Plantar FasciitisDirect Myofascial Release

• Cross thumbs while contacting the plantar fascia

• Cephalad pressure is applied to engage fasica

• Lateral and distal pressure is applied to engage barrier

• Tension is held against the barrier until release is noted

• Can (and should) be performed with midfootactively plantar- and dorsi-flexed

Nicholas and Nicholas, Atlas of Osteopathic Techniques, 3rd Edition, Wolters Kluwer.

Indications for FPR

• Superficial and deep hypertonic

muscles

• Somatic dysfunction

• Pain

• Decreased ROM

FPRHow is FPR applied?Muscle/muscle fibers must be at rest

1. Body part in neutral position

2. Compression applied to shorten muscle/muscle fibers

3. Place area into EASE of motion (indirect)

4. “IMMEDIATE” relief from muscle spasm (“3-5 seconds”)

5. eassively return body part to neutral

6. Re-assess

α motorneuron(muscle tension)

Type Ia afferent

(Dynamic)(acceleration)

γ motorneuron(spindle

tension)

Nuclear BagMuscle Fiber

Nuclear ChainMuscle Fiber

Sudden decrease in load on muscle spindles

• Stops Ia fiber discharge

• Interrupts the excitatory signal being sent to motor neurons controlling the extrafusal muscle fiber (relaxes).

Thus muscle spindle reflex resets

Physiologic Theory FPR

8

Neutral

Compress

Ease

“Neutral Positioning” of Body

A position between flexion and

extension to approach Neutral

position as defined by Fryette

• In the spine

– flatten the A-P curvature

• For joints in extremities

– place them in “loose pack” positions

FPR (OA Ext RLSR)

Patient supine

1. Physician monitors basiocciput with with thumb and index finger of one hand, and stabilises skull with other hand

2. The head is flexed slightly to bring the OA into neutral position

3. The physcian adds gentle caudal compression down to the OA(basiocciput), until softening of tissue occurs.

4. This gentle compression is followed by left rotation, right side bending, and extension to the ease position, to a point of balance, and minimum muscle tone

5. Hold for 3-5 seconds, then slowly release compression, while returning to neutral

6. RECHECK

Diagnosis of Radial Head Ant./Post.

Thumb and Index finger grasp radial

head

Monitor Proximal radial head during

pronation & supination

Supination should move the proximal

head Anteriorly

Pronation should move the proximal

head Posteriorly

Translate Proximal radial head

Effectively:

passive motion testing

Radial head dysfunction has a significant effect on supination/ pronation

FPR (Radial Head)

Posterior/Anterior Radial Head:1. Support flexed patient elbow at 90 degrees with physician hand, and hold

wrist and hand of patient as to shake hands.

2. Place forearm in neutral position

3. Add slight compression vector toward radial head

4. Position in ease until point of balance is met

1. Pronate (passively) the forearm in the case of a posterior radial head

2. Supinate (passively) the forearm in the case of an anterior radial head

5. Slowly release compression and return to neutral

6. RECHECK

Lateral EpicondylitisFPR

In essence:

1. Compress

2. Move to position exactly opposite Cozen’s

3. Hold for 5 sec

Can easily teach patients to do this for themselves

Still TechniqueHow is Still Technique applied?1. Area of body must be locally at rest

2. Tissue/joint placed in EASE of motion position

3. Exaggerate position of ease

4. Compression (or traction) vector force (5#) added

5. Tissue/joint moved through restriction while maintaining compression (or traction) and force vector

6. Release compression (or traction) (force vector)

7. Return passively to neutral position

8. Re-assess

BASIC PRINCIPLE

STILL TECHNIQUE

Ease

Compress

Barrier

Indications for Still Technique

Hypertonic muscles and

Joint Somatic Dysfunction

Pain

Decreased ROM

Contraindications: Same as FPR

FPR vs Still Technique

Principles

FPRNeutral

Compress

Ease

StillEase

Compress

Barrier

SACRUM (Still)Diagnosis SFT ILA

Right Diagonal +Right +Left Named for

Left Diagonal +Left +Right side of

Right Rotation +Right +Right positive

Left Rotation +Left +Left SFT

(1) Seated Flexion Test: (SFT)

(a) Modified from traditional seated flexion test.

(b) Both ischial tuberosities bear equal weight.

(c) Physician sensing fingers placed over SI joint on the sacral side just

medial to the PSIS at the level of the sacral base (sacral sulcus).

(d) Patient asked to bed forward dropping arms between their legs.

(e) Skin on skin. Observe superior travel of sensing fingers.

(2) Position of Inferior Lateral Angle (ILA)

Technique (Left Diagonal Sacrum) Seated(Still)

(1) Patient seated (on stool or table)

(2) Doc stands or seated behind patient to the left side

(3) Doc places left arm over patient left shoulder with Doc

placing Doc’s left hand on patient right shoulder(operating

arm and hand)

(4) Doc’s right hand senses tissue changes just medial to (L) PSIS

(5) Doc rotates and sidebends patient to left and extends

patient until relaxation of tissue tension over (left) SI area

(6) Doc introduces compression through patient (L) shoulder

toward (left) SI joint

(7) Flex and sidebend and rotate patient to (R) until release felt

(8) Release force vector, return the spine to neutral and RECHECK

Left Diagonal Sacrum

Initial Position Final Position

Technique: Left Rotation Sacrum (Still)

(1) Patient seated (stool or table). Doc behind patient to (left)

(2) Doc left arm is placed over patient left shoulder with left

hand on patient right shoulder. Doc’s left arm and hand

will be the operating arm and hand.

(3) Doc’s right hand will sense tissue changes over the sacrum

just medial to the the (left) PSIS.

(4) Patient’s (left) shoulder is rotated to the left and posterior

until relaxation of tissue tension over Doc’s sensing finger.

(5) Introduce compression with vector toward (L) PSIS.

(6) Rotate (left) shoulder anterior and right shoulder

posterior until sacral release felt.

(7) Release force vector and return spine to neutral. RECHECK

Left Rotation (Sacrum)

Initial Position Final Position

First Rib (Still)Diag: - Based on position of rib head. (Superior or inferior)

(1) Check for compliance and tenderness.

(2) A restricted rib

(a) does not move during part of the respiratory cycle

(b) is relatively immobile to external pressure

(c) is tender to palpation usually

Superior First Rib: (1) Superior relative to other side

(2) Caught in exhalation and will not

readily move in inhalation.

Inferior First Rib: (1) Relatively inferior to other side.

(2) Will be in inhalation, does not move

easily in exhalation

Superior First Rib (Still) (RIGHT)

(1) Place sensing finger (Left hand) on superior right 1st rib head

Patient seated. Doc seated or standing in front of patient.

(2) Place your operating hand on top of patient’s head.

(3) Patient’s neck is sidebent and flexed away from affected rib.

(exaggerating the dysfunction and bringing it into ease)

(4) Introduce a force vector from head, toward affected rib.

(5) Maintain force vector to move patient’s head and neck into

extension and sidebending to the side of the affected rib.

(6) Release compression.

(7) Return head and neck to neutral.

(8) RECHECK

Superior Right 1st Rib

Initial Position Superior Right 1st Rib

Final Position

Inferior First Rib (RIGHT) (Still)

(1) Doc’s (left) sensing hand monitors the (right) inferior first

rib head. Patient seated. Doc seated or standing.

(2) The operating hand (right) is on top of the patient’s head.

(3) Patient’s head and neck are slightly extended and sidebent

toward the affected (right) rib .

(4) Doc introduces compression with operating hand toward

toward the right rib head.

(5) Head and neck are brought into flexion and sidebent away

from affected right rib.

(6) Release compression.

(7) Return head and neck to neutral. RECHECK

Inferior Right 1st Rib

Initial Position

Inferior Right 1st Rib

Final Position

Upslipped Innominate (Superior Shear) Left(Still)

(1) Doctor on left side of supine patient.

(2) Doc abducts the affected left leg to ease position.

(3) Doc introduces axial traction from the lower left leg.

(4) Doc maintains traction on left leg, and adducts left leg

across midline (slightly).

(5) Release traction, return leg to neutral.

(6) RECHECK

Superior Left

Shear

Initial Position

Superior Left

Shear

Final Position

Downslipped Innominate (Inferior Shear) Left(Still)

(1) Doc on left side of supine patient.

(2) Doc adducts left leg across midline slightly.

(3) Doc introduces axial compression to the left lower leg.

(4) Maintaining compression, Doc abducts left leg.

(5) Release compression, return leg to neutral position.

(6) RECHECK

Inferior Left Shear

Initial Position

Inferior Left Shear

Final Position

Ribs 3-12 Inspiratory and Expiratory Somatic Dysfunction: (Pump handle, Bucket Handle, Calliper)

(1) Evaluate patient for the presence of inspiratory or expiratory

somatic dysfunction: (pump-handle, bucket-handle, calliper).

(2) Next, identify the key rib:

- Inspiratory Somatic dysfunction: Bottom Rib

- Expiratory Somatic Dysfunction: Top Rib

(3) Patient seated at the edge of the table.

(4) Physician standing next to patient on the side of the somatic

dysfunction.

(5) Physician’s arm closest to posterior aspect of the patient,

(patient’s back) is extended over the patient’s upper back,

stabilizing patient’s shoulder with his/her axilla, with physician’s hand

grasping opposite shoulder and stabilizing.

(6) Physician’s arm and hand closest to the anterior chest, monitors

the key rib.

Example: Expiratory Somatic Dysfunction Left 7th Rib

(7) Continue 1-6 with physician’s right arm extending over patient’s upper

back, with physician’s axilla resting on patient’s left shoulder.

(8) While physician monitors patient’s left 7th rib with his/her left hand, the

physician sidebends the patient to the left (toward physician) until motion

is fealt at the left 7th rib, followed by flexion of the patient, until motion

is fealt at the left 7th rib, ( picture #1)

(9) The physician adds a gentle compressive force, with an axis vector

directed from his/her axilla toward the 7th rib being monitored.

(10) The physician simultaneously introduces sidebending away and

extension toward the opposite restricted barrier, with moderate

acceleration, while maintaining the gentle compressive force.(picture #2)

(11) Release and RECHECK

• Picture #1• Expiratory SD left 7th rib

• Initial position

• Picture #2• Expiratory SD left 7th rib

• Final position

• *** Note: Everything reverses sides for right sided somatic dysfunction

Example: Inspiratory Somatic Dysfunction, Left 7th Rib

(7) Repeat steps 1-6 with physician’s right arm extending over over patient’s

upper back, with physician’s axilla resting on patient’s left shoulder.

(8) While physician monitors patient’s left rib with physician’s left hand, the

physician sidebends the patient to the right (away from physician), until

motion is fealt at the left 7th rib, followed by extension of the patient until

motion is fealt at the left 7th rib (picture #3).

(9) The physician adds a gentle compressive force, with an axis vector,

directed from the physician’s right axilla on the patient ‘s left shoulder

toward the patient’s left 7th rib, which is being monitored.

(10) The physician simultaneously introduces sidebending to the left, toward

the physician, and flexion toward the restricted barrier, with moderate

acceleration, while maintaining the compressive force (picture #4).

(11) Release and RECHECK

• Picture 3• Inspiratory SD left 7th rib

• Initial position

• Picture 4• Inspiratory SD left 7th rib

• Final position

• ***Note: Everything reverses sides for right sided somatic dysfunction

Seated Still Technigue for Thoracic and Lumbar Somatic Dysfunction (SD) T3-12 and L1-5

(1) Note, when treating upper thoracic somatic dysfunction, T1-4, the

physician uses the head and neck to control the force and movement.

(2) Treating somatic dysfunctions of the lower thorax and lumbar, T5-L5, the

physician can use his/her method of choice, the Osteopathic Salute,

physician forearm across upper back, or controlling patient anteriorly with

physician’s forearm, wrist, and hand. Whichever technique is used, the

student needs to demonstrate control of patient and monitoring segment.

(3) The technique included from page 425 of Nicholas, showing thoracic

somatic dysfunction, can be modified to treating lumbar somatic

dysfunction, as shown in lab.

(4) Remember, Type II SD is taken to the freedom in all three (3) planes, while

type I SD is treated in neutral position, and taken to the freedom in side-

bending and rotation only (opposite), while monitoring apex of the curve.

Ligamentous Articular Strain(LAST)

• Dallas Osteopathic Study Group

Rollen Becker, D. O.

Alan Becker, D.O.

Neil Pruzzo, D.O.

Herb Miller, D.O.

Robert Fulford, D.O.

Conrad A. Speece, D.O.

William Thomas Crow, D.O.

Steven L. Simmons, D.O.

Ligamentous Articular Strain (LAST)

The term LAST describes the somatic dysfunction that occurs in the ligamentous structures that surround a joint.

The tension in all the ligaments and structures surrounding a normal joint are generally balanced, keeping structures around the bones and joints balanced. This balance prevents bones from being jammed together, pulled apart, shifted, twisted, or bent.

The goal of LAST is to balance the tension in both ligaments

and maintain that equal tension until the body re-centers the

bones by tightening the lax ligament.

LAST (Cont’d)

When somatic dysfunction or injury occurs, one bone in the joint

is disrupted out of its physiologic and balanced position, and ligaments become strained.

The more lax ligament is the strained one.

Goal: Balance the tension in the ligaments, and maintain this balance until

tightening of the lax ligaments, and physiologic position of the joints

bones, and tissues.

Iliolumbar ligament

Symptoms: Pain in the low back, radicular pain down the back of

leg, restricted motion of the SI joints, and lumbar

spine.

Position: Lateral recumbent direct ligamentous articular release

Knees and hips flexed

Technique: Push anterior and inferior with your thumb on

Iliolumbar ligament, just superior and medial to PSIS

Iliolumbar Ligament

Piriformis

Symptoms: Spasm slightly posterior and inferiorly to the

superior portion of the Greater Trochanter.

Technique: Lateral recumbent direct myofascial release.

Maintain balanced pressure with thumb pad

down toward the table.

Piriformis

Rationale

» Hold Patients together

» Insurance protocol

• (pre-authorization: 8 visits)

» Keep self together

Exercise Rx: General Principles

» Identify the hypertonic muscle group– This is KEY because this is the dysfunction

– It may well likely NOT be the painful muscle group

» Inhibition should be focused on that group only

» What you are really doing is contracting the antagonists of the dysfunctional, hypertonic muscle. If the theory holds, the hypertonic group is inhibited and thus relaxes.

Exercise Rx: General Principles

• Use reciprocal inhibition to shut down the hypertonic

muscle.– Not unlike Reciprocal Inhibition Muscle Energy

• Exercise prescription allows the patient to retrain the

muscles that have been chronically inhibited – Unlike muscle energy

How often

• Start daily

• Once stable, move to 3x weekly.

Exercise Prescription

• Who’s a candidate?– Just about everyone

• Need to have the cognitive ability

– Special focus on• Folks who seem to need maintenance OMT

• Patients with balance issues

Balance

• One foot

• Arms Crossed

• Eyes closed

• 15 seconds

Motion Testing

• Pelvic clock

• Utilizes pelvic tilt

• Can help make diagnosis

• Can lead treatment goals

• Not just pelvic dysfunction– Can also give clues about lumbar

dysfunction

Core Stability

• The sit-back

• Level 1– Seated on flat surface

– Hips and knees bent to 90 deg

– Back Straight – throughout the exercise• Very Important to avoid injury

– Arms straight out in front parallel to floor• For balance

– Lean back until heels just come off table

– Hold for 30 sec

Muscle Firing Sequence

Hip Extension

Hip extension1. Hamstrings2. Gluteus maximus3. Contralateral lumbars low4. Ipsilateral lumbars low5. Contralateral lumbars high6. Ipsilateral lumbars high

Monitor with1. Middle finger2. Thumb3. Middle finger4. Thumb

Retraining

Hip Extensors (glutes)

• Prone with toes on the table

• Straighten the knee– Concentrate on tightening the gluteus – Do not move on to next step until gluteus can be contracted on

command

• Lift the leg (extend the hip)– Keep the knee straight

• Hold for 5-7 seconds

• Repeat 5-7 times

Stretch is caused by posterior pelvic tilt.

BE CAREFUL NOT TO FALL!

Rectus

Femoris

Stretch

Rectus

Femoris

Stretch

Keep the back straight!

Hold for 20 sec.

Let off for 5 seconds.

Hold for another 20 sec.

Done!

Psoas

Stretch

Stretch is caused by the posterior pelvic tilt

Psoas

Stretch

Keep the back straight!

Keep iliac crests level!!

Hold for 20 sec. Let off for 5 seconds. Hold for another 20 sec. Done!

Piriformis Stretch

Extensor surface of antebrachium on table.

Stretch is achieved as torso is pulled towards the heel.

(hip flexion while elbows stay put)

Piriformis Stretch

Keep the back straight!

Hold for 20 sec. Let off for 5 seconds. Hold for another 20 sec. done!

Levator Scapulae Stretch(right levator scapulae)

• Patient Seated

• Grasp the side of the chair with the right hand

• Rest the left hand on the top of the head

• Flex the cervical spine (slowly)

• Sidebend and rotate to the left until tension is noted in right neck and upper scapula

• Lean the body to the left

• DO NOT PULL with the left hand

• Hold for 20 seconds relax 5 seconds and repeat

Adapted from: Greenman, Philip., Principles of Manual Medicine, 3rd ed.; 2003

Upper Trapezius and SCM Stretch

(right trapezius and SCM)

• Patient seated

• Grasp the side of the chair with the right hand

• Rest the left hand on the top of the head

• Flex the cervical spine (slowly)

• Sidebend to the left and rotate to the right until tension is noted in right neck and trapezius

• Lean the body to the left

• DO NOT PULL with the left hand

• Hold for 20 seconds, relax 5 seconds and repeat

Adapted from: Greenman, Philip., Principles of Manual Medicine, 3rd ed.; 2003

Scalene Stretch

(right scalenes)

• Patient seated

• Grasp the side of the chair with the right hand

• Rest the left hand on the clavicle to stabilize shoulder

• Translate the cervical spine posteriorly (slowly)– Chin tuck

• Sidebend and rotate to the left until tension is noted in right neck – may need to rotate right to get the anterior scalene

• Lean the body to the left

• DO NOT PULL with the left hand

• Hold for 20 seconds, relax 5 seconds and repeat

Adapted from: Greenman, Philip., Principles of Manual Medicine, 3rd ed.; 2003

Exercise PrescriptionKeeping them together once they leave the office

• Be very descriptive about the force and the duration of the exercise

• Be very descriptive about the frequency of exercise

• Keep the exercise simple and short

• Minimize the number of exercises– Try to limit it to 4 exercises

• Alter the exercise program as the patient progresses– Remember to limit it to 4 exercises

References1 CDC/NCHS, National Ambulatory Medical Care Survey, 2012 State and National Summary Tables. National Center for Health Statistics. Vital Health Statistics. Table 30. 2 Kroenke, K., Jackson, J. Outcomes in general medical patients presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up. Family Practice, Oxford University Press, 1998, Vol 15, No.: 398-403 3 Assendelft, W, Morton, S, Yu, E., et.al. Spinal Manipulative Therapy for Low Back Pain. Annals of Internal Medicine 2003; 138: 871-881 4 Greenman, P. Principles of Manual Medicine, 3rd ed. 2003, 103, 493-5705 DiGiovanna, et.al. An Osteopathic Approach to Diagnosis and Treatment, 3rd Ed. 20046 Hall, J,. Guyton, A., Textbook of Medical Physiology, 12th Ed. 7Hoppenfeld S. Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, New York, 1976, pp 143-235.8Kuchera W. Kuchera M. Osteopathic Principles in Practice, 2nd edition, Greyden Press, Columbus, 1994, pp 629-61.9Moore KL. Persaud TVN. The Developing Human: Clinically Oriented Embryology, 6th Edition, W.B. Saunders Company, Philadelphia, pp 433-50. 10Snell, RS. Clinical Anatomy for Medical Students, 5th Edition, Little, Brown and Company, Boston, pp 507-630.11Ward R. Foundations for Osteopathic Medicine, Williams and Wilkins, Baltimore, 1997, pp 784-818.12Nicholas and Nicholas, Atlas of Osteopathic Techniques, 3rd Edition, Wolters Kluwer.

13The Still technique, 2nd Edition, 2006, Richard L. Van Buskirk, D.O., PH.D., F.A.A.O.

14Ligamentous Articular Strain, Osteopathic Manipulative Techniques for the Body, Conrad A. Speece, D.O., William Thomas Crow,D.O., Steven L. Simmons,D.O. revised edition 2009, pg 60-63, 81,90