2 Osteopathic Static Musculoskeletal ExaminationThe osteopath ic s tructural examinat ion has both stat ic and dynamic components. The phys ic ian wi l l normal ly use stat ic examinat ion as a method to discern obv ious s tructura l

asymmetr ies of osseous and myofasc ia l or ig in and ext rapolate f rom that in format ion to determine et io log ies that af fect funct ion. Therefore, on v isual examinat ion alone, a

phys ic ian can postu late what the subsequent speci f ic dynamic examinat ion wi l l e l ic i t .Observance of gai t may preface the stat ic examinat ion, as the pat ient can be observed

walk ing into the examinat ion room. A number of condi t ions produce obv ious anta lg ic and asymmetr ic tendencies, such as osteoarthr i t is o f the hips and knee, degenerat ive

discogenic spondylos is o f the lumbar sp ine, and acute problems, inc luding st ra ins and spra ins. The visual observance of gai t and the associated stat ic examinat ion (which may be

performed e i ther before or a f ter ga i t eva luat ion) wi l l help the physic ian understand the pat ient 's medica l and psychological s ta tus and a lso help avoid por t ions of the examinat ion

that may be painfu l or in other ways detr imenta l to the pat ient . These types of scrut iny af fect the pat ient less than dynamic examinat ions wi th physica l contact and therefore are

less l ikely to cause pain or damage the pat ient .As an example, a pat ient wi th the asymmetr ic f ind ings i l lust ra ted in Figure 2.1 (see p. 10 )

could be reasonably expected to exhib i t mot ion restr ic t ion and mot ion asymmetry in the thoracic and lumbar sp ine wi th restr ic t ions in lumbar s ide bending to the lef t and

midthorac ic s ide bending to the r ight . These f indings would a lso cause the physic ian to be concerned with r ight and lef t la t iss imus dors i , psoas, and erector sp inae tension

asymmetr ies af fect ing range of mot ion of the hip, pe lv is , and shoulder gi rd le ( Fig. 2 .1 ) .Therefore, the physic ian should observe the pat ient in poster ior, anter ior , and la teral

(sagi t ta l and coronal plane) v iews to develop the most complete understanding of the pat ient 's physica l makeup before performing the remainder o f the examinat ion. These v iews

may be star ted at the feet or at the head. We genera l ly recommend start ing at the feet , as that is the gravi ta t ional contact po int .

The stat ic musculoskeleta l (st ructural ) examinat ion uses super f ic ia l anatomic landmarks that he lp the phys ic ian “see the forest for the t rees. ” Sometimes sl ight asymmetr ies are

missed, but a l ign ing two or three landmarks makes the asymmetry obvious. Some anatomic landmarks are impor tant for f ind ing spina l vertebral levels. The sp ine of the scapula is

typica l ly a t the leve l of T3, and the in fer ior angle of the scapula is typica l ly at the leve l of the sp inous process of T7 and transverse processes of T8 ( Fig. 2 .2 ) . Some landmarks

assist in locat ing a more cl in ical ly impor tant landmark. The masto id process and angle of the mandible are commonly used to help the nov ice palpate the C1 transverse process ( Fig.

2.3 ) . Other landmarks, such as the coracoid process, b ic ip i ta l groove of the humerus, and greater and lesser tuberos i t ies of the humerus, he lp d is t inguish one tendon from another,

hence d i f ferent ia te between a rotator cuf f syndrome and another somat ic problem ( Fig. 2.4 ) . The most commonly used landmarks tend to be the ones that determine hor izonta l

symmetry or asymmetry (Figs. 2.5 , 2.6 , 2.7 , 2.8 , 2.9 ) . Landmarks such as the t ib ia l tuberos i t ies, anter ior super ior i l iac sp ines, poster ior super ior i l iac sp ines, i l iac crests ,

n ipp les, shoulders at the acromioclav icular jo int , ear lobes, and eyes as hor izonta l leve ls plane are of ten used for th is purpose.

Asymmetry is one of the three measurable components of somat ic dysfunct ion ( tenderness or sens i t iv i ty be ing more subject ive) and therefore is one of the bas ic s teps to develop the

diagnosis for somat ic dysfunct ion.

Figure 2.7. Anterior view points of reference.

Figure 2.8. Posterior view points of reference.

Figure 2.9. Lateral view points of reference and midgravity line.