OPP Study Guide

OMS1 OPP Study Guide

Created by Zachary Hanson for the SAAO

The information provided is a condensed summary for the information presented in the 2016-2017 OPP 502
class. The guide is intended to aid in the study of OMT and to be a quick reference for future treatments. It has
not been verified by OPP faculty, and thus all official materials are contained in the published powerpoints,
lecture, and lab materials.

The anatomy reviews have been removed for this final study guide to aid in its brevity but are vital to the
understanding of osteopathic treatments as this is a mechanical fix for mechanical problems. Understanding
the basic principles presented along with the anatomy should give everyone the groundwork to work through
our work as osteopaths. The materials in blue correlate the lab material to the lecture material and material in
red is of highest yield for OPP 502 testing as well as COMLEX.

Great resources include the green book in the library, FirstAid for COMLEX, and
https://www.youtube.com/channel/UClcuqC4ZK0vbRQzVQWQ3urA

Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Table of Contents Ligamentous articular strain .............................. 9
Background ............ Error! Bookmark not defined. Visceral autonomics ............................................. 9
Founder of the Osteopathic profession, Dr. Thorax ...................................................................9
Andrew Taylor Still .............................................. 5 Thoracic spine characteristics ................................ 9
Basic milestones of the Osteopathic profession.. 5 Tripositional diagnosis (use your hands during the
OPP Principles ...................................................... 5 test!) ....................................................................... 9
Definitions ............................................................. 5 Rule of 3’s............................................................... 9
Somatic dysfunction (TART) .............................. 5 Thoracic Vertebral movements ........................... 10
Landmarks ............................................................ 5 Anterior Tender point treatment (arm over knee)
Palpation ..............................................................5 ............................................................................. 10
Acute vs. chronic – “cold is old, hot is not” ........ 5 Posterior Tender point treatment (prone) .......... 10
Palpation (know each one, distribution, what Facilitation............................................................ 11
they sense) ............................................................. 6 Osteoporosis ........................................................ 11
Dominant Eye ....................................................... 6 Thoracic intervertebral disk herniation ............... 11
Barriers and Range of Motion ............................ 6 Rib Cage .............................................................. 11
Tips to Palpation................................................... 6 Rib cage Characteristics ....................................... 11
Somatic Dysfunction .............................................6 Motion of Ribs...................................................... 11
Somatic dysfunction ............................................. 6 Rib dysfunction .................................................... 11
Facilitation (more for the future, but good to Diagnosis of rib dysfunction................................. 11
know) ..................................................................... 6 Rib tender points ................................................. 11
Anatomical relationships - view .......................... 6 Posterior Rib tender points .................................. 11
Motion and Barriers .............................................6 Thoracic inlet vs. outlet........................................ 11
Dynamic motion.................................................... 6 Intercostal Space Naming .................................... 12
Motion characteristics.......................................... 6 Autonomics .......................................................... 12
Barriers ................................................................. 7 Chapman’s reflex ................................................. 12
Pathologic .............................................................. 7 Sternum anatomy ................................................ 12
Three laws of Fryette ........................................... 7 Tenderpoint associations ..................................... 12
Direct Modalities ..................................................7 End Feel ................................................................ 12
Vertebral unit ....................................................... 7 Muscle energy for EXHALED ribs –remember the
Orientation of superior Facets ............................ 7 rib dance .............................................................. 12
Types of muscle contractions............................... 7 Muscle energy ...................................................... 12
Types of joint restrictors...................................... 7 Lumbar ................................................................ 12
Choice of treatment .............................................. 7 Secondary curves ................................................. 12
General Soft tissue Concepts ............................... 7 Lumbar spine........................................................ 13
Direct Soft tissue ................................................... 8 Bony Asymmetry .................................................. 13
Cervical Direct Soft Tissue .................................. 8 Fracture ................................................................ 13
Thoracic Direct Soft Tissue ................................. 8 Disk load ............................................................... 13
Lumbar Direct Soft tissue.................................... 8 Disk herniation ..................................................... 13
Myofascial release ................................................ 8 Sources of low back pain ..................................... 13
1) Muscle Energy (PIPA, RIPT) ..................... 8 Tests ..................................................................... 13
Articulatory Technique........................................ 8 Surgical indications for herniated disc ................. 13
HVLA .................................................................... 8 Greenman’s dirty half dozen (things OMT cannot
Indirect Modalities ...............................................9 fix) ........................................................................ 13
Activating forces for indirect techniques ........... 9 Dermatomes and neurologic exam...................... 13
Thoracic respiration ............................................. 9 Red Flags (when to jump to cancer screening not
Counterstrain........................................................ 9 OMT) .................................................................... 14
Classifying OMT .................................................. 9 Worrisome ........................................................... 14
Fascia ..................................................................... 9 Piriformis syndrome ............................................. 14
Tender point.......................................................... 9 GI influence .......................................................... 14
Counterstrain........................................................ 9 Spondylolisthesis.................................................. 14
Trigger point .......... Error! Bookmark not defined.

Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
a. Forward slippage of one vertebral body on Neuromuscular imbalance ................................ 19
the one below it. Causes aching pain ................... 14 Lower extremity skeletal anatomy ................... 19
Spondylosis ........................................................... 14 Terrible triad ...................................................... 19
Cauda equina syndrome....................................... 14 Patella .................................................................. 19
Ankylosing Spondylitis .......................................... 14 Lower extremity innervation ............................ 19
Spina bifida ........................................................... 14 Tibia .................................................................... 20
Spinal stenosis ...................................................... 14 Fibula .................................................................. 20
Structural sources of back pain ............................ 14 Pes planus ........................................................... 20
Nerve root compression....................................... 14 Pronation of the foot .......................................... 20
Differential diagnosis of low back pain (Low Yield) Supination ........................................................... 20
.............................................................................. 14 Sprained ankle.................................................... 21
Radicular Symptoms ............................................. 15 Mechanics ........................................................... 21
Systemic symptoms .............................................. 15 Grading ............................................................... 21
Referred back pain ............................................... 15 Ankle Drawer Test ............................................. 21
Iatrogenic back pain ............................................. 15 Ottawa ankle rules ............................................. 21
Cauda equina syndrome....................................... 15 Special Tests ....................................................... 21
Testing .................................................................. 15 Muscle Energy for Lower Extremity ............... 22
Lumbar Counterstrain .......................................... 15 Soft Tissue for Lower Extremity ...................... 22
Upper Extremity .................................................. 16 LAS ...................................................................... 23
Evaluation of the shoulder ................................... 16 Counterstrain ..................................................... 23
Arm dermatomes ................................................. 16 diagnosis of the foot ........................................... 23
History and PE findings......................................... 16 Foot Treatments ................................................. 23
Upper extremity tests .......................................... 16 Diagnosis of lower extremity – .......................... 24
Spencer Technique ............................................... 17 Treatments of lower extremity.......................... 24
Acute Somatic dysfunction................................... 17 Innominate .......................................................... 24
Counterstrain of ................................................... 17 Pelvic pain ............................................................ 24
Pronation and supination ..................................... 17 Types of somatic dysfunction .............................. 25
Parallelogram effect ............................................. 17 Screening Tests .................................................... 25
Wrist motions ....................................................... 17 Goals for treating the pelvis................................. 26
Mechanisms of dysfunction ................................. 17 Pelvis Counterstrain Points .................................. 26
Fractures............................................................... 17 Sacrum ................................................................ 27
Carpal tunnel syndrome ....................................... 18 Sacral anatomical axis .......................................... 27
DeQuervain (stenosing) tenosynovitis ................. 18 Sacral physiologic axis .......................................... 27
Dupuytren’s contracture ...................................... 18 Sacral somatic dysfunction .................................. 27
Arthritis................................................................. 18 Rules ..................................................................... 27
Evaluation and diagnosis of.................................. 18 Diagnosing sacral dysfunction ............................. 27
Ligamentous Articular Strain of the interosseous Sacral Diagnosis.................................................... 27
membrane ............................................................ 18 Cervical................................................................ 28
Strain- Counterstrain of epicondyles.................... 18 Characteristics...................................................... 28
BLT of forearm ...................................................... 18 Cervical spine range of motion ............................ 28
Muscle energy of forearm ................................... 18 Cervical spine mechanics ..................................... 28
HVLA of the forearm ............................................ 18 Palpation findings ................................................ 29
Ligamentous articular strain (carpal tunnel ......... 18 Why examine the C-spine .................................... 29
Articulation of the wrist (carpal tunnel) ............... 18 Counterstrain fixing headaches. .......................... 29
Myofascial release of the flexor retinaculum Special Tests ......................................................... 30
(carpal tunnel) ...................................................... 18 Cervical strain/Counterstrain ............................... 30
Counterstrain of the wrist .................................... 18 Cranial ................................................................. 31
Lower Extremity................................................. 19 Characteristics...................................................... 31
Lymphatic flow from lower extremities ........... 19 Cranial nerves ...................................................... 32
Vasculature of lower extremity ......................... 19 Cranial nerve symptoms ...................................... 32
Inguinal ligament................................................ 19 Cranial Sutures ..................................................... 32
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Strain patterns ...................................................... 32
Treatment considerations .................................... 33
Cranial examination ............................................. 33
Core link................................................................ 33
Reciprocal tension membrane ............................. 33
Cranial Treatments ............................................... 33
Autonomics ......................................................... 33
Characteristics ...................................................... 33
Organization ......................................................... 34
Anatomy ............................................................... 34
Sympathetic Nervous System............................... 34
parasympathetic Nervous System........................ 34
Autonomic balance –............................................ 34
Viscerosomatic reflexes........................................ 34
Parasympathetic levels......................................... 35
Musculoskeletal origins ........................................ 35
Chapman reflexes ................................................. 35
Sympathetic Treatments ...................................... 35
Parasympathetic treatments................................ 36
Diaphragm and Lymphatics .................................. 36
Respiratory circulatory model .............................. 36
Models of assessment and treatment ................. 36
Lymph ................................................................... 36
Diagnosis .............................................................. 36
Treatment............................................................. 37

Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
History and Osteopathic Principles • Lesions of somatic dysfunction are fascial distortion,
vertebral rotations and side bending, tissue texture changes,
Founder of the Osteopathic profession, Dr. Andrew Taylor motion restrictions, bilateral differences in tissue
Still • If NO somatic dysfunction, then no OMT treatment: ie.,
degenerative disease, fracture, inflammation
• Born in VA; 1828-1917 • Somatic dysfunction is always named for its FREEDOM
• Son of missionaries OF MOTION!!!
• Civil war soldier • NOTE: Examination Sequence (think superficial to deep)
• Abolitionist; suffragist 1) Observation
• Three children died from spinal meningitis 2) Temperature
• One died of Pneumonia, (all in the same year) and wife 3) Skin topography and texture
died in childbirth. 4) Fascia
• Believed the drugs that were worthwhile were 5) Muscle
o Anesthetics 6) Tendon
o Antidotes 7) Ligament
o Antiseptics 8) Erythema friction rub
9) Bone
Basic milestones of the Osteopathic profession
Screening Exam
• Developed: 1880s
• American School of Osteopathy founded 1882 (Kirksville, 1. Static portion –observe and palpate (TART)
Missouir) 2. Dynamic portion – regional motion testing
• First state to license was VT 1896
• American Association for the Advancement of Osteopathy Landmarks
1897 1) Relationships/levels (know the landmarks in relation to one
• Became AOA in 1901 another, ie pubic symphysis is medial to ASIS)
OPP Principles – know how a case relates to these i. Sternal angle of louis (rib 2)-T4/5
ii. Suprasternal notch -T2
principles
iii. Xiphoid = T9
1) The human being is a dynamic unit of function. (Illness or iv. Umbilicus L3/4
injury in one part of the body affects other parts, therefore v. Superior angle of scapula T2
you must treat the whole person) vi. Scapular spine (T3)
2) The body possesses self-regulatory mechanisms that are vii. Inferior angle of scapula (T7)
self-healing in nature. viii. Four abdominal quadrants
3) Structure and function are interrelated at all levels. 1. Upper right
4) Rational treatment is based on these principles. a. Liver
b. Gall bladder
Definitions 2. Lower right
OPP a. Appendix
1) Medical philosophy b. Gall bladder
OMT 3. Upper left
1) Therapeutic application of guided forces a. stomach
OMM 4. Lower left
1) Application of philosophy, diagnosis and OMT a. Sigmoid colon
ix. Iliac crest (L4)
Somatic dysfunction (TART)
Palpation
a. Tissue texture abnormality
i. Temperature, dampness/dryness, Acute vs. chronic – “cold is old, hot is not”
bulging, firm, hard, soft, spongy,
stringy, ropey, skin drag condition Acute Chronic
b. Asymmetry Skin Increased Decreased
i. Balanced, right/left, temperature
superior/inferior, anterior/posterior Tissue texture Boggy, rough Thin, smooth
c. Restriction of motion Skin moisture Increased Decreased
i. Normal range of motion or Tissue tension Increased, Increased,
limited, how limited, involved spasm ropy, stringy
joint or soft tissue, how many Tenderness Increased, Present but
planes sharp, localized lessened, dull,
d. Tenderness ache, burning
i. Pain with palpation Tissue edema Yes No
• Impaired or altered function of related components of the Red reflex Redness lasts Redness fades
somatic system: skeletal, arthrodial and Myofascial History Recent Remote
structures and related vascular, lymphatic, and neural Color Erythematous Pale
elements
• NOT degenerative diseases, fractures, inflammation,
microbial infections, medication side effects
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Palpation (know each one, distribution, what they sense) 7) NOT
a. Fractures
b. Degenerative processes
c. Inflammatory process
Facilitation (more for the future, but good to know)
1. Heart – T1-T5, chest, shoulder, neck, jaw
2. Asthma T2
3. Appendix – periumbilical pain (T10-11)
4. Prostate T12-L2
5. Stomach T5-T9 LEFT
6. Gall Bladder T5-T9 RIGHT
7. Esophagus T4-T5 Right, T5-T9 Left
Anatomical relationships - view
a. Sagittal plane
i. AP plane through midline
ii. Rotates on transverse axis
iii. Forward and backward bending, also called
flexion and extension
b. Coronal
Dominant Eye i. Vertical plane through lateral aspect
ii. Rotates on anterior posterior plane
1. Stand on the side of the physician’s dominant eye to iii. Sidebending occurs in this plane. Also
diagnose dysfunction according to ‘height’ or depth AB/ADduction
2. Determines what side of the table to stand on c. Transverse
Barriers and Range of Motion i. Plane through body parallel to floor
ii. Rotates on vertical axis
iii. Rotation occurs in this plane

Motion and Barriers

Dynamic motion
1) Abduction – moves away from midline
2) Adduction – moves toward midline
3) Flexion – anterior structures move toward each other
4) Extension – posterior move away from each other
5) External rotation – rotates away from midline
6) Internal rotation – rotates toward midline
Motion characteristics
Red arrow is passive range of motion, blue is active 1) Active
a) Voluntary by patient
b) Within physiologic barriers
Tips to Palpation 2) Passive
a) Outside force
1. Flexibility
a. Flexibility of the joints of the elbows, wrists, hands, and b) Within anatomic barriers
fingers is important 3) Inherent
2. Relaxation a) Spontaneous, all cells, organs, system
a. Important to perception
b. Eliminates muscle tension (which would block perception) 4) Physiologic
3. Hand strength a) Within normal range
a. Squeezing a ball
b. Playing an instrument
5) Barrier
c. Finger exerciser a) Limit to motion
4. Hands i) Resistance and ease
a. Should be protected and cared for
b. Sensitive diagnostic instruments. 6) End feel
a) Quality of motion at anatomic or physiologic barrier
Somatic Dysfunction i) Ease
ii) resistance
Somatic dysfunction 7) Rotation
1) The diagnostic criterion for OMM. a) Movement in a transverse plane about a vertical axis
2) Disturbance of the normal function of somatic structures 8) Sidebending
3) Possesses characteristics identifiable by means of palpation a) Movement in a coronal plane about an anterior
4) Basis of the phenomenon appears to be neurophysiological posterior axis
5) Deleterious effects on health when present b) Translation is a lateral shifting of a vertebra inducing
6) Improves with OMT sidebending
9) Flexion
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
a)Anterior movement in a sagittal plane about a Direct Modalities
transverse axis
10) Extension Vertebral unit
a) Posterior movement in a sagittal plane about a
transverse axis 1. When there is a group of vertebrae being named, the
name is given for the superior member
Barriers 2. Rotation is in reference to the anterior/superior surface
of the vertebral body
1) Anatomic
a) Limit imposed by anatomic structure Orientation of superior Facets
b) Bone and ligament are final limits
c) Damage if pushed past Region Facet orientation Mnemonic
2) Physiologic (stretching increases) Cervical Backward, upward, BUM
a) Limit of active motion medial
3) Elastic Thoracic Backward, upward, BUL
a) Range between physiologic and anatomic barrier medial
b) End feel Lumbar Backward Medial BM
c) Range expands with stretching
4) Restrictive Direct vs indirect treatments
a) Functional limit. Not found in a normal joint 1. Direct treatments apply motion into the barrier
b) Results from a somatic dysfunction
(restriction). Or away from the named somatic
5) Pathologic
a) Restriction of joint due to a perminant pathologic dysfunction (remember it is named for freedom or
change in tissues ease of motion)
a. Best for acute injuries and patients that can
Pathologic take aggressive treatments.
2. Indirect treatments apply motion away from the
barrier or in the direction of the somatic dysfunction.
a. Best for chronic injuries and tender patients
Types of muscle contractions
1. Isometric – no winners (most common)
2. Isotonic – concentric – PT wins
3. Isolytic – eccentric – Dr. wins
Types of joint restrictors
1. Monoarticular muscles (short restrictions)
a. Type 2
2. Polyarticular Muscles (long restrictors)
a. Type 1

Three laws of Fryette Choice of treatment

1. Type I Dysfunction (only in Thoracic and Lumbar 1. Most aggressive to least aggressive
Vertebrae) → causes DISCOMFORT a. HVLA
a. MOST COMMON – think chronic dysfunction b. Articulation
b. FOG = “first opposite group” c. Soft Tissue
c. GROUP, N, R and SB in OPPOSITE directions d. Direct Fascial Release
d. SB precedes rotation e. Muscle Energy
e. NO sagittal component f. Counterstrain
2. Type II Dysfunction (only in Thoracic and Lumbar g. FPR
Vertebrae) → causes ACUTE pain! h. Indirect fascial release
a. SSS = “single same side” i. Indirect Cranial
b. Either F (flexed) or E (extended) – at ease General Soft tissue Concepts
i. If gets worse on flexion AND
extension, then neutral is position of 1. Effleurage – movement of lymph
ease (Type I Dysfunction!!!) 2. Petrissage skin rolling
c. Rotation precedes SB 3. Tapotement – rhythmic tapping
3. Type III Dysfunction a. Clomping – cupping of hands – movement of
a. Can occur in CERVICAL, Thoracic and Lumbar lung fluid
b. Mvmt in one plane will modify movement of that 4. Inhibition – direct pressure on hypertonicity
segment in other planes of motion 5. Traction lengthening the segment
6. Compression – shortening the segment
7. Stretching – longitudinal force
8. Kneading – tangential force

Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Contraindications connective tissue plastic changes, which are associated with
a release of energy
1. All treatments are CI if patient refuses or is i) Tensegrity principles with piezoelectric properties
uncooperative. c) Indicated for somatic dysfunctions involving myofascial or
2. Relative CI if there is severe injury in the locaiton of connective tissue
the injury. There are specifics but I just remember d) Contraindicated relatively with patients with open wounds,
that general rule. fractures, thermal injuries, and other local disease
3. Indirect treatments typically have more leaniency i) Direct
(1) ID direction of barrier, position at barrier, hold
(remember no lymph techniques if pt has cancer)
until release
Direct Soft tissue ii) Indirect
(1) ID direction of EASE, position at EASE, hold
1. Direct technique, form of myofascial, diagnostic and until releae (direction of ease is also the direction
therapeutic of your somatic dysfunction diagnosis)
2. Relaxes hypertonic muscles by decreasing alpha motor e) Thoracic inlet and outlet
neuron activity and hoffman reflexes i) Seated steering wheel
3. Stretches and increases elasticity of shortened fascia ii) Pt is seated, physician at back with hands around base
4. Enhances circulation, neutrition, oxygenation, immune of neck, monitor right and left rotation for ease of
system, relaxation, and autonomic tone motion
Cervical Direct Soft Tissue f) Ligamentous articular strain
i) Anterior cervical (sibson’s) fascial release
1) suboccipital release (1) For anterior scaline
a) patient is supine, physician at head, physicians hands (2) Pt supine physician at head, engage cervical
are under subocciptal region, applies traction force fascia at clavicle, after release, draw thumb
anterior. laterally
i) May be done rhythmically or sustained
2) Supine traction 1) Muscle Energy (PIPA, RIPT)
a) Patient is supine, physician at head, one hand a) Patient’s muscles are actively used from a precise position,
stabilizes occiput and the other grasps under the chin. in a specific direction, against a physician’s counterforce.
Force is cephalad to the patient. Traction is applied i) The neuromusculoskeletal apparatus is in a refractory
rhythmically or sustained state after an isometric contraction, where passive
3) Cradling traction stretching can be performed without a myotatic reflex
a) Patient is supine, physician at head of table with hands opposition
under neck bilaterally contacting the cervical (1) Sensed by the golgi tendon organ (which is
paraspinal muscles. Gentle anterior force and superior stretched in muscular contraction)
force with traction ii) Hypertonic muscles can cause somatic dysfunction
4) Bilateral fulcrum b) PostIsometric relaxation,
a) Patient is supine with physician at head, with hands i) Pt pushes Away from barrier (PIPA)
crossed under the pt’s head. Physician flexes the neck c) Reciprocal Inhibition
to produce a longitudinal cervical muscluature stretch i) Pt pushes Toward barrier (RIPT)
5) Contralateral traction (kneading) d) Joint mobilization
a) Patient supine, cephalad hand stabilizes head, caudad i) Articular hvla thrust
hand contacts the paraspinal muscles: pushing and e) Respiratory assistance
pulling them anteriorly f) Oculocephalogyric reflex
Thoracic Direct Soft Tissue i) Using voluntary eye movements to reflexively afect
cervical and tuncal musculature
1. Stretching, longitudinal g) Crossed extenosr reflex
2. Stretching kneading (bowstringing) i) In severely injured patients, cross pattern locomotion.
3. Prone pressure with counterpressure Use oposite antagonist to relax injured muscle
4. Lateral recumbent kneading ii) So for a right arm that you want to extend.,,you have
5. Supine kneading the patient flex the left arm and the right arm relaxes
in extension
Lumbar Direct Soft tissue
Articulatory Technique
1) Supine kneading
2) Prone stretching i) LVHA to increase motion of a joint
3) Prone pressure (kneading) b) Carpal bone release
4) Prone pressure with counterleverage (kneading)
a) Grip on ASIS with kneeding over lumbar HVLA
5) Scissor technique prone a) Posterior tibia on talus
a) Grip knee with kneeding over lumbar i) Grasp foot at talotibial joint, dorsiflex foot at talar
b) Can be done with knee flexed or extended joint and apply force toward talus
Myofascial release b) Transtarsal
i) Counter clockwise rotary thrust around the tarsal
a) System of diagnosis and treatment joints
b) Peripheral neuroreflexive alterations in muscle tone and
neural facilitation by engaging fascia. Allows for
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Inbetween indirect and direct: Still Technique. a. Posterior
b. Abdominal ganglia (prevertebral)
1. Start the patient indirect, and move them into the direct a. Anterior
barrier. Adding a compression force. i. Celiac
ii. Superior mesenteric
iii. Inferior mesenteric
Indirect Modalities
Activating forces for indirect techniques Thorax
1) Inherent forces Thoracic spine characteristics
a) The tendency of the body to seek homeostasis 1. Framework for thoracic cavity, protection of spinal cord
2) Assistant activating forces and vital organs. Assist with respiration/ventilation,
a) Respiratory cooperation movement, and connections with the body
b) Respiratory force (breathe past normal point) 2. Thoracic curve – Primary Curve (kyphosis)
a. T1-2 – transition from cervical lordosis
Thoracic respiration b. T3-12 kyphosis
c. T10-12 – transition to lumbar lordosis
1) Exhalation 3. Transitional areas (areas most prone to dysfunction)
a) Internal rotation, increase in spinal curves a. OA
2) Inhalation b. C7-T1
a) External rotation, spinal curves flatten c. T12-L1
d. L5-S1
Counterstrain 4. Functional divisions
a. Cervico-thoracic junction
i) Takes muscles to ease i. T1-4
b) Normalization of Gamma muscle fibers b. True Thoracis
i. T5-9
c) Proprioceptive imbalance c. Thoraco lumbar junction
d) Sustained abnormal metabolism i. T10-12
e) Impared ligamento muscular reflex 5. Bones
a. Articular facets (BUL)
Classifying OMT b. Inferior (Forward, downward, medial)
1) Direct c. Costal facets: demifacets: only in T-spine
a. Engage restrictive barrier 6. Atypical vertebra
b. “take the tissues where they resist you” a. One entire facet on 1, 10, 11, 12 (all have a 1)
2) Indirect b. No facet on transverse process of 11, 12
a. Away from restrictive barrier Tripositional diagnosis (use your hands during the test!)
b. Equal tension in all planes
c. “take the tissues in a direction of ease” 1. Determine which transverse process is posterior
2. Determine if flexion or extension moves TP anterior
Fascia 3. If rotational component does not move it is neutral
1) Connective tissue covering all surfaces of the body. A 4. Sagittal component = type 2
continuous sheet connecting the lymphatics, vasculature, all 5. No sagittal component = type 1
fibers, muscles, tendons, organs, bone 6. Movement in one plane changes movement in another =
a. Restriction reduces flow to any of the above structures type 3

Tender point Rule of 3’s

1. Specific discrete area of local tenderness 1. T1-3: spinous processes project posteriorly therefore the tip
2. No radiation of pain (if radiation it’s a trigger point) of the spinous process is in the same plane as the
3. Anterior and posterior points, usually unilateral, but can be transverse process of that vertebra
bilateral 2. T4-6: spinous processes project slightly downward,
therefore the tip of the spinous process lies in a plane
Counterstrain halfway between that vertebra’ s transverse processes and
the transverse processes of the vertebra below it
1. Dr. Jones in Ontario Or. In 1955 produced spontaneous release
3. T7-9: spinous processes project moderately downward,
of somatic dysfunction
therefore the tip of the spinous process is in a plane with
2. Find it, fold it, hold it
the transverse process below it
3. Generally, anterior points will be flexed and posterior points will
4. T10 follows 7-9
be extended
5. T11 follows 4-6
a. Medial points will not have much side bending or
6. T12 follows 1-3
rotation
b. Lateral points will have more sidebending and rotation
Ligamentous articular strain
1. A form of myofascial release, mostly indirect techniques
2. BLT
Visceral autonomics
a. Sympathetic chain ganglia (paravertebral)
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
Sympathetic levels. This continues to grow in importance, so Thoracic Vertebral movements
learn it at some point.
1. Best in Rotation →side bending → flexion → extension
2. Rotation
a. Guided by thoracic articular facets
b. Limited by multiple ligamentous tensions
3. Side bending
a. Guided by articular facets of any two adjacent
vertebrae
b. Limited by contralateral ligamenta flava,
intertransverse ligaments, Ribs, Sternum
4. Flexion
a. Space between vertebrae open out posteriorly
b. Limited by extensor mm. Interspinous ligaments,
ligamenta flava, posterior longitudinal ligament
5. Extension
a. Intervertebral disc expands anteriorly and
crushed posteriorly
b. Limited by articular processes and spinous
process
Anterior Tender point treatment (arm over knee)
Tender Location Classic treatment acronym
point
anterior
AT1 Midline or lateral to Flex head to F
episternal notch dysfunctional level
AT2 Midline or just Flexion to F
lateral to manubrium dysfunctional level
AT3-AT5 Midline at level of Flexion to F
corresponding rib dysfunctional level
AT6 Midline or lateral to Flexion to F
xiphoid sternal dysfunctional level
junction
AT7-AT9 AT7- midline to Flexion to F ST RA
xiphoid dysfunctional level
AT8 – 3cm below side bending
xiphoid toward and rotate
AT9 – just above away
umbilicus
Seated position
AT10- AT10 – just below Supine position F ST RT
AT12 umbilicus
AT 11 – below level Hip flexion 90-135 F ST RA
Lymphatic distribution of iliac crests (L5) deg, slight side
For any lymphatic treatment. Open the thoracic outlet FIRST. Then AT12 – superior bending, rotation
inner surface of iliac toward (Type1) ,
move from the outlet to the area of restriction in order, as in
crest or side bending
clearing the path for the lymphatic fluid to flow back to the heart.
toward, rotation
away (Type 2)
Posterior Tender point treatment (prone)
Tender Location Classic treatment acronym
point
Posterior
PT1-4 Spinous Extension to E
process or dysfunctional level
transverse
process
Lateral PT Spinous Rotation to R
4-9 process or dysfunctional level
transverse (arm under pt.’s
process arm)
PT 9-12 Spinous Rotation of hips R
process or

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OPP Study Guide
transverse 2) 6-10 bucket handle
process a. Coronal motion
b. Palpate mid axillary line
HVLA 3) 11-12 caliper
a. Transverse planar motion
1. Neutral dysfunction = side bend patient to the barrier
b. Palpate posteriorly
(smiley)
Rib dysfunction
a. force is directly down into the table (90°)
1. Named for the direction it is stuck in
2. Flexed or Extended dysfunction = sidebend patient to the 2. Key rib (what to treat)
barrier (frowning face) a. BITE
a. Extended dysfunction = force is applied at a 45° i. Refers to the group that is ‘stuck’
angle cephalad ii. When there is a ‘widening’ you know
b. Flexed = force is applied straight (90° down) there is either an inhaled dysfunction
Facilitation for the upper rib in the widening, or an
exhaled dysfunction in the lower rib in
1. The maintenance of a pool of neurons in a state of partial or the widening
sub-threshold excitation = less stimulation to trigger 3. Terminology
impulse a. Inhaled dysfunction
a. Due to increased afferent input i. Exhaled restriction, restriction in
2. Reflexes exhalation, inhaled rib, elevated rib,
1. Viscero-somatic – visceral stimulus = response in inhalation strain
somatic structure ii. COPD, Emphysema, chronic
2. Somatic-visceral – somatic stimulus = visceral bronchitis, asthma, pneumonia
response b. Exhaled dysfunction
3. OMT – at the spinal level can decrease sympathetic activity i. Inhalation restriction, restricted in
inhalation, exhaled rib, depressed rib,
Osteoporosis exhalation strain
1. Compression fractions increasing kyphosis ii. Pulmonary fibrosis, pneumonitis,
neuromuscular disorders, pneumonia
Thoracic intervertebral disk herniation
Diagnosis of rib dysfunction
1. Not common, limited by posterior longitudinal ligaments,
ribs 1. Global movement of rib cage (springing)
2. Structural asymmetry
Rib Cage 3. Intercostal spacing
4. Rib motion upon breathing
Rib cage Characteristics 5. Where to put hands
1) True Ribs a. Rib 1 inferior to earlobes
a. 1-7, attach directly to sternum via costochondral b. Rib 2-5 hands on top of chest
cartilage c. Rib 6-10 in intercostal spaces Mid-Axillary
2) false ribs d. Rib 11-12 on back
a. 8-10, attach via synchondrosis to costochondral Rib tender points
cartilage of rib 7
3) floating ribs 1. Ribs 1-2 presents with pain in anterior chest wall
a. 11-12 which do not attach to sternum 2. Ribs 3-6 present with pain in lateral chest wall
4) Typical ribs 3-9 AR1 Below clavicle on 1st Flex, STRT
a. Head, neck, tubercle, angle, shaft chondrosternal articulation
5) Atypical ribs (1,2,11,12) associated with pectoralis
a. Rib 1, articulate with T1, no angle major
b. Rib 2, large tuberosity for serratus anterior. AR2 Superior aspect of 2nd rib in Flex, STRT
Articulates with both T1 and T2 via demifacets mid clavicular line
c. Ribs 11,12, articulate with corresponding AR3-10 On the dysfunctional rib at Flex STRT
vertebrae, lack tubercles the anterior axillary line
d. Rib 10 is sometimes atypical because it has a
single articulation with the rib head and T10 Posterior Rib tender points
e. Atypical have a 1 or 2 in them
PR1 Posterior superior aspect STRT
6) Innervated by the phrenic nerve C3,4,5 (keeps the
of 1st rib, cervicothoracic
diaphragm alive)
angle anterior to trapezius
PR2-6 On superior aspect of the SARA
angle of the dysfunctional
Motion of Ribs
rib
1) 1-5 Pump handle
a. Attachments to body of vertebrae Thoracic inlet vs. outlet
b. sagittal motion a. Inlet
c. palpate mid clavicular line a. Manubrium, rib 1, T1
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OPP Study Guide
b. Outlet b. Posterior - inhaled
a. Clavicle, scapula, rib 1
b. Thoracic outlet syndrome End Feel
i. Between anterior and middle
scalene
ii. Between clavicle and first rib
iii. Underneath pectoralis minor
iv. Fascial distortions
c. Rib 1 separates inlet from outlet
Intercostal Space Naming
a. Name for the rib above it,
Autonomics
a. Sympathetic
a. Dilates bronchioles
i. Increase oxygen exchange
b. Increase pulmonary artery pressure
c. Increase ratio of goblet cells to ciliated
columnar cells Muscle energy for EXHALED ribs –remember the rib dance
i. Thickens and dries pulmonary a. Rib1 Anterior and middle scalene
secretions a. Hand on forehead
b. Parasympathetic b. Rib 2, posterior scalene
a. Constricts bronchioles a. Hand on lateral head
i. Decreasing oxygen exchange c. Rib 3, 4, 5, pectoralis minor
b. Stimulates watery pulmonary secretions a. Arm pushes to contralateral hip
c. Vagus nerve innervates everything from d. Rib 6, 7, 8, (9) serratus anterior
mouth to the middle of the transverse colon a. Arm punches toward ceiling
Chapman’s reflex e. Rib 9, 10 latissimus dorsi during Abduction
a. Patient Adducts arm
1. Puffy or boggy tissue (rice like) = viscerosomatic reflex f. Ribs 11, 12 quadratus lumborum
2. 2nd ICS a. Patient side bends to the same side as the rib
a. bronci, myocardium, thyroid, esophagus
3. 3rd ICS Pathological correlations (really a second year topic)
b. upper lung Inhaled: obstructive lung dx
4. 4th ICS b. COPD
c. lower lung c. Emphysema
5. 5th ICS d. Chronic bronchitis
d. Right: Liver e. Asthma
e. Left: stomach acid f. Pneumonia
6. 6th ICS Exhaled dysfunctions: Restrictive lung dx
f. Right: liver gallbladder a. Pulmonary fibrosis
g. Left: stomach peristalsis b. Pneumonitis
7. 7th ICS c. Neuromuscular disorders
h. Right: Pancreas d. pneumonia
i. Left: Spleen
HVLA
Sternum anatomy
a. just like the cascade crunch for the thoracics but you
a. Motion are contacting the rib angle and sidebending toward
a. A/P compression and decompression, the physician (opposite side of dysfunctional rib)
superior and inferior gliding motion, rotation
around a transverse axis, rotation around a Muscle energy
vertical axis, torsion around oblique axis
a. Manubrium a. Inhaled
b. Sternal notch a. Patient is supine with physician at head of table
a. Anterior to T2 i. Pump handle ribs – flex neck
c. Angle of Louis ii. Bucket handle ribs – side bend patient
a. Articulation with second rib anterior to T4/5 b. Place hand on anterior surface of dysfunctional
intervertebral disk rib (for inhaled rib), upon inhalation hold for 3-5
d. Gladiolus (body) seconds as physician resists motion of the rib
e. Xiphoid process
Lumbar
Tenderpoint associations
Secondary curves
1. AE-PI
a. Anterior Exhaled 1. Develops as a child, lordotic, develops as children begin to
walk
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OPP Study Guide
Lumbar spine c. Bragard test
a. Modified SLR with dorsiflexion
b. Tests for radiculopathy
d. Contralateral straight leg raising test
a. Radicular pain in contralateral leg,
b. Large herniation
e. Hip drop test
a. Lumbar spine compensates with sidebending to
sacral base
b. Positive if less than 20 degrees
f. Trendelenburg
a. Tests gluteus medius strength. Lift leg off
ground.
1. Anatomical L1-5 b. Positive on contralateral leg if hip angle increases
2. Functional T11-L5 more than 20 degrees
3. Weight bearing design g. Thomas test
4. Ferguson’s angle a. Supine, pull knee to chest
a. 30-40 degrees between L5 and sacrum b. Psoas/hip flexion
5. Motion of lumbar spine h. Hoover Test
6. Backward bending →forward bending --→bad rotation and a. Test for malingers
side bending b. Hold calcaneus, PT raises leg = normal people
a. Facets lie in a sagittal plane will produce contralateral pressure
Bony Asymmetry i. Kernig test
a. Stretch spinal cord by flexing head to chest
1. Facet asymmetry b. Pain down the back =meningeal irritation
a. Facet is in a different plane 1. Assess side bending ability of contralateral lumbar
2. Sacralization a. Observe range of motion
a. L5 looks like the sacrum (fuses) b. Observe levelness of horizontal plane at iliac
3. Lumbarization crests
a. S1 looks like the 6th lumbar vertebra i. 20degrees or more is negative
4. Spina bifida occulta ii. Positive is less than 20 degrees
Fracture Surgical indications for herniated disc
1. Wolfe’s law-bone formation along stress lines a. Cauda equina syndrome
2. Anterior triangle is the weak link for compression fractures b. Progressive neurologic defects
c. Profound neurologic deficit
Disk load d. Severe and disabling pain refractory to four to six weeks of
a. Least load (better for you)- Laying supine →laying conservative treatment
recumbent → standing → standing hunched forward =
Greenman’s dirty half dozen (things OMT cannot fix)
sitting → sitting slouched – most load (worst for you)
a. Non neutral dysfunction
Disk herniation b. Dysfunction in symphysis pubis
a. Posterior/lateral is most common c. Restriction of anterior nutational movements of sacral base
a. Most common l4/l5, l5/s1 d. Innominate (hip) shear dysfunction
b. X+1, herniation at disk x affects nerve below e. Short leg, pelvis tilt syndrome
f. Muscle imbalance of the trunk and lower extremities
Sources of low back pain
Sacralization
1. Muscular ligamentous, iliolumbar ligament, piriformis,
psoas When a lumbar vertebra looks like the sacrum (L5 fuses to sacrum)
2. Facet pain (arthritis)
3. Annulus tear or degeneration Lumbarization
4. Nerve root compression (disc rupture or degeneration) When the sacrum looks like the lumbar vertebra (S1 becomes L6)
5. Other joint dysfunction (SI, Pubes, Sacral base)
6. Misc (renal calcanulus, diverticulitis, CA) Dermatomes and neurologic exam
Tests a. L4 – foot inversion, patellar reflex, medial foot sensation
b. L5 – great toe extension, no reflexes, dorsum foot sensation
a. Babinski reflex c. S1 – foot eversion, achilles tendon reflex, lateral foot
a. Scrape bottom of foot sensation
b. Positive for adults is when the toes dorsiflex
c. (children do not have upper motor neuron
control yet)
b. Straight leg raising test
a. 0-35 slack in sciatic nerve
b. 35-70 – sciatic nerve deformation
c. Over 70 normal joint pain

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OPP Study Guide
Spondylosis
a. Degeneration of disk, can cause compression fractures

Cauda equina syndrome

a. Pressure on cauda equina due to disc herniation
b. Sharp low back pain causing saddle anesthesia
c. Tx- surgery

Ankylosing Spondylitis
• Bamboo spine
• Fusing of vertebral body
Spina bifida
a. Developmental, lamina does not close over vertebral segment
b. Types
a. Occulta – no herniation
b. Meningocele – herniation of meninges
c. Meningomyelocele – herniation of nerve roots
Spinal stenosis
a. Narrowing of spinal canal or intervertebral foramina due to
Red Flags (when to jump to cancer screening not OMT) degenerative changes which cause pressure on nerve roots
b. Caused by hypertrophy of facet joints, calcium deposits in ligamentum
a. Over 50 Years Old
flava and posterior longitudinal ligament, and loss of intervertebral disc
b. Previous history of cancer height
c. Unexplained weight loss
d. Failure to improve with 1 month of therapy Structural sources of back pain
e. No relief with bed rest
a. Fibro-skeletal structures
Worrisome a. Periosteum, ligaments, anuli fibrosa
b. Meninges – coverings of spinal cord
a. Severe low back pain with sudden onset c. Synovial joints – capsules of zygapophysial joints
b. Wakes them from sleep (think malignancy) d. Muscles – intrinsic muscles of the back
c. Neurological defects e. Nervous tissue – spinal nerves or nerve roots exiting
d. Claudication symptoms with back pain the intervertebral foramina
Piriformis syndrome Nerve root compression
a. Hypertrophy/spasm - Sciatic nerve problems 1) Due to increased lumbar lordosis
a. Hip/butt pain, radiation to calf and foot a) Decrease the size of the intervertebral foramen
GI influence b) Cause buckling of the ligamentum flava
i) Buckle forward compresses the nerve
a. Sympathetic ii) Facet bone spurs compress or cut the nerve
a. Ileus c) Causes pressure on facet joints
b. Constipation i) Osteophytes at the facet joints impinge on the
c. Abdominal pain exiting nerve
d. Flatulence d) Causes
e. Distension i) Obesity
b. Parasympathetic ii) Weak abdominal muscles
a. Diarrhea iii) Hypertonic psoas muscles
b. Vomiting iv) Hypertonic quadratus lumborum
Spondylolisthesis Differential diagnosis of low back pain (Low Yield)
a. Forward slippage of one vertebral body on the one below it. 1) Children
Causes aching pain a) Congenital (scoliosis), trauma, overuse, tumor, infection
2) Adults
a. Increased pain with extension, tight hamstrings, stiff legs a) Ankylosing spondylitis, bamboo spine
and waddling gait, no neurological deficits, positive step b) Metabolic bone disease
off sign c) Acute fractures
b. Types d) Disc disease
a. Dysplastic – sacral facets e) Spondylothithesis
b. Isthmic – stress fracture on pars f) Spinal instability
c. Degenerative – changes on posterior=anterior slip g) Unequal leg length
d. Traumatic – acute stress on pars = instability = herniation 3) Older adults
c. Grades a) Spinal stenosis
a. 1 : 0-25 b) Metastatic disease
b. 2: 25-50 c) Osteoporotic compression fractures are more common
c. 3 : 50-75 d) Hip arthritis
d. 4 : >75 e) Degenerative facet disease
d. Tx – wt loss, exercises, OMT, watch for progression f) Zoster (shingles)
4) Non Radicular symptoms

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OPP Study Guide
a) Annular tear Lumbar Counterstrain
b) Discogenic pain
c) Compression fractures
d) Lumbar stenosis
e) Osteoporotic compression fractures
5) Facet joint arthropathy
a) Arthrosis following disc degenerative disease
b) Normal intact annulus and longitudinal ligaments protect the
facet from abnormal stress and loading

Radicular Symptoms
1) Often associated with disc herniation or spinal stenosis
2) Intra spinal pathology
3) Herpes zoster
Systemic symptoms
1) Metabolic disease, ankylosing spondylitis, infection, spondylo-
arthropathy
Referred back pain
1) Abdominal aortic aneurysm and vascular disease
2) Visceral: ulcer, pelvic inflammatory disease, endometriosis,
gallbladder disease, pleural disease
3) Infection: UTI, PID
4) Hip Arthritis
Iatrogenic back pain
a) Dural adhesions and nerve root adhesions
b) Pseudoarthrosis
c) Post surgical instability
d) Arachnoiditis
e) Post operative diskitis
2) Psychogenic back pain
Cauda equina syndrome
1) Symptoms – low back pain, sciatic pain, bladder or bowel
problems, saddle anesthesia
2) Exam findings – dermatomal sensorimotor deficits, altered
DTR, forward leaning posture
3) Treatment – NASID, steroids, pain meds, antibiotics,
chemo, surgical decompression
Testing
1) Neutral – physician introduces motion to determine the
freedom of vertebral motions for rotations, side bending, 1. Posterior Counterstrain
and flexion a. L1-L5
2) Non-neutral- PT introduced the motion evaluates primary b. ESARA
positional symmetry of the transverse processes in the 2. Psoas major
neutral flexed, extended ranges of posture a. Tender point 2/3 distance from ASIS for midline
b. FST
3. PL3 (at the inferior aspect of the PIIS), PL4 (halfway
between greater trochanter and iliac crest)
a. Extend thigh
4. PL5
a. On ilium inferior to PSIS
b. F IR ADD

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OPP Study Guide
lateral recumbent direct HVLA a. Serratus anterior or trapezius
b. Long thoracic injury
a. put the rotational side recumbent (so on the table). 2. Seizure and inability to passively or actively rotate
Flex the knees till you feel motion at the lumbar affected arm externally
vertebra that is out. Rotate the thorax so the chest is a. Posterior shoulder dislocation
facing toward the ciling. Attempt to sidebend the 3. Supraspinatus/infraspinatus wasting
patient into the barrier. Thrust the hip toward the a. Rotator cuff tear, suprascapular nerve
ground entrapment
b. Cant initiate abduction
Upper Extremity 4. Pain radiating below elbow, decreased cervical range
Evaluation of the shoulder of motion
a. Cervical disc disease
1) Observation 5. Shoulder pain in throwing athletes, anterior
2) Palpation glenohumeral joint pain and impingement
3) Motion testing (quality and quantity) a. Glenohumeral joint instability
4) Muscle strength testing 6. Pain or clunking with overhead motion
5) Sensation testing a. Labral disorder
6) Clinical tests 7. Nighttime shoulder pain
a. Arm drop, Appley’s, apprehension, Yergason’s a. impingement
8. generalized ligamentous laxity
Arm dermatomes a. multidirectional instability
Upper extremity tests
1) Appley’s scratch test
a) Touch hands behind back (above and below)
i) Positive test is when hands do not
meet/differences in flexibility
b) Motions
i) Above shoulder
(1) External rotation
(2) Flexion
(3) abduction
ii) lower shoulder
(1) internal rotation
(2) extension
(3) adduction
2) Apprehension test
a) Flex elbow to 90 degrees with shoulder abducted to 90
degrees. Physician holds wrist as pt. applies pressure
internally rotated
i) Positive if produces pain
b) Motion
i) Internal rotation
c) Relocation maneuver, if apprehension maneuver is
positive, continue external rotation
i) Apply backward pressure from front of shoulder
(1) Positive if pain is reduced
(a) Anterior shoulder instability, SLAP
lesion
(2) Negative if pain is not relieved
(a) AC impingement
3) Arm Drop Test (non specific)
a) Hold arm at 90 degrees abduction, let go of arm
i) Positive if arm falls
(1) Tear of rotator cuff muscles
4) Yergason’s test
a) Traction applied to elbow and the arm externally
rotated, pt. applies internal rotation against resistance
i) Positive if biceps tendon is unstable in groove
(1) Dislocation of biceps tendon in bicipital
groove
5) Empty Can Test
a) Pt. with elbow extended, arm abducted, thumbs
pointed down. Pt. attempts to elevate arms against
History and PE findings resistance
i) Positive if pain or weakness are experienced
1. Scapular winging
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OPP Study Guide
(1) Testing Supraspinatus iii) Externally rotate the patient’s arm until tender point
6) Finklestein’s test dissipates
a) Physician rotates thumb toward an inferior
hypothenar, ulnar deviates the hand Pronation and supination
b) Diagnose DeQuervain’s tenosynovitis 1) Pronation
i) Positive if pain of extensor hallucis longus a) Distal radius crosses over ulna and moves
tendon anteromedial
7) Eichoff’s test b) Proximal radial head glides posterior
a) Modified finklestein 2) Supination
b) Pt. grabs thumb, flexes toward hypothenar, deviating a) Distal radius moves posterolaterally
the hand b) Proximal radial head glides anterior
i) Positive if painful 3) Reciprocal motion by the interosseous membrane
8) Carpal tunnel tests a) Both anterior and posterior fibers.
a) Tinel –tapping on medial nerve i) Transmits force from wrist to elbow, elbow to
b) Phalen’s – praying with hands facing downward with wrist, ulna to radius and radius to ulna
backs of hands touching ii) The fulcrum between radius and ulna in
i) Positive with numbness or pain supination and pronation
Spencer Technique (1) Dysfunction at the wrist can limit function at
the elbow and vice versa
a) PT lateral recumbent, physician circumducts and rotates,
and extends arm in all planes of motion. Parallelogram effect
i) Extension 1) As ulna abducts, radius glides distally and wrist is pushed
ii) Flexion into increased adduction
iii) Circumduction with compression 2) Normal carrying angle
iv) Circumduction with traction 3) As ulna adducts, radius glides proximally and wrist is
v) ABduction pulled into abducted position
vi) ADuction with external rotation
vii) Internal and external rotation with abduction Wrist motions
viii) pumping 1) Wrist
a) Supination - 90°
Acute Somatic dysfunction b) Pronation - 90°
c) Flexion – 80-90°
1) Impairment or altered function of related components of the
d) Extension - 70°
somatic system e) Ulnar deviation - 30°
2) Characterized in early stages by vasodilation, edema, f) Radial deviation 20°
tenderness, pain, and tissue contraction 2) MCP
3) Diagnosed by history and palpatory assessment of TART a) Flexion - 90°
b) Extension 30-40°
Counterstrain of 3) DIP
a) Flexion - 90°
a) Shoulder b) Extension - 20°
i) Subscapularis 4) Thumb
a) Palmar abduction - 70°
ii) Found on the antero-lateral border of scapula on the b) Palmar adduction 0°
subscapularis muscle pressing from an anterior lateral c) MCP flexion 50°
to posteromedial direction d) MCP extension 0°
iii) Shoulder is extended and internally rotated e) IP flexion 90°
b) Biceps- long head f) IP extension 90°
i) Over the tendon of the bicep muscle in the bicipital Mechanisms of dysfunction
groove
ii) Pt. flexes elbow, shoulder flexion, abduction, and 1) During pronation distal radius moves anteriorly and radial
internally rotated head moves posteriorly (falling forward with hand
c) Biceps – short head outstretched)
i) Short head/coracobrachialis, at the inferolateral aspect a) Leading to extension of wrist, allowing carpal bones
of the coracoid process to glide over anterior or posterior
ii) Flexion of elbow and shoulder b) Also strain on interosseous membrane
d) Levator scapulae 2) During supination the distal radius moves posteriorly and
i) Superior medial border of the scapula at the radial head moves anteriorly (falling backwards with hand
attachment of the levator scapula extended)
ii) Glide the scapula superiorly and medial to shorten a) Forces on the olecranon can induce lateral glide within
muscle the fossa causing varus dysfunction
(1) May also be treated by marked internal rotation b) Wrist extension can affect carpals and interosseous
of the shoulder with traction and slight abduction membrane
e) Supraspinatus
i) At the mid supraspinatus muscle superior to the spine Fractures
of the scapula 1) Monteggia fracture, bado type 1
ii) Move the patient’s shoulder into 45 degrees of flexion a) Radius break
and abduction 2) Colles fracture
a) Break head of wrist
3) Displaced olecranon
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Carpal tunnel syndrome 3) Starting at the pt’s elbow, bent 90°. Grasp pt’s olecranon
with thumb and finger. With the other hand grasp the
1) Median nerve compression within tunnel causing pain or dorsum of the wrist.
paresthesia a) Compress forearm between hands, steady and balance
a) May lead to thenal atrophy against any barriers
b) Tinel sign and Phalen test are diagnostic
Strain- Counterstrain of epicondyles
DeQuervain (stenosing) tenosynovitis
1) On the heads of the ulna and radial heads
1) Inflammation within thenar tendon sheath
2) Pain with circumduction BLT of forearm
3) Swelling around anatomic snuffbox
4) Finklestein test indicative (or Eichoff’s modification) 1) Find hypertonic area over the interosseous membrane
2) Find position of forearm which is at ease, hold it there,
Dupuytren’s contracture reassess
1) Contracture of palmar fascia with nodule formation Muscle energy of forearm
a) Genetic predisposition
1) anterior radial head (supinated forearm)
Arthritis i) PT is seated, physician facing patient
ii) Hold wrist, cephalad hand monitors head of radius
1) Osteoarthritis, rheumatoid, psoriatic, gouty iii) Pronate forearm until motion at head, instruct
2) Involve joints of wrist and hand patient’s supination, isometric contraction, then find
a) Small motions are lost first new barrier
Evaluation and diagnosis of 2) Posterior radial head (pronated forearm)
i) PT is seated, physician facing patient
1) ulna ii) Hold wrist, cephalad hand monitors head of radius
a) Carrying angle iii) Supinate forearm until motion at head, instruct
i) Normal patient’s supination, isometric contraction, then find
(1) Males 5-15° new barrier
(2) Females 10-15°
ii) Abnormal HVLA of the forearm
(1) >15° cubitus valgus 1) Anterior Radial Head
(2) <5-15°cubitus varus i) Pt is seated, physician facing patient
b) ulnar motion testing ii) Hold pt’s wrist, cephalad hand monitors head of radius
i) grasp olecranon, and wrist iii) Pronate until motion at radial head, carry forearm into
(1) ab/ad-duct forearm at wrist, palpating for flexion, thrust into barrier
medial and lateral glide and seating into 2) Posterior radial head
fossa i) Pt is seated, physician facing patient
2) Radius ii) Hold pt’s supinated wrist, cephalad hand monitoring
a) Short lever head of radius
i) Palpate radial head, induce pronation and iii) Supinate until motion at radial head, carry forearm
supination at wrist into extension with a thrust.
ii) AP glide and rotation should be palpable
(1) Pronation = posterior Ligamentous articular strain (carpal tunnel
(2) Supination = anterior
b) Short lever 1) Grasp hypothenar and thumb, supinate forearm, flex wrist.
i) Elbows at the sides and bent to 90°, grasp wrist Apply compressive force downward through thumb through the
proximal to carpal bones inducing supination and thenar eminence
pronation at the extremes of motion 1) If barrier is encountered, remain there until it releases
(1) Isolate motion of radius, ulna and Articulation of the wrist (carpal tunnel)
interosseous membrane at end point of
supination and pronation 1) Squeeze with rapid circumduction, placing heel of both hands
3) Wrist and carpals over the carpal bones.
a) Flexion/extension
b) Ab/ad-duction
Myofascial release of the flexor retinaculum (carpal
c) Pronation/supination tunnel)
d) Palmar/dorsal glide 1) Interlace patient’s pinky and thumb. Place thumbs over each
4) Metacarpals and phalanges bony prominence of the wrist. Providing gentle lateral traction
a) Flexion/extension and anterior pressure (extending patient’s wrist)
b) Ab-ad-duction
c) Rotation Counterstrain of the wrist
Ligamentous Articular Strain of the interosseous 1) Follows the lines of the wrist and the metacarpal barriers
membrane 2) Anterior points
a. Flex hand with internal and external rotation
1) Patient supine, seated or standing (shortening the muscles at that point
2) Physician standing slightly in front of patient on the side of 3) Posterior points
the affected elbow b. Extend hand with internal and external rotation

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OPP Study Guide
Lower Extremity e. Normal 12-15 degrees
f. Anteversion (increased angle) >15
Lymphatic flow from lower extremities – toe IN
g. Retroversion <12 – toe out
a. Inguinal nodes collect lymphatic fluid from superficial
abdominal wall, gluteal area, perineum, and superficial Terrible triad
lower extremities
b. Superficial inguinal nodes flow to deep lymphatic nodes 1. ACL
along femoral vein 2. MCL
c. Pathway 3. Medial meniscus
• Follow external iliac veins into cisterna chyli (saccular • Induced by valgus force on knee
area of dilated lymph vessels in retro-crucial space of
diaphragm to right abdominal aorta to the thoracic Patella
duct
1. Pathology
Vasculature of lower extremity • Chondromalacia patellae
• Wearing or roughening of
a. Arterial supply – femoral artery posterior articular surface
b. Venous supply – femoral vein • Typically due to chronic changes
c. Femoral triangle NAVeL secondary to overuse
a. Lateral to medial (central line importance) • Contributing factors
b. Nerve – artery – vein – lymphatics i. Coxa varus
Inguinal ligament ii. Genu valgus
iii. Pronated foot
a. Primary structural cause of groin or inguinal pain iv. Pes planus
i. Also in meralgia paresthesia v. Tight/hypertonic vastus
i. In the lateral femoral cutaneous nerve due to lateralis
compression vi. Tight tensor fasciae
ii. Burning or prickling sensation of skin (pins and latae
needles) vii. Weak vastus medialis
• Treatment
Neuromuscular imbalance
i. Orthotics
a. Biomechanical stressors ii. Stretching
b. Tight hypertonic muscles iii. OMT
• Postural or antigravity muscles become tense iv. Surgery
with asymmetric somatic dysfunction • Patellofemoral pain syndrome
• Quadratus lumborum, piriformis, • Improper tracking of patella
hamstrings, gastrocnemius-soleus, • Weakness of vastus medialis
iliopsoas, tensor fasciae latae, rectus • Overuse (runners)
femoris, adductor magnus
c. Weak pseudoparetic muscles Lower extremity innervation
• Paralyzed flaccid 1. Sciatic Nerve
• Counterpart to the hypertonic muscles • Pathway through greater sciatic notch,
(which become inhibited) with exits beneath piriformis into posterior
asymmetric somatic dysfunction 2. Neuro-exam – T4 radiculopathy
• Gluteus minimus, rectus abdominis, • Deep tendon reflex, dysesthesia
tibialis anterior, gluteus maximus, • Consequences
peroneus, quadriceps femoris • Diminished DTR patellar tendon
Lower extremity skeletal anatomy • Weakness/cramping of muscles of
L4 innervation
1. Femur h. Foot inversion
• Q angle i. Knee giving way
• Between functional longitudinal axis of j. (difficulty climbing
femur and tibial longitudinal axis stairs)
a. Normal 10-12 decrees k. Caused by L3L4
b. Increased angle is genu valgus herniated disc
c. Decreased angle is genu varus 3. Neuro-exam testing for L5
• Angle of inclination • No abnormal DTR
• Angle between anatomic longitudinal axis • Dysesthesia of L5 dermatome
and axis of femoral neck • Weakness/cramping of muscles of
d. Normally 120-135 L5 innervation (gluteus medius,
• Coxa valgus >135 tibialis anterior, extensor hallucis,
• Coxa varus <120 extensor digitorum)
• Angle of anteversion l. Diminished strength of
• Between condyles of distal femur in hallux extension, foot
transverse plane an axis of femoral neck
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OPP Study Guide
drop, trips on carpet • Cause of dysfunction
or cracks on sidewalk • Restricted plantar flexion
m. Caused by L4/L5 • Forced dorsiflexion
herniated disc • Forced eversion
4. Neuro-exam testing for S1 radiculopathy • Forced external rotation
• Diminished Achilles DTR • Symptoms of dysfunction
• Dysthesia of S1 dermatome • Knee pain, ankle pain, mid heal
• Weakness/cramping of S1 pain
innervation • Most common for acute pain
n. Intrinsic foot muscles, 2. Posterior fibular head
buttock, gastrocnemius, • Natural in supination
soleus, peroneus longus,
• Mechanism
impaired foot eversion,
• Fibular head moves posteromedial
can’t walk on tip toes
• Foot supinates
• Most common radiculopathy with
herniation between L5S1 • Tibia internally rotates
• Distal fibula moves anterior
• Cause of dysfunction
• Restricted dorsiflexion
• Forced plantar flexion
• Forced inversion
• Forced internal rotation
• Tight hamstrings
• Common fibular nerve entrapment
• Sudden disuse of high heals
• Symptoms of dysfunction
• Knee pain, ankle pain,
• Difficulty with ambulation
• Neuropathy
Pes planus
1. Flat foot
• Talus rotates anteriorly
• Navicular glides inferomedially
• Cuboid glides interolaterally
• Cuneiforms glide inferiorly
Pronation of the foot
1. Dorsiflexion
2. Abduction
3. Eversion
4. Distal fibula moves posteromedial
5. Muscles
• Dorsiflexion
o Extensor digitorum longus
o Extensor hallucis longus
o Fibularis tertius
Tibia o Tibialis anterior
• Abduction
1. Internal rotation o Combination
• Tibia internally rotates • Eversion
• Tibial plateau glides posterolaterally o Fibularis brevis
2. External rotation o Fibularis longus
• Tibia externally rotates o Fibularis tertius
• Tibial plateau glides anteromedially
Supination
Fibula
1. Components of motion
1. Anterior fibular head ii. Plantar flexion
• Occurs in pronation iii. Adduction
• Mechanism iv. Inversion
• Fibular head moves v. Distal fibula moves anterolateral
ANTEROLATERAL vi. Muscles
• Foot pronates i. Plantar flexion
• Tibia externally rotates a. Fibularis longus
• Distal fibula moves posterior b. Gastrocnemius
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OPP Study Guide
c. Plantaris • Patient is tender on tip or posterior aspect of medial
d. Soleus malleolus
e. Tibialis posterior
ii. Adduction Special Tests
a. Combination 1) FABERE Test – assessment of gross hip motion
iii. Inversion a. Flexion, Abduction, External Rotation, Extension
a. Tibialis posterior b. Patrick’s test or figure “4” hip test
Sprained ankle c. Opposite hand stabilizes ASIS
i. Groin pain = hip joint pathology
1. Inversion sprain 2) FADIR (see fabere for info)
• 75-90% of all sprains a. Flexion, Adduction, Internal Rotation
• Type 1 b. Tests SI joint
i. Anterior talofibular 3) Ober’s Test - Tensor Fasciae Latae and Iliotibial Tract Tension
a. Always torn first… a. Stabilize hip and knee, with knee flexed, extend hip
• Type 2 (pt in lateral recumbent) allowing for thigh to adduct
ii. Anterior talofibular toward table
iii. Calcaneofibular i. Positive if thigh cannot adduct past
• Type 3 midline
iv. Anterior talofibular 4) Thomas – Iliopsoas contracture
v. Calcaneofibular a. Flex one thigh up to abdomen,
vi. Posterior talofibular i. Positive if opposite knee lifts up off table
5) Trendelenburg test – gluteus medius weakness (antigravity)
Mechanics a. Pt standing, lift/flex knee
i. Positive if pelvis tilts toward side of
i. Foot supinates
flexed knee
ii. Ankle inversion
6) Drawer Tests (knee)
iii. Cuboid : plantar glide and lateral rotation
a. Anterior tests anterior cruciate ligament
iv. Navicular: plantar glide and medial rotation
i. Flexed knee at 90 degrees pulling on tibia
v. Calcaneus: eversion
b. Posterior tests posterior cruciate ligament
vi. Talus: posterolateral glide
i. Flexed knee at 90 degrees pushing on
vii. Fibular head: posterior (anterior if anterior talofibular
tibia
ligament tears)
7) Lachman’s
viii. Tibia: external rotation, plateau glides anteromedial
a. More specific than anterior drawer for ACL diagnosis
ix. Femur, internal rotation
b. Pt supine with knee flexed at 30 degrees, stabilize foot
x. Innominate: ipsilateral is posterior
and pull proximal tibia anterior while pushing distal
xi. Sacrum: ipsilateral forward sacral torsion
femur posterior
xii. Lumbar spine: rotates to opposite side of sprain
i. Positive with excessive motion of tibia
xiii. Thoracic spine: rotates to same side as sprain
8) Valgus stress test
xiv. Cervical spine: rotates to opposite side of sprain
a. Tests MCL
Grading b. Pt supine or seated with knee flexed to 30, applied
valgus stress by pushing knee medially while
• 1st degree stabilizing knee
• ligament integrity is intact i. Positive if gapping of medial joint space
• RICE treatment 9) Varus stress test
• 2nd degree a. LCL test
• partial tear b. Same as valgus but pulling knee lateral
• slight ligament laxity 10) Collateral ligament testing
• usually no need for surgery (splinting) a. Asses medial and lateral collateral ligament
• 3rd degree b. Pt seated or supine with knee at 30
• complete ligamentous rupture c. Valgus stress (MCL) stabilize ankle and apply force to
• splinting and surgery lateral aspect of knee in medial direction
i. aBduct tibia with medial glide
Ankle Drawer Test d. varus tests LCL
i. same as valgus but applying a lateral
1. Purpose is to assess ankle ligaments force to the knee and adducting tibia with
2. Patient is supine, physician stabilizes tibia allowing foot to lateral glide
plantar flex e. positive if increased joint laxity and significant pain
3. Positive test with increased or excessive ligament laxity 11) McMurray’s test
Ottawa ankle rules a. Evaluate meniscal tears
b. Pt supine with knee flexed
1. To determine the rules for radiographic analysis in acute i. Medial meniscus – external rotation of
ankle injuries tibia applying valgus pressure to knee
2. Criteria ii. Lateral meniscus – internally rotates tibial
• Unable to bear weight immediately and in ER Appling varus pressure at knee
• Tender on TIP or posterior aspect of lateral malleolus c. Positive with a palatable click or pain
12) Appley’s grind test

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OPP Study Guide
a. Medial and lateral meniscal integrity 3) Hip internal rotation dysfunction
i. Prone with knee flexed 90 physician a. Supine muscle energy
kneels on thigh while pushing down i. Supine with knee and hip flexed to 90
toward table while internally and ii. Physician at treated side, cephalad hand
externally rotating leg stabilizes medial aspect of knee. Grasp
ii. Positive with pain dysfunctional ankle, externally rotate hip
13) Appley’s distraction test by pushing ankle medially. Into barrier,
a. Same as above but tests medial and lateral collateral isometric contraction
ligaments by distracting the foot away from the joint b. Prone muscle energy
14) Bounce home test i. Flex knee 90. Cephalad hand stabilizes
a. Tests for meniscal tears due to effusion medial aspect of knee. Grasp
b. Hold heal flex knee and allow knee to bounce into dysfunctional ankle externally rotating
extension hip, isometric contraction at restrictive
c. Positive with incomplete extension of knee or slight barrier
bounce on extension 4) Hip external rotation dysfunction
15) Patellar grind test a. Supine muscle energy
a. Test for irregular posterior patellar articulatory i. Pt supine flexed hip and knee on
surface, possible chondromalacia dysfunctional side 90 degrees. Physician
b. Pt supine, knees extended, physician applies on side to be treated. Cephalad hand
downward pressure on patella while patient contracts stabilizes lateral aspect of knee, grasp of
quadriceps muscle ankle rotating hip internally. Isometric
i. Positive with pain contraction at barrier
16) Patellofemoral apprehension test b. Prone muscle energy
a. Tests quality of articulating surfaces of patella and i. Flex knee, internally rotate hip, isometric
trochlear groove of femur contraction at barrier
b. Pt supine, physician pushes patella distally in trochlear 5) Piriformis
groove, pt tightens quadriceps femoris. Patellar a. Post isometric relaxation
movement should be smooth and gliding i. Pt supine flexed hip and knee on
i. Positive with roughness/crepitation as dysfunctional side, hand on asis of
patella moves dysfunctional side, caudal hand pulls knee
medial to rotate hip internally. Instruct pt
Muscle Energy for Lower Extremity to pull knee away from physician
1) Hip flexion dysfunction b. Reciprocal inhibition is also advisable
a. Prone muscle energy 6) Knee flexion dysfunction
i. Pt prone with physician at opposite side a. Prone muscle energy
of dysfunction i. pt supine with physician at side to be
1. Cephalad hand on sacrum treated, cephalad hand stabilizes knee,
2. Index finger on PSIS of caudal hand supports leg proximal to
dysfunctional side ankle, extend dysfunctional knee to
3. Caudal hand supports knee of feather edge of restrictive barrier.
affected lower extremity Isometric contraction, rest repeat
4. Extend hip until motion detected 7) Knee extension dysfunction
5. Pt resists physician with an a. Prone/supine muscle energy
isometric contraction, then i. Physician at side to be treated, cephalad
relaxation, and rechecked/repeated hand stabilizes knee, caudal hand supports
b. Supine muscle energy leg proximal to ankle, extend
i. Pt supine knees at end of table. Flex knees dysfunctional knee to feather edge,
and hips pulling knees to chest with arms. isometric contraction, relax, repeat
Pt extends affected leg until it dangles off Soft Tissue for Lower Extremity
the table. Physician is at the end of the
table on the side of dysfunction. The 1) Prone soft tissue technique
treating hand on anterior distal thigh of a. Diagnosis of contracted iliotibial band with pain,
affected lower extremity. Pt pushes leg up positive ober test
resisting physician. Isometric contraction, b. Technique – pt prone with knee flexed to 90,
relax, recheck/repeat physician on OPPOSITE side, grasping angle with
2) Hip adduction dysfunction caudal hand, reach across with cephalad hand over the
a. Supine muscle energy lateral thigh, contracting force from the thigh and the
i. Pt supine, physician at foot grasps and ankle pushing toward the physician engaging the
stabilizes knee or ankle of functional iliotibial band
lower extremity. Opposite hand grasps c. At the barrier, keep pressure for 10-20 seconds until
and abducts dysfunctional side. Isometric release or with a rhythmic manner
contraction, check, repeat 2) Lateral recumbent soft tissue
2) Hip abduction dysfunction a. Pt in lateral recumbent with dysfunctional side UP.
a. Supine muscle energy Physician stabilizes pelvis with cephalad hand on the
i. Same as above but adduction into the posterolateral iliac rest. Caudal hand makes a fist to
restrictive barrier apply pressure over iliotibial band

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OPP Study Guide
LAS viii. tender point is midway between greater
trochanter and ILA
1) Ligamentous articular strain ix. flex hip to rest on physician’s thigh, use
a. Low velocity high amplitude hip flexion aBduction and external
b. BLT but with more force. rotation to fine tune
c. LAS to center femur in acetabulum
i. Stabilize ilium, while applying pressure diagnosis of the foot
toward the neck of the femur
1) range of motion
Counterstrain a) talus range of motion
i) passively plantar flex and dorsiflex foot
a. Tensor fasciae latae (1) plantar flexion/anterior glide
(2) dorsiflexion/posterior glide
b) calcaneus range of motion
i) posteromedial/anterolateral
ii) superior/inferior glide
c) navicular range of motion
i) superior/inferior glide
ii) rotation
d) cuboid range of motion
i) superior/inferior glide
ii) rotation
e) cuneiform range of motion
i) superior/inferior glide
f) metatarsal range of motion
i) superior/inferior glide
g) phalange range of motion
i) superior/inferior glide
ii) rotation

ii. For pain in lateral thigh, hip or pelvis. Foot Treatments

Tender point within the fascia below the 1) Soft tissue – foot
crest of the ilium. d. Indication
iii. Flex and aBduct hip i. Plantar fasciitis
b. Iliotibial band ii. Rigid acquired pes planus
iii. General relaxation
iv. Lymphatic drainage
e. Modality
i.Patient supine
ii.Physician at foot using moderate thumb
for a spread plantar fascia longitudinally
or laterally
2) BLT fallen subtalar joint
a. Pt supine, physician at foot of table. Grasp foot with
both hands with fingers on plantar aspect of distal
metatarsals. And thumbs on dorsal aspect. Slight flex
of distal forefoot. Pushing thumbs downward into
metatarsals toward table. Position at balance point
3) Muscle Energy – fallen subtalar joint
iv. a. Supine. Physician at foot. Grasp foot at dysfunction,
v. for pain in lateral thigh or lower hip. tarsal bones, metatarsal bones. Press thumb cephalad,
Tender point below greater trochanter patient curls toes, relax, take up slack, repeat
along iliotibial band 4) Trans-Tarsal HVLA
vi. Abduction with slight flexion, and play a. PT supine with physician opposite dysfunction.
with external/internal rotation Position knee FABER. Cross thenar eminences over
c. Piriformis the calcaneus and over forefoot. HVLA at angle
5) HVLA posterior tibia on Talus
a. Pt supine with physician at foot of table. Hands are
either interlaced on dorsum or one on dorsum and on
heal. Dorsiflex foot to barrier (with traction) deliver
traction tug with an increase in dorsiflexion.
6) HVLA – inversion ankle sprain
a. Patient supine with physician at foot of table. Same
setup as above, but with an eversion force.
7) HVLA – eversion ankle sprain
vii. a. Same as above but inverting the ankle
8) Muscle Energy – inversion ankle sprain
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a. Same as above, but when put into the barrier (NO 3) Muscle energy for posterior fibular head
thrust) but have a PI or RI force. – eversion motion 1. Same as above but pt provides internal rotation
into barrier counterforce
9) Muscle Energy – Eversion ankle sprain 4) HVLA – anterior fibular head
a. Same as above with inversion motion 1. Indication
10) Muscle energy – plantar somatic dysfunction i. Medial ankle sprain, forced dorsiflexion
a. Pt supine with physician at foot of table with one hand of ankle, genu recurvatum deformity.
on dorsum and one on heal. Dorsiflex foot to barrier, ii. Pt supine with physician placing cephalad
pt plantar flexes hand over anterior surface of fibular head.
11) Muscle energy – dorsiflexion dysfunction Plantar flex, invert, and internally rotate
a. Same as above but put into plantar flexion barrier and patient’s ankle with caudal hand to move
a dorsiflexion extension distal fibula anterior. Thrust through
12) HVLA – cuboid, navicular, cuneiforms fibular head to back of table
a. Hiss whip 5) HVLA posterior fibular head
b. Tender prominence on plantar surface 1. Inversion ankle sprain
c. Pt prone or standing 2. Prone with knee flexed to 90 degrees. Physician places
d. With hands around foot, thumbs over dropped bone, cephalad hand posterior to dysfunction fibular head.
apply a whipping motion so thumbs thrust DOWN Caudal hand grasps ankle. Knee flexed to restrictive
into sole of foot barrier. Externally rotate foot with a thrust toward
13) HVLA metatarsals buttocks
a. Indication – plantar flexion restricted 6) HVLA supine – posterior fibular head
b. Pt supine with physician’s cephalad hand stabilizing 1. Inversion ankle sprain
calcaneal talar region. Caudal hand grasps metatarsals 3. Pt supine with knee flexed to 90 degrees. Physician
and phalanges. Rapid plantar flexion of distal foot with hand on fibular head. And on ankle/tibia. Flex
14) Counterstrain – medial ankle knee to barrier, dorsiflex, evert, and externally rotate
a. On anterior tibialis muscle ankle or externally rotate tibia into barrier, thrust hand
b. Pt laterally recumbent with pillow under medial distal toward buttocks
tibia. Physician inverts and internally rotates foot for 7) Diagnosis of lower extremity
the 90 seconds 1. Tibia
15) Counterstrain lateral ankle i. Pt seated with legs off side of table,
a. Location – fibularis longus, brevis, tertius grasping the malleoli internally and
b. Pt laterally recumbent with pillow under lateral distal externally rotate tibia bilaterally to locate
tibia. Physician everts and externally rotates foot for restrictive barriers.
90 seconds. 8) BLT – supine – interosseous membrane
16) Counterstrain calcaneus 1. Pt supine with physician on same side as dysfunction
a. Location- anterior calcaneus on plantar surface of foot contacting the tibia and fibula with both hands moving
at quadratus plantae them until reaching a balance point. Hold until release
b. Pt prone with knee flexed. Dorsum on physicians 9) BLT seated interosseous membrane
thigh. Physician on the tender point side with knee on 1. Pt seated with legs off table. Physician facing patient
table. Compress calcaneus with fine tuning for the 90 contacting the tibia and fibula with hands proximal
seconds. hand inferior to knee and distal hand superior to ankle.
Compressive force moving to a balance point.
Diagnosis of lower extremity – 10) Myofascial release
1. Proximal fibula 1. Seated or supine, with physician contacting fascia
i. Evaluate fibular head of a seated patient by surrounding tibia and fibula moving fascia in all three
stabilizing pt’s ankles then moving fibular head planes until a release is palpated.
anteriorly and posteriorly comparing bilaterally 11) Muscle energy – internally rotated tibia
2. Distal fibula 1. Seated with legs off table. Physician uses cephalad
i. Pt seated with physician grasping the lateral malleoli hand to contact medial tibia plateau and caudal hand
with thumb and forefinger moving them on medial aspect of foot and ankle. Dorsiflex ankle
anterolaterally and posteromedial comparing them and externally rotate the distal tibia to barrier. Pt
bilaterally internally rotates tibia
12) Muscle energy – externally rotated tibia
Treatments of lower extremity 1. Same as above but dorsiflex and internally rotate. Pt
externally rotates.
1) BLT – fibular head
13) Muscle energy – externally rotated tibia Cephalad hand on
1. Pt supine with knee flexed, physician on dysfunctional
medial aspect of knee. Caudal hand on medial aspect of ankle.
side grasping the fibular head and lateral malleolus,
Put into barrier, pt internally rotates hip and knee while flexing
finding the balance point
knee. Counterforce. Put the foot higher, repeat
2. Muscle energy – anterior fibular head
2) Muscle Energy for an anterior fibular head Innominate
1. Pt seated or supine with legs off table. Physician
grasps anterolateral fibular head with cephalad hand, Pelvic pain
plantar flex and invert ankle with caudal hand, while
internally rotating leg until fibular head meets its a) Source
posterior restrictive barrier. Pt gives counterforce with i) Ligamentous structures
external rotation ii) Pubic synchondrosis
iii) Musculotendinous attachments
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OPP Study Guide
iv) Periosteum i) Positive standing flexion
v) Referred pain from abdominopelvic viscera ii) Distance from ASIS to umbilicus decreased on
b) Causes of pelvic somatic dysfunction dysfunctional side (more medial)
i) Congenital malformations iii) Deep sacral sulcus
ii) Tight muscles b) Treatment – muscle energy
iii) Horseback riding i) Pt supine flex and aBduct pt hip into the figure 4 or
iv) Running frog leg position. Have them push their knee toward
v) Mis-step the ceiling.
vi) Falling 6) Innominate out-flare
vii) Bicycle wrecks a) Signs
viii) Sports injuries i) Positive standing flexion
ix) Trauma ii) Distance from asis to umbilicus increased on
x) Other dysfunctional side (more lateral)
iii) Shallow sacral sulcus
Types of somatic dysfunction b) Treatment – Muscle Energy
1) Anterior innominate rotation i) Pt supine, grasp knee and aDduct knee, the pt
• Signs – longer leg contracts muscles to aBduct knee
• Positive standing flexion 7) Superior pubic shear – most common
a) Signs
• Inferior ASIS
i) Tenderness on tubercle
• Superior PSIS
ii) Step-off sign
• Shallow sacral sulcus iii) Elevated pubic ramus on affected side
• Equal iliac crest height b) Treatment – Muscle Energy
• Possible inferior pubis i) Supine pt, with dysfunctional side over the edge of the
• Medial malleolus inferior table. abduct knee to gap the pubic symphysis. Push
a) Treatment - Muscle energy their leg to barrier toward the floor, they contract leg
i) Pt supine, stabilize contralateral ASIS, pt leg against toward the ceiling.
shoulder with PSIS cupped on lateral hand. Push leg 8) Inferior pubic shear – result of trauma
toward chest, have them push back down a) Signs
2) Posterior innominate rotation i) Tenderness on tubercle
• Signs – short leg ii) Step-off sign
• Positive flexion test iii) Inferior pubic ramus on affected side
• Superior ASIS b) Treatment – Muscle Energy
• Inferior PSIS i) Pt supine, knee into physicians chest. Push toward pt
• Deep sacral sulcus chest. Flex hip and abduct thigh. They push down into
• Equal iliac crest height chest
• Possible superior pubis 9) Anterior pubic shear
• Superior medial malleolus a) Signs
a) Treatment – muscle energy i) Tenderness on symphysis
i) Pt supine with dysfunctional leg over the edge of the ii) Step-off sign
table. Push knee into extension, and have them push iii) Anterior pubic ramus on affected side
back upward 10) Posterior pubic shear
ii) Can also do prone by holding the knee in extension a) Signs
3) Innominate up-sip i) Tenderness on symphysis
• Signs- ii) Step-off sign
• Positive standing flexion iii) Posterior pubic ramus on affected side
11) Pubic decompression
• Superior ASIS
a) Pt supine, knees together (bent) have them Abduct their
• Superior PSIS
knees with isotonic contraction. Then adduct with a fist
• Superior iliac crest height between the knees. Repeat as moving knees outward
• Superior pubis
a) Treatment – muscle energy Screening Tests
i) Pt supine, grasp lower extremity. flex hip and aBduct,
traction, while pt pulls their hip cephalad 1) Standing flexion test
b) Treatment – HVLA a) For iliosacral dysfunction
i) Same setup as before, but tug the leg b) Pt standing, place thumbs on PSIS (eyes level with PSIS).
4) Innominate down slip Pt place hands on thighs and flex forward
a) Signs c) Last moving side is the positive side
d) Possible
• Positive standing flexion
i) Iliosacral somatic dysfunction
• Inferior ASIS
ii) Contralateral tight hamstrings (false positive)
• Inferior PSIS
iii) Ipsilateral tight hamstrings (false negative)
• Inferior iliac crest height 2) Seated flexion test
• Inferior pubis a) Sacroiliac dysfunction
a) Treatment – muscle energy and HVLA as above, but b) Pt seated thumbs on sacral base. Eyes level to sacral base.
treating the superior hip. Pt puts hands together between their knees and flex at the
5) Innominate in-flare waist Keeping their ischial tuberosity’s on the table.
a) Signs
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c) Last moving side is positive attachment of the Lower leg pulled
3) ASIS compression test pectineus laterally to
a) Apply posterio-medial pressure on ASIS while stabilizing create slight
the other. The more restrictive side is the positive one internal rotation
of the hip
Goals for treating the pelvis
a) Improve ROM, asymmetry, motion of related structures,
pain and discomfort, and resolve somatic dysfunction
2) Myofascial release – pelvis
a) Pt supine, cephalad arm across ASIS, caudad hand under
sacrum. Have them flex hips and knees to put feet flat on
table. Monitor tissue tension until release
3) Anterior Counter Strain
a) In addition to the AL tenderpoints
Pelvis Counterstrain Points

Tenderpoint Location Classic treatment Acronym

position
Upper pole Superior medial Hip extension, E add
L5 (UPL5) surface of PSIS fine tune with IR/ER
adduction,
internal/external
rotation
High ilium 2-3 cm lateral to Hip extension, E AB ER
sacroiliac PSIS pressing fine tine with
medial toward abduction,
PSIS external rotation
Lower pole On ilium inferior Hip flexed 90, F IR ADD
L5 (LPL5) to PSIS pressing slight internal
superiorly rotation and
adduction
High ilium Lateral aspect of Hip extension E Add
Tender Location Classic acronym flare out ILA (or coccyx
point treatment Gluteus Upper outer Hip extension E er abd
position medius portion of gluteus with fine tuning
posterior medius at level of in abduction and
Psoas Starting 2/3 from the Bilateral hip F ST L3; L4 PSIS to tensor external rotation
distance from the flexion; external fasciae latae
ASIS to the midline rotation of the
and pressing deep in hips, side bend PL4-posterior
a posterior direction lumbar spine margin of tensor
toward the belly of toward fasciae latae
the psoas Piriformis Midway point Flexion of hip F Abd ir/er
Iliacus 1/3 distance from the Bilateral flexion FER between lower and abduction,
ASIS to the midline and external half of lateral fine tune with
and pressing deep in rotation of the aspect of sacrum external or
a posterior-lateral hips with knees and ILA and internal rotation
direction toward flexed greater trochanter
iliacus
Low Superior surface of Ipsilateral hip F
ilium the iliopectineal flexion
eminence associated
with the attachment
of psoas minor
Inguinal Medial aspect of Flexion of thighs FADDIR
inguinal ligament with
near the pubic contralateral
tubercle in thigh crossed
association with the over the
ipsilateral thigh.
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OPP Study Guide
i. Movement is a good thing (negative)
ii. No movement is bad, a positive test – will
be very painful
b. To assess if sacral base has moved backward
3) Sphinx test
a. Backward bending test
b. Determines if sacral base has moved posterior or
anterior
c. Positive test if part of or whole sacral base has moved
posterior.
i. Unilateral sacral extension
ii. Backward sacral torsion
d. Fingers on sacral sulci/sacral base
i. If asymmetry, then a side has moved
anterior or posterior
e. Patient props up on elbows (Causing a sacral flexion)
i. If a part of the sacral base is posterior it will
resist anterior movement
f. Positive if sacral bases become more asymmetric.
Sacrum
Sacral Diagnosis
Sacral anatomical axis
1) Bilateral
1) Transverse axis a. flexion
a. Superior i. Sacral bases will be anterior, no
i. Cranial primary respiratory mechanism lateralization with seated flexion test,
b. Middle deep sacral sulcus, with bilateral
i. Sacral base anterior and posterior posterior ILA, and tight bilateral sacral
(FB/BB) tubule ligaments
c. Inferior ii. Negative sphinx test
i. Innominate rotate around this axis iii. Negative spring test
iv. Indirect/inherent respiratory force
Sacral physiologic axis 1. Pt supine, physician’s hand
1) Oblique cradles sacrum in palm.
a. Left and right oblique axis named for superior pole Apply anterior tension on
b. Side opposite of the seated flexion test sacral base to move it further
2) Sagittal anterior (BLT)
a. Both a mid-sagittal and an infinite number of b. extension
parasagittal axes i. Unclear lateralization, bilateral
3) Horizontal posterior sacral base, bilateral shallow
a. Functional axis of sacral flexion/extension sacral sulcus, bilateral anterior ILA,
loose STL
Sacral somatic dysfunction ii. Negative sphinx test
iii. Positive spring test
1) Physiologic iv. Indirect/respiratory force
a. Occurs along a physiologic axis 1. Supine pt, physician caudad
i. Transverse, oblique (neutral and non- hand under sacrum with the
neutral) fingers at base, and palm on
2) Non physiologic apex. Lift the sacral apex to
a. Not around an axis – caused by trauma BLT point. Then take a deep
i. Unilateral sacral shear (flexion and breath and hold it
extension) v. HVLA
Rules 1. Pt prone and on elbows.
Physician hand on
1. L5 sidebends in the direction of the oblique axis lumbosacral junction. Caudad
2. L5 rotates in the opposite direction of sacral rotation hand on ankle or leg to
stabilize. Breath and then
Diagnosing sacral dysfunction thrust
1) Seated flexion test 2) Torsions – axis named for cranial end of axis
a. Pt seated with feet flat on floor and shoulder width a. Neutral
apart. i. LOL
b. Physician monitors inferior aspect of PSIS 1. Right lateralization. L
c. Tests the Sacro-ilio dysfunction Shallow sacral sulcus, L
i. (standing flexion tests ilio-sacral) sacral base posterior, L
2) Lumbosacral spring test posterior ILA, L tight STL.
a. Pressure applied to lumbosacral junction when patient Negative spring and sphinx
is prone tests

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ii. ROR 1. L seated flexion test
1. Left lateralization, R shallow 2. L sacral sulcus shallow, R
sacral sulcus. L sacral base deep
posterior, L posterior ILA, L 3. L sacral base posterior, R
tight STL, Negative spring anterior
and sphinx tests 4. L ILA anterior/superior
iii. Lateral recumbent on axis side. Hug the 5. Positive spring and sphinx
table. Knees over the table and tests
GREATER than 90 degrees. Support 6. Pt prone, left hypothenar on
knees. Have pt push up, isometric posterior sacral sulcus. Pt
contraction exhale, hold for 3-6 seconds
b. Non-Neutral
i. ROL
1. Right lateralization, l deep
sacral sulcus, L anterior
sacral base, L anterior ILA, L
Loose STL. POSITIVE
spring and sphinx tests
ii. LOR
1. L lateralization, R deep sacral
sulcus, R anterior sacral base,
R anterior ILA, R Loose
STL. POSITIVE spring and
sphinx tests
iii. Lateral recumbent on axis side. Face
the sky, hips flexed LESS than 90.
Same isometric contraction
c. Walking cycle
i. Spinal column sidebending to weight
bearing side pinning the upper pole of
the sacrum on the side of the
sidebending.
ii. As the free extremity swings forward, it
carries the free pole of the sacrum
anterior creating a rotation of the
sacrum
iii. On a right step, creates a LOL
iv. And a left step creates an ROR
v. The torso rotates toward the moving
lower extremity
1. Right step – torso rotates
right
3) Unilateral
a. Sacral flexion
i. RUF
1.R seated flexion test
2.R sacral sulcus deep, L Cervical
shallow Characteristics
3. R sacral base anterior, L
posterior 1) Cervical Spine is adapted for upright posture
4. R ILA posterior a. Need to diagnose the thoracic and cervical region
5. Negative spring and sphinx to perform OMT
tests 1. Diagnose the upper thoracic before cervical
ii. Pt prone, hypothenar on posterior ILA, b. Muscles, fascia, sympathetic nervous system
hold breath and push anterior. Hold for c. T3/4 specifically for Myofascial patterned
3-5 seconds on the PT’s inhalation symptoms
breath.
iii. HVLA Cervical spine range of motion
1. Block ILA with pt hand, • Flexion and extension +/- 110 degrees
wallet, towel or wedge, grasp a. Think OA joint
leg, ab/adduct to gap SI • Rotation +/- 160 degrees
jointing. Internally rotate leg a. Think AA joint
to further gap SI joint. • Side bending +/- 90 degrees
Traction to tension and then
tug. Cervical spine mechanics
b. Sacral Extension
i. LUE 1) OA (occiput on C1)
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a) Flexion/extension Counterstrain fixing headaches.
b) Type 1 like – SB/RT in opposite directions
c) Treatment focus on 1. Vertex
i) cranial dysfunction
ii) Temporal and occipitomastoid dysfunctions.
iii) Cervical dysfunction
iv) Sacral dysfunction
d) Conditions affecting OA
i) Dizziness and vertigo, headache, suboccipital muscle
spasm, cervical pain, feeding and digestive functions,
low back pain
e) BLT of OA
f) Springing +/- respiratory cooperation
g) Occipital release with motion toward orbits, then use
respiratory cooperation
h) Suboccipital release – traction of occiput
i) Crossed arm traction
j) Muscle energy – never hyperflex - put into feather barrier
in all planes
k) HVLA – Only into rotational barrier but sidebending
freedom. – HVLA force is directed in a rotation correction
2) AA (C1-C2)
a) Rotation only
b) BLT C1, C2
c) Muscle energy – never hyperflex - put into feather barrier
in Rotation
d) HVLA – flex neck to 45 degrees, rotate into barrier
3) C2-C7
a) Flexion, Extension, Sidebending
b) Type 2 like – RT/SB same side
c) TRAUMA may cause opposite directions 2. Occiput
d) BLT of C2-C7
e) Cervical traction with kneading
f) Brace forehead, add counter pressure from lateral neck in a
kneading motion to soften lateral and posterior neck
muscles
g) Muscle energy – never hyperflex - put into feather barrier
in all planes - can fix in either rotation or side bending
h) HVLA- either rotation or sidebending correction. Put into
freedom for plane that is not being corrected
Palpation findings
1. Palpate over articular pillars to test motion differences of
SINGLE segments
2. Evaluate muscle tension, active, then passive motion
testing for a group dysfunction (not forgetting upper
thoracic spine)
3. Myofascial strain is due to simple muscular strain
4. Like whiplash, complex regional pain syndrome, upper
thoracic spine dysfunctions
Why examine the C-spine
a. Upper cervical somatic dysfunction (OA, AA)
• Affects lumbar, pelvis, sacrum) 3. Frontal
b. Secondary related dysfunctions
• Viscerosomatic reflexes
• Inflammatory conditions
• Sinuses, throat, lungs, etc.
c. Painful conditions
• Cervicocephalic syndromes, cervicobronchial
syndromes, muscle contraction cephalgia, TMJ,
otalgia, cervicalgia, dysphagia
d. General approach to treatment – treat the structures or the
physiology

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c. Spurling test
• For radicular symptoms
• Pt supine, rotate and sidebend to the SAME side, add a
compressive load
• Positive if elicit of radicular symptoms
d. Vertebral artery compression test
• Test for vertebral artery compression suggesting
cerebral perfusion
• Support neck at C2, extending upper cervicals
• Positive if pt blinks rapidly or looses consciousness
e. OA joint eval
• Place index fingers of atlas, with second finger on
occiput evaluating for motion
• Extension with Left side bending and Right rotation
• Checks for anterior motion at right occipital
condyle
• Extension with right side bending and left rotation
• Checks for anterior motion at left occipital
condyle
• Flexion with Left side bending and Right rotation
• Posterior glide of right occipital condyle
• Flexion with right side bending and left rotation
• Posterior glide of left occipital condyle
f. AA joint eval
• Contact lateral processes, rotate head without any side
bending or flexion. Rotation is more free on side that
can go further.
4. Temporal • Can also flex head and neck to spinal unit
g. C2-C7
• Short lever
• Palpate articular pillars using lateral translation,
evaluating each segment in flexion and extension
and neutral
• Long lever
• Move head in an arch to the level of the side
bending dysfunction, adding rotation in the
direction of side bending – assessing flexion and
extension.
2. Cervical spine work up
5. DDX Cervical strain/Counterstrain
• Fracture, space occupying lesion, malignancy,
metabolic conditions 1. Scalene
6. Work up a. Rotation causes transverse process to move closer to
• Labs, x-ray, CT, MRI, Electromyography, Nerve the anterior rib, thus shortening
conduction test
Special Tests
7. Motion testing
• Sidebending
• Supine patient, seated physician, supporting head
and neck. Test side bending, flexion and
extension, then introduce lateral translation
• Rotation
• Supine pt, seated physician, support head and
neck, induce small cranial extension, then
localize cervical segment to test adding rotation
a. Compression test
• For facet joint irritation (minor for radicular)
• Place compressive load into the neck, positive with
irritation or pain
b. Distraction testing AC8
• For facet joint irritation with minor test for radicular
symptoms AC7
• Distraction force on the neck, positive if there is
REDUCTION of pain
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i. SARA is odd at 1am/pm and at 3 pm and 7am 1. Reciprocal tension membrane
a. AC1 – Rotate Away iv. Articulatory mobility of the cranial
b. 2-6, 8 – F-SARA bones
i. SCM explains flexion 1. The sutures dictate the
c. AC7 – F STRA motion which is palpated
i. SCM explains flexion and v. Involuntary mobility of the sacrum
clavicular head explains side between the ilia
bending toward. 1. Sacrum rocks on superior
transverse axis in conjunction
with the basiocciput
b. Cranial rhythmic impulse – CRI
i. Palpable rhythmic fluctuation
synchronous with the primary
respiratory mechanism
1. Flexion and extension
ii. 8-12 cycles/minute
1. increased with fast
metabolism and acute
infection
2. decreased with slow
metabolism and chronic
infection/fatigue
3. flexion=FATTER
a. midlines flex
b. paired externally
rotate, occurs on
INHALATION
c. SBS angle
increases
i. PC1 – push inion – flex d. Sphenoid anterior
ii. PC2-7 – E-SARA rotation
e. Occiput posterior
rotation
f. Foramen magnum
moves superior
g. Sacral base rotates
posteriorly
COUNTERnutation
4. Extension = HOTDOG
a. Midlines extend
b. Paired internally
rotate
c. SBS flattens
d. Occiput anterior
rotation
e. Sphenoid posterior
i. PCL1-2 – ESARA rotation
ii. PCL-3 – F-STRA f. Foramen magnum
inferior movement
Cranial g. Sacrum anterior
rotation = nutates
Characteristics h. exhalation
c. Sphenobasilar synchondrosis
1) Cranial
i. Point of diagnosis between sphenoid
a. The cranium changes shape according to the five and occiput
rules of the primary respiratory mechanism d. Motion
i. Inherent motility of the brain and
i. Midline bones flex/extend
spinal cord
1. Sphenoid
1. Subtle fluctuation and 2. Occiput
movement 3. Ethmoid
ii. Fluctuation of the CSF
4. vomer
1. CSF made in choroid plexus
ii. Paired bones internally/externally
and drainage into venous
rotate
system 1. Frontal
2. Palpatable movement
2. Parietal
iii. Mobility of the intracranial and
3. Temporal
intraspinal membranes
4. Maxilla
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5. Zygoma Cranial Sutures
6. Lacrimal
7. Mandible
8. Nasal
9. Palatines
iii. Sacrum follows occiput
iv. Temporalis follows occiput
v. Facial bones follow sphenoid
e. Still point
i. Pause in CRI
1. Therapeutic within typical
motion
Cranial nerves
1) Superior orbital fissure
a. III, IV, V1 VI, Ophthalmic V
2) Foramen rotundum
a. V2
3) Foramen Ovale 1) Suture shape
a. V3 a. Serrate (sawtooth)
4) Foramen Spinosum 1) Rocking
a. Middle meningeal b. Squamous (scale like)
5) Jugular foramen 1) Gliding
a. IX, X, XI c. Harmonic (edge to edge)
6) Cribriform 1) Shearing
d. Squamoserrate
a. I
1) Combination
7) Optic Canal
a. II, ophthalmic A, Central Retinal V Strain patterns
8) Internal acoustic meatus
a. VII, VIII • Physiological
9) Hypoglossal o Torsions, side bending
a. XII • Non physiological
10) Sphenoid o Lateral, vertical, SBS compression,
a. I-VIII 2) Torsions
a. AP axis
Cranial nerve symptoms b. Rotation – sphenoid & occiput rotation opposite
1) Anosmia (CN1) directions
2) Visual disturbances, amblyopia (II, III, IV, VI) c. One hand rotates posteriorly (index finger
3) Strabismus (CN VI) superior, little finger inferiorly) named for this
4) Trigeminal neuralgia (V) side
5) Bells palsy, hearing disorder (CN VII) d. Other hand moves anterior (index finger inferior,
6) Vertigo, tinnitus, (CN VIII) little finger superior)
7) Dysphagia (CN IX) 3) Side bending
8) GI respiratory, cardiac arrhythmia, nausea (CN X) a. Two parallel vertical and one A/P axis
9) Dysphagia, dysphonia (IX, X) b. Sphenoid and occiput rotate opposite directions
10) Torticollis (SCM) upper trapezius spasm (XN XI) about the vertical axis, and they rotate the same
11) Sucking/swallowing problems (IX< X, XI, XII) direction about the A/P axis
12) No CRI = SBS compression c. Named for the side of the convexity
d. Spreading or widening of index and little finger
on the side of the convexity,
4) Lateral strain
a. Two parallel vertical axes
b. Sphenoid and occiput rotate in the same direction
c. Named for the location of the base of the
sphenoid
d. PARALLELOGRAM named for the direction the
pinky’s face
5) Vertical Strain
a. Two parallel transverse axes
b. Sphenoid and occiput rotate in same direction
c. Named for the direction of the sphenoid
d. Hands point down for superior vertical strain
e. Hands point bilateral up for inferior strain
6) Sphenobasilar compression
a. Smashed together, no movement, head feels
heavy

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Treatment considerations iii. As the SBJ flexes, the head gets fatter, thus the
falx tentorium gets tighter
1) Cranio-sacral treatment
a. Birth, trauma, dentistry, otitis media, TMJD, Cranial Treatments
Headaches
2) Cranio-sacral complications and contraindications 1) Inducing cranial motion
a. Complications a. In vault initiate the procedure from the neutral
i. HA, Dizziness, tinnitus point between extension and flexion
ii. Altered autonomic functions b. Move in the direction of the pattern – follow it,
b. Contraindications allow motion to establish itself
i. Absolute 2) Palpate a still point
1. Intracranial bleed a. Identify SBS strain pattern, accentuate motion of
2. Increased intracranial strain into extension, resist motion into flexion,
pressure repeat until motion disappears. Maintain tension
3. Skull fracture in extension until everything gets disorganized
4. Acute CVA 3) Condylar decompression
ii. Relative a. Contact occiput posterior and medial to OM
1. Known seizure history, TBI, suture. Palpate for release of tension (not a
or space occupying lesion suboccipital release)
b. To decompress foramen magnum and
Cranial examination vagus/hypoglossal nerves
4) Sagittal suture spread
1) Vault hold a. Cross thumbs to spread the parietals apart starting
a. feel PRM, sutural restriction, and strain patterns at the lambdoid suture – moving superior toward
i. Index – greater wings of sphenoid coronal suture
ii. Middle – zygomatic processes of b. To release vascular congestion and facial tension
temporal 5) Frontal lift
iii. Ring-mastoid processes of temporal a. Contact frontal bone medial to coronal suture.
iv. Pinky – squamous portion of occiput During internal rotation, lift superiorly until a
v. Thumbs – on top of head slight release
2) A-P hold b. Can be done with a folded hands approach
a. Caudad hand under occipital squama c. To relieve vascular and sinus congestion
b. Cephalad over frontal bone 6) V-spread
i. Thumb and middle fingers over the a. Index and middle fingers of ipsilateral hand along
greater wings of sphenoid each side of the occipitomastoid suture with
c. Feel PRM, CRI, which bones have CRI separating force perpendicular to suture. With
amplitude other hand contact frontal eminence.
3) Becker hold b. Direct a fluid wave diagonally from frontal bone
a. Crossing palms under the occiput, so thenar through cranium toward OM suture
eminences lie on mastoid of temporal, thumbs at c. For release sutural restrictions to improve fluid
tips of mastoid dynamics
b. Inhalation (flexion) the mastoid widen
c. To assess PRM, CCRI especially in occiput and Autonomics
temporal bones
4) Sacral hold Characteristics
a. Hand holds into the sacrum, with the fingertips at
1) Autonomic Nervous System
the base and the palm at the apex
a. Sympathetic vs parasympathetic
b. To confirm that the sphenobasilar flexion is
i. Sympathetic – thoracic/lumbar
synchronous with sacral counternutation and
ii. Parasympathetic – cranial sacral
extension is synchronous with nutation
b. Function
5) Cranial end points
i. Maintain homeostasis
a. Therapeutic change – anatomic, physiologic,
ii. Coordinate body responses to
fluid,
stressors
b. Physiologic manifestations – respiratory,
iii. Control movement by movement
circulatory, PRR
activity of viscera
c. Still point – interchange due to balance within
iv. Fight or flight vs vegetative
PRM
v. Influence on immune system
Core link vi. Control blood and lymph flow
vii. Assist thermoregulation
1) Why do things move the way they do? The link between c. visceral vs musculoskeletal = viscero has a
a. Dura, C2, S2 rubbery end feel, while MSK has hard end feel
d. facilitated only has to do with thoracic
Reciprocal tension membrane
1. segmental facilitation = sympathetic
a. One component of PRM 2. visceral somatic are both parasympathetic
i. Alternation of flexion/extension influenced by and sympathetic
CSF fluctuation 3. somatic dysfunction can happen
ii. The ‘check’ ligament of the skull anywhere in body
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Organization a. From the 3 cervical ganglia, paravertebral ganglia T1-
L2, and the 3 prevertebral ganglia (celiac, superior
1) CNS – brain/spinal cord mesenteric, and inferior mesenteric
2) PNS b. Greater splanchnic nerve (t5-T9) – celiac ganglion,
a. Somatic nerves stomach, liver, Pancrease, duodenum
i. Efferents – musculoskeletal motor c. Lesser splanchnic (T10-11) – superior mesenteric,
ii. Affterants – somato sensory small intestines, and right colon
b. Autonomic d. Least splanchnic nerve (T12) and lumbar splanchnic
i. Sympathetic (SANS) (L1-2) – inferior mesenteric ganglia and left
1. Through the thoracolumbar spinal colon/pelvic organs
cord and then the paravertebral
and prevertebral ganglia
2. Fight or flight
3. Vascular, visceral, and gland
components
4. Oriented into bilateral
paravertebral arrangement,
anterior to transverse processes of
the rib heads, and posterior to
pleura.
5. T1-L2 – location of preganglionic
cell bodies which exit at the
corresponding ventral roots
6. Paravertebral ganglia is the
sympathetic trunk of 3 cervical
ganglia which runs anterior to the
T&L spine and sacrum,
converging inferior at the ganglion
impar
7. Receives information from CNS
from preganglionic neurons
8. a preganglionic axon can travel
from the ganglia in 3 ways parasympathetic Nervous System
a. at vertebral level
b. synapse with another a. CN III, VII, XI – supply the head
ganglia a. III – Ciliary ganglion
c. exit chain without b. VII – pterygopalatine and submandibular
synapsing c. IX- otic ganglion
ii. Parasympathetic (PANS) b. X – almost everything else, thoracic viscera, GI tract
1. Through the brainstem nuclei and up to proximal 2/3 transverse colon, kidneys, upper
sacral spinal cord, and the organ ureters, and gonads
ganglia c. S2-4 – remainder of GI, lower GU tract
2. Rest and digest
Autonomic balance –
3. Craniosacral portion of the ANS
a. Cranial CN III, VII, IX, • synergistic relationship between SANS and PANS through
X the afferent fibers called reciprocal activation
b. Sacrum: S2-4 a. Reflex arc – neural pathway that controls and action
4. Long preganglionic axons reflex – both somatic and autonomic
iii. Enteric a. Somatic – through spinal and cranial nerves,
c. Ganglia can be mono, di, or poly
i. Afferent and efferent
Anatomy b. Autonomic – spinal, cranial and splanchnic
a. Sympathetic chains of the ganglia are bilaterally nerves.
oriented in a cephalad – caudad direction from T1-L2 i. Only 2 sequential neurons in the
b. Fibers exit cord along with somatic motor axons at the output pathway
ventral roots through the intervertebral foramina ii. Some can bypass CNS completely
c. They exit the root along the white ramus into the b. Segmentalization – afferent fibers that accompany the
ganglia where they synapse with post ganglionic preganglionic and postganglionic fibers of the SANS
nerves are segmental
d. Post ganglionic axons return to the spinal nerve via the
gray ramus
Viscerosomatic reflexes
e. The sympathetic nerves travel intimately with somatic • disruption, irritation, or disease of internal organ or tissue
axons Head and neck T1-4
Sympathetic Nervous System Heart T1/2-T5-6
Respiratory T1/2-T6/7
1) To the viscera Esophagus T2-8

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Upper GI T5-9 f. Location: Posterior
Middle GI T10-11
Lower GI T12-L2
Appendix T10-11
Kidneys T10-12
Adrenal medulla T10
Upper ureters T10-11
Lower ureters T12-L1
Bladder T11/12-L2
Gonads T10-11
Uterus/cervix T1—L2
Erectile Tissue T11-L2
Prostate T12-L2
Arms T2-T8
Legs T11-L2

Parasympathetic levels
a. Vagus OA, AA, C2
a. Trachea, esophagus, heart, lungs, liver, gallbladder,
stomach, Pancrease, spleen, kidneys, proximal ureter,
small intestine, ascending colon, transverse colon
b. S2-4
a. Distal to splenic flexure of transverse colon,
descending colon, sigmoid colon, rectum, distal ureter,
bladder, reproductive organs, and genitalia
c. Facilitation
g. Important ones
a. Maintenance of a pool of neurons that are
a. Appendix – anterior to tip of right 12th rib
partial/subthreshold excitation
i. Posteriorly at Transverse Process of T11
b. Secondary to
(acute)
i. Sustained increase of afferent input
b. Adrenals – anterior – 2” superior and 1” lateral to
ii. Changes within affect neurons/chemically
umbilicus
c. if in the spinal level = segmental facilitation
i. Posterior - between spinous and transverse
d. spinal cord segment can receive input from:
process of T11 and T12
i. higher centers (brain)
c. Kidneys – 1” superior and 1” lateral to umbilicus
ii. viscera via sympathetic/parasympathetic
i. Posterior – between spinous and transverse
afferents
process of T12 and L1
iii. somatic afferents
d. Bladder – periumbilical region
d. Mechanism
e. Colon – on lateral thigh within IT band
a. Visceral dysfunction → Facilitation → excessive
h. OMT has decreased ileus rates leading to better surgical
SANS Tone → Lymphatic stasis/Myofascial
outcomes
contraction → somatic dysfunction
e. Location: anterior Musculoskeletal origins
1) Sympathetics
a. T1-L2, Rib Heads, Mesenteric Collateral Ganglia
2) Parasympathetics
a. Vagus, OA, AA, S2-S4
3) Chapman reflexes
a. Somatic manifestation of visceral dysfunction
Chapman reflexes
a. viscerosomatic reflexes, predictable TART Findings
b. manifest as gangliform contractions/nodules or excessive tissue
congestion
c. pea sized, boggy, ropy, shotty, thickened (2-3mm in diameter)
Sympathetic Treatments
1) Rib Raising
a. Normalize SANS, improve lymphatics, and
thoracic/rib excursion
b. Initially produce short lived increase in
sympathetic activity, followed by long lasting
sympathetic inhibition
i. Encourage maximum inhalation

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c. Put hands on posterior rib, pt rolls supine on-top 3) Transport 3L of fluid every day
of hands, kneed toward laterality 4) Structure and function
2) Lumbar inhibition – similar to rib raising but on transverse a. Formation phase
process of lumbar spine i. Movement of extracellular fluid into
3) Mesenteric collateral ganglia blind ended epithelial tubes. The
a. Celiac T5-T9 motion of the tissue opens endothelial
b. Superior Mesenteric T10-T11 flaps
c. Inferior Mesenteric Ganglion T12-L2 1. Too much congestion pinches
d. Dysfunction due to increased sympathetic input off flaps so they are closed
to abdominal viscera b. Vascular phase
i. Treatments are to normalize SANS i. Move lymph through vessels.
through inhibitory pressure ii. Lymphangion is wrapped in
e. Palpate for tissue texture changes, penetrate myoendothelial fibers moving 6-10
tissue with patients breath meeting new barriers times per minute
with each exhalation. Prolonged pressure (90 1. Becomes dysfunctional with
seconds) on last breath tension
2. Lymph are compressed first,
Parasympathetic treatments before capillaries and veins
1) OA decompression a. Superior thoracic
a. Improve parasympathetic tone through cranial inlet compressed
IX,X twice
2) Sacral Rock/inhibition c. Drainage phase
a. Alter parasympathetic activity in left colon/pelvic i. Right lymphatic duct
structure 1. Right side of head and neck,
b. Indicated by dysmenorrhea, pelvic congestion, SI right upper extremity, right
dysfunctions. chest, heart and lungs
c. Contraindicated by undiagnosed pelvic pain, ii. Left lymphatic duct
pelvic malignancy 1. Left arm, left side of head,
left thorax. All of abdomen
Diaphragm and Lymphatics and both lower extremities
iii. Each region has a gate, treat
Respiratory circulatory model transitional areas first to open drain
1. Thoracic inlet
1) Lymph approach. Look at all body regions together as a
2. Respiratory diaphragm
system as we connect the fluids moving between the
3. Pelvic diaphragm
regions
4. Popliteal fossa
2) Indicated by
5. Plantar fascia
a. Congestion, diaphragm flattening, COPD, CHF,
6. Tentorium cerebelli
GI, OB, Geriatric
b. Contraindications Diagnosis
i. Necrotizing fasciitis, abbesses,
osteomyelitis, DVT, Hemorrhage. 1) Indications and risks
ii. Relative to cancer infections and a. Upper respiratory infection
circulatory disorders b. Lower respiratory infection
c. GI
Models of assessment and treatment d. OB during 28-36 weeks
e. Assess local and regional areas for swelling,
1) Biomechanical
organ dysfunction, infection
a. Body structure with impediments caused by
2) Central Myofascial pathways
muscles and joints
a. Transitional zones
2) Respiratory circulatory
b. Zink’s transitional zones
a. Focus on cellular environments delivering
i. Compensatory - alternating
oxygen and nutrients, and removing waste
1. OA RL SR
3) Neurological
2. CT RR SR
a. Focus on neuroendocrine immune network
3. TL RL SL
through spinal facilitation, proprioceptive
4. LS RR SR
function and autonomic nervous system
ii. uncompensatory
4) Metabolic energy
1. OA RR SL
a. Focus on energy economy of body
2. CT RL SL
5) Behavioral
3. TL RR SR
a. Focus on mental, emotional, spiritual, states and
4. LS RL SL
lifestyle
3) Fluid pump mechanism
Lymph a. Motion of respiratory should be visible to pubic
symphysis
1) Organs i. Pelvic diaphragm moves fully with
a. Spleen, liver, thymus, tonsils, appendix thoracic diaphragm
2) Structures 4) Spinal Involvement
a. Lymph nodes, lymph tissue in GI and Pulmonary
Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative
OPP Study Guide
a. Tension due to drainage at transitional regions
introduced by other somatic dysfunction
5) Peripheral and regional pathways
a. Evaluate terminal drainage for congestion/edema
Treatment
1) Focus on areas of greatest restriction from proximal to distal
a. Thoracic inlet
b. Axillary
c. Diaphragm
d. Inguinal
e. Popliteal
f. Plantar fascia
2) After opening the blocked areas →Transmit motion in order to
pump fluid flow back to the heart
a. External rhythmic and compression forces. Thoracic
pump, spleen pump, liver pump, pedal pump, pectoral
traction, exercise pump
b. Acts to accelerate the muscular layer of the lymph
which will propel the fluid to the heart
3) Mobilize targeted tissue fluids into lymphaticovenous system
a. Head - Mandibular drainage/galbreath
b. Upper extremity – axillary fold, ulnoradial
interosseous membrane
c. Lower extremity – fascial unwinding, interosseous
membrane
d. GI/Pelvis – mesenteric lift, colonic sweep

Blue are topics covered in lab, and are testable. Items in red are highest yield All things OPP are cumulative