Savarese (for OPP shelf) 2017
introduced counterstrain tenderpoints
Jones
lateral collateral lig
O: femur I: fibula
medial collateral lig
O: femur I: tibia also articulates with medial meniscus
quadratus lumborum
O: iliac crest & iliolumbar lig I: TP of L1-4 & R12 A: SB the trunk, inspiration
Piriformis
O: inf ant aspect of sacrum I: greater trochanter of femur A: ext rotates, extends thigh & abducts thigh with hip flexed N: S1&2 roots Approx 11% pop have sciatic nerve running through the belly--> hypertonicity cause but pain radiating down thigh (but not usually below knee)
coccygeous
O: ischial spine I: coccyx & sacrum
adductor magnus
O: ischiopubic ramus and ischial tuberosity I: linea aspera of the femur; the ischiocondylar part inserts on the adductor tubercle of the femur A:adducts, flexes, and medially rotates the femur; extends the femur (ischiocondylar part)
vastus lateralis
O: lateral intermuscular septum, lateral lip of the linea aspera and the gluteal tuberosity I: patella and medial patellar retinaculum A: primary extensor of the knee
Lower GI SNS level
T12-L2 via least splanchnic n & inf mes gang After splenic flex (distal 1/3 transverse colon, desc & sig colon, rectum)
level of spine at sternal notch
T2
Resp System SNS level
T2-7
arms SNS level
T2-8
level of spine of scapula
T3
dermatome at nipple
T4 dermatome
level of spine at sternal angle
T4, R2
UpperGI SNS level
T5-9 via greater splanchnic n & celiac gang Anything b4 lig of treitz (stomach, liver, GB, spleen, pt of pancreas & duo)
Entire GI SNS level
T5-L2
facilitation from som dys causes
TART in offending unit & surrounding structures via interneuron release of bradykinins, serotonin, histamines, potassium, prostaglandins, substance P, and leukotrienes--> TART via local vasoD & tisssue text change, muscle spasm--> asymetry
Wright's test
TOS -pectoralis minor muscle at coracoid process -hyperabducting the arm above the head with some extension -positive with a severely decreased or absent radial pulse.
treatmetn for lymph congest
Thoracic Inlet Release- Improve lymphatic return in left and right lymphatic ducts
types of compression causing TOS
cervicle rib excessive tension of the andt or middle scalenes somatic dys of clavicle or upper ribs abn insertion of pectoralis minor
treatment for Psoas syndrome
acute: ice counterstrain followed by ME or HVLA to lumbar dys dont use heat initially, stretching acute psoas spasm may cause spasm chronic: stretch
cubitis varus
adduction of the ulna id som dys present carry angle <3
scalenes
ant: O=post tubercle of TP of cer vert; I= R1 mid: O=post tubercle of TP of cer vert; I= R1 post: O=post tubercle of TP of cer vert; I= R2 SB neck to same side individually & flex Aid in resp TP= post to cloavicle at base of neck
compartment most often to get compartment syndrome
anterior
minor motions of the ankle
anterior glide of the talus (with plantar flexion) and posterior glide of the talus (with dorsiflexion)
most common injured lig in foot
anterior talofibular lig (ATF= Always Tears FIrst)
Sensation for L3
anterior thigh just above knee
Sensation for L1
anterior thigh just below inguinal ligament
contraindications for celiac gang, sup mes, inf mes releases
aortic aneurysm
treatment of mild scoliosis
conservative management: PT, Konstancin exercises (series of exercises proven to improve pt with postural decompensation), OMT (not intended to completely straighten) improve flexibility & strengthen trunk & abs
treatment of cauda equina syndrome
emergent surg decompression of cauda equina imprrative; otherwise irreversibel paralysis may result
CN X PNS
heart bronchial tree lower 2/3 eso stomach sm intestine liver GB pancreas asc & trans colon (1st 1/2 colon) ovary & testes kidney & up ureter
acute low back pain that has electric type pain that shoots down leg, after trauma
herniation
spina bifida meningomyelocele
herniation fo meninges +nerve roots--> neuro defects
spina bifida meningocele
herniation meninges
key rib in exhale dys
highest one in group
R2
large tuberosity on shaft for serratus ant
Sensation for C5
lateral aspect of elbow
Navicular som dys of transverse arch
lateral edge will glide toward the plantar surface
Sensation for C6
lateral forearm and thumb
Sensation for S1
lateral malleolus
L UE lymph drains into
left (main) duct
R sulcus deeper L ILA post & slightly inf Lumbar curve convex to R pos seated flex on R spring of R base present spring of L ILA restricted spring at poles of L oblique restricted neg lumbosacral spring test L5 SB L Rot R
left on left
forward sacral torsion
left on left right on right
L sulcus shallow R ILA ant and slightly sup Lumbar curve convex to L pos seated flex test on L sspring at the L base restricted spring at R ILA is present spring at poles of R oblique axis is restricted pos lumbosacral spring test' pos backward bending test L5 flex/ext, SB R Rot R
left on right
eccentric contraction
lengthen of muscle duing conraction due to ext force
motion of brain & cord on expiration of prm
lengthens & thins
Klumpke's pasly
less common brachial plex injury, injury to C8-T1 paralysis occurs in the intrinsic muscles of the hand
treatment from herniated nucleus pulposus
less than 5% surgical candidates most treated conservatively--> bed rest for no more than 2 days, indirect techniques followed by gentle direct tech HVLA contra
C2-7 motion
like T2 50% of flex/ext, & rot C2-4 more rot C5-7 more SB
sick pts frequenct of omt
limit OMT to few key areas
peroneal nerve
motor: short head of biceps femoris, evertors and dorsiflexors of the foot, and most extensors of the toes sensory: lower leg and dorsum of foot
posterior innominate rot dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
superior innominate shear dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
superior pubic shear dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
ant innominate rot dynamic findings
pos standing flex ipsi post innominate rot restricted ipsi ASIS restricted to compression ipsi
spencer technique
test individual moritons of shoulder
typical rib landmarks
tubercle (articulate w TP) head (art w vert at level & above) neck angle shaft
ASIS sup ipsi PSIS inf ipsi short leg ipsi )or compensation for anatomic long leg) pos standing flex ipsi ASIS restricted to compression ipsi
posterior innominate rot
acquired scoliosis
tumor, infection, osteomalacia, sciatic irritability, psoas synd, short leg synd
middle transverse axis of sacrum
postural motion
Joint Mobilization using muscle force
restores normal range of motion of joint using muscle contraction. (contracting the hip flexors helps pull the innominate anterior in a posterior innominate dysfunction)
an radial head findings
restricted pronation of the forearm restricted post glide of radial head
post radial head findings
restricted supination of forearm restricted ant glide of radial head
torticollis
restriction due to SCM
2nd most common somatic dys of shoulder
restriction in abduction
least common som dys of shoulder
restriction in extension
most common somatic dys of shoulder
restriction in int & ext rot
pathogenesis of lateral epicondylitis
result of overuse of forearm extensors & supinatrs (tennis & turning screwdriver)
scapulothoracic joint
scapula--ribcage
Apley's Scratch
screen exam for gross ROM of shoulder
relative contraindications for cranial
seizure history or dysonia traumatic brain injury
Primary knee flexors
semimembranosus & semitendinosus
symptoms of compartment syndrome
severe unrelenting pain after and during exercise anterior tibialis muscle is hard and tender to palpation, pulses are present and stretching the muscle causes extreme pain
motion of brain & cord on inspiration os prm
shortens & thickens
Acute cases frequency of omt
shorter interval btwn, as they respond, interval inc
inc pain when stand/walk, pos thomas test, tender poind med to ASIS, ***T2 dys of L1/2***, pos pelvic shift test to the contra side, sacral dys on oblique axis, contralateral piriformis spasm
sign & symp for Psoas syndrome
weakness & dec reflexes associated with affected nerve root sensory deficit over corresponding dermatome pos straight leg raise test
signs & symp from herniated nucleus pulposus
saddle anesthesi, dec deep tendon reflexes, dec rectal sphincter tone, loss of bowel & bladder control
signs & symp of cauda equina syndrome
inc pain with extension-based activities tight hamstrings b/l stiffed-legged, short-stride, waddling type gait no neuro deficits pos vert step off sign
signs/symp of Spondylolisthesis
(back strain/sprain) inc pain with activity or prolonged standing/sitting, inc muscle tension
signs/symp of som dys lumbosacral spine
worsened in ext (standing/walking/lying supine)
signs/symps of spinal stenosis
ape hand
similar to claw hand but also has wasting of the thenar eminence and the thumb is adducted results from median nerve damage
Guyon's canal contents
ulnar nerve
floating ribs
unattached to sternum via cartilage of the rib superior
R sulcus shallow R ILA dignificantly sup R ILA slightly ant pos seated flex on R spring at R sulcus restricted spring at R ILA present pos lumbosacral spring pos backward bending test
unilateral sacral extension on the L
L sulcus shallow L ILA dignificantly sup L ILA slightly ant pos seated flex on L spring at L sulcus restricted spring at L ILA present pos lumbosacral spring pos backward bending test
unilateral sacral extension on the R
R sulcus deeper R ILA significantly inferior R ILA slightlt post pos seated flex test on R spring at R sulcus present spring at R ILA restricted
unilateral sacral flexion on the left
L sulcus deeper L ILA significantly inferior L ILA slightlt post pos seated flex test on L spring at L sulcus present spring at L ILA restricted
unilateral sacral flexion on the right
Oculocephalogyric reflex
uses extraocular muscle contraction to reflexively affect the cervical and truncal musculature
fibular anterior glide
with protonation (dorsiflex, eversion, & abduction) causes the talus to push the distal fibula postly and reciprocally the prox fibula will mve antly
fibular posterior glide
with supination (plantarflex, inversion, adduction) causes anterior talofibular lig to pull the distal fibula antly--> prox move postly
inhalation dys
wont move caudad during exhalation
exhalation dys
wont move vephalad on inhalation
signs/symps of spinal stenosis
worsened in ext (standing/walking/lying supine)
Motor for C6
wrist extensors
Developmental dislocation of the hip
encompasses the severity spectrum from mild acetabular dysplasia to frank dislocation. Hip X-ray would have demonstrated a shallow acetabulum with a completely or partially subluxed femoral head
CN VIII
exits: Int'l acoustic meatus Som Dys: Sphenoid, temporal, occiput Symp: ***Tinnitus, vertigo or hearing loss***
CN IX
exits: Jugular foramen Som Dys: temporal, occiput
CN X
exits: Jugular foramen Som Dys: temporal, occiput, ***OA, AA, C2*** Symp: Headaches, arrhyth- mias, Gl upset, respira- tory problems
CN II
exits: Optic canal Som Dys: Sphenoid, occiput Symp: Visual changes
CN XI
exits: Spinal division (C1-C6) enters foramen mag- num joins with the cra- nial division and exits the jugular foramen Som Dys: temporal, occiput Symp: Tenderness in the SCM or trapezius
CN IV
exits: Superior orbital fissure Som Dys: Sphenoid, temporal Symp: Diplopia
CN VI
exits: Superior orbital fissure Som Dys: Sphenoid, temporal Symp: Diplopia, esotropia
CN III
exits: Superior orbital fissure Som Dys: Sphenoid, temporal Symp: Diplopia, ptosis or accomodation problems
Boutonniere deformity
extension contracture of MCP & DIP flexion contracture of the PIP results from rupture of the hood of the extensor tendon at the pip often assoc with RA
Claw hand
extension of MCP flexion of PIP & DIP results from median and ulnar injury (loss of intrinsic muscles and overactivity of the extensor muscles)
intercostals
external: course down & med internal: course up & med innermost: course up & med subcostal: attach to rib & rib 2-3 below
int rotation of hip dys
finding: hip restricted in ext rotation Et: spasm of int rotators (glut min, semimembranosis, semitendinosis, TFL, adductor mag, adductor long)
ext rotation of hip dys
finding: hip restricted in int rotation Et: piriformis or iliopsoas spasm
Motor for T1
finger abduction
claw toes
fixed flexion deformity of the proximal interphalangeal joints associated with hyperextension of the metatarsophalangeal articulations. All toes, especially the lesser toes, tend to be effected
swan-neck deformity
flex contracture of MCP & DIP extension contracture of the PIP result from contracture of teh intrinsic muscles of hand and is often assoc with RA
Dupuytren's contracture
flex contracture of MCP & PIP usually seen with contractue of last 2 digits unlike bishops, its due to contracture of the palmar fascia
6 types of SBS strains
flex/ext torsion SB & rot vertical lateral compression
functional scoliosis
flexible, can be partially or completely corrected with SB to opposite side may progress to structural
Deep intervertebral muscle treatment with FPR
for C5 E SrRr 1. pt supine w/ head beyond end of table, resting on pillow on physician's lap 2. pt in neutral, straighten the cervical lordosis by flexing the head slightly. 3. applies the facilitating force 4. place C5 in E SrRr using the head as a lever. 5. The position is held for 3 to 4 seconds. 6. release and reevaluates
bunion
hallux valgus, is a lateral deviation of the proximal phalanx of the first toe associated with soft tissue changes, pain, swelling, and inflammation at the aspect of the head of the first metatarsal, which is angled medially
C2
has dens
C2-6
have bifid spinous processes articular pillars btwn sup and inf facets, post to transverse process, palpated
Flat back posture
head forward cervical spine has slightly increased lordosis thoracic spine slightly kyphotic in upper portion then flattens in lower segments lumbar lordosis flattened hips and knees extended
Swayback posture
head forward cervical spine lordotic thoracic spine kyphotic decreased lordosis of lumbar spine posterior tilt of pelvis hip and knee joints hyper-extended
anterior glide of the hip
head of femur glide antly with ext rotation
posterior glide of the hip
head of femur glide postly with int rotation
Military posture
head tilted slightly posteriorly cervical curve and thoracic curve normal anterior cervical and posterior thoracic deviation from plumb line anterior pelvic tilt knees extended ankles plantar flexed
adrenal medulla SNS level
T10 btwn ligament of Treitz & splenic flex?
lower ureters SNS level
T12-L1 via inf mes gang after splenic flex?
prostate SNS level
T12-L2 after splenic flex
Braggard's Test
dorsiflexes the foot to stretch the sciatic nerve
protonation of ankel
dorsiflexion, eversion & abduction***
tinnitus, vertigo, hearing loss
dys of CN VIII (dys of Sphenoid, temporal, occiput)
indications for sacral inhibition
dysmenorrhea labor pain from cerv dilation constipation
motion of clavicle
each end can glide (ant/post or sup/inf--> seesaw) can rotate w/int/ext rot of arm
Motor for C7
elbow extensors
Motor for C5
elbow flexors
findings for an inhalation dys of pump handle rib
elevated antly ant part moves cephalad on insp ant narrowing of IC space above dys sup edge of post rib angle prominent tender & tissue change at costochoneal junction, chondrosternal junction, & post rib angles
findings for an inhalation dys of bucket-handle rib
elevated latly lat part (shaft) of ib moves up on insp lat narrowing of IC space above lower edge of rib shaft is prominent tender & text change at IC muscles on mid-axillary line, & post rib angles
SI joint
inferted L shaped joint with upper and lower arms converging antly at S2
isotonic contratction
"approximation" of origin & insertion, no change in tension operator force<patient force
concentric contraction
"aproximation" of origin & insertion
chapman point
"gangliform contractions" -somatic manifestation of visceral dysfunction pressure will elicit sharp, nonradiating, and exquisitely distressing pain Ant: smooth, firm, discretely palpable nodules, approximately 2-3 mm in diameter, located within the deep fascia or on the periosteum of a bone Post: between the spinous and transverse processes of vertebrae, described as rubbery
what causes facilitation
"sensitized" intemeurons will have an increased or exaggerated output to the initiating site as well as other areas (neighboring muscles, or organs via autonomic efferents)
cranial rhythmic impulse
(CRI) rhythmic impulses of CSF at 10-14 cycles/minute
reciprocal tension membrane
(RTM) any motion of the brain & csf that can move the dural membranes will thus move its attachements to the cranial bones (inelastic rope)
sphenobasilar synchondrosis
(SBS) articulation of the sphenoid with occiput
Transient synovitis of the hip
(also known as toxic synovitis) is a nonspecific, common, unilateral inflammatory arthritis involving the hip joint, which occurs in children under 10 years of age most common cause of limp with hip pain in children. The male to female ratio is 3-5:1. There maybe a history of a preceding URI. X-ray of the hip is normal treat with NSAID idopathic
treat of som dys lumbosacral spine
(back strain/sprain) counterstrain, ME, HVLA decrease restrictions in other areas that may alter structure-functionrelationship of lumbosacral spine
signs/symp of som dys lumbosacral spine
(back strain/sprain) inc pain with activity or prolonged standing/sitting, inc muscle tension
Spring ligament
(calcaneonavicular ligament) one of the plantar ligs strengthens and supports the medial longitudinal arch
common peroneal nerve
(common fibular nerve) lies directly post to the prox fibular head therefore post fibular head or fracture of the fibula may disturb the function of this nerve
inherent motion of sacrum
(craniosacral) about superior transverse axis at S2 during cranial flexion, sacrum extends/counternutates during cranial extension, sacrum flexes/nutates
inferior innominate shear
(innominate downslip, inferior innominate subluxation)
superior innominate shear etiology
(innominate upslip, superior innominate subluxation) fall on the ispilateeral but or a mis-step
Plantar aponeurosis
(plantar fascia) one of the plantar ligs Strong, dense, connective tissue that originates at the calcaneus and attaches to the phalanges. Chronic irritation to this structure may cause calcium to be laid down along the lines of stress, leading to a heel spur.
iliopsoas
(psoas major & minor) O: T12-L5 vert bodies I: lesser trochanter A: flexor of hip mintains the lumbosacral angle
ME for R forearm restriction to pronation
(radial head ant) Treatment Position: Seated 1. Support pt's R elbow L hand. 2. Place R hand at distal end of pt's R forearm & pronate to initial resistance. 3. Direct the patient to supinate the R forearm against an equal counterforce supplied through your R hand. 4. Maintain force 3-5s, then both relax. phys re-engage new barrier. Repeat 3-5 times& recheck findings.
ME for R forearm restriction to supination
(radial head posterior) Treatment Position: Seated 1. Place R hand at distal end of pt's R forearm & supinate to initial resistance as you monitor with the other thumb at the radial head. 2. Direct the patient to pronate the R forearm against equal resistance supplied through your right hand. 3. Maintain the forces long enough to sense the patient's contractile force at the localized segment or area (usually 3-5 seconds). 4. pt & phys relax & phys takes slack to the new point of initial resistance. 5. Repeat 3-5 times & recheck findings.
treat sacral som dys
(sacral inhibition) Purpose: 1) normalize hyperpara in L colon & pelvic structures 2) reduce labor pain from cervical dilation
lumbosacral spring test
(spring test) assesses whether or not the sacral base is tilted posterior -patient prone position -physician place the heel of the hand over the lumbosacral junction. -Gentle and rapid springing is applied downward onto the lumbosacral junction. -positive when there is little or no springing. --> ***indicative of the sacral base moving posterior. ***
Articulatory techniques
(springing techniques, low velocity/moderate amplitude) passive, direct engage restric barrier & use gentle repetitive forces to inc ROM add resp & ME activation to further streth
O'Donahue's triad
(terrible triad) common knee injury resulting in the injury to the ACL, MCL and medial meniscus
infraspinatus
*** O: infraspinatous fossa I: greater tubercle of the humerus (middle facet) A:ext rotate arm (one of primary ext rot of shouler N:suprascapular nerve
subscapularis
*** O: medial two-thirds of the costal surface of the scapula (subscapular fossa I: lesser tubercle of the humerus A: internal rot arm; assists extention of the arm (one of primary int rot of shoulder) N: upper and lower subscapular nerves (C5,6)
supraspinatus
*** O: supraspinatous fossa I: greater tubercle of the humerus (highest facet) A: abduct arm N: suprascapular nerve (C5,6)
teres minor
*** O: upper 2/3 of the lateral border of the scapula I: greater tubercle of the humerus (lowest facet) A:ext rotate arm (one of primary extensors & ext rot of shoulder) N:axillary nerve (C5,6)
dural attachments
*** foramen magnum, C2, C3, S2***
sacral torsion rules
***1) then L5 SB, sacral oblique engaged on the same side 2) when L5 rotated, sacrum rot opposite way on oblique axis 3) seated flexion test on opposite side of oblique axis*** torsion=twisting of 2 (rotate opposite)
Myofascial release procedure
***1. Palpate restriction 2. Apply compression (indirect) or traction (direct) 3. Add twisting or transverse forces 4. Use enhancers 5. Await release***
rotator cuff
***4 muscles of shoulder that hold head of hermerus in glenoid fossa SITS supraspinatus infraspinatus teres minor subscapularis***
contraindications for HVLA
***Absolute 1. Osteoporosis 2. Osteomyelitis (including Pott's disease) 3. Fractures in the area of thrust 4. Bone metastasis 5. Severe rheumatoid arthritis - esp cervical; RA may weaken the transverse ligament of the dens, resulting in atlantal- axial subluxation--> catastrophic neurologic damage 6. Down's Syndrome - laxity may develop in the transverse ligament Relative 1. Acute whiplash 2. Pregnancy 3. Post-surgical conditions 4. Herniated nucleus propulsus 5. Patients on anticoagulation therapy or hemophiliacs 6. Vertebral artery ischemia (positive Wallenberg's test)***
anterior L5 tenderpoint
***One cm lateral to the pubic symphysis on the superior ramus*** patient supine, knees and hips flexed and markedly rotated away
Spondylolisthesis
***ant displacement 1 vert in relation to one below often at L4/5 usually due to fatigue fractures in pars interarticularis of the vert
Hip-drop test
***assess SB ability of lumber spine & thoracolumbar junction*** -patient standing -physician locates the most superior and lateral aspect of the iliac crests -patient bend one knee without lifting the heel from the floor. -lumber spine should sidebend toward the side contralateral to the bending knee, producing a smooth convexity in the lumbar spine on the ipsilateral side. -ipsilateral iliac crest should drop more than 20-25°. -positive test is indicated by anything less than a smooth convexity in the lumbar spine, or a drop of the iliac crest of less than 20-25°, and alerts the physician to a somatic dysfunction of the lumbar or the thoracolumbar spine
Spondylolysis
***defect of pars interarticularis without ant displacement of vert body findgins similar to spondylolisthesis ***oblique X-ray ID as a "collar" on the scotty dog***
what position is ankle more stable
***dorsiflexion***
DRIP sacral motions
***dynamic resp inherent/innominate postural***
poor suckling in newborn due to
***dys CN XII from occipital condylar compression dys of CN IX & CN X at the jugular foramen***
purpose of hip-drop test
***evaluate SB of lumbar spine***
Parallelogram efect
***inc in cary angle-->ulna ab-->adduction of wrist dec in carry angle--> ulna add--> abd of wrist***
Erb-Duchenne's palsy
***most common brachial plex injury upper arm paralysis injury to C5&6 nerve roots usualy during childbirth result in paralysiss of deltoid, ext rotators, biceps, brachioradialis, supinator musles***
spondylosis
***radiographical term for degenerative changes within the intervertebral disc and ankylosing of adjacent vert bodies
SITS
***supraspinatus infraspinatus teres minor subscapularis***
Wallenberg's Test
-To test for vertebral artery insufficiency -supine -flex patient's neck -holding for ten seconds -extend the neck holding it for ten seconds. -same is done for head and neck rotation to the right and left, rotation with neck extended -positive test when the patient complains of dizziness, visual changes, lightheadedness, or eye nystagmus occurs. -there are many variations: Underberg's test= perfomed with the neck backward bent and the head fully rotated to either side--> If patient develops vascular or neurologic symptoms, HVLA is contraindicated
3 places for TOS compression
-btwn ant & mid scalenes - btwn clavicle & R1 -btwn pec minor & upper ribs
reciprocal inhibition
-contract antagonist muscle -signal to cord reflex arc--> agonist relaxes direct or indirect: -direct- extend bad muscle, contract opposite muscle--> new barrier -shorten bad muscle, contract opposite muscle
Postisometric relaxation
-engage restrictive barier -pt contract equally against the offered counterforce -Golgi senses change in tension and causes reflex relaxation of the agonist muscle fibers -passive stretch to new restrictive barrier
Spencer technique
-good for inactivity, adhesive capsulitis following injury -pt in lat recumb -stabilize scapula -can use ME at the restrictive barriers Stage I: Stretching tissues and pumping fluids with the arm extended Stage II: Glenohumeral extension/flexion with the elbow flexed Stage III: Glenohumeral flexion/extension with the elbow extended Stage IV: IVa: Circumduction and slight compression with the elbow flexed/extended. IVb: Circumduction and traction with the elbow extended. Stage V: Adduction and external rotation with the elbow flexed Stage VI: Abduction with Internal Rotation with the arm behind the back Stage VII: Stretching tissues and pumping fluids with the arm extended.
interstitial fluid pressure
-normal= 6.3 mmHg at rate of 120cc/hr -inc--> inc lymph absorb -0mmHg causes lymph caps to collapse
sign & symp of TOS
-scalenes, cerv rib, or clavicle can be tender -pulses in UE may be normal or diminished -pos adison test (scalenes) -military posture (btwn clavicle & R1) -hyperextension test (under pec minor)
articulatory procedure procedure
1. Move the affected joint to the limit of all ranges of motion. Once a restrictive barrier is reached slowly and firmly, continue to apply gentle force against it. 2. At this time you may use respiratory cooperation or muscle energy activation to further increase myofascial stretch of tight tissues. 3. Return the articulation to its neutral position. 4. Repeat the process several times. 5. Cease repetition of motion when no further response is achieved.
thoracoabdominal dia release
-used to inc pressure gradients so can inc lymph return Indirect 1. Patientseated. 2. Physician standing behind patient. 3. Pass your hands around the thoracic cage (under the patient's arms) and introduce your fingers underneath the costal margin. 4. Test for motion by gently rotating the thoracic tissues. 5. Treatment phase: With your fingers still underneath the costal margin, hold the thoracic tissues in the direction which it moves more freely. Allow the fascia to unwind, until it settles into a rhythmic vertical motion.
Grade 1 Spondylolisthesis
0-25% slip
CN V
1 exits:Superior orbital fissure Som Dys: Sphenoid, temporal Symp: Decreased sensation to the eyelid and scalp 2 exits: Foramen rotundum Som Dys: Sphenoid, temporal Symp: Tic Douloureux 3 exits: Foramen ovale Som Dys: Sphenoid Symp: Decreased sensation to the mandible
treatment for short leg syndrome
1) OMT for spine & lower extremities 2) standing postural x-ray to quantify diff in height of fem head--> heel lift if diff >5mm
how does motion of L5 influence sacral motion
1) SB L5--> sacral oblique axis engaged on same side 2) Rot of L5--> sacrum rotate to opposite side
General procedure of HVLA
1) diagnose, move to restric barrier (in as many planes as possible) 2) pt relax--take deep breath 3) thrust (w/out backing off) 4) reevaluate
treat lymph of UE
1) open thoracic inlet 2)redome thoraco-abdominal dia 3) post axiallary fold technique
Heel lift guidelines
1) should be applied to short leg side 2) the final lift height should be 1/2-3/4 the measured leg length discrepancy (unless prosthesis or hip fracture) 3) "fragile" (elderly, arthritic, osteoporotic, or acute pain) pt should begin with 1/16" heel lift & increase 1/16" evry 2 wks 4) "flexible" pt should begin with 1/8" heel lift and inc by 1/8" evry 2 wks 5) max 1/4" may be applied to inside of shoe; if more needed, apply to then needs to be applied to outside of shoe 6) max lift = 1/2"; if more needed, ipsilat ant sole lift to keep pelvis from rot to opposite side
order of lymp treatment
1) thoracic inlet 2) rib raiding or paraspinal inhibitions 3) redome diaphram 4)lymph pump
Counterstrain steps
1)find tenderpoint 2)palpate tenderpoint & compare to other side 3) place pt in optimal comfort by shortening muscle until 70% reduction in pain; while monitoring tenderpoint 4) maintain for 90s 5) slowly return to neutral 6)recheck, no more than 30% should remain
signs & symp of short leg syndrome
1)sacral base unleveling (lower on short leg side) 2) ant innominate rotation on short leg side 3) post innominate rotation on short leg side 4)lumbar spine SB away & rot toward short leg side 5) lumbosacral angle inc 2-3deg 6) 1st iliolumbar lig, then SI lig become stressed on short leg side
atypical ribs
1,2,11,12 (10)
parts of spinal reflex
1. An afferent limb (sensory input) 2. A central limb (spinal pathway) 3. An efferent limb (motor pathway) ...spinal reflex is actually part of a vast ever-changing network of neurons that is finely tuned to regulate the activity of the body.
HVLA for L3 N SlRr with TP up
1. Patient in L lat recumb (post tp up). 2. Stand in front 3. Flex patient's legs until palpate motion at L3. 4. Straighten patient's inf leg. 5. Hook sup foot in lower leg's popliteal fossa. 6. Pull patient's inferior arm out (toward you) to rotate the torso and up (cephalad) to induce right sidebending down to the dysfunctional segment 7. Place one arm in patient's axilla and the other on the patient's iliac crest. 8. deep breath in and exhale. 9. At end exhalation, apply a HVLA thrust by rotating the patient's pelvis forward and toward the table. 10. Retest the range of motion.
HVLA for L3 N SlRr with TP down
1. Patient in R lat recumb (post tp down). 2. Stand in front 3. Flex the patient's legs until you palpate motion at L3 4. Straighten patient's inf leg. 5. Hook the superior foot in the lower leg's popliteal fossa. 6. Pull patient's inferior arm out (toward you) to rotate the torso and down (caudad) to induce right sidebending down to the dysfunctional segment. 7. Place one arm in the patient's axilla and the other on the patient's iliac crest. 8. deep breath in and exhale. 9. At end exhalation, apply a HVLA thrust by rotating the patient's pelvis forward and toward the table. 10. Retest the range of motion.
Rib Raising procedure
1. Patientsupine. 2. Physician seated at the side of the patient. 3. Place your hands under the patient's thorax, contacting the rib angles with the pads of your fingers. 4. Apply gentle traction. 5. Raise the patients ribs by pushing your fingertips upwards and lowering your forearms (It is easier to push your fingers upward by using your forearm as a lever)
Diag for lymph dys
1. Supraclavicular fullness from lymph congest of head & neck. (sinusitis) 2. Post axillary fold fullness from lymph congest of arm (post-mastectomy lymphedema) 3. Epigastric fullness from organ congest of chest or abdomen. (cirrhosis) 4. Inguinal fullness from congest of LE. (infection) 5. Popliteal fullness from congest of leg (thrombophlebitis) 6. Achilles fullness from congest of ankle/foot (sprained ant talofibular lig) other dys: tense pelvic dia, restricted thoracic cage motion, paravertebras spasm-->inc lumb lordosis--> flat dia, chapmans from organ lymph dys, closed thoracic inlet, cranial base strain
HVLA using SBing thrust for C6 E SrRr
1. The patient supine and the physician at the head of the table. 2. The MCP joint of the left hand is placed at the articular pillar of C6. 3. Grasp the patient's head and flex the neck to the C6 - C7 joint. Induce a small amount of extension by applying anterior translation at C6 4. Sidebend the neck to the left until localized at the C6- C7 joint. 5. Rotate the neck to the right to limit motion of (lock) the above facets. 6. Apply a sidebending HVLA thrust by translating C6 to the right. The direction of the thrust should be directed toward the patient's opposite shoulder. 7. Re-evaluate
HVLA for AA Rr
1. The patient supine and the physician at the head of the table. 2. The palm of the physician's left hand grasps the patient's chin. 3. The index finger of the physician's right hand is placed by the soft tissue of the AA joint. The physician's right thumb contacts the patient's right zygomatic process, avoiding the right mandible. 4. The patient is asked to inhale, then exhale fully. 5. At the end of exhalation, the physician applies a left rotational high velocity, low amplitude thrust using the right index finger as a fulcrum 6. Re-evaluate
HVLA for T7 N SlRr
1. The patient supine and the physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process). 2. Patient crosses arms opposite over adjacent. 3. Place the thenar eminence under the posterior transverse process of the dysfunctional segment. 4. With the other hand flex the patient's torso to the T7 -T8 joint space. 5. Sidebend the patient to the right (away from you) engaging the restrictive barrier. 6. Have the patient take a deep breath in and exhale. 7. At end exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence).
HVLA for T7 F SrRr
1. The patient supine and the physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process). 2. The patient will cross his arm over his chest, so that the superior arm is opposite that of the physician. For simplicity this is referred to as "opposite over adjacent". 3. Place the thenar eminence under the posterior transverse process of the dysfunctional segment. 4. With the other hand flex the patient's torso to the 17 -T8 joint space. 5. Sidebend the patient to the left engaging the restrictive barrier. 6. Have the patient take a deep breath in and exhale. 7. At end exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence).
HVLA for T7 E SlRl
1. The patient supine and the physician standing on the right side of the patient (stand on the opposite side of the posterior transverse process). 2. Patient crosses arms across chest opposite over adjacent. 3. Place the thenar eminence under the posterior transverse process of the vertebrae below the dysfunctional segment. 4. With the other hand, flex the patient's torso to the T7 -T8 joint space. 5. Sidebend the patient to the right engaging the restrictive barrier. 6. Have the patient take a deep breath in and exhale. 7. At end exhalation, apply a HVLA thrust directed 45° cephalad toward your fulcrum (thenar eminence).
ME for C3 E RrSr
1. With the distal pad of one finger on the articular pillar of the dys segment, engage the restrictive barrier by reversing the som dys in all three planes of motion 2. Direct the patient to gently straighten his head while you apply an equal counterforce. 3. Repeat steps 4-5 in the above example.
HVLA using rotational thrust for C3 F SlRl
1. patient supine and the physician at the head of the table. 2. Grasp the patient's head and flex the neck slightly. 3. The MCP joint of the thrusting hand is placed at the articular pillar of C3. 4. Flex the head and neck down to C3 and then induce a small amount of extension by applying ant translation at C3. 5. Rotate the head and neck to the right to the restrictive barrier. Right sidebending is achieved by keeping the patient's right temple close to the table. 6. Apply a right rotatory HVLA thrust using the left MCP as a fulcrum. The direction of the thrust should be directed toward the patient's opposite eye. 8. Re-evaluate
HVLA for OA F SrRl
1. patient supine and the physician at the head of the table. 2. Grasp the patient's head and flex the neck slightly. 3. The MCP joint of the thrusting hand is placed at the base of the occiput. 4. Extend the occiput slightly, make sure that extension is limited to only the OA joint. 5. Sidebend the occiput to the left and rotate it to the right to engage the restrictive barrier. 6. Apply a HVLA thrust by translating the occiput to the right. The direction of the thrust should be directed toward the patient's opposite (right) eye. 7. Re-evaluate the range of motion.
ME treatment procedure
1. positions to engage the restrictive barrier (direct treatment) in all planes of motion. 2. instructs the patient to reverse direction 3. The patient contracts the appropriate muscle(s) 4. The physician maintains an appropriate counterforce for 3-5 seconds. 5. patient to relax and the physician also relaxes. Then during the post-isometric relaxation phase, the physician takes up the slack, allowing it to be passively lengthened. 6. Steps 1-5 are repeated for 3-5 times until the best possible increase in motion is obtained.
superficial muscle treatment with FPR
1. pt in neutral position, straighten AP curve 2. apply the facilitating force 3. shorten the muscle 4. hold for 3 to 4 seconds. 5. releases and reevaluates
width of posterior longitudinal lig at L4/5
1/2 of what it was at L1
group rib dys
2+, usually there is key rib that is causing dys in the others--> lowest rib for inhale & highest for exhale
profunda brachial a
1st major branch of brachial a accompanies radial n in its posterior course of the radial groove
Uncommon Compensatory Pattern
20% OA rot R, CT rot L, TL rot R, and LD rot L
Grade 2 Spondylolisthesis
25-50% slip
Bones of the foot
26 Talus Calcaneous Navicular Cuboid 3 Cuneiforms 5 Metatarsals 14 Phalanges
SB/Rot of SBS
3 axes: SB on 2 parallel vert axes (one through foramen mag & ther through center of sphenoid) ("SB" on a transverse plane= rotation) (looks like translation of the SBS--occiput joint) rot on AP axes through SBS (same axis as torsion...rot on a coronal plane); both ends rot together in one way; rot to the same side SBS is rotated
lumbricles
4 1&2 innervated median n 3&4 innervated ulnar n
DTR grade
4/4 Brisk with sustained clonus (up motor n injury) 3/4 Brisk with unsustained clonus (normal/ up motor injury) 2/4 Normal 1/4 Decreased but present (normal/ low motor n injury) 0/4 Absent (lower motor n injury)
Muscle strength grades
5 (normal)- Full range of motion (FROM) against gravity and resistance 4-FROM against gravity with some resistance 3- FROM against gravity with no resistance 2- FROM with gravity eliminated 1- Evidence of slight contractility 0- No evidence of contractility
sacrum
5 fused vert
epidemilogy scoliosis
5% by 15 10% of these have clinival symp male:fem = 1:4
Maverick point
5% of tenderpoints wont improve treat by positioning pt in position opposite of what would typically be used
Prevalence of Spondylolisthesis
5% population 1/2 asymp pt become symp after 20
AA motion
50% of neck rotation rot is only movement
Grade 3 Spondylolisthesis
50-75% slip
anterior rib 2 tenderpoint
6-8cm lat to sternum on rib 2 flex head, SB & Rot toward
Carpal bones
8 Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capate Hamate
Common Compensatory pattern
80% OA rot L, CT rot R, TL rot L, and LD rot R
idiopathic scoliosis
80% cases fam hist
cranial blood drains into
85-95% into venous sinuses 5% into facial veins & ext jugular
when is resp fxn compromised in scoliosis
>50 deg
when is CV fxn compromised in scoliosis
>75 deg
Grade 4
>75% slip
Fryette's 1st law
Neutral, SBR, Opposite sides, group
Innominate inflares static findings
ASIS more medial ipsi--> distance btwn ASIS & umbilicus less than the contra side Ischial tuberosity more lat ipsi
posterior innominate rot static findings
ASIS sup ipsi PSIS inf ipsi short leg ipsi )or compensation for anatomic long leg)
1st cervical segment
AA
motion of shoulder
AB: 180 (120=GH, 60= scapulothoracic--> for every 3 of ab, GH moves 2 & ST moves 1)
inferior innominate shear static findings
ASIS & PSIS more inf ipsi pubic rami inf ipsi long leg ipsi
superior innominate shear static findings
ASIS & PSIS more sup ipsi pubic rami sup ipsi shorter leg ipsi
superior pubic shear static findings
ASIS appear level PSIS appear level pubic bone sup ipsi
Inferior pubic shears static findings
ASIS level PSIS level pubic bone inf ipsi
ant innominate rot static findings
ASIS more inf ipsi PSIS more sup ipsi longer leg ipsi (or comprensation for anatomically short leg)
Innominate outflare static findings
ASIS more lat ipsi--> distance btwn ASIS & umbilicus more than cont side Ischial tuberosity more med ipsi
digastric
Ant belly O: mandible I: hyoid Post belly O: mastoid (temporal bone) I: hyoid A:elevate hyoid, depress mandible
Iliacus tenderpoint
Approximately 7 cm medial to the ASIS Patient supine with the hip flexed and externally rotated
lumber facet orientation
BM backward, medial
thoracic facet orientation
BUL backward, up, lateral
Cervical facet orientation
BUM backward, up, medial
intrinsic forces that affect lymph
CM contraction interstitial fluid pressure
primary respiratory mechanism
CNS + CSF + Dural membranes + cranial bones + sacrum --> function together to control and regulate pulm respiration (secondary resp), circulation, digestion, & elimination
post neck triangle contents
CNXI, cervical plexus, trunks of brachial plexus, occipital a, phenic n, subclavian a&v, subscapular a, subclavian lns
Bracial plex made up of what cerv roots
C5-T1
brachial plex
C5-T1
moderate scoliosis
Cobb angle 20-45 deg
mild scoliosis
Cobb angle 5-15 deg
severe scoliosis
Cobb angle >50 deg resp fxn compromised
Zink
Compensatory patterns
Spurling Test
Compression test -patient seated, -extends and sidebends the C-spine to the side being tested, and pushes downward on the top of the patient's head. -positive if pain radiates into the ipsilateral arm--> distribution can help localize the affected nerve root that is being compressed (due to narrowing of neural foramina)
Chronic texture
Cool, dry, tension, flaccid, ropey, fibrotic
thoracic inlet release
Direct 1. Patient supine with arm abducted to 90°. 2. Physician seated at the side of the patient. 3. With one hand, place your fingers in the patient's supraclavicular fossa and apply traction towards the patient's wrist. 4. With the other hand, move the patient's wrist superiorly until tension develops in the supraclavicular fossa. Hold this until some relaxation is noted. 5. repead 2-3 times
gondads SNS level
T10-11 (same as kid & up ureter) btwn ligament of Treitz & splenic flex?
upper ureters SNS level
T10-11 via sup mes gang same as kid btwn ligament of Treitz & splenic flex?
Myofascial release
Counterstrain, facilitated positional release, unwinding, balanced ligamentous release, functional indirect release, direct fascial release, cranial osteopathy, and visceral manipulation
Kidneys SNS level
T10-11 via sup mes gang same as upper ureter btwn ligament of Treitz & splenic flex?
uterus & cervix SNS level
T10-L2 after ligament of Treitz & splenic flex?
techniques for chapman points
Decrease sympathetic tone, improve lymphatic return and increase myofascial motion associated with visceral dysfunction
signs & symp of patello-femoral synd
Deep knee pain, especially when climbing stairs. The physician may notice atrophy in the vastus medialis, and often the patient will have patella crepitus.
Chronic tenderness
Dull, achy, burning
legs SNS level
T11-L2
Acute texture
Edematous, erythematous, boggy, inc moisture, hypertonicity
sphenopalatine ganglion technique
Enhance para--> encourage thin watery secretions (indicated for thick nasal secretions) short intermittently manual finger pressure intraorally to the sphenopalatine ganglion
Patrick's test
FABERE Test assess pathology of the sacroiliac and hip joint, especially osteoarthritis of the hip -FABERE indicates the positioning of the hip being tested. Flexion, Abduction, External Rotation, then Extension--> hip is put into a figure-4 position -Any pain in or around the hip joint indicates general pathology of that hip joint -place one hand on the contralateral ASIS and the other hand on the knee of the testing leg. Pressure is placed downward on both points, the most important motion being the further extension of the hip. -Pain will be accentuated by any arthritic changes in the hip or sacroiliac join
Schiowitz
FPR
Fryette's 2nd law
Flex/Exend, RSB, same sides, single vert
major motion of lumbar spinw
Flex/Ext
Purpose of Lift technique
Frontal and parietal lifts are commonly used to aid in the balance of membranous tension.
indication for celiac gang, sup mes, inf mes releases
GI dys pelvic dys
0-25% slip
Grade 1 Spondylolisthesis
25-50% slip
Grade 2 Spondylolisthesis
50-75% slip
Grade 3 Spondylolisthesis
>75% slip
Grade 4
Lumbar roll
HVLA for T10-L5 Flexion, extension or neutral lesions can all be treated in the same lateral recumbent position. The physician may treat the patient with the posterior transverse up or the posterior transverse process down (LorR lat recumb) There is only one modification with the patient's position between the two treatments
Vault hold
Index finger - greater wing of the sphenoid Middle finger - temporal bone in front of the ear Ring finger - mastoid region of temporal bone Little finger - squamous portion of the occiput
Facilitated Positional Release D/I, A/
Indirect, Passive
technique for lower GI dys, GU dys, pelvic dys
Inferior Mesenteric Ganglion Release- Reduce sympathetic tone at T12 - L2
ASIS level PSIS level pubic bone inf ipsi pos standing flex ipsi ASIS restricted to compression ipsi
Inferior pubic shear
HVLA for R1 Inhalation dys
Inhalation dysfunctions of rib one cannot be treated using the Kirksville Krunch 1. The patient prone and the physician at the head of the table. 2. Sidebend the head and neck to the side of the dysfunctional rib. 3. Rotate the head and neck away. 4. Place the 1sl MCP on the tubercle of rib 1. 5. Have the patient take a deep breath in and exhale. 6. At end exhalation, apply a HVLA thrust through the thenar eminence. The direction of the thrust should be posterioanterior and caudad.
ASIS more medial ipsi--> distance btwn ASIS & umbilicus less than the contra side Ischial tuberosity more lat ipsi pos standing flex ipsi ASIS restricted to compression ipsi
Innominate inflares
ASIS more lat ipsi--> distance btwn ASIS & umbilicus more than cont side Ischial tuberosity more med ipsi pos standing flex ipsi ASIS restricted to compression ipsi
Innominate outflare
HVLA for R R5 inhale/exhale dys
Kirksville Krunch type for R2-10; can be used for inhal or exhale dys 1. The patient supine and the physician standing on the left side of the patient (stand on the opposite side of the dysfunctional rib). 2. Patient crosses arms opposite over adjacent. 3. Place the thenar eminence under the posterior rib angle of the "key" rib 4. With the other hand flex, the patient's torso and slightly sidebend away from the dysfunctional rib. 5. Have the patient take a deep breath in and exhale. 6. At end exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence).
who established that there is hypersympathetic activity in disease
Korr
unilateral sacral flexion on the right static findins
L sulcus deeper L ILA significantly inferior L ILA slightlt post
Right on right static findings
L sulcus deeper R ILA post and slightly inf Lumbar curve convex left
Unolateral sacral extension on the right static findings
L sulcus shallow L ILA dignificantly sup L ILA slightly ant
left on right static findings
L sulcus shallow R ILA ant and slightly sup Lumbar curve convex to L
at what level does spinal cord terminate
L1/2
psoas synd cause what spinal dys?
L11/2 flex, SB & rot to same side of iliopsoas contracture
level at umbilicus
L3/4 intervertebral disc
Sacral rotation on an oblique axis
L5 rotated to the same side as the sacrum no standardized treatment
Straight Leg Raise Test
Lasegue's test -used in the evaluation of sciatic nerve compression -patient supine -physician grasps the leg being tested under the heel with the hand, and to keep the knee extended, places the other hand on the anterior aspect of the knee -physician lifts the leg upward, flexing the hip -leg is lifted until the patient feels discomfort -Normally, the leg can be raised to about 70-80° of hip flexion. -->if pain, the cause most likely will be due to hamstring tightness or due to problems with the sciatic nerve. -If pain, physician lowers the leg just beyond where the pain was felt, and then dorsiflexes the foot (Braggard's Test) to stretch the sciatic nerve. -If no pain, tight hamstrings and the test is considered negative. -If pain is felt all the way down the leg, this indicates a sciatic origin, and the straight leg raising test is considered positive.
treatment for Right sided CHF Liver and splenic congestion Infection Parenchymal disease of the liver and/or spleen
Liver and Spleen Pumps- Augments pressure gradient to improve lymphatic movement thus, enhancing immune function and remove toxins contraindications; acute hepatitis, friable liver, trauma to liver or spleen
HVLA for L3 E RrSr with Post TP down
Lumbar roll 1. Patient in R lat recumb (post tp down). 2. Stand in front of patient. 3. Flex patient's legs until palpate motion at L3. 4. Straighten patient's inf leg. 5. Hook sup foot in lower leg's popliteal fossa. 6. Pull patient's inferior arm out (toward you) to rotate the torso and up (cephalad) to induce left sidebending down to the dysfunctional segment. 7. Place one arm in patient's axilla and other on patient's iliac crest. 8. patient take deep breath in and exhale. 9. At end exhalation, apply a HVLA thrust by rotating the patient's pelvis forward and toward the table. 10. Retest the range of motion. (Flexion/ext can also be added to further engage another barrier. With patient in the lat recumb, ant motion of torso will produce flex, post motion will produce ext)
HVLA for L3 E RrSr with post TP up
Lumbar roll 1. Patient in the left lateral recumbent position (posterior transverse process up). 2. Stand in front of the patient. 3. Flex the patient's legs until you palpate motion at L3 4. Straighten the patient's inferior leg. 5. Hook the superior foot in the lower legs popliteal fossa 6. Pull patient's inferior arm out (toward you) to rotate the torso and down (caudad) to induce left sidebending down to the dysfunctional segment. 7. Place one arm in the patient's axilla and the other on the patient's iliac crest. 8. Have the patient take a deep breath in and exhale. 9. At end exhalation, apply a HVLA thrust by rotating the patient's pelvis forward and toward the table. 10. Retest the range of motion. (Flexion/ext can also be added to further engage another barrier. With patient in the lat recumb, ant motion of torso will produce flex, post motion will produce ext)
imaging from herniated nucleus pulposus
MRI
Halstead Test
Military Posture Test Costoclavicular synd test =clavicle & 1st rib -examiner palpates the radial pulse while depressing and extending the shoulder. -positive with a severely decreased or absent radial pulse.
Described sacral motion in relation to L5
Mitchell
erectile tissue SNS level
T11-L2 (same as bladder) at/after splenic flex?
prevalence of patello-femoral synd
Mostly in women. A wider pelvis often results in a larger Q angle.
treatment of lateral epicondylitis
NSAIDs, rest, ice tennis elbow strap to prevent reoccurances OMT to correct cervical/upper thoracic dys, counterstrain to affected muscles (extensors), myofascial release to dec fascial restrictions
bladder SNS level
T11-L2 at/after splenic flex?
gold standard for the diagnosis of carpal tunnel syndrome
Nerve conduction studies will identify if there has been any damage to the myelin or axon of the median nerve. Electromyography will identify if this damage is severe enough to cause denervation of the distal muscles innervated by the median nerve
sacrotuberous lig
O: ILA I: ischial tuberosity can help diagnose dys of innominate or sacrum
serratus anterior
O: R1-9 I: med border of scapula on ant side A: draw scapula ant, rot sacp sup, inspiration
pectoralis minor
O: R3-5 I: coracoid proces of scapula A: draw scap ant, med, & inf, inspiration
latissimus dorsi
O: SP from T7 to sacrum, iliac cres, R 10-12 I: intertubercular groove A: extend arm and rotate arm medially, inspiration (one of primary extensors & adductors of shoulder)
iliolumbar lig
O: TP of L4/5 I: med side of iliac crest first lig to be painful in lumbosacral decompensaton
posterior cruciate lig
O: ant aspect of femur I: post aspect of tibia A: prevents post translation of the tibia on femut
vastus intermedius
O: anterior and lateral surface of the femur I: patella A: primary extensor of the knee
tensor fasciae latae
O: anterior part of the iliac crest, anterior superior iliac spine I: iliotibial tract A: flexes, abducts, and medially rotates the thigh
psoas major
O: bodies & TP of lumbar verts I: lesser trochanter via iliopsoas tendon A: flex thigh, flex and lat bend lumbar vert column
psoas minor
O: bodies of T12 & L1 vert I: iliopubic emanence A: flex and lat bend lumbar vert column
gluteus minimus
O: external surface of the ilium between the anterior and inferior gluteal lines I: greater trochanter of the femur A:abducts the femur; medially rotates the thigh
aortic hiatus level
T12
semitendinosus
O: lower, medial surface of ischial tuberosity (common tendon with biceps femoris m.) I: medial surface of tibia (via pes anserinus) A: extends the thigh, Primary knee flexor
mylohyoid
O: mandible I: hyoid bone A: elevate hyoid & tongue, depress mandible
sternothyroid
O: manubrium I: thyroid cartilage A: depress hyoid
sternohyoid
O: manubrium & sternum I: hyoid A: depress hyoid
vastus medialis
O: medial intermuscular septum, medial lip of the linea aspera I: patella and medial patellar retinaculum A: primary extensor of the knee
adductor longus
O: medial portion of the superior pubic ramus I: linea aspera of the femur A: adducts, flexes, and medially rotates the femur
obturator internus
O: obturator foramen I: greater trochanter A: lat rot & abduct thigh
anterior cruciate lig
O: post aspect of femus I: ant aspect of tibia A: prevents ant translation of tibia on femur
levator ani
O: post surface of body of pubis, ischial spine I:coccyx A: elevate pelvic floor
Gluteus max
O: posterior gluteal line, posterior surface of sacrum and coccyx, sacrotuberous ligament I: upper fibers: iliotibial tract; lowermost fibers: gluteal tuberosity of the femur A: primary extensor of the thigh; laterally rotates the femur
sacrospinous lig
O: sacrum I: ischial spines ***divides greater and lesser sciatic foramen***
rectus femoris
O: straight head: anterior inferior iliac spine; reflected head: above the superior rim of the acetabulum I: patella and tibial tuberosity (via the patellar ligament) A: primary extensor of the knee, flexes the thigh
semimembranosus
O: upper, outer surface of the ischial tuberosity I: medial condyle of the tibia A: extends the thigh, Primary knee flexor
diaphragm
O: xiphoid, costal margin, lat & med arcuate ligs, bodies L1-3 I: central tendon of the dia A: inspiration
deltoid
O:lateral one-third of the clavicle, acromion, the lower lip of the crest of the spine of the scapula I:deltoid tuberosity of the humerus A:abducts arm; anterior fibers flex & medially rotate the arm; posterior fibers extend & laterally rotate the arm; primary shoulder flexor, abductor, extensor N:axillary nerve (C5,6)
Pectoralis Major
O:medial 1/2 of the clavicle, manubrium & body of sternum, costal cartilages of ribs 2-6, sometimes from the rectus sheath of the upper abdominal wall I: crest of the greater tubercle of the humerus A: flexes and adducts the arm, medially rotates the arm; primary adductor of shoulder N:medial and lateral pectoral nerves (C5-T1)
SCM
O= mastoid process & lat 1/2 sup nuchal line I= med 1/3 clavicle & sternum SB & rotate to otherside individually & flex neck when together divides ant and post triangles restriction causes torticollis
extrinsic forces taht affect lymph
OMT exercise contraction of muscles pulsation of adjacent structures resp movement to inc - intrathoracic pressure
posterior lumbar tenderpoints
On either side of the spinous process or on the transverse process. L3 and L4 may be found on the iliac crest. Also, L5 may be found on the PSIS. patient prone, extended and sidebent away (rot either way) Maverick Pt lower pole L5 -caudad to PSIS as much as 1cm -pt prone, hip & knee flex, leg int rot & adducted
respiratory epithelium para/symp effects
Para: dec goblets--> thin secretions Symp: inc goblet--> thick secretion
treatment for Lymphatic congestion Works well in patients that cannot tolerate thoracic pump
Pectoral Tractio- Augments thoracic range of motion via pectoralis minor stretch, improving lymphatic return.
treatments for Same as abdominal pump. Better suited in patients that cannot tolerate thoracic pump
Pedal (Dalrymple) Pump- Augments thoracoabdominal pressure gradients improving lymphatic return. contraindications- DVT, recent abdominal surgery
ME for Forward sacral torsion
Positional Diagnosis: L on L Treatment Position: L Lat Sims Position (Forward torsion, pt Face down) 1. Patient lies axis side (L) down with torso rotated so that he is face down. 2. Flex patient's hips until motion is felt at the lumbosacral junction. 3. Drop the patient's legs off the table to induce left sidebending and engage a left sacral oblique axis. 4. Ask the patient to lift his legs toward the ceiling against your equal counterforce for 3-5 seconds. Monitor 5. Repeat for 3-5 times and then retest for symmetry
ME for backward sacral torsion
Positional Diagnosis: R on L Treatment Position: L Lat Recumbent with face up (Backward torsion, pt lie on Back) 1. Patient lies w/ axis side (L) down with torso rotated so face up. 2. Grasp patient's L arm and pull to Rot torso to the R. Flex patient's hips until motion is felt 3. Drop the patient's legs off the table to induce L SB and engage a L sacral oblique axis. 4. Ask the patient to lift legs toward the ceiling against your equal counterforce for 3-5 seconds. Monitor 5. Repeat for 3-5 times, each time re-engaging the new restrictive barrier, and retest for symmetry of motion.
ME for anterior Innominate
Positional Diagnosis: Right Ant Innominate Treatment Position: Supine 1. Flex patient's R hip and knee until resistance is felt. 2. Instruct patient to extend hip against your counterforce for 3- 5 seconds. 3. Wait a few seconds for the tissues to relax, then take up the slack to the new restrictive barrier. 4. Repeat until no restrictive barrier is felt (usually 3-5 times).
ME for inferior pubic shear
Positional Diagnosis: Right Inferior Pubic Shear Treatment Position: Supine 1. Flex and abduct patient's R hip and knee and until resistance is felt. Stabilize the patient's L ASIS with your right hand. 2. Instruct patient to push his R knee to his left foot (extension and adduction) against your counterforce for 3-5 seconds. 3. Repeat steps 3-4.
ME for posterior innominate
Positional Diagnosis: Right Post Innominate Treatment Position: Supine 1. Drop the patient's R leg off the table until resistance is felt. Stabilize the patient's L ASIS with your right hand. 2. Instruct patient to flex his hip against your counterforce for 3-5 seconds. 3. Repeat steps 3 and 4.
ME for superior pubic shear
Positional Diagnosis: Right Superior Pubic Shear Treatment Position: Supine 1. Drop the patient's R leg off the table and abduct until resistance is felt. Stabilize the patient's L ASIS with your right hand. 2. Instruct patient to bring his R knee to his L ASIS (flexion and adduction) against your counterforce for 3-5 seconds. 3. Repeat steps 3 and 4.
ME for unilateral sacral extension
Positional Diagnosis: Right USE Treatment Position: Prone 1. L hypothenar eminence on the patient's R sacral sulcus. 2. Ask the patient to exhale and hold his breath, while you push anterior and caudad on superior sulcus. Hold for 3-5 seconds. 3. Direct the patient to inhale while you resist any anterior superior movement of the sacrum. 4. Repeat steps two and three 3-5 times and retest.
ME for Unilateral Sacral Flex
Positional Diagnosis: Right USF Treatment Position: Prone 1. Place L hypothenar eminence on patient's R ILA. 2. Ask patient to inhale and hold breath, while you push anterior on the ILA. Hold for 3-5 seconds. 3. Direct the patient to exhale while you resist any posterior, inferior movement of the sacrum. 4. Repeat steps two and three 3-5 times and retest.
Chronic asymmetry
Present with conpensation in other areas
Fryette's 3rd law
Proposed by Nelson Motion at 1 in any plane of motion modifies the other planes of motion
Rib raising
Purpose #1: normalize symp -thoracic sympathetic ganglia lie anterior to their corresponding rib -target R2-7 for resp secretions to be less thick Purpose #2: improve lymph -there is symp to larger lymphatic vessels-->should improve lymphatic return & create pressure gradients directly affecting return -works best in pt with noncompliant chest wall Purpose #3: encourage max inhale & provoke more neg intrathoracic pressure
axillary n
R T D C B
dorsal scapular n
R T D C B
lat pectoral n
R T D C B
long thoracic n
R T D C B
lower subscapular n
R T D C B
medial antibrachial cutaneous n
R T D C B
medial brachial cutaneous n
R T D C B
medial pectoral n
R T D C B
median n
R T D C B
musculocutaneous n
R T D C B
radial n
R T D C B
suprascapular n
R T D C B
thoracodorsal n
R T D C B
ulnar n
R T D C B
upper subscapular n
R T D C B
Bilateral sacral flex static findings
R & L sulci deep ILA shallow b/l inc lumbar curve
Bilateral sacral extension static findings
R & L sulci shallow ILAs deep b/l dec lumbar curve
left on left static findings
R sulcus deeper L ILA post & slightly inf Lumbar curve convex to R
unilateral sacral flexion on the left static findings
R sulcus deeper R ILA significantly inferior R ILA slightlt post
right on left static findings
R sulcus shallow L ILA ant and slightly sup lumber curve convex to the R
unilateral sacral extension on the L static findings
R sulcus shallow R ILA dignificantly sup R ILA slightly ant
pump handle
R1-5 use primarily
true ribs
R1-7 attach to sternum
caliper
R11+12 use primarily
bucket handle
R6-10 use primarily
false ribs
R8-12
appendix SNS level
T12 after splenic flex?
Apley's scratch test
ROM shoulder -To test abduction and external rotation, ask the patient to reach behind the head and touch the opposite shoulder -To evaluate internal rotation and adduction, ask the patient to reach in front of the head and touch the opposite shoulder. -to further evaluate internal rotation and adduction, instruct the patient to reach behind the back and touch the inferior angle of the opposite scapula. -Another way to evaluate range of motion of both shoulders at once is to ask the patient to abduct the arms to 90°, then supinate the forearms and continue abduction until the hands touch overhead. -->compare bilateral abduction. -to test abduction and external rotation, ask the patient to interlock the hands behind the head and push the elbows posterior. -place the hands behind the back as high as possible as if to touch the ipsilateral inferior angle of the scapula
Somatic dysfunction
Restriction in in bones, joints, muscle, fascia; blood, lymph, & nerve may be altered
Prayer test
Reverse Phalen carpal tunnel -patient extend the wrist while gripping the physician's hand. -If after one minute, the same symptoms are seen as in Phalen's test, the reverse Phalen's test is positive.
L sulcus deeper R ILA post and slightly inf Lumbar curve convex left pos seated flex on L spring at L base present spring in R ILA restricted spring at poles of oblique axis restricted neg lumbosacral spring test L5 SB R, Rot L
Right on right
Really Thirsty? Drink Cold Beer!
Roots Trunks Divisions Cords Branches
Pelvic Splanchnic PNS
S2-4 low ureter bladder uterus prostate genitalia desc & sig colon (2nd 1/2 colon) rectum
Flex lesion of SBS
SBS deviated cephalad, dec ext of SBS
Ext lesion of SBS
SBS deviates caudad, dec amount of flexion at SBS
divides neck into ant and post triangles
SCM
ant triangle borders
SCM, mandible, midline of neck
post neck triangle borders
SCM, trap, clavicle
true pelvic ligs
SI ligs ant, post, interosseous SI ligs surround & stabilize
level of spine for inf angle of scap
SP T7
multifidus
SP-TP of vert 2-4 below action: extend & lat bend; rotate to opposite side
rotatores
SP-TP or vert 1-2 below, more lateral than multifidus A: rotate to opposite side
technique for Dysmenorrhea Diarrhea
Sacral Inhibition- Inhibit sacral motion, increasing parasympathetic activity to the left colon and pelvic organs. With patient in prone position apply deep direct pressure at the sacrum for 2 minutes.
treatment for Tight lumbosacral paraspinals
Sacral rocking- Relaxes the muscles of the lumbosacral junction With the patient in the prone position, apply gentle pressure at the sacrum with rocking motion. The rocking motion augments flexion and extension phases associated with respiration or with the cranial rhythmic impulse (CRI)
Mitchell's 3 sacral dys
Sacral torsions (rot on oblique axis) Sacral shears (unilat flet/ext) b/l sacral flex/ext
Some Lovers Try Positions That They Cant Handle
Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capate Hamate
Middle GI SNS level
T10-11 via lesser splanchnic n & sup mes gang btwn lig of treitz & splenic flex (pt of pancreas & duo, jej, ilium, asc olon & prox 2/3 transverse)
developed FPR
Schiowitz
Acute tenderness
Severe, sharp
somato-visceral reflex
Somatic stimuli may produce patterns of reflex response in segmentally related visceral structures
technique to treat Thick secretions associated with an upper respiratory tract infection (URI)
Sphenopalatine Ganglion Treatment- Enhances parasympathetic activity which decreases goblet cells thus encourages thin watery secretions
Backward bending test
Sphinx test determines if the sacral base has moved posterior or anterior -positive if a part of the sacral base moves posterior -patient prone -physician places his thumbs on the superior sulci. -If asymmetry is present, one side of the sacrum is post, or the other side is ant -patient prop up on their elbows (sphinx position)--> extension. (--> causes sacrum to flex/go ant) -if thumbs become more symmetric with lumbar extension, part of the sacral base moved anterior. - If thumbs become more asymmetric with lumbar extension, part of the sacral base has moved posterior.
dermatome at umbilicus
T10
Describer of sacral movements
Strachan
Lasegue's test
Straight Leg Raise Test -used in the evaluation of sciatic nerve compression -patient supine -physician grasps the leg being tested under the heel with the hand, and to keep the knee extended, places the other hand on the anterior aspect of the knee -physician lifts the leg upward, flexing the hip -leg is lifted until the patient feels discomfort -Normally, the leg can be raised to about 70-80° of hip flexion. -->if pain, the cause most likely will be due to hamstring tightness or due to problems with the sciatic nerve. -If pain, physician lowers the leg just beyond where the pain was felt, and then dorsiflexes the foot (Braggard's Test) to stretch the sciatic nerve. -If no pain, tight hamstrings and the test is considered negative. -If pain is felt all the way down the leg, this indicates a sciatic origin, and the straight leg raising test is considered positive.
treatement of patello-femoral syndrome
Strengthen the vastus medialis muscle
serratus posterior
Superior O:SP C7-T3 I: R1-4 A: elevates upper ribs, inspiration Inferior O: SP T11-L2 I: R9-12 A: pulls down lower ribs, inspiration
technique for GI dys from jej to mid-transverse colon
Superior Mesenteric Ganglion Release- Reduce sympathetic tone at T10 - T i l
omohyoid
Superior belly O: intermediate tendon I: hyoid Inferior Belly O: scapula I: intermediate tendon A: depress hyoid
established the cranial field
Sutherland
head & neck SNS level
T1-4
Heart SNS level
T1-5
Adson's test
TOS test -ant & post scalens -While monitoring the patient's pulse, the arm is extended at the elbow, the shoulder is extended, externally rotated, and slightly abducted. -patient take a deep breath and turn his/her head toward the ipsilateral arm. -positive with a severely decreased or absent radial pulse
Lumbar roll for T2
TP up--> pull pt inf arm down TP down--> pull pt inf arm up
Lumber roll for T1
TP up--> pull pt inf arm up TP down--> pull pt inf arm down
TART
Tissue texture, asymmetry, restriction, tender
purpose of Vault hold
To address the strains at the SBS. The operator can use either a direct or indirect method of treatment. Most commonly, an indirect method is used to balance membranous tension
purpose of V spread
To separate restricted or impacted sutures. The principle can be applied to any suture.
ME for R anterior fibular head
Treatment Position: Prone 1. patient prone and knee flexed, place R hand on lateral side of the patient's foot, cupping the ankle. 2. Plantar-flex & invert patient's foot to resistance. 3. Externally rotate tibia. 4. Direct patient to dorsiflex against isometric counterforce for 3-5seconds. 5. Relax forces, plantar-flex, invert and externally rotate the tibia to the new barrier. Repeat steps 1 -4.
ME for T posterior fibular head
Treatment Position: Prone 1. prone & knee flexed, place R hand on lateral side of the patient's foot, cupping the ankle. 2. Plantar-flex & invert patient's foot to resistance. 3. Internally rotate the tibia 4. Direct patient to dorsiflex against counterforce for 3-5s 5. Relax, plantar-flex, invert and int rotate tibia to new barrier. Repeat steps 1 -4.
ME for T3 E SlRl
Treatment Position: Seated 1. In the upper thoracic spine, use the head and neck as lever to induce motion 2. With one hand monitor the posterior transverse process of T3. Engage the restrictive barrier by flexing, Rot & SB R until motion is felt 3. Direct the patient to use a small amount of force to straighten his head while you exert an equal amount of counterforce. 4. Maintain the forces for 3-5 seconds, have the patient relax, the physician relaxes, and re-engage the new restrictive barrier. 5. Repeat step four 3-5 times and then recheck for increased symmetry.
ME for T7 E RlSl
Treatment Position: Seated 1. Use your left hand to monitor the posterior transverse process of T7. 2. Instruct the patient to place his left hand behind his neck, and to grasp his left elbow with his right hand. 3. Reach across the patient's chest with your right arm, SB & Rot T7 R until motion is felt 4. Direct the patient to use a small amount of force to straighten his body while you exert an equal amount of counterforce. 5. Repeat step four 3-5 times and then recheck for increased symmetry.
ME for AA RotR
Treatment Position: Supine 1. Cradle the occiput in your hands and flex patient's cervical spine 45° 2. Rot L to the point of initial resistance. 3. Direct the patient to gently Rot R. Apply an equal counterforce 4. Maintain the forces for 3-5 seconds, repeat 3-5 times, each time re-engaging the new restrictive barrier. 5. Recheck for symmetry of motion
ME for OA E SlRr
Treatment Position: Supine 1. With the distal pad of one finger, monitor the OA joint, engage the restrictive barrier in all three planes by SB R, Rot L and flexing the patient's head until tension is felt (localization). Direct the patient to use a small amount of force to straighten his head while you exert an equal amount of counterforce. 2. Maintain for 3-5 seconds, repeat 3-5 times, each time re-engaging the new restrictive barrier. 3. Recheck for symmetry of motion.
ME for inhalation dys
Treatment Position: Supine Key Rib: Lowest in Group 1. patient supine, one hand on the anterior aspect of the key rib. Flex the patient for pump handle dysfunctions & SB the patient for bucket handle dysfunctions--> tension is taken off the dys rib 2. palpates the dys rib. 3. Patient inhales, then exhales deeply. For bucket handle dysfunctions, patient is instructed to reach for his knee on the affected side. 4. The patient is instructed to hold his breath at end- expiratory phase for 3-5 seconds. During this time, the physician adjusts flexion/sidebending to the new restrictive barrier. Physician follows rib shaft into exhalation with his hand during the expiratory phase. 5. On inhalation, the physician resists inhalation motion of the rib. 6. Repeat steps 3-5 a total of 3-5 times. Retest for symmetry of motion.
indications for lymph treatment
URI bronchitis, pneumonia, asthma, COPD, atelectasis post MI, CHF, heart infection mastitis, lymphedema GI disorder (hernia, chrons, colitis) cirrhosis, hepatitis, pancreatitis, nephrotic synd premenstrual synd, uterine fibroma, endometriosis, cystitis disorder of extremities: tendonitis, swell from trauma/infect, ezcema/psoriasis
Piriformis tenderpoint
Usually in the piriformis muscle 7 cm medial to and slightly cephalad to the greater trochanter Pt prone. Hip and knee flexed. Thigh abducted and externally rotated
Underberg's test
Variation of Wallenberg test perfomed with the neck backward bent and the head fully rotated to either side--> If patient develops vascular or neurologic symptoms, HVLA is contraindicated
Compensatory pattern
Zink Compensatory curves at: 1. Occipitoatlantaljunction 2. Cervicothoracic junction 3. Thoracolumbar junction 4. Lumbosacraljunction
adrenals chapman
ant: 2 inch sup & 1 inch lat to umbilicus post: btwn sp & tp of T11 & 12
ME types
active, direct (or indirect) postisometric relaxation (direct) reciprocal inhibition joint mobilization using muscle force oculocephalogyric reflex resp assistance crossed extensor reflex
absolute contraindications for cranial
acute intracranial bleed inc intracranial pressure skull fracture
AC joint stabilized by
acriomioclavicualr lig coracoacromial lig coracoclavicular lig
acromioclavicular joint
acromion of scapula--clavivle
deltoid lig
a Medial stabilizer of the ankle--> prevents excessive pronation Since the ankle is more stable in the pronation position and the deltoid ligament is very strong, pronation sprains are very uncommon. Excessive pronation usually results in a fracture of the medial malleolus rather than pure ligamentous injury
axis and plane for SB
aP & coronal
treatment for Upper and lower GI dysfunctions CHF COPD, asthma, URI Hiatial hernia Decreased motion of L-spine and thoracic cage
abdominal pump- Augments thoracoabdominal pressure gradients improving lymphatic return. Massages thoracic duct at cisterna chyli. contraindications- full stomach, disruption of liver/spleen
cubitus valgus
abduction of ulna if somatic dys present carry angle >15
postural motion of sacrum
about middle transverse axis at S2 as person bends foward, sacrum flexes at terminal flexion, sacrotuberous ligs become taut & sacrum will extend
respiratory motion of sacrum
about superior transverse axis at S2 during inhalation, sacrum extends (base move post)
S1 DTR
achilles reflex
treat cervical paraspinal symp gang
adjacent to the superior (C1 - C3), middle (C6 - C7), and inferior (C7 - T1) ganglia may influence sympathetic tone to the head and neck structures
Frequency of OMT
allow time for pt to respond to treatmen
anterior rib 3-6 tenderpoint
along mid-ax line on corresponding rib SB & Rot thorax toward, slight flexion
Substances found in the lymph
amino acids, glycerol and glucose; long chain fats, chylomicrons, and cholesterol; clotting factors; lymphocytes
When performing indirect myofascial release, which barrier is engaged?
anatomic
short leg syndrome
anatomicl or functional leg length discrepancy results in: 1) sacral base unleveling 2) vertebral SB & Rot 3) Innominate Rotation
Motor for L4
ankle dorsiflexors
Motor for S1
ankle plantar flexors
4 compartments in leg
ant lat deep post superficial post
ASIS more inf ipsi PSIS more sup ipsi longer leg ipsi (or comprensation for anatomically short leg) pos standing flex ipsi post innominate rot restricted ipsi ASIS restricted to compression ipsi
ant innominate rot
sacral promontory
ant portion of S1
pain from bicipital tenosynovitis
ant portion of the shoulder which may radiate to biceps tenderness over bicip groove pain aggrivated by resisted flex or supination of forearm
appendix chapman
ant: ***tip of R R12*** post: TP of T11 (moreso in acute)
kidney chapman
ant: 1 inch sup and 1 inch lat to umbilicus post: btwn sp & tp of T12-L1
Cranial rotation axis
around AP axis (normal SB)
Cranial Flex axis
around transverse axis (normal)
Cranial SB axis
around vert axis (normal is rotation)
cervical foraminal stenosis treatment
articularoty techniques, muscle energy, MFR, counterstrain, FPR
R1
articulate only with T1 no angle
R11 & 12
articulate only with vert at level & lack tubercles
R10
articulates only with T10
Trendelenberg's test
assess glut med muscle strength -physician stands behind the patient -patient pick one of legs up off the floor -Normally, the gluteus medius muscle should pull up the unsupported pelvis to keep it level. -A positive test occurs when the pelvis falls, which indicates weakness in the gluteus medius muscle
Ant & post drawer test
assess the anterior and posterior cruciate ligaments -patient supine with the hip flexed to 45° and knee flexed to 90° -physician sits on the patient's foot of the knee being tested, wraps both hands around behind the tibia -places one thumb on the medial joint line and one on the lateral joint line -tibia is then pulled anteriorly to test the ACL. -If the tibia slides out from under the femur, the test is positive for an ACL tear. -compare with other side -physician then pushes posteriorly on the tibia to check the PCL -test is positive if the tibia excessively moves backward under the femur
Anterior drawer test of ankle
assess the medial and lateral ligaments of the ankle, mainly the anterior talofibular ligament, but also the superficial and deep deltoid ligaments -patient supine -physician grasps the distal tibia/fibula with one hand, and pulls the foot forward with the other hand grasping the posterior aspect of the calcaneus. -The foot should be held in 20° of dorsiflexion the entire time. -If, after comparing both sides, excessive movement of the talus under the tibia/fibula occurs, then a bilateral injury has occurred to the mentioned ligaments. -If there is deviation to one side, then only the ligaments to the opposite side of the foot are damage
Valgus & Varus Stress Tests
assess the stability of the collateral ligaments -patient lying supine or sitting on the table -knee flexed just enough to unlock it from full extension -physician stabilizes the ankle with one hand while the other pushes against the knee, first medially then laterally. -Pushing the knee medial (with a Lateral force ) is the vaLgus stress test. -If there is gapping on the opposite side, then the medial collateral ligament is torn. -To test the lateral collateral ligament, the physician pushes the knee laterally (varus stress test). -positive If there is any gapping of the lateral joint line
Thomas test
assesses the possibility of a flexion contracture of the hip, usually of iliopsoas origin. -patient supine--> physician checks for exaggerated lumbar lordosis, common in hip flexion contractures. -physician flexes one hip so that knee and anterior thigh touches the patient's abdomen -If a flexion contracture is not present, the patient's opposite leg will remain flat on the table. -If present, a contracture of the iliopsoas will cause the opposite leg to lift off of the table.
Patellar Grind Test
assesses the posterior articular surfaces of the patella and the possibility of chondromalacia patellae, commonly seen with patello-femoral syndrome -patient supine with knees fully extended and relaxed. -physician pushes the patella distally, then instructs the patient to contract the quadriceps muscles. -Any roughness of the articular surfaces will grind, and be palpable and painful when the quadriceps contract and move the patella -positive if the patient feels pain with contraction of the patella
Lachman's test
assesses the stability of the ACL and is somewhat more accurate than the Draw tests. -patient supine -physician grasps proximal tibia with one hand and the distal femur with the other hand. -knee flexed to about 30° -tibia pulled forward by the grasping hands -Both sides are compared -test is positive if the tibia excessively moves out from under the femur.
posterior rib tenderpoints
associated with elevated ribs need extra time: 120s Location ange of corresponding rib treat position min flex, SB & Rot away
anterior rib tenderpoints
associated with depressed ribs need extra time: 120s Location R1: below med end of clavicle R2: 6-8cm lat to sternum on rib 2 R3-6 along mid-ax line on corresponding rib Treat R1&2: flex head, SB & Rot toward R3-6: SB & Rot thorax toward, slight flexion
treat TOS
at C2-T1, R1, thoracic inlet, clavicle, scalenes dys exercise to trap & levator scapula
cisterna chyli
at level of L2 18 inches from drainage point of thoracic duct innervated by T11
secondary pelvic muscles
attach to the true pelvis -iliopsoas -obturator internus -piriformis
flexor digitorum profundus
attaches to distal interphalangeal joint (DIP) Deep finger glexors attach to Dips
transverse lig
attaches to lateral masses of C1 weakened by Down's and RA--> atlanto-axial subluxation
flexor digitorum superficialis
attaches to proximal interphalangeal joint (PIP)
anterior rib 1 tenderpoint
below med end of clavicle flex head, SB & Rot toward
DTR for C5
biceps reflex
Speed's test
biceps tendon in bicipital groove -patient flexes the elbow to 90° while the physician grasps the elbow with one hand and the wrist with the other hand. -While pulling downward on the patient's elbow, the physician externally rotates the forearm as the patient resists this motion. -positive test results when pain is elicited as the biceps tendon pops out of the bicipital groove
supinators of forearm
biceps--musculocutaneous nerve supinator--radial nerve
R & L sulci shallow ILAs deep b/l dec lumbar curve false neg seated flexion tst spring at both sulci restricted spring at both ILAs present pos lumbosacral spring test
bilateral sacral extension
R & L sulci deep ILA shallow b/l inc lumbar curve false neg seated flex test spring at both sulcu present spring at both ILAs restricted nec lumbosacral spring test
bilateral sacral flex
Allen's test
blood via radial and ulnar as -pt open and close the hand being tested several times and then to make a tight fist. -physician occludes the radial and ulnar arteries at the wrist. -patient is then asked to open the hand; the palm should be pale. -physician releases one of the arteries and assesses the flushing of the hand. -If it flushes slowly, or not at all, then the released artery is not adequately supplying the hand. -procedure is repeated for the other artery
Myofascial release D/I, A/P
both, both
Cranial D/I, A/
both, passive
sacral apex
botton part which articulated with coccyx
DTR for C6
brachioradialis reflex
normal angle of femur
btween neck and shaft of femur 120-135
lateral longitudinal arch
calcaneus, cuboid, and 4th and 5th metatarsals
radio-opaque kid stone on X ray
calcium oxalate (80% of stones)
Phalen's test
carpal tunnel -physician maximally flexes the patient's wrist and holds this position for one minute. -If a "tingling" sensation is felt in the thumb, index finger, middle and lateral portion of the ring fingers, the test is positive
tinel test
carpal tunnel -physician taps over the volar aspect of the patient's transverse carpal ligament. -positive test will cause tingling or paresthesia into the thumb, index, middle and lateral half of the ring finger -may also be used in the diagnosis of other neuropathies, such as ulnar nerve entrapment at the elbow; peroneal compression at the fibular head and posterior tibial nerve entrapment at the ankle.
adduction of the ulna findings
carry angle dec (olecranon dev lat & distal ulna dev medially) olecranon process restricted in medial glide radial head may be distracted from lat humerl condyle distal ulna restricted in lat glide wrist/hand abduct & restrict in add
abduction of ulna findings
carry angle inc (olecranon dev med & distal ulna dev lat) olecranon process restricted in lat glide radial head compressed against lat humeral condyle distal ulna restricted in med glide wrist/hand adduct & restrict in abd
technique for upper GI dys
celiac gang release- dec symp tone at T5-9
treat lymph dys
chapmans thoracic pump pedal pump cranial ME/any treatment to thoracic inlet rib raising splenic/liver pump fascial sinus pressure/Galbreath ant cervical mobilization (gentle motion of hyoid, thyroid, cricoid, trachea) Extremity pump (wave motions in arms & legs)
CN III PNS
ciliary gang--> pupils (midbrain)
radiology of Spondylolisthesis
classified based on degree of slippage: Grade 1- 0-25% Grade 2- 25-50% Grade 3- 50-75% Grade 4- >75%
clavicle ant & sup findings
clavicle resist post & inf glide at sternum sup glide present with shoulder depression inf glide restricted with shoulder elevation ant glide present with shoulder retraction post glide restricted with shoulder protraction dec motion of clavicle around transverse axis
most common AC dys
clavicle sup & lat on acromion
somatic dys of iliopsoas
common caused by prolinged shortening pelvic side shift, pos thomas test, dys of upper lumbar susally associated
bilateral sacral flex epidemiology
common dys in post-partum pts
shoulder dislocation
common in athletes usually trauma humeral dislocation- ant & inf recurrent are common & req less force can injure axillary nerve
adhesive capsulitis/Frozen shoulder syndrome
comon, pain & restrict of shoulder motion that gets inc worse over course of year
3rd degree grade of sprains
complete tear resulting in no tensile strength with mild to moderate laxity may require surgery
thoracic oultet syndrome
compression of the neurovascular bundle (subclav a & v, & brachaial plex) as it exits thoracic outlet
alar ligamnet
connect dens to skull on both sides
neuromuscular scoliosis
due to musc weakness or spasticity -poliomyelitis, cerebral palsy, Duchenne's musc dys, meningomyelocele
treatment of moderate scoliosis
conservative management: PT, Konstancin exercises (series of exercises proven to improve pt with postural decompensation), OMT (not intended to completely straighten) improve flexibility & strengthen trunk & abs PLUS bracing with a spinal orthotic is often indicated
pathogenesis of supraspinatus tendinits
continuous impingement of greater tuberosity against acomion as the arm is flexed and internally rotated
Isolytic contraction
contract against resistance while forcing muscle to lengthen operator force> pt force
Bishops deformity
contracture of the last 2 digits with atrophy of hypothenar eminence due to ulnar nerve damage
sacral extension
counternutation
Jones
counterstrain tenderpoint
ulnar a
courses med aspect of forearm supplying blood to elbow, wrist, dorsal aspect of hand & eventually most of the superficial palmar arterial arch
radial a
courses the lat aspect of the forearm supplying blood to the elbow, wrist, dorsal aspect of the hand and eventually forming most of the deep palmar arteral arch
sciatic nerve
courses through greater sciatic foramen in 85% of pop, the sciatic nerve will be inferior to the piriformis 2 divisions: tibial & peroneal
what to treat first to make pt relax for treat in other areas
cranial
SBS goes down
cranial extension "looks like the sphenoid bone is extending bc the caudad pt (SBS) goes anterior ish"
SBS tips up
cranial flexion "looks like the sphenoid bone is flexing bc the caudad pt (SBS) goes posterior ish"
palpation of lateral SBS strain feels like what
cranium shaped like a parallelogram
dextroscoliosis
cruve SB L--> scoliosis (convexity) to R
levoscoliosis
curve SB R--> scoliosis (convexity) to L
genu varum
dec Q angle pt appear bowlegged
signs & symp of adhesive capsulitis/Frozen shoulder syndrome
dec ROM with active & passive movement, abduction, int & ext range of motion often effected extension preserved
treatment for spinal stenosis
dec restrictions & inc ROM--> PT, NSAIDs/low dose steroids; if doesnt work--> epidural--> laminectomy with decompression
misoprostol
dec serious GI comp by 40% use with NSAIDs
Treating Chapman's
dec symp tone to assoc visc tissue treated using soft, circular manipulation over the point itself. Posterior Chapman's points feel rubbery, similar to a classic viscerosomatic reflex
Motor for C8
deep finger and wrist flexors
CV4 Bulb decompression
done by first resisting the flexion phase and encouraging the extension phase of the C.R.I, until a "still point" is reached, then allowing restoration of normal flexion and extension to occur ***inc amplitude of CRI***, induce uterine contraction, help with fluid homeostasis
spina bifida
defect in closure of lamina of vert segment usually in lumbar spine 3 types: occulta, meningocele, meningomyelocele
Definition of cervical foraminal stenosis
degen in joint of Lushka, hyperT in facet joints, osteophytes that narrow foramina
pathogensis of spinal stenosis
degenertive changes in the lumbar spine can include 1) hpertrophy of the facet joints 2) Ca deposits within the ligamentum flavum and the post long lig 3) loss of intervertebral disc height
Heisey & Adams
demonsrated movement of cranial bone movement in animal models
exhalation dys findings for pump-handle rib
depressed antly ant part moves caudad on exp ant narrow of IC space below inf edge of post rib angle prominent tender & text change at costochoneal junction, chondrosternal junction, & post rib angles
exhalation dys findings for bucket-handle rib
depressed latly lat part (shaft) of rib moves down on exp lat narrowing of IC space below tender & text change at IC muscles on mid-axillary line, & post rib angles
Mitchell
described sacral motion in relation to L5
Strachan
describer of sacral movements: ant & post
Ober's test
detects a tight tensor fascia lata and iliotibial band -patient lies on the side opposite the iliotibial band being tested -physician stands behind the patient stabilizes the pelvis to keep the patient from rolling -phys flexes the knee on the side being tested to 90°, abducts the hip as far as possible, and slightly extends the hip. -Slight hip extension is necessary to ensure that the iliotibial band passes directly over the greater trochanter -physician slowly allows the thigh to fall to the table. -test is positive if the thigh remains in the abducted position--> indicate a tight iliotibial band.
McMurray's Test
detects tears in the posterior aspect of the menisci -to test the medial meniscus, the patient's knee is fully flexed -physician's fingers palpate the medial knee joint line -tibia is then externally rotated and a valgus stress is placed on the knee -knee is then slowly extended. -If a palpable or audible "click" is noticed, the test is positive for a posterior tear of the medial meniscus. -To test the lateral meniscus, the same procedure is used with internal rotation of the tibia and a varus stress on the knee
ASIS compression test
determine side of SI dys; helpful when the standing or seated flexion tests are equivocal -patient in the supine position -physician comes in contact with the ASIS's and applies a posterior compression to each ASIS while stabilizing the other -There is usually an ease of posterior compression (some authors describe this as a sense of "resiliency"). -If there is a resistance to compression (that side did not have "resiliency") then the test is considered positive on that side. -A positive test indicates dysfunction of the sacrum, innominate or pubic bones
Muscle Energy D/I, A/
direct, active
High Velocity, Low Amplitude D/I, A/
direct, passive
chapman's reflexes D/I, A/
direct, passive
lymphatic treatment D/I, A/
direct, passive
Slipped capital femoral epiphysis
displacement of the femoral head from the femoral neck due to a stress fracture through the femoral capital epiphyseal growth plate. It is classically seen in obese adolescent males. This would have been diagnosed by the X-ray of the hip treat with surg fixation
lig of treitz
divides duo & jejunum
brachial a
divides into ulnar & radial as under the bicipital aponeurosis
Sensation for L5
dorsal aspect of foot and big toe
Anterior postural deviation
entire body leans forward deviating anteriorly from plumb line patient's weight supported by metatarsals
carpal tunnel syndrome
entrapment of medial nerve at the wrist
Sutherland
established the crainial field
Apley's compression & distraction tests
evaluate the meniscus and ligamentous structures of the knee -patient prone and the knee is flexed to 90° -compression performed with the physician pressing straight down on heel, and internally and externally rotating the tibia in this position. -Pain indicates a meniscal tear. -physician pulls upward (the "distraction" part) on the foot, and internally and externally rotates the tibia. -Pain this time indicates ligamentous injury, usually the medial and/or lateral collateral ligaments
Bounce Home Test
evaluates problems with full knee extension, usually due to meniscal tears or joint effusions. The patient is supine and the physician grasps the heel. The knee is flexed completely. Then, the knee is allowed to drop into extension. Normally, the knee should "bounce home" into full extension to a sharp end-point, without restriction. The test is positive if extension is incomplete or there is a "rubbery" feel to end-point extension
how do lumbar nerves exist
exit sup aspect of corresponding intervertebral foramina, just above intervertebral disc
CN I
exits: Cribiform plate Som Dys: Sphenoid, frontal, ethmoid Symp: Altered sense of smell
CN VII
exits: Enters internal acoustic meatus and exits the stylomastoid foramen Som Dys: Sphenoid, temporal, occiput Symp: bell's palsy
CN XII
exits: Hypoglossal canal Som Dys: occiput Symp: Dysphagia ***compression can cause poor suckling in newborn***
most common congenital anomaly of lumbar spin
facet tropism- misaligned facets
segmental facilitation
facilitation occurs at an individual spinal level
lumbarization
failure of susion of S1 with other sacral segs less common than sacralization
post radial head etiology
fall foward on protonated forearm
ant radial head etiology
falling backward on supinated forearm
Bilateral sacral flexion dynamic findings
false neg seated flex test spring at both sulcu present spring at both ILAs restricted nec lumbosacral spring test
bilateral sacral extension dynamic findings
false neg seated flexion tst spring at both sulci restricted spring at both ILAs present pos lumbosacral spring test
morton's neruoma
fibroneuromatous reaction between the heads of the third and fourth metatarsals. Pain is present at the forefoot at the site of the neuroma it is often accompanied with dysesthesia or burning plantar pain
inferior lateral angles
inferor lateral part recorded as shallow/post, deep/ant, superior, or inferior in dys
Seated flexion test
for SI motion, eval som dys in pelvis -patient is seated with both feet flat on the floor. -physician locates the patient's PSIS's and places his thumbs on the inferior notch. -patient bend forward and the physician assesses the level of the PSIS's as this motion is completed. -positive test occurs when, at the termination of forward bending, the PSIS's are not level. Somatic dysfunction is present on the side of the superior PSIS.
scoliosis screening
for children age 10-15 1) examine lievels of occiput, shoulders, iliac crests, PSIS, & greater trochanters 2) bend at waist--> if rib hump, pos test 3) screen for lumbosacral dys that may give short leg--> treat & recheck for scoliosis--> if still there--> get x-ray
Standing flexion test
for iliosacral motion, eval som dys in leg or pelvis, more commonly in innominate -patient standing -physician locates the patient's PSIS's and places his thumbs on the inferior notch -patient bend forward and the physician assesses the level of the PSIS's as this motion is completed -positive test occurs when, at the termination of forward bending, the PSIS's are not level--> Somatic dysfunction is present on the side of the superior PSIS
Finkelstein's test
for tenosynovitis in the abductor pollicis longus and extensor pollicis brevis tendons at the wrist (De Quervain's disease) -patient makes a fist with the thumb tucked inside the fingers. -physician stabilizes the patient's forearm and deviates the wrist ulnarly. -positive test results when the patient feels pain over the tendons at the wrist
Foramen transversarium
foramina in the TP of C1-6 vert artery passes
Q angle
formed by intersection of a line from the ASIS through the middle of the patella and a line from the tibial tubercle through the middle of the patella normal= 10-12
carry angle
formed by intersection of longitudinal axis of humerus & distal radial/ulnajoint-proximal radial ulna joint men normal= 5deg women normal= 10-12 deg has direct effect on wrist position
acute causes low back pain
fracture, strain, disc herniation, infection, referred pain
condylar decompression
free parasympathetic responses to structures innervated by cranial nerves IX and X by freeing the passage through the jugular foramen (i.e.occipito-mastoid suture) ***-ex. after childbirth (compression) to help suckling***
axillary a
from subclav starts at lat border of first rib becomes brachial artery at the inf border of teres minor
Zollinger-Ellison syndrome
gastrin-secreting neuroendocrine tumors (gastrinomas), which result in hypergastrinemia and acid secretion. Over 90% of patients with this syndrome develop peptic ulcers. In most cases, the two conditions are indistinguishable and present as peptic ulcer disease
glenohumeral joint
glenoid fossa of scapula--humerus
radial head motion
glide ant & post with sup & pronation respectively of forearm
primary extensor of hip
gluteus max
medial epicondylitis
golfer's elbow strain of flexor muscles of the forearm near the medial epicondyle
sign & symp of supraspinatus tendinitis
gradual onset & may be preceded by strain pain exacerbated by abduction (esp 60-120= painful arc)
talocrural joint
hinge joint located between the talus and the medial malleolus of the tibia, and the lateral malleolus of the fibula
Motor for L1
hip flexors
Motor for L2
hip flexors & adductors
corns
hyperkeratotic lesions found between the toes, usually the fourth and fifth toes; they are extremely painful. Hard corns are associated with hammer or claw toe
treatment of compartment syndrome
ice & myofascial release--> inc venous and lymph return surgical fasciotomy if muscle necrosis develops (w/in 4-8 hrs)
Pelvic side shift test
if sacrum is midline -patient standing -physician stabilizes the shoulders with the right hand and pushes the pelvis to the right with the left hand. -hands are then switched and the pelvis is translated to the left. -positive on the side of freer translation -indicates that the pelvis is shifted to that side. -often seen in a flexion contracture of the iliopsoas (psoas syndrome). -flexion contacture of the right iliopsoas will cause a positive pelvic shift test to the left and vice versa
Hip joint ligaments
iliofemoral lig ischiofemoral lig pubofemoral lig capitis femoris
primary flexor of the hip
iliopsoas
innominate
ilium, ischium, pubis bones fuse at 20
patello-femoral syndrome pathophysiology
imbalance of the musculature of the quadriceps (strong vastus lateralis and weak vastus medialis) -->cause patella to deviate latly & lead to irregular or accelerated wearing on the post surface of the patella - thought to be related to a larger Q angle
Cranial manipulation purpose
improve para fxn in head structures innervated by CN III, VII, IX, X
when will lumbosacral spring test be positive
in all dys in which sacral base moves (is stuck) posterior (unilateral sacral extension, sacral margin posterior, sacral base posterior and when the sacrum rotates backward on an oblique axis)
genu valgum
inc Q angle pt appear knocked-kneed
CV4
inc amplitude of CRI
Factors that inc ECF-->lymph capillary
inc arterial cap pressure dec plasma colloidal osmotic pressure inc protein in interstitium inc cap perm Due to OMT: CT movement fluid fluctatations
isometric contraction
inc in tension, no "approximaion" origin & insert operator force = pt force
sign & symp for Psoas syndrome
inc pain when stand/walk, pos thomas test, tender poind med to ASIS, ***T2 dys of L1/2***, pos pelvic shift test to the contra side, sacral dys on oblique axis, contralateral piriformis spasm
cervical foraminal stenosis sign & symptoms
inc pain with extension, + Spurling, cervical tenderpoints
signs/symp of Spondylolisthesis
inc pain with extension-based activities tight hamstrings b/l stiffed-legged, short-stride, waddling type gait no neuro deficits pos vert step off sign
treatment for elderly
indirece, gentle direct (articulatory)
acute neck strain/sprain treatment
indirect
Treat first for acute injury to cervical spine
indirect fascial techniues or counterstrain
Facilitated Positional Release
indirect myofascial release treatment Schiowitz placed into a neutral position in all planes, activating force (compression or torsion) is added, takes 3-4 seconds to induce a release used to treat: 1. Superficial muscles 2. Deep intervertebral muscles to influence vertebral motion
counterstrain D/I, A/
indirect, passive
ASIS & PSIS more inf ipsi pubic rami inf ipsi long leg ipsi pos standing flex ipsi ASIS restricted to compression ipsi
inferior innominate shear
Pathogenesis of Bicipital tenosynovitis
inflammation of the tendon and its sheath of the long head of biceps usually due to overuse, combined with physiological wear & tear, leading to adhesions that bind tendon to bicipital groove ALso from subluxation of bicepital tendon out of bicip groove
muscles in thenar eminence
innervated by median nerve (except adductor pollicis brevis--ulnar)
muacles in the hypothenar eminence and interossi
innervated by ulnar n
Innominate outflare
innominate rotate laterally
Innominate inflares
innominate rotate medially
inferior transverse axis of sacrum
innominate rotation, duing walking cycle, also where ant/post somatic dys happens
ant neck triangle contents
internal jugular, carotid & branches, ansa cervicalis, thyroid, CNX-XII, submandibular gland, facial & lingual a&v, nerve to myelohyoid, submental lns
lumbosacral angle
intersection of horizontal line & line of inclination of sacrum =25-35 decrees inc cause stress--> low back pain
Type I supination sprain
involves the anterior talofibular ligament
Type II supination sprain
involves the anterior talofibular ligament and the calcaneofibular ligament
Type III supination sprain
involves the anterior talofibular ligament, calcaneofibular ligament and the posterior talofibular ligament
Joints of Lushka
joint where uncinate processes (edges of vert body that are tiped up; on C3-7) meets sup vert body limit SB degeneration cuases intervertebral foramina stenosis--> most common cause of cervical nerve root compression
Legg-Calve-Perthes disease
juvenile idiopathic avascular necrosis of the femoral head. The onset is insidious taking weeks to months, which does not fit the case history.
Motor for L3
knee extensors
Sensation for C8
little finger and middle forearm
majority of lymph produced by
liver & intestines
contraindication for sacral inhibition
local infections or incisions
viscero-somatic reflex
localized visceral stimuli produce patterns of reflex response, in segmentally relatedsomaticstructures
lower back & lower leg
location of pain from herniated nucleus pulposus
anterior thoracic tenderpoints
location: T1-6 midline sternum at corresponding rib attachment T7-12 in rectus abdominis 1in lateral to midline R/L treatment: flex & SB&Rot away
anterior cervical tenderpoints
location: ant to lateral masses treatment position: SB & rot pt head away Maverick Point: 7th cervical -location 2-3cm lat to med end of clavicle at lat attachment of SCM -treat: flex, SB toward, Rot away
posterior thoracic tenderpoints
location: either side of sp or on tp treat: extend, rot away, SB away
Posterior cervical tenderpoints
location: tip of sp or lateral sides of sp treat: extend, SB, rot away Maverick Point: Inion -location: at inion or just below -treat: flexion
Indications for articularoty techniques
loss of motion need to inc frequency or amplitude of a motion (breathig) need to normalize sympathetics
pain for Psoas syndrome
low back sometimes radiating to groin ache, muscle spasm
pain from spinal stenosis
low back to low leg (s) ache, shooting pain or paresthesias
pain in Spondylolisthesis
low back, buttock, & post thigh ache
cauda equina syndrome pain
low back, sharp
contraindications for ME
low vitality pt who can be compromised by active muscle exertion (post surgical pt, ICU pt)
location of pain from herniated nucleus pulposus
lower back & lower leg
key rib in inhale dys
lowest one in group
facet trophism
lumbar facet joints more closely aligned to coronal plane than saggital most common anomaly in lumbar spine may predispose to early degenerative disease
what to treat first for psoas syndrome
lumbar spine or thoraco-lumbar spine
Ferguson's angle
lumbosacral angle
sibson's fascia
made up of CT of scalenes & longus colli muscles traversed by lymphatic ducts
facilitation
maintenance of a pool of neurons in a state of partial or sub-threshold excitation--> less stimulation is required to trigger the discharge of impulses
primary pelvic muscles
make up pelvic diaphragm -levator ani -coccygeous muscles
congenital scoliosis
malformation of vert progressive
treat vagus
manipulation OA, AA, or C2--> para--> vagus
sternoclavicular joint
manubrium--clavicle
ME for R10-12 exhalation dys
many variations Treatment Position: Supine Key Rib: Top Rib in Group Target muscle: 10-11: latissimus dorsi & 12: quadratus lumborum 1. The patient is instructed to place the hand on forehead on affected side with the palm up. 2. The physician grasps the key rib posteriorly at the rib angle. 3. The patient is instructed to inhale deeply while the physician applies an inferior traction on the rib angle. 4. The patient is instructed to hold his breath at full inhalation while adducting arm for 3-5 seconds. 5. Repeat step 4 a total of 3-5 times and then retest.
ME for R1 exhalation dys
many variations Treatment Position: Supine Key Rib: Top Rib in Group Target muscle: ant & mid scalenes 1. The patient is instructed to place the hand on forehead on affected side with the palm up. 2. The physician grasps the key rib posteriorly at the rib angle. 3. The patient is instructed to inhale deeply while the physician applies an inferior traction on the rib angle. 4. The patient is instructed to hold his breath at full inhalation while raising head directly toward ceiling for 3-5 seconds 5. Repeat step 4 a total of 3-5 times and then retest.
ME for R3-5 exhalation dys
many variations Treatment Position: Supine Key Rib: Top Rib in Group Target muscle: pectoralis 1. The patient is instructed to place the hand on forehead on affected side with the palm up. 2. The physician grasps the key rib posteriorly at the rib angle. 3. The patient is instructed to inhale deeply while the physician applies an inferior traction on the rib angle. 4. The patient is instructed to hold his breath at full inhalation while pushing elbow of affected side toward the opposite ASIS for 3-5 seconds 5. Repeat step 4 a total of 3-5 times and then retest.
ME for R2 exhalation dys
many variations Treatment Position: Supine Key Rib: Top Rib in Group Target muscle: post scalene 1. The patient is instructed to place the hand on forehead on affected side with the palm up. 2. The physician grasps the key rib posteriorly at the rib angle. 3. The patient is instructed to inhale deeply while the physician applies an inferior traction on the rib angle. 4. The patient is instructed to hold his breath at full inhalation while turning head 30 degrees away from dysfunctional side and lifting head toward ceiling for 3-5 seconds 5. Repeat step 4 a total of 3-5 times and then retest.
ME for R6-9 exhalation dys
many variations Treatment Position: Supine Key Rib: Top Rib in Group Target muscle: serratus anterior 1. The patient is instructed to place the hand on forehead on affected side with the palm up. 2. The physician grasps the key rib posteriorly at the rib angle. 3. The patient is instructed to inhale deeply while the physician applies an inferior traction on the rib angle. 4. The patient is instructed to hold his breath at full inhalation while Pushing arm anterior for 3-5 seconds 5. Repeat step 4 a total of 3-5 times and then retest.
Cobb method
measure scoliosis 1)draw horizontal line from vert body of extreme ends 2) draw perpendiculat lines from these & measure angle (Cobb's)
Cuboid som dys of transverse arch
medial edge will glide toward the plantar surface
Sensation for T1
medial elbow and medial arm
Sensation for L4
medial malleolus
anterior L1 tenderpoint
medial to ASIS patient supine, knees and hips flexed and markedly rotated away
Sensation for L2
middle and anterior thigh
Sensation for C7
middle finger
Cranial Flexion
midline boes of cranium (sphenoid, occiput, ethmoid, vomer) flex & paired bones ext rotate fl EX ion = EXternal rotation cause dura pulled cephalad--> sacral base posterior (ext)= counternutation will widen head & dec AP diameter
Cranial Extension
midline bones (sphenoid, occiput, ethmoid, vomer) ext & paired bones int rotate dura fall caudad--> sacral base anterior (flex)= nutation will narrow head & inc AP diameter
chronic causes low back pain
more common congenital, metabolic, neoplastic, degenerative, mechanical, cauda equina syndrome
anatomical leg length discrepancy
most common cause is hip replacement
Radial nerve injury
most common nerve injured in UE due to direct trauma
Sternoclavicular joint
most common som dys= clavicle ant & sup
dynamic motion of the sacrum
motion that occurs during ambulation engages 2 oblique axes weight bearing on left leg (stepping foward with right leg) cause left sacral axis to be engaged
tibial nerve
motor: hamstrings except short head of biceps femoris, most plantar flexors, and toe flexors sensory: lower leg & plantar aspect of foot
femoral nerve
motor: quads, iliacus, sartorius, pectineus sensory: ant thigh and med leg
pathogenesis of herniated nucleus pulposus
narrow of post long lig posteriolateral herniation of intervertebral disc is common problem 98% herniations occur btwn L4&5 or L5&S1 Exerts pressure on nerve root of vert below
lumbar more disc herniations bc
narrowing of post longitudinal lig--> weaken posteriolat aspect of the intervertebral disc
spinal stenosis
narrowing of spinal canal or intervertebral foramina usually due to degenerative changes, causing pressure on nerve roots
transverse arch
navicular, cuneiforms, and cuboid where som dys usually happen--> nav, cub, or cun displace--> pain (long distance runners)
pain for TOS
neck pain or pain radiating to arm ache or paresthesias
cervical foraminal stenosis pain
neck pain radiating to upper extremitiy dull ache, shooting pain/pareshesias
diagnosis of carpal tunnel
nerve conduction studies/electromyography
brachial plex injuries
nerves of brachial plex suceptible to traction injury esp in childbirth
spina bifida occulta
no herniation only sign is patch of hair
C1
no spinous process no vertebral body
1st degree grade of sprains
no tear resulting in good tensile strength and no laxity
Nutation
nod/foward
celiac gang, sup mes, inf mes releases
normalize symp Midline abdominal pressure over the celiac, superior mesenteric, and/or inferior mesenteric ganglia will reduce hypersympathetic activity. Pressure is applied until a fascial release is palpable
Soft tissue paraspinal inhibition
normalize symp (prevent ileus) direct paraspinai pressure ontheerectorspinaemassproducesthesameautonomiceffectsasribraising
L3-5 SNS
nothing
quality of pain from herniated nucleus pulposus
numbness/tingling accompanied by sharp, burning, shooting pain radiating down leg worsen with flex of lumbar spine
sacral flexion
nutation
OA motion
occipital condyles of skull -- atlaas 50% of neck flex/ext Like T1 in Flex/Ext
anterior L2-4 tenderpoint
on AIIS patient supine, knees and hips flexed and markedly rotated away
colon chapman
on lat thigh in IT band from greater trochanter to just above knee
sacralization
one or both of TP of L5 are long and articulate with sacrum 3.5% of people may lead to early disc degeneration
course of R thoracic duct
only traverses the thoracic inlet once usually drains into the right brachiocephalic vein or the junction of the right internal jugular and subclavian veins
venous sinus technique
operator gently, but directly spreads apart the sutures of the cranium that overly the occipital, transverse and sagittal sinuses. supposed to inc venous flow
extensors of wrist & hand
originate at lateral epicondyle of humerus innervated by radial nerve
flexors of wrist & hand
originate on med epicondyle of humerus innervated by median nerve (except flexor carpi ulnaris--ulnar)
contraindications for lymph treatment
osseous fractures bact infect with temp > 102 abscess or localized infect stages of carcinoma
Korr
osteopathic researcher established there is hypersymp activity in disease process
Contra for HVLA
ostroporosis/met cancer--> fracture
CN IX PNS
otic gang--> parotid gland (medulla)
dura mater
outermost, thick, inelastic forms falx and tentorium projects caudally down cord with firm attachement to foramen magnum, C2, C3, & S2
pain in lateral epicondylitis
over lat epicondyle that worsend with wrist exension against resistance may radiate to lat aspect of aarm & forearm
pathogenesis of medial epicondylitis
overuse of forearm flexors and protonators
Treatment of acute congestive heart failure
oxygen and IV furosemide. Nitroglycerine, which also can be used, is a venodilator that can potentiate the effect of furosemide. Other agents include morphine (reduces anxiety and dilates pulmonary and systemic veins 34p,2°) and nitroprusside (a useful adjunct in the treatment of CHF due to acute valvular regurgitation or hypertension).
low back sometimes radiating to groin ache, muscle spasm
pain for Psoas syndrome
low back to low leg (s) ache, shooting pain or paresthesias
pain from spinal stenosis
low back, buttock, & post thigh ache
pain in Spondylolisthesis
pain for adhesive capsulitis/Frozen shoulder syndrome
pain present at end of ROM ant pt of shoulder
technique to treat sympathetic tone associated with an ileus
paraspinal inhibition at L1/2
pain in carpa tunnel synd
paresthsias on thumb and first 2.5 digits
2nd degree grade of sprains
partial tear resulting in a decreased tensile strength with mild to moderate laxity
subclavian v
pass ant to ant sclene--> contract of scalene doesnt compromise becomes axillary a
subclavian a
pass btwn ant & middle scalenes --> contraction of scalenes can cause compromise
inferior innominate shear dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
counterstrain
passive indirect tissue positioned at point of ease for 90 seconds Jones
HVLA Mechanism
passive, direct technique Theory #1 - forcefully stretch a contracted muscle producing a barrage of afferent impulses from the muscle spindles to the CNS--> reflexively sends inhibitory impulses to the muscle spindle to relax Theory #2 -forcefully stretch the contracted muscle pulling on it's tendon activiating the Golgi tendon receptors and reflexively relaxing the muscle
L4 DTR
patella reflex
Ped vs geriatric treatment frequency
ped more frequnt, geri longer time to respond
bladder chapman
periumbilical region
main motions of the ankle
plantar flexion and dorsiflexion
supination of ankle
plantarflexion, inversion, & adduction***
Normal posture
plum line: post to apex through ext aud meat through cerv through shoulder through lumber post to hip axis ant to knee axis ant to lat mall
Right on right dynamic findings
pos seated flex on L spring at L base present spring in R ILA restricted spring at poles of oblique axis restricted neg lumbosacral spring test L5 SB R, Rot L
unilateral sacral extension on the R dynamic findings
pos seated flex on L spring at L sulcus restricted spring at L ILA present pos lumbosacral spring pos backward bending test
unilateral sacral extension on the L dynamic findings
pos seated flex on R spring at R sulcus restricted spring at R ILA present pos lumbosacral spring pos backward bending test
left on left dynamic findings
pos seated flex on R spring of R base present spring of L ILA restricted spring at poles of L oblique restricted neg lumbosacral spring test L5 SB L Rot R
unilateral sacral flexion on the right dynamic findings
pos seated flex test on L spring at L sulcus present spring at L ILA restricted
left on right dynamic findings
pos seated flex test on L sspring at the L base restricted spring at R ILA is present spring at poles of R oblique axis is restricted pos lumbosacral spring test' pos backward bending test L5 flex/ext, SB R Rot R
right on left dynamic findins
pos seated flex test on R spring at R base restricted spring at L ILA present spring at poles of left oblique axis restricted pos lumbosacral spring test pos backward bending test L5 will be flexed or extended (noneutral), SB L, Rot L
unilateral sacral flexion on the left dynamic findings
pos seated flex test on R spring at R sulcus present spring at R ILA restricted
Inferior pubic shear dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
Innominate inflares dynamic finding
pos standing flex ipsi ASIS restricted to compression ipsi
Innominate outflare dynamic findings
pos standing flex ipsi ASIS restricted to compression ipsi
cauda equina syndrome
pressure on nerve roots of cauda equina usually due to massive central disc herniation
lateral stabilizers of the ankle
prevent excessive supination ant talofibular lig calcaneofibular lig post talofibular lig
treatment for adhesive capsulitis/Frozen shoulder syndrme
prevention early mobilization following shoulder injury essential, injection steroids & NSAIDs OMT, esp spencer techniques Also GH & upper thoracic
etiology of adhesive capsulitis/Frozen shoulder syndrome
prolonged immobility of shoulder
Pathogenesis of Psoas syndrome
prolonged position that shortend Organic causes from viscero-somaic/somato-somatic reflexes: appendicitis, sigmoid colon dys, ureteral calculi, ureter dys, met carcinoma of prostate, salpingitis
protonators of forearm
protonator teres & protonator quadratus median nerve
anterior fibular head dys
prox fibular head resists posterior spring distal fibula may be posterior talus externally rotated causing foot to evert & dorsiflex
posterior fibular head dys
proximal fibular head resists ant spring distal fibula may be ant and resist post spring talus int rotated causing foot to invert & plantarflex
hammer toes
proximal interphalangeal (PIP) joint is hyperflexed. Typically there is an obvious deformity and the patient may have pain at the PIP when wearing shoes
epidemioloy of adhesive capsulitis/Frozen shoulder syndrome
pt over 40
primary extensor of the knee
quadriceps
numbness/tingling accompanied by sharp, burning, shooting pain radiating down leg worsen with flex of lumbar spine
quality of pain from herniated nucleus pulposus
Drop-wrist deformity
radial nerve damage--> paralysis of extensor muscles
humeral fractures
radial nerve injured as it travels within the spinal groove typically result in wrist drop & triceps weakness (depending on location of injury)
saturday night palsy
radial nerve injury caused by compression of the nerve against the humerus ad teh arm is draped over the back of a chair during intoxication or deep sleep
crutch palsy
radial nerve injury in axilla from direct pressure, caused by improper use of crutches
treatment for Decreased diaphragmatic excursion Lymphatic congestion
redome dia- Increase thoracoabdominal diaphragm excursion improving respiration and improve lymph return. Pelvic Diaphragm Release- Improve pelvic diaphragm excursion and improve lymph return
stuctural scoliosis
relatively fixed inflexible will not correct w SB in opposite direction assoc w vert wedging and shortened ligs & muscles on concave side
contraindications to articulatory techniques
repeaded hyper-rotation of upper cer spine when positioned in extension can cause damage to vert a acute inflam joint esp where cause of inflam may be from infection or fracuteq
4 types of sacral motion
respiratory inherent (craniosacral) postural dynamic
superior transverse axis of sacrum
respiratory & inherent (craniosacral) motion
treatment for bicipital tenosynovitis
rest & ice for acute for severe: injection with lidocaine or stroids OMT free up restrictions in GH area & myofascial release
treatment for supraspinatus tendinitis
rest, ice, NSAIDs for acute for severe: sling & injection with lidocaine or steroids OMT to shoulder, upper thoracic, & ribs--> inc motion, loosen fascia--> expidate healing
treatment of rotator cuff tear
rest, ice, NSAIDs for minor acute OMT free restrictions of GH, clavicle, upper thoracic, & ribs surgery req for complete avulsion
Goal of myofascial release
restore tissue balance improve lymph flow
what to treat first for cervical spine
ribs and upper thoracic spine
R UE lymph drains into
right (minor) duct
R sulcus shallow L ILA ant and slightly sup lumber curve convex to the R pos seated flex test on R spring at R base restricted spring at L ILA present spring at poles of left oblique axis restricted pos lumbosacral spring test pos backward bending test L5 will be flexed or extended (noneutral), SB L, Rot L
right on left
Backward sacral torsion
right on left left on right
drain into R lymphatic duct
right upper extremity, the right hemicranium (including the head and face), and the heart and the lobes of the lung (except the left upper lobe)
scoliosis
rotoscoliosis any SB induces rot appreciable deviation from normal vert line
atlanto-axial subluvation
rupture of transverse lig--> neuro damage (death) more likely with Down's and RA
counternutation
sacral extension
sacral torsion
sacral rotation about oblique axis along with somatic dys at L5
accessory pelvic ligs
sacrotuberous lig sacrospinous lig Iliolumbar lig
signs & symp of cauda equina syndrome
saddle anesthesi, dec deep tendon reflexes, dec rectal sphincter tone, loss of bowel & bladder control
pain, signs, & treatment from medial epicondylitis
same for tennis elbow but directed at the med epicondyle
ME for L3 E RSr
same steps as lower thoracic (osteo salute)
most common complication
soreness vertebral artery injury low back: cauda equina synd
Compression of SBS
sphen & occip pushed together--> ***dec in amplitude of flex & ext of CRI can obliterate the CRI due to trauma to back of head***
Torsion of SBS
sphenoid & ant cranium rotate ("rotate" on coronal plane... so actually SB) in one direction on AP axis occiput & post cranium rot in opposite direction named for greater wing of sphenoid that is more superior (so "L rotation" = is really R SB when viewing cranium postly)
Vertical strain of SBS
sphenoid dev cephalad or caudad flex/ext about 2 transverse axes (one in center of sphenoid & other superior to occiput) in opposite directions (one is stuck up)
Lateral strain of SBS
sphenoid dev laterally in relation to cciput Rot around 2 vertical axes (one through center of sphenoid and other through foramen magnum) sphen dev L= L lat strain--> if sphen rots one way, occip will rot other way (unlike a SB/Rot dys)
CN VII PNS
sphenopalatine gang--> lacrimal & nasal glands submandibular gang--> submandibular & sublingual glands (pons)
erector spinae group
spinalis, longissimus, iliocostalis
what to treat first for extremities
spine, sacrum, & ribs/askial skeleton
treatment of carpal tunnel synd
splints, NSAIDs, steroid inject surgery indicated if tretmetn fails OMT: rib & upper thorax to des symp tone; treat cervical dys & myofascial restrictions to enhance brachial plex fxn; direct release technique to inc space in tunnel
treatment of trigger point
spray and stretch using vapocoolant spray injection with local anesthetic ME, MFR, recip inhib
palpatory model for sacral torsions
spring test spring restricted over poles of oblique axis pos for post
clavicle sup & lat on acromion findings
step off at AC clavicle resist inf glide at AC tenderness over AC
factors that dec CRI
stress depression chronic fatigue chronic infections
2 types of scoliosis
structural & functional
clavicle
strut for upper limb to allow max freedom of motion as well as transmit forces from UE to ax skeleton only bone connecting the UE to ax spine
Sensation for C4
superior aspect of shoulder
ASIS & PSIS more sup ipsi pubic rami sup ipsi shorter leg ipsi pos standing flex ipsi ASIS restricted to compression ipsi
superior innominate shear
sacral sulci
superior lateral part of sacrum recorded as post/shallow or ant/deep in dys
ASIS appear level PSIS appear level pubic bone sup ipsi pos standing flex ipsi ASIS restricted to compression ipsi
superior pubic shear
Sensation for C3
supraclavicular fossa
sign & symp of rotator cuff tear
supraspinatus tears, weakness in active abduction is often present alsong with a pos drop arm test atrophy common
treatment of severe scoliosis
surgery often indicated if resp conpromise or if progess quickly despite conservative management
tibiofibular joint
synovial composed of the lateral aspect of the prox tibia and prox fibular head movement occurs with protonation & supination of foot
factors that inc interstitial pressure above 0mmHg
systemic HTN cirrhosis (dec plasma protein synthesis) hypoalbuminemia assoc with starvation toxins such as rattlesnake poisoin
medial longitudinal arch
talus, navicular, cuneiforms, 1st to 3rd metatarsals.
rotator cuff tear
tear at insertion of one of rotator cuff tendons, usually supraspinatus Minor tears of cuff common complete tear can occur resulting in retraction of the affected muscle and sharp shoulder pain
Sensation for C2
temple and occipital area
signs & symp of lateral epicondylitis
tenderness at lat epicondyle or just distal, worsens with activity
pain from rotator cuff tear
tenderness just below tip acromion transient, sharp pain in shoulder followed by steady aceh that may last for days often pt will have pain for months, esp at night
compression fracture findings
tenderness to percussion on SP & confirmed on Xray
pain supraspinatus tendinitis
tenderness, esp at tip of acromion gradual onset & may be preceded by strain pain exacerbated by abduction (esp 60-120= painful arc) chronic tendinits may lead to calcification of tendon
Travell's myofascial trigger points
tenderpoint that can give rise to referred pain a trigger point represents the somatic manifestation of a viscero-somatic, somato-visceral or somato-somatic reflex
lateral epicondylitis
tennis elbow strain of extensor muscles of forearm near lateral epicondyle
diaphragms of body
tentorium cerebelli thoracic inlet ab dia pelvic dia
Kirksville crunch
thoracic HVLA corrective thrust is directed at the vertebrae below the dysfunctional segment thrust is aimed 45° cephalad. neutral lesion is treated the same way as a flexed dysfunction, however SB the patient away from you. A purely flexed or extended lesion (no rotation or sidebending) is treated using roughly the same position, except the physician will use a bilateral fulcrum (thenar eminence under one transverse process and a flexed MCP under the other transverse process). Ribs 2-10 can also be treated using the Kirksville Krunch. The difference is that the physician's thenar eminence is under the posterior rib angle of the "key" rib.
treatment for Lymphatic congestion Chest congestion Fever Infection
thoracic pump- Augment thoracic range of motion and affect intrathoracic pressure gradients, improving lymphatic return contra: osteoporosis
what to treat first for rib dys
thoractic spine
lymphoid tissue not connected to lymphatics
thyroid, esophagus and the coronary and triangular ligaments of the liver bypass lymphoid tissue and drain directly into the thoracic duct
posterior innominate rot etiology
tight hamstrings
ant innominate rot etiology
tight quads
Drop arm test
to detect tear in rotator cuff -abduct the shoulder to 90°, and then to slowly lower the arm. -positive test results if the patient cannot lower the arm smoothly, or if the arm drops to the side from 90°
Motor for L5
toe extensors
sacral base
top part of sacrum In somatic dys, can be recorded as shallow/post or deep/ant
Axis and plane for flex/ext
transverse sagittal
etiology of rotator cuff tear
trauma
Inferior pubic shear etiology
trauma or tight adductors
superior pubic shear etiology
trauma or tight rectus ab muscle
course of L thoracic duct
traverses Sibson's fascia of the thoracic-inlet up to the level of C7 before turning around and emptying drains into the junction of the left internal jugular and subclavian veins
what to treat first for acute somatic dys
treat peripheral areas (allow access to acute area
dec restrictions & inc ROM--> PT, NSAIDs/low dose steroids; if doesnt work--> epidural--> laminectomy with decompression
treatment for spinal stenosis
DTR for C7
triceps reflex
Crossed extensor reflex
uses the crossed extensor reflex to achieve muscle relaxation typically used in extremities that are so severely injured or not accessable that direct manipulation is impossible. (contraction of the right biceps produces relaxation of the left biceps and contraction of the left triceps)
Respiratory assistance
uses the patient's voluntary respiratory motion to restore normal motion. Most inhalation rib dysfunctions are treated in this fashion.
Cuneiforms som dys of transverse arch
usually caused by the second cuneiform gliding directly downward, toward the plantar surface
compartment syndrome
usually from trauma or vigorous overuse--> inc in intracompartmental pressure--> will compromise circulation within that compartment
OA, AA, & C2 dys can cause
vagal somatic dys
Sensation for C1
vertex of skull
axis and plane for rotation
vertical and transverse
Measuring scoliosis
via x-ray with Cobb method
factors that inc CRI
vigorous physical exercise systemic fever after OMT to cranial sacral mechanism
Indications for rib raising
visceral dys dec rib excursion lymph congest fever paraspinal muscle spasm
signs & symp from herniated nucleus pulposus
weakness & dec reflexes associated with affected nerve root sensory deficit over corresponding dermatome pos straight leg raise test
signs & symp of carpal tunnel synd
weakness and atrophy usually appear late on exam, symp reproduced by tinel's, phalen, & prayer tests
winging of scapula
weakness of ant serratus muscle due to long thoracic nerve injury evident if scapula protrudes postly while pt pushing on wall
coxa vara
when angle of head of femur is <120
coxa valga
when angle of head of femur is >135
