OMM and the AthleteLower Body Workshop

Jake Rowan DODept of OMM

MSUCOM

Goals/Objectives

• Review OPP and how they apply to sports medicine

• Discuss functional biomechanics• Review palpatory dx• Discuss OMM tx approach

An Osteopathic Approach to Treatment

• The role of the physician is to facilitate the healing process

• The focus of treatment is the patient• The patient is treated in the context of the

disease process they are experiencing.– The patient has the primary responsibility for his or

her health.• There is a somatic component of disease and

manipulative therapy can restore the body’s function, enhance wellness, and assist in recovery from disease and injury.

OPP - Manual Medicine Approach

• Somatic Dysfunction– Impaired or altered function of related

components of the somatic system (skeletal, arthrodial and myofascial structures) and the related vascular, lymphatic, and neural elements

Diagnostic Triad of Somatic Dysfunction

• Asymmetry of position– Comparing left to right and

superior to inferior

• Range of motion restrictions– Standing Flexion Test– Stork Test– Seated Flexion Test

• Tissue texture abnormalities– Change in soft tissue texture

MANUAL MEDICINE APPROACH

• Physician needs to identify the problem, make the Dx, and Rx the appropriate TX– Tx – surgery, drugs, manipulation, therapeutic exercise

• Goal for Manipulation To improve mobility of tissues (bone, joint, muscle, ligament, fascia, fluid) and restore to normal physiological motion if possible.– Restore the maximal pain free movement of the

musculoskeletal system in postural balance

MODELS OF MANUAL MEDICINE

• Biomechanical model.• Neurologic model.• Respiratory-circulatory model.• Bioenergy model.• Organ system model.

Models, Mechanisms & Activating Forces

• Model relates to the therapeutic objective of the intervention.

• Method relates to the approach to the restrictive barrier. ( Direct, Indirect, Combined).– Depend on the clinician, patient, and

environment/setting• Activating Forces - intrinsic and extrinsic.

Tx Approach Principles

• Treat the axial skeleton first

• Extremities: start proximal work distal– LE – pelvis, hip, knee,

ankle, foot, toes– UE – scapula, SC, AC,

glenohumeral, elbow, wrist, hand, fingers

Tx Approach Principles

• Motor Control– Balance – Core stability– Stretch before

strengthening

Tx Approach Principles - LBP

• Pelvis– Pubes– Ilium

• Lumbar spine• Lower Thoracic• Sacrum• Core stability

Lumbar Spine and Sacrum

Muscle Imbalance

Three dimensional evaluation of function of the lumbar spine and pelvis.Used diagnostically and therapeutically.

The Pelvic Clock

The Lower Extremity (LE)• The primary fxn of the LE is ambulation

– The complex interactions of the foot, ankle, knee, and hip regions provide a stable base for the trunk in standing and a mobile base for walking/running

• Dysfxn in the LE alters the functional capacity of the rest of the body – particularly the pelvic girdle

PROPRIOCEPTIVE BALANCEAssessment & Treatment

PROPRIOCEPTIVE BALANCEAssessment and Treatment

Tx Approach Principles - LE

• Pelvis• Lumbar spine• Lower T-spine• Sacrum• Hip• Knee• Ankle• Foot• Toes

The Pelvis

The Pelvis

Lower Extremity

ILIOPSOAS & RECTUS FEMORIS

Gluteal Muscles

Hip Capsule

Assessment of Hip Capsule Pattern

• Circumduct in a counterclockwise direction– internally– FADIR

• Circumduct in a clockwise direction– externally– FABER

Posterior Hip Capsule Stretch

• Operator’s hand is placed over the ischial tuberosity with the other hand controlling the flexed hip and knee

• Operator abducts/adducts and internally/externally rotates the against restrictive barriers

• Operator’s activating force is repetitive mobilization in a posterior direction through the shaft of the femur

Acetabular Labrum Mobilization Technique

• Internal & external hip rotation.

• Lateral to medial impaction-distraction of femoral head.

• Anterior to posterior impaction-distraction femoral head.

Anterior Hip Capsule Stretch• Operator flexes knee and

grasps anterior aspect of distal femur with one hand and the other contacts the posterior aspect of the proximal femur

• Operator gently lifts knee and applies a series of mobilizing forces in an anterior direction to proximal femur

• Operator fine-tunes against resistant barriers with internal/external rotation and medial/lateral directional forces

Muscle Energy Technique of the Hips & Thighs

MET Rx for Hips & Thighs

• Motion Tested– ABduction

• Muscles Tested– ADDuctors

MET Rx for Hips & Thighs

• Motion Tested– ADDuction

• Muscles Tested– Abductors –

Gluteus medius & minimis

MET Rx for Hips & Thighs

• Motion Tested– ADDuction

• Muscles Tested– ABductors – Tensor

Fascia Lata

MET Rx for Hips & Thighs• Motion Tested

– Internal rotation with hips in neutral• Muscles Tested

– External rotators – obturators, gemellus, quadratus femoris, piriformis

MET Rx for Hips & Thighs

• Motion Tested– Internal rotation

• Muscles Tested– External rotators -

piriformis

MET Rx for Hips & Thighs• Motion Tested

– External rotation with hip in neutral• Muscles Tested

– Internal rotators – gluteus minimus & medius, tensor fascia lata

MET Rx for Hips & Thighs

• Motion Tested– External rotation –

hip flexed 90%• Muscles Tested

– Internal Rotators – Gluteus medius & minimus

MET Rx for Hips & Thighs

• Motion Tested– Hip flexion (straight

leg raising)• Muscles Tested

– Hip Extensors – hamstrings; gluteus max & adductor magnus when hip flexed

MET Rx for Hips & Thighs

• Motion Tested– Hip extension

• Muscles Tested– Hip flexors –

iliopsoas, rectus femoris

– Modified Thomas Position

– Treat L-spine first

MET Rx for Hips & Thighs

• Motion Tested– Knee flexion

• Muscles Tested– Quadriceps group

MET Rx for Hips & Thighs

• Preferred Prone Position for Tx of iliopsoas and Rectus Femoris

MET Rx for Hips & Thighs• Tx for rectus femoris

• Tx for iliopsoas

The Knee and Proximal Leg

THIGH MUSCLES

KNEE JOINT

KNEE JOINT

• Joint stabilization:– Medial meniscus.– Lateral meniscus.– Articular capsule.– Medial collateral

ligament.– Lateral collateral

ligament.– Posterior ligaments.– Oblique popliteal

ligaments.– Anterior cruciate

ligament.– Posterior cruciate

ligament.

KNEE JOINT BURSA

• Subcutaneous prepatellar bursa.

• Suprapatellar bursa.• Deep infrapatellar

bursa.• Subcutaneous

infrapatellar bursa.• Infrapatellar fat pad.

Lower Extremity

CALF MUSCLES

KNEE: MOBILIZATION WITHOUT IMPULSE

Thumbs on medial meniscus.

Gap medial compartment and extend knee.

KNEE: MOBILIZATIONWITHOUT IMPULSE

Thumbs on medial or lateral meniscus.

Circumduct and extend knee.

KNEE: MENISCAL TRACKING

Rotation into extension.

KNEE: EXTENSION COMPRESSION TEST

• Restriction of extension and pain provocation indicate lack of terminal external torsion of the tibia and/or meniscal injury.

MET KNEE: Dx OF INTERNAL AND EXTERNAL ROTATION

• External rotation of the tibia• Internal rotation of the tibia

KNEE: MET Tx OF INTERNAL AND EXTERNAL ROTATION

• Position– Tibia internally rotated

• Motion restriction– External rotation of tibia

• Position– Tibia externally rotated

• Motion restriction– Internal rotation of tibia

Proximal Tibiofibular Joint• This articulation is intimately related to the knee and is

equally important to the ankle• Proximal tib/fib jt has an anteroposterior glide and is

influenced by the biceps femoris • Plane of the joint is approx 30% from lateral to medial

– Testing should be done within the plane of the joint

PROXIMAL TIBIOFIBULARJOINT

• Gliding synovial joint with anterior and posterior head ligaments.

• Relates to tibial torsion.

• Relates to distal tibiofibular joint at the ankle.

• Tibiofibular interosseous membrane.

Lower Extremity

MET Dx Fibular Head• Patient supine or sitting on

table• Operator grasps the

proximal fibula between thumb/thenar eminence & fingers– Be careful not to compress

peroneal nerve• Operator translates the

fibular head ant/post

MET Tx for Posterior Fibular Head

• Dx– Posterior fibular head

• Motion restriction– Anterior glide

• Operator inverts and internally rotates the foot– Anterolateral force on

posterior fib head• Patient should evert and

dorsiflex foot

MET Tx for Anterior Fibular Head

• Dx– Anterior fibular head

• Motion Restriction– Posterior glide

• Operator inverts and externally rotates patients foot– Posteromedial force on anterior

fib head• Patient everts & plantar flexes

the foot

HVLA for Posterior Fibular Head• Dx

– Posterior fibular head• Motion Restriction

– Anterior glide

HVLA for Posterior Fibular Head

• Dx– Posterior fibular head

• Motion Restriction– Anterior glide

• Patient Prone• Operator’s index

finger metacarpophalangeal jt is posterior to the fibular head in the popliteal space– Add slight external

rotation to leg

HVLA of Anterior Fibular Head• Dx

– Anterior fibular head• Motion restriction

– Posterior glide• Patient supine• Operator internally

rotates leg 30%– thenar eminence is

placed over proximal anterior fibular shaft

The Ankle and Foot

Help arrives: MSU trainer Tom Mackowiak (left) and team doctor Jeff Kovan tend to Spartan junior guard Kalin Lucas after he went down with a sprained ankle against Wisconsin

DISTAL TIBIOFIBULAR ARTICULATION

Dx: Antero-posterior glide of distal tibio-fibular joint. Related to dysfunction at proximal tibio-fibular joint.

RESTRICTED ANTERIORDISTAL TIB-FIB JOINT

Thumb on anterior aspect of distal fibula.

Compressive posterior thrust through left thumb.

RESTRICTED POSTERIORDISTAL TIB-FIB JOINT

Thumb on posterior aspect of distal fibula.

Compressive anterior thrust through left thumb.

Dx: MORTISE JOINT DORSIFLEXION RESTRCTION

Thumbs on neck of talus.Hands introduce dorsiflexion of talus at mortise joint.

Rx MORTISE JOINT DORSIFLEXION RESTRICTION

Left hand web on neck of talus. Resist plantar flexion.

Internal vs External Rotation Restrictions

Restricted internal/medial rotation.

Restricted external/lateral rotation.

Muscle energy activating force

Dx INTERTARSAL JOINTS

Rx INTERTARSAL JOINTS

Thumb under middle cuneiform. Resist forefoot

dorsiflexion.

Dx CALCANEOCUBOID JOINT

Test internal-external rotation of cuboid.Palpate tenderness & prominence of cuboid tubercle.

Rx CALCANEOCUBOID JOINT

Lift cuboid. Plantar flex &medially rotate forefoot.

Resist dorsiflexion of forefoot or HVT of acute plantar flexion.

MET OR HVLA ACTIVATING FORCE

J-STROKE FOR CALCANEOCUBOID JOINT

Control forefoot and thumbs on cuboid.

Throw foot to floor.

Review

• OPP Review• Functional

Biomechanics and the use of OMT in treating the athlete

• Questions ?

OsteopathicMedicine

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