OPP REVIEW

May 1, 2015
The Class of 2017
NSU-COM
 Somatic Dysfunction
Impaired or altered function of ANY part
of the soma -- skeletal, myofascial, and
related vascular, lymphatic, and neural
elements
Diagnosed via PALPATION - restricted
vs. freedom of motion
Somatic dysfunctions are always named
from the FREEDOM (ease) of motion!
 Diagnosis of Somatic
Dysfunctions
T. -- tenderness
A. – asymmetry (a static finding)
R. -- restricted range of motion
(a dynamic finding)
T. -- tissue texture changes
… or S.T.A.R. ( S. is for
sensitivity)
 Somatic Dysfunction
Acute Chronic
immediate long standing
vasodilation fibrosis
edema “itchiness”
increased skin cool (decreased
moisture temperature)
heat/redness *ropy tissue (can be
rough texture acute as well)
swelling dryness
“boggy” tissue thin texture
stringiness
Barriers to Motion
Anatomic Barrier
the limit of motion imposed by anatomic
structure (limit of passive motion)
Physiologic Barrier
the limit of active motion
Restrictive Barrier
the functional limit within the anatomic and
physiologic range of motion which
abnormally diminishes the normal
physiologic range of motion
Pathologic barrier
Permanent restriction of joint motion
associated with pathologic changes of
tissues (e.g. osteophytes, contracture)
 Type I vs. Type II
Type I: Type II:
neutral hyperflexion/
long restrictors hyperextension
several segments (3 short restrictors
or more) 1-2 segments
sidebending/rotation sidebending/rotation
opposite to the same side
rotation into the rotation into the
convexity of the concavity
curve traumatic
postural
 3rd Law of Physiologic
Motion
Inducing motion in one plane reduces or
modifies the motion in the other two planes

Other pearls:
FRS and ERS terminology
FRS left (FRSL)
– Flexed, rotated and sidebent left
ERS right (ERSR)
– Extended, rotated and sidebent right
 Autonomics
Sympathetics: T1-L2
Parasympathetics: CN III, VII, IX, X
and S2-4
 ANS techniques
OA decompression – normalizes vagal
tone
Sacral rocking – increases
parasympathetics
Sacral inhibition – decreases
parasympathetics
Rib raising – increases sympathetics
(typically less than 90 sec)
Paraspinal inhibition – decreases
sympathetics
 Osteopathic Planes of
Motion
Motion: Plane:
Rotation Horizontal
(transverse)
Sidebending Coronal
(frontal)
Flexion/extension Sagittal
 Vertebral Unit
Two (2) vertebral segments and their
spinal and extraspinal articulations, and
the intervertebral disc
Motion of a vertebra is named from the
motion of the upper vertebra in relation
to the one below
 Naming S.D.
“ T7 rotated right” means T7 is rotated
right in relation to T8.
Rotation is named from a point on the
anterior/superior surface of a vertebral
body.**
 Techniques
Direct
toward the barrier
the barrier is “engaged”
Indirect
away from the barrier
the barrier is “disengaged” and moved to a
point of balance (new neutral position)
Barriers to Motion
 Techniques
Passive treatment
A technique in which the patient refrains
from voluntary muscle contraction
Active treatment
A technique in which the patient performs
voluntary muscle contraction
Direct Techniques Indirect Techniques
HVLA Counterstrain
Muscle Energy Myofascial Release
Articulatory Cranial
Springing Facilitated Positional
LVMA Release
Cranial Still
Myofascial Release LAS/BLT
Still Functional
Soft Tissue
 LVMA
Low velocity/moderate amplitude
Also known as articulatory techniques
Rib raising
Greater than 90 seconds will decrease
sympathetic activity
Less than 90 seconds will increase sympathetic
activity
Spencer techniques (for the shoulder) can be
LVMA as well as Muscle Energy
 Functional Technique
Using palpatory information gained from
assessing all planes of motion around a
segment or dysfunction looking for ease
and restriction at that dysfunction
Diagnosis is made by assessing for all
planes of “ease” including what the
tissues feel with respiration
Physician needs continuous feedback of
the response to motion
 Functional Technique
continued
An indirect method of treatment
Looking for the “ease” (compliance) of
the tissues vs. the “bind” (resistance) of
the tissues
 Soft Tissue
Effleurage
Stroking movement to move fluids
Pettrisage
Deep kneading or squeezing to express
swelling
Tapotement
Striking the belly of a muscle to increase it’s
tone/arterial perfusion
 Soft Tissue
Need to monitor response to tissues for
length of use
Aids in circulation/movement of fluids
Relief of muscle spasm
NO specific joint correction
Mostly a direct treatment
Galbreath’s technique
AKA :Mandibular drainage
To increase drainage of middle ear
structures via eustachian tube
Good for children with otitis media
 Muscle Energy
Pt. uses his/her muscles on request
from a certain controlled position
To test, we perform the opposite
function of the muscle
The patient will then perform the
function of the muscle
Mechanism via the Golgi tendon reflex
Isometric
change in muscle tension without
approximation of origin/insertion
Isotonic
approximation of origin/insertion without a
change in muscle tension
Isolytic
contracture of muscle with forced
lengthening
Concentric contraction
Contraction where the origin and insertion
of a muscle approximate
Eccentric contraction
Contraction where the origin and insertion
of a muscle separate or lengthen
Isokinetic contraction
Contraction of the muscle at a constant,
controlled speed
Reciprocal Inhibition
Goal: To lengthen a contracted muscle
due to spasm
When a gentle contraction is initiated in
the agonist muscle, there is a reflex
relaxation in the muscle’s antagonistic
group
 Muscle energy
Contraindications
Muscle tear
Fracture
Severely ill (ICU or post-surgical pts.)
 Counterstrain
Find tenderpoint
Position of comfort (75-100%)
Hold for 90 sec. (120 sec. for ribs)
Slow, passive return to neutral
Recheck tenderpoint
**Remember-- ant. points usually treated with
flexion; post. points usually treated with
extension
**The further from the midline a tenderpoint is,
the more sidebending and/or rotation is needed
Counterstrain continued..

?? Cervicals, lumbars commonly

asked??
Anterior cervicals : flex, rotate away, and
sidebend away (FSARA) – on TP’s
Posterior cervicals: ESARA - on SP’s
Anterior L5 – just lateral to pubic
symphysis
 Cranial

Sphenobasilar synchondrosis (SBS) -

key articulation for all cranial motion
Cranial Flexion - SBS rises, sacrum
moves posterior/superior **
Cranial Extension - SBS falls, sacrum
moves anterior/inferior **
Cranial continued..
Inhalation
midline bones flex, paired bones externally rotate
Exhalation
midline bones extend, paired bones internally
rotate
Midline bones: occiput, vomer, ethmoid,
sphenoid, sacrum
Paired bones: temporal, parietal, palatine,
zygoma, (frontal considered embryologically
as a paired bone)
 Primary Respiratory
Mechanism
Inherent motility of the CNS
Fluctuation of the CSF
Mobility of the interspinal and
intracranial membranes
Articular mobility of the cranial bones
Mobility of the sacrum between the ilia
 Cranial
CRI = 10-14 cycles per minute
Things that increase CRI:
Infection, fever, physical exercise
Things that decrease CRI:
Stress, depression, chronic fatigue
 Vault Hold
Little finger : occiput
Index finger: sphenoid
3rd and 4th fingers: in front of and
behind ear
Cranial continued..
Flexion will increase the transverse
diameter of the skull
Extension will increase the A-P
diameter of the skull
Reciprocal Tension Membrane = dura
Falx cerebri, tentorium cerebelli, falx
cerebelli, spinal dura
Know axes for all strain patterns, and
how to name them!
 Cranial axes
Flexion/extension
2 transverse axes
Named by the motion at the SBS or the angle of
occiput/sphenoid
Torsions
One A-P axis
Named by the greater wing of the sphenoid
Sidebending/rotation
2 vertical axes, and one A-P axis
Named by the side of the convexity
Cranial patterns continued..
Vertical strain
2 transverse axes
Named by the motion at the base of the
sphenoid
Lateral strain
2 vertical axes
Named by the motion at the base of the
sphenoid
** gives the classic parallelogram head
 Motions – what you feel
Flexion – hands go toward patient’s feet
Extension – hands go toward you (cranially)
Torsions – left torsion : left index finger goes
superior; right torsion: right index finger goes
superior
Sidebending-rotations – left SBR: left hand
gets fuller and moves down toward patient’s
feet; right SBR: right hand gets fuller and
moves down toward patient’s feet
Vertical strains – superior vertical strain: both
index fingers move inferiorly and both little
fingers move superiorly; inferior vertical
strain: both index fingers move superiorly and
both little fingers move inferiorly

Lateral strains – left lateral strain: both index

fingers move to the right and little fingers
move to the left; right lateral strain: both index
fingers move to the left and little fingers move
to the right (**parallelogram head)

SBS compression – no or little motion of all

fingers
Cranial Strain Patterns - MOA
SBS compression – hit either directly in
front of head or behind head
Sidebending-Rotation – hit directly on
side of head at level of SBS
Torsion – hit on outer head quadrants
from above or below
Lateral strain – hit on side of head in
front of/or behind SBS
Vertical strain – hit on top of or below
head in front of/or behind SBS
 Cranial extras..
Tinnitus = treat temporals
Anosmia = treat ethmoid
Temporal bone dysfunction can cause
problems with
– Glossopharyngeal CN
– Vagus CN
– Accessory CN
Baby with sucking/swallowing difficulties
Treat cranially by decompression of
occipital condyles
Temporal bones most commonly
internally rotated when in dysfunction
mastoids move more laterally
A patient with high pitched ringing in
the ears = internally rotated temporal
bone
A patient with low pitched ringing in the
ears = externally rotated temporal bone
Contraindications to cranial:
Intracranial bleed
Skull fracture/trauma
Increased intracranial pressure
 Cranial Techniques
CV 4 – increases CRI amplitude
V –spread – for releasing a peripheral suture
(e.g.. If patient has a pinpoint headache)
***O-M suture release
Parietal lift – pain at top of head
Frontal lift – frontal headache, sinus pain
Venous sinus technique – to drain venous
sinuses; good for a hard, rigid head
 HVLA
Contraindications
Absolute:
– Metastasis
– Fracture
– Rheumatoid (AA), and Down’s syndrome (AA)
Relative:
– Rheumatoid arthritis
– Osteoarthritis
– Osteoporosis
– Disc herniation
 Facet Orientation
Cervicals -- BUM
Thoracics -- BUL
Lumbars – BM

–Remember, these are how the

superior articular facets are
positioned
 Cervical Spine
OA = flexion/extension
AA = rotation (50%)
Lower cervicals = main motion is sidebending
Sidebending increases as you go down the
cervical spine
Rotation increases as you go up the cervical
spine
C2-C7 - coupled motion of rot/SB due to facet
joints
 C - Spine continued..
No disc between occiput and C1, or C1
and C2
Atlas = no body
Axis = odontoid process
Bifid spinous processes
**Uncovertebral joints (of Luschka) --
osteophyte formation
lateral portion of vertebral bodies
Uncovertebral Joint – Joint of Luschka
 Ligaments
Posterior Longitudinal -- prevents
hyperflexion
Anterior Longitudinal -- prevents
hyperextension
 C - spine continued..
OA joint -- not pure Type I or II
translation left = rotated left, sidebent right
flexion/extension or neutral component
chin deviates left = rotated left, sidebent
right
posterior left occiput = rotated left, sidebent
right
AA -- check rotation by fully flexing neck
C2-7 -- coupled motion of rot/SB
 C - Spine continued..
Diagnosis via articular pillars
Translating a cervical vertebra
translating to the left = inducing right
sidebending at that level
translating to the right = inducing left
sidebending at that level
Pure A-A diagnosis alone = rotation
only! (Treatment of A-A alone = rotation
only, too!)
Oculocephalogyric Reflex
Eye movements reflexively affect the
cervical musculature as the body
attempts to follow the lead provided by
eye motion
So, if you want the patient to push his/her
heard to the left, have the patient first
look to the left. This will cause the start of
a contraction of the muscles on that side.
Example: C3 F RL SL. The physician will
rotate and sidebend patient’s head to the
right. The patient will look to the left.
Spurling test
Tests for nerve root impingement in neural
foramina
Most common cervical disc C5-6
Wallenberg test/DeKlyne’s test
Tests for vertebral artery insufficiency
Rotating head to left will test right vertebral
artery and visa versa
 Thoracic Spine
Least mobile area of spine
Landmarks:

T3 = spine of scapula
7th rib = inferior angle of scapula
T2 = jugular notch
T4 = angle of Louis
Rib 2 = angle of Louis
T4 = nipple dermatome
T10 = umbilicus
 Rules of Three
T1-3
spinous process horizontal - at level of
transverse process
T4-6
spinous process halfway between
transverse processes
T7-9
spinous process at level of transverse
process below
T10
like T7-9
T11
like T4-6
T12
like T1-3
Diagnosis of Thoracic/Lumbar
Dysfunctions
Prominent (shallow) TP = vertebral
rotation
Spinous process close to segment
above = flexed dysfunction
Spinous process close to segment
below = extended dysfunction
 Scoliosis
Named for the convexity of the curve
Many times have 2 scoliotic curves (double
major)
scapula more prominent on convex side (rib
hump)
Convex side = vertebral rotation
treat apex of curve 1st
more common in women
Dx with Cobb Angle
5-15 degrees – mild
20-45 degrees – moderate
> 50 degress - severe
“Rotoscoliosis”
Term used to describe Type I curve –
rotation and sidebending of a group
(opposite directions)
Dextroscoliosis = right scoliosis
Levoscoliosis = left scoliosis
 Motions of the Thoracic
Spine
Rotation is greatest
Extension is the least

Rotation Sidebending Flexion

Extension
 Ribs
True
Ribs 1-7
False
Ribs 8-12
Typical
Ribs 3-10
Atypical
Ribs 1, 2, 11-12
 Ribs continued..
Pump handle ribs
increase A-P diameter of thorax
rotate around a transverse axis
ribs 1-5
Bucket handle ribs
increase transverse diameter of thorax
Rotate around an antero-posterior (A-P) axis
ribs 6-10
Caliper
no sternal attachment
ribs 11-12
exhalation restriction
inhalation SD
inhalation rib ** Treat most inferior rib
elevated rib

inhalation restriction
exhalation SD
exhalation rib
** Treat most superior rib
depressed rib
Muscles used for Inhalation
Restricted Ribs
Rib 1 Ant./Middle Scalenes
Rib 2 Post. Scalene
Ribs 3-5 Pectoralis minor
Ribs 6-10 Serratus Anterior
Ribs 11-12 Latissimus Dorsi
or Quadratus
Lumborum
 Bony Attachments of
Thoracoabdominal Diaphragm
Lower 6 ribs
L1-3 right
L1-2 left
xiphoid process

Thoracic pump techniques will increase

the negative intrathoracic pressure of
the thorax!
 Lumbar Spine
Major motion is flexion/extension
Batwing deformity
seen in sacralization of L5

Ferguson’s Angle (Lumbosacral Angle)

is increased in any lumbar lordosis
Spondylolysis
pars interarticularis defect
Spondylolisthesis
forward slipping of one vertebra
on another
Grading I - IV
Heel-toe walk
walking on heels – tests L5 nerve rt. (L4-L5
disc)
walking on toes – tests S1 nerve rt. (L5-S1
disc)
 Alternate Lumbar Spine
Muscle Energy
For Type II lumbars:
F.D.R. - for flexed dysfunctions, vertebral
rotation (post. TP) down toward table,
patient in lateral recumbent position
S.U.E. – for extension dysfunctions,
vertebral rotation (post. TP) up to ceiling,
patient in Sim’s position, hugging the table
 Skin Drag
The skin superficial to a somatic
dysfunction will move in the same
direction as the dysfunction, and will
“drag” opposite to it.
Example: inhaled left 2nd rib, pump
handle
The skin will move freely superiorly, and
the skin will “drag” inferiorly on top of the
left 2nd rib
 Hip
FABERE test - hip vs. SI joint
Hip drop test - lumbar sidebending
(higher hip = lumbar sidebending to that
side)
Standing and Seated Flexion tests
Standing tells which side the problem is on
Seated eliminates the lower
extremity/innominates, therefore tests
sacrum
+ standing = iliosacral (innominate dysf.)
+ seated = sacroiliac (sacral dysf.)
Ober test
For iliotibial band contraction
Trendelenberg test
For gluteus medius weakness
Trendelenberg test

For gluteus medius

weakness
Hip - Angle of Inclination
Formed by shaft and neck of femur
Measured in frontal plane
approx. 120-135 degrees
higher in females
Greater than 135 degrees = coxa valga
Less than 120 degrees = coxa vara
 Psoas Syndrome
Unilateral -- sidebending to contracted
side
Pelvic sideshift opposite the contracture
will lead to opposite piriformis contracture
and sciatica
Usually L1 or L2 is in somatic
dysfunction (L1 or L2 is F RxSx) – this is
the “key” dysfunction in psoas syndrome
The rest of the lumbars below will sidebend
to the side of the psoas and rotate away
(type I curve)
Bilateral -- flexed forward when
standing; will increase lumbar lordosis
when patient is lying supine
Thomas test – to test for psoas
contracture
 Piriformis Syndrome
Pain in middle of buttocks
Paresthesias in sciatic-type distribution
Leg and foot externally rotated and
abducted; leg resists internal rotation
and adduction
Right piriformis hypertonicity will cause
a L on L forward torsion and Left
piriformis will cause a R on R torsion
 Innominates
Diagnosis
Standing flexion test
–Tells you which side the dysfunction in
on
AP Compression Test (Pelvic rock)
–Will be positive on dysfunctional side
Landmarks
–ASIS and PSIS
 Diagnosis
ASIS and PSIS both superior =
superior shear
ASIS and PSIS both inferior =
inferior shear
ASIS closer to midline/PSIS
further = inflared
ASIS further from midline/PSIS
closer = outflared
 Dx. continued
ASIS superior/PSIS inferior =
posterior rotation
ASIS inferior/PSIS superior =
anterior rotation
 Innominates
Posterior innominate rotation will cause
an apparent deep sacral sulcus on that
side
Anterior innominate rotation will cause
an apparent shallow sacral sulcus on
that side
 Muscles used in treatment
of Innominate Dysfunctions
Anterior rotation
Patient contracts their hip extensors (hamstrings)
Posterior rotation
Patient contracts their hip flexors (psoas and
quads)
Inflared innominate
Patient contracts their adductors
Ouflared innominate
Patient contracts their abductors and piriformis
 Pubes
Superior
Inferior
Abducted - pubic gapping
**Seen post-partum
Adducted - pubic compression
 The Sacrum

Everything happens at S2!

Nutation – sacral base moves anterior
Counternutation – sacral base moves
posterior
Sacral Axes
 Sacrum
Seated flexion test
Torsions:
– Positive on opposite side of axis
Unilaterals:
– Positive on same side as the dysfunction
Bilaterals:
– Bilaterally negative
 Sacrum tests
Lumbosacral spring test
A “+” test (no spring) indicates that a
portion of the sacral base has moved
posterior

A “-” test (does spring) indicates that a

portion of the sacral base has moved
anterior
Backward bending test (Sphinx test)
If findings worsen (become more
asymmetric), then the sacral base is
posterior (+ sphinx test)
If findings improve (become less
asymmetric), then the sacral base is
anterior (neg. sphinx test)
 Sacrum
Torsions
L5 rotates OPPOSITE sacral rotation.
Forward torsions induce L5 to be in neutral
Backward torsions induce L5 to flex or
extend! **
Unilateral Shears (unilateral
flexion/extension)
Bilateral Flexion/Extension
 Sacrum
Torsions
Forward: sulcus deep on one side, ILA
posterior on the opposite side
Backward: sulcus shallow on one side, ILA
anterior on the opposite side
M.E. treatment : place patient on side of
axis
 Sacrum
Unilateral dysfunctions
Flexions: deep sulcus and inferior ILA on
the same side
Extensions: shallow sulcus and superior
ILA on the same side
Deep sulcus right, ILA posterior left, +
SeFT (L), + spring test, + sphinx test
Dysfunction?

Deep sulcus right, ILA inferior right,

+ SeFT (L), + spring test, + sphinx test
Dysfunction?
Deep sulcus left, ILA inferior left, +
SeFT (L), - spring test, - sphinx test
Dysfunction?

Deep sulcus left, ILA posterior right, +

SeFT (L), - spring test, - sphinx test
Dysfunction?
Deep sulcus left, ILA posterior right, +
SeFT ®, + spring test, + sphinx test
Dysfunction?

Deep sulcus right, ILA posterior left, +

SeFT ®, - spring test, - sphinx test
Dysfunction?
 Sacrum continued..

Both ILA’s posterior

Both sulci deep Bilateral Sacral
Neg. spring test Flexion

Both ILA’s anterior

Bilateral
Both sulci shallow Sacral
Positive spring test Extension
Sequence of Treatment
General rules:
Treat acute somatic dysfunctions last
Treat from center of the body outward
Treat thoracics prior to treating cervicals or
ribs
Treat the spine before treating the
extremities
Open thoracic inlet (cervico-thoracic
junction) prior to any lymph techniques
 Walking Cycle
Normal walking cycle
2 phases:
–Stance phase – when foot is planted on
ground
60 %
–Swing phase – when foot moves forward
40%
Patient starts to walk forward by moving right
foot out first.
Trunk rotation in thoracic area to left.
Weight shifts to left leg.
Sacrum rotates left on left oblique axis; L5
rotates right.
Right innominate moves posterior to anterior
as right heel strikes.
Trunk rotation then shifts to right as left leg
moves forward.
 Shoulder
Be sure to know rotator cuff muscles,
and which one is most commonly
injured
Supraspinatus ** most commonly injured
Infraspinatus
Teres Minor
Subscapularis

Weakness in abduction and external

rotation with RC tear
 Shoulder
Know 7 stages of Spencer
Extension, Flexion, Circumduction
without traction, Circumduction with
traction, Abduction/Adduction, Int.
Rotation, Abduction with pumping
Articulatory (LVMA) or muscle energy **
Good for adhesive capsulitis (frozen
shoulder), and improving ROM (not for
acutely inflamed joints)
 Tests
Arm drop/Empty can test- rotator cuff injury
Yergason’s – bicep’s tendonitis
Bicep’s or Speed’s – bicep’s tendonitis
Apprehension – chronic shoulder
dislocation
Adson’s – TOS (scalenes)
Hyperabduction – TOS (pect. minor)
Costoclavicular – TOS (1st rib and clavicle)
Apley’s scratch tests – evaluates shoulder motion
Neer’ sign, Hawkins-Kennedy – impingement
syndrome
Winging of scapula:
SALT : serratus anterior, long thoracic
nerve
Shoulder dislocations -- most common
anterior/inferior
Scapulo-humeral rhythm:
2:1 glenohumeral joint/scapula
for every 15 degrees of shoulder abduction, 10
degrees is glenohumeral, and 5 degrees is
scapular rotation
 Causes of T.O.S.
Cervical Rib
Anterior Scalenes = Adson’s Test
Pect. Minor = Hyperabduction Test
1st rib and Clavicle = Costoclavicular
Test
Symptoms: pain down arm (positional),
decreased pulses, paresthesias down
arm
 Clavicle
The only bony attachment of the upper
extremity to the axial skeleton
Test abduction/adduction with shoulder
shrug
Test anterior/posterior (horizontal
flexion/extension) with rowing/reaching
motion
Abduction/adduction and
flexion/extension named for what
happens at distal end of the clavicle.
 Elbow
Carrying angle
10-15 degrees in females
5 degrees in males
Cubitus valgus = increased carrying angle
Cubitus varus = decreased carrying angle

Reflexes
C5 - biceps
C6 - brachioradialis
C7 - triceps
 Elbow continued..
Radial Head
posterior -- restricted in supination
anterior -- restricted in pronation
Nursemaid’s elbow -- subluxation of radial
head
Partial dislocation of radial head from annular lig.
Tennis elbow = lateral epicondylitis (pain with
wrist extension)
Golfer’s/little leaguer's elbow = medial
epicondylitis (pain with wrist flexion)
Humeroulnar somatic dysfunctions
Ulnar ABduction – increased carrying
angle
– Olecranon glides medially, and will not glide
laterally

Ulnar ADduction – decreased carrying

angle
– Olecranon glides laterally, and will not glide
medially
Abducted/Adducted Ulna
named for the distal ulna position

wrist
Is
opposite
direction
of
distal ulna
 Hand/Wrist
Carpal Tunnel Syndrome:
Phalen’s test
Tinel’s test
Allen test
To test patency of radial and ulnar arteries
 Hand
DeQuervain’s tenosynovitis
+ Finkelstein test
Dupuytren’s contracture
Flexion contracture of MCP/PIP of ring and little
finger
Boutonniere deformity
Seen in RA – Flexion of PIP/extension of DIP
Swan neck deformity
Seen in RA – extension of PIP/flexion of DIP
Herberden’s nodes
DIP joint osteophyte – seen in OA
Bouchard’s nodes
PIP joint osteophyte – seen in OA
 Wrist biomechanics
Wrist flexion = carpals glide dorsally
Wrist extension = carpals glide volarly
 Wrist trauma
Most common wrist fracture
Scaphoid fracture (pain at anatomic
snuffbox)

Most common carpal dislocation

Lunate
 “Glide”
The term “glide” refers to the freedom of
motion in a joint.
Examples:
fibular head has an anterolateral glide
means that the fibular head moves easier
anterolaterally
radial head has a posterior glide means
that the radial head moves easier
posteriorly
 Knee
Pes Anserine – “say grace before tea”
Sartorius
Gracilis
SemiTendinosus
Knee most stable in extension
Terrible triad : MCL, ACL, lateral
meniscus
 Knee Tests
Cruciates
Drawer, Lachman
Meniscus
McMurray, Apley’s compression
Collaterals
Apley’s distraction, valgus/varus tests
Inflammation
Ballottement, Bulge sign, Bounce home
Patellar grind test
Patello-femoral syndrome
 Fibular Head
Motion is anterolateral and
posteromedial
Supination of foot = post. fibular head
Pronation of foot = ant. fibular head
Muscle energy tx. : If fibular head is
posterior, then dorsiflex and evert foot; if
fibular head is anterior, then plantar flex
and invert foot.
Fibular head dysfunction can cause
peroneal nerve impingement at the
knee **
Q- angle
Increased in:
Genu valgum
Coxa vara
Decreased in:
Genu varum
Coxa valga
 Foot and Ankle
Arches
Med. Longitudinal : talus, calcaneous,
navicular, 1st 3 cuneiforms, 1st 3
metatarsals
Lat. Longitudinal: calcaneous, cuboid, 4th
and 5th metatarsals
Transverse: cuboid, navicular, 3
cuneiforms
 Definitions
• Pronation of the foot =
Eversion, dorsiflexion, abduction
– This causes talus to glide anteromedially

• Supination of the foot =

Inversion, plantar flexion, adduction
– This causes talus to glide posterolaterally
 Foot continued..
Morton’s syndrome -- short 1st
metatarsal
Morton’s neuroma -- bet. 3rd and 4th
metatarsals
Spring ligament of foot – stabilizes
medial arch
bet. calcaneous and navicular
Navicular Dx -- pain, decreased motion,
dropped med. arch
Navicular drops down and rotates medially
Cuboid dx: pain, decreased motion,
callus under 4th/5th metatarsal
Cuboid drops down and rotates laterally
Cuneiform dx: pain on plantar surface,
decreased motion
Cuneiforms glide plantarly when in
dysfunction
 Ankle Sprains
Grade I
anterior talofibular
(ATF)
– Test by anterior
drawer test
Grade II
ATF and
calcaneofibular (CF)
Grade III
ATF, CF, and
posterior talofibular
 Ankle Sprains
Inversion sprain will cause:
Tibia external rotation
Femur internal rotation
Posterior fibular head
Sacrum goes into forward torsion on side
of ankle sprain (R sprained ankle = R on R
torsion)
Pelvis – posterior rotation on the side of
sprain
Thompson test
For torn achilles
tendon
Be sure to review Chapman’s reflexes
lecture.
May see the common anterior points
Posterior Chapman’s point usu. correlate
with areas of viscerosomatics
– Exceptions:
eye – suboccipital mm.
Middle ear: TP of C1
Pharynx: TP of C2
 Myofascial points
Jones Travell’s Chapman’s
Tenderpoints trigger points reflex points

No radiation Radiates and No radiation

with local refers pain to
tenderness other areas
Small, Spindle shaped Small, nodular,
hypersensitive thickening in smooth, deep to
area in muscle band skin on deep
superficial fascia or
fascia periosteum
Short Leg Syndrome
Diagnosis = standing AP pelvic x-ray
Look for amt. of sacral base unleveling

Heel lift typically goes on the side of the

sacral base declination

Start with 1/16” lift for fragile/elderly patients

Max ¼” in heel, than rest on outside of heel
(up to ½”). Greater than ½”, need to lift sole
also
Short leg side:
Innominate will rotate anteriorly
Spine will sidebend away from side of sacral base
declination
– Iliolumbar ligaments and SI joint stressed on side of
convexity
Pelvis will side-shift away from side of sacral base
declination
Long leg side:
Innominate will rotate posteriorly
Leg will internally rotate and foot will pronate
Viscero-somatic reflexes
T1-4 : Head and neck
T1-6: Heart and Lungs
T5-9: All upper abdominal viscera
(stomach, duodenum, pancreas, liver,
GB, spleen)
T10-11: Remainder of small intestine,
kidney, ureter, gonads, right colon
T12-L2: Left colon and pelvic organs
Use your test taking skills to eliminate
certain answers.
Remember your foundation of
knowledge, and start from basics.
Good Luck on Boards &
BE CONFIDENT!!