Extremity Adjusting in Youth and Adults
EXTREMITY ADJUSTING
Best Practices, Pitfalls, New Studies/Evidence
Kevin Wong
DC
Let me begin by asking you a question: Do you adjust extremities on a regular basis in your practice? Before you say a resounding “yes,” I want you to think for a second. On an average day, what percentage of your patients have a bona fide extremity that needs to be adjusted? On a regular basis, patients walk into our offices with extremities that are causing problems for the body.
Now think a bit deeper. Extremity adjusting on the surface seems easy
When a patient says, “Hey, Doc, my wrist hurts. Can you fix it?” our first inclination is to take that patient’s wrist, palpate it, and perform some kind of manipulation to get the bones moving. While this may be enough in some instances, I want you to realize that a person with wrist pain likely has issues with the elbow, shoulder, and the cervicothoracic spine. As chiropractors, we have the power to actually fix the problems and help our patients heal naturally. So wielding your power wisely and intelligently comes with knowledge and experience.
We have varying comfort levels with treating extremities that originate from our training and exposure in chiropractic college. Some of us had more foundational instruction and practice in school while others had only one upper and lower extremity class and hardly touched extremities in student clinic. We now understand that school is where we were introduced to basic ideas and concepts, but then it’s up to us to figure out how to expand our knowledge and skill level. Your ability to identify, analyze, and treating the extremities will be one of the most powerful tools in your tool belt.
Why bother adjusting extremities?
Chiropractic is defined as “a system of integrative medicine based on the diagnosis and manipulative treatment of misalignments of the joints, especially those of the spinal column, which are held to cause other disorders by affecting the nerves, muscles, and organs.”1 What I like about this definition is it mentions “especially those of the spinal column,” but does not limit our abilities to just the spinal column.
Chiropractors are experts when it comes to being able to evaluate and assess the spine from occipital down to the coccyx. That is part of the very fiber of who we are, dating back to when D.D. Palmer created our profession. But do you have that same burning passion for the extremities? Do you believe that the extremities have just as much to do with overall body health as the spine does?
No matter where you are in your practice career, you likely have come to understand that there is a relationship to the extremities and other body parts. Rarely does a patient come in with just “tennis elbow.” The tennis elbow is part of a larger picture involving the wrist/hand, shoulder, and thoracic and cervical spine. Classically, we are taught about extremities in school in sections or pieces. It’s not often brought together to see how it all relates. Let’s put some patterns together to see if we can make more sense of it.
Patterns of extremity involvement!
Think back to the last time you saw a new patient intake form and that individual marked multiple body parts on their diagram. At first glance, when you see the knees, hips, back, shoulders, and neck all marked up, it is quite stressful. How can this person be in so much pain? They marked so many areas, how am I going to treat all of this?
Sometimes, you actually find a mechanism of injury during the exam. That may explain why the pain can be in so many regions, but often we are not that lucky, and the patient has no real clue about what caused his or her pain presentation. They guess reasons such as posture, stress, sports, etc. are the cause. Patients often are quite surprised to learn that an extremity misalignment has destabilized the spine.
Lower Extremity:
The feet have three functional arches. Almost every patient thinks we only have one on the inside of the foot. Here is where many problems begin. After age seven, the arches have all the support they will ever get no matter how big we grow into adulthood.2 When the patient stands in front of you in anatomical position, their feet show you how supported or unsupported they are. Eight out of ten people in the world overpronate so that their three arches fall toward the floor, and 5 to 7% of people supinate where their feet roll out (they have a high instep and flat transverse and lateral arches)
As the feet flatten out in excessive pronation, the ankle drops down towards the floor. This creates inward twisting or torsion of the tibia and femur bones, which results in biomechanical stress pattern on the medial ankles, medial knees, and deep inside the hips and pelvis. These are also all areas of potential pain. When you can identify the pattern, the lion’s share of patients who present this way become much easier to identify.
Conversely, when someone is supinating, then his or her feet roll outward. The ankles, knees, hips, and pelvis are subjected to the tibia and femur externally rotating, which causes pain in the lateral ankle, lateral knee, outer hips, and the lumbar spine.
Upper Extremity:
As with the lower extremity, some patients may relate a specific mechanism of injury to their hand, wrist, elbow, or shoulder. However, insidious onset of pain is extremely common, which only adds to their frustration.
The shoulder girdles are very important parts of the upper extremity. In fact, patients will often point to the trapezius muscles for where they feel “shoulder pain.” We know that area is not technically the shoulder, but patients do not. It is common that the glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic joints are out of alignment. Each of these joints needs to be addressed, and it is something chiropractors do extremely well.
As shoulder joints move further out of alignment, the surrounding muscles—deltoids, pectoralis, trapezius, rotator cuff, rhomboids, scalenes, and paraspinals—will become more hypertonic. That muscle tightness and pain drives patients to seek care. When someone has elbow or wrist pain, evaluate the shoulder joints and the CT of the spine to see how they can be closely related.
Wrist/hand and elbow issues also relate to the shoulder girdle. When those joints are out of alignment, extra stress is placed on the elbow and wrist. Where there is smoke, there is fire. Follow the pattern starting at the wrist/hand and elbow back to the shoulder, upper back, and neck. This helps you do a comprehensive job.
Words ofWisdom:
1. Start checking extremities on the first visit, (i. e., feet upward)
2. Know the pain referral sites in the body that come from the extremities
3. Know the extremity subluxation patterns
4. Teach your patients what you find so they understand and are “all in”
5. Have a digital foot scanner that helps you find the foot pronation/supination
6. Use elastic sports tape for support of the extremities (patients heal faster)
Remember that our job as chiropractors gives us the ability to get to the real cause of the patient’s pain. Rarely do other healthcare providers have the power of doing this because they either cover up the symptoms or give the patient temporary relief. You have undoubtedly noticed that certain practitioners make a daily practice of chasing the pain locations that the patient points to—X rarely marks the spot of where pain really originates. As much as chiropractic is rooted in spinal care, please do not forget the power the extremities have on spinal stability. It is a powerful concept that will serve you well for many years to come.
References:
1. Oxford Living Dictionaries Online, https:// en. oxforddictionaries. com VV
2. Gould Nl, Moreland M, Alvarez R, Trevino S, Fenwick J. “Development of the child's arch ” Foot Ankle. 1989 Apr;9(5):241-5.
Kevin Wong, DC, is a 1996 summa cum laude graduate of Palmer College of Chiropractic West. A past instructor of chiropractic technique for the college, he is currently part of the adjunct faculty. Dr. Wong is also a past lecturer and instructor for the International Chiropractic Association of California. Currently, he is in full-time practice in Orinda, California, and has been a speaker for Foot Levelers for many years.
