Management of common musculoskeletal disorders: physical therapy principles and methods

803 Pages·1996·443.95 MB·English

by  Darlene Hertling

"-"
,.
Management of

Common
Musculoskeletal
Disorders
Physical Therapy
Principles and Methods
THIRD EDITION
. .
...
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Lippincott
)
Philadelphia • New York
Sponsoring Editor: Andrew Allen
Development Editor: laura Dover
Project Editor: Tom Gibbons
Indexer: Victoria Boyle
Design Coordinator: Doug Smock
Interior DeSigner: Maria Karkucinski
Cover Designer: Ilene Griff
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Third Edition
Copyright © 1996 by Lippincott-Raven Publishers.
Copyright © 1990, by J B. Lippincott Company. Copyright © 1983
by Harper & Row, Publishers, Inc. All rights reserved. No part of
this book may be used or reproduced in any m,lnner whatsoever
without written permission except for brief quotations embodied
in critical articles and reviews. Printed in the United States of
America. For information write Lippincott Williams & Wilkins, 227
East Washi.ngton Square, Philadelphia, PelUlsylvania 19106.
Library of Congress Cataloging-in-Publication Data
Hertling, Darlene.
Management of common musculoskeletal disorders: physical
therapy principles and methods / Darlene Hertling, Randolph M.
Kessler; with 5 additional contributors: illustrations by Elizabeth
Kessler. -3rd ed.
p. cm.
A Lippincott physical therapy title.
Includes bibliographical references and index.
ISB 0-397-55150--9
1. Physical therapy. 2. Musculoskeletal system-Diseases­
Patients-Rehabilitation. I. Kessler, Randolph M. U. Kessler,
Randolph M. Ill. Title.
[0 LM: 1. Bone Diseases-therapy. 2. Bone Diseases­
therapy. 3. Physical Therapy. 4. Muscular Diseases-ther­
apy. 5. Physical Therapy. WE 140 H574m 1996]
RM700.H48 1996
616.7'062-----<ic20
DNLM/DLC 95--4483
for Library of Congress CIP
The material contained in this volume was submitted as previously
unpublished material, except in the instances in which credit has
been given to the source from which some of the illustrative mater­
ial was derived.
Any procedure or practice described in this book should be applied
by the health-care practitioner under appropriate supervision in ac­
cordance with professional standards of care used with regard to
the unique circumstances that apply in each practice situation. Care
has been taken to confirm the accuracy of information presented
and to describe generally accepted practices. However, the authors,
editors, and publisher cannot accept any responsibility for errors or
omissions or for any consequences from application of the informa­
tion in this book and make no warranty, express or implied, with
respect to the contents of the book.
The authors and publisher have exerted every effort to ensure that
drug selection and dosage set forth in this text are in accordance
with current recommendations and practice at the time of publica­
tion. However, in view of ongoing research, changes in government
regulations, and the constant flow of information relating to drug
therapy and drug reactions, the reader is urged to check the pack­
age insert for each drug for any change in indications and dosage
and for added warnings and precautions. This is particularly im­
portant when the recommended agent is a new or infrequently em­
ployed drug.
Materials appearing in this book prepared by individuals as part of
their official duties as U.s. Government employees are not covered
by the above-mentioned copyright.
9 8 7 6
Preface

In the decade that has elapsed since the first edition of cations of the preceding materials as they relate to se­
Management of Common Muscuioskeletal Disorders, lected conditions affecting the peripheral joints and
a number of therapeutic advances have either been the spine. Each of the regional chapters in these sec­
newly introduced or been made generally available. tions is organized to include functional anatomy and
This book was conceived at a time when the lack of biomechanics, specific regional evaluation, and com­
proper textbooks on impaired function and manage­ mon lesions and their management. Most of the chap­
ment of common musculoskeletal disorders was a ters have been expanded, including Chapter 14, which
major obstacle to teaching. Now there are numerous formerly covered only the ankle and hindfoot and
texts dealing with the teaching of soft tissue and joint now includes the lower leg and forefoot. Chapters on
mobilization, stabilization techniques, exercises, and the thoracic spine and the sacroiliac joint have been
so forth. added for completeness.
This third edition has again been expanded. Three Identification of the treatment most likely to suc­
entirely new chapters have been added. The tech­ ceed continues to improve, emphasizing either
niques formerly described in the chapters on periph­ "hands on" procedures (Grieves 1986; Maitland 1987)
eral joint mobilization techniques and automobiliza­ or the "hands off" approach (McKenzie 1979; Holten
tion for the extremities have been absorbed into their
1984). Active mobility rather then passive mobility
respective peripheral joint chapters.
continues to be emphasized. Significant clinical contri­
The book comprises three parts: Basic Concepts and
butions have been made by Robin McKenzie, a New
Techniques, and Clinical Applications of the Periph­
Zealand physiotherapist of international renown who
eral Joints and the Spine. Part One, dealing with back­
has expanded on an original contribution with his lat­
ground material, is not meant to be a comprehensive
eral shift treatment technique for patients with lumbar
discussion of the musculoskeletal system, which is
discogenic disorders, and by Brian Edwards of Aus­
well covered in other studies. A new Chapter 2, Prop­
tralia, who has formalized combined movements in
erties of Dense Connective Tissue and Wound Heal­
examination and treatment.
ing, was authored by Larry Tillman and Neil Chasan.
The works of Lewit, Fryett, Mitchell, Grieves, Janda
The overview of important concepts concerning con­
and others have resulted in new methods of post-iso­
nective tissue properties, behavior, injury, and repair
metric relaxation techniques. Lewit (1985), having
is long overdue. The material vital for further discus­
worked for about 30 years in the field of painful disor­
sion of a variety of topics is presented later in this text.
ders stemming from impaired locomotor function, has
We thank these authors for their work, cooperation,
observed that movement restrictions are not necessar­
and patience.
ily due to an articular lesion. Post-isometric relaxation
Chapter 6, Introduction to Manual Therapy, in­
techniques (which employ the patient's active partici­
cludes a history of mobilization techniques (from the
pation during manual therapy techniques) are based
first edition) and a broad overview of manual ther­
on the prime importance of soft tissues, particularly
apy. This chapter addresses a number of new tech­
the muscles, as opposed to the skeletal elements of
niques that sometimes do not enjoy support in the lit­
joint structures, in producing various abnormal states
erature but are being used by an ever-increasing
of joint pain and movement limitations.
number of therapists. It can be disastrous to confine
one's interest to one area of specialty and to remain This book was originally written for the student in
unaware of both the broader context of treatment and the advanced stages of training and for the practicing
the possible alternatives. clinician. Originally it was directed toward physical
The key chapter in this first section, from a clinical therapists, but we soon recognized that its cross-sec­
standpoint, is Chapter 5, Assessment of Muscu­ tional interest should be much broader. Patients with
loskeletal Disorders. A comprehensive system of pa­ musculoskeletal disorders are likely to consult any
tient evaluation is a crucial component of the clini­ one of a wide variety of practitioners. We trust that or­
cian's overall approach to management. Ways to elicit thopaedists, osteopaths, physiatrists, rheumatologists,
subjective and objective data are presented, along family practitioners, chiropractors, orthopaedic assis­
with guides to the interpretation of findings. tants, occupational therapists, physical therapy assis­
Parts Two and Three encompass the clinical appli­ tants, athletic trainers, massage therapists, ortho-
ix
x Preface
paedic nurses, and alternative somatic practitioners continuous encouragement for the research and writ­
will also find it useful. ing of this edition. Thanks are also due to various peo­
It is our hope that this third edition will continue to ple-some students, some colleagues, patients, and a
provide a foundation for designing creative and ap­ family member who allowed us to use them as pictor­
propriate therapeutic programs. Occasionally we have ial models. Our thanks to the physical therapy stu­
chosen to introduce complex materials at a somewhat dents and the staff at the University of Washington for
superficial level with the intent of exposing the reader their contributions to the development of this edition.
to advanced concepts. Readers who wish to pursue Furthermore, we acknowledge the contributions of
topics in depth are encouraged to continue reading in the following individuals who reviewed this edition:
the reference lists at the end of each chapter. Most of Laura Robinson, Jenny Cole, Anita Sterling, Beth Mor­
the techniques described here are widely accepted. No timer, Kelly Fitzgerald, and Robert Reif.
claim is made for original methods of treatment. We particularly recognize the important role Eliza­
We thank the readers who have been so responsive beth Kessler played in providing the art work as well
to our efforts to develop a readable and comprehen­ as Bruce Terami in providing the photography. Fi­
sive text on management of common musculoskeletal nally, I am especially appreciative of the invaluable
conditions and would like to encourage colleagues in assistance and encouragement provided me by the
the field to continue their dialogue with us. We ac­ following members of the editoral staff of Lippincott­
knowledge Professor Jo Ann McMillian, Head of Raven Publishers: Andrew Allen, Laura Dover, and
Physical Therapy, Rehabilitation Medicine, University Tom Gibbons.
of Washington Medical Center, for her support and
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Contents

1.
EMBRYOLOGY OF THE MUSCULOSKELETAL SYSTEM

Randolph M. Kessler 3

Axial Components 3

Umbs 5

Terminology 7

2.
PROPERTIES OF DENSE CONNECTIVE TISSUE AND WOUND HEALING

Larry J. Tillman and Neil P. Chasan 8

Physical Properties of Collagen 8 Summary 20

Mechanical Properties of Collagen 11

Wound Healing Injury and Repair of

Dense Connective Tissue 14

3.
ARTHROLOGY

Randolph M. Kessler and Darlene Hertling 22

Kinematics 22 Joint Nutrition 36

Neurology 33 Approach to Management of Joint Dysfunction 40

4. PAIN
Maureen K. Lynch, Randolph M. Kessler, and Darlene Hertling 50

Pain of Deep Somatic Origin 51 Central Modulation of Nociceptive Input 57

History and Development of Pain Theories Clinical Applications 63

and Mechanisms 54 General Considerations of the Patient in Pain 64

5.
ASSESSMENT OF MUSCULOSKELETAL DISORDERS AND CONCEPTS OF MANAGEMENT

Darlene Hertling and Randolph M. Kessler 69

Rationale 69 Clinical Decision-Making and Data Collection 100

History 70 Concepts of Management 105

Physical Examination 75

6.
INTRODUCTION TO MANUAL THERAPY

Darlene Hertling and Randolph M. Kessler 112

History of Joint Mobilization Hypermobility Treatment 127

Techniques 112 Therapeutic Exercises 129

Hypomobility Treatment 116

7. FRICTION MASSAGE
Randolph M. Kessler and Darlene Hertling
133
Principles of Deep Transverse Friction Massage 134

Clinical Application 137

xl
xii Contents
8. RELAXATION AND REU\TED TECHNIQUES
Darlene Hertling and Daniel, Jones
140
Components of the Stress Response 141 Guidelines for Administering Relaxation Techniques in

Role of Physical Therapy 142 Musculoskeletal Disorders 154

Types of Relaxation and Related Research 159

Techniques 144

Chronic Pain Management Relaxation and

Movement Training 153

PART TWO
CUNICAL APPUCATIONS-PERIPHERAL JOINTS
9.
THE SHOULDER AND SHOULDER GIRDLE

Darlene Hertling and Randolph M. Kessler 165

Review of Functional Anatomy 165 Common Lesions 182

Biomechanics 170 Passive Treatment Techniques 194

Evaluation of the Shoulder 176

10. THE ELBOW AND FOREARM
Darlene Hertling and Randolph M. Kessler 217

Review of Functional Anatomy 217 Common Lesions 228

Evaluation of the Elbow 225 Passive Treatment Techniques 236

11. THE WRIST AND HAND COMPLEX
Darlene Hertling and Randolph M. Kessler 243

Functional Anatomy 243 Examination 261

Function and Architecture of the Common Lesions 265

Hand 255 The Stiff Hand 273

Functional Positions of the Wrist and Passive Treatment Techniques 277

Hand 260

12. THE HIP
Darlene Hertling and Randolph M. Kessler 285

Review of Functional Anatomy 285 Common Lesions 298

Biomechanics 290 Passive Treatment Techniques 306

Evaluation 291
13. THE KNEE
Darlene HertJing and Randolph M. Kessler 315

Review of Functional Anatomy 315 Basic Rehabilitation of the Knee 343

Biomechanics of the Femorotibial Common Lesions 347

Joint 320 Passive Treatment Techniques 365

Evaluation 325

14. THE LOWER LEG, ANKLE, AND FOOT
Darlene Hertling and Randolph M. Kessler 379

Functional Anatomy of the Joints 379 Common Lesions and Their Management 418

Biomechanics 395 Joint Mobilization Techniques 434

Examination 406

15. THE TEMPOROMANDIBUu\R JOINT

444

Darlene Hertling J
Temporomandibular Joint and the Applied Anatomy 456

Stomatognathic System 444
Common Lesions 468

Functional Anatomy 445
Treatment Techniques 472
Contents xiii
PART THREE
CLINICAL APPLICATIONS-THE SPINE
16.
THE SPINE-GENERAL STRUCTURE

AND BIOMECHANICAL CONSIDERATIONS

Darlene Hertling
489
General Structure 489 Kinematics 521

Review of Functional Anatomy Common Patterns of Spinal Pain 523

of the Spine 491
Types of Spinal Pain 524

Sacroiliac Joint and Bony Pelvis 519

17.
THE CERVICAL SPINE

Mitchell G. Blakney and Darlene Hertling 528

Review of Functional Anatomy 528 Common Disorders 544

Joint Mechanics 535 Treatment Techniques 553

Examination 537

1
THE CERVICAL-UPPER LIMB SCAN EXAMINATION

Darlene Hertling and Randolph M. Kessler 559

Common Disorders of the Cervical Spine, Temporomandibular Joint, and Upper Limb 560

Format of the Cervical-Upper Limb Scan Examination 563

Summary of Steps to Cervical-Upper Limb Scan Examination 568

19.
THE THORACIC SPINE

Darlene Hertling 570

Epidemiology and Pathophysiology 570 Thoracic Spine Evaluation 585

Functional Anatomy 571 Thoracic Spine Techniques 606

Common Lesions and Their

Management 573

20.
THE LUMBAR SPINE

Darlene Hertling 622

Epidemiology 622 Evaluation 640

Applied Anatomy 624 Common Lesions and Management 658

Medical Models and Disease Entities 632 Treatment Techniques 669

21.
THE SACROILIAC JOINT AND THE LUMBAR-PElVIC-HIP COMPLEX

Darlene Hertling 698

Functional Anatomy 698 Pelvic Girdle Treatment 726

Common Lesions and Management 705 Summary 733

Lumbar-Pelvic-Hip Complex

Evaluation 707

THE LUMBOSACRAL-LOWER LIMB SCAN EXAMINATION

Darlene Hertling and Randolph M. Kessler 737

Common Lesions of the Lumbosacral Region and Lower Limbs and Their Primary Clinical Manifestations 739

The Scan Examination Tests 744

Clinical Implementation of the Lumbosacral-Lower Limb Scan Examination 754

APPENDIX A 757

APPENDIX B 770

INDEX 773
o
E
Basic Concepts

and Techniques