This article first appeared in the November 2019 issue of Lifelines, the Life West student magazine.
Assessing the stability of a joint is a key part of the patient assessment, but what does it mean to be stable? What determines stability, and how do you assess it? What do you do if you find that an area of the spine or skeleton is unstable? These questions must be answered to ensure the safety of the patient, as well as the efficacy of your adjustment.Stability is something we are usually familiar with, and typically able to identify, as we see the more stable version of a joint, articulation, or body part. There are exceptions, especially when working with athletes or other populations with a high occurrence of instability, but detailing those here would be too large of a digression. We usually find a joint to be stable when the bones and connective tissue are intact, the range of motion (ROM) is within a specified range (1, 2), and rigidity is in the places we expect. For example, we wouldn’t expect there to be a joint located mid-shaft of the femur!
The determination and assessment of stability can be done in several ways. The most common methods are through motion palpation and orthopedic testing. Imaging findings are also commonly used to assess the stability of a joint, especially where motion palpation or orthopedic testing are insufficient. Assessment of the stability for the upper cervical complex is famous for this; we use lateral cervical X-ray in flexion and extension and observe the atlantodental interval (ADI) for any large changes, with large changes in ADI indicating instability of the C1-C2 articulation. Instability at the atlantodental interval can occur for a number of reasons, ranging from trauma to congenital reasons and degenerative changes (3–5). Pregnancy is another instance where some instability can occur due to the loosening effects of progesterone on the ligaments. Damage to connective tissues can also contribute to instability.
What to do depends on the nature and/or location of the instability. Sometimes the best thing to do is leave it alone and let it stabilize on its own. Other instances require taping to maintain regional integrity, while more severe cases require fixation. Taping is commonly used when there is an instability in the connective tissue, and the individual requires use of the affected area, situation permitting (6). We commonly find this in the extremities of athletes, especially the shoulder and ankle (7, 8). Fixation is usually required when there is a fracture that is unstable and requires fixation in order to heal correctly, prevent further injury, or prevent non-union (9, 10).
When do we adjust? Almost always, instability of a region will be a contraindication to adjust the affected area. Adjustments will have to be done to other areas until the unstable area has stabilized. Even though we cannot adjust the affected area, through the adjusting of areas around and good rehabilitation of the area in question, we can help to return stability to the region more quickly, and hopefully to an even better degree that what would otherwise have been achieved.
- Bogduk N, Mercer S. Biomechanics of the cervical spine. I: Normal kinematics [Internet]. [cited 2019 Oct 20]. Available from: www.elsevier.com/locate/clinbiomech
- Bible JE, Biswas D, Miller CP, Whang PG, Grauer JN. Normal functional range of motion of the lumbar spine during 15 activities of daily living. J Spinal Disord Tech. 2010 Apr;23(2):106–12.
- El-Khouri M, Mourão MA, Tobo A, Battistella LR, Herrero CFP, Riberto M. Prevalence of atlanto-occipital and atlantoaxial instability in adults with Down syndrome. World Neurosurg [Internet]. [cited 2019 Oct 20];82(1–2):215–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24530459
- Mohindra S, Tripathi M, Arora S. Atlanto-axial instability in achondroplastic dwarfs: a report of two cases and literature review. Pediatr Neurosurg [Internet]. 2011 [cited 2019 Oct 20];47(4):284–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22472460
- Taniguchi D, Tokunaga D, Hase H, Mikami Y, Hojo T, Ikeda T, et al. Evaluation of lateral instability of the atlanto-axial joint in rheumatoid arthritis using dynamic open-mouth view radiographs. Clin Rheumatol [Internet]. 2008 Jul [cited 2019 Oct 20];27(7):851–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18087762
- Reneker JC, Latham L, McGlawn R, Reneker MR. Effectiveness of kinesiology tape on sports performance abilities in athletes: A systematic review. Vol. 31, Physical Therapy in Sport. Churchill Livingstone; 2018. p. 83–98.
- Reynard F, Vuistiner P, Léger B, Konzelmann M. Immediate and short-term effects of kinesiotaping on muscular activity, mobility, strength and pain after rotator cuff surgery: a crossover clinical trial. [cited 2019 Oct 20]; Available from: https://doi.org/10.1186/s12891-018-2169-5
- Jackson K, Simon JE, Docherty CL. Extended Use of Kinesiology Tape and Balance in Participants With Chronic Ankle Instability. J Athl Train [Internet]. 2016 [cited 2019 Oct 20];51(1):16–21. Available from: www.natajournals.org
- Sahai N, Faloon MJ, Dunn CJ, Issa K, Sinha K, Hwang KS, et al. Short-Segment Fixation With Percutaneous Pedicle Screws in the Treatment of Unstable Thoracolumbar Vertebral Body Fractures. Orthopedics [Internet]. 2018 Nov 1 [cited 2019 Oct 20];41(6):e802–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/30222793
- Kao F-C, Hsieh M-K, Yu C-W, Tsai T-T, Lai P-L, Niu C-C, et al. Additional vertebral augmentation with posterior instrumentation for unstable thoracolumbar burst fractures. Injury [Internet]. 2017 Aug [cited 2019 Oct 20];48(8):1806–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28662833