16.1 Manual Therapy Techniques
Key Takeaways
- Maitland grades I–II treat pain in a pain-free range; grades III–IV stretch into stiffness; grade V is a thrust only if education and the state practice act allow it.
- Kaltenborn traction: grade I loosens, II takes up slack, III stretches; the convex-concave rule is a planning heuristic with documented in-vivo exceptions.
- STM uses effleurage, petrissage, and friction; IASTM evidence is mixed and requires skin, infection, fracture, and anticoagulant screening.
- Do not mobilize through fracture, infection, malignancy, or hypermobility/RA; a negative vertebral artery test is not a clearance gold standard.
- Exam trap: a grade V thrust on an unstable cervical spine because a positional vascular test was negative.
Quick Answer: Manual therapy is a graded, screened intervention—not a generic massage. Use Maitland grades I–II for pain in a pain-free range and grades III–IV for stiffness into resistance. Grade V is a high-velocity, low-amplitude thrust used only when it is in your education and state practice act. Kaltenborn traction grades I (loosen), II (take up slack), and III (stretch) are sustained translatoric holds. Soft-tissue work (effleurage, petrissage, friction), IASTM, myofascial and trigger-point techniques, PNF stretching, and nerve glides all require the same screen: fracture, infection, malignancy, and instability are stops. Vertebral artery tests are not a clearance gold standard. Exam trap: thrusting an unstable cervical spine.
Practice Analysis, 8th Edition (PA8) Domain IV, task 0405, asks the athletic trainer (AT) to use manual therapy techniques to restore joint and soft-tissue mobility as part of the plan of care. That is not permission to “crack” a neck because a video looked decisive. You select the tissue, the grade, the direction, and the stop rules under physician direction or collaboration and the state practice act, then you reassess a comparable sign. Tasks 0404 (taping, bracing, orthoses) and 0407 (general medical conditions during activity) are later in this chapter.
Soft-Tissue Mobilization: Strokes, IASTM, Myofascial, Trigger Point
Classic massage strokes still appear on exams because they have different mechanical intents. Effleurage is gliding, usually distal-to-proximal on a limb, used to introduce contact, encourage venous and lymphatic return, and assess tissue. Keep it light when irritability is high; deeper gliding waits until the tissue tolerates load. Petrissage is kneading, wringing, and lifting of muscle to affect deeper layers and residual tone after the acute phase. Friction, including Cyriax-style transverse friction, is a small-amplitude, deep stroke across a tendon or scar, historically aimed at mobilizing adhesions. Dose by pain and skin integrity—do not sandpaper an acutely inflamed tendon or corticosteroid-thinned skin.
Myofascial techniques use sustained pressure, skin rolling, or slow shear. Treat them as graded load to fascia and muscle, not as a guarantee that you “broke stuck fascia” in one session. Trigger-point work (ischemic compression, local pressure, historically spray-and-stretch) targets a taut band with a referred-pain pattern. Stop if neurologic signs appear or if the patient bruises out of proportion to the dose.
Instrument-assisted soft-tissue mobilization (IASTM) uses a tool to apply shear along a tissue plane. Outcome evidence is mixed: some trials show short-term pain or range-of-motion (ROM) change; many do not beat exercise-only or sham once you account for the loading program. Do not sell IASTM as collagen remodeling in two visits. Skin precautions are not optional. Expert-consensus contraindications include open wounds, scrapes, blisters, uncontrolled local infection, unexplained insect bites, allergy to metal/emollient/latex, unhealed fracture at the site, thrombophlebitis or osteomyelitis, and acute systemic infection. Anticoagulation, cancer history, and fragile skin are precautions—expect petechiae; petechiae are not a treatment goal. Clean and disinfect instruments between patients.
Maitland Grades I–IV vs Grade V Thrust
Geoffrey Maitland graded oscillatory accessory or physiologic movements by amplitude and where in the available range they live:
| Grade | Amplitude | Position in range | Typical intent |
|---|---|---|---|
| I | Small | Beginning of available range | Pain, high irritability |
| II | Large | Within available range, short of resistance/spasm | Pain, irritability |
| III | Large | Into stiffness or spasm, to limitation | Stiffness, ROM |
| IV | Small | At end of available range, stretching into stiffness | Stiffness, ROM |
| V | Small, high velocity | Thrust at the limit of available range | Manipulation |
Grades I and II do not stretch the capsule into stiffness. They are first-line when pain and irritability dominate—use a pain scale and a severity–irritability–nature picture, not a protocol week number. Grades III and IV are for stiffness-dominant, quieter joints. A hot ankle with an empty or spasm end-feel does not get a grade IV “because the chart says it is stiff.” Reassess the comparable sign (pain, ROM, function) after a short bout; more oscillations are not automatically better.
Grade V is a high-velocity, low-amplitude (HVLA) thrust. It is not an entry-level default and is not the same as a grade IV oscillation done faster. Perform thrust only if it is in your professional education, your demonstrated competence, your state practice act, and the directing physician’s standing orders or protocols. Many athletic-training practice acts are silent or restrictive on spinal manipulation. A loud cavitation is not an outcome measure and does not prove the segment was “out.”
Kaltenborn Traction and the Convex-Concave Heuristic
Freddy Kaltenborn described sustained translatoric traction and glide, graded by slack rather than oscillation:
- Grade I (loosen): equalizes joint pressure without true surface separation; used for pain by unloading articular surfaces.
- Grade II (tighten / take up slack): separates surfaces enough to remove capsular play; used to assess irritability and to maintain motion.
- Grade III (stretch): stretches periarticular tissue to increase joint play in a hypomobile joint.
These are holds, not Maitland oscillations. You can combine a Kaltenborn I–II traction with a Maitland oscillation so the joint is slightly decompressed while you oscillate. Do not apply a Kaltenborn III stretch to an unstable or acutely inflamed joint.
The convex-concave rule is a planning heuristic: when a convex surface moves on concave, roll and glide are classically opposite (glenohumeral abduction: humeral head rolls superior and is taught to require an inferior glide). When a concave surface moves on convex, roll and glide are classically the same (tibial-on-femoral knee extension: tibia rolls and glides anterior). Use the rule to pick a first glide, then reassess.
Caveats are the 2026 exam point. In-vivo imaging at the glenohumeral joint, knee, and proximal radioulnar joint has shown translations that do not always match the textbook glide (posterior humeral-head behavior in late cocking; femoral rollback in knee flexion; radioulnar findings that conflict with a simple anterior/posterior prediction). Neumann and others have argued the rule was never a prescription for which manual glide will best restore a target osteokinematic motion. Treat it as a heuristic, not a law, and do not keep grinding an “obligatory” direction when the comparable sign does not change.
Contraindications, Vascular Tests, PNF, Nerve Glides
Do not mobilize or manipulate through suspected fracture, acute infection, malignancy in the field, cord signs, cauda equina, or hypermobility/instability—including rheumatoid or connective-tissue instability of the upper cervical spine. Unstable spondylolisthesis, acute inflammatory arthropathy, and a patient who cannot consent are stops. Osteoporosis and anticoagulant use are stronger precautions for thrust than for gentle grade I oscillation.
Vertebral artery / vertebrobasilar (VBI) positional tests are not a clearance gold standard. Diagnostic accuracy is poor; published work (including Côté and colleagues) has shown essentially no useful positive predictive value in some samples, with false negatives that matter. A negative test does not prove the artery is safe to thrust. Contemporary cervical screening (IFOMPT-style vascular frameworks) emphasizes history and risk—sudden severe headache, neurologic symptoms with neck movement, connective-tissue disease, recent trauma, clotting history, a changing migraine pattern—plus a neurologic exam. Historical “5 Ds and 3 Ns” lists are teaching aids, not a standalone clearance. If the story is vascular, do not thrust; refer.
Proprioceptive neuromuscular facilitation (PNF) stretching—hold-relax, contract-relax, and hold-relax with agonist contraction—uses a brief isometric or concentric of the tight muscle (classically autogenic inhibition via Golgi tendon organ teaching) and/or contraction of the antagonist (reciprocal inhibition) to gain ROM. It is stretching with a motor strategy, not a joint thrust. Skip aggressive PNF on an acutely inflamed muscle-tendon unit.
Nerve glides (neurodynamic sliders and tensioners) for median, ulnar, radial, sciatic/tibial, and slump sequences treat mechanosensitive neural tissue. Sliders move one end of the track then the other so the nerve glides without a large tension spike; tensioners load the entire track. Irritable radiculopathy, progressive neurologic deficit, and spinal instability are reasons to delay or avoid aggressive tensioners. Pain that peripheralizes or produces new numbness is a stop, not a “release.”
Exam trap: grade V on an unstable C-spine. Rheumatoid upper-cervical instability, Down syndrome with possible atlantoaxial laxity, recent cervical trauma without imaging clearance, or myelopathic signs do not get a thrust because “the vertebral artery test was negative.” Manual therapy is a graded tool. Instability is a referral, not a grade increase.
An athlete has an irritable, pain-dominant talocrural joint two days after a grade I inversion sprain. Swelling is moderate and accessory glide is limited by pain before tissue resistance. Which Maitland approach is most appropriate as the first oscillatory technique?
A 34-year-old with longstanding rheumatoid arthritis reports neck stiffness. Ligamentous testing of the upper cervical spine is uncomfortable and you are considering a high-velocity technique because a vertebral artery positional test was negative. What is the most appropriate decision?
Which statement about IASTM and joint-mobilization planning is most accurate for BOC-level practice?