1. Osteopathic Mimics of Primary Care Complaints
Shawn Kerger, DO, FAOASM
Associate Professor, OMM – OU-HCOM, Dublin Campus
Medical Director, Peter E. Johnston, DO, Simulation & Education Center

2. A SHORT REVIEW OF OSTEOPATHIC PRINCIPLES2

3. 4 Tenets of Osteopathic Philosophy
The body is a unit.
The body possesses self-regulatory, self-healing, and health maintenance mechanisms.
Structure and function are reciprocally interrelated.
Rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure & function.
Ski pyramid -
Skinned knee photo - 3

4. Rational Treatment
HOST +
Disease =
Illness 4

5. Disease MDs vs. DOs – Site of allopathic care
– Site of osteopathic care
HOST 5

6. Disease Disease Rational Treatment + + Disease + Illness = Illness =
HOST +
Disease =
Illness
Medical and surgical care very successful …
HOST +
Disease =
Illness
Usual medical/surgical care unsuccessful, & OMM very beneficial & often DRAMATIC …
Deviated septum from a fracture – OMM not much help!
Headache, presumably sinus – doesn’t respond to Abx, other meds, then gets surgery. No change until OMM applied and then everything’s fixed.
Peritonsillar abscess – drainage, Abx, and OMM
HOST +
Disease =
Illness
Medical care helpful, but doesn’t produce the expected clinical outcome – the addition of OMM enables the patient to realize their “health potential” 6

7. Presence of a somatic dysfunction
Indications for OMM
Only ONE –
Presence of a somatic dysfunction 7

8. Value of Physical Examination - Introduction
The main utility for an accurate physical exam in modern medicine?
Rapid
Readily available
Rational
Results (of your treatment)
Rapport / Relationship with patient
Reasonable (in cost)
Repeatable = Reliable

9. Value of Physical Exam: ACL Rupture
Accuracy of 3 Diagnostic Tests for ACL Tears (2003) 1
Meta-analysis of 17 studies from potential 1090 studies
Writings in English, French, German or Dutch were included
From 1966 to 2003 for MEDLINE & 1980 to 2003 for EMBASE databases
Inclusion criteria:
Investigation of at least one physical diagnostic test for ACL tears in the knee
Use of a reference standard or arthrotomy, arthroscopy, or MRI
Tests included pivot shift, Lachman and the anterior drawer.
Sensitivity, specificity and predictive values were reported.

10. Value of Physical Exam: ACL Rupture (cont)
Accuracy of 3 Diagnostic Tests for ACL Tears (2003)
Results: (pooled together using bivariate random effects model – BREM)
Anterior Drawer Test – inconclusive either way.
Sensitivity = 0.2 (BREM)
Specificity = (BREM)
Pivot Shift – best test for ruling in an ACL injury (highest PPV)
Sensitivity = 0.18 – (too low # of studies for BREM)
Specificity = (too low # of studies for BREM)
Lachman Test – best test for ruling out an ACL injury (highest NPV), & also best test overall.
Sensitivity = (BREM)
Specificity = (BREM)

11. Value of Physical Exam: ACL Rupture (cont)
What about MRI? 2

12. Value of Physical Exam: ACL Rupture (cont)
Lachman Test –
Sensitivity = (BREM)
MRI – (BREM not done)
Sensitivity =
Specificity = (BREM)
Specificity =

13. Reliability of Physical Examination
While a single physical examination test result may not be as high as radiographic studies, the ease of repeatability (and allowing for variations…) increases the likelihood of making an accurate diagnosis.

14. Problems with Physical Examination
Poor performance of technique
Incomplete or erroneous understanding of test’s purpose / MOA
Lack of adaptation to patient or circumstances
Poor manual ability to perform
Inaccurate interpretation of findings
Incomplete or erroneous understanding of test’s purpose / mechanism of action
Pain only vs. reproduction of patient’s complaint
Doing test too fast / not receiving the information
Examiner bias / preconceptions

15. Cyriax System of Orthopaedic Medicine
Every pain has a source.
Treatment much reach the source.
Treatment must benefit the source in order to relieve the pain.
Physical Exam:
Use active and resisted movements to evaluate tendons and muscles
Use passive movement to assess ligaments for pain, laxity or alterations in range of motion.
Capsular patterns indicate inflammation of the capsule/joint.
Non-capsular patterns indicate intra- or extra-articular tissue is inflamed.

16. Spurling’s Manuever, & Standing/Seated Kemp’s Test
Anatomy:
All these tests involve lateral nerve root compression by extension and sidebending, resulting in neuroforaminal encroachment.
Classic tests reproduce patient’s radicular / shooting pains for nerve root compression; and local, nonradicular reproduction of patient’s pain from facet compression.
Modified interpretations include radicular and non-radicular pains on opposite side.

17. Spurling’s Manuever – Mechanism of Exam
Pt usually seated.
The physician passively extends the neck and then rotates and sidebends to the same side.
If pain hasn’t been reproduced with extension first, nor with the sidebending/rotation – then added compression axially down the cervical column along the lateral facets from the top of the head.
Radicular pain that is reproductive is a classic positive test & indicates nerve compression. Non-radicular reproductive pain indicates facet.
The Physician and Sportsmedicine Volume 24, Issue 10, October 1996, pages 37-46

18. Spurling’s Manuever Common Errors in Performance:
Not using the same amount of force.
Not determining when the pain begins by palpation, or the pain pattern (radicular vs. non-radicular).
Mimics:
Some facet syndromes can give near-radicular pain pattern – but won’t follow dermatomes and pain quality is not usually electric-shock or shooting pains
Associated / Confirmatory Testing:
Facet blocks (diagnostic – may be therapeutic)
MRI or other imaging (U/S or X-ray), based on availability and circumstances.
The Physician and Sportsmedicine Volume 24, Issue 10, October 1996, pages 37-46

19. Lhermitte’s Test Anatomy:
This is a test of the function of the dorsal columns of the spinal cord as they move through a flexion maneuver – it can be limited due to extradural, intradural or intramedullary lesions.
This can be a sign (pt complains of this without being tested) or a test – with flexion of the neck actively or passively, there is an electric-shock sensation shooting down from the head and into the trunk and/or limbs.
Caused by multiple sclerosis lesions in the C-spine, transverse myelitis, Behçet disease, trauma, large herniated discs, space-occupying mass in c-spine, severe vitamin B12 deficiency, and others.
Most recently IMRT (intensity-modulated radiation treatment) has been added to the list for head and neck cancer pts…

20. Lhermitte’s Test Mechanism of Exam:
Pt seated and head in neutral position.
Can either:
Ask patient to flex the neck Or
Physician can passively flex the neck.
If there is an electric-shock sensation shooting down from the head and into the trunk and/or limbs, the test is considered positive.
Please note that I did not say if it reproduced the patient’s symptoms – if this finding is present, it deserves immediate workup and attention…you may then still have to figure out what ELSE may be creating the patient’s problem!

21. Lhermitte’s Test Common Errors in Performance:
Really not much – just make sure the neck is flexing and that the patient is asked to describe the pain.
Mimics:
Some patients will report ‘pulling’ or ‘strain’ down the thorax or even into the lumbars with this motion – be sure to get clear information about the quality of the pain, not just the location/direction of the symptoms.
Associated / Confirmatory Testing:
Other malingering tests – Axial compression, and others.
MRI or other imaging (U/S or X-ray), based on availability and circumstances.

22. BAD technique here – pt extending at knee, not lumbar spine!
Standing Kemp’s Test – Mechanism of Exam
Pt standing with physician monitoring ipsilateral lumbar spine
The patient actively extends the lumbar region, as they rotate and sidebend to the same side.
Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminal area is more likely.
Non-radicular reproductive pain indicates facet, & is usually “late” in motion.
BAD technique here – pt extending at knee, not lumbar spine!

23. Seated Kemp’s Test – Mechanism of Exam
Pt seated with physician monitoring ipsilateral lumbar spine
The physician passively extends patient’s lumbar region, adding rotating and sidebending to the same side.
Interpreted the same as standing!
Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminal area is more likely.
Non-radicular reproductive pain indicates facet, & is usually “late” in motion.

24. Standing/Seated Kemp’s Test
Common Errors in Performance:
Not using the same amount of force.
Allowing knees to bend instead of lumbar extension (St Kemp’s).
Not determining when the pain begins by palpation, or the pain pattern (radicular vs. non-radicular).
Mimics:
Some facet syndromes can give near-radicular pain pattern – but won’t follow dermatomes and pain quality is not usually electric-shock or shooting pains
Associated / Confirmatory Testing:
Facet blocks (diagnostic – may be therapeutic)
MRI or other imaging (U/S or X-ray), based on availability and circumstances.

25. Bonnet’s Test Anatomy:
This test uses the external rotation mechanics of the piriformis at less than 60° of hip flexion to determine if piriformis tension has a role in the patient’s pain.
Note – this does NOT mean that there’s not another factor in the patient’s pathophysiology, but rather that the piriformis does have some role in the pathology…and so addressing the piriformis might be of benefit.

26. Bonnet’s Test Mechanism of Exam:
Physician performs a routine SLR, careful to stop at the reproduction of pt’s radicular pain.
Physician then very slightly returns the leg toward the table until just the point where the patient’s pain reduces / goes away, and stops there.
At this level of hip flexion, the physician then internally rotates the leg which puts tension on the piriformis.
If the pain is reproduced w/ the internal rotation, the piriformis has a role in the patient’s pain and should be addressed.

27. Bonnet’s Test Common Errors in Performance:
Not having a positive SLR first!
Moving too far into flexion past the patient’s pain threshold point, or not far enough back to a reduced or pain-free location.
Not internally rotating the leg enough.
Not paying attention to if this maneuver reproduces the patient’s pain!
Mimics:
Intraarticular process of the hip – shouldn’t cause radicular pain with SLR, though.
Associated / Confirmatory Testing:
Other hip tests (Fabere’s / Patrick’s, Yeoman’s, Hibbs, Gaenslen’s, etc.).
MRI or other imaging (U/S or X-ray), based on availability and circumstances.

28. Force Distribution Through the Bony Pelvis
Thieme 2007, pp
Sacroiliac & Pubic Joints are key components in the integrity of force distribution from above and below.
This is the ‘Foundation’ for trunk function.

29. Sacropelvic Function Three Joints: 2 Sacroiliac Joints Pubic Joint
Important for ‘Shock Absorption’
The main ligaments are
the superior pubic ligament: between pubic tubercles
arcuate pubic ligaments: lower border, bounding the pubic arch

30. Two ways to address these elements: Treat these muscles, and / or
Primal Pictures 2003
Piriformis
Iliacus
Quadratus
Lumborum
Psoas Maj. & Min.
IMPORTANT Muscular Players in LBP:
Two ways to address these elements:
Treat these muscles,
and / or
use these muscles to engage the restricted joints.

31. Facilitated Positional Release Approach

32. History of FPR
Described by Stanley Schiowitz, DO, FAAO, in conjunction with his teaching fellows at the time (DiGiovanna & Dowling) in the 80s & 90s.
The fellows referred to the technique as “IO” in their notes – short for “Instant Osteopathy”.
The paper describing his technique was published in 1990, and it was titled then as “Facilitated Positional Release”.

33. Facilitated Positional Release (FPR)
Flatten any A-P curves.
Apply compressive, torsional, or traction force through area affected. (can also be done after neutral positioning)
Position lesioned area into a neutral position.
Hold for 3-4 seconds & return to neutral position passively (on pt’s part). Recheck.

34. Diagnosis and Treatment
Requires different diagnosis technique altogether – and might not align with diagnosis in other models/approaches
Benefits of FPR approach:
Pt remains prone, no need to switch positions
Very well tolerated, requires minimal patient effort (guided breaths at most)
Diagnostic path is shorter/cleaner – right side vs. left side is all…
Downsides of FPR approach:
Pt remains prone – there are lateral recumbent variations, but those are technically difficult to perform…
Usually need 2 pillows – one for abdomen and one for leg. Can adapt with additional patient effort and physician adaptation, though…

35. Sacral Diagnosis for FPR
Pt prone with pillow under abdomen to flatten the lumbar curve (and thereby, the sacrum…)
Place heels of both hands inferior to the ILAs
Direct a cephalad force in either an alternating fashion or simultaneously through the ILAs
Compare sides of the sacrum for freedom/restriction
Restricted side is dysfunctional
DiGiovanna, An Osteopathic Approach to Diagnosis and Treatment, 3rd Edition : Facilitated Positional Release.

36. Sacral Restriction
Pt prone with a pillow under abdomen, & another under thigh below hip joint
Physician monitors affected SI joint with finger, and rest of hand on sacrum
With other hand, abduct thigh until motion is felt at SI (can add IR to leg if needed/beneficial)
Push leg down toward floor until motion is again felt
Pt performs a deep inhalation & exhalation while physician pushes cephalad against ILA
Release and recheck
DiGiovanna, An Osteopathic Approach to Diagnosis and Treatment, 3rd Edition : Facilitated Positional Release.

37. History of Still Technique
It shares quite a bit of technical similarity to a different technique described in 1996 by Richard van Buskirk, DO, FAAO, which he titled “Still Technique”, but there are a few differences:
Still technique’s position of ease is usually more exaggerated than FPR’s.
Still technique requires the practitioner to move from the position of ease through neutral and into the barriers – FPR does not, although many FPR practitioners do so as well.

38. Cervical Technique – AA (C1-C2): Rotated Left
Pt supine, w/ physician sitting or standing at the head of table.
Physician places hands over the parietotemporal regions, palpating Lt C1 trans process.
Rotate pt’s head to the left ease barrier, & introduce gentle compression toward C1 until softening is perceived.
FPR – hold this position for 3-5 secs and return to neutral passively
Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to right restrictive barrier.
Recheck.

39. Anterior Talar Dysfxn
Commonly anteriorly displaced, or impacted/’jammed’.
Usually secondary to a traumatic inversion of ankle, but also be d/t chronically tight post. calf muscles.
Frequently associated w/ plantar fasciitis.
Pt complains of ant. talar pain w/ attempted dorsiflexion, & possibly of reduced calf stretch when attempted.

40. Evaluation for Anterior / “Impacted” Talus – Swing Test
Pt complains of ant. talar pain w/ attempted dorsiflexion, & possibly of reduced calf stretch when attempted.
Swing Test – with foot passively dorsiflexed, posteriorly glide the talus under the mortise joint – evaluate for range & ‘endfeel’ of motion, compared with unaffected side.

41. Articular Techniques HVLA – High velocity, low amplitude
Short, but quick motion at barrier
LVHA –
Low velocity, high amplitude
Slow, long motion into and through barrier

42. Articular Techniques HVLA Technique Define the lesion.
Take up the slack toward the barrier, ideally in all three planes.
Have patient relax fully.
Move joint in a planar fashion through the barrier with a quick, directed thrust.
Recheck your findings.
LVHA Technique
Define the lesion.
Take up the slack toward the barrier, ideally in all three planes.
Have patient relax fully.
Move joint in a planar fashion through the barrier with a gentle, steady motion.
Recheck your findings.

43. Talar Release
Pt supine w/ knee & hip flexed to 90° & hip slightly abducted, nestle your elbow against the mid-hamstring area while forming a “ring” with your thumbs & forefingers around the talus.
Slowly, but firmly, flex the hip while maintaining the ring around the talus. You should feel a traction force building.
Maintaining the tension, either exert a quick thrust with the talus or gently rock the talus into dorsiflexion with a little inversion/eversion until you feel a release, pop, or clunk.
Recheck for improved ROM or deeper calf muscle stretch.

44. Articular Techniques for Talus
Place ipsilateral middle or ring finger over superior aspect of talus, below tib-fib joint.
Dorsiflex ankle to barrier, while cradling calcaneus w/ contralateral hand. May fine tune w/ inversion & eversion to maximize dorsiflexion.
With the patient relaxed, either:
tug the foot quickly w/ moderate force in a caudal direction, (High-velocity / low-amplitude = HVLA)
or w/ traction force caudally, rock calcaneus & talus as a unit in an inversion/eversion plane. (Low-velocity / high-amplitude = LVHA)

45. Talar Tug (HVLA) – Alternate Hold
Need to engage barrier, then rapidly pull & dorsiflex at the same time – makes a ‘sleeping J’ pattern movement when viewed this way

46. Alternative Techniques for Talus

47. Conclusion
“Education is what you remember after you have forgotten what you studied for the test."
- Emerson

48. References
Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract.2003;52:689–694
Hoyt M, Goodemote P, Morton J. How accurate is an MRI at diagnosing injured knee ligaments? J Fam Pract. 2010;59(2):118–120.
Thieme, Atlas of Anatomy, 2nd Edition.
Nicholas & Nicholas, Atlas of Osteopathic Techniques, 3rd edition, Chapter 13.
Special thanks to Nicole Alexander, OMS-IV & Abby Huck, OMS-IV for their help with some of these photos.

49. APPENDIX

50. Cervical Still Technique – C2-7: C4ESRRR
Pt supine, w/ physician sitting or standing at the head of table.
Physician places hands so that one is palpating Rt C4 articular process & the other can control pts head.
Extend pt’s head until C4 is engaged, & then rotate & SB head Rt until C4 softening is perceived.
FPR – hold this position for 3-5 secs and return to neutral passively
Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to left restrictive barrier.
Recheck.

51. Cervical Still Technique – OA (C0-C1): C0ESRRL
Pt supine, w/ physician sitting or standing at the head of table.
Physician places hands so that one is palpating Rt C4 articular process & the other can control pts head.
Extend pt’s head until C4 is engaged, & then rotate & SB head Rt so that C4 softening is perceived.
FPR – hold this position for 3-5 secs and WHILE ADDING TRACTION (only time you do this) return to neutral passively
Still’s – maintain compression force axially toward C4 & w/ moderate acceleration, SB head to Lt (as you rotate Rt) through neutral while simultaneously adding graduated flexion.
Recheck.

52. Fibular Head Dysfunction
Goal of all the following treatments are for the return of anterior glide of the proximal fibular head & to allow external rotation of tibia.

53. Articular Technique - Fibular Head
Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus
Externally rotate tibia to barrier
Place ipsilateral 2nd MCP joint behind fibular head
Flex knee up to barrier
Either quickly flex knee about the 2nd MCP joint, or smoothly continue flexion. Recheck.

54. Articular Technique - Fibular Head
Another view
Note the use of the operator’s left wrist/forearm to maintain external rotation of tibia prior to knee flexion

55. Articular Technique - Fibular Head (Prone)
Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus & stabilize
You may externally rotate tibia to barrier, or not
Place heel of hand behind fibular head
Either quickly exert an anterior impulse or smoothly apply pressure anteriorly

56. Peroneal Muscles – Soft Tissue Technique
Goal here is to reduce pain & tension, & promote fluid evacuation from distal ankle
Can also serve as a prep for another technique for ankle or leg
Gently massage or apply perpendicular traction to affected tendons & muscles
As with any fluid model, start proximally & work distally

57. Popliteal Release
Relaxes popliteal fossa tissues & promote drainage from lower leg
Exert an anterior force with fingers in midline of fossa
While patient extends knee (maintaining heel on table), exert a firm, spreading force with fingertips
This can be uncomfortable, but should not be painful