 Kurt Heinking, D.O., F.A.A.O., C.S.

 Professor and Chair OMM

 CCOM / MWU
 Little League……..  Ultra-marathon……..
 Bone and synovium
 Muscle
 Connective tissues
 Arterial
 Venous
 Lymphatic
 Skin
 Metabolic (or referred from a viscera)
 Examples:
◦ Improve fibular motion
◦ Increase hip extension
◦ Normalize the seated flexion test
◦ Revert Jobes test to normal
◦ Decrease reliance on a cane
◦ Eliminate need for wrist splint
 “Cleaning the engine doesn’t make the
car run any better” Dr. Kappler
 Example:
◦ You can’t find a position that eliminates a CS
point.
◦ You bounce off of an attempted HVLA
◦ Prone soft tissue technique is painful
◦ MET doesn’t make enough change
◦ You can’t appreciate a myofascial release
◦ The tissue becomes warm to the touch
 Especially useful in
chronic conditions
 How does that
region change over
time?
 Concept of
“watering the lawn”
 Patient Astride Table / Walk Around
 Kappler’s Hamstring Release
 Posterior Fibular Head
 Q: “ Dr. Heinking, I am taking my PE exam
and I don’t know any techniques to treat the
lower extremities”
 A: Here are some to get you going.
Remember, you can’t use HVLA, but
articulation is fair game.
 Diagnosis  FPR Treatment
  Treatment
 Diagnosis
 Diagnosis  Treatment
 Diagnosis
 Treatment
 Diagnosis  Turn HVLA into
MET: Treatment
 Diagnosis  MFR Treatment
 Loading the
hamstring and calf
allows the
quadriceps and
anterior knee to
soften.
 Jones called this
extension ankle point
EXA.
 He called the ankle in
plantar flexion to be
in “hyperextension”
 This technique works
for tenderpoints in
either medial or
lateral head of the
gastrocnemius
 Diagnosis  Turn HVLA into
MET: Treatment
 With applying external rotation, rapidly flex
the knee, against your fulcrum.
 Can be turned into a MET
 Procedure:
 Dysfunction:
Example: left anterior

Place the heel of your right hand over the
fibular head. The

anterior aspect of the left fibular head with
your fingers projecting downward under the head of the left fibula
knee joint. is in a position of
anterior displacement
Grasp the patient’s left distal leg with your

left hand positioned just superior to the in relation to the
malleolus (thumb projects downward just tibia.
above the lateral malleolus and the fingers
project downward above the medial
malleolus).

 Corrective movement is then applied with a

downward pressure against the head of the
fibula with the heel of your hand in
conjunction with internal rotation of the tibia
with your left hand. This will move the head
of the fibula posteriorly on the tibia.
 Dysfunction: Restricted ankle  Anterior Tibia on Talus HVLA can
motion/dorsiflexion of the left be turned into a springing
foot and ankle. technique

 1. The physician grasps the patient’s

foot with their left hand, applying
plantar flexion and traction.

 2. The physician’s right hand

contacts the distal tibia. The first
metacarpal phalangeal joint is firmly
placed against the tibia.

 3. While maintaining a slight traction

force through the foot to disengage
the tibial-talar joint, a downward and
posteriorly directed HVLA force is
applied to the distal tibia.

 4. Reassess ankle motion.

 Dysfunction: Restricted ankle  HVLA: Talar Tug can be
motion/dorsiflexion of the left foot and ankle.
turned into an articulation
Procedure:
 1. The physician grasps the patient’s foot by placing
the middle finger of his left hand in contact with the
talus.

 2.Now interlace your fingers over the dorsum of the

foot allowing your thumbs to project under the plantar
surface of the foot.

 3.The physician then applies a slight traction force

through the foot to disengage the tibial-talar joint.

 4. The foot and ankle are moved through short arcs of

motion (primarily inversion/eversion with variable
amounts of dorsiflexion) until a restrictive barrier is
found. Typically, eversion and dorsiflexion tend to
localize the restrictive barrier.

 5. While maintaining the barrier localization with

traction, eversion and dorsiflexion, the patient is asked
to relax and the physician applies a short, quick, high
velocity, low-amplitude “tug” causing a brief gapping
of the joint.
 Make a new fulcrum
with your right
thumb.
 Moderate plantar
flexion of ankle, foot
and toes.
 HVLA (or MET): T-L junction
 CS- Rib supine
 CS- Coracoid process
 Q: “ Dr. Heinking, I am taking my PE exam
and I don’t know any techniques to treat the
upper extremities”
 A: Here are some to get you going.
Remember, no HVLA but articulation is fair
game.
  HVLA Treatment
 Diagnosis
 Diagnosis  Treatment
  Treatment
 Diagnosis
 Diagnosis  Treatment
 Anterior Rotation
Dysfunction: MET

Posterior
Rotation
Dysfunction: MET

Anterior
Dysfunction: MET

Superior Glide
Dysfunction: MET

 Diagnosis
 Treatment
 Treatment of an
upward displacement
of the sternal end of
the clavicle.
 “The joint is
commonly restricted
also in attempted
separation of the joint
surfaces by traction in
the long axis of the
clavicle. This
indicates an element
of impaction as a part
of the lesion.”

E. Fraser Strachan, D.O.

 HVLA Technique for
Anterior Displacement
of sternal end of
clavicle
 Downward and lateral
traction on the
shoulder with your
right hand
 Downward /posterior
pressure to medial 1/3
of clavicle through
your left hand
William J. Walton, DO, FAAO
 Diagnosis  Treatment
 Diagnosis  Treatment
Diagnosis  Treatment
“The Bomb” Treatment
 Diagnosis  Treatment
 Diagnosis  Treatment
 Diagnosis  Treatment
Dysfunction: Right ulna abducted relative to the humerus.
(Remember: in the anatomic position, ulnar abduction occurs
when the distal ulna is moving away from the midline.)
Procedure:
1. Brace the patient’s right hand under your left axilla while
maintaining forearm supination.

2. Contact the patient’s right elbow by placing the dorsal aspect of

the middle phalanx of your index fingers in contact with the
medial and lateral aspects of the right olecranon process. You
may also use the pads of your index fingers as an alternative.

3. Cross your thumbs over the anterior aspect of the patient’s

forearm in or just distal to antecubital space of the elbow.

4. With the elbow held just out of full extension, introduce

adduction at the elbow by gently laterally translating the
ulnohumeral joint through your index fingers, while moving the
distal forearm (through the hand) medially until a barrier is
engaged.
5. Ask the patient to “lean back” to introduce a slight amount of
traction.

6. The corrective force is a short, quick increase in adduction

through your hands.

7. Reassess motion.
Note: Patient’s arm can be held under the physician’s right axilla
as an alternative position.
Dysfunction: Right ulna adducted relative to the humerus. (Remember: in
the anatomic position, ulnar adduction occurs when the distal ulna is
moving toward the midline.)

Procedure:
1. Brace the patient’s right hand under your left axilla while maintaining
forearm supination.

2. Contact the patient’s right elbow by placing the dorsal aspect of the
middle phalanx of your index fingers in contact with the medial and
lateral aspects of the right olecranon process. You may also use the
pads of your index fingers as an alternative.

3. Cross your thumbs over the anterior aspect of the patient’s forearm
in or just distal to antecubital space of the elbow.

4. With the elbow held just out of full extension, introduce abduction at
the elbow by gently medially translating the ulnohumeral joint
through your index fingers, while moving the distal forearm (through
the hand) laterally until a barrier is engaged.

5. Ask the patient to “lean back” to introduce a slight amount of

traction.

6. The corrective force is a short, quick increase in abduction through

your hands.

7. Reassess motion.

Note: Patient’s arm can be held under the physician’s right axilla as
an alternative position.
 Dysfunctions
◦ Anterior Radial Head
 Supination is free
 Pronation is
restricted
◦ Posterior Radial
Head
 Pronation is free
 Supination is
restricted
739.7 HVLA - UE - ANTERIOR RADIAL HEAD (RADIO-ULNAR)

Dysfunction: The right radial head resists posterior motion and internal rotation of
the forearm is restricted (pronation).

Objective: Restore free posterior motion of the radial head and improve pronation.

Discussion: The anterior radial head dysfunction is relatively rare.

Patient Position: Seated.

Physician Position: Standing facing patient.

Procedure:

1. Grasp patient’s right hand with your right hand, as if shaking hands.
2. Grasp patient’s right elbow in such a way that the fingers of your left hand
contact the olecranon process.
3. Place your left thumb (alternatively you may use the fingers of your left hand) in
the antecubital space applying a firm posterior directed pressure over the radial
head. Your thumb will act as a wedge to thrust the radial head posteriorly.
4. Use your right hand to induce pronation and flexion of the patient’s forearm and
wrist while introducing rapid flexion of the elbow. This flexion results in the
simultaneous posterior thrust of the radial head through the wedging action of
your left hand or thumb between the radius and the biceps muscle.
5. Re-assess motion of the radial head.
Dysfunction: Right radial head resists anterior motion relative to the ulna, and is
free in posterior motion. A resistance of external rotation (supination) may also be
found.

Objective: Restore free anterior motion of the radial head and restore supination.

Discussion: The posterior radial head dysfunction is relatively common.

Patient Position: Seated.

Physician Position: Standing facing patient.

Procedure:

1. Grasp patient’s right hand with your right hand, while stabilizing the wrist.

2. Hold patient’s proximal forearm in your left hand, with your thumb applying
an anteriorly directed pressure to the posterior aspect of the radial head.

3. Now, while maintaining the anterior pressure on the radial head, with the arm
in a pronated position and the elbow flexed, the corrective technique should
be a fluid movement supinating the forearm and wrist and extending the
elbow.

4. Just before reaching complete extension, apply a high-velocity low-amplitude

thrust through your left thumb on the proximal radial head moving it
anteriorly.
 Diagnosis  Treatment
 Pronator tension is
related to upper
thoracic segmental
& rib dysfunction.
 Pronate flex wrist
and elbow.
There is a reciprocal
motion between ab
/adduction at the
elbow and at the
wrist. When the elbow
is abducted the wrist
prefers adduction and
vise versa.
Restriction of wrist
extension is more
common than restriction
of wrist flexion. This is
probably due to a more
developed and dominant
flexor muscle mass. A
restriction of wrist
extension is typically
seen with increased
tension of the forearm
flexors.
 Diagnosis  Treatment
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2005:409-537

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Churchill Livingstone; 2003:189-214

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Approach. 2nd ed. Williamston, MI: RennieMatrix;2004:75-99, 123-149

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Approach. Philadelphia, PA: Saunders; 2007:238-310

5. Myers H. Clinical Applications of Counterstrain. Compendium ed. Tucson,

AZ: Osteopathic Press; 2012:135-147, 185-222

6. DeStefano L. Greenman’s: Principles of Manual Medicine. 4th ed.

Philadelphia, PA: Lippincott Williams & Wilkins; 2011:390-475

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