Radial Head Manipulation

Patient and Practitioner set-up

1. The patient can be sitting or standing.
2. Ideally, the patient's shoulder should be at about the height of the practitioner's chest.
3. The practitioner should be standing on the patient's affected side.

Passive Motion Assessment

• Arthrokinematic motion of the radial head can be assessed using posterior-to-anterior (PA) or anterior-to-posterior (AP) radial mobilization .
• Arthrokinematic motion of the humeroulnar (elbow) joint can be assessed using the PA humerus on ulnar mobilization .

Lockout Position:

1. The practitioner should use the hand furthest from the patient to control the patient's arm, by grabbing the patient's wrist using a lumbrical grip.
2. The practitioner then passively moves the patient's arm into a comfortable amount of shoulder abduction and neutral external rotation, with the elbow near end-range extension.
3. The practitioner then uses the hand closest to the patient, to approach the distal aspect of the humerus from the posterior side. The practitioner will assume an under-handed grip of the distal humerus, while simultaneously palpating the posterior aspect of the radial head using the thumb of the same hand.
   • Note: This is a crucial step in the set-up of this technique. This hand placement is critical for achieving lock-out and applying the desired direction of force.
4. Lockout position of the radial head can be achieved with full supination or pronation. The motion that results in lock-out most comfortably, should likely be used. Clinically, BI has found that full supination tends to be easiest in most cases, and is less likely to require manipulating into terminal elbow extension (which can be painful).
5. The practitioner will find lock-out position using a "wind-up"; slowly moving from mid-range to near end-range elbow extension, elbow varus, forearm supination, and a PA force on the radial head.
   • Again, lock-out position is not end-range elbow extension (which can be painful), it is a soft lock that can be felt a few degrees from terminal elbow extension when the end of supination (or pronation), varus force, and PA force on the radial head, has taken up all tissue "slack".

High-Velocity Thrust

Important Note: 90% of the manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great "thrust technique" will be rendered useless.

1. The high-velocity portion of this technique is a quicker version of the "wind-up" described above, which is a combination of near end-range forearm elbow extension, elbow varus, forearm supination, and PA force on the radial head.
   • This combination of forces is a little tricky at first, but with a little practice, the motion should start to feel natural. Note, the motion feeling natural is dependent on achieving the correct hand position described in step 3 above.
2. Once slow wind-up motions aid in identifying the "lock-out" position, the wind-up motion is done quickly in a small whip-like motion with the intent of moving just past lock-out.
   • The elbow is NOT a stubborn or inherently stiff joint. This manipulation requires speed and accuracy, but not a large amount of force or pressure. If you are tempted to use more force, first start by trying to increase your speed, and if that does not result in a successful manipulation, then start the technique over. Also, remember that cavitation is not necessary for a successful manipulation. Success is an increase in arthrokinematic motion and a measurable change in ROM.