OFFICIAL PPOM2 OMM Practical 1

dx oa (cervical spine)

OA joint = “opposite always” (deep sulcus = side of rotation so SB will be opposite of that)

• for examination: translate head from left - right and right to left with head in neutral position

  dx: determine translation (gives S/R) check with slight flexion/extension

  ex: if motion is greater from L to R, freedom is side-bent L and rotated right (restriction in right side-bending), if restriction of lateral translation is MORE signficant in flexion, but goes away in extension, then the segment is extended

dx aa (cervical spine)

AA joint = rotation only

• you must be standing

  1. ensure pt nods head forward to lock out OA joint

  2. flex pt next to approx 45 degrees until locking occurs below the AA joint in the rest of the cervical spine

  3. slowly rotate head from midline to left and then midline to right

  if head rotates more freely to the right the diagnosis is AA Rr

dx c2-c7

follows type 2-like (rotation & side bending = same)

check for flexion/extension

cervical landmarks:

• C2 - mandible

• C3 - hyoid

• C4 - superior aspect of thyroid

• C5 - thyroid cartilage

• C6 - cricoid ring

• C7 - vertebral prominence

hvla of cervical spine (c2-c7)

Ra

stand on SAME side of dysfunctional rotation component

MCP of index finger POSTERIOR to articular pillar of dysfunctional segment

**must lock out

can slightly flex to point and also side bend towards to initiate lockout

rotational thrust on exhale

met of cervical spine (c2-c7)

F/E Sa Ra

V-hold: thumb and index fingers to monitor articular pillae

pt is asked to rotate into freedom with 10% strength against counterforce

cs of anterior cervical spine

C1 = Ra (TP or mandible)

C2-C6 = FSaRa (posterior to SCM)

C7 = FStRa (posterior/superior surface of clavicle)

C8 = FSara (medial end of clavicle)

dx of thoracic spine (t1-4 or t5-12)

• screen (TART changes)

• T1-T3 = TP is same level as SP

• T4-T6 = TP ½ level up

• T7-T10 = TP whole step up

• T11 = TP ½ level up

• T12 = TP same level

• thumb rolling superior = flexion, inferior = extension

hvla of thoracic spine

• type 1 SD = neutral, elbow down

• type 2 SD = f/e, elbow up

• stand on opposite side of rotation

• arms opposite over adjacent

• thenar eminence on TP, inhale, thrust on exhale

met of thoracic spine

osteopathic hug or pt arm on neck

monitor TP

t1-4 = move head to engage in barrier

t5-12 = move body to engage in barrier

cs of anterior thoracic

Patient is supine for T1-6

• T1 = F (episternal notch)

• T2 = F (angle of louis)

• T3-6 = F to dysfunctional level

Patient is seated for T7-9

• FStRa (slouch to F, move leg out to SB pt, pt wraps arms around leg to R)

• use the OPPOSITE leg on table

  • T7 = ¼ from xiphoid process

  • T8 = halfway xiphoid and umbilicus

  • T9 = ¼ from umbilicus

Patient is supine for T10-12

• FStRa (stand on same side, flex legs, knees and ankles to me)

  • T10 = ¼ from umbilicus to pubic symphysis

  • T11 = halfway umbilicus and pubic symphysis

  • T12 = anterior superior aspect of iliac crest

dx of rib cage

• TART changes (i.e. red reflex, skin drag)

• spring test while pt is prone

  • focus on side with + spring test

• assess breathing

  • inhalation dysfunction = likes to stay inhaled (will have trouble moving caudad in exhalation)

  • exhalation dysfunction = likes to stay exhaled (will have trouble moving cephalad in inhalation)

• BITE = inhale (bottom rib = key rib); exhale (top rib = key rib)

• side w/ less motion = dysfunctional side, name for freedom

• rib 1-5 = pump handle

• rib 6-10 = bucket handle

hvla ribs 1, 2 exhalation sd

RaSt

• pt seated

• physcian leg opposite of SD to stabilize

• one hand on pt head, forearm against head to stabilize

• mcp of index finger on posterior aspect of dysfunctional rib

• thrust directed down and slightly diagonally (as if you were aiming at ur opposite knee)

hvla ribs 3-10

pt supine, arms opposite over adjacent

stand on OPPOSITE side of dysfunctional rib

thenar eminence on ___ angle of rib angle to push rib back

• inferior aspect of rib angle for exhalation sd → ribs stuck down

• superior aspect of rib angle for inhalation sd → ribs stuck up

(basically thoracic HVLA other than hand placement)

hvla ribs 11, 12 exhalation sd

exhalation sd

Sa = legs away from dysfunctional rib (towards me)

stand OPPOSITE of dysfunctional rib

active hand: hand pulls UP on ASIS to push rib back down

other hand: hypothenar eminence on inferior aspect of rib ABOVE dysfunctional rib to stabilize rib

ribs stuck UP

hvla ribs 11, 12 inhalation sd

inhalation sd

St = legs away from me

standing OPPOSITE side of dysfunctional rib

hypothenar eminence on inferior aspect of dysfunctional rib - to push rib back UP

(other hand stabilizes on ASIS)

ribs stuck DOWN

met of rib inhalation sd

Inhalation

push down on exhale. repeat 5-7 times

• rib 1 = FStRa

• ribs 2-6 = FSt

• ribs 7-10 = St

• ribs 11-12 = on the dysfunctional rib, stabilize hip, push up on rib on exhale, pt legs position away from you

met of rib exhalation sd

Exhalation

stand on same side

make sure to hook index and middle finger on rib, pulling inferior and lateral

• woe is me (1-2) = scalenes

  • pt head is rotated away for this one

  • have pt push head up

• wave hi (3-5) = pec minor

  • pt elbow should be above their shoulder

  • apply pressure to the elbow area

  • have pt push elbow up

• shut the gate (6-8) = serratus anterior

  • have pt push elbow up

• outstretched arm (9-10) = latissimus dorsi

  • have pt push arm down (against your hip/leg)

• 11-12 = on the inferior aspect of rib above, pull ASIS down, have pt hike hip up towards ear, pt legs position towards you

cs anterior rib

anterior = exhalation sd

AR 1,2 = FStRt

AR 3-10 = FStRt

• ASS! - anterior same side -> pt mermaid legs same side as TP

• Arm back = Rt

• Physician moves leg out = St

• physician leg on opposite side

cs posterior rib

posterior = inhalation sd

PR 1 = ESaRt

• PIE is OP

  • posterior

  • I = 1

  • E = ESaRt

  • OP = use opposite leg for stabilizing

PR 2-10 = FSaRa

• pt mermaid legs opposite of TP

• use same side leg

• Arm back = Ra

• Physician moves leg out = Sa

dx of lumbar spine

• dx can be done seated

• sphinx = testing for extension

• child’s pose = testing for flexion

• landmarks = iliac crest btwn L4/L5

• Type 1 = opposite N S R

• Type 2 = same side F/E R S

hvla of lumbar spine

• side of rotation faces DOWN (on table); pt faces physician

• localize SP of dysfunction AND level below (monitor throughout setup)

• flex pt until dysfunctional segment is in neutral

  • if type I = keep neutral

  • if type 2 = adjust for F/E by moving legs

• arm closest to table is pulled TOWARD physician to engage rotation

• pt grabs their own elbows; physician’s cephalad forearm loops through and braces ribcage (switch monitoring hand prn)

• caudad arm placed on greater trochanter

• if type I → keep neutral (no need to adjust)

• if type II extension SD → flex legs further until felt at level of dysfunction

• if type II flexion SD → tell pt to straighten bottom leg

• drop top leg down

• THRUST

  • type 1

    • arms come APART horizontally (caudad arm moves down; cephalad arm moves up to resist torso moving down)

    • arms come apart perpendicularly (caudad arm moves pelvis towards you; cephalad arm moves slighly forward/kind of away from you)

  • type 2

    • arms come TOGETHER horizontally

    • arms come apart perpendicularly

    • like ur punching yourself

met of lumbar spine

osteopathic hug or pt arm on neck

monitor TP

(same as thoracic sitting MET)

cs anterior lumbar

• 1, 5 same side

• 2, 3, 4 across the floor (opposite side)

AL 1 = FRaSt (medial to ASIS) → knees and ankles to me

AL 2-4 = FSaRt (my little igloo) → knees and ankles to me

• AL 2 = medial to AIIS

• AL 3 = lateral to AIIS

• AL 4 = inferior to AIIS

AL 5 = FSaRa (lateral to pubic symphysis) → knees to me, ankles AWAY

cs QL

QL = EXTEND, ABDUCT, EXTERNALLY ROTATE HIP

• stand on same side of TP

• attachments = inferior aspect of 12th rib, lateral aspect of lumbar TPs, superior aspect of iliac crest

Sacral diagnosis steps

- verbally indicate landmarks as you diagnose (e.g., “left sacral base posterior”, “left ILA posterior”)

1. Seated flexion test

   1. Place thumbs on inferior aspect of PSIS

      1. Positive for side that moves first/forward

2. Spring or sphinx test

   1. + spring = extension

   2. - spring = flexion

3. Identify deep sulcus

   1. Locate PSIS and roll your thumbs so they’re more medial and superior

4. Identify posterior ILA

   1. Palpate down sacral bone until you feel the ledge and find the points on both ends

met forward sacral torsion

1. Pt’s side of axis faces DOWN

2. Monitor sacral sulcus (slightly medial to PSIS, hook thumbs medial to help locate it)

3. Flex hips and knees of pt towards you until motion is felt

4. Pt turns away and hugs table

5. Drop pt knees off table

6. Engage in barrier by pushing pt legs down while continuing to monitor + passive stretch

met backward sacral torsion

1. Pt side of axis faces DOWN

2. Monitor sulcus

3. Flex hips and knees until motion is felt

4. Straight bottom leg and hook top leg over

5. Grab pt shoulder to rotate them onto their back

6. Drop top leg off table, but keep it parallel to the floor. 

7. Push top leg DOWN and pt resists by move leg UP + passive stretch

met unilateral sacral flexion

Pt prone

Stand on opposite side

Walk fingers/palpate down to ILA

ABduct leg and int rot side of dysfunction

Hypothenar on SD ILA, cover sacrum, place cephalad hand on top

Push down on inhale for ILA, as they exhale maintain pressure on SD ILA (push on inhale, resist exhale)

5-7 breaths

Test both sacral bases for reassessment

met unilateral sacral extension

Pt prone, physician stands on opposite side

Hand monitor PSIS and sacral bases of side of dysfunction

Abduct and int rot leg of SD

Place hypothenar on sacral base of side of dysfunction (points caudad), other hand on top (points cephalad)

Ask pt to Sphinx pose

Resist on inhale and follow on exhale for 5-7 times

Reassess sulci

met bilateral sacral flexion

Pt prone

Hypothenar and thenar on BOTH ILAs

ABduct and int rot BOTH legs

Push on inhale and resist exhale 5-7 times

Reassess sacral bases and ILA and spring test

met bilateral sacral extension

Pt sphinx pose

Locate sacral bases with two fingers of one hand. Other hand covers the two fingers.

Optional: loose pack the legs

Resist on inhale and follow through on exhale 7-10 times.

Reassess.

dx pelvis/innominate

standing flexion test (+ is side where thumb moves first)

pt reseats pelvis (observe anterior and posterior)

• asis compression test (+ on side with more resistance)

• locate landmarks (asis, pubic tubercles, medial malleoli. psis)

naming is based off of side of + standing flexion test

use the weird longhorn gang sign to help in naming dx (thumb is psis, index is asis, pinky is pubic tubercle)

hvla of anteriorly rotated innominate

1. Patient lies dysfunctional side up

2. Monitor medial to PSIS and flex both hips and knees up until motion is felt

3. Extends bottom leg

4. Grasp the patient’s arm that is in contact with the table and rotate their torso away from table until motion is felt

5. Drop upper leg off the table and held between the physician’s knees

6. With the patient’s arms crossed, pass the cephalad hand through the patient’s arms and stabilize caudad (thrusting) arm behind greater trochanter

7. Check lockout

8. Instruct patient to inhale deeply and exhale fully. At the end of exhalation, exert a quick, rotational, slightly downwards thrust through the iliac crest through the patient’s top leg. Greater thrust with arm on trochanter 

9. Reassess

hvla of posteriorly rotated innominate

1. Patient lies on nondysfunctional side with the posteriorly rotated innominate facing up

2. Monitor medial to PSIS and flex both hips and knees up until motion is felt at monitoring hand

3. Patient straightens bottom leg and hooks foot of top leg over the popliteal fossa 

4. Grab pt arm closest to table  and bring that arm towards you till motion is felt at the monitoring hand over the SI joint

5. Pt cross arms, weave your hand through to monitor SI joint. Thrusting arm on posterior iliac crest. 

6. Maintain sufficient rotation localized to level of the somatic dysfunction

7. CHECK FOR LOCK OUT.

8. Instruct patient to inhale deeply and exhale fully. At the end of exhalation, exert a quick, rotational thrust through the dysfunctional ilium in an anterior superior direction (LIKE YOU’RE PUNCHING/HUGGING YOURSELF)

9. Reassess

hvla of superior innominate shear

Abd IR

1. Grasp the tibia and fibula above the ankle on the side of the innominate dysfunction

2. Abduct and internally rotate the hip and leg until movement is felt at hip

3. Leaning back gently to provide an axial traction and instruct the patient to inhale and exhale. Provide more traction with each exhale

4. Repeat this 5-7 times

5. On the last exhalation tug on the leg

6. Reassess

hvla of inferior innominate shear

1. Pt lies with dys side up

2. Standing in front of the patient, monitoring the lumbosacral junction

3. Flex the legs and knees until motion at the lumbosacral junction

4. Induce rotation towards you by pulling pt’s arm

5. Extend the bottom leg and place the foot of top leg over the popliteal space of other leg

6. Tell pt to box their arms. Stabilize the trunk while monitoring the sacroiliac joint on the side of the dysfunction

7. Firmly contact the inferior aspect of the ischial tuberosity with the caudad forearm

8. Provide a cephalic thrust through the ischial tuberosity parallel to the table toward pts head (basically straight up to the pt’s head)

9. Reassess

met anteriorly rotated innominate

1. Pt is supine.

2. Sit on edge of table.

3. Pt’s ankle (side of dysfunction) is placed against your shoulder.

4. Hold onto thigh above knee.

5. Monitor PSIS on dysfunctional side (not shown in image)

6. Flex leg up until motion is felt at PSIS (this is the barrier)

   1. Pt resists by pushing leg down against your shoulder

7. Flex leg further

   1. New barrier is when movement is felt at PSIS again

8. Repeat 3-5 times + passive stretch

9. reassess (reseat pelvis right before), can look at ASIS and possible compression test

met posteriorly rotated innominate

1. Pt is supine.

2. Raise table as needed.

3. Drop leg (ischial tuberosity of dysfunctional side) off table. Instruct pt to hold onto edge of table with opposite hand. PT FOOT SHOULD NOT TOUCH FLOOR

4. Hand on opposite ASIS to stabilize.

5. Push leg DOWN (hand above knee)

   1. Pt resists by pushing leg back up

6. Repeat 3-5 times + passive stretch

met superior innominate shear

Abd IR

1. Pt is supine.

2. One hand holds heel and the other cups the bottom of the foot of side of dysfunction.

3. ABduct leg until hip is loose packed (feels loose) + internally rotate leg. Add traction by pulling leg toward yourself.

4. “Bring your foot towards your shoulder without bending knee as you inhale”

   1. Traction is maintained during inhalation. (You lean back to keep the traction)

   2. Traction is ADDED at end of each exhale to reach new barrier

5. Articulatory component: thrust at the end of the last exhalation.

   1. Give a nice tug as pt coughs “on your final exhale cough”

   2. Respiratory assist method so NO passive stretch

met inferior innominate shear

1. Pt is prone.

2. Pt at edge of table, leg (on side of dysfunction) drops off table with knee bent (rests on your thigh)

3. Monitor SI joint until you get pt into position THEN move hand to monitor IT.

4. Monitor SI until movement is felt at joint, then switch hand to IT

5. Hand pushes ischial tuberosity UP

   1. Ischial tuberosity is pushed further up at the end of each exhale to reach new barrier.

   2. As they inhale, I’m resisting, as they exhale, I’m applying force to pt head for 3-5 seconds

   3. “Inhale deeply and exhale forcefully”

6. Internal rotation of hip is added by moving knee slightly under table.

met innominate inflare

1. Pt is supine. 

2. Leg (on same side as inflare) is crossed over the other knee.

3. Can stand on either side of patient. One hand on bent knee and the other on opposite ASIS

   1. Hand on opposite ASIS to stabilize or monitor ASIS on side of dysfunction.

4. Engage in barrier by pushing knee OUT (toward table)

   1. Pt resists by pushing knee in against your hand. OR BRING THEIR KNEE INWARDS

5. Leg is pushed out further each time to engage new barrier.

6. Repeat 3-5 times + passive stretch

met innominate outflare

1. Pt is supine.

2. Leg (on same side as outflare) is crossed over.

3. Can stand on OPPOSITE side (can stand on same but set up would be harder). Reach out and hold knee.

   1. Hand on opposite ASIS to stabilize (not pictured) or monitor PSIS on side of dysfunction.

4. Engage in barrier by pushing knee IN

   1. Pt resists by pushing knee OUT against your hand

5. Leg is pushed in further each time to engage new barrier.

6. Repeat 3-5 times + passive stretch

met superior pubic shear

1. Same set up as posterior innominate rotation MET EXCEPT:

   1. Ischial tuberosity stays on table (localizes to pubic tubercle)

2. Pt is supine.

3. Hand on opposite ASIS to stabilize.

4. Ischial tuberosity (on side of dysfunction) ON table 

5. Push leg DOWN (hand above knee)

   1. Pt resists by pushing leg back up and slightly medially (as if they’re trying to get back onto the table)

6. Repeat 3-5 times + passive stretch

7. Stand with your hip against pt’s hip to stabilize.

met inferior pubic shear

1. Pt is supine. You stand on opposite side.

2. Monitor PSIS on dysfunctional side.

3. Flex pt’s leg up until motion is felt at PSIS (this is the barrier)

4. Pt resists by pushing up to ceiling

5. Flex leg further

6. New barrier is when movement is felt at PSIS again

7. Repeat 3-5 times + passive stretch

met pubic compression

1. Pt is supine.

2. Hips are flexed at 45 and knees at 90

3. Make sure pts ankles are touching!

4. Push knees apart until you feel resistance.

5. Pt pushes knees back together (toward freedom)

6. Start with fist between knees, then forearm; gradually increasing distance between knees

   1. Can do with palm, then fist, then additional hand for length IF YOU FIT FOREARM BETWEEN LEGS.

met pubic gapping

1. Pt is supine.

2. Other knee against your abdomen

3. Make sure pts ankles are touching

4. Push knees together (into barrier)

5. Pt pushes knees apart (into freedom)

6. Distance between knees is decreased each time

cs of anterior pelvic points

cs iliacus

F ER (hips)

1. Pt supine

2. Stand on same side of Tender pt which is located ⅓ from ASIS to midline (straight line across)

3. Cross ankles opposite over adjacent 

4. Flex pt hip/knees bilaterally and rest legs on your thigh (FROGGY LEGS)

5. Finetune with further flexion and external rotation.

cs psoas

F St er (hips)

1. Pt supine

2. Stand on same side of tender pt

3. Tender pt is ⅔ distance from ASIS to midline (straight line across)

4. Cross pt ankles (opposite over adjacent)

5. Flex pt hips/knees bilaterally and rest legs on your thigh

6. Bring knees towards me

   1. add slight external rotation and pull knees towards tender pt slightly side bend lumbar spine

7. Fine tune with more or less hip flexion, side bend and rotation

cs low ilium

F

1. Use iliac crest to find ASIS, then move to AIIS.

2. Follow from AIIS down inguinal ligament until you feel a bulb OR feel pubic tubercle and go ½ in lateral and ½ in superior

3. Physician stands on the same side of the tender point

4. Markedly flex patient’s hip 

5. Fine tune with more/less hip flexion

cs inguinal

F ADduct Internally Rotate

1. Tender point is located on the lateral aspect of the pubic tubercle; associated with the attachment of the inguinal ligament and/or pectineus muscle

2. Standing on the same side of the tender point

3. Cross the patient’s thighs opposite over adjacent. flex hips/knees bilaterally and place legs on physician’s thigh

4. Pull patient’s ipsilateral leg towards physician to induce adduction and internal rotation of the hip

5. Fine tune with more/less hip flexion, internal rotation and adduction

cs of posterior pelvic points

we just need to know UPL5 and Piriformis

cs piriformis (posterior pelvic)

Point is between sacral ILA and greater trochanter

1. Stand on same side

2. Ask pt to move to edge of table

3. Move leg down and hold between your knees

4. Flex and ABduct leg on affected side

5. Hold just below ankle and fine tune with internal or external rotation

cs UPL5 (posterior pelvic)

Point is superior and medial to PSIS

1. Pt is prone

2. Stand on opposite side

3. Hold pt leg of the tender point above knee

4. Extend and ADduct

dx sc joint

• proximal clavicle

• spring test (superior to inferior, anterior to posterior)

  • the side that has less springing is the side you’ll diagnose

• check motions by placing two fingers at proximal clavicle

• have patient move (abduct, adduct, flex, extend)

• name for direction of ease

  • shoulder elevation = inferior/abduction sd

  • shoulder depression = superior/adduction sd

  • shoulder retraction = anterior/extension sd

  • shoulder protraction = posterior/flexion sd

dx ac joint

• spring test superior to inferior in distal clavicle

• you can ask pt which side they’re having issues with

• dx side with most restriction

• check range of motion by passively moving pt arm

• compare both sides (check one arm at a time)

• movement pairings

  • adduct, external rotation, inferior glide

  • abduct, internal rotation, superior glide

dx gh joint

• assess active ROM (ballerina pose - dysfunctional side is the one with the lower arm) or ask pt which side bothers them

• Place digits 3 and 4 on ball anteriorly and thumb on humerus posteriorly

• do passive ROM and check for restriction

• name for direction of ease

  • shoulder extension (swings back) = anterior sd

  • shoulder flexion (swings forward) = posterior sd

  • shoulder elevation = superior sd

  • shoulder depression = inferior sd

dx ulnohumeral joint

• Motions

  • aBduction SD (medial glide) = arm is more angulated = increased carrying angle.

  • aDduction SD (lateral glide) = arm appears straighter = decreasing the carrying angle (producing a “gunstock deformity”).

1. tell pt to do active forearm pronation and supination

2. ballerina pose (arms go overhead)

3. is there’s a side that’s bothering you?

4. Feel for both medial and lateral olecranon process.

5. Two-hand hold possible OR place thenar/hypothenar on one end then cup using fingers while other hand grabs wrist rather than hand instead.

6. Naturally elbow should be 5-45°

7. Test for ROM (Abduct, adduct, flex, extend)

8. greater angle with carrying position = prefers aBduction

dx radial head / radioulnar joint

Easy posterior glide on pronation = posterior SD

1. Test active ROM bilateral

2. Locate medial epicondyle then go to lateral epicondyle then more distal

3. Divot when arm is extended and go to the BOTTOM of the divot. Feel the bone and PINCH

4. Pt arm flexed 90

5. Test for right area using pronation and supination

6. Dx focused on more proximal area

dx of wrist (radiocarpal)

1. test active ROM bilateral

2. Put thumbs on anterior/palmar surface of proximal carpals. On backside, fingers are monitoring posteriorly.

3. Compare side to side with wrist flexion and extension

4. Now do radial and ulnar deviation.

5. On practical just need to name one of the SD if you find two.

hvla anterior radial head

1. Pt seated, physician stands facing pt

2. Thumb on anterior head

3. Other hand is shaking hands

4. Rotate forearm into pronation until barrier

5. Flex into barrier

6. Thrust is a flex from hand holding wrist

hvla posterior radial head

1. Pt seated, physician stands facing pt

2. Thumb on posterior aspect of radial head

3. Other hand holds pt hand like hand shake

4. Supinate forearm into barrier

5. Extend forearm into barrier

6. Thrust into extension

hvla displaced carpal (standard)

Dorsal displaced = flexed sd

Ventral displaced = extended sd

1. Pt seated, physician faces pt

2. Hold wrist like dx

3. Extend/flex into barrier while maintaining pressure

4. Thrust is baby whip further into barrier

hvla seated combined method for wrist

1. Pt seated, physician faces pt

2. Hold wrist like dx

3. Extend/flex into barrier while maintaining pressure

4. pt will lean back for slightly back for traction

5. Thrust is baby whip into barrier

Flex SD w posterior glide

Extension SD w anterior glide

met sc joint - adduction sd (superior glide)

1. patient is supine

2. stand on same side of dysfunction

3. place one hand on proximal clavicle

4. other hand grabs wrist to extend and internally rotate arm

5. patient raises arm to ceiling

6. engage in barrier by moving arm down (no need to further internally rotate)

7. repeat 3-5 times + passive stretch

met sc joint - extension sd (anterior glide)

1. patient is supine

2. stand on same side of dysfunction

3. with one hand monitor SC joint

4. other hand cups scapula

5. ask patient to hold onto your shoulder with their SD arm

6. pull scapula up which moves distal clavical anterior (kind of balances the dysfunction out since SC joint is anterior)

7. patient pulls shoulder back

8. engage in barrier by pulling scapula further up

9. repeat 3-5 times + passive stretch

met ac joint - internal rotation sd

1. patient is seated + you stand behind them

2. stabilize lateral end of clavicle

3. monitor AC joint

4. flex 30, abduct 90

5. hold distal forearm

6. EXTERNALLY rotate

7. pt will internally rotate

met ac joint - external rotation sd

1. patient is seated + you stand behind them

2. stabilize lateral end of clavicle

3. monitor AC joint

4. flex 30, abduct 90

5. weave through to hold distal forearm

6. INTERNALLY rotate

7. pt will externally rotate

met ac joint - adduction sd

1. patient is seated + you stand behind them

2. compress distal clavical towards AC joint

3. flex 30 + abduct into barrier

4. patient adducts/moves to freedom

full spencer (7 steps) articulatory technique without met

elephants fart constantly to annoy intoxicated people

note that the techniques are where you position the patient

• extension

• flexion

• compression (circumduction)

• traction (circumduction)

• abduction/adduct

• internal rotation

• pumping

spencer technique - extension

1. patient on lateral recumbent (on their side)

2. cephalad hand grabs patient’s shoulder to lock AC and SC joint

3. caudad hand holds patient’s arm above elbow and moves shoulder into extension

4. patient resists by flexing shoulder

5. repeat 3-5 times + passive stretch

6. if articulatory (not MET), then just pulse

spencer technique - flexion

1. patient on lateral recumbent (on their side)

2. caudad hand’s palm on spine of scapula + fingers wrap around clavicle

3. cephalad hand holds patient’s forearm and moves shoulder into flexion

4. patient resists by extending (moving arm toward the feet)

5. repeat 3-5 times + passive stretch

6. if articulatory (not MET), then just pulse

spencer technique - compression w/ circumduction

1. patient on lateral recumbent (on their side)

2. abduct patient’s shoulder to 90

3. cephalad hand holds shoulder

4. caudad hand on elbow, applying downward pressure, circumducting

spencer technique - traction w/ circumduction

1. patient on lateral recumbent (on their side)

2. abduct patient’s shoulder to 90

3. cephalad hand holds shoulder

4. caudad hand on wrist, applying traction (upward tension), circumducting

spencer technique - abduct

1. patient on lateral recumbent (on their side)

2. patient shoulders abduct (chicken wing) to restrictive barrier

3. cephalad hand is placed on shoulder

4. patient grabs physician’s arm (same one that’s holding shoulder)

5. patient resists by adducting

6. repeat 3-5 times + passive stretch

7. if articulatory (not MET), then just pulse

spencer technique - adduct

1. patient on lateral recumbent (on their side)

2. patient shoulders adduct (chicken wing) to restrictive barrier

3. cephalad hand is placed on shoulder

4. patient grabs physician’s arm (same one that’s holding shoulder)

5. patient resists by abducting

6. repeat 3-5 times + passive stretch

7. if articulatory (not MET), then just pulse

spencer technique - internal rotation

1. patient on lateral recumbent (on their side)

2. internally rotate patient’s arm + palms face out + hand placed on back

3. cephalad hand holds patient’s shoulder

4. caudal hand is behind patient’s elbow to induce internal rotation

5. patient resists by externally rotation (pushing elbow backwards)

6. new barrier is engaged by moving elbow forward

7. repeat 3-5 times + passive stretch

8. if articulatory (not MET), then just pulse

spencer technique - pumping

1. patient on lateral recumbent (on their side)

2. patient’s hand on physician’s shoulder

3. both of your hands clasp and “scoop” under head of humerus

4. pull head of humerus anteriorly (towards you)

met elbow (radial head)

pronation sd = posterior radial head

• monitor radial head with one hand

• other hand holds pt’s wrist

• supinate pt forearm to engage in barrier

• pt tries to pronate forearm against resistance

• bring into new barrier by adding supination

• repeat 3-5 times + passive stretch

supination sd = anterior radial head

• same set up just opposite movement

• pronate pt’s forearm

• pt tries to supinate

cs shoulder - supraspinatus

F Abd ER

Location is in belly of supraspinatus muscle

1. Pt supine

2. Physician sits by pt at level of shoulder girdle

3. Palpate tender point and use other hand to move arm

4. Flex arm 45 degrees, abduct 45 degrees, externally rotate (like a parade wave or Statue of Liberty)

cs shoulder - biceps brachii (long head)

F Abd IR

Location is over the tendon of the biceps muscle in the bicipital groove

1. Pt supine

2. Physician sits or stands same side of point

3. Point is found at the bicipital groove (flex to feel for tendon)

4. Flex, abduct, and internally rotate (like you’re scratching head)

cs shoulder - biceps brachii (short head) / coracobrachialis

F Add IR

Location is at the inferolateral aspect of the coracoid process

1. Pt supine

2. Physician can stand from either side

3. Start at AC joint and follow down until you feel a bony prominence (will need to move through muscle). Then go inferior and lateral of coracoid process to locate point.

4. Tip - feel for humeral head and point will be slightly medial to that. Or just cup and thumb should feel it.

5. Shoulder stays on table!!!!

6. elbow and shoulder are flexed, shoulder minimally adducted and internally rotate (same side arm crosses to grab onto opposite shoulder)

cs shoulder - pec minor

F Add

Location is inferior and medial to the coracoid process

1. Pt supine

2. Physician stands opposite of tender point

3. Point is inferior and medial to coracoid process

4. Arm is adducted across chest, shoulder/scapula is pulled anterior, inferior, and medial

5. Shoulder should be OFF table

6. Can stabilize by holding arm or forearm

cs shoulder - subscapularis

E IR

Location is at the anterolateral border of the scapula on the subscapularis muscle pressing from an anterior lateral to posteromedial direction

1. Pt supine

2. Physician sits or stands on same side

3. Locate Scapula, follow the lateral border, press deeper as your go superior (must go through muscle layers)

4. Tender point is on anterior surface of scapula, palpating in a posterior and medial direction. (Deep enough as you should not be able to see your finger tip)

5. Shoulder is extended and internally rotated

cs shoulder - levator scapulae

IR Abd traction

Location is on the superior medial border of the scapula at the attachment of the levator scapula

1. Pt prone with head looking away from point and arms at the sides

2. Physician sits on same side

3. Find spine of scapula, follow border up, point is superior and medial of the border

4. Physician caudad hand grabs pt wrist while other hand holds point.

5. Internally rotate pt shoulder and add mild to moderate traction and minimal abduction

cs shoulder - rhomboid minor/major

E Add

Location is along the medial border of the scapula at the attachment of the rhomboid muscles

1. Pt prone

2. Physician stands on either side (Cornick stood on opposite side)

3. Point is along medial border of scapula. Press medial to lateral. Shoulder be between spine of scapula and angle of scapula.

4. One hand on point, other hand holds elbow to set into position.

5. Shoulder is extended and adducted by pulling arm/elbow posterior and medial

6. Try to have pt hand stay on side and not on their back.

cs radial head

E Sup Val

Point is anterolateral aspect of radial head at attachment of supinator

1. pt supine, physician same side as point

2. pt elbow in full extension, forearm supinated

3. fine tune w/ supination and valgus force

cs lateral epicondyle

E Sup Abd

Point is lateral epicondyle of humerus

1. pt supine, physician on same side of point

2. pt elbow fully extended. Use table as fulcrum to put arm into position

3. arm supinated and abducted with varying amounts of force

cs medial epicondyle

F Pro ADd with slight flexion of wrist

Point is medial epicondyle of humerus at common flexor tendon and attachment of pronator teres

1. pt supine, physician on same side of point

2. pt elbow flexed, wrist pronated, forearm slightly adducted, wrist slightly flexed

3. fine tune with elbow flex, wrist pronation, forearm adduction

cs extensor carpi radialis (dorsal)

Wrist extension, slight abduction (radial side)

Distal end and Dorsal surface of 2nd metacarpal in extensor carpi radialis

Like if you palpate 2nd MC joint then go down to tendon

1. pt either seated or supine, physician faces pt

2. pt wrist extended and abducted (radial deviation)

cs extensor carpi ulnaris distal attachment to 5th metacarpal

Wrist extension, slight Add

dorsal surface of 5th MC joint in extensor carpi ulnaris muscle

1. pt either seated or supine, physician faces pt

2. pt wrist extended and adducted (ulnar deviation)

cs abductor pollicis brevis

F wrist, ABd thumb

Radial aspect of palmar base at 1 MC joint (abductor pollicis brevis)

1. pt seated or supine

2. locate point w/ index finger

3. pt wrist flexed, thumb abducted

cs flexor carpi radialis

F ABd(radial)

distal attachment to 2nd and 3rd MC joint

1. pt seated or supine, physician faces pt

2. pt wrist flexed and abducted (radial deviation)

cs flexor carpi ulnaris

F aDd (ulnar)

Located t palmar base of 5th MC in flexor carpi ulnaris

1. pt seated or supine, physician faces pt

2. pt wrist flexed and adducted (ulnar deviation)

if patient moves easily with shoulder elevation, what is SC dx?

inferior/abduction somatic dysfunction

if patient moves easily with shoulder depression, what is SC dx?

superior/adduction somatic dysfunction

if patient moves easily with shoulder retraction, what is SC dx?

anterior/extension somatic dysfunction

if patient moves easily with shoulder protraction, what is SC dx?

posterior/flexion somatic dysfunction

name the motion pairings for AC joint

• adduct, external rotation, inferior glide

• abduct, internal rotation, superior glide

step up indicates which glide

inferior

• clavical sits inferior to acromion, so you step up