It usually takes severe force to rupture an abdominal muscle unless it is weakened by prior injury. Symptoms of overstress are pain, localized swelling, and tenderness at the point of torn muscle or tendon fibers. Motion increases pain, and ecchymosis develops later. If a rupture has occurred, there are usually a depression and hematoma at the site.
Local support by strapping in a position of relaxation and cool packs for 24--48 hours are advised. This should be later followed by the judicious use of heat, massage, and other appropriate physiotherapeutic and support measures. Stretching exercises are important during rehabilitation. If proper care is not administered, abdominal contractures may result that can lead to spinal distortion.
Rectus Abdominis Rupture
Although tearing of the abdominis muscle is rare, diagnosis must be rapid to avoid secondary lesions from hematoma. The common site is at the right-inferior aspect of the abdomen. Because of its sheath of strong transverse bands, bleeding easily pools; and because of its extension from the lower ribs to the pubis, difficult breathing (thoracic) and coughing spells usually arise. These signs are followed by severe "stomach ache," rigidity, and inability to forward flex the trunk when supine. Avulsion from the ASIS may be involved. This is most common in adolescents. Traction stress exhibits localized tenderness at the pubic attachment; later, roentgenography will show osseous sclerosis.
A torn inferior epigastric artery may be involved, which is characterized by shock and a large tender hematoma. When bleeding is suspected, apply padded ice packs to the area and refer immediately for surgical evaluation.
Abdominal Abrasions and Contusions
Abdominal abrasions are caused by tangential forces producing excoriation of the superficial layers of skin. They are often highly contaminated. Flush with soap and water to help avoid infection. Apply an antiseptic, a sterile dressing, and a cool pack to enhance healing.
Exudation in and around the involved tissues is usually due to a rather strong force. Temporary shock may occur, associated with transient vomiting, localized pain, tenderness, and swelling. Ecchymosis often appears later, and sometimes a hematoma forms from ruptured vessels. Treat by resting the part, applying cold packs for 24 hours, and follow in 3—4 days with mild heat and other appropriate physiotherapy measures. A small hematoma will be controlled by pressure and natural absorption; others must be referred for aspiration or evacuation. Minor contusions readily respond to cool packs, but severe muscle injury can be a clinical problem.
Solar Plexus Impaction
The large celiac plexus of nerves and ganglia located in the peritoneal cavity at the level near L1 contains two large ganglionic masses and a dense network of fibers surrounding the roots of the celiac and superior mesenteric arteries. It supplies nerves to the abdominal viscera and is indirectly associated with respiration. Thus, a blow to the abdominal area can inhibit breathing (winding) that may result in unconsciousness. Such trauma overstimulates the autonomic fibers of the plexus, especially the parasympathetic fibers, and causes delayed venous return to the inferior vena cava.
The profile often includes neurologic shock: faintness, prostration, dyspnea, clammy skin, and pallor. Air hunger leads to panic. Fortunately, symptoms subside spontaneously in 1--2 minutes. Then, deep abdominal injury should be ruled out. A serious condition that may be associated is splenic, enteric, or hepatic rupture producing hemorrhage within the abdominal cavity.
In unconsciousness from an abdominal blow, place the victim on his back, moisten the face with a cool damp cloth or sponge, loosen clothing around the neck, waist, and thorax, and encourage the patient to relax and breathe slowly and rhythmically. The knees may be carefully flexed, but forceful spinal flexion or leg pumping is contraindicated because an anterior vertebral injury can occur with forceful flexion from the abdominal blow. The patient should not be allowed to return to stressful physical activity until all signs are normal for at least 15--20 minutes. Delayed hemorrhage is always a risk.
Rest alone will usually allow the temporary bradycardia and bronchiospasm to subside. If unconsciousness is prolonged or possible rupture exists, surgical consultation should be made immediately. The greater the delay in diagnosis, the greater the incidence of fatality.
Abdominal Muscle Shortening or Weakness
Muscle contractures, stitches, strains, ruptures, and direct blows are the most common somatic causes of pain in the abdominal wall. The abdominal muscles offer considerable protection to the viscera when active. When they are relaxed, however, they are easily damaged by intrinsic or extrinsic forces. This is especially true of the rectus abdominis.
Once direct trauma, bleeding, and infection are ruled out, a hypertonic abdominal wall can be secondary to primary pelvic fixations. Gillet believed that these fixations are often related to sacrotuberous ligament shortening, shortening of the lumbar anterior longitudinal ligament, or a pubic articular fixation.
Bilateral shortening anteriorly reduces the sternal-pubic distance, especially in the upright position. This tends to produce a flat chest and a long thoracic hyperkyphosis. Unilateral lateral shortening of both obliques reduces the rib-ilium space and produces a C curve of the spine with a contralateral convexity. Ipsilateral shortening of the external oblique with contralateral internal oblique shortening produces an S scoliosis. Bilateral shortening of the internal oblique and lateral stretching of the external oblique produces the anterior rotation of the pelvis and thoracic hyperkyphosis so often seen in a "slumped" posture.
Rectus Abdominis Weakness and Hyperlordosis
Rectus abdominis debility is reflected in a loss in trunk flexion strength and posterior pelvic rotation strength. In the upright posture, a lengthening of the sternal-pubic distance, lumbar hyperlordosis, and anterior pelvic tilt will be evident. The rectus is almost never shortened by itself.
Oblique Weakness and Its Relationship to Functional Scoliosis
A weak oblique exhibits decreased respiratory efficiency and loss in abdominal support on that side. Trunk flexion strength and posterior pelvic tilting strength are diminished in bilateral weakness. This is suggested by obvious anterior pelvic tilt and lumbar hyperlordosis or an exaggerated S curve of the spine laterally. Ipsilateral weakness of the external oblique with contralateral weakness of the internal oblique encourages lumbar scoliosis with rotation and tilting, while unilateral weakness of these two muscles promotes a C curve toward the side of weakness.
Oblique Shortening and Its Relationship to Postural Faults
Bilateral shortening anteriorly reduces the sternal-pubic distance. This tends to produce a flat chest and a long thoracic hyperkyphosis. Unilateral lateral shortening of both obliques reduces the rib-ilium space and produces a spinal C curve with a contralateral convexity. Ipsilateral shortening of the external oblique with contralateral internal oblique shortening produces an S scoliosis. Bilateral shortening of the internal oblique and lateral stretching of the external oblique produces the anterior rotation of the pelvis and thoracic hyperkyphosis so often seen in a "slumped" posture.
Transversus Abdominis Weakness
A loss of transverse abdominis strength is exhibited best in the lateral bulging of the flanks during arching of the back in the prone position.
Pelvic Contusions and Strains
The gluteus maximus muscle is innervated by an independent nerve (inferior gluteal) from the sacral plexus that exits from the pelvis typically under the piriformis muscle near the lateral edge of the sacrotuberous ligament. This nerve and accompanying inferior gluteal artery and vein commonly pierce the gluteal fascia and then spread between the fascia and the muscle. The gluteus medius is supplied by the superior gluteal nerve and vessels that exit the pelvis above the piriformis muscle.
Gluteal contusions sometimes occur in the area of an ischial tuberosity or well-developed athletic buttocks. Incidence is high in hockey and field sports. Just walking may be aggravating, but the related pain is usually not severe. Swelling and bleeding may be extensive, but it is reduced quickly if a cold pack is applied immediately. Recurrent bleeding is always a problem, but its likelihood is reduced if cryotherapy is continued for 3--4 days. Activity can be resumed with padding, but it is rarely adequate protection against reinjury. Full healing without reinjury will usually take place within a month.
Strain may occur in muscles that rotate the thigh and stabilize the hip such as the glutei, piriformis, gemelli, and quadratus femoris. Awkward slips are the typical mechanism of injury, and the dysfunction is extremely debilitating. When the gluteus maximus is injured, it produces pain on hip extension from a flexed position, walking up stairs, external hip rotation against resistance, thigh adduction against resistance when the limb is extended, and thigh abduction against resistance when the hip is flexed. Injury of the gluteus medius and minimus produces increased pain on resisted thigh abduction and medial rotation of the femur.
Because the fascia of the gluteus maximus is continuous with that of the fascia lata, differentiation must be made from "hip pointer," iliotibial band dysfunction, and proximal femur lesions. In many cases of what is first thought to be a sacroiliac sprain, palpable tenderness will be most acute just laterally or superolaterally to the PSIS rather than medially over the joint. This suggests gluteal strain (eg, hip overstress), low sacrospinalis strain, or tender hypertonicity emitted from L5 irritation.
Strains at the origin of the hamstring muscles associated with lower buttock pain on exercise and ischial tenderness on forward flexion are common. An unimpeded forceful, full swing of an object (eg, golf club) may cause an avulsion of the ischial apophysis. Sciatica tests will be negative. Prudent heat in the postacute stage, gentle passive stretching, and graduated active exercises should be incorporated into the standard strain management program.
Superficial Perineal Area Injuries
Contusions and Lacerations. These are rare, usually occurring from kicks or impaling a hurdle or some other obstacle.
Pudendal Neuritis. Priapism sometimes occurs in racing cyclists from a poorly fitting saddle that irritates the pudendal nerve. A persistently painful erection is the only major feature.
Saddle Sores. Bicyclists may exhibit a paniculitis leading to localized areas of fat necrosis from excessive friction between saddle and perineal skin. Rest and release of edema pressure by puncture offers quick relief. If left unattended, ulceration and secondary infection result.
Cyclists Saddle Neuropathy. Paresthesia of the pudendal nerve is a compression neuropathy seen in bicyclists. It is produced by pressure on the perineum by the narrow seats of racing bicycles. In the male, scrotal and penile numbness may be the complaint.
Groin strains are often difficult to manage and arise often in athletics early in the season before full conditioning has occurred. They are common in hockey and from slips on muddy fields where severe hip abduction or adduction overstress might occur. A wrenching-type disability usually arises slowly rather than suddenly as in a quickly torn muscle.
Sartorius injury is usually mild, but persistent disability frequently occurs. In sports, it is seen with "squatting" football linemen and occasionally with oarsmen. Discomfort is aggravated by abduction, extension, and eased after warm-up. The common "scissors" kick of soccer frequently leads to instability of the sacroiliac and symphysis pubis joints. Groin pain is aggravated during full stride, jumping, and in the stretching motion of kicking with power. Also in soccer players and jockeys, a periosteal reaction may be noted at the origin of the adductor muscles (gracilis syndrome). An unimpeded forceful full golf swing may injure a golfer by causing an avulsion of the ischial apophysis. An adductor strain is frequently suffered by horsemen, cyclists, power bowlers, and runners. The complaint will be stiffness, tenderness, and pain that is high in the groin during abduction.
When pain in the area of the symphysis pubis is the complaint, views should be taken in the weight-bearing position, first with full weight on one limb and then the other to exhibit instability. Oval or semicircular lucency and avulsion sites may show on the pubic bone near the symphysis at the origin of the gracilis muscle and adductors longus and brevis. In addition, symphysis widening, instability, frayed corners, fluffy margins, pubic osteoporosis, and muscle attachment periosteal reactions may be seen. Stress scleroses of the iliac portions of the sacroiliac joints is often associated.
Despite extensive ecchymosis, there is usually immediate relief after correcting attending sacroiliac and pubic subluxations if severe avulsion has not taken place. Cold, compression, pressure by an elastic Figure-8 bandage to prevent hyperextension, and rest rapidly controls the swelling. Standard physiotherapy relieves attending muscle spasm due to irritation from the inflammatory reaction. Carefully monitored graduated exercises must be initiated as soon as logical to avoid posttraumatic contractures that can produce recurrent disability. Return to full-scale activity can usually be expected within a week.
Pubic Area Disorders
Pubic Sprains and Subluxations
There is a good degree of bone elasticity between the extreme A-P points of the pelvis except in the very elderly or osteoporotic pelvis. Healthy bone is not brittle.
Normal iliac movements are bilaterally reciprocal. This places a torsion on the pubic fibrocartilage that can be likened to slowly wringing a wet cloth by hand. Thus, it is no wonder that this symphysis often becomes fibrotic as the result of frequent yet relatively mild sprains in sports.
Pubic sprains and subluxations are frequently occurring conditions that are often mistaken for sacroiliac slip, although sacroiliac displacement may have occurred and been spontaneously reduced. The syndrome is also associated with lateral hip subluxations. In pure pubic subluxation, the predominant evidence will be found at the pubic symphysis. The sacroiliac area will not be excessively tender; rather, acute tenderness will be found over the painful pubis. After severe trauma, pubic and sacroiliac displacement may coexist.
The pubic articulation is not adjusted directly. Rather, an appropriate contact is applied posteriorly to the ilium or ischium as is necessary.
Osteitis pubis is a rare disability that is becoming more common with the increase of poorly conditioned joggers. It is generally defined as a painful inflammation of the pubic symphysis from various causes, but some authorities report an idiopathic form. Regardless, it is usually an episodic condition and often self-limiting. The onset is typically gradual, with symptoms peaking several days after the precipitating traumatic incident.
Diagnosis. The clinical picture of osteitis pubis reflects severe groin pain that may radiate to the hips, abdomen, or groin (especially in the adductor and rectus abdominis muscles). The cause may be traced to trauma suffered during athletics, a fall, or childbirth. The related pain is aggravated by passive femur abduction or active adduction, abdominal flexion, and sometimes by iliac compression. Swelling and tenderness occur over the symphysis pubis and within adjacent soft tissues. A slight epiphyseal slip may be a predisposing factor during youth. Fever, dysuria, leukocytosis, and an increased sedimentation rate are inconsistent findings. Priority differentiation must be made from ankylosing spondylitis, adductor-origin strain, and perineal disease. Roentgenography may reveal an eroded symphysis with joint widening, tending to calcification, sclerosis, and spotty demineralization in late stages. Early signs are usually absent.
Management. Initial rest and cold followed later by diathermy, mild ultrasound, vitamin-mineral supplementation, and attention to lumbar and sacral subluxations are helpful in these often-stubborn cases. Mobilization of frequently associated hip fixations is essential. Graduated return to activity must be carefully monitored to prevent recurrence of acute symptoms. If conservative measures fail, fusion of the symphysis may be advised, but postoperative results are not always good.
Symphysis Pubis Fixation
Pubic fixation offers a clinical dilemma awaiting resolution. The pubic articulation is not a gliding type as seen in spinal facets, thus one might think it would be prone to only a ligamentous type of fixation. If this were true, a degree of torsion would be possible in spite of fixation. However, motion palpation demonstrates that (1) normal A-P iliac rotation does not take place when pubic mobility is inhibited and (2) adjustment results in a rapid improvement in mobility. Gillet reported that neither of these characteristics is typical of ligamentous fixation.
Visceral Implications in Chronic Balance Faults
Chronic visceral disorders are not usually a topic in traumatology but the subject deserves some attention. Trauma may precipitate a subclinical disorder or the effects of trauma may have noxious influences on visceral function through the formation of scar tissue, adhesions, and/or postural distortion.
It is unwise to consider the various parts of the body as separate entities. All parts share responsibility. Any disturbance in one part causes an immediate and definite functional change in others. In addition, there is no doubt that the relationship of the soma and the viscera forms an interdependence. Disorders in the neuromusculoskeletal system may often be a factor in visceral disorders and disease, and various somatovisceral and viscerosomatic reflexes can frequently be related to specific pathologic states.
When an average threshold stimulus is applied to a somatic receptor (eg, the skin), visceral function is influenced via the central connection in the gray matter of the spinal cord. If the sympathetics are involved, the activation occurs in the cells of the mediolateral column in the thoracolumbar area. Since the sympathetic axons end in the contractile mechanism of vascular smooth muscle fibers, the end effect could be vasoconstriction. Other sympathetic fibers affect heart rate, bronchial dilatation, sphincter contraction, etc.
If body mechanics are good, the abdominal cavity is shaped like an inverted pear with adequate space above L4 for the abdominal viscera of an intermediate body type. Nature provides good support for the abdominal organs when the body is normally erect. In the ideal attitude, tissue ledges and shelves exist that partially support the abdominal organs. However, if the lumbar and dorsal curves increase and the abdominal wall relaxes, these vital supports are lost.
Gross spinal distortion and minute articular malalignments or articular fixations in the spine can produce physiologic changes and are considered to be potentially pathologic. But how much deviation is possible without causing severe impairment of health? The effect on function varies among research reports. Most agree, however, that poor body mechanics predisposes certain visceral disorders; ie, the viscera are held in their optimum position for function in good body mechanics.
The Stomach and Digestive Disturbances
With the stomach lying mainly to the left of the spine and supported by a diaphragmatic attachment behind the transverse sagittal plane, there is little tendency for downward displacement if there is no rib cage deformity or abdominal muscle weakness.
Mild digestive symptoms may present in the apparently healthy person. This is sometimes traced to a degree of visceroptosis producing dysfunction of the displaced organs. Abdominal dilatation and motility disturbances are not infrequent occurrences. This is likely the outcome of stretching of the sympathetic nerves. Pottenger points out that stretched nerves within involuntary or voluntary muscles usually produce a temporary paralysis. In addition, when the abdominal cavity becomes shortened longitudinally, the viscera become crowded as do the glands of internal secretion and nerve ganglia. Thus, orthostatic albuminuria, dysmenorrhea, and constipation may sometimes be associated.
Position of Other Major Abdominal Organs
The liver usually rests posterior to the transverse sagittal plane. It is partly supported by the surrounding organs and its attachments to the diaphragm, but most of its weight is borne by the concave space at the side of the spine and by the curves of the lower ribs. The spleen lies well back and is held by peritoneal folds. The pancreas depends chiefly on the surrounding organs for support. The hepatic and splenic flexures of the colon attach near the kidney and the posterior surface of the abdominal cavity. About 87% of the weight of the abdominal organs is borne by the psoas shelf and the muscles of the abdominal wall. The kidneys normally rest in definite depressions that begin around the level of L4 and are supported by the psoas muscle, quadratus lumborum, and retroperitoneal fat.
Effects of Visceral Prolapse
As a result of visceroptosis, a compensating lumbar lordosis, and the insult at the intervertebral foramina, symptoms can be diffuse and subtle. Duodenal stasis may be attributed to increased tension on the superior mesenteric vessels. One study shows that postural correction relieved 65% of cases exhibiting a picture of duodenal obstruction and 75% of cases complaining of gastric distress, nausea, and abdominal pain associated with visceroptosis. Narrowing of one or more middle or lower thoracic IVFs may cause severe pain that has a segmental distribution and evidenced in the skin, muscle, or parietal peritoneum. This condition can be misleading as to origin as it suggests the presence of some intra-abdominal disorder.
Pelvic Entrapment Syndromes
The most common entrapment syndromes related to the pelvis are sciatic nerve compression, lateral femoral cutaneous nerve compression, obturator nerve compression, and adhesive arachnoiditis.
Extraspinal Sciatic Nerve Compression Syndromes
The most common site for the sciatic nerve to become "caught" is at the sciatic notch as the nerve exits the pelvis between the piriformis and sacrotuberous ligament. At this point, it can become compressed against the bony ridge by piriformis spasm, thickened fascia, or adhesions. It should also be kept in mind that many patients fail to follow this textbook route. In most people, the sciatic nerve courses below the piriformis muscle. However, the nerve sometimes courses over the piriformis or pierces its belly.
Clinical Features. The major symptom of sciatic entrapment in the pelvis is pain behind the greater trochanter that radiates down the thigh and lateral leg to the foot. This is usually aggravated by walking and relieved by rest. Numbness and tingling are invariably restricted to below the buttocks. The pain is increased by flexing the knee and hip to right angles and forcing the thigh into internal rotation and adduction (ie, piriformis stress). Tenderness will be acute near and below the notch. Major signs usually include a positive Lasegue’s sign and hypesthesia of the weight-bearing surface of the plantar surface.
Diagnostic Complexities. Differentiation must be made from disc failure, inflammatory sciatica, and acute sacroiliac sprain, but an entrapment syndrome may coexist with these disorders. Tumors within the buttocks, a neurofibroma, or a compartment syndrome can also mimic an entrapment syndrome. A fall on the buttocks or a posteriorly dislocated femur head may injure the nerve at the inferior buttock and produce identical signs and symptoms as those of an entrapment syndrome.
Femoral Cutaneous Nerve Syndromes
After the lateral femoral cutaneous nerve leaves the L2--L3 roots, it runs across the lateral border of the psoas muscle before it descends along the posterior wall of the pelvic cavity. Here it enters and travels within the fascia covering the iliacus muscle, pierces the lateral V attachment of the inguinal ligament just medial to the ASIS, travels in a fascial tunnel under the ligament, then pierces the fascia lata and enters the thigh. It offers cutaneous branches to the anterolateral thigh from below the hip to the knee and motor branches to the anterior thigh. It is at the point where the nerve leaves the subinguinal tunnel and enters the fascia lata that entrapment of the nerve (meralgia paresthetica) usually occurs. At this site, the nerve’s sheath is firmly fixed to adjacent tissue.
Precipitating Factors. Thigh adduction increases tensile forces on the nerve, and if this occurs simultaneously with severe trunk movements above or thigh movements below, the nerve can become severely stretched. In some cases, just prolonged sitting with the legs crossed can produce a compression syndrome in the upper thigh. An improperly fitted brace may cause compression, and, in obese women, a tight corset may produce compression. In rare cases, the nerve becomes entrapped by a pelvic tumor or encapsulated psoas abscess, hypertrophic arthritis of the upper lumbar spine, a pregnant uterus, or occupational pressure. Visceroptosis may produce a stretch syndrome.
Clinical Features. Typical symptoms are severe unilateral burning pain and paresthesia in the anterolateral thigh. The onset is usually spontaneous. The major signs are aggravation of pain when the nerve is pressed against the medial side of the iliac crest, relief of pain when recumbent, and hyperesthesia of the anterior thigh.
Obturator Nerve Syndromes
The obturator nerve leaves the L3-L4 nerve roots, passes through the pelvis, and supplies the gracilis and adductor muscles and the skin of the hip and medial thigh. An obturator hernia and pressure from the edema of osteitis pubis are common causes of obturator neuritis or neuralgia. Some circulatory impairment may be associated.
Clinical Features. Pain typically radiates from the groin to the medial thigh and is aggravated by any Valsalva maneuver. Hypesthesia (infrequent) and paresthesia (frequent) may be associated. As the obturator nerve innervates the adductors of the thigh, the major signs are weakness of thigh adductors and an unusual gait (the involved leg is brought outward in a wide arc during the swing phase). Even in chronic cases there is little or no atrophy because of dual innervation from the sciatic nerve.
Adhesive arachnoiditis can produce severe unrelenting sciatica. The common site of entrapment is where the L4 root crosses the transverse process of L5 and the iliolumbar ligament in the nerve’s descent into the pelvis.
REFERENCES AND BIBLIOGRAPHY:
Barham JN, Wooten EP: Structural Kinesiology. New York, Macmillan, 1973.
Basmajian JV: Man’s Posture. Archives of Physical Medicine, 46:26-36, 1965.
Bowen WP, Stone HA: Applied Anatomy and Kinesiology, ed 6. Philadelphia, Lea & Febiger, 1949.
Branton P: Behavior, Body Mechanics, and Discomfort. Ergonomics, 12:316-327, 1969.
Brunarski DJ: Functional Considerations of Spinal Manipulative Therapy. ACA Journal of Chiropractic, May 1980.
Burns L, et al: Pathogenesis of Visceral Disease Following Vertebral Lesions, American Osteopathic Association, Chicago, 1948.
Carpenter, SA, et al: An Investigation into the Effect of Organ Irritation on Muscle Strength and Spinal Mobility, Bulletin of the European Chiropractors Union, 25(2), 1977.
Cooper JM, Glassow RB: Kinesiology, ed 3. St. Louis, C.V. Mosby, 1972.
Copass MK, Eisenberg MS: The Paramedic Manual. Philadelphia, W.B. Saunders, 1980.
Craig AS: Elements of Kinesiology for the Clinician. Physical Therapy, 44: 470-473, 1964.
Delp MH, Manning RT (eds): Major’s Physical Diagnosis, ed 7. Philadelphia, W.B. Saunders, 1968.
Edwards LF, Gaughram GRL: Concise Anatomy. New York, McGraw-Hill, 1971.
Gardner E, et al: A Regional Study of Human Structure, ed 4. Philadelphia, W.B. Saunders, 1975.
Gardner WD, Osburn WA: Structure of the Human Body. Philadelphia, W.B. Saunders, 1967.
Gillet H, Liekens M: Belgian Chiropractic Research Notes. Huntington Beach, CA, Motion Palpation Institute, 1981.
Goldthwait JE, et al: The Essentials of Body Mechanics in Health and Disease, ed 5. Philadelphia, J.B. Lippincott, 1952.
Grice AS: Posture and Postural Mechanics, Journal of the Canadian Chiropractic Association, July 1970.
Hirata I Jr: The Doctor and the Athlete, ed 2. Philadelphia, J.B. Lippincott, 1974.
Howe JW: The Role of X-Ray Findings in Structural Diagnosis, in The Research Status of Spinal Manipulation Therapy. NINCDS Monograph No. 15 (M. Goldstein, ed), DHEW Publication No. (NIH) 76-998, Stock No. 017-049-00060-7, U.S. Government Printing Office, Washington, DC, 1975.
Howe JW: Frequently Missed Fractures. Roentgenological Briefs, American Council on Roentgenology of the American Chiropractic Association. Date not shown.
Janse J: Principles and Practice of Chiropractic. Lombard, Illinois, National College of Chiropractic, 1976.
Jaquet P: The Upright Position of Man: Its Phylogenetic and Psychological Aspects and Some Therapeutic Considerations of Interest. Annals of the Swiss Chiropractic Association, IV:185-195, 1969.
Johnson AC: Postural Correction. Los Angeles, Chiropractic Educational Extension Bureau, place of publication and date not listed.
Jones L: The Postural Complex: Observations as to Cause, Diagnosis, and Treatment. Springfield, IL, Charles C. Thomas, 1955.
Kendall HO, et al: Muscles Testing and Function, ed 2. Baltimore, Williams & Wilkins, 1971.
Larson LA: Fitness, Health, and Work Capacity. New York, Macmillan, 1974.
Logan AL, McKinney WC: Kinesiology. Dubuque, Iowa, W.C. Brown, 1970.
Martin RM: Cum Gravity. San Marino, California, Essential Publishing, 1975.
Morehouse LE, Rash PJ: Sports Medicine for Trainers, ed 2. Philadelphia, W.B. Saunders, 1963.
O’Donoghue DH: Treatment of Injuries to Athletes, ed 4. Philadelphia, W.B. Saunders, 1984, pp 353--359, 361, 407--408, 416--424.
Pace JB, Nagle D: Piriform Syndrome. Western Journal of Medicine, 124: 435-439, 1976.
Petty AH: Abdominal Injuries. Annals of the Royal College of Surgeons, 53:169, 1973.
Pottenger FM: Symptoms of Visceral Disease. St. Louis, C.V. Mosby, 1944.
Sato A: The Somatosympathetic Reflexes. In Goldstein M (ed): The Research Status of Spinal Manipulative Therapy. Washington, DC, U.S. Government Printing Office, NINCDS Monograph No. 15, DHEW Publication No. (NIH) 76-998, Stock No. 017-049-00060-7, 1975.
Schafer RC: Chiropractic Management of Extraspinal Articular Disorders. Arlington, Virginia, American Chiropractic Association, 1989, pp 163--264.
Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 2. Baltimore, Williams & Wilkins, 1986, pp 446--450, 453, 454.
Schafer RC: Clinical Biomechanics: Musculoskeletal Actions and Reactions, ed 2. Baltimore, Williams & Wilkins, 1987, pp 134--135.
Schafer RC: Perineal Injuries Common to Cyclists. The Journal of the ACA Council on Sports Injuries, 1:2, April 1982.
Steindler A: Kinesiology of the Human Body Under Normal and Pathological Conditions. Springfield, Illinois, Charles C. Thomas, 1955.
Stish EE: Anthropokinetics. Journal of Health, Physical Education, and Recreation, 35:33, November-December 1964.
Williams JGP, Sperryn PN (eds): Sports Medicine, ed 2. Baltimore, Williams & Wilkins, Baltimore, 1976.
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