Bottom right Kneading thenar eminence

In this operator viewpoint photograph, the lateral border of the hand is being held stable while the operator's thumb is applying kneading to the thenar eminence.

Tips: Use care and a gradual introduction of force as these muscles are often extremely tender initially. Try adding circumduction articulation simultaneously.

28.4 • Stretching palmar surface In this operator viewpoint photograph the hand is being stretched laterally between the operator's hands.

Tips: Most useful in cases of carpal tunnel syndrome where shortening of the flexor retinaculum may be a maintaining factor. Extra considerations: Try inducing an ulnar and radial deviation of the operator's hands when tension has been applied to reach different parts of the flexor structures.

28.5 • (bottom left) Stretching proximal part palmar surface The operator is gripping over the hammate and scaphoid to produce a strong stretch on the flexor retinaculum.

Tips: Most useful in cases of carpal tunnel syndrome. Extra considerations: Try sustained stretch for several seconds and then adding a diagonal torsion to reach the proximal and distal parts of the retinaculum.

28.6 • (bottom right) Stretching palmar surface

This operator's viewpoint photograph shows the hand held against the operator's abdomen and his hands applying a diagonal stretch to the ulnar border of the patient's hand.

Tips: Most useful in carpal tunnel syndrome and Dupetrens contracture if slowly applied and maintained for several seconds.

28.7 • General mobilization The operator is interlocking fingers with the patient and then while his other hand stabilizes the forearm he introduces a variety of forces to the wrist and hand.

Tips: Try each range of possible movement including combinations, not forgetting traction and compression.

28.8 • (bottom left) Specific articulation carpo-metarcarpal joints This operator viewpoint photograph shows the distal hand pulling on a meta-carpal bone while the proximal hand fixes on the appropriate part of the wrist to introduce a traction articulation. Other vectors can be used, such as rotation, circumduction and abduction/adduction, as the restriction demands.

Tips: Most useful in cases of carpo-metacarpal dysfunction rather than the actual wrist itself.

28.9 • (bottom right) Specific articulation carpo-metarcarpal joints This operator viewpoint photograph shows the patient's pronated hand being fixed against the table while the operator's distal hand grips one of the metacarpals. Traction, with or without other ranges of movement, can be introduced.

Tips: Most useful in impaction injuries where the metacarpal may be driven into the related carpal bone.

28.10 • (see previous page, top left) Articulation carpo-metarcarpal joints lateral border The operator clasps the wrist of the supine patient to his abdomen by turning his back to the table. He holds firmly on the relevant metacarpal and carpal bone and then turns his body to produce the traction and mobilizing effect. Many different vectors of force can be introduced while the traction is applied, to effectively address the restriction of movement.

28.11 • (see previous page, bottom left) Circumduction articulation/thrust The operator is very firmly clasping the patient's hand between the heels of his hands. He applies a circumduction motion and, within the movement, an arc of effective resistance will be felt. If this is a soft resistance, increased pressure between his hands may create a suitable thrust barrier, where he can perform a short, sharp force against the restriction.

Tips: Try varying the part of the applicator performing the compression, thus directing the force to different parts of the wrist (see photograph 28.12). Extra considerations: This technique requires fairly high compression force that must be varied to reduce operator strain and patient discomfort.

28.12 • (see previous page, top right) Circumduction articulation/thrust See description for photograph 28.11, but note that in this hold the operator is applying the force with his hypothenar eminences to the proximal part of the patient's wrist. He is also in a different arc of the circumduc-tion cycle.

28.13 • (see previous page, bottom right) Thrust mid carpus pronated This operator viewpoint photograph shows the patient's hand pronated and the operator is pressing firmly with his pisiform directly over a chosen articulation. His other hand is reinforcing the pressure and he maintains this pressure while slightly deviating the thrusting hand into ulnar or radial deviation to find the optimum tension. Without releasing the tension a very small amplitude thrust is applied.

Tips: Most useful where it is necessary to reduce the angle of the curve of the wrist and stretch the anterior structures while specifically manipulating any restricted joint.

28.14 • Thrust mid carpus supinated This operator viewpoint photograph shows the patient's hand supine and the operator is applying a direct force between the scaphoid and the hammate to open out the wrist curve, The other hand is reinforcing. He slowly twists his applied hand until tension accumulates in the wrist and then a very small amplitude thrust is introduced. Note: for clarity, this illustration shows the initial contact; at the point of thrust the fingers will be in the same direction as those of the patient.

28.15 • Thrust specific articulations dorsal surface This operator viewpoint photograph shows the patient's pronated hand held between the operator's hands. He crosses his thumbs over the dysfunctional articulation on the dorsum of the wrist. He circumducts the wrist while introducing small changes in ulnar and radial deviation and if tension accumulates efficiently he can apply a very short amplitude thrust with the thumbs.

Tips: This can be a very uncomfortable technique unless the amplitude is kept extremely small. Try making the thrust more of an increase of compression rather than dorsi-flexion.

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