OMM 3 Exam 3 Study Guide PDF

Study Guide for Exam 3, OMM III Lumbar HVLA: 1. Review making a three-plane diagnosis in the lumbar spine. RTV SCAP FEST a. Sagittal plane consists of flexion-extension b. Horizontal/transverse plane consists of rotation c. Frontal/coronal plane consists of sidebending...

Study Guide for Exam 3, OMM III Lumbar HVLA: 1. Review making a three-plane diagnosis in the lumbar spine. RTV SCAP FEST a. Sagittal plane consists of flexion-extension b. Horizontal/transverse plane consists of rotation c. Frontal/coronal plane consists of sidebending 2. Review the indications and contraindications of HVLA techniques in the lumbar spine. a. Absolute contraindications: Joint instability severe osteoporosis metastasis in area receiving treatment osteoarthritis joint with ankylosis severe discogenic spondylosis with ankylosis osteomyelitis in area receiving treatment infection of tissues in the area receiving treatment joint replacement in area receiving treatment severe herniated disc with radiculopathy congenital anomalies (Klippel-Feil syndrome, blocked vertebra, Chiari malformation, absent vertebral artery) conditions such as down syndrome rheumatoid arthritis of cervical spine achondroplastic dwarfism vertebrobasilar insufficiency  b. Relative contraindications: mild to moderate strain or sprain in area receiving treatment mild osteopenia or osteoporosis in area receiving treatment osteoarthritis joints with moderate motion loss rheumatoid disease other than spine minimal disc bulge/herniation with radicular symptoms atypical joint or facet hypermobile states 3. Cite the steps to position a patient correctly for direct HVLA technique in the lumbar spine. a. Patient lies with side-bent side down for both Type 1 and Type 2 SDs (in order to induce side bending into the barrier), which means also rotational side down for Type 2. Place cephalad hand at the spinous process of the level of dysfunction to monitor sagittal motion. Flex patients knees and hips with caudad hand until you feel motion at level of dysfunction. Instruct patient to extend bottom leg and place top foot into popliteal fossa of lower leg. Switch to monitoring with caudad hand. Grasp patient’s shoulder/upper arm with cephalad hand and pull toward the ceiling to introduce rotation toward the barrier. Have the patient hold their forearms and thread your cephalad arm under their elbow with your elbow on the anterior aspect of the patient’s superior shoulder to stabilize their upper body. Switch back to monitoring with cephalad hand. Place caudad forearm over the patient’s pelvis, just lateral to SI joint. Fine tune localization by pushing the pelvis anteriorly and the shoulder posteriorly with each of your hands, causing rotation at the level of SD. Apply a thrust anteriorly and superiorly toward your navel after the patient has exhaled. Reassess. Cervicals: Classify CS and FPR technique. 1. Identify the main indications and contraindications in using CS and FPR technique. a. Counterstrain Indications: Somatic dysfunction of myofascial or articular origin. Adjunctive treatment necessary for systemic complaints with associated somatic dysfunction (ex: viscerosomatic reflex causing rib dysfunction) Contraindications: Sprained or strained tissues which would limit positioning, severe illness with positional restrictions, instability of the area being positioned, vascular or neurologic syndromes (such as basilar insufficiency or neuroforaminal compromise), severe degenerative spondylosis with local fusion where treatment positioning would normally take place b. FPR Indications: Somatic dysfunction of myofascial or articular structures Contraindications: Joint instability, vertebrobasilar insufficiency, injuries where positioning to treat would exacerbate symptoms (herniated nucleus pulposis, foraminal stenosis, severe sprains, etc) c. Main contraindications for both are lack of SD, lack of consent, and inability for pt to follow directions. 2. Know the set-up for performing FPR technique for somatic dysfunctions C1-C7. a. Typical cervicals (C2-C7): Flex or extend to find a neutral position (facets are neither fully open nor fully closed), add a compressive force to the level of the joint being treated, rotate and sidebend to the same side into the ease, maintain compressive force for 3-5 seconds, return to neutral b. Atypical cervicals (C0-C1): Flex or extend to find a neutral position (facets are neither fully open nor fully closed), add a compressive force to the level of the joint being treated, rotate and sidebend to opposite sides into the ease (OA) or just rotate into the ease (AA), maintain compressive force for 3-5 seconds, return to neutral 4. Describe the significance of and be able to perform these tests: a. Lhermitte: Patient sits in pike position on table (sitting with legs straight in front). Physician simultaneously flexes patient’s head and hip. Positive: Pain radiating down spine and both extremities b. Hoffman: Patient’s hand is held by the physician. The patient’s third distal phalanx (middle) is flexed and then flicked. Positive: Patient’s index and thumb flex toward each other c. Spurling: Patient’s head is extended, sidebent, and rotated toward the affected side. Physician applies downward compression on head of the patient. Positive: Radiating pain in same arm d. Wallenberg (Vertebral artery insufficiency): Physician passively extends then rotates the patient’s neck toward one side and holds the position 10- 30 seconds. Physician repeats test to opposite side. Positive: Dizziness, nausea, nystagmus, syncope 5. Review cervical anatomy in order to understand how the cervical spine (C0-7) moves. a. Typical cervicals (C2-7): Move in 3 planes, Type 2-like (sidebending and rotation occur in same direction) b. OA (C0-C1): Major motion is flexion/extension. Small amount of sidebending and rotation. Sidebending and rotation are coupled (movement happens @ same time). DOES NOT follow Freyette’s laws, but is referred to as having Type 1-like motion because the sagittal plane can be flexed, extended, or neutral. c. AA (C1-C2): Major motion is rotation. Small amount of flexion/extension and sidebending. Evaluated for rotation only. DOES NOT follow Freyette’s laws. 6. Counterstrain points 7. Describe the terms occiput anterior and occiput posterior. a. If the occiput is rotated RIGHT and sidebent left, the RIGHT side is called POSTERIOR occiput and the LEFT side is called ANTERIOR occiput A posterior occiput right exhibits motion restriction, tissue texture abnormalities, and tenderness on the right side Posterior occiput side exhibits restriction of extension Anterior occiput side exhibits restriction of flexion 8. Review the principles of MET and Still technique in the cervical spine and execute treatment of the same appropriately and safely. a. MET: Patient supine, physician standing at head of table, using hand on the side of the rotational component of the SD place the index finger against the articular pillar of the affected segment and the thumb against the zygoma cradle the head with the other hand under the occiput, flex/extend, rotate, and sidebend to the barrier instruct patient to rotate to the ease hold for 3-5 seconds allow patient to relax for 3-5 seconds and reposition to new barrier repeat 3-5 times until no further increase in motion when taking up slack b. Still: Place dysfunctional tissues into their position of ease and then exaggerate it a little add axial force vector through dysfunction tissues maintain vector of force as you move tissues through restrictive barrier return region being treated back to neutral Best to correct sagittal plane last 9. Describe the indications and contraindications of MET and Still technique, particularly in the cervical region. a. MET: Indications: SD  Contraindications: Fractures, neurologic signs/symptoms/abnormalities on cervical rotation, eye surgery or trauma for oculocephalogyric reflex b. Still: Indications: SD Contraindications: Absence of SD, fracture or open wound at the site of SD or in lever used to correct SD, any tubes or IV lines that might be jostled during technique, lack of consent Lymphatics: 1. Describe the indications/contraindications for the described techniques. 2. Lymphatics treatment order: a. Remove central impediments Thoracic inlet, diaphragms, myofascial restrictions (Zink’s Common Compensatory Pattern) b. Remove distal obstructions Any myofascial or joint restrictions in the extremities, esp in cases of extremity edema c. Move lymph from distal to central Lymphatic pumps (thoracic pump, pedal pump, liver/spleen pump, abdominal pump) Effleurage and petrissage 3. Pelvic Torsion Technique (to indirectly release pelvic diaphragm) (BLT) a. Physician stands at side of supine patient and contacts both ASISs with the hands, cupping them with the palms Physician compresses them toward each other and then rotates one ASIS more posteriorly and vice versa to determine ease of motion Physician rotates the innominates into their ease and maintains balanced tension until a release occurs, reassess. 4. Liver and Spleen Drainage  a. Indications: Passive congestion of liver or spleen, CHF, infectious processes, consider with liver or splenic disease as it may improve disease process by modulating blood and lymphatic fluid dynamics b. Contraindications: Fracture or dislocation in thoracic cage, trauma to liver or spleen, other internal trauma, malignancy in lymphatic system, acute hepatitis, friable hepatomegaly (ex: infectious mono) c. Treatment: Patient is supine with physician on the right side Physician’s cephalad hand is underneath the lower ribs and caudad hand is on the abdominal wall below the costal margin As the patient takes a deep breath the physician palpates the inferior border of the liver with caudad fingers, as patient exhales the physician’s fingers go over the liver and underneath the thoracic cage As the patient takes another deep breath and exhales the physician uses vibratory motion of the caudad hand on patient’s liver Repeat several times each time moving a little deeper under costal margin Same procedure on left side may be used to treat the spleen 5. Abdominal Pump a. Indications: CHF, infectious processes (ex: URI), asthma, COPD, restricted mobility of the thoracic cage and lumbar spine, hiatal hernia, upper and lower GI dysfunction b. Contraindications: Fracture or dislocation in the thoracic cage, trauma to liver or spleen, other internal trauma, recent abdominal surgery, a full stomach c. Treatment: Patient is supine Physician stands on side of patient with their palms (one or both) placed on the patient’s abdomen - fingers pointing cephalad Physician gently direct the pumping toward the respiratory diaphragm in a posteriocephalad direction (with arms extended and elbows locked at a rate of 20-30 times/minute) Patient’s acuity will determine length of time for procedure (generally 30 seconds to 2 minutes) Lower Extremity: 1. Explain the whole-body effects of an acute ankle sprain a. Ankle inverts b. Fibular head moves posterior, lateral malleolus moves anterior (this could impinge the common peroneal/fibular nerve and cause foot drop) c. Tibia externally rotates d. Femur internally rotates e. Ipsilateral innominate posteriorly rotates f. Anterior torsion of the sacrum facing the side of the ankle sprain (right ankle sprain = right on right torsion)  L5 will rotate opposite sacrum 2. Know the diagnostic criteria for all somatic dysfunctions in the lower extremity and how to treat them with MET and HVLA. a. Tibiofibular Joint Anterior distal Pt is supine with physician at feet Medial hand grasps foot maintaining ankle at 90 deg of flexion; thumb remains over lateral malleolus Thenar eminence of lateral handis places over thumb of medial hand with fingers curling around heal. Foot is externally rotated to barrier, and a sudden brief impulse is applied posteriorly to the distal fibula. Posterior distal Exact same but pt is prone and the foot is rotated internally to engage barrier. The pulse will still be directed to the floor but is anterior on the pt. b. Tibia: Internal rotation with posterolateral glide External rotation with anteromedial glide Treating is done via MET. Right hand is placed around tibial plateau with thumb on knee joint to monitor motion ○ Tibia is rotated to feather edge using left hand on the ankle. MET ensues. c. Fibular head: Fibular head moves anteriorly with pronation of the foot and posterior with supination of the foot MET or HVLA can be used to treat d. Tibia on talus: Assess dorsiflexion and plantar flexion Pt is supine for treatment → water toward pt e. Foot (LC, NM): Navicular (medial) will drop and medially rotate Cuboid (lateral) will drop and laterally rotate Cuneiforms will glide inferiorly Pt may be supine or prone for treatment. If supine, water toward you. If prone, whip it. 3. Know the indications and contraindications, and set-ups (mostly above) for MET and HVLA treatment of lower extremity SD. a. MET Indication: SD of myofascial origin, SD of articular origin to mobilize restricted joints and improve ROM Contraindications: Moderate to severe muscle strains, severe osteoporosis, Infection, hematoma, or tear in involved muscle, fracture or dislocation of involved joint, rheumatologic conditions causing instability of the joint, undiagnosed joint swelling in involved joint, positioning that compromises vasculature  b. HVLA Indications: Articular somatic dysfunction, distinct articular barrier Contraindications: Fracture, dislocation, spinal or joint instability, surgical fusion or joint replacement, inflammatory joint disease, Klippel-Feil syndrome, joint infection, osteomyelitis, bony malignancy, acute radiculopathy, severe muscle strain or sprain, osteopenia or osteoporosis, hypermobile states Upper Extremity: 1. Identify the type of radial head SD when falling anteriorly or posteriorly on an outstretched hand. (SAPP) a. Anteriorly: Distal radius displaces anteriorly because the forearm is pronated, proximal radius (radial head) displaces POSTERIORLY i. Can also cause Colles fracture of the distal radius and the distal fragment will displace POSTERIORLY b. Posteriorly: Distal radius displaces posteriorly because the forearm is in supination, proximal radius (radial head) displaces ANTERIORLY 2. Know how to diagnose a radial head SD and how to treat it with MET. a. Diagnosis: Pronate and supinate the patient’s wrist with handshake hold while palpating the radial head with the opposite hand i. If supination of wrist is easier: Anterior radial head ii. If pronation of wrist is easier: Posterior radial head 3. Know how to diagnose an olecranon SD and how to treat it with articulatory technique/HVLA. a. Diagnosis: Motion testing i. Adduction of olecranon=lateral glide ii. Abduction of olecranon=medial glide b. Treatment: i. Articulatory: Patient’s elbow slightly flexed, physician firmly grasps distal forearm (from medial aspect for adducted olecranon, from lateral aspect for abducted olecranon), physician grasps elbow (thenar eminence on lateral margin for adducted olecranon and medial margin for abducted olecranon), apply force opposite the dysfunction and slightly superior at the elbow, and opposing force at the distal forearm to engage the barrier, take arm into full extension in a sweeping motion applying the same forces above ii. HVLA: Same as above, but a fast, short thrust through barrier while straightening elbow Tissue Health Lecture: 1. Review the phases of tissue / wound healing and cite the timeline of each phase. a. Inflammation phase: ~100 hours, proinflammatory factors cause rupture of neighboring vessels -> classical intrinsic coagulation cascade and formation of fibrin clot -> infiltration of neutrophils and monocytes -> macrophage activation principally controls and regulates further wound healing  b. Granulation: Begins ~48 hours after injury, peaks 6-10 days, about 4-5 weeks duration. Dominated by macrophage, fibroblast and endothelial cell activity. Fibroblasts construct a new permanent extracellular collagen- based matrix c. Remodeling phase: ~20 weeks duration. Fibroblast begin to produce considerable amounts of glycosaminoglycans, proteoglycans, and proteins high in cysteine. By 6th week fibroblasts begin to decrease and the wound progresses from cell rich granulation tissue to normal relative hypocellularity. Can take up to 2 years 2. Understand the prolongation of a particular healing phase secondary to the extent of damage, poor nutrition, and re-injury prior to complete healing. a. Protein i. Proline and L-lysine needed for collagen production ii. L-lysine and L-methionine needed to synthesis L-carnitine iii. L-carnitine needed for fatty acid breakdown and conversion of fat to ATP b. Vitamins i. Vitamin C: essential for converting procollagen to collagen ii. Vitamin B: cofactors for cellular respiration c. Essential fatty acids i. DGLA: Prostaglandins 1 and 2 ii. Eicosapentaenoic acid: Prostaglandin 3 d. MSM: aids in formation of sulfur containing amino acids e. Stress: i. Lack of sleep: Increases inflammation and delays healing ii. Allostatic load: Magnitude of trauma, # of injuries, and perceived effects iii. Prolonged elevated corticosteroids: Promotes delayed-type hypersensitivity, suppresses gonadotropic steroid release iv. Hypermetabolic-hypercatabolic: Shift from normal metabolism v. Stress steroid hormones: Pregnenolone deficiency leads to decreased sex hormones and depression 3. Identify points of appropriate intervention with a specific type of OMT (based on physiology) within the construct of wound/injury healing. a. MET: Within first 4 hours after an injury or after 4 days b. CS: At any point during healing process c. HVLA: Within first 4 hours of after 4 days d. BLT: At any point during healing process e. Still: Within first 4 hours or after 4 days 4. Understand the significance of healing secondary injuries in a relative injury deficit state due to the overall energy expenditure of healing the primary injury site (Metabolic-Nutrition Model) a. Pts need more fat (calories) and protein for healing! If they are really ill/injured, get a dietary consult!  5. Other tidbits: Don’t pretreat with ibuprofen → increased incidence and severity of AKI in marathon runners above that of placebo a. Allows for ignorance of the body’s limits. Also, NSAIDs and corticosteroids suppress healing. Respiratory System: 1. Specify the sympathetic innervation of the upper and lower respiratory tract structures/systems. a. T1-4: Upper airway, head i. Superior cervical ganglion ii. Stellate ganglion (inferior cervical and first thoracic) b. T2-6: Bronchioles, lungs c. Superior cervical ganglion i. Fused ganglia of C2 through C4 ii. Provides postganglionic innervation to the head and neck d. Stellate ganglion i. Fusion of the inferior cervical sympathetic ganglion of T1 ii. Middle cervical and stellate ganglia innervate the heart, lungs, and bronchi 2. Specify the parasympathetic innervation of the upper and lower respiratory tract structures/systems. a. Vagus: Lungs and upper airway b. Pterygopalatine (sphenopalatine) ganglia: Sinuses, nose, lacrimal gland, and blood flow to nasal mucosa i. Also has sympathetic fibers from T1-2 3. Specify the lymphatic drainage of the upper and lower respiratory tract structures. Heart and lungs drain to the right lymphatic duct 4. Describe the effects of increased sympathetic and parasympathetic tone on the upper and lower respiratory tract structures. a. Sympathetic stimulation causes: i. Mucous glands and blood vessels are heavily innervated by sympathetic nervous system ii. Smooth muscles are not iii. Increases water secretion iv. Decreases viscosity of mucous b. Parasympathetic stimulation causes: i. Slightly constricted smooth muscle tone in the normal resting lung ii. Innervation is greater in the larger airways, and diminishes toward smaller conducting airways in the periphery iii. Bronchial glands increase synthesis of mucus glycoprotein iv. Increases viscosity of mucus 5. Identify the Chapman’s reflexes for the sinuses, middle ear, nose, pharynx, larynx, tonsils, bronchus, upper lungs, and lower lungs. a. Sinuses  i. Anterior: 3 ½ inches from the sternum, on the upper edge of the 2nd rib and in the 1st intercostal space ii. Posterior: Midway between the tip of the transverse and spinous processes of C2 on the posterior aspect of the transverse process b. Middle ear i. Anterior: Upper edge of the clavicle, just lateral to where it crosses the 1st rib ii. Posterior: Upper edge of the posterior aspect of the tip of the C1 transverse process c. Nose i. Anterior: Costochondral junction of 1st rib ii. Posterior: Lateral aspect of transverse process of C1 d. Pharynx i. Anterior: Front of 1st rib ¾ - 1 inch medial to where the clavicle crosses the first rib ii. Posterior: Midway between the spinous process and tip of the transverse process of C2, on the posterior aspect of the transverse process e. Larynx i. Anterior: Upper surface of 2nd rib, 2-3 inches lateral from the sternum ii. Posterior: Midway between the tip of the transverse process and spinous process of C2 on the posterior aspect of the transverse process f. Tonsils i. Anterior: Between 1st and 2nd ribs (1st intercostal space) close to sternum ii. Posterior: Posterior surface of the C1 transverse process, midway between the nuchal ligament and lateral most aspect of the C1 transverse process g. Bronchus i. Anterior: Between ribs 2-3, close to the sternum ii. Posterior: Midway between the tip of the transverse process and spinous process of T2 on the posterior aspect of the transverse process h. Upper Lungs i. Anterior: Between ribs 3-4, close to the sternum ii. Posterior: Intertransverse space, midway between spinous and transverse processes of the T3-T4 vertebrae i. Lower lungs i. Anterior: Between ribs 4-5, close to the sternum ii. Posterior: Intertransverse space, midway between spinous and transverse processes of the T4-T5 vertebrae 6. Describe how somatic dysfunction is created in patients with COPD. a. - Increased work of breathing creates need to use accessory muscles of respiration - Hypertrophic accessory muscles create barrel chest - Barrel chest changes the biomechanics of the thorax cage - Respiratory mechanics altered – decreased efficiency of rib motion and diaphragm motion - Decreased diaphragm motion affects lymphatics - Restricted musculature in thorax and upper cervical area creates facilitation of the sympathetics and parasympathetics 7. Explain the most common areas of somatic dysfunction in patients with chronic obstructive pulmonary disease (COPD) and asthma. a. Diaphragm: Main breathing muscle, lymphatics. Treat QLs. Psoas and diaphragm relationship. b. Thoracic inlet and accessory muscles: Assist in lymphatic drainage and breathing c. Ribs/thoracic spine/sternum: Improve motion and compliance of the thoracic cage d. OA, AA, C2: Parasympathetics via the vagus e. C3-5: Phrenic nerve f. T1-T6: Sympathetics g. Lymphatics: Remove waste h. Pelvic diaphragm i. Visceral j. Asthma specific: “Asthmatic reflex” at T3 on the left (visceral afferents from the lung follow the bronchial nutrient artery which is on the left side, need sympathetic stimulation to break bronchospasm) 8. Describe how patients with COPD and asthma benefit from OMM. a. Decreases work of breathing; resets the sympathetic and parasympathetic tone. 9. Explain the approach to a patient with COPD or asthma using each of the five osteopathic treatment models. a. COPD i. Biomechanical: Need to make diaphragm more mobile, need to improve bellows function of ribcage, need to address scalenes/1st ribs ii. Respiratory-Circulatory: Diaphragm function to improve lymphatic/immune functioning iii. Neurological: Viscerosomatics (Chapman) iv. Metabolic-Energy: Protein/calorie malnutrition is common, altered gait patterns increase energy expenditure v. Behavioral: Anxiety from air hunger, smoking cessation b. Asthma i. Biomechanical: Optimizing mechanical function of the structures involved with breathing decreases the overall workload placed on the cardiopulmonary system ii. Respiratory-Circulatory: Movement of the diaphragm important to aid in the circulatory and lymphatic flow iii. Neurological: Viscerosomatics (important for the parasympathetic and sympathetic influences on the lungs), afferent drive increases the neuroendocrine immune response - eliminating somatic dysfunction decreases afferent drive thus decreasing inflammation  iv. Metabolic-Energy: Dietary intake very important regarding food allergens as well as food additives, magnesium, vitamins B and C, inhaled steroids may affect normal flora of intestine v. Behavioral: Emotional triggers, poor outcomes in those with inadequate support systems and insufficient self care 10. Describe the relevant anatomy and physiology of the respiratory system. a. Muscles of respiration: thoracic diaphragm, intercostal muscles b. Accessory muscles: SCM, scalenes, serratus anterior, pec major and minor, lat dorsi, trapezius c. Forceful exhalation: Rectus abdominus, transverse abdominus, internal and external oblique 11. List the viscerosomatic and sympathetic levels as they apply to the respiratory system. a. Lungs (visceral pleura): T1-6 b. Trachea, bronchi: T1-6 c. Viscerosomatic reeflexes: i. Lung: T1-T6 ii. Bronchomotor reflex: T1-T3 iii. Mucosa: T2-T3 iv. Parenchyma: T3-T4 v. Parietal pleura: T1-T12 12. Explain how to treat pneumonia osteopathically. a. Chapman’s reflexes b. Upper thoracic vertebrae (T1-6) c. Sternum, ribs d. Accessory muscles of respiration e. Thoracic diaphragm f. T10-L2 and lower ribs g. Anterior cervical fascia h. OA/Vagus i. Cervical spine (sympathetic ganglia, phrenic n) j. Cranial mechanism, OM suture) Common Clinical Conditions of the Upper and Lower Extremities: 1. Correlate the divisions of the brachial plexus and the nerve roots with the muscles they supply. a. Musculocutaneous (C5-7): All muscles of anterior arm - flex elbow, supination b. Median (C5-T1): Most of anterior compartment of forearm, thenar and central (lumbricals) compartments of hand - opposition of thumb, flex MPs, extend PIP and DIP c. Ulnar (C8-T1): Anterior compartment (medial 1.5 fingers), thenar and central (interossei) compartments - flex wrist (weak) and 4th and 5th digits, flex MP, extend 4th and 5th PIPs and DIPs, adduct thumb, abduct and adduct digits 2-5 Describe the HumeroScapular Rhythm. 2:1 Ratio of Glenohumeral to Scapulothoracic Abduction: For every 2° of glenohumeral abduction, there is an associated 1° of scapulothoracic abduction i.e., to abduct shoulder to 90°, 60° of motion must come from glenohumeral joint and 30° must come from the scapulothoracic (which incorporates motion at the sternoclavicular and acromioclavicular joints)  d. Axillary (C5-C6): Deltoid - abduct shoulder 15-110 degrees, teres minor - lateral rotation of shoulder e. Radial (C5-T1): Posterior compartment of arm and forearm - extend MPs, wrist, elbow, supination 2. Specify the muscles of the rotator cuff, which one is likely to tear and why. a. Supraspinatus: Most likely to be torn because it sits between the acromion and the humeral head b. Infraspinatus c. Teres minor d. Subscapularis 3. Specify which structures contribute to which component of thoracic outlet syndrome. A group of signs and symptoms caused by compression of the brachial plexus and/or the subclavian artery Thoracic Inlet = T1, bilateral ribs 1, manubrium Five potential entrapment sites of the brachial plexus: Thoracic Outlet = ribs 7-12, xyphoid, T12, diaphragm Foramina for the cervical nerve roots Through the inter-transversarii muscles Roots forming the brachial plexus by scalenes/ribs Costoclavicular canal Under the insertion of pectoralis minor 4. Describe “double crush” syndrome, adhesive capsulitis, tennis/golfer’s elbow. a. Double crush syndrome: Impaired neural function of a single nerve where there may be a sub-threshold decrease of axoplasmic flow in one end of the nerve couple with another lesion at a distant site that further compromises axoplasmic flow. Decreased blood supply alters nerve conduction. It has been suggested that decreased nerve conduction also occurs with venous and lymphatic congestion. b. Adhesive capsulitis: Considered an inflammatory condition of the synovium, connective tissue enclosing the joint thickens and tightens. Frozen shoulder, also called adhesive capsulitis, involves stiffness and pain in the shoulder joint. Signs and symptoms typically begin slowly, then get worse. Over time, symptoms get better, usually within 1 to 3 years. c. Tennis/golfer’s elbow: Can be caused by anything with repetition and gripping, lifting with wrist and elbow extended, mouse use, racket sports i. Tennis elbow: Pain/tenderness/inflammation of the lateral epicondyle and wrist extensor tendons ii. Golfer’s elbow: Pain/tenderness/inflammation of the medial epicondyle and wrist flexor tendons 5. Specify the components of the carpal and cubital tunnels, contributing factors to and symptoms of median and ulnar nerve impingement. a. Carpal tunnel: i. Bounded by the carpal bones deeply, and the flexor retinaculum superficially ii. Contributing factors: DM, hyperthyroidism, RA, obesity, pregnancy, amyloidosis, smoking, repetitive activities (typing, hair stylist, sewing, cashier, musician, assembly line worker) iii. Most likely affects median nerve, C5-6, C8-T1 iv. Symptoms: Numbness/tingling and pain on the lateral aspect of hands and lateral 3 digits  b. Cubital tunnel: i. Extends from the medial epicondyle of the humerus to the olecranon process of the ulna. The ulnar nerve runs superficial to the ulnar collateral ligament (UCL) and deep to the aponeurotic attachment of the flexor carpi ulnaris (FCU), which is also known as Osborne's ligament ii. Contributing factors: Compression of the nerve, overuse of the arm, trauma to the medial humeral epicondyle, ganglion in Guyon’s canal iii. Most likely affects ulnar nerve, C8-T1 iv. Symptoms: Numbness/tingling and pain on the medial aspect of the hands and medial 2 digits 6. Know how to perform the various tests of upper extremity function and what they reveal. 7. Describe the Ottawa Rules for knee and ankle injuries, and Grades of Sprain injuries. a. Ottawa Ankle Rules: i. Pain in the malleolar zone AND 1. Bone tenderness at the posterior edge of the tip of the lateral or medial malleolus ii. Pain in the midfoot zone AND 1. Bone tenderness at the base of the 5th metatarsal or at the navicular iii. Pain in the malleolar zone OR midfoot zone AND 1. Inability to bear weight both immediately AND in the ED iv. Not for use in patients under 18 (growth plates still open and may be affected with injury) b. Grades of Sprain injuries: i. Grade 1: Microtears within the ligament - swelling and disability but no instability (no laxity) ii. Grade 2: Partial tear of ligament - Severe swelling over the ankle, mild instability, antalgic gait, mild ligamentous laxity, laxity noted with a good end point, decreased ROM iii. Grade 3: Complete tear - Marked loss of function and complete instability, no endpoint noted on provocative testing 8. Describe the effect of an ankle sprain on pelvic and sacral mechanics. a. Ipsilateral innominate posteriorly rotates b. Anterior torsion of the sacrum facing the side of the ankle sprain (right ankle sprain = right on right torsion) i. L5 will rotate opposite sacrum Pediatric Orthopedic Conditions: 1. Describe the techniques that are used on an infant, child, and adolescent according to their stage of development. a. Infant: BLT, Myofascial release, cranial osteopathy b. Child: Myofascial release, Still, FPR  i. Focus on: Pelvis, sacrum, SI joints, transitional areas, rib mechanics, C spine, cranial, extremities c. Adolescent: ALL 2. Explain the normal findings of tibial assessment during both flexion and extension. a. Flexion: Tibial tubercle is in line with middle of patella b. Extension: Tibial tubercle should move laterally compared to patella 3. Detail the clinical findings in a child with nursemaid’s elbow and explain how to treat it. a. Partial dislocation of the radial head usually occurring when the arm is pronated and extended - radial head isn’t fully developed and slips through annular ligament b. Treatment: Immobilize the child’s elbow and palpate region of the radial head with one hand, the other hand applied axial compression at the wrist while supinating the forearm and flexing the elbow, as the arm is manipulated a click or snap can be felt at the radial head. 4. Specify the muscles that may be involved in Osgood Schlatter’s disease and how they affect the motion of the knee joint. a. Associated with eccentric contraction of quadriceps b. Anterior hip muscles i. Shortened rectus femoris 1. Medially: can limit external rotation of tibia during knee extension 2. Laterally: can limit external rotation of tibia during knee flexion ii. Posterior innominate rotations and outflares may increase tensile forces across patella iii. Anterior innominate rotations alter tone in knee flexion and may influence knee rotation iv. Hypertonicity of the sartorius may cause external tibial rotation 5. Describe pes planus including when it is normal and abnormal in a child and how to evaluate it a. Functional flat foot: when great toe is passively extended the median arch will lift up b. Rigid flat foot: when great toe is extended the median arch remains flattened (requires further workup) c. Pes planus is normal until age 2-3 Review Questions - See powerpoint attached at bottom for additional support: 1. Sacrum, diagnosis and treatment a. Diagnosis: Lateralize with seated flexion test (or ASIS compression test), assess depth of sacral sulci and ILAs, confirm preference of flexion or extension with sphinx test or lumbar spring test i. Sphinx: if landmarks improve/become more symmetrical when patient induces backward bending, sacrum prefers flexion (test induces extension of lumbar spine)  ii. Lumbar spring: No resistance is normal. POSITIVE = lack of spring, and sacrum is stuck in extension 2. L5 rules → Unilateral extension/flexion have L5 rules? a. Forward sacral torsions occur with NEUTRAL mechanics in the lumbar spine (Type 1) b. Backward sacral torsions occur with NON-NEUTRAL mechanics in the lumbar spine (Type 2) c. In a left-on-left sacral torsion, it is expected that L5 is neutral, rotated right, sidebent left d. In a left-on-right sacral torsion, it is expected that L5 is flexed or extended, rotated right, sidebent right 3. Exhaled rib SD treatment with MET a. Patient supine, Physician at the head of the table b. Use muscle attachments to “pull” the rib up. c. Pump and bucket handle motion less important for exhaled ribs than inhaled ribs. d. Use the patient’s respiratory effort to move the rib closer to the barrier (inhalation). e. Treat uppermost rib with i. Scalenes for Ribs 1 & 2 ii. Pectoralis minor for Ribs 3-5 iii. Serratus anterior for Ribs 6-8 iv. Latissimus dorsi for Ribs 9-10 v. Quadratus Lumborum for Ribs 11-12 f. Physician uses pressure on superior edge of the posterior aspect of the affected rib to pull it down. g. Position the supine patient i. Rib 1 with hand on forehead, eyes ahead. Patient lifts head toward ceiling against your counterforce ii. Rib 2 with hand on forehead, face turned away from affected rib. Patient lifts head toward ceiling against your counterforce iii. Ribs 3-5 with arm flexed up near head. Patients moves ipsilateral elbow towards opposite ASIS against your counterforce iv. Ribs 6-8 with arm flexed 90 degrees from body. Patient pushes ipsilateral arm toward the ceiling against your counterforce v. Ribs 9-10 with arm abducted 90 degrees from body. Patient adducts ipsilateral arm to the same side against your counterforce h. Physician grasps posterior rib at the angle and directs it caudally and laterally to put it into the barrier. i. Physician places patient’s arm in correct position for isometric contraction j. Patient inhales deeply and holds breath in during isometric contraction of head or arm. k. Patient pushes for 5 seconds to activate the muscle in use. l. Patient relaxes for 2-3 seconds. m. Engage new barrier when head/arm is repositioned. n. Repeat until no further gain achieved when head/arm repositioned Ppt: OMS 2 OMM 3 Exam 3 Semester is almost over - if you need a laugh: https://www.youtube.com/watch?v=wpFQLw5_N2o Backstory → in the 70s, a group decided to make an orchestra where the only rule was you had to play an instrument you didn’t know how to play.