Extremties HVLA

Question 1

Carrying angle

Answer 1

Measured by the angle of deviation of the forearm from the long axis of the humerus

Normal angle in males = 5-10 degrees
Normal angle in females = 10-15 degrees

Abnormal angles:

• cubitus valgus = >15
• cubitus varus <5-10

Question 2

3 joints of the elbow

Answer 2

1) humeroulnar joint
- hinge joint
- articulation is between trochlea of humerus and the ulna

2) humeroradial joint
- Radioulnar joint

Question 3

What is the most commonly injured ligament of the elbow?

Answer 3

Ulnar collateral ligament (UCL)

- commonly injured in baseball pitches

Question 4

Steps in adduction of the ulna

Answer 4

1) adduction of the ulna
2) lateral glide of the olecranon
3) radius is pulled proximally
4) abduct of the wrist

Question 5

Adducted forearm/varus elbow

Answer 5

remember start in anatomic position

Distal ulna shifts MEDIALLY

Proximal ulna shifts LATERALLY

Wrist abducts

• The somatic dysfunction diagnosis*
• forearm adduction (varus elbow)
• decreased carrying angle <5
• restricted proximal ulnar medial glide

Question 6

Steps in abduction of the ulna

Answer 6

1) abduction of the ulna
2) results in medial glide of the olecranon
3) radius is pushed dismally
4) adduction of the wrist

Question 7

Abducted forearm/valgus elbow

Answer 7

remember anatomical position

Distal ulna shifts laterally

Proximal ulna shift medially

Wrist movement moves in adduction

• the somatic dysfunction diagnosis*
• Abduction of the distal forearm/ valgus elbow
• increased carrying angle
• restricted proximal ulnar lateral glide

Question 8

How are upper extremity somatic dysfunction named?

Answer 8

Direction of the distal ulna movements

however the proximal ulna is both how the varus/valgus stress is determined and where the thrust is applied

Question 9

Wrist compensation for respective forearm somatic dysfunction

Answer 9

Wrist is abducted = compensation for adducted forearm/varus elbow

Wrist is adducted = compensation for abduction forearm/valgus

Question 10

Abducted forearm/valgus elbow somatic dysfunction

“Humeroulnar joint abducted HVLA”

Answer 10

Ease of motion when applying a lateral -> medial force to the posterolateral aspect of the proximal radius

Restriction when applying medial -> lateral force to the posterolateral aspect of the proximal ulna

Steps:
1) hold Patient forearm between physician arm and lateral rib cage and place it into full extension

2) grasp elbow using thenar eminence and place MCP joint of index finger on posterior lateral aspect of proximal ulna
3) apply a medial -> lateral thrust on the posterolateral aspect of the proximal ulna

Question 11

Adducted forearm/varus elbow

“Humeroulnar joint adduction HVLA”

Answer 11

Diagnosis:
- Ease of motion when applying a medial -> lateral force to the posterolateral aspect of the proximal ulna

• Restricted motion when applying a lateral -> medial force to the posterolateral aspect of the proximal radius

Steps:
1) hold Patient forearm between arm and lateral rib cage and place it into full extension

2) grasp elbow using thenar eminence and place MCP joint of index finger on posterior lateral aspect of proximal radius
3) apply a lateral -> medial thrust on the posterolateral aspect of the proximal radius

Question 12

How does pronation and supination affect radioulnar joint

Answer 12

Pronation

• proximal radius moves posterior
• distal radius moves anterior and medial

Supination

• proximal radius moves anterior
• distal radius moves posterior and lateral

Question 13

Pronation somatic dysfunction

“Posterior radial head HVLA”

Answer 13

Supination restriction and pronation ease of motion
- the radial head is found “stuck” in the posterior position with the proximal ulna in the anterior position

Steps:
1) place the patients elbow in full extension and place thumb pad on posterior aspect of radial head

2) grasp patient distal radius and ulna with other hand and induce supination through the long lever of the forearm to the barrier. Fine tune supination and extension to localize to the joint

3) apply corrective thrust (MUST do long lever first)
- short lever = apply posterior-> anterior thrust to posterior radial head as you reach end of supination
- long lever = apply quick supination to forearm with hand on distal radius

Question 14

Supination somatic dysfunction

“Anterior radial head HVLA”

Answer 14

Pronation restriction and ease of motion is in the supination
- the radial head is “stuck” in the anterior position

Steps:
1) place patient elbow in flexion and forearm in “swan position”

2) contact anterior portion of radial head with hypothenar eminence or finger pads
3) grasp your patients distal radius and ulna and induce pronation to the barrier. Fine rune with pronation and flexion

4) apply corrective thrust (MUST apply long first)
- short lever = apply anterior -> posterior thrust to anterior aspect of radial head
- long lever = quick pronation thrust to the forearm with your hand that is on the distal radius and ulna

Question 15

Radiocarpal HVLA

Answer 15

• can be subdivided into whatever carpal bone that is being worked on*
  1) grasp patient hand with your thumbs on the dorsal aspect of the hand and your fingers on the palmar aspect of the hand
  2) apply thumb pads over the dorsal surface of the affected bone and apply slight traction
  3) extend and abduct/adduct the patients hand at the wrist to localize to the dysfunctional segment
  4) apply posterior -> anterior thrust to the dorsal surface of the affected bone. Retest

can also add figure 8 movements as you apply the force on the endorsement of the patient hand

Question 16

How does rotation of the tibia affect fibular head placement?

Answer 16

External rotation of the tibia

• causes proximal fibular head to move anteriorly
• causes distal fibula to move posteriorly

Internal rotation fo the tibia

• causes proximal fibular head to move posteriorly
• causes distal fibula to move anteriorly

Question 17

Posterior fibular head HVLA

Answer 17

1) patient is laying down with knee and hip flexion
2) proximal phalanx of the index finger is placed behind the fibular head as a wedge

3) external rotate the tibia through the ankle to move the anterior fibular head to the barrier
- at same time increase knee flexion and apply slight lateral traction with the hand behind the fibular head to take up slack

4) once the barrier is reached = short lever thrust by pushing the fibular head Anteriolateral while flexing the knee further

Question 18

Anterior fibular head HVLA

Answer 18

1) patient is laying down with leg and knee extended.
2) place thenar eminence over the anterior fibular head
3) invert and slightly plantar-flex the foot to disengage the fibular head
4) internally rotate the tibia through the ankle to move the fibular head posteriorly. Slightly extend and induce internal rotation to barrier to take up slack
5) short thrust posterior and laterally (11 o’clock position)

Question 19

Hiss whip

Answer 19

Used for cuboid, navicular or cuneiform bones

1) patient is either prone on table or standing and leaning over the tables end with the knee flexed. Physician is standing behind the patient

2) place your thumbs on the plantar surface of the dysfunctional bone
- direct the thrust straight down for navicular and cuneiform bones. Down and lateral for cuboid bone

Question 20

Talus and tibia mechanics

Answer 20

Talus moves anteriorly and posteriorly depending on the tibia

Anterior glide of the talus and posterior glide of the tibia = plantar flexion

Posterior glide of the talus and anterior glide of the tibia = dorsiflexion

Question 21

Anterior talus/plantar flexion somatic dysfunction

“Anterior talus”

Answer 21

diagnosis = restricted dorsiflexion and tibia is posterior on the talus/ has restricted anterior glide on the talus

Steps

1) patient is supine on table and physician grasp the patient’s dysfunctional foot
- thumbs are on plantar aspect of foot, little or ring fingers are on anterior talus

2) dorsiflex the foot and ankle and glide the talus posteriorly to the barrier
3) apply inferior traction while also inducing more dorsiflexion on the ankle to take up slack
4) short lever force = rapid inferior tug on the foot while also inducing dorsiflexion with a downward scooping motion

Question 22

Posterior talus/dorsiflexion somatic dysfunction

“Posterior talus HVLA”

Answer 22

diagnosis = restricted plantar-flexion and tibia is anterior on the talus/ has restricted posterior glide on the talus

Steps:
1) grasp heel to stabilize it with one hand and apply traction to the calcaneus while dorsiflexion the foot to get it to a more neutral position

2) grasp the distal end of the tibia with the other hand and apply pressure through the distal tibia down toward the table to take out the tissue slack
3) apply a posterior thrust On the tibia while using the other hand to increase traction and dorsiflexion

Question 23

Cuboid and navicular bone movements

Answer 23

Cuboid = inversion and eversion

1) somatic dysfunction
- eversion with plantar flexion
- flattened longitudinal arch
- tenderness/palpation of the medial edge of the cuboid

Navicular = inversion and eversion

1) somatic dysfunction
- inversion with plantar flexion
- flattened medial arch
- tenderness and palpable protrusion of the medial edge of the navicular

Question 24

Cuneiform motion and somatic dysfunction

Answer 24

Physiologic motion = inversion and eversion

Somatic dysfunction = dropped/inferior intermediate cuneiform
most common