It is hard to imagine performing daily activities without the use of our arms and hands, which together complete the kinetic chain of the upper extremity. The upper extremity assists with tasks such as lifting and carrying; however, it also functions to protect the body during collisions, falls, and injuries.

The elbow functions as the link between the powerful movement of the shoulder and the fine motor control of the hand. The shoulder positions the hand in space, while the elbow adjusts the height and length of the arm and rotates the hand into position.

Because the wrist and the hand are the most active and intricate parts of the upper extremity, they are also vulnerable to injury and do not respond well to trauma. And, in addition to performing numerous functional tasks, the hand is an important sensory organ that provides information about our surroundings such as temperature, texture, shape, and motion. Under certain circumstances, the hands and the upper extremities also assist in communication when used for things such as sign language.

Assessing and treating the elbow, forearm, wrist, and hand can be challenging because of the complexity of the joints; moreover, the sources of dysfunction in these areas can arise from myriad causes. Each component of the upper extremity must work in harmony with related components for the entire structure to function properly.

Any disruption of balance, regardless of cause, can lead to dysfunction and disability. In addition, this region is susceptible to both chronic and traumatic injuries. The elbow is second only to the shoulder as the most dislocated joint in the body, and it is second to the knee in overuse injuries. The wrist can sustain acute injuries through falls or blunt force on a hyperextended joint, and it is also subject to injuries from chronic overuse conditions.

As with the other regions of the body, it is essential for massage practitioners to have a thorough knowledge and understanding of the anatomy and physiology of the region. By taking an extensive history and conducting a thorough assessment, the therapist will be able to properly identify and treat most conditions. While this chapter is not a comprehensive study of the elbow, forearm, wrist, and hand, it does provide a general understanding of the region, its functions, and how to recognize, assess, and treat some common pathologies. In addition to reviewing the structures, this chapter discusses:

• Specific bony landmarks for palpation

• Soft tissue structures, including the muscles of the region

• The movements of the region, and basic biomechanics of the elbow, forearm, and wrist

• Manual muscle tests for the region

• Dermatome and trigger-point referral patterns for the involved muscles

• Some common causes of dysfunction and how to assess and treat them using soft tissue therapy

The hip and the knee compose an important part of the lower extremity. While constructed differently, they are interrelated and dysfunction in one can affect the other. The hip and the knee provide a stable foundation that allows the upper body and the trunk to perform activity. Since humans interact with their surroundings through bipedal locomotion, limitations in either of these regions can be devastating.

The hip's strong, bony stability helps protect it from injury. It is one of the body's two ball-and-socket joints, and it is one of the largest and most stable joints in the body. During locomotion, however, the hip can be subjected to forces that are four to seven times the body's weight, thus making the joint vulnerable to stress-related injuries (Anderson et al., 2000). While injuries to the hip are not as common as injuries to the lower extremities, the overall prevalence of hip pain in adults has increased over time (Paluska, 2005). Yet 30% of hip-related pain still remains without a clear etiology.

There are three reasons why it is difficult to determine the origin of hip pain:

1. The joint is not superficial. Pain may be felt across a broader region, making it more difficult to determine which structures are involved.

2. Hip pain is often referred from the surrounding structures, and dysfunction in the sacrum, the lumbar spine, and the groin can all refer pain into the hip.

Not surprisingly, the prevalence of hip pain depends largely on the assessment methods used, and, unfortunately, no gold standard of assessment exists.

Quite different from the hip, the knee is prone to traumatic injury because of its anatomy. It is located at the ends of the two longest bones in the body, the femur and tibia, which act as two long lever arms, exposing the joint to large torques. Because these two long bones are stacked on one another, the knee has to rely on soft tissue structures, such as ligaments and muscles, to provide stability. This intricate balance between static and dynamic structures makes the knee a complicated area to assess. All the relevant structures must be considered, including related areas that may refer pain into the knee, such as the lumbar spine, hip, and ankle.

Entire texts are written on the pathology of the hip and knee. While this chapter is not a comprehensive review of these regions, it does provide a thorough assessment of the dysfunctions and some of the more common pathologies in the regions. In addition, this chapter covers:

• Specific bony landmarks for palpation

• Soft tissue structures, including the muscles of the region

• The movements of the region, and basic biomechanics of the hip and knee

• Manual muscle tests for the hip and knee

• Dermatome and trigger-point referral patterns for the involved muscles

• Some common causes of dysfunction, and how to assess and treat them using soft tissue therapy