OMM and the Athlete
Lower Body Workshop
Jake Rowan DO
Dept of OMM
MSUCOM
Goals/Objectives
• Review OPP and how they apply to sports
medicine
• Discuss functional biomechanics
• Review palpatory dx
• Discuss OMM tx approach
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.
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
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
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
MODELS OF MANUAL MEDICINE
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Biomechanical model.
Neurologic model.
Respiratory-circulatory model.
Bioenergy model.
Organ system model.
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.
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
Tx Approach Principles
• Motor Control
– Balance
– Core stability
– Stretch before
strengthening
Tx Approach Principles - LBP
• Pelvis
– Pubes
– Ilium
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Lumbar spine
Lower Thoracic
Sacrum
Core stability
Lumbar Spine and Sacrum
Muscle Imbalance
The Pelvic Clock
Three dimensional evaluation of function
of the lumbar spine and pelvis.
Used diagnostically and therapeutically.
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
PROPRIOCEPTIVE BALANCE
Assessment & Treatment
PROPRIOCEPTIVE BALANCE
Assessment and Treatment
Tx Approach Principles - LE
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Pelvis
Lumbar spine
Lower T-spine
Sacrum
Hip
Knee
Ankle
Foot
Toes
The Pelvis
The Pelvis
Lower Extremity
ILIOPSOAS & RECTUS FEMORIS
Gluteal Muscles
Hip Capsule
Assessment of Hip Capsule Pattern
• Circumduct in a
counterclockwise
direction
– internally
– FADIR
• Circumduct in a
clockwise direction
– externally
– FABER
Posterior Hip Capsule
Stretch
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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
Acetabular Labrum
Mobilization Technique
• Internal & external
hip rotation.
• Lateral to medial
impactiondistraction of
femoral head.
• Anterior to
posterior
impactiondistraction femoral
head.
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
Muscle Energy Technique of the Hips &
Thighs
MET Rx for Hips & Thighs
• Motion Tested
– ABduction
• Muscles Tested
– ADDuctors
MET Rx for Hips & Thighs
• Motion Tested
– ADDuction
• Muscles Tested
– Abductors –
Gluteus medius &
minimis
MET Rx for Hips & Thighs
• Motion Tested
– ADDuction
• Muscles Tested
– ABductors – Tensor
Fascia Lata
MET Rx for Hips & Thighs
• Motion Tested
– Internal rotation with hips in neutral
• Muscles Tested
– External rotators – obturators,
gemellus, quadratus femoris, piriformis
MET Rx for Hips & Thighs
• Motion Tested
– Internal rotation
• Muscles Tested
– External rotators piriformis
MET Rx for Hips & Thighs
• Motion Tested
– External rotation with hip in neutral
• Muscles Tested
– Internal rotators – gluteus minimus &
medius, tensor fascia lata
MET Rx for Hips & Thighs
• Motion Tested
– External rotation –
hip flexed 90%
• Muscles Tested
– Internal Rotators –
Gluteus medius &
minimus
MET Rx for Hips & Thighs
• Motion Tested
– Hip flexion
(straight leg
raising)
• Muscles Tested
– Hip Extensors –
hamstrings;
gluteus max &
adductor magnus
when hip flexed
MET Rx for Hips & Thighs
• Motion Tested
– Hip extension
• Muscles Tested
– Hip flexors –
iliopsoas, rectus
femoris
– Modified Thomas
Position
– Treat L-spine first
MET Rx for Hips & Thighs
• Motion Tested
– Knee flexion
• Muscles Tested
– Quadriceps group
MET Rx for Hips & Thighs
• Preferred Prone Position for Tx of
iliopsoas and Rectus Femoris
MET Rx for Hips & Thighs
• Tx for rectus femoris
• Tx for iliopsoas
The Knee and Proximal Leg
THIGH MUSCLES
KNEE JOINT
KNEE JOINT
• Joint stabilization:
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Medial meniscus.
Lateral meniscus.
Articular capsule.
Medial collateral
ligament.
Lateral collateral
ligament.
Posterior ligaments.
Oblique popliteal
ligaments.
Anterior cruciate
ligament.
Posterior cruciate
ligament.
KNEE JOINT BURSA
• Subcutaneous
prepatellar bursa.
• Suprapatellar bursa.
• Deep infrapatellar
bursa.
• Subcutaneous
infrapatellar bursa.
• Infrapatellar fat pad.
Lower Extremity
CALF MUSCLES
KNEE: MOBILIZATION
WITHOUT IMPULSE
Thumbs on medial
meniscus.
Gap medial compartment
and extend knee.
KNEE: MOBILIZATION
WITHOUT IMPULSE
Thumbs on medial or
lateral meniscus.
Circumduct and extend
knee.
KNEE: MENISCAL TRACKING
Rotation into extension.
KNEE: EXTENSION
COMPRESSION TEST
• Restriction of extension
and pain provocation
indicate lack of terminal
external torsion of the
tibia and/or meniscal
injury.
MET KNEE: Dx OF INTERNAL AND EXTERNAL
ROTATION
• External rotation of the
tibia
• Internal rotation of the
tibia
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
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
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.
Lower Extremity
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
MET Tx for Posterior Fibular Head
• Dx
– 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
MET Tx for Anterior Fibular Head
• Dx
– 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
HVLA for Posterior Fibular Head
• Dx
– Posterior fibular head
• Motion Restriction
– Anterior glide
HVLA for Posterior Fibular
Head
• Dx
– 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
HVLA of Anterior Fibular Head
• Dx
– Anterior fibular head
• Motion restriction
– Posterior glide
• Patient supine
• Operator internally
rotates leg 30%
– thenar eminence is
placed over proximal
anterior fibular shaft
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
DISTAL TIBIOFIBULAR
ARTICULATION
Dx: Anteroposterior glide
of distal tibiofibular joint.
Related to
dysfunction at
proximal tibiofibular joint.
RESTRICTED ANTERIOR
DISTAL TIB-FIB JOINT
Thumb on anterior aspect
of distal fibula.
Compressive posterior thrust
through left thumb.
RESTRICTED POSTERIOR
DISTAL TIB-FIB JOINT
Thumb on posterior
aspect of distal fibula.
Compressive anterior thrust
through left thumb.
Dx: MORTISE JOINT
DORSIFLEXION RESTRCTION
Thumbs on neck
of talus.
Hands introduce
dorsiflexion of
talus at mortise
joint.
Rx MORTISE JOINT
DORSIFLEXION RESTRICTION
Left hand web on neck of talus.
Resist plantar flexion.
Internal vs External
Rotation Restrictions
Restricted internal/medial
rotation.
Restricted external/lateral
rotation.
Muscle energy activating force
Dx INTERTARSAL JOINTS
Rx INTERTARSAL JOINTS
Thumb under middle
cuneiform.
Resist forefoot dorsiflexion.
Dx CALCANEOCUBOID JOINT
Test internalexternal
rotation of
cuboid.
Palpate
tenderness &
prominence of
cuboid
tubercle.
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
J-STROKE FOR
CALCANEOCUBOID JOINT
Control forefoot and
thumbs on cuboid.
Throw foot to floor.
Review
• OPP Review
• Functional
Biomechanics and
the use of OMT in
treating the athlete
• Questions ?
Osteopathic
Medicine
The science of medicine
The art of caring
The power of touch