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OMM and Musculoskeletal

Medicine in the Urgent Care

Leslie Ching, DO

Clinical Assistant Faculty-OSU, OMM Department

May 2, 2015

OOA

Objectives

Review some common and uncommon

causes of musculoskeletal pain in the UC

Review OMM techniques that can be helpful in the UC or in a busy outpatient

clinic

Review home stretches that can be helpful

Ankle Pain

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Case #1

9 yo F gymnast and soccer player presenting with

2 weeks of R ankle pain

Does not recall injury

Hurts to dorsiflex R ankle

No bruising, swelling

Can walk on ankle with minimal pain

No history of lower extremity injuries

PMHx, PSHx, meds is noncontributory (no recent fluoroquinolone use)

#1 continued

PE

Intact cap refill, pulses, sensation

Distal motor strength intact

Limited active and passive ROM only with R

ankle dorsiflexion; otherwise, plantarflexion, inversion, eversion intact

No findings that would require Xray under

Ottawa Ankle Rules

Ottawa Ankle Rules

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#1 continued

Osteopathic

No proximal or distal fibular dysfunction

+R anterior talus

Anterior Talus

Diagnosis

Dorsiflex ankle (either one

at a time or both at the

same time)

If one ankle doesn’t

dorsiflex easily, that ankle

has an anterior talus

Treatment by Articulation

Palpate over ankle joint while stabilizing heel

Grasp forefoot with other hand

Introduce dorsiflexion of ankle to restrictive barrier

Gently repeat the motion against the barrier 8-10 times to improve range of motion

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Treatment by HVLA Intertwine your fingers so 4th

fingers are resting over tibiotalar joint

Place 3-5 pounds of traction, dorsiflexing the foot to the

barrier

Apply a high-velocity low-amplitude thrust towards

yourself to reseat the talus in the mortis joint of the ankle.

Alternative: use 3-4 tugging

motions while at barrier

Retest motion at the tibiotalarjoint.

Knee Pain

Case #2 26 yo slender M presenting with L medial knee pain x 5

months after falling off porch

Had been seen about once a month since then in UC,

repeated knee Xrays showing no signs of fracture or OA

No radiating pain, numbness, tingling

Able to ambulate, but it is somewhat painful—pt could

walk immediately after accident

No swelling, bruising, locking. Some pain with going up and down stairs. Mild crepitus.

No previous injuries

PMHx, PSHx, meds noncontributory

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#2 continued

PE

No bruising, effusion. Sensation, DTRs, distal

strength intact.

ACL/PCL/MCL/LCL intact

Neg McMurray’s

Mild patellar crepitus b/l

On standing exam, patient has flat feet bilaterally and increased Q angle(these are

often linked)

Pes Planus (Flat Fleet)

Patellofemoral Syndrome

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Treatment

Arch supports

Roll bottom of feet on frozen water bottle

Stretch with towel around arch of foot

Vastus MedialisStrengthening

Knee squats

Stand with heels

shoulder-width apart, toes pointing out as far

as possible

Squat ¼ of way down

Come up slowly,

focusing on VM activation

3 sets of 10 reps

Seated isometric contractions

Sit on floor with legs extended and toes

pointed forward,

towel under knees

Flex quads, hold for 10 seconds (check

VM to see if this is

firing appropriately)

10 reps

Case #3

49 yo overweight F presenting for lateral R knee pain x 1 year

Had seen orthopedics, was told that it was not surgical problem

Pain with ambulation.

No radiating pain or paresthesias. No edema, bruising, or previous injury

Had tried steroid injection without improvement

Otherwise, PMHx, PSHx, med hx noncontributory

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#3 continued

PE

No bruising, effusion, joint-line pain. Sensation, DTRs, distal strength intact.

ACL/PCL/MCL/LCL intact

Neg McMurray’s

Mild patellar crepitus but this did not reproduce pain

Osteopathic

Proximal anterior fibular head, reproduces pain when palpated

Fibular Head Anatomy

Treatment of Anterior Fibular Head (HVLA) Var #1

Place pillow distal to knee

Place cephalad hand on

proximal fibular head

Internally rotate foot until

you feel barrier with cephalad hand

Have patient take deep

breath; when pt exhales,

apply thrust down towards direction of table

Recheck

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Treatment of Anterior Fibular Head (HVLA) Var #2

Stand on affected side

Have patient bend affected knee

Place thenar eminence on proximal fibular head

Apply posterior-to-anterior pressure to bring proximal fibular head to barrier

Have patient take deep breath; on exhalation, apply posterior thrust with other hand against thumb (karate chop)

Recheck

Treatment of Posterior Fibular Head (HVLA)

Stand on the dysfunctional side

Flex the hip and knee.

Place cephalad hand in the popliteal space, palm upward, with first MP joint posterior to the fibular head (avoid direct pressure over the anterior fibular nerve).

Grasp the patient’s foot with your caudad hand (top figure).

Flex the knee to the barrier, while simultaneously externally rotating the ankle.

Apply a thrust by flexing the leg with your caudad hand, while you apply an anterior counterforce with your first MP joint (bottom figure).

Recheck

Case #4

33 yo morbidly obese F presenting with 4 days of L knee pain after falling: “I heard it pop”

Pt had h/o ACL and meniscus repair 5 years ago; states she feels similar to how she did when

she tore ACL

Feels like knee is unstable but can ambulate

slowly. Lots of crepitus and pain “below kneecap”

Otherwise PMHx, PSHx, meds hx unremarkable

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#4 continued

PE

Difficult to do physical exam because of body habitus (very large leg)

Mild joint effusion; no bruising

Sensation, DTRs, distal strength intact.

However, did have a positive posterior drawer

Neg ACL/LCL/MCL

Couldn’t do McMurray’s

Mild patellar crepitus

Also had sulcus sign of knee

Important confirmatory sign

Sulcus Sign of Knee

Sign of PCL

laxity/tear

Treatment

Pain control

Non-weight bearing

MRI

Ortho referral

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Acute Low Back Pain

Case #5 43 yo non-obese M with no history of low back

pain presents with acute low back pain x 2 weeks

States he was stepping out of a semi cab onto his L leg and “felt like my hip got jammed into my back!”

Since then, has had a lot of LBP and hip pain—states he feels like he is walking funny and one leg is shorter

No radiating pain, paresthesias, incontinence. ROS otherwise neg.

Noncontributory PMHx, PSHx, med hx

PMP negative

#5 continued PE

Moderate distress

BLE DTRs, sensation, distal motor strength

intact

Neg SLR/Braggard’s

Osteopathic

L innominate upslip

L5 noncompensated (L5FSlRl)

Sacrum L on L

Positive L iliopsoas tenderpoint

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LBP Mnemonic Refresher

L: lower extremity (knee, fibula, ankle, foot

arches)

I: innominate (upslip or downslip)

P: pubic shear

L: lumbars (especially L5)

S: sacrum

I: ilia (anterior, posterior, outflare, inflare)

P: psoas

Example Screen

Palpate bottom of feet for any dropped

cuboid or navicular bones

Dorsiflex, plantarflex, invert, evert ankles

Screen proximal fibular heads

B/l AP compression of pelvis: the most restricted side is the dysfunctional side

Screen continued

Check for upslip/downslip

Upslip: on dysfunctional side, ASIS, pubic bone superior, medial malleolus appears shorter

Downslip: on dysfunctional side, ASIS, pubic bone inferior, medial malleolus appears longer

Have pt flip over

Check L5 and sacrum in static position while pt prone (lumbars flexed, sacrum extended)

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Screen continued

Have pt get into Sphinx position (prop up on

elbows)—this extends lumbars and flexes sacrum; recheck findings

Have pt return to supine position: check ilia

for anterior/posterior rotations or inflares/outflares

Check iliopsoas for tenderpoints

Upslipped InnominateFindings

On dysfunctional side

ASIS, pubic bone

superior

Medial malleolus appears shorter

Treatment

Externally or internally

rotate leg to barrier

On patient’s exhale, HVLA thrust or series of short tugs

towards you

Downslipped Innominate

Findings

On dysfunctional

side

ASIS, pubic bone inferior

Medial malleolus appears longer

Treatment

Have patient bounce on affected innominate on firm

surface x 5-7 times

OR

Have patient flex hip and knee

Support leg on your shoulder

Apply cephalad pressuretoischial tuberosity with hand

while having the patient

push knee against your shoulder x 3 times

Recheck

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Psoas TenderpointFindings

Psoas TP is found 2/3

of distance from ASIS to midline and

pressing deeply into the abdomen

May also be found

with iliacus TP (next section)

Psoas Counterstrain Tx

Stand on affected side

Flex pt’s hips and knees

Pull feet/ankles towards tender point

May also need to pull knees towards tender point

Fine tune until tenderness completely alleviated

Hold for 90 seconds

Iliacus TenderpointFindings

Located 1/3 of

distance from ASIS to midline with pressure

in posterior-lateral direction towards ilia

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Iliacus Counterstrain Tx

Stand on affected side

Flex pt’s hips and

knees, support on your knee

Cross pt’s ankles, knees fall out to sides

Fine tune until

tenderness completely

alleviated

Hold for 90 seconds

Non-Cardiogenic Chest Wall Pain

Case #6

A 67 yo M with a history of a MI and s/p CABG (3 years ago) presents with b/l anterior chest wall pain. States that this chest pain has been intermittent since his CABG.

The pain lasts for 15-20 minutes at a time, occurs 4-5x/week, is nonradiating, feels like a dull cramp, and is 4/10. Occurs with raising arms, gets better with putting arms down.

States he has been worked up extensively by cardiologist—has had multiple EKGs, a CXR, an echo, a stress test, and an angiogram since CABG and no cardiac etiology for chest pain was found

No chronic cough

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#6 continued

PMHx: CAD, 2 MI, HLD, HTN

PSHx: CABG 3 yrs ago

Meds: lisinopril, metoprolol, simvastatin, Plavix

Social

50 pack-year smoking hx, stopped smoking 3 years ago

Occasional beer (1-2x/week), no illicit drug use

Wife adds that he used to hang wallpaper until CABG

#6 continued

PE: VSS, RRR, nml S1, S2, b/l CTA, no carotid

bruits, sternal scar consistent with CABG

EKG without acute findings

CXR-no acute findings

Positive b/l pectoralis major trigger points

Associated with inhaled ribs

Pectoralis Major Trigger Points

Evaluate thoracics, ribs, and clavicle

May also have TrPs after MI

(viscerosomatic): 61% of 72 patients

with pec major TrPs in study had cardiac disease (Simons and Travell,

p 833)

Treating TrPs from viscerosomaticorigin may temporarily relieve pain—

CANNOT use temporarily successful

tx to exclude cardiac origin

Postural: rounded shoulders

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Treatment

Counterstrain, direct inhibition, or Still techniques are helpful if trigger point is acute

If more chronic, stretch and spray

If stretch and spray doesn’t work, consider dry needling (no injection) or wet needling (injection of medication, usually lidocaine)

Be very careful with needles around intercostal region, iatrogenic pneumothorax is to be avoided!

Pec Major/Minor Counterstrain

Stand on opposite side of tender point

Adduct pt’s arm across

chest

Fine tune until tenderness

completely alleviated

Hold for 90 seconds

Book and Towel Stretch

Bath towel rolled up to 3.5”

in diameter and place

under head (should reach to lumbars)

1.5” paperback book under

sacrum.

Lie there for 15-20 minutes a day.

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Non-CervicogenicRadiating Arm Pain

Case #7

CC: “I think I have a bulging disc”

A 56 yo F who is a long-distance trucker comes into your urgent care; she is on her way from Arizona to Ohio but needed to stop

History

Her usual partner couldn’t drive with her so she has been having to drive more than she usually does

Pain in her L shoulder going to her neck and down her L arm with some numbness and tingling

No previous history of disc disease

PMHx: OA; otherwise unremarkable

#7 continued

PE

Neuro: DTRs intact, sensation to light touch

limited on affected side in ulnar distribution

of L arm, thumb-finger opposition intact, ptcan cross 2nd and 3rd fingers, 4+/5 L wrist F/E

and elbow E due to pain, restricted shoulder ROM due to pain

Negative Spurling’s/Lhermitte’s

Positive L trapezius and supraspinatus trigger

points (reproduces pain)

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Supraspinatus Trigger Point

DDx includes C5 radiculopathy, nerve root irritation, brachial

plexus injuries, subdeltoid

bursitis, rotator cuff tears, frozen shoulder

Osteopathically, evaluate

thoracics, ribs, scapula (AC), clavicle

May have entrapment of

suprascapular nerve

Postural considerations:

elevation of arms or carrying heavy object

Treatment

Counterstrain, direct inhibition, or Still

techniques are helpful if trigger point is acute

If more chronic, stretch and spray

If stretch and spray doesn’t work, consider dry needling (no injection) or wet needling

(injection of medication, usually lidocaine)

Recommended patient not to prop L arm up on window when driving

Supraspinatus Counterstrain

Stand on affected side and palpate tender

point

Flex pt’s arm to approx45 degrees, abducted

approx 45 degrees,

externally rotated

Fine tune until tenderness

completely alleviated

Hold for 90 seconds

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Wrist Pain

Case #8

53 yo M presenting with 6 months of persistent R wrist pain and swelling

No known history of injury but had been working for years as heavy machine operator; not able to work for several months at this point

No radiating pain, paresthesias

No previous surgery to wrist

Noncontributory PMHx, PSHx, med hx

#8 continued

PE

Intact pulses, cap refill, sensation, finger strength

Minimal edema around ulnar process, no bruising,

warmth, erythema

Mild pain and difficulty with active and passive ROM with wrist extension and flexion

Moderate/severe pain and difficulty with active

and passive ROM with ulnar and radial deviation

Cannot actively do ulnar deviation because of

pain and weakness

Significant tenderness that reproduces pain over

TFCC

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TFCC Anatomy

• Inserts into the lunate and triquetrium

• Stabilizes the distal radioulnar joint

Further Management

Pain control

Xray to rule out fracture

MRI, wrist arthrography

Ortho referral

Persistent Sinusitis

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Case #9

33 year old female with h/o seasonal allergies presents with “bad allergies.”

Has had facial pain, nasal congestion, mild sore throat, mild ear pain, and mild nonproductive cough for 3 weeks. No fevers.

Has already been on augmentin x 10 days. Sx did not really get better.

Taking claritin, flonase (2 sprays/nostril/day), using Neti pot daily, has humidifier in room.

#9 continued

PMHx: seasonal allergies

PSHx: balloon sinuplasty 4 years ago

Does not smoke

PE: VSS

HEENT: TMs and EAC wnl, erythematous

mildly swollen turbinates, postnasal drainage, maxillary and frontal sinuses mildly tender but

not warm, minimal shotty LN

CV: RRR, nml S1, S2

Resp: B/L CTA

Refractory Sinusitis

Very common diagnosis

Patient has continued sx but does not really appear to have bacterial sinusitis at this point

Treatments?

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#9 continued

Consider OMM

Diagnose and treat (in this order)

T1-4

1st and 2nd ribs

Thoracic inlet

Cervicals

OA

Venous sinus release (also good for headaches)

Specific sinus techniques

Review of Venous Sinus Release

OA decompression

Confluence of sinuses release

Occipital sinus release

Condylar decompression

Transverse and straight sinus releases

Sagittal sinus release

Metopic suture release

Venous Sinuses

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OA Decompression

Confluence of Sinuses Release (Hand Position)

Confluence of Sinuses Release

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Occipital Sinus Release

Condylar Decompression

Transverse/Straight Sinus Release

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Transverse/Straight Sinus Release (Lateral View)

Sagittal Sinus Release 1

Sagittal Sinus Release 2

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Metopic Suture Release

Bonus: Knee Pain

Case #10

54 moderately obese F presenting with 2 months of R knee pain

Painful to ambulate, worse in am but gets better within half an hour as she walks around

Crepitus but no locking, instability, edema, bruising, known injury

Pt also wanted to talk about her mild back pain, mild leg edema which she attributed to not moving around so much and shortness of breath that she attributed to being out of shape

Also wanted to talk about a lot of other things

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#9 continued

PE

New 4/6 murmur at aortic listening post

Bibasilar crackles in lungs

1+ pitting edema BLE

Knee exam

No bruising, edema, warmth, jointlinetenderness

Intact ACL/PCL/MCL/LCL

Neg McMurray’s

Xray R knee showed OA

Further WorkupEKG showed LVH

CBC wnl, CMP wnl

BNP nml

Bronchoscopy revealed that mass was pressing into ascending aorta

Biopsy showed nonmalignant tumor, was surgically removed

(Not sure what happened with knee)

CXR

References

Graham KE. Muscle Energy Manual, 2nd edition. OSU.

Mills MV. Venous Sinus Drainage, 2nd Year Lab. 2015.

Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques, 2nd Edition. Philadelphia, PA: WoltersKluwer-Lippincott Williams & Wilkins. 2012.

Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1. Philadelphia, PA: Lippincott Williams &Wilkins. 1999.

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Questions?