OMM 1

Exam 3 LGT

Prepared and Presented by:

Kenton Venhuizen and Milind Chinoy
November 4, 2009
Tibia:
Flexion with anterior glide
Extension with posterior glide
Abduction with medial glide
Adduction with lateral glide
External rotation with anteromedial glide
Internal rotation with posterolateral glide

Fibula:
Anterior fibular head
Posterior fibular head
Question 1
A pt reports to your clinic. She works as a grocery store cashier,
has 12 hour shifts, and has worked 7 days a week for the past 9
years. She comes to your office complaining of knee pain, which
you localize to the posterior knee during your examination.
Which of the following statements is most accurate?

A. The force for the appropriate technique for this situation is directed
superiorly and anteriorly.
B. The force for the appropriate technique for this situation is directed
inferiorly and anteriorly.
C. Your left and right thumbs will be applying the activating force
D. You use an indirect force as part of the treatment
E. The pt is asked to participate in the treatment through respiratory
cooperation
 Direct MFR: Popliteal Fascia
Procedure:
1. With the patients leg relaxed
place your fingertips just
above the popliteal fossa.
2. Fingers of both hands are
bent with the fingernails of the
two hands facing each other
and thenar eminences about
3 apart to form a plow
shape.
3. Press anteriorly just superior
to popiliteal fossa.
4. Draw the fingers inferiorly
until resistance is felt, then
hold until the release occurs.
Question 2
The fibular head has two primary motions. They are
______ and ______.

A. Anterior; posterior
B. Anteriomedial; posteriorlateral
C. Anteriorlateral; posteriormedial
D. Rotation; flexion
 Fibular Head Somatic Dysfunction
The head of the fibula is
grasped between the thumb
and index fingers and moved
anterolaterally and
posteromedially along its
plane of motion
Is there restriction in either
direction?
If the fibular head prefers
anterior motion with restriction
of posterior motion, it is
termed anterior fibular head
somatic dysfunction
Question 3a
A patient presents to your clinic with LE pain which as
been ongoing for several days. Upon examination, you
find that the patients distal aspect of his fibular prefers
posterior motion.

How would you name this somatic dysfunction?

A. Talus lateral rotation SD

B. Fractured fibula SD
C. Posterior fibular head SD
D. Anterior fibular head SD
Question 3b
A patient presents to your clinic with LE pain which as been ongoing for
several days. Upon examination, you find that the patients distal
aspect of his fibular prefers posterior motion.

Which of the following is most accurate in describing the appropriate

treatment for this pt?

A. Balance the patients fibular head between your thumbs and apply posterior force
while utilizing Muscle Energy to guide the fibula back
B. Grasp the patients fibular head between your thumb and 2 nd digit and dorsiflex
the patients foot, asking them to plantarflex while you apply a posterior force at the
distal fibula
C. Grasp the patients fibular head between your thumb and 2 nd digit and plantarflex
the patients foot, asking them to dorsiflex while you apply an anterior force at the
proximal fibula
D. Grasp the patients fibular head between your thumb and 2 nd digit and plantarflex
the patients foot, asking them to dorsiflex while you apply a posterior force at the
proximal fibula
ME: Fibular Head Anterior
(seated)
Treatment:
1. Patient is seated with legs
hanging.
2. Operator is seated in front of
the patient.
3. Operator grasps fibular head
with thumb and presses
posteriorly.
4. Other hand is used to plantar
flex and invert the foot.
5. Patient is instructed to evert
and dorsiflex foot against
operator counterforce for 3-5
sec.
6. Patient relaxes 2-3 sec and
doc moves to new barrier
7. Repeat several times for
correction.
Question 4
Which of the following pieces of information regarding a
patients history would be most applicable in
differentiating between the use of Direct MFR Popliteal
Fascia vs. Supine Direct Ligamentous Articular Release
Fibular Head and Interosseous Membrane?

A. The patient reports chronic knee pain from sports

B. The patient has had several visits to their PCP for ankle sprains
C. The patient has had no vaccinations as a child
D. The patient was hospitalized 3 years ago for a sacral fracture
E. The patient is a crackhead
 Fibular Head and Interosseous
Membrane
Technique: Supine Direct Ligamentous Articular Release
Findings:
Posterior and lateral knee pain or unstable ankle with chronic
spraining of the ankle. The latter is a result of an unstable ankle
mortise with the fibula displaced at the knee.

Pt is supine and Physician

is seated facing the side
of the table at the level
of the affected knee
 Fibular Head and Interosseous
Membrane
Treatment.
1. Flex the hip and the knee to 90
deg.
2. Slightly externally rotate the
femur
3. With the cephalad arm, bend
elbow to 90 deg and prop it on
the table making a pedastal out
of your forearm and thumb.
4. With the pad of the thumb push
the posterior superior portion
of the fibular head inferiorly
toward the pts foot.
5. The distal hand inverts and
slightly medially rotates the
foot.
6. A release occurs when the
fibular head moves inferiorly and
anteriorly and slides back into
the socket.
Cruciate Ligaments
Indirect Ligamentous Articular Strain
Place the cephalad hand approx 4-5 above the knee joint, the caudal
hand approx 4 inches below.
(1) Add gentle compression down towards the table
(2) Add gentle compression between the two hands, approximating the
femur and tibia, gently seating the joint.
(3) Add a slight rotational torsion,
external or internal on the tibia
to a point of ease while
stabilizing the femur. (indirect
balance point)
Wait for a release, usually a
sensation of moving further
to the direction of ease
in the tiba. Recheck. The
tibial tuberosity should be more
centered on femur.
Question 5
While on vacation in Barbados, you notice another beach-
goer having difficulty walking. They seem to be kicking a lot
of sand around with their right foot as they walk, dragging
their foot along. They fall face first several times, even
though theyre sober. They try to compensate by keeping
their knee high when they walk. If you were to treat them,
which of the following would best describe your method?

A. You order a prompt CT scan

B. The patient is placed supine with their knee flexed to 90 degrees
C. Treatment is usually aimed at the medial head of the gastrocnemius
D. The patient doesnt need help they need a drink
E. The patient is prone with their knee flexed to 90 degrees and their
ankle joint is maximally flexed
JSCS: Gastrocnemius
Findings: Plantar flexion
S/D
When severe, an apparent
foot drop. Pt may scuff
shoe on floor. Prone to
stumbling on rough ground.

Characteristic gait is lifting

the knee high and flopping
the foot upward.
Milder cases are far more
common.

REVIEW
JSCS: Gastrocnemius
Treatment:
Treatment is usually aimed
at the medial head of the
gastrocnemius (although
the lateral should also be
assessed).
The ankle is strongly
extended with the patient
prone (pressure is kept
high on the instep to avoid
straining the metatarsals)
REMEMBER: your usual
J-SCS protocol!
Question 6
While on rotations you meet a patient who had just come
back from a camping trip, during which he was forced to run
from a bear. During his escape (the patients, that is), he
fell and injured himself. He now has pain in his lower leg
and ankle you find SD in his knee, fibula, ankle joint.
What is the first treatment youll do (assuming he doesnt
need emergent care)

A. You will call the forest rangers to hunt the bear down
B. You will do cranial manipulation on the pt
C. You will treat the ankle joint first
D. You will treat the knee first
E. You will treat the fibula first
Usually treat the Fibula before the
ankle and foot!
Question 7
The transverse arch is comprised of:

A. Talus and calcaneus

B. Navicular and lateral maleous
C. Cuboid and navicular
D. Cuboid, Navicular, and cuneiforms, and proximal ends of the
metatarsals
E. Pedicle and transverse process
 Transverse Arch:
Cuboid, Navicular and cuneiforms SD.
Dx:
A. Cuboid everted/lateral.
B. Navicular inverted/medial
C. Cuneiforms depressed
Transverse Arch of the Foot

Cuboid
Navicular
Three
Cuneiforms
Proximal
ends of
metatarsals
Question 8
During the Talus Tug technique, which finger(s) is/are
placed on the head of the Talus?

A. Both of your 5th digits

B. Both of your 4th digits
C. Both of your 3rd digits
D. The 5th digit of the hand that is most cranially placed on the pt
E. The 4th digit of the hand that is most cranially placed on the pt
Talus in Plantar flexion (supine direct
HVLA; Talar Tug)

This is an extremely useful and

effective technique.

Patient supine, leg extended, operator at

end of table.
Operator grasps foot and curls 5th finger
around head of talus. The other 5th
finger reinforces.
Remaining fingers are across dorsum of foot
with both thumbs on plantar surface of
foot.
The ankle is now dorsiflexed to engage the
restrictive barrier.
Maintain steady caudal traction at the ankle
joint.
The corrective force is a short, quick caudal
HVLA thrust carried from the 5th
fingers through the talus.

Recheck
Question 9
Usain Bolt comes to your office seeing your expert medical
advice. He recently rolled his ankle while trying to break
the sound barrier by foot. After your workup, you localize
the SD to his Talus. What is MOST LIKELY shift in the
Talus?

A. Anteriomedial
B. Posteriorlateral
C. Anteriolateral
D. Posteriormedial
E. Left shift
 Articulatory with Traction:
Talocalcaneal SD
Findings: SUBTALAR JOINT
1. EVERSION OF FOOT:
2. Anteromedial shift of talus
(restriction of foot inversion)

3. INVERSION OF FOOT
4. Posterolateral shift of talus
(restriction of foot eversion)

Tissue texture changes in foot &

musculature, or tenderness
along joint lines
Motion Testing and Evaluation of Joint
Articulatory with Traction:
Talocalcaneal SD (seated)

Treatment Procedure

Articulatory Procedure with Traction

1. Patient is seated at end of table with their legs
dangling
2. Operator grasps heel with one hand and dorsum of
foot near ankle with other hand
3. Traction is exerted by a downward pull on the
calcaneus while the other hand articulation the
talocalcaneal joint through its full range of inversion
and eversion
Circular motions in both directions
4. Recheck
Dropped Arch Imp Info
Navicular findings
Plantar glide & inverted
Plantar surface rotates medially (navicular inverts)
Midline edge of navicular is prominent and inferiorly
displaced
Cuboid findings
Everts & rotates laterally
Midline edge is inferiorly displaced
Supine, Direct patient cooperation
(ME)
Patient supine operator at end of table
Contact the area over the cuboid and navicular bones
by crossing your thumbs and grasping dorsum of foot.
Apply tension to separate the components of the
transverse arch
Encourage a normal arch, by taking up the slack to
approach the barrier.
Have patient plantar flex while operator applies a
counterforce with their thumbs.
Take up the slack as per ME protocol, engaging the
new barrier.
 Gait

GAIT
Initial contact Other
Terminal swing terminology:
Heel strike
Foot flat
Loading response
Push-off
Mid-swing Knee bend
Toe-off
Acceleration
Mid-stance
Deceleration
Initial swing

Terminal stance

Preswing
Propulsion and Stability:

The foot has three arches.

The medial longitudinal arch is the highest
and most important of the three arches. It is
composed of the calcaneus, talus, navicular,
cuneiforms, and the first three metatarsals.
The lateral longitudinal arch is lower and
flatter than the medial arch. It is composed of
the calcaneus, cuboid, and the fourth and
fifth metatarsals.
The transverse arch
 PLANTAR FASCIA: The
function of the plantar fascia is
to provide static support for the
longitudinal arch of the foot and
to assist with shock absorption
during foot strike.
During the heel-off phase of
gait, tension increases on the
plantar fascia, which acts as a
storage of potential energy.
During toe-off, the plantar fascia
passively contracts, converting
the potential energy into kinetic
energy and imparting greater
foot acceleration.
Plantar fasciitis: this condition
causes pain by inflammation of
the insertion of the plantar
fascia on the medial process of
the calcaneal tuberosity
Question 10
Pt presents with collapsed transverse and longitudinal
arches. Which of the following is most likely to be seen?

A. Navicular prominence on the medial side of the foot

B. Talus prominence on the superior aspect of the foot
C. Cuboid prominence on the lateral side of the foot
D. Medial maleolus subluxation
E. Metatarsal dislocation
 Pes Planus
Longitudinal &
transverse arches fall
Subtalar axis more
horizontal
Tarsal somatic
dysfunction
Navicular prominence
on medial side of foot
Plantar fasciitis may be
from decreased
ligamentous arch
stability (flattened
arches)
 Functional Ankle: Motions
Tibiotalar joint (true ankle mortise)
Axis of Motion
Major & Minor Motions
Dorsiflexion with posterior glide
Plantar flexion with anterior glide

Talocalcaneal joint, subtalar joint

(shock-absorber)
Distributes forces for foot
Axis of Motion
Motions
Posterolateral glide with foot inversion
Anteromedial glide with foot eversion
Pronation-Supination
Each occurs at the subtalar joint (talocalcaneal)
They occur around an oblique axis
Each are combinations (triplanar) movements:
Supination: PIA
Plantarflexion
Inversion
aDduction KNOW THESE!!!
Pronation: DEA
Dorsiflexion
Eversion
aBduction
Question 11
What is the ligament that is MOST LIKELY to be the FIRST
one injured in an ankle sprain?

A. Posterior talofibular ligament

B. Anterior talofibular ligament
C. Calcaneofibular ligament
D. Anterior Cruciate ligament
E. Deltoid ligament
Shin Splints
The complaint is usually of pain at the medial border
of the tibia, the bone on the inside of the lower leg. It
involves degeneration and micro-tearing of the
tendons of the muscles that flex the toes and the
forefoot- the flexor digitorum longus, flexor hallucis
longus and tibialis posterior. The usual biomechanical
source of the syndrome is either functional lowering
of the longitudinal arch together with hyperpronation
which is normally compensated for by the tendons of
those muscles; or through weakness and overloading
of the muscle in front of the shin, the tibialis anterior.
 Kinetic Chain:
Ankle Sprains
Inversion Sprain Mechanics
(most common)
Eversion of calcaneus
Posterolateral talus glide
Anterior distal fibular/lat malleolus
Posterior fibular head
External rotation with
anteromedial glide of tibia
Internal rotation of femur
Posterior ipsilateral
innominate
Neutral ipsilateral sacral
oblique axis (forward torsion
on ipsilateral side)
 Femoroacetabular Joint
ROM
Flexion
Extension
Abduction
Adduction
External Rotation 120 - 135
Internal Rotation 30 - 35
Minor Motions 50 - 55
30 - 35
Anterior glide occurring with external rotation
45 -rotation
Posterior glide occurring with internal 55
35 -with
Dysfunction in these motions are treatable 45OMT:
ligamentous articular strain, myofascial release and other
treatments
Hoppenfeld S. Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, New York, 1976, pp 155-59.
Question 12a
Pt presents with hip and buttock pain and discomfort that
radiates down the back of their left thigh (but not past their
left knee).

What is the neural contribution to the nerve that is being

impinged?

A. L2-S1
B. S2-4
C. L1-L5
D. L4-S3
E. T10-L2
Question 12b
Pt presents with hip and buttock pain and discomfort that
radiates down the back of their left thigh (but not past their
left knee).

What is the MOST LIKELY course of this nerve with respect

to the muscle that is impinging it?

A. The nerve travels above the muscle

B. The nerve travels below the muscle
C. The nerve travels through the muscle
D. The nerve bifurcates through AND below the muscle
E. The nerve bifurcates through AND above the muscle
 Piriformis Spasm
Piriformis Spasm/Syndrome
Signs & symptoms
Hip and buttock pain that radiates down the
back of the thigh (not past knee)
Low back pain - not a major componet
Lack of neurologic symptoms!
Piriformis tenderpoint
Decreased internal rotation of the hip!

Sciatica = Radicular pain in the distribution of a sciatic nerve root (L-4, L-5, S-1, S-2,
or S-3), usually producing symptoms along the posterior or lateral aspect of the lower
extremity extending to the ankle or foot

May include pain in the distribution of that root, dermatomal sensory disturbances,
weakness of the muscles innervated by that root, and hypoactive stretch reflexes
Question 13
The true knee joint is composed of _____ ?

A. Femur, fibula, tibia

B. Femur, tibia
C. Femur, tibia, ACL, PCL
D. Femur, tibia, fibula, ACL, PCL
E. Femur, tibia, fibula, ACL, PCL, patella
Anterior and Posterior Cruciate
Ligaments
They are named for their
attachment on the tibia.

The Anterior Cruciate

Ligament (ACL) attaches to
the anterior portion of the
tibia and prevents Posterior
excessive anterior glide. cruciate
ligament

The Posterior Cruciate

Ligament (PCL) attaches
to the posterior aspect of
the tibia and prevents
excessive posterior glide.

Posteriolateral view
Important Points (maybe..)

Anteromedial glide of tibia at knee occurs with full flexion

Posterolateral glide of tibia at knee occurs with full extension
Menisci and Collateral Ligaments
Menisci
(Posterior View) Medial Menisci
Attachment to MCL makes it prone to
injury if MCL is disrupted
Medial is less tightly bound by its
ligament that lateral meniscus
Lateral Menisci
Collateral Ligaments
Lateral Collateral
limits lateral glide
Medial Collateral
limits medial glide
Attached to the medial menisci
The Terrible Triad
Tearing of the:
Anterior Cruciate Ligament, Blow to
Medial Collateral Ligament lateral
aspect
Medial Meniscus
of knee
Commonly occurs
when leg is
completely extended
and the foot is flexed
and a blow is taken
from the lateral
aspect of the knee
Important Tests to Review

Anterior Drawer Test

Posterior Drawer Test
Lachmans Test
McMurrays Test
Collateral Ligament Tests
Apley Test
Ankle Drawer Test
 Q-Angle
Q-Angle The functional longitudinal
axis of femur and the tibial longitudinal
axis
Femoral Longitudinal Axis
Females because of normal anatomic
variation of wider hips for childbearing, Tibial Longitudinal Axis
have a slightly increased Q angle than
males.

Normal Q-Angle
10 to 12
Genu Valgus
Angle increased
Knock-kneed
Genu Varus
Angle decreased
Bowlegged
 Tibia & Fibula
Proximal Tibiofibular Joint
Separate synovial joint from knee
Same horizontal plane as tibial plateau
Clinical relevance: common fibular n.(aka peroneal n).
posterior to fibular head
Distal Tibiofibular Joint
Syndesmosis joint
Allows fibula to move laterally from tibia

Interosseous Membrane
Fibrous connective tissue between tibia and fibula
Most fibers run inferolateral
Allows sharing of compressive forces & movements
Knee to ankle & Tibia to fibula
Can translate and store somatic
dysfunction from proximal/distal fibula
 Reciprocal Motions of the Fibula
Posterior Fibular Head

INVERSION of the foot moves

the distal talofibular joint
anteriorly, while moving the
fibular head posterior
(postero-medially)

EVERSION of the foot moves Anterior Fibular Head

the distal talofibular joint
posteriorly, while moving the
fibular head anterior
(antero-laterally)
Question 14
A soccer player comes into your office a couple of days
after spraining her ankle. Her pain has not improved. An
ankle drawer test is performed and you find that there are
incomplete tears of the anterior talofibular ligament and
calcaleofibular ligment. What grade of inversion sprain is
this?

A. Grade I
B. Grade II
C. Grade III
D. Grade 1a
E. Grade 2b
 Types of Inversion Sprains
Grade I: mild lateral ankle pain
with sl. edema, no laxity
(ATF) partial tear

Grade II: goose egg swelling

with slight laxity (CF &
ATF) incomplete tear

Grade III: Complete Tear

immediate diffuse swelling
with (+) anterior drawer test
(CF, ATF, may include PTF)
complete tear
Anatomy of the Ankle
The ankle has two joints
Tibiotalar-true ankle
joint
Hinge Joint Allowing
Pure Dorsiflexion &
Plantar Flexion
Subtalar
(Talocalcaneal)
Main shock absorber
Distal fibula
Lateral malleolus
Distal tibia
Medial malleolus
Arches of the Foot
Longitudinal Arch(es)
Medial Arch
Elastic shock absorbing
Lateral Arch weight
bearing

Transverse Arch
Metatarsal Arch

Combination of arches is a kind of

tripod
Question 15
Usain Bolt is back with more problems. This time, he is
hunched over and cant seem to stand up straight. He has
just completed a weekend packed with several strenuous
races, and is worried about getting back to training ASAP.
Which of the following muscles is most likely the cause of
his SD?

A. Quadratus Lumborum
B. Iliacus
C. Psoas
D. Rectus Femoris (bilat)
E. Sartorius
Diagnosis of Tight / Short
Extensors
Flexion Restriction = Extension Somatic
Dysfunction (S/D)
Slowly increase flexion to
point of resilient barrier
Estimate degree of flexion
(Optimal is 90)
Compare to contralateral limb
The limb that resists
flexion is positive

Motion tested: Flexion

Muscles tested: Extensors
Internal or External Rotation
Somatic Dysfunction: Combined
Muscle Energy Technique
1. Indirect. Take hip away from the restrictive barrier, toward the
direction of ease. Reciprocal Inhibition
Internal S/D: Take into internal rotation
External S/D: Take into external rotation
2. Flexion. Maintain internal or external rotation and go into flexion.
3. Direct. Take hip toward the restrictive barrier, away from the
direction of ease. Post Isometric relaxation
Internal S/D: Take into external rotation
External S/D: Take into internal rotation
4. Extension. Maintain direct counterforce and allow leg to return to
extended position.
5. Recheck.
GOOD LUCK!!!