Including extremity and extravertebral adjusting procedures is an important aspect of patient care

D.D. Palmer advocated the use of extravertebral adjustments, especially the feet, to supplement and complement his chiropractic regimen. He wrote, “Chiropractors adjust any or all of the 300 joints of the body, more particularly those of the spinal column. Why adjust in the lumbar for displacements in the joints of the foot?”¹

Why the Extremities?
A neurological research model explains why positive clinical results are achieved when extravertebral articulations are examined and adjusted. This model, known as dysafferentation, shows why a variety of symptom complexes not usually associated with altered joint function are reduced or eliminated following extravertebral adjustments.

Dysafferentation deals with the two main types of sensory receptors, nociceptors, and mechanoreceptors that inervate the joint structures. Depolarization of nociceptors occurs via noxious mechanical stimuli and the chemical mediators released in response to injured tissue. The depolarization of mechanoreceptors occurs only via mechanical stimuli, such as that associated with touch and normal body movements. Examples of these mechanoreceptors are Pacini’s corpuscles, Meissner’s corpuscles, Ruffini corpuscles, Merkel’s receptors, muscle spindles, and Golgi tendon organs.²

With joint subluxation/misalignment/hypomobility, nociceptors excessively fire while mechanoreceptors decrease their firing rate. Hooshmand demonstrated how restricted joint motion causes an increase in the firing of nociceptive axons (A-delta and C fibers) and a decreased firing rate of large diameter mechanoreceptor axons (A-beta fibers).³

An important function of mechanoreceptor input is to inhibit nociception at the spinal cord level. Therefore, reduced mechanoreception can magnify the symptoms generated by excessive nociceptor input.

Dysafferent input produces a variety of symptoms not usually associated with dysfunctional joints. Research explains that nociceptive input from dysfunctioning joints can cause symptoms such as sweating, pallor, nausea, vomiting, abdominal pain, sinus congestion, dyspnea, cardiac palpitations, and chest pain that mimics heart disease.⁴ Cabell states, “Nociceptor activity reflexively activates the sympathetic nervous system.”⁵

In addition to relieving symptoms, most patients leave the office with a relaxed and lighter feeling after extremity adjustments. Based on research and clinical observation, I contend that the examination of extravertebral articulations and their appropriate adjustment and rehabilitation be an integral part of chiropractic procedure and not only when patients complain of extremity symptoms.

Adjusting the Pronated Foot
In 80% of the adult population, the foot will subluxate in a very predictable pattern, excessive pronation. The following is a simple explanation of how I adjust the pronated foot in less than 10 seconds.

Figure 1: The navicular: inferior and medial subluxation.

The navicular: inferior and medial subluxation (Figure 1).
1) Touch the contact point (CP). This is located at the height of the medial longitudinal arch, on the plantar surface of the foot, approximately 1¼2 inch lateral to the medial border of the foot with the thenar of your inside hand.

2) Stabilization is via the flat palm of your outside hand contacting the lateral aspect of the foot and ankle.

3) With both hands contacting the foot, bring the foot and ankle to its inversion tension point.

4) Without winding up, thrust with the thenar of your inside hand toward the lateral malleolus, which is in a superior and lateral direction.

5) Exercise caution when an inversion sprain has occurred since the adjustment can aggravate the effects of excessive ankle/foot inversion.

Figure 2: The cuboid: superior and lateral subluxation.

The cuboid: superior and lateral subluxation (Figure 2).
1) The CP is located on the superior and lateral aspect of the foot directly over the cuboid. Notice some degree of plastically deformed tissue in and around the area of the extensor digitorum brevis.

2) Put the distal interphalangeal joint of your thumb of your inside hand on the superior aspect of the CP while the palm of your outside hand contacts directly over the inside hand.

3) With both hands on the patient’s foot, lift the foot laterally off the table and place between your slightly bent knees. For your comfort, make sure that the dorsums of your hands are contacting the posteromedial aspect of the knees.

4) The thrust is a combination of a) squeezing the hands and knees together and b) extending the knees. The thrust or pull is fast but not extremely forceful.

Figure 3: The cuneiforms: inferior subluxation.

The cuneiforms: inferior subluxation (Figure 3).
1) With the patient supine, stand on the involved foot side facing the opposite leg.

2) With your head-ward hand, make a “U” shape and stabilize the hind foot with the finger pads contacting the medial aspect of the calcaneus.

3) The anteromedial aspect of your foot-ward hand contacts the plantar surface of the foot under the cuneiforms.

4) Make sure your forearms are parallel to the tibia.

5) With your head-ward hand, apply inferior traction as your foot-ward hand thrusts superior.

6) Instead of hearing an audible release, you might feel a sliding motion. Remember that the cuneiforms are some of the most mobile bones in the foot.

Figure 4: The metatarsal heads.

The metatarsal heads (Figure 4).
1) The CP is on the plantar surface of the foot under the second, third, and fourth metatarsal heads. Place your thumb pads on the contact point while the palmar surfaces of your fingers contact the dorsum of the foot.

2) This procedure is a four- to five-repetition squeeze as opposed to a dynamic thrust. The thumb pads push superior as the fingers pull lateral/medial in a smooth and slow motion.

Figure 5: The talus: anterior and lateral subluxation/fixation.

The talus: anterior and lateral subluxation/fixation (Figure 5).
1) Typically, there is joint tenderness on the anterolateral aspect of the ankle at the junction (CP) of the cuboid and talus.

2) Contact the second, third, and fourth metatarsal heads with your thumb pad while both little fingers are placed on the CP of the patient.

3) Tension is achieved by adding inferior traction and slight dorsiflexion to the joint.

4) Thrust is a scooping-type action in an anterior to posterior and lateral to medial direction. Again, remember that this is a quick thrust, not a forceful one.

5) A relatively loud audible release is typically heard when this adjustment is performed on an anterolateral subluxated/fixated talus.

Figure 6: The calcaneus: plantar-flexed and everted subluxation/ fixation.

The calcaneus: plantar-flexed and everted subluxation/fixation (Figure 6).
1) The calcaneus is adjusted from the supine position.

2) Contact the patient’s calcaneus with palmar surface your outside hand and the thenar contacting the lateral aspect of the calcaneus.

3) The inside hand shakes hands with the mid-foot.

4) The thenar of the outside hand applies constant lateral to medial pressure as the inside hand performs several clockwise and counterclockwise rotations.

5) It is typical to hear a crepitus-type sound that decreases with subsequent rotations of the foot.

Figure 7: Fibular head: posterior and lateral subluxation/fixation

Fibular head: posterior and lateral subluxation/fixation (Figure 7).
1) Standing on the lateral aspect of the leg, grasp the lower leg slightly above the ankle with your inside hand.

2) While the index finger of the outside hand locates the fibular head, this same index finger will take a tissue pull on the fibular head in an anterior to posterior direction followed by a tissue pull in a lateral to medial direction.

3) The first metacarpal-interphalangeal joint should be contacting the posterior aspect of the fibular head and you should not be able to see the first metacarpal-interphalangeal joint. This knuckle is acting as a fulcrum and does not move after this placement.

4) With the inside hand grasping the ankle, flex the knee, and approximate the heel to the buttocks.

5) When tension is achieved, thrust with the inside hand approximating the heel to the buttocks in a quick short arc. This provides a posterior to anterior force on the fibular head.

6) A crisp audible release is common. Keep the foot, knee, and hip in alignment to avoid inducing tibial rotation.

An important aspect of extravertebral adjusting is balancing the feet. Extremity adjusting is more beneficial when the body is in proper alignment. Patients with postural abnormalities (which is a large segment of your patient population) should have their arches supported to reduce pronation and prevent further plastic deformation. I check all of my patients for orthotics as part of my protocols, and I find weight-bearing casting to be the most accurate method.

Mark N. Charrette, DC, is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 17 years, he has lectured extensively on spinal and extremity adjusting in the United States, Europe, the Far East, and Australia. Charrette can be reached at: mncdc@aol.com.

References
1. Palmer DD. The Chiropractor’s Adjustor, The Science, Art, and Philosophy of Chiropractic. Portland, Ore: Portland Printing House; 1910.
2. Guyton A. Basic Neuroscience: Anatomy and Physiology. 2nd ed. Philadelphia, Pa: WB Saunders; 1991.
3. Hooshmand H. Chronic Pain: Reflex Sympathy Dystrophy, Prevention and Management. Boca Raton, Fla: CRC Press; 1993:33–35.
4. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther. 1995:18:379–97.
5. Cabell J. Sympathetically maintained pain. In: Willis W. ed. Hyperalgesia and allodynia: the Bristol-Myers Squibb Symposium on Pain Research. New York, NY: Raven Press; 1992.