Manipulation while the patient is under anesthesia is an old, widely recognized procedure in musculoskeletal medicine. It is used for treating acute and chronic musculoskeletal conditions with significant biomechanical dysfunction unresponsive to conservative therapy. The procedure is helpful when muscle spasm and irritability preclude success without anesthetization of the patient. Safety and effectiveness are favored by appropriate selection of patients, knowledge of indications and contraindications, suitable anesthetic, and services of a qualified physician trained in structural diagnosis and manipulative technique. A team approach is recommended. To illustrate effective use of the procedure, a classic case is described.