1. MANIPULATION PEARLS: PRACTICAL APPLICATIONS FOR KNEE MANIPULATION
Nick Buratovich, NMD
AANP
Snowbird Resort Salt Lake City, Utah
Wednesday, July 27, 2016
Professor, Department Chair of Physical Medicine
Southwest College of Naturopathic Medicine

4. GEORGIAN NATIONAL BALLET

5. PRESENTATION ABSTRACT
Knee joint manipulation, using the wrist extension release technique, for a posterior tibia will be described and demonstrated. Indicators for a posterior tibia will be presented and discussed. Manual manipulative techniques for correction and management will be demonstrated and an opportunity for practice of the technique will be provided.

6. PRESENTATION OUTLINE 1. Review the anatomy of the knee joint
2. Review the diagnosis of a posterior tibia
3. Present the indicators for a posterior tibia
4. Describe case studies of a posterior tibia
5. Demonstrate the manipulative treatment for a posterior tibia using the wrist extension release technique
6. Demonstrate and describe additional manipulative treatments for a posterior tibia
7. Supervise the application of the techniques by the attendees

7. EDUCATIONAL OBJECTIVES
At the end of this presentation the attendee should be able to:
1. Foundational Knowledge
Identify the relevant anatomy of the knee joint
2. Application
Be able to recognize the indicators for a posterior tibia
3. Integration
Be able to execute an effective manipulative treatment protocol

8. EDUCATIONAL OBJECTIVES con’t
4. Human Dimension
Be aware of the value of whole body treatment as structure governs function
5. Human Caring
Be able to appreciate the skill development of manual manipulative techniques for corrective and supportive management of the knee joint
6. Learning to Learn
Be able to reflect on the value of naturopathic principles used through manipulative techniques to help compose effective patient treatment in naturopathic primary care

9. NATUROPATHIC PERSPECTIVE
First and foremost and simply put, ND’s treat disease by restoring health
In the clinical history we should focus on the obstacles to cure and the individual determinants of health
Genotype/constitutional/lifestyle factors
Diet, bio-mechanical and psycho-emotional stresses and/or any history of injury or overuse
Our naturopathic treatment, in a vitalistic tradition, should help our patients return to health by following the laws of nature, the principles of naturopathic medicine, and the Therapeutic Order
Structural integrity – structure governs function

10. NATUROPATHIC PERSPECTIVE (continued)
We want to relieve the stress of injury, bio-mechanical overload, adaptive stress compensations and psycho-emotional influences with manipulation
Relieve pain, restore function and return to health
We do this through the mechanics of the techniques of manipulation with a therapeutic intent focused on healing
Stimulate the Vis with minimum force
Touch has an inherent capacity and manipulation can be a catalyst for:
Increasing body awareness and integrating the body-self
Manipulation can be used in an instrumental/bio-mechanical way or as an expressive whole person process

11. A NATUROPATHIC MUSCULOSKELETAL MODEL OF CARE
1. Identify segmental and general (postural) imbalances.
2. Identify and relax/stretch tight muscles.
3. Strengthen/tone weak muscles.
4. Mobilize/manipulate restricted joints.
5. Re-educate postural/movement patterns.
Naturopathic Physical Medicine, Chaitow et al, 2008

12. KNEE ANATOMY
ANTERIOR
POSTERIOR

13. KNEE ORTHOPEDIC TESTS
Primary knee orthopedic tests for stability and fluid:
Bounce home
Varus and valgus stress tests
Anterior/posterior drawer
Reduction click (meniscus)
McMurray medial/lateral (meniscus)
Minor effusion (bulge) test (fluid)

14. KNEE INDICATORS

15. KNEE INDICATORS
Doctor’s palms contact over the collateral ligaments of a supine patient with the ankle between the doctor’s legs and with the elbows flexed as demonstrated and parallel to the ground
About 10 – 15 pounds of pressure is used to bring the knee into extension
It is important that constant pressure be applied otherwise knee flexion will allow for medial and lateral motion creating an inaccurate listing
With the knee in “locked” extension the doctor applies medial/valgus and lateral/varum pressure to the knee
When the condyles are in proper alignment there is absolutely no motion of the knee joint when it is “locked”
Any amount of motion indicates some degree of subluxation of the tibial condyles

16. KNEE INDICATORS What you should avoid: Don’t do:
Pumping with one or both hands
Going back and forth
Letting up on extension pressure
Twisting the hips

17. BLOCKED EXTENSION
Blocked extension can be due to acute or chronic conditions
This is where the patient’s knee cannot get into a locked position
This limits the validity of the “knee indicators test”
This is usually seen in conditions where there is fluid in the knee or meniscal fragments or a tear

18. POSTERIOR MEDIAL CONDYLE 10% POSTERIOR LATERAL CONDYLE 45%
KNEE LISTINGS
POSTERIOR MEDIAL CONDYLE 10%
POSTERIOR LATERAL CONDYLE 45%

19. KNEE LISTINGS POSTERIOR TIBIA 45%

20. CONTACT POINTS (POSTERIOR KNEE)
Upper middle portion of condyle
Medial condyle – medial listing
Lateral condyle – lateral condyle
Both condyles – posterior tibia
Manipulate medial condyle first then the lateral condyle

21. WRIST EXTENSION RELEASE TECHNIQUE
Give credit where credit is due:
I learned this technique from Dr. Mark Charrette
He credits Dr. Ray Zindler. Both are DC’s
Dr. Zindler is a Canadian of Russian decent and his technique has origins in Russian bone- setting techniques
When applied to the tibial condyles, rapid reduction of knee symptomology and rapid knee stability can be achieved

22. WRIST EXTENSION RELEASE TECHNIQUE
A finger tip is applied to the pressure hand thumb to protect it from the speed/release hand thumb as it crosses over the thumb cuticle in the manipulation maneuver

23. WRIST EXTENSION RELEASE TECHNIQUE
With a listing of a posterior medial condyle, only the medial condyle is manipulated
With a listing of a posterior lateral condyle, only the lateral condyle is manipulated
With a listing of a posterior tibia, both condyles are posterior, both condyles are manipulated
It is recommended that the medial condyle is manipulated first

24. WRIST EXTENSION RELEASE TECHNIQUE
PRESSURE HAND
PRESSURE HAND

25. CONTACT POINTS

26. PALPATE

27. WRIST EXTENSION RELEASE TECHNIQUE
PRESSURE HAND
The pressure hand is the non- dominant hand
The doctor makes a fist so that the proximal phalanges (space between the MCP’s and the PIP’s) and the thumb make a single flat surface
Pressure hand applies about pounds of pressure on the corresponding tibial condyle

28. WRIST EXTENSION RELEASE TECHNIQUE
SPEED/RELEASE HAND
The speed (release) hand is the dominant hand
The doctor criss crosses the DIP of the index finger and then is placed on the cuticle of the pressure hand thumb
The thumb points toward the doctor
Applies about 8 – 10 pounds of pressure
Pressure remains constant
Total pressure applied is 60 – 80 pounds

29. WRIST EXTENSION RELEASE TECHNIQUE
SET UP
SET UP

30. WRIST EXTENSION RELEASE TECHNIQUE SET UP
The thumb pad of the pressure hand contacts the appropriate contact point
The thumb pad of the speed/release hand contacts the thumbnail of the pressure hand
The entire speed/release hand then “rolls” toward the pressure hand putting the speed/release hand into flexion
The medial border of the speed/release hand is contacting the thumbnail of the pressure hand
The doctor’s knee is then flexed and placed next to the patient’s knee so the lateral thigh is parallel to the forearm of the speed hand

31. WRIST EXTENSION RELEASE TECHNIQUE THRUST

32. WRIST EXTENSION RELEASE TECHNIQUE THRUST
The thrust is achieved by simultaneously applying appropriate pressures with the hands and extending the wrist of the speed/release hand as quickly as possible
The doctor’s anterior inside surface of the forearm and the lateral surface of the thigh should be parallel prior to the thrust
The flat surfaces of the forearm and thigh should meet from the wrist to the elbow upon extension of the wrist
It is important to stop the thrust abruptly by striking the forearm against the thigh

33. WRIST EXTENSION RELEASE TECHNIQUE
COMMON MISTAKES
Not applying enough pressure
Pressure should be applied evenly from the thumb to the little finger on the pressure hand
Do not torque the wrist in a rotary motion, simply extend the wrist
Do not rebound
There should be a momentary “holding” of the forearm against the thigh in what may be described as a “thrust and set”
The elbows are not involved

34. WRIST EXTENSION RELEASE TECHNIQUE RIGHT KNEE

35. WRIST EXTENSION RELEASE TECHNIQUE LEFT KNEE

36. PRONE KNEE FLEXION MANIPULATION

37. PRONE KNEE FLEXION MANIPULATION
With a listing of a medial condyle more force pressure (thrust) is applied to the medial condyle
With a listing of a lateral condyle more force pressure (thrust) is applied to the lateral condyle
With a posterior tibia (bilateral) the thrust is applied evenly to the knee

38. SUPINE KNEE FLEXION MANIPULATION

39. SUPINE KNEE FLEXION MANIPULATION
With a listing of a medial condyle you can provide internal (medial) rotation of the tibia prior to the thrust
With a listing of a lateral condyle you can provide external (lateral) rotation of the tibia prior to the thrust
With a posterior tibia the condyles are neutral with the thrust

40. EFFECTIVE PATIENT CARE
Treat according to the naturopathic principles:
First do no harm
With manipulation do not violate the anatomical boundary
Find and treat the cause
Look at the indicators for knee dysfunction and pain
Treat the whole person
Treat associated asymmetry patterns
Doctor as Teacher/Prevention
Instruct the patient in proper posture and exercise
Stimulate the VIS
Doing these things will stimulate the VIS

41. BIOGRAPHY
Dr. Nick Buratovich is a professor of naturopathic medicine and the Department Chair of Physical Medicine at the Southwest College of Naturopathic Medicine and Health Sciences in Tempe, Arizona.
Dr. Buratovich graduated from the National College of Naturopathic (Natural) Medicine in He is a founding faculty member at SCNM (1993) and also has served as the Secretary of the Board of Trustees. He maintains a clinical rotation at the Southwest Naturopathic Medical Center as well as a private practice in naturopathic family medicine with an emphasis in musculoskeletal disorders and pain management.

42. CONTACT INFORMATON
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