Muscle contraction

Isotonic: no change in tension

o Concentric: shortening (internal force > external force; raising a weight)
o Eccentric: lengthening of muscle during contraction due to an external force (lowering a weight)

Isometric: no change in length (no approximation of origin and insertion)

Treatment
Direct/Indi
Active/Pas
rect
sive
CS
Indirect
Passive
FPR
Indirect
Passive
Chapmans
Direct
Passive
reflexes
The cervical spine:

Muscles:
o Anterior and middle scalene (elevates 1st rib)
o Posterior scalene (elevates 2nd rib)
o SCM: SB towards, R away, involved in torticollis

Joints:
o Joints of Luschka: articulation of uncinated process and above vertebra

Degeneration and arthritis of intervertebral facet joints = MCC of cervical nerve root
compression

Dull neck pain

Shooting pain/paresthesias

Osteophyte formation/degenerative joint changes/narrowing of intervertebral foramina

OA: occiput and C1 (atlas)

AA: C1 and C2 (axis)

C2-4: rotation emphasis

C5-7: SB emphasis
The thoracic spine:

Landmarks:
o Sternal notch: T2
o Sternal angle: attaches to the 2nd rib and level with T4

Rotation is the main movement

Muscles:
o Diaphragm

Xyphoid process

Ribs 6-12

L1-3
o Intercostals: elevate the ribs on inspiration

Ribcage:
o Tubercle: articulates with corresponding TP
o Head: articulates with vertebra above and corresponding vertebra
The lumbar spine:

Narrowed posterior longitudinal ligament at L4 and L5 makes this the most common level for disc herniation
(also L5-S1)

In the T/L region: the spinal nerve exits BELOW the corresponding vertebra and above the IV disc

MC anomaly of the lumbar spine: facet trophism asymmetry of the facet joint angles; facet joints are more
aligned to the coronal plane (rather than sagittal)

Motion of L5 affects sacrum:

o SB sacral oblique axis engagement on the same side
o R sacral rotation to the opposite side

Low back pain

o Strain/sprain
o Herniated disc: most treated conservatively (no surgery); HVLA is relatively CId
o Psoas syndrome: shortened psoas due to prolonged sitting CS and treat L1/L2

Nonneutral dysfunction (flexion) of L1/L2 on the same side as the tight psoas

Pelvis shift to contralateral side

Sacral dysfunc on oblique axis

Contralateral piriformis spasm

o Spinal stenosis: narrowing of spinal canal/intervertebral foramina due to degenerative changes

Nerve root compression


Similar symptoms as herniated disc

Worse with extension (vs herniated disc)

o Spondylolisthesis: anterior displacement of a vertebra over the one below

L4/L5

Due to fractures of the pars interarticularis of the vertebrae

Aching pain

Stiff leg, short stride, waddling gait

Tight hamstrings bilaterally

Most managed conservatively

HLVA is CId
o Spondylolysis: defect of pars interarticularis w/o displacement of the vertebral body

Diagnose with oblique XR (vs. listhesis: lateral)

Scotty dog

Similar symptoms as listhesis

o Spondylosis: degenerative changes in the IV disc and ankylosing (lipping) of adjacent vertebral bodies
o Cauda equina syndrome: pressure on nerve roots of the cauda due to massive central disc herniation

Decreased DTRs

Loss of bowel/bladder control

Emergency surgery
Scoliosis and short leg syndrome

Scoliosis: rightward protrusion of spine is SB right

o Mild: 5-15 degree Cobb angle *conservative
o Moderate: 20-45 *bracing
o Severe: >50 compromises resp function; >75 compromises CV function *surgery
o MC idiopathic

Short leg syndrome:

o Sacral base unleveling: lower on side of short leg
o Vertebral SB and R: SB away and R toward the short leg
o Innominate R: anterior R on side of short leg
o Increased lumbosacral angle (Fergusons)
o Use heel lift:

Start with 1/16 (1.5mm) in fragile pts

1/8 (3.2mm) in flexible pts

Max of 1/4 inside the shoe (if more require outside the shoe)

Max total:
Sacrum and innominates:

Anatomy:
o Innominates articulate with femur at acetabulum
o SI joint (L shape) converges anteriorly at L2
o Ligaments:

True/sacroiliac: anterior, posterior, interosseous

Accessory:

Sacrotuberous: ILA ischial tuberosity

Sacrospinus: sacrum ischial spines; divides greater and lesser sciatic foramen

Iliolumbar: TP of L4/L5 medial iliac crest

o Muscles:

Piriformis: inferior anterior aspect of sacrum greater trochanter of femur

External rotation, extends thigh, abducts thigh when hip flexed

S1/2

Hypertonicity buttock pain that radiates down thigh but not below knee (11% of pop
have sciatic nerve running through the m)
o Inherent craniosacral motion:

CS flexion sacral extension

CS extension sacral flexion

o Dynamic motion: walking *occurs about the oblique axes

Weight bearing on L leg L sacral axis engagement

Sacral dysfunction
o When L5 is SB sacral oblique axis is engaged on the SAME side
o L5 is F RR SR:

+ seated flexion on the L

Sacrum rotation to the L on a R axis (LOR)

Forward torsion: lumbars are neutral (type I)

Backward torsion: lumbars are nonneutral (type II)

o
o
o

Positive spring

Positive backward bending

Bilateral sacral flexion is a common dysfunction in the post-partum pt (due to birth mecahnics)
Sacral shear = unilateral sacral F/E
Treat L5 first may resolve sacral dysfunction

Upper extremities:

Shoulder
Primary muscles of the
shoulder
Flexion
Anterior deltoid
Abduction
Middle deltoid
Extension
Lat, teres major, posterior deltoid
Adduction
Pec major, lat
External rotation
Infraspinatus, teres minor
Internal rotation
Subscap
o Subclavian a axillary a brachial a radial and ulnar aa

Radial a deep palmar arch

Ulnar a superficial palmar arch

o MC SD of the shoulder: internal and external rotation restrictions
o Common shoulder problems:

TOS:

Compression:
o Anterior and middle scalenes Adsons test
o Clavicle and 1st rib military posture test
o Pec minor and upper ribs hyperextension test

Supraspinatus tendinitis: compression of the greater tuberosity against the acromion

Bicipital tenosynovitis: inflammation of the tendon and sheath of the long head of the biceps

Rotator cuff tear

Adhesive capsulitis: typically due to prolonged immobility of the shoulder after injury

Shoulder dislocation

Winging of scapula

Brachial plexus injuries: Erb Duchennes is MC (C5/6)

Radial n injury

Elbow, wrist, hand

Elbow joint: ulnar and humerus

Flexors (of the wrist and hand) originate near the medial epicondyle of the humerus

Extensors originate near the lateral epicondyle

Pronators (median n): pronator teres and pronator quadratus

FDP attaches to the DIP

FDS attaches to the PIP

Somatic dysfunction:

Swan neck: extension contracture of the PIP (RA)

Boutonniere: flexion contracture of the PIP (RA)

Ape hand: claw hand + thenar eminence wasting (due to median n damage)

Dupuytrens contracture: of the palmar fascia (flexion of MCP and PIP usually of last two digits)
Lower extremities

Hip and knee:

o Primary extensor of knee: quadriceps (RF, VL, VM, VI)
o Primary flexor of knee: hamstrings (SM, ST)
o Head of femur glides anteriorly with external hip rotation
o Head of femur glides posteriorly with internal hip rotation
o Piriformis/iliopsoas spasm external rotation of the hip
Femoral n (L2-4)
Quads, iliacus, sartorius, pectineus
Anterior thigh and medial leg
Sciatic n (L4-S3) tibial n
Hamstrings (except short head of
Lower leg and plantar foot
biceps femoris), plantarflexors, toe
flexors
Sciatic n (L4-S3) peroneal n
Short head of biceps femoris,
Lower leg and dorsum of foot
dorsiflexors, extensors of toes
o Head of femur angulation: b/t neck and shaft of femur (120-135)

> 135: coxa valga

< 120: coxa vara

Q angle: at knee

> 12: genu valgum

< 10: genu varum

o Patellar-femoral syndrome:

Weakness of VM lateral deviation of patella

o Compartment syndrome:

MC: anterior compartment

Due to overuse increased intracompartmental pressure

Compromises circulation within that compartment

Ankle and foot:

o Joints:

Talocrural joint (tibiotalar joint): b/t the talus and the medial malleolus of the tibia and lateral
malleolus of the fibula

Plantarflexion and dorsiflexion

Ankle is more stable in dorsiflexion (80% of sprains occur in plantarflexion)

Subtalar joint (talocalcaneal joint):

Shock absorber

Allows internal and external rotation of the leg while the foot is fixed
o Arches:

Longitudinal:

Medial:
o Talus
o Navicular
o Cuneiforms
o 1-3 MTs

Lateral:
o Calcaneus
o Cuboid
o 4-5 MTs

Transverse: cuboid, navicular, cuneiforms

MC SD of the arches

Plantar glide of one of the bones

o Ligaments:

Lateral stabilizers: prevents excessive supination

Anterior talofibular**MC sprained

o Supination sprains:

I: ant TF ligament

II: ant TF and CF

III: ant TF, CF, post TF

Calcaneofibular

Posterior talofibular

Medial stabilizer: prevents excessive pronation (ankle is more stable in pronation)

Deltoid:
o Excessive pronation fracture of the medial malleolus (more likely than pure
ligament injury)

Plantar ligaments:

Spring (calcaneonavicular): strengthens and supports the medial longitudinal arch

Plantar aponeurosis: calcaneus phalanges

o Chronic irritation: heel spur
Craniosacral motion:

Primary respiratory mechanism:

o Inherent motility of the brain and SC

Lengthens during exhalation

o Fluctuation of CSF

Rate of CRI: 10-14 cycles per min

Increase rate: exercise, fever, after OMT

o Movement of the intracranial and intraspinal membranes

Dural attachments: C2, C3, S2

Reciprocal tension membrane

o Articular mobility of the cranial bones
o Involuntary mobility of the sacrum b/t the ilia

Flexion at SBS: SBS rises

o Flexion of midline bones (sphenoid, occiput, ethmoid, vomer)
o

o External rotation of paired bones

o Extension of sacral base
o Widens head and decreases AP diameter (ernie)
o Inhalation phase

Extension at SBS: SBS descends

o Extension of midline bones
o Internal rotation of paired bones
o Flexion of sacral base
o Thinning of head and increased AP diameter (bert)
o Exhalation phase

Cranial nn:
o V2 dysfunction tic douloureux (trigeminal neuralgia)
o Superior orbital fissure: 3, 4, V1, 6
o 9, 10, 12 dysfunction poor suckling in the newborn

Cranial treatments:
o Venous sinus drainage 568-69

To increase intracranial venous drainage by affecting the dural membranes

T: superior nuchal line

C: middle finger of one hand on the inion

O: 2nd-4th fingers of both hands vertically from inion to suboccipital tissues

S: sagittal suture with crossed thumbs bregma

2nd-4th fingers in opposition at metopic suture

o CV4: bulb decompression:

To enhance the amplitude of CRI

Resist flexion phase and encourage extension until a still point is reached

Then allow restoration of normal F/E

o Vault hold:

Index finger: greater wing of sphenoid

Middle: temporal bone in front of ear

Ring: mastoid regions of temporal bone

Little: squamous portion of the occiput

o Absolute CIs: bleed, increased ICP, skull fracture
o Relative CIs: seizure history, dystonia, traumatic brain injury
Facilitation:

Sensitized interneurons increased output

Autonomic innervation
o Parasympathetics:

Sweating in palms and soles

Decreased number of goblet cells thin secretions (resp epith)

No effect on systemic arterioles

Maintains normal ureter peristalsis

Glycogen synthesis in liver

Relaxes uterus/constricts cervix

X (vagus)

Heart

Bronchial tree

Esophagus, stomach, sm intestine, liver, gallbladder, pancreas

Kidney and upper ureter, ovaries/testes, ascending/transverse colon

Pelvic splanchnics lower ureter and bladder, uterus/prostate/genitalia, descending

colon/sigmoid/rectum
o Sympathetics:

Copious sweating (cholingeric)

Increased number of goblet cells thick secretions

Contracts skin and visceral vessels

Relaxes skeletal muscle vessels

Vasoconstriction of AA decreased GFR decreased urine volume

Ureterospasm

Glycogenolysis in liver

Constricts uterus/relaxes cervix

Respiratory
T2-7
Esophagus
T2-8
Arms
T2-8
Upper GIT
T5-T9
Greater

(before the
ligament of
treitz: b/t
duodenum
and jejunum)
Middle GIT

Lower GIT
(after the
splenic
flexure)
Kidneys
Upper
ureters/gona
ds
Lower ureters
Bladder/genit
alia
Prostate
Legs

splanchinic/celi
ac ganglion

T10-11

T12-L2

Lesser
splanchnic/sup
erior
mesenteric
ganglion
Least
splanchnic/infer
ior mesenteric
ganglion

T10-11
T10-11

T12-L1
T11-L2
T12-L2
T11-L2

Techniques:
o Sympathetic

Rib raising

Soft tissue paraspinal inhibition

Ganglion release

Chapmans

Cervical paraspinal ganglia

o Parasympathetic

Cranial

Sphenopalatine ganglion technique: encourages thin watery secretions through short

intermittently manual finger pressure intraorally to the sphenopalatine ganglion

Condylar decompression: frees passage through the jugular foramen

Vagus nerve influence: manipulation of OA, AA, or C2

Sacral SD treatment

Points:

Chapmans: ganglioform contraction

o Presents vicero-somatic dysfunction
o Does not radiate

Trigger point: hypersensitive focus

o Referred pain
o Taut band within a muscle
o Somatic manifestation of a VS, SV, or SS reflex
o Treatment: vapocoolant spray, local anesthetic

Tender point: hypersensitive points in the myofascial tissues

o Taut myofascial bands
o No referred pain
Myofascial release:

Includes:
o CS
o FPR
o Unwinding
o BLT
o Functional indirect release
o Direct fascial release
o Cranial
o Visceral

Diaphragms:
o Tentorium cerebelli
o Thoracic inlet

Common compensatory pattern: LRLR

Lymphatics:

Major thoracic duct:

o Drains into the junction of the L internal jugular and subclavian vv
Minor thoracic duct:
o Drains into the R brachiocephalic vein
o Drains right UE, right hemicarnium, heart, lungs (except L upper lobe)
Production: 2/3 by liver and intestines
Thoracic duct:
o Cisterna chili (L2) aortic hiatus (T12) neck L major duct
Innervation: sympathetics vasoconstriction and increased peristalsis
o Intercostal nn
o Cisternal chyli: T11
Increases in interstitial fluid pressure (normally -6.3mmHg) increased absorption of lymph into lymph caps
(increased lymphatic drainage)
o If increased above 0, collapse decreased lymphatic drainage:

HTN

Cirrhosis

Hypoalbuminemia

Toxins: rattlesnake poisoning

o Increased entrance of ECF into lymphatics:

Increased arterial cap P

Decreased plasma oncotic P

Increased interstitial oncotic P

Increased cap permeability

CT movement

Fluid fluctuations
Treatment:
o Chapmans reflexes
o Thoracic pump
o Pedal pump
o Cranial
o Thoracic inlet treatment
o Rib raising
o Splenic/liver pump
o Facial sinus pressure/Galbreath technique
o Anterior cervical mobilization
o Extremity pump of Wales
o Sequence:

Thoracic inlet first

Rib raising/paraspinal inhibition

Redome TAD

Lymphatic pumps
CIs:
o Osseous fractures
o Bacterial infections with fever
o Abscess/local infection
o CA