1. OMM and the Athlete Lower Body Workshop
Jake Rowan DO
Dept of OMM
MSUCOM

2. Goals/Objectives Review OPP and how they apply to sports medicine
Discuss functional biomechanics
Review palpatory dx
Discuss OMM tx approach

3. 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.

4. 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

5. 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

6. 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

7. MODELS OF MANUAL MEDICINE
Biomechanical model.
Neurologic model.
Respiratory-circulatory model.
Bioenergy model.
Organ system model.

8. 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.

9. 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

10. Tx Approach Principles
Motor Control
Balance
Core stability
Stretch before strengthening

12. Tx Approach Principles - LBP
Pelvis
Pubes
Ilium
Lumbar spine
Lower Thoracic
Sacrum
Core stability

13. Lumbar Spine and Sacrum

14. Muscle Imbalance
The Pelvic Clock
Three dimensional evaluation of function of the lumbar spine and pelvis.
Used diagnostically and therapeutically.

15. 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

16. PROPRIOCEPTIVE BALANCE Assessment & Treatment

17. PROPRIOCEPTIVE BALANCE Assessment and Treatment

18. Tx Approach Principles - LE
Pelvis
Lumbar spine
Lower T-spine
Sacrum
Hip
Knee
Ankle
Foot
Toes

19. The Pelvis

20. The Pelvis

21. Lower Extremity

22. ILIOPSOAS & RECTUS FEMORIS

23. Gluteal Muscles

24. Hip Capsule

25. Assessment of Hip Capsule Pattern
Circumduct in a counterclockwise direction
internally
FADIR
Circumduct in a clockwise direction
externally
FABER

26. 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

27. Acetabular Labrum Mobilization Technique
Internal & external hip rotation.
Lateral to medial impaction-distraction of femoral head.
Anterior to posterior impaction-distraction femoral head.

28. 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

29. Muscle Energy Technique of the Hips & Thighs

30. MET Rx for Hips & Thighs Motion Tested Muscles Tested ABduction
ADDuctors

31. MET Rx for Hips & Thighs Motion Tested Muscles Tested ADDuction
Abductors – Gluteus medius & minimis

32. MET Rx for Hips & Thighs Motion Tested Muscles Tested ADDuction
ABductors – Tensor Fascia Lata

33. MET Rx for Hips & Thighs Motion Tested Muscles Tested
Internal rotation with hips in neutral
Muscles Tested
External rotators – obturators, gemellus, quadratus femoris, piriformis

34. MET Rx for Hips & Thighs Motion Tested Muscles Tested
Internal rotation
Muscles Tested
External rotators - piriformis

35. MET Rx for Hips & Thighs Motion Tested Muscles Tested
External rotation with hip in neutral
Muscles Tested
Internal rotators – gluteus minimus & medius, tensor fascia lata

36. MET Rx for Hips & Thighs Motion Tested Muscles Tested
External rotation – hip flexed 90%
Muscles Tested
Internal Rotators – Gluteus medius & minimus

37. MET Rx for Hips & Thighs Motion Tested Muscles Tested
Hip flexion (straight leg raising)
Muscles Tested
Hip Extensors – hamstrings; gluteus max & adductor magnus when hip flexed

38. MET Rx for Hips & Thighs Motion Tested Muscles Tested Hip extension
Hip flexors – iliopsoas, rectus femoris
Modified Thomas Position
Treat L-spine first

39. MET Rx for Hips & Thighs Motion Tested Muscles Tested Knee flexion
Quadriceps group

40. MET Rx for Hips & Thighs
Preferred Prone Position for Tx of iliopsoas and Rectus Femoris

41. MET Rx for Hips & Thighs
Tx for rectus femoris
Tx for iliopsoas

42. The Knee and Proximal Leg

43. THIGH MUSCLES

44. KNEE JOINT

45. 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.

46. KNEE JOINT BURSA Subcutaneous prepatellar bursa. Suprapatellar bursa.
Deep infrapatellar bursa.
Subcutaneous infrapatellar bursa.
Infrapatellar fat pad.

47. Lower Extremity

48. CALF MUSCLES

49. KNEE: MOBILIZATION WITHOUT IMPULSE
Thumbs on medial meniscus.
Gap medial compartment and extend knee.

50. KNEE: MOBILIZATION WITHOUT IMPULSE
Thumbs on medial or lateral meniscus.
Circumduct and extend knee.

51. KNEE: MENISCAL TRACKING
Rotation into extension.

52. KNEE: EXTENSION COMPRESSION TEST
Restriction of extension and pain provocation indicate lack of terminal external torsion of the tibia and/or meniscal injury.

53. MET KNEE: Dx OF INTERNAL AND EXTERNAL ROTATION
External rotation of the tibia
Internal rotation of the tibia

54. 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

55. 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

56. PROXIMAL TIBIOFIBULAR JOINT
Gliding synovial joint with anterior and posterior head ligaments.
Relates to tibial torsion.
Relates to distal tibiofibular joint at the ankle.
Tibiofibular interosseous membrane.

57. Lower Extremity

58. 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

59. MET Tx for Posterior Fibular HeadDx
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

60. MET Tx for Anterior Fibular HeadDx
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

61. HVLA for Posterior Fibular HeadDx
Posterior fibular head
Motion Restriction
Anterior glide

62. HVLA for Posterior Fibular HeadDx
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

63. HVLA of Anterior Fibular HeadDx
Anterior fibular head
Motion restriction
Posterior glide
Patient supine
Operator internally rotates leg 30%
thenar eminence is placed over proximal anterior fibular shaft

64. 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

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

66. RESTRICTED ANTERIOR DISTAL TIB-FIB JOINT
Thumb on anterior aspect of distal fibula.
Compressive posterior thrust through left thumb.

67. RESTRICTED POSTERIOR DISTAL TIB-FIB JOINT
Thumb on posterior aspect of distal fibula.
Compressive anterior thrust through left thumb.

68. Dx: MORTISE JOINT DORSIFLEXION RESTRCTION
Thumbs on neck of talus.
Hands introduce dorsiflexion of talus at mortise joint.

69. Rx MORTISE JOINT DORSIFLEXION RESTRICTION
Left hand web on neck of talus.
Resist plantar flexion.

70. Internal vs External Rotation Restrictions
Restricted internal/medial rotation.
Restricted external/lateral rotation.
Muscle energy activating force

71. Dx INTERTARSAL JOINTS

72. Rx INTERTARSAL JOINTS Resist forefoot dorsiflexion.
Thumb under middle cuneiform.
Resist forefoot dorsiflexion.

73. Dx CALCANEOCUBOID JOINT
Test internal-external rotation of cuboid.
Palpate tenderness & prominence of cuboid tubercle.

74. 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

75. J-STROKE FOR CALCANEOCUBOID JOINT
Control forefoot and thumbs on cuboid.
Throw foot to floor.

76. Review
OPP Review
Functional Biomechanics and the use of OMT in treating the athlete
Questions ?

77. The science of medicine
Osteopathic
Medicine
The science of medicine
The art of caring
The power of touch