The patient is allowed to come round and, as soon as possible, is called upon voluntarily to perform the movement which has hitherto been limited. If the movement is performed more freely or with less pain, the manipulation may be regarded as having been skilfully performed; if it is more limited or if pain persists for more than, say, half an hour to an extent that limits voluntary activity, then we must have grave doubts as to whether we have not been over-zealous. It is essential that properly devised exercises should be prescribed forthwith, and that these should be faithfully carried out. If any period of rest is necessary after the manipulation on account of pain, the whole success of the proceeding is jeopardised.

If the limitation of movement has been due to dense muscular adhesions, or to adhesions within tendon-sheaths, an alternative course is open to us. If we proceed as already indicated, very little progress will be made and frequent repetition will be essential. As it is usually unwise to repeat manipulation within a week, this means a prolonged and tedious recovery. It is well, then, to have an alternative method of treatment, and this is to be found in free manipulation followed by immediate fixation in plaster over very thick padding. The reaction is intense and pain acute, usually for several days, and nothing except morphia suffices, as a rule, to secure sleep. The plaster should be left untouched until the pain is definitely easing off, which usually means a delay of several days. Then it is cut sufficiently to allow the part to be massaged while still resting on the padding on the surface opposite to our manipulations. Pure relaxed movement is then performed, as for recent injury, in the direction opposite to that in which the limb has been fixed; the original posture is next restored, and the portion of the plaster removed for the manipulation is replaced in position and fixed there rigidly by adhesive plaster. The retentive apparatus is usually required for four weeks, after which it is discarded by slow stages.1

A few details regarding the essentials to be noted when moving individual joints call for special emphasis.

When dealing with the shoulder it must be remembered that few people can, when recumbent, touch the side of their face with the surface of the arm by movement solely in the horizontal plane. The limit of normal movement in this direction depends on the position of rotation of the head of the bone, and the widest range of abduction is reached when the internal epicondyle faces directly forwards. Even so, full abduction is rarely possible without a small degree of flexion. Movement in the horizontal plane may be performed until the angle between the arm and the neck is some 30°; the limb then requires to be carried forward before it is dropped back nearly into the former plane resting against the side of the head. Neglect of this precaution only tends to strain normal structures, and, should the surgeon imagine that the normal limitation of movement is pathological, a very severe sprain will be inflicted. After abduction movement has been performed, the elbow is flexed to a right angle and carried forward across the chest. External rotation is performed in this position, but natural movement ceases considerably before the forearm is vertical.2 Abduction is then performed, combining this with both external and internal rotation, and the elbow is carried round the base of a cone of which the head of the humerus forms the apex. Until the abduction is just short of a right angle the scapula should not have moved; if it has done so it is well that an assistant should check it by pressure on the axillary border. The movement proceeds until an offending band is felt to give or until the movement has been completed as already indicated. The patient is then rolled on to his side and internal rotation is carried out until the posterior aspect of the second finger rests vertically upon the spinous processes between the scapulae.1 Movement in any given direction ceases the moment any definite obstruction has been overcome. Only one other detail calls for emphasis. It is well to guard the biceps tendon with the thumb as it rests in the bicipital groove throughout the manipulation.2

1 See Chapter XXXII (The Combination Of Massage And Splintage In Orthopaedic Surgery).

2 During external rotation it is not uncommon to detect a succession of "snaps" during the movement. Whether these represent the rupture of a series of adhesions or not, I do not know. If abduction has been freed they seem to offer little or no impediment to movement, and no tension - as of stretching the elastic tissue component of the muscles- is felt. However this may be, they can be ignored unless one of them follows the rupture of a band that has afforded definite impediment to the movement.

When manipulating an elbow one special precaution is necessary which does not apply to the treatment of other joints. Here, too vigorous treatment is liable to meet with a disaster which is not likely to be encountered in other situations. If there has been a recent fracture in the neighbourhood, an excessive outpouring of callus is very liable to take place; while, if no fracture has previously been present, vigorous movement is liable so to damage the bone that a similar disaster is likely to follow. The greatest caution is needed when manipulating an elbow in a patient who has recently sustained a fracture through the olecranon fossa, fracture of the anterior part of the head of the radius or a dislocation of the joint, even though X-ray examination reveals no evidence of injury to bone. After fracture of the olecranon,3 a T-shaped fracture into the joint, or oblique separation of part of the head of the radius, less caution is called for. No special laws govern the performance of flexion, though the existence of the "carrying angle" must be kept in mind; but when extension is limited, two points of paramount importance must be regarded. First, every care must be taken to prevent the head of the radius from being pulled forward. This can be done by exerting backward pressure with the thumb over the head of the bone throughout the manipulation. Then, second, it is essential to note that the movement is performed with due respect to the "carrying-angle." Unless this is done the lateral ligaments on the outer side of the joint are sure to suffer severe injury. Full extension should, of course, be secured in full supination. Far better is it to do too little when manipulating an elbow than to do too much.