Clinical presentation and manual therapy for lower quadrant musculoskeletal conditions

Abstract

Chronic lower quadrant injuries constitute a significant percentage of the musculoskeletal cases seen by clinicians. While impairments may vary, pain is often the factor that compels the patient to seek medical attention. Traumatic injury from sport is one cause of progressive chronic joint pain, particularly in the lower quarter. Recent studies have demonstrated the presence of peripheral and central sensitization mechanisms in different lower quadrant pain syndromes, such as lumbar spine related leg pain, osteoarthritis of the knee, and following acute injuries such as lateral ankle sprain and anterior cruciate ligament rupture. Proper management of lower quarter conditions should include assessment of balance and gait as increasing pain and chronicity may lead to altered gait patterns and falls. In addition, quantitative sensory testing may provide insight into pain mechanisms which affect management and prognosis of musculoskeletal conditions. Studies have demonstrated analgesic effects and modulation of spinal excitability with use of manual therapy techniques, with clinical outcomes of improved gait and functional ability. This paper will discuss the evidence which supports the use of manual therapy for lower quarter musculoskeletal dysfunction.

Keywords: Ankle; Hip; Knee; Low back pain; Lower quadrant; Pain; Sensitization.

Figures

Figure 1

Clinical assessment of hyperalgesia through use of algometry. Typical measures include pressure pain threshold and pressure pain tolerance.

Figure 2

Clinical assessment of vibratory perception through use of a Rydel–Seiffer graduated tuning fork. The device, typically applied at a bony prominence, allows an objective measurement of the intensity at which the vibration is no longer perceived.

Figure 3

Lumbar rotational thrust manipulation.

Figure 4

Oscillatory mobilization technique at the hip.

Figure 5

Longitudinal thrust manipulation at the hip.

Figure 6

Oscillatory mobilization at the tibiofemoral joint.

Figure 7

Longitudinal thrust manipulation at the ankle.