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Common Patterns of

Impact Injury

Lawrence J. Bellew D.O.

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Plantar Impacts
Hip in Flexion

Hip in Extension

Posterior Hip Impacts

Frontal Impacts

Occipital Impacts

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Plantar Impacts -- Hip in Flexion
Left calcaneal impact with hip in flexion is the most
common. Usually from "missing a step". Patient will
usually not remember the incident and symptoms are
variable, many times contra lateral to the side of impact.

Observation in the standing position will reveal the left


shoulder to be held posterior/superior relative to the right
shoulder.

Rotation of the body in the standing position while


grasping the shoulders will be restricted to the right.

In the supine position the side of impact will have an


apparent short leg. Superior motion from the plantar
surface of calcaneus is severely restricted at the L/S
junction (bounce test).

Compression extends from the plantar aspect of the left


calcaneus to the right parietal eminence following a
predictable path and creating predictable somatic
dysfunction:

1. Force entering the plantar aspect of the calcaneus


posterior to the axis of rotation of the ankle drives the
talus anterior in the ankle which becomes restricted to
dorsi flexion.

2. Force from the calcaneal impact arrives at the knee


too soon driving the tibia posteriorly on the femur
resulting in restricted anterior translatory motion of the
tibia on the femur.
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Plantar Impacts -- Hip in Flexion
3. Force from the posterior tibia arrives at the hip before
its internal rotation in the gait cycle begins, creating an
external rotational strain in the capsule of the hip which
restricts internal rotation of the hip.

4. The unopposed external rotation of the hip carries the


innominate into posterior rotation on the sacrum at the
sacroiliac articulation which becomes restricted to
anterior rotation on the sacrum.

5. The force is carried from the hip via the psoas muscle,
and from the pelvis via the quadratus lumborum muscle
to the arcuate ligaments of the diaphragm which creates a
left rotational strain of the thoracolumbar diaphragm
limiting right rotation of the thorax.

6. The straining of the diaphragm into left rotation


allows the force of impact to travel contra laterally to the
right hemi diaphragm and then back to the left along the
dome of the diaphragm exiting in part through the left
supraclavicular fossa. This creates a left rotational strain
in the deep fascia of the thoracic inlet restricting right
rotation of the thoracic inlet.

7. A portion of the force is carried from the diaphragm


through its central tendon to the pericardial sac and its
extensions into the carotid sheath to the Basi cranium .
This creates an inferior vertical strain combined with a
left lateral strain pattern of the sphenobasilar junction.

This sequence of somatic dysfunction can be verified


either by gross motion testing or by their affect on the
PRM which becomes uni-phasic along the path from the
entry to the exit of the impact force.
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Plantar Impact -- Hip in Extension
Impact occurs with hip in extension i.e. "coming down
hard while stepping backward."

Patient will often complain of pain localized to the


quadratus lumborum or iliolumbar ligament attachments
to the posterior iliac crest ipsilateral to the side of impact.

Pelvic asymmetry in the standing position will be present


with the side of impact anterior and superior.

Rotation of the pelvis and hips in the standing position


will be restricted to the side of impact.

In the supine position, there will be an apparent short leg


on the side of impact. A superiorly directed force from
the plantar surface will be severely restricted at the L/S
junction.

Compression extends from the plantar aspect of the


calcaneus to the lumbar sacral junction, creating this
sequence of somatic dysfunction:
1. Force from the plantar aspect posterior to the axis of
rotation of the ankle drives the talus anterior in the ankle
which becomes restricted to dorsi flexion.

2. Force from the ankle arrives at the knee too soon ,


forcing the tibia posterior which becomes restricted to
anterior translatory motion on the femur.

3. Force propagated from the knee arrives at the hip


while it is moving into external rotation creating a strain
in the hip capsule which restricts internal rotation of the
hip.
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Plantar Impact -- Hip in Extension
4. Force is transmitted into the pelvis posterior to the
axis of rotation of the sacroiliac articulation driving the
innominate into anterior rotation on the sacrum and
creating a lumbar sacral compression.

Posterior Hip Impacts


Usually the result of a slip and fall which patient
remembers.

The force enters the posterior aspect of the hip passes


through the pelvis to the contra lateral ASIS and then
ricochets inferiorly to the plantar aspect of the contra
lateral calcaneus.

Observation in the standing position will revealed a


flattening of the ipsilateral gluteal curvature.

Rotation in the standing position of the hips and pelvis


will be restricted to the side contra lateral to the impact.

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Occipital Impacts Unilateral
Nearly universal in motor vehicle accidents from impact
with the headrest; side corresponds to position of
shoulder harness.

Patients usually complain of thoracocervical pain and/or


stiffness as well as symptoms from cranial dysfunction.

Force enters the interparietal area of the occiput near the


lambdoidal suture and passes anteriorly and contra
laterally to the opposite orbit than ricocheting inferiorly
and medially to the fourth costotransverse articulation
ipsilateral to the impact. This produces the following:

1. A flattening of the occipital convexity at the point of


impact.

2. A superior vertical strain combined with left lateral


strain pattern of the sphenobasilar junction.

3. Regional cervical spine motion restricted to backward


bending and side bending to the side of impact.

4. Regional upper thorax side bending restriction from


T1 through T4 contra lateral to the side of impact (i.e. if
impact is on the left, upper thoracic side bending will be
restricted to the right.

5. Restricted motion of the fourth costotransverse


articulation ipsilateral to the impact with associated soft
tissue changes.

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Frontal Impacts Unilateral
Frontal impacts of all kinds very common. Lateral and
anterior/ lateral frontal impacts exhibit a predictable
pattern. Patients may complain of thoracocervical
stiffness and/or pain. May be part of a larger pattern of
dysfunction creating headaches.

Impact on the lateral or anterior lateral frontal bone


passes to the contra lateral parietal notch where it
ricochets passing inferiorly and medially to the fourth
costotransverse articulation ipsilateral to the impact.
This creates the following:

1. Internal rotation and extension of the structures of the


contra lateral parietal notch.

2. Restriction in regional cervical spine motion to


forward bending and side bending to the side of impact.

3. Restriction in regional upper thoracic side bending


contra lateral to the side of impact.

4. Restriction in motion of the fourth costotransverse


articulation ipsilateral to the side of impact with
associated soft tissue changes.

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Treatment
Plantar Impacts- Hip in Flexion (left calcaneal
impact)

1. The left calcaneus is cradled in the palm of the


physicians left hand and the left foot brought into
plantar flexion . The right hand guides the left knee
into 90 degrees of flexion and the left hip into
external rotation as slight superior pressure is applied
to the calcaneus until the left tibia is felt to
involuntarily move in to external rotation and the left
knee into extreme flexion.

2. Maintaining the positioning achieved in step one,


slight proximal pressure is applied to the distal femur
until the hip is felt to involuntarily move into external
rotation and extreme flexion/abduction . This position
(as well as the position achieved in step one) is
maintained until the hip is felt to involuntarily move
into internal rotation at which point the release of the
entire leg, pelvis, and lumbar-sacral junction occurs
and the entire leg is brought back to the neutral
position. This typically restores leg length equality
and motion at the lumbar sacral junction.

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Treatment
Plantar Impact- Hip in Flexion(left calcaneal
impact)

3. The left leg is brought back into the same position


that was held just prior to release of the entire leg.
The hip is slowly brought in to adduction until
resistance is felt from the psoas and quadratus
lumborum muscles and their attachments to the
arcuate ligaments of the diaphragm. The patient is
asked to exhaled and hold his breath in the position
of exhalation. This lowers the resistance in the psoas
and quadratus lumborum and allows the hip to be
further flexed and adducted following the path of the
impact through the crus of the diaphragm to the
contra lateral hemi diaphragm up to the level of the
right sixth rib. The left hip is then brought slowly
into abduction following the path of the impact
across the dome of the diaphragm to the left sixth rib
at which point the leg is brought back into a neutral
position. tuned and in

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Treatment
Plantar Impact- Hip in Flexion(left calcaneal
impact)

4. The patient is asked to extend the left shoulder


180 degrees and then bend the left elbow 90 degrees
and make a fist with the left hand. The left leg is
then brought through the same motions as in steps 1
through 3 and then once again returning it to neutral .

5. The patient is asked to maintain the left arm in the


same position as in step 4 . The patient is then asked
to move their closed eyes superiorly to the right. The
left leg then is brought through the same motions as
in step one through 3.

6. Reevaluation should now show normal dorsi


flexion of the left foot, restored motion at the lumbar
sacral junction with a superior force applied to the
plantar aspect of the left foot while supine,
restoration of shoulder symmetry when standing, and
symmetric whole-body rotation in the standing
position.

If total resolution of motion restrictions does not


occur then additional evaluation is necessary for
underlying somatic dysfunction.

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Treatment
Plantar impact -- hip in extension(left calcaneal
impact)

1. The left calcaneus is cradled in the palm of the


physicians left hand and the left foot brought into
plantar flexion . The right hand guides the left knee
into 90 degrees of flexion and the left hip into
external rotation as slight superior pressure is applied
to the calcaneus until the left tibia is felt to
involuntarily move in to external rotation and the left
knee into extreme flexion.

2. Maintaining the positioning achieved in step one,


slight proximal pressure is applied to the distal femur
until the hip is felt to involuntarily move into first
external rotation and then internal rotation/adduction
as the inominate rotates anteriorly at the S-I This
position (as well as the position achieved in step one)
is maintained until the hip is felt to involuntarily
move into external rotation at which point the release
of the entire leg, pelvis, and lumbar-sacral junction
occurs and the entire leg is brought back to the
neutral position. This typically restores leg length
equality and motion at the lumbar sacral junction and
S-I.

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Treatment
Posterior Hip Impact

1. The evaluation and treatment is carried out in the


standing position. It is useful to have the patient
stand facing the treatment table at arms length in case
they should feel the need to steady themselves during
the treatment process. The table should be adjusted
to the height of the pubes.

2. The side of impact is identified by a flattening of


the gluteal curvature and restriction of standing
pelvic and hip rotation to the contra lateral side. The
physician sits behind the patient with one hand on the
point of impact and the other on the contra lateral
ASIS.
3. The patient is asked to move the leg contra lateral
to the impact forward and away from the body until
repeat testing of standing rotation in the hips and
pelvis becomes symmetric.

4. The patient is asked to hold their breath in


inhalation as they bend their knees until a
spontaneous derotation away from the impact occurs
in the pelvis. The degree of knee bending needed for
derotation will vary from patient to patient.

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Treatment
Unilateral Occipital Impacts

1. The treatment is carried out either in the


standing or seated position with the physician
behind the patient. The side of impact is
identified by a flattening of the posterior
occipital convexity as well as somatic
dysfunction of the fourth costotransverse
articulation ipsilateral to the impact.

2. With the hand contra lateral to impact


fingertip contact is made with the maxilla,
zygoma, sphenoid, and frontal bone surrounding
the orbit contra lateral to impact.

3. With the hand ipsilateral to impact contact


with the fourth costotransverse articulation
ipsilateral to impact is made usually with the
thumb.

4. The patient is asked to shrug the shoulder


ipsilateral to impact as high as possible and hold
it.

5. With the eyes closed the patient is asked to


move the eyes and hold them upward and to the
side contra lateral to impact.
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Treatment
Unilateral Occipital Impacts

6. The patient is then asked to move the head


and neck forward and to the side contra lateral to
impact until rotation of the shoulders occur.

7. The patient is then asked to exhale and hold


their breath in exalation until a change in tissue
tension occurs at the fourth costotransverse
articulation ipsilateral to impact. The patient
then inhales deeply and sits or stands erect.

Treatment
Frontal Impacts Unilateral

1. Treatment is carried out either in the seated or


standing position with the physician behind the
patient. The side of impact is identified by a
flattening of the frontal bone and somatic
dysfunction of the ipsilateral fourth
costotransverse articulation.

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Treatment
Frontal Impacts Unilateral

2. With the contra lateral hand the physician


makes fingertip contact with the occipital,
parietal, and temporal bones at the parietal notch.

3. With the ipsilateral hand the physician makes


contact with the fourth costotransverse
articulation ipsilateral to impact usually with the
thumb

4. With the eyes closed the patient is asked to


hold them upwards and contra lateral to the side
of impact.

5. The patient is asked to shrug the ipsilateral


shoulder as high as possible and hold it.

6. The patient is asked to bend the head and


neck backwards away from the side of impact
until rotation of the shoulders occur.

7. The patient is asked to inhale deeply and hold


the breath in inhalation and bend the knees until
a change in tissue texture at the ipsilateral fourth
costotransverse articulation occurs.The degree of
knee bending required will vary .

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