As presented by your RVUCOM OPP Fellows

 Manual of Selected Osteopathic Techniques

(Furlano and Prest)
 Kaplan OPP
 Savarese*
 Foundations for Osteopathic Medicine
 Special MSK Tests
 Sacrum / Pelvis Diagnosis
 L5 Rules
 VISCEROSOMATIC REFLEXES
(Including Chapman’s Reflexes)
 Treatment Modalities
 Contraindications
 Fryette’s Principles
 Cranial Strain Patterns
 Types of somatic dysfunction – acute and chronic
 Naming of somatic dysfunction and spinal motion
 Direct and indirect treatments
 Cranial questions (basic)
 Common compensatory patterns
 Trigger points
 Physiologic motion of the cervical spine
 Cervical spine pathology – neurologic findings
 Rule of 3’s (relationship of thoracic transverse processes to spinous processes)
 Rib motion terminology, concept of the key rib
 Scoliosis
 Psoas
 Non-musculoskeletal causes of back pain
 Cauda equina syndrome
 Lumbosacral congenital anomalies
 Spondylolisthesis, spondylolysis
 Short leg, sacral base un-leveling, lift therapy
 Ottawa Ankle Rules
 Rotator cuff muscles and injury
 Spencer’s technique for the shoulder
 Carpal tunnel
 Lymphatic drainage
 Treatment of sinusitis
 Findings in cardiovascular patient
 Approach to pulmonary patient
 Musculoskeletal findings in GI disease
 Genitourinary problems
 Headaches – types, treatment approaches
 The OB patient
 TART
 Tenderness
 Asymmetry
 Restriction
 Tissue Texture Changes
 Somatic Dysfunction
Characteristics
 Acute Findings
 Warm
 Red
 Swollen
 Moisture
 Chronic Findings
 Fibrosis
 Cool/Dry
 Ropy
 Restrictive Barrier – functional limit within the
anatomic range of motion, diminishes the normal
physiologic range
 Aka = Pathologic Barrier
 Physiologic Barrier – limit of active motion, can be
altered to increase range of active motion by warm up
activity
 Anatomic Barrier – the limit of motion imposed by
anatomic structure; the limit of passive motion
 The end point of ligament, fascia, muscle etc
 23 y/o male presents to ED with mid-back pain.
Tenderness is noted over the right transverse process
of T7. Motion testing shows a posterior transverse
process of the left which resolves in extension. What
is the most likely somatic dysfunction?
A. T7FRSR
B. T7FRSL
C. T7ERSR
D. T7ERSL
E. T7NSRRL
 23 y/o male presents to ED with mid-back pain.
Tenderness is noted over the right transverse process
of T7. Motion testing shows a posterior transverse
process of the left which resolves in extension. What
is the most likely somatic dysfunction?
A. T7FRSR
B. T7FRSL
C. T7ERSR
D. T7ERSL
E. T7NSRRL
Rotation:
Transverse (Horizontal) Plane;
Vertical Axis

Side-bending:
Coronal Plane;
Anterior-Posterior
Axis

Flexion/Extension:
Sagittal Plane;
Transverse Axis
 Principle I
 Neutral (Type I Mechanics)
 Rotate and Side bend OPPOSITE
 Group curves
 Ex: T3-T6 NSRRL, T7 NSLRR

 Principle II
 Non-Neutral (Type II Mechanics)
 Rotate and Side bend SAME
 Single segment
 Ex: C5 FRRSR, L2 ERSL

 Principle III
 Motion in one plane affects ALL planes

PRINCIPLES I and II - DO NOT APPLY TO OA, AA,

CERVICALS, SACRUM!
 Neutral (Type I) Non-Neutral (Type II)
Segments Group curve Single vertebral segment
Muscle Erector spinae Transversospinal group
involvement
Rotation/ Opposite sides Same side
Sidebending
Cause Chronic process, Acute process,
Postural compensation Trauma,
Viscero-somatic reflexes

Reproduced with permission from Nate Nakken

Intermediate:
Serratus posterior Splenius capitus

superior & inferior Serratus posterior superior

Iliocostalis
Deep: Longissimus
Splenius Spinalis

Erector Spinae
Serratus posterior inferior
Spinalis
Longissimus
Iliocostalis
Deep Muscles of the Back:
Transversospinal group
Semispinalis Semispinalis capitis Rotatores
Multifidus Interspinalis

Rotatores
Intersegmental Muscles Semispinalis thoracis Levator
costarum
Interspinalis Multifidus
Intertransversarii
Interspinalis
Levator costarum
Intertransversari
i
 OA
 Rotate and Side bend
OPPOSITE
 AA
 ROTATION exclusively
 Typicals: C2-C7
 Rotate and Side bend
SAME
 57 y/o male presents with rib pain. Tenderness is
noted over the posterior rib angle of rib 5. Where
would one expect to find the spinous proces of T5?
A. At the level of the transverse processes of T4
B. At the level of the transverse processes of T5
C. At the level of transverse processes of T6
D. Half way between T4 & T5
E. Half way between T5 & T6
 57 y/o male presents with rib pain. Tenderness is
noted over the posterior rib angle of rib 5. Where
would one expect to find the spinous proces of T5?
A. At the level of the transverse processes of T4
B. At the level of the transverse processes of T5
C. At the level of transverse processes of T6
D. Half way between T4 & T5
E. Half way between T5 & T6
 Rule of 3’s – relationship between spinous process in relation to transverse
processes.
 T1-3: Same level
 Ex: T2 spinous process at same level as T2 transverse processes.
 T4-6: Half down
 Ex: T5 spinous process half level below T5 transverse processes.
 T7-9: Full down
 Ex: T8 spinous process full level below T8 transverse processes.
 T10-12: “Walk back up”
 T10 – same as T7-9
 T11 – same as T4-6
 T12 – same as T1-3

*This diagram refers to transverse processes in relation to spinous

processes.
 Rib Organization
 Typical vs Atypical
 Atypical: 1, 2, 11, 12

 True vs False
 True: 1-7
 False 8-10
 Floating: 11 &12

 What makes a rib true vs.

false?
 Direct connection to the
sternum via cartilage
 Pump Handle
 Ribs 1-5
 Anterior-Posterior Motion

 Bucket Handle
 Ribs 6-10
 Lateral motion

 Caliper
 Ribs 11 & 12
 Ribs 1-5: Pump
 Transverse processes
of upper thoracics
extend lateral = a
more transverse axis

 Ribs 6-10: Bucket

 Transverse processes
of lower thoracics
angle back posteriorly
= a more AP axis
 78 y/o female presents with costochondritis. Ribs 4-8
on the right do not move fully in inhalation. What
muscle is used in treatment?
A. Anterior scalene
B. Posterior scalene
C. Pec Minor
D. Serratus Anterior
E. Quadratus Lumborum
 78 y/o female presents with costochondritis. Ribs 4-8
on the right do not move fully in inhalation. What
muscle is used in treatment?
A. Anterior scalene
B. Posterior scalene
C. Pec Minor
D. Serratus Anterior
E. Quadratus Lumborum
 BITE
 Bottom Inhaled, Top Exhaled

 Inhaled
 “Push it back into place”
 1-5 flexion of neck, fine-tune with SB
 6-10 SB of body, fine-tune with flexion
 11-12: QL; same as exhaled but hand lateral on rib angle

 Exhaled
 Rib 1: Anterior scalene
 Rib 2: Posterior scalene
 Ribs 3-5: Pec Minor
 Ribs 6-9/10: Serratus Anterior (10- Lat dorsi)
 Ribs 11-12: Quadratus Lumborum; hand medial on rib
tubercle
 Sympathetics
 Head/Neck/Heart/ Lungs T1-T4(T6)
 Upper GI T5-T9
 Lower GI/Pelvis T10-L2

 Parasympathetics
 Head/Neck CNIII, VII, IX, X
 Chest/Upper GI X
 Lower GI/Pelvis S2-S4
 Parasympathetics
 Vagus Nerve
 Mid-Transverse Colon
and Above
 S2-4
 Mid-Transverse Colon
and Below
 Sympathetics
 Head: T1-4
 Heart: T1-5
 Lungs: T2-6
 UE: T2-6
 Celiac Ganglion: T5-9
 Superior Mesenteric
Ganglion: T10-11
 Inferior Mesenteric
Ganglion: T12-L2
 LE: T10-L3
 Organ Sympathetic Parasympathetic
 Pupil Dilation Constriction
 Ciliary Muscle -------- Contraction
 Lacrimal Gland -------- Secretory
 Mucus Glands Inhibition Secretory
 Salivary Glands Inhibition Secretory
 Blood Vessels (skin) Vasoconstriction ---------
 Pilomotor Muscles Contraction ---------
 Sweat Glands Secretory ---------
 Common Carotid Artery Vasoconstriction ---------
 Mucous Glands (Phx-Larx) Vasoconstriction Secretory
 Thyroid Gland Vasoconstriction --------
 Heart Excitation Inhibition
 Bronchial Glands Inhibitory Secretory
 Bronchial Muscles Relaxation Contraction
 Upper body vasculature Vasoconstriction --------
 Organ Sympathetic Parasympathetic
 Stomach Inhibition Motor and secretion
 Liver Glycogenolysis Glycogen Synthesis
 Spleen Vasoconstriction --------
 Gallbladder & ducts Relaxation Contraction
 Pancreas Vasoconstriction Secretory
 Kidney Vasoconstriction --------
 Adrenal Medulla Adrenaline / secretion --------
 Intestinal Tract Contraction Relaxation
 Rectal Sphincter Contraction Relaxation
 Vesicle Sphincter Contraction Relaxation
 Vesicle body Relaxation Constriction
 Uterine Body Constriction Relaxation
 Uterine Cervix Relaxation Constriction
 Male Reproductive Organ Ejaculation Erection
 Ovary and Testes Vasoconstriction (unknown)
 Localized visceral stimuli
producing patterns of reflex
response in segmentally
related somatic structures
 Tissue texture abnormality
and tenderness in the
dermatomes and myotomes
that share innervation with
the etiologic pathology
 Ex: facilitated vertebral
segment
 Afferent: visceral afferent
nerves
 Efferent: rotatores,
interspinales,
intertransversarii, levatores
costarum, semispinalis
 Visceral irritation
 Message of irritation
travels back on bifurcating
neuron
 Synapses on somatic
motor neurons and causes
muscle contraction
 Releases proinflammatory
polypeptides at that level
 Prolonged stimulation can
lead to facilitation
 “Facilitation indicates an
area of impairment or
restriction that develops a
lower threshold for
irritation and dysfunction
when other structures are
stimulated.”
 Facilitated segments are
hyper-irritable and hyper-
responsive.
 Muscles are maintained in
a hypertonic state.
 Maintenance of a pool of
neurons in a state of
partial or subthreshold
excitation
 In this state less
stimulation is required
to trigger the discharge
of impulses
 Somato-Somatic: localized somatic stimuli
producing patterns of reflex response in segmentally
related somatic structures.
a) DTRs
b) Withdrawal Reflex
c) T5 dysfunction caused by tight linea alba
 Somato-Visceral: localized somatic stimulation
producing patterns of reflex response in segmentally
related visceral structures.
a) Spinal Manipulation changes in HR, BP, and
sympathetic activity to kidney and adrenal medulla
 Viscero-Visceral: localized visceral stimuli producing
patterns of reflex response in segmentally related
visceral structures.
a) Gut Distention  Gut Contraction
b) Baroreceptor Reflex  Blood vessel stretch change
causes change in heart rate
 Viscero-Somatic: localized visceral stimuli producing
patterns of reflex response in segmentally related
somatic structures.
a) Cardiac Disease  Somatic Dysfunction T1-5 RSL
 Convergence-Projection
Theory
 Visceral and somatic
afferents converge on the
same or associated
neurons or interneurons in
the spinal cord
 Can follow a viscero-
somatic pattern (MI 
Left Arm)
 Or a somato-somatic
pattern (Gallbladder 
Diaphragm Phrenic
Nerve  Right Shoulder)
Cranial

Sacral
 Nope.
 47 y/o male presents to ED with right flank pain. UA
is positive for hematuria. A calcified object is found
on CT scan in the proximal ureter. On osteopathic
exam, one would expect to find paraspinal
hypertonicity at the level of:
A. T6
B. T9
C. T11
D. L2
E. S2
 47 y/o male presents to ED with right flank pain. UA
is positive for hematuria. A calcified object is found
on CT scan in the proximal ureter. On osteopathic
exam, one would expect to find paraspinal
hypertonicity at the level of:
A. T6
B. T9
C. T11
D. L2
E. S2
 47 y/o male presents with urgency and weak stream.
UA is negative. DRE finds a boggy enlarged prostate.
Where would a Chapman’s point most likely be found?
A. Periumbilically
B. Transverse process T11
C. Pubic tubercle
D. Anterior thigh
E. IT band
 47 y/o male presents with urgency and weak stream.
UA is negative. DRE finds a boggy enlarged prostate.
Where would a Chapman’s point most likely be found?
A. Periumbilically
B. Transverse process T11
C. Pubic tubercle
D. Anterior thigh
E. IT band
 Gangliform contraction that may block lymphatic
drainage, causing inflammation in distal tissues
 Believed to be part of sympathetic dysfunction
 Found in regions which overlap with visceral sympathetic
efferent innervation
 Used for diagnosis, treatment, and evaluation
 Part of a viscero-somatic reflex
 Chapman and Owens clinical uses
1) For diagnosis
2) For influencing the motion of fluids, mostly lymph
3) For influencing visceral function through the
peripheral nervous system
  Often tender, but don’t
 Small, smooth, firm, discrete
nodules in fixed anatomic radiate
locations  “Tenderness is not the
 Deep to skin and
sole criterion for a
subcutaneous areolar Chapman’s point; rather,
tissue on deep fascia or it is lymphatic
periosteum congestion and altered
myofascial texture”
 Feel like a BB or split pea
 Treatment: firm, circular
 Usually paired anterior and
pressure
posterior
 Attempt to flatten
 Anterior points often
 10-30 sec
painful with light
compression
Anterior Chapman’s Points
 Middle ear (otitis media) – upper edge of the clavicle, just beyond where it crosses the 1st rib
 Pharynx – front of 1st rib ¾-1” toward the sternum from where the clavicle crosses the rib
 Nose – costochondral junction of 1st rib
 Tonsils –1st and 2nd intercostal space close to the sternum
 Tongue – front of 2nd rib cartilage ¾” from the sternum
 Bronchus, Esophagus, Thyroid – 2nd and 3rd rib intercostal space close to the sternum
 Larynx – upper surface of 2nd rib, 2-3” from the sternum
 Sinuses – 3 ½” from the sternum, on the upper edge of 2nd rib and in the 1st intercostal space above
 Cerebellum – tip of coracoid process
 Neck – inner aspect of the upper end of the humerus from the surgical neck downward
 kidneys = 1’’ lateral and 1’’ superior from the umbilicus and intertransverse region of T11-T12;
 Retina, conjunctiva – front of the humerus, middle aspect of the surgical neck downward.
Posterior Chapman’s Points
 Conjunctiva, retina – around the suboccipital nerve
 Cerebellum – just under the skull, midway between the posterior median line and the C1 TP
 Tonsils – post surface of C1 TP, midway between the median line of the neck and the tip of the TP
 Middle ear (otitis media) – upper edge of the posterior aspect of the tip of C1 TP
 Nose – place finger under the jaw angle, like you are drawing a line across the face to parallel the
line of the mouth and shoving the finger backward until you come in line with the TP of the
vertebrae
 Cerebrum – laterally from the spines of C3-5 (anterior points), Between TPs of C1 and C2 near
their tip ends (posterior points)
 Pharynx – midway between the SP and TP of C2, on the post aspect of the TP
 Larynx, Sinuses, Tongue – midway between the TP and SP of C2 on the superior aspect of the TP
 Neck – across the posterior aspect of the TPs of C3, C4, C6, C7
 Bronchus, Esophagus, Thyroid - midway between the TP and SP of T2 on the posterior aspect of
the TP
 Middle Pharynx
Retina
ear
Conjunctiva
Nose
Sinuses
Middle
Ear Cerebellum
Tonsils Tonsils Cerebellum

Pharynx Nose
Tongue Retina,
Tongue
Larynx conjunctiva
Bronchus
Sinus
Cerebrum Esophagus
Thyroid Esophagus
Neck Bronchus
Thyroid Neck

Bilateral Larynx Bilateral

 GI – Chapman’s Points

Pyloric
stenosis

Stomachac
Liver idity
Liver

Liver
Stomach Liver gallbladder
hyperacidity Gallbladder
Pancreas Stomach
Stomach Pancreas
peristalsis peristalsis

Spleen Small
Intestines Spleen
Pyloric
Bilateral
stenosis
Small
intestine
Intestinal Appendix
Appendix peristalsis
Organ Anterior Posterior

Esophagus 2nd intercostal space bilaterally Across the face of the transverse process of the 2nd vertebra and
midway between the spinous process and tip of the transverse
process.

th th
Stomach In the left 5 intercostal space between the mid- Left 5 Intertransverse space midway between the spinous
(Hyperacidity) mammilary line and sternum process and tip of the transverse process.

th th
Stomach In the left 6 intercostal space between the mid- Left 6 Intertransverse space midway between the spinous
(Peristalsis) mammilary line and sternum process and tip of the transverse process.

Liver and Gall In the right 6th intercostal space between the mid- Right 6th Intertransverse space midway between the spinous
Bladder mammilary line and sternum process and tip of the transverse process.

Pancreas Right 7th intercostal space close to the costochondral Right 7th intertransverse space midway between the spinous
junction process and the tip of the transverse process

Intestines Bilateral 8th (upper), 9th (middle), and 10th (lower) Bilateral of 8th, 9th, and 10th intertransverse spaces midway
intercostal spaces close to the costochondral junctions. between the spinous process and the tip of the transverse
process

Intestinal Peristalsis Bilaterally in the muscle tissues between the ASIS and Bilaterally along the face of the 11th rib at the costotransverse
(Constipation) the Greater Trochanter junction.

Pyloris Anterior Midline of the Sternum Right costovertebral junction of the 10th rib

Appendix Tip of the right 12th rib, upper edge Outer end of the right 11th inter-transverse space
 Anterior
 2nd intercostal space
along sternal border

 Posterior
 2nd thoracic vertebrae
transverse processes
 Arteries – Superior and inferior thyroid
 Veins – Superior, middle, and inferior thyroid
 Lymph - prelaryngeal, pretracheal and paratracheal
nodes
 Sympathetics – T1 via superior (C2/3), middle (C6),
and inferior (stellate/1st rib) ganglia
 Parasympathetics - Uncertain
 Anterior
 1 inch superior and 1
inch lateral to the
umbilicus

 Posterior
 Between 12th thoracic
and 1st lumbar vertebrae
transverse processes
 Arteries – Renal
 Veins – Renal
 Lymph – lateral aortic nodes
 Sympathetics – T10-L1 (check thoracolumbar junction)
 Parasympathetics - Uncertain
 Anterior
 2 inches superior and 1
inch lateral to
umbilicus

 Posterior
 Between 11th and 12th
vertebrae, between
spinous and transverse
processes
 Arteries – Superior, middle and inferior suprarenal
 Veins – suprarenal
 Lymph – para-aortic nodes
 Sympathetics – T6-L2
 Parasympathetics – Vagus (maybe)
 Anterior
 7th intercostal space
approximated to
costochondral junction

 Posterior
 Between 7th and 8th
thoracic vertebrae
 Arteries – superior and inferior pancreaticoduodenal
 Veins – superior and inferior pacreaticoduodenal
 Lymph – Pancreaticosplenic and pre-aortic
 Sympathetics – T6-9 (vasomotor)
 Parasympathetics – Vagus (secretory motor)
 Anterior
 6th intercostal space from
mid-mammilary line to
sternal border

 Posterior
 Between 6th and 7th
thoracic vertebrae
transverse processes
 Arteries – hepatic
 Veins – Portal system and hepatic
 Lymph – nodes above and below diaphragm
 Sympathetics – T6-9
 Parasympathetics - Vagus
 Pertinent Sympathetics:
 T10-11 = ovaries
 T10-L2 = uterus, fallopian tubes, vagina,

 T10-11 = testicles
 T10-L2 = vas deferens, seminal vesicles
 L1-L2 = prostate

 T10-L1 = kidney
 T10-11 = proximal ureters
 T12-L1/2 = distal ureters
 T10/11-L1/2 = bladder
 Adrenal
tThese
are
Kidney around
Abdomen the
umbilicus
Bladder

Ovaries
Testes
Urethra

Prostate Prostate
Uterus Broad ligament

Inguinal
lymph
nodes
Bilateral
 Anterior:
 Ovaries = round ligaments from the upper border of the pubic bone downward to the attachment of the
muscles on the lower border of the pubic bone
 Broad ligament = from the trochanter downward on the outer aspect of the femur to within 2’’ of the knee joint
 Fallopian tubes = midway between acetabulum and sciatic notch
 Uterus = upper edge of the junction of the pubic ramus with the ischium
 Vagina = (leucorrhea) between PSIS and spinous process of L5, the inner femoral condyle, and upwards from 3-
6” on the posterior aspect
 Vagina = upper, inner aspect of posterior thigh, 3-5’’ long and 1.5-2’’ wide
 Testicles = round ligaments from the upper border of the pubic bone downward to the attachment of the
muscles on the lower border of the pubic bone
 Prostate = laterally on either side of the pubic symphysis and from the trochanter downward on the outer aspect
of the femur to within 2’’ of the knee joint
 Note – the testicles and prostate are the same as the ovaries and broad ligament
 Adrenals = 2-2.5” above and 1” on either side of the umbilicus
 Kidneys = 1’’ on either side of the median vertical line of the abdomen and 1” above the horizontal plane of the
umbilicus
 Bladder = around the umbilicus as well as on the pubic symphysis close to the median line
 Ovary
Testes

Adrenals
Kidneys
Urethra
Bladder
Uterus
Abdomen
Broad ligament
Prostate Inguinal lymph
Fallopian tubes nodes
Seminal vesicles
Uterus
Vagina

Vagina
Clitorus
Fallopian tubes
Seminal vesicles Bilateral
Vagina
 Posterior:
 Ovaries = in the intertransverse space between the T9 and T10 vertebrae (inner ½ of the ovary) and
intertransverse space of T10and T11 vertebrae (outer ½ of the ovary)
 Broad ligament = between PSIS and spinous process of L5
 Fallopian tubes = same as broad ligament
 Uterus = tip of transverse process of L5 toward iliac crest and between PSIS and spinous process of L5
 Vagina = upper, inner aspect of posterior thigh, 3-5’’ long and 1.5-2’’ wide; and on the side of the
articulation of the coccyx with the sacrum
 Testicles = in the intertransverse space between the T9 and T10 vertebrae (inner ½ of the testicle) and
intertransverse space of T10 and T11 vertebrae (outer ½ of the testicle) (same as ovaries)
 Prostate = between PSIS and spinous process of L5 (same as the broad ligament and fallopian tube)
 Adrenals = intertransverse space between T11 and T12 vertebrae between spinous process and transverse
process
 Kidneys = intertransverse space between T12and L1 vertebrae between spinous process and transverse
process
 Bladder = upper edge of transverse process of L2
 65 y/o female presents with 3 week history of hip pain.
Findings include: right positive standing flexion, left
positive seated flexion, superior left PSIS, inferior left
ASIS, right ASIS is more lateral than the left. The most
likely diagnosis is?
A. Left innominate anterior rotation
B. Left innominate inflare
C. Right innominate posterior rotation
D. Right innominate outflare
E. Right inferior pubic shear
 65 y/o female presents with 3 week history of hip pain.
Findings include: right positive standing flexion, left
positive seated flexion, superior left PSIS, inferior left
ASIS, right ASIS is more lateral than the left. The most
likely diagnosis is?
A. Left innominate anterior rotation
B. Left innominate inflare
C. Right innominate posterior rotation
D. Right innominate outflare
E. Right inferior pubic shear
 Composed of 3
fused bones
 Ilium, Ischium,
Pubis
 Landmarks
 ASIS, PSIS, Pubic
Tubercles
 Standing Flexion Test  Lateralization
 Diagnoses
 Rotations – anterior or posterior
 Shears – superior or inferior
 Flares – medial (inflare) or lateral (outflare)
 In relation to umbilicus

Flare

Rotation

Shear
 36 y/o male presents with low back pain for 1 month
due to a snow boarding fall. Imaging was negative.
Standing flexion test is positive on right. Seated
flexion test is positive on left. Left ASIS is inferior,
right PSIS is inferior, right sacral base is deep, and left
ILA is anterior. What is the most likely sacral
diagnosis?
A. Right Unilateral Flexion
B. Left on Right
C. Left Unilateral Extension
D. Right innominate posterior rotation
E. Left innominate anterior rotation
 36 y/o male presents with low back pain for 1 month
due to a snow boarding fall. Imaging was negative.
Standing flexion test is positive on right. Seated
flexion test is positive on left. Left ASIS is inferior,
right PSIS is inferior, right sacral base is deep, and left
ILA is anterior. What is the most likely sacral
diagnosis?
A. Right Unilateral Flexion
B. Left on Right
C. Left Unilateral Extension
D. Right innominate posterior rotation
E. Left innominate anterior rotation
 Seated flexion test is positive on left. Right sacral base
is deep, and left ILA is anterior. What is the most
likely sacral diagnosis?
A. Right Unilateral Flexion
B. Left on Right
C. Left Unilateral Extension
D. Right innominate posterior rotation
E. Left innominate anterior rotation
 Seated flexion test is positive on left. Right sacral base
is deep, and left ILA is anterior. What is the most
likely sacral diagnosis?
A. Right Unilateral Flexion
B. Left on Right
C. Left Unilateral Extension
D. Right innominate posterior rotation
E. Left innominate anterior rotation
 Superior transverse / Respiratory axis/ Inherent (Craniosacral) axis (S2)
 Flexion and Extension occur with respiration and craniosacral motion.
 The sacrum flexes when lumbar lordosis increases (lumbar extension).
 Respiratory exhalation.
 Craniosacral extension/nutation.
 The sacrum extends when lumbar lordosis decreases (lumbar flexion)
 Respiratory inhalation.
 Craniosacral flexion/counternutation.

 Middle transverse / Postural axis. (S2)

 Flexion and extension occurs with motion of the sacrum on the ilium.

 Inferior transverse / Iliosacral axis. (S3)

 Flexion and extension occurs with motion of the ilium on the sacrum
(inominate rotation).

 BOTTOM LINE:
All 3 axes allow flexion & extension.

 Also R oblique axis and L oblique axis

 Dynamic motion during walking.
 Torsions.
 Landmarks
 Sacral base/sulcus, ILAs
 Evaluation
 Seated Flexion test - lateralization
 Backward Bending Test
 Spring test
 Positive Negative

Backwards Sacral findings do not improve Sacral findings improve 

Bending Test  prefers extension. prefers flexion.
(Sphinx)
1. Unilateral extension 1. Unilateral flexion
2. Bilateral extension 2. Bilateral flexion
3. Backward torsion (L on 3. Forward torsion (R on R/ L
R/R on L) on L)
Spring Test Sacrum does not spring  Sacrum springs 
prefers extension. prefers flexion.

1. Unilateral extension 1. Unilateral flexion

2. Bilateral extension 2. Bilateral flexion
3. Backward torsion 3. Forward torsion

Backward Torsion = L on R or R on L = Non-Physiologic

Forward Torsion = L on L or R on R = Physiologic
*Chart in OMM Manual
 both sulci deep, - spring test = B/L
sacral flexion
both sulci shallow, + spring test = B/L
sacral extension shear

Same side = torsion Different side = shear

3. Backward bending or
- BBT (- spring) +BBT(+ spring)
Sphinx test
Forward sacral
torsion Backward sacral
torsion
- BBT (- spring) + BBT(+ spring)
L on L R on R L on R R on L Unilateral sacral Unilateral sacral
flexion extension
Tx: pt prone Tx: pt prone
Hold big inhalation Hold big exhalation
Push toward table on Push toward table on
ipsilateral ILA ipsilateral sacral
Tx: Axis side down Tx: Axis side down
sulcus
Forward torsion = pt Backward torsion = pt
goes backward (top Seated flexion test or pelvic rock:
goes forward and
shoulder toward + on the R = R unilateral flexion or extension
hugs the table
table) + on the L = L unilateral flexion or extension
Physiologic strain = Nonphysiologic = L5
L5 is neutral and is non-neutral and Sacral torsion mechanics
rotated opposite the rotated opposite the Ex: L on L
sacral rotation sacral rotation Tight R piriformis causes a +R
seated flexion test and a L oblique
Seated flexion test or pelvic rock:
axis because it is named by the
+ on the R = left axis
superior aspect (left sacral base)
+ on the L = right axis
 both sulci deep, - spring test = B/L
sacral flexion
both sulci shallow, + spring test = B/L
sacral extension shear

Same side = torsion Different side = shear

3. Backward bending or
- BBT (- spring) +BBT(+ spring)
Sphinx test
Forward sacral
torsion Backward sacral
torsion
- BBT (- spring) + BBT(+ spring)
L on L R on R L on R R on L Unilateral sacral Unilateral sacral
flexion extension
 Sacrum Treatment – Muscle Energy
 Axis side DOWN
 Forward = Face down
 Backward = on Back
 45 y/o male presents with low back pain. Positive
standing flexion on left. Right ASIS superior, left PSIS
inferior, right sacral base anterior, left ILA shallow.
Positive spring test. What is L5 most likely doing?
A. L5NSLRR
B. L5NSRRL
C. L5FRSL
D. L5FRSR
E. L5ERSL
 45 y/o male presents with low back pain. Positive
standing flexion on left. Right ASIS superior, left PSIS
inferior, right sacral base anterior, left ILA shallow.
Positive spring test. What is L5 most likely doing?
A. L5NSLRR
B. L5NSRRL
C. L5FRSL
D. L5FRSR
E. L5ERSL
 Rule 1
 L5 rotates OPPOSITE sacrum
 Rule 2
 L5 side bends SAME as axis
 Rule 3
 Oblique Axis is OPPOSITE of seated flexion

 Q) Can you apply L5 rules to shears?

 A) No! These are only for TORSIONS!

 Q) Do the L5 rules tell me about flexion or extension?

 No, not directly.

 If it helps you:
 ROSS: Rotate Opposite (of sacrum), Sidebend Same (as axis).
 Naming based on convexity of curve.
 Sidebend opp., rotate same, type I (neutral)
 Classification
 Structural: will not correct with sidebending.
 Functional: will correct with sidebending.
 Severity
 Mild – Cobb angle 5°-15°
 Moderate – Cobb angle 20°-45°
 Severe – Cobb angle >50°
 50°  respiratory involvement
 75°  cardiac involvement R
 Surgery considered at 45-50° L
 Causes
 Idiopathic – most common
 Congenital
 Ex: malformation of vertebrae
 Neuromuscular
 Ex: Cerebral palsy, Poliomyelitis, etc.
 Acquired
 Ex: Tumor, infection, psoas syndrome, short leg syndrome, etc.
 Sacral base unleveling
 Lower on side of short leg.
 Innominate rotation
 Ant. on side of short leg.
 Post. on side of long leg.
 Lumbar spine
 Sidebend away and rotate
towards side of short leg.

 C-curve earlier
 S-curve later (compensation)
 Diagnosis is made after OMT.
 Consider lift if >5mm difference.
 “Frail” patients (elderly, arthritic, acute
pain, etc.)
 1/16” (1.5mm) lift initially, increase
1/16” every 2 wks
 Mobile spine/flexible patient
 1/8” lift (~3.2mm) initially, increase
1/16” every week or 1/8”every 2wks
 Sudden shortening (fracture,
prosthesis)
 Full compensation
 Resolution based on standing flexion
test
 Goal is to have sacral base within
1mm
 Factors affecting PRM (primary respiratory motion)
 Tenet 1: The fluctuation of the CSF and the potency of the
tide
 Tenet 2: The mobility of the intracranial and intraspinal
membranes, and the function of the reciprocal tension
membrane
 Tenet 3: The inherent motility of the central nervous
system
 Tenet 4: The articular mobility of the cranial bones
 Tenet 5: The involuntary mobility of the sacrum between
the ilia
 Motion of the Cranial Bones: Midline bones Flex and
Extend, Paired bones Internally and Externally Rotate
 Midline bones
 Sphenoid, occiput, vomer, ethmoid (median plate) &
sacrum
 SOVES
 Flexion & extension phases

 Paired bones
 Temporals, parietals, frontals, ethmoid (lateral mass),
nasals, lacrimals, maxillae, palatines, zygomae, inferior
conchae & mandible
 External & internal rotation phases

Subject material taken from Cranial Strains lecture dated 3/13/12

 Normal cranial rate is **8-14 cycles/minute **

 Inhalation phase
 Flexion of midline structures
 External rotation of paired structures

 Exhalation phase
 Extension of midline structures
 Internal rotation of paired structures
Greater wing

Basisphenoid

Basiocciput

Occipital
squama

Pictures modified from: Upledger

Subject material taken from Cranial Strains lecture dated 3/13/12

 Background
 Vault hold
 Paired vs Midline bones
 Inherent Motion
 Flexion
 Extension
 Cranio-sacral motion
 Cranial flexion +
Counternutation(sacral
extension)
 Cranial extension +
Nutation(sacral flexion)
 Pterion: Overlapping of Frontal, Parietal, Sphenoid and Temporal.
Area of anterior branch of middle meningeal artery.
 Asterion: Meeting of parietal, temporal and occiput.
 Opisthion: Dorsal aspect of foramen magnum.
 Basion: Ventral aspect of foramen magnum.
 Nasion: Meeting of frontal and nasal bones.
 Glabella: Bump on distal frontal bone, above nasion.
 Bregma: Meeting of coronal and sagittal sutures.
 Inion: Flat area of greater occipital protuberance.

 Sutherland's Fulcrum: Area of straight sinus (junction of three sickles

of dura mater); automatic shifting suspension fulcrum “…point of rest
on which a lever moves and from which it gets its power..." (Magoun)
Flexion:

Extension:
 Inherent motion of the
sacrum is related to the
craniosacral mechanism.
 During flexion of the
sphenobasilar symphysis, the
sacrum counternutates or the
sacral base moves posteriorly
into sacral extension.

 During the extension phase of

the craniosacral mechanism,
the sacrum nutates, or the
sacral base moves anteriorly
into sacral flexion.
 Torsion
 Right or left
 Sidebending rotation
 Right or left
 Vertical strain
 Superior or inferior
 Lateral strain
 Right or left
 SBS compression

Subject material taken from Cranial Strains lecture dated 3/13/12

 Sphenoid and occiput
rotate in OPPOSITE
directions around an A-P
axis from nasion to
opisthion.
 Named by the Superior
greater wing of the
sphenoid
 Sphenoid and occiput
move in OPPOSITE
directions around parallel
vertical axes to side bend
(one axis through base of
sphenoid and one through
foramen magnum)
 Then, sphenoid and
occiput rotate around an
A-P axis in the SAME
direction to rotate
 Named by the side of the
SBS convexity and the side
that moves inferiorly.
 Sphenoid and occiput
rotate in the SAME
direction about parallel
vertical axes.
 Lateral strains named by
the direction the
basisphenoid moves.
 Note: This is ROTATION,
not TRANSLATION!
 (The picture is deceiving
and could give you the
opposite diagnosis!)
 Sphenoid and occiput
rotate in the SAME
direction about parallel
transverse axes.
 Vertical strains are
named by the direction
of the basisphenoid.
 Basisphenoid and
basiocciput are
approximated or
“jammed” together along
the A-P axis.
 Decreased quality and
quantity of CRI
 Feels like “bowling ball
head”
 Questions to ask:
 What are your hands
doing?
 What is the SBS doing?
 What are the axes?
Traumatic Forces and Cranial Strain Patterns
Strain Pattern Potential Traumatic Forces Involved

Superior Vertical Strain -Caudal force applied centrally over the

anterior-superior frontal bone.
-Force to the superior occiput (near lambda) &
directed from superior/posterior to anterior.

Inferior Vertical Strain -Caudal force transmitted to the basisphenoid

such as a caudal force transmitted from
bregma.
-A cephelad force transmitted to the
condylar parts such as a fall on the base of
the spine (ie. landing on the buttocks with
a force transmitted up the spine).
-A caudal force transmitted over the bilateral
posterior-superior parietal bones or along the
posterior sagittal suture.
SBS Compression -Force directed along the AP axis leading to
longitudinal compression of the SBS. May
originate at nasion or at opisthion. Tight hats
or headbands.
Traumatic Forces and Cranial Strain Patterns, cont…..

Strain Pattern Potential Traumatic Forces Involved

Lateral Strains -Lateral to medial directed force applied over

External Rotations of the Temporal Bones
the greater wing of the sphenoid pushing the
greater wings to the left or right.
-Lateral to medially directed force applied
over the occiput pushing the posterior aspect
of the occiput left or right.
-Force applied to the left mandible in a left to
right direction yields a right externally rotated
temporal bone rotation and a left internally
rotated temporal bone rotation.
-Traction of one side of the mandible due to
dental work yields internal rotation on the
ipsilateral side as the traction and external
rotation on the contralateral side of the
traction forces.
 18 y/o male presents with a concussion. Neuro exam is
within normal limits. Further questioning reveals he
was hit in the left temple. On palpation with the vault
hold, the 2nd digits shift toward the right and the 5th
digits shift to the left. What axis does this strain
pattern move about?
A. A-P axis
B. Two Transverse axes
C. Two Vertical axes
D. Two Vertical + A-P axis
E. Vertical axis
 18 y/o male presents with a
concussion. Neuro exam is within
normal limits. Further questioning
reveals he was hit in the left temple.
On palpation, the 2nd digits shift
toward the right and the 5th digits
shift to the left. What axis does this
strain pattern move about?
A. A-P axis
(torsion & compression)
B. Two Transverse axes
(vertical)
C. Two Vertical axes
(lateral)
D. Two Vertical + A-P axis
(side bending rotation)
E. Vertical axis
(does not exist)
Cranial questions can cover cranial nerve dysfunction due to cranial strain patterns. It is important
to be familiar with the cranial foramen and the nerves that pass through them.
Material taken from Netter, Atlas of Human Anatomy
Material taken from Netter, Atlas of Human Anatomy
Material taken from Netter, Atlas of Human Anatomy
• Temporal bone associations
• External rotation of temporal bone  low-pitched tinnitus
• Internal rotation of temporal bone  high pitched tinnitus

•
C5 Clavicles
C6 Thumb
C7 Middle finger
C8 Ring/Little Finger
C5-C6 Ball of shoulder (deltoid)
C5-C7 Lateral Arm (C5 for lateral upper arm, C6 for lateral forearm)
C8-T1 Medial Inner Arm
T4 Nipple
T7 Xiphoid
T10 Umbilicus
T12 Groin
L4 Innermost foot
L5 Dorsum of foot
S1 Outermost foot
L4-L5 Medial Foot
L3-L4 Knee
L5, S1-S2 Posterior/Outer Thigh
L1-L4 Anterior/Inner Thigh
S1-S5 Perineum
Nerve Root Motor Sensory Reflex
C5 Deltoid & biceps Lateral arm & lateral Biceps
elbow
C6 Biceps & wrist Lateral forearm & Brachioradialis
extensors thumb
C7 Triceps & wrist flexors Middle finger Triceps
C8 Wrist flexors and Little finger & middle None
interossi forearm
T1 Interossi Medial elbow & None
medial arm
L4 Dorsiflexion of foot Medial calf/medial Patellar
malleolus
L5 Dorsiflexion of big toe • Lateral calf None
• Dorsal foot/big toe
S1 Plantarflexion • plantar foot Achilles
• Lateral
foot/malleolus
 Phrenic nerve (C3-5)
 Innervates diaphragm
 Long thoracic nerve
 Innervates serratus anterior
 Injury leads to Winged Scapula
 Upper brachial plexus (C5 & 6)
 Injury leads to Erb-Duchenne Palsy
 Lower brachial plexus (C7-T1)
 Injury leads to Klumpke’s palsy
 Radial nerve
 Injury leads to wrist drop
 Tendinous attachment of :
 Subscapularis - internal rotation
 Supraspinatus - abduction
 Infraspinatus - external rotation
 Teres Minor - external rotation

 Impingement Syndrome – @ impingement interval

(space between humeral head and acromion)
 Primary – anatomic restrictions
 Secondary – pain (reflex inhibition and weakness)
 Loss of humeral head placement in glenoid fossa
 Results in superior translation
 Also caused by scapular muscle dysfunction
 Sx
 Decreased ROM, pain, weakness
 Early trap firing, weak scapula stabilizers
 Leads to winging
 Painful arc between 90-120 degrees of abduction

 Dx
 Use Scapular Y-View for imaging

 Tx
 Conservative 1st (if possible)
 Core strengthening
 PRICE: Prevention (stretching), Rest, Ice, Compression, Elevation (if possible),
 NSAIDs – if not contraindicated
 Heat and deep muscle message
 Corticosteroid injections – sub-acromial space
 Inflammation of the Biceps tendon
 Speed’s and Yergason’s tests
 Snapping, tenderness, crepitation
 Can be associated with impingement syndrome

 Treatment
 U/S, NSAIDs, EMS, Rest
 Corticosteroid use
 CAUTION: can further weaken the biceps tendon & lead to
rupture, esp with repeat injections
 Lateral Epicondylitis (Tennis Elbow)
 Augmented Soft Tissue Manipulation (ASTYM)

Medial Epicondylitis (Golfer’s Elbow)

Tendinosis – angiofibroblastic degeneration

 Chronic condition occurring longer than a “few weeks” of
inflammation

Nursemaid’s Elbow (Radial head annular ligament subluxation)

 Common in young children
 Occurs with longitudinal traction while the arm is extended (with
pronation), rarely occurs after 7 yrs
 Check neurovascular supply before & after reduction
 Tx: reduction is performed by placing pressure over the radius while
maximally supinating & flexing the arm
 Remember your mneumonic: SAPP
 Supination = Anterior
 Pronation = Posterior

 Ex. A: “Falling forward on an outstretched arm”

 Hand is in pronation
 Radial head will be pushed posterior

 Ex. B: “Falling backward on an outstretched arm”

 Hand is in supination
 Radial head will be pushed anterior
 Depressed right Navicular
 Post right talus
 Ant lateral malleolus
 Ext rotated tibia
 Posterior fibular head
 Internally rot femur
 Right anterior innominate
 R on R sacrum
 L5NSRRL
 Tight right QL
 Restricted left abd diaphragm
 T12 ERSL
 Restricted left Sibson’s fascia
 Elevated left 1st rib
 C3-5 FRSL with tight left ant scalene
 RSBR of cranial base
 Based on Hx & Physical
 Ottawa ankle rules
 Order x-ray if and only if:
 Bony tenderness of the distal 6
cm of the med mal, or
 Bony tenderness of the distal 6
cm of the lat mal, or
 Inability to bear weight
immediately and in the ER for
4 steps
 Bony tenderness at the base of
the 5th MT (for foot injuries),
or
 Bony tenderness at the
Navicular bone (for foot
injuries), or

 Rules do not apply under 18

years old – must order X-ray
Hemiplegic gait
 Affected leg is stiff
 Loss of flexion at hip & knee
 Pt will lean to affected side
 Will whip the leg around in a
circumduction pattern
 Shoe drags on the floor
 Decreased ipsilateral arm
movement & held against the
abdomen & flexed at the
elbow (aka no arm swing)
 Commonly associated with
strokes
Shuffling gait
 Small flat footed steps
 Foot does not clear ground
 Pt is in truncal flexion (lack
of extension at hip, knees &
elbows)
 Thorax & pelvis rotate the
same direction in swing
phase
 Seen in Parkinson’s (often the
first sign) & arteriosclerosis
Type 1 (toe touch)
 Toe touches first
 Usu due to foot drop
 Caused by paralysis of
pretibial or peroneal
(fibular) muscles
 Increased hip & knee
flexion raise the leg high to
clear the toes
 The foot slaps the floor
 Also known as “foot slap
gait” (or “slap foot”)
Type 2 (heel strike)
 Heel touches first
 Due to lack of proprioception
 b/l high steppage gait
 With ataxia and side-to-side
reeling
 Heel hits first with a stomp of the
foot
 +Rhomberg can be present
 Causes
 CA, diabetic neuropathy, MS,
posterior column problems in the
cord, tabes dorsalis, Friedrich’s
ataxia, B12 deficiency
Ataxic gait Scissors gait
 Unsteady gait with a wide  Legs are adducted & cross in
base front of one another
 Tendency to fall towards  b/l LE are spastic with spasm
side of the lesion of the adductor muscles at
the hip
 Drunken/ staggering gait
fall forward or backward  Often has compensation
pattern in the trunk & UE
 Seen in
 Causes
 MS, myxedema, cerebellar
 B/L upper motor neuron
dysfunction…
lesions, MS, severe OA of hip
 may be accompanied by &/or knee…runway models
vertigo simulate this on occasion
Waddling gait
 Rolling from side to side
 Penguin-like walk
 Pelvic rotation & tilt are
to the same side
 Seen in
 Muscular dystrophy,
increased abdominal
panus, late-term
pregnancy
Hysterical gait
 May be completely
bizarre
 May simulate paralysis
 May be unable to
ambulate, but while in
bed will not be spastic
Sacrum faces leg in swing phase, Innominate in swing phase goes from Ant rotation to Post
 23 y/o female presents with upper back pain.
Paraspinal hypertonicity is found at T5 with motion
improving in flexion. T5 transverse process is less
prominent on the left. While using direct muscle
energy, in which direction would the patient push?
A. Flex & rotate left
B. Flex & side bend right
C. Extend & rotate right
D. Extend & side bend left
E. Side bend left & rotate left
 23 y/o female presents with upper back pain.
Paraspinal hypertonicity is found at T5 with motion
improving in flexion. T5 transverse process is less
prominent on the left. While using direct muscle
energy, in which direction would the patient push?
A. Flex & rotate left
B. Flex & side bend right
C. Extend & rotate right
D. Extend & side bend left
E. Side bend left & rotate left
 Direct treatments
 Muscle Energy Treatment (MET)
 HVLA (High-Velocity Low-Amplitude)
 Myofascial Release (MFR)*
 Articulatory
 Still’s Technique

 Indirect treatments
 Myofascial Release (MFR)*
 Counterstrain (CS)
 Facilitated Positional Release (FPR)
 Facilitated Positional Release
 Def: component region of body is placed in neutral,
diminishing tissue & joint tension in all planes, & an
activating force is applied (compression or torsion)
 Used to Tx (but not limited to):
 Superficial muscles
 Deep intervertebral muscles to influence vertebral motion
 Still’s Technique
 Def: position body into position of ease (somatic
dysfunction), add compressive force, & move through
the barrier while maintaining force
 Used to Tx (but not limited to):
 Muscle hypertonicity
 Restricted ROM
Body Region Position
Anterior cervicals Flex, STRA
Posterior cervicals Extend, STRA

Anterior thoracics Flex

Posterior thoracics Extend
Anterior ribs Side bend toward
Posterior ribs SARA
Anterior lumbars Flex, rotate away
Posterior lumbars Extend, side bend away
 90 y/o male presents with upper respiratory infection.
To aid in his recovery, what would initially be treated?
A. Rib 3
B. T1
C. T4
D. OA
E. Diaphragm
 90 y/o male presents with upper respiratory infection.
To aid in his recovery, what would initially be treated?
A. Rib 3
B. T1
C. T4
D. OA
E. Diaphragm
 Organization of flow into lymphatic
ducts

 Treat thoracic inlet first (central to

peripheral)
 T1, Rib 1, Manubrium
 Spondylolysis
 Defect in pars interarticularis without anterior
displacement of vertebral body
 Dx with oblique x-ray
 “collar on scotty dog”

 Spondylolisthesis
 Bilateral defect in pars interarticularis WITH anterior
displacement of vertebral body
 Dx with lateral x-ray
 “decapitated scotty dog” 
 Cauda equina syndrome
 Saddle anesthesia
 Loss of bowel or bladder function

 Herniated Nucleus Pulposus

 Nerve impingement thru HNP or stenosis or mass on the
nerve root of the level below
 ie. Herniation of L5 disk impacts S1 nerve root (L5/S1 leads to
impingement of S1)

 Sciatica (piriformis syndrome)

• Tight piriformis contracting on sciatic nerve leading to
sciatica
• Sciatic nerve can go above, thru, below, or around the
piriformis muscle
 Savarese
 Manual of Selected Osteopathic Techniques
 FOM 3rd edition
 Clinically oriented anatomy
 Kaplan
 DiGiovanna
 fionaterry.co.uk
 As the SBS rises, the sacral base:
A. Flexes
B. Internally rotates
C. Counter-nutates
D. Externally rotates
E. Nutates
 As the SBS rises, the sacral base:
A. Flexes
B. Internally rotates
C. Counter-nutates
D. Externally rotates
E. Nutates
 57 y/o female presents after being diagnosed with a
compression fracture at T1. She is now complaining of
a visceral problem. Which is the most likely organ
affected?
A. Left Colon
B. Kidney
C. Uterus
D. Stomach
E. Thyroid
 57 y/o female presents after being diagnosed with a
compression fracture at T1. She is now complaining of
a visceral problem. Which is the most likely organ
affected?
A. Left Colon
B. Kidney
C. Uterus
D. Stomach
E. Thyroid
 With cranial flexion, paired bones undergo:
A. Internal rotation
B. Flexion
C. Extension
D. External rotation
E. Counter-nutation
 With cranial flexion, paired bones undergo:
A. Internal rotation
B. Flexion
C. Extension
D. External rotation
E. Counter-nutation
 The findings of a left on right sacral torsion are:
A. Seated flexion test positive on left, spring test negative
B. Seated flexion test positive on left, negative backward
bending
C. Seated flexion test positive on right, spring test
positive
D. Seated flexion test positive on left, spring test positive
E. Seated flexion test positive on right, sprint test
negative
 The findings of a left on right sacral torsion are:
A. Seated flexion test positive on left, spring test negative
B. Seated flexion test positive on left, negative backward
bending
C. Seated flexion test positive on right, spring test
positive
D. Seated flexion test positive on left, spring test positive
E. Seated flexion test positive on right, sprint test
negative
 Patient has Barrett’s esophagitis as diagnosed by
endoscopy. OMT applied to the following region
would best affect the sympathetic innervation?
A. S3
B. T4-5
C. C2
D. L1
E. T1-2
 Patient has Barrett’s esophagitis as diagnosed by
endoscopy. OMT applied to the following region
would best affect the sympathetic innervation?
A. S3
B. T4-5
C. C2
D. L1
E. T1-2
 A 32 y/o presents with neck pain for 3 months after
being “rear ended” in an MVA. Palpation reveals C3 to
be markedly side bend right. After extending the
segment, it gets worse. What is the most likely
diagnosis?
A. C3FRRSR
B. C4FRRSR
C. C3ERRSR
D. C4ERRSR
E. C3NSLRR
 A 32 y/o presents with neck pain for 3 months after
being “rear ended” in an MVA. Palpation reveals C3 to
be markedly side bend right. After extending the
segment, it gets worse. What is the most likely
diagnosis?
A. C3FRRSR
B. C4FRRSR
C. C3ERRSR
D. C4ERRSR
E. C3NSLRR
 Osteopathic exam of a patient finds a positive spring
test and equal sacral bases. What is the most likely
diagnosis?
 Bilateral Sacral Flexion
 Right Unilateral Sacral Extension
 Bilateral Sacral Extension
 Left Unilateral Sacral Flexion
 No dysfunction
 Osteopathic exam of a patient finds a positive spring
test and equal sacral bases. What is the most likely
diagnosis?
 Bilateral Sacral Flexion
 Right Unilateral Sacral Extension
 Bilateral Sacral Extension
 Left Unilateral Sacral Flexion
 No dysfunction
 16 y/o male wrestler presents with numbness of his left
arm. Further exam reveals absent bicep reflex on the
left. What nerve is most likely impinged?
A. C5
B. C6
C. C7
D. C8
E. T1
 16 y/o male wrestler presents with numbness of his left
arm. Further exam reveals absent bicep reflex on the
left. What nerve is most likely impinged?
A. C5
B. C6
C. C7
D. C8
E. T1
 What are the dural attachments?
A. C1, C2, S2
B. C1, C3, S1
C. C2, C3, S2
D. Foramen magnum, C3, S2
E. Foramen magnum, C1, S3
 What are the dural attachments?
A. C2, S2
B. C1, C3, S1
C. C2, C3, S2
D. Foramen magnum, C3, S2
E. Foramen magnum, C1, S3
 12 y/o presents with ankle pain after rolling his ankle
falling off a curb. What is his most likely diagnosis?
A. Internal rotation of tibia
B. Anterior talus
C. Anterior fibular head
D. Posterior lateral maleolus
E. Posterior fibular head
 12 y/o presents with ankle pain after rolling his ankle
falling off a curb. What is his most likely diagnosis?
A. Internal rotation of tibia
B. Anterior talus
C. Anterior fibular head
D. Posterior lateral maleolus
E. Posterior fibular head