Incorporating OMM to Enhance Your Clinical Practice:

Diagnostic and Treatment approach to the extremities

To Shan Li, D.O. Assistant Professor

3/1/14

Lower Extremity

• Hip • Thigh • Knee • Leg • Ankle • Foot

General Considerations

Trauma

• Strain • Sprain • Fracture • Dislocation • Repetitive use • “itis”

Non-Trauma • Infection • Malignancy • Inflammatory • Visceral • Skin • Neurologic

– Referred – Neuropathy

• Vascular

Where’s the osteopathic component?

• It exists in all of the above – Joint mechanics, Posture (Structural) – Autonomic (Neurologic)

• Upper Ext: T5 to T7 • Lower Ext: T10 to L2-3

– Diaphragms (Circulatory/Lymphatic) – Ergonomics, Functional (Behavioral) – Disease states (Metabolic)

What are the essentials of an osteopathic approach?

• Localize the complaint • Know the anatomy

– landmarks – functional anatomy

• Diagnose the underlying cause – Musculoskeletal

• Spasm or myofascial strain – Tender point, Trigger point – Interosseous membrane

– Neurologic • Sympathetics • Chapman point • Nerve impingement

What are the essentials of an osteopathic approach?

• Diagnose the underlying cause – Circulatory/Lymphatic

• Vascular supply and drainage

– Metabolic • Improve state of tissue • Decrease work of the body

Clinical Tips

• Think broadly • Be flexible • Diagnose SD and understand its relevance

– Palpate structures – Assess motions

Hip

• Flexion • Extension • Internal rotation • External rotation • Adduction • Abduction

• 2-3 x body weight with walking

Psoas

• Connects to the hip • Thomas test to check for psoas tightness (can

restrict hip extension)

Hip & Thigh- Some considerations • Inguinal ligament

– Can treat with direct MFR using fingertips into inguinal ligament

• Greater trochanter – Can check for tender point

• Quadriceps • Iliotibial band

– Check for tension and Chapman points

Hamstrings

• Evaluate as part of straight leg raise • Compare left and right

Q-angle of the knee

• Increased Q-angle introduces mechanical strain into the knee

KNEE: Don’t forget to examine the fibular head and its reciprocal

(“see-saw”) motion distally

Foot dorsiflexion Lateral view of Fibula

What is this?: Common fibular nerve

The fibular nerve is behing the fibula head

• Common Fibular (peroneal) nerve – Directly posterior to

fibular head – A posterior fibular head

or fracture may cause foot drop

Tibiofibular Joint

• The fibular head glides anteriorly with pronation (dorsiflexion, eversion and external rotation) of the foot • The fibular head glides posteriorly with supination (plantarflexion, inversion and internal rotation) of the foot

Knee motion • Primary motion is flexion and extension, so

check for restrictions in these motions – Unable to flex knee normally = knee flexion

restriction, or alternatively, knee extension dysfunction (extended knee is also acceptable terminology)

– Unable to extend knee normally = knee extension restriction, or alternatively, knee flexion dysfunction (flexed knee is also acceptable)

• Can test for medial and lateral glide of the patella

Ligaments of the Knee

• Anterior Cruciate ligament • Posterior Cruciate ligament • Medial Collateral ligament • Lateral Collateral ligament • Patella ligament (aka Patella tendon)

Tibia

• Compare the anterior tibial tubercle and how it relates to the center of the patella

• Common tibial dysfunctions are – Internal tibial torsion (tibial tubercle is more

medial relative to patella) – External tibial torsion (tibial tubercle is more

lateral relative to patella)

Ankle • Inversion sprains are common • Check for ankle motion

– Dorsiflexion (if restricted = ankle dorsiflexion restriction or ankle plantarflexion dysfunction)

– Plantarflexion (if restricted = ankle plantarflexion restriction or ankle dorsiflexion dysfunction)

– Inversion (if restricted = ankle inversion restriction or ankle eversion dysfunction)

– Eversion (if restricted = ankle eversion restriction or ankle inversion dysfunction)

Deciding to treat

• Name the somatic dysfunction? • What is its role?

– Primary vs. Secondary

• What model do you have in mind? – What is the intended purpose of treatment

• Direct vs. Indirect • Reassess

Techniques/Regions to consider • Spine (esp. thoracic, lumbar) • Thoracic inlet • Pectoral traction • Ribs & Diaphragm • Pelvis & Sacrum • Limb muscles and joints (hip, knee, ankle,

foot) – ME, MFR, Articulatory, CS

• Interosseous membrane • Pedal Pump