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This classic text has become one of the foundation texts for all modern manual 
therapists. The fourth edition has been extensively revised by two authors who worked 
closely with Geoff Maitland and who have added invaluable and up-to-date input in the 
revision of this new edition. The accompanying CD-ROM contains videos of all relevant 
examination and treatment techniques. All line drawings have been replaced with high 
quality photographs which , together with the CD-ROM and the book's new layout, 
afford an in-depth and user-friendly experience for readers. 
New for this edition: 
• Text is extensively updated and revised 
• CD-ROM of examination and treatment techniques described in the book 
• High quality photographs replace line drawings making the techniques clear and easy 
to follow 
• New chapter on Contemporary Perspectives in Physiotherapy Practice 
• Additional appendix: 'Self-management Strategies: Compliance and Behavioural 
Change' 
• Existing chapters extended and enhanced with evidence-based information and 
current practice 
Features: 
• New user-friendly text with bullet points and summaries 
• New design and layout of illustrations 
• Chapter summaries at the beginning of each chapter, including glossary of terms 
• Clinically accessible 
• Evidence-based 
• Colour highlighted boxes to reinforce the key concepts and aid revision 
• Clinical pathology with treatments for pathologies made clear 
• Assessment and treatment of patients clearly explained 
• Case studies included 
Maitland's Peripheral Manipulation serves as an important resource for all practicing and 
trainee manipulative therapists, as well as providing invaluable evidence-based teaching 
material and case studies for undergraduate study programmes. 
This product is appropriate for: 
• manual therapists 
• physiotherapists 
• undergraduates and lecturers 
• osteopaths 
www.elsevierhealth.com • chiropractors 9 
Maitland's Peripheral Manipulation 
For Butterworth-Heinemann 
Senior Commissioning Editor: Heidi Harrison 
Development Editor: Siobhan Campbell 
Project Manager: Morven Dean 
Design Direction: George Ajayi, Judith Wright 
Maitland's Peripheral 
Manipulation 
Fourth Edition 
Edited by 
Elly Hengeveld MSc BPT OMT,vomp 
Senior Teacher. International Maitland Teachers' Association, Oberentfelden, Switzerland 
Kevin Banks BA MMACP MSCP SRP IMTA Member 
Chartered Physiotherapist, Rotherhom, UK 
Foreword by 
Peter Wells BA FCSP DIPTP SRP 
Consultant Specialist Physiotherapist, Sports and Spinal Clinics, Fulham, London, UK 
ELSEVIER 
BlTTTERWORTI-1 
HEINEMANN 
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2005 
ELSEVIER 
BUTTER\\IORTH 
liEINEMANN 
C 2005. Elsevier Ltd 
First published 1970 
Second edition 1977 
Third edition 1991 
Fourth edition 2005 
Reprinted 2006 
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Notice 
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Contents 
Foreword vii 
Preface to the fourth edition ix 
Preface to the first edition xi 
Companion texts to this edition xiii 
1. The Maitland Concept - an introduction 
2. Mobilization and manipulation - definitions, 
desired effects, role in rehabilitation and 
evidence base 25 
3. Communication and the therapeutic 
relationship 39 
4. Contemporary perspectives in physiotherapy 
practice 71 
5. Principles of assessment 89 
6. Principles of examination 125 
7. Principles and method of mobilization/ 
manipulation techniques 165 
8. Principles of selection and progression of 
mobilization/manipulation techniques 179 
9. Recording 237 
10. Peripheral neuromusculoskeletal disorders 249 
11. The shoulder and shoulder girdle complex 275 
12. The elbow complex 357 
13. The wrist and hand complex 399 
14. The hip region 445 
15. The knee complex 487 
16. The ankle and foot complex 525 
17. The temporomandibular joints, larynx and hyoid 
(the craniomandibular complex) 577 
Appendix 1 Movement diagram theory and compiling 
a movement diagram 599 
Appendix 2 Self-management strategies: compliance 
and behavioural change 617 
Index 625 
v 
Foreword 
It is not difficult to see why this book has stood the test 
of time and critical appraisal to reacl1 its 4th edition. 
Like its companion volume, Vertebral Manipulation, it 
was, in its slimmer original version published in 1970, a 
landmark publication. Other books on the 'why's and 
how's of manipulation existed but they were written by 
doctors, essentially for doctors. Physiotherapists were 
the 'also rans'. Not trained as primary medical diag­
nosticians, unable to prescribe medication or inject or 
carry out manipulations under anaesthetic, they and 
their skills were usually relegated to a secondary, tech­
nicians role in the assessment and treatment of mus­
culo-skeletal conditions. This approach was inevitably 
centred exclusively on the medical model of examina­
tion, diagnosis, and treatment but incorporated tech­
niques of manual skill commonly viewed as 'fringe' or 
'alternative'. Some of these stemmed from osteopathy. 
Whilst the skills of passive movement used in treat­
ment of a wide range of disorders such as those within 
orthopaedics and neurology, had always been an 
essential part of the work of physiotherapists, a com­
prehensive text of sufficient substance and originality, 
written by a physiotherapist for physiotherapists was 
lacking. Maitland's Vertebral Manipulation changed all 
of that and Peripheral Manipulation (1970) followed 
on in the same vein. 
The development of aspects of 'the Maitland con­
cept' as it became known, was fascinating to follow. 
Numerous ideas, such as 'movementdiagrams' and the 
'grading' of each technique to define its force and 
amplitude and mode of application, became valuable 
teaching tools for communication and were an attempt 
at accurate recording, both in the clinical setting and in 
the process of teaching and learning. The conceptualiza­
tion of an imaginary (permeable!) 'brick wall' separat­
ing, but not mutually excluding, scientific knowledge 
and clinical presentations, was illuminating and it is 
still, contrary to the views of a few who seem entirely to 
have missed the point, a valuable idea. 
Sound clinical reasoning, long before that term was 
on everybody's lips, was the foundation of the pio­
neering work of Geoffrey Maitland, as recorded in his 
books and articles. This was not only what he 
preached but also very much seen in what he prac­
tised, as those privileged to watch him treating 
patients, can confirm. 
His saying that 'technique is the brainchild of inge­
nuity' was demonstrated on one occasion when an 
observer, watching him on a course treating a patient, 
enquired what was the technique he was using. "I don't 
know" came the reply "I've never done it before"! this 
was not, of course, a facetious remark, but an enjoinder 
to "go thou and do likewise". 
The process of ongoing, continuous re-assessment 
at all stages of treatment and its follow-on, using pre­
cise, detailed questioning and retesting has remained 
as a fundamental strength of this approach. This 
process exemplifies the enormous contribution made 
by Geoffrey Maitland in his emphasis on the impor­
tance of subtle communication as a fundamental skill 
to be mastered in the process of "proving clinically" 
the value or otherwise of particular passive movement 
strategies and other associated techniques. This is well 
documented in Chapter 3, essential reading for all 
medical personnel of whatever profession. 
Another great strength of the approach described in 
this book is that it is non-dogmatic. Consequently, an 
evolving knowledge base has been incorporated, over 
the years. It is not a 'method' or 'school' in the narrow 
sense. Its 'open' approach has facilitated a develop­
ment and expansion of the whole, "developing and 
extending" as Maitland himself put it (Chapter I). With 
vii 
viii FOREWORD 
no necessity to change its basic principles it has been 
possible to add to and develop the work. Compare the 
size and content of this edition with the first. 
The authors are to be congratulated on their success 
in developing the contents of this third edition to incor­
porate, apparently seamlessly, the advances made in, 
for example, the pain sciences, in the last fifteen years 
or so. An osteo-arthritic knee is no longer viewed as 
simply a painful, stiff joint, but a problem having, like 
low back pain, a bio-psychosocial construct, and this is 
right. Peripheral nociceptive, peripheral neurogenic, 
central and sympathetically maintained pain are exam­
ples highlighting variations within nervous system 
pain physiology which must help guide and modify 
our use of manipulative therapy. 
However the brilliance and originality of so many 
of Geoffrey Maitland's ideas have not been lost. For 
example, the concept of 'irritability' as distinct from 
'severity', whilst it has been criticised from a narrow 
academic viewpoint, remains a valuable insight help­
ing the clinician make crucial decisions about the for­
mulation of their day to day treatments. 
Likewise the perceptive subdivision of 'overuse', 
'misuse', 'abuse', 'new use' and 'disuse' to illuminate 
clinical states is as useful as ever in gaining further 
insight into the nature of the great array of musculo­
skeletal problems. Even terms such as 'unstable insta­
bility' and 'stable instability' which have thrown some 
moderate people into a rage, are supported by an 
underlying wisdom coupled with a wealth of clinical 
experience. 
The expansion of the text to incorporate referenced 
research and other material, case studies, physiothera­
pists thoughts and hypotheses, clinical profiles, pho­
tography of techniques and much else adds greatly to 
the work as a standard reference and a course text, 
as well as a rich source of clinical guidance and 
illumination. 
It must surely have been an inspiration to the 
authors that a growing amount of research across a 
wide spectrum of expertise in physiotherapy and the 
field of manipulation has stemmed from the teaching 
summarized in this book and its previous editions. 
The foundation of the International Maitland 
Teacher's Association (IMTA) in Switzerland was due 
to the foresight and determination of a remarkable 
physiotherapist, Gisela Rolf. This organization has 
overseen the training of teachers who attempt to satisfy 
the demand in Europe and elsewhere for regulated, 
high standard, post-graduate courses in this field. They 
will, without doubt, be encouraged by this new edition. 
The pioneering work of Geoffrey Maitland, 
reflected in these pages has, over the years, generated 
some heat in discussion but, most importantly, great 
light. This present edition will illuminate further its 
subject. 
Most importantly it presents us with an absorbing 
and comprehensive text helping to define a crucial 
part of the work of physiotherapists. 
Peter Wells, 
London 2005 
Preface to the fourth edition 
The preface to the first edition of this book was written 
35 years ago and is as relevant to today's physiother­
apy profession as it was in 1970. The advancement of 
orthopaedic medical imaging and diagnostics, and the 
advent of extended scope physiotherapy practice have 
distracted the profession from the detail of joint pain 
and the ability to deal with it at face value. The mes­
sage in the preface to the first edition, therefore, could 
be applied to contemporary physiotherapy practice in 
2005. Read it and see. 
'The Maitland Concept', as it has come to be known, 
appears to be contradictory, exhibiting both the quali­
ties of stability and flexibility. The clinical basis and the 
Concept's fundamental elements have remained the 
same throughout its evolution. At the same time it has 
changed with the times and accepted contemporary 
manipulative physiotherapy methods. The Concept 
has maintained an unassuming, non-judgemental and 
open-minded approach, which perpetuates a patient­
centred model of clinical practice. This is its backbone 
and the strengtl1, stability and flexibility of the symbolic 
permeable 'brick wall' analogy. 
The fourth edition of Maitland's PeripheraL Manipula­
tion presents an integrated, contemporary and evidence­
based model of manipulative physiotherapy. Such a 
model is placed within the context of 'best practice' for 
movement-related neuromusculoskeletal disorders of 
the upper and lower limb. Each chapter of this text has 
been revised and expanded to reflect advances in 
knowledge and the role of manipulative physiotherapy 
within contemporary clinical practice. This includes: 
the reference to the International Classification of Func­
tioning, DisabiLities and Health (rCF, WHO 2001); pain 
mechanisms; biopsychosocial paradigms; the rehabili­
tation process and current definitions and descriptions 
of physiotherapy practice. Guidelines for assessment, 
examination and treatment have been updated with 
relevant evidence from the current literature, including: 
contemporary developments in physiotherapy practice 
(Chapter 4); clinical reasoning science; the biopsycho­
social paradigm, including psychosocial assessment 
(Chapters 4 and 5) and fue essence of self-management 
strategies with a focus on compliance enhancement 
and behavioural change (Appendix 2). Appendix 1 is 
preceded by a review of topical issues in the definition 
of R], the definition of grades of mobilization and 
manipulation, and thereliability of detecting and repre­
senting the parameters encountered during passive 
movement testing. 
A bullet-point method of presenting the text has been 
used for clarity and to improve the user-friendliness of 
the book. The line drawings so expertly produced by 
Anne Maitland have been superseded by photographs. 
The main reason for tlUs is to complement the CD-ROM 
which accompanies this fourfu edition and helps to 
bring to life most of the techniques of examination and 
treatment described in the book. 
Kevin Banks expresses his thanks to: Jukka Kangas 
and Donna Ardron for their constructive comments on 
the revised text; Robin Blake for sharing his knowl­
edge and expertise over many years, and Nancy and 
the kids for their patience and understanding in seeing 
this project through. 
Elly Hengeveld wishes to thank everybody who has 
given constructive suggestions to the texts, in particu­
lar Renee de Ruyter-Bouwman and Hugo Stam; Gisela 
Rolf, as a teacher in the 1980s, for her dedication, 
thoroughness and determination to give everything 
for her visions; Franzi and Ueli, Catherine, Christin 
and Roland, Renee and Henk - thanks for being such 
ix 
L 
x PREFACE TO THE FOURTH EDITION 
good friends, even in more difficult times, and most of 
all to Charles, Lijda and Kees, I remember what is truly 
important in life. 
Both authors thank the medical publishing team at 
Elsevier and their IMTA colleagues for their support 
and guidance. 
Last but not least to Geoff and Anne Maitland to 
whom we owe everything and to whom we feel it is 
our duty to be the custodians of their knowledge and 
to nurture and develop this concept into its early 
adulthood. 
Kevin Banks, Rotherham, UK 
Elly Hengeveld, Oberentfelden, Switzerland 
2004 
Preface to the first edition 
Treatment of painful peripheral joints by passive move­
ment has become almost a forgotten art among physio­
therapists. In the present era active exercise, combined 
with heat or cold therapy, is the popular and estab­
lished approach. Passive movement is not routinely 
used because in the past its techniques have been used 
too strongly, causing the patient unnecessary discom­
fort and sometimes aggravating the condition. 
Hesitation on the part of doctors and physiother­
apists to use passive movement arises from a lack of 
understanding of how and when to apply gentle tech­
niques, and of their effectiveness. P hysiotherapists, inex­
perienced in handling painful joints passively, may 
have inadvertently aggravated the pain and thus 
wrongly concluded that passive movement should not 
be used. This condition is unfortunate; when precise 
physical signs of joint disturbance can be determined, 
quicker and better results may be achieved using pas­
sive movement guided by the signs. Often quite gentle 
techniques can be used. 
Many books have been written about manipulation 
of peripheral joints. Among these are important con­
tributions by Dr Cyriaxl and Drs James2 and John 
Menne1l3 Dr Cyriax's work is particularly notable for 
the presentation of accurate methods of examination. 
The treatment techniques he outlines are those of the 
stronger type, some of which require the assistance of 
physiotherapists. Dr John Menne1l3 continues the work 
I Cyriax, J. Textbook of Orthopaedic Medicine. Vol. II, 7th edn. 
London; Bailliere TindalJ (1965) 
2 Mennell, James Science and Art of Joint Manipulation. Vol. II. 
London; Churchill (1952) 
3 Mennell, John McM. Joint Pain. Boston; Little Brown & Co 
(1965) London; Churchill (1964) 
of his father, Dr James Menne1l2, who stressed the 
importance of accessory movement (or, in his own ter­
minology, 'joint play'). 
Even with these books, and others written by lay 
manipulators, there are still several facets of the field of 
passive movement treatment which are not covered. 
There are occasions when patients are referred for 
physiotherapy with joint disorders which require tech­
niques not previously described, or when the reasons 
for choosing particular amplitudes and positions in the 
range have not previously been described or related to 
the examination finding of the joint disorders. 
The purpose of this book is to present techniques 
for all peripheral joints, to discuss in detail the relevant 
parts of examination by passive movement, and to 
relate the method of applying the techniques to the 
examination findings. 
Most people think of passive movement treatment 
as a stretching process to increase the range of move­
ment of a stiff joint. However, the application of passive 
movement to painful peripheral joints is far wider than 
this. Its use in the treatment ofjoint pain, whether the range 
of movement is limited or not, has not been appreciated. This 
subject has not been treated in any other text published 
and possibly may not have been considered before. For 
this reason alone the following text is necessary to fill a 
gap in the physical treatment of joint pain. 
Although some of the techniques will be similar to 
those published by others, many will be different, and 
some of the moving parts for which techniques are 
described have not been presented before. Also, some 
of the movements described for certain joints have not 
been presented before. 
Diagnosis will not be discussed in this book as this 
is the province of the medical practitioner. However, 
xi 
[ 
xii PREFACE TO THE FIRST EDITION 
when he refers a patient, very careful examination of 
joint movement must be undertaken by the physiother­
apist. The findings will guide the choice of technique 
and the style of movement to be used (i.e. small ampli­
tude, large amplitude, avoiding pain or moving into 
pain), and the range in which it is performed. The find­
ings also act as guides for the assessment of progress. 
When any new form of treatment becomes popular, 
people tend to think only about the new techniques; 
the idea being that once the techniques are learned, 
nothing remains but to apply them to patients. If this 
idea is carried out by numerous people, it follows that 
standards of treatment fall, results are poor, and con­
sequently the treatment method lapses. This idea of 
solely learning techniques and applying them indis­
criminately is totally inadequate. For this reason con­
siderable space in the ensuing text is given to minute 
examination detail and to the ways in which the tech­
niques should be applied to the findings. The process 
may seem tedious at first and may even emphasize the 
points which seem too trivial to mention. However, 
this depth of detail is designed to prevent misunder­
standing of the reasons for the application of the tech­
niques. Also, as a musculoskeletal disorder may 
present different joint signs at different stages of devel­
opment of the complaint, it is essential that examin­
ation of the joint signs be carried out in detail. Different 
joint signs require different treatment techniques. 
In the chapter on Examination appreciation of the 
various factors which constitute the joint signs deter­
mined by passive movement tests is discussed. In the 
appendices 'movement diagrams' have been offered 
as the best method at present available for teaching 
this appreciation. The 'movement diagram' has also 
been used in the chapter on Treatment to express more 
clearly the relationship between passive movement 
used in treatment and the clinical signs. The concept of 
a 'movement diagram' was evolved by Miss J-M. 
Ganne, MCSP, MAPA, DipTP, and further developed 
in an article jOintly written by Miss Jennifer Hickling, 
MCSP and the author, published in the Journal of the 
Chartered Society of Physiotherapy4 and the Australian 
Journal of Physiotherapy5 Thanks are due to Miss 
Hickling and to the Editors of both journals for permit­
ting partof the article to be reproduced in this book. 
Dr D. A. Brewerton, MD, FRCP, has provided an 
invaluable medical approach to the many aspects of 
passive movement treatment, and I am grateful to him 
for his contribution. Much needs to be said about atti­
tudes to and prejudices against this form of treatment 
which cannot properly be said by a physiotherapist, 
and I am very pleased to have Dr Brewerton's willing 
support and I thank him sincerely. Many amendments 
regarding presentation were made to the text as it 
evolved and Mrs J. Trott, Miss P atricia Trott, AVA, 
Grad. Dip. Manip. Ther., MAPA, MCSP, and Miss M. J. 
Hammond, AVA, MAPA, MCSP, Dip.TP, have been 
patient, helpful and encouraging. The illustrations 
drawn by my wife more than achieve their purpose. 
They clearly and simply illustrate the text and avoid 
the distractions often present with photographs. I am 
especially grateful for her helpfulness and suggestions 
throughout the project. Without the willing help of the 
many people who carried out typing, modelling, and 
drawing of graphs, the book could not have been com­
pleted and I extend to them my grateful thanks. 
G. D. Maitland 
Adelaide 1970 
4 Hickling, J. and Maitland, G. D. Abnormalities in passive 
movement: diagrammatic representation. Journal of the 
Chartered Society of Physiotherapists, 56, 105 (1970) 
5 Hickling, J. and Maitland, G. D. Abnormalities in passive 
movement: diagrammatic representation. Australian Journal of 
Physiotherapy, XVL 13 (1970) 
Companion texts to this edition 
Boissonnault, W. 1995. Examination in Physical Therapy 
Practice - Screening for Medical Disease. New York: 
Churchill Livingstone 
Butler, D. 1. 2000. The Sensitive Nervous System. Adelaide: 
NOIGroup 
Corrigan, B. & Maitland, G. D. 1983. Practical Orthopaedic 
Medicine. London: Butterworth 
Goodman, C. & Snyder, T. 1995. Differential Diagnosis in 
Physical Therapy, 2nd edn. Philadelphia: W. B. Saunders 
Higgs, J. & Jones, M. A. 2000. Clinical Reasoning in the Health 
Professions, 2nd edn. New York: Butterworth-Heinemann 
Jones, M. & Rivett, D., eds. 2004. Clinical Reasoning for 
Manual Therapists. Edinburgh: Butterworth-Heinemann 
Maitland, G. D. 1992. Neuro/musculoskeletal Examination and 
Recording Guide, 5th edn. Adelaide: Lauderdale Press 
Maitland, G. D., Hengeveld, E., Banks, K. & English, K. 2005. 
Maitland's Vertebral Manipulation, 7th edn. Oxford: 
Bu tterworth-Heinemann 
Sahrmann, S. A. 2002. Diagnosis and Treatment of Movement 
Impairment Syndromes. St Louis: Mosby 
xiii 
Chapter 1 
The Maitland Concept - an 
introduction 
THIS CHAPTER INCLUDES: 
• Key words for this chapter 
• A glossary of terms for this chapter 
• General themes of the book 
• Introduction to the Concept 
• The central core 
• The brick wall approach to clinical 
decision making 
• Examination 
• Treatment techniques 
• Assessment 
• The Concept in context. 
KEY WORDS personal commitment, symbolic treatment techn iques, assessment, 
Maitland Concept, movement system, permeable brick wall, examination, context. 
GLOSSARY OF TERMS 
Accessory movement - accessory or 
joint play movements are those 
movements of a joint that cannot 
be performed actively by the 
individual. Such accessory 
movements include the roll, spin 
and slide which accompany a 
joint's physiological movements. 
Accessory movements should be 
examined passively for range and 
pain (symptom) response in the 
joint's loose packed position, in 
painful positions of a free range of 
movement or at the end of a 
limited range. 
Analytical assessment - assessment 
made during the episode of care or 
at its conclusion. It takes into 
account all details of the past and 
present history of the patient's 
disorder, the diagnostic details and 
the response to the different 
treatments that have been 
admin istered. This collection of 
information is analysed so as to 
allow understanding of the likely 
future of the patient's disorder. 
Biomedical engineering - the 
association between cellular and 
tissue biology and disease and 
engineering as in prosthetics, 
materials used in tissue healing 
and replacement and, more 
recently, gene therapy. 
Clinical reasoning - the th inking 
underlying clin ical practice 
through information gathering, 
interpretation of information, 
actions upon findings and 
evaluation of such actions, each 
strand of information resulting in 
an ever-evolving understanding of 
the patient and their disorder. 
Differentiation testing -
examination procedures which 
assess which joint or structure is 
the source of symptoms when one 
or more joints or structures is 
involved in a particular movement. 
Disorder - any complaint from which 
any patient may suffer and be 
referred to a physiotherapist. This 
will include those disorders which 
can be given an accurate titled 
diagnosis, as well as those that, 
though perhaps being recognized 
as a syndrome, cannot be precisely 
titled. 
Frame of reference - the context 
into wh ich the patient places their 
experiences (of pain) based on their 
present and past experiences of 
similar situations. In turn this 
determines the manner in wh ich 
they will respond to pain and 
functional impairment and the 
endeavours of health professionals 
to help them. 
Functional corners - combinations 
of functional joint movement 
2 MAITLAND'S PERIPHERAL MANIPULATION 
which are regularly incorporated 
into everyday activities. Such 
functional corners need restoring 
to their ideal pain-free status with 
passive movements in cases where 
minimal joint signs are preventing 
full recovery (e.g. h ip flexion / 
adduction, elbow extension / 
abduction). 
Illness behaviour - during illness, pain 
experience or functional impairment, 
the means by which an individual 
can sample and express their 
feelings, thoughts and emotions 
about their state of health or illness. 
This can be through verbal or 
non-verbal expressions, including 
both actions and inactions, which 
may be either adaptive and beneficial 
to recovery or maladaptive and 
unhelpful to recovery. 
Impairment - problems in body 
function or structure such as a 
significant deviation or loss. 
Injuring movement - re-enactment 
of a particular injuring direction 
of stress in the physical 
examination in order to reproduce 
symptoms or divulge relevant 
comparable signs. 
Mode of thinking - the separation of 
th inking into a theoretical 
compartment and a clinical 
compartment so that thoughts 
related to the theory of a patient's 
disorder do not inh ibit the 
discovering of the finer details of 
the disorder's history, symptoms 
and signs. This mode of thinking 
also takes into account diagnoses 
which are incomplete or 
uncertain. 
Movement diagram - a two­
dimensional pictorial or mental 
image, a dynamic map showing the 
physiotherapist's perceptions of the 
extent and relationship between 
joint signs (usually pain, spasm­
free resistance, and protective 
muscle spasm) during the 
assessment of a particular passive 
movement direction of a joint. 
Movement diagrams serve as a 
self-learn ing process, a teaching 
medium and a means of 
commun ication. 
Movement system - an anatomical 
and physiological system that 
functions to provide motion 
of the body as a whole or of 
its component parts (Sahrmann 
2001). 
Overpressure - every joint has a 
passive range of motion which 
exceeds its active range. To this 
passive range, further normal 
movement can be gained by a 
stretching application of 
overpressure. This overpressure 
range has, in nearly all examples, a 
degree of discomfort or hurt and 
should be assessed before declaring 
a joint movement to be normal 
or ideal. 
Pain mechanisms - the complexinteractions within the 
neuromatrix by wh ich sensory 
input is processed, influenced by 
autonomic, endocrine and motor 
output and consequentl y 
experienced by an individual 
patient as pain. 
Paradigm - a model of beliefs based 
on a professional body of 
knowledge, such as the paradigm 
that physiotherapy is a 
rehabilitation profession with an 
expertise in disorders of the 
movement system. 
Physiological movement - those 
movements of a joint which can be 
performed actively by the 
individual and wh ich can be 
examined for range, quality and 
symptom response, both actively 
and passively. 
Prognosis - the forecast of the 
probable course of a case of 
disease or injury, or the art of 
making such a forecast (The 
Shorter Oxford Dictionary 
1980). 
The body's capacity to inform -
the patient's perception of 
their own bodily health, disorder 
or functional status and how, 
w ith guidance from their 
physiotherapist, they can 
express these perceptions 
through description and / or 
demonstration. 
GENERAL THEMES AROUND WHICH THE 
4TH EDITION IS BASED 
importance to the patient and the order in which 
the physiotherapist should be thinking about them 
(Fig. 1.1 ): 
The fundamental components of the Maitland Concept 
are inextricably linked and interrelated. They give the 
manipulative physiotherapist a platform for the deliv­
ery of a flexible and innovative clinical reasoning 
approach to the management of neuromusculoskeletal 
and movement-related disorders. The following sum­
mary reflects the themes which will emerge throughout 
the text. These themes are presented in order of their 
• The patient-centred approach to dealing with 
movement disorders 
• The brick wall approach and the primacy of 
clinical evidence 
• The paradigm of identifying and maximizing 
movement potential 
• The science and art of assessment. 
The Maitland Concept - an introduction 3 
Cent thinking col' .. 
• 
,tie 'orick wall ' . 
• 
,tie Ilfimacy of clinical ev;a 
• 
J>.llllfollnate wording ef/ce 
The patient-centred approach to dealing with 
movement disorders 
This key component is based around a personal com­
mitment to the patient. In the context of the Maitland 
Concept a personal commitment means: 
• developing a level of concentration such that the 
manipulative phYSiotherapist feels mentally and 
physically challenged throughout each episode of 
care: take for example the Test cricketer who makes a 
Test Match century and is at the crease for several 
hours. A high level of concentration is needed to 
enable his shot selection to be accurate throughout 
his innings. Likewise the physiotherapist who is 
with a patient must see each piece of information as 
'a good length ball' and think how to reply or ask 
a relevant follow-up question, carry out another 
examination procedure, or select an appropriate treat­
ment technique in order to build a problem solving 
innings each time the patient is seen (Fig. 1 .2) 
• being prepared to revisit, time and time again, the 
patient's sensory, cognitive and emotional world until 
the information that the patient provides makes 
sense 
• being totally non-judgemental at all times, actively 
listening to the patient and believing that every­
thing the physiotherapist is told is true 
• developing a skilled understanding of verbal and 
non-verbal communication and being prepared to 
critically appraise one's own communication skills; 
[ 
4 MAITLAND'S PERIPHERAL MANIPULATION 
the physiotherapist should always shoulder the 
blame for errors in communication 
• using the patient's own terminology (the physio­
therapist should adapt to the patient rather than 
continuously expecting the patient to adapt to the 
clinician) 
Figure 1 .2 Australian Test Cricket Captain Steve Waugh 
(1999-2003) who scored over 10 600 Test runs including 32 Test 
centuries. Reproduced by kind permission from The Wisden 
Cricketer(January 2004) and from Steve Waugh. © Patrick Eagar 
(photographer). 
• endeavouring to understand the 'frame of refer­
ence' from which the patient expresses the effects of 
the disorder 
• knowing what the clinician should know 
• creating an interpersonal environment in which the 
patient feels comfortable, confident and trusting in 
the clinician. 
The brick wall approach and the primacy of 
clinical evidence 
The brick wall approach to clinical decision making 
applies to all aspects of this manipulative physio­
therapy model. The manipulative physiotherapist is 
encouraged to decide which side of the brick wall is 
being considered during each stage of decision mak­
ing. The decision-making process of the Maitland 
Concept is primarily on the clinical evidence side of 
the brick wall although diagnostic/theoretical consid­
erations will influence the exact nature and dosage of 
the intervention. Therefore the primacy of clinical evi­
dence is a major part of the Maitland Concept. For 
example, the prime concern of a patient with a diagno­
sis of tennis elbow will be that the problem resolves 
and does not recur (history), that the pain being experi­
enced will go away (symptoms) and that grip strength 
when lifting things will return to normal (signs). 
Figure 1 .3 is a dynamic representation of the use of the 
brick wall for clinical decision making. 
At the heart of the Maitland Concept is a special 
mode of thinking in two interdependent compartments 
separated by a symbolic permeable brick wall, thus 
allowing for hypotheses and speculations. The separ­
ation into 'theoretical compartment' and 'clinical com­
partment' in the clinician's mind prevents thoughts 
relating to the theory of a disorder overriding the 
Figure 1.3 The symbolic 
permeable 'brick wall'. . 
- Elbow pain and soreness 
since decorating 
Symptoms - Sharp pain on the outside 
o 
o 
� 
of the elbow when gripping 
- Reduced grip strength 
painful and stiff 
o elbow extension/adductions 
o 
� 
clinician's decision-making processes and does not 
inhibit the clinician from discovering the patient's dis­
order in terms of its history, its symptoms and its signs 
in fine detail. It also allows for safe and effective man­
agement of disorders where there is an incomplete or 
uncertain diagnosis. 
The paradigm of identifying and maximizing 
movement potential 
The World Congress of Physical Therapy (WCPT 1999) 
in an updated description 'recognizes that physiother­
apy is concerned with identifying and maximizing 
movement potential within the spheres of promotion, 
prevention, treatment and rehabilitation'. The Maitland 
Concept, with attention to detail in the analysis of 
quantity and quality of human movement and with 
mobilization/manipulation techniques designed to 
restore movements to their pain-free ideal state, is 
well placed to contribute to the realization of such a 
paradigm. 
Examination 
An essential requirement is believing that a patient can 
have: 
• more than one kind of pain 
• different pains in overlapping areas 
• different pains with different behaviours and 
histories. 
It is also important to believe that there are fine details 
of information which the body can tell the patient and 
that the clinician cannot know about unless the patient 
is encouraged to talk about these trivia, thereby encour­
aging a personal and total commitment to the patient. 
In the physical examination, aspects which are 
emphasized within the Maitland Concept are: 
• functional movements which the patient can 
perform to demonstrate the pain or other 
symptoms for which treatment is being sought 
• re-enacting the injuring movement when the 
disorder has been caused by some traumas 
• differentiation tests 
• pain response to accessory movements performed 
in loose-packed positionsand at the end of range 
of physiological movements 
• pain response to 'combined movement' tests 
• pain response to the testing of 'functional 
corners' 
• pain response to movement, both physiological 
and accessory, performed while the joint surfaces 
are held compressed together 
The Maitland Concept - an introduction 5 
• test movements requiring overpressure to establish 
normality 
. 
• not thinking of range of movement without 
relating the pain response to it and vice versa 
• movement diagrams for the purpose of learning 
and teaching. 
Mobilization / manipulation techniques 
Although it is necessary to have a basic set of techniques 
from which to teach, the clinician must be totally open 
minded and capable of adapting and modifying tech­
niques to achieve the purposes for which £hey were cho­
sen in relation to movement and pain. A technique is the 
brainchild of ingenuity. For example, a patient may 
experience pain at the front of the knee when going 
up stairs. A possible treatment technique may be 
tibiofemoral joint passive accessory movement in the 
weight-bearing position, thus reproducing the pain, the 
desired effect being to enable the patient, subsequently, 
to go up stairs without any symptoms (Fig. 1.4). 
Grades of passive movement and rhythms are 
used for teaching, communication between clinicians, 
recording purposes and to allow the clinician to think 
in finer detail about the technique. Two styles of tech­
nique are specific to the Concept: 
• Performing a movement in an oscillatory manner 
within a range of movement where there is no 
stiffness, muscle spasm or pain . 
• Using compression as a component of a treatment 
technique. 
Figure 1.4 Tibiofemoral accessory movement in weight­
bearing. 
MAITLAND'S PERIPHERAL MANIPULATION 
Recording of treatment must be complete and in depth, 
yet brief. 
The science and art of assessment 
Repeated assessment and ongoing analytical assess­
ment are the means of evaluating and reflecting on 
everything done during the clinical decision-making 
process. Assessment is the epitome of the Concept. 
Clinical proof of whether treatment is working or not 
is achieved by continually comparing the effects of the 
selected treatment forms on the patient's symptoms 
and signs. At the same time hypotheses about 
the cause of the problem, the structures at fault, the 
pathobiological mechanisms involved, expectations 
for recovery and appropriate management strategies 
can be confirmed, discarded or re-ranked. Therefore 
this process of evaluation involves the clinical science 
of measurable change and the art of decision making 
about treatment, often based on clinical experience 
and intuition. 
Assessment is used at the initial consultation in a 
manner which determines the effects of the disorder 
on the patient as a person and to identify relevant 
movement impairments and consequent activity limi­
tations. The second application of assessment is in clin­
ically proving the value of treatment techniques by 
repeated, detailed assessment and re-assessment of the 
patient's symptoms and signs. Analytical assessment 
is used throughout the episode of care. 
Such assessment must be made in light of the fact 
that the body has an enormous capacity to compensate 
for injury, disease or congenital abnormalities. The 
body also has the capacity to inform the patient of 
seemingly trivial details which the clinician must 
encourage the patient to report so that assessment can 
be more informed and accurate. 
It is open-mindedness, mental agility and mental 
discipline linked with a logical and methodical 
process of assessing cause and effect which are the 
demands of the Concept. 
THE MAITLAND CONCEPT - A MANIPULATIVE 
PHYSIOTHERAPY MODEL 
Introduction 
The International Maitland Teachers' Association 
(IMTA) defines the Maitland Concept as a process of 
examination, assessment and treatment of neuromus­
culoskeletal disorders by manipulative phYSiotherapy 
(Hengeveld 2002). The Concept demands an open­
minded, non-judgemental, unassuming and flexible 
approach to dealing with patients who suffer from dis­
orders of their movement system (Sahrmann 2001). 
The central core 
The central core or theme of the Concept is a positive 
personal commitment to understand what the person 
(patient) is enduring. Therefore the Maitland Concept 
is a patient-driven model. It is inclusive and places the 
patient and their main probLems at the centre of every­
thing the manipulative physiotherapist will do or say. 
The body's capacity to give information about how the 
patient is affected by these problems (symptoms, activ­
ity limitations, etc.) is the key to the planning, selection 
and progression of manipulative physiotherapy inter­
vention. For example, if a patient is unable to put his 
socks on in the mornings because of pain and stiffness 
in his groin, the prime aim should be to use this func­
tional loss in examination and assessment to discover 
the source and cause of the symptoms and treat them in 
a way that allows the patient to put his socks on in the 
morning without pain and stiffness in his groin. 
To achieve a high level of commitment it is also 
essential to achieve a high level of verbal and non­
verbal communication (Chapter 3) and a self-critical 
approach to the task of translating the patient's story 
into a clinical picture that can be helped by manipula­
tive physiotherapy. This includes listening carefully 
and believing the information that the patient is giv­
ing, interpreting the non-verbal messages which are 
a reflection of illness experience and carefully consider­
ing the wording, relevance and impact of the next line 
of questioning. 
It is sad to hear patients say that their doctor or 
physiotherapist does not listen to them, or listen care­
fully enough, or listen sensitively enough, or listen in 
sufficient depth, when they want to discuss their 
disorder. The following quotation from The Age, an 
Australian daily newspaper, sets out the demands of 
'listening' very clearly: 
Listening is itself, of course, an art: that is zuhere it 
differs from merely hearing. Hearing is passive; 
Listening is active. Hearing is voLuntanj; Listening 
demands attention. Hearing is naturaL; Listening is 
an acquired discipline. The Age (1982) 
Believing the patient is essential if trust between 
patient and clinician is to be established. We must 
believe the patient's subtle comments about the dis­
order even if they may sound peculiar. Expressed in 
another way, the patient and the symptoms are inno­
cent (i.e. the patient is giving a truthful report about 
the disorder) until proven guilty (i.e. the patient's 
report is unreliable, biased or downright false). In this 
context the patient needs to be guided to understand 
that the body can reveal things about the disorder and 
its behaviour and that we (the clinicians) cannot know 
these things unless the patient expresses them. 
This central core of the concept of total commitment 
(putting the patient at the centre and making as much 
use as possible of the body's capacity to inform) must 
begin at the outset of the first consultation and be car­
ried throughout the total episode of care, right to the 
end, and should include: 
• Question 1 (Chapter 6) - 'In your own words, as far 
as you are concerned, what do you consider to be 
your main problem(s)': 
(a) Pain, discomiort, stiffness, weakness, swelling, 
fear of movement and many other symptoms 
(b) Functional loss of activities of daily living, job, 
hobbies, sleep disturbance, etc. 
(c) An injury resulting in pain and disability. 
• Communication strategies (Chapter 3) - calibrated to 
the patient's frame of reference including: 
(a) use the patient's terminology 
(b) seek spontaneousinformation: 
- Where does it hurt? 
- What makes it worse, what makes it easier? 
- How did it start, when did it start? 
- How is your general health? 
- How have you been since 1 saw you last time? 
(c) listen for key words (which require an immediate 
response or confirmation of their importance): 
- 'I always seem to get the pain in my knee at 
work.' 
- The soreness in my elbow started in the summer.' 
- 'After treatment my hip was sore up until 
Tuesday.' 
(d) inspire confidence and trust: 
- remove non-verbal barriers such as desks 
from between you and the patient 
- arrange the seating and plinth so that you are 
never looking down on the patient. 
• Functional demonstration (Chapter 6) - asking the 
patient to 'show me' the function, movement, activity 
or position which the patient knows will reproduce 
the symptoms or which the patient knows will be 
difficult to perform. 
• Differentiation tests (Chapter 6) - 'Now you are 
squatting down you have a pain which you say you 
feel under your knee cap. Does it change if 1 squeeze 
your knee cap like this?' (adds patellofemoral com­
pression only). 
• Palpation, passive testing and construction of movement 
diagrams (Chapter 6, Appendix 1) - 'When I move 
The Maitland Concept - an introduction 7 
your wrist like this (performs a posteroanterior 
movement of the carpus on the radius and ulna), 
tell me the exact point at which the sharp pain deep 
in your wrist comes on.' 
• Selection of mobilization technique (Chapter 8) - 'It 
seems that you get the pain and stiffness in your 
ankle when you have your weight on it as in walking. 
The best way I have found that reproduces your 
symptoms is for you to stand with your weight on 
your foot and for me to push on your fibula (pos­
teroanterior movement of the fibula). This will be the 
mobilization technique 1 will use and then we will see 
if the pain and stiffness with walking has changed.' 
• Progression of treatment (Chapter 8) - 'You have the 
feeling that 1 now need to stretch your shoulder a 
bit firmer (into the quadrant position, Chapter 11 ) 
and that this will get rid of the stiffness quicker, is 
that correct?' 
• Decision to stop treatment (Chapter 5) - 'After all the 
treatment you have had on your knee you have the 
feeling that the mobilization has done its job. You 
are now about 80% better and you feel it just needs 
time and the exercises and rehabilitation you are 
doing now to get full recovery.' 
Concept thinking, the symbolic permeable brick 
wall and the primacy of clinical evidence 
At the heart of the Concept is what has been called the 
symbolic permeable brick wall. This flexible, open­
minded and non-judgemental approach to thinking 
about clinical presentations and how to treat them pro­
vides the clinician with the facility to explore all pos­
sible hypotheses relevant to neuromusculoskeletal 
disorders. The permeable brick wall separates the the­
oretical compartment from the clinical compartment in 
the clinician's mind. However, a free flow of informa­
tion can take place across the permeable brick wall for 
the purpose of hypothesis formulation and testing. 
This mode of thinking is not used in any other phil­
osophy of manipulative therapy; it is the strength of 
the Concept and the security of the therapist whose 
primary concern should be the importance of the clin­
ical compartment in the decision-making process. 
There are five requirements that enable the ther­
apist to make the most of the brick wall approach to 
clinical decision making, as follows. 
The first requirement 
The first requirement is to learn to think in two dis­
tinctly separate compartments which, although separate 
[ 
8 MAITLAND'S PERIPHERAL MANIPULATION 
Figure 1 .5 The two-compartment mode of thinking. 
G 
o o 
o o 
~ 
� 
o 
o 
o 
o 
Figure 1.6 The symbolic permeable 
·brick wall": theoretical and clinical 
compartments. 
� 
� 
and quite different, are interdependent. One compart­
ment should contain all the theoretical information 
(known and speculative) and the other compartment 
should contain all the clinical information about the 
patient's disorder (Fig. 1 .5). 
Because much of the medical theoretical knowledge 
(e.g. diagnosis, pathology, biomedical engineering, 
etc.) is still incomplete, it should not be given any 
opportunity to obstruct the searching for all the appro­
priate clinical facts associated with a patient's disorder 
(Le. its history, its subjective presentation and its 
effects on the patient's movements) (Fig. 1 .6). In the 
day-to-day encounters with patients, such obstruction 
is a frequent occurrence and the theory does spoil the 
clinical search, thereby affecting the treatment poten­
tial. The two-compartment modus operandi is there­
fore a demand requirement. It is helpful to imagine that 
the two interdependent compartments are separated 
by a symbolic, permeable, 'brick wall'. 
This mode of thinking also allows for discussion 
about hypotheses and speculations about patients' 
clinical presentations without there being any restric­
tions placed upon the progress of knowledge and skill. 
It also encourages the formulation of sensible research 
questions and projects which take the physiotherapy 
profession forward in its understanding of the causes 
of disabilities, particularly painful disabilities. A bonus 
from the 'brick wall' is that the theoretical compart­
ment allows for the widest of thinking (in fact, it 
encourages it) while knowing that, if the thinking is 
correct, it must match the clinical compartment which 
must always be correct (Fig. 1 .7). 
The second requirement 
The clinician must know the history, the symptoms 
and the signs very clearly, and while keeping these 
at the forefront of thinking, full use can be made of the 
o o 
o o 
The Maitland Concept - an introduction 9 
Figure 1 .7 Freedom for speculation, 
hypotheses and research. 
� � 
theoretical compartment in terms of formulating as 
accurate a diagnosis or classification as possible. In 
such a manner, as clear an understanding as is possible 
about the patient and the disorder can be achieved. 
Coping with diagnosis and diagnostic titles is diffi­
cult. Even within medicine, many diagnostic titles are 
somewhat inadequate or even incorrect; they may be 
merely linked to patterns of symptoms or even based 
on suppositions. Titles are often used loosely and even 
inappropriately. It is often impossible to arrive at a 
specific, complete diagnosis, yet the treatment required 
is clearly known. Many people consider that treatment 
should not be administered unless an accurate diagno­
sis is available. This is true to some extent; it is neces­
sary to know whether a patient's symptoms are 
believed to be arising from a musculoskeletal disorder 
rather than an active disease, but it is not always neces­
sary to have a precise diagnostic title. Provided that 
the word 'diagnosis' is used in the terms defined 
in Butterworth's Medical Dictionary (Critchley 1978) 
quoted below, there is no difficulty: 
Diagnosis. The art of applying scientific methods to 
the elucidation of the problems presented by a sick 
patient. This implies the collection and critical 
evaluation of all the evidence obtainable from every 
possible source by the use of any method necessary. 
From the facts so obtained, combined with the 
knowledge of basic principles, a concept is formed of 
the aetiology, pathology, lesions and disordered 
functions which constitute the patient's disease. This 
may enable the disease to be placed in a certain 
recognized category but, of far greater importance, it 
also provides a sure basis for the treatment and 
prognosis of the individual patient. 
Therefore the 'brick wall' mode of thinking caters for 
the recognizablesyndromes and recognizable patholo­
gies, it caters for the partially diagnosed disorder and 
it also caters for the clinical disorders of the movement 
system which are yet to fall into any recognizable clas­
sification. In all cases the clinical compartment has pri­
ority over the theoretical compartment in the final 
treatment/management decisions. Take for example 
the diagnosis 'chronic tennis elbow'. Such diagnostic 
specificity may encourage narrow thinking in terms of 
the nature and a locality of the disorder. This may limit 
the examination and assessment of the problem and so 
confine treatment, which thus may be ineffective. By 
broader-based thinking, a detailed examination of the 
associated joint structures and muscles, the sensitivity 
of the neural tissue in the arm, neck and thoracic spine 
and their reaction to movement testing, as well as asso­
ciated cervical and thoracic joint examination, may 
reveal relevant comparable signs to consider in treat­
ment. By coupling this to all the other clinical features 
of the problem, a working hypothesis can be made in 
which all the components of the condition and its clin­
ical presentation fit together. 
The third requirement 
The clinician is required to use words in particular 
ways. To speak or write in incorrect terms means that 
the thought processes required to choose the words 
must also be incorrect. The phrases used show very 
clearly the way the thought processes are working. 
A simple example may help to make this point clear. 
If a patient describes a symptom area and the clinician 
describes the patient's pain as being 'hip joint pain', 
this is a poor choice of words. To be true to the Concept, 
L 
10 MAITLAND'S PERIPHERAL MANIPULATION 
i.e. true to the separated theoretical and clinical com­
partments of thinking, the words that should be used 
in place of 'hip joint pain' are 'pain in the hip area'. It 
would be better still if the clinician demonstrated the 
area of pain and said 'pain in this area'. To have used the 
words 'hip joint pain' indicates that the thought 
processes could include the thought that the hip joint is 
the cause of the pain. Obviously it does not mean that 
the thought processes must include this thinking, but it 
does mean that it could. On the other hand, by using the 
words 'hip area', or demonstrating the area of pain, indi­
cates that although the thought processes may include 
the thought that the hip joint could well be the source 
of the pain, it is virtually impossible for the subconscious 
thought process to include the thought that the hip joint 
is the source of the pain. This is an important and essen­
tial element of the Concept. Some readers may believe 
that attention to this kind of detail is unnecessary. Quite the 
opposite is true: if the correct choice of words is made 
with care, and with the right mode in mind, then the 
thinking processes must be right. And when this is so, 
the whole process of examination, treatment and inter­
pretation must be the best that is possible. A clinician's 
written record of a patient's examination and treatment 
findings shows clearly whether the thinking processes 
are right or wrong for this concept (Chapter 9). 
The fourth requirement 
The clinician is required to choose a treatment tech­
nique in relation to the patient's signs and symptoms 
rather than the diagnostic title. However, the theoret­
ical compartment may influence the vigour and choice 
of the technique. For example, a patient may have been 
diagnosed as suffering from an 'acute subacromial 
bursitis' with severe pain in the area of the shoulder 
when trying to lift the arm out to the side. The tech­
nique of choice is likely to be an accessory passive 
movement of the shoulder or shoulder girdle per­
formed in such a manner that it achieves the desired 
effect of enabling the patient to lift the arm out to the 
side without experiencing as much severe pain. The 
acute stage of the disorder would require the tech­
nique to be gentle, soothing and pain modulating. 
Planning the treatment, therefore, demands logical 
thinking. The treatment carried out at any one session 
is chosen with care and it must make sense both logic­
ally and methodically. Each step in the planning of the 
whole treatment programme is made on the basis of 
the same logical methodical sense. 
Prognosis is another aspect of treatment that is deter­
mined logically. This is achieved by assessing changes 
in the patient's symptoms and signs effected by treat­
ment, at the same time relating to the hypothesis about 
the diagnosis. Full use is made, therefore, of the two 
interdependent compartments of thinking to achieve 
the best end result. In such a way, when a seriolls dis­
order is present, the importance of accurate diagnosis 
takes priority. However, when the presentation clearly 
shows a movement system disorder is present, the clin­
ical compartment takes precedence. 
The fifth requirement 
The clinician should be encouraged to apply and adapt 
the two-compartment mode of thinking to contempo­
rary models of clinical decision making. The brick wall 
approach to clinical reasoning is well suited to estab­
lished hypothesis categories and the decision-making 
models (Box 1.1) which are relevant to the manipulative 
physiotherapy management of neuromusculoskeletal 
disorders (Higgs & Jones 2000). 
Examination 
Examination is analytical assessment at the initial con­
sultation. Clinical information is gathered, hypotheses 
made, treatment options planned and prognosis specu­
lated upon. Information is gathered and interpreted 
during the subjective examination (Chapter 6). The­
oretical and clinical hypotheses are formulated during 
the planning of the physical examination. The hypotheses 
are then put to the test during the physical examination 
and subsequently through the application of carefully 
Hypothesis categories 
• Pathobiological mechanisms: diagnosis, mechanisms 
of symptom production (Fig. 1.8) 
• Dysfunction: impairment and disability - both 
physical and psychological (Fig. 1.9) 
• The source and cause of the source of the 
symptoms (Fig. 1.10) 
• Contributing factors (Fig. 1.11) 
• Precautions and contraindications (Fig. 1.12) 
• Prognosis (Fig. 1.13) 
• Treatmentl management (Fig. 1.14) 
Decision-making models 
• Hypothetico-deductive reasoning (Fig. 1.15) 
• Pattern recognition (Fig. 1.16) 
• Lateral thinking (Fig. 1.17) 
o 
o 
� 
Torn fibres of the 
o 
o 
� 
Source 
- Common extensor origin 
- Radiohumeral, radioulnar joints 
- Radial nerve 
o 
o 
~ 
The Maitland Concept - an introduction 1 1 
Figure 1.8 Pathobiological 
mechanisms. 
- Felt something 'go' when 
throwing javelin 2 days ago 
- Sore, sickly pain outer elbow 
- Local, red, swollen, hot, tender 
o 
o 
� 
Figure 1 .9 Dysfunction: im pairment! 
o 
o 
disab i l ity. 
- Painful isometric testing 
of finger extensors 
- Elbow supination stiff and painful 
- 'Tingling' back of hand with 
ULNT 2B (Butler 2000) testing 
- Wrist extension stiff 
- Shoulder quadrant stiff 
o 
o 
� 
Figure 1 . 1 0 Source 
and cause of the source 
of symptoms. 
1 2 MAITLAND'S PERIPHERAL MANIPULATION 
c::: 
o 
o 
� 
o 
o 
� 
Figure 1.13 Prognosis. 
o 
o 
� 
o 
o 
� 
Figure 1.11 Contributing factors. 
Figure 1.12 Precautions and contra indications. 
Favourable 
o 
� 
o 
o 
� 
Possible components: 
- Patellofemoral 
- Tibiofemoral 
- Hip 
- Lumbar spine 
- Alignment faults 
- Femoral nerve 
- Footwear/Biomechanics 
o 
o 
� 
ligaments 
o 
o 
� 
o 
o 
� 
The Maitland Concept - an introduction 1 3 
Figure 1.14 Treatmentl management. 
Figure 1.15 Hypothetico-deductive 
reasoning.Anterior knee pain 
o 
o 
� 
Figure 1.16 Pattern recognition. 
o 
o 
� 
1 4 MAITLAND'S PERIPHERAL MANIPULATION 
o o 
o o 
� � 
chosen and performed treatment techniques. All relevant 
treatment/management strategies should be con­
sidered for all relevant components of the disorder. 
Recognized clinical methods of history taking and 
routine examination by physical means are used and 
are not necessarily special to the Maitland Concept. 
The universal aim of any concept of manipulative 
physiotherapy should be to identify movement dis­
orders and maximize movement potential. However, 
knowing in detail the intensity, behaviour and rela­
tionship of pain, stiffness and muscle spasm during 
the test movements is special. Such care reveals to the 
clinician the evidence of 'through-range pain', 'end-of­
range pain', 'irritability' and the var ieties of 'latent 
pain', all of which are special and fundamental to the 
use of passive movement espoused by this Concept. 
There are particular details to examination procedures 
which are special and do relate to the Concept. 
Examination, therefore, should be logical, method­
ical, comprehensive and relevant (Wells 1988). 
Subjective examination (C/O) 
The clinician should be able to 'live' the patient's symp­
toms throughout a complete cycle and 'feel' emotion­
ally what the patient is experiencing. 
The aims of the subjective examination should be to: 
• place the patient at the centre of everything that 
the clinician wishes to do 
• identify, with asterisks (Chapter 6), the kind of 
disorder, the site, nature, bel;laviour and history of 
the patient's symptoms 
• identify how the patient is affected and has been 
affected by the disorder (impairment/ disability) 
Figure 1.17 Lateral thinking. 
• establish the extent of the physical examination 
required and the desired effect of treatment based 
on the sever ity, irritability and nature of the 
symptoms and the stage of the disorder 
• identify precautions and contraindications for 
treatment 
• identify the structures at fault (the source/the 
cause of the source of the symptoms) 
• hypothesize about the mechanisms of symptom 
production (nociception, per ipheral neurogenic, 
central, autonomic, affective) 
• identify the factors contributing to the disorder 
• hypothesize about the pathology involved 
• identify clues to possible treatment techniques (e.g. 
the injuring movement, functional demonstration, 
or strategies which the patient has developed) 
• establish factors which help to make a forecast for 
a favourable or unfavourable prognosis 
• record findings in a logical methodical way. 
Table 1.1 provides a summary of the subjective exami­
nation; Box 1.2 outlines the planning of the physical 
examination (planning sheet). 
Physical examination (PIE) (Chapter 6) 
The aims of the physical examination should be to: 
• establish, with asterisks, the signs relevant to the 
patient's disorder 
• test the clinical and theoretical hypotheses 
identified in the C/O 
• analyse movements in terms of their 
range/ symptom response / quality 
• apply an appropriate amount of examination 
(shor t of symptoms, up to the onset of symptoms, 
Table 1 . 1 Su mmary of the subjective exa mination 
The Maitland Concept - an introduction 1 5 
Question 1 : Establ ish the k ind of d isorder 
Areas of symptoms Behaviour of symptoms 
Where are the symptoms? What makes the symptoms 
worse, what makes them better? 
Fi l l in a body chart 
Be aware that different 
kinds of pa in (symptoms) 
can interact together in 
associated areas 
Be aware that there could 
be overlapping areas of 
pa in (symptoms) from 
different components of 
one disorder 
The effects of rest, activity and 
position on the pain / symptoms 
Be aware that the pain (symptoms) 
can behave in many different ways. 
It is necessary to know the behaviour 
of the patient's symptoms if a 
reasonable understanding of the 
status of the disorder is to 
be determined 
to the limit of range, to the limit of range with 
overpressure added) 
• reproduce symptoms 
• find comparable signs 
• establish the source, cause of the source and 
contributing factors to the disorder 
• exclude structures not at fault 
• confirm or rule out the need for caution with 
special testing (e.g. neurological examination, 
vertebral artery testing) 
• follow a logical, methodical, comprehensive, 
relevant and integrated format 
• record in a logical methodical way 
• follow-up examination not completed at the initial 
consultation during subsequent visits (D + 1) . 
Physical examination should include the following 
(asterisk as you go along). 
Present pain Calibration of the symptoms (pain) pres­
ent before the physical examination commences. 
Observation (correct! overcorrect deformities) Alignment 
faults, protective/adaptive deformities, structural 
deformity, wasting, swelling and other signs of injury 
or disease. The effects on the symptoms/pain of 
correction or overcorrection of the deformity. 
Functional demonstration (functionally reproducing move­
ment, to P, or limit) When pain, rather than stiffness 
is the problem, the patient can quite often demonstrate 
a particular movement, activity or function that will 
reproduce the symptoms (and it is the use of this that is 
History of symptoms 
How did it start? 
When did it start? 
The history of the present 
episode of symptoms from 
onset to present 
The history of 011 past episodes 
of the symptoms from onset 
incl uding progression of 
symptoms 
Determine the stage in the 
natural history of the disorder 
Specia l questions 
Can I do harm? 
Determine all possible 
precautions and 
contra ind ications to 
manipu lative 
physiotherapy and any 
factors contributing to or 
infl uencing the resol ution 
of the disorder 
the aspect related to the Concept). Encouraging the 
patient to so demonstrate the movement, together with 
the clinician's analysis of it, is another aspect that is 
special to the Concept. Frequently the demonstrated 
movement may be used, or give an idea for the treat­
ment movement. 
Injuring movement When a comparable examination 
movement/pain response cannot be found, or when a 
sprain or injury has been the cause of the symptoms, 
re-enacting the injuring direction of the stress as an 
examination procedure may divulge the comparable 
sign. Again, such use in physical examination, which is 
routine in the Maitland Concept, is not found in other 
examination routines. 
Differentiation (including compression tests) Differentia­
tion tests are special tests that can be used when a test 
movement (active or passive), causing simultaneous 
movement of at least two joints or two movement sys­
tem structures, reproduces the patient's symptoms. 
The method is as follows: when the test movement is 
at the point in the range of reproducing the patient's 
pain, further movement is produced in one of the two 
joints or structures, which, at the same time, either 
reduces the movement in the joint or retains it at an 
unchanged degree of mechanical stress. This test, 
which increases the stress at one joint or structure and 
reduces it at another will either increase or decrease 
the reproduced pain. The test is then performed in 
the reverse manner. The pain response (i.e. increase or 
[ 
1 6 MAITLAND'S PERIPHERAL MANIPULATION 
A) REFLECTION OF THE SUBJECTIVE EXAMINATION 
(Verification that the subjective exam i nation is complete i n order to be able to start the physical exam i nation and to perform a 
reassessment of subjective parameters - 'asterisks' - in subsequent sessions.) 
1. Summary of the main information of the subjective examination : 
2. Agreed treatmentobjectives based on the findings of the subjective examination: 
3. Which subjective parameters ('asterisks') wi l l be used in subsequent sessions as part of the reassessment procedures? (Describe the 
parameters in sufficient deta i l ) : 
4. Has the subjective examination been sufficiently comprehensive to be ab le to make confident statements a nd to develop 
hypotheses with regard to precautions and contra i ndications to physical examination procedures? (Check information of 'Q1 ' , 
body chart, behaviour of symptoms, Hx, SQ): 
B) HYPOTHESES 
• Dominant neurophysiological symptom mechanisms 
List the subjective information which supports the hypotheses of the various neurophysiological symptom mechanisms: 
- Input mechanisms - nociceptive symptoms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
- Input mechanisms - peripheral neurogenic mechanisms: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . 
- Processing - central nervous system mechanisms and/or cognitive/affective/sociocultural influences: . . . . . , . . . . . , . . . " . . 
- Output mechanisms - motor and autonomic responses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . • . . . . . . . . . 
• Sources of sympto ms / i m pa irments 
List all the possible sources of a ny part of the patient's symptoms that must be examined : 
- Joints underlying the symptomatic area(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . 
- Joints referring into the symptomatic area(s): . . . . . . . . . . . . . . . . . . • . . . . . • . . . . . . . . . . . . . . . . . . . . . . . , . . . . . • . . . . • . . . . • . . . 
- Neurodynamic elements related to symptoms and dysfunction: . . . . . . . . • . . . . . . • . . . . . • . . . . . • . . . . . • . . . . • . . . . • . . . . • . . . . 
- Muscles underlying the symptomatic area(s): . . . . . . . . . . . . . . . . . . . . , . . . . . . , . . . . • , . . . . . , . . . . . • . . . . • • . . . • . . . . . . . . . . • . 
- Soft tissue structures underlying the symptomatic area(s) : . . . . . . • . . . . . . . . . . . . • . . . . . • . . . . . • . . . . . . . . . . • . . . . , . . . . . . . . . 
- Others: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . , . . . . . . • . . . . . . . . . . . • . . . . , . . . . . . . . . . . . . . . . 
• Contributing factors 
Which associated factors may be contributing/causing / mainta ining the problem and disabi l ity?: 
- Neuromusculoskeleta l : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
(a) as reasons why the joint/ muscle or other structure has become symptomatic/ as reasons why the disorder may recur 
(e.g. posture, muscle imbalance, muscle coord ination, obesity, stiffness, hypermobil ity, instabi l ity, deformity in neighbouring 
joints, etc.): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
(b) the effect of the disorder on joint stability: 
- Medical factors: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . • . . . . . . . . . . . . • . . . . . • . . . . . . . . . . . . . . . . • . . . . , . . . . . . . . . . . 
- Cognitive factors: . . . . . , . . . . . . • . . . . . . , . . . . . . , . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . , . . . . . , . . . . . • . . . . • . . . . . , . . . . • . . . . 
- Affective factors: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . 
- Behavioural factors: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . 
When do you expect to incorporate these factors in physical examination procedures (immediately/ in later sessions?). 
Specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , . . . 
• Precautions and contra i nd ications to examination procedures and treatment interventions 
- Are the symptoms severe / irritable? Yes / No 
(a) Specify your answer with examples from the subjective examination: 
(b) Is it possible that ongoing sensitivity takes place due to central nervous system sensitization or avoidance behaviour? 
Specify your answer: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
- Does the nature of the problem indicate caution? Yes/ no 
(a) Tissue pathology: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . • . . . . . • . . . . . . . . . . • . . . . • . . . . • . 
(b) Other pathological processes (e.g. osteoporosis): . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . , . . . . , , . . . . , . . . . • . . . . • . . 
The Maitland Concept - an introduction 1 7 
(c) Stages of tissue hea l ing: . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . . . . . . . . . • . . . . . . . • . . . . . 
(d) Stage of the disorder (Hx) (progressive/ regressive/ static): . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
(e) Easy to provoke exacerbation or acute episode (stabi l ity of disorder): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
(f) Confidence to move/ extreme guarding of the patient: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . • . . . . . . . . . . . . . . . . . . . . 
What are the impl ications of this answer with regard to the extent of the physical examination?: . . . . . . . . . . • . . . . . . . . . . . . • . . . . . . . 
• Management - objectives/ if treating local movement impairment - P or R 
1 . Which short-term or long-term goals of treatment are pursued?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
2. If passive mobil ization is a treatment option, do you expect to be treating pain, resistance but respecting pain, resistance or 
resistance to provoke 'bite'?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
3. Are there any precautions or contra indications which need to be respected ('nothing at the price of . . . )?: . . . . . . . . . . . . . . . . . . . 
4. What advice should be included a nd / or measures would you use to prevent / l essen recurrences and provide the patient with a 
sense of control over the symptoms?: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
C) PROCEDURES OF EXAMI N ATION 
• Anticipation of the results of exam ination procedures 
- Do you think you wi l l need to be gentle or moderately firm with your examination procedures?: . . . . . . . . . . . . . . . . . . . . . . . . . . 
- Do you expect a 'comparable sign' to be easy/hard to find? (if hard to find, 'functional demonstration tests' and 'if necessary 
tests' may be planned in