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67 Cards in this Set
- Front
- Back
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Superior Shear
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ASIS - superior
PSIS - superior Pubic ramus Pelvic pain Ipsilateral SI joint and pubes Etiology – fall to the buttocks same side |
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Anterior Innominate Rotation
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ASIS more inferior
PSIS more superior ipsilateral hamstring tightness/spasm and sciatica are common complaints tissue changes at ILA of sacrum same side as well as iliolumbar ligament tenderness freedom of motion anteriorly |
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gold standard as to whether or not you have a shear
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ischial tuberosities and medial maleolus
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Anterior Ilium Rotators
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Tensor Facial latae muscle
Quadratus lumborum Iliocostal muscles Internal abdominal oblique muscles Latissimus dorsi muscle |
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Tensor fascia latae
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Origin:
Anterior lateral iliac crest Insertion Anterolateral tibia below the plateau |
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Quadriceps
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Origin:
Rectus femoris – AIIS Insertion: Tibial Tuberosity via patellar ligament |
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Posterior Innominate Rotation
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ASIS - superior
PSIS - inferior Inguinal/groin pain Medial knee pain Inguinal tenderness Tissue changes at the sacral sulcus Etiology -tight hamstrings |
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Posterior Rotators
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Gluteus maxiums muscle
Semitendinosis muscle Biceps Femoris muscle Semimembranosus muscle Piriformis muscle (weak) External abdominal oblique muscle |
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Hamstrings
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Origin:
Ischial tuberosity Insertion: Lateral condyle tibia Lateral aspect head of fibula |
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Fibular Head Mechanics
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Rotate foot and ankle dorsiflex-> medial maleolus is displaced posteriorly, brings fibular head anterior
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Quadratus Lumborum
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Origin @ iliac crest and iliolumbar ligament
Attached to the 12th rib, iliac crest, and transverse process L1-4 Functions with respirations Stabilizes the origin of the diaphragm |
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Quadratus Lumborum innervation and function
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Innervation – T12, L1, L2, L3
Bilateral – extension Unilateral – extension and ipsilateral sidebending |
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Quadratus Lumborum Spasm
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Low back pain
Referred to the hip and groin Exhalation 12th rib dysfunction Diaphragm restriction |
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Psoas Syndrome
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A spasm and/or an irritation of the psoas muscle
Usually develops as a bilateral psoas spasm Eventually concentrates more on one side Key somatic dysfunction is a non-neutral dysfunction of L1 or L2 May be seen in the acute or chronic stage |
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Functional Anatomy (Psoas)
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Psoas origin L1-4 (L5)
Extends over the superior pubic ramus and under the inguinal ligament Inserts on the lesser trochanter on the medial side of the femur Innervated by lumbar nerves 2 & 3 Flexes trunk on thigh, flexes lumbar spine, and laterally flexes lumbar unilaterally Shortens and externally rotates the leg |
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Organic Causes (Psoas syndrome)
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Must first rule these out:
Femoral bursitis and arthritis of the hip Iliac or femoral phlebitis Retroperitoneal lymphadenopathy Diverticulitis of the colon Cancer of descending or sigmoid colon Renal or urethral dysfunction (calculi) Prostatitis, salpingitis, appendicitis |
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Functional Etiology Psoas syndrome
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Sitting in a soft chair or slumped in a hard chair
Bending over at the waist for a long period of time (e.g.... weeding or working at a desk) Then the patient returns to neutral suddenly |
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Physiology psoas syndrome
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The person is in this flexed position
The intrafusal muscle fibers of its spindle tighten to better monitor the relaxed fibers of the psoas muscle Rapid return to neutral produces confusion at the spindles and spinal cord Psoas muscle goes into spasm Inappropriate signals report that they are being overstretched before the muscle’s extrafusal fibers have reached their usual resting length = spasm of the psoas |
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Somatic Findings (Example Left Psoas Spasm)
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At first both are involved causing flattening of the lumbar spine (forward bending)
Then one usually becomes more prominent L1 or L2 will rotate left then sidebend left Then the rest of the spine sidebends left The other vertebrae act according to Type I Remember that L1 or L2 is the key lesion of any psoas syndrome If the spastic psoas carries through to the sacrum, the left sidebending induces a non-neutral sacral response (lumbar flexed) Left oblique axis is engaged Sacrum rotates right Shallow right sacral sulcus (deep left) Prominent ILA on the right Pelvic side shift occurs to the opposite side Opposite piriformis spasm occurs May get sciatic nerve irritation opposite (on same side of piriformis spasm) Gluteal muscular and posterior thigh pain that does not go past the knee (opposite side) |
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Symptoms (Left psoas syndrome)
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First there’s pain when the patient sits especially sitting straight
Vague pain in lumbar or lumbosacral area Soon the key lesion pain leaves and moves down and over to the right sacroiliac joint Now the patient is bent forward and to the left but doesn’t have much pain Left leg short and externally rotated Right piriformis is involved so pain includes the gluteal area on right Then the sciatic irritation occurs Pain develops down the posterior thigh Notice that although the pain may be similar to a disc problem, the posture of a psoas patient would lead to worsening of the symptoms |
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Treatment: Psoas syndrome
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Depends on acuteness and syndrome stage
Remember to r/o and treat any organic cause Use counterstrain on the iliopsoas point patient supine with knees flexed Ice (heat would irritate/worsen problem) As acuteness recedes, HVLA of key lesion MUST cool down an acute muscle - do not stretch |
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Chronic Psoas Shortening
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If left untreated may get fibrosis of muscle
Thomas test - pt supine, flexes hip, if other knee raises from the table then it is positive Treatment is to stretch it Above position and operator pushes the affected knee toward the table, the patient tries to pull opposite knee toward chest, hold position 6 secs, pt relaxes, repeat |
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Weak Psoas
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Allows excessive backward bending of the lumbar spine because of strong back muscle
Increase lordosis, protruding abdomen Treatment - Pt supine and Dr... has a hand palm up under midlumbar area Pt asked to push against Dr.’s fingers (told not to use abdominals) for count of 6 Pt should do this 3-4 times twice a day Will see a decrease lordosis in one month |
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Piriformis Syndrome
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Peripheral neuritis of the sciatic nerve caused by an abnormal condition of the piriformis muscle
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Origin: Piriformis
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Anterolateral border of the sacrum at the sacroiliac joint capsule
Anterior portion of the sacrotuberous ligament |
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Insertion: Piriformis
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Superomedial aspect of the greater trochanter of the femur
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Sciatic Nerve Tract
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Passes through the greater sciatic foramen
Under the piriformis Posterior thigh |
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Sciatic Nerve Variations
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Common peroneal and tibial components remain separate in 10%
One of them passes directly through the piriformis muscle Piriformis arises from 2 tendinous origins with the sciatic nerve passing between them in 10% |
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Causes of Irritation: Piriformis
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Piriformis muscle spasm
Piriformis contracture Local trauma to the buttocks Repeated mechanical stressors (running) Sacral base unleveling Pelvic instability Excessive local pressure, especially in thin or cachectic patients (hip pocket neuritis) Anatomic variation Local perineural inflammation secondary to the endogenous release of vasoactive substances from an inflamed piriformis muscle |
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Symptoms: Piriformis syndrome
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Easily confused with herniated disk disease or facet joint pathology
Hip and buttock pain radiating down the posterior thigh Sometimes to the calf or foot Low back pain not common Usually no neurological deficits |
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Physical Exam: Piriformis
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Muscle strength, sensation, DTR normal
Extreme tenderness along the piriformis May produce radicular pain when palpated Gluteal tender points may be present |
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Assessment of piriformis – patient prone
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Patient prone
Knees flexed Hold the ankles Internally rotate both hips until you feel resistance Compare |
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Treatment of Piriformis
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OMT!!!!!!!!
Muscle energy techniques Myofascial techniques to lumbar and lumbosacral area Counterstrain Myofascial release of the sacrum Trigger-point therapy |
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Assessment of piriformis– patient supine
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Patient supine
Leg grasped above the ankle Internally rotate both hip joints until you feel resistance Compare |
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Muscle Energy Technique
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Definition: Per Glossary of Osteopathic Terminology3
A System of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the physician; this directed patient action is from a precisely controlled position, against a defined resistance by the physician First used by Fred L. Mitchell, Sr., D.O. Classification: Direct technique |
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Indications for muscle energy
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Mobilize joints in which movement is restricted
Stretch tight muscles and fascia Lengthen muscle fibers & decrease hypertonicity Reduce the restraint of movement Improve local circulation Alter related respiratory and circulatory function Balance neuromuscular relationships to alter muscle tone Strengthen the weaker side of an asymmetry |
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Oculocervical (Oculogyric) Reflex
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When a patient makes certain eye movements, certain cervical & truncal muscles contract, which reflexively relax the antagonist muscles
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Respiratory Assistance
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Physician directs the forces of respiration to the area of s.d.
Simultaneously uses a fulcrum (hand) to direct the s.d. through the barrier |
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Postisometric Relaxation
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“immediately following (an isometric) contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotatic reflex opposition. All the operator needs to do is resist the contraction and then take up the slack in the fascias during the relaxed refractory period.” -Mitchell, Jr.
Following increased tension on the Golgi tendon receptors (contraction), there is a refractory period in which there a muscle relaxation (lengthening |
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Joint Mobilization using Muscle Force
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Similar to HVLA but the patient actively contracts muscles to cause movement
Use patient positioning & muscle contractions to restore motion |
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Reciprocal Inhibition
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Contract an agonist to relax the antagonistic muscles
Ex. Biceps / Triceps |
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Absolute Contraindications of muscle energy
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Fracture, dislocation or severe joint instability at treatment site
Uncooperative patient |
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Relative Contraindications
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Moderate to severe muscle strains
Advanced osteoporosis Severe illness Examples: Post-surgical patient Patient on monitor in intensive care unit who is having a Myocardial infarction. |
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Muscle Energy (how to)
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Engage the barrier in three or more planes
Reverse the s.d. diagnosis Patient contracts into the freedom of motion with a small amount of force for 3-5 seconds into the freedom of motion - Against physician resistance Wait 1-2 seconds (allowing tissues to relax) Physician re-engages the barrier (Take up the slack) Repeat 3-5 times Recheck |
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Lumbar Vertebral Body
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Large size
Designed to support postural weight Wedge Shaped Higher in front Maintains lordosis Landmark L4 at level of iliac crest |
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The Vertebral Processes
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Spinous process
Quadrangular Same level as vertebral body. Transverse Process Long and thin Directed laterally |
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Intervertebral Motion
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Flexion / Extension**
Because facets are lined backward & medial couples with ventral-dorsal translatory slide Sidebending couples with contralateral translatory slide SR – Translates left Rotation couples with disk compression |
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Lumbar Musculature: Latissimus dorsi
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Origin:
Humerus Insertion: T7-12 Iliac crest Thoracolumbar fascia Action: Humerus motion and raises body to arms during climbing Innervation: Thoracodorsal nerve (C6-8) |
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Hypertonicity in the Latissimus dorsi can yield pain
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in the shoulder
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Lumbar Musculature: Gluteus maximus
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Origin:
Thoracolumbar fascia Dorsal sacrum Insertion: Iliotibial band Femur Action: Extends hip and stabilizes torso Innervation Inferior Gluteal nerve (L5,S1-2) |
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Lumbar Musculature: Erector Spinae
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Origin & Insertion:
Sacrum to cervical Includes: lumbar region Spinalis Longissimus Iliocostalis Action: bilateral contraction extention unilateral contraction extension, ipsilateral sidebending |
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Lumbar Musculature: Quadratus Lumborum
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Origin:
Inf. border of 12th rib and tips of lumbar transverse processes Insertion: Iliolumbar ligament & iliac crest Action: bilateral contraction creates extension unilateral contraction causes extension with ipsilateral sidebending Innervation: T12,L1-4 ventral rami |
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Lumbar Musculature: Multifidus & Rotatores
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Postural muscles
Action: Control individual vertebral motions Bilateral contraction - local extension Unilateral contraction - lateral flexion with contralateral rotation |
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Abdominal Muscles
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Synergistic action creates forward bending
Sit-ups Strong abdominal muscles decrease stress on low back |
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Lumbar musculature: Illiacus
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Origin:
superior 2/3 of iliac fossa inner lip of illiac crest ventral sacroilliac and iliolumbar ligaments upper lateral sacrum Course: iliac spines & capsule of hip joint Insertion: Lateral tendon of psoas |
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Lumbar musculature: psoas major
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Origin:
Transverse process of T12-L5 Course: along pelvic brim behind inguinal ligament in front of hip joint Insertion: Lesser trochanter of Femur Action: Flexes and internally rotates hip Innervation: L1-3(2-4) ventral rami |
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Lumbar Musculature: Iliopsoas
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Important in function and stability
Actions: Flexes thigh on pelvis Flexes trunk forward Lumbar sidebending (unilateral contraction) Constant activity in erect posture Prevents hyperextension of hip in standing |
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Anterior Longitudinal Ligament
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From the base of the occiput
To the anterior sacrum |
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Posterior Longitudinal Ligament
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From posterior body of the axis
To the sacrum |
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Iliolumbar Ligament
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Attaches:
Transverse processes of L4 & L5 & iliac crest Increase stability at the lumbosacral junction Commonly strained in traumatic injuries First ligament to become tender with lumbar posture changes Tender area 1” superior & lateral to PSIS on the crest |
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WORRISOME back pain
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Severe low back pain of sudden onset and without history of trauma
Dissecting aortic aneurysm Pain that wakes the patient from sleep Malignancy until proven otherwise! Rapidly progressing neurological deficits Epidural abscess/ infection Claudication symptoms with back pain Spinal stenosis |
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Somatic Dysfunction of the LS Spine
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Low Back Pain
Increased muscle tension, Aching pain Treatment: OMT Lumbar region Other areas which may affect the Lumbar area – after all – THE BODY IS A UNIT! Sacrum, Innominates, Psoas, Lower extremities as well as other areas. |
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LUMBAR SOMATIC DYSFUNCTIONS
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Make a diagnosis: Lumbar vertebrae follow Fryette’s mechanics
Type I Lesion Neutral Sidebend & Rotate in Opposite Directions Group Type II Lesion Flexed or Extended Sidebend & Rotate to Same Direction Single |
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Lumbar Muscle Energy
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Account for all 3 planes of motion:
Coronal (sidebending) Horizontal (rotation) Sagittal (FB or BB) *Remember Drs. Evans & Stephany Esper demonstrating motion using the Cut-outs? |
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FDR
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Flexion Dysfunction
Down (Rotation side of S.D. down) Recumbent (that’s lateral rec.) Patient: Lateral recumbent Extends the lumbar spine Erector Spinae & Q.L. – Bilaterally engaged Rotate into the barrier Some multifides & rotatores When the leg is lifted Sidebends the spine into the barrier Erector Spinae & Q.L. – Unilaterally engaged |
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SUE
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Sim’s (Lateral Sim’s)
Up (S.D. side up) Extension dysfunction Patient in the Sim’s flexes Psoas & Abdominal muscles) rotates the lumbar spine into the barrier Some multifides & rotatores Dropping the legs off the table Sidebends into the barrier by unilaterally engaging erector spinae |
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Type I Somatic Dysfunction
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Pt conVEX up, lateral recumbent
Ex. Here is N RRSL Doc faces patient & monitors apex Flex knees and hip until motion felt Psoas & Abdominal muscles Doc lifts both ankles toward the ceiling until motion at apex Sidebending component Pt pushes legs toward floor against doc’s isometric resistance |
