OMM Exam 2 Outline

8/9/2019 OMM Exam 2 Outline

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Lumbar Biomechanics

• Dural Column is a very dense and thick CT that invests itself onto the bone. Ittravels from the body of the sacrum to the skull in one solid piece

o Can be seen with a laminectomy where you remove the transverse processes

from all vertebral segments

• Lumbar Spine

o Three main functions

To protect the spinal cord

Allow movement

Support the upper body

o Comple system consisting of!

Spinal Cord

"erves

#ones

Ligaments

$uscles % Tendons

o &elatively large' s(uare and act as building blocks that stack up on top of

one another. Designed to be able to bear weight from the upper body

It is very easy for the lumbar spine to )e and etend' but not rotate

• Lumbar rotation rotates among itself and also along the facet

*oints. #ecause of this' the lumbar spine is not very good atrotating + small range of motion

• $ost of the body rotation comes from the Thoracic spine

• The only way to move the vertebral body is along the vertebral

disk and thus' put on a large amount of sheering force thatmakes it relatively viable.


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o

,acet connects one vertebrate to the net

Inferior facet will connect to Lumbar below whereas the superior facet

connects to the Lumbar spinous process above. It is relatively in linewith the body that it is connected to whereas in the Thoracics' theymay be a little lower.

o Spinal Ligaments

• Longitudinal ligament - ne very long cable that connects all

vertebrate together.o Anterior Longitudinal ligament - anterior to vertebral body

and allows the spine to move as an individual unit. /erybroad and runs the entire width of the vertebral body toprovide tremendous stability in the anterior side for )eionand etension.


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• Starred ligaments have nociceptors in them and have the abilityto generate pain

• #ack edge of the vertebral canal

• Ligamenta )ava - connects between the vertebrate - strongest

ligament

• Transverse ligament - cables that help to protect sidebending


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• 0osterior longitudinal ligament - ,ront of the vertebral canal but

runs posterior to the vertebral body. $uch smaller compared tothe anterior longitudinal ligament. Connects to intervertebraldisks and provides a neural framework that makes their way outin the body and etremities.

• If a herniated disk in the lumbar spine occurs either on the lateraside and the back' this can lead to paralysis and then pain sinceit travels down and catches the nerve route from the side.

o 1erniated disks are best diagnosed using an $&I vs. an 23

&ay

• 4hite - abnormal disk

• #lack - normal disk

• #lue - Spinal cord5&oots

• &ed - spinal canal


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•

o Deltoid - spine of scapula inserts on top of the humerus

and contributes to creating 6ne control of the shoulder withthe relatively large muscles.

This is how we generate control over large amounts

of the area and spare using the 6ne muscles as muchas we can in order to prevent them from beingoverworked and supporting our body weight.

o Largest muscle is the most super6cial and connects from

sacrum to the middle of the back.o Trape7ius overlaps with the Latissmus Dorsi 8lateral of body

to the middle of the back9 4here these two muscles overlap' we have stability

and tons of control over movements

•


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o Intermediate layers

:ncases the erector spinous muscles - intermediate

stability to the lumbar spine

• :ncased by the Longissimus' spinalis' and

iliocostalis

• Iliocostalis

o rigin at the sacrum; iliac crest;

thoracolumbar fasciao Inserts at th ribs; thoracolumbar

fascia 8deep9; upper lumbar vertebrae8transverse processes9

o Spinal nerves C?3L= 8posterior rami;

lateral branches9o Action! #ilateral! etends the spine;

@nilateral! #ends spine laterally to sameside

• Longissimus

o rigin at Sacrum; iliac crest; lumbar

vertebrae 8spinous processes9; lowerthoracic vertebrae 8transverse processes9

o Insertion at >nd3=>th ribs; lumbar

vertebrae 8costal processes9; thoracicvertebrae 8transverse processes9

o Spinal nerves C=3L 8posterior rami'

lateral branches9o Action! #ilateral! etends the spine;

@nilateral! bends the spine lateral to thesame side

• Spinalis Thoracis

o rigin at T=B3L 8spinous processes'

lateral surfaces9o Insertion at T>3T? 8spinous processes'

lateral surfaces9o Spinal nerve 8posterior rami9

o Action! #ilateral! etends cervical and

thoracic spine; @nilateral! bends cervicaland thoracic spine to the same side

• $ulti6dus

o rigin % insertion at C> - Sacrum

8between transverse and spinousprocesses skipping >3 vertebrae9

o Spinal innervation 8posterior rami9

o #ilateral action! etends the spine

o @nilateral action! )ees the spine to the

same side and rotates to the oppositeside

• Interspinales Lumborum

o rigin % insertion L=3L 8between

spinous processes of ad*acent vertebrae9


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o Spinal innervation posterior rami

o #ilateral action! Stabili7es and etends

the cervical and lumbar spineso @nilateral action! bends the cervical and

lumbar spines laterally to the same side

• Intertransversarii $ediales Lumborum

o rigin % Insertion L=3L 8between

mammillary processes of ad*acentvertebrae9

o #ilateral action! stabili7es and etends

cervical and lumbar spineso @nilateral action! bends the cervical and

lumbar spines laterally to the same side

• Intertransversarii Laterales Lumborum

o rigin % Insertion L=3L 8between

transverse processes of ad*acentvertebrae9

o #ilateral action! stabili7es and etends

the cervical and lumbar spineso @nilateral action! bends the cervical and

lumbar spines laterally to the same side Thoracolumbar fascia is connected to the sacrum

from the cervical spine Eeep in mind that fascia is ": large piece that

connects as ": functional unit.

• Intersegmental $otion

o 1ow the spine moves under physiological conditions

considering that the spine is physiologically intacto Dictated by ,reyetteFs Laws Type I

4hen the spine is in neutral position' it is really

governed by the tiny muscles and in particular' themulti6di and rotatores 8rotation' stabili7ation9. Theystart on the transverse process and make their wayupwards and insert into the lateral process a fewsegments above. ne the spinous process


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•

• Soft Tissue Techni(ues 3 Direct

o Act to! &educe spasm' increase circulation' decrease

hypertonicity' induce general relaation' % identify areas ofrestriction

o Contraindications

Absolute! lack of somatic dysfunction and lack of

consent &elative! acute in*ury 8fasciitis' fracture' tears'

burns9' infection' neoplasm' blood disorderso Longitudinal 8superior - inferior9' 0erpendicular 8lateral -

medial9' &otate 8clockwise - counterclockwise9• $yofascial &elease - Direct or Indirect

o $ore principle than techni(ue

0ie7oelectric viscosity related to amount of stress

placed on the ground substance. If you stress andpull and keep under tension as long as you can' thiswill change the tension and con6guration so that itnow stretches and is able to move around.

o #ased on fascial property of creep

o Contraindications the same as soft tissue

Innominate Diagnosis and Muscle Energy

Innominate

o De6nition! means Gno nameH

o Composed of bones!

Ilium - most superior part; ,eel at the )ank

Ischium - inferior and posterior; 1ip

0ubis - Inferior and anterior; roin


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4hen children are born' the three bones were unfused until about


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o

o Components to diagnose

0osterior Superior Iliac Spine 80SIS9

0osterior Inferior Iliac Spine 80IIS9

Ischial Tuberosity

Iliac Crest

Ilium

0ubis

ender diJerences

o 0elvis is heavier and has more pronounced muscle attachment sites in men

o 0ubic arch is narrower and the suprapubic angle is more acute in men

o Ischial tuberosities are closer and pelvis outlet is comparatively smaller in men

o All ilia is less )ared in men and thus' greater pelvis is deeper

o 0elvic inlet is heart shaped in men and transversely oval in women

o bturator foramen is round in men and oval in women

o 0elvis is broader in women Koints

o Sacroiliac 8SI9 *oint

Small amounts of motion

Atypical synovial *oint with 6brocartilage rather than hilar cartilage

Stabili7ed by anterior and posterior ligaments

o 0ubic Symphysis

Cartilaginous *oint

Stabili7ed by superior and inferior ligaments

Allows the *oint to rela during childbirth

Ligaments


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o

Anterior Longitudinal

oes all the way up the course of the spine and connects to the

anterior tubercle of the cervical spine' terminating where it spreadsacross the pelvic bone.

In order to switch that ligament you need to etend. Limits

hyperetension of the spine 0osterior Longitudinal ligament

Does the opposite and prevents hyper)eion of the spine

Sacrotuberous ligament

Sacrum and tuberosity of the ischium

Stabili7ation and posterior rotation5functions in conduction with the

ligament to stabili7e posterior rotation of the pelvis Anterior SI ligament

Attaches to the surface of the Ileum and the lateral part of the

sacrum. Common cause of pain in people. Attaches to thetransverse process of the th Lumbar and the inner iliac crest.


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o

Interosseus SI ligaments

Deep to the posterior ligaments and connects tuberosities of the

sacrum and the Ileum. ,untions to keep the sacrum and the ileumclose together.

0osterior SI ligaments

Stronger than the anterior counterpart. Strengthens the bonds

between the sacrum and the ileumCan also see the sacrospinous and sacrotuberous ligaments from the

posterior side.o $uscles

$a*or 1ip ,leors

Iliacus


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o Ilia to the lesser trochanter of the femur

0soas

o ,rom the Lumber vertebrae to the lesser trochanter of the

femuro A huge muscle that attaches to every lumbar vertebrate'

crosses the hip *oint anteriorly and attaches to the femuro A spasm can lead to hip pain' groin pain' pain near the lesser

trochanter' etc

Iliacus and 0soas both located on each side that attaches from the

spine and then eventually comes together and ends at the innergreater trochanter

$inor 1ip ,leors

&ectus ,emoris

o AIIS to patella

o Attaches to the AIIS' cross the anterior hip *oint of the body'

and then attaches to the knee *oint. n the anterior surface ofthe thigh and hip' it will )e' and pull the leg up. This is)eion of the lower legs.

Sartorius

o ASIS to medial tibia

o $inor )eor as it crosses the hip *oint and also a hip )eor of

the lower leg :tensor


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Semimembranosus and Tendinosus

o #oth attach at the ischial tuberosity and medial proimal tibia

o 4ork together and the attachments are pretty similar.

o Located on the posterior surface of the body and crosses the

hip *oint.o They will etend backwards and pull the leg upwards

o If the muscle comes together' it pulls the butto closer to thehip *oint.

#iceps ,emoris

o Attaches to the sacrotuberous ligament5Ischial tuberosity

luteus $aimus


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o

o riginates at the 0osterior sacral base and 0SIS of

innominates

Crosses the hip *oint and attaches to the posterior

surface of the femur. So when the two ends cometogether' it pulls that part of the leg back towards thehip *oint and thus' etends

IT band - etension of all the 6brous tissue that runs all

the way down. Common in marathon runners % runnersand is the ma*or cause of pain on the side and kneepain.

o Inserts at the lateral femur Adductors


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Adductors attach closest along the pubic symphisis and control

movements toward the body

$a*or Adductors

o Adductor $agnus

Inferior pubic ramus to the medial epicondyle

o Adductor #revis

Inferior pubic ramus to the medial aspect of the femuro Adductor Longus

Superior pubic ramus to the medial aspect of the femur

$inor Adductors

o racilis

0ubic ramus to the medial border of the tuberosity on

the tibiao 0ectineus

0ubic ramus' anterior to the posterior aspect of the

proimal femur

Abductors - away from the body


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luteus $edius

o Attaches to the ilium and greater trochanter of femur

o Common place of dysfunction that often goes ignored. It

spreads across the iliac crest and the greater trochanter onthe lateral side. If the muscle comes together' it pulls the legup and out laterally

luteus $inimus

o Attaches to the ilium and the greater trochanter of femur

Tensor ,ascia Lata

o ASIS to the IT# tract

:ternal &otators


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0iriformis

o Special since it is the only one that attaches to the anterior

sacrumo ,unction depends on position

o Sciatic "erve

#elow

Through

Comes right under the muscle. If a muscle is in spasm'

it clamps down on those nerves and shoots downcausing sciatic pain wallet syndromeH

o The only rotator that connects directly to the sacrum and the

only muscle on the anterior surface of the sacrum

If the hip is )eed' it can function as an abductor

If it isnFt etended' it is more like an eternal rotator -

$ost common

bturator internus

o Ischial tuberosity + Lesser trochanter

bturator eternus

o

emellus superior

emellus inferior

o Ischial tuberosity + Lesser trochanter

Muadratus ,emoris

o 0ubis + lesser trochanter

o 4eightbearing


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,leors

0ull the pelvis anteriorly 8&ectus ,emoris' 0soas' Iliacus9

:tensors

0ulls pelvis posteriorly 81amstrings' luteus $aimus9

Adductors

Stabili7e and GpullH medially 8adducter' $agnus' #revis' Longus9 Abductors

Stabili7e and GpullH laterally 8luteus $edius' $inimus9 All will work in con*unction to help stabili7e the pelvis.

Somatic Dysfunctions

o Innominate

&otate

0osterior Innominate % Anterior Innominate

Shear

Superior % Inferior

,lare

In)are % ut)are

o 0ubis Shear

Innominate Diagnosis

o Standing ,leion Test

Tells us whether you have an innominate or a hamstring dysfunction

o ASIS compression test

0atient is supine and you place pressure on the ASIS. 0urposeful palpation

to compare one side to the other. The end feel is as if you are hitting a wall and cannot compress anymore.

The Side that moving more is normal and the other is the dysfunctionalside.

o Compare positions of the ASIS 8patient supine9 and 0SIS 8patient prone9

o Compare leg lengths and rotation of leg

Short vs. Long' Internal vs. :ternal rotations

o :ample

ASIS compression test positive on Left side. Thus left is

abnormal and !ight is normal. ASIS is more anterior"for#ard.$SIS more posterior"inferior.Left %nger for#ard & leg goes for#ard and becomes longer. ASIS

is more anterior compared to the normal right side. $SIS becomesmore for#ard and this is #hat an anterior innominate diagnosis

loo's li'e.Bac' to#ards you & posterior innominate. Leg gets shorter

!ight side is abnormal and $SIS and ASIS is both higher on the

left side. Inferior shear of the right innominate Left side #hich is abnormal its $SIS and ASIS are both higher

than the right side ma'ing it a superior shear on the leftinnominate.To determine out(ares and in(ares you can measure in

comparison to one another by using the umbilicus. )ingers onASIS and then pointer %nger on the belly button. *e+. ! side is


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abnormal and shorter thus that is an in(are & stuc' in ma'ing itshorter and closer together,-

Standing & normal anterior innominate

Sitting & normal posterior innominate

0ubic Diagnosis

o 0alpation of 0ubic rami

4ant to determine whether one is more superior or inferior to the other

$uscle :nergyo Anterior Innominate

0atient prone - aJected leg is lowered oJ the table with the foot

contacting the doctorFs thigh. The patientFs leg is pushed forward rotatingthe innominate posteriorly. The patient pushes backward with the legagainst the doctorFs leg while the doctor resists

0atient supine - doctor lifts the leg up' rotatin the innominate backward

and the )ees the knee' eternally rotating and abducting the leg whileapplying pressure on the shin with the torso while eerting a cephalwardand lateral force with the lower hand on the ischial tuberosity.1amstring muscles are used.

o 0osterior Innominate 0rone - doctor stands on the side opposite of the dysfunction. Dysfunction

side leg is lifted to barrier of anterior rotation while cephalward handapplies the anterior pressure over 0SIS

Supine - aJected side leg is lowered oJ the table while the doctor pushes

down from *ust above the knee while stabili7ing the opposite side of ASIS. 0rone - doctor lifts the aJected side leg from the contralateral side of the

table while the patient pushes back down towards the table Muadricep muscles are used.

o In)are

0atient supine crosses the leg of the dysfunction side so that the ankle

rests on the opposite knee' physician on side of dysfunction places caudalhand on patients knee of leg on dysfunctional side and places cephaladhand on the patients opposite 8non3dysfunctional9 ASIS

0atient eerts a force of internal rotation of hip *oint on the dysfunction

side' physician isometrically opposes the patients force. Adductor muscles are used

o ut)are

0atient supine with the leg of dysfunction side bent. 0hysician sits on the

dysfunction side with torso against the knee and leg internally rotatingthe patients hip' cephalad hand under patient monitoring and applying

traction force on dysfunction side 0SIS laterally

0atient attempts to eternally rotate leg at hip *oint' physician

isometrically opposes patients force

Abductors % eternal rotator muscles are used

o Inferior

0atient prone with dysfunction side leg bent at hip and knee oJ table'

grasping table leg with the same side hand. 0hysician on the side ofdysfunction rests patients foot on physicians upper thigh and closest tothe table same 6rst applies cephalad force on the patients ischialtuberosity.


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0atient asked to etend bent leg while pushing against a table leg'

physician isometrically opposes patientFs force. 1amstring and Muadricep muscles used.

$ubic Somatic Dysfunction

• 0elvic girdle and pelvic ring

o

Composed of two innominate bones and a sacrum in between

them. The pubic symphysis comes right in front to the form thepelvis 8innominate % sacrum9

The pelvic girdle is the pubic rim formed by the innominate

coming together with the sacrum The female pubic is oval shaped and has a wide angle

The presence of the pubic arch can be seen in females 8NB

degrees9 and the suprapubic angle in males 8OB degrees9

• 0regnancy plays a very large role in this and thus the

reason why the aperture is much larger in females in orderto allow the baby to pass through.

• 0elvic Diaphragm

o ften overlooked as a source of pain

o $a*or crossroads for blood' lymph' and nerves

This is the reason that problems with the diaphragm can cause

kinking of all the items that pass through ito 1ouses I and @ organs

The prostate is held directly within and around the pelvic

diaphragm and thus would often lead to problems with the pelvic

)ooro Closely connected to the abdominal diaphragm

The pelvic diaphragm and abdominal diaphragm work in

con*unction with another. The pelvic )oor is another end of theprocess since it functions as a hydraulic system.


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• Schematic side view

o Diaphragm comes down' blends into the abdominal

pubic fascia and inserts onto the pelvic )oor. $usclesthat come along will transverse the anterior portion

of the spinal column and then comes back up andaround.o It functions as one continuous container so that when

you breathe' it s(uee7es the contents of theabdomen in order to cause increased pressurepumping action that the abdominal muscles have.#oth the bottom and top of the container worktogether.

o Lymphatics

• Lymph is a secondary circulatory system that brings

lymphatics from the periphery back into cardiac circulation

• Since the lymphatic system runs through the pelvic

diaphragm and is only one cell thick' sheer strain can leadto restriction of )uid that comes back up into circulationcan lead to ligamentous edema.

• n the & side! & arm' head' and neck + & lymphatic duct +

Kugular vein


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• n the L side! lymphatic channels + Inguinal lymph nodes+ Cisternal chyle + thoracic duct + Subclavian vein

o These drain all of the lower etremities

• Super6cial - beyond the pelvic diaphragm

• Deep - within the pelvic diaphragm

• #oth super6cial and deep must make their way back into

circulation for drainage.o

0elvic $uscles

• Three muscles make up the Levator Ani

o 0uborectalis

o 0@bococcygeus

o Iliococcygeuso These muscles pass between the sacrum and the

pubic symphysis. These muscles connect theinnominate to the sacrum

• @rogenital 1iatus - where the urethra passes through

• penings - apertures through which the rectum and theanus passes through

• bturator ,oramen 8Internus9 where the pelvic diaphragm

6rmly attaches. It is relatively small and has really strongfascial attachments to the pelvic.


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• The deep transverse perineal muscle is a very thin etra

layer of support that attaches directly to the Levator Aniand also has lateral attachments. This is muscle isimportant to hold when you need to peeP

• Levator Ani muscles fan out and swoop their way up andinsert into the bturator ,oramen and onto the sacrum.

• Iliococcygeal ligamens - attaches from the coccy and

onto the tail bone

• 0iriformis


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• The pelvic )oor is directly medial to the ischial tuberosity

• Arrow indicates where we press up against the bone. In this

area' there is loosely packed adipose tissue that 6lls thespace around the rectum and the urogenital organs. It is

very compressible and if you push up far enough' you canhit the ischial muscles that make up the pelvic diaphragm.

• A patient may come to you and say that their genitalia

hurts' pain when they have bowel movements or evenwhen urinating. This is a deep seeded pain and doctorshave a tendency to shy away from this area. &ealistically'its an easy muscle to access and because there are somany muscles that pass through the pelvic diaphragm andits so prone to shearing' itFs a /:&Q :ASQ 6 andinstantaneous relief will be shownP

o 0ubic Symphysis

1eld together by dense 6brocartilage

@nder physiological conditions' pubic tubercles should be R= cm

apart Symphysis has the ability to move about > mm superior or

inferior' and has about =3> degrees of rotation Designed to transmit forces in typical conditions

Characteristics change dramatically in >nd or rd trimester of

pregnancy for females

• Since the pelvis is not big enough to allow for a baby to

pass through under physiological conditions' the body will

release !ela+in during the >nd and rd trimesters in orderto soften up the cartilage and allow for the cartilage in thepubic symphysis to pull apart. This then allows the baby topass through. nce they pass through' the pubic will snapback together.

• &elain only delivers for so long' but once the baby is born'

it will go away and you only have about < weeks for thepubic symphysis to come back together. If doesnFt' thisleaves the mom with a gapped peripartumP

o 0ubic Symphysis dysfunction


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apped 8pubic symphysis diastasis9

• Common with child3birth

• 4here it widens and stays widens

Compressed

Superior shear

• Mirrors a posterior innominate shear Inferior shear

• Mirrors an anterior innominate shear Shears are where the symphysis is gapped slightly

• Invariable fall into = of > categories

o If someone that has pelvic pain and points to the pubic symphysis'

check for unleveling since this region is not very tolerant to beingpulled and being stretched. This would lead to signi6cant pain in thearea.

o 1owever' if someone doesnFt have pubic pain 8possibly because this

was a chronic issue9 and they get diagnosed with lower backinnominate dysfunction thatFs been treated multiple times and stilldoesnFt help' then you can con6rm it as a pubic symphysis sheer. This

can occur anytime' but most of the time it occurs peripartum

o

Superior % Inferior longitudinal ligaments

o

Adductors


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OMM Exam 2 Outline

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