When Manual Therapy Techniques are not Enough

Part 1 of 3

Sometimes when treating lateral elbow pain with manual therapy techniques, I have found myself stuck.

Have you ever felt stuck when treating lateral epicondylitis?

Well, I have discovered over the years that a little bit of manual therapy combined with very specific muscle retraining exercises have made a significant difference for these particular cases.

A loss of Motion or Restriction related to
the elbow and forearm may be due to “GIVE”.

Give as defined by Gibbons et al. 2001 is a
lack of active low threshold muscle control
in the Local or Global muscle systems.

An example of this in the elbow is dominance of
Extensor Carpi Radialis Longus (ECRL) muscle over Brachialis or
Brachioradialis as an elbow flexor.  This excessively loads
the common extensor origin and may result in
lateral elbow pain with elbow flexion which may
eventually result in a some loss of elbow motion.

Gibbons et al. 2001 classify muscles around the elbow
into Local Stabilizers, Global Stabilizers and Global

In this post I will describe the elbow muscle classification:

Local Stabilizers
Anconeus (deep fibres) which are active during pronation / supination and elbow extension provides stability for the Ulnohumeral and Radiohumeral joints

Pronator Quadratus (deep fibres) which is active during pronation and
supination plays a stability role for the distal radio-ulnar joint.

Supinator (deep radial and ulnar fibres) are active during supination
and pronation play a stability role for proximal Radio-ulnar & Radio-humeral joints.

Global Stabilizers (produce stability through ROM)
Brachalis, Brachioradialis, Triceps Brachii, Superficial Anconeus, Superficial Supinator
Superficial Pronator Quadratus, Ulnar heads of Extensor Capri Ulnaris and Flexor Carpi Ulnaris.

Global Mobilizers (concentric – produce ROM)
Biceps, Triceps (long head), all common extensors such as ECRL, ECRB,
Extensor Digitorum, Extensor Digiti Minimi, ECU, etc. Pronator Teres, Palmaris
Longus and many forearm flexors such as Flexor Digitorum and Flexor Carpi Ulnaris and Radialis.

Stay tuned for the next post as I will describe the ideal elbow movement patterns using 4 base clinical tests.

To Your Manual Therapy Success.

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Mid-Cervical Spine Anatomy & Biomechanics Webinar

Well, it has been a busy time since my last post…

I have been teaching manual therapy techniques through many recent courses.  Over the last month, I have taught manual therapy courses related to the Hip, Elbow, Mid-Cervical Spine and upcoming, the Acromioclavicular and Sternoclavicular joints.

The most recent course that I taught was at the Ontario Athletic Therapists Association AGM, along side Gray Cook’s course on Functional Movement Screening.

For the first time, I had my course registrants prepare for the Anatomy and Biomechanics of the Mid-Cervical Spine through a webinar that I prepared for them.  This gave us more time for practical review of manual therapy techniques.

If you would like access to this webinar please click on the link below:

PLEASE NOTE: you will need to enter the following password to gain access >>> oatacspinecourse

Mid-Cervical Spine Anatomy and Biomechanics Webinar

P.S. Click on the Seminars and Products Tab for an upcoming workshop on the Shoulder Girdle.



Ankle Case Study Teleseminar Replay

The Replay is Ready!

On the evening of Wednesday March 3, 2010, I held a live teleseminar on an Ankle Case Study.  For those of you who attended the live event and weren’t able to hear the call, I have made the replay available to you as a courtesy for your inconvenience.  I do appreciate those who attended live and those who were not able to attend the event, I encourage you to listen to the replay.  Simply click on the link below to access the Replay and MP3 download of the Ankle Case Study Teleseminar.

To download and listen to the replay, click this link:

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Ankle Case Study Teleseminar

Please join me on Wednesday March 3 at 9 pm EST for a FREE teleseminar on an Ankle Case Study Review with a Clinical Reasoning Process.  Simply sign up by entering your name and email address on the side bar of this blog.

Read part of the case study below:

Current History

Anne who is a 28 year-old competitive basketball player comes to you with a complaint of an achy sharp pain over the right anterior ankle region (P1) – 6/10.  She noticed that it started 2 weeks ago after starting to play basketball for the season.  She says that she has been experiencing stiffness in her ankle joint for the last few weeks now.

She has also noticed an aching type of pain (P2 – 4/10) over the right medial ankle region that started after she returned to playing basketball.  She has become somewhat frustrated and would like to deal with this quickly so that it doesn’t interfere with her basketball season.

 Anne reports that her stiffness occurs primarily into her ankle in the morning and her aching increases in evening especially the day of basketball.

Symptom Behaviour

She reports that landing from a jump and running especially trigger her anterior ankle pain (P1), and her medial ankle pain (P2) bothers her after prolonged walking or playing basketball in general.

What are your thoughts so far as to what is causing Anne’s symptoms?

Join me on the evening of Wednesday March 3 at 9pm EST to learn more!

Promised Audio – Rotator Cuff Impingement Secondary to Scapular Dyskinesis

It took me a little while but it is finally available to you as previously promised…

FREE MP3 DOWNLOAD OF THE LIVE RECORDING given on the Shoulder Girdle.

You can put it on your iPod and listen to it while driving or exercising.

Approximate length is 50 min>>> CLICK on the link below to download:

Rotator Cuff Impingement Secondary to Scapular Dyskinesis



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Lumbar Spine Spondylolysis Case Study – Part 2

This excerpt is part 2 of 2 from the Lumbar Spine Case Study Teleseminar that
was held on January 27, 2010:

In part 1, I presented some of the assessment
findings for Jordan`s low back pain problem.

Now, I would like to share with you some treatment
techniques implemented in his case.

I separated the treatment under various categories:

Manual Therapy:
- Soft tissue mobilization of the erector spinae muscle group for  5 – 10 minutes
– Mobilization of the right L5 Z-joint into a superior / anterior glide
using an indirect technique with a bias into flexion at the L5/S1 motion segment.
Grade 3 oscillatory glide 3×20

see picture and video below:


– Initiate pelvic floor & transversus abdominis activation (TA). 6 x 6 secs hourly
– Knees to chest stretch 3×30 sec holds, in morning and after extension activities

- Educate regarding the condition & the importance of home exercise in managing this problem
– Discuss the importance of avoiding extension activities
– Educate on avoiding shear stress, i.e. avoiding resisted hip flexion, bending & lifting
– Educate on the importance of taking time off aggravating physical activities

-Heating pad x 15 minutes and or electrotherapy over the right lumbar multifidus

To Your Manual Therapy Success.

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Lumbar Spine Spondylolysis Case Study – Part 1

This excerpt is part 1 of 2 from the Lumbar Spine Case Study Teleseminar

that was held on January 27, 2010:


Jordan describes a two-year history of variable low back pain.
The symptoms started two years ago when he was hit from behind
into the boards in hockey, and he describes this as a hyperextension
injury.  He has re-aggravated the symptoms when playing sports
throughout the past two years.
Currently, he complains of an ache (P1, intensity 3/10) across
his lower back that is worse after activity (7/10) and also
describes feeling “really tight a little higher” in his
lower back.  There are some symptoms into the buttocks at times,
but doesn’t particularly complain of symptoms extending into the

Some Clinical Findings Included:

Lumbar Spine ROM:
Flex  had decreased segmental movement – flattened Lumbar Spine,
Ext is limited to neutral with sharp pain reported lower lumbar region,
LSB caused a pulling pain on right side,RSB was no problem,
RRot produced sharp pain over right lower lumbar region,
LRot felt very tight over the right lower back.

Stork Test = +ve right side

Lumbar Spine Passive Mobility Tests:
Decreased flexion L5/S1 right Z-joint with stretch type pain reported
Decreased extension L3/4, L4/5 right Z-joint

Lumbar Spine Stability Tests:
Pain with muscle splinting anterior & right torsional translation of L5

Based on his clinical findings it was determined that the patient’s
symptoms are a result of instability at the L5/S1 joint. 

His symptoms are consistent with spondylolysis. 
The young athlete with a pars interarticularis defect will
typically present with complaints of an ache in the lower back
that increase with activity.  There may or may not be a distinct
mechanism of injury but the athlete will often describe an
increase in pain with activities involving lumbar spine extension
and/or rotation.  The symptoms are typically localized to the
lumbar region with radicular symptoms seldom experienced. 

There may also be pain with active or resisted hip flexion
which produces anterior shear to the vertebra.

In part 2, I will demonstrate appropriate manual therapy
treatment techniques.

To Your Manual Therapy Success.

Manual Therapy Mini Case Study – Atlanto-Axial Joint

A client presents with restricted left neck rotation…

The detailed biomechanical exam reveals an articular restriction at the left Atlanto-Axial joint with no other significant findings.  They have been cleared from any upper cervical instabilities and vertebral artery compromise.

Assuming this is simply an articular restriction of C1-2…

…how would I determine the side of restriction? 


…what is my manual therapy technique of choice to restore left rotation?

 To answer the first question…

I could use a manual therapy assessment format whereby I evaluate the PAIVMs (Passive Accessory Inter-Vertebral Movements) of C1 (Atlas) moving on C2(Axis), at the facet joints.  I would manually check the anterior and posterior accessory glides (with a slight bias towards inferior glide as well for both) of C1 moving on C2 at the facet joints.  This would be compared from left to right to determine which side is not moving well or is restricted.  With a left rotation restriction in this case, I would expect either to find a restricted posterior (with slight inferior) glide of the left C1-2 facet joint OR a restricted anterior (with slight inferior) glide of the right C1-2 facet joint. 

You may be wondering why the slight inferior glide that is incorporated…this is because the shape of the Atlanto-Axial articular surfaces are slight biconvex due to the articular cartilage and this gives rise to a slightly inferior component of the glide.

Here is my answer for the second question…

Assuming that in this case (restricted left neck rotation), it was the left side of C1 not gliding posterior and slightly inferior on C2.  My preferred choice of a manual therapy technique to restore the mobility problem would be a Unilateral Traction of the left C1 on C2.  Below is a picture of this technique….

Unialteral Traction of Left C1 on C2:


To learn more about the details of assessing and treating Craniovertebral Region Joint Restrictions please email me at michael@manualtherapymentor.com  to sign up for the upcoming 1 DAY Workshop on the  January 17, 2010 located in the City of Vaughan.


If a 6 Year Old Can Do It, So Can You!!

Have you ever had a challenge in your professional career or personal life?

I know I have…

Have you ever had to perform and felt unsure of the possible outcome?

I know I have…

Have you ever felt anxious in dealing with a difficult situation?

I know I have…

The next time you are faced with uncertainty, I would like you to remember this video…

In the video you will witness a 6 year old girl tackling the biggest challenge of her life. She finally faces her fear and anxiety during a difficult situation…

…Singing Solo in front of a Public Audience.

Olivia, my 6 year old daughter has been taking singing lessons for about 9 months now and on a several occaisons was asked to perfom on stage in front of a public audience by her music teacher. She repeatedly said no out of fear and anxiety in performing solo on stage. This past month she hesitantly accepted the task of performing solo for a christmas concert. She practised her skill and finally did it.

 After witnessing this huge accomplishment in her life, I was inspired.

I thought to myself, if a 6 year old can get up in front of a public audience with no prior experience and very little practice to face her own anxiety, then I should be able to face any uncertainty in my professional career.

My hope is that you are inspired to tackle your own challenges, whether they are in your professional or personal life.

I leave you with a quote from Anthony Robbins:

“If you feel you can’t, then you must.”

 To Your Manual Therapy Success!



Shoulder Joint Manual Therapy Techniques

Here is one more follow up note on the shoulder joint…

If you go back to one of my previous blog posts dated
March 18, 2009 on Manual Therapy for a ‘Catching Shoulder’,
you will have read that one of the manual therapy techniques that
I used was a glide and wind technique to target lengthening of the
anterior capsule.

Below is a picture that shows this technique as well as
a manual therapy technique that targets the posterior
capsule of the shoulder joint. Enjoy!

Wind and Glide slide

P.S. I am still working on the audio file from the previous post…