Solving Today s Pain and Injury Puzzle with Erik Dalton An Online Workshop for ABMP Members Session 4 Handout Please Note: Erik Dalton teaches his Myoskeletal Alignment Techniques with the expectation that participants are well versed in anatomy, physiology, soft-tissue injury and dysfunction, palpation, and biomechanics, and have conducted thorough client intakes and health histories before using any of these protocols. These advanced techniques the presenter is demonstrating today will offer you a glimpse into the value this work, and its mastery, can afford your clients; more advanced learning of these techniques is available at www.erikdalton.com. Lower Body Nerve Entrapment 1. The Slump Test a. The client slumps forward at the thoracic and lumbar spine. b. If this position causes no pain, the client flexes their neck by placing the chin on the chest and then extending one knee as much as possible. c. If extending the knee causes pain, have the client extend their neck to neutral. If the client is still unable to extend the knee due to pain, the test is considered positive. d. If extending the knee does not cause pain, ask the client to actively dorsiflex the ankle. If dorsiflexion causes pain, have the client slightly flex the knee while still dorsiflexing. e. If the pain occurs, the test is considered positive. f. Repeat the test on the opposite side. 2. Soft Tissue Prep a. Warm the Fascia i. The therapist s thumb and index finger contacts both sides of the client s lumbar spine, with the fingers of the therapist s other hand bracing on top. ii. The therapist rocks back and forth, pushing and pulling on the lumbar fascia assessing for ART (Asymmetry, Restriction of motion, Tissue texture abnormality). iii. Search for protective muscle guarding and release any contractures with continued rocking.
b. Iliolumbar Ligament Technique ( Flying V ) i. Stand at the head of the massage table or on the client s right side. ii. Create a V with the index finger and middle finger of the right hand and straddle the spinous processes at L4 and the index and middle fingers of the opposite hand are placed on top to form Dalton s Flying V. iii. With firm extensor forearms and extended elbows, the therapist leans his body weight and begins accessing the iliolumbar ligaments. iv. A jolting action is added that helps drive the extended fingers down to L5 S1 to scrub fibrotic ligaments. v. Try using the thumbs or knuckles if you re having trouble with extended fingers. c. Freeing the Lumbar Region i. Stand at the head of the massage table or on the client s right side. ii. The therapist s left hand braces the sacrum, and his right palm contacts the lumbar spine. iii. A counterforce occurs when the therapist pushes with his left hand and resists with his right hand. iv. The therapist s hands mobilize the sacrum and lumbars in a variety of directions. 3. Sciatic Nerve Soft Tissue Prep a. Sacrotuberous and Sacrospinous Ligament Technique i. The therapist s thumbs come under the gluteal fold to contact the sacrotuberous/sacrospinous ligaments on the contralateral side. ii. The client is instructed to perform slow pelvic tilts while the therapist s thumbs release fibrotic sacrospinous ligaments that might be entrapping the sciatic nerve. iii. Always work through draping or over shorts or underclothing when performing this technique. b. Piriformis Technique i. With the client prone, flex the knee to 90 degrees. ii. Place a flat forearm as close to the sacrum as possible and position your body so you can internally and externally rotate the client s leg with the opposite hand. iii. With your elbow, palpate for protective sciatic muscle guarding and gently compress the area while internally and externally rotating the client s femur. c. Iliosacral Alignment Technique
d. Jelly Roll 4. Sciatic Nerve Notes i. This technique helps restore pelvic alignment and level the sacral base. ii. With the client prone, the therapist stands on the client s right side and reaches across with both hands and grasps the client s left anterior superior iliac spine (ASIS). iii. Transition to using the right hand to contact and lift the client at the ASIS. iv. Place the fingers of your left hand (fingers turned back toward the therapist s body) on the client s posterior superior iliac spine (PSIS). v. Rock the client back toward the therapist and then pull and push on the ASIS/PSIS to mobilize the area within the client s comfort level. vi. Repeat this technique on the opposite side. i. The client grasps their knees and pulls them into their chest (this motion should be pain-free). ii. The therapist s up-table forearm braces on top of the client s knees. iii. The therapist rolls the client into trunk flexion allowing his opposite hand to come under and grasp the client s sacrum or lumbar vertebrae. iv. The therapist uses both arms to rock the client into more flexion as he drags on the sacrum to decompress the lumbar vertebrae. v. Discontinue the use of this technique if the client reports sciatic nerve pain during trunk flexion. vi. Note that this is a mobilization technique, but also an assessment test. 5. Sciatic Nerve Mobilization (Sidelying) a. The client is positioned sidelying with their thorax and lumbars flexed and their knees and arms bent. b. The therapist grasps the client s ankle (of the leg on the top) and flexes the client s knee to hip to 90 degrees. c. The therapist steps behind the client s flexed knee so that the outside hand grasps and dorsiflexes the client s ankle.
d. The therapist slowly extends the client s knee to the first painful sciatic barrier. e. To traction the sciatic nerve, the client tucks their chin as the therapist introduces knee extension and foot dorsiflexion to that barrier. f. To floss the sciatic nerve distally, the client releases the chin tuck as the therapist gently extends the knee and dorsiflexes the foot to the new barrier. g. To floss the nerve proximally, the client tucks their chin as the therapist slowly flexes the knee. 6. Sciatic Straight-Leg Raise Nerve Mobilization (Supine) a. Standing on the client s right side, the therapist s left hand crosses on top of the client s thigh above the knee and flexes the client s hip to allow their right arm to come under and grasp the client s right ankle. b. The therapist flexes the client s hip and knee to the first restrictive barrier. c. The therapist s right hand dorsiflexes the client s ankle while slowly extending the client s knee to the next barrier. d. The client tucks their chin to traction and stretch the sciatic nerve. e. To floss distally, the client releases the chin tuck as the therapist increases knee extension and foot dorsiflexion. f. To floss proximally, the client tucks their chin as the therapist slowly flexes the client s knee. 7. Peroneal Nerve Mobilization a. Perform the sciatic straight-leg raise nerve mobilization as above, but add foot supination and ankle inversion to isolate the peroneal nerve. 8. Tibial Nerve Mobilization a. Perform the sciatic straight-leg raise nerve mobilization as above, but add foot pronation and ankle eversion to isolate the tibial nerve. 9. Femoral Nerve Notes
10. Femoral Nerve Mobilization a. With the client sidelying on their left side, ask them to grasp the left knee with both hands, and bring it in to knee and hip flexion. b. The therapist s left hand grasps the client s right ankle and his right hand grasps the knee. c. The therapist steps behind the client s knee as it is brought into flexion. d. With the right hand on her knee and the therapist s left hand securing the ankle, the therapist can create knee flexion or hip extension. e. The therapist gently extends the client s hip to the painful femoral nerve barrier and backs off to the inter-barrier zone. f. The client tucks their chin to traction the femoral nerve. g. To floss the nerve distally, the therapist gently adds knee flexion as the client brings her head back to neutral. 11. Obturator Nerve Notes 12. Obturator Nerve Mobilization a. With the client prone, the therapist flexes the client s knee to 90 degrees. b. The therapist places the client s arch in the therapist s armpit. c. The therapist lifts the client s knee so his right hand can snake around and grasp the client s knee. d. The therapist slowly hip flexes, internally rotates, and abducts the client s leg to the restrictive barrier and backs off to the inter-barrier zone if pain is felt in the adductor muscles. e. The therapist brings the leg back to neutral and repeats the internal femoral rotation, hip extension, and abduction. 13. Lower Body Nerve Entrapment Home Retraining
a. Sciatic Slump Home Retraining i. The client performs the motions of the slump test as a retraining exercise. b. Sciatic Straight-Leg Home Retraining i. The client places a yoga strap or Theraband strap around the arch of the foot and brings the extended leg to their first painful hip extension barrier and backs off to the interbarrier zone. ii. To traction the sciatic nerve, she flexes her neck and dorsiflexes her foot. iii. To floss the nerve, she extends her neck and increases hip extension. iv. To floss headward, she flexes her neck while slowly plantarflexing her foot. c. Femoral Nerve Home Retraining i. The client begins on their knees and flexes the hip on their nonpainful side so that the leg is in a 90-90 position. ii. Keeping the pelvis level, the client slowly begins leaning forward as if she were stretching the quadriceps on her affected leg. iii. As soon as she begins to feel the nerve pain in the quadriceps, she backs off to the interbarrier zone and tucks her chin to increase femoral nerve sensitivity. iv. To stretch the nerve, she simply leans forward. v. To floss the nerve distally, she returns her head to neutral while increasing hip extension. vi. To floss proximally, the client tucks her chin while slowly returning her hips back to neutral. d. Obturator Nerve Home Retraining i. The client sits with her arms behind her back and grasps her wrists to prevent slumping. ii. The client brings the affected leg into abduction to painful barrier (sensitivity is felt in the groin). iii. To stretch the obturator nerve, the client flexes her chin and abducts her leg. iv. To floss the nerve proximally, she adducts her leg and increases neck flexion. v. To floss distally, she extends her neck and increases hip abduction.