OMM Board Review

HISTORY
AT Still born
1874
1892
1896
1910
1917
1918

Osteopathy founded "...I flung to the breeze the banner of Osteopathy."

1st class at American School of Osteopathy
Vermont first state to license D.O.'s
Flexner report
AT Still dies
Spanish influenza pandemic; osteopathy dramatically reduces
morbidity/mortality
1962 D.O.'s exchange degrees for M.D. in California
1973 Mississippi last state to license D.O.'s
2001 Louisiana accepts COMLEX

OSTEOPATHIC PRINCIPLES
1.
2.
3.
4.

The body is a unit.

It has its own self-protecting and regulating mechanisms.
Structure and function are reciprocally related.
Treatment considers the preceding three principles.

AUTONOMICS
Sympathetic vs. Parasympathetic Response
Organ

Sympathetic

Parasympathetic

Pupil
Ciliary Muscle
Lacrimal Gland
Mucus Glands
Salivary Glands
Blood Vessels (skin)
Pilomotor Muscles
Sweat Glands
Common Carotid Artery
Mucous Glands (Phx-Larx)
Thyroid Gland
Heart
Bronchial Glands
Bronchial Muscles
Upper body vasculature
Stomach
Liver

Dilation
--------------Inhibition
Inhibition
Vasoconstriction
Contraction
Secretory
Vasoconstriction
Vasoconstriction
Vasoconstriction
Excitation
Inhibitory
Relaxation
Vasoconstriction
Inhibition
Glycogenolysis

Constriction/accomodation
Contraction
Secretory
Secretory
Secretory
--------------------------------Secretory
-------Inhibition
Secretory
Contraction
-------Motor and secretion
Glycogen Synthesis

Spleen
Gallbladder & ducts
Pancreas
Kidney
Adrenal Medulla
Intestinal Tract
Rectal Sphincter
Vesicle Sphincter
Vesicle body
Uterine Body
Uterine Cervix
Male Reproductive Organ
Ovary and Testes

Vasoconstriction
Relaxation
Inhibition
Vasoconstriction
Adrenaline
Secretion
Contraction
Contraction
Contraction
Relaxation
Constriction
Relaxation
Ejaculation
Vasoconstriction

-------Contraction
Secretory
--------------Relaxation
Relaxation
Relaxation
Constriction
Relaxation
Constriction
Erection
(unknown)

Sympathetics Thoracolumbar outflow (T1-L2)

Head/Neck
T1-4
Thyroid
T1-4
Mammary
T1-6
Esophagus (lower 2/3rds)
T1-6
Trachea/bronchi
T1-6
Heart
T1-6 (T2 on left is most common area of
somatic dysfunction for MI)
Lung
T1-6
Pleura of lung (visceral)
T1-6
Pleura of lung (parietal)
T1-11
Abdominal Viscera
T5-L2
Stomach
T5-9 (left)
Duodenum
T5-9
Liver
T5-9
Gall bladder
T5 (right)
Gall bladder (ducts)
T6 (right)
Pancreas
T7 (right)
Spleen
T7 (left)
Small intestine to right colon
T10-11
Left colon to rectum to pelvic organs
T12-L2
Appendix
T10 (if not presented with T10 as an
option go with T12) (Appendicitis--Right
twelfth rib tip is tender)
Ovary-/teste
T10-11
Adrenals
T10-11
Kidney
T10-11
Upper ureter
T10-11
Lower ureter
T12-L1

Cisterna Chyli
Pelvic Viscera
Uterus
Prostate
Bladder
Upper extremity
Lower extremity

T11
T12-L2
T12-L2
T12-L2
T12-L2
T2-8
T11-L2
Sympathetic Innervation of the GI tract

Greater Splanchnic Nerve

(T5-9)

Stomach, Liver
Pancreas,
duodenum

(T5-9)
(10)

Celiac Ganglion

Lesser Splanchnic Nerve

(T10-11)

Small intestine
Rt. Colon

(T10-11) Superior Mesenteric

(12)
Ganglion

Least Splanchnic Nerve

(T12) &
Lumbar Splanchnic Nerve
(L1-L2)

Left Colon
Pelvic Organs

(T12-L2) Inferior Mesenteric

Ganglion

Parasympathetics--cranial and sacral areas

CN III
CN VII
CN IX/X
CN X
S2-S4

Pupil (constriction and accomodation)

Lacrimal/salivary glands (secretomotor) sinuses and eustachian tube
Carotid body/sinus (blood pressure regulation & C02/02 tension)
Vagus nerve (thorax. abdomen &- pelvis)
Mnemonic 1973 (X. IX. VII. III)
Left colon and pelvis via pelvic splanchnic nerve

Parasympathetic Innervation
Nucleus/Plexus
Edinger-Westphal

Cranial Nerve
Oculomotor III

Superior Salivatory Facial VII

Inferior Salivatory

Ganglia
Ciliary

End Organs
Eye , Accomodation

PterygoPalatine &
Submandibular

Submandibular/Sublingual
gland, Lacrimal/palatine
glands

Glossopharyngeal IX

Dorsal Motor &

Vagus X
Nucleus Ambiguous

Otic

Parotid
Respiration, heart
GI, Liver, Pancreas

Pelvic Splanchnic

Pelvic, GU Tract
Descending Colon &
Rectum

Buzz words for vagus: Dysfunction of the vagus is reflected to OM, OA, AA, C1
& C2. Vagal viscerosomatic reflex from the lungs may be seen as a dysfunction
of the OM. Reason for this is probably due to the ganglion nodosum, which is
anterior to C2. All organs from the thyroid and below except (?) mammary
glands, (?) ovaries and (?) testes. Innervates GI tract up to the middle transverse
(right) colon. ALWAYS LOOK AT THE OCCIPUT, SUBOCCIPITAL, C1 OR C2
AREA FOR PARASYMPATHETIC VISCEROSOMATIC REFLEX BECAUSE OF
CLOSE PROXIMITY OF VAGUS (GANGLIA NODOSUM) TO THIS REGION.
In inferior wall MI: There are many cholinergic fibers located in the inferior wall
of the myocardium. Viscerosomatic reflex will be to the suboccipital region. The
anterior wall MI viscerosomatic reflex is to T1-T7, predominantly T2.
Upper respiratory tract: Sympathetics produce epithelial hyperplasia resulting
in an increase in the number of goblet cells in relation to the ciliated cells
(increased goblet to ciliated cell ratio). Due to this, there is an increase in mucus
production and thickening of the secretions. Parasympathetic stimulation
produces the opposite. There is increased ciliated to goblet cell ratio. This helps
the sweeping mechanism by the thinning of secretions.
PUD: This disease is related to an excessive vagal type of syndrome.
Viscerosomatic reflex due to PUD will also be to the OA/OM region. Be aware of
pepsin and acid production secreted by parasympathetic overstimulation.
PostOp ileus: Under sympathetic stimulation the intestines contract. During
surgery there is an acute disruption of the intestinal system, which goes into
shock. Sympathetic override inhibits peristalsis leading to post-op ileus. Rib
raising is an effective treatment to tone down the sympathetic gain to the
intestines.
Misc. Notes:
Pelvic splanchnic (S2-S4) vs. Sacroiliac joint (S1-S3)
Pelvic splanchnics (S2-S4) innervate from left colon down to genital
cavernous tissue except adrenals.
Note: No parasympathetic innervation to the extremities.
Right vagus (AKA Posterior vagal trunk) gives rise to the celiac branch
and the left vagus (AKA Anterior vagal trunk) gives rise to the hepatic
branch.

 The right vagus innervates the Ascending colon and the 1st 2/3 of the
Transverse colon. The left vagus innervates the liver and part of the
duodenum. Therefore the right vagus is longer than the left vagus.
Rt. Vagus innervates the SA node: excess parasympathetic stimulation
can cause brady arrhythmias.
Rt. Sympathetic fibers innervate the SA node: hypersympathetic
stimulation may lead to supraventricular arrhythmias.
Lt. Vagus innervates the AV node: excess parasympathetic stimulation
can cause heart block.
Lt. Sympathetic fibers innervate the AV node: hypersympathetic activity
may lead to malignant dysrhythmias (ventricular tachycardia and
ventricular fibrillation).
Sympathetics to the head and neck come from T1 to T4. Travel up to the
Superior Cervical Ganglia at the level of C1 to C3, follows the arterial
supply and goes through the Sphenopalatine Ganglion without synapsing
continuing on to the eyes, nasal mucosa, etc.
Sphenopalatine ganglion is basically a parasympathetic mechanism
mainly from CN VII. Covers throat, sinuses, ears and others.
Greater petrosal nerve carries parasympathetic fibers.
Deep petrosal nerve carries sympathetic fibers.
Hering-Breuer Reflex: Mediated by the 10th cranial nerve occurs when
the air sacs are filled with fluid. The respiratory centers receive confusing
information.
The vagus sends signals to decrease diaphragmatic
excursion since the air sacs are filled. Concurrently, the carotid body
perceives the need for more oxygen and sends signals to increase the
diaphragmatic rate. The result of these signals is rapid and shallow
breathing.
Autonomics Big Picture
Sympathetics
Head/Neck/Heart/Lungs:
Upper GI:
Lower GI/Pelvis:

T1-4 (6)
T5-9
T10-L2

Parasympathetics
Head/Neck:
Chest/Upper GI: X, Lower GI/Pelvis

CN111, VII, IX, X

S2-4

NEUROLOGIC (PROPRIOCEPTIVE) REFLEXES

Muscle Energy: (Golgi tendon organ reflex). (Direct method). A pull on the tendon
sends signal from the Golgi tendon organ to spinal cord. At the spinal cord inhibitory
interneurons synapse with alpha motor neurons causing a reflex relaxation of the
muscle. When tension on a tendon becomes extreme the inhibitory effect from the
organ can become so great it causes a sudden relaxation of the entire muscle. Golgi
tendon organs respond to rate and changes in muscle tension. Summary: Activation of
large myelinated group 1b afferent fibers from tendon insertion reflexively inhibits alpha
motor neuron to muscle spindle. Buzz: Golgi, alpha motor neurons, tension/force,
direct technique.
Counterstrain: Decrease gamma gain: "...stop inappropriate proprioceptor activity...
shortening the muscle that contains the malfunctioning muscle spindle by applying a
mild strain to its antagonist." (Jones) This is an indirect technique that employs the
Muscle spindle reflex. This reflex responds to rate and changes of intrafusal fiber
length. Hypershortening the extrafusal fibers by bringing the origin and insertion of the
muscle mass closer together, decreases the length of the intrafusal fibers and relaxes
them. This relaxation phase is followed by a slow return to neutral in order to allow the
CNS to reset the gamma gain activity in the spindle to a new lower level. The end result
of counterstrain on the muscle spindle fibers is a turning down of the gamma gain.
Remember: Position of ease, slow return after 90 seconds. Red herrings: C3 posterior
put into flexion. C4 anterior put into extension, inion put into flexion, lower pole L5 put
into flexion. Key words: proprioceptor, gamma gain. Note: FPR also employs the muscle
spindle reflex.
HVLA: Can involve both the Golgi tendon organ and muscle spindle reflex. HVLA may
produce changes in muscle tension and length of muscle spindles.
1. Thrust activation initiates so much afferent input into the CNS, causing the
CNS to turn down the gamma gain to the muscle spindles, which relaxes the
tight muscle mass.
2. During a thrust the tension on the tight muscle firmly pulls on the tendon.
This activates the Golgi tendon receptors, which in turn causes a reflex
relaxation to that tight muscle.
3. The stretch of the extrafusal fibers of the tight muscle pulls on the Golgi
tendon receptors, which will cause a reflex activation to inhibit the contraction
of the same muscle.
4. HVLA of 1/8 to 1/4 of forceful stretching of a contracted muscle may
produce such a barrage of afferent impulses from the spindles to the CNS
causing the CNS to respond by sending inhibitory impulses to the gamma
gain cell bodies. This turns down the gamma gain activity to the spindles,
thus relaxing the muscle mass via a central inhibitory reflex.

CHAPMAN'S REFLEXES
Chapmans reflexes are a system of reflex points originally used by Frank Chapman,
D.O. These reflexes present as predictable anterior and posterior fascial tissue texture
abnormalities assumed to be reflections of visceral dysfunction or pathology
(viscerosomatic reflexes).
A given reflex is associated with the same viscus;
Chapmans reflexes are manifested by palpatory findings of plaque-like changes of
stringiness of the involved tissues.
The Chapman's reflexes follow sympathetic afferent pathways and therefore are
manifest along the dermatome, sclerotome and myotome segmental lines. Chapmans
reflexes are neurologic, lymphatic and myofascial reflexes that indicate increased
functional activity of the sympathetic nervous system. They do not reflect the
parasympathetic nervous system.
These reflexes in the thoracic area are palpated anteriorly in the intercostal spaces via
sympathetic fibers of intercostal nerves. The heart reflex is located at the 2nd intercostal
space and posteriorly at T2, which is a major innervation of the heart. The reflex for the
bronchus, thyroid and esophagus is also at the anterior 2nd intercostal space.
The Chapmans reflexes for the colon are located on the lateral thigh along the Iliotibial
band and Tensor fascia lata. Also, in this same area are the reflexes for the broad
ligament of the uterus and prostate. The reflex for the cecum is located at the Rt.
Greater Trochanter and for the sigmoid colon at the Lt. Greater Trochanter.
Ex. Disorder in middle ear and sinuses will increase sympathetic tone to clavicle and
first rib anteriorly and C2 posteriorly. They tend to follow classic viscerosomatic
patterns.

OTHER TREATMENT MODALITIES

Effleurage: Form of lymphatic stroking, distal to proximal

Petrissage: Grasp, lift and twist skin to break superficial fascial adhesions.
Tapotement: Striking belly of muscle with hypothenar eminence to increase
blood flow and tone

SOMATIC DYSFUNCTION
Somatic dysfunction: Is an impaired or altered function of related components of the
somatic (body framework) system; skeletal, arthrodial and myofascial structures, and
related vascular, lymphatic and neural elements. Mnemonic: SAM VLN. Remember
TART (Tissue texture changes, Asymmetry, Restricted motion & Tenderness)
Acute:

Increase temperature (blood flow from kinins, etc).

Increase moisture (sudomotor from sympathetics).
Increased bogginess (edema from leakage of vessels and stagnant lymph)
Increased tenderness (nociceptor firing in tissues).
Erythema (vascular response, redness lasts more than 15-30 seconds).

Chronic:
Decreased temperature (cool, decreased blood supply from ongoing
sympathetonia).
Dryness (sustained sympathetic tone "burns out" sweat glands and
decreases sudomotors).
Blanching in response to erythema streaking (sympathetics vasoconstrict
blood vessels).
Ropy, stringy, soft tissues.

ERYTHEMA TEST
Acute: A positive red reflex sign due to release of substance P and other biochemical
neuropeptides, kinins, etc., into soft tissues causing dilation of capillaries and
inflammation. Redness shouldn't last > 30 sec.
Chronic: There is a blanching response due to excess vasoconstriction from
sympathetic override.

BARRIERS
Restrictive Barrier: A functional limit within the anatomic range of motion, which
abnormally diminishes the normal physiologic range (1). (Between normal midline range
and physiologic barrier). AKA: Pathologic Barrier.
Physiologic Barrier: The limit of active motion; can be altered to increase range of
active motion by warm-up activity.
Anatomic Barrier: The limit of motion imposed by anatomic structure; the limit of
passive motion. (End point of ligament, fascia, muscle, etc. Beyond these joint is
disrupted).
Pathologic Barrier: 1. Restrictive barrier; 2. Permanent restriction of joint motion
associated with pathological change of tissues (ex. Contracture, osteophytes).
Elastic Barrier: The range between the physiologic and anatomic barrier of motion in
which passive ligamentous stretching occurs before tissue disruption.

FRYETTE'S LAWS
Type I:
Sidebending and rotation to opposite sides.
Involves more than one segment (usually 3 or more) = group curve.
Dysfunction greatest in neutral (N) position.
Long restrictors maintain lesion (erector spinae).
Compensatory/gradual onset.
Treat after Type II.
Example: T3-L1 N SBI Rr: To treat put patient into RI SBr N (for muscle energy).
Type II:

Sidebending and rotation to same side.

Single segment.
Dysfunction greatest in either flexion or extension.
Short restrictors maintain lesion (rotatores brevis & intertransversarii muscles.)
Abrupt/traumatic (found at apex, beginning or end of group curve).
Treat first.
Example: T8 F SBl Rl: To treat put patient into Rr SBr E (for muscle energy).

Law III:
Named by Dr. CR Nelson in 1948: Initiation of motion in one plane MODIFIES
motion in all other planes.

RULE OF THREES FOR THORACIC SPINE

A. T1-3
B. T4-6
below
C. T7-9
D. T10
E. T11
F. T12

Spinous process of segment is with its transverse process

Spinous process of segment is half way, to t-process of segment
Spinous process of seg. is at level with t-process of seg. below
Like "C"
Like "B"
Like "A"

FACILITATION
1. The maintenance of a pool of neurons (e.g. premotor, motorneurons or
preganglionic sympathetic neurons in one or more segments of the spinal cord)
in a state of partial or subthreshold excitation; in this state, less stimulation is
required to trigger the discharge of impulses.
2. Facilitation may be due to sustained increase in afferent input, or changes within
the affected neurons themselves of their chemical environment.
Once
established facilitation can be sustained by normal CNS activity.

3. Synapses in the cord that have low threshold are easily triggered by impulses of
sublevel intensity. Visceral afferent and somatic propioceptor bombardment to
the cord from visceral or somatic disease produces facilitation. These facilitated
segments will then fire sympathetic outburst to related organ and soma
structures when other visceral or somatic impulses pass through that region of
the cord. This inappropriate sympathetic bombardment of visceral and somatic
tissue will have detrimental effects to these tissues and the body in general.

DERMATOMES
C5
C6
C7
C8
C5-C6
C5-C7
C8-T1
T4
T7
T10
T12
L4
L5
S1
L4-L5
L3-L4
L5, S1-S2
L1-L4
S1-S5

Clavicles
Thumb
Middle finger
Ring/Little Finger
Ball of shoulder (deltoid)
Lateral Arm (C5 for lateral upper arm, C6 for lateral forearm)
Medial Inner Arm
Nipple
Xyphoid
Umbilicus
Groin
Innermost foot
Dorsum of foot
Outermost foot
Medial Foot
Knee
Posterior/Outer Thigh
Anterior/Inner Thigh
Perineum

T1 In MI, T1 is probably the connection to viscerosensory pain referral to

the inner arm.
Viscerosensory vs. viscerosomatic = pain vs. tissue texture changes
Pain: In general, pain above the uterine fundus is mediated by the sympathetics. Pain
below (except the gonads) are mediated by the parasympathetics.

Perineum (S1-S5), very important when assessing for Cauda Equina Syndrome. Patient
with large central disc herniation will have trouble with urinary or bowel retention.

KEY REFLEXES
L4
L5
S1
C5
C6
C7

Patella (knee jerk)

None (test strength of great toe dorsiflexion-extensor hallucis longus-- and
heel walking)
Achilles (ankle jerk/toe walking)
Biceps
Brachioradialis
Triceps

CRANIAL
Founded in 1899 by Dr. A.T. Still's student. William Gardner Sutherland. D.O.
Five phenomena:
1. The fluctuation of the cerebrospinal fluid (or potency of the Tide)
2. The motility of the brain and spinal cord (alternating shape of CNS)
3. The mobility of the intracranial and intraspinal membranes (reciprocal tension
membranes)
4. The articular mobility of the-- cranial bones joint/suture motion)
5. The involuntary movement of the sacrum between the ilium (via the dural
membranes to S2)
#s 1 and 2 are thought to be the "motive power" behind #s 3-5
The five phenomena make up the Primary Respiratory Mechanism.
Note: Most cranial dysfunctions are named in relation to the position of the sphenoid
bone.
Flexion: Increase in transverse diameter, decrease in longitudinal and A-P
diameters.
Extension: Decrease in transverse diameter, increase in longitudinal and A-P
diameters.
Torsion: Twisting of articulation of sphenoid and occiput, the sphenobasilar
synchondrosis. Name lesion for side of higher greater wing of the sphenoid.
Greater wing of the sphenoid is superior on the right and a low occiput on the
right = Rt. Torsion.
Sidebending/Rotation: Bending of articulation of sphenoid and occiput, the
SBS; the low greater wing of sphenoid is on same side as low occiput, head
fuller, convex, on this side and named for this convex side (of low sphenoid and
low occiput). Mnemonic: "Down and Out in Beverly- Hills". Greater wing and

occiput both inferior on the right and convex (fuller) on the right
Sidebending/Rotation

= Rt.

Lateral Strain: Sphenoid shifted to either right or left of occiput. Sphenoid

shifted to the right in relation to the occiput = Rt. Lateral Strain. Traditionally
named for which side the basisphenoid shifts towards, however, recently
contested by some to be defined as to the direction opposite the sphenoid is
shifted towards. Its really an intellectual argument because they are both
incorrect according to Magoun's Osteopathy in the Cranial Field. He contends
that the greater wing of the sphenoid actually shifts ANTERIORLY in a right
lateral strain and ANTERIORLY in a left lateral strain. Parallelogram head.
Vertical Strain: Sphenoid shifted up or down in relation to the occiput. If
sphenoid is shifted upward, for example from a punch to the bottom of the chin
upward, then its a superior vertical strain. If shifted downward, it's an inferior
vertical shear. When palpating in an A/P direction along the frontal bone and
there is a dip at the coronal suture = anterior cranium is superior = Superior
vertical strain. If anterior cranium (dividing line being the coronal suture) is
inferior = Inferior vertical strain.
A hit with a bat on head anterior to the coronal suture or a fall on the tailbone
may result in an Inferior vertical strain. The later is possible since there is a
change in the relation of the sphenoid and the occiput. Caution: do not name the
lesion in relation to the occiput.
Compression: A-P compression at sphenobasilar symphysis, worst lesion:
overall decreased cranial motion. Described as a "bowling ball " head.
Bones:
22 cranial bones.
28 if you count the ossicles (3 in each temporal bone).
8 neurocranial bones (occiput, temporal (2), ethmoid, parietals (2), sphenoid
and frontal).
14 viscerocranial bones (facial).
7 orbital bones (frontal, zygoma. maxilla, sphenoid, lacrimal, ethmoid and
palatine).
29 bones in the cranium (incl. Hyoid and Ossicles)
79 articulations in the face
43 articulations in the cranium
55 articulation in the foot
26 bones in the foot
The skull has about 142 articulations. (79 face, 43 neurocranium)
Basilar bones are occiput (except interparietal portion), petrous temporals,
sphenoid (except tip of greater wing) and ethmoid and are all formed in cartilage.

Vault bones are frontal, parietals, and temporals (include tip of greater wing of
sphenoid and interparietal occiput). All formed in membrane and are
accommodative to the basilar bones.

Sphenobasilar synchondrosis:
Major joint in cranium, formed in cartilaginous tissue, becomes cancellous bone around
the age of 25 and maintains pliability, flexibility thereafter.
Movement:
Normal cranial rate is 8-14 cycles/minute. A cycle = 1 inhalation & 1 exhalation.
Cranial amplitude is quantitative 1/10 10/10. The latter being healthiest
Inhalation phase of the primary respiratory mechanism (PRM) = flexion of
midline structures, (i.e. sphenoid, occiput, sacrum) and external rotation of paired
structures (i.e. temporal bones, femur, etc.).
Exhalation phase of PRM = extension of midline structures and internal rotation
of paired structures.
Occiput, ethmoid and vomer all rotate (circumducts) in the same direction in flexion and
extension. Sphenoid rotates (circumducts) in opposite direction.

Landmarks:

Pterion: Overlapping of frontal parietal sphenoid and temporal. Area of anterior

branch of middle meningeal artery.
Asterion: Meeting of parietal, temporal and occiput.
Opisthion: Dorsal aspect of foramen magnum.
Basion: Ventral aspect of foramen magnum.
Nasion: Meeting of frontal and nasal bones.
Glabella: Bump on distal frontal bone, above nasion.
Bregma: Meeting of coronal and sagittal sutures.
SS pivot point: Sphenosquamous point where temporal overlaps the sphenoid
superior to joint and sphenoid overlaps temporal below point.
Sutherland's Fulcrum: Area of straight sinus (junction of three sickles of dura
mater); automatic shifting suspension fulcrum point of rest on which a lever
moves and from which it gets its power..." (Magoun)

Beveling:

External bevel: Suture is on the external surface of the bone. If a bone

is externally beveled it is overlapped by another bone.
Internal bevel: Suture is on the internal surface of the bone. If a bone is
internally beveled then it overlaps another bone.
Example: At the occipitomastoid suture the Temporal has internal
beveling and the Occiput has external beveling. In this case the Temporal
overlaps the Occiput.
Note: Above the SS pivot point the temporal overlaps the sphenoid and
below this point the sphenoid overlaps the temporal.

The beveling concept gives an indication of how certain treatment would work. When
treating a patient with a CV4 the occiput is compressed since it is overridden by the
temporals.
The Three Articulations between the Temporal and Occipital Bones:
1. Condylosquamomastoid Pivot: Rocking motion
2. Jugular Process: occiput drives the temporal
3. Petrobasilar: Tongue and groove & Hinge/Glide motion
4. Combination of all three equals wobble
The Major Attachments of the Dura (Reciprocal Tension Membrane):
1. Posterior pole:
Occipital bone
2. Lateral poles:
Petrous portion of the Temporal bone
3. Anterior Superior pole:
Cribiform and Crista Galli of the Ethmoid
4. Anterior Inferior pole:
Clinoid processes of the Sphenoid
5. Inferior pole:
S2 at the superior transverse axis of the
sacrum
Flow of CSF:

Lateral ventricles Interventricular foramen of Monroe 3rd ventricle Aqueduct

of Sylvius 4th ventricle through Midline foramen of Magendie or lateral to
foramen of Luschka subarachnoid space brain and spinal cord

Venous flow:
Superior Sagittal sinus Rt. Transverse sinus
Inferior Sagittal sinus Lt. Transverse sinus
Transverse sinus Sigmoid sinus Internal Jugular Vein which courses along
with CN IX, X & XI and exit through Jugular Foramen which is between two
bones, the occiput and temporal.
Great vein of Galen together with the Inferior Sagittal sinus Straight sinus
Confluence of Sinus
Cavernous sinus empties into the Inferior and Superior Petrosal sinuses. Inferior
Petrosal sinus Sigmoid sinus and the Superior Petrosal sinus Transverse
sinus.
The venous sinuses lie between the two layers of dura. These veins lack smooth
muscle, elastic fibers and valves. They are dependant on the mobility of the dura
for drainage.
Techniques:
CV4 (compression of the fourth ventricle): Generalized technique, used in any
instance except acute head trauma. Operator places thenar eminences medial to
mastoid processes: encourage extension phase by holding the occiput towards
you (very gently!) or away from the flexion phase. You are harnessing the
"Potency of the Tide." Pronounced effect on total body physiology. For example:
The medulla is on the floor of the fourth ventricle; if you work with the CSF to
alter this respiratory center you can in turn effect a change in the
thoracoabdominal diaphragm and hence increase lymphatic flow from the
cisterna chyli/thoracic duct via the aortic hiatus in the diaphragm (level of T12).
Sphenopalatine Ganglion: It hangs in its respective fossa via the second
division of CN V, but it is supplied by the greater petrosal nerve, a branch of the
geniculate ganglion of CN VII. To treat: Go to maxillary ridge near pterygoid plate
and gently inhibit to effect a decrease in goblet to ciliary cell ratio and lessen
thickened secretions of the nasopharynx (especially the Eustachian tube).

CRANIAL NERVE ENTRAPMENTS

Cranial Nerve
Entrapment Neuropathy
I
Olfactory
Anosmia
II
Optic
Visual Acuity/Field
III
Oculomotor
Eye deviation - down and out
Pupils not constricting (via Edinger-Westphal
Nucleus)
IV
Trochear
Eye deviation - slight upward
V
Trigeminal*
Anesthesia of the face, paralysis of muscles of
mastication, Trigeminal Neuralgia (V2)-Stabbing pain
VI
Abducens
Eye deviation - inward, strabismus
VII
Facial
Bells Palsy, Decreased Tears/Taste to anterior
2/3 of tongue
VIII Vestibulocochlear Decrease hearing, vertigo, Meniere's disease
IX
Glossopharyngeal Decreased swallowing
X
Vagus
Anesthesia of External auditory meatus
Circulation/Respiration changes
Digestion, swallowing
Swallowing/Speaking
XI
Accessory
Shoulder shrugs, swallowing
XII
Hypoglossal
Tongue: Suckling
*Trigeminal neuralgia most commonly occurs in V2 distribution.
-V1 exits via the Superior Orbital Fissure
-V2 exits via Foramen Rotundum
-V3 exits via Foramen Ovale

PELVIS AND SACRUM

Standing flexion Test provides information on laterality or iliosacral dysfunction. The
seated flexion test provides information only on sacroiliac dysfunction, not on
laterality, except to say that the side of the (+) seated flexion test is opposite the axis
(named) or the same side as the inferior pole of the axis = piriformis spasm.
Example of Innominate diagnosis:
Lt ASIS - Superior
Lt PSIS - Inferior
Lt Pubic Bone - Superior
(+) Rt Standing Flexion Test
Dx = Rt Innominate Anterior Rotation

Lt ASIS - Inferior
Lt PSIS - Inferior
Lt Pubic Bone Inferior
(+) Rt Standing Flexion Test
Dx = Rt Innominate Superior Shear

Distance from ASIS to umbilicus is greater on the right, with a positive standing
flexion test on right=right outflare innominate. Distance from ASIS to umbilicus is
less on right than on left, standing flexion test positive on the right=right inflare

innominate. Same as above but positive standing flexion test on the left=left
outflare innominate.
The axis in a sacral torsion is named for the superior pole of the axis
The stork test is positive for INNOMINATE or iliosacral dysfunction: Operator
palpates PSIS, pt bends knee (one side) and you see if PSIS comes posteriorly. If it
does NOT, then a restriction or dysfunction of the INNOMINATE/iliosacral is noted.
The Sphinx test just has the patient prone, in TV watching position to induce
lumbar extension. It would make a backward sacral dysfunction worse. A forward
sacral dysfunction would be more symmetrical.
For sacral torsion remember that L5 is rotated opposite to the rotation of the sacral
rotation.
Superior transverse axis of the sacrum corresponds to Respiratory motion/
craniosacral. Middle transverse axis for sacroiliac motion and the inferior transverse
axis for iliosacral motion. For all of these axes motion occurs through S2.
A question regarding a resistant ILA is referring to a posterior/inferior ILA
Anterior Superior ILA on the Rt = Posterior Inferior ILA on the Lt
Counternutation of the Sacrum = Base is posterior = Craniosacral Flexion = Postural
extension
Nutation of the Sacrum = Base is anterior (nods) = Craniosacral Extension =
Postural flexion
In the birthing process, as the baby comes down the birth canal the sacral base 1st
moves posteriorly in counternutation and 2nd as the baby comes further down the
apex of the sacrum moves posteriorly in nutation.

Sacral Dysfunctions
Torsion: By definition deep sacral sulcus opposite from side of inferior lateral angle
(ILA) being posterior-inferior. That is the sacrum moves about an oblique axis. Should
have concomitant somatic dysfunction of the lumbar region (with lumbar or lumbars
rotated to the opposite side of the sacral rotation). Torsions either forward (left on left.
right on right) or backward (right on left, left on right). Most common: Left on left forward
sacral torsion. Note: L5 must be rotated in the opposite direction as the sacrum to be a
torsion. Also, the seated flexion test is generally positive on the side opposite the axis

because the inferior pole of the axis is fixed by a piriformis spasm. The superior pole of
the axis is fixed by a quadratus lumborum spasm.
Rotation: L5 is rotated in SAME direction as sacrum.
Flexion/Extension lesions: Remember flexion/extension in the muscle energy model
is opposite the cranial model. That is the postural and respiratory models are not to be
confused. Both have an axis in the S2 region, but then, are called "middle transverse"
for the postural, muscle energy model and "superior transverse" for the respiratory
cranial model. If a deep sacral sulcus is on the same side of the ILA being posteriorinferior it is a unilateral sacral flexion lesion or sacral shear. For example: Deep sulcus
and posterior-inferior ILA on the left = left unilateral sacral flexion lesion or left sacral
shear. If both sulci deep = bilateral sacral flexion. If both sulci, shallow = bilateral sacral
extension. Most common USFL/shear is on left. Mnemonic: United States Football
League. You can also have a bilateral sacral flexion or extension lesion (postural
model) whereby the sacral sulci are either deep or shallow bilaterally.
The fifth lumbar: Is key to the latest version of sacral dysfunction: If L5 is rotated
opposite to the sacrum you most likely have a sacral torsion. If L5 is rotated in the
same direction then it is a sacral rotation.
Spring test: Used to distinguish whether you have a backward v. forward sacral torsion.
If the lumbars are taut, kyphotic, tense and do not spring well on compression in the
prone position = positive spring test. If the lumbars retain natural lordosis and are
flexible = negative spring test. Positive = backward torsion. Negative = forward torsion.
Nomenclature: Name Rotation on Axis.

Mnemonic: Rheumatoid Arthritis

Note: Spring test equivocal or negative and positive with shear.

Note: Positive sitting flexion test is opposite the axis in a torsion and ipsilateral in
a shear.
Note: Sacrotuberous ligament taut on side of posterior inferior ILA and posterior
innominate.
Forward sacral torsion: In any torsion whether it's forward or backward always lie the
patient on the involved axis. If left axis, lie on left side, etc. etc. For forward torsion, lie in
the lateral Sims's position, that is their chest is forward on the table. Have patient flex
both legs and attempt to bring both ankles toward the ceiling against your isometric
resistance.
Backward sacral torsion: Patient in lateral recumbent position that is their back is
towards the table. Have patient straighten out bottom leg on table, flex upper leg and
attempt to bring their ankle towards the ceiling against your isometric resistance.
Unilateral sacral flexion or sacral shear: Patient prone. You place thenar or
hypothenar eminence on their ILA and push cephalad and anteriorly as they exhale.
Resist inhalation.
Sacral Rotations: Essential L5 is rotated in the same direction as the sacrum.
Summary:
FST: Negative spring, deep sulcus opposite post/inf ILA: lat. Sims's (forward on
table 2 legs)
BST: Positive spring, deep sulcus opposite post/inf ILA: lat. recumbent (back on
table I leg).
USF/shear: Equivocal spring, deep sulcus ipsilateral to post/inf ILA; prone
position.
Primary ligaments of sacrum: Anterior interosseous and posterior sacroiliac
ligaments

Accessory ligaments of sacrum: Sacrospinous, sacrotuberous and iliolumbar

ligaments.
Note: Sacrotuberous ligament is taut with a post/inf ILA or posteriorly rotated
innominate.
Note: Iliolumbar ligament attaches from the transverse processes of L4/5 to the
PSIS/iliac crest. Dysfunction here can refer pain to groin and simulate "hernia"
symptoms.
Sacral motion during vaginal delivery: Counternutation = base going in
extension or backward about the middle transverse axis. Nutation (nodding) =
base going in flexion or forward about the middle transverse axis.

THE MANY DIAPHRAGMS OF THE BODY

Tentorium cerebelli: Dura neater lying transversely on posterior cranial fossa
separating cerebellum from cortex. Area of automatic shifting suspension fulcrum (of
Sutherland).
Sibson's fascia: Thoracic inlet, measures 4 by 2 inches, attaches C7-TI around first rib
to manubrium, also attaches to cupula of lung. Comprised of fascia from the scalenes
and the longus colli muscles. Thoracic duct travels up through and down through this
diaphragm before entering into the venous circulation (left internal jugular and
subclavian or brachiocephalic veins).
Thoracoabdominal: 60% motive force for inhalation. Innervated by C3-5 somatic
nerves. Hiatus for vena cava is T8, esophagus is T10 and aorta (and thoracic duct) is
T12.
Pelvic:
Comprised of two muscles, levator ani and coccygeus. Somatic and
parasympathetic innervation by the cord segments S2-4 (pudendal and pelvic
splanchnics respectively).
Popliteal fossa: Fascial pathways for lymph from the leg.
Medial longitudinal arch of foot: Navicular and plantar fascia supportive and stress
bearers.

THORACIC INLET VS. THORACIC OUTLET

Thoracic Inlet: Structures coming from the head, neck and upper extremity enter the
thorax through the thoracic inlet. It is the opening for the pharyngeal structures into the
thorax and is one of the diaphragms of the body.

Keep in mind that these diaphragms assist in maintaining the intracavitary pressures
(intrathoracic {-}, pharyngeal {+} and abdominal/pelvic {+}). The maintenance of these
pressure gradients is vital for fluid movement.
The thoracic duct travels up through the thoracic inlet to the level of C7, then reenters
the thoracic cavity through the thoracic inlet to empty into the venous system.
Buzz words for the thoracic inlet: Sibson's fascia and suprapleural membrane. These
keep the pharyngeal structures from being "sucked" into the thorax by the negative
pressure in the thoracic cavity.
Thoracic Inlet
Structures
Apices of the lungs
Trachea
Esophagus
Brachiocephalic veins
Vagus
Cervical symphathetics
Phrenic Nerve
Thoracic Duct

Functional
T1, T2, T3, T4
Ribs 1 & 2
Manubrium

Anatomic
Manubrium
Ribs 1 & T1

Thoracic inlet assessment: This is used to assess the dimension of thoracic inlet
torsion. Example:
If the left coracoclavicular angle is anterior or more convex = right
coracoclavicular angle is deep = Thoracic inlet is rotated to the
right.
If left rib is elevated = Thoracic inlet is sidebent to the right.
Rotation is assessed by the coracoclavicular angle or infraclavicular
fossa. Sidebending is determined by an elevated 1st rib.
Thoracic Outlet: Structures leave the thorax through the thoracic outlet mainly to the
upper extremities.
Thoracic Outlet
Clavicle
1st rib
Neurovascular Bundle
Downward displacement of the clavicle onto the 1st rib may cause compression of the
neurovascular bundle resulting in thoracic outlet syndrome. Compression of the
subclavian artery and brachial plexus may occur: (1) As these structures pass through
the triangle formed by the 1st rib and the anterior and medial scalenes; (2) As the

neurovascular bundle passes between the pectoralis minor near its attachment to the
coracoid process and the rib cage.

COMMON COMPENSATORY PATTERN OF ZINK

Dr. Zink described patterns of fascia, which alternated direction at certain anatomical
junctions (OA, Thoracic Inlet, Thoracolumbar area, Lumbosacral area). These junctions
coincide with diaphragms of the body. According to Dr. Zink the alternating fascial
patterns are the bodys response to provide postural compensation. Most common
pattern is L, R, L, R.

OA-- Rotated to left.

Thoracic inlet-- Rotated (and side-bent) to right
Thoracolumbar junction-- Rotated to left
Lumbosacral junction-- Rotated to right

Note: This is the most compensatory (physiologic) pattern of fascial directions. As long
as it alternates L-R-L-R (80%) or R-L-R-L (20%) this is good. Very dysfunctional to have
R-L-L-R or R-R-R-R, etc.

LYMPHATICS
Right minor system vs. Left main thoracic drainage. Right upper extremities, Rt.
Hemicranium, heart and lungs (except the Left upper lung) drains into the right thoracic
duct. The right thoracic duct in turn drains into variable sites one of which is the Rt.
Brachiocephalic vein. The left thoracic duct drains into the junction of the Subclavian
and Internal Jugular veins.
Ex: Lymphangitis of the Lt. Foot will eventually drain in the Lt. Thoracic duct and an
abscess of the Rt. Index finger would drain into the Rt. Thoracic duct.

SPINAL CORD/COLUMN
Facets of cervical spine are oblique.
Facets of thoracic spine are coronal.
Facets of lumbar spine are sagittal.
Cervical spine:
OA = flexion/extension (50%)
AA = rotation (50%)
C2-7 = increasing sidebending as you proceed distally
Spinal cord:
Ends at L1-2 vertebral level (L3 in infant)
Thirty-one pairs of nerve roots (8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal)

SCIATIC NERVE

Comprised of L4-L5 and S1-S3

Peroneal portion pierces belly of Piriformis 10% of population. Most often exits
inferior to muscle and 0.5% exits superiad to muscle.
Sciatica is a lay term to describe a syndrome of chemical irritation of the nerve
bundle, usually related to piriformis spasm, in which pain does not extend below
the knee.
Note: Psoas syndrome usually involves contralateral piriformis spasm.

MUSCULOSKELETAL PATHOLOGY
Herniated Disc
Herniated intervertebral disk (herniated nucleus pulposus): A posterior-lateral herniation
of the nucleus pulposus through the posterior longitudinal ligament. Most common
between L4-5 and L5-S1 vertebral segments. Specifically, however, the fifth lumbar disk
(btw L5-S1) is the most commonly herniated.
Lower extremity radiculopathies are mainly from L5-S1. Which nerve gets impinged in a
disc herniation at L5-S1? L5 or S1? The nerve root that is affected is S1. Herniations
affect the nerve root of the lower vertebral level. (See Netters plate no. 149).
Spondylolisthesis
Most common type is isthmic spondylolisthesis (Type IIA). It is also the most
common cause of lower back pain in the pediatric population.
Spondylolisthesis is a primary defect of the pars interarticularis.

 Anterior slippage of one vertebra on its subjacent vertebra. Most commonly L5

slips forward on S1.
Most commonly occurs in the general population of < 50 y.o.
The affected children will have an exaggerated lumbar lordosis, high gluteal
crease line and tight hamstrings. The hamstrings innervation is between L5-S1
nerve roots. The nerve roots are not necessarily impinged but they are affected
and cause somatosomatic reflex.
A Scotty dog seen on X Ray is a sign for spondylolysis:
Collar:

Microfracture between the superior and inferior articular

facets
Eye:
Pedicle
Hind leg:
Spinous process
Fore leg: Inferior articular facet
Nose:
Transverse process
Spondylolysis: Defect in the posterior neural arch (pars interarticularis which is at the
junction of the superior and inferior articular facets): usually bilateral; postulated as
microfractures sustained over time; gives rise (usually) to....listhesis.
Spondylitis: Inflammatory arthritis of the spine begins at sacroiliac, joint and ascends
up spine then extremities, males, 15-30 years old.
Spinal stenosis: Result of DJD/disk degeneration; spinal foramen closes due to
calcium build up and compromises spinal cord (normal AP diameter of canal is 1.2-1.5
cm). Gives rise to pseudoclaudication" in which radicular symptoms are worse in lumbar
extension, for example, standing or walking. Symptoms are better with lumbar flexion,
for example sitting. "Pseudo" because true aortic-iliac plaque stenosis would give leg
pain/paresthesias that are relieved by simple rest, i.e. standing, which would not relieve
cord compromise (spinal stenosis).
L5: Best answer for the vertebra with the most common congenital malformations.
Some Tests:

Sitting flexion: Tests sacroiliac dysfunction

Standing flexion: Tests iliosacral dysfunction
Trendelenberg: Tests strength of gluteus medius. > 15 degree pelvic drop = (+).
Hip Drop: Tests lumbar sidebending capability on opposite side
Lachman: Tests anterior and posterior Collateral ligament laxity/rupture with knee
semi-flexed
Allen (modified): Tests ulnar and radial collateral circulation of the hand
Finkelstein's: Tenosynovitis of the tendon sheath of the extensor pollicis brevis
(De Quervain's disease), at the radial wrist
Straight leg raising: Puts tension on the sciatic nerve epineurium from a disk
impingement.

RIBS
Pump handle: Ribs 1-5; larger "spinotransverse angle", favors motion about a
transverse axis.
Bucket handle: Ribs 6-10, smaller "spinotransverse angle", favors motion about an AP
axis.
Treatment involving muscle energy:
Rib 1: use anterior and middle scalenes
Rib 2: use posterior scalenes
Ribs 3-5 (6): use pectoralis minor
Ribs 6-9: use serratus anterior
Ribs 10-11: use latissimus dorsi
Rib 12: use quadratus lumborum
Inhalation restrictions: Equals "exhalation somatic dysfunction", the rib is caught
expired, held and stuck down.
Note: TREAT UPPER RIB IN RIB GROUP STUCK DOWN
Exhalation restrictions: Equals "inhalation somatic dysfunction", the rib is caught
inspired, held and stuck up. Treatment involving respiratory cooperation will have
operator increasing thorax flexion for pump handle ribs and increasing thorax
sidebending for bucket handle ribs as patient exhales.
Note: TREAT LOWER RIB IN GROUP STUCK UP
Ribs 11 & 12:
Eleventh and Twelfth rib motion is caliper or pincher like motion. Inhalation will move
these ribs upward and outward. Exhalation will move them downward and inward. The
latissimus dorsi pulls the 11th and 12th ribs up, while the quadratus lumborum pulls the
12th rib down.

UPPER EXTREMITY
Shoulder has seven articulations (five true and two false): The costovertebral joint of the
first rib, the costosternal joint of first rib, the sternoclavicular, acromioclavicular and the
glenohumeral joints are all true shoulder joints. The scapulothoracic and suprahumeral
joints are false shoulder joints.
Rotator cuff: Mnemonic: SITS muscles for Supraspinatus, infraspinatus, teres minor
and subscapularis. Does little rotation, however, stabilizes and maintains glenohumeral
joint function, especially holding head of humerus in glenoid fossa and gliding it
inferiorly during abduction.

SITS: C5 somatic nerve

Falling on outstretched hand will tear infraspinatus and teres minor and dislocation
humerus posteriorly. Additionally, it will facilitate a posterior radial head dysfunction at
the elbow. Also, lateral cord of brachial plexus compromised against coracoid process
leading to paralysis or paresis of cuff muscles.
Rotator cuff tear: Most common tendon torn is supraspinatus. Test: Jobe or Drop Arm.
common after age 40 due to lifetime of Gravitational stress on tendon with resultant
weaker arterial supply to muscle.
Spencer techniques for shoulder: (for glenohumeral motion restrictions)
Extension
Every
Flexion
Fine
Circumduction
Cartoonist
Circumduction with traction
Creates, then
Abduction
Abounds
Internal rotation
In Red
Abduction with traction
Abs tracts
Elbow dysfunction: Hyperpronation of forearm such as a forward fail onto the palm
creates a posterior radial head lesion. Tx: Hypersupinated, extend and thrust radial
head anteriorly.
Elbow dysfunction: Hypersupination injury, such as falling backward and landing on
the palm creates an anterior radial head. Tx: Hyperpronated, flex and thrust radiaI head
posteriorly.
Remember: Pronation = posterior radial head. Supination = anterior radial head
Reciprocal motion of forearm: Abduction of distal ulnar causes medial glide of
olecranon and adduction of wrist joint with resulting distal glide of proximal radial head.
Wrist dysfunction: Restricted extension due to ventral glide of proximal carpal bones
(scaphoid, lunate and triquetral) is most common. Lunate usual trouble maker.
Carpometacarpal joint of thumb: Saddle shape, great motion (except axial rotation),
therefore susceptible to somatic dysfunction.
Other carpometacarpal joints: Somatic dysfunction with dorsal glide.
Note: Gliding motions, which are considered minor motions, are the major area of
somatic dysfunction in the extremities.

LOWER EXTREMITY
Femur: 1/3 length of human body. Has four axes: A-P (abduction 55, adduction 35),
transverse (flexion 85-130, extension 35), anatomical longitudinal (along shaft of femur),
and functional longitudinal (internal & external rotation: from line imagined from ASIS to
patella).
Note: Internal rotation of femur equals a relatively shortening of the leg.
(Kuchera)
Note: External rotation of the femur equals a relatively lengthening of the leg.
(Kuchera)
Knee dysfunction: Due to restricted gliding motions. Remember 6 glides: Posterior,
anterior, medial, lateral and anterior-medial (increased with knee flexion) and posteriorlateral (increased with knee extension).
Usual somatic dysfunction of the knee are anteromedial, medial and posterior glide.
(Kuchera)
Anterior cruciate ligament: Keeps tibia from gliding anteriorly on femur. (Lachman's
test)
Posterior cruciate ligament: Keeps tibia from gliding posteriorly on femur.
Fibular head: Reciprocity of Proximal and distal fibula: External rotation of the tibia and
ankle will carry the distal fibula posteriorly and will elevate and glide the proximal fibular
head anteriorly." This is the basis for the HVLA thrust with a posterior fibula head.

Opposite occurs with internal rotation of tibia and inversion of ankle.

Plantar flexion of the ankle tends to create a posterior fibular head
Dorsiflexion of the ankle tends to create an anterior fibular head
Joint configuration of proximal tiblofibula joint is oblique therefore
glide is actually posterior-medially, or anterior-laterally.

HVLA treatment for posterior fibular head therefore involves thrusting the
proximal fibula head both anteriorly and laterally while flexing the knee,
externally rotating the tibia and everting the ankle to engage and
breakthrough restrictive glide barrier.
Usual somatic dysfunction of ankle joint occurs in plantar flexion when the
talus glides anteriorly, that is ankle is restricted in dorsiflexion and the talus is
restricted in posterior glide.

 HVLA treatment for anterior talus is "tug" thrust with ankle locked out in
dorsiflexion.
Somatic dysfunction of the navicular bone is plantar glide plus internal
rotation (about an AP axis) of its plantar surface.
Somatic dysfunction of the cuboid bone is plantar glide plus external rotation
(about an AP axis) of its plantar surface.
Somatic dysfunction of cuneiforms is plantar glide.
HVLA treatment for navicular, cuboid and cuneiform is "Hiss Whip Maneuver".
You literally whip the tarsals dorsally with thrust contact on plantar surface of
foot.
Note: Again, somatic dysfunction of the extremities tends to involve a
restriction in gliding motion.
Note: To paraphrase Dr. Korr: In any disease process there will be
hypersympathetic tone. If you have a sustained injury in the extremities and
develop, say, reflex sympathetic dystrophy, you must treat the cord levels that
supply sympathetics to the extremities. Thoracic cord segments T2-8 supply
the upper extremity; thoracic cord segments T11-L2 supply the lower
extremity.

SUPINATION INJURY OF THE ANKLE

Most common form of strain/sprain of the ankle is supination injury.
Supination of the ankle involves:
Inversion
Plantarflexion
Adduction
Biomechanics of Supination injury of the Ankle
Structures
Talus
Fibular head
Innominate (via Biceps Femoris)
Sacrum

Tibia

Motion
Moves posteriorly
Moves posteriorly
Rotates posteriorly
Superior oblique axis,
usually on the same side of
the somatic dysfunction
Anterior medial glide

Femur
Navicular
Cuboid

Internal Rotation
Plantar/Medial glide
Plantar/Lateral glide

Pronation of the ankle involves:

Eversion
Dorsiflexion
Abduction
Inversion sprain affects the anterior talofibular ligament. An eversion sprain affects the
deltoid ligament.
Ligaments most commonly affected in an ankle sprain are the anterior talofibular,
calcaneofibular and posterior talofibular (in this order).

SHORT LEG SYNDROME

Heilig formula:
Lift required (L) = Sacral base unleveling in inches (SBU)
Duration (D) + Compensation (C)
Duration:

1 = 1 to 10 years
2 = 10 to 30 years
3 = > 30 years

Compensation:

0 = Sidebending only
1 = Rotation toward the convexity
2 = wedging, altered facets

Example: 50 y.o. patient with a 1/4" SBU for the past 31 yrs with a compensation of
rotation toward the convexity, similar to that of a Type I group curve, with no major
spinal deformities (no zygopaphyseal or facet deformity, no wedging of the vertebra).
SBU = 1/4 "
Duration (3) + Compensation (1)

= 1/16"

If structural short leg (congenital, etc) the ASIS will be low and the medial
malleoli high on the side of the short leg.
Functional compensation (due to sacral torsion, etc) the ASIS will be higher on
the side of the higher malleoli. A higher ASIS in posterior rotation of the
Innominate can be related to short leg only if it is compensated.
Any sacral base unleveling of greater than 5 mm should be addressed
Dropped sacral base will result in a short leg. May use lift therapy to correct the
short leg. Use Heilig to determine the lift required.

 The side of SBU is the side where the lumbar convexity will be found. This is
where the body begins to compensate.
The final analysis for a heel lift will be different by a 50 to 75% less than the
original X-Ray findings. This is due to X-Ray distortion of bone size.
Pelvis rotates and sideshifts towards the long leg side
There is an increase in the lumbosacral angle of 2 to 3 degrees
The shoulder will be low on the opposite side of the SBU
Fragile/Acute pain/Aged, osteoporosis: 1/16" q 2 wk. Do not start with more than
1/16"
Patient is stable: 1/8" q 2 wk
Sudden loss (Acute fracture): restore full amount/length, this is to prevent
compensation by the body.
Up to1/4 replaceable heel lift can be used inside the shoe
Up to1/2" total heel lift can be placed between the heel of the patients foot and
the floor. This can be 1/4" inside the shoe & 1/4" to the heel of shoe. Not more
than 1/4 of the total heel lift can be placed inside the shoe.
An increase beyond a 1/2 heel lift must be added to the heel and to the anterior
half sole. Ex: If heel had been lifted 1/2 and an increase of 1/4 was required:
1/4 would be added to the heel and 1/4 to the anterior half sole.
Heel lift rotates pelvis opposite side
Sole lift rotate pelvis same side
Therefore if lift > 1/2" need half sole
Lift therapy will elevate the lower extremity and sacral base and also rotate the
pelvis to the opposite side. This rotation of the pelvis needs to be addressed
when the lift is > 1/4". In this case you need an anterior half sole to help bring
back the pelvis to midline.

PSOAS SPASM
A psoas spasm will give you a non-neutral (Type II, flexion or extension) somatic
dysfunction at L1 and L2.
The psoas originates from T12-L5 and inserts into the lesser trochanter of the femur
Somatic nerves to the psoas are T12-L3. A psoas spasm can cause a contralateral
piriformis spasm leading to a piriformis syndrome with pain referral to the L2 range.
The nerve supply to the piriformis is S2.
A spasm of the piriformis will be the cause of an Inferior pole in a sacral torsion. The
spasm anchors the inferior pole of the oblique axis. Sidebending of the lumbar spine
will anchor the superior pole of the oblique axis.
The psoas can go into spasm in a patient that is passing a renal stone through the
ureters. Psoas spasm may also affect ureteral function since the ureters descend
on the fascia of the psoas.

SPECIFIC MUSCLE ACTIONS

Muscle
Suboccipital muscles
Intertranversarii
Rotatores Brevis
Splenius
Trapezius
Semispinalis
Longissimus

Action
Extends and rotates head to same side
Bends column to same side
Rotates column to opposite side
Extends, sidebends & rotates to same side
Extends & sidebends toward; rotates away
Extend and rotate to opposite side
Extends, sidebends & rotates to same side

**Erector Spinae: Iliocostalis, longissimus & spinalis

RANGE OF MOTION BY REGION

Range of Motion

Region
Cervical

Muscles

Flexion - 45 degrees
Extension - 90 degrees
Sidebending - 45 degrees
Rotation - 90 degrees

Thoracolumbar

SCM/Scaleni
Trapezius/Spleni/Erector Spinae
SCM/Scaleni/Spleni/ES
SCM/Scaleni/ES/Spleni
*SCM & Scaleni rotate opposite
Flexion - 45 degrees
Rectus Abdominis/psoas
Extension - 45 degrees
Erector Spinae
Sidebending - 45 degrees ABS/ES/Quadratus Lumborum/psoas
Rotation - 45 degrees
Obliques/ES

REMEMBER: Range of motion only comprises 1/4th of somatic dysfunction!!!

T.A.R.T. Try to alleviate and improve the others.

GATE THEORY OF WALL AND MELZACK

According to this theory, the substantia gelatinosa acts as a gating mechanism for the
control of afferent input to the spinothalamic neurons. The activity in pain carrying slow,
small unmyelinated C fibers keep the gates open and activation of fast, large myelinated
A delta fibers closes the gate. Impulses carried by the larger faster fibers are thought to
cause synaptic inhibition of the tracts carrying pain perception (C fibers). Under this
gate control theory, on the basis of all afferent stimuli, the neurons of the spinal cord
would decide whether or not a particular event should be reported to the brain as being
painful.
The spray and stretch technique for the treatment of trigger points is believed to act
through this theory. "The vapocoolant or TENS unit activates cold sensitive receptors

which report centrally via fast fibers. The afferent volley conveyed through these fast
fibers blocks the trigger point nociceptive impulses transmitted by slow fibers at the
substantia gelatinosum (lamina 5). This allows the operator to stretch the muscle
containing the trigger point without pain or reflex spasm."

Coolant Spray(or TENS)

Deep pain is blocked

Krause fibers

Muscles can be stretched

and reset

Gate is blocked(dorsal horn)

PAIN
Fast fibers ascend the cord via the neospinothalamic tracts (new). Slow fibers ascend
the cord via the paleospinothalamic tracts (old).
The fibers enter the dorsal horn, may ascend or descend a few segments, synapse at
the substantia gelatinosa which precedes the posterior grey matter, then cross over the
cord to ascend ultimately to among other areas the thalamus (and periaquaductal grey
matter of the ventricles) and cortex.
Pain from the viscera is transmitted via the sympathetic nerves. Exceptions include the
cervix, upper vagina, bladder trigone, prostate and the esophagus, trachea, and main
bronchi, which transmit pain via the parasympathetics (2). Remember, however, that
there are no parasympathetic fibers in the extremities. Autonomic mediated pain from
an extremity (reflex sympathetic dystrophy) is the result of sympathetic activation and
During inflammation of an organ, the appendix for example, pain is first recorded in the
visceral layer which obviously refers pain to the embryological origin (around the
umbilicus) then inflames the parietal layer (and peritoneum) which stimulates the
somatic nerves which are dermatomally related, in this instance to the right lower
quadrant of the abdominal wall. Thusly the pain of appendicitis moves because of
different neural activation; first the visceral then somatic. In addition, the organs are
insensitive to burning, cutting, heat and cold but are sensitive to traction, distension,
anoxia or contractions.

FIBROMYALGIA
Pathogenesis and Clinical Presentation: Largely unknown. Look for a preceding
traumatic event. Abnormal levels of serotonin and norepinephrine and substance P.
Disturbances of stage 4 (non-rapid eye movement, non-REM). Female, pain, stiffness
and fatique. Total body pain for greater than 3 months in at least 11 of 18 areas:
1. Occiput, suboccipital mm
2. Low cervical, anterior intertransverse process space C5-7
3. Trapezius
4. Suprapinatus
5. Second rib at costochondral junction
6. Lateral epicondyle
7. Gluteals
8. Greater trochanter
9. Knee (medial knee fat pad)
Note: 9 areas bilaterally equals 18 total. You need at least 11 of the above (bilaterals
count for two areas) to secure a diagnosis of Fibromylagia. In addition, axial spinal pain
is important as Is having pain in 3 of the four quadrants of the body; ie, my right arm,
back and both lower extremities hurt all the time.
Treatment includes
Cardiofitness

OMT,

Tricyclics,

SSRIs,

Cognitive

Behavioral

Therapy,

MISCELLANEOUS TIDBITS
1st rib: most dysfunctions are of exhalation restriction. Rib is stuck up.
In a question regarding scoliosis that only refers to the side of the convexity of the
curve, this will indicate the side of the rotation. Sibebending will be opposite.
Ex: convexity to the right = rotated right, sidebent left.
Piriformis tenderpoint for counterstrain is between the PSIS and the Greater
Trochanter.
L5 nerve root supplies motor innervation to the extensor hallicus longus.
Muscles of the Pelvic Diaphragm = Levator Ani and Coccygeus. The innervation is
from S2-S4
The first rib that you feel below the tip of the scapula is the 8th rib. Important
landmark for centesis of the pleura.