OMM and the Athlete
Upper 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
•
•
•
•
•
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).
– Depends on the clinician, patient and
environment/setting
• Activating Forces - intrinsic and extrinsic.
JOINT PLAY
• Definition: Movement within a synovial joint that is
independent of, and cannot be reproduced by, voluntary
muscle contraction, but essential for maximal pain free
movement of the joint.
• Joint examination: Examination is made for the precise
joint play movements of that joint.
• Joint treatment/manipulation: Movements that restore
joint play.
• Occurs in all synovial joints.
John McM. Mennell, M.D.
• Physiatrist trained at
Cambridge England.
• His father James also a
manual medicine physician.
• They introduced Joint Play
examination & treatment.
• One of founders of
NAAMM.
TYPICAL SYNOVIAL JOINT
JOINT WITH INTRA-ARTICULAR DISC
JOINT DYSFUNCTION
• A specific type of somatic dysfunction
• The loss of joint play movement that
cannot be recovered by voluntary muscle.
• Normal voluntary movements are restricted
and frequently painful.
JOINT PLAY EVALUATION &
THERAPEUTIC MANIPULATION
• Evaluate each play movement and compare
with contralateral side.
• Therapeutic manipulation is the use of a
high velocity, low amplitude thrust to
restore the play movement.
THE “NEVERS” IN JOINT PLAY
EVALUATION
• Normal ligaments are NEVER tender to
palpation.
• You can NEVER palpate a normal joint
capsule.
• You can NEVER palpate fluid in a normal
joint.
• NEVER manipulate a swollen, warm, or
inflamed joint.
10 RULES OF JOINT PLAY
EXAM & TREATMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient must be relaxed.
Therapist must be relaxed. Therapeutic grasp must be painless,
firm, and protective.
One joint mobilized at a time.
One movement in a joint restored at a time.
One aspect of the joint is stabilized and the other aspect moved.
Extent of movement is same as assessed in the same joint on the
opposite side.
No forceful or abnormal movement must ever be used.
The manipulative movement is a sharp thrust, with velocity, to
result in a 1/8th “ gapping or sliding at the joint being treated.
Therapeutic movements occur when all of the “slack” has been
taken up in the joint.
No therapeutic maneuver is done in the presence of joint or bone
inflammation or disease (Heat, redness, swelling, etc.).
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 - Neck
• Thoracic spine
• Ribs
– Structural & functional
• Scapula
• Cervical spine
• Cranium
– OA jt
• Muscle imbalance
Tx Approach Principles - Neck
Tx Approach Principles - UE
•
•
•
•
•
Thoracic spine
Ribs
Scapula
Cervical spine
SC, AC, glenohumeral,
elbow, wrist, hand
Anatomy of the Scapula and Posterior Shoulder
The Quadrangular Space
SCAPULAR ROTATION ON THE THORAX
• Athlete’s arm on your
shoulder
• Fingers under medial
edge of blade
• Both hands move
scapula medially,
laterally, superiorly and
inferiorly
• Athlete breathes through
maneuvers
SCAPULAR ROTATION ON THE THORAX
Shoulder/Arm Circles
Sternoclavicular Joint
STERNOCLAVICULAR JOINT
• Articular capsule & disc.
• Anterior sternoclavicular
ligament.
• Posterior sternoclavicular
ligament.
• Interclavicular ligament.
• Costoclavicular ligament.
Sternoclavicular Joint Diagnosis
Test for Restricted Abduction
• Patient supine on table with
arms resting easily at the side.
• Operator stands at side or head
of table with paired fingers over
the superior aspect of the
medial end of the clavicle.
• The patient is asked to actively
‘shrug the shoulders’ by
bringing the shoulder tip to the
ear bilaterally.
• The operators palpating fingers
follow the movement at the
medial end of the clavicle.
Sternoclavicular Joint Diagnosis
Test for Restricted Abduction
• The normal finding is equal
movement of the medial end of
both clavicles in a downward
direction.
• A positive finding is the failure
of one clavicle to move
downward when compared to
the opposite. It appears to be
held in the original starting
position.
• Note: This test can also be
done with patient sitting.
Sternoclavicular Joint Muscle Energy
Technique Supine
•
•
•
Operator internally rotates the
dysfunctional upper extremity and
carries it into extension off the edge
of the table to the resistant barrier
while monitoring with the opposite
hand at the sternoclavicular region
Patient performs a 3-to 5-second
muscle contraction to lift the arm
toward the ceiling against operator
resistance for 3 to 5 repetitions.
Following each relaxation, the
operator increases the extension of
the upper extremity to a new
resistant barrier and patient again
repeats the effort of lifting the arm
toward the ceiling.
Sternoclavicular Joint Muscle Energy
Technique Sitting
•
•
•
Patient sitting on table or stool.
Operator standing behind patient with
the thenar eminence of one hand in
contact with the superior aspect of the
medial end of the dysfunctional
clavicle and the other hand controlling
the dysfunctional upper extremity at
the elbow
With the elbow at 90 degrees, the
upper extremity is externally rotated
and abducted to approximately
90 degrees with additional abduction
until the resistant barrier is engaged
Sternoclavicular Joint Muscle Energy
Technique Sitting
•
•
Patient performs muscle
contraction to adduct the
upper extremity three to
five times for 3 to 5
second against
resistance offered at the
elbow by the
operator.
After relaxation, operator
engages new barrier.
RESTRICTED ABDUCTION
OF SC JOINT
caudal pressure on clavicle
sweep arm to opposite knee
Sternoclavicular Joint Diagnosis
Test for Restricted Horizontal Flexion
•
•
•
•
•
•
Patient supine on table.
Operator stands at side or head of table
with fingers symmetrically placed on the
anterior aspect of the medial end of
each clavicle
Patient extends the upper extremities in
front of the body by reaching toward the
ceiling
Operator evaluates movement of the
medial end of each clavicle
The normal finding is for each clavicle to
move symmetrically in a posterior
direction as the lateral end of the
clavicle moves anteriorly
A positive finding is for one clavicle not
to move in a posterior direction during
the reaching effort
Sternoclavicular Joint Muscle Energy
Technique Supine
•
•
•
•
Patient supine on table.
Operator stands on side of table
opposite the dysfunctional
sternoclavicular joint.
Operator places one hand over the
medial end of the dysfunctional
clavicle and the caudad hand
grasps the patient’s shoulder girdle
over the posterior aspect of the
scapula
Patient’s hand grasps back of
operator’s neck with an extended
arm
Sternoclavicular Joint Muscle Energy
Technique Supine
•
•
•
Operator engages the
horizontal flexion barrier by
standing more erect and
lifting the dysfunctional
scapula
Patient pulls down upon the
operator’s neck with 3 to 5
second muscle effort for 3 to
5 repetitions while operator
maintains posterior
compression on the anterior
aspect of the medial end of
the dysfunctional clavicle.
Operator engages new
barrier after each of
patient’s muscular
contraction
RESTRICTED HORIZONTAL
FLEXION OF SC JOINT
posterior pressure on clavicle
arm sweeps from horizontal
extension to flexion
Acromioclavicular Joint
ACROMIOCLAVICULAR JOINT
• Superior acromioclavicular
ligament.
• Inferior acromioclavicular
ligament.
• Coracoclavicular ligament.
Acromioclavicular Joint
Test for Restricted Abduction and Adduction
•
•
•
•
Patient sitting with operator standing
behind.
Operator’s medial hand palpates
the superior aspect of the ac joint
monitoring a gapping movement at
the ac joint and the lateral hand
controls the pt’s proximal forearm
and takes pt’s upper extremity to
horizontal flexion of 30 degrees then
adds ADduction and ABduction.
Absence of the gapping movement
is evidence of restriction of
adduction or abduction movement.
Comparison is made with the
opposite side.
Muscle Energy Technique Sitting
Tx: Restricted Abduction
•
•
•
•
•
Patient sitting on table or stool with
operator standing behind.
Operator maintains compressive
force on lateral end of the clavicle,
medial to the ac joint.
Operator’s lateral hand takes
patient’s upper extremity to
horizontal flexion of 30 degrees and
abducts to the barrier
Patient pulls elbow to the side
against resistance offered by the
operator for 3 to 5 seconds and 3 5 repetitions.
Operator engages new abduction
barrier after each muscle effort
Acromioclavicular Joint
Diagnosis: Test for Restricted Internal and
External Rotation
• Patient sitting on table or stool
with operator standing behind.
• Operator’s medial hand
palpates the superior aspect of
the ac joint.
• Operator’s lateral hand moves
the upper extremity into
horizontal flexion to 30 degrees
and abduction to the first barrier
Acromioclavicular Joint
Diagnosis: Test for Restricted Internal and
External Rotation
• Operator introduces
internal rotation and
external rotation while
monitoring mobility of the
ac joint.
• Comparison is made with
the opposite side
Muscle Energy Technique
Tx: Restricted External Rotation
• Operator’s medial hand stabilizes
the lateral aspect of the clavicle
and monitors the ac joint.
• Operator takes upper extremity to
30 degrees of horizontal flexion
and abduction to 90 degrees.
• External rotational barrier is
engaged with the operator’s
lateral hand grasping the
patient’s wrist and places forearm
to patient’s forearm
Muscle Energy Technique
Tx: Restricted External Rotation
• Patient provides muscle
contraction for 3 to 5
seconds and 3 - 5
repetitions against
resistance of external
rotation.
• Operator engages new
barrier after each muscle
contraction.
Muscle Energy Technique
Tx: Restricted Internal Rotation
• Operator’s medial hand stabilizes
the lateral aspect of the clavicle and
monitors the ac joint.
• Operator takes upper extremity to
30 degrees of horizontal flexion and
abduction to 90 degrees.
• Operator engages internal rotation
barrier by threading lateral forearm
under patient’s elbow and grasping
distal forearm
Muscle Energy Technique
Tx: Restricted Internal Rotation
• Patient provides muscle
contraction for 3 to 5
seconds and 3 - 5
repetitions against
resistance of internal
rotation.
• Operator engages new
barrier after each muscle
contraction.
Glenohumeral Joint
GLENOHUMERAL JOINT
SHOULDER JOINT BURSAE
•
•
•
•
•
Subdeltoid bursa.
Subacromial bursa.
Deltoid.
Supraspinatus.
Acromion &
coracoacromial ligament.
GLENOHUMERAL JOINT
• Articular capsule.
• Glenoidal labrum.
• Transverse humeral
ligament.
• Biceps tendon.
MUSCULAR SHOULDER
GIRDLE STABILIZATION
Serratus anterior
Pectoralis minor.
MUSCULAR SHOULDER
GIRDLE STABILIZATION
• Levator scapulae.
• Rhomboid.
• Trapezius.
ROTATOR CUFF MUSCLES
ARM MUSCLES
GLENOHUMERAL JOINT
Green Technique for the Glenoidal
Labrum
7 Step Spencer Technique
GREEN GLENOIDAL LABRUM
TECHNIQUE
• Principle is to restore
caudad range of
humeral head to
glenoidal labrum
• First stage of
management of “Frozen
shoulder”
GREEN GLENOIDAL LABRUM
TECHNIQUE
Rotation of distracted
humerus.
Circumduction of humeral
head on glenoidal labrum.
Glenohumeral Joint
MET
Neutral flexion
Neutral extension
Neutral external rotation
Neutral internal rotation
Neutral internal rotation
Adduction
Abduction
Horizontal Flexion
Horizontal Extension
Horizontal Internal Rotation
Horizontal External Rotation
Elbow Region MET
ELBOW JOINT STABILIZATION
 Articular capsule.
 Ulnar collateral
ligament.
 Radial collateral
ligament.
ELBOW JOINT STABILIZATION
Dx & Rx ELBOW REGION RESTRICTED
EXTENSION
Engage extension barrier.
Resist flexion efforts.
Post-isometric relaxation of biceps contraction.
Dx & Rx ELBOW REGION RESTRICTED
FLEXION
Flex elbow
Resist extension efforts.
PROXIMAL RADIOULNAR JOINT
A pivotal synovial joint between the radial
head and the radial notch of the ulna.
Joint stabilization:
Annular ligament.
Quadrate ligament.
RADIOULNAR INTEROSSEOUS
MEMBRANE
Dx RESTRICTED HEAD OF RADIUS
Supinated forearms together.
Extend elbows.
Observe symmetry of reaction at elbows.
Dx RESTRICTED HEAD OF RADIUS
Palpate for symmetry.
Pronate/supinate radius.
Position: posterior radial head > Motion Restriction: supination
Position: anterior radial head > Motion Restriction: pronation
Dx ELBOW REGION
SUPINATION/PRONATION
Elbow flexed, thumb vertical.
Dx ELBOW REGION
SUPINATION/PRONATION
Forearm supination (external rotation).
Dx ELBOW REGION
SUPINATION/PRONATION
Forearm pronation (internal rotation)
Rx ELBOW REGION
SUPINATION/PRONATION
Restricted supination.
Restricted pronation.
MET Rx RESTRICTED HEAD OF RADIUS
Resist pronation.
Resist elbow flexion.
HUMEROULNAR JOINT
• Mobilization without
impulse (articulatory)
technique.
– Stabilize hand against
chest wall.
– Grasp ulna and provide
caudal distraction.
– Mobilize medially and
laterally as the elbow is
taken into extension.
HUMEROULNAR JOINT
Lateral (radial) deviation.
Medial (ulnar) deviation.
Wrist & Hand Injuries
DISTAL RADIOULNAR JOINT
• Pivots with the proximal
radioulnar joint in
forearm supination and
pronation.
• Joint stabilization:
– Articular cartilage.
– Articular capsule.
– Not a synovial joint.
RADIOCARPAL JOINT
• A condyloid synovial
joint between distal
radius and the proximal
row of the carpal bones,
scaphoid, lunate, and
triquetral bones.
INTRACARPAL JOINTS
• Proximal row:
Scaphoid, lunate &
triquetrum. The pisiform
articulates with the
triquetrum.
• Distal row: Trapezium,
trapezoid, capitate &
hamate.
• Midcarpal Joint:
Between the proximal
and distal rows of the
carpal bones. (Line A)
CARPOMETACARPAL JOINTS
• Saddle type synovial joint between first metacarpal
and trapezium.
• Gliding synovial joints between second, third,
fourth,and fifth metacarpals and distal row of carpals.
• Intermetacarpal joints are gliding synovial joints
between metacarpal bases.
INTERPHALANGEAL JOINTS
MET Dx WRIST AND HAND
Palmar flexion.
Dorsal flexion.
MET Rx WRIST AND HAND
Restricted palmar flexion.
Restricted dorsal flexion.
MET Dx WRIST AND HAND
Pronated ulnar deviation.
Pronated radial deviation.
MET Rx WRIST AND HAND
Restricted pronated ulnar
deviation.
Restricted pronated radial
deviation.
MET Dx WRIST AND HAND
Supinated ulnar deviation.
Supinated radial deviation.
MET Rx WRIST AND HAND
Restricted supinated ulnar
deviation.
Restricted supinated radial
deviation.
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