Q&A Time | Modern Manual Therapy Blog

Q&A Time

It's Q&A time. These questions were submitted by readers via email or facebook.

Two questions today, 1) STM and TKA 2) Clunking in the upper C-Spine...

Q: Is it appropriate to use STM who recently had a TKA?

A: Absolutely! Here are STM indications. 1) Limits in movement or pain during movement 2) The patient has tissues. While I wouldn't use it very aggressively, I have used both functional release and IASTM on a patient's quadriceps, hamstrings, and gastroc/soleus as soon as they come in for outpatient therapy. Manual therapy can be no more forceful than the WB ADLs or going "beyond" the physiologic range . Tissues are tissues and joints are joints. In any setting, you should notice better outcomes if you use OMPT plus exercise as most multi-modal studies show.

After being in outpatient and women's health, my wife started doing home care PT after becoming a mother. She used STM and joint mobilizations on her patients. It's not just for the outpatient orthopaedic setting. A local DPT/FAAOMPT Ortho instructor's response to his students who say "I don't want to do ortho," is, "EVERY patient is an orthopaedic patient."

While I don't see many TKAs, I saw two bilateral TKAs 2 years ago. They both got back to ROM WFL and to their ADLs with near full strength in just 12 visits.

Q: I have a patient who has very high upper cervical "clunking" every time she rotates to the right. She has history of head trauma, falling and hitting her head around the right temporal area. Her pain is right sided. The "clunk" occurs with each movement, and does not appear to be a cavitation or crepitus. What are my treatment options? I have performed unilateral OA gapping and started deep cervical flexor strengthening. She has severe forward head and unilateral HA. Is the "skull crusher" appropriate?

A: I would focus on light IASTM to her occiput and upper cervical musculature. Not being sure of her exact ranges, I would perform upper cervical stability tests. If negative, and if gentle Mulligan SNAGs reduce or eliminate the clunking, that suggests possible positional fault caused by unilaterally restricted tissues. Focus on restoring tissue mobility unilaterally and try the unilateral OA nod which can be aggressive, but is more comfortable if IASTM/STM is performed first. This is safe even in cases of transverse ligament laxity and works wonders on unilateral cervicogenic HA.

Keep the questions coming if you want this to be a regular blog topic!


  1. Kyle Ridgeway, PT, DPTJanuary 26, 2012 at 12:42 AM

    Nice post. I use a similiar, but opposite saying very regularly. Every patient is a neuro and/or medicine patient! The neuro part is obvious in regards to pain and movement since this are neurologically driven, but there is a TON that PT's can do to impact, reduce, or prevent progression of current, future, or possible medical conditions!!

  2. Thanks Kyle! I used to say that back when I taught ortho full time. That was before modern pain science. I should ammend that to every patient is a neuromusculoskeletal patient. I know you wouldn't be completely happy with that, but you know I'm a bit more mechanical!

  3. Stability tests can be conducted. This also has the same factors with a dentist summerville procedure.