Osteopathic Manipulative Medicine Atf

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TABLE OF CONTENTS
1. Principles of Osteopathy
Osteopathic 2.
3.
Thoracic Region
Lumbar Region
4. Cervical Region
Manipulative 5. Innominate
Medicine
OUTLINE
1. Somatic Dysfunction
A. TART Changes
Osteopathic
B. Planes of Motion
2. Tissue Texture Changes
A. Acute Changes
Manipulative 3.
B. Chronic Changes
Viscerosomatic Reflexes
A. Autonomic Reflexes
Medicine: 4.
B. Sympathetics
E. Parasympathetics
Lymphatic Drainage
Principles of
A. Lymphatic Anatomy
B. Respiratory-Circulatory Model
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C. Lymphatic Flow
Osteopathy
5. Treatment Principles
A. Muscle Energy Technique (MET)
B. High Velocity Low Amplitude (HVLA)
C. Counterstrain (CS)
D. Myofascial Release (MFR)
E. Facilitated Positional Release (FPR)
F. Still’s Technique
G. Articulatory Technique
H. Progressive Inhibition of Neuromuscular Structures (PINS)
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Somatic Dysfunction
• TART Changes
• Tissue texture changes
• Asymmetry
• Restriction of motion
• Tenderness
• Planes of Motion:
• Sagittal: Flexion/extension, occurs around a horizontal axis
• Transverse: Rotation, occurs around a vertical axis
• Coronal: Sidebending, occurs around an AP axis
Tissue Texture Changes

• Acute changes:
• ↑ Temperature
• Tension - Rigid
• Texture - Boggy/Rough
• ↑ Skin Drag
• Tenderness - Moderate/Severe
• Erythema Test/Red Reflex - Persistent Redness
• Edema - Present
• ↑ Moisture
• Chronic Changes:
• ↓ Temperature
• Tension - Stringy/Ropy
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• Texture -Thin/Smooth
• ↓ Skin Drag
• Tenderness - Mild
• Erythema Test/Red Reflex - Fades/Blanching
• Edema - Absent
• ↓ Moisture
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Viscerosomatic Reflexes
• Autonomic Reflexes:
• Viscerosomatic Reflex: Organ pathology manifests in somatic tissue (Ex: Heart failure presents w/ T1-T5 tissue texture changes)
• Viscerovisceral Reflex: Organ pathology manifests in a different visceral organ (Ex: Abdominal Distention causes GI motility)
• Somatovisceral Reflex: Somatic issue manifests as visceral pathology (Ex: Back pain causes diarrhea)
• Somatosomatic Reflex: Somatic issue manifests as a different somatic issue (Ex: Cervical SD results in arm pain)
• Sympathetics:
• Head, Neck, Thorax, Arms:
• Head and Neck: T1-T4
• Heart: T1-T5
• Lungs: T1-T6/T2-T7 (NOT T8)
• Esophagus and arms: T2-T8
• Foregut, Midgut, Hindgut:
• Foregut (Stomach, liver, gallbladder, spleen, pancreas, proximal duodenum): T5-T9
• Midgut (Distal duodenum, jejunum, ileum, ascending colon, proximal ⅔ of transverse colon): T10-T11
• Hindgut (Distal transverse colon, descending colon, sigmoid colon, rectum): T12-L2
• Miscellaneous:
• Adrenals: T10
• Kidneys and Gonads: T10-T11
• Ureters: T10-L1
• Bladder: T11-L2
• Uterus, Cervix and Prostate: T10-L2
• Appendix: T12
• Parasympathetics:
• Head and neck: CN X (OA, AA, C1-C2) (III, VII, IX)
• Heart, lungs, esophagus, stomach, duodenum, testicles, adrenals, kidneys, proximal 2/3rds of transverse colon: CNX (OA, AA, C1-C2)
• Distal ⅓ of transverse colon until anus, uterus, cervix, lower ureters, bladder: S2-S4
Lymphatic Drainage
• Lymphatic Anatomy
• Lymphatic capillaries, afferent lymphatic vessels, lymph nodes, efferent lymphatic vessels
• Primary lymph organs: Bone marrow and thymus
• Secondary lymph organs: Lymph nodes, spleen, tonsils
• Respiratory-Circulatory Model:
• 4 diaphragms: Occipito-atlanto joint (OA), cervicothoracic (CT), thoracolumbar (TL), pelvic
• Zink Pattern
• Lymphatic Flow
• Respiration
• Muscle contraction
• ↑ Capillary filtration: Venous Hypertension, ↑ Capillary permeability
•
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OMT: Thoracic inlet, pedal pump, MFR of diaphragms, rib raising
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Treatment Principles
• Muscle Energy Technique (MET):
• Direct, active technique, used to treat somatic dysfunctions, relax hypertonic muscles
• Barrier → Freedom → Isometric contraction
• High-Velocity Low-Amplitude (HVLA):
• Direct, passive technique, used to treat somatic dysfunctions, relax hypertonic muscles
• Barrier →Thrust
• Counterstrain:
• Indirect, passive technique, used to relax hypertonic muscles and relieve pain
• Establish pain scale → Hold for 90 seconds → Bring patient to neutral
• Myofascial Release (MFR)
• Indirect or direct technique, used to ↓ tissue tension, ↑ lymphatic flow
• Engage barrier/freedom → Hold → Release
• Facilitated Positional Release (FPR):
• Indirect, passive technique, used to ↓ tissue tension, ↑ joint mobility and/or function
• Neutralize → Compress → Freedom
• Still’s Technique
• Direct, passive technique, used to ↓ tissue tension, ↑ joint mobility and/or function
• Freedom → Compression → Barrier
• Articulatory Technique
• Direct, passive technique, used to ↑ range of motion of joints
• Joint moved through range of motion —> Rhythmic repetition
• Progressive Inhibition of Neuromuscular Structures (PINS)
• Direct, passive technique, used to ↓ muscle tension
• Palpate primary tender point → Palpate insertion site of muscle → Apply inhibitory pressure to both → Repeat at different point
OUTLINE
1. Thoracic Diagnosis 5. Rib Diagnosis, Rib MET
A. General Principles A. General Principles
B. Diagnosis
Osteopathic
B. Rule of 3’s
C. Viscerosomatic Reflexes C. MET for Inhalation Dysfunction
D. Fryette’s First Law D. MET for Exhalation Dysfunction
6. Rib Counterstrain, Rib HVLA
Manipulative
E. Fryette’s Second Law
F. Fryette’s Third Law A. Anterior Counterstrain
2. Thoracic Treatment Techniques B. Posterior Counterstrain
A. MET C. HVLA
Medicine: B. HVLA
C. MFR
D. Counterstrain
Thoracic Region 3. Scoliosis
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A. General Principles
B. Classification
C. Location
D. Evaluation
E. Treatment
4. Thoracic Chapman’s Points
B. HEENT
C. Cardiovascular & Pulmonary
D. GI
E. Miscellaneous
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Thoracic Diagnosis
• General Principles:
• Rotation: More posterior (Ex: More posterior on the right = Rotated right)
• Sidebending: Prefers translation (Ex: Translates better from right to left = Sidebent right)
• Flexion/extension/neutral: More symmetric (Ex: Spine becomes more symmetric in extension = Extended)
• Spine of the scapula: T3
• Inferior angle of the scapula: T7
• Rule of 3’s:
• T1-T3, T12: Transverse process is in the same horizontal plane as the spinous process
• T4-T6, T11: Transverse process is ½ segment above the spinous process
• T7-T9, T10: Transverse process is 1 segment above the spinous process
• Viscerosomatic Reflexes:
• Head and neck: T1-T4 heart: T1-T5, lungs: T1-T7, esophagus and arms T2-T8
• Foregut (Stomach, liver, gallbladder, spleen, pancreas, proximal duodenum): T5-T9
• Fryette's First Law:
• Rotation and sidebending are OPPOSITE directions: Type 1 dysfunction
• Does not improve with flexion/extension: Neutral dysfunction
• Group curve of at least 3 vertebrae
• Ex: T2-T4 NSrRl
• Fryette’s Second Law:
• Rotation and Sidebending are the SAME direction: Type 2 dysfunction
• Does improve with flexion/extension: Non-neutral
• Can be group curve or single vertebrae
• Ex: T5 ERSr
• Fryette’s Third Law:
• Movement in 1 plane of motion affects all 3 planes
• Ex: FRrSr→ MET requires movement in 1 plane to address all freedoms
Thoracic Treatment Techniques

• Muscle Energy Technique (MET):
• Direct, active technique
• Monitor at posterior transverse process
• Isometric contraction/post isometric relaxation
• Type 1 dysfunction: Monitor at apex of curve (Ex: T4 NSrRl)
• Type 2 dysfunction: Monitor at posterior transverse process (Ex: T6 FRSr)
• High Velocity Low Amplitude (HVLA):
• Direct Technique: Opposite of diagnosis
• Perform MFR/MET/CS prior to doing HVLA
• Thrust on dysfunctional segment as patient finishes exhalation
• Contraindications: Sepsis, degenerative joint disease, disc herniation
• Myofascial Release (MFR):
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• Direct or indirect, passive technique
• Direct: Patient is placed opposite position of the diagnosis
• Indirect: Patient is placed in the same position as diagnosis
• Counterstrain
• Anterior points:
• AT1: Midline or just lateral to episternal notch, F, AT2: Midline or just lateral to the angle of Louis, F
• AT3-AT6: On sternum at corresponding costal level, F, AT7: Inferior tip of the xiphoid and/or ¼ from tip of xiphoid to umbilicus, FStRa
• AT8: Halfway from inferior tip of xiphoid to umbilicus, FStRa, AT9: ¾ from tip of xiphoid to umbilicus, FStRa
• AT10: ¼ from umbilicus to pubic symphysis, FStRa, AT11: Halfways between umbilicus and pubic symphysis, FStRa
• AT12: On Iliac crest midaxillary, FStRa
• Posterior points:
• Spinous process/Inferolateral points: PT1-PT9 ESaRa, Transverse process PT4-PT9, ESaRt
• Spinous process/Inferolateral points PT10-PT12: Inferolateral aspect of spinous process of dysfunctional segment, ESaRt (Pelvis), Ra (Torso)
• Transverse process PT10-PT12: Posterolateral aspect of transverse process of the dysfunctional segment, ESaRt (Pelvis), Ra (Torso)
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Scoliosis
• Definition: Lateral group curves of 10 or more degrees using the Cobb method of measurement
• Dextroscoliosis: Right curve
• Levoscoliosis: Left curve
• Named for side of convexity
• Apical vertebra is one that is most deviated
• Classifications:
• Reversibility: Functional vs. Structural
• Severity: Mild = 10-15°, moderate = 20-45°, severe = >50°
• Clinical: >50° can compromise respiratory, >75° can compromise cardiovascular system
• Cause: Mostly idiopathic, can also be neuromuscular (Ex: Marfan syndrome), traumatic, pathologic (Ex: Tumor)
• Location:
• Double major scoliosis: Most common, usually thoracic and lumbar
• Single thoracic scoliosis: Second most common, progressive, can affect heart and lungs
• Single lumbar scoliosis: Associated with arthritic changes
• Evaluation:
• Adam’s forward bending test: Look for rib hump
• Scoliometer: While patient is in Adam’s forward bending test
• Radiograph: Indicated if scoliometer is ≥7°
• Cobb method: Angle between the upper border of the upper vertebra and the lower borders of the lowest vertebra
• Treatment:
• Mild: OMT, exercise, education
• Moderate: Bracing + treatments above
• Severe: Surgery + treatments above
Thoracic Chapman’s Points

• Viscerosomatic reflex
• Described as a small, smooth, firm, discreetly palpable, neurolymphatic, 2-3mm nodule
• HEENT:
• Middle ear, A: Superior portion of the clavicle, P: C1 articular process,
• Sinuses, A: 1st rib, P: C2 b/w SP/TP
• Pharynx, A: Inferior aspect of SC joint, P: C2 b/w SP/TP
• Tonsils, A: 1st ICS, P: C1 b/w SP/TP
• Tongue, A: 2nd rib, P: Lamina of C2
• Larynx, A: Lateral to sternocostal junction at rib 2, P: C2 b/w SP/TP
• Cardiovascular & Pulmonary:
• Bronchi: A: 2nd ICS, P: T2 TP, AfraTafreeh.com
• Heart, A: 2nd ICS, P: T2/T3 intertransverse space
• Upper lung, A: 3rd ICS, P: T3/T4 intertransverse space
• Lower lung, A: 4th ICS, P: T4/T5 intertransverse space
• GI:
• Esophagus: A: 2nd ICS, P: T2 TP
• Stomach (Acid), A: 5th L ICS , P: T5/T6 L intertransverse space, Stomach (Peristalsis), A: 6th L ICS, P: T6/T7 L intertransverse space
• Spleen, A: 7th L ICS, P: T7 L transverse process
• Liver, A: 5th R ICS, P: T5/T7 R intertransverse space
• Gallbladder, A: 6th R ICS, P: T5/T7 R intertransverse space
• Pancreas, A: 7th R ICS, P: T7/T8 R intertransverse space
• Small intestine: A: 8th-10th ICS, P: T8-T10 TP
• Pylorus: A: Midsternal, P: T9 R TP, Appendix, A: Tip of the 12th rib, P: T11/T12 R intertransverse space
• Miscellaneous:
• Kidney, A: 1 inch superior and 1 inch lateral to the umbilicus, P: T12/L1 intertransverse space
• Gonads, A: Pubic symphysis, P: T10 transverse process, Thyroid: A: 2nd ICS, P: T2 TP
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Rib Diagnosis, Rib MET

• True ribs: Attach directly to sternum, ribs 1-7
• False ribs: Attach to sternum through costal cartilage, ribs 8-10
• Floating ribs: Do not connect to sternum anteriorly, only connect posteriorly to vertebral body, ribs 11-12
• Ribs 1-5: Pump handle motion, AP diameter increases with inhalation
• Ribs 6-10: Bucket handle motion, transverse diameter increases with inhalation
• Ribs 11-12: Caliper motion
• Diagnosis:
• Inhaled ribs: Palpate ribs as patient breathes in and out, moves more freely in inhalation, “stuck up”
• Exhaled ribs: Palpate ribs as patient breathes in and out, moves more freely in exhalation, “stuck down”
• Treatment: BITE
• MET for Inhalation Dysfunction:
• Patient is supine, then flexed to allow physician to access the posterior aspect of the rib being treated
• Physician palpates the superior surface of the dysfunctional rib
• Patient inhales and exhales deeply
• During exhalation the physician guides the rib caudad
• During inhalation the physician resists the inhalation motion
• Ribs 11-12 differences: Patient is prone, physician grasps ASIS to stabilize pelvis
• MET for Exhalation Dysfunction:
• Ribs 1-2: Patient places hand on forehead, patient pushes up, physician resists and pulls caudad on dysfunctional rib, scalene muscles
• Ribs 3-5: Patient places hand above head, patient pushes elbow up, physician resists and pulls caudad on dysfunctional rib, pectoralis minor
• Ribs 6-8: Patient reaches arm across chest, patient pushes elbow up, physician resists and pulls caudad on dysfunctional rib, serratus anterior
• Ribs 9-10: Patient sticks arm out laterally, patient lifts arm up, physician resists and pulls caudad on dysfunctional rib, latissimus dorsi
• Rib 11: Patient lays prone, physician pushes rib 11 cephalad, using ASIS as counterforce by pulling it caudad, latissimus dorsi/quadratus lumborum
• Rib 12: Patient lays prone, physician pushes rib 11 cephalad, using ASIS as counterforce by pulling it caudad, quadratus lumborum
Rib Counterstrain, Rib HVLA

• Anterior Counterstrain:
• Exhalation dysfunction, all FStRt
• AR1: Below the clavicle on the first chondrosternal articulation, utilize patient’s head and neck for motions
• AR2: On superior aspect of rib 2 midclavicular line, utilize patient’s head and neck for motions
• AR3-AR10: On dysfunctional rib, anterior axillary line, utilize patient’s legs for sidebending
• Posterior Counterstrain:
• Inhalation dysfunction
• PR1: Posterior, superior angle of rib 1 lateral to costotransverse articulation, ESaRt
• PR2-PR10: Superior aspect of the angle of the dysfunctional rib, FSaRa
• HVLA
• BITE
• Perform MFR/MET/CS prior to doing HVLA
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• Inhalation dysfunction: Patient is supine, thrust cephalad
• Exhalation dysfunction: Patient is supine, thrust caudad
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OUTLINE
1. Lumbar Diagnosis & Treatment
Osteopathic
B. MET
C. HVLA
D. Counterstrain
Manipulative
2. Lumbar Chapman’s Points
A. GI
B. GU
Medicine:
Lumbar Region
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Lumbar Diagnosis & Treatment

• Iliac crest: L4
• Type 1 and Type 2 dysfunctions
• Straight leg raise: Pt supine → Flex at hip and lift leg up → pain = + test, indicates nerve root irritation or disc herniation
• Bragard’s sign: Lower leg to just below where straight leg is + and dorsiflex ankle, pain = + test, indicates lumbosacral radiculopathy
• MET:
• Neutral: Lateral recumbent, rotated TP up → Monitor apex of curve → Flex legs until motion is felt → Pick legs up → Push down
• Extended: Lateral recumbent, rotated TP up → Flex legs until motion is felt → Turn and hug table → Legs off table → Push up
• Flexed: Lateral recumbent, rotated TP down → Flex legs until motion is felt → Straighten lower leg → Turn torso face upward → Push top leg down
• HVLA:
• Lateral recumbent, rotated TP down → Monitor at dysfunctional segment → Put top leg off the table → Rotate patients torso → Thrust w/ exhalation
•
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Neutral: Account for sidebending barrier, thrust is toward physician and caudad
• Non-Neutral: Thrust is toward physician and cephalad
• Counterstrain:
• Anterior counterstrain:
• AL1: Medial to ASIS, FStRa, pull ankles toward (Sidebending), pull knees toward (Rotates torso away)
• AL2: Medial to AIIS, FSaRt, pull ankles away (Sidebending), pull knees away (Rotates torso towards)
• AL3: Lateral to AIIS, same as AL2, AL4: Inferior to AIIS, same as AL2-AL3
• AL5: Anterior, superior aspect of pubic ramus, lateral to symphysis, FSaRa
• Posterior Counterstrain: All ESaRa, patient prone
• PL1-PL5 spinous process: On inferolateral aspect of spinous process on dysfunctional segment
• PL1-PL5 transverse process: On posterolateral aspect of transverse process on dysfunctional segment
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Lumbar Chapman’s Points

GI:
• Large intestine: A: Iliotibial band, P: L2-L4 TP
• Cecum: A: Upper ⅕ of the R lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Ascending colon: A: Middle ⅗ of the R lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Hepatic flexure: A: Lower ⅕ of the R lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Sigmoid colon: A: Upper ⅕ of the L lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Descending colon: A: Middle ⅗ of the L lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Splenic flexure: A: Lower ⅕ of the L lateral thigh, P: Triangular area b/w TP of L2, iliac crest, and TP of L4
• Rectum: A: Proximal inner thighs on lesser trochanter, P: S2, near the lower end of the sacroiliac articulation
GU:
• Kidney: A: 1 inch superior and 1 inch lateral to the umbilicus, P: T12/L1 intertransverse space
• Bladder: A: Periumbilical, P: L2 TP
• Urethra: A: Superior pubic ramus, P: L3 TP
• Broad Ligament: A: Lateral aspect of the thigh from greater trochanter to 2 inches proximal to the knee, P: B/w PSIS and and TP of L5
• Prostate: A: Lateral aspect of the thigh from greater trochanter to 2 inches proximal to the knee, P: B/w PSIS and and TP of L5
• Uterus: A: Inferior pubic ramus, P: L5 TP
OUTLINE
1. Cervical Diagnosis, MET, HVLA
Osteopathic
B. Special Tests
C. Parasympathetics
D. OA
Manipulative
E. AA
F. C2-C7
G. MET
H. HVLA
Medicine: 2. Cervical Counterstrain
A. Anterior Counterstrain
B. Posterior Counterstrain
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Cervical Diagnosis, MET, HVLA

• Landmarks:
• C2: Angle of the mandible, C3: Hyoid bone, C4: Superior aspect of thyroid cartilage, C5: Body of thyroid cartilage, C6: First cricoid ring, C7: SP
• Cervical nerves exit above corresponding vertebrae except C8 nerve root, “7 up, 8 below”
• Special Tests:
• Spurling maneuver: Seated, sidebend towards dysfunctional side → Compress → Pain = + test, indicates cervical radiculopathy
• Wallenberg test: Supine, extend and rotate neck to side → Hold → Dizziness, nausea, nystagmus = + test, indicates vertebral artery insufficiency
• Parasympathetics:
• Head and neck: CN X (OA, AA, C1-C2) (III, VII, IX)
• Heart, lungs, esophagus, stomach, duodenum, testicles, adrenals, kidneys, proximal 2/3rds of transverse colon: CNX (OA, AA, C1-C2)
• OA (Occipito-Atlanto Joint):
• Primary motion is flexion/extension, secondary motion is sidebending
• One of the osteopathic diaphragms
• Diagnosed by palpating depth of occipital sulci, deeper sulcus = Side of rotation
• Sidebending and rotation are “opposite always”, type 1 like mechanics
• AA (Atlantoaxial Joint):
• Primary motion is rotation
• Flex patient’s head until motion is isolated at AA, rotate head for direction of ease = Side of rotation
• C2-C7:
• Palpate articular pillars, more posterior = Rotation
• Translation from right to left = Right sidebending
• Type 2 mechanics
• MET:
C8 C8
• Diagnosis, FRrSl → Treatment setup, ERlSr → Patient rotates right
• HVLA
• MFR/MET/CS first
• Put patient into barrier
• OA, C2–C3 → Thrust toward opposite eye, C4–C5 → Thrust perpendicular to the cervical spine, C6–C7 → Thrust toward opposite shoulder
Cervical Counterstrain
• Anterior Counterstrain:
• AC1: On the posterior edge of the ramus of the mandible b/w earlobe and angle of the mandible, Ra
• AC2-AC6: Anterolateral tip of the anterior tubercle of the transverse process, FSaRa
• AC7: Superior surface of the clavicle at the clavicular attachment of the sternocleidomastoid, FStRa
• AC8: Medial head of the clavicle at the sternal attachment of the sternocleidomastoid, FSaRa
• Posterior Counterstrain:
• PC1 midline (Inion): Inferior nuchal line, lateral to the inion, FStRa
• PC1 lateral (Occiput): Below the nuchal line b/w inion and mastoid process, ESaRa
• PC2 midline: Superior aspect of the C2 spinous process, ESaRa
• PC2 lateral (Occiput): Inferior nuchal line at the attachment of semispinalis capitis, ESaRa
• PC3 midline: Inferolateral aspect of C2 Spinous process, FSaRa
•
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PC4-PC8 midline: Inferior aspect of the spinous process of the vertebrae above the point, ESaRa
• PC3-PC7 lateral: Posterolateral aspect of the articular process of the named point, ESaRa
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OUTLINE
1. Innominate Anatomy
Osteopathic
B. Vertebropelvic Ligaments
2. Innominate Diagnosis
A. Special Tests
Manipulative
B. Diagnosis
3. Innominate MET, HVLA
A. MET
B. HVLA
Medicine: 4. Innominate Counterstrain
A. Anterior Counterstrain
B. Posterior Counterstrain
Innominate 5. Short Leg Syndrome
B. Presentation
C. Diagnostic
D. Management
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Innominate Anatomy
General Principles:
• Innominate: Ilium + Ischium + Pubis bones
• Standing flexion test: Pt stands → Physician places thumbs below PSIS → Pt bends forward → Whichever finger moves more anterior = + side
• ASIS compression test: Pt is supine → Physician places hands on ASIS → Physician applies compressive force → More resistance = + side
• Check ASIS, PSIS, medial malleolus, b/l
Vertebropelvic Ligaments:
• Stabilize lumbosacral spine
• Sacrotuberous: Stabilizer of the SI joint, connects bony pelvis to vertebral column
• Sacrospinous: Connects ischial spine to sacrum
• Iliolumbar: Connects L5 to iliac crest
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Pelvic Special Tests

Special tests:
• Trendelenburg's sign: Pt on one leg → Pelvis drops toward unimpaired side = +, indicates gluteus medius insufficiency on side of standing leg
• Ober test: Pt lays on side→ Flex knee, abduct hip → Extend hip → Lower hip → Thigh remains abducted = +, tight IT band and tensor fascia lata
• Patrick test (FABER test): Pt supine → Flex, abduct, external rotation, and extension → Pain in Hip and/or SI joint = +, evaluates Hip and SI joint
• Thomas test: Pt supine → Flex hip joint opposite to affected side → Ipsilateral leg will flex as a reflex = +, indicates hip flexion contracture
Innominate Diagnosis
Diagnosis:
• Anterior innominate: ASIS = Inferior, PSIS = Superior, medial malleolus = Inferior, etiology: Tight quadriceps
• Posterior innominate: ASIS = Superior, PSIS = Inferior, medial malleolus = Superior, etiology, Tight hamstrings
• Superior innominate shear: ASIS = Superior, PSIS = Superior, medial malleolus = Superior, etiology: Fall on i/l buttock or missed step
• Inferior innominate shear: ASIS = Inferior, PSIS = Inferior, medial malleolus = Inferior
• Innominate inflare: ASIS is closer to the umbilicus
• Innominate outflare: ASIS is farther from the umbilicus
• Superior pubic shear: Pubic tubercle is superior, ASIS and PSIS are equal b/l, etiology: Trauma or tight rectus abdominis muscle
• Inferior pubic shear: Pubic tubercle is inferior, ASIS and PSIS are equal b/l, etiology: Trauma or tight adductors
• Pubis compression: Pubic tubercles even, painful
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Innominate Treatment: MET, HVLA

MET:
• Anteriorly rotated: Flex hip until physiologic barrier → Pt extends against resistance
• Posteriorly rotated: Extended hip until physiologic barrier → Stabilize c/l hip → Pt flexes against resistance
• Superior shear: Grasp leg above ankle/knee → Abduct and internally rotate → Pt lifts hip against resistance
• Inferior shear: Prone flex and abduct hip → Pt inhales/exhales → In inhalation physician applies cephalad force to ischial tuberosity
• Innominate inflare: Pt crosses dysfunctional LE so ankle is lateral to knee → Pt internally rotates hip against resistance
• Innominate outflare: Pt crosses dysfunctional LE so ankle is lateral to knee → Pt abducts and externally rotates against resistance
• Superior pubic shear: Extend hip until physiologic barrier → Pt flexes against resistance → Repeat
HVLA:
• Anteriorly rotated: Rotated innominate up → Top foot in bottom popliteal fossa → Rotate torso up → Top leg off table → Thrust along leg
• Posteriorly rotated: Rotated innominate up → Top foot in bottom popliteal fossa → Rotate torso up → Top leg off table → Thrust anterosuperiorly
• Superior shear: Pt supine → Grasp leg above ankle/knee → Abduct and internally rotate → Thrust inferiorly
• Inferior shear: Rotated innominate up → Monitor at SI joint → Top foot in bottom popliteal fossa → Cephalad thrust, parallel to table
Innominate Treatment: Counterstrain

Anterior Counterstrain:
• Iliacus:⅓ distance from ASIS to midline, b/l F ER
• Psoas: ⅔ distance from ASIS to midline, b/l FSt ER
• Low ilium: On superior surface of iliopectineal eminence, i/l F
• Inguinal: Lateral aspect of pubic tubercle at attachment of inguinal ligament/pectineus muscle, b/l F ADD IR
Posterior Counterstrain:
• Piriformis: Midway point between sacral ILA and greater trochanter, F ABD ER
• Upper pole L5 (UPL5): Superomedial aspect of PSIS b/w SP of L5 and PSIS, E ADD
• Lower pole L5 (LPL5): On ilium, inferior to PSIS, F IR ADD
• High ilium sacroiliac (HISI): Superolateral of PSIS, E ABD ER
• Posterior lateral lumbar 3 (PL3): ⅔ distance between PSIS and tensor fascia lata, on upper portion of gluteus medius, E ABD ER
•
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Posterior lateral lumbar 4 (PL4): Posterior margin of tensor fascia lata, on lateral portion of gluteus medius, E ABD ER
• High ilium flare out (HIFO): Lateral aspect of ILA, E ADD
• Lateral trochanteric: Inferior to crest of ilium in body of tensor fascia lata, F ABD
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Short Leg Syndrome

General Principles:
• Definition: Anatomical or functional leg length discrepancy, clinical importance is the unleveled sacral base
• Anatomical discrepancy: One leg is anatomically shorter than the other, most common cause = hip replacement
• Functional discrepancy: One leg appears shorter than the other
• Etiology: Idiopathic, traumatic (Salter-Harris fracture), congenital, functional
Presentation:
• Anteriorly rotated innominate = Functional short leg
• Posteriorly rotated innominate = Anatomical short leg
• Iliolumbar ligaments then sacroiliac ligaments become stressed on side of short leg
• Scoliosis, back pain and/or abnormal gait
Diagnostic:
• Observe: Iliac crest heights level, ASIS & PSIS b/l, ↑ lordosis of lumbar spine, orientation of knees and feet, medial malleoli, trochanters
• X-ray of spine and/or pelvis
• Lift required = Sacral base unleveling/(Duration + Compensation)
• Duration: 1-10 years = 1 point; 11-30 years = 2 points; >30 years = 3 points
• Compensation: Sidebending + Rotation of spine = 1 point; Wedging, facet size changes endplates with horizontal growths, spurring = 2 points
Management
• Treat all somatic dysfunctions prior to treating short leg
• Lift is placed on the shorter leg
• Elderly: 1/16” heel lift, increase by 1/16” every 2 weeks
• Young: 1/8“ heel lift, increase by 1/8“ every 2 weeks
• Maximum lift possible is ½ inch
• Surgery
References
• Body planes.jpg
• https://commons.wikimedia.org/wiki/File:BodyPlanes.jpg
• National Cancer Institute, Public domain, via Wikimedia Commons
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References
• Scoliosis (15-year old).jpg
• https://commons.wikimedia.org/wiki/File:Scoliosis_(15-year-old).jpg
• JanDerChemiker, CC BY-SA 3.0, via Wikimedia Commons
References
• Rib anatomy
• https://commons.wikimedia.org/wiki/File:Rib_anatomy.png
• Derivative work: TheRibinator, CC0, via Wikimedia Commons
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References
• Cervical Spine Computer Generated Labeled.jpg
• <a href="https://commons.wikimedia.org/wiki/File:Cervical_Spine_Computer_Generated_Labeled.png >DrJanaOfficial</a>, <a href=
https://creativecommons.org/licenses/by-sa/4.0 CC BY-SA 4.0</a>, via Wikimedia Commons
References
• Innominate Anatomy
• <a href="https://commons.wikimedia.org/wiki/File:Figure_38_01_12.jpg >CNX OpenStax</a>, <a
href="https://creativecommons.org/licenses/by/4.0 >CC BY 4.0</a>, via Wikimedia Commons
• PSIS
• <a href="https://commons.wikimedia.org/wiki/File:PSIS_03_posterior_view.png >BodyParts3D is made by DBCLS</a>, <a
href="https://creativecommons.org/licenses/by-sa/2.1/jp/deed.en >CC BY-SA 2.1 JP</a>, via Wikimedia Commons
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References
• Trendelenburg Sign
• <a href="https://commons.wikimedia.org/wiki/File:Trendelenburg_gait.jpg ">S. Bhimji</a>, <a href="https://creativecommons.org/licenses/by/4.0
">CC BY 4.0</a>, via Wikimedia Commons

Osteopathic Manipulative Medicine Atf

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Osteopathic Manipulative Medicine Atf

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AfraTafreeh.

Tissue Texture Changes

Thoracic Treatment Techniques

Thoracic Chapman’s Points

Rib Diagnosis, Rib MET

Rib Counterstrain, Rib HVLA

Lumbar Diagnosis & Treatment

Lumbar Chapman’s Points

Cervical Diagnosis, MET, HVLA

Pelvic Special Tests

Innominate Treatment: MET, HVLA

Innominate Treatment: Counterstrain

Short Leg Syndrome

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