The Muscle Energy Manual

VOLUME 1WO

Evaluation and Treatment

of the Thoracic Spine, Lumbar Spine,
and Rib Cage
II THE MUSCLE ENERGY MANUAL
The Muscle Energy Manual
VOLUME TWO

Evaluation and Treatment

of the Thoracic Spine, Lumbar Spine,
and Rib Cage

BY

Fred L. Mitchell, Jr., D.O., F.A.A.O., F.C.A.

Professor Emeritus of Osteopathic Manipulative Medicine
College of Osteopathic Medicine
Michigan State University
East Lansing, Michigan

AND

P. Kai Galen Mitchell, B.A.

Second Edition

MET Press

East Lansing, Michigan

2004
iv TH F. MUSCLE ENERGY MANUAL

Dedicated to my father>s memory.

Fred L. Mitchell, Jr., D.O., F.A.A.O., F.C.A.

Professor Emeritus of Osteopathic Manipulative Medicine
College of Osteopathic Medicine
Michigan State University
906 Lantern Hill Drive
East Lansing, Michigan 48823 U.S.A.

THE MUSCLE ENERl;Y MANUAL, V OLU ME Two SECOND EDITION. (SECOND PRINTING) Copyright© 2002
by Fred L. Mitchell, Jr. and P. Kai Galen Mitchell. First Edition Copyright© 1998
All rights reserved. This book is protected by copyright. No part of this book may
be used or translated or reproduced or transmitted in any manner or form whatsoever
including photocopy, recording, or utilized by any information storage or retrieval
system, without written permission trom the copyright owners, except in the case
of brief quotations embodied in critical articles and reviews.

Inquiries and requests for permission to reproduce material from this work should
be sent to MET Press, P.O. Box 4577, East Lansing, Michigan 48826-4577.
Fax: (5 I 7) 332-4196.

Editors: P Kai Galm Mitchell, Carol P Mitchell, & Amz McGlothlirz Weller

Desig•·• and La_vottt: P Kai Galm Mitchell

Photography: P Kai Galm Mitchell, Marilyn Fox, &Royal OlsMl

Prirzter: McNaughtorz & Gurm, Inc., Saline, Michigan

Printed in the United States of America.

Library of Congress Catalog Card Number: 95-77816

ISBN 0-9647250-1-0- PB (Volume One)

ISBN 0-9647250-2-9- PB (Volume Two)

ISBN 0-9647250-3-7- PB (Volume Three)

ISBN 0-9647250-0-2- PB (Set)

Disclaimer: This book is intended to provide accurate int'l1rmation regarding the subject matter covered. However, it is impossible to ensure that the
int()rmation presented will be accurately interpreted and applied. Therctore, the authors and the publisher specifically disclaim any liability, loss, or risk,
personal or otherwise, which is incurred as a consequence, directly or indirectly, of the usc and/or application of any of the contents of this book.

Direct correspondence with the publisher can be forwarded to:

MET PRESS, P.O. Box 4577, EAST LANSING, MICHIGAN 48826-4577 • FAX: (517) 332-4196
 PREFACE V

Preface to the First Edition

T
his series greatly expands upon the concepts presented in the first texts ever published on
Muscle Energy (Mitchell, Jr., Moran, Pruzzo; 1973 and 1979). This current work is the
culmination of more than thirty-five years of clinical practice, research, and teaching.
Muscle Energy Technique (MET) was first introduced by the author into the curriculum of osteo­
pathic colleges in 1964 at the Kansas City College of Osteopathy and Surgery, following a four-year
postdoctoral joint practice with Fred L. Mitchell, Sr. ( 1960-64 ) . Since that time, its concepts and
methods have spread to osteopathic colleges in the USA, Canada, and overseas. Today, Muscle
Energy is taught at all osteopathic colleges- and many other manual medicine and manual therapy
programs worldwide - making the need for an updated, comprehensive Muscle Energy text and
manual even more urgent.
Although the 1973 and 1979 Muscle Energy manuals were enthusiastically received at home and
abroad, years of teaching have made it apparent that certain deficiencies of the earlier publications
have led to incomplete understanding and misapplications of MET. The earlier works did not include
sufficient explanation of physiological mechanisms, nor the anatomic detail necessary to provide a
rationale for the procedures. Additionally, although some readers no doubt appreciated the brevity
of the cookbook approach, the diagnostic and treatment procedure descriptions did not provide
enough information for the procedures to be performed reliably and consistently. The new MET
series was written to address these omissions.
Possibly because of the name, Muscle Energy has often been perceived as solely a treatment modal­
ity for "tight" muscles. Far too often, MET treatment techniques have been taught without suffi­
cient reference to MET's distinctive diagnostic algorithms. MET is more than a method of treat­
ment or therapy; it is also a biomecha·nics-based analytic diagnostic system, using precise physical diagnosis
evaluation procedures designed to identifY and quantify articular range-of-motion restriction. The
unique MET method of evaluation and diagnosis is an essential part of MET, in that it provides the
necessary informarion needed to apply MET correctly, and therefore effectively. Among the algo­
rithms presented in this text is new material on rib-based vertebral joint diagnosis. Expanded also is
discussion of the biomechanics of non-neutral ERS and FRS segmental dysfunction.
The series is intended as both a text- especially emphasizing the theory and systematic methods
of MET diagnosis- and an evaluation and treatment manual. The Muscle Enu;gy Manual, Volume
One ( 1995), covered Muscle Energy concepts and mechanisms, the musculoskeletal screen, and cer­
vical region evaluation and treatment. Volume Two (1998) covers the evaluation and treatment of
the thoracic spine, lumbar spine, and rib cage. Volume Three ( 1999) deals exclusively with the eval­
uation and treatment of the joints of the pelvis. A forthcoming Volume Four will address evaluation
and treatment of the extremity joints.

Fred L. Mitchell, Jr., D.O., FAAO, FCA

vi PREFACE

Preface to the Second Edition

0 ne of the significant changes in this edition came about through the author's correspon­
dence with Karel Lewit, MD, the reknowned teacher of manual medicine from Prague. Dr.
Lewit pointed out that the procedures for localization for MET treatment as described in
The Muscle Enet;gy Manuals, as well as in the two earlier texts, instructs the student to engage the
barriers to motion simultaneously in all three planes, sagittal, coronal, and transverse, before initi­
ating the contract-relax part of the procedure. To do this precisely is virtually impossible.
Confronted with Lewit's rationality, the principal author recognized immediately that he had not
been following the advice of his own books for many years. He had, in fact, localized treatment in
a manner similar to Lewit, in which motion in one plane, usually sidebending, was precisely local­
ized, and no other plane of motion was addressed until the first plane of motion is released, at which
time addressing other planes of motion was usually not necessary.
The application of MET tor the release of articular range-of:motion blockage requires careful
positioning to precisely localize the eflect of treatment to the impaired joint. Localization always
begins with the joint in its tree-motion ("neutral") range, between flexed and extended positions.
From this starting position a bend is introduced passively, localized to the joint. In the axial skele­
ton coronal plane bending (sidebending) is preferred over sagittal plane bending (flexion or exten­
sion) in order to localize the treatment to one zygapophyseal joint or the other. The preferred
method to induce localized sidebending is lateral translation of the joint, rather than sidebending
from above down, because Jess effort is required to maintain the patient's postural balance and
localization is more precise. Without postural balance extra effort on the part of the patient and/or
the operator is required to prevent the patient falling. The precision necessary for Muscle Energy
treatment localization requires a relaxed patient and a gentle, light-handed operator who is using
minimum effort.
In a flexible plastic structure such as the spine, axial rotation is not a localizable movement- the
twist or torque is simultaneous throughout all segments of the spine. Introducing sidebending first,
however, does have a localizing effect on segmental rotation. Thus, when sidebending is appropri­
ately localized to a segment, freedom to rotate the segment in either direction becomes quite lim­
ited, and will remain limited until additional sidebending mobility is released. Until this release is
complete, symmetrical flexion or extension of the segment is not possible.
The general principle is that the sidebending barrier is addressed throughout the treatment pro­
cedure, and localization to it is tested and confirmed by gentle rotation movements. Once the
sidebending barrier is released, rotation with flexion or extension becomes possible. In other words,
release in the other two planes of motion is usually automatic.
Extensive rewriting of procedures was required to describe this aspect of technique more pre­
cisely. Volume I, in its second printing since 1995, was already extensively edited and rewritten in
response to feedback from readers. Its procedure descriptions were re-edited.
Considerable editorial pains have been taken to make the manuals even more user-friendly than
they were. In addition to rewriting text and adding new text in all three volumes, an index was con­
structed for all the volumes, with cross-references. And the text has once again been combed for
clarity of expression, resulting in numerous instances of rewording of text.
In tl1e previous edition of this text tradition was honored more than the one-plane localization
principle; in this edition the treatment procedure descriptions have all been changed to follow the
principle. We must thank Karel L<;wit for pointing out that localizing in all three planes of motion
simultaneously is difficult, if not impossible-:
For practical clinical reasons we have included brief descriptions of examination and treatment
techniques for imbalance of the abdominal oblique muscles, which are among the long restrictors
of the trunk capable of generating and maintaining secondary segmental dysfunctions of the spine.
A more comprehensive consideration of long restrictors 'is planned tor a finure volume.

Fred L. Mitchell, Jr., D.O., FAAO, FCA

 THE MUSCLE ENERGY MANUAL vii

Brief Contents
Preface for First Edition v
Preface for Second Edition vi
Brief Contents vii
Table of Contents viii
List of Illustrations xiv
List of Tables xv
List of Procedures xvi
Historical Chronology of Muscle Enu;gy Technique xvii

PART I ANATOMY AND BIOMECHANICS

CHAPTER l RELEVANT GROSS ANATOMY OF THE TRUNK 1

CHAPTER 2 NORMAL SPINAL MOTION 15

CHAPTER 3 BIOMECHANICS OF SEGMENTAL MOTION RESTRICTION 31

PART II RIBS AND RESPIRATION

CHAPTER 4 THE MOV EMENTS OF NoRMAL RESPIRATION 43

CHAPTER 5 RESPIRATORY RESTRICTIONS OF THE RIBS 55

PART III EVALUATION AND TREATMENT OF THE THORACIC

AND LUMBAR SPINE
CHAPTER 6 THE THORACIC INLET 79

•Structural subluxations of the first rib •T 1 ERS and FRS vertebral dysfunction •First rib screening and scanning
procedures • Vibratory isolytic technique for muscle contracture

CHAPTER 7 ERS AND FRS SEGMENTAL DYSFUNCTION: T 1 - T6 97

• Using rib motion and position for diagnosis • Key rib concept • Diagnosis by transverse process position
•Treatment procedures

CHAPTER 8 STRUCTURAL RIB LESIONS ( RIBS II - X) 133

• Evaluation and treatment of costovertebral subluxations and intraosseous deformities

CHAPTER 9 EVALUATION AND TREATMENT OF THE LoWER THORACIC

AND LUMBAR SPINE 153
•Aspects of the screening examination relevant to the lower thoracic and lumbar regions • Detailed examination
of the lower thoracic and lumbar spine •Treatment procedures for Type II dysfunctions of the lower thoracic and
lumbar spine • Diagnostic and treatment procedures for neutral (Type I) dysfunction

APPENDIX: Pain Control with Travell's Trigger Points 219

BmLIOGRAPHY and RECOMMENDED READING 223

INDEX 231
viii TAJlLE OF CONTENTS

Table of Contents

PART I ANATOMY AND BIOMECHANICS

CHAPTER l RELEVANT GROSS ANATOMY OF THE TRUNK 1

Anatomic Features of the AnteriorTrunk 2

Posterior Landmarks and Regions 4
Elements of Costal Cage Anatomy 8
Facet variation 11
Normal and Abnormal Anteroposterior Spinal Curvatures 12
Abnormal Anteroposterior Spinal Curvatures 12
Scoliosis 12
Anatomy of the Sympathetic Nervous System 14

CHAPTER 2 NoRMAL SPINAL MOTION 15

Kinesiology of the Trunk 18

Kinesiologic Relationship of Cervicals toThorax 18
Kinesiologic Relationship of theThorax to the Lumbars and Beyond 19
Kinesiology of Flexion and Extension Movements 19

Biomechanics of Segmental Spinal Flexion and Extension (x-axis motion) 20

Regional Ranges of Sagittal Motion 20
Influence of the Ribs onVertebral Motion 20
Zygapophyseal Arthrokinematics 20
Arthrokinematics of the Intervertebral Disc 20
Lumbosacral Flexion/Extension 21
Sacroiliac Flexion/Extension 21

Biomechanics of Segmental Spinal Axial Rotations (y-axis motion) 22

Vertebromanubrial Segment: T1 -T2 22
Costal Cage Deformation withVertebromanubrial Rotation 22
Axial Rotation ofVertebrosternal Segments: T2-T7 22
Lee Hypothesis 23
Mechanism of RibTorque 24
Unifacet Ribs andVertebral Rotation 24
Axial Rotation ofVertebrochondral Segments: T7-T10 24
Axial Rotation ofVertebroabdominal Segments: T10- L1 24
Axial Rotation of Lumbar Segments 25

Biomechanics of Segmental Spinal Sidebending (z-axis motion) 25

Introduction to Neutral Spinal Motion 27

Neutral and Non-Neutral Sidebending of the Thoracolumbar Spine 28
Sidebending Adaptation to Habitual Movements 28
Sidebending Adaptation in Rotoscoliosis 28
Coupling of Rotation and Sidebending 29

CHAPTER 3 BIOMECHANICS OF SEGMENTAL MOTION

RESTRICTION 31
Causes of Joint Movement Restriction 31
Role ofTight Muscles in Joint Restriction 33
Role of Facets inTypes I and II Segmental Dysfunction 33
Clinical Characteristics ofType I andType II Segmental Dysfunction 34
 T A B L E 0 F C 0 NT E NT S ix

Neutral Sidebending of Segments 38

Historical Notes and Comments on Fryette's Laws 40

PART II RIBS AND RESPIRATION

CHAPTER 4 THE MOVEMENTS OF NoRMAL RESPIRATION 43

The Diaphragm and Associated Muscles of Respiration 44

Accessory Breathing Movements 46

Breathing Movements of the Pelvic Diaphragms 46
Respiratory Movements of the Axial Skeleton 47
Chest Movements 49
Respiratory Movements of the Paired Muscles 52

CHAPTER 5 RESPIRATORY RESTRICTIONS OF THE RIBS 55

Diagnosing Respiratory Rib Dysfunction: Overview 56

Rib Cage Screening Procedures 57

Screening for Exhalation or Inhalation Restriction of the Ribs (Step Breathing Method) 58
Individual Rib Respiratory Diagnosis 59
Locating the Key Rib 59

Scanning Procedures for the "Key" Rib 61

Supine and Prone Scanning Examinations 61
- Counting and Monitoring Individual Ribs 61
Scanning for the Key Rib (ribs i- xii): The Procedure 62

Treatments for Respiratory Rib Restrictions 66

Sequence ofTreatment 66
Treatment of Inhalation Restrictions 67
Procedure forTreating Restricted Inhalation (ribs i and ii- ix) 68
Procedure forTreating Restricted Inhalation (ribs x- xii) 70
Treatment of Exhalation Restrictions 71
Procedure forTreating Restricted Exhalation (ribs x- vii) 72
Procedure forTreating Restricted Exhalation (ribs vi- iii) 73
Procedure forTreating Restricted Exhalation (ribs ii and i) 74

Summary of Rib Respiratory Evaluation and Treatment 75

Relationship of Respiratory Restriction of the Ribs to Spinal Evaluation 75

PART III EVALUATION AND TREATMENT OF THE

THORACIC AND LUMBAR SPINE

CHAPTER 6 THE THORACIC INLET 79

Consequences of Altered Shape of the Inlet 80

Causes of Altered Inlet Shape: Segmental Dysfunction vs. Rib Subluxation 81
Causes of Restriction 81
Structural Lesions of the First Rib 81

First Rib Screening and Scanning Procedures 84

Rib Motion Step BreathingTest: Procedure 1 84

Seated Screening and Scanning of the First Ribs 84

Static and Variable PositionTests: Procedure 2 86

SeatedTests for First Rib Posterior Subluxation and Anterior Subluxation 86
X TABLE OF CONTENTS

First Rib Superior Subluxation 87

-Possible Mechanism of First Rib Superior Subluxation 87

The Test for Superior Subluxation of Rib i: The Procedure 88

Anterior and Posterior Subluxations of Rib i 89

- Etiology of Anterior or Posterior Subluxation of the First Rib 89

Practice Exercises for the Evaluation of the First Ribs and First Thoracic Segment 90

Treatment Procedures for First Rib Subluxations 91

Comments on Treating Rib Subluxations 91

The Procedure for Reducing First Rib Superior Subluxation 92

The Procedure for Reducing First Rib Anterior Subluxation 93
The Procedure for Reducing First Rib Posterior Subluxation 93
-Preventing Recurrence of First Rib Subluxations 94

Isolytic Technique for Correcting Muscle Contracture of Scalenes 94

A Brief Theoretical Explanation of the Isolytic Technique Mechanisms 94
Vibratory Isolytic Technique for Treatment of Scalene Muscle Contracture:
The Procedure 95

C HAPTER 7 ERS AND FRS SEGMENTAL DYSFUNCTION: T 1 - T6 97

Integrated Vertebral Segment and Rib Motion 100

Diagnosing Segmental Dysfunction in the Thoracics 101
Procedures for Evaluating Segmental Dysfunction in the Thoracics 101

Four Methods for Stereognostic Screening for Rib Position

and Motion to Diagnose Segmental Dysfunction 102
Method l: Seated Anterior Screening Procedure 102
Method 2: Seated Posterior Screening Procedure 104
Method 3: Supine Screening Procedure 105
Method 4: Prone Posterior Screening Procedure 106

Scanning One Pair of Ribs at a Time 107

"Key Rib" Test Protocols to Assess Vertebral Mechanics or Structural Rib Lesions 107
Scanning Procedures: Key Rib Test Protocols 108

Three Transverse Process Tests for Upper Thoracic Segmental Dysfunction 112
I. The First Procedure: Superior View 112
II. The Second Procedure: Posterior View 114
III. The Third Procedure: The Prone Focused Extension Test for FRS Dysfunction 116
Protocol for The Prone Focused Extension Test 116
Comparison of Rib Based Diagnosis with Transverse Process Palpation 117
Relationship of Rib Evaluation to Spinal Evaluation 117
Practice Review 118

Treatment Procedures for Non-Neutral Dysfunctions of the Thoracic Spine 118

Localization Sequences in Treatment 118
Use of Breathing in Articular Mobilization 119

Treatment of Type II ERS Segmental Dysfunction 120

Turban Technique 120

Treatment of Type II FRS Segmental Dysfunction 122

Longus Colli Technique 122
The Longus Colli Technique Protocol for Treating FRS 122
The Modified Longus Colli Technique 124
Procedure Protocol for Modified Longus Colli Technique 125
 TABLE OF CONTENTS Xi

Cervicothoracic Recumbent Techniques 126

Lateral Recumbent Salad BowlTechnique 126
Salad BowlTechnique Protocol 126
SupineTechnique forTreating ERS or FRS Segmental Dysfunction 127
SupineTechnique Procedure Protocol 127
Seated Axial Rotation Procedure 128
Seated Axial Rotation Procedure Protocol 128

A Clinical Example of Vertebral Diagnosis Using the Ribs 129

CHAPTER 8 STRUCTURAL RIB LESIONS ( RIBS II - X) 133

Acquired Intraosseous Deformities 133
Rib Dislocations (Costovertebral Subluxations) 136
Differential Diagnosis of Structural Rib Lesions 137

Evaluation and Treatment of Costovertebral Subluxations 138

Testing for Anterior or Posterior Costovertebral Subluxations: The Procedure Protocol 138
Palpating Rib Angles for Position and Breathing Motion: The Procedure Protocol 140
Treatment of Anterior Subluxation of the Ribs 142
Reducing Anterior Rib Subluxation-The "HaraKiri" Technique 142
Treatment of Posterior Rib Subluxation 144
Reducing Posterior Rib Subluxation-The "Push Me Pull You" Procedure 144
Management of Recurrent Rib Subluxation 145
Diagnosis and Treatment of Bucket Bail Lesions 146
Protocol for Diagnosing "Bucket Bail" Lesions 146
Reducing a Bucket Bail Rib Subluxation 147
Bucket BailTreatment Protocol 147

Evaluation and Treatment of Intraosseous Deformities 148

Single RibTorsion 148
Differentiating RibTorsion and Compression 148
Testing for Torsions and Curvature Deformities (Compressions) 149
RibTorsion Evaluation Procedures 149
Diagnosing Single RibTorsion by Stereognostic Palpation 149
Diagnosing Anteroposterior and Lateral Compression 150
Treatment Procedures for Intraosseous Deformities of the Ribs 150
Treatment of Persistent Intraosseous Structural Rib Lesions 150
Treatment Procedure Protocol 150

CHAPTER 9 EVALUATION AND TREATMENT OF THE LOWER

THORACIC AND LUMBAR SPINE 153
Symptom and Sign Indicators of LowerThoracic and Lumbar Segmental Dysfunction 153

Applied Anatomy and Physiology ofT7 - L5 154

LowerThoracic and Lumbar Diagnostic Landmarks 154
Rule ofThrees in Reverse 155
Costovertebral Relationships 155
Normal Segmental Motion for the LowerThoracic and Lumbar Spine 156
Normal Mechanics of the Lumbosacral Joint 157
xii THE MUSCLE ENERGY MANUAL

Aspects of the Screening Examination Relevant to the Lower Thoracic

and Lumbar Regions 158

Relevant Screening Examinations 158

The Walking Screen 158

Postural Evaluation - Standing Statics 158

Posture from the Front 158
Posture from Behind 158
Posture from the Side 160

Iliac Crest Heights Test 161

Seated Iliac Crest Heights Test 161

Spinal Rotation Tests 162

Seated Trunk Rotation Screening Test 162
Observing Paravertebral Fullness 162

Abdominal Muscle Tension Imbalance 164

Testing the Muscles of the Abdominal Wall 164

The Pelvic Flexion Tests 165

Relevance of the Standing and Seated Flexion Tests 165
Locating the PSIS for Execution of the Flexion Tests 165

Standing Flexion Tests 166

The Standing Flexion Test Protocol 167

Seated Flexion Test 168

The Seated Flexion Test Protocol 168

Sacral Position 170

Inferior Lateral Angles of the Sacrum (ILAs) 170

Seated Trunk Sidebending Tests 171

Rib Screen for the Lower Thoracic Spine 172

Detailed Examination of the Lower Thoracic and Lumbar Spine 173

Lower Thoracic Respiratory Rib Scan for ERS or FRS Segmental Dysfunction 175
The Posterior Seated Test 175

Locating Lumbar and Lower Thoracic Transverse Processes 176

The Procedure Protocol for Locating Lumbar Transverse Processes- Patient Prone 176
The Procedure for Locating the Lower Thoracic Transverse Processes- Patient Prone 178

Diagnosing FRS Segmental Dysfunction: T 7 - L5 180

Testing for FRS Dysfunction 180

The Sphinx Test 180

Diagnosing ERS Dysfunctions: T 7 - L5 182

The Seated Hyperflexion Test 182

Testing for ERS Segmental Dysfunction: L5- T 7 183

The Seated Hyperflexion Test Procedure Protocol 183

Alternative Testing Positions for Lower Thoracic and Lumbar ERS and FRS Dysfunctions 184
Alternate Test: The "Slump-Sit Tall" Transverse Process Test- Procedure Protocol 184
Alternate Test: The Hip Drop Test 185
The "Hip Drop" Test as a Lumbosacral Test 185
 THE MUSCLE ENERGY MANUAL xiii

Treatment Procedures for Non-Neutral (Type II) Dysfunctions

ofthe Lower Thoracic and Lumbar Spine 186
Treatment of Type II Non-Neutral (ERS and FRS) Dysfunctions 186

Treatment forERS Segmental Dysfunction 186

The 50-Step Procedure 186
The 50-Step ERS Treatment Protocol 188
Alternative Short-Cut Treatment for ERS Dysfunction 192
The Procedure Protocol 192

Treatment for Obliquus Abdominis Imbalance 193

Protocol for Releasing Tension in Oblique Muscles 193

Treatment for FRS Dysfunction 194

The 500-Step Procedure 194
Stages of the 500-Step Treatment Procedure 194

AnExample of the 500-Step Treatment for FRS Dysfunction 196

The 500-Step Procedure Protocol 196
Stage I -Neutral Rotation 196
Stage II -Extended Rotation 198
Stage III-Pure Extension Stage 199

Alternative Short-Cut FRS Treatment 200

The 499-Step Procedure 200
The Procedure Protocol 200

The Lateral Recumbent Treatment Procedures 201

Lateral Recumbent Treatment of Lumbar ERS Dysfunction 202
The Procedure Protocol 202
Lateral Recumbent Treatment of Lumbar FRS Dysfunction 204
The FRS Treatment Protocol 204

Diagnostic and Treatment Procedures for Neutral (Type I) Dysfunction 206

Group Lesions 206

"Stacked" Segmental Dysfunctions 206
Dysfunction or Adaptation? 206

Diagnosis and Treatment of Type I Neutral Dysfunction 207

Testing for NSR Dysfunction of T3 to L4 208

Group Curve Tests and Results 208
The Focused Sidebending Test for Thoracic NSR Dysfunction 210

The "Universal" Technique- Using Type I Mechanics to TreatERS, FRS, and NSR
Dysfunctions 211
Lateral Recumbent Position 211

Lateral Recumbent Procedure Protocol for NSR, FRS, orERS Dysfunction 212
The Lateral Recumbent "Universal" Technique 212
Treatment of Type I Thoracic NSR Dysfunction 214
Procedure Protocol 214
Step l of 500-Step Procedure Applied to Treatment of NSR Dysfunction 215
Procedure Protocol 215
Sidebending Stretch Treatment for Lumbar NSR Dysfunction 216
Lateral Recumbent Sidebending Stretch Isometric Procedure for Lumbar NSR 217

Appendix: Pain Control with Travell's Trigger Points 219

Bibliography and Recommended Reading 223

Index 231
xiv THE MUSCLE ENERGY MANUAL

List of Illustrations

Figure 1.1 Regions of the anterior trunk 2 Figure 4.10 Respiratory axes of the ribs 50
Figure 1.2 Anterior landmarks 3 Figure 4.I1 Following rib motion with the hands 51
Figure I.3 Landmarks and subregions of the Figure 4.12 Superior surtace of the first rib 51
posterior trunk 4 Figure 4.I3 Divisions of the erector spinae 52
Figure I.4 Lateral trunk landmarks and lines of reference 5 Figure 5.7 Finger pad placements for monitoring breathing
Figure I.Sa Superior view of typical thoracic vertebra - T7 5 movements of the ribs 60
Figure l.Sb Lateral view of typical thoracic vertebra 5 Figure 5.8 Bucket handle and pump handle motion 61
Figure l.Sc Posterior view of typical thoracic vertebra 5 Figure 5.9 Finger contact points for posterior rib scanning 61
Figure 1.6 The two finger method of counting Figure 6.1 Lymphatic system of the trunk and neck 80
thoracic spinous processes 6 Figure 6.2 Thoracic inlet size 80
Figure 1.7 The Rule of Threes 7 Figure 6.3 Anterior topography of the rib cage 81
Figure 1.8 Typical lumbar vertebra 7 Figure 6.4 Posterior topography of the rib cage 81
Figure 1.9 Muscular attachments and relations of Figure 6.5 Physiologic movements of the
second rib 9 upper thoracic segments 82
Figure I.IO Vertebromanubrial region: first and Figure 6.6 Actions of the scalenes and tilting of the
second rib relationship 9 manubrium 83
Figure 1.I1 Typical costovertebral relationships in the Figure 6.14 First rib superior subluxation 87
vertebrosternal region 10 Figure 6.17 Anterior subluxation of the right first rib 89
Figure I.12 Typical costovertebral relationships and ligaments in Figure 6.18 Posterior subluxation of the right first rib 89
the vertebrosternal region 10 Figure 6.19 Direction of reduction procedure for
Figure l.I3 Atypical thoracic vertebrae 11 superior first rib subluxation 91
Figure 1.14 Zygapophyseal facet plane orientations 12 Figure 6.24 Direction of reduction procedure tor anterior
Figure l.IS Scoliosis 13 first rib subluxation 93
Figure 1.16 Detormation of the rib cage with scoliosis 13 Figure 6.25 Direction of reduction procedure for
Figure 1.17 Sympathetic chain ganglion 14 posterior first rib subluxation 93
Figure 1.18 General pattern of sympathetic innervation 14 Figure 6.27 Operator's hand movement in
Figure 2.1 The right handed orthogonal coordinate system isolytic technique 95
adapted to clinical language 16 Figure 7.1 Examples of non-neural dysfunction 98
Figure 2.2 Anterior view of the vector line origins and Figure 7.2 Diagrams ofERS and FRS combinations 99
insertions of the left longus colli and the Figure 7.3 Ribs as indicators of vertebral
right scalene muscles 18 segmental dysfunction 100
Figure 2.3 The deepest layer of sacrospinalis muscles: Figure 8.I Mechanism of rib torsion secondary to
rotatores and multifidi 18 vertebral rotation 134
Figure 2.4 T2-3 FSU sagittal motion. 20 Figure 8.2 A-P compression of the left seventh rib 135
Figure 2.5 Counternutating sacrum with Figure 8.3 Lateral compression of the left seventh rib 135
lumbar hyperAexion 21 Figure 8.4 Anterior or posterior subluxation of a third rib 136
Figure 2.6 The counternutation hypothesis in reverse 21 Figure 8.5 Bucket bail lesion of the left second rib 136
Figure 2.7 Tight axial rotation of the first on the Figure 8.6 Bucket bail lesion of the second rib,
second thoracic vertebra 23 lateral view 136
Figure 2.8 Right axial rotation is automatically coupled with Figure 8.7 Finger contact points for A-P rib position 137
tight sidebending tor the first two thoracic FSUs 23 Figure 9.1 Finger pad contacts and
Figure 2.9 Mechanism of rib torsion 24 Rule of Threes in reverse 154
Figure 2.10 Comparison of upper and lower thoracic Figure 9.2 Cross section of lumbar deep fascia 155
costotransverse facets 25 Figure 9.3 Landmarks for lumbar and
Figure 2.II Left axial rotation of a lumbar intervertebraljoint 27 lumbosacral evaluation 155
Figure 2.12 Adaptive lumbar curve 29 Figure 9.4 Contours of the lumbar facets 156
Figure 3.1 ERS and FRS movement patterns 35 Figure 9.5 Left axial rotation of a lumbar type
Figure 3.2 The effect of non-neutral vertebral rotation on the intervertebraljoint 157
associated ribs 37 Figure 9.6 Normal mechanics at the lumbosacraljoint 157
Figure 3.3 Adaptive rotoscoliosis 38 Figure 9.7 and 9.8 Scolioses 159
Figure 4.1 The respiratory relationship of the Figure 9.34 Superior view ofEltS-L dysfunction 173
thoracoabdominal diaphragm, quadratus lumborum, Figure 9.35 Superior view of FitS-L dysfunction 173
and anterior abdominal wall 44 Figure 9.51 Cross section through
Figure 4.2 Postural support tunctions of abdominal muscles 45 seventh thoracic vertebra 178
Figure 4.3 ObservingEupea 45 Figure 9.72b Step 7 with arrows 189
Figure 4.4 Action of thoracoabdominal and Figure 9.100 Neutral adaptive biomechanics of the spine to tilted
pelvic diaphragms 46 base of support 206
Figure 4.5 Two methods of observing sacroiliac respiratory Figure 9.103 Spinal thoracic scoliosis trom
motion 48 three perspectives 209
Figure 4.6 Sacroiliac respiratory motion 48 Figure 9.109 Facet gapping effect of rotation on
Figure 4.7 Anterior view of the sternum 49 Tll-12joint 213
Figure 4.8 Normal respiratory movement of the sternum 49 Figure 9.110 Facet gapping effect of rotation on
Figure 4.9 Pump handle, bucket handle, and T12-Lljoint 213
caliper actions 50
 THE MUSCLE ENERGY MANUAL XV

List of Tables

Table 1.A The Rule of T hrees for Thoracic Vertebrae 7

Table 1.8 Classical Anatomic Groupings of the Ribs 8
Table 1.C Kinesiologic Units of the Thorax 8
Table 1.0 Typical and Peculiar Ribs- Typical and Atypical Vertebrae 8

Table 2.A. Definitions of Clinical and Biomechanics Terms Describing Joint Motions 17
Table 2.8 Summary of Segmental and Regional Ranges of Motion 26

Table 3.A Causes of Restricted Joint Motion 32

Table 3.8 Laws of Non-physiologic Spinal Motion (including definitions of
Type I and Type II segmental dysfunction) 33
Table 3.C Characteristics of Vertebral Segmental Dysfunction and Adaptation 34
Table 3.0 ERS and FRS Segmental Dysfunctions 36
Table 3.E The Secondary Effect of ERS and FRS Segmental Dysfunction on the Ribs 37

Table 4.A Pump Handle/Bucket Handle/Caliper Action Proportions 51

Table S.A Definitions of Terms Describing Manipulable Disorders of the Trunk 56

Table 5.8 Manipulable Disorders of the Trunk Relevant to Muscle Energy 57

Table 7.A Muscle Energy Evaluation and Treatment Procedures for Upper T horacic Segmental
Vertebral Dysfunctions 129

Table 8.A Types of Structural Rib Lesions 137

Table 9.A. The Rule of Threes in Reverse 154

xvi T H E M USCLE EN E RG Y MAN UAL

List of Procedures
I. Diagnostic Procedures Page Range
A. Screening for respiratory restriction of ribs
(Step breathing method) 58 Ribs i-xii
B. Scanning tor the key rib 62 Ribs i-xii
C. Seated screening and scanning of ribs i and T1 84 Rib i & T1
D. Diagnosing rib i subluxations 86 Ribs i (ii-x)
E. D iagnosing scalene contracture 94 Cervical
F. Screening for rib position/motion to diagnose segmental dysfunction
1. Seated anterior screening procedure 102 T1-T10, Ribs i-x
2. Seated posterior screening procedure 104 T3-T12• Ribs iii-xii
3. Supine screening procedure 105 T1-T10, Ribs i-x
4. Prone posterior screening procedure 106 T3-T12• Ribs iii-xii
G. Key rib tests 108 Ribs i-xii, T1-T12
H. Transverse process tests tor upper thoracic segmental dysfunction 112 c5-L5
I. Testing tor anterior or posterior costovertebral subluxation 13 8 Ribs i-x
J. Palpating rib angles fiJr position and breathing motion 140 Ribs iii-x, T3-T10
K. Diagnosing "bucket-bail" lesion 146 Ribs ii-v
L. Testing tor rib torsion and curvature deformity 149 Ribs v-ix ,T4-T8
M. Screening tests for lower thoracics and lumbars
1. Walking screen 158
2. Postural evaluation - standing statics 158
3. Iliac crest heights test - standing and seated 161
4. Spinal rotation tests 162
5. Abdominal Musle Tension Imbalance 164
6. Pelvic flexion tests 165
7. Seated trunk sidebending tests 171
8. Rib screen for lower thoracic spine 172
N. Lower thoracic respiratory rib scan tor ERS or FRS dysfunction 175 T/Tl2
0. Sphinx test (for FRS) and seated hyperflexion test (for ERS) 180 T 7-L5
P. Seated Hyperflexion Test 183 T 7-L5
P. "Slump" and "Sit tall" tests tor lower thoracic and lumbar ERS and FRS 184 T1L5
Q. Hip Drop Test 185 L5-Sl
R. Diagnosing neutral (Type I) dysfunction 206 T3-L4
Focused sidebending test for thoracic NSR dysfunction 210 T3 -T12

II. Treatment Procedures

1. Inhalation rib restriction 68 Ribs i-xii
2. Exhalation rib restriction 72 Ribs xii-i
3. First rib subluxations 92 Rib i
4. Scalene contracture (Vibratory Isolytic technique) 95 Ribs i-ii
5. Turban technique for ERS 120 C6 -T6
6. Longus colli technique for FRS 122 C 5-T 2
7. Modified longus colli technique tor FRS 125 T3-T6
8. Salad bowl MET technique - ERS, FRS, or NSR 126 C 3-T7
9. Supine thoracic MET technique - ERS or FRS 127 C 5-T6
10. Seated axial neutral rotation - ERS or FRS 128 T3-L5
11. Anterior rib subluxation 142 Ribs ii-x
12. Posterior rib subluxation 144 Ribs ii-x
13. "Bucket bail" subluxation 147 Ribs ii-v
14. Persistent intraosseous rib lesions 150 Ribs iv-ix
15. 50-step procedure for ERS 186 T7-LS
16. Short-cut alternative tor ERS 192 T 7-L5
17. Treatment for Obliquus Abdominis Imbalance 193
18. 500-step procedure tor FRS 194
19. Short-cut alternative for FRS 200
20. Lateral recumbent procedures:
For ERS 201 L1 -L5
For FRS 204 L1-L5
"Universal" technique 212 TIO-Ls
21. Seated treatment for T ype I thoracic dysfunction 214 T 3-Ll
22. Lateral recumbent sidebending stretch isometric procedure
tor lumbar NSR dysfunction 217
 THE MUSCLE ENERGY MANUAL xvii

Historical Chronology of Muscle Ener;gy Technique

1909 Birth of Frederic Lockwood Mitchell, Sr. (FLM, Sr.), the originator of MET, on December 3, 1909.

1929 Frederic Lockwood Mitchell, Jr. (FLM, Jr.) is born on January 10, 1929.

1934 FLM, Jr. suffers third-degree burns over 50 percent of his body (considered uniformly fatal at that time). After
witnessing the family physician, Charles Owens, D.O., reverse renal failure using Chapman's Reflexes- there­
by saving "Freddie's" Life - FLM, Sr. makes the decision to become an osteopath.

1935-37 FLM, Sr. studies with Dr. Owens before entering the Chicago College of Osteopathy in 1937.

1941 FLM, Sr. graduates from the Chicago College of Osteopathy.

194 1 FLM, Sr. sets up private practice at 517 James Building, Chattanooga, Tennessee.

1948 FLM, Sr. publishes the article The Balanced Pelvis in Relation to Chapman's Reflexes in the Yearbook of the
Academy of Applied Osteopathy.

1958 FLM, Sr. publishes the article Structural Pelvic Function in the Yearbook of the Academy of Applied
Osteopathy (reprinted in 1965).

1959 FLM, Jr. graduates from the Chicago College of Osteopathy.

1960-64 FLM, Jr. joins FLM, Sr. in private practice, studying osteopathic principles and techniques intensively with
FLM, Sr. for several years.

1964 FLM, Jr. joins the faculty at the Kansas City College of Osteopathy and Surgery (KCCOS- now University of
Health Sciences College of Osteopathic Medicine); introduces Muscle Energy Technique into the curriculum,
making KCCOS the first osteopathic college to include MET in the curriculum.

1970 FLM, Sr., teaches the first of six Muscle Energy Tutorials at Fort Dodge, Iowa. The tutorial was hosted by
Sarah Sutton, D.O., who was later very active in the development of the posthumous Muscle Energy tutorials.

1973 Publication of An Evaluation and Treatment Manual of Osteopathic Manipulative Procedures by FL

Mitchell, Jr., PS Moran, and NA Pruzzo- the first text to include Muscle Energy evaluation and treatment.
Text based on class notes taken by PS Moran from lectures given by FLM, Jr. at KCCOS.

1973 FLM, Jr. joins the faculty at Michigan State University College of Osteopathic Medicine.

1974 FLM, Sr. dies on March 2, 1974.

1974 The Muscle Energy Tutorial Committee is formed to develop a Continuing Medical Education course on
MET. Principally taught by FL Mitchell, Jr., the first posthumous MET course was offered in December by
the College of Osteopathic Medicine at Michigan State University.

1979 FLM, Jr., PS Moran, and NA Pruzzo publish the first strictly Muscle Energy textbook, An Evaluation and
Treatment Manual of Osteopathic Muscle Energy Procedures (out of print 1991).

1980 Paul Kimberly, D.O. includes "muscle force (energy)" techniques in "Outline of Osteopathic Manipulative
Procedures," the Kirksville College of Osteopathic Medicine's OMT syllabus.

1995 Volwne 1 of The Muscle Ener,gy Manual (FL Mitchell, Jr. & PK Mitchell) is published by MET Press.

1998 Volwne 2 of The Muscle Energy Manual (FL Mitchell, Jr. & PK Mitchell) is published by MET Press.

1999 Volume 3 of The Muscle Energy Manual (FL Mitchell, Jr. & PK Mitchell) is published by MET Press.
xviH THE MUSCLii ENEI.GY MANUAL
 THE MUSCLE ENERGY MANUAL

PART I

Anatomy and
Biomechanics
TH! MUSCLE ENEJ.GT MANUAL
 THE MUSCLE ENERGY MANUAL 1

CHAPTER l

Relevant Gross Anatomy

of the Trunl(

T
he analysis of joint movement is the essence of Mus­
cle Energy diagnosis. With MET, mobility of osseous­ «For thirty-five years I have labored to
articular joints is evaluated by looking at the static posi­ acquaint myself lVith the exact form of
tion of one bony landmark relative to another at the every bone that belongs to the frame­
beginning and end of a range of motion. Attempting to observe a work of man )s lVhole body. I have given
bone, or other tissues, while movement is occurring is subject to attention not only to the form of each
complex distractions that may lead to errors in diagnosis. The com­ bone but also to why it is different in
plexity is due to dynamic activities of soft tissues surrounding the form and action from all other bones
bones and joints: skin and fascia get tight or loose; muscles con­ ..... For days) months and years, and
tract or relax; tissue fluids are taken in or removed; proprioceptive many of them, I have examined and
reflexes are stimulated or inhibited. This principle is as true when criticised the normal and the abnormal
evaluating the pelvis and vertebrae as it is when evaluating the ribs. position of all bones of the whole system.
MET diagnosis is based on bone, rather than soft tissue, anatomy. By this extensive study I have formed in
Even in Muscle Energy diagnostic procedures where it appears my head a perpetual image of every
that movement is being observed, the information about the range articulation in the framework of the
or duration of movement depends on a comparison of the bone's human body.» (Still, A. T., OSTEOPATHY,
static position before it moves and after it has stopped moving. RESEARCH AND PRACTICE. Published by the
For example, there are MET procedures that involve observing Author, Kirksville, Missouri 1910)
the duration of rib motion with respiration. For these procedures,
specific landmarks on a pair of ribs are found by palpation. Once
these landmarks are located, the practitioner's fingers follow the
corresponding landmarks on the ribs while the patient inhales and
exhales. Rib movement cannot be seen clearly because the ribs
slide under the skin with respiration; the palpating fingers are used
as visible guides to follow the actual rib motion. However, it is
not the rib motion per se that is the criterion for evaluation, but
the duration and distance the rib moves with inhalation and exha­
lation- the before and after positions of a rib as compared with its
paired rib on the other side.
With MET evaluation procedures, the variance in the before and
after positions of the bony landmarks is sometimes only a few mil­
limeters. The effectiveness of the procedures is dependent on rec­
In this chapter:
ognizing variance from normal symmetry. Thus, a thorough and
• Anatomical r eg i ons and landmarks of
ongoing study of the gross anatomy of the locomotor system is the essen­
th e trunk
tial foundation for accurate MET diagnosis.
• Thoracic and lumbar practical osteology
In this text, anatomic descriptions related to the key landmarks
• Palpabl e anatomy exer cis es
will be supplemented by suggested hands-on exercises designed to
strengthen confidence in the palpatory and visual assessment skills
necessary for physical diagnosis as it relates to MET.
2 THE MUSCLE ENERGY MANUAL

B. Supraclavicular Fossa

o --- D. Shoulder

H. Line of costochondral junctions ------1--­

J. Epigastrium ------11----'---+-
'
'

M-:7¥-+---+---- M. Inguinal region

0 1---- 0. Hip

Figure 1.1 Regions of the anterior trunk.

Anatomic Features of the Anterior Trunk

The human body is divided into regions (e.g., interscapu­
lar region) and subregions that include all the structures­
bones, ligaments, muscles, organs, vessels, skin, fascia -
within the stipulated regions. Familiarity with general body
regions will facilitate discussion of musculoskeletal physical
diagnosis. Figure 1.1 shows some examples of regional
terms. Some regional terms are part of the vocabulary of
laymen (neck, shoulder, back, chest, etc.) and are generally
understood correctly. Other lay terms (hip, stomach) clear­
ly need more precise definition. Many regional names
derive from structures that lie deep to the area of skin.
Landmarks are used principally to demarcate regions
and to measure deviations from normal anatomic geome­
try. Landmarks for specific regions will be covered in the
sections devoted to the evaluation and treatment of those
regions.
Anterior Landmarks
Landmarks are specific points or locations on the body that
are easily identified visually or by palpation. The palpatory
sense most used for identifYing landmarks is stereognosis.
Figure 1.2 shows some examples of landmarks important
tor Muscle Energy Technique.
Both pubic crest and tubercle are shown to dispel the
widespread confusion about them. The pubic tubercle is
the anchor of the inguinal ligament. It is tound slightly
lateral on the anterior surface of tl1e pubic bone. The pubic
crest is the landmark tor evaluating pubic subluxations. It
is on the superior edge of the pubic bone just lateral to the
symphysis. The anterior superior iliac spines (ASIS) are
identified most quickly by laying tl1e flat palms on the
inguinal regions (stereognosis). The anterior inferior
iliac spines (AilS), the origins of the rectus temoris mus­
cles, can also be identified stereognostically as large round­
ed prominences about tl1e size of a door knob, interior and
slightly medial trom the ASIS.
The ribs and costal cartilages are very important for
Muscle Energy diagnosis. Botll palmar and digital stereogno­
sis are required to identifY specific ribs. The ribs are custom­
arily counted from the second ribs, which attach to tile
manubrium and gladiolus at the sternal angle. The lower
border of rib x is at the level of the second lumbar vertebra.
 CHAPTER I � RELEVANT GROSS ANATOMY OF THE ·TRUNK 3

Jugular notch -------____::,....;;���-t--:==:;;;;.,-£---'\-- Clavicle

First intercostal space __________

--JR�'f±,;_±_;'.,__,-T-+--- ----\---
... ::=�--=--
_...o::: First costal cartilage

Sternal angle Second costal

cartilage

IZ\llib-::--1o;+--A�------\--
@ Male nipple
(at the level
of rib v)

---=�""'-!"--- Lower border of rib x

(at the level of 2nd
lumbar vertebra)

Inguinal ligament ------+---->r---7"/

---
Anterior Inferior Iliac Spine (AilS)
r----#'---
� -7 ---11----Pubic Symphysis
Pubic crest - ------------"Y"r�\�-r"<-�C:i�----1------_:___: Pubic tubercle

Figure 1.2 Anterior landmarks.

The junction of the manubrium and the body of the

sternum is called the sternal angle. It is a transverse ridge
that usually can be palpated quite easily by placing the
entire palm of the palpating hand in the anterior middle of
the chest with the fingertips between the heads of the clav­
icles. By sliding the loose skin up and down, the bony
ridges can be felt. Occasionally, other ridges, representing
the fusion junctions of sternebrae, may be felt. The sternal
angle, usually the most prominent ridge, is an important
landmark for counting ribs. The costal cartilages of the
second ribs articulate at the sternal angle, with two small
encapsulated synovial demifacet joints separated by an
interarticular fibrous septum. The septum attaches firmly to
the fibrocartilage disc between the manubrium and the
body of the sternum, the gladiolus. See Figure 1.2.
Sternal Angle Landmark Exercise
Stand or sit in front of your partner (the subject). Place the entire
palm of your hand in the anterior middle of the subject's chest with
your fingertips located between the heads of the clavicles. Applying
mild pressure with your palm, slide the skin on the sternum up and
down. Can you feel the transverse bony ridge between the sternum
and the manubrium- the sternal angle? This is called stereognostic
palpation. (Note: occasionally, other less prominent ridges represent­
ing the fusion junctions of sternebrae may be felt.) Using that bony
ridge as a reference point, place the pads of your fingers on the ster­
nal angle and move them laterad 2 or 3 inches. With your fingers in
that new position, apply mild but firm pressure posteriorly and slide
the loose skin up and down. Can you feel the rounded shape of the
costal cartilage of rib ii? You can now use the second rib as a start­
ing point to count ribs.
4 THE MUSCLE ENERGY MANUAL

Nuchal
region

T
h
0

a �==--d'----\--Scapular spine
c (level of T3)
c
1---'1-M
---�-- edial scapular
r
border
e
'-"---+---+---Inferior angle of
g scapula (level of TB
i
0
vertebra and n
n
rv:.+----+---+- Transverse spinous process
Median furrow process of T1 0

Twelfth rib
u r
m e

� �
;---­
r � 7"""<::7---;?""'""'::-t-""----'r---- lliac crest (level
P
-

f""- T-./..!=JV·<..--.... of L4)

- e r
I e +---."'+---�-->,----Dimple of Michaelis
v g (level of gluteal
tubercle and sacral
i i sulcus)
0
c
n
Posterior Superior Iliac Spine
(PSIS)- level of S2

Figure 1.3 Landmarks and subregions of the posterior trunk.

Posterior Landmarks and Regions

Figure 1.3 shows examples of posterior landmarks and
regions. The median furrow is the vertical groove down the
middle of the back where the spinous processes of the ver­
tebrae can be palpated and counted.
Rib Angles
The line of rib angles is an important region for Muscle
Energy diagnosis. Sliding the scapulae laterad will uncover
all angles trom rib iii to rib x. The other ribs do not have
palpable rib angles.
Scapttlar Spine
On the posterior surface of the trunk, in spite of thickness­
es of skin and muscle, the scapula can be seen - a triangu­
lar, flat, osseous structure that covers the posterior surfaces
of the ribs ii through vii trom the rib angles medially to
approximately the posterior axillary line laterally. The spine
of the scapula is normally at the level of the T3 vertebra,
while the superior angle of the scapula is at the level ofT2,
and the inferior angle is at the 8th intercostal space, the
Scapular Spine Landmark Exercise
Stand or sit behind the subject. whose upper back is exposed. To
make the scapula more visible, have the subject place the backs of
the hands on the small of the back with the arms bent at the elbow,
and move the elbows anteriorly. This position makes the medial bor­
ders of the scapulae more prominent. Next. place the palm of your
hand on the scapula, and, with firm anterior pressure, slide the loose
skin on the scapula around in a circular pattern. This allows you to
feel the shape of the scapula. The transverse ridge you feel is the
scapular spine. Using your stereognostic palpation, identify the medi­
al border. inferior angle, and acromion process of the scapula. The
scapular spine and inferior angle are landmarks related to vertebral
and rib levels. Identify those vertebrae and ribs.
 CHAPTER I � RELEVANT GROSS ANATOMY OF THE TRUNK 5

POSTERIOR
AXILLARY FOLD
AND LINE

costal
rib vii

ANTERIOR
AXILLARY FOLD
AND LINE

Figure1.5.a Superior view of typical thoracic vertebra- T7.

LOWER BORDER
OF rib x, LEVEL OF
L2
Superior articular
process and zygo­
pophyseal facet

A SIS Superior demifacet

FEMORAL
Costotransverse
TROCHANTER
pit for rib vii

Vertebral
body

Figure 1.4 Lateral trunk landmarks and lines of reference.

Intervertebral
foramen

Inferior articular
process and facet

horizontal plane that incorporates the 7th thoracic spinous

Figure 1.5.b Lateral view of typical thoracic vertebra.
process and the body and transverse processes ofT8.
The point at which the tenth rib meets the mid-axillary
line and the most lateral and inferior edges of the eleventh
and twelfth ribs all correspond transversely to the second
lumbar vertebrae. Similarly, the tops of the iliac crests cor­
Superior articular
respond transversely to L4 vertebra. (Figure 1.4) process and zygo­
pophyseal facet
These lateral and posterior landmarks are used fre­
quently to more efficiently find the way to specific vertebral
segments, or to confirm positioning along the spine.

Palpable Thoracic Vertebral Anatomy

Transverse
The spinous processes, transverse processes, ribs, and process

the layers of back muscles, including the deepest layer of

paravertebral (erector spinae) muscles, are ctirectly accessible
Inferior articular
to palpation (see Volume l, Chapter 3 for instruction in process and facet
layer-by-layer palpation). Figure 1.5 (a, b, and c) identifies
the salient features of a typical thoracic vertebra.
Figure 1.5.c Posterior view of typical thoracic vertebra.

Figure 1.5. - a, b, and c Typical thoracic vertebrae (T 71. A "typical" tho­

racic vertebra has four demifacet articulations, two upper for its own ribs
and two lower for the ribs of the segment below, plus two costotrans­
verse facets. Thoracics two through eight are the typical vertebrae. The
facet joint processes lie upon each other like shingles on a cone-shaped
roof, the superior facets facing a little laterad and superior.
6 THE MUSCLE ENERGY MANUAL
Figure 1.6 The two finger method of counting thoracic
spinous processes. Hold the fingers horizontal
and parallel to the surface of the back, strad­
dling each spinous process with the finger pads.
In the middle thoracic area discriminating
between two adjacent spinous processes by
palpation becomes increasingly challenging due
to the increased angulation of the spinous
processes. By approximately maintaining the
same distance between the finger pads one is
less likely to count the same vertebra twice or
mistake two vertebrae for one.
Median Furrow and Spinous Processes
vertebral spinous processes is more
The skin over the
tightly bound to the deep fascia and periosteum of the ver­
tebrae, creating the median furrow. The spinous process­
es are the most posterior projection of the vertebrae and
therefore the most superficial, the most palpable, and the
most easily visible portion of the axial skeleton (see Figures
l.3 and l.5 ).
Note that the cervical, thoracic, and lumbar vertebrae
are named by numbering them from the top down. The
names are usually abbreviated: C2 (for cervical #2, the axis),
T8 (the thoracic vertebra at the level of the inferior scapu­
lar angles), L5 (usually the lowest vertebra, the one sitting
on the sacrum).
Counting Spinous and Transverse Processes
Counting spinous processes is the surest method of finding
a selected vertebra or rib .The seventh cervical spinous
process is the landmark for locating the first thoracic ver­
tebral processes. Recall that locating the seventh cervical
vertebra is facilitated by having the neck hyperflexed and
hyperextended while palpating the prominent spinous
processes in the lower neck and upper thoracic regions.
Although the seventh cervical spinous process is most
prominent in hypertlexion, hyperextension drastically
reduces its prominence so much that it feels like the spin­
ous process slides forward and disappears. The sixth cervi­
cal or the first thoracic may have an equally prominent spin­
ous process in the hyperflexed position. But T 1 has less
mobility, and hyperextension changes the prominence of its
spinous process only slightly. c6 acts very much like c7.
The thoracic spinous processes are fairly long, and in
the mid-thoracic region they point downward at a sharp
angle. Because of this angulation the countable parts, the
tips, sometimes blend together, creating the possibility of
counting two vertebrae as one, counting the same vertebra
twice, or missing a recessed spinous process.
To avoid this error, place your fingers flat on the back,
horizontally, at right angles to the median furrow, and
straddle each spinous process with two finger pads. See
Fig. 1.6. Sliding down the median furrow over the spinous
processes, the distance between finger pads does not vary.
The center-to-center distance represents the height of one
vertebra. When counting from above, the seventh cervical
spinous process is the most reliable landmark (see Volume
1 ), and the inferior angle of the scapula is fairly reliable to
identifY the plane of the seventh thoracic spinous process,
or the transverse processes of the eighth thoracic vertebra.
The rib necks are level with the transverse processes.
The transverse processes of the thoracic spine are
widest at the top, spanning about 2.75 inches or 7 cen­
timeters, and taper to extremely narrow at T 12 ( 1.875 inch­
es or 4.75 em.). Most of the tapering is below T10. They
project straight posterolaterally trom the pedicles of the
vertebrae, and hence are in the same transverse plane as the
vertebral body. Their relationship to the tips of the spinous
processes varies, and is roughly described by the Rule of
Threes. (Table l.A and Figure l.7) Some anatomic V<J.ria­
tion from the rule can be expected.
The transverse processes of the first thoracic vertebra
are the widest, partly because they lie very close to a coro·
 CHAPTER I � RELEVANT GROSS ANATOMY OF THE TRUNK 7

Table 1.A

The Rule of Threes for Thoracic Vertebrae Unifacet- ---�:at""r·•_...• � _ _ _ _ _ _ _

G
1. T1_2,3 The upper three thoracic vertebrae have spinous
processes that project directly posterior and there­
1 R 0
0 N
fore the tip of the spinous process is in the same
plane as the transverse processes of that same ver­
U E
Demifacets "!1'""t--"t-..-..-6Jl
tebra, similar to cervicals 6 and 7. p
(ribs ii- ix) :
2. T4,5,6 The next three vertebrae have spinous processes I
I
that project slightly downward and therefore the tip I

of the spinous process is in a plane that is halfway Horizontal : G

T
between its own transverse processes and that of planes : R
the vertebra below it. passing : 0 w
0
u
3. T7,8,9 The next three vertebrae have spinous processes through :
the: p
that project moderately downward and therefore the
tip of the spinous process is in a plane with the trans­ transverse�
verse processes of the vertebra below it. processes �
(black �
4. T10,11,12 The last three vertebrae have spinous processes that
are shorter and smaller. The spinous process angle
circles) �
of declination regresses until T 12 is much like L1.
I
I T
Tips of
H
spinous
R
processes
E
Rule of Threes Exercise
E

Practice palpating and counting spinous processes on a partner. The

best method is to orient your palpating fingers horizontally, straddling
each spinous process. Keep the distance between your finger pads
constant as you slide them over the row of spinous processes. For
each spinous process find the transverse processes of the same ver­
tebra (see layer-by-layer palpation exercise in Volume 1) and check
Group Four:
the accuracy of the Rule of Threes. Expect some individual variation
Ignore the
from the rule. transverse
process; use
the ribs
instead.
nal plane. They can be palpated through the fibers of the
superior portion of the trapezius muscle. But progressively Figure 1.7 The Rule of Threes. The horizontal planes running through the
down the spine the transverse processes gradually angle transverse processes variously intersect the spinous processes depending
backwards, moving the respiratory axis of the ribs from rel­ on the group. In group one, the horizontal plane passing through the trans­
verse process corresponds to the tip of the spinous process of the same
atively coronal to a more sagittal orientation. This change
vertebra. In group two, the tip of the spinous process is halfway between
in orientation of the costotransverse joints partially the vertebra and the subjacent vertebra. In group three, the horizontal
accounts for the predominantly pump-handle movement of plane running through the transverse process intersects the tip of the spin­
the upper ribs and the predominantly bucket-handle move­ ous process of the vertebra above. Notice the unifacets for rib head artic­
ulation on vertebrae 1, 10, 11, 12, and the "absence" of transverse process­
ment of the lower ribs.
es on vertebrae 11 and 12.
The lumbar spinous processes are large, roughly rec­
tangular structures, about one inch on a side. The height
superior
of the lumbar vertebrae does not vary much - about 1.25 spinous process
articular
inches. However, the fifth lumbar spinous process is about
half the size of the others, because of the sharpness of the
lumbosacral angle.
The lumbar transverse processes are wide (Figures
1.3 and 1.8), and lie in the transverse planes which rest on
the superior corners of the spinous processes. Lines con­
necting the tips of the transverse processes on each side
form a truncated rhomboid figure with the side corners at
L3, the widest transverse processes (3 to 4 inches to each
side). (see Figure 9.3, Chapter 9)

Figure 1.8 Typical lumbar vertebra.

8 THE MUSCLE ENERGY MANUAL

Elements of Costal Cage Anatomy Table 1.8

Usually there are twelve pairs of ribs arising embryological­ In classical anatomy the ribs are grouped as follows:
ly from the vertebrae. Anatomic anomalies in the form of True Ribs Have individual costal cartilages linking
extra ribs, missing ribs, merged or bifid ribs are rare and, (ribs i- vi} them to the sternum-manubrium;

when present, are generally not a problem for manual ther­

False Ribs All connect to a single cartilage mass
apists aside from changing the rib count. (ribs vii- x} which contacts the sternum;

Only the upper ten pairs of ribs are linked to the ster­ Floating Ribs Have no costal cartilage except for small
num and/or manubrium by costal cartilages. The details (ribs xi & xii} pointed tips on the ribs.

of these linkages are clinically important, inasmuch as they

aftect segmental and rib mechanics. Thus, an examination
of these details will provide an explanation for how and
Table 1 C
why certain variations in the motion or position of these
Kinesiologic Unit Com�onents
parts can be used as indicators of dysfimction.
Vertebromanubrial T 1 2, ribs i & ii, disc, mm. & ligs.
Various groupings of the vertebra-rib-cartilage-ster­
_

Superior vertebro- T 2 3• ribs ii & iii, disc, mm. & ligs.

num complexes arise from classifYing them fi.mctionally and _

sternal
morphologically. classical anatomy, the ribs are
In
Inferior vertebro· T 3 7• ribs iii-vii, disc, mm. & ligs.
grouped as true, false, and floating (Table l.B);kinesio­
_

sternal
logic units are organized as shown in Table l.C; the cos­ Superior vertebro- T 7 _
10• ribs vii- ix, disc, mm. & ligs.
chondral
tovertebral relationship classification considers typical
Inferior vertebro- T10 11• rib x, disc, mm. & ligs.
and peculiar ribs and vertebrae . (Table l.D) _

chondral

Superior vertebral T11 12• rib xi, disc, mm. & ligs.
Kinesiologic Units of the Thorax
_

Inferior vertebral T12 L1, rib xii, disc, mm. & ligs.
Although the breathing movements of the ribs disturb ver­
_

tebral positions very little, movements of the thoracic ver­

a unit of thoracic ver­
tebrae move the ribs a lot. Thus,
tebral movement consists of more than the classical kine­
siologic unit: two vertebrae, an intervertebral disc, inter­
segmental ligaments and joint capsules, and the monoartic­
ular muscles of the segment. The ribs attached to the
two vertebrae are also an integral part of the kinesio­
logic unit. The kinesiologic unit of T1-T2 includes ribs i
and ii; the T8-T9 unit includes ribs viii and ix; the T11-T12
unit includes ribs xi. (See Table l.C) The ways in which
these components fit together into fi.mctioning mecha­
nisms varies significantly and importantly.
It is useful to divide the thorax into sections based on
anterior rib attachments: vertebromanubrial (ribs i and ii),
vertebrosternal (ribs ii - vii), vertebrochondral (ribs vii- x),
vertebral (ribs xi - xii).
Table 1.0
Typical Ribs (ii- ix} share the following characteristics:
• The rib head articulates with two adjacent vertebrae and
the intervertebral disc at superior and inferior demi­
facets;
• The rib neck articulates with the transverse process
of the vertebra with the same number;
• A rib angle is present for the attachment of the ilio­
costalis muscle;
• The rib has a curving body (the rib shaft) which
extends anteriorly to meet a costal cartilage where it
forms a synovial joint.
Peculiar Ribs (i, x, xi, xii} have:

• Rib heads articulating with unifacets;

Ribs and Vertebrae
• The digit "1" in their number.
The costovertebral relationships give rise to another classi­
fication which is more useful for manual therapists than the Typical Vertebrae (T2- T sJ have:
typical and peculiar ribs and typical
classical grouping:
• Two pairs of demifacets, one for its own ribs and
and atypical vertebrae. one for the inferior pair.
The second through the ninth ribs are all typical ribs,
Atypical Vertebrae have:
i.e., they are attached in front to cartilage, and in back they
are each attached to two vertebral bodies (their own and • One pair of unifacets for their ribs, except forT 1,
which has a pair of demifacets for the second ribs, and
the one superior to it) and to a transverse process of their
T9, which usually has only one pair of demifacets for
own vertebra. The head of each of these ribs has two the ninth ribs.
demifacet articular surfaces, not in the same plane, but
beveled superiorly and inferiorly. Between the demifacets is
a fibrous interarticular septum attached firmly to the
intervertebral disc. The two synovial demitacet joints,
above and below, share the interarticular septum as part of
 CHAPTER 1 � RELEVANT GROSS ANATOMY OF THE TRUNK 9

their capsules; this anchors the rib head to the two verte­
bral bodies.
With the exception of the first rib costal cartilage,
which forms a synchondrosis between the first rib and the
manubrium, all the vertebrosternal ribs (ii through vii)
have synovial joints between the osseous rib shafts and the
costal cartilages, which have synovial joints where they
meet the sternum. In one study, the first costochondral Internal intercostal
joint was found to have what appeared to be a
pseudoarthrosis (synovial) in six out of thirty cadavers
(Pettman, 1984). This was attributed to years of shoulder
girdle rigidity, requiring more costal mobility for respira­
tion.
Synovial costochondral joints are found on ribs ii
through x. Synovial chondrosternal joints are found on
the cartilages of ribs ii through vii; each second rib has two.
The cartilages of "false" ribs viii, ix, and x blend
together with the seventh costal cartilage. Each of these
false ribs is shorter than the one above it, and, of course,
the loss of length is at its anterior extremity where it meets
the cartilage. The anterior di�ergence of the cartilages of
the false ribs creates what is called the intercostal angle,
Lateral costotransverse ligament
which is usually greater than ninety degrees. In thin,
asthenic, ectomorphic body types the angle is more acute;
in endomorphic body types the angle is more obtuse. Figure 1.9 Muscular attachments and relations of second rib. The area

Although the second rib is included with the typical marked vertebral fascia behind the scalenus posterior insertion affords
attachment for the iliocostalis muscle. (From England, 1967. Reprinted
ribs, it has very unique features. Twice as long as the first
with the permission of the American Academy of Osteopathy. I
rib, it is sharply curved anteriorly from its tubercle, a part
of which articulates on the slightly concave costotransverse
pit of the second thoracic vertebra's transverse process,
which faces anteroinferiorly and slightly laterally.
The sharp curvature of the second rib makes its angle
less accessible to palpation. Consequently, the third is usu­
ally the highest rib which has an easily palpable rib angle.
While the second rib has demifacet spinal articulations,
which makes it a "typical" rib, its costal cartilage unique­
ly has demifacets for articulation with both the manubrium
and the body of the sternum.
In preteen children the second rib has only one facet
on the second thoracic vertebra. The ossification center for
the superior rib facet that articulates on the first thoracic
vertebra in adults appears at about age twelve or thirteen
Figure 1.10 Vertebromanubrial region; first and second rib relationships.
and develops to fusion during the teens. Notice the second rib demifacet articulations, front and back, and the
Muscles which attach to the second rib include the pec­ superior costotransverse ligament attaching rib i to C7. The superior
toralis major, but not the pectoralis minor, which passes costotransverse ligaments (S C-TI are often absent, but when they are

over it to attach to the third, fourth and fifth ribs. The first present, they clearly give C7 some influence on the first ribs.

and second digitations of the serratus anterior muscle

attach to a large tuberosity on its lateral surface, a promi­
nent feature of the second rib. Between that large serratus
tuberosity and the tubercle of the neck of the second rib,
the following muscles attach: scalenus posterior, levator
costae, iliocostalis cervicis and dorsi , and the serratus poste­
rior superior. On its internal edge are the attachments of
the internal and external intercostal muscles. (Figure 1.9)
10 THE MUSCLE E NE R G Y MANUAL

Figure 1.11 Typical costovertebral relationships in the

vertebrosternal region. Depicted are thoracic vertebrae 6, 7, and 8
and ribs vii and viii. Notice the prominent rib angle (11). Labels:
1. transverse process,
2. articular process,
3. zygapophysis,
4. anterior costotransverse ligaments,
5. costotransverse facets,
6. Posterior costotransverse ligaments,
1. superior costotransverse ligament,
8. spinous process,
9. costovertebral joint capsule and radiate ligaments,
10. costotransverse facets,
11. angle of rib vii,
12. demifacet for subjacent rib,
13. superior demifacet for rib viii,
14. inter-vertebral foramen,
11
15. vertebral body,
16. intervertebral disc,
17. pedicle,
18. pars interarticularis.

Figure 1.12 Typical costovertebral relation-

ships and ligaments in the vertebrosternal
region. Shown is the seventh thoracic verte­
bra and ribs. Notice the prominent rib angle(1).
2. Posterior costotransverse ligament,
3. Superior costotransverse ligament from the
transverse process of the vertebra above,
4. Anterior costotransverse ligament,
5. Intra-articular costovertebral ligament,
6. Capsular and radiate ligaments,
7. Superior articular process and facet,
8. Superior demifacet of rib vii for articulation
with the body ofT6.

Rib Cage Ligaments

Some ligaments of the rib cage have special interest for Counting Ribs Exercise
manual medicine practitioners, because they couple verte­
bral motion to costal motion. The middle costotrans­ With your partner supine. count the ribs. starting with the second rib.

verse ligaments allow some twisting of the rib necks as well Count them both anteriorly and laterally. Locate the second rib by

as some medial and lateral glide. placing your palm over the sternum and gently sliding the skin up and

Of the ligaments of the vertebral extremity the most down until you feel the transverse ridge of bone that is the sternal

interesting in terms of rib torsion is the superior costo­ angle. where the second rib cartilages attach to the sternum. This

transverse ligament. It passes from the transverse process palpation method is called palmar stereognosis.

of the vertebra above to the cranial border of the neck of With your partner prone. count the ribs from the bottom up,

the rib, and probably contributes to the torsion deforma­ starting with the twelfth rib. Find the twelfth ribs using your palmar

tion of the rib which occurs when the superior vertebra stereognosis on each side of the lower back. Use palmar stereogno­

rotates. sis to find the rib angles from the tenth rib up. These are the most

The superior costotransverse ligaments, especially posterior parts of the ribs. Where are the rib angles in relation to the

the anterior portion, link rotation movements of the supe­ transverse processes?

rior vertebra to the shafts of the subjacent ribs. (Figures

l.ll and 1.12)
 CHAPTER 1 �RELEVANT GROSS ANATOMY OF THE TRUNK 11

The rib shafts come from in front of the transverse

processes and run posteriorly and laterally before they bend
1
and curve anteriorly. Their most posterior portions are the
rib angles where the itiocostales muscles attach. Whereas
the typical thoracic vertebra features four dernifacets for
the diarthrodial articulation of rib heads, the atypical tho­
racks with the digit "1" in their number - T l> T 10, T ll,
and T 12 possess unifacets for the heads of their respective
-

ribs. (Figure 1.13) Because of the unifacet articulation of

the tenth ribs, the ninth thoracic vertebra has only two
demifacets for the ninth ribs, which also articulate on T8
demifacets. Thus the typical thoracic vertebrae are from T2
through T8. These anatomic details are relevant to the
coupled motions of the thoracic spine and rib cage.
Understanding coupled motions, in turn, is necessary for
understanding the diagnostic procedures applied to them.
The first ribs form part- of the vertebromanubrial
complex. Their attachment to the manubrium is unique.
Unlike the other costal cartilages, which have synovial
joints where they meet the rib and also where they meet the Figure 1.13 Atypical thoracic vertebrae (lateral view). 1. Unifacet for rib
head; 2. Inferior demifacet for subjacent rib; 3. Superior demifacet for
sternum, the first costal cartilages are synchondroses,
ninth rib- which also articulates on T8; 4. Costotransverse facet for rib
solid pieces of fibrocartilage uniting the first ribs to the
neck; 5. Inferior articular facet of T12, lumbar-type zygapophysis.
manubrium. The osseous portion of the first rib is small, Note: There are no costotransverse facets for the eleventh and twelfth
broad, and flat, and difficult to palpate. However, its car­ ribs, nor inferior demifacets on the ninth vertebral body.

tilages follow the movements of the first ribs reliably, and

can be easily palpated inferior to the medial one-fourth of
the clavicles. Both pump handle and bucket handle move­
ments can be evaluated from contacts on these cartilages.
Only the upper ten ribs have costotransverse joints.
The costotransverse articular pits on the transverse process­
es of the upper six or seven are very concave and face ante­
riorly and inferiorly. The pits on the transverse processes of
T8, T9, and T 10 are flat planes facing up and anterior, allow­
ing some posterior glide of the rib necks in inhalation
movements, similar to the caliper actions of the eleventh
and twelfth ribs.
"Backward and Upward," "Backward and Lateral," and
"Backward and Medial." The transition from cervical to
thoracic planes is not as abrupt as the thoracolumbar tran­
sition. The first two thoracic facets resemble cervical ver­
tebrae more than typical thoracics, at least in their orienta­
tion to the cardinal planes of the body. The facet orienta­
tion is due to the anterior inclination of the upper thoracic
kyphosis. This makes the planes of the facets less vertical
and more horizontal. Usually the twelfth thoracic vertebra
has thoracic facets superiorly and lumbar facets inferiorly, a
quick transition. (Figure 1.14)

Facet Variations
Anatomic variations in lumbar facets are frequent. About Figure 1.14

0
half the time the lumbosacral facets are nearly flat planes Zygapophyseal facet
plane orientations.
oriented closer to a coronal plane than to sagittal planes.
Cervical-type facets are
They show an oval configuration on A-P X-rays, in con­ between horizontal and
Cervical
tradistinction to the typical lumbar facet, which shows a lordosis
coronal; thoracic facets
vertical line because of its sagittal orientation. Lumbar are approximately coro­

facets are rarely flat planes, but are convex (inferior facets) nal; lumbar facets are
between sagittal and Thoracic
and concave (superior facets) surfaces, often with a very kyphosis
coronal, the superior
short radius of curvature. Asymmetric orientation of lower facets having a concave
(L5, L4) lumbar facets - zygapophyseal tropism - is fairly configuration. The infe­
common, and accompanies sacroiliac auricular asymmetry. rior facets of T12 are
lumbar-type facets.
Lumbar
Orientation of the Zygapophyseal Joints lordosis
The general scheme of orientation of the planes of the facet
joints has been reduced to a medical student mnemonic,
"BUbBLe BuM," where the pairs of upper case letters rep­
resent the planes of the superior facets of the cervical, tho­
racic, and lumbar vertebrae respectively, and stand for
12 THE MUSCLE ENERGY MANUAL
Normal Anteroposterior Spinal Curvatures
In average adult human anatomy the cervical lordosis
includes the first two thoracic vertebrae, making the cervi­
cothoracic junction at the T2_3 intervertebral joint, and
the lumbar lordosis includes the last two thoracics, T11 and
T12. There is individual variation in the segmental level of
this junction. This information is relevant because segmen­
tal dysfunctions occur more frequently at the junctional areas
of the spine and near the apices (middle portion) of the
spinal curves, probably resulting from gravitational and
inertial forces.
The spinal kyphosis, or primary curve, is a mild flex­
ion curve, the apex of which is approximately at T 7. It typ­
ically includes thoracic vertebrae 3 through 10. (See Figure
4.1, Volume L) This kyphotic curvature - of thoracics 3
through 10 and the sacrococcygeal segments - is some­
times referred to as the "primary" curve, in the sense that
it has been present since it was a part of the curled up fetus.
The lumbar and cervical curvatures are "secondary" inas­
much as they are acquired at later stages of maturation.
The thoracic kyphosis is the least supple region of the
spine, being restrained by the rib cage, and having relative­
ly thinner intervertebral discs. The mobility of a particular
segment is expressible as a ratio of disc thickness to verte­
bral body height. In the cervical spine the ratio is 1:2, lum­
bars 1:3, and thoracics 1:5, with the large ratio indicating
less mobility.
The term "middle thoracic" usually refers to segments
from T4 to T10, i.e., below the lowest attachment of the
longus cotli muscle and above the beginning of the lumbar
lordosis.
Abnormal Anteroposterior Spinal Curvatures
Abnormal curvatures are frequently observed during phys­
ical examination. Exaggerations of the normal anteroposte­
rior curvatures are called kyphosis (increased posterior
convexity), lordosis (increased posterior concavity), or
kypholordosis (both increased). A sharply angulated pos­
terior convexity is called a gibbous kyphosis and suggests
either traumatic compression fracture of a vertebra or
osteoporosis.
Of course, it is not possible to change structural spine
deformities with manipulation. But when treating a patient
with such deformity, changes in the manipulable parts of the
body that JVitl improve the adaptation to the deformity should
be made. A good adaptation is one that is least stressful and
most comfortable in the activities of daily living. The best
postural adaptation to structural asymmetry is the one
which minimizes effort and pain, maximizes mobility, and
optimizes proprioception.
Scoliosis
Scoliosis, or lateral curvature of the spine, comes in many
shapes - elongated "C" curves, which can be described as
"convex left," meaning "right sidebent," or "convex
right," meaning "left sidebent"; long, graceful "S" curves;
or multiple "S" curves. Although scoliosis is considered
an abnormal curvature, a slight scoliosis with the upper
thoracic spine mildly convex to the left is regarded by
anatomists as normal. More severe scoliosis may be either
structural (due to bony, ligamentous, or fascial deformity)
or functional (adaptation or compensation for postural or
other structural asymmetry). Most of the observed spinal
deformity in structural scoliosis is functional, i.e., adaptive.
Structural deformation of the rib cage is a natural conse­
quence of scoliosis of the thoracic spine (see Figures LIS-
1.16).
In the depicted example (Figure 1.15 ), the primary
scoliotic curve appears to be a right convexity in the mid­
thoracic (vertebrosternal) region with compensatory left
convex curvatures above and below it. However, the
extremely altered head position suggests that the primary
structural asymmetry might be in the upper neck, or even
the cranium (i.e., plagiocephaly). If observation is limited
to the median furrow (the line of spinous processes), the
degree of lateral deformity is deceptive, because the oblig­
atory rotation of the vertebral bodies brings the tips of the
spinous processes into better alignment than a spinal X-ray
of the vertebral bodies would show.
 CHAPTER I � RELEVANT GROSS ANATOMY OF THE TRUNK
Figure 1.15 Scoliosis. Scoliosis which disappears with seated flexion is
a functional adaptation to leg length asymmetry. When seen in seated
flexion it is adaptation to spinal asymmetry.
' t
t '
Figure 1.16 Deformation of the rib cage with scoliosis. When the thoracic
spine sidebands, the ribs on the concave side are brought closer together
and the ribs on the convex side are spread apart. Additionally, the
intersegmental rotation of the vertebral bodies alters the shape of the
demifacet articulations of the ribs, which tends to slightly rotate and torque
each pair of ribs in opposite directions. These deformities of the rib cage
are resisted by the thoracoabdominal diaphragm, with the result that later­
al fullness of the ribs on the convex side is minimized as the rib shafts bend.
This accounts for the sharp angle prominence of the posterior rib shafts, as
seen in the previous illustration. !Reprinted with permission, from Lee 0,
Manual Therapy for the Thorax. DOPC, 19941
13
A more precise term, rotoscoliosis, refers to the rotat­
ed component of sidebending curves. Figure 1.15 shows
the rotation deformity of thoracic scoliosis. If the patient
sits down, bends forward, and the rotoscoliosis disappears,
the deformity is an adaptation to leg inequality. The
extreme example in Figure 1.15 is more likely to be a pri­
mary structural thoracic scoliosis. The exaggerated defor­
mity is largely due to altered shape of the rib cage.
Ribs on the convex side of a scoliotic curve have sharp
bends at their angles, and their intercostal spaces are
stretched wide. The ribs on the concave side are pushed
together. Respiratory movements of the ribs will, there­
fore, have a greater amplitude on the convex side of the
chest. However, the reduced amplitude of the concave side
ribs does not constitute rib dysfunction, which is manifest­
ed as reduced duration of respiratory movement.
Intersegmental rotation has an effect on the shape of
ribs, regularly causing slight deformity in response to habit­
ual movements of the spine. Because of the elasticity of the
ribs, these slight deformations are immediately reversible.
However, if the deformity persists for any reason, the tra­
becular architecture of the rib is remodeled. The humping
up of rib angles is absolutely the most obvious feature of
scoliosis. An observable feature is that the A-P dimension
of the rib is foreshortened on the contralateral side of the
rotation as it bows out and elongates on the ipsilateral side
by bending at the rib angle.
Scoliosis alters the shape of the rib cage. Such remod­
eling of the ribs is a good example of Wolff's Law govern­
ing the arrangement of the collagen matrix of bone in
response to physical stresses on the piezoelectric collagen
and calcium apatite crystals of the bone. Sidebending
deformity of the spinal segments, whether it is due to struc­
tural asymmetry or due to adaptations, is inevitably associ­
ated with intersegmental rotation. W hile the sidebending
accounts for the crowding together of the ribs in the con­
cavities of the curves and the spreading apart of the ribs on
the convexities, the deformity of the ribs is primarily caused
by the intersegmental rotation of spinal segments.
14 THE MUSCLE ENERGY MANUAL

Figure 1.17 Sympathetic

chain ganglion. Three of
the left sympathetic chain
ganglia are seen lying
behind the prevertebral
fascia close to the heads
of ribs where they articu­
late with the vertebral
bodies and discs of the
spine.

Anatomy of the Sympathetic Nervous System

The sympathetic nervous system (SNS) is primarily motor,
although small unmyelinated "C" sensory nerves often
accompany its nerves. It is more widely distributed than
the parasympathetic nervous system, innervating sweat
glands, the smooth muscle in the walls of most blood ves­
sels, glands and viscera of the abdominopelvic cavity, arrec­
tor pili muscles of the skin hairs, the heart, the lungs, and
even the lymphatic capillaries throughout the body. Figure 1.18 General pattern of sympathetic innervation. Spinal nerve seg­
ments Tl through L2 from which the preganglionic sympathetic nerve
Nerve impulses in the SNS originate trom specific loca­
fibers to the internal organs, glands, erector pili, the arterial tree land
tions in the thoracic and lumbar spinal cord, and leave the through it the striated muscles) and some special sense organs arise.
spinal cord via pre-ganglionic nerves by traveling with the Notice that the first five thoracic segments supply sympathetic innervation
to everything above the diaphragm.
ventral nerve root a short distance before spearating from
it to make connections with post-ganglionic nerves in the
ganglionic chain (see Figure 1.17). These connections are
polysynaptic, resulting in amplification of the original
impulse often by a factor of 500 to 600 times. The ulti­
mate distribution of these post-synaptic impulses is depict­
ed in Figure 1.18. Small anatomic variations in these dis­
tribution patterns are frequent, and there is a lot of inter­
segmental overlapping in the ganglionated chain .
The SNS has a large repertoire of effects. Some of these
are detailed in Chapter 2 of The Muscle Energy Manual,
Volume One (q.v.).
 THE MUSCLE ENERGY MANUAL 15

CHAPTER 2

Normal Spinal Motion

nderstanding normal biomechanical function is basic

U
to assessment and treatment of dysfunctions of the
trunk. Everyone who treats the musculoskeletal sys­
tem needs a conceptual model of normal in his or her
mind. Regardless of how efficacy of treatment is measured clini­
cally, the outcomes are significantly influenced by the accuracy and
relevance of that model. A brief review of normal thoracic and
lumbar spinal motion will be provided, emphasizing the research­
based or empirical details that profoundly affect treatment out­
comes. For a comprehensive review of this topic, the reader is
referred to the works of authors such as Bogduk and Twomey
(1991), Kapandji (1974), Lee (1994), Nachemson (1985), Vleem­
ing, et al (1997), and White and Panjabi (1990).
As clinicians assessing segmental motion and utilizing MET in
the treatment of segmental dysfunction, it is important to consider
the following criteria:

• Changes in the bony position ( osteokinematics) of the supe­

rior vertebra relative to its subjacent vertebra, within a coordi­
nate system;
• Changes in the relationship of joint surfaces (arthrokine­
matics);
• The role the muscles play in the movement (kinesiology).

In the evaluation and treatment of joint dysfunction, these

terms or concepts fit into the MET paradigm as follows: In this chapter:

• The orthogonal coordinate system

• The dysfunctions MET addresses are arthrokinematic in
explained
nature;
• Biomechanics terms defined
• MET uses bony positions and relationships ( osteokine­
matics) to determine the presence of an arthrokinematic • Kinesiology of the trunk
dysfunction; • Vertebrovertebral mechanics

•In treating the arthrokinematic dysfunction, MET uses • Vertebrocostal mechanics

muscles - or employs kinesiology- to treat the dysfunction. • Lumbosacral mechanics
• Regional and segmental ranges of
The primary focus of this chapter is thoracic and lumbar verte­
motion
bral motion. We will discuss what moves the bones- i.e., muscles
or external forces pulling on the deep fascias of the body ( kinesi­
ology)- and how the bones move in relation to each other (kine­
matics). The incidental movement of the ribs secondary to verte­
bral motion will also be described.
16 THE MUSCLE ENERGY MANUAL

Figure 2.1 The right-handed orthogonal (90° angle) coordinate system adapted to clinical language. The three planes and the x, y, and z axes are
derived from the cardinal planes of the anatomic position. In osteokinematics the planes and axes belong to the individual vertebra, and their orienta­
tion moves with the vertebra when it moves. In the functional spinal unit (FSU), the superior vertebra moves in relation to these planes and axes.

Although principles of kinesiology and kinematics in
regard to cervical motion were addressed in Volume I, this
volume will take a look at these principles as they apply to
the thoracic and lumbar spine. There are distinct ditlerences
in the kinesiology, osteokinematics, and arthrokinematics of
the thoracic and lumbar spinal segments as compared with
the cervicals. One significant difference between cervical seg­
ments and the rest of the spine (to L5-S1) is that the rota­
tion and side bending coupling rules tor the cervical spine do
not apply to the thoracic and lumbar spine. For example,
physiologic rotation and sidebending are coupled ipsilater­
ally in the functional spinal units (FSUs) from C2_3 through
T 2_3. In contrast, from T3_4 through L5-Sl> physiologic rota­
tion and sidebending are variously coupled depending on the
location of the FSU, and which plane of motion comes first.
Understanding and visualizing the spatial orientation of
segmental motion and position is greatly facilitated by famil­
iarity with the coordinate system applied to biomechanics.
(Figure 2.1) Addit. ionally, correct use of terms that describe
both normal and impaired movements of the spinal joints,
vertebrae, and regions of the spine is extremely important.
Clarity of communication and comprehension depends on
it. As much as possible this text will avoid the mathemati­
cal terms of biomechanics, preferring to use conventional
clinical language. Some biomechanics concepts cannot be
avoided, however, since they succinctly clarity the scientific
basis of MET diagnosis. (Figure 2.1 and Table 2.A)
 CHAPTER 2 � BIOMECHANICS OF NORMAL SPINAL MOTION 17

Table2.A

Definitions of Biomechanics and Clinical Terms Describing Joint Motions

Biomechanics Biomechanics is the scientific study of normal and abnormal mechanical and biological aspects of muscles, joints, lig­
aments, and related tissues using the application of mechanical laws. It incorporates the disciplines of anatomy, bio­
chemistry, biophysics, physiology, kinetics, kinematics, kinesiology, and materials science.

Kinetics Kinetics studies the effects of external forces on the motion of bodies of a given mass. Moving bones on bones
requires an external force provided by muscles (kinesiology) or inertial forces provided by gravity and mass in motion
(kinetics), usually operating through the planes of contiguous deep fascias of the body. The muscles may belong to
the patient (active motion) or the clinician (passive motion).

Osteokinematics Kinematics is the branch of mechanics that studies the motion of a body or a system of bodies without considering
its mass or the forces acting on it. Movement of a vertebra relative to the subjacent bone (vertebra or sacrum) is the
subject of Osteokinematics (see Fig. 2.1). Common osteokinematic terms are derived from the six actions of mus­
cles: flexion, extension, right rotation, left rotation, right sidebending, and left sidebending (primary movements). All
these terms refer to rotation (a biomechanics term) around an x (right to left), y (top to bottom), or z (back to front)
axis. These account for only 3 of the 6 degrees of freedom familiar to biomechanics. A less common term, transla­
tion (translatory, adj.), is used to describe linear movements, for which there are no muscles (with one exception, the
opposite of distraction- compression, which may be produced by the co-contraction of two or more muscles).
Translatory movement is produced passively or as an adventitious coupled movement secondary to a primary move­
ment. For example, a flexing vertebra automatically translates anteriorly. Translations account for the other three
degrees of freedom.

Arthrokinematics Arthrokinematics concerns itself with how joint surfaces move on each other. The inferior or proximal bone is consid­
ered to be the stationary member of the pair. Common terms are spin (pivot, y axis rotation), compression (com­
paction), sliding gliding, translation, and distraction (gapping, angular gapping, peeling). Very few joint surfaces are
perfectly flat planes; one bone is concave, the other convex. Bending of the joint is described osteokinematically as
rotation around an instantaneous axis of rotation liAR), which is located somewhere in the convex bone and tends
to shift about, depending on the contour of the joint surfaces. The actual intra-articular event is a gliding, or sliding
motion. The linear displacement of the bone may be described as a translation.

Coordinate In Figure 2.1 enough of the common osteokinematic terms are defined with labeled arrows that their opposites (the
System negative values in the coordinate system)- extension, right rotation and sidebending- can be correctly surmised.
When parts of the body move out of the anatomical position, the moved parts take their own orthogonal coordinate
system with them. For example, if the body twists, so that the upper part is facing to the right and the lower part is
still in the anatomical position, the sagittal plane of the upper part turns with the rotated torso. Bending the upper
part forward from its rotated position in its sagittal plane would still be called "flexion" and not "sidebending."

Axis An axis is a stationary imaginary straight line. It is like an axle, upon which a wheel rotates; when the wheel rotates,
the axle does not move.

Coupled Motion Coupling refers to motion in which rotation or translation of a body around or along one axis is consistently combined
or compounded with simultaneous rotation or translation on another axis.

Degrees of One degree of freedom is motion back and forth in a straight line or rotation back and forth around a particular axis. A
Freedom vertebra has six degrees of freedom, translations and rotations on each of three orthogonal axes.

Kinesiology Kinesiology is the study of the actions of muscles on bones and joints.

Functional The functional spinal unit (motion segment) consists of two adjacent vertebrae (or the sacrum and a vertebra) and
Spinal Unit their shared ligaments, monoarticular muscles, and joints. Motion is always described in terms relative to the coordi­
!FSUJ nate system of the subjacent vertebra (or sacrum). See Figure 2.1.

Extension Segmental extension is backward bending from the anatomical position, or, more precisely, negative rotary move­
ment in a sagittal plane around a transverse (x) axis so that its superior surface moves posteriorly relative to the bone
inferior to it.

Flexion Segmental flexion is forward bending from the anatomical position, mathematically defined as positive rotary move­
ment in a sagittal plane around an x axis. The x axis for segmental flexion/extension is referred to as an instanta­
neous axis because it changes position in different ranges of the motion. The transverse processes move primarily in
a coronal plane parallel with the inferior zygapophyseal facet.

Rotation In physics rotation may occur around any axis, regardless of the orientation of the axis. In human anatomy, however,
rotation on a y-axis moves the parts in a transverse plane, the anterior parts moving to the left or right, customarily
known as Hrotation. n If a bone rotates on an x-axis, all its parts move in circular paths in sagittal planes, like the
wheels on a car. The x-axis is stationary. In general, we call these x-axis motions flexion (superior part forward) and
extension (superior part backward). Z- axis rotations are called sidebending; they occur in a coronal plane, the supe­
rior parts going left or right, or, for the limbs, in (adduction) or out (abduction).

Sidebending Sidebending, or lateral flexion, or sideflexion, is a rotary movement in a coronal plane on a z-axis, positive to the left
and negative to the right. Left or right refers to the direction of movement of the superior surface of the superior
bone on the inferior bone of the FSU.

Translation Linear movement in a plane is called "translation." Strictly speaking, only rectilinear movements should be called
translations, but curvilinear movements also may be called translations, especially if the axis of rotation is far enough
away.
18 THE MUSCLE ENERGY MANUAL
Longus Colli:
'llo:o�·��-- Superior
oblique portion
Scalenes: •r-�1---Monoarticular
medial portion
�=b?l�--::;::;--- lnferior
UJ."""'"""" oblique
portion
Figure 2.2 Anterior view of the vector line origins and insertions of the
left longus colli and the right scalene muscles. Each has three divisions.
The medial division of the longus calli contains some monoarticular
fibers.
J(inesiology of the Trunk
A lighthearted tradition in Muscle Energy tutorials holds
that there are only six muscles in the body- flexors, exten­
ders, right and leti: sidebenders, and right and left rotators.
Any of these muscles may have various lengths, from
monoarticular muscles crossing only one joint- the short
intersegmental muscles- to polyarticular muscles or inter­
regional muscles spanning several joints, or even an entire
region. AJthough both mono- and poly articular muscles
play a role in the normal spinal motion and the body's
overall response to dy sfunction- and therefore should not
be neglected in the clinician's overall evaluation- the MET
paradigm gives special emphasis to the role of the monoar­
ticular muscles.
Monoarticular muscles serve several functional roles in
defining the nature and specificity of segmental motion,
both normal and abnormal. The types of functions vary in
complexity, but, in general, these muscles establish the
appropriate conditions for a given movement by stabilizing
the segment and by initiating the direction of movement.
These small muscles have a rich proprioceptive sensory and
motor nerve supply. Some kinesiologists have suggested
that the monoarticular muscles of the vertebral column are
too small and too weak to move something as large as a ver­
tebra, and that they primarily serve a proprioceptive func­
tion by fine-tuning the position of the vertebra as it is being
acted on by muscles of greater strength and leverage. This
neuro-reflex mechanism serves to control the movements
and position of individual intervertebral joints so that the
spine can move in a coordinated fashion and resist the com­
pressive forces to which it is subjected without buckling.
Rotatores <r"---7!!!
Muscles
Figure 2.3 The deepest layer of sacrospinalis muscles: rotatores and
multifidi. Rotatores can be palpated in the intermuscular sulcus separat­
ing spinalis from longissimus in the thoracic area, but only when they are
in spasm.
Kinesiologic Relationship of Cervicals to Thorax
The cervical region is connected to the thorax by muscles
and fascia. The deep cervical fascia arising from the base of
the skull becomes the st-t-perior mediastinum, the thoracic
prevertebral fascia, and, where it crosses over and under the
collar bones, the clavipectoral fascia. The planes of back
muscle fascia reach down fi·om the posterior occiput to the
pelvis.
The complex posterior spinal muscles not only extend
the cervicals, but also straighten the thoracic spine against
the force of gravity. Anteriorly, the longus calli muscle, a
flexor, arises from the anterior bodies of each of the upper
three thoracic segments. From there the oblique portions
of the muscle ascend to the anterior tubercles of cervicals
six, and then five, with no intermediate insertions. The
medial portion of the longus colli, however, attaches to the
anterior body of each vertebra, C3 through T3, and to the
anterior arch of the axis vertebra. The monoarticular fibers
within this portion of the muscle are in a position to flex an
individual vertebra, or to resist its extension (see Figure
2.2).
The scalenes, through their attachments to the upper
two ribs, lift the rib cage in forced inhalation, as well as pro­
vide lateral stability to the neck.
 CHAPTER 2
Kinesiologic Relationship of the Thorax to the
Lumbars and Beyond
The lower thorax is connected to the lumbars by the
diaphragm, the sacrospinalis (extender) muscles, and the
quadratus lumborum (sidebenders). The most superior
fibers of the psoas muscle, originating above the diaphragm,
are segmental flexors of theT 12- L1 articulation. The fas­
cial continuities run from the diaphragm through the
quadratus lumborum and abdominal walls to the iliac
crests, and from the mediastinum through the psoas muscle
to the femur. The lumbodorsal fascia is mechanically linked
to the fibulas through the sacrotuberous ligament, gluteal
fascia ,fascia lata, and iliotibial band (Vleeming et al, 1995;
van Wingerden et al, 1993).
Kinesiology of Flexion and Extension Movements
Muscle activity in flexion/extension movements of the
spine varies depending on whether the movements are
active, opposed or assisted by gravity, or passive. Flexing
the spine from a standing or seated position is assisted by
gravity and requires primarily eccentric isotonic contrac­
tions of the extensor muscles. Flexion initiated from a
supine position requires strong isotonic concentric contrac­
tions of large trunk flexors. Muscle activity is minimal with
slow passive movement, but rapid passive movement can
stimulate myotatic reflexes and increase muscle tone.
Rotatores as Extenders
The rotatores muscles are not positioned to cause pure hor­
izontal rotation of a vertebra. Just like the other transver­
sospinal muscles - multifidi and semispinalis- there is a
strong vertical component in their contraction, making
them extenders as well as rotators. In order for the trans­
versospinal muscles (e.g., rotatores, multifidi) to produce
axial rotation of an individual vertebra, their extension
action must be opposed by a co-contraction of flexor mus­
cles. Obviously, human beings, without appropriate train­
ing, are not coordinated to perform axial rotation of indi­
vidual vertebrae.
The abdominal oblique muscles are the primary rota­
tors of the lumbar vertebrae, even though they do not
attach to them. Transversus abdominis, a lumbar stabiliz­
er, may have segmental control of individual lumbar verte­
brae. In addition to being rotators, the abdominal obliques
are strong flexors of the lumbars. The transversospinal
muscles in the lumbar region, especially the multifidi, may
co-contract, cancelling the flexion and allowing pure axial
rotation of the lumbar segment. Rotatores, multifidi, and
semispinalis thoracis may play a similar role, regulating spe­
cific thoracic vertebrae as more powerful rotational forces
act upon the vertebra. Even the segmentally specific rota­
tores and multifidi must be opposed by flexor muscle
action, possibly of rectus abdominis, but more likely by the
segmental stabilization of segmented portions of transver­
sus abdominis (Richardson, et at, 1999), if it is to produce
axial rotation without extension.
� BIOMECHANICS OF NORMAL SPINAL MOTION 19
There are no rotatores muscles in the cervical or lum­
bar regions of the spine, or at least their presence is irregu­
lar and variable. However, there are eleven pairs of well­
developed rotatores muscles in the thoracic spine. Clearly
other transversospinal muscles perform the task of rotating
individual vertebrae on each other in the cervical and lum­
bar regions.
Bogduk andTwomey ( 1991) have suggested that the
sacrospinalis muscles should be described from above
down, instead of the anat?mists' convention of describing
them from the bottom up, in order that intersegmental
biomechanics will be better understood, considering the
patterns of their nerve supply. For example, all the fascicles
of multifidi arising from the spinous process of a given ver­
tebra are innervated by the medial branch of the dorsal
ramus which issues from below that vertebra. Thus, mus­
cles acting on a specific vertebral segment are innervated by
the nerve of that segment. Although they are polyarticu­
lar, the multifidi are in a position to move individual ver­
tebral segments. Their principal role is segmental stabiliza­
tion of the lumbar spine.
The thoracic region, as a whole, is flexed by the action
of anterior trunk muscles, principally abdominals, pec­
torals, and intercostals. Flexion action also is augmented
by inhalation. Except for the first, second, and twelfth tho­
racic segments, there are no prevertebral flexor muscles
containing monoarticular fibers capable of flexing
individ­
ual vertebral segments. This anatomic fact does not in any
way compromise, empirically, the effectiveness of Muscle
Energy treatment of FRS dysfunction ofT3 throughT 11,
for reasons discussed below.
To understand localized segmental flexion, it is worth
noting that all spinal flexors have both monoarticular
(short) and polyarticular (long) extender antagonists.
Unlike the monoarticular flexors, the monoarticular exten­
ders are present for all of the vertebral segments, principal­
ly as rotatores and multifidi muscles. Active flexion local­
ized to a specific FSU in this region is clearly not the result
of monoarticular muscle contraction, but, presumably, the
result of the actions of the more proprioceptively adept
antagonist monoarticular extenders controlling the move­
ment. These small extender muscles serve to resist and
control the actions of the polyarticular flexors, having the
potential to make their net kinetic effect more specific to an
individual segment. The long extensors are primarily the
sacrospinalis group of muscles. Interspinous and inter­
transversarii muscles are absent in the T 3-T10 region,
replaced by ligaments.
Flexion against an unyielding counterforce can be a
light effort involving primarily the few monoarticular flex­
ors of the thoracic spine with corresponding inhibition of
the monoarticular extenders, or hard efforts involving con­
traction of the more powerful polyarticular muscles. Light
force isometric contractions are commonly used in Muscle
Energy treatments of segmental restrictions.
20 THE MUSCLE ENERGY MANUAL
T2-3 FSU Flexed
T2-3 FSU Extended
Figure 2.4 Thoracics 2 on 3- the T2 Functional Spinal Unit IFSU)- repre­
sent sagittal motion of all thoracic intervertebral joints. Degrees of flexion
and extension have been slightly exaggerated.
Biomechanics of Segmental Spinal Flexion and
Extension (x-axis motion)
All thoracic and lumbar segments flex and extend similarly,
with slight variations in stitfness. See Figure 2.4 and Table
2.A. With flexion the two spinous processes move apart in
the sagittal plane. In pure flexion/extension movements
the transverse processes move parallel to the interior zyg­
apophyseal facets of the superior vertebra moving on the
subjacent vertebra. The intervertebral disc becomes thinner
in front and thicker in back. The body of the superior ver­
tebra translates slightly anteriorly. The instantaneous trans­
verse axis of this sagittal plane motion is variable, but lies
somewhere within the lower vertebra (Bogduk & Twomey,
1991).
Regional Ranges of Sagittal Motion
The range of flexion to extension tor the whole thoracic
spine in very supple contortionists is about 70 angular
degrees. The average range is about 60° and progressive­
ly diminishes with age. The five lumbar segments, taken
together, average about 77° of sagittal motion, with the
upper segments contributing relatively less than the middle
segments (Bogduk & Twomey, 1991). See Table 2.A. The
sagittal motion of the sacrum permitted by the sacroiliac
joints is quite variable. In young women Kottke (1941)
measured changes in pelvisacral angles of 0° to 12.5°
(average 7.5°). The coccyx segments are rather rigid,
except in late pregnancy.
Influence of the Ribs on Vertebral Motion
The attachment of ribs to the thoracic vertebral column
significantly stiftens the motion characteristics of thoracic
segments, primarily due to the costovertebral and costo­
transverse ligaments. X-axis (sagittal plane) motions are
most constrained in the upper thoracic spine (vertebra­
manubrial and vertebrosternal segments), where the verte­
brae are linked directly to the sternum and/or the
manubrium by ribs and costal cartilages. These motions
are somewhat freer for the tenth (vertebrochondral seg­
ment), eleventh, and twelfth (vertebroabdominal seg­
ments), due to the absence of costal cartilages, and the uni­
facet rib articulations of these vertebrae.
Zygapophyseal Arthrokinematics
With flexion and extension the zygapophyseal facets slide
up and down on each other. The inferior facets of the flex­
ing superior vertebra move mperiorly and a11teriorly in rela­
tion to the superior facets of the lower vertebra, slightly
gapping the inferior margin of the zygapophyseal joint. See
Fig. 2.4. Of course, extension is the reverse. Below T 3 the
facets slide on each other loosely, without impinging. Thus,
neutral sidebending and rotation is not modified by facet
impingement, except possibly at the extremes of flexion or
extension. When facet surfaces are pushed together, the
point of impingement becomes a pivot for segmental
movement. This explains the behavior of non-neutral seg­
mental dysfunction.
Arthrokinematics of the Intervertebral Disc
When a vertebral body translates anteriorly with flexion,
the posterior fibers of the annulus fibrosus become more
vertically oriented as that portion of the annulus tenses,
while the anterior annulus compresses, its fibers becoming
more horizontal. The anterior translation causes a shear
strain deformity of the intervertebral disc. These events,
contrary to conventional wisdom, press the nucleus pulpo­
sus anteriorly into the yielding anterior annulus. The con­
ventional view of this mechanism sees the nucleus being
squirted backward like a watermelon seed when the seg­
ment is flexed, accounting tor posterior ruptures of the
annulus. The tendency of the nucleus to be displaced pos­
teriorly by flexion is the natural consequence of vertical
compression on the disc combined witl1 the angulation of
the vertebral body surfaces. However, the tensing fibers of
the posterior annulus oppose this posterior motion of the
nucleus. The net effect of these opposing forces is proba­
bly central stabilization of the nucleus. 1f one considers the
alternative mechanism, it appears more likely that annulus
rupture occurs during beginning extension, when the
"squirting" compressive force is combined with the tensing
of the anterior annulus.
 CHAPTER 2 -b- BIOMECHANICS OF NORMAL SPINAL MOTION 21

le Tension

I
I
I
I I
�'

... - ....
... '
,
'
I \
I '
I
I I

•,

'
I '
'
I '
\
' - '
' , �

' - --
...,
... ... -I
I
I I

Figure 2.5 Counternutating sacrum with lumbar hyperflexion. The base I I

_ ...
of the sacrum moves up and back following the arc of the auricular joint '
I
surface. I

.
..
. ...
.,.
Lumbosacral Flexion/Extension \
, ,
'

When the fifth lumbar flexes on the sacrum, the lum­ ,' , � -, '

bosacral angle changes just as the angles change between

'
\ ,
individual lumbar vertebrae. The lumbosacral angle, in this ' ' \ ,
;
I
instance, is a lateral radiographic measurement of the angu­ ,
... , �-'· ,._''
I , '

lar degrees between lines drawn across the base of the I ' '
'
I
sacrum and across the top of the fifth lumbar. This should
- - '
not be confused with another radiogrammetric technique,
,
'
also called lumbosacral angle, which measures the angle ..... - ... ...
-
;

- ;
-
between a vertical line and a line drawn on the base of the
-
- ,

.... .... ... - ,

sacrum, with the patient standing posturally erect, arms

crossed, "holding the collar" (Grant, 1961).
Sacroiliac Flexion/Extension
Changes in the pelvisacral angle accurately measure sacroil­
iac flexion-extension motions (Mitchell & Pruzzo, 1971).
This angle is between a line drawn from ASIS to PSIS and
a line drawn on the sacrum.
technique is ±0.1 degree.
been used to study how the sacrum gets from hyperflexed
position to hyperextended position, but only the total
quantity of the change.
sacrum does not move at a uniform velocity, and may, at
times, counternutate (reverse its direction of nutation while
the trunk continues to bend in the same direction). This
would account for the posterior movement of the PSIS
sometimes seen on the side of positive standing or seated
flexion tests. The mechanism of this paradoxical observa­
tion can be explained hypothetically.
The standard error of this
So far this technique has not
Empirically, it appears that the
Figure 2.6 The counternutation hypothesis in reverse: anterior nutation
of the sacral base with lumbar hyperextension. This reverse counternu­
tation probably occurs more commonly than its spinal flexion counterpart.
As the trunk bends forward, tension progressively
increases in the erector spinae muscles, eventually reaching
a level of tension sufficient to draw the sacrum cephalad
(after it has nutated slightly forward, presumably on its
middle transverse axis, to parallel the forward bending of
the trunk). In order to move cephalad, the sacrum must
slide up the short arm of the auricular joint surface, which
directs the base of the sacrum posteriorly as it rotates
around the superior transverse axis. In tl1c positive flexion
test the sacrum docs this motion on the normal side, the
restricted ilium following the sacrum as its base goes pos­
teriorly. (For a more detailed discussion, sec Volume 3, The
Muscle Energy Manual.)
22 THE MUSCLE ENERGY MANUAL
A "reverse" counternutation may also occur at the
extreme of backward bending of the trunk. No muscular
tension hypothesis has been suggested for this phenome­
non. That it occurs is suggested by the clinical history of
certain low back injuries. In the rare instances of bilateral
flexed sacrum dysfunction, a distressingly painful condi­
tion, patients usually describe the injury as happening when
they were catching a heavy load with their upstretched
hands while standing in a backward-bent posture. When
the dysfunction does occur, it must be the result of gravi­
tational leverage force mechanics on the sacral base and
sacroiliac ligament structures. See Figure 2.5.
Biomechanics of Segmental Spinal Axial
Rotations (y-axis motion)
In terms of segmental mechanics, rotation can be defined
as a turning motion of a vertebral body occurring around a
vertical axis. Rotation can be described as left rotation or
right rotation. It is important to remember that, conven­
tionally, the left/right descriptors are based on the direc­
tion of movement of any point on the anterior surface of
the vertebral body, using the subjacent vertebra as the basis
for comparison. [Note: Colloquial conventions may be
encountered in which the movement of the spinous process
is used to define the direction of vertebral rotation. This
maverick terminology should be discouraged in the interest
of clarity.]
Vertebromanubrial segment: T1-T2
The biomechanics of axial rotation of the cervical spine is
discussed in Volume 1. Recall the inclusion of flexion and
extension components of the ipsilaterally coupled
sidebending and rotation (Volume 1, Chapter 7). Because
of the forward-bent configuration of the thoracic kyphosis,
the first (and second) thoracic vertebra(e) face(s) anterior­
ly and inferiorly, inclining they-axis forward to an angle of
30° to 45°. The plane of its facets is consistent with the
anterior inclination of its axial rotationy-axis. AsT 1 rotates
and sidebends to the right, for example, either its right
zygapophysis slides down and back or the left zygapophysis
slides up and forward. The angle of forward inclination of
the upper thoracic spine has considerable individual varia­
tion. In an individual with a very straight spine it may be
inclined forward from the coronal plane 20° to 30°.
extreme kyphosis the plane of the facets may be nearly hor­
izontal.
Lee ( 1994) comments as tallows on the coupling of
axial rotation and sidebending of the first two thoracic ver­
tebrae:
"In the vertebromanubrial region, C7-T1 and T1-T2 follow the
same pattern of motion coupling as the mid cervical spine when
the head rotates. Rotation is coupled with ipsilateral sideflexion
of the superior vertebra."
The "same-side" rotation-sidebending coupling of the first
two thoracic FSUs occurs regardless of where the joint is in
its x-axis (flexion-extension) range and regardless of
whether motion is initiated as y-axis (rotation) or z-axis
(sidebending) motion. As in the cer vical spine, the weight­
bearing function of the zygapophyses precludes neutral
(facets not engaged) intervertebral biomechanics, unless
passive longitudinal distraction is first applied. The weight­
bearing function is, in part, due to the dorsal kyphosis
which puts the plane of the c7-T I zygapophyses close to
horizontal and theT1-T2 zygapophyses close to 45°.
Costal Cage Deformation with Vertebromanubrial
Rotation
With any amount of right rotation ofTl> the right first rib
is pushed back by the costovertebral unitacet and pulled
back by the posterior costotransverse ligaments, or the left rib
is pushed torward by the transverse process. The first costal
cartilages (between rib i and the manubrium) undergo
slight elastic deformation to allow the ribs to move in this
manner. Unlike the remainder of the costal cartilages,
which are attached to their ribs and to the sternum (as tar
down as rib vii) by synovial diarthroses, the first one con­
stitutes a synchondrosis joint linking the first rib and the
manubrium in a somewhat more stable relationship. The
manubrium itself may rotate a small amount on the body of
the sternum at the sternal angle whenT1 rotates.
If the ribs abnormally remain in this state over an
extended period (months or years), the costal cartilage is
remolded, causing a large one-sided intraclavicular lump,
4cm x Scm, on the anterior chest, which persists even after
normalization of biomechanics of the vertebromanubrial
segment. These bumps have been observed to regress to
normal configuration over a period of two to tour years in
patients receiving continuous maintenance care with man­
ual therapy intervention when appropriate.
Axial Rotation ofVertebrosternal Segments: T2-T7
Kapandji ( 1974) describes axial rotation of the thoracic ver­
tebral column succinctly:
"The mechanism of axial rotation at thoracic level ditTers from that
seen at lumbar level. In fact (Fig.2.7), the joints between the artic­
ular processes have a completely ditlerent orientation. The profile
of the interspace also corresponds to the mrface of a cylinder bttt the
cmtre of this cylinde1· lies 1mwe or less at the centre of each vertebral
body. When one vertebra rotates on another, the articular facets of
the articular processes slide relative to each other and this leads to
In rotation of a vertebral body relative to another about this common
axis. This is followed by rotation and twisting of the intervertebral
disc and not by shearing movements of the disc as in the lumbar
region. This rotation and twisting of the disc has a greater range of
movement, especially as the elementary rotation of a thoracic verte­
bra is at least three times that of a lumbar vertebra.
"However, this rotation would be greater if the thoracic column
was not intimately connected with the bony thorax. In fact, ar1y
moJiemmt at each level uf the colttmn ittduces a similar muvemmt in
the corresponding ribs but the sliding of a rib pair on the underlying
pair is limited by the presmce of the sterrmm to which each .rib is
attached by a costal cartilage. Therefore, rotation of a vertebra will
lead to distortion of the corresponding rib pair owing to the elas·
ticity of the rib, especially of its cartilage.
 CHAPTER
Figure 2.7 Right axial rotation of the first on the second thoracic vertebra.
The y-axis !black dot) passes through both vertebral bodies. The superior
facets face backward.
Figure 2.8 Right axial rotation is automatically coupled with right
sidebending for the first two thoracic FSUs. The ipsilateral coupling
occurs for the same reason as it does in the cervical spine. The above FSU
appears to be flexed, but it could do the same rotation/sidebending by
extending.
"During this movement the sternum is subject to shearing
forces and it comes to lie obliquely superoinferiorly so as to follow
the rotation of the vertebral bodies. This induced obliquity of the
sternum is very small and cannot be shown clinically; radiological­
ly it is difficult to demonstrate because of superimposition of mul­
tiple planes.
"The mechanical resistance of the thorax therefore plays a role
in limiting appreciably the range of movement of the thoracic col­
umn. When the thorax is still flexible, as in the young, the move­
ments of the thoracic column have a considerable range but with
age the costal cartilages ossifY and this reduces the chondrocostal
elasticity. As a result, in the aged the thorax is almost rigid and
movement is correspondingly reduced."
When a typical thoracic vertebra rotates, its y-axis, the ver­
tical one, passes through a point near the center of the ver­
tebral body. A circle whose radius is the distance from that
center point to a zygapophyseal facet joint will pass
through both facet joints and approximately fit the con­
tour of the articular surfaces of the facets. Thus, vertebral
rotation causes medial and lateral translation of the verte­
bra's inferior facets moving in an arc on the superior facets
of the vertebra below.
2 --& BIOMECHANICS OF NORMAL SPINAL MOTION 23
Lee Hypothesis
Lee ( 1994) suggests the following clinical hypothesis to
account for rotation and sidebending coupling:
"During right rotation of the trunk the following biomechanics are
proposed. The superior vertebra rotates to the right and translates
to the left. Right rotation of the superior body 'pulls' the superior
aspect of the head of the [subjacent?, Ed.]left rib forward at the
costovertebral joint inducing anterior rotation at the neck of the left
rib (superior glide at the left costotransverse joint) and 'pushes' the
superior aspect of the right rib backward, inducing posterior rota­
tion of the neck of the right rib (inferior glide at the right costo­
transverse joint)." {Editor)s notes: Since the axis of rotation is in the
center of the vertebral body, the mtire nettral a1·ch and the posterior
part of the vertebral body can be said to be "translating» to the left i1J
an arc. Also, «sttperior glide at the left costotransverse joint» is not
eqttivalent to mperior translation, 1vhich is possible only for the 8th,
9th, and I Oth costotransverse joints JVhich permit a posterosttperior
glide of the rib.}
To account for the empirical observation that axial
rotation of the upper thoracic vertebrae is coupled to ipsi­
lateral sidebending, Lee offers the following:
"When the limit of this horizontal translation is reached, both the
costovertebral and the costotransverse ligaments are tensed.
Stability of the ribs both anteriorly and posteriorly is required for
the following motion to occur. Further right rotation of the supe­
rior vertebra occurs as the superior vertebral body tilts to the right
(glides superiorly along the left superior costovertebral joint and
inferiorly along the right superior costovertebral joint). This tilt
causes right sideflexion of the superior vertebra during right rota­
tion of the midthoracic segment."
Lee's biomechanical hypothesis makes sense by assum­
ing the involved rib being discussed is the rib subjacent to
the rotating thoracic vertebra, e.g., the eighth ribs and a
rotating seventh thoracic vertebra. The vertebromanubrial
(T 1- T2) axial rotation coupled to ipsilateral sidebending has
already been accounted for. However, the above descrip­
tion is consistent with T 1 and second rib biomechanics.
With extreme rotation the superior costovertebral facets of
the second ribs are analogous to the cervical uncovertebral
joints, which permit a gliding action of the vertebral bod­
ies consistent with the zygapophyseal motion.
If Lee's hypothesis is in fact a description of a rotating
vertebra in the vertebrosternal region (Tr T7) and its sub­
jacent ribs (T 5 and the sixth ribs, for example), the expla­
nation works. As T 5 rotates to the right, its left inferior
demifacet (on the superior aspect of the left sixth rib)
moves anterolaterally. This causes anterior rotation of the
neck of the left sixth rib, which spins and translates slightly
laterally on the left transverse process of T6, the left sixth
rib costovertebral radiate and posterior costotransverse lig­
aments tensing and eventually resisting further rotation of
T5. If T5 is to rotate further to the right, it must, as Lee
suggests, slide its left inferior demifacet up (superior) on
the (sixth) rib head, which becomes analogous to a cervical
uncovertebral joint (see Volume 1 ), coupling right side­
bending with right rotation, but only at the end of extreme
axial rotation. This corresponds with clinical observation.
24 THE MUSCLE ENERGY MANUAL

Mechanism of Rib Torque

Simultaneously, the right inferior demifacet of T5 moves
posteriorly and medially, rotating the neck of the right sixth
rib posteriorly. If the ribs were unattached anteriorly, the
rotations of the necks of the ribs would result in the lefi:
sixth rib depressing anteriorly, as in exhalation, and the
right sixth rib elevating anteriorly, as in inhalation. Such
displacements, however, are resisted by the sternum, the
costal cartilages, and the intercostal my ofascial tissues. The
rotation of the rib necks becomes a twisting, or torque,
deformity of the rib shafts, which absorb some of the ener­
gy of vertebral rotation by elastic deformation. The supe­
rior border of the shaft of the left sixth rib inverts and the
superior border of the shaft: of the right sixth rib everts.
The superior costotransverse ligaments, passing from the
transverse processes of the superior vertebrae to the necks
of the subjacent ribs, contribute to the rotations of the rib
necks. There is also a change in the radius of curvature of
the rib shafts.
Figure 2.9 Mechanism of rib torque. Adapted and reprinted with permis­
What happens to the fifth ribs when T5 rotates to the
sion from D Lee: Manual Therapy for the Thorax. DDPC, 1994.
right? If this rotation is a part of axial rotation of the entire
trunk, then T4 does the same things to the fifth ribs as T5
In the vertebrosternal region (Tr T7) the costal pits on
did to the sixth ribs. Moreover, the fifth ribs follow the
the transverse processes are concave anteriorly, permitting a
transverse processes of T5, the right rib being drawn poste­
twisting or spinning of the rib neck but neither physiolog­
riorly and the left rib being pushed anteriorly. The costal
ic interior-anterior nor superior-posterior translation of the
cartilages are flexible enough to allow visible and measur­
rib neck. (Figure 2.10) The costotransverse articulations of
able anterior-posterior rib motions, but in so doing they
the eighth, ninth, and tenth ribs are flatter planes, which
(probably) more rigidly resist the inhalation-exhalation dis­
would allow such translations to occur. However, the tenth
placements of the ribs.
costovertebral articulations are considered to be unifacets,
Unifacet Ribs and Vertebral Rotation and less influenced by rotation of the ninth thoracic verte­
Ribs i, x, xi, and xii do not acquire structural torsion asym­ bra. The superior costotransverse ligament remains a fac­
metry, because they articulate on unifacets. They do, how­ tor, however.
ever, turn with their vertebrae when the vertebrae rotate.
It is easy to understand how a rotated position of the first Axial Rotation of Vertebroabdominal Segments:
thoracic vertebra causes respiratory motion of a first rib to T L
w- l
be restricted. The displacement of the first rib by the ver­ The absence of rib head articulations on the intervertebral
tebral rotation is resisted by the first rib's synchondrosis discs of T10, Tll, and T12 should permit greater interseg­
with the manubrium. Without the elasticity of the first mental rotation (and flexion/extension) movements.
rib's costovertebral and costotransverse articulations, the However, they account for less than l 0% of thoracic region
body of the rib, its cartilage, and the manubrium, the first rotation. The tenth thoracic is still relatively restrained by
thoracic vertebra would not be able to rotate at all. The the tenth ribs and their costochondral articulations, but its
elastic deformation of these tissues may be related to the freedom to rotate on T11 is limited only by its interarticu­
respiratory impairment. The same mechanical reasoning lar ligaments and disc. T11 has 2 to 3 degrees of axial rota­
may be applied to the tenth rib, its joints and costal carti­ tion, but its ribs, unattached anteriorly, follow its rotations
lage. freely. Since the eleventh and twelfth thoracic vertebrae
have only vestigial transverse processes, their floating ribs
Rotation of Vertebrochondral Segments: T 7· T 10
are better indicators of vertebral rotation than the trans­
"In the vertebrochondral region, the relative glide of the rib at the
verse processes, which are too close to the axis of rotation
costotransverse joint is posteromediosuperior on the left and
anterolaterointerior on the right. The left lateral translation of the to be us�ful as rotation indicator landmarks.
superior vertebral body {as it rotates to the right, Ed.} 'pushes' the The superior facets of the twelfth thoracic vertebra are
left rib posterolaterally along the line of the neck of the rib and caus­ typical thoracic facets, upon which the eleventh thoracic
es a posterolateral translation of the rib at the left costotransverse
vertebra rotates freely with its y-axis through the center of
joint. Simultaneously, the left lateral translation 'pulls' the right rib
its vertebral body, as in thoracics one through ten. But the
anteromedially along the line of the neck of the rib at the right cos­
totransverse joint. An anteromedialjposterolateral slide of the ribs inferior facets of T12 are lumbar-type facets. They have
relative to the tra11sverse processes to which they attach is thought to convex surfaces facing anterolaterally and fit into the first
occur during axial rotation." (Lee, 1994)
 CHAPTER
Figure 2.10 Comparison of upper and lower thoracic costotransverse
facets. Notice that the upper ribs rotate their necks on concave pits on
transverse processes, but the lower ribs glide on facet planes that face
superior and anterior. Thus the ninth and tenth ribs are able to participate
slightly in the caliper-type motion characteristic of ribs xi and xii, but
restrained by the costal cartilage.
lumbar's superior facets, which are concave surfaces facing
medially and posteriorly. The twelfth thoracic, therefore,
rotates like a lumbar vertebra, mostly about a y-axis which
is posterior to its annulus fibrosis.
Axial Rotation of the Lumbar Segments
According to the zygapophyseal anatomy of the lumbar
segments, very little rotation of lumbar vertebrae is possi­
ble, at least on a y-axis through the vertebral body.
Clinically the lumbar vertebrae appear to defY the
anatomists' edict. It is not unusual to find segmental dys­
functions causing positional unilateral displacement of lum­
bar transverse processes on the order of one or two cen­
timeters. According to Hickey and Hukens ( 1980), rota­
tion beyond 3 degrees should cause micro-injury to the
annulus fibroses. However, it appears they did not take
into account the inherent capacity of the disc to shear.
There has been an apparent contradiction between the
anatomists' contention that lumbar segmental interverte­
bral rotation is severely limited to l to 3 degrees by the
shape of the zygapophyseal joints, and the clinicians' obser­
vations that lumbar intervertebral rotation is often much
greater than 3 degrees. In fact, radiographic and spondy­
lometric measurements of axial rotation in the lumbar spine
have shown axial rotation of the lumbar region to average
about 35° with a wide range of variation from 10° to 70°.
The mechanism of axial rotation which accounts for this
large movement involves transposition of the y-axis of rota­
tion from within the vertebral body for the first 1 to
degrees of rotation to the impacted zygapophyseal joint for
2 � BIOMECHANICS OF NORMAL SPINAL MOTION 25
the remainder of the rotation. The posterior location of
this second axis causes the vertebral body to translate later­
ally as the vertebra rotates, producing a shear distortion of
the intervertebral disc. The lumbar discs are usually more
than a quarter-inch thick, and presumably can deform in
this way without injury. Torsional injury to the disc has
been proposed as a major factor in low back pain.
Bogduk and Twomey (1991) explain the lumbar rota­
tion phenomenon as a shift in the y-axis to a point on the
zygapophysis after a very limited amount of axial rotation
on an axis through the vertebral body. Axial rotation caus­
es compaction of the contralateral zygapophysis, which
becomes the axis for further rotation. When this axis shift
occurs, the rotating vertebral body "translates" in the
direction of rotation/sidebending, causing a shear defor­
mation of the intervertebral disc.
Sidebending associated with 3 degrees or less of axial
rotation may go either way, favoring contralateral coupling
in the upper four lumbar segments and ipsilateral coupling
of the lumbosacral segment. Lumbar sidebending is usual­
ly accompanied by extension, and, once the contralateral
zygapophysis is compacted, rotation and sidebending nec­
essarily become ipsilaterally coupled, the compacted
zygapophysis being unable to extend.
Axial rotation of the sacrum in relation to the ilia is
minuscule. Twisting forces from the spine exerted on the
sacrum tend to be converted to sacral rotation on an
oblique axis. This causes a coupled contralateral sidebend­
ing of the sacrum. This significant unleveling of the sacral
base evokes a contralateral sidebending adaptation of the
lumbar spine, as described below.
Biomechanics ofSegmental Spinal Sidebending
(z-axis motion)
Beginning with the T 3_4 segment, normal sidebending and
rotation are no longer ipsilaterally coupled movements.
This is because the facet joints are not weight-supporting
structures as they are in the cervical lordosis ( C0 - T2).
Hence, in their "neutral" condition the facet joints are free
to gap apart, as they must when rotation and sidebending
are contralateral movements. Sidebending coupled to pri­
mary axial rotation has been studied. Contralateral cou­
pling is favored, but is not entirely consistent.
Lateral flexion of the spine has almost eluded biome­
chanical analysis because of the complexity of measurement
of coupled motions. Empirically, it can be observed that
normal, "neutral," sidebending of a group of thoracic or
lumbar vertebrae has a predictable rotational effect. The
vertebrae in the lower half of the group rotate contralater­
ally, and the vertebrae in the upper half of the group rotate
ipsilaterally. With more than one vertebra rotating in the
same direction, the sum total of small increments of rota­
tion can be quite large at the middle of the group.
These group sidebending movements occur with the
3 undulations of the trunk in walking and running, or when
changing an overhead light bulb.
26 THE MUSCLE ENERGY MANUAL

Table 2.8 SUMMARY OF SEGMENTAL AND REGIONAL RANGES OF MOTION

Combined Flexion and One Side Lateral One Side Axial

Extension Bending Rotation
Segments (x-axis rotation) (z-axis rotation) (y-axis rotation)

CO- C1 •
1+-1:
C1- C2 • •

C2- C3 ' :I • i
C3- C4 t--+ .....---t
: .. .. l : .......
C4- C5 I' ' I; ' .I
:,
C5- C6 :1 • :1 ' :I
'
C6- C7 .• 1: I
I '
·
C7- T1
Region
:•
�
Average: ;11s;oegree� (±1iZI 351;Jeg�ees;
Flexion: : 40 Degrees (±5:)
Extension: : 75 Degrees (±7)
T1- T2
� 141 �

T2- T3 141 �: �

�
T3- T4 �: �
T4- T5 �: �
T5- T6 141 �: �
T6-TI � :IJH: �
T7- TS �: ·-�·+ jet
TS- T9 �: 1--i-•{ ill
T9- T10 ...... : �: Ill
T10- T11 (' I; � Ill
T11- T12 :1 '. 1411
T12- L 1 :�o-1 ........ ·
..;. ,.;...
.. -�1 : Ill
Region
Average: ;so Oegr�es !40-78) 20 �eg�ees; 79 Qegrpes;
Flexion: :50 Qegr�es :
Extension: :10 Degr�es:

L1 - L2 I. • I:
:
L2- L3 1: • 1: .

L3- L4 !I :I ·,

L4- L5 :1 I!
L5- S1 : -•

Region
Average: ;n Qegr�es i±27} 20 �eg�es;
Flexion: :11 Degrees (±9):
Extension: :so Degrees i±7):

Angular
Degrees: 5 10 15 20 25 30 35 40 45 5 10 15 20 5 10 15 20 25 30 35 40 45 50

IEstimated Mean = 1 Range of Averages=� �

Table 2.8 Summary of Segmental and Regional Ranges of Motion. This table is a compilation of research data reported by J. Dvorak and V Dvorak,
M. Panjabi, A. White, A. Stoddard, N. Bogduk, L. Penning, J. Jirout, I. Macrae, M: Pearcy, and, through them, many other investigators. Because the
research methods varied widely, summarizing the results was difficult and complex, taking methodology into account. The summary data given aliove
must be considered approximate. Nevertheless, the estimations derived from this endeavor appear likely to be useful to clinicians and students of
manual therapy.
 CHAPTER 2 � BIOMECHANICS OF NORMAL SPINAL MOTION
Sidebending is considered to be coupled with rotation
in the lumbar spine, but not necessarily ipsilaterally. The
coupling is variable in different positions and at various seg­
ments, and is quite complex. Contralateral rotation­
sidebending coupling is said to be rather consistent in the
upper three lumbar segments. Apparently it does not mat­
ter whether axial rotation precedes sidebending or the
other way around. The lumbosacral joint seems to favor
ipsilateral rotation-sidebending coupling.
Introduction to Neutral Spinal Motion
The third thoracic vertebra and its ribs play an important
role in the postural dynamics of locomotion. Partly because
of the increased leverage of the iliocostales muscles, and
clearly related to the termination of the longus co IIi muscle
at the third thoracic vertebra, the T3-4 joint is usually a
crossover point (a node) for the coordinated movements of
walking. The undulations of the spinal column are phylo­
genetically basic to locomotion. The T3-4 joint is the
beginning point for neutral sidebending-rotation motion.
Neutral in this sense means zygapophyseal facets not
engaged, and, therefore, represents the potential for
uncoupled rotation and sidebending. All spinal joints
above T3 have coupled sidebending and rotation, i.e., are
obliged to rotate and sidebend to the same side, regardless
of the joint's degree of flexion or extension.
The zygapophyseal facet joint processes lie upon each
other like shingles on a cone-shaped roof, the superior
facets of the inferior vertebra facing mainly posteriorly and
a little lateral and superior, and the inferior facets of the
superior vertebra facing forward in the same curved plane.
See Figure 2.4. A superior view of a thoracic vertebra
shows that an arc passing through the facet planes can be
drawn with its center at the center of the vertebral body at
the axis for thoracic vertebral rotation. See Figures 2.7 and 2.8.
Rotation and sidebending coupling from T 3 to the
lumbosacral joint is variable, because the facet joints do not
support weight. This variability is due to the fact that their
zygapophyses are not compacted under normal circum­
stances. This normal condition, when the facets are not
engaged and, therefore, do not guide segmental motion, is
called "neutral." The term "neutral" does not refer to
some arbitrary halfway position, but simply means that the
facets are not engaged, i.e., not in contact, not compacted
or impinged, not in control of segmental motion.
When a zygapophysis on one side of a vertebral seg­
ment becomes engaged, or impinged, it may become a
pivot for motion of that one segment. Such unisegmental
motion is characterized as "non-neutral" motion. The
term "non-neutral" motion also applies to the normal con­
dition of the cervicothoracic region, where the facet sur­
faces remain in contact with each other, even when there is
insufficient compaction of a facet to create a pivot. It
applies there simply because rotation and sidebending are
automatically coupled to the same side because of the
oblique inclination angle of the weight-bearing facet joints.
27
transposed
y-axis
Figure 2.11 Left axial rotation of a lumbar intervertebral joint. After 2
or 3 degrees of rotation about a y-axis centered in the vertebral body, the
zygapophyses on the side opposite the direction of rotation gently collide
and the y-axis shifts to that point. As rotation continues, the interverte­
bral disc shears and the disimpacted facet joint gaps.
Theoretically, a rotating cervical vertebra may slide one
facet down and back, and, at the same time, slide the other
facet up and forward. Such an event is tantamount to a sin­
gle vertebra simultaneously extending on one side and flex­
ing on the other. Somehow this seems like an oxymoron.
Whether or not it actually occurs that way, it is certain, or
at least likely, that cervical rotation, wherever it occurs, will
not simultaneously flex and extend a vertebra in equal
amounts.
In the thoracolumbar segments below T2 non-neutral
motion also automatically couples rotation and sidebend­
ing ipsilaterally, just as they are always coupled in the cervi­
cothoracic region. Here the ipsilateral coupling occurs
whenever a zygapophyseal joint becomes sufficiently com­
pacted to become a pivot. When this occurs, movement of
the FSU is no longer normal, and, therefore, non-adaptive.
Such compaction may occur anywhere within the flex­
ion-extension range. If the pivoting occurs on the way
from extension to flexion, the compacted facet stops mov­
ing forward and superior. As flexion continues, the free
facet continues to move forward and superior, but in an arc
whose center is the pivoting facet. The combination of
anterior and superior movement results in rotation and
sidebending toward the side of the compacted facet.
If the pivoting occurs on the way from flexion to
extension, the compacted facet stops moving backward and
inferior. If extension continues, the free facet continues to
move backward and inferior, but in an arc whose center is
the pivoting facet. The combination of posterior and infe­
rior movement results in rotation and sidebending toward
the side of the free facet. It is not often that the pivot is in
the same place for both flexion and extension. If a facet
becomes impacted with movement in one direction, mov­
ing in the other direction usually disimpacts it. Refer to Chapter
7 for more detailed discussion of these abnormal movements.
28 THE MUSCLE ENERGY MANUAL
Neutral and Non-Neutral Sidebending of the
Thoracolumbar Spine
We have already described neutral axial rotation tor the
entire spine. In summary, axial rotation is variously cou­
pled to sidebending, most strongly in the cervicothoracic
region and weakly and variably in the thoracolumbar
region. The term "neutral" does not apply to the cervi­
cothoracic region in a physiologic sense, because all of its
rotation-sidebending movements are non-neutral (facets
engaged), both physiologic and pathologic.
In those parts of the spine where the facets do not
carry weight (T3 through L5), nor are they held together in
any way that would cause their surfaces to serve as guides
or tracks tor intervertebral movement, there exists the pos­
sibility of neutral sidebending (lateral flexion), or z-axis
coronal plane motion. In the thoracic (vertebrosternal,
vertebrochondral, and vertebroabdominal) and, in a limit­
ed way, lumbar regions, a neutral condition is conceived
within a large mid-range, in which zygapophyseal tacet sur­
taces are separated from each other and do not guide ver­
tebral motion.
The standard sidebending theory suggests that the
coupled contralateral rotation that accompanies neutral
sidebending is a consequence of the lateral shift of the load
on the vertebral body and intervertebral disc. As the load
increases on the concave side of the segment it pushes the
vertebral body, translating it toward the convexity. This
mechanism not only accounts tor the automatically coupled
contralateral group rotation with group sidebending in any
portion of the thoracic or lumbar spine having a "tacets­
idling" neutral range, but also can be applied to the
observed segmental de-rotation of vertebrae above the
apex of the sidebending curve.
Lee ( 1994) advances an alternative explanation tor the
contralateral coupling of sidebending and rotation in the
T 3 to T 10 region. Lee's suggested mechanism has to do
with transverse processes sliding up or down on ribs, atter
the rib cage has reached the limit of its sidebending flexi­
bility. This mechanism is easy to visualize in the thoracic
segments T8, T9, and T10, where the articular pits on the
transverse processes are flat planes tacing superior and ante­
rior. For example, the right sidebending T10 slides its right
transverse process down and torward on the right tenth rib
and its lett transverse process up and back on the left tenth
rib, combining lett rotation and right sidebending.
The articular pits on the third thoracic transverse
processes are concave surtaces and tace anterior, lateral, and
interior. Lateral orientation gradually increases trom T4 to
T 7 while the interior orientation diminishes. This seems to
require that rotation and sidebending of T3 are coupled
ipsilaterally, as they are in the portion of a group curve
superior to the apex of the curve. However, the vertebrae
in this region are sometimes tound in the subapical portion
of a sidebending curve, and are rotated toward the convex­
ity of the curve.
Clearly, Lee's and the standard theories are comple­
mentary. The shifting load mechanism would apply even in
less extreme sidebending, and to segments in the lower lor­
dosis, T 11 to L5, where there are no costotransverse joints
to guide the vertebrae. In the lumbar segments the con­
tralateral rotation component is very small, but adds up,
segment by segment, to the apex and then diminishes seg­
ment by segment in the supra-apical portion of the curve,
which may extend into the thoracic spine.
Sidebending Adaptation to Habitual Movements
Neutral sidebending actions of the trunk occur regularly
and habitually as positional shifts to accommodate volun­
tary locomotor functions. These accommodations are, for
the most part, involuntary actions. In brachiation (reach­
ing overhead) lateral curvatures of the spine are generated
trom above down, starting with a lateral concavity on the
up-reaching side. When we begin to walk, the undulating
motions of the trunk do not need to be consciously direct­
ed; they occur automatically. Of course, these actions can
be consciously and precisely controlled, as every thespian
knows.
The automaticity of these neutral sidebending actions
is best demonstrated by postural adaptations to base of sup­
port asymmetries such as anatomic short leg, dysgenesis of
the pelvis, sacroiliac somatic dysfunctions, and segmental
dysfunctions or vertebral detormity of the spine. When we
find a segmental dysfunction of one vertebra, we must
assume that there will be some compensation or adaptation
to rearrange the posture of the spine in relation to the dys­
functional unit.
Such postural rearrangement quickly restores equilibri­
um to the body, and tends, over time, to pull the- masses of
the body closer to the central line of gravity by shortening
the length of alternating compensatory curvatures. Thus,
long "C" curves convert to "S" curves, which may become
multiple "S" curves, over time.
Sidebending Adaptation in Rotoscoliosis
Scoliosis is not a static condition; it has a natural history.
Most of the vertebrae within scoliotic curves are not
deformed, but are simply doing what they must do to adapt
to the detormed vertebra(e). The Fourth "Law" of spinal
motion explains why scoliotic spines are not as flexible as
spines that are not deformed. The law states that after ver­
tebral joint motion is initiated in one plane, mobility in
other planes is reduced. Both as a consequence of aging,
and because of the reactions of collagen to load stress, loss
of flexibility in scoliotic spines tends to be progressive,
affecting primarily the tops and bottoms of the curves,
where non-neutral dysfunctions tend to occur more often.
Non-neutral dysfunctions may develop anywhere with­
in regular scoliotic curves as the result of trauma or load
stresses. The apices of curves are particularly vulnerable to
trauma and load stress. Detecting non-neutral segmental
dysfunctions within the context of a neutral group curve is
 CHAPTER 2 �BIOMECHANICS OF NORMAL SPINAL MOTION 29

not difficult. The transverse process asymmetries come and

go with flexion or extension, and the associated pair of ribs
demonstrates movement duration asymmetry. Regular
manipulative treatment is required to maintain flexibility
and maximize adaptability of the nondeformed portions of
the spine.
The physical appearance of these lateral curvatures of
the spine catches the eye, especially because of the rotation
of the vertebrae within the sidebending groups. When vol­
untary or involuntary spinal movement is initiated with
sidebending occurring first, the coupled rotation is second­
ary to the sidebending, and the ratio of sidebending to
individual segmental rotation appears to be a number
greater than 2 (empirical clinical observation). So when
sidebending of a group occurs in neutral, the group tends
to twist out from under the load and the midpoint of that
group becomes rotated to the opposite direction from the
direction of the sidebending.
Neutral adaptive sidebending-rotation behavior is a
phenomenon which affects groups of vertebrae instead of
segmental vertebral joint units. Non-neutral sidebending­
rotation is not adaptive; it is a reaction to direct trauma.

Coupling of Rotation and Sidebending

The following quotation from Kapandji (1974) applies to
all the vertebral segments from T 3 to L5.
"During lateral flexion the vertebral bodies rotate con­
tralaterally. This can be seen on anteroposterior radi­
ograph: the bodies lose their symmetry and the inter­
spinous line moves towards the side of movement... . This
automatic rotation of the vertebrae depends on two
mechanisms - compression of intervertebral discs and the
stretching of ligaments. The effect of disc compression is
easily displayed on a simple mechanical model. Paste
together wedge-shaped segments of cork and soft rubber
to represent vertebrae and discs respectively and draw a
line centrally on their anterior aspects. If the model is
flexed to one side, contralateral rotation of the 'vertebrae'
is shown by the displacement of the various segments of
the central line. Lateral flexion increases the internal pres­
sure of the 'disc' on the side of movement; as the disc is
wedge-shaped its compressed substance tends to escape
towards the zone of lower pressure, i.e., contralaterally.
This leads to rotation. Conversely, lateral flexion stretch­
es the contralateral ligaments, which tend to move
towards the midline so as to minimize their lengths."
The automatic rotation component of the sidebending
prevents the facet joints from sliding on each other, as they
would if their surfaces were touching. But when this part
of the spine is in its normal state, physiologic "neutral," the
facet joints can be described as "idling," i.e., not touching
surfaces. Thus, when the vertebra sidebends to the right
and rotates to the left, the right facet surfaces move closer
together and the left facet surfaces move apart, i.e., "gap."
Figure 2.12 Adaptive lumbar curve. This lumbar curve could be an adapta­
tion to a short left leg. The solid line connects the centers of the spinous
processes; the dotted line connects the centers of the vertebral bodies. Note
the straightening of the spinous process curve due to segmental rotations.
The amount of rotation that occurs under these circum­
stances is usually quite small, usually much less than 25 per­
cent of the vertebra's potential range of axial rotation. But,
since the phenomenon is often seen in groups of vertebrae,
the rotation effect can be cumulative up to the apex of the
sidebending group. Group rotation is more visible, vis-a­
vis group sidebending.
Above the apex of the sidebending group the mecha­
nisms described by Kapandji sometimes seem not to apply,
as the vertebrae begin to derotate in small increments.
Thus the description of neutral lateral flexion with con­
tralateral rotation is best applied to a group of vertebrae at,
or below, the apex of the curve, not to individual segments.
It can only be said that when vertebral segments are within
their neutral range, sidebending and rotation are not cou­
pled motions (in the sense of an obligatory relationship).
The mechanism should better be described as the apex of
the group twisting out from under the load. This descrip­
tion fits what can be observed in normal, reversible, spinal
sidebending as well as in the fixed sidebending-rotation
patterns of scoliosis.
S0 THE MUSCLE ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 31

CHAPTER 3

Biomechanics of Segmental
Motion Restriction

T
he primary concern in Muscle Energy is to evaluate
and treat restricted joint motion in the body. Spinal
segment lesions exhibit abnormal movement patterns
because of specific joint restrictions. Analyzing these movement
patterns is essential for successful application of MET, and will be
the subject of this chapter. Appropriate and accurate application
of MET to restricted spinal segments makes possible the restora­
tion of normal range of motion and the elimination of the signs
of segmental dysfunction.

Causes of Joint Movement Restriction

Joint motion restriction (articular blockage) represents the end
result of a process which probably begins as a neuroreflexive mus­
cle contraction response to trauma, faulty movement patterns,
faulty body statics, or viscero-somatic reflexes. With the passage
of time, cumulative vascular and connective tissue changes occur
in the intrinsic joint tissues and the periarticular tissues, accom­
panied by a process of general organismic adaptation.
The adaptive process is progressive and goes through stages. In this chapter:
The initial joint motion restriction is made worse over time by
• Causes of joint movement restriction
these progressive changes. Some of the changes are due to
• Biomechanics of Types I and II verte­
deformation of tissue, some are due to chemical or rheologic
bral segmental dysfunction
changes. Collagen molecules become more intricately linked and
stiffer. Rheologic properties of ground substance and synovial • Role of facets and tight muscles in

fluid shift toward a gel state. Impaired lymphatic flow from segmental dysfunction

mechanical compression on lymphatic vessels, or diminished • Criteria for diagnosing ERS, FRS, and

noradrenergic response, results in edema and interstitial gelosis. NSR segmental dysfunction

Articular wedging - cartilage deformation from compression or • Primary sidebending of segments

meniscoid entrapment - can alter joint mobility. Table 3.A out­ • Neutral adaptation versus neutral

lines the multidetermined causes, effects, and feedback mecha­ dysfunction

nisms involved in the body's response and adaptation to joint • Effect of segmental dysfunction on the

motion restriction. ribs

32 THE MUSCLE ENERGY MANUAL

Table 3.A Causes of Restricted Joint Motion

Initial precipitating cause·

a) Arthrogenic changes
Trauma/micro-trauma
i) Cartilage deformation
Faulty movement patterns
(wedging)
Faulty body statics
ii) Meniscoid entrapment
Viscero-somatic reflexes
iii) Rheologic changes in
synovial fluid
iv) capsular fibrosis

Neuroreflexive muscle reaction
(the first step in the development
of segmental dysfunction)
b) Periarticular changes
i) Connective tissue changes
1--- Causing: __ __,.,� in muscles, tendons, fascia
ii) Changes in the muscle pro­
prioceptor gamma system

c) Vascular changes
i) Capillary- petechiae
ii) Lymphatic- congestion,
edema, rheologic changes
in interstitial fluid

. - ·
Eit��t� ;
; ,; �-,: �-�d·d;. ·:
below can reinforce
or perpetuate
the neuroreflexive
muscle reaction

Restricted joint motion of a

vertebral segment is mani­
fested osteokinematically as:

FRS - ERS - NSR

a) respiratory, positional, and shape
changes in ribs associated with
the dysfunctional segment

b) general organismic adaptations T hese lesions, in turn,

c) faulty movement patterns can result in the following
d) faulty statics secondary effects:

I
Possible symptoms:
� (pain, spasm, etc.)
 CHAPTER 3 .._,. BIOMECHANICS OF SEGMENTAL MOTION RESTRICTION 33

Table 3.8

LAWS OF NON-PHYSIOLOGIC SPINAL MOTION (Based on Fryette"s Laws- revised by F.L. Mitchell Jr.)

• Law 1: The neutral sidebent vertebra tends to be contralaterally rotated unless it is above the apex of the curve. The apical vertebra attains its
maximally rotated position by summating the small increments of rotation of the subjacent vertebrae in the group curve. Above the apex derotation occurs
in small increments.

• Law II: A vertebra which has flexed or extended far enough to encounter unilateral facet blockage will rotate with ipsilateral sidebending if it
continues to move in the sagittal plane in the same direction.

• Law Ill: Introducing motion to a vertebral joint in one plane automatically reduces its mobility in the other two planes (sometimes called Beckwith's
Law).

(I apologize to Or. Fryette's and Or. Beckwith's memory for presuming to express these laws in this form, designated as their laws. However. I believe the laws contain the
essence, if not the form, that they would have used. - FLM, Jr.)

DEFINITIONS OF TYPE I AND TYPE II SEGMENTAL DYSFUNCTION

TYPE I (NSR) SEGMENTAL DYSFUNCTION is defined as impaired sidebending mobility of any number of contiguous functional spinal units (FSUs)
without specific zygapophyseal restriction (the facets are not involved). The rotation asymmetry seen with Type I dysfunction is adaptive and secondary
to the sidebent relationship of the vertebral bodies. Type I dysfunctions are based on Law I. Also, because of Law Ill, loss of the sidebending degree of
freedom (the primary restriction) reduces mobility in the sagittal and transverse planes.

TYPE II (ERS, FRS) SEGMENTAL DYSFUNCTION is defined as impaired flexion or extension movement of one or both of the zygapophyseal joints of a
single FSU. Usually unilateral, the restriction produces ipsilateral rotation-sidebending coupling of the superior vertebra when it moves into the
restricted range. Type II dysfunction is based on Law II. There are two types, ERS and FRS (Tables 3.C, 3.0, and Fig. 3.1).

Role of Tight Muscles in Joint Restriction
The MET "six-muscle" paradigm referred to in Chapter 2
is intended to reduce one aspect of joint restriction - the
muscular component- to its simplest elements. The para­
digm is not meant to suggest that all joint motion restric­
tion (articular blockage) is due to muscular tightness or
shortness. Refer to Volume l, Chapter 2, for a more
extended discussion of the causes of articular blockage.
Another aspect of joint restriction,
Muscle Energy in several areas of the body, is its use to
mobilize passive joints, or to mobilize joint play motions,
by using muscle forces to distort fascia. Treatments for the
passive joints of the pelvis and foot are good examples.
Shortened monoarticular muscles may, or may not, be
the cause of intervertebral motion restriction and segmen­
tal dysfunction. We believe, however, that the deeper
shorter muscles are the agents of therapeutic change in
Muscle Energy treatment techniques for the spinal seg­
ments. Since the monoarticular muscles proprioceptively
inform the nervous system what movements are allowed by
the joint, including them in the therapy possibly serves to
reprogram the neuroreflexive signal that factors into main­
taining the conditions for restriction.
Treating joint motion restriction as ifthe cause were
tight muscle is one approach which makes· possible the
restoration of normal joint motion. Regardless of the caus­
es of restriction, MET treatment based on a "short muscle"
paradigm is usually completely effective in eliminating a
blockage and restoring normal range of motion, even when
the blockage is due to nonmuscular factors. The MET pro­
cedure reduces, or eliminates, the physical signs of somatic
dysfunction, and is a safe and effective alternative to thrust
procedures.
Role of Facets in Types I and II Segmental
Dysfunctions
Variations in facet joint movement patterns are the distin­
guishing features of segmental dysfunction types. See Table
3.B. According to facet involvement, segmental dysfunc­
tions can be classified as neutral (facets not engaged- rare)
and non-neutral (facets engaged - common). To say that
the facet joint is "involved" in certain types of segmental
addressed by dysfunction is subject to ambiguous interpretation. In a
sense, the facets are "involved" in all intervertebral move­
ment patterns - normal and abnormal.
Normal flexion involves superior-anterior gliding of
the vertebra's inferior facets on the superior facets of the
subjacent vertebra in a sagittal plane. Extension is the
reverse - with the facets exhibiting inferior and posterior
gliding. No rotation or sidebending motion is coupled to
this sagittal plane motion; it is pure sagittal motion.
The specific involvement of facets in Type II (non­
neutral) dysfunction can be described as altered flexion or
extension movement patterns (hence, ERS and FRS). In
Type II dysfunction the motion of one tacet is stopped pre­
maturely by any of the restrictors mentioned in Table 3.A.
Once the restriction is present and encountered, the
motion can no longer continue as pure sagittal plane
motion. On the tree side the facet changes direction, forc­
ing the vertebra to move in an arc around the restricted
tacet pivot. This inevitably produces ipsilaterally coupled
rotation and sidebending.
In Type I dysfunction neither facet is arrested specifi­
cally by monoarticular restrictors. Both facets can flex,
extend, and rotate normally (except, as Law III states, as
diminished slightly by the prior sidebending). In normal
sidebending, the vertebra's inferior facet glides in a coronal
plane down on one side and up on the other side. There is
34 THE MUSCLE ENERGY MANUAL

Table 3.C

Characteristics of Vertebral Segmental Dysfunction and Adaptation

Neutral
Non-Neutral Segmental Dysfunctions Dysfunctions Adaptations
Flexed Position Extended Position Mid-range Position Varies
Positional names FRS Left ERS Left NSR Left (Not a lesion)
("'-ed'' endings) Flexed, Rotated, Sidebent Left Extended, Rotated, Sidebent Left

Restricted motions SRE Right SRF Right SLR Right None

("'-ing"' endings) Sidebending,Rotation, Extension Sidebending,Rotation, Flexion

Lesion type Type II (non-neutral) Type II (non-neutral) Type I (neutral) (Not a lesion)

Number Single Single Group Group

Cause (etiology) Trauma Trauma Adaptation Adaptation

Facet motion impairment Right extension Left flexion None None

Effect of hyperextension Worse Re-establishes symmetry Less deformity Depends on

key lesion

Effect of hyperflexion Re-establishes symmetry Worse Less deformity Depends on

key lesion

Coupled rotation - Same side Same side Group left rotated, Group left rotated,
sidebending (e.g.,Lt,lt) (e.g.,Lt,lt) right sidebent right sidebent

Observed posterior Left Left Left Left

transverse process(es)

always some axial rotation coupled to this movement,
which typically occurs in a group of adjacent vertebrae.
The axial rotation causes a small amount of gapping (dis­
traction) of the facet joints on the convex side of the curve,
and/or compression (pinching together) of the facets on
the concave side.
Type I dysfunction restricts the coronal plane motion
of both facets in one direction by limiting sidebending of a
group of vertebrae with tight polyarticular sidebender mus­
cles on the other side. The facet motion in other planes is
still relatively free, in contrast to the Type II dysfunction
which has significant movement impairment in all three
planes.
Clinical Characteristics of '!YPe I and '!YPe II
Segmental Dysfunctions
Not all visible asymmetries of the spine are dysfunctions.
Some asymmetries are caused by voluntary or involuntary
muscle action and are adaptations which are spontaneous­
ly reversible without treatment. In contrast to adaptations,
Type I dysfunctions are not spontaneously reversible, even
after all other asymmetries have been corrected. WithType
I dysfunctions, the asymmetry persists throughout the
whole flexion-to-extension range.
Type II Vertebral Dysfunctions
Single vertebral segments that demonstrate ipsilateral
rotation and sidebending coupled with either flexion or
extension are classified as Type II dysfunctions. Type II
dysfunctions always have a flexion or extension component
(the principal restriction), are always manifested in single
vertebral joint units, and always have the rotation and
sidebending coupled to the same side. The etiology of the
Type II dysfunction is trauma or microtrauma. The
amount of rotation seen with the non-neutral, or Type II,
dysfunction is large enough that one can see the transverse
processes of the vertebra rotate as it is put through motion
in the sagittal plane.
It is especially important to know that with Type II
dysfunctions, at some point within the flexion/exten­
sion range of movement, the vertebra will become per­
fectly symmetrical if the segment is flexed (or extend­
ed) enough. Thus, a rotated vertebra that becomes per­
fectly symmetrical when it is extended is an ERS dysfunc­
tion. An FRS dysfi.mction is symmetrical in the flexed posi­
tion. (Table 3.B and Fig. 3.1) In extreme Type II dys·
functions, extreme forced flexion or extension may be
required to make the segment symmetrical.
The discovery of Type I dysfunctions is possible only
afterType II dysfunctions are treated and eliminated. The
characteristic differences betweenType I and the two kinds
ofType II vertebral dysfunctions are outlined inTable 3.B.
See Figure 3.1 and Tables 3.C and 3.D for a detailed
description of movement patterns in ERS and FRS dys­
functions.
Certain FSUs are prone to more frequent occurrences
of Type II dysfunction. Among these are the junctional
areas - cervicothoracic, thoracolumbar, and lumbosacral.
Also included are the apices of the A-P curves. The high
incidence of segmental dysfunction ofT rT4 can be attrib­
uted to its pivotal locomotor function, fatigue stress; and
the kinematic ambiguity of its motion functions.
 CHAPTER 3 � BIOMECHANICS OF SEGMENTAL MOTION RESTRICTION 35

Figure 3.1 ERS and FRS Movement Patterns

A. B. c.

Normal Major ERS Left Minor ERS Left Major FRS Left Minor FRS Left

Flexed

Mid-range

Exte11ded

Fig.3.1.A No Facet Restriction.
All of the above diagrammatic
figures represent posterior
views of an FSU, identified by the
superior (shaded) segment. The
position of the superior segment
relative to the segment below is
shown in hyperflexed, mid­
range, and hyperextended posi­
tions. The normal FSU retains its
symmetry bilaterally in all posi­
tions.
Fig.3.1.B Left Facet Flexion Restriction.
In ERSL (Extended, Rotated, Sidebent left) dysfunc­
tion, the left facet joint is not permitted full flexion,
causing rotation/sidebending asymmetry (left) with
flexion. The major dysfunction (> 50% restriction)
causes asymmetry in both mid-range and hyper­
flexed position. In the minor dysfunction (< 50%
restriction) the asymmetry is seen between mid­
range and hyperflexion. In both major and minor
dysfunctions, the facets and transverse processes
are bilaterally symmetrical in the hyperextended
position.
Fig.3.1.C Right Facet Extension Restriction.
In FRSL (Flexed, Rotated, Sidebent left) dysfunc­
tion, in both major and minor dysfunctions, the
facets and transverse processes are bilaterally
symmetrical in the hyperflexed position. The
major FRSL dysfunction shows left rotation at, or
before reaching, mid-range. The minor FRSL
retains its symmetry through mid-range. The left
rotation is a consequence of right facet extension
restriction.

Figure 3.1 ERS and FRS Movement Patterns. ERS stands for Extended, Rotated, Sidebent. FRS stands for Flexed, Rotated,
Sidebent. Each of these acronyms is customarily followed by an L, or an R, representing Left or Right. Each letter in the
acronym describes vertebral position. The letters also represent the vertebra's free movements as well as designating the
muscles that may be too tight. Thus a vertebra with ERSL dysfunction has free extension, free left rotation and free left
sidebending. In the tight muscle paradigm the extenders, left rotators, and left sidebenders are too tight.

Note: Not illustrated above are the conditions of bilateral ERS or bilateral FRS lesion patterns. With a bilateral ERS the vertebra is positional­
ly extended and cannot flex. Similarly, with a bilateral FRS the vertebra is positionally flexed and cannot extend. Because such lesions appear
as bilaterally symmetrical they are easily missed. A definitive diagnosis of bilateral non-neutral dysfunction can only be made by treating one
side as either an FRS or ERS lesion and then retesting to see if the segment becomes laterally asymmetric.
36 T H E M U S C L E E N E RG Y M AN U A L

Table 3.0 ERS and FRS Segmental Dysfunctions

''·· FRS left Right zygopophy-

"
With FRS Left, the Major FRS:
,,
seal facet meets left facet moving Restriction is
Vertebra left rotates restriction moving toward extension 1- encountered
as it moves toward toward extension causes the vertebra before mid-
extension to rotate and side- range-toward
bend left extension
FRS 1- Minor FRS:
Restriction is
FRS Right Left zygopophy- With FRS Right, the
encountered
seal facet meets right facet moving
after mid-range
Vertebra right rotates restriction moving towards extension
-toward
as it moves toward toward extension causes the vertebra
y extension
extension to rotate and side-
bend right

Starting from an extended position,. the segme'1Us symmetrical. As the segment moves
" "
toward flexion, an asymmetry develops a� the;ye !}ebra rotates left or right.,\;;,'
>�--;;: :'l' ;.};: ':t:,: :_M
: £t4t�W:{- ?/?' /f:: ,.-:�- �- _-.::;:�: '·':Y?Jil ';t\

-�,
ERS left Left zygopophy- With ERS Left, the MajorERS:
seal facet meets right facet moving

177�if)t';
Restriction is
Vertebra left rotates restriction moving toward flexion 1- encountered
as it moves toward toward flexion causes the vertebra before mid-
' flexion to rotate and side- range-toward
bend left flexion
ERS I"- Minor ERS:
ERS Right Right zygopophy- With ERS Right, the Restriction is
seal facet meets left facet moving encountered
Vertebra right rotates restriction moving toward flexion after mid-range
as it moves toward toward flexion causes the vertebra 1- -toward
flexion to rotate and side- flexion
w

ZJt,,
bend right

NSR left Right sidebenders

With NSR lesions, the
are too tight through­
vertebra is rotatated
Vertebra is left rotated out the range of
left or righ� throughout
and right sidebent flexion and extension
flexion and e)(tension.
' for that segment
The degree bt rota • ''
is t�rMtest april ·

NSR lesions cd6 dn1

diagnosed if no h<;!h
'
neutral dysfuncti9 ns NSR Right . Left sidebenders
are present. .,. are too tight through­
Vertebra is right rotated out the range of
and left sidebent flexion and extension
for that segment
 CHAPTER 3 --1> BIOMECHANICS OF SEGMENTAL MOTION RESTRICTION 37

Table 3.E T he Secondary Effect of ERS and FRS Segmental Dysfunction on the Ribs

With the segment in the The pair of ribs subja­ With the segment in the The pair of ribs subja­
extended position, the cent to the dysfunction flexed position, the cent to the dysfunction
right rib has restricted may exhibit rib torsion left rib has restricted may exhibit rib torsion
respiratory motion, and -the left rib everted respiratory motion, and -the left rib everted
the rib on the left is -the right rib inverted the rib on the left is -the right rib inverted
posterior posterior

With the segment in the The pair of ribs subja­ With the segment in the The pair of ribs subja­
extended position, the cent to the dysfunction flexed position, the cent to the dysfunction
left rib has restricted may exhibit rib torsion right rib has restricted may exhibit rib torsion
respiratory motion, and -the left rib inverted respiratory motion, and -the left rib inverted
the rib on the right is -the right rib everted the rib on the rib is -the right rib everted
posterior

Effect of Type II Segmental Dysfunction on the Ribs

Impairment of respiratory movement of ribs is usually the
direct result of Type II segmental dysfunction of the tho­
racic spine. In addition, one can also see the effect that the
type of rotation associated with dysfunctional vertebrae has
on the shape and position of the rib to which the vertebra ,. - -
0
- ,- ', -, - , - - '�- - - -
- - - -

'
- - -

'
- - - - - - - -

�: JiiEI '
- - - - - -

'
r

is attached. The rib shafts, being a greater distance trom

the axis of vertebral rotation, are displaced farther by the �:
rotation of the vertebra than are the transverse processes of
the vertebra, which are closer to the axis. Type II vertebral
segmental dysfunctions (FRS and ERS) tend to produce \_
',
- - - _ : ---�- --- �
I
-
I
- - - _ :
I
- - - - - : _ - - -

I ·,
,

marked antero-posterior rib asymmetry in the upper ribs (i

through iii or iv) and the lower ribs x, xi, and xii. The ster­
num tends to dampen the displacements of the middle ribs.

Y-Axis Shift in Segmental Dysfunction
With the occurrence of Type II dysfunction, the physio­
logic y-axis shifts from the vertebral body to the impaired
facet. The occurrence of rib respiratory restriction associ­
ated with segmental dysfunction of a thoracic vertebra
oflers a seeming paradox: the rib is usually restricted on the
side of the displaced dysfunctional y -axis, not on the side
with the greater rotation. Thus, if T5 rotates to the right
by extending and pivoting on the left zygapophysis, we find
that the left fifth rib has restricted breathing movement,
instead of the right rib whose posterior motion is elastical­
ly restrained by the costal cartilage and sternum.
Single Rib Torsion
While the ribs attached to the transverse processes of the
rotated vertebra follow their vertebra and show its rotated
position even more obviously than the transverse processes,
the subjacent ribs are torqued by the rotated vertebra (see
Chapter 2).
Such torquing of rib shafts varies among individuals,
but it may become especially appreciable when associated
with the rotation of single FSU non-neutral segmental dys­
function in the lower vertebrosternal region (ribs v to ix, or
Figure 3.2 The effect of non-neutral vertebral rotation on the associated
ribs. The rib shafts, being farther from the axis of vertebral rotation, are
displaced farther by the rotation of the vertebra than are the transverse
processes of the vertebra, which are closer to the axis. Shown is ERSL.
The black dot marks the shifted y-axis. The vertebra has attempted to flex,
but is able to flex on the right side only. The right inferior facet of the ver­
tebra slides up and forward, producing left rotation/sidebending.
T4- T8). The everted rib can be detected easily by palmar
stereognostic palpation; it "sticks out" into the palm in
relation to the neighboring ribs, in contrast to the inverted
rib, which is flattened and receded in relation to its neigh­
bors. This stereognostic palpatory finding, referred to clin­
ically as a "single rib torsion," is often the most dramatic
evidence of segmental dysfunction to be found. If the right
fifth rib is everted, it signals that T4 is right rotated due to
non-neutral segmental dysfunction. (Figure 3.2)
An evaluation and treatment algorithm which ties
together spinal joint and rib joint biomechanics will be pre­
sented in Chapters 6, 7, 8, and 9. This unification of spine
and ribs, while presenting a more complex model than the
separate models of spine and ribs, offers greater diagnostic
precision and more alternative evaluation and treatment
options, thereby improving clinical results.
38 T H F. M USCLE E N E R G Y M AN U A L

® CD ®

Apex

Crossover

Apex

Non-neutral
Dysfunction

Anterior Posterior
View View

Figure 3.3 Adaptive Rotoscoliosis. The above figures show the details of neutral segmental rotation secondary to an adaptive "S" curve of the lumbars
and lower thoracics- anterior view on the left and posterior view on the right The "S" is formed by a right sidebending group curve in the lumbars and a
left sidebending group curve in the lower thoracics. The arrows in the left figure show the direction of vertebral body rotation. Notice that the fifth lum­
bar is both left sidebent and left rotated in relation to the sacrum, indicating either an ERS left or an FRS left dysfunction of the lumbosacral joint. The auto­
matic rotation depends on the shifting compression load on the intervertebral discs, the shearing torque of the discs, anuli fibrosi, and stretching of liga­
ments on the side opposite the sidebend. The entire lumbar group appears rotated to the left because of the left rotation of the subapical segments. Above
the apex segmental derotation occurs. A similar adaptation could be generated by a short left leg or an asymmetrical position of the sacrum between the ilia.

Type I Vertebral Dysfunctions

The principal restriction of a Type I (neutral type) dys­
function is sidebending, as opposed to Type II dys­
functions in which flexion or extension is the principal
restriction. In Type I dysfunctions, all the vertebrae in a
group are engaged in sidebending, as opposed to a single
vertebral unit. In the Type I dysfunction, flexion and
extension restriction exists secondary to the primary restric­
tion, which is sidebending. The contralateral rotation that
results, secondary to the sidebending, occurs in relatively
small increments, vertebra by vertebra, up to an apex,
where small increments of derotation commence.
However, if many such small increments take place in the
same direction, ultimately a very noticeable rotation of that
portion of the spine will be quite apparent, especially at the
apex of the curve.
The etiology of the Type I dysfunctions is adaptation
to a stressor or non-neutral dysfunction, and can be viewed
as an automatic adjustment of vertebral positions and pos­
tures to improve the body's relationship to gravity. Any
asymmetric element in the postural support system,
whether it is an anatomically short leg, a tilted sacrum, a
fractured vertebra, or simply a Type II segmental dysfunc­
tion, evokes an adaptation reaction as described above.
This describes both the group behavior of neutral adapta­
tion, which is reversible and therefore is not really a
dysfunction, and a Type I (group) lesion, which may be
treated by stretching the sidebender muscles which are the
primary restrictors.
Neutral Sidebending of Segments
Neutral Adaptation versus Neutral Dysfunction
Most of the time, the phenomenon of neutral adaptation
is spontaneously reversible once the cause of the adapta­
tion, a somatic dysfunction or other asymmetry, has been
removed. However, if the adaptation persists over a long
period of time, the neutral adaptations can become restrict­
ed themselves, unable to spontaneously reverse and
become normal after the non-neutral dysfimctions are
treated. Under those circumstances we can speak of neu­
tral (NSR), or Type I lesions, which are properly called
compensations. [Note: The difference between compensation and
adaptation has been discussed in Volume 1.] The NSR abbrevia­
tion stands tor Neutral Sidebent and Rotated. Placing
secondary to
the S betore the R indicates that the rotation is
the sidebending, and that they are not coupled ipsilateral
motions as they are in the cervical spine.
 CHAPTER 3 �BIOMECHANICS OF SEGMENTAL MOTION RESTRICTION
Adaptive and Secondary Nature of Neutral Segmental
Rotation
In order to accurately diagnose NSR dysfunction one must
first rule out, or correct, all instances of the non-neutral
segmental dysfunctions ERS and FRS. Whenever these
exist, there is necessarily, in adjacent parts of the spine,
some amount of adaptive neutral sidebending/rotation
caused by the ERS or FRS dysfunction. These adaptations
should not be considered manipulable lesions. They are
not lesions at all if they spontaneously resume normal func­
tion as soon as the non-neutral dysfunction is corrected. If
the rotational asymmetry persists after all non-neutral
dysfunctions are corrected, including sacroiliac dys­
functions, then the possibility of neutral (NSR)
dysfunction may be considered.
In NSR dysfunctions, the rotational asymmetry is
maximum when the spine is in its mid-range position with­
in the neutral (facets not engaged) range. Flexion or
extension may diminish the asymmetry, but not complete­
ly eliminate it. Flexion or extension will completely elimi­
nate the asymmetry of adaptive curves, but not NSR dys­
functions.
Adaptations to FRS or ERS segmental dysfunctions
may occur above and below the lesioned segment. The
adaptations above the dysfunctional segment are rather
predictable; they take the form of the neutral sidebent
group described above, with small increments of rotation
into the convexity up to and including the apex, and small
decrements of rotation from the apex to the top of the
curve. The length of the curve can vary from one segment
to many segments. Below the lesioned segment there may
be no adaptive shift of the vertebral segments, or an adap­
tive group may be seen with a convexity left or right.
Group adaptations over time may become group
dysfunctions (NSR).
39
Sidebending in the Lumbosacral - Sacroiliac Regions
The lumbosacral segment responds to neutral sidebending
in the same way as the other lumbars, with a small amount
of contralateral rotation. If the sacrum is moved by the
sidebending lumbar spine, it tends to form an extension of
the curve. Thus, if the lumbar convexity is to the left, the
sacrum tends to sidebend to the left, but not always by
rotating right on a right oblique axis. The left side of the
sacrum simply slides down the left auricular joint. Because
of the track of the auricular joint, this causes some anterior
nutation of the left side of the sacral base. Naturally, this
rotates the sacral base slightly to the right. Therefore, the
incremental left rotations of the lumbar convexity may start
with the fifth lumbar left rotating on the sacrum, and con­
tinue up to an apex.
A right lumbar convexity is more apt to produce a left
rotation of the sacrum on its left oblique axis. This predis­
position favoring left rotation on the left oblique axis over
right rotation on the right oblique axis is probably related
to the structural bias in the deep fascias' adaptation to the
torque of the Coriolis gravitational effect. The preference
for left unilateral sacral anterior nutation can also be
explained by the Coriolis effect. Opposite side preferences
have been observed in sacroiliac and iliosacral dysfunctions
of people living south of the equator, compared with resi­
dents of the northern hemisphere.
40 THE MUSCLE ENERGY MANUAL
Historical Notes and Comments on Fryette's Laws
The ERS and FRS terms derive from Harrison H. Fryette,
Principles of Osteopathic Technic (1954), but their meaning
has changed drastically. The meanings of R (Rotation) and
S (Sidebending) remain the same, but F (Flexion) and E
(Extension) have changed. Fryette preferred the physics
definitions of Aexion and extension, stating, "The dictio­
nary defines extension as the movement by which two ends
of an arc are separated, while flexion is the opposite of
extension." According to this definition, backward bend­
ing (BB) of the lumbar and cervical regions of the spine
would be flexion, the natural state of their A- P curves. He
did advise us that the last two thoracic vertebrae are part of
the lumbar "Aexion" curve.
Following this line of reasoning, Fryette considered
the entire spine to be "Aexed" in its normal, neutral state­
as he said, "with the facets idling." For this reason neutral
dysfi.mctions, "lesions" to Fryette, were "Aexed, sidebent
[one way] and rotated" [the other] - FSR. Placing the S
before the R was to indicate that the lesion was produced
by first sidebending, followed by (secondary) rotation.
This term was eventually dropped and replaced with the
more familiar "NSR."
ERS and FRS in the lumbars and cervicals were
defined by Fryette according to the "dictionary definition
of extension." Consequently they meant the opposite of
what they mean today. Our modern terminology considers
all forward bending (FB) of the spine to be "Aexion."
Much of our modern terminology - ERS, FRS, NSR,
Type I, Type II (and ESR, FSR tor the occipitoatlantal
joint), as well as other terms since discarded, were the out­
growth of arguments during the presentation of the
Academy of Applied Osteopathy "A" and "B" courses,
taught by Fryette, Hoover, Beckwith, Strachan, Beilke, and
others. Although Type I and Type II terminology is not
used in Fryette's book, the concepts are there.
Fryette's so-called "Laws" were formulated by this
Academy faculty. However, they could not bring them­
selves to accept Fryette's definitions of "Aexion" and
"extension," fortunately for us.
According to the Academy's revision of the Fryette
Laws, neutral spinal dysfunctions are classified as Type I
dysfunctions. Most habitual normal movements of the
spine follow Fryette's Physiologic Law I, the neutral
sidebending law. A modern formulation of Law I would
describe neutral physiologic sidebending as "uncoupled" to
rotation, i.e., the rotation may go in either direction,
depending on the placement of load. According to
Fryette, load combined with sidebending is an essential ele­
ment of Law I.
Type I dysfunctions (based on Law I) are extremely
rare, a fact not stressed by Fryette.
Far more common are Type II (non-neutral) dysfunc­
tions. The Type II dysfi.mction is based on Fryette's
Physiologic Law II - which remains clouded in controversy.
Fryette would have had us believe that a circumducting
lumbar or lower thoracic moving from hyperAexion to lefi:
sidebending to hyperextension to right sidebending to
hyperAexion will sequentially rotate left, right, leti:, right,
leti:, right before it comes back to the hyperAexed position.
Such a description strikes us as absurd. Yet, if Law II
applies to the hyperAexed and hyperextended sidebend­
ing/rotation coupling, and Law I applies to the mid-range
(neutral) sidebending/rotation, then these complex events
could be observed. So far, they have not been observed.
THE MUSCLE ENERGY MANUAL 41

PART II

Ribs and
Respiration
42 THE MUSCLE ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 43

CHAPTER 4

The Movements
of Normal Respiration

n Part I the anatomy and biomechanics of the thoracic spine

I were discussed, including the positional relationships of the

ribs to the thoracic spine. The major emphasis in Part II is
on the respiratory functions of the ribs. This chapter deals
with the normal respiratory movements of the ribs and other
parts of the body. Understanding normal function is the basis for
understanding abnormal functioning of the ribs, to be presented
in Chapter 5.
Exercises will be suggested to provide a hands-on opportu­
nity to observe these movements as a total body systemic function,
as well as to demonstrate normal breathing physiology. The
inclusion of noncostal breathing functions is to provide a broad
context for the evaluation and treatment of the rib cage, and to
emphasize that breathing is a total body function of the
motor system.
Every cell in the body breathes; if blood and lymph do not
circulate freely enough, the cells may be deprived of oxygen.
Only one-fourth of the total blood volume is pumped by the In this chapter:
heart. The heart provides the pressure ( 80-120+ millimeters of
• Respiratory functions of the
mercury) that pushes the blood through the arteries into the cap­
musculoskeletal system
illaries. The arteries contain 25 percent of the total blood vol­
• Respiratory motion/palpation exercises
ume. After the blood passes through the capillaries it must be
returned to the heart by way of the veins. The pressure pushing • The diaphragm and associated
it along its way is drastically reduced to l 0-12 millimeters of muscles of respiration
water (over atmospheric pressure), insufficient to move a column • Breathing movements of the pelvic
of blood from the foot to the heart. Ihus 75 per cent of the circu­ diaphragm

lating body ful ids is pumped by the actions of striated muscles and • Sagittal plane respiratory movements
the contractile endothelium of the lymphatic capillaries. The effi­ of the axial skeleton and sacrum
ciency of the circulatory effect of breathing is largely dependent • Bilateral respiratory movements
on the normal respiratory functions of the noncostal parts of the • Chest movements associated with
system. respiration
 �
44 THE M USC.LE ENERGY MANUAL � ----
�
�
.. ... :: . ....
: ·-··········· ··. .. : � : � : :.,: •I: �
�·
. . . . . ... .. . . :�� ;:.)
,··, ...
;· · ·

:=
. ._ .. . .... :.:: • •

·.>
�.... . , .. - . . ... .. . . .-··: : ··· .:.
..._·: ::::: _-::::.��;;sr_._ :
·
. .·
··

.. .....: .:
.

. .
· .
_.
. . . ·
:::
.- :

:
_:

r- �
.- 11th rib

Mr+---- 12th rib attachment ----+-----'-'--.-,":---:&Y

of Diaphragm

V�H----- Arcuate "ligament" -----+-----lr

over Psoas Major

A. Inhaled B. Exhaled

Figure 4.1 A and B The respiratory relationship of the thoracoabdominal diaphragm, quadratus lumborum. and anterior abdominal wall. As the
diaphragm contracts (AI- pulling the central tendon down for inhalation- the abdominal viscera push the abdominal wall out. Stretching the abdomi­
nal wall in this manner should require a minimum of effort, and needs abdominal muscle relaxation. The quadratus contracts to stabilize the twelfth rib,
which anchors the back of the diaphragm. Elastic recoil, rather than active muscle contraction, restores the exhaled position of the abdomen (Bl.
Forced exhalation (sneezing or playing a wind instrument! requires active contraction of the abdominal muscles.

The Diaphragm and Associated Muscles ofRespiration Quadratus Lumborum

The thoracoabdominal diaphragm is the primary mus­
cle of respiration. In the supine resting state, the actions
of the diaphragm, along with the reciprocal passive compli­
ance of the abdominal walls and pelvic floor, should be suf­
ficient to meet the respiratory and circulatory needs of the
body, without requiring any observable rib motion (Figure
4.3 A and B). Forced breathing and coughing recruit many
other muscles, the so-called "secondary muscles of respira­
tion." Assisting in the work of circulation -and cellular
Diaphragm contractions during respiration coordinate with
the contractions of the quadratus lumborum muscles, i.e.,
as the central tendon of the diaphragm pulls downward
during inhalation the quadratus lumborum can be felt to
contract simultaneously. As the diaphragm domes upward
during exhalation the quadratus lumborum can be felt to
relax. (Figure 4.1 A and B)
Quadratus Lumborum and Respiration Exercise

respiration - are the rest of the striated muscles of the body
and the cranial rhythmic impulse (CRI). The diaphragm,
which has been called the "heart of the venous system,"
needs all the help it can get from other striated muscles in
moving three-fourths of the total blood volume, especially
during periods of exercise.
Place your palms on the lower back of a prone or seated subject.
between the iliac crests and the twelfth ribs. the area spanned by the
quadratus lumborum muscle. Have the subject inhale forcibly. Of
course. the tissues will push out against your hands as the diaphragm
pushes down against the contents of the abdomen. But notice. also.
the hardening of the back muscles due to their contraction during
forced inhalation. and their softening as the breath is exhaled. Notice
that a cough, a sudden forced exhalation, also softens the quadratus
lumborum.
 CHAPTER 4 -&THE MOVEMENTS OF NORMAL RESPIRATION 45

Rectus abdominis

Transversus
abdominis

Figure 4.2 Postural support functions of abdominal muscles. Rectus
abdominis must hold the front of the pelvis up and the intestines in while at
the same time yielding to the physiologic movements of diaphragm
inhalation. Transversus abdominis provides segmental stabilization for the
lumbar spine. It is a true tonic muscle with a short chronaxie.
Figure 4.3 A and 8 Observing eupnea. A patient demonstrating eupnea
(Zink, 1970) in the supine position will show, among other things, full
abdominal wall participation in the work of breathing, rising all the way
from the xyphoid to the pubis with inhalation, and passively flattening with
exhalation. No active contraction of abdominal muscles is involved.
Energy is stored and released in the elasticity of the abdominal wall tissues.
The lumbars must remain flattened to the table.

Abdominal Rectus and Obliquus Muscles

The abdominal musculature relaxes with inhalation to
allow the diaphragm to move inferiorly and may tighten
during exhalation to assist the superior movement of the
diaphragm. Forced exhalation is accomplished by hard
contraction of the rectus and obliquus abdominal muscles,
as well as the muscles of the pelvic diaphragm, most evident
during coughing. These muscles may also have postural
and locomotor functions. However, their active participa­
tion should not be required for quiet respiration.
elasticity assists the doming up of the relaxed diaphragm,
without a need for them to actively contract. (Figure 4.2)
Rectus and obliquus abdominis muscles should not be used
vulnerability to inhibition from the tightness-prone lum­
bosacral extensors and iliopsoas muscles. Perhaps this vul­
nerability arises from its dual role as both postural and res­
piratory muscle. In some individuals the oblique abdomi­
nal muscles become tighter to compensate for weakness of
the recti. This alters the gait pattern, and reduces respira­
tory efficiency. Resistance exercises have little therapeutic
effect on rectus weakness, unless the inhibiting lumbosacral
Their extender muscles are first stretched (Janda, 1978 ).
Abdomen and Respiration Exercise

for spinal stabilization, the primary function of the trans­

If you place the palmar surface of one hand on the abdomen of a
versus abdominis (Richardson C, Jull G, et al., 1999).
patient in the standing position. the accommodation to breathing
When rectus and obliquus muscles substitute for transver­
should be easily felt. Observe the hard contraction during a cough.
sus, low back pain and/or costochondral pain often occur.
The rectus abdominis is notoriously prone to weak­
ness. Weakness of the recti reduces the ventilatory efficien­
cy of the diaphragm (Kapandji, 1974) and, by implication,
compromises ly mphatic and venous return flow (Zink,
1970 ). As a postural muscle it is seriously disadvantaged by
46 THE MUSCLE ENERGY MANUAL

Inhaled

1---'oc-- Pelvic Diaphragm -----+---1'''

�==��

Figure 4.4 Action of thoracoabdominal and pelvic diaphragms. The thoracoabdominal and pelvic diaphragms move in parallel. The muscular elements
of the diaphragm are activated by motor fibers within the left and right phrenic nerves, which also innervate the subclavius muscles. Even though con­
tractions are under voluntary control, the respiratory center in the floor of the fourth ventricle exerts absolute control. It places an absolute limit on the
length of time you can hold your breath, for example. When relaxed, the dome of the diaphragm- its central tendon- is held high in the thoracic cav­
ity by intrathoracic fascias, particularly the mediastinum, and by the tonus and elasticity of the abdominal walls which cause the abdominal viscera to
press up against the diaphragm. Contraction of the muscular elements of the diaphragm pulls the central tendon inferiorly, decreasing intrathoracic
pressure and increasing intra-abdominal pressure. Diaphragm may be inhibited by tight scalenes and pectoralis major. The pelvic diaphragm is an
important trunk stabilizer, co-contracting with transversus abdominis and the lumbar multifidi.

Accessory Breathing Movements

Breathing Movements of the Pelvic Diaphragms
Ischiorectal Fossa and Respiration Exercise
With inhalation the levator ani muscle descends and
expands laterally, obturating the ischiorectal fossa. The breathing movements of the pelvic diaphragm can be felt by pal­
Exhalation liti:s the pelvic organs and opens up the ischio­ pating the ischiorectal fossa, just medial and adjacent to the ischial
rectal tossa. (Figure 4.4) The pumping action on the tuberosity. Have the subject lie supine or on the side. Use your palm
venous plexus due to this respiratory action in the ischio­ to stereognostically locate the ischial tuberosity precisely, and then
rectal tossa moves large quantities of blood out of the place two or three finger pads on the medial aspect of the ischial
pelvis. The exhalation action may be passive elastic recoil bone. With gentle insistent pressure. push your fingertips cephalad
most of the time, just as it is in the abdominal muscles. But into the ischiorectal fossa. Have your subject inhale deeply, and feel
torced exhalation, as in coughing, evokes active contraction the levator ani muscle press laterally against the backs of your fin­
of the pelvic diaphragm muscles. It is reasonable to assume gers. Have your subject cough and feel the quick action of the leva­
that the urogenital diaphragm muscles act similarly to the tor and coccygeus muscles.
levator ani.
 CHAPTER 4 -IJ. THE MOVEMENTS OF NORMAL RESPIRATION 47

Respiratory Movements of the Axial Skeleton

Cranial Respiratory Movements
Just as inhalation expands the chest laterally, it widens the
whole body. The respiratory movements of some paired
structures of the body are very subtle and difficult to pal­
pate, unlike the pairs of ribs. The paired bones of the cra­
nium externally rotate with inhalation, widening the skull
slightly. Experienced cranial manipulators and unbiased
observers should be able to feel them.
Cervical Muscle Respiration Exercise
Feel the anterior lateral surface of the seated subject's neck with the
palmar surface of your hand and feel the contraction of the scalene
muscles as the patient inhales deeply. The effect of deep inhaling is
quite obvious. Now see if you can feel the different effects of inhal­
ing and exhaling on the third cervical versus the second.

Spinal Movements during Respiration

Cranial Respiration Exercises
Expansion of the chest is not the only sagittal plane motion
occurring with inhalation. A broad craniosacral principle
(Sutherland, 1948) is that inhalation causes flexion
throughout the body, including the base of the cranium.
Inhalation decreases the A-P diameter of the cranium, as it
flexes the sphenobasilar sy mphysis.
Exercise 1: Place the pad of your index finger on your own glabella.
a point on your forehead midway between your eyebrows. and take a
deep breath. As the midline bones of the cranial base flex. the eth­
moid bone tips back. moving the crista galli superiorly and posterior­
ly. The glabella follows. moving enough posteriorly that it can be felt
with your finger.
Exercise 2: While the A-P diameter of the head shortens. the trans­
verse diameter widens as the paired bones externally rotate. Place
your palms on the sides of your head above and in front of the ears.
Take a deep breath. Feel your head widen.
Note: If one side of the skull widens and the other does not. there may
be compression of the sphenosquamous suture on the unmoved side.
usually from head trauma. This is a lesion manipulable by a certified
cranial physician.
On inhalation a straightening (flexion) of the lumbar and
cervical lordoses occurs. Some flexion also occurs in the
lower thoracic segments. Whether this flexion occurs in
the entire thoracic spine is controversial, but is quite likely
in light of clinical observations (Kapandji, 1974). With
quiet breathing, the flexion and extension movements of
the intervertebral joints are almost imperceptible. When
track runners are out of breath, they often put their hands
on their knees and breathe into their backs, flexing the
lower thoracic segments with inhalation.
Spine and Respiration Exercises
Inhalation tightens (increases the bend) of the primary
(thoracic) curve of the spine and straightens the secondary
(cervical and lumbar) lordotic curvatures.
Exercise 1: Place your four fingertips in the midline of the back of
your own neck and take a breath. You may not be able to discern the
direction of the movement. but you can feel something happening.
Exercise 2: Have your subject lie prone and put your hand on the
small of the subject's back. When the subject takes a deep breath.
notice the posterior movement of the lumbar vertebrae.

Respiratory Synkinesis in the Spinal Muscles

Effects of Breathing on Cervical Muscles
As mentioned in Volume 1, inhalation tenses the side
flexor muscles bilaterally of the even-numbered cervical
vertebral segments, C0_1, C2_3, C4_5, and C6_7, while
relaxing the sideflexors of the odd-numbered segments,
C1_2, C3_4, Cs_6, and C7 -T1• The effect toggles with
exhalation. The phenomenon diminishes as one goes
down the spine, and is imperceptible in the thoracics. The
effect is quite useful in treating the upper cervical segments
with MET, because it enhances localization.
The anterior and medial scalene muscles pull the first
ribs up for deep inhalation. They may also selectively
sidebend individual cervical vertebrae. The posterior
scalenes run down to the second ribs where their attach­
ments make them "antagonists" to the iliocostales muscles.
Their usual function is not antagonistic, however, but pos­
tural stabilization by co-contracting with the iliocostales.
48 THE MUSCLE ENERGY MANUAL

A. B.

Figure 4.5 A & B Two methods of observing sacroiliac respiratory movement. In (A) the index fingers are on the two posterior superior iliac
spines to follow them while the patient takes a full breath. Respiratory restriction on one side makes the PSIS on that side move more than the
one of the other side, as indicated by the double exposure photographic technique. With deep inhalation, the caudal linear movement of the
hand should be about 3 millimeters greater than the caudal movement of the PSIS. In (8), double exposure photography and markers on the
skin over the gluteal tubercle and over the median crest of the sacrum were used to demonstrate and compare the inhaled and exhaled posi­
tions of the sacrum relative to the ilium. Notice that on the right the marker for the sacrum and the gluteal tubercle moved in parallel fashion
and the corresponding markers on the left did not move, indicating normal respiratory movement on the left and restricted movment on the
right. In practice, clinicians would use their hands and fingers, in place of the markers, to evaluate these relative respiratory movements.

Sacroiliac Respiration Exercise

Respiration moves the sacrum between the ilia (Mitchell, Jr

1979; Mitchell, Jr & Pruzzo, 1971 ). The straightening
lumbars push the base of the sacrum posteriorly with
'
inhalation. (Figure 4.6) \

'

Exercise: Place the palm of your hand on the prone subject's sacrum. \
I
Have the subject take a deep breath. Notice the rocking movement of
I
your hand on the sacrum. By placing a finger on the iliac crest land­ I

mark (near the dimple) you can observe the movement of the sacrum I

relative to the ilium (Figure 4.5 B). With a deep breath your hand on I

the sacrum should move about 3 millimeters more than your finger on
the posterior iliac spine. If they move parallel and equal distances.
there is respiratory restriction of the sacroiliac joint. a manipulable
lesion, usually unilateral. When the restriction is unilateral. it can be
easily detected in a prone patient by following the PSISs bilaterally Figure 4.6 Sacroiliac respiratory motion. Inhaled and exhaled sacral posi­
with your thumbs. and observing the thumbs for asymmetric move­ tions. Inhalation rotates the sacrum caudad on its respiratory axis, which
passes through the most anterior point on the auricular surfaces at the
ment during a deep breath. (Figure 4.5.A)
level of s2. The white sacrum is "exhaled." The dark sacrum is "inhaled."
 CHAPTER 4 �THE MOVEMENTS OF NORMAL RESPIRATION 49

First Rib Synchondrosis
Sternal Angle and Second
Rib Cartilage Oemifacets
Jugular Notch
Figure 4.8 Normal res­
piratory movement of
the sternum. Note the
hinge action at the
sternal angle. The
manubrium helps to
lift the superior medi­ I
I
astinum, thereby cre­
ating negative pres­
Sternal
sure changes in the
Angle
superior vena cava.
--�:::===:::::-..u
The white sternum is
"inhaled."

Chondrosternal
Articulations:

iv

Gladiolus
v

vi

vii
''
I'

'
'

'
'J

Figure 4.7 Anterior

view of the sternum.

Chest Movements
Sternum
The sternum is a movable bone. Not only is the entire ster­
num moved by the actions of ribs, but also the joints
between its three components- manubrium, gladiolus, and
xyphoid - are mobile, allowing hinge-like bending in the
sagittal plane. (Figure 4.7)
The relationship of the second and third ribs to the
sternum is worth noting. In man the third costal cartilage
Anterior Expansion of the Chest
As the upper ribs inhale, increasing the anteroposterior
dimension of the chest, there is a corresponding anterior­
superior expansion of the sternum. There are three trans­
verse axes across the sternum that allow this movement.
• Clavicular Axis - runs transversely across the manu­
brium from the head of one clavicle to the head of the other;

is the normal axis for respiratory movement of the sternal this axis allows the manubrium to swing anterior and supe­

body. Many sternum specimens when viewed from the side rior.

show a nearly perfect circular pit for the third costal carti­
lage facet and semilunar shaped facets for the fourth
through the seventh, indicating a pivotal action at the third
costal cartilage.
The normal breathing movements of the sternum
require slight hinge-like bending at the sternal angle. With
inhalation the manubrium tilts out, swinging from the clav­
icles. The body of the sternum moves superiorly, tilting its
superior portion anteriorly while the xyphoid end of the
sternum moves posteriorly. (Figure 4.8) In obesity the
sternal axis may be shifted up to the sternal angle, or even
• Sternal Body Axis - runs transversely across the body
of the sternum from one rib iii articulation to the other,
allowing the body of the sternum to pivot so that the supe­
rior portion travels superior/anterior while the inferior por­
tion travels superior/posterior.
• Sternal Angle Axis - runs transversely across the ster­
nal angle, and allows the gross sternal respiratory movement
during inhalation to be superior-anterior at this point.
Sternum Respiration Exercise

to the clavicles, causing the whole sternum to swing for­
ward with the manubrium.
Deformities of the sternum (funnel chest, pigeon
chest, congenital sternal fissures, and episternae) are com­
mon, and usually of little biomechanical significance. Some
sternal deformities are caused by scoliosis of the thoracic
spine.
Have your subject supine. Place one of your hands so that the fingers
lie transversely across the manubrium, and the other hand on the
body of the sternum with the fingers pointed cephalad. Let the ster­
num move your hands as the subject takes deep breaths. Can you
detect the hinge motion at the sternal angle? Abdominal obesity may
prevent it. Notice, especially, the anterior displacement of the ster­
num with inhalation.
 50 T H E M USC L E E N E R G Y M A N U A L

A. B. c.

Figure 4.9 A. B. C Pump handle. bucket handle, and caliper action in the rib cage. (See Table 4.A.I

Pump or Bucket Handle?

The anterior-superior movement of the anterior extremities
of the ribs is often referred to as "pump handle" move­
ment (in this case, obviously the kind of pump people used
to have in their yard near the house for getting well water).
It characterizes the principal action of ribs ii through v.
The body of the rib is the long lever arm which comes for­
ward to the sternum, the "handle" of the "pump." Lower
Lateral/superior expansion ("bucket handle" motion) of Ribs

these ribs also exists, but is a lesser motion. The ratio of

"pump handle" to "bucket handle" motion for a given rib
is determined by the orientation of the axis which passes
through the costovertebral joint and the costotransverse
joint. In the upper ribs these axes lie closer to a coronal
plane than the more sagittally oriented axes of ribs vi
through x. (Figure 4.1 0)
The transverse processes ofT 7 to T10 difler from the Figure 4.10 Respiratory axes of the ribs. Pump and bucket handle motions
transverse processes of the upper thoracics in that they are proportional, and largely determined by the respiratory axis of the rib.
The axis is an imaginary line passing through the two rib articulations with
angle backwards toward the sagittal plane. This posterior
the vertebra, costovertebral and costotransverse. The rib iv axis is closer
medial migration of the costotransverse articulation moves to the coronal plane than to the sagittal plane, allowing for relatively more
the respiratory axes of the lower ribs closer to the sagittal pump handle motion, in contrast to the tenth rib.
plane and accounts tor the "bucket handle" breathing
movements favored by these ribs. The transverse processes
ofT11 andT 12 are not large enough to provide costotrans­
verse articulations for their ribs.
All ribs move with complex combinations of pump
handle, bucket handle, and/or caliper motion. (Figure 4.9
and Table 4.A) Ribs ii, iii, and iv have a greater propor-
 CHAPTER 4 --&-THE MOVEMENTS OF NORMAL RESPIRATION 51

tion of pump handle movement as they rise and fall with

the sternum, lifted by pectoralis minor. This motion
enlarges the chest anteriorly. (Figure 4.11) Ribs i have
about half pump handle and half bucket handle motions,
acted on, in inhalation, by the anterior, medial, and poste­
rior scalene muscles. (Figure 4.12) In quieter respiration
they may be moved passively by the tilting manubrium, or
they may not move much at all. Ribs viii, ix, and x have
a greater proportion of bucket handle motion as they
increase and decrease the transverse diameter of the chest.
The caliper-type motions of ribs xi and xii, and, to some
degree, ribs ix and x, expand the chest posteriorly.

Anterior It1halation Action of the Rib Cage

The secondary muscles of inhalation are the scalenes (first
ribs), pectoralis minor (pump handle of ribs iii, iv, and v),
pectoralis major (pump handle of ribs ii through viii), ser­
ratus anterior (bucket handle of ribs ii through ix), and the
external intercostal muscles (varied). These are the principal
muscles that cause inhaling movement of the ribs.
Figure 4.11 Following rib motion with the hands. This photo was made by
double-exposing the same photographic frame, first with the subject com­
pletely exhaled, and then with the subject completely inhaled. The camera
Anterior Rib Motion - Respiration Exercise was on a tripod. This photogrammetric technique was later used to study
inter-rater reliability using the observation/palpation physical examination
With your subject supine on an examining table. you stand facing the
technique to evaluate respiratory movement of the ribs individually and in
table and place your palms flat on each side of the sternum with the groups (F. Mitchell, Jr. & Page-Echols, unpublished studyl. The distance
tips of your fingers just below the clavicles. The average-size hand between the two images of the fingertips was measured on each hand on
will cover the costal cartilages of the first five ribs. Ask the subject to each side of the chest, and compared left to right. Inter-rater reliability pro­
duced correlation coefficients greater than .75 for all subjects.
deeply inhale and exhale. Try to allow the moving costal cartilages to
move your hands. Observe your hands as they follow the anterior/
superior movement of the upper ribs. Notice the direction and ampli­
tude of this pump handle movement.

Table 4.A Pump/Bucket/Caliper Action Proportions

Costoclavicular
ligament

Rib# %Pum Handle %Bucket Handle %Cali er Action

1
2
3
4
5
6
7
8
9
10
11
12
Scales 0 50 100 0 50 100 0 50 100 Iliocostalis
Muscle

Rib Cage Respiration Exercise

Place the palmar surfaces of both hands in the mid-axillary lines just
above the waist of the supine patient to feel the lateral expansion of
the rib cage during inhalation.
Figure 4.12 Superior surface of first rib. Scalene, subclavius and
iliocostalis attachments to first rib. Note the attachment of the costoclav­
icular ligament.
52 TH F. MUSCLE ENERGY MANUAL

Respiratory Movmtents ofthe Paired Muscles

Even more subtle are the respiratory actions of the limbs.
Inhalation causes external rotation, abduction, and
flexion in all the extremities. Even though they are
extremely subtle, the twisting movements of the extremi­
ties can be palpated and observed visually. The outward
Longissimus turning of the anterior tissues occurs in a downward spiral
direction with inhalation, and spirals up and in with exhala­
tion. Changes in flexor and abductor muscle tonus are the
most difficult to perceive. The slight increase in flexor
muscle tonus does not produce perceptible movements of
the limbs, but its occurrence should be detectable by ultra­
sensitive electromyography.

Note: Weight lifters know that inhaling with Valsalva generally tens­
es muscles and "sets the joints." The general effect of exhaling is to
reverse this effect. This principle is often used to enhance relaxation
when using Muscle Energy Technique. Other. more specific. respira­
tory actions are also utilized in MET.

Extremity Respiration Exercise

Have your subject lie supine. Place the palms of your hands on the
anterior surfaces of both legs or both arms. Without watching the
chest. see if you can tell when the subject takes a deep breath.

Figure 4.13 Divisions of the erector spinae. The erector spinae muscles
iliocostales
are arranged in three vertical columns: the most lateral are the
(vertical lines). the most medial are the spinales (light grey), and in
between them, the longissimus (dark grey). Their posterior contours are
slightly cylindrical, especially palpable in the region of T4 to T10.
1/iocostales attach to the rib angles. and are usually inhaler muscles.
Longissimus attaches to vertebral laminae and transverse processes with
a few slips to the rib necks. It is a spinal extender.

Posterior Inhalation Action of the Rib Cage

With inhalation the posterior shafts of the ribs at the rib
angles move cephalad, just like the anterior rib shafts.
However, they are restrained by the action of the iliocostales
muscles, which draws the rib angles inferiorly with inhala­
tion, causing the anterior extremities of the same ribs to
move anteriorly and more superiorly than the rib angles.

Posterior Rib Motion - Respiration Exercise

With the subject in the prone position. place the palmar aspects of
both hands bilaterally on the angles of the ribs and feel their motion
during inhalation. Let the rib angles move your hands. Do the same
in the seated position. Notice that inhalation moves the rib angles
less superiorly. compared to the anterior chest.
 CHAPTER 4 �THE MOVEMENTS OF NORMAL RESPIRATION 53

Breathing Movement Styles The Circulation - Respiration Connection

The secondary muscles of respiration are intricately coordi­ In addition to aeration of the lungs, the breathing move­
nated to provide a symphonic spectrum of firing sequence ment of the chest has a circulatory function. J. Gordon
patterns which may be preferentially selected by cortico­ Zink ( 1970) has described eupnea as normal breathing
spinal mediators according to the respiratory and circulato­ activity and posture in the supine resting state. The impor­
ry needs of the body. Thus, different combinations, pro­ tance of such standards can hardly be overstated. Normal
portions, and sequences of abdomina-diaphragmatic basal respiration (eupnea) described in Zink's terms is the
breathing, lower costal breathing, middle costal breathing, foundation for the body's ability to breathe properly in
and upper costal breathing are available to meet changing other postures and activities. A later work will discuss the
physiologic requirements as circumstances of rest, exercise, diagnosis and treatment of dysfunctions in the context of
or stress vary. the anatomy and neuromuscular physiology of the respira­
While all these breathing movements are automatic tory-circulatory paradigm (cf. Mitchell, 1984 ). This area
and will occur without our having to think about them, of knowledge and skill has wide clinical applications. The
they are also subject to voluntary control. Thus there is the respiratory-circulatory paradigm of J. Gordon Zink pre­
possibility of breathing in specific ways to enhance health. sents an important alternative model for clinical problem
With practice, a person can learn to activate specific verte­ solving in internal medicine and general surgery.
bral joints with breathing. Controlled breathing is a
health-enhancing aspect of yoga training, for example.
The concept of ideal human posture varies from cul­
ture to culture. In the Huna Polynesian culture of Hawaii,
the socially accepted ideal posture is one which encourages
the physiologic breathing movements of the spine
(Kenneth Little, D.O., personal communication), a breath­
ing into the back, rather than the chest and abdomen. The
western, northern European, cultures have adopted a more
militaristic postural standard - "Stand tall and stick your
chest out!" It is very hard to breathe into your back in that
position . Yet, we can see people with air hunger - track
sprinters immediately after a race, for example - with their
hands on their knees breathing into their backs - presum­
ably the quickest way to pay off an oxygen debt.
Learning to breathe into the back can add a new
dimension to self-treatment, and the skill can be added to
MET procedures to enhance their effectiveness. In the
craniosacral concept the Primary Respiratory Mechanism
(PRM) is manifested throughout the body. Because inhala­
tion generally causes flexion, external rotation, and abduc­
tion, both tl1e kyphotic and lordotic portions of the spine
forward bend slightly with breathing in.
54 T H E M U S C L E ENERGY M A N U A L
 THE MUSCLE ENERGY MANUAL 55

CBAPTER 5

Respiratory Restrictions
of the Ribs

S
ince the first manual on MET was published (Mitchell, Jr.,
Moran, & Pruzzo, 1973), the author has come to a differ­
ent understanding of the priorities and relationships in the
evaluation and treatment of somatic dysfunction in the tho­
racic region. This understanding has led to the development of a
new algorithm for trunk evaluation that gives primacy to costoverte­
bral relationships. It has become apparent that thoracic vertebral
segmental dysfunction causes the vast majority of respiratory
movement restrictions of the ribs. The rest of respiratory rib dys­
functions, a small percentage, are due to two classes of structural rib
lesions: rib subluxation and intraosseous rib deformity, and to "pri­
mary" respiratory rib dysfunctions. (See Tables S.A and S.B.)
Evaluation of the thoracic region has undergone much meta­
morphosis as the functions and dysfunctions of ribs, thoracic spine,
and other elements of the thorax have begun to reveal themselves as
more integrated than they once seemed. In fact, they are so inte­
grated that it is possible, and usually preferable, to diagnose tho­
racic vertebral dysfunctions through analysis of rib motion
impairment.
Vertebral dysfunctions and structural rib lesions almost always
impair breathing motion of the rib. In very chronic vertebral dys­
function and long-standing structural rib lesions, breathing motion
In this chapter:
is rarely spontaneously recovered, unless there is a strong demand
for it because of exercise. Because respiratory movement impair­ • Step breathing
ments that are secondary to vertebral dysfunction tend to persist, • Differential diagnosis of respiratory rib
performing a screening examination of the ribs in order to deter­ lesions
mine the presence or absence of thoracic vertebral segmental dys­ Pump handle
function has proven to be a reasonable alternative to direct examina­ Bucket handle
tion of vertebral processes, with some unique advantages that will be Inhalation

explained in the following chapters. Direct visual/palpatory Exhalation

examination of the thoracic transverse processes may be used to • Scanning for the key rib
• Treatment procedures for inhalation
confirm the rib-based thoracic diagnosis.
restriction
This chapter is about finding the "key" rib lesion and defining
Ribs i through x
its functional impairments in sufficient detail to effectively treat it as
Ribs xi and xii
if it were a "primary" rib lesion. If such an entity as a "primary res­
• Treatment procedures for exhalation
piratory rib dysfunction (lesion)" exists, it must be extremely rare,
restriction
because treatment of the associated vertebral or structural rib lesion
Ribs xii through x
nearly always resolves the respiratory impairment. However, the
Ribs x through vii
clinical skills required to find and define the "key" rib, presented in
Ribs vi through i
this chapter, are needed for vertebral segmental diagnosis covered
in later chapters.
56 THE MUSCLE ENERGY MANUAL

Table 5.A Definitions of Terms Describing Manipulable Disorders of the Trunk

Vertebral Segmental Abnormal motion restriction between two vertebrae, usually asymmetrical. Synonyms:
Dysfunction osteopathic lesion. spinal somatic dysfunction. segmental dysfunction.

Key Rib T he rib to be treated in a group of ribs with respiratory restriction. the "primary rib lesion." or the rib
attached to the primary vertebral dysfunction responsible for the breathing restriction. If the group
has restricted inhalation, the key rib will be the most superior rib in the group. If the group has
restricted exhalation, the key rib will be the most inferior rib in the group. Generally, the key rib
identifies. by number. the thoracic vertebra with segmental dysfunction. which is the usual cause of
rib breathing restriction.

Structural Rib Lesion Abnormal alteration of the position or shape of a rib. A generic term for intraosseous deformity,
such as torsion or compression. or subluxation (dislocation) of a rib. Lay synonym: the rib is "out."
Structural rib lesions restrict breathing movement.

Respiratory Dysfunction of a Rib Reduced duration and distance of normal rib breathing movement. characterized by restricted exha­
lation or inhalation motion, compared with the contralateral side. Synonyms: costovertebral somatic
dysfunction. rib lesion. For purposes of this manual. respiratory dysfunction of the ribs is opera­
tionally defined as an abnormal or asymmetric decrease in the duration of the respiratory
motion of the ribs. Where the shape of the chest is symmetrical. this is equivalent to a decrease
in their range of motion. (NOTE: In rib cage deformities due to scoliosis the ribs on one side may be
crowded together. and spread apart on the other side. Restricted breathing movement on the
spread-apart side will have a shorter duration of movement even though the distance the rib moves
may be greater than the distance on the crowded side. Clearly, then. the object of the following
treatment procedures is to increase the range of motion of the affected ribs to normal. not to put
ribs back in place as in treating rib subluxations.)

Primary Rib Lesion Abnormally restricted exhalation or inhalation motion of a rib not caused by a vertebral segmental
dysfunction or a structural rib lesion. The restriction is intrinsic to a single rib. The cause is usually
(Respiratory Rib Dysfunction}
neuroreflexive. Treatment reprograms spinal cord reflexes.

Primary Respiration Defined otherwise in other contexts. In the craniosacral model (Sutherland,1939) the Primary Res­
piratory Mechanism (PRMI is defined as the rhythmic oscillations of the brain, cerebrospinal fluid,
dural membranes. osseous-articular kinematics of the skull, and the involuntary rocking of the
sacrum. Even more basic and "primary" is the respiration which occurs at the cellular level. This is
where oxygen leaves the erythrocyte in the capillary blood vessel, passes through the capillary wall.
enters the interstitial fluid that surrounds the cells, is captured and pulled through the cell mem­
brane into the cellular cytoplasm where a specific exothermic oxidation reaction occurs under the
direction and regulation of mitochondria. This cellular respiration event is quite rapid; it requires 0. 7
seconds. Stirring of the interstitial fluids by the PRM may be a necessary condition for cellular respi­
ration and survival.

Secondary Respiratory Restricted exhalation or inhalation motion of a rib due to vertebral segmental dysfunction or struc­
Rib Dysfunction tural rib lesion. Treatment is applied to the vertebral segmental dysfunction or to the structural rib
lesion. After successful treatment normal respiratory rib movement is restored. Treatment applied
to the restricted rib also restores respiratory motion, but only temporarily.

The eJJaluation of respiratory rib motion is a basic early
step in identifying and defining vertebral segmental dys­
function according to the new integrated model. The
treatments for respiratory rib dysfunctions are included to
bolster self-confidence in rib diagnosis skills, since the cor­
rectness of the pre-treatment diagnosis can be confirmed
by post-treatment evaluation.
Diagnosing Respiratory Rib Dysfunction: Overview
The evaluation and treatment procedures for rib dysfunc­
tion presented in this chapter will be done with the subjects
resting recumbent: supine for the upper ribs- prone for the
lower ribs. The subjects will be required to voluntarily con­
tract and relax the secondary muscles of respiration by
breathing on request.
To streamline and also increase the sensitivity of the
procedures, emphasis will be on the minor breathing
motions of the ribs, where the highest frequency of
dysfunction is to be found. Thus, greater emphasis will
be placed on the bucket handle movements of the upper six
ribs (whose major movement is pump handle); the pump
handle movements of ribs vii through x (whose major
movements are bucket handle); and the caliper movements
of the xi and xii ribs. (Figure 5.8; also see Chapter 4.)
In evaluating tor respiratory dysfunction of the ribs,
attention will also focus on the breathing motions of the
ribs that are associated with the end range of full inhalation
and the end range of full exhalation. For example, to reli­
ably detect exhalation restriction, it is important to have
the patient exhale completely. A rib with restricted exhala­
tion will stop moving down before the "normal" rib on the
other side has finished its exhalation movement. After the
patient has exhaled completely, the inhalation will begin
with movement of the normal side, joined later by the
restricted side. This is the jknctional description of exhala­
tion restriction. Positionally, the rib with exhalation restric­
tion can be described as being "up." The rationale for
describing the rib with restricted exhalation as being "up"
is based on the observable phenomenon that occurs when
the rib cannot participate in the end range of exhalation
because it is stuck in an "up" position.
Conversely, with inhalation restriction the restricted
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS 57

respiratory motion of a rib will be evident toward the end Table 5.8
of full inhalation. Only the unrestricted rib will be able to
Manipulable Disorders of the Trunk
fully inhale because the rib with restriction is stuck in a Relevant to Muscle Energy
"down" position, and cannot fully inhale. Likewise, at the
I. Vertebral Segmental Dysfunction
beginning of exhalation from the condition of full inhala­
Types Causes
tion, the examiner will notice movement of the unrestrict­
ed rib first, followed a moment later by the rib with restrict­ ERS A. Motor System Stress

ed inhalation. 1. Direct trauma to vertebral

FRS
To make small exhalation restrictions more obvious, segment

the patient may be instructed to exhale completely and B. Reflexes

then breathe in and out in fast, short breaths. Similarly, to 1. Viscero-somatic Reflexes
make small inhalation restrictions more obvious, the 2. Somato-somatic Reflexes

patient may be instructed to inhale completely and then

breathe out and in with quick, short breaths. This is called ERS or FRS dysfunctions can be expressed as either:
-Major dysfunction > 50% segmental motion loss
step breathing.
-Minor dysfunction< 50% segmental motion loss
When no parallel rib movement is observed with either
inhalation or exhalation, forced inhalation or exhalation
NSR C. Postural Adaptation (chronic)
may be necessary to establish whether the restricted rib is
1. Adaptation to a mechanical stressor
"up" or "down." A restricted rib that begins to move with (other somatic dysfunctions,
forced inhalation is considered "up." A restricted rib that anatomic abnormalities, etc.)
begins to move with forced exhalation is considered
"down." 2. Adaptation to emotional stress

Note: Observing the behavior of the soft tissues of the rib cage through­
out the full respiratory cycle is unnecessary and irrelevant to step breath­ II. Structural Rib Lesions
ing analysis. In fact. it can be quite misleading. The extra effort of mus­ Types Causes
cles trying to move restricted ribs may be palpated and misinterpreted as
A.lntraosseous Deformities (ribs v-ix)
greater rib motion. There may be a lot of asymmetrical activity in these
1. A-P Compressions Trauma
tissues, but it does not correlate well with the range of motion end point
Lateral Compressions Trauma
analysis by which the effectiveness of MET treatment will be evaluated.
Fortunately, rib dysfunctions are very forgiving, and can often be correct­ 2. Rib Torsions* Vertebral Segmental
ed with imprecise technique, or even a few deep breaths. Dysfunction

3. Persistent Rib Torsion Trabecular Remolding

Rib Cage Screening Procedures
In Volume l, screening procedures were presented that B. Dislocations/subluxations (ribs i-x)
would determine if respiratory motion impairment could 1. Superior (ribs i) Scalene Spasm
be found for a group of ribs. When groups of ribs are 2. Bucket Bail (ribs ii-v) Probably Trauma
found with breathing motion impairment, usually one 3. Anterior (ribs i-x) Trauma
4. Posterior (ribs i-x) Trauma
"key" rib is the cause of the group motion restriction.
In this chapter, we will describe in more detail the proce­ *Note: A rib torsion is not considered a lesion unless it is persistent. !See
Chapter B.)
dures used to screen for asymmetric respiratory rib
restriction. If applied with palpatory sensitivity, these pro­
cedures can reveal if a dysfunction of a single key rib is pre­ Ill. Primary Rib Lesion or Respiratory Rib Dysfunction

sent within a group of ribs.

Causes
The step breathing method is preferred for screening
Secondary to:
procedures. It is recommended that beginning students
Vertebral Segmental Dysfunction > 95% of cases
start with the subject lying supine, until the psychomotor
Structural Rib Lesion <4% of cases
skills of eye-hand coordination involved in these test pro­
cedures are mastered. Those skills can be later carried over Neuroreflexive
for use in seated tests. (See Figure 5.1.) Primary Respiratory Rib Dysfunction <0.01% of cases
Pump handle up,
Note: Table 5.8 outlines the manipulable disorders covered in Parts II
Bucket handle up,
and Ill. The purpose of the table is to orient the reader to a system of
Pump handle down,
manipulable disorders of the trunk. It begins with vertebral segmental
Bucket handle down
dysfunctions, which are the most frequently encountered manipulable
disorders of the trunk. However, the order of presentation in this book is Note: Percentages are based on the author's clinical impressions.

reversed because accurate diagnosis of vertebral segmental dysfunction

is facilitated by initial examination of the ribs for respiratory dysfunction.
58 THE MUSCLF. ENERGY MANUAL

Figure 5.1 Figure 5.2 Figure 5.3

Step Breathing Method for Supine Screening for Exhalation or Inhalation Restriction: Figure 5.1 Bucket handle assessment of the upper 5 or 6 ribs.
An abbreviated screening procedure might use only the bucket handle contacts. In female patients, the tender areas of the breasts can be avoided by
staying close to the sternum for the pump handle assessment, and palpating close to the mid-axillary line lateral to the pectoralis tendon for bucket
handle assessment. Figure 5.2 Pump handle assessment of the upper 5 or 6 ribs. Figure 5.3 Pump handle assessment of middle ribs (vi- x).

Screening for Exhalation or Inhalation Restriction

of the Ribs (Step Breathing Method)
l. Patient lies supine on the examining table. This posi­
tion is somewhat better than the seated position, because it
allows for relaxation, which makes palpation of the ribs eas­
Jer.
2. You stand facing the side of the table, so that when
your face is turned toward the head of the table your dom­
inant eye is nearer the table. Lean forward and turn your
head so that your dominant eye is over the mid -line of the
patient's chest. Keep your eyes on that mid-line.
3. Place your palms over the anterior lateral aspect of the
upper 4 or 5 ribs, fingertips just below the clavicals, heels
of the hands lateral and posterior to the pectoralis major
tendons. Slide the skin and soft: tissues over the ribs by
slight movement of the hands until the location and shapes
5. Instruct the patient: 'Take a full breath in. Now, let
half of your breath out and quickly take it i�z again.'' This
step breathing may be repeated, if necessary. I:oUow the move­
ment as in Step 4.
6. Move your hands to cover the next lower group of ribs
with your thumbs in the parasternal position and fingers
pointed up and out. (Figure 5.3) Repeat Steps 4, 5, and 6.
Note: Respiratory movements of the rib angles can be screened after
sliding the scapulae laterally (Figure 5.4). The prone position provides
access to the lowest ribs for screening or scanning purposes (Figure 5.5).
Interpretation of Results
• If both sides move together at the same time

of the ribs can be stereognostically palpated. (Figure 5.1) through the full range ofinhalation and exhalation, there

Because bucket handle movement of the upper ribs is is no rib impairment, or there is bilateral impairment.

smaller than the pump handle movement, it is more fre­
quently impaired. One has a greater chance of finding
movement asymmetry with the bucket handle hand con­
tacts on the upper ribs. The converse is true with the lower
ribs. Pump handle screening contacts tor the upper ribs is
shown in Figure 5.2.
4. Instruct the patient: ((Let your breath all the way out.
Now take half a breath in and let it out.» This step breath­
ing may be repeated, if necessary. When the ribs move, fol­
low their movement with your hands. This is the palpato­
• In Step 4, if one side moves tor a shorter duration
toward the end range of exhalation, or not at all, then the
ribs are "up" positionally and have restricted exhalation.
• In Step 5, if one side moves tor a shorter duration
toward the end range of inhalation, or not at all, then the
ribs are "down" positionally and have restricted inhalation.
• If"up," find the key rib at the bottom of the restricted
group.
• If "down," find the key rib at the top of the restricted

ry part of the procedure. Monitor your hand movement group.

using your peripheral vision by focusing on the sternum.

This is the visual part of the procedure.
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS 59

Figura 5.4 Figure 5.5 Figura 5.6

Prone Rib Contacts for Step Breathing Tests: Figura 5.4 Prone rib contacts for step breathing tests of the middle ribs. When the scapulae are approxi­
mated, as in horizontal extension of the upper extremities, they cover the first eight rib angles. Horizontal flexion of the arms uncovers these rib angles
for palpation and counting ribs. Figura 5.5 Prone screening for the lower ribs. Figura 5.6 Screening the eleventh and twelfth ribs.

Individual Rib Respiratory Diagnosis

How the Key Rib Causes Restriction of a Rib Group
The mechanism of respiratory restriction of ribs is consid­
ered to be neuroreflexive, regardless of whether the restric­
tion is primarily respiratory or is secondary to vertebral seg­
mental dysfunction or to a structural rib lesion.
The actions of the respiratory muscles which move the
ribs are coordinated in specific patterns to insure appropri­
ate firing sequences. These firing sequence programs are
probably set up in spinal cord interneurons, and may be
preferentially selected by corticospinal mediators according
to the respiratory and circulatory needs of the body at a
particular time.
The intersegmental reflexes which coordinate respira­
tory muscle activity determine what we observe when the
respiratory motion of a rib is abnormally restricted. When
inhalation motion is restricted for one rib, the inhaling
muscles, which attach to that rib and pull its anterior and
lateral shaft superiorly, are not permitted to complete a full
contraction. Regardless of what opposes their action, the
ipsilateral ribs below the abnormally restricted rib tend to
be affected by the lesioned rib so that their inhalation
movement is also abbreviated. The number of ribs which
may be affected in this way is variable. The important
thing to remember is to treat the most superior rib
when inhalation motion is restricted, and the most
inferior rib when exhalation is restricted. The ribs
below or above the restriction will usually self-correct, and
therefore do not usually require treatment.
A mechanical analogy of this mechanism is permissible
in order to understand the concept. One may think of a rib
that cannot go down as "blocking" the ribs above it and a
rib that cannot go up as "blocking" the ribs below it.
The mechanism whereby vertebral segmental dysfunc­
tion causes rib restriction is unclear. It could be strictly
mechanical, i.e., ligament tension and bone position. Or it
could be from altered proprioceptive reflexes, a neurophys­
iologic response to nociception or vertebral joint proprio­
ception.
Locating the Key R i b
The "key" rib concept applies t o those instances when a
group of ribs is exhibiting respiratory restriction. If
restricted respiratory motion of a rib is unilateral during the
first portion of exhalation, it should not be confused with
exhalation restriction which occurs during the last portion
of exhalation. The nonmovement may be the result of
restricted inhalation of one of the upper ribs- the "key" rib
- in which case symmetrical bilateral movement will be seen
toward the end of exhalation. On the other hand, ribs with
restricted exhalation tend to restrict the exhalation of the
ribs above a "key" rib. These ribs will be able to finish
inhalation symmetrically. Therefore, the lowest rib with
exhalation restriction is the key rib, and is the one to be
treated first.
60 THE MUSCLE ENERGY MANUAL

\ I

C11

figure 5.7 Finger pad placements for monitoring breathing movements of the ribs. Both first and second ribs are monitored with finger pads in the first
intercostal space. First rib pump handle motion contacts (P) are against the inferior rib margin on either side of the manubrium. Their bucket handle
contacts (B) are lateral at the point where rib i passes under the clavicle. Pump handle contacts are at the costochondral junctions. With the excep­
tion of the first three or four ribs, the finger contacts for bucket handle respiratory movement evaluation should be in the mid-axillary line. The smaller
lateral view shows bucket handle contacts from a spatial perspective. Cll and C12 are for the caliper actions of the floating ribs.

Since the key rib for inhalation restriction is at the
top of the "down" rib group, and the key rib for exha­
lation restriction is at the bottom of the "up" rib
group, we know approximately where to start looking tor
the key rib, and which direction to go, up or down, in our
search tor the key rib. This search involves tollowing a
matched pair of ribs with palpating fingers, one pair at a
time, while they move with breathing, until coming to a
pair of ribs that moves symmetrically. (Figure 5.7)
Having located the maintaining rib dysfunction (the
highest if inhalation is restricted, the lowest if exhalation is
restricted), it is often important to know if pump handle
(anterior) or bucket handle (lateral) rib motion is the great­
est restricted motion. After all, the ribs are acted on by
many difterent muscles, some of which move the anterior
portions of the ribs while others move the lateral portions.
Etlective treatment sometimes depends on making a diag­
nosis with this degree of precision.
Pump handle and bucket handle motions of the first
ribs can be monitored with the index fingers in the first
intercostal spaces by contacting the interior aspect of the
first rib cartilages with the fingertips, just lateral to the
manubrium tor pump handle and one to two inches more
lateral tor bucket handle monitoring. Even an inch lateral
on the first rib is far enough to monitor bucket handle
motion because of the size and shape of the rib. Palpating
the first rib through the supraclavicular tossa is more diffi­
cult.
The superior aspect of the second ribs and their carti­
lages can be palpated through the pectoral soft tissues trom
the sternum to the axilla by gently pressing the fingertips
into the fleshy space above the second ribs - the first inter­
costal spaces.
 CHAPTER 5 -tJ. RESPIRATORY RESTRICTIONS OF THE RIBS 61

Lower
Ribs

Figure 5.8 Bucket handle and pump handle motion. A simple model for
describing the differences in rib motion between the upper and lower tho­
racic can be visualized if one imagines a line (in the transverse planel
between the head of the rib at the costovertebral joint on the vertebral
body and the neck of the rib at the costotransverse joint on the anterior sur­
face of the transverse process. This line approximates the axis of respira­
tory movements for the rib. It can be observed that the axis of respiratory
movement for the upper ribs is nearly coronal. For the lower ribs, the axis
of respiratory movement is closer to a sagittal plane owing to the posterior
angulation of the vertebral transverse processes. Obviously, there are
muscles which produce primarily pump handle motion and other muscles Figure 5.9 Finger contact points for posterior rib scanning with the
which produce bucket handle motion. Depicted here are the second and patient in the prone (or seated) position. The 8(#1 represents bucket
seventh ribs, for comparison, showing predominant pump handle and handle contact points, and the C(#l represents caliper contact points.
bucket handle motions, respectively.

Counting and Monitoring Individual Ribs

Scanning Procedures for the ccl(ey)) Rib
Supine and Prone Scanning Examinations
The procedures will start with a search for the key rib. This
will involve scanning the ribs, a pair at a time, from the top
down for exhalation restriction, or from the bottom up for
inhalation restriction, depending on the results of the
screen. Once the key rib is found, its pump handle and
bucket handle motions will be evaluated comparatively to
see which demonstrates the restriction more emphatically.
Treatment techniques will then be described for mobilizing
a key rib with restricted inhalation, pump or bucket handle.
Searching for the key rib with inhalation restriction may
start as low as ribs xii and go up. Treatment for restricted
inhalation will also be presented from the bottom up, start­
ing with rib xii. For the finger contacts to assess respirato­
ry restrictions of ribs vii through xii in the prone position
or posteriorly, see Figure 5.9.
Reliable detection of rib motion asymmetry requires the
following:
(a) the ability to palpably locate specified anatomic
landmarks,
(b) the ability to palpably and visually determine
structural or congenital anomalies,
(c) the ability to visually discern and assess bilateral
asymmetries (both static and dynamic) of the ribs.
When examining one pair of ribs for breathing movement
asymmetry, placement of the palpating fingers in the inter­
costal spaces is important. So is the position of the exam­
iner's eyes, to the advantage of the dominant central and
peripheral visual fields.
Possible descriptors for respiratory rib dysfunction are as follows:
Ribs i through x may have:
( 1) restricted pump handle inhalation,
( 2) restricted bucket handle inhalation,
( 3) restricted pump handle exhalation, or
(4) restricted bucket handle exhalation.
Ribs xi and xii may have:
( 5) restricted caliper motion inhalation,
( 6) restricted caliper motion exhalation.
62 T H F. M U S C L F. E N E R G Y M AN U A L

Figure 5.11 Pump handle

finger contacts for evalu­
ating the respiratory
movement of the first
ribs: Finger pads in the
first intercostal spaces
on each side of the
manubrium; fingertips
against inferior edge of
the first costal cartilage.
Use the fingertips to per­
form the evaluation.

Figure 5.10 Bucket handle finger contacts for evaluating respiratory

movement of the first ribs: Finger pads are against the inferior edge of
the first costal cartilage just before it disappears underneath the clavicle.

Figure 5.13 Pump handle

contacts for second ribs:
Finger pads in the first
intercostal spaces on
each side of the
manubrium contacting
the superior margin of
the second costal
cartilages. Use the
fingerpads to perform the
evaluation.

Figure 5.12 Bucket handle finger contacts for evaluating respiratory

movement of the second ribs: Finger pads in the first intercostal spaces
palpating the superior edges of the second ribs through pectoralis major
tendon.

Scanning for the Key Rib (ribs i through xii)

The Procedure
l. The patient is supine. The seated position may be pre­
ferred by more experienced practitioners, who may be
using this part of the procedure for vertebral diagnosis.
2. You stand at the side of the table corresponding with
your dominant eye. Position yourself so that your domi­
nant eye is over the midline.
Note: Except for the first rib, the finger pads should be placed on the
superior margins of the bony (not cartilagenous) part of the pair of ribs.
The tips of the fingers will be in the intercostal spaces. To follow the first
rib. the fingertips will be in the first intercostal spaces. between the first
and second ribs. touching and following the inferior margins of the first
rib costal cartilages. The close positioning makes Figures 5.11 and 5.13

Note: It is usually more comfortable to stand facing the table, and bend appear almost identical. but in Figure 5.11 the finger!iJ:ls are used for eval­

slightly forward, then rotating your trunk to permit the visual alignment uation- for Figure 5.13 it is the fingerJlill[s.

-compared with sidebending your trunk to achieve this.

3. You use the pads of your fingers to palpate motion as
you concurrently observe it. Your finger pressure should
be light enough not to interfere with rib motion, but firm
enough to maintain a positive contact with each rib and to
follow it as it moves.
4. Start by choosing a pair of ribs within the group
demonstrating restricted motion. The group can be very
small, and even limited to one rib, the first, tor example. If
you are not sure about the screen, start with the first ribs.
(The alternative would be to start with the twelfth ribs,
which requires turning the patient prone.)
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS 63

Figure 5.14 Bucket han­ Figure 5.15 Pump han­

dle contacts for third rib dle contacts for the
bucket handle: Finger third ribs: Finger pads in
pads in second inter­ the second intercostal
costal spaces, palpating spaces on each side of
through pectoralis major the sternum resting on
myotendinous portion. the superior margins of
the third costal carti­
lages.

Figure 5.16 Fourth rib Figure 5.17 Pump han­

bucket hand!e contacts dle evaluation of fifth
in mid-axillary line, ribs: Finger pads in
inferior and posterior to fourth intercostal
the pectoralis major spaces.
tendons, lateral to the
breast; fingertips under­
neath the tail of Spence.

Figure 5.18 Bucket han­

dle finger contacts for
ribs vi.

5. At this point, introduce step breathing. At each

monitoring point ask the patient to let all the breath out,
take half a breath in, and let it out again. Look for one rib
moving while the other rib (the lesion side) does not move.
This will disclose a rib with exhalation restriction. Now
have the patient take a full breath in and let half out. Again,
observe for one-sided movement, indicating restricted
inhalation of the nonmoving rib.
6. Continue up, or down, the rib cage, monitoring one
pair of ribs at a time until you come to a pair exhibiting
symmetrical movement, or until you reach the top or bot­
tom rib demonstrating the restriction (the key), or rib x,
whichever comes first.
64 THE MUSCLF. ENERGY MANUAL

Figure 5.19 Sixth rib

pump handle evalua­
tion. Notice the diver­
gence of the fingers'
contacts following the
intercostal angle below
the xyphoid.

Figure 5.20 Bucket handle contacts for rib x. Observe the finger move­
ment with your peripheral vision.

Figure 5.21 Tenth rib pump handle evaluation. Rngertips are just lateral
to the confluence of costal cartilages.
Figure 5.22 Tenth rib contacts: At the tenth ribs the difference between
pump handle and bucket handle contacts is small. Usually the distin­
guishing judgement can be made comparing anteroposterior movement
against lateral-medial movement. The two fingers on each hand are
pump and bucket handle contacts, respectively.
 CHAPTER 5 � RESPIRATORY RESTRICTIONS OF THE RIBS 65

7. Testing ribs xi and xii. The patient now turns to the

prone position. The twelfth rib is found initially by palpat­
ing just above the iliac crests lateral to the paraspinal mus­
cle mass and searching with the finger pads for the inferior
border of the twelfth ribs. (Figure 5.23) It will be
encountered about the level of the second lumbar. The
twelfth rib should not be confused with the transverse
process of the third lumbar, which is quite long but does
not have breathing motion.
The inferior borders of the twelfth ribs are carefully
followed laterally to the free ends. (Figure 5.24) These free
ends are often tapered, and, if you are not paying close
attention, your fingers may continue on to the eleventh
ribs. Use the step breathing process as you monitor the
breathing movements of the tips of ribs xii, and then ribs xi
with your peripheral vision. One of these ribs may be the Figure 5.23 Prone rib tests. Finding the twelfth ribs using stereognosis.
key rib, especially if exhalation motion is restricted.

Note: The twelfth ribs rarely extend as far as the mid-clavicular line.
Occasionally, the lengths of the right and left twelfth ribs are not the Figure 5.24 Prone rib
same. In order to assess the respiratory excursion of morphologically tests. Examiner's index
finger pads contacting
asymmetrical twelfth ribs, the movement of the end of the shortest rib is
the free ends of the
compared with a contact on the longer rib that is an equal distance from
twelfth ribs.
the mid-sagittal plane.

Interpretation of Results

• If exhalation motion of a rib is restricted, it will stop

moving inferiorly before the rib on the other side stops.
It may stop very soon after exhalation begins, if it is severely
restricted, or it may stop very near the end of exhalation (a
slight restriction).

• The less restricted rib on the other (normal) side will

be seen to move alone during the remainder of the exhala­
tion portion of the respiratory cycle. And when the breath
is inhaled the less restricted rib will move alone until it is
opposite the restricted rib, which will then accompany it for
the remainder of inhalation.

• The reverse happens with restricted inhalation.

Inhalation is sometimes restricted bilaterally, but only rarely
is the restriction symmetrical. Exhalation is frequently
restricted bilaterally in chronic obstructive lung disease. Sym­
metrical bilateral restriction can be diagnosed by tentatively
treating one side and retesting the breathing movement.

• If asymmetry of respiratory rib motion occurs in the

Sphinx position, and no other, then the presence of an FRS
dysfunction at T11 or T12 is indicated.

Figure 5.25 Prone rib tests. Sphinx position for evaluating breathing
motions of the eleventh or twelfth ribs.
66 THE MUSCLE ENERGY MANUAL

Treatments for Respiratory Rib Restrictions

If rib dysfunctions are discovered in the course of our more Sequence of Treatment
detailed scanning evaluation, they may be treated, per se, Inhalation restrictions are treated from the top down;
with MET, even though they are usually secondary to ver­ exhalation restrictions are treated from the bottom up,
tebral segmental dysfunction. The key rib is the first, and starting in each case with a 'key rib.' Usually, this
usually the only, rib treated. However, as long as the struc­ approach will entail treating only one or two ribs. Fol­
tural rib lesion or the vertebral dysfunction - either of lowing this logic we will present the treatment of inhalation
which is located at the key rib- persists, the respiratory rib restriction starting with the first rib and ending with the
dysfunctions will tend to recur. tweltth. Treatment of exhalation restriction will begin with
Reciprocal inhibition of antagonists - Sherrington's the twelfth and end with the first.
Second Law ( 1907) - is the mechanism of most rib treat­ Treatment of the ribs is usually postponed until the
ments, which employ some of the varieties of isotonic tech­ thoracic spinal joints have been examined and appropriately
nique. The best way to apply Sherrington's Second Law treated. Type II dysti.mction (FRS and ERS types) not only
clinically is with isotonic contractions. As the antagonist causes restricted breathing movement of the rib articulated
muscle contracts, some of the tissues that resist its action to its restricted side, but also tends to produce marked
are forced by reflexes to relax. As the relaxation occurs, the antero-posterior rib asymmetry in any of the ribs, whenev­
concentric action of the antagonist is allowed by a con­ er the spine is flexed or extended tar enough to cause the
trolled yielding resistance. lesioned vertebra to rotate.
Usually a moving counterforce is required for a con­
centric isotonic contraction. In rib treatment, however, the
rib is the moving part, and it is not advisable to resist its
movement. To do so would risk rib fracture or costochon­
dral separation. Think what could happen if the patient
had osteoporosis, multiple myeloma, or any other metasta­
tic disease of the rib.
Thus, the patient's muscles are used to move the rib
unopposed by anything other than the resisting antagonist
myotascial tissues. When the inhaler muscle holds a rib up,
restricting exhalation, the exhaler muscle is used to pull it
down with a concentric isotonic contraction, after per­
forming positional localization to the lesioned rib. To pull an
exhaled rib up, the inhaler muscles - secondary muscles of
respiration (pectorals and serratus anterior) - are contract­
ed while applying a counterforce to the upper limb.
Localization is achieved by a slight joint gapping force
applied to the rib shaft.
An understanding of the neurophysiology, histology,
myology, and kinesiology related to Muscle Energy
Technique is basic to its clinical application. A review of
the first two chapters of Volume 1 is recommended.
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS 67

Treatment of the Inhalation Restrictions

General Comments
To enhance relaxation, the patient is recumbent for the
treatment of rib somatic dysfunctions; prone for treating
the tenth, eleventh, and twelfth ribs; supine for the rest.
Localization is obtained by direct articulation of the
rib from a posterior contact on or near the rib angle to gap
(disengage) the rib from the spine by drawing it laterally
and pushing it anteriorly. With inhalation the posterior
aspect of the rib turns caudad, so in treatment of ribs i
through ix the rib angle is pulled caudad after the antero­
lateral disengagement. Ribs xi and xii do not have costo­
transverse articulations. Therefore, no anterior pressure is
needed to disengage them from their transverse processes.
Only lateral pressure is required to disengage the rib head
from the vertebral body. Because of the caliper type action
of the floating ribs xi and xii, the iliocostales muscles do
not have as much leverage for inhalation as they do on ribs
iii through x, which have prominent rib angles. Their prin­
cipal exhalers are the external abdominal obliques. We
have mentioned earlier the role of the quadratus lumborum
as a co-contractor with the diaphragm.
The corrective force in the following techniques is pri­
marily isotonic muscle contraction of the secondary mus­
cles of respiration to pull the rib beyond the abnormal bar­
rier where its movement is restricted. Localization for this
purpose is further obtained by holding the rib against this
barrier as it is being disengaged from the spine. To maintain
localization during the procedure, the finger used to disen­
gage the rib takes up slack during the post-isotonic relax­
ation phase.
With the exception of the first two ribs, the rib angles
are easily palpable prominences on the posterior aspect of
the ribs two to three inches lateral to the line of the spin­
ous processes.
It is not necessary to actually palpate the first or second
rib angles to obtain contact for localization purposes. If
the contacting finger is placed 21;4inches (about 5 em.) lat­
eral to the spinous process of the respective vertebra, it will
be close enough to move the rib and localize the proce­
dure.
68 THE MUSCLE ENERGY MANUAL
Figure 5.26 Treatment
for inhalation
restriction of rib i.
Finding the posterior
shaft of rib i for
localization traction.
Procedure for Treating Restricted Inhalation
(ribs i and ii- ix)
l. The patient is supine.
2. You stand at the side of the table opposite to the side
to be treated.
3. To locate the posterior aspect of rib i, reach under­
neath the supine patient to place the middle finger on the
spinous process of the first thoracic vertebra and the index
finger 21;4 inches directly lateral over the posterior aspect
of the trapezius. In the photographs the right first rib is
being treated. By pressing the finger(s) into the trapezius
at this point, tension can be applied to the first rib in an
antero-latero-caudal direction. One or two pounds of ten­
sion is sustained in this manner. This second rib may be
contacted similarly lateral to the second thoracic spinous
process, and treated (Figures 5.26 and 5.27).
4. When the first rib is the most superior rib with
restricted inhalation and is being treated, the patient's
shoulders are allowed to rest flat on the table and the head
is rotated contralaterally about 30 degrees. The back of the
patient's ipsilateral hand is rested on the patient's forehead.
(Figures 5.28 and 5.29)
To treat pump handle restriction, the operator pro­
vides uny ielding resistance at the patient's forehead and
instructs patient to lift his head up off the table anteriorly
against the back of his own hand with 5-l 0 pounds of
force. The effort is sustained for 2-3 seconds and then
relaxed as the operator's countertorce is relaxed. During
relaxation, the hand underneath the patient increases the
disengagement of the rib (gapping the costovertebral
joints) by drawing it laterally, anteriorly, and inferiorly. The
Figure 5.27 Treatment
for inhalation restric­
tion of rib i.
Inferior lateral traction
is applied to the first rib
shaft through the
trapezius muscle with
less than 2 pounds of
force.
lift, relaxation, and disengagement are repeated two or
three times, maintaining the disengagement tension
throughout the procedure.
To treat a bucket handle restriction, the patient is
instructed to lift his head diagonally up toward his own
elbow. In all other respects, the treatment procedure is
exactly the same as that described above. For the pump or
bucket handle treatment, the patient's face may be turned
20-30 degrees away trom the side being treated to increase
scalene etfectiveness.
Contraction of the anterior scalene muscle produces
pump handle inhalation movement of the first rib. The
middle scalene produces bucket handle inhalation move­
ment.
5. When the second rib is being treated as the most
superior rib with inhalation restriction, the patient's
position is the same as tor treatment of first rib restriction
described tor Figure 5.28. Beginning with the second rib
the restricted isotonic efforts will be made by the patient
pushing the elbow against the operator's hand. This will be
true of inhalation restriction treatments tor ribs ii through
ix (or even x, although serratus anterior does not usually
reach the tenth ribs). (Figures 5.30 and 5.31)
Pump handle restrictions require anterior/inferior
pushes of the elbow activating pectoral and anterior inter­
costal muscles. Bucket handle restrictions require the addi­
tion of a lateral component to the push, activating the ser­
ratus anterior and lateral intercostals.
 CHAPTER 5 � RESPIRATORY RESTRICTIONS OF THE RIBS 69

Figure 5.28a Treatment for pump handle inhalation restriction of rib i. Figure 5.2Bb Treatment for bucket handle inhalation restriction of rib i.
Patient's head is rotated 30 degrees contralaterally with the wrist I on the The patient is told to "Push your head obliquely up toward your elbow."
same side as the restriction I resting on the forehead. Operator doesn't
allow the head to move as the patient is given instructions to contract the
anterior scalenes for pump handle I"Push your head forward against
your wrist." I. or lateral scalenes for bucket handle restriction. The
expectation is that the muscle contraction will isotonically move the first
rib as its costovertebral articulation is being localized by traction with the
operator's finger.

Figure 5.30 Treatment

for pump handle
inhalation restriction
of ribs ii- ix.
Unyielding counter­
force is provided for
the patient's humerus
extension effort.
("Push your elbow
toward the opposite
hip.")

Figure 5.29 Treatment for bucket handle inhalation restriction of ribs ii- ix.
Unyielding counterforce is provided for the patient's humerus adduction
effort. ("Pull your elbow down to your side.") Operator localizes treat­
ment effect to the rib whose angle is being drawn away from the spine
anteriorly, laterally, and inferiorly.

Note: The movements of the humerus may be defined in relation to the anatomi·
cal position. Rotations in the sagittal plane are called flexion- initiated anterior
1+1 movement of the arm, or its continuation- or extension- the opposite of flex­
ion, i.e., movement which will carry the arm posteriorly 1·1 past the anatomical
position. After the arm is abducted, anterior movement may be called horizontal
flexion, or posterior movement may be called horizontal extension. Long axis ly­
axisl rotations of the humerus may be designated either anatomic or horizontal.
70 THF. MUSCLE ENERGY MANUAL

Procedure for Treating Restricted Inhalation

(ribs x through xii)
l. The patient is prone with the body curved sideways,
convex on the side of the rib to be treated (the left side in
the illustration). To achieve this, the feet and shoulders are
pulled to the right.
2. The patient's arm on the convex side (left) is hyper­
abducted to the side of the head.

Note: Positioning of the patient's arm is the only difference between

treating inhalation and treating exhalation restrictions of these ribs.

3. You stand on the concave (right) side of the patient

and contact the most medial part of the tenth, eleventh, or
twelfth rib accessible to the hand (about 2.5 to 3 inches lat­
eral to the spinous processes) with the hamate process of
Figure 5.31 Treatment for inhalation restriction of ribs x- xii.
the cephalic (right) hand. This contact will enable you to Operator's far hand is medial to the iliocostalis attachment to the rib, and
push the rib anterior, lateral, and superior: localization by pushes the rib laterally away from the spine to localize the treatment
disengagement. effect to that rib. Operator's near hand (left in this easel, with the fingers

4. Now stand as close to the toot of the table as the fitted around the tendon of rectus femoris, draws the pelvis inferior and
posterior, taking the slack out of the left quadratus /umborum. Patient's
length of your arm will allow, and then with your left hand
lleftlarm is abducted.
grasp the patient's hip either at the anterior superior iliac
spine or in front of the greater trochanter of the temur.
5. Now a superior-interior (longitudinal) stretd1 is applied,
between the hand contacts, just sufficient to take the slack
out of the inhaler and exhaler muscle tissues which attach to
the rib being treated. This usually takes approximately 5-
I 5 pounds of tension. As the tension is applied, the hip will
be lifted off the table a tew inches, resulting in a slight tor­
sion of the lower trunk.
6. While holding the tension and resisting movement,
instruct the patient to pull the hip back down to the table
with 5 or 10 pounds of eftort sustained tor about 3 sec­
onds. This step may be augmented by having the patient
inhale.
7. Tell the patient to relax. After the patient is relaxed,
the additional slack in the tissues is taken out as you push
with the superior hand while pulling with the caudal hand.
You can conserve your own etfort by keeping your elbows
straight and using your body.
8. The sequence of contraction, relaxation, and the tak­
ing up of slack is repeated about three times betore reeval­
uating the excursion of the rib.
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS
Treatment of Exhalation Restrictions
The same prone procedures for treating inhalation restric­
tions of ribs x, xi, and xii are usually effective treatment for
exhalation restriction of those ribs as well, provided the
treatment is applied to the key rib.
A consideration of the principles and mechanism of the
treatment will de�ystify this seeming contradiction. The
localization is achieved by disengaging the rib from the
spine. The corrective force is made by alternately contract­
ing and relaxing the inhalation and exhalation muscles of
the rib. Both isometric and isotonic contractions occur in
the procedure. The muscles are contracted while in a
stretched, no-slack condition and are, therefore, more effi­
cient in moving the rib both toward inhalation and toward
exhalation.
The only difference between this procedure and the
one described for the treatment of inhalation restrictions is
the position of the patient's arm, which remains down at
the side (in most instances a trivial ditTerence, but it serves
a heuristic purpose). Otherwise the task analysis given for
inhalation restrictions may be followed to the letter. The
superior disengagement of the rib does not in any way
interfere with the effectiveness of the technique. In tact,
it may assist exhalation because the pivot at the head of the
rib is anterior to the point of operator's hand contact and
in exhalation the lateral anterior part of the rib moves infe­
rior relative to the contact point.
71
Note: The principles of relaxation, localization, and corrective force
specificity are applied somewhat differently in the following proce­
dures.
Relaxation is assured by the recumbent position with the patient's
comfort and support provided by the operator. For the lower ribs (vii
through x) support the patient's upper back and shoulders by placing
your hand under the mid-thoracic spine between the scapulae. This
reduces the strain on the cervical region.
Localization is achieved by positioning the trunk in progressive flex­
ion and/or sidebending (lateral ftexion) until the rib being treated has
moved toward exhalation as far as possible without any exhalation
movement of the rib immediately inferior to the lesioned rib. This
specific localization can be felt with fingers on the "key" rib and the
one below it. As soon as motion is felt on the normal rib you stop and
back off.
Specific corrective force is obtained by having the patient breathe
3 or 4 times with a forced exhalation effort (isotonic) at the end of
each breath. Before the patient inhales again, adjust the localization,
ftexing or lateral flexing the trunk until the rib above the target rib has
reached the end of its motion.
In these techniques it is not necessary to apply any pressure to the
rib. The procedures can be applied safely, even to patients with bone
fragility due to metastasis or osteoporosis.
72 THE MUSCLE ENERGY MANUAL

Treatment for Exhalation Restriction (ribs xii- x)

The procedure for treating exhalation restriction of ribs xii
- x is the same as for treating restricted inhalation, except
for the patient's arm position. (Figure 5.32)(cf. Fig. 5.31)

Treatment for Exhalation Restriction (ribs x-i)

For the rest of the ribs, exhalation restriction is treated with
the patient supine, with slight variations.

Procedure for Treating Restricted Exhalation

(ribs x -vii)
l. The patient is supine.
2. You stand at the corner of the head of the table, on
Figure 5.32 Treatment for exhalation restriction of ribs xii- x. Patient's
the side of the rib to be treated.
arm is adducted.
3a. Treatment of restricted pump handle exhalation of
rib x is shown by Figure 5.33. The monitoring fingers are
palpating, but not pressing on, the tenth and eleventh ribs Figure 5.33 Treatment

as far anterior as the eleventh ribs extend. The upper back for pump handle exha­
lation restriction of ribs
is supported by a hand between the scapulae as the trunk is
x- vii. Patient's upper
flexed. thorax is supported by
3b. Treatment of restricted bucket handle exhalation of operator's hand
rib x is shown by Figure 5.34. The fingers monitor the between the scapuli.

tenth and eleventh ribs in the mid-axillary line. The sup­ The trunk is flexed in
the sagittal plane until
porting hand between the scapulae sidebends the trunk
the rib being treated is
until localization is felt between the tenth and eleventh rib. felt to move and the rib

Note: Ribs ix. viii. and vii are treated in the same fashion by support­ inferior to it has not yet
moved. Localization is
ing the spine between the scapulae.
achieved in this manner,
treating the ribs as
4. Localization tor this method is obtained by palpating
individual links in a
the rib being treated and the one just below it. Flexing or
chain of bones.
sidebending the trunk stops after the treated rib has moved
and before the rib below it moves. The corrective force is
provided by the patient's breathing etlort. Inhalation
etlort is resisted only by the supporting hand, not by the
palpating fingers. Complete exhalation is sustained while
you relocalize. Three of these controlled breaths are usu­
Figure 5.34 Treatment
ally sufficient.
for bucket handle exha­
Instruction to the patient after localizing positioning:
lation restriction of ribs
«Take a breath!)) . then, «Let your breath out. Force all of
. .
x- vii. Patient's trunk
your breath out. While the patient's breath is held out,
11 is laterally flexed in the
reposition tor localization. coronal plane for local­
ization.
 CHAPTER 5 � RESPIRATORY RESTRICTIONS OF THE RIBS 73

Procedure for Treating Restricted Exhalation

(ribs vi- iii)
l. The patient is supine.
2. You stand on either side of the lesion when treating
pump handle restrictions (Figure 5.35); the same side
when treating bucket handle restrictions. (Figure 5.36)
3. Treatment of pump handle exhalation restriction of rib
v on the left is shown by Figure
5.35. Localization requires
monitoring the rib to be treated and the rib inferior to it.
Flexion positioning stops just before the inferior rib moves.
For example, to treat pump handle restricted exhalation of
the fifth rib on the left side ("rib v up left"), the monitor­
ing fingers are in the parasternal line on superior borders of
,./
.....
:· · '
the fifth and sixth rib costal cartilages. Trunk flexion Figure 5.35 Treatment for pump handle exhalation restriction of ribs vi-
through the fifth rib is obtained by lifting the head slightly iii. Rib motion is monitored at the costal cartilages.
tipped toward the treatment side (left).
4. Treatment of bucket handle exhalation restriction of
the left fifth rib is shown in Figure 5.36. Sidebending the
trunk down to this rib can be produced by tilting the head
toward the left shoulder. The monitoring fingers are in the
mid-axillary line on the fifth and sixth ribs.

Note: Bucket handle exhalation restrictions can be managed in this

way for ribs iii, iv, and v as well. Monitoring the bucket handle move­
ments of ribs i and ii must be done through the pectoralis maj or muscle
tendon.

After the target rib is in the localized postion, instruct the

patient: 'Take a breath.» Resist tl1e slight extension effort
accompanying inhalation. «Breathe out. Force all your
breath out.» Relocalize positioning while the patient's
breath is held out.
Figure 5.36 Treatment for bucket handle exhalation restriction of ribs
vi- iii. Rib motion is monitored in the mid-axillary line.
74 TH F. MUSCLE ENERGY MANUAL

Procedure for 'Ireating Restricted Exhalation Figure 5.37 Treatment

(ribs ii and i) for pump handle exha­
lation restriction of ribs
Note: Execution of the procedure and instructions to the patient are i or ii. Less neck flexion
the same as in the previous procedure for treating ribs vi to iii for exhal­ is required, compared

tion restriction. with the lower ribs.

l. The patient is supine

2. You stand at the head of the table, otf to the side
opposite to the lesion.
3. Treatment of pump handle exhalation restriction of rib i
is shown by Figure 5.37. Note the similarity to the proce­
dure illustrated by Figure 5.35. The monitoring fingers are
off the side of the manubrium on the costal cartilages of
ribs i and ii, or ribs ii and iii.
4. Treatment of bucket handle exhalation restriction of
rib i on the right is shown by Figure 5.38. The first rib is
monitored just below the clavicle. Both ribs must be pal­
pated through the pectoralis major. Sidebending is pro­
duced as in the procedure illustrated by Figure 5.36.
Figure 5.38 Treatment
for bucket handle exha­
lation restriction of ribs
i or ii. Monitoring
bucket handle motion
for ribs i or ii in the mid­
axillary line is impracti­
cal. These ribs must be
monitored through the
pectoralis major muscle.
 CHAPTER 5 �RESPIRATORY RESTRICTIONS OF THE RIBS 75

Summary of Rib Respiratory Evaluation

and· Treatment
Step breathing is a useful tool in evaluating respiratory Relationship of Respiratory Restriction of the Ribs
movements of ribs. The examination technique involves to Spinal Evaluation
both observation and palpation. Palpation allows the Treatment of rib dysfunction per se is an alternative to con­
examiner's hands or fingers to find and follow the ribs. sider in those rare instances when vertebral dysfunction is
Observation of one's moving hands allows rib movement resistant to initial treatment with MET or any other treat­
to be visible. Abnormal breathing restriction occurs either ment modality. Temporary restoration of respiratory
at the end of inhalation (key rib at the top) or at the end of movement to the ribs may be sufficiently beneficial to the
exhalation (key rib at the bottom). Unilateral rib motion respiratory-circulatory physiology of the body to allow the
observed in the mid-range of the respiratory cycle, inhaling spinal tissues to decongest and become more amenable to
or exhaling, is not diagnostically decisive. manipulative intervention. For the vast majority of cases,
In subsequent chapters the evidence of respiratory respiratory restriction of the ribs is due to segmental dys­
restriction will be applied to the diagnosis of structural rib function. When segmental dysfunction is the cause of rib
lesions and thoracic vertebral segmental dysfunctions, for­ restriction, and restriction is exhibited by a group of ribs,
merly called "osteopathic lesions." the objective is to identifY the "key rib" for the group using
As was stated in Volume 1, all manipulative procedures the techniques described in this chapter. Locating the key
are better -that is, safer, more precise, and more effective rib is the key to identifYing tl1e dysfunctional segment
-when the three basic principles of relaxation, balance, and responsible for the respiratory restriction of tl1e rib group.
localizatior.. are applied. The principle of relaxation is the In Chapter 7, the techniques of rib cage evaluation will be
main reason the rib treatment procedures are done with the shown to have wide application to thoracic vertebral diag­
patient recumbent. Remember that relaxation is also nosis.
important for the operator, who must be comfortable and
balanced in order to be relaxed.
For treating inhalation restrictions localization is
achieved by slightly disengaging (gapping) the rib from its
spinal articulations. Localization for exhalation restriction
treatment is achieved by flexing the thorax one rib at a
time, like a chain of bones, until the rib being treated is the
last one to move. The "chain of bones" analogy also has
application to the treatment of vertebral dysfunctions.
The corrective Muscle Energy Technique forces are
provided by controlled concentric isotonic contractions of
secondary muscles of respiration. Voluntary respiratory
cooperation is used to treat exhalation restriction, using the
exhaler muscles isotonically («Force your breath out!)� after
positional localization to the key rib. For the treatment of
inhalation restriction, isotonic contraction of the inhaler
muscles is utilized by controlled operator resistance to the
action of an upper limb.
Treating primary rib dysfunction per se without regard
for the cause -vertebral dysfunction or structural rib lesion
-is generally temporarily effective. But, in most instances,
it is treating an effect, not a cause; treating the cause pro­
duces better, more lasting, clinical results. If you treat a
vertebral segmental dysfunction, you can check the efficacy
of the treatment by examining the respiratory motion of
the ribs, which have not been directly treated.
76 T H E M U S C L E ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 77

PART Ill

Evaluation and Treatment

of the Thoracic and Lumbar Spine
78 T H E M U S C L E ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 79

CHAPTER 6

The Thoracic Inlet

anipulable disorders found in the vertebromanubr­

M
ial segment, also known as the thoracic inlet, can
profoundly affect the body's ability to maintain
health and ward off disease. This chapter focuses
on the evaluation and treatment procedures for structural sublux­
ations of the first rib. Structural lesions of ribs ii-x are the subject
of Chapter 8. DiagnosisofT1 ERS and FRS vertebral dysfunction
will be discussed in this chapter; complete evaluation and treatment
ofT 1 -T6 ERS and FRS vertebral dysfunctions will be covered in
Chapter 7.
Although there are some examination and treatment procedures
that apply only to the first ribs- due to anatomic details which are
unique to the first ribs- the concepts and principles presented in
this chapter will have application in other areas of the thorax. Of
special importance is the differential diagnosis of structural rib
lesions versus vertebral segmental dysfunction, consideration of
which is sometimes thrust upon us when we evaluate the thoracic
inlet. A brief discussion of the nature of the thoracic inlet and its
importance in the overall health of the body will introduce the
MET procedures for this important region.
The thoracic inlet, the superior aperture of the thoracic cav­ In this chapter:

ity, is a ring of bone bounded anteriorly by the manubrium, later­ • Evaluation and treatment of structural
ally by the first ribs and their costal cartilages, and posteriorly by subluxations of the first rib
the body of the first thoracic vertebra. Other names for this supe­ • Diagnosis of T1 ERS and FRS
rior opening of the thoracic cage include the operculum (Latin vertebral dysfunction
for "lid"), or thoracic outlet -"outlet" in this case referring to the
• First rib screening and scanning
direction of blood flow in the arteries that pass through it.
procedures:
Venous blood and lymph, of course, flow in the opposite direc­
Superior, posterior, and anterior
tion through thinner walled vessels which are more easily com­
subluxations
pressed. It is to acknowledge this vulnerability to compression,
Static and variable position tests
and its consequences - venous and lymphatic stasis and conges­
• Vibratory isolytic technique for muscle
tion - that the operculum is called, preferably, the superior tho­
contracture
racic inlet.
80 THE MUSCLE ENERGY MANUAL

Any change in the shape of this aperture can partially

obstruct the flow of the entire lymphatic system of the
body. Particularly vulnerable to such obstruction are the
venous and lymphatic drainages from the head and neck, and
the sympathetic nerve chains to the neck and head that arise
within the aperture. A portion of the brachial plexus arises

Jugular vein from the upper thoracic spinal cord and passes through this
aperture to the upper limbs. Partial obstruction of veins and
Superior lymph vessels in this region may have far-reaching conse­
vena cava quences, such as epistaxis, pharyngitis, tonsillitis, or edema
and paresthesias of the arm.
Serving to maintain the patency of these important ves­
sels, the shape of the operculum changes very little with
basal respiration. The net effect of respiration on venous
(and, by inference, lymphatic) return has been shown to be
0 generally positive, i.e., breathing accelerates venous return.
Manipulable lesions of the thoracic inlet may impair
Cysterna +----+-t�>L-----1 microcirculation of the thyroid, parathyroid, and thymus
chylae
glands, as well as obstruct the terminal drainage of the
entire lymphatic system. The immune system depends on
the free flow of lymph through the body for its optimum
function. Lymphatic stasis - edema - promotes cellular
and tissue degeneration.

Figure 6.1 Lymphatic system of the trunk and neck. The thoracic duct car­
ries lymph from three-fourths of the body. It passes through the operculum
twice as it loops above the level of the hilum of the lung. The stellate
ganglion of the sympathetic chain usually rests on the head of the first rib.
Sometimes the stellate ganglion is broken up into smaller nodules extend­
ing up along the cervical sympathetic chain. Mechanical pressures on these
ganglia may produce autonomic symptoms such as Horner's syndrome or
anisocoria. Patients with situs inversus may have their maj or lymphatic duct
on the right.

Consequences of Altered Shape of the Inlet

The thoracic inlet is a small area- approximately the size of
a dressed 2 x 4. Through this relatively small opening pass
many tubes: esophagus, trachea, and blood and lymphatic
vessels. The compressible tubular structures, importantly
related to circulation, include:

• the ascending and descending terminal thoracic duct car­

rying approximately three-fourths of the lymph of the body
up into, and back down out of� the lett supraclavicular fossa;

• the head/neck (jugular), and upper extremity venous

drainage;
• the right lymphatic duct;
• the venous and lymphatic components of the vasa nervo­
rum of the nerves which pass through the operculum -such
as the vagus, the phrenic, the sympathetic chain, and por­
Figure 6.2 Thoracic inlet size. The thoracic inlet is a small area I approxi­
mately the size of a dressed 2 x 41. The dimensions of this spac e may change
with vertebral dysfunction of the first thoracic segment or subluxations of
the first rib, causing partial occlusion of the entire lymphatic system; the
venous drainage from the head, neck, and upper limbs; and the vasa nervo­
rum of the phrenic and vagus nerves. as well as the sympathetic trunk. The
brachial and carotid arteries, the longus colli muscles, the trachea, and the

tions of the brachial plexus. esophagus also occupy some of this space.

Figura 6.3 Anterior
topography of the rib
cage. Note that the
first ribs rather quick­
ly disappear under
the clavicles.
Causes of Altered Inlet Shape:
Segmental Dysfunction vs. Rib Subluxation
The shape of the operculum is subject to asymmetric distortion
from dysfunction of the first thoracic segment or subluxation
of the first rib, causing a decrease in its cross-section area.
One way to distinguish between anatomic distortion due to
first rib subluxation and anatomic distortion due to seg­
mental dysfunction of the first thoracic vertebra is to
motion test the first ribs as they participate in flexion and
extension of the vertebra. Vertebral segmental dysfunc­
tions and costovertebral subluxations may be detected
through a visual/palpatory examination of the rib cage,
and are differentiated using the following criteria:
• Asymmetry due to a structural rib lesion, such as
subluxation, will persist in both flexion and extension,
i.e., may never become straight.
• Asymmetry of rib position or respiratory motion
associated with segmental dysfunction varies with flex­
ion and extension. In other words, the antero-posterior
asymmetry of the ribs associated with segmental vertebral
dysfunction will either increase or go away with flexion or
extension of the trunk.
Rib subluxation and vertebral segmental dysfunction
may coexist. In this case, reducing (eliminating) the sub­
luxation will help clarifY the exact nature of the segmental
dysfunction, or vice versa.
Causes of Restriction
Breathing restriction of any rib is usually due to segmental
vertebral dysfunction. The rotated position of the dys­
functional vertebra, in some way, interferes with the respi-
CHAPTER 6 �THE THORACIC INLET 81
Figura 6.4 Posterior topography of the rib cage. The first ribs bend
sharply forward soon after they emerge from in front of the T1 transverse
processes, which extend laterad about 6 centimeters measured from the
spinous processes. The third rib angles at the level of the scapular
spines may be covered by the medial borders of the scapulae unless they
are abducted.
ratory motion of the associated rib. However, restriction
may also be secondary to subluxation or intraosseous
deformity of a rib. If anteroposterior asymmetries of the ribs
remain regardless of whether the spine is flexed or extended, a
rib subluxation or an intraosseous deformity of the rib is pre­
sent, instead of segmental dysfunction; both of these cause
breathing restriction. The breathing restriction tells us
which side the lesion is on, and, therefore, which side to
treat. In terms of the comparative A-Pposition of the ribs,
anterior subluxation of the right rib and posterior subluxa­
tion of the left rib look the same, until you test their
breathing motion.
Structural Lesions of the First Rib
The first rib can be subluxated superiorly. "Superior" refers
to the direction of displacement of the rib neck on the
transverse process. Anterior or posterior subluxations of ribs
i through x are also possible. "Anterior" and "posterior"
refer to the direction of displacement of the head of the rib
on the vertebral body. Treatment techniques for anterior or
posterior subluxation of ribs ii through x are presented in
Chapter 8.
Other structural rib lesions - torsions and compres­
sions - do not affect the first rib. They are found only in
the long slender ribs v through ix. "Bucket bail" lesions,
similar to superior subluxation, are relatively rare and main­
ly affect ribs ii through iv. In contrast to anterior or poste·
rior subluxations, the bucket bail lesion is a superior dis­
placement of the rib neck on the transverse processes. These
species of structural rib lesions will be presented in Chapter
8 along with their diagnosis and treatment procedures.
 82 THE MUSCLE ENERGY MANUAL
Figure 6.5.A T1 flexing on T2.
Figure 6.5.C T1 right side bending on T 2•
Figure 6.5. A and B Physiologic movements of flexion and extension. The
T1-T2 vertebral segment is shown approximately in its anatomic position
relative to the transverse and coronal planes of the body. With flexion, T1
rotates about a transverse axis compressing the anterior portion of the disc
and distracting the posterior fibers of the disc annulus. The body of T1
translates slightly forward. The inferior articular processes of T1 slide
upward and anterior and the spinous processes separate. The transverse
processes of T1 move up and forward. The nucleus pulposus does not
move much. Some theories treat the nucleus like a watermelon seed, and
would have us believe that the nucleus is squirted back by flexion.
However, that movement of the nucleus would be opposed by the
increased tension of the posterior fibers of the annulus, which would tend
to push the nucleus toward the relaxed anterior fibers.
Figure 6.5.C Sidebending (to the right in the illustration) of T1 on T2 is cou­
pled to ipsilateral rotation, just as it is in the cervical segments.
Consequently, the first rib on the concave side is moved down and back,
and, on the convex side, up and forward. The second ribs are affected by
the rotational component of the coupled side bending in a way similar to the
effect of axial rotation of T1. Sidebending is limited by the costovertebral
facets on the concave side and the intertransverse ligaments on the con­
vex side.
Figure 6.5.8 T1 extending on T2.
Figure 6.5.0 T1 right rotating on T2.
Figure 6.5.0 Axial rotation (to the right in the illustration) occurs around an
axis through the centers of the vertebral bodies. A circle drawn from this
center will pass through the planes of the zygapophyseal facet joints. The
first ribs move with the vertebra, being somewhat restrained by their cos·
tochondral attachments to the manubrium, which rotates very slightly to
the right at the sternal angle. The superior demifacet of the left second rib
acts like a cervical uncovertebral joint, with sidebending and rotation ipsi­
laterally coupled. As theT1 left demifacet translates over to the left it rides
up on the rib head, sidebending the vertebra to the right, a movement con­
sistent with the ipsilateral rotation-sidebending rule for this segment. The
slight torque imparted to the heads of the second ribs is dissipated in tis­
sue elasticity and very little deformation of the second ribs can be seen or
palpated.
Note: This classical representation ofT1 rotation assumes that the weight·
bearing function of the facet joints is insignificant. It is more likely that
rotation is coupled to flexion or extension, and the axes of rotation are at,
or near, the facet joints.
 CHAPTER 6 .-!> THE THORACIC INLET 83

Anterior scalene
muscles

/�
1\--.� /
,' ' /
I ' @. ;. -
/I
I

Manubrium--------,'
1

I
I
I

Angle of Louis -----

I I
,I

,,
I '
\ \
\ I

\
\I

Figure 6.6 Lateral view showing actions of the scalenes and tilting of the manubrium with forced inhalation. As the scalene muscles elevate the first
ribs, the manubrium tilts outward, hinging at the clavicle heads. The sternal angle moves up and out. Normally the body of the sternum pivots at the third
costal cartilage, and the xyphoid process moves up and posteriorly. Obesity may modify this aspect of sternal movement.
84 THE MUSCLE ENERGY MANUAL
Figure 6.7 Pump handle
evaluation of first ribs.
Finger pads palpate in
first intercostal spaces
on each side of manubri­
um; fingertips then press
against the inferior edge
of first costal cartilage,
just below the clavicles.
The difference between
the respiratory pump
handle contact and the
A-Ppositional anterior
pump handle contact is a
fraction of an inch.
First Rib Screening and Scanning Procedures
The technique of palpatory-visual assessment of the respi­
ratory movements of the first pair of ribs is unique because
it is not possible to rest the finger pads on the superior mar­
gins of the ribs. The clavicles are in the way. This anatom­
ic feature necessitates contacting the inferior margins of the
first ribs with the fingertips in order to follow the breath­
ing movements of these ribs. Very little of the osseous por­
tion of the first rib is accessible to palpation; most of the rib
is deep behind the clavicle. The accessible portion is the
costal cartilage, which follows the breathing movement of
the rib precisely.
The first ribs have pump handle and bucket handle
motions in approximately equal measure. In spite of the
short distance from the pump handle to the bucket handle
finger contacts, they can be easily distinguished from each
other. Because one may be more asymmetric than the
other, both contacts should be utilized to avoid missing the
less obvious asymmetries.
By conducting the examination of the first rib with the
patient in the seated position, flexion and extension move­
ments of the first thoracic vertebra are possible. Adding
this dimension to the rib evaluation procedure allows us to
discriminate rib dysfunction due to vertebral segmental
dysfunction from that due to rib subluxation. If the flex­
ion and extension parameters are omitted from the follow­
ing step breathing test, it constitutes a screening evaluation
of the first ribs. A screening examination will not discrim­
inate between the various causes of respiratory restriction,
and, in fact, may miss restrictions which appear only at the
extremes of flexion or extension.
Figure 6.8 First rib
bucket handle evalua­
tion. The fingertips
contact the inferior
margin of the first rib,
just under the clavicle
and approximately 2 or
3 centimeters lateral to
the pump handle con­
tacts.
Rib Motion Step Breathing Test: Procedure 1
Seated Screening and Scanning of the First Ribs
l. The patient is seated on the examination table. You
stand or sit in front of the patient.
2. Find the inferior margins of the first rib cartilages with
your fingertips by locating the first intercostal space above
the second ribs. Follow the margins of the first rib carti­
lages from points on each side of the manubrium - the
pump handle contacts - to the points just before the ribs
disappear behind the clavicles- the bucket hand!e contacts.
3. Maintaining either pump handle or bucket handle fin­
gertip contact with the rib, have the patient breathe in and
out deeply and observe your finger movements with your
eyes anterior to the patient's chest. It is advisable to have
the patient step breathe (see Chapter 5), first with full exha­
lation and then with fi.dl inhalation, to make more obvious
minor asymmetry.
4. Have the patient flex the first thoracic vertebra by
dropping the chin down toward the chest, and repeat the
breathing tests, noting if asymmetric movement appears or
disappears. (Figure 6.9)
5. Have the patient extend the first thoracic vertebra by
tilting the head back and looking up at the ceiling. Note
any appearance or disappearance of breathing asymmetry.
(Figure 6.10)
 CHAPTER 6 �THE THORACIC INLET 85

Figure 6.9 Testing Tt for Interpretation of Results

segmental dysfunction
• If asymmetric breathing movement occurs with deep
or first rib subluxation by
inhalation only, there is definitely a manipulable disorder
observing the finger pa
on the anterior surfaces of the thoracic inlet -.either segmental dy sfunction of the
of the first costal first thoracic vertebra, or subluxation of the first rib on the
cartilages (anterior pump restricted side. Proceed to the flexed and extended testing
handle contacts) for
positions (Steps 4 and 5 above).
unilateral anterior
movement while the • If asymmetric breathing movement occurs with deep
patient's head and neck exhalation only, the first rib may or may not be the key rib
are flexed. The patient is (see Chapter 7). If it is, the second ribs will show no asym­
seated.
metry. Proceed to the flexed and extended testing positions
(Steps 4 and 5 above).

• If asymmetric breathing movement (of the key rib)

occurs only in the extended position, and not in the flexed
position, there is FRS dysfunction of the first thoracic ver­
tebral segment. Proceed to the variable rib position tests
(Chapter 7).

• If asymmetric breathing movement (of the key rib)

Figure 6.10 Testing T1
occurs only in the flexed position, and not in the extended
to confirm subluxation
position, there is ERS dysfunction of the first thoracic ver­
by ruling out that
asymmetry is due to tebral segment. Proceed to the variable rib position tests
segmental dysfunction. (Chapter 7).
With finger pads on the
• If asymmetric breathing movement (of the key rib)
anterior pump handle
contacts, assess for
persists in all positions, either the flexed or extended posi­
asymmetry in A-P tions were not extreme enough, or there is a subluxation
position. Patient is in of the first rib on the restricted breathing side. Proceed to
the extended position. the static rib position tests (this chapter).

Reminder: Recall that impaired respiratory movement

of ribs usually is directly due to Type II segmental dys­
function of a thoracic vertebral joint. Type II dysfunction
(FRS or ERS) tends to produce marked anteroposterior
position asymmetry of the pair of ribs attached to the
transverse processes of the lesioned vertebra (the pair
of ribs superior to the dysfunctional joint).
The side of restricted breathing movement tends to be
the side of restricted zygapophyseal movement of the
segmental vertebral dysfunction. Thus, T1 ERSL will usu­
ally restrict the left first rib in the neck flexed position,
whereas FRSL will restrict the right rib in the neck
extended position. (see pages 35-37- Chapter 3)

Proceed to the variable rib position tests (Chapter 7).

Figure 6.11 Diagnosing anterior/posterior first rib subluxations by palpat­

ing the posterior aspect of the shafts of the first ribs.
86 THE MUSCLE ENERGY MANUAL
Figure 6.12 Palpating
clavicles as a reference
plane for first rib A-P
positions.
Static and Variable Position Tests: Procedure 2
Seated Tests for First Rib Posterior Subluxation
and Anterior Subluxation I Range: ribs i- x}
Note: The step breathing screening tests for posterior and anterior subluxa­
tion of rib i have already been demonstrated in Procedure 1.
l. Patient is seated on the examining table.
2. You stand facing the patient, if you are tall; sit facing
the patient, if you are short. The object is to get your eyes
positioned so that you can visually assess the anterior-poste­
rior positions of the rib cartilages. This is most difficult if
your eyes are at the same level as the ribs you are observing.
3. Place your two index finger pads on the anterior sur·
faces of the clavicles just lateral to the clavicular heads.
(Figures 6.12 and 6.13) Then slide them interiorly onto
the anterior surfaces of the first costal cartilages. Notice if
one cartilage is more posterior to the plane of the clavicle
than the other cartilage is.
4. Have the patient flex the first thoracic vertebra by
dropping the chin down toward the chest, and notice any
change in anteroposterior symmetry of the first costal car­
tilages in relation to the anterior planes of the clavicles.
5. Have the patient extend the first thoracic vertebra by
tilting the head back and looking up at the ceiling. This
time, notice any appearance or disappearance of anteropos­
terior symmetry or asymmetry of the first rib cartilages in
relation to the anterior planes of the clavicles.
6. Now step behind the subject and place your thumb
pads 5 or 6 centimeters (2. 5 inches) straight lateral trom
the spinous process of the first thoracic vertebra. Your
thumbs should be slightly lateral to the transverse process­
es and directly posterior to the first ribs. Feel the first ribs
through the trapezius muscle and decide if they lie sym­
metrically in the same coronal plane (Figure 6.11). Is one
more posterior?
7. Repeat the flexion and extension of steps 4 and 5.
Notice if the anteroposterior symmetry of the first ribs
changes.
Figure 6.13 Measuring
the first costal carti­
lages against the ante­
rior plane of the clavi­
cles, for A-P symmetry.
Diagnosing anterior,
posterior, or superior,
first rib subluxations.
or testing T1 for verte·
bral segmental dys­
function.
Interpretation of Results
• Ifthere is anteroposterior symmetry in all positions,
there is neither rib subluxation nor segmental dysfunction
of the first thoracic vertebra.
• If asymmetry persists (does not vary) through all
positions of flexion and extension, there is subluxation
of the first rib on the side of restricted breathing motion.
If the breathing restricted rib is anterior, the rib is sublux­
ated anteriorly. If the restricted rib is posterior, and supe­
rior subluxation has been ruled out (by finding it - as the
next procedure will demonstrate- and then treating it), then
that rib is subluxated posteriorly. Proceed to the treatment
tor posterior subluxation.
• If there is symmetry with extension and asymme­
try with flexion, there is ERS dysfunction ofT 1, and its
rotated position is toward the posterior rib. Proceed to the
transverse process tests (Chapter 7) to confirm the initial
diagnosis.
• If there is symmetry with flexion and asymmetry
with extension, there is FRS dysfunction of T 1, and its
rotated position is toward tl1e posterior rib. Proceed to the
transverse process tests (Chapter 7) to confirm the initial
diagnosis.
• If there is asymmetry with flexion and extension,
but the amount of asymmetry changes slightly, there may
be a complex lesion, combining ERS and FRS dysfunc­
tion of the first thoracic segment,or vertebral segmental dys­
function with costovertebral subluxation. (Figure 7.2 and Chap­
ter 3)
 CHAPTER 6 -&-THE THORACIC INLET 87

Figure 6.14 First rib superior subluxation. When the rib tubercle gets above the level of the transverse process, it can slide back and become lodged on
top of the transverse process. The darkened rib on the left is the rib's original position before the subluxation. The arrow indicates the path of displace­
ment. The rib must be pushed forward before it can be put back down in place. This lesion has great potential to generate pain. The eighth cervical nerve
root crosses over the neck of the first rib, and could possibly be severely kinked by the elevated rib. Amazingly, many patients adapt to this deformity with­
out ever experiencing symptoms from it.

First Rib Superior Subluxation
A sudden jerking or contraction of the cervical scalene
muscles may pull the first rib out of place. When this hap­
pens, the neck of the first rib is pulled from its articulation
on the anterior facing facet on the transverse process ofT I
in a superior direction. If it is pulled far enough superior,
i.e., the full thickness of the rib neck, it may then be drawn
slightly posteriorly to become lodged on the top of the
transverse process. From that position spontaneous reduc­
tion of the subluxation may not occur, even if the scalene
muscle tension is relaxed.
Superior subluxation of the first rib is easy to detect,
when comparing the subluxated side with the normal side,
because of the large vertical (7 mm. to 9 mm.) asymmetry.
The breathing movement of the subluxated rib will be
impaired. In turn, the first rib could restrict the inhalation
movements of the ribs inferior to it (on the same side).
Additionally, the subluxated rib will be slightly receded
posteriorly, in relation to the plane of the clavicle, when
compared with the normal side.
Possible Mechanism of First Rib Superior Subluxation
The mechanism of first rib superior subluxation may be
rooted in the normal anatomy and biomechanics of the ver­
tebromanubrial segment. Because the first ribs are some­
what restrained by their attachment to the manubrium, the
T I vertebra may sidebend farther than the ribs can follow.
Consequently, with extreme right rotation/sidebending of
T I> its right transverse process glides (in this case, trans­
lates) inferiorly on its first rib, and the left transverse
process glides (translates) superiorly on its first rib. If this
occurs at the same time as a sudden forceful contraction of
the right medial and anterior scalene muscles, superior sub­
luxation of the right first rib may occur, the neck of the rib
becoming caught up and back on the superior surface of
the transverse process. This prevents the rib from dropping
down on its costotransverse facet without assistance.
Superior subluxation of the first rib is a common finding in
patients who present with neck/shoulder/arm syndromes.
 88 THE MUSCLE ENERGY MANUAL

The Test for Superior Subluxation of Rib i

[Rartge: rib ij
The Procedure
l. The patient is seated on the examining table.
2. You stand behind the patient. Locate the junction of
the trapezius and posterior scalene, where the lateral sagit­
tal plane along the side of the neck meets the superior bor­
der of the trapezius. (Figure 6.15) With your index finger
pads on the anterior surface of the trapezius at this point,
pull the trapezius posteriorly to separate it from the poste­
rior scalene and create space in the deep fascial interface.
(Figure 6.16)
3. Direct your index fingers 45 degrees inferiorly and
medially in the fascial plane separating the posterior
scalenes from the trapezius until they bump into bone at
the necks of the first ribs, where they articulate with the Figure 6.15 Geometry of the neck and shoulders. Find the junctions of the
vertical planes which run along the sides of the neck and the tilted
transverse processes ofT 1•
horizontal planes which rest on top of the shoulders. The examiner's index
4. To verify that your fingers are on the first ribs, instruct
fingertips then palpate in front of the trapezius at the junctions of the
the patient to take some deep breaths. You should be able lateral planes of the neck and the superior planes of the shoulders.
to feel the rib necks rotate on their respiratory axes.
5. Compare the vertical heights of the rib necks by look­
ing at your fingers. The asymmetry should be noted as
quantitatively as possible. Step back at arm's length and
observe with your eyes level with your fingers to reduce
errors of parallax.
6. Confirm results by performing a palpatory-visual eval­
uation of rib i position and breathing motion from in front
of the patient.

Interpretation of Results
• If the vertical heights are symmetrical, there is no supe­
rior subluxation. "Symmetrical," in this case, is only approx­
imate. Significant asymmetry tor this test is about 9 mm.,
3;8 inch, the thickness of the first rib neck. With
or 5;16 to
6 mm. (1;4 inch) difference, or less, the rib neck is probably
not elevated far enough to become lodged on the transverse
process and it is probably not a superior subluxation.

• There is the remote possibility of bilateral superior sub­

luxations of both first ribs. Rib asymmetries on the order of
3 to 5 mm. can be seen with sidebent position of the first
thoracic vertebra. Additionally, an asymmetry of 3;4 inch
might be due to a cervical rib, a fairly common anatomic vari­
ant, usually of no clinical significance.
• The Muscle Energy treatment is so nontraumatic that
normal ribs may be subjected to it without risk. Sometimes
treating the segment as if an ERS or FRS dysfunction is pre­
sent is the only way to discover bilateral superior subluxa­
tion of the first rib.
Figure 6.16 Palpating the necks of ribs i between trapezius and scalenes.
With the examiners fingers positioned in front of the trapezius but behind
the scalenes, the trapezius muscle is pulled away from the scalenes,
creating a space to insert the fingertips inferiorly and slightly medially to
reach the neck of the first rib. The examiner can then sight horizontally
across his or her flexed knuckles to assess the vertical symmetry of the
necks of the first rib. If there is superior/inferior asymmetry of the vertical
heights that is more than 3Js inch, there is superior subluxation on the side
which is higher.
 CHAPTER 6 -I) THE THORACIC INLET 89

Anterior or Posterior Subluxations of Rib i

Etiology f Anterior
o or Posterior Subluxation f the
o

First Rib
The scalene muscles have the ability to dislocate the first, or
second, ribs in several directions, depending on the resul­
tant vector of muscle tensions. Like other ribs, the first rib
head can subluxate anteriorly or posteriorly in relation to
the first thoracic vertebra. The designation "anterior" or
"posterior" refers to the direction of displacement of
the head of the rib on the vertebral body. Increased sca­
lene tension may be caused by segmental dy sfunction in the
cervical spine. High levels of anxiety may also cause the
increased tonus of muscles which are capable of pulling a
rib out of place.
When the head of the rib is driven forward, the neck of
the rib must slide medially on the transverse process.
Similarly, when the head of the rib is driven backward, the
neck of the rib must slide laterally on the transverse process. Figure 6.17 Anterior subluxation of the right first rib. The arrow indicates
the path of displacement.
Thus, we can describe the anterior and posterior subluxa­
tions of the first rib as displacements along an arc clockwise
or counterclockwise. In the longer, more slender ribs, the
lateral shaft may bend slightly to accommodate the medial
or lateral displacement. The anterior ends of the ribs do
not deform to adapt, but follow the movement of the rib
head. Thus, an anterior subluxation is anterior front and
back, and a posterior subluxation is posterior front and
back, with very little medial or lateral displacement of the
rib shafts.
Treatment of anterior subluxations of any rib requires
that the posterior part of the rib be guided laterally in rei a­
tion to the transverse process as well as posteriorly along
the arc which passes through the costovertebral and the
costotransverse joints of the subluxated rib. Treatment of
posterior subluxation requires movement of the posterior
part of the rib in this same arc, but in the contrary direc­
tion: anterior and medial.

Figure 6.18 Posterior subluxation of the right first rib. The arrow indicates
the path of displacement.
90 THE MUSCLE ENERGY MANUAL

Practice Exercises for the Evaluation of

the First Ribs and First Thoracic Segment
It is important to practice the psychomotor skills involved
in the first rib evaluation procedures:

• The seated breathing tests

• Finding the key rib (Chapter 5)

• The tests for anterior or posterior rib subluxation

• Testing tor superior subluxation of rib i

• Variable respiratory restriction

• Anteroposterior position indicating ERS or FRS

dysfunction

Remember to apply the basic rules of physical diagnosis:

balance, relaxation, and anatomic specificity (localization).
The balance and relaxation principles boil down to "don't
use any more energy than is necessary." Both the operator
and the patient must be balanced and relaxed. When per­
forming a procedure for the first time, these are difficult
goals to achieve. It is natural for a beginner to use much
more effort than is actually required to do the procedure.
Review the steps of learning a new psychomotor skill,
presented in Volume 1. The stages for learning the psy­
chomotor skills for screening examination procedures can
be characterized as: ( 1) Conceptual- understand the rea­
sons for doing things in certain ways, (2) Procedural
imagery- rehearse the steps of a procedure in your mind
before actually doing it, (3) Sequential performance- do
the procedure in rote blocked out steps to get the moves in
order, ( 4) Skilled performance - practice by repeating the
procedure, adding in the fine points and finesse necessary
to make it effective, and ( 5) Integrative intnpretation- be
sure you understand the significance of the outcome.
Anatomic specificity means being sure of the exact anatom­
ic location of the structure you are evaluating. Learn to
count ribs and vertebrae. Know the landmarks both visu­
ally and by feel.
 CHAPTER 6 �THE THORACIC INLET 91

Treatment Procedures for First Rib Subluxations The next three treatment techniques are for the reduction
of first rib subluxations. Treatment procedures for sublux­
Comments On Treating Rib Subluxations
ations of ribs ii through x will be presented in Chapter 8.
Some general orthopedic principles pertaining to the
A fairly common subluxation unique to the first rib is
reduction of dislocations are:
superior subluxation. When it occurs, its malposition is
( l) Reduce tension in the tissues surrounding the dislocated maintained because a small part of the rib catches on the
Joint before attempting to put the bones back in place. superior surface of the first thoracic transverse process and
is prevented from the forward movement necessary to dis­
( 2)Reduce the friction contact of the parts to a minimum
lodge it by tension of the anterior scalene muscle. The sca­
before and during the reduction of the dislocation.
lene muscles tend to contract reflexly in the presence of first
The first principle refers to the periarticular tissues - rib subluxation, establishing a vicious cycle that can main­
muscles, fascias, and ligaments. Fascias and ligaments can tain the subluxation.
be relaxed by positioning. Relaxing muscle tissue requires To reduce a superior subluxation of the first rib, the rib
a more complex approach. Often guarding muscle spasm must first be moved anteriorly and laterally to dislodge it
surrounds a dislocated joint. To obtain the necessary relax­ from the transverse process. Replacing the rib inferiorly to
ation, pain and anxiety must be avoided. Balance and relax­ its proper position in front of the transverse process is then
ation are as important in reducing rib subluxation as they quite easy. Usually, the first rib drops down in place on its
are in treating motion restriction of joints. B�lance is con­ own, once it is pushed far enough forward to be dislodged
sidered in the positioning of patient and operator, and from the transverse process.
makes relaxation possible. The principle of reciprocal inhi­
bition of muscle antagonists (Sherrington's Second Law)
can be effectively applied to reduce muscle tension.
Specific "localized" relaxation is obtained by contracting
antagonist muscles. When using antagonist muscle con­
traction to relax a tense muscle, care must be taken to avoid
co-contraction of the tense muscle, which can occur if the
antagonist contraction force is too great.
The second principle refers to "loose-packing" the
articular members, i.e., putting the joint in least congruent
contact. For any given joint there is a position within the
range of motion where the joint surfaces are least congru­
ent, that is, in minimal contact. If this position can be
approximated before traction is applied to separate the
parts in preparation for reducing the dislocation, the pro­
cedure can be accomplished with minimum force.
Thrust techniques should never be used to reduce
rib subluxations. Subluxated joints are hy permobile
joints, and they should be protected from forces capable of
Figure 6.19 Direction of reduction procedure for superior first rib sublux·
making them even more unstable. ation. The arrow indicates the direction of the corrective force.
92 THE MUSCLE ENERGY MANUAL

The Procedure for Reducing First Rib Superior Figure 6.20 Finding rib i
Subluxation [Ra11ge: rib i} 2.25 inches lateral to T1
spinous process.
1. The patient sits in front of you. Rest your foot on the
treatment table or seat beside the patient on the side oppo­
site the subluxation to be reduced, and support the
patient's axilla on your thigh. This method of supporting
the patient permits adjusting the patient's balance by trans­
lating the shoulders in the direction opposite from the
sidebending of the head and neck. (Figure 6.20)
2. Without rotating the head, the neck is sidebent toward
the subluxation.
3. Place your fingers lightly in the supraclavicular fossa, in
relation to the rib, in front of the trapezius muscle, and the
thumb palpates the posterior aspect of the rib through the
trapezius about 6 em. lateral trom the spinous process of
the first thoracic vertebra. (Figure 6.22)
4. When sidebending of the neck is positioned such that
it allows for maximum relaxation of the muscles and fascia
above the first rib, then adjust the patient's position tor
optimum postural balance by moving the patient's torso Figure 6.21 Starting
position for reducing a
sideways with the supporting thigh. (Figure 6.21)
right first rib subluxa­
5. Then ask the patient to push their head sideways in the
tion -whether superior,
opposite direction against your unyielding resistance using anterior, or posterior.
about 5 to 7 pounds (2 to 3 Kgs.) of sustained force. To facilitate patient
6. During the time that the muscles above the rib are relaxation, the patient is
supported under the left
relaxed due to reciprocal inhibition, while the patient is sus­
axilla by the operator's
taining the moderate intensity isometric contraction of the thigh.
antagonist muscles, your thumb pad pushes the first rib
straight anterior and slightly lateral (do not push down).
The pressure is applied through the trapezius muscle until
the rib is felt to move slightly torward and then down inte­
riorly about 7 to 9 millimeters, until the pressure has been
maintained tor 3 seconds, whichever comes first. (Figure
6.23)
7. Recheck the first rib tor superior subluxation.

Note: The reciprocal inhibition principle works only up to a certain

intensity of contraction of the antagonist muscles. More intense con­
tractions can have the opposite effect as the antagonist muscles co­
contract to become stabilizers. The appropriate intensity may be more
or less than 5 pounds.
 CHAPTER 6 �THE THORACIC INLET 93

Figure 6.22 Reduction of Figure 6.23 Step 6,

rib i anterior subluxation. Procedure for reducing
The operator monitors tis­ first rib superior sub­
sue relaxation in the right luxation. Once the
supraclavicular fossa, patient is properly posi­
while sidebending the tioned, the operator's
neck to the right and thumb pushes the first
translating the shoulders rib forward and lateral
to the left. By way of reci­ to treat superior sub­
procal inhibition, the luxation, or forward
patient sustains a moder­ and medial to treat
ate intensity isometric posterior subluxation.
contraction of the antago­
nist muscles in order to
further relax the muscles
above the rib while the
operator's fingers in the
supraclavicular fossa pull
the scalene muscles and
fascia posteriorly and lat­
erally to guide the rib back
into place.

Figure 6.24 Direction of reduction procedure for anterior first rib subluxa­ Figure 6.25 Direction of reduction procedure for posterior first rib sublux­
tion. ation.

The Procedure for Reducing First Rib The Procedure for Reducing First Rib
Anterior Subluxation [Range: rib i} Posterior Subluxation [Range: rib i}
As with the previous procedure, after the patient is posi­ After the patient is positioned to reduce tissue tension to a
tioned to reduce tissue tension to a minimum (Steps 1-5 minimum (Steps 1-5), the only difference between treat­
for superior subluxation), the only difference between ing a posterior and a superior subluxation of the first rib is
treating an anterior and a superior subluxation of the first the direction of force required to guide the rib back in
rib is the direction of force required to guide the rib back place. The posterior rib must be pushed straight anterior
in place (Step 6). and slightly medial (instead of lateral). The pushing pres­
6 the anteriorly subluxated rib must be pulled
For Step sure is provided by the operator's thumb pushing against
laterally and slightly posteriorly. During the time that the the rib tubercle through the trapezius muscle - similar to
muscles above the rib are relaxed due to reciprocal inhibi­ the treatment of the superior subluxation. (Figure 6.23)
tion, and JVhile the patient is sustaining the moderate inten­
sity isometric contraction of the antagonist muscles, the
operator's fingers in the supraclavicular fossa can gently
guide the rib back in place by drawing the scalene muscles
and their fascias lateral and posterior. Rechecking the rib is
the last step of the procedure. Several trials may be neces­
sary before a reduction of the subluxation is obtained.
94 THE MUSCLE ENERGY MANUAL

Preventing Recnrrence of First Rib Subluxations Isolytic Technique for Correcting Muscle
Avoiding scalene muscle tension to prevent redislocation
Contracture of Scalenes
sometimes requires more than merely reducing the sublux­
Poor postural adaptations may result in chronic shortness
ation of the rib. Sometimes, segmental dystimction in the
of the scalene muscles due to fibrotic contracture. In some
cervical spine must be resolved betore the scalenes can suf­
instances this may be the reason for recurrent first rib sub­
ficiently relax. (See Evaluation and Treatment, Cervical luxations. Home stretching exercises can help restore sup·
Spine, Volume 1.) In addition to correction of cervical seg·
pleness to the neck over time. To accelerate the restoration
mental dysfunctions, it is sometimes necessary to stretch
of mobility, fibrotic muscles can be elongated using a
tight, fibrotic (contractured) cervical muscles. V ibratory
Muscle Energy technique called, generically, "vibratory
isolytic technique can be effectively applied in these cases.
isolytic" technique, derived from T. ] . Ruddy's Rapid
Various stress reduction methods can also be a valuable
Rhythmic Resistive Duction Technique. (Ruddy, 1962)
adjunct to treatment.
When applying vibratory isolytic technique the opera­
The costovertebral ligaments need time, approximate­
tor's counterforce is oscillated, within a small range of dis­
ly two to eight weeks, to heal and regain the necessary ten­
tance, in a rapid vibratory movement (approximately 4 to 6
sion to pertorm their support function. It may be difficult
Hz) while the patient attempts to maintain a steady con­
tor the patient to maintain adequate balanced rib motion
tinuous, moderate force contraction (about 2 Kg). This
tor this length of time. In order to reduce muscle tension
has the effect of alternating eccentric and concentric iso­
and maintain the balance of the muscles involved, the
tonic contractions. The distance covered by the oscillation
patient should be counseled to avoid a "chin torward" or
is quite small, usually less than a centimeter. The rapid
slouching posture. As an alternative, it may be necessary to
quick movements accelerate lymphatic drainage flow, stir
put the muscles to rest by using various immobilization
interstitial fluids, and increase tissue perfusion. The rapid­
devices, e.g., collars, slings, rib belts, and/or short courses
ity of the movement defeats the myotatic reflex mechanism,
(10-14 days) of muscle relaxants to permit healing. One
allowing more rapid deformation of the collagenous per­
patient with recurring second rib subluxation eventually
imysium, epimysium, and endomysium which surround the
observed that her rib would stay in place as long as her trav­
muscle and its fascicles.
eling boss was out of town. But when the boss returned,
she would soon schedule an appointment to have her rib
A Brief Theoretical Explanation of the Isolytic
subluxation reduced. Diazepam (5 milligrams) taken only Technique Mechanisms
on those rare days the boss was in town allowed the rib to
Permanent deformation of collagen requires alteration of
stay in place and ultimately heal.
its molecular structure. Hydrogen bonds, the most unsta­
ble linkages within the collagen molecule, are least stable
Scalene Contracture when their environment is slightly more acidic than the
Contracture of scalene muscles is a frequent late eftect of
normal pH of interstitial fluid. This is part of the mecha­
cervical fracture or other cervical trauma, or it may be part
nism of progressive ligamentous weakness and degenera­
of a posture imbalance syndrome. The tight scalene nms­
tion in the feet of patients with chronic venous insufficiency
cles can be palpated on the sides of the neck. Typically,
in the legs. In isolytic technique the sustained muscle con­
some portions of the scalene muscles are tighter than other
traction generates lactic acid, which lowers the pH of the
portions, producing a palpable difference between left and
interstitial fluid. Dr. Kenneth Little's adaptation (personal
right, or between anterior, middle, and posterior scalenes.
communication) of Ida Rolfs techniques included having
The scalene muscles arise trom most, and sometimes all, of
the patient hold the breath to create respiratory acidosis
the cervical transverse processes. Often scalene tendons
while the fascias were being stretched. The resulting
arising trom particular vertebrae are palpably tighter than
stretches were more profound and more stable.
tendons trom neighboring vertebrae. Stretching tech­
The voluntary contraction of the muscle during isolyt·
niques should be localized as specifically as possible.
ic technique appears to contribute to the defeat of the
myotatic reflex, probably by inhibiting it at the cord level.
If the oscillation is rapid enough, it seems to ddeat the
tonification etTect of intermittent myotonic stretches, pos­
sibly by overwhelming the proprioceptive mechanisms.
 CHAPTER 6 -tJ. THE THORACIC INLET 95

Vibratory Isolytic Technique for Treatment of Figure 6.26 The

vibratory isolytic
Scalene Muscle Contracture
technique for tight
The Procedure scalenes.

1. The patient is seated on the treatment table leaning

back against you.
2. On the side to be stretched, place your palm on top of
the shoulder covering the clavicle and first costal cartilage.
3. From above, reach the fingers of your other hand to
the forehead at the frontal angle on the same side as the
scalene to be stretched.
4. While holding the ribs and clavicle down with your
other hand on top of the shoulder, tilt the head back diag­
onally (Figure 6.26) . Tilt until the slack of the anterolat­
eral muscles is taken up, stopping as soon as the first resis­
tance- but not tension- is encountered.
5. Ask the patient for a moderate intensity (2 to 5
Kilograms of force) sustained push of the head diagonally
forward and downward against your resisting fingers.

Note: In cases of recurrent first rib subluxation it is most important to

stabilize the rib with your hand on the shoulder. First rib recurrent sub­
luxations can be very problematic.

6. While the patient is pushing, flutter your resisting fin­

gers rapidly ( 4 to 6 cycles per second) causing the point of
contact to oscillate back and forth about one centimeter.
7. Sustain the oscillation against the patient's push
through 40 to 60 cycles (8 to 12 seconds), then tell the
:
.·

patient to stop pushing. You relax your resistance simulta­ ·.

·.
·
.

�
neously, and wait for patient's full relaxation.
8. Then take up the slack to the new point of resistance,
stretching the muscle gently.
9. Repeat the oscillation procedure (Steps 5, 6, and 7)
two more times.
10. Reevaluate the muscle tightness, comparing before
with after. Figure 6.27 Operator's hand movement in isolytic technique. The fingers,
resisting the oblique forward push of the forehead, flutter very rapidly in a
waving motion. The rate of oscillation should be 4 to 6 per second, to
suppress myotatic reflexes and agitate interstitial fluids.
96 T H E MUSCLE ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 97

CHAPTER 7

ERS and FRS Segmental

Dysfunction: Tl - T6

RS and FRS segmental dysfunctions account for the vast

E
majority of vertebral segmental dysfunction from c2
through L5. In fact, for C2 through T2' ERS and FRS
dysfunctions are the onlytypes of vertebral segmental dys­
function po&sible. For segments T3 through L5, a small percent­
age of dysfunctions are classed as
NSR, but ERS and FRS dys­
functions predominate. NSR dysfunctions are rare, in contrast to
normal neutral sidebending adaptation, which is quite common.
All ERS and FRS dysfunctions can be described as impair­
ment ofzygapophyseal (facet) joint motion, even when the patho­
logic condition is not actually within the facet joint. When ERS
dysfunction is present at a particular vertebral segment, as that
segment moves toward flexion, a restriction is encountered for
one of the inferior zygapophyseal joints for that segment. Thus,
the vertebra with an ERS dysfunction, instead of flexing normal­
ly and bending straight forward in the sagittal plane on the sub­
jacent vertebra, rotates (and sidebends) toward the side of the
restricted facet in relation to the subjacent vertebra. (Figure 7.1)
Likewise, if an FRS dysfunction is present, as the segment
moves from flexion toward extension, one of the inferior
zygapophyseal facets for that segment is restricted or engages the
superior zygapophyseal joint of the subjacent vertebra. As with In this chapter:

the ERS dysfunction, the segment with FRS dysfunction will also • Using rib motion and position to
manifest coupled rotation/sidebending, but it will move away diagnose ERS, FRS, and NSR
from the restricted side after the restriction is engaged. In a nor­ segmental dysfunctions
mal vertebral joint, there should be no rotation coupled to flex­ • Application of the Key Rib concept to
ion or extension.
vertebral dysfunction identification
Whether ERS or FRS, the point at which the segment
• Diagnosis by transverse process
encounters the restriction varies. Both ERS and FRS types may
position
occur as major dysfunctions (more than 50 percent range of
• Treatment procedures for non-neutral
motion loss) or minor dysfunctions (less than 50 percent range of
dysfunction, T1- T6
motion loss). In the majority of cases, the dysfunction is unilat­
Longus colli technique
eral - that is, restricted motion is only present on one side of the
Turban technique
vertebral joint. However, there may be variations as the types
may be combined unilaterally or bilaterally (Figure 7.2 ). Modified longus colli technique

When a vertebral segment is in neutral (i.e., zygapophyseal Lateral recumbent technique

facets not engaged), and there is no segmental dysfunction pre­ Supine technique

sent, the vertical axis for rotation passes through the vertebral Seated axial rotation technique

body. When coming from the neutral range, the vertebra with
ERS or FRS dysfunction engages the restricted facet, the y-axis
for rotation shifts from the vertebral body to the restricted facet.
98 THE MUSCLE ENERGY MANUAL

A. FRS Left B. ERS Left

NORMAL

Figure 7.1 Examples of non-neutral dysfunction. In the left-hand column, FRS Left; normal in the flexed position (topl and left rotated in the extended posi·
tion (bottoml. In the right-hand column, ERS Left; normal in the extended position (bottom I and left rotated in the flexed position (top I. In the case of FRS
Left, the left transverse process is posterior because only the left side can move into extension [i.e., move posteriorly 1+11: with ERS Left, the left transverse
process is posterior because only the right side can move into flexion [i.e., move anteriorly HJ.

Arthrokinematically, with all ERS and FRS dysfunc­
tions, one inferior zygapophyseal facet becomes a tempo·
rary pivot for the segment. The inferior facet on the other
side of the superior vertebrae, instead of sliding in a sagit­
tal plane straight superior-anterior with flexion, or inferior­
posterior with extension, moves along the arc of a circle
whose central pivot point is on the zygapophysis with
restricted motion. (Figure 7.1) When rotation
sidebending) movements are occurring along this arc, pal­
pable and observable displacement of the transverse pro·
cesses of the thoracic vertebra and the corresponding ribs
naturally occur. Also, once the axis for rotation shifts to the
facet, whether moving toward extension or flexion, verte·
bral rotation will necessarily result in much larger transla­
tion of the vertebral body. (Chapter 2)
This translation of the vertebral body puts a shearing
strain on the intervertebral disc, which, in addition to the
abnormally arcing facet, may be another source of nocicep·
tion. In general, the potential for nociception is greater on
the moving side of the segment than it is on the blocked
side. The consequences of the increased nociception on
one side of the vertebral segment may be guarding spasm
(and of paravertebral muscles, altered autonomic functions, or
locomotor adaptation altering posture or movements.
Successful adaptations allow the dysfunctional segment to
remain symptomatically silent. Unsuccessful adaptations
manifest visceral or somatic symptoms locally, or at a dis­
tance in the adapting mechanism. Visceral consequences of
ERS and FRS dysfunctions depend on how and where the
stresses of adaptation present themselves.
 CHAPTER 7 _.,. ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 99

. 1. 2. 3. 4. 5. 6.

Normal Normal Minor ERSL Minor FRSL Major ERSL Major ERSL
Flexion Extension with Flexion with Extension with Flexion with Extension

7. 8.
Flexion and extension movement in an In minor dysfunctions the moving facet
unrestricted FSU. The sliding horizontal meets the abnormal end field (darkened
bar represents the paths of the moving area) after it has traveled more than half
facets and transverse processes. The its normal range of motion.
darker tips of the vertical bars, the inferior
facets, are the viscoelastic end fields of
the range of motion. The V represents the
spinous process.

11. 15. Major FRSL Major FRSL

9. 10. with Extension with Flexion

In major dysfunctions the abnormal end

field is met before the facet has trav­
elled half of its normal range of motion.
Extreme extension may be required to
make the ERS vertebral position sym­

'..
metrical. Straightening the FRS segment
Bilateral ERS sometimes requires extreme flexion.
Minor ERSL & FRSR Minor ERSL & FRSR Minor ERSL & FRSR
with Flexion
with Flexion in Mid-range with Extension
ERSL > ERSR

12. 13. 14.

."
16. 17. 18.

. bt .
.
.

Major ERSR & FRSL Major ERSR & FRSL Major ERSR & FRSL Minor ERSL & FRSL Minor ERSL & FRSL Minor ERSL & FRSL
with Flexion in Mid-range with Extension with Rexion in Mid-range with Extension

When both flexion and extension restriction exists in the same facet 19. 20. 21.
joint, flexing the vertebra will rotate it toward that side and extending
will rotate it in the opposite direction.

Figure 7.2. Diagrams of ERS and FRS combinations - Overlapped ERSL & Overlapped ERSL & Overlapped ERSL &
FRSL with Flexion FRSL in Mid-range FRSL with Extension
examples of varieties of segmental dysfunction. Each pair
of vertical bars represents the path of range of movement, nor­
mal or abnormal, of the inferior facets of the superior vertebra Bilateral facet restrictions are not common, but any combination can
sliding on the superior facets of the inferior vertebra. as seen occur. In the minor combinations a mid-range position of symmetry
from behind. The dark shaded areas represent restriction -the may be found (#'s 15, 16, 17, 18). When bilateral restrictions overlap, no
symmetrical position can be found (#'s 19, 20, 21 ), Bilateral ERS or FRS
range of motion not permitted. The horizontal bar with the V in dysfunctions may be suspected, but treating one side-the most
the middle represents the transverse and spinous processes (V) restricted-will allow discovery of the restriction on the other side.
of the superior vertebra. When the V shifts to the right. the
transverse processes are rotating and sidebending to the left.
The curved vertical bars represent the abnormal arcuate move­
ment of the more mobile facet. Bear in mind that these twenty­
one examples do not exhaust all the possibilities.
100 THE MUSCLE ENERGY MANUAL
,....-----
.... _____ .,.
Right side
Note: Because of the coronal orientation of the thoracic zygapophyses.
flexing a thoracic vertebra moves its transverse processes mainly in a
cephalic direction and extending moves them caudally. Because of the
normal thoracic kyphosis. the zygapophyseal facet planes in the upper
thoracic vertebrae are tilted forward. adding to the anterior movement
of the transverse processes caused by flexion. For the same reason.
unilateral anterior or posterior displacement occurs with segmental
dysfunction. where one zygapophyseal facet becomes a pivot and the
contralateral facet moves in the anteriorly inclined plane of the joint.
The dysfunctional zygapophyseal arthrokinematics just
presented should not lead to an erroneous conclusion that
the pathological condition always lies within the
zygapophyseal joint. Certainly, intra-articular blockage due
to malcongruence of joint surfaces or meniscoid entrap­
ment can be causes of joint motion restriction. However,
abnormal tensions in the myofascial components of the
intervertebral segment can be pragmatically conceived as
the site of pathology, especially the monoarticular myofas­
cial tissues of the segment, e.g., rotatores, longus colli medi­
alis, and/or intertransversarii. The distinction is academ­
ic, however, since MET easily treats both conditions effec­
tively.
Integrated Vertebral Segment and Rib Motion
Robert England ( 1964 ) , quoting extensively trom Angus
Cathie, acknowledged the timctional integration of verte­
bral motion and rib motion, laying the foundation tor the
new diagnostic algorithm presented in this text. Although
Cathie provided the anatomic detail, the diagnostic ramifi­
cations of this integration were not well understood, and
clinical applications were not extensively developed at that
time.
Figure 7.3. Ribs as indicators of vertebral
segmental dysfunction. A vertebra rotating
to the left will take the superior pair of ribs
with it, deforming them slightly because of
their anterior attachments. The ribs which
articulate on its inferior demifacets are
torqued by the rotating vertebral body, the
right rib inverted, the left rib everted. This
phenomenon is called "single rib torsion"
(q.v.). and, in the mid-thoracic region, it may
be the most obvious evidence of Type II seg­
I mental dysfunction of the spine. (The solid
I
I
line represents the rotated position.)
Left side I
I
I
I
I
I
I
I
I
'/
..
England: "Movements of the thoracic vertebrae are associat­
ed with or accompanied by movements of the ribs, and the
reverse is true. The degree of motion in these clearly and
closely related articulations is slight. It has been stated by
some earlier writers that lesions of the thoracic vertebrae may
exist without the associated rib being in lesion, and that a rib
lesion may exist without a lesion of the associated vertebra.
This may well be true but, after considering the integrated
movements of the thorax, one must conclude that this situa­
tion would be quite rare. Dr. Angus G. Cathie points out
some facts to substantiate the rarity of this occurrence in a
lecture on 'Thoracic Motion and Integrated Activity of
Related Joints,' given at the Philadelphia College of
Osteopathy:"
Cathie: "An analysis of the physiologic motions of the thorax
reveals combined movements of the ribs and vertebrae. It is
a requirement of normal respiratory activity and what is
described as normal physiologic movements of the spine.
Physiologically, then, there is some motion in all of the artic­
ulations entering into the formation of a thoracic interverte­
bral joint or thoracic vertebral unit. In the thoracic region
we must consider the spinal joints, including the costoverte­
bral and costotransverse articulations. A study of the
Halladay spine and of the prolongation of the fibers of liga­
ments and associated structures gives further evidence of the
related activity taking place between these sets of joints. It is
unfortunate that our mental picture of these motions has
been limited to the gross view, having stopped short of the
motion of tension of ligaments, fascia, and even of elated are­
olar tissue. A lesion may be one of restricted motion without
change in the relationship of articulating surfaces, and due to
tension restraining the coordinated motion of an associated
joint. Unless we are able to comprehend the details of'joint
activity it is impossible to understand the greater osteopathic
lesion complex .... In those rare instances in which one type of
lesion (either true rib or true vertebral) exists without the
associated lesion, we must understand that the simple lesion
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 101

exists for a short period of time, and that it will soon be com­ As was demonstrated by the first rib step breathing
plicated by the other. The radiate ligament of the costoverte­
procedure (Chapter 6), almost full flexion and extension is
bral joint attaches to the neck of the first rib and sends fibers
possible for the seated patient, both for screening (using
to the body of the seventh cervical vertebra as well as to the
first thoracic, and is an important consideration in the the palms on groups of ribs) and scanning (using the fin­
mechanics of the cervicodorsal junction, especially when one ger-tips or pads on individual rib pairs). In searching for
considers the frequency of lesioning of the seventh cervical the key rib, several ribs at a time may be screened as a
and first thoracic vertebra in association with lesions of the
group, using the behavior of the group to indicate the
first rib."
presence or absence of a manipulable disorder at the top or
the bottom of the group. As with the evaluation proce­
Diagnosing Segmental Dysfunction in the Thoracics
dures for primary respiratory dysfunction (Chapter 5 ),
A diagnosis of segmental dysfunction in the thoracics can
when a rib exhibits respiratory restriction, attention is paid
be arrived at from several different evaluation approaches.
to whether the restriction occurs at the end of inhalation or
To diagnose ERS or FRS segmental dysfunction, one
the end of exhalation. For the purposes of diagnosing seg­
approach is to evaluate the position of transverse processes
mental dysfunction, we will also want to note whether the
at the beginning and end of a range of motion (e.g., flex­
respiratory restriction exists only in flexion but not in
ion/extension). Another approach is based on an inter­
extension (or vice versa), and whether there is A-P asym­
pretation of the findings from rib position and motion
metry of the rib in either of those ranges of motion.
tests. Based on the results of these tests, the location, type,
There are several patient positions - seated, supine or
and nature of a segmental dysfunction can be identified.
prone - for evaluating segmental dysfunction using the
Findings regarding positional asymmetry and respiratory
ribs. Which position is used is dependent on a variety of
restriction of a rib in various stages of flexion and extension
factors based on the ribs and/or segments involved, and
are all relevant to the diagnosis of segmental dysfunction.
what limitations - in terms of positioning- the patient may
The ribs are extremely sensitive indicators of verte­
have.
bral segmental dysfunction, because they tend to move
Instructions to the seated patient to obtain as much
with the vertebra. In a practical clinical sense, the thoracic
active flexion of the entire thoracic spine as possible
ribs act as if they are part of the transverse processes - that
include: «stump your back.'' «Let your upper back sag back­
is, long extensions of the transverse processes. Thus, iden­
ward.» «Put your chin down on your chest.'' Instructions for
tifying and assessing the key rib will not only locate the
maximal extension include: <<sit up tall and push your chest
dysfunctional vertebra, but can also indicate its posi­
(and/or abdomen) as far forward as you can.» «Put your
tion. For example, when a thoracic vertebra is ERS Left,
head back, and look up at the ceiling above you.''
the rib which articulates with its right transverse process
Even though the screening and scanning procedure
will be moved anteriorly when that vertebra flexes, where­
protocols are described separately, they are usually blended
as the left rib will remain posterior. The anterior and pos­
together as screening findings quickly indicate the presence
terior movements of the key rib (which can be observed
and approximate location of a manipulable disorder.
with spine flexion and extension) can often define the ver­
In applying the step breathing test, ribs ii through x are
tebral somatic dysfunction more precisely than palpating
monitored by placing the finger pads in the intercostal
paravertebral tissues or transverse processes.
spaces, contacting the superior margins of the pair of ribs
Note: The rib with restricted breathing motion tends to be on the side being tested (instead of the finger pads on the inferior mar­
of impaired vertebral facet motion. In the above example (ERS Left), gins, as in testing the first ribs). Examining one pair of ribs
the left rib would have breathing restriction; the right rib would move at a time may be used to scan for the key rib, or for testing
forward with flexion and breathe freely. the key rib with flexion and extension to distinguish FRS
from ERS segmental dysfunction. While the patient is in
the more extreme positions of flexion and extension, indi­
Procedures for Evaluating Segmental Dysfunction vidual pairs of ribs can be tested with step breathing.
in the Thoracics Anteroposterior variations in rib position can also be
In addition to using the transverse processes, the presence tested in these same positions by placing the finger pads on
of segmental dysfunction between T1-T10 can be deter­ the anterior surfaces of the ribs just lateral to the costo­
mined by assessing positional asymmetry and restricted chondral junctions and observing them from a proper van­
breathing motions of the corresponding ribs. If such asym­ tage point.
metry or restriction exists, vertebral segmental dysfunction
is the likely cause.
102 THE MUSCLE ENERGY MANUAL

Four Methods for Stereognostic

Screening for Rib Position and Motion
to Diagnose Segmental Dysfunction
Method 1: Seated Anterior Screening Procedure
[Range: T1 - T10 an d ribs i- xj

l. Patient is seated erect, slumped into flexion, or arched

into extension, on the examining table. To induce flexion
the chin is moved to the chest and the upper back is
slumped by translating the mid-thoracic region posteriorly.
2. Seat yourself, or stand, in front of the patient.
3. Place your palms over the anterior lateral aspect of the
upper 4 or 5 ribs; fingertips are located just below the clav­
icles, with the heels of the hands positioned:
a. lateral and posterior to the pectoralis major tendons Figure 7.4 Palpating for anterior prominence of ribs i- v, erect position.
tor bucket handle observation, or Screening hand contacts for upper ribs. This hand position serves
several purposes. One purpose is to detect stereognostically any left­
b. lateral to the sternum tor pump handle observation.
right asymmetries of anterior prominence of a rib. Another is to observe
Slide the skin and soft tissues over the ribs by slightly altered respiratory movements resulting from variations in flexion and
moving the hands until the location and shapes of the extension postures. The spine is extended to look for FRS effects on the
ribs can be palpated (stereognostic palpation). breathing motion pattern.

4. Notice any shape asymmetries of the rib cage due to

anterior prominence, flattening, elevation, or depression of
a rib or ribs.
5. Instruct the patient: «Now let your breath all the way
out. NoJJ! take half a breath in and let it out.'' (This step
breathing may be repeated, if necessary.) When the ribs
move, follow their movement with your hands . Monitor
your hand movement using your peripheral vision by focus­
ing your central gaze on the sternum.
6. Instruct the patient: «'Take a full breath in. Now let
half of yottr breath out and take it in again.'' (This step
breathing may be repeated, if necessary.) Again, monitor
the motion of the ribs as in Step 5.
7. Ask tl1e patient to flex the thoracic spine
(«stump�,
and then extend it («Arch your back and stick your chest
out))). Notice if either of these positions causes or elimi­
nates shape or breathing motion asymmetry by repeating
Steps 5 and 6.
Figure 7.5 Palpating for anterior prominence of ribs i- v. Upper rib screen
8. Move your hands to the middle group of ribs, vi hand placement- spine flexed to look for ERS effects on breathing motion
through x, on or just lateral to the costochondral junctions pattern.
with your thumbs in the:
a. parasternal position (pump handle aspect) and fin­
gers pointed up and out, or
b. farther lateral to the bucket handle, mid-axillar y line
area.
9. Repeat Steps 4, 5, 6, and 7.

Note: The massive piece of blended costal cartilage for ribs vii through
x may be too rigid to reflect anterior and posterior movements of indi­
vidual ribs. It is. therefore. preferable to palpate the bony ribs at this
level. The ribs with individual costal cartilages. i through vi, can be pal­
pated reliably with the hands in the parasternal positions described
above in Step 3.

• Interpretation of results for Methods 1 - 3 will immediately

tollow Method 3.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 103

Figure 7.6 Palpating for Figure 7.7 Palpating for

anterior prominence of anterior prominence of
ribs vi x, extended
· ribs iv x. Middle rib
•

position. Screening screen- pump handle

hand contacts for lower hand placement- trunk
ribs pump handle to flexed to look for ERS
detect stereognostically effects.
any left-right asymme­
tries of anterior promi­
nence of a rib, and to
observe altered respira­
tory movements result­
ing from variations in
flexion and extension
postures.

Note: Although rib based diagnosis of segmental dysfunction of the thoracic spine is reliable approximately 98 percent of the
time. there are occasions when respiratory rib motion exists in the presence of dysfunction. For this reason. even when respira­
tory movements are symmetrical. anteroposterior positional asymmetries of the anterior rib contacts should be noted. Recall from
Chapter 5 that specific treatment can temporarily restore symmetrical respiratory movements to the ribs, even though the verte­
bral dysfunction or structural rib lesion which caused the respiratory motion impairment may persist until it is treated specifical­
ly. Spontaneous autocorrection of respiratory rib lesions can also occur. sometimes as a result of having the patient do a lot of
deep breathing. It is. therefore. a mistake to rely totally on rib respiration for all vertebral and structural rib diagnosis. To assess
A-P symmetry, the best hand contact position is to place the index fingers near the costochondral junctions- the anterior pump
handle screening contacts. In the interest of thoroughness and/or precision. A-P symmetry of the transverse processes of the ver­
tebra and/or rib angles should also be observed.
104 THE MUSCLE ENERGY MANUAL
Figure 7.8 Hand
placement for posteri­
or screening of respi­
ratory motion for ribs
viii-xii.
Method 2: Seated Posterior Screening Procedure
/Applicable range: T.�- T12 and ribs iii- xiij
l. Patient is seated erect, slumped, or arched into exten­
sion. With the back of the patient's hands placed against
the small of the back and the elbows moved torward, the
scapulae will slide laterally to uncover the rib angles which
are normally hidden under the scapulae.
2. Seat yourselt� or stand, behind the patient.
3. Place your palms flat on either side of the spine
between the scapulae and slide the skin up and down to feel
the rib angles stereognostically (Figures 7 .8 and 7.9). The
first two rib angles are not very prominent, and neither are
the angles of the eleventh and twelfth ribs. The angles on
the third through the tenth ribs are noticeable bumps on
the rib and are quite easy to identifY stereognostically. The
angles of the third through the seventh or eighth ribs
should be underneath your hands. Place your palms over
the posterior rib angles of the lower ribs and/or over the
posterior surfaces of the shafts of ribs xi and xii. Slide the
skin and soft tissues over the ribs by slightly moving the
hands until the location and shapes of the ribs can be pal­
pated stereognostically.
4. Notice any shape asymmetries of the rib cage due to
posterior prominence or depression of a rib or ribs.
5. Instruct the patient: ccLet your breath all the way out.
Now take half a breath in and let it out.» Repeat step
breathing as necessary. When the ribs move, tollow their
movement with your hands. Monitor your hand move­
ment using your peripheral vision by focusing your central
gaze on the median furrow of the spine.
6. Instruct the patient: cTake a full breath in. Now let half
ofyour breath out and take it in again.'' Repeat step breathing
as necessary. Again, monitor the motion of the ribs as in Step 5.
Figure 7.9 Assessing
for variation in rib
angle prominence for
ribs iii -viii (seated
alternate).
7. Ask the patient to flex the thoracic spine: «stump,»
«Look down at your lap.» and then extend it, «Arch your
back and stick your chest out.» «Put your head back and look
at the ceiling.» Notice if either of these positional changes
causes or eliminates positional or respiratory rib motion
asymmetry.
8. Move your hands to the lower group of rib angles and
assess position and breathing motion. The eighth rib
angles should be about at the level of the inferior angles of
the scapulae . Repeat Steps 4, 5, 6, and 7.
9. Move your hands to the shafts of the ekventh and
twelfth ribs and assess for position and breathing motion
asymmetry.
Note: Each of these ribs tends to rotate with its vertebra. just as if it
were the vertebra's transverse process. A-P asymmetry of a pair of
these ribs seen with the patient seated in this position is an indication
of abnormal rotated position of the respective vertebra. Structural
lesions of the eleventh or twelfth rib are almost never seen.
Developmental dysgenesis can result in length asymmetry, which has
little effect on A-P symmetry, and no effect on breathing symmetry.
Repeating Steps 4. 5, 6, and 7 will rule in or out non-neutral dysfunction
of segments T and T 2.
11 1
 CHAPTER 7 -I> ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 105

Method 3: Supine Screening Procedure Figure 7.10 Supine

[Applicable range: T1 - T10 and ribs i- x} screening evaluation of
anterior rib prominence
1. The patient lies supine on the examining table. using pump handle
2. Stand at the side of the treatment table facing the hand contacts. Note:
patient's chest (if you are right eye dominant, stand on lying supine may push
patient's right side; left eye dominant, vice versa). Lean an unstable rib out of
position.
over the patient and turn your upper torso toward the head
of the table, best positioning yourself for visual assessment.
(Figure 7.10)
3. Place your palms over the anterior aspect of the upper
4 or 5 ribs; fingertips are located just below the clavicles,
with the heels of the hands positioned lateral to the ster­
num. Slide the skin and soft tissues over the ribs by slight­
ly moving your hands until the location and shapes of the
ribs can be palpated stereognostically.
4. Notice any shape asymmetries of the rib cage due to
anterior prominence, flattening, elevation, or depression of
a rib or ribs.
5. Ask the patient to flex the thoracic spine: ({Raise your
head up offthe table," and then extend, ({Put your head back
down." Notice if either of these positions changes (worsens
or eliminates) the asymmetry.
6. Move your hands to the middle group of ribs, vi
through x, on or just lateral to the costochondral junctions.
The massive piece of blended together costal cartilage for
ribs vii through x may be too rigid to reflect anterior and
posterior movements of individual ribs. It is, therefore,
preferable to palpate the bony ribs at this level. The ribs
with individual costal cartilages, i through vi, can be pal­
pated reliably with the hands in the parasternal positions
described above in Step 3.
7. Additionally, assessment of respiratory rib motion may
be performed in the positions of Steps 3, 5, and 6, while
watching the movement of your hands with your peripher­
al vision.
• If breathing impairment is manifested in the flexed posi­
Note: The supine position can push an unstable rib (IC0-9-CM code: tion and disappears in the extended position, there is verte­
718.38) out of place. The dislocation may spontaneously correct when
bral segmental dysfunction, ERS type, at the level of the
the patient sits or lies prone. Such recurrent dislocation is an indication
for a rib belt. "key" rib. If breathing impairment is manifested in the
extended position and disappears in the flexed position, there
is vertebral segmental dysfunction, FRS type, at the level of
the "key" rib.
Interpretation of Results for Methods l - 3
The same kind of information related to both rib position • If anteroposterior positional asymmetry of a pair of ribs

symmetry and breathing symmetry is obtained in the seat­ is detected stereognostically only:

ed and supine screening tests. a. when the trunk is extended, there is FRS dysfunction
• If the ribs on both sides move together at the same time, at the key rib; the side with the more anterior rib is the
there is no rib impairment. side of facet restriction, or

• If one side moves for a shorter duration, or not at all
(Step 5 in the Seated Test), then the ribs on that side have
restricted exhalation (are"up"), or (Step 6 in the Seated Test)
have restricted inhalation (are "down").
• If"up," find the key rib at the bottom of the group; if
"down," find the key rib at the top of the group. See the
Seated Search for the Key Rib for the protocol.
b. when the trunk is flexed, there is ERS dysfunction at
the key rib; the side with the more posterior rib is the side
of facet restriction.
• If neither flexion nor extension causes the impairment
to disappear, there is either a structural rib lesion (more com­
monly) or a primary respiratory restriction of the rib
(extremely rare). In either case, the"key" rib must be found.
106 THE MUSCLE ENERGY MANUAL

Method 4: Prone Posterior Screening Procedure

[Applicable range: T3- T12 and ribs iii- xiij

l. The patient lies prone on the examining table. By plac­

ing the backs of the patient's hands against the small of the
back and moving the elbows forward, the patient slides the
scapulae laterally to uncover the rib angles which are nor­
7.11)
mally hidden under the scapulae. (Figure
2. Stand at the side of the treatment table facing the
patient's chest (if you are right eye dominant, stand on
patient's right side; left eye dominant, vice versa). Lean over
the patient and turn your upper torso toward the head of the
table, best positioning yourself for visual assessment, while,
at the same time, avoiding straining your back.
3. Place your palms flat on either side of the spine between
the scapulae and slide the skin up and down to feel the rib
angles stereognostically. The first two rib angles are not very
prominent, and neither are the angles of the eleventh and
twelfth ribs. The angles on the third through the tenth ribs
are bumps on the bone and are quite easy to identifY stere­
ognostically. The angles of the third through the seventh or
eighth ribs should be underneath your hands.
4. Notice any shape asymmetries of the rib cage due to
posterior prominence or depression of a rib or ribs.
5. Ask the patient to extend the thoracic spine: «Raise your
shoulders up on your elbows and support your chin with your
Figure 7.11 Prone rib screening hand contacts. When the scapulae are
hands,'' and then flex it, «Go back down." Notice if either of
approximated, as in horizontal extension of the upper extremities, they
these positions changes (worsens or eliminates) the asymme­ cover the first eight rib angles. Horizontal flexion of the arms uncovers
try. these rib angles for palpation and counting ribs.
6. Move your hands to the lower group of rib angles.
(Figure 7.12) !Note: The eighth rib angles should be about
at the level of the interior angles of the scapulae .) Repeat
Steps 4 and 5.
7. Move your hands to the shafts of the eleventh and
5.
twelfth ribs. Repeat Steps 4 and
8. You may do the breathing tests in the positions of Steps
3, 5, 6, and 7. Watch your hand movements with your
peripheral vision.

Interpretation of Results
• Asymmetries of position or breathing which persist in
all positions are due to structural rib lesions.

• Asymmetries which are eliminated by flexion or exten­

sion (Step 5) are due to segmental vertebral dysfunction.
• Combinations of structural rib lesions with segmental Figure 7.12 Prone screening for the lower ribs.
vertebral dysfunction may at times cause inconsistencies, such
as false symmetry. More detailed palpatory and visual eval-
uation of the vertebral segments, as well as the ribs, is
required to clarity the diagnosis.

• The side with impaired (diminished) respiratory motion

is the side of the structural rib lesion, or (usually) the side of
impaired zygapophyseal kinematics associated with vertebral
segmental dysfunction.

• If asymmetries appear (or disappear) only in the recum­

bent tests, but not in the seated tests, the asymmetries are
probably due to unstable anterior or posterior rib subluxations .
 CHAPTER 7 -f> ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 107

Scanning One Pair of Ribs at a Time Figure 7.13 "Slump"

position. Observing
"Key Rib" Test Protocols to Assess Vertebral finger pads on the
Mechanics or Structural Rib Lesions anterior surfaces of the
third costal cartilages
[Range: T1 - T12, ribs i - xii]
for unilateral anterior
Respiratory dysfunction of the key rib is usually due to seg­ movement while the

mental dysfunction of the vertebra of origin (e.g., rib vi -as head and neck are
flexed. Patient seated.
the key rib - would correspond to T6 for ERS or FRS dys­
functions). Postures that do not challenge the segment
with vertebral dysfunction will temporarily restore normal
breathing motion of the key rib. For example, a flexed
patient position will not compromise the normal breathing
motions for the rib associated with the segment that has an
FRS dysfunction. However, an extended patient position
will compromise the normal breathing motions for the rib
because that is in the range of restriction for the segment.
Thus, breathing restrictions which disappear in extension
signifY ERS dysfunction, and those which disappear in flex­
ion signifY FRS segmental dysfunction. Breathing restric­
Figure 7.14 "Arch"
tion may also help to identifY the side of structural rib position. Observing fin­
lesion. Just as the rib associated with a dysfunctional ver­ ger pads on the anterior
tebral segment will lose its A-P symmetry in the range of surfaces of the third

restriction, the dysfunctional vertebra will also lose its posi­ costal cartilages for
unilateral posterior
tional symmetry in the range of restriction.It is the dys­
movement while the
functional segment's positional asymmetry that is head and neck are
responsible for the respiratory motion impairment of extended. Patient
the rib. seated.

In our search for the "key rib," we evaluate both the

respiratory motion (by monitoring the rib motion from
the intercostal space) and the comparative symmetry of
A-P rib position (by placing the finger pads on the anteri­
or surface of the rib) . These two forms of assessment are
ideally performed - while on a given rib pair - in both the
extended and flexed patient positions. With screening
examinations, we determine the presence of dysfunction
within a group of ribs. If more than one pair of adjacent
ribs (i.e., a group) exhibits restricted respiratory motion,
the scanning examination can help to determine if one seg­
Figure 7.15 Scanning the
ment in the group is responsible for the group restriction, upper ribs for breathing
with the restriction for the rest of the ribs secondary. asymmetry. For the
Scanning involves examining one pair of ribs at a time upper ribs, impairment of

for the purpose of identifying a specific vertebral seg­ breathing movements

tends to occur first in the
mental dysfunction. The upper ten ribs are examined
lesser- bucket handle­
from the front; the eleventh and twelfth ribs are examined plane of respiratory
from the back (both seated and prone). movement. Therefore,
The scanning examination is best done with the patient the bucket handle evalu­

seated. As compared with the supine position, the seated ation is a more sensitive
test for the upper ribs
position allows the addition of "slump" and "arch" posi­
than is the pump handle
tions (Figures 7.13 and 7.14), making the test sensitive evaluation. For bucket
enough to detect even minor dysfunctions of the thoracic handle evaluation, the
spine. The diagnosis of ERS or FRS segmental dysfunc­ fingers are placed more

tion is more definitive when the examination is performed laterally on the ribs.

in the extremes of both end ranges of flexion and exten­

sion. However, in a hospital practice, a supine patient posi­
tion may be the only option.
108 THE MUSCLE ENERGY MANUAL

Figure 7.16. Seated rib Figure 7.17 Checking

position scanning evalu­ the sixth ribs for
ation for ribs vi, patient breathing or A-P asym­
flexed. Examiner moni­ metry due to T6 FRS
tors the anterior pump dysfunction. Pump han­
handle finger contacts dle is the minor respira­
while standing, looking tory motion for ribs vii
down. The flexed through x, and is the
patient position will show first to become
two of the effects of any impaired. Therefore,
ERS dysfunction, the more medial pump
impaired breathing handle placement of the
motion and altered A-P palpating fingers
symmetry. The cocked increases the sensitivity
thumbs make it possible of the test. The patient
to observe any changes is extended to show the
in A-P symmetry when effects of any FRS dys­
the fingertips are cov­ function. The step
ered by large breasts or breathing technique is
fatty tissue. used to detect any res­
piratory motion impair­
ment.

Scanning Procedures [Range: TJ - Trb ribs i- xiij

Key Rib Test Protocols
l. The patient is seated on the examining table tacing
you. The seated position will enable the patient to more
fully flex and extend the spine tor the test. To monitor res­
piratory motions of the ribs, have your eyes horizontally
level with your fingers. To observe changes in A-P sym­
metry you should be either looking up at, or down at, your
fingers. (Figure 7.16)
2. Finger placements:
a) For step breathing tests of the upper six ribs, your
finger pads should be placed on the bucket handle supe­
rior rib margin contact points (Figure 5.7). To be more
thorough, you can also test the pump handle motions of
the same pair of ribs.
b) For step breathing tests of ribs vii - x, your finger
pads should be placed on the pump handle superior rib
margin contact points (Figure 5.7). To be more thor­
ough, you can also test the bucket handle motions of the
same pair of ribs.
3. Start by choosing a pair of ribs within the group
demonstrating restricted motion. The group can be very
small, and even limited to one rib - the first, tor example.
If you are not sure about the screen, start with the first ribs.
Place your index finger pads in the intercostal spaces to
contact the interior border of the first rib cartilage at its
pump handle or bucket handle contact points, or on the
superior borders of ribs ii through x at pump or bucket
handle points. Check for asymmetrical respiratory motion.
4. Step breathing tests of ribs xi and xii must be done
from behind, or with the patient lying prone, placing your
finger pads on the lateral points of the pair of ribs.
Remember the tapered shape of the lateral ends of these
ribs, and pay close attention to avoid counting two ribs as
one. Be sure your eyes are level with your fingers. The
breathing tests can be done with the patient lying flat, or
with the shoulders propped up on the elbows in what has
become known as the "Sphinx" position. The interpreta­
tion of the step breathing tests has already been covered.
(Chapter 5)
5. Step breathing. At each monitoring point, and in each
flexed or extended position, ask the patient to let all the
breath out, take half a breath in, and let it out again. Look
tor one rib moving, and the rib on the side with the lesion
to not move. This will disclose a rib with exhalation restric­
tion. Now have the patient take a full breath in Jnd let half
out. Again, observe for one-sided movement, indicating
restricted inhalation of the nonmoving rib.
6. For testing A-P positional symmetry of any pair of ribs
i through x, the finger pads are on the ante1·ior rib contact
point.
Note: Anterior pump handle contacts are different from the pump han­
dle respiratory contacts, where the finger pads are in the intercostal
spaces resting on the superior edges of the ribs. The anterior contact
is down a fraction of an inch on the anterior surface of the rib.
7. The A-P symmetry of any rib pair between i--' x can also
be tested with the finger pads or thumbs on the rib angles.
Make sure to count the ribs so that you can compare your
finding from the anterior rib evaluation with your findings
posteriorly.
8. Ask the patient to flex the thoracic spine: «stump and
put your chin down toward your chest,» and then extend,
«Put your head back and push your chest out.» Notice if
either of these positions causes unequal breathing move­
ment for a pair of ribs.
9. Move your finger pads to the next, or the "key" pair
of rib contact points, and repeat Steps 3, 4, and 5.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 109

10. If a group of ribs demonstrates respiratory restric­

tion, start with a pair of ribs at the very top or bottom of
the restricted group. Continue up or down the rib cage,
monitoring one pair of ribs at a time with step breathing,
until you reach the top or bottom rib demonstrating the
restriction (the key), or rib x, whichever comes first. To
examine the eleventh and twelfth ribs, you must go behind
the patient. To diagnose ERS dysfunction, the patient is in
a seated flexed (or hyperflexed) position; to diagnose FRS
dysfunction of a segment in the T 7 - T l2 or L1 - Ls
regions, the patient is in the prone Sphinx (or
Hypersphinx) position. Evaluate each pair of ribs (or the
key rib if it has been identified) for position and step
breathing restriction with the patient: a) flexed, b)
erect, and c) extended. Figure 7.18 Supine version of the test for ERS segmental dysfunction.
Note: A supine version of this test is sometimes possible for the upper six
ribs, depending on whether the patient can lift his head up off the table far
Interpretation of Results enough to cause a change in rib respiratory or position symmetry. With
Interpretation of the seated A-P symmetry tests follows the your index fingers on the anterior pump handle or bucket handle contacts
for the key rib pair, have the patient flex the thoracic spine by raising the
same guidelines as the A-P symmetry tests for the first rib.
head off the table. While your fingers are contacting the ribs, use your fin­
• If equal breathing movement is maintained through­ gers as a visual reference to assess the comparative A-Pposition for a pair
out the flexed ("slumped") to extended ("arched") positions, of ribs. Respiratory movements of the upper ribs may be assessed using
there is probably neither vertebral segmental dysfunction nor the step breathing method with the fingers on the superior rib margins. For
the patient to extend while in a supine position is difficult and usually not
structural rib lesion.
worth the trouble. If a more complete examination is required, examine the
• If asymmetry of breathing motion is observed any­ patient in the seated position.
where within the range of flexion to extension, determine if
inhalation or exhalation is restricted. If inhalation is
restricted, look for the top rib (the key) of the restricted
Figure 7.19 Seated rib
group. If exhalation is restricted, look for the bottom rib of
position scanning eval­
the restricted group. uation, patient extend­
ed. Examiner assessing
• If the key rib pair has asymmetrical breathing motion
the anterior pump
with flexion ("slump"), but is symmetrical in extension, the
handle finger contacts
associated vertebra has ERS dysfunction, probably with rota­ for ribs x with the
tion toward the side with the restricted rib. patient in the seated,
arched (extended)
• If the key rib pair has asymmetrical breathing motion
position.
with extension ("arch"), but is symmetrical in flexion, the
associated vertebra has FRS dysfunction, probably with rota­
tion toward the side with the unrestricted rib.

• If the breathing asymmetry remains regardless of

extreme flexion and extreme extension patient positions,
there is a structural rib lesion on the side with breathing
restriction. If the degree of asymmetry varies, but no posi­
tion can be found which produces perfect breathing sym­
metry, there is probably a combination of a structural rib
lesion with vertebral segmental dysfunction.
110 THE MUSCLE ENERGY MANUAL

lf the key rib is vii, or lower, and indicates vertebral segmental dys­
function, consult Chapter 9 for greater detail on diagnosis and treat­
ment.

• The interpretation for the supine examination is the

same as for the seated tests, but the information is, of course,
incomplete given the limited range of flexion/extension
patient position. Minor FRS and major ERS dysfunctions
may be missed by this method.

• If supine flexion eliminates the asymmetry and the flat

supine position shows asymmetry, then the vertebra has
major Type II, or non-neutral, FRS dysfunction and will be
rotated toward the side with the posterior rib.

• If the flat supine position eliminates the asymmetry and

flexion shows it, then the vertebra has minor Type II, or non­
Figure 7.20 Assessing rib angles with the patient in the seated, flexed
neutral, ERS dysfunction and will be rotated toward the side
position.
with the posterior rib.

• If the asymmetry persists throughout both positions,

either the key rib has a structural lesion, or the vertebra has
a major ERS dysfunction. Figure 7.21 Assessing
rib angles for ribs vii to
Note: The supine position may disclose an unstable anterior rib sub­ x, in the slumped
luxation which spontaneously reduces in the seated position. It is also patient position.

possible that an unstable posterior subluxation might be seen only when

the patient is lying prone. Such a lesion does not necessarily need manip­
ulating. but probably will require stabilization with a rib belt.

Restriction: Major or Minor?

It is important to grade the severity of motion restriction in
segmental dysfunction. In the thoracic region the amount
of trunk flexion (slumping) or extension (arching) required
to restore symmetry to rib breathing motions, rib positional
relationships, or transverse process positions should be
noted. If symmetry is restored before the erect (mid-range)
posture is assumed, the dysfunction is classed as minor, i.e.,
less than half the normal range of motion has been lost. In
major dysfunctions, asymmetry will persist through mid­
range and into some degrees of flexion and extension. Some­
times demonstrating an FRS dysfunction may require a Figure 7.22 Assessing
forced slumped position, or an ERS dysfunction may not rib angles for ribs vii to

demonstrate symmetry until the patient is maximally x, in the extended

patient position.
extended (arched).
The position which produces symmetry represents what
is left of the neutral range of the dysfunctional segment, and
is the starting position for treatment.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 111

Figure 7.23 Seated posterior evaluation for T7- T12. Performing A-P Figure 7.24 Seated posterior evaluation for T7- T12. Performing A-P
position and respiratory rib motion tests on the 11th or 12th ribs. position and respiratory rib motion tests on the 11th or 12th ribs.

Figure 7.25 "'Sphinx" test for T7- T12. Performing breathing tests on the Figure 7.26 Checking for structural rib lesions. Examiner performing rib
11th or 12th ribs. position and rib shaft evaluation for torsion by stereognosis, ribs vii to x.
112 THE MUSCLE ENERGY MANUAL

Three Transverse Process Tests for Upper Figure 7.27 The hyper­
flexed patient position
Thoracic Segmental Dysfunction
for assessing ERS
[Range T1 - T6. With modifications, the principles here can also dysfunction. Comparing
be applied to C5 -C7 and T7- L.si however, there are more accu­ the transverse processes
rate methods for these areas.] of T1 and T2 with the
patient in the hyperflexed
position and the
I. The First Procedure: Superior Vuw
examiner standing in
[Range T1 - T6} front. . Positional
asymmetry indicates ERS
1. The patient is seated on the edge of the examining
dysfunction.
table; a lower level would be required for a short examiner.
The criteria tor the proper sitting height is based on the
examiner's ability to sight down along the thoracic spine
with ease.
2. You stand in front of the patient, close to the table.
These positions will improve your visual parallax perspec­
tive. The accuracy of your visual observations is improved
by viewing from this perspective. (Figure 7.27) This base­
line information must be as accurate as possible, because of
the conclusions that can be drawn from the changes that
occur with active movements.
3. The patient flexes the head and neck, bringing the
chin close to the chest, which allows the upper thoracic
spine to slump into full flexion.
4. Supporting the top of the patient's head against your
chest, reach around the patient to monitor with your finger
pads the transverse processes of two adjacent vertebrae, i.e.,
the vertebra being examined and the subjacent vertebra.
(Figure 7.27)
5. Using the Rule of Threes (Chapter 1) and your own
stereognostic palpatory sense, locate the transverse process­
es whose position you wish to observe. The patient's flexed
position stretches and thins the posterior myofascial tissues
and minimizes - but does not eliminate - asymmetry due
to these soft: tissues. Swelling, abnormal muscle tension, or
other soft: tissue masses detected by palpation must be
taken into account. If the tissue density caused by these
factors significantly alters tl1e thickness of the tissue, tl1e
vertebral palpatory findings cannot be trusted, and more
reliance should be placed on the rib findings tlun on the
transverse process findings.
6. Wi t h the two finger pads of each hand in relatively
firm contact with tl1e transverse processes of the two verte­
brae, position your line of sight tangent to the curvature of
the back where your fingers are. Observe your fingers as
indicators of intersegmental vertebral rotation, comparing
the superior vertebra with the interior vertebra.
7. Examine each of the upper six thoracic vertebrae in
turn, comparing each with the vertebra below. For exam­
ple, the sixth thoracic will be compared with the seventh.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR Tt-T6 113

Interpretation of Results
• If all the transverse processes are positioned symmetri­
cally, and the transverse processes ofT7 line up in the coro­
nal plane, there is no ERS dysfunction in theT 1-T6 region.

• If the T7 transverse processes do not line up with the

coronal plane, and the T 1-T6 vertebrae show no interseg­
mental rotation, an adaptive rotoscoliosis originating atT7
or below exists (explained in Chapter 9). If theT1-T6 seg­
ments are involved in such adaptation, several possible vari­
ations would include:

1) The lower segments may be below the apex of the

group, and, if so, each vertebra in ascending order will add
a small increment of rotation to rotated position ofT7, up
to the apex. The segmentsT rLs are capable of"neutral"
NSR (zygapophyseal facets not engaged) sidebending
movements. The spine from T2 up through the cervical
spine is also capable of adapting, but must do so with non­
neutral movements which entail some flexion or extension.

2) Derotation in small increments fromT6 up to a verte­

bra whi<.:h has its transverse processes parallel with the coro­
nal plane.

3) Complete derotation ofT6 with all vertebrae above in

perfect alignment. If the derotation required turningT6
on T7 more than two or three degrees, the possibility of
a non-neutral ERS dysfunction of theT6-T7 segment must
be entertained until the segment can be examined in spinal
extension, and/or the seventh ribs can be checked for tor­
sion.

Note: Remember the transverse processes as they were observed in this

position.
• If one vertebra appears rotated in comparison to the ver­
tebra below it, that segment may have ERS dysfunction -
but only if extension causes the vertebra to become perfectly
symmetrical. Remember the direction and degree of rotated
position until that segment can be tested with the patient in
the extended position. An ERS dysfunction held in a posi­
tion of spinal flexion will tend to evoke the adaptation phe­
nomenon discussed in the previous paragraph. For a more
basic discussion of spinal adaptation to segmental dysfunc­
tion, please refer to Volume 1, Chapter 2.
114 THE MUSCLE ENERGY MANUAL

II. The Second Procedure: Posterior View

[Range: T1 - T10}

l. The patient is seated, either on an examining table or

on a chair or stool, with his/her back to you.
2. You stand behind the patient so that your eyes are
above the level of your examining thumbs, which are
placed upon the lateral extremity of each pair of transverse
processes, just medial to the rib angles (or the tubercle of
the first rib).
3. Using the Rule of Threes, stereognostically locate the
transverse processes of the thoracic vertebra while the
patient is still in a trunk/neck flexed position. The trans­
verse processes are approached through the fascial cleft Figure 7.28 The hyperflexed patient position for assessing ERS dysfunc­
between longissimus and iliocostalis muscles by sliding the tion. Examiner's thumbs will follow the tips of the transverse processes,

thumbs anteromedial along the rib neck from the rib angle. which are found in the cleft between the levator costae/iliocostalis and
the longissimus muscles. The patient moves the vertebra through the full
The transverse processes of T 1 are the widest, spanning
range of flexion/extension motion, stopping at different stages of the
approximately 3 inches. range while the examiner assesses the static position of the transverse
4. Observe the position of your thumbs on the transverse processes.
processes from the best visual perspective, taking note as to
whether they look the same as when you performed The
First Procedure from in front of the patient.
5. As you palpatorily and visually assess each vertebral
level, observe the static position of the transverse processes
with the patient first in a hyperflexed position (Figure
7.28), then then in the mid-range position (Figure 7.29),
and then in a hyperextended position (Figure 7.30).
Maintaining a firm but nontorceful contact, allow the trans­
.
verse processes to push your thumbs back and down. This
should happen on both sides symmetrically. Watch for one
side not moving and note any A-P asymmetry.

Note: Hyperextension requires full neck extension (possibly with the

patient's mouth open to avoid platysma restraint) plus translating the
chest forward.
6. Continue upward, assessing all of the vertebrae tor A-P
asymmetry of the transverse processes of one vertebra rela­
tive to the transverse processes of the interior vertebra. (The
lower two cervicals may also be examined in this fashion.)
Figure 7.29 The mid-range ("neutral" I patient position for assessing ERS
or FRS dysfunction. The patient is positioned such that the segment is in
the mid-range ("neutral"l position. Recall that T1 does not have a physio­
logic neutral position (zygapophyseal facets not engaged). If a major dys­
function (ERS or FRS I exists here, the vertebra will already (or still) be in a
rotated position at this mid-range point. Minor dysfvnctions will show no
asymmetry in this position.

Figure 7.30 The hyperextended patient position for assessing FRS dys­
function. Examining the transverse processes with the patient in the
hyperextended position. The platysma muscle may restrain this motion in
some individuals. Opening the mouth will permit greater extension, if it is
needed for examination purposes.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6
Interpretation of Results
• If only one transverse process moves back and down, it
may be an ERS dysfunction derotating toward a symmetri­
cal position in extension, or it may be an FRS dysfunction
becoming rotated as it moves from a symmetrical flexed posi­
tion to a rotated extended position.
Note: One may be easily deceived by asymmetric muscle tension. which
affects the soft tissue and may vary with flexion or extension. When the
validity of your findings is in doubt. believe the findings of the variable
rib position tests (previous procedures). even when they conflict with the
transverse process findings.
• Common errors are to mistake the moving transverse
process for the posterior one, or to label the posterior side as
the restricted side,. It is important to remember the positions
of the vertebrae as they were observed from in front of the
patient during the rib examination. A-P asymmetries of the
transverse processes, indicating vertebral rotation, which
straighten with extension indicate ERS dysfunction; rotations
which straighten with flexion indicate FRS dysfunction. In
each case the vertebra is (positionally) rotated and sidebent
toward the side of the more posterior transverse process. If
a transverse process is relatively more posterior in the flexed
position, and becomes symmetrical in the extended position,
there is ERS dysfunction toward the posterior side. In this
case the moving transverse process comes from a relatively
more anterior position when flexed, to the symmetrical posi­
tion when extended.
Note: The terms ERS (Extended, Rotated, Sidebent) and FRS
(Flexed, Rotated, Sidebent) denote vertebral position, not a state
of restricted motion of one of the zygapophyseal joints. It is
grammatically incorrect to say "ERS on the left." The correct expression
is "ERS to (or toward) the left." The preposition "on" is used to indicate
the side of facet motion impairment.
• If a transverse process is relatively more posterior in the
extended position, and becomes symmetrical in theflexed posi­
tion, there is FRS dysfunction toward the posterior side. In
this case the moving transverse process comes from a sym­
metrical position when flexed, to a relatively posterior posi­
tion when extended. In other words, the moving transverse
process is the posterior one.
• If the asymmetry disappears before half the sagittal
plane motion has been completed, the dysfunction is con­
sidered minor.
• If the asymmetry disappears after more than half the
sagittal plane motion has been completed, the dysfunction
is considered major.
• The distinction between minor and major dysfunction
is important when positioning the patient for treatment. It
informs the therapist how much of the neutral range of the
segment remains. Most clinically significant dysfunctions are
major.
• If symmetry of the transverse process positions persists
throughout the range from flexion to extension, there is no
dysfunction.
115
• If asymmetry of the transverse process positions persists
unchanged throughout the range from flexion to extension,
or gets worse as the vertebra passes through the mid-range,
the segment, and probably several of its neighbors, involved
in NSR dysfunction. This is not a possibility with the first
two thoracic segments.
• If the asymmetry of 2 or more adjacent segments is elim­
inated by flexion and worsened by extension, (or vice versa)
assume that the lowest segment of the group has FRS (or
ERS, if vice versa ) dysfunction and that the segments above
it are adapting to the FRS (or ERS) dysfunction and, there­
fore will not need treatment, per se. Taking this approach
will lead to the subsequent discovery of adjacent non-neu­
tral dysfunctions, if any exist. The sequence of treatment for
adjacent dysfunctions will always start from the bottom and
proceed superiorly.
• If the asymmetry of a single segment persists in all posi­
tions, check first to be sure that flexion and extension pos­
tures are as extreme as possible. Some major non-neutral
dysfunctions may be so extreme that almost no "neutral"
range of motion (where the vertebra is able to become sym­
metrical) remains. Single segment or group rotations which
persist in all postures could represent structural scoliosis,
which may be a compensation for anatomic anomalies.
The unlikely possibility that the persistence of asymmetry
of the single segment in all positions may be due to complex
segmental dysfunctions of that segment must sometimes be
entertained. Bilateral facet motion impairment producing
FRS and ERS dysfunction in the same motion segment
occurs rarely. But when it does, it can perplex the examiner.
Even though the segment never becomes symmetrical with
flexion or extension, close observation may detect unilateral
movement of one transverse process or the other, while the
spine is being actively flexed or extended.
116 THE MUSCLE ENERGY MANUAL

III. The Third Procedure: The Prone Focused Figure 7.31 The
Extension Test for FRS Dysfunction focused extension test
Test for FRS in the mid­
IRange: T4 - T8]
dle thoracics T4-Ta
When the patient is lying prone, exerting pressure with the with the patient prone.

thumbs against the two transverse processes of one of the

vertebrae in the region of the thoracic kyphosis will cause
that vertebra to extend in relation to the vertebra inferior
to it. This maneuver can be used to test that vertebral seg­
ment for FRS dysfunction, which, if present, will cause the
vertebra to rotate as it extends. Other methods of diag­
nosing FRS dysfunctions have already been presented, i.e.,
the seated "slump" and "arch" procedures for observing
respiratory rib movement, A-P positional changes of the
ribs, and positional changes of the transverse processes.
The prone tocused extension test is an alternative proce­
dure which may be used to confirm the results of one of the
other tests, or in circumstances where the patient is prone
and cannot be moved.
The thumb on the anterior side of the rotated vertebra
Figure 7.32 The
will sink in deeper than the other thumb. Do not be
focused extension test
deceived by this paradoxical experience. The anterior side
for mid-thoracic FRS
of the vertebra is the side of the blocked zygapophyseal dysfunction. Notice
joint in an FRS dysfunction. the right thumb has
You may already know which vertebra to test, if you sunk in deeper, indicat­
ing that extending has
have located a "key" rib. The transverse processes of that
caused the vertebra to
vertebra can be found by counting ribs, or, using the Rule
rotate left.
of Threes, by counting spinous processes. If you do not
know which vertebra to test, you may perform the test on
each vertebral segment sequentially. The practical range of
this procedure is from T4 to T8.

Protocol for The Prone Focused Extension Test

[Rar�ge: T4 - T8}

I. The patient lies prone on the examining table. Ideally,

the patient's head should be midline, resting on the chin,
or resting the forehead on a small pillow. Some examining
tables have a padded slot at the head end of the table tor
the prone patient's tace. If the patient is more comtortable
with the face turned to one side, it should be allowed. The
patient should be comtortable enough to relax, and turn­
ing the head does not usually significantly alter the results
of the test. The arms may hang treely over the sides of the
table, or rest on the table at the sides.
2. You stand at the side of the table, near the vertebra to Interpretation of Results
be tested. • If a vertebra rotates as it is forced to extend, we may
3. As you palpate the transverse processes at each of the conclude that the more anterior zygapophysis is blocked and
middle thoracic vertebrae, exert a firm downward (anteri­ unable to extend. Therdore, the vertebra is flexed, rotated,
or) pressure simultaneously with equal pressure on both and sidebent- FRS- toward the posterior transverse process.
transverse processes, torcing the vertebra to extend on its
Note: When vertebral diagnosis made by observing the ribs disagrees
neighbor.
with the diagnosis made by observing the transverse processes, it is
4. As the vertebra extends, notice if one thumb goes in
best to rely on the ribs.
anteriorly easier and deeper. The less vertical your line of
sight, the easier this is to see.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T 6 117

Comparison of Rib Based Diagnosis with Thansverse Relationship of Rib Evaluation to Spinal Evaluation
Process Palpation Examining the position and respiratory motion of the ribs
To try to palpate transverse process or articular process can be the beginning of thoracic spine evaluation.
movement during the actual movement of the vertebra, as, Respiratory restriction of a rib or ribs, in the majority of
for example, while the patient is flexing and extending the cases, indicates the presence of segmental dysfunction.
thoracic spine, is extraordinarily challenging. Although One approach to thoracic vertebral diagnosis may involve
some experienced clinicians may be able to use palpation to identifYing the key rib, if there is a group of ribs with the
reliably detect and quantity movements of these bony same breathing restriction. In most instances, this will
processes as they occur, the inexperienced manual therapist eventually lead to treating and resolving the vertebral seg­
will most certainly have trouble telling the difference mental dysfunction that corresponds to the key rib. To
between bone movement and contractile activity of mus­ illustrate, if ribs i through v have lost their ability to exhale
cles, and variable soft tissue tension states. completely (see Chapter 5), they will manifest no move­
Assessing facet joint motion by palpating the transverse ment at the completion of exhalation, and they will also
processes (and, in particular, the articular processes) is show no movement at the beginning of inhalation.
complicated by the overlying layers of muscle, some of However, they will be able to continue inhalation, along
which are active during the movement. It is not unusual with the noninvolved or normal side, to the end of inhala­
for increased contractile muscle activity to occur in muscles tion. Exhalation restriction simply means that the exhala­
overlying a moving hypermobile joint, regardless of its tion phase of breathing is prematurely stopped on one side.
direction of movement. Such muscle activity is frequently When you observe such restriction, it tells you that the
mistaken for a bone moving posteriorly, especially by lowest rib in the group with exhalation restriction is the key
beginners. rib. The vertebra associated with the key rib is the place
To reduce the incidence of such error, palpatory-visu­ to look for vertebral segmental dysfunction.
al observations of static vertebral positions are made while
the patient keeps the thoracic spine motionless in both
hyperflexed and hyperextended postures. However,
although the static examination is less error-prone than the
dynamic examination, it is not entirely error-free. The
muscles and soft tissues overlying the transverse processes
may be thickened on one side by spasm, swelling, fibrosis,
or occasionally by neoplasia. Inasmuch as the inferior ver­
tebra serves as the reference point for determining the
direction and degree of rotation of a given vertebra, (and
since assessment of the reference vertebra's position is sub­
ject to the same sources of error), one could misdiagnose a
segmental dysfunction by not having an accurate reading of
the reference vertebra's position. This source of error can
be minimized by following the principles of layer-by-layer
palpation of the muscles of the back. Volume l, Chapter 6
points out that palpatory access to a bone is along the deep
fascial planes that separate the overlying muscles.
118 THE MUSCLE ENERGY MANUAL
Practice Review
This is a good time to practice the skills of the procedures
just acquired. Remember the learning steps for developing
psychomotor skills.
Examine the upper six thoracic vertebrae and the lower
two or three cervical vertebrae with your subject seated on
the examining table. Use the rib cage as well as the trans­
verse processes of the vertebrae to evaluate the symmetry
of flexion and extension of the upper thoracic trunk. Check
the respiratory movement of the ribs with your subject
seated. The most frequent cause of restricted rib move­
ment is vertebral dysfunction. Vertebral dysfunction will
demonstrate rotation of the vertebra and its ribs whenever
the flexion or extension motion is restricted for one
zygapophyseal facet.
With your subject seated, follow each pair of transverse
processes and each pair of ribs with your thumbs or fingers
while your subject slumps and arches the spine to flex and
extend the neck and upper trunk. Use ribs as extensions of
the transverse processes, following the anterior and poste­
rior motions of the angles or the anterior shafts of a pair of
ribs. Anteroposterior asymmetries of ribs which persist
throughout flexion to extension are structural rib lesions
(e.g., dislocations or intraosseous lesions of the rib). Does
the misaligned vertebra go in and out of alignment? What
happens to the ribs attached to it? Check the ribs anterior­
ly and posteriorly. Are all your findings in agreement?
Examine your subject lying supine. Remember to use
your dominant eye to watch your hands move as they follow
the ribs. First check for breathing restrictions of portions of
the rib cage with a screening procedure. Observe the two
extremes of the breathing cycle, inhalation and exhalation,
to discover a part of the cycle when one rib does not con­
tinue to move. Narrow the search down to the "key" rib
(lowest in the restricted exhalation group or most superior
in the restricted inhalation group). Examine the lowest ribs
with your subject prone. Use your stereognostic sense to
detect ribs which are misaligned relative to the other ribs.
The key ribs and the misaligned ribs may point you to a spe­
cific vertebral dysfunction.
Examine the thoracic spine one segment at a time while
your subject is prone. Palpate the transverse processes,
and remember which ones are misaligned. Around the
region of the mid-dorsal kyphosis (T5 to T8), vertebrae may
be extended by firm ventrad pressure against the trans­
verse processes. Does this force the vertebra to rotate?
Does misalignment of transverse processes correspond to
misalignment of rib angles?
Make a somatic dysfunction diagnosis in positional
terms. Do not mistake adaptations for lesions. What is the
difference between neutral dysfunction and neutral adap­
tive vertebral behavior?
Treatment Procedures for Non-Neutral
Dysfunctions of the Thoracic Spine
Each of the treatment procedures starts with the vertebra
in its neutral position, i.e., zygapophyseal facets not
engaged.(See Vol.l, Chapter 1, "Localization Sequence in
Treatment") In major segmental dysfunctions very little of
the neutral range remains, and the neutral position is
extremely flexed or extended. The palpatory signal that
the neutral range has been reached is when a definite
movement between the spinous processes, pinching and
gapping, can be felt with passively extending and flex­
ing the head and neck in slight nodding or bobbing
movements. When the joint is not in neutral, flexing and
extending produces no palpable change in the space
between the spinous processes. The "feather edge" of the
flexion or extension barrier has been met just before reach­
ing the position where slight passive nodding movements
produce no pinching or gapping in the interspinous space.
The following treatment procedures may be used to
effectively restore full symmetrical mobility to thoracic or
lumbar intervertebral joints, whenever segmental dysfunc­
tion occurs, whatever the cause:
• The Turban Technique for ERS segmental dys­
functions of lower cervical or upper thoracic vertebral
joints to T6;
• The Longus Colli Technique for FRS dysfunctions
of lower cervical or upper thoracic joints to T 2;
• The Modified Longus Colli Technique for thoracic
joints T3-T6;
• The Lateral Recumbent ((Salad Bowl" Techniqtte
for cervical and thoracic joints C3- T 6;
• The Supine Technique for thoracic joints C3- T6;
• The Seated Axial Rotation Technique for thoracic
joints T3 through L5;
• The SO-step Procedure for ERS dysfunctions of T 7
through L5 (Chapter 9); and
• The 500-Step Procedure for FRS dysfunctions ofT 7
through L5 (Chapter 9).
It is rarely necessary to repeat the treatment to achieve
normalization of the range of motion. When the properly
applied technique fails, it is an indication that the sequence
of treatment is inappropriate. Appropriate sequence of treat­
ment ideally begins with correcting the "key lesion," pro­
vided it can be identified. Persistent �econdary lesions may
then be corrected, if necessary. Often the key lesion identi­
fication is an hypothesis to be tested by actual treatment. In
acute painful conditions a judicious sequence might begin
as far away from the pain as possible, working toward the
painful area in carefully chosen steps. Normalization of the
symptomatic area may eventually be accomplished after other
parts of the body are restored to normal function.
Localization Sequences in Treatment
All initial setups in Muscle Energy Treatment (MET) com­
mence in tl1e neutral range as described above. Until recently
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FORT 1-T 6
descriptions of localizing procedures were characterized as
"engaging the barriers in each of the three planes of motion
- sagittal, coronal, and transverse." What seemed to be
implied was that the barriers in each plane were to be engaged
simultaneously.
Although it sounds reasonable, such an objective is
impractical and unnecessary. The author has discovered that
in his own practice localization needs to be controlled in only
one plane at a time. The fact that the primary restriction in
ERS or FRS dysfunction is sagittal plane motion suggested
that the flexion (or extension) barrier should be localized first.
However, Fryette's own clinical experience led him to con­
clude that, since sidebending restriction was the last event
in production of the lesion. it should be the first plane of
motion addressed, followed by rotation and then sagittal
motion (in other words, treatERS Left with Right SRF).
Whether Fryette's hypothesis was sound or not, empiri­
cally it does seem to work better that way. When position­
ing a dysfunctional vertebra for treatment, it does make sense
to be near the flexion end of the neutral range for an ERS
dysfunction or near the extension end of the neutral range
for an FRS dysfunction. But to attempt to first localize to
the feather-edge of the barrier in the sagittal plane, and then,
without losing the sagittal plane localization, localize in the
coronal plane to the sidebending barrier, and finally to the
rotation barrier, is a virtual impossibility, and not at all nec­
essary for effective technique.
Do not confuse sequence of localization with the thera­
peutic isometric contractions which are a part of the
MuscleEnergy Technique protocol. In treating the FRS or
ERS dysfunctions in the cervical and thoracic spine the
patient's flexion or extension effort is resisted by the oper­
ator's counterforce after the vertebra is carefully positioned
for localization. The rationale for this choice of muscles is
that the primary restriction in FRS orERS dysfunction is in
the sagittal plane. Another reason is that these muscle
efforts are easy for the operator to control for isometric
contraction.
The first plane of localization should probably be the
coronal, moving the vertebra to the feather edge of the
sidebending restriction, and remaining localized there dur­
ing the isometric effort and the post-isometric relaxation of
the flexor or extender muscles. Localization in the other
two planes is not attempted until the sidebending barrier
yields to re-localization. Then, and only then, will there be
available rotation and sagittal motion slack. The absence of
rotation and sagittal motion slack is an indication that the
sidebending barrier has not yielded.
There are a few exceptions to the isometric contraction
principle mentioned above, mainly in treating the lower
lumbar segments, where sidebending effort is easier for the
operator to control. But the sequence of localization
remains the same - sidebending first, rotating second, and
flexing or extending last.
119
Use of Breathing in Articular Mobilization
Breathing may be used as an adjunct to any manipulative
procedure, regardless of the presence of costovertebral
somatic dysfunctions. The use of respiratory cooperation
in the treatment of cervical segmental dysfunction was pre­
sented in Volume l. The general principle of respiratory
cooperation as an adjunct to treating segmental dys­
function is to have the patient voluntarily control
breathing so that inhalation or exhalation occurs at
appropriate times.
While it is generally true that inhalation increases mus­
cle tension ubiquitously, and exhalation promotes relax­
ation, it is often more effective to utilize breathing to take
advantage of the naturally occurring synkinetic actions cou­
pled to inhalation and exhalation, especially in treating dys­
functions of the trunk. Thus, if you wish to enhance a
flexion action anywhere in the spine, have the patient
inhale. Or use exhalation to enhance extension.
Many patients seem to be unable to exhale without
first inhaling. When instructing the patient in respiratory
cooperation it is usually best to start with «Jnhale, please,»
even if inhalation is not the action needed. It is generally
easier to adjust the sequence of your own actions.
Recall that in the craniocervical region the even num­
bered articulations (Occiput [C0]- CI> C2- C3, C4- Cs,
and c6 - c7) tense their sideflexors with inhalation and
relax them with exhalation. The odd-numbered cervical
articulations ( 1, 3, 5, and 7) tense their sideflexors with
exhalation and relax them with inhalation. When using res­
piratory coupling in treatment of craniocervical dysfunc­
tions, it is best, after localization positioning, to start with
the instruction «J'ake a breath» even if you are treating an
odd-numbered segment. Then, when the patient inhales,
resist any movement that would alter the localized position.
When the patient exhales, have the patient activate the
appropriate flexor or extensor muscles with eye movement,
or head nodding, and offer sufficient resistance to make the
contraction isometric.
In treating the thoracic or lumbar portions of the
spine, respiration is most importantly used to enhance
relaxation during the appropriate step in the treatment pro­
tocol. Inhalation will relax extensor muscles; exhala­
tion will relax flexor muscles. Thus, in treating an FRS
dysfunction, have the patient inhale during the flexion iso­
metric contraction, and exhale during post-isometric relax­
ation and relocalization. ERS treatment procedure may
seem counterintuitive. Inhalation should occur during the
post-isometric relaxation and relocalization, contrary to the
popular theory that exhalation causes relaxation.
The physiologic respiratory flexion and extension
actions in the cervical region are often abnormally
reversed. Inhaling often causes extension, instead of
flexion. The abnormal coupling of trapezius excitation
with inhalation is probably related to its proneness to tight­
ening and shortening (Janda, 1978). This abnormal reflex
coupling should be treated with proprioceptive retraining
(Lewit, 1991).
120 THE MUSCLE ENERGY MANUAL

Figure 7.33 Turban Figure 7.34a Turban

technique for minor ERS technique for major ERS
dysfunction ofT1. The dysfunction ofT1• start­
starting position is ing position. The oper­
found by palpating for ator's body is prepared
interspinous movement to push against the
while passively slightly patient's shoulder
nodding the head up toward T1 for sidebend­
and down. ing localization.

Treatment of Type II ERS

Segmental Dysfunction
Turban Technique IRange: c(} - T(}} 5. Keep the palpating finger of your other hand at the
I Case study using «'furban technique)) protocol for treating T1 interspinous space just inferior to the lesioned vertebra to
ERSR (Extended, Rotated, Sidebent Right)} monitor for localization, which is achieved by positioning

1. The patient is seated on a low stool. The stool is the lesioned vertebra at the feather edge of the barriers.
First to be localized is the sidebending barrier. Side­
preferable to the examination table because it is oti:en nec­
bending is produced by translating the patient's shoulders
essary to control the patient's head in a position of extreme
away from you, using your body to push against the near
extension (Fig. 7.34), quite awkward if the patient is seat­
shoulder in the direction of the treated segment. Then the
ed on the same level as the operator.
rotation barrier is sought in order to confirm sidebending
2. You stand beside and close to the patient on the side
localization. If sidebending is appropriately locaiized, cou­
of the anterior transverse process.
pled ipsilateral rotation has already occurred, and moving
3. While palpating the spinous processes of the dysfunc­
the head to produce more rotation should cause no palpa­
tional vertebra and the one interior to it (this can be done
with one finger pad in the interspinous space, or, if you ble segmental movement. This is not the time to move the

prefer, the middle finger pad in the interspinous space and

segment into more flexion, seeking a barrier. Rotation and

adjacent finger pads on the two spinous processes), find the
neutral range by flexing and extending the patient's head
and neck in small amplitude movements, exploring the full
range of extension to flexion (see Steps 3 and 4 in the
longus colli procedure (presented next) for more detailed
discussion of neutral motion). It is a good idea to start in
a hyperextended position. Occasionally this is absolutely
necessary in order to localize behind the flexion barrier of
a major ERS dysfunction. Having the patient lean forward
at the hips can facilitate translating the patient's shoulders
forward tor the purpose of maintaining postural balance.
4. Once the neutral range has been found, reach around
the tar side of the patient's head to place your hand on the
back of the occiput. The patient's forehead, not his/her
eyeballs, should be resting on your biceps muscle near the
antecubital space. Don't squeeze the head!
flexion mobility will not be available until after sidebending
release.
Note: From the hyperextended position the first barrier to be localized
would be sidebending, since the hyperextended position is already in
the proper relationship to the flexion barrier. The same concerns
regarding sidebending localization expressed in the next procedure
apply here. Almost no movement should be required to localize the
rotation barrier. because sidebending and rotation are coupled to the
same side under these circumstances and the sidebending localization
automatically produced the rotation. If appreciable rotation is required
to reach the rotation barrier. it means that sidebending was not local­
ized precisely enough, and that step should be repeated.
If the dysfunction is maj or. the starting position will be quite extend­
ed. approximately as shown in Figure 7.34a. If the dysfunction is minor
( less than 50 percent of the flexion - extension range of motion lost ),
the patient's starting position will look more like Figure 7.33, with the
spine flexed to bring the vertebra to a posterior apical position. localiz­
ing flexion from above down.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 121

Figure 7.34b. Turban Figure 7.34c. Turban tech­

technique. Step 8. After nique, final position. With
sidebending release, full flexion the segment is
more rotation is permit­ aIIowed to derotate and
ted, and flexion mobility straighten.
becomes available. The
segment is kept sidebent
and rotated as it is being
flexed.

6. Instruct the patient to attempt to extend the head and Figure 7.34d. Retest
neck with 6 to 8 ounces of force for 2 seconds against your T 1 using the ribs or the
unyielding resistance and then relax. To make the exten­ transverse processes.
sion action more specific for the joint being treated, ask the
patient to pull the back of the head toward that joint (des­
ignated by tapping on the patient's back with your finger)
«putt the back ofyour head against my hand toward this ver­
tebra» [Pause] «Relax.» A straight backward push will not
contract the appropriate muscles.

Note: Having the patient exhale during the push and inhale during
relaxation adds specificity and efficiency to the technique.

7. Allow the patient to achieve full relaxation, before

introducing more motion to the segment. Once the
patient has relaxed, take up any available slack to the new
barrier in sidebending by translating the segment with
slight pressure against the shoulder with your body.
Confirm localization by testing rotation, i.e., try to rotate
the segment toward you by turning the head passively. If
no palpable rotation is felt at the segment, you may assume
that sidebending is appropriately localized, but has not yet
released. This step is repeated three times, or until
sidebending release is sensed.
8. After a release of sidebending, new rotation mobility
Note: In order to keep the patient balanced while flexing or extending
will be available, indicating that new flexion mobility has
the upper thoracic spine, the upper trunk must be translated backwards
been created. After the third repetition assume that this
for flexion or forward for extension. A small amount of forward and
has occurred, even if you did not feel a release. While keep­
backward translation at the level of your palpating finger can add pre­
ing the segment sidebent and rotated, move it into full flex­
cision to the localization process. In the mid-thoracic region, T4 to T9•
ion, and then de-rotate the neck. full flexion should produce enough posterior translation of the vertebra
9.To evaluate treatment outcome, observe the transverse that it becomes the most posterior point of the spine. Full extension
processes ofT 1 for symmetry in extended and flexed posi­ requires that the patient moves the chest forward over the lap and tips
tions. You can also observe the first rib in extension and the head back as far as possible.
flexion to assess the effects on rib position or breathing
motion. These tests can be used independently or to con­
firm the results of the other. Repeat the treatment if nec­
essary.
122 THE MUSCLE ENERGY MANUAL
Figure 7.35 Longus colli
technique for major
dysfunction of Tt.
Extreme flexion may be
required for localization
to the barrier, especially
if no pinching or
gapping can be felt
between the spinous
processes.
Treatment for Type II FRS
Segmental Dysfunction
Longus Colli Technique [Range: C5 - T2}
The longus colli muscle is a complex prevertebral muscle
composed of mixed monoarticular and polyarticular fibers
which attach to the bodies and pedicles of all the cervicals
and the first three thoracics. Its monoarticular fiber is a pri­
mary restrictor in the Type II FRS dysfunction -along with
the intertransversarii muscles- in the upper three thoracics
and lower six cervicals.
The figures for the following procedure show treat­
ment of a first thoracic dysfunction with restricted exten­
sion, left sidebending, and left rotation (FRS right, posi­
tionally), first major, then minor. Do not be confused
about the terms major and minor. They refer to the dys­
function, not to normal joint motions. Recall that normal
joints have both major movements (ranges of movement
under active muscular control) and minor movements
(accessory, or passive joint play). Articular somatic dys­
functions can also be classified as major (loss of more than
50 percent of the normal range of motion) or minor (loss
of less than 50 percent of the normal range of motion).
Figure 7.36 Longus colli
technique for minor
dysfunction of T1.
The Longus Colli Technique Protocol for Treating
FRS [Range: C5 - T2i Case Study: T1 FRS Left
l. The patient is seated on the treatment table or on a
low stool. You stand on the side of the posterior transverse
process, supporting and controlling the patient's forehead,
which is held gently on the palm of your hand between the
thumb and fingers. (Figure 7.35)
2. With your other hand, palpate the space between the
spinous processes of the first and second thoracic vertebrae.
Place the pad of your index finger on that spac'! such that
it contacts both spinous processes. An alternative contact,
which slightly enhances palpatory sensitivity, is to use three
fingers, one on each of the spinous process tips and one in
the interspinous space.
Note: In Step 2 it is important to start with the neck extremely hyper­
flexed in some patients. Sometimes the ability to extend a spinal joint
is reduced by 90 percent or more. The amount of normal extension
movement remaining is between the hyperflexed position and a few
degrees of extension. With further extension. localization is lost [a fre­
quent error with beginners) and treatment will be ineffective.
3. Start with the neck and upper thoracics in a flexed
neutral position, shoulders translated backward to maintain
postural balance. To find neutral for the dysfunctional seg­
ment it may be necessary to hyperflex the neck and upper
thoracic spine. When the segment is in neutral, gently bob­
bing the head up and down an inch or two will cause the
spinous processes to pinch together (with extension) and
gap apart (with flexion). When the segment is not in the
range of neutral, but rather in the range of the restriction,
pinching and gapping will not be felt between the spinous
processes.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6
4. With the patient relaxed and resting the full weight of
the head on your hand, slowly raise the head, extending the
neck from above down into the thoracics, stopping near the
end of the free-motion range. (Figure 7.37) The starting
localized position is at the extension end of the neutral range,
not at the beginning of the restriction. As passive extension
occurs from above down, each vertebra in turn begins to
extend at the moment the vertebra above it reaches the end
of its neutral range. In other words, the vertebrae are
moved like links in a chain, one link at a time, provided the
movement is passive and not active. Thus, to localize to the
"feather edge" of the extension barrier ofT 1, extension of
the spine must stop just beforeT2 moves.
If the dysfunction is major, the starting position will be
quite flexed, as shown in Figure 7.35. If the dysfunction is
minor (less than 50 percent of the flexion to extension
range of motion lost), the patient's starting position will
look more like Figure 7.36.
5. From the free-motion (neutral) position, localize the
sidebending barrier by passively leaning the head sideways,
usually away from you. This action should always be
accompanied by contralateral translation of the shoulders in
order to maintain postural balance. The chain of bones con­
cept applies here. The sidebending movement must stop
just before T2 moves with T 1. In rare instances the
sidebending restriction is so severe that localization is
attained before the vertebra reaches an erect position.
6. Next test segmental rotation by passively turning the
face in the same direction as the sidebending. If the
sidebending barrier was well localized, almost no move­
ment should be required to reach the rotation barrier,
because sidebending and rotation are coupled to the same
side under these circumstances, and the sidebending local­
ization automatically produced the rotation. If appreciable
rotation is required to reach the rotation barrier, it means
that sidebending was not localized precisely enough, and
that Step 5 should be repeated. Be sure the patient is bal­
anced and relaxed throughout the localization procedures.
7. Instruct the patient to attempt to flex the head and
neck with 6 to 8 ounces of force for 2 seconds against your
unyielding resistance ... and then relax. To make the flexion
action more specific for the joint being treated, ask the
patient to push the forehead, or nose, toward the upper
chest, or toward the clavicle: «Push your nose toward your
upper chest with one-half pound of force.» [Pause] «Relax.»
A straight forward push will not contract the appropriate
muscles.
123
Figure 7.37 Bilateral symmetrical extension. The final position in the
treatment of FRS dysfunction is bilateral symmetrical extension. Having
the patient open the mouth eliminates the restraining effect of the
platysma muscle.
8. If necessary, request relaxation again. Allow the
patient to achieve full relaxation before introducing more
motion to the segment. Once the patient has relaxed, take
up any available slack to the new barriers in the following
sequence: first in ( 1) sidebending, then in (2) rotation,
and finally in (3) extension. If there is no rotation slack,
there will be no extension slack.
Note: In a flexible chain of bones pure axial rotation is not a localizable
motion. Angular bends (such as sidebending, extension, or flexion) are
localizable. Even though rotation is automatically coupled to sidebend­
ing, it is important to check the rotation localization after sidebending
localization. The rotation may have a decompressing effect on the
zygapophyseal facet joint, such as occurs with pure axial rotation, facil­
itating the last step in localization, which is extension.
9. Steps 4 through 8 are repeated three times, or until
release of the desired sidebending motion is felt. If no
release is felt after using the flexor muscle isometric con­
tractions, the monoarticular sidebenders may be used,
alternatively, in a light (one-half pound) isometric push of
the ear toward the shoulder as a substitute for Step 7. If
you did not feel a release by the third repetition, you might
have missed it. Assume the release occurred, and rotate the
segment. Then extend it until the joint is bilaterally sym­
metrically extended (Figure 7.37).
10. Retest. With the patient seated, reexamine the stat­
ic positions of the segment to make sure that it maintains
symmetry throughout the range of flexion and extension.
Observe either the transverse processes from behind (Figs.
7.28, 7.29, 7.30), or in front of(Fig. 7.27), the patient, or
the first ribs for breathing motion and A-P position from in
front of the patient (Figs. 6.9, 6.10). Repeat the treatment
if necessary.
124 THE MUSCLE ENERGY MANUAL

Figure 7.38 Modified Figure 7.39 Modified

longus co IIi technique. longus co IIi technique.
Patient and operator Supporting patient"s
positions. Step 1. head and elbow on the
operator's arm. Step 2.

Figure 7.40 Modified

Treatment of Type II FRS
longus co IIi technique
Segmental Dysfunction (continued) viewed from the side.
Finding neutral. Step 3.
The Modified Longus Colli Technique IRange: T3- T6]
Although there is no longus colli muscle involved, the fol­
lowing procedure is called the modified longus colli tech­
nique because of its similarity to the longus colli technique.
In actual tact, the lowest attachment of longus colli is the
body ofT3. Monoarticular flexor muscles are almost absent
in most of the thoracic spine. There may be some monoar­
ticular flexor fibers within the intertransversarii connected
toT10_12, but even these are absent in thoracic segmentsT1
through T9.
So why is the modified longus colli technique an effec­
tive treatment for FRS dysfunctions of the third, fourth,
fifth, and sixth thoracic segment? The effectiveness of the
Modified Longus Colli Technique is possibly attributable
to selective inhibition of segmental extensor muscles and
their subsequent post-isometric facilitation. It is also possi­
ble that the noncontractile tissues of the prevertebral fas­
cias, or possibly some portion of the intercostal muscle, tebra being treated to its most posterior apical position. To
serve as flexor stabilizers of thoracics three through nine. reach the extension barrier of a minor FRS dysfunction, the
Regardless of what mechanism is activated by the mod­ vertebra is then translated anteriorly until the spinous
ified longus colli technique, positional localization is the processes stop pinching together. From that point it is
sine qua non tor successful execution of the technique. The important to translate slightly posteriorly to be sure the
treatment begins in the "neutral" position (i.e., any posi­ segment is in its neutral range. The neutral range is
tion within the range which allows unrestricted flexion and exceeded much sooner in a major FRS dysfunction.
extension). The neutral range is determined by palpably If the dysfunction is major, the starting position will be
monitoring the interspinous space for movements such as quite flexed. If the dysfunction is minor (less than 50 per­
gapping and pinching together of the two spinous process­ cent of the flexion-extension range of motion lost), the
es. The goal of localization in treating an FRS dysfunction patient's starting position will more erect.
is to be at the extension end of this neutral tree range, but To demonstrate the Modified Longus ColliTechnique,
to not move into the barrier. The more precisely the seg­ treatment for T4 FRSR (i.e., the segment is positionally
ment is localized, the more effective the treatment proce­ Flexed, Rotated, and Sidebent Right; with restricted
dure will be. In treating minor or major FRS dysfunction extension, left sidebending, and left rotation) will be used
the patient's thoracic spine may be flexed to bring the ver- as a case study.
 CHAPTER 7
Figure 7.41 Modified
longus co IIi technique.
Examiner palpates
between the spinous
processes of the seg­
ment for localization.
Lateral translation
toward the operator is
aimed at the segment
from the patient's left
shoulder. Coupled rota­
tion to the left should
occur simultaneously.
Steps 4 and 5.
Procedure Protocol fur Modified Longus Colli ndmique
I. The patient is seated with the side of the posterior
transverse process close to the edge of the treatment table.
For example, to treat FRS Right at T4 the patient's right
side would be close to the edge of the table. You stand
close to the patient on the side of the posterior transverse
process (Figure 7.38). Once you and the patient are in
position, the patient places the hand nearer to you on
his/her opposite shoulder, raises the elbow, and rests
his/her forehead on the elbow. (Figure 7.40)
2. Standing on the side of the posterior transverse
process, you support and control the patient's raised elbow
and head by reaching across in front of the patient's chest
to hold the far arm. For increased leverage, your support­
ing arm should be underneath the elbow as far anterior
from the axilla as possible. (Figure 7.39) The patient is
relaxed, resting the full weight of the head and elbow on
your arm.
3. Keep the palpating finger of your other hand at the
interspinous space just inferior to the lesioned vertebra to
monitor for localization (Figure 7.40). Localization is
achieved by positioning the lesioned vertebra at the feath­
er edge of the barriers, starting from a position of extreme
flexion (backward slump) and slowly translating the verte­
bra forward until the extension barrier is reached. If exten­
sion goes far enough to cause the dysfunctional segment to
rotate, then it has gone too far, and localization has been
lost. Do not remain at the extension barrier; be sure the seg­
mmt is in net1tral before localizing sidebending.
4. The sidebending barrier is engaged first. Tell the
patient, «J am going to pull your shoulders slightly toward
me.» Pull the far shoulder toward the vertebral segment
(Figure 7.41) and stop when the sidebending movement
(away from you) is felt at the interspinous space being pal­
pated. Passively turn the shoulders away from you for rota-
..-&- ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 125
Figure 7.42 Modified
longus coIIi technique.
The upper body is trans­
lated anteriorly to
extend the segment
while maintaining
sidebending and rota­
tion. The segment
becomes fully extended
and symmetrical at the
end of the treatment.
Step 6.
tion localization. Little or no rotation should be required
to reach this point, since coupled ipsilateral rotation should
have already occurred. If appreciable rotation is required
to reach the rotation barrier, it means that sidebending was
not localized precisely enough, and that the step should be
repeated.
5. Instruct the patient to attempt to flex the neck and
trunk with 12 to 16 ounces of force by pushing the elbow
and head down against your resisting unyielding arm for 2
seconds and then relax. «Push your elbow and forehead down
against my arm with about 500 grams of force. [Pause] Now
relax.»
Note: Having the patient inhale deeply at the same time as pushing
down with the elbow and head may add some specificity to the action
by using the flexion effect of inhalation on the mid-thoracic spine.
6. When relaxation is complete, sidebending is relocal­
ized. Allow the patient to achieve full relaxation (and com­
plete exhalation), before making a move. Then take up any
available slack to the new barriers, first sidebending, then
rotation, and finally extension. If there is no rotation slack,
there will be no extension slack.
7. Steps 5 and 6 are done three times, or until release of
the desired motion is felt. After a release is sensed it is best
to continue extending until the joint is symmetrically
extended. The third localization should bring the patient
to a fully extended position most of the time.
8. If no release is felt after using the flexor muscle iso­
metric contractions three times, stop the procedure after
relocalizing the third time, rotating away from you and
extending the segment by translating the shoulders anteri­
orly and retest the segment. Repeat the treatment, if nec­
essary.
126 T H E M U SC L E E N E RG Y M AN UA L

Cervicothoracic Recumbent Techniques

Lateral Recumbent Salad Bowl MET
[Ra��ge: C3- T7]
Bedfast patients can be treated in bed, if necessary. With a
little ingenuity the principles of Muscle Energy diagnosis
and treatment can be applied with the patient in a recum­
bent position. The following are some Muscle Energy pro­
cedures based on the lateral recumbent salad bowl tech­
niques:

Salad Bowl Technique Protocol /Case St11dy: T1_v

l. The patient lies on the side of the lesioned segment's
posterior transverse process, facing you.
2. Cradle the side of the patient's head on your forearm
with your hand stabilizing the back of the head. To avoid
mashing the patient's ear keep your arm above the ear.
3. Find the interspinous space between T1 and T2 and
place your finger pad there to monitor intersegmental
motion. (Figure 7.43)
4. Find the neutral range as in the previous treatment
procedures.
5. If treating ERS dysftmction, move the superior seg­
ments from the mid-neutral position to the flexion end of
the neutral range. If treating FRS dysftmction, move the
superior segments from the mid -neutral position to the
extension end of the neutral range.
6. Localize sidebending and then test rotation by bend­
ing the neck and turning the face up away from the bed. If Figure 7.43 Salad bowl lateral recumbent techniques for ERS, FRS, NSR.
the patient can lie only on one side, sidebending and rota-
tion can be produced and controlled just as well by bend-
ing the neck and turning the face down toward the bed.
7. If treating ERS dysfunction, have the patient pull
the back of the head against your resisting hand toward the
vertebra your finger is touching, using about 8 ounces of
force tor 2 seconds, and then relax. If treating FRS dys­
function, have the patient push the forehead against your
resisting biceps brachii muscle toward the upper chest, using
about 8 ounces of force for 2 seconds, and then relax. A
straight backward or forward push will not contract the
appropriate muscles.
8. During the post-isometric relaxation the segment is
repositioned to the new sidebending barrier. Confirm
sidebending localization by testing rotation. After the
release of sidebending/rotation, or after the third repeti­
tion, move the segment into ipsilateral rotation, and then
full flexion (tor ERS) or extension (for FRS).
9. Retest the segment.

Note: Upper thoracic segmental dysfunctions may also be treated with

the patient in the supine position.
 CHAPTER 7 --&- ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T 6 127

Supine MET for Treating ERS or FRS Segmental

Dysfunction [Range: C5 - T6}

Supine Technique Procedure Protocol

1. The back of the patient's head rests in your support­
ing hand.
2. Your other hand reaches under the patient's back to
monitor the spinous processes a,s in the preceding proce­
dures. (Figure7.44)
3. Localization is done from segmental neutral, sideben­
ding first, then checking the coupled rotation. Relocaliza­
tion follows the same sequence with the addition of sagit­
tal motion (flexion or extension) at the conclusion of the
procedure, after sidebending release occurs and rotation
increases. See previous procedures for more discussion of
the localization sequence.
4. For ERS treatment, have the patient press the back
of the head back against your hand, as if pushing the head
toward your palpating finger, using about 8 ounces of force
for 2 seconds, and then relax. For FRS treatment, since
you do nut have a third hand to resist anterior pushes of the
head, you must rely on the weight of the head to be suffi­
cient counterforce to the flexion effort. Several alternative
patient efforts are possible, each sustained for 2 seconds
followed by post-isometric relaxation: (l) Ask the patient
to push the nose toward the upper chest without lifting the
head off your hand. Relocalize sidebending during relax­
ation. (2) Ask the patient to take a deep breath, making as
much of the breath as possible go into the back where your Figure 7.44 Supine technique for treatment of minor ERS dysfunction in
palpating finger is. Relocalization is done after the breath the upper six thoracics.
is exhaled. (3) Ask the patient to look at the upper chest
without raising the head. To relax the flexor muscles ask
the patient to look up at his or her own eyebrows. These
methods may be combined.
5. After the third relocalization, recheck the segment.

Note: Not all ERS or FRS dysfunctions can be conveniently treated with
the patient in a supine position. The minor ERS and the major FRS dys­
functions can be treated while the patient lies supine. It is not coinci­
dental that these are the dysfunctions which can be diagnosed with the
patient lying supine.
128 THE MUSCLE ENERGY MANUAL

Figure 7.45
Seated Axial Neutral Rotation Procedure
Seated axial (neutral)
[Range: T.� - L5] rotation procedure.
Sometimes a more effective mobilization of a thoracic (or
lumbar) non-neutral segmental dysfunction is to be slight­
ly less specific and focus on gapping the facet with the
impaired motion -the anterior facet with FRS dysfunction,
or the posterior facet with ERS dysfunction. Axial rotation
of vertebrae gaps the facets on the side toward which rota­
tion occurs. The range of axial rotation is greatest from the
mid-neutral position; from T3 down to L4 it is facilitated by
contralateral sidebending. The addition of the right
amount and direction of sidebending can localize the axial
rotation/facet gapping effect at a specific vertebral seg­
ment.
This principle is utilized by several procedures to be
presented later. For the present, it is used for the follow­
ing alternative mobilization procedure for the upper tho­
racic type II dysfunctions. This procedure is also the spe­
cific treatment for type I (NSR) dysfunctions, which are
normally djagnosed and treated after all type II (non-neu­
tral ERS or FRS) dysfunctions have been corrected.
Treatment for NSR dysfunction is ideally localized to the
segment with the greatest sidebending restriction, usually
located at the apex or the crossover of the compensatory
group.

Seated Axial Rotation Procedure Protocol

l. Patient is seated on the treatment table. (If you are
short, you may need to seat the patient on a lower surtace.)
2. You stand on the side toward which the intended rota­
tion will occur.
3. Patient clasps the fingers together on the back of the
neck. If the patient's arms are very short, one hand can
hold the back of the neck while the other hand holds the
flexed elbow.
4. You reach across in front of the patient. Your arm
goes below the near axilla to hold the top of the far shoul­
der with the hand. This hold facilitates sidebending away
from , and rotating toward you.
5. Your free hand palpates the spinous processes to local­
ize intersegmental motion. The monitored point is trans­
lated toward you, while the far shoulder is depressed to
localize sidebending away from you at the segment.
6. Once sidebending is localized, axial rotation can be
added by turning the patient's shoulders toward you until
the rotation is felt at the superior spinous process.
7. Tell the patient to pull the near shoulder down against
your upper arm. «Pull your (right/left) shoulder down
against me toward your hip with 5 to 10 kilograms of force.
Hold the contraction for 1 to 3 seconds. Now relax.»
8. Rclocalize the sidebending and take up the contralat­
eral axial rotation slack.
9. Repeat Steps 7 and 8 twice, or until a release is sensed.
10. Repeat the diagnostic procedure which led to the dis­
covery and definition of the dysfunction.
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T1-T6 129

Table 7.A Muscle Energy Evaluation and Treatment Procedures for Upper Thoracic Segmental Vertebral Dysfunctions

At this point, the reader should possess the knowledge and skills necessary to perform a complete evaluation and treatment of
the upper thoracic region. A review of these skills is suggested. The following is a summary list of the procedures covered:

• Seated rib position observation/assessment screening procedures: [Range: T1- T10 and ribs i-x]

• Step breathing tests for structural rib lesions and vertebral segmental dysfunction: [Range: T1- T10 and ribs i-x]

• The test for superior subluxation of rib i

• The test for anterior or posterior rib subluxation: [Range: T1- T10 and ribs i-x]

• The seated search for the key rib: [Range: T1- T12, ribs i- xii]

• Step breathing and position rib tests for ERS and FRS diagnosis T1- T6, ribs i- vi: [Range: T1- T12, ribs i-xii]

• Treatment procedures for first rib subluxations: superior, anterior, and posterior

• Vibratory isolytic technique for treatment of scalene muscle contracture: [Range: ribs i-ii]

• Evaluation of transverse processes of T1 - T6 flexed and extended

• Turban technique

• Longus co IIi technique

• Modified longus calli technique

• Salad Bowl Muscle Energy technique

• Supine Muscle Energy technique

• Seated Axial Rotation technique

A Clinical Example of Vertebral Diagnosis Using

the Ribs
Among practitioners of manual medicine and manual ther­
apy there exist many different methods of evaluating verte­
bral mobility. In the system of Muscle Energy, the meth­
ods of examination utilize what is known of vertebral cou­
plings and relationships, saving time and effort and signifi­
cantly increasing validity and reliability.
The following clinical case example illustrates how the
ribs can be used for vertebral diagnosis, with the diagnosis
later confirmed by transverse process palpation/observa­
tion. A screening history and physical has been completed,
and suggests the possibility of dysfunction in the thoracic
region. Visualize tl1e patient lying supine as we start. The
rib motions are screened first.
Begin by placing the palms of the hands over the later­
al aspects of the upper five or six ribs in order to assess their
bucket handle motion. The bucket handle motion is used
for screening because the majority of upper rib dysfunc­
tions affect bucket handle motion - which is the minor
movement of the upper ribs - more than they affect the
pump handle motion, which is their major movement.
When they become restricted they are more likely to lose
their minor movements. Therefore, we will be able to see
the asymmetric rib movement more easily when we watch
for the minor breathing motions.
The patient should be given instructions in step­
breathing, which will make it easier to see what we are
looking for: «Let your breath all the way out. Breathe all the
way out. Now take half a breath in and let it out. Now take
it back in and let it out.» For this patient, we notice that
the ribs on the right side move up and down, and the ribs
on the left side barely move. In order to monitor the
patient's rib motion we place our hands on the chest to fol­
low the ribs, because the ribs slide under the skin. Our
hands will track the ribs and follow along and ride on and
move with the ribs as we observe. <<Now take a deep breath,
really deep, deep as you can get, and let half of your breath
out. Take it back in and let it half out. Keep doing that for
a few breaths.» We notice that in this deeper phase of
inhalation and exhalation both sides move symmetrically.
«Now let your breath out."
What we have observed is restricted exhalation move­
ment of some ribs on the left side which are not able to go
down all the way, so they stop prematurely when exhaling
is occurring, and begin inhaling later in the cycle after the
right side has begun its inhalation.
We go to the lower ribs, and cover five or six more ribs
with our hands. We monitor the pump handle movement
of the lower ribs because that is its minor motion, which is
130 THE MUSCLE ENERGY MANUAL
more prone to be restricted. «Let yottr breath all the way
out and take a halfa breath in and out.» Once again we see
the right side moving and the left side not moving. <<Let
your breath all the way out.» We see that the right side con­
tinues to exhale all the way, and the left side does not go all
the way down. We now know that there are more than six
ribs involved in this restricted motion.
With the discovery of a group of ribs with restricted
respiration, we begin looking for the key rib. To count
ribs, start at the sternal angle and come off to the side,
which is where the second ribs attach to the sternum.
Count ribs two, three, four, five, six, seven, eight, nine, ten.
Let us see if the tenth ribs have that same restricted move­
ment. «Let your breath all the n1ay out. Breathe back in a
haifa breath, and back out." The tenth ribs move symmet­
rically. Notice how far apart the fingers are on the tenth
ribs. When observing your hands on both sides like this,
with that much distance between your fingers, the best way
to see what you are looking for is to use your peripheral
vision, because if you try to look from one finger to the
other you are liable to miss the comparison of the move­
ment. So use the peripheral vision by simply keeping your
eyes focused in the midline, and watching the simultaneous
movement of both hands with your peripheral vision.
Now that we have identified the key rib- the rib which
is the lowest one in the group with the motion restriction
of exhalation - we have also identified the ninth thoracic
vertebra as the place to look for segmental dysfunction. We
can use the ninth ribs to discover the nature of that dys­
function.
In the supine position, the ninth rib appears to be more
prominent anteriorly on the left side.<<Take a halfa breath
again. Let it out.» (Confirming that we are on the ninth).
We observe what happens to the position of the ninth ribs
when the spine is flexed. «Raise your head and shoulders up
off the table. Okay. Go back down." What we saw then was
that when the patient was in the flexed position the ribs
became more symmetrical, and then when the patient lay
down flat the right rib went back posterior more than the
left rib did. Now we have some information about how the
ninth thoracic vertebra actually moves.
We can confirm the validity of our observations by pal­
pating the ninth thoracic transverse processes. The patient
lies prone so that we can examine the spine and the ribs
from the back. If it had been necessary to search lower than
the ninth thoracic and the ninth rib for the key, we would
also have had to turn the patient over into the prone posi­
tion in order to palpate the breathing movements of the
tenth, eleventh, and twelfth ribs.
(Patient turns over and lies prone.) The tvvelfth ribs
can be palpated by sliding the skin over the ribs. We find
the lateral tips of the twelfth ribs and follow their breathing
movement. «Take in a breath. Let it all out. Take in a half
a breath and let it out. I am going to do the same with the
eleventh ribs, half a breath, and out; and tenth ribs, half a
breath, and out; and ninth ribs, in and ottt.» We find that
the ninth rib is restricted, just as we observed when the
patient was supine. We can also use the ninth rib to help
find the transverse processes of the ninth thoracic vertebra.
The transverse processes of T9 are to be found by follow­
ing the shafts of the ninth ribs in to locate the bumps along
the rib shafts which are between the longissimus and the
iliocostalis muscle. Watch as the patient puts the ninth tho­
racic vertebra into extension. «Brirtg your shoulders up off
the table and prop your shoulders up on your elbows 1vith your
chin up on your hands.» We see in this position that the left
side of T 9 stays anterior, the right side comes posterior as
the patient extends. «Now lie back down flat.»
We have determined thatT 9 is flexed, rotated, and side
bent to the right. It becomes symmetrical when the patient
flexes it- and is rotated to the right, i.e., posterior on the
right. When it is in this position it gets more posterior on
the right when it is being further extended, and it is already
extended past where it can remain straight. The eighth
transverse processes are symmetrical, the ninth is rotated to
the right, the tenth transverse processes are symmetrical. So
we have a right rotated T9.
Is the eighth vertebra rotated to the left? If it appears
that it is, it may be as dysfunctional as the ninth; or, it may
be simply adapting to the ninth to compensate for its asym­
metric position. 1fT8 is dysfunctional, we will find that out
after T 9 has been treated. Treatment of the ninth vertebral
segment may restore symmetry to the ninth ribs, but not
the eighth.
Now we can also look at transverse process movements
with the patient seated.
In addition to the screening examination which we
have demonstrated in the supine breathing tests, there are
some other screening examinations which may call atten­
tion to the possibility of somatic dysfunction in the thoracic
vertebral column. One such screening examination proce­
dure is a simple side bend induced by depressing the shoul­
der and translating the back from side to side, noticing if
there is symmetrical reluctance or symmetrical compliance
with that movement. When we assess sidebending symme­
try, it is important to instruct the patient to maintain an
erect seated position (i.e., not flexed or extended) through­
out the test.
When performing the sidebending screening test of the
thoracic region, it is a good idea to stand close to the
patient. Stand close enough to be touching the patient with
your body so that you can impart the sidebending test
forces by shifting your body instead of using your anns. In
this way, you can feel the subtle differences in resistance to
the sidebend which call attention to the possibility of
somatic dysfunction.
Next we will perform a trunk rotation test for the tho­
racics. The patient is told; «Now fold your arms across yottr
chest. Keep sitting up tall." As we rotate the trunk to the
right we notice that the shoulders will turn almost ninety
 CHAPTER 7 � ERS AND FRS SEGMENTAL DYSFUNCTIONS FOR T 1-T 6
degrees with minimal resistance. However, in going
beyond the approximately ninety degree point, we reach a
point where resistance is quite firm. We go back to
straight. «Keep sitting up straight and we will turn to the
left.» When we turn to the left we see that we can go out
ninety-five to one hundred degrees to the left. So that
small difference indicates to us that there may be a somat­
ic dysfunction, especially in the lower thoracic spine. We
have already determined that somatic dysfunction exists at
T9.
To examine the thoracic vertebral column (one verte­
bra at a time) in the position of flexion, we have the patient
sit with the back slumped. «Put your chin down on your
chest and let your back slump over.» With the patient in this
position, we can more easily feel the individual transverse
processes. This is a time when the Rule ofThrees becomes
useful because we can tell which vertebra we are palpating
by counting the spinous processes, which are easy to count
in this position. There is C7, which is the vertebra promi­
nens, T1, 2, 3, 4, s, 6, 7, 8. Remember that T8's spinous
process is at the level of theT 9 transverse processes which
we are particularly interested in. In the flexed position T 9
was symmetrical and T10 looks symmetrical, as doT u and
T12. Remember how short the T 12 and T 11 transverse
processes are. Keeping that in mind, it makes sense to
check the position of the ribs that attach to those vertebrae.
If the twelfth ribs are symmetrical, and the eleventh ribs are
symmetrical - which they are - we can assume that the ver­
tebra is not rotated.
When we come to the tenth rib, we see that the right
tenth rib is posterior. While in this position we can check
the breathing movement of the pair of tenth ribs to see if
they show restriction. «J'ake a halfof a breath and let it out.
And take a deep breath and let a little bit out, back in, and
let it all the way out.» The right tenth rib does not exhale
all the way in this position.
Watch the tenth ribs to see what happens to their posi­
tions when the spine is straight. «Sit up tall.» As the
patient comes into an erect position, the tenth ribs become
symmetrical. Watch the tenth ribs breathe in this erect
position. «J'ake a breath. Let it out. Now half a breath. Let
it out.» Symmetrical movements. So the asymmetry of
breathing movement of the tenth ribs occurred only when
the spine was flexed and the tenth rib and its vertebra
became rotated to the right (ERSR).
Look again at the ninth thoracic vertebra- eleven, ten,
nine. In this position the transverse process is posterior on
the right. It becomes anterior, or symmetrical, when the
patient is flexed. So there is ERS Right atT10, and an FRS
Right atT9.
There is an advantage to observing and palpating the
transverse processes while standing in front of the patient.
The resulting visual parallax makes the rotation of the ver­
tebra more obvious, and we can now palpate the transverse
processes and look at the fingers as we go down the verte-
131
bral column. One, two, three, four, five, six, seven, eight;
we are now at nine, and it looks symmetrical. When we
reach ten, we see that the right side ofT 10 is posterior and
its rib angle is posterior on this side too.
By sitting in front of the patient, we can observe the
positions and movements of the ribs just as we observed
the positions of the transverse processes from behind. «Let
your chin go d01vn on your chest and let your upper back
slump.» As the patient assumes a flexed position for the
upper thoracic, we follow the positions of the first rib, sec­
ond rib, third, fourth, etc. «Now sit up straight. Put your
head back and stick your chest out forward.'' We can see if
the ribs rotate in either of these positions, in flexion or
extension. <<Now sit straight again.'' We once again
demonstrate what happens to the ninth rib. Two, three,
four, five, six, seven, eight, nine - which is posterior on the
right at this point. <<Now let your back slump.'' We cannot
see the tips of the fingers, but we can put the thumbs next
to each other and observe what happens to the thumbs
when the patient straightens up. «Come up straight.» We
can see that the right thumb comes out anteriorly more
than the left thumb. «stump again.» The thumbs go back
even with each other in the flexed position.
<<Okay, come up straight.'' We will get on the tenth ribs
and see if we can get the same information. We are now a
little far from the midline and, of course, we are on the
costal cartilage of the tenth ribs, so this may be a little mis­
leading. <<What I want you to do is slump.» As the patient
slumps, the right tenth rib goes posterior. <<Now come up
straight.» They become even. This is another way of eval­
uating the rotation of the vertebra. We have confirmed the
diagnosis that we have made. T 9 is FRS Right. That means
that it becomes maximally rotated to the right when it is
being extended. It becomes symmetrical when it is flexed.
T 10, on the other hand, is ERS Right, which means it
becomes rotated to the right when it is flexed, and gets
straight when it is extended.
What we have just scripted is a routine examination,
with some redundancy to confirm findings, which allows us
to make a diagnosis of segmental dysfunction of a vertebra
in the thoracic spine. In this case, we were fortunate that
the rib findings agreed with the transverse process findings.
Sometimes they do not agree.This may occur, for example,
when the ribs are subluxated. It may also occur when the
rib shaft has been deformed, sometimes traumatically, or
following greenstick fractures of the ribs, a deformity of the
rib shaft may occur and persist. The most frequent cause
of disagreement is unilateral hypertonus of the paraverte­
bral muscles, which can deceive us about the positions of
the transverse processes. In such cases of disagreement the
rib findings are the most credible. To diagnoseT11 orT12,
because their transverse processes are very short, we
depend entirely on the eleventh and twelfth ribs.
132 T H E MUSCLE ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 133

CHAPTER 8

Structural Rib Lesions

(ribs ii- x)

S
tructural rib lesions are visible and palpable disorders of rib
shape or position. Caused by minor trauma, they are com­
mon - but widely neglected - orthopedic problems that
can be treated effectively with manipulation. Structural rib
lesions are sometimes quite painful; in fact, they account for a sig­
nificant percentage of chest wall pain syndromes.
Structural lesions of the first rib (Chapter 6) are limited to
subluxations. This chapter will discuss structural rib lesions of
ribs ii through x, which include two classes: acquired
intraosseous deformities and dislocations, best referred to as
costovertebral subluxations.
Structural rib lesions often exhibit impaired breathing
motion. In rib dislocation, the mechanism of breathing impair­
ment is transparently obvious. In rib deformities, it is likely that
the energy stored in the elastic deformation subtracts from the In this chapter:
rib's degrees of free or normal movement.
• Anatomy and biomechanics of
structural rib lesions
Acquired Intraosseous Deformities
• Acquired intraosseous deformities
All ribs have elastoplastic properties which allow them to be
slightly deformed without fracturing, but some deform more Rib torsion

than others. Immediately below the thoracic inlet the skeletal Rib curvature deformities

thoracic cage begins gradually to expand its dimensions, mostly A-P compression

by changing the size and shape of the ribs, which become longer, Lateral compression

slimmer, and acquire a larger radius of curvature. The elasticity • Rib dislocations (costovertebral

becomes more and more apparent as the rib shafts become longer subluxations)

and more slender. The ribs have been aptly described by Robert Anterior subluxation
England ( 1967) as "elastic arches of bone." Posterior subluxation
Superior subluxation
Rib Torsions Bucket Bail lesion
Intraosseous deformities may be classed as eitl1er curvature • Differential diagnosis of structural rib
deformities, such as A-P and lateral compressions, or as tor­ lesions
sions. The most common intraosseous rib deformity is single
• Evaluation and treatment of structural
rib torsion, in which the shaft of the rib becomes twisted, and
rib lesions
the twist perseveres around the curvature of the rib, similar to the
• Management of recurrent rib
way torque is transmitted through a speedometer cable. Rib tor-
subluxation
134 THE MUSCLE ENERGY MANUAL
sion is caused by tensions at the costovertebral articu­
lations due to rotation of a vertebral body. Most of the
time when the vertebral rotation is treated and derotated,
the rib elastically recoils to its original natural shape. In
such cases, the rib torsion is not considered a lesion, but
rather a marker for non-neutral vertebral segmental dys­
fimction.
For ribs ii - ix, intervertebral rotation will cause some
degree of inversion/eversion of the associated rib, but not
always to the degree that it can be teJt. The middle ribs,
approximately v through ix, often exhibit palpable torsion
deformity when Type II vertebral dysfunction results in a
rotated positioning of the vertebral demitacet joints where
the head of a rib articulates. This torsion asymmetry is lim­
ited to the pair of ribs that articulates immediately inferior
to the lesioned vertebra. (Figure 8 .l) It does not occur
with group scoliotic curvature of the spine.
To visualize how intervertebral rotation produces tor­
sion of the rib associated with a segment, imagineT5 rotat­
ing to the right on T6. Visualize the head of the sixth rib
articulating with the interior demitacet of T5 above, and
the superior demitacet ofT6 below. As T5 rotates to the
right, its demitacets move in a small arc around the y�xis of
vertebral rotation; the right interior demitacet moving pos­
teriorly and the left: interior demitacet moving anteriorly.
As the interior demitacet on the right moves posteriorly
along the arc of rotation, it exerts a backward pressure
against the superior portion of the head of the right rib,
causing the head of the rib to rotate out (otherwise known
as eversion). Simultaneously, the superior demitacet tends
to spin the interior portion of the rib neck in the opposite
direction on an approximately transverse axis passing
Figure 8.1. Mechanism of rib torsion secondary to vertebral rota­
tion. As the vertebra rotates to the right, the right subjacent rib
everts and the left one inverts. The ribs in the middle, approxi­
mately v through ix, often exhibit a characteristic shape asymme­
try when Type II dysfunction results in a rotated positioning of the
vertebral demifacet joints where the head of a rib articulates.
These demifacets push on the head of the rib, resulting in a
torquing force which deforms the slender rib shaft. The upper
ribs (i through iii or ivl and the lower ribs x, xi, and xii are, of
course, exempt from these deformities. This asymmetry is limited
to the pair of ribs which articulate immediately inferior to the
lesioned vertebra. Torquing the rib changes its shape. The sharp
superior border of the everted rib (AI makes it feel bulged out
front, sides, and back. The inverted rib (BI feels flat and receded.
Of the typical ribs, the ones with the longest. most slender bodies
(ribs v- ixl permit deformities great enough to palpate stereog­
nostically. (Adapted and reprinted with permission from Lee 0: Manual
Therapy for the Thorax. OOPC. 19941
lengthwise through the neck and head of the rib. The spin
translates the rib interiorly on the costotransverse facet; if
not tor the rib's anterior attachments, the anterior extrem­
ity of the rib would flip up. Because of the anterior liga­
mentous attachments, it is prevented trom doing this, caus­
ing the rotation of the rib neck to be converted into a
torque of the rib shati: which everts its entire superior mar­
gin. The superior margin of the left: sixth rib is simultane­
ously inverted by the right rotation ofT5.
Rib torsion frequently is the most obvious feature of
vertebral segmental dysfunction in the area includingT4 to
T8 and their associated ribs v through ix. The aftected pair
of ribs are kept torqued in opposite directions. The rib on
the side toward which the superior vertebra is rotated turns
its entire superior edge out, everting, so to speak. The
twist is imparted to the rib by the backward pressure on the
superior demitacet of the rib head due to the vertebral rota­
tion. On the opposite side the superior margin of the rib
is inverted due to the anterior pressure against its superior
demitacet. The asymmetric shapes of the ribs are palpable,
especially on the side of the everted rib, where the rib
above is displaced posteriorly by the rotated vertebra.
With long-standing chronic vertebral rotation, the
elasticity of the rib may be lost and the deformity of the rib
will persist after the correction of the vertebral dysfunction.
This probably represents microscopic restructuring of the
trabeculae of the bone. Such persistent rib deformities are
called intraosseous rib lesions. A torsion intraosseous rib
lesion can be remolded using Muscle Energy techniques.
The rib torsion deformity is common; the intraosseous tor­
sion lesion is very rare.
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II - X) 135

Figure 8.2. A-P compression of the

left seventh rib (highlighted). The
anterior extremity and the angle of
the rib are compared with those of
the adjacent ribs. If both anterior
extremity and angle are posterior,
either T7 is rotated left, or the
seventh rib is subluxated
posteriorly. In A-P compression
both the front and the back of the
rib are receded.

Figure 8.3. Lateral compression of

the left seventh rib (highlighted).
The distance between rib angle and
the anterior extremity is increased.

Rib Curvature Deformities Lateral Compression

The curvature of the ribs may be deformed by compressive
forces, resulting in two possible intraosseous lesions:
anteroposterior (A-P) compression or lateral compres­
sion. If the chest is mashed front to back with excessive
force, or a gradually applied force, the deformation - A-P
or lateral compression -of a rib may persist. Some of these
deformities may, in fact, be greenstick fractures of ribs
which were not visible on X-ray. We can assume that under
some circumstances a force which would break the rib if
applied suddenly will bend it if applied gradually. Forceful
"bear hugs," head-on automobile collisions where the vic­
tim's chest hits the steering wheel, or being the bottom
man in a football pileup can cause this type of structural rib
lesion. The anterior extremity of the rib shaft is posterior
and the posterior rib shaft (rib angle) is anterior.
Lateral compressions, which are less common, cause the
anterior and posterior extremities of the rib to spread apart,
i.e., the A-P dimension of the rib increases. They are
caused by a lateral compressive force. A traumatic crushing
blow to the side of the rib cage may buckle the rib shaft in.
Sometimes this bends the rib shaft without breaking it.
Such injuries may occur with motor vehicle side collisions,
the arm rest on the car door impacting the rib cage. (Figure
8.3)
136 TH E M U S C L E E N E R G Y M AN U A L

Rib Dislocations (Costovertebral Subluxations)

In addition to rib torsions and compressions, another type
of structural rib lesion is dislocation, or costovertebral
subluxation. Vertebral segmental dy sfunctions, anterior
or posterior costovertebral subluxations, as well as rib com­
pressions, may be detected through a visualjpalpatory
examination of the rib cage to locate asymmetries. The
anteroposterior asymmetry of the ribs associated with
segmental vertebral dysfunction will either increase or
go a1vay with flexion or extension of the trunk.
Asymmetry due to a structural rib lesion will persist in
both flexion and extension.

Figure 8.5 Bucket bail lesion of left second rib llightenedl. The dark semi­
Anterior and Posterior Subluxation
circles on the rib are the pump and bucket handle finger contact points.
Any one of ribs i through x can be dislocated (subluxated) The bucket handle position is displaced more than the pump handle posi­
either anteriorly or posteriorly.(Figure 8.4) Although this tion because of its more lateral position.
finding is relatively uncommon, patients with these cos­
tovertebral subluxations are likely to seek medical help
because of the high incidence of associated chest wall pain.
In anterior rib subluxation the head of the rib is dis­
placed anteriorly on the vertebral body(ies). The neck of
the rib is displaced medially on the costotransverse joint.
Posterior subluxation slides the rib neck laterally and the
rib head posteriorly. Even though the displacement of the
rib in relation to the vertebra occurs in an arc, the dislocat­
ed rib, as a whole, has the appearance of straight anterior or
posterior displacement. The anticipated medial or lateral
displacement is not tound. (Figure 8.4)

Superior Subluxation and Bucket Bail Rib Lesion

Superior subluxation is limited to the first rib (see
Chapter 6). However, an analogous lesion is sometimes
tound at the second, third, or fourth rib. Paul Kimberly
named it a "bucket bail" lesion. It seems that it is some-
Posterior
Subluxation
Figure 8.4 Anterior or posterior subluxation of a third rib. The third rib
lhighlightedl is either subluxated posteriorly on the left, anteriorly on the
right, or lrarelyl a combination of both. The subluxated rib will have dimin­
ished respiratory movement.
Figure 8.6 Bucket bail lesion of second rib, lateral view. The neck of the
second rib is caught on top of the T1 transverse process. Orientation of the
lower transverse facets IT8_9_101 precludes this possibility.
times possible for one of these ribs to get its neck lodged
up on the top of a transverse process, if the lateral shaft: is
elevated enough. The rib head does not dislocate.
The concavity of the first seven thoracic costotransverse
pits allows the rib necks to "spin" on their respiratory axes.
The upper four or five costotransverse pits also face slight­
ly interiorly. This increases the probability that the rib neck
may become lodged on its superior rim, as in superior sub­
luxation of the first rib or bucket bail lesions of the second,
third, or fourth ribs. This subluxation may occur as a result
of excessive vertebral rotation in the opposite direction,
and/or a sudden traumatic lateral flexion of the neck to the
opposite side. The posterior scalene may provide the dis­
locating force for the second rib, but obviously not the
third. The ninth and tenth costotransverse pits are flatter
and face anterosuperiorly, allowing ribs ix and x to slide
freely up and back with inhalation and down and forward
with exhalation (or with vertebral rotation) without danger
of subluxation.
 CHAPTER 8-&- STRUCTURAL RIB LESIONS (RIBS II - X) 137

Table S.A Types of Structural Rib Lesions

\ I
Causes
A. lntraosseous Deformities (ribs v-ixl
1. Curvature deformities
a. A-P compressions Trauma
b. Lateral compression Trauma

2. Rib Torsion Lesion Trabecular

(Persistent Rib Torsion) Remolding

Rib Torsion 'krtebral Segmental

Note: Rib torsion is not Dysfunction
a lesion unless persistent

B. Dislocations /costovertebral subluxations (ribs i - x)

1. Superior (ribs i) Scalene Spasm
2. Bucket Bail (ribs ii - x) Probably Trauma
3. Anterior (ribs i - x) Trauma
4. Posterior (ribs i - x) Trauma

Differential Diagnosis of Structural Rib Lesions

The differential diagnosis of structural rib asymmetry
includes both rib subluxation and intraosseous rib
lesion deformity (Table 8.A). Several methods of exam­
ining the anterior chest wall for rib position and motion
have already been presented, both seated and supine, using
palmar stereognosis and finger pad contacts on single rib
pairs. (See Chapters 6 and 7)
For structural rib djagnosis of anterior or posterior
subluxations and anteroposterior (A-P) compressions, the
Figure 8.7 Finger contact points for A-P rib position. Anatomy and
posterior rib cage must be examined as well. For rib tor­
topography. Notice the fifth rib passes beneath the male nipple. The
sions and bucket bail lesions, the lateral rib cage must be
tenth rib meets its costal cartilage at a point 1 or 2 inches anterior to the
palpated stereognostically. mid-axillary line. The points of finger pad contact for assessing changes
in anteroposterior symmetry are shown on the anterior surfaces of the
Breathing Motions Affected
ribs just lateral to the costal cartilages. Compare with superior margin
To some degree, all structural rib lesions interfere with rib contact points (Chapter 7) for monitoring respiratory movement.
breathing motion. This is especially true of subluxations.
Acquired intraosseous deformities, especially rib torsions,
have minimal effect on breathing motion, compared with
the more obvious effect of rib subluxations or vertebral
segmental dysfunction. These restricted breathing motions they are, embryologically. The resulting tissue tensions
may be restored in spite of a persistent causative lesion, may interfere with the respiratory motion of the rib or ribs.
either by specific manipulative procedures or as a conse­ This tissue tension mechanism may account for the
quence of rigorous exercise. In some long-standing breathing motion restrictions of ribs i, x, xi, and xii associ­
(chronic) anterior or posterior subluxations, a pseudo­ ated with segmental dysfunction of the first, tenth,
arthrosis may form, permitting breathing movement of the eleventh, or twelfth thoracic segments.
rib to occur. Since both vertebral segmental dysfunctions and struc­
Although the upper and lower ribs do not acquire tural rib lesions interfere with rib breathing motion, screen­
structural torsion asymmetry, either because they articulate ing examination procedures employing breathing tests
on unifacets or because the rib shaft is too thick and mas­ always require other, more specific tests for differential
sive to undergo enough twisting to be palpably deformed, diagnosis.
they tend to turn with their vertebrae as if they were exten­
sions of the vertebral transverse processes, which, in fact,
138 THE MUSCLE ENERGY MANUAL

Figure 8.8 Observing Figure 8.9 Observing

finger pads on the finger pads on the
anterior surfaces of anterior surfaces of
the second costal the second costal
cartilages for cartilages for
unilateral anterior unilateral anterior
movement while the movement while the
head and neck are head and neck are
flexed. Patient supine. extended. Patient
Instruction: "Raise seated. Instruction:
your head off the table "Stick your chest out
and bring your chin and lean your head
toward your chest." back."

Evaluati�n and Treatm�nt of Costovertebral Testing for Anterior or Posterior

Subluxatwns- Dtslocattons /Range: ribs i -xi Costovertebral Subluxations
As it was tor the first rib, the designation "anterior" or The Procedure Protocol {Range: ribs i x.j -

"posterior" refers to the direction of displacement of the
head of the rib on the vertebral body at the costovertebral
joint. Any of the upper ten ribs may be subluxated anteri­
orly or posteriorly, but the ribs in the middle of the tho­
racic cage are especially vulnerable to this kind of trauma.
Most of the time patients can describe the trauma which
torced the rib out of place- reaching over a counter or the
back of a car seat and applying localized pressure to a rib
shaft, or a blow to the chest from in front or behind.
However, subluxations can also be tound in the absence of
a definite trauma history.
Ribs two through five may also become lodged superi­
orly on their transverse processes, similar to the first rib
superior subluxation. As we have already mentioned, these
extremely rare "superior" subluxations have been labeled
"bucket bail lesions" by Paul Kimberly.
The findings of anterior or posterior rib subluxation,
especially in the mid-thoracic ribs five to nine, may be
unstable in different patient positions. When the patient
lies down he or she may push the unstable rib in or out of
place, resulting in a discrepancy between seated and supine
examinations of the same pair of ribs. This being the case,
a more thorough examination would include supine,
prone, and seated patient positions.
1. Patient is supine or seated erect, slumped, or arched
into extension, as instructed in a previous procedure
(Chapter 7: Scanning tor the Key Rib and Supine A-P
Symmetry Tests).
2. You stand facing the patient, if you are tall; sit facing
the patient, if you are short. When the patient is supine,
lower your line of sight so that it is more tangent to the
chest. The object is to get your eyes positioned so that you
can visually assess the anterior-posterior positions of the rib
cartilages. This is most difficult if your eyes are at the same
level as the ribs you are observing.
3. Place your index finger pads on the anterior sudaces
of the costal cartilages on each side of the sternum.
4. With your finger pads tollow the anterior surtaces lat­
erally to points about tour inches from the midline. This
should put your fingers on the bony part of the rib, which
may be preferable to palpating the cartilage, especially if the
cartilage is deformed.
5. Ask the patient to flex the thoracic spine, «stump» and
then extend it: «Arch your back a�td stick your chest out and
head bacP. Notice if either of these positions causes one
rib or costal cartilage to become more anterior than the
other. When the patient is supine, ask the patient to raise
the head up off the table for flexion and back down tor
extension (Figure 8.8).
6. Move your finger pads to the next, or the "key," pair
of the bony parts of the ribs just lateral to the cartilages,
and repeat the previous step.
 CHAPTER 8--&- STRUCTURAL RIB LESIONS (RIBS II - X) 139

Figure 8.10 Rib position

evaluation for anterior or
posterior subluxation.
Anterior contacts,
patient flexed (slumped).
Anterior view.
Examiner's palms may be
flat for stereognosis, or
finger pads may be
placed on individual rib
pairs for comparison.
Finger pads are best
placed on the osseous
part of the ribs, rather
than the costal carti­
lages.

Figure 8.11 Rib position evaluation for anterior or posterior subluxation.

Posterior contacts, with the patient flexed (slumped). The patient's arm­
shoulder position- hands behind lumbars, elbows forward- uncovers
interscapular jrib angles for palpation.

Interpretation of Results
• If anteroposterior symmetry is maintained through­ Note: Costochondral hyperplasia or deformity, producing a prominent
out the flexed ("slumped") to extended ("arched") posi­ bump on the upper anterior chest, can be the long-term consequence of
tions, there is probably neither vertebral segmental dys­ chronic persistent costovertebral (anterior or posterior) subluxation. Its
function nor structural rib lesion. presence can predispose to recurrent subluxation after treatment.
Patient's treated for anterior or posterior subluxations under these cir­
• If the starting position shows A-P asymmetry, i.e.,
cumstances should be rechecked every 2-4 weeks to ensure that reduc­
one side more anterior than the other, then the vertebra of tion of the subluxation is stable. Remodeling of the deformed cartilage
that rib is probably rotated toward the posterior rib side. can take one to two years.
• If the asymmetry persists, or develops, with flexion
("slump"), but disappears with extension, the vertebra prob­
ably has ERS dysfunction and is rotated toward the poste­
rior rib side.

• If the asymmetry persists, or develops, with exten­

sion ("arch"), but disappears with flexion, the vertebra prob­
ably has FRS dysfunction and is rotated toward the poste­
rior rib side.

• If the A-P asymmetry remains unchanged, there is a

structural rib lesion on the side with breathing restriction.
If the degree of asymmetry varies, but no position can be
found which produces perfect symmetry, there is probably
a combination of a structural rib lesion with vertebral seg­
mental dysfunction.
140 THE MUSCLE ENERGY MANUAL

Palpating Rib Angles for Position and

Breathirig Motion [Range: ribs iii-x, T3- Twl
The Procedure Protocol
l. The patient is seated or prone. It is more thorough
to examine the patient in both positions since, in some
instances, lying prone can push an unstable rib into or out
of place. This may result in discrepancy between seated
and prone examinations of the same pair of ribs.
2. You stand or sit, depending on the patient's position.
You should be facing the patient's back with your line of
sight as near tangent to the curve of the back as practical.
3. Instruct the patient to place his/her hands in the small
of the back to horizontally flex the scapulae and expose the
Figure 8.12a Looking for A-P asymmetry of the 10th rib angles. Posterior
rib angles (Figure 8.12 ) . rib subluxation sometimes only appears in the prone postion.

Note: The rib angles are at the points of attachment of the iliocostales
muscles and are found 1-4 inches lateral to the spinous processes on Figure 8.12b Palpating
rib angles for position
ribs iii to x. The third rib is the highest rib to exhibit a palpable rib
and breathing motion.
angle. The second rib angles are fairly smooth and difficult to palpate.
Palms may be kept flat
The first ribs have thickened prominences, called the articular tuber­
for stereognostic
cles, where they articulate with the transverse processes of the first
detection of rib angle
thoracic vertebra. but the shafts of the ribs curve immediately forward irregularities, or finger
from the tubercles. making the tubercles elusive to stereognostic pal­ pads may be placed on
pation. individual rib pairs for
bilateral comparison.
4. Use the palms of your hands and/or the pads of index Patient slumped (flexed).
fingers to note any A-P asymmetries by making bilateral Step-breathing instruc­
tions: "Let your breath all
comparisons of the posterior surfaces of the rib angles.
out. Take a short breath
This is a combination of stereognostic palpation and visual
in and out." or "Take a
observation. deep breath. Let a little
5. Have the patient slump and arch (flex and extend the breath out and take it

spine) to see if rib angle symmetries, or respiratory move­ back in."

ment patterns, change. When the patient is prone, exten­

sion is accomplished by propping the shoulders up on the
elbows; flexion is simply lying flat.
6. To evaluate the breathing motions of a pair of rib
Figure 8.12c Palpating
angles, put your finger pads on the superior margins of the
A-P symmetry of rib
pair of rib shafts at the angles, and have the patient step angles. Patient arching.
breathe, as described in the previous chapter. The breath­ Instruction: "Put the
ing motions observed from this perspective are composites backs of your hands
against your lower back
of spinal breathing motion and rib breathing motion in
and move your elbows
which the iliocostales muscles participate. Apparent dis­
forward. Stick your
crepancy between breathing motions seen anteriorly and chest out and put your
posteriorly occasionally occurs because of this complexity. head back."
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II- X) 141

Interpretation of Results
• If the structure and breathing motion pattern are
·

symmetrical bilaterally in all positions of flexion and

extension, there is no lesion.
• If asymmetry is seen in all positions of flexion and
extension, there is a structural rib lesion - anterior or pos­
terior subluxation, single rib torsion, or lateral or A-P com­
pression of a rib.

a) If a rib angle is prominent, it indicates a posterior

subluxation provided there is anterior depression of the
same rib, and the rib demonstrates impaired breathing
motion on that side.
b) If a rib angle is depressed (retracted), it indicates
an anterior subluxation provided there is anterior promi­
nence of that rib, and the rib demonstrates impaired
breathing motion on that side.
c) If a rib is depressed (indented might be a better
word) both anteriorly and posteriorly, that rib has A-P
compression, an intraosseous deformity which may or may
not dem�:mstrate greenstick fracture lines on X-ray. This
lesion is fairly rare, and usually has a history of sustained
compressive force on the chest.
d) If a rib is prominent both anteriorly and poste­
riorly (as well as laterally), there is a single rib torsion
lesion. The lateral prominence of a single rib torsion can
be palpated stereognostically with the palms in the mid­
axillary lines, sliding the skin up and down over the ribs.
This finding is often the most obvious indicator of non­
neutral segmental dysfunction of the vertebra above the
rib. See the discussion which follows.
e) If a rib has both anterior and posterior promi­
nence but no lateral prominence, it is most likely that the
rib on the opposite side has A-P compression, even if res­
piratory motion is impaired on the same side. An extreme­
ly rare possibility is that the rib has lateral compression
from a traumatic sustained lateral compressive force on the
chest.
• If flexion and extension (slump and arch) make the
breathing and position asymmetry come and go, there is
non-neutral segmental vertebral dysfunction.

a) If the breathing and position asymmetry disappears

with flexion, there is FRS vertebral segmental dysfunction
with the vertebra rotating toward the rib which becomes
more posterior with extension.
b) If the breathing and position asymmetry disappears
with extension, there is ERS vertebral segmental dysfunc­
tion with the vertebra rotating toward the rib which
becomes more posterior with flexion.
• Anterior palpatory examination may reveal a costo­
chondral separation. A simple separation is not manipulated,
but should be stabilized with an elastic rib belt. If the sep­
aration coexists with a subluxation, the subluxation should
be treated before the belt is applied.
142 THE MUSCLE ENERGY MANUAL

Figure 8.13 Reducing Figure 8.14 "Harakiri"

anterior subluxation of Technique, Step 2.
the right fourth rib. Patient covers the left
"Hara-kiri" Technique. fist with the right hand.
The patient contacts the
anterior extremity of
right rib iv with the
hypothenar edge of the
left fist. Operator pal­
pates the angle of right
rib iv while bending the
trunk with the shoulders
toward the rib to find
the loosest-packed
costovertebral trunk
position for that rib.

Figure 8.15. "Harakiri"

Treatment of Anterior Subluxation of Ribs
Technique, Step 3.
{Range: Ribs ii x]
While the patient uses
·

Treatment of anterior subluxation of any rib requires that the right hand to press
the posterior part of the rib be drawn laterally, as well as the left fist back against
rib iv (bone, not
posteriorly, in the arc which passes through the costoverte·
cartilage), the operator
bra! and the costotransverse joints of the subluxated rib.
presses against the
Treatment of posterior subluxation requires movement in medial aspect of the rib
this same arc, but in the contrary direction: anterior and angle to push the
posterior extremity of
medial.
the rib laterad, keeping
Balance and relaxation are as important in reducing rib
the trunk in the loose­
subluxation as they are in treating motion restriction of packed position.
joints. Balance is considered in the positioning of patient
and operator and makes relaxation possible. Thrust tech·
niques should not be used to reduce rib subluxations.
Subluxated joints are hypermobile joints, and they should
be protected from torces capable of making them even
more unstable.

Reducing Anterior Rib Subluxation

-"Harakiri" Technique [Range: ribs ii · x}
l. The patient is seated on the treatment table with his
or her back to you.
2. You identifY an anterior point on the anterior sublux­
ated rib just lateral to the costochondral junction. The
patient is instructed to make a fist with the contralateral
hand and supinate the torearm, placing the ulnar (smaller)
side of the fist on the identified point (Figure 8.13).
3. The patient is then instructed to cover the fist with
some part of the ipsilateral upper limb (Figures 8.14 and
8.15). For the ribs vii through x the ipsilateral elbow can
be placed on the radial side of the fist. For ribs ii through
vi the ipsilateral hand can rest on the fist.
4. You palpate the posterior surtace of the anterior sub­
luxated rib at a point just medial to the rib angle.
5. While monitoring the rib with the palpating thumb,
you tip the shoulders to sidebend the trunk until the tissue
tension around the rib is minimal ("loose-pack" the rib).
Obviously, this requires bending the trunk toward the side
of the lesioned rib. Small amounts of flexion, extension,
and rotation are used to fine-tune the position of.maximal
ease (loosened tensions).
6. The patient is then instructed to press the ipsilateral
arm or hand back against the fist, driving the rib backward.
At the same time the you press laterally against the rib
angle.
Note: When this procedure is practiced on a normal subject. a small
amount of movement, normal joint play, of the rib can be felt with the
palpating thumb. When an actual subluxation is reduced the move­
ment is larger.
7. Retesting breathing motion of the rib is a good way
to assess the effects of treatment.
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II - X) 143

Figure 8.16 "Hara-kiri"

Technique. Reducing an
anterior subluxation of
the right ninth rib. The
patient's left fist is
covered by the right
elbow. More trunk
sidebending is required
to loose-pack the lower
rib.

Figure 8.17 "Hara-kiri" Technique. Patient drives the fist back against the
rib with the elbow.

Figure 8.18 "Hara-kiri" Technique. Operator translates the right ninth rib
laterad, while it is being pushed back by the patient's fist.
144 THE MUSCLE ENERGY MANUAL

Figure 8.19 Push Me

Treatment of Posterior Rib Subluxation
Pull You Procedure.
/Range: Ribs ii- xj Reducing posterior
subluxation of right rib
Reducing Posterior Rib Subluxation
iv. Posterior view.
- The "Push Me Pull You" Procedure
Operator's thumb is
I. You stand or sit behind the seated patient and reach placed lateral to the
under the axilla on the side opposite the subluxated rib. fourth rib angle in order
Ask the patient to hold your hand in front of him with the to push it anteromedial.

hand on the side of the lesion. Your thumb is on the rib

shaft, just lateral to the angle of the rib (Figure 8.19).
2. You lift up on the axilla and translate the shoulders
toward that side, until the tissues around the lesioned rib
feel as relaxed ("loose-packed") as possible, as determined
by the palpating thumb on the rib angle. The patient's
trunk position should be controlled to maximize relaxation
of the muscles around the affected rib. This will require
some sidebending and rotation while the thumb on the rib
monitors the etTect.
3. Offering unyielding resistance, say: "Push my hand
straight out forJl!ard." (Figure 8.20) Figure 8.20 Push Me
4. While the patient exerts the eftort, you push on the Pull You Procedure.
rib with your thumb to guide the rib anteriorly and medi­ Reducing posterior
subluxation of right rib
ally (Figure 8.21). If the rib angle, in addition to being
iv. Anterior view.
prominent to palpation, also appears to be slightly superi­
Operator's left arm is
or or inferior, the reduction will be accomplished more eas­ underneath the
ily if the thumb presses lightly down, or up, in putting the patient's left axilla.
rib back in place. Raising the left shoul­
der sidebends the trunk
5. Several trials may be necessary to reduce some sub­
to the right to loose­
luxations. While the patient is pushing, it sometimes helps
pack the fourth rib.
to slightly change the sidebend and rotation of the shoul­ Patient's right hand
ders, especially if the rib does not promptly slide back into holds the operator's left

place. hand.

6. If you are alert for it, sometimes you can tell when the
rib goes back in place; it may have to travel as much as a
quarter inch, which should be palpable. Nevertheless, it is
a good idea to reexamine the rib angles and costal cartilage
junctions for symmetry, after the treatment attempt.

Note: Ribs xi and xii do not have costotransverse joints, and seem to
Figure 8.21 Push Me
never subluxate. The author has had no experience treating subluxa­ Pull You Procedure.
tion of these ribs. Reducing posterior
subluxation of right rib
Review "Comments" for Treatment of Subluxations, and iv. Posterior view.
Patient pushes forward
rib i.
against the operator's
left hand. The forward
pressure is transferred
to the rib angle by the
operator, who actively
provides the medial
pressure.
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II- X) 145

Figure 8.22 Push Me Management of Recurrent Rib Subluxation

Pull You Procedure. Subluxation of a rib may cause the costovertebral and cos­
Reducing posterior
totransverse ligaments and capsules to stretch, paradoxical­
subluxation of right rib
ly making the joint hypermobile and at the same time
ix. Posterior view.
More right sidebending impairing its respiratory motility. Such joints may, there­
is required for loose­ fore, be unstable to some degree after the dislocation is
packing the lower rib. reduced. The relatively high frequency of recurrent rib dis­
locations suggests a degree of hypermobility resulting from
the original trauma which disturbed the rib's relationship
to its vertebra.
Rib subluxations should never be reduced with high
velocity thrust techniques, as was routine in the past.
Thrusting a rib back into place risks increasing the instabil­
ity of the joint.
A subluxated rib may repeatedly go into and out of
place, depending mainly on the recumbent pressures
applied to it. Breathing restriction is manifested only when
the rib is out of place. Once the subluxated rib is reduced
by manipulating it back into normal relationship with the
vertebrae, it usually stays in place, especially if its displace­
ment was relatively small, suggesting the absence of liga­
ment rupture. In order for damaged ligaments to heal, the
rib must stay in place during the healing time.
An elastic rib belt is often a useful adjunct to treatment
of ribs vi to x; it provides additional stability while the cos­
tovertebral and costotransverse ligaments heal, and reduces
the discomfort and sharp pains many patients experience
during the healing process.
The costovertebral ligaments need time (two to six
weeks) to heal and tighten. Torn ligaments are like broken
bones: in order to heal, the fragments must be relatively
immobilized in close proximity to each other during the
first stages of healing. Inflammation is a necessary part of
the first stage of healing. For this reason, corticosteroids
and nonsteroidal anti-int1ammatory drugs (NSAIDS)
should be avoided during the initial stage of healing.
Nutritional supplements and/or alternative remedies
(herbal or homeopathic) which support collagen metabo­
lism may be appropriate.
It may be difficult to maintain physiologic rib motion
during the healing time. A costovertebral joint which has
been dislocated (subluxated) is an unstable joint, vulnera­
ble to repeated dislocation from relatively minor move­
ments and forces. Lying recumbent can sometimes push
the rib out of place. Often the best one can do is to main­

Figure 8.23 Push Me Pull You Procedure. Reducing posterior subluxation
of right rib ix. Lateral view. Patient's right hand presses operator forward
against the ninth rib angle.
tain the balance of the muscles involved by counseling the
patient to avoid a "chin forward" posture, and encourage a
"chin tucked" position. As an alternative, it may be neces­
sary to put the muscles to rest by using various immobi­
lization devices, e.g., collars, slings, rib belts, figure eight
clavicle stabilization, and/or short courses ( 10-14 days) of
muscle relaxants, or an anxiolytic drug, to permit healing.
146 THE MUSCLE ENERGY MANUAL

Figure 8.24 Palpating

ribs iii for bucket bail
lesion.

Figure 8.25 Palpating ribs ii for bucket bail lesion. Bucket handle respi­
ratory movement may also be evaluated with this contact. The bucket bail
shows greater and persistent positional asymmetry.

Diagnosis and Treatment of

Bucket Bail Lesions Interpretation of Results
Ribs ii through v may subluxate in a manner similar to the • lf breathing motion is symmetrical, there is no sublux­
superior subluxation of the first rib - however, this is an ation (bucket bail lesion, or otherwise).
extremely rare occurrence. When it occurs, the neck of the • If the margin of one rib feels much more prominent
rib becomes lodged superiorly and slightly posteriorly on than its mate on the other side, check to see which of the
the transverse process behind it, just as occurs with superi­ two ribs is more superior, and how much asymmetry is seen.
or subluxation of the first rib. Bucket bail lesions are not
• If the positional asymmetry of the lateral shafts of the
bucket handle lesions. Bucket handle lesions are costover­
ribs is more than a quarter inch (6+ millimeters), the supe­
tebral somatic dysfunctions. Bucket bail lesions are rib
rior rib has a bucket bail lesion, provided the rib angle of the
subluxations.
superior rib is visibly superior also.

Protocol for Diagnosing "Bucket Bail" Lesions • If the lateral shati: of one rib is visibly superior, but the

[Range: ribs ii v]-

rib angles are symmetrical, there is probably exhalation
restriction of the superior rib. Have the patient inhale as
l. The patient may be sitting, facing you, or lying supine.
deeply as possible to see if the pair of ribs becomes sym­
2. Place the palms of your hands on the sides of the chest
metrical. The bucket bail lesion does not become symmet­
with the fingers pointing posterior and slightly superior.
rical; a bucket handle lesion will.
Your index fingers should be high in the axilla behind the
• To differentiate bucket bail rib lesions from bucket han-
pectorales major muscle tendons (Figure 8.24).
dle respiratory lesions, remember that:
3. Stereognostically assess the shape symmetry of the lat­
eral shati:s of ribs ii through v, by sliding the skin up and •
The respiratory bucket handle lesion will come and go
down over the ribs. with flexion or extension; the bucket bail lesion persists
4. Test the breathing motions of these ribs with your in all degrees of flexion and extension.
hands in the same place, in order to locate the key rib. •
Because of its similarity to superior first rib subluxa­
5. Place your index fingers gently in the intercostal tion, tl1e bucket bail lesion will have a slight posterior dis­
spaces above the key rib, and visually assess their superior­ placement of the entire rib, but sometimes not enough
interior positional symmetry (Figure 8.25 ). to notice.
6. Look at the patient's thorax from behind while pal­
pating the superior margins at the rib angles of the sus­
pected ribs.
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II- X) 147

Reducing a Bucket Bail Rib Subluxation

[Rarw: ribs ii vJ
-

The treatment procedure originally used was very similar

to the Muscle Energy treatment for bucket handle exhala­
tion restriction of a rib in this region and was taught to the
author by P aul Kimberly. The author has had relatively few
occasions to use it in his entire professional career. In ret­
rospect, it is possible that the evidence of bucket bail lesion
has been occasionally ignored, thus avoiding the utilization
of a rather painful treatment technique. Fortunately, a
more humane method of reducing bucket bail subluxation
has been developed by P. Kai Mitchell. Since its develop­
ment the incidence of bucket bail subluxation has miracu­
lously increased.
The lateral positional asymmetry of the bucket handle
respiratory restriction is rarely as great as that of a bucket
bail lesion, and the bucket bail lesion demonstrates
impaired inhalation and exhalation not restored by flexing
or extending.

Bucket Bail 'Ireatment Protocol

l. You stand or sit behind the seated patient and reach
under the axilla on the side opposite the subluxated rib.
Ask the patient to hold your hand in front of the chest
using the hand on the side of the lesion. The thumb of
your other hand is on the angle of he subluxated rib. So
far this is similar to the "push me pull you" procedure,
except that the thumb is on the posterior surface of the rib
angle, not on the rib shaft lateral to the angle. This thumb
placement is similar to the method for reducing a first rib
superior subluxation.
2. Loose-packing the subluxated rib is accomplished, in
a manner similar to the "push me pull you" procedure, by
translating that part of the chest laterally away from the
lesioned rib while supporting the opposite shoulder on
your forward arm. This sidebends the thoracic spine
Figure 8.26 Seated treatment for right rib iii bucket bail lesion is similar to
treating a posterior subluxation. It helps to have the patient turn the head
slightly to the right to loose-pack the costovertebral joint.
Note: Not only was the older procedure quite painful, it was
absolutely contraindicated in osteoporosis, multiple myeloma,
and metastatic bone disease. These are the same contraindica­
tions which led to the development of gentler methods of treating
respiratory restriction of the ribs (Chapter 5). The fingers should
never be used to resist rib motion.
Comment: It was suggested by my son and co-author, P. Kai Mitchell

toward the rib. that, in light of the lesion's similarity to superior subluxation of the first

3. Ask the patient to turn the head and look over the rib, it might be treated in a similar fashion; putting more emphasis on

shoulder on the lesion side(Figure 8.26). This action pushing the rib forward while rotating the spine to keep the transverse

rotates the vertebra upon which the rib is subluxated and process back. When the rib is pushed forward off the transverse process.

holds its transverse process posterior while the rib is being it should drop down in line with the transverse process, just like the first

pushed forward. rib does in the treatment of superior subluxation.

4. Offer unyielding resistance, and say to the patient: The author has had opportunity to test this hypothesis and, indeed, it

"Push my hand straight out forward." appears to be less painful for the patient. It is also a more effective way

5. While the patient exerts the effort, you push anterior­ to reduce the bucket bail lesion. It has become my preferred method of

ly and slightly laterally on the rib angle, adjusting the angle treatment for bucket bail rib lesions. Basically, I treated the bucket-bail

of the push to follow the path of least resistance guiding subluxation as if it were a posterior costovertebral subluxation, but with

the rib anterior on the transverse process until it drops a slight modification - the patient's upper spine was slightly torqued

down in front of the costotransverse articulation. toward the side of the lesion, bringing the involved transverse process

6. Repeat the procedure if no rib movement has been posteriorly while I pushed the rib angle forward and lateral. The reduc­

felt. tion occured when the patient pushed my free hand forward. (FLM)

7. Re-examine the anterior chest wall for bucket bail

lesion, looking for rib shaft positional asymmetry and res­
piratory motion impairment to be sure the subluxation was
reduced.
148 THE MUSCLE ENERGY MANUAL
Evaluatfo.n and Treatment of Intraosseous
Deformtttes {Range: ribs iv through ix}
Single Rib Torsion
Of the intraosseous deformities, the most common are the
single rib torsions. Theoretically the second, third, and
fourth ribs could be torsioned because they have demitac­
et articulations with two vertebral bodies. But, as a rule,
their bodies are too short, thick, and rigid to allow enough
deformity to be palpable. Nevertheless, rotation of the
first, second, or third thoracic vertebra does introduce a
torsional strain on the elasticity of ribs ii, iii, or iv.
The small elastic deformation may interfere with the
breathing motion of the rib, occasionally enough to be
detected by physical examination. (See Figure 8.1, which
shows the mechanism of single rib torsion.) Most of the
time the breathing restriction is seen at the key ribs - the
ribs attached to the superior vertebra of the lesioned seg­
ment - and is usually unilaterally restricted exhalation.
This means that any secondary respiratory restrictions will
be observed above the key rib, not below it. Occasionally
the key rib has restricted inhalation, instead of exhalation.
In this case the torsioned rib may show secondary inhala­
tion restriction.
There is rarely a need tor manipulative intervention to
restore the shape of torsioned ribs. Most of the time the
ribs spring back into their original shape elastically as soon
as the vertebra is derotated. However, if the torsioning
mechanism persists for months or years, the trabecular
architecture of the rib may become remodeled through the
mechanism of Wolff's Law, and the torsion deformity may
be retained after the vertebral dysfunction is resolved. The
persistent rib deformity can be a predisposing factor in
recurrent segmental dysfunction of the spine. Protracted
treatment of this vicious cycle of segmental dysfunction
and rib torsion can usually be avoided by remolding the
ribs using Muscle Energy Technique.
Differentiating Rib Torsion and Compression
Traumatic deformations of the shafts of the ribs may occa­
sionally interfere with their breathing motion, but this
etrect is relatively rare and inconsistent. Evaluation of
breathing motion is an unreliable way to screen tor
intraosseous lesions of the ribs. Stereognosis is a more reli­
able way to diagnose rib deformity. Palmar stereognostic
palpation of the shafts of the ribs in the mid-axillary line
will usually detect the shape asymmetry characteristic of
single rib torsion, even in the absence of respiratory restric­
tion.
AssessingA-P rib position at the rib angles and at the
costochondral junctions, as already described, can lead to
the diagnosis ofA-P compression or lateral compression of
a rib. InA-P compression both the anterior and posterior
extremities of the rib are receded. The combination of cos­
tochondral and rib angle prominence of the same rib can be
seen in single rib torsion as well as in lateral compression.
What distinguishes these two conditions is the shape
asymmetry palpated in the mid-axillary line- present in
single rib torsion but absent in lateral rib compression.
Anterior or posterior costovertebral subluxation will
usually have a restricting etlect on breathing motions,
except in long-standing (chronic) subluxations, which may
form a pseudo-arthrosis, permitting breathing movement
of the rib to occur.
Single rib torsion is a very common condition, but per­
sistent rib torsion is as rare asA-P and lateral rib compres­
sions. Nearly all of these intraosseous rib deformities- sin­
gle rib torsion,A-P compression, and lateral compression­
are to be found in ribs v through ix. They are frequently
associated with recurrent or persistent chest wall pain.
 CHAPTER 8 �STRUCTURAL RIB LESIONS (RIBS II - X) 149

Testing for Torsions and Curvature

Deformities (Compressions)
Rib Torsion Evaluation Procedures
The diagnosis of single rib torsion relies heavily on palmar
stereognostic palpation to compare the shapes of a pair of
ribs. The everted rib has a prominent superior border, in
contrast to the inverted rib on the other side, whose supe­
rior border is rolled in. The stereognostic finding is
enhanced by the rotated position of the pair of ribs above
the torsioned ribs. The rib above the everted rib is dis­
placed posteriorly, bringing the anterior prominence of the
everted rib into starker relief, stereognostically.

Diagnosing Single Rib Torsion by

Stereognostic Palpation
Figure 8.27 Evaluation for single rib torsion or bucket handle lesions of
l. The preferred position for the patient is lying supine. ribs iv- x. Patient supine.
However, the patient may be seated on the examining table
while you are seated on a low stool in front of the patient.
2. Your palms are placed flat against the sides of the rib
cage with the fingers parallel with the rib shafts, i.e., angled
superiorly and posteriorly.
3. With your palms move the patient's skin, sliding it
inferiorly and superiorly across the rib shafts. This action
enhances your stereognostic palpatory sense of the shapes
of the rib shafts.
4. Anterior and posterior rib prominence has already
been addressed. This information is considered in con­
junction with the lateral rib shaft prominence.

Interpretation of Results
Single rib torsion feels like the rib on one side of the chest
is bowed outward, bulging into the palm of your hand.
This effect is in contrast to the other rib of the pair which
is flattened and slightly receded. Your attention will be
more drawn to the bulging rib, but both ribs are probably
torqued, one everted and one inverted. The rib with the
greater torque will naturally be on the side of freer inter­
vertebral motion. Thus, FRS dysfunction torques the
everted rib more, whereas ERS dysfunction torques the
inverted rib more.
The everted rib is less likely to be missed, compared to
the inverted rib, which has simply become flatter to palpa­
tion.
Since the vertebra above is rotated toward the side of
the bulging rib, the rib of the vertebra above will be drawn
back on the same side as the bulging rib, emphasizing the
anterior prominence of the bulging rib.
150 THE MUSCLE ENERGY MANUAL

Figure 8.28 Rib floating technique. Treating persistent intraosseous rib Figure 8.29 Rib floating technique. T he patient firmly leans against the
lesions, rib floating method. operator's thumbs until the rib feels free to float in any direction. Once
this floating condition is obtained, molding forces can be applied to alter
the rib's shape.

Diagnosing Anteroposterior and Lateral Compression Treatment of Persistent Intraosseous

As already presented, A-P compression is diagnosed by Structural Rib Lesions
finding both anterior and posterior extremities of the ribs
Treatment Procedure Protocol
(costochondral and rib angle) receded; lateral compression
I. The patient is seated at the end of the treatment table
is diagnosed by the opposite finding - prominence of both
so that you can sit near the side of the intraosseous rib
anterior and posterior extremities of the ribs. In both
lesion.
lesions the front-to-back dimension of the rib is altered:
2. You sit facing the patient's side. The patient puts the
decreased in A-P compression, and increased in lateral
straightened arm on the more posterior of your shoulders.
compression. The deformity of the rib is often not mani­
3. "Surround" the rib to be treated with your two hands,
fested both front and back. What matters is the sagittal
placing your thumbs near the mid-axillary line and your
dimension of the rib.
index and middle fingers near the anterior and posterior
Since these findings are based on comparing the two
extremities of the rib. The precise location of yot;r thumbs
paired ribs, the question naturally arises, "Which is the
and fingers depends on the nature of the intraosseous
abnormal rib?" The abnormal rib is the one with respi­
deformity to be treated.
ratory motion impairment. If no respiratory motion
a. To treat an everted rib torsion contact the superi­
restriction is apparent, deciding which side to treat must be
or border of the rib with your thumbs and fingers.
based on the trauma history, or the side of chest wall pain.
b. To treat an inverted rib torsion contact the interi­
Both lateral compression and single rib torsion with ever­
or border of the rib with your thumbs and fingers.
sion produce anterior and posterior prominence of the rib
c. To treat A-P compression contact the lateral sur­
extremities. What distinguishes the two is the contour of
face of the rib shaft firmly with your thumbs and light­
the lateral rib shaft. With the everted torsion the lateral
ly at the anterior and posterior extremities with your fin­
shaft bulges out. With lateral compression the lateral shaft
gers.
of the prominent rib is flat, or even receded.
d. To treat lateral compression contact the lateral sur­
face of the rib shaft lightly with your thumbs and firm­
'J.reatment Procedures for lntraosseous Deformities of
ly at the anterior and posterior extremities with your fin­
the Ribs
gers.
There are three possible intraosseous lesions of ribs:
anteroposterior compression, lateral compression, and 4. Ask the patient to press the rib against your thumbs by
torsion. The trophic remodeling of the ribs due to scolio­ leaning toward you. In a, b, and c above, the pressure is
sis is developmental rather than traumatic. The etiology of resisted by your thumbs. In d, the pressure is resisted by
the torsion has been explained. The finding of a rib torsion the index and middle finger pads. Adjust your resisting
can be the most obvious feature of a non-neutral vertebral pressure until the rib teels "loose-packed," i.e., free to float
dysfunction. in any direction. Try to keep the rib "loose-packed"
throughout the procedure.
 CHAPTER 8 -tJ. STRUCTURAL RIB LESIONS (RIBS II - X) 151

5. Directions for Muscle Energy patient cooperation vary,

depending on the nature of the structural rib lesion. The
force ( 5 to 7 Kilograms) and duration ( 3 to 5 seconds) of
the contraction is the same. During the muscle contraction
the thumbs and fingers are used to assist the muscles in
remolding the rib.

• To treat a rib torsion or lateral compression ask the

patient to pull the arm straight down against your resisting
shoulder with 5 to 7 Kg. of force, for 3 to 5 seconds. The
intercostal muscles exert a remodeling effect on the loose­
packed rib.

• To treat an anteroposterior compression ask the

patient to pull the arm forward (with resistance for the arm
provided by your neck) with 5 to 7 Kg. of force, tor 3 to 5
seconds. The action of the serratus anterior and pectoralis
major is to pull laterally on the anterior extremities of the
ribs, increasing rib A-P diameter.

6. Repeat Steps 4 and 5 three times, making sure to keep

the rib "loose-packed."
7. Reevaluate the rib.

Comments
Although the Muscle Energy procedure described above
usually does not remodel the rib perfectly in one treatment,
the results are often astonishingly close to perfect. Several
treatments spaced at two- to four-week intervals may be
necessary to achieve the desired goal. There is no point in
remodeling the ribs of a scoliotic patient, unless the scolio­
sis is straightened first. Until the persistently torsioned rib
is remodeled, the vertebral segmental dysfunction above it
may tend to recur.
The above procedure can be adapted to treat a recum­
bent patient, but the "loose-packing" is not as easy to
arrange. Pushing the rib slightly into the rib cage reduces
the tension in the capsular and costotransverse ligaments,
and allows the tensions in myofascial tissues to be balanced
and equalized. Under these conditions, forces acting on
the rib itself can more easily affect its structure. Readers
with experience in indirect cranial or myofascial techniques
will have little difficulty with the "loose-packing" concept
or method. Beginning students will need to practice focus­
ing their attention. Like other Muscle Energy techniques,
this procedure is quite forgiving; often imprecise applica­
tions by beginners will yield good results.
Although the previously described "Hari kiri" and
"Push me pull you" techniques are more appropriate for
beginners, the seated "rib floating" procedure can also be
modified to treat anterior or posterior subluxation of a rib.
With the fingers guiding the rib from its "loose-packed"
position toward the reduction position, appropriate muscle
forces can be applied to assist the rib movement. The
basics of this technique are believed to have originated with
A.T. Still, whose students referred to it as the "universal rib
technique." With the addition of Muscle Energy patient
cooperation, it is even more "universal."
Torsions of the rib shafts, secondary to Type II dys­
functions of the associated vertebral joint, usually sponta­
neously untwist themselves after the spinal lesion is cor­
rected. When they do not, application of this procedure,
with the thumbs and fingers on the prominent edge of the
rib, may assist remolding of the rib. Usually only the evert­
ed rib needs treatment, because it is the more deformed of
the pair. Occasionally the inverted rib has the more pro­
found architectural deformity. In very chronic cases such
remolding may require repeated treatments over a period
of several weeks to months.
182 T H E MUSCLE ENERGY MANUAL
 THE MUSCLE ENERGY MANUAL 153

CHAPTER 9

Evaluation and Treatment of the

Lower Thoracic and
Lumbar Spine

T
he lower thorax and lumbar spine are combined in this
chapter because many of the diagnostic and treatment
procedures for segmental dysfunction are identical for
segments T7 through L5. As with the upper and middle thoraci­
cs, diagnosis of vertebral segmental dysfunction in the lower tho­
racics is facilitated by the presence of the ribs - using "key rib"
position and respiratory asymmetry as outlined in Chapter 7.
The gross neuroanatomy of these regions, and its relevance to
problem-based clinical approaches to back pain, is another reason
for combining the lower thoracic region and lumbar spine.
Because the peripheral nerves descend great distances from where
they arise in the spinal cord, symptoms experienced in the lumbar
region often are generated by adaptive malfunction in the lower
thoracic region. Nerves arising trom the lumbar portion of the
spinal cord may descend as far as the feet. In contrast to the
descending influence of the nervous system, postural mechanics In this chapter:
reverses the direction of influence. Segmental dysfunction in the • Diagnostic landmarks
lumbar region may be the reason for adaptive stress and malfunc­
• Relevant screening examinations
tion in the lower thoracic spine or, even more frequently, in the
Walking screen
cervical spine.
Postural evaluation
Iliac Crest Heights Test
Symptom and Sign Indicators of Lower Thoracic and
-standing and seated
Lumbar Segmental Dysfunction
Spinal rotation tests
Symptoms in the lower back, pelvis, hips and trochanters, and
Seated trunk sidebending tests
abdomen should make detailed manual examination of the lower
Rib Screen for lower thoracic spine
thoracic and lumbar spine mandatory. Some symptoms which
• Scanning examinations
would indicate the possibility of lower thoracic segmental dys­
Diagnostic criteria for segmental
function include: sacrolumbalgia, meralgia paresthetica, and
dysfunction
lower abdominal and groin pain. Segmental dysfunction or adap­
Detailed evaluation procedures
tive stress in the lumbar spine can generate symptoms such as sci­
• Treatment of non-neutral (Type II)
atica, coccydynia, or inguinal pain. Loss of normal lumbar lor­
dysfunctions
dosis is associated with a three-fold higher incidence of pelvic
Treatment of ERS segmental
organ prolapse and incontinence. These effects do not constitute
dysfunction
a complete or exclusive list. Often relieftrom symptoms is imme­
Treatment of FRS segmental
diate following appropriate manipulative treatment of lower tho­
dysfunction
racic and/or lumbar dysfunctions - essentially ruling out more
• Diagnosis and treatment of neutral
serious pathology.
(Type I ) dysfunctions
154 THE MUSCLE ENERGY MANUAL

Table 9.A.

The Rule of Threes in Reverse

If you are on the ...the tip of its spinous process can
transverse process of: be found at the level of:

Levels of Ts Tg
Inferior
Tips of Tg
Spinous 3/4 between T10 and T 11
Processes
T11 (Ribs xi) 1/2 between T11 and T1
(S.P.) 2
T12 (Ribs xii) 1/4 between T12 and l1
All Lumbars L1-5 Superior corner of correspond­
ing spinous processes

Because of variation in the angulation of the floating ribs, it is

best to find the T 11 or T12 spinous processes by counting
down or up from a known spinous process.

Figure 9.1 Finger pad contacts for bucket handle (B) and caliper action (C) rib respiratory evaluation (left side of drawing) and Rule of Threes in Reverse
(right side). These contact points are the same for the ribs on the right as for the left, and are monitored simultaneously for a given rib pair.

Applied Anatomy and Physiology ofT7- Ls

Lower Thoracic and Lumbar Diagnostic Landmarks
For the purposes of discussing diagnostic landmarks, the
lower thoracic vertebrae will be divided into two groups:
I) T7_10 - which possess ribs that have anterior attach­
ments; 2) T11_12 - which possess ribs without anterior
attachments.
Thoracic vertebrae 7 through 10 have two sets of
palpable posterior landmarks for the evaluation of seg­
mental rotation: transverse processes of the vertebrae
and their corresponding rib angles. These landmarks are
used to compare the bilateral A-P symmetry of the verte­
brae. The side of the more posterior transverse process des­
ignates the direction of rotation; e.g., posterior on the left
means the vertebra is rotated lefi:. The transverse process­
es ofT7 throughT1 0 are found in the fascial groove sepa­
rating the iliocostales trom the longissimus muscles, just as in
the upper 6 thoracic vertebrae.
The rib angles are the most posterior aspects of the
ribs, and are especially prominent on ribs iii through x.
Their prominence is augmented by tuberosities where the
iliocostales muscles attach. Getting from the rib angles to
the corresponding transverse processes is simply a matter of
following the rib shaft medially and anteriorly until your
thumbs bump into the transverse processes whose symme­
try is to be evaluated.
The widths of the transverse processes from T6
through T10 remain almost constant (Figure 9 .l ). They
are slightly narrower than those of the first thoracic, which
has the widest transverse processes of the thoracic verte­
brae, spanning approximately four inches (9 em.).
The transverse processes of T11 and T 12 are very
small, diminishing their utility as rotation landmarks.
However, as the vertebrae rotate, the eleventh and twelfth
pairs of ribs dutifully follow their respective vertebrae as if
they were transverse processes. This vertebra-rib combina­
tion essentially creates a longer-than-normal transverse
process that can be used for evaluation. When T12 has
Type II segmental dysfunction, it is not unusual to see one
twelfth rib shaft I or 2 centimeters more posterior than its
mate when palpated and observed at the tips of the ribs.
This is because the tips are a great distance from the y-axis
of vertebral rotation, which may shift to a facet joint in
order to permit more rotation. Bear in mind that there is
considerable individual variation in the angulation of the
twelfth ribs; some twelfth ribs are almost horizontal.
Compared to their thoracic counterpart, the lumbar
transverse processes are wide, and lie in the transverse
planes which pass through the superior corners of the spin­
ous processes. Imaginary lines connecting the tips of the
transverse processes on each side form a truncated rhom­
boid figure with the side corners at L3, the widest trans­
verse processes, three to tour inches to each side (Figure
9.3). The transverse processes of the lumbars are found
most easily by following the deep fascia that separates the
quadratus lumborum from the iliocostalis portion of the
erector spinae. (Figure 9.2)
 CHAPTER 9 �EVALUATION & T x . OF THE LOWER THORACIC AND LUMBAR SPINE 155

the shaft of the eleventh rib. Because of the proximity of

the tapered cartilaginous end of rib xii to the shaft of rib xi,
careful palpation is required to avoid mistaking the shaft of
rib xi as the continuation of rib xii. The eleventh rib usu­
ally curves around the trunk as far as the mid-axillary line.
The twelfth rib is shorter, usually by two or three inches
(50 to 75 millimeters).

L1

Figure. 9.2 Cross-sections of lumbar deep fascia. The deep fascia sepa­
rating the iliocostalis portion of the erector spinae muscles from the L2
quadratus lumborum is a direct palpatory path to the tips of the lumbar
transverse processes.

L3
The Rule of Threes in Reverse
Diagnos>ic procedures for segmental dysfunction frequent­
ly involve palpating transverse processes or rib angles.
Treatment procedures, however, are usually monitored by L4
palpating the spinous process of the lesioned vertebra and
the spinous process of the subjacent vertebra. Getting
from the transverse to the spinous process is a matter of
reversing the Rule of Threes (Figure 1.7). L5

The Rule ofThrees allows us to find transverse process­

es by counting spinous processes. However, if we are pal­
pating known transverse processes and wish to find the cor­
responding spinous process for treatment purposes, the
Rule of Threes in Reverse applies. For example, the spin­
ous process ofT7 is one full vertebral unit below the plane
of its transverse process. (Figure 9 .l andTable 9.A)
Using the Rule of Threes in Reverse may seem like an
unnecessary mental gymnastic. But it is an alternative to
counting a long string of spinous processes. The more
spinous processes to be counted, the greater the opportu­
nity for error.

Costovertebral Relationships
An important anatomic detail pertaining to the use of ribs
to evaluateT7 through T 12 is that there is variation in the Right Cornu
way the ribs articulate with these segments. Ribs vii, viii,
and ix articulate on the demifacets ofT6 throughT9; ribs x,
xi, and xii articulate on the unifacets ofT 10, T II> and T 12
respectively. It is important to remember that because of
the unifacet articulation, ribs x, xi, and xii are not subject to
rib torsion, a diagnostic clue to ERS and FRS dysfunction
Figure 9.3 Landmarks for lumbar and lumbosacral evaluation. The five
found in the middle thoracics. lumbars are flexing on each other and on the sacrum. The sacrum is nutat­
Rib x is the lowest rib with a costotransverse articula­ ed posteriorly. All of the inferior articular processes have slid cranially on
tion; ribs xi and xii are floating ribs and do not attach ante­ the subjacent vertebrae. The transverse processes of L1 - L5 are framed
with a dotted outline, a truncated rhomboid shape. The tips of the trans­
riorly to the costal cartilage. Instead, their free anterior
verse processes are in the horizontal planes (linesl resting on the superior
ends terminate in abdominal muscle. There is usually a
corners of the spinous processes, and can be accessed by following the
small piece of tapered or pointed cartilage on the end of the deep fascia between quadratus lumborum and iliocostalis muscles. The
twelfth rib which, occasionally, is positioned very close to Inferior Lateral Angles (I LAs I of the sacrum are highlighted in grey.
156 THE MUSCLE ENERGY MANUAL
Although the transverse processes on the eleventh and
twelti:h thoracic vertebrae are very small, when one of these
peculiar vertebrae is abnormally rotated due to non-neutral
dysfimction, its ribs turn with it, and one of its ribs will
almost aln,ays ha11e respiratory restriction. Since rotated
position of these vertebrae is frequently a part of normal
rotoscoliotic adaptation, either due to persistent asymme­
tries of the lumbar spine, pelvis, or lower limbs, or to mid­
thoracic dystimctions, the specific segmental breathing tests
of rib motion can help determine the presence or absence
of nonadaptive, non-neutral dysfunction of thoracic seg­
ments 11 or 12.
The mechanism of respiratory impairment of ribs xi
and xii secondary to segmental dysfunction of their respec­
tive vertebrae is probably related to myofascial tensions.
Because treatment and correction of a thoracic segmental
dysfunction nearly always restores normal respiratory
movement to the ribs, without specifically treating the res­
piratory restriction, it is reasonable to assume there is a
causal relationship.
Normal Segmental Motion for· the Lower Thoracic
and Lumbar Spine
The intersegmental motion characteristics of flexion, exten­
sion, and sidebending do not change much from T3_4 to
T11_12. Unlike vertebral segments C2 through T2 where
sidebending and rotation are coupled ipsilaterally (Figure
2.8), the coupling of sidebending and rotation for T3
throughT12 is variable and dependent on a variety of fac­
tors. Normal sidebending in neutral causes a small con­
tralateral rotation of segments up to and including the apex
of the sidebend curve. Above the apex, derotation occurs
in small increments. The incremental rotation and derota­
tion is similar to the neutral sidebending that occurs in the
lumbars (Figure 2.12).
When axial rotation is initiated, neutral sidebending
coupling is different from what occurs when sidebending is
the initial movement. Theoretically, axial rotation is thought
to cause contralateral sidebending of the segments fromT9
through L3. Ipsilateral coupling is thought to occur at L4
and L5, and in segments T3 to T8, at least with extreme
rotation (Lee, 1994).
Physiologic Movements of T12 and the Lumbar Segments
Movements of the lumbar vertebrae follow the same gen­
eral rules as the thoracic vertebrae with regard to neutral
and non-neutral segmental motion. Normal lumbar flex­
ion and extension are accomplished in a manner similar to
the thoracic spine, but they are much freer movements
because of the thickness of the intervertebral discs. During
flexion the lumbar lordosis straightens and bends forward
on the sacrum. The lordotic curvature may be reversed in
the upper lumbar segments, but this is usually not possible
at the lumbosacral segment. As in the thoracic spine, flex-
center
(y-axis)
Figure 9.4 The arcuate contours of the lumbar facets fit a circle with a
center at o, the postulated y-axis. The lumbar facets do not usually con­
form exactly to the depicted geometry, which is essential for the location
of the axis. Rotation on such an axis requires a large shearing strain on
the intervertebral disc. Disc hysteresis may not allow more than 2 or 3
degrees of rotation on this axis. (Adapted from Guy, 1949. Reprinted with
the permission of the American Academy of Osteopathy.)
ing a lumbar or thoracic vertebra is accompanied by a small
anterior translation of the vertebral body. The range of
flexion to extension for the lumbar spine averages about
77° (±27°). From the anatomic position, almost 80 per­
cent of sagittal mobility is extension. (Figures 2.5 and 2.6)
Sagittal mobility (i.e., flexion/extension) of the tho­
racic spine is extremely limited except in the last three seg­
ments. The five lumbars together have more sagittal
mobility than the twelve thoracics.
The axis for axial rotation ofT12 on L1 should be like
all the lumbar y-axes because of the shape of the inferior
facets. The exact location of lumbar y-axes is still contro­
versial. Based on joint morphology, the y-axis should be
located posteriorly in the region of the neural arch (Guy,
1949; Kapandji, 1974). (Figure 9.4)
More recently, Bogduk andTwomey (1991) have pos­
tulated that the lumbar y-axis passes through the vertebral
body (Figure 9.5 A and B). In either case, the amount of
rotation is considered minimal, at least on this axis.
Although rotation may begin on one or the other of these
axes, it must quickly move closer to the posterior neural
arch as rotation continues, because theT12-L1 zygapophy­
seal facets are oriented much like lumbar intervertebral
facets (Figure 9.5C).
In spite of its lumbaresque anatomy, T12 appears to
have great capacity for rotation on L1, at least when there is
non-neutral dysfunction ofthat segment. This clinical obser­
vation is not explained by current research findings.
Perhaps the lesion mechanism is a combination of the· two
theories of axial rotation; certainly some intervertebral disc
shearing may be involved at times.
 CHAPTER 9 �EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE
A panying trunk forward and backward bending. With either
superior facet
of subjacent
lumbar vertebra
B
subjacent lumbar
vertebra
transposed
y-axis
Figures 9.5 A. B, C. Left axial rotation of a lumbar type intervertebral joint
viewed from above. The inferior lumbar vertebra is shaded, the superior
lumbar vertebra is solid white. Superimposed on the superior lumbar ver­
tebra are dotted outlines representing the superior facets of the inferior
vertebra. A: Lumbar segment in neutral before the initial rotation (2 or 3
degreesl, which occurs about an axis in the vertebral body (according to
Bogduk and Twomeyl. B: The neural arch of the superior vertebra moves
to the right, impacting the right superior articular process of the inferior
vertebra and gapping the left zygapophysis. C: The y-axis shifts to the
impacted zygapophysis. Additional rotation on this axis shears the inter­
vertebral disc. The thicker lumbar discs allow more shear.
157
Normal Mechanics of the Lumbosacral ]oint
Adaptations to sacral position occur frequently in the lum­
bosacral joint as, for example, with every walking step. The
base of the sacrum can nutate forward or backward, accom­
of these sacral movements in the upright posture there is
obligatory postural adaptation of the lumbar spine, includ­
ing the fifth lumbar. The fifth lumbar adaptations are the
reverse of the movements of the sacral base. Rotation and
sidebending of the sacral base are always coupled contralat­
erally due to the anatomy of the sacroiliac joints. The phys­
iologic response of the fifth lumbar to changes in sacral
base position is to reverse the movements of the sacrum.
As long as neither flexion nor extension is restricted, the
fifth lumbar sidebends and rotates opposite to the sacral
position. The amount of rotation required of the fifth lum­
bar for this adaptation is just enough to reverse the amount
of sacral rotation. This puts the fifth lumbar transverse
processes in symmetrical relationship to the iliac crests.
Asymmetrical rotated position of the fifth lumbar, there­
fore, indicates Type II non-neutral lumbosacral
dysfunction, especially if trunk flexion or extension makes
the L5 rotation worse.
Figure 9.6 Normal mechanics at the lumbosacral joint. The rotary, undu­
lating movements of the trunk during gait produce twisting sidebending
movements at the lumbosacral joint. The shifting forces on the sacral base
passively rotate and sideband the sacrum, which rotates on one of the
oblique sacral axes, shown by the pencil. IFrom Mitchell FL. 1965: Reprinted with
the permission of the American Academy of Osteopathy.)
158 THE MUSCLE ENERGY MANUAL
Aspects of the Screening Examination
Relevant to the Lower Thoracic and
Lumbar Regions
Parts of the Ten-Step screening examination described in
Volume 1 are specifically pertinent to evaluation of the
lower thoracic and lumbar spine. These parts will be
reviewed here as follows:
Relevant Screening Examinations
A. Walking Screen
B. Postural Evaluation - Standing Statics
C. Iliac Crest Heights Test - Standing and Seated
D. Spinal Rotation Tests
I ) Seated Trunk Rotation Screening Test
2) Observing Paravertebral Fullness
3) Pelvic Flexion Tests
a) Locating the PSISs
b) Standing Flexion Test
c) Seated Flexion Test
4) Sacral Position Tests
E. Seated Trunk Sidebending Tests
F. Rib Screen for Lower T horacic Spine
The Walking Screen
When joint and muscle fimction in the thoracic and lumbar
spine is abnormal, it affects gait and arm swing patterns.
Asymmetric patterns of hip sway can indicate zygapophy­
seal and sacral trophism (see Volume 1 ), reflect adaptive
scoliosis of the lumbothoracic spine regions, and/or sug­
gest tight quadratus lumborttm or lumbar erector spinae.
Asymmetric tension in the latissimus dorsi - shoulder
muscles with origins in both the pelvis and lumbar spine -
will affect the pattern of arm swing during walking.
Abnormal tensions in the latissimus dorsi may be caused by
adaptive stress affecting the cervicothoracic junction, and
such tensions are one of the causes of lower back pain.
Integrating limbs and trunk, the lumbodorsal aponeu­
rosis, a large sheet of deep fascia, serves as an attachment
site for the major muscle groups of the spine, the abdomen,
and the upper and lower extremities. Mechanically, the
limbs may atlect the lower back, and the lower back can
atlect the limbs, during the walking cycle and in postural
ti.mction .
Postural Evaluation- Standing Statics
Posterior and lateral views may reveal abnormal spinal cur­
vatures, and possible leg length asymmetry. If asymmetry
is present, comparison of iliac crest heights will help deter­
mine if the scoliosis pattern is appropriate for the leg length
asymmetry.
Posture from the Front
Abdominal scars, masses, and asymmetries should be looked for
because they can affect lower spine posture. Rib cage distortion
and intercostal angle asymmetry due to polio or other childhood
neurologic disease is usually more obvious from the front than
from the back. The clavicles should be inspected for asymmetry.
The rotational asymmetry of rotoscoliosis is often more obvious
from the front than from behind.
Posture from Behind
The thoracic lumbar spine viewed from behind may show
sidebending curvature deformity in the shape of a "C" curve, an
"S" curve (Figure 9.7), or multiple "S" curves. Such curvature
may represent "postural" (functional) scoliosis, i.e., adaptive cur­
vature, which usually disappears when the trunk flexes forward; or
it may represent osseous deformity or segmental motion impair­
ment within the spine itself.
Bear in mind that the severity of curvature is minimized by
the column of spinous processes in the median fimow, because of
rotation of the vertebral segments. Note the comparative heights
of the shoulders. Usually the left shoulder is about I or 2 cen­
timeters higher than the right. Imagine a plumb line dropped
from the seventh cervical spinous process. Does it bisect the
sacrum?
The ideal posture is symmetrical, but slight asymme­
tries are the norm. A slight left convex scolioJis of the
upper thoracic spine has been described by Lockhart
( I963) as normal anatomy, causing the left shoulder to be
a fraction of an inch higher and slightly more posterior
compared with the right shoulder. The presence of these
asymmetries, widely known as the Common Compensatory
Pattern, does not generally signifY dysfunction or impair­
ment. However, their absence, exaggeration, or reversal
should raise suspicion of somatic dysti.mction in the affect­
ed area.
Asymmetric rigidity of the scoliotic curves can be
observed by having the patient bend sideways ldi: and right
(Figure 9.8).
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 159

A B

Figure 9.7 A and B. "C" curve scolio­

sis (A), and ·s· curve scoliosis (B).

1
A 8

Figure 9.8 A and B. Left sidebending

with right convexity scoliosis­
viewed from behind. The right convex
thoracic scoliosis complies with left
sidebending (A), but not right
sidebending (B).

Observations of Posture from Behind

Observation Relevance

a) Arm distances from the sides If space is greater on one side, it indicates that the shoulders and thoracic spine are
of body are greater on one side shifted toward that side because of scoliosis. For example, if the space is greater on
than the other the left, then the shoulders and thoracic spine are shifted to the left, and there is
sidebending to the right. (Figure 9.7)

b) Presence of asymmetric A crease or fold on one side indicates the approximate level of the concave side of a
waist creases or folds curve apex. (Figure 9.7)

c) Lateral shift of the pelvis Indicates lumbar scoliosis (either chronic or acute), and the possible presence of an
anatomically short leg. Imbalance of lumbar or pelvic muscles can also be reflected
in scoliosis of the lower back.
160 THE MUSCLE ENERGY MANUAL

Figure 9.9 Posture

Posture from the Side
viewed from the side.
In an X-ray of a normal lumbar lordosis, a plumb line orig­
Look for the common
inating in the center of the L3 vertebral body should pass poor posture markers:
through the promontory of the sacral base. The plumb line flat foot, slew foot, sabre
leg, knock-knee, rump­
is anterior to the sacral base with increased lordosis.
sprung, swayback, pot­
Obviously, degenerated posture is judged in comparison belly, hunched shoulders,
to an ideal standard. Our eyes are so accustomed to average chicken neck. chin
posture that we tend to think of average as "normal." Many forward. These can all
be consequences of
people are walking around with some degree of postural
postural muscle
degeneration, but they do not complain about it. Yet, these
imbalance (cf. Janda-
degenerations of posture can contribute to pathology, vis­ 1978, 1983, 1996, and
ceral diseases as well as locomotor lameness. Keep a picture Lewit, 1998).
of the ideal standard in mind when examining the patient
from the side.
There are four normal anteroposterior curves, two primary
and two secondary. The thoracic (T2 through T10) and the
sacrococcygeal curves are concave anteriorly, and are primary
because they persist trom fetal development throughout lite.
They are the normal kyphoses. The cervical (C1 through T1)
and the lumbar (T11 through L5) are normally lordotic, i.e.,
concave posteriorly, and are secondary curves because they
are acquired as the body develops and matures. The cervi­
cal lordosis is formed when the prone infant raises its head
to look around. The lumbar lordosis begins to torm during
all-tours creeping and completes its development in the erect
standing context.
Increasing the curvature (decreasing the radius of curva­
ture) of any portion of the spine tends to exaggerate the cur­
vature of the other regions to compensate, or restore bal­
ance to the body masses. Such compensatory alterations may
be stressful enough to cause symptoms. Thus, finding the
cause of pain may entail evaluating the entire postural sys­
tem.

Observations of Posture from the Side

Observation Relevance

a) Increased lumbar Since the lumbars sit on the sacrum, sacral position affects lumbar posture. Typically,
lordosis increased lumbar lordosis indicates, or is found with, an anterior declination of the sacral
base. Also, it is generally accompanied by increases in the cervical lordosis and thoracic
kyphosis. Such postures are more prone to injury, and, due to the reduced mobility for the
segments in the region, are more prone to disc rupture. With these postural patterns, one is
more likely to find FRS segmental dysfunction, forward sacral torsion, and/or unilateral sacral
flexion.

b) Increased lumbar Generally caused by tight psoas and quadratus lumborum muscles. It is usually an acute
kyphosis, or reduced condition which presents itself as a bent forward posture often accompanying backward
lumbar lordosis sacral torsion. As the reduced lumbar lordosis moves from acute to chronic, thoracic kypho­
sis will become less kyphotic.

c) Protuberant abdomen The protuberant abdomen is a strong indicator of tight lumbosacral extender muscles, caus­
ing inhibition and weakness of the rectus abdominis muscles. Often this weakness is asso­
ciated with compensatory tightness of obliquus abdominis muscles, seen as a vertical
hypochondral groove.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 161

Figure 9.10 Observing

Iliac Crest Heights Test
static posture from
An anatomically short leg can account for a variety of scol­ behind and measuring
iotic asymmetries. Variance in scoliotic patterns is to be iliac crest heights.
expected as the developing scoliosis goes through stages of Examiner's eyes should

compensation. The stages are as follows (according to be close to the level of

the hands.
Larson, 1966):
Stage I - a long "C" curve convex on the side of the
short leg, with a contralateral sidebend in the upper cervi­
cals to level the eyes and vestibular apparatus. The sacral
base plahe is consistent with the leg length asymmetry.
Stage II - the sacral base plane changes by tipping
down on one side, probably depending on the side carry­
ing the greatest postural load. If the load increases on the
side of the scoliotic convexity, the sacrum may tip down on
that side, increasing the compensatory scoliosis.
Stage III - with the increase of imbalance of body
masses, "S" curves are formed to rearrange the body mass­
es in more balanced relationship relative to the center line
of gravity. This sometimes results in reversal of the lumbar
compensatory scoliosis (Chapter 4, Volume 1). Non-neu­
tral dysfunctions tend to develop at the base or the
crossovers of the "S" curves. Seated Iliac Crest Heights Test
Knowledge of the stages of postural compensation for Old pelvic fractures or dysgenesis of the pelvis can make the
anatomic short leg helps with planning the sequence of hipbone sizes unequal. The resulting asymmetry of the
treatment, i.e., reversing the order of occurrence before seated posture can be stressful enough to cause symptoms
prescribing a short leg shim. Leg length asymmetry may anywhere in the body. Shimming the small side of the pelvis
cause muscle imbalance with altered firing sequences of the with a magazine or book to level the iliac crests should be
quadratus lumborum, erector spinae, iliopsoas, gluteus, and done in these cases, in order to observe the effect on spinal
hamstring muscles. Before doing the treatment for muscle curvatures. This anatomic asymmetry has effects similar to
imbalance (Janda, 1997), it is important to correct the those of an anatomic short leg. Shimming the small side of
non-neutral and nonadaptive spinal and sacroiliac dysfunc­ the pelvis can be an important part of therapy. The patient
tions. can carry along his own shim to sit on.
To enhance reliability and interpretation of flexion
tests and recumbent malleolus measurement, relative
anatomic (true) leg length can be estimated by using the
superior aspect of the iliac crests as a landmark. To avoid
varying thickness of soft tissue between hands and crests,
hands are first placed laterally below the iliac crests. Flesh
is then pushed superior-mediad until the index fingers top
the crest (Chapter 6, Vol. 1).
If you determine that the leg lengths are not equal, a
book, or other shim, may be used until the crests look level.
Untrained observers can usually make such a determination
with a standard error of less than 3 millimeters (Mitchell,
Jr., 1976). Your eyes should be down at the level of the
hands. Patient's heel centers should be 4 to 6 inches apart.
Shimming the short leg is a wise precaution to increase
validity of the standing flexion test (Chapter 6, Volume 1).
The shim does not alter the standing flexion test results;
it just makes them easier to see. If the shim alters the Figure 9.11 Seated iliac crest heights test for pelvic dysgenesis.
results, you are doing the test incorrectly. The seated spinal posture can be stressed by unequal hip bone size I due to
pelvic dysgenesis or old pelvis fracture). Such patients can benefit by
carrying their own shim to sit on. The examiner's eyes must be level with
the hands in order to compare iliac crests.
162 THE MUSCLE ENERGY MANUAL

Figure 9.12 The seated

Spinal Rotation Tests
trunk rotation test. The
Screening tests which focus on regional ranges of motion patient sits erect for this
are essentially static position tests. That is, visual and pal­ test. The shoulders are
patory information is obtained at the limits of ranges of turned passively to the
end of the range of
motion, while the part being tested is held stationary to
motion, stopping short of
visually estimate angular degrees. The quality of the moving the pelvis.
motion at the end of a range of motion may be difficult to Angular degrees are
precisely quantity, but it often allows one to distinguish estimated visually.

between muscle spasm, muscle contracture, fibrositic tissue

states, periarticular edema, and articular malcongruence
(intra-articular blockade).

Seated Trunk Rotation Screening Test

When the ranges of trunk rotation left and right are not
symmetrical, most of the rotation restriction is due to adap­
tive rotoscoliosis, not to segmental dysfunction. However,
rotoscoliosis in the thoracic, or even the lumbar, spine is
often an adaptation to segmental dysfunction in a lower
thoracic segment. Therefore, asymmetry is an indication to
examine the lower thoracic segments closely. Occasionally,
Figure 9.13 Observing
the key spinal lesion is in the lumbars. In some instances
from behind for paraver­
an "S" curve in the thoracics may result in symmetrical tebral muscle fullness
trunk rotation. The patient must not be allowed to slump symmetry in the standing
during the performance of this test, because of the unquan­ flexed position. The line
of sight is tangent to the
tifiable effect it has on the outcome of the test. A little
lower thoracic kyphosis.
slump reduces the trunk rotation range "a little bit." A lot Observations in the
of slump reduces the range "a lot." standing flexed position
will be compared with
the seated flexed
Observing Paravertebral Fullness
position.
One function of the standing and seated flexion tests (to be
discussed in detail in Volume 3) is to show the rotation
component of rotoscoliosis. Unilateral paravertebral mus­
cle fullness is the visible evidence of rotoscoliosis. In the
lumbars, paravertebral muscle fullness is due to transverse
processes pushing the muscles back. The same paraverte­
bral muscle fullness can be observed in the thoracics, and
the rib cage becomes full on the same side as the muscle
fullness. In chronic scoliosis, the ribs deform and present a
sharp razorback hump at the rib angles on the posterior
side.
The rotation component of scoliosis is especially evi­
dent when the trunk is flexed. Comparing the standing
and seated flexed positions for severity of rotoscoliosis may
indicate whether the primary asymmetry causing the scol­
iosis is in the spine, in the pelvis, or in the lower limbs. If
the rotoscoliosis is most severe in the standing flexed posi­
tion, the causative asymmetry is in the lower limbs.
Intrapelvic functional asymmetries - sacroiliac or iliosacral
lesion - cause asymmetric movement of the PSISs with
trunk flexion. Primary spinal idiopathic scoliosis and adap­
tation to spinal asymmetries (postural scoliosis) tend to
look the same in both standing and seated flexed positions.
 CHAPTER 9 ..-&-EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE 163

Figure 9.14 Observing from in front for paravertebral muscle fullness Figure 9.15 Observing paravertebral fullness from the front. The lumbar
symmetry in the standing flexed position. The line of sight is tangent to paravertebral muscles are slightly fuller on the patient's right.
the lumbar "kyphosis." Observations in the standing flexed position will
be compared with the seated flexed position.

Figure 9.16 Observing from behind for paravertebral muscle fullness Figure 9.17 Observing from in front for paravertebral muscle fullness
symmetry in the seated flexed position. symmetry in the seated flexed position.

Observed Spinal Rotation

Observation with Patient Flexed Interpretation

a) Muscle fullness asymmetry Mainly rotoscoliotic adaptation to anatomic short leg or lower limb muscle
greater standing than sitting imbalance.

b) Muscle fullness asymmetry Spinal adaptation to sacral or vertebral asymmetry, either ERS or structural scoliosis.
greater sitting than standing Some adaptation may be in the legs or hips.

c) Muscle fullness asymmetry Vertebral or sacral asymmetry with little or no adaptation in the legs.
same standing and sitting

d) No muscle fullness asymmetry No ERS dysfunctions in the lumbar or lower thoracic spine, or anatomic short
standing or sitting leg completely adapted in the pelvis.
164 THE MUSCLE ENERGY MANUAL
Abdominal Muscle Tension Imbalance
Segmental dysfunctions, either acute or recurrent, of the
lumbar and lower thoracic spine may, at times, be sec­
ondary to myofascial tension imbalance of the muscles of
the abdominal wall. In these cases treatment of the
abdominal wall muscle imbalance can result in "miracu­
lous" autocorrection of spinal segmental dysfunctions, that
would otherwise require specific mobilization tor tempo­
rary normalization. It is in the interests of clinical efficien­
cy that a quick evaluation of the obliquus abdomi11is mus­
cles, where tension imbalance is frequently found, is includ­
ed in the screening tests tor lumbar and lower thoracic
spine. Treatment tor obliquus imbalance is quick and sim­
ple following the procedure depicted on page 193.
Testing the Muscles of the Abdominal Wall
The anterior abdominal wall is supported by tour pairs of
muscles. Two vertical muscles, the recti, connect the cos­
tochondrum to the pubic crests (many anatomists consider
the pyrimidalis muscles to be anatomically, if not function­
ally, separate from the rectus abdominis muscles). The recti
are connected to each other by a midline seam (raphe), the
linea alba. They are powerful trunk flexors, unless they
become inhibited and weak, as they are prone to do.
There are two layers of obliquus abdominis muscles on
each side. They are trunk rotators, and they have a pro­
clivity tor (asymmetric) tightness. The external (superfi­
cial) obliques arise by digitations from the costal cartilages
of the lower seven ribs and run interiorly to their more
medial attachments -the anterior aponeurosis of the rectus
abdominis and the iliac crests. Thus, the orientation of
their fibers parallels the movements of your hands when
you put them into the side pockets of your trousers. The
lefi: external obliquus abdominis is, therefore, a right trunk
rotator, as well as a left trunk sidebender.
The internal obliquus abdominis muscles arise from the
inguinal ligaments and iliac crests, and, tor the most part,
ascend superiorly to the interior margins of the lower three
ribs and supero-ventrad to their attachments in the rectus
aponeurosis. Thus, the left interior oblique muscle is a
trunk leti: rotator and lefi: sidebender. Fibers of the interi­
or oblique on one side approximately parallel those of the
external oblique of the other side.
Figure 9.18a.
Comparing left with
right external oblique
abdominal muscles for
asymmetric tension.
The muscles in the
intercostal angle attach­
ing to the last 7 costal
cartilages are external
obliques.
Transversus abdominis, the third and deepest layer, is
best described as arising fi·om the aponeurosis of the rectus
abdominis, whose posterior sheath links the transversus
aponeurosis to the linea alba. Its important lateral attach­
ments are to the lumbodorsal aponeurosis, where it func­
tions as a segmental lumbar spine stabilizer (Richardson, et
al, 1999). It has a tendency to become weak through dis­
use atrophy, which can be regarded as a failure of co-con­
traction reflexes integrating stabilization functions of the
pelvic diaphragm, lumbar multifidi, and transversus abdo­
minis. When it functions normally, it contracts, rather iso­
metrically, about 30 milliseconds before any movement
occurs of any part of the body - raising an arm or a foot,
tor example. This short chronaxie twitch of the transver­
sus abdominis is often palpable a split-second before the
patient raises an arm or tips the head back. Its absence can
indicate a profound imbalance of the postural stabilizer
muscles.
Tight obliquus muscles can inhibit the tranSJ1ersus abdo­
minis. Restoration of postural muscle balance may require
stretching of the obliquus muscles. This may most easily be
accomplished utilizing the post-isometric relaxation eftect
of Muscle Energy Technique (see Treatment tor Obliquus
Abdominis Imbalance).
Palpation for tightness of tl1e obliquus muscles can be
done while sitting behind the seated patient. Place the
hands on the iliac bones of the pelvis in the mid-axillary
line, and then bring the index fingers up on top of the iliac
crests. Compare the ease of indenting the abdominal mus­
cles medially with your hands just above the iliac crests.
Resistance to indentation may be due to tight internal
oblique muscles or to tight quadratus lumborum muscles.
Now move your hands ventrally to the intercos�al angle,
and compare the tightness of the muscles attaching to the
right and left costal cartilages -the external obliques - by
indenting the abdominal muscles just below the costal mar­
gins. Next, palpate the two interior quadrants of the
abdomen to compare tensions of the internal obliques.
It is not uncommon to find tight external obliques and
tight internal obliques on contralateral sides. One Muscle
Energy procedure will serve to loosen both.
Figure 9.18b. Palpating
internal obliques for
tension. Two areas may
be palpated: above the
iliac crests, and the two
abdominal inferior quad­
rants. Each of these
areas should be
checked.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 165

Figure 9.19a. Locating

The Pelvic Flexion Tests the gluteal tubercle.
Relevance of the Standing and Seated Flexion Tests The dimple of Michaelis.

Although generally considered screening examinations for the

pelvis, the Standing and Seated Flexion Tests are also relevant to
lumbar evaluation. Since the lumbars rest on the sacrum, they
influence each other mechanically. Stress from lumbar dysfunc­
tion can atlect abdominal or thigh muscles sufficiently to alter
the positional relationships of the pubic bones to each other,
which always disrupts mechanical functions of the sacroiliac
joints. It is wise to attempt to correct these lumbar influences
on the pubic bones before attempting to assess sacroiliac
mechanics. Additionally, uncorrected dysfunction of the lumbar
spine can be significantly stressed - sometimes resulting in back
muscle spasm - when treatment alters the position of the sacral
base. Also, many apparent dysfunctions of the sacroiliac joint are
secondary to lumbar dysfunction, and may self-correct when the
lumbar dysfunction is treated. For these reasons, dysfunction in
the lumbars should be treated before addressing the sacrum or
Figure 9.19b. Locating
pelvis.
the gluteal tubercle.
Flexion tests are reliable indicators of the side of pelvic joint
Using circular motion
dysfunction, but only when the positive results continue after stereognosis to locate
lumbar dysfunctions have been corrected. It is not uncommon the gluteal tubercle
for pelvic and lumbar dysfunction to coexist, and the resulting deep to the dimple of
adaptive mechanisms can be unraveled only by treating the tum­ Michaelis, which is
bars first. The influence of lumbar dysfunction on the flexion sometimes not visible.

tests is not uniform, is manifested only occasionally, and is

removed once the lumbar dysfunction is treated. For example,
at times the flexion test will result in a positive on one side, but
then after correcting dysfunction in the lumbars, may be positive
on the other side. Although the flexion test will not disclose the
side of dysfunction in the lumbars, it does reliably lateralize
pelvic dysfunction.

Locating the PSIS for Execution of the Flexion Tests

The PSIS, a bony prominence at the posterior termination
of the iliac crest, can be found by pressing the flat finger pads
against the back of the pelvis at the dimple, if there is one
(Chapter 6, Volume 1 ) . If the flat hand is then moved in the Before doing the flexion test, the bilateral symmetry of
coronal plane in a circular fashion while maintaining pres­ these prominences should be assessed. If, after leveling the
sure with the finger pads, bony prominences are immediately crests, the PSIS is inferior on one side, there may be an
palpable stereognostically. The opposite hand may be used iliosacral somatic dysfunction. Anterior-posterior asymmetry
to stabilize the pelvis against the pressure of the palpating suggests hip rotator imbalance, which would cause the entire
hand. If more than one knot is felt, the extra knots are usually pelvis to rotate.
fibrolipomas, which (though somewhat softer than bone) are
sometimes rather firmly attached to the periosteum of the
bone. The actual posterior superior iliac spine (PSIS) is often
a centimeter or more inferior to the dimple of Michaelis. The
bony prominence that can be felt deep to the dimple may be
called the "posterior iliac prominence (PIP)" or gluteal tubercle,
and is the superior corner of the small diamond-shaped fossa
where gluteus maximus originates.
166 THE MUSCLE ENERGY MANUAL
Standing Flexion Test
Either the PSIS or the PIP (gluteal tubercle) may be used to
perform this test. Ideally, the patient's feet should be posi­
tioned parallel and approximately acetabular distance apart,
and the iliac crests leveled with a shim, if necessary. Place your
thumbs firmly against the inferior slopes of the bony promi­
nences in order to follow the movement of the large hipbones
with minimum distraction from soft tissue activity. When the
patient bends torward, allow the patient's pelvis to come back
toward you, to keep from pushing him/her off b alance. To
keep the thumbs firmly on the PSIS point and not compro­
mise patient balance, your fingertips may grasp the gluteus
muscle mass to help pull the thumbs in on the PSIS. Keep­
ing the thumbs in contact with the same points on the PSIS,
ask the patient to bend all the way forward at the hips, keep­
ing the knees straight. Again, avoid pushing the patient off
balance as your thumbs tollow the movement of the contact
points. For this reason, a light touch is always preferred, with
just enough firmness to ensure that the thumbs follow the
bone accurately.
An important improvement, absolutely essential for beginners, is
to observe the movement of your thumbs during the first few
degrees of straightening. The positive side will move alone. before
the normal side begins moving. This part of the action can be observed
repeatedly within this narrow range. Significant movement asymmetry
tends to occur just before completion of the bend. Therefore, if the con­
tact points are lost on the way down, relocate the points with the thumbs
and follow them during the first few degrees of straightening. The same
asymmetry will be noted.
The point with the greatest (longest) excursion is consid­
ered the abnormal ("positive") side. The range of"positive"
movement varies from 1 millimeter (barely perceptible) to
20 millimeters (about an inch). The extra movement occurs
when the ilium locks on and follows the sacrum.
The unilateral movement of the PSIS/PIP seen with a pos­
itive standing or seated flexion text is generally expected to
be in a cranial (i.e., superior) direction with flexion, and in
a caudal direction with extension. However, at times this
movement may be partially, or even predominantly, poste­
rior with flexion and anterior with extension. This variation
should be looked tor (it is easy to miss!) and judged just as
quantitatively as the cranial/caudal motion.
{Note: The standing and seated flexion tests, including indi­
vidual variatiom in responses to the tests are discussed in greater
detail in Volume 3 ofThe Muscle Ene1ljy Manual, Second Edi­
tion, Chapter 6.}
Comments: The Standing Flexion Test is a test for iliosacralmotion. i.e..
how the ilia move on the sacrum. Other tests allow you to diagnose the
type of iliosacral lesion. but the Standing Flexion Test determines the side
of the lesion.
Note: The expected unilateral movement of the PIP seen with a positive
flexion test would be cranial (superior) with flexion and with extension
caudal (inferior) motions. At times this movement may be partially, or
even predominantly, posterior with flexion and anterior with extension.
This variation should be looked for (it is easy to miss) and judged just as
quantitatively as the cranial/caudal motion. (see Volume 3 of The Mus­
cle Energy Manual: Evaluation and Treatment of the Pelvis and Sacrum,
for a more detailed discussion)
 CHAPTER 9 �EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE 167

The Standing Flexion Test Protocol Fig. 9.20 The New

Standing Flexion Test
l: The patient is barefooted and stands, or attempts to Step 1. After first
stand, erect. If the iliac crests are not level, a temporary lift having the patient do
should be in place. a full forward bend,
the thumbs are placed
2. The feet are 4 to 6 inches apart so that the heels are firmly on the inferior
directly under the acetabula. The toes should point straight slopes of the gluteal
ahead. The weight should be evenly distributed on both feet. tubercles. As the

The arms hang freely at the sides. patient bends

forward, allow the
3. Stand or sit directly behind the patient so that your eyes hips to move posterior
are level with the patient's PSIS. in relation to
placement of the feet.
4. Palpate the inferior slopes of the PSIS on both sides,
Having the patient
using your thumbs. move repeatedly from
5. Instruct the patient to keep the knees straight and bend the fully flexed to the
partially flexed
forward, as if attempting to touch the toes.
positions will insure
detection of the more
Note: The most common error, when performing this test. is that the subtle asymmetries.
patient does not bend forward far enough. The last few degrees of flex­
ion are crucial to a successful test. Therefore. the best way to perform
the test is to relocate the gluteal tuberosities on the posterior aspect of Fig. 9.21 The New
the iliac crests, or the PSISs. after the patient is fully flexed. Then ... Standing Flexion Test
Step 2. The patient is
instructed to "Come
6. Instruct the patient to straighten (extend the back)
up a foot and stop."
"about a foot," and to stop in that position. Watch your The thumbs follow the
thumbs closely for any asymmetry of movement of the gluteal movements of the
tuberosities or PSISs, i.e., one side moving and the other side gluteal tubercles; the

not moving. Repeat the flexion and extension movements eyes watch the
thumbs for unilateral
in this small range if you are not sure of the results.
movement, indicating
restricted iliosa cral
Note: The next most common error is allowing the thumbs to be pulled mobility on the moving
superiorly by the soft tissue tensions generated by the forward bend. This side. {The temporary

is more likely to happen at the beginning of the forward bend. Keeping shim under the foot is
to level the iliac crests
firm thumb pressure on the inferior slope of the landmark and following
on an anatomic short
the advice of Step 5 closely will help prevent this problem.
leg, an advisable
preliminary to the
7. Make the comparison. standing flexion test,
when leg length
asymmetry is greater
than one centimeter.}

Interpretation of Results

• The bilateral PSIS should be pulled superiorly in equal

amount, if both sides are normal.

• A positive test occurs when one PSIS is pulled more
superiorly than its mate; the more superior of the two PSISs
is the restricted (lesioned) side. When straightening (extend­
ing), the positive side moves first before the normal side
begins to move. In this range of flexion the positive side
moves alone.
• Carryover effect. The two pelvic flexion tests, standing
and sitting, do not completely separate iliosacral from sacroil­
iac functions. The sitting and standing tests overlap. Only
by comparing the results of the Standing and Seated Flex­
ion Tests can iliosacral be separated from sacroiliac dysfunc­
tions (without the usual follow-up evaluation of pelvic land­

• Sometimes the positive side moves slightly posterior, as marks).

well as superior, at the extreme end of the forward bend. This • The positive test tends to be a marked (more than a 5
is a "normal" variant of the positive test result. Grading the -millimeter difference) response. If not, suspect a false pos­
degree of positive response should take the posterior move­ itive or a false negative result.
ment into account.
168 THE MUSCLE ENERGY MANUAL

Seated Flexion Test

The seated position increases the stability of the ilia in rela­
tion to the lower extremities by resting the ilia on the ischial
tuberosities, and by buttressing them with the femurs into the
acetabula. The sacrum, moving as a part of the spine
between the two ilia, is still relatively free to move as com­
pared with the two ilia. Such motion can be called sacro­
iliac to distinguish it from iliosacral motion (motion of one
ilium in relation to the other, or in relation to the sacrum).
Sacroiliac dysfunctions affect the seated flexion test more, and
the standing flexion test somewhat less. Conversely, iliosacral
dysfunction affects the standing flexion test more, the seated
less. Lumbar dysfunction can cause a false positive Seated
Flexion Test, just as it may cause a talse positive Standing
Figure 9.22 Seated Flexion Test (sacroiliac).
Flexion Test.
Step 1. Doing the seated flexion test in reverse may increase the
reliability of the test. Find the gluteal tubercles after the patient is
fully flexed, feet and knees widely apart, elbows between the ankles.

The Seated Flexion Test Protocol

l. The patient sits on a firm low stool. The knees are spread
wide apart. The feet should be flat on the floor.

2. Sit directly behind tl1e patient so that your eyes are level
with the patient's PSIS level.

3. Place your thumbs bilaterally on the interior slopes of

the patient's gluteal tubercles, or the Posterior Superior Iliac
Spines (PSIS).

4. Instruct the patient to bend completely forward.

Instruction:«Put your ftet and k11ees shoulder-width apart,
and bend forward, putting your elbows between your feet.»

Note: The most common error. when performing this test. is that the
patient does not bend forward far enough. The last few degrees of flex­
ion are crucial to a successful test. Therefore. the best way to perform Figure 9.23 Seated Flexion Test (sacroiliac).
the test is to relocate the gluteal tuberosities on the posterior aspect of Step 2. Follow the gluteal tubercles as the patient begins to extend
(straighten). In this part of the range of motion one is most likely to see
the iliac crests. or the PSISs. after the patient is fully flexed. Then. .
.

unilateral movement of the ilium. indicating sacroiliac joint restriction on

that side.
5. Instruct the patient to straighten (extend the back)
"about a foot," and to stop in that position. Watch your
thumbs closely for any asymmetry of movement of the gluteal
tuberosities or PSISs, i.e., one side moving and the other side
not moving. Repeat the flexion and extension movements
in this small range if you are not sure of the results.

Note: The next most common error is allowing the thumbs to be pulled
superiorly by the soft tissue tensions generated by the forward bend. This
is more likely to happen at the beginning of the forward bend. Keeping
firm thumb pressure on the inferior slope of the landmark and following
the advice of Step 5 closely will help prevent this problem.
 CHAPTER 9 -f> EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 169

Interpretation of Results

• The bilateral PSIS (or PIP) should be pulled superiorly

an equal distance.

• A positive test is demonstrated when one PSIS (or PIP)

is pulled more superiorly after its mate has stopped moving;
the more superior of the two is the restricted (lesioned) side.
With straightening (extending), the positive side moves first
before the normal side begins to move.

• Sometimes the positive side moves slightly posterior, as

well as superior, at the extreme end of the forward bend. This
is a "normal" variant of the positive test result. Grading the
degree of positive response should take the posterior move­
ment into account.

• If a positive result is obtained, you must use other tests

(tests for sacral sulci depths and sacral ILA positions, and
other pelvic landmark positions) to make the definitive diag­
nosis; i.e., sacral torsion or flexion, or pubic or iliac sublux­
ation, or anterior/posterior innominate rotation.

• Carryover factor. As mentioned under the Standing

Flexion Test, you may get some "carryover" effect from
Standing Flexion to Seated Flexion testing. If the same side
is positive for both standing and sitting, compare the actual
distance of unilateral superior movement in order to decide
whether the test is more positive standing or sitting. If the
distances are the same, there is either complete carryover, or
a combination iliosacral and sacroiliac dysfunction on the
same side. Evaluation of all the pelvic landmarks will resolve
the question.

• Occasional complication: During forward flexion, some

patients (especially obese patients) may experience sharp
chest pain due to intercostal or abdominal muscle spasm. This
is not serious, and clears when the patient straightens up.
170 THE MUSCLE ENERGY MANUAL

Sacral Position
Inferior Lateral Angles of the Sacrum (ILAs)
ILA symmetry in the prone position essentially rules out
postural sacroiliac dysfunction, either torsion or lateral flex­
ion, thus eliminating one possible etiology of adaptive
rotoscoliosis.
The normal fifth lumbar adaptation to sacral base
asymmetry is not to follow the sacral base, but to reverse
itself in all three planes just enough to become symmetrical
in relation to the iliac crests. If it is unable to do this, such
adaptation must be accomplished at higher segments.
Depending on the degree of flexion or extension impair­
ment of the fifth lumbar, there will be times when the
superincumbent lumbar spine must adapt to the fifth lum­
bar, as well as to the sacral base.
Figure 9.248 Left ILA (left thumb) in relation to sacral hiatus (right index
finger).
Position of the Sacral Base

Observation Interpretation

ILA on the left is·6t mm. more The sacral base is

posterior than the ILA on the rotated left, sidebent
right, and less than 6 mm. more right.
inferior than the right.

ILA on the left is 6+ mm. more The sacral base is

interior than the ILA on the sidebent left, rotated
right, and less than 6 mm. more right.
posterior than the right.

Always approach the ILAs from posterior first, never

from interior. The interior midline bones are coccyx, the
first bones to be encountered when approaching the ILA Figure 9.25 Observing the A-P symmetry of the ILAs. Examiner lowers
from interior. After the posterior surfaces of the ILAs are the line of gaze to look at the thumbs on the posterior surfaces of the
assessed tor sacral rotation, the thumbs are slid otf the inte­ ILAs, so that sacral rotation can be seen more easily. Rotation can
produce as much as a centimeter of A-P asymmetry.
rior edges of the sacrum, pulling skin with them. When the
pads of the thumbs are pressing superiorly against the infe­
Figure 9.26 Observing
rior edges of the sacrum, the sacrum can be assessed for
the craniocaudal sym­
sidebending.
metry of the ILAs.
Thumbs on the inferior
edges of the ILAs. Slide
the thumbs with the skin
from the posterior aspect ·

of the ILAs to their

inferior edges, turning
the thumb pads to press
superiorly. Examiner's
visual perspective is
moved to a vertical gaze
to detect superior-inferi­
or asymmetry of the ILAs.

Figure 9.24A Finding the ILAs just lateral to the sacral cornua, the bifid
spinous processes of S5 on either side of the sacral hiatus.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 171

Seated Trunk Sidebending Tests Figure 9.27 The seated

trunk sidebending test.
Unequal resistance to passive sidebending of the trunk The patient must sit
indicates an imbalance in the motion functions of spinal erect for this test, with
the examiner's body
segments. Passive sidebending tests are fairly focused at
close enough to touch
specific segments. However, the results are more indicative the patient's back.
of complex adaptive mechanisms than of single segment Sidebending (lateral flex­
ion) is tested with an
osteokinematics.
oblique translatory force
In performing this test stand close enough to the applied through the
patient to touch the patient's back with your chest or shoulder and aimed at a
specific vertebra.
abdomen. The patient must sit tall (remember the third
Instead of using the
law of spinal motion). The shoulders are translated side to arms, the examiner
side, keeping the translatory movement approximately hor­ should move his or her
whole body to move the
izontal. Move the patient's shoulders with your body, not
patient's shoulders.
with your arms. Sidebending pressure is aimed at specific
vertebrae to determine the area of greatest sidebending
restnctton. A transverse push with little obliquity will
sidebend the upper thoracics; more vertical pushes
sidebend lower segments. Alternate left and right pressure
and let the patient's weight shift from one buttock to the
other. Figure 9.28 The standing
Stiff resistance to passive sidebending is a palpatory trunk sidebending test.
The patient must not
experience. The focused sidebending pressures allow the
bend forward or back·
stiffness to be more precisely pinpointed. Although this ward when sidebending.
may feel like a single segment resisting sidebending, it is Observe the position of
the patient's fingers on
usually the sidebending resistance of an adapted group.
the side of the leg and
There is also a standing trunk sidebending test. When the shapes of the spinal
the patient performs active sidebending of the trunk first to curves.

one side and then to the other, the shapes of the formed
curves can be compared as mirror images. If the mirror
comparison shows asymmetry, there is an adaptive
sidebending curve resisting sidebending to the other side.
However, the most productive way to test trunk sidebend­
ing is with the patient seated. Compared with standing
tests, seated tests yield more information, partly because of
the palpatory aspect of the tests.
172 THE MUSCLE ENERGY MANUAL

Rib Screen for the Lower Thoracic Spine

Chapter 7 has shown how useful the ribs can be for spinal
diagnosis. These same principles may be applied to the
screening of the lower half of the thoracic spine. Just as it
was for the upper six thoracics, the seated position is pre­
ferred for rib examination, because it freely allows tor flex­
ion and extension of the spine. In clinical practice, the rib
screening procedures are rarely separated from the scan­
ning and lesion definition procedures. The key rib is quick­
ly identified and analyzed.
If the patient is bedfast, the breathing (and some posi­
tional) tests of the ribs can be performed with the patient
supine.

Figure 9.31 Rib angle contacts, patient seated. The patient moves the
scapulae laterally, out of the way, by placing the hands in the small of the
Figure 9.29 The seated
back and moving the elbows forward. Both A-Ppositional and Trunk
rib screen - middle rib
respiratory symmetry may be assessed with the patient slumped and then
screen -hand contacts.
arched, alternately.
Both A-Ppositional
symmetry and breathing
motion symmetry should
be assessed. Having the
patient slump and arch
the back makes the test
more sensitive to minor
ERS or FRS dysfunctions.

Figure 9.32 Prone examination of the ribs for lower thoracic screening.

Figure 9.30 Supine

middle and lower ribs.
Supine examination of
the ribs for lower
thoracic screening. The
patient may be able to
flex the spine by lifting
up the head and
shoulders.

Figure 9.33 Observing the effect of spine extension on respiratory motion.

The lower ribs can be screened with the palms flat on the lower ribs.or
they can be assessed a pair at a time. When respiratory restriction is
eliminated by spinal extension, the restriction is due to vertebral
segmental dysfunction with flexion restriction. Alternatively, extension of
the back may cause respiratory restriction I due to vertebral segmental
dysfunction).
 CHAPTER 9 �EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE 173

Figure 9.34 Superior view of the mechanism of ERS-L dysfunction (using Figure 9.35 Superior view of the mechanism of FRS-L dysfunction (using
L3 on L4 as an example). The L3 vertebra (light outline) is unable to slide its L3 on L4 as an example). The L3 vertebra (light outline) is unable to slide its
left inferior facet superior and anterior as it flexes on l4. right inferior facet inferior and posterior as it extends on L4.

Detailed Examination of the Lower

Thoracic and Lumbar Spine
A detailed examination, also known as scanning, is used to The scanning procedures for more detailed examination will
discover individual impaired functional units within a sus­ be covered in the following sequence:
picious region. The exact nature of the impairment should
• Basic Patient Positions used for Scanning T7 to�
then be determined with enough specificity to enable the
• Lower Thoracic Respiratory Rib Scan for ERS or FRS
designing of corrective therapy.
Segmental Dysfunction
ERS dysfunctions occur more frequently in the mid-to­
• Locating the Lumbar and Lower Thoracic Transverse
lower thoracic segments, while FRS dysfunctions are more
Processes
common than ERS dysfunctions in the lumbar segments.
This statistical perspective should not seriously influence • Diagnosing FRS Segmental Dysfunction

the diagnosis. Painstaking examination may disclose many • Testing for FRS Dysfunction: The Sphinx Test
surprises. • Diagnosing ERS Segmental Dysfunction
The movement patterns for dysfunction - FRS, ERS,
• Testing for ERS Dysfunction: The Seated Hyperflexion Test
and NSR types - are essentially the same from T3 toTn_12. - L5 to T7
The mechanism for abnormal movements ofT12 is slightly • Alternative Testing Positions: ERS and FRS Dysfunctions
different, however, because of the transition to lumbar type • The Slump-Sit Tall Test
zygapophyseal facets between T 12 and L1. As with all of • The Hip Drop Test
the other thoracic zygapophyses, the superior facets ofT12
are in a coronal plane facing backwards. The inferior facets
ofT12 are like lumbar zygapophyses in that they are convex
surfaces facing laterally and anteriorly. Segmental dysfunc­
tion of FSUs in the lumbar spine, L1-L5, cause palpable Note: One long-term consequence of chronic lumbosacral segmental
and observable A-P displacement of lumbar transverse dysfunction is dehydration of, and eventual degeneration of, the lum­
bosacral disc, which predisposes it to rupture or to fragmentation.
processes (Figures 9.34 and 9.35) in spite of the nearly
sagittal orientation of the zygapophyseal joints.
When the fifth lumbar is observably and palpably rotat­
ed, both in relation to the sacrum and in relation to the
iliac crests, probability is high that there is ERS or FRS dys­
function at the lumbosacral joint. There is a high incidence
of FRS dysfunction at L5, probably as a result of adaptation
stresses and strains. Somatic dysfunction is common in the
pelvis, especially the sacroiliac joints. When the lum­
bosacral joint becomes dysfunctional it is no longer able to
adapt to the movements of the pelvis in walking, bending,
and lifting. With lumbosacral dysfunction, the stress of
adaptation is shifted to other segments in the lumbar spine.
174 THE MUSCLE ENERGY MANUAL

Figure 9.36 The seated

slumped position for
thoracic and lumbar
evaluation procedures.
To achieve this position,
the patient is told to
"push your back out and
put your chin on your
chest."

Figure 9.38 Basic "Sphinx" position for thoracic and lumbar evaluation
procedures. The chin should be supported on the hands to permit relax­
ation of the spinal extensor muscles. Because of muscular relaxation, this
position enhances examiner reliability, and is preferable to the seated
extended position.

Figure 9.37 The seated

extended position for
thoracic and lumbar
evaluation procedures.
To achieve this position,
the patient is told to
"arch your back, push
your chest out, and
bend your head back to
look at the ceiling."

Figure 9.39 The hypersphinx position for thoracic and lumbar evaluation
procedures. The hypersphinx position is an alternative to the basic
"Sphinx" position, and may be used to achieve full extension in some sup­
ple patients.

Figures 9.36 - 9.40 Patient positions for detailed

examination of lower thoracic and lumbar spine.
Varying degrees of flexion or extension are
required to diagnose ERS or FRS dysfunction.

Figure 9.40 The seated hyperflexed position for thoracic and lumbar
evaluation procedures. The feet must be on a supporting surface, like the
floor. Some patients will not be able to hyperflex this far even if the feet are
supported. If the feet are allowed to dangle from the sitting surface, some
patients will lose their balance in the hyperflexed position and fall forward.
 CHAPTER 9 � EVALUATION & T x . OF THE LOWER THORACIC AND LUMBAR SPINE 175

Figure 9.41 Sit-Tall Test

Lower Thoracic Respiratory Rib Scan for
for T 12 rotation using
ERS or FRS Segmental Dysfunction 12th ribs. Respiratory rib
The lower rib respirator y scan is the most efficient ini­ motion tests for rib xii­

tial approach to segmental investigation of the lower patient is extended

(arched) while seated.
thoracic spine. The hyperflexed and Sphinx evaluation
positions to be discussed later may be used as supplemental
and confirmatory tests for the rib-based lower thoracic
diagnosis. Finger pad contacts for the bilateral respiratory
scan of the lower ribs are shown in Figure 9.1.

The Posterior Seated Test

1. The patient is seated erect, slumped or arched (partly
flexed or partly extended). You sit or stand behind the
patient.
2. One pair of ribs at a time, follow the contact points with
fingers and eyes- remember to use peripheral vision- as the
patient step breathes (see Chapter 5 ) .

3. Once the key rib has been identified, check the pair for
anteroposterior asymmetry of rib shafts, rib angles, and the
Figure 9.42 Slump Test
corresponding transverse processes. If checking the patient
for T12 rotation using
in a flexed position, it is worth going around in front of the 12th ribs. Respiratory rib
patient to get your line of sight tangent to the curve of the motion tests for rib xii -
back at the point being examined. This evaluation requires patient is flexed (slumped
forward) while seated.
both palpation and visual assessment to be sure the asym­
metry is bone, and not merely a soft tissue phenomenon.

Interpretation of Results
• When you have found the lowest rib with asymmetric
exhalation restriction, or the highest rib with inhalation
restriction, it is the key rib, and identifies the vertebra with
Type II, non-neutral segmental dysfimction.

• If slumped breathing shows key rib restriction which

becomes normal in extension (arched position), the dys­
function is ERS Type II.

• If arched position breathing shows key rib restriction

which becomes normal in flexion (slumped position), the
dysfunction is FRS Type II.

• The restricted rib tends to be on the side of facet

Figure 9.43 Seated
motion impairment. Therefore:
Hyperflexion Test for
a) If the key rib is restricted on the left in the slumped evaluating the position

position, the lesion is probably ERSL. of the twelfth ribs.

b) If the left key rib is restricted in the arched position,

the lesion is probably FRS Right. Diagnoses based on
the last two principles should be confirmed by observing
the transverse processes in the slumped and arched posi­
tions. If respiratory restriction spontaneously corrects
during the examination, do not assume that the vertebral
dysfunction also corrected. Check transverse process posi­
tion.

• If transverse process asymmetry does not coincide with

rib position asymmetry, the rib asymmetry is usually the more
valid diagnostic finding for segmental dysfunction. In com­
plex combinations of vertebral dysfunction and rib sublux­
ations, treat the suspected vertebral dysfunction first.
176 THE MUSCLE ENERGY MANUAL

Locating Lumbar and Lower Thoracic

Transverse Processes
The prone patient position is important for evaluating sta­
tic indicators of segmental dysfunction in the lumbar or
lower thoracic region. One advantage is that the prone
position reduces the myofascial tensions that can obscure a
more accurate reading of the asymmetries of transverse
processes and rib angles - both in terms of position and of
respiratory function - that accompany segmental dysfunc­
tion in the combined region.

Protocol for Locating Lumbar Thansverse Processes

- Patient Prone
1. The patient is prone, lying straight with arms at the
side. It is not necessary for the patient to rest the head on
the point of the chin. A more comfortable neck rotated
position is acceptable, since it usually does not rotate the
lower thoracics significantly.
2. Stand to the side of the patient that favors your dom­
inant eye, and locate the inferior lateral angles (ILAs) of the
sacrum by stereognosis, or by following the sacral hiatus to
the ends of the cornua. Determine if the sacrum is rotated
or sidebent. This method is described earlier in this chap­
ter, under sacral position.
3. Locate the tips of the transverse processes of the third
lumbar vertebra with your thumbs by following the fascial
plane separating the quadratus lttmborum muscles from the
iliocostales. Start with L3 because it has the widest trans­
verse processes of the lumbars and, therefore, is the easiest
to find by palpation. The tips of the transverse processes lie
in the same transverse plane as the superior corner of the
spinous process. Be gentle in your approach because ten­
der myofascial trigger points are frequently found near the
transverse processes of the lumbars, either in the quadratus
lumborum or in the iliocostalis muscle.
Note: Blanching of your own thumbnail beds is a fair indicator of the
uniformity of your pressure bilaterally. But it is preferable to have a
clear stereognostic sense of the location of the tips of the transverse
processes by palpating them through the epimysium separating the
quadratus lumborum muscles from the iliocostales muscles. Less
thumb pressure is required.
Figure 9.44 Finding L4. With the patient prone, the examiner stands at
the patient's side. The examiner places one hand at the top of the
patient's iliac crest, and the index finger of the other hand is pointed at L4.
The L4 spinous process is in the same transverse plane as the tops of the
iliac crests.
You must also judge whether the compressibility of the
myofascial tissues is bilaterally the same.
Find the transverse processes of the second and first lum­
bar vertebrae. They line up in the same transverse planes
as the superior corners of their spinous processes. These
transverse processes are significantly shorter. Their tips can
be approached through the same fascial plane, but it is
harder to get under the iliocostales muscles. It is sometimes
necessary to palpate them through the thin lateral border
of the erector spinae muscles.
Note: It is a good idea to identify both the first lumbar and the last
lumbar independently, using the nearly constant level of the iliac crests
to identify the fourth lumbar, and one of the thoracic landmarks (verte­
bra prominens, scapular spine, inferior scapular angle, for example) to
count down to the first lumbar. Then count those in-between, to con­
fiml the expected five lumbar vertebrae. Not all vertebral columns have
five lumbars; some have six, a few have four. These anatomic varia­
tions are usually due to modification of the fifth lumbar to become a
part of the sacrum, or separation of the first sacral segment from the
sacrum to become the sixth lumbar.

Find the fourth lumbar transverse processes in the plane

of the iliac crests. They are typically slightly narrower than
the third, but can be reached through tl1e same fascial
plane. The fifth lumbar transverse processes are between
the iliac crests, slightly above the level of the gluteal tuber­
cles, and are quite deep. Do not expect to feel hard bone
through two inches of muscle and fascia. However, these
tissues are somewhat compressible. Their compressibility
varies - firmer in the hyperflexed position because they are
stretched taut, softer in the hyperextended position
because of the slack in the tissues. You must judge whether
you are applying equal pressure with your thumbs as you
press them in toward the fifth lumbar transverse processes.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 177

Figure 9.47 Thumbs palpating the transverse processes of L4. Figure 9.50 Thumbs palpating the transverse processes of L1.

Figure 9.49 Thumbs palpating the transverse processes of Ll.

Figure 9.46 Thumbs palpating L5 transverse processes (just medial to
iliac crests).

Figure 9.45 Observing thumbs on inferior edges of ILAs for sacral Figure 9.48 Thumbs palpating the transverse processes of LJ.
sidebending.

Figures 9.45-50 Palpating lumbar transverse processes with the thumbs. The photographs show the palpation of the transverse processes for each of
the lumbar vertebrae. This is done to demonstrate the typical, but not universal, variation in width as one begins just above the sacral base (whose
position has been determined) on the fifth lumbar transverse processes and proceeds superiorly.
178 T H E M U SC L E E N E RG Y M AN UA L

The Procedure for Locating the Lower Thoracic

Transverse Processes - Patient Prone

l. Locate the twelfth ribs stereognostically, palpating with

your Aat palms. (Figure 9.52) Use the twelfth and eleventh
ribs as if they were the transverse processes of their respec­
tive vertebrae. After evaluating the anteroposterior sym­
metry of these ribs, test their breathing motion with the
step breathing tests.
2. From the tenth to the seventh thoracic vertebra, the
transverse processes are accessible to palpation in the fascial
cleft between the longissimus and iliocostalis muscles.
(Figures 9.51 and 9.54) They can also be found by sliding
the fingers medially along the rib shafts, following the ribs Figure 9.52 Stereognostic palpation of twelfth ribs is the easiest way to
locate them.
as they bend forward from the rib angles to pass in front of
the transverse processes. The sliding fingers will bump into
the transverse processes. As you palpate the tips of each
vertebra's transverse processes, evaluate each for antero­
posterior symmetry. Concurrently, observe each by sight­
ing horizontally to detect and quantifY rotation asymmetry.
3. Make comparisons. You should make special note of
any transverse process which is displaced posteriorly or
anteriorly compared with adjacent segments and with the
contralateral transverse process.
4. Palpate and observe the angles of ribs x, ix, viii, and
vii, making the same comparisons. (Figure 9.53) Do tl1e
rib angle findings agree witl1 the transverse process find­
ings? If they do not agree, make sure that a structural rib
lesion does not exist. If after treating any existing struc­ Figure 9.53 A-P comparison of tenth rib angles. Rib angles are easy to
feel stereognostically from ribs x- iii.
tural rib lesion they still do not agree, trust the rib findings
over the transverse processes. Transverse process positions
may be obscured by asymmetric tension in overlying mus­
cles.

Figure 9.54 Finding T10 transverse processes. Stereognostic palpation

with fingers parallel to erector spinae muscles between iliocostalis and
longissimus bundles, at T 10·

Figure 9.51 Cross section through the seventh thoracic vertebra. The
transverse process is close to the groove between the iliocostalis and the
longissimus.
 CHAPTER 9 .._,.EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 179

Interpretation of Preliminary Findings

Although these procedures are not
definitive tests, in the • Whatever positions you find the transverse processes
course of locating the transverse processes certain conclu­ in while the patient is prone, remember that those posi­
sions may be drawn. tions may change when the spine is flexed or extended.
• Rotation. Posterior displacement of the transverse If asymmetries disappear when the spine is flexed, then there
process of a vertebra corresponds with the direction of its is a non-neutral FRS dysfunction at the caudal end of the
rotation, i.e., if the left transverse process is displaced pos­ asymmetric group, and the group is adapting normally, i.e.,
teriorly, it is rotated to. the left. there is no Type I (NSR) lesion. If asymmetries disappear when
the spine is extended, then there is a non-neutral ERS dys­
Note: Recall that rotation is expressed in terms of the direction in function at the caudal end of the asymmetric group, and there
which the anterior face of the vertebral body is turning, and in terms of is no Type I lesion. Neutral dysfunctions (NSR) tend to show
what is happening to that vertebra in relation to the vertebra just below
the greatest asymmetry in mid-range neutral, becoming
it. The fifth lumbar is compared to the position of the base of the
slightly less rotated with flexion or extension.
sacrum, which can be assumed to be symmetrical if the inferior lateral
angles (ILAs) of the sacrum are level, both in a transverse plane (i.e., not
rotated) and in a coronal plane (i.e., not sidebent). If the inferior later­
al angles of the sacrum indicate rotation, the base of the sacrum is
rotated toward the posterior ILA and sidebent to the other side. If the
ILAs indicate that the sacrum is sidebent, the base of the sacrum is
sidebent to the inferior side and rotated toward the other side. You
must take the sacral position into account when evaluating the fifth
lumbar.

• From your exam, you have determined if any of the

lumbar or lower thoracic vertebrae are rotated, which ones,
which direction they are rotated (left or right), and how
much they are rotated.

Note: From Chapter 3, recall:

T ype I lesions involve multiple vertebrae. The amount of inter­

segmental rotation is relatively small, and does not change much with
flexion and extension; that is, the rotations do not completely disappear
with either flexion or extension. Usually the middle segment of the
group, the apex, is the point of maximal rotation. Type I lesions cannot
be distinguished from normal adaptations of the spine until the Type II
lesions and other postural asymmetries are eliminated.

• Type II lesions involve a single vertebra. The amount of interseg­

mental rotation is relatively large, and worsens or disappears with flex­
ion or extension. These lesions are usually located at the bottom of a
rotated group, but may be located at the top of an adapting group.

• Severity of rotation in NSR (group) adaptations and

lesions. Having examined all the vertebrae within the group,
the degree of the rotation of an individual vertebra may be
graded. The most extremely rotated individual vertebra will
usually be found at the bottom of a group adaptive curve,
with all segments appearing to be rotated toward the same
direction. The amount of segmental rotation in a Type
II lesion (ERS or FRS) will be two to four times greater
than the segmental rotation of an individual vertebra
within an adaptive group or a Type I (NSR) lesion.
Remember that the small rotations of vertebrae within adap­
tive groups are added to the rotation of the primary Type II
.
dysfunction as far up as the apex of the group. Thus the most
posterior transverse process in relation to the coronal plane
will be at the apex of the group, and not necessarily at the
Type II lesion.
180 THE MUSCLE ENERGY MANUAL

Diagnosing FRS Segmental Dysfunction

Arching the erect seated posture to evaluate spinal seg­
ments and ribs may not result in enough extension of the
vertebral segments. For the lower thoracic and lumbar seg­
ments, a prone position with the shoulders pushed up,
(which has come to be known as the "Sphinx" or the
"hypersphinx" position) ensures full extension for defini­
tive testing of FRS dysfunction for T7 through L5. The
method of palpating is exactly as previously described in the
protocol for locating lower thoracic and lumbar transverse
processes - prone position. The tips of the transverse
processes of each of the lumbar vertebrae are palpated
sequentially from the sacrum upward. Then the shafts of
Figure 9.55 Prone Sphinx Test. The shafts of ribs xii and xi, the angles of
ribs xii and xi, the angles of ribs x -vii, and the transverse
ribs x- vii, and the transverse processes of T7_10 and L1_5 can be
processes of vertebrae ten, nine, eight, and seven are pal­ palpated and visually assessed for positional symmetry and respiratory
pated and observed. restriction in this position.

Testing for FRS Dysfunction 1 Range: T7- L.sl

The Sphinx Test Procedure Protocol
l. The patient is prone on the table.
2. Instruct the patient to «Raise your shoulders up off the
table and rest your chin in yottr hands.» The elbows should
be directly under the shoulders, making the humerus as
near vertical as possible.

Note: Hypermobile patients (or for a very minor FRS dysfunction) may
require the "hypersphinx" position for maximum extension .

3.a. You stand at the side, adjusting yourself so that your

eye level allows sighting on the midline as you palpate, as
shown in Figures 9.55 and 9.56.
3.b. Alternatively, you may look at your fingers trom a
cephalic perspective tor a more tangential view. (Figures Figure 9.56 Testing L1 for FRS dysfunction using the Hypersphinx Test.
9.57-9.59)
4. Make comparisons with the asymmetries seen in the
Figure 9.57 The hyper­
prone "neutral" (Figure 9.60) and seated hyperflexed posi­ sphinx scan of L3 or L4
tions (Figure 9.61). -cephalic perspective.
 CHAPTER 9 -f> EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 181

Figure 9.60 Prone

neutral examination
position. Prone finger
contacts on lateral ends
of ribs xii to follow
breathing action or
positional change.

Figure 9.58 Cephalic perspective of the Sphinx position- tangent view.

Examining T9- T10 transverse processes. The low table position
facilitates this examination. (This photo is reproduced from the 1973
ICEOP manual. Neil Pruzzo is the examiner.)

Figure 9.5!1 Cephalic

perspective of the
hypersphinx position.
Ribs xi or xii are being
palpated instead of the
transverse processes to
evaluate T11- T12· Note:
unless the operator is
very tall, it may be
necessary to stand on a
stool to get this
advantageous view.

Figure 9.61 The seated hyperllexed position. Transverse process and rib
findings in this position are to be compared with findings in prone
"neutral" and "Sphinx" positions.
182 THE MUSCLE ENERGY MANUAL

Diagnosing ERS Dysfunctions T7 - L5

The Seated Hyperflexion Test
The purpose of the Seated Hyperflexion Test is to discover
emergent rotatory asymmetry of vertebrae caused by
hyperflexing the spine. Thus, the static positions of trans­
verse processes and ribs are observed while the patient
remains hyperflexed.
When the patient is hyperflexed with the elbows and
shoulders between the knees, only shallow breathing is pos­
sible, especially with an adipose abdomen. For the breath­
ing tests, therefore, it is best to allow the patient to sit
erect, slumping to flex the lower thoracics, and arching the
back (protruding the abdomen) to extend them.
It is as important to discover a symmetrical verte­
bra in the hyperflexed position as it is to find an asym­
metrical one, especially if the symmetrical vertebra was
Figure 9.62 Diagnosing ERS. Palpatory location of lumbar transverse
rotated in the prone neutral or hyperextended position.
processes and the posterior portion of the rib shafts to observe them for
Some FRS dystunctions do not become symmetrical until rotation asymmetry caused by hyperflexing the spine.
they are forced into complete flexion. If the test stops
short of tull flexion, you might erroneously conclude that
the dysfunction is NSR instead of FRS.
To ensure tull flexion of segments T 7 to L5, a more
protound seated flexed position is required. The patient's
static position is the same as the first step in the Seated
Flexion Test (Screening Test Step SA, Volume 1 ). To
improve the parallax view of the transverse processes or rib
angles, it can be worthwhile to step around to the front of
the patient and arrange your line of sight parallel to the
curve of the back.
Observing paravertebral fullness with the patient in
this position was described as a screening procedure in
Volume 1, and earlier in this chapter. We will now use the
seated flexed position for segmental evaluation. Procedures
for the thoracics are slightly different from the lumbar pro­
cedures, but the patient's position remains the same. In Figure 9.63 Diagnosing ERS. Examiner assumes a tangent view of the
the thoracics, rib position as well as transverse process flexed spine curve from either in front of or behind the patient. If
asymmetry occurs in flexion, but not in extension, a diagnosis of ERS can
position is observed.
be made.
 CHAPTER 9 � EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 183

Testing for ERS Segmental Dysfu.riction:

Ls-T7

The Seated Hyperflexion Test Procedure Protocol

l. The patient sits on a low stool with the feet and knees
shoulder width apart, and bends forward hanging the
elbows between the knees. Be sure that the patient
achieves full trunkal flexion. To this end the patient is
instructed to «Put your elbows between your feet.» Although
this is an impossibility unless the patient is a contortionist,
it should result in a maximum flexion effort by the patient.
2. You either sit behind the patient or kneel in front. If
you squat or kneel in front of the patient, you can take a
position from which you can sight over your palpating fin­
gers.
Figure 9.64 Seated hyperflexed position for lumbar ERS diagnosis, �
3. Starting with the fifth lumbar transverse processes contacts. The thumbs start lateral to the transverse process tips at the
(between the iliac crests) - and evaluating their rotated edges of erector spinae, and press medially toward the transverse
position relative to the iliac crests - assess each pair of lum­ process tips.
bar transverse processes for rotation (Figure 9.64 ).
Note: Remember to follow the fascial plane between the iliocostalis
Interpretation of FRS and ERS Test Results
(which is at the lateral edge of the erector spinae muscle fullness) and
Interpretation depends on the combined results of the seat­
quadratus lumborum muscles when approaching the transverse
ed hyperflexed, flat prone, and Sphinx tests. No firm con­
processes of L1 - L4. Even though the flexed position tightens the mus­
cles and fascia, this deep fascial plane is still the most direct route to clusions can be drawn from a single observation of static
the transverse processes of these vertebrae. The transverse processes position. Taken together, the flat prone, seated hyperflexed,
of L5 cannot be accessed through this plane. The myofascial tissues and prone hyperextended (Sphinx) tests are interpreted in
which lie over the fifth lumbar transverse processes will feel very hard the same way as previous A-Ppositional symmetry tests.
and incompressible. You must judge whether you are applying equal
pressure with your thumbs as you press toward the tips of the fifth lum­ • Whatever positions you find the transverse processes
bar transverse processes. You must also judge whether the compress­ in while the patient is prone, remember that those posi­
ibility of the myofascial tissues is bilaterally symmetrical. Your eyes
tions may change when the spine is flexed or extended.
should be in a good position to sight your thumbs for anteroposterior
If asymmetries disappear when the spine is flexed, then there
symmetry.
is a non-neutral FRS dysfunction at the caudal end of the
asymmetric group, and the group is adapting normally, i.e.,
4. Locate the twelfth ribs stereognostically, with one
there is no Type I (NSR) lesion. If asymmetries disappear when
index finger placed on each rib as far laterally as the tips of
the spine is extended, then there is a non-neutral ERS dys­
the ribs. If there is a noticeable difference in the size of the
function at the caudal end of the asymmetric group, and there
two ribs, put your fingers on the longer rib a symmetrical
is no Type I lesion. Neutral dysfunctions (NSR) tend to show
distance from the midline.
the greatest asymmetry in mid-range neutral, becoming
5. Test each pair of ribs in a similar manner, looking for
slightly less rotated with flexion or extension.
anterior-posterior asymmetry.
6. Examine the transverse processes from T10 up by pal­
pation and observation. Slide your thumbs or finger pads
from the rib angles medially and anteriorly to the contacts
on the transverse processes, and observe them for A-Psym­
metry. The thumbs or fingers should be in the groove
between the iliocostalis and longissimus muscles.
If a vertebra is rotated, the asymmetry will be slightly
greater at the rib angles than at the tips of the transverse
processes, because the rib angles are farther from the y-axis
of rotation.
184 THE MUSCLE ENERGY MANUAL

Figure 9.65 Seated

Alternative Testing Positions for Lower
slumped lumbar trans­
Thoracic and Lumbar ERS and FRS verse process palpation.
Dysfunctions
Alternate Test: The "Slump-Sit Tall" Thansverse
Process Test Protocol
l. Patient sits on the examining table or on a low stool.
2. Sit behind the patient and palpate the lumbar trans­
verse processes, thoracic transverse processes, or ribs, to
monitor changes in the vertebra's position through the
range of flexion and extension.
3. Ask the patient to «stump,» and then <<sit tall,'' and
follow the transverse processes or ribs to see if any of them
indicate rotation with flexion or extension.

Note: This method will detect a high percentage of lumbar and lower
thoracic dysfunctions. and takes very little time. A disadvantage is the
back muscle action, which can distract inexperienced examiners. espe­
cially at the fifth lumbar. The Seated Hyperflexion and the prone Sphinx
tests avoid the muscle action distraction.

Interpretation of Results Figure 9.66 Seated

arched lumbar trans­
• If there are no rotated vertebral segments in any
verse process palpation.
position, seated hyperflexed, prone flat, or prone hyperex­
tended (Sphinx), then there are no segmental dysfunctions
of the tumbars or lower thoracics. Rotation of the fifth
(last) lumbar is evaluated in comparison to the sacrum. If
the I LAs indicate that the sacrum is rotated and the fifth lum­
bar looks straight with the coronal plane, then the fifth lum­
bar is rotated as much as the sacrum is, but in the opposite
direction. This is the usual adaptive relationship found with
sacroiliac dysfunctions, and the fifi:h lumbar will usually
straighten spontaneously once the sacrum is treated. How­
ever, if the fifi:h lumbar shows rotation which disappears with
flexion (FRS) or extension (ERS), and is maximized in the
opposite position, the rotation is not adaptive, and, there­
fore, requires treatment in advance of treating the pelvis.

Comment: When the patient is unable to lie prone because of pain or

spasm. diagnostic examination may be done with the patient standing
at the end of the examination table supporting the shoulders with the
arms or elbows (semi-recumbent position). Additionally, rib scans for
segmental dysfunction may also be done with the patient supine
(recumbent position).
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 185

Alternate Test: The Hip Drop Test Figure 9.67 The Hip Drop
Test for assessing the
Originally presented as a screening procedure, the Hip
symmetry of lumbosacral
Drop Test also qualifies as a specific lumbosacral motion sidebending. The patient
test. The comparison of distances the iliac crests drop bends one knee while
is directly related to the sidebending mobility of the keeping the other straight
The examiner's hands
fifth lumbar on the sacrum. For example, if the right iliac
stay on the iliac crests
crest drops more than the left, it is due to the fact that the
while the patient performs
fifth lumbar is able to sidebend more to the left than to the the test on both the left
right. The distance the crest drops is not influenced and right sides, estimating
noticeably by dysfunctions of other spinal segments. the distance the hip drops
from the starting position.
Observing the contour of thoracolumbar curvatures form­
ing during the Hip Drop Test serves as a screening proce­
dure for the thoracic and upper lumbar spine. The infor­
mation pertaining to the fifth lumbar sidebending mobility
can be interpreted in the light of observations of fifth lum­
bar rotated positions in flexed, neutral, and extended posi­
tions.

The Hip Drop Test as a Lumbosacral Test

[Range: L5 Sd -

l. The patient stands erect, weight evenly on both feet,

which are about 4 inches apart, toes straight ahead.
2. Squat or sit behind the patient and palpate the highest
points of the iliac crests. With your hands on the iliac crests
to observe their position, make sure your eyes are at the
same level as the hands.
3. Instruct the patient to support the entire weight on
one leg, flexing the opposite knee and making a simultane­
ous etTort to keep the upper body erect. This produces the
hip drop effect on the side of the flexed knee. Have the
patient do the same on the other leg.
4. Observe the amount of hip drop on each side and esti­
mate the distances quantitatively.

Interpretation of Results
• Hip drop distance should be equal bilaterally. If one
hip does not drop as far, L5 * has restricted sidebending to
the opposite side.

*(Ls connotes "lumbosacral junction," even if there are an

even number of lumbar vertebrae.)
186 THE MUSCLE ENERGY MANUAL
Treatlnent Procedures for Non-Neu tral
(Type II) Dysfu nc tions of the Lower
Thoracic and Lumbar Spine
In this section, we will address the treatment of non-neu­
tral dysfunction for vertebral segments T7 - L5. The treat­
ment protocols will start with the procedures designed to
treat ERS segmental dysfunction - patient seated, followed
by the procedures designed to treat FRS dysfunction -
patient seated. The section will conclude with the Lateral
Recumbent procedures for treating ERS and FRS segmen­
tal dysfunction in the lumbars. To serve as a quick refer­
ence for this section, the following lists the sequence of
treatment procedure presentation:
Treatment of Type II Non-Neutral
(ERS and FRS) Dysfunctions
A. Treatment of ERS Segmental Dysfunction
l) The 50-Step Procedure (Range T7- L5)
2) Alternative Short-Cut Treatment for ERS
Dysfunction (Range T7- L5)
B. 71-eatment of FRS Segmental Dysfunction
I) The 500-Step Procedure (Range T7- L5)
2) Alternative Short-Cut Treatment tor FRS
Dysfunction (Range T7- L5)
3) The 499-Step Procedure (Range T7- L5)
C. The Lateral Recumbent Treatment of ERS and
FRS Segmental Dysfunction
1) The Lateral Recumbent Treatment of Lumbar
ERS Segmental Dysfunction (Range L3- L5)
2) The Lateral Recumbent Treatment of Lumbar
FRS Segmental Dysfunction (Range L3- L5)
Treatment for ERS Segmental Dysfunction
The 50-Step Procedure f Range: T7 to L5j
Patient Position. The patient's starting position for the
50-Step Procedure is with the lesioned segment in neutral.
If the flexion restriction is great, i.e., more than 50 percent
of the range of flexion motion lost, then the starting posi­
tion will have the patient arched up into relative extension,
not just s1ttmg erect. Whatever degree of extension is
needed for the patient position, it is important that the
patient be balanced and relaxed, and be able to stay in the
position with minimum effort. Thus, arching the back to
extend the spine should be accomplished by translating the
middle of the spine forward, rather than by leaning back­
wards. In the process of localizing sidebending of the ver­
tebral segment, the segment should be translated laterally
rather than leaning the shoulders to the side. The patient
is seated on a chair or stool with the feet flat on the floor.
The patient's hand on the same side as the posterior trans­
verse process is then placed on top of the shoulder opposite
to the side of the posterior transverse process.
Operator Position. To make smooth transitions from
one stage of the procedure to the next, and to avoid unnec­
essary strain on the operator, your own proper positioning
is important as well. The position must allow for enough
maneuverability to reposition the patient's shoulders dur­
ing the treatment. The patient's shoulders are to be held
between your hand and shoulder. It is best not to get your
shoulders down at this level by stooping or bending,
because staying in that position for 30 to 60 seconds can
fatigue your back. A much better way to lower your shoul­
ders is to put your feet apart and bend your knees. This
position permits moving the trunk to reposition the
patient's shoulders without having to move your feet. On
the other hand, there is no rule against moving your feet.
If necessary, move your feet in order to keep your body in
an unstrained, comfortable, and relaxed state. Balance and
relaxation are as important for you as for the patient.
Precise localization depends on it.
Determining Neutral. Finding neutral for the seg­
ment is the starting point for the actual treatment proce­
dure. Determining when a vertebral segment is in neutral
is done by palpating the spinous processes of the two ver­
tebrae of the motion segment (FSU). When the segment
is in neutral, its superior vertebra flexes and extends freely
and symmetrically on the inferior vertebra, causing the tips
of the spinous processes to separate and pinch together
respectively. When the segment is no longer in neutral, this
action of the spinous processes in response to flexing and
extending the vertebral column is altered and is barely pal­
pable. Looking for the neutral position involves passively
flexing and extending the vertebral column while palpating
the space between the two spinous process tips. If, in the
examination of this segment, its transverse processes were
observed to remain asymmetrical until the segment was
nearly fully hyperextended, it makes no sense to induce pas­
sive flexion and extension while the patient is sitting erect
or sitting slumped. We already know that the neutral range
will be found near the end of the hyperextended range.
Engaging the Barrier. Once neutral has been estab­
lished, the next step is to engage the sidebending barrier.
Engaging the barrier does not mean moving to a locked
position. It is important to remain in the neutral range just
before, but not into, the barrier. With each successive
repositioning the movement is subtle and must avoid mov­
ing into a locked position, staying at the barrier within the
neutral range. The principles of barrier engagement in
Muscle Energy technique are the same for high velocity
low amplitude (HVLA) thrust technique, or should be. The
fact that HVLA thrust technique often successfully mobi­
lizes a segment which has been positionally locked is too
often a testament to the forcefulness of the procedure, not
its precision.
 CHAPTER 9 -f) EVALUATION & T x . OF THE LOWER THORACIC AND LUMBAR SPINE 187

Treatment Sequence. You stand, with feet apart and The duration of isometric contraction is not a fixed
knees slightly flexed, on the side of the posterior transverse time. One or two seconds is sufficient, provided the
process. Positioned near the patient's knee, put your for­ amount of force is appropriate. Sustaining the force longer
ward shoulder or arm up under the patient's axilla on the than two seconds may allow time for the patient to gradu­
ally increase the torce until you can sense that the force has
side of the posterior transverse process, then reach across in
acted on the segment being treated. Once that occurs, you
front of the patient to hold the patient's far shoulder with
can say, «Relax. JJ
that hand. Palpating the spinous processes to monitor
At the conclusion of the procedure, trunk rotation is
motion between the two involved vertebrae, you must
maintained by holding back the far shoulder with the pal­
determine when the joint is in neutral (or what is left of it).
pating (posterior) hand, and the patient is instructed to flex
While staying in the neutral range, the involved verte­
the trunk down between the knees, leading with the near
bra is then sidebent away from you by translating that
shoulder. After full flexion is gained, the far shoulder is
region of the patient toward you (by pulling the patient's
guided forward between the knees to full symmetrical flex­
far shoulder toward the segment) until the sidebending
ion. Check the transverse processes to see if the treatment
barrier is engaged. Take care to maintain postural balance
was successful, and then allow the patient to straighten and
while doing so. To test sidebending localization the shoul­
sit up.
ders are rotated away from you. You must turn your whole
This last (full flexion) maneuver has the effect of
body with the patient's shoulders. If sidebending has been
stretching out the concavity of the adaptive curve above the
precisely localized, very little rotation should be palpable.
ERS dysfunction. This occurs as the one shoulder leads the
No flexion localization should be attempted at this point.
flexion motion. Complete release of the ERS dysfunction
Flexion mobility will not be available until after the
sometimes does not occur until this final stage of the pro­
sidebending/rotation release.
cedure.
Maintaining this localized position, instruct the patient
to press the near shoulder down sideways against your
resisting shoulder with a force of one or two pounds for
two or three seconds. On the command «Relax)) the
patient must stop pushing completely, and relax in the bal­
anced position. When relaxation is complete enough,
reposition the vertebra to the new sidebending barrier, tak­
ing care to maintain postural balance. The isometric con­
traction and post-isometric relocalization are repeated two
more times, or until a release is sensed, indicated by a sud­
den increase in rotation mobility.
In eliciting the patient's cooperation, the more precise
the instructions the better. Thus, to focus the action on an
individual segment, it is most precise to ask the patient to
pull the scapula tOJvard the segment. Rather than just say­
ing, «Pull, JJ specifY the amount of force to be used and how
long: «Using two pounds of force, pull your left scapula
against me toward this point on your back where my palpat­
ing fingers are..... Now stop pulling, and relax. JJ Tapping
your finger on the patient's back (or the segment being
treated) gives the patient something to aim at, and increas­
es the precision of the action. The amount of force should
increase slightly as you go down the spine, from about
eight ounces (250 grams) at T7, to two pounds (l kilo­
gram) at L5 in half- or one-pound increments. One does
not expect that either you or the patient will have an exact
idea of what eight ounces of force feels like. But quantifY­
ing the force by putting a number on it gives a basis for
negotiating up or down the scale. The actual amount of
force desired is the least amount necessary to produce a
palpable twitch of movement at the segment.
188 THE MUSCLE ENERGY MANUAL

Figure 9.68 Step 1 of Figure 9.69 Step 2.

the 50-Step procedure The operator lifts the
for treating L3 ERSL of patient's elbow to allow
any functional spinal the operator's arm to be
unit (FSUI from T7- Ls· placed snugly under the
axilla, reaching across
the chest to hold the
shoulder.

Figure 9.70 Steps 1, 2, 3,

The 50-Step ERS Treatment Protocol
and 4 of the 50-Step
I. The patient is seated on a chair or stool, teet flat on
procedure for treating
the floor. The hand on the side of the posterior transverse T8 ERSL. Extending the
process is placed on top of the opposite shoulder. This segment to the

facilitates getting yottr shoulder underneath the axilla. "neutral" range. By

palpating the spinous
2. Stand with your feet apart and knees slightly flexed on
processes of the two
the same side as the posterior transverse process near, or
involved vertebrae (for
even astride, the patient's knee. Put your forward shoulder example, T8 on T91 to
and arm up under the patient's axilla and reach across in feel bone movement,

front of the patient to hold the patient's tar shoulder with the operator determines
when the joint is in
that hand. (Figure 9.69)
neutral.
3. Palpating the spinous processes to monitor motion
between the two involved vertebrae of the lesioned seg·
ment, determine when the joint is in neutral. Start from a
position of hyperextension, and alternately translate the
segment backward and forward to flex and extend the ver­
tebral column in that region. When the spinous processes
pinch and gap, the segment is in neutral. When they do
not pinch or gap, the segment is not in neutral. (Figures
9.70 and 9.71)
 CHAPTER 9 � EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 189

Figure 9.71 Steps 3 and Figure 9.72.a Steps 5

4 of the 50-Step proce­ and 6. Right sidebending
dure for treating l3 is localized to the L3.4 joint
ERSL While palpating by pulling the patient's
the spinous processes right shoulder toward
for pinching and the palpating finger and
gapping, extend the lifting up on the left
segment to its "neutral" shoulder. The lumbar
range. spine translates to the
left- Step 5. Right
rotation is added to the
localized position-
Step 6.

4. Sta�ting from neutral, find the flexion barrier by trans­

lating the vertebra posteriorly (to maintain the patient's
postural balance). Then, extend the segment slightly into
the neutral range by translating the vertebra anteriorly until
the interspinous gapping action is no longer felt. (Figure
9.71)
5. The involved vertebra is ilien sidebent away from you
by translating it toward you, pulling the far shoulder
toward the segment, and lifting up on the near shoulder,
until the sidebending barrier is localized. (Figure 9.72)

Note: Applying the 50-Step procedure to different vertebral levels

requires making adjustments in the method of sidebending localization.
For thoracics 7 through 12, the emphasis is on pulling the far shoulder
toward the vertebral segment to create a spinal concavity on that side
with the apex at the segment being treated. This requires some trans­
lation of the patient's trunk toward you. In the upper lumbars, there
needs to be more shifting of the seated weight onto one side of the
pelvis, with more downward pressure on the far shoulder and more lift­
ing on the near shoulder. To localize sidebending to the fifth lumbar
segment. the far hip may need to be lifted off the seat as the weight on
the pelvis is shifted toward you.

Figure 9.72.b Step 7. The operator's left arm is passed underneath the
patient's axilla IAI, to hold the far shoulder ICI. By drawing the patient's
shoulders toward him, the operator creates additional right concavity to
increase right sidebending at IBI. The arrow 101 shows the direction of
the patient's isometric pull, repeated three times in Step 7.
190 THE MUSCLE ENERGY MANUAL

6. Next, the shoulders are rotated away from you to Figure 9.73 Steps 8 and
ascertain the precision of sidebending localization. If 9. After the patient
relaxes following the
sidebending is properly localized, there should be very lit­
third isometric pull, trunk
tle rotation slack available. You must turn the whole trunk
rotation is then main·
with the patient's shoulders. For this step it is often neces­ tained by holding back
sary to ask the patient to hang the far hand off the side the far shoulder with the

down toward the floor. Otherwise, dragging it across the palpating (posteriori
hand; the patient is
lap may cause some resistance.
instructed to flex the
7. Maintaining this localized position, instruct the
trunk down between the
patient to press the near arm down sideways and backwards knees, leading with the
against your resisting shoulder with a force of one or two near shoulder.

pounds for two or three seconds. «Using ("2 pounds" or

"1 kilogram") of force, pull your left scapula against me
toward this point on your back where my palpating fingers
are... (wait two seconds). No1v stop pttlling and relax!" On
the command «Relax" the patient must stop pushing com­
pletely, and relax in the balanced position. For this to
occur, you must relax, also. When relaxation is complete
enough, reposition the vertebra to the new sidebending
barrier, taking care to maintain postural balance and stay­
ing on the "neutral" side of the barrier.

Comment: Of historic interest is the isotonic version of step 7 of the

above procedure. Instead of contracting the muscles on the concave
side of the dysfunction the patient is instructed to attempt to touch the
floor with the hand of the arm farthest from you as you oppose the
motion. This contracts the muscles on the convex side of the dysfunc­
tion. The lateral translation of the spine toward the operator is unop­
posed, even though the downward movement of the shoulder is
opposed. The patient's muscles are doing the work of pulling the ver­
tebra through its restriction. depending on the inhibitory effect of the
forceful contraction on the shortened muscles on the concave side. The
force of the contraction is much greater, and, therefore more work for
the operator to resist the motion of the shoulder. After 5-10 seconds of
isotonic contraction, the patient is told to relax, and the operator relo­
calizes to the new barriers. This is how Fred Mitchell. Sr.. originally
treated ERS dysfunctions of the lower thoracics and lumbars. He began
using the light isometric technique in the early 1960s, including the final
"rollout." F. Mitchell, Jr. added the operator and patient positioning
details. and began teaching the revised technique in 1964 at the Kansas
City College of Osteopathy and Surgery.
 CHAPTER 9 -& EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 191

8. When sidebending releases, more rotation slack is cre­ Figure 9.74A Step 9. Tell
ated. This means that more flexion is possible. Usually a the patient, "Put your
left elbow between your
full symmetrical range of motion is restored at this point.
feet." Guide the left
Occasionally, only a partial release occurs, necessitating one shoulder between the
or two more repetitions of steps 5, 6, and 7. After the third knees and restrain the
repetition it is reasonable to assume that complete release right shoulder by hold­

has occurred, even if you did not feel it. At this point, you ing it back.

no longer straddle the patient's leg, but should be posi­

tioned to the side of the patient to make room for the
patient's trunk flexion.
9. Trunk rotation is then maintained by you. To main­
tain rotation you must hold back the far shoulder with the
hand which you had been using to palpate posteriorly
between the spinous processes. Instruct the patient to flex
the trunk down between the knees, leading with the near
shoulder. (Figure 9.74.A and B)
10. After full flexion is gained, the far shoulder is guided
forward between the knees to full symmetrical flexion.
Check the transverse processes to see if the treatment was
Figure 9.748 Step 9,
successful, and then allow the patient to straighten and sit
(continuedI.
up. (Figure 9.74.C) Full flexion is attempted,
while keeping the trunk
Note: For patients with painful lower back muscle spasm. it is a good rotated. This stretches
idea to assist the patient up from the hyperflexed position. Do this by the right polyarticular

placing the palm of your hand on the sternum. instructing the patient to sidebenders.

mildly resist your efforts to return him or her to the fully erect seated
position. The patient's forward push relaxes the spastic extensor mus­
cles. and passive straightening with this method is usually painless.

Figure 9.74C Step 10.

After full rotated flexion,
the right shoulder is
released and the patient
is told to "Put your right
elbow down with the
left one."
192 THE MUSCLE ENERGY MANUAL
Figure 9.75.a Short-Cut
treatment for ERS-R,
(using T 7 to demon­
strate). After finding the
neutral range of the
segment, sideband the
patient left by reaching
over to the right
shoulder from above the
left shoulder (Step 3).
Alternative Short-Cut 1reatment fur ERS Dysfunction
f Rat1ge: T7- L5}
The illustrations show treatment for a segment with
restricted flexion, left rotation, and left sidebending (posi­
tionally: extended, rotated and sidebent right, or ERS
Right).
The Procedure Protocol
l. Patient is seated on or astride the end of the treatment
table. You stand behind the patient near the side opposite
the posterior transverse process, i.e., the side toward which
you wish to rotate the vertebra.
2. Patient clasps the fingers together on the back of the
neck. Or, alternatively, if the patient's arms are very short,
one hand can hold the back of the neck while the hand near
you holds the flexed elbow of the opposite arm.
3. Reach across in front of the patient, with your arm
over the patient's near arm and your hand holding the back
of the patient's far shoulder (the scapula or humerus),
which is on the side of the posterior transverse process. In
this way it should be easy to sidebend and rotate the
patient's trunk toward you. Very short operators may need
to seat the patient on a lower surface.
4. W ith your free hand, palpate the spinous processes of
the involved segment to detect the neutral range and to
monitor localization as the patient's trunk is sidebent pas­
sively toward you. (Figure 9.75.a) Translate the segment
forward and backward to find the flexion end of the neutral
range, i.e., before the vertebra is forced to rotate in order
to flex. For example, while palpating L5-S1 interspinous
space, adjust the spine position to L5-S1 neutral (facets not
engaged, spinous processes free to pinch and gap). From
that position sidebend the spine toward you, stopping as
soon as spinous process movement is felt. To restore pos-
Figure 9.75.b Treating
T 11 ERS-R. "Taking up
the slack." Relocalizing
to the barriers for
sidebending, rotation,
and flexion- in that
order.
tural balance and facilitate relaxation, the monitored point
of localization is translated away from you by leaning your
body against the patient while pulling the shoulders toward
you.
5. After sidebending is localized, and the patient is re­
balanced and relaxed, the rotation is localized by turning
the patient's shoulders slightly toward you until the verte­
bra either moves, indicating sidebending was not precisely·
localized, or the inferior vertebra of the segment moves,
indicating that you should back otl the rotation a little.
6. The patient is instructed to make a rotational push
with the far shoulder using one pound of force, back and
down toward the segment against your resisting hand for
two to three seconds, and relax. «Pull this shoulder (tapping
shoulder) back and down toward this vertebra (tapping
spinous process) with one pound of force... (Wait two sec­
onds.) Relax.» The instruction, «straighten your back,))
has often been used in this context, but lacks precision.
7. Wait tor relaxation. Then relocalize to the new
sidebending motion barrier, adjusting the rotation and flex­
ion localization as appropriate. Remember to take up the
slack one plane of motion at a time: sidebend, rotate, flex.
8. Steps 6 and 7 are done three times, or until the desired
release is obtained.
9. The patient is reexamined in the seated hyperflexed
position for spinal symmetry.
 CHAPTER 9 -fJ. EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 193

Figure 9.76.a The

Treatment for Obliquus Abdominis
Muscle Energy
Imbalance Treatment for tight
abdominal oblique
A fairly frequent finding is tension inequality between the
muscles. Positioning
left and right
obliquus muscles of the abdomen (see page for treatment stops
164). The obliquus muscles are polyarticular trunk rota­ passive rotation of
tors. Both internal and external obliques are ipsilateral the trunk at the first
sidebenders. Tight external oblique muscles on one side sense of increasing
resistance. Each
(palpable at the intercostal angle) restrict trunk rotation to
repositioning follows
that side. Tight internal oblique muscles on one side (pal­ this same principle.
pable in a lower abdominal quadrant or above the iliac
crest) restrict trunk rotation to the opposite side.
The myofascial tensions are capable of generating or
maintaining segmental dysfunction, especially in the lum­
bar spine and occasionally in the lower thoracic spine.
Because the oblique muscles are prone to tightness, evalu­
Figure 9.76.b Final
ation of them should be incorporated into screening exam­
outcome should be
ination procedures for the thoracic and lumbar spine.
about 90 degrees of
The treatment procedure requires pure axial rotation of rotation. This takes
the trunk. This is accomplished with the patient seated. about three repeti­
The seat should be stable to prevent the pelvis from spin­ tions of procedure.
ning with trunk rotation.
While some coupled sidebending and/or flexion/exten­
sion segmental movements are unavoidable, no deliberate
movement in these planes should be attempted by the
patient or the operator, whose focus should be on increas­
ing pure axial rotation. For example, tight left external
obliques and/or tight right internal obliques are treated by
increasing the range of left axial rotation.

Sequence of Treatment. Treatment of the obliquus mus­

cle imbalance should be done as soon as the imbalance is
of the last seven ribs; for internal obliques the lumbar
discovered, unless the treatment procedure evokes pain. In
region near the iliac crest is monitored. Trunk rotation is
cases where pain contraindicates treatment, the treatment
done gently, stopping when the first resistance is encoun­
should be postponed until after the mechanism(s) of pain
tered, i.e., just before rib motion or iliac crest motion
generation is (are) found and treated successfully. In the
process of treating the spinal mechanical pain generators, occurs due to myofascial tension.

the tension in the oblique muscles sometimes releases
spontaneously, and no longer need treatment. But if it per­
sists it should be treated to prevent recurring spinal dys­
function patterns.
Protocol for Releasing Tension in Oblique Muscles
1. Patient position: seated with his/her back to you,
preferably astride a treatment table to stabilize the pelvis.
Posture must be erect, arms folded across the chest, hands
holding elbows.
2. You stand (or sit) near the side toward which the trunk
is to be rotated. Reach across the patient's chest to grasp
the far arm just below the shoulder with your hand, which
will be used to passively rotate the trunk.
3. For tight external oblique muscles the i:runk will be
rotated toward the side of the tighter muscle. For tight
internal oblique muscles the trunk will be rotated away
from the side of the tighter muscle. Trunk rotation posi­
tioning is done carefully while monitoring with the free
hand over the erector spinae muscle mass on the side of the
tighter muscle. For the external obliques the preferred
monitoring contact is in the low thoracics near the angles
4. Resisting with your hand on the patient's arm and
with your upper arm that is in front of the near shoulder,
tell the patient, "While breathing out and pulling your anus
in, try to twist yourself back to the (right, left)." After the
patient has developed a moderately forceful effort- usual­
ly 3 to 5 seconds- tell the patient, "Relax."
5. Wait tor complete relaxation before taking up the
available slack in the obliquus muscle. Be sure the patient
remains sitting erect. "Sit up taller." You may use your
monitoring hand to cue the patient to straighten (without
derotating).
6. Take up the slack in the obliquus muscle, taking care
that the pelvis does not spin on the seat or the lower ribs
get drawn forward by myofascial tension.
7. Repeat the isometric derotation effort and post-iso­
metric relaxation (step 4.) two or three times. Except for
elderly patients the treatment outcome bilaterally should be
approximately 90 degrees of rotation of tl1e shoulders com­
pared with the coronal plane of the pelvis.
8. Recheck the obliquus muscles for myofascial tension
inequality. This may lead to the discovery of bilateral
abnormal tension in these muscles.
194 THE MUSCLE ENERGY MANUAL
Treatment for FRS Dysfunction
The 500-Step Procedure {Range: T7 to L5}
The 500-step procedure is a treatment for FRS dysfunction
of the lower thoracic (T7_n) and lumbar spine(L1_5). With
FRS dysfunction, rotational asymmetry is worse when the
spine is examined in the hyperextended position, which
indicates an extension restriction. Compared to other
manual therapy techniques, the 500-Step is a more effec­
tive procedure for mobilizing FRS segmental dysfunction
from T7 to L5• The effectiveness of the 500-Step proce­
dure can be attributed to the facet-gapping effect of
neutral rotation of the vertebral column. For example,
right axial, or neutral, rotation gaps the right zygapophy­
seal joints. With FRS dysfunctions, the impaired
zygapophyseal motion is on the anterior side of the verte­
brae. With the facet slightly gapped, it is easier to move the
restricted facet back into extension and restore symmetrical
mobility to the segment. Although seemingly complex,
the procedure will seem less complex when it is orga­
nized into three stages: neutral rotation, extended rota­
tion, and pure extension.
The magnitude of the extension restriction varies,
sometimes reducing the range of motion of the vertebra in
the sagittal plane by considerably more than 50 percent.
Restrictions of such magnitude will demonstrate rotation
asymmetry long before the rest of the spine gets to a hyper­
extended position. The severity of restriction, however,
does not reliably correlate with severity of symptoms. Even
when extension movement is reduced by 90 percent -with
the remaining 10 percent of movement available, of course,
between the hyperflexed position and a semiflexed position
-the body often compensates (or adapts) by changing pos­
ture and function of the rest of the body, so that local or
distant symptoms are absent most of the time.
Localization
While the difterence between major and minor dysfunction
has important diagnostic application, it is also relevant to
localization in the treatment procedure, which begins in
the mid-neutral range. Sometimes tl1e extension barrier is
encountered soon after coming out of the hyperflexed posi­
tion. The "neutral" range for such a dysfunctional joint is
within these few degrees of movement, and not necessarily
when the spine is in the seated erect position.
Stages of the 500-Step 'lreatment Procedure
Stage I (Neutral Rotation). The treatment procedure is
done in three stages: neutral rotati011, extended rotation,
and pure extension. In the neutral stage, the spine is rotat­
ed with the lesioned vertebra slightly bent forward away
from its extension barrier. In order to get neutral rota­
tion, the spine must be sidebent away from the direc­
tion of desired rotation movement for the lesioned seg­
ment. For example, if the positional asymmetry of the
lesioned vertebra is left rotated when the dysfimctional seg­
ment attempts to hyperextend, the treatment will attempt
to increase the range of neutral right rotation tor that ver­
tebra by turning the trunk to the right while the vertebra is
in a neutral left sidebent position.
In the first stage of the treatment, the pathologic
motion barrier (which is preventing full extension, right
rotation, and right sidebending in the same example) is not
engaged. Two tl1ings are accomplished by the neutral rota­
tion in Stage 1: first, any compensatory group behavior of
the spine above the lesioned segment is released so that it
can spontaneously readapt after correction of the lesion;
and second (but more important), the right facet joint is
gapped apart to allow tor the localization of right sidebend­
ing and extension in the second stage without jamming or
compressing the facet joint surfaces.
Localization in the first stage is accomplished by
sidebending the spine to produce a lateral apex at the
lesioned vertebra so that an imaginary plumb line
might pass through that vertebra but no others. Such
localization requires balance and some relaxation of the
patient. Balance is maintained during sidebending by the
patient assisting in shifting (i.e., translating) the weight
toward the right hip (with FRSL), and lifting the lett hip
slightly. You can help support the left hip by pressing a
knee up against it.
Localize position and motion by palpating (with the
left hand) the spinous processes of the dysfimctional verte­
bra and the one below it. The right hand is used to help
communicate positioning instructions to the patient. With
the patient in a neutral (with regard to the lesioned joint)
left sidebent, right rotated position, the strong, polyarticu­
lar right sidebender muscles of the spine above tl1e segment
will be stretched using isometric technique, to allow tor
greater left sidebending, and therefore, greater right rota­
tion.
 CHAPTER 9 �EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE
To get an isometric contraction of these right side­
benders, you must provide unyielding resistance under the
patient's right axilla as the patient, on command, pushes
downward with the right shoulder with a force of 20-30
pounds (10-15 Kg.). Reaching underneath the axilla
improves control of the patient's position and balance. The
greater force selectively activates the more powerful pol­
yarticular sidebender muscles. After each of these two-sec­
ond efforts, relocalize while the patient is relaxed, first
increasing sidebending, then taking up the rotation slack.
Stage II (Extended Rotation). Stage I (neutral rotation)
flows into Stage II (extended rotation) in the following
manner: the localized rotation achieved in neutral is kept
the same, while the sidebending is reversed from left to
right. This reversal of sidebending entails a shift of the
patient's body weight, which has been on the patient's
right buttock, by translating the patient's weight onto the
left buttock. With the patient's relaxed cooperation, you
passively (relatively) sidebend the spine to the right from
above down by depressing the right shoulder, until the
sidebending is localized at the lesioned joint. Extension is
then added to complete the localization process by
instructing the patient to actively extend the spine while
retaining postural balance. This concept is often hard for
patients to understand. The instruction, «Push your belly
button forward toward your left knee,'' often obtains the
desired action. The balanced anteroposterior posture
should now be arranged with the lesioned segment at the
apex of the anterior convexity.
Using isometric technique, the spinal flexors - and,
incidentally, the left rotators - will be stretched. This is
accomplished by instructing the patient to pull the right
shoulder forward against your unyielding right hand
(which is moved forward onto the anterior aspect of the
shoulder for this purpose).
The force of this contraction is small, approximately
one pound, to selectively activate the muscles concerned
with monoarticular motion at the chosen segment. In this
region of the spine (TrT12), there are no monoarticular
flexor muscles. Flexion of these segments is mostly accom­
plished by abdominal muscles. Segmental specificity is pro­
vided by the transversus abdominis muscle and by the
anatomic organization of its extensor antagonists, the
195
transversospinal muscles (multifidi). In the lumbar spine,
the monoarticular rotatores muscles are missing from the
set of transversospinal muscles. The monoarticular speci­
ficity of single segment flexion and rotation in the lumbar
spine is provided by the flexor antagonists, multifidi and
semispinalis muscles. There is probably some monoarticu­
Jar action of parts of the psoas major muscle, a lumbar spine
flexor as well as a hip joint flexor.
These two-second efforts are repeated until release of
normal motion is achieved (usually about three times).
Relocalization is attempted during the relaxation between
isometric efforts in a definite sequence.
For an FRS Left,
the sequence would be: (1) sidebend right, (2) rotate
right, and (3) extend (active patient cooperation by
arching the back).
Stage III (Pure Extension). Stage II flows into Stage Ill.
Keeping the localized extension position the same, the
patient's trunk is straightened so that it is no longer rotat­
ed and sidebent. Your resisting right hand is moved farther
anteriorly to the sternum (or all the way across the chest),
and your monitoring left hand applies firm supporting and
resisting pressure to the spine just below the lesioned seg­
ment. The patient does a straight isometric flexion effort
against your unyielding resistance for about three seconds.
After complete relaxation is obtained, increase straight
extension both passively and actively. It is usually not nec­
essary to repeat this step.
Patient Instructions. The 500-Step procedure
requires a lot of verbal instructions to the patient. Some
examples of instructions to the patient are: «Let your back
slump," «sit up straighter," «Not so straight," «'J'ranslate this
part of your back straight over to the right," «Let your left hip
raise off the seat," «Lower your left shoulder," «Push hard
with your right hand down against my knee. Brace with your
left foot while you push," «Relax," «Translate this part of your
back a little farther to the right," «Shift your weight to the left
and straighten a little, without rotating," «Push your chest
(or abdomen) out over your lap." Finding the right words
to say can be a challenge. Probably this verbal complexity
earned the procedure its name.
196 THE MUSCLE ENERGY MANUAL

An Example of the 500-Step Treatment Figure 9.77 500-Step

procedure arm positions
for FRS Dysfunction 1 Rar1ge: T7- L5} -Alternative #1. The
The 500-Step Muscle Energy treatment procedure is per­ placement of the
patient's hand on the
tormed on a seated patient to resolve a thoracic or lumbar
operator's knee makes it
vertebral dysfunction which has its greatest rotational
easy for the operator to
asymmetry when it is extended, and no asymmetry when it resist an isometric con­
is fully flexed. As an example, consider a situation where traction of the spinal
the patient's left eleventh rib becomes most posterior when sidebenders on that side,
especially if the operator
the spine is extended (as in the "Sphinx" position). The
is smaller than the
positional diagnosis is T11 FRS Left; the functional diag­
patient. One possible
nosis is that T 11 has decreased right rotation, right lateral disadvantage is that the
flexion (sidebending), and extension (of the right interior patient may use arm and
tacet). shoulder muscles for the
"push your hand down
on my knee." It may be
Reminders:
necessary to add, "using
1. BALANCE, RELAXATION, and LOCALIZATION are important ele­
your back muscles."
ments of this. or any other, manual therapy procedure.
2. Remember that pure rotation is not a localizable movement. because
axial rotation of a flexible rod, like the spine. occurs throughout every
torquable element simultaneously. However, once an angular bend Figure 9.78 500-Step
procedure arm positions
occurs in the rod, rotation can be localized to the bend.
-Alternative #2. A good
way to resist the spinal
sidebender contraction
is for the operator to get
The 500-Step Procedure Protocol [Range: T7 to L5] his or her whole
As a case study, the follmPing procedure description 111ill apply the shoulder- instead of just
the arm- under the
500-Step to an FRSL dysfunction at T1 J.'
patient's shoulder.

Stage I- Neutral Rotation

l. Patient is seated on a low stool or bench, with feet flat
on the floor. Position the patient so that the lesioned ver­
tebra is close to neutral within the flexion/extension range.
A major FRS dysfunction (i.e., more than 50 percent of
extension range lost) will require the patient to be in a
slouched posture. Patient's teet are comtortably apart and
flat on the floor.
Note: If using an armless chair, the chair back must be on the side of
the posterior transverse process and the seat should be nearly level.

2. You sit close to the patient's right hip with your right
leg beside the patient's right leg.
3. With the patient's right arm draped over your right
shoulder, reach your right arm underneath the axilla and
across the patient's chest to hold the left shoulder.

Note: At this stage, the patient can either hold the right hand with the
left hand, or. depending on patient and operator size and seat heights.
the patient can put the right hand on your right knee. This position will
be used in Step 7. where you will resist the downward pushes of the
patient's right shoulder.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 197

4. Monitoring the motion between spinous processesT 11 Figure 9.79 500-Step

procedure. Finding T7
andT 12 with your left hand, find the mid-neutral range of
neutral (Step 4) and
that segment by passively flexing and extending the
localizing sidebending
patient's back (i.e., by slumping and arching the back), (Step 5). T7 is translated
translating the segment backward and forward. Feel for to the right to stretch the
the gapping and pinching of the spinous processes. right sidebenders. Left
sidebending in neutral
5. In order to produce left sidebending at the level of
automatically produces
T 11-T 12, instruct the patient to:
"Let this part of your back
right rotation, gapping
sag to the right toward me.» To localize sidebending to the (idling) the right facet
segment, control the shape of the sidebending curve by joint.
pulling the left shoulder down and drawing the patient's
weight over toward you. Take care to stay within the mid­
neutral flexion-extension range, and to not allow the apex
of the sidebending curve to go higher than the segment
being treated. Be sure the patient remains balanced.
6. The left sidebend will produce automatic coupled
right rotation of the lesioned vertebra. To ensure all avail­
able slack in the rotation range is taken up, turn the
patient's shoulders to the right until the rotation barrier is
Figure 9.80 500-Step
felt at the lesioned segment,T 11.
procedure- neutral
7. With your right shoulder under the patient's axilla to
rotation. Finding T11
provide unyielding resistance, tell the patient to, <<Brace neutral and localizing
your left foot against the floor and pull your right shoulder sidebending. The
down toward your right hip with 20 pounds (10 kilograms) patient's waist is

of force... (wait two seconds). Now relax and let this part of translated right.

your back sag toward me.''

Note: The larger force is to activate the large polyarticular sidebender
muscles in an isometric contraction. If the patient's right hand is on
your knee, the knee can resist the downward push of the patient's hand,
which involves contracting the same muscles. They are elongated dur­
ing the post-isometric relaxation phase.

8. Control and focus the right lateral translation ofT ll

by pulling the left shoulder toward the segment, and then
turn the patient's shoulders to the right until rotation is felt
atTu.
9. Steps 7 and 8 are performed three times. In other
words, reposition the patient to the neutral left sidebend­
ing/right rotation barriers, and repeat the push, relax, and
Figure 9.81 500-Step
repositioning sequence twice. procedure -neutral
Note: This completes the neutral rotation stage, which is intended to rotation. Finding L4
neutral (Step 4) and
gap the right zygapophysis. Remember, the end of Stage I is the begin­
localizing sidebending
ning of Stage II, so do not derotate the shoulders. Keep the lesioned
(Step 5). Translating the
segment rotated right.
lumbosacral region to
the right is facilitated by
supporting the left
buttock on your knee.
198 THE MUSCLE ENERGY MANUAL

Stage II - Extended Rotation Figure 9.82 500-Step­

l. Maintain right rotation at T ll by telling the patient, Stage II. Beginning of
extended rotation. Your
<<Keep your left shoulder forward where it is.» Then, to guide
right arm is removed
the motion in the next step, remove your right hand from from in front of the
the patient's left shoulder and place it on the top and front patient, and the right
of the right shoulder. hand is used to control

2. Next, while monitoring the T 11-T 12 interspinous space the patient's right
shoulder (Step ll.
with your left hand, passively induce right sidebending by
guiding the patient's shoulder inferiorly and translating the
segment to the left until you feel the feather-edge of the
sidebending barrier. Instructions to enlist patient cooper­
ation might include: <(Lower your right shoulder and your
left hip.)) To insure that sidebending is precisely localized,
find the feather-edge of the rotation barrier by right rotat­
ing the patient's shoulders. If significant rotation mobility
is available, either sidebending is not precisely localized or
normal segmental mobility has been achieved. After rotat­
ing, take up the slack in the extension range, gently guid­
ing the patient in the right direction by pushing on the seg­
Figure 9.83 500-Step­
ment anteriorly, and instructing the patient to «Push your
Stage II. T11 is now
belly forward toward your left knee.)) When the localized beginning right
position is achieved the patient should be balanced, and sidebending, right
therefore, able to relax. The patient should not be leaning rotation, and extension.

his/her weight backwards onto your palpating thumb or I Step 2).

finger.
3. With your right hand, resist forward movement of the
patient's right shoulder. Tell the patient, «Push your right
shoulder fonvard n1ith one pound of force... (Wait two sec­
onds). Relax.»
4. While the patient is relaxed, localization is obtained in
a definite order: sidebend right (you may have to say,
«Lower your right shoulder» or «Translate this vertebra over
o the left.)'), rotate right, and extend (you may have to say,
«Push your belly button forward)'). You may also need to
give the patient appropriate instructions to maintain bal­
ance and relaxation.
5. Steps 3 and 4 are usually done three times, but may be
more or less, depending on the sense of release noted by
Figure 9.84 500-Step -
monitoring Tn.12with a thumb or finger. Stage II. Extending L4,
after right sidebending
and right rotation,
requires more forward
tilt to the pelvis, as well
as more anterior
translation of the
abdomen and
!umbo-thoracic spine.
You should not be
supporting the patient's
weight on your thumb.
 CHAPTER 9 -e. EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE 199

Stage III (Pure Extension Stage) Figure 9.85 Stage Ill of

l. Move your right hand across the patient's chest (at the 500-Step. T8 is
stabilized with the fist
level of the sternal angle) so that your arm is positioned in
I Step 11 while T7 is bent
front of both shoulders. This position will provide the backwards over it I Step
unyielding resistance required in the next step. Be sure that 31. Operator's right arm
your resisting arm on the front of the chest is not touching is in front of the

the neck (don't choke the patient). At the same time, your shoulders.

left hand, formed into a fist, puts firm anterior pressure

against the spine below Tn to maintain extension. The
patient's trunk is passively turned straight (un-sidebent and
derotated) but kept hyperextended.
2. Tell the patient, «Push your chest forward.. (Wait two
.

seconds) ... Now relax.» Force is moderate (several

pounds).
3. Assist the hyperextension ofT11 onT12 by holding the
shoulders back and pushing your fist forward on T12 while
the patient follows your instruction, «Push your belly button
out over your knees.»
4. Steps 2 and 3 do not need to be repeated. Re-exam­
Figure 9.86 Stage Ill of
ination ofT11 is made with the patient in the prone extend­
500-Step. T12 is
ed (Sphinx) posture to confirm whether the treatment was stabilized with fist and is
fully successful. pushed forward during
the patient's active
anterior translation of
the abdomen I Step 31.

Figure 9.87 Stage Ill of

500-Step. Fist is on L5 to
maintain the forward tilt
of the pelvis, and to
increase it during active
anterior translation
I Step 31.
200 THE MUSCLE ENERGY MANUAL

Alternative Short-Cut FRS 'freatment Figure 9.88 Short-Cut

The 499-Step Procedure /Range: T7- L5] FRS treatment (using
FRS-R at T11 as an
The setup for the following technique is similar to the pre­
example). The patient's
ceding procedure. The obvious ditlerences are the posi­ hands may be clasped
tioning for localization and the direction of the patient's on the back of the neck,
isometric etlort. The concept of breathing cooperation, singly or together; or the

introduced earlier in Volume l with the treatment of the arms may be folded on
the chest. Operator
cervical spine, is presented here in a ditlerent context. As
controls localization
with the craniosacral model of respiration, inhalation cor­ with a hand on the
responds to flexion (in this case of the thoracic spine) and patient's shoulder.
exhalation corresponds to extension. This procedure takes
advantage of this respiratory synkinesis etlect.
The illustration shows treatment for restricted exten­
sion, left rotation and left sidebending. Osteokinematically, or
positionally, the lesion may also be described as flexed,
rotated right, and sidebent right (FRS right). Arthrokinematic­
ally, the motion of extension is restricted for the left facet
joint but not the right.
Although the treatment may be done in two steps as
illustrated below, results are more often improved if it is
combined with the treatment ofType I dysfunction, going
directly from that procedure to Step l in this procedure by
staying in the released rotated position and reversing the
sidebending (from left to right in this case). If this com­
bined technique is used, the monitored localization stays at
the joint with theType II FRS dysfunction throughout the
entire procedure. Thus the neutral rotation stage of the
treatment flows into the extended rotation stage, which
begins the localization for this procedure, as in the 500-
step procedure.

The Procedure Protocol

l. The patient is seated on the treatment table with the
fingers laced on the back of the neck.
2. You stand behind the patient near the side opposite
the posterior transverse process of the lesioned segment.
3. You may control the patient's localizing position by
holding an elbow, or holding the top of the shoulder.
4. With your free hand, palpate the spinous processes of
the involved segment to detect the neutral range and to
monitor localization as the patient's trunk is sidebent pas­
sively toward you. Translate the segment forward and
backward to find the extension end of the neutral range.
From that position sidebend the spine toward you. To
restore postural balance and facilitate relaxation, the moni­
tored point of localization is translated away from you by
pressing your body or hand against the patient while hold­
ing the shoulders close to you. For the lower lumbars it
helps to have the patient raise the buttock on the side near
you. Alternatively, a book or journal may be placed under
the buttock as a shim.
5. After sidebending is localized, and the patient is re­
balanced and relaxed, the rotation is localized by turning
the patient's shoulders slightly toward you.
6. The patient is instructed to inhale and make a rota­
tional push forward with the near shoulder using l pound
of force against your resisting arm for 2-3 seconds, then
relax and exhale. <<rake a deep breath and make a one-potmd
push fonvard with your shotJlder against my arm... (Wait two
seconds, or as long as it takes to feel the localized action of
the muscle contraction at the segment with your palpating
finger) ... Relax and breathe out."
7. Relocalization to the new sidebending motion barrier
is achieved, and the rotation and extension localization is
adjusted appropriately. The extension is done actively by
the patient by pushing the umbilicus farther forward.
8. Steps 6 and 7 are done three times, or until the desired
release is obtained.
9. The patient is reexamined in the Sphinx position for
spinal symmetry.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 201

Lateral Recumbent Treatment Procedures

The lateral recumbent treatment (with patient sidelying) is
probably the easiest way to correct fifth lumbar FRS dys­
function (Figure 9.90). Depending on the type of dys­
function being treated (whether ERS or FRS), variations in
position are implemented to more specifically and precisely
address the dysfunction. As with all of the other MET
treatment techniques, patient positioning is designed to
localize the dysfunctional segment, or joint, right at the
feather-edge of the motion restriction barrier - in each of
the three planes of motion sequentially. In treating seg­
mental dysfunction in the lumbars, the lateral recumbent
technique is different from the seated techniques in that
the forces of gravity can be more effectively controlled and Figure 9.89 Patient Position for Lateral Recumbent Treatment of ERS-R.
utilized in the procedure.
Whether the segment being treated has a flexion
restriction (ERS) or an extension restriction (FRS), certain
principles apply. The axial rotation component of the bar­
rier, and therefore the patient positioning, is arrived at by
having the portion of the upper thorax that is above the
restriction rotating one way, and the portion below the
restricted segment rotating the other way. These rotations
going in opposite directions produce a torque on the spinal
column. The obj ective is to position the patient so that
these gravitational contrarotational forces are localized
at the segment being treated.
The flexion/extension and sidebending component of
Figure 9.90 Patient Position for Lateral Recumbent Treatment of FRS-L.
localization is accomplished by adjusting the position of the
patient's legs in the sagittal and coronal planes. Thus, the ment table, the left arm resting behind the back. With the
legs can be brought into flexion or extension until the seg­ pelvis stabilized on the table as you hold the patient's knees
ment is in neutral, and the legs can be raised or lowered to up, the rotation component is localized when the patient
engage the sidebending component. rotates the upper torso to the left. After the patient is in
As mentioned, the Lateral Recumbent techniques this position, while monitoring the segment being treated
employ the forces of gravity. If, for example, you are treat­ with your left hand, find neutral for the flexion/extension
ing an FRS dysfunction, the patient's upper torso will be component by extending and flexing the pelvis and legs,
rotated opposite to the direction the segment rotates when and palpating for interspinous gapping. With neutral es­
it is in extension, and the portion of the body below the tablished, introduce left sidebending by hanging or push­
dysfunctional segment will be rotated against it. At the ing the feet (with the patient's knees resting on your knees)
point when these contrarotational-gravitational forces are toward the floor. Once the sidebending barrier has been
localized at a segment, the area of intersegmental torque localized the necessary conditions have been established to
will be perpendicular to the table. Furthermore, the forces isometrically contract the extenders, left rotators, and left
of gravity will be equilibrated at that segment; that is, the sidebenders for that segment by having the patient attempt
force of rotation of the superior vertebral body will be to push the feet up toward the ceiling against resistance.
equal to the opposing or stabilizing force of rotation of the After the patient's effort, while he or she is in the relaxation
inferior vertebral body. Another way to conceptualize the phase, take advantage of the post-isometric relaxation
relationship between these opposing forces and the seg­ response and relocalize to the new sidebending barrier
ment we are attempting to localize is that the gravitational (which will automatically adjust the rotation component
moments of torque will meet at that segment which is per­ because they are coupled motions). The flexion compo­
pendicular to the table. One way to localize gravitational nent may then be addressed with additional hip flexion.
torque is to raise or lower the support of the knees. For the Lateral Recumbent technique applied to
For the Lateral Recumbent technique applied to FRS dysfunction, in addition to positioning the segment
ERS dysfunction, the patient lies on the side of the hip, at the feather-edge of the barrier, there is also the intention
with the chest turned toward, and resting on, the table. If of gapping the restricted facet. To achieve this gapping
treating an ERS Right, which means the right facet is effect requires the application of specific and locali.zed axial
restricted and cannot flex, the starting position of the rotational forces. Thus, for an FRS Left dysfunction, the
patient will be lying on the left side. The patient then turns restricted facet is on the right and is, therefore, the facet to
the upper torso to the left and rests the chest on the treat- be gapped by rotation. (see Figures 9.90, 9.95- 9.98)
202 T H E M U S C L F. E N E R G Y M A N U A L
Figure 9.91 Lateral recumbent treatment for lumbar ERS Right.
The patient's starting position is the same as for the treatment of sacral
torsion left on the left oblique axis. The procedure performed with the
operator standing is an alternative to the operator seated, as demonstrat­
ed in Figures 9.92 and 9.94.
Lateral Recumbent Treatment of Lumbar ERS
Dysfunction I Range: L3 - L5}
ERS dysfunction of the lower lumbar segments can be
treated in a lateral recumbent position. The rotation com­
ponent of the technique is managed by rotating the trunk
to turn the chest down while the patient rests on the side
of the hip. Although not identical, this position has been
compared to the Sims position, named after the nineteenth
century proctologist. This procedure is the author's adap­
tation of a technique developed by Fred Mitchell, Sr. to
treat forward torsion of the sacrum. A more descriptive
term would be "forward sacral torsion treatment position."
It differs from the Sims position in that both hips and knees
are flexed together, the thighs are lifted otT the edge of the
examining table, and the feet are lowered (which external­
ly rotates the top thigh and internally rotates the lower
thigh). The position can be either left or right lateral
recumbent. The semi-prone aspect of the position refers to
the upper body, with the chest turned toward the table and
the lower arm laid along the back. The difterence between
the forward sacral torsion treatment and the lower lumbar
ERS treatment is the flexion barrier localization in the ERS
treatment. In the sacral technique the lumbosacral joints
remain in their neutral range, whereas in this lumbar tech­
nique the hips are hyperflexed until segmental neutral is
localized at the flexion end of the neutral range of the spe­
cific spinal joint being treated.
Figure 9.92 Lateral recumbent treatment for lumbar ERS Right.
The sidebending is localized to the segment by lowering the patient's feet.
The Lateral Recumbent Treatment Procedure
Protocol for ERS
l. The patient lies in a lateral semi-prone position (the
chest down on the table) with the more anterior transverse
process down toward the table. For example, to treat L5
ERS Right, the patient lies on the left hip. «Lie on your left
side with your left arm behind your back.'' (Figure 9.91)
2. Tell the patient, «Jam going to sit on the table and sup­
port your knees on my leg.» You sit on the table very close
to the patient, so that the patient's thighs can rest on your
thigh. Initially the patient's teet will be in your lap (Figure
9.92 ). You will need to move your other leg aside so that
the patient's toot can be lowered. Propping the legs up like
this creates room to rotate the spine by turning the shoul­
ders down toward the table. (Figure 9.93) Your own com­
tort will be greatly improved if you use a footstool tor your
propping leg. This will allow you to lift the patient's thigh
for more rotation. Be sure to ask the patient if he/she is
lying on a tender point, or is uncomfortable in any way.
Make the necessary adjustments in position so that the
patient is comfortable.
3. Palpate between the spinous processes of the vertebra
being treated and the one interior to it, and flex the
patient's hips by bringing the knees up toward the head of
the table until the vertebra, or the sacrum, interior to the
joint being treated has been bent forward to the flexion
barrier of the segmental dysfunction. For a major ERS, it
may be necessary to passively tilt the pelvis back into lum­
bosacral extension before starting the search tor the flexion
barrier.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 203

Figure 9.93 Lateral

recumbent treatment for
lumbar ERS Right.
During post-isometric
relaxation the lumbar
segment is relocalized
by sidebending first, then
flexing (bringing knee up
toward the head I.
Localization is monitored
with a finger between
the spinous processes.
Rotation localization is
mostly coupled to
sidebending, but can be
checked by having the
patient reach the right
hand toward the floor. Figure 9.94 Lateral recumbent treatment for lumbar ERS Right.
This procedure is most appropriate for minor ERS dysfunctions, or the
major dysfunctions which do not require extreme lordotic positioning to
localize from articular neutral (Step 31.

4. While supporting the patient's raised knees, lower the

patient's feet until the sidebending effect is localized to the
correct joint in the same way that flexion was localized.
5. The patient is then asked to reach the forward hand
toward the floor until rotation is localized in the correct
joint. Actually the rotation barrier is automatically engaged
at the same time as sidebending. If too much rotation
movement can be felt at the interspinous palpation point,
more sidebending is needed to localize to the joint.
6. Provide unyielding resistance to the feet (usually by
holding on to the heels) and ask the patient to push the feet
upwards toward the ceiling with a force of two pounds
( 1 Kg.) or less. The push should be sustained for a few sec­
onds, and then relaxed.
7. During relaxation, relocalize sidebending first by low­
ering the patient's feet; then flexion, by flexing the hips
more (by sliding your supporting leg toward the head of
the table). Check the rotation slack by asking the patient
to reach closer to the floor with the forward hand.
Rotation torque can also be increased by raising the knee
support.
8. Steps 4 through 7 are repeated three times, or until a
release of joint movement is felt. The lumbars are reexam­
ined in the seated hyperflexed position.
204 THE MUSCLE ENERGY MANUAL

Figure 9.95 The

lateral recumbent
technique for 4; FRS
Left Step 1 is similar
to the basic patient
position for treating
sacral torsion to the
right on the left
oblique axis. The
patient lies close to
the edge of the table,
on the side of the
posterior transverse
process of L5. The
top foot is rested
behind the bottom
popliteal space.
Figure 9.96 The lateral recumbent technique for 4; FRS Left (Step 5).
The legs are used to flex or extend the L5-S1 joint to its neutral range for
neutral axial rotation. The right hand is used to palpate the pinching­
gapping motion of the L5-S1 spinous processes.

Lateral Recumbent Treatment of Lumbar FRS The FRS Treatment Protocol

Dysfunction I Range: L3 - L5} 1. The patient lies on the side of the posterior transverse
process of the vertebra to be treated. «Lie on your left side
Lateral recumbent is the treatment of choice for Ls FRS
close to the front edge of the table.»
dysfunctiom. With the 500-Step procedure localization to
2. You stand at the side of the table, facing the patient.
the lumbosacral joint is difficult; it is much easier in the
3. The starting position is shown in Figure 9.95. The
lateral recumbent technique. The principles of the 500-
patient lies close to the front edge of the table. Because the
Step procedure are applied here in a ditlere·nt way, but
shoulder on which the patient is lying is directly under
there are still three stages to the technique. The neutral
him/her, the head needs support -either an arm or a pil­
rotation of the 500-Step procedure becomes axial rotation
low. The knee of the leg on which the patient is lying is
in the lateral recumbent technique. The objective remains
slightly flexed; the uppermost leg is flexed at the hip and
the same -to gap the impaired zygapophyseal joint. The
knee so that foot rests in the popliteal space of the lower leg
extended rotation stage of treatment begins with the lifting
(Figure 9.96).
of the bottom foot to bring the sidebending localization to
4. Your cephalic hand palpates the intervertebral space
the segment being treated. The final stage of the proce­
immediately below the vertebra to be treated.
dure is to extend the segment to its limit by pushing the
5. Your other hand grasps the knee of the leg on which
temurs back against the pelvis after facet motion has been
the patient is lying, and that leg is flexed at the hip, bring­
released.
ing the foot in the popliteal space with it, until spinous
process gapping movement is detected by the hand palpat­
ing the spine. This indicates that the segment is in neutral.
6. Next, reposition your hands. Your hand which moved
the leg now becomes the palpating hand for the spine, and
the other hand moves to the uppermost shoulder. Ask the
patient to put the upper hand behind the back as shown by
(Figure 9.96).
7. Instruct the patient to take a deep breath. As he/she
exhales, the trunk is actively rotated (by the patient) so that
the patient's back approaches the table surface. Say, '7ake
a breath. Let it out. Now reach your hand back behind you
toJllard the table edge, and look around over your top shoul­
der.» Do not allow the pelvis to move during this maneu­
ver. Step 7 is repeated three times.
 CHAPTER 9 -&-EVALUATION & T x . OF THE LOWER THORACIC AND LUMBAR SPINE 205

Figure 9.97 The lateral

recumbent technique for
ls FRS Left (Step 7).
Neutral axial rotation of
the spine to the right,
gapping the right lum­
bosacral facet. The
patient takes three
breaths, and, with each
exhalation, twists farther
to the right while looking
over the right shoulder.
The operator uses the
left arm to stabilize the
pelvis while palpating the
L5-S1 interspinous space
to feel the segment
rotate.
Figure 9.98 The lateral recumbent technique for Ls FRS Left (Step 10).
Lifting the foot of the bottom leg internally rotates the bottom femur and
sidebands the lumbosacral joint to the right. When sidebending motion is
felt by the palpating hand, the lift stops. Isometric pull-down of the foot is
resisted, preferably with the elbow straight. Finally, the joint is extended.

8. To maintain the rotation, instruct the patient to hold

the edge of the table (behind). «Hold the table with your
hand behind you.» If the patient cannot reach the table
edge, simply have the patient keep the arm extended out
behind as a counterweight to maintain rotation.
9. Next, move one hand from the shoulder to palpate the
interspinous space, and the other hand from the spine to
grasp the ankle or foot of the lower leg. Previous descrip­
tions of this procedure have recommended using the ankle
of the upper leg. However, this method often proved too
uncomfortable for the upper hip when the foot was raised
to localize sidebending.
10. As shown in Figure 9.98, lift upward on the ankle
until the sidebending movement is felt at the vertebra to be
treated. Use your arm (or abdomen) to hold down the Figure 9.99 Sphinx position for testing the lumbars. The final step of
every treatment procedure is reexamination, preferably with the same
uppermost knee to maintain rotation localization.
test that was used to discover the dysfunction.
11. Next, slightly extend the uppermost hip until exten­
sion localization is achieved at the joint to be treated. The
extension is accomplished by pushing the femur back into
the pelvis, causing the pelvis to tilt backwards. Lifting the 13. After full relaxation, take up the slack achieved by the
bottom leg helps the pelvis slide back. Be careful to stay in contraction, first lifting the foot upwards to the point of
neutral for this step. sidebending localization, then pushing the knee back for
12. Instruct the patient to attempt to pull the foot down extension. Then, have the patient repeat the contraction.
toward the table with about two pounds of force as you 14. Usually three repetitions of Steps 10 through 13 will
oppose the motion. After a two- to three-second isometric be required. Then retest in the Sphinx position (Figure
contraction, have the patient relax. «Pull this foot toward the 9.99). Repeat the treatment, if necessary.
table with two pounds of force... (pause 2 seconds)... Now let
go.» (The expression "let go" was suggested by John
Goodridge as more universally understood than the word
"relax.")
206 THE MUSCLE ENERGY MANUAL

® CD CD ®

Apex

Figure 9.100 Neutral adaptive

biomechanics of the spine in
Crossover
response to a tilted base of
support. The activities of
groups of vertebral segments
are organized initially by the
nervous system at the spinal Apex

and cerebellar levels. Over

time, tissue memory, in the
form of altered fascial archi­
tecture, may take over this Non-neutral
Dysfunction
adaptive function and become
a more stable compensation.
Anterior Posterior
View View

Diagnostic and Treatment Procedures

for Neutral (Type I) Dysfunction
Group Lesions
The term "group lesion" is synonymous with "Type I
lesion," "NSR dysfunction," "NSR lesion," or "neutral
dysfunction." The terms "neutral adaptation" and "adap­
tive curve" are reserved to mean a spontaneously reversible
state of the spine when it is adapting to positional asymme­
try - no dysfunction is implied. Adaptive curves are pre­
sent only when the asymmetries to which they are adapting
are present. Recall that rotation accompanies, and is sec­
ondary to, the sidebending curving of the spine. When the
sidebending straightens, the rotation disappears. Thus, an
ERS dysfunction in the hyperextended position should not
exhibit rotation, either of the dystunctional segment or of
the adjacent adapting spinal segments. Discussion of group
lesions has been reserved until now because group lesions
can be diagnosed only after the non-neutral lesions have
been ruled out (or removed by treatment), and the need
tor the spine to adapt to positional asymmetry is no longer
present. Adaptive curves of the spine which persist under
these circumstances are group lesions. The term "group
curve" is generic and includes both neutral adaptation and
neutral dysfunction.
NSR, or Type I, lesions are usually treated afi:er all
"Stacked" Segmental Dysfunctions
How to distinguish, interpret, and treat apparently
"stacked" dysfunctions, especially in the lower lumbar
spine, are frequent clinical challenges, both for diagnostic
labeling and in terms of deciding on treatment sequence.
The term stacked refers to two or more non-neutral dys­
functions of the same type occurring in adjacent segments;
for example, two FRS left dysfunctions, one on top of the
other. How does one know the upper segment is an FRS
left dysfunction and not merely an adaptation? Because of
neutral rotation-sidebending "coupling," the right
sidebend adaptation to the (FRS left) lesioned vertebra
causes left rotation additional to the left rotation of the
non-neutral lesion segment. This could be mistaken for
another FRSL, because the rotation goes away with flexion.
Its resistance to left sidebending with direct motion testing
may be too subtle to detect, leaving the difterential diag­
nosis, FRSL or NSRL, unresolved.
However, by starting treatment with the most interior of
the asymmetric FSUs, it is possible to discover "stacked"
non-neutral lesions.
•Note: bt Volume 1, review spinalliinematics, Chapter 1; Mtd adap­
tatitm and compmsation i11 Chapter 2.

Type II dystimctions have been eliminated. The reason is

a practical one. Type I dysfunctions and normal spinal Dysfunction or Adaptation?
adaptive curves look the same. The difference is that the A similar ambiguity is presented when the upper segment
adaptive curves go away after the primary problem, usually appears to have straightened itself by rotating an equal
Type II dysfimction, is treated and eliminated. Type I dys­ amount in the opposite direction. Are we seeing an FRS
functions persist. right on top of an FRS left, or is the upper segment mere-
 CHAPTER 9 --& EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE
ly adapting? The answer to both these puzzles is that we
do not know, for certain, until the lower segment is treat­
ed, and the vertebrae retested. Stacked non-neutral dys­
functions sometimes occur. The diagnosis can be made
with confidence by treating them one at a time, starting
with the lower segment.
A question sometimes arises when the fifth lumbar may
or may not be adapting to sacroiliac dysfunction. Even
without making a precise diagnosis, the presence or
absence of sacroiliac dysfunction can be determined by
observing the sacral inferior lateral angles (ILAs) for A-P
and craniocaudal asymmetry. A-P asymmetry indicates a
rotated sacrum. Craniocaudal asymmetry indicates a
sidebent sacrum. From the perspective of the ILAs, rota­
tion and sidebending of the sacrum are always coupled to
the same side (in relation to the two innominates).
However, the sacral base always couples sidebending and
rotation contralaterally. Thus, if the ILAs show left rotat­
ed sacral position (left ILA posterior), the sacral base- the
postural support platform for the spine- will always be tilt­
ed inferiorly on the right (right sidebent). If the ILAs show
left sidebent sacral position- a completely different sacroil­
iac mechanism - the sacral base will be left sidebent, also.
In the second example, the sacral base "rotates" slightly to
the right.
The rule is that lumbar dysfunctions should be
treated before addressing lesions of the pelvis. There
are several good reasons for this sequence. Many pelvic
lesions are secondary to spinal dysfunction, and will spon­
taneously self-correct once the spinal dysfunction is treated
successfully. Pubic subluxations and sacral torsion dysfunc­
tions are frequent participants in this kind of relationship.
An even better reason to treat the lumbar dysfunction first
is that straightening the sacrum may stressfully alter the
postural dynamics of the lumbar dysfunction, precipitating
painful muscle spasm.
The perplexing question is when is the fifth lumbar
inappropriately rotated on the sacrum, and therefore
requiring prior treatment? The fifth lumbar appropriately
adapts by moving opposite to the position of the sacral
base, up to, but not exceeding, the amount of sacral rota­
tion. These are normal spinal relationships to sacral posi­
tion asymmetry, and they do not require treatment. Thus,
if the ILA is posterior on the left, indicating a left rotated
and right sidebent sacral base, the fifth lumbar should be
rotated to the right, in neutral, usually enough to make its
transverse processes even with the coronal plane.
Sometimes the right rotation continues in a group of lum­
bar vertebrae, gradually increasing the rotation up to the
apex of the group, which is rarely above L4.
Non-neutral segmental dysfunction of the lumbosacral
joint may occur with or without sacroiliac dysfunction, and
should be treated before treating the sacrum. Non-neutral
dysfunction is obvious when the fifth lumbar is rotated to
the wrong direction on the asymmetric sacrum. But when
207
non-neutral dysfunction causes the fifth lumbar to be rotat­
ed to the same direction as appropriate neutral rotation,
how is one to distinguish one from the other?
Non-neutral dysfunction rotation varies with flexion
and extension, derotating to perfect symmetry in one
direction, and rotating maximally in the other. Maximal
rotation is three to four times greater than any neutral rota­
tion. The rotation of the sacrum may vary with flexion and
extension, and, as the position of the sacrum changes, the
What distin­
fifth lumbar appropriately changes with it.
guishes the non-neutral dysfunction is the inappropri­
ate response (direction or temporal sequence of rota­
tion) to sacral position changes, and the magnitude of
the rotation.
Suppose the sacrum is found left rotated in the prone
position, and the fifth lumbar symmetrical in relation to the
cardinal planes of the body (i.e., rotated to the right in rela­
tion to the sacrum). One would reasonably assume that
the fifth lumbar is appropriately adapted to the sacrum.
But, what if, in the extended (Sphinx) position, the sacrum
derotates - becomes symmetrical - and the fifth lumbar
appears right rotated? The diagnosis L5 FRSR can be
made. The L5 lesion is independent of the sacrum, not
caused by its adaptive right rotation which it was able to do
before it was challenged by extension. If it had been mere­
ly adapting, it would have straightened along with the
sacrum at the same time, while going into the Sphinx posi­
tion.
NSR dysfunctions with inappropriate rotation direc­
tion should be treated before treating the pelvis. When the
NSR rotation direction is appropriate for the sacral dys­
function, it cannot be distinguished from normal spinal
adaptation until after the sacrum has been treated.
Therefore, it would not be treated before the sacrum.
Considering the relative rarity of NSR dysfunction, these
possibilities are not very likely.
Diagnosis and Treatment of Type I
Neutral Dysfunction
A. Evaluation ofNSR Dysfunction
1) Group Curve Tests
(Range T3 - L4)
2) The Focused SidebendingTest
(Range T3 - T12)
B. Treatment ofNSR Dysfunction
1) The Lateral Recumbent "Universal" Procedure
for NSR, FRS, and ERS (Range T10 - L5)
2) SeatedTreatment ofType IThoracic NSR
Dysfunction (Range T3- L1)
3) Step 1 of 500-Step Applied toTreatment of
NSR Dysfunction (Range T4 - L4)
4) Sidebending StretchTreatment of Lumbar
NSR Dysfunction (Range T10 - L5)
208 THE MUSCLE ENERGY MANUAL

Figure 9.101 Hip Drop Figure 9.102 Trunk

Test. Asymmetric Sidebending Test. The
responses of the patient does not bend
mid-thoracics to the Hip forward or backward
Drop Test may indicate when sidebending.
NSR dysfunction or Observe position of
neutral group fingers on the side of
adaptation. Observe the the leg and the shape
median furrow for group of the spinal curve.
curvature. Note: Due to
the rotation of the
vertebral bodies into the
convexity of the curve,
the tips of the spinous
processes will show
less curvature than
would be seen on an A­
P X-ray. Look for areas
of paraspinal fullness
caused by vertebral
rotation.

Testing for NSR Dysfunction ofT3 to L4

Group Curve Tests and Results [Range T.� - L4]
Group curves are often visible when looking at the back of
the patient, both standing and sitting. (Recall from the
Ten Step Examination the observation of the posterior
aspect of the patient, looking tor skin folds at the waist and
arms hanging asymmetric distances from the sides of the
body.) Most of the "positive" or abnormal findings in
the Ten Step Screen can be attributed to adapted states
of the neuro-musculo-skeletal system, rather than seg­
mental dysfunctions. Screening findings strongly sug­
gest the presence of segmental dysfunction, but are
rarely directly caused by them. The seated screening
examination is preferable tor spinal evaluation, since some
curves seen in the standing patient are adaptations to lower
extremity inequalities, most of which are temporarily elim­
inated by sitting down. The innominate bone, or os coxa,
being a part of the lower extremity, may be smaller on one
side, requiring an adaptive spinal curve even in the sitting
position. A magazine, or other shim, can be placed under
the buttock in these cases, to see if the spinal curve can
spontaneously straighten.
The Standing Hip Drop Test and the Trunk
Sidebending Test can be sensitive indicators of neutral
adaptation or NSR lesions, provided the entire spine is
observed during these tests. If the sidebending curvature
to the right is less than the curvature to the left of the same
region, then there is a group curve of that region, with a
right convexity. The Trunk Sidebending Test described in
Volume 1, Chapter 6, allows us to palpate the stifti1ess or
resistance of the spine to passive sidebending. By aiming
the pressure on the shoulder toward a specific segment and
repeating the test sequentially tor each vertebra, the points
of maximum stiffness can be discovered, information quite
relevant to NSR treatment localization. One important
thing to find out about a group lesion is where its restric­
tion is greatest. Sidebending is the most significant
restriction in NSR dysfunction. But where is sidebend­
ing restriction greatest? This information is needed in
order to treat the condition etlectively.
When the patient was lying prone tor the palpation of
the lumbar and lower thoracic transverse processes and the
lower ribs in a previous test, the interpretation of observed
asymmetries was considered. Recall that observed asym­
metries which disappear with hyperflexion or hyperexten­
sion were attributed to non-neutral segmental dysfunction
of individual vertebrae, or to the adaptive spinal deformities
necessitated by them, which are called "neutral adaptation"
or "adaptive curves."
Keep in mind that the spinous processes of the verte­
bra in the curve will be shifted slightly contralaterally by the
rotation of the vertebrae, which, up to the apex of the
curve, is toward the convexity of the curve. The spinous
processes move in toward the concavity of the curve. This
makes the row of spinous processes less curved than a line
drawn through the vertebral bodies on an anteroposterior
X -ray. V isual inspection of the median furrow of the back
provides a deceptively minimized perception of the severi­
ty of scoliosis.
When the patient is partially forward bent and the
observer sights tangentially to the kyphotic curve of the
back, the observer's visual parallax will easily detect the
rotation of the vertebrae in the group, especially in the tho­
racic spine where the rib angles are displaced by it. Even
though sidebending restriction is primary in group scoliotic
 CHAPTER 9 � EVALUATION & T x . OF THE LOWER THORACIC AND LUMBAR SPINE 209

�
Figure 9.103 Spinal thoracic scoliosis from three perspectives. Flexing the spine demonstrates the rotation component of rotoscoliosis. Lesser
degrees of rib angle deformity are quite visible with the patient flexed. In this example, the rib hump is more extreme in the seated, compared to the
standing, flexed position, suggesting that the legs partially compensate for the deformity. Adaptive, or compensatory, group curves may show this
rotational effect.

curves, the rotation asymmetry tends to be the most obvi­
ous visible manifestation of the scoliosis. In the thoracic
region, the rotation is magnified by the displacement of the
rib angles, creating the "hump" of humpback.
Flexing the spine has little effect on Type I (NSR) dys­
function. However, with flexion, group curve adaptations
to FRS dysfunctions will change significantly, even disap­
pear, just as adaptations to ERS dysfunction disappear with
extension. The reason Type I does not change much is
because of the degrees of freedom rule: once movement is
initiated in one plane, mobility in other planes is dimin­
ished. In the Type I lesion, the vertebrae are sidebent.
Contralateral rotation of the subapical vertebrae was auto­
matic, restricting rotation in the opposite direction.
Flexion and extension mobility is also diminished.
Before choosing a specific joint to which you will local­
ize, the whole group can be tested for right and left
sidebending mobility by repeated lateral flexing of the
trunk, passively, to the right and left. The pressure on the
shoulder can be aimed at a specific vertebra and the lateral
flexion tests repeated sequentially on each vertebra. Most
of the time the greatest sidebending restriction will be dis­
covered at the joint below the vertebra at the rotation apex
of the group, just below the joint where the adaptive rota­
tion reverses direction. However, if the greatest sidebend­
ing restriction is perceived somewhere else, it makes sense
to localize the treatment there. Rarely is the maximum
sidebending restriction found above the apex, but when it
is, the rotation localization should go toward the same side
as the sidebending localization. Otherwise, of course, rota­
tion goes toward the side opposite the sidebending.
Note: The treatments described below for group curves are used infre­
quently, because most group curves correct spontaneously, indicating
that they were adaptations, not compensations (Type I lesions).
Scoliosis is sometimes an orthopedic problem, espe­
cially when rapidly progressing deformity during adoles­
cent growth spurts threatens to ultimately compromise
internal organs through crowding. Some cases of "idio­
pathic" scoliosis may have a recognizable cause, such as pla­
giocephaly or orthodontic malocclusion.
210 THE MUSCLE ENERGY MANUAL

Figure 9.104 Focused

sidebending test for
NSR dysfunction in
thoracics T3.12.
Sidebending (lateral
flexion) is tested with
an oblique translatory
force applied through
the shoulder and aimed
at a specific vertebra.
The patient must con­
tinue to sit tall.

The Focused Sidebending Test for Thoracic NSR

Dysfunction I Range: T.� T12}-

l. The patient sits on a low stool. The arms may be fold­

ed across the chest, or hanging loosely at the sides.
2. You stand close behind the patient so that your trunk
and abdomen touch the patient's back. This physical con­
tact is essential because the palpatory experience of the test
must include your trunk proprioceptors.
3. Put your hands on top of the patient's shoulders on the
acromia.
4. Apply oblique and medial pressure to the acromion,
alternating left and right, toward a specific vertebra to
cause that vertebra to translate laterally. Use your trunk
muscles more than the muscles of your shoulders and arms
to cause this movement. Allow your torso to translate side­
to-side.
5. Sense the comparative reluctance of each vertebra to
translate laterally left and right, and make note of any asym­
metries.
6. Decide where the stifTest segment is, after sequential­
ly testing thoracic vertebrae three through twelve.
7. Determine where the stitTest segment is within the
observed group curve. Is it at, below, or above the apex of
the observed curve?
 CHAPTER 9 �EVALUATION & TX. OF THE LOWER THORACIC AND LUMBAR SPINE
The "Universal" Technique:
Using Type I Mechanics to Treat ERS, FRS,
and NSR Dysfunctions
Lateral Recumbent Position
Some lateral recumbent manipulative procedures are done
with the intention of causing zygapophyseal facet joints to
gap apart, as opposed to causing the facet surfaces to slide
on each other in the plane of the joint. [See Chapter 2 for
a review of neutral vertebral motion.] Notice especially
that axial, or neutral, rotation at a vertebral segment caus­
es the zygapophyseal facet surfaces to move apart on the
side of rotation. Right rotation separates, or gaps, the right
zygapophyseal joints and compresses the left zygapophyses.
If non-neutral dysfunction impairs movement of one facet,
gapping that facet joint with neutral rotation may restore
its physiologic mobility- both for flexion and extension.
Axial (neutral) rotation of individual vertebral seg­
ments can be localized in the lateral recumbent position by
two combined methods. As in the seated techniques, pro­
ducing an angular bend in the spine by sidebending (or
flexing or extending) an individual segment allows rotation
to be localized to that segment. In the left lateral recum­
bent position left sidebending is accomplished by drawing
the weight-bearing shoulder anteriorly and caudally.
Allowing the top leg to hang forward off the table also
gives you some control of sidebending localization, provid­
ed the foot is rested on a chair seat or stool to support part
of the weight of the leg.
Rotation localization requires balancing the moments
of torque on either side (inferior and superior) of the seg­
ment. This amounts to holding the vertebra perpendicular
to the table, rotating all the upper transverse processes
superior to it backward, and rotating all the upper trans­
verse processes inferior to it forward. Thus the point of
torque is established by the moments of gravity acting on
the masses of the body.
When these two methods are combined, rotation can
be precisely localized to a specific vertebral segment.
Simply increasing the torque at that segment while staying
in the neutral range will have a gapping effect on the
zygapophysis on the uppermost side of the segment. In
ERS dysfunction the impaired zygapophyseal motion is on
the side of the posterior transverse process. In FRS dys­
function the impaired zygapophyseal motion is on the side
of the anterior transverse process. In NSR dysfunction
there is no zygapophyseal motion impairment, per se.
NSR dysfunction is primarily sidebending (not rota­
tion) restriction of the interbody articulations - the
disc joints.
The setup for this "Universal" technique is similar to
the lateral recumbent neutral thrust technique, which has
been popular with many generations of osteopaths. The
thrust technique has been called the "hip roll technique" or
the "million dollar roll." The difference is that the correc-
211
Figure 9.105 Lateral recumbent treatment for T12, ERSR or FRSL.Palpating
with cephalic hand and elbow on the patient's deltoid, patient's foot on a
stool is better than on knee. Neutral rotation gaps the zygapophyses on
the upper side. This tends to free up motion in any direction. Ira Rumney,
DO, is shown demonstrating at the 1970 AAO Convocation. )Reprinted with
permission from the American Academy of Osteopathy Yearbook, 1971)
tive forces are provided by the patient, using Muscle
Energy Technique; or by the physician, using a thrust.
The use of Muscle Energy in this application varies
with the type of dysfunction being treated. Rotational
forces can be applied in one of two ways: the patient either
pushing one side forward or pulling the other side back­
ward. Or, in the case of torque focused on one segment in
a lateral recumbent technique, the options are for the
patient to either push the shoulder forward or to pull the
hip back. A forward push involves contracting flexors; a
backward pull involves contracting extensors. To utilize
post-isometric relaxation to treat an extended dysfunction,
e.g., ERS Left, pulling the right hip back contracts the
extenders and left rotators. On the other hand, pushing
the right shoulder forward contracts the flexors and left
rotators, appropriate for treating FRS Left with light iso­
metric technique.
The force of the forward or backward contractions is
light, i.e., a pound or less, because we wish to activate the
muscles concerned with the movement of only one seg­
ment; whereas the (sidebending) force for treating an NSR
dysfunction is greater - ten to forty pounds - because the
more powerful polyarticular muscles are involved.
For FRS treatment, the posterior transverse process
goes down (i.e., the patient lies on that side). For ERS
treatment, the posterior transverse process goes up, which
seems to be counterintuitive since the treatment rotation
goes in the wrong direction. Keep in mind that the goal
of this type of treatment is to gap the blocked facet
joint by neutral axial rotation toward the same side.
212 THE MUSCLE ENERGY MANUAL

Figure 9.106 lateral

Lateral Recumbent Procedure Protocol for
recumbent "Universal"
NSR, FRS, or ERS Dysfunction Technique forT 12 ERS or
I Range: T111 - L5} FRS. Neutral rotation
gaps the zygapophyses
The Lateral Recumbent "Universal" Technique
on the upper side. To
l. The patient lies on the appropriate side, near enough
facilitate sidebending
to the forward edge of the treatment table so that the top down toward the table,
leg can be allowed to hang otT the table to rest the toot on the bottom arm is pulled
a chair seat or stool. This toot placement is preferable to anteriorly and inferiorly.
The top foot rests on a
hanging the toot in the popliteal fossa, because it permits
stool in front of the table
more neutral sidebending to accompany the axial rotation.
for more precise control
Note: For FRS treatment. the posterior transverse process goes down of sidebending localiza­
(i.e., the patient lies on that side). For ERS treatment, the posterior tion. This position works

transverse process goes up. Keep in mind that the goal of this treat­ well with the thrust tech­
nique, also for the same
ment is to gap the blocked facet joint by neutral axial rotation toward
reasons. See Step 7.C
the same side.
I NSR treatment
variation!.
2. You stand facing the table near the patient's abdomen.
Locate the lesioned segment and position it in mid-neutral
range. This positioning can be done by moving the shoul­
ders forward and backward on the table, or by sliding the
pelvis forward or backward. Use the spinous process
pinching and gapping criteria to establish when the seg­
ment is in neutral. For this positioning, try to keep the
shoulders approximately perpendicular to the table to keep the
spine straight, or slightly bowed up from the table.
3. For the lumbars, palpate the segment with your cau­
dal hand; for the low thoracics, palpate the segment with
your cephalic hand. Segmental palpation is best when con­
tacting the spinous processes to feel vertebral movement.
4. Rest your cephalic elbow on the anterior deltoid area
of the patient's shoulder. Rest your caudal elbow on the
patient's hip. Roll the patient toward you and away from
Figure 9.107 lateral recumbent treatment for t..c. ERS or FRS. Palpating
you until you can feel that the vertebra being treated is per­
with caudal hand- patient's foot on stool.
pendicular to the table top. Notice that when the patient
is rolling away from you the torque in tl1e spine moves
down toward the pelvis, and when the patient is rolling
Figure 9.108 lateral
toward you the torque shifts up toward the head. You can RecumbentTechnique
feel the torque with your finger between the spinous for l4• neutral varia1ion
processes. Stop the torque at the segment to be manipu­ for ERS, FRS, NSR -
facet gapping !separat­
lated.
ing! principle. The inter­
5. Increase the torque at the segment by pulling the hip
spinous spaces L3-4o L4-5•
toward you and holding the shoulder back. Do not force and L5- S1 are monitored
it. Just take up the slack. Taking up the slack feels ditler­ to localize the torque.
ent in different types of patients. Less force is required to
reach the position of no slack when treating asthenic or
endomorphic individuals who are well relaxed.
Mesomorphic, hypertensive "Type A" patients require
much more patience, more breaths, and more time to reach
the no-slack position.
6. The patient is instructed to inhale and exhale a few
times. You take up the slack after each exhalation.
 CHAPTER 9 �EVALUATION & Tx . OF THE LOWER THORACIC AND LUMBAR SPINE 213

gapped Tll inferior facet

L1 superior
articular process

T12 superior facet

rotation axis
gapped
zygapophysis

rotation axis

T11 Rotated Left on T12 T12 Rotated Left on L1

Figure 9.109 Facet gapping effect of axial rotation on T11_12 joint Figure 9.110 Facet gapping effect of axial rotation on T12- L1 joint
T11, on top, is the darker outline. T l2• is the darker outline.

7a. The Muscle Energy application varies with the type

of dysfunction being treated. To treat FRS dysfunction,
ask the patient to press the shoulder forward against your
resisting elbow: ccusing one pound of force press your shoul­
der forward against my elbow or hand. .. (Wait 2 seconds, or
as long as it takes to teel the localized action of the muscle
contraction at the segment with your palpating finger) ...
Now relax.» During the post-isometric relaxation period,
take up the slack in the torque. Be sure the vertebra being
treated remains perpendicular to the table top.
7b. To treat ERS dysfunction, ask the patient to press
the hip back against your resisting elbow and relax while
you take up the slack.
7c. This position was originally designed to treat
NSR dysfunctions. For this purpose, it is best to pull the
lower shoulder forward and caudally out from under the
patient to cause sidebending down toward the table. Since
sidebending is the primary restriction, the Muscle Energy
application works best if you ask the patient to ccraise your
top leg up against my resisting hand with several pounds of
force.(Wait 2 seconds) ... and now relax.)) While the patient
is in the relaxation phase, take up the slack in sidebending
and rotation.
8. Steps 6 and 7 are done three times, or until the desired
release is obtained.
9. The patient is reexamined in the appropriate position
for spinal symmetry.
214 THE MUSCLE ENERGY MANUAL

Treatment of Type I Thoracic NSR Dysfunction Figure 9.111 Treatment

for NSR dysfunction.
[Range: T3 to Ld
Sidebending moderate
Before treating an NSR lesion, be sure there is no primary
intensity isometric. The
lesion to which it is adapting. Not only non-neutral seg­ dysfunction being
mental dysti.mctions, but also visceral reflex etiologies treated in the illustration
should be ruled out. Abdominal and pelvic visceral pathol­ is restricted sidebending
to the right of a group of
ogy can aftect paraspinal muscles reflexly. The primary
middle thoracic
problem may be farther away than you think. Suspect den­
vertebrae, apex at T7.
tal malocclusion, or functional asymmetry of the head,
pelvis, and limbs - especially the feet and shoulders. A
mechanical fascial continuity has been demonstrated from
the fibula, through the fascia lata, and through the pelvis,
to the lumbodorsal fascia (VIeeming, et al, 1993, 1995 ).
Proximal fibular dysfunction can cause recurrent lower
back dysti.mction, pain and disability.

Note: This is essentially the same procedure as illustrated in Chapter

7. Seated Axial Rotation Procedure. The only difference is that the
sidebending curve apex is lower. in the low thoracic or lumbar spine.

Procedure Protocol [Examples: T7 and T11 NSR Right}

Figure 9.112
l. Patient sits on the treatment table. You stand behind Treatment for NSR
patient near the side of the group lesion concavity (the lefi: dysfunction.
side, in this case). Sidebending

2. Patient clasps the fingers together on the back of the moderate intensity
isometric. The
neck. Or, alternatively, if the patient's arms are very short,
dysfunction being
one hand can hold the back of the neck while the other treated in the
hand holds the flexed elbow. illustration is
3. You reach across in front of the patient. Your arm restricted

goes below the near arm and your hand holds the top of sidebending to the
right of a group of
the tar shoulder. In this way it should be easy to sidebend
middle thoracic
the patient's trunk away from you; if you are very short, vertebrae, apex
you may need to seat the patient on a lower surface. atT11.
4. Your tree hand palpates the spinous processes to mon­
itor localization as the patient's trunk is sidebent passively
to the leti:. To restore posture balance and facilitate relax­
ation, the monitored point of localization is translated to
the left toward you.
5. Ati:er sidebending is localized, and the patient is re­
balanced and relaxed, the rotation is localized by turning
the patient's shoulders slightly toward you (if treating the
apex or below), or away (if treating above the apex).
6. The patient is instructed to make a sidebending down­
ward push with the left shoulder using ten or fifteen
pounds of force down against your arm tor 2-3 seconds,
and then relax.
7. Relocalization to the new sidebending motion barrier
is achieved, and the rotation localization is adjusted appro­
priately.
8. Steps 6 and 7 are done three times, or until the desired
release is obtained.
9. The patient is reexamined in the seated or prone neu­
tral position tor spinal symmetry. It is best to conduct the
reexamination in the same position as when the lesion was
found.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 215

Step l of 500-Step Procedure Applied to
Treatment ofNSR Dysfunction [Range: T7 to L4]
Compensatory NSR dysfunctions can be treated in the
seated position on the examining table. Phase 1 of the
500-Step procedure illustrates all the principles: lengthen­
ing the sidebender muscles in order to increase lateral flex­
ion to cause automatic vertebral rotation toward the con­
vexity.
6. The left sidebend produces automatic coupled right
rotation of the vertebra. Turn the shoulders to the right
until the rotation is felt at the segment, T6. This takes up
the slack in the available rotation.
7. Providing unyielding resistance with your right shoul­
der, tell the patient, <<Brace your left foot against the floor
and pull your right shoulder down toward your right hip n1ith
tJventy pounds (10 kilograms) of force... (wait 2 seconds,. or
until the action is felt at the segment)... Now relax and let

Procedure Protocol this part of your back sag tOJvard me.)) The larger force is to
*As a case study, the treatment will be applied for a left con­ activate the large polyarticular sidebender muscles in an iso­

vex group lesion, NSRL metric contraction. If the patient's right hand is on your

l. Patient sits on a low stool, bench or armless chair (the knee, the knee can resist the downward push of the

chair back must be to the side of the posterior transverse patient's hand, which involves contracting the same mus­

process and the seat should be nearly level) in a position cles. They are elongated during the post-isometric relax­

which puts the lesioned vertebra close to its mid-neutral ation phase.

range. The feet are comfortably apart and flat on the floor. 8. Control and focus the right lateral translation ofT6 by

2. You sit close to the patient's right hip with your right pulling the left shoulder toward it. Turn the shoulders to

leg beside the patient's right leg. the right until T6 can be felt to rotate.

3. The patient's right arm is draped over your right 9. Steps 7 and 8 are done three times. In other words,

shoulder, so that you can reach your right arm underneath reposition the patient to the neutral right rotation left

the axilla and across the patient's chest to hold the left sidebending barriers, and repeat the Push, Relax,

shoulder. The patient can hold the right hand with the left Reposition sequence twice.

hand. Depending on your size, and the patient's, and on

the seat heights, this arrangement can sometimes be Figure 9.113 Step I of the
accomplished by having the patient put the right hand on 500-Step procedure
your right knee, which can then resist the downward push­ applied to treatment for
es of the patient's right shoulder. NSR dysfunction.
Patient's right shoulder is
4. While palpating T6 andT7 spinous processes with the
on top of the operator's
left hand, find the mid-neutral range of that segment by shoulder. As the patient
passively slumping and arching the patient's back, translat­ is translated right, left
ing the segment backward and forward, and feeling for the sidebending is localized
to the selected segment.
gapping and pinching of the spinous processes.
Right sidebending effort
5. Produce left sidebending of the vertebral column with
is resisted.
the apex no higher than the segment being treated. The
patient may cooperate in this positioning. Tell the patient,
<<Let this part of your back sag to the right toward me.)) You
can control the shape of the sidebending curve by pulling
the left shoulder down and drawing the patient's weight
over toward you, taking care to stay within the mid-neutral
flexion-extension range. Check to be sure the patient is
balanced.
216 THE MUSCLE ENERGY MANUAL

Sidebending Stretch Treatment for Lumbar

NSR Dysfunction [Range: T10- L.sl
The lateral recumbent high velocity low amplitude
(HVLA) thrust technique has been used for at least a hun­
dred years to treat NSR dysfunctions, however they were
labeled, in the lumbar spine. The focused torque of this
technique has great power to rotate a lumbar segment, or
segments. Such axial rotation has the effect of gapping the
uppermost zygapophyseal joint, which tends to free its
movement in other planes. Consequently, the procedure
could be used to treatERS or FRS dysfunctions in the !urn­
bars or lower thoracic spine, provided the impaired facet is
positioned up instead of down toward the table.
Even though the thrust technique emphasizes rotation,
the important restriction in NSR dysfunction is sidebend­
ing. The Muscle Energy approach to treating NSR dys­
function addresses the sidebending impairment more
directly, and is, therefore, potentially even more etTective.
The Muscle Energy lateral recumbent treatment for
low thoracic or lumbar NSR dysfunction can be used in the
same universal way, as an approach to treating ERS or FRS
dysfunction, as well as treating NSR dysfunction. In order
to use the leverage of the legs to control sidebending of the
spine, it is preferable to have the patient lie on the side of
the group concavity. Lifting the feet up stretches the
sidebenders (Figure 9.114).
In addition to the Standing Trunk Sidebending Test,
the Hip Drop Test, and the Seated Passive Sidebending
tests, the evidence for lumbar NSR dysfunction is a
finding of persistent left-right asymmetry of the lum­
bar transverse processes. The persistent asymmetry
tends to be greatest in the mid-neutral range. It usual­
ly does not straighten (become symmetrical) when the
spine is flexed or extended, but may lessen, especially with
extreme flexion or extension.
 CHAPTER 9 �EVALUATION & Tx. OF THE LOWER THORACIC AND LUMBAR SPINE 217

Lateral Recumbent Sidebending Stretch Isometric

Procedure for Lumbar NSR
l. The patient is lying on the side of the concavity of the
curve to be treated. The legs should be arranged with the
ankles crossed, top leg behind the bottom knee.

Note: Since the posteriorly displaced transverse processes coexist

with the side of the convexity, the patient is lying on the side opposite
to the posteriorly displaced transverse processes.

2. You stand at the side of the table, facing the patient .

3. A!> a starting position, the legs are flexed 75- 90 degrees
at the hips. The arm position is optional.

Note: Theoretically, it could be argued that the arm (on which the
patient is lying) should be extended along the side in front of the patient
when treating the rotational component of the upper part of the curve,
and extended along the side in back when treating the rotational com­ Figure 9.114 Treating lumbar NSR, lateral recumbent while palpating at
the apex of the group curve.
ponent of the lower part of the curve where the stiffest part of the curve
is usually found. Actually the rotational component of sidebending
lesions in neutral is trivial, and does not require treatment.

4. The placement of your hands is shown by Figure

9 .114; one hand grasps the bottom foot or ankle, the other
hand palpates the lumbar spine.
5. Next, locate the segment of greatest sidebending
restriction by raising and lowering the foot as you palpate
the lumbar spine. Localize sidebendjng to that segment.
6. Instruct the patient to attempt to move the teet
toward the table with 15 to 20 pounds of force, or more,
as you oppose the motion. Mter a five-second isometric
contraction, have the patient relax. Wait for relaxation.
7. Take up the slack created by the contraction by lifting
the feet upward. Then have the patient repeat the contrac­
tion.
8. Usually, three repetitions are required. Then retest
and repeat the treatment if necessary.
218 T H E MUSCLE ENERGY MANUAL
THE MUSCLE ENERGY MANUAL �APPENDIX 219

APPENDIX
220 T H E M US C L E E N E R G Y M AN U A L
Appendix
Pain Control with Travell's Trigger Points
Travell's Trigger Points (TTP) have been found to be an
especially useful adjunct to MET, providing sate and effec­
tive pain control. The author uses them frequently, espe­
cially after correcting vertebral segmental dysfunctions.
The reader is urged to consult Travel! and Simon ( 1983
and 1992) for a complete presentation of this valuable
technique. Trigger point treatment can be applied effec­
tively without any more knowledge than the location of the
trigger point, and the distribution of the referred sensation.
But it is not very efficient to "poke around" on the body
until a trigger point is found. Also, without a knowledge
of the referral patterns, much time could be wasted treat­
ing associated and satellite myofascial trigger points which
may not need treatment.
There is a high correlation between activated or latent
trigger points and vertebral segmental dysfunction. For
example, unilateral triggers in the rotator cuff muscles are
fi·equently found in association with segmental dysfunction
of the third thoracic FSU. The author regards the trigger
point as a local peripheral neurological mechanism to sus­
tain guarding muscle spasm. What is frequently being
guarded is a facilitated vertebral tacet joint - one being
stressed by being forced to adapt to a mechanically dys­
functional segment.
The author has used TTP as part of the treatment of about
half the patients seen in the last thirty years, and prefers to
treat trigger points with a sustained pressure stimulus, rather
than using injections, dry needling, vapocoolant agents,
pulsed ultrasound, or electrical stimulation. These alterna­
tives are effective, but can be more time consuming and
expensive. All the clinician requires is a thumb, knuckle, or
elbow to apply the pressure. Some trigger points, e.g.,
trapezius and sternocleidomastoid, are best compressed with
a pincer action between the thumb and forefinger. A device
for self-treatment, called a Theracane, is available from phys­
ical therapy suppliers. Ice massage, or pressure with a piece
of ice, can also be effective. Electrical muscle stimulation
(EMS) is quite effective in deactivating deep inaccessible trig­
ger points.
Brief Comments on the Application of
Travell's lligger Point Pain Control Therapy
The ideal thumb pressure is the least pressure needed to pro­
duce the referred sensation, about five to ten pounds. Trav­
el! recommends thirty to torty pounds of what she calls
"ischemic pressure," gradually increasing and sustained until
the pain stops. In the author's experience, thirty pounds is
excessive, and likely to produce so much pain at the point of
stimulation that subtle referred paresthesias may not reach
conscious perception. Even subtle paresthesias are worth
treating. They may be the key to serious muscle imbalance.
Exactly how hard to press is best determined by first
explaining tl1e trigger point concept to the patient. Then
tell the patient you want to know how intense the pain is,
both at the site of pressure and in the referral area, on a ten­
point scale. Explain that the pain at the site of pressure should
never become intolerable, and to let you know if it does, so
that you can ease the pressure off On the other hand, the
more intense the referred sensation is, the better, because
the quicker it will become anesthetized. Ask the patient to
put up witl1 as much referred sensation as possible. Begin
by applying the initial pressure gradually until the referred
sensation is produced.
Occasionally, the referred sensation does not develop
immediately. It may take up to five seconds tor the referred
sensation to begin after the pressure is applied to the point.
It helps a lot to know where the points are, by consulting
Travell's charts. With practice, the points can be tound by
palpation. The Travel! charts are essential tor beginners.
Once the trigger point is located, it is preferable to keep
the initially effective stimulus pressure constant, and instruct
the patient to provide a continuous report on the referred
sensation's intensity, location, and quality. Such reporting
changes the patient's attitude toward the pain, which
becomes the object of scientific observation. Ideally, the
stimulus is sustained until the referred sensation intensity is
diminished by half This may require several seconds to sev­
eral minutes. When to stop the pressure is sometimes ditli­
cult to judge. The referred sensation may come in waves,
usually each wave with less intensity than the previous one.
The therapist may experience a series of melting sensations
under the thumb; these are usually soon tollowed by a reduc­
tion in referred sensation intensity. If the pressure is kept
constant, the thumb will sink deeper into the tissue. This
common experience has prompted the theoretical explana­
tion labeled "myogelosis," which is also oflered as the expla­
nation tor the diagnostic palpable quality of the trigger point.
Sometimes the same pressure on the deeper layer of tissue
causes more intense referred sensation or a change in its loca­
tion. Subjectively the patient may feel that your pressure has
increased. Make sure that it has not.

Appendix (continued)
Travell distinguishes between active and latent trigger points.
Active trigger points produce referred sensation symptoms
without external stimulation. Latent trigger points produce
symptoms when stimulated by active use of the muscle or by
the therapist's pressure. Treatment of latent trigger points
is both therapeutic and preventive. Local tenderness does
not constitute a trigger point. It is simply a sore spot, or a
Jones point, which 15 to 30 seconds of sustained pressure
will usually anesthetize. However, it is a good idea to defer
deciding for a few seconds. If the spot does not refer a pain
or paresthesia after more than five seconds of pressure, it is
not a trigger point.
The trigger point area may be larger than the tip of your
thumb. It is worth exploring the periphery of the trigger
area. It is probably not a good idea to stretch or "snap" the
muscle before treating the trigger point. Such gratuitous
stimulation tends to reinforce the trigger point reflex feed­
back loop. Post-trigger-point-treatment stretching of the
involved muscle is a good idea, however. It permits a reset­
ting of the gamma system.
In spite of the "ischemic pressure" description, the
author prefers to explain the excellent results of trigger
point treatment by pain pathway endorphin inhibition in
the zona pellucida. The sustained pressure stimulation
brings about local anesthesia, as the nervous system adapts
to it. Most importantly, the positive feedback reflex pain­
spasm loop is inhibited, reducing the likelihood of recur­
rence.
The rational clinical sequence for applying TTP
treatment is:
1. Treat and correct segmental dysti.mctions.
2. Treat the associated trigger points.
3. Gently stretch the muscles where the trigger points
were found and treated.
4. Teach the patient to treat their own trigger points,
or train someone else to administer TIP to the patient
between office visits.
5. Advise the patient that some patients have reported
that excessive sugar in the diet may activate trigger
points.
Fibromyalgia or fibromyositis
Can the presence of Travell trigger points (myofascial pain
syndrome) be diagnosed as fibromyalgia or fibromyositis
[ICD-9-CM code 729.1 ]? Inasmuch as the International
Classification of Diseases fails to list or provide a separate
code number tor Travell's trigger points, the diagnosis of
fibromyalgia is the only way to record TIPs for third party
medical records. The ICD-9-CM does list in its alphabet­
ical tabulation "myofascial pain syndrome" and assigns it
the same code number (729.1), but the numerical tabula­
tion does not mention it.
Rheumatologists have decided to define fibromyalgia as
a minimum number (currently ll out of 18) of tender
spots without reference to referred sensation. This has led
APPENDIX � 221
some authors to try to differentiate between fibromyalgia
and myofascial pain syndrome. One of the 18 areas of ten­
der points specified for fibromyalgia corresponds to the
area identified in Owens' An Endocrine Interpretation of
Chapman's Reflexes as the diagnostic and treatment area for
neurasthenia. Considering the neuroendocrine comorbid­
ity associated with fibromyalgia, Chapman's reflexes could
prove to be an appropriate ancillary treatment for
fibromyalgia.
The American College of Rheumatology criteria for
diagnosis of fibromyalgia:
A. Widespread pain for at least 3 months
1. Pain in both right and left sides of the body
2. Pain both above and below the waist
(including shoulder and buttock).
3. Cervical, thoracic, lumbar, or anterior chest pain.
B. Pain on palpation with a 4 Kg. force in 11 of 9
bilateral sites:
1. suboccipital (including trapezius, sternocleidomas­
toid, splenius capitis, or semispinalis capitis)
2. anterior intertransverse spaces C5-C7.
3. middle upper trapezius border.
4. supraspinatus
5. anterior second rib area.
6. 2 em. distal to the lateral epicondyle
7. anterior edge of gluteus maximus, upper outer
quadrant of buttock.
8. posterior greater trochanter
9. medial knee proximal to the joint line.
At least six of these bilateral areas correspond to com­
monly occurring Travell trigger point sites. Notice that no
mention is made of referred sensation in the fibromyalgia
criteria, however. Insisting on an exact number of tender
points for the diagnosis strikes this author as silly. If the
patient is one or two tender points shy of tl1e requisite
number, what is the diagnosis?
One of the possible etiologies of fibromyalgia is sleep
disorder, especially sleep deprivation due to recurrent sleep
apnea. Sleep deprivation also makes TTPs worse by con­
verting latent to active TIPs or making the active TIPs
more active. Breathing machines (CPAP or the like) have
a definite place in the management of fibromyalgia as well
as myofascial pain syndrome.
Metabolic stress from an unhealthy diet makes both
TIPs and fibromyalgia worse. For example, excess glyco­
genic carbohydrates (sugar) in the diet of a pre-diabetic or
insulin-resistant patient is a predictable offender for the
fibromyalgia patient as it is in the myofascial pain syn­
drome.
222 T H E MUSCLE ENERGY MANUAL
 BIBLIOGRAPHY AND RECOMMENDED READING 223

Bibliography and
Recommended
Reading
224 T H E M U S C L E ENERGY M A N U A L
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 THE MUSCLE ENERGY MANUAL --t; INDEX 231

ASIS 2-3 cervical rib 88

INDEX FOR VOLUME Two
asymmetries of rib position or breath­ cervicals, lower two
ing examine and treat as thoracics 114
Numbered Terms 106 cervicothoracic transverse process
499-step procedure (short-cut) 200 atypical thoracics 11 evaluation 114
50 step procedure 18,186,188 axial rotation chain of bones concept 123
isotonic version of 190 neutral seated 128 circulation - respiration connection 53
500 step procedure 118 of a lumbar 27 clavicle stabilization
for FRS dysfunction 194 spinal 22 in first rib subluxation 145
protocol 196 axis 17 co-contraction of tense muscle 91
stages of 196 Axis vertebra Volume 1,pp 187,192 coccydynia 153
step 1 for NSR dysfunction 215 coccygeus muscles 46
collagen 31
B molecule 94
A common compensatory pattern 158
balance, relaxation, and localization
compensatory group 128
abdominal oblique muscles 19 75,123
compensatory NSR dysfunctions
Academy of Applied Osteopathy 40 barrier
215
adaptation, adapting 27,97-98,
treatment for
MET and HVLA: similarities and
compensatory scoliosis 161
130,183 differences 186
complex segmental dysfunctions 115
as group spinal curve 209 sidebending 190
compressed rib 57
above the ERS dysfunction 187 feather edge of 118,198
141
biomechanics of the spine 206 neutral side of 190
A-P
141
34 Beckwith, C. Gorham 40
lateral
characteristics of
connective tissue changes 32
group 179 Beilke, Martin 40
contractile muscle activity and joint
in rotoscoliosis 28,38,170 biomechanics 17
hypermobility 117
mechanisms 164 blockage, articular
coordinate system, right-handed
mistaken tor lesions 118 due to muscular tightness 33
orthogonal 16-17
postural 12,157 due to non-muscular factors 33
Coriolis effect 39
process 31 body statics, faulty 31
costal cage deformation
rotoscoliosis 28,38,170 Bogduk, N 156
with vertebromanubrial rotation 22
scoliosis 209 bony landmark
costal cartilages 3,9,11
sidebending-rotation 29 static position of 1
22
1,13 breathing
remolding of
spinal
costochondral 9,82
stress 153,173 as a function of the motor system 43
66, 141
to habitual movements 28 motion, asymmetry of 109
separation
costoclavicular ligament 51
to sacroiliac dysfunctions 184 movement styles 53
costotransverse
to segmental dysfunction 162 �striction(rib) 101,107,117,148
50
206 due to structural rib lesion 139
articulation
vs. dysfunction
11
analytic diagnostic system of MET step 57-58,63,65,75,84
facets
v
25
anatomic specificity 90 symmetry duration 105
orientation of
22
anatomically short leg tests 90,106,111
ligaments, posterior
costovertebral
stages of compensation 161 total body
82
bucket and pump handle 60-64, 68-
facets
annulus fibrosus 20
145
anterior landmarks of trunk 2 69,72-74,84,102-103
ligaments
8
anterior rib subluxation bucket bail lesion (rib) 81,136-138
relationship classes
133-137
treatment for 142 diagnosis and treatment 146
subluxations
138
anterior scalene muscles 68 147
evaluation and treatment
treatment for
counternutation 21
anterior superior iliac spine (ASIS) 2, bucket handle 7,102,107-108
counting
3 ribs vii, viii, ix, and x 50
10
anteroposterior spinal curvatures 12
ribs
spinous and transverse processes 6
A-P asymmetries of the transverse
116
processes 115
transverse processes
c coupled motion 17
A-P curves 12,40
caliper motion 61,67 28
apex 128
contralateral rotation
ribs xi and xii 50 sidebending and rotation 23 27 29
28,38
capsular fibrosis 32
of scoliotic curve
first two thoracic vertebrae 22 '
arm
carryover effect cranial respiratory movements 47
edema and paresthesias 80
of flexion tests 169 cranial rhythmic impulse (CRl) 44
arthrokinematics 15,17
cartilage deformation 32 crista galli 47
articular blockage
Cathie, Angus G., DO 100 crossover (scoliotic) 128
33
cephalic perspective of the sphinx
due to non-muscular factors
articular range-of-motion restriction
position 181
quantified v
232 INDEX --&-THE MUSCLE ENERGY MANUAL

exhalation functional spinal unit (FSU) 16-17,

D
promotes relaxation 119 19-
demifacets ll
restriction 108 20,23
dental malocclusion 214
treatment 71,72-74 Tl-T2
diagnosing thoracic segmental
extension and flexion 17,40 flexing , rotating, sidebending 82
dysfunction l 0l
eye dominance l06
diagnostic algorithms of MET v
diaphragm
pelvic 45-46
G
thoracoabdominal 44,46
F gapping and pinching, interspinous
diet facet gapping 128 122,212
in fibromyalgia 2I9 eftect of neutral rotation 194 gapping (facet) effect of neutral
dimple of Michaelis 4 facet joints 27 vertebral rotation 128,194
dislocations/subluxations of ribs 57 arthrokinematics of 20 gel state 31
dominant eye 58,62 motion, vertebral, impaired 101 gelosis, interstitial 31
duration of isometric contraction 187 non-weight bearing 25 gibbous kyphosis 12
dysfunction orientation 12 glabella 47
iliosacral 164 facets-idling 28 gladiolus 49
nonadaptive spine and sacroiliac 16I false positive flexion tests 168 gluteal tubercles 168
pelvic I64 feather edge of the barrier 118 Goodridge, John DO 205
respiratory 107 fibrolipomas in the low back 164 gravitational contrarotational forces 20I
sacroiliac I68 fibromyalgia or fibromyositis 219 greenstick fracture I41
segmental vertebral 57,I06-7,Il7 fibula 19 ground substance
vs. adaptation 206 in low back dysfunction 214 rheologic properties of 31
dysfunction, segmental 56,79,102, 137 fifth lumbar FRS dysfunction group lesion vs. adaptation
adaptation to I62 treatment for 201 diagnostic tests, interpretation 208
cervical spine 94 finger contact points group lesions
stacked 206 tor A-P rib position 137 diagnosis and treatment 206
thoracolumbar 154 first rib superior subluxation 87 guarding muscle spasm 91,98
upper thoracic I12 flexion and extension 17,40
dysgenesis of the pelvis 161 flexion tests
dysgenesis, developmental interpretation of I67,I69 H
rib 104 standing and seated carryover 167
hara kiri technique 142-143
floating ribs 67
hip drop test
fluids
tor lumbosacral sidebending 185
interstitial 95
E interpretation of 185
focused extension test for FRS
edema and paresthesias of the arm 80 hip roll technique (HVLA)
dysfunction 116
endorphin inhib. of pain pathway cf. "universal" technique 211
focussed sidebending test for NSR
2I9 historical chronology of MET xv11
210
England, Robert, DO I00 Hoover, Harold, DO 40
fracture, greenstick 141
epistaxis 80 HVLA
freedom, degrees of 17
erector spinae muscle 154 tor lumbothoracic dysfunction 216
FRS and ERS 32,35,37,39-40,
ERS 34,57 hyperflexed seated position 174
79,85-86,90,97-99, 101-
treatment, lumbar 213 hypermobility
103,105,107-109,112-113,
short cut I92 costovertebral 145
Il9,128,131,172-174,179,
major and minor 120 hypermoble joints 91
201
ERS and FRS v, 32-33,35,37,39- contractile muscle activity over 117
diagnosis 183
40,79,85-86,90,97-99, hypersphinx position 109,17
. 4,180
diagnostic criteria 141
10I-I03, 105,107-109,112-
lateral recumbent treatment 126
I13,119,128,131,172-174,
major and minor 36,110,
179,20I
114-115,124
I
diagnosis I83
rib scan for lower thoracic 175 ideal human posture 53
rib scan for low thoracic I75
FRS dysfunction 57 ILA symmetry for sacral position 170
diagnostic criteria 141
focused extension test for 116 ILAs I76
lateral recumbent treatment I26
minor or major 122 iliocostales muscles ll,27,47,51,
lower lumbar segments 202
supine MET treatment 127 52,130,I40,154,
minor and major 36,II0, 114-
treatment, lumbar 213 I76,178
115,120
treat upper mid-thoracic 124 cervicis and dorsi muscles 9
supine MET treatment 127
fifth lumbar, treatment for 201 iliosacral dysfunction I64
treatment of 190
Fryette, Harrison H. impaired zygapophyseal kinematics
visceral consequences of 98
laws 40 106
eupnea 45, 53
 THE MUSCLE ENERGY MANUAL � INDEX 233

incontinence 153 lumbar vertebrae 177 flexion/extension 21

inferior lateral angle (ILA) sacral 207 twelfth ribs 178 mechanics 157
inguinal pain 153 landmarks sidebending 39
inhalation restriction 108 anterior 2 lymphatic capillaries
treatment 67-68 lateral trunk 5 contractile endothelium of 43
inhibition of antagonists 66 posterior 4 lymphatic
instantaneous transverse axis 20 Larson, Norman DO 161 flow, impaired 31
intercostal angle 9 lateral recumbent technique return 45
intercostal muscles 51 for L5 FRS dysfunction 204 system 80
interspinous muscles 19 for lumbar ERS 202 capillary changes 32
interspinous pinching and gapping for sidebending MET stretch 216
212 salad bowl MET technique 126
interstitial fluids 94,95 for treating ERS, FRS, and M
gelosis 31 NSR dysfunction 211
major and minor
intertransversarii muscles 19,122 lateral trunk landmarks 5
dysfunction 114,115,123
intervertebral disc layer-by-layer palpation 5,117
joint motion 122
arthrokinematics of 20 Lee, Diane 22-24,28
somatic dysfunctions 122
rupture of 20 leg length asymmetry 158
malleolus measurement 161
intraosseous deformities, rib 55,57, leg, anatomically short
malocclusion, orthodontic
81,141 stages of compensation 161
as possible etiology for scoliosis 209
altered curvature 133 levator ani muscles 46
dental 214
intraosseous rib lesions 134 levator costae muscles 9
manubrium 22, 49,83
treatment for 150 Lewit, Karel 119
median furrow 4,6
rib shaft torsion 133 ligaments
meniscoid entrapment 31-32
single rib torsions commonest 148 costoclavicular 51
meralgia parestlietica 153
ischiorectal fossa 46 posterior costotransverse 22
MET (Muscle Energy Technique)
isolytic technique, vibratory 94,95 sacrotuberous 19
distinctive diagnostic algorithms v
isometric contraction 71 limbs
neutral, staying in, importance 187
isotonic contraction 71 respiratory actions of 52
physical diagnosis 1
line of sight 162,163,175,182,208
primary concern 31
Little, Kenneth, DO 53,94
metastatic
J localization 120,124
for rib treatment 72
bone disease
Janda, Vladimir MD 119,161 force contraindicated in 147
in the "universal" technique 211
joint motion restriction, causes of 31 disease 66
and relaxation 71
Jones, Lawrence, DO 219 modified longus colli technique 118,
of sidebending 190
124-125
sequence 119,127
Moran PS, DO xvii
localization, balance, and relaxation
K 75,123
motion restriction of joint, causes of
32
Kapandji, lA 29 localizing spinal torque 212
movement patterns, faulty 31
key lesion 118 longissimus muscles 18,52,130,
multifidi muscles 18-19,46,195
key rib 55-57,59-61,62,63,66, 71, 154,178
multiple myeloma 66
75,85,90,101,105,107- longus colli muscles 18,27
force contraindicated in 147
110,116-118,130,148,153, longus colli technique 118,122
Muscle Energy Technique (see MET)
172,175 longus c. technique, modified 124-125
primary concern 31
key spinal lesion 162 loose-packing 91,142,150-151
Muscle Energy Tutorials xvn
Kimberly, Paul DO 136,138,147 lordosis 12
muscle imbalance161
kinematics 15 lordotic curvature, lumbar 156
hip rotator 164
kinesiologic units 8 lumbar
muscle relaxants
kinesiology 15,17,19 adapting to sacroiliac dysfunction207
as subluxation preventive 94
of the trunk 18 dysfunction 153,164
muscle spasm
kinetics 17 NSR dysfunction diagnosis 216
dealing with during treatment 191
kypholordosis 12 rotation 25,157
guarding 91
kyphosis 12 segments, axial rotation of 25
muscles
sidebending 25
abdominal oblique 19
spine, stabilization of 19
anterior scalene 68
L spinous processes 7
coccygeus 46
transverse processes 154
landmark, bony erector spinae 154-155
lumbosacral
static position of 1 iliocostales 11,27,47,51-52,130,
adaption vs. dysfunction 207
landmarking 140,154,176,178
angle 21
lower thoracic trans. proc. 178 9
iliocostalis cervicis and dorsi
dysfunction 157,173
234 INDEX -&THE MUSCLE ENERGY MANUAL

intercostal 51 non-neutral dysfunction 157,175 treatment for 142,144

interspinous 19 non-neutral unisegmental motion 27 posterior scalene muscles 88
intertransversarii 19,122 NSR 34,36,38-40,57,97,113, postural adaptation 12,157
levator ani 46 128,173,183,207 postural stabilization
levator costae 9 diagnosis and treatment 206 neck 47
longissimus 18,52,130,154-155, NSR dysfunction, lumbar posture, ideal human 53
178 diagnosis 216 primary curve 12
longus colli 18,27 NSR dysfunctions, compensatory primary respiratory mechanism 56
multifidi 18-19,46,195 treatment tor 215 prolapse, organ 153
obliquus abdominis 45 NSR treatment, thoracic 214 proprioceptive mechanisms 94
pectoralis major 9,46,51, nutation21 Pruzzo, Neil Alan, DO xvii, 181
66 pseudo-arthrosis 148
pectoralis minor 9,51 PSIS 4,168
platysma 114 0 for standing flexion test 166
psoas major 19,155,195 psoas major muscle 19,195
obesity
quadratus lumborum 19,44,154, psychomotor skills
efrect on breathing 83
155,176 stages for learning 90
oblique axis
rectus abdominis 19,45 pubic bones 164
sacral rotation on 25
rectus femoris 2 pubic crest vs. pubic tubercle 2
obliquus abdominis muscles 45
of respiration 44 pubic subluxation
operculum 79
rotatores 18-19,195 secondary to lumbopelvic
orthogonal coordinate system,
sacrospinalis 18-19 dysfunction 207
right-handed 16
sagittal plane in spinal MET 119 pubic symphysis 2
osteokinematics 15-17
scalene 18,46-47,51,83,94 pump and bucket handle 60-64,68,
osteoporosis 66
scalenus posterior 9,88 69,72-74,84,102-103
force contraindicated in 147
semispinalis 195 pump handle movement 7,105,108
thoracis 19 ribs ii, iii, and iv 50
serratus anterior 9,51,66,68 push me pull you technique 144
serratus posterior superior 9
p
six muscles in the body 18, 33 pain
spinalis 18,52,155 chest wall 148
in relation to posture 160
Q-R
sternocleidomastoid 218
quadratus lumborum muscle 19,44,
subclavius 46,51 control with trigger points 218
154,176
tensor fascia lata 19 pathway endorphin inhibition 219
range of motion
transversus abdominis 19,45-46, pain-spasm
beginning and end of
155,195 positive feedback reflex loop 219
sagittal 20
trapezius 88,119,218 paradoxical sacral nutation 21
range-of-motion restriction, articular
myofascial pain syndrome 219 parallax view 182
quantified v
myotatic reflex 94,95 parathyroid, microcirculation of 80
ranges of motion
partial release (during treatment) 191
segmental and regional 26
passive joints, mobilization of 33
rectus abdominis muscles 19,45
pectorales muscles 9,46,51,66
N rectus femoris muscle 2
pelvic dysfunction 164
nerves reflexes
secondary to spinal dysfi.mction 207
phrenic and vagus 80 myotatic 94,95
pelvic dysgenesis 161
neuroreflexive muscle viscero-somatic 31
pelvic organ prolapse 153
contraction 31 relaxation, balance, and
peripheral vision 58,64-65,102,
reaction, gamma system 32 localization 71,75,123
104-106,130,175
neutral 97 relocalization 119,127
pharyngitis 80
range, finding 120,122,124,186, remolding of costal cartilage 22
phrenic and vagus nerves 46,80
188 respiration
physical diagnosis
rotation, f.Ket-gapping eftect 194 cellular 44
precision of MET vO
side of the barrier 190 spinal movements during 47
piezoelectric tissues 13
sidebending 156 respiration, muscles of 44
pinching and gapping of spinous
sidebending-rotation 27 respiratory acidosis as an aid to
processes 122,212
spinal motion 27 fascial stretching 94
plagiocephaly 13
staying in 187 respiratory actions of the limbs 52
as possible etiology for scoliosis 209
neutral (type I) dysfunction respiratory
platysma muscle 114
diagnosis and treatment 206 cooperation 119
positions, static, of the segment 123
neutral and non-neutral sidebending dysfunction, rib 56,107,156
post-isometric relaxation 119
of the thoracolumbar spine 28 impairment of ribs 56,107,156
posterior landmarks 4
nociception 98 respiratory mechanism, primary 56
posterior rib subluxation
 THE MUSCLE ENERGY MANUAL � INDEX 235

respiratory motion impairment 150 key 59-63,66,71,75,85,90, Ruddy, Thomas Jefferson, DO 94

respiratory motion of the ribs 117 101,105,107-110,116-118, rule of threes 6-7,112,114,116
respiratory movements l 03 130,148,153,172,175 rule of threes in reverse 154-155
cranial 47 lateral compression 148 Rumney, Ira, DO 211
normal 43 diagnostic criteria 150
posterior rib l04 minor breathing motions 56,129
sacroiliac 48 monitoring movement of 137 s
sternal body 48 one (i), structural lesions of 133
sacral
styles 53 positional asymmetry 101,106
base 157,170
respiratory movement, rib 105 positional symmetry 117
nutation 157
monitoring 137 respiratory dysfunction of 56
torsion 170
motion tests Ill respiratory impairment of 156
unilateral flexion 170
respiratory restriction of ribs 81,90, respiratory motion of 117
sacroiliac
101,107,117,148 respiratory restriction 81,103,107,
dysfunction 173
rib group l09 175
lumbar adapting to 207
due to structural rib lesion 139 restricted exhalation movement 129
flexion/extension 21
respiratory sy nkinesis 47,200 screening 58,84,l03-l06
respiratory movement 48
respiratory/circulatory model 53,75 second 9
sidebending 39
restricted structural lesions 55-57,79
sacrolumbalgia 153
exhalation l08 subluxation 55,106,133,138
sacrospinalis muscles 18-19
inhalation l 08 subluxation, diagnostic criteria 141
sacrotuberous ligament 19
joint motion superior, anterior, posterior 90
sacrum
causes of 31, 32 subluxation, recurrent 145
coupled contralateral
restriction of articular range-of-motion superior subluxation 136
sidebending of 25
quantified v subluxation vs. segmental
salad bowl MET technique 118,126
rib(s) dysfunction 81
scalene muscles 18,46-47,51,83,
"up" or "down" 60 torsion 37, 57,113,133,134,137
94
A-Pcompression 148 torsion, diagnostic criteria 141,149
scalenus posterior muscles 9
diagnostic criteria 150 torque, mechanism of 24
scanning test
A-Pposition 107,111,172 typical and peculiar 8
observing paravertebral fullness 182
A-Psymmetry 108 unstable 138
scapular spine 4
angle breathing motion 140 up or down 56
sciatica 153
angles 4,11,52,104,106,110, rib cage deformation with scoliosis 13
scoliosis 13,158-159,161
111,114,139-140,154 rib cage ligaments l0
as adaptation 209
ant. or post. subluxation 89,136 rib lesions, cause of most 55
compensatory 161
asymmetry, antero-posterior 37,108 rib motion
idiopathic 162
belt 94,141,145 duration of
rotation component of 162
breathing asymmetry 106 ribs slide under the skin l
secondary curves 160
breathing motion 104,137,172 rib respiratory motion 105
thoracic (see plagiocephaly,
breathing restriction l 0 l, 139 effect of spine extension on 172
malocclusion) 209
bucket bail lesion 136 rib respiratory restriction
screen(ing)examination
compression associated with segmental
iliac crest heights 161
A-Por lateral 135 dysfunction 37
observing paravertebral
compression, diagnostic criteria 141 rib, first
fullness 162-163
compressions 57,137 structural lesions of 81
posterior rib l04
counting 2, l 0 rib-based vertebral diagnosis 55,175
prone posterior 106
curvature deformities 135,137 compared with transverse process
ribs 58
diagnosis skills, self-confidence 56 palpation 117
seated flexion test 164,168
dislocation 133,136,138 ribs as indicators of vertebral
sidebending test of the thoracic
dislocation and subluxation 57,137 segmental dy sfunction l00
region 130
elastoplastic properties 133 ribs, unifaceted
spinal rotation tests 158,162
false, true, and floating 8-9 and vertebral rotation 24
standing flexion test 164-166
findings in hyperflexed position 181 Rolf, Ida 94
static posture from the side 160
fracture 66 rotation 17
stereognostic 102
group 130 rotation and sidebending, uncoupled 27
supine breathing tests 130
group respiratory restriction l 09 rotation, neutral technique 128
supine 105
influence on vertebral motion 20 rotation/sidebending coupling 156
thoracic and lumbar 158,172
instability 145 sacral base 157
trunk rotation test 130
intraosseous deformities 57,55,81, rotational component of NSR
trunk sidebending tests 171
133,141,137 dysfunction, triviality of 217
walking, static posture 158
intraosseous lesions 134,135 rotatores musclesl8-l9,195
seated axial rotation technique 118
treatment for 150 rotoscoliosis 13
236 INDEX �THE MUSCLE ENERGY MANUAL

seated flexion test 168 spasm of muscle syndromes

carryover effect with dealing with during treatment 191 myofascial pain 219
standing flexion 167 specificity, anatomic 90 neck/shoulder/arm 87
seated hyperflexed position 174 sphenobasilar symphysis 47 synkinetic, synkinesis
seated hyperflexion test sphenosquamous suture 47 oculomotor 119
for ERS lesions in lower sphinx position 65,108,109,111 respiratory 47,119, 200
thoracic and lumbar 182 174,180 synovial fluid
interpretation of 183 cephalic perspective 181 rheologic changes in 32
transverse processes and ribs, sphinx test 183,199-200,205,207
static position 182 spinal motion, neutral 27
secondary curves 160 spinal torque, localizing 212 T
segmental dysfunction 57,79,97,99, spinalis muscles 18,52
technique
102,106,107,113,117-118, spinous processes, counting 6
499-step proc. (short-cut) 200
130,184 stabilization, postural
50 step procedure,
adaptation to 162 neck 47
isotonic version ofl90
combined with structural stabilization, segmental 19
50-Step procedure 118,188
rib lesion 139 stacked segmental dysfunctions 206
500-Step procedure 118,196
complex 115 standing flexion test 165-166
500-step procedure,stages of 194
diagnostic criteria 141 carryover effect
anterior rib subluxation 142
ERS and FRS vO with seated flexion 167
bucket bail lesion treatment 147
FRS 122 static positions of the segment 123
hara kiri,for anterior rib 142,143
in the cervical spine 94 step breathing 57-58,63,65,75,
isometric 119
neutral and non-neutral 33,175 84,104,108,129,175
lateral recumbent for L5 FRS 204
recurrent 148 stereognosis 2,4,37,46,58,102-
lateral recumbent MET
role of facets 33 104,106,111,112,114,
tor sidebenders 216
stacked 206 118,137,139,140-141,
longus colli 118,122
thoracic 148-149, 164,176,178
MET: duration of contraction 187
diagnosing 101 sternal angle 3,83
million dollar roll,similar to
causes most rib lesions 55 sternal body
universal technique 211
thoracolumbar 153-154 respiratory movement of 49
modified longus colli 118,124-125
upper thoracic 112 sternal body axis 49
posterior rib subluxation 142
vertebral 56,75,137 sternocleidomastoid muscle 218
push me pull you (posterior rib)l44
vs. rib subluxation 81 sternum
salad bowl 118,126
segmental stabilization 19 in relation to 2nd and 3rd ribs 49
seated axial neutral rotation 128
semispinalis muscle 195 respiratory axis 49
seated axial rotation 118
semispinalis thoracis muscles 19 Still,A.T.,MD 151
supine,for joints C3- T6 118
sequence Strachan, Frasier 40
thrust (HVLA) 91
of lumbopelvic treatment 207 stress reduction 94
thrust ( HVLA), contraindicated
of treatment 66,118,187 structural lesions of the first rib 81
in rib subluxation 145
serratus anterior muscles 9, 51,66,68 structural rib lesions 55-57,79,106,
turban 118,120
serratus posterior superior muscles 9 107,110-111,136-137
vibratory isolytic 94,95
Sherrington's Second Law 66,91 combined with
technique, lateral recumbent
shim 161 segmental dysfunction 139
for lumbar ERS 202
for standing flexion test 165 diagnostic criteria 141
universal tor FRS, ERS, NSR21l-213
short leg, anatomic styles of breathing movement 53
tensor fascia lata muscles 19
stages of compensation 161 subclavius muscles 46,51
test
sidebending 17 subluxation, rib 55,57,90,133
focussed sidebending for NSR 210
in neutral NSR mechanics 156 first rib 79
hip drop 185
localization 190 first rib anterior
tor first rib subluxation 86
MET, lateral recumbent 217 treatment for 93
thoracic inlet 2,80
screening test of the first rib posterior
shape,altered
thoracic region 130 treatment for 93
causes of 81
segmental spinal biomechanics of 25 first rib superior 87,91
venous blood and lymph flow 79
sight, line of 162-163,175,182,208 preventing recurrence 94
thoracic segmental dysfwtction
Sims position 202 test tor 88
causes most rib lesions 55
single rib torsion 37 treatment for 92
thoracic vertebrae, typical 5
six-muscle paradigm in MET 33 supine technique for
thoracics, atypical ll
sleep disorder thoracic joints C3 T6 118
thoracoabdominal diaphragm
-

in fibromyalgia 219 sympathetic trunk 80

as heart of the venous system 44
slump-sit tall transverse process test symphysis
thoracolumbar sidebending
interpretation of 184 sphenobasilar 47
neutral and non-neutral 28
somatic (segmental) dysfunction 158 pubic 2
 THE MUSCLE ENERGY MANUAL -b INDEX 237

thrust techniques contraindicated NSR dysfunction,thoracic 214 vertebroabdominal segments

in rib subluxation 145 of vertebral dysfunction 75 axial rotation of 24
thrust techniques (HVLA) 91 posterior rib subluxation 142 vertebrochondral segments 8
thymus, microcirculation of 80 sequence of 66,187 rotation of 24
thyroid, microcirculation of 80 trigger points, Travell 218 vertebromanubrial segment 8,11,22,
tonsillitis 80 active and latent 219 79
torque, spinal, localizing 212 associated with vertebrosternal segments 8-9
torsion, single rib 37,57,113,134 guarding muscle spasm 218 axial rotation of 22
diagnostic criteria 149 associated with vibratory isolytic technique 94-95
translation movement 17 segmental dysfunction 218 visceral consequences
of the vertebral body 98 compared with tender point 219 of ERS and FRS dysfunction 98
physiologic of vertebral body 20 delay of referred sensation 218 visceral pathology
transverse process myogelosis, theory of 218 and paraspinal reflexes 214
A-P asymmetries 115 pressure treatment of 218 viscero-somatic reflexes 31
asymmetry referred sensation due to 218 Vleeming, A., PhD. 214
lumbar 173 trophism
counting 6,116 zygapophyseal and sacral 158
examination of trunk sidebending tests 171 w
lower two cervicals 114 turban technique 118,120
Wolff's Law 13,148
upper six thoracics 114 two finger method
finding 176 for counting spinous processes 6
findings in hyperflexed position 181 Twomey LT 156
in lower thoracic diagnosis 175 type I and type II dysfunction 34,38,
X
interpretation of findings 179 40,85,128,179, x-axis 22
lumbar 154 type I dysfunction 33 xyphoid 49
finding 177 diagnosis and treatment 206
palpation 130 type I thoracic lesions
palpation of treatment for 214 y
compared with rib-based type II dysfunction 33,110,122,124,
y-axis 22-23, 25, 27,37,156
diagnosis 117 134,151,154,157,
positions 131 175
relation to rib angle 154 effect on ribs 37
tests 112 typical thoracic vertebrae 5
z
transversus abdominis muscle 19, 45- z-axis 22,25
46, 195 Zink, J. Gordon, DO 53
zona pellucida
trapezius muscle 88,119, 218 u
Travell, Janet, MD 218 and pain control 219
uncoupled rotation and sidebending 27
treatment zygapophyseal (facet) joints 27,82
uncovertebral joint 82
50-Step Procedure 186 arthrokinematics of
undulations of the spinal column 27
50-Step procedure 188 dysfunctional 100
unifacets 11
anterior rib subluxation 142 normal 20
universal rib technique
for ER.S dysfi.mction 190 compaction of 25
of Andrew Taylor Still 151
50 step 186-191 kinematics,impaired 106
unstable rib subluxation 138
short cut 192 not engaged (in neutral) 113
upper thoracic dysfunction 112
lumbar lateral recumbent 202, orientation 12
213
for FRS dysfi.mction
500-step procedure 194-196 v
lumbar lateral recumbent 213 vasa nervorum 80
for restricted inhalation 67,70 venous return 45
for restricted exhalation 71-74 vertebrae
for first rib subluxations 91 typical and atypical 8
for first rib anterior subluxation 93 vertebrae, numbering 6
for first rib posterior subluxation 93 vertebral dysfunction 148
for first rib superior subluxation 92 vertebral facet motion
for inhalation restriction68 impaired 101
for non-neutral (type II) vertebral segmental dysfunction
dysfunctions 186 56-57,107,137
for respiratory rib restrictions 66 as indicated by ribs 100
lateral recumbent for L5 FRS 204 characteristics of 34
lower thoracic and lumbar 186 combined with structural rib lesion 139
MET: duration of contraction 187 marked by single rib torsion 134
238 INDEX T H E M U S C L E ENERGY MANUAL