temporal fossa oT Coronoid process of Trigeminal
closmg jaw skull and deep s urface mandible
qf_ temporal fascia
Scalenus Flexes neck and Transverse processes Tubercle of 1 st rib Cervical plexus
anterior elevates 1 st rib of 3rd to 6th cervical C3 - 8
vertebrae
Subclavius Elevates 1 st rib or First rrb and its Undersurface of Nerve fibers from 5th
draws clav1cle forward cartilage calicle a nd 6th cerv1cal
and downward CS - 6
Superior Pulls scapula anteri
orly Outer surface of upper Medial border of Long thoracic
serratus and upward nbs scapula C5 - 6

l
�nterior
c-
I - .-:-
- - --- -

Ex1ernal oblique- Contracts abdomen Lower 8 ribs '"Anterior half of Iliac Branches of intercostal
- -

and viscera crest, linea alba and and ilioinguinal and

pubic crest iliohypog�tric n - 1 2

_L
-- -·--·-- ---- - - ;-;-
Internal oblique Compresses v1scera, I l i a c crest, inguinal Costal cartilages of Branches of intercostal
flexes thorax forward iigament, lumbar lower 3 or 4 ribs, linea and Ilioinguinal and
fascia alba, pubic crest �qhypogastrrc n-L ! ;
i-=-
Transverse
---·-
Compresses abdomen, Iliac-crest, inguinal Pubic crest, ;- -
Branches of i nte rcostal
abdominis flexes thorax ligament, lumbar iliopectineal line, linea and ilioingumal and

r
fascia, 7th to 1 2th alba and xiphoid iliohypogastnc TS- 1 2
costal cartilages cartilage
Gluteus medius Abducts thigh and Lateral surface of ilium Lateral surface of Superior gluteal
medially rotates thigh g reater trochanter L4, 5, S 1 , S2
G,,,."' Abducts thigh and Lateral surface of ilium Anterior surface of Superior gluteal
minimus medially rotates thigh --- --- �ater trochanter L4. 5. S 1 , S2
Tensor fasciae Steadies fem ur on tibia Anterior iliac crest; Iliotibial tract Superior gluteal
latae and pelvis on fem ur lateral surface of L4. 5 . S 1
anterior superior iliac
SRine
Iliotibial tract Provides deep fascia of Iliac crest and tensor Lateral condyle of
(tendon) thigh to connect tensor fasciae latae tibia
fasciae latae to knee
Vastus lateralis Ex1ends leg Greater trochanter and Base of patella, Femoral
linea aspera of femur tuberosity and L2, 3. 4
condyles of tibia
Biceps femoris Flexes and rotates From linea aspera of Lateral condyle of Peroneal
(short head) knee outward femu r tibia and head of LS, S 1 . 2
fibula
Ex1ends, abducts a n d -Ex1ernal condyle of
--

Peroneus Tendon to internal Branch of peroneal

longus everts foot tibia and upper fibula cuneifonn and 1 st L4, 5, S1
-
metatarsal
Peroneus Extends and abducts Middle portion of fibula Base of 5th Branch of peroneal
brevis foot metatarsal L4, S, S 1
Ex1ensor Ex1ends toes Dorsal s urface of os Tendons of ex1ensor Branch of peroneal
digitorum brevis cal cis digitorum longus and L4, 5 , S 1
1 st phalanx of big toe
I
--

4th Dorsal Adducts toes Shaft of 4th and 5th First phalanges of 4th Ex1erna l plantar
[ interosseous metatarsals and 5th toe S1 , 2

LF Muscle Pathology
When the LF longitudinal muscular pathway is disordered it can result in acute cramps in
the fourth and fifth toes, stretched muscles and acute cramps in the lateral aspect of the
knee. The knee is unable to bend or extend, along with contractions in the back of the
knee. Conditions can include tight and stretched muscles in the anterior aspect of the
thigh and posteriorly in the sacral region. Extending above there can be pain in the lateral
abdomen and hypochondrium. Extending further upward there can be spasms in the
supraclavicular region, the breast, and in the neck muscles and tendons. If the spasms

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 57

extend from left to right, the right eye will not be able to open, because the (right side) of
this muscular pathway extends up along the right side of the forehead where it combines
with one of the singular vessel. Since the muscle and tendons on the left side connect
with those on the right (frontalis muscle), when the left aspect of the head is injured it can
result in paralysis of the right foot. This is called the "mutual relationship of the muscle
connections" (referring to possible brain injury affecting the motor cortex. (LS 1 3)

LF Treatment Strategies
To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive neurovascular
nodes along these muscular pathways. S ymptoms associated with this muscular
distribution are called "early spring" rheumatism. (LS 1 3 )

Media l Foot (MF) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the medial
lower extremity starts on the upper region of the big toe with the tendon of extensor
hallucis longus, and then includes the 1 st dorsal interosseous muscle (See Figure 2.8 and
Table 2 . 7). Above this it follows along the tibia with the extensor hallucis longus muscle,
continuing along the inner thigh with the gracilis muscle to tie into the region of the sex
organs with the pubococcygeus. Here the MF longitudinal muscular distribution makes
connections with all the other muscles in this local region. (LS 1 3)

MF Muscle Pathology
When the MF muscular pathway is disordered it can cause pain in the big toe and the
anterior region of the medial malleolus, pain in the medial aspect of the fibula, and pain
and acute cramps of the inner thigh. Also, the sexual organs will be dysfunctional,
including impotence in the case of internal injury. If the injury is due to cold, there will
be contraction and shrinkage of the sex organs. In case of injury due to heat, there may be
abnormal erection (priapism) that can not be put away. (LS 1 3)

MF Treatment Strategies
The preceding disorders are treated by promoting the circulation of water and clearing the
sexual organ vital substance. If these disorders involve pain and acute cramps they should
be treated by quick insertion with a (previously) heated needle of indefinite duration. To
understand the duration and frequency of treatment involves assessing the effectiveness
by palpation of painful and sensitive neurovascular nodes along this muscular pathway.
Symptoms associated with the MF muscular distribution are called "late-autumn"
rheumatism. (LS 1 3 )

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics M uscu l a r Distributions 58

,� .
•

t l
r- .,
,r 1
r 1
r� 1

"'
�- �
'r 1
. ·'

-
' --

I{. �

1
�1
r- j
"f j..

��
• r 1 ..
'C ��...
"' C l"
"r J ""'

Pubococcyg

Gracilis

I l

Extensor Hallucis
Longus

' -�-- 1st Dorsal I nterosseus

Figure 2.8. Muscles of the medial foot (MF) longitudinal body region

DE Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 59

�ble 2. 7. M uscles of the medial foot (MF) longitudinal bod region r

Muscle Function Origin Insertion ! Innervation & Root

I
Pubococcygeus Supports rectum and Pubis, pelvic fascia, Rectum, coccyx and Sacral and perineal
pelvic floor, aids in ischial spine fibrous raphe of S3, 4
defecation -- �rineum __ - --
Gracilis
_

Medially rotates and Pubic arch and body of Medial su rface of Branch of obturator
___
flexes leg pubis - - shaft of tibia L2. 3. (4)
Extensor Extends big toe; Fibula and i nterosseous Dorsal su rface base Deep peroneal
hallucis longus dorsiflexes foot membrane of distal phalanx of L4, 5, S 1
btg toe
1 st dorsal Adducts 2nd toe Shalt of second First phalange of 2nd External plantar
interosseus '-- _c...Jl1etatarsal - toe - S1 . 2 I

Anterior Lateral Hand (ALH) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the anterior
lateral upper extremity starts at the thumb and forefinger and ties into the wrist to include
the 1st dorsal interosseous, adductor pollicis and extensor pollicis brevis muscles (See
Figure 2.9 and Table 2.8). Above it follows the forearm to include the extensor digitorum
communis, extensor carpi radialis longus, extensor carpi radialis brevis and the supinator.
Continuing along the upper arm it includes the biceps brachii, long head, and the middle
deltoid. A branch distributes to the scapula with the subscapularis, and then on to spine
with the rhomboid major and minor muscles. A branch from the scapula travels up to the
neck with the omohyoid, and branch continues up with the digastric, anterior belly to the
face to include the depressor anguli oris, risorius, and buccinator. Another upward branch
in the neck includes the scalenus medius muscle, and continuing upward to the
protuberance to the left (sphenoid bone), attaches with the head by the lateral pterygoid,
and down to the right to the chin with the medial pterygoid muscle. (LS I 3)

ALH Muscle Pathology

When the ALH longitudinal muscular distribution is disordered, it will result in pain and
acute cramps along its traveling route (this includes problems affecting the fingers, hand,
wrist, arm, elbow, shoulder, upper back, neck, and face). There will be an inability to
raise the shoulders and also the inability to tum the neck left or right to look either
direction. (LS I 3)

ALH Treatment Strategies

To treat the above described disorders, quick insertion with a (previously) heated needle
of indefinite duration, should be employed. To understand the duration and frequency of
treatment involves assessing the effectiveness by palpation of painful and sensitive
neurovascular nodes along the ALH longitudinal muscular pathways. Symptoms
associated with the ALH muscular distribution are called "early-summer" rheumatism.
(LS I3)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics M uscular Distributions 60

Lateral Pterygoid
Buccinator
Depressor Anguli Oris
--=�- Digastric (Anterior Belly)

Rhomboid Minor �
Middle Deltoid --��L-��
· fl
' ::::�"
:::; � .f: -
ilj�- -
,

_ f:..-�-
Subscapularis --f/'-:i

Biceps Brachii --+-17-:. ,.

(Long Head) <

Rhomboid Major ,

-
:_ -
..
'( }
f j ,. I

ri ' ,

<!o f J·
.. r J •
- '"', ( l'"'
Supinator -
\�
Extensor Carpi j '- Posterior Veiw
Radialis Longus
Extensor Extensor Carpi .
Digitorum Radialis Brevis
(Communis) 1\:rl¥1'-1-- Abductor Pollici s
Longus
Extensor Pollicis
Long us & Brevis

I i I
. /I Muscles Not Shown: Risorius
1 st Dorsal I nterosseus and Adductor Pollicis

Figure 2.9. Muscles of the anterior lateral hand (ALH) longitudinal body region

Anterior Medial Hand (AMH) M uscles

The longitudinal distribution of the muscles and related tendons belonging to the anterior
medial upper extremity (AMH), arise at the superior aspect of the thumb with the tendon
of extensor pollicis brevis (See Figure 2 . 1 0 and Table 2.9). From here it distributes above
and ties in behind the thenar region with the opponens pollicis; abductor pollicis brevis;
and flexor pollicis brevis, superficial and deep head, and distributes to the lateral side of
where the radial pulse is detected. It then follows up along the forearm to tie into the
center region of the elbow with the flexor pollicis longus and brachioradialis. It continues
up the medial aspect of the upper arm with the biceps brachii , short head to enter the
region below the axilla and moves out to the supraclavicular fossa and ties into the
shoulder anterior to the acromion extremity with the anterior deltoid. Above it ties into
supraclavicular fossa (coracoid process of scapula). Below, it ties into the interior region
of the chest with the pectoralis minor, where it spreads below with the transversus
thoracis to pass through the cardia to include the diaphragm, joining the cardia below
(crura of diaphragm) and then supporting the hypochondrium. (LS 13)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 61

Taqle 2.8. Muscles of the a�terior lateral hand (ALH) l of!Qitudinal bo�_y - ��Ofl _
...� ! Innervation & Root
__ _ -

I Function
� -

Muscle Origin Insertion

Medial pterygoid Raises mandible Pterygoid fossa of I n ner s u rface of angle of Trigeminal

f I
closing jaw sphenoid; palatine bone; mandible CN 5
tuberosity of mal<il@__ __
r- -- ---
Lateral pterygoid Opens jaw, brings Great wing of sphenoid
� --- --
Neck of condyle of Trigeminal
jaw forward, moves and infratemporal ridge; mandible CN 5
jaw from side to side outer plate of sphenoid
process ---
Buccinator Compresses cheek Posterior alveolar Orbicularis oris at angle Facial
and d raws back processes of maxilla and of mouth CN 7
-- �_gle of mouth mandible
1- --
Risorius Com p resses cheek Fascia over masseter Angle of mouth Facial
and d raws angle of muscle
-- -
Depressor anguli
mouth outward -- -- ---
Depresses angle of
--- -- -- -
Lateral oblique line ofAngle of mouth
t" '
Facial
-- -
-
oris mouth mandible -
CN 7 ·-
Digastric, anterior Raises hyoid or Mandible Hyoid Trigem inal
belly depresses mandible, CN 5
opening mouth _

Scalenus Medius Flexes neck and Transverse processes of Cranial surface of 1 st rib Cervical and
elevates 1 st rib 2nd to 7th cervical between tubercle and brachial plexus
vertebrae subclavian groove C3 - 8
Omohyoid Depresses hyoid Superior border of Lateral border of hyoid Branches from
scapula ansa cervicalis
Rhomboid minor Moves scapula Spinous process of 7th Scapular vertebral border Dorsal scapular
backward cervical and 1 st thoracic at root of spine C4 , 5

f--_ .
vertebrae -
Rhomboid major Moves scapula Spines of 2nd to 5th Scapular vertebral border Dorsal scapular
�

backward thoracic vertebrae ------+ C4,

5
Subscapularis Medially rotates anm Subscapular fossa Lessor tubercle of Subscapular
humerus C5. 6. 7
Middle deltoid Abducts a nm Acromion Deltoid tuberosity on shaft Axillary
of humerus C5, 6

I Biceps brachii,
long head
Flexes foreanm;
supinates foreanm
and hand ---
Upper margin of glenoid
cavity of scapula
Tuberosity of radius; deep
fascia of medial foreanm
Muscu locutaneous
C5, 6
I
Supinator Supinates foreanm Lateral epicondyle of Lateral and anterior Posterior
and hand humerus; shaft of ulna surfaces of shaft of radius interosseous
-- --- -- C5, 6, (7)
Extensor carpi Extends, abducts Lower third of lateral Base of 2nd metacarpal Radial
radialis longus wrist supracondylar ridge of bone C6. 7. 8
humerus ----- -
Extensor carpi Extends, abducts Lateral epicondyle of Base of 3rd metacarpal Radial
radialis brevis wrist humerus bone C6. 7, 8
Extensor Extends wrist and Lateral epicondyle of Extensor tendon to each Posterior
digitorum fingers humerus finger, from common interosseous
communis extensor tendon C6. 7, B
Extensor pollicis Extends phalanges Lateral side of dorsal Base of 2nd phalanx of Radial I
lon us of thumb surface of ulna thumb C6, 7 , 8
Extensor pollicis Extends proximal Dorsal su rface of radius; Dorsal surface of Posterior
brevis phalanx of thumb interosseous membrane proximal phalanx of interosseous
thumb C6, 7 , B
� -
Abductor pollicis Abducts, extends Posterior surface of Radial side of base of 1 st Posterior
longus thumb radius and ulna metacarpal interosseous
--- C6. 7. 8
Adductor pollicis Adducts thumb Capitate; trapezoid; 2nd Ulnar side of base of 1 st Ulnar
and 3rd metaca rpals phalanx of thumb CB, T1
_
1 st dorsal Abducts index finger Sides of 1 st and 2nd Proximal phalanx and Ulnar
interosseus, metacarpals dorsal digital expansion of CB, T1
lateral and medial 2nd finger
heads

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 62

Anterior Deltoid
- Pectoralis M inor
Transversus
Thoracis
(Not Shown)
Biceps Brachii
(Short Head)

Brachioradialis
Vena Caval •, � • Esophageal
._,( ,.., ,
-'= • Hiatus
Foramen
I { "1 1'

... r l.'"Aortic
-
,__-
Hiatus Abductor
Pollicis
Brevis
'
1' Flexor Pollicis
Longus
/1 , I
Opponens
Pollicis
Flexor Pollicis
Brevis

Figure 2. 1 0. Muscles of the anterior medial hand (AMH) longitudinal body region

AMH Muscle Pathology

When the AMH muscle distribution pathway is disordered it will result in acute cramps
along its longitudinal traveling route, and severe pain that result in dyspnea affecting the
region of the cardia, spasms in the sides of the ribs and spitting or vomiting blood. (LS
1 3)

AMH Treatment Strategies

To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive areas and
neurovascular nodes along the anterior medial hand (AMH) muscular pathways.
Symptoms associated with this muscular distribution are called "midwinter" rheumatism.
(LS 1 3)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 63

. me d'1a I h an d (AMH ) I onQitudma I b____Q_d }' reg1on

Ta ble 2 9 M usc es o f the an tenor -- -

Muscle Fu nction Origin Insertion Innervation & Root

Diaphragm Increases vertical Xiphoid process; costal Central tendon Phrenic
diameter of thorax by cartilages of lower 6 C3, 4, 5
pulling central tendon ribs; lumbar vertebrae
downward during
insp!r�!!Q il__ ___ --

Transversus Narrows the chest Sternum and xiphoid Costal cartilages of Branches of intercostal
'"
thoracis --
cartilage 2"ct to 6 ribs T3. 4, 5. 6
Pectoralis Depresses shoulder Upper margins and Medial border of - Anterior thoracic
minor and rotates scapula outer surfaces of 3rd to coracoid process of C7. 8. T1
downward 5th ribs; fasciae scapula
covering intercostals --- -�

Anterior deltoid Abducts arm; flexes Lateral third of clavicle Deltoid tuberosity on Axillary
and medially rotates shaft of humerus CS, 6
arm - - -- - -

Biceps brach ii, Flexes forearm; Coracoid process of Tuberosity of rad ius; Musculocutaneous
short head supinates forearm and scapula deep fascia of medial CS, 6
hand --
forearm -- --- --

Brachioradialis Flexes forearm Lateral supracondyloid Lower end of radius Radial

ridge of humerus CS, 6
Flexor pollicis Flexes phalanges of Body of radius, anterior Base of distal phalanx Anterior interosseous
longus thumb su rface of thumb C7. 8, T1
Flexor pollicis Flexes proximal Flexor retinaculum; Base of proximal Median and ulnar
brevis, sup and phalanx of thumb tubercle of trapezium phalanx of thumb C6, 7, 8. T1 (sup head)
de�p heads --
�8. T1 _Ldeep head)
Abductor Abducts thumb Flexor retinaculum; Lateral surface of Median
pollicis brevis scaphoid; trapezium base of proximal C7. 8. T1
phalanx of thumb -- -

Opponens Opposes thumb, Tubercle of trapezium; Radial side of 1 st Median

pollicis medially rotates and flexor retinaculum metacarpal C6, 7, 8, T1
flexes 1 st metacarpa I -- -

Lateral Hand (LH) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the lateral
upper extremity starts at the little finger and the fourth finger with the 4th interosseous
muscle (Figure 2 .1 1 and Table 2 . 1 0). It follows along the center of the forearm to include
the extensor indicis and extensor pollicis longus, as well as the extensor digiti minimi and
extensor carpi ulnaris that tie into the elbow, and then includes the anconeus muscle.
Above it wraps around the lateral aspect of the upper arm with the lateral head of the
triceps brachii, then up to the shoulder with the posterior deltoid, and then the
supraspinatus, as well as traveling to the neck with the scalenus posterior muscle. A
branch of this distribution includes the stylohyoid muscle where a branch fastens to the
root of the tongue with the hyoglossus and genioglossus muscles. Another branch
includes the temporoparietalis muscle. (LS 1 3 )

LH Muscle Pathology
When this muscular distribution is disordered it will result in acute cramps along its
traveling route and also will cause the tongue to curl up. Symptoms associated with this
distribution are called "late-summer" rheumatism. (LS 1 3)

DE Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 64

LH Treatment Strategies
To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive areas and
neurovascular nodes along the lateral hand (LH) muscular pathways. (LS 13)

�- Temporoparietalis

Genioglossus
( Not Shown)
Hyoglossus --='---+\
Hyoid Bone
Supraspinatus -.....____�?'��=
�··

Triceps Brachii
( Lateral Head)

Extensor Digiti
Minimi

- Extensor Carpi
Ulnans
Extensor
l nd icis

lnterossus

Figure 2 . 1 1 . M uscles of the lateral hand (LH) longitudinal body region

Medial Hand (MH) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the medial
upper extremity starts with the 1 st and 2nd palmar interosseous and associated lumbrical
muscles (Figure 2 . 1 2 and Table 2 . 1 1 ) . From here the distribution travels up to the medial
aspect of the elbow with the flexor carpi radialis and flexor digitorum profundus, and
includes the pronator quadratus lower on the forearm. Above the elbow, it follows the
inner aspect of the upper arm with the coracobrachialis muscle. From here it spreads

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 65

anteriorly and posteriorly to clasp to the upper ribs on the sides with the serratus anterior
muscles. Another branch spreads to the center of the chest with the pectoralis major,
clavicular and upper sternal portions, and inserts into the humerus. (LS 13 )

Table 2. 1 0. Muscles
Muscle ·- -T
Temporoparietalis
Genioglossus
--

J
·f:ufictiori ·

_
. (LH) longitudinal
of the lateral hand

galea aponeu!_otica
Depresses tongue and
th rusts it forward
body region
Origi-;;--- - !"
-

I
Internal surface of
mandible, near the
Insertion
-----· · ·

I nferior surface of
tongue; hyoid bone
1
- -r
- -
I nnervation & Root
•ci•I CN 7
Hypoglossal CN 1 2

----- - ..
sy'!lphysis ___ _ _ - -- --- -- -
r-!:! �lossus Depresses tongue Body_ of hyoid _
Side of tong_LJ� -- . H_yp99 �ossal CN 1 2
Stylohyoid D raws hyoid up and to Styloid process Body of hyoid Facial CN 7
the back -
Posterior Flexes neck, elevates Transverse processes Second rib I Cervical and brachial

I
scalenus 2nd rib of 4th to 6th cervical plexus
vertebrae C3 - 8 -
Supraspinatus Abducts arm Fossa superior to Greater tuberosity of I Subscapular
-- �plJiar spine humerus C4, 5, 6 -
I Posterior deltoid
-·-

Abducts, extends and Spine of scapula Shaft of humerus ; Axillary

r:----- ___ _l_
a!�r�ly rotates �rm -�
- -
- ' C5_,_6_ _ --
Triceps brachii, Extends forearm Lateral and posterior Olecranon of ulna Radial
-
--
· ·

lateral head surfaces of shaft of C6, 7, 8

humerus
Anconeus Ex1ends forearm Posterior surface of Olecranon and dorsal Radial
lateral epicondyle of surface of ulna C7, 8. T1
humerus
Extensor digiti Extends little finger Lateral epicondyle of Dorsum of phalanx of Radial
mimmi humerus l ittle finger C6, 7, 8
Extensor carpi Extends, adducts wrist Lateral epicondyle of Base of 5th Radial
ulnaris humerus metacarpal --
C6, 7, 8
Extensor indicis Extends index finger Dorsal surface and Phalanges of index I Posterior
Interosseous membrane finger interosseous
-- of ulna �· 7, 8
4th dorsal Abducts 4th finger Sides of 4th and 5th Proximal phalange of nar
interosseus metacarpal _j
_ 4th finger C_8, T1

MH Muscle Pathology
Disorders of the medial hand (MH) longitudinal muscular distribution pathway include
acute cramps along its traveling route, and pain in the anterior region of the chest
(sternmn) with dyspnea related to the region of the cardia. (LS 1 3)

MH Treatment Strategies
To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive areas and
neurovascular nodes along the MH muscular pathways. Symptoms associated with the
MH muscle distribution are called "early-winter" rheumatism. (LS 1 3 )

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics M uscular Distributions 66

Serratus Anterior

Pectoralis Major
(Clavicular and Upper
Sternal Pa rts)
• • Coracobrach ialis
� }
'[ 1
h
"'[ l• Flexor
.. , l "' J
Digito ru m
"'r �1 ""
"r 1 ;llll
Profundus
'r , ..

Flexor Carpi
'""'"' · Rad1al1s

Pronator Quadratus

n 1 st and 2nd Palmar

fI I nterosseous

Lumbricals I, I I , I l l

Figure 2 . 1 2 . M uscles of the medial hand (MH) longitudinal body region

Table 2.1 1 . Muscles of the medial hand (MH) longitudinal body region
Muscle I Function Origm I nsertion I I nnervation & Root
Serratus anterior Moves scapula forward Outer surfaces and Ventral surface of Long thoracic
and away from spine superior borders of scapular vertebral C5, 6, 7, a
upper a or 9 ribs; border
fasciae covering
intercostals -

Pectoralis major, Adducts, flexes and Anterior surface of Lateral border of Anterior thoracic
clavicular and rotates a rm medially sternal half of clavicle; bicepital groove of cs. 6, 7
upper sternal upper half of sternum; humerus
portions aponeurosis of external
oblique; costal
cartilages of upper ribs --- - -

Coracobrachialis Adducts and flexes Coracoid process of Medial and middle Musculocutaneous
arm scapula --
surface of humerus C5, 6, 7
Flexor carpi Flexes a nd abducts Medial epicondyle of Base of 2nd and 3rd Median
radialis wrist humerus metacarpals C7, a
Flexor digitorum Flexes d istal phalanx Medial and a nterior Bases of distal Ulnar and median
profundus -
� each fin�t_e r__ _ surface of shaft off ulna phalanges of fingers ca. T1
Pronator Pronates forearm and Lower part of anterior Lower part of anterior Anterior interosseous
�ratus hand surface of ulna surface of radius ca. T1
Lumbricals I, I I Flexes 1 st and extends Tendon of flexor First phalanx and Median and ulnar
and I l l 2nd and 3rd phalanges digitorum profundus extensor tendon of C(6), 7, a, T 1
muscle 2nd, 3 rd & 4th finger
1 st and 2nd Adducts 2nd and 4th Second and 4th Dorsal digital Ulnar
palmar fingers metacarpal bones expansions of index ca, T1
interosseous and ring fingers

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 67

Posterior Latera l Hand (PLH) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the
posterior lateral upper extremity starts at the superior border of the small finger with the
tendon of the extensor digiti minimi and ties into the wrist with the abductor digiti
minimi (Figure 2 . 1 3 and Table 2 . 1 2). It follows up the posterior lateral aspect of the
forearm with the flexor carpi ulnaris. Snapping the tendon at this point will cause a
response to radiate down to the little finger. From here the distribution continues upward
with the long head of the triceps brachii muscle. Posteriorly it winds around the scapula
to include the teres major, teres minor, and infraspinatus muscles and then follows along
the neck with the levator scapulae muscle. Another branch ties into the ear with the
auricularis posterior, anterior, and superior muscles. Below this it ties into the chin with
the posterior belly of the digastric muscle. (LS 1 3)

Auricularis S uperior,
Anterior, and Posterior

Digastric
(Posterior Belly)

Infraspinatus - ·· ··· --­

Teres Minor

Teres Major

Triceps Brachii
(Long Head)

- 1' �

L·
/
ll
.
Flexor Carpi Ulnaris--
1. -�- .

'r
I

Abductor Digiti Minimi

Figure 2. 1 3. Muscles of the posterior lateral hand (PLH) longitudinal body region

D.E. Kendall, OMD, PhD ©2005-2009

 -- - .
Chinese Orthopedics -, Muscular Distributions 68

Table 2. 1 2. Muscles of the posterior

- .
.
lateral hand (PLH)
-
lo gitudinal -- - - -
- --body
--- - -- -l
region
- -!Innervation &Rooi
- ··- Muscle -� Function · Origin Insertion
Digastric, post. Raises hyoid or Mandible Hyoid Trigeminal and facial
belly depresses mandible to CN V, CN VII
open mouth
Auricularis Elevates pinna of ear Galea aponeurotica Upper portion of pinna Facial

�
supenor of ear CN VII
Auricularis Draws pmna of ear Superficial temporal Helix of ear anteriorly Facial
I
anterior forward fascia CN VII
Auricularis Draws pinna of ear Mastoid process Root of auricle Facial
posterior
- backward CN VII
Levator Elevates scapula Upper 4 or 5 cervical Vertebral border of Dorsal scapular

I
scapulae --- vertebrae scapula - C3. 4. 5
-
Tnfrasp inatus Rotates arm backward I nfraspinous fossa of G reater tubercle of Subscapular from
and outward scapula humerus brach1al plexus
-- -- - C5, 5
-- -:-=
Teres minor Rotates arm outward Dorsal surface of Greater tubercle of Branch of axillary

I
axillary border of h umerus cs. 6
scapula
Teres major Adducts, extends and Posterior axillary border Medial border of Branch of lower
rotates arm medially
I of scapula bicepital groove of
humerus
subscapular
C5, 6. 7
- -
r-olecranon of ulna
-- -·

Triceps brachii, Extends forearm Axillary border of Rad1al

long head scapula below glenoid C6, 7, 8, T1
cavity
--

I
Flexor carpi Flexes and abducts Medial epicondyle of Pisiform, hamate, and Ulnar
ulnaris wrist humerus; upper two 5th metacarpals ca. r1
I thirds of ulnar dorsal
border - --
Abductor dig iti l Abducts little finger Pisiform bone: tendon Medial base surface Ulnar
I
I
minimi 1 of flexor carpi ulnaris of little finger proximal ca. T1
phalanx
- J
PLH Muscle Pathology
When this muscular distribution pathway is disordered it will result in pain in the little
finger as well as in the posterior aspect of the medial epicondyle of the elbow which
follows along the inner aspect of the arm to enter below the axilla causing pain below the
axilla, pain in the posterior aspect of the axilla, pain wrapping around the scapula and
leading to the neck, pain and ringing in the ears leading to the chin. There can also be a
heavy sensation in the eye after having been closed for some time, and spasms in neck
muscles which can result in fistula of these muscles and swelling in the neck. (LS 1 3)

PLH Treatment Strategies

When there are cold or hot sensations in the neck, they should be treated by quick
insertion with a (previously) heated needle of indefinite duration. To understand the
duration and frequency of treatment involves assessing the effectiveness by palpation of
painful and sensitive neurovascular nodes. If there is swelling, this should be treated by
use of very sharp needles. In addition, since this muscular pathway passes through the
angle of the j aw, follows anterior to the ear, connects with the outer canthus of the eye
and upper jaw, and ties into the temporal region, there can be pain along these traveling
areas as well as acute cramps. (LS 13)
To treat the above mentioned disorders, quick insertion with a (previously) heated
needle of indefinite duration, should be employed. To understand the duration and
frequency of treatment involves assessing the effectiveness by palpation of painful and

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Muscular Distributions 69

sensitive neurovascular nodes along these muscular pathways. Symptoms associated with
this muscular distribution are called "midsummer" rheumatism. (LS 1 3)

Posterior Medial Hand (PMH) Muscles

The longitudinal distribution of the muscles and related tendons belonging to the
posterior medial upper extremity starts with the 3rd palmar interosseous and associated
lumbrical muscles (See F igure 2. 1 4 and Table 2 . 1 3). From here it continues as the flexor
digiti minimi , opponens digiti minimi, and palmaris brevis muscles. Above this it ties into
the medial aspect of the elbow with the flexor digitorum superficial is, palmaris longus,
and pronator teres muscles. From here it extends on the upper arm with the brachialis and
the triceps brachii, medial head. It travels across the bosom to ties into the center of the
chest with the pectoralis major, lower sternal, costal and abdominal portions, and has its
insertion in the upper arm . From here it is fastened to the ligaments that descend to the
umbilicus including the costoxiphoid and linea Alba ligaments. (LS 1 3 )

,. - .d�
--� · - ,-:.. Pectoralis Major
(Lower Portion)

Ticeps Brachii
(Medial Head)

Brachialis
Pronator Teres

Flexor Digitorum
Su perficialis
/

Plamaris Brevis -- ---

3rd Plamar
Interosseus

Flexor Digiti Minimi

Brevis (Not Shown) Opponens Digiti Minimi

Figure 2. 1 4. M uscles of the posterior medial hand (PMH) longitudinal body region

D.E Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics M uscular Distributions 70

Table 2. 1 3. M uscles of the posterior medial hand (PMH) longitudinal body region
-- ------ --�
�uscle - r- Function Origm I l nsertron I I n nervation & Root ;

I
Pectoralis Adducts, flexes and Lower half of stern um; Lateral border of

I
Anterior thoracic

� I
major, lower rotates ann medially aponeurosis of external bicipital groove of C7, 8, T1
sternal, costal oblique; costal cartilages humerus
and abdominal
-!!.�f!is>_ns
Triceps brachii, Extends forearm
of middle and lower ribs

Posterior surface of 01"""'" of the "'"'

I Radial
--
medial head shaft of humerus below C6, 7, 8, T1
- lateral head
,_Brachialis Flexes forearm Lower half of anterior Coronoid process and M"""""'"''�'"'
--

I
surface of humerus tuberosit� of the ulna _ _ and radial C5, 6
Pronator teres Pronates forearm and ! Coronoid process of Middle lateral surface Median - -----
hand ulna and medral of shaft of radius C6, 7

-.Flexor -
- digitorum epicondyle of humerus --
Flexes mrddfe and then Coronoid process of Middle phalanges of Median
superficialrs proximal phalanges ulna and medial fingers C7, 8, T1
epicondyle of humerus.
humeroulnar head:

-�''"
radial head; antenor

l
border of radrus -
Palmaris longus Flexes wrist , Medial epicondyle of Palmar aponeu rosis
humerus ' 8_,__I!_ -
t Palmaris brevis Wrinkles skin on side - Gentral part of palmar Skin of ulnar side of nar
of hand aponeurosis and hand , T1
transverse carpal
,_!l
gament --
Flexor digit1 Flexes little finger Hamate; flexor Ulnar side of base of Ulnar
miniml brevis retinaculum proximal phalanx of C8, T1
-- little finger
Opponens digiti Flexes a nd laterally Hamate: flexor Ulnar side of 5th Ulnar
minimi rotates little finger retinaculum
Tendon of flexor
metaca rpal C8, T1 -
Lumbrical I l l & Flexes 1 st and extends First phalanx and Median and ulnar
2nd and 3rd phala nges digitorum profundus j extensor tendon of 5th C8, T1
I
IV
-
muscle finger
'-_
3rd palmar Adducts little finger Fifth metacarpal bone I Dorsal digital Ulnar I
interosseus expansions of little C8, T1
-
fin er -- J

PMH Muscle Pathology

Serious disorders of this muscular longitudinal pathway include a condition called "fu
liang", which means bent over like a bridge. This disorder causes pressure on the heart
and a sensation in the arms like a net wrapped around the elbow. Ordinary disorders of
this muscular distribution include acute cramps and muscular pain in the muscles along
its traveling route (this includes conditions affecting the fingers, hands, wrist, arm, elbow,
shoulder, and chest). (LS 13)

PMH Treatment Strategies

To treat these disorders, quick insertion with a (previously) heated needle of indefinite
duration, should be employed. To understand the duration and frequency of treatment
involves assessing the effectiveness by palpation of painful and sensitive locations and
neurovascular nodes along these muscular pathways. If the condition of "fu liang"
worsens to include the spitting of blood and pus, there is no cure and death will follow.
Symptoms associated with this distribution are called "late-winter" rheumatism. (LS 13)

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Basis of Chinese Orthopedics 71

Basis of Chinese Orthopedics

The Chinese approach to orthopedics is based on a solid foundation of historically-based
information as understood by present day views of anatomy and physiology involving the
cardiovascular, musculoskeletal, and nervous systems. Critical to this is the sophisticated
Chinese understanding of the vascular system, including identification of critical
neurovascular nodes (acupoints) and their pathways supplied by superficial vessels, and
the elucidation on the longitudinal organization of the muscular system (See Chapter 2).
Key to the Chinese efforts was the fact that longitudinal organization of the bodily
systems is dominated by spinal segmental related events that give rise to somatovisceral
and somatosomatic relationships and directing needling-induced restorative actions. It is
now understood that these features are mediated by axial (longitudinal) relationships of
the spinal cord that communicate with peripheral nerves at specific spinal segmental
levels.
Chinese orthopedics relies on a physiological understanding of the mechanisms
induced by needling (acupuncture) (Chapter 2). Knowledge of these mechanisms in
conjunction with the longitudinal muscular distributions provides a rational approach to
develop effective Chinese treatment protocols for orthopedic conditions. The Chinese
have a long history in treating orthopedic conditions including trauma and war wounds.
They also resolved dislocated joints, treated fractures, and performed surgical procedures
related to orthopedics. In addition, the Chinese conducted orthopedic examinations based
on observation, examination, and movement of body limbs and j oints, and also conducted
reflex testing. They also developed a wide range of active care modalities involving
flexibility, movement, rehabilitation, and strengthening exercises.

Logical Process of Assessment and Diagnosis

Orthopedic examination, assessment, and diagnosis rely on a solid understanding of
functional anatomy including the essential importance of the nervous system. Focus is on
those aspects of anatomy and physiology related to orthopedic function and dysfunction.
Disability or pain involving the musculoskeletal system manifests mainly in the muscles
and joints of the body. Problems are usually reflected in the articulation of specific body
regions or limbs and may be isolated to a particular longitudinal muscular distribution.
By careful clinical examination of the articular system it is possible to isolate the most
likely muscles, tendons or joints involved in a particular problem.
All movable joints have corresponding tendons, muscles, ligaments, and synovial
capsules. These unique anatomical characteristics provide a basis for specific tests and
reflexes yield objective information by which to make a diagnosis. Two of the most
important tests involve range of motion (ROM) and muscle strength testing.
Characteristics of the joint performance through the range of motion including the feel at
the end ofjoint movement can be assessed as well as possible problems affecting the
joint capsule. Key reflexes and sensibility testing along with the information derived on
key muscles, permits a neurological evaluation of the presenting problem.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 72

Collection of valid information pertaining to the probl em can follow a somewhat

logical process that starts with a complete patient history. Initial observations can provide
a gross understanding of the limitations imposed by the problem. More specific active
movements on part of the patient then provide specific indications. Special orthopedic
tests may be considered to develop a better understanding of the problem. Neurological
assessment in terms of reflexes and cutaneous distributions provide additional
infommtion to further assess the presenting problem. Joint behavior is then assessed by
practitioner controlled passive (on part of patient) movements. Affected areas of the body
and palpated and specific diagnostic imaging studies may be considered. The orthopedic
assessment is preceded by review of the regional anatomy, physiology, and pathology.
Finally a treatment plan is devised to address likely problems of the particular body
region. This musculoskeletal assessment sequence and treatment is repeated in Chapters 6
through 1 7 that address al l major areas of the body that include:
• Regional anatomy
o Osteology and arthrology
o Muscles, nerves, and vessels
o Surface anatomy
•
Normal physiology
o Muscular distributions
o Kinesiology
•
Typical conditions affecting area
• Musculoskeletal Assessment
o Patient history (Subj ective)
o Observation (Objective)
o Examination of movement (Assessment)
Active
Passive
Resistive
o Special tests
o Reflexes and cutaneous distribution
o Joint play movement
o Palpation of affected area(s)
o Diagnostic imaging
•
Treatment planning and protocols (Plan)
o Massage, mobilization, and manipulation
o Needling therapy including possible electroneedling (EN)

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 73

o Movement and rehabilitation exercise

o Herbal remedies (herbal remedies are not recommend in this text)

Rational Basis of Ch inese Therapeutics

Chinese therapeutics strategies where derived in China and used to address orthopedic
conditions. These approaches have been in use since ancient times and has survived today
with little change. The main principle of application relies on the anatomical organization
and physiological relationships of the body, including longitudinal (axial) and segmental
relationships of the spinal cord. Most important of these is utilizing the twelve
longitudinal muscular distributions and related neurovascular node pathways in a
systematic approach to bring about restorative responses (See Chapter 2).

Treatment Strategy
Inserting a needle anywhere in the human body will bring about complex defensive
reactions that are mediated by tissue damage responses, immune complement system
activation, differential neurogenic local blood vessel control, nociceptive and
proprioceptive responses, and sustaining the response through neurogenic mechanisms.
The overall effect is to activate central nervous system (CNS) mediated descending
control to specific spinal segmental levels in order to reduce pain, reduce muscle spasms,
restore blood flow, and restore autonomic balance and homeostasis (See Chapter 2).
Restorative descending control is provided to the area of the body which
originated the needling responses. Recognition of this fact allows the practitioner to apply
a rational scheme to direct restorative descending control responses to obtain the most
efficient therapeutic effect. This involves the use of appropriate neurovascular nodes in
local and adjacent area of the problem in conjunction with proximal and distal nodes (See
Figure 1 .3). The result is to direct descending control over a range that brings restorative
actions the cover the area of the problem being treated (See Chapters 6 1 7 for treatment
-

protocols).

Anatomical Orientation and Nomenclature

Certain nomenclature systems applied to describing certain features of the human body
were developed over the years to derive a standard method of reference when relating
information from one practitioner to another. The Chinese may have been the first to use
such a system. The West developed the idea of using imaginary orthogonal planes as a
reference to describe body articulation.

Chinese Anatomical Position

In very early times the Chinese identified the maj or vessels in the body by the regions to
which they distributed. They used sun relative positions during the day and night to
describe six longitudinal lateral and medial body regions for the upper and lower
extremities (See Figure 1 .2, and Table 1 .2). Specifically identified longitudinal muscles,
vessels, nerves, and neurovascular nodal (acupoint) were assigned to these pathways.
Peripheral vessels are considered to form somatovisceral relationship since the vessels
and related nerves supply both the superficial body regions and internal organs. However,

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 74

the muscles are considered not to communicate with the internal organs and therefore
musculoskeletal conditions are treated as external disorders.

Conventional Anatomical Orientation

The Western anatomical positions are based on the prone position of a cadaver and hence
the hands are rotated to upward. When applied to the human subject in the erect standing
position the palms face forward. This position may not be consistent with the
organization and function of body tissues, vessels, nerves and even sweat glands and
pores of the skin. A set of three mutually perpendicular i maginary planes are used as a
reference in describing orientation and articulation of body regions. One of the three
planes is known as the frontal or coronal plane that divides the body into anterior and
posterior sections. The second plane divides the body into right and left sections and is
called the sagittal plane. If this plane splits the body down the midline, it is referred to as
the midsagittal (median) plane. If it cut though the body away from the midline, then it is
called a parasagittal plane. The third plane is horizontal and divides the body into upper
and lower sections. This is also known as a transverse plane. The standard planes and
axes of the body are summarized in Table 3 . 1 .

Table 3. 1 . Planes and axes of body

Plane Description of Plane Axis of Description of Axis Most Common
Rotation Movement
Frontal Divides body into anterior Sagittal Runs anterior/ Abduction, adduction
(coronal) and posterior sections posterior
Sagittal/ Divides body into right and Frontal/ Runs m edial/lateral Flexion, extension
ParasaQittal left sections Transverse
Horizontal Divides body i nto upper Longitudinal Runs superior/ Internal rotation,
(transverse) and lower sections (vertical) inferior external rotation

Review Blood Vascu l a r System

The vascular system is fundamentally important in normal function and health since the
perfusion of oxygenated blood and nutrients, and a host of other essential substances to
all tissues is critically important. This includes arterial supply by the proximal capillaries
to all the body cells comprising the nerves, brain, muscles, bones, skin, and internal
organs with the distal capillaries carrying away metabolic waste products and carbon
dioxide (C02) in the venous return blood return. The musculoskeletal system needs to be
continually supplied with oxygenated blood and nutrients for proper function, consistent
with the demand placed on muscular activities. Metabolic byproducts, including carbon
dioxide, also need to be transported out of the muscular tissue.
Some musculoskeletal conditions are the result of local and temporary impairment of
blood flow known as ischemia (holding back blood flow). Ischemic conditions affecting
the peripheral vascular system are very serious, but even slight restriction of blood to the
skeletal muscles, especially if it is sustained, can produce pain and dysfunction. One
obvious example is when blood flow is restricted to cardiac muscular tissue; it produces
significant pain known as angina. This pain often reflects in the left arm along the

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 75

Chinese posterior medial hand (PMH) anatomic division (See Table 1 .2) related to the
heart. If blood restriction to the heart muscle is significant, it is commonly fatal.

Vessel Distribution Organization and Pathways

The single greatest discovery of the ancient Chinese is that the vessels in the extremities
and superficial regions of the trunk follow along specific longitudinal pathways. It is now
known that the vessels are accompanied by related sympathetic nerves. Collateral
branches of the superficial vessels supply the skin area with a dense distribution of fine
vessels along with sensory nerve fibers. This superficial branching of vessels and
associated afferent and efferent nerve fibers give rise to the neurovascular nodes
(acupoints). These are the nodes of needling therapy that distribute along the Chinese
longitudinal pathways of the body. Muscles of the body are supplied by these vessel
distribution and the muscles themselves are organized in a similar manner.

Vascular Control
Blood flow is controlled by sympathetic influence on the heart and vessels and by
parasympathetic influence on heart function. Sympathetic outflow increases heart rate,
breathing rate, blood pressure, restricts blood flow to the gut and upper extremities,
shunts blood to the lower extremities, and bronchial dilates the lungs. Parasympathetic
outflow basically normalizes the impact of sympathetic stimulation. The vessels receive
efferent motor signals and transmit afferent sensory impulses via sympathetic neural
fibers. These are distributed to and from the vessels via the paravertebral sympathetic
ganglia that lie on both sides of the thoracic and lumbar vertebra.
Neural control of the vessels is mediated mainly by contacting arteries and
arterioles. Veins have less sympathetic control that does come into play when tissue is
damaged, even by needling. The response increases blood flow to the area in question to
bring in immune cells and activate restorative processes. The veins that drain the affected
area are constricted to help force immune cell egress from capillaries in the damaged
area. The overall effect is differential neurogenic control in to response tissue damage
including that due to needling therapy.

Deep Transmission of Environmental Influences

Because of superficial branching of blood vessels to the surface of the body, the Chinese
determined that environmental factors, left unchecked, can transmit deeper into the body
by virtue of influence directly on the vessels. These mechanisms are operative in many
musculoskeletal problems as well as in visceral dysfunction. Environmental factors first
attack the fine vessels in the skin and if left unchecked, the effect moves deeper along the
vascular route. Certain hallmark symptoms including pain are noted at each penetration
level. Extreme cases of environmental factors penetrating the body can result in either
hypothermia and hyperthermia or heatstroke, both of which can be fatal . Sometimes the
effect of cold impacts the sympathetic nerve fibers distributed to a particular area
impairing blood flow to that area even after the body warmed.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 76

Rev iew of M uscu loskeletal System

Skeletal muscles represent complex structures of muscle tissue, fascia, and tendons that
distribute across a joint and attach to the two bones making up the articulation. The
attachment location to where the muscle contact is known as the "origin" while the other
attachment on the bone that moves during contraction is known as the "insertion" point.
Muscle tissue consists of fibers (cells) that are highly specialized to exert force by
converting chemical energy into tension and contraction. As result of this characteristic,
muscle tissue provides motion, maintenance of posture, and heat production. On the basis
of certain functional and structural characteristics, muscles are classified into the three
categories of: skeletal, cardiac, and smooth.
Skeletal muscle tissue is considered to be striated since the fibers (cells) contain
alternating light and dark bands (striations) that are perpendicular to the long axis of the
fibers. These striations are visible under a microscope. Skeletal muscle tissue is also
considered to be voluntary in that it can be made to contract by conscious control. A
single muscle fiber is cylindrical, and the fibers are all parallel to each other in a tissue.
Each muscle fiber contains a plasma membrane, the sarcolemma surrounding the
cytoplasm, or sarcoplasm.
Skeletal muscle fibers are multinucleate, having more than one nucleus, where the
nuclei lie close to the sarcoplasm. The contractile elements of skeletal muscle fibers are
proteins called myofilaments. They contain wide, transverse, dark bands and narrow light
ones that give the striated appearance. Each of more than 600 muscles is served by nerves
which link the muscle to the brain and spinal cord. Skeletal muscles are the body's most
abundant tissue, comprising about 23% of the female body weight and about 40-45% of
the male body weight.

Review of Bone Physiology

Bones consist of the hard form of connective tissue that constitutes the skeleton of most
vertebrates. They are the structural components of the skeleton which provides insertion
and origin locations for muscular attachments across a joint which permits movement of
the joint when the muscle is contracted. Bone, also called osseous tissue, consists of an
organic component of cells and matrix, and an inorganic mineral component. The matrix,
which imparts the rigid quality to bone, contains a framework of collagenous fibers and is
impregnated with the mineral component which consists of 85% calcium phosphate and
1 0% calcium carbonate.
Although seemingly rigid, osseous tissue is very dynamic with some part of each
bone continuously being broken down by the action of osteoclast cells (a large
multinuclear cell associated with absorption and removal of bone) and reabsorbed. At the
same time new bone growth take place by the osteoblast cells derived from fibroblasts,
replacing that which was previously dissolved and reabsorbed. In this way the bones are
viable and living structures that are continually renewed. These same processes are
involved in the healing mechanisms of bone fractures.
Unfortunately, the body considers the bones to be a storehouse for calcium.
Hence, many situations occur where the body breaks down bone tissue to provide needed
calcium. Most common of these events is emotional stress which will trigger the release

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 77

of parathyroid hormone which will promote the breakdown of bone. Smoking will also
have the same effect. Diets chronically low in calcium or one that contains excess
calcium phosphate (contained in many soft drinks) will result in impaired calcification of
bone, resulting in weak bones and failure to heal fractures. The Chinese considered that
the kidneys were responsible for controlling the bones. As it turns out this idea is true
since the kidneys are responsible for maintaining a constant product of calcium and
phosphorous. Consequently, any diet that is either deficient in calcium or provides an
excess of phosphorous, can lead to problems and weakness of the bones.
Bones receive load signals when moving the body or working where external
forces, such as the forces due to gravity, provide a load signal for the bones to develop
sufficient strength to maintain viability. Lack of proper exercise will cause the body to
lose bone strength. The most serious problem with space flight is that astronauts suffer
serious calcium loss since they are basically operating in a zero gravity situation.

Body Joints
The body contains a variety of immovable joints that basically hold critical parts of the
skeleton together and moveable synovial joint articulations and their associated joint
capsules for moving the body.

Immovable Joints
Types of immovable joints include:
•
Fibrous joints such as sutures and other joints of the skull
•
Cartilaginous joints such as the pubis symphysis and the synchondrosis between
the manubrium and the body of the sternum
•
Osseous joints of the sacrum

Moveable Joints
The moveable joints usually involves two of more bones with articular cartilage on their
moveable contact surfaces that fall into to certain classifications based on their
fundamental structure and mechanical function. Major joints of the arms and legs can be
articulated to the end of their range of motion. The characteristics of this "end feel"
provide diagnostic information about the joint function. Types ofjoints of the arms and
legs are classified as follow:
•
Shoulder j oint which is considered to be a condyloid joint with the head of the
humerus articulating with glenoid fossa of the scapula
•
Hip joint which is a true ball and socket joint with the head of the femur
articulating within the hip socket
•
Wrist joint which is an ellipsoid joint where the radial bone and ulna articulate
with the wrist bones
• Interphalangeal joints and the ulna articulation with the humerus are considered
hinge joints

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Chinese Orthopedics Basis of Chinese Orthopedics 78

•
Rotation of the radial bone on humerus that allows pronation of the arm is
considered a pivot joint
• Articulation of the tibia and fibula on the talus is considered a cochlear joint
•
Articulation of the carpo-metacarpal joint of the thumb is considered a saddle
joint
•
Articulation of the navicular with the intermediate and lateral cuneiform of the
foot is considered a plane joint

Spinal Column
The spinal or vertebral column is like a somewhat flexible rod held together by strong
ligaments. It is perhaps the most important body structure and accounts for about 40% of
person height. The spine consists of 24 vertebrae separated by 23 intervertebral discs,
plus the fused bones of the sacrum and the coccyx (See Figure 3 . 1 ). The spinal column
supports the weight of the upper body, and together with related muscles and ligaments,
enables upright posture and walking. An interior opening (vertebral foramen) in the
vertebrae provide a protective channel for the spinal cord which gives rise to spinal
nerves distributed to the body at every segmental level between each vertebra. An
intervertebral foramen is formed by features between two vertebra separated by an
intervertebral disc, through which spinal nerves are distributed.

Cervical
Lordosis

Thoracic
Kyphosis

Lumbar
Lordosis

Sacral
Kyphosis

Posterior Anterior Lateral

Figure 3. 1 . Posterior, Anterior, and Lateral View of Spinal Column showing Normal Curves.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Basis of Chinese Orthopedics 79

The cervical region of the spine is comprised of seven vertebrae (designated as C 1

through C7), the thoracic region has 1 2 vertebrae (Tl - T 1 2) and the lumbar region has
five vertebrae (L1 - L5). The sacrum consists of five vertebrae all fused together to form
one continuous bone mass. The coccygeal region consists of four fused vertebrae to form
the coccyx or tailbone.

Vertebrae

With the exception of C 1 (the atlas which articulates with the occipital bone of the
skull), all vertebrae have a strong load bearing body along with an intervertebral disc that
carries the successive weight ofthe body above its location in the spine. Vertebrae also
have other features including spinous and transverse processes, and a vertebral foramen
through which the spinal cord and the cauda equina (in the lumbar vertebrae) distribute.
Vertebrae C3 through L5 also have superior and inferior articular processes which form
facet joints between adjacent vertebrae.
The vertebra in each area of the spine is somewhat different in nature and
function. Cervical vertebrae are l ighter in structure and movement of the cervical spine is
more flexible, especially between the atlas (C l ) and the axis C2). Cervical vertebrae also
have transverse foramen through which the vertebral arteries and veins distribute (See
Figure 7.2). Thoracic vertebrae are heavier than those in the cervical spine and they also
have facets that articulate with the ribs (See Figure 1 2 . 1 ). Typically, there are two costal
facets with one on the transverse process and one on the vertebral body (See Figure 1 2.2).
Sometimes this latter facet represents only half of the articular process (demifacet) with
the other half being on the vertebral body above or below. The lumbar vertebrae are
much larger since they must carry all of the body weight above sacrum (Figure 1 3. 1 ).

Intervertebral Discs

There is an intervertebral disc below the bodies of each vertebra from C2 (the
axis) to L5 that provides spacing between the bony structures and contributes to the
flexibility of the spine. Discs are composed of fibrocartilage material consisting of a
fibrous outer lining or ring (annulus fibrous) and a pulpy gelatin-like inner core (nucleus
pulposus). These discs are under constant pressure making them susceptible to "wear and
tear" problems, and actual rupture due to traumatic events. The intervertebral discs also
tend to dry out and shrink due to aging. This reduces flexibility and spacing between the
vertebral bodies which results in orthopedic conditions including the formation of
osteophytes and nerve impingement.

Facet Joints

The superior and inferior articular processes of the vertebrae form facet joints
where they articulate on vertebrae above and below from C3 through L5. These facet
joints are enclosed by a joint capsule. Purpose of spinal facet joints is to provide
rotational stability of the spine, and hence they greatly restrict spinal rotation. The
thoracic vertebrae also have costal facets where the ribs articulate. The costal-thoracic
joint is also enclosed by a joint capsule.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Basis of Chinese Orthopedics 80

Joint capsules
The j oint articulations are surrounded by a lose sac-like envelop of inert ligamentous
tissue which encloses the cavity of a synovial joint. The capsule has an internal synovial
membrane that contains synovial fluid. Some conditions of the j oint capsule such as
capsulitis can impair joint function.

Muscu lar System Organ ization

One of the most unique organizational features of the muscular system involves
longitudinal association and grouping discovered by the Chinese. Here the
musculoskeletal system is organized into 1 2 distinct longitudinal distributions related to
the nerves and blood vessels supplying the same regions. These distributions are
discussed in detail in Chapter 2 . Pain and pathology can reflect along the muscular
distributions which allow a convenient approach for assessment and treatment.

Neuromuscular Attachments (Motor Points)

Efferent motor signals to skeletal muscles are supplied by peripheral nerves (including
some cranial nerves for the head and face) emanating at specific spinal levels. These
motor nerves attach to particular sites of the muscles known as neuromuscular
attachments or simply motor points. Specific muscles are supplied by discrete spinal root
levels and the location of the muscle is viewed terms of a myotome with respect to the
segmental level. The trapezius and sternocleidomastoid are supplied by the spinal
accessory nerve (CN 1 1 ) portion that derives from the first five cervical segments of the
spinal cord. The muscles of mastication are supplied by the trigeminal nerve (CN 5)
while the facial muscles of expression are supplied by the facial nerve (CN 7).

Muscle Fiber Characteristics

Muscles are composed of fast twitch phasic fibers and slow twitch tonic muscle fibers
(See Table 3.3). Those that have a high percentage of the slow twitch fibers are the
postural muscles and are resistant to fatigue. Tonic muscles have a tendency to
developing tightness and contractures. Muscles with a high percentage of phasic fibers
are quickly contracted and relaxed and are easily fatigued. Phasic muscles have a
tendency to develop weakness. Many muscles have a somewhat equal distribution of both
phasic and tonic fibers and are considered to be intermediate in terms of speed and
fatigability. Many important neurovascular nodes (acupoints) are located in tonic muscles
while the phasic muscles have few nodes.

Propagated Sensation along Vessel and Muscular Pathways

The body' s response to needling involves the activation of nociceptive (pain) fibers and
proprioceptive (position and load sensors) fibers. Proprioceptive fiber participation is
mainly required in order for muscle to contract in response to an upper motor neuron
signal from the motor cortex. The proprioceptive fibers activated by needling also
produce the phenomena of propagated sensation when threshold conditions are proper.

Formation of Sensitive/ Trigger Points

The highly integrated system of muscular control and the related sensory functions give
rise to the mechanisms that produce the spontaneous formation of a sensitive or painful

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Chinese Orthopedics Basis of Chinese Orthopedics 8 1

location. These were later called trigger points to indicate that pathology in one muscle
can cause a painful spot to occur in another location. These are basically somatosomatic
referred pain locations that usually occur along a particular or related muscular
distribution. Palpation of the sensitive areas are used in assessment and determining the
success of treatment. Since both somatic and visceral pain signals integrate in the same
spinal segments, somatovisceral and viscerosomatic relationships also exist. Hence, some
painful phenomena are actually an indication of internal organ inflammation or
dysfunction.

Table 3.3. Characteristics of fast, intermediate and slow twitch muscles fibers.
Phasic (Fast Twitch) Intermediate Tonic (Slow Twitch)
• Pale in color • Red in color • Red in color
• Few mitochondria • Many mitochondria • Many mitochondria
• Poorly vascularized • Richly vascula rized • Richly vascularized
• Anaerobic metabolism (uses • Both oxidative (myoglobin) and • Oxidative metabolism (myoglobin)
glycolysis) anaerobic (glycolysis) metabolism
• Quick contraction and relaxation • Intermediate range of contraction • Slow contraction and slow
and relaxation relaxation
• Fatigue easily • Medium range of fatigability • Resistant to fatigue
• Develop wide range of tensions • Average tension range • Develop tension over narrow range
of displacement
• Suited for h igh intensity short­ • Suited for muscles of motion where • Suited for long-term contraction
duration muscular activity wide range of performance activity such as needed in maintaining
is crucial posture

Conditions Affecting Musculoskeletal System

Most diseases, injuries, and problems affecting the musculoskeletal system have been
described since ancient times. Many of these conditions are still denoted or designated by
use of Greek terms, as are many problems identified in more recent times. The Chinese
also described most musculoskeletal and traumatic conditions including fractures,
dislocated joints, and even including broken neck and its treatment. They also described
various forms of arthritis and rheumatism due to restricted blood flow to the
musculoskeletal system. In addition, they described flaccid conditions including atrophic
disorders, trauma, nutritional problems, and also includes rheumatoid arthritis. Ancient
Chinese provided a clear description of pain due to rheumatic fever which they referred
to as "wandering or circular pain," They described all types of strain, sprain, swelling,
and pain conditions, including low back pain. Cerebral vascular accident (CVA) or stroke
was described separately and noted to be the result of major blockage of vessels in the
brain.

Present Day View

Chinese orthopedics uses standard Western disease terminology including that for
musculoskeletal conditions since this represents the World body of evidence based
understanding. This allows practitioners to be able to communicate with the medical
community to best serve patient needs. It also allows practitioners to communicate with
patients using the same type of information they received from their physicians or
diagnostic centers, or detailed information they may have obtained on the Internet. Some
of the more commonly encountered conditions and terms applied in orthopedics include:

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Chinese Orthopedics Basis of Chinese Orthopedics 82

•
Ankylosing spondylosis: indicates ankylosis of the vertebrae
•
Ankylosis : indicates consolidation or immobility of a j oint due to a disease, injury, or
surgical procedures
•
Arthritis: rheumatism in which the inflammatory lesions are confined to the joints
manifesting as acute, rheumatic, osteoarthritis, and rheumatoid arthritis
•
Bursitis: is an inflammatory lesion of a bursa; sometimes accompanied by a calcific
deposit in its associated tendon, such as the supraspinatus tendon and other common
tendons. Usually results in clinical signs of sharp pain along with impaired active and
passive range of motion in the affected joint or region
•
Capsulitis: is an inflammatory lesion of a joint capsule that can lead to capsular
thickening and contraction with loss of internal j oint volume resulting in clinical signs
of pain and stiffness in the active and passive range of motion of the joint
•
Common soft tissue inj uries: involves lesions to muscles, tendons, tenosynovial
sheaths, j oint capsules, ligaments, and bursae
•
Disc injuries and herniation: occur mainly in cervical and lumbar spine often
involving a lateral herniation which compresses the nerve root below, such as a C5-
C6 disc herniation compresses C6 nerve root. Acute disc herniation usually occurs in
younger patients which may result in a soft disc protrusion from nuclear herniation.
Chronic disc disease affects older patients resulting in a hard disc l esion associated
with spondylosis
•
Fractures: refers to broken bones, including vertebrae, which can be classed as a:
o Simple fracture with single fracture l ine through a bone without breaking
the skin
o Comminuted fracture with the bone broken into two or more fragments; or
o Compound or open fracture where the bone penetrates the skin
•
Frozen shoulder: highly restrictive movement of the arm due tendinomuscular
problems of the shoulder; or adhesive capsulitis
•
Gout and pseudogout: are the two most common crystal-induced debilitating illnesses
arthropathies in which pain and j oint infl ammation is caused by the formation of
crystals within the joint space:
o Gout is inflammation caused by monosodium urate monohydrate (MSU)
crystals
o Pseudogout is inflammation caused by calcium pyrophosphate (CPP)
crystals and is sometimes referred to as calcium pyrophosphate disease
(CPPD)
•
Ligament sprains: a joint injury is which fibers of the supporting ligament are tom,
classed as:
o First degree sprain ( 1 °) when few l igament fibers are tom
o Second degree sprain (2°) when about half of ligament fibers are tom

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Chinese Orthopedics Basis of Chinese Orthopedics 83

o Third degree sprain (3 °) when all fibers of the ligament are torn
•
Muscle strain: an injury in which contractile tissue is damaged, classed as:
o First degree strain ( 1 °) when few muscle fibers are torn
o Second degree strain (2°) when about half of muscle fibers are torn
o Third degree strain (3 °) when all fibers of muscle are torn (rupture)
•
Nerve inj ury and compression, graded as:
o First degree ( I 0) neuropraxia involving transient physiological block
caused by ischemia due to pressure or stretch of the nerve with no
Wallerian degeneration
o Second and third degree (2° and 3 °) axonotmesis where internal
architecture of nerve is preserved but axon is cut or crushed causing
Wallerian degeneration in which the part of the axon separated from the
neuron's cell nucleus degenerates. This is also known as anterograde
degeneration.
o Fourth and fifth degree (4 o and 5°) neurotmesis where structure of nerve is
destroyed by cutting, severe scarring, or by prolonged severe compression
•
Osteoarthritis: i s a degenerative joint disorder occurring mainly in older people
characterized by degeneration of the articular cartilage, hypertrophy of bone at the
margins, and changes in the synovial membrane, and is accompanied with pain and
stiffness
•
Osteopenia: is a condition where bone mineral density is lower than normal and often
considered to be a precursor to osteoporosis. Osteopenia is defined as a bone mineral
density T score between 1 0 and -2
-
.

• Osteoporosis: is a systemic skeletal disorder characterized by decreased bone mass

and deterioration of bony microarchitecture. The result is fragile bones and an
increased risk for fracture even with minimal trauma. Osteoporosis is a chronic
condition of multifactorial etiology and usually is clinically silent until a fracture
occurs
• Reflex sympathetic disorder (RSD): this is a serious degenerative disorder that is also
known as "regional pain syndrome" of unknown etiology that has sympathetic neural
involvement
•
Rheumatoid arthritis: is a chronic systemic inflammatory disease of undetermined
etiology involving primarily the synovial membranes and articular structures of
multiple j oints. Disease is often progressive and results in pain, stiffness, and swelling
of joints. In late stages deformity and ankylosis develop
•
Spondylitis: denotes inflammation of the vertebrae; also indicates hypertrophic
changes in the vertebrae, including osteophytes (a bony excrescence or osseous
outgrowth)
•
Spondylolisthesis: a shifting or subluxation of one vertebra upon another, usually
anteriorly; or could be degenerative deformities of the spine

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Chinese Orthopedics Basis of Chinese Orthopedics 84

•
Spondylosis: a general term for degenerative vertebral changes due to osteoarthritis;
or ankylosis of a vertebral joint
•
Spondylolysis: a dissolution of a vertebrae; or aplasia of the vertebral arch and
separation of the pars interarticularis
• Sprain and strains: involves injury to j oints and muscles involving ligaments (inert
tissue) and contractile tissue (muscle, tendons, and attachment) graded in terms of 1 °,
2°, and 3 ° (see ligament sprain and muscle strain above)
•
Tendonitis: indicates inflammation of tendon
• Thoracic outlet syndrome: is a brachial plexus peripheral nerve entrapment by the
anterior scalene muscle or where the nerve traverses under the clavicle
•
Vertebral artery syndrome: problem caused by affect on vertebral arterial flow into
the brain possibly resulting in vertigo or visual problems

Nervous System Review

The nervous system can be viewed in terms of the central nervous system (CNS) and the
peripheral nervous system (PNS). Included within this system are components that
mediate the motor and sensory functions of visceral systems including the blood vessels
and is referred to as the autonomic nervous system (ANS). The ANS is further divided
and classified into the sympathetic nervous system (SNS) and the parasympathetic
nervous system (PSNS).

Central Nervous System

The CNS consists of the brain and spinal cord which forms one continuous structure. The
spinal cord contains various tracts of nerve cells that carry related or specific types of
information. Neurons comprising the spinal cord mainly originate in the brain to provide
(descending) signals to specific spinal segmental levels of the cord, or those that originate
at spinal levels for sending signals to the brain (ascending) and other spinal cord areas. In
addition there are numerous intemeurons associated with the descending and ascending
neurons.

Autonom ic Nervous System (ANS)

The sympathetic nervous system (SNS) branch and the parasympathetic nervous system
(PSNS) branch of the ANS are the main functional innervation to all organs in the body.
The SNS also innervates the blood vessels and presently there are no known distributions
of PSNS fibers to the extremities. The auricle is the only place on the body where PSNS
fibers in terms of small sprigs of the Vagus or 1 Oth cranial nerve have a superficial
distribution.
The ANS contains both autonomic sensory and motor fibers. The sensory nerves are
afferent fibers that provide signals to the autonomic ganglia, spinal cord and brain on
pain, pressure and temperature and information pertinent to vascular and organ function.
The autonomic motor nerves are efferent fibers that provide control signals to the vessels
and organs. The processes of acupuncture depend greatly on an interaction between these
nerve fibers and those that innervate the muscles and superficial regions of the body.

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Chinese Orthopedics Basis of Chinese Orthopedics 85

Physiological responses of the PSNS and SNS can be viewed in terms of yin and yang
qualities respectively, assigned to visceral characteristics by the early Chinese physicians.
These classifications are valuable in understanding certain conditions or status of the
internal organs.

Peri pheral Nervous System

The peripheral nervous system consists of cranial nerves directly from the brain and
brainstem and peripheral nerves communicating with the spinal cord at specific
segmental levels as described below. Except for the olfactory (CN I) and the optic (CN
II) nerves, the nuclei of the cranial nerves are located in the brainstem. Cranial nerves I,
II, and VIII are purely sensory while III, IV, VI, XI, and XII are motor nerves, and the
last four, namely V, VII, IX, and X are mixed sensory and motor nerves.

Nerve Roots
Nerve bundles connected to the dorsal and ventral horns of the spinal cord that combine
close to the intervertebral foramen to form the 3 1 pairs of spinal nerves. The dorsal roots
contain mainly afferent sensory fibers while the ventral roots contain both somatic and
visceral efferent motor fibers. Specific nerve roots supply certain muscles to create a
myotome. Lack of strength or dysfunction of key muscles then indicates possible
problems at a particular root level (See Table 3 .4.). Pain or dysfunction along peripheral
nerve route emanating from a specific nerve root is referred to as a radiculopathy.
Radicular pain is often produced in the distribution of a nerve root as a result of some sort
of mechanical or irritation of that root.

Anterior and Posterior Rami

After the spinal nerves exits the intervertebral foramen they divide into anterior and
posterior rami to supply those regions of the body. The relationship of some
neurovascular nodes (acupoints) rely on their anterior or posterior innervation, and the
specific use of points to bring about certain responses.

Table 3.4. Key muscle function for representative nerve root levels.
Root Muscle Function Root Muscle Function
C1 Head o n neck flexion C8 D I P* flexion (flexor d igitorum profundus)
C2 Head on neck extension T1 Finger abduction (dorsal interossei)
C3 Cervical lateral flexion L2 Hip flexion (iliopsoas)
C4 Scapular elevation L3 Knee extension (quadriceps)
C5 Shoulder abduction L4 Ankle dorsiflexion (tibialis anterior)
C6 Elbow flexion_(biceps) L5 Big toe extension (extensor hallucis longus)
C7 Elbow extension (triceps) S1. 2 Ankle plantar flexion (gastrocnemius-soleus)
*DI P: Distal interphalangeal joints

Spinal Nerves
There are 3 1 pairs of nerves which connect with the spinal cord. Includes 8 cervical, 1 2
thoracic, 5 lumbar, 5 sacral and 1 coccygeal. Spinal nerves are designated by their
segmental level of the cord. Spinal nerves form plexuses where peripheral nerves are
formed that distribute to various areas, especially the extremities.

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Chinese Orthopedics Basis of Chinese Orthopedics 86

Cervical Plexus (Cl - C4)

The cervical plexus is formed on both sides of the spine by the ventral rami of the
first four cervical nerves (C l - C4) with some contribution from the fifth cervical nerve
(C5). This plexus supplies the skin and muscles of the head (not including facial muscles
and muscles of mastication), neck, and part of the shoulders. Branches of the cervical
plexus also connect with the spinal accessory nerve (CN XI) and the hypoglossal nerve
( CN XII). The phrenic nerves are a critical pair of nerves rising from the cervical plexus
that supply the motor function for the diaphragm. Paralysis of the diaphragm occurs when
the spinal cord is damaged above the origin of the phrenic nerve. Without the ability to
contract the diaphragm, the individual cannot breath.

Brachial Plexus (C5 - Tl)

The brachial plexus is comprised of a network of nerves arising from both sides of
the spine at the base of the neck. This plexus gives rise to the nerves supplying the arm,
forearm, hand and some parts of the shoulder girdle. Anterior rami of cervical nerves C5
- C8 and first thoracic spinal nerves (T l ) are the source input to the brachial plexus which
runs between the spine and the upper arm just after the axilla.
Peripheral nerves formed by the brachial plexus innervate the shoulder, scapula, and
upper extremity musculature can be injured through traumatic episodes and during
athletic events. It is susceptible to blunt and penetrating trauma, traction inj ury,
compression, and inflammatory conditions. In addition, peripheral nerves innervating the
shoulder, scapula, and upper extremity musculature can be injured due to a fall, stretch
inj ury, dislocation, or compression.
The general features of the brachial plexus involves spinal levels (C5 to Tl )
transitioning into 5 rami which subsequently divide into 3 trunks, which further divide
into 3 cords. The cords then give rise to the peripheral nerves. The course of the brachial
plexus nerves passes between middle and anterior scalene muscles, beneath clavicle, and
passes beneath pectoralis minor (in axilla). The lower trunk (C8, T l ) passes over first rib.
Certain key sensory tests can give an indication if one of the peripheral nerves is involved
in a particular problem (See Table 3 .5).

Table 3.5. Major peripheral nerves of upper extremities with relevant motor and sensory
indications.
Nerve Motor Test Sensation Test
Radial Wrist extension Dorsal web space between thumb and index
Thumb extension finqer
Ulnar Abduction of little finqer Distal ulnar aspect - little finqer
Median Thumb pinch, opposition, Distal radial aspect - index finger
and abduction
Axillary Deltoid Lateral arm - deltoid patch on uoper arm
Musculocutaneous Biceps Lateral forearm

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Chinese Orthopedics Basis of Chinese Orthopedics 87

Intercostal (Thoracic) Nerves

The ventral rami of spinal nerves on both sides of the body from T2 - T 1 2 do not
enter into forming nerves plexuses. These are known as intercostal or thoracic nerves and
distribute directly to the structures they supply in the intercostal spaces. The ventral rami
of spinal nerve T2 supply the second intercostal space muscle and the skin of axilla and
posteromedial aspect of the arms. Nerves T3 and T6 distribute to the intercostal muscles
and skin of the anterior and lateral chest wall. Nerves T7 - T i l supply the intercostal
muscles and abdominal muscles and overlying skin. The dorsal rami of the intercostal
nerves supply the deep back muscles and the skin of the dorsal aspect of the thorax.

Lumbar Plexus

The lumbar plexus is formed by ventral rami of spinal nerves L I - L4 on both

sides of the body. This plexus differs from the brachial plexus in that there is no intricate
interlacing of the fibers. The lumbar plexus passes obliquely outward behind the psoas
major muscle (posterior division) and anterior to the quadratus lumborum muscle
(anterior division). The resulting peripheral nerves supply the anterolateral abdominal
wall, external genitalia, and part of the lower extremities. The femoral nerve is the largest
nerve emanating from the lumbar plexus.

Sacral Plexus

The sacral plexus is formed by the ventral rami of spinal nerves L4 - L5 and S I -
S4 on each side of the body. This plexus is situated mainly in front of the sacrum and
contains roots that form anterior and posterior divisions. The sacral plexus supplies the
buttocks, perineum, and lower extremities. The largest nerve in the body, the sciatic
nerve, arises from the sacral plexus. The sciatic nerve (L4 - S3) supplies the entire
musculature of the leg and foot.

Derma tomes
Cutaneous nerves are comprised of fibers from different spinal nerves at specific
segmental levels and therefore patterns related to a particular spinal cord level reflect on
the skin. These regions have significant diagnostic utility in differentiating symptoms to
determine the affected root or spinal nerve level.

Cutaneous Nerve Distribution

Cutaneous nerve distribute to unique regions of the skin, so loss of sensation in these
specific areas can provide a clue to determine if only a specific cutaneous nerve is
involved or if there a specific segmental level involved.

Myotomes
Specific nerve roots carry fibers to groups or regions of muscle fibers. Pathology in an
entire group of these muscles provides a clue concerning the affected root level.
Myotomes in each of the areas covered in Chapters 6 - 1 7. A summary of root
innervation to key muscles is provided in Table 3 .6.

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Chinese Orthopedics Basis of Chinese Orthopedics 88

Table 3.6. Summary of spinal segment nerve root innervation levels for general muscles in
the body
Segment Muscles
C 1 - C4 Neck M uscles
C3 - C5 Diaphragm
C5 - C6 Biceps
C5 -C8 Shoulder Joint Muscles
C7 - C8 Triceps and Long Muscles of Arm
C8 - T1 Digit Movement and Small Intrinsic Muscle of Hand
T2 - T 1 2 Axial Musculature. Intervertebral. Respiration, and Abdominal Muscles
L 1 - L2 Thigh Flexors
L2 - L3 Quadriceps Femoris
L5 - S 1 Gluteal Muscles
S 1 - S2 Ankle Plantar Flexors
S2 - S4 I ntrinsic M uscles of the Feet
S3 - S5 Pelvic Floor Muscles, Bladder Sphincters and External Genitalia

Sclerotomes
A sclerotome represents an area of bone or fascia supplied by a specific nerve root.
Sclerotomal pain is not well localized and has a deep seating characteristic. Sclerotomes
are difficult isolate. Reflex tests and dermatome findings may indicate radicular
involvement, but the sclerotomes may indicate referred pain.

Neurological Lesions
Common neurological lesions are classed as to their source along the pathway including
the spinal cord to the termination of a peripheral nerve. These include:
Myelopathy: a neurogenic disorder involving the spinal cord or brain resulting in an
upper motor lesion. The symptoms and pattern of pain are different than that of radicular
pain. Both the upper and lower limbs are often affected.
Avulsion: involves a severe injury where the nerves are pulled from the spinal cord as
evidenced by a totally flaccid extremity.
Radiculopathy: a nerve root lesion that results in radicular or radiating pain due to a
direct involvement of a nerve root or spinal nerve. Pain may be felt in a dermatome,
myotome, or sclerotome.
Plexopathy: symptoms, dysfunction, and pain due to conditions including trauma that
affect a plexus, especially the brachial plexus.
Neuropathy: is a lesion of the peripheral nerve.

Peripheral Nerve Injuries

Because of their anatomical features, peripheral nerves are commonly affected by
pressure, friction, traction (stretch), anoxia, and cutting. Peripheral nerves are also
damaged by environmental conditions of cold or heat as well as electrical inj ury. These
are classified as:

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Chinese Orthopedics Basis of Chinese Orthopedics 89

Neuropraxia: a transient ischemic physiological block due to pressure or stretch of the

nerve with no Wallerian degeneration. Manifests with pain, no or little muscle wasting,
numbness, with affected proprioception, and recovery is quick.
Axonotmesis: involves badly damaged axons resulting in Wallerian degeneration
although the nerve internal architecture is preserved. Results of this injury manifests with
pain, muscle wasting, and complete loss of sensory, motor, and sympathetic function.
Recovery is slow with sensation restored before motor function.
Neurotmesis: is situation where the nerve has been destroyed by severe scarring, cutting,
or prolonged severe compression. Symptoms include no pain, muscle wasting, with
complete loss of motor, sensory, and sympathetic function. Recovery is prolonged and
requires surgery.

Sensory Function
Efferent nerves are those that transmit impulse signals from a nerve center to the
periphery (e.g., motor nerve). Afferent nerves are those that transmit impulses from the
periphery to a nerve center (e.g., nociceptive and proprioceptive fibers). The general
scheme by which afferent sensory and efferent motor fibers interrelate are essential to the
mechanisms involved in needling (acupuncture) stimulation.

Nociceptive (Pain) and Temperature

Nociception is the process of detecting and transmitting signals in response to noxious
stimuli such as pain, to provoke responses in the body. Temperature sensitive fibers
detect changes in local temperatures. Both pain and temperature afferent fibers are dorsal
root ganglia cells that synapse on crossed fibers at their entry cord level that ascend in the
anterior lateral tract on the opposite side of the cord. They distribute to the reticular
formation, periaqueductal gray, and the ventral posterolateral nucleus of the thalamus.
From here, fibers distribute to the sensory cortex, excluding the portion related to the
face.
Pain and temperature impulses from the face travel along fibers in different
components of the spinal trigeminal tract which then sends fibers to opposite side ventral
posteromedial nucleus of the thalamus. From here, fibers distribute to sensory cortex
region representing the face.

Proprioceptive, Tactile, and Vibratory Impulses

Complex system of detecting and transmitting afferent signals related to body and j oint
position, muscle loads, and acceleration. The propriospinal system is fundamental in
controlling lower motor neurons, mediating spinal reflexes, and producing propagated
sensation that travels along the muscular and vascular distributions.
Proprioceptive and tactile discrimination dorsal root ganglia cell impulses travel
in the dorsal column to the cuneate nucleus where they synapse on fibers that cross over
to the ventral posterolateral nucleus of the thalamus. From here, fibers distribute to the
sensory cortex, except the area representing the face. Proprioceptive and tactile
discrimination dorsal root ganglia cell impulses also travel in the dorsolateral funiculus.

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Proprioceptive and tactile discrimination impulses from the face travel to chief sensory
nucleus of trigeminal nerve which then sends fibers to opposite side ventral
posteromedial nucleus of the thalamus. From here, fibers distribute to sensory cortex
region representing the face.

Touch and Pressure

A secondary major pathway mediating impulses for tactile discrimination, including
touch and pressure synapse on fibers in the dorsal hom that ascend in the dorsolateral
funiculus to the lateral cervical nucleus at the upper cervical region. Axons from the
lateral cervical nucleus cross over to the opposite side spinothalamic track. From ventral
posterolateral nucleus of the thalamus, fibers distribute to the sensory cortex, except the
area representing the face.

Somatic Motor Control

Voluntary control of the striated skeletal muscles is mainly accomplished by signals
originating in the motor cortex of the brain. The basal ganglia and cerebellum have
important roles related to smoothness of control and coordination. Motor control relies on
atierent feedback signals that provide information on load, position and acceleration,
which are operative at the spinal segmental and brain levels.

Upper Motor Fibers

Upper motor neurons originate in the motor cortex and descend in the cord via the
corticospinal tracts. A lesion ofthe cord anywhere above L l level, affecting motor
neurons, may cause upper motor neurons signs in the legs. Although the sensory and
motor tracts of the cord are somatotopically organized, it is difficult to identify segmental
levels of involvement associated with muscles of the thorax and trunk. Some obvious
signs of upper motor neuron lesions include:
• Paralysis
• Exaggerated tendon reflexes
• Hypersensitivity

Lower Motor Fibers

These are the nerves that originate in the ventral hom of the spinal cord and connect
directly with the muscle tissue at regions called the motor end-plate, neuromuscular
attachment, or motor point. A single motor neuron and the muscles fibers its branches
innervate are known as a motor unit.
Fibers of lower motor neurons are contained in the spinal nerves and therefore
susceptible to external mechanical pressure either by compression, disc impingement,
osteophytes, swelling, and soft tissue contractions. Lower motor neurons participate in
deep tendon and other spinal mediated reflexes. Typical problems associated with lower
motor neuron involvement include:
• Weakness
• Wasting (atrophy)

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Chinese Orthopedics Basis of Chinese Orthopedics 9 1

• Fasciculations
•
Loss of deep tendon reflexes

Propriospinal System
The propriospinal system has a complex role of proprioception in terms muscular static
load and joint positions. The lower motor neurons cannot contract in response to an
efferent upper motor signal without participation of the proprioceptive function. Lower
motor neurons have a feedback control system that is mediated by small sensory devices,
containing load fibers, called muscle spindles. The spindles receive an efferent signal by
means of motor gamma loop fibers in response to the upper motor signal. This results in
the muscle spindle sending an afferent response back to the spinal cord. If loads on the
target muscle are within normal range, then the muscle will contract in response to the
upper motor signal. These features provide the mechanism for lower motor function and
also participate in deep tendon reflexes. Impairment of the gamma loop can result in
condition of flaccidity and atrophy.
The propriospinal system also sends numerous fibers up and down the spinal
cord. Some of these only traverse over a few spinal segments or distribute over the entire
length of the spinal cord. These spinal pathways send motor signal to other skeletal
muscles in the body, both on the same and opposite side, in response to maintaining
bodily balance and function when other muscles contract, especially to emergency
situations or external stimulation.

Basal Ganglia System

This important region of the brain is involved in providing signals to make muscular
control a smooth process. Problems in this area include Parkinson' s disease and other
movement anomalies. The basal ganglia are influenced by and participate in the needling
induced (acupuncture) processes.

Cerebellum
Observation of patients with cerebellar diseases indicates that it is an important center for
coordination of movement and postural adj ustment. Cerebellum receives information
from all parts of the body in order to regulate these functions including: interoceptive and
proprioceptive impulses from muscles and j oints and from visceral organs; signals from
the skin and from the visual, auditory, and the vestibular system; and a variety of
impulses from motor centers of the CNS .

Somatic and Autonomic Relationships

A significant integration of somatic and autonomic afferent fibers exists mainly to
perform important reflex responses involving muscles, vessels and internal organs. Some
of these interrelationships are important to understanding tissue and somatic responses.

Clinically Importa nt Reflex Tests

The organization of the spinal afferent processing system, including the propriospinal
system, provides the mechanisms to mediate important reflex phenomena. Some of these
reflexes are mediated at near the same segmental level that contains the structures

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 Chinese O rthopedics Basis of Ch inese Orthoped ics 92

involved. This is much the case for deep tendon reflexes. Other reflexes involve the
participation of higher levels of the CNS and therefore can be used in conjunction with
the tendon reflexes to help isolate a problem, such as determining if an upper or lower
motor neuron was involved in the problem.

Deep Tendon Reflex Tests

Several well known and applied deep tendon reflexes have been in use for some time,
even by the ancient Chinese. One involving the mandible is used to determine proper
supply to the temporalis muscl e by the 5th cranial nerve motor fibers. Other deep tendon
reflexes involve both the brachial plexus (See Table 3 .7) and the plexuses of the low back
(See Table 3 .8). Deep tendon muscle reflexes that are below normal indicate possible
problems affecting lower motor neurons. Hyperactive deep tendon reflexes indicate
possible involvement of upper motor neurons.

Table 3. 7. Nerve roots, cervical d isc, motor and sensory levels, and reflexes of the mandible and
the brach ial plexus.

Root Disc Motor Level Reflex Reflex Response Sensory Level

CN 5 Mandible Jaw Mouth closes
C5 C4 - C5 Shoulder Biceps Biceps Lateral arm
abduction contraction
C6 CS - C6 Wrist extension Brachioradialis Elbow flexion Thumb, index
and/or forearm finger and
pronation latera l forearm
C7 C6 - C7 Triceps, wrist Triceps Elbow extension Middle finger
flexion and
finger extension
C8 C7 - T1 Finger flexion (none) Ring and l ittle
finger, and medial
forearm
T1 T1 - T2 Finger abduction (none) Med ia l arm

Table 3.8. Nerve roots, spinal d isc, motor and sensory levels, and reflexes of the lumbar and
sacral plexuses

Root Disc Motor Level Reflex Reflex Response Sensory Level

L4 L3 - L4 Tibialis anterior Patellar Leg extension Medial leg and

(L2 , 3) foot
LS L4 - L5 Extensor Tibial is posterior Slight plantar Lateral leg and
hallucis longus (weak) inversion dorsum of foot
L5, L4 - L5, Med ial Knee flexion
S1 LS - S 1 hamstrings
S1 L5 - S 1 Lateral Knee flexion
hamstrings
S1 L 5 -S1 Peroneus Achilles Pla ntar flexion: Lateral malleolus,
longus and Gastrocnemius plantar and lateral
brevis contraction aspect of foot

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Ch inese Orthopedics Basis of Chinese Orthopedics 93

Pathologic and Sensory Reflexes

Reflexes that are thought to involve higher levels of the CNS sensory and pathological
tests. These reflexes are summarized in Tables 3.9 and 3 . 1 0.

Table 3.9. Normal superficial responses indicating C N S segment level

Reflex Normal Response CNS Segment

U pper U m bilicus moves up and toward the T7 - T9
Abdominal region beinQ stroked
Lower U mbilicus moves down and toward T1 1 - T12
Abdominal stroked region
C remasteric Scrotum elevates T12 - L1
Plantar Flexion of toes S 1 - S2
Gluteal Skin tenses over gluteal region L4 - L5. S1 - S3
Anal Contraction of anal sphincter muscles S2 - S4

Table 3 . 1 0. Responses to pathological reflexes

Reflex How to Elicit Positive Response

Babinski Stroke lateral aspect of sole of foot Extension of big toe and
fanning of four small toes
Chaddock Stroke lateral aspect of foot beneath lateral Same response as above
malleolus
Oppenheim Stroke anterior medial tibial surface Same response as above
Gordon Squeeze calf muscles firmly Same response as above

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Oriental Orthopedics H istory and Physical Examination 95

H istory and Physical Exam ination

The principal obj ective in practice is to find a solution to the patient' s problem. Also, it is
important to determine the patient's expectations and what the practitioner' s involvement
will be to meet these expectations. It is important to gain the patient' s cooperation and to
work together with the practitioner to help resolve their problem. In order to accomplish
this goal the nature and cause of the problem must be known before appropriate treatment
and case management can be instituted. A logical step-by-step process to accomplish this
task is detailed in this and Chapter 5 that follows.
Initially, this requires data collection and interpretation relying on information
mainly supplied by the patient (Subjective signs) which constitutes the patient history.
General observations and possibly a preliminary examination then takes place in order to
determine a present health status of the patient (Objective signs). Results of these two
functions then provides a general idea of the problem from which a general clinically
impression is developed. A careful detailed and systematic examination is then necessary
to understand the patient ' s problem which may verify or disprove the initial clinical
impression (Assessment phase).
Responses to pertinent historical queries suggest how the examination should be
planned, what course it should take, and what areas may require special consideration.
Several methods of examination exist, however the process follows a logical sequence of
procedures that are optimized to obtain valid diagnostic information without causing
undue stress and discomfort of the patient. This sequence is followed in Chapters 6 - 1 7
for specific regions of the body that will provide the essential information from which a
diagnosis can be developed and the treatment and case management plan (Plan: see
Chapter 5) is finally formulated.
It is the initial patient contact that establishes the nature of the practitioner/patient
relationship and determines the degree of confidence and trust involved in the case
management. Certain definitions apply to the process of the history and physical
examination as follow:
Consultation
This involves any combination of history taking, physical examination, and explanation
and discussion of the clinical findings and prognosis. A consultation can also be the
service provided by a practitioner whose opinion or advise regarding evaluation and/or
management of a specific problem is requested by another practitioner or other
appropriate source. An outside consultation requires at least a verbal recommendation
which should be fol lowed by a written report.
Diagnosis
This refers to a decision regarding the nature of the patient' s complaint; the art or act of
identifying a disease or condition from its signs and symptoms.
Examination
Involves procedures conducted by the practitioner necessary to determine a working
diagnosis or hypothesis concerning the problem. The goal of the examination is not to

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 Oriental Orthopedics History and Physical Examination 96

attain diagnostic certainty but rather reduce the level of uncertainty sufficient to make
optimal recommendations for care.
History
A history represents the patient's account of the clinical problem(s) given in response to
the practitioner' s questions, including information obtained by the use of intake forms.
Neurological Examination
Most commonly refers to evaluation of motor function, deep tendon reflexes, sensation,
and muscle strength. Special orthopedic test may also be conducted to provide
confirmation of the neurological contribution to the problem. Most pain and neurological
deficits emanate from an irritation or damage at a particular nerve root level of the spinal
cord classed as a "radiculopathy" and hence most testing is directed to determining the
specific segmental level of the problem.

The History
The initial phase of trying to understand the patient' s problem is to collect information
provided by the patient themselves (subj ective). This information is combined with
general observation on the part of the practitioner (objective). This phase may also
include a scanning examination of an initial clue on which region of the body the
problem mostly affects, if this is not obvious by the information provided by the patient.
Early Chinese physicians recognized that the patient knows more about their
problem than anyone else and thus the most important part of making an accurate
diagnosis is to inquire about all aspects of the presenting complaint. Leading questions
are to be avoided such as, "Does this increase your pain?'' as opposed to, "Does this alter
your pain in anyway?" The history process provides the patient an opportunity to provide
their impression of their problem. It is important to listen carefully to the patient but also
to keep the patient focused on describing their complaint and its onset. Determining the
onset or factors that induced the problem or disability is most fundamental.
It is important to determine the location of the problem and if it radiates into other
regions of the body. It is important to determine if there are any patterns associated with
the distribution pathways of muscles, vessels, nerves and neurovascular nodal (acupoint)
pathways. The severity of the condition and whether it produces impairment of any extent
is next determined.
The quality or nature of the presenting symptoms provides additional clues as to
its source as does considering factors that make the problem either better or worse. The
behavior of the problem, especially related time of day patterns as well as how it affects
joint function is also important. Many questions are directed to understanding the onset
and history of the condition, including inquiry into previous disease history and family
history. In the case of a trauma induced problem, many detailed questions are employed
to determine the extent of the damage and details concerning specific regions of the body
that were affected.

Taking the History

This important process derives critical information by which one determines the initial
impression of the presenting problem and should be adequately recorded and

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 Oriental Orthopedics H istory and P hysical Examination 97

documented. Use of preprinted forms can greatly aid in the process of obtaining a
consistent and well organized set of information. If the patient is allowed to fill out the
history or some portion of a preprinted form, the practitioner must go over the
information with the patient to clearly establish that both the patient and the practitioner
have the same understanding of the problem. If a historian, other than the practitioner, is
used to elicit the information from a patient, the practitioner is still obligated to go over
the information directly with the patient. It is always advisable for the practitioner to take
the history and conduct the subsequent detailed examination. A good history plays the
most critical role in the assessment and diagnostic process and will appropriately identify
the region to be examined. The history also provides the extent of the condition.

Components of History
A history may include any or all of the following items, dependent on the presentation of
the patient and the j udgment of the practitioner. Those sections of a history or
examination that makes use of preprinted forms that are not specifically used in the data
gathering and diagnosis should be annotated with an appropriate designator.
Abbreviations such as "'NA" (not applicable) or "NT" (not tested) or other terms the
practitioner might use. All abbreviations and terms need to have a key or be explained.
This is important should the case need to be defended or if there is any dispute as to
which test was or was not performed. Patients are often in a profound state of discomfort,
disability or pain and frequently have poor recall concerning what was said or done.
Patients often cannot accurately recall what areas of the body they were examined or
even needled. The same comments apply to treatments, which have to be accurately
documented as discussed later. It is critically important that the practitioner refrain from
making any comments in the chart of a personal or suggestive nature.
Identifying Data
Includes information on the identity of the patient such as name, age, gender, occupation
and includes the date of the history. The chief complaint and its onset can also be
identified and a provisional diagnosis, especially if the patient was referred by another
practitioner. The hand and l eg dominance should also be identified and what was the
condition of the affected part before the present onset of problems.
Age
Knowing the patient's age is important since many orthopedic conditions occur
within certain age ranges. A higher incidence of degenerative conditions such as
osteoporosis and osteoarthritis may be seen in the older population. Various growth
disorders such as Scheuermann' s disease or Legg-Calve-Perthes disease can be seen in
teenagers and adolescents. Shoulder impingement in people 1 5 to 3 5 years old is more
likely the result of weakness in muscles controlling the scapula, while in those older than
40, it i s more likely the result of degenerative changes to the shoulder complex.
Occupation
The ancient Chinese noted that prevalent conditions and treatment approaches
varied based on one's occupation or status in life. Labors and farm workers tend to have
stronger muscles and are less likely to suffer muscle strain, whereas individuals with
sedentary j obs tend to have weaker muscles and hence more susceptible muscular strain.
However, laborers are more susceptible to on-the-job injury due to the nature of their job
and workplace. F arm workers primarily involved in stoop-labor tasks are susceptible to

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Oriental Orthopedics H istory and Physical Examination 98

developing chronic low back problems. Sedentary workers usually have no need to
maintain high muscle strength levels and therefore may be susceptible to overstrain
injuries to muscles and joints, especially on weekends when they participate in activities
they are not used to. Certain habitual postures and repetitive strain induced by certain
occupational tasks may give an indication on the location and source of the problem.
Chief Complaint
This is the condition or reason that the patient is seeking help and is often referred
to as the "history of the present illness." This part of the history gives the patient an
opportunity to describe in their own words as to what is bothering them and the extent to
which the condition bothers them. Gathering this information is important from a
functional aspect which can help the examiner to determine if the patient' s expectations
for treatment are realistic.
Onset
Was the onset of the disorder slow or did it occur suddenly? Was there a specific
incident in which the body part was traumatized or injured, or did the condition start as
an insidious, mild ache, which then progressed to level of continuous pain? If inciting
trauma is involved it is often obvious about the location of the problem. Was the problem
caused by sudden trauma, or did it suddenly occur as result locking due to muscle spasm
and/or pain?
Provisional Diagnosis
If the patient has been treated by other practitioners or has been referred by a
practitioner it is important to note the findings of their efforts. This information can be
considered as a "provisional diagnosis." This provides an important starting point or
possible guideline for the history and examination efforts but the practitioner is still
obligated to determine the cause of the patient's problem. This effort may confirm the
provisional diagnosis or may result in an entirely different diagnosis or a deeper
understanding or explanation of the original diagnosis. The examination and assessment
may also indicate the need for further diagnostic imaging and testing.
Description of Symptoms
The patient is asked to describe the symptoms of their present complaint in terms of its
location and possible radiation patterns on the body, severity, possible impairment,
nature, and behavior. The patient is also asked about the characteristics of the joint in
question as well as additional comments or other symptoms
Location and Radiation
The patient is asked to indicate location of the problem of their body. This
information can also be noted on a figure representing the human body with an
appropriate key to indicate pain, paresthesia, numbness, or other conditions such as
atrophy. Patients often have difficulty in identifying various parts of the body of a figure,
thus it important for the practitioner to carefully review this information with the patient.
It is also necessary to indicate if the presenting symptoms radiates to other regions of the
body.
Severity
The patient is asked about the severity of their pain, which could be ranked on a
numerical range ( I 5 or I I 0). However, this is highly subjective and a magnitude line
- -

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Oriental Orthopedics H istory and P hysical Exam ination 99

(visual analog scale [VAS]) works just as well, if not better. The patient marks on a line
where they consider the intensity of their symptoms to lie. The line can represent the
range from none (no symptoms at all ) to worst (the most severe the problem gets).
Impairment
In making an assessment of permanent disability, the process usually involves
assigning numerical values derived from various guides such as the: AMA Guides to the
Evaluation ofPermanent Impairment, Fifth E.aition (Revised) or latest recognized edition.
For the purpose of the initial history it is only important to understand to what extent the
presenting symptoms are impairing normal function. This can also be assigned numerical
values ( 1 - 5 or 1 - 1 0), but a magnitude line (VAS) works just as well. The patient
indicates a relative position on the line between indicating where the symptoms are only
an annoyance to where they can be totally disabling.
Nature
The patient is asked about the nature of the symptoms which provides the
practitioner clues as to the possible tissue or structures involved in the problem. Table 4. 1
indicates a summary of types of pain responses that can be associated with certain tissues
and structures.

Table 4 . 1 . Pai n characteristics and possible related structures.

Pai n C haracteristics I nvolved Structure
Cramping, dull, aching Muscle
Dull, aching Ligament. joint capsule
Sharp. shooting Nerve root
Sharp, bright, lightning-like Nerve
Burn ing, pressure-like, stinging, ach i ng Sympathetic nerve
Deep, nagging, d u ll Bone
Sharp, severe, intolerable Fracture
Throbbing, diffuse Vasculature

Behavior
There are several questions of the patient on the behavior of their symptom in
terms of its constancy or lack there of, or when it occurs and what factors elicit a
response, to provide additional clues. Palliative factors that relieve the symptoms or
provocative factors that aggravate the problem are also noted. Rest, for example may
make the condition better whereas walking aggravates the problem. Does the pain get
worse as the day progresses? Does the problem show any diurnal variations (24 hour
pattern)? Is the condition highly irritable, mildly irritable, or not irritable at all?
Joint Characteristics
The patient is asked to describe the characteristic of the affected joint. This
provides important clues to possible pathology. Loose bodies in the j oint, for example
may cause it to catch or lock, while joints giving way may indicate tendon damage.
Additional Symptoms
The patient is then asked to describe any other symptoms or complaints not
addressed in the preceding inquiries. Often the patient experiences other symptoms that
may not seem related to anything obvious and they are encouraged to volunteer any items

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Oriental Orthopedics H istory and P hysical Examination 1 00

they want. Seemingly strange radiation patterns or referred pain patterns may not be
recognizable by the patient but these are valuable observations for the examiner. One
example may include bladder problems coincident with problems with the intrinsic
muscles of the foot since both areas are supplied by nerves emanating from S2, S3 and S4
levels. Think of pathology in terms of how the bodily function and organization are
viewed in Chinese medical theory.
Background and Associated Findings
The second part of the history involves a set of questions that are pertinent to obtaining
additional information on the extent and background on the present condition. Most of
these inquires can be accommodated by a preprinted form. However, in case of trauma
induced injury due usually to accidents, more detailed questions may be required. A good
chart file should have a general "additional notes/comments" form that can be inserted
anywhere to provide a means of recording additional information. An area on the page
for making simple diagrams or sketches or taping photographs is useful as well.
Status of Present I njury/Condition
The patient is asked about the date of the present inj ury or condition, or the date
of onset of the problem, and whether the symptoms are insidious or not. Dates of
hospitalization/surgery, other health care, treatments and the results should also be
obtained or indicated on preprinted form. Current medications being used for this
condition are listed as well as recent radiographs or diagnostic images. It is always
essential to avoid repeating diagnostic imaging procedures that involve exposure to
radiation so it is important for the patient or referring practitioner to provide existing
pertinent radiographs. Inquiry is also made on the present status of the condition in terms
of its characteristics of either being acute or chronic, constant or intermittent, better or
worse.
Nature and Mechanism of Inj u ry/Precipitating Events
It is important to fully understand the nature and mechanisms involved in inj uries,
or events that precipitated the condition. The patient is therefore asked detailed questions
with this regard. This is essential in order to understand the extent and likely damage to
the patient. In case of trauma induced problems, more detailed information is needed as
noted below for common categories of inj ury sources. Possible environmental factors,
toxic fumes or material, or radiation exposure should also be taken into account.
Condition of one's residence or work place that may be the source of the problem should
be explored. Things such as poor furniture that does not properly support the body while
seated (soft couches), environmental influences from air-conditioners or heaters, or lack
thereof should also be considered.
Slip and Fall Injury
This common category of episodes can produce significant trauma and even
permanent disabil ity. The key to the inquiry process is to determine which parts of the
body struck the floor, hard surface, or ground during the fall. Was a hand or leg extended
to break the fall and did this part receive damage as result. Did the coccyx or tailbone
strike first? The location and time of the fall are needed as well as what where the local
conditions where the slip and fall took place. Was the surface wet or dry? Was it windy,
raining, storming, or any other prevailing condition at the time. Did the fall involve a flat
or inclined surface or were stairs involved? In case of stairs, was the tailbone impacted

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 Oriental Orthopedics H istory and P hysical Examination 1 0 1

during the fall, i f not what body part was, and how far down the stairs was the fall. Was
the accident an up stairs falling? Was the fall from a ladder, and in which case did the
shoulder, head, face, back or bottom strike the ground or hard surface first? Was the fall
from a high region, such as a roof? If so, were safety restraints involved? What part of the
body impacted the ground or hard surface first?
Vehicular Incident
Automobiles accidents account for most of vehicular induced trauma although
motorcycle accidents produce significant inj uries, as do trucks, pickup trucks, airplanes,
hang gliders, bungee jumping, sky diving, boats, and trains. In case of a vehicle, was it in
motion or stopped at the time of impact? Were seat belts being used or was an airbag
deployed? Was the patient the driver or passenger, and if so what position were they
seated in the vehicle? Were they riding in the back of pickup truck or passenger on a
motorcycle? Did the vehicle cause the accident or was it struck by another? If struck,
what was the direction of the impact such as head-on, right side, left side or rear end?
What was the approximate speed of the vehicles involved? Did the patient's head strike
the steering column, dash board, rear view mirror, windshield, back head rest, roof, other
passengers or the driver? Did the vehicle roll over? Was the patient ejected from the
vehicle during the accident?
One of the common results of vehicular accidents and falls is the significant side
bending (lateral hyperflexion) of the cervical spine. This often results in a broken neck or
significant trauma to the spinal cord that some degree of motor impairment or paralysis
results. In less forceful accidents, excess flexing of the neck produces significant soft
tissue damage affecting the ligament, muscles and tendons in the neck and shoulders.
These later conditions frequently are resolved with proper management. However, these
traumas often lead to deterioration of the cervical spine that manifests some years later as
spondylitis. This involves osteophyte (bony outgrowth) formation develops where the
vertebral edges sustained trauma in the original incident. The neck is quite flexible and
any type of impact can result in hyperflexion, hyperextension, or excess side bending.
Often the victim is unaware of the extent the head and upper body is flexing back and
forth. Crashes from various directions can preferentially produce the following:
• Rear Ended - Hyperextension
•
Head On - H yperflexion
•
Lateral Crash - Hyper side-bending to the side being struck
Repeated Stress Injury (RSI) or Cumulative Trauma
The advent of modern work environments and the repetitive nature of many
industrial and clerical tasks produce a situation where injury eventually results. Stress
fracture of the fibula, eventually leading a complete fracture, in professional dancer is
one dramatic example. Others RSI cases may not seem so obvious since they involve
wrist, elbow, shoulder and neck injuries just from doing what seems to be ordinary tasks
like typing or operating a computer or a cash register. The slight trauma induced each day
is not measurable, but eventually the accumulated effect causes a problem. Often the
cause is simply performing the task too frequently, even though all other conditions are
ideal. But, more frequently RSI results because of a posture problem or an equipment
contribution.

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Oriental O rthopedics History and Physical Examination 1 02

Sometimes it is just working with the body and equipment interface not being
aligned or adjusted. In these types of injuries it is important to ascertain as much
information about the patient/equipment interface. What is the height of the desk,
machine or computer keyboard? If a computer monitor is involved, what is its location in
respect to the eye level of the patient? Is either the keyboard or monitor directly lined up
with the patient' s straight forward orientation or are they to one side or the other? What
side? Does the patient work with the telephone held under ear by bending the neck or
raising the shoulder? If involved in a repetitive agriculture or manufacturing process,
what are the rest periods in relation to production? Is the patient paid on an hourly or
piece-part basis? Are there environmental conditions in the work place that either makes
the problem worse or better? Are there unrealistic work demands placed on the
employees?
Treatment of this class of problem often involves remedial procedures to
improving posture or stability of the back. After the patient starts to recover it may be
necessary to analyze the worker/equipment interface to make certain that minimum stress
is placed on the body by assuring that arms, hands and fingers are held in optimum
positions to prevent recurrence of the problem.
Sports Injury
This is a common source of trauma for the young and adults of all ages. These
injuries can be quite serious and often have a significant impact, especially on the
professional athlete. It is important to understand the circumstances of incident that
precipitated the injury, including the conditions of the sports area (playing field, court,
track, swimming arena, etc.). Was the event recorded on film or video? It is also
important to understand the history and experience of the individual in participating in
the sport that provoked the inj ury. What is the training level of the patient, are they
experts or beginners, and were they using proper equipment? These questions are
essential to understand the extent of the injury and how best to formulate a treatment and
management plan.
Difficulties arise when the athlete has pressure or economic necessity to return to
action as soon as possible. Many other health conscious people are eager to get back on
their fitness program as soon as possible and these people may sometimes ignore the
activity restrictions recommended by the practitioner. It is essential that all such
recommended restrictions and limitations be properly documented in the patients file
under the treatment and management plan. The patient should be made aware that the
recommendations will be noted in their file.
Results of I njury
If the presenting condition involves an injury it is important to ascertain if it
resulted in deformity and whether it can be corrected, and if any disability resulted from
the trauma. The patient is asked about any:
•
loss in motion or strength and when this loss developed
• presence of swelling, edema, or bleeding and when these occurred as well

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Oriental Orthopedics History and Physical Exam ination 1 03

Relevant Past History and Family History

The patient is asked about their past health history, especially if they have had similar
problems. The health history of their families is also determined if the condition may
have potential familial component.
History of Similar Conditions
If the patient has a history of similar problems it is important to determine when
these occurred and the nature of the disorder. Inquiry is made concerning the treatment of
these prior conditions as well as there outcome. Also, it is important to determine if the
patient experienced other diseases relevant to their chief complaint.
Present Health Status
It is important to inquiry about the patient's health status irrespective of the
presenting complaint. Has there been in color changes in the affected limb or other areas
of the body? Ischemic changes resulting from restricted blood flow may include loss of
hair, abnormalities in nails of the foot and hand, and white brittle skin areas. Conditions
such as reflex sympathetic dystrophy (RSD)/ regional pain disorder, or Raynaud' s disease
can cause some of these symptoms. The patient is also asked about any bilateral spinal
cord symptoms, fainting, or drop attacks. Is the bladder function normal? Have there been
any episodes of dizziness, vertigo, or ataxia?
Health Problems of Immediate Family
Some diseases or conditions have a familial incidence. Hence, the patient is asked
about any family health history that may be related their present situation such as tumors,
cancer, heart disease, diabetes, allergies, and arthritis.
Relevant Past or Present Disease History
The patient is asked if they have any chronic or serious systemic or other
disorders that might affect the course of treatment. A check off table can be utilized to list
a range of diseases that either have an impact on musculoskeletal disorders or the general
health condition of the patient. The following list contains common problems that
influence the treatment musculoskeletal disorders and general health:

0 Arthritis D Hyperthyroid Syndrome 0 Osteomyelitis 0 Urticaria (hives)

0 Cancer 0 Parathyroid Disorder 0 Osteoporosis 0 Vascular
0 Diabetes Mellitus* 0 Multiple Sclerosis/ ALS 0 Rickets 0 Herpes**
0 Gout 0 Myasthenia Gravis 0 Rheumatoid Arthritis 0 Hepatitis
0 Hypothyroid Syndrome 0 Osteomalacia 0 Rheumatic Fever 0 H I V (date)
* I ndicate if juvenile or mature onset; **Indicate if either herpes zoster, oral or genital.

Lifestyle
Modem lifestyles contribute dramatically to wear and tear disorders as well as to
degenerative diseases of all types, many of which manifest as pain, chronic pain, and
musculoskeletal problems. Use of substances known to be counterproductive to
maintaining proper health is quite common. This behavior is often accompanied with bad
dietary habits, high stress jobs and financial worries, lack of proper exercise, and poor
sleeping habits. Many patients are uneasy about discussing or recognizing the
contribution that their daily habits have on the present condition or the impediment they

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Oriental Orthopedics H istory and Physical Examination 1 04

represent in fully resolving their present condition. Certain inquiries are made about
lifestyle habits and the patient is advised about those that have a possible effect on the
outcome of their condition.
Substance Use
The patient is asked about smoking habits, alcohol consumption, drugs and
medication, and use of steroids?
Dietary Habits
Inquiry is made about the dietary intake in terms normal, high fat content, or low
fat intake, as well food preferences, and vitamin and mineral supplementation.
Stress Level
Does the patient have a high, medium, or low stress occupation, or financial
burdens that cause stress?
Sleeping Habits
Poor sleeping habits contribute many disorders, including musculoskeletal
problems and depression. The patient is asked about their daily sleep patterns. This
problem is often aggravated for those individuals that work the night shift or those have
very disturbed sleeping habits that they think they are "night people."
Health Promotion/Fitness Activities
Does the patient regularly engage in physical activities, including exercise? Are
these directed developing strength, endurance, flexibility, or agility? Exercise routines
may have to altered or discontinued during the course of treatment for the condition.
Other movement and strength exercises may be required during the course of treatment or
rehabilitation. Also, does the patient engage in any health promotion activities?
Patient's Goals or Expectations of Treatment
As the final part of the history, the patient is asked about their view or thoughts on
the cause of their problem. In addition, it is important for the practitioner to gain the
patient' s confidence and their cooperation during both the examination and treatment
process. This is an opportunity for the patient to express what their goals and
expectations are for the outcome of the examination and treatment program. It is
important to provide the patient with a realistic estimate of expected outcomes of the
treatment program.

Observation and Examination

General observations and examination are considered objective signs and involves an
inspection of the patient' s vitality and function. Observation and directly looking at the
patient is an important aspect of the assessment process. The observation phase can also
include a screening examination to evaluate active, passive, and resistive movement of
either the cervical or lumbar spine, or a specific joint depending on the information
derived from the history. Observation involves gathering information on vital signs,
vitality, visible defects, alignment abnormalities, movement problems, and functional
deficits. Ideally, the observation activities start while the patient is in the reception area
where the seated posture can be noted. In addition, it is important to observe the patient's
gate as they are walking into the examination and assessment area. The examiner needs

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Oriental Orthopedics H istory and Physical Examination 1 05

to note how the patient is moving as well as their attitude, manner, willingness to
cooperate, and any overt signs of pain behavior.
The patient is advised on the importance of the observation phase with respect to
understanding their problem, and preparation for the more detailed examination that
follows. However, in order to make valid observations the patient needs to be adequately
undressed in a private assessment area. Male patients should wear shorts, while female
patients should wear a bra or halter top and shorts. Informing the patients on the need for
the state of undress should alleviate potentially embarrassing situations which can have
possible legal implications. The initial observation of the patient' s gate is only cursory.
However, if obvious problems such as a Trendelenburg or drop foot gait which are easily
noticed, a more detail examination can be made after the patient has undressed.
The examiner should compare both sides of the body simultaneously and should
be positioned to make best use of their dominant eye. The examiner is only looking at the
patient and does not require the patient to move. Also, the examiner does not palpate at
this time, except to locate a particular landmark or to determine if an area is either warm
or hot.

Vital Signs
This part of the obj ective data collection can be performed by an assistant, but the pulse
should be measured by the examiner. Measurement of signs includes: height, weight,
pulse rate, pulse characteristics, blood pressure, and temperature.

Observations and Inspection

These activities involves determining the patient's state of vitality, posture, gait,
abnormal movements, shape, utilization, conditions of the skin, and the use of assistive
devices.
Vitality
The patient' s vitality is reviewed with respect to a Chinese medical aspect which is valid
for orthopedic and any other condition. Is the patient cheerful, dull, worried, irritated, or
fearful? What is the patient' s responsiveness in terms of being cooperative, hyper­
responsive, or agitated or non-responsive?
Posture
Observation of posture involves looking at the patient while seated and then standing.
Seated posture provides more information on the patient' s vitality and also reflection of
abnormalities due to orthopedic conditions. Seated posture is assessed as being either
normal, slumped, guarded, or painful. Standing alignment is viewed from the front, side,
and back of the body. Normal anterior alignment exist when the tip of the nose,
xiphisternum, and umbilicus are in straight alignment. N ormal alignment of the lateral
view exists when the tip of the ear, high point of the iliac crest, and the ankle are in
straight alignment. Posterior alignment considers the alignment of the spine and
comparative alignment or height of the iliac crest on each side, and perhaps the
comparative alignment of the shoulders.

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Gait
By observing the patient' s gait. the examiner can determine if it is normal or has certain
characteristics indicative of specific problems. There are about fifteen pathological gait
conditions.
Movement
Here, the examiner is looking for unwanted and abnormal movements of the body or
extremities which are involuntary. Normal movement would indicate the absence of any
unwanted or involuntary movements, including: tremors, tics, chorea, athetosis,
myoclonus, asterixis, and tardive dyskinesia
Shape
Body shape is observed to classify the body type as being ectomorph, mesomorph, or
endomorph. The body is also examined to determine if the patient has any defonnities,
asymmetries, swellings, masses, or atrophy.
Utilization
This involves a cursory observation of some of the key concerns that are normally
examined later in detail under activities of daily living (ADL). Does the patient handle
clothing independently or require minimum or maximum assistance? How well does the
patient transfer from one situation to another, such as ability to get in and out of a shower
or tub, or get in and out of an automobile? This can be assessed in terms of normal,
guarded, painful, or impossible.
Skin
The skin is observed with respect to color or areas of discoloration, temperature, possible
lesions, and scars.
Aids
Inquiry is made concerning the patient's use aids including braces, orthotics, corsets,
shoe l ifts, and other assistive devices, including walkers. How long have they required
such aids and what conditions were they prescribed for?
Review of Sensory and Visceral Systems
In the presence of what appears to be involvement of sensory and visceral systems, or if
the patient includes these problems within their main complaints, it is important to review
these systems and determine if further examination may be required, perhaps by a
medical specialist in each particular area. Also, in making an assessment of impairment it
is necessary to factor in the contribution that the presenting problem or condition has on
the sensory and visceral systems. This evaluation can be accomplished by the use of a
special form that provides convenient tables which the patient reviews and checks off
present and former symptoms. The examiner must then go over the information to discuss
those items checked by the patient. The following area should be examined:
• Visual and Auditory Systems
• Nose, Throat, and Related Structures
• Respiratory System
• Cardiovascular System
• Digestive System

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Oriental Orthopedics H istory and Physical Examination 1 07

• Urinary and Reproductive Systems

• Mood and Behavior

Assessment P rocess
The final phase of the assessment process involves a detailed evaluation of the patient
from which a diagnosis is made in order to formulate a viable treatment plan. This effort
consists of a logically ordered examination, including the screening examination
previously discussed. Accurate assessment of the muscles, j oints, and vessels involved in
a problem is critical to isolating the cause or etiology of the problem. This relies on
standard diagnostic methods, however, it is also necessary to determine which particular
muscle, joint, tissue, and spinal elements are involved. A variety of approaches including
muscle and reflex testing as well as palpation of sensitive points and body regions are
involved.
The concept of diagnosis has been a matter of significant historical debate among
all health care professionals. This is especially true in acupuncture where training and
licensing standards are greatly varied from state-to-state. Additionally, different schools
of thought in Chinese education promote different methods of diagnosis. Some
practitioners use the full range of modes where a visceral problem might by eval uated
and treated strictly in terms of the Chinese view while orthopedic problems are viewed in
terms of both Western and Eastern concepts. It is a challenge to needling therapy to bring
the Chinese concepts into the mainstream of science-based understanding using modem
English to explain diagnosis and treatment so that any other health care professional and
the patients as well, can understand the process involved.
A differentiation of the derived information is performed to focus on the most
likely pathology involved in the presenting case. This diagnosis is critical in order to
determine the most efficient treatment plan or decide to refer the case for additional
studies. Guidelines for differential diagnosis are provided in Chapters 6 1 7 for those
-

particular regions that are covered.

An assessment is made each time the patient comes into the clinic for treatments.
This is necessary to evaluate the effectiveness of the treatment approach and determine if
the situation is improving, getting worse, or is static. It is important to understand the
patient's status before possible work, exercise, or physical activity restrictions are
removed or further restrictions are instituted. Assessment, over time, also provides a basis
for determining possible disability or impairment. The patient's status and progress, or
lack thereof, is always written down in the patient record.

Defin itions
The following definitions are relevant to diagnostic and assessment efforts:
Analysis
This represents the act of separating the clinical evaluation of a condition or disease into
component parts, in order to identify the clinical impression or determine the diagnosis.
Clinical Impression
A working hypothesis formulated from significant items in the history and the physical
findings; a tentative diagnosis; or a working diagnosis.

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Oriental Orthopedics History and P hysical Examination 1 08

Diagnosis
Represents a decision regarding the nature of the patient's complaint and also refers to
the art or act of identifying a disease or condition from its signs and symptoms.
Differential Diagnosis
The determination of which one of two or more complaints or conditions a patient is
suffering from by systematically comparing and contrasting their clinical findings.
Portal of Entry
This represents the first level of contact for the patient with an intake into the health
delivery system.
Utility
This refers to a significant benefit to both the patient and clinician resulting from a
reduction in uncertainty of the diagnosis, clinical impression, or analysis.

Releva nt Term inology

The practitioner always has certain responsibilities and obligation related to their
encounter with the patient. The most common of these are described as follows:
Necessity
Deriving a clinical impression or diagnosis, or diagnostic conclusion or analysis, is a
necessary outcome of the patient encounter. Responsibility of the practitioner does not
change because of the terminology used to describe clinical findings. The practitioner is
required to assess the patient upon presentation and respond to the clinical situation in a
manner consistent with the best interests of the patient, the practitioner's clinical
judgment, and the law of the jurisdiction in question.
Initial Responsibility
The initial responsibility of the practitioner is the immediate discernment as to the nature
and status of the patient on initial presentation. A practitioner should be expected to
recognize and respond to life-threatening situations in a manner consistent with the
patient's best interest. Some clinical signs that may indicate a need for medical
consultation include:
• Pale complexion, which may be accompanied with indigestion
•
Pain in left shoulder that radiates along medial aspect of the arm
• Severe unremitting pain
• Pain unaffected by position or medication
• Pain that returns shortly after having been reduced by needling therapy or other
modalities
• Severe night pain
• Severe pain with no history of trauma
• Severe spasm
• Possible psychologic overlay

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Oriental O rthoped ics H istory and Physical Exam ination 1 09

Subsequent Responsibility
After the initial evaluation has been completed the practitioner begins a series of
differentiations that result in many clinical decisions being implemented. This process is
not an end in itself, but merely designates suspected conditions that become the focus for
prognostic j udgments, further assessment, and patient management. Initiation of needling
therapy care, additional studies, and referral with or without continuing treatments as well
as cessation of needling therapy care is possible.
Terminology
Terminology used to describe a clinical impression, diagnosis, diagnostic conclusion, or
analysis should be consistent with appropriate usage in needling therapy and related
health care communities. If a practitioner is required to use specific terminology, or is
prohibited by law from the use of such terminology, then that legal requirement is the
guiding factor.
Content
Patients may have various conditions/symptoms/findings that result in a number of
unrelated clinical impressions. The primary clinical impression, diagnosis, diagnostic
conclusion, or analysis should address the chief complaint expressed by the patient.
Secondary diagnoses should be prioritized and addressed as needed and may be of greater
clinical consequence to the patient.
Information which constitutes the diagnostic data base should reflect a
classification scheme that consists of statements reflective of severity, region, and
organ/tissue involvement. In addition, this information should be related to the subjective
and/or obj ective findings of the patient, and be consistent with evidence-based criteria.
Process
When additional tests or studies are required to confirm the c linical impression,
diagnosis, diagnostic conclusion, or analysis, it is the practitioner's responsibility to
ensure that these are conducted in a timely fashion. Practitioners may perform such
procedures consistent with their qualifications and the law, or they may seek to have such
procedures performed by other qualified professionals.
Where procedures relevant to the diagnostic database process are not within the
qualifications or competence of a practitioner, the practitioner should make appropriate
consultations with others. The clinical impression, diagnosis, diagnostic conclusion, or
analysis, should be recorded in the patient' s record and qualified as to its certainty.
Dynamics
The clinical impression, diagnosis, diagnostic conclusion, analysis or assessment should
be a working hypothesis that may change over time, given additional information and/or
changes in the condition of the patient as noted in the clinical progress.
Communication
The practitioner should communicate the diagnosis, clinical impression, diagnostic
conclusion, analysis or assessment and its significance, to the patient in understandable
terms, and convey such findings to other providers or agencies as the patient requests and
consents to, or as required by law.

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Oriental Orthopedics H i story and Physical Examination 1 1 0

Examination Principles
The examination process requires certain tests that can possibly cause exacerbation of the
patient' s problem. Therefore the examination follows a fixed logical sequence to make
certain that an early group of tests do not adversely affect the outcome of subsequent
tests. For example, resistive muscle testing can possibly increase discomfort levels, so
these tests must follow the active and passive movements which have a lower probability
of increasing the patient' s symptoms. Palpation of the joints and muscle, which is often
conducted early in a Chinese medical examination, is scheduled as the last test since this
activity can possibly aggravate the patient's pain condition in the affected joints. The
examination sequence is as follows:
• Examination of movement
o Active
o Passive
o Resistive
• Special tests
• Reflexes and cutaneous distribution
• Joint play movement
•
Palpation of affected area(s)
• Diagnostic imaging
Patient Consent
The examination portion of the assessment process involves touching the patient, which
may in some situations cause the patient discomfort. Therefore, the examiner must obtain
a valid consent to perform the examination before it begins. A valid consent has to be
voluntary, must cover the procedure being done (informed consent), and the patient must
be legally competent to give consent. The examiner must carefully tell the patient the
purpose of the test and what is going to done during the examination process.
Examination Guidelines
The examination is used to confirm or refute the provisional diagnosis or clinical
impression derived from the history and observation. The examination involves a
systematic effort of looking for a consistent pattern of signs and symptoms that leads to a
differential diagnosis. Special care should always be taken in the situation where the
condition of the joint is acute or irritable. The following guideline need to be considered
in the examination effort:
The normal side is tested first unless bilateral movement is required. By testing
the unaffected side first the examiner establishes a baseline for normal movement for
joint in question. This also demonstrates to the patient on what to expect during the
examination. This should reduce apprehensions on the part of the patient when the
injured or affected joint is tested.
Active movements on the part of the patient are done first at which time range of
motion (ROM) measurements are made. Passive movements by the examiner follow the
active movements which are then followed by resisted isometric movements. This allows

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the examiner to have a good idea of what the patient thinks he or she can do before the
structures are fully tested.
When possible, any painful movements are conducted last to prevent overflow of
painful symptoms to the next movement, which in fact may be pain free.
Overpressure to measure end feel during passive movement is applied only with
extreme care to prevent exacerbation of symptoms in the situation where the active ROM
is not full.
If the ROM is full during active movements overpressure may be carefully
applied to determine the end feel of the joint. In this situation, the passive movement test
is often not needed.
Each active, passive, or resisted isometric movement may be repeated several
times or sustained for a certain time. This is done to determine if symptoms increase or
decrease, whether a change in movement pattern results, if there is an increase in
weakness, or whether there is a possible change in vascular insufficiency. Assessing
repetitive or sustained movements or resistance is important for those individuals that
have complained that their symptoms are altered by repetitive motion or by sustained
postures.
Resisted isometric movements are done with the joint in the resting or neutral
position to minimize stress on the joint capsule (inert tissues). This is done to make
certain that any symptoms that are produced by the movement are likely to be caused by
the contractile tissue.
Although the amount of opening is important for ligamentous and passive range
of motion (ROM) tests, the quality (end feel) of the opening is important as well.
When testing ligaments, the examiner gently applies and repeats the appropriate
load several times. The load is increased up to but not beyond the point of inducing pain.
This allows demonstration of maximum instability without inducing muscle spasms.
When testing muscles supplied by a particular myotome each contraction should
be held for a minimum of 5 seconds to see if weakness results. Myotomal weakness takes
time to develop.
A detailed examination often involves stressing different tissues. The examiner
needs to alert the patient that he or she may experience possible exacerbation of their
symptoms as a result of the assessment process. Otherwise the patient may think that the
initial treatment made their problem worse and may be apprehensive to return for further
treatment.
If the examiner has found, at the end of the examination that the patient has
presented with unusual signs and symptoms or if the condition seems to be beyond the
examiners scope of practice, he or she should not hesitate to refer the patient to an
appropriate health care professional.
Scanning Examination
Orthopedic examinations concentrate on the joints of the body, their movements, and
stability. All appropriate tissues that comprise the joint and their function need to be
examined in detail to delineate the affected area. Tension, stretch, or isometric

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Oriental Orthopedics H istory and Physical Examination 1 1 2

contractions are applied to specific tissues to produce either normal or appropriate

abnormal responses. These results allow the examiner to determine the site and nature of
the symptoms and observe the patient' s subjective reaction to these symptoms. The
examination indicates if these activities provoke or change the patient's perception of
their pain. When asked about changes in pain, the patient needs to be clear about changes
in symptoms and not confuse movement induced pain with a query about their already
existing pain. Hence, the examiner is looking for two sets of information: 1 .) what the
patient feels (subjective) and 2.) responses that can be measured by the examiner
(objective).
By necessity, the examination is very extensive. In the upper part of the body it
begins with the cervical spine, includes the temporomandibular joints, scapular areas,
shoulder, and upper limbs to the fingers. In the lower body the examination starts at the
lumbar spine and continues down to the toes. This phase, often referred to as a
"scanning" or "'screening" examination, may not be essential if there is a history of
trauma to a specific joint. The scanning orthopedic examination should be considered
when it is not clear where the primary injury is located, especially if it not obvious from
the history and observation as to where the problem lies. The scanning examination is
considered when:
• there is no history of trauma
• there are radicular signs
• there is trauma with radicular signs
• there is altered sensation in a l imb
• there are spinal cord signs
• the patient presents with abnormal patterns
• there is suspicion of psychogenic pain
This general screening examination includes:
• Possible movement assessment of either the cervical spine, lumbar spine, or
selected peripheral joint(s) scan
• Special orthopedic tests
• Myotomes
• Sensory tests
• Reflexes
•
Identification of areas requiring further tests
• Recommendation for diagnostic imaging/laboratory tests
• Initial clinical impression

Exami nation of S pecific Joints

A systematic and unchanging approach is used in the examination effort to further
evaluate clues uncovered in the history and observation. If the history clearly indicates a

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Oriental Orthopedics History and Physical Examination 1 1 3

specific problem such as a disc lesion or a radiculopathy, the examination needs to be

detailed concerning all the tissue that might be affected by either of these conditions. A
brief examination can be used for all of the other joints to exclude contradictory signs.
However, if the history indicates a possible muscle lesion, then it likely that pain will be
provoked upon movement of the affected joint. But once again, all the other structures
that appear normal are not excluded from the examination in order to eliminate possible
contradictory signs.
During movement testing, the examiner must note whether joint restriction or pain
predominates. If pain predominates, the condition may be more acute and gentler
assessment and treatment is required. If the signs of restriction predominate, the condition
may be subacute or chronic and a more vigorous effort in the assessment and treatment
may be indicated.
Active Movement
Active or physiological movements are dynamically performed by the patient. Since this
involves use of the patient's voluntary musc1es there is a combined effect of observing
and testing range of motion (ROM), muscle control and strength, and the wi1lingness of
the patient to perform the movement. The physical impediment at the end of active
movements is sometimes referred to as the "physiological barrier." Active movements
involve participation of contractile, inert, and nervous tissues. One or more bones (rigid
structures) participate when active movements take place. Hence, all attached or nearby
structures to the bone move as well.
Active movement usually not performed during fracture healing or in the case of
newly repaired soft tissue healing. Must note which movements elicits pain or increases
pain or other symptoms and their quality. An acute irritable joint may manifest with
intense pain during small unguarded movements. It may not be possible to test all
movements when the symptoms are acute and highly irritable.
Examiner should observe the smoothness and rhythm of movement, painful arcs, and
any limitations or pain. Also, need to look for trick movements or cheating where patient
uses accessory muscles or posture to compensate for weakness in a target muscle.
Abnormal active movements can be the result of:
•
Pain, spasm, muscle weakness, or paralysis
•
Joint-muscle interaction, tight or shortened tissue, change in length-tension
relationships, or modified neuromuscular factors
The examiner usually performs active movements once or twice in each direction
while noting any problems or possible cheating. When patient reports pain or difficulties
in any specific movement, these should be tested last to prevent painful symptoms
overflowing to other movements. If presenting problem manifests due to sustained
posture or repetitive motions, these are repeated in order to induce symptoms. Depending
on the history, movements can be repeated 5 - 1 0 times or sustained for 5 - 30 seconds
until symptoms manifest.
Standard movements for each joint typically lie within the cardinal orientation
planes. If patient reports problems outside these single plane movements symptoms may
be elicited by multiple plane movements, or by repeated, quicker, or compressive

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Oriental Orthopedics H istory and Physical Examination 1 1 4

movements. In situations where the joint is not too reactive, overpressure might be
carefully applied at the end of active ROM. If the end feel is normal and no symptoms
were produced, the examiner may forego passive movements for this joint.
Passive Movement
In passive movement the joint is put through a range of motion by the examiner while the
patient is relaxed. The movement must proceed through as full range of movement
possible. Although the movement must be gentle, the examiner must find out whether
there is any limitation of range (hypomobility) or excess range (hypermobility) and, if so,
whether it is painful . Hypermobility joints tend to be more susceptible to ligament sprain,
joint effusion, chronic pain, recurrent inj ury, tendonitis resulting from lack of control, and
early osteoarthritis.
Hypomobile joints are more susceptible to muscle strains, pinched nerves
syndromes, and tendoniti s resulting from overstress. For any given individual, evidence
of either a hypermobility or hypomobility condition does not necessarily indicate
pathology. The examiner should also attempt to determine the cause ofjoint limitation
(e.g., pain, spasm, adhesions, or compression) and the quality of movement (e.g., lead
pipe, cogwheel). The feel at the end of range of each passive motion is observed in order
to help understand the pathology present. There are three to four standard normal end
feels and five to six patterns considered abnormal end feels.
Normal E nd Feel
Hard (bone to bone):Characterized by a painless, abrupt, hard stop to movement
when bone contacts bone, such as occurs in hyperextension of the knee joint or in case of
passive elbow extension when the olecranon process contacts the olecranon fossa.
Soft (soft tissue apposition):Occurs when two body surfaces come into contact
that result in tissue compression, such as occurs in passive flexion of the knee when the
posterior aspects of the leg and thigh come together, or in the case of hip flexion where
the thigh comes in contact with the abdominal region.
Provides a firm or springy sensation that has some
Firm (soft tissue stretch) :
give when muscle is stretched such as occurs when passive ankle dorsiflexion, performed
while the knee is extended, is stopped by tension in the gastrocnemius.
Firm (capsular tissue stretch): Characterized by a firm arrest to movement with
some give when the ligaments of the joint capsule are stretched, such as occurs in passive
shoulder external rotation. Feeling is similar to stretching a piece of leather.
Abnormal End Feel
Hard (bone to bone): Indicated by abrupt hard stop to movement when bone
contacts bone, or a bony grating sensation when rough articular surfaces move pass each
other. This occurs in situations where a joint may contain either loose bodies,
degenerative joint disease, dislocation, or fracture.
Soft: Produces a boggy sensation indicating possible synovitis or soft tissue
edema.
Firm (tissue and capsular):A springy sensation or a firm arrest of movement
with some give, indicating either muscular, capsular, or ligamentous shortening.

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Muscle Spasm: Is characterized by a firm sudden stop to passive movement that

is often accompanied by pain and is indicative of acute or subacute arthritis, the presence
of a severe lesion, or fracture. If pain is absent, a spasm at end feel may indicate a lesion
of the central nervous system with resultant increased muscular tonus.
Empty: This end feel is detected when considerable pain is produced by
movement, which is almost impossible because of the pain, although no real mechanical
restriction is detected. Examples might include an acute subacromial bursitis or a
neoplasm. It is difficult for the patient to describe the empty pattern since no muscle
spasms are involved.
Springy Block: This is similar to a tissue stretch, and occurs where one would
not expect it to occur; it tends to be found in joints with menisci. There is rebound effect,
and it usually indicates and internal derangement within the j oint. A springy block might
be found associated with knee joint with a torn meniscus when it is locked or unable to
go into full extension.
Capsular Patterns
With passive movement the full range of motion must be carried out. A short, too­
soft movement in the mid range will not achieve the proper results. In addition to looking
at the end feel, the examiner must look at the patterns of limitation. These result due to
problems that arise in the joint capsule structure which can include a variety of
pathology. A predictable set of recognizable patterns are manifest, some of which are
summarized in Table 4.2.

Table 4.2. C a psular patterns for selected joints.

J oi nt Pattern of Lim itation
Temporoma nd ibu lar Limitation in opening mouth
Cervical Spine Side flexion a nd rotation equally limited extension
Sternoclavicular and Pain at the extremes of range
Acromioclavicular
Shoulder Given a limitation of abduction, there will be a greater
percentage loss of externa l rotation and a lessor percentage
loss of internal rotation
Elbow More limitation of flexion than extension
Wrist Equal lim itation of flexion and extension
Thumb and Fingers More limitation of flexion than extension
Thoracic Spine Side flexion and rotation equally limited, extension
Lumbar Spi ne Side flexion and rotation equally limited, extension
Hip Gross limitation of flexion, abduction, and internal rotation;
slight limitation of extension; and little or no limitation of
external rotation
Knee Gross limitation of flexion; slig ht limitation of extension

Noncapsular Patterns
The examiner must be aware of limitations in movement which do not correspond
to classical capsular patterns for a particular joint. These are called noncapsular patterns.
In the shoulder for example, abduction may be restricted without any or, at least little,
restriction in rotation. Thus, the total capsular pattern is absent. Possibilities for the

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Oriental O rthopedics H istory and P hysical Examination 1 1 6

observed difference could be ligamentous adhesions in which only part of the capsule is
involved. Other causes of noncapsular patterns include internal derangement of the joint,
which the elbow and knee joints commonly exhibit. Loose bodies within the joint are
another category of possible causes in restricting motion.
I nert Tissue
Noncapsular patterns are also apparent in the situation that restricted motion is the
result of inert tissues. This can manifest with pain in both active and passive movement in
the same direction, whereas resisted isometric movements are not painful. Inert tissue
refers to all tissue that is not considered contractile. Patterns involving inert tissue may
include:
•
Pain and limitation of movement in every direction. The entire joint is affected
in this pattern, indicating arthritis or capsulitis.
•
Pain and limitation or excessive movement is some directions but not others,
such as in a ligament sprain or local capsular adhesion.
•
Limitation of movement that is pain free, often with abnormal bone-to-bone
end feel. This usually indicates symptom-free osteoarthritis.
•
because there is no inert tissue lesion in the
Pain free full range of motion
movement being tested, however, there may lesions in the other directions or
around the joint.
Resisted Isometric Movement
Resisted isometric movements are tested last in the examination of the joints. Principal
goal is determine the condition of the muscles and to identify involved myotomes. These
techniques involve strong, static (isometric) voluntary muscle contraction. If movement is
allowed to occur at the joint permitting inert tissue around the joint to move as well, it
will not be clear then if pain that results is due contractile or inert tissue. A neutral or
resting position (loose pack position) the joint is selected to minimize tension on inert
tissue (See Table 4.6). The patient is asked to strongly contract the muscle while the
examiner prevents movement by resisting the patient ' s effort. Isometric resistive tests are
first tested in anatomical positions of full gravity reacting on the patient's body. In case
of significant weakness, the test is conducted that zeros out the influence of gravity. The
purpose of this test is to determine which myotome is involved in the problem, and to
determine the degree weakness of the affected muscle or muscles.
M uscle Strength Grading
Muscle strength can be graded 5 0 with 5 being normal, or given a letter grade
-

with the letter "A" representing normal strength (See Table 4.3). In case of weak
contractions it is important to determine if it is due either to pain or patient's fear or
unwil lingness. Muscle weakness may be due to:
•
upper motor neuron lesion
•
inj ury to a peripheral nerve
•
pathology of neuromuscular j unction
•
muscle tissue problems

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Oriental Orthopedics H istory and Physical Examination 1 1 7

Table 4 . 3 . Use of number (No.) or l etter grade to ind icate m uscle strength under gravity
and with g ravity eliminated
N o. Letter Description of Range of Motion
Against g ravity tests
5 N ( normal) Full available ROM against gravity and maximal resistance
4 G (good) Full available ROM aga inst gravity and moderate resistance
4- G- Greater than one-half of available ROM against gravity and moderate
resistance
3+ F+ Less than one-half of available ROM against gravity and moderate
resistance
3 F (fair) Full range of ROM aQai nst g ravity
3- F- Greater than one-half of available ROM against gravity
2+ P+ Less than one-half of available ROM against gravity
Gravity-eliminated tests
2 P (poor) Full available ROM with g ravity eliminated
2- P- Greater than o ne-half of available ROM with gravity eliminated
1+ T+ Less than one-half of available ROM with gravity eliminated
1 T (trace) Absence of ROM with gravity eliminated, with palpable or observable flicker
of m uscle contraction
0 None Absence of ROM with gravity eliminated without palpable or observable
flicker of muscle contraction

Contractile Tissue
Resisted isometric testing examines possible problems of the contractile tissue,
including muscles, tendons and attachments. It is further needed to examine the muscle
tissue involvement which can be facilitated by considering both the strength and degree
of pain associated with movement. Often the passive movements are fuJI and pain free,
except perhaps at the end-feel. The following conditions of pain and strength are noted:
•
Strong and Pain Free: Indicates no lesion in the muscle being tested, regardless
of how tender the muscle may be when touched. Muscles function painlessly and
are not source of patient' s discomfort.
• Strong and Painful: Indicates a local lesion of the muscle or tendon, such as
first- or second-degree muscle strain. Usually there is no primary limitation in
passive movement, except in case of gross muscle tear with hematoma and
muscle spasm.
•
Weak and Painful: Indicates a severe lesion around that joint, such as a facture.
Weakness results from reflex inhibition of muscles around joint.
•
Weak and Pain Free: Indicates a rupture of a muscle (third-degree strain) or
involvement of the nerve supplying that muscle.
Tonic and Phasic Muscles
One view is to consider that postural muscles (tonic) tend to develop tightness and
contractures while the phasic muscles develop weakness. Thus the examiner carefully
notes the range of motion available (active movements) as well as strength (resisted
isometric movements) when testing the muscles. A general grouping of primary postural
muscles and phasic muscles are noted as follow with all others considered neutral:

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Oriental Orthopedics History and Physical Examination 1 1 8

•
Postural (tonic): soleus, rectus femoris, thigh adductors, hamstrings, iliopsosas,
tensor fasciae latae, trunk erectors, quadratus lumborum, pectoralis major (sternal
portion), upper trapezius, levator scapulae, and triceps
•
Phasic: tibialis anterior, gastrocnemius, vastus medialis, vastus lateralis, gluteal
muscles, abdominal muscles, upper limb flexors, lower stabilizers of the scapula,
and deep flexors of the neck.

Functional Assessment
The key to bodily movements is to perform all normal functions of daily living. Hence,
some degree of functional assessment of the affected joint(s) should be performed during
the examination process. This could simply involve observation of certain activities of
the patient or may involve a detailed task analysis effort using certain tests or information
derived by means of a questionnaire. Functional assessment is essential to determine the
impact that the condition or injury has on the patient's daily life, including their sex life.
In addition to being an annoyance, functional impairment may be completely disabling.
Functional assessment testing that should be considered when appropriate
includes self care activities such as daily hygiene (e.g., showering, bathing, shaving, and
combing hair), going to the bathroom, dressing, walking, and eating; hobbies or
recreational activities such as gardening, playing a musical instrument, reading, sewing,
going to movies, and watching television.

Special Tests
After the examiner has completed movement evaluation, special tests may be performed
on the target j oint. These joint-specific special tests provide additional information to
understand the type of disease, condition, or injury affecting the join in question. There
are perhaps some 600 specialized orthopedic tests have been devised over the years to
provide additional means to evaluate the status of major joints or neurological
involvement. These tests are mostly used to sort out nerve root or radicular involvement.
They are usually designed to either provoke or lessen presenting symptoms. Several
different tests are discussed in Chapters 6 1 7 that are appropriate to each specific region
-

of the body.

Reflexes and Cuta neous Distribution

The deep tendon, superficial, and pathological reflexes are tested after completion of any
special orthopedic tests, to obtain an indication on the nerve or nerve root supplying the
reflex. The reflex tests are not performed if it is determined that the neurological system
is normal.
Deep Tendon Reflexes
Deep tendon reflex testing is a familiar routine that usually involves sharply striking a
particular tendon with a small rubber hammer to provoke a spinal mediated jerk response.
This provides information on the various neural pathways involved and to a lesser extent
the health of the muscular tissue. The most common deep tendon reflexes tested are
summarized in Table 3 . 7 for the temporomandibular joint and brachial plexus and in
Table 3 . 8 for the lumbar and sacral plexuses. The ancient Chinese employed reflex
testing as well by snapping or striking certain tendons, joints, or particular critical
neurovascular nodes (acupoints). Reflex testing is used to assess muscular dysfunction,

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 Oriental Orthopedics H istory and Physical Examination 1 1 9

isolate particular nerve roots, and also to help differentiate between various symptoms.
The speed and magnitude of the particular reflex is used to judge the condition and its
prognosis. Deep tendon reflexes can be graded from 0 - 4 as noted in Table 4.4.

Table 4.4. Grading deep tendon reflexes

Grade Reflex Qual ity Possible I ndication
0 Absent Lower motor neuron
1 Diminished Lower motor neuron
2 Average Normal
3 Exaggerated May ind icate u pper motor neuron problem
4 Clonus. very brisk May ind icate u pper motor neuron problem

Superficial Reflexes
Superficial reflexes are stimulated by stroking particular regions of the skin. A sharp
object is used that doe snot break the skin. Some degree of practice is needed to develop
proficiency in testing superficial reflexes. Expected responses are noted in Table 3 .9.
With respect to superficial reflexes, abdominal and cremasteric reflexes may be absent in
both upper and lower motor neuron disorders.
Pathological Reflexes
Pathological reflexes (See Table 3 . 1 0) may indicate possible lesions in upper motor
neurons if they are present on both sides. If they are present only one side, this may
indicate problems in the lower motor neurons. Voluntary withdrawal may be seen in
normal individuals if too much pressure is used to stimulate the reflex. In order to be of
clinical significance there should be an asymmetric response to the bilateral reflexes,
unless there is a central lesion.
Sensory Examination
This involves a scanning examination to check the cutaneous distribution of peripheral
nerves and dermatomes associated with the target joint to determine:
• Extent of sensory loss and if result of nerve root or peripheral nerve lesions, or
compressive tunnel syndrome
•
Degree of functional impairment
•
State of nerve recovery after injury or repair

Joint Play Movements

There is a small ROM in synovial and cartilaginous joints beyond that which is achieved
by active movements. This movement is called joint play or accessory movement which
is not under voluntary control. These movements are necessary for pain free full ROM
joint function. Joint dysfunction usually signifies a loss ofjoint play movement (See
Table 4.5).
Assessment ofjoint play is an essential part of the examination. Ifjoint play is
found to be decreased or absent, it needs to be restored before full voluntary movement
can be accomplished. Joint play movements may be similar to same movement as
examined during passive movements or ligamentous testing.

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Oriental Orthopedics History and Physical Examination 1 20

Table 4.5. Grad ing accessory joint movement

Grade Joint Status
0 Ankylosed
1 Considerable hypomobility
2 Slight hypomobility
3 Normal
4 Slight hypermobility
5 Considerable hypermobility
6 Unstable

Loose-Packed Position
The examiner places the joint in its resting or loose-pack position in order to test joint
play. The loose-pack position is any position of the joint other than the full congruent
close-pack position, where the joint capsule is lax. The position of least stress and least
congruency of joint surfaces and the greatest laxity of the capsule and ligaments is the
resting position of the joint. The loose-pack positions may be used to prevent joint pain
when testing isometric muscle strength in the region of a painful joint. This reduces
tension on the joint capsule and ligaments and decreases intra-articular pressure. The
loose-pack (resting) positions of selected joints are noted in Table 4.6.
Close-Packed Position
When a j oint is in the close-packed position the joint surfaces are fully congruent. I n this
position maximal tension exists in the joint capsule and ligaments; the joint surfaces are
firmly pressed together and the joint surfaces cannot be pulled apart using traction.
The close-packed position needs to be avoided when testing muscle strength. The
patient can lock and hold the joint in position against resistance in the presence of a weak
prime mover resulting in an inaccurate strength test. The practitioner should be careful of
close-pack positioning at the elbow, knee, and ankle j oints. Close-pack positions are
noted in Table 4.6 for selected joints.

Palpation
Palpation for tenderness plays no part in the initial phase of the assessment since referred
manifestations of tenderness and pain can be misleading as to its exact source. Hence,
palpation is not considered until the tissue at fault has been identified and the extent of
the lesion within that tissue determined. Palpation is then only considered if the affected
tissue is superficial and can be easily touched with the fingers. Palpation has long been an
essential Chinese assessment tool which requires much practice to be effectively applied.
Signs of tenderness, along with results of the movement and neurological assessment, do
provide the examiner sufficient information to identify the likely ligament or area of
tearing or bruising.
Effective palpation requires a systematic approach to make certain that all
structures are properly examined. Procedure should start at one location and works into
surrounding tissues ascertain normalcy or pathological involvement. The examiner starts
slowly by carefully applying light pressure and then applying deeper pressure feeling for
pathological conditions and tissue changes. Examiner palpates the uninvolved side first to
determine how the normal side feels, and to demonstrate what the patient to expect
during the examination.

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 Oriental Orthoped ics H istory and Physical Examination 1 2 1

The area being palpated needs to b e relaxed and hence the body part may need to be
supported. The following areas and conditions are examined during the palpation effort.

Table 4.6. Loose-packed and close-packed and positions of selected joints

Joi nt(s) Loose-Packed (resting) Position Close-Packed Position
Facet (spine) M idway between flexion and extension Extension
Temporomandibular Mouth slightly open Clenched teeth
Glenohumeral 55" abduction. 30" horizontal adduction, Abduction and external rotation
rotated so that the forearm is in the
transverse plane
Acromioclavicular Ann resting by side, shoulder girdle in the Ann abducted 30"
physiological position
Sternoclavicular Ann resting by side, shoulder girdle in the Maximum shoulder elevation
physiological position
Ulnohumeral (elbow) 70" elbow flexion. 1 o· forearm supination Extension
Radiohumeral Full extension. full supination Elbow flexed 90" forearm supinated s·
Proximal radioulnar 70" elbow flexion. 35" forearm supination s· supination
Distal radioulnar 1 o· forearm supination s· supination
Radiocarpal (wrist) M idway between flexion-extension (so Extension with ulnar deviation
that a straight line passes through the
radius and third metacarpal) with slight
ulnar deviation
First Midway between abduction-adduction and Full opposition
carpometacarpal flexion-extension
Metacarpophalangeal Slight flexion Full flexion
(fingers)
Metacarpophalangeal Slight flexion Full opposition
(thumb)
Interphalangeal Slight flexion Full extension
Hlp 30" flexion, 30" abduction, and slight Full extension, internal rotation and
external rotation abduction
Knee 25" flexion Full extension and external rotation of
the tibia
Talocrural (ankle) 1 o· plantar flexion, midway between Maximum dorsiflexion
maximum inversion and eversion
Subtalar Midway between extremes of inversion Full supination
and eversion
Midtarsal Midway between extremes of ROM Full supination
Tarsometatarsal Midway between extremes of ROM Full supination
Metatarsophalangeal Neutral Full extension
Interphalangeal Slight flexion Full extension

Tissue Tension
Regions are examined for effusion (escape of fluid into a part or tissue), tight and spastic
muscles, and flaccidity.
Tissue Texture
Distinguish texture in terms of small bands of contracted muscular fibers, and fiber
direction.
Shape
Identify differences in shapes, structures, and tissue types, including bones, to detect any
abnormalities.
Tissue Characteristics
Note tissue thickness and whether it is resilient, pliable, and soft, and if there is an
obvious presence of swelling.

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Oriental Orthopedics History and Physical Exam ination 1 22

Joint Tissue and Tenderness

Assess joint tenderness by applying firm pressure to the j oint. Application of pressure
always performed with care, especially during the acute phase. Examiner should also
determine pathological conditions of tissue around the joint, noting any thickening or
other signs.
Temperature and Moisture
Note possible variations in temperature often by using the back of the hand, and also
comparing temperature of the uninvolved side. Also, feel for dryness or the presence of
excess moisture.
Pulses
Pulses tested for rhythm and strength to determine circulatory sufficiency, including
palpation of the carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and
dorsalis pedis locations.
Tremors and Fasciculations
Tremors are the result of agonist and antagonist muscle groups contracting at the same
time to cause rhythmic movements of a j oint. Foot tremors can be the result of the tibialis
anterior and posterior contracting at the same time, which the Chinese attribute to the
stomach related muscular distribution. Signs of fasciculations indicate the involvement of
several muscle cells innervated by a single lower motor axon.
Abnormal Sensation
Note any abnormal sensations including diminished (dysesthesia) or increased
(hyperesthesia) sensations or lack of sensation (anesthesia). Also note possible j oint
crepitus, creaking, or snapping of tendons.
Skin and Subcutaneous Tissue
Note skin lesions, scars, discoloration, ulcers, nodules or lumps under the skin and
deformities.
Sensitive Locations
Chinese orthopedics places importance on palpating sensitive or painful spots which
develop (sensitive or trigger points) which indicate possible dysfunction or pain in
muscles above or below the spot. Distribution of sensitive spots or tight muscular tissue
bands is consistent with the Chinese muscular pathways. These small sensitive regions
can be treated using most modalities, including cupping, massage and pressure. Normally
these locations are not needled unless the area is coincident with a known neurovascular
node.
Muscles and Tendons
Consider palpation along the longitudinal Chinese muscular distributions to determine if
problem mainly related to a particular distribution. Isolating problem area to particular
distribution provides clue to treatment using acupuncture.

Diagnostic Imaging
Special imaging, instrumentation testing and laboratory tests may be necessary to confirm
the initial clinical impression. Practitioner needs to determine if imaging and laboratory
tests are essential to confirm the diagnosis or if there is a suspicion of more serious
pathology that requires attention. The following procedures may be considered:

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Oriental O rthopedics H istory and P hysical Examination 1 2 3

Plain Film Radiography (X-rays)

Radiography or plain film X-ray is the oldest and most frequently used form of medical
imaging. Discovered on November 8, 1 895 by the German physics professor Wilhelm
Conrad Roentgen ( 1 845- 1 92 3 ), X-rays can produce diagnostic images of the human body
on film or digitally on a computer screen.
X-ray imaging is the fastest and easiest way to view and assess broken bones,
such as skull fractures and spine injuries. At least two images (from different angles) are
taken and often three images are needed if the problem is around a joint (knee, elbow or
wrist). X-rays also play a key role in guiding orthopedic surgery and in the treatment of
sports-related inj uries. X-ray may uncover more advanced forms of cancer in bones,
although early screening for cancer findings requires other methods.
Advantages
Plain x-rays are still the primary means of looking for trauma to bones. They have
the advantages of low cost, wide availability, and good anatomic resolution. X-rays do
not give a good image of soft tissue structures (muscles and ligaments). The actual
reading of radiographs and other diagnostic imaging results is a science in itself and may
be performed by any knowledgeable practitioner with critical evaluation by a radiologist.
C ommon Uses
Probably the most common use of bone radiographs is to assist the physician in
identifying and treating fractures. X-ray images of the skull, spine, joints and extremities
are performed every minute of every day in hospital emergency rooms, sports medicine
centers, orthopedic clinics and physician offices. Images of the injury can show even very
fine hairline fractures or bone chips, while images produced after treatment ensure that a
fracture has been properly aligned and stabilized for healing. Bone x-rays are essential
tools in orthopedic surgery, such as spinal repair, joint replacements or fracture
reductions.
X -ray images can be used to diagnose and monitor the progression of
degenerative diseases such as arthritis. They also play an important role in the detection
and diagnosis of cancer, although usually computed tomography (CT) or MRI is better at
defming the extent and the nature of a suspected cancer. On regular x-rays severe
osteoporosis can be visible, but bone density determination for early loss of bone mineral
is usually done on specialized, more sensitive equipment (See discussion on Bone
Densitometry below).
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging (MRI) is a technique that uses a magnetic field and radio
waves to create cross-sectional images of the head and body. The process produces
detailed, clear images of soft tissue (not detected by X-ray) to identify and diagnose a
wide range of conditions. MR1 cannot be used for people with implanted or other metallic
foreign bodies not firmly fixed to bone but is reportedly safe with prosthetic joints and
internal fixation devices. It is often preferred over myelography for the assessment of
disk disease because it is noninvasive. Its principal disadvantages include cost and lack of
availability. There are no known harmful effects from exposure to the magnetic field or
radio waves used in making MRI images.

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Oriental Orthopedics H istory and P hysical Exam ination 1 24

The MDI data can be used to create a composite, three-dimensional representation

of the body. Any two-dimensional plane (slice) can be selected electronically from this
representation and displayed on a television-type screen for examination. Photographic
images also can be produced from the screen for further viewing and analysis. These
images are especially helpful for evaluating joint, ligament, muscle and bone problems.
MRl images are also very useful for examination of the brain, neck, spinal cord and soft
tissues. MRl often is used in the diagnosis of central nervous system disorders, such as
multiple sclerosis, because of its high-resolution images of the brain and spinal cord's
white and gray matter.
Computerized Tomography
Computerized tomography is often referred to as CT, CT scan and CAT scan. This is an
X-ray technique that produces more detailed images of the internal organs than do
conventional X-ray exams. X-rays are a form of energy radiation. Conventional X-ray
exams produce two-dimensional images. But CT uses an X-ray-sensing unit, which
rotates around the body, and a large computer to create cross-sectional and axial images
(like slices) of the inside of the body.
Unlike the conventional X-ray a CT scan can reveal the bones as well as soft
tissues of joints and organs such as the pancreas, adrenal glands, ureters and blood
vessels, all with a higher degree of precision. CT is used to help:
•
Diagnose muscle and bone disorders, such as osteoporosis
•
P inpoint the location of a tumor, infection or blood clot
•
Guide procedures such as surgery, biopsy and radiation therapy
•
Detect and monitor diseases such as cancer or heart disease, and monitor the
progression of a disease
•
Detect internal injuries and internal bleeding

Unlike MRl CT exams can be done even if the patient has a pacemaker or
cardioverter defibrillator, devices implanted in the chest to help regulate heartbeat.
However, if the patient is pregnant or suspects they might be, they must inform the
radiologists or practitioner. The procedure may be postponed or an alternative
examination that doesn't involve radiation, such as ultrasound or MRI may be considered.
Arthrography
Arthrography is the radiographic examination of a j oint after the injection of a dye-like
contrast material and/or air to outline the soft tissue and joint structures on the images.
This procedure is done most commonly to identify abnormalities associated with the
shoulder, wrist, hip, knee and ankle. Patients who undergo this procedure usually have
complained of persistent, unexplained joint pain or discomfort. Arthrographic images
may allow identification of problems with a joint's function or indicate a need for a joint
replacement.
Joint fluid is removed and replaced with inj ected contrast material or air and
sometimes both. A series of radiographs, sometimes called "arthrograrns," are obtained
before the joint tissue absorbs the contrast material. Occasionally, the examiner will take
additional x-rays as he or she pushes and pulls on the patient's joint.

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Oriental Orthopedics H istory and P hysical Examination 1 25

Myelography
This is a technique that involves spinal cord imaging by use of a water-soluble contrast
dye is injected into the epidural space via lumbar puncture and allowed to flow to
different levels of the spinal cord. Plain x-rays, or more commonly CT scan, are then
performed, to indirectly visualize structures outlined by the dye. This technique is very
sensitive at detecting disk disease, disk herniation, nerve entrapment, spinal stenosis, and
tumors of the spinal cord. Side effects of the procedure include headache, dizziness,
nausea, vomiting, and seizures.
Diskography
This involves the inj ection of radiopaque dye into the center of an intervertebral disk
(nucleus pulposus), using radiographic guidance, and may be used to determine disk
disruptions. This procedure is not commonly performed but is sometimes used in cases
where the precise cause of the presenting symptoms is difficult to ascertain to see
whether the injection brings on exacerbates symptoms.
Radiography-Based (X-ray) Bone Densitometry
Radiologists use x-rays to view and evaluate bone fractures and other injuries of the
musculoskeletal system. However, a plain x-ray test is not the best way to assess bone
density. To detect osteoporosis accurately, an enhanced form of x-ray technology called
dual-energy x-ray absorptiometry (DXA or DEXA). DEXA bone densitometry is today's
established standard for measuring bone mineral density (BMD). DEXA is a quick,
painless procedure for measuring bone loss. Measurement of the lower spine and hips are
most often done. More portable devices that measure the wrist, fingers or heel are
sometimes used for screening, including some that use ultrasound waves rather than x­
rays.
DEXA bone densitometry is used most often to diagnose osteoporosis, a condition
that often affects women after menopause, but may also be found in men. Osteoporosis
involves a gradual loss of calcium, causing the bones to become thinner, more fragile,
and more likely to break. The DEXA test can also assess risk for developing fractures. If
bone density is found to be low a treatment plan is needed to help prevent fractures
before they occur. DEXA is also effective in tracking the effects of treatment for
osteoporosis or for other conditions that cause bone loss.
Radionuclide Scanning
Radionuclide scanning (nuclear medicine) is a subspecialty within the field of radiology.
It comprises diagnostic examinations that result in images of body anatomy and function.
The images are developed based on the detection of energy emitted from a radioactive
substance given to the patient, either intravenously or by mouth. Generally, radiation
level to the patient is similar to that resulting from standard X-ray examinations.
Nuclear medicine images can assist in diagnosing diseases. Tumors, infection and
other disorders can be detected by evaluating organ function as well as conditions and
disorders affecting the skeleton. Specifically, nuclear medicine can be used to:
•
Evaluate bones for fractures, infection, arthritis or tumor
• Analyze kidney function
•
Image blood flow and function of the heart
•
Scan lungs for respiratory and blood-flow problems

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Oriental Orthopedics History and Physical Examination 1 26

•
Identify blockage of the gallbladder
•
Determine the presence or spread of cancer
•
Identify bleeding into the bowel
•
Locate the presence of infection
•
Measure thyroid function to detect an overactive or underactive thyroid

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 Chinese Orthoped ics Treatment Planning and Case Management 1 27

employed to prevent irritation. In some situations special oils are used to stimulate the
skin. S ome massage teclmiques even involve the use of hot water in conjunction with the
massage activity. There are some methods that employ only hands and could be
considered superficial or light massage and some involve application of the fists,
knuckles, arms or elbows to provide a deeper stimulation. Massage therapy is employed
to treat pain and a wide range of musculoskeletal problems, as well as to regulate tissues,
relax muscles and tendons, restore blood and vital nutrient flow and remove blockages in
the superficial vessels. Common massage techniques generally consist of: 1 ) roiling, 2)
kneading, 3) rubbing, 4) scrubbing, 5) pushing, 6) grasping, 7) flat-pushing, 8) patting, 9)
tapping and 1 0) vibrating methods.
Mobilization and Manipulation
Therapies classed as joint mobilization and manipulation includes a variety of techniques
that involve manipulation of the joints of the body including the fingers, toes, arms, legs,
head, neck and body. Some of the maneuvers are called "glides" because of the type of
joints involved. Manipulation therapy often includes specialized and general massage to
specific areas or to the entire body. Sometimes the specific approaches involve controlled
mobilization or practitioner-guided articulation of the extremities, head, neck and the
spme.
The main purpose of manipulation is to remove obstructions in the superficial
vessels; improve the circulation of blood and vital nutrients; regulate tissues; and to relax
muscles and tendons. Manipulation is also used to lubricate the joints, reduce swelling,
alleviate pain, restore normal joint function, treat soft tissue injuries, reduce dislocated
joints, enlarge joint spaces, relieve nerve compression, reduce adhesions, or increase
range of motion. There are many specialized manipulation methods that focus on specific
effects or are directed to particular joints. Common techniques generally include: 1 )
rolling-kneading, 2) holding-twisting, 3 ) shaking, 4) wiping, 5) rotating, 6) pulling, 7)
compressing, 8) stretching, and 9) traction-countertraction manipulations. The last two
manipulations of stretching and traction-countertraction are also employed as part of
active treatments used during rehabilitation.
Although mobilization and manipulation are in the same category they are
sometimes thought of in terms of slow and gentle for mobilization and faster or more
forceful techniques for manipulations. These refinements are arbitrary but are used to
distinguish between a high thrust maneuver, which may be counter-indicated for certain
conditions, and a low risk mobilization. Some practitioners assign grades to the
techniques to indicate what specific therapy was applied in certain cases. These grades
are summarized in Table 5 . 1 . Generally, Grade V movement is to be avoided.

Table 5. 1 . Grad ing passive movement treatment.

Grade Movement Use
Grade I Small amplitude oscillation at the beginning of range Reduce pain
Grade I I Large amplitude oscillation with in range without moving into Reduce pain
resistance or the limit of range
Grade I l l Large ampl itude oscillation from m iddle to e n d of range that I ncrease mobility
reaches limit of range
Grade I V Small amplitude oscillation at the limit (end) of range I ncrease mobility
Grade V Sharp thrust beyond the pathological limitation of range I ncrease mobility

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Chinese Orthopedics Treatment Planning and Case Management 1 28

Needling and Essential Modal ities

Chinese needling therapy is the key and perhaps most unique treatment method and
involves the insertion of very fine needles into specific locations on the body. The
Western term "acupuncture" denotes the idea of puncturing something with a needle but
does not convey any hint of something that may be therapeutically useful. However,
when the practice of needling therapy was first legalized in Oregon and California the
proponents used the term "acupuncture" to include needling and related modalities that
are a critical part of Chinese needling therapy. This incl udes moxibustion, heating
therapy, cupping, scraping, and massage. Training in these areas is not generally covered
in undergraduate programs and therefore instruction on these methods is not specifically
addressed in this text. Dietary and herbal remedies are also part of Chinese medicine and
not discussed herein as well. The Chinese also employed therapeutic bathing, use of
splints, and orthotic devices which are also not discussed in this text.
Needling Therapy
There are several hundred neurovascular node (acupoint) locations on the body, primarily
related to the peripheral and superficial distribution of blood vessels, related nerves, and
the longitudinal muscular distributions. In addition to being needled, nodes can be
massaged, scraped, pressured, cupped, heated by moxibustion, heated by other means, or
even pricked to release a few drops of blood. Nodes can be palpated for sensitivity,
numbness or minute temperature differences for diagnostic purposes and to assess
effectiveness of treatment.
Insertion of needles into the superficial body requires knowledge of the location
of the nodes as well as the underlying anatomical features. Each node has a nominal
insertion depth that i s adj usted for the size, shape and condition of the patient. Needles
are typically inserted perpendicularly to the skin but some node locations require
insertion to be at a certain angle. This is necessary because of local anatomical
considerations. Although node locations are found in association with nerves and blood
vessels, under no circumstances are needles to be inserted into these structures. Likewise,
needles are never inserted into the internal organs.
Other considerations on needle insertion involve how long the needles are left
inserted, how strongly they are manipulated, and the depth of insertion. Needle insertion
time and strength of manipulation are related to the type of therapeutic response that is
needed to address the presenting problem in terms of whether inflammatory or anti­
inflammatory reaction is desired. Consideration of either shallow or deep insertion,
within the safe limits of each node nominal depth, depends on what aspect of the needling
reaction is needed in terms of somatovisceral, defense system, or neuromuscular
responses.
Neurovascular nodes can be sensitive to touch and other spots can develop on the
body as well. These latter locations are now often referred to as trigger points but the
Chinese called them "Oh yes ! " Sensitive points can spontaneously develop in muscle and
tendon locations throughout the body. They are not usually needled if they are not
coincident with a known Chinese neurovascular node location, but they can be treated by
application of heat, pressure, cupping, massage, ointments, liniments, plasters, poultices,
etc. Needling is usually only applied to well-established node locations because some
non-nodal muscle locations produce muscular fatigue when needled and thus the

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Ch inese Orthopedics Treatment Plan ning and Case Management 1 29

condition might become worse by needling certain types of muscles in the body. Presence
of sensitive nodes is very useful for diagnosis and assessment of treatment progress.
E/ectroneedling (EN)
Nodal locations can also be stimulated electrically by means of either electric nerve
stimulation to inserted needles (EN) or by transcutaneous conductive pads (TENS). In
this text EN is only applied to needles inserted into established neurovascular nodal sites
and therefore more properly referred to as electroneedling (EN). Application of EN is
often considered where profound analgesia is desired, such as in surgical use. It i s also
employed in treating nerve dysfunction, paralysis, and substance abuse. Even though EN
seems to be quite modem, it has the longest history of any electrical therapy with its
introduction in Europe and the United States in the early 1 820 - 1 830 (See Chapter 1 ) .
Practical guidelines for electroneedling are presented in Appendix B.
Moxibustion
Moxibustion involves igniting a stick or ball containing the wooly fibers of Artemi sia
Vulgaris (moxa) to apply heat to specific areas or nodes to promote warming, usually in
localized. areas. Sometimes this procedure is referred to as cauterization. It is employed to
treat the effects of cold attacking or invading the body, or to strengthen the body' s
immune or defensive system. Balls o f moxa can b e ignited o n the metal handles o f
needles to direct heat into specific nodes. Lighted moxa sticks are used to provide heat
over a greater area of the body by holding them a safe distance above the skin and then
moving them back and forth over the area being treated.
Heating Therapy
Heating therapy, which is different than moxibustion, is used in clinical situations where
it is necessary to heat larger areas of the body, or sometimes where the heat needs to be
applied in deeper regions of the muscles. Sometimes heat is applied to induce
perspiration. Heat therapy can involve the use of heat packs, infra red lamps and
ultrasound stimulation. These devices are in common use in Chinese medical clinics in
present day China, Japan, Europe, and to some extent in the United States.
Heat Packs
U se of heat packs, including those containing herbs, has continued from ancient
time' s right up to present day. They are applied in treatment of many musculoskeletal
problems, especially where cold conditions are involved or in the situation where there is
impairment in the flow of blood, oxygen and essential nutrients. Heat packs are also used
for a variety of other conditions.
Radiant Heating
Present-day heat lamps are safely and efficiently used to provide radiant heat
therapy that is equivalent to traditional methods. Use of these devices provides greater
uniformity and control of radiant heat than is possible with the ancient approach of
seating a patient close to a fire.
U ltrasound
Application of this technique also provides a modem means and can be
considered to safely duplicate some of the traditional heating approaches. It induces heat
by mechanical vibration of the tissue and can be thought of as a combination of heat and
deep massage. In cases where it is important to achieve a deeper heat penetration,

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Ch inese Orthopedics Treatment P lanning and Case Management 1 30

ultrasound may be a more efficient and safer consideration. To accomplish this same
effect with either heat packs, radiant heat or moxibustion would require the affected area
to be heated longer; ultrasound is more comfortable and safer for the patient and is a
more efficient therapy. This modality, just as the other described in this text requires
proper training and certification on the part of the practitioner that is consistent with
appropriate state laws.
Cupping
Cups of various sizes are employed to treat a wide range of disorders. Application of a
cup results in a suction contact with the body causing a local vasodilatation and
mechanical expansion of the underlying tissue. This physically increases the flow of
blood and nutrients in the muscular and superficial regions and also activates needling
response mechanisms. Small cups may be applied to the face in treating facial paralysis
whereas large diameter cups placed in the lumbar region are used to treat lumbago.
Cupping is frequently applied over nodes but they can also be used in non-nodal regions
as well . Cups can also be applied over inserted needles but in some cases this can result
in blood oozing into the cup space. The occurrence of such an event requires the proper
handling and disposal of blood products.
Scraping Therapy
This is a technique involving scraping the skin with a smooth sided objects, employed in
conj unction with an oil. The side of a typical Chinese porcelain spoon or other small and
smooth objects i s used. The oil contains certain herbs that, along with the scraping action,
enhance superficial vasodilatation. This technique is used to remove stagnations and
improve circulation in the superficial regions. It often produces a reddening of the skin
that may last from several hours to a full day.
Baths and Water Therapy
Although these therapies are to be found in modem physical therapy clinics, these skills
are not routinely taught in Chinese schools in the United States. Modem therapeutic
bathing equipment is now available in most hospitals and physical therapy clinics.
Therapeutic bathing therefore is not normally used in modem Chinese clinics and is
usually limited to i nstructing the patient on self-help use of bathing. Some therapeutic
bathing included the addition of herbs.
Orthotics and Restraints
Simple splints, restraints, and taping are sometimes necessary to temporarily immobilize
a joint to allow the healing process to proceed. Some of these involve making temporary
soft casts of herbal material to promote healing. Modem devices are employed as well
and emphasis is placed on very short duration of use. Use of orthotics and restraints, just
as the other described in this text, requires proper training and certification on the part of
the practitioner that is consistent with appropriate state laws.

Medicines for I nternal a n d External Use

Foods (including vitamins and minerals), herbal remedies, and medicated diet make up
the complete category of what would be considered as medicines. Medicated diet and
foods are all consumed internally as are most herbal remedies. Some herbs however are
only used externall y to apply to the superficial body. The therapeutic use of foods is
perhaps most fundamental to the practice of Chinese therapeutics. Considering the flavors

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Chinese Orthopedics Treatment Planning and Case Management 1 3 1

of both foods and herbs is important to understand how they are used to treat or prevent
certain conditions.
As a rule, severe and acute disorders are treated with needling and herbs and
possibly the combination of both food and herbs or medicated diet (contains herbs). In
long term chronic ailments, both Chinese and modem dietetics are considered most
important. All herbs have the potential of producing unexpected and unwanted side
effects and so long term use of any formulation is usually inappropriate. Dietary therapy,
on the other hand, is more forgiving and safe and so it can be maintained for longer time
periods without risk of adverse reactions.
Foods and herbs are also considered based on their essential properties of either
being hot, cold, warm, cool or neutral. This property does not refer to the temperature of
the food or herb, but to the effect it has on the body when consumed. The property of the
herb or food is used in opposition to the nature of the disease. Specific diseases may
manifest as being either hot or cold, or deficient or excess in nature.
Cold foods or herbal remedies are considered in case of a hot disease which is
severe, whereas, cool foods or herbal remedies are considered in case of a hot disease
which is mild. Hot foods or herbal remedies are considered in case of a cold disease
which is severe, whereas, warm foods or herbal remedies are considered in case of a cold
disease which is mild. The properties of food and herbs are also considered with respect
to the prevailing climatic conditions. Certain cold foods are avoided during cold seasons
and certain hot foods are avoided during hot seasons. Also, the actual temperature of an
herbal decoction, to be consumed, is considered with respect to the nature of the disease.
Dietary Therapy
Use of dietary means in treating orthopedic conditions are appropriate where metabolic
disorders may be involved in the problem or in situations where poor diet or dietary
habits are directly affecting the condition. Modern dietary supplementation with minerals
and vitamins are appropriate to consider when indicated although emphasis is usually on
consumption of proper foods. Chinese dietetics first described in the Neijing involves a
highly sophisticated system where consumption of foods, classed as certain flavors, are
considered to exert interrelated dynamic influences on the organs and tissues of the body,
and even emotions as well. Foods are consumed based on a well balanced daily diet and
avoiding the over consumption or under consumption of any particular flavor. Excess
consumption of most flavors has impact on the musculoskeletal system (See Table 2 . 1 ) .
In addition, flavors are used in treating prime visceral symptoms, promoting certain
visceral tendencies or used during different seasons to treat either excess or deficiency
conditions.
Herbal Remedies
Many effective, traditional herbal formulas are applied in treating orthopedic conditions
including trauma, arthritis, rheumatism, inflammation, swelling, pain, and stiffness. Most
of these herbal remedies are consumed for internal use although they are also used
externall y as a liniment, poultice, plaster, creme, paste, ointment, powder or suppository.
Several types of over-the-counter herbal plasters are in common use of orthopedic
conditions. Some of the well known liniments are use to promote bone healing and
relieve pain. In addition herbs are available in ready-to-use herbal products that are

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Chinese Orthopedics Treatment Planning and Case Management 1 32

frequently referred to as patent medicines. Ready-to-use products are usually in the form
of either pills, powders, extracts, pellets, soluble granules, tablets, capsules, tinctures,
dilutions, syrups or oral liquids. Recommendations for herbal formulas, remedies, and
medicated diet are beyond the scope of this text.
Medicated Diet
The Chinese add herbs to various food products to create a medicated diet. Medicated
diets are used to treat both acute and chronic disorders. Both the foods and the introduced
herbs are selected based on their inherent flavors and basic properties as well as their
known therapeutic effects. Rice gruel is frequently used as a vehicle to introduce a
variety of different herbs to treat certain conditions. Gruel can also be made with wheat,
millet, or maize, but these are considered inferior to rice.
Many additional food products are used to introduce herbs for the treatment of
acute and chronic disorders. The type of food is selected for its ability to work in
harmony with the herbal component and bring about the best therapeutic result. Different
forms of medicated diets or the materials used in their production are generally in the
following categories: 1 ) gruel or porridge, 2) thick soups, 3) drinks, 4) medicated tea, 5)
stable foods, 6 ) specially cooked dishes, 7 ) medicated wine and liquor, 8) decoctions, 9)
juices, 1 0) honey paste, 1 1) honey extract, 1 2) preserved fruits and vegetables and candy,
and 1 3) miscellaneous items.

Movement Therapy, Exercise, P reve ntion a n d Rehabilitation

This aspect of treatment constitutes the active phase where the patient takes a
participative role in restoring or improving their health. The basic ideas in health
preservation and rehabilitation include living a calmer life, reducing stress, avoiding
excess physical and mental activity while considering remedial steps to promote health.
Some of these strategies rely on dietary changes, medicated diet, movement therapy and
remedial exercise, breathing exercise, relaxation techniques to calm the mind, and
protecting oneself from harmful environmental exposure.
In case of rehabilitation, it is also necessary to consider needling therapy,
moxibustion, heat therapy, sometimes even hot baths, cupping, pressure, massage, and
manipulation. In addition, the practitioner has a major task in paying attention to the
patient' s lifestyle and provides advice, guidance and counseling where necessary. The
primary requirement however, is that the practitioner themselves, conduct their lives by
the same principles. Otherwise the practitioner has little or no credibility.

Movement Therapy and Exercise

Prescribed exercise includes practitioner directed routines to strengthen specific muscles
or general health promoting programs. The initial emphasis however is directed to
restoring pa i n-free range of motion t h rough mov rnent therapy before strengthenin!!
exercises are considered. The Chinese developed diverse and excellent exercise
approaches, some of which involve guided stretching of tendons and muscles. Many of
these are taught to patients to address specific muscular or articulation joint problems.
Sometimes the therapy is directed to strengthen particular muscle groups or those
associated with a particular joint or muscular distribution. Remedial exercises are
included as part of the therapeutic approach in treating many musculoskeletal problems

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Chinese Orthopedics Treatment Plan ning and Case Management 1 33

during rehabilitation. Some exercises are directed to general problems, such as tight
tendons or general weakness. Remedial exercise programs can be considered in different
categories as follow:
Passive Stretch
Passive stretch consists of a gentle sustained muscle lengthening process applied by the
practitioner or therapist. Numerous variations of passive stretching exist with some using
distractors or techniques to inhibit afferent nociceptive and vasodilatory fibers
contributing to the pain. Some of these include: 1 ) cryotherapy (ice, cold packs, coolant
sprays); 2) analgesic balms (tiger balm, blue ice) and: 3) needling therapy.
Mobility and Stretching Exercise
Active mobility maintenance and stretching by the patient are encouraged by the
practitioner. Training, counseling and advice in stretching and mobility exercises are
provided to assure safe and effective use of these procedures. Sometimes the exercises
are performed in conjunction with needling treatment to relieve acute spasms, especially
of the low back, neck and shoulders.
-+ Caution: No exercising or stretching is permitted in conjunction with or after
electroneedling (EN) treatment. This modality usually produces profound
analgesia putting the patient at potential risk of self injury if active exercise is
undertaken or is at risk of practitioner induced problems in case of passive
exercise and stretching .

Stretching-Contrac tion Exercise

In certain situations, especially if it involves a foreshortened muscle condition, the
process of stretching the muscle prior to each contraction exercise is employed.
Exercising the muscle without prior stretching may only aggravate the condition. The
exercise routine then consists of stretching followed by contraction for each repetition.
Flexibility and Stability
These exercise and training strategies concern the axial muscles of the body involved in
posture. The long term goal of rehabilitation is to restore the patient to pre-injury function
and reduce the chances of recurrent episodes. Repetitive microtrauma due to poor or
weak posture, superimposed on a previous injury can lead to advanced degeneration.
Spinal stabilization is used to teach the trunk muscles recruitment as an effort to control
and reduce flexion and torsional stresses on the joint segments. Through the use of
voluntary muscles, pain-free regional postures can be maintained while the patient carries
out normal daily activities. The necessary posture and combination of muscle actions
determined experimentally are specific for each case. Once the comfortable position is
found, the patient is assisted while rehearsing progressively more complex tasks, keeping
the body part in its neutral, pain-free position.
Strength. Conditioning and Endurance
Active conditioning exercises are helpful in bringing about a resolution of the patient's
problem and help prevent its recurrence once strength is recovered or even improved over
the pre-inj ury status. Some problems cannot be successfully resolved without the
inclusion of exercise therapy.
Early during the recovery phase, isometric exercises and stretching within the
pain-free range of motion may be used to limit the effects of deconditioning. Once the

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Chinese Orthopedics Treatment Planning and Case Management 1 34

case has successfully passed the remobilization phase, progressively increasing loads
throughout the full range of motion are initiated. These may be accomplished through use
of free weights, weight stack machines, or the same computerized i sokinetic or isoinertial
machines that aid in assessment of muscle strength and function.

Exercise Planning
Patient compliance is extremel y poor if they are only advised concerning certain
exercises. Thus, prescribed exercise plans during the initial stages need to be supervised
by the practitioner or other responsible health care provider (i.e., physical therapist,
kinesiologist). Usually an exercise training plan begins with direct supervision, three to
five times per week, of assigned exercises tasks intermixed with rest periods. Many
progressive-resistance protocols are available, some using isometric force and slow speed
movements. The combination of multiple sets of repetitions with increasing or decreasing
increments of weight or force results in benefits for both strength and endurance. The
maximum resistance is progressively increased as strength improves over a course of four
to six weeks for a typical case.
Computerized instruments are available that are used as the prime exercise
equipment which also provides objective strength measurements. These devices, found in
some modern orthopedic rehabilitation clinics, provide instant feedback on progress and
help maintain the patient' s interest in the program. However, such equipment is not
essential to assure a good clinical outcome.
Patients who fail to comply with the exercise/treatment/care schedule or who are
insincere in their efforts should be advised about being discontinued from the program
and discharged from care if minimal compliance cannot be maintained. The other patients
are reassessed near tht:: completion of the treatment plan to determine the outcome.
Kinesiology
This term refers to the study of human motion and is derived from " kinesis" meaning
motion and "logy" meaning "study of' or "logic." When considering exercise therapy it
is important to understand the basic kinesiology involving the role of each muscle in the
articulation of each joint or body region. Muscles that play a maj or role in articulating a
joint are referred to as prime movers (PM). Several other muscles may also be involved
in the same joint and have an assisting role and are referred to as assistant movers (AM).
The prime movers are usually stronger and can compensate for the assistant movers. A
table is provided in Chapters 6 - 1 7 that lists all muscles that participate as prime and
assistant movers in each degree of movement for each maj or joint articulation. This
kinesiology information is essential in the assessment and treatment of muscular
problems and for exercise planning.
Elements of Reconditioning Program
Possible weakness, dysfunction and pain in particular muscles and j oints are determined
by the appropriate orthopedic testing. Weak muscles are sometimes difficult to isolate
since strong muscles involved in the same articulation compensate for the weak muscle.
In this case isometric exercises may be used to strengthen the suspected weak muscle.
Restoring an impaired muscle to pre-injury status requires special attention. The
practitioner must decide on the type of exercise needed as well as how many times it

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Chinese Orthopedics Treatment Planning and Case Management 1 35

should be performed with respect to repetitions and sets. These elements are discussed
below.
A therapeutic exercise program is considerably different than simply exercising a
normal muscle to gain strength. Care has to be taken not to cause the musculoskeletal
problem to worsen. Consequently, loads applied in rehabilitating an impaired muscle are
much less than required to build strength. As movement improves and strength increase,
the conditioning load can be increased as well . Often this is accomplished by use of light­
weight dumbbells or strap-on weights. Under no conditions are exercises permitted to
push into the painful range of motion. Likewise, weights are never increased to the point
of inducing pain during an exercise.
One general consideration is that humans are bipedal with the lower leg extensors
(quadriceps) and hip extensors (gluteal muscles including maximus, medius, and minis)
being the most important muscles to maintain function. Hence, restoring these critical
muscles to normal function has an overall impact on the rest of the body, especially the
lumbar and thoracic spine. With respect to the upper body, functions of muscle that
control the arms and shoulder likewise have an influence on total body performance.
Patient Instructions
Patients are instructed in how to take special care when standing up from the seated
position, or how to roll out of bed without putting undue load on the affected area. Any
positive means of reducing mechanical loads on the inj ured or impaired body region
helps the recovery process. In addition, only one side of body typically has the presenting
problem. For example, shoulder, elbow, wrist, hip, knee and foot problems are often
ipsilateral. Consequently, as in the case of resistive strength testing, the good side is
exercised first. Afterwards, the problem area is subjected to the same exercise routines.
Most of the exercises are performed either while the subject is seated in a chair or
on the floor, lying prone or supine, side lying, or while standing. The examination table
may be used to demonstrate or teach the routine but most patients do not have such
equipment at home and thus exercises have to be conducted with the minimum of amount
of equipment. It is advisable that practitioners use an exercise mat or towel to teach and
supervise the exercise program and to observe the patient's progress.
Many exercises basically use the force of gravity as the main resistive load. Light
weights can eventually be brought into the routine when progress permits. Self-applied
external dynamic resistance (EDR) or i nternal dynamic resistance (IDR) is also employed
to provide the main force to challenge muscle contractions (See following discussion).
Some clinics have modem exercise equipment to address each specific muscle group. In
this case, the patient must come to the clinic for supervised and monitored exercise. Even
in these situations it advisable to still teach the patient all the necessary manual exercises
to be used in maintaining and improving strength once they have completed the initial
program.
General Terms Applied to Exercise
A few common terms are frequently used with respect to exercise. These are described by
Greco-Latin elements and found in almost all literature associated with exercise. These
are mainly of Western invention as are most medical terms because of the efficiency and
compactness of ancient Greek and Latin. The three most common terms are:

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Chinese Orthoped ics Treatment Planning and Case Management 1 36

Isotonic
This term denotes exercise involving fixed weights and is derived from "isos"
meaning "equal" and the Greek "tonikos" which refers to tone. The Latin equivalent
"tonus" refers to "stretching," and hence tone generally applies to the contractile
condition of muscles. A dumbbell is a dead weight of particular magnitude and is good
example of an isotonic load. Various parts of the body that are moved during exercise
also represent isotonic loads as well. Isotonic loads are commonly used in most
therapeutic exercises.
Isometric
This term is applied to a certain type of exercise and derives form the Greek
"isos," which means "equal," and "metron," which means "measure. " It refers to
subjecting a muscle or muscle group to a resistive force at a fixed length or position. A
force is applied while the j oint or extremity is constrained not to move by increasing the
load to counteract the muscle contractive force. Hence the muscle contracts, but is held at
some constant length or position. This is the technique used in orthopedic muscle strength
assessment. When used as an exercise technique, the strength of the muscle can increase.
lsokinetic
This term is derived from the Greek "isos," meaning equal and "kinesis," meaning
motion. Thus, it refers to equal motion, or equal velocity. It is used to describe exercise
involving equal motion which is typical of certain strength measuring instrumentation
devices or machines, and also pertains to certain movement exercises.

Features of Rehabilitation Movement

Therapeutic and rehabilitation exercises are different than normal strength building
exercises as found in sports training or normal physical fitness efforts. The target muscles
for rehabilitation may involve impairment, weakness, and pain. This requires a certain
amount of care to slowly and systematically rehabilitate the affecting area by increasing
range of motion, reducing pain, and eventually restoring strength to the fullest amount
possible. Certain protective movements may be involved as well as stretching to prepare
for the rehabilitation exercises.
Protective Movements
Some protective movements were previously discussed i n teaching the patient how to
perform certain daily activities without aggravating their condition, such as getting out of
bed or standing up from a seated position. Other protective movements involve
stabilizing the back and cervical spine to provide a posture that prevents further
deterioration in these areas.
Pre-Exercise Stretches
It is important to subj ect the muscle group being reconditioned, to passive stretch prior to
the exercise routine. If a planned workout includes several different muscle groups, a
series of related stretches can be performed before exercising.
Strengthening Exercise
The primary means of strengthening an impaired muscle or muscle group is to apply light
loads (isotonic) over the pain free portion of the range of motion. The joint, extremity or
muscle is moved under load, j ust to the point of pain. No attempt should be made to push
into the region of pain. No exercise should be continued if it results in producing pain.

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 Chinese Orthopedics Treatment Planning and Case Management 1 37

Strength is restored by subjecting the muscle to loads that result in contractions. These
can be concentric, where the muscle shortens in the process of contracting. Contractions
can also be eccentric, where the muscle lengthens while developing tension. Exercises are
repeated in groups or sets (see below) to progressively increase the intensity of the
routines as strength is developed.

Load Consideration
Muscles operate through contractions to shorten the distance between its origin and its
insertion on two bones across a joint or body region. In order to move an articulation, the
contraction must produce sufficient force to overcome any mechanical loads being
subjected to the body part in question. Loads additional to one's body weight can be
added such as picking something up or just due to normal human daily activities
involving movement. All of this basically takes place under the influence of the forces of
gravity. However, there are some orthopedic and pain problems where the patient does
not have sufficient strength to move some articulation, and hence gravity-eliminated
exercises are indicated. Also, loads can be judiciously added to challenge muscle
contractions such as using isotonic loads, or by application of external and internal
dynamic resistance.
Gravity-Eliminated
In some situations the patient's muscle strength is measured to be less than Grade 3 (See
Table 4.3). Thus, they have insufficient strength to initially perform the reconditioning
exercises which are performed in the configuration where gravity provides the primary
resistive force. In this case, the exercise is modified to place the patient in the gravity­
eliminated position used to perform the initial orthopedic assessment. Exercises are
modified so the principal plane of motion is at 90° to the gravitational field, basically the
plane of motion is parallel with the ground.
Isotonic Loads
Most exercise routines involve the use of isotonic loads such by use of dumbbells or
barbells. Most fitness centers are equipped with numerous machines that provide an
isotonic load for a specific degree of motion. The load can be adjusted consistent with the
capability and goal of the individual.
External Dynamic Resistance
This involves self-application of external dynamic resistance (EDR) by using one hand
placed on a particular body part or area to provide a load to challenge muscle contraction.
The load is basicall y isotonic in nature as the articulation is moved through its normal
range of motion. Use of EDR eliminates the need for using any dead weight devices or
machines. One advantage of EDR is the fact the person' s own efforts are employed to
resist their own muscular contraction, and hence risk of overloading the muscle is
unlikely. The other advantage is being able to exercise at the patient's own time and
location convenience. Disadvantages include the limitation on the exercises that can be
performed.
Internal Dynamic Resistance
This refers to self-application of internal dynamic resistance (I DR) by contracting the
antagonist muscles of a particular degree of motion to apply a resistance to contraction of
the agonist muscles. The IDR load is applied through the full range of motion possible.

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Chinese Orthopedics Treatment Planning and Case Management 1 38

Advantages of using IDR are that all body motions can be exercised and strengthened.
Also, since the individual is resisting movement by contraction of their own muscles,
there is little l ikelihood of self inj ury. The main disadvantage is that individuals need to
learn how to contract the correct antagonist muscles. Many training and conditioning
exercises related to Gongfu and other martial art practices make use of IDR.
Peak or Maximum Contraction
Muscles need to contract in order to shorten the muscle length which then results in
motion of a joint by normal lever action with respect to the bones. The force of
contraction can vary over the range of motion, depending on the differences in load as
result of the effects of gravity with respect to joint position. Heavier loads can cause the
muscles to produce maximum contractive force. Muscles can also be consciously
contracted using IDR to produce maximum contraction throughout the full range of
motion to enhance reconditioning effect.

Frequency of Exercise
Certain terminology is used to describe the features of an exercise program in terms of
how often a program is performed and how often exercises are performed. This
information is expressed in terms exercise repetitions, sets, and workouts.
Repetitions
This refers to how many times a specific exercise is to be performed basically without
resting between each completion. The frequency of repeating a particular exercise is
related to the maximum strength and condition of the muscle or muscle group performing
the motion. Estimation of how much load to use for a given set of repetitions is derived
from the maximum load or weight that an individual can move through just one
repetition. This number is referred to as the one-repetition maximum ( l RM) load and is
used determine how much weight is appropriated for a given number of repetitions.
For example, if a patient can perform a biceps curl with a 20 pound dumbbell one
time only without being able to immediately repeat the exercise, then 20 pounds is their
l RM for that exercise. The appropriate weight and number of repetitions can be derived
from the l RM value. Here repetitions relate to percentage of l RM load approximately as
follow: 2 reps, 94%; 3 reps, 86%; 4 reps, 78%; 5 reps, 70%; 6 reps, 60%; and 7 reps,
50%. If a person has a biceps curl 1 RM of 20 pounds, they potentially could perform 6
repetitions of the biceps curl with a 1 2 pound dumbbell, or 7 repetitions with a 1 0 pound
dumbbell, etc.
In experienced adult and late-teen athletes, l RM values for different muscle
groups can be determined by adding weights until l RM is reached. In individuals
untrained in exercise and weight training, or in the case of prepubescent and midgrowth­
spurt athletes, a conservative estimate is made concerning the appropriate load. The
resisted isometric orthopedic test for an affected muscle group or articulation provides an
estimate of the maximum load that should not be exceeded. The indicated exercise load
should be about 50% of the maximum to assure that several repetitions can be achieved.
-+ Prepubescent individuals should not perform maximum load exercises.

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Chinese Orthopedics Treatment Planning and Case Management 1 39

Exercise Sets
This indicates a preplanned number of repetitions or the maximum times a specific
exercise is performed. The strength of most muscles increases when subj ected to a fixed
number of repetitive exercises performed in groups consisting of sets. Maximum benefit
occurs at about 4 to 5 sets. A brief rest period is provided between sets. Duration of the
rest period depends on the condition the patient and the load being applied in the
exercise. Usually, in therapeutic exercise, the load is light and the rest period between
sets is short.
Repetitions and sets can be varied over a considerable range. Typically, up to 6-8
repetitions of a particular exercise is planned to be conducted over 3-5 sets. Use of light
loads in therapeutic exercises assures that at lease a few sets can initially be completed.
As strength increases, the number of repetitions and sets are, likewise, increased.
Building up to eight repetitions, repeated for up to 5 sets, is ideal for most muscle groups.
Some exercises that inherently place light loads on the muscles can be performed for
sixteen repetitions. Certain types of muscles, such as the abdominal group, improve better
with higher numbers of repetitions, but not as many sets.
In heavy weight training, the load used in each set may vary depending on
different approaches to training. Often two or three warm-up sets with use of light loads
are followed by three or four intense sets using constant resistance. Individuals in this
category are usually serious weight trainers, athletes, or professional sports figures.
Rehabilitating patients in this category often proceeds quicker, since they are generally in
good condition, except for their particular presenting problem.
The number of repetitions per set can also be progressively decreased to account
for possible fatigue that develops with repeated exercise. The initial set may have 1 2
repetitions while the second set has 1 1 , and the third set has 1 0, and so on.
Workouts
This term describes the total period of the exercise program for any given time period.
Several exercise routines involving different muscle groups are usually addressed during
any particular workout. Typically, three to five workouts are performed each week,
depending on the condition of the patient and the particular exercises involved. Most
workouts can be scheduled on consecutive days unless it involves high intensity training
or performance. In this latter situation, a rest period of 48 hours is required to regain
normal strength after a high intensity workout.

Time Dependencies
The nature and efficiency of exercise therapy is influenced by certain time dependencies,
such as speed of movement and hold time. Faster movements have a lower potential for
increasing strength while slower movement are more efficient in producing stronger
muscles. A well balanced rehabilitation and conditioning program will employ exercises
over the full range of time relationships in the following categories:
Fast Movement (Ballistic)
Fast movements produce momentum which in-turn helps power the articulation through
its full possible range of motion. Faster movements are sometimes referred to as
"ballistic" because once a limb is put into motion l ittle energy expenditure i s needed to
continue the movement through to completion. Calisthenics ("kalos" beautiful +

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 Chinese Orthopedics Treatment Planning and Case Management 140

"sthenos" strength) are in this category and consists of l ight gymnastics to promote
strength, maintain conditioning, and improve grace of carriage. One of the more
important uses of fast movements is to restore the full range of pain-free motion.
Normal Routine
Movement will normally proceed at a fairly constant rate when exercising any particular
articulation if the level of resistance (usually an isotonic load) is within an appropriate
range for patient's condition and the muscle group in question. A single repetition of the
movement should only take a few seconds, usually 2 seconds up and 2 seconds down in a
bicep curl. Determining the proper load or resistance in rehabilitating a weak or injured
muscle requires careful attention. In a normal individual, load value and number of
repetitions for a particular movement are determined by the maximum weight the
individual can move in one repetition only (See preceding discussion on Repetitions).
This may be too severe in case of rehabilitation so lighter than normal weights are
initially considered. Weight has to be light enough not to induce pain on movement.
Super Slow Exercise
It has recently been rediscovered that exercising a muscle at a much slower rate can
produce greater strength using lighter weights, reduced repetitions, and fewer workouts
over the same period of time for normal speed exercise. The lifting period is 1 0 seconds
as opposed to the normal 2 seconds. The lowering time can also be 1 0 seconds although
some studies have recommended 4 - 5 seconds. Although lighter weights are employed,
this workout is demanding. Patients have to be coached to correctly perform the super
slow exercises. It also requires mental stamina to stay focused on maintaining the slow
speed. Normal routines involve 1 0 - 1 2 exercises with three sets of 1 0 - 1 2 repetitions
each with three or more workouts per week. The super slow routines usually involve 1 0 -
1 2 exercises of one set with 6 I 0 repetitions no more than tvv·ice a week. No significant
-

exercise is recommended for 48 hours after a super slow workout.

Using lighter weights is an advantage for rehabilitation and older patients since
increasing weights to increase strength can often produce pain. Also, the super slow
routine does not result in sore muscles the day after the exercises which is fairly normal
after regular speed exercises. Research efforts showing the benefit of super slow exercise
gives credence to the purported benefits of slow movement involved in Taijiquan and
Daoyin routines, and many other similar approaches developed by the ancient Chinese.
Isometric Exercise
Isometric contractions are applied to a joint by restricting its motion and hence the speed
of movement is zero. Basically, the muscle is contracted at its full or nearly full strength,
and this may be why isometric contractions can be used to develop considerable strength
in muscles. The mechanisms may be similar to how super slow movements work. There
is some question as to whether strength is developed over the total range of motion, or
just only for the position to which the joint is being held. Recent information however
suggests that the total muscle is strengthened especially if it is held in its fully contracted
position.
Isometric contractions are applied to the target muscle or muscle group by moving
the j oint to its fully flexed, extended, or rotated position and contracting the particular
groups of muscles responsible for the specific movement. In the case of the biceps
brachii, the forearm is flexed to the maximum extent possible while holding the biceps in

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Chinese Orthopedics Treatment Planning and Case Management 1 4 1

full isometric contraction. The contraction i s held for 8 1 0 seconds and then released.
-

The muscle is contracted again and held for the same period of time and this is repeated
for the desired number of repetitions. It is important to breathe normally while holding
the isometric contraction and not to constrict the chest. One disadvantage of isometric
contraction is training an individual in how to contract the target muscle or muscles to be
strengthened.
Isometric contraction can be accomplished at any angle along the range of motion
by using one hand to restrict motion of particular j oint while isometrically contracting the
appropriate muscles responsible that degree of freedom of motion.
-+ Care must be considered in using isometric exercises with hypertensive patients
since some people cause their blood pressure to increase by isometric
contractions.

-+ Isometric contractions applies sustained and often maximum loads on the

tendons, these structures may develop soreness.

B reathing Exercises
Remedial breathing therapy involves teaching, guiding or instructing the patients in
certain breathing exercises appropriate to their condition. Often the breathing routines are
performed coincident with physical or movement exercises, although in some forms of
breathing techniques the patient remains seated or is in the prone position. Some of the
procedures are similar to guided imagery where the patient is trained to mentally direct
vital breath to certain areas of the body or extremities. Sometimes it is directed to areas of
chronic muscular disorders or pain.

Relaxation Routines
A wide range of different procedures are used to train the patient in relaxation skills.
These are employed in prevention, health preservation, or rehabilitation. Routines
involving slow body movement or breathing exercises may be suitable for this purpose,
but sometimes the patient needs a simple and speedy method of calming, that only
requires a few minutes to accomplish.
Passive Techniques
Passive relaxation approaches are similar to meditation routines. The person is usually
seated or lying down, although they can be standing as well. No relaxation techniques
should be attempted while operating a vehicle, airplane, or while doing anything of a
critical nature.
Active Techniques
Active relaxation routines differ in that they are performed along with body motion,
usually with slow deliberate movements similar to many slow movement routines.
Several specialized exercises can be employed while controlling the breathing in concert
with the body motion. Some specific exercises may be recommended, if it is important to
concentrate on a particular problem.

Lifestyle Counseling
The main focus in counseling is basically non-psychological. Even though emotional
problems are treated with needling therapy and herbs, they are mostly considered in terms

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Ch inese Orthopedics Treatment Planning and Case Management 1 42

of being either physically induced by organ dysfunction, influenced by dietary habits,

related to seasonal effects, or are stress related. Counseling can involve advice on eating
habits, alcohol and drug use, sleep patterns, physical and emotional stress, environmental
stress, and condition of one's residence. Many of these factors have profound influence
on calcium utilization in the body and can impair bone healing.
Major factors considered in work related stress are time demands, overwork, and
unrealistic goal setting. The impact of the work environment includes interaction with
machines and equipment, office equipment, lighting, air conditioning, heating, dampness,
and possible toxic exposure. Repeated activities that may lead to physical stress inj ury are
also considered with remedial steps suggested to avoid or reduce incidence of re-inj ury.

F req uency a n d D u ratio n of Ca re

Determining the frequency and duration of care is the most essential part of treatment
planning. Guidelines for this aspect of the treatment plan rely mainly on clinical
experience. Normally this is tempered with the latest scientific information to understand
the processes of treatment or by data derived from valid evidenced-based clinical
outcome studies.
Unfortunately, for the American practitioner of Chinese needling therapy, the
historic base and modem clinical studies mostly exist only in China. More effort has to be
made in the future to document clinical effectiveness based both on subj ective and
repeatable obj ective results to refine the historic data base. Nevertheless, the guidelines
provided by the early Chinese practitioners are quite useful and are consistent with
modem clinical experience. Standards in patient management require close attention to
fundamental aspects of the treatment plan including:
•
Criteria for selecting treatment/care procedures
• Close monitoring of the therapeutic response in relation to expected outcome of
natural history
•
Flexibility of the treatment/care protocol when less favorable or unexpected
responses are encountered

Defi nitions
A common set of terms and definitions are often used across many professions treating
pain and orthopedic problems, as follows:
Active Rest
Also called relative rest, it involves the resting of a tissue or body part only to the point of
restriction of the deforming and pathological forces during the healing period, while at
the same time allowing normal physiological stresses.
Adequate Trial of Treatment/Care
This refers to a course of two weeks each (four weeks total) of two different types of care
modes, including manipulations and needling therapy, after which, in the absence of
documented improvement, these modes are no longer indicated.

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Chinese Orthopedics Treatment Planning and Case Management 1 43

Chronicity
Stages of progress of a disorder that are related both to severity and duration: acute,
subacute, chronic, and recurrent.
Complicated Case
Involves the situation where the patient, because of one or more identifiable factors,
exhibits regression or retarded recovery in comparison with expectations from the natural
history.
Elective Care
Treatment/care requested by the patient designed to promote optimum function to
alleviate subjective symptomatology in cases having reached maximum therapeutic
benefit.
Essential Procedures
This involves the standard treatment modalities of needling therapy, electroneedling
(EN), moxibustion, heat therapy, and cupping.
Manual Procedures
Include a variety of physical techniques including massage, joint mobilizations,
manipulation, and therapeutic exercise.
Maximum Therapeutic Benefit
Return of the patient to pre-injury/episode status or failure to improve beyond a certain
level of symptomatology or disability, despite the treatment/care approach. This is also
referred to as Maximum Medical Improvement (MMI).
Natural History
This denotes the anticipated clinical course of recovery for uncomplicated disorders
either without treatment/care or with conservative treatment/care.
Preventive/Maintenance Care
This involves the care given to reduce the incidence or prevalence of illness, impairment,
and risk factors, and to promote optimal function.
Stages of Treatment/Care
This includes four categories with specific goals for passive and active care as follow
(See Table 5 .2):
1 . Acute Intervention: Initial therapeutic intervention to assist and promote anatomical
rest, reduce muscle spasms, inflammatory reactions, alleviate pain, and to restore visceral
and somatic function.
2. Remobilization : Continuing intervention to increase the pain-free range of motion and
to minimize de-conditioning.
3 . Rehabilitation: Efforts to restore strength and endurance in the pain-free range of
motion, and increase physical work capacity.
4. L ifestyle Modification: Modify social and recreational activity, diminish work
environment risk factors, and adapt psychological factors affecting or altered by the
musculoskeletal or orthopedic disorder.

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Chinese Orthopedics Treatment Planning and Case Management 1 44

Supportive Care
Refers to the treatment/care for patients having reached maximum therapeutic benefit, in
which periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains
that would otherwise progressively deteriorate.
Treatment Necessity
This situation exists in presence of an impairment/illness/injury evidenced by recognized
signs and symptoms, and likely to respond favorably to a planned treatment approach.
Treatment/Care Terms
Common terminology applied to treatment and care includes:
1 . Intervention: The process of providing either passive (practitioner applied) or active
(patient participation) care to intervene in an ongoing disease process or condition.
2. Modality: Refers to a particular or specific therapeutic mode of care.
3 . Frequency: Refers to how frequently treatment/care is provided necessary and
sufficient to maintain effects while healing occurs. This is not to be confused with
stimulation frequency in Hz. used in electroneedling (EN).
4. Interval: Minimum treatment/care period to obtain a stable response.
5. D uration: Is the time that needles are left inserted or time period that heat, cold, or
electroneedling (EN) are applied. Also is used to denote length of time of presenting
condition from the time of onset.
6. Combination : The potentiation or competition of response by simultaneous
treatment/care applications.
Treatment/Care Goals
This consists of written short term and long range expectations of patient response to the
treatment plan.
Treatment/Care Type
Type of care is broadly divided in two categories with specific goals for each (See Table
5 .2):
1 . Passive Care: Application of treatment/care modalities by the care-giver to a patient
who "passively" receives care.
2. Active Care: Modes of treatment/care requiring "active" involvement, participation,
and responsibility on part of the patient.
Treatment Plan
A written description of intended therapeutic actions divided according to relevant
treatment/care goals and prognosis.
Uncomplicated Case
Refers to a case where the patient exhibits progressive recovery from an illness or injury
at a rate greater, or equal to, the expectation from the natural history.

Reducing Variables in Practice

Contributing to problem of establishing standard guidelines for treatment planning is the
great variability among practitioners on their diagnostic skills and what they think is most

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Chinese Orthopedics Treatment Planning and Case Management 1 45

important in analyzing the patient's problem. Another complication concerns different

opinions on what modes of care are best applied in the treatment of certain conditions.
One of the goals of this text is to provide an organized approach by which an accurate
diagnosis and treatment plan can be accomplished. The various modes of care can then be
applied with a clear understanding on how these processes work on the body in bringing
about tissue repair and promote healing.

Principles of Case Management

The primary goal of health care is to provide adequate treatment to restore health,
maintain it, and prevent the recurrence of injury, disability, and illness. The practitioner
uses a myriad of procedures and skills that are grouped into the categories of passive
intervention, active intervention, and patient education. The practical boundaries on what
constitutes sufficient planning is situational, with the outcome judged on previous clinical
experience on a case-by-case basis. Basic considerations in case management concern the
following ideas:
A. Early return to activity is associated with reduced disability and symptoms.
B. Based on the experienced gained from comparing the response of patients having
no treatment and those with treatment, there is a natural history of recovery for
uncomplicated cases that can be used as a time frame from which to judge and
formulate a successful treatment plan.
C. Chronicity should be prevented wherever possible. Those at risk of doing so show
characteristic behavior patterns involving their illness and life situation. Warning
signs can include:
• Somatic or visceral complaints that remains static longer than 2 - 3 weeks
• Anxiety or depression
• Functional or emotional disability
• Family turmoil
•
Drug dependence: recreational, non-prescription or prescription

Process of Treatment Planning

A number of questions are usually considered in formulating a fundamental approach to
treating a given problem or category of problems, once the diagnostic process provides a
reasonably clear picture of the presenting condition. As in former times, it is important to
understand the factors involved in causing the disorder. The early Chinese physicians
always looked at the situation in terms of external and internal factors. The external
factors mainly include environmental conditions, such as wind, cold and damp which are
thought to be directly damaging to the body. Strain, sprain, overwork and injury are also
included in factors that directly cause trauma to the body. Internal sources mainly involve
emotional factors of worry, fear and anger which were thought to harm the functional
activity of the body which then results in damage.
The modern understanding of the effects of emotions and stress on bodily
function is well documented and shows that these factors are still a major source of
problems, particularly how they affect the utilization of calcium and other minerals.

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Chinese Orthopedics Treatment Planning and Case Management 1 46

These factors are presently known to be important in the development of arthralgia, joint
problems, and degenerative problems of the spine. Poor diet and lack of exercise are also
important in the Chinese view and these problems are addressed in the preventive and
rehabilitation phase of the case.
Many pain and orthopedic problem have an associated natural history where they
will resolve on their own without passive treatment/care. All that is applied is rest and
relaxation. Other problems can become worse, eventually becoming chronic without
treatment/care intervention. The purpose of treatment in the first situation is to relieve
pain and suffering and promote resolution of the problem as quickly as possible to return
the patient to the pre-episode work and functional status. It is also essential to prevent
establishing chronicity.
The treatment plan for therapeutically necessary care can be viewed as containing
4 phases with each having obj ectives for both passive and active care (See Table 5 .2)

Table 5.2. Stages of treatmenUcare with goals and objectives for passive and active care
Passive Care
1. Acute I ntervention (Chinese orthopedics modes of care)
A. To promote anatomical rest
B. To diminish muscular spasm
C. To reduce inflammation
D. To alleviate pain
E. To restore somatic function
F. To restore visceral function and homeostasis
Active Care
2. Remobilization
A. To increase the range of pain free motion
B. To minimize deconditioning
3. Rehabilitation
A To restore strength and endurance
B. To increase physical work capacity
4. Lifestyle Adaptations
A To modify social and recreational activity
B. To diminish work environment risk factors
C. To adapt psychological factors affecting or altered by the
disorder/ musculoskeletal problem/orthopedic condition

Short and Long Range Planning

At the onset of treatment/care, a written estimated time frame for reaching intermediate
functional milestones and treatment outcomes should be made. The functional milestones
represent short term goals and can consist of activities such ability to move the affected
part, exert force or to walk. Outcome expectations are long term goals and may include
the ability to return to work, renew sports, and regain full activity. The length of time to
reach these objectives can be affected by specific historical factors of the condition. Some
of these jnclude the following factors:
1 . Pre-consultation D uration of Symptoms: In the situation that pain duration is less
than nine days: no anticipated delay in recovery. Pain more than nine days, but less than
thirty days: recovery may take 1 .5 to 3.0 times longer.
2. Typical Severity of Symptom s : Mild pain: no anticipated delay in recovery. Severe
pain: recovery may take 2 times longer.

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Chinese Orthopedics Treatment Planning and Case Management 1 47

3 . Number of Previous Episodes: 0 3 : no anticipated delay in recovery. 4 - 7: recovery

-

may take 2 times longer.

4. I njury Superimposed on Preexisting Condition(s): Skeletal anomaly : may increase
recovery time by 1 .5 2 . 0 times. Structural pathology: May increase recovery times by
-

1 .5 2 times.
-

Treatment /Care Frequency

The basic question on the part of the practitioner usually involves, how many treatments
are needed and how frequently should they be applied to bring about maximum
therapeutic benefit? If the practitioner has an established protocol for certain disorders
that consistently produce clinical success, then they can be confident in using a tried and
tested approach. Although Chinese medicine has been in full use for many more centuries
than any other system, few modem studies provide guidelines for establishing
treatment/care frequency and total time period of treatments. Part of the problem has been
a lack of standardized objective data. One of the goals of this text is to educate the
practitioner about the need to use consistent data gathering means so that exchange and
review of useful information will eventually lead to establishing a modem data base.
The ancient Chinese addressed this perplexing problem as well and provided
some general guidelines in the Neijing Lingshu Treatise 6: Longevity, Premature Death,
Firmness, and Suppleness. The main external and internal factors of disease are noted
and acknowledged that the number of treatments for a given disorder depends mostly on
how long the person has had the problem and whether only external factors are involved
or if the problem is complicated by internal factors (emotional factors). Diseases that
persist for one month or longer are considered more difficult to treat and here the key is
to consider both the internal and external factors involved. Guidelines from the LS 6 are
summarized as follow:
•
An acute somatic disorder (musculoskeletal/orthopedic condition) of less than 9
days duration should be given 3 treatments.
•
A somatic disorder of 1 month duration should be given 1 0 treatments.
•
If the somatic problem of 1 month duration has not yet affected the internal
organs the treatment plan can be reduced by half, namely, it can be given 5
treatments.
•
If the somatic disorder of 1 month duration is first preceded by an internal
condition (emotion, stress, diet, etc. induced) then the number of treatments
should be doubled, namely, 20 treatments are provided.
These guidelines are reasonably consistent with modern day clinical experience
and consistent with the observation that the duration of symptoms of the case history is a
good predictor of response to treatment/care. Uncomplicated acute disorders of less than
nine days duration, usually respond in 3 to 5 treatments. Those of one month or less
duration usually respond in 5 to I 0 treatments. Conditions of one month or less duration,
involving internal factors, usually are resolved in 1 0 to 20 treatments.
A typical case in this latter category, that is expected to take up to 20 treatments,
could be scheduled over a ten week interval as follow: 3 treatments for each of the first
two weeks followed by 2 treatments per week for the next six weeks and finally 1

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Chinese Orthopedics Treatment Planning and Case Management 1 48

treatment per week for the last two weeks. The clinical response is always evaluated each
time the patient returns for the next treatment. If response is greater than anticipated, then
the number and frequency of treatments is correspondingly decreased. Conversely, poorer
response may indicate the need for spreading the treatments over a longer time period.
In general, an assertive in-clinic intervention of up to three treatments a week for
one or two weeks is typical early in the case. Treatment frequency then progressively
declines or levels out until discharge of the patient from passive care or they continue
treatment on an elective care basis.
Chronic disorders, often of long duration, or those involving significant trauma or
those involving CNS complications usually take more treatments spread out over a longer
time period. The ancient Chinese noted that in treating patients suffering from stroke, if
they have lost ability to speak along with paralysis, that full recovery is unlikely, but
those whose speech is unaffected, that recovery is possible. In either case Chinese
needling therapy is applied to bring about significant therapeutic benefit. Additional
recommendations on treatment/care time periods is given below for uncomplicated and
complicated cases.
Patient Cooperation
It is essential to explain the purpose and strategy in the treatment/care plan to address the
patient' s disorder. The rationale for the treatment/care approach should be shared with
the patient, in addition to answering all the patient' s inquiries about how and why the
plan is expected to bring about clinical success. Patients who are either non-compliant to
the treatment/care recommendations or prove to be insincere, should be considered for
discharge from care, with referral when it is appropriate.
Failure to Meet Treatment/Care Objectives
Failure to meet treatment/care goals i s frequently due to not having an accurate diagnosis
or true understanding of the problem. The other complication is not to provide an
adequate number of treatments during the early course of the case. Normally, the process
of reviewing the case each time the patient returns for the next treatment in a planned
course of care is to keeping refining the diagnosis to better understand the dynamics of
the recovery process. Despite this continued effort, some cases fail to meet treatment/care
expectations and it i s necessary to consider additional steps, including discharging the
patient. Several steps can be considered that possibly include the following:
1. Acute Disorders : After a maximum of two trial needling therapy series over a course
of two to four weeks, without documented improvement, alternative care including
manual procedures should be considered.
2. Un responsive Acute, Subacute, or Chronic Disorders: Repeated use of passive
treatment/care normally designed to manage acute conditions should be avoided as it
tends to promote physician dependence and chronicity.
3 . Complicating Factors: Systematic interview of the patient and immediate family
should be carried out in search for complicating or extenuating factors responsible for
prolonged recovery.
4. Record of Goals : Specific treatment/care goals should be written to address each
ISSUe.

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Chinese Orthopedics Treatment Planning and Case Management 1 49

5. Continued Failure: Continued failure should result in patient discharge as

inappropriate for Chinese orthopedics, or that the case has achieved maximum
therapeutic benefit/maximum medical improvement (MMI).
Uncomplicated Cases (acute episode)
The consistency in clinical practice of Chinese needling therapy, provided as passive
care, shows that only acute episodes can truly be considered uncomplicated. Acute
episode refers to the first occurrence, recurrent, or exacerbation of a chronic condition.
The following are characteristic of an uncomplicated case:
1 . Symptom Response: Significant improvement within 1 0 - 1 4 days with two to three
treatments per week.
2. Activities of Daily Living (ADL): The promotion of rest, elevation, active rest, and
remobilization, as needed, are expected to improve ADL followed by a favorable
response in symptoms.
3. Return to Pre-episode Status: Accomplished in six to eight weeks with up to three
treatments per week.
4. Supportive Care: Inappropriate.

Complicated Cases
Implementation of up to two independent treatment plans relying of repeated use of
passive care is usually acceptable in the management of cases undergoing prolonged
recovery. Complicated cases manifest some of the following characteristics:
1 . Signs of C hronicity: All episodes of symptoms that remain unchanged for two to
three weeks should be evaluated for risk factors of pending chronicity. Patients at risk for
becoming chronic should have treatment plans altered to de-emphasize passive care and
refocus on possible active care approaches.
2. Subacute E pisode:

a. Symptom Response: Symptoms have been prolonged beyond six weeks, and
passive care in this phase is as needed but generally does not exceed two
treatments per week to avoid promoting chronicity or physician dependence.
b. Activities of Daily Living (ADL): Management emphasis shifts to active care,
dissuasion of pain behavior, patient education, and flexibility and stabilization
exercises. Rehabilitation may be appropriate.
c. Return to Pre-episode Status: Approximately 6 - 16 weeks.
d. Supportive Care: Inappropriate.
3. Chronic Episode:

a. Symptom Response: Symptoms have been prolonged beyond 1 6 weeks, and

passive care is for acute exacerbation only.
b. Activities of Daily Living (ADL): Supervised rehabilitation and life style
changes are appropriate.

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Chinese Orthoped ics Treatment Planning a nd Case Management 1 50

c. Return to Preinjury Status : Possibly may not return. Maximum therapeutic

benefit using needling therapy may have been reached.
d. Supportive Care: Supportive care using passive therapy may be necessary if
repeated efforts to withdraw treatment/care result in significant deterioration of
clinical status.
Elective Care
Therapeutic necessity is absent in elective care by definition. Under specific
circumstances for individual cases, elective care is usually considered safe and effective.
Presently this is the most common avenue of care for Chinese needling therapy. Elective
care must be designed to avoid physician dependence and chronicity.

Disa b i l ity a n d Permanent I m pairment

Most states have some sort of workers' compensation plan where employers pay
insurance premiums that provide them protection from being sued by an inj ured worker,
if the employer offers adequate compensation to cover the problem. Compensation can be
for time loss from the job, possible retraining if the employee is no longer able to do their
normal function, or long term compensation for permanent impairment where it leads to
disability. In many situations, especially involving either job related or accident caused
injuries; the patient does not fully recover to the pre-incident condition. Consequently,
these individuals are left with some degree of possible impairment, which may be either
slight or significant, and may either be temporary or permanent.
•
Impairment is generally viewed in terms of what impact that a problem or inj ury
has on activities of daily living (ADL)
•
Disability, on the other hand, considers what impact the problem has on a
person' s ability to perform their work activities
It is essential that practitioners treating musculoskeletal and pain problems be able
to perform permanent impairment evaluations. The evaluations may then be used by
designated specialists to determine the degree of disability resulting from a specific injury
or disease condition. Injuries or conditions that result in necessary amputation of either
digits or limbs, or in the case of inj uries directly causing the loss of a limb or body part,
the degree of impairment may self evident. However, in the more common situation, the
person is left with chronic pain and dysfunction, making it more of a challenge to
accurately assess the degree of impairment. The practitioner further needs to determine if
the impairment is either temporary or permanent. As a general rule, a condition is
considered to be permanent if it has remained static, showing no improvement, for at
least 1 2 months. At this point the patient is considered to have reached their maximum
medical improvement (MMI). If there is some continued improvement in the case, even
though the individual displays some degree of impairment, then the case may be
considered temporary.
Unfortunately, there are many cases of malingering and even out right fraud in
both the workers compensation plans and the personal injury automobile insurance cases.
This places an additional burden on the practitioner in making a reliable assessment of
impairment. This problem is partly resolved by utilizing a rational and technical approach
to impairment assessment. such as is provided by the American Medical Association

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Chinese Orthopedics Treatment Planning and Case Management 1 5 1

Guides to the Evaluation of Permanent Impairment, Fifth Edition (A.MA Guides). Key to
this process involves making a thorough and systematic use of medical records and
reports. This includes gathering and evaluating all of the documentation pertinent to any
given case. Some states do not rely on the A.MA Guides and have their own approach to
permanent impairment and disability evaluation.

Approach to I m pa i rment Evaluation

The main emphasis on impairment assessment by an acupuncture orthopedist involves
evaluation of dysfunction of the musculoskeletal system. This requires significant
attention to the nervous system and other features affecting special regions, such as the
head and neck. A necessary framework is provided by the A.MA Guides to evaluate any
medical impairment, including the musculoskeletal system and all of the other body
areas, and the internal organs. In situations where an accident or condition results in
injury or impairment of the internal organs or other systems outside the expertise of any
practitioner, the subj ect should be evaluated by the appropriate medical specialists for
those portions. Successful and consistent use of the A.MA Guides relies on a good
understanding of their intended approach and the concepts on which the rules and
procedures have been developed. Following these basic rules should result in an
objective, fair and reproducible assessment of impaired subj ects.

Basic Terms
Many terms, including "impairment," "disability," and "handicap," is used in laws,
regulations, and policies, throughout the country, with no prior consensus on what they
mean or the ways in which they are to be used. Some states require the practitioner to
perform an "impairment rating" in relation to a workers compensation claims, while other
states require a "disability evaluation." The degree of dysfunction is the underlying
physical or mental basis of medically assessed impairment.
Accurate evaluation of this parameter (impairment) will produce the necessary
information from which to make all other assessments, including possible disability. It is
essential to understand the context in which the terms "impairment," "disability, " and
"handicap" are applied. A practitioner's assessment of the patient should generally be
understood to mean a medical evaluation of the subj ect's health status in relationship to
accepted rules and standards (AMA Guides). Any types of losses, including economic or
industrial losses, that give rise to awarding disability payments, are not determined by the
practitioner.
Impairment
The term "impairment" indicates an alteration or change in an individual's health and
functional status, which can be assessed by medical methods. Impairment is what is
wrong with a body part or organ system that alters its normal function. If the impairment
is supported by medical findings, case history and impairment evaluation, and has been
unchanged or static for at least 1 2 months, it is considered to be "stable" and
"permanent." Both impairment and disability can also be classed as either "temporary,"
"partial," or " complete."
Disability
The term "disability" means an alteration of an individual's capacity to meet
occupational, personal, or social demands or meet statutory or regulatory requirements.

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Chinese Orthopedics Treatment Planning and Case Management 1 52

Disability is assessed by non-medical methods and represents the disparity between what
an individual needs or wants to do and what they actually can do. A medically established
impairment leads to disability only when the subject has a loss in capacity to meet the
demands of normal living. Thus, a person who is impaired may not necessarily be
disabled, if they can meet the demands of daily activities. Impairment in a digit, limb or
joint, for example, may be disabling to people of certain professions or labor categories,
but not affect individuals involved in other types of work.
Handicap
The term "handicap" is used in reference to barriers or obstacles to functional activity.
Although this term is related to and frequently interchanged with " impairment" and
"disability," it is also independent of these two terms. Laws of various states have
different interpretations of this term. Federal law uses such a broad definition of
"handicap" that any individual who has a documented impairment that substantially
limits one or more of life's activity, can qualify as being handicapped. A functionally
impaired person could be considered handicapped when there are barriers to
accomplishing their daily activities, which can be overcome only by compensating in
some way for the impairment. Such "accommodation" to compensate for the impairment
often involves use of assistive devices such as wheel chairs, crutches, hearing aids,
optical magnifiers, prostheses, or special tools and equipment, modification of the work
environment or work tasks.
If there are no accommodations that permit an individual to complete needed
tasks, or i f the person is not able to accomplish an activity, despite accommodation, then
that individual is both handicapped and disabled. However, if an impaired subject is able
to accomplish a task, with or without accommodation, he or she is not considered to be
either handicapped or disabled, with respect to that task.

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 Chinese Orthopedics Head and Face 1 53

Head and Face

Assessment and treatment of the head and face covers the regional and surface anatomy,
physiology, pathology, assessment, and treatment of problems associated with this area of
the body. Many inj uries and problem affecting the head and face, including fractures and
severe trauma, are typically addressed in emergency care facilities immediately after the
initial incident causing such problems. X-rays and other diagnostic imaging studies are
often undertaken as part of the emergency care. These patients then present in the normal
clinical setting for follow-up and rehabilitation care. Many other conditions affecting the
head and face occur due to wear and tear distress as well as other environmental and
work related factors. Assessment and treatment of head and face problems may cover a
wide range of conditions.

Head a n d Face Reg ional Anatomy

The skull or cranial vault which houses and protects the brain i s the most prominent
feature of the head along with the facial bones. Several cavities of the facial skull include
those of the eye orbits, nasal cavity, and oral cavity. The mandible is the only moveable
bone of the head which i s articulated by means of the temporomandibular j oint (TMJ).
Muscles of the head and face including the mandible are controlled by 1 2 bilateral pairs
of cranial nerves including sensor and motor functions.

Face and Skull Bones

The skull or cranial vault is composed of several bones held together by suture j oints.
This includes one frontal, one occipital, two parietal, two temporal, and two sphenoid
bones (See Figure 6. 1 ) . The occipital bone is the strongest of these while the two
temporal bones are the thinnest and the weakest. There are 1 4 facial bones including: the
mandible forming the lower jaw; the maxilla forming the upper j aw on each side; the
zygomatic bones forming the cheek bones; the nasal bones forming the bridge of the
nose; and the ethmoid, palatine, and lacrimal bones. The two sphenoid bones also form
part of the orbital cavities that accommodate the eyes. The mandible is a single bone that
contains the lower teeth and the support structure of the neck and head of the condyle
which articulates with skull by means of the temporomandibular joints (See Figure 6.2)

Temporomandibular joint (TMJ)

The temporomandibular joints are the most frequently used joints in the body. The TMJ
is a synovial, condylar, hinge type joint with an articular disc (intra-articular meniscus)
that is moved anteriorly by the lateral pterygoid (ALH) muscle as the j aw opens. The
j oint has fibrocartilaginous surfaces rather than hyaline cartilage. The disc divides each
joint into two cavities referred to as the superior and inferior compartments. Rotation or
hinge movements occur in the inferior compartment during the initial phase of opening
the jaw. A gliding-sliding movement occurs in the superior compartment as the disc is
moved anteriorly over the articular eminence as the jaw is opened widely.

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Chinese Orthopedics Head and Face 1 54

Coronal suture
Squamous suture
Parietal bone - Frontal bone

Temporal bone , Sphenoid bone

Lambdoid suture __

Nasal bone
Occipital bone - _ _

Zygomatic bone
External auditory
meatus
- - Maxilla
Masstoid
process -- Zygomatic arch
Occipital condyle
Mandible
Styloid process
Temporomandibular joint
Figure 6. 1 . Major Bones of Skull

Condyle Condylar process _

Head
Coronoid
Neck of process
condyle

Mental Mental
Base protuberance foramen

Figure 6.2. Anterior and lateral view of mandible

Nerve Supply to Head and Face

Both sensory and motor function of the head and face is provided by 1 2 pairs of cranial
nerves as follow:
I. Olfactory: Sense of smell
II. Optic: Sense of sight

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Chinese Orthopedics Head and Face 1 55

III. Oculomotor: Voluntary levator of eyelid; voluntary motor function of rectus

superior, medial, inferior; and obliquus inferior muscles of eyeball; autonomic
motor of smooth muscles of eyeball
IV. Trochlear: Voluntary motor function of obliquus superior muscles of eyeball
V. Trigeminal: Sensory function of face and deeper structures of head; voluntary
motor function of mastication
VI. Abducens: Voluntary motor function of rectus lateral is of eyeball
VII. Facial : Voluntary motor function of muscles of expression; motor function of
stapedius muscle; sensory function of taste for anterior 2/3 of tongue;
autonomic function of lacrimal, submandibular, and sublingual glands
VIII. Vestibulocochlear (acoustic nerve): Sensory function of hearing and balance
IX. Glossopharyngeal: Sensory function of touch and pain for posterior tongue
and pharynx; sensory function of taste for posterior tongue; voluntary motor
function of pharynx muscles; autonomic function of parotid gland
X. Vagus: Sensory function of touch and pain for pharynx, larynx, and bronchi ;
sensory function of taste for tongue and epiglottis; voluntary motor function
of palate, pharynx, and larynx; autonomic motor function for thoracic and
abdominal viscera
XI. Accessory: Vohmtary motor function of the sternocleidomastoid and trapezius
muscles
XII. Hypoglossal: Voluntary motor function of muscles moving the tongue

Blood Supply
Blood vessels supplying the head and face include the major arteries supplying the brain
and return flowing veins as well as those supply other areas as follow:
•
fnternal carotid artery and internal jugular vein
•
Vertebral artery and vein
•
External carotid artery and external j ugular vein
•
Cervical artery and veins
•
Lingual artery and vein
• Sublingual vein
•
Facial artery and vein

Head and Face Phys i o l ogy

Physiological function of the muscles and tendons that articulate the temporomandibular
joint, tongue, anterior neck, and muscles of expression are presented below. Each specific
muscle is grouped by the Chinese longitudinal muscular distributions by logical regions
of the head and face.

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Chinese Orthoped ics Head and Face 1 56

Muscles of the Face, Scalp and Tongue

Muscles of the face have little to do with articulation of j oints in head region, except for
function of mastication. Main purpose of these muscles is for facial expression (See
Figures 6.3 and 6.4), moving the lips and tongue, and closing the eyes. Muscles moving
the scalp have some function involving expression and the elevation and retraction of the
ears. Muscles of the face, scalp and tongue are all important since they are the focus of
many disorders i ncluding: headache, facial paralysis, deviation of tongue, and
dysfunction in j aw.

Muscles of Facial
Expression
Muscles of expression
Frontalis
innervated by the Facial nerve
Frontal
(CN 7) mainly involve the Temporalis

anterior l ateral foot (ALF)

distribution including: the
zygomaticus maj or and minor,
orbicularis oris, mentalis,
depressor labii inferior and
orbicularis oculi (lower parts)
- Maxilla
(See Figure 6.3 and Table 6.2).
Masseter
Also includes the buccinator, Buccinator --­

risorius, depressor anguli oris Orbicularis oris

Mandible
Triangularis------ -
muscles assigned to the
Quadratus labii- -
anterior lateral hand (ALH) rnfenoris
Mentalis
distribution (See Figure 6.4 and

\ I
Table 6.2) and the orbicularis
oculi (upper parts) belong to
the posterior lateral foot (PLF)
muscle distribution (See Figure
6.4 and Table 6.2).
Figure 6.3. Facial muscles, anterior view
Muscles of the Scalp
Four principal muscles move the scalp by tying into the galea aponeurotica ligamentous
fascia to form the epicranius system. These consist of the occipitalis (PLF) and frontalis
(LF: See Figure 6.4 and Table 6.2) that attach to the galea aponeurotica at the occiput and
forehead respectively, and the temporoparietalis (LH) muscles located on each side of the
head. The temporoparietalis muscle overlies the temporalis (LF) muscle. Other muscles
associated with the scalp are related to moving the auricle consisting of the auricularis
superior, anterior and posterior muscles belonging to the posterior lateral hand muscle
distribution (See Table 6.2). These muscles overlie the temporoparietalis muscle.

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Chinese Orthopedics Head and Face 1 57

Muscles of Mastication
One of the more important
functions of muscles of the head Frontalis

includes articulation of the

temporomandibular joint which i s Orbicularis oculi

critical to the function of

mastication. This involve four Quadratus labii
supenons
muscles including the masseter
Zygomaticus - ­

(ALF), temporalis (LF), and

Orbicularis:�ris
medial pterygoid (ALH) and
Buccinator
lateral pterygoid (ALH). The first
Quadratus labii
three of these function to close inferioris
the mouth by raising the mandible Mentalis

while the l ateral pterygoid muscle Triangularis

functions to open the mouth. All

four of these muscles are
innervated by the Trigeminal
nerve (CN V). Figure 6.4. Facial muscles, lateral view

Muscles Moving the Tongue

Both the PLF and LH muscular distributions tie into root of tongue via the styloglossal
(PLF) and stylohyoid (LH) muscles. The styloglossal muscle draws tongue upward and
backward, is one of three extrinsic muscles that move tongue. The LH muscle
distribution also includes the hyoglossus muscle which depresses tongue and the
genioglossus muscle which depresses tongue as well, and also thrusts the tongue forward.
The intrinsic muscles of tongue are responsible for controlling its shape. All the muscles
that move tongue are innervated by the Hypoglossal nerve (CN XII) and the stylohyoid
muscle is innervated by Facial nerve (CN VII).

Suprahyoid and I nfra hyoid Muscles of the Neck

Muscles tying into the hyoid bone from above (suprahyoid) include the digastric, anterior
belly (ALH) and posterior belly (PLH); stylohyoid; and mylohyoid and geniohyoid
(ALF), all of which raise hyoid bone. With the exception of the geniohyoid, these
muscles assist in the function of opening the mouth by depressing the mandible. This
action is secondary to that of the lateral pterygoids and comes into play when there is
resistance to overcome in opening the mouth or if it is necessary to open the mouth wide.
Muscles below the hyoid bone (infrahyoid) include the omohyoid, which
originates at the superior border of the scapula and belongs to the Large Intestine
distribution and the sternohyoid, sternothyroid and thyrohyoid belonging to the ALF
distribution. These four muscles are antagonists of suprahyoid muscles. These muscles
function to hold hyoid bone in place when suprahyoid muscles are involved in opening
the mouth. They also combine in fixing hyoid bone during tongue motion.

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Chinese Orthopedics Head and Face 1 58

Problems of Head and Face Muscles

It is important to consider the historic indications for disorders of specific muscular
distributions when making a more detailed assessment and examination. This is
extremely useful because the formation of sensitive points and the development of
muscular dysfunction follow along these pathways. In addition. treatment protocols also
consider selection of candidate neurovascular nodes with respect to the muscular
distributions.
Disorder in Muscles of the Scalp
Posterior lateral foot (PLF) and lateral foot (LF) distributions:
•
Muscular spasms in occipital region and forehead.
• Frontal, occipital and vertical headaches.
Lateral hand distribution (LH) distribution:
•
Acute cramps and spasms along lateral side o f head.
Posterior lateral hand (PLH) distribution:
•
Pain and ringing in the ears leading to pain in chin.
• Heavy sensation in the eye after having been closed for some time.
Disorders Involving Muscles of Facial Expression
Facial paralysis can involve the upper or lower motor neurons of CN VII with slightly
different manifestations as discussed later. This condition was described by the ancient
Chinese with specific reference to a specific dysfunction related to anterior l ateral foot
(ALF) distribution:
•
Unexpected or sudden deviation of the mouth, with acute condition that eye
cannot close
Disorders Involving Muscles of Mastication
Lateral foot (LF) distribution (temporalis) :
•
Acute cramps, spasms and pain in j aw and parietal region including TMJ
syndrome
•
Conditions can include clenched j aw (trismus), one-sided parietal headache,
migraine, dizziness, vertigo or retroauricular pain
Anterior lateral foot (ALF) distribution (masseter):
•
Acute cramps, spasms and pain in region ofjaw and cheek
• Conditions can include either trismus, toothache, swelling of face and cheek,
tinnitus or motor impairment of the jaw
Anterior lateral hand (ALH) distribution (lateral and medial pterygoids):
•
Pain, spasms and acute cramps under angle ofj aw, possibly including toothache
•
Pain, spasms and acute cramps under angle of j aw when opening or closing mouth

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Chinese Orthopedics Head and Face 1 59

Disorders Involving Muscles Moving the Tongue

Pathology related to region of tongue associated with the posterior lateral foot (PLF) and
lateral hand (LH) distributions include:
•
Acute cramps, spasms and swelling along the lower j aw
•
Acute cramps and spasms that cause the tongue to curl up
Other apparent conditions include stiff tongue, tremulous tongue and deviation to
one side when the tongue is thrust forward. These conditions usual ly indicate some fault
associated with the Hypoglossal nerve. Deviation of tongue to one side indicates lesion
on same side.
Disorders Suprahyoid and lnfrahyoid Muscles
Anterior lateral foot (ALF) distribution:
•
Stretching sensation from supraclavicular fossa reaching jaw.
•
Pain and spasms along anterior aspect of neck and throat.
•
Difficulty or inability to open mouth widely.
Posterior lateral hand (PLH) distribution:
• Spasms in muscles below lateral anterior aspect ofjaw.
•
Swelling below lateral anterior aspect of jaw.
Lateral hand (LH) distribution:
• Acute cramps and spasms along lower margin of mandible.
Anterior lateral hand (ALH) distribution:
• Pain, spasms and acute cramps below the chin.

Disorders of Head a n d Face

Problems affecting the head and face are viewed in terms of pain and pathology
manifesting in the specific muscle distribution as well as other pathological conditions.
Common conditions affecting the head and face include sensory and motor impairment as
result of cranial nerve dysfunction. This includes deficits in vision, hearing, and
equilibrium; facial paralysis; and facial pain. Other problems include temporomandibular
joint disorders as well as herpes zoster that can affect the face.

Tem poromandibular Joint (TMJ)

Pain in the TMJ and face along with j oint dysfunction occur more frequently in women.
TMJ problems occur in two age groups involving young adults with all their teeth or
middle-aged people who are edentulous (have no teeth). Pain radiates widely into the
head, face, and neck. Main findings include abnormality of movement, deviation ofjaw
to painful side on opening, and clicking ofj oint. Tenderness and thickening can be
detected by palpation over the joint.

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Ch inese Orthopedics Head and Face 1 60

TMJ Dysfunction
Pain i s common complaint in TMJ problems, especially with younger patients. It can be
associated with spasms in the muscles articulating the jaw or due to hypomobility lesions.
Pain can also be the result intermittent claudication in muscles during mastication. TMJ
pain can also manifest as occipital headache, burning sensation in throat, deafness,
tinnitus, vertigo, nystagmus, and sensation of fullness in ear.
Although TMJ pain is a common complaint it must be differentiated from other
3 rd
sources of facial pain such as unerupted molar, carcinoma of tonsils or pharynx in the
elderly, or trigeminal neuralgia. Pain can be referred from the cervical spine incl uding
traumatic cervical spine syndrome.
Osteoarthritis
Degenerative arthritic changes in the TMJ are seen in 40% of people over 40 years of age
and in women over 50. Is common source of problems in the elderly and can result from
inflammatory synovitis. Osteoarthritis of the TMJ may also follow a traumatic incident,
such as an intra-capsular fracture.
Ankylosis
Ankylosis of the TMJ may follow an incident of inflammatory arthritis and childhood
infectious diseases. This was once a complication of scarlet fever that led to deformation
of the j aw (often called bird face).

Facial Paralysis
Paralysis of the facial muscles of expression can involve upper (UMN) or lower (LMN)
motor neurons of facial nerve (CN VII). Cranial nerve VII supplies voluntary motor
function to facial, scalp, and anterior neck muscles; and parasympathetic motor to
lacrimal, sublingual, submandibular, nasal, and palatine glands. In addition, CN VII
supplies motor input to the stapedius muscle which functions to dampen the movement of
the stapes in the ear in response to loud sounds. When this muscle is flaccid or paralyzed
sounds become louder and annoying which is referred to as "hyperacusia." Cranial nerve
VII also conveys taste sensory function to the anterior 2/3 of the tongue, and afferent
proprioceptive signals from muscles of the face and scalp.
Paralysis due to UMN
Characteristics of facial paralysis as result of lesions in the UMN of CN VII provide
important clues to help distinguish it from the LMN problems, which include:
•
Muscles of forehead and around eyes have UMN supply from both sides of
brain
•
Unilateral cortical lesions have relatively little effect on upper part of face
•
Can close eye on affected side but with weakness
•
Can raise eyebrows and wrinkle forehead
•
Paralysis of lower face on affected side
•
Causes flat nasolabial fold or groove

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Chinese Orthopedics Head and Face 1 6 1

Paralysis due to LMN

Facial paralysis due to the LMN of CN VII usually occurs the morning after being
exposed to cold air blowing on one side of the face. This exposure can be the result of
driving or riding in a car while the window is rolled down; sleeping with a close window
being open; or even due to exposure to air conditioners or cold work environment. The
cause and typical symptoms that slightly different from UMN problems and can include:
•
Due to wind or cold exposure affecting vessels and collaterals and facial
paralysis occurring on side exposed to wind
•
Often involves inability to close eyelid (ALF and PLF distributions)
•
When attempted to do so eye to rotates upward and outward
•
This condition is known as "Bell's" palsy
•
Causes flat nasolabial fold or groove
•
Cannot raise eyebrow to wrinkle forehead on affected side

Trigeminal Neuralgia
This involves facial pain that can manifest in one or more branches of the trigeminal
nerve. This includes the ophthalmic, maxillary, or mandibular branch of the trigeminal
nerve.

Herpes Zoster of Face

Herpes outbreak on the face is particularly painful condition that often manifests in the
nerves related to one branch of the trigeminal nerve. Patterns may be apparent that follow
the ophthalmic, maxillary, or mandibular branch of the trigeminal nerve. The outbreak
can also affect more than one trigeminal nerve branch.

Assess ment of Face a n d Jaw

Pathology affecting the head reflects in the face and j aw, or in the cervical spine region.
Therefore, these areas are examined and evaluated separately with face and jaw described
below and cervical spine follows in Chapter 7. Problems can develop in the face and jaw
that are the result of cervical spine pathology and thus examination of this area i s
accomplished whil e maintaining awareness o f possible influence from the neck. Some
problems affecting the face and j aw are also the result of dental related problems and
therefore some conditions may require dental evaluation as well .
Difficulties are also manifest a s result problems related to the cranial nerves such
as deficits in vision, hearing, and equilibrium; problems moving the eyeball and in
closing the eyelid; loss is sensory function of smell and taste; facial paralysis and
weakness in the trapezius and sternocleidomastoid muscles.

Inspection and Observation

Subj ective findings are considered first by identifying the location of either pain,
paresthesia, numbness, flaccidity or other manifestations. These are usually indicated on
a figure in the examination form. Nature ofthe symptoms is also noted as cramping,

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Chinese Orthopedics Head and Face 1 62

aching, shooting, burning, throbbing, tingling, and stabbing or soreness to help identify
the most likely structures or tissues involved.
Areas of possible swelling, heat, coldness or deformities are also identified.
Deformities should be described. The face and jaw as well as other regions of the body,
develop sensitive and painful sites. Certain radiation patterns may also be apparent and
these pathways, including direction that pain seems to radiate are noted.

Cranial Nerve a n d Facial Muscle Assessment

Assessment of muscles of the face, head and neck can provide a general condition of the
cranial nerves. This information can help determine if problems are associated with either
peripheral or central lesions. Many conditions that affect the head can manifest with
certain conditions that indicate possible cranial nerve involvement. Patients may also
present with complaints that directly implicate a specific cranial nerve. Cranial nerve
assessment should be considered when symptoms suggest their involvement, but also in
cases involving problems affecting the head and brain.
Cranial Nerve Assessment
A series of routine tests can be performed that test the sensory and motor function of the
twelve cranial nerves. Most of these tests derives information on possible pathology in
one particular cranial nerve, or can isolate the problem to one particular area of
involvement. The following represent initial tests that can be performed to derive
important clinical data or to indicate the need for more comprehensive testing. The
function of each of the twelve cranial nerves is listed below, indicating their function and
possible tests of these functions.
CN I. Olfactory: Sense of smell.
•
Inquire about any changes or impairment in their sense of smell
•
Have patient identify common odors like coffee and pungent substances
•
Test conducted with patient's eyes closed
CN II. Optic: Sense of sight.
Visual acuity:
•
Vision checked by eye chart or having patient read something; in acute head
trauma subject attempts to identify number of finger being held up
•
Patient asked to read something held close and then further away
Visual field:
•
Visual field checked by wiggling two fingers that are passed across various
levels of visual field on both sides moving first from periphery to center
•
Examiner wiggles two fingers and passes hand across visual field starting
from the far right or left at upper, middle, and lower levels
CN III. Oculomotor: Voluntary levator of eyelid; voluntary motor function of rectus
superior, medial, i nferior; and obliquus inferior muscles of eyeball; autonomic motor of
smooth muscles of eyeball. Eye muscles mediated by CN III include the superior rectus
that rolls the eyeball upward; inferior rectus that rolls the eyeball downward; medial

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Ch inese Orthopedics Head and Face 1 63

rectus which rolls the eyeball medially; and the inferior obliquus that rotates the eyeball
on its axis directing the cornea upward and laterally.
Pupillary reaction:
• Measure pupil accommodation with penlight obliquely shined into eye
•
Compare pupil size and measure "direct" and "consensual" response in both
eyes
Eye movement:
•
Six cardinal directions of gaze (See Figure 6.5) are measured by patient eyes
following finger tip, 45 em from patient' s nose, moved in space to form a
capital "H" pattern first to one side then up and down and back to start point
to move laterally to other side and move up and down and back to start. Finger
tip then moved to within several inches of nose causing eyes to cross

Figure 6.5. Six cardinal fields of gaze mediated by

Cranial Nerves I l l , IV, and VI

CN III lesion reflects as outward and slightly downward deviation of eye

Rolling the eyeball upward and medially involves using both the superior rectus
(CN III) in combination with the medial rectus (CN III). Rolling the eyeball downward
and medially involves using both the inferior rectus (CN III) in combination with the
medial rectus (CN III).
CN IV. Trochlear: Voluntary motor function of obliquus superior muscles of eyeball. The
superior obliquus mediated by CN IV rotates the eyeball on its axis directing the cornea
downward and laterally.
•
For eye movement, see six cardinal directions of gaze assessment under CN
III
•
CN IV lesion can cause upward and inward repositioning of affected eye
CN VI. Abducens: Voluntary motor function of rectus lateral is of eyeball. The lateral
rectus mediated by CN VI rolls the eyeball laterally.
•
For eye movement, see six cardinal directions of gaze assessment under CN
III
•
CN VI lesion can cause affected eye to drift medially

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Chinese Orthoped ics Head and Face 1 64

CN V. Trigeminal: Sensory function of face and deeper structures of head; and voluntary
motor function of mastication.
•
Facial sensation can be tested by touching the face for response by patient
•
Muscles of mastication including the temporalis, masseter, and medial
pterygoid function to close the mouth and can be collectively tested for
strength as well as by a reflex test
•
Lateral pterygoid functions in opening the mouth can also be tested for
strength
CN VII. Facial: Voluntary motor function of muscles of expression; motor function of
stapedius muscle; sensory function of taste for anterior 2/3 of tongue; autonomic function
of lacrimal, submandibular, and sublingual glands. The facial muscles of expression can
not be tested for strength, but can be observed for function which then can be graded as
either normal (N , 5), fair (F, 3 ), trace (T, 1 ), or zero (0) .
Facial motor function:
•
Have patient smile, wrinkle forehead, close eyes, pucker lips
1 . Upper motor neuron lesion, patient can wrinkle forehead and weakly close
eyes
2. Lower motor neuron lesion cannot wrinkle forehead and eye rolls upward
and outward when attempting to close eye
Taste:
•
Check anterior 2/3 of tongue by tasting and identifying sweet, sour, bitter, and
salty substance with patient' s eyes closed
Hyperacusia:
•
Stapedius muscle paralysis causes failure to dampen the stapes resulting in
increased acuteness of hearing
•
Inquire if patient has noticed that sounds have become loud and annoying
Autonomic function:
•
Check for lack of tearing or possible mouth dryness
CN VIII. Vestibulocochlear (acoustic nerve) : Sensory function of hearing and balance.
Hearing:
•
Can be tested by various means including a full auditory examination by a
specialist
•
Measured by snapping fingers or using ticking watch; also tuning fork applied
to forehead to see if sound heard in each ear
1 . Tuning fork applied to mastoid and timed until vibration not detected and
immediately placed next to ear for air conducted sound
2. Tuning fork normally heard in air conducted sound twice a s long as
mastoid bone conduction sound

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Chinese Orthopedics Head and Face 1 65

Equilibrium:
•
Tested by balance and coordination tests which should be differentiated from
problems associated with proprioception
•
Rhomberg's test - Patient stands with feet together, arms by side, eyes open
and note any problems with balance; then close eyes for 20 seconds and note
differences in balance
CN IX. Glossopharyngeal: Sensory function of touch and pain for posterior tongue and
pharynx; sensory function of taste for posterior tongue; voluntary motor function of
pharynx muscles; autonomic function of parotid gland.
Swallowing:
•
Have patient swallow
•
Can be tested by the gag reflex and the ability to swallow
Voice:
•
Have patient say "aaaah"
Taste:
• Apply common substances on the root of the tongue for patient to identify
flavor, with patient' s eyes closed
CN X. Vagus: Sensory function of touch and pain for pharynx, larynx, and bronchi;
sensory function of taste for tongue and epiglottis; voluntary motor function of palate,
pharynx, and larynx; autonomic motor function for thoracic and abdominal viscera.
•
Vagus nerve can be tested by gag reflex using tongue depressor
•
Check ability to swallow
•
Have patient say "aaah."
CN XI. Accessory: Voluntary motor function of the sternocleidomastoid and trapezius
muscles.
•
Motor supply to the trapezius muscle can be tested by a resisted shoulder
shrug test
•
Motor supply to the sternocleidomastoid muscles can be tested by resisted
head rotation test
CN XII. Hypoglossal: Voluntary motor function of muscles moving the tongue
•
Possible lesions tested by having the patient stick out their tongue and moving
it rapidly
•
Measure strength by applying resistance with tongue depressor held on side of
tongue
•
Tremulous movement of tongue or deviation of tongue to one side might
suggest a central lesion
•
In this case tongue deviates to same side as lesion

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthoped ics Head and Face 1 66

Graded Assessment
Several important muscles of the head and eyes are innervated by Cranial Nerves III, IV,
V, VI, IX, X, XI and XII (See Table 6. 1 ). Of these, CN V is of great importance since it
supplies motor function to the muscles which move the j aw for mastication. Unlike the
muscles which articulate body joints, most of the head and eye muscles cannot be graded
in terms of strength. Therefore, grading is based on completion of test movements.

Table 6. 1 . Facial motor and sensory function by Cranial Nerves I l l , IV, V, VI, VI I I , IX, X, XI and
X I I , along with assig n ment of muscular d istributions, excluding CN VI I .
Grd?
1
CN Region MD Motor or Sensory Area
I Nose Sens. Sens. Smell
II Eye Sens. Sens. Sight
Ill Eyelid PLF Levator PaiQ_ebrae Superior
Eye Rectus Superior. Medial. & I nferior
Obliquus Inferior
IV Eye Obliquus Superior
v Face Sens. Sens. Face & internal structure of head
Ear Tensor Tympani
Palate Tensor Veli Palatini
Mastication ALF Masseter
LF Temporalis
ALH Medial Pterygoid
ALH Lateral pterygoid
Suprahyoid ALH Anterior Digastric
ALF Mylohyoid
VI Eye Rectus Lateralis
VI I I Ear Sens . Sens. Hearing & Equilibrium
IX Tongue Sens. Sens. Taste. posterior 1 /3 tongue
Pharynx Stylopharyngeus
X Palate Soft Palate: Striated Muscles
Ear Sens. Sens. Auricular
XI Neck PLF Trapezius & Sternocleidomastoid
Palate Levator Veli Palatini
XII Tongue PLF Styloglossus
LH Hyoglossus
LH Geniglossus
Tongue lntrinsics
1 . Chinese muscular drstnbutron assrgnment.
2. Functional grade (Grd .) of either normal (N. 5), fair (F. 3), trace (T, 1 ) or zero (0).

The following grades can be considered: normal (N, 5) for completion of

effortless and controlled movement; fair (F, 3) for difficult completion of test
movements; trace (T, 1 ) for minimal muscle contraction; and zero (0) when no
contraction can be elicited. The muscles of mastication can be tested for strength but it is
not possible separate the combined effects of the temporalis, masseter and the medial
pterygoid muscles. The strength of the lateral pterygoid muscles can be evaluated.
Graded Assessment of Facial Muscles
Most of the face muscles are involved in facial expression and are innervated by CN VII
(See Table 6.2). Facial muscles also cannot be graded in terms of strength; therefore,
grading is based on completion of test movements. These are graded the same as the head

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthoped ics Head and Face 1 67

and eyes muscles . Paralysis of the facial muscles can be evaluated to determine if CN VII
is affected by a central or peripheral lesion.

Table 6.2. Facial m uscles of expression innervated by CN VI I showing relationship to superficial

branches of the Facial Nerve and assig nment of muscular d istributions.
1
CN Region MD Grd ? Motor or Sensory Area
_
VI I Tongue Sens. Sens. Taste. anterior 2/3 tongue
Ear Sens. Sens. External Ear
PLH Stapedius
Supra Hyoid PLH Posterior Digastric
LH Stylohyoid Facial Nerve Branches
Scalp PLF Occipitalis Posterior Auricular
Ear Ear lntrinsics
PLH Auricularis Posterior
PLH Auricularis Anterior Temporal
PLH Auricularis Superior
Scalp LF Frontalis
Eyebrow PLF CorruQator Supercilii Temporal & Zygomatic
Eyelid PLF Orbicularis Occuli - Upper
ALF Orbicularis Occuli - Lower
Nose PLF Procerus Buccal
ALF Dep. Septi & Nasi Transvr.
ALF Nasalis. Alar Portion
Mouth ALF Zygomaticus M ajor
ALF Levator Labii Superior
ALH Buccinator
ALF Orbicularis Oris
ALF Levator Anguli Oris
ALH Risorius
ALH Depressor Anquli Oris Mandibular
ALF Depressor Labii Inferior
Chin ALF Mentalis
Neck PLF Platysma Cervical
. .
1 . Trad1t1onal muscular d1stnbut1on ass1gnment.
2. Functional grade (Grd . ) of either normal (N, 5), fair (F, 3), trace (T, 1 ) or zero (0).

Temporomandibu lar Joint (TMJ)

The joint structures involved in the movement of the j aw associated with the
temporomandibular j oint are note in Table 6.3. The temporomandibular j oint is a critical
structure since movement of the mandible is essential to the mastication and intake of
food. This is perhaps why the four muscles that articulate the jaw are innervated by CN V
which lies deeper in the j aw and head.

I nspection and Observation

The j aw is inspected for possible deformities and functional abnormalities, including pain
and other symptoms associated with articulating the mandible.
Jaw Deformities
Typical deformities that may be present include an underdeveloped or small j aw
(micrognathia), a large or protruding j aw (prognathism) or hyperplasia of condyle of the
mandible.

D . E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Head and Face 1 68

Table 6.3. Joint structures involved in jaw movements.

Opening of Mouth Closing Protrusion Retrusion Lateral
Mouth Deviation
Articulation Temporomandibular (TM) TM TM TM TM
Plane Sagittal Sagittal Horizontal Horizontal Horizontal
Axis Frontal Frontal
Normal limiting Tension in temporomandibular, Occlusion or
factors sphenomandibular, and contact of
stylomandibular ligaments the teeth
Normal end feel Firm Hard
Capsular pattern Limitation in opening mouth to Limited: Limited:
(1 em) with deviation to restricted deviation to deviation to
side restricted opposite
side side
Normal range of 43.5 - 52. 1 7 . 1 - 9. 3 8.6 - 1 1 .5
motion (mm) 1
1 . There is wide variation in ROM values that are gender and age related where values decrease with age.

Occlusion of Teeth
The function of the j aw in normal closing is observed to note possible overbite or
crossbite. If overbite or crossbite/underbite is present, then anterior-posterior lateral
distance is noted as well the lateral offset from centerline.
Other Problems
Other problems are also noted that may be associated with temporomandibular j oint
dysfunction, including either missing teeth, presence of tooth pain, grinding of teeth or
dizziness/tinnitus.
Aggravating Conditions
Conditions or actions which aggravate temporomandibular joint problems, such as
opening or closing the mouth, chewing, speaking or swallowing are also noted.

TMJ Active Movements

Movement of the j aw is first observed by the placing the examiner' s index fingers in ear
of the seated patient with finger pads facing forward to feel the equality of condylar
movement as the patient opens mouth. Possibly clicking and grinding of the
temporomandibular j oint may be observed in addition to any differences as the condyles
move forward. The examiner stands in front of the patient and observes possibly lateral
deviation of the j aw during opening and closing the mouth. Obj ective measurements are
obtained during open the mouth as well as during lateral movement, protrusion and
retrusion of the j aw.
Depression of Mandible (Opening mouth)
Measurement of the possible deviation of the j aw, lateral to the midline, is noted at
approximately at the mid-range and also at full range of mouth opening. Amount of
deviation to either right of left of vertical in noted.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Head and Face 1 69

Functional ROM
The functional range of motion can be measured by having the patient place one or more
flexed fingers onto their mouth. I f the mouth can only accommodate one finger, this
indicates significant impairment. Normal mouth opening can accommodate two flexed
fingers and normal wide-opening can accommodate three. The total vertical distance that
the patient can open the mouth as measured between the upper and lower central incisors
is noted.
Protrusion of Mandible
With the mouth slightly opened the anterior-posterior distance that the jaw can be
protruded is measured along with any possible lateral deviation to right or left.
Retrusion of Mandible
With the mouth slightly opened and jaw in its normal position, the jaw is pulled back
(retrusion) as far as possible. This anterior-posterior distance is noted along with any
possible deviation in the lateral direction to right or left.
Lateral Movement of Mandible
With the mouth slightly opened the jaw is moved laterally to the right and left extremes.
The difference in the lateral deviation can be measured with a tape from the posterior
aspect of temporomandibular joint to the notch of the chin, noting the distance on both
the right and left sides for both right and left movement. Measurement of the offset
between upper and lower central incisors can be used in place of the tape measurements.

Auscultation
In addition to measuring the equality of movement and possible sounds of
temporomandibular joint by placing the examiner' s fingers in the ears, this joint can also
be examined by means of a stethoscope placed anterior to the auricle. Sounds are noted
during opening and closing the mouth as well as those during occlusion of the teeth.
Sounds during lateral movement and protrusion of the jaw are also noted. Characteristic
sounds include clicking, grating (crepitus), slipping and solid. Slipping and solid sounds
are often associated with the teeth coming together and seating during occlusion.

Passive Movements of TMJ

The active movements are next performed passively including opening and closing the
mouth, lateral movement both to right and left sides, and protrusion and retraction of the
jaw. Overpressure i s applied at the limit of each available range and most of these tests
are performed by taking a firm grip of the mandible with the examiner' s thumbs inside
the patient's mouth (examiner needs to wear sterile examination gloves). Overpressure at
the limit of passive movement permits assessment of end feel and the mobility of the
joint (graded 0 - 6) to distinguish between conditions such as muscle spasm versus joint
stiffness. Any change or reproduction of presenting symptoms is also noted.

Resisted Isometric Movement of TMJ

Resisted i sometric movements of the temporomandibular joints are difficult in that it is
not possible to isolate muscle strength of one particular TMJ. The jaw is held in the

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Head and Face 1 70

resting position by having the mouth opened slightly. This places the TMJ in the rotation
or hinge movements region of the inferior compartment. Firm but gentle pressure is
applied to the jaw or teeth and the patient is asked to only resist the movement.
-+ With regard to the resistive force, the examiner tells the patient, " Don't let me
move you" to avoid the patient trying to move the examiner's hand by applying a
greater counteracting force. This allows the examiner to control the applied force
to ensure isometric movement with minimum amount of unnecessary movement.

Depression
Opening the mouth or depression of the jaw involves the action of the lateral pterygoid
muscles. This isometric movement can be tested with the mouth slightly opened and
applying an upward resistance below the chin with one hand while the other hand is
placed behind the head or neck to stabi lize the head.
Occlusion
Closing the mouth (elevation or occlusion) involves the action of the temporalis,
masseter, and medical pterygoid muscles. This isometric movement can be tested with
the mouth slightly open and applying downward resistance at the chin with one hand
while the other hand is placed on the forehead to stabilize the head. Alternatively, the
examiner can apply pressure with two fingers of one hand on the lower teeth (use of
sterile examination gloves required) while the other hand is placed on the forehead to
stabilize the head.
Lateral Deviation
Lateral deviation of the jaw individually involves the lateral pterygoid of each TMJ. The
examiner places one hand above the TMJ opposite to the side being tested to stabilize the
head while the other hand is placed along the patient' s jaw with the mouth slightly open.
Patient pushes the jaw out in lateral deviation against the resistance of the examiner's
hand. Both sides are individually tested.

Functional Assessment
Functional activities or activities of daily living (ADL) are tested after the basic
movements of the TMJ have been completed. Activities examined include chewing,
swallowing, talking, coughing, and blowing.

Neurological Assessment
The main neurological assessment of the temporomandibular joint involves the jaw reflex
test (graded 0 - 4). This test is performed in the seated position with the patient' s mouth
slightly opened. The examiner places one thumb on mandible just below the lower lip
and this is struck with the reflex hammer. This test can also be performed with a tongue
depressor placed in the mouth in contact with the lower teeth, and the other end held by
the examiner. The tongue depressor is struck with the reflex hammer to produce a
response.
-+ This test is best performed with the patient having their eyes closed; otherwise
apprehension may result when patient sees the reflex hammer movement.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Head and Face 1 71

Additional neurological information, concerning the trigeminal nerve (CN V)

motor fibers which innervate the muscles that articulate the temporomandibular j oint, can
be obtained by resisted strength testing of the jaw or functional assessment as noted
above.

Accesso ry Movements of TMJ

Accessory movement of the temporomandibular joint on each side of the jaw can be
applied to evaluate the mobility (graded 0 6) in each plane by application of pressure on
-

the mandible or teeth. This involves five possible tests, described below, that are applied
independently to each side. These are performed with the mouth slightly opened for
external manipulation while other movements are performed by placing the examiner's
thumbs into the patient' s mouth. In the latter case, sterile gloves are used.
Accessory movement of the temporomandibular j oint can also be evaluated, with
the patient seated, by the examiner placing both thumbs on the lower posterior teeth
inside the mouth with the index fingers supporting the mandible outside the mouth. The
mandible is then distracted by downward pressure of thumbs while pulling downward
and forward with the index fingers while the other fingers push against the chin as a pivot
point. The examiner notes the characteristic tissue stretch of the j oint. Each j oint can be
tested individually while the other hand of the examiner is used to stabilize the head.
Transverse-Medial
Transverse medial accessory movement is accomplished by applying pressure with both
thumbs over the head of the mandible. With the patient in supine position, the examiner's
hands are placed on the head and j aw of the tested side with the thumbs on the head of
the mandible. Force is then applied in the transverse direction to determine the mobility
of the temporomandibular joint in this direction.
Transverse-Latera/
With the patient in supine position, transverse lateral accessory movement is produced by
placing one thumb in the patient 's mouth over the head of the mandible. Thumb pressure
is applied in the transverse lateral direction while the examiner's other hand is placed
over the head and forehead to stabilize the head position.
Posterior-Anterior
Posterior anterior accessory movement is evaluated with patient in prone position with
head resting on a pillow and rotated slightly to the test side. With the examiner' s hands
on the occiput and j aw of the tested side, pressure is applied by both thumbs over the
posterior surface of the mandible head in the anterior direction.
Longitudinal-Cauda/
Longitudinal caudal accessory movement is produced, while the patient is in supine
position, by using the downward pressure of one thumb over the molars to distract the
joint. Thumb pressure is applied in the downward longitudinal direction while the
examiner's other hand is placed over the head and forehead to stabilize the head position.

D.E. Kendall, OMD, PhD ©2005-2009

Ch inese Orthopedics Head and Face 1 72

Longitudinal-Cephalad
Longitudinal cephalad accessory movement is produced, while the patient is in supine
position, by using the upward compression of the temporomandibular joint by thumb
pressure over the lower mandible just anterior to the angle of the j aw. Thumb pressure is
applied in the upward longitudinal direction while the examiner's other hand is placed on
top of the head to stabilize the head position.

Palpation
The temporomandibular joint is first palpated at rest to determine the relationship
between the head of the mandible and the articular eminence of the temporal bone.
Palpation over the j oint confirms the presence of possible warmth, tissue tenderness and
swelling or thickening. Possible capsular thickening or hyperplasia of the condyle is
evaluated by comparison with the good side. The temporomandibular joint is also
palpated on motion with the examiner' s fingers in the patient' s ears as previously noted,
or placed anterior to the external auditory meatus. The movement, possible sounds and
crepitus can be detected.
The teeth are also palpated to detect painful or missing teeth and determine if pain
radiates from sensitive into the temporomandibular joint. The hyoid bone is checked for
position and movement as well as for possible pain, sensitivity or spasm in the anterior
and posterior digastric mm. The thyroid cartilage is also checked for freedom of motion.
Muscles articulating the j aw, especially the temporalis m., are palpated for possible
spasm or contraction and the existence of sensitive sites. Possible sensitive locations are
also checked for in the region surrounding the mastoid process and other muscles that
related to those that distribute to the jaw, such as the anterior and medial scalene mm .
The cervical spine area is also palpated for possible complications affecting the jaw.
Diagnostic Imaging
Plain Film Radiography
Anteroposterior view. The practitioner should note normal bone contours to
detect possible bone fractures; and should also note the condylar shape and contours.
Lateral view. The practitioner should also note normal bone contours in this view
to detect possible fractures. Position of the condylar heads with the mouth open and
closed should be noted along with condylar shape and contours. Condylar movement in
the open and closed positions should be noted in relationship to the TMJ and other bony
structures of the skull and cervical spine.
Magnetic Resonance Imaging
Magnetic resonance imaging of the head and face can provide a means to detect
soft tissue lesions which can than be differentiated between bone and soft tissue,
including the TMJ and the disc from the bony structures.
Computed Tomography
Computed tomography scans can produce cross section and axial views of the
head and face bones and soft tissue, providing a more precise image of fractures.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthopedics Head and Face 1 73

Dental Evaluation
In some situations it may be helpful for the patient to have a current dental evaluation.

M a nagement of Head and Face Problems

Head and face problems are somewhat unique since they are mostly influenced by the
effect that cranial nerves have on the muscles, vessels and sensory organs in this region
of the body. Needling therapy, therefore, mostly involves selecting those nodes that have
a profound affect on the cranial nerves and other structures of the head and face. The only
articular j oint is the temporomandibular joint and consequently mobilization and
manipulation techniques onl y apply to this specific area. Pressure techniques, including
ischemic pressure is effective in the treatment of both facial pain and temporomandibular
joint problems. Cupping with long but small diameter cups is sometimes employed in
treatment of facial paralysis. Remedial exercises are appropriate for both
temporomandibular j oint problems and facial paralysis.

Tem po romandibular Joint Mobilization

Physical techniques are typically used in treatment of pain and musculoskeletal disorders,
including the application of ischemic pressure technique on sensitive locations. In some
situations, needling therapy is applied prior to physical manipulations, but caution must
be exercised. Hence, physical manipulations are usually not applied after EN application
since electrical stimulation can produce profound analgesia.
Improving the function of the temporomandibular j oint involves using the same
techniques applied in performing accessory movements of the j oint (See Section on
Temporomandibular Joint Assessment). These techniques can involve transverse-medial,
transverse-lateral, posterior-anterior, longitudinal-caudal and longitudinal-cephalad
movements of the mandible.
Head and Face
Use of needling therapy to treat problems of the head face and neck consist of three
principal categories. The first of these involves the muscles, joints, ligaments and bones
of the jaw and the treatment of temporomandibular joint problems. The second involves
pathology affecting Cranial Nerve V resulting in facial pain or trigeminal neuralgia (See
Table 6. 1 for facial muscle innervation, except for CN VII). Facial paralysis, as result of
impairment of Cranial Nerve VII is the other important problem affecting the head and
face (See Table 6.2).
Temporomandibular Joint Dysfunction
Treatment of temporomandibular joint (TMJ) syndrome is unique in that all the
muscles articulating the mandible are innervated by the trigeminal nerve. For this reason
the node Xiaguan (ALF 7) is critically important to consider since it overlies the
trigeminal nucleus. Four muscles involved in moving the j aw belong to either the LF,
ALH or ALF distributions and therefore selection of possible distal nodes is simplified
(See Table 6.4). The lateral pterygoids and the temporalis muscles mostly affect the
temporomandibular j oint and therefore nodes affecting these muscles are selected. The
masseter muscle (ALF) also articulates the mandible but does not seem to play an
important role in TMJ problems, and therefore no distal ALF vessel nodes are indicated.

D.E. Kendall. OMD. PhD ©2005-2009

Chinese Orthopedics Head and Face 1 74

However, if it is determined that the masseter muscle is involved. distal ALF vessel
nodes could be considered. Pain radiation patterns associated with the
temporomandibular joint can distribute either to or from the teeth, mandible, scalene
muscles, temporal region or forehead. Thus under some situations additional nodes
influencing these regions may be considered as well. Indications for the related muscular
distribution include:
Lateral foot (LF) distribution:
•
Acute cramps, spasms and pain in jaw and parietal region including TMJ
syndrome
•
Conditions can include clenched jaw (trismus), one-sided parietal headache,
migraine, dizziness, vertigo, or retroauricular pain.
Anterior lateral foot (ALF) distribution:
•
Acute cramps, spasms and pain in region ofj aw and cheek.
•
Conditions can include either trismus, toothache, swelling of face and cheek,
tinnitus or motor impairment of the jaw.
Anterior lateral hand (ALH) distribution:
•
Pain, spasms and acute cramps under angle ofjaw, possibly including toothache
•
Pain, spasms and acute cramps under angle ofjaw when opening or closing the
mouth.

Table 6.4. Regiona l selection of nodes for temporomandi bular joint problems.

Temporomandibular Candidate Local & M D* Proximal Nodes Distal Nodes

Joint Disorder1 Adjacent Nodes
Shauigu (LF 8) LF Fengchi (LF 20) Zulingqi (LF 41 )/
Fubai (LF 1 0) Diwuhui (LF 42)
Qubin (LF 7 ) ALH Fengchi (LF 20) Hegu (ALH 4)
2
Xiaguan (ALF 7)
Jiache (ALF 6)
Yifeng ( L H 1 7)
*Muscular d1stnbut1on
( 1 ) Can consider bilateral treatment for TMJ although pain in only one side.
(2) Temporalis, latera l and medial pterygoids and masseter served by trigeminal nerve (CN V).

Candidate Electroneedling (EN) application for: temporomandibular joint dysfunction

Frequency/Mode/Duration: 2 Hz, continuous, 20-30 minutes
•
Xiaguan (ALF 7) + lead, to Shauigu (LF 8) - lead, if problem manifests in the
temporalis muscle
•
Xiaguan (ALF 7) + lead, to Hegu (ALH 4) - lead, if problem manifests in the
TMJ

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthoped ics Head and Face 1 75

Facial Pain
Pain affecting the face can either involve the entire face or manifest only
ipsilaterally. It may further only manifest in one particular region or face supplied by one
of the branches of the trigeminal nerve (CN V) and hence pain is felt only in either the
supraorbital, maxillary or mandibular regions. If pain is only reflected in a particular area,
nodes are selected specifi c ally for each region. Since sensory innervation of the face
involves the trigeminal nerve, the node Xiaguan (ALF 7) which overlies this cranial
nerve is selected for pain in any region of the face (See Table 6.5). Additional nodes can
also be considered depending on the particular pattern of facial pain and the progress
noted during the course of treatment.

Table 6.5. Regional selection of neurovascular nodes for treatment of facial pain or trigeminal
neura lgia in either the supraorbital, maxillary or mandibular reg ions of the face.
3 Cand idate Local & MD Proximal Nodes Distal Nodes
Facial Pain
Adjacent N odes
Su praorbital Region Yangbai (LF 1 4 ) LF, Xiaguan (ALF 7 ) Zhongzhu ( L H 3)
Taiyang (extra) PLF Fengchi (LF 20)
Zanzhu (PLF 2)
Maxillary Region Quanliao (PLH 1 8) ALF, Xiaguan (ALF 7) Hegu (ALH 4)
Sibai (ALF 2) ALH Fengchi (LF 20)
Yingxiang (ALH 20)
Mand ibular Region Mental Foramen Pt. ALF, Xiag uan (ALF 7) Hegu (ALH 4)
Daying (ALF 5) ALH Yifeng (LH 1 7)
J iache (ALF 6)

(3) Facial pain and trigeminal neuralgia usually treated on same side as problem.

Candidate Electroneedling (EN) application for:facial pain

Frequency/Mode/Duration: 2 Hz continuous mode, 20-30 minutes
Supraorbital Region:
•
Xiaguan (ALF 7) + lead, to Yangbai (LF 1 4) - lead
Maxillary Region :
•
Xiaguan (ALF 7) + lead, to Yingxiang (ALH 20) - lead
Mandibular Regi n:

•
Xiaguan (ALF 7) + lead, to Mental Foramen Pt. - lead
Facial Paralysis
Facial paralysis is usually the result of external affects on the facial nerve (CN
VII). Most often the condition is ipsilateral and involves the lower motor neurons. Since
the facial nerve is involved, the node Yifeng (LH 1 7) is critical to employ even though
the problem may only manifest in either the supraorbital, maxillary or mandibular regions
(See Table 6.6). Additional nodes can also be considered depending on the particular
pattern of paralysis and the progress noted during the course of treatment.

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Ch inese Orthopedics Head and Face 1 76

Facial paralysis often involves the inability to close the eyelid (ALF and PLF).
When attempted to do so eye to rotates upward and outward. This condition is known as
"Bell's" palsy. It is due to wind attacking vessels and collaterals and facial paralysis
occurs on the side exposed to the wind. Many of people are afflicted with this problem by
driving while window is open. Facial paralysis can also be induced by exposure to cold
from air conditioners, sleeping with neck exposed and weather conditions. Specific
dysfunction related to ALF distribution:
•
Unexpected or sudden deviation of the mouth, with acute condition that the eye
cannot close.

Table 6.6. Regional selection of neurovascular nodes for facial paralysis affecting either the
su praorbital, maxillary or mandibular reg ions of the face.

Area of Facial Candidate Local & MD Proximal Nodes Distal Nodes

4 Adjacent Nodes
Paralysis
Su praorbital Region Yangbai (LF 1 4) LF, Yifeng (LH 1 7) Zhongzhu (LH 3)
Taiyang (extra) PLF Fengchi (LF 20)
Zanzhu (PLF 2)
Maxillary Region Quanliao (PLH 1 8) ALF, Yifeng ( LH 1 7) Hegu (ALH 4)
Sibai (AL F 2 ) ALH Fengchi (LF 20)
Yingxiang (ALH 20)
Xiaguan (ALF 7)
Mand ibular Region Mental Foramen Pt. ALF, Yifeng (LH 1 7) Hegu (ALH 4)
Daying (ALF 5) ALH Fengchi (LF 20)
Jiache (ALF 6)
Xiaguan (ALF 7)
(4) Fac1al paralys1s usually treated on same Side as problem .

facial paralysis
Candidate Electroneedling (EN ) application for:
Frequency/Mode/Duration: 2 Hz - 25 Hz, mixed mode, 20-30 minutes
Supraorbital Region:
•
Yifeng (LH 1 7) + lead, to Yangbai (LF 1 4) - lead
Maxillary Region:
•
Yifeng (LH 1 7) + lead, to Yingxiang (ALH 20) - lead
Mandibular Region:
•
Yifeng (LH 1 7) + lead, to Mental Foramen Pt. - lead

D.E. Kendall. OMD. PhD ©2005-2009

Chi nese Orthopedics Cervical Spine 1 77

Cervical Spine
The cervical spine is unique in the fact that it is an easily articulated flexible structure that
supports the heavy mass of the head. Consequently, it is susceptible accidental damage as
well as wear and tear stress. Cervical spinal nerves supply the neck, shoulders, upper
back, and the arms. Pain and muscular problems can reflect in these areas making it
essential that assessment determines the most likely source cervical spine disorders as
opposed to problems originating in the upper body and limbs. One critical feature is the
phrenic nerve which supplies the diaphragm and has roots at the C3, 4, and 5 level and
upper cervical spine inj uries can impair breathing. Treatment involves mobilization
methods and needling therapy including possible electroneedling (EN), along with
possibl e movement and exercise rehabilitation.

Reg ional Anatomy of Cervical Spine

The cervical spine consists of 7 vertebra which form several joints. The first two of these
are the atlanto-occipital j oints (CO - C l ) where the atlas (C l ) articulates on the occipital
condyle (CO) of the skull (See Figure 7. 1 .). These two joints are critical to nodding the
head in flexion-extension ( 1 5° to 20°) and side flexion (about 1 0°) with negligible
rotation. The remaining intervertebral j oints contribute to remaining range of motions of
the cervical spine (See Table 7 . 1 ).

Apophyseal joints

- - I ntervertebral discs

T1 · I ntervertebral foramen

Figure 7 . 1 . Cervical Spine, Skull, and Thoracic A rea

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Chinese Orthopedics Cervical Spine 1 78

Verlabra
The atlas (C 1 ) does not have any
semblance of a vertebral body because Transverse Superior
Foramen Facet
during development it becomes the
odontoid process of the axis (C2). The
atlanto-axial joints, where the atlas (C 1 ) Body Spinous
articulates on the axi s (C2) i s the most Process
mobile spinal joint. It contributes about Transverse
1 oo of movement in flexion and P rocess Inferior
extension, approximately 5° in side Facet
flexion, and approximately 50° in
rotation. The odontoid process of C2
serves as a pivot point for this rotation.
Figure 7. 2 Featu res of cervical vertebra
Cervical vertebra C2 - C 7 have transverse foramen to accommodate vertebral arteries and
veins that respectively supply blood to and receive blood from the posterior brain.
Rotating the cervical spine beyond 50° can result in kinking of the contralateral vertebral
artery while the ipsilateral vertebral artery may be affected at 45° rotation. This can result
in a condition called "vertebral artery vertigo," as well as nausea, visual disturbances,
tinnitus, and falling attacks without fainting. There are intervertebral discs between each
cervical vertebrae from C2 - C7 consisting of a nucleus pulposus and a tough fibrous
outer ring, the annulus fibrosis.
Many features of cervical vertebra are common to thoracic and lumbar spine
except they are generally smaller. Vertebra C2 to C7 are unique by having transverse
foramen on each side to accommodate the vertebral arteries and veins. They also have a
body to support the weight on the spine, an intervertebral disc, neurocentra] joints,
apophyseal (facet) joints, transverse processes, spinous process, and intervertebral
foramen to distribute spinal nerves (See Figure 7.2).
Cervical Spine Ligaments
The cervical spine is held tightly together by strong ligaments that provide a crucial
function and are by necessity the normal limiting factors in movement (See Table 7. 1 ).
Cervical spine ligaments provide stability to the joints, absorb energy during trauma, and
act as a joint position indicators during physiologic motions. In addition, the ligaments
and paracervical muscles prevent motion between vertebrae that might injure the spinal
cord or nerve roots. The major ligaments of the cervical spine include the following:
•
Anterior longitudinal ligament: attaches to the anterior aspect of the body and disc of
each vertebra running longitudinally up and down the spine.
•
Posterior longitudinal ligament: runs longitudinally up and down posterior aspect of
the spine inside the spinal canal and attaching to the vertebral body and disc. This
ligament is thick in its central portion and helps prevent a disc herniation from
pressing posteriorly on the spinal cord.
•
Ligamentum flavum: forms a cover over the dura mater tissue that protects the spinal
cord and overlies the space between the laminae of adjacent vertebrae and the neural
arches. Due to its posterior location the ligamentum flavum helps to restrain
hyperflexion.

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Chinese Orthoped ics Cervical S pine 1 79

•
Apical ligament: single median ligament extending from the odontoid process of the
axis (C 2) to the occipital bone.
•
Alar ligaments: extend from the posterolateral aspect of the odontoid process of the
axis (C 2) and insert on the medial surfaces of the occipital condyles. Their main
function is to restrain rotation.
•
Transverse ligament of atlas: functions as a restraining band by holding the odontoid
process of C2 against the anterior ring of the atlas.
• Cruciate ligament: a cross shaped ligament of the atlas (C2) consisting of a transverse
ligament and superior and inferior bands, the former passing upward and attaching to
the margin of the foramen magnum, the latter passing downward and attaching to the
body of the atlas.
•
Capsular ligaments: are oriented approximately orthogonal to the articular facets to
provide maximal mechanical efficiency in resisting distraction of the facets but
relatively poor resistance to shear.
Nerve Supply
The cervical spine accommodates the cervical plexus (C l - C4) and most of the brachial
plexus (C5 - Tl ). Key muscle function supplied by the cervical spine, relative motor and
sensory functions, spinal segment nerve roots, and key reflexes are respectively provided
in Tables 3 .4, 3.5, 3 .6, and 3 .7. Function of prime mover (PM) and assistant mover (AM)
muscles of the head and neck supplied by the cervical and brachial plexuses indicating
related muscle distribution (MD) assignment and nerve root is provided in Table 7.2.
The cervical plexus is formed on both sides of the spine by the ventral rami of the
first four cervical nerves (C l - C4) with some contribution from the fifth cervical nerve
(C5). This plexus supplies the skin and muscles of the head (not including facial muscles
and muscles of mastication), neck, and part of the shoulders. Branches of the cervical
plexus also connect with the spinal accessory nerve (CN XI) and the hypoglossal nerve
(CN XII). Branches of the cervical plexus also connect with the spinal accessory nerve
(CN XI) and the hypoglossal nerve (CN XII). The phrenic nerves are also a critical pair
of nerves rising from the cervical plexus that supply the motor function for the
diaphragm.
The brachial plexus ( C5 - T 1 ) is comprised of a network of nerves arising from
both sides of the spine at the base of the neck. This plexus gives rise to the nerves
supplying the arm, forearm, hand and some parts of the shoulder girdle. Anterior rami of
cervical nerves C5 - C8 and first thoracic spinal nerves (Tl ) are the source input to the
brachial plexus which runs between the spine and the upper arm j ust after the axilla.

Cervica l S pine Physiol ogy

Physiological function of the muscles and tendons that articulate the cervical spine are
presented below. Each specific muscle is grouped by the Chinese longitudinal muscular
distributions by logical regions of the neck and shoulders. Joint structures involved in the
movement of the cervical spine along with those features, including the ligaments, which
contribute to restricted movement are noted in Table 7. 1 .

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Chinese Orthopedics Cervical Spine 1 80

Table 7 . 1 . Joint structu res involved in movement of cervical spine.

Flexion Extension Lateral Flexion Rotation
Articulation Atlantoccipital , atlanta- Atlantoccipital, Atlantoccipital, Atlantoccipital,
axial, intervertebral atlanto-axial, intervertebral atlanto-axial,
intervertebral (with rotation) intervertebral (with
lateral flexion)
Plane Sagittal Sagittal Frontal Transverse
Axis Frontal Frontal Sagittal Vertical
Normal limiting Tension in posterior Tension in anterior Tension in alar Tension in alar
factors atlantoaxial ligament, longitudinal and ligament limits ligament limits
posterior longitudinal anterior atlantoaxial flexion to the rotation to the
ligament, ligamentum ligaments, anterior contralateral side ipsilateral side
nuchae, ligamentum neck muscles, bony
flavum, tectorial contacts between
membrane, posterior spinous processes
neck muscles
Normal end feel Firm/ springy Bony Springy Soft/ soft springy
Normal active 0 - (45°- 50°) 0 - (45°- 60°) 0 - 45° 0 - (60°- 80°)
1 • 2
range of motion
1 . There is wide variation in ROM values that are gender and age related where females tend to be more
flexible and overall values decrease with age.
2. ROM values from the American Association of Orthopedic Surgeons (MOS) and American Medical
Association (AMA) guidelines.

Muscles of the Head and Neck

Function of these muscles is to extend, flex and rotate head by articulation of the cervical
spine. The specific function of each muscle is noted in Table 7.2 along with its particular
assignment in terms of the Chinese muscular distributions. The nerve root level for each
muscle is also noted. Additional information on the head and neck muscles include:
•
Are involved in many musculoskeletal problems especially involving trauma or
accident causing hyperextension or hyperflexion of head
• One of most common problems and can result from a simple fall or accident
•
These muscles also susceptible to tension related to stress and dysfunction due to
environmental exposure.
•
Muscles responsible for extending head belong mostly to the PLF distribution.
•
Muscles that flex head belong mostly to PMF distribution.
•
Muscles in lateral aspect of neck include the scalenus anterior (LF distribution),
scalenus medius (ALH) and scalenus posterior (LH).

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 Chinese Orthopedics Cervical Spine 1 8 1

Table 7.2. Function of prime mover (PM) and accessory/assistant mover muscles of the head and
neck indicating related muscle d istribution ( M D) assignment and nerve root.
- - - -- --

ActinQ Bilaterally Unilateral

Muscles MD Nerve Root Extension Flexion Lateral Rotation to Rotation to
Flexion Same Side Opposite Side
Rectus capitis anterior PMF C1 , 2 AM AM
- - - -- - --
1- --
Rectus capitis latera lis PMF C1 . 2 AM
-
1-- - --

Longus capitis
--
PMF
-
C 1 , 2. 3
-
r- r-
AM AM
-- I
I
- -- -

Longus colli cervicis PMF C2 - 7 AM AM AM

- -
1- -

l
--

Scalenus anterior LF C3 - 8 AM PM AM

I
r-- 1--
-- - -- - -- - - - -

Scalenus medius ALH C3 - 8 AM PM AM

-- -- --

Scalenus posterior LH C3 - 8 AM PM AM
- -
'---

Platysma PLF CN VII AM

-- -- -- - -- --

Sternocleidomastoid PLF CN XI: C 1 - 3 PM PM PM I

--- --

Rectus capitis pos. maj . PMF C1 , 2 AM AM

I -r--- :----
-- -
- -

Rectus capitis pos . min . PMF C1 . 2 AM

-r-- -
Obliquus capitis inf. PMF C1 , 2
- -
AM I
Obliquus capitis sup. PMF C1 , 2 AM AM

;
I
--

Splenius capitis PLF C1 - 5 PM PM PM

Splenius cervicis PLF C6 - 8

r-
PM I PM PM

Trapezius, upper PLF CN XI; C 1 - 3 AM AM

-

Iliocostalis cervicis PLF C6 - 8 PM PM

- - ----

Longissimus capitis PLF C6 - 8 PM PM PM

f- 1- ·-
-- - --

I
- -

Longissimus cervicis PLF C6 - 8 PM

-

- - -- ----
f-
Spinalis capitis PLF C6 - 8 AM
Spinalis cervicis PLF C6 - 8 PM
-

Semispinalis capitis PLF C1 - 5 PM PM

1- --

Semispinalis cervicis PLF C3 - 6 PM PM PM

- --

Rotatores, cervical PMF C2 - 8 PM PM

1- 1- --

I
-- - --

Multifidi, cervical PMF C2 - 8 PM PM PM

Interspinales, cervical
--
PMF
-
r-
C2 - 8
--
PM
I
lntertransversaii, cerv. PMF C2 - 8 PM PM
-- - _ _L _ J

Disorders of Muscles of the Cervical Spine

Common disorders manifested in the muscular distributions (See Chapter 2) associated
with the cervical spine involves pain and stiffness of the neck with the inability to turn
the neck in either direction or to flex the neck forward or backward. Any of the six
muscular distribution of the neck has slight variation in either the posterior or lateral
aspect of the neck.
Posterior Aspect
Posterior lateral foot (PLF) distribution:
•
Inability to bend the head forward.
•
Inability to tum neck left or right.
•
Abnormal curvature in the nape of the neck.
•
Muscular spasms in the nape of the neck.

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Chinese Orthopedics Cervical Spine 1 82

Posterior medial foot (PMF) distribution:

• Inabi lity to bend the head backwards.
Lateral Aspect
Lateral foot (LF) distribution:
•
Pain and spasms in the muscles and tendons in anterior lateral aspect of the neck.
Anterior lateral hand (ALH) distribution:
• Pain, spasms and acute cramps along lateral aspect of neck.
•
Inability to tum the neck left or right to look either direction.
Lateral hand (LH) distribution:
• Acute cramps and spasms along lateral aspect of neck.
Posterior lateral hand (PLH) distribution:
• Spasms in the neck muscles which can result in fistula of these muscles.
•
Swelling in the neck.

Pathology of Cervica l S pi ne
Given the unique anatomic features of the cervical spine it is susceptible to common wear
and tear disorders in present times as well as damage due slip and fall incidents and other
accidental trauma. Cervical disc degeneration is perhaps most common problem followed
by hypomobility lesions, cervical disc prolapse, and traumatic injuries.

Cervical Disc Degeneration

Intervertebral disc degeneration is commonly associated with the cervical spine. The neck
is a flexible structure supporting the weight of the head with an inflexible joint (fixed
inferiorly) at the thorax. Because of these features, the lordotic curve of the neck tends to
localize disc degeneration problems to the C5 - 6 and C6 7 levels.
-

Cervical Spondylosis
Spondylosis is much more common in the cervical spine than the lumbar spine. However,
cervical disc prolapse is less common than lumbar disc prolapse. Degenerative changes
noted in cervical spondylosis are associated with the discs, vertebrae, and apophyseal
joints, neurocentra} joints, often including osteophytic outgrowths. Common clinical
manifestations include:
Neck Pain
Neck pain is a common complaint in cervical spondylosis and is often associated
with stiffness. Manifests as a dull, aching but not severe pain, which is persistent and
made worse by sudden movements or by most physical activities associated with the
neck. Pain may be felt diffusely in neck, interscapular region, shoulder, or referred
distally into the arms. In this latter situation, the site of the pain does not always indicate
the spinal level of the disc degeneration.

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 Chinese Orthopedics Cervical Spine 1 83

Arm Pain
Pain in the arm due to cervical spondylosis may be referred pain from the neck or
be the result of nerve-root pressure. Referred neck pain often radiates into the extensor
aspect of the upper arm, but may be felt at times anywhere in the extremity. It can be
associated with deficits of sensation that are not segmental, or manifest with sensations of
heat and cold in the arm.
Arm pain due to nerve-root pressure often follows minor trauma or overuse by
activities involving excessive use of the arm or extension of the head. Mostly likely
associated with synovitis of the apophyseal joints and evidence of disc prolapse is usually
absent. The nerve root of C6 or C7 is commonly involved, with or without neurological
signs.
Headache
Headache is a common complaint in cervical spine disc degeneration involving
spondylosis and is also caused by hypomobility lesions of the upper cervical spine.
However, this does not include migraine headache which rarely is caused by cervical
spine problems. Migraine headaches mostly result from problems associated with the
cranial vessels and blood flow. Other causes for headache of cervical origin include:
arthritis of the atlantoaxial joints; musculotendinous lesions of the attachment of the
cervical muscles to the nuchal line; and, entrapment neuropathy of the occipital nerves.
Atlantoaxial Arthritis
The atlas (C l ) and axis (C2) vertebrae can be affected by infl ammatory and degenerative
arthritis including rheumatoid arthritis, spondyloarthritis, and osteoarthritis involving the
lateral atlantoaxial joints. Diagnosis of arthritis i s confirmed by suitable X-rays of
atlantoaxial region.
Entrapment Neuropathy
Neuropathy associated with the cervical spine can include entrapment of the occipital
nerves which are medial branches of the posterior rami of C2. Entrapment may occur as
the occipital nerve passes through the semispinalis capitis or trapezius muscles about 1
em from the midline. From here it crosses the nuchal line along with the occipital artery
and is distributed to the scalp and over to the frontal region.
Musculotendinous Lesions
Lesions involving musculotendinous attachments of cervical muscles to the skull at the
nuchal line may result in head pain. These may be the result of: alteration in the patient' s
posture perhaps due t o cervical spondylosis o r hypomobility lesions; tension i n the
underlying muscles in patients complaining of head and neck pain; and, tendinitis
occurring as the single clinical finding without evidence of the other associated
conditions.
Facial Pain
Facial pain can occur is lesions of the cervical spine, even in the absence of headaches.
Nature of the pain is often deep-seated, dull, and aching whereas pain due to the facial
muscles is more superficial. The pain is often unilateral and tends to be constant at a

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Chinese Orthopedics Cervical Spine 1 84

particular location. Can occur in the supraorbital regions, behind the eyes, or infraorbital
where it is sometimes mistaken for pain due to sinusitis.
Vertigo
Vertigo due to cervical spine disorders affecting the vertebral arteries and can involve
cervical spondylosis, hypomobility lesions, cervical trauma, and rheumatoid arthritis.
Vertigo as result of vertebral arteries is worse on moving the head or straining.
Scapular Pain
Pain referred to the scapula as result of cervical spine disorders has dull, throbbing like
toothache in relation to the scapula, with or without neck pain on the same side.
Anterior Chest Pain
Pain referred to the anterior chest can be bilateral, substernal, or felt in the anterior chest
wall . This arises from cervical spondylosis or hypomobility lesions. Pain is related to
exertion, posturing, or breathing. This pain can mimic pain due to heart disease and lung
disease.
Cervical Myelopathy
Cervical myelopathy can result from a narrowing of the spinal canal, hard bone and
cartilage projecting from the posterior aspect of the vertebral body affecting the spinal
cord. These conditions produce symptoms similar to spinal cord compression. The onset
is insidious with weakness in the lower legs. Exhibits upper and lower motor nerve signs.
Nerve Root Palsy
Nerve root palsy is a source of atrophy involving radicular lesions involving cervical
spondylosis at C5 level.
Leg Pain
Leg pain can manifest without signs of lumbar intervertebral disc changes, but can be
evident in cases of marked cervical spondylosis. The leg pain manifests as being poorly
localized with a dull, aching, or bursting nature. This is in contrast to signs of numbness
or paresthesia characteristic of cervical spondylosis which produces cervical-cord
compression. This may be a similar basis for leg pain and would help explain the
common occurrence of exaggerated tendon reflexes in the lower limbs in such cases.
Pressure Effects on Surrounding Tissue
Large anterior osteophytes can cause pressure effects on surrounding tissue even causing
dysphasia. These are often palpable as tender bony protuberances.

Cervical Hypomobility Lesions

Cervical hypomobility lesions manifest with pain and stiffness of the lower cervical spine
producing symptoms similar to cervical spondylosis, but without neurological signs.
C linical signs of hypomobility lesions involve the following:

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Chinese Orthopedics Cervical Spine 1 85

Neck Pain
Neck pain is usually well localized to one side. There may be painful restriction of active
and passive range of motion in certain directions only. Most common restrictions are in
extension, lateral flexion, and rotation toward the painful side.
Fibrositis
Fibrositis affecting the cervical spine involves infl amm atory hyperplasia of the muscle
sheaths and fascia of the neck muscles. This results in neck pain and stiffness with
palpable locations above and medial to the scapula.
Torticollis (Twisted Neck)
This condition involves a contacted condition of the cervical muscles producing a
twisting of the neck and an unnatural position of the head. Torticollis is prime example
hypomobility syndrome. Acute torticollis involves unilateral pain radiating up and down
the head and scapular regions. Neurological signs are absent except for the case of
torticollis due to pressure or irritation of the accessory nerve. Head flexes away from
painful side and not usually associated with head rotation.
Shoulder Pain
Hypermobility lesions of the cervical spine can result in shoulder pain. In one situation,
pain radiates from neck above the scapula into the shoulder where shoulder movements
are painless while neck movements are painfully restrictive and may reproduce the
shoulder pain. In another situation the patient may present with shoulder pain without any
neck pain but shoulder pain is reproduced by neck movements. Finally, there can be a
less common clinical situation where shoulder movements are painful while neck
movements are slightly painful or clinically normal. Although this seems to implicate the
shoulder, mobilization therapy to the C4 - 5 and C5 - 6 and traction can be beneficial to a
number of these cases.

Cervical Disc Prolapse

Prolapse of a cervical disc presents with severe pain usually felt in the neck, scapula, and
down the arm initially felt along a dermatome distribution.
Pain Distribution
Pain radiation patterns due to cervical disc prolapse are slightly different for specific
cervical spinal nerves as follow:
C5 - pain is felt over shoulder, but may radiate down arm.
C6 - pain radiates into the scapula, shoulder, lateral aspect of arm, to thumb and index
finger.
C7 - pain is felt over the upper border of the scapula, shoulder, down back of arm and
forearm, and middle fingers. Sensory changes may be apparent in the middle and index
fingers.
C8 - pain radiates to shoulder, medial arm, and forearm. Sensory changes may be
apparent in the two medial fingers (4 th and 5 1h fingers).

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Chinese Orthoped ics Cervical Spine 1 86

Neurological Manifestations
A complete lower and upper limb neurological examination is indicated in the case of
cervical disc prolapse. Neurological deficits including sensory, motor, and reflex changes
are assessed in the upper limbs. Possible motor neuron involvement affecting the lower
extremities is examined in terms of motor weakness or reflex changes, including
alteration in the p lantar responses.

Traumatic Cervical Syndrome

The cervical spine is highly susceptible to traumatic injury given the anatomical
configuration of the reasonably fl exible cervical spine fixed at thorax, carrying the
pendulous mass of the head. Any type of high velocity force imparted to the body, as
occurs in accidents and even simple fal ls, can result in inj uries to the head and cervical
spine. Some of these incidents result in factures of the cervical vertebra. Here, C 1 is often
fractured if the force is applied directly downward on the head. Fractures of C 1 are often
fatal. Impact of the body from different directions produce hyper forward and side
flexion, and hyperextension of the head, all which causes damage to the cervical spine.
Hyperflexion Injuries (Head-on or Side Impact)
Accidents involving a head-on or side impact results in hyperflexion of the head and
cervical spine in the direction from which the force was received. All structures in the
cervical spine can be injured, including intervertebral discs, ligaments, tendons, muscles,
and vertebrae. Cervical disc prolapse can result as can vertebral fractures.
Hyperextension Injuries (Rear-end)
Hyperextension of the head and cervical spine is limited by the apophyseal or facet joints.
These joints can be damaged resulting in significant pain and trauma to the cervical
spme.
Slip and Fa// Injuries
Slip and fall inj uries can also results in hyperflexion of the head and cervical spine,
especially if the individual ' s shoulder first impacts the ground. This put a high torque
load on the neck which can result in significant damage to the cervical spine, including a
broken neck.

Assess ment of Cervi ca l S pi ne

Inspection
The general impression of the patient's condition is derived during the initial intake as
described in Chapter 4. Once it is determined that the cervical spine is the most l ikely
source of the presenting symptoms special care is taken to observe finer details
concerning posture and other behaviors that may confirm these suspicions. Torticollis
may manifest by holding the head laterally flexed away from the affected side. Cervical
nerve root pressure may be associated with the patient holding a hand under the elbow or
arm of the affected side in an effort to relieve tension, or holding the head or neck to gain

temporary relief of pain.

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Chinese O rthopedics Cervical Spine 1 87

The upper, middle and lower portions of the cervical spine are somewhat unique
and symptoms arising from these areas manifest in slightly different patterns basically
associated with spinal nerve distribution. Problems associated with the upper division
cervical segments (0/C l , C l /C2 and C2/C3) may manifest symptoms in any area of the
cranium, the upper and middle cervical regions, the face, the temporomandibular joint,
the anterior and lateral aspects of the neck, the sternoclavicular region and the
suprascapular area. Pathology associated with the middle division segments (C3/C4 and
C4/C5) may produce signs in the lower cervical regions, the supra and medial scapular
areas, the shoulder, and the lateral aspect of the arm. Problems in the lower segments
(C5/C6, C6/C7 and C7/T l ) can produce symptoms in the lower cervical region, the supra
and medial scapular areas, and any aspect of the upper l imb, with the possible exception
of the axilla.

Active M ovements (Range of Motion)

Before active movement assessment is performed it is essential to consider the presence
of certain findings which would indicate possible caution. These include subjective
findings of osteoporosis, vertebral artery symptoms, acute nerve root symptoms, bilateral
limb symptoms (upper or lower), rheumatoid arthritis, and constant pain of unvarying
intensity, and current use of anticoagulant medication.
In the case of upper and lower limbs, the good side is tested first to obtain a
normal value to compare with the affected side. This same concept is also applied to the
cervical spine, however, many of the muscles from each side insert in close proximity
and therefore it is difficult to accurately assess the good side without influence from the
affected side. The patient first performs active flexion, extension, lateral flexion, rotation,
protraction and retraction in the seated position.
During these movements the examiner is noting possible limitations along with
signs of pain, spasms, or stiffuess. In addition, the examiner may help guide the
movements to assure correct completion and also may isolate the thorax to prevent
participation of the upper body in the movements. The examiner may also apply
overpressure at the end of movement range to either start confirming the irritability level
of the problems or to obtain a better estimate of the movement restrictions or production
of symptoms. Range of motion data are recorded along with subjective symptoms noted
during movement. Flexion, extension, and side flexion can be measured with a
goniometer or by using inclinometers. Head rotation in the seated position is measured by
goniometry or using a tape measure.
Neck Flexion
Forward bending or flexion of the neck can be achieved to a maximum of 80° to 90°.
especially when the chin is tucked in and touches the chest. Normal active range is
considered from 45° to 50°. A two finger width space between the chin and chest at full
forward neck flexion is considered normal. Some studies indicate a range in active neck
flexion of 3 9° to 64° with the lower values associated with older individuals.
Neck Extension
Backward bending or extension of the head is usually limited to 70° and normal range is
considered 45° to 60°. There is no anatomical block to prevent movement from going

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Chinese Orthopedics Cervical Spine 1 88

beyond this position with exception of eventual bony contacts between the spinous
processes and compression of the apophyseal joints. It is for these reasons that significant
problems occur due to hyperextension injuries (whiplash or cervical strain). Normally,
the plane of the nose and forehead is almost horizontal when the head is extended to the
full position. The atlas tilts upward when the head i s held if flexion resulting in posterior
compression between the atlas and the occiput.
Lateral Flexion
Lateral or side flexion ranges from 20° to 45 ° to the right and to the left. The greatest
amount of side flexion is contributed between the occiput and C 1 and between C 1 and
C2. While moving the head in side flexion the examiner needs to make certain that the
patient does not move their shoulder up to meet the ear.
Head Rotation
Normal head rotation is 60° to 80° in both right and left directions from the seated
position. The chin does not quite reach the plane of the shoulders.

Active Movement with Overpressu re

The purpose of examining active movement as noted above is to start confirming or
altering the impression of the problem's irritability and to establish a general view
concerning the patterns of motion restriction or production of symptoms. Passive testing,
such as discussed under accessory movements or even active tests with overpressure are
conducted to attempt to better understand the nature of the presenting symptoms.
Overpressure to active movements is applied at the end of the painless range of motion
and is applied as controlled small amplitude oscillatory movements at the limit of range
to determine end feel.
Cervical Rotation
Active rotation is requested of all patients, but some conditions should only proceed to
the onset of pain while others may continue to the physiological limit of motion. This
latter group is patients with non-irritable cervical disorders whose rotation is mostly
limited by stiffness as opposed to pain. Patient is seated while the examiner standing to
side, places their hands of each side of the head applying overpressure at the temporal
regions. If the patient has reached their limit of active rotation, the examiner may apply
pressure to the temporal region while the elbow of the other arm is applied to the back
and scapular region of the patient to passively move the head further into rotation.
Cervical Flexion
At the limit of cervical flexion, overpressure may be applied to determine the end feel
and pain response at the limit of physiological movement. Only the active cervical
flexion is performed in patients with predominantly irritable or painful conditions. For
others, passive overpressure in flexion is applied to determine the quality of end feel and
pain symptoms. Standing at the seated patient' s side, with one hand over the upper
thoracic area to monitor that trunk movement does not occur, the examiner places the
other hand on the crown of the head with the forearm aligned with the median of the
sagittal plane. If the patient is able to flex the head to the limit of range the examiner then
applies overpressure to determine the quality of end feel and pain symptoms.

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Head Protraction
Active head protraction with overpressure is used help differentiate between lower and
upper cervical involvement by comparison with cervical flexion, extension and head
retraction. While standing besides the seated patient, the examiner places one hand on
crown of patient' s head while other hand is held below the patient' s chin. Both forearms
are aligned in the median of the sagittal plane. The patient then shifts their head forward,
keeping their face aligned vertically. Overpressure may be applied to further flex the
lower division of the cervical spine while extending the upper segments.

Passive Movements
Passive movement of cervical spine involves tissue stretch at the limit of movement in:
• Flexion
• Extension
•
Right and left side flexion
•
Right and left rotation
Passive movements are conducted in the situation where the patient does not have
full ROM, or the end feel has not been assessed by applying overpressure at the end of
active movements. Passive movements are conducted with the patient lying in the supine
position.
Passive ROM values are greater in this position since residual contraction of neck
muscle is not required to support the head against gravitational forces. This is why
passive movements with overpressure are conducted in the supine position because
overpressure at the end of active movements under full gravity does not provide an
accurate impression of the true end feel.

Resisted Isometric Movements

Muscle strength resistive tests to help differentiate between contractile and non­
contractile lesions may have limited value for the cervical spine region. This occurs due
to the fact that cervical muscles, which resist a given movement, are not confined to one
aspect of neck motion. Thus, a particular muscle may be involved in resisting a number
of movements. It therefore becomes difficult to isolate the exact source of the patient's
symptoms. The other problem associated with resistive tests of the cervical spine occurs
because any contractions of the neck muscles tend to produce compressive effects on the
mobile segments they span. Contraction of some muscles may reproduce symptoms that
are the result of compression of an intervertebral disc or facet joint. Consequently,
muscular contractions which cause vertebral compression, tilt or shift or causes either
increased or decreased deformation of pain-sensitive joints can mimic contractile lesions
by producing or relieving symptoms. For these reasons, certain functional tests can be
used in place of resisted strength testing (See Table 7.3).
Isometric Movements
Isometric movements can be tested in the seated position as was done in the active
movements of the cervical spine. A resistive force is applied to oppose head movement in
the direction of flexion, extension, lateral flexion, and rotation.

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Chinese Orthopedics Cervical Spine 1 90

-+ With regard to the resistive force, the examiner tells the patient, "Don't let me
move you" to avoid the patient trying to move the examiner' s hand by applying a
greater counteracting force. This allows the examiner to control the applied force
to ensure isometric movement with minimum amount of unnecessary movement.

Flexion
Flexion of the head is resisted by the examiner' s hand on the patient' s forehead
while the other hand is placed between the scapulas to stabilize the thorax.
Extension
Extension of the head is resisted by the examiner's hand placed on the back of the
head while the other hand is placed on the upper chest to stabilize the thorax.
Lateral Flexion
Lateral flexion of the head is resisted by the examiner' s hand placed on the side of
the head while the other hand is placed on the opposite shoulder. Test is repeated to test
side flexion in the other direction.
Rotation
H ead rotation is resisted by the examiner's hands placed on each side of the head.
Patient resists movement in both direction of rotation.
Resisted Strength Tests
Useful information on the resistive strength of the cervical muscle can still be gathered to
assess possible contractile related symptoms. These tests are limited to flexion and
extension of the neck and examine the muscles in a general sense.
-+ In some types of neck problems, such as vertebral artery syndrome, these tests
are contraindicated.

Anterior Neck Flexors

Resisted movement of the neck into flexion involves the anterior neck flexor
muscles including the longus capitis, longus colli, rectus capitis anterior,
sternocleidomastoid and scalenus anterior muscles. Muscles which work as accessory to
these include the scalenus posterior, scalenus medius, suprahyoids, infrahyoids and the
rectus capitis laterali s muscles.
Patient is in the supine position with the elbows flexed and arms over the head
resting on the examination table. Strong anterior abdominal muscles help stabilize the
thorax; otherwise the examiners must perform this function by exerting hand pressure
force on the patient's chest during resisted movement.
With the chin depressed, the patient flexes the neck through partial (grade 2) or
full range (grade 3) of flexion. With the head partly flexed, resisted isometric force is
applied to the forehead while the patient attempts to maintain position.
Anterior-Lateral Neck Flexor (Sternocleidomastoid)
By rotating the head either to the right or left, the sternocleidomastoid muscle can
be tested when the neck is flexed. The patient laterally flexes the neck on the test side
while rotating the head to the opposite side. The sternocleidomastoid muscle can be

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Ch inese Orthoped ics Cervical Spine 1 91

palpated during flexion on the test side after which an isometric resistive force can be
applied by pressure on the forehead of the test side. Both sides are tested.
Neck Extensors
The neck extensors, including the splenius capitis, splenius cervicis, longissimus
capitis, spinalis cervicis, spinalis capitis, semispinalis cervicis, semispinalis capitis, rectus
capitis posterior (major and minor), and obliquus capitis (inferior and superior), are tested
as a group against gravity with the neck into rotation. The patient in prone position, with
arms above the head and elbows flexed, extends and rotates the neck either to the right or
left. Neck extensors on the side to which the head is rotated can be palpated
paravertebrally as a group. For resistance testing, an isometric force is placed just
proximal to the occiput on the rotated side of the head, to prevent extension and rotation.
The examiner's other hand is placed on the upper back of the patient between the
scapulae to stabilize the thorax.

Functional Assessment
Functional Strength Tests
As a result of possible complications of resistive strength test of the cervical muscles,
some examiners apply repetitive or sustained and gentle functional tests to gather
information on the condition of these muscles (See Table 6.3 . These functional strength
tests of the cervical spine can be graded as either normal/functional (N, 5), fair (F, 3),
poor (T, 1) or non-functional (0).
Functional Activity Assessment
Functional assessment can also be used to provide an overall assessment of the cervical
spine function. These can be the indications for the longitudinal muscular distributions as
previously discussed or it can also involve observation of normal activities including the
following: swallowing; looking at the ceiling; looking down at belt buckle or shoes;
checking the shoulder; retracting chin; or protruding the chin.

Table 7.3. Fu nctional strength testing of cervical spine muscles

Position Action Functional Fair Poor Non-functional
Supine Neck Flexion 1 6-8 Repetitions 3-5 Repetitions 1 -2 Repetitions 0 Repetitions
Prone Neck Extension Hold 20-25 sec. Hold 1 0-1 9 sec. Hold 1 -9 sec. Hold 0 sec.
2
Side Side Lifting Hold 20-25 sec. Hold 1 0-1 9 sec. Hold 1 -9 sec. Hold 0 sec.
3
Supine Rotated Flexion Hold 20-25 sec. Hold 1 0-1 9 sec. Hold 1 -9 sec. Hold 0 sec.
1 . Head is lifted keepmg chin tucked m. 2. Head IS l ifted 1n side bending, both sides are tested .
3. Head is lifted and rotated to one side; rotation to both sides is tested.

Neurological Assessment
The critical nature of cervical spine pathology dictates that a thorough neurological
examination be performed. This involves assessment of myotomes, key reflexes,
dermatome sensibility, motoric status and coordination.

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Myotomes
Neurological assessment with respect to the myotomes covers the whole range of cervical
nerves from C I to C8 and also including Tl . Nerve roots associated with the cervical
spine are evaluated by conducting resisted isometric force tests on muscles of neck and
upper extremities. These tests can immediately follow the review of the peripheral joints
noted above. They are conducted with the patient in the seated position, with the
examiner standing in front of the patient and the j oint(s) usually in neutral position. The
shoulder and upper extremity muscles of both sides of the body are evaluated
simultaneously to note differences in the left and right myotomes. Care is taken not to
apply force or pressure directly on the joints to prevent false indications. Muscle
strengths are graded 0 - 5 (Table 4.3).
Neck flexion (C1 , C2)
For this test, the patient' s head should be slightly flexed while the examiner
applies pressure to the forehead while stabilizing the trunk with the other hand placed
between the scapulae.
Neck Side Flexion (C3)
Neck side flexion is tested for both right and left movement. The examiner applies
force with one hand placed above the patient's ear while stabilizing the trunk by applying
pressure on the opposite shoulder.
Shoulder Elevation (C4)
With elbows partly flexed the patient raises the shoulder to about one half of full
elevation. The examiner applies a downward pressure on both shoulders while the patient
attempts to maintain position.
Shoulder Abduction (CS)
Patient abducts shoulders to about 70 to 80° while elbows are 90° flexed with
forearms in neutral or pronated position. Examiner applies force on the humerus of each
arm while the patient attempts to maintain position.
Elbow flexion (C6)
With the patient' s elbows flexed 90° and forearms in neutral position, the
examiner applies an isometric downward force on the forearms while the patient
maintains arm position.
Wrist Extension (C6)
With the patient's elbows flexed 90° and forearms pronated, the examiner applies
a downward force to the hands whi le patient resists extension of the wrist.
Elbow Extension (C7)
With the patient's elbows flexed 90° and forearms in neutral position, the
examiner applies an isometric upward force on the forearms while the patient maintains
arm position.

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C h inese Orthopedics Cervical Spine 1 93

Wrist flexion (C7)

With the patient' s elbows flexed 90° and forearms pronated, the examiner applies
an upward force to the hands while patient resists flexion of the wrist.
U l nar Deviation (C8)
With the patient's elbows flexed 90° and forearms pronated, the examiner applies
a lateral force (radially deviated) to the hands while patient maintains hand position.
Thumb Exte nsion (C8)
With the patient' s elbows flexed 90° and forearms in neutral position with the
thumb partly extended, an isometric downward force (into flexion) is applied by the
examiner' s thumb while stabilizing the patient's hand with the examiner's fingers.
Finger Abduction/ Hand lntrinsics (T1 )
Intrinsic muscles of the hand can be tested by having the patient hold a piece of
paper between the fingers while the examiner pulls the paper away or the patient may
squeeze the examiner's fingers. Finger abduction can also be tested by having the patient
slightly abduct the fingers while the elbows are flexed 90° and forearms pronated, and the
examiner applies isometric force (into adduction) while patient maintains finger position.

Key Reflexes
Key reflexes for the upper extremities are evaluated to provide additional information
concerning C5 to C8 root levels. The jaw reflex test provides information on cranial
nerve V. Key reflexes of upper extremity muscles supplied by lower cervical root nerves
are checked for both sides to note possible differences. The biceps, brachioradialis and
triceps reflexes are tested. In situations of possible upper motor neuron involvement,
plantar reflexes may be tested as well. Reflexes are graded 0 - 4 as noted in Table 4.4.
Biceps (CS - C6)
The biceps reflex is tested by placing the examiner' s thumb over the patient's
biceps tendon and then tapping the thumb.
Brachioradialis (CS - C6)
The brachioradialis reflex is tested by tapping directly on the patient's
brachioradialis tendon.
Triceps (C7 - C8)
The triceps reflex is tested by tapping directly on the patient' s triceps tendon.
Jaw Jerk (CN V)
(See previous Chapter 6 on temporomandibular joint)
Sensibility Tests
Sensory disturbances to light touch or pin prick are noted in relationship to cervical nerve
root dermatome distributions.

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Motoric Evaluation
The condition and status of the muscles are noted and the location of either spastic,
flaccid, rigid or clonic conditions are noted as well spasms or fasciculations. The
Babinski response can be evaluated in cases where a central lesion is suspected. Wasting
of muscle tissue is also noted and the girth of the affected muscle is measured and
recorded to be compared to the unaffected side.
Coordination
Simple index finger to nose coordination as well as reciprocal supination/pronation can
be noted for degree of completing the tasks.

Accessory Movements
Passive movements can include accessory movement, which for the cervical spine
involves applying pressure over the spinous processes and the articular pillar of the
cervical spine. Some passive movements are used to check the "passive range" of
movement by feeling the movement between adjacent structures, spinous processes and
articular pillars. One example of passive range testing is provided below in the test to
check the rotation of the occiput and C 1. Some of the accessory movement testing is
general in nature and can be considered passive physiological testing. Specific testing of
cervical spine accessory movement is performed to improve manual contact with bony
prominences and may involve displacing overlying soft tissue. These tests are directed to
discover if movement of specific segment levels reproduces the patient's main complaint
or symptom and whether certain spinal segments are restricted in normal accessory
movement.
General Joint Play Tests
Many of the j oint play movements performed on the cervical spine involve entire cervical
spine and are not directed to any specific joint. These involve glides of the head in
various directions, including traction.
Side Glide
With the patient lying supine and head extended over the end of table, the
examiner supports patient's head and moves it from side to side. The head is maintained
in normal longitudinal position and is moved in the same plane (frontal plane) as the
shoulders. This movement can be compared with overall cervical side flexion. Side glide
places the upper and lower cervical divisions in side flexion to opposite sides with the
middle division serving as transitional zone. Pain responses reproduced in side glide can
be compared with overall side flexion to help differentiate between upper and lower
cervical disorders.
Anterior and Posterior Glide
With the patient lying supine and head extended over end of table, the examiner
supports the patient' s head with one h and around the occiput and the other around the
chin, without choking the patient, and moves the head anteriorly and posteriorly. The
head is maintained in normal longitudinal position and is moved in the sagittal plane
without allowing the head to either flex or extend.

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Traction Glide
With the patient lying supine and head extended over end of table, the examiner
supports the patient's head with one hand under the neck and occiput and the other
around the chin, while applying a longitudinal pulling force in the vertical axis. This
traction is applied in a straight longitudinal direction with the major pull being exerted on
the occiput. This technique is useful evaluating symptoms affecting the distal regions of
the upper extremities.
Specific Joint Play Tests
Specific accessory movement tests can be used to gather information on the mobility of
specific joints in the cervical. These consist of rotation test for motion between the
occiput and Cl. The remaining tests involve application of pressure to the vertebrae and
the articular pillar. For these latter three tests the patient is prone with their head at the
edge of the table, with forehead resting in the palms of their hands, without a pillow
under the chest.
Rotation of Occiput on C1
With the patient lying supine and head extended over the table the examiner
supports the patient's head with a hand under the occiput and the other holding the
forehead. The tip of the thumb of the hand supporting the occiput lies between the
transverse process of C 1 and the adjacent mastoid process. Transverse process of C 1 is
located anterior and inferior to the mastoid process. When the patient's head is rotated
fully to the right, the tip of the examiners left thumb is positioned between the left
transverse process of C 1 and the left mastoid process. The patient's head is then rotated
back and forth through 20° of the inner third range. As the maximum rotation is
approached the transverse process is felt to draw nearer to the mastoid. Spacing between
the transverse process and mastoid increases as motion of the head approaches the
midline.
Central Posterior-Anterior Pressu re
This is often the first accessory movement of the cervical spine to be examined
and can be used as a pain-relieving treatment when performed at grade I or II (Table 3. 1)
with the cervical spine in neutral or pain-relieving position. Examiner stands at the
patient's head, leaning slightly forward with shoulders over the cervical spine, with
thumbs placed tip to tip over the spinous processes of interest. The pads of the thumb
make contact with the spinous processes while the fingers are directed toward the floor,
making comfortable contact with the sides of the patient's neck. Small amplitude
oscillations produced by movement of the hands is applied which is gradually increased
in depth while assessing the pain, stiffness and spasm responses. The force applied to the
vertebrae is imparted by the action of the arms and trunk and not by the thumbs.
Posterior-Anterior P ressure to Articular Pillar
This accessory movement involves posterior-anterior oscillations applied to the
articular pillar usually for unilateral symptoms in the neck, or conditions which cause
unequal limitations between right and left sides in rotation or side flexion. The Examiner
stands at the patient's head, leaning slightly forward with shoulders over the cervical
spine, with thumbs placed tip to tip to one side of the spinous processes over a facet

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Ch inese Orthoped ics Cervical Spine 196

region of the articular pillar of interest. The pads of the thumb make contact with the
articular pillar on the side of interest while the fingers are directed toward the floor,
making comfortable contact with the sides of the patient's neck. Small amplitude
oscillations produced by movement of the hands is applied in the anterior direction,
which is gradually increased in depth while assessing the pain, stiffness and spasm
responses. The force applied to the articular pillar is imparted by the action of the arms
and trunk and not by the thumbs.
Transverse Pressures
The Examiner stands to the side of the patient's head with thumbs placed tip to tip
along the side of the spinous processes of the cervical and thoracic spine. The pads of the
thumb (tip to tip) makes contact with the spinous process on the side of interest while the
fingers rest on the patient's neck and upper back on the opposite side. Small amplitude
transverse springy oscillations are applied to the side of the spinous processes while
assessing quality of movement. The amplitude of movement can be gradually increased
in depth while assessing the pain, stiffness and spasm responses. The transverse force
applied to the spinous processes is imparted by the action of the arms and trunk and not
by the thumbs.

Palpation of Cervical Spine

Posterior Aspect
• Occipital protuberance
• Spinous processes and facet joints
• Mastoid process
Lateral Aspect
• Transverse processes
• Lymph nodes
• Carotid arteries
•
Mandible, parotid glands, TMJ
Anterior Aspect
• Hyoid bone, thyroid cartilage, and first cricoid ring
• Paranasal sinuses
• Upper three ribs
• Supraclavicular fossa

Diagnostic Imaging
Diagnostic imaging is considered when deemed necessary to complement or expand on
the information derived from the clinical examination. Do to the nature and structure of
the cervical spine, and its role in supporting the head, it is susceptible to common
degenerative changes, anatomical variations, and congenital problems. These conditions
may or may not contribute to the patient's complaint.

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Plain Film Radiography

Plain film x-rays considered for the cervical spine include an anteroposterior, open mouth
(odontoid), and oblique view. Other views are considered to address specific pathologies.
Anteroposterior view. This orientation is used to examine the shape of the vertebrae, the
disc space, presence of lateral wedging or osteophytes, or cervical rib. Frontal alignment
of cervical spine is also evaluated.
Open mouth or odontoid view. This is an anteroposterior view through the mouth
observe the odontoid process of C2 in relation to C 1.
Lateral view. This view provides significant information about the cervical spine
including: variations in curvature; subluxations, kinking, displacements, or forward
shifting (Cl on C2) of vertebrae; horizontal displacement; abnormal shape of the
vertebrae; disc space; and lipping at vertebral edge or osteophytes.
Oblique view. This orientation provides a view of the intervertebral neural foramen and
the posterior elements of the cervical spine. Practitioner should note the presence of: facet
joint overriding; and lipping or osteophytes.
Magnetic Resonance Imaging (MRI)
MRI used to differentiate between various soft tissues and bone, including differentiating
between the disc annulus fibrosus and nucleus pulposus. May also reveal: disc lesions
and protrusions; visualization of spinal cord, nerve roots, thecal sac, bone, and bone
marrow. MRI angiography is useful in determining the condition of the vertebral artery.
Computed Tomography
Computed tomography (CT) helps delineate bone and soft tissue anatomy of the cervical
spine in cross section, including axial views, and show disc prolapse. CT scans can also
reveal: true size and extent of osteophytes; bone fragments in spinal canal after a fracture;
and bony defects in vertebral bodies and neural arches.

Management of Cervical Spine Disorders

Findings derived from the preceding process are considered in a logical process to
differentiate the presenting symptoms. From this, the most likely cause of the problem is
determined from which a treatment a management plan is devised. A logical approach to
treatment planning is based on the practical application of muscular distribution theory in
the selection of critical nodes to be used. Also, assessment and use of sensitive locations,
application physical modalities, and application of mobilization techniques are
considered. Needling therapy is then based on application local and adjacent nodes
associated with the affected region as well as use of both distal and proximal nodes
related to specific muscular distributions.
Typical treatment modalities include needling therapy, electroneedling (EN),
mobilization, and manipulation. Other modes of care are employed as needed and can
include cupping, moxibustion (in cold disorders), heat application, manual pressure,
tuina, and massage, articulation of joints, plasters and liniments. Traction and stretching
techniques may be appropriate as well. In situations of muscle weakness as result of
cervical spine pathology, a remedial exercise program may be indicated.

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Cervical Spine Mobilization

Physical techniques are typically used in treatment of pain and musculoskeletal disorders,
including the application of ischemic pressure technique on sensitive locations. In some
situations, needling is applied prior to physical manipulations, but caution must be
exercised. Hence, physical manipulations are usually not applied after electroneedling
since this technique can produce profound analgesia.
A wide range of mobilization procedures can be applied, each to address specific
problem areas or manifestation of specific clinical signs. These can be applied to affect
either the upper or lower portion of the cervical spine and can involve movement in
different directions. The techniques listed below provide one set of possible approaches
to address the most common problems encountered in the cervical spine.
Mobilization - Upper Cervical Spine
The following three mobilization techniques for the upper cervical spine are used to
address unilateral cervical pain or pain in the head arising from pathology at C 1- C2.
Longitudinal Movement
This procedure is basically the same as "traction glide" except an oscillatory
motion is induced by gentle longitudinal pulling to elongate the intervertebral joints and
then releasing the force and repeating the process. The procedure is concentrated on the
upper cervical region. Care is exercised not to relieve irritable nerve root type symptoms
completely so as not to induce patient apprehension when the procedure is completed and
some of the symptoms return.
Posterior-Anterior Central Vertebral Pressure
This procedure is basically the same as "central posterior-anterior" pressures. The
only difference is that oscillations of applying therapeutic force are deeper than that
which used to evaluate accessory movement. The other difference is this technique is
concentrated on the upper cervical spine.
Posterior-Anterior U nilateral Vertebral Pressure
This procedure is basically the same as "posterior-anterior pressure to articular
pillar." The main difference involves the amplitude of the oscillatory pressures, which in
the case of mobilization, is deeper and stronger. This procedure is concentrated on the
upper cervical spine.
Mobilization - Lower Cervical Spine
Mobilization techniques applied to the lower cervical spine include problems from C2 -
C7 and can also be considered applicable for the cervical spine in general.
Longitudinal Movement
This technique is basically identical to the procedure of the same name applied to
the upper cervical spine. The only difference in this case it is applied to concentrate on
the lower cervical spine region. This is often the first maneuver to consider and is used to
treat most cervical pain problems and also torticollis. Use of this technique gains the
confidence of the patient and also serves as a prognostic indicator if the patient improves.

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Posterior-Anterior Central Vertebral Pressure

Same as the same mentioned procedure noted above for the upper cervical spine.
This is used in situations of pain distributed down the midline or unilaterally down the
cervical spine. It is also applied for severe muscle spasms and cervical spondylosis.
Posterior-Anterior U n ilateral Vertebral Pressure
This is basically the same as the procedure noted above for the upper cervical
spine. It is applied for unilateral neck pain and cervical spondylosis.
Lateral Flexion
Used for unilateral pain in the neck, head, scapula or arm, and also used in case of
painfully restricted cervical rotation.
Transverse Vertebral Pressure
This technique is applied for cervical spondylosis and in situations of cervical
pain, especially if it is well localized or unilateral.
Rotation
This valuable technique is the first to be applied for unilateral neck pain.
Anterior-Posterior U nilateral Vertebral Pressure
This technique is used when pain is felt in the anterior or lateral aspect of the neck
which is reproduced by posterior-anterior pressure.
Cervical Traction
Manual traction can be used to address lesions affecting the upper and lower cervical
spine. Traction in flexion is useful to treat conditions of arm pain where there is
restriction of lateral flexion and rotation of the neck toward the painful side. Intermittent
variable traction can be used for cervical spondylosis. The rate of improvement in signs
and symptoms may be slower with device aided traction than is experienced with
mobilization techniques. Manual traction techniques are very similar to longitudinal
movement as described above. The difference being that longitudinal movement is
applied in the form of gentle oscillations while traction is applied as a steady force.
Sometimes traction can immediately relieve symptoms characteristic of acute
nerve root disorder, such as pain, numbness, tingling running down the upper arm, and
deep seated pain in the neck or shoulder. These symptoms can return after release of
traction forces. Therefore, the practitioner is careful to only apply manual traction to the
point that symptoms decrease but not necessarily disappear. This is necessary so not to
cause the patient distress when the symptoms return to full amplitude when the
longitudinal force is released. Relief of symptoms by manual traction would indicate that
this technique should be considered as a treatment choice, perhaps along with other
manipulations.
Manual Traction - Neutral Position
Manual traction in position of neutral rotation is used both as an examination and
treatment approach, especially where upper limb distal symptoms predominate. This

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technique is basically the same as "traction glide" or "longitudinal movement" previously

mentioned.
Manual Traction - Rotation
This procedure is the same as manual traction noted above, except the head is
rotated to the position of least pain before the traction is applied.

Needling Therapy for Cervical Spine Disorders

Problems related to the cervical spine frequently manifest in the posterior or lateral aspect
of the neck with possible radiation patterns to the upper extremities and sometimes the
lower extremities. Often the situation involves both the posterior and lateral aspect of the
neck. Use of needling to treat problems of the neck involves the muscles, joints,
ligaments and bones of the cervical spine as viewed in terms of the posterior and lateral
aspects of the neck (See Tables 7.4 and 7.5).
Posterior Aspect of Neck
Pain resulting from problems affecting the posterior aspect of the neck can also radiate
down into the upper back, the scapular and shoulder regions, as well as over the head to
cause headache. Local and adjacent neurovascular nodes are selected based on known
good nodes that inf1uence the local affected area. Selected proximal and distal nodes are
associated with the three (PLF, PMF, PL H) muscular distributions, which are usually the
source of the pathology (See Table 7.4). The PL H distribution (levator scapula muscle) is
frequently involved in both the posterior and lateral aspect of neck related problems.
Additional nodes may be selected as well, depending on either the specific nature of the
problem or the unique musculoskeletal dysfunction and pain radiation patterns.
Indications for related muscular distributions include:
Posterior lateral foot (PLF) distribution:
•
Inability to bend the head forward.
•
Inability to tum neck left or right.
•
Abnormal curvature in the nape of the neck.
•
Muscular spasms in the nape of the neck.
Posterior medial foot (PMF) distribution:
•
Inability to bend the head backwards.
Table 7.4 . Regional selection of nodes for treatment of pain and musculoskeletal dysfunction
of the posterior aspect of the head and neck.
Head and Neck Candidate Local & MD Proximal Nodes Distal Nodes
Reg ions Adjacent Nodes
Posterior Aspect Fengchi (LF 20) PLF Tianzhu (PLF 1 0) Feiyang (PLF 58)/
Jianjing (LF 2 1 ) Dazhu ( PLF 1 1 ) Kunlun (PLF 60)
Jianzhongshu ( PLH 1 5) PMF Tianzhu (PLF 1 0) Zhubin ( P M F 9)/
Dazhu (PLF 1 1 ) Taixi ( PMF 3)
PLH Tianzhu (PLF 1 0) Houxi ( P LH 3)
Dazhu (PLF 1 1 )

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Candidate EN application for:posterior aspect of the head and neck

Frequency: 2Hz; Mode: continuous; Duration: 20 - 30 minutes (consider bilateral
treatment); Candidate Nodes:
• Tianzhu (PLF 1 0) + lead, to Dazhu (PLF 1 1) -lead, if problem manifest
posterior neck muscles
• Fengchi (LF 20) + lead, to Jianzhongshu (PLH 15) -lead, if problem manifests
in the trapezius or levator scapula muscles
Lateral Aspect of Neck
Problems related to the lateral aspect of the cervical spine frequently manifest with
possible radiation patterns to the upper extremities and sometimes the lower extremities.
Radiation patterns can also distribute to the shoulders, jaw, teeth, anterior neck and the
forehead. Local and adjacent nodes are selected based on known good nodes that
influence the local affected area. Selected proximal and distal nodes are associated with
the four (LF, ALH, LH, PLH) specific muscular distributions related to the lateral aspect
of the neck. These structures are typically the source of the noted pathology (See Table
7.5). Additional nodes may be selected as well, depending on either the specific nature of
the problem or the unique musculoskeletal dysfunction and pain radiation patterns.
Possible indications and related muscular distribution include:
Lateral foot (LF) distribution:
• Pain and spasms in the muscles and tendons in anterior lateral aspect of the neck.
Anterior lateral hand (ALH) distribution:
• Pain, spasms and acute cramps along lateral aspect of neck.
• Inability to tum the neck left or right to look either direction.
Lateral hand (LH) distribution:
• Acute cramps and spasms along lateral aspect of neck.
Lateral posterior hand (LPH) distribution:
• Spasms in the neck muscles which can result in fistula of these muscles.
• Swelling in the neck.
Table 7.5. Regional selection of nodes for treatment of pain and musculoskeletal dysfunction of
the lateral aspect of the head and neck.

Head and Neck Cand idate Local & MD Proximal Nodes Distal Nodes
Reg ion Adjacent Nodes
Lateral Aspect Fengch i (LF 20) LF Fengchi (LF 20) Zulingqi (LF 41 )/
Tianyou (LH 1 6) Diwu hui (LF 42)
Tianchuang (PLH 1 6) APH Dazhu (PLF 1 1 ) Feish u Hegu (LI 4)
Jianji n g (LF 21) (PLF 1 3)
LH Fengchi (LF 20) Zhongzhu (LH 3)
PLH Jianzhongshu (PLH 15) Houxi (PLH 3)

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Ch inese Orthopedics Cervical Spine 202

Candidate EN application for: lateral aspect of the head and neck

Frequency: 2 Hz; Mode: continuous; Duration: 2 0-30 minutes (consider bilateral
treatment); Candidate Nodes:
•
Fengchi (L F 2 0) +lead, to Jianjing (LF 21) -lead, if problem manifest in
posterior neck muscles
•
Fengchi (LF 20) +lead, to Jianzhongshu (PL H 15) -lead, if problem manifests
in the trapezius or levator scapula muscles

Remedial Exercises for Head and Neck

Exercises ofthe head and neck include flexion, lateral flexion, extension, and rotation of
the neck to strengthen the prime movers and assistant muscles (See Table 7.2). In some
types of neck problems, such as vertebral artery syndrome, some of these exercises may
be contraindicated. In addition, in cases of traumatic neck injuries involving significant
movement of the head, the patient may be susceptible to benign paroxysmal positional
vertigo (BPPV). In this situation the neck exercises need to be performed in the seated or
standing position so as to not to provoke a BPPV episode.
Anterior Neck Flexors
Exercise of the neck in flexion involves the anterior neck flexor muscles including the
longus capitis, longus colli, rectus capitis anterior, sternocleidomastoid and scalenus
anterior mrn. Muscles exercised as assistant to these include the scalenus posterior,
scalenus medius, suprahyoids, infrahyoids and the rectus capitis lateralis mm .
Subject is in the supine position with elbows flexed and arms over the head
resting on the floor. With chin depressed, the subject flexes the neck through full range of
flexion and holds the position for 2 - 3 seconds and then slowly lowers head to start point.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5 sets as
conditions improve. As strength permits, shoulder and neck muscles can be contracted to
provide antagonistic internal dynamic resistance (IDR) (See Chapter 5) to head flexion.
Initial use of IDR for head flexion and other movements may require supervised practice
to assure that patient is able to effectively provide adequate internal resistive force for
. .
any given exercise.
Anterior-Lateral Neck Flexor (Sternocleidomastoid)
The sternocleidomastoid muscle is exercised by forward flexing the neck with the head
rotated to the opposite side of the problem side. The exercise is first conducted on the
unaffected side with the head rotated to the affected side. While supine with the elbows
flexed and arms over the head resting on the floor, the subject forward flexes the neck
through full range of flexion with the head rotated to the contralateral side and holds the
end-position for 2 - 3 seconds and then slowly lowers head to start point. This exercise is
repeated up to 8 repetitions and eventually performed for 4- 5 sets as conditions improve.
Repeat other side. As strength permits, shoulder and neck muscles can be contracted to
provide antagonistic IDR to anterior-lateral neck flexion.

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Ch inese Orthopedics Cervical Spine 203

Lateral Flexion
Prime movers: scalenus anterior, medius and posterior, sternocleidomastoid, splenius
capitis and cervicis, semispinalis capitis and semispinalis cervicis.
Subject is side lying with head on a pillow or on the floor. Head is slowly lifted
off the floor and laterally flexed to the full range possible. The end-position is held for 2 -
3 seconds and the head slowly lowered to start point. This exercise is repeated up to 8
repetitions and eventually performed for 5 sets as conditions improve. As strength
permits, shoulder and neck muscles can be contracted to provide antagonistic IDR to
head side flexion.
Neck Extensors
Exercising the neck extensors, includes the splenius capitis, splenius cervicis,
longissimus capitis, spinalis cervicis, spinalis capitis, semispinalis cervicis, semispinalis
capitis, rectus capitis posterior (major and minor), and obliquus capitis (inferior and
superior), muscles moved as a group with the neck into rotation. Neck extension is
performed with the head laterally rotated to one side to isolate extensor muscles on each
side of the neck. Neck problems often manifest one side.
With the subject in prone position, and arms above the head and elbows flexed,
the laterally rotated head is slowly lifted off the floor to extend to the full range possible.
The end-position is held for 2 - 3 seconds and the head slowly lowered to start point. Care
is taken to avoid moving the thoracic spine or shoulders during head extension. This
exercise is repeated up to 8 repetitions and eventually performed for 5 sets as conditions
improve. As strength permits, shoulder and neck muscles can be contracted to provide
antagonistic IDR to head extension. Repeat other side.
Neck Rotation
The function of neck rotation is unique in that muscles on both sides of the neck have
prime and assistant roles in moving the neck in the one direction. Those on the same side
include the splenius capitis and cervicis, and the erector spinae of the neck as prime
movers with the suboccipital group as assistants. At the same time, muscles on the
opposite side of the neck have prime mover role in simultaneously rotating the neck in
conjunction with the preceding muscles include the sternocleidomastoid, semispinalis
cervicis, cervical rotatores, and cervical multifidi, with the upper fibers of the trapezius as
assistant mover.
Subject is seated and gravitational forces are cancelled so externally directed
resistance (EDR) (See Chapter 5) needs to be employed to challenge muscles providing
neck rotation. Patient needs to be instructed in how to apply EDR for any particular
exercise. The same caution also applies to the use ofiDR to efficiently provide
significant internal resistive force to neck rotation.
While seated and facing forward, the subject places one palm on the lateral aspect
of their forehead to provide EDR to resist head rotation as the head is moved to the same
side. Basically the force provided by the muscles to rotate the head is only resisted by
hand on the forehead to the level that the head is allowed to rotate when applying EDR. If
head rotation is fully resisted, then this is applying an isometric force. Initially, it is
desirable to move the head with the external force.

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Chinese Orthopedics Cervical Spine 204

The head is rotated to one side using EDR with the palm on the side of the
forehead from the neutral position to full rotation to one side and back to start point. The
EDR is applied in both directions. This exercise is repeated up to 8 repetitions and
eventually performed for 4 5 sets as conditions improve. Rotation exercises first
-

performed on the good side and then on the affected side.

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Chinese Orthopedics Scapula 205

8.

Scapula

The scapula (omo or shoulder blade) in humans is a large but thin flat bone that is
basically triangular in shape and placed on a posterolateral aspect of the thoracic cage.
The scapula forms the posterior part of the shoulder girdle. Its main main purpose is to
provide the articualation surface of the glenoid fossa for the humerus and is the origin site
for several muscles that move the humerus. The scapula is held in its position by the
clavicle which articulates with the sternum and scapular acromium. There is a large spine
on the posterior upper aspect of the scapula that is easily noted externally and by
palpation.
Borders of the
scapula are identified
as the superior angle
at the top, the medial
border close to the
Levator Scapulae
spine, the inferior
Rhomboid Minor
angle at the lower
Rhomboid Major
Trapezius
aspect of the scapula, Superior angle
and the lateral border. Clavi cal
There are three main Supraspinatus Glenohumeral
fossa joint
fossa that provide -I

origins for key Acromium {' ;­

- _
Humerus

muscles that move the Scapular, ,

spme
1
humerus including the Infraspinatus
infraspinatus located fossa
on the posterior aspect Lateral border

below the scapular Medial border

Inferior angle
spine, the
supraspinatus on the
upper aspect of the
scapula above the
spine, and the Figure 8.1. Posterior muscles moving sca pu la
subscapular fossa on
(Serratus anterior, first serratus anterior,
the front of the pectoralis m inor, and subclavius not shown)
scapula for the
subscapularis muscle (See Figure 8.1 ). Other muscles that have their origins on the
scapula include the (See Table 9.3):
•
Coracobrachialis on the coracoid process
•
Biceps brachii (short head) on the coracoid process
•
Biceps brachii (long head) on the supra-glenoid tubercle
•
Triceps brachii (long head) on the infra-glenoid tubercle

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Ch inese Orthopedics Scapula 206

•
Deltoid on the spine of scapula
•
Teres major and minor on the lateral border
•
Latissimus Dorsi (a few fibers) on the inferior angle
•
Omohyoid on the superior border
The several muscles that function to move the scapula (along with the shoulder)
necessarily have their insertion sites on the scapula itself. Scapular movements are in
elevation, depression, protraction. retraction, lateral rotation, medial rotation, upward
rotation, downward rotation, anterior tipping, and posterior tipping (See Table 8.2). Two
fundamental joint are involved in moving the scapula with articulation between the
scapula, clavicle and sternum to form the acromioclavicular and sternoclavicular joints.
These joints are held together by ligaments which normally restrict movement of the
scapula (See Tables 8.1 a and 8.1 b). The scapula also provides the glenoid fossa for the
articualation surface of the humerus to form the important glenohumeral joint for
movement of the humerus (See Chapter 9).

Scapulothoracic Joint
The clavicle is anchored to the manubrium of the sternum to support and hold the
acromion of the scapula out from the rib cage to allow free movement of the arm. The
main body of the scapula is held in place on the upper posterior thorax by virtue of
musculotendinous structures and this is often referred to as the scapulothoracic joint. This
allows the scapula to be moved upward (elevation), downward (depression), outward
from the vertebral column (abduction) and inwardly toward the vertebral column
(adduction), as well as being rotated either medially or laterally. Two specific joints of
the scapula include the acromioclavicular and sternoclavicular joints.
A cromioclavicular Joint
The acromioclavicular (AC) joint is the junction between the acromion and the clavicle
and provides the ability to raise the arm above the head. This is gliding synovial joint and
functions as a pivot point; acting like a strut to provide a greater degree of arm rotation.
The acromioclavicular joint is stabilized by following ligaments:
•
Superior acromioclavicular ligament: consists of a quadrilateral band, covering the
superior part of the articulation, and extending between the upper part of the lateral
end of the clavicle and the adjoining part of the upper surface of the acromion.
•
Inferior acromioclavicular ligament: is somewhat thinner than the superior portion; it
covers the under part of the articulation, and is attached to the adjoining surfaces of
the both bones.
•
Coracoacromial ligament: consists of a strong triangular band extending between the
coracoid process and the acromion attached to the top of the acromion just in front of
the articular surface for the clavicle; and by its broad base covering the whole length
of the lateral border of the coracoid process.
•
Coracoclavicular ligament: connects the clavicle with the coracoid process of the
scapula providing an efficient means of retaining the clavicle in contact with the
acromion and consists of two fasciculi called the:

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 Chinese Orthopedics Scapula 207

o Trapezoid ligament, and

o Conoid ligament
Sternoclavicular Joint
The sternoclavicular (SC) joint is the junction between the clavicle and sternal
manubrium to provide a fixed reference on the thorax. It permits rotary movement of the
clavicle as well as elevating the arin in abduction above 1 10 degrees. There several
essential ligaments involved along with an articular disc, including the:
•
Anterior sternoclavicular ligament: is a broad band of fibers covering the anterior
surface of the articulation and attached to the upper and front part of the sternal end of
the clavicle. This ligament is covered by the sternal portion of the
sternocleidomastoid and the integument.
•
Posterior sternoclavicular ligament: is a band of fibers, covering the posterior surface
of the sternoclavicular joint and attached to the upper and back part of the sternal end
of the clavicle. It passes obliquely downward and medially, and fixed below to the
back of the upper part of the sternal manubrium.
•
Interclavicular ligament: is a flattened band which passes in a curved direction from
the upper part of the sternal end of one clavicle to that of the other, and is also
attached to the upper margin of the sternum.
•
Costoclavicular ligament: is short, flat, strong, and rhomboid in form attached below
to the upper and medial part of the cartilage of the first rib, it ascends obliquely
backward and laterally, and is fixed above to the costal tuberosity on the under
surface of the clavicle.

Neurology
Muscles moving the scapula are supplied by nerves that originate from spinal nerves C2
- T l and the Accessory Nerve XI, C2- 4 (See Table 8.2) as follow:
•
Spinal accessory nerve: trapezius, upper, middle, and lower fibers
Dorsal scapular and 3 r and 4th cervical nerves: levator scapulae
•
d

•
Dorsal scapular nerve: rhomboid minor, rhomboid major
•
Long thoracic nerve: serratus anterior
•
Anterior thoracic nerve: pectoralis minor
•
Nerve to Subclavius: subclavius
•
Thoracodorsal nerve: Latissimus dorsi

Scapular Physiology
The main function of the shoulder girdle is to hold the arm out from the body, by means
of the scapula and clavicle to allow full movement of the arm, hand and fingers. The
scapula must be elevated and rotated to accommodate either full flexion or abduction of
the arm, in order to maintain proper function of the glenohumeral joint. The planes and
axes of articulation of the scapular joints, normal limiting factors to movement, normal

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Chinese Orthopedics Scapula 208

end feels and active range of motion for shoulder girdle movements involving elevation
by either full flexion or full abduction of the arm, are noted in Table 8.1 a and 8.1 b.

Table 8 . 1 a. Joint structures involved in movement of the scapula.

Elevation DeQression Abduction Adduction
Articulation Scapulothoracic, Scapulothoracic, Scapulothoracic, Scapulothoracic,
Acromioclavicular, Acromioclavicular, Acromioclavicular, Acromioclavicular,
Sternoclavicu lar Sternoclavicular Sternoclavicu lar Sternoclavicular
Plane Frontal Frontal Horizontal Horizontal
Axis Sagittal Sagittal Vertical Vertical
Normal limiting Tension in Tension in Tension in trapezoid Tension in the conoid
factors costoclavicular interclavicular ligament, anterior ligament, a nterior
ligament, inferior ligament, sternoclavicular lamina of the
stemoclavicular joint sternoclavicular ligament, posterior costoclavicular
capsule, lower fibers of ligament, articular disk, lamina of the ligament, pectoralis
trapezius, pectoralis upper fibers of costoclavicular minor, and serratus
minor, and subclavius trapezius and levator ligament, trapezius, anterior
scapulae; bony contact and rhomboids
between the clavicle
and the superior
aspect of the first rib
Normal end feel Finn Finn/ hard Finn F1rm
Normal active 1 0 - 1 2 em (total range 10- 12 em (total range 15 em
(total range for 1 5 em (total range for
range of motion for elevation- for elevation- abduction-adduction) abduction-adduction)
depression) depression)

Table 8 . 1 b. Joint structures involved in movement of the scapula.

Medial (Downward) Rotation Lateral (Upward) Rotation
Articulation Scapulothoracic, Acrom ioclavicular, Scapulothoracic, Acromioclavicular,
Sternoclavicular Sternoclavicular
Plane Frontal Frontal
Axis Sagittal Sag itta l
Nonnal limiting Tension in the conoid ligament and serratus Tension in trapezoid ligament, anterior
factors anterior sternoclavicular ligament. the rhomboids and the
levator scapulae
Normal end feel Finn Firm/ hard
Normal active 60° displacement of inferior angle is 10 - 1 2 em 60° displacement of inferior angle is 1 0 - 1 2 em
range of motion (total range for medial-lateral rotation) (total range for medial-lateral rotation)

Muscles Moving the Shoulder Girdle

Only a small area of the head of the humerus makes contact with the glenoid fossa of the
scapula. Consequently, when the arm is raised in flexion or abduction beyond a certain
l imit, the shoulder must also rise and laterally rotate the scapula to maintain contact
between the glenoid fossa and the head of the humerus. Of the many muscles involved in
the complex movement of the shoulder girdle, the interplay between the trapezius (PLF),
rhomboids (ALH) and levator scapulae (PLH) muscles have strong influence on
problems affecting the shoulders. The muscles moving the scapula along with their
functions, nerve root innervation and muscular distribution assignments are noted in
Table 8.2. The lower (sternal) part of the pectoralis major muscle (PMH) also functions

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Chinese Orthopedics Scapula 209

as a prime depressor and accessory/assistant medial (downward) rotator of the scapula

although it inserts on the humerus.
Table 8.2. Function, nerve root, and muscle distribution ( MD) of prime mover (PM) and
accessory/ assistant mover (AM) muscles articulating the scapula and shou lder girdle
Medial 1 2 Adduc.4
Muscle MD Nerve Root Elevation Depress. Lateral Abduc3
Rotation Rotation
Trapezius upper fibers PLF XI; C2- 4 PM
Trapezius middle fibers PLF XI: C2 - 4 PM PM PM
Trapezius lower fibers PLF XI; C2 - 4 PM
Levator scapulae PLH C3-5 PM PM
Rhomboid minor ALH C4, 5 PM PM
Rhomboid major ALH C4, 5 PM PM
Pectora lis minor AMH C7, 8, T1 AM PM
Subclavius LF C5, 6 AM AM
First serratus anterior LF C5, 6 AM AM
Serratus a nterior, upper MH C 5 , 6, 7 PM
Serratus anterior. lower MH C5, 6, 7, 8 AM PM PM
Latissimus dorsi PLF C6, 7, 8 PM AM
1. Downward rotat1on; 2. Upward rotat1on; 3. Protraction; 4. Retraction

Disorders of Affecting Scapula

Problems of Muscles Moving the Scapula

There is a dynamic interplay between muscles that articulate the shoulder girdle,
especially between the trapezius and the rhomboids. Inability to raise the shoulders, for
example can be the result of problems in the trapezius, however, contraction or spasm of
the rhomboids can prevent the scapula from rotating and hence causes inability to raise
the shoulders as well. Therefore this particular problem can involve both the posterior
lateral foot (PLF) and posterior lateral hand (PLH) muscle distribution groups. Specific
disorders associated with the longitudinal muscle distributions related to the shoulder
girdle include:
Posterior lateral foot (PLF) distribution:
•
Inability to raise the shoulders due to pain in the trapezius and neck.
Posterior lateral hand (PLH) distribution:
•
Pain wrapping around the scapula and leading up to the neck.
Anterior lateral hand (ALH) distribution:
•
Pain, spasms and acute cramps from region of the rhomboids traveling up along
the neck.
•
Inability to raise the shoulders due to pain in the region of the rhomboids.
Anterior medial hand (AMH) distribution:
•
Spasms in the sides of the upper ribs associated with the pectoralis minor muscle.
Medial hand (MH) distribution:

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C hinese Orthoped ics Scapula 2 1 0

• Acute cramps and spasms along the serratus anterior muscles.

Lateral foot (LF) distribution:
•
Pain and spasms along top of shoulder.

Pathology of the Shoulder Girdle

Injuries o f shoulder affecting the scapula are common in athletics, bicycle incidents,
automobile accidents, and simple slip and fall accidents where the shoulder impacts the
ground or floor. Ligaments of the acromioclavicular (AC) and sternoclavicular (SC)
joints can be ruptured and joints can also be separated or dislocated. The joints are also
affected by arthritis. Ends of the clavicle can also be fractured requiring medical
assistance. Separated shoulders often occur in people who participate in sports such as
football, soccer, horseback riding, hockey, biking, rowing, rugby, snowboarding, and
wrestling. Joint separation are classified into 6 types, with 1 through 3 increasing in
severity, and 4 through 6 being the most severe.
A C Joint Sprains and Separations
Separation of the AC joint usually results from a fall or blunt force injury to the corner of
the shoulder. Referring to the AC joint as "separated" is understood to mean that the
ligaments are tom and the clavicle no longer lines up with the acromion. The injury
occurs at a point between the clavicle and acromion and felt as a prominence on the top
outside edge of the shoulder. This type of injury is common in sports such as hockey,
football, lacrosse, rugby, horseback riding, hockey, biking, and rowing. It also can occur
as the result of any fall or blow to the shoulder. The injury causes pain and difficulty
moving the arm, and depending upon severity may produce a bump or "step-off' which is
seen to increase by a downward pull on the arm, or when holding a weight by the side.
Examination may reveal signs of tenderness and swelling at the end of the clavicle with
potential instability at this site. This indicates that scapula may display excessive motion
in relation to the distal end of the clavicle. X-rays may used in the evaluation to exclude a
fracture of the scapula and grade the severity of the injury, especially if a weight is placed
in the hand and an X-ray is taken for comparison to the uninjured side.
Type I
A Type I AC separation involves trauma to the ligaments that form the AC joint
without no severe tearing or fracture. This would also be referred to as a First degree (1 °)
ligament sprain where only a few ligament fibers are torn (See Chapter 3). This results in
pain without any evidence of an AC joint separation.
Type II
A Type II AC separation involves a Second degree (2°) sprain or partial tear of
the coracoclavicular ligaments along with a complete tearing or Third degree (3 °) sprain
of the acromioclavicular ligament. When these injuries occur, the lateral clavicle
becomes a little more prominent appearing as causing a noticeable bump on the shoulder.
Severe pain and loss of movement are common.

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Chinese O rthopedics Scapula 2 1 1

Type Ill
In a Type III AC separation both acromioclavicular and coracoclavicular
ligaments are tom typical of a Third degree (3 °) ligament causing a complete separation
of the clavicle along with a significant permanent bump formed by the lateral end of the
clavicle.
Type IV
This is a type UI injury with avulsion of the coracoclavicular ligament from the
clavicle, with the distal clavicle displaced posteriorly into or through the trapezius. This
is a serious injury and generally known to require surgery.
Type V
This is type III but with exaggeration of the vertical displacement of the clavicle
from the scapula, and generally requiring surgery.
Type VI
This is type III with inferior dislocation of the lateral end of the clavicle below the
coracoid. It is extremely rare and generally the result of motor vehicle collisions. This
problem also requires surgery.
AC lntraarticular Meniscus Injury
The AC joint contains 2 types of fibro cartilaginous discs which vary considerably in size
and shape. They are classed as either complete or partial (meniscoid). This intraarticular
meniscus undergoes rapid degeneration with time until it is basically no longer functional
beyond the age of fifty.
A C Arthritis
Arthritis of the AC joints is a wear and tear condition affecting the cartilage needed to
allow the bones to move smoothly with each other. It is characterized by pain and
swelling, especially aggravated by activity. Eventually, the joint can continue to wear
down causing the joint get larger and with the development of spurs. Arthritis of the AC
joint can be aggravated by certain motions of the arm, such as reaching across the body
toward the other arm. Weight lifters are susceptible to AC joint wear and tear especially
with the bench press and to a lesser extent military press. Arthritis at the AC joint in
weight lifters is also referred to as "osteolysis" (an active resorption or dissolution of
bone).
Sternoclavicular Joint
The SC joint is one of the least commonly dislocated joints in the body. Motor vehicle
accidents cause nearly half of all SC dislocations. Sports injuries cause about 20 percent
and the remaining due to falls and other types of accidents. Indirect force by something
hitting the shoulder very hard causes most injuries to the SC joint. This causes the
shoulder to be pushed in and rolled either forward or backward, affecting the SC joint.
When the SC joint is dislocated by pushing the clavicle forward to be in front of the
sternum, is called an anterior dislocation. Dislocating in the opposite direction is less
common because the ligaments on the back side of the joint are so strong. This is called a
posterior dislocation.

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Chinese Orthopedics Scapula 2 1 2

SC Joint Dislocations
Dislocation of the SC joint causes severe pain that is aggravated by any
movements of the arm. The medial end of the clavicle juts out near the sternum in
anterior dislocation. This causes a hard bump in the middle of the chest while in posterior
dislocation a bump is usually not obvious. Severe pain and tenderness are present over
the SC joint in an anterior dislocation. Any movement of the shoulder causes increased
pain. Pain is also increased when the patient is supine, and the individual usually prefers
a sitting position, supporting the arm on the injured side.
Posterior dislocation of the SC joint is caused by both direct and indirect trauma
resulting in the backward displacement of the clavicle medial. Posterior dislocations are
extremely hazardous to the mediastinal structures, causing pressure against the trachea
and heart and its great vessels. This is very serious and can cause difficulty breathing,
shortness of breath, or a feeling of choking. Some patients have trouble swallowing or
have a tight feeling in their throats. This situation requires immediate medical help to get
the SC joint back into position.
Sprains
Sometimes excessive force may only sprain the SC joint. Mild sprains cause pain,
but the joint is still stable. However, the joint becomes unstable in moderate sprains.
Ligament Inj u ry
In rare cases, patients have a stable joint but a painful clicking, grating, or
popping feeling. This indicates an injury to the intra-articular disc ligament. This type of
injury causes pain and problems moving the SC joint.
Arthritis
Injury to the SC joint can result in the development of osteoarthritis which
eventually causes pain and stiffness.

Examination of the Scapula

The shoulder is inspected with respect to clavicle, sternum, and acromion for possible
dislocation, separation, or obvious signs of arthritis affecting the acromioclavicular (AC)
and sternoclavicular (SC) joints. A preliminary functional assessment can be performed
by having the patient to elevate, depress, protract, or retract the scapula. Patient is asked
to report any clicking or grinding sounds from the AC or SC joints. If possible, the
patient is asked to elevate the arm in abduction above 11 0 degrees to check for scapular
rotation.

Active Movements of Scapula

Active and passive movement of the scapula is usually evaluated on the basis of visual
observations because of the nature of the scapulothoracic structures that are sometimes
considered as a joint. The range of motion (ROM) is estimated as either "full" or
"restricted" although some objective measurements can be obtained. Measurements of
individual scapular movements are usually relative over a given range between the limits
of opposing motions, such as between the limits of elevation and depression, abduction
and adduction, and medial rotation and lateral rotation (see Table 8. 1 a and b). Active

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Chinese Orthopedics Scapula 2 1 3

movements of the scapula are observed with the patient seated, initially in a relaxed
anatomical position.
Elevation
The normal active range of motion (ROM) between elevation and depression of the
scapula is 1 0 - 1 2 em. In active elevation of the scapula the patient moves the shoulders
up toward the ears in a cranial direction.
Depression
The normal active range of motion (ROM) between elevation and depression of the
scapula is 1 0 - 1 2 em. In active depression of the scapula the patient moves the shoulders
downward toward the waist in a caudal direction.
Abduction
The normal active range of motion (ROM) between abduction and adduction of the
scapula is approximately 1 5 em. From the start position, the patient flexes the arms to 90°
and scapular abduction is observed as the patient reaches forward. The vertebral border of
the scapula moves away from the vertebral column.
Adduction
The normal active range of motion (ROM) between abduction and adduction of the
scapula is approximately 1 5 em. In active adduction the patient moves the scapulae
horizontally toward the vertebral column.
Medial Rotation
The normal active range of motion (ROM) between medial and lateral rotation of the
scapula is approximately 60° or 1 0 - 1 2 em displacement of the inferior angle of the
scapula. In active medial rotation of the scapula the patient adducts and extends the arm
as if to place the dorsum of the hand on the small of the back. The inferior angle of the
scapula moves in a medial direction during this movement.
Lateral Rotation
The normal active range of motion (ROM) between medial and lateral rotation of the
scapula is approximately 60° or 1 0 - 1 2 em displacement of the inferior angle of the
scapula. In active lateral rotation of the scapula, the patient elevates the arm either in
flexion or abduction. The inferior angle of the scapula moves in a lateral direction away
from the vertebral column.

Passive Movements of Scapula

Passive movements of the scapula are employed to further evaluate presenting symptoms
and to assess end play characteristics at least for scapular elevation, depression, abduction
and adduction. In these four passive tests the patient is lying on the side with the test side
up and with the head relaxed and supported on pillows.
Elevation
The normal end feel at the limit of scapula elevation is firm. This is assessed with
examiner's right or left hand cupping the inferior angle of the scapula and elevating the

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Chinese Orthopedics Scapula 2 1 4

scapula by pressure applied in the cephalad direction. The examiner's other hand assists
in controlling the direction of movement.
Depression
Normal end feel at the limit of scapula depression is finn/hard. In passive depression of
the scapula the examiner's right or left hand i s placed on top of the shoulder and
depresses the scapula. The examiner's other hand cups the inferior angle of the scapula to
assist in controlling the direction of movement.
Abduction
Normal end feel at the limit of scapula abduction is finn. In passive abduction of the
scapula, the examiner grasps the vertebral border and inferior angle of the scapula and
abducts scapula by pulling laterally upward. The examiner's other hand is placed on top
of the shoulder to assist in scapular abduction.
Adduction
Normal end feel at the limit of scapula adduction is firm. In passive adduction of the
scapula, th e examiner grasps the vertebral border and inferior angle of th e scapula and
adducts scapula by pushing medial toward the vertebral column. The examiner's other
hand is placed on top of the shoulder to assist in scapular adduction.

Resisted Movements of the Scapula

Isometric muscle strength testing of the scapula is conducted for scapular elevation,
depression, adduction, abduction and rotation. These movements are necessary in order to
evaluate the principal muscles that move the scapula. Against-gravity isometric tests and
gravity-eliminated tests are considered for each movement to measure the full range of
strength for all the muscles involved. Resisted movements against-gravity are used for
measuring muscle strength grades from 3+ to 5, while unresisted movement just against
the force of gravity result in grades from 2+ to 3 (see Table 4.3). The unresisted against­
gravity tests are conducted first through the full range of motion (ROM) as an initial
screening. Successful completion of this test then directs the examiner to perform
against-gravity isometric tests to evaluate muscle strengths in the range of 3 + to 5, and
the gravity-eliminated test is not required to be conducted.
Failure of the against-gravity screening test then indicates that examiner go
directly to performance of gravity-eliminated tests. Gravity-eliminated tests are necessary
to evaluate muscle strength grades from 0 to 2.
-+ With rega rd to the resistive force , the examiner tells the patient, "Don't let me
move you" to avoid the patient trying to move the exa m iner' s hand by applying a
g reater counteracting force . This a l l ows the exam iner to control the appl ied force
to ensure isometric movement with m inimum amount of unnecessary movement.

Trapezius Muscle Screening Test

A convenient screening test can be performed before a detailed assessment is performed
on scapular elevation. This i nvolves simultaneous contraction of the upper, middle, and
lower fibers of the trapezius muscles on both sides. The patient stands with hands raised
above their head with the back facing the examiner. The hands are held together with
palms facing forward and one palm placed on the back of the other. The patient maintains

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 Chinese Orthopedics Scapula 2 1 5

their standing position while the examiner pushes on both elbows. Contraction, o r lack
thereof, can be observed for upper, middle, and lower fibers of the trapezius muscles.
Scapular Elevation
Elevation of the scapula is accomplished by the upper fibers of th e trapezius (PLF) and
the levator scapulae (PLH) muscles pulling up on the scapula. The rhomboid major and
minor muscles (ALH) are accessory muscles to scapular elevation.
Against-Gravity: Upper F ibers of Trapezius and Levator Scapulae
Elevation of the scapula is tested with the patient seated, the shoulder abducted
slightly, and the elbow flexed 90°. The patient elevates the shoulder to bring the
acromion closer to the ear while the examiner palpates the upper fibers of the trapezius
about midway between the inion and the acromion process. The l evator scapula lies
deeper a may not be palpable. This test can be conducted unilaterally by elevating only
one shoulder while the examiner stabilizes the origins of the muscles in question by
placing one hand on the lateral aspect of the head. When successfully completed, resisted
strength grades are then determined.
-+ During the u n ilateral shoulder elevation screening test the patient may attempt to
substitute towering the ear to the shoulder and contralateral trunk side flexion.

Isometric strength tests are performed starting with the shoulder partially elevated
with resistance applied over the top of the shoulder downward in the direction of scapular
depression. If tested unilaterally, the examiner stabilizes the h ead by placing one h and on
the lateral side of the head while resisting elevation by pressure applied over the shoulder
with the other hand.
Gravity-Eliminated : Upper Fibers of Trapezius and Levator Scapulae
This test is conducted with th e patient lying prone, with arms at the side and the
shoulder in neutral position and the head stabilized on the examination table. The
examiner supports the weight of the upper extremity on the tested side to reduce friction
between the shoulder and the table. The patient then elevates the scapula through the full
range of motion while the examiner palpates the upper fibers of the trapezius.
-+ During the u n i lateral scapu lar elevation the patient m a y attem pt to su bstitute
contralateral trunk side flexion .

Depression and Adduction o f Scapula

The lower fibers of the trapezius (PLF) h ave a principal role in depressing and adducting
the scapula and the middle fibers of the trapezius work as an accessory muscle to this
movement.
Against-Gravity: Lower Fibers of Trapezius
This initial screening test is conducted with the patient lying prone, with h ead
rotated to the opposite side, and the shoulder abducted to about 1 30° with forearm in
neutral position. The patient then raises the test arm to produce depression and adduction
in the scapula while the examiner palpates the lower fibers of the trapezius medial to the
inferior angle of the scapula along a line between the spinous process of T1 2 and the root
of the scapular spine. When this screening test is successfully completed, resisted
strength grades are then determined.

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Chinese Orthopedics Scapula 2 1 6

� Patient m a y attem pt to su bstitute contraction o f t h e m iddle fibers of t h e trapezius

and trunk extension.

If the patient is unable to abduct the arm into the screening test position or the
posterior shoulder joint muscles are weak, the arm can be placed at the side or allowed to
hang down over the edge of the table. With a hand placed on the scapula the examiner
moves it into depression and adduction and the patient then attempts to hold the scapula
in this position.
For the resisted isometric strength test, the patient lies prone in the screening test
position noted above with the shoulder abducted to about 130° and forearm in neutral
position. Resistive force is applied over the scapula in the direction of scapular elevation
and abduction to fully resist movement when the patient raises the arm. In all tests where
the examiner stabilizes the scapula care is taken not to actual move the scapula. An
alternate to this test involves applying resistive force against the patient's forearm in a
downward direction. Use of the arm as a resistive lever assumes that the posterior
shoulder joint muscles (deltoids) are strong.
G ravity E liminated: Lower Fibers of Trapezius
Gravity-eliminated testing of scapular depression and adduction is conducted with
the patient lying prone with arms relaxed at the sides. The examiner supports the upper
extremity to react out the force of gravity and to reduce friction between the patient's
shoulder and the examination table. The patient then depresses and adducts the scapula
through full range of motion.
� Patient may attem pt to su bstitute contraction of the middle fibers of the trapezius
and ipsilateral trunk side flexion.

Scapular Adduction
Scapular adduction is primarily accomplished by the middle fibers of the trapezius (PLF),
with accessory participation of the trapezius upper and lower fibers.
Against Gravity: Middle F ibers of Trapezius
The initial screening test is conducted with the patient prone, shoulder flexed to
90° and in neutral rotation, with the arm hanging vertically over the examination table.
The patient then adducts the scapula toward the midline of the back while the examiner
palpates the middle fibers of the trapezius between the medial (vertebral) border of the
scapula and the vertebrae, above the spine of the scapula. When this screening test is
successfully completed, resisted strength grades are then determined.
� D u ring scapular adduction the patient may attem pt to substitute contraction of the
rhomboid m ajor and minor m uscles, and ipsilateral trunk rotation .

The isometric test is performed with the patient in the same position noted above
for the screening test. The examiner applies the resistive force in the direction of scapular
abduction by placing the hand flat on the scapula to resist the patient's attempt to move
the scapula into adduction. For good results, care should be exercised to prevent any
resistance forces being applied over the humerus.

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Chinese O rthopedics Scapula 2 1 7

Gravity Eliminated: M iddle Fibers of Trapezius

The gravity-eliminated scapular adduction test is performed with the patient
seated with the shoulder flexed 90°, with slight horizontal abduction and internal rotation.
Examiner supports the patient's upper limb and the patient is advised to avoid trunk
rotation while adducting the scapula through full range of motion. The examiner palpates
the middle fibers of the trapezius.
-+ During scapular adduction the patient may attem pt to su bstitute shou lder
horizontal abduction, and ipsilateral trunk rotation.

Medial Rotation and Adduction of Scapula

The rhomboid major (ALH) m. is mainly responsible for medial rotation of the scapula
which also involves some movement in adduction as well. The rhomboid minor (ALH)
m. also participates in this movement. Accessory muscle participation includes the
middle fibers of the trapezius.
Against Gravity: Rhomboid Major and M inor
The initial screening test is performed with the patient prone with the shoulders
relaxed and the arm lying at the side with the palmar surface of the hand facing upward.
The arm is moved to where the dorsum of the hand on the tested side is placed over the
buttock of the non-test side. The patient then raises the arm up away from the back
maintaining the position over the buttocks, while the examiner palpates the rhomboids
along an oblique line between the vertebral border of the scapula and C 7 to T5. The
rhomboid major can further be palpated medial to the vertebral border of the scapula near
the inferior angle, lateral to the lower fibers of the trapezius. When this screening test is
successfully completed, resisted strength grades are then determined for the rhomboids.
-+ During scapu lar medial rotation and adduction the patient m a y attempt to
substitute tipping the scapula forward by contraction of the pectoralis m i nor.

Isometric resistance is applied over the scapula in the direction of scapular

abduction and lateral rotation, with care not be apply pressure over the humerus. The
patient lifts the arm on the test side as noted above to medially rotate the scapula which is
fully resisted by the isometric force.
Gravity E l iminated : Rhomboid Major and M i nor
Medial rotation and adduction in the gravity-eliminated case is performed with
the patient seated with relaxed shoulders and the dorsum of the hand positioned over the
buttocks of the non-test side. The patient is advised to avoid ipsilateral trunk rotation
and/or forward flexion of the trunk. The scapula is rotated and adducted when the patient
moves the test hand away from the back, while maintaining the same position over the
buttock of the non-test side.
-+ D u ring scapular medial rotation and adduction the patient may attem pt to
s ubstitute ipsilateral trun k rotation and/or forward flexion of the trunk, and tipping
the scapula forward by contraction of the pectoralis m inor.

Abduction and Lateral Rotation of Scapula

Abduction of the scapula mainly involves the serratus anterior (MH) muscles, with lateral
rotation involves the lower serratus anterior muscles. Muscles acting accessory to these

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Ch inese Orthopedics Scapula 2 1 8

movements include the upper fibers o f the trapezius (lateral rotation) and the pectoralis
minor (abduction).
Against Gravity: Serratus Anterior
The initial screening test is conducted with patient supine and the shoulder of the
test side flexed to 90° with slight horizontal abduction, and elbow extended with forearm
in neutral position. The patient then lifts the shoulder and arm straight up (shoulder
protraction) by abducting the scapula, while the examiner palpates the serratus anterior
muscles along the midaxillary line over the thorax. When this screening test is
successfully completed, resisted strength grades are then determined for the serratus
anterior mm .
Caution must be considered in the situation where the shoulder joint is unstable.
The test position can still be configured but the examiner must fully support the upper
extremity and resistive forces cannot be applied. In this instance it is only possible to
assess a strength grade of 3 .
-+ Patient m a y attem pt to substitute contraction of the pectoralis major muscle to
protract the s hou lder.

Isometric strength testing of the serratus anterior muscles is conducted in the same
test position noted above with the arm flexed to 90° with slight horizontal abduction, and
elbow extended with forearm in neutral position, and with the scapula abducted about
half way. The examiner grasps the upper arm proximal to the elbow to apply a downward
force with one hand while steadying the arm with the other hand against the inner side of
the patient's forearm. The examiner fully resists the patient's attempt to move the scapula
into further abduction and lateral rotation.
Gravity Eliminated: Serratus Anterior
The gravity-eliminated test is conducted with the patient seated with the shoulder
flexed to 90° with slight horizontal abduction, and the elbow extended. The examiner
supports the weight of the upper extremity and the patient is instructed to avoid trunk
rotation during scapular abduction. The patient then abducts the scapula (shoulder
protraction) through the full range of motion while the examiner palpates the serratus
anterior muscles.
-+ Patient may attem pt to substitute contraction of the pectoralis major and m inor,
a nd contraction of the upper and lower fibers of the trapezius, and contralateral
trunk rotation , i n place of scapular abduction.

An alternate to this position can be utilized if the patient is unable to assume a

seated position. The serratus anterior mm. can be tested in the against-gravity supine
configuration where the examiner holds the arm into scapular abduction while the patient
attempts to maintain this position. The examiner palpates the serratus anterior mm. to
evaluate quality of the contractions.
Serratus Anterior: Clinical Test
A simple and effective clinical test can be quickly performed to observe weakness
or strength in the serratus anterior muscles, although a specific grade cannot be assigned.
While standing, the patient's hands, at shoulder l evel with the shoulders in slight

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Chinese Orthopedics Scapula 2 1 9

horizontal abduction and elbows extended, are placed against a wall . Initially the patient
leans into the wall while allowing the thorax to sag toward the wall resulting in adduction
of the scapulae. The patient then pushes the thorax away from the wall causing abduction
of the scapulae.
Weakness is demonstrated by "winging" of the scapula. Here the medial border
and inferior angle become more prominent, with the scapula remaining in an adducted
and medially rotated position.

Accessory Movements
Two accessory or j oint play movements can be applied to the acromioclavicular and
sternoclavicular joints. Accessory j oint movement graded 0 - 6 as noted in Table 4.5.
A cromioclavicular Joint
Accessory movement of the acromioclavicular j oint is determined by applying dorsal and
ventral movement (glides) to the clavicle.
Dorsal Glide
Patient is seated with arm resting at side. While facing the patient from the side,
the examiner places one hand on the scapular spine to fixate the acromion while the other
hand moves the lateral end of the c lavicle posteriorly. The examiner' s forearms are held
parall e l to the direction of force and its resistance.
Ventral Glide
Patient is prone whil e the examiner is seated on the table facing patient' s head.
One hand of the examiner grasps the shoulder and fixates the scapula by pressure on the
coracoid process while the thumb of the other hand is placed on the dorsal surface of the
clavicle. Thumb pressure is applied to move the clavicle in the ventral direction
(anteriorly).
Sternoclavicular Joint
Accessory movement of the sternoclavicular j oint is determined by applying craniodorsal
and caudoventral movement (glides) to the clavicle.
C raniodorsal G l ide
Patient is supine with arm resting on abdomen with trunk stabilized by pressure
on table. While standing at patient' s side, examiner places both thumbs on the medial
inferior side of the clavicle being tested. Thumb pressure is applied to move the clavicle
in the dorsal-cranial direction to accommodate the obliquity of the j oin axis. Adj ust
thumb pressure for comfort and avoid applying pressure to the supraclavicular nerve.
Caudoventral G lide
Patient is supine with arm resting on abdomen and trunk is stabilized by pressure
on the table. While standing at patient's the examiner places fingers behind the medial
clavicle, parallel to the clavicle. The clavicle is moved in the ventral-caudal direction to
accommodate the obliquity of the j oint by pulling forward and downward.

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Chinese Orthopedics Scapula 220

Diagnostic Imaging
See Chapter 9, Shoulder

Management of Scapular Problems

Scapular problems are addressed by mobilization of the shoulder girdle joints where is
signs ofhypomobility. Needling therapy is the primary treatment approach using local
and adjacent, distal, and proximal nodes related to the muscular distributions.
Electroneedling (EN) stimulation may be employed to enhance therapeutic effect of
needling if manual needling doesn't achieve desired therapeutic results after several
treatments. Exercise therapy may be appropriate if weakness is apparent in the trapezius
muscles. Pressure techniques can be applied to address sensitive nodes, tight muscle
bands, or muscle spasms.

Scapular Mobilization
Sternoclavicular and Acromioclavicular Joints
If accessory movement of the sternoclavicular or acromioclavicular joints has a grade of
0 - 2, small amplitude mobilization movements can be applied identical to the movements
used to measure their accessory movements or j oint play as previously described.
Movement is made only to the amplitude that does not result in pain.
Scapulothoracic Joint
Hypomobility problems of the scapula can be addressed with small amplitude motion of
the scapulothoracic j oint as described below. Caution is advised to not move the scapula
into the region that causes pain.
Dorsal Tilt of Scapula
Patient is prone with arm resting at their side. Practitioner stands at side of patient
and cups the scapula inferior angle with one hand while other hand grasps the shoulder.
Opposite parallel and opposite forces are applied through the practitioner' s forearms to
lift the scapula away from the thorax. Patient must be completely relaxed to facilitate this
mobilization effort.
Scapulothoracic Mobilization
With patient lying on their side facing the practitioner, the patient' s arm is
supported by the therapist's arm. Practitioner grasps the medial and lateral scapular
borders in the web spaces of both hands and glides the scapula in various directions. This
includes elevation, depression, abduction, adduction, and rotation. Procedure used to
enhance relaxation and mobility of all shoulder girdle j oints.

Needling Therapy for Scapular Problems

Regional selection of nodes to treat pain and dysfunction that mainly manifests in the
scapular region or involves impaired function in moving the shoulder girdle needs to
consider nodes that have great influence on this region (see Table 8.3). As noted in
treating problems of the cervical spine, a general group of local and adjacent nodes are
selected for scapular problems regardless of the specific muscular distribution that is

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Ch inese Orthoped ics Scapula 22 1

involved. However, proximal and distal nodes are selected based on the specific muscular
distribution involved.

Table 8. 3 . Cand idate reg ional, proximal and distal nodes for pain and disorders of the scapula .
Pain or Disorder Candidate Local & MD Proximal Nodes Distal Nodes
of the Scapula Adjacent Nodes
Jianzhen (PLH 9) ALH* Dazhu (PLF 1 1 ) Hegu (ALH 4)
Naoshu (PLH 1 0) Feishu (PLF 1 3)
Tianzong (PLH 1 1 ) LH Fengchi (LF 20) Zhongzhu (LH 3)
Bingfeng (PLH 1 2) PLH Tianzhu ( P LF 1 0) Houxi ( PLH 3)
Jianwaishu (PLH 1 4) Jianzhongshu (PLH 1 5)
Gaohuangshu (PLF 43)
* Can consider H uatuojiaji nodes at T1 and T3 level.

Candid ate EN application for:scapular problems

Frequency/Mode/Duration: 2 Hz, continuous, 20-30 minutes
Anterior lateral hand (ALH) distribution
•
Dazhu (PLF 1 1 ) + lead, to Naoshu (PLH 1 0) - lead
•
Feishu (PLF 1 3) + lead, to Jianzhen (PLH 9) - lead
Lateral hand (LH) distribution
•
Fengchi (LF 20) + lead, to B ingfeng (PLH 1 2 ) - lead
Posterior lateral hand (PLH)
•
Jianzhongshu (PLH 15) + lead, to Tianzong (PLH 1 1 ) - lead

Remedial Exercises for Muscles Moving Shoulder Girdle

Exercise of muscles moving the scapula and shoulder girdle are considered for scapular
elevation, depression, adduction, abduction and rotation (See Table 8 .2).
Scapular Elevation
Exercise in scapular elevation involves the upper fibers of the trapezius and the levator
scapulae mm. with the rhomboid maj or and minor mm. participating as assistant muscles.
Exercise is conducted with the subj ect seated, shoulder abducted slightly, and the elbow
flexed 90°. The shoulder is then slowly elevated to bring the acromion closer to the ear.
The end-position is held for 2 - 3 seconds and the shoulder slowly lowered to start point.
Exercise can be performed simultaneously on each side if strength is the same on each
side. This exercise is repeated up to 8 repetitions and eventually performed for 4 5 sets. -

As strength permits, shoulder and back muscles should be contracted to provide

internal dynamic resistance (IDR) to scapular elevation. As strength increases a light­
weight dumbbell can be held with the arm extended straight down to increase exercise
load and further the strengthening process.

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 Chinese Orthopedics Scapula 222

Depression and Adduction of Scapula

The lower fibers of the trapezius have a principal role in depressing and adducting the
scapula and the middle fibers of the trapezius work as an assistant muscle to this
movement. The subject is prone, with head rotated to the opposite side, and the shoulder
abducted to about 1 30° with forearm in neutral position. The arm is then slowly raised to
produce depression and adduction in the scapula. The end-position is held for 2 - 3
seconds and the arm slowly lowered to start point.
This exercise is repeated up to 8 repetitions and eventually performed for 4 5-

sets. As strength permits, shoulder and back muscles should be contracted to provide IDR
antagonistic resistance to scapular depression and adduction. As strength increases a
light-weight dumbbell can be held in the hand to increase exercise load and further the
strengthening process.
Scapular Adduction
Scapular adduction is primarily accomplished by the middle fibers of the trapezius, with
assistant participation of the trapezius upper and lower fibers. The subj ect is prone, with
arms to the side. The shoulder in then slowly lifted off the floor (shoulder retraction). The
end-position is held for 2 3 seconds and the shoulder slowly lowered to the floor. This
-

exercise is repeated up to 8 repetitions and eventually performed for 4 - 5 sets. As

strength permits, chest and back muscles should be contracted to provide IDR
antagonistic resistance to shoulder retraction.
As strength recovers, the arm can be extended from the side, abducted 90° with
forearm in neutral position and palms on floor. The shoulder is slowly retracted and arm
lifted off the floor. The end-position is held for 2 - 3 seconds and the shoulder and arm
slowly lowered to the floor. This exercise is repeated up to 8 repetitions and eventually
performed for 4 - 5 sets. As strength increases light-weight dumbbell can be held in the
hand to increase exercise load and further the strengthening process.
Medial Rotation and Adduction of Scapula
The rhomboid major m. is mainly responsible for medial rotation of the scapula which
also involves some movement in adduction as well. The rhomboid minor m. also
participates in this movement. Assistant muscle participation includes the middle fibers
of the trapezius. The subj ect is prone with the shoulders relaxed and one arm lying at the
side while the other, with the palmar surface of the hand facing upward, and dorsum of
the hand of the target side placed over the buttock of the non-exercise side. The arm is
slowly raised away from the back maintaining the position over the buttocks. The end­
position is held for 2 3 seconds and the hand slowly lowered to the buttock.
-

This exercise is repeated up to 8 repetitions and eventually performed for 5 sets.

As strength permits, shoulder and back muscles should be contracted to provide IDR
antagonistic resistance to the rhomboids. As strength increases light-weight dumbbell can
be introduced to increase exercise load and further the strengthening process.
Abduction and Lateral Rotation of Scapula
Abduction of the scapula mainly involves the serratus anterior muscles, with lateral
rotation involving the lower serratus anterior muscles. Muscles acting assistant to these

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Ch inese O rthopedics Scapula 223

movements include the upper fibers of the trapezius (lateral rotation) and the pectoralis
minor (abduction). The subj ect is supine and the shoulder of the exercise side flexed to
90° with slight horizontal abduction, and elbow extended with forearm in neutral
position. The subject then slowly lifts the shoulder and arm straight up (shoulder
protraction) by abducting the scapula. The end-position is held for 2 - 3 seconds and the
shoulder slowly lowered to the floor.
This exercise is repeated up to 8 repetitions while keeping the arms held straight
up, and eventually performed for 4 5 sets. As strength permits, shoulder and back
-

muscles should be contracted to provide IDR antagonistic resistance to the serratus

anterior muscles. As strength increases light-weight dumbbell is grasped in the hand to
increase exercise load and further the strengthening process.

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Chinese Orthopedics Shoulder 225

Shoulder

Three actual j oints are involved i n moving the shoulder b y articulation between the
humerus, scapula, clavicle and sternum to form the glenohumeral, acromioclavicular and
sternoclavicular j oints. The clavicle is anchored to the manubrium of the sternum to
support and hold the acromion of the scapula out from the rib cage. The main body of the
scapula is held in place on the upper posterior thorax by virtue of musculotendinous
structures often referred to as the scapulothoracic j oint (See Chapter 8). The scapula must
be elevated and rotated to accommodate either full flexion or abduction of the arm, in
order to maintain proper function of the glenohumeral joint. The planes and axes of
articulation, normal limiting factors to these scapular movements, normal end feels and
active range of motions are noted in Tables 8 . 1 a and 8 . 1 b.

Glenohumeral Joint
The glenohumeral j oint permits extension, flexion, rotation, abduction and abduction of
the arm. The arm can be abducted and adducted in the frontal plane as well in the
horizontal plane. When flexion exceeds 60° or abduction in the frontal plane exceeds 30°
the scapulothoracic movement comes into play. The planes and axes of articulation,
normal limiting factors to movement of the humerus, normal end feels and active range
of motion for arm movements are noted in Table 9. 1 . Arm flexion and frontal plane
abduction are noted in Table 9.2.

Table 9. 1 . Joint structures involved in movement of the g lenohu meral joint.

Extension Internal External Horizontal Horizontal
Rotation Rotation Abduction Adduction
Articulation Glenohumeral Glenohumeral Glenohumeral Glenohumeral Glenohumeral
Plane Sagittal Horizontal Horizontal Horizonta l Horizontal
Axis Frontal Longitud inal Longitudinal Vertical Vertical
Normal limiting Tension in Tension in Tension in all Tension in Tension in
factors anterior band of posterior joint bands of anterior joint posterior joint
coracohumeral capsule, glenohumeral capsule, capsule; Soft
ligament. infraspinatus & ligament, glenohumeral tissue apposition
anterior joint teres minor coracohumeral ligament, and
capsule, & ligament, anterior pectoralis major
pectoralis major joint capsule,
clavicular fibers subscapularis,
pectoralis major,
teres major and
latissimus dorsi
Normal end feel Firm Firm Firm Firm Firm/ soft
Normal active 0-60° 0 - 70° o - go· 0 - 45° 0- 1 35°
range of motion

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Chinese Orthopedics Shou lder 226

Table 9.2. Joint structures involved in elevation movement of the shoulder

Elevation Through Flexion Elevation ThrouQh Abduction
Articulation Glenohumeral, Scapulothoracic, Glenohumeral, Scapulothoracic,
Acromioclavicular, Sternoclavicular Acromioclavicular, Sternoclavicular
Plane Sag ittal Frontal
Axis Frontal Sagittal
Normal limiting Tension in posterior band of coracohumeral Tension in middle and inferior bands of
factors ligament, posterior joint capsule. shoulder glenohu meral ligament, inferior joint capsule,
extensors , and externa l rotators; scapular shoulder add uctors; greater tuberosity of humerus
movement limited by tension in rhomboids, contacting upper portion of glenoid and glenoid
levator scapula, and trapezoid ligament labrum or lateral surface of acrom ion; scapular
movement limited by tension in rhomboids, levator
scapula, and trapezoid ligament
Normal end feel Firm Firm/ hard
Normal active 0 - 1 80° 0 - 1 80°
range of motion 0 - 60°, glenohumeral 0 - 30°, glenohumeral
60 - 1 80°. glenohumeral, scapular movement 30 - 1 80°, glenohumeral, scapular movement and
and trunk movement trunk movement
Capsular Glenohumeral: Externa l rotation, abduction (only through 90-1 20° range), internal rotation
Pattern Sternoclavicu lar/Acromioclavicular: Pain at extreme range of motion

Shoulder Physiology
Movement of the head of the humerus on the glenoid fossa does not represent a true ball
and socket joint because this structure is held together by tendons and muscles involved
in moving the humerus itself. The glenoid fossa of the scapula has a fibrocartilage labrum
which increases the glenohumeral cavity by 5 0%. Articulation of the humerus is perhaps
one of the more complex mechanical functions in the body. These unique features result
in the shoulder being susceptible to many problem involving tendon lesions of muscles
holding the glenohumeral joint together.

Muscles Moving Upper Arm

Most of the muscles moving upper arm have insertions on the proximal end of the
humerus bone with their origins on the scapula, clavicle, chest and back. Other major
muscles include the long head of the biceps brachii (ALH) which originates at the
supraglenoid tubercle and inserts on the radial tuberosity and forearm and the long head
of the triceps (PLH) muscles that originate on the axillary border of the scapula and
inserts on the olecranon of the ulna. The biceps brachii, short head (AMH) and the
coracobrachialis (MH) muscles originate at the coracoid process of the scapula and
respectively insert at the radial tuberosity and medial surface of the humerus. These
muscles all function to extend, flex, abduct, adduct or rotate the humerus. Muscles
moving the humerus along with their function, nerve root innervation and Chinese
muscular distribution assignments are noted in Table 9.3 . Many of these muscles work in
conjunction with those that move the shoulder girdle (See Table 8 .2).

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 Chinese Orthopedics Shoulder 227

Table 9 . 3 . F unction , nerve root, and muscle distribution (MD) assignment of primary mover (PM)
and accessory/assistant mover (AM) muscles a rticulating the humerus
Muscle MD Nente Root Ext. Flex. Abd. Add. l ntr. Extr. Hor. Hor.
Rot. Rot. Abd. Add.
Supraspinatus LH C4, 5, 6 PM
Infraspinatus PLH cs. 6 PM PM
Teres minor PLH CS, 6 PM PM
Teres major PLH CS, 6, 7 PM PM PM
Anterior deltoid AMH C5. 6 PM AM AM PM
Middle deltoid ALH C5, 6 PM PM
Posterior deltoid LH C5, 6 AM AM AM PM
1 1 2
Subscapularis ALH C5, 6, 7 AM AM AM PM AM 1
Latissimus dorsi PLF C6. 7. 8 PM PM AM AM
Pectoralis major, upper MH C5. 6. 7 PM AM2 AM PM
Pectoralis major, lower PMH C7, 8, T1 PM PM
Triceps, long head PLH C6, 7, 8, T1 AM AM
Biceps brachii. long head ALH CS, 6 AM AM
Biceps brachii short head AMH C5, 6 AM AM AM
2 AM2
Coracobrachialis MH C5, 6, 7 AM AM AM 3 PM
. . . .
1 . Vanes With JOmt pos1t1on and act1v1ty of synerg iC muscles; 2. Only when arm IS above the
horizontal; 3. Only from a position of rotation to the neutral point

Neurology
All muscles moving the humerus receives innervation from the brachial plexus except for
the supraspinatus and infraspinatus which are supplied by nerve roots C4, 5, and 6 (See
Table 9.3). Specific nerves supplying these specific muscles include:
•
Suprascapular nerve: supraspinatus, infraspinatus
•
Axillary (circumflex) nerve: teres minor, anterior deltoid, middle deltoid,
posterior deltoid
•
Subscapular nerve: teres maj or, subscapularis
•
Thoracodorsal nerve: latissimus dorsi
•
Lateral and medial pectoral nerves: pectoralis maj or upper and lower
•
Radial nerve: triceps, long head
•
Musculocutaneous nerve: biceps brachii (long head and short head),
coracobrachialis

Disorders Affecting Shoulder

Disorders affecting muscles moving the humerus result in dysfunction of the shoulder
joint, inability to full y use the upper arm and pain in the region of particular muscles
involved, including pain in the chest area. The most common disorders include shoulder
pain, tendon lesions, capsulitis, pain referred from cervical spine problems, and possible
visceral referred pain reflecting in the shoulder and upper arm area.
Muscles with their origin on the chest that insert on the humerus (MH and PMH
longitudinal muscular distributions) can experience pain and disorder as result of

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Chinese Orthopedics Shou lder 228

muscular type problems. They can also reflect cardiac referred pain due to conditions that
produce angina pectoris. Chest pain that radiates down left ann that is worse on exertion,
accompanied with shortness of breath and facial pallor, should be carefully examined in
light of possible heart disease.

Problems in Muscles Moving Upper Arm

Specific disorders related to the longitudinal muscular distributions associated with
moving the humerus include the following conditions:
Posterior lateral hand (PLH) distribution:
•
Pain in posterior aspect of ann, shoulder and axilla
•
Pain wrapping around scapula
Lateral hand (LH) distribution:
•
Acute cramps and spasms along posterior deltoid muscle and upper scapular
regwn
Anterior lateral hand (ALH) distribution:
•
Pain, spasms and acute cramps along medial deltoid muscle and subscapular
regwns
•
Inability to raise shoulders due to pain in medial deltoid muscle and subscapular
regwns
Anterior medial hand (AMH) distribution:
•
Acute cramps and spasms along anterior deltoid muscle
Medial hand (MH) distribution:
•
Acute cramps and spasms along clavicle and upper sternal pectoralis muscle
•
Pain in anterior region of chest with dypsnea related to region of the cardia
(indicates possible angina pectoris)
Posterior medial hand (PMH) distribution:
•
Acute cramps and muscular pain in lower sternal, costal and abdominal pectoralis
muscles
•
Pain and pressure in chest and heart radiating down arm and elbow (indicates
possible angina pectoris)
Posterior lateral foot (PLF) distribution:
•
Cramp like pain in axilla, involving latissimus dorsi muscle, extending to
supraclavicular region

Pathology of the Shoulder

Pain is obviously the most common complaint in problems affecting the shoulder. This
may arise from intrinsic disorders of the glenohumeral joint or may be referred from
extrinsic causes outside the shoulder area due to cervical spine or visceral problems.
Elbow pain can also reflect into the shoulder on the same side. Shoulder pain can
manifest as a painful arc on abduction of the arm or be due to tendon lesions involving
the principal muscles moving the arm, or due to capsulitis of the glenohumeral capsule.
Shoulder can also be affected by glenohumeral joint instability and thoracic outlet
syndrome.

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Chinese Orthoped ics Shoulder 229

Shoulder Pain
Pain in the shoulder is a very common symptom principally because of the glenohumeral
joint structure and function, and because this joint normally enjoys considerable mobility
and stability. However, the shoulder experiences degenerative changes that develop in its
surrounding soft tissue structures. Hence, shoulder pain may arise from intrinsic disorders
of the glenohumeral joint. Shoulder pain may also be the result of extrinsic source such as
cervical spine disorders or visceral referred pain. In both of these cases there may be neck
pain alone, neck and arm pain, or arm pain alone. But shoulder pain due cervical spine
disorders involves nerve root compression and pain is felt down the arm along with
neurological signs and possible muscular weakness.
Pain Quality
Quality and characteristics of shoulder pain provide clues to its source. Patients
describe pain arising from intrinsic shoulder lesions as having a deep aching quality,
which is made worse by movement. Night pain sufficient to disturb the patient's sleep is
commonly found with glenohumeral joint lesions and reflects the degree of the
underlying inflammation. Sleep-disturbing shoulder pain is a common symptom for
inflammation of the joint capsule (capsulitis) or arthritis of the glenohumeral joint. It is
also a common sign in patients with supraspinatus tendinitis, especially when patient rolls
over on their affected shoulder.
Pain Location
The location of pain often provides possible clues to its source. In
acromioclavicular joint pain, the patient often places fingers over upper part of the
affected joint. Pain due to intrinsic disorders of the glenohumeral joint may be felt deep
inside the joint and patient clasps hand over lateral aspect of the joint and sometimes over
the tip of the shoulder. Patients with pain referred from the neck often clasps opposite
hand over the trapezius area. Referred pain from the viscera may be localized diffusely in
scapular region.
Some patients with intrinsic problems of the glenohumeral joint report pain in the
area of the deltoid insertion, and it may be difficult to convince them that the source of
pain is from the shoulder. Pain felt in the deltoid insertion region is typically referred
further distally as the degree of inflammation in the involved structures is greater.
Cervical Spine
Pain referred to one shoulder due to cervical spine disorders can manifest with
neck pain alone which radiates to the shoulder which is reproduced by neck movements
but not by shoulder movements. Another situation involves shoulder pain alone without
neck pain where neck movements reproduce the pain while shoulder movements do not.
This latter situation often associated with hypomobility lesions at C4 - 5, C5 - 6 where
movement of these joints reveal pain and restriction.
Another, but uncommon, variation manifests with shoulder pain alone in absence
of neck pain. Shoulder movements cause pain at the limit of movement range while
active neck movements may be normal or may result in slight degree of pain or
restriction of neck movement. However, passive intervertebral movements of C4 5 or -

C5 - 6 produce pain and reveal restricted joint movement on same side as shoulder pain.

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Ch inese O rthopedics Shou lder 230

Visceral Referred Pai n

Shoulder pain referred from visceral sources is important but uncommon, and can
be confusing. Visceral referred pain arises from intra-thoracic or intra-abdominal diseases
that can be differentiated through associated symptoms, such as cough, chest pain, heart
signs, or abdominal symptoms. A full physical examination may be required, including
X-ray or other diagnostic imaging studies.
Shoulder pain referred from the gallbladder or right lung reflects in the right
shoulder and the right upper back. Pain referred from the diaphragm reflects on the left
upper shoulder, while pain from the left lung, spleen, and heart reflect into the left
shoulder. Heart referred pain also radiates down the left arm following the pathway of
,

the radial artery.

Tendon Lesions
Common tendon lesions are mainly associated the supraspinatus muscle but can also
involve tendons of the infraspinatus, bicep, and subscapularis muscles. Tendon lesions
include tendinitis, tendon rupture, subluxation concerning the bicep tendon, and
calcification.
Supraspinatus Tendon
Lesions of the supraspinatus tendon are a common source of shoulder pain. This
lesion basically involves degeneration of the tendon. This condition may remain
asymptomatic for a considerable period of time before clinical manifestations appear.
Clinical signs that arise include: supraspinatus tendinitis; subacromial bursitis,
incomplete rupture of the tendon; complete rupture of the tendon; and calcification.
Tendinitis

Supraspinatus tendinitis usually follows overuse or trauma involving tendon

degeneration or damage. Patient complains of pain usually over outer aspect of shoulder
which may radiate down to the deltoid insertion region, or only be felt there. The deltoid
and the supraspinatus work as a single unit. If pain is sufficiently severe to radiate down
to the elbow, it is likely to disturb patient's sleep. Natural history is often one of
exacerbations and remissions over several years.
Major clinical signs include pain being reproduced on active and/or passive
abduction of the shoulder. Often felt as a painful arc in the midrange of abduction ( 60° -
1 20°) as further discussed below. When returning arm from full abduction, patient may
feel pain again, and arm may suddenly drop. Pain may be reproduced on isometric
resistance testing.
Confirming signs include a disturbance of the scapulohumeral rhythm during
abduction and returning arm to neutral position. Supraspinatus tendon can also be
palpated. Plain film X-rays of shoulder are usually normal. However, there may be
degenerative changes in the tendon resulting in sclerosis, roughening, and possible pitting
on the greater tuberosity of the humerus.
Tendon Rupture

Degeneration of the supraspinatus tendon makes it susceptible to partial rupture

involving the superior or inferior surface of the tendon. Clinical presentation is
essentially the same as supraspinatus tendinitis. This condition occurs in younger people

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Ch inese Orthopedics Shou lder 231

through overuse in athletics or work, but most commonly occurs in the elderly
population.
Complete rupture of the supraspinatus tendon usually occurs in a region just
proximal to its insertion into humeral greater tuberosity called the "critical zone." The
tendon can occasionally be avulsed from its insertion into the greater tuberosity and
patient may report having felt or heard a painful snap in the shoulder. This is a serious
condition that can occur in the elderly with a long standing history of tendinitis. It can
also occur in athletes with no history of supraspinatus tendinitis. Onset can fol low a
sudden movement or injury of the shoulder.
Calcification

Calcification of the supraspinatus tendon is present in a low percentage of routine

shoulder X-rays. It develops in the degenerated portion of the tendon proximal to its
insertion. This condition may be asymptomatic or be associated with supraspinatus
tendinitis. Clinical signs for calcific tendinitis are essentially the same as uncomplicated
supraspinatus tendinitis. Calcific deposit can be of sufficient size to catch beneath the
acromion to produce a mechanical impedance of full shoulder abduction. Acute calcific
bursitis can result in an intense painful situation in the shoulder. It can be common in the
younger and more active age group. Pain may start rapidly, radiate down upper arm, and
become worse especially by any shoulder movement, and can disturb sleep. Patient
reports painful limitation in movement of any direction making it difficult to properly
assess these movements. Plain film X-rays used to confirm presence of calcific deposits.
After problem is resolved, X-rays may show that calcific deposits have disappeared.
I nfraspinatus Tendinitis
This condition is not as common as supraspinatus tendinitis but is related to
degenerative changes in the infraspinatus tendon. Infraspinatus tendinitis is more
common in individuals involved in sports like swimming or tennis, and also in laborers.
Area of the lesion may be at the musculotendinous juncture or over the insertion site of
the tendon posterior to the greater tuberosity of the humerus. Clinical signs initially
manifest with pain in the posterior aspect of the shoulder which is made worse by most
shoulder movements. Pain may radiate down posterior aspect of upper arm when this
condition is severe. Pain can be reproduced by stretching or contracting the infraspinatus
tendon. Patient may report a painful arc in the midrange of shoulder abduction where the
tendon may catch on the acromion. A tender location of swelling or thickening may be
palpable over the tendon insertion site or at the musculotendinous junction.
Biceps Tendon
The bicep participates in all shoulder movement which involves the groove
sliding along the tendon. This action makes the bicep tendon susceptible to wear and tear
degeneration including the following:
Tendinitis

Bicep tendon is second most common source of shoulder tendinitis usually

involving the bicipital groove of the humerus. Overuse and trauma to the shoulder can
result in degeneration of the tendon leading to tendinitis. Problems with the bicep tendon
can also be associated with tenosynovitis of the synovial sheath covering the bicep
tendon, producing similar symptoms as tendinitis.

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Ch inese Orthopedics Shoulder 232

Patients complain of chronic and recurring pain in the anterior shoulder which
may radiate down anterior aspect of the upper arm. Pain may be reproduced on some
shoulder movements and by contracting or stretching the bicep tendon.
Tendon Rupture

Rupture of the long head bicep tendon within the bicipital groove is not
uncommon. It often occurs in middle-aged or older males with a history of bicep
tendinitis. Rupture may occur by lifting activities or extreme overuse, or by a fall on an
outstretched hand, or may spontaneously occur. Patient may have been conscious of a
tearing or snapping sensation in shoulder. Shoulder becomes painful and difficult to
move with evidence of bruising appearing over the upper shoulder a few days later. One
of the most obvious signs is the long head bicep muscle is displaced to the lower aspect
of the upper arm and bulge appears when the bicep is contracted.
Subluxation of Biceps Tendon

The long head bicep tendon is retained in the bicipital groove by the strong
transverse humeral l igament which also prevents bowstringing in when the muscle is
contracted. The transverse ligament may be ruptured during injury where the shoulder is
abruptly forced into extension while the shoulder is in abduction. The ligament can also
be ruptured by bending down and lifting heavy weights from the ground level. Other
factors include an individual having a shallow bicipital groove. When the transverse
ligament ruptures the bicep tendon is free to sublux out of the bicipital groove. Examiner
can reproduce patient' s symptoms by holding arm in 90° abduction with the elbow
flexed. Bicep tendon is palpated and can be felt to slip in an out of its groove when the
arm is rotated medially and laterally.
Subscapularis Tendi nitis
Tendinitis of the subscapularis tendon is not a common condition. Patient may
present with pain in the anterior shoulder usually after overuse trauma due to excessive
internal rotation of the shoulder. Examiner should be able to reproduce patient' s pain by
resisted isometric contraction of the subscapularis muscle. Shoulder abduction and lateral
rotation may produce a painful arc. Tenderness may be palpated localized medial to the
lessor humeral tuberosity where the subscapularis muscle inserts.
Painful Arc
Painful arc refers to the situation where pain is felt in the middle range of arm abduction
( 60° - 1 20°). There is no pain with arms at the side, but as the arm is moved into
abduction (45° - 60°) in the frontal or coronal plane, pain is felt as the greater tuberosity
approaches the acromion process. Painful and inflamed structures between these two
bony prominences are impinged and cause pain. Inflammation possibly caused by:
subacromial bursitis; calcium deposits; or tendinitis of rotator cuff muscles. As the
shoulder is further abducted ( 1 20°), the painful structure slides under the coracoacromial
ligament and the pain ceases.
Pain may be felt on active and passive movement in abduction, or as the arm is
raised or lowered. Also, painful arc condition often shows a disturbance of the
scapulohumeral rhythm, with jerky type of movement usually demonstrated on lowering
through the painful region. A sudden hitch may be apparent. Possible substitution or trick
movements may include moving the arm forward from the frontal plane.

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Chinese O rthopedics Shoulder 233

Soft tissue lesions associated with painful arc include: posteriorly the
infraspinatus tendon; superiorly the supraspinatus tendon; and anteriorly the
subscapularis tendon. Degenerative changes can be apparent in the inferior
acromioclavicular j oint, acromion, and the greater humeral tuberosity.
Bursitis
A bursa is a special sac or saclike structure or cavity filled with a viscid fluid situated in
various locations in the musculoskeletal system where friction between two moving
tissue surfaces may develop. A bursa can become inflamed producing an intensely
painful condition called bursitis.
Subacromial Bursitis
The subacromial bursa consists of serous sac that is in intimate contact with the
supraspinatus tendon which forms the maj or part of the floor of the bursa. The tendon and
the bursa form a functional unit in the subacromial space. Hence, chronic subacromial
bursitis is often coupled with supraspinatus tendinitis. Subacromial bursitis is usually
secondary to lesions in the rotator cuff and not associated with capsulitis. Patient may
experience a painful arc in mid range of passive or active shoulder abduction. However,
the patient' s pain is not reproduced by resisted shoulder abduction which distinguishes it
from supraspinatus tendinitis.
Subcoracoid Bursitis
This condition occurs infrequently and may follow overuse, especially with
repetitive shoulder rotation which may occur in people driving heavy vehicles or in
playing table tennis. Pain usually localized over the anterior aspect of the shoulder just
distal to coracoid process of the scapula. Patient' s pain can be reproduced at the end by
lateral shoulder rotation movement and by passive horizontal adduction of the arm across
the chest. Resisted movements are usually pain free.
Capsulitis of Shoulder Joint
This condition represents an infl ammatory lesion of the glenohumeral j oint capsule which
leads to thickening and contraction of the capsule resulting in joint volume loss. Clinical
signs include painful stiffness affecting the active and passive range of all shoulder
movements. Capsulitis occurs most commonly in middle aged females but almost never
arises as a complication of existing intrinsic lesions such as supraspinatus or bicipital
tendinitis.
Pathology associated with capsulitis indicates that shoulder capsule is thickened
and retracted causing marked restriction in the glenohumeral joint. However, joint
surfaces and surrounding tissue, such as the subacromial bursa and tendons are normal.
Plain film X-ray findings may be essentially normal or may show disuse osteoporosis or
small cystic inclusions along the capsule insertion line into the humeral head. X-rays are
essential to differentiate between capsulitis and arthritis of the shoulder j oint which may
have similar clinical fmdings. Clinical findings of capsulitis may be confirmed by
arthrography demonstrating loss in joint volume and joint recesses. Only 5 1 0 ml of
-

contrast medium can be injected instead of the 20 - 30 ml for a normal joint.

Onset of capsulitis is usually gradual, but can be sudden at times. Condition may
occur in one shoulder and then after some variable time, occur in the other shoulder.

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Ch inese Orthopedics Shoulder 234

Once an attack is resolved, second attacks in the same shoulder are rare. Typical findings
indicate four stages of progressive restriction as follow :
Stage 1
Pain usually experienced in and around glenohumeral joint which is made worse
by movement, but stiffness is not usually noticed by patient.
Stage 2
Pain becomes more intense and is present at night distributing patient's sleep
especially if they roll onto affected shoulder. Most shoulder movements produce pain and
sudden movements or jarring, produce intense pain. Pain commonly felt deep in the
shoulder or in region of deltoid insertion, and may radiate further into the elbow.
Shoulder becomes increasingly stiffer with severe functional limitations. At this time
there is great difficulty in dressing, working, driving car, hanging clothes on line or in
closet.
Stage 3
At this stage there is little spontaneous pain at rest, although pain is produced on
sudden stretching the joint. Stiffness is now more pronounced due to adhesion formation
and contracture of the thickened joint capsule. The supraspinatus and infraspinatus
muscles can become atrophic and wasted. Unfortunately, the term "frozen shoulder" is
applied to this situation causing confusion in treatment of this problem.
Stage 4
This stage involves a gradual resolution of stiffness and gradual return of shoulder
mobility. However, degeneration and weakness of the shoulder is apparent. Course of a
protracted case can be 9 1 8 months, or even longer.
-

Instability of Shoulder Joint

Shoulder joint instability or recurrent subluxation can result from a capsular tear as found
in recurrent dislocations. This condition often related to a previous injury resulting in
dislocation of the shoulder. Recurrent su bluxation can occur if the glenohumeral joint
capsule has been tom, even in absence of a previous dislocation. Patient has a history of
recurrent attacks of shoulder pain in response to movement. Pain may be so severe that
patient is unable to move arm. Attacks may only last for short period of time and patient
may aware of clicking sensation in shoulder or that shoulder slips out.
Examiner may demonstrate abnormal shoulder movements by positioning
patient's arm in abduction and lateral rotation while applying pressure to the back of the
humeral head. This may reproduce patient's pain and the shoulder joint may be felt to
begin to sublux.
Entrapment Neuropathy
Thoracic O utlet Syndrome
Peripheral nerves of the brachial plexus and the subclavian artery form a
neurovascular bundle that passes through the thoracic outlet of the neck and passing
under the clavicle. Any compression affecting this area due to trauma or other causes can
produce various neurological and vascular symptoms including pain affecting the
shoulder and arm Resulting pain and paresthesia commonly manifest along the ulnar side
.

of the arm Onset of symptoms can be spontaneous but may follow injury to the neck or
.

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Chinese Orthopedics Shou lder 235

arm, and especially due to crushing type trauma to the upper thorax. Patient's symptoms
may be reproduced by sustained traction of the shoulder by pulling on down and
backward on the patient' s wrist (costoclavicular syndrome or military brace test), while
passive elevation of the shoulder girdle may relieve symptoms (shoulder girdle passive
elevation test). (Also see Adson' s maneuver for thoracic outlet syndrome)
Suprascapular Nerve Entrapment
The suprascapular nerve derived from C5 and C6 provides motor function to
supraspinatus and infraspinatus muscles along with sensory function to posterior shoulder
capsule and the acromioclavicular j oints. This nerve runs through the suprascapular notch
on the upper anterior border of the scapula before entering the supraspinatus fossa.
Compression of this nerve occurs in the suprascapular notch which is enclosed by a
transverse ligament. Entrapment can be the result of overuse, such as painting a house or
trimming trees, or trauma especially in traction.
Pain may be severe or vaguely localized in the posterolateral aspect of the
shoulder, and may radiate down the arm. If entrapment is prolonged there may be wasting
of the supraspinatus and infraspinatus muscles. Pain can be reproduced by passively
adducting the arm fully across the chest and applying overpressure at end of range to
compress the nerve. Pain may also be reproduced by elevating the arm above the head
and then depressing the shoulder girdle. In addition, pressure over the nerve can
reproduce the pain.

Examination of Shoulder

Active Shoulder Movements (ROM)

Movement assessment of the shoulder starts by the patient articulating upper arm and
shoulder through full range of motion possible in all axes to include extension, internal
rotation, external rotation, horizontal abduction, horizontal adduction and elevation of the
shoulder through flexion and abduction. Range of motion (ROM) is measured in degrees
and any symptoms occurring during movement, along with their qualities are noted.
-+ Possible movements that a l ready present with pain and dysfunction a re tested
after all other tests so as not to increase patient discomfort and apprehension
wh ich can affect the other tests

Extension
Normal active ROM for shoulder extension is 0 60° and can be measured with patient
-

either seated or lying prone starting with arm at side with palm facing medially. In the
prone position, goniometer axis is placed over axis of glenohumeral joint lateral aspect at
the center of humeral head, about 2 . 5 em inferior to lateral aspect of acromion process.
The stationary arm of the goniometer is maintained parallel to the lateral midline of the
trunk and the moveable arm parallel to longitudinal axis of humerus, pointing toward the
lateral epicondyle. Humerus is then moved posteriorly to extend upper arm to full limit of
extension. Elbow is allowed to simultaneously flex so the hand remains near surface of
the examination table. Arm extension can also be measured with a bubble inclinometer
held against lateral aspect of the humerus at about the mid point, adjusted to indicate zero
before moving arm.

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Chinese Orthopedics Shoulder 236

In seated position, arm is at the side with palm facing medially. Goniometer
positions are same as measuring in extension as noted above with the fixed arm of the
goniometer held vertically. Patient's arm is moved posteriorly from the neutral position
until full range of pain free extension is obtained.
-+ Patient m a y attempt to su bstitute scapu lar anterior ti lting and elevation , and
shoulder a bd uction. In the seated position the patient may flex the trunk

Internal Rotation
Normal active ROM for internal rotation of shoulder is 0 - 70° and can be measured in
the prone, supine, or seated position. Shoulder is abducted 90° in prone test configuration
with elbow flexed 90° and forearm held down from side of table in neutral position. A
small pillow or towel can be placed under humerus to maintain the abducted position.
-+ This position is contrai ndicated if patient has a h istory of posterior dislocation of
the glenohumeral joint (conduct measurement from supine position)

Axis of the goniometer is placed on the olecranon process of the ulna with the
stationary arm pointing perpendicular to the floor. The movable arm is aligned parallel
with the longitudinal axis of the ulna, pointing toward ulnar styloid process. A gravity
sensitive b ubble inclinometer can be held on ulna with start position adjusted to zero.
Palm of hand is moved posteriorly and up toward to ceiling to limit of internal rotation.
-+ P atient m a y attem pt to substitute elbow extension and scapular elevation and
abd uction

The seated position can be used, especially if the patient cannot achieve 90° of
shoulder abduction. With the patient seated, the shoulder is abducted about 1 5° with the
elbow flexed 90° and the forearm in neutral position. Goniometer axis is placed under the
olecranon process of the ulna with the fixed arm perpendicular to the trunk while the
movable arm is held parallel to the axis of the ulna. The palm of the hand is moved
toward the abdomen to the full limit of internal rotation.
-+ I n seated position, patient may attempt to substitute scapular elevation and
a bduction

External Rotation
Normal active ROM for external rotation of the shoulder is 0 - 90° and can be measured
in the supine, prone, or seated position. In the supine test configuration, the shoulder is
abducted 90° with the elbowed flexed 90° and forearm held upright and pronated. A
small pillow or towel is placed under the humerus to achieve the abducted position.
-+ This start position is contraindicated if the patient has a history of anterior
dislocation of the g leno h u m eral joint (do test from prone position)

Goniometer axis is placed on olecranon process of the ulna with the stationary
arm pointing upward and perpendicular to the floor. The movable arm is aligned parallel
with the longitudinal axis of the ulna, pointing toward the ulnar styloid process. A gravity
sensitive bubble inclinometer can be used and held on the ulna and adj usted to zero at
start position. Dorsum of the hand is moved posteriorly and downward toward the
examination table to the limit of external rotation.

D. E. Kendall, OMD, PhD ©2005-2009

Ch inese Orthopedics Shoulder 237

-+ Patient may attem pt to substitute elbow extension and scapular depression and
adduction

Seated position can be used, especially if patient cannot achieve 90° of shoulder
abduction. With patient seated, shoulder is abducted about 1 5° with the elbow flexed 90°
and forearm in neutral position. Goniometer axis is placed under the olecranon process of
ulna with fixed arm perpendicular to trunk while the movable arm is held parallel to axis
of the ulna. Dorsum of the hand is moved laterally away from the body to the full limit of
external rotation.
-+ In seated position, patient may attempt to substitute scapular depression and
adduction

Horizontal Abduction (Horizontal Extension)

Normal active ROM for shoulder horizontal abduction is 0 - 45° and is normally
measured with patient seated. Shoulder is placed in 90° of abduction and neutral rotation,
with elbow flexed 90° and forearm in neural position, with examiner supporting arm in
abduction. The axis of the goniometer is placed over the acromion process with the fixed
arm perpendicular to the trunk of the body. The moveable arm is parallel to the
longitudinal axis of the humerus. The humerus is then moved posteriorly to the limit of
motion in horizontal abduction.
-+ Patient m a y s ubstitute ipsilateral trunk rotation or scapular retraction

Horizontal Adduction (Horizontal Flexion)

Normal active ROM for shoulder horizontal adduction is 0 - 1 35° and normally measured
with the patient seated. The shoulder is placed in 90° of abduction and neutral rotation,
with elbow flexed 90° and forearm in neural position, with the examiner supporting the
arm in abduction. The axis of the goniometer is placed over the acromion process with
the fixed arm perpendicular to the trunk of the body. The moveable arm is parallel to the
longitudinal axis of the humerus. The humerus is then moved anteriorly with the hand
approaching the opposite side of the chest, to the limit of motion in horizontal adduction.
-+ Patient m a y substitute ipsilateral trunk rotation or scapular protraction

Elevation through Flexion

Normal active ROM for shoulder elevation through flexion is 0 - 1 80° with the
glenohumeral joint providing the initial 0 - 60° range of movement with participation of
scapular and trunk movement required in the range of 60 - 1 80°. This test can be
performed with patient lying supine or standing. In supine position, patient with arm to
side, the goniometer axis is placed at lateral aspect of the head of the humerus, about 2.5
em inferior to the lateral aspect of the acromion process. The stationary goniometer arm
is aligned parallel to the lateral midline of trunk while the movable arm is parallel to the
axis of the humerus, pointing toward lateral epicondyle of the humerus. The humerus is
then actively moved anteriorly into full flexion.
In seated position, patient's arm hangs down at the side, with palm facing
medially, with examiner stabilizing the scapula. The goniometer is placed at the center of
the head of the humerus with the fixed arm aligned vertically parallel to the trunk and the
moveable arm is aligned with the humerus. The patient raises their arm anteriorly up over
the head to the limit in flexion. Measurement with a gravity sensitive bubble inclinometer

D. E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Shou lder 238

can be performed by holding it against the humerus adjusted to zero before start of
movement. This position is held throughout the range of movement in flexion.
In seated position, goniometer can also be placed on medial border of the scapula
to measure lateral rotation of scapula during elevation through flexion.
-+ In seated position patient may attem pt to substitute trunk extension and shoulder
a bduction.

Elevation through Abduction

Normal active ROM for shoulder elevation through abduction is 0 - 1 80° with the
glenohumeral joint providing the initial 0 - 30° range of movement with participation of
scapular and trunk movement required in the range of 30 - 1 80°. Elevation though
abduction can be conducted with the patient supine, seated, or prone position. In the
supine patient, the arm is at the side and held in the position of adduction and external
rotation with palm facing upward to allow more clearance for the greater tuberosity of the
humerus to clear the acromion process. Before abducting the ann, it is necessary to
confirm that the patient is capable of full external rotation.
The goniometer is placed so that its axis coincides with the midpoint of the
anterior or posterior aspect of the glenohumeral joint (about 1 .3 em inferior and lateral to
the coracoid process) with the fixed arm parallel to the sternum and the moveable ann
parallel to the longitudinal axis of the humerus. The patient then moves the humerus
laterally, in abduction. to the full limit of motion in elevation.
In the seated configuration, the ann is held at the side, externally rotated so the
palm of the hand is facing forward. The goniometer is positioned over the posterior axis
of the glenohumeral j oint, just lateral to scapula and about 2 . 5 em inferior to the posterior
aspect of the acromion process. With a bubble inclinometer, it is placed on the shaft of
the humerus and adj usted to zero before movement starts. The shoulder is then abducted
to the full limit of elevation.
-+ Patient may attem pt to substitute contralateral trunk side flexion , scapula r
elevation, and shoulder flexion.

In seated or posterior position of this test, the goniometer can also be placed on
medial border of scapula to measure lateral rotation of scapula during elevation through
abduction.

Passive Shoulder Movement

Shoulder passive movements are accomplished by examiner for the same configurations
and test positions noted above in: Active Movements of Shoulder (ROM). All the same
motion directions are evaluated to assess symptoms and to measure joint end feel in those
directions.
Extension
Normal end feel for shoulder extension is firm.
Internal Rotation
Normal end feel for shoulder internal rotation is firm.
External Rotation
Normal end feel for shoulder external rotation is firm.

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 Chinese Orthoped ics Shoulder 239

Horizontal Abduction
N ormal end feel for shoulder horizontal abduction is firm.
Horizontal Adduction
Normal end feel for shoulder horizontal adduction is firm/soft.
Elevation through Flexion
Normal end feel for shoulder elevation through flexion is firm.
Elevation through Abduction
Normal end feel for shoulder elevation through abduction is firm/hard.

Resisted Movements of Shoulder

The maj or tendon lesions affecting the shoulder usually involve the supraspinatus,
infraspinatus, biceps, and subscapularis muscles. These muscles and tendons are
evaluated by resisted isometric movement in abduction, lateral rotation, forward flexion,
and medial rotation of the shoulder. Resisted strength measurements are also obtained to
evaluate the condition of the other muscles involved in the remaining movements of the
shoulder. Resisted strength measurements graded 0 - 5 (See Table 4.3).
Shoulder Abduction to 90°
Resisted abduction is used principally to test the supraspinatus tendon (LH) although the
middle fibers of the deltoids m. (ALH) have a significant role in abducting the arm.
Isometric resistance testing is performed with patient seated with elbow flexed 90° and
glenohumeral joint abducted to 30°. Examiner stands behind patient with one hand on
lateral aspect of elbow while patient's resists only to the point of preventing examiner in
moving the arm downward. Simultaneously, the practitioner palpates supraspinatus
tendon over its insertion into the greater tuberosity. This is often difficult to accomplish
because the tendon lies deep to the deltoids.
-+ Patient may substitute shoulder e levation (upper fibers of trapezius) , shoulder
externa l rotation (biceps brachii, long head), and contralateral or ipsi l ateral side
flexion of the trunk to compensate for failure to perform this test

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This can be conducted with the patient lying supine and test arm is at the side
with elbow extended. The examiner supports the patients arm with one hand and arm
while stabilizing the scapula with other hand. The patient then abducts the shoulder to
90°.
-+ Patient may substitute contralateral trunk side flexion, shoulder elevation (upper
fibers of the trapezius) and shou lder external rotation (long head of biceps) to
com pensate for extreme weakness in s u praspinatus and m iddle deltoid or
rupture of supraspinatus tendon.

Lateral (External) Rotation

Resisted lateral rotation is used to principally test the infraspinatus tendon (PLH)
although accessory muscles including the teres minor (PLH) and posterior deltoid (LH)
mm . have a role as well in external rotation. Resisted strength test in normal prone
configuration involves externally rotating shoulder approximately 30° from start position
before application of resistive force. Isometric resistance is applied proximal to wrist
joint on posterior aspect of the forearm in direction of shoulder internal rotation.

D.E. Kendall, OMD, PhD ©2005-2009

Ch inese Orthopedics Shoulder 240

Application of resistive force stresses the elbow and shoulder joints and must be applied
with caution, especially if there is possible pathology in those structures.
-+ Patient may su bstitute elbow extension (triceps) and sca pular depression (lower
fibers of trapezi us) if unable to contract the infraspinatus muscle

If patient is unable to lie prone or is not able to abduct the shoulder 90°, resisted
lateral rotation can then be considered depending whether patient is not able to lie prone
or abduct the shoulder ( 1 ) or if patient is unable to lie prone (2) as follow:
,

I ) Examiner stands in front of patient who is either seated or standing with elbow
flexed 90° and arm held firmly against side with palm facing inward. Examiner
applies force on dorsal surface of patient's wrist while the patient prevents
examiner moving their arm into medial rotation.
2) E xaminer stands behind patient who is either seated or standing with elbow flexed
90° and arm abducted 90° which is then fully rotated medially with palm of hand
facing backward. With one hand the examiner stabilizes the patient's arm
proximal to the elbow while other hand is placed over dorsal surface of patient's
hand to resist forward movement and prevent lateral rotation.
If the isometric strength is less then Grade 2+, a gravity eliminated may be
indicated. This can be conducted with the examiner standing to side of patient who is
either seated or standing with elbow flexed 90° and arm held firmly against the side with
palm facing inward. Examiner then supports forearm with one hand while stabilizing
humerus with the other while patient externally rotates shoulder by swinging hand away
from body.
-+ Patient m a y attempt to su bstitute elbow extension (triceps), scapular depression
(lower fibers of the trapezius), and forearm supination if fai l i ng to normally
complete this test.

Medial (Internal) Rotation

Resisted medial rotation is principally used to test the subscapularis tendon (AL H)
although accessory muscles including latissimus dorsi (PLF), teres major (PLH), upper
pectoralis major (MH) and anterior deltoid (AMH) muscles are involved in this
movement. Resisted strength test in normal prone configuration involves internally
rotating shoulder approximately 30° from start position before application of resistive
force. Isometric resistance is applied proximal to wrist joint on anterior aspect of forearm
in direction of shoulder external rotation. Application of resistive force stresses the elbow
and shoulder joints and must be applied with caution, especially if there is possible
pathology in those structures.
-+ Patient m a y attempt to su bstitute elbow extension (triceps) and scapular
protraction (pectoralis m i no r) if unable to intern a l l y rotate the shoulder.

If patient is unable to lie prone or is not able to abduct shoulder 90°, the gravity­
eliminated seated or standing position is used to conduct shoulder internal rotation
screening test. An alternate resisted internal rotation can also be considered where
examiner stands in front of patient who is either seated or standing with elbow flexed to
90° and held firmly by side with palm facing inward. Examiner places palm over palmar
surface of patient's wrist to fully resist medial movement while simultaneously palpating
the subscapularis tendon over its insertion into the lessor tuberosity.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Shou lder 24 1

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This can be conducted with examiner standing to side of patient who is either
seated or standing with elbow flexed 90° and arm held firmly against the side with palm
facing inward. Examiner then supports forearm with one hand while stabilizing the
humerus with other while patient internally rotates shoulder by swinging palm of hand in
toward the abdomen.
-+ Patient may attempt to substitute elbow extension (triceps), shoulder abduction,
a n d pronation of the forearm if u nable to interna l ly rotate the shoulder.

Forward Flexion
Resisted forward flexion is used primarily to test the biceps, long head tendon (ALH)
although the biceps, short head (AMH), anterior deltoid (AMH), upper pectoralis major
(MH) and coracobrachialis (MH) muscles are involved in flexion of the upper arm .
Isometric resistance testing is performed by first placing biceps tendon in a stretch while
patient is standing with shoulder extended (approximately 50 - 60°) and elbow fully
extended with forearm pronated causing palm to face backward. Standing behind patient,
the examiner places hand over dorsal aspect of the patient's wrist to fully resist any
forward movement to flex the arm while simultaneously palpating long head biceps
tendon in the bicipital groove.
Additional isometric tests of the biceps can be performed to address the role of the
biceps in flexing the elbow and supinating the forearm (See Chapter 9 on Elbow).
If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This can be conducted with the patient in a side-lying position with test side
up, with the arm supported at the side and shoulder held in full extension (approximately
5 0 - 60°) with slight abduction and neutral rotation. With examiner supporting arm, the
patient flexes shoulder to 900.
-+ Patient may attempt to substitute scapu lar elevation and tru n k extension when
failing to perform shoulder flexion .

Shoulder Flexion to 90°

Shoulder flexion to 90° is used to test anterior fibers of the deltoid (AMH) although this
movement involves accessory muscles, including the biceps brachii, coracobrachialis,
and middle fibers of the deltoid, clavicular fibers of the pectoralis major, upper and lower
fibers of the trapezius and the serratus anterior. Isometric strength grades for anterior
deltoid are obtained with the patient seated or lying supine. Patient holds shoulder in
flexion to approximately 80 - 90° while isometric resistance is applied on the
anteromedial aspect of the arm j ust proximal to elbow joint while. Resistive force is
applied in direction of shoulder extension, slight abduction and external rotation.
If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This can be conducted with the patient in a side-lying position with test side
up, with arm supported at the side and shoulder held in slight abduction and neutral
rotation. With examiner supporting the arm, patient flexes shoulder to 90°, while
simultaneously adducting and slightly internal rotating the shoulder.
-+ Patient may attem pt to substitute scapular elevation and trun k extension when
fai l i ng to perform shoulder flexion

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C hinese Orthoped ics Shou lder 242

Shoulder Flexion and Adduction

Shoulder flexion with shoulder adduction is used to test the coracobrachialis (MH), with
accessory muscles including the anterior fibers of the deltoid, clavicular fibers of the
pectoralis major, and the short head of the biceps brachii muscles. With the patient lying
supine and shoulder flexed approximately 80°, isometric resistance is applied to the
anteromedial aspect of the distal humerus applying the force in the direction shoulder
abduction and extension.
-+ Patient may su bstitute scapular elevation to assist this movement

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. The patient is placed in a side-lying position with the test side up, with the arm
supported at the side and the shoulder held in slight abduction and external rotation, with
the elbow fully flexed with forearm supinated. With the examiner supporting the arm, the
patient flexes the shoulder through full range of motion, while simultaneously adducting
and externally rotating the shoulder slightly.
-+ Patient may su bstitute sca pular elevation to assist this movement

Shoulder Extension
Shoulder extension is primarily performed by the latissimus dorsi (PLF) and teres major
(PLH) muscles, although accessory muscles to this movement include the teres minor,
posterior fibers of the deltoid, and the triceps muscles. Resisted i sometric testing is
performed with patient lying prone with the test arm to the side and slightly extended
with the shoulder in internal rotation and palms facing upward. Force is applied proximal
to the elbow on the posteromedial aspect of the arm in the direction of flexion and slight
abduction to full y resist patient's attempt to extend arm.
-+ Patient may attempt to su bstitute contraction of the pectoralis minor

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. The patient is placed in a side-lying position with the test side up, with the arm
supported at the side with forearm supinated and the shoulder in internal rotation. The
patient's hips and knees are flexed and the examiner supports the arm as the patient
extends the shoulder while maintaining shoulder adduction.
-+ Patient may attempt to substitute contraction of the pectora l is m i nor

Shoulder Horizontal Abduction

Horizontal abduction of the shoulder provides a test for the posterior fibers of the deltoid
(LH) although accessory muscles include the infraspinatus and teres minor muscles.
Isometric test performed with patient lying prone with shoulder in slight abduction,
elbow flexed 90° and the forearm pronated and hanging vertically over edge of table,
with portion of arm j ust distal to the shoulder resting on the examination table. The
resistive isometric force is applied on the posterolateral aspect of the arm proximal to the
elbow joint in direction of shoulder horizontal adduction and slight internal rotation, to
fully resist further abduction of the shoulder. Examiner stabilizes shoulder by applying
pressure over the scapula.
-+ Patient may attempt to substitute contraction of the rhomboids, middle fibers of
the trapezius, and ipsilateral trunk rotation

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Chinese Orthopedics Shoulder 243

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This test is conducted with the patient seated and shoulder abducted to about
75°, with the elbow flexed 90°, and the forearm pronated. The examiner supports the
patient's full ann with one hand and ann while stabilizing the scapula with the other
hand. The patient horizontal abducts and slightly externally rotates the shoulder.
-+ Patient m a y a ttempt to substitute contraction of the rhomboids, m iddle fibers of
the trapezius, and ipsilateral trunk rotation

Shoulder Horizontal A dduction

Muscles used in horizontal adduction of the shoulder primarily involve the clavicular
(MH) and sternal (PMH) heads of the pectoralis major muscle. Muscles providing
accessory movement include the anterior fibers of the deltoid (AMH) and to a lessor
degree, the latissimus dorsi and teres major muscles that extend the shoulder. These
muscles are all tested as a group with prime emphasis on the pectorali s major. If
weakness is detected in the pectoralis muscle, the individual clavicular and sternal heads
can be tested separately, since each head has a separate innervation. In this situation the
humerus is positioned so that its direction of resistive force is aligned directly opposite to
pull of the fibers in each portion of the pectoralis major.
Pectoralis M ajor (clavicular and sternal heads)
This test performed with patient supine, shoulder abducted to 90°, elbow flexed
90° with forearm pronated, and shoulder horizontally adducted 90°. Isometric force is
applied on anterior aspect of the arm proximal to elbow joint, in the direction of shoulder
horizontal abduction, while examiner's other hand is placed on the patient's opposite
shoulder for stabilization.
-+ Patient m a y attem pt to substitute tru n k rotation or scapular protraction

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. This test is conducted with the patient sitting with the shoulder abducted to
90°, and the elbow flexed 90°, and the arm supported by the examiner, while the patient
adducts the shoulder. The scapula and trunk are stabilized by examiner's other hand
placed on top of the shoulder.
-+ Patient m a y attem pt to substitute contralateral trunk rotation to simu late
horizontal adduction of the shoulder

Pectoralis Major (Clavicular Head)

With the patient lying supine, the shoulder is abducted to 70 - 75°, with elbow
flexed 90° and forearm pronated. Resistive isometric force is applied on anteromedial
aspect of the ann j ust proximal to elbow in the direction of abduction, extension, and
slight external rotation of the shoulder.
-+ Patient m a y atte m pt to substitute contra lateral trunk rotation, and contraction of
the coracobrachialis and short head of biceps brachii in place of pectoralis
clavicu lar head contractions

Pectoralis Major (Sternal Head)

With the patient lying supine, the shoulder is abducted to approximately 1 25 -

l 3 5°, with elbow flexed 90° with forearm pronated. Resistive isometric force is applied

D. E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Shou lder 244

on anteromedial aspect of arm j ust proximal to elbow in the direction of abduction,

flexion, and slight external rotation of the shoulder.
-+ Patient may attempt to substitute contralateral trunk rotation a nd contraction of
the latissimus dorsi and teres major in place of pectoralis sterna l head
contractions.

Functional Assessment
The shoulder plays an obvious and important role in activities of daily living (ADL) that
require movement in flexion, abduction, adduction, extension, lateral and medial rotation,
horizontal abduction and horizontal adduction. Common activities including eating,
dressing, combing hair, reaching for something on a shelf, washing opposite shoulder,
and other functions. Simply motions can demonstrate proper or abnormal movement of
the shoulder include:
•
Arm elevation
• Opposite shoulder touch
•
Scapula superior angle touch
•
Scapula inferior angle touch
•
Shoulder protraction and retraction
•
Painful arc

Special Tests
A significant number of special tests have been developed over the years to assess
possible conditions of the shoulder including instability of the glenohumeral joint,
impingement disorders, tendon lesion of the muscles moving the arm, labral tears.
Shoulder Instability
Apprehension Test
Purpose of this test is to detect anterior shoulder subluxation or dislocation
involving the inferior glenohumeral ligament. Patient is supine in a relaxed position on
the examination table. Patient's arm i s supported with the shoulder abducted 90° and the
elbow flexed 90°. While supporting the humerus at the elbow with one hand, grasp
patient's forearm with other hand. Gently and gradually externally rotate shoulder. If
patient has had a recent anterior dislocation or subluxation of the glenohumeral j oint,
apprehension or discomfort will occur as the shoulder approaches 90° of external
rotation. Be careful not to cause an actual anterior dislocation when externally rotating
the arm. Test may be modified to detect more subtle cases of anterior instability by
placing the patient prone on examination table. Place one hand on the forearm and the
palm of other hand on the posterior aspect of the proximal humerus. Abduct and
externally rotate the shoulder 90° while pushing the humeral head anteriorly. When
anterior instability is present, this position accentuates the anterior subluxation and elicits
further apprehension and patient discomfort.
Relocation Test
Purpose of test is to detect chronic anterior dislocation of the glenohumeral joint
and is a companion to the apprehension test. Patient is patient supine with the shoulder in
90° abduction and zero degrees internal rotation, with the elbow flexed 90°. Examiner

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 Chinese Orthopedics Shoulder 245

places one hand on patient's mid-forearm and other hand on the anterior aspect of the
proximal humerus. The shoulder is carefully rotated externally while applying a
posteriorly directed force to the anterior proximal humerus. Application of posteriorly
directed force should prevent anterior subluxation and reduce the patient's pain and
apprehension. If anterior instability is present, removing the posteriorly directed force
will cause the patient's apprehension and pain to return.
Anterior I nstability Test
This test is used to detect anterior instability in the glenohumeral joint. Patient is
supine with the glenohumeral j oint slightly over edge of table. Shoulder is abducted 90°
and externally rotated 60 to 80° with elbow flexed 90°. Examiner grasps the patient' s
distal humerus at the elbow and supports the arm. Thumb of examiner's other hand is
placed in the axilla on the anterior inferior humeral head with fingers on the posterior
aspect of the humeral head. While maintaining elbow flexion and neutral shoulder
rotation, examiner applies a posterior force to the humerus as the fingers of the other
hand push the humeral head anteriorly. Examiner' s thumb used to detect amount of
anterior translation. Test is repeated as amount of glenohumeral abduction is increased.
As the humerus is abducted, varying amounts of anterior translation and laxity may be
felt. If the capsular structures are intact a firm end point is noted at the end of each
anterior levering maneuver. Also, compare bilaterally. Lack of a firm end point, patient
apprehension and pain, and excessive anterior levering may indicate capsular structure
InJUry.
Anterior/ Posterior Translation Test
This test used to assess anterior or posterior glenohumeral laxity. Patient is seated
with arms relaxed at side. Examiner places one hand on the scapula superior aspect,
stabilizing it against the thorax while the humeral head is grasped with the other hand.
Examiner' s fingers and thumb used to push the humeral head anteriorly and then
posteriorly. Note the amount of translation in both directions as compared to test
application on uninvolved shoulder.
Posterior Glenohumeral Instability Test
This test used to assess humeral head posterior subluxation. Patient is supine and
relaxed while examiner holds the patient's arm in 90° of abduction and 3 0 to 45° of
horizontal adduction. Thumb of the other hand is placed on the anterior humeral head,
using the fingers to locate the posterior glenohumeral joint. Apply a posteriorly directed
force on the anterior humeral head while palpating posteriorly for any subluxation.
Maintain the posterior displacement with thumb, while slowly abducting arm horizontally
to neutral. If the humeral head is actually subluxed, a sudden reduction may be felt as the
arm is horizontally abducted. To fully ascertain the amount of posterior subluxation, this
maneuver may be repeated a few times.
I nferior Shoulder I nstability (Sulcus Sign)
Purpose of test is to assess inferior glenohumeral laxity. Patient is standing with
the involved arm hanging relaxed at the side. Examiner grasps the patient's forearm
below the elbow and pulls the arm distally. Alternatively, the patient can be instructed to
use their unaffected hand to grasp the wrist of the involved arm. While patient applies a
downward directed, distractive force on the involved arm, examiner palpates the space

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Chinese Orthopedics Shoulder 246

between the humeral head and the undersurface of the acromion. An indention or sulcus
may be noticed on the top of the middle deltoid as the humeral head subluxes inferiorly
indicating inferior glenohumeral instability. Examiner also performs this test on the
uninvolved shoulder, comparing bilateral ly.
I nferior Drawer Test or Feagin Test
Purpose of test is to assess humeral head inferior subluxation involving the
inferior glenohumeral ligament and is a modification of the sulcus sign test. Patient is
standing with shoulder abducted 90°, elbow in full extension and arm resting on
examiner' s shoulder. Examiner places both hands along the proximal humerus over the
deltoid and with fingers interlocked. An inferiorly directed force is applied to the
humerus and examiner palpates for inferior movement, which is indicative of
glenohumeral joint inferior instability. Also, must watch for apprehension or discomfort
displayed in the patient's face which indicates a positive result. Test should also be
performed on the uninvolved shoulder, comparing bilaterally.
Test can also be performed with patient seated on examination table with shoulder
abducted 90° while examiner holds patient's extended (straight elbow) arm at the elbow
and holding arm against examiner' s body. The other hand is used to apply a downward
and forward force on the head of the humerus. A sulcus may be observed above the
coracoid process.
Impingement Syndromes
Hawkins Impingement Sign
Patient is sitting or standing while examiner places patient's arm in 90° of forward
flexion and forcefully internally rotates the arm, bringing the greater tuberosity in contact
with the lateral acromion. A positive result is indicated i f pain is reproduced during the
forced internal rotation. These results suggest that pain is in the supraspinatus tendon.
Neer Impingement Sign
With the patient seated or standing the examiner places one hand on the posterior
aspect of the scapula to stabilize the shoulder girdle. The other hand used to take the
patient's internally rotated arm by the wrist and place it in full forward flexion. If there is
impingement, the patient will report pain in the range of 70° to 1 20° of forward flexion as
the rotator cuff comes into contact with the rigid coracoacromial arch.
Muscle and Tendon Lesions
Drop Arm (Godman's) Test (Supraspinatus)
This test used to evaluate supraspinatus tendon problems. Patient can be standing
or seated. Examiner passively abducts the patient' s arm to full range of pain free motion
and then observes as patient slowly lowers arm. Frequently, the arm will drop to the side
if patient has a rotator tear or supraspinatus dysfunction. Patient may be able to lower arm
to 90° (since abduction range above 90° mostly due to deltoid function) but will not be to
continue maneuver as far as the waist. Positive test indicates supraspinatus tear.
Yergason Test
This test is used to evaluate condition of the bicep tendon. Patient is seated while
the elbow is flexed 90° with the thumb up and forearm in neutral position. Examiner

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Chinese Orthopedics Shoulder 247

grasps the wrist resisting attempts by patient to actively supinate the forearm and flex the
elbow. Suggests bicep tendonitis if pain is provoked.
Ludington's Test
This is a test of the biceps long head tendon. While seated the patient' s clasps
both hands on top of the head or back of neck, allowing the interlocking fingers to
support the weight ofthe upper limbs. This allows maximum relaxation of biceps tendon.
Patient then alternately contracts and relaxes the biceps muscles. Examiner palpates the
biceps tendon. If positive, tendon wil l not be felt and this indicates a rupture.
S peed's Test (Bicep or Straight Arm Test)
Biceps tendon is tested while patient' s arm is extended behind and the forearm
supinated with elbow slightly flexed. Examiner resists shoulder forward flexion by the
patient while patient' s arm is supinated and the elbow is completely extended. Positive
test elicits increased tenderness in the bicipital groove and indicates bicipital tendinitis.
Bicep Subluxation (Transverse H umeral Ligament Test)
Test for rupture of the transverse humeral ligament. Patient is seated with the
shoulder abducted and medially rotated. Examiner's fingers are then placed along the
bicipital groove and the patient' s shoulder is laterally rotated. Feel for the bicep tendon
popping out of its groove. This indicates a positive test.
Dro p Sign (I nfraspinatus)
This test is concerned with the infraspinatus muscle and possible dysfunction of
the posterosuperior cuff. Patient is seated on examination table with back to the
examiner. Examiner holds affected arm at 90 degrees of abduction (in the scapular plane)
and at almost full external rotation, with the elbow flexed at 90 degrees, by the patient's
wrist while supporting the elbow. Maintenance of this position of external rotation of the
shoulder is a function mainly of the infraspinatus. Patient then asked to actively maintain
this position as the examiner releases the wrist while supporting the elbow. The sign is
positive if a lag or " drop" occurs. Magnitude of the lag is recorded to the nearest 5°.
H o rnblower's Sign (Teres M i nor)
Patient is sitting or standing with shoulder externally rotated at 90° of abduction.
Examiner supports the arm in the scapular plane. Elbow is flexed to 90° and the patient is
asked to rotate the arm externally against the resistance. Positive sign is the inability to
maintain the externally rotated position and the arm drops back to neutral position.
Positive result suggests possible tear or dysfunction of infraspinatus and teres minor.
Gerber Lift-Off Test (Subscapularis)
Patient can be sitting or standing with hand of affected side placed on the small of
the back, causing the arm to be extended and internally rotated. Examiner then passively
lifts the hand off the small of the back, placing the arm in maximal internal rotation, after
which the examiner releases the hand. If the hand falls onto the back because the
subscapularis is unable to maintain internal rotation, the test result is positive. Patients
with subscapularis tears have an increase in passive external rotation and a weakened
ability to resist internal rotation. Positive results indicate possible rupture of the
subscapularis.

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Ch inese Orthopedics Shou lder 248

Labral Tears
Glenoid Labrum Clunk Test (Internal Derangement)
Purpose of test is to assess the glenoid labrum's integrity and stability. Patient is
supine with the glenohumeral j oint slightly over the edge of table. Examiner places one
hand on the elbow supporting patient's arm with the shoulder maximally flexed and the
elbow relaxed in approximately 60° of flexion. Place examiners fingers of other hand on
the posterior aspect of the humeral head. Rotate the humerus and maneuver it between
the end ranges of glenohumeral abduction and flexion. As the humerus is moved through
these extreme ranges of motion, a glenoid labrum tear, if present, may be trapped or
caught. This trapping of the tom labrum will often cause a grinding or "clunking"
sensation to be felt or heard. Examiner should also perform this test on the uninvolved
shoulder and compare bilaterally.
O'Brien Test
This test used to examine superior labral pathology. Patient is sitting or standing
and attempts to elevate the extended, pronated arm from a starting position of 90°
forward flexion and 20° to 30° of adduction against resistance. Resisted flexion,
adduction, and internal rotation will cause more pronounced symptoms. The result is
considered positive if symptoms are relieved with resisted forward flexion when the test
is repeated with the arm supinated.
Thoracic Outlet Syndrome
Addison Maneuver
Involves test for thoracic outlet syndrome with patient seated and arm hanging
relaxed. Patient rotates head to face tested shoulder. Patient then extends head while
examiner lateral rotates and extends patient' s shoulder while locating the patient's radial
pulse. Patient then instructed to take a deep breath and hold it. Disappearance of radial
pulse indicates positive result showing compression of neurovascular structures to arm.
Costoclavicular Syndrome (Military Brace)
This test is one of several that are similar to the Adson maneuver. Patient is seated
or standing with arms hanging relaxed. Symptoms of possible thoracic outlet syndrome
may be reproduced by sustained traction of the shoulder. Examiner first palpates the
radial artery pulse and pulls patient's wrist downward and backward into extension.
Examiner feels radial pulse. Positive result indicated if radial pulse disappears. Test
effective for patients complaining of symptoms from wearing a heavy coat or back pack.
Elevated Arm Stress Test (EAST) (Roos Test)
Patient is seated or standing with both arms abducted to 90° with elbows flexed
90° and laterally rotated with palms facing forward. The forearm muscles are exercised
by slowly closing and opening the fingers for three minutes. Test is positive if patient
cannot keep arms in starting position for three minutes; suffers ischemic pain, heaviness,
or weakness in arm; or numbness and tingling occur in hand before three minutes. Any of
these responses indicate neurological impingement within the thoracic outlet.
Shoulder Girdle Passive Elevation
This test used to verify thoracic outlet syndrome by relieving existing symptoms.
Patient is seated with both arms crossed over the chest. Examiner is positioned behind

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Chinese Orthopedics Shoulder 249

patient and passively elevates the shoulder girdle by applying an upward force toward the
shoulder by placing hands below both elbows of the patient (passive bilateral shoulder
shrug). The shoulder girdle elevated position is held for 30 seconds. Improved arterial
flow is noted by a stronger pulse, hand temperature increase, and improved skin color
changes. Restored venous flow is noted by decreased venous engorgement and cyanosis.
Possible changes in neurological signs include reduced pain as neural ischemia is
rel eased, as well as the feeling of numbness changing to pins and needles or tingling.
Neurological Functional Tests
U pper Limb Tension Test (Brachial Plexus Tension or Elvey Test)
This test is thought of as the upper limb equivalent of the straight leg raising test
for the leg. It is considered when patient presents with upper limb radicular signs or
peripheral nerve involvement. With the patient supine, the joints of the upper arm are
placed into certain positions to stress each of the neurological structures differently.
Upper arm symptoms are more readily aggravated than those of the lower arm. Side
flexion of the contralateral cervical spine can further sensitize the test.
-+ If patient's neurological signs are in an acute phase or a re becoming worse, or if
there a re cauda e q uina or spi nal cord lesions, these stress tests are
contraindicated

It is important that the shoulder is positioned and held in constant depression

during the test even with abduction. There are four upper limb tension tests as follow:
UL TT J

This test provides stress or bias on the median nerve, anterior interosseous nerve,
and nerve root levels C5, C6, and C7. With the contralateral cervical spine in side
flexion, the shoulder on the affected side is held in depression while abducted at 1 1 0°
with the elbow extended, forearm supinated, with wrist extended, and fingers thumb held
in extension.
UL TT 2

This test provides stress or bias on the median nerve, musculocutaneous nerve,
and axillary nerve. With the contralateral cervical spine in side flexion, the shoulder on
the affected side is laterally rotated and held in depression while abducted at 1 oo with the
elbow extended, forearm supinated, with wrist and fingers held in extension.
UL TT J

This test provides stress or bias on the radial nerve, musculocutaneous nerve, and
axillary nerve. With the contralateral cervical spine in side flexion, the shoulder on the
affected side is medially rotated and held in depression while abducted at 1 oo with the
elbow extended, forearm pronated, wrist extended in ulnar deviation, and fingers and
thumb held in flexion.
UL TT 4

This test provides stress or bias on the ulnar nerve and nerve root levels C8 and
T 1 . With the contralateral cervical spine in side flexion, the shoulder on the affected side
is laterally rotated and held in depression while abducted at 1 oo to 9 0° until hand touches
ear with the elbow flexed, forearm supinated, wrist extended in radial deviation, and
fingers and thumb held in extension.

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Chinese Orthopedics Shoulder 250

Tinel's Sign (at S houlder)

This test involves tapping an area of the brachial plexus above the clavicle located
in the scalene triangle. Stimulating a tingling sensation in one or more nerve roots is
considered a positive sign.

Neurological Evaluation of Shoulder

Myotomes-Key muscle strength (graded 0-5)
Trapezius muscle (XI, C4)
Deltoid muscle (C5)
Key Reflexes:
None at shoulder

Accessory Movements: Glenohumeral Joint

F ive accessory movements are evaluated for the shoulder j oint, conducted with the
patient supine with the upper arm in neutral position. In some situations it may be useful
to repeat these tests with the arm abducted or flexed 90°.
Caudal Humeral Glide
Longitudinal caudal movement is produced by application of pressure over the head of
the humerus directed downward toward the humeral shaft.
Cephalad Humeral Glide
Longitudinal cephalad movement is produced by grasping the upper arm and applying a
compressive force along the humeral shaft.
Ventral Humeral Glide
Posteroanterior movement is produced by applying pressure under the posterior surface
of the humeral head with the patient supine, which is directed to the front. This test can
also be performed with the patient lying prone with the coracoid process stabilized on a
firm table or sandbag.
Dorsal Humeral Glide
Anteroposterior movement is produced by applying pressure on the anterior surface of
the humeral head which is directed downward toward the back.
Lateral Traction
Lateral movement is produced by grasping proximal region of upper arm and pulling the
humeral head away from the glenoid cavity.

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View. May consist of a true anteroposterior view or a tilt view.
Axillary Lateral View. This view shows the relationship of the humeral head to the
glenoid fossa and useful in diagnosing anterior and posterior shoulder dislocations, and
avulsion fractures of the glenoid. Patient must be able to abduct the arm 70° to 90°.
Transscapular (Y) View. This is the true lateral view of the scapula and shows the
position of the humerus relative to the glenoid, acromion, and coracoid process.

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 Chinese Orthopedics Shou lder 251

Stryker Notch View. This view centers on the coracoid process with the patient lying
supine with the arm flexed and hand on top of head.
West Point View. The patient is prone in this view which is used to delineate possible
glenoid fractures.
Arch View. This a lateral view to determine the width and height of the subacromial
arch.
Magnetic Resonance Imaging (MRI)
MRI is useful in diagnosing soft-tissue injuries to the shoulder and is the imaging method
of choice for demonstrating shoulder soft-tissue abnormalities. This allows differentiation
of bursitis, tendonitis, muscles strains, impingement, labral tears, glenoid irregularities,
and state of bone marrow.
Computed Tomography
Computed tomography is effective in diagnosing bone and soft tissue injuries and
abnormalities of the shoulder, especially when used in conjunction a radiopaque dye
(computed tomoarthrogram). Main advantage is to view cross sections including axial or
perpendicular views.

Management of Shoulder Disorders

Management of shoulder disorders involves physical modalities to improve mobility,
needling therapy, possible electroneedling EN application, and remedial exercises or
rehabilitation.

Shoulder Mobilization
Any of the physiological or accessory movements previously described can be applied to
the shoulder to improve mobility and reduce pain in affected joints. Passive movement
treatments are graded from I-V and consist of either small or larges amplitude oscillations
that do not move into the restricted or painful area, except for grade V which involves a
sharp thrust beyond the pathological limit of movement (See Table 5 . 1 ). Grade V
mobilization techniques are not usually applied to the shoulder. Mobilization application
usually starts with small amplitude oscillatory movements at the end of range (Grade IV)
to improve joint mobility. When pain is present, Grade I and II movements are used by
just moving to the area where pain manifests. The following movements are considered:
• Glenohumeral joint
• Caudal humeral glide
• Ventral humeral glide
• Dorsal-ventral humeral oscillation
• Dorsal humeral glide
• Dorsal humeral glide (flexion exceeding 70°)
• Graded lateral rotation
• Lateral traction

Needling Therapy for Shoulder Problems

Treatment of problems affecting the shoulder and upper arm usually involves using most
of the nodes local to the shoulder, as well as appropriate distal and proximal nodes. Local

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Chinese Orthopedics Shou lder 252

shoulder nodes include ALH, PLH, and LH distribution nodes. Distal sites on the hand
and arm and proximal locations on the upper back and neck are selected depending upon
the most likely muscular pathways to be involved.
Appropriate local and adjacent, distal and proximal nodes for treatment of
shoulder problems are noted in Table 9.4 which concerns pain and dysfunction related to
the shoulder. Additional nodes are considered that have a direct influence on the muscle
moving the arm mainly located on the scapula. Selection of nodes is considered in terms
of the problems affecting either the anterior-lateral or lateral-posterior aspect of the
shoulder. Treatment only applied to the affected side.

Table 9.4. Candidate reg ional, proximal and distal nodes for pain and disorders of the shoulder.
Pain or Disorder of Candidate Loca l & MD* Proximal Nodes Distal Nodes
the Shoulder Adjacent Nodes
Anterior Lateral Yunmen (AMH 2) AMH Fengchi (LF 20) Hegu (ALH 4)
Jugu (ALH 1 6) ALH
Jianyu (ALH 1 5) Dazhu (PLF 1 1 )**
Jianliao (LH 1 4) Feishu _{PLF 1 3)
Lateral Posterior Jugu (ALH 1 6) ALH Dazhu (PLF 1 1 ) Hegu (ALH 4)
Jianliao (LH 14) Feishu (PLF 1 3)
J ianzhen (PLH 9) LH Fengchi (LF 20) Zhongzhu (LH 3)
Naoshu (PLH 1 0) PLH Tianzhu (PLF 1 0) Houxi (PLH 3)
Jianzhongshu (PLH 1 5)
* Muscular d istribution
** Add if signs of su bscapu laris tendon itis or pain
Node Selection
Anterior Lateral Shoulder
Candidate node selection for anterior lateral shoulder problems (Table 9.4)
address shoulder pain and dysfunction reflecting in this area. This includes glenohumeral
joint problems, including capsulitis, as well as pain in the anterior and lateral deltoids,
subacromial or subcoracoid bursitis, involvement of the teres major muscle, bicepital
tendonitis, and latissimus dorsi involvement. Additional nodes can be considered
depending on the extent and nature of the patient' s problems:
•
In case of capsulitis, subacromial bursitis, or swelling of shoulder, Naoshu (PLH
1 0) may also be added
•
If shoulder pain is reflected to deltoid insertion, Binao (ALH 1 4 ) can be
considered as well
•
If the pain is more anterior with suspected involvement of the subscapularis
muscle (ALH), nodes Dazhu (PLF 1 1 ) and Feishu (PLF 1 3) (related to the
rhomboid muscles-ALH) can be added as additional proximal locations
•
Proximal nodes Dazhu (PLF 1 1 ) and Feishu (PLF 1 3) or Jianzhongshu (PLH 1 5 )
may also be considered for capsulitis
Lateral Posterior Shoulder
Node selection for lateral posterior shoulder (Table 9.4 for the PLH, LH, and
ALH muscular distributions) problems includes shoulder pain and dysfunction reflecting
in this area. This involves glenohumeral joint problems, including capsulitis, as well as

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Chinese Orthopedics Shou lder 253

pain in the lateral and posterior deltoids, subacromial bursitis, supraspinatus tendonitis,
infraspinatus tendonitis, and teres minor involvement. Additional nodes may be added to
the treatment protocol that addresses the extent and nature of the patient's problems:
•
In case of capsulitis, subacromial bursitis, or swelling of shoulder, Yunmen
(AMH 2) may also be added
•
Bingfeng (PLH 1 2 ) added for supraspinatus muscle belonging to the lateral hand
(internal membrane) distribution
•
If shoulder pain is reflected to deltoid insertion, Naohui (LH 1 3 ) can be
considered as well
•
In case of infraspinatus, teres major, or teres minor involvement, Tianzong (PLH
1 1 ) may be added.
Candidate E/ectroneedling (EN) Application
Electroneedling (EN) may be considered for uncomplicated cases of shoulder problems if
they fail to respond to standard needling therapy after three to five treatments.
Electroacupuncture might be introduced from the tim f lhe fi rst treatment for
complicated cases. These cases have a long history and may hav involved surgery as
well. They typically have a well documented record of previous treatments and
diagnostic imaging studies. Nodes selected for standard treatment are based on Table 9.4
as modified according to the preceding discussion. These same nodes are still used and
EN will be applied only to some selected nodes, or one or two additional nodes are to be
added. Candidate EN to be added to the standard needing treatment is discussed below
for the anterior lateral and lateral posterior shoulder. Frequency, mode, duration, and lead
placement for EN are noted as follows:
Anterior Lateral Shoulder
Frequency: 2 Hz
Operating Mode: continuous
Duration : 20-30 minutes
Anterior Lateral Shoulder (two circuits)
Fengchi (LF 20) + lead*, to Jianyu (ALH 1 5) - lead
Jianzhongshu (PLH 1 5) + lead, to Jianliao (LH 1 4) - lead
* Plus (+) lead refers to the positive while the minus (-) lead refers to the negative
Lateral Posterior Shoulder
Frequency: 2 Hz
Operating Mode: continuous
Duration : 20-30 minutes
1 . Lateral Posterior Shoulder (two circuits for ALH distribution)
Dazhu (PLF 1 1 ) + lead, to Jianliao (LH 1 4) - lead
Feishu (PLF 1 3) + lead, to Naoshu (PLH 1 0) - lead
2. Lateral Posterior Shoulder (two circuits for PLH and LH distributions)
Fengchi (LF 20) + lead, to Jianliao (LH 1 4) - lead, for LH (internal membrane)
Jianzhongshu (PLH 1 5) + lead, to Naoshu (PLH 1 0) - lead, for PLH

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Chinese Orthoped ics Shou lder 254

Remedial Exercises for Muscles Moving the Shoulder Joint

Muscular and tendon problems afTecting the shoulder often involve the so-called "rotator
cuff" which includes the supraspinatus, infraspinatus, teres minor and subscapularis
muscles. The muscles and tendons biceps brachii are also prominent in shoulder
dysfunction. These and other muscles moving the shoulder j oint are exercised using
movements of the ann and shoulders in abduction, lateral rotation, forward flexion, and
l ateral rotation (See Table g.3).

Rotator Cuff
The rotator cuff is comprised of ligaments and tendons of the supraspinatus,
subscapularis, infraspinatus, and teres minor muscles. The first of these muscles is
involved in shoulder abduction up to about goo while the other three are essential to
internal and external rotation of the shoulder. External rotation exercises, involving the
infraspinatus and teres minor mm . are more important is restoring strength since these
muscles are not strongly helped by other muscles working assistant to the prime mqvers.
Internal rotation is assisted by strong muscles such as the latissimus dorsi and teres
major. Thus special care should be taken to assure that subscapularis m. is participating
strongly during internal rotation of the shoulder.
Shoulder Abduction to 90°
This exercise involves abducting the shoulder to goo while in the seated position to
strengthen the supraspinatus m (prime mover), although the middle fibers of the deltoids
m. participate. Initially subject is seated with arm at side, with the elbow flexed goo,
forearm in neutral position and shoulder in neutral rotation. This exercise can also be
performed side-lying. The subject slowly abducts the ann to goo and holds the position
for 2 - 3 seconds and then slowly lowers arm to start point.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder and back should be contracted to provide antagonistic
resistance to shoulder abduction.
When subject is fully capable of completing the above routine it is modified to
fully extend the elbow in order to increase to resistive gravity load. With arm by the side
and elbow extended in neutral position, the ann is slowly abducted to goo and held in
position for 2 3 seconds and then slowly lowers arm to start point. This exercise is
-

repeated up to 8 repetitions and eventually performed for 4-5 sets. As strength permits,
shoulder and back muscles should be contracted to provide IDR antagonistic resistance to
shoulder abduction. As strength increases light-weight dumbbell can be introduced to
increase exercise load and further the strengthening process.
Medial (Internal) Rotation
Medial rotation is used to exercise the prime movers consisting of the subscapularis and
teres major muscles, although assistant muscles including the latissimus dorsi, upper
pectoralis major and anterior deltoid muscles participate in this movement.
The subject is supine with the shoulder externally rotated and slightly adducted by
holding elbow next to body with the elbow flexed goo, and the forearm in neutral
position. The subject slowly internally rotates the shoulder by moving the palmar side of
the hand up arcing over toward the lower chest. The arm in then slowly moved by
external rotation to the start point.

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Chinese Orthopedics Shoulder 255

This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5

sets. As strength permits, shoulder and back muscles should be contracted to provide lOR
antagonistic resistance to shoulder internal rotation. As strength increases light-weight
dumbbell can be introduced to increase exercise load and further the strengthening
process.
Lateral (External) Rotation
Lateral rotation is used to exercise the prime movers involving the infraspinatus and teres
minor mm. although the posterior deltoid participates as assistant mover in external
rotation. The subj ect is side lying with the upper arm resting on the side and the shoulder
internally rotated and elbow flexed 90°, and the forearm in neutral with palm resting on
lower chest. While making a fist the arm is slowly raised in an arc to the full extent of
external rotation. The end position is held for 2 3 seconds and the arm slowly moved
-

back so fist is resting on lower chest.

This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder and back muscles should be contracted to provide lOR
antagonistic resistance to shoulder external rotation. As strength increases light-weight
dumbbell can be introduced to increase exercise load and further the strengthening
process.
Combined Lateral (External) and Medial (Internal) Rotation
This exercise is conducted while lying supine with the shoulder abducted to 90° and
elbow t1exed to 90° and forearm held in pronation. The arm is externally rotated by
moving the dorsum of the hand toward the direction that the head is pointed until the
back of the hand touches the floor. The direction is reversed by moving the palmar
surface of the hand up toward the ceiling (internal rotation) and then toward the feet,
making a 1 80° arch, until the palm touches the floor. The rotator cuff muscles should be
tightened (IDR) to increase the contractile force and alternatively stretch one set of
rotator cuff muscles while contracting the other set. This exercise is repeated up to 8
repetitions and eventually performed for 4 - 5 sets. As strength increases a light weight
dumbbell may be introduced to further improve strength.

Shoulder Forward Flexion

Forward flexion is used exercise the anterior deltoid and upper pectoralis major muscles
as prime movers with the biceps long head and short head, and coracobrachialis as
assistant muscles participating in flexion of the upper arm.
Biceps Brachii (long head)
Subject is supine with elbow extended and forearm supinated and resting on floor. The
arm is slowly lifted, with elbow extended, to flex the shoulder to 90°. End position is held
2 - 3 seconds and then arm is slowly lowered to start point.
This exercise is repeated up to 8 repetitions and eventually performed for 4-5 sets.
As strength permits, shoulder, ann and back muscles should be contracted to provide lOR
antagonistic resistance to shoulder forward flexion. As strength increases light-weight
dumbbell can be introduced, grasped with palm facing upward, to increase exercise load
and further the strengthening process.

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Chinese Orthopedics Shoulder 256

Anterior Fibers of Deltoid: Shoulder Flexion to 90°

Shoulder flexion exercise to 90° is used to strengthen the anterior fibers of the deltoid
although assistant muscles, including the biceps brachii, coracobrachialis, middle fibers
of the deltoid, clavicular fibers of the pectoralis maj or, upper and lower fibers of the
trapezius and the serratus anterior mm. participate. Subject is supine with arms at side
and palms facing the body and with the shoulders slightly abducted. The arm is slowly
raised to flex the shoulder to 90° while maintaining the elbow extended and forearm in
neutral. End position is held 2 3 seconds and then arm is slowly lowered to start point.
-

This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5

sets. As strength permits, shoulder, arm and back muscles should be contracted to provide
IDR antagonistic resistance to shoulder forward flexion. As strength increases light­
weight dumbbell can be introduced, grasped with palm facing the body, to increase
exercise load and further the strengthening process.
Coracobrachialis: Shoulder Flexion and Adduction
Exercise in shoulder flexion with shoulder adduction is used to strengthen the
coracobrachialis m., with assistant muscles including the anterior fibers of the deltoid,
clavicular fibers of the pectoralis maj or, and the short head of the biceps brachii mm
participating.
The subject is supine, while shoulder is slightly adducted with external rotation
while the elbow is flexed with the forearm supinated. While making a fist, the subj ect
flexes and adducts the shoulder raising the hand above the shoulder, while maintaining
slight external rotation. End position is held 2 3 seconds and then arm is slowly lowered
-

to start point.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder, arm and back muscles should be contracted to provide
IDR antagonistic resistance to shoulder forward flexion. As strength increases light­
weight dumbbell can be introduced, grasped with palm facing upward, to increase
exercise load and further the strengthening process.

Latissimus Dorsi and Teres Major: Shoulder Extension

Shoulder extension exercise involves the prime movers, latissimus dorsi and teres major
muscles with the teres minor, posterior fibers of the deltoid, and the triceps participating
as assistant movers. The subject is lying prone (test can also be performed seated) with
arms to the side with the shoulder in internal rotation and palms facing upward. The
subject then slowly extends the shoulder through full range of motion while maintaining
slight shoulder adduction. End position is held 2 3 seconds and then arm is slowly
-

lowered to the floor.

This exercise is repeated up to 8 repetitions and eventually performed for 4 5-

sets. As strength permits, shoulder, arm and back muscles should be contracted to provide
IDR antagonistic resistance to shoulder extension. As strength increases light-weight
dumbbell can be introduced, grasped with palm facing upward, to increase exercise load
and further the strengthening process.

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Chinese Orthopedics Shoulder 257

Posterior Fibers of Deltoid: Shoulder Horizontal Abduction

Horizontal abduction (horizontal extension) exercise of the shoulder strengthens the
posterior fibers of the deltoid, infraspinatus, and teres minor muscles, with the teres major
and latissimus dorsi muscles as assistant movers. The subj ect is prone with the shoulder
abducted to about 75°, the elbow flexed 90°, and the forearm pronated and resting on
floor. The elbow is then slowly lifted off the floor to horizontally abduct and slightly
externally rotate the shoulder. End position is held 2 - 3 seconds and then elbow is slowly
lowered to the floor.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder, arm and back muscles should be contracted to provide
IDR antagonistic resistance to shoulder horizontal abduction.
As strength increasing this exercise is modified to extend the elbow to increase
the resistive load while still abducting the shoulders to about 75°. The arm is then slowly
lifted off the floor to horizontally abduct and slightly externally rotate the shoulder. End
position is held 2 3 seconds and then elbow is slowly lowered to the floor. This exercise
-

is repeated up to 8 repetitions and eventually performed for 4 - 5 sets. As strength is

further increased, light-weight dumbbells can be introduced, grasped with palm facing
downward, to increase exercise load and further the strengthening process.
This exercise can also be performed from the standing position by bending
forward and allowing the arms to hang down. Shoulder is still maintained in abduction of
about 75°, with elbows slightly flexed. Arms are raised to move shoulder into horizontal
abduction.

Pectoralis Major: Shoulder Horizontal Adduction

Exercising the shoulder in horizontal adduction (horizontal flexion) involves the
clavicular and sternal heads of the pectoralis major muscle, anterior deltoid, and
coracobrachialis muscles as prime movers, with the subscapularis and biceps brachii,
short head muscles participating as assistant movers. These muscles are all exercised as a
group with prime emphasis on the pectoralis major. If weakness is present in only one
group of fibers of the pectoralis muscle, the individual clavicular and sternal heads can be
exercised separately, since each head has a separate innervation. In this situation the
humerus is positioned so that its direction of resistive force is aligned directly opposite to
pull of the fibers in each portion of the pectoralis major.
Pectoralis Major: 90° Shoulder horizontal adduction
With the subj ect supine with shoulder abducted to 90°, elbow flexed 90°, and forearm
neutral and pointing straight up. While making a fist, the shoulder is slowly adducted
horizontally through the full range of motion. End position is held 2 - 3 seconds and then
arm is moved back to slowly lower the elbow to the floor.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder, arm and back muscles should be contracted to
provide IDR antagonistic resistance to shoulder horizontal adduction. As strength is
increased, light-weight dumbbells can be introduced, grasped with palm facing the body,
to increase exercise load and further the strengthening process.
As strength increases, exercise can be performed with shoulder abducted to 90°,
and the elbows extended with arms lying on floor with palms up. Arm is then raised to

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Chinese Orthopedics Shou lder 258

vertical. As strength is increased, light-weight dumbbells can be introduced, grasped with

palm facing upward, to increase exercise load and further the strengthening process.
Pectoralis Major (Clavicular Head)
The subject is lying supine with the shoulder abducted to 70 - 75°, and elbow flexed 90°.
While making a fist, the arm is moved through the full range of motion in the direction of
horizontal adduction, forward flexion, and internal rotation with the hand traveling to a
point above the contralateral shoulder. End position is held 2 3 seconds and then arm is
-

moved back to slowly lower the elbow to the floor.

This exercise is repeated up to 8 repetitions and eventually performed for 5 sets.
As strength permits, shoulder, arm and back muscles should be contracted to provide IDR
antagonistic resistance to shoulder horizontal adduction. As strength is increased, light­
weight dumbbells can be introduced, grasped with palm facing the body, to increase
exercise load and further the strengthening process. As strength increases this exercise
can be performed with the elbows extended.
Pectoralis Major (Sternal Head)
The subj ect is lying supine with the shoulder abducted to approximately 1 25 - 1 3 5 ° and
elbow flexed 90°. While making a fist, the arm is moved through the full range of motion
in the direction of horizontal adduction, extension, and internal rotation with the hand
traveling toward the contralateral hip. End position is held 2 3 seconds and then ann is
-

moved back to slowly lower the elbow to the floor.

This exercise is repeated up to 8 repetitions and eventually performed for 5 sets.
As strength permits, shoulder, arm and back muscles should be contracted to provide IDR
antagonistic resistance to shoulder horizontal adduction. As strength is increased, light­
weight dumbbells can be introduced, grasped with palm facing the body, to increase
exercise load and further the strengthening process. As strength increases this exercise
can be performed with the elbows extended.

D. E. Kendall, OMD. PhD ©2005-2009

Chinese Orthopedics Elbow 259

10

Elbow

The elbow functions as a hinge-like joint that allows articulation of the ulnar and
humerus bones (humeroulnar j oint) by bending and straightening of the elbow in flexion
and extension. This hinge action moves only in one plane. The radial bone also articulates
with the humerus forming the radiohumeral j oint. The elbow also provides the complex
action of turning the forearm over in pronation or supination. This movement happens by
virtue of articulation between the radius and the ulna occuring simultaneously at the
elbow (superior radioulnar joint) and the wrist (inferior radioulnar joint). In the
anatomical position of forearm supination, the radius and ulna lie parallel to each other.
During pronation the ulna remains fixed while the radius rolls around it at both the wrist
and the elbow j oints. Forces transmitted through the elbow joint are bascially transferred
between the humerus and the ulna. Little force is transmitted between the humerus and
the radius. However, at the wrist j oint, most of the force is transferred between the radius
and the carpus, with the ulna taking very little part in the wrist joint.
The elbow has a joint capsule and key ligaments including the medial collateral
ligament, lateral collateral ligament, annular L igament, an interosseou membrane, and the
dorsal and palmar ligaments of the inferior radioulnar joint. Primary stability of the elbow
is provided by the ulnar collateral ligament located on the medial side of the elbow.
However, one of the most common injuries to the elbow occurs on the lateral aspect of
the elbow known as lateral epicondylitis, or tennis elbow. The planes and axes of
articulation, normal limiting factors to movement of the elbow and forearm, normal end
feels and active range of motion for arm movements are noted in Table 1 0. 1 .
Neural supply to the elbow and the muscles moving the forearm include the
branching of the ulnar nerve (C7 8, T l ), radial nerve (C5 8, Tl ), and median (C5
- - - 8,
T l ) nerves to supply the follow nerves:
•
Posterior, lateral and medial cutaneous nerves
•
Musculocutaneous: Biceps brachii, long head; Biceps brachii, short head
•
Radial: Brachioradialis; Triceps brachii, long head, and lateral; Triceps brachii,
medial head; Triceps brachii, lateral head; Anconeus
•
Posterior interosseous: Supinator
•
Median nerve: Pronator teres
•
Anterior interosseous: Pronator quadratus

Elbow Physiology
Muscles moving the forearm act on the elbow joint to either extend or flex the forearm.
They also act on the proximal radioulnar joint to pronate or supinate the wrist and
forearm (See Table 1 0.2).

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 Chinese Orthopedics Elbow 260

Table 1 0. 1 . Joint structures involved in movement of the elbow

Flexion Extension Supination Pronation
Articulation Humeroulnar, Humeroulnar, Radiohumera l , Radiohumeral,
rad iohumeral radiohumeral superior radioulnar, superior radioulnar,
inferior radioulnar, inferior rad ioulnar,
i nterosseous i nterosseous
membrane membrane
Plane Sagittal Sagittal Horizontal Horizontal
Axis Frontal Frontal Longitud inal Longitudinal
Normal limiting Soft tissue apposition Olecranon process Tension in pronator Contact of radius on
factors of anterior forearm and contacting olecra non mm., palmar radioulnar ulna; tension in dorsal
upper arm; coronoid fossa ; tension in elbow ligament of inferior radioulnar ligament of
process contacting flexors radioulnar joint, inferior radioulnar joint,
coronoid fossa oblique cord, and interosseous
i nterosseous membrane, and biceps
membrane brachii mm.
Normal end feel Soft/hard Ha rdffirm Firm Hardffirm
Normal active 0 - 1 50° 1 50 - o· o - (80 - go·) o - (80 - go·)
range of motion
Capsular Elbow joint: flexion, ex1ension, and rotation full and painless
pattern I nferior radioulnar joint: full rotation with pain at extremes of rotation

Table 1 0.2. Fu nction , m u scle d istribution ( M D) assignment, and nerve root of primary movers
(PM) and assistant/accessory movers (AM) for forearm and radio-u lna articulation

Muscle MD Nerve Flexion Extension Medial 1 Rotation Lateral2 Rotation

Root
Biceps brachii, long head ALH C5, 6 PM AM

Biceps brachii, short head AMH C5, 6 PM AM

Brachioradialis AMH C5. 6 PM

Brachialis PMH C5, 6 PM

Triceps brachii, medial head PMH C6 , 7 , 8 PM

Triceps brachii, long head PLH C6, 7, 8 PM

Triceps brachii, lateral head LH C6, 7 , 8 PM

Anconeus LH C7, 8, T1 AM

Supinator ALH C5, 6, (7) PM

Pronator teres PMH C6, 7 AM

Pronator quadratus MH C8, T1 PM

Wrist and finger flexors AM

Wrist and finger extensors AM

1 = Pronation; 2 = Supination

Disorders Affecting El bow

There are many common problems associated with the elbow and the wrist joints. These
include inflammation and pain in the elbow which is sometimes referred to as "tennis
elbow," and similar disorders affecting the wrist, sometimes including tunnel carpal
syndrome. All the muscles and joints of the forearm and wrist can experience pain,

D.E. Kendall, OMD, PhD. ©2005-2009

Ch inese Orthopedics Elbow 261

spasms, paralysis and sensory deficits as well as arthritic conditions, all of which impair
the function of the elbow and wrist.

Problems of Muscles Articulating Elbow

Specific disorders associated with the six longitudinal muscular distributions associated
with articulation of the elbow joint and forearm includes:
Anterior medial hand (AMH) distribution:
•
Acute cramps and spasms along the anterior lateral aspect of the radius and
lateral cupital fossa
Anterior lateral hand (ALH) Intestine distribution:
•
Pain, spasms and acute cramps along the lateral posterior aspect of the radius and
lateral aspect of the elbow
Lateral hand (LH) distribution:
•
Acute cramps and spasms along the posterior region of the forearm between the
ulna and radius traveling up to the elbow
Posterior lateral hand (PLH) distribution:
•
Pain in the posterior aspect of the medial epicondyle of the elbow which follows
along the inner aspect of the arm to enter below the axilla causing pain below the
axilla
Posterior medial hand (PMH) distribution:
•
Acute cramps and pain in the muscles along the medial anterior region of the
ulna and medial aspect of the elbow
Medial hand (MH) distribution:
•
Acute cramps, spasms and pain along the anterior region of the forearm between
the ulna and radius, up to the cupital fossa

Pathology of Elbow and Forearm

Musculotendinous Lesions
Lateral Epicondylitis
This condition occurs mostly in the dominant arm of middle-aged patients, being
less common in males than in females, and occasionally may be bilateral. It is often seen
in persons whose sports activities or occupation involves excessive forearm pronation
and supination, or use of the wrist. Onset may be gradual being noticed initially in the
elbow or forearm, or it may be sudden as seen in playing tennis especially following a
change in action, a miss-hit, or following a direct impact to the epicondylar area. Pain is
initially apparent over the lateral aspect of the elbow and if severe, it may radiate down
forearm and into the dorsum of the hand, including the middle and ring finger. Rarely
does the pain radiate up the arm. Wrist movements involving gripping or shaking the
hand become difficult due to pain. X-rays of the elbow appear normal for the patient' s
age although calcification may be noted in small areas in the wrist extensors origin.
A nerve root irritation at C7 can also produce pain that reflects into the lateral
aspect of the elbow. But, this particular condition is often associated with paresthesia or
other neurological signs thereby helping to differentiate clinical findings.

D.E. Kenda ll, OMD, PhD. ©2005-2009

Ch inese Orthopedics Elbow 262

Medial Epicondylitis
This condition is not as common as lateral epicondylitis and manifests with pain
over the medial compartment of the elbow involving the medial epicondyle which is the
origin site of the forearm pronator and wrist flexors. This condition is also known as
golfer' s elbow although it occurs in people who have never played golf. Occurrence
mainly involves middle aged patients whose occupational or athlete endeavors require
strong hand grip and adduction movements of the elbow. Pain may radiate distally and is
made worse wrist movements, especially involving gripping or repeated wrist flexion.
Isometric contraction of the wrist flexors can reproduce the pain. It may also be
reproduced by fully resisting forearm pronation or stretching the flexor muscles by fully
extending the supinated forearm and then passively hyperextending the wrist.
Biceps Tendinitis
This condition is somewhat uncommon with the patient complaining of pain that
is usually localized to the center of the cupital fossa. Examiner can reproduce the
patient's pain by resisting forearm supination or elbow flexion. Stretching the bicep
tendon can also reproduce the pain. This is accomplished by the examiner extending the
elbow and then applying full passive forearm pronation. Accessory movements of the
radioulnar joint may indicate a painful restriction of movement.
Triceps Tendi n itis
This condition occurs infrequently and usually follows a sudden severe strain to
the triceps tendon as the arm is fully extended, such as by throwing a javelin. With the
patient standing, their pain can be reproduced by fully resisting elbow extension while
elbow is flexed with forearm fully supinated. Palpation over the insertion of the triceps
into the olecranon may reveal tenderness.

Examination of Elbow
The elbow is examined prior to prior to any musculoskeletal assessments including
possible function tests by having the patient move the elbow in flexion, extension,
supination and pronation without moving in to areas of pain. General observation for
possible deformities, swellings, and coloration changes are also noted.
Elbow Carrying Angle
The forearms angle slightly away from the body when the arms are held relaxed along the
body while standing in the anatomical position. This slight angularity makes it easier to
carry something against the body and hence is referred to as the carrying angle. One type
of deformity usually the result of a fracture causes the forearm to be angled toward the
body. This is called a "gun stock" deformity since it gives the appearance of a gun stock
and is classed as "cupitus varus." Normal carrying angle for males is 5 ° - 1 oo, while in
females it is 1 0° - 1 5 °.
•
Carrying angles greater than 1 5° is classed as "cupitus valgus"
•
Carrying angles less than 5° - 1 oo is classed as "cupitus varus"

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Chinese O rthoped ics El bow 263

Active Movements (Range of Motion)

Elbow
Elbow extension and flexion can be measured with the patient either supine or seated. In
either case the examiner stabilizes humerus during active movement. Normal range of
flexion is 0 - 1 50° with range of extension being just opposite ( 1 50 - 0°). Standard
goniometer is used to measure range of flexion and extension. Fixed arm of goniometer is
positioned parallel to shaft of the humerus with the axis over the lateral epicondyle.
Extension
Extension is measured with the arm in the anatomical position and the elbow
extended 0°. In muscular males, with over development of the biceps brachii muscle,
extension to oo may not be possible.
-+ Patient su bstitute shoulder extension

Flexion
From the start position of oo elbow extension, the forearm is moved in the anterior
direction until the hand approximates chest or biceps brachii, to the full limit of elbow
flexion.
-+ Patient s ubstitute shoulder flexion

Hyperextension
Hyperextension of 1 0 - 1 5° is not uncommon in females because a smaller
olecranon. When measured in supine position, humerus is supported on a towel or roll to
allow additional motion in hyperextension. Measurement is started from 0° of extension.
If measured from seated position, examiner stabilizes humerus at oo of extension
reference.
Forearm
Pronation and supination of the forearm are measured with patient seated with shoulders
adducted and elbow flexed to 90° with forearm in held in midposition. Subject grasps a
pencil or similar obj ect, protruding from radial aspect of the hand with fist tightly closed.
This provides a visual reference for alignment of the hand. Examiner stabilizes patient's
humerus. Range of motion can be measured with a standard goniometer or gravity
sensitive bubble inclinometer. With use of standard goniometer, the stationary arm is held
perpendicular to floor and moveable arm parallel to the pencil. When using an
inclinometer, it is positioned on palmar or dorsal surface of the hand from the neutral
position. Normal range for both supination and pronation from neutral position midpoint
is 80 - 90°.
S u pination
From the midpoint start position, the forearm is rotated externally so palm faces
upward toward ceiling and the pencil is parallel to floor and pointing laterally.
-+ Patient may substitute a ltered grasp of penci l , wrist extension and/or radial
deviation, external rotation and adduction of shoulder, and trunk side flexion

Pronation
From the midpoint start position, the forearm is rotated internally so palm faces
downward toward floor and the pencil is parallel to floor and pointing medially.

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Chinese Orthopedics Elbow 264

-+ Patient may substitute altered g rasp of pencil , wrist flexion a nd/or u l nar deviation,
intern a l rotation and abduction of shoulder, and contra latera l trunk side flexion

Passive Movement with Overpressure

Elbow
•
Flexion: Normal end feel is soft/hard
•
Extension: Normal end feel is hard/firm
Forearm
•
Supination: Normal end feel is firm
•
Pronation: Normal end feel is hard/firm

Resisted Isometric Movement (Elbow)

Muscle strength of the elbow and forearm is evaluated by resisted i sometric tests, which
are graded 0 - 5 (see Table 4.3). Principal signs of either pain or weakness, or both, are
noted. Of the resisted isometric tests, extension, flexion, supination and pronation are
conducted for the elbow.
Possible Wrist Involvement
Because of the close association between the wrist and elbow, and the possibility that
problems in wrist muscles may reflect at the elbow, resisted isometric tests are often
tested at the wrist prior to testing the elbow. Initially, the patient is asked to strongly grip
the practitioner's hand. If this reproduces elbow pain, then additional isometric
contraction tests are conducted at the wrist.
Resisted extension and radial deviation of the wrist and extension of the fingers
are tested if pain i s felt over the lateral compartment of the elbow.
Resisted flexion and ulnar deviation of the wrist and flexion of the fingers are
tested pain i s felt over the medial compartment of the elbow. Reproduction of these
if
symptoms by the wrist indicates that the problem is mostly related to the wrist.
Isolating Problem to Elbow
Pain on resisted flexion or extension may indicate possible tendinitis of the main muscles
moving the forearm. The patterns of pain reflected at the elbow are consistent with the
function of each particular muscle that articulates this joint. For example, pain on resisted
flexion may manifest in tendinitis of either the biceps brachii, brachioradialis or
brachialis muscles, while pain associated with resisted extension may be the result of
tendinitis of the triceps brachii mm. Pain on resisted supination might implicate the
supinator muscle, however, if pain on lateral rotation of the forearm is accompanied by
pain on resisted flexion, the biceps brachii muscle may be indicated. Pain patterns are
evaluated in terms of muscle function in order to isolate the particular muscle involved
(see Table 1 0 .2).
Painless weakness in the resisted flexion or extension of the forearm usually
indicates a neural lesion although ruptures of the musculotendinous structures controlling
the elbow do occur. Patterns of muscular weakness can also be noted to identify the
particular muscle, nerve root and traditional musculotendinous distribution pathway. All
of this information is essential to formulate an effective treatment approach, including the
needling therapy strategy.

D.E. Kenda ll, OMD, PhD. ©2005-2009

Chinese Orthopedics Elbow 265

Elbow flexion
The biceps brachii (long head: ALH, short head: AMH) muscle is the principal flexor of
the elbow although the brachialis (PMH) and brachioradialis (AMH) are important
accessory muscles to this movement. The biceps brachii is tested separately in flexion
from the other two muscles which are examined as a group.
Biceps Brachii
In this test the patient is either supine or sitting with the shoulder adducted, with
the elbow flexed 90° and the forearm supinated. Isometric resistance is applied to the
anterior aspect of the forearm, just proximal to the wrist joint. Resistive force is applied
in the direction of elbow extension and forearm pronation.
-+ Patient may substitute contraction of brach ialis, since this m uscle functions as an
elbow flexor regardless of forearm positioning.

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. Patient is in a side-lying position with forearm supinated and fl e xes elbow
through full range of motion while examiner supports weight of upper extremity.
-+ Patient m a y substitute contraction of brach i a l i s , since this muscle fu nctions as an
el bow flexor regardless of forearm positioning .

Brachialis and Brachioradialis

As with the biceps brachii test, the patient is either supine or sitting with the
shoulder adducted and the elbow flexed 90° with the forearm is pronated. Isometric
resistance is applied to posterior aspect of forearm, j ust proximal to the wrist joint.
Resistive force is applied in direction of elbow extension.
If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. Patient is in a side-lying position while the examiner supports weight of upper
extremity and stabilizes the humerus and the patient flexes elbow through full range of
motion with forearm pronated.
Elbow Extension
Triceps (medial head-PMH, lateral head-LH, long head-PLH) are the principal extensors
of elbow. Anconeus (LH) is accessory muscle to this movement. Patient is supine with
shoulder intemal1 y rotated and flexed to 90° and elbow flexed 90° so arm is above the
chest. Resistance is applied in the direction of elbow flexion, on posterior aspect of
forearm proximal to the wrist, while examiner stabilizes humerus.
Alternative to this, in case of weakness in shoulder muscles, patient can be placed
in prone position with shoulder abducted, elbowed flexed 90°, and supinated forearm
hanging straight down over edge of table. A towel or roll is used to support humerus for
patient comfort while stabilizing humerus, especially when resistance is applied.
Isometric resisted force is applied in the direction of elbow flexion, on posterior aspect of
forearm proximal to the wrist, while examiner stabilizes humerus.
If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. Patient is in a side-lying position while examiner supports weight of upper
extremity and stabilized the humerus and patient extends elbow from fully flexed
position, through full range of motion while forearm supinated.

D.E. Kendall, OMD, PhD. ©2005-2009

Chinese Orthopedics Elbow 266

-+ Patient may substitute scapular depression and shoulder external rotation,

permitting gravity to complete ROM

Supination
Muscles responsible for supination of the forearm are the supinator (ALH) and biceps
brachii (long head - ALH, short head - AMH). Test is performed with patient seated,
shoulder adducted, elbow flexed to 90°, and forearm supinated. Isometric resistance is
applied on posterior surface of the radial distal end with counter resistance on anterior
aspect of the ulna. Force is applied in direction of forearm pronation.
-+ Patient may substitute shou lder external rotation , shoulder adduction, and side
flexion of ipsilateral trun k

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. Patient is supine with shoulder adducted, elbow flexed to 90° and forearm
pronated. Forearm is pointing straight upward. Alternate to this, patient can be seated
with shoulder and elbow flexed to 90° with forearm pronated. Patient supinates forearm
through full range of motion while examiner stabilizes humerus and palpates supinator
and biceps brachii muscles.
-+ Patient m a y substitute shoulder adduction and externa l rotation

Biceps brachii does not supinate forearm when elbow is in extension. Thus, the
supinator muscle can be isolated in seated patient while shoulder is adducted and forearm
extended so arm hangs straight down. Supinator can be isolated as patient supinates the
forearm trom the pronated position.
Pronation
Pronator teres (PMH) and pronator quadratus (MH) muscles are responsible for pronation
of the forearm. Test is performed with patient seated, shoulder adducted, elbow flexed to
90°, and forearm pronated. Isometric resistance is applied on anterior surface of the radial
distal end with counter resistance on posterior aspect of the ulna. Force is applied in
direction of forearm supination.
-+ Patient may substitute shoulder abduction and shou lder internal rotation .

If the isometric strength is less then Grade 2+, a gravity eliminated test may be
indicated. Patient is supine with shoulder adducted, elbow flexed to 90° and forearm
supinated. Forearm is pointing straight upward. Alternate to this, patient can be seated
with shoulder and elbow flexed to 90° with forearm supinated. Patient pronates forearm
through full range of motion while examiner stabilizes humerus and palpates pronator
teres muscle.
-+ Patient may su bstitute shoulder abduction and shou lder internal rotation .

Functional Assessment
Can involve simple movements such as flexing the elbow to touch shoulder, extending
the elbow to touch front of body, and pronating and supinating the forearm with the
elbow flexed 90° and with the elbow fully extended (0°). Possible painful arc (in degrees)
is noted during elbow flexion.

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Ch inese Orthoped ics Elbow 267

Accessory Movements
The small ROM in synovial and cartilaginous joints of the elbow beyond that which is
achieved by active movements is evaluated and graded according to Table 4.S.
Humeroulnar Joint
Longitudinal-Caudal
Longitudinal caudad accessory movement of the humeroulnar j oint is produced by
applying force along the forearm, while it is in flexion, to distract the joint. Pressure is
applied in direction aligned with the humerus.
Extension-Adduction
Accessory movement of the humeroulnar joint, in adduction, is evaluated through
the first s o of flexion from the position of full extension. With the patient supine, the
examiner holds the fully extended elbow while applying pressure to the arm in the
direction of adduction by holding the wrist and hand. The elbow is then moved from full
extension through the initial so of flexion. Examiner feels the accessory movement with
the hand supporting the elbow.
Extension-Abduction
Accessory movement of this j oint in abduction is just opposite to the procedure
for testing adduction. The fully extended humeroulnar joint is held and supported by one
hand while the examiner applies pressure to the wrist in the direction of abduction. The
elbow is then moved from full extension through the initial so of flexion.
Radiohumeral Joint
Anteroposterior
With the patient supine anteroposterior gliding movement is induced by applying
thumb pressure over the head of the radius. Examiner's fingers surround the elbow to
stabilize the distal end of the humerus and help palpate accessory movement.
Posteroanterior
Posteroanterior gliding movement is induced by applying thumb pressure to
posterior surface of the radial head, while patient's arm is flexed and resting against the
exammer.
Longitudinal caudal (distraction)
Longitudinal caudad movement is produced by pulling along distal region of
radius while holding the humerus with examiner's other hand. Patient's arm can be held in
extension or with a few degrees of flexion. Force is applied to distract radius
longitudinally in respect to the humerus while examiner feels accessory movement with
hand stabilizing the elbow.
Longitudinal cephalad (approximation)
With the patient supine and arm extended or flexed a few degrees, examiner
applies longitudinal cephalad compressive force along the shaft of the radius by holding
the distal region of the radius. Accessory movement of radius in respect to the humerus is
detected by palpating the region of the lateral aspect of the elbow j oint.

D.E. Kendall, OMD, PhD. ©2005-2009

Chinese Orthopedics Elbow 268

Superior Radioulnar Joint

Anteroposterior
Anteroposterior movement is produced by applying pressure over the anterior
surface of the head of the radius with the thumbs of both hands while stabilizing the ulna
from behind with the examiner's fingers. Elbow is extended or slightly tlexed and the
forearm may be pronated, supinated, or held midway between the two extremes.
Posteroanterior
Posteroanterior movement is also applied to the head of the radius in opposite
direction of the anteroposterior movement. With the patient's arm either held in slight
flexion or rested against the practitioner, pressure is applied over the posterior surface of
the radial head. Fingers surround the joint to stabilize the ulna on the anterior side and
detect movement between the radius and ulna. Patient can also be positioned on their side
with tested limb up, to perform this movement assessment.
Longitudinal Caudal (Distraction)
Longitudinal caudad movement is produced by pulling along the distal region of
radius while holding the elbow with the examiner's other hand. Patient's arm is held in
slight flexion. Force is applied to distract the radius longitudinally in respect to the ulna
while the examiner feels accessory movement with the hand stabilizing the elbow.
Long itudinal Cephalad (Approximation)
With the patient supine and arm flexed to 90°, the examiner applies downward
force by holding the distal region of the radius to produce longitudinal cephalad
movement along the shaft of the radius. Accessory movement of the radius in respect to
the ulna is detected by palpating the region of the superior radioulnar j oint.
Inferior Radioulnar Joint
Five accessory movements are routinely examined for this joint as noted in the following.
Normally, the patient is supine with the elbow flexed 90° and the forearm held straight up
for easy access by the examiner.
Anteroposterior
Anteroposterior movement is produced by grasping the ulnar between the thumb
and side of the index finger, which is flexed, with one hand of the examiner while
holding the radius in similar manner with the other hand. Thumb pressure is applied over
the anterior surface of the ulnar while stabilizing the radius.
Posteroanterior
Posteroanterior movement is produced by grasping the ulnar and radius as
described above, but from the posterior aspect of the wrist. Thumb pressure is applied
over the posterior surface of the ulnar while stabilizing the radius.
Compression
Approximation of the inferior radioulnar joint surfaces is produced by laterally
compressing the ulnar and radius toward each other. The examiner grasps the patient's
hand from the posterior aspect with thumbs on the dorsal surface and fingers holding the
palm. The examiner flexes his or her wrists so that the forearms are aligned perpendicular

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Chinese Orthopedics Elbow 269

to the patient's forearm and the base of the examiner's hands apply pressure over the ulna
and radius.
Longitudinal Caudad
Longitudinal caudal movement of the radius is produced by holding the forearm
proximal to the wrist and deviating the wrist in the ulnar direction.
Longitudinal Cephalad
Longitudinal cephalad movement of the radius is produced by holding the
forearm proximal to the wrist and deviating the wrist in the radial direction.

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View : Used to note the relationship of the epicondyles, capitulum,
trochlea, radial head, radial tuberosity, olecranon process, and coronoid process. Possible
loose bodies, joint space narrowing, myositis osssificans, calcifications, or osteophytes
should be noted.
Lateral View: Also used to note the relationship of the epicondyles, capitulum, trochlea,
radial head, radial tuberosity, olecranon process, and coronoid process.
Axial View: This view obtained with the elbow flexed 45° to show the olecranon process
and epicondyles.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging is used to differentiate bone and soft-tissue due to its high
contrast of soft-tissue. MRI is used to discriminate among bone marrow, cartilage,
tendons, nerves, and vessels and therefore demonstrate tendon ruptures, collateral
ligament ruptures, cubital tunnel pathology, and epicondylitis.

Management of Elbow Disorders

Elbow Mobilization
Any of the physiological or accessory movements of the elbow and radioulnar joints
described above can be applied to improve mobility and reduce pain in affected joints.
Passive movement treatments are graded from I-V and consist of either small or larger
amplitude oscillations that do not move into the restricted or painful area, except for
grade V which involves a sharp thrust beyond the pathological limit of movement (See
Table 5 . 1 ). Grade V mobilization techniques are not usually applied to the elbow.

Needling Therapy for Elbow Problems

Appropriate local and adj acent, distal and proximal acupoints for the treatment of
common elbow problems are noted in Table 1 0.3. Different sets of proximal and distal
points are applied in the treatment of elbow problems depending on the associated three
yang muscular distributions of the hand, which is either associated with the problem or
contains the problem within the affected muscular distribution pathway.
Node Selection
Candidate node selection for elbow problems (Table 1 0. 3) addresses elbow pain and
dysfunction reflecting in this area. These nodes represent three muscular distributions

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Ch inese Orthopedics Elbow 270

with appropriate proximal and distal nodes. Candidate local and adjacent nodes are
considered depending on the specific area of the elbow in which pain is reflected. If
elbow pain is accompanied with pain in the shoulder then appropriate nodes in thi s region
may be added, such as Jianyu (ALH I 5 ), Jianliao (LH 1 4), or Naoshu (PLH 1 0). I f elbow
problem is manifest within the entire joint and it is not obvious as to which muscular
distribution in involved, then all the candidate local and adjacent nodes as well as the
distal nodes may be considered.

Table 1 0.3 . Selection of reg ional, proximal and distal nodes for treatment of elbow and forearm
problems.
Pain or Disorder of Candidate Local & MD Proximal Nodes Distal Nodes
Elbow Adjacent Nodes
Quchi (ALH 1 1 ) ALH* Dazhu (PLF 1 1 ) Hegu (ALH 4)
Zhouliao (ALH 1 2) Feishu (PLF 1 3)
Chize (AMH 5) LH Fengchi (LF 20) Zhongzhu (LH 3)
Tianjing (LH 1 0) Jianzhongshu (PLH 1 5)
Xiaohai (PLH 8) PLH Tianzhu (PLF 1 0) Houxi (PLH 3)
Jianzhongshu (PLH 1 5)
* Can consider H uatuojiaji nodes at T 1 and T3 level.
Lateral Elbow
If problem principally manifests in the lateral epicondyle it mainly relates to the
ALH distribution. Candidate local and adj acent nodes would include Quchi (ALH I I ),
Zhouliao (ALH 1 2), and Tianj ing (LH l 0), with proximal and distal nodes associated
with the ALH distribution and perhaps LH (internal membrane) distribution. In addition
the node Chize (AMH 5 ) can be considered. Wrist extensors may be involved in l ateral
epicondylitis with pain in the forearm. In this case the nodes Shousanli (ALH 1 0) or
Shanglian (ALH 9) could be added, which also address problems in supination.
Medial Elbow
If problem principally manifests in the medical epicondyle it mainly relates to the
PLH distribution. Candidate local and adjacent nodes would include Xiaohai (PLH 8) and
Tianj ing (LH 1 0), with proximal and distal nodes associated with the PLH distribution.
The node Shaohai (PMH 3) can also be considered and is specific for problems in the
pronator teres muscle. Wrist flexors may be involved in medial epicondylitis with pain in
the forearm. In this case the node Zhizheng (PLH 7) could be added. Neiguan (MH 6)
added for the pronator quadratus.
Olecranon Area
If problem principally manifests in the olecranon it mainly relates to the L H
distribution. Candidate local and adj acent nodes would include Tianj ing (LH I 0), Xiaohai
(PLH 8), and Zhouliao (ALH 1 2), and, with proximal and distal nodes associated with the
LH (internal membrane) distribution. If pain is reflected into the forearm, Sidu (LH 9)
can be considered.
Candidate Electroneedling (EN) Application
One suggested lead placement for adding electroneedling is listed below for the three
muscular distributions involving a proximal and local node. A possible alternative i s
provided involving a circuit from the local node to the distal node. Elbow problems may

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Chinese Orthopedics Elbow 271

manifest within more than one distribution. In that situation two or even three candidate
EN circuits could be employed. If more than one EN circuit is employed, then they have
to be consistent with all using the proximal to local circuit or the local to distal circuit.
Specific recommendations include the following:
Frequency: 2 Hz
Mode: Continuous
Duration: 2 0-30 minutes

Anterior lateral hand (ALH) distribution (lateral epicondyle of humerus) :

•
Dazhu (PLF 1 1 ) + lead, to Quchi (ALH 1 1 ) - lead
•
Or Zhouliao (ALH 1 2 ) + lead, to Hegu (ALH 4) - lead
Posterior lateral hand (PLH) distribution (medial epicondyle of humerus):
•
Jianzhongshu (PLH 1 5) + lead, to Xiaohai (PLH 8}- lead
•
Or Xiaohai (PLH 8) + lead, to Houxi (PLH 3 ) - lead
Lateral hand (LH) distribution:
•
Fengchi (LF 20) + lead, to Tianj ing (LH 1 0) - lead
•
Or Tianj ing (LH 1 0) + lead, to Zhongzhu (LH 3 ) - lead

Remedial Exercises for Elbow and Radio-Ulnar Articulation

Exercises of the elbow and forearm involve movements in extension, flexion, supination
and pronation (See Table 1 0.2).

Elbow Flexion
Prime movers in elbow flexion include the biceps brachii (long head and short head),
brachialis, and brachioradialis muscles with several other muscles participating as
assistant movers (See Table 1 0.2). The biceps brachii can be exercised separately in
flexion from the other two muscles which are exercised as a group.
Biceps Brachii
The subject i s either seated or supine with the shoulder adducted, the elbow extended,
and the forearm supinated. While making a fist, the forearm is slowly raised to the full
extent of elbow flexion. End position is held 2 - 3 seconds and then forearm is slowly
moved back to the start position.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder and arm muscles should be contracted to provide IDR
antagonistic resistance to elbow flexion. As strength is increased, light-weight dumbbells
can be introduced, grasped with palm facing up or forward, to increase exercise load and
further the strengthening process.
Brachia/is and Brachioradialis
The subject is either seated or supine with the shoulder adducted and the elbow extended,
but here the forearm is pronated or in neutral position. While making a fist, the subj ect
slowly flexes the elbow through the full range of motion End position is held 2 - 3
seconds and then forearm is slowly moved back to the start position.

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 Chinese O rthoped ics El bow 272

This exercise is repeated up to 8 repetitions and eventually performed for 4 5

-

sets. As strength permits, shoulder and arm muscles should be contracted to provide IDR
antagonistic resistance to elbow flexion. As strength is increased, light-weight dumbbells
can be introduced, grasped with palm facing down or backward, to increase exercise load
and further the strengthening process.

Triceps: Elbow extension

Triceps (medial, lateral, and long heads) are the principal movers that extend the elbow.
The anconeus and several other muscles of the forearm are assistant movers for elbow
extension. The subject is supine with shoulder internally rotated and flexed to 90° so
upper arm is pointed straight up. Elbow is flexed and forearm supinated with hand resting
near opposite shoulder. While making a fist, the subject slowly lifts forearm to extend
elbow through full range of motion and arm is fully extended vertically. End position is
held 2-3 seconds and then arm is moved back to slowly lower the hand to the chest.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, shoulder and arm muscles should be contracted to provide IDR
antagonistic resistance to elbow extension. As strength is increased, light-weight
dumbbell s can be introduced, grasped with palm facing the chest, to increase exercise
load and further the strengthening process.

Supinator and Biceps Brachii : Supination

Muscles responsible for supination of the forearm are the supinator and biceps brachii.
The subj ect is seated, shoulder adducted, elbow flexed to 90°, and forearm pronated.
While making and holding a fist, the subject slowly supinates the forearm on the count of
3 and holding the end position 2 - 3 seconds. Forearm is then slowly rotated back to the
start position.
This exercise is repeated up to 8 repetitions and eventually performed for 5 sets.
As strength permits, arm and forearm muscles should be contracted to provide IDR
antagonistic resistance to supination. As strength is increased, light-weight dumbbells can
be introduced, grasped with palm facing downward, to increase exercise load and further
the strengthening process. Forearm supination exercise is normally combined with
pronation exercise.

Pronator Teres and Pronator Quadratus: Pronation

Pronator teres and pronator quadratus muscles are responsible for pronation of the
forearm. The subject is seated, shoulder adducted, elbow flexed to 90°, and forearm
supinated. While making and holding a fist, the subject slowly pronates the forearm on
the count of 3 and holding the end position 2 - 3 seconds. Forearm is then slowly rotated
back to the start position.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, arm and forearm muscles should be contracted to provide IDR
antagonistic resistance to pronation. As strength is increased, light-weight dumbbells can
be introduced, grasped with palm facing upward, to increase exercise load and further the
strengthening process. Forearm pronation exercise is normally combined with supination
exercise.

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Chinese Orthopedics Wrist and Hand 273

11.

Wrist and Hand

The wrist joint is made up of the distal end of the radial and ulnar bones involving the
radial and ulnar styloid processes of the forearm and the eight carpal bones (scaphoid or
navicular, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, and the hamate).
The wrist joints are referred to as the radiocarpal and midcarpal joints and structures
involved in their movement are noted in Table 1 1 . 1 . Joints within the carpus include the
pisiform, midcarpal, common carpometacarpal, and trapeziometacarpal joints. Many
ligaments connect these bones to each other. The wrist is a common source of fractures as
well as ligament sprains which can occur without any evidence of bone injury; basically
without bones fractures or cracks. In the case a sprain there i s usually only a partial
tearing of the ligaments such as in a First ( 1 °) or Second (2°) degree sprain. In a severe or
Third (3 °) wrist sprain, there would be complete rupture of a ligament. Wrist injuries can
also result in a strain or tearing of the muscle fibers in the area surrounding the wrist.
Repetitive motion associated with the constant use of computer keyboards and
cash registers has resulted problems of both the wrist and hand. One condition resulting
in pain and numbness is occurring more often. This is called carpal tunnel syndrome and
results from irritating or compressing the median nerve which supplies movement feeling
to the thumb and thumb side of the hand.
The hand contains a large number of small bones including the metacarpal bones
which proximally articulates with the carpus and distally with the phalanges of the thumb
and fingers. These form metacarpophalangeal (MCP) joints, proximal interphalangeal
(PIP), and terminal interphalangeal (TIP) for second to fifth fingers. Characteristics of
joint structures involved in movement of second to fifth fingers are noted in Table 1 1 .2.
Movement of the thumb is slightly different involving the carpometacarpal (CM),
metacarpophalangeal (MCP), and interphalangeal (IP) joints. Characteristics ofj oint
structures involved in movement of the thumb are listed in Table 1 1 .3 . Planes and axes of
articulation, normal limiting factors to movement of wrist, fingers and thumb, normal end
feels and active range of motion for these movements are noted in Tables 1 1 . 1 , 1 1 .2 and
1 1 .3 .

Physiology of the Wrist and Fingers

Muscles of the Wrist

Muscles moving the wrist have their origins on the distal part of the humerus and extend
to the wrist, inserting mostly on the metacarpal bones. They function to extend, flex,
abduct or adduct the wrist (See Table 1 1 .4).

Muscles of Thumb and Fingers

Thumb and fingers can be extended, flexed, abducted and adducted from their
metacarpophalangeal joints as well as extended and flexed from their interphalangeal
j oints (See Table 1 1 .5). In addition, owing to the fact that the thumb has two
interphalangeal joints, it can also be rotated and circumducted.

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Ch inese Orthopedics Wrist and Hand 274

Table 1 1 . 1 . Joint structures involved in movement of wrist

Flexion Extension Radial Deviation Ulnar Deviation
Articulation Midcarpal, Midcarpal, Midcarpal , Radiocarpa l
Radiocarpal Radiocarpal Radiocarpal
Plane Sagittal Sag ittal Frontal Frontal
Axis Frontal Frontal Sagittal Sagittal
Normal limiting Tension in posterior Tension in anterior Tension i n ulnar Tension in radial
factors radiocarpal ligament radiocarpal ligament collateral ligament, collateral ligament and
and posterior joint and anterior joint ulnocarpal ligament, radial portion of joint
capsule capsule; contact and ulnar portion of capsule
between radius and joint capsule; contact
carpal bones between radial styloid
process and scaphoid
bone
Normal end feel Firm/hard Firm/hard Firm/hard Ftrm
Normal active 0 - aoo 0 - 70° 0 - 20° 0 - 30°
range of motion
Capsular pattern Flexion and extension equally restricted

Table 1 1 . 2. Normal limiting factors and characteristics of joint structures i nvolved in movement of
second to fifth fingers
Flexion Extension Abduction Adduction
Articu lation Metacarpophalangeal MCP MCP MCP
(MCP) ,
Proximal interphalangeal
(PIP),
Terminal interphalangeal
(TIP) (second to fifth fingers)
Plane Sagittal Sagittal Frontal Frontal
Axis Frontal Frontal Sagittal Sagittal
Normal limiting MCP: tension in posterior Tension in a nterior Tension in ulnar Tension in radial
factors joint capsule, collateral radiocarpal ligament collateral ligament, collateral ligament and
ligaments, contact between and anterior joint ulnocarpal ligament, radial portion of joint
the proximal phalanx and capsule; contact and ulnar portion of joint capsule
metacarpal between radius and capsule; contact
PIP: contact between middle carpal bones between radial styloid
and proximal phalanx; soft process and scaphoid
tissue apposition of middle bone
and proximal phalanges;
tension i n posterior joint
capsule, collateral ligaments
TIP: tension i n posterior joint
capsule, collateral
ligaments, and oblique
retinacular ligament
Normal end feel MCP: firm/hard MCP: firm Firm
PIP: hard/soft/ firm PIP: firm
DIP: firm TIP: firm
Normal active MCP: 0 - goo MCP: 0-45°
range of motion PIP: 0 - 1 00° PIP: oo
TIP: 0 - goo TIP: oo
Capsular Metacarpophalangeal and interphalangeal joints: extension, flexion
pattern

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Chinese Orthopedics Wrist and Hand 275

Table 1 1 . 3. Normal limiting factors and characteristics of joint structu res involved in movement of
the thumb
Flexion Extension Palmar Abduction Adduction
Articulation Carpometacarpal (CM) CM CM CM
Metacarpophalangeal (MCP) MCP MCP MCP
Interphalangeal (IP) IP
Plane CM: oblique frontal CM: oblique frontal CM: oblique sagittal CM: oblique
MCP: frontal MCP: frontal sagittal
IP frontal IP: frontal
Axis CM: oblique sagittal CM: oblique sagittal CM: oblique frontal CM: oblique
MCP: sagittal MCP: sagittal frontal
I P: sagittal IP: sagittal
Normal limiting CM: Soft tissue apposition CM: tension in anterior Tension in fascia and Soft tissue
factors between thenar eminence and joint capsule, flexor skin of first web space, apposition
palm; tension in posterior joint pollicis brevis, and first first dorsal between thumb
capsule, extensor pollicis dorsal interosseous i nterosseous, and and index finger
brevis, and abductor pollicis MCP: tension in anterior adductor pollicis
brevis joint capsule, palmar
MCP: contact between first ligament. and flexor
metacarpal and proximal pollicis brevis
phalanx; tension in posterior IP: tension in anterior
joint capsule, collateral joint capsule, palmar
ligaments, extensor pollicis ligament
brevis
I P : tension in posterior joint
capsule, collateral ligaments;
contact between distal phalanx,
fibrocartilagenous plate, and
proximal phalanx
Normal end feel CM: soft/ firm CM: firm Firm
MCP: hard/ firm MCP: firm
IP: firm/ h a rd IP: firm
Normal active CM: 0 - 1 5° CM: 0 - 20°
range of motion CMP: 0 - 50° CMP: oo
IP: 0 - BOo IP: 0 - 20°
Capsular Carpometacarpal joint: abduction, extension
pattern Metacarpophalangeal and interphalangeal joints: extension, flexion

Muscles of Thumb and Fingers

Thumb and fingers can be extended, flexed, abducted and adducted from their
metacarpophalangeal joints as well as extended and flexed from their interphalangeal
joints (See Table 1 1 .5). In addition, owing to the fact that the thumb has two
interphalangeal j oints, it can also be rotated and circumducted.

Disorders of Wrist and Hand

Disorders in Moving the Wrist

There are many common problems associated with the elbow and the wrist joints. These
include inflammation and pain in the elbow which is sometimes referred to as "tennis
elbow", and similar disorders affecting the wrist, sometimes including tunnel carpal
syndrome. All the muscles and joints of the forearm and wrist can experience pain,
spasms, paralysis and sensory deficits as well as arthritic conditions, all of which impair
the function of the elbow and wrist. Specific disorders associated with the six muscular
pathways of the arm and wrist includes:
Anterior medial hand (AMH) distribution:

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Chinese Orthopedics Wrist and Hand 276

•
Acute cramps and spasms along the anterior lateral aspect of the radius from the
region between wrist and lateral cupital fossa
Anterior lateral hand (ALH) distribution:
•
Pain, spasms and acute cramps along the lateral posterior aspect of the radius
from the region between wrist and lateral aspect of the elbow
Lateral hand (LH) distribution:
•
Acute cramps and spasms along the posterior region of the forearm between the
ulna and radius traveling up from the wrist to the elbow
Posterior lateral hand (PLH) distribution:
•
Pain in the posterior aspect of the medial epicondyle of the elbow which follows
along the inner aspect of the arm to enter below the axilla causing pain below the
axilla
Posterior medial hand (PMH) distribution:
•
Acute cramps and pain in the muscles along the medial anterior region of the
ulna from the wrist to the medial aspect of the elbow
Medial hand (MH) di stribution:
•
Acute cramps, spasms and pain along the anterior region between the ulna and
radius, from the wrist to the cupital fossa
•
Pain and dysfunction in the wrist including tunnel carpal syndrome

Table 1 1 .4. Fu nction, m uscle d istribution (MD) assignment, and nerve root of primary movers
(PM) and assistant/accessory movers (AM) articulating the wrist
M uscle MD* Nerve Root Flexion Extension Ulnar1 Radial2
Deviation Deviation
Flexor carpi radialis MH C6, 7 PM PM

Flexor carpi ulnaris PLH C8, T1 PM PM

Flexor digitorum superficialis PMH C7, 8, T1 AM

Flexor digitorum profundus MH ca. T1 AM

Extensor carpi radialis brevis ALH C6, 7, 8 PM AM

Extensor carpi radialis longus ALH C6. 7, 8 PM PM

Extensor carpi u lnaris LH C6, 7, 8 PM PM

Extensor digitorum (communis) ALH C6, 7, 8 AM AM

Extensor indicis LH C6, 7, 8 AM

Extensor digiti minimi LH C6, 7, 8 AM

Palmaris longus PMH C7, 8, T1 AM

Flexor pollicis longus AMH C7, 8, T1 AM

Abductor pollicis longus ALH C6, 7, 8 AM AM

Extensor pollicis brevis ALH C6, 7, 8 AM

Extensor pollicis longus ALH C6, 7, 8 AM AM

*Muscle longitudinal distribution pathway; 1 = Adduction; 2 = Abduction

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Ch inese Orthopedics Wrist and Hand 277

Table 1 1 . 5. Fu nction, muscle distribution (MD) assign ment, and nerve root of the primary movers
(PM) and assistant/accessory movers that articulate the thumb and fingers
Muscle MD Nerve Root Extension Flexion Abduction Adduction Opposition
Extensor dig itorum (communis) ALH C6, 7, a PM AM

Extensor digiti minimi LH C6, 7 , a PM AM

Extensor indicis LH C6, 7 , a PM AM

Extensor pollicis longus ALH C6, 7, a PM AM

Extensor pollicis brevis ALH C6, 7, a PM AM

3 3
Abductor pollicis longus ALH C6, 7, a PM PM
3
Abductor pollicis b revis AMH C7, a, T1 AM AM2 PM

Abductor digiti minimi PLH ca. T1 AM2 AM2

3 PM3
Adductor pollicis ALH ca. T1 PM

Flexor pollicis longus AMH C7, a, T1 PM

Flexor pollicis brevis AMH C6, 7, a , T1 PM AM

AMH 3
Opponens pollicis C6, 7, a , T1 PM

Flexor digitorum superficialis PMH C7, a, T1 PM

Flexor digitorum profundus MH C7, a. T1 PM

Flexor digiti minimi PMH C8, T 1 PM

PMH 3
Opponens digiti minimi C8, T1 PM

I & I I Lumbricals PM 1 PM2

-
MH C7, 8, T1

I l l & IV Lumbricals PMH C8, T1 PM 2

'
1 st dorsal interosseous ALH ca. T1 AM AM 2 AM2

4th dorsal i nterosseous LH C8, T1 AM ' AM2 AM2

1 st & 2nd palmar interosseous MH C8, T1 AM ' AM2 PM2

3rd palmar interosseous PMH ca. T1 AM1 AM2 PM 2

"Muscle and vessel distribution pathway; 1 . For 1 st and 2nd lumbricals at interphalangeal joints;
2. For metacarpophalangeal joint; 3. For carpometacarpal joint of thumb

Disorders in Moving the Thumb and Fingers

Disorders of muscular distributions in the hand and fingers can result in cramps, spasms
and pain and dysfunction of the thumb and fingers. This can include inflammation,
arthritic conditions and paralysis. Specific disorders related to the six muscular
distributions to the thumb and fmgers include the following:
Anterior medial hand (AMH) distribution:
• Acute cramps, spasms and pain in the thumb up to the wrist
Anterior lateral hand (ALH) distribution:
•
Pain, spasms and acute cramps in the index finger and along dorsal region of the
second (2nd) metacarpal up to the wrist
Latera] hand (LH) distribution:
•
Acute cramps, spasms and pain in the region of the fourth (4th) finger and dorsal
surface of hand up to the wrist

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Chinese Orthopedics Wrist and Hand 278

Posterior lateral hand (PLH) distribution:

•
Pain in the little finger following up along the medial posterior aspect of the hand
up to the wrist
Posterior medial hand (PMH) distribution:
•
Acute cramps and pain in the muscles along the radial side of the fifth (5th)
finger and medial palmar region of the hand up to the wrist
Medial hand (MH) distribution:
•
Acute cramps, spasms and pain along region of middle finger and palmar surface
of hand up to the wrist

Pathology Affecting Wrist and Hand

Soft-tissue Lesions
M usculotendinous Lesions
• Extensor Carpi Radialis
•
Extensor Carpi Ulnaris
•
Flexor Carpi Ulnaris
•
Flexor Carpi Radialis
Ligamentous Sprains
•
Inferior Radioulnar Joint
•
Radiocarpal Joint
•
Intercarpal Joints
• Metacarpophalangeal Joints
Compound Palmar Ganglion
This condition involves a chronic inflammatory synovitis of the flexor tendon
sheath at the wrist with visible and palpable swelling proximal to the flexor retinaculum
in the forearm and distal to it in the palm. The inflamed synovial membrane is thickened
and may contain fibrin deposits. Rheumatoid arthritis is most common cause
Dupuytren's Contracture
This condition involves a shortening, thickening, and fibrosis of the palmar fascia,
producing a progressive flexion deformity of a finger or fingers. This term is also applied
to a flexion deformity of the toes involving the plantar fascia.
Vol kmann's Ischemic Contracture
This condition involves a contraction of the fingers and sometimes the wrist, with
loss in strength, developing rapidly after a severe injury in the region of the elbow joint,
or due to the improper use of tourniquet. A similar condition may develop in the distal
extremities involving the foot when similar vascular damage is sustained to the muscles
of the foot.
de Quervain's syndrome
This syndrome consists of a painful tenosynovitis due to a relative narrowness of
the common tendon sheath of the abductor pollicis longus and the extensor pollicis

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Chinese Orthopedics Wrist and Hand 279

brevis. Pain due to this condition can be reproduced by patient grasping their thumb by
fingers on same hand and examiner then moves the wrist into passive ulnar deviation.
Bouchard's and Heberden's nodes
These conditions involve degenerative bone disease where bony and cartilaginous
enlargement occurs in the proximal interphalangeal (PIP) joints (Bouchard's nodes) or
terminal interphalangeal (TIP) joints (Heberden's nodes) of the fingers.
Chondrocalcinosis
This consists of calci um deposits in cartilage. May involve an apparent hereditary
condition similar to gout (pseudogout) but with crystals of calcium pyrophosphate, as
opposed to urate crystals for true gout, in the synovial fluid. This leads to calcification
and degenerative changes in the cartilage.
Colles' or Smith's fractures
Fracture of the distal end of the radius in which the lower fragment is displaced
posteriorly. If it is displaced anteriorly it is a reversed Colles' or Smith's fracture.
Joint Lesions
Lesions of wrist and joints include soft-tissue and bony-tissue swelling as well as
deformities, instability and ankylosis. These problems are often the result of various
forms of arthritis, including rheumatoid, osteo, psoriatic and inflammatory types. Trauma
and repeated stress injuries also account for joint lesions. Some of the more common
changes noted by joint lesions are summarized in Table 1 1 .6 for wrist and hand j oints.
Bone Disorders
• Osteochondritis of Lunate
• Neurovascular Lesions
o Shoulder-Hand Syndrome
o Sudeck's Atrophy
Nerve Entrapments
• Carpal-Tunnel Syndrome
• Ulnar Nerve Compression
• Bowler' Thumb

Examination of Wrist and Hand

Observation
• Posture
• Deformities
• Swelling
• Muscle Wasting
• Skin Changes

Active Movements (Range of Motion)

Wrist and Carpus
Flexion and Extension

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Chinese Orthopedics Wrist and Hand 280

Wrist flexion and extension ROM are measured with patient seated and forearm
resting on a table in pronation. Hand is held over end of table with wrist in neutral
position while examiner stabilizes forearm. Fingers are slightly extended for
measurement of flexion and slightly flexed for measurement of extension.
Axis of goniometer is held at the level of the ulnar styloid process with stationary
arm parallel to shaft of the ulna. Goniometer moveable arm is held parallel to
longitudinal axis of fifth metacarpal. For flexion measurement, wrist is moved in volar
direction to limit of motion (80°) and is moved in dorsal direction to limit of motion (70°)
for extension. lt is i mportant to not to allow wrist deviation to occur if full range cannot
be achieved.

Table 1 1 .6 . Summary of lesions affecting joints of the wrist and hand.

Affected Joint Swelling Deformity Instability Ankylosis
Wrist and carpus Soft-tissue swelling Possibly due to Instability of inferior May follow
due to infective or trauma as in Calles' radioulnar joint may inflammatory a rthritis
inflammatory arthritis, or Smith's fractures; follow triangular
tenosynovitis, flexion deformities as ligament rupture
ganglion or de result of inflammatory
Quervain's syndrome arthritis or RA 1 may
lead to volar
subluxation or radial
deviation of wrist
Carpometacarpal of Soft-tissue swelling Deformity common in Lateral instability
thumb usually results from OA; adduction occurs in OA and
RA; bony swelling deformity of thumb inflammatory arthritis
more common in OA2 common in RA
Metacarpophalangeal Soft-tissue swelling Palmar and/or ulnar Marked instability
(MCP) common in RA and subluxation is may occur in opera-
other types of common deformity in glass hand
arthritis; bony RA; flexor deformity
swelling by OA is rare can result from
but can occur with rupture of extensor
chondrocalcinosis or tendon
trauma
Proximal Soft-tissue swelling Flexion, swan-neck Lateral instability in Uncommon but may
interphalangeal (PIP) due to RA producing or boutonniere RA and psoriatic occur in erosive OA
spindle-shaped deformities may arthritis and psoriasis
swelling; bony result from RA
swelling may be
Bouchard's node or
erosive OA
Terminal Soft-tissue swelling in Flexion deformity May occur in psoriatic Usually due to
interphalangeal (TIP) psoriatic arth ritis and producing mallet arth ritis or RA and psoriatic arthritis, may
sometimes in RA and finger also in OA rarely occur in RA or
tophaceous gout; gout
bony swelling may be
Heberden's nodes or
erosive OA
. . . .

1 - Rheumatoid Arthnt1s; 2 - Osteoarthnt1s

U l nar and Radial Deviation
Wrist deviation in both ulnar (adduction) and radial (abduction) directions is
measured in seated patient with forearm in pronation and hand in neutral position. Palmar
surface rests lightly on a table and fingers are relaxed whi le examiner stabilizes forearm.
Goniometer axis is placed over dorsal aspect of wrist over the capitate bone.
Stationary arm is placed along forearm midline with moveable arm parallel to
longitudinal axis of third metacarpal. Wrist is adducted (referenced to anatomical

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Chinese Orthoped ics Wrist and Hand 281

position) to limit of motion in ulnar deviation (30°), while in radial deviation it is

abducted to limit of motion (20°) to radial side. It is important to not to allow either wrist
flexion or extension to occur if full deviation range cannot be achieved.
Finger Joints (2nd - 5th)
Finger ROM measurements are conducted with patient in seated position with forearm
resting on an examination table or with elbow slightly flexed and resting on table. Small
goniometers are used which provide ease of measurement and better accuracy because of
small size and complexities of the fingers.
Metacarpophalangeal (MCP) flexion
Wrist is slightly extended and MCP joint of finger being tested is positioned at oo
extension while examiner stabilizes appropriate metacarpal.
Axis of goniometer is placed on dorsal aspect of MCP joint being measured with
stationary arm parallel to longitudinal shaft of related metacarpal. Movable arm is held
parallel to longitudinal axis of proximal phalanx. Each fmger being measured is moved to
limit of motion in direction of palm (90°). Value of flexion ROM slightly increases
progressively from index to fi fth finger. During measurement, flexion of proximal
interphalangeal (PIP) joint is allowed while terminal interphalangeal (TIP) joint remains
in extension.
Alternate to method described above, goniometer axis can be placed on the lateral
aspect of the MCP joint when measuring flexion ROM for either the index or fifth finger.
MCP extension
Wrist is slightly flexed and MCP j oint of finger being tested is positioned at oo
extension while examiner stabilizes appropriate metacarpal.
Axis of goniometer is placed on volar aspect of MCP j oint being measured with
stationary arm parallel to longitudinal shaft of related metacarpal. Movable arm is held
parallel to longitudinal axis of proximal phalanx. Each finger being measured is moved to
limit of motion in direction of dorsum (45°). During measurement, flexion of proximal
interphalangeal (PIP) joint is allowed.
Alternate to method described above, goniometer axis can be placed on the lateral
aspect of the MCP joint when measuring extension ROM for either the index or fifth
finger.
MCP add uction and abduction
Finger MCP adduction and abduction are measured with elbow flexed 90°,
forearm pronated and resting on table. Wrist is in neutral position, fingers in the
anatomical position, and examiner stabilizes the metacarpal bones.
Goniometer axis is placed over dorsal aspect of MCP joint being measured with
stationary arm parallel to longitudinal shaft of related metacarpal. Movable arm is held
parallel to longitudinal axis of proximal phalanx. Finger is moved away from midline of
hand to limit of motion in abduction. Finger is then moved toward midline of hand to
measure full limit of adduction. During adduction, other fmgers are allowed to move to
permit full adduction of tested finger.
Alternate to above method, finger and thumb abduction can be measured by
placing patient's hand on a piece of paper, with fingers fully abducted, and tracing outline

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 Ch inese Orthopedics Wrist and Hand 282

of the hand. Abduction in terms of linear distance between each finger and thumb tip is
recorded in centimeters or inches. A straight line can also be drawn on hand outline along
longitudinal axis of each finger and the thumb from which an angular measurement
between each digit i s derived by means of a protractor.
I nterphalangeal (PIP and TIP) flexion and extension
Measurement is made with forearm resting on table in midposition or pronated.
Fingers and wrist are initially held in anatomical reference of 0° extension. Proximal
phalanx is stabilized by examiner while measuring PIP joints and middle phalanx is
stabilized while measuring the distal or terminal interphalangeal (TIP) joints.
Axis of goniometer is placed on dorsal surface of PIP or TIP joint being measured
with stationary arm parallel to longitudinal axis of proximal phalanx for PIP joint, and
parallel to middle phalanx for measuring TIP joints. Likewise the movable arm is parallel
to longitudinal axis of middle phalanx for PIP measurement and parallel to distal phalanx
for TIP joints.
Middle phalanx is moved toward palm to full limit in flexion for PIP ( 1 00°) j oints
and distal phalanx is flexed to full limit for TIP joints (90°). Limits of extension for PIP
and TIP joints are then checked.
MCP and IP flexion
Other measurements can be derived for flexion of the fingers that are useful in
determining degree of impairment or disability of hand function, especially associated
with problems of grasp. Patient is seated with elbow flexed with forearm resting on table
in supination. Initially, the patient flexes the TIP and PIP joints while maintaining the
MCP j oints at oo of extension. Ruler is placed vertically on the palmar surface to measure
linear distance from palm to tip of the middle finger. Possible anomalies in other fingers
are noted as well. Patient then flexes MCP, PIP and TIP j oints and measurement is
repeated from tip of middle finger and palmar surface.
Thumb
Carpometacarpal (CM) flexion and extension
Patient is seated with elbow flexed with forearm resting on table in midposition.
Wrist is held in slight ulnar deviation with fingers in anatomical position while the thumb
maintains contact with metacarpal and proximal phalanx of index finger.
Goniometer axis is placed over CM j oint with the fixed arm parallel to
longitudinal axis of radius. Movable arm is held parallel to longitudinal axis of thumb
metacarpal . Thumb is flexed across palm to full limit of motion ( 1 5 °) and then is
extended from the start position away from the palm to full limit of extension (20°).
MCP and IP flexion and extension
Measurement is made with elbow flexed with forearm resting on table in
midposition. Fingers and wrist are in anatomical position with MCP and IP joints held in
extension (0°). Metacarpal is stabilized by examiner while measuring MCP joint and
proximal phalanx is stabilized while measuring the interphalangeal (IP) joint.
Axis of goniometer is placed on dorsal or lateral aspect of MCP joint or IP joint of
thumb with stationary arm parallel to longitudinal axis o f thumb metacarpal for MCP
joint, and parallel to thumb proximal phalanx for measuring IP joint. Likewise the

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movable arm is held parallel to longitudinal axis of proximal phalanx for MCP
measurement and parallel to distal phalanx for thumb IP joint.
Interphalangeal joint of thumb can be actively hyperextended to 1 0° and passively
extended to 3 0°. Measurement can be obtained by placing goniometer on lateral or volar
surface of thumb.
CM abduction
Patient is seated with elbow flexed and the forearm resting on table in
midposition. Wrist and fingers are in anatomical position while thumb maintains contact
with metacarpal and proximal phalanx of index finger.
Axis of goniometer is placed over junction of first and second metacarpal bases.
Stationary arm is held parallel to longitudinal axis of second metacarpal while the
movable arm is parallel to longitudinal axis of thumb metacarpal. Goniometer in this
position usually indicates 1 5 - 20°, which is recorded as the 0° position. Thumb is then
abducted to limit of motion (70°) moving in a plane oblique to palm.
Alternate to goniometer method described above, a linear measurement of thumb
abduction can be obtained by means of a ruler or tape measure. A ruler measurement
from dorsal aspect of MCP joint midpoint of index finger to MCP of the thumb, while
thumb is abducted, provides measure of abduction.
Opposition
Normal full range of motion in thumb opposition allows pad of thumb and fifth
finger to touch. A deficit in opposition can be obtained by measuring linear distance
between thumb pad and center of pad on tip of fifth finger.

Passive Movement with Overpressure

Wrist and Carpus
Flexion a nd Extension
Ulnar and Radial Deviation
Finger Joints (2nd - 5th)
MCP, PIP and TIP flexion and extension
MCP abduction and adduction
Thumb
C M , MCP and I P flexion and extension
C M abduction and adduction

Resisted Isometric Tests

Muscle strength of the wrist, hand and fingers is evaluated by resisted isometric tests and
graded 0 - 5 (see Table 4.3). Principal signs of either pain or weakness, or both, are noted.
Of the resisted isometric tests, four are conducted at the wrist, three at the thumb, four at
the metacarpophalangeal joints and two at the interphalangeal joints.
The four isometric tests performed at the wrist include flexion, extension, ulnar
deviation and radial deviation. Pain on any of these tests indicates possible tendinitis of
the main muscles moving the wrist. The patterns of pain are consistent with the function

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of each particular muscle. For example, pain on resisted extension may manifest in
tendinitis of either the extensor carpi radialis or extensor carpi ulnaris muscles, while pain
associated with resisted contraction in radial deviation, may be the result of tendinitis of
either the flexor carpi radialis or extensor carpi radialis mm . Consequently pain patterns
can be differentiated to isolate the particular muscle involved (see Table 1 1 . 7).

Table 1 1 . 7. Pa in patterns in isometric tests of wrist are consistent with the function of muscles
moving the wrist and pattern ind icates possible site of tendinitis
Muscles MD* Nerve Root Flexion Extension Ulnar Radial
Deviation Deviation
Flexor carpi radialis MH C6. 7. 8 p 0 0 p
Flexor carpi ulnaris PLH C7, 8, T1 p 0 p 0
Extensor carpi radialis ALH C5, 6, 7, 8 0 p 0 p
Extensor carpi ulnaris LH C6. 7. 8 0 p p 0

*MD = Muscle d istribution; P = pain; 0 = no pain

Painless weakness in the resisted contractions of the wrist usually indicates a

neural lesion, since rupture of the musculotendinous structures controlling the wrist is
rare. Patterns of muscular weakness can also be noted to identify the particular muscle,
nerve root and traditional musculotendinous distribution pathway. All of this information
is essential to formulate an effective treatment approach, including the needling therapy.
Wrist flexion and radial deviation
Flexor carpi radialis is one of principal wrist flexors and also produces radial deviation.
Both the flexor carpi ulnaris and palmaris longus are accessory muscles to wrist flexion,
but neither produce radial deviation.
Wrist flexion with radial deviation is evaluated with patient either seated or
supine. In seated position, forearm is supinated and resting on a table, while wrist is
extended in ulnar deviation. Fingers and thumb are relaxed and examiner stabilizes
forearm proximal to wrist. For screening test, patient flexes and radially deviates the
wrist through full range while maintaining relaxation of fingers and thumb. Examiner
palpates anterolateral aspect of wrist in line with the second web space, radial to palmaris
longus.
Isometric resistance is then applied distal to wrist over lateral aspect of palm or
thenar eminence. Resistance is applied in direction of wrist extension and ulnar deviation.
-+ Patient may substitute flexion with palmaris longus and flexor carpi u l naris.
Flexion with ulnar deviation results if only flexor carpi ulnaris is em ployed. Flexor
dig itorum superficialis and profundus may substitute to i n itiate wrist flexion.

Failure of the gravity resisted isometric test indicates a gravity eliminated test for
the flexor carpi radialis muscle should be considered. Patient is either seated or supine
with forearm in neural position and resting on a table or powder board. Wrist is extended
in ulnar deviation, fingers and thumb are relaxed, and examiner stabilizes forearm
proximal to wrist. Patient flexes and radially deviates wrist through full range of motion
while maintaining relaxation of fingers and thumb. Examiner palpates anterolateral
aspect of wrist in line with the second web space, radial to palmaris longus.

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 Chinese Orthopedics Wrist and Hand 285

-+ Patient may substitute pal m a ris long us, flexor carpi u l naris, and flexor dig itorum
s uperficialis and profundus. Forearm pronation and thumb abduction by action of
a bd u ctor pol l i cis longus may be substituted as wrist is flexed from anatomical
position

Wrist flexion and ulnar deviation

Flexor carpi ulnaris is one of principal wrist flexors and also produces ulnar deviation.
Both the flexor carpi radialis and palmaris longus are accessory muscles to wrist flexion,
but neither produce ulnar deviation.
Wrist flexion with ulnar deviation is evaluated with patient either seated or
supine. In seated position, forearm is supinated and resting on a table, while wrist is
extended in radial deviation. Fingers and thumb are relaxed and examiner stabilizes
forearm proximal to wrist. For screening test, patient flexes and ulnarly deviates the wrist
through full range while maintaining relaxation of fingers and thumb. Examiner palpates
anteromedial aspect of wrist proximal to pisiform bone.
Isometric resistance is then applied distal to wrist over medial aspect of palm.
Resistance is applied in direction of wrist extension and radial deviation.
-+ Patient may substitute flexion with palmaris longus, flexor carpi radialis, and
flexor dig itorum su perficialis and profundus; flexion with radial deviation results if
o n ly flexor carpi rad ialis is e m ployed.

Failure of the gravity resisted isometric test indicates a gravity eliminated test for
the flexor carpi ulnaris should be considered. Patient is either seated or supine with
forearm in midposition and resting on a table or powder board. Wrist is extended in radial
deviation, fingers and thumb are relaxed, and examiner stabilizes forearm proximal to
wrist. Patient flexes and ulnarly deviates the wrist through full range while maintaining
relaxation of fingers and thumb. Examiner palpates anteromedial aspect of wrist proximal
to pisiform bone.
-+ Patient may substitute pal m a ris long us, flexor carpi radialis, and flexor d ig itorum
s u perficialis and profundus.

Wrist flexion - Palmaris longus

Palmaris longus is weakest of three wrist flexors and is not isolated for individual muscle
testing. Normally it can be palpated on midline of anterior wrist during testing of flexor
carpi radialis and ulnaris. Palmaris longus is a vestigial muscle in about 1 0 - 1 3% of
subjects, but its tendon prominently stands out when present. This can be checked by
flexing wrist while cupping fingers and palm of hand to visually determine if tendon
stands out.
Wrist extension and radial deviation
Extensor carpi radialis longus and brevis are principal muscles that produce wrist
extension and radial deviation. Extensor carpi ulnaris is accessory to this movement but
does not participate in radial deviation.
Wrist extension with radial deviation is evaluated with patient either seated or
supine. In seated position, forearm is pronated and resting on a table, while wrist is flexed
i n ulnar deviation. Fingers and thumb are slightly flexed and examiner stabilizes forearm
proximal to wrist. For screening test, patient extends and radially deviates the wrist
through full range while maintaining relaxation of fingers and thumb. Examiner palpates

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C h inese Orthopedics Wrist and Hand 286

dorsal aspect of wrist at base of second metacarpal for extensor carpi radialis longus and
at base of third metacarpal for extensor carpi radialis brevis.
Isometric resistance is then applied distal to wrist over dorsal lateral aspect of
hand over second and third metacarpal. Resistance is applied in direction of wrist flexion
and ulnar deviation.
-+ Patient may s ubstitute with extensor carpi ulnaris which produces extension with
ulnar deviatio n .

Failure of the gravity resisted isometric test indicates a gravity eliminated test for
the extensor carpi radialis longus and brevis should be considered. Patient is either seated
or supine with forearm in midposition and resting on a table or powder board. Wrist,
fingers and thumb are flexed and examiner stabilizes forearm proximal to wrist. Patient
extends and radially deviates the wrist through full range of motion while maintaining
relaxation of fingers and thumb. Examiner palpates dorsal aspect of wrist at base of
second metacarpal for extensor carpi radialis longus and at base of third metacarpal for
extensor carpi radialis brevis.
-+ Patient may substitute extensor carpi u l nari s .

Wrist extension and ulnar deviation

Extensor carpi ulnaris is principal muscle that produces wrist extension with ulnar
deviation. Extensor carpi radialis longus and brevis are accessory to this movement but
do not participate in ulnar deviation.
Wrist extension with ulnar deviation is evaluated with patient either seated or
supine. In seated position, forearm is pronated and resting on a table, while wrist is flexed
in radial deviation. Fingers and thumb are slightly flexed and examiner stabilizes forearm
proximal to wrist. For screening test, patient extends and ulnarly deviates the wrist
through full range while maintaining relaxation of fingers and thumb. Examiner palpates
dorsal aspect of wrist proximal to fifth metacarpal and distal to ulnar styloid process.
Isometric resistance is then applied distal to wrist over dorsal medial aspect of
hand over fourth and fifth metacarpals. Resistance is applied in direction of wrist flexion
and radial deviation.
-+ Patient may substitute extensor carpi radialis longus and brevis which do not
participate in ulnar deviatio n .

Failure of the gravity resisted isometric test indicates a gravity eliminated test for
the extensor carpi ulnaris should be considered. Patient is either seated or supine with
forearm in neural position resting on a table. Wrist, fingers and thumb are flexed and
examiner stabilizes forearm proximal to wrist. Patient extends and ulnarly deviates the
wrist through full range of motion while maintaining relaxation of fingers and thumb.
Examiner palpates dorsal aspect of wrist proximal to fifth metacarpal and distal to ulnar
styloid process.
-+ Patient may s ubstitute extensor carpi radial is longus and brevis.

Fingers
Force of gravity is not considered an important factor in strength testing fingers and
thumb since these structures are light in mass compared to the strength of their muscles.

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Chinese Orthopedics Wrist and Hand 287

MCP Extension
MCP extension involves the extensors digitorum communis, indicis and digiti
minimi. Patient is seated or supine with forearm pronated. Wrist is in neutral position
with fingers flexed and examiner stabilizes metacarpals. Patient extends all four MCP
joints while holding PIP joints in flexion. Examiner palpates extensor digitorum tendon
to each finger on dorsum of hand proximal to metacarpal heads. Extensor indicis is
palpated medial to extensor digitorum tendon to index finger. Extensor digiti minimi is
palpated lateral to extensor digitorum tendon to fifth finger.
For strength evaluation, isometric resistance is applied on dorsal aspect of
proximal phalanx of each finger, in direction of MCP flexion.
MCP abductio n
MCP abduction involves the dorsal interossei and abductor digiti muscles. Patient
i s seated or supine with forearm supported on table, either pronated for dorsal interossei
testing or supinated for abductor digiti testing, with wrist in neutral position.
Fingers are extended and adducted for dorsal interossei test and thumb is in
anatomical position. Examiner stabilizes dorsum of hand over metacarpal bones and
wrist. Patient first abducts the index finger toward thumb and then abducts middle finger
toward index finger. Middle finger is then abducted toward ring finger and then ring
finger abducted toward fifth finger. Examiner may need to stabilize non-test digits. First
interosseous is palpated on radial aspect of second metacarpal. Other interossei cannot be
reliably palpated.
Forearm is supinated while examiner stabilizes wrist and lateral three metacarpals
for testing abductor digiti. Patient abducts fifth finger while examiner palpates on ulnar
aspect of fifth metacarpal.
For isometric testing, examiner applies resistance against proximal phalanx of
finger being tested. Resistance is applied to radial side of index and middle finger, and to
ulnar side of middle, ring and fifth fingers. Force i s applied in direction of adduction.
-+ Patient may s ubstitute extensor digitorum com m unis to abduct fingers.

MCP adduction
MCP adduction involves the palmar interossei muscles. Patient is seated or supine
with forearm supinated and supported on table. Wrist is in neutral position and fingers are
abducted. Examiner stabilizes wrist and metacarpal bones. Patient then adducts index,
ring and fifth finger toward middle finger. Palmar interossei muscles cannot be palpated.
Isometric testing is conducted by applying resistance against proximal phalanx of
finger being tested. Resistive force is applied to ulnar aspect of index finger and on radial
side for ring and fifth finger.
MCP Flexion and PIP Extension
Lumbricals fl ex the MCP joints and simultaneously extend PIP joints of fingers.
Interossei muscles which are isolated by abduction and adduction in preceding two tests
also flex MCP joints and extend PIP j oints. Weakness in present test following a strong
result for interossei muscles, implicate the lumbricals. Flexor digiti minimi (MCP
flexion) acts accessory to lumbricals.

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Chinese Orthopedics Wrist and Hand 288

Patient is seated with forearm supported on table either supinated or in

midposition. Wrist is in neutral position, MCP joints extended and abducted, and PIP
joints are slightly flexed. Examiner stabilizes metacarpals on palmar side and lumbricals
cannot be palpated.
Patient flexes MCP joints while simultaneously extending PIP j oints. Fingers are
allowed to abduct to avoid influence from adjacent fingers in static adduction.
For isometric strength testing, resistance is directed toward MCP extension and
PIP flexion. Resistive force is applied on volar surface of proximal phalanx and dorsal
surface of middle phalanx.
-+ Patient may s ubstitute extensor d ig itorum com m unis

Little finger MCP flexion

Flexor digiti minimi is principal flexor of little finger MCP j oint. Other muscles
accessory to thi s movement includes abductor digiti minimi, fourth lumbrical and fourth
palmar interosseous muscles. Patient is seated with forearm supinated and supported on
table and wrist is in neutral position with fingers extended. Examiner stabilizes
metacarpals and palpates on hypothenar eminence medial to abductor digiti minimi.
Patient flexes MCP j oint of little finger while maintaining extension of PIP j oint.
For isometric strength testing, resistance is directed toward little finger MCP
extension. Resistive force is applied on volar aspect of little finger proximal phalanx.
-+ Patient may s ubstitute flexor dig itorum superficialis and profundus, thus it is
im portant that flexion of PIP joint not occur. Patient may abduct little finger by
abductor d ig iti m i n i m i if flexion cannot be initiated.

PIP flexion
Flexor digitorum superficialis is principal flexor of PIP joints of fingers. F lexor
digitorum profundus acts accessory to this movement. Patient is seated with forearm
supinated and supported on table and wrist is in neutral position or slight extension with
fingers extended. Examiner stabilizes metacarpals and proximal phalanx of finger being
tested. Flexor digitorum superficialis is palpated on volar surface of wrist between
palmaris longus and flexor carpi ulnaris tendons, or on proximal phalanx.
Patient flexes PIP joint of each finger while maintaining TIP joints in extension.
Little finger is not isolated during test and may with ring finger since isolated action of
fifth finger superficialis is not always possible. Fingers not being tested may be held in
extension to rule out contribution of flexor digitorum profundus.
For isometric strength testing, resistance is directed toward PIP extension.
Resistive force is applied on volar aspect of middle phalanx.
-+ Patient may s ubstitute flexor dig itorum profundus.

TI P Flexion
TIP flexion involves the flexor digitorum profundus muscle. Patient is seated with
forearm supinated and supported on table and wrist is in neutral position or slight
extension with fingers extended. Examiner stabilizes proximal and middle phalanx of
each finger being tested. Flexor digitorum profundus is palpated on volar surface of
middle phalanx.

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 Chinese Orthopedics Wrist and Hand 289

Patient flexes each TIP joint through full range of motion. Isometric strength is
assessed by applying resistive force on volar aspect of terminal phalanx in direction of
extension.
Thumb
I P Flexion
IP flexion involves the flexor pollicis longus muscle. Patient is seated with
forearm supinated and supported on table and wrist is in neutral position, and thumb
extended. Examiner stabilizes wrist, thumb metacarpal, and proximal phalanx. Patient
flexes IP j o int through full range of motion while examiner palpates on volar surface of
distal phalanx.
Isometric strength is assessed by applying resistive force on volar aspect of distal
phalanx in direction of extension.
-+ Rel axation of thumb following IP joint extension may give false i m pression of
flexor poll icis longus contraction.

MCP Flexion
Flexor pollicis brevis is second flexor of thumb and controls flexion of thumb
MCP j oint. Flexor pollicis longus acts accessory to this movement. Patient is seated with
forearm supinated and supported on table and wrist is in neutral position, with thumb
extended and adducted. Examiner stabilizes wrist and thumb metacarpal and palpates
proximal to MCP joint on middle of thenar eminence, medial to abductor pollicis brevis.
Patient flexes MCP j oint through full range of motion while maintaining extension of IP
joint to reduce effects of flexor pollicis longus.
Isometric strength is assessed by applying resistive force on volar aspect of
proximal phalanx in direction of extension.
-+ Patient m a y substitute flexor pollici s longus

I P Extension
IP extension involves the extensor pollicis longus muscle. Patient is seated with
forearm in midposition or slight supination supported on table and wrist is in neutral
position. Thumb is adducted with MCP joint extended and IP joint flexed. Examiner
stabilizes thumb metacarpal and proximal phalanx. Patients extends IP j oint through full
range of motion while examiner palpates on dorsal surface of proximal phalanx or on
ulnar border of anatomical snuff box.
Isometric strength is assessed by applying resistive force on dorsal aspect of distal
phalanx in direction of flexion.
-+ P l acing thumb in adduction l i m its extensor action of abd uctor pollicis brevis.
Rebound contraction of flexor pollicis longus m a y occur.

M C P extension
Extensor pollicis brevis is second extensor of thumb and it influences extension of
MCP joint of thumb. Extensor pollicis longus acts accessory to this movement. Patient is
seated with forearm in midposition or slightly pronated supported on table and wrist is in
neutral position. Thumb MCP j oint and IP j oint are flexed. Examiner stabilizes first
metacarpal while patient extends thumb MCP j oint while maintaining IP joint in slight
flexion. Examiner palpates on dorsoradial aspect of wrist at base of thumb metacarpal.

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Tendon forms radial border of anatomical snuff box and is medial to tendon of abductor
pollicis longus.
Isometric strength is assessed by applying resistive force on dorsal aspect of
proximal phalanx in direction of flexion.
-+ Patient may substitute extensor pollicis longus.

Radial Abduction
Radial abduction involves the abductor pollicis longus muscle. Patient is seated
with forearm in supination s upported on table and wrist is in neutral position. Thumb is
adducted against volar aspect of index finger. Examiner stabilizes wrist and second
metacarpal. Patient abducts thumb in radial direction through full range of motion.
Thumb i s moved away from index finger at an angle of 45° towards extension. Examiner
palpates on lateral aspect of wrist at base of thumb metacarpal, and on radial side of
extensor pollicis brevis.
Isometric strength is assessed by applying resistive force on lateral aspect of
thumb metacarpal in direction of adduction and flexion.
-+ Substitution of palmar a bduction may be attempted through action of abd uctor
pollicis brevis .

Palmar Abduction
Palmar abduction involves the abductor pollicis brevis muscle. Patient is seated
with forearm in supination supported on table and wrist is in neutral position. Thumb is
adducted against volar aspect of index finger. Examiner stabilizes wrist and second
metacarpal . Patient abducts thumb through full range of motion. Thumb is moved away
at a right angle from index finger. Examiner palpates on lateral aspect of thumb
metacarpal.
Isometric strength is assessed by applying resistive force on lateral aspect of
thumb proximal phalanx in direction of adduction.
-+ S ubstitution of radial a bduction may be attempted throug h action of abductor
pollicis longus.

Adduction
Adductor pollicis is principal thumb adductor, and flexor pollicis brevis acts
accessory to this movement. Patient is seated with forearm supinated supported on table
and wrist is in neutral position. Thumb MCP joint and IP j oint are flexed and thumb is in
palmar abduction. Examiner stabilizes wrist and second through fifth metacarpals. Patient
adducts thumb while maintaining flexion of MCP and IP joints. Examiner palpates on
palmar surface of hand between first and second metacarpals.
Isometric strength is assessed by applying resistive force on medial aspect of
proximal phalanx in direction of palmar abduction.
-+ Patient may substitute flexor pollicis longus and extensor pollicis longus.

Opposition with 5th finger

Opponens pollicis and opponens digiti minimi function in opposition of thumb.
Muscles accessory to this movement include abductor pollicis brevis, adductor pollicis
brevis and flexor pol licis brevis. Patient is seated with forearm supinated supported on

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table and wrist is in neutral position. Fingers are extended and thumb MCP and IP joints
are extended. Thumb is in palmar abduction since opponens pollicis cannot effectively
oppose thumb until it is abducted. Examiner stabilizes distal forearm and thumb may be
supported in abduction if abductor pollicis brevis is weak.
Patient flexes and medially rotates thumb metacarpal toward little finger while
little finger flexes and rotates toward thumb so pads of thumb and little finger touch,
while distal phalanges remain extended. Examiner palpates opponens pollicis lateral to
abductor pollicis brevis on radial aspect thumb metacarpal shaft. Opponens digiti minimi
is palpated on volar surface of fifth metacarpal shaft.
Isometric strength is assessed by applying resistive force simultaneously against
both movements. Resistance is applied on volar surface of thumb metacarpal and fifth
metacarpal.
-+ Patient may attempt flex thumb and l ittle finger distal joints near end of range,
g iving appe a rance of full opposition

Accessory Movements
Table 5. 1
Radiocarpal Joint
Anteroposterior (dorsal glide)
Anteroposterior movement or dorsal glide is produced by grasping the proximal
carpals as close to the wrist joint as possible and applying pressure over the anterior
surface of the carpus with one hand while stabilizing the forearm at the wrist with the
other. Examiner's hand can grasp the patient's thumb with his or her thumb and index
finger while applying pressure over the radiocarpal joint with the base of the examiner's
hand.
Posteroanterior (volar glide)
Posteroanterior movement or volar glide is produced by grasping the proximal
carpals as close to the wrist joint as possible and applying pressure over the posterior
surface of the carpus with one hand while stabilizing the forearm with the other. Wrist of
stabilizing hand is flexed with the base of the hand positioned j ust proximal to the wrist
joint.
Medial Transverse (ulnar g lide)
Medial transverse movement or ulnar glide is produced by grasping the proximal
carpals as close to the wrist joint as possible and applying pressure over the medial aspect
of the carpus while stabilizing the patient's forearm. Forearm rests on the ulnar side with
wrist held extended over the end of the table.
Lateral Transverse ( radia l glide)
Lateral transverse movement or radial glide is produced by grasping the proximal
carpals as close to the wrist joint as possible and applying pressure over the lateral aspect
of the carpus whil e stabilizing the patient's forearm. Forearm rests on radial side with
wrist held extended over the end of the table.

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Chinese Orthopedics Wrist and Hand 292

Supination
One hand of the examiner grasps the patient's forearm at the wrist, while the other
hand grasps the proximal carpals from the dorsal surface. The patient's hand is then
rotated in supination.
Pronation
One hand of the examiner grasps the patient's forearm at the wrist, while the other
hand grasps the proximal carpals from the dorsal surface. The patient's hand is then
rotated in pronation.
Longitudinal Caudad
While grasping the proximal carpals as close to the wrist j oint as possible, traction
is applied in the longitudinal caudal direction while stabilizing the patient's forearm
resting pronated on the table with the wrist extended over the end of the table.
Longitudinal Cephalad
While grasping the proximal carpals as close to the wrist j oint as possible,
compression is applied to approximate the j oint in the longitudinal cephalad direction.
Patient's forearm is stabilized forearm resting pronated on the table with the wrist
extended over the end of the table.
Intercarpal Joints
The carpal bones are normal held together tightly. Producing and evaluating accessory
movement in the intercarpal joints is therefore difficult and it takes much practice to
perfect.
Posterior-anterior
Posteroanterior movement of any one carpal on another is produced by grasping
the patient's hand j ust distally to the wrist j oint and applying pressure over the dorsal
surface.
Anterior-posterior
Anteroposterior movement of any one carpal on another is produced by grasping
the patient's hand j ust distally to the wrist j oint and applying pressure over the palmar
surface.
Horizontal Extension
Horizontal extension is produced by grasping the patient's hand just distally to the
wrist j oint and applying pressure over the dorsal surface of one carpal bone as a fulcrum
and extending the other carpal bones around it by pressure of the fingers on the palmar
surface.
Horizontal Flexion
Horizontal flexion is produced by grasping the patient's hand j ust distally to the
wrist joint and applying pressure over the palmar surface of one carpal bone as a fulcrum
and cupping the other carpal bones around it by pressure of the practitioner's palm and
fingers on the dorsal surface.

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Longitudinal Caudal
Longitudinal caudal movement is produced by grasping the patient's hand over
the metacarpal joints and applying traction in the longitudinal direction while stabilizing
the forearm.
Longitudinal Cephalad
Longitudinal cephalad movement is produced by grasping the patient's hand over
the metacarpal joints and applying compression in the longitudinal direction while
stabilizing the forearm.
Carpometacarpal Joints
Accessory movement is evaluated in the medial four carpometacarpal joints as follow:
Anterior-posterior
Anteroposterior movement of any one carpometacarpal j oint is produced by
grasping the patient's hand just proximal to the carpometacarpal j oints and applying
thumb pressure over the palmar surface of the metacarpal bone j ust distal to the joint in
question while holding the patient's hand and fmgers with the practitioner's mobilizing
hand.
Posterior-anterior
Posteroanteri or movement of any one carpometacarpal joint is produced by
grasping the patient's hand with one hand just proximal to the carpometacarpal j oints and
applying thumb pressure with the other hand over the dorsal surface of the metacarpal
bone j ust distal to the joint in question while holding the patient's hand and fingers with
the practitioner's mobilizing hand.
Medial Rotation
Medial rotation of any one carpometacarpal joint is produced by grasping the
patient's hand j ust proximal to the carpometacarpal joints with one hand and holding the
proximal end of metacarpal bone in question with the thumb and index finger of the
practitioner's other hand and rotating the metacarpal bone in the medial direction.
Lateral Rotation
Lateral rotation of any one carpometacarpal joint is produced by grasping the
patient's hand j ust proximal to the carpometacarpal joints with one hand and holding the
proximal end of metacarpal bone in question with the thumb and index finger of the
practitioner's other hand and rotating the metacarpal bone in the lateral direction.
Longitudinal Caudal
Longitudinal caudad movement of any one carpometacarpal j oint is produced by
grasping the patient's hand j ust proximal to the carpometacarpal j oints with one hand and
holding the proximal end of metacarpal bone in question with the thumb and index finger
of the practitioner's other hand and applying traction in the longitudinal direction.
Long itudinal Cephalad
Longitudinal cephalad movement of any one carpometacarpal joint is produced by
grasping the patient's hand j ust proximal to the carpometacarpal j oints with one hand and
holding the proximal end of metacarpal bone in question with the thumb and index finger
of the practitioner's other hand and applying compression in the longitudinal direction.

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Metacarpophalangeal Joints
Medial Rotation
Medial rotation is produced by stabilizing the metacarpals and rotating the
proximal phalanx in the medial direction by means of the practitioner's thumb and index
finger.
Lateral Rotation
Lateral rotation is produced by stabilizing the metacarpals and rotating the
proximal phalanx in the lateral direction by means of the practitioner's thumb and index
finger.
Longitudinal Caudal
Longitudinal caudad movement is produced by stabilizing the metacarpals and
applying traction on the metacarpophalangeal joint by means of the practitioner's thumb
and index finger pulling on the proximal phalanx in the longitudinal direction.
Longitudinal Cephalad
Longitudinal cephalad movement is produced by stabilizing the metacarpals and
applying compression on the metacarpophalangeal j oint by means of the practitioner's
thumb and index finger pushing on the proximal phalanx in the longitudinal direction.
Posterior-anterior
Posteroanterior movement is produced by stabilizing the metacarpals and
applying thumb pressure on the dorsal surface of the proximal phalanx j ust distal to the
metacarpophalangeal joint.
Anterior-posterior
Anteroposterior movement is produced by stabilizing the metacarpals and
applying thumb pressure on the anterior surface of the proximal phalanx j ust distal to the
metacarpophalangeal joint.
Abduction
Abduction is produced by stabilizing the metacarpals and moving the proximal
phalanx away from the middle finger.
Adduction
Adduction is produced by stabilizing the metacarpals and moving the proximal
phalanx toward the middle finger.
Proximal and Terminal Interphalangeal Joints (PIP, TIP)
Accessory movement of the proximal and distal interphalangeal j oints (PIP, TIP) can be
evaluated in terms of medial and lateral rotation, medial and lateral transverse movement
and Posteroanterior and Anteroposterior movements. The same techniques used in
section e. above are applied to the PIP and TIP j oints except the stabilizing hand first
holds the proximal and then middle phalanx respectively while evaluating the j oint in
question.

Neurological Evaluation
Myotomes: Key muscle strength (graded 0 - 5)
• Extensor carpi radialis longus and brevis muscles ( C6)

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Chinese Orthopedics Wrist and Hand 295

•
Extensor digitorum muscle (C7)
•
Flexor digitorum superficialis and profundus (C8)
•
Dorsal interossei muscles (T 1 )

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View. This view is useful to show the shape and position the wrist and
hand bones to note possible displacement or fractures, decrease in joint space, changes in
bone density, and pathologies.
Lateral View. This view is useful to show shape and position of bones for presence of
any fractures or displacements. This view also used to note relationship of the scaphoid
and lunate to the radius and metacarpals, as well as for detecting swelling around carpal
bones.
Scaphoid View. This view is useful to isolate the scaphoid to show possible fractures.
Carpal Tunnel (Axial) View . This view is useful to show possible fractures of the hook
of hamate and trapezium, and to show margins of the carpal tunnel.
Clenched Fist View. This view is useful to show possible increased gapping between
carpal bones, indicating instability.
Magnetic Resonance Imaging (MRI)
Magnetic resonance images are useful in viewing wrist and hand soft-tissue including the
ligaments and the median nerve in the carpal tunnel.
Computed Tomography
Computed tomography used to visualize the bones and soft tissues by viewing cross
sections of various features.

Management of Wrist and Hand Disorders

The main therapeutic approach in addressing wrist and hand problems involves physical
modalities of mobilization and needling therapy. Selection of candidate nodes for
treatment of wrist (Table 1 1 .8) and hand problems (Tables 1 1 .9 and 1 1 . 1 0) vary slightly
because the problems lie within the extremities. Essentially, the local and adjacent nodes
for hand and fingers are normally used as distal nodes and therefore intermediate nodes
are introduced. Electroneedling (EN) application is also considered after an initial course
of needling has not produced the full therapeutic effect. Electroneedling may be
considered early, including during the first treatment in complicated cases with an
established history. Remedial exercises are also considered for rehabilitation.

Wrist and Hand Mobilization

Any of the physiological or accessory movements described above in under passive and
accessory movement can be applied to specific regions of the wrist, hand and fingers to
improve mobility and reduce pain in affected joints. Passive movement treatments are
graded from I-V and consist of either small or larges amplitude oscillations that do not
move into restricted or painful area, except for Grade V which involves a sharp thrust
beyond pathological limit of movement (See Table 5. 1 ) . Grade V mobilization techniques
are not usuall y applied to wrist and hand.

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Wrist Extension
Some situations involve significant hypomobility of the wrist, such as occurs after wrist
has been immobilized with an orthotic or cast as result of a fracture or injury. Following
technique is effective for progressively increasing wrist mobility and reducing pain and
involves the patient immersing their hand, with the palm facing down, in a sink or pan
filled with water heated to point that it can still be tolerated. While standing, patient
presses their palm onto inside bottom of sink and then leans their body slightly forward
while elbow remains fixed. This causes extension of wrist joint as patient moves forward.
After reaching point of restriction, patient leans backwards to relieve pressure on wrist.
This procedure is continuously repeated to produce a slow and gentle oscillatory
action of wrist extension and is repeated until water cools. Each oscillation always moves
up to point of restriction which may result in increasing range of motion during the
therapy. Just as with other mobilization techniques, this procedure is repeated over a
course of treatments until problem is resolved or a different treatment approach is
undertaken. Patient can be instructed in this technique to perform at home after the
practitioner is satisfied that patient can perform procedure safely and effectively.
Radiocarpal and Midcarpal Joints
Anterior-posterior (dorsal g l ide)
Dorsal glide of radiocarpal joint is especially effective in increasing wrist flexion.
Anteroposterior movement or dorsal glide is produced by grasping proximal carpals as
close to wrist joint as possible and applying pressure over anterior surface of carpus whi le
stabilizing the forearm. Patient's arm can rest supinated on table with wrist extended over
end of table. Practitioner applies pressure perpendicularly to carpus while stabilizing
forearm with other hand. Traction is also maintained while applying pressure with
mobilizing hand.
Same technique can be used to apply dorsal glide to midcarpal j oints by placing
practitioner's mobilization hand slightly distal to the wrist j oint.
Posterior-anterior (volar g lide)
Volar glide of radiocarpal j oint is especially effective in increasing wrist
extension. Posteroanterior movement or volar glide is produced by grasping proximal
carpals as close to wrist joint as possible and applying pressure over posterior surface of
carpus while stabilizing the forearm. Patient's arm can rest pronated on table with wrist
extended over end of table. Practitioner applies pressure perpendicularly to carpus while
stabilizing forearm with other hand. Traction is also maintained while applying pressure
with the mobilizing hand.
Same technique can be used to apply volar glide to midcarpal joints by placing
practitioner's mobilization hand slightly distal to wrist j oint.
Medial Transverse (ulnar g lide)
Ulnar glide of radiocarpal j oint is especially effective in increasing wrist ulnar
deviation. Medial transverse movement or ulnar glide is produced by grasping proximal
carpals as close to wrist j oint as possible and applying pressure over medial aspect of
carpus while stabilizing patient's forearm resting on its ulnar border with wrist extended
over end of table.

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Same technique can be used to apply ulnar glide to midcarpal j oints by placing
practitioner's mobilization hand slightly distal to wrist joint.
Lateral Transverse (radial glide)
Radial glide of radiocarpal joint is especially effective in increasing wrist radial
deviation. Lateral transverse movement or radial glide is produced by grasping proximal
carpals as close to wrist joint as possible and applying pressure over lateral aspect of
carpus while stabilizing patient's forearm resting on its radial border with wrist extended
over end of table.
Same technique can be used to apply radial glide to midcarpal j oints by placing
practitioner's mobilization hand slightly distal to the wrist j oint.
Traction (longitudinal caudad)
Traction of radiocarpal j oint is effective in addressing general hypomobility or
pain syndromes of wrist. While grasping proximal carpals as close to wrist joint as
possible, traction is applied while stabilizing patient's forearm resting pronated on table
with wrist extended over end of table.
Same technique can be used to apply traction to midcarpal joints by placing
practitioner's mobilization hand slightly distal to the wrist j oint.
Metacarpal Joints
Metacarpal dorsal and volar glides are general mobilization techniques for increasing
intermetacarpal and carpometacarpal joint mobility.
Dorsal glide
Patient is seated with forearm pronated resting on table. Practitioner's fingers
grasp volarly over thenar and hypothenar eminences while thumbs rests over dorsal
surface of metacarpals. Thumbs press against dorsum of hand simultaneous to fingers
pulling dorsally on metacarpals.
Volar glide
Volar glide is similar to above technique except practitioner's fingers are moved
from thenar and hypothenar eminences to press into palm while thumb presses more
medially and laterally on dorsum of hand. This technique is useful for improving cupping
function of the palm.
Metacarpophalangeal Joints
Posterior and Anterior G l ide
Finger flexion and extension can be increased by applying posterior and anterior
mobilization to metacarpophalangeal joints. Either posteroanterior or anteroposterior
movement can be applied to metacarpophalangeal joints by practitioner stabilizing
patient's hand j ust proximal to joint and applying either pressure on dorsal or anterior
surface of proximal phalanx j ust distal to joint.
Joint Tractio n
Metacarpophalangeal j oint traction is useful for treatment o f pain of general
hypomobility. Patient is seated with forearm either in midposition or pronated resting on
table. Practitioner grasps proximal phalanx as close as possible to j oint while stabilizing

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associated metacarpal with other hand. Light traction force is applied in line with
longitudinal axis of metacarpal and phalanx. Force can be applied in oscillatory manner.
Medial-Lateral Glide
Medial-lateral glide of metacarpophalangeal joints is effective in addressing pain
or restricted motion, especially in abduction and adduction. Patient is seated with forearm
resting on table. Practitioner grasps proximal phalanx as close to joint as possible while
stabilizing appropriate metacarpal with other hand. Medial or lateral pressure is applied
to perpendicularly to phalanx by thumb and index fmger of practitioner while
maintaining a slight traction force.
Joint Rotation
Rotation of metacarpophalangeal joints is effective in addressing pain or any
restricted movement. Patient is seated with forearm resting on table. Practitioner
stabilizes metacarpals while grasping proximal phalanx as close to joint as possible.
Flexed TIP joint is held between practitioner's middle and ring finger to insure firm
grasp. Rotational motion is applied to phalanx by thumb and index finger contacts, while
sight traction force is maintained.
Interphalangeal Joints
Traction, medial-lateral glides and rotation mobilization techniques applied to
metacarpophalangeal joints can also be applied to interphalangeal j oints by simply
moving the practitioner's hand placement distally to specifically stabilize and manipulate
the joints between affected phalanges.

Needling Therapy for Wrist Problems

Appropriate local and adjacent, distal and proximal acupoints for the treatment of
common wrist problems are noted in Table 1 1 . 8. Different sets of proximal and distal
points are applied in the treatment of wrist problems depending on the associated three
yang muscular distributions of the hand, which is either associated with the problem or
contains the problem within the affected muscular distribution pathway.

Table 1 1 . 8 . Selection of reg ional, proximal and distal nodes for treatment of wrist problems.
Pain or Disorder of the Candidate Local & MD Proximal Nodes Distal Nodes
Wrist Adjacent Nodes
Yangxi (ALH 5) ALH Dazhu (PLF 1 1 ) Hegu (ALH 4)
Yangchi (LH 4) Feishu (PLF 1 3)
Yanggu (PLH 5) LH Fengchi (LF 20) Zhongzhu (LH 3)
Waiguan (LH 5) Jianzhongshu (PLH 1 5)
PLH Tianzhu (PLF 1 0) Houxi (PLH 3)
JianzhonQshu (PLH 1 5)

Node Selection for Wrist Problems

Appropriate local and adjacent, distal and proximal nodes for the treatment of common
wrist problems are noted in Table 1 1 . 8 . Different sets of proximal and distal nodes are
applied in the treatment of wrist problems depending on the associated three yang
muscular distributions of the hand, which is either associated with the problem or
contains the problem within the affected muscular distribution pathway. One or two local
and adj acent nodes associated with the three medial muscular distributions of the hand

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 Chinese Orthopedics Wrist and Hand 299

are sometimes considered to be added in the treatment of wrist problems. Additional

nodes may be considered depending on the specific problems as follows:
•
Yanglao (PLH 6) may be added if pain is in inferior radioulnar joint or lateral
aspect of the wrist
•
Other nodes for pain in the lateral wrist include Taiyuan (AMH 9)
•
If lateral wrist pain is accompanied with forearm pain or is due to wrist
extension, nodes Sidu (LH 9) and Shanglian (ALH 9) may be added
•
For medial wrist pain the node Shenmen (PMH 7) may be considered
•
If medial wrist pain is accompanied with forearm pain or is due to wrist flexion,
nodes Zhizheng (PLH 7) and Xiaohai (PLH 8) may be added
•
The node Daling (MH 7) added for carpal tunnel syndrome, and Ximen (MH 4),
Taiyuan (AMH 9), and Shenmen (PMH 7) may be added as well

Candidate Electroneedling (EN) Application for Wrist

One suggested lead placement for adding electrostimulation is listed below for each of
the three muscular distributions involving a proximal and local node. A possible
alternative is provided involving a circuit from the local node to the distal node. Wrist
problems may manifest within more than one distribution. In that situation two or even
three candidate EN circuits could be employed. If more than one EN circuit is employed,
then they have to be consistent with all using the proximal to local circuit or the local to
distal circuit. Specific recommendations include the following:
Frequency: 2 Hz
Mode: Continuous
Duration: 20 - 30 minutes

Anterior lateral hand (ALH) distribution:

•
Dazhu (PLF 1 1 ) + lead, to Yangxi (ALH 5 ) - lead
•
Or Yangxi (ALH 5) + lead, to Hegu (ALH 4) - lead
Lateral hand (LH) distribution:
•
Fengchi (LF 20) + lead, to Waiguan (LH 5) - lead
•
Or Waiguan (LH 5) + lead, to Zhongzhu (LH 3) - lead
Posterior lateral hand (PLH) distribution:
•
Jianzhongshu (PLH 1 5) + lead, to Yanggu (PLH 5) - lead
•
Or Yanggu (PLH 5) + lead, to Houxi (PLH 3) - lead

Needling Therapy for Hand and Finger Problems

Regional selection of nodes is considered for pain and stiffness (see Table 1 1 .9) or pain
and numbness (see Table 1 1 . 1 0) of the fingers. The local and adjacent nodes in the region
of the fingers are essentially distal points and thus intermediate nodes are introduced to
provide adequate stimulation. Local and adjacent nodes are different for the fingers
depending on whether the manifestations of stiffness or numbness predominate. The
reasons for this are that nodes for stiffness have a stronger influence on the muscles and
tendons whi le those for numbness have a stronger influence on nerves. Different sets of

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Chinese Orthopedics Wrist and Hand 300

proximal and intermediate nodes are applied in the treatment of finger and hand problems
depending on the associated three yang muscular distributions of the hand, which is either
associated with the problem or contains the problem within the affected muscular
distribution pathway.

Table 1 1 . 9. Selection of reg ional, proximal and intermediate nodes for treatment of pain and
stiffness of the fingers.
Pain & Stiffness of Candidate Local & MD Proximal Nodes I ntermediate Nodes
Fingers Adjacent Nodes
Zhongzhu (LH 3) ALH* Dazhu (PLF 1 1 ) Shanglian (ALH 9)
Houxi (PLH 3) Feishu (PLF 1 3)
Yanggu (PLH 5) LH Fengchi (LF 20) Waiguan (LH 5)
Hegu (ALH 4) Jianzhongshu (PLH 1 5)
PLH Tianzhu (PLF 1 0) Zhizheng (PLH 7)
Jianzhongshu (PLH 1 5)
*Can consider H uatuojiaji nodes at T1 and T3 level.

Node Selection for Finger Pain and Stiffness

Candidate nodes in Table 1 1 .9 address pain and stiffness related problems associated
with the hand and fingers. In this situation the former distal nodes are now considered to
be local and adjacent nodes. Proximal nodes for the three yang muscular distributions for
shoulder, elbow, wrist, and finger problems remain the same. Intermediate nodes that
have an influence on the hand and fingers are introduced for finger problems. The same
analogy as used to decide which candidate nodes to use as previously discussed for the
wrist are appl ied to the hand.
Pain and stiffness reflecting in the lateral aspect of the hand and finger would
indicate the use of Hegu (AL H 4) and Zhongzhu (LH 3) for local and adjacent nodes,
Shanglian (ALH 9) as an intermediate node, along with the proximal nodes for the large
intestine distribution. For the medial hand, Houxi (PLH 3), Yanggu (PLH 5), and
Zhongzhu (LH 3 ) could be considered as local and adjacent nodes, Zhizheng (PLH 7) as
an intermediate node, along with the proximal nodes for the small intestine distribution.
For pain and stiffness in the dorsum of the hand Hegu (ALH 4), Zhongzhu (LH 3 ), and
Houxi (PLH 3 ) can be considered for local and adjacent nodes, with Waiguan (LH 5) as
an intermediate node, along with the proximal nodes for the internal membrane
distribution.
In condition of Dupuytren' s contracture nodes need to be added that may
influence the palmar tendons. This would include nodes such as Laogong (MH 8) and
Shaofu (PMH 8) needled at a shallow angle parallel to the tendons in the directed toward
the wrist. The Baxie node between the index and middle finger, middle and ring finger,
and ring and little finger can also be considered.
E/ectroneedling (EN) Application for Finger Pain and Stiffness
One suggested lead placement for adding electrostimulation is listed below for each of
the three muscular distributions involving a proximal and local node. A possible
alternative is provided involving a circuit from an intermediate node to the local node.
Finger pain and stiffness may manifest within more than one distribution. In that situation

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Ch inese Orthopedics Wrist and Hand 301

two or even three candidate EN circuits could be employed. If more than one EN circuit
is employed, then they have to be consistent with all using the proximal to local circuit or
the intermediate node to the local node circuit. Specific recommendations include the
following:
Frequency: 2 Hz
Mode: Continuous
Duration: 20 - 30 minutes

Anterior lateral hand (ALH) distribution:

• Dazhu (PLF 1 1 ) + lead, to Hegu (ALH 4) - lead
• Or Shanglian (ALH 9) + lead, to Hegu (ALH 4) - lead
Lateral hand (LH) distribution:
• Fengchi (LF 20) + lead, to Zhongzhu (LH 3) - lead
• Or Waiguan (LH 5 ) + lead, to Zhongzhu (LH 3) - lead
Posterior lateral hand (PLH) distribution:
• Jianzhongshu (PL H 1 5) + lead, to Houxi (PLH 3) - lead
• Or Zhizheng (PLH 7) + lead, to Houxi (PLH 3 ) - lead

Table 1 1 . 1 0. Selection of regional, proximal and intermediate nodes for treatment of pain and
num bness of the fingers.
Pain &Numbness of Candidate Local & MD Proximal Nodes Intermediate Nodes
FinQers Adjacent Nodes
Sanjian (ALH 3) ALH* Dazhu (PLF 1 1 ) Shanglian (ALH 9)
Yemen (LH 2) Feishu (PLF 1 3)
Houxi (PLH 3) LH Fengchi (LF 20) Waiguan (LH 5)
Baxie (Extra) Jianzhongshu (PLH 1 5)
PLH Tianzhu (PLF 1 0) Zhizheng (PLH 7)
Jianzhongshu (PLH 1 5)
* Can consider Huatuojiaji nodes at T1 and T3 level.

Node Selection for Finger Pain and Numbness

The node selection logic for addressing pain and numbness of the fingers is basically the
same as noted above for pain and stiffness of the fingers. The only difference being that
the Baxie nodes located in the web space of the fingers are added to the candidate local
and adjacent nodes.
Electroneed/ing (EN) Application for Finger Pain and Numbness
One suggested lead placement for adding electrostimulation is listed below for each of
the three muscular distributions involving a proximal and local node. A possible
alternative is provided involving a circuit from an intermediate node to the local node.
Finger pain and numbness may manifest within more than one distribution. In that
situation two or even three candidate EN circuits could be employed. If more than one
EN circuit is employed, then they have to be consistent with all using the proximal to
local circuit or the intermediate to local node circuit. Numbness also may be the result of

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C h inese Orthopedics Wrist and Hand 302

neural or vascular influence and mixed mode of 2 Hz - 25 Hz may be considered.

Specific recommendations include the following:
Frequency: 2 Hz, may also consider 2 Hz - 25 Hz mixed mode
Mode: Continuous, or mixed mode at 2 Hz - 25 Hz
Duration: 20-30 minutes

Anterior lateral hand (ALH) distribution

• Dazhu (PLF 1 1 ) + lead, to Sanjian (ALH 3) - lead
• Or Shanglian (ALH 9) + lead, to Sanj ian (ALH 3) - lead
Lateral hand (LH) distribution:
• Fengchi (LF 20) + lead, to Yemen (LH 2) - lead
• Or Waiguan (LH 5) + lead, to Yemen (LH 2) - lead
Posterior lateral hand (PLH) distribution:
• Jianzhongshu (PLH 1 5) + lead, to Houxi (PLH 3) - lead
• Or Zhizheng (PLH 7) + lead, to Houxi (PLH 3) - lead

Remedial Exercises for Muscles Moving the Wrist

Exercises performed at the wrist include flexion, extension, ulnar deviation and radial
deviation and wrist rotation (see Table 1 1 .4).

Flexor Carpi Radialis: Wrist Flexion and Radial Deviation

Both the flexor carpi radialis and flexor carpi ulnaris are the prime movers for wrist
flexion. The flexor carpi radialis and the extensor carpi radialis brevis and longus are the
prime movers for radial deviation. The palmaris longus, flexor digitorum superficialis
and profundus, and the flexor pol licis longus muscles participate as assistant muscles to
wrist flexion, but do assist in radial deviation. Flexor carpi radialis is exercised in wrist
flexion and radial deviation.
Subject is seated, forearm is supinated and resting on the opposite leg or knee
with wrist in the neutral position and held in radial deviation. While making and holding
a fist, the subj ect slowly flexes the wrist on the count of 3 and holding the end position 2-
3 seconds. Wrist is then slowly returned to the neutral start position and can be further
lowered into the wrist extension position, from which to start the next repetition.
This exercise is repeated up to 8 repetitions and eventually performed for 4-5 sets.
As strength permits, forearm muscles should be contracted to provide IDR antagonistic
resistance to wrist flexion and radial deviation. As strength is increased, light-weight
dumbbells can be introduced, grasped with palm facing upward, to increase exercise load
and further the strengthening process.

Flexor Carpi Ulnaris: Wrist Flexion and Ulnar Deviation

Both the flexor carpi ulnaris and flexor carpi radialis are the prime movers for wrist
flexion. The flexor carpi ulnaris and extensor carpi ulnaris are prime movers for ulnar
deviation. The palmaris longus, flexor digitorum superficialis and profundus, and the
flexor pollicis longus muscles participate as assistant muscles to wrist flexion, but do

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C hinese Orthopedics Wrist and Hand 303

assist in ulnar deviation. Flexor carpi ulnaris is exercised in wrist flexion and ulnar
deviation.
Subject is seated, forearm is supinated and resting on the opposite leg or knee
with wrist in the neutral position and held in ulnar deviation. While making and holding a
fist, the subj ect slowly flexes the wrist on the count of 3 and holding the end position 2 -
3 seconds. Wrist is then slowly returned to the neutral start position and can be further
lowered into the wrist extension position, from which to start the next repetition.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, forearm muscles should be contracted to provide IDR
antagonistic resistance to wrist flexion and ulnar deviation. As strength is increased,
l ight-weight dumbbells can be introduced, grasped with palm facing upward, to increase
exercise load and further the strengthening process.

Extensor Carpi Radialis: Wrist Extension and Radial Deviation

The extensor carpi radialis longus and brevis, and extensor carpi ulnaris are the prime
movers for wrist extension. Both the extensor carpi radialis longus and brevis are prime
movers for wrist radial deviation. The extensor carpi ulnaris does not participate in radial
deviation. Extensor carpi radialis longus and brevis are exercised in wrist extension and
radial deviation.
S ubject is seated, forearm is pronated and resting on the opposite leg or knee with
wrist in the neutral position and held in radial deviation. While making and holding a fist,
the subject slowly extends the wrist on the count of 3 and holding the end position 2 - 3
seconds. Wrist is then slowly returned to the neutral start position and can be further
lowered into the wrist flexion position, from which to start the next repetition.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, forearm muscles should be contracted to provide IDR
antagonistic resistance to wrist extension and radial deviation. As strength is increased,
light-weight dumbbells can be introduced, grasped with palm facing downward, to
increase exercise load and further the strengthening process.

Extensor Carpi Ulnaris: Wrist Extension and Ulnar Deviation

The extensor carpi ulnaris and extensor carpi radialis longus and brevis muscles are the
prime movers for wrist extension. Both the extensor carpi ulnaris and flexor carpi ulnaris
are the prime movers for wrist ulnar deviation. The extensor carpi radialis longus and
brevis do not participate in ulnar deviation. Extensor carpi ulnaris is exercised in wrist
extension with ulnar deviation.
S ubject is seated, forearm is pronated and resting on the opposite leg or knee with
wrist in the neutral position and held in ulnar deviation. While making and holding a fist,
the subject slowly extends the wrist on the count of 3 and holding the end position 2 - 3
seconds. Wrist is then slowly returned to the neutral start position and can be further
lowered into the wrist flexion position, from which to start the next repetition.
This exercise is repeated up to 8 repetitions and eventually performed for 4 - 5
sets. As strength permits, forearm muscles should be contracted to provide IDR
antagonistic resistance to wrist extension and ulnar deviation. As strength is increased,

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Chinese Orthopedics Wrist and Hand 304

light-weight dumbbells can be introduced, grasped with palm facing downward, to

increase exercise load and further the strengthening process.

D.E. Kendall, OMD, PhD ©2005-2009

 Chinese Orthoped ics Thoracic Spine 305

12

Thoracic Spi ne

The thoracic and lumbar (Chapter 13) spine are consists of twelve thoracic and five
lumbar vertebrae and joints they form involving intervertebral discs and related
ligaments. Thoracic vertebra have larger bodies than the cervical vertebra, have
transverse and spinous processes, superior and inferior facets that form apophyseal j oints,
a spinal canal , and intervertebral foramen in conjunction with a vertebra above and below
(See Figure 1 2 . 1 ). In addition, they have costal facets to accommodate the twelve ribs
(See Figure 1 2.2. Features of joint structures involved in trunk movements of the thoracic
and lumbar spine, and the lumbosacral articulation are noted in Table 1 2. 1 .
Main features of the thoraco-
lumbar intervertebral joints are Superior
the intervertebral discs that hold Facet
Costal Facet
Transverse
the vertebrae together and provide Process
cushioning to axial loads as well
Costal Facet
as bending that permit side Body _

flexion of the spine. The main

structural element of the discs is Dem ifacet
called the annulus fibrosus which
is comprised of concentric elastic Inferior Spinous
fibro-cartilaginous outer layers Facet Process
(lamellae) which encloses the soft
nucleus pulposus. In adults the
annulus fibrosus represents the Fig ure 1 2 . 1 . Features of thoracic vertebra
largest portion of the disc.
Lamellae are in successive layers similar to the skin of an onion and are separated by
loose connective tissue. Fibers of the annulus are embedded in the cartilage end-plates
and vertebra. The more superficial lamel lae are firmly attached to the anterior margins of
the vertebrae. There are approximately 1 2 lamellae in the lumbar discs. The intervertebral
joints are held together by the following ligaments: anterior longitudinal ligament,
posterior longitudinal ligament, intertransverse ligaments, ligamentum flavum, and
supraspinous ligament.
Rib fractures in accidents or other blunt force trauma may be common but the
upper thoracic spine (T l - 1 0) is relatively strong being stabilized by the ribs and facets
j oints. Consequently, fractures occur more commonly in the lower thoracic vertebrae.
Increased range of motion at the T 1 2 - L l j unction allows acute hyperflexion and rotation
during major trauma, usually by automobile accidents. Some 60-70% of thoracolumbar
inj uries occur in the T 1 2 - L2 region. Since the spinal cord terminates at about this level,
lower thoracic region fractures may result in bladder and bowel problems as well as
decreased sensation and movement in the lower extremities.
The thoracic spine is also susceptible to arthritic conditions and osteoporosis.
Vertebral body compression deformities are more common among elderly women as

D.E. Kendall, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 306

opposed to males. Problems can also occur in facet joints which are particularly painful.
Herniated discs in the thoracic area are not nearly as common as in the lumbar spine.

Intervertebral foramen

I ntervertebral discs

Apophyseal Joint

Costal Facets

Demifacets
Costochondral Joints

F i g u re 1 2 . 2 . Costal Vertebral Joints a nd Costal Facets

Table 1 2 . 1 . Features of joint structures associated with trunk movements involving the thoracic
and lumba r spine and the lumbosacral articulation.
Flexion Extension Lateral Flexion Rotation
Articulation Lumbar spine, thoracic Lumbar spine, thoracic Lumbar spine, thoracic Thoracic spine,
spine (mainly T6-1 2) spine (mainly T6- 1 2) spine lumbosacral articulation
Plane Sagittal Sagittal Frontal Horizontal

Axis Frontal Frontal Sagittal Vertical

Normal limiting Tension in posterior Tension in the anterior Contact between the Tension in the
factors longitudinal long itud inal ligament, iliac crest and thorax; costovertebral ligaments
supraspinous ligament abdominal m uscles, tension in the and ann ulus fibrosus of
and interspinous facet joint capsules and contralateral trunk side the intervertebral discs;
ligaments, the the anterior fibers of the flexors and spinal tension in the ipsilateral
ligamentum flavum and annulus; contact ligaments; tension in the external and
spinal extensor between adjacent lateral fibers of the contra lateral internal
muscles; apposition of sp1nous processes a nnulus abdominal oblique
vertebral body a nterior muscles; apposition of
margins, anterior the articular facets.
compression of
i ntervertebral discs
Normal end feel Firm Firm Firm/soft Firm
Normal active 0 - 80° 0 - (20 - 30°) 0 - 35° 0 - 45°
ROM 1 0 em (4 inches)
Capsular It is difficult to perform passive movements of the trunk due to its size and weight
pattern It is also difficult to determine capsular patterns for the trunk.

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Ch inese O rthoped ics Thoracic Spine 307

Physiology of Thorac ic Spine

Major muscles of the trunk are those that move the vertebral column which function
primarily to maintain the back in an erect position (See Table 1 2.2a). These muscles
along with the spine form the main axial structure of the body. Muscles on the front
portion of the trunk include the abdominal muscles that form the anterior wall of the
abdominal cavity to hold and protect the abdominal organs. Additional muscles of the
back are involved in elevating or depressing the ribs (See Table 1 2.2b). The thorax
encloses the ribs and the pleural cavity to protect the lungs and contains the muscles
related to respiration (See Table 1 2.2c). Their main function is related to the critical task
of breathing.

Table 1 2 . 2a . M uscle d istribution ( M D) assignment, nerve root, and function of prime mover (PM)
and accessory/assistant mover (AM ) muscles of thoracolumbar spine
M uscles MD Nerve Root Erection Extension Flexion Lateral Rotation to Rotation to
Flexion Same Side Opposite Side

Rectus abdominis ALF T7 - 1 2 PM AM

External oblique LF T7 - 1 2 AM PM PM
I nternal oblique LF T7 - L 1 AM PM PM
Iliopsoas ALF L1 . 2. 3, 4 AM AM
Semispinalis thoracis PLF T1 - 6 PM PM PM
I liocostalis thoracis PLF T1 - 6 PM PM PM PM
Spinalis thoracis PLF T4 - 1 2 PM PM PM
Longissimus thoracis PLF T4 - L3 PM PM PM
Iliocostalis lumborum PLF T5 - L3 PM PM PM
Rotatores PMF T1 - 1 2 PM PM
Multifidus PMF T1 - 1 2 PM PM PM
lntertransversarii thoracis PMF T1 - 1 2 PM PM
lntertransversarii lumborum PMF T 1 2 - L3 PM PM
Interspinales PMF Spinal PM
Quadratus lumborum PMF T 1 2 - L3 PM

Table 1 2.2b. M uscle d istribution assignment and nerve root of muscles that elevate and depress
the ribs
Muscles MD Nerve Root Elevation Depression
Levatores costarum brevis PMF T1 - 6 Upper ribs

Levatores costarum longi PMF T6 - 1 0 Lower 2-3 ribs

Serratus posterior superior PLF T1 - 4 Upper ribs
Serratus posterior inferior PLF T9 - 1 2 Lower 3 ribs

Muscles of Respiration
The diaphragm (AMH distribution) is obviously the most essential muscle of respiration,
and when pulled down by contraction, air is drawn into the lungs during inspiration (See
Table 1 2.2c). The external intercostals (AMF) also contract during inspiration to increase
the anterior-posterior as well as the lateral dimension of the thorax. Some individuals
develop inefficient breathing styles by employing these latter muscles to a great extent.

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Chi nese Orthopedics Thoracic Spine 308

Some pathological conditions of the lung, such as emphysema, also result in significant
development of using the external intercostals in an attempt to increase lung intake.
During deep inspiration muscles that raise the sternum and thorax when the head
is fixed, such as the sternocleidomastoid (PLF) muscles and muscles that raise the ribs
such as the scalene muscles (LF, ALH, LH) that come into play. Forceful inspiration can
also involve the pectoralis major and minor muscles which raise the ribs if the arms and
shoulders are fixed.
Normal expiration is a passive process by relaxing the diaphragm and external
intercostals. Forced expiration involves contraction of the transversus thoracis (AMH)
muscles which narrows the chest and the internal intercostals (AMF) muscles which draw
the ribs together. Forced expiration can also be assisted by contraction of the abdominal
muscles, especially involving the obliques (LF).

Table 1 2.2c. Muscle d istribution assignment and nerve root of muscles of inspiration
Muscles MD Nerve Root Inspiration Expiration
Diaphragm AMH Phrenic: Draws in air during contraction Passive expiration by relaxation
C3, 4, 5
External intercostals AMF T1-T1 1 Increases internal dimension of Passive expiration by relaxation
thorax
Internal intercostals AMF T1-T1 1 Forced expiration by drawing ribs
together
Transversus AMH T3 - 6 Forced expiration by narrowing internal
thoracis dimension of thorax

Muscles of the Abdomen

Abdominal organs are held in place and protected by the firm pressure of the abdominal
wall. It is formed by the four large flat muscles that comprise the external oblique (T7 -
T l 2), internal oblique (T7 - L l ) and transversus abdominis (LF) and the rectus abdominis
(ALF) muscles. The first three muscles wrap around the abdomen with their aponeuroses
blending together at the midline, from right and left, to form the linea alba. Of these, the
transversus is the innermost muscle with the external oblique being the outermost muscle.
The strap-like rectus abdominis muscle (ALF) extends up the length of the
abdomen with the right and left sides divided by the linea alba. It is contained between
the aponeuroses of the transversus and oblique muscles forming the rectus sheath .
Contraction of the abdominal muscles assists in expiration, urination, defecation,
vomiting, and childbirth (parturition). Bilateral contraction of the rectus abdominis
muscles cause flexion of the spine. Unilateral contraction results in bending the spine to
the side that is contracted. To a lessor extent the oblique muscles have a similar action on
the spine.

Muscles of the Back

The vertebral column is controlled by the muscles of the back (See Table 12.2). Those in
the region of the cervical spine have been previously discussed in the section pertaining
to the muscles controlling the head and neck. The remaining muscles related to the back
are distributed in the thoracic and lumbar regions. They belong mostly to the posterior

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Chinese Orthopedics Thoracic Spine 309

lateral foot (PLF) muscular distribution, especially the more superficial muscles. The
deeper back muscles generally belong to the posterior medial foot (PMF) muscular
distribution.
One problem for treatment this is that there are no neurovascular nodes for the
PMF distribution on the region of the back. However, there are nodes on the legs that
influence the deeper areas in the back, especially those muscles in the lower back region,
including nodes Zhubin (PMF 9), Fuliu (PMF 7), and Taixi (PMF 3). All the Back Shu
nodes influence both the PLF and PMF muscles di stribution routes along the back. Nodes
from Shenshu (PLF 23) and below also have influence on the muscles in the legs. These
locations represent posterior rami of the spinal nerves while the leg nodes and muscles
represent the anterior rami associated with the same or proximate segmental levels.

Neurology
Muscles of the thoracolumbar spine are innervated by posterior rami emanating from
spinal nerve root levels from Tl to L3 as noted in Table 12.2.

Problems Affecting the Trunk and Bac k

Pain is the most common complaint of patients presenting with musculoskeletal problems
of the trunk and back. Pain in the anterior trunk can be the result of strain of muscles
serving this area, be reflected pain from internal organs, or be the result of problem in the
thoracic spine. The thoracolumbar spine is subj ect to similar wear and tear as the cervical
spine resulting in degenerative changes including arthritis, spondylosis, disc prolapse and
other problems. Nerve root compression and irritation can result in radiculopathies
affecting the thoracic area or radicular pain radiating into the legs in the case of l umbar
problems.

Disorders in Muscle D istributions of Trunk

Common disorders manifested in the l ongitudinal muscular distributions (See Chapter 2)
associated with the trunk involve problems with the deeper and more anterior muscles.
This includes the diaphragm, intercostals, the obliques and abdominal muscles. These are
associated with the anterior medial hand (AMH), anterior medial foot (AMF), anterior
lateral foot (ALF) and lateral foot (LF) muscle distribution pathways. Specific symptoms
include the fol lowing:
Anterior medial hand (AMH):
•
Acute cramps and spasms along sternum and in the diaphragm
•
Severe pain that results in dypsnea affecting the region of the cardia
•
Spasms and cramps in the sides of the ribs related to the diaphragm
Anterior medial foot (AMF):
•
Stretching pain from below the umbilicus extending up through the ribs on each
side (internal intercostals)
•
Stretching pain extending from the breast around to the spine (external
intercostals)
Anterior lateral foot (ALF):

D . E. Kendall, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 3 1 0

•
Incarcerated hernia
•
Contractions and spasms of the abdomen
Lateral foot (LF):
•
Contractions and pain in the lateral abdomen and hypochondrium, extending
further upward to cause spasms in the breast and supraclavicular region.

Disorders in Upper and Lower Back Muscles

The main symptoms related to musculoskeletal disorders involving both the PLF and
PMF muscular distributions of the back include:
Posterior lateral foot (PLF) :
•
Muscular spasms and pain in the upper back, often radiating up to the neck and
head.
•
Inability to tum the upper body to the left or to the right.
•
Abnormal curvature in the back due to contraction of the superficial muscles,
resulting in the inability to bend forward.
•
Abnormal lateral curvature in the back due to contraction of the muscles on one
side, resulting in scoliosis.
•
Low back pain, possibly radiating down one or both legs.
Posterior medial foot (PMF):
•
Acute cramps and pain in the muscles of the upper back and nape of neck.
•
Contraction of deeper muscles in the back with inability to bend backwards.
•
Low back pain, possibly radiating down one or both legs.

Pathology Affecting Thoracic Spine

Presently, thoracic and chest pain are the chief complaints related to the thoracic spine
and are a common cause of disability. These can result from degenerative changes
affecting all the joints of thoracic spine, hypomobility conditions, and muscular lesions.
Intervertebral disc lesions are not common in the thoracic spine. Similar symptoms may
arise from either visceral or musculoskeletal disorders. Sometimes visceral disease
produces symptoms that mimic musculoskeletal problems, such as angina, leading an
incorrect diagnosis and treatment. It i s important to make certain that chest pain is not
due to heart, lung or mediastinal structures. Visceral diseases are presently not addressed.
Thoracic pain is usually felt on either side of the spine, possibly radiating out
several inches along the chest wall or be localized to one side of the spine. It may also be
felt more diffusely over several thoracic intervertebral levels.
Thoracic Intervertebral-Disc Lesions
Intervertebral disc lesions are uncommon in the thoracic spine, probably because the
discs are relatively thin and because of reduced mobility as result of the splinting action
of the ribs.

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Chinese Orthopedics Thoracic Spine 3 1 1

Disc Prolapse
Prolapse of a thoracic intervertebral disc is relatively uncommon with the problem
more likely to occur between T l l and T l 2 . Clinical manifestations include local back
pain and radicular pain which may fol low along the intercostal space of the rib at the
affected level. Prolapse at the T 1 1 - 1 2 disc may show signs of spinal cord compression
with upper motor neuron lesion, sensory loss, and bladder symptoms.
Senile Kyphosis
This condition occurs in older people of either gender involving severe
degeneration of the mid-thoracic intervertebral discs. The condition produces the
common feature of patients having rounded shoulder with a forward carriage of the head.
X-ray findings show involvement of the anterior part of these discs indicating a loss of
disc space. This condition is typically asymptomatic although patients can present with
significant pain. Often aching pain has been present for many years that disturbs sleep
and is worse with activity.
Localized Degenerative Disc Lesions
These are also relatively rare with a higher incidence in people who are involved
in activities of repeated thoracic rotation, such as with professional golfers. Radicular
signs may be present indicating possible nerve root involvement. Pain radiates around the
chest wall following the rib which may also be associated with numbness or paresthesia
over the same area. Pain is often worse by lying down or by movement.
Thoracic Hypomobility Syndromes
Hypomobility conditions of the thoracic spine may present with pain in the chest wall, or
pain which radiates around the chest, or is felt to pass through from the back. The pain
may also occur only as pain in the chest wall without any pain in the back.
C hest Pain
Chest pain can have a sudden onset and may be severe at times. When aggravated
by activities or breathing it is difficult to differentiate from possible visceral disease.
Visceral referred pain may be found anywhere around the chest wall but the most
common site is anteriorly over the costochondral area. Since pain in this region may also
be caused by local lesions in the costochondral j unctions, it is difficult to differentiate the
cause of the patient' s symptoms. Pain that does arise from hypomobility syndrome may
indicate a localized area of tenderness and pain in the costochondral region which may
also be referred pain.
T4 Syndrome
This condition refers to symptoms involving a hypomobility lesion at the T4
level. Patient often manifests with arm pain or a vague discomfort in the arm with
possible paresthesia that does not follow the dermatome pattern. There also may be
diffuse posterior neck pain. Hypomobility at the T3 - 4, T4 - 5, and T5 - 6 level is the
only positive finding which is relieved by needling therapy, manipulation, or
mobilization techniques.
Lower Cervical Spine
Pain referred from the cervical spine is typically experienced above or between
the scapulae. However, this pain may be felt over the upper anterior chest wall which is
episodic or brought on by exertion, making it difficult to distinguish from angina.

D.E. Kendall, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 3 1 2

Thoracic joints
Sternoclavicular Joint
Pain from the sternoclavicular joint can be referred into the upper costochondral
area. This may be the result of an inflammatory synovitis due rheumatoid arthritis or
spondyloarthritis that results in degenerative changes in this joint.
Manubriosternal Joint
The manubriosternal joint is generally classified as a cartilaginous joint although
about 3 0% of the population has a synovial cavity present. Spondyloarthritis and
rheumatoid arthritis can result in inflammatory lesions in this joint. Most common
problem is ankylosing spondylitis along with bony sclerosis and joint erosion eventually
leading to bony fusion.
Costovertebral Joint
These may be involved in inflammatory or degenerative joint disease with
patients complaining of pain in this region. This condition develops early in ankylosing
spondylitis due to synovitis. Examination may reveal local tenderness along with
reduction in chest expansion. Measurement of chest expansion can be used to assess the
progress of this disease.
Degenerative changes may also occur starting in the forth decade which are
usually asymptomatic and only found by chance on x-rays. Symptoms of localized
tenderness and pain may only occur after some type of local trauma.
Costochondral Joints
The seven upper ribs articulate anteriorly with the sternum through their costal
cartilages. The junction (costochondral) between the ribs and the costal cartilages form a
fibrocartilaginous joint where the cartilage and rib are slotted together. These costal
cartilages (except for the first rib) also articulate with the sternum by means of a synovial
sternocostal joint. Ribs 8, 9, and 1 0 articulate through their costal cartilage with the rib
above it, but the last two ribs ( 1 1 and 1 2) are not attached.
Pain in the upper costochondral area may be referred, post traumatic, due to
polyarthritis, or be due to a rare disorder called Tietze's syndrome. Pain referred from
thoracic or cervical spinal lesions is perhaps the most common cause of upper
costochondral pain, as previously described. Pain in the synovial sternocostal joint may
be produced by spondyloarthritis or rheumatoid arthritis. Pain commonly associated with
one or two prominent costochondral joints may occur after local trauma or a burst of
coughing. This condition, sometimes confused with Tietze 's syndrome, may be
associated with thoracic hypomobility syndrome.
Pain may also manifest in the lower costochondral area associated with ribs 8, 9,
and 1 0 commonly due to traumatic lesions, but can also be referred from lesions in the
thoracic spine. The first situation may result from a direct or indirect trauma and can
produce a painful clicking of costochondral junction. This condition is referred to as a
clicking or slipping rib which produces sharp stabbing or aching pain which is made
worse on movement but can also occur at rest.
Xiphoid P rocess
Pain in the xiphoid is usually post traumatic but can be the result arthritis

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 Chinese Orthopedics Thoracic Spine 3 1 3

Scapulothoracic Joint {See Chapter 9)

Muscular Lesions
M uscle I nj u ry
Chest wall muscle inj uries are not common but can involve the serratus anterior
(MH), intercostal muscles (AMF), or the musculotendinous origins of the abdominal
muscles (ALF, LF). These problems may be induced by exercise or by attacks of violent
coughing.
One commonly occurring problem involves a periodic episode of a sudden,
disabling, sharp, and cramping l ike muscular pain in the anterior chest wall. This
condition often follows a sudden movement of the thorax or setting on a soft couch or
chair. The cause and mechanism is not understood but may be the result of a mechanical
derangement of a costal joint or perhaps a facet joint.
Postural Pai n
Muscular pain can also develop without any particular underlying lesion o f the
cervical and thoracolumbar joints which is basically due to postural changes. Patient is
likely to be a female and middle aged, although with the computer age, young to middle
aged males are involved in keyboard activities while staring at poorly placed monitors.
Stiffuess and tenderness in shoulder girdle and thoracic muscles is a common complaint.
The condition often becomes worse as the day progresses and the patient is aware that the
pain is possibly related to their postural activities. These include sitting for prolonged
periods, typing or other types of repetitive or continuous work. Pain may be aggravated
by work demands, fatigue, emotional stress, workplace environment such as temperature,
and even weather changes.

Assessment of Thoracolum bar Spine

Assessment of thorax and thoracic spine also involves movement of the lumbar spine. If
the patient history, observation, or examination indicates possible symptoms reflecting
into or from the neck, upper limb, lumber spine, or lower limb, these structures must
necessarily be examined as well.

Observation
Typically, the patient needs to be suitably undressed so the spine and other features can
be viewed for possible alignment abnormalities. The body is viewed anteriorly and
posteriorly in the standing position and seated. The vertical alignment of the spinal
column is examined to detect possible curvatures, listing, or twisting, and possible
scoliosis. A weighted plume line can be used. The body is also viewed from the lateral
aspect to assess cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis
(See Figure 1 .2). Any misalignments are noted for the entire body including the position
of head being forward or backward of normal, thoracic spine, lumbar spine, pelvis, hip
joint, knee j oint, ankle j oint, amount patient is listing to right or left, and the length from
both the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS) to
the floor.
Position of the scapula is also noted. The scapular spine is normally at the level of
the T3 spinous process while the inferior angle is level with the T7 spinous process.

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Ch inese Orthopedics Thoracic Spine 3 1 4

Medial border of the scapula should be about 5 em lateral to the spinous process and be
parallel to the spine.
Kyphosis
Normally this term applies to the forward primary curvature of thoracic spine but is
consider a problem when the curvature results in misalignment of the body with resulting
functional and pain problems. Some individuals have congenital thoracic kyphosis and
other deformities of the spine including scoliosis. Kyphosis comes about by degeneration
of the thoracic vertebrae that is often accentuated by aging. Some conditions are referred
to as senile kyphosis. These conditions can manifest with a rounded back and decreased
pelvic tilt, a sharp angulation or hump back called "gibbus" or a dowager' s hump seen in
elderly women.
Scoliosis
Scoliosis is a deformity where there are one or more lateral curves in the thoracic or
lumbar curve. In the cervical spine it referred to as "torticollis" (twisted neck). The
curvature can occur in the thoracolumbar, thoracic, or lumbar spine. Idiopathic scoliosis
often occurs in young women and may be due to poor posture, problems in coordination
and proprioception, osteoporosis, nerve root irritation, inflammation in the spinal area,
diet, leg length discrepancies, or hip contractures, and possible contractures of other
muscles. Congenital scoliosis can be the result of structural conditions due to failure of
vertebral segmentation, wedge vertebra, or hemivertebra.
Breathing
It is important to determine in what manner is the patient breathing. Problems in the
thoracic and chest area can have an influence on breathing while poor breathing habits
may have an effect as well. Lack of diaphragmatic breathing may result in problems in
the in ribs, thoracic spine, and chest area. Children typically breathe abdominally while
women may tend to breathe by using the upper thorax. Men may tend to be upper and
lower thoracic breathers while in the elderly breathing may be in the abdominal and
lower thoracic regions. Many trained athletes also have poor breathing habits that limit
their performance. Examiner must note the rate, rhythm, and quality of breathing, and the
effort to inhale and exhale. Any signs of rough breathing or cough should be noted since
this may aggravate tissues and structures involved in breathing and aggravate painful
conditions.
Chest Abnormalities
There are certain abnormalities in the shape of the chest such as pigeon chest (pectus
carinatum) where the sternum projects outward and downward. This increases the
anteroposterior dimension of the chest but impairs breathing by restricting overall
ventilation volume. Another chest deformity results in the sternum being displace
posteriorly due to overgrowth of the ribs. This condition is known as a funnel chest
(pectus excavatum) and decreases the anteroposterior chest dimension and may displace
the heart. In this condition the sternum is depressed on inspiration affecting respiration
and can lead to kyphosis. The barrel chest is another deformity that proj ects the sternum
forward and upward thereby increasing the anteroposterior diameter. This condition is
seen in conditions like emphysema.

D . E. Kendall, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 3 1 5

Active Movements of Trunk

Most active movements of the thoracolwnbar spine are conducted with the patient
standing, although some can be conducted in the seated position to eliminate contribution
from the hip. As with all other movement assessment, the most painful movements are
conducted last. Movement of the thoracic region is normally limited by the rib cage and
the long spinous processes of the thoracic spine. If problems are possibly indicated above
or below the thoracic spine, then scanning examinations should be considered for the
cervical spine and upper limb or the lumbar spine and lower limb.
Costovertebral Expansion
Movement of the costovertebral joints is determined by measuring chest expansion. A
tape measure is placed around the patient's chest starting at the level of the 4th intercostal
space on the back. The patient is then instructed to exhale as much as possible and hold it
while the examiner take a measurement. The patient is then instructed to inhale as much
as possible and hold it while the examiner takes a second measurement. Normal
difference between exhalation and inhalation is 3 to 7.5 em.
An alternate method is to measure exhalation and inhalation at three different
positions on the chest. The tape measure is placed around the chest just below the axilla
in the first position. The second measurement is taken at the nipple line or xiphysternal
junction for midline expansion, and the third measurement at the level of the 1 oth rib.
Care must be taken that the levels where the measurements are taken in consistent.
After completion of chest expansion measurements, the patient may be asked to
cough to see if this produces pain, which could indicate possible respiratory problems.
Trunk Flexion
The examiner must be sure to note whether trunk flexion occurs in the spine or the hips.
Some individuals can touch the toes with a rigid spine if there is sufficient range of
motion in the hip joints. On the other hand, tight hamstrings may limit forward flexion.
Thoracolumbar Flexion
From the standing position, with feet a shoulder width apart, the patient is
instructed to gradually forward flex the body with both arms hanging down to the side
relaxed while the examiner stabilizes the pelvis to prevent anterior pelvic tilting. End of
motion occurs when resistance to further flexion occurs and examiner feels the pelvis
starting to tip anteriorly. Normal end feel is firm and assessed by pushing down on C7 -
Tl area.
Flexion range of motion is determined with the end of a tape measure held at the
S 1 spinous process and the other end at C7. As the patient forward flexes the end of the
tape at C7 is allowed move while remaining on the C7 location. Normal of motion is
about 1 0 em.
Flexion is also measured by using two inclinometers adjusted to zero with one
placed on the midsacrum and the other on C7. Total angle for forward flexion is the
difference between the two readings (60°).
Forward flexion of the thoracolumbar spine is also evaluated in terms of the
distance from the tip of the third finger to the floor. This measurement results in

D . E . Kenda ll, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 3 1 6

differences to due body size. One approach i s to measure the distance of the third finger
from the floor from the standing position before forward flexion of the body. Range
forward flexion is then assessed by measuring the distance from the tip of the middle
finger to the floor. Can measure distance for both hands.
Lumbar Flexion
Amount of total thoracolumbar forward flexion contributed by the lumbar spine is
measured from the center of line (or dot) at drawn at the level of the PSIS on each side.
Another line (or dot) is then marked across the spine measured 1 5 em above the lower
line. The tape measure is held on the upper line as the patient gradually flexes the
forward as before. The tape measure is allowed to play out from the lower line to
completion of forward flexion. Lumbar forward flexion is determined by subtracting 1 5
from the total measurement. This technique is a further modification of the Schober Test
which uses a 1 0 em starting separation. Lumbar forward flexion with this modified
method is approximately 7 em in males and 6 em in women.
Lumbar flexion is also measured by using two inclinometers adjusted to zero with
one placed on over the spinous process of T 1 2 and the other placed over the midsacrum.
The thin dimension of the goniometers is aligned with the spine. Total angle for forward
flexion is the difference between the two readings.
Trunk Extension
Extension or backward bending of thoracolumbar spine occur over twelve vertebrae with
a total angle of25 to 45°. In extension it is difficult visually detect movement between
individual vertebrae.
Thoracol umbar Extension
From the standing position, with feet a shoulder width apart, the patient is
instructed to gradually lean backwards to extend the body. Both arms are allowed to
move forward or be placed on the hips while the examiner stabilizes the pelvis to prevent
posterior pelvic tilting. End of motion occurs when resistance to further extension occurs
and examiner feels the pelvis starting to tip posteriorly. Normal end feel is firm. As is
done in forward flexion, a tape measurement between S 1 and C7 is made before
extension movement is conducted. The starting measurement is noted before backward
extending the body and the second is noted at full extension. Difference between the two
measurements is about 2.5 em.
Lumbar Extension
Amount of total thoracolumbar extension contributed by the lumbar spine is
measured from the center of line (or dot) at drawn at the level of the PSIS on each side.
Another line (or dot) is then marked across the spine measured 1 5 em above the lower
line. The tape measure is held on the upper line as the patient graduall y extends backward
in thoracolumbar extension. The tape measure is allowed move below the lower reference
point to completion of extension. Lumbar backward extension is determined by
subtracting the measured value from 1 5 . Total lumbar extension may be approximately
1 .6 em.

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 Chinese Orthopedics Thoracic Spine 3 1 7

Thoracolumbar Spine Lateral Flexion

Lateral flexion of the thoracolumbar spine ranges from 1 8 to 38° by using a goniometer
and from 5 to 7 em using a tape measure. The patient is standing with feet apart and the
cervical, thoracic and lumbar spine in 0° of flexion, extension, and rotation. The
examiner places both hands on the patient' s pelvis to prevent lateral pelvic tilting. The
patient then gradually bends the trunk to one side while the arms hang relaxed at the
sides. End of lateral motion occurs when the heel on the opposite side starts to lift and the
pelvis starts to tilt laterally. Normal end feel is firm or firm/soft.
If a goniometer is used it needs to have sufficiently long arms. A skin marking
pencil can be used to mark the spinous process of C7 and S I . The fulcrum of the
goniometer is centered on the spinous process of S 1 . The goniometer arms are
perpendicular to the floor and in line with the spine with the upper arm pointing to the C7
spinous process. The upper arm is moved to be pointing at C7 through the range of
motion while the lower arm is held perpendicular to the floor.
Lateral flexion can be measured with dual inclinometers with one placed flat
against the body with the base at the spinous process of S 1 with the other placed on the
spinous process of T l with its base held parallel to the floor. Both inclinometers are
zeroed out before lateral flexion begins. The total angular measurement of lateral flexion
is determined by subtracting the smallest number measured at S 1 from the largest
number.
Lateral flexion can also be assessed by using a tape measure to determine the
distance of the middle finger to the floor in the standing position and measured again in
full lateral flexion. Difference between the two measurements i s recorded as the value for
lateral flexion.
Trunk Rotation
Thoracolumbar rotation normally takes place in the transverse plane around a vertical
axis, usually with the patient seated. However, it can also be measured in the frontal
plane about the horizontal axis using dual inclinometers with the patient bending over.
Patient is seated on a low stool with feet on the floor for stabilization with the
cervical, thoracic, and lumbar spine at zero degrees of flexion, extension, lateral flexion,
and rotation. Examiner stabilizes the patient's pelvis to prevent rotation while the patient
avoids moving in flexion, extension, and lateral flexion of the spine. Patient is instructed
to gradually rotate to the left or right (measurement is made for both directions of
rotation). End of motion occurs when the patient' s pelvis starts to rotate. Normal end feel
is firm.
Thoracolumbar rotation can be measured with a universal goniometer with the
fulcrum center placed over the superior aspect of the head with the goniometer arms
parallel to an imaginary line between the two acromion processes. The acromion
processes need to be aligned with an imaginary line between the two i liac crests. The
fixed arm of the goniometer remains aligned with the iliac crests while the movable
follows the reference location on the acromion process of the side being rotated. Care is
taken to make certain the patient does not substitute shoulder retraction to increase
apparent rotation. Rotation can be in the range of 30 to 45°.

D . E. Kendall, OMD, Ph.D. ©2005-2009

Chinese Orthopedics Thoracic Spine 3 1 8

A skin marking pencil i s used to place a mark over S 1 and C7. The patient is
placed in forward flexion in the standing position such that the back is reasonably parallel
to the floor. One inclinometer is placed vertically over S 1 and the other over C7 with the
long axis of the inclinometer perpendicular to the spine. Both inclinometers are zeroed
out before the patient gradually rotates the thoracolumbar spine to the right or left. Total
rotational angle determine by subtracting the value obtained at S 1 from that obtained at
C7.

Passive Movements of Thoracic Spine

Passive movements of the thoracic spine intervertebral joints are tested at each joint level.
Movement is felt between adjacent spinous processes. Flexion-extension, lateral flexion,
and rotation are tested separately in the upper (C5 - T3) and lower (T3 - Ti l ) thoracic
vertebrae.
C5 - T3 Flexion-Extension, Side Flexion, and Rotation
This test is performed with the patient seated with the examiner standing to one side
placing the left hand just above the forehead to move the patient's head into flexion and
extension. The fingers of the examiner' s right hand are used to palpate over and between
the spinous processes of the lower cervical and upper thoracic (C5 - T3) spines.
Intervertebral movement is detected by the middle fmger of the examiner's right hand on
the spinous process while the index and ring fingers on either side of it between the
spinous processes of two adjacent vertebrae. The quality of passive movement is assessed
by examiner including if it hypomobile or hypermobile relative to adjacent vertebrae.
Degree of hypomobility or hypermobility may indicate possible pathology.
Assessment of rotation and side flexion passive movement for the lower cervical
and upper thoracic (C5 - T3) spines is performed as discussed above. The examiner
moves the patient ' s head into rotation or side flexion in both directions. During side
flexion the examiner using the thumb and index finger placed on each side of the spine to
palpate on the lateral aspect of the intervertebral space. During rotation intervertebral
movement is detected by the middle finger of the examiner's right hand on the spinous
process while the index and ring fingers on either side of it between the spinous processes
of two adj acent vertebrae. The degree and quality of left and right rotation and side
flexion movement are compared at each level.
T3 - T1 1 Flexion and Extension
These tests are performed with the patient seated with his or her hands clasped behind the
head. Standing to the left side, the examiner places his or her left arm under the patient's
left arm to grasp the patient' s elbows. The examiner's right hand is placed across the
spine just below the level being tested. The pad of the middle finger tip is placed in the
far side of the interspinous space to palpate between adjacent spinous processes.
Flexion is produced by lowering the trunk from the neutral position by pushing
down on the elbows until movement can be detected under the right middle fmger. The
patient is returned to neutral position by lifting under the elbows. An oscillatory
movement can be produced through an arc of approximately 20°.
Extension is produced in a similar way by the examiner assisting in trunk
extension with the left arm while the heel and ulnar border of the right hand is used

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Chinese Orthoped ics Thoracic Spine 3 1 9

steady the back. Simultaneously, the pad of the middle finger is placed between adjacent
spinous processes to assess movement. Movement at one j oint is evaluated at a time,
thus, large trunk movements into extension is unnecessary.
T3 - T1 1 Lateral Flexion and Rotation
These tests are performed with the patient seated with his or her hands clasped behind the
head. Standing to the left side, the examiner places one arm around and over the patient's
elbows to grasp the right shoulder while the heel of the right hand is placed on the left
side of the patient's back. The pad of the flexed middle finger placed in the far side (right
side) of the interspinous space of the joint being tested. The examiner then firmly holds
across the patient's elbows and laterally flexes the patient's trunk pulling on the right
shoulder toward the examiner while pressing downward with the heel of the right hand
while lifting up with the left hand. The examiner can also press down on the patient's left
shoulder with his or her axilla. The examiner's position can be reversed to assess passive
lateral flexion to the right.
In passive rotation the examiner holds the patient in the same configuration as
noted above for lateral flexion. The examiner rotates the patient's shoulders to the right
or left by alternately pulling forward and pushing backward on the right shoulder. The
patient's trunk is gently rotated back and forth through an arc of about 25° by the
examiner's left hand and forearm. The intervertebral space being tested is palpated using
the pad and the middle finger. Examiner compares the degree and quality of movement of
each spinal segment. Movement in rotation of the upper spinous process is felt like a
pressure against the pad of the upward directed middle finger.

Resistive Isometric Thoracolumbar Movements

Resistive isometric movement of the trunk evaluates the strength of the muscles moving
the thoracolumbar spine. Since the thoracolumbar spine functions as an integrated
structure these tests are common to assessing problems either associated with the thoracic
spine or lumbar spine. These tests measure isometric resistance in forward flexion,
extension, side flexion, and rotation with the patient seated.
The presence of pain may restrict movement in many cases and testing is only
conducted up to the point of pain. In some situations, especially involving intervertebral
disc lesions, certain tests are contraindicated. With respect to extension, the prone push­
up can be performed as a screening test to ensure the safety in conducting the resisted
extension test.
� Prone press-up: the production of loca l ized pain over the spine as result of
extending the back by pressing u p with the elbows from the prone position
indicates that the pain is centralized and further back activities i n extension are
ind icated. If the push-up causes pain to radiate to the lower limbs, then further
extension activities are contra indicated.

The thoracic spine should be in neutral position and the most painful movements
are to be done last. With the patient seated and the examiner standing to one side with
one leg pressed behind the patient' s buttocks, the examiner places both arms around the
patient' s upper chest and back. The examiner then instructs the patient, "Don't let me
move you" as the examiner applies a force opposite to direction being isometrically

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Chinese Orthopedics Thoracic Spine 320

tested (i.e. force directed toward extension to test isometric forward flexion) for all of the
following motions:
• Forward flexion
• Extension
• Side flexion left and right
• Rotation left and right

Resistive Isometric Thoracolumbar Specific Movements

These series of isometric movements of the trunk test for the same conditions noted in the
preceding tests. These tests are conducted for the individual groups of muscles moving
the thoracolumbar spine in the range of full to eliminated gravity to obtain a grade of 0 to
5 (See Table 4.3). The presence of pain may restrict movement in many cases and testing
is only conducted up to the point of pain. In some situations, especially involving
intervertebral disc lesions, certain tests are contraindicated. With respect to extension, the
prone push-up can be performed as a screening test to ensure the safety in conducting
extension tests, as noted above.
Trunk Flexion: Rectus Abdominis
The primary muscle involved in testing trunk flexion in the supine position is the rectus
abdominis muscle. Muscle acting accessory to assist trunk flexion include the iliopsoas,
rectus femoris, internal abdominal oblique, and external abdominal oblique muscles.
Trunk flexion is performed from the supine position with knees and hips flexed so
that the patient's feet are flat on the examination table. The patient attempts to perform a
setup from the start position. The initial phase of the setup, from lying flat to about 45°, is
the result of contracting the rectus abdominis muscles and no stabilization is provided.
The last 45° of movement from the midpoint to the full setup position involves the
iliopsoas muscle. Here, the examiner provides stabilization by holding the patient's feet
down so that the hip flexors have a fixed reference.
During testing, the examiner palpates the rectus abdominis muscles lateral to the
midline on the anterior abdominal wall midway between the sternum and the pubis for
possible contractions.
Screen position (grade 3)
From the start position the patient posteriorly tilts the pelvis to flex the lumbar
spine, then flexes the cervical spine, flexes the thoracic spine and holds his or her arms
out in front of the trunk. The patient then slowly performs a setup by moving the thorax
toward the thighs by first contracting the rectus abdominis muscle and then flexing the
hip to obtain the full setup position. The examiner stabilizes the patient's feet during hip
flexion. Successful completion of the screening test requires testing for grades 4 and 5,
while failure requires assessment of a possible grade 0 2 condition.
-

-+ Patient m a y attempt to substitute hip flexor contractions (lumbar lordosis) to flex

the trunk.

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Chinese Orthopedics Thoracic Spine 32 1

Grades 4 - 5
Both grade 4 and 5 tests are similar to the screening test, except the resistance is
increased by changing the position of the arms. For a grade 4 assessment the patient
slowly performs the setup while holding his or her arms folded across the chest. In the
case of the grade 5 assessment, the patient's hands, with fingers interlocked, are placed on
top of the head to increase the resistance load.
Grades 0 - 2
Failure to perform the grade 3 screening test requires further examination to
determine the appropriate strength level. The patient remains in the start position, lying
supine with knees and hips flexed with his or her feet flat on the examination table. For a
grade 0 condition, the patient attempts to posteriorly tilt the pelvis but no is possible and
no palpable contractions are evident. For a grade 1 condition, no movement is possible
when attempting to tilt the pelvis and a flicker of muscle contraction may be apparent
when the patient attempts to lift the head off the table.
Trunk Rotation: Abdominal Obliques
The external and internal abdominal oblique muscles are mainly involved in rotating the
trunk. Other muscles operating accessory to trunk rotation include the rectus abdominis,
semispinalis thoracis, multifidus, rotatores, and latissimus dorsi. Trunk rotation is tested
against gravity and with gravity eliminated.
The start position is the same as testing the rectus abdominis muscles with the
patient lying supine with knees and hips flexed with his or her feet flat on the
examination table. The patient performs a setup, but in this situation the trunk is rotated
either to the left or right. During the last 45° of movement from the midpoint to the full
setup position the examiner provides stabilization by holding the patient's feet down.
When the trunk is rotated to the left, the right external abdominal oblique and left
internal abdominal oblique muscles are contracted. Conversely, when the trunk is rotated
to the right, the left external abdominal oblique and right internal abdominal oblique
muscles are contracted. The position of the arms is varied, as in the case of testing the
rectus abdominis muscle, to provide different level s of resistance. Gravity-eliminated
testing of trunk rotation is performed from the seated position.
During testing, the examiner palpates the external abdominal oblique at the lower
edge of the rib cage, and the internal abdominal oblique above and medial to the ASIS for
possible contractions.
Against g ravity
For the initial screening test (grade 3 ), the patient slowly performs a setup while
the trunk is rotated either to the left or right while the arms are extended straight out
toward the thighs. The test is then repeated while the trunk is rotated to the opposite
direction from the first test. Successful completion is graded as 3, and further
exclamation is conducted to determine if strength grades are higher.
The same test is conducted for a possible grade 4 or 5 and each is repeated with
the trunk rotated to both right and left. The grade 4 test is performed with the patient
holding his or her arms folded across the chest to provide additional resistance.
Successful completion of grade 4 then requires testing for grade 5. In this case the test is

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Chinese Orthopedics Thoracic Spine 322

repeated while the patient clasps his or her hands over the top of the head to increase the
resistance load.
Gravity-Eliminated
Trunk rotation with gravity-eliminated is performed i f the grade 3 screening test
cannot be successfully completed. The patient is seated to stabilize the pelvis and his or
her hands are held o ff the table and the feet are supported by a stool or other means. The
patient attempts to rotate the thorax with slight flexion. Rotation to the left tests the right
external abdominal oblique and left internal abdominal oblique muscles. Rotation to the
right tests the opposite configuration.
Ability to rotate the thorax to full range of motion while confirming contraction of
the abdominal oblique muscles is given a grade 2 score. Accessory muscles may be able
to produce some rotation in the presence of weak abdominal oblique muscles. Thus, no
rotation of the thorax or impaired rotation with flicker contraction of the abdominal
obliques is assigned a grade 1 score. Inability to rotate the thorax or impaired rotation
along with no palpable contraction of the abdominal obliques results in a grade 0
assessment.
Deviation of the umbilicus during testing can also provide information in the
situation of marked weakness of the abdominal muscles. Normally the umbilicus is
pulled toward the stronger muscles and away from the weaker muscles. The umbilicus
can deviate toward a muscle that is shortened or being stretched. Muscle palpation is used
to confirm possible deviation of the umbilicus due to muscle impairment.
Trunk Extension: Erector Spinae
Extension of the trunk mainly involves the spinae erector muscles which include the
iliocostalis thoracis and lumborum, longissimus thoracis, spinalis thoracis, semispinalis
thoracis, and multifidus. Accessory muscles to extension include the interspinales,
latissimus dorsi, and the quadratus lumborum.
Neck and hip extensors are tested prior to trunk extension. If neck extensors are
found to be weak, the head must be supported during trunk extension testing. If hip
extensors are weak or paralyzed, the pelvis cannot be adequately fixed and trunk
extension therefore may not be testable. The trunk extensors are tested as a group in the
against gravity configuration.
Screen position (grade 3)
In this test configuration, the patient lies prone with a pillow under the abdomen
and feet over the end of the examination table. The pelvis is stabilized with a strap around
the table while the examiner stabilizes the legs proximal to the ankles. The patient holds
his or her hands behind the back positioned over the pelvis and extends the trunk to lift
the head and sternum to where the xiphoid is off the table. Ability to hold this position i s
graded as 3 , after which further testing is performed to determine if the strength is either
grade 4 or 5 . No manual resistance is applied by the examiner and the amount of
extension and the position of the hands are varied to increase the load for grade 4 and 5
assessment.

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 Chinese Orthopedics Thoracic Spine 323

Grades 4 - 5
Testing trunk extension for grades 4 or 5 uses the same position as the screening
test above. But here, the patient extends the trunk further, lifting the head higher off the
table, while the hands are held over the lumbar region for grade 4 results. The same test is
conducted for grade 5 score except the hands are clasped behind the head to increase the
resistance.
Grades 0 - 2
Failure to successfully perform the screening test then requires determining
whether the condition is either a grade 0, 1 , or 2. For the grade 2 assessment, the patient
is in the same test configuration except the arms are placed at the sides and the patient
extends the trunk to the point where the upper sternum is off the table. There is no
movement possible for a grade 2 condition, but possible muscle contractions may be
palpated as the patient attempts to lift his or her head. In the case of a grade 0 condition,
there are no observable or palpable muscle contractions or flickers.
Pelvic Elevation: Quadratus Lumborum
Pelvic elevation is the function of the quadratus lumborum which is tested in the gravity­
eliminated position, with and without resistance. Accessory muscles to this movement are
the latissimus dorsi, contralateral hip abductors, internal abdominal obliques, and external
abdominal oblique muscles.
Pelvic elevation is tested with the patient lying prone with his or her feet off the
end of the table. The patient is stabilized on the table by the weight of the trunk and he or
she can hold the edges of the examination table. The examiner palpates above the iliac
crest, lateral to the paravertebral extensor muscle mass.
Gravity-eliminated
In this test the hip on tested side is held in slight abduction and extension, with the
patient's leg supported by the examiner. The patient then elevates the pelvis by moving
the iliac crest toward the ribs while the examiner palpates the quadratus lumbar on the
tested side. The test is then repeated to assess the other side.
-+ The patient m a y contract the lateral fibers of the external abdom inal obli q ue and
internal a bdominal obli q ue, l atissimus dorsi, and erector spinae muscles to
com pe nsate for weak q uadratus l u m boru m .

Resisted gravity-eliminated
The test configuration is identical to the gravity-eliminated quadratus lumborum
test above. Resistance is applied at the anterior aspect of the femur distal end. If hip
pathology is present, resistance can be applied on the posterolateral aspect of the iliac
crest.
As a screening test (grade 3), a traction resistance force about equal to the weight
of the leg is applied to the femur. Additional resistance is applied to obtain either a grade
4 or 5 assessment.

Functional Assessment
The thoracic spine plays a key stabilization role during many specific activities. Hence,
those activities involving the cervical spine, shoulder, and lumbar spine may be i mpaired
by thoracic spine lesions. Functional activities involving these three areas can be

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Chinese Orthopedics Thoracic Spine 324

considered if functional impairment seems related to the thoracic spine. Heavy work and
activities such as lifting and rotating the thorax are likely to provoke thoracic symptoms

Joint Play (Accessory) Movements

Thoracic Spine
Passive accessory movement can be produced by application of thumb pressure to the
spinous and transverse processes o f the thoracic vertebra. The spinous processes are
tested using posteroanterior and transverse pressures, which may be varied by angling the
direction of the pressure either toward the head or feet. This is then fol lowed by
posteroanterior pressures against the transverse processes.
Accessory movements of the thoracic spine are similar to those previously
described for the cervical spine in Chapter 7 and are essentially the same as mobi lization
techniques described under Mobilization. When these are used to examine accessory
movement, the characteristics of end-feel, j oint mobility and reproduction of symptoms
are the parameters being evaluated. Mobilization techniques are used for treatment.
Costovertebral Joints
Oscillatory posteroanterior pressures are used to test the costovertebral and intercostal
movement. Thumb pressure is applied over the angle of the rib. This may be varied by
angling the direction of the pressure either toward the head or feet, to attempt to
reproduce the patient's pain.

Special Tests
If there is suspicion of a thoracic spine problem related to spinal cord movement tests that
stretch the cord can be considered including a range of straight leg raising tests including
Lasegue's sign and Kemig ' s sign. The spinal cord can be stretched either by neck flexion
from above or straight leg raising from below. Any of these tests, including the
following, should be performed only if the examiner considers they are relevant to the
case being evaluated.
Slump Test (Sitting Dural Stretch)
The patient is seated on the examination table with legs hanging over edge, and is asked
to "slump" the upper body causing the spine to flex and the shoulders to sag forward. The
examiner then passively flexes the patient' s neck and then passively extends the patient's
knee starting with the unaffected side first. Passive ankle dorsiflexion may be added to
provide more tension on the spinal dura from below. If no symptoms are provoked the
first leg is allowed to relax while passive knee extension and possibly ankle dorsiflexion
are performed on the other leg. The test is classified positive if production of the patient' s
pain o r other symptoms i s reproduced. This implicates impingement o f the dura and
spinal cord or nerve root. Pain is usually produced at the site of the lesion.
Passive Scapular Approximation
With the patient lying prone the examiner passively approximates the scapulae by
moving the shoulder up and back. Pain provoked in the scapular area indicates possible
lesion of a Tl or T2 nerve root on the same side that the pain is being experienced.

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Chinese Orthopedics Thoracic Spine 325

First Thoracic Nerve Root Stretch

This test is performed by the patient first abducting the arm to 90° and then flexing the
pronated forearm to 90° which should not provoke any symptoms. The patient then fully
flexes the elbow, putting the hand behind the neck. Thi s action stretches the ulnar nerve
and the T 1 nerve root. Provoked pain into the scapular area or arm is considered a
positive test.

Neurological Evaluation of Thoracic Spine

Myotomes (graded 0 - 5)
There are no convenient tests for muscles related to specific thoracic spinal nerves.
Possible intervertebral disc prolapse in the thoracic spine and other conditions can
potential result in pressure on the spinal cord to affect the upper motor neurons supplying
the muscles of the hip and legs. Therefore, when thoracic problems involve suspected
disc problems or if there is weakness, pain or dysfunction also noted in either the regions
of the lumbar, hip or lower extremities, testing of these areas should be considered.
Isometric tests to isolate specific spinal nerve roots supplying the lower back and
extremities to be considered in conjunction with assessing the thoracic spine include:
•
L2 : I liopsoas muscle - hip flexion
•
L3 : Quadriceps muscle - knee extension
•
L4: Tibialis anterior muscle - ankle dorsiflexion and inversion
•
L 5 : Extensor halluc is longus muscle - extension of big toe
•
S l , 2 : Gastrocnemius and soleus muscles - plantar flexion
Key Reflexes (graded 0 - 4)
There are no single myotome reflexes to isolate a problem to a specific spinal root. But in
the case where a thoracic problem has resulted in pressure applied against the spinal cord,
upper motor neurons to the lower part of the body may be affected. If this is the case,
then reflexes tested in the lower legs are affected. Reflexes to consider include:
•
L4: quadriceps muscles - knee jerk
•
S 1 , 2 : Achilles' tendon - ankle j erk

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View : This view is used to observe possible abnormalities of the
thoracic spine including wedging of the vertebrae, reduced intervertebral disc space,
presence of "bamboo spine" indicating ankylosing spondylitis, scoliosis, and symmetry
of the ribs.
Lateral View: The examiner should look for a normal or mild kyphosis, wedging of the
vertebrae, condition of intervertebral disc space, angles of the ribs, or osteophytes.
Magnetic resonance imaging (MRI)
Magnetic resonance images are useful for delineating soft-tissues problems including
herniated discs and spinal cord lesions as well as bony tissue. Presence of disc herniation

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Chinese Orthopedics Thoracic Spine 326

should be confirmed by the clinical findings since presence of this condition noted by
MRI may be asymptomatic.
Computed tomography
Computed tomof,rraphy is useful in evaluating the bony spine, facet joints, spinal
contents, and surrounding soft-tissue in cross-sectional view, including axial views.

Management of Thoracic Spine Disorders

Mobilization
Mobilization techniques applied to the thoracic spine involves applying pressure over
various regions of the vertebrae similar to procedures discussed for the cervical spine
(See Chapter 7). The techniques used are posteroanterior central, transverse and
posteroanterior unilateral vertebral pressure. All three of these procedures along with
possible traction, are considered to address unilateral thoracic spine symptoms. In case of
bilateral symptoms, posteroanterior central and transverse vertebral pressure to each side
is considered along with possible traction.
Posteroanterior Central Vertebral Pressure
This technique involves the application of oscillatory pressure on the spinous process by
means of the therapist's body transmitted through the arms and thumbs. It is essential that
the pressure be produced by the therapist's body weight and not by the thumbs alone.
Posteroanterior central vertebral pressure is important for addressing all cases of thoracic
pain, especially midline or bilateral pain. This technique is also important in treating
poorly defined or widespread unilateral pain as well.
The patient lies prone and the therapists apply vertebral pressure by leaning over
the thoracic spine or sacrum depending on accessibility from different positions. The goal
is to apply pressure essentially at right angles to the area being mobilized.
U pper Thoracic Spine
The therapist stands at head of the patient and leans over to place his or her thumb
pads over the spinous process. The fingers spread out over the rib cage on each side.
Pressure is applied through the weight of the therapist basically at right angles to the
upper thoracic vertebrae being treated.
M id-Thoracic Spine
T]?.e therapist stands at the side of the patient and leans over to place his or her
thumb pads over the spinous process aligned along the spine. The thumbs point to each
other and the fingers are allowed to spread out over the spine above and below the mid­
region being mobilized. Pressure is applied through the weight of the therapist basically
at right angles to the vertebrae being treated.
Lower Thoracic Spine
The therapist, facing forward, stands at the side of the patient and leans over the
sacrum to place his or her thumb pads over the spinous process. The fingers spread out
over the rib cage on each side. Pressure i s applied through the weight of the therapist
basically at right angles to the lower thoracic vertebrae being treated.

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Ch inese Orthopedics Thoracic Spine 327

Transverse Vertebral Pressure

Th e therap i t appl i c . Lhe lat ral aspect of the thoracic spinous process in this
pre sure to
te c hn j q u e . Osc i l l atory
pres ure is appl i e d thr ugh the therapist's arms and thumbs by
m o v i n g b j s or h r trunk. Tran er e ertebral pressure is used to address unilateral
thorac ic pain and may need to be combin d with mobilization of the rib.

The upper thoracic vertebrae are accessible for transverse mobilization but this
region of the thoracic spine has limited movement . The lower thorac i c spine has greater
capacity for movement and requires less pre sure for tran verse mob i I ization. The lateral
aspects of the mjd-thoracic spinous processes are relati e l y i naccessible, making
transverse mobilization more difficult.
With the patient lying prone, the therapist stands at the side of the patient at the
vertebral level requiring transverse mobilization. The therapist's thumbs are placed
against the side of the spinous process with the fingers spread out over the back.
Transverse pressure is reinforced by placing one thumb on top of the other.
Posteroanterior Unilateral Vertebral Pressure
Th i mobi l izat ion
technique involves oscillatory pressures to the vertebral transverse
processe by movement o f the therapist's trunk directed through the arms and thumbs.
O n l y l ight movement can be produced by this technique and it is used to address
unilateral thoracic pain.
The patient lies prone with his or her head turned to one direction and arms over
the side of the table. The therapist stands to one side, leaning over to apply the thumb
pads over the transverse proces The thum bs face each other, tip to tip, with the fingers
.

p read out ove r the back. Press ure i appl ied in a direct line through the shoulders and
anns at right angl e to t he pati ent's body .

Manipulation
Manipulation involves passive-movement techniques that include either small amplitude
oscillations at the limit of range (Grade IV) or sharp thrusts beyond the pathological limit
of movement (Grade V) (See Table 5 . 1 ). Grade IV and V movements are used to increase
mobility.
There is some overlap between marupulation and mobilization techniques.
Marupulation usually involves quick movements and thrusts, while mobilization involves
oscillatory movements. Mobilization techniques involve Grade I and II movements that
are used to reduce pain, and also involves Grades III and IV, used to increase mobility.
Non-Specific Posteroanterior Pressure
This manipulation technique is performed with the patient lying prone and the therapist
standing to the side. Using the dominant hand, the therapist places ills or her pisiform
bone against the patient's spinous process, applying pressure to stretch the intervertebral
joint. When the joint is stretched to the limit a sudden, very small range, movement is
applied.

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C hinese Orthopedics Thoracic Spine 328

Posteroanterior Central Pressure (T3 - T10)

The patient initially sets up, with his or her hands linked behind the head, with legs
extended down the length of the table. The therapist stands to the right side and reaches
around the left side of the patient to place his or her right hand, made into a fist, along the
patient's thoracic spine. The fist is formed by flexing the middle, ring and little fingers
into the palm while the thumb and index finger remain extended. The right hand is
positioned to where the patient's lower spinous process is grasped between the terminal
phalanx of the middle finger and the palmar surface of the first metacarpal head. The
index finger and thumb are used to maintain the fist position and aid in grasping the
spinous process.
The patient is then lowered to where the therapist's fist is wedged between the
patient's back and the treatment table, with the therapist's forearm projecting laterally.
The therapist then grasps the patient's elbows with his or her left arm and hand, and
gently rocks the upper trunk back and forth in flexion and extension to obtain the mid
position of this movement. Once determined, the full weight of the patient's trunk rests on
the therapist right fist and table. Manipulation is then applied by a quick downward thrust
directed through the patient's elbows and upper arms.
Rotation (T3 - T10)
Thoraci c manipulation in rotation starts with the patient seated at the edge of the
treatment table, while hugging his or her arms across the chest, and turning the trunk to
the left. Standing behind the patient, the therapist reaches around the patient with his or
her left arm to grasp the right upper arm and cradles the patient's left shoulder in his or
her axilla. The therapist uses the right hand to apply pressure over the line of ribs on the
patient's right side.
Clasping the patient with his or her left arm while simultaneously applying
pressure with the right hand, a synchronous movement is produced by the therapist's
trunk rotation. An oscillatory movement is established at the limit of rotation.
Manipulations consist of applying oscillatory over-pressure into the limit of the range.

Manual Thoracolumbar Traction

Thoracic spine traction is not as successful as either cervical or lumbar spine traction.
This may be due to the influence of the thoracic cage which limits the degree of
movement. Mobilization techniques are usually conducted before traction is considered,
and then only when mobilization and other therapies including needling therapy have not
resolved the problem. The main idea of applying traction is to position the joint being
treated in a relaxed orientation midway between all of its ranges.
This procedure serves as both a screening assessment to observe possible changes
in signs and symptoms, and as a trial treatment. Traction is considered to address
conditions involving a wide distribution of thoracic pain usually due to either
hypomobility lesions or disc degeneration. Traction can be considered even when disc
problems are complicated by neurological changes and nerve-root pain. Relief of
symptoms by traction indicates possible reduction in the size of a disc protrusion or the
movement of a sensitive structure away from the point of pressure.

D.E. Kendall, OMD, Ph.D. ©2005-2009

 Chinese Orthopedics Thoracic Spine 329

This technique is applied with the patient either seated or standing, depending on
the relative sizes between the therapist and the patient. The patient crosses his or her arms
across the chest to grasp the opposite shoulders. The therapist then stands behind the
patient, reaching around to clasp the patient's elbows with both hands. The therapist then
leans back to apply a traction force on the thoracolumbar spine while the patient relaxes
his or her thorax. Relief of the patient's symptoms is a positive indication that traction can
be considered to reduce symptoms.
The therapist can use manual traction as a mobilization technique for
hypomobility problems. After placing the patient in manual thoracolumbar traction, the
therapist gently rocks back and forth to apply an oscillatory force on the intervertebral
joints.

Needling Therapy for Thoracic Spine Problems

Muscle distributions of the trunk include the anterior and lateral muscles, and those of the
back. Common disorders manifested in muscular distributions of the anterior and lateral
aspect of the trunk involve problems with the deeper and more anterior muscles. This
includes the diaphragm, intercostals, the obliques, and abdominal muscles. These are
associated with the AMH, AMF, ALF, and LF muscular pathways.
Node Selection for Anterior Lateral Trunk
Treating problems affecting the anterior and lateral trunk involves selecting candidate
nodes that correspond to the spinal segmental levels associated with the particular
muscular distributions. Although the diaphragm is not a skeletal muscle per se, it does
belong to the AMH distribution. The diaphragm receives its innervation from the phrenic
nerve emanating from the spinal cord level of C3 - 4. Hence, a proximal node should be
selected that is above this level, such as Tianzhu (PLF 1 0). This is a key proximal node
along with the communication node, F eishu (PLF 1 3) also being utilized to provide a
wide coverage along the cervical and upper thoracic cord. Anterior and distal nodes to
address pain and functional problems are selected relevant position of the diaphragm and
key nodes on the upper extremity (See Table 1 2.3 ).

Table 1 2. 3. Regional selection of nodes for treatment of anterior and lateral trunk.
Anterior & Anterior Nodes MD Proximal Nodes Distal Nodes
Lateral Trunk
Diaphragm Zhongting (RN 1 6) AMH Tianzhu (PLF 1 0) Geshu (PLF 1 7)
Zhangmen (MF 1 3) Feishu (PLF 1 3) Taiyuan (AMH 9)/
Burong (ALF 22) Yuji (AMH 1 0)
l ntercostals* Yuzhong (PMF 26) AMF Dazhu (PLF 1 1 ) Zusanli (ALF 36)
Bulang (PMF 22) Pishu (PLF 20)
Fuai (AMF 1 6)
Fujie (AM F 1 4)
Obliques & Riyue (LF 24) LF Geshu (PLF 1 7) Zulingqi (LF 4 1 )
Transverse Burong (ALF 22)** Danshu (PLF 1 9)
Abdominis Qichong (ALF 30)** Qihaishu (PLF 24)
Rectus Burong (ALF 22)** ALF Xinshu (PLF 1 5) Zusanli (ALF 36)
Abdominis Guilai (ALF 29)** Weishu (PLF 2 1 )
*Candidate anterior nodes can b e replaced b y either relevant ALF o r P M F nodes.
**Nodes selected over this range depending on specific location of problem.

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C h inese Orthopedics Thoracic Spine 330

The internal and external intercostal muscles associated with the AMF
distribution are supplied by the 1 st - 1 1 th intercostal nerves. Hence, proximal nodes Dazhu
(PLF 1 1 ) and Weishu (PLF 2 1 ) are used to cover this spinal segmental range. Then at
least two anterior nodes ranging from Yuzhong (PMF 26), Bulang (PMF 22), Fuai (AMF
1 6), and Fuj ie (AMF 1 4) are selected that cover range of the specific intercostals that are
affected.
The external and internal obliques (LF), and the transverse abdominis muscles
(LF) are supplied by branches of lower intercostal, iliohypogastric, and ilioinguinal
nerves. Hence, Geshu (PLF 1 7) and Qihaishu (PLF 24) selected as proximal node range
with Danshu (PLF 1 9) being considered as well. Anterior nodes include Riyue (LF 24)
and other nodes selected in the range of Burong (ALF 22) to Qichong (ALF 30),
depending the specific location of the problem being treated.
The abdominis rectus muscle associated with the ALF distribution is supplied by
branches of ih - 1 2 intercostal nerves. Hence, proximal nodes Xinshu (PLF 1 5) and
th
Weishu (PLF 2 1 ) selected to cover this range. Anterior nodes are selected within the
range of Burong (ALF 22) and Guilai (ALF 29), depending on the problem location.

Candidate Electroneedling (EN) for Anterior Lateral Trunk

Frequency: 2 Hz
Mode: Continuous
D uration: 20-30 minutes
Lead Placement:

Anterior medial hand (AMH): Diaphragm

• Tianzhu (PLF 1 0) + lead, to Feishu (PLF 1 3)/Geshu (PLF 1 7) - lead (Bilateral)
Anterior medial foot (AMF): Intercostals
• When specific intercostals are affected: posterior nodes + lead to anterior nodes
- lead at the same intercostal nerve level, such as Dazhu (PLF 1 1 ) + lead, to
Yuzhong (PMF 26) - lead
• Or can use two posterior (+ lead) to anterior (- lead) circuits placed proximal
(above) and distal (below) to the affected intercostal muscles being treated
• If herpes is present along a particular intercostal muscle, then may consider
2 Hz - 25 Hz mixed mode for treatment
• For general treatment: Dazhu (PLF 1 1 ) + lead, to Pishu (PLF 20) - lead
Lateral foot (LF): Obliques and transverse abdominis
• Posterior nodes from Geshu (PLF 1 7) to Qihaishu (PLF 24) + leads, to specific
anterior nodes from Burong (ALF 1 9) to Qichong (ALF 30) - leads that cover
range of problem being treated

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Chinese Orthopedics Thoracic Spine 331

Anterior lateral foot (ALF): Rectus abdominis

• Posterior nodes from Xinshu (PLF 1 5) to Weishu (PLF 2 1 ) + leads, to specific
anterior nodes from Burong (ALF 1 9) to Guilai (ALF 29) - leads that cover range
of problem being treated
Spinal and Upper Back Pain
Thoracic and chest pain are the chief complaints related to the thoracic spine and are a
common cause of disability. These symptoms may arise from either visceral or
musculoskeletal disorders. Sometimes visceral disease produces symptoms that mimic
musculoskeletal problems, such as angina, leading an incorrect diagnosis and treatment.
It is important to make certain that chest pain in not due to heart, lung or mediastinal
structures. Visceral diseases are presently not addressed. Assessment and treatment of
spinal and upper back pain (See Table 1 2.4) follows the same general guidelines for any
other part of the body. Treatment of spinal pain employs special nodes that have an
influence on the spine itself including Jinsuo (DU 8) in the upper back and Yaoyangguan
(DU 3 ) in the lower back.

Table 1 2.4. Candidate regional, proximal and distal nodes for spinal and upper back pain.
Back Pain Candidate Local & MD Proximal Nodes Distal Nodes
Adjacent Nodes
Spinal Pain Shenzhu ( D U 1 2) Bai h u i ( DU 20) Shugu (PLF 65)
Yaoyangguan (DU 3) Renzhong (DU 26) Kunlun (PLF 60)
Upper Back Feishu ( PLF 1 3) PLF Feiyang (PLF 58)
Jinsuo (DU 8) PMF Zhubin (PMF 9)
Ganshu ( PLF 1 8)

Candidate Electroneedling (EN) for Spinal and Upper Back Pain

Frequency: 2 Hz
Mode: Continuous
Duration : 20-30 minutes
Lead Placement:

Spinal pain:
• Shenzhu (DU 1 2) + lead, to Yaoyangguan (DU 3 ) - lead
Upper back pain:
• Feishu (PLF 1 3) + lead, to Ganshu (LF 1 8) - lead

Remedial Exercises Muscles of the Trunk and Back

Exercises for the trunk and back are to restore strength and function to the muscles
moving the thoracolumbar spine. Since the thoracolumbar spine functions as an
integrated structure some of the routines are common to address problems either
associated with the thoracic spine or lumbar spine (See Table 1 2.2). The greater
incidence of weakness affecting the back generally involves the lower back region.
Presence of pain may restrict movement in many cases and exercise is only performed up
to the point of pain. In some situations, especially involving intervertebral disc lesions,

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Chinese Orthopedics Thoracic Spine 332

certain exercises are contraindicated. Orthopedic tests provide a clear idea concerning the
location and nature of the problem with the weak muscle groups identified. General
findings usually indicate a sprain or strain, or involvement of either a herniated disc,
spinal stenosis due to disc degeneration or a facet/subluxation syndrome. Certain
remedial steps may be contraindicated for specific problems. Such as in situations where
neural symptoms manifest when doing the "prone push-up" "sphinx" or the "cobra, "
indicates that exercises involving extension must be avoided.

Back Flexion Stretches

These routines flex the back and put the back extensor muscles into stretch. Flexion
stretches can be performed from either a standing or supine position. It is not necessary to
do both routines and thus either can be employed.
Standing Back Flexion Stretch
From the standing position, with hands on hips or on the legs, or with arms hanging down
in front, slowly lean forward directing the head toward the floor to place the back into
flexion. Hold the end position l 0 - 1 5 seconds and then slowly return to the full standing
position. Repeat 3 5 times.
-

Supine Back Flexion Stretch

While lying supine with knees and hip flexed, grasp the legs and slowly pull up toward
the chest while flexing the neck and upper back at the same time. Hold the end position
1 0 - 1 5 seconds and slowly return to the start position. Repeat 3 - 5 times.

Strengthening Trunk Flexion

The primary muscle exercised to strengthen trunk flexion in the supine position involves
the rectus abdominis muscle. Muscles participating as assistant movers to assist trunk
flexion include the i liopsoas, rectus femoris, and internal and external abdominal oblique
muscles. The upper and lower rectus abdominis fibers are exercised separately.
Upper Rectus Abdominis
Trunk flexion is performed from the supine position with knees and hips flexed so that
the feet are flat on the floor. The subject performs a partial setup from lying flat by
raising the shoulders off the floor, but not exceeding about 45°. This is the result of
contracting the rectus abdominis muscles. The arm can be placed in three different
positions in order to increase the resistive load as strength is restored.
a) From the start position the subject posteriorly tilts the pelvis to flex the lumbar
spine, then flexes the cervical spine, flexes the thoracic spine and holds his or her arms
out in front of the trunk, pointing to the knees. The subj ect then slowly lifts the shoulders
off the floor the maximum extent possible and holds the end position for 2 - 3 seconds.
The shoulders are then slowly lowered to the floor. This exercise is repeated for up to 8-
25 repetitions depending on level of fitness and eventually performed for 3 5 sets. As
-

strength permits, back and abdominal muscles should be contracted to provide IDR
antagonistic resistance to trunk flexion.

D.E. Kendall, OMD, Ph. D. ©2005-2009

 Chinese Orthopedics Thoracic Spine 333

b) When strength increases, the preceding exercise is modified to place the arms
crossed over the chest to increase the resistive load. Exercise is repeated for the same
schedule as noted in the preceding exercise.
c) When strength further increases, the preceding exercise is modified to place the
arms so that the hands can be placed on each side of the head or on top of the head. Care
must be taken so subject does not use the hands to pull the neck into flexion during the
exercise. Exercise is repeated for the same schedule as noted in the first rectus abdominis
exercise.
Lower Rectus Abdominis
Lower abdominal strengthening exercises are performed with the subject supine. One leg
is slowly raised to an angle of about 30 - 45°, while the knee is fully extended. Leg is
held at the end position for 2 - 3 seconds and the leg is slowly lowered to the floor. This
exercise is repeated for up to 8 1 6 repetitions and eventually performed for 3 5 sets.
- -

During each leg lift, the lower abdominal muscle is contracted (IDR) to achieve peak
contraction. The subject places one hand to touch the lower abdominal muscle on the
exercised side to assure that peak contraction i s maintained.
At the end of each set, the leg is raised to the full range of hip flexion, with knee
extended, while subject pulls lower leg into the extended position to stretch the hamstring
muscles.

Abdominal Obliques Stretches

The abdominal obliques can be stretched from either the standing or seated position.
Standing Side-Bending
From the standing position, the subject slowly leans to one side to lower the hand closer
to the floor while the other arm is held up over the head to increase stretch. This position
is held for 1 0 1 5 seconds while maintaining side bending forces and attempting to move
-

the hand lower toward the floor during the whole time period. Repeat the stretch 4 - 6
times, alternatively stretching in each direction.
Standing Rotation
While standing, the subject rotates about the vertical axis approximately 75 90°, while
-

the arms are either held stretched out from each side or both are stretched straight out in
front of the body. Arms are held in the same orientation to the shoulders as the subj ect
slowly rotates. The end position is held for 1 0 - 1 5 seconds while maintaining rotational
forces and attempting to move further into rotation during the whole time period. Repeat
the stretch 4 6 times, alternatively stretching in each direction.
-

Seated Rotation
Preceding stretches can also be performed in the seated position.

Abdominal Obliques: Trunk Rotation

External and internal abdominal oblique muscles are exercised mainly by flexing the
trunk while it is held in rotation. The rectus abdominis, semispinalis thoracis, multifidus,
rotatores, and latissimus dorsi participate as assistant movers to trunk rotation. The
subject is supine with knees and hips flexed with his or her feet flat on the floor. The

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C hinese Orthopedics Thoracic Spine 334

subject then performs a partial setup, not exceeding about 45°, from lying flat by raising
the shoulders off the floor while rotating the trunk to one side. Alternate to this, the
subject can lower the flexed legs to one side so they rest on the floor. The partial setup is
then performed with trunk straight as in the case of exercising the abdominis erectus
muscle. In either configuration, the arm can be placed in three different positions in order
to increase the resistive load as stren!,Tt:h is restored. When the trunk is rotated to the left
or the legs are lowered to the right, the right external abdominal oblique and left internal
abdominal oblique muscles are being exercised. Conversely, when the trunk is rotated to
the right or the l egs lowered to the left, the left external abdominal oblique and right
internal abdominal oblique muscles are being exercised.
a) The subject slowly performs a partial setup, but in this situation the trunk is
rotated approximately 45° either to the left or right while directing both outstretched arms
toward the side of the knee in the same direction that trunk is rotated. The subject then
slowly lifts the shoulders off the floor the maximum extent possible with trunk rotated
and holds the end position for 2 3 seconds. The shoulders are then slowly lowered to the
-

floor while still pointing the arms to the side of the knee. This exercise is repeated for up
to 1 6 repetitions for each side and eventually performed for 3 5 sets. As strength
-

permits, back and abdominal muscles should be contracted to provide IDR antagonistic
resistance to trunk flexion.
b) When strength increases, the preceding exercise is modified to place the arms
crossed over the chest to increase the resistive load. Exercise is repeated with the trunk
rotated for the same schedule as noted in the preceding exercise.
c) When strength further increases, the preceding exercise is modified to place the
arms so that the hands can be placed on each side of the head or on top of the head.
Exercise is repeated for the same schedule as noted in the first abdominal oblique
exercise.
-+ Care m ust be taken so subject does not use the h a nds to pull the neck i nto
flexion d u ring the exercise.

Back Extension Stretches

These stretches extend the back and put the abdominal muscles into stretch. It is not
necessary to do all three routines and thus any one can be employed. The sphinx and
prone push-up are easier to perform and more controllable.
Standing Back-Bending
While standing with feet slightly apart, place hands on hips or extended straight up over
the head, or on the hips, and then slowly lean body backwards to put back into extension.
Hold end position 1 0 - 1 5 seconds and then slowly return to the standing position. Repeat
3 - 5 times.
Sphinx Position
This technique puts the back into a mild extension stretch once the position is established.
The subject is prone with hands on the floor, placed at the side level with the chest or
shoulder. Arms are used to push chest off the floor while keeping the elbows flexed with
the pronated forearms flat on the floor. The pelvis also rests on the floor and the low back

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Chinese Orthopedics Thoracic Spine 335

and abdominal muscles are relaxed to increase the extension curvature of the back. This
position is held 1 0 - 1 5 seconds and then the chest is slowly lowered to the prone start
position. Repeat 3 5 times.
-

Cobra (Prone Push-Up)

The subject is prone with hands on the floor, placed at the side level with the chest or
shoulder. Arms are used to push chest off the floor while keeping the pelvis on the floor
and the low back and abdominal muscles relaxed. Head is kept down to prevent arching
the neck backwards. Slowly raise the chest and hold the full extended position for 1 0 - 1 5
seconds and then slowly lower chest to the floor. Repeat 3 - 5 times.

Strengthening Trunk Extension

Exercising the trunk in extension mainly involves the spinae erector muscles, including
the iliocostalis thoracis and lumborum, longissimus thoracis, spinalis thoracis,
semispinalis thoracis, and multifidus. Assistant muscles to extension include the
interspinales, latissimus dorsi, and the quadratus lumborum. The trunk extensors are
exercised as a group.
Contralateral Arm and Leg Raise: Lizard on Hot Sand
The subject is prone with both arms extended up over the head and resting on the floor.
The head is held in neutral position while one arm is slowly lifted up and off the floor
while at the same time the opposite leg is extended to lift off the floor. End position is
held 2-8 seconds with the arm and leg slowly lowered to the floor. The opposite arm and
other leg are then slowly lifted off the floor and held in the end position for 2 - 8 seconds
before being slowly lowered to the floor. This exercise is repeated up to 8 repetition
cycles including each side and eventually performed for 4 5 sets.
-

Trunk and Leg Raise: Seal

As strength increases the following exercise is then used to continue the recover process.
The subject is prone with both arms held at the sides with dorsum of each hand resting on
the floor. While the head is held in neutral position, it is slowly lifted off the floor by
extending the trunk while at the same time both legs are extended up off the floor. Arms
remain at the sides with the dorsum of both hands resting on the floor. End position is
held 2 8 seconds with the head and legs then slowly lowered to the floor. This exercise
-

is repeated up to 8 repetitions for each side and eventually performed for 4 5 sets.
-

Trunk, Leg and Arm Raise: Swallow

This is a variation of the preceding exercise, and introduces a slight increase the resistive
load. The subject is prone with both arms held at the sides with dorsum of each hand
initially resting on the floor. While the head is held in neutral position, it is slowly lifted
off the floor by extending the trunk while at the same time both legs and both arms are
extended up off the floor. End position is held 2 - 8 seconds with the head, legs and arms
then slowly lowered to the floor. This exercise is repeated up to 8 repetitions for each
side and eventually performed for 5 sets.

Quadratus Lumborum: Pelvic Elevation

Pelvic elevation is the function of the quadratus lumborum with the latissimus dorsi,
contralateral hip abductors, internal abdominal obliques, and external abdominal oblique

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Chinese Orthoped ics Thoracic Spine 336

muscles participating as assistant movers. The quadratus lumborum will normally be

exercised and strengthened by trunk extension exercises. If there is weakness in the
quadratus lumborum that is impairing to ability to perform adequate trunk extension
exercise, this muscle can be addressed individually.
It is exercised from a standing position with the subject leaning against a wall for
stabilization. While maintaining the body as near vertical as possible, the subject raises
the leg which is hanging vertically down, by contracting the quadratus lumborum and
slowly lifting the iliac crest on the exercise side. End position is held 2 3 seconds with
-

the leg then slowly lowered to the floor. This exercise is repeated up to 8 repetitions for
each side and eventually performed for 4 5 sets. As strength improves, strap-on leg or
-

ankle weights can be introduced to increase the resistive load.

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Chinese Orthoped ics Lu mbar Spine 337

13

Lum bar Spi ne

Anatomical features of the lumbar spine, including the osteology, arthrology, and
mechanics, are discussed along with the details of the thoracic spine in Chapter 1 2 . The
lumbar vertebrae are larger (Figure I 3 . 1 ) than those in the thoracic and cervical spine,
and their intervertebral discs have approximately 1 2 lamellae.

Superior
Facet

Transverse

Body

I nferior Facet
Spinous
Process

Figure 1 3. 1 . Features of lumba r vertebra

Disorders of the Lum bar Spine

The main symptoms related to musculoskeletal disorders affecting the lumbar region
involve both the posterior lateral foot (PLF) and posterior medial foot (PMF) muscular
distributions. Specific problems associated with these muscular assignments are provided
in Chapter 1 2. Deeper muscles of the lumbar region are assigned to the PMF distribution
while the more superficial muscles belong to the PLF distribution (See Table 1 2.2).
Problems in the lumbar spine are similar to those affecting the thoracic spine except the
lumbar spine is susceptible to intervertebral disc prolapse. Problems associated with the
lumbar spine include those that affect the vertebral column, lumbar intervertebral discs,
and lumbar movement.

Disorders of Vertebral Column

Problems that affect the lumbar vertebrae are mainly medical and rheumatological
conditions. Some surgical condition such as fractures, dislocations, and structural
scoliosis are not included in this text. Also, metabolic diseases such as metabolic bone
disease, chondrocalcinosis, gout, acromegaly, and ochronosis, as well as Reiter' s disease
and psoriatic arthritis can affect the lumbar spine.
Inflammatory Diseases
Spondyloarthritis
This includes a group of diseases characterized by inflammation in the vertebral
and peripheral j oints and are usually classified as spondyloarthritis. They are also linked
to inflammatory changes in the sacroiliac joints as well as being frequently associated
skin, eye, mucus membrane, bowel, and urinary tract lesions.

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Chinese Orthopedics Lu mbar Spine 338

Spondyloarthritis includes ankylosing spondylitis which is involved in

inflammatory changes in the spinal joints and bilateral sacroiliitis. Pathological lesions
occur in the central j oints of the axial skeleton, such as the sacroiliac joint, symphysis
pubis, and the intervertebral j oints of the spine. In the spine these changes manifest as
erosive lesions either anteriorly or posteriorly at the upper and lower vertebral body
surfaces which eventually become ossified, giving rise to osteophytes.
Typically, ankylosing spondylitis has a history of episodic pain in the lower back
radiating into the buttocks, thigh, and groin. The pain may also radiate down the posterior
leg to be confused with true sciatica, but neurological signs are absent. Initially the
disease presents with periodic attacks but later the pain becomes more constant. There is
low back stiffness which may be worse in the early hours or on awakening. Subject may
have to walk around when they first get up to loosen up the body to obtain relief. Severity
of the int1amm ation correlates with the degree of stiffness, although most symptoms are
exacerbated by immobility. Overall range of lumbar spine movements becomes reduced.
especially in lateral flexion.
Rheumatoid Arthritis
This condition commonly involves the cervical spine possibly due to it mobility
and the fact that there are 29 synovial joints between the skull and the first thoracic
vertebra. However. this disease is rare in the thoracic and lumbar spine. The main lesion
is a rheumatoid discitis, spreading in from adjacent apophyseal (facet) or costovertebral
joints. In lumbar spine discitis there already may be disc degeneration and may be caused
by vertebral instability with the resulting chronic trauma producing discovertebral
destruction.
Traumatic and Degenerative Conditions
Numerous traumatic and degenerative conditions affect the lumbar spine including but
not limited to spondylolysis, spondylolisthesis, ankylosing vertebral hyperostosis, and
Scheuermann' s disease.
Spondylolys i s
This condition is caused by a defect in the pars interarticularis, the narrow strip of
bone lying between the lamina and the inferior articular process below and the pedicle
and superior articular process above. Etiology of this condition has been a subject of
much debate but suspicion is now considering a stress fracture being the cause. Or it may
be that there is some inherent weakness in the pars interarticularis. Spondylolysis is not
uncommon in athletic injuries and occurs in weight lifters, rowers, and fast bowlers.
Some indications suggest the fracture is the result of rotational stress since it occurs in the
left pars interarticularis of fast right hand bowlers and in the right pars interarticularis in
left hand fast bowlers.
This condition may asymptomatic but the patient usually complains of pain in the
lower lumbar region localized to one side of the spine. Pain may radiate into the buttocks
or leg especially after continuous use of the back. This condition does not usually
produce nerve root pressure. When a patient with spondylolysis presents with clinical
evidence of neurological signs this may be due to an associated disc prolapse. X-rays are
needed to confirm the diagnosis. An oblique view X-ray of the lumbar spine is required

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 Chinese Orthopedics Lumbar Spine 339

to show the area that has the appearance of Scottish terrier dog. The spondylolysis
appears as a collar around the dog 's neck.
Spondylolisthesis
This represents a vertebral subluxation consisting of a forward displacement of
one vertebral body on the vertebral body below. Any vertebra can be involved but this
condition most commonly occurs in the LS vertebra. The degree of spondylolisthesis is
viewed in terms of the distance the slipped vertebra moves on its lower counterpart which
is divided into four degrees or grades. A displacement of one quarter of anteroposterior
vertebral body distance is considered a frrst degree or grade 1 slippage, while slippage
resulting in a full diameter displacement is a forth degree or grade 4. The five types of
spondylolisthesis are : traumatic; congenital; spondylolytic; degenerative; and
pathological.
Patient presents with back pain and possible leg pain, which may be related to the
effect of the spondylolisthesis on spinal mechanisms. Symptoms may vary with the
degree of the slip so that minimal movement could possibly have minimal effect on the
surrounding tissues. But, soft tissues may be stretched or traumatized with increasing
degrees of spondylolisthesis. When progression is slow a buttress of bone may form at
the anterior border of the first sacral segment thereby reducing the tendency to slip. The
diagnosis of spondylolisthesis may be suspected when the patient's history indicates l ow
back pain that is made worse by standing and eased by sitting.
Ankylosing Vertebral Hyperostosis
This condition may occur in middle age and involves laying down new bone on
the anterolateral aspect of the vertebrae which produce bony bridges across the disc
space. This may occur in any area of the spine but is most common in the thoracic spine.
Sacroiliac joints are radiologicall y normal but degenerative changes may also occur in
weight bearing j oints. Patient presents with pain and stiffness although there is little
correlation between the symptoms and x-ray findings. This condition may be a chance x­
ray finding in asymptomatic patients.
Scheuermann's Disease
This problem is of unknown etiology and produced by a vertebral epiphysitis
(which is an inflammation of the epiphysis of the vertebra: osteochondrosis of the
vertebra). Most common site of involvement is the lower thoracic vertebrae usually
around T9. In the lumbar spine there is a decreasing incidence from L 1 where it is
common to LS where it is rare. Usually affects several vertebrae.
Usual complaint is mild or moderate pain the thoracic spine and which sometimes
radiates into the lower lumbar region. Pain usually follows physical actively, especially
where it involves overuse of the spine. Typical findings include :
•
Smooth, rounded dorsal kyphosis that is most evident on forward flexion
•
Loss of spinal mobility including a loss of normal flexion, extension, and of
passive intervertebral j oint range
•
Tightness of the hamstring muscles
X-ray changes are necessary to confirm the diagnosis which must include at least
one of the following changes:

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 Chinese Orthopedics Lumbar Spine 340

•
Wedging of the vertebral body
•
Kyphosis of the thoracic vertebrae or a loss in normal lumbar curve
•
Irregular, narrowed intervertebral disc spaces
•
Schmorl' s nodes, which may be an indication of a milder form or precursor to
Scheuermann's disease

Disorders of Lumbar Intervertebral Disc

Intervertebral-Disc Prolapse
Disc prolapse presents with back pain which may occur for no apparent reason, but many
patients usually relate it to some seemingly minor strain or traumatic incident. This may
have involved lifting, twisting, or bending activities. Pain may be described as dull or
aching or even knife-like, cutting, or burning sensation in the low back, either on one side
or in the midline. The initial pain symptoms are usually confined to the lower back, may
be sudden and severe, or may develop gradually. Pain may be intermittent and relieved
by changes in position, or by rest, but usually made worse by movement, straining,
coughing, sneezing, or sitting. Also, pain may be severe enough to disturb sleep. Later,
the back pain may be accompanied by leg pain, alterations sensation, and motor
weakness (See Table 1 3 . 1 ) .

Table 1 3 1 . N erve root pa in, sensory loss, a n d motor weakness in intervertebral disc prolapse
Involved Pain Distribution Sensory Loss Motor Weakness Reflex
Root Change
L2 Anterior aspect of upper Upper outer aspect of Flexion and adduction of hip
thigh thigh
L3 Anterior thigh to anterior Lower inner aspect of Flexion, adduction, and Knee
region of knee thigh and knee internal rotation of hip jerk
L4 Lateral aspect of thigh Medial aspect of calf Dorsiflexion and inversion of Knee
to medial side of calf and knee ankle and extension of knee jerk
L5 From buttocks to lateral Dorsum of foot and Dorsiflexion of great toe and
aspect of leg and great toe. Anterolateral other toes, and dorsiflexion
dorsum of foot and aspect of lower leg and eversion of ankle
g reat toe
S1 From buttocks to back Lateral aspect of ankle, Plantar flexion of ankle and Ankle
of thigh and leg, lateral foot, and posterior calf toes, extension of hip and jerk
a�ect of ankle and foot flexion of knee

Lumbar Spondylosis
Patient complains of either unilateral or bilateral back or leg pain with or without
neurological signs. Character of pain may be reported as being dull and aching associated
with stiffness, which is located in the lower lumbar midline possibly radiating into the
buttocks or groin. Symptoms may get worse as the day progresses but on the other hand
they may be aggravated after a night's rest, and then improve after moving around. It is
not possible to determine the exact mechanism that produces the patient' s symptoms
since degenerative changes occur in the anterior and posterior areas of the intervertebral
joint complex. Attacks of mechanical derangement of the lumbar may occur as result or
recurrent synovitis in the apophyseal j oints after overuse. If sciatica is present it may be

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Chinese Orthopedics Lumbar Spine 34 1

due to encroachment of the intervertebral neural canal by osteophytic overgrowths which

can arise from the vertebral and apophyseal j oints.
Vertebral instability
This condition produces mechanical spinal derangement following the initial stages of
disc degeneration where fissures appear with softening and bulging of the disc. Occurs
more commonly in males usually in the third and forth decade involving L4 - L5 disc.
The instability causes increased strain on ligamentous support and soft tissues, which
contribute to development of postural pain. This condition makes the spine more
susceptible to trauma so that any unguarded or forced movements may result in
apophyseal j oint synovitis or subluxation with resulting mechanical derangement.
Pain may present as being constant, dull, aching, deep seated, and localized to the
back or radiate into one or both buttocks and legs. Rarely, does it radiate below the knee
and evidence of nerve root pressure is absent. The pain can be made worse by
maintaining one posture for a long time such as standing or sitting. An alteration of
posture such as arching the back or lying down may relieve the pain.
Isolated Disc Resorption
This involves severe progressive degenerative changes in one intervertebral disc alone.
Back and leg pain can develop due to altered spinal mechanics and not to disc prolapse.
Some cases show that the disc is completely resorbed only leaving a rim of the annulus.
Radiological findings show a marked loss of disc space, associated with a vacuum
phenomenon, vertebral margin sclerosis, and often a retrospondylolisthesis which results
in apophyseal j oint overriding with resulting degenerative changes.
Spinal-Canal Stenosis
This refers to limiting the space in the spinal canal by congenital defects or changes in the
surrounding bony structures associated with degenerative disc and apophyseal joint
changes along with possible thickening of the l igamentum flavum. The disc lesions
commonly include a hard annular bulging along with osteophyte formation, or may be the
result of a nuclear prolapse. Hypertrophic apophyseal joint changes can bulge into the
spinal canal from their posterolateral angle to produce stenosis.
Patient symptoms may be similar to the condition of arterial insufficiency caused
by intermittent claudication. Pain in one or both legs involving the whole leg is provoked
after walking a certain distance. This may be accompanied with paresthesia and possible
leg weakness. Pain is relieved by resting and patient may need to sit down immediately.
Relieving pain in spinal canal stenosis may require a longer rest period as opposed to the
rapid disappearance of pain in patients with peripheral vascular disease. Hence, it is often
difficult to differentiate between these two condition based only on the history. Leg
weakness may affect any part of the leg. Some patients may report experiencing a sudden
loss in leg strength that resulted in them falling to the ground.
Stenosis can also occur in the neural root canal, especially at L5 and S 1 , where
patients present with leg pain but do not have the symptoms usually seen in disc prolapse,
such as pain be aggravated by straining or coughing.

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Chinese O rthopedics Lumbar Spine 342

Cauda Equina Compression

This condition results from a sudden massive extrusion of nuclear material through the
posterior longitudinal ligament. This may occur in younger patients following a sudden
flexion strain. Patient complains of back pain that radiates into both legs and the buttocks.
There are sensory and motor neurological changes in the legs as well as sensory changes
in the sacral dermatomes of the scrotal and perianal area that can also be associated with
urinary retention. Early recognition is critical in order to allow early surgical
decompression before permanent damage occurs.
Juvenile Disc Syndrome
Previous discussions on disc prolapse usually involves patients that are 20 years of age
and older. C linical presentation of disc problems in adolescent patients differs. Trauma
appears to play a greater role in this problem which may be the result of direct trauma to
the spine, or by indirect trauma such as falling onto the buttocks. Patient complains of
pain that may vary to some extent while marked spinal stiffness and muscle spasms
predominate. This may result in abnormal spinal movement with the possible
manifestations of a shuftling gait. Scoliosis may present only on movement. Straight leg
raising is markedly restricted but neurological deficits are uncommon.

Movement Disorders in Lumbar Spine

After excluding patients with pathological disorders of the intervertebral discs and of the
vertebral column as noted in the preceding information, there are still a large number of
patients who symptoms do not place them in either category. Clinically, these patients
could be classified in terms of having an alteration in the range of spinal movement
which may be restricted (hypomobility) or increased (hypermobility). In the l umbar spine
there an acute form of mechanical derangement that is referred to as acute low back pain
(lumbago).
Acute Low Back Pain (Lumbago)
The term lumbago could be used to describe any low back pain. But here it is used to
denote a lumbar spinal problem characterized by sudden onset of severe persistent pain
with marked restriction of lumbar movement, and a sensation of locking in the back.
Attacks can range from severe and incapacitating or to one that is minor in nature. In
serve cases the patient presents with an intense lower lumbar pain of sudden onset that
may be bilateral . The pain and resulting l ocking sensation in the back may incapacitate
the patient with the back stuck in one position, usually in flexion. Patient may even fall
down or have to immediately lie down, may not be able to move, or may have to crawl to
a couch or bed.
Attacks often occur after forward flexion of the body, even though the movement
was slight. This could include brushing the teeth, standing up from a forward flexed
position, coughing, sneezing, bending to lift a weight, or bending over a patient. The may
be combined twisting motion. Pain is made worse by almost any back movement.
Lumbar spine examination shows that active movements are very difficult to perform.
There may be marked bilateral paraspinal muscle spasm, frequently more prominent on
one side than the other, which is apparent on inspection.

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Chinese Orthopedics Lumbar Spine 343

Hypomobility Lesions
This lesion is a chronic fonn of mechanical derangement of the intervertebral joint
complex involving reduced range of joint movement. C linical presentation includes pain
that is localized in the back or referred into the buttock, leg, or abdominal region. Pain is
reproduced while testing active spinal movements, which may show a pattern of
restricted movement only in certain directions. There is a restricted range in accessory
intervertebral movements with possible evidence of mechanical derangement of spinal
movements. X-ray findings may be normal for the patient' s age.
Hypermobility Syndrome
This syndrome is defined as having a range of movement in excess of the usually
accepted range, possibly involving spinal or peripheral joints. Movement throughout the
hypermobile range can be controlled by muscular activity. This distinguishes it from joint
instability which has an abnormal range of movement which may be excessive at times,
but cannot be controlled by voluntary muscular control.
Hypermobility patients tend to be young females and the condition may affect
spinal and peripheral joints or spinal j oints alone. Hypermobility affecting the spinal
joints manifests with back pain that is either continuous or recurrent. There is a general
increase in the range of passive intervertebral movements as well as in spinal mobility.
There may be an associated hypermobility of peripheral j oints. X-ray findings and other
studies are normal.

Assessment of Lumbar Spine

Observation
Typically, the patient needs to be suitably undressed so the spine and other features can
be viewed for possible alignment abnormalities. The body is viewed anteriorly and
posteriorly in the standing position and seated. The vertical alignment of the spinal
column is examined to detect possible curvatures, listing, or twisting, and possible
scoliosis. A weighted plume line can be used. The body is also viewed from the lateral
aspect to assess cervical lordosis, thoracic kyphosis, l umbar lordosis, and sacral kyphosis
(See F igure 1 .2). Any misalignments are noted for the entire body including the position
of head being forward or backward of normal, thoracic spine, lumbar spine, pel vis, hip
joint, knee joint, ankle joint, amount patient is listing to right or left, and the length from
both the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS) to
the floor.
Position of the scapula is also noted. The scapular spine is normally at the level of
the T3 spinous process while the inferior angle is level with the T7 spinous process.
Medial border of the scapula should be about 5 em lateral to the spinous process and be
parallel to the spine.

Active Movements of Lumbar Spine

See information under Active Movements of Trunk in Chapter 1 2 on the thoracic spine.

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Chinese Orthopedics Lumbar Spine 344

Passive Movements of Lumbar Spine

Two distinct passive intervertebral movements can used to assess the range of movement,
reproduction of pain and symptoms, behavior of these clinical manifestations throughout
the range of movement, presence of muscular spasms, and the end-feel of the movements.
These movements consist of passive physiological and accessory (See following section)
movements of the lumbar spine.
The passive range of physiological movements at each individual spinal j oint is
evaluated by the examiner by producing physiological spinal movements with one hand
while feeling the relative movement between adjacent bony spinous processes with the
fingers of the other hand. Flexion-extension, lateral flexion, and rotation are tested.
Flexion-Extension
This test can be performed by moving either both legs of the patient or only a single leg.
The fol lowing procedure involves moving only a single leg. For this movement test, the
patient lies on the right side with the underneath leg held in slight flexion of the hip and
knee. Standing in front of the patient's upper chest, facing towards the hips, the
examiner's left forearm is placed across the thorax so that his or her left hand fingers can
palpate the lumbar spinous processes. The patient's thorax is stabilized between the
examiner's left arm and left side. The examiner then grasps the patient's above leg distal
to the knee with his or her right hand.
Flexion and extension of the lumbar spine are produced by the examiner pulling
up on the patient's left leg to produce flexion at the hip and then releasing the hip flexion.
The examiner's left hand middle finger is placed in the interspinous space to feel the
movement of lumbar flexion and extension by noting a corresponding opening and
closing of the interspinous gap.
Lateral Flexion
In this test the patient lies on the right side with his or her hips and knees flexed so that
the lumbar spine is relaxed midway between flexion and extension. Standing in front of
the patient, the examiner reaches across the patient's left side to align his or her left
forearm along the spine with the fingers pointing to the feet. With the right hand, the
examiner grasps under the patient's left ischial tuberosity. The pad of the examiner's left
hand middle finger is placed facing upwards in the underside of the interspinous space to
feel the bony margins of the adj acent vertebrae.
The examiner laterally flexes the patient's lumbar spine by grasping the pelvis and
upper left leg with his or her right arm and side, and then pulling up with the right
forearm so the patient's left ilium moves cephalad. The pelvis is then returned to its mid
position by examiner pushing against the patient's upper left side with his or her right
side. This oscillatory movement rocks the pelvis around the fulcrum created by the
underside hip and femur and thus, lateral flexion is easy to produce and detect by
palpation.
Rotation
Active measurements of lumbar rotation often does not provide much diagnostic
information, while testing the small range of passive rotation is valuable. The test

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 Chinese O rthopedics Lumbar Spine 345

configuration is similar to that noted above for lateral flexion and the examiner must
confirm that the patient's left knee can slide forward over the underneath knee.
The examiner leans across the patient to align his or her left forearm along the
patient's spine with the pad of the middle finger facing upwards in the underside of the
interspinous space to feel the bony margins of the adjacent vertebrae. With his or her
right hand, the examiner grasps over the patient's left greater trochanter, with the fingers
spread out behind it.
The examiner stabilizes the patient's thorax with his or her left arm and side. The
patient's pelvis is pulled toward the examiner with his or her right hand to rotate the left
side of the pelvis and lumbar spine forward. The palpating finger keeps pace with the
movement so that the displacement of the distal spinous process relative to the proximal
spinous process can be detected. The pelvis is then returned to the start position by the
heel of the examiner's right hand and forearm.

Accessory Movements of Lumbar Spine

Passive accessory movement can be produced by application of thumb pressure or
pressure by applying the pisiform of the hand, first over the patient's spinous processes of
the lumbar vertebra and then over the transverse processes. The spinous processes are
tested using posteroanterior and transverse pressures, which may be varied by angling the
direction of the pressure either toward the head or feet. This is then fol lowed by
posteroanterior pressures against the transverse processes. These accessory movements
are similar to those previously described above for the thoracic and cervical spine.
Accessory movements are performed with the patient lying prone, with hands by
the sides and head turned in one direction. The three basic techniques are noted below,
and these can be varied by directing the pressure against the bony structures either toward
the head or feet:
•
Posteroanterior pressure applied to the spinous process
•
Transverse pressure applied to the lateral surface of the spinous process
•
Posteroanterior pressure applied to the transverse processes

Resistive Movements of Lumbar Spine

See information under Resistive Isometric Thoracolumbar Movements in the preceding
Chapter on the thoracic spine.

Peripheral Joint Scanning Examination

If examiner did not perform a scanning examination during the history and observation, it
should be performed after completion of resistive isometric movements of the lumbar
spine. The lower limb scanning test is applied to the sacroiliac, hip, knee, ankle, and foot
joints. Test should be conducted quickly but if any deviations from normal found, a more
detailed examination should be performed for the affected joint.
Sacroiliac Joints
Examiner palpates the PSIS on one side with one thumb and palpates one of the sacral
spines with the other thumb while the patient is standing. Patient then instructed to fully

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Chinese Orthopedics Lu mbar Spine 346

flex the hip on that side while noting if the PS IS drops as it normally should or whether it
elevates indicating possible fixation of the sacroiliac joint on that side. The examiner then
tests and compared the other side. The examiner next places one thumb on one of the
patient' s ischial tuberosities and one thumb on the sacral apex. The patient is instructed to
flex the hip again on this side. If the thumb on the i schial tuberosity moves lateral, the
motion is normal. If the sacroiliac joint on this side is fixed, the thumb moves up. The
other side is then tested and compared. This test is referred to as Gillet's test or sacral
fixation test.
Hip Joints
The hip joints are actively moved through flexion, extension, abduction, adduction,
medial rotation, and lateral rotation in a full as possible ROM. Any pattern of restriction
or pain is noted. As the patient flexes the hip, the ilium, sacrum, and lumbar spine may be
palpated to determine when movement in the sacroiliac j oint starts on that side and at the
lumbar spine during the hip movement. Both sides are tested and compared.
Knee Joints
Patient actively moves the knee joint through a full range of flexion and extension as
possible. Any abnormal signs, restriction of movement, or symptoms should be noted.
Foot and Ankle Joints
Active full ROM is performed for plantar flexion, dorsiflexion, supination, and pronation
of the foot and ankle as well as flexion and extension of the toes. Any alterations in signs
and symptoms are be noted.

Myotomes (graded 0 - 5)
Several different isometric tests involving muscles of the hip and lower extremity are
used to evaluate possible weakness or dysfunction due to impairment of lumbar and
sacral spinal nerves (see Table 1 3 .2). Some of the tests involve more than a single muscle
while others provide a clear indication affecting a particular myotome.

Special Tests
Quadrant Position Test
This test is intended to position the lumbar j oints under maximum stress by means of
passive movements. This is accomplished by passively moving the patient first into full
lumbar extension, followed by lateral flexion and rotation toward the affected side. This
position results in maximal reduction in the intervertebral foramen space.
The examiner stands behind and slightly to one side of the patient and then
passively moves the patient into full lumbar extension with the examiner holding the
patient' s shoulder. Examiner' s shoulder is positioned near patient' s occiput to support the
weight of the head. Overpressure is applied at the limit of this range and the patient i s
guided into the quadrant position by laterally flexing and then rotating the spine toward
the affected side. Movement is continued until the limit of range is achieved and the
patient is asked if their pain is reproduced.

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 Chinese Orthopedics Lumbar Spine 347

Straight-Leg Raising (SLR) Tests

The presence of a disc prolapse may produce pressure on the affected nerve root within
its dural sleeve. The nerve root in question is not subjected to any increase in tension
while the patient is l ying supine or by raising the affected leg with the hip and knee
flexed. However, the inflamed nerve root can be subjected to increased tension and
caused to move in the intervertebral foramen when the leg is passively elevated with the
knee extended. Reproducing the patient' s pain is necessary for a positive sign. It is
common for the range of straight-leg raising to be lower in patients with intervertebral
disc prolapse which produces nerve root pressure at L4, L5, or S 1 .
The patient is lying supine in all the SLR type tests with each leg being tested
separately starting with the unaffected or painless side first. To ensure that hip-joint
movements are normal the hip is first placed in slight adduction and slight medial rotation
before being passively flexed by raising the leg by the heel in one hand while the other
hand is place proximal to the knee to maintain knee extension.

Table 1 3.2. Isometric tests for neurological assessment of lumbar spine

Root Muscle MD Movement Isometric Test
l2 Iliopsoas ALF Hip flexion Patient is supine with hip and knee both flexed go·, resistance to
further hip flexion is applied just proximal to the knee
L3 Quad riceps ALF, Knee extension The examiner slightly flexes the hip of the patient's test leg by
AMF slipping one arm under the lower thigh to grasp the opposite thigh,
and the patient moves the leg to near full extension, while
examiner applies a force on top of the leg just proximal to the
ankle, to resist knee extension
L4 Tibialis a nterior ALF Ankle dorsiflexion While supine, the patient holds the foot in dorsiflexion and
& inversion inversion while the examiner applies force against the
dorsomedial surface over the proximal end of the first metatarsal
to resist movement
L5 Extensor hallucis MF Big toe extension Lying supine, patient holds the foot and toes in dorsiflexion while
longus the examiner applies resistance against the nail of the big toe
L5. S 1 Extensor ALF Extension of toes Lying supine, the patient holds the foot and toes in dorsiflexion
d igitorum longus while the examiner applies resistance against the dorsal surface
of all toes
S1 Peroneus longus PLF Ankle eversion Lying supine, patient holds heels together while sides of the feet
and brevis are twisted outward from each other, and the examiner applies
resistance to the lateral border of the feet to push them together
L5, S 1 Hamstrings PLF, Knee flexion Either prone or supine, the patient holds the knee flexed 90" ,
PMF, while the examiner applies resista nce behind the patient's heel
LF
L4, 5, Gluteus maxim us PLF Hip extension Lying prone with knee bent, patient holds the hip extended while
S1. 2 the examiner applies downward resistance on the back of the leg
with one hand and palpates the gluteus maxim us with the other
S1 Gastrocnemius PLF, Plantar flexion Patient stands on one leg and attempts to raise his or herself up
PMF onto the toes through the full range, six times
S2 Flexors digitorum AMF Flexion of toes Lying supine, the patient holds all toes into flexion while the
& hallucis longus examiner applies resistance against the plantar surface of all toes
MD - Muscle D1stnbut1on

Standard SLR Test

Leg on the affected side (after testing the pain free side) is passively lifted by the
heel while the examiner's other hand is placed proximal to the knee to keep it extended
while the hip is in slight adduction and slight medial rotation. The pelvis in not allowed
to rotate or rise. Elevation of the leg continues smoothly until pain and/or paresthesia are

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C hinese Orthopedics Lumbar Spine 348

elicited and their distribution is consistent with the patient' s presenting complaints. The
range of the movement is estimated.
SLR with Foot Dorsiflexion
This is a slight variation of the above test where the affected leg is passively
elevated as before to produce pain after which the foot is dorsiflexed which should cause
the patient' s pain to be exacerbated as the nerve root is further stretched. This would
confirm that the pain is not being produced by muscle or ligamentous pull. One variation
of this test is to initially raise the affected leg with the foot dorsif1exed until pain is
provoked in which case the foot is returned to the normal position to see if the pain is
relieved. Another variation is to provoke pain in the affected leg with the standard SLR
and slightly lower to leg until the pain subsides, at which time the foot is dorsiflexcd to
reproduce the pain.
SLR with Neck Flexion (Dural Stretch)
This test is basically the same as the standard SLR where the affected leg is
passively elevated as before just short of producing pain. The patient then f1exes the neck,
or the examiner may passively flex the patient's neck to stretch the dura and possible
reproduce the leg pain.
SLR with Popliteal Compression (Bowstring or C ram Test)
In this variation, the affected leg is passively elevated just short of producing the
patient's pain. The knee is then flexed and supported on the shoulder of the examiner,
who then applies pressure over the popliteal fossa with both thumbs to reproduce
patient's pain. Test considered positive if there is a tingling, burning sensation in the hip
and buttocks, indicating possible sciatic nerve root impingement.
Lasegue's Sign
This variation of the leg test is performed in the supine position with the knee and
hip flexed to 90° and supported by the examiner. The knee is then passively extended by
the examiner, while stabilizing the leg with the other hand just above the knee, until the
pain is reproduced.
Kernig/Brudzinski Test
The patient is supine with hands cupped behind the head and is instructed to flex the head
onto the chest. The patient then actively raises one extended leg by flexing the hip until
pain is reproduced. At this point the patient is instructed to flex the knee and the pain
should be relieved. A positive sign may indicate meningeal irritation, dural irritation, or
nerve root involvement. This test is similar to some of the straight leg raising tests except
the movements are actively performed by the patient. Kemig described the hip flexion
component of this test while Brodzinski originally described the neck flexion aspect of
this test.
Well Leg Raising Test (Fajersztajn/ Lhermitt's Test)
This is also known as the cross leg test or cross over sign, the well leg raising test of
Fajersztaj n, sciatic phenomena, prostrate leg raising test, or Lhermitt's test. It involves
provoking pain and other symptoms while raising the leg of the unaffected side. It often
indicates a large intervertebral disc protrusion that lies medially to the nerve root on the
affected side. Raising the unaffected leg also stretches the dura causing the roots on the

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Chinese Orthopedics Lumbar Spine 349

opposite side to slide slightly downward and toward the midline. In the presence of a disc
lesion this test increases root tension. The test is positive if pain extends from the back
into the leg in the sciatic nerve distribution.
Anintervertebral disc central protrusion will likely cause pain in the back; a
protrusion in the intermediate area causes pain in the posterior aspect of the lower limb
and low back; and a lateral protrusion will primarily cause posterior leg pain.
Prone Knee Bending
Patient lies prone while the examiner passively flexes the knee as far as possible with the
heel resting on the buttocks. This position should be held for 45 to 60 seconds unless pain
is provoked sooner. At the same time the examiner should ensure that the patient' s hip is
not rotated. If the knee cannot be flexed beyond 90° because of pathological conditions,
the test may be continued by flexing the hip along with maximum knee flexion possible.
Unilateral lumbar pain may indicate an L2 or L3 nerve root lesion.
This test also stretches the femoral nerve. Pain in the anterior thigh may indicate
tight quadriceps muscles. If the rectus femoris is tight, taking the heel to the buttocks may
cause torsion to the i lium causing possible sacroiliac or lumbar pain.
Femoral Nerve Stretch Test
Patient lies on the unaffected side with the leg slightly flexed at the hip and knee.
Patient' s back should be straight with the head slightly flexed. Examiner grasps patient's
affected leg and extends the patient' s knee while gently extending the hip to about 1 5°.
Patient's knee on the affected side is then flexed further stretching the femoral nerve.
Pain will radiate down anterior thigh if test is positive.
Valsalva Test
While seated the patient is instructed to take in a full breath and hold it, and then bear
down as if they were trying to move the bowels. If pain increases it indicates increased
intrathecal pressure which leads to symptoms in the sciatic nerve distribution. Symptoms
may be accentuated by first having the patient flex the hip to a position just short of
causing pain. Test is positive if pain increases or there is a mass protrusion.

Neurological Evaluation of Lumbar Spine

Key Reflexes (graded 0 - 4)
1 ) L4: quadriceps muscles
2) S l , 2 : Achilles' tendon

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View: This view is used to note: vertebrae shape and possible
deformities; presence of wedging; possible fractures; disc space; presence of bamboo
spine; and osteophyte formation.
Lateral View : This view is used to note: evidence of spondylosis or spondylolisthesis
(grade degree of slippage); vertebrae wedging; disc space; condition of intervertebral
foramina; alignment of vertebrae; normal lordosis; and osteophyte formation.

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Chinese Orthopedics Lumbar Spine 350

Oblique View : This view is used to note evidence of spondylolisthesis of spondylolysis.

Magnetic resonance imaging (MRI)
Magnetic resonance imaging is commonly used to examine the lumbar spine to view: the
spinal cord within the spinal canal; presence of syringomyelia; spinal cord infarction;
delineation of disc features, diagnose tumors; and examine effects of traumatic incidents.
Computed tomography
Computed tomography (CT) scans can delineate spinal stenosis caused by bony
outgrowths, disc protrusion, or tumor, and well as fractures. Axial views can delineate
spinal anatomic details including the facet joints, paravertebral muscles, vascular
structures, and internal organs.
Myelography
A myelography examination can confirm the presence of spinal stenosis, tumor,
protruding disc, and osteophytes but is not commonly used due to possible side effects
and the fact the MRI and CT scans can provide the same information.
Discography
A discography involves i nj ection of a radiopaque dye into the nucleus pulposus to
observe details of disc abnormalities. This technique is not commonly used.

Management of Lum bar Spine Disorders

Mobilization
Mobilization techniques for the lumbar spine are similar to what is applied in the thoracic
region. Many procedures are available for use in the lumbar region and only the most
common techniques are described below.
Posteroanterior Central Vertebral Pressure
This technique involves the application of oscillatory pressure on the spinous process by
means of the therapist's body transmitted through the arms and hands. It is essential that
the pressure be produced by the therapist's body weight and not by the arms and hands
alone. Posteroanterior central vertebral pressure is important for addressing all cases of
lumbar pain, especially midline pain with some radiation out to both sides. Thus, it is
valuable to use in patients with a mechanical derangement of the lumbar intervertebral
joint and is particularly valuable in patients with lumbar spondylosis.
The patient lies prone with the arms at the side and the head turned to side, while
the therapist stands at the left side. The therapist leans over the patient to place his or her
pisiform area of the left hand over the spinous process and reinforces it with pressure by
the right hand. Pressure is app lied through the weight of the therapist basically at right
angles to the lumbar vertebrae being treated. The goal is to apply pressure essentially at
right angles to the area being mobilized.
The therapist produces an oscillatory movement by rocking his or her upper trunk
up and down, with the pressure being applied through the shoulders and arms.

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Posteroanterior Unilateral Vertebral Pressure

This mobilization technique involves oscillatory pressures to the vertebral transverse
processes by movement of the therapist's trunk directed through the arms and thumbs.
This technique is used to address hypomobility lesions involving the upper or middle
lumbar spine associated with localized back pain and muscle spasm.
The patient lies prone with his or her head turned to one direction and arms to the
side. The therapist stands on the side being treated, leaning over to apply the thumb pads
lateral to the spinous process in question. The therapist positions his or her shoulders
directly over the hands and applies pressure in a direct line through the shoulders and
arms at right angles to the patient's body. The thumbs do not move independently.
Transverse Vertebral Pressure
The therapist applies pressure to the lateral aspect of the lumbar spinous process in this
technique. Oscillatory pressure is applied through the therapist's arms and thumbs by
moving his or her trunk. Transverse vertebral pressure is used to address unilateral
lumbar pain and is more useful for upper than for lower lumbar pain.
With the patient lying prone with arms to the side, the therapist stands at the right
side of the patient with thumbs against the right side of vertebra requiring transverse
mobilization. The therapist's thumbs are placed against the side of the spinous process to
apply the oscillatory movement by motion of his or her trunk. Transverse pressure can be
reinforced by the therapist placing one thumb on top of the other. The range of movement
produced b y this technique is greater at L l than at L4.
Rotation
Rotation mobilization is perhaps the most common effective technique for the lumbar
spine. It is used for patients with unilateral back or leg pain and in patients who have
central-back pain with a restriction of movement on one side only.
It is important to localize the rotation to the lumbar region. This is accomplished
by appropriate positioning of the patient's thorax and pelvis while positioning the lumbar
spine toward either extension or flexion by extension or flexion of the hip.
The patient lies on the side with a pillow under the head and the therapist applies
an oscillatory movement to the pelvis. Initially the patient's hips and knees are slightly
flexed. If the patient is lying on his or her right side the therapist stands behind with the
left hand placed on the left side of the patient's pelvis to rotate it back and forth while
stabilizing the thorax with the therapist's right hand applied to the patient's left shoulder.
In using rotation to treat conditions involving the upper lumbar region, the spine
is held in minimal extension by keeping the leg above the one interfacing with the table,
either straight or in slight extension. In addressing lower lumbar region problems the
above leg is flexed to move the lumbar toward flexion. The amount of leg flexion can be
varied to focus the rotation mobilization to specific vertebrae. The above leg position can
be varied from no flexion to full flexion with the leg hanging over the treatment table.
Longitudinal Movement (Traction)
Application of a longitudinal traction force is especially effective in patients who
experience a sudden onset of severe pain, either in the lower lumbar midline or radiating

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Chinese Orthopedics Lumbar Spine 352

to one side, and in those patients who might not be able to be positioned for the other
mobilization techniques.
A gentle and rhythmical longitudinal movement is induced by the therapist
pulling on one or both of the patient's legs. As in other mobilization procedures, the
therapist applies the force by holding the arms straight and then moving the trunk
rhythmically backward and then relaxing the pull each time.
Spinal Traction
(See section on manual thoracolumbar spine traction in Chapter 1 2)

Manipulation
Manipulation of the lumbar spine is an extension of the mobilization techniques
previously discussed. The main difference in manipulation is that a rapid thrust is often
applied at the limit of normal range (Grade V movement, to increase mobility). Non­
specific manipulation techniques, such as rotation and posteroanterior pressure, are
directed to areas of the lumbar spine rather than localizing the therapy to a specific
intervertebral segment.
Rotation
In this procedure, the patient is supine while the therapist stands to the right side of the
treatment table with his or her left hand stabilizing the patient's left shoulder. With the
right hand the therapist positions the patient's left hip and knee into flexion at a right
angle. The therapist rotates the patient's pelvis to the right limit of range by pulling the
left knee across the body and down toward the floor.
At this point the therapist grasps the posterolateral aspect of the patient's left
upper calf with his or her right hand and applies a counter-pressure with the left hand
against the shoulder. The underneath leg can be appropriately positioned to place the
lumbar spine into either extension to address the upper lumbar region or flexion to
address the lower lumbar region.
An oscillatory rotational movement at the limit of range is applied by both hands
once the patient is suitably positioned. A sudden downward and rotary thrust is added to
the leg while maintaining a strong counter-pressure against the patient's left shoulder. It is
essential for this movement to produce a rotation of the pelvis and lumbar spine and not
simply adduction movement of the leg.
Posteroanterior Pressure
This manipulation technique is performed with the patient lying prone and the therapist
standing to the side. Using the dominant hand, the therapist places his or her pisiform
bone against the patient's lumbar spinous process, applying pressure to stretch the
intervertebral j oint.
When the joint is stretched to the limit a sudden, very small range, thrust
movement is applied. To increase the effectiveness of this procedure, the patient's legs or
trunk may be supported in a position of extension.

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Chinese Orthopedics Lumbar Spine 353

Needling Therapy for Low Back Problems

Assessment and treatment of the low back region follows the same general guidelines for
any other part of the body. Since the muscles in the low back region are assigned either to
the posterior lateral foot (PLF) or posterior medial foot (PMF) muscular distributions the
nodes Feiyang (PLF 58) or Zhubin (PMF 9) are respectively selected as the candidate
distal nodes (See Table 1 3 .3). Low back pain is normally treated bilaterally even though
the patient only complains of pain on one side. Lumbar pain frequently reflects in the
sacral region and hence additional nodes are selected that have an influence on this region
(See Table 1 3 . 1 ).
Acute Presentation
In acute presentation of low back pain, which often involves severe pain and cramps,
different special nodes may be considered. These are used reduce the symptoms to the
level where the condition can be treated with the general nodes noted in Table 1 3 .3 . One
of the most effective special nodes for reducing acute low back pain is the node
Yaotongdian (low back pain spot) which is employed as follow:
Yaotongdian consists of special nodes on the dorsum of the hand located in the proximal
aspect of the second and forth interosseus spaces. These are used specifically to reduce
pain and spasms in the low back. Needles are inserted into each location at a 45° angle to
the dorsum pointing toward the metacarpal heads while the needle handle leans distally.
Needles are inserted while patient is seated with hands and fingers held straight out, and
then strongly stimulated to obtain good needling reaction. While holding hands and
fingers in same relative position, the patient stands and periodically slowly rotates body
and hips and then slowly walks around. Needles are periodically stimulated to sustain the
needle reaction. Needles are removed in approximately 1 5 minutes and normal treatment
proceeds
Node Selection for Low Back Pain and Related Conditions
Candidate local and adjacent nodes consist of nodes appropriately selected for their
influence on the lumbar region as well as node Huantiao (LF 30). All these nodes also
function as proximal nodes. Distal nodes are selected for either the PLF or PMF muscular
distribution, depending on the assessment to determine the most likely distribution
involved in the presenting complaint. Additional nodes can be added if the pain and other
symptoms radiate into the sacrum. Also, additional node along the PLF muscular
distribution may be added depending on specific patterns of pain and other symptoms.

Table 1 3. 3 . Candidate reg ional, proximal and distal nodes for low back pain and related
disorders.
Low Back Pain Candidate Local & MD Proximal Nodes Distal Nodes
Adjacent Nodes
Shenshu (PLF 23) PLF Feiyang (PLF 58)
Mingmen (DU 4)
Dachangshu (PLF 25) PMF Zhubin (PMF 9)
Huantiao (LF 30)
With Kidney Xu Taixi (PMF 3)
Acute Presentation Yaotongdian (Extra)

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Chinese Orthopedics Lumbar Spine 354

Candidate Electroneedling (EN) Application Low Back Pain

Electroacupuncture lead placement for low back pain is initially selected for the main
nodes that cover the area of the low back bilaterally. Placement of the negative ( ) lead
-

can be changed to lower positions on the back and leg to address other specific symptoms
using the following protocol :
Frequency: 2 Hz
Mode: Continuous
Duration : 20 - 30 minutes
Lead placement (bilateral):

•
Shenshu (PLF 23) + lead, to Dachangshu (PLF 25) - lead
•
If pain in buttocks present, especially involving the hip lateral rotators, the lower
(negative) lead is moved after 1 5 minutes from Dachangshu (PLF 25) to Huantiao
(LF 3 0)
•
If sciatica is present, after 1 5 minutes switch - lead, from Dachangshu (PLF 25)
to Feiyang (PLF 58) for another 1 5 minutes
•
In the case with pain in the buttocks along with sciatica and the negative lead is
switched from Dachangshu (PLF 25) to Huantiao (LF 30) after 1 0 minutes and
then switched to Huantiao (LF 30) after another 1 0 minutes
Possible Treatment for Scoliosis
Idiopathic scoliosis can be addressed with needling therapy, especially in the early stages
of development. Needling therapy as well as EN can be considered. Node selection
depends exactly what section of the thoracolumbar spine is involved. Needle selection is
symmetric of each side of the spine, but EN is to be applied to the nodes on the affected
weak side that involves the flaccid muscles. The stronger muscles on the good side cause
the spine to bend toward that side and away from the weak side. There are few if any
studies showing that scoliosis can be effectively treated with needling therapy or with
exercise.
Some studies suggest that scoliosis may be the result of problems in coordination
involving the proprioceptive system since many patients suffer with nystagmus. Also,
there may be a postural component to this problem. Some studies that used a biofeedback
type device to train patients to maintain better posture showed positive results. In
addition, diet and behavior may have an influence since weak bones have also been
suspected. Consumption of soft drinks that contains phosphoric acid is now known to
weaken bones because it causes the body to lose calcium. These are popular drinks for
young people. Also, smoking has a major impact on bone weakness due to the
stimulation of parathyroid hormone. Finally, exercise is essential to help strengthened the
weak muscle, but to date this has not shown to be the only answer. One study did show
that thoracolumbar rotation exercises did tend to stabilize scoliosis.
The treatment protocol uses bilateral needling therapy including EN only on the
affected side to address possible problems in the proprioceptive system while also
strengthening the weak muscles as follows (See Table 1 3 .4):

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Ch inese Orthopedics Lumbar Spine 355

•
Nodes Tianzhu (PLF 1 0) to influence coordination problems as mediated by the
cerebellum
•
Nodes on the thoracic spine at the upper level of the scoliosis that may be around
Jueyinshu (PLF 1 4), Xinshu (PLF 1 5), or Dushu (PLF 1 6), only select one.
•
Nodes on the lumbar spine at the lower level of the scoliosis that may be around
Shenshu (PLF 23) or Qihaishu (PLF 24), only select one.
•
Three intermediate nodes spaced between the upper nodes on the thoracic and
lumbar spine
•
Possibly consider Huantiao (LF 30) to influence posture
•
Consider both Feiyang (PLF 58) and Zhubin (PMF 9) since the superficial back
extensors and the deeper muscles are involved in this problem
Exercise is directed strengthening thoracolumbar rotation and back muscles on the
weak side. Rotation is accomplished by having the patient while seating to cross their
arms across the chest and slowly rotate to the left and then right through the full possible
range of motion. Patient is trained to tighten the antagonistic muscles that oppose
rotation. This may require some effort to get the patient to be able to dynamically resist
voluntarily controlled axial rotation. Other exercises include lifting a light weight straight
up from the shoulder while seated on the edge of the treatment table. Slowly build up the
number of repetitions. Other additional exercises include lying prone with the arm on the
weak side extended straight above the head. Patient lifts the arm off the floor through
several repetitions. Then the patient extends the leg on the weak side by lifting it up off
the floor. Several sets can be completed by first doing the arm lift followed by the leg lift
and then repeat.

Table 1 3.4. Candidate regional, proximal and distal nodes for scoliosis.
Scoliosis Candidate Local & MD Proximal Nodes Distal Nodes
Adjacent Nodes
Cervical spine Tianzhu (PLF 1 0) PLF, Feiyang (PLF 58)
PMF Zhubin (PMF 9)
Thoracic spine Jueyinshu (PLF 14),
Xinshu (PLF 1 5) , or
Dushu (PLF 1 6)
Lumbar spine Shenshu (PLF 23) or
Qihaishu (PLF 24)
I ntermediate nodes 3 selected between
upper thoracic and
lower lumbar nodes
Buttocks Huantiao (LF 30)
MD = Muscular D1stnbutron

Candidate Electroneedling (EN) Application for Scoliosis

Electroneedling lead placement for scoliosis is for the selected upper thoracic spine node
and the selected lower lumbar spine node only on the side that has muscle weakness
which is opposite to the strong side which is causing the spine to bend to the strong side,

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using the following protocol :

Frequency: 2 to 25*Hz
Mode: Mixed mode
Duration : 20-30 minutes
Lead placement (unilateral):

•
Positive lead (+) on the upper thoracic node and the negative (-) on the lower
lumbar node.
*Increase amplitude only during the high frequency period of the mixed frequency mode.

Remedial Exercises
See Chapter 1 2

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Chinese Orthopedics Pelvis 357

14

Pelvis

The pelvis basically consists of the sacrum including the coccyx and the innominate bone. It forms
two maj or joints in the body consisting of the lumbosacral j oint that articulates with the fifth
lumbar vertebra and the hip joint which articulates with the femur. There are three other important
joints, along with their ligaments, that basically hold the pelvis together including the sacroiliac,
symphysis pubis, and sacrococcygeal joints. M�jor ligaments of the pelvis include:
•
Interosseous ligament (Syndesmosis: a type of fibrous joint in which intervening fibrous
connective tissue forms an interosseous membrane or ligament)
• Dorsal ligaments
• Sacrotuberous ligament
• Sacrospinous ligament
•
lliosacral ligaments (anterior and posterior sacroiliac ligaments)
• lnguinal ligament
The sacroiliac joint consists of a synovial joint formed between the lateral aspect of the
upper sacral vertebrae and the medial surface of the ilium. The sacroiliac joint is unique in that the
space formed between the sacrum and ilium above this synovial joint is joined by a strong
interosseous ligament (syndesmosis) which occupies about one third of the vertical distance
between these two bones. The articular surfaces are slightly irregular and interlocked giving
stability to the joint. The bony surfaces are lined by articular cartilage which is thicker on the sacral
side of the joint. The joint is surrounded by a synovial membrane lined capsule. Stability of
sacroiliac joint relies on two ligaments that connect the sacrum and i lium which lie anteriorly and
posteriorly to the joint. The posterior sacroiliac ligament i s strong while the anterior ligament is
thin and weak.

Physiology of the Pelvis

The pelvis serves as a maj or structural component of the body that supports the weight of the upper
body and transmits this load through to the legs and ground. Although the pelvis serves as the
origin and insertion site for numerous muscles, there are no intrinsic muscles that articulate the
bones comprising the pelvis. However, there is slight but critical movement in the sacroiliac joint
and in the symphysis pubis during pregnancy. The sacroiliac joints basically connect with the
spinal column and are the most likely source of pain and other problems. Problem affecting the hip
and the hip joint are discussed in Chapter 1 5.

Surface anatomy
The pelvis surface anatomy can easily be palpated and identified including the following important
landmarks:
• I liac crest
•
Anterior superior iliac spine (ASIS)
• Posterior superior iliac spine (PSIS)

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• Coccyx
• Ischial protuberance
• Pubis

Problems of Sacroiliac Joint

This j oint is the main source of pathology in the pelvis which is similar in nature to problems
affecting other joint of the spine. However, there is little movement in the sacroiliac joint and in
that sense the problems are focused on this area, and are limited.
Sacroiliac Pain
Thi s i s the most common complaint of the sacroiliac joint and is normally characterized as a dull
ache that is usually felt in the buttocks but can be referred to the groin. The pain can be referred to
the lower abdominal region as well, and may also radiate into the posterior aspect of the thigh but
normally does not go below the knee. Pain may be felt in the iliac fossa which is usually due to
tenderness over the iliacus muscle. This condition may cause confusion with intra-abdominal
problems. Patients may also feel pain anteriorly over the adductor tendon origin or the pubic
symphysis. There is often a history of buttock pain in subjects with infl ammatory sacroiliitis which
alternates from one side to another, which is worse at night. There may be associated back stiffness
that is not related to postural problems. Neurological symptoms of parestheiasis and numbness are
absent in patients with sacroiliac problems even if they may report a dull, heavy feeling in the leg.
Pain felt in the sacroiliac area may be referred from the lower lumbar spine or hip joint.
Therefore it is essential to perform a clinical assessment of both of these areas before assessing the
sacroiliac j oint. It is not uncommon for degenerative hypomobility lesions of the lumbosacral joint
to reflect into the sacroiliac joint mimicking possible sprain. Pain as the result of mechanical
lesions of the sacroiliac joint is typically unilateral and can be exacerbated by movements which
stress the sacroiliac joint.
Inflammatory disease
Inflammatory disease of the sacroiliac joint with spondyloarthritis including variety sources such as
ankylosing spondylitis, Reiter's disease, Still ' s disease, Behcet' s disease, psoriatic arthritis, and
arthritis associated with inflammatory bowel disease, such as ulcerative colitis, and Crohn's disease.
Spondyloarthritis includes ankylosing spondylitis which is involved in infl ammatory changes in the
spinal joints and bilateral sacroiliitis.
Infections
These usually involve only one sacroiliac joint caused by tuberculosis or staphylococcal infections.
These conditions now occur more rarely than in previous years.
Hypomobility Lesions
This i s a mechanical derangement lesion of the sacroiliac j oint that remains an infrequent but
relatively important cause of pain in the lower back. This usually occurs in younger people and
may be associated with activities that put rotation stress on the sacroiliac j oint as tennis, golf, and
ballet dancing. It can also follow pregnancy, childbirth, or trauma. It may also be the result of
structural deficits such as unequal leg length, or an unsymmetrical development of the pelvis.
Sacroiliac tests should reproduce the patient's symptoms that may be addressed by mobilization
techniques.

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Hypermobility Lesions
This lesion of the sacroiliac joint is rare and can occur in one or two ways. The first of these usually
occurs in athletes and is secondary to instability in the pubic symphysis. The condition may be
complicated by a mechanical derangement of one or both sacroiliac joints and may also be
associated with osteitis condensans ilii. The second situation usually occurs during or soon after
pregnancy with the patient complaining with sacroiliac pain that is made worse by walking or
standing. Manual therapeutic methods usually exacerbate the symptoms.
Degenerative Changes
These changes would be expected to occur in the articular cartilage of the sacroiliac synovial joints.
Changes are first seen in the iliac surface where the cartilage is thinner as opposed to the sacral
side. Cartilage changes are similar to what is seen in the peripheral joints with an eventual fibrous
ankylosis of the joint cavity. X-rays show a loss or irregularity of the j oint space, subchondral
sclerosis, and osteophyte formation. Degenerative changes are increasingly more common with
advancing age, which may be secondary to conditions where movement of the sacroiliac j oint is
decreased. This condition is seen in people who are immobilized including patients with hip joint
diseases. It is common to find degenerative changes in the contralateral sacroiliac joint in patients
with unilateral hip disease.
Osteitis Condensans /Iii
This condition is characterized by a condensation of bone on the iliac side of the sacroiliac joint.
Etiology is uncertain but may represent a bony response to unequal stress on this j oint. Detection of
the problem is usually a coincidental radiological finding and not particularly associated with the
patient' s symptoms. This occurs most often in young adults, especially after childbirth when
complaints in pain in the back and sacroiliac j oint are common.

Assessment of Sacroiliac Joint

Observation
Posture of the patient is first examined looking for any abnormalities in posture, patient listing,
body alignment, spinal curvatures, and deviations from the frontal and sagittal planes. Distance of
the PSIS and ASIS to the floor is measured on each side. The symphysis pubis is also palpated to
determine if both sides of the joint are level. The ischium on each side is palpated to determine
their alignment. Pelvic alignment while standing and sitting with forward bending is assessed as
well as measurements of leg length.
Pelvic Movement
Several tests can be employed that assess the function and status of the anterior and posterior
sacroiliac innominate rotation displacement with respect to the sacrum, including fixation of the
sacroiliac j oint (hypomobility), by detecting movement of the PSIS or ischium. These tests can be
performed with the patient standing or sitting.
Sta nding (Gillet's Test)
Examiner palpates the PSIS on one side with one thumb and palpates one of the sacral
spines with the other thumb while the patient i s standing. Patient then instructed to fully flex the hip
by pulling the leg with the knee flexed, up to the chest on that side while noting if the PSIS drops as

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it normally should or whether it elevates indicating possible fixation of the sacroiliac j oint on that
side. The examiner then tests and compares the other side.
The examiner next places one thumb on one of the patient's ischial tuberosities and one
thumb on the sacral apex. The patient is instructed to flex the hip as before again on this side. If the
thumb on the ischial tuberosity moves l aterally, the motion is normal. If the sacroiliac j oint on this
side is fixed, the thumb moves up. The other side is then tested and compared. This test is referred
to as Gillet' s test or sacral fixation test.
Sitting Forward Bend ( Piedallu's Sign)
This test is conducted with the patient sitting on a firm surface to keep the muscles
(hamstrings) from affecting pelvic flexion symmetry while increasing stability of the ilia. The
examiner palpates the PSIS and compares their heights. If the PSIS on the affected or painful side is
lower than the other, the patient is instructed to bend forward while remaining to be seated. If the
PSIS that was in a lower aspect now becomes higher than the other, this a positive test confirming
sacroiliac joint hypomobility on the affected side. This indicates an abnormality in torsion
movement of the sacroiliac joint.
This test can also be performed from the standing position with the examiner holding the
pelvis from the posterior aspect with fingers on the iliac crests and each thumb placed on one of the
posterior superior i liac spines (PSIS). The patient is then instructed to bend forward slowly while
the examiner maintains the hands on the pelvis and thumbs on both posterior superior iliac spines
(PSIS). If the PSIS levels are equal when standing but unequal with forward bending, the test is
considered positive. This finding implicates possible unilateral sacroiliac joint hypomobility with
either anterior sacral innominate displacement on the higher side, or posterior sacral innominate
displacement on the lower side.
Leg Length Measurement
This measurement should always be performed if the examiner suspects a lesion in the sacroiliac
joint. Nutation (backward rotation) of the ilium on the sacrum will result in a decrease in leg length
as will contranutation (anterior rotation) on the opposite side. If the iliac bone is lower on one side
of the symphysis pubis, that leg will usually be shorter. True leg length is measured with the patient
supine with the anterior superior iliac spines (ASIS) level and the patient's lower limbs
perpendicular to the line j oining the two the anterior superior iliac spines. Using a flexible tape
measure, the examiner obtains the distance from the ASIS and the lateral or medial malleolus on
the same side. The measurement is repeated on the other side. A difference of 1 to 1 .3 em is
considered normal.
Leg Length Reversal (Supine to Set Test)
The patient lies supine with the legs straight with the body while the examiner compares the
relative length and symmetry of the two legs. The patient is then instructed to sit up and the
examiner observes if one leg moves up (proximal) farther than the other leg. This situation
indicates that there is a functional leg length difference resulting from a pelvic dysfunction as result
of pelvic torsion.
If the leg on the affected side appears Longer than the other leg when the patient is supine
but Shorter when sitting, this is a positive test implicating Anterior innomination rotation on the
affected side (LSA). On the other hand, if the leg on the affected side appears Shorter than the other

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leg when the patient is supine but Longer when sitting, this is a positive test implicating Posterior
innomination rotation on the affected side (SLP).

Passive Movement Tests

Movement of the sacroiliac joint is normally slight, but can be assessed by a series of passive tests.
These are designed to reproduce the patient's symptoms and help differentiate between lumbar and
sacral problems. Movement of the sacral area has an obvious affect on the lumbar region and
therefore false-positive and false-negative findings are not uncommon.
Posteroanterior Sacral Glide (PA Oscillation)
With the patient lying prone the examiner imparts rhythmical oscillation of the sacrum by applying
posteroanterior pressure over the sacrum. This is accomplished by examiner by placing the heel of
his or her hand over the patient's sacrum and then placing the other hand over the first hand for
stabilization. The examiner's arms are held extended and his or her body weight is used to impart a
springing movement that produces a shearing movement of the sacroiliac joint and produces
movement in the lumbosacral joint. This technique is considered one of most useful tests to apply
to the sacroiliac joint.
Cephalad Sacral Glide
This procedure stresses the sacroiliac j oint by stabilizing the ilium of the prone lying patient with
one hand of the examiner and then moving the sacrum in the cranial direction. The examiner places
the stabilizing hand against the ilium on one side and applies counteracting force toward the feet.
The examiner's other hand is placed over the apex of the sacrum to direct sacral movement toward
the head.
Caudal Sacral Glide
This procedure is opposite to the one j ust described above and stresses the sacroiliac j oint by
stabilizing the ischium of the prone lying patient with one hand of the examiner and then moving
the sacrum in the caudal direction. The examiner places the stabilizing hand against the ischial
tuberosity on one side and applies counteracting force toward the head. The examiner's other hand
is placed over the head of the sacrum to direct sacral movement toward the feet.
Anterior Sl Joint Distraction (Pelvic Rock)
This procedure produces anterior distraction of the sacroiliac j oint by putting pressure against each
anterior superior iliac spine ASIS. With the patient lying supine, the examiner leans over the patient
with his or her arms crossed to place the right hand on the patient's right ASIS and the left hand on
the left ASIS. Anteroposterior pressure is applied which seems like the two iliae are being spread
apart.
-+ Reprodu ction of the patient's symptoms by anterior sacroiliac j oint distraction indicates
possible involvement of the anterior sacral ligament, which could include a potential tear in
this ligament.

Posterior Sl Joint Distraction (Iliac Compression)

This procedure is basically opposite to the one j ust described above and involves posterior
distraction of the sacroiliac joint by putting lateral pressure against each i liac crest. With the patient
lying supine, the examiner leans over the patient placing his or her hands against the lateral aspect

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of each iliac crest and applying a medially directed force. This compresses the iliac crests like
squeezing them together.
This test can also be performed with patient lying on one side with the examiner applying a
downward pressure on the lateral aspect of the iliac crest to produce the effect of compressing the
two together by resistance of the other iliac crest against the table.
-+ Reproduction of the patient's symptoms by posterior sacroiliac joint distraction ind icates
possible i nvolvement of the posterior sacral l igament, which could include a potential tear
in this ligament.

Active Movement Tests

There is controversy and speculation over the role of movement in the sacroiliac joint and whether
active muscle testing is appropriate to stress this j oint. However, there is little doubt about the
importance of movement in the sacroiliac joint, which is only a few millimeters, and its essential
role in normal movement of the lumbar spine. Sacroiliac movement as well as that of the
symphysis pubis is important in pregnancy. However, there are active and resisted isometric
movements that can be performed with muscles that attach to the pelvis with the intention of
applying stress to the sacroiliac j oint.

Resisted Isometric Movements

Certain resisted isometric tests of muscles that move the spine or hip can be used to apply stress on
the pelvis and the sacroiliac joint. These tests can be performed with the patient in a supine position
to include the following resisted isometric movements:
•
Forward flexion of the spine by contraction of the abdominals to apply stress on the
symphysis pubis
•
Flexion of hip by the iliacus to stress the sacroiliac j oint
•
Extension of hip by gluteus maximus to stress sacroiliac j oint
•
Abduction of hip by gluteus medius to stress sacroiliac j oint
•
Adduction of hip by adductors to stress the symphysis pubis

Functional Assessment
The sacroiliac joints do not work in isolation so it is difficult to perform a meaningful functional
assessment of the pelvis. From a functional viewpoint the sacroiliac j oints should be considered as
part of the lumbar spine or associated with the hip joint depending on the details of presenting
clinical problem.

Special Tests
Additional tests are usually necessary to obtain more information in order differentiate sacroiliac
joint pain from pain originating with the lumbar spine. The first of these tests, involving passive
extension of the hip is usually always performed, even when suspecting the presenting back pain is
due to the lumbar problems. The other tests involve contraction of the hip adductors and abductors
and other movements to test the ligaments of the pelvis and the sacroiliac joint.

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Passive Hip Extension

Patient is supine and positioned to one edge of examination table. Examiner passively lowers the
leg, with knee flexed, to move leg and hip into full extension. Reproduction of the patient's pain is a
positive sign. Test often follows just after the straight leg raise (SLR) test performed in conjunction
with assessment of the lumbar spine.
Gaenslen's Test
The patient is side lying with the upper leg straight with the knee hyperextended while the
unaffected underside leg hyperflexed by pulling the knee up to the chest. The examiner stabilizes
the pelvis with one hand whil e extending the affected leg. It is considered a positive test if pain is
provoked. Source of pain may be due to an ipsilateral sacroiliac joint lesion, hip pathology, or an
L4 nerve root lesion.
A variation of this test and the passive hip extension test is performed with the patient
supine with the hip on the affected leg extended over the edge of the table. The patient first draws
both the affected and unaffected legs up to the chest. The affected leg is then slowly lowered until it
hangs down in extension over the table edge. This test position may inhibit the amount of
extension. The other leg is tested in the same manner. Pain in the sacroiliac joint is considered a
positive test.
Isometric Contraction of Hip Adductors
The patient is supine with hips flexed 45° and knees flexed 90°, with feet flat on examination table.
Hip adductors are isometrically contracted by the patient attempting to squeeze the examiner's fist
placed between the knees.
Isometric Contraction of Hip Abductors
The patient is supine with hips flexed 45° and knees flexed 90°, with feet flat on examination table.
Isometric contraction of hip abductors is produced when examiner's hands are placed on lateral
aspect of the knees to fully resist patient's attempt spread knees apart.
Gillet's Test
This test to assess possible sacral fixation (See discussion under Sacroiliac Joints on page 345)
Goldthwait's Test
With the patient supine the examiner places one hand under the lumbar spine so that each finger is
placed in the interosseous spaces of L2 - L3 (DU 4: Mingmen), L3 - L4, L4 - L5 (DU 3 :
Yaoyangguan), and L 5 - S 1 (Shiqizhui). The examiner then uses the other hand to conduct a
straight leg raising test. If pain is provoked before movement in the intervertebral spaces is
detected, the problem lies in the sacroiliac j oint. If pain is provoked only after movement in the
intervertebral space, the problem lies in the lumbar spine. As with any straight leg raising tests,
pain may be referred along the course of the sciatic nerve.
Yeoman's Test
With the patient prone, the examiner flexes the patient' s knee 90° while simultaneously extending
the ipsilateral hip. Provocation of pain in the sacroiliac j oint indicates possible pathology in the
anterior sacroiliac ligaments. Provoked pain in the lumbar region is indicative of lumbar problems.

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Trendelenburg's Test or Sign

The patient is standing and is asked to stand or balance first on one leg and then on the other. The
examiner observes the movement ofthe pelvis while the patient i s balanced on one leg. If the pelvis
on the side of the non-stance leg rises, the test is negative. However, if the pelvis on the side of the
non-stance leg falls, the test is considered positive indicating weakness or instability of the hip
abductors, mainl y the gluteus medius muscle on the stance side.

Neurological Evaluation
a. Myotomes (graded 0 - 5)
L5 : Extensor hallucis longus muscle - extension of big toe
L5, S 1 : Extensor digitorum longus - extension of toes
L5, S 1 : Hamstrings - knee flexion
S 1 : Peroneus longus and brevis - ankle eversion
S 1 , 2: Gastrocnemius and soleus muscles - plantar flexion
S2: Flexors digitorum & hallucis longus - flexion of toes
Key Reflexes (graded 0 - 4)
S 1 , 2 : Achilles' tendon - ankle jerk

Diagnostic Imaging
Plain film radiography anteroposterior view of the pelvis is used to : delineate any fractures;
ankylosis of the sacroiliac joints (ankylosing spondylitis); displacement of one sacroiliac joint;
displacement of the symphysis pubis; demineralization or sclerosis of one or both pubic bones at
the symphysis pubis; and relationship of the sacrum to the i lium.

Management of Sacroiliac Joint Disorders

Mobilization
Posteroanterior Pressure
In this technique, the patient lies prone with arms by the side. The therapist leans over the patient
from the left side to place his or her left hand over the sacrum and reinforces it with the right hand.
The therapist's shoulders are positioned over the hands to apply oscillatory posteroanterior pressure.
Pressure is applied to the dorsal surface of the sacrum in a small amplitude oscillatory manner.
Posterior Innominate Rotation
These procedures involve backward rotation of the i liac crest to address hypomobility of the
sacroiliac j oint by correcting sacroiliac innominate anterior displacement. Mobilization therapy is
applied in the direction of posterior innominate rotation and is effective for correcting anterior
sacroiliac j oint disorders.
Side Lying
The patient is lying on the unaffected side with a pillow to support the head while the
practitioner stands in front of the patient situated between the patient's legs in order to use the
uppermost leg to support posterior innominate rotation. Practitioner grasps the patient' s pelvis with
palmar contact over the anterior iliac crest and the ischial tuberosity. Practitioner applies a rotary

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force through the palms with forearms parallel to the direction of force. An anteroposterior force is
applied to the anterior iliac crest while a posteroanterior force is applied to the ischium.
Sl Gapping (supine)
With the patient supine, the hip is flexed approximately to 1 00° and slightly abducted with
the knee fully flexed. Standing to the opposite side, the practitioner places one hand around the
ilium with fingers on the PSIS. The other hand is placed on the patient' s knee to use practitioner's
body weight to apply a force through the femur in direction of the umbilicus to rotate the
innominate bone posteriorly. Applied force can be oscillated while practitioner palpates sacroi liac
j oint gapping and accessory movement.
Supine (self-mobilization)
While lying supine the patient draws the knee on the affected side up to the chest while
bringing the upper back off the table (or mat). This position is sustained for several seconds and
then slowly released by lowering the leg. Patient can oscillate the sacroi liac j oint on the affected
side by partially easing off on the knee, especially if there is pain, and then bringing it back to the
chest. This technique is useful for sacroiliac hypomobility problems by restoring anterior sacral
innominate displacement.
Standing (self-mobilization)
This mobilization is similar to the preceding test except the patient is standing with one foot
flat on a table with the hip and knee fully flexed. Patient shifts weight forward onto the flexed leg
while using the arms to draw the knee to the chest. This position is held for several seconds and
then slowly released. Patient can oscillate the sacroiliac joint on the affected side during weight
shift and leg pull to ease any pain or other symptoms. This technique is useful for sacroiliac
hypomobility problems by restoring anterior sacral innominate displacement.
Anterior Innominate Rotation
This involves forward rotation of the iliac crest. Mobilization therapy applied in the direction of
anterior innominate rotation and is effective for correcting sacroiliac joint hypomobility disorders
by correcting posterior innominate displacement.
Side Lying
The patient is lying on the unaffected side with a pillow to support the head while the
practitioner stands in front of the patient. Practitioner grasps the patient' s pelvis with palmar
contact over the posterior iliac crest and the groin. Practitioner applies a rotary force through the
palms with forearms parallel to the direction of force. A posteroanterior force is applied to the
posterior iliac crest while an anteroposterior force is applied to the groin. This method is effective
for sacroiliac hypomobility by correcting posterior sacroiliac innominate displacement.
Through H i p Extension
Patient is prone with the leg of the unaffected side fixed on the table. Practitioner stands to
the unaffected side with one hand placed over the iliac crest of the opposite (affected leg) to
stabilize the pelvis. Practitioner grasps the femur while cradling the patient's flexed knee with the
forearm. Practitioner presses on the ilium anteriorly with the stabilizing hand while extending the
hip with the other hand to rotate the ilium anteriorly. This method is effective for sacroiliac
hypomobility by correcting posterior sacroiliac innominate displacement.

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Sacroiliac Manipulation
The same procedure used in manipulation of the lumbar spine in rotation is appropriate to treat
hypomobility lesions of the sacroiliac joint.

Needling Therapy for Sacral Problems

Node Selection for Sacral Pain
Candidate node selection for pain in the sacral area and related problems are selected to cover the
whole sacrum (Table 1 4. 1 ):
•
Nodes above the sacrum such as Pangguanshu (PLF 28), Shenshu (PLF 2 3 ), and Mingmen
(DU 4) are considered as proximal nodes
•
Feiyang (PLF 58) and Zhubin (PMF 9) used as distal nodes
•
If sacral pain occurs along with low back pain, most of these nodes can be added to the low
back nodes previously discussed under low back pain
•
Can consider substituting particular Baliao nodes (PLF 31 - 34) if pain is concentrated in
specific region of sacrum
•
With pain in coccyx consider adding Changqiang (DU 1 ), Xialiao (PLF 3 4), and Huiyang
(PLF 3 5)

Table 1 4. 1 . Regional and d istal nodes considered in treatment of sacral pain.

Sacral Pain Candidate Local & MD Proximal Nodes Distal Nodes
Adjacent Nodes
Yaoyangguan (DU 3) PLF Pangguanshu (PLF 28) Feiyang (PLF 58)
Guanyuanshu (PLF 26)
Zhongl ushu (PLF 29) PMF Shenshu (PLF 23) Zhubin (PMF 9)
Yaoshu (DU 2) Mingmen (DU 4)
MD = M uscular D1stnbut1on

Candidate Electroneedling (EN) Application for Sacral Pain

Frequency: 2 Hz
Mode: Continuous
Duration : 20 - 3 0 minutes
Lead placement (bilateral) :
•
Guanyuanshu (PLF 2 6) + lead, to Zhonglushu (PLF 29) - lead
•
If pain radiates into the leg then after 1 5 minutes switch - lead from Zhonglushu (PLF 29)
to Feiyang (PLF 5 8) for another 1 5 minutes

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Oriental Orthopedics Hip and Thigh 367

15

H ip and Thig h

The main feature of the hip is to provide an articulation for the femur as well as
attachment sites for the key muscles involved in the movement of the thigh. This is a
similar situation to the scapula and the humerus bone. The hip joint (iliofemoral joint) is a
synovial ball and socket mechanism permitting motion in three planes, including flexion
and extension in the sagittal plane, abduction and adduction in the frontal plane, and
rotation in the horizontal transverse plane. Normal limiting factors and characteristics of
the joint structures involved in movement of the hip j oint are noted in Table 1 5 . 1
The pelvis i s a bony ring structure composed of the two innominate (hip) bones
and the sacrum (Chapter 1 4) . This structure holds and protects the lower abdominal
viscera and provides a base of origin for the thigh musculature. The arch-like
construction of the pelvis transmits the body weight to the legs and ground while standing
and supports the weight of a seated individual. The sacrum is key to the structural
efficiency of the pelvic arch by directing the forces of the body weight bilaterally to the
innominate acetabulum and consequently to the femurs. The acetabulum is a cup-shaped
indentation on the lateral side of the innominate bone that forms the socket for the hip
j oint.
The innominate bones display a broad irregular shape to accommodate the
attachment of large thigh muscles such as the gluteus maxim us, medius and minimus, and
the iliopsoas muscles. The bony ring of the pubic beam and ischium provide attachment
for the hamstrings and thigh adductor muscles.
The femur is the longest bone in the body and contributes to the striding gait of
humans. The femur is also the strongest bone and must withstand significant forces of
strong muscle contractions, as well as accommodate the weight of the body. The femurs
extend obliquely from the pelvis, medially toward the knees to bring the legs closer
together in order to more efficiently support the body.
The hip joint has two close-packed positions with one at 90° of flexion and slight
abduction and lateral rotation. The other close-packed position occurs at complete
extension, internal rotation, and abduction. The hip j oint is completely slack at the "rest"
position at 1 oo flexion, 1 0° abduction, and 1 oo external rotation. Patients with an
inflamed hip may hold the hip in the rest position to help reduce pain.

Hip Physiology
The principle function of the legs and feet are to provide the capability of efficient
bipedal locomotion. Walking is probably the most common human activity and can be
performed for considerable periods of time without inducing fatigue. Disorders involving
either the legs or feet often manifest as problems or difficulties in locomotion. Muscles of
the hip function to extend, flex, abduct, adduct and rotate the thigh. Some of the thigh
muscles cross the knee j oint where they assist to extend and flex the lower leg.

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Table 1 5. 1 . N ormal limiting factors and characteristics of joint structures involved in movement of
the hip joint
Flexion Extension Abduction Adduction Internal External
Rotation Rotation
Articulation Iliofemoral I liofemoral Iliofemoral Iliofemoral I liofemoral Iliofemoral
Plane Sagittal Sagittal Frontal Frontal Horizontal Horizontal
Axis Frontal Frontal Sagittal Sagittal Longitudinal Longitudinal
Normal limiting Soft tissue Tension in the Tension in Soft tissue apposition Tension in the Tension in the
factors apposition of anterior joint ischiofemoral and of the thighs With the ischiofemoral iliofemoral
the anterior capsule, the pubofemoral opposite leg in ligament, the and
thigh and the iliofemoral, ligaments, the abduction or flexion: posterior joint pubofemoral
abdomen ischiofemoral inferior band of tension in the iliotibial capsule, and ligaments,
(with knee and the iliofemoral band, the superior joint the lateral and the
flexed) pubofemoral ligament, the capsule, superior band rotators anterior joint
ligaments, and inferior joint of the iliofemoral capsule
iliopsoas capsule, and hip ligament, the
abductors ischiofemoral ligament
and hip abductors
Normal end-feel Soft Firm Firm Soft/firm Firm Firm/ soft
Normal active 0 - 1 20° 0 - 30° 0 - 45° 0 - 30° 0 - 45° 0 - 45°
range of motion

Muscles Moving the Thigh

Muscles related to movement of the thigh have their origins on processes of the lumbar
spine, sacrum and the pelvis (See Table 1 5 .2). The iliopsoas (ALF), consisting of the
psoas major and minor, and i liacus muscles represent the principle flexor of the thigh.
There are no neurovascular nodes ( acupoints) on this important muscle and therefore
when it needs to be treated ALF nodes in the lumbar region and distal ALF nodes on the
foot and leg need to be considered.
The gluteus maximus is an important extensor and works in conj unction with the
hamstrings, which include the biceps femoris. long head (PLF), biceps femoris, short
head (LF), semitendinosus (PLF) and semimembranosus (PMF). The gluteus maximus
comes into play when powerful extension of the thigh is needed, such as occurs in
runnmg.
The gluteus medius and minimus (LF) muscles are unique in the bipedal human
primate. They are important for stable and smooth walking. When they are disordered or
paralyzed, it represents a serious problem for the hip and results in an ungainly, lurching
gait.

Disorders Affecting the Hip

In addressing problems affecting the hip it is important to consider the lumbar spine and
sacroiliac joint as a possible source. Trauma may be the most common source of pain
although many disease conditions including arthritis affect the hip. Hip problems are
viewed in terms of pain and dysfunction due to the muscles (including the muscular
distributions) that articulate the thigh as well as other sources of hip disorders. This
includes intrinsic and extrinsic sources of pain, bone and joint lesions, soft tissue lesions,
and entrapment of the lateral cutaneous nerve.

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Table 1 5.2. Fu nction , nerve root, and muscle d istribution (MD) assignment of prime mover ( PM)
and associate/assistance mover (AM) muscles of the hip and those that extend over knee (K)
joint to influence movement of lower leg
Muscle MD* Nerve Root Extension Flexion Abduction Adduction Medial Lateral
Rotation Rotation
Psoas major ALF L 1 , 2, 3, (4) PM AM AM
Iliacus ALF L( 1 ) , 2, 3, 4 PM AM AM
Rectus femoris ALF L2, 3, 4 K PM AM K
Sartorius AMF L2, 3, (4) AM & K AM AM
Pectineus AMF L2. 3, 4 PM PM AM
Tensor fasciae latae LF L4, 5, S1 AM AM AM
Gluteus maximus, upper PLF L5, S1 , 2 PM AM PM
Gluteus maximus, lower PLF L5, S 1 , 2 PM AM PM
Biceps femoris, I. h. PLF L5, S 1 , 2 PM K AM & K
Semitendinosus PLF L5, S 1 , 2 PM K AM & K
Semimembranosus PMF L5, S 1 , 2 PM K AM & K
Gluteus medius. ant. LF L4. 5 , S 1 , 2 AM PM AM
Gluteus medius, post. LF L4, 5 , S 1 , 2 AM PM AM
Gluteus minimus, ant. LF L4, 5, S1 , 2 AM AM PM
Gluteus minimus, post. LF L4, 5, S 1 , 2 AM AM AM
Pirifonmis PLF L(5), S 1 , 2 AM AM PM
Quadratus femoris PLF L4, 5, S 1 PM
Gemellus superior PLF L5, S 1 , 2 AM PM
Gemellus infe rior PLF L4, 5, S 1 AM PM
Obturator internus PLF L5. S 1 , 2 AM PM
Obturator extern us ALF L3, 4 AM PM
Adductor longus PMF L2, 3, 4 AM PM AM
Adductor brevis PMF L2, 3, 4 AM PM AM
Adductor mag nus, upper PMF L2, 3, 4 AM PM AM
Adductor mag nus, lower PMF L4, 5 , S 1 AM PM AM AM
Gracilis MF L2, 3 , 4 AM & K PM AM & K
Muscle fibers: ant. = anterior fibers; post. = posterior fibers; upper = upper fibers; lower = lower
fibers; l.h. = long head

Problems in Muscles Moving the Thigh and Knee

Specific disorders of the six longitudinal Neijing muscular distributions of the hip and
knee include the fol lowing:
Posterior lateral foot (PLF):
•
Pain in the buttocks sometimes radiating down the posterior thigh.
Lateral foot (LF):
•
Stretched muscles and acute cramps in the lateral aspect of the thigh.
•
Tight and stretched muscles in the anterior aspect of the thigh, and posteriorly in
the sacral region.
•
Pain extending above to cause pain in the lateral abdomen and hypochondrium.
Anterior lateral foot (ALF):
•
Acute cramps and spasms in the rectus femoris muscle.

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•
Swelling and edema in the anterior aspect of the thigh.
Anterior medial foot (AMF):
•
Stretching pain sensation along the inner thigh.
•
Cramping pain around the genitalia.
Medial foot (MF):
•
Pain and acute cramps of the inner thigh .
•
Dysfunction of the sexual organs including impotence in the case of internal
lllJ Ury.
Posterior medial foot (PMF):
•
Acute cramps and pain in inner aspect of thigh and pubic region.

Pathology of the Hip

Trauma to the hip is a common source of pain and dysfunction; however, one must
consider possible contribution from the lumbar spine and sacroiliac j oint areas. Soft­
tissue lesions include tendinitis of muscles moving the thigh and bursitis as well. The hip
joint is also affected by inflammation of the joint capsule. Typically, diagnosis and
confirmation of hip problems requires x-ray, tomography, bone scans, MRI, and
appropriate laboratory tests.
Intrinsic Hip Disorders
Pain arising from the hip joint may be felt at several sites the most common being in the
groin or lateral aspects of thigh. Less common area of pain i ncludes the deep buttocks,
back of thigh, or in medial aspects of thigh. Pain may also radiate down leg, with the
degree and extent of radiation pattern related to degree of underlying inflammation.
Characteristic of hip pain manifests as pain brought on by walking or standing that is
relieved by rest suggests mechanical derangement of lumbar spine or hip. It may also
display constant pain that disturbs sleep usually indicating an inflammation or neoplastic
lesion. Hip pain occurring at night often involves an inflammatory component related to
overuse during day, and is common in osteoarthritis.
Sources of hip pain may include osteoarthritis of hip or soft tissue lesions
involving tendons and bursae. Another possible source includes polymyalgia rheumatica
commencing with bilateral hip joint and muscle pain, with stiffness, and high erythrocyte
sedimentation rate (ESR), which is common in the older age group. Pain can also be
caused by a complete or sometimes incomplete fractures of hip which are common in
elderly (diagnosis requires X-rays, including a lateral view of the femoral neck). The hip
and groin regions are commonly a source of metastatic deposits or primary tumors, such
as multiple myeloma (tumor composed of cells type normall y found in bone marrow),
and these conditions often present with hip pain at night. X-ray, bone scans or MRI
should always be considered where malignancy is suspected, in patients presenting with
hip pain.
Extrinsic Hip Disorders
These can include hip pain referred from upper lumbar spine area (L2), possibly
indicating secondary deposits or a psoas abscess. Nerve root pressure at L3 may also
present as hip pain, but usually pain radiates down front of the thigh and may be
aggravated by coughing, bending or straining, and quadriceps weakness or wasting is

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present, or diminished knee jerk is present. Sacroiliac arthritis may occasionally present
as hip pain as well as intra-abdominal causes, such as due to appendicitis or intrapelvic
diseases. Problems in local structures, such as femoral hernia or lymphadenopathy
(disease of the lymph nodes) may reflect as hip pain.
Bone Disorders
Avascular Necrosis of Femora l Head
This condition is believed to follow interruption of vascular blood supply, which
can be the result of trauma, or a rare complication of some diseases. The underlying
cause is often unknown which is then classed as being primary or idiopathic. The initial
pathological changes involve subchondral osteolysis in the femoral head, while the
articular cartilage appears normal in early stages. The underlying subchondral bone
rapidly becomes necrotic and liable to collapse. The degeneration continues to progresses
and the femoral head becomes irregular in shape. All these changes are consistent with an
ischemic necrosis of bone due to vascular occlusion but, has not been demonstrated in all
cases.

Paget's Disease
This commonly involves bones of the hip and presents with pain that is often
worse at night. The pain may be of bony origin as result of Paget' s disease or its
complications such as fracture or osteosarcoma.

Acute Osteoporosis
This condition occurs mostly in middle-aged men often in absence of any
recognizable cause or rarely after trauma. The patient may present with severe pain and
stiffness in hip and thigh. Onset is sudden but gradually becomes progressive over
following months so that walking becomes increasingly difficult. The course of recovery
is usually slow over several months. X-ray changes are necessary for diagnosis and show
rarefaction in the hip and especially the femoral head, but j oint space is preserved.

Stress Fractures
This condition of the femoral neck is not uncommon and tends to occur in young
active males or elderly patients with osteoporosis. Two types of fractures are noted
including a compression fracture occurring in lower border of neck in the young, or a
transverse fracture across upper border of neck in the elderly. The first type of stress
fracture responds well to rest while the second type tends to become displaced requiring
surgical intervention.
Joint Lesions
Osteoarthritis
This is one of the most common forms of hip disorder, which may be bilateral,
occurring patients of either gender after the age of 50 of any body type. The condition
can be divided into primary causes involving an intrinsic disorder affecting the articular
cartilage, and secondary cause after a disease or misalignment of the hip j oint. Onset of
the problem tends to be insidious with pain being a usual presenting complaint; degree of
pain often correlated with radiological changes. Pain often related to movement or weight
bearing and may appear after unaccustomed or prolonged activity. The pain tends to get
worse as day progresses but can be relieved by rest; but later it may be present at night

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and disturbs sleep. Patients may have considered initial restriction in hip movement as
consequence of natural aging until restriction starts limiting functional activities,
including walking and other daily activities

Monoarthritis
This is an uncommon and unique form of arthritis involving only one hip usually
affecting the middle-aged. The onset of pain and stiffness i s rapid that gradually settles
down after 2-3 years with x-rays showing narrowing of joint space with destructive
changes in the acetabulum and femoral head without osteophyte formation. There may be
inflammatory changes and ESR levels are always elevated. This disorder is distinct from
other hip diseases such as : infections, chondrocalcinosis, rheumatoi d arthritis, and
spondyloarthriti s

Septic Arthritis
This condition is relatively uncommon in the hip and usually caused by
Staphylococcus aureus, but other causative factors can include: gonococcal,
streptococcal, and pneumococcal infections. Another but rare cause is tuberculosis of the
hip. The patient presents with sudden onset of severe hip pain usually worse at night with
marked restriction of hip movement. In addition, they may have an increased
temperature, leucocytosis, and elevated E S R levels. This usually requires surgical
drainage, immobilization, and full antibiotic course of treatment.

Instability of Symphysis Pubis

This condition may follow confinement or trauma; or in athletes especially
football players, runners, and fast walkers; or may follow surgery on the sacroiliac joint.
The patient may have restricted ipsilateral hip movement and presents with pain in one or
both groins which may radiate widely to lower abdomen, thigh adductor region, hip,
testis, or perineum. It may also cause low back pain when associated with a lesion of the
sacroiliac joint. The pain is made worse by adopting certain postures such as standing on
one leg; or by exercise, straining, walking upstairs; or thrusting the hip forward. The pain
is typically so severe that running or kicking is impossible and may cause patient to limp.
Pain and tenderness may be reproduced by pressure applied over symphysis
pubis; pain and tenderness also over the pubic attachment location of the adductor longus
and rectus abdominis muscles. The pain is also reproduced by passive abduction of the
patient' s hip, resisted adduction, and by resisting patient' s attempt of sitting up.
Diagnosis is confirmed by x-ray observing the gap of the symphysis pubis and also by
comparing relative height of the pubic bones when the patient is standing on one leg.
Soft-tissue Lesions
Gluteal Tendinitis and Burs itis
Gluteal tendinitis and trochanteric bursitis is the most common soft-tissue lesion
around hip: it may occur together or separately. The gluteus medius tendon is separated
from greater trochanter and other hip muscles by a small and large bursa. When inflamed,
the patient' s pain becomes well localized over outer aspect of greater trochanter, and may
radiate down posterior or posterolateral aspect thigh. The pain is brought on by hip
movements in walking and climbing stairs and can be reproduced by stretching or
contracting gluteus medius muscle. In this case the tendon passively stretched with hip
and knee both flexed 90° while leg is fully laterally rotated with patient supine. The

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muscle is contracted by resisted isometric test in abduction with patient lying on

unaffected side.

Addu ctor Tendinitis

This condition most often occurs in athletes but also happens in horse riders. It is
characterized by pain well localized over origin of adductor longus from the pubis or a
few centimeters distally at the musculotendinous j unction. The pain is reproduced by
stretching or contracting adductor longus tendon; which is stretched by moving patient's
hip into full passive abduction whi le supine. The muscle then contracted by isometric
resistance to patient moving hip in direction of adduction.

Psoas Tendinitis and Bursitis

The iliopsoas muscle is powerful hip flexor that inserts into the lessor trochanter
of femur. It is separated from anterior aspect of hip capsule proximal to its insertion by
the psoas bursa which may communicate with hip joint. Tendinitis and bursitis may
present with pain in the anterior thigh made worse by activity. The pain can be
reproduced b y contracting or stretching the tendon with patient supine. Here, the hip is
flexed to 90° and examiner then isometrical ly resists any further flexion. Alternatively,
with the patient prone with knee flexed to 90°, the examiner passively hyper-extends the
hip to stretch the psoas tendon.

Hamstri n g Tendinitis
Origin of hamstrings tendons is from ischial tuberosity and may be involved in
tendinitis due to overuse syndrome, especially in runners and sprinters. The resulting
tenderness wel l localized over ischial tuberosity. The pain can be reproduced by resisting
hip extension or by stretching tendon origin by fully flexing hip. Avulsion of the
hamstring origin from the ischial tuberosity can occur in young athletes by separation of
part of the bony cortex.

Rectus Femoris Tendinitis

This tendinitis may involve the origin of the rectus femoris muscle at the anterior
inferior iliac spine. A traction inj ury to an adolescent may result in avulsion of the spine.
This could fol low sudden exertion in patient with previous tendinitis. Also, this can result
from direct contusion to thigh muscles with subsequent loss in extensibility.

lschiogluteal Bursitis
The ischiogluteal bursa can be chroni cally inflamed by prolonged sitting while
acute inflammation of this bursa is rare. This condition presents with pain at the ischial
tuberosity, made worse by sitting, and relieved by standing. Resulting tenderness is
localized over the ischial tuberosity and pain may be reproduced by straight leg raising
test.

P iriformis Syndrome
P art or all of the sciatic nerve passes through rather than below the piriformis
muscle in about 1 5% of the population. These individuals are more likely to develop
piriformis syndrome by compression of sciatic nerve. This condition presents with
burning pain and hyperesthesia in sacral or gluteal area as well as along sciatic nerve
distribution. In addition the patient may have pain and weakness on abduction and lateral
rotation of hip. The pain reproduced from stretching the piriformis muscle by passive

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medial rotation of the extended hip . Medial rotation with hip flexion also accentuates the
patient' s condition.

Capsulitis of Hip
This condition is found in middle-aged and young people, but occurs much less
frequently than capsulitis of the shoulder. The patient presents with pain and stiffness
which came on over a short period for no apparent reason and is made worse by activity.
There is a loss in hip flexion-adduction, rotation, and hyperextension which occurs earl y.
The condition progresses to a loss in abduction and restriction of flexion to about 90°,
with loss of accessory movements. The pain gradually resolves over several months
while stiffness of the hip movements improve more slowly.

Snapping Hip
This condition involves a situation where a loud snapping sound emanates over
the lateral aspect of the hip. It may occasionally be associated with pain as well. The
sound is produced by the tensor fasciae latae sliding over the greater trochanter; usually
brought on by hip flexion and rotation.
Entrapment Neuropathy of Hip
Often occurs in middle-aged males presenting with burning pain, numbness or
paresthesia, or itching in the anterior lateral aspects of the thigh down to j ust above the
knee. This involves the lateral cutaneous nerve of the thigh derived mainly from L2 and
L3 nerve roots; which supplies skin over the anterolateral aspect of thigh. The nerve
emerges from the lateral border of the psoas muscle crossing the iliacus muscle to enter
the thigh. Here it either passes through a tunnel in the inguinal ligament near its
attachment to the anterior superior iliac spine, or passes under the ligament. Entrapment
usually involves the tunnel as the nerve angulates to enter the thigh; degree of angulation
and nerve compression is increased by hip extension. Compression of the nerve can also
be the result of trauma, pregnancy, alteration in body weight, and activity after prolonged
bed rest.

Examination of the H ip
Prior to active testing of the hip it is observed for possible deformities, synovial swelling,
muscle spasms, muscle wasting, abnormal gait, and perhaps the Trendelenburg test.

Active Movements of Hip

Following the standard rule in orthopedic assessment of active, passive, and resistive
movements, the painful movements are done last. Likewise, it is important to minimize
moving the patient into various test positions. For example, all test performed in the
supine position would be completed before conducting those that required the patient to
lying in the prone or side lying positions. Hence, hip flexion, abduction, and adduction
can be performed while the patient is supine before moving patient to the prone position
to measure hip extension, medial rotation, and lateral rotation. These l ast to
measurements can also be performed with the patient seated with legs over the end of the
examination table.
Each of the active movements is conducted to measure range and characteristics
of motion, including possible restrictions and pain. If the movement is pain free

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overpressure can be applied at the limit of motion to assess the characteristics of the end­
feel. Otherwise, end-feel is measured during passive movements.
Hip Flexion
Active flexion is conducted with the patient supine and flexing the hip by lifting the thigh
up off the examination table with the knee allowed to flex to keep potentially tight
hamstrings in limiting the motion. Hip is normally flexed from 1 1 oo to 1 20° and the end­
feel is typically soft due the muscular contact of the anterior thigh with the lower
abdomen. Hip flexion can be measured with a goniometer that has sufficiently long arms
or by using an inclinometer.
Flexion can be measured with a goniometer with the fulcrum centered on the
lateral aspect of the hip joint. The greater trochanter of the femur is used as a reference.
The proximal fixed arm is aligned with the lateral midline of the pelvis while the
movable distal arm is aligned along the lateral midline of the femur using the lateral
epicondyle as reference. Flexion is maintained at the end of movement while the
examiner aligns the distal arm with the lateral aspect of the femur to note the angular
movement value.
Hip flexion can also be measured with a bubble or gravity sensitive inclinometer.
A bubble inclinometer is held vertically, proximal to the knee, with the long axis aligned
with the femur. The inclinometer is adjusted zero as the horizontal reference. The patient
flexes the leg as before allowing the knee to flex while the examiner holds the
inclinometer on the thigh. Full extension angle can be read directly at the end of flexion
movement.
If using a gravity sensitive inclinometer, it is strapped onto the lateral thigh just
proximal to the knee with the dial on the midline of the femur. The dial is adjusted to
zero. The examiner stabilizes the pelvis as the hip is moved to the limit of flexion and the
measurement recorded.
Hip Extension
Active extension is conducted with the patient prone with the feet over the end of the
examination table. The hip is extended from 1 oo to 30° by the patient lifting the thigh up
off the examination table. The end-feel is typically firm due to tension in the iliofemoral
ligament and anterior joint capsule. Other contribution to the firm end-feel is possible
tension in hip flexors including the iliopsoas, adductor longus, tensor fasciae latae,
sartorius, and gracilis muscles.
Extension can be measured with a goniometer with the fulcrum centered on the
lateral aspect of the hip j oint. The greater trochanter of the femur is used as a reference.
The proximal fixed arm is aligned with the lateral midline of the pelvis while the
movable distal arm is aligned along the lateral midline of the femur using the lateral
epicondyle as reference. Extension is maintained at the end of movement while the
examiner aligns the distal arm with the lateral aspect of the femur to note the angular
movement value.
Hip extension can also be measured with a bubble or gravity sensitive
inclinometer. A bubble inclinometer is held vertically on the posterior surface of the
thigh, proximal to the knee, with the long axis aligned with the femur. The inclinometer
is adjusted zero as the horizontal reference. The patient extends the leg as before while

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the examiner holds the inclinometer on the thigh. Full extension angle can be read
directly at the end of flexion movement.
A gravity sensitive inclinometer i s strapped onto the lateral thigh just proximal to
the knee with the dial on the midline of the femur. The dial i s adjusted to zero. The
examiner stabilizes the pelvis as the hip is moved to the limit of extension and the
measurement recorded.
Hip Abduction
Active hip abduction of 30° to 50° is conducted with the patient supine initially with both
knees extended legs and aligned straight on the table in oo of flexion, extension, and
rotation. Examiner stabilizes the hip by placing one hand on the pelvis. Abduction is
accomplished by the patient sliding one foot laterally out across the table while avoiding
rotation of the leg. Examiner may partially support the leg as it moves off the table in the
horizontal plane. The normal end-feel is firm due to the inferior (medial) joint capsule,
ischiofemoral ligament, inferior band of the iliofemoral ligament, and the pubofemoral
ligament. Passive tension in the adductor l ongus, adductor magnus, adductor brevis,
pectineus, and gracilis muscles may contribute to the firm end-feel .
Abduction can be measured with a goniometer with the fulcrum centered on the
anterior superior iliac spine (ASl S ) of the extremity being measured. The proximal fixed
arm is aligned with an imaginary line connecting one ASIS to the other. The distal arm is
aligned with the lateral midline of the femur using the midline of the patella for reference.
The goniometer is then reading 90°. The patient then moves the leg into full abduction
and the reading is obtained by subtracting 90° from the total angular abduction.
Abduction can also be measured with a compass device used in measuring
rotation in the horizontal plane. The dial is strapped on the anterior aspect of the thigh
proximal to the knee. The compass is set to zero degrees and the abduction angle is read
at the full abduction range of motion.
Hip abduction can also be measured with a bubble or gravity sensitive
inclinometer if the patient is lying on their side and are able to lift their upper leg off the
lower leg into full abduction. A bubble inclinometer is held vertically on the lateral thigh,
proximal to the knee, with the long axis aligned with the femur. The inclinometer is
adj usted zero as the horizontal reference when the leg is supported by the examiner to be
level with the table. The patient abducts the leg by l ifting it up into full abduction. If
using a gravity sensitive inclinometer, it is strapped onto the anterior or posterior thigh
j ust proximal to the knee with the dial on the midline of the femur. The dial is adj usted to
zero. The examiner stabilizes the pelvis as the leg is lifted off the upper leg as before into
full abduction.
Hip Adduction
Active hip adduction of 20° to 30° is conducted with the patient supine initial ly with both
knees extended legs and aligned straight on the table in 0° of flexion, extension, and
rotation. Examiner stabilizes the hip by placing one hand on the pelvis. The contralateral
leg is first moved in abduction to allow space to adduct the leg being assessed. The test
leg is initially held in its straight aligned position. Adduction is then accomplished by
sliding the foot medially across the table while avoiding rotation of the leg. The normal
end-feel is soft/firm due to the superior (lateral) j oint capsule and the superior band of the

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iliofemoral ligament. Passive tension in the tensor fasciae latae, gluteus medius, and
gluteus minimus muscles may contribute to the firm end-feel .
Adduction can be measured with a goniometer with the fulcrum centered on the
anterior superior iliac spine (ASIS) of the extremity being measured. The proximal fixed
arm is aligned with an imaginary line connecting one ASIS to the other. The di stal arm is
aligned with the lateral midline of the femur using the midline of the patella for reference.
The goniometer is then reading 90°. The patient then moves the leg into full adduction
and the reading is obtained by subtracting the final value from 90°.
Adduction can also be measured with a compass device used in measuring
rotation in the horizontal plane. The dial is strapped on the anterior aspect of the thigh
proximal to the knee. The compass i s set to zero degrees and the adduction angle is read
at the full adduction range of motion.
Hip adduction can also be measured with a bubble or gravity sensitive
inclinometer if the patient is lying on their side and are able to lift their lower leg off the
examination table into full abduction. The upper leg is extended or flexed with the foot
resting on the examination table to provide clearance for the lower leg to be raised into
adduction. A bubble inclinometer is held vertically on the l ateral thigh, proximal to the
knee, with the long axis aligned with the femur. The inclinometer is adj usted zero as the
horizontal reference. The patient abducts the lower leg by lifting it off the table into full
abduction. If using a gravity sensitive inclinometer, it is strapped onto the anterior or
posterior thigh just proximal to the knee with the dial on the midline of the femur. The
dial is adj usted to zero. The examiner stabilizes the pelvis as the leg is lifted off the table
into the full of adduction.
Hip External (Lateral) Rotation
Normal external (lateral) hip rotation of 40° to 60° can be measured with the patient
prone, supine, or seated. Normal end-feel of this movement is firm/soft due to tension in
the iliofemoral ligament, pubofemoral ligament, and inferior joint capsule. Passive
tension in the anterior portion of the adductor magnus, adductor longus, gluteus medius,
gluteus minimus, pectineus, and the piriformis muscles may also contribute to the firm
end-feel.
While seated with legs over the edge of the examination table the examiner places
one hand on the patient' s distal femur to prevent hip flexion and abduction. The patient is
instructed to shift their weight onto the hip being tested to assist in stabilizing the hip
while flexing the other leg to allow clearance for lateral rotation of the test leg. A towel
may be placed under the distal humerus to provide better horizontal alignment. This
configuration is reversed to test the other leg in external rotation.
The fulcrum of the goniometer is placed on the anterior aspect of the patella with
the fixed arm perpendicular to the floor and aligned with of the lower leg midline. The
crest of the tibia and a point midway between the two malleoli are used as a reference.
The leg i s then moved into full external rotation with the movable arm of the goniometer
held on the leg during movement.
If a gravity sensitive device is used to measure external rotation, it is strapped on
the leg proximal to the ankle with the dial on the anterior of the leg. If using a bubble
inclinometer, it is held on the medial aspect of the leg proximal to the ankle.

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Measuring external rotation while prone, the knee of the test leg is flexed goo with
the leg standing straight up. A goniometer is placed on the anterior aspect of the patella
and aligned in reverse of the seated position as previously noted. The leg is allowed to
rotate toward the other leg. A gravity sensitive device or bubble inclinometer can be used
as well as previously described.
In the supine test configuration, the test leg is held with the knee and hip both
flexed goo. Movement directions are similar to the seated position except the patient is
lying on their back and supporting the weight of the lower leg. Examiner may help
support lower leg during rotation. A goniometer or compass device can be used to
measure hip external rotation in this configuration.
Hip Internal (Medial) Rotation
Normal internal (medial) hip rotation of 30° to 40° can be measured with the patient
prone, supine, or seated. Normal end-feel of this movement is firm due to tension in the
ischiofemoral ligament and posterior joint capsule. Passive tension in the hip lateral
rotators (piriformis, quadratus femoris, gemellus superior, gemellus inferior, obturator
intern us, and obturator extern us) and gluteus maximus contribute to the firm end-feel.
While seated with legs over the edge of the examination table the examiner places
one hand on the patient's distal femur to prevent hip flexion and abduction. The patient is
instructed to shift their weight onto the hip being tested to assist in stabilizing the test hip.
A towel may be placed under the distal humerus to provide better horizontal alignment.
This configuration is reversed to test the other leg in internal rotation.
The fulcrum of the goniometer is placed on the anterior aspect of the patella with
the fixed arm perpendicular to the floor and aligned with of the lower leg midline. The
crest of the tibia and a point midway between the two malleoli are used as a reference.
The leg is then moved into full internal rotation with the movable arm of the goniometer
held on the leg during movement.
If a gravity sensitive device is used to measure internal rotation, it is strapped on
the leg proximal to the ankle with the dial on the anterior of the leg. If using a bubble
inclinometer, it is held on the lateral aspect of the leg proximal to the ankle.
Measuring internal rotation while prone, the knee of the test leg is flexed goo with
the leg standing straight up. A goniometer is placed on the anterior aspect of the patella
and aligned in reverse of the seated position as previously noted. The leg is allowed to
rotate away from the other leg. A gravity sensitive device or bubble inclinometer can be
used as well as previously described.
In the supine test configuration, the test leg is held with the knee and hip both
flexed goo. Movement directions are similar to the seated position except the patient is
lying on their back and supporting the weight of the lower leg. Examiner may help
support lower leg during rotation. A goniometer or compass device can be used to
measure hip internal rotation in this configuration.

Passive Movements of Hip

If the end-feel was not measured during the active movements, passive movement would
then be necessary to obtain this information. The movements are basically the same as
those performed in the preceding active movements. With the exception of hip extension,
all of these movements are performed in the supine position, with extension performed in

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the prone position. End-feel for all hip movements essentially involves tissue
approximation or tissue stretch which is characterized from soft, fi rm, soft/firm to
firm/soft.
The capsular pattern for the hip is flexion, abduction, and internal (medial)
rotation usually being the motions that are most limited (Table 1 4. 1 ). However, the order
of restriction can vary such as internal rotation being more restricted followed by flexion
and abduction.
Hip Flexion
With the patient supine, the examiner lifts the thigh by the knee while allowing the knee
to flex through the complete range of passive movement as possible. Areas of pain,
restriction, and end-feel are noted.
Hip Extension
Patient is prone while the examiner extends the thigh by lifting up just proximal to the
knee and the knee is allowed to flex.
Hip Abduction
Patient is supine with both legs aligned straight with the body. The examiner slightly lifts
and supports the leg by placing one hand under the ankle. The leg is then slowly moved
into the complete range of passive abduction as possible.
Hip Adduction
Patient is supine with the test leg aligned straight with the body while the contralateral
leg is moved into abduction to allow clearance for the other leg to be adducted. Examiner
supports the test leg by slightly lifting with one hand placed under the ankle to assure leg
can slide across the examination table surface to move it into the complete range of
passive adduction as possible.
Hip Internal and External Rotation
Patient is supine while the examiner supports the thigh and lower leg with the hip and
knee of the test leg flexed at 90°. While maintaining the lower leg parallel to the floor,
the examiner slowly moves the leg outward from the midline into the complete range of
passive internal (medial) rotation as possible. After possible restriction and end-feel are
determined, the leg i s return to oo position of rotation. The leg is then slowly moved
toward the midline into the complete range of passive external (lateral) rotation as
possible. Leg is returned to original position and the other leg is tested.

Resistive Movements of Hip

The isometric resistive movements of the hip can be performed while the patient is
supine. Due to the strength of the hip muscles it is important that the patient' s hips and
body are positioned properly. If the knee is not going to be assessed following the hip,
then it is essential to also perform an isometric resistive test for knee flexion and
extension since the rectus femoris and hamstrings act over the knee and hip j oint as well .
T o ensure that the examiner is applying a constant isometric resistive force, the patient is
instructed to only supply sufficient resistance to keep the examiner from moving them.
Hence, the patient is told: "Don' t let me move you." For functional reasons not all of the
muscle groups have the same strengths. Hip adductors may be 2.5 times stronger than the
abductors, whi le hip flexors and extensors may be nearly equal in strength.

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 Oriental Orthopedics Hip and Thigh 380

Resisted isometric movements can produce pain in affected or weak muscles or

reproduce the patient's pain. Focus of the assessment is to determine if a particular
muscle is involved in the presenting case. Some muscles participate in more than one
movement of the hip (See Table 1 5 .2). I f a particular muscle is the only one involved in
specific movements that result in pain being produced, then this might indicate a possible
source of the problem . For example, the gluteus maximus (lower fibers) is the only
muscle i nvolved in the three movements of hip adduction, extension, and lateral rotation.
If pain is experienced in all three of these movements, the gluteus maximus may be
involved.
Examiner must be aware that some internal problems can manifest as muscular
pain on resisted isometric testing. Some cases of intra-abdominal i nflammation in the
region of the psoas muscle may result in pain on resisted hip flexion. Other intra­
abdominal conditions may manifest with rigidity of the abdominal wall.
Hip Flexion
Resisted isometric movement in hip flexion mainly involves the psoas and iliacus
muscles (iliopsoas) with accessory participation of the rectus femori s, sartorius, tensor
fasciae ]atae, and pectineus muscles. Patient is supine with body and hip properly aligned
and the test leg fl exed about 45°. The examiner raises the lower leg off the table and
maintains it also flexed about 45°. Isometric force is applied j ust proximal to the knee in
the direction of hip extension.
Hip Extension
Resisted isometric movement in hip extension mainly involves the gluteus maximus,
biceps femoris, semitendinosus, and semimembranosus muscles. Accessory muscles
include the adductor magnus, piriformis, and gluteus medius muscles. The patient is
supine with the test leg aligned straight with the body while the contralateral leg is held in
slight abduction on the table. Standing to the test side, the examiner grasps the patient' s
thigh with both hands o n the underside o f the leg j ust proximal to the knee. The leg, with
the knee extended, is lifted off the examination table into several degrees of flexion and
the patient is then asked to keep the examiner from moving the leg further into flexion.
Other leg is similarly evaluated.
Hip Abduction
Resisted i sometric movement i n hip abduction mainly involves the gluteus medius and
gluteus minimus muscles, with accessory participation of the tensor fasciae latae and
gluteus maximus muscles. The patient is supine with both legs slightly abducted. While
standing to the test side, the examiner grasps the patient' s leg with one hand proximal to
the ankle to slightly lift it off the table. The other hand is placed on the lateral aspect of
the leg j ust proximal to the knee to apply a resistive isometric force in the direction of hip
adduction by pushing in the medial direction on the thigh.
Hip Adduction
Resisted i sometric movement i n hip adduction mainly involves the adductors longus,
brevis, and magnus, along with the pectineus and gracilis muscles. The patient is supine
with both legs slightly abducted. While standing to the test side, the examiner grasps the
patient' s leg with one hand proximal to the ankle to slightly lift it off the table. The other
hand is placed on the medial aspect of the leg j ust proximal to the knee to apply a

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Oriental Orthopedics H ip and Thigh 381

resistive isometric force in the direction of hip abduction by pulling in the lateral on the
thigh.
Hip Internal (Medial) Rotation
Resisted isometric movement in hip internal rotation mainly involves the gluteus medius,
gluteus minimus, and tensor fascia latae muscles, with accessory involvement of the
adductor longus. The patient is supine with both legs initially aligned straight with the
body. The test leg hip and knee are both flexed 90° with the thigh straight up and the
lower leg parallel to the floor. The examiner stands on test side while grasping the
patient's leg with one hand proximal to the ankle. The other hand is placed just above the
knee to stabilize the thigh. A resistive isometric force is applied by the hand above the
ankle by pushing in the direction of hip external rotation.
Hip External (Lateral) Rotation
Resisted isometric movement in hip external rotation mainly involves the piriformis,
obturator externus and internus, gemellus superior and inferior, and quadratus femoris
muscles. The patient is supine with both legs initially aligned straight with the body. The
test leg hip and knee are both flexed 90° with the thigh straight up and the lower leg
parallel to the floor. The examiner stands on test side while grasping the patient's leg
with one hand proximal to the ankle. The other hand is placed j ust above the knee to
stabilize the thigh. A resistive isometric force is applied by the hand above the ankle by
pulling in the direction of hip internal rotation.
Hip Abduction and Hip Flexion
This test specifically addresses the resistive isometric strength of the tensor fascia latae
muscle with accessory participation of the gluteus medius and gluteus minimus muscles.
The patient is lying on the non-test side with the leg held in maximum hip and knee
flexion by drawing the knee up toward the chest with both hands. The test leg is extended
at the knee and placed into 1 0 - 20° of hip flexion and internal rotation with the pelvis
rolled backward. Examiner stands behind the patient and stabilizes the pelvis by placing
one hand on the iliac crest. Patient then slowly abducts the hip through full ROM while
the examiner palpates on the iliotibial band distal to the greater trochanter or lateral to the
upper part of the sartorius muscle. The leg is returned to a position of slight hip abduction
and a resistive isometric force is applied on the anterolateral aspect of the thigh just
proximal to the knee. Resistive force is applied in the direction of hip adduction and
extension.
Hip Flexion, Abduction, and External Rotation with Knee Flexion
This test specifically addresses the resistive isometric strength of the sartorius muscle
with accessory participation of the iliopsoas, rectus femoris, and tensor fascia latae
muscles. Patient is supine with legs aligned straight with the body. The patient flexes the
hip to approximately 90° and then abducts and internally rotates the hip and flexes the
knee to where the heel of the foot is almost over the opposite knee j oint. The examiner
grasps the medial posterior aspect of the lower leg j ust above the ankle while the other
hand i s placed over the anterolateral aspect of the thigh just proximal to the knee j oint.
Resistive isometric pressure is then applied to the anterolateral aspect of the thigh and
also on the posterior aspect of the lower leg by pulling up. Resistance is applied in the
direction of extension, adduction, and internal rotation of the hip with one hand and in
knee extension with the other hand.

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Functional Assessment
Normal function of the hip is required for ambulation and gait, but more range of motion
(ROM) is involved in normal daily activities including: sitting, tying a shoe, getting up
from the seated position, stooping, squatting, going up stairs, and picking things up from
the floor. Functional assessment of the hip can be accomplished by conducting tests that
require normal ROM in the principal hip movements involving: going up and down stairs
one or two steps at time; squatting; running sideways; touching the knee of one leg with
the ankle of the other leg, etc. There are several functional assessment and grading
methods in use for the hip.

Accessory Movements of Hip

The accessory or j oint play movements of the hip are first examined on the unaffected
side to compare with the affected hip. Small differences in joint play may be difficult to
determine due to the large bulky muscles associated with the hip.
Longitudinal Caudad
Patient is supine and the examiner uses both hands to grasp the lower end of the femur o f
the test leg. The thigh is lifted into slight hip flexion and abduction. Lower leg may be
allowed to flex with heel rested on table or it may be rested on examiner' s flexed knee
that is positioned on the table. The examiner then pulls longitudinally on the thigh is a
direction aligned with the axis of the femur to evaluate accessory movement. An
oscillatory application the traction force can be used for mobilization. Technique is
effective as a test or mobilization treatment for any hypomobility problem or painful
restriction.
If the patient does not have any problems with the knee, the caudal force can be
applied by grasping the ankle and pulling longitudinally.
Longitudinal Cephalad
Patient is supine and the examiner uses both hands to grasp the knee with one hand under
the posterior aspect of the knee and the other on the anterior aspect. The thigh is lifted
into slight hip flexion and abduction. Lower leg may be allowed to flex with heel rested
on table or it may be rested on examiner' s flexed knee that is positioned on the table. The
examiner then pushes on knee in the cephalad direction aligned with the axis of the femur
to evaluate accessory movement. An oscillatory application the longitudinal cephalad
force can be used for mobilization. Technique is effective as a test or mobilization
treatment for any hypomobility problem or painful restriction.
Posteroanterior
Patient lies on side with hip and knees slightly flexed with a pillow between the legs to
maintain the femur in 0° of abduction and adduction. A posteroanterior force i s applied
from behind the greater trochanter with one hand while the other hand stabilizes the
anterior iliac crest. Accessory movement is evaluated. An oscillatory application of the
posteroanterior force can be used for mobilization. Technique is effective as a test or
mobilization treatment for any hypomobility problem or painful restriction, and for
increasing extension.
Anteroposterior
Patient lies on side with hip and knees slightly flexed with a pillow between the legs to
maintain the femur in oo of abduction and adduction. An anteroposterior force is applied

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 Oriental Orthopedics H ip and Thigh 383

to the anterior aspect of the greater trochanter with one hand while the other hand
stabilizes the posterior iliac crest. Accessory movement is evaluated. An oscillatory
application of the posteroanterior force can be used for mobilization. Technique is
effective as a test or mobilization treatment for any hypomobility problem or painful
restriction, and for increasing flexion.
Lateral Femoral Glide
Patient is supine with the hip of the test leg flexed 90°. The examiner gasps the upper end
of the thigh with both hands wrapped around leg. Knee can be flexed as well in which
case the examiner grasps both the thigh and flexed lower leg. A force is applied to the
upper thigh region by pulling laterally from the body. An oscillatory application the
lateral force can be used for mobilization. This technique is useful for testing accessory
joint play and treating hypomobility and any painful restriction.
Caudal Femoral Glide
The same test configuration applied in the Lateral Femoral Glide can be used for
accessory movement in the caudal direction. In this case the thigh is grasped in the upper
anterior aspect and the patient can also rest the lower leg on the shoulder of the examiner.
An oscil latory application in the caudal directed force can be used for mobilization. This
technique is useful for testing accessory j oint play and treating hypomobility and any
painful restriction.

Special Tests
There a number of auxilary orthopedic tests of the hip that can provide additional
information to confirm the clinical impression derived by the standard assessment tests.
90 - 90 Straight Leg Raise Hamstring Test
Patient is supine and stabilizing both hips at 90° of flexion using both hands while the
lower legs are relaxed. Patient is then instructed extend each lower leg one at a time. If
the knee remains flexed 20° or greater after full extension possible, it indicates the
hamstrings of that leg are tight.
This test is not considered to be a complete assessment of hamstring extensibility
since the passive motion of the hamstring muscle group is limited by the strength of the
patient's quadriceps muscle group.
Thomas Test
Patient is initially sitting with buttocks at the end of the table and then lying supine while
simultaneously passively flexing both legs by drawing them up to the chest. The
examiner stands to the side of the patient to place one hand on the lumbar spine or iliac
crest to monitor lumbar lordosis or pelvic tilt respectively. Patient slowly lowers the leg
on the affected side until the leg is fully relaxed or until either there is an increase in
lumbar lordosis or anterior pelvic tilting. Increases in lumbar lordosis and pelvic tilt must
be eliminated to prevent false negative findings.
A lack of hip extension with knee flexion greater than 45° is indicative of
iliopsoas muscle tightness. F u ll h i p extension with knee flex ion J ess than 45° ind icates
possible tightness in the rectus femori mu c l e . A lack of h i. p c tension i t h knee flexi n
less than 45° indicates po sible tightness in t h e rectus femoris and il iopsoas m u clcs. Hip
external rotation of any of these situations indicate po s i b l e tightness in the tensor
fasciae latae.

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Oriental Orthopedics Hip and Thigh 384

A variation of this test is performed with the patient is resting supine while the
examiner places a goniometer fulcrum on the lateral aspect of the greater trochanter of
the affected side with the fixed and moveable arms held aligned along the axis of the
femur. The patient then stabilizes the hip by passive flexion of the uninvolved hip by
drawing the leg up to the chest with the knee flexed. If the opposite leg moves into
flexion the movable arm is allowed to move with the thigh to determine amount of
possible flexion. Flexion of the thigh indicates a hip flexor contraction.
Ober Test
Patient is side lying on the uninvolved side with the lower leg hip and knee slightly
flexed. The examiner passively moves the upper leg into abduction and extension by
lifting the leg with one hand grasping just distal to the knee while stabilizing the pelvis
with the other hand on the ilium. The examiner then releases the grip to allow the leg to
drop. If the leg does not drop into adduction the test is positive for contracture of the
i liotibial band.
Patrick (FABER) Test
Patient is supine and instructed move the affected hip into flexion and abduction so the
leg can be externally rotated to place the lateral malleolus on the opposite knee. Examiner
places one hand on the uninvolved hip to stabilize the pelvis while slowly pushing on the
knee of the affected leg to push it into abduction. The test is considered positive
indicating possible hip pathology if the patient cannot complete this maneuver; or if the
lower leg of the involved side cannot be abducted to the same level as the uninvolved leg;
or if inguinal pain is reproduced; or if it reproduces posterior sacral pain. These findings
may be indicative of iliopsoas, sacroiliac, or hip joint abnormalities.
FABER is an acronym for the initials for positioning the patient, namely: F =

flexion; AB = abduction; and ER = external rotation.

Piriformis Test
Patient lies on the unaffected or non-test side with the test leg in 60° of hip flexion with
the lower leg in relaxed knee flexion. Examiner stands behind patient with one hand on
the lateral aspect of the pelvis and the other on the lateral side of the knee. With the
pelvis stabilized the examiner applies a downward force on the patient's knee in the
direction of adduction. Pain or tightness in the hip or buttock area indicates possible
tightness in the piriformis muscle. Pain in the buttock and posterior thigh may indicate
sciatic nerve impingement secondary to piriformis tightness.
This test can also be performed with the patient supine by moving the uninvolved
leg into slight abduction to allow room for moving the test leg into adduction. Examiner
stands to affected side and places one hand on the patient' s hip to stabilize the pelvis. The
other hand is placed just proximal to the knee to lift the thigh off the table and slowly
move it into adduction. Positive indications are the same as in the previous piriformis test
configuration above.

Neurological Evaluation
Myotomes
Generally the isometric screening tests (See Table 1 3 .2) for the lumbar spine and lower
extremities are conducted as part of the initial examination for problems affecting the hip

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Oriental Orthopedics Hip and Thigh 385

and lower extremities. The only specific myotome test for the hip is that of L2 - iliopsoas,
with strength graded 0 - 5 .

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View: This view is used to compare the two hips to examine: j oint space
and pelvis lines; presence of bone diseases; femur neck and shaft angles; femoral head
shape; presence of osteophytes or arthritis; possible fracture or dislocation; and pelvic
distortion.
Lateral (Axial "Frog-Leg") View: This view provides a true lateral image of the
femoral head and neck by the patient in the supine position with hip in flexion, abduction,
and lateral rotation. Examiner looks for slipping of the femoral head and any pelvic
distortion.
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging of the hip i s useful to show soft-tissue problems such as
bursitis and tendon lesions, as well as osseous tissue problems.
Computed Tomography
Computed tomography (CT) scans used to show size and shape of acetabulum and
femoral head, including relative position and congruity of the femoral head in
relationship to the acetabulum.
Arthrography
An arthrogram may be indicated in situation where a hip dislocation cannot be reduced.

Management of Hip and Thigh Disorders

Needling therapy and mobilization techniques used to treat hip and thigh problems.
Mobilization is employ to address pain, hypomobi lity, and restricted movement of the
hip.

Mobilization
The previously described accessory movements can be used for hip mobilization by
applying oscillatory movements, depending on the specific signs and symptoms. This
includes the following tests plus additional techniques discussed in the following:
•
Longitudinal caudal
•
Longitudinal cephalad
•
Posteroanterior
•
Anteroposterior
•
Lateral femoral glide
•
Caudal femoral glide
Dorsal Femoral Glide
Patient is supine with the hip flexed 90° and slightly adducted. Examiner stands to the
patient' s opposite side with one hand behind the patient' s hip to stabilize the pelvis. The
other hand is placed on the flexed knee along with the chest to apply a dorsal-lateral force
through the longitudinal axis of the femur. This maneuver has a similar effect as

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 Oriental Orthopedics Hip and Thigh 386

anteroposterior mobilization previously di scussed. Technique is effective in increasing

hip flexion.
Ventral Femoral Glide
Patient is prone with a towel slightly raising and supporting the pelvis. Standing at the
opposite of the patient the practitioner places their overlapping hands the dorsal proximal
femur. With the arms somewhat parallel to the line of force, the practitioner applies body
weight to direct a ventral force to the femoral head. This maneuver has a similar effect as
posteroanterior mobilization previously discussed. Technique is effective in increasing
hip extension.
Medial Femoral Rotation
Patient i s prone with the hip sl ightly abducted and medially rotated until the ASIS on the
opposite side lifts off the table. Standing to the affected side of the patient, the
practitioner stabilizes the lower leg with one hand and forearm with the other hand placed
on the unaffected pelvis. Practitioner presses ventrally (rotates hip opposite to medial
rotation) with gentle oscillatory movements. Generally, this technique is effective in
increasing medial hip rotation; however, it is used with caution or modified if patient has
knee instability problems.
Lateral Femoral Rotation
P atient is prone with hip slightly abducted and laterally rotated unti l the ASIS is lifted
from the table. Standing on the opposite side, the practiti oner stabilizes the lower leg with
one hand and forearm while the other hand is placed on the pelvis of involved side.
Practitioner presses ventrally (rotates hip opposite to lateral rotation) with gentle
oscillatory movements. Generally, this technique is effective in increasing lateral hip
rotation; however, it is used with caution or modified if patient has knee instability
problems.

Needling Therapy for Hip and Thigh Problems

Pain and dysfunction of the hip may reflect in the j oint itself or may be reflected to
various regions of the thigh, including the buttocks and low back. There may be restricted
motion in extension, flexion, abduction, adduction, medial rotation, or lateral rotation.
Each of these areas involves one or more muscular distribution and so treatment
approaches vary . Thus, different nodes may be considered depending on the specific area
and nature of the problem.
Hip Joint Pain
When pain and restricted motion probl ems are specifically reflected in the hip joint,
candidate local and adjacent, proximal and distal nodes can be considered as summarized
in Table 1 5.3.
Table 1 5. 3. Reg ional nodes considered in treatment of h i p joint pain and dysfunction
H i p Joint Pain or Cand idate Local & MD Proximal Nodes Distal Nodes
Disorder Adjacent Nodes
Guanyuanshu (PLF 26) LF Danshu (PLF 1 9) Zulinqi (LF 4 1 )/
H uantiao (LF 30) Diwuhui (LF 42)
J ul iao ( LF 29)
Fengshi (LF 3 1 )
Xuanzhong (LF 39)

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Oriental Orthopedics Hip and Thigh 387

Candidate Electroneedling (EN) Application for Hip Joint Pain

Frequency: 2 Hz
Mode: continuous
Duration: 20-30 minutes
Lead placement:
•
Danshu (PLF 1 9) + lead to luliao (LF 29) - lead
•
Guanyuanshu (PLF 26) + lead to Huantiao (LF 30) - lead
Pain and Dysfunction of Hip
Candidate local and adj acent, proximal and distal nodes considered in treatment of hip
joint pain and dysfunction, which reflects in three particular muscular distributions, are
summarized in Table 1 5 .4. Pain and weakness associated with specific muscles and
related hip movements may require adding particular nodes related to those muscles,
while restricted movements might involve tightness or contractures would require
examination of muscles that oppose specific movements. Additional nodes may be added
or deleted from those listed in Table 1 5 .4 for particular disorders affecting specific
muscle distributions moving the hip including:
•
Flexion: mainly involves the iliopsoas belonging to the ALF distribution; may
replace Yanglingquan (LF 34) with Zusanli (ALF 36), add Biguan (ALF 3 1 )
and Qihaishu (PLF 24), and delete Zhibian (PLF 54), Chengfu (PLF 36) and
Huantiao (LF 3 0)
•
Extension: mainly involve the gluteus maximus belong to the PLF distribution
muscles; may add Shenshu (PLF 23), Guanyuanshu (PLF 26), Baiyuanshu
(PLF 3 0) and Feiyang (PLF 48), and delete Zhibian (PLF 54), Yanglingquan
(LF 34) and Liangqiu (ALF 34)
•
Abduction: mainly involve the gluteus minimus, gluteus medius, and the
tensor fasciae latae muscles belong to the LF distribution; add Qihaishu (PLF
24) and Fengshi (LF 3 1 ), and delete Zhibian (PLF 54), Chengfu (PLF 36), and
Liangqiu (ALF 34)
•
Adduction: mainly involve the adductor magnus, longus, and brevis belonging
to the PMF muscle distribution; treat using PLF distribution but add Shenshu
(PLF 23), Zhubin (PMF 9), and limen (AMF 1 1 ), and delete Zhibian (PLF
54), Chengfu (PLF 36), and Liangqiu (ALF 34)
•
Medial rotation: mainly involve the adductor longus, adductor brevis
belonging to the PMF muscle distribution and the gluteus minimus and tensor
fasciae latae belonging to the LF distribution; treat using PLF and LF
distributions but add Shenshu (PLF 23), Zhubin (PMF 9), and limen (SP 1 1 ),
and delete Zhibian (PLF 54), Chengfu (PLF 36), and Liangqiu (ALF 34)
•
Lateral rotation: mostly involve the hip lateral rotators including the
piriformis, quadratus femoris, gemellus superior, gemellus inferior, obturator
intemus, and obturator extemus muscles belonging to the PLF distribution;
treat as PLF distribution and add Qihaishu (PLF 24), Ciliao (PLF 32),
Baiyuanshu (PLF 3 0) and Feiyang (PLF 5 8), and delete Zhibian (PLF 54),
Chengfu (PLF 3 6), and Liangqiu (ALF 34)

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Oriental Orthopedics Hip and Thigh 388

Table 1 5.4. Regional nodes in treatment of pain and dysfu nction in moving the hip
Thigh Pain or Cand idate Local & MD Proximal Nodes Distal Nodes
Disorder Adjacent Nodes
Zhibian (PLF 54) PLF Pangguanshu (PLF 28) Shugu ( P LF 65) I
Chengfu (PLF 36) LF Danshu (PLF 1 9) Zulinqi (LF 4 1 )
Huantiao (LF 30) ALF Weishu (PLF 2 1 ) Xiangu (ALF 43)
Ya ngl ingquan ( LF 34)
Liangqiu (ALF 34)

Candidate Electroneedling (EN) Application for Thigh Problems

Frequency: 2 Hz
Mode: continuous
Duration : 20-30 minutes
Lead placement:
Anterior lateral foot (ALF) distribution (flexion):
•
Weishu (PLF 2 1 ) + lead to Biguan (ALF 3 1 )
•
Qihaishu (PLF 24) + lead to Liangqiu (ALF 34)/Zusanli (ALF 36) - lead
Posterior lateral foot (PLF) distribution (extension):
•
Shenshu (PLF 23) + lead to Huantiao (LF 30) - lead
•
Guanyuanshu (PLF 26) + lead to Baiyuanshu (PLF 3 0) - lead
Lateral foot (LF) distribution (abduction):
•
Danshu (PLF 1 9)/Huantiao (LF 3 0) + lead to Fengshi (LF 3 1 ) - lead
•
Qihaishu (PLF 24) + lead to Yanglingquan (LF 34) - lead
Posterior medial foot (PMF) distribution (adduction):
•
Shenshu (PLF 23) + lead to Jimen (AMF 1 1 )/Zhubin (PMF 9) - lead
Posterior lateral foot (PLF) distribution (lateral rotation):
•
Qihaishu (PLF 24) + lead to Huantiao (LF 30) - lead
•
Guanyuanshu (PLF 26) + lead to Baiyuanshu (PLF 3 0) - lead
Posterior medial foot (PMF) and lateral foot (LF) distributions (medial rotation):
•
Shenshu (PLF 23) + lead to Jimen (AMF 1 1 )/Zhubin (PMF 9) - lead
•
Huantiao (LF 30) + lead to Yanglingquan (LF 34) - lead

Remedial Exercise for Muscles Moving the Hip Joint

The pelvis and femur that comprise the hip j oint have some similarities to the shoulder
joint, and the hip muscles have similar movements in extension, flexion, abduction,
adduction, and rotation (See Table 1 5 .2). However, the pelvis is basically a fixed
structure and is the major load bearing element that directs the upper body weight onto
the legs and the ground. Hence, the function of the hip is dramatically different from the
shoulder. Given that humans are bipedal, the task of the muscles moving the hip is
critical to maintaining overall body function.

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Oriental Orthopedics Hip and Thig h 389

Hip Flexor Stretches

The iliopsoas (psoas + iliacus) muscles can be stretched while lying supine or standing.
In the supine position the subj ect lies down from a seated position at the end of a
treatment table or other location that allows the upper legs extended without the feet
touching the floor. One leg is drawn up to the chest to flex the lumbar spine and rotate the
pelvis while the other leg is extended relaxed over the end of table to allow the dead
weight to put a stretching load on the iliopsoas. The lower leg can also be relaxed and
allowed to flex to not involve the rectus femoris muscle. This position is held for 1 0 - 1 5
seconds after which the leg drawn up to the chest is partially lowered to relieve the
iliopsoas stretch, and then drawn up to the chest again. This cycle can be performed for 3
- 5 repetitions and then performed with the other leg being stretched. Both legs can also
be extended over the end of the table at the same time to stretch both simultaneously. The
lumbar spine needs to be flexed and the pelvis rotated back against the table.
The iliopsoas can also be stretched from the standing position. The subject is
steadied with one hand against a wall or other strong support while partially flexing the
knee on the other side. The free hand is used to pull up the lower leg by grasping at the
ankle while allowing the thigh to move into extension but keeping the lower leg from
moving into full flexion. This position is held for 1 0 1 5 seconds and repeated 3 - 5
-

times. Repeat procedure on other leg.

Exercising Hip Flexors

The prime movers in hip flexion include the psoas major, i liacus, rectus femoris, and the
pectineus muscles. Other muscles involved in flexion of the hip function as assistant
movers include the sartorius, tensor fasciae latae, gluteus medius anterior fibers, gluteus
minimus anterior fibers, adductor longus, adductor brevis, adductor magnus upper fibers,
and the gracilis muscles.
Bent-Leg Raise
Hip flexor strengthening exercises are performed with the subject supine with hands
straight down along body with palms down. One leg is slowly raised while allowing the
lower leg to flex about 90°. This provides a lighter load on the iliopsoas muscles and also
reduces the contribution of rectus femoris in flexing the thigh. Leg is held at the end
position for 2 3 seconds and the leg is slowly lowered to the floor. This exercise is
-

repeated for up to 1 0 - 1 6 repetitions and eventually performed for 3 5 sets. Repeat

-

exercise with other thigh.

Straight-Leg Raise
This exercise i s performed with the subject supine with hands straight down along body
with palms down. One leg is slowly raised with the knee full y extended. This places a
greater load on the iliopsoas muscles but also includes participation of rectus femoris in
flexing the thigh. Leg is held at the end position for 2 3 seconds and the leg is slowly
-

lowered to the floor. This exercise is repeated for up to 1 0 - 1 6 repetitions and eventually
performed for 3 5 sets. Repeat exercise with other thigh.
-

At the end of each set, the leg is raised to the full range of hip flexion, with knee
extended, while subj ect pulls lower leg into the extended position to stretch the hamstring
muscles.

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Hip Lateral (External) Rotation

Lateral rotation of the hip is mainly accomplished by six small muscles lying deep to the
gluteus muscles and includes the piriformis, quadratus femoris, obturator externus and
internus, and the gemellus superior and inferior muscles. These are all prime movers in
hip lateral rotation as is the gluteus maximus muscle. All lateral hip rotators are
considered as a group and typically are exercised in opposition to the medial hip rotators.
Stretch-Contraction
While lying prone with knees flexed 90° and the lower legs pointing straight up with feet
in the neutral position, the hip is externally rotated by contracting the lateral rotators. This
results in both feet moving inward to approach each other and eventual cross with one
foot passing behind the other. Feet are moved to the maximum extent possible and held in
the end position for 1 0- 1 5 seconds stretching the medial rotators. By medially rotating the
hip, with knees still flexed 90° the feet are then moved outward toward the f1oor to the
m aximum extent possible and held in the end position for 1 0 - 1 5 seconds. This causes
the lateral rotators to be put into stretch. The exercise is repeated by contracting the
lateral rotators and moving the feet toward each other again and then allowing them to
cross each other. Reverse the order of what foot passes behind the other on each
repetition of the exercise. Repeat for 3 5 repetitions for 1 3 sets. This exercise is
- -

identical to the stretch-contraction of the hip medial rotators.

Side-Lying Strength Exercises
While side-lying with the below leg knee flexed 90° and the above leg pointing straight
out along the axis of the body, the below foot is raised off the floor to the maximum
extent possible. The foot is held for 2 - 3 seconds and then lowered to rest of the floor
surface. This exercises the hip lateral rotators of the below leg against the gravity load of
its lower leg. Repeat for up to 8 or more repetitions for 2 - 3 sets. As strength increases,
and no pain is present as result of this exercise, light strap-on ankle weights can be
employed to increase the resistive load. This exercise is usually performed in conjunction
with medial rotation exercises of the above leg while still in the same side-lying position.
Each set of below leg lateral and above leg medial rotator exercises is alternated, after
which the subject then lies on the opposite side to exercise the other set of medial and
lateral rotators.

Hip Medial (Internal) Rotation

The gluteus minimus, anterior fibers are the prime mover for hip medial rotation. The
tensor fascia latae, semitendinosus, semimembranosus, gluteus medius anterior fibers,
and adductor magnus lower fibers muscles acting as assistant movers in medial rotation
of the hip. These muscles are considered as a group when performing medial hip rotation
and typically are exercised in opposition to the lateral hip rotators.
Stretch-Contraction
While lying prone with knees flexed 90° and the lower legs pointing straight up with feet
in the neutral position, the hip is internally rotated by contracting the medial rotators.
This results in both feet moving outward toward the floor to the maximum extent
possible. This end position is then held for 1 0 - 1 5 seconds. Feet are then moved in the
opposite direction to approach each other and eventual cross with one foot passing behind
the other to the maximum extent possible and held in the end position for 1 0 - 1 5

D . E . Kendall, OMD, PhD ©2005-2009

Oriental Orthopedics Hip and Thigh 39 1

seconds. By laterally rotating the hip, with knees still flexed 90° the medial hip rotators
are put into stretch. The exercise is repeated by contracting the medial rotators and
moving the feet again toward the floor. When moving the feet back toward each other to
stretch the medial rotators, reverse the order of what foot passes behind the other on each
repetition of the exercise. Repeat 3 5 times for 1 - 3 sets. This exercise is identical to
-

stretch-contraction of the hip lateral rotators.

Side-Lying Strength Exercises
While side-lying with the above leg knee flexed 90° and the below leg pointing straight
out along the axis of the body, the above foot is lifted off the floor to the maximum extent
possible. This exercises the hip medial rotators of the above leg against the gravity load
of its lower leg and held for 2 3 seconds. The foot is then lowered to rest of the floor
-

surface. Repeat for up to 8 or more repetitions for 2 3 sets. As strength increases, and no
-

pain is present as result of this exercise, light strap-on ankle weights can be employed to
increase the resistive load. This exercise is usually performed in conj unction with lateral
rotation exercises of the below leg while still in the same side-lying position. Each set of
below leg lateral and above leg medial rotator exercises is alternated; the subj ect then lies
on the opposite side to exercise the other set of medial and lateral rotators.

Hip Adduction
The adductors longus, brevis and magnus, along with the pectineus and gracilis muscles
are the prime movers in hip adduction with the gluteus maximus lower fibers
participating as assistant mover. Hip adduction exercise can easily be performed from the
side-lying position with the above leg hip flexed 90° and its lower leg externally rotated
so the foot rests on the floor. This forms a bridge-like configuration to provide stability
and allow space to lift the below leg off the floor. The below leg remains on the floor
aligned with the body axis until being lifted off the floor to the highest extent possible
and held for 2 3 seconds and then slowly returned to the starting position.
-

Repeat for up to 8 or more repetitions for 2 - 3 sets. As strength increases, and no

pain is present as result of this exercise, light strap-on ankle weights can be employed to
increase the resistive load. This exercise is usually performed in conj unction with hip
abductor exercises of the above leg while still in the same side-lying position. Each set of
below leg adductors and above leg abductors exercises is alternated, after which the
subject then lies on the opposite side to exercise the same muscles on other leg.

Hip Abduction
The gluteus medius muscle is the prime mover for hip abduction while the gluteus
minimus, gluteus maximus upper fibers, tensor fascia latae, iliopsoas, rectus femoris, and
sartorius function as assistant movers. Hip abduction exercise can easily be performed
from the side-lying position with the below leg knee flexed 90° to provide stability. The
above leg is pointed straight out along the axis of the body, and is raised to the highest
extent possible and held for 2 - 3 seconds. The above leg is then lowered to rest on the
below leg. Repeat for up to 8 or more repetitions for 2 3 sets. As strength increases, and
-

no pain is present as result of this exercise, light strap-on ankle weights can be employed
to increase the resistive load. This exercise is usually performed in conj unction with hip
adductor exercises of the below leg while still in the same side-lying position. Each set of
below leg adductors and above leg abductors exercises is alternated, after which the

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Oriental Orthopedics H i p and Thigh 392

subject then lies on the opposite side to exercise the other set of below leg adductors and
above leg abductors.

Hip Abduction/ Flexion

Hip abduction in slight flexion is performed to specifically address strengthening the
tensor fascia latae, although the gluteus medius and gluteus minimus participate as well.
Hip abduction exercise can easily be performed from the side-lying position with the
below leg knee flexed 90° to provide stability. The hips are rotated backwards around the
vertical axis approximately 1 5 ° to place the tensor fasciae latae in the best position. The
above leg is pointed straight out along the axis of the body, and is raised to the highest
extent possible and held for 2 - 3 seconds. The above leg is then lowered to rest on the
below leg. Repeat for up to 8 or more repetitions for 2 - 3 sets. As strength increases, and
no pain is present as result of this exercise, light strap-on ankle weights can be employed
to increase the resistive load.

Hip Abduction/ Extension

Hip abduction in extension i s performed to specifically address strengthening the gluteus
medius and gluteus minimus muscles although the tensor fascia latae participates as well.
Hip abduction exercise can easily be performed from the side-lying position with the
below leg knee flexed 90° to provide stability. The hips are rotated forwards around the
vertical axis approximately 45° to place the gluteus medius and gluteus minimus muscles
in the best position. The above leg is pointed straight out along the axis of the body, and
is raised to the highest extent possible and held for 2 - 3 seconds. The above leg is then
lowered to rest on the below leg. Repeat for up to 8 or more repetitions for 2 - 3 sets. As
strength increases, and no pain is present as result of this exercise, light strap-on ankle
weights can be employed to increase the resistive load.

Hip Extension
The gluteus maximus, biceps femoris, semitendinosus, and semimembranosus muscles
are the prime movers in hip extension with the gluteus medius posterior fibers, gluteus
minimus posterior fibers, and adductor magnus lower fibers participating as assistant
movers. Hip extension is performed with the subject in the prone position with arm along
side of the body with head usually turned to one side. Hip extension is performed in two
parts, first with the knee flexed to allow the gluteus maximus to fully contract and with
the leg extended to include the hamstrings.
The subject slowly lifts the thigh of one leg off the floor while the knee is flexed
90° and moves it into the fullest extension possible and held for 2 3 seconds. The thigh
-

is then slowly lowered to the floor. Repeat for up to 8 repetitions for 2 3 sets. Repeat
-

exercise for the other leg.

The hip extension exercises are then repeated with the leg extended provided
strength has improved to the point for the subject to perform to complete the routine. Hip
extension will be less since the hamstrings will be involved. As in the previous hip
extension exercise, the subj ect slowly lifts one leg off the floor while the knee is fully
extended and moves the leg into the fullest extension possible and held for 2 3 seconds.
-

The leg is then slowly lowered to the floor. Repeat for up to 8 repetitions for 2 3 sets.
-

Repeat exercise for the other leg.

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 Chinese Orthopedics Knee 393

16

Knee

The knee is the largest synovial joint in the body and combines considerable strength and
mobility while providing the stability necessary to lock the knee in the upright position.
The two active movements that take place in the knee joint include flexion-extension and
axial rotation. Flexion and extension are about an axis that runs through the femoral
condyles as the knee functions somewhat as a hinge joint. Spiral action is also possible to
permit axial rotation of the lower leg. Axial rotation of the knee around the long axis of
the l eg only takes place when the knee is flexed, and is normally not possible while the
knee is extended. The extensive synovium associated with the knee joint communicates
with many bursae important to the knee. Cruciate ligaments within the knee joint have an
important functional role and tibial menisci improve congruency between the tibia and
femur. A summary of normal limiting factors and other characteristics of the knee joint
structures involved in movement of the knee joint are provided in Table 1 6. 1 .

Table 1 6. 1 . Normal limiting factors and characteristics of joint structures involved in movement of
the knee joint
Flexion Extension Internal Rotation External Rotation
Articulation Tibiofemoral Tibiofemoral Tibiofemoral Tibiofemoral
Patellofemoral Patellofemoral
Plane Sagittal Sagittal Horizontal Horizontal

Axis Frontal Frontal Longitudinal Longitudinal

Nonnal limiting Tension in the rectus Tension in parts of both Tension in the cruciate Tension in the collateral
factors femoris; soft tissue cruciate ligaments, the ligaments ligaments
apposition of the tibial and fibular collateral
posterior aspects of ligaments, the posterior
the calf and thigh or a spect of the capsule,
the heel and buttocks and the oblique posterior
ligament
Nonnal end-feel Firm/soft Firm Firm Firm
Nonmal active 0 - 1 35" 1 35" - o· 30" with 90" knee flexion 40" with 90" knee flexion
range of motion
Capsular Knee joint: flexion, extension
pattern Tibiofibular joint: pain on joint stress

Tibiofemora/ Joint
The tibiofemoral joint is the largest joint in the body and functions as a modified hinge
with three degrees of rotational freedom. The articular surfaces of the femur are convex
from side to side and from front to back. The medial surfaces of the tibia are
correspondingly concave from side to side and from front to back, while the lateral tibial
surface is concave only side to side and is convex from front to back. The articular
surfaces of the tibia and femur are not congruent which allows the two bones to move
different amounts as controlled by the muscles and ligaments. The tibia and femur
approach congruency in full extension, which is the close packed position for this joint.

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Chinese Orthopedics Knee 394

Patellofemoral joint
Excursion of the patella in its femoral groove is controlled by the quadriceps femoris
muscle and tendon during flexion and extension of the knee. The patella is fixed in
relationship to the tibia by means of the patellar ligament attached to the tibial tuberosity.
As the knee is flexed, the tibia slides back along the surface of the femoral condyles and
pull the patella downwards and backwards. During flexion the patella moves on the
femoral trochlear surface, extending down to the articular surface of the medial and
lateral femoral condyles. As flexion increases the patella moves into the deep groove
between the condyles to lie within the intercondylar notch.
Capsular Ligaments
The joint capsule of the knee consists of two tibiofemoral compartments that separately
surround the medial femoral and tibial condyles, and the lateral femoral and tibial
condyles.

Medial joint compartment

The medial compartment is bounded medially by the medial capsular ligament,
and laterally by the posterior cruciate ligament. The medial capsular ligament is divided
into anterior, middle and posterior thirds.

Lateral joint com partment

The lateral compartment is bounded laterally by the lateral capsular ligament, and
medially by the anterior cruciate ligament. The lateral capsular ligament is also divided
into anterior, middle and posterior thirds.
Cruciate Ligaments
The two cruciate ligaments occupy the central intercondylar space of the knee. They are
named because they cross each other and are further identified according to their tibial
attachments. The posterior cruciate inserts on the tibia at the posterior aspect of the
intercondylar area, while the anterior cruciate inserts more anteriorly in this space.
Menisci
Space between the femur and tibia is partially occupied by a lateral and medial meniscus
attached to the tibia by means of the coronary ligaments. The menisci are avascular in
their cartilaginous inner two thirds and are partly fibrous and vascular in their outer one
third. The menisci are also attached to joint capsule and capsular ligaments. The menisci
move forward during knee extension and move backwards on knee flexion. They are
compressed between the posterior aspect of the tibia and femur in maximum knee
flexion.

Physiology of the Knee

The principal muscles controlling flexion-extension of the leg include the medial
hamstrings consisting of the semitendinosus (PLF) and semimembranosus (PMF) which
rotate the tibia medially while flexing the knee, and the vastus medialis (AMF) which
extends the knee. The popliteus (PLF) performs the key function of stabilizing the femur
while flexing the knee. The rectus femoris, vastus intermedius muscles (ALF) and vastus
lateralis (LF), play a major role in extension of the leg.

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 Chinese Orthopedics Knee 395

The biceps femoris, short head (LF) along with the biceps femoris, long head
(PLF) serve as the principal lateral rotators of the tibia. The gracilis (MF), sartorius
(AMF) and popliteus (PLF) serve as medial rotators of the tibia.
Many of the knee muscles also have a role in movement of the thigh. Summary of
muscles moving the knee, along with their nerve roots and muscular distribution
assignments are noted in Table 1 6.2.

Table 16.2. Function, nerve root, and m u scular distribution ( M D) assignment of prime mover (PM)
and assistant/accessory mover (AM) muscles of knee, and moving the hip (H)
Muscle MD Nerve Root Flexion Extension Medial Lateral
Rotation Rotation

Biceps femoris, L h. PLF L5, S 1 , 2 PM H PM&H

Biceps femoris. s. h. LF L5, S1, 2 PM PM

Semitendinosus PLF L5, S 1 , 2 PM H PM&H

Semimembranosus PMF L5, S1, 2 PM H PM&H

Sartorius AMF L2, 3, (4) AM&H AM

Gracilis MF L2, 3, (4 ) AM&H AM

1
Popliteus PLF L4, 5, S1 PM

Gastrocnemius. lat. h. PLF S 1 , S2 AM

Gastrocnemius. med. h. PMF S1 , S2 AM

Plantaris PLF L4, 5, S 1 AM

Tensor fasciae latae LF l4 , 5, S1 H AM H

Rectus femoris ALF L2, 3, 4 H PM

Vastus lateralis LF L2, 3, 4 PM

Vastus medialis AMF L2, 3 , 4 PM

Vastus intermedius ALF L2, 3,4 PM

1. Unlocks knee at start of knee flexion; l.h. ==long head; s.h. ==short head; lat. h.= lateral head; med. h . =
medial head

Disorders of the Knee

Since the knee is the largest synovial joint in the body it is susceptible to traumatic,
degenerative, and inflammatory disorders. Pain may be felt in the knee or reflected from
hip disorders where it manifests as a dull aching pain in the knee or suprapatellar area.
Problems affecting the knee also include pain and weakness in muscles moving the knee
which may reflect in particular muscle distributions.

Muscular Distribution Problems

Specific disorders of the six longitudinal muscular distributions of the knee include the
following:
Posterior lateral foot (PLF) distribution:
•
Contractions and pain in the back of the knee.
Lateral foot (LF) distribution:
•
Stretched muscles and acute cramps in the lateral aspect of the knee.
•
Knee is unable to bend or extend.
•
Contractions in the back of the knee, with tight and stretched muscles in the
anterior aspect of the thigh.

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Chinese Orthopedics Knee 396

Anterior lateral foot (ALF) distribution:

•
Acute cramps and spasms in the rectus femoris muscle.
Anterior medial foot (AMF) distribution:
•
Acute cramps and pain in the medial knee with pain in the upper medial fibula.
Medial foot (MF) distribution:
•
Pain and acute cramps of the inner thigh and medial aspect of knee.
Posterior medial foot (PMF) distribution:
•
Acute cramps and pain in region of knee at major insertion sites of the PMF
muscles (posteromedial aspect).

Pathology Affecting the Knee

Problems affecting the knee cover a wide of symptoms with pain perhaps being the most
common complaint. There may be instability of the knee as well as episodes of the joint
locking. The knee is susceptible to soft-tissue injuries, inflammatory diseases, and joint
lesions. As in all other areas of the musculoskeletal systems of the body, a detailed
history is essential.
Knee Symptoms
Knee Pain
Pain usually manifests within the knee joint but can also be the result of disease in
the more proximal structures. Pain due to hip problems may radiate down the anterior
aspect of the thigh and to the knee. Patients with an intervertebral prolapse that results in
nerve root pressure at L3 or L4 may also complain of pain in the knee. Problems
associate with the knee joint typically cause pain within the knee itself.
Pain associated with the tibiofemoral joint has certain characteristics. Pain is often
worse when the patient first stands up and starts to walk, or after walking for some
distance. Pain on the affected side is typically worse on load bearing or while going up
and down stairs. Pain may be accompanied with or associated with stiffness after being
seated for some time.
Pain produced by disorders of the patellofemoral joint often manifests as pain in
the retropatellar aspect of the knee. This pain is made worse by going up stairs, riding a
bicycle, walking, running, or after sitting for a long period such as riding in a vehicle or
airliner, or sitting in a theater.

Locking
Locking of the knee refers to a sudden complete block to full extension of the
knee while movement in full flexion is possible. Typically there is about a 1 5° to 45° loss
in extension, along with some impairment in rotation. End-feel of a locked knee in
extension may be "Muscle Spasm or Springy Block" due to protective muscle spasms.
Locking may not be the best term since it conveys the idea of a complete block with no
possible motion. Patients may use this term to denote an inability to move the knee due to
stiffness or pain.
Patient may have a history of the joint unlocking which may occur spontaneously
or after manipulation of the knee. Patient may report the feeling of something slipping or

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Chinese Orthopedics Knee 397

snapping back into place. Locking may result from a loose bony fragment, tom meniscus,
tom cruciate ligament, dislocated patella, or avulsed tibial spine.

Instability
The giving way, buckling, or feeling of instability of the knee on use is a common
complaint. The knee can suddenly give way without any pain or prior indication but with
the feeling that one bone has slipped or moved over the other. This may occur when
walking or running over uneven ground, or walking down stairs. Instability may be the
result of many disorders including arthritis, a loose bony foreign body, or tom meniscus.
It can also result from damage to ligaments causing rotatory instability.
Ligament Injuries
Integrity of the ligaments is essential to prevent abnormal movements of the knee joint.
Sprain of the knee ligaments is perhaps one of the most common of all soft-tissue
injuries. The knee is normally stable in extension where the ligaments function as static
stabilizers of the knee. While flexed the knee is less stable and able to rotate so abnormal
stresses in this situation are more likely to result ligamentous injury.
Ligamentous injuries are classified in terms of various degrees of sprain. A first
degree sprain involves the tear or damage of only a few ligament fibers. Assessment and
diagnosis is straight forward with the patient's pain being reproduced by stressing the
ligament. A valgus directed force is used to evaluate sprains of the medial ligament,
whereas a varus directed force is used to evaluate sprains of the lateral ligament. Possible
tenderness is usually localized over the site of injury, which may be at the upper or lower
attachments or over the joint line. There may be some swelling over the site of injury
without synovial effusion, and the knee is stable.
In a second degree sprain synovial effusion may be present and it may be
difficult to determine if there is any damage to intra-articular structures. A diagnosis is a
little more difficult than with a first degree sprain. The magnitude of pain and disability is
greater than a first degree sprain and a slight instability of the knee joint may be present.
A third degree sprain involves a complete rupture of the ligament. In the case of
the lateral ligament, it is usually tom from its lower fibular attachment while the medial
ligament is tom from its upper femoral attachment. A fragment of bone may also be
avulsed in either case, which may be visible on x-ray. Severe pain and disability is
instantly obvious and diagnosis may be straight forward if the patient is seen
immediately. Later the pain may decrease and the diagnosis may not be obvious since a
synovial effusion may not develop since blood and fluid can escape from the synovial
cavity through the capsular tear. A ruptured ligament requires surgical intervention.
Rupture of the anterior cruciate ligament may occur but it is more likely for this
ligament to be damaged along with other ligaments of the knee. A tear in the anterior
cruciate ligament can progressively become worse and fmally give way when additional
stress is placed on other supporting soft-tissues. Injury to the anterior cruciate ligament is
usually the result of hyperextension of the knee. This occurs by a direct blow to the
anterior femur when the tibia and foot are fixed to the ground, or by a rotational injury to
the knee when changing direction while running. Patient is usually aware that something
seemed to give way in the knee and they were not able to continuing their activity. A
tense effusion develops within 24 hours and arthroscopy or arthrography may be needed
to confirm the diagnosis.

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Chinese Orthopedics Knee 398

Musculotendinous Lesions at Knee

These lesions involve muscles that articulate the knee or whose insertion or origin is at
the knee and their tendons often manifesting with tendinitis.

Quadriceps Tendon
A partial tear or complete rupture can occur where the quadriceps tendon inserts
into the upper border of the patella. This is a significant injury since the quadriceps is
essential in maintaining the stability and function of the knee. The injury can occur
during an unexpected slip and fall accident while the quadriceps are held in flexion with
maximum contraction. This problem is more likely to be seen in elderly male patients and
possibly associated with degenerative tendon changes. If not treated there may be some
amount of repair but patient will probably not be able to climb stairs or walk up hills
without the knee giving way. Condition is confirmed when patient cannot sustain an
isometric contraction of the quadriceps.

Quadriceps Injury
The quadriceps can quickly lose strength and bulk following any injury affecting
its function or following any knee joint disorder. This is especially true for the vastus
medialis which is essential in maintaining balance in the quadriceps group. These late
effects can lead to self-perpetuating painful knee conditions which may be confused with
intrinsic disorders. It is important that any iJ1iuries to the quadriceps be properly treated
and rehabilitated through proper exercises.

Bicipital Tendinitis
The biceps tendon inserts into the fibular head and is susceptible to tendinitis
usually following overuse injury from running and can be associated with bursitis.
Tenderness is well localized over the tendon insertion as confirmed by palpation. The
patient's pain can be reproduced by isometric resistive flexion of the knee.

Popliteal Tendinitis
The popliteal muscle runs from the posterior aspect of the tibia and is attached by
its tendon into the lateral surface of the lower end of the femur. Patient's pain is located
at the posterolateral corner of the knee joint and may be intense for the first 24 hours after
running, or other activities that aggravate the condition, and then often improves. In some
cases the tendon may produce a painful click as its slips out of its groove on femur
condyle. Patient's pain may be reproduced on contraction of the popliteal muscle which
is tested in the supine position with the lip flexed, abducted, and laterally rotated with the
knee flexed 90°. Examiner applies resistive flexion with one hand while palpating the
tendon just posterior to the lateral collateral ligament. Popliteal tendinitis is further
confirmed by tenderness in the posterolateral comer of the knee just above the joint line.

Gastrocnemius Tendinitis
This lesion is due to overuse and more often manifests in the origin of the
gastrocnemius medial head (PMF) and can also involve inflammation of the underlying
bursa. Usually involves distance runners that have changed their program by running up
and down hills, or running at a faster rate, and is also common at the beginning of an
athletic season. Patient's pain well localized above the joint line and if severe, pain can

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Chinese Orthopedics Knee 399

radiate down lower leg. Pain can be reproduced by fully resisting knee flexion while
patient is prone. Tenderness is localized over the head of the gastrocnemius muscle.

Iliotibial Tract
Patient presents with pain over the lateral compartment of the knee where the
iliotibial tract passes over the lateral femoral epicondyle. Pain is usually brought on by
running a few miles along a flat surface or on running downhill, but may occur at the end
of a run and then becomes worse. Pain can radiate distally or proximally, and patient may
even complain of clicking in the hip. With the patient side lying, the pain may be
reproduced by applying compression on the iliotibial band just proximal to the lateral
epicondyle while flexing and extending the knee. Patient's knee is initially flexed 90° and
then slowly moved into extension and pain is reproduced at about 30° of flexion.
Condition is confirmed by palpating about 3 em proximal to the joint line.
Bursitis
There are numerous bursae related to the patella, ligaments, and muscle tendons inserting
or originating at the knee. Some of these may be inflamed resulting in bursitis or also
related to tendinitis of the affected muscle.
Tibiofemoral Joint Lesions
Include damage to the menisci, traumatic synovitis, osteoarthritis of the bone, other bony
lesions, and loose body formation.
Patellofemora/ Joint Lesions
Include patellofemoral pain, recurrent subluxation of the patella, infrapatellar pain, and
patellar tendinitis

Assessment of Knee
Generally, the lumbar spine, hip, and lower leg are evaluated before the knee is
examined. The trunk and pelvis function as a supporting pedestal that transmits body
forces through to the lower legs, feet, and the ground. The knee is the intermediate joint
in this linkage and problems in the lower limbs can produce alterations in the
biomechanical loads on the knee joint resulting in pathology. Lumbar spine and hip
movements are tested for any limitations in movement or weakness, tightness, or wasting
in thigh muscles that result in knee pain.

Observation
Standing: patient is viewed head-on to note the alignment of the femur on the tibia which
in the adult straight leg is normally offset by 6° to 7° of valgus. It is necessary to be able
to see the medial aspect of the knees and the medial malleoli to observe upper and lower
leg alignment. Patient is instructed to put the limbs to together as close as possible. If the
knees touch and the ankles do not, the patient has genu valgum. A distance of 9 to 1 0 em
between the ankles is considered excessive. If the patient's malleoli touch but the knees
do not, the patient has a genu varum. The normal tibiofemoral shaft angle difference as
measured on X-ray studies is about 6°
Patella position: at 45° knee flexion the patella articular surface is directly against
the anterior femur; when ratio of patellar length to length of patellar ligament (measured

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Chinese Orthopedics Knee 400

from patella inferior pole and the tibial tuberosity with knee extended) is greater than I it
indicates patella baja, when less than I it indicates patella alta
Q Angle: This is the acute angle between a line which bisects the patella and the
anterior superior iliac spine (ASIS) and a line which bisects the patella and the tibial
tuberosity. This angle represents the frontal plane alignment of the knee extensor
mechanism which is normally about 1 oo when the quadriceps muscles are contracted. A
Q angle greater than 20° may indicate excessive lateral forces on the patella
• Deformities
• Swellings
• Muscle wasting

Active Movements of Knee

The knee joint functions somewhat as a complex hinge joint which primarily moves in
flexion and extension. The lower leg can also rotate when the knee is flexed at 90°. The
range of active movements in flexion, extension, and axial rotation are measured as
follow:
Knee Flexion-Extension
Extension of the knee is usually not measured and recorded since it is the return to the
starting position in measuring flexion ROM. However, hyperextension is measured.
Restriction in flexion indicates possible tightness in the quadriceps muscles. Of these the
rectus femoris can be specifically tested for possible involvement (See Ely Rectus
Femoris Test).
Active knee flexion ranges from oo to 1 3 5° with 0° representing a straight leg.
This can be measured in the supine or prone position. With the patient supine the knee is
simultaneously flexed with the hip where the hip is held perpendicular to the examining
table at 90° flexion while the knee is fully flexed. Initially, the patient is supine with the
leg fully extended; the fulcrum of a goniometer is placed on the lateral aspect of the knee
joint with the center on the axis of knee joint movement in flexion/extension. A towel
may be placed under the ankle to make certain the knee is fully extended. The fixed arm
of the goniometer is aligned with the femur and pointing at the greater trochanter. The
movable arm is aligned with the tibia and pointing at the lateral malleolus. Examiner
holds the goniometer on the thigh and lower leg as the patient flexes the thigh 90° while
fully flexing the knee.
In the prone position, the patient's feet should be off the end of the examination
table. The fulcrum of a goniometer is placed on the lateral aspect of the knee joint with
the center on the axis of knee joint movement in flexion/extension. The fixed arm of the
goniometer is aligned with the femur and pointing at the greater trochanter. The movable
arm is aligned with the tibia and pointing at the lateral malleolus. Examiner holds the
goniometer on the thigh and lower leg as the patient fully flexes the knee.
A gravity sensitive goniometer can be employed to measure knee flexion with the
patient prone. The gravity sensitive goniometer is strapped on the lower leg just proximal
to the ankle with the dial on the lateral aspect of the leg. The device is zeroed out before
flexing the knee through the full range flexion that is possible.

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 Chinese Orthopedics Knee 401

Knee Hyperextension
Active knee extension is close to oo but may be hyperextended up to 15° in some people,
especially women. Restrictions in knee extension may be due to tightness in the
hamstring muscles (See Hamstring Tightness Test).
Hyperextension is passively measured with patient supine while the examiner lifts
the foot with one while stabilizing the thigh by placing the other hand just proximal to the
knee. This procedure is then repeated by placing one hand on the tibial condyle and
lifting the foot with the other.
Ely Test (Rectus Femoris)
Purpose of this test is to determine possible tightness in the rectus femoris muscle in
limiting knee flexion. The rectus femoris flexes the hip and extends the knee (See Table
15.2). Hence, any shortness in the rectus femoris can restrict knee flexion. The knee
flexion ROM value obtained in this test is compared with the knee flexion ROM
measured with the patient supine and hip flexed to 90° as noted above. The rectus
femoris test configuration is the same as used in measuring knee flexion in the prone
position as previously described. The difference here is that thigh is stabilized so that it
can not flex. Tightness in the rectus femoris will cause the hip to move in the direction of
flexion when the knee is fully flexed.
If the rectus femoris is short there will be a limitation in knee flexion when the hip
is maintained in a neutral position. When knee flexion is limited while the hip is flexed to
90°, the restriction is possibly due to joint structure abnormalities or shortness in a one­
point knee extensor muscles (See Table 16.2).
Hamstring Tightness
The three hamstring muscles (semitendinosus, semimembranosus, and biceps femoris
long head) that attach to the ischial tuberosity function to extend the hip. All four
hamstrings (including the biceps femoris short head) flex the knee. Shortness or tightness
in the hamstrings can result in knee flexion restriction. This can be evaluated using a
variation of the test in measuring knee flexion in the supine position. This measurement
could actually be performed immediately after measuring full knee flexion as previously
described.
The patient is supine with the test leg hip flexed at 90° while held in oo of hip
abduction, adduction, and rotation, with the knee allowed to relax in flexion. The other
leg rests on the examination table with the hip in 0° of flexion, extension, abduction,
adduction, and rotation, with the knee fully extended. The examiner stabilizes the femur
to prevent hip rotation, abduction, and adduction while maintaining the hip in 90° of
flexion.
Examiner passively extends the patient's knee to the full range of extension until
resistance is felt as tension in the posterior thigh and further extension causes the hip to
move toward extension. Normal end-feel is firm due to tension in the hamstrings. The
ROM is measured by placing the fulcrum of a goniometer on the lateral aspect of the
knee joint with the center on the axis of knee joint movement in flexion/extension. The
fixed arm of the goniometer is aligned with the femur and pointing at the greater
trochanter. The movable arm is aligned with the fibular head and pointing at the lateral
malleolus. The ROM measured from the zero point provides the amount of flexion
deficit. Value may range from 15° to 45° with an average of about 30°.

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Lateral-Medial Tibial Rotation

The tibia can be laterally rotated on the femur from 3 0° to 40° and medially rotated 20° to
30°. Axial rotation of the tibia is conducted with the patient seated with knees flexed 90°
and lower legs dangling over edge of the examination table. The hip is flexed in the
seated position with 0° abduction, adduction, medial rotation, and lateral rotation. Patient
actively rotates tibia from the neutral position in
0° of knee rotation, with the foot in the
neutral position, while maintaining the tibial axis perpendicular to the floor. Care is taken
to make certain that the hip is not rotated or the foot is not dorsiflexed, plantar flexed,
everted, or inverted during tibial rotation.
Rotation can be measured with a compass device with a goo platform strapped to
the lower leg proximal to the ankle. Compass needle moves in the horizontal plane and
set to zero degrees in the neutral position. Tibia is first rotated either medially or laterally
with the angular measurement read at the end of each axial rotation ROM. Tibia is
returned to the neutral zero degree position before rotating in the other direction.
Rotation can also be measured with a goniometer placed on the knee with the
fulcrum over axis of the tibia with the fixed arm aligned with the femur and the movable
arm aligned with the space between the first and second toe with the foot in the neutral
position. Movable arm is moved along with tibial rotation to record the full ROM.

Passive Movements of Knee

The knee is passively moved in flexion, extension, medial rotation, and lateral rotation.
Distal, medial, and lateral passive movement of the patella is also performed. Main
purpose is to assess possible hypomobility, hypermobility, and end-feel for the
movements for the knee. If the above active movement can be performed without
restrictions due to pain, the end-feels can be assessed at the end of ROM.
Flexion
Passive flexion of the knee can be accomplished with the patient supine or prone. In the
supine position the examiner grasps the knee with one hand and holds the ankle with the
other. The patient's knee is gently lifted up to goo of hip flexion while ankle is moved
into full degree of flexion possible. The end-feel is tissue approximation.
In measuring passive flexion with the patient in the prone position, the examiner
lifts the lower leg and gently moves it into full flexion. While moving the lower leg into
full knee flexion, the examiner looks for possible flexion of the hip that would suggest
possible tightness in the rectus femoris muscle.
Extension
Patient is supine while the lifts up on the ankle with one hand while stabilizing the thigh
with one hand placed just proximal to the knee joint. The end-feel is tissue stretch. The
hip can also be passively moved into goo of flexion with lower leg moved into extension
until the hip starts to extend due to hamstrings. If the flexion deficit is large this may
indicate tightness in the hamstrings.
Lateral-Medial Tibial Rotation
Passive rotation of the tibia is conducted with the patient seated with knees flexed goo
and lower legs dangling over edge of the examination table. The hip is flexed in the
seated position with oo abduction, adduction, medial rotation, and lateral rotation. The
examiner grasps the lower tibial area with one hand while stabilizing the knee with the

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other hand. While maintaining the tibia perpendicular to the floor, the examiner rotates
the tibia on its axis to the full range of lateral and then medial rotation. The end-feel of
tibial rotation on the femur is tissue stretch.
During knee rotation the menisci move with the femur which can be easily felt by
palpating the joint line while the flexed knee is laterally (externally) and medially
(internally) rotated. On lateral rotation the lateral meniscus moves anteriorly in its
tibiofemoral compartment while the medial meniscus moves posteriorly in its
compartment. These menisci movements are reversed during medial rotation.

Resistive Movements of Knee

Resisted isometric movements are tested for knee flexion and extension. If the lower leg
and ankle are not going to be evaluated then it is advisable to conduct resisted isometric
movement testing in dorsiflexion and plantar flexion.
Knee Flexion
Resisted isometric movement in knee flexion mainly involves the biceps femoris,
semitendinosus, and semimembranosus muscles with accessory participation the
gastrocnemius, popliteus, gracilis, and sartorius muscles. Patient is supine with the
examiner standing to the test side and holding the thigh in about 75° of hip flexion with
the knee flexed 90°. The examiner stabilizes the thigh with one hand just proximal to the
knee joint while the other hand applies a resistive force to the posterior aspect of the
lower leg just above the ankle. Resistive force is applied in the direction of knee
extension.
Knee Extension
Resisted isometric movement in knee extension mainly involves the rectus femoris and
vastus intermedius, lateralis and medialis muscles. Patient is supine with the examiner
standing to the test side. The examiner places on hand under test leg thigh to place a hand
on the opposite thigh. This places the patient's thigh into slight flexion and the patient
moves the test into knee extension to lift leg off the table. The examiner then uses the
other hand placed proximal to the ankle to apply an isometric force in the direction of
knee flexion while the patient counteracts the force so the leg is not moved.
Ankle Dorsiflexion
This test mainly assesses the isometric strength of the tibialis anterior muscle. This is
described in the following section on the Lower Leg and Ankle and would be conducted
while assessing the knee if it was not required to test the lower leg and ankle.
Ankle Plantar Flexion
This test mainly assesses the isometric strength of the gastrocnemius and soleus muscles.
This is described in the following section on the Lower Leg and Ankle and would be
conducted while assessing the knee if it was not required to test the lower leg and ankle.

Accessory Movements of the Knee

Accessory joint play movements for the knee are conducted with the patient in the supine
position. As is all cases of movement assessment of uninvolved side is tested first to
compare with the affected side. The passive movements of the patella consisting of the
distal, medial, and lateral glides are also used to evaluate accessory movements of the
patella. Accessory movements can also be used in mobilization methods in those cases of

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Chinese Orthopedics Knee 404

hypomobility where the force is applied in an oscillatory manner. Accessory movements

for the knee include:
Anteroposterior and Posteroanterior Movement of Tibia on Femur
Both anterior to posterior and posterior to anterior movement of the tibia on the femur are
conducted to feel the quality of movement, which is normally tissue stretch. These two
tests are similar to anterior and posterior drawer test for ligamentous instability.
With the patient supine and knee flexed 90° and the hip flexed 45° the examiner
places the heel of one hand over the tibial tuberosity while stabilizing the limb with the
other hand. The examiner may partially set on the patient's foot to stabilize the lower leg.
The examiner applies an anteroposterior directed force to move the tibia backward on the
femur.
To perform the posteroanterior accessory movement, the examiner then places
both hands around the posterior aspect of the tibia. The examiner needs make sure that
the hamstrings and gastrocnemius muscles are relaxed. The examiner then moves the
tibia forward on the femur.
Lateral and Medial Movement of Tibia
The patient is supine and knee flexed 90° and the hip flexed 45° while the examiner holds
the patient's leg between examiner's trunk and arm. For lateral movement of the tibia on
the femur, the examiner places one hand on the medial side of the tibia and the other hand
on the lateral femur. The tibia is then pushed laterally on the femur and the normal end­
feel is tissue stretch. Excessive moment may indicate a tom posterior cruciate ligament.
To test medial translation of the tibia on the femur, the examiner places one hand
on the medial aspect of the femur while the other hand is placed on the lateral side of the
tibia. The tibia is then pushed medially on the femur and the normal end-feel is tissue
stretch. Excessive movement in the medial direction may indicate a tom anterior cruciate
ligament.
Medial and Lateral Rotation of Tibia
Medial rotation of the tibia on the femur is produced by the examiner with the patient
supine with the knee and hip flexed 90°. In the case of the right leg, the examiner while
standing to the side of the patient and facing toward the end of the table holds the
patient's heel with the right hand while using the left hand to reach around the top of the
foot to grasp the lateral edge of the foot over the fifth metatarsal and little toe. The left
hand is used to medially rotate the tibia on the femur while the right hand stabilizes the
foot and holds the axis of the tibia parallel to the floor and longitudinally aligned.
Lateral rotation is performed in the same test configuration and conducted
immediately following the medial rotation test, but here the hands are reversed. The left
hand now supports the heel while the right hand is placed over the anterior foot to grasp
the medial edge of the foot over the first metatarsal and big toe. The right hand is then
used to laterally rotate the tibia on the femur.
Testing the left leg in medial and lateral tibial rotation requires standing on the
other side of the table and reversing the hand placements used for the right leg.
Patellar Mobility
Passive movement of the patella is also conducted to determine its mobility and to
compare it with the unaffected side. Passive movements include distal, medial, and lateral

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Chinese Orthopedics Knee 405

glides. These are conducted with the patient supine and supported under the knee to
provide some degree of flexion (about 30°). Medial and lateral patellar mobility is
greatest at 45° of flexion and should be tested at position as well . Caution is to be applied
when assessing the lateral movement especially in patients with a history of patellar
dislocation. The end-feel in all three movements is tissue stretch
Distal Glide
This passive motion is performed by placing the heel of one hand on the base of
the patella with the forearm lying aligned along the thigh. The other hand is placed on top
of the first hand and both are used to move the patella in the distal direction.
Medial-Lateral Glide
For this movement the palmar aspect of the examiner's thumbs is placed on the
lateral border of the patella. The pads of the index fingers are placed on the medial border
of the patella. The thumbs are used to apply a medially directed force to move the patella
in that direction whil e the index fingers are used to move the patella laterally in a side-to­
side motion. Typically, the patella should move about half of its width medially and
laterally. Full or restricted ROM is noted.
Posteroanterior Movement of Fibula on Tibia
Patient is supine with hip flexed 45° and knee flexed 90° while examiner partially sets on
patient' s foot. Examiner places one hand around the patient' s knee to stabilize leg while
the other hand grasps the head of the fibula. The fibula is drawn forward on the tibia and
the accessory movement and end-feel are tested. The fibula will return to its original
position when examiner releases grip. This movement is then repeated several times and
compared with the unaffected side.
-+ This test must be perfonned with care since the common peroneal nerve winds
around the fibular head and may be easily compressed resulting in pain. If the
superior tibiofibular joint is hypomobile this test can cause discomfort.

Functional Assessment
There are several functional and numerical rating approaches that have been developed
for the knee. Some of these are specialized for specific populations, such as athletes or
individual recovering from knee surgery. If the active, passive, and resisted isometric
tests are uneventful, the patient can be subj ected to a series of functional tests to
determine if sequential activities produce pain or other symptoms. These activities can be
given a numerical score based on the time required to complete each test. A sequence of
candidate functional activities can be selected consistent with the patient's normal ability
and interest, such as being work related, recreational, or sports that could include:
•
Walking
•
Ascending and descending stairs (can include both normal pace and running)
•
Squatting (observe for symmetrical flexion of both knees)
•
Running straight ahead (possibly stopping on command)
•
Running and twisting (over a figure 8 course about 4 by 20 meters)
•
Verticaljump
•
Jumping and then going into a full squat

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Chinese Orthopedics Knee 406

•
Hopping, twists, hard cuts, pivots

Special Tests
There numerous special tests for the knee to knee instabilities due to damage to the main
ligaments and other problems, as well as those that detect possible menisci damage
Anterior Lachman's Test
Patient is supine with the test knee flexed 20° to 30° while the examiner stands to next to
the examination table with one hand on the lateral aspect of the distal thigh immediately
proximal to the patel la. The other hand is placed on the posteromedial aspect of the
proximal tibia immediately distal to the tibial tuberosity.
An alternative test position involves the examiner placing their flexed knee under
the patient' s test knee, with one hand on the anterior aspect of the distal thigh with the
other hand on the medial aspect of the proximal tibia j ust distal to the tibial tuberosity.
Starting from a neutral anterior-posterior position an anterior directed force is
applied to the tibia while the other hand stabilizes the femur. The same approach applies
to the alternate test position. Excessive anterior movement of the tibia on the femur (as
compared to the unaffected side) from the neutral position with a diminished or absent
endpoint indicates a possible partial or complete rupture of the anterior cruciate ligament.
Increased proximal tibial translation by itself is not totally indicative of anterior
cruciate l igament pathology. A tom posterior cruciate l igament can allow the proximal
tibia to translate posteriorly thereby allowing increased anterior translation of the tibia on
the femur when the anterior Lachman' s test is performed. A meniscal tear involving the
posterior hom may also contribute to anterior translation. It is essential to determine the
presence and quality of the endpoint before the integrity of the anterior cruciate ligament
can be accurately assessed. Some individuals may use their dominant hand for translation
assessment, but it is important to stabilize the tibia on the medial side for this test to
prevent increased lateral rotation that can contribute to increased anterior translation.
Anterior Drawer Test
The patient is supine with the hip flexed 45° and knee flexed 90° and the foot is in the
neutral position. The examiner partially sets on the patient' s foot while grasping the
patient's tibia with both hands behind the proximal tibia with thumbs of the tibial plateau.
An anterior force i s then applied to the tibia while assessing anterior displacement of the
tibia on the femur. Increased anterior tibial translation on the femur as compared to the
unaffected side possible indicates a partial of complete tear of the anterior cruciate
ligament.
Assessment of the endpoint during this test i s less reliable than the anterior
Lachman's test and hence there is a greater chance for false negative findings, secondary
to the increased possibility for hamstring guarding.
Pivot Shift Test
Patient is supine with the leg fully extended while the examiner stands with one hand on
the anterolateral tibiofemoral joint and thumb on the posterior fibular head. The other
hand grasps the patient's heel and midfoot.

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Chinese Orthopedics Knee 407

An alternate position involves placing the patient' s foot between the examiner's
arm and body while the other hand remains on the anterolateral tibiofemoral j oint and
thumb on the posterior fibular head.
Slowly flex the knee while internally rotating the tibia with the hand on the foot
and apply a valgus force with the hand on the tibiofemoral joint. This same procedure
also applies to the alternate test position, except a slight axial load first applied to the case
starting with the extended knee.
A palpable pivot shift or "clunk" occurring between 20° and 30° of flexion
indicates a possible anterolateral rotary instability that is secondary to tearing the
posterolateral capsule and anterior cruciate ligament.
It is essential to apply the axial load in the test configuration that starts with the
leg fully extended before flexing the knee in order to accentuate the shift or clunk that
facilitates detecting the trace pivot shift.
+ This test may create apprehension and anxiety since it often reproduces the
injury mechanisms, which can contribute to false negative findings .

+ This test may be the most sensitive in detecting anterior tibiofemoral instability;
however, this test is difficult to perform and potential patient apprehension and
anxiety make it difficult to allow the practitioner to gain experience as compared
to other tests.

Posterior Drawer Test

The patient is supine with the hip flexed 45° and knee flexed 90° and the foot is in the
neutral position. The examiner partially sets on the patient' s foot while grasping the
patient's tibia with both hands behind the proximal tibia with thumbs of the tibial plateau.
A posterior force is then applied to the tibia while assessing posterior displacement of the
tibia on the femur. Increased posterior tibial translation on the femur as compared to the
unaffected side possible indicates a partial of complete tear of the posterior cruciate
ligament.
It is essential that the quadriceps and hamstring muscles are completely relaxed
during this test. In addition, the examiner should carefully assess and posterior step-off of
the tibia on the femur while applying the posteriorly directed force.
Posterior Lachman's Test
Patient is supine with the test knee flexed 20° to 30° while the examiner stands to next to
the examination table with one hand on the lateral aspect of the distal thigh immediately
proximal to the patella. The other hand is placed on the medial aspect of the proximal
tibia immediately distal to the tibial tuberosity. Starting from a neutral anterior-posterior
position a posterior directed force is applied to the tibia while the other hand stabilizes
the femur. Excessive posterior movement of the tibia on the femur (as compared to the
unaffected side) from the neutral position with a diminished or absent endpoint indicates
a possible partial or complete rupture of the posterior cruci ate ligament.
If this test is not conducted from the neutral position the test knee may appear to
present with decreased posterior tibial translation when compared to the unaffected knee.
This apparent discrepancy is most likely due to posterior cruciate ligament pathology
allowing the proximal tibia to posteriorly translate, thereby producing a false negative

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Chinese Orthopedics Knee 408

result. It is essential to determine the presence and quality of the endpoint before the
integrity of the posterior cruciate ligament can be accurately assessed.
Posterior Sag Test (Gravity Drawer Test)
Patient is supine with the affected hip flexed 45° and knee flexed 90° and the foot is in
the neutral position. Examiner notes the position of the tibia relative to the femur in the
sagittal plane. The patient is then instructed to actively contract the quadriceps muscle
group in an attempt to extend the knee while retaining the hip flexion. The foot of the test
leg is to remain fixated on the table during the attempted knee extension.
Posterior displacement of the tibia on the femur while the patient's quadriceps
remain silent shows a possible posterior instability. This situation may indicate possible
inj ury to any of the following structures: posterior cruciate ligament, arcuate l igament
complex, and posterior oblique l igament.
It is essential for the examiner to identify a neutral tibiofemoral j oint position
since this test can be misinterpreted as an anterior instability when one observes an
anterior translation of the tibia on the femur
Lateral Rotation-Recurvatum Test
Patient is supine while the examiner stands at the foot end of the examination table and
grasps a big toe with each hand. Examiner then lifts both relaxed legs off the table by
pulling up on the big toes. An increase in tibial lateral rotation and hyperextension as
compared to the unaffected knee is indicative of posterolateral rotary stability secondarily
due to damage mainly of the posterior cruciate l igament, lateral collateral ligament,
posterolateral capsule, and arcuate complex.
It is essential for the examiner to be aware that the test results are possibly due to
the patient' s normal j oint extensibility, and hence a positive finding may be a false
positive.
Valgus Stress Test (0° - 30°)
Examiner holds the patient' s fully extended leg sli ghtly up off the table with one hand
grasping the lower leg proximal to the ankle. With the ankle stabilized with the first hand,
the other hand is placed on the lateral aspect of knee to apply a valgus directed force.
This test i s repeated with the knee in 20° to 30° of flexion.
An increase in medial knee pain and/or valgus movement with an absence or
diminished endpoint indicates possible damage mainly to the medial collateral ligament,
posterior cruciate ligament, and posteromedial capsule when found in full knee extension.
When these symptoms are found in 20° to 30° of flexion it indicates possible
involvement of the medial collateral l igament.
-+ Examiner must ensure that the femur is not allowed to internal or externally
rotate during this test since it may give a false impression of increased valgus
movement. This can be prevented by having the patient lying with their lower
legs off the end of the table which stabilizes the thigh on the table.

Varus Stress Test (0° - 30°)

Examiner holds the patient's fully extended leg slightly up off the table with one hand
grasping the lower leg proximal to the ankle. With the ankle stabilized with the first hand,
the other hand is placed on the medial aspect of knee to apply a varus directed force. This
test is repeated with the knee in 20° to 30° of flexion.

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Chinese Orthopedics Knee 409

An increase in lateral knee pain and/or varus movement with an absence or

diminished endpoint indicates possible damage mainly to the lateral collateral ligament,
posterior cruciate ligament, and arcuate complex when found in full knee extension.
When these symptoms are found in 20° to 30° of flexion it indicates possible
involvement of the lateral collateral ligament.
-+ Examiner must ensure that the femur is not allowed to internal or externally
rotate during this test since it may give a false impression of increased varus
movement. This can be prevented by having the patient lying with their lower
legs off the end of the table which stabilizes the thigh on the table.

McMurray Test
This test is used to evaluate the knee for meniscal injury. The patient is supine with the
hip flexed 45° and knee flexed 90°. The examiner stabilizes the leg by one hand grasping
the patient's ankle or distal leg while the other hand grasps the knee with the fingers able
to palpate the medial and lateraljoint lines.
For medial meniscus assessment the medialjoint line is carefully palpated for
pain and tenderness with knee flexed. The tibia is then externally rotated (toes pointing
outward) at which time a valgus force is applied to the medial aspect of the lower leg. A
"click" felt along the medialjoint line may be indicative of a medial meniscus tear.
For lateral meniscus assessment the lateraljoint line is carefully palpated for pain
and tenderness with knee flexed. The tibia is then internally rotated (toes pointing
inward) at which time a varus force is applied to the lateral aspect of the lower leg. A
"click" felt along the lateral joint line may be indicative of a lateral meniscus tear.
A patellar "click" or "pop" should not be confused with meniscus pathology. If
there is excessivejoint swelling that limits ROM, or a flap tear of the meniscus, it may be
difficult to accurately perform this test. Also, the examiner needs to be aware that
palpation along the joint line can result in significant pain especially if there is a
meniscus tear associated with collateral l igament injury.
Apley Compression-Distraction Tests
This test is used to evaluate the knee for meniscal injury. Patient is prone with both legs
initially straight on the table and the examiner standing to the affected side. Examiner
stabilizes the thigh by placing one handjust proximal to the knee while the other hand
lifts knee into 90° flexion with the other hand placed on the patient' s heel and plantar
region over the longitudinal axis of the tibia.
For the longitudinal cephalad movement direction the tibia is medially and
laterally rotated while the examiner pushes straight down on the foot toward the knee to
compress the tibia on the femur. Any restriction in movement and/or pain and clicking, is
indicative of either a medial or lateral meniscus tear, depending on the location of the
symptoms.
This test may be repeated with the patient in the same position by applying a
longitudinal distraction force along the axis of the tibia. In this case the examiner
stabilizes the thigh by placing one handjust proximal to the kneejoint while the other
hand grasps the distal aspect of the lower leg. The examiner then pulls longitudinal
upward to distract the tibia from the femur while rotating the tibia medially and laterally.
If pain and/or clicking found on the compression test is followed by an absence of these

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Chinese Orthopedics Knee 41 0

symptoms on distraction of the tibia, this is most likely indicates meniscal pathology. On
the other hand, an increase and/or change in location of the pain on tibial distraction is
more indicative ofligamentous pathology.
Steinman's Displacement Test
Patient is supine with both legs in full extension while examiner stands to the side with
one hand under the affected knee while the other hand grasps the ankle and heel. The leg
is lifted into various degrees of knee flexion. The examiner then dynamically moves the
tibia into internal rotation and external rotation while using the other hand to palpate
along the l ateral and medial kneejoint line. If the patient complaints of pain during the
tibial rotation or lacks full flexion, this may be indicative of a meniscal tear.
It is essential to maintain relaxation of the quadriceps and hamstrings muscles
during this test. If the patient has restricted flexion the examiner may choose to conduct
passive internal and external tibial rotation with the knee in maximum possibly flexion to
determine if pain and other symptoms are reproduced.
Medial-Lateral Grind
Patient is supine with the examiner standing to the affected side with one hand holding
the patient' s foot while the other hand is placed over thejoint l ine of the knee. Examiner
then fully flexes the patient's hip and knee after which the tibia is moved in a circular
clockwise and counterclockwise manner. Any pain, grinding, or clicking is indicates a
possible meniscal tear.
A varus and valgus stress may also be applied simultaneously by the hand over
the knee joint line as the knee is passively extended.

Neurological Evaluation
Myotomes (strength graded 0 - 5)
In assessment of problems associated with the hip, knee, and lower extremities, all the
myotomes of the lower body are routinely performed. If any of these tests indicate
possible upper motor neuron involvement, all the myotomes of the upper body are
performed as well. Key myotomes associate with the knee include:
L3 : Quadriceps Femoris
The L3 myotome is evaluated by performing a resistive isometric test involving
knee extension. See preceding discussion.
51 - 52: Gastrocnemius-Soleus
The S 1 - S2 myotome is evaluated by performing a resistive isometric test
involving foot plantar flexion. See preceding discussion.
Key Reflexes
After completion of movement, muscular, and ligamentous testing of the knee it is
important to check relevant reflexes, especially if myotome testing and other signs
indicate possible neurological involvement. Reflexes are first tested on the unaffected
side for comparison to the affected side. Two key reflexes at the knee include the patellar
and medial hamstring tests. Reflexes are graded from 0 to 4 with 0 being absent, 2 normal
and 4 indicating clonus or very brisk.

D.E. Kendall, OMD, PhD ©2005-2009

Chinese Orthopedics Knee 41 1

Patel lar Reflex

This i s the well know knee jerk reflex which provides information on motor
control function served by the L3 L4 spinal cord root level. This test is typically
-

performed with the patient sitting on the examination table with the leg dangling over the
edge of the table. The examiner strikes the patient's patellar ligament between the tibial
tuberosity and the patella. This reflex test can also be performed with the subj ect seated
in a chair with the test leg crossed over the opposite knee. In addition, it can be tested
with the patient supine. In this case the examiner places one hand under the test leg thigh
to grasp the thigh of the opposite leg. This causes the hip and knee to be slightly flexed.
Examiner then strikes the patellar ligament midway between the tibial tuberosity and the
patella.
Medial Hamstring Reflex
The medial hamstring reflex provides information on motor control function served by
the L5 S 1 spinal cord root level. The patient is prone and the examiner lifts the lower
-

leg and cradles it with the arm while placing the examiner' s thumb on the medial
hamstring tendon. The other hand is used to strike the reflex hammer onto the examiner
thumb held on the medial hamstring tendon.

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View: This view is used to examine the knee for possible fractures,
diminished joint space, osteoarthritis, epiphyseal damage, lipping, osteophytes, loose
bodies, abnormal calcification, and ossification.
Lateral View: Delineates the same structures as observed in the anteroposterior view.
Intercondylar Notch (Tunnel View X-ray): This view is taken with the patient prone
and knees flexed from 45° to 90° to show the tibia and intercondylar attachments of the
cruciate ligaments, as well as the intercondylar notch.
Axial (Skyline) View: This involves a 30° tangential view mainly when patellar
problems are suspected such as patellar subluxation and dysplasia.
Magnetic Resonance Imaging (MRI)
Magnetic resonance images are useful in diagnosing lesions of the menisci and cruciate
ligaments, but should be used only to confirm clinical findings.
Computed Tomography
Computed tomography (CT) scans to view soft tissue and bony tissue of the knee.
Arthrography
Arthrograms of the knee have been commonly used to diagnose menisci tears, but their
use is being replaced by arthroscopy.
Arthroscopy
Use of the arthroscope has increased in diagnosis of knee lesions, and to repair them
surgically.

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Chinese Orthopedics Knee 412

Management of Knee Disorders

Management of knee problems relies on mobilization techniques to address hypomobility
and restricted movements. Needling therapy including electroneedling (EN) is also
essential as is remedial exercises for rehabilitation.

Mobilization
Knee mobilization involves the use of the accessory movements as previously described.
Accessory Movements
Accessory movements involve application of small ampl itude forces to address
hypomobility of the knee joint including the following:
•
Anteroposterior and posteroanterior movement of tibia on femur
•
Lateral and medial movement of tibia
•
Medial and lateral rotation of tibia
•
Patellar mobility
•
Posteroanterior movement of fibula on tibia
Passive Movements
Knee passive movements are used to passively move the knee joint in its maj or directions
of flexion, extension, lateral tibial rotation, and medial tibial rotation. Oscillations may be
move the knee up to the point of pain and restriction, or at the end of motion range to
increase ROM . Active movements in these same directions can be employed to actively
move the knee repetitively into the area of pain and restriction to regain full movement.

Needling Therapy Knee Problems

Candidate local and adj acent, proximal and distal nodes considered in treatment of knee
joint pain and dysfunction, with respect to the muscular distributions are summarized in
Table 1 6. 3 .
•
Several o f the candidate local and adjacent nodes are selected to cover the
affected area of the knee, such as the medial, lateral, anterior, and posterior
aspect depending where the main problem is situated
•
Proximal nodes are selected for the related lateral muscular distribution,
however, if problems lie within the PMF muscles, the node Shenshu (PLF 23)
may be considered
•
The same concept applies to the distal nodes which are selected for the PLF,
ALF, and LF related muscle distributions on the leg, if the knee problem
mainly affects the PMF distribution then the node Zhubin (PMF 9) can be
considered.

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Chinese Orthopedics Knee 4 1 3

Table 1 6 . 3 . Regional, proximal and distal nodes for knee pain and dysfunction

Knee J oint Pain Cand idate Local & MD Proximal Nodes Distal N odes
or Disorder Adjacent Nodes
Dubi (ALF 35) PLF Shenshu (PLF 23) Shugu ( PLF 65)
Xiyan (Extra) ALF Weishu (PLF 21) Xiangu (AL F 43)
Heding (Extra) LF Danshu ( P L F 1 9) Zulinqi (LF 4 1 )
Xiyangguan (LF 33)
Yanglingquan (LF 34)
Xuehai (AM F 1 0)
Yinlingquan (AMF 9)

Candidate Electroneedling (EN) for Knee Pain and Other Problems

In uncomplicated cases affecting the knee one or two circuits are employed that basically
distribute over the knee j oint. In the situation where the problem affects to whole knee
joint, both of the circuits listed below can be used.
Frequency: 2 Hz
Mode: Continuous
Duratio n : 20-30 minutes
Lead Placement:
•
Xiyangguan (LF 3 3 ) + lead to Yanglingquan (LF 34) - lead
•
Xuehai (AMF 1 0) + lead to Yinlingquan (AMF 9) - lead
In complicated cases or those that reflect in PLF and PMF aspect of the knee the
following two additional circuits could be considered using the same frequency and mode
as noted above:
•
Fuxi (PLF 3 8) + lead to Feiyang (PLF 58) - lead
•
Yingu (PMF 1 0) + lead to Zhubin (PMF 9) - lead

Remedia l Exercises for M uscle Moving the Knee J oint

The main function of the knee is to flex and extend the lower leg which involves several
muscles that muscles that move the hip j oint as well such as the rectus femoris, tensor
fasciae latae, bicep femoris, semitendinosus, semimembranosus, sartorius, and gracilis
muscles which are also responsible for hip motions (See Table 1 6.2). The knee can also
be internally and externally rotated when it is flexed 90°.

Hamstring Stretches
The hamstrings play a major role in flexing the knee and are often affected by tightness.
There are several approaches to stretching these muscles in the supine, floor seated, and
standing positions.
Supine
This procedure stretches the hamstrings of one leg at a time. While lying supine and
keeping one leg straight, it is lifted off the floor to the maximum extent of hip flexion.
The subj ect then grasps the knee, while keeping the leg straight with back flat on the
floor, and gently pulls the leg into slightly further extension and holds that position for 1 0

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Chinese Orthopedics Knee 414

- 15 seconds. Do not pull leg into region of pain. Leg is then slowly lowered, while still
maintaining the straight leg configuration and the stretch is repeated. Repeat this
procedure with other leg.
Floor Seated
This procedure isolates the stretching of the hamstrings of one leg at a time. While seated
on the floor both legs are abducted to form approximately a 45 60° angle between the
-

two, the knee of one leg is flexed in order to rest the bottom of one foot on the inner thigh
surface of the leg to be stretched. A slight downward pressure can be exerted on the knee
of the flexed leg by the hand of the same side to hold the knee down to the floor. The
upper body is then flexed while the other hand is slowly extended out in an attempt to
touch the toes of the leg being stretched. The end position is held for up to 1 0 1 5
-

seconds after which the subject returns to the start position to repeat the process 3 5-

times. The other leg i s then straightened and the stretched in the same manner with the
other leg flexed to place its foot on the inner surface of the opposite thigh. Hamstrings of
the un-stretched leg are then stretched in the same manner.
Hamstring Stretch with Abdominal Oblique Movement Exercise
This procedure isolates the stretching of the hamstrings of one leg at a time. While seated
on the floor both legs are abducted to form approximately a 45 - 60° angle between the
two. The subject then rotates and flexes the upper body while stretching out one hand to
touch the toes of the opposite foot. The right hand touches the left foot alternated by the
left hand touching the right foot. Each stretch is held for up to 1 0 - 1 5 seconds. Routine is
repeated for up to 8 cycles for each set and performed for 3 - 5 sets.
The abdominal oblique muscles should be contracted while rotating the body
during this routine. Muscles of the arm can also be contracted to obtain exercise benefit
as the arm is being drawn back after touching the toes. The wrist should be supinated
(turning the wrist upward) immediately after touching the toes to obtain optimum benefit
from contracting the arm muscles during the retraction movement.
Standing
This procedure stretches the hamstrings of both legs at the same time. This is the simplest
means of stretching the hamstrings and is often best performed after any of the other
hamstring stretches. It is performed from the erect standing position by slowly bending
forward to flex the body and extend the hands down the front of legs, moving them lower
toward an effort to touch one's toes. The end position is held for up to I 0 - 1 5 seconds,
after which the subject slowly moves back to the erect standing position. Exercise can be
repeated 3 - 5 times. This exercise is similar to the standing back flexion stretch.

Knee Flexion
The biceps femoris, semitendinosus, and semimembranosus muscles are the prime
movers for knee flexion while the sartorius, gracilis, gastrocnemius, and plantaris
muscles function as assistant movers. Knee flexion can be performed in prone or the
standing position. Advantage of the standing position is the knee can be flexed through
its full range of flexion.
In the prone position, the subject is lying with both arms to the side and both legs
extended straight aligned with the body axis. The lower leg of one leg is slowly lifted off
the floor and flexed to the fullest extent possible up to 90° and then slowly lowered to the

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Chinese Orthopedics Knee 4 1 5

floor. This exercise can be repeated 8 1 6 times for 3 5 sets. Repeat exercise with other
- -

leg. As strength increases, and no pain is present as result of this exercise, light strap-on
ankle weights can be employed to increase the resistive load.
Knee flexion in the standing position involves placing one hand on the wall or
other structure to steady the body. The lower leg on the same side that is being supported
by the hand is slowly lifted off the floor and moved into flexion to the greatest extent
possible and held for 2 - 3 seconds. This exercise can be repeated 8 1 6 times for 3 5
- -

sets. Repeat exercise with other leg. As strength increases, and no pain is present as result
of this exercise, light strap-on ankle weights can be employed to increase the resistive
load.

Quadriceps Stretch
The quadriceps (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius)
are the prime movers that extend the knee and are often develop or experience tightness.
This muscle group can be stretched while side lying or standing. In the side lying
position, the knee of the above leg is flexed while the hand of the same side is used to
grasp the foot. The foot is pulled up extending the leg and stretching the quadriceps for
1 0 - 1 5 seconds and then releasing the stretch. This routine is repeated for 3 5 cycles for
-

each set and performed for 3 - 5 sets.

In stretching the quadriceps the subj ect is steadied with one hand against a wall or
other strong support while partially flexing the knee on the other side. The free hand is
used to grasp and to pull up the moving the thigh into extension and stretching the
quadriceps. This position is held for 1 0 - 1 5 seconds and repeated 3 - 5 times and
performed for 3 5 sets. Repeat procedure on other leg.
-

Knee Extension
The rectus femoris and vastus intermedius, laterali s and medialis muscles are the prime
movers for knee extension, with the tensor fasciae latae having an assistant mover role.
Knee extension can be exercised in the seated and supine positions.
Seated Knee Extension
The subj ect is seated at the end or side of treatment table with lower legs hanging down
toward the floor. One knee is slowly extended to the maximum extent possible and held
for 2 - 3 . The lower leg is then lowered to the start position. This exercise can be repeated
8 1 6 times for 3 - 5 sets. Repeat exercise with other leg. As strength increases, and no
-

pain is present as result of this exercise, light strap-on ankle weights can be employed to
increase the resistive load.
Supine Knee Extension
Subj ect is supine with one thigh flexed to 90° perpendicular to the floor. One knee is
slowly and fully extended to the maximum extent possible and held for 2 - 3 . The lower
leg is then lowered to the start position. This exercise can be repeated 8 1 6 times for 3
- -

5 sets. Repeat exercise with other leg. As strength increases, and no pain is present as
result of this exercise, light strap-on ankle weights can be employed to increase the
resistive load.

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Chinese Orthopedics Knee 41 6

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Chinese Orthopedics Lower Leg, Ankle, and Foot 4 1 7

17

Lower Leg , An kle, and Foot

The tibia and fibula are joined proximately at the superior tibiofibular joint and distal ly at
the inferior tibiofibular joint. These two j oints form a functional structure that is essential
to movement of the ankle joint. The movement of the ankle j oint permits extension
(plantar flexion) or flexion (dorsiflexion) of the foot whi le the subtalar joint provides for
eversion and inversion of the foot. Normal limiting factors to these movements and other
characteristics of ankle and subtalar joint structures are summarized in Table 1 7. 1 .

Table 1 7. 1 . Normal limiting factors and characteristics of joint structures involved in movement of
the ankle joint.
Plantar Flexion Dorsiflexion Inversion Eversion
Articulation Talocrural Talocrural Subtalar Subtalar

Plane Oblique sagittal Oblique sagittal Oblique frontal Oblique frontal

Axis Oblique frontal Oblique frontal Oblique sagittal Oblique sagittal

Normal limiting Tension in the Tension in posterior joint Tension in the lateral Contact between the
factors a nterior joint capsule, capsule, the deltoid, collateral ligament, ankle talus and calcaneous;
a nterior portion of the calcaneofrbular and evertors tension in the medial joint
deltoid and anterior posterior talofrbular capsule and medial
talofrbular ligaments, ligaments, and the ankle collateral ligaments
and the ankle plantar flexors; contact
dorsiflexors; contact between the talus and the
between the talus tibia
and the tibia

Normal end-feel Firm/hard Firm/hard Firm/hard Hard/firm

Normal active 0 - soo 0 - 20° 0 - so (forefoot at 0 - 3S0) 0 - so (forefoot at 0 - 20°)

range of motion

Capsular Knee joint: flexion, extension

pattern Tibiofibular joint: pain on joint stress

Principal joints of the foot and toes provide for extension, flexion, abduction and
adduction of the toes. The subtalar j oint also permits inversion and eversion of the foot.
The normal limiting factors involved in movement of the toes, and other characteristics of
joint structures of the foot and toes are summarized in Table 1 7.2.

Physiology of Lower Leg, Ankle, and Foot

Muscles Moving the Foot

The principal muscles of the lower leg are involved in moving the foot in either extension
(plantar flexion) or flexion (dorsiflexion). These motions are essential for bipedal
locomotion and for c limbing up or down inclines or stairs. Several of these muscles also
act to either evert or invert the foot and some act on the toes as well. The main muscles in
plantar flexion include the soleus, lateral (PLF) and medial (PMF) parts, gastrocnemius,
lateral (PLF) and medial (PMF) heads, tibialis posterior (AMF), and the flexor digitorum
longus (AMF). The plantaris (PLF) also participates in plantar flexion and in addition to
the gastrocnemius, can assist in flexion of the knee as well . Principal muscles providing
dorsiflexion include the tibialis anterior (ALF), extensor digitorum longus (ALF) and the

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Chinese Orthopedics Lower Leg, Ankle, and Foot 4 1 8

peroneus tertius (LF). These latter two muscles along with the peroneus longus (PLF) and
brevis (PLF) are foot evertors. Muscle that function as foot invertors include the flexor
hallucis longus (AMF), extensor hallucis longus (MF) and the extensor digitorum longus
(ALF) (See Table 1 7.3.).

Table 1 7. 2 . Normal limiting factors and characteristics of joint structures i nvolved in movement of
the toes.
Flexion Extension Abduction Adduction
Articulation Metatarsophalangeal (MTP), MTP MTP MTP
Proximal interphalangeal (PIP),
Distal interphalangeal (DIP)
(second to fifth toes)

Plane Sagittal Sag ittal Horizontal Horizontal

Axis Frontal Frontal Vertical Vertical

Normal limiting MTP: tension in the dorsal joint MTP: tension in the Tension in the medial Contact between
factors capsule, extensor muscles, plantar joint capsule, joint capsule, collateral the toes
collateral ligaments flexor muscles, plantar ligaments, adductor
PIP: soft tissue apposition ligament PIP: tension in muscles, fascia and
between the plantar aspects of the plantar joint capsule. skin between the web
the phalanges; tension in the plantar ligament DIP: spaces
dorsal joint capsule, collateral tension in the plantar
ligaments joint capsule, plantar
ligament
DIP: tension in the dorsal joint
capsule, collateral ligaments

Normal end-feel MTP firm MTP firm Firm

PIP soft/ firm PIP firm
DIP firm DIP firm

Normal active Big toe: Big toe:

range of motion MTP: 0 - 45" MTP: 0 - 70"
IP: 0 - 95" IP: 0"
Toes 2-5: Toes 2-5·
MTP: 0 - 40" MTP: 0 - 40"
PIP: 0 - 35" PIP: o·
DIP: 0 - 60" DIP: 0"

Capsular First metatarsophalangeal joint: extension, flexion

pattern Second to fifth metatarsophalangeal joints: tend to fix in extension with the interphalangeal joints in
flexion

Fascial Compartments of Lower Leg

The bones and muscles of the lower leg are invested by a layer of deep fascia in addition
to the opposed interosseous surfaces of the tibia and fibula being joined by the
interosseous membrane. This arrangement encloses the lower leg muscles within four
fascial compartments, three of which pass to the tibia and fibula. These are known as the
anterior, medial, lateral and posterior compartments. Certain pathologies of the lower leg
are viewed in terms of these compartments.

Muscles Moving Toes

The foot provides a strong, but slightly flexible, structure to distribute the weight of the
body on the surface of the ground. The joints and muscles of the toes permit an efficient
and smooth transfer of weight from the heel to the toes during the process of walking.
The foot can accommodate uneven surfaces to some degree as well as slanted surfaces.
Muscle acting on the toes results in movements of extension, flexion, abduction and

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Chinese Orthopedics Lower Leg , Ankle, and Foot 4 1 9

adduction. The specific function o f the muscles moving the toes and their nerve roots and
traditional distribution assignment are summarized in Table 1 7.4.

Table 1 7. 3 . Fu nction, nerve root, and muscular d istribution (MD) assig nment of primary mover
(PM) and accessory/assistant mover (AM) extrinsic muscles of the ankle, foot, and toes

Extrinsic Muscles MD Nerve Root Ankle and Foot Toes

Plantar Dorsi- Inver- Ever- Flexion Exten-

Flexion flexion sian s1on SIOn

Soleus, lateral part PLF L5, S 1 , 2 PM

Soleus, medial part PMF L5, S 1 , 2 PM

Gastrocnemius, I h . PLF S1 , 2 PM K

Gastrocnemius. m. h . PMF S1 . 2 PM K

Plantaris PLF L4, 5 , S 1 AM K

Tibialis posterior AMF L5. S 1 AM PM

Tibialis anterior ALF L4, 5, S 1 PM PM

Peroneus tertius ALF L4, 5 , S 1 PM PM

Extensor digitorum longus ALF L4, 5 , S 1 PM PM PM1

Extensor hallucis longus MF L4, 5, S 1 AM AM PM2

Peroneus longus LF L4, 5, S1 AM PM

Peroneus brevis LF L4. 5. S 1 AM PM

Flexor digitorum longus AMF L4, 5 , S1 AM AM PM1

Flexor hallucis longus AMF L5, S 1 , 2 AM AM PM2

. .
1 . 2nd through 5th toes only; 2. Great toe only; K: part1c1pates 1n knee flex1on

The primary extensors of the toes include the extensor digitorum longus (ALF)
and brevis (LF), extensor hallucis longus (MF) and brevis (ALF) muscles. The main
flexors of the toes include the flexor digitorum longus (AMF) and brevis (PMF), flexor
hallucis longus (AMF) and brevis (PMF), and the flexor digiti minimi brevis (PLF)
muscles. Muscles abducting and adducting the great toe respectively include the abductor
hallucis (AMF) and adductor hallucis (PMF) muscles. Abductors and adductors of the
other toes include the abductor digiti minimi (PLF), 1 st - 4th dorsal interossei (MF, ALF,
LF) and the plantar interossei (PMF) muscles. Muscles acting on the toes also participate
in eversion and inversion of the foot. The extensor digitorum longus assists in eversion
while the flexor digitorum longus, flexor hallucis longus and extensor hallucis longus all
assists in foot inversion.

Disorders of the leg, Ankle, and Foot

Muscular Distribution Problems

Specific disorders of the six longitudinal muscular distributions of the lower leg, ankle,
and toes include the following:
Anterior medial foot (AMF) distribution:
•
Pain in the big toe and medial ankle
Medial foot (MF) distribution:
• Pain in the medial aspect of the fibula
• Pain in the big toe and the anterior region of the medial malleolus

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Chinese Orthopedics Lower Leg, Ankle, and Foot 420

Anterior lateral foot (ALF) distribution:

• Acute cramps and spasms in the middle toe and along the tibia
•
Foot tremors
Lateral foot ( LF) distribution:
• Acute cramps and spasms in the fourth and fifth toes
•
Pain along anterior aspect of lateral ankle and anterior lateral region of lower leg
Posterior l ateral foot (PLF) distribution:
•
Pain and swelling in the small toe and the region of the lateral heel
•
Pain along tendo calcaneous and lateral region of calf
Posterior medial foot (PMF) distribution:
• Pain along tendo calcaneous and medial region of calf
•
Acute cramps in the bottom of the feet as well as pain and cramps in the medial
ankle and heel

Table 1 7.4. F u nction, nerve root, and m uscu lar distribution assignment of intrinsic muscles of the
foot and toes

I ntrinsic Muscles M D" Nerve Root Function

Abductor hallucis AMF L5, S 1 . 2 Spreads big toe away from 2nd toe

Adductor hallucis PMF S1, 2 Draws big toe toward 2nd toe

Flexor hallucis brevis PMF L4, 5 , S1 Flexes proximal phalanx of big toe

Flexor digitorum brevis PMF L4, 5 , S1 Flexes 2nd through 5th toes

Quadratus plantae PMF S1, 2 Flexes 2nd through 5th toes

Extensor digitorum brevis LF L4, 5. S1 Extends proximal phalanx of 1st to 4th toes

Extensor hallucis brevis ALF L4, 5 , S1 Extends big toe

Flexor digiti minimi brevis PLF S1, 2 Flexes proximal phalanx of 5th toe

Abductor digiti minimi PLF S1, 2 Spreads 5th toe away from 4th toe

Lumbricals I, I I , I l l , IV PMF L4, 5 (1st), Flex proximal phalanx and extends distal
S 1 , 2 (2nd-4th) phalanx of 2nd to 5th toes

I nterosseous 1

1st dorsal i nterossei MF S1, 2 Draws second toe toward big toe
2 n d & 3rd dorsal interossei ALF S1, 2 Draw 2nd, and 3rd away from big toe
4th dorsal interossei LF S1, 2 Draw 4th toe away from big toe

Plantar interossei PMF S1, 2 Draw 3rd, 4th, and 5th toes away from 2nd toe
1 . Also flex proxi mal phalanx and extends
distal phalanx of 2nd through 4th toes

Pathology of Leg and An kle

Anterior Compartment
The anterior compartment of the lower leg contains the tibialis anterior muscle and toe
extensors, the anterior tibial artery, and the deep peroneal nerve which supplies the
muscles. Problems affecting the anterior compartment include:

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Chinese Orthopedics Lower Leg , Ankle, and Foot 421

Acute Anterior Tibial Syndrome

This condition usually follows sudden, intense or unusual running type activities
but can occur after moderate effort in those who recently started exercising. The patient
presents with history of pain in anterior compartment that quickly becomes worse. The
pain is made worse by passive plantar flexion of ankle or by isometric contraction of the
ankle dorsiflexors. In addition, the overlying skin may be reddened, warm, and
edematous. Possible muscle necrosis and nerve damage can result if compression is not
relieved; can lead to foot drop and sensory changes.
C hronic Anterior Tibial Syndrome
In this condition, pain i s provoked by exercise, becoming worse so the patient is
not able to continue physical activity. Resulting symptoms are similar to arterial
insufficiency and may include swelling and tenderness over the anterior compartment of
the lower leg. The patient' s pain can be reproduced on passive dorsiflexion of foot or
toes. If the patient continues to exercise, there risk of developing muscle necrosis and
nerve compressiOn.
Tendinitis of Tibialis Anterior
This is an overuse condition involving the musculotendinous junction of tibialis
anterior in lower third of the leg. This muscle is the principle decelerator of foot at heel
strike when running and patient may not be aware of the problem in early stages of
training. Patient complains of pain made worse by ankle movements. In addition, marked
crepitus may be palpable or even audible over the involved area of the muscle.
Medial Compartment
The medial compartment contains the tibialis posterior, flexor hallucis longus, and flexor
digitorum longus muscles, along with the posterior tibial artery and nerve.
Medial Tibial Compartment Syndrome
This condition is similar to anterior compartment problems where exercise
produces muscular swelling in a tight medial compartment. This is the most common of
the compartment problems usually due to overuse inj ury which may manifest bilaterally.
The patient presents with pain over the lower third medial border of the tibia. Initially,
pain may be dull and aching and come on with running and is relieved by rest. The pain
gradually increases to point where patient has to alter their activities, such as shortening
running stride, or running flatfooted. The patient' s pain can be reproduced by passive
plantar flexion, active dorsiflexion, or isometric contraction of the tibialis posterior
muscle. Marked tenderness may also be found along lower third of posteromedial border
of the tibia. X-ray examination may be required to differentiate this condition from a
tibial stress fracture.
Lateral Compartment
This compartment contains the peroneus longus and brevis muscles (LF) along with the
lateral popliteal nerve. Acute swelling the peroneal compartment is uncommon but can
develop several hours after strenuous exercise. The resulting pain is made worse by
active and passive inversion of the foot. The swelling may compress the lateral popliteal
nerve resulting in sensory changes followed by a foot drop with inversion of the foot.

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Chinese O rthopedics Lower Leg, Ankle, and Foot 422

Posterior Compartment
The posterior compartment contains the gastrocnemius, soleus, and plantaris muscles that
form the Achilles tendon. Pathology associated with this compartment includes:

Tear of Gastrocnemius
This is a common injury occurring in middle-aged males, often while jogging or
playing tennis (sometimes called "tennis leg"). Minor degrees of this problem can also
occur in the elderly while walking, especially on uneven surfaces. History of the problem
often indicates that pain occurred suddenly, as if someone had hit them in the leg from
behind with a rock. Site of injury is usually the medial belly of the gastrocnemius or at
the medial musculotendinous junction. The pain in the calf can be reproduced by
stretching the gastrocnemius muscle by passive dorsiflexion of the ankle. The pain can
also be reproduced by active contraction of this muscle by having the patient to attempt
standing on their toes, or by resisted plantar flexion of the ankle.

Acute Posterior Com partment Syndrome

Problems in the posterior compartment are rare; however, exercise can produce
acute ischemia of the soleus muscle in the tight confines of the posterior compartment.
Surgical treatment may be required to relieve the pressure by splitting the fascia over the
medial side of the soleus muscle.

Chronic Posterior Com partment Syndrome

This condition may follow an overuse injury of the soleus or be the result of a
previous fracture of the tibia and fibula. The problem is characterized by calf pain on
activity and may be associated with an altered sensation on the plantar surface of the foot
along with weakness in ankle flexion. The patient' s pain is reproduced on passive
dorsiflexion of the foot which stretches the structures in the posterior compartment.
Lesions of the Achilles' Tendon
The Achilles tendon is the strongest tendon in the body and curves around the concave
posterior surface of the calcaneous, from which it is separated by a bursa, to insert into
the lower part of the posterior surface of the calcaneous. The tendon does not have a
tenosynovial layer but is invested by a relatively rigid fibrous paratenon that contains the
major part of the blood supply to the tendon. The Achilles tendon is susceptible to
degenerative changes as commonly found in other tendons, including:
•
Achilles tendinitis: occurs as a combination of degenerative and/or inflammatory
changes due to overuse involving the tendon and its paratenon
•
Chronic thickening of paratenon: produced by chronic inflammatory changes in the
paratenon possibly as a complication of acute peritendinitis due to overuse
•
Bursitis: can involve the deep and superficial bursae associated with the Achilles
tendon
•
Rupture of tendon: complete rupture is uncommon in young people and occurs more
commonly with increasing age especially over 40 years of age
•
Partial rupture of tendon: is becoming increasingly recognized where patient suffers a
sudden sharp pain in the tendon, often while running, and then is noticed while
stepping off the affected leg; rupture usually occurs a few centimeters above the
tendon insertion

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 Ch inese Orthopedics Lower Leg , Ankle, and Foot 423

•
Avulsion of Achilles tendon: is serious but rare condition occurring in the elderly
patient when a portion of the calcaneous bone is avulsed along with the Achilles
tendon attachment
•
Ossification: this may occur in the tendon as a complication of Achilles tendinitis but
rarely does this fracture which would result in severe pain with the tendon rupturing
at the same time
•
Pathological conditions: spondyloarthritis may present with tendinitis or bursitis and
rheumatoid involvement of the bursa can produce erosive changes in the calcaneus
bone
•
Osteochondritis of calcaneus: this condition occurs in young males and is due the
traction by the Achilles tendon on an un-united calcaneal apohysis; the child is
usually involved in sports
Disorders Involving Ankle Joint
Lateral Collateral Ligament Sprains
Three bands of lateral collateral ligament injuries are consistent with its function
and direction in which the fibers run.
The anterior band (anterior talofibular ligament) runs from the anterior border of
lateral malleolus passing medially to neck of talus fusing with anterior capsule of ankle
joint. It is taut during plantar flexion and therefore damaged by sudden forced or excess
degree of plantar flexion.
The middle band (fibulocalcaneal ligament) runs vertically downward from tip of
lateral malleolus to lateral surface of calcaneus. It is taut with the ankle at a right angle
and tends to be inj ured by inversion strain.
The posterior band (posterior talofibular ligament): runs medially from the
posterior aspect of the lateral malleolus to the talus, strengthening the posterior aspect of
ankle capsule. It is rarely inj ured but mechanics involving sports like long j umpers
landing on feet with their body weight thrusting forward forcibly dorsiflexing ankle can
result in sprains.
Anterior Tibiofibular Ligament Sprain
This is a relatively common ankle inj ury possibly resulting from an unusual type
of inversion strain. The sprain may also follow either a dorsiflexion or eversion injury. In
eversion injury the talus is forced against medial malleolus straining ligament fibers. A
rupture of this ligament widens inferior tibiofibular joint with disruption of normal ankle­
joint mortise.
Medial Ligament S prain
Sprains to this ligament do not occur frequently because eversion injuries are
relatively uncommon and the medial ligament is strong. It is also called the "deltoid
ligament" consisting of following bands:
•
Anterior tibiotalar ligament
• Posterior tibiotalar ligament
•
Tibiocalcanean ligament
•
Tibionavicular ligament

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Chinese Orthopedics Lower Leg , Ankle, and Foot 424

Recu rrent I nstability of Ankle

•
Functional instability: common after ligamentous injury resulting in mechanical
derangement of joint
•
Complete ligamentous rupture: may involve anterior talofibular or calcaneofibular
ligament or both causing talus to be loose in its mortise
•
Inadequately treated sprains: may lead to pain and sudden giving way of ankle
involving sprains of lateral ligament
•
Foot deformities: due to valgus deformity of forefoot altering peroneus function
resulting in recurring pain and disability in lateral ankle compartment
•
Undiagnosed causes : possibly due to improper footwear, including high heels, and
may require active exercises and proprioceptive retraining
Tenosynovitis of Ankle Tendons
Tenosynovitis of the peroneal tendons may occur along tendon course from
behind fibular malleolus to outer side of foot. The patient' s pain can be reproduced by
fully resisting foot eversion or by stretching peroneal tendon by full passive inversion of
foot. Tenosynovitis of the tibialis posterior i nvolves the tendon behind or j ust below
medial malleolus. The patient's pain can be reproduced by resisting active foot i nversion
or stretching tendon by full passive eversion of foot.
Talotibial Exostoses
Thi s condition involves bony growths or spurs on surface of talus and tibia at
ankle j oint. They develop on the anterior margins of ankle joint on upper surface of talus
and lower surface of tibia. They can also develop on the posterior margins of talotibial
joint. This condition may result from talotibial impingement on dorsiflexion or plantar
flexion of ankle.
Osteochondritis Dissecans
This is a type of fracture that occurs in adolescents often involving the superior
surface of talus, usuall y on the fibular side. It often follows an inversion strain of the
ankle when in dorsiflexion. The patient presents with ankle pain with possible swelling
with a limp and there may be a history of inj ury.

Pathology the Foot and Toes

General Conditions
Pes Planus Deformity
This condition involves lowering of medial longitudinal arch of the foot. It may
be an intrinsic disorder in how body weight is distributed and affects the j oints and
ligaments of the feet. It can be associated with genu valgum, external rotation of limb,
shortening of Achilles tendon with valgus deformity of hindfoot, and hypermobility. It
can be a functional condition or result of congenital lesions and classed as:
•
Static deformity: depression of medial longitudinal arch associated with a valgus
deformity of hindfoot and abduction of forefoot
•
Rigid deformity: degenerative changes in late stages with painful and stiff foot
fixed in valgus; condition helped by strong mobilization techniques

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•
Spastic flat foot: associated with marked spasm of peroneal muscles and long
extensors of toes
Pes Cavus Deformity
This i s a foot deformity involving increased elevation of medial longitudinal arch
where the forefoot lies at lower level than hindfoot. The foot is foreshortened and
eventually dorsal ligaments become contracted with toes clawed. Primarily this involves
either a posterior or anterior bony compartments of medial arch.
Ankle Equinus
Indicates decreased range of dorsiflexion of ankle joint usually produced by
tightness or shortening of gastrocnemius-soleus and Achilles tendon complex or
restricted ankle j oint movements. This condition may be congenital or acquired due to
pes cavus, high heeled shoes, or after prolonged be rest. The congenital form involves an
ankle flexion deformity and in a serve case the calcaneus is unable to touch floor.
Hindfoot Varus Deformity
This i s a common problem in which calcaneus posterior surface is inverted
relative to Achilles tendon. It may not be considered functionally significant unless
deformity is greater than so in adults or go in children. This problem may be produced by
varus deformity of tibia or by acquired or congenital lesions of subtalar joint. The foot
may become inverted with patient walking on lateral surface of foot.
Forefoot Varus Deformity
This i s a common deformity where forefoot is inverted relative to hindfoot. This
is a basic abnormality resulting from a fai lure in normal degree of valgus rotation in talus
head to develop. A varus deformity of s o is common up to age of 2 years, but later this
will result in foot pain and dysfunction.
Forefoot Valgus Deformity
This deformity occurs when plane of forefoot is everted relative to hindfoot. It is
caused by an increase in the degree of valgus torsion taking place in talus head and neck
during development. The patient may present with forefoot pain below the second or fifth
metatarsal heads with callus formation.
Sudeck's Atrophy
This condition causes severe pain, swelling, and disability in the foot, but may
also occur in other j oints. It also known as reflex sympathetic dystrophy now referred to
as regional pain syndrome. The etiology unknown but probably represents a sympathetic
neurovascular disorder. The condition leads to hyperemia and osteoporosis of bone,
similar to the shoulder hand syndrome. The condition may be idiopathic or follow
prolonged immobilization but commonly follows trauma, which may even be trivial.
Entrapment Neuropathies
Several possible nerve entrapment problems are associated with the feet including
the following conditions:
•
Tarsal-tunnel syndrome: involves posterior tibial nerve as it passes behind and
below medial malleolus

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•
Medial plantar nerve: involves branch of posterior tibial nerve where it runs
through an opening in abductor hallucis longus muscle
•
D igital nerves : occurs in course of nerve between metatarsal heads, most
commonly involving third plantar digital nerve
•
Deep peroneal nerve: may be entrapped in front of ankle where it lies beneath
extensor retinaculum
Localized Regional Conditions
Pain in Toes
Several conditions of the toes have been identified that cause pain as follow:
•
Hallux valgus: lateral deviation of proximal phalanx of great toe on first
metatarsal
•
Hallux rigidus: result of osteoarthritis of first MTP joint but rarely produces
complete rigidity
•
H ammer toe: common toe deformity due to fixed flexion PIP joint contraction
•
Mallet toe: flexion deformity of the DIP/TIP joint of one or more toes
•
Varus deformity of fifth toe: congenital deformity where little toe comes to lie
1h
across base of 4 toe
•
Bunion of fifth metatarsal head: produced by inflammation bursa overlying
lateral aspect of fifth metatarsal head
•
Arthritis: spondyloarthritis, inflammatory changes in IP joints and tendons of
dorsum of toes are common
Anterior Metatarsalgia
Several conditions involve pain that is common in the metatarsals of the forefoot.
Most foot deformities may be the underlying cause of pain resulting from traumatic
conditions including stress fractures, synovitis of MTP joint, and sesamoiditis. One
condition called "Freiberg's disease" involves the head of second and rarely the third
metatarsal bone during adolescence. Morton's syndrome is another condition that
involves congenital shortening of first metatarsal with hypermobility of first
tarsometatarsal joint.
Midtarsal Pain
Patients with pes planus or pes cavus foot deformities may present with midtarsal
pain. Hypomobility lesions of transverse tarsal joints may follow trauma with strain of
midtarsal j oints. Stress fracture of navicular is another but rare condition that occurs in
sprinters. Other conditions of the midtarsals include rare osteochondritis of navicular and
dorsal exostosis which is an osteocartilaginous swelling over first tarsometatarsal joint.
Midtarsal pain also results by soft tissue lesions involving overuse tendinitis of the
peroneal brevis tendon.
Heel Pain
Heel pain can be due to soft-tissue lesion including plantar fasciitis, bruised heel,
and lesions of Achilles tendon. It is also due direct trauma and fractures to the bones
including stress fractures. Paget's disease can cause heel pain as result in joint disorders
involving synovitis of the subtalar joint and hypomobility of subtalar joint.

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Plantar Pain
Plantar pain can be the result of soft-tissue lesions involving tendinitis of flexor
halluc is longus muscle. It can also be the result of fibromatous swelling occurring usually
in medial aspect of plantar fascia (Ledderhose's disease). Plantar pain may present in
patients with pes planus or pes cavus. Plantar pain is also found in patients with
inflammatory arthritis, hypomobil ity lesion of transverse tarsal j oint or acute strain of
medial longitudinal arch.

Assessment of the Leg, Ankle, and Toes

Observation
The weight-bearing (WB) and non-weight-bearing (NWB) posture of the foot as well as
forefoot and hindfoot deformities, including the toes, is observed by viewing the patient's
foot from the back, front, and side. Alignment of the leg and calcaneus bone are observed
for supination or pronation of the subtalar joint as noted by an angular deviation of the
heel with respect to the tibial axis. The foot is then observed for other deviations and
deformities.

Active Movements of Ankle and Toes

These movements can be performed on both feet at the same time if there are no painful
restrictions; otherwise the non-painful side is tested last.
Weight-Bearing
These movements performed in the weight-bearing standing position with the patient
standing on a solid surface to determine the weight-bearing alignments. This series of
tests to be performed in the following sequence:
1 . Dorsiflexion: standing on the heels
2. Plantar flexion: standing on the toes
3 . Supination: standing on the lateral edge of the foot
4 . Pronation: standing on the medial edge of the foot

5 . Toe extension
6. Toe flexion
Non-Weight-Bearing
The non-weight-bearing tests are conducted with the patient lying supine with both legs
extended with feet over the end of the examination table for some of the measurements.
This series of tests to be performed in the following sequence:
Dorsiflexion
Dorsiflexion of the ankle is about 20° past the anatomical position with the foot at
90° to the bones of the leg. The dorsiflexion ROM is measured by placing the fulcrum of
a goniometer about 1 .5 em below the lateral malleolus with the fixed arm aligned with
the fibula. The moveable arm is held aligned parallel to the axis of the fifth metatarsal.
The ROM can also be measured with a gravity sensitive device strapped around
the foot with the dial on the lateral side and zeroed out with the foot the anatomical
position.

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C h inese Orthopedics Lower Leg , Ankle, and Foot 428

Plantar Flexion
Plantar flexion of the ankle is about 50° past the anatomical position with the foot
at 90° to the bones of the leg. The plantar flexion ROM is measured by placing the
fulcrum of a goniometer about 1 .5 em below the lateral malleolus with the fixed arm
aligned with the fibula. The moveable arm is held aligned parallel to the axis of the fifth
metatarsal.
The ROM can also be measured with a gravity sensitive device strapped around
the foot with the dial on the lateral side and zeroed out with the foot the anatomical
position.
Inversion and Eversion
Inversion (0 - 5°) (forefoot at 0 - 3 5 °) involves the combined movements of supination,
adduction, and plantar flexion; eversion (0 - 5 °) (forefoot at 0 - 20°) involves the
combined movements of pronation, abduction, and dorsiflexion. Inversion involves
turning the sole of the foot i nward elevating the medial border; eversion involves
elevating the lateral border turning the foot outward. Patient is supine with a roll placed
under the knee to provide a slight flexion of the knee. The foot is held in the anatomical
position in neutral dorsiflexion, plantar flexion, inversion, and eversion, with a piece of
paper placed under the foot, and perhaps temporarily taped to the table.
A flat broad surface obj ect, such as piece of plexiglass or clipboard supported
vertically on the paper, is placed against the plantar surface of the foot. A base line is
drawn on the paper using the edge of the device as the guide. The patient moves the foot
into inversion (25 - 3 5°) while the flat object moves with the foot. A second line is then
drawn on the paper using the flat object held against the plantar surface. The foot is then
returned to the neutral position lined up with the first line on the paper. The foot is then
moved into eversion ( 1 5 - 20°) and a third line is drawn. A protractor or goniometer is
then used to measure the angular ROM for both inversion and eversion.
Inversion and eversion can also be measured with gravity sensitive goniometer
with the patient seated with the leg hanging down over the edge of the table. The device
needs to have a 90° platform to hold it vertical in the gravity field. The device is strapped
on the forefoot with the dial zeroed out and the foot moved into inversion and eversion
while the examiner stabilizes the lower leg.
Movements of Great Toe
Active movements and ROM of the great toe in flexion and extension can be measured
with a universal goniometer positioned on the medial aspect of the foot or with a small
baseline 1 80° digit goniometer placed on the dorsal or plantar aspect of the big toe.
Range of motion in flexion (45 °) and extension (70°) is measured for
metatarsophalangeal (MTP) joint, and flexion (90°) is measured for the interphalangeal
(IP) joint. Extension for the IP is normally 0°. Abduction and adduction are also
measured for the MTP.
In following movements the patient is supine with the knee slightly flexed with
the ankle and toes in the neutral position. Alternatively, the patient can be seated with
legs dangling over edge of table.

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Metatarsophalangeal (MTP) Flexion

Examiner stabilizes the frrst metatarsal while the axis of the goniometer is placed over the
dorsum of the MTP j oint with the fixed arm parallel to the longitudinal axis of the first
metatarsal. The movable arm is parallel to the longitudinal axis of the proximal phalanx.
The MTPjoint is flexed to the limit of motion (MTP 45°). Alternatively, flexion of the
first toe can be measured by placing the goniometer on the lateral aspect of MTP with the
fixed arm parallel to the longitudinal axis of the first metatarsal and the movable arm
parallel to the longitudinal axis of the proximal phalanx.
Interphalangeal (IP) Flexion
Examiner stabilizes the proximal phalanx while the axis of the goniometer is placed over
the dorsum of the IP joint with the fixed arm parallel to the longitudinal axis of the
proximal phalanx. The movable arm is parallel to the longitudinal axis of the distal
phalanx. The IP j oint is flexed to the limit of motion (IP 90°).
Metatarsophalangeal Extension
Examiner stabilizes the first metatarsal while the axis of the goniometer is placed over the
plantar aspect of the MTP j oint with the fixed arm parallel to the longitudinal axis of the
first metatarsal. The movable arm is parallel to the longitudinal axis of the proximal
phalanx. The MTP joint is extended to the limit of motion (MTP 70°). Alternatively,
extension of the first toe can be measured by placing the goniometer on the lateral aspect
of the MTP with the fixed arm parallel to the longitudinal axis of the first metatarsal and
the movable arm parallel to the longitudinal axis of the proximal phalanx.
Metatarsophalangeal Abduction and Adduction
Patient is supine with the ankle and toes in the neutral position. The examiner
stands to the foot of the examination table and stabilizes the foot proximal to the MTP
joint with one hand grasping the lateral edge of the foot in web of the thumb. The fingers
are placed across the dorsal aspect of the foot with the thumb below the foot. The axis of
the goniometer i s held the dorsum of the frrst MTP by the examiner' s stabilizing hand.
The goniometer fixed arm is parallel to longitudinal axis of the first metatarsal with the
movable arm parallel to the longitudinal axis of the proximal phalanx. The MTP joint is
abducted to the limit of motion, with the ROM recorded. The MTP joint is then adducted
to the l imit of motion, with the ROM recorded.
Movements of Lateral Four Toes
Active movements and ROM of the lateral four toes metatarsophalangeal (MTP) j oints
can be measured in flexion ( 40°) of each toe with a small baseline 1 80° digit goniometer
or short universal goniometer placed on the dorsal aspect or the toe. Extension (40°) of
the MTP joint is measured by placing the goniometer on the plantar aspect of the foot.
Flexion and extension of the proximal interphalangeal and distal interphalangeal j oints of
the lateral four toes is observed and the ROM recorded as either "full" or "decreased."
In following movements the patient is supine with the knee slightly flexed with
the ankle and toes in the neutral position. Alternatively, the patient can be seated with
legs dangling over edge of table.

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Metatarsop halangeal ( MTP) Flexion

Examiner stabilizes the metatarsals while the axis of the goniometer is
sequentially placed over the dorsum of each MTP joint with the fixed arm parallel to the
longitudinal axis of the metatarsal of each toe being tested. The movable arm is parallel
to the longitudinal axis of the proximal phalanx. The MTP joint is flexed to the limit of
motion (lateral four toes: MTP 40°). Alternatively, flexion of the fifth toe can be
measured by placing the goniometer on the lateral aspect of MTP with the fixed arm
parallel to the longitudinal axis of the fifth metatarsal and the movable arm parallel to the
longitudinal axis of the proximal phalanx.
Metatarsophalangeal Extension
Examiner stabilizes the metatarsals while the axis of the goniometer is
sequentially placed over the plantar aspect of each MTP j oint with the fixed arm parallel
to the longitudinal axis of the metatarsal of each toe being tested. The movable arm is
parallel to the longitudinal axis of the proximal phalanx. The MTP j oint is extended to the
limit of motion (lateral four toes: MTP 40°). Alternatively, extension of the fifth toe can
be measured by placing the goniometer on the lateral aspect of the MTP with the fixed
arm parallel to the l ongitudinal axis of the fifth metatarsal and the movable arm is parallel
to the longitudinal axis of the proximal phalanx.

Passive Movemen ts of the Foot and Toes

The passive movements of the ankle and toes are performed in a non-weight bearing
posture usually with the patient supine with feet slightly off the end of the examination
table. If patient is able to achieve full active ROM, overpressure can be applied at the end
range of active movements to assess the end-feel characteristics, there by eliminating the
need for separate passive movement tests. The end-feel for all passive movements of the
lower leg, ankle, and foot is tissue stretch. Passive movements of the ankle and toe
include:
Plantar Flexion
Patient is supine with legs extended with the feet over the end of the examination table.
The Examiner stabilizes the lower leg by grasping the distal tibia and fibula with one
hand while grasping the forefoot with the other hand. The lower leg and foot need to be
relaxed as the examiner pushes downward to rotate the foot at the talocrural j oint into
plantar flexion to note the end-feel and other characteristics of the movement.
Dorsiflexion
Patient is supine with legs extended with the feet over the end of the examination table.
The Examiner stabilizes the lower leg by grasping the distal tibia and fibula with one
hand while grasping the ankle below the calcaneus with the other hand. The lower leg
and foot need to be relaxed as the examiner pulls up on the calcaneus to rotate the foot at
the talocrural joint into dorsiflexion to note the end-feel and other characteristics of the
movement.
Inversion
Patient is supine with legs extended with the feet over the end of the examination table.
The Examiner stabilizes the lower leg by grasping the distal tibia and fibula with one
hand while grasping the foot with the other hand under midtarsal region with fingers on
medial aspect of the foot. The lower leg and foot need to be relaxed as the examiner

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inverts the foot by rotation at the subtalar joint by flexing the examiner' s hand. The end­
feel and other characteristics of the movement are assessed.
Eversion
Patient is supine with legs extended with the feet over the end of the examination table.
The Examiner stabilizes the lower leg by grasping the distal tibia and fibula with one
hand while grasping the foot with the other hand under midtarsal and calcaneus region
with fingers on medial aspect of the calcaneus. The lower leg and foot need to be relaxed
as the examiner everts the foot by rotation at the subtalar joint by extending the
examiner's hand to pull on the lower medial border of the calcaneus. The end-feel and
other characteristics of the movement are assessed.
Adduction and Abduction
Patient i s supine with the knee slightly flexed and ankle just off the table. The examiner
stabilizes the navicular, talus, and calcaneus by grasping these bones in the web space,
thumb, and fingers of one hand on the dorsum while the mobilizing hand grasps the distal
row of tarsal bones (cuneiforms and cuboid). The hands should nearly touch each other if
they are properly placed. A torsional force is applied in the medial direction to the distal
row of tarsal bones in adduction while the proximal tarsal bones are stabilized. The
torsional force on the distal row of tarsal bones is then moved in the lateral direction to
the distal row of tarsal bones in abduction. The end-feel and other characteristics of the
movement are assessed for both adduction and abduction.
Flexion and Extension of Toes
Passive movements for flexion and extension of the toes are applied individually for each
of the metatarsophalangeal and interphalangeal joints. Initially the examiner stabilizes the
distal metatarsals by grasping these bones in the web space, thumb, and fmgers of one
hand on the dorsum while fingers and thumb of the mobilizing hand grasps the distal
phalanx of interest which is moved into flexion and extension. Moving distally to the
next joint, the examiner stabilizes the proximal phalanx bone of interest with one hand
while the fingers and thumb of the mobilizing hand grasps the distal phalanx of interest.
The distal bone i s then moved into flexion and then extension to assess the characteristics
of movement and the end-feel.
Adduction and Abduction of Toes
Passive movements for adduction and abduction of the toes are applied individually for
each of the metatarsophalangeal and interphalangeal j oints. Initially the examiner
stabilizes the distal metatarsals by grasping these bones in the web space, thumb, and
fingers of one hand on the dorsum while fingers and thumb of the mobilizing hand grasps
the distal phalanx of interest which is moved into adduction and abduction. Moving
distally to the next joint, the examiner stabilizes the proximal phalanx of interest with one
hand whil e the fingers and thumb of the mobilizing hand grasps the distal phalanx of
interest. The distal bone is then moved into adduction and then abduction to assess the
characteristics of movement and the end-feel.

Resistive Movements of Foot and Toes

Resisted i sometric movements of the lower leg, ankle, and toes are conducted to test the
contractile tissue moving these structures. Some of these tests can be performed with the
patient seated or lying supine. The following tests are described with the patient supine

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Chinese Orthopedics Lower Leg , Ankle, and Foot 432

although the hip and knee may be flexed in order to conduct the test. The foot is
maintained in the anatomical position for those tests involving the foot.
Knee Flexion
Patient is supine while the examiner lifts the test leg into about 60° of hip flexion and 90°
of knee flexion. The other leg is relaxed in full extension. The examiner supports the test
lower leg above the table surface with one hand under the distal aspect of the lower leg
while the other hand is placed on the anterior thigh j ust proximal to the knee. The patient
is instructed to not let the examiner move them as an isometric force is applied to the
lower leg in the direction of leg extension.
Dorsiflexion
Patient is supine with heel of the test leg touching the examination table with the hip
flexed 45°, knee flexed 90°, and the foot in the anatomical position. The other leg is
relaxed in full extension. Standing to the test side, the patient's knee is held between
examiner arm and body while the hand reaches over the thigh and under the lower leg to
hold the calf to stabilize the leg. The other hand grasps the dorsal surface of patient's foot
to apply an isometric force in the direction of plantar flexion. Patient is instructed to not
let the examiner move them.
Plantar flexion
Patient is supine with heel of the test leg touching the examination table with the hip
flexed 45°, knee flexed 90°, and the foot in the anatomical position. The other leg is
relaxed in full extension. Standing to the test side, the patient' s knee is held between
examiner arm and body while the hand reaches over the thigh and under the lower leg to
hold the calf to stabilize the leg. The other hand is placed on the plantar surface over ball
of the patient ' s foot to apply an isometric force in the direction of dorsifl exion. Patient is
instructed to not let the examiner move them.
Foot Supination
Patient is supine with both leg fully extended and relaxed. Standing to the test side the
examiner stabilizes the test leg by placing one hand on the mid tibial area while the other
hand is used to grasp the under the forefoot from the lateral side with fi ngers reaching
under the foot to hold the medial edge of the foot. Patient is instructed to not let the
examiner move them as the examiner applies an isometric torsional movement in the
direction o f foot pronation.
Foot Pronation
Patient is supine with both leg fully extended and relaxed. Standing to the test side the
examiner stabilizes the test leg by placing one hand on the mid tibial area while the other
hand is used to grasp the lateral edge of the foot with the thumb on the top of the foot and
the finger under the foot. Patient is instructed to not let the examiner move them as the
examiner applies an isometric torsional movement in the direction of foot supination.
Flexion and Extension of Great Toe
Patient is supine with both legs fully extended and relaxed to stabilize the legs with the
examiner standing to the foot of the examination table. For flexion of the great toe the
examiner applies an isometric force to the great toe nail in the direction of great toe
extension while the patient is instructed to not let the examiner move them.

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For extension of the great toe the examiner applies an isometric force to the pad
of the great toe in the direction of great toe flexion while the patient is instructed to not
let the examiner move them.
Flexion of Lateral Four Toes
Patient is supine with both legs fully extended and relaxed to stabilize the legs with the
examiner standing to the foot of the examination table. The examiner grasps all four
lateral toes by placing the base of the examiner' s hand j ust distal to the ball of the
patient' s foot while examiner's fingers hold all four lateral toes. Patient is instructed to
not let the examiner move them as the examiner applies an isometric force on all four
lateral toes in the direction of toe extension.
Extension of Lateral Four Toes
Patient i s supine with both legs fully extended and relaxed to stabilize the legs with the
examiner standing to the foot of the examination table. The base examiner's palm is
placed on the dorsal surface of the distal foot and all four lateral toes. Patient is instructed
to not let the examiner move them as the examiner applies an isometric force on all four
lateral toes in the direction of toe flexion.

Joint Play Movements

Joint play or accessory movements of the lower leg, ankle, and foot can be performed
with the patient supine or side lying depending on the specific movement. Comparison of
normal movement on the unaffected side is always compared to the affected or injured
side. Certain types of movements can be applied to several different joints so each case
has to be specificall y considered using the following guidelines:
Talocrural (ankle joint)
Long-Axis Extension
This test involves applying a distraction force on a particular joint while
stabilizing the proximal segment and providing traction to the distal segment. For the
ankle the examiner stabilizes the tibia and fibula by having the patient lying supine with
the test leg relaxed. A strap could also be employed to stabilize the leg. The examiner
grasps the ankle with both hands distal to the malleoli and applies a longitudinal
distractive force that is in line with the axis of the ankle and leg.
Anteroposterior Glide
Patient is supine with the foot slightly off the table while the examiner stabilizes
the tibia and fibula with one hand on the distal leg while the other hand grasps the
forefoot to draw the talus and foot forward toward the anterior direction. The direction of
force is then reversed to push the talus and foot backward to provide the posterior
movement.
Subtalar Joint
Talar Rock
This joint play test is performed with the patient side lying with the hip and knee
flexed and test foot on the table side, with the examiner sitting behind the patient. The
examiner places both hands around the ankle j ust distal to the malleoli. A mild distractive
force is applied to the ankle while a forward (dorsiflexion) and backward (plantar

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Chinese Orthopedics Lower Leg , Ankle, and Foot 434

flexion) rocking movement is applied to the ankle. The examiner should usually feel a
"clunk" at the extreme end of each movement.
Medial and Lateral Side Tilt
Patient is supine with legs extended slightly over the end of the table while
examiner standing at the foot end of the table grasps the heel with both hands around the
calcaneus. The examiner' s wrists are alternately flexed and extended thereby tilting the
calcaneus medially and laterally on the talus. Examiner maintains the foot in the
anatomical position during this movement. This particular movement is identical to that
in the talar tilt (inversion and eversion) tests respectively for the calcaneofibular and
deltoid l igaments.
Midtarsal Joints
Anteroposterior Glide
Patient is supine with the knee slightly flexed and ankle just off the table. The
examiner stabilizes the navicular, talus, and calcaneus by grasping these bones in the web
space, thumb, and fingers of one hand on the dorsum while the other hand grasps the
distal row of tarsal bones (cuneiforms and cuboid). The hands should touch each other if
they are properly placed. An anteroposterior gliding movement of the distal row of tarsal
bones is applied while the proximal tarsal bones are stabilized.
Rotation
This joint play movement should be performed immediately following the
midtarsal joint anteroposterior glide. Patient is supine with the knee slightly flexed and
ankle just off the table as before. Examiner stabilizes the navicular, talus, and calcaneus
by grasping these bones in the web space, thumb, and fingers of one hand on the dorsum
while the other hand grasps the distal row of tarsal bones (cuneiforms and cuboid). The
hands should touch each other if they are properly placed. The examiner then rotates the
distal row of tarsal bone with respect to the proximal row of bones. Rotation movement is
to be performed in both directions.
Tarsometatarsal Joints
Anteroposterior glide
The examiner's hands are shifted distally from the Anteroposterior Glide position
for the midtarsal j oints so the stabilizing hand is over the distal row of tarsal bones and
the mobilizing hand rests on the proximal aspect of the metatarsal bones. The hands are
still positioned so they touch each other. An anteroposterior gliding movement is applied
to the proximal metatarsal bones while the distal row of tarsal bones is stabilized.
Rotation
This j oint play movement should be performed immediately following the
tarsometatarsal joint anteroposterior glide. Patient is supine with the knee slightly flexed
and ankle just off the table as before. Examiner' s stabilizing hand is over the distal row of
tarsal bones and the mobilizing hand rests on the proximal aspect of the metatarsal bones.
The hands are still positioned so they touch each other. The examiner then rotates the
proximal metatarsal bones while the distal row of tarsal bones is stabilized. Rotation
movement is to be performed in both directions.

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Chinese Orthopedics Lower Leg , Ankle, and Foot 435

Metatarsophalangeal and Interphalangeal Joints

The joint play movements are applied individually for each of the metatarsophalangeal
and interphalangeal j oints. In the following four tests the patient is supine with the knee
slightly flexed and ankle just off the table. The following four movements are applied to
each j oint in question before testing the next j oint.
The procedure involves the examiner stabilizing the proximal bone of interest
(metatarsal or phalanx) with one hand while the fingers and thumb of the mobilizing hand
grasps the distal bone of interest (phalanx). The distal bone is then moved into long-axis
extension, anteroposterior glide, rotation, and lateral or side glide.
Long-Axis Extension
Examiner applies a traction force by pulling longitudinally on the distal phalanx
of interest with respect to the stabilized proximal bone (metatarsal or phalanx).
Anteroposterior Glide
Examiner moves the distal phalanx of interest in an anteroposterior and then
posteroanterior direction with respect to the stabilized proximal bone (metatarsal or
phalanx).
Rotation
Examiner moves the distal phalanx of interest in rotation about the long axis of
the bone in both directions with respect to the stabilized proximal bone (metatarsal or
phalanx).
Lateral or Side Glide
The side glide movement at the metatarsophalangeal and interphalangeal j oints is
conducted by first stabilizing the proximal bone (metatarsal or phalanx) of interest with
one hand. Examiner then uses the fingers and thumb of the other hand to apply a slight
traction force to the distal bone and moving the distal bone sideways right and left with
respect to the stabilized proximal bone (metatarsal or phalanx) .

Functional Assessment
If the patient can adequately perform the foregoing movements, functional tests may be
considered to determine if pain and dysfunction results in performing routine activities.
Many conditions involving pain and dysfunction may not have any functional impact on
the patient in carrying out activities of daily living and even performing their
occupational activities. A series of tests can be considered to determine to what extent
that problems of the lower leg, ankle, and foot compromise normal activities. Examiner
must consider expected differences in individuals in being able to carry out certain tests.
Differences to consider include age, gender, health status, body weight, and other
parameters. The fol lowing type tests may be considered:
•
Squatting: observe that both ankles dorsiflex symmetrically
•
Standing on toes: observe that both ankles plantar flex symmetrically
•
Standing on one foot at a time: observe that balance is stable
•
Standing on toes, one foot at a time: observe that balance is stable
•
Walking up and down stair
•
Walking on toes

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Chinese Orthopedics Lower Leg, Ankle, and Foot 436

•
Running straight ahead
•
Running, twisting, and turning: run on a short (4 x 20 meters) figure 8 course
•
Jumping: only for younger people
•
Jumping and going into a full squat: only for the very fit

Special Tests
Several special tests can be performed on the lower leg, ankle, and foot to provide
additional information, including possible ligamentous damage, fractures, and other
problems.
Homan Test
Patient is supine with the affected leg fully extended on the examination table. The
examiner stands to side of foot of the table and passively dorsiflexes the patient's foot. If
this produces pain in the calf it is possible positive finding for deep vein thrombophlebitis
(DVT).
Pain may also be provoked on palpation of the calf with the examiner' s hand
placed under the calf to grasp the gastrocnemius muscle and then passively dorsiflexing
the patient's foot. A positive finding in this situation may indicate a potential life
threatening condition that needs immediate medical attention.
Anterior Drawer Test
Patient is seated at the end of the examination table with knees flexed goo and hanging
over edge of table with the affected foot relaxed and in slight plantar flexion. The
examiner grasps the leg just proximal to the ankle j oint with one hand to stabilize the
tibia and fibula while using the other hand to grasps the calcaneus. This test can also be
performed with the patient in the prone position with both feet hanging over the end of
the examination table.
While maintaining stability of the distal tibia and fibula, the examiner applies an
anterior directed force to the calcaneus and talus. Anterior translation of the talus away
from the ankle mortise that is greater than the uninvolved ankle indicates a positive sign
for a possible sprain of the anterior talofibular ligament. The uninvolved ankle should be
tested first.
Flexion of the knee to goo reduces the tension on the gastrocnemius muscle.
Possible ankle swelling may restrict the amount of anterior translation of the talus.
Talar Tilt Test (Eversion)
Patient is side lying on the involved side with the involved foot relaxed and the knee
flexed goo and the foot over the edge of the table. Examiner stabilizes the leg by grasping
the distal tibia and fibula with one hand and grasping the talus with the other hand
holding the medial aspect of the foot.
The foot is moved into the anatomical position of neutral dorsiflexion and plantar
flexion. The examiner then tilts the talus into an abducted position. If the range of motion
in abduction of the i nvolved foot is greater than the uninvolved foot, this is a positive
sign. This may indicate a tear in the deltoid ligament of the ankle. The uninvolved ankle
should be tested first.
Flexion of the knee to goo reduces the tension on the gastrocnemius muscle.
Conducting this test with the ankle plantar flexed to various amount may assess different

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Chinese Orthopedics Lower Leg , Ankle, a nd Foot 437

aspects of the deltoid ligament. Possible ankle swel ling may restrict translation of the
talus.
Talar Tilt Test (Inversion)
Patient is side lying on the uninvolved side with the involved foot relaxed and the knee
flexed 90° and the foot over the edge of the table. Examiner stabilizes the leg by grasping
the distal tibia and fibula with one hand and grasping the talus with the other hand.
The foot is moved into the anatomical position of neutral dorsiflexion and plantar
flexion. The examiner then tilts the talus into an adducted position. If the range of motion
in adduction of the involved foot is greater than the uninvolved foot, this is a positive
sign. This may indicate a tear in the calcaneofibular ligament of the ankle. The
uninvolved ankle should be tested first.
Flexion of the knee to 90° reduces the tension on the gastrocnemius muscle.
Conducting this test with the ankle more plantar flexed places less stress on the
calcaneofibular ligament and instead may stress the anterior talofibular ligament. Possible
ankle swelling may restrict translation of the talus.
Thompson Test
Patient is prone with feet extending over the end of the examination table with the
gastrocnemius-soleus muscle complex fully relaxed. Examiner stands to the side at the
table end and squeezes the belly of these muscles.
A normal response to squeezing the patient' s calf would be to plantar flex the
foot. Lack of a plantar flexion response would be a positive indication for a possible
rupture of the Achilles' tendon.
Tap or Percussion Test
Patient is supine with the foot of the affected leg extended with the heel just over the end
of the examination table. The examiner stands at the table to grasp the patient' s foot over
the dorsum to passively move it into maximal dorsiflexion while two flexed fingers of the
other hand are used to strike a firm tap to the bottom of the patient's heel.
If the tap produces pain at the site of inj ury it is indicative of possible fracture.
Tapping along the long axis of the bones will exaggerate pain at the fracture site.
-+ This test should not be conducted if there is an obvious deformity

Feiss Line
The patient sits on the examination table with the affected leg extended on the table
surface. Examiner places a mark on the apex (tip) of the patient' s medial malleolus and
another on the base (plantar aspect) of the first metatarsophalangeal (MTP) joint. A line
is then drawn between the two marks and the examiner notes the position of the navicular
tuberosity. Alternatively, the edge of a small transparent ruler can used to place on the
two locations to check the position of the navicular tuberosity.
The patient is then asked to stand on the floor with the feet 3 to 6 inches apart.
Examiner determines that the original two marks are still located over the apex of the
medial malleolus and the base of the first MTP j oint, and notes the position of the
navicular tuberosity.
The navicular tuberosity should be in line with the two points. If the navicular
tuberosity is below the line while the patient is seated, this is indicative of possible

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Chinese Orthopedics Lower Leg , Ankle, and Foot 438

congenital pes planus. If the navicular tuberosity is in line with the other two points while
seated, but falls below the line when the patient is standing, this is indicative of
functional pes planus.
Varying degrees of pes planus may be indicate by this test based on how far the
navicular tuberosity drops toward the floor. Pes planus may also be indicative of
hyperpronation.
lnterdigital Neuroma Test
The patient is seated on the examination table with the affected leg fully extended. While
standing at the next the affected foot, the examiner grasps the patient's foot with one
hand over the plantar aspect of the metatarsal heads while the other hand stabilizes the
lower leg by holding the tibia and fibula on the mid tibia. Examiner then squeezes the
patient's metatarsal heads together and holds this for 1 to 2 minutes.
Production of pain, tingling, or numbness in the ankle, foot, or toes is indicative
of a possible neuroma. A positive sign of a neuroma is indicated if the pain is relieved
when the pressure is released. Pain can also indicate a stress fracture.
Pain between the metatarsal heads is indicative of Morton' s neuroma. The most
common site of occurrence is between the third and forth metatarsal heads.
Compression Test
Patient is supine with the affected leg extended with the ankle/foot j ust off the end of the
examination table. The examiner stands next to the patient's leg and notes the origin of
the patient' s pain. Examiner places one hand on either side of the lower leg with the
hands on the medial and lateral aspect aligned with the leg.
Examiner squeezes the tibia and fibular bones together at a location that is away
from the painful area. Reproducing or exaggerating the pain may be indicative of a
facture. It should be noted that a positive test is not exclusive of a fracture. An X-ray is
recommended when a fracture is suspected.
-+ This test should not be conducted if there is an obvious deformity

Long Bone Compression Test

Patient is seated on the examination table with the affected leg extended with the heel just
off the end of the table. Examiner stands at the end of the table and grasps the patient' s
ankle to stabilize the foot while the fingers and thumb of the other hand apply a
compression along the long axis of the toe bones or metatarsals of interest.
Reproduction or exaggeration of pain at the inj ury site is indicative of a possible
fracture.
-+ This test should not be conducted if there is an obvious deformity

Swing Test
Patient is seated on edge of table with knees flexed 90° and legs hanging over end of the
examination table. Examiner is seated at end of table with hands over the dorsum of the
patient' s feet to keep the feet parallel with the floor.
The examiner palpates the anterior aspect of the patient's talus with the thumb
while passively dorsiflexing and plantar flexing the ankle and observing the level of
movement, especially in dorsiflexion. Resistance to dorsiflexion is a positive indication
for possible posterior tibiotalar subluxation.

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 Chinese Orthopedics Lower Leg , Ankle, and Foot 439

Kleiger's Test
Patient is seated on examination table with knee flexed 90° and leg hanging over end of
the examination table. Examiner is seated at the end of the table and grasps the patient' s
distal tibia and fibula with one hand t o stabilize the lower leg while the other hand i s
under the plantar surface to clasp the medial and inferior aspect o f the calcaneus.
Examiner then applies an externally rotated force on the calcaneus. The test is repeated
with the ankle moved into dorsiflexion.
Production of pain or reproduced pain along the medial aspect of the ankle when
the externally rotated force is applied in neutral dorsiflexion indicates possible deltoid
l igament inj ury. Pain that presents medially and slightly more proximally when the ankle
is dorsiflexed and externally rotated indicates distal tibiofibular syndesmotic
involvement.
The syndesmosis may be injured when the foot is fixated and subjected to a
significant rotational force. This is sometimes referred to as a "high ankle sprain" which
may be very painful to the patient when a rotational torque is applied.
Tine/'s Sign at the Ankle
Patient is supine with the affected leg straight with the foot extended over the end of the
table. While holding and stabilizing the patient's foot in the anatomical position the index
finger of the other hand is used to tap over the medial aspect of the ankle just posterior to
the medial malleolus where the posterior tibial nerve is most superficial. Production of
pain or tingling that radiates along the route of the tibial nerve is indicative of a possible
tarsal tunnel syndrome. Posterior tibial nerve compression in the tarsal tunnel wil l result
in referred symptoms to the medial and plantar regions of the foot.
A positive indicates that the posterior tibial nerve had been compromised. The
nerve could be undergoing compression as might be seen in inflammation within the
tarsal tunnel, or it could be subjected to traction as is found with a hyperpronated foot.

Neurological Evaluation
Myotomes (strength graded 0-5)
•
L4: tibialis anterior
•
L 5 : extensor hallucis longus
•
S1 - S2 : gastrocnemius-soleus
Key Reflexes
•
Achilles tendon reflex- ankle jerk
•
Babinski reflex

Diagnostic Imaging
Plain Film Radiography
Anteroposterior View of Ankle: This view shows the shape, position, and texture of the
bones of the ankle to delineate possible fractures or new subperiosteal bone.
Mortise View of Ankle: The ankle mortise and distal tibiofibular can be visualized.
Lateral View of Leg, Ankle, and Foot: This view delineates the shape, position, and
texture of the bones, including the tibial tubercle, and allows detection of fractures, new
subperiosteal bone, and bone spurs.

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Ch inese Orthopedics Lower Leg, Ankle, and Foot 440

Dorsoplanar View of Foot: This view mainly projects the forefoot to show the shape,
position, and texture of the foot bones.
Medial Oblique View of Foot: This view is useful in providing a clear image of the
tarsal bones and j oints, and the metatarsal shafts and bases.
Magnetic Resonance Imaging (MRI)
Magnetic resonance images are useful in delineating bony and soft tissues around the
ankle and foot, and to diagnose ruptured tendons and fractures.
Computed Tomography
Computed tomography (CT) scans for delineating bony and soft tissues and viewing the
relationship of these structures i n the ankle and foot.
Arthrography
Arthrograms of the ankle are indicated whenever there is acute ligament inj ury, chronic
ligament laxity, or indications of loose bodies.

Management of Leg, Ankle, and Foot Disorders

Mobilization
Mobilization of the lower leg, ankle, and foot may be valuable for the relief of foot pain,
including pain due to either hypomobility syndrome or entrapment neuropathies. All
accessory and passive movement of the leg, ankle, and foot can be applied.
Joint Play Movements
Joint play or accessory movements of the leg, ankle, and foot are intended to assess joint
play characteristics and can be used as small amplitude oscillatory movements to improve
joint space to address hypomobility, restricted movement, and pain. Each particular
accessory movement has a specific purpose to affect the j oint for which it is applied.
Passive movements
Passive movements involving mobilizing the lower leg, ankle, and foot are used when a
wider range of motion needs to be applied to reduce pain and increase mobility.
Mobilization by use passive movements are applied over a range of small and large
amplitudes are graded from I to V as noted in Table 4. 1 .

Needling Therapy for Leg, Ankle, and Foot

Lower leg
Candidate local and adj acent, proximal and distal nodes considered in treatment of leg
pain and numbness are summarized in Table 1 7.5. Nodes are listed with respect to
addressing problem within the medial, posterior, anterior or lateral muscular
compartments, consistent with the muscular distributions. Electroneedling (EN)

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Chinese Orthopedics Lower Leg, Ankle, and Foot 441

Table 1 7.5. Regional, proximal and distal nodes for treatment of lower leg pain and numbness
Leg Pain and Candidate Local & MD* Proximal Nodes Distal Nodes
Numbness Adjacent Nodes
Medial Zhubin (PMF 9) Shenshu ( PLF 23) Taichong (MF 3)
Chengshan (PLF 57)
Posterior Chengshan ( PLF 57) PLF Pangguanshu (PLF 28) Shugu (PLF 65)
Feiyang (PLF 58)
Anterior Zusanli (ALF 36) ALF Weishu ( PLF 2 1 ) Xiangu (ALF 43)
Taichong (MF 3)
Lateral Yanglingquan (LF 34) LF Danshu (PLF 1 9) Zulinqi (LF 4 1 )
*MD = Muscular Distribution

Candidate E/ectroneedling (EN) for Leg Pain

Frequency: 2 Hz
M ode: Continuous
Duration: 20-3 0 minutes
Lead Placement:

Medial:
•
Zhubin (PMF 9) + lead to Taichong (MF 3) - lead
Posterior:
•
Feiyang (PLF 5 8) + lead to Shugu (PLF 65) - lead
Anterior:
• Zusanli (ALF 3 6) + lead to Xiangu (ALF 43) - lead
Lateral:
• Yanglingquan (LF 34) + lead to Zulinqi (LF 4 1 ) - lead

Ankle
Candidate local and adj acent, proximal and distal nodes considered in treatment o f ankle
pain and dysfunction, with respect to the muscular distributions are summarized in Table
1 7.6.

Table 1 7.6. Regional, proximal and distal nodes for ankle pain and dysfunction
Ankle Pain or Candidate Local & MD* Proximal Nodes Distal Nodes
Disorder Adjacent Nodes
Jiexi (ALF 41 ) PLF Feiyang ( PLF 58)/ Jinmen ( PLF 63)
Shangqiu (AMF 5) Pangguanshu (PLF 28)
Qiuxu (LF 40) ALF Fenglong (ALF 40)/ Xiangu (ALF 43)
Kunlun (PLF 60) Weishu (PLF 21 )
Taixi ( PMF 3) LF Xuanzhong (LF 39)/ Zulinqi (LF 4 1 )
Danshu ( PLF 1 9)
PMF Zhubin ( PMF 9)/ Rangu ( PMF 2)
Shenshu (PLF 23)
*MD = Muscular Distribution

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Chinese Orthopedics Lower Leg, Ankle, and Foot 442

Candidate Electroneedling (EN) for Ankle Pain

Frequency : 2 Hz
Mode: Continuous
Duration : 20-3 0 minutes
Lead Placem ent:
Posterior lateral foot (PLF) distribution:
•
Feiyang (PLF 58) + lead to Jinmen (PLF 63 ) - lead
Anterior lateral foot (ALF) distribution:
•
Fenglong (ALF 40) + lead to Xiangu (ALF 43) - lead
Lateral foot (LF) distribution:
•
Xuanzhong (LF 39) + lead to Zulinqi (LF 4 1 ) - lead
Posterior medial foot (PMF) distribution:
• Zhubin (PMF 9) + lead to Rangu (PMF 2) - lead
Foot and Toe Problems
Possible local and adjacent, proximal and intermediate nodes to be considered for
treatment of pain and numbness of the foot and toes are summarized in Table 1 7.7.

Table 1 7. 7. Regional, proximal and intermediate nodes for pain and numbness of the foot and
toes
Toe Pain and Candidate Local & MD Proximal Nodes Intermediate Nodes
Numbness Adjacent Nodes
Shugu (PLF 65) PLF Pangguanshu (PLF 28) Feiyang (PLF 58)
Neiting (ALF 44) ALF Weishu l_PLF 21) Fenglong (ALF 40)
Xiaxi (LF 43) LF Danshu ( PLF 1 9) Xuanzhong (LF 39)
Gongsun (AMF 4) PMF Shenshu ( PLF 23) Zhubin ( PMF 9)

Bafeng (Extra)

Candidate Electroneedling (EN) for Toe Pain and Numbness

Freq uency: 2 Hz
Mode: Continuous; may also consider 2Hz - 25Hz mixed mode for numbness
Duration: 20 - 3 0 minutes,
Lead Placement:

Posterior lateral foot (PLF) distribution

•
Feiyang (PLF 58) + lead to Shugu (PLF 65) - lead
Anterior l ateral foot (ALF) distribution
•
Fenglong (ALF 40) + lead to Neiting (ALF 44) - lead
Lateral foot (LF) distribution
•
Xuanzhong (LF 3 9) + lead to Xiaxi (LF 43) - lead

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 Chinese Orthopedics Lower Leg, Ankle, and Foot 443

Posterior medial foot (PMF) distribution

• Zhubin (PMF 9) + lead to Gongsun (AMF 4)/Rangu (PMF2) - lead

Remedial Exercises for Muscles Moving the Foot and Ankle Joint
The principal movements of the foot involve dorsiflexion and plantar flexion for walking
and other activities (See Table 1 7.3). Muscles of the foot also provide movements of
inversion and eversion to allow the foot to adapt to non-level surfaces. Extension and
flexion of the toes are also critical to the function of the foot and ankle.

Ankle Dorsiflexion
The tibialis anterior, extensor digitorum longus, and peroneus tertius muscles are the
prime movers in dorsiflexion, with extensor hallucis longus muscle having an assistant
role. Dorsiflexion is exercised with the subject seated and feet on the floor. Foot is
dorsiflexed to the fullest extent possible and held in this position for 2 3 seconds with
-

the ankle remaining on the floor. The lower leg is then lowered to the start position. Foot
is then returned to the floor. This exercise can be repeated 8 1 6 times for 3 5 sets.
- -

Repeat exercise with other foot. As strength increases, and no pain is present as result of
this exercise, light strap-on ankle weights can be placed on the foot dorsum to increase
the resistive load.
The dorsiflexors can also be exercised by negative stretch contraction with the
subject placing their toes on the edge of a step or flat object that is about 2 inches thick.
The plantar flexors are contracted to lift the ankles up and putting the dorsiflexors into a
stretch contraction. This approach actually is directed at strengthening plantar flexion as
described below.

An kle Plantar Flexion

The gastrocnemius and soleus muscles are the prime movers for plantar flexion with the
tibialis posterior, peroneus longus, peroneus brevis assisting this movement. Plantar
flexion is an essential function for walking and running served mainly by the strong and
large soleus and gastrocnemius muscles, while dorsiflexion is mainly to lift the foot up
while the leg is being forward in dorsiflexion to start the next step. Plantar flexion can be
exercised in the seated or standing position.
With the subj ect seated and feet flat on the floor, one heel is lifted up off the floor
thereby lifting the leg by plantar flexion to the maximum extent possible and held for 2 -

3 seconds. Heel is then lowered to the floor. This exercise can be repeated 8 - 1 6 times
for 3 5 sets. Repeat exercise with other foot. As strength increases, and no pain is
-

present as result of this exercise, a resistance load can be applied to the top of the flexed
knee to increase the resistive load. This added load can be applied by subj ect pushing
down on the target knee.
In the standing position with both feet on the fl oor the subject lifts both heels off
the floor by plantar flexion to the maximum possible and held for 2 3 seconds. Heels are
-

then lowered to the floor. This exercise can be repeated 5 1 0 times for 3 - 5 sets. Repeat
-

exercise with other foot. Subject may have to steady body by placing one hand on a wall
or other structure.

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Chinese Orthopedics Lower Leg , Ankle, and Foot 444

As strength increases and no pain is present as result of this exercise, the subject
alter the setup by placing their toes on the edge of a step or flat obj ect that is about 2
inches thick. The plantar flexors are contracted to l ift the ankles up and putting the
dorsiflexors into a stretch contraction. Subj ect may still have to steady body by placing
one hand on a wall or other structure.
As a further modification of this routine the subject can be performed the standing
dorsiflexion by standing on a single foot at a time. This can be performed starting with
the feet flat on the floor or with toes on a step or flat 2 inches thick solid object.

Foot Inversion
The tibialis anterior and posterior muscles are the prime movers in foot inversion with the
extensor hallucis longus, flexor hallucis longus, and flexor digitorum longus serving as
assistant movers. Foot inversion can be exercised from a seated or standing position.
With the subject seated and feet flat on the floor, the medial aspect of the foot is
lifted up off the floor thereby inverting the foot to the maximum extent possible and held
for 2 - 3 seconds. Foot is then lowered to the floor. This exercise can be repeated 8- 1 6
times for 3 - 5 sets. Repeat exercise with other foot. As strength increases, and no pain is
present as result of this exercise, a resistance load can be applied to the top of the flexed
knee to increase the resistive load against foot inversion. This added load can be applied
by subject pushing down on the target knee.

Foot Eversion
The extensor digitorum longus, peroneus tertius, peroneus longus, and peroneus brevis
are the prime movers in foot eversion. Foot eversion can be exercised from a seated
position. With the subject seated and feet flat on the floor, the lateral aspect of the foot is
lifted up off the floor thereby everting the foot to the maximum extent possible and held
for 2 - 3 seconds. Foot is then lowered to the floor. This exercise can be repeated 8 - 1 6
times for 3 5 sets. Repeat exercise with other foot. As strength increases, and no pain is
-

present as result of this exercise, a resistance load can be applied to the top of the flexed
knee to increase the resistive load against foot eversion. This added load can be applied
by subj ect pushing down on the target knee.

Remedial Exercises for Muscles Moving the Toes

The toes much l ike the case for the finger are small and light weight and not particularly
affected by gravity. Also, unlike the fingers, it i s difficult to exercise individual toes. The
toes are exercised in flexion and extension together. It is even more difficult to exercise
the intrinsic muscles of the foot. Functions of the intrinsic muscles of the foot are noted
in Table 1 7.4. Deficits in extension, flexion, abduction, and adduction of the toes can be
determined by comparing the intrinsic muscle function.

Toe Extension
The prime movers for extension of the great toe and second through fifth toes are the
extensor hallucis longus and extensor digitorum longus muscles (See Table 1 7.4). Toe
extension exercises can be performed with the foot flat on the floor and then extending all
toes to the maximum extent possible and hold for 2 - 3 seconds. This exercise can be
repeated 8 - 1 6 times for 3 - 5 sets. Repeat exercise with other foot.

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Chinese Orthopedics Lower Leg , Ankle, and Foot 445

Toe Flexion
The prime movers for flexion of the great toe and second through fi fth toes are the flexor
digitorum longus and flexor hallucis longus muscles (See Table 1 7.4). Toe flexion
exercises can be performed with the heel on the floor with the ball of the foot slightly
lifted off the floor and then flexing all toes to the maximum extent possible and hold for 2
- 3 seconds. This exercise can be repeated 8 1 6 times for 3 5 sets. Repeat exercise with
- -

other foot.
Toes can also be exercised where flexion of all toes is immediately followed by
toe extension and held the end position for both directions for 2 3 seconds. This exercise
-

can be repeated 8 1 6 times for 3 5 sets. Repeat exercise with other foot.
- -

Abduction and Adduction

The intrinsic muscles that abduct and adduct the toes are noted in Table 1 7.4 including
the dorsal interossei and plantar interossei muscles. Abduction and adduction of the toes
is performed with one heel on the floor with the ball of the foot slightly lifted up (slight
dorsiflexion). All the toes are then abducted and held for 2 3 seconds and then adducted
-

and held for 2 3 seconds. This exercise can be repeated 8 1 6 times for 3 5 sets.
- - -

Repeat exercise with other foot.

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Chinese O rthopedics Appendix A 447

Appendix A. Applicati on of Electrosti m u lation

Use o f electrostimulation i n treating orthopedic and other conditions with needling
therapy (acupuncture) involves the application of electrical stimulation to conductive
needles inserted into various locations of the superficial body. This is a form of
percutaneous electrical nerve stimulation (PENS) which is also referred to as
electroneedling (EN). Therapeutic use of EN started being popularized around 1 95 8 when
China started using small electrical devices attached to needles inserted through the skin
(percutaneous) to treat a wide range of medical conditions, and even using it to induce
surgical analgesia. Small amounts of adjuvant drugs that enhance the effect of needling
were often required to produce acceptable levels of analgesia for surgery.
Since Chinese needling therapy is based on a physiological understanding on how
the human body functions in health and disease, and a keen insight into how the bodily
systems are organized, including the importance of somatovisceral relationships, it seems
natural to rely on the superficial location of neurovascular nodes ( acupoints) that are a
hall mark feature of Chinese medicine. Having thousands of years experience in treating
every known disease affecting the human population by their understanding of the
neurovascular nodes of the superficial body, the Chinese simply added electrical
stimulation to a few key nodes used in particular treatment protocols to enhance the effect
of needling therapy. Chinese percutaneous stimulation is called acupuncture by the West,
which is of itself another Latin term (acus-needle + punctura-puncture) that means
percutaneous needle insertion.

Early use of E lectrical Stimu lation

The ancient Egyptians and Greeks may have been the first to use electrical stimulation for
therapeutic purposes, by the application of electric fish. A depiction of malopterurus
electricus (Nile catfish) is prominently displayed in an Egyptian tomb relief dated to the
Fifth Dynasty, ca.2750 BCE. Both gnathonerus petersi and torpedo ray were depicted on
ancient green pottery (Greek pinax) which were honored and feared for their unusual
ability to numb the senses.

Therapeutic Use
In Hippocrates times electric fish could be stepped on or placed on a particular body
location, such as the low back or forehead, to treat particular pain conditions. The Greeks
provided the earliest known written records of using electric fish for pain relief. Aristotle
noted:
"The torpedo ray is known to cause numbness, even in humans."

Both Pliny (Natural History) and Plutarch (Morales) refer to the numbing effects
of the ray. Seribonius Largus (ca. 46 CE) advocated electrotherapy for pain relief and
preventative measures:
"For any type of gout, a live black torpedo ray should , when pain begins, be
placed under the feet. The patient must stand on a moist shore washed by the
sea, and he should stay like this until his whole foot and leg, up to the knee, is

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C h inese Orthopedics Appendix A 448

numb. This takes away present pain and prevents pain from coming on if it has
not already arisen.

Headache, even if it is chronic and unbearable is taken away and remedied

forever by a live torpedo ray placed on the spot which is in pain, until the pain
ceases . As soon as numbness has been felt the remedy should be removed
lest the ability to feel to be taken away from the part. "

Features of Electric Fish

The electrical characteristics of electric fish are for defensive purposes against human,
animals, and other fish. Typical output properties consist of pulse trains with voltage
amplitude levels ranging from 1 -350 volts (40-50v for the torpedo ray). Pulse
characteristics show a low frequency component of 200 Hz and a higher frequency at
1 000 Hz. Pulse trains can range from 1 00 to several thousand. These outputs are
specifically directed at producing significant pain and dysfunction for any unfortunate
critter or human that comes in contact with an electric fish.

Defining Electricity
The term "electric" was coined by the English physician William Gilbert in 1 600 to
describe some static electrical effects, distinguishing them for the first time from
magnetism. This term was derived from the Greek word eleckrom for amber since it had
been known from Roman times that rubbing amber with a dry cloth could produce a
static electric discharge. Otto Von Guericke built the tlrst electrical machine in I 660.
Luigi Galvani ( 1 73 7- 1 798), an Italian physician and physiologist, caused a skinned frog
leg to twitch when touched by two bars of dissimilar metal, when held together at their
ends. The therapeutic use of a unidirectional direct current supplied by a chemical battery
became known as Galvanism. Alessandro Volta ( 1 745- 1 827) developed the voltaic pile
and voltaic battery. However, the discovery of 2000 year old batteries in Baghdad in
1 936 indicates a very early discovery of electrical devices in human history. These
batteries may have been used for electroplating instead of therapeutic use, but then again,
no one really knows what they were used for.

Early Western Interest in Electrotherapeutics

Interest in applying electrical devices to treat human ailments in Europe and the United
States evolved simultaneously with the exploration and understanding of electrical
phenomena from 1 600 to the late 1 800s. Machines of various types were developed.
These involved direct current (Galvanism), alternating current (Faradism), devices which
employed static electricity (Franklinism, after Benj amin Franklin, 1 706- 1 790), and
capacity storage techniques. A wide range of disorders were treated including paralysis,
defibrillation, nerve stimulation, resuscitation, and pain conditions, up to the early 1 800s.
Then a few French practitioners, including Sarlandiere le Chevalier ( 1 825), started
experimenting with Chinese needling therapy based on the 1 683 treatise of Will em ten
Rhijne on acupuncture.
Sarlandiere le Chevalier was perhaps the first to hook up an electrical device to
inserted needles. This is the first known application of PENS. Transcutaneous electrical
nerve stimulation (TENS) with conductive pads was also applied during this time. Use of
PENS was investigated in Italy shortly thereafter by da Camino ( 1 834, 1 83 7). However,

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Chinese Orthopedics Appendix A 449

by the year 1 900 PENS induced electroanalgesia promoted by Sarlandiere and da Camino
was already in disrepute. In 1 95 8 the Chinese reintroduced EN and used it to treat many
common ailments, dental disorders, nerve dysfunction, paralysis, substance withdrawal,
musculoskeletal conditions, and to induce surgical analgesia. Many practitioners of
Chinese needling therapy in the United States and Europe presently use EN in their
normal clinical routines.

Discovery of Neuromuscular Attachments

One interesting outcome from the early use of electrostimulation was the observation of
Guillaume Benj amin Amand Duchenne de Boulogne ( 1 806- 1 875) that stimulation of
specific small areas on the body could elicit muscular contractions. These locations
became known as "points of election." Both Hugo Wilhelm Von Ziemssen ( 1 829- 1 902)
and Wilhelm Heinrich Erb ( 1 840- 1 92 1 ) continued these studies and began to plot the
location of these points. These sites were mapped out on agonal patients (those about to
die) for dissection immediately after death. These locations were found to correspond to
the entrance of nerves supplying muscles (motor points).

Features of Typical Unit

Electrostimulation is usually applied by percutaneous means with leads of a simple,
battery powered, pulse waveform output device connected to inserted needles. Positive
and negative wire leads are attached by suitable clips to inserted needles. Output
frequency and amplitude of electroneedling (EN) units are adjustable and they have
several operational modes with respect to output pulse patterns. Many devices are similar
to transcutaneous electrical nerve stimulation (TENS) units, although output
characteristics may vary. Application of TENS uses conductive pads applied to the skin,
in lieu of needles. Needles are generally inserted at known neurovascular nodes that
address the segmental and axial relationships of the body as described by the Chinese.
Selection of nodes fol lows the same principles of application as normal needling therapy,
but often fewer needles need to be employed. There are other approaches to the
application of EN, but most still rely on the segmental and axial relationships of the
peripheral and central nervous system.

Output Leads and Clips

Output leads of an EN device usually have a clip on the terminal end which is capable of
grasping the metal shaft of the inserted needle, or needle handle if it is made of metal.
These clips sometimes have opposing metal j aws with serrated edges and are referred to
as "alligator clips." Other clips have opposing smooth surfaces (duck bill clips) and some
are simply constructed from spring steel wire.

On-Off Switch Control and Mode Selections

Most EN devices have a master on/off switch and two or four outputs, with a positive and
negative lead associated for each output. Most units also have a mode select function to
provide a range of different output pulse patterns usually consisting of:
• Continuous Output
• D iscontinuous (Intermittent) Output

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Chinese Orthopedics Appendix A 450

•
Mixed Frequencies (Dense Disperse)

Waveform Characteristics
Units are battery powered (6-9 v.) and use a pulse transformer design to increase output
voltage. This type of circuit produces a pulse which has both a positive and negative
voltage component (See Figure A. I ). The pulse wave output can be adj usted in amplitude
from zero volts to a level necessary to activate EN induced processes.
Biphasic Pulse
Output of typical circuit produces a biphasic waveform consisting of a near square wave
positive portion followed by a negative attenuated spike.
Pulse Width
Width of the positive pulse is usually a fixed value of 0.2-0.4 ms. Pulse widths greater
than 0.6 ms. have a greater potential to induce pain by stimulating nociceptive C fibers.
Areas under the positive and negative portions of the waveform are equal and no net
electrical energy is imparted to the body. Purpose of the biphasic pulse is to depolarize
and repolarize tissue during each pulse cycle and therefore produces no deleterious
effects at local site of needle insertion.

General Featu res of Biphasic P u lse

--+ I I +--- 0 . 2- 0.4 ms (Usual ly Fixed Pulse Width)

+ v

• Depola rizes and repolarizes

tissue d uring each pulse cycle

0 • Pu lse widths g reater than 0 . 6 ms.

can activate N ociceptive C F ibers

• Areas u nder positive and negative

voltage curves a re equ a l

- v

Figure A 1 . Characteristics o f positive a n d negative voltage portion o f output waveform

Amplitude Control
Output circuits should have an individual amplitude control capability (potentiometer) to
manipulate the output voltage and some have on/off switches on each circuit. Output can
be controlled from zero volts to maximum (See Figure A.2). Units can typically produce
p ulses with positive and negative amplitudes of 60 volts, while the current i s limited to a
negligible value. Some devices, especially when used for TENS application, produce

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Ch inese Orthopedics Appendix A 451

pulses up to +80 v. and negative spikes of - 1 3 0 v. Both positive and negative amplitudes
increase and decrease together proportionately as the output is adj usted.

Am p l itu d e Contro l

+v

-v Low
Med i u m
H ig h (+60v, -60v)
Figure A.2. C hange in output signal as result of i ncreasing or decreasing a m plitude

PRECAUTIONS in controlling A mplitude include:

•
It i s necessary to make certain that all amplitude settings are at zero volts and unit
is turned off before connecting leads to needles
•
It i s important to zero out (tum down) the amplitude before disconnecting the
leads from needles or turning the unit off
•
During initial application the amplitude is only adjusted to the l evel that the
patient can just feel the sensation or the practitioner observes slight movement of
the needle
•
B e aware that in some cases of pain and also paralysis the patient may have
impaired ability to feel the stimulating signal
•
Patient needs to be checked on every few minutes after initiating treatment, and
practitioner must be aware of recruitment phenomena of motor fibers
Recruitment is the phenomena where electrostimulation of a few muscle fibers
eventually causes some of the adj acent fibers in the same muscle to start contracting in
unison. More and more fibers can also be recruited until the entire muscle is contracting.

Frequency Control
Devices usually have a frequency control capability that is common to all outputs in order
to select appropriate stimulation in terms of number of pulses\second (See Figure A. J ).
Most biological and neural processes that beneficially respond to needling therapy and
EN involve low frequency responses. Most EN devices provide either a range of

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Ch inese Orthopedics Appendix A 452

selectable fixed frequencies or have an adjustable frequency capability. Useful selected

fixed frequencies by means of a rotary switch range from 0. 1 , 1 , 2, 1 0, 25, and 1 00 Hz,
with some units providing considerably higher frequency settings at 1 ,000 to 1 ,500 Hz.
Some devices have a rotary potentiometer type control that provides a smooth frequency
change over a narrow or wide range. It i s difficult to select a precise and repeatable
frequency with this type of control. Increasing the output signal frequency causes an
increase in the intensity that the signal has on the body, and the subjective feeling
experienced by the patient.
PRECAUTIONS in controlling Freq uency include:
•
When increasing the frequency during treatment, where the amplitude has been
adj usted to address patient comfort and utility for the actual treatment, it is
necessary tu m down the signal amplitude on all outputs being used before
switching to the desired higher frequency
•
After increasing the frequency, the amplitude for all outputs then need to be
readj usted as necessary for therapeutic effect following the precautions for
amplitude control as previously described above
•
Increasing the frequency without a corresponding reduction of the amplitude can
lead to inducing stress analgesia

Freq uency Control

+v.

0 2 H e rtz
2 Pulses/Sec.
-v .

1- H
+v.

-v .

+v .

11 HtW UJ _ -UlU--
0 25 H e rtz

-v . Ill IIIII 25 Pulses/Sec.

1 �-- 1 Second

Figure A.3. Typical pulse patterns of selected freq uencies

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Chinese Orthopedics Appendix A 453

Pulse Patterns
Most EN devices provide several different variations in output pulse patterns that offer
certain advantages for specific type of treatments. Typical patterns include continuous,
intermittent (discontinuous), and mixed (dense dispersed) operating modes (See Figure
A.4).
Continuous
Continuous wave output pattern is characterized by a steady train of output pulses at a
constant frequency selected by the practitioner. This is the most common and useful
operating mode applicable to standard clinical situations.
Discontinuous (Intermittent)
The discontinuous or intermittent pulse profile consist of an output signal at the selected
frequency that is on for only about three seconds followed by no output for about three
seconds. This on-off pattern continually alternates as long as the discontinuous pattern is
selected.
PRECAUTIONS in controlling Discontinuous Mode Adj ustment:

•
Amplitude in discontinuous mode is adjusted only during the "on cycle" period of
operation
•
Frequency is only changed during the "on cycle" period consistent with turning
down the output amplitude before increasing the frequency and then readj usting
the amplitude

Mixed (Dense Dispersed)

In the mixed mode of operation a selected output frequency is provided for a short
duration (approximately 3 seconds) followed by lower frequency for the same duration.
The high and low frequencies portions of the mixed pattern continually alternate. In
mixed mode, most devices only require selection of the high frequency with automatic
generation of the low frequency component. Some devices allow selection of the low
frequency setting as well.

PRECAUTIONS in controlling Mixed Mode Amplitude:

•
Amplitude i s only adjusted during the high frequency "on" period of the mixed
cycle

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Chinese Orthopedics Appendix A 454

M ode Control

1 11 11 1 1 1 11 1 1 1 1 1 11 1 1
+v .

0
Continuous
2 Hertz
-v.

On Off On

II II II I 11 11 1 1 1
+v.
Discontin uous
0

-v .

1 0 Hertz 2 Hertz 1 0 Hertz

+ v.

111111 1 1 1 1 1 111111
0
Mixed
(Dense Disperse)
-v .

I.... - - 3 Seconds •I

Figure A 4 . Typical operational output modes

Genera l Operationa l G uidelines

The physiological features of the body allow the use of simple, rational, repeatable rules
for the application of EN. This includes proper placement of the output leads to achieve
the best therapeutic effect while at the same avoiding unwanted current paths in the body.
Perhaps the most important consideration in the use of EN, and needling therapy in
general, is the selection of candidate neurovascular nodes (acupoints) to be employed to
achieve the best clinical outcome for the patient' s condition. A rational approach for node
selection is discussed in the following section. The first consideration is to decide if EN is
appropriate for the presenting complaint and if it is suitable for the specific patient.
Duration of treatment, output ampl itude, output frequency, and selection of proper
operating mode also need to be considered.

When to Consider Using Electroneedling (EN)

Generally the application of EN stimulation greatly enhances the effect of needling
therapy and can increase level of analgesia and significantly extends the period of
treatment effectiveness. Insertion of needles into neurovascular nodes stimulate afferent
proprioceptive and nociceptive fibers that activates spinal afferent processes eventually
provoking descending control signals from the brain. The net effect is to restore visceral
homeostasis, normalize autonomic balance, normalize blood flow, inhibit pain, reduce
muscular contractions, and normalize motor functional activities. When very small
electrical signals are applied to the needles this continuously supplies uninhibited signals
along the afferent pathways to provoke stronger descending control.

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Ch inese Orthopedics Appendix A 455

In some individuals, EN induced analgesia is suitable for use in surgery or as an

adjuvant to normal anesthetics. It is especial ly effective in reactivating neural centers
habituated by drug and substance use. Use of EN can also be applied to enhance cervical
dilatation and uterine contractions to induce l abor. Stimulation promotes tissue repair and
healing essential to treat many chronic disorders as well. In addition, EN application
promotes regeneration of nerve fibers in situations where cell bodies of damaged nerves
are still vital.

Electroneedling (EN) as a Secondary Consideration

In the normal course of needling therapy the patient typically receives a series of three to
seven or even more treatments depending on the particular condition. The effect of
needling i s somewhat transitory with some percentage of improvement being achieved on
each treatment. It is important for the practitioner to evaluate the patient at each treatment
to gage the case progress. This provides additional information to the practitioner and
sometimes indicates the need to slightly alter the protocol to address the progressive
improvement in the condition.
If the patient condition is i mproving as expected then the case would normally
achieve the projected clinical outcome. On the other hand, if the case is not proceeding as
expected or is not responding after three treatments, the application of EN would then be
considered. Some practitioners apply EN as a primary modality for pain and
musculoskeletal problems because of its ability to produce a strong analgesic effect. This
may be appropriate for some cases but generally the immediate analgesic effect could
mask valuable diagnostic information.

Electroneedling (EN) as a Primary Consideration

The application of EN is a primary consideration in those situations where a profound
analgesic effect is desired, such as in surgical or dental procedures. Use of EN can also be
a primary consideration when employed in treating nerve dysfunction, paralysis, and
atrophy. Use of EN is very effective in treating withdrawal symptoms of individuals
quitting the use of addictive substances such as nicotine, alcohol, cocaine, opiates, and
some prescription drugs. Practitioners often receive musculoskeletal case referrals that
have been through a series of different treatment modalities. Usually these cases have
accumulated significant diagnostic information, including laboratory tests and diagnostic
imaging results. The condition of the patient is generally well known and hence the use of
EN can be primary consideration.

Placement of Leads
Physiological organization of the body that is critical to afferent and efferent processes
affecting the vessels, viscera, muscles, and peripheral nerves is basically longitudinal and
ipsilateral in nature. This feature is consistent with the physiological view of Chinese
medicine. The spinal afferent processing system that provides ascending signals to the
brain is basically ipsilateral. However, there is about a 40% crossover on the descending
control restorative signals. Thi s crossover features allows treatment of the opposite side
to the one containing a problem to benefit the affected side, especially where the patient
cannot tolerate direct treatment of the affected side. However, the ipsilateral nature of the
ascending afferent signals dictates placing the positive and negative leads of one

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Chinese Orthopedics Appendix A 456

particular output channel of the EN device along vertical pathways on the same side of
the body.
Application of EN, therefore, is directed to apply signals along these same
longitudinal pathways in the body to obtain expected clinical effect. Leads are thus
placed to enhance stimulated reactions to propagate along longitudinal pathways. One
principal goal in l ead placement i s to conform which the segmental and axial
organization of the body while making certain to prevent cross currents. Cross currents
are to be avoided especially in preventing transcranial current pathways. It i s also
important not to generate cross currents through any of the major nerve plexuses, such as
the brachial and lumbar plexuses.
This is accomplished by placing the positive and negative leads of one particular
output channel of the EN device along vertical pathways on the same side of the body. I f
the presenting problem is ipsilateral in nature, such a s pain in one shoulder, the positive
and negative leads are placed at appropriate locations along the affected muscular
pathway. If the problem is bilateral, such as low back pain, then one set of positive and
negative leads, are placed on one side of the back, and another set placed at the same
relative locations on the other side. In this situation it is necessary for both positive and
negative leads to be located at the same relative level. If not, then cross currents could
possibly develop from one channel output to the other. One easy rule is to always place
the positive lead (red) on the upper location and the negative (black) on the lower aspect.

Duration of Electroneedling (EN) Stimulation

Typical duration of EN application is 1 5 - 30 minutes. In cases of dental or surgical
analgesia, the duration may by longer. In treatment of withdrawal from a powerful opiate,
the duration may be increased to 45 minutes and applied twice a day for 3-4 days.
Applying either EN or TENS stimulation for several hours in any one day can lead to
tolerance and loss of any further therapeutic effect until the central nervous system is
allowed to recover. This may require several days. When intermittent or discontinuous
mode is applied, stimulation duration can be longer.

Amplitude
Under most conditions, amplitude of the output signal is only adjusted to the level that
the patient can detect a slight sensation that feels like tapping on the skin. In many cases
of trauma and pain there may be a deficit in sensory perception. These patients may not
feel the electrical signal even though strong muscular contractions are activated. Thus,
amplitude is adjusted only to the level where either the patient feels a slight sensation or
the practitioner observes small movements of the needle or perhaps very slight muscular
contractions. Excess strength of stimulation can induce a stress response.
In addition, muscular tissue activated by electrical stimulation can sometimes
recruit adj acent fibers to start contracting. If the signal amplitude is not reduced, very
strong unwanted muscular contraction can be induced. This can result in worsening of the
condition being treated. Patients should be checked every few minutes to assure their
comfort and safety.
After several minutes of stimulation, control signals generated in the body, reduce
the response to the stimulus and the patient no longer feels the EN stimulus. Thus, the

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Chinese Orthopedics Appendix A 457

amplitude is periodically readjusted to maintain an awareness of a slight tapping

sensation. The control response generated by the body is mediated by descending neural
pathways in the spinal cord. This is the prime effect that is sought in the treatment of all
problems, including musculoskeletal and viscera conditions.

Frequency and Operating Mode

Endogenous pain and autonomic control centers in the brainstem operate around 0.5-4
Hz. and stress can be induced above 1 2- 1 4 Hz. when applied to the brainstem area. In
addition to endogenous pain control, humans and animals also have stress analgesic
mechanisms that can be invoked at about 1 00 Hz. This seems mostly operative at specific
spinal segmental regions and may involve different neurotransmitters at different
segmental levels. This endogenous system may be responsible for providing analgesia in
severe trauma and/or provides for merciful predation. If chronic pain patients are treated
by induced stress analgesia, they feel fantastic at first but later the problem gets worse. So
care needs to be taken not to induce stress by either excess amplitude or using
frequencies that are too high.
Low frequency application (2 Hz.) always invokes the analgesic and restorative
processes of needling therapy. This frequency (2 Hz.) is suitable for use in treating all
pain conditions, substance abuse, osteoarthritis, rheumatoid arthritis, vascular or blood
distribution problems and organ dysfunction. Higher frequencies (25-50 Hz.) are selected
where nerve dysfunction or paralysis is involved and this is usually in conj unction with a
low frequency (mixed mode). Frequencies of 25 Hz. and above can produce tonic
contraction of muscles and is useful in treating certain muscular conditions when applied
in discontinuous or mixed mode. General considerations of mode selection involve the
fol lowing:
Continuous mode: U sed for most conditions, especially in treating pain,
substance withdrawal symptoms, visceral problems, inducing labor, and using EN for
surgical analgesia.
•
Normal treatment duration is about 20-35 minutes and there is little risk of
developing tolerance even if this i s applied several times a day
•
When used for surgical or dental analgesia, the duration may be extended
•
Tolerance can be produced after many hours of continuous application or in
several days with a few hours of dail y EN stimulation
Mixed mode: Is considered when clinical condition involves paralysis, atrophy,
and impairment due to loss of nerve function. Mixed mode can also be applied to enhance
segmental levels with the higher frequency component as well as activating axial effects
with the lower frequency component.
Discontinuous mode: Employed where a longer period of stimulation is needed
and also where stimulation is directed strengthen particular muscular areas or treating
complex problems such as scoliosis.
•
In situations of long duration EN, use of discontinuous mode (about 3 sec. on and
3 sec. off) can be considered to reduce potential of developing tolerance

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 Chinese Orthopedics Appendix A 458

Precautions and Contraindications

Profound analgesia induced by electroneedling (EN) puts patients at risk of self inj ury,
and they must be advised or restricted from engaging in strenuous physical activity after
treatment. Stimulation by EN is usually contraindicated in patients with cardiac
pacemaker., i m b dd d neura l st i m u lator and o t h er e l ectricaJ devices u ·ed on the bodv .
E l ctrical st i m u lation sho u l d n o t be u d on l ower b o l y or I g po i n ts i n ca e o r
pregnancy, especially during third trimester, except in the case where it is used to induce
labor, or used in support of normal labor. High frequency or high amplitude application
may induce stress, which is contraindicated in cases of hypertension. Electroneedling
(EN) can over sedate older patients causing risk of falling asleep after treatment and
therefore these individuals should be driven to and from clinic. Excess EN and TENS can
produce tolerance by depleting central serotonin but is not addictive.

PRECAUTIONS and CONTRAINDICAT I ON S :

•
Profound analgesia induced by Electroneedling (EN) put patients at risk of self
inj ury, therefore the patient must be advised or restricted from strenuous physical
activity after treatment
•
Contraindicated in patients with cardiac pacemakers, imbedded neural stimulators
and other electrical devices
•
Not to be used on lower body or leg points in case of pregnancy, especially during
third trimester
•
High frequency or high amplitude application may induce stress, which is
contraindicated in cases of hypertension
•
Electroneedling (EN) can over sedate older patients causing risk of falling asleep
after treatment; hence patient should be driven to and from clinic, usually by a
friend or fami ly member
•
Excess EN and TENS can produce tolerance by depleting central serotonin
potentially causing exacerbation of the presenting condition

D.E. Kendall, OMD, PhD ©2005-2009