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4/10/2015
1
OMM and Musculoskeletal
Medicine in the Urgent Care
Leslie Ching, DO
Clinical Assistant Faculty-OSU, OMM Department
May 2, 2015
OOA
Objectives
Review some common and uncommon
causes of musculoskeletal pain in the UC
Review OMM techniques that can be helpful in the UC or in a busy outpatient
clinic
Review home stretches that can be helpful
Ankle Pain
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Case #1
9 yo F gymnast and soccer player presenting with
2 weeks of R ankle pain
Does not recall injury
Hurts to dorsiflex R ankle
No bruising, swelling
Can walk on ankle with minimal pain
No history of lower extremity injuries
PMHx, PSHx, meds is noncontributory (no recent fluoroquinolone use)
#1 continued
PE
Intact cap refill, pulses, sensation
Distal motor strength intact
Limited active and passive ROM only with R
ankle dorsiflexion; otherwise, plantarflexion, inversion, eversion intact
No findings that would require Xray under
Ottawa Ankle Rules
Ottawa Ankle Rules
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#1 continued
Osteopathic
No proximal or distal fibular dysfunction
+R anterior talus
Anterior Talus
Diagnosis
Dorsiflex ankle (either one
at a time or both at the
same time)
If one ankle doesn’t
dorsiflex easily, that ankle
has an anterior talus
Treatment by Articulation
Palpate over ankle joint while stabilizing heel
Grasp forefoot with other hand
Introduce dorsiflexion of ankle to restrictive barrier
Gently repeat the motion against the barrier 8-10 times to improve range of motion
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Treatment by HVLA Intertwine your fingers so 4th
fingers are resting over tibiotalar joint
Place 3-5 pounds of traction, dorsiflexing the foot to the
barrier
Apply a high-velocity low-amplitude thrust towards
yourself to reseat the talus in the mortis joint of the ankle.
Alternative: use 3-4 tugging
motions while at barrier
Retest motion at the tibiotalarjoint.
Knee Pain
Case #2 26 yo slender M presenting with L medial knee pain x 5
months after falling off porch
Had been seen about once a month since then in UC,
repeated knee Xrays showing no signs of fracture or OA
No radiating pain, numbness, tingling
Able to ambulate, but it is somewhat painful—pt could
walk immediately after accident
No swelling, bruising, locking. Some pain with going up and down stairs. Mild crepitus.
No previous injuries
PMHx, PSHx, meds noncontributory
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#2 continued
PE
No bruising, effusion. Sensation, DTRs, distal
strength intact.
ACL/PCL/MCL/LCL intact
Neg McMurray’s
Mild patellar crepitus b/l
On standing exam, patient has flat feet bilaterally and increased Q angle(these are
often linked)
Pes Planus (Flat Fleet)
Patellofemoral Syndrome
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Treatment
Arch supports
Roll bottom of feet on frozen water bottle
Stretch with towel around arch of foot
Vastus MedialisStrengthening
Knee squats
Stand with heels
shoulder-width apart, toes pointing out as far
as possible
Squat ¼ of way down
Come up slowly,
focusing on VM activation
3 sets of 10 reps
Seated isometric contractions
Sit on floor with legs extended and toes
pointed forward,
towel under knees
Flex quads, hold for 10 seconds (check
VM to see if this is
firing appropriately)
10 reps
Case #3
49 yo overweight F presenting for lateral R knee pain x 1 year
Had seen orthopedics, was told that it was not surgical problem
Pain with ambulation.
No radiating pain or paresthesias. No edema, bruising, or previous injury
Had tried steroid injection without improvement
Otherwise, PMHx, PSHx, med hx noncontributory
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#3 continued
PE
No bruising, effusion, joint-line pain. Sensation, DTRs, distal strength intact.
ACL/PCL/MCL/LCL intact
Neg McMurray’s
Mild patellar crepitus but this did not reproduce pain
Osteopathic
Proximal anterior fibular head, reproduces pain when palpated
Fibular Head Anatomy
Treatment of Anterior Fibular Head (HVLA) Var #1
Place pillow distal to knee
Place cephalad hand on
proximal fibular head
Internally rotate foot until
you feel barrier with cephalad hand
Have patient take deep
breath; when pt exhales,
apply thrust down towards direction of table
Recheck
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Treatment of Anterior Fibular Head (HVLA) Var #2
Stand on affected side
Have patient bend affected knee
Place thenar eminence on proximal fibular head
Apply posterior-to-anterior pressure to bring proximal fibular head to barrier
Have patient take deep breath; on exhalation, apply posterior thrust with other hand against thumb (karate chop)
Recheck
Treatment of Posterior Fibular Head (HVLA)
Stand on the dysfunctional side
Flex the hip and knee.
Place cephalad hand in the popliteal space, palm upward, with first MP joint posterior to the fibular head (avoid direct pressure over the anterior fibular nerve).
Grasp the patient’s foot with your caudad hand (top figure).
Flex the knee to the barrier, while simultaneously externally rotating the ankle.
Apply a thrust by flexing the leg with your caudad hand, while you apply an anterior counterforce with your first MP joint (bottom figure).
Recheck
Case #4
33 yo morbidly obese F presenting with 4 days of L knee pain after falling: “I heard it pop”
Pt had h/o ACL and meniscus repair 5 years ago; states she feels similar to how she did when
she tore ACL
Feels like knee is unstable but can ambulate
slowly. Lots of crepitus and pain “below kneecap”
Otherwise PMHx, PSHx, meds hx unremarkable
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#4 continued
PE
Difficult to do physical exam because of body habitus (very large leg)
Mild joint effusion; no bruising
Sensation, DTRs, distal strength intact.
However, did have a positive posterior drawer
Neg ACL/LCL/MCL
Couldn’t do McMurray’s
Mild patellar crepitus
Also had sulcus sign of knee
Important confirmatory sign
Sulcus Sign of Knee
Sign of PCL
laxity/tear
Treatment
Pain control
Non-weight bearing
MRI
Ortho referral
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Acute Low Back Pain
Case #5 43 yo non-obese M with no history of low back
pain presents with acute low back pain x 2 weeks
States he was stepping out of a semi cab onto his L leg and “felt like my hip got jammed into my back!”
Since then, has had a lot of LBP and hip pain—states he feels like he is walking funny and one leg is shorter
No radiating pain, paresthesias, incontinence. ROS otherwise neg.
Noncontributory PMHx, PSHx, med hx
PMP negative
#5 continued PE
Moderate distress
BLE DTRs, sensation, distal motor strength
intact
Neg SLR/Braggard’s
Osteopathic
L innominate upslip
L5 noncompensated (L5FSlRl)
Sacrum L on L
Positive L iliopsoas tenderpoint
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LBP Mnemonic Refresher
L: lower extremity (knee, fibula, ankle, foot
arches)
I: innominate (upslip or downslip)
P: pubic shear
L: lumbars (especially L5)
S: sacrum
I: ilia (anterior, posterior, outflare, inflare)
P: psoas
Example Screen
Palpate bottom of feet for any dropped
cuboid or navicular bones
Dorsiflex, plantarflex, invert, evert ankles
Screen proximal fibular heads
B/l AP compression of pelvis: the most restricted side is the dysfunctional side
Screen continued
Check for upslip/downslip
Upslip: on dysfunctional side, ASIS, pubic bone superior, medial malleolus appears shorter
Downslip: on dysfunctional side, ASIS, pubic bone inferior, medial malleolus appears longer
Have pt flip over
Check L5 and sacrum in static position while pt prone (lumbars flexed, sacrum extended)
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Screen continued
Have pt get into Sphinx position (prop up on
elbows)—this extends lumbars and flexes sacrum; recheck findings
Have pt return to supine position: check ilia
for anterior/posterior rotations or inflares/outflares
Check iliopsoas for tenderpoints
Upslipped InnominateFindings
On dysfunctional side
ASIS, pubic bone
superior
Medial malleolus appears shorter
Treatment
Externally or internally
rotate leg to barrier
On patient’s exhale, HVLA thrust or series of short tugs
towards you
Downslipped Innominate
Findings
On dysfunctional
side
ASIS, pubic bone inferior
Medial malleolus appears longer
Treatment
Have patient bounce on affected innominate on firm
surface x 5-7 times
OR
Have patient flex hip and knee
Support leg on your shoulder
Apply cephalad pressuretoischial tuberosity with hand
while having the patient
push knee against your shoulder x 3 times
Recheck
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Psoas TenderpointFindings
Psoas TP is found 2/3
of distance from ASIS to midline and
pressing deeply into the abdomen
May also be found
with iliacus TP (next section)
Psoas Counterstrain Tx
Stand on affected side
Flex pt’s hips and knees
Pull feet/ankles towards tender point
May also need to pull knees towards tender point
Fine tune until tenderness completely alleviated
Hold for 90 seconds
Iliacus TenderpointFindings
Located 1/3 of
distance from ASIS to midline with pressure
in posterior-lateral direction towards ilia
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Iliacus Counterstrain Tx
Stand on affected side
Flex pt’s hips and
knees, support on your knee
Cross pt’s ankles, knees fall out to sides
Fine tune until
tenderness completely
alleviated
Hold for 90 seconds
Non-Cardiogenic Chest Wall Pain
Case #6
A 67 yo M with a history of a MI and s/p CABG (3 years ago) presents with b/l anterior chest wall pain. States that this chest pain has been intermittent since his CABG.
The pain lasts for 15-20 minutes at a time, occurs 4-5x/week, is nonradiating, feels like a dull cramp, and is 4/10. Occurs with raising arms, gets better with putting arms down.
States he has been worked up extensively by cardiologist—has had multiple EKGs, a CXR, an echo, a stress test, and an angiogram since CABG and no cardiac etiology for chest pain was found
No chronic cough
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#6 continued
PMHx: CAD, 2 MI, HLD, HTN
PSHx: CABG 3 yrs ago
Meds: lisinopril, metoprolol, simvastatin, Plavix
Social
50 pack-year smoking hx, stopped smoking 3 years ago
Occasional beer (1-2x/week), no illicit drug use
Wife adds that he used to hang wallpaper until CABG
#6 continued
PE: VSS, RRR, nml S1, S2, b/l CTA, no carotid
bruits, sternal scar consistent with CABG
EKG without acute findings
CXR-no acute findings
Positive b/l pectoralis major trigger points
Associated with inhaled ribs
Pectoralis Major Trigger Points
Evaluate thoracics, ribs, and clavicle
May also have TrPs after MI
(viscerosomatic): 61% of 72 patients
with pec major TrPs in study had cardiac disease (Simons and Travell,
p 833)
Treating TrPs from viscerosomaticorigin may temporarily relieve pain—
CANNOT use temporarily successful
tx to exclude cardiac origin
Postural: rounded shoulders
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Treatment
Counterstrain, direct inhibition, or Still techniques are helpful if trigger point is acute
If more chronic, stretch and spray
If stretch and spray doesn’t work, consider dry needling (no injection) or wet needling (injection of medication, usually lidocaine)
Be very careful with needles around intercostal region, iatrogenic pneumothorax is to be avoided!
Pec Major/Minor Counterstrain
Stand on opposite side of tender point
Adduct pt’s arm across
chest
Fine tune until tenderness
completely alleviated
Hold for 90 seconds
Book and Towel Stretch
Bath towel rolled up to 3.5”
in diameter and place
under head (should reach to lumbars)
1.5” paperback book under
sacrum.
Lie there for 15-20 minutes a day.
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Non-CervicogenicRadiating Arm Pain
Case #7
CC: “I think I have a bulging disc”
A 56 yo F who is a long-distance trucker comes into your urgent care; she is on her way from Arizona to Ohio but needed to stop
History
Her usual partner couldn’t drive with her so she has been having to drive more than she usually does
Pain in her L shoulder going to her neck and down her L arm with some numbness and tingling
No previous history of disc disease
PMHx: OA; otherwise unremarkable
#7 continued
PE
Neuro: DTRs intact, sensation to light touch
limited on affected side in ulnar distribution
of L arm, thumb-finger opposition intact, ptcan cross 2nd and 3rd fingers, 4+/5 L wrist F/E
and elbow E due to pain, restricted shoulder ROM due to pain
Negative Spurling’s/Lhermitte’s
Positive L trapezius and supraspinatus trigger
points (reproduces pain)
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Supraspinatus Trigger Point
DDx includes C5 radiculopathy, nerve root irritation, brachial
plexus injuries, subdeltoid
bursitis, rotator cuff tears, frozen shoulder
Osteopathically, evaluate
thoracics, ribs, scapula (AC), clavicle
May have entrapment of
suprascapular nerve
Postural considerations:
elevation of arms or carrying heavy object
Treatment
Counterstrain, direct inhibition, or Still
techniques are helpful if trigger point is acute
If more chronic, stretch and spray
If stretch and spray doesn’t work, consider dry needling (no injection) or wet needling
(injection of medication, usually lidocaine)
Recommended patient not to prop L arm up on window when driving
Supraspinatus Counterstrain
Stand on affected side and palpate tender
point
Flex pt’s arm to approx45 degrees, abducted
approx 45 degrees,
externally rotated
Fine tune until tenderness
completely alleviated
Hold for 90 seconds
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Wrist Pain
Case #8
53 yo M presenting with 6 months of persistent R wrist pain and swelling
No known history of injury but had been working for years as heavy machine operator; not able to work for several months at this point
No radiating pain, paresthesias
No previous surgery to wrist
Noncontributory PMHx, PSHx, med hx
#8 continued
PE
Intact pulses, cap refill, sensation, finger strength
Minimal edema around ulnar process, no bruising,
warmth, erythema
Mild pain and difficulty with active and passive ROM with wrist extension and flexion
Moderate/severe pain and difficulty with active
and passive ROM with ulnar and radial deviation
Cannot actively do ulnar deviation because of
pain and weakness
Significant tenderness that reproduces pain over
TFCC
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TFCC Anatomy
• Inserts into the lunate and triquetrium
• Stabilizes the distal radioulnar joint
Further Management
Pain control
Xray to rule out fracture
MRI, wrist arthrography
Ortho referral
Persistent Sinusitis
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Case #9
33 year old female with h/o seasonal allergies presents with “bad allergies.”
Has had facial pain, nasal congestion, mild sore throat, mild ear pain, and mild nonproductive cough for 3 weeks. No fevers.
Has already been on augmentin x 10 days. Sx did not really get better.
Taking claritin, flonase (2 sprays/nostril/day), using Neti pot daily, has humidifier in room.
#9 continued
PMHx: seasonal allergies
PSHx: balloon sinuplasty 4 years ago
Does not smoke
PE: VSS
HEENT: TMs and EAC wnl, erythematous
mildly swollen turbinates, postnasal drainage, maxillary and frontal sinuses mildly tender but
not warm, minimal shotty LN
CV: RRR, nml S1, S2
Resp: B/L CTA
Refractory Sinusitis
Very common diagnosis
Patient has continued sx but does not really appear to have bacterial sinusitis at this point
Treatments?
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#9 continued
Consider OMM
Diagnose and treat (in this order)
T1-4
1st and 2nd ribs
Thoracic inlet
Cervicals
OA
Venous sinus release (also good for headaches)
Specific sinus techniques
Review of Venous Sinus Release
OA decompression
Confluence of sinuses release
Occipital sinus release
Condylar decompression
Transverse and straight sinus releases
Sagittal sinus release
Metopic suture release
Venous Sinuses
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OA Decompression
Confluence of Sinuses Release (Hand Position)
Confluence of Sinuses Release
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Occipital Sinus Release
Condylar Decompression
Transverse/Straight Sinus Release
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Transverse/Straight Sinus Release (Lateral View)
Sagittal Sinus Release 1
Sagittal Sinus Release 2
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Metopic Suture Release
Bonus: Knee Pain
Case #10
54 moderately obese F presenting with 2 months of R knee pain
Painful to ambulate, worse in am but gets better within half an hour as she walks around
Crepitus but no locking, instability, edema, bruising, known injury
Pt also wanted to talk about her mild back pain, mild leg edema which she attributed to not moving around so much and shortness of breath that she attributed to being out of shape
Also wanted to talk about a lot of other things
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#9 continued
PE
New 4/6 murmur at aortic listening post
Bibasilar crackles in lungs
1+ pitting edema BLE
Knee exam
No bruising, edema, warmth, jointlinetenderness
Intact ACL/PCL/MCL/LCL
Neg McMurray’s
Xray R knee showed OA
Further WorkupEKG showed LVH
CBC wnl, CMP wnl
BNP nml
Bronchoscopy revealed that mass was pressing into ascending aorta
Biopsy showed nonmalignant tumor, was surgically removed
(Not sure what happened with knee)
CXR
References
Graham KE. Muscle Energy Manual, 2nd edition. OSU.
Mills MV. Venous Sinus Drainage, 2nd Year Lab. 2015.
Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques, 2nd Edition. Philadelphia, PA: WoltersKluwer-Lippincott Williams & Wilkins. 2012.
Simons DG, Travell JG, Simons LS. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1. Philadelphia, PA: Lippincott Williams &Wilkins. 1999.
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Questions?
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