University of Wisconsin – Department of Family Medicine and Community Health Madison Family Medicine Residency Program Osteopathic Manipulative Treatment for the Allopathic Physician (OMT4MD) Module 3 Lab Handout : The Lower Extremity November 30, 2016 In the lower extremity, your conventional orthopedic exam and assessments remain paramount, especially when assessing pain in the LE. The osteopathic examinations discussed here should be considered in addition to your orthopedic exams, but will likely be more relevant in cases where symptomatology is not located at the site of dysfunction. I. Screening the lower extremity a. Active – ask patient to squat and observe movement at hip, knee, & ankle (you are looking for asymmetries and/or restrictions of motion) b. Passive – with patient prone, send an oscillation/fluid wave superiorly from the foot and observe for areas of restriction II. Foot and Ankle (A complete discussion is beyond the scope of the lab. Instead, we focus on diagnosis and treatment of the tibiotalar joint) a. Palpatory scanning (note tissue texture changes or tenderness) - patient supine, foot over edge of table for free motion of ankle b. Diagnosis: Have patient dorsi and plantar flex, note range of motion AND feel for posterior and anterior glide of talus. Repeat with passive motion. c. Example: Dx - anterior talus [which would indicate a restriction to dorsiflexion) d. Treatment: Bring to restriction of motion (both major and minor as able). Using principles of ME, have patient contract in the direction of ease against your unyielding counterforce. Rest, pause, repeat. Recheck. III. Knee (Again, too much to cover in one day, we will focus on femorotibial joint) a. Palpatory scanning (noting tissue texture changes or tenderness), look at major motion b. Diagnosis: Assess minor motions of internal and external rotation: Patient supine with knee supported on physicians thigh. Induce passive motion and assess for restrictions of motion. Example: Dx – tibia externally rotated c. Treatment: Using principles of MFR. Can be direct or indirect. Can add compression or distraction as well to augment treatment (see video on ACOFP site – MFR of knee) IV. Fibular head (aka proximal fibula) a. Often a problem in knee and/or ankle dysfunction b. Diagnosis: with patient’s knee flexed 45 – 90 degrees, grasp fibular head and induce passive motion – anterolateral and posteromedial. c. Example: Dx – posterior fibular head d. Treatment: Using principals of ME. Can be direct or indirect. Use pt's foot position to induce proximal fibular motion to barrier (inversion of the ankle results in posterior motion of proximal fibula), ask pt to move foot in opposite motion (inversion/eversion) against unyeilding counterforce, stretch, repeat. V. VI. Counter Strain points for hamstring, piriformis, calf a. Refer to counterstrain atlas text Muscle Energy for hypertonic quadriceps, hamstring and psoas a. Palpatory scanning (noting tenderness, hypertonicity, or tissue texture changes) b. Diagnosis: Assess barrier using major motions i. quads: knee flexion in prone position ii. hamstrings: knee extension in supine position iii. psoas: hip extension past midline either prone or supine with leg off the table c. Example: Dx - hypertonic left quadriceps, hypertonic right hamstring and psoas d. Treatment: Using principas of ME. Usually direct, can use indirect in the setting of acute injury or severe pain. Bring muscle to barrier, resist pt's motion towards ease, stretch, repeat. VII. MFR of tibiofibular interosseous membrane – if time a. Many applications for this treatment b. Diagnosis: Wrap your 2 hands around the patients tibiofibular joint at the anke and the knee (both ends of the joint), test by inducing passive rotation of the fibula about the tibia, feel for position of ease. c. Example: Dx - intersosseous membrane restriction d. Treatment: Find position of ease, hold and follow patient's body's process toward homeostasis (unwinding). Can use compression to augment by squeezing fibula and tibia together, this puts some slack in the interosseous membrane. Example office visit note documentation using the above S: Nursing notes reviewed. Patient presents for possible osteopathic manual therapy. Jane Deaux is a 35 yo female with no pertinent medical history who complains of pain in her right knee and left ankle for 3 weeks. She tripped getting off her horse and landed "funny." She denies any loss of strength in LE's or numbness. Pain is achy, sometimes sharp with certain movements, never had similar issues before. O: HR 72, RR 16, BP 120/80 General: Jane is healthy, in no distress. Neuro: CN 2-12, strength and sensation grossly intact. Head: atraumatic Eyes: PERRL, EOMI Osteopathic Structural Exam Lower Extremities: pain with palpation of R lateral knee, left lateral ankle, restriction of motion in L knee with flexion, restriction of motion with R knee in extension, restriction of R hip extension, SD as below A: R knee pain, L ankle pain P: Osteopathic manual therapy, as detailed below. OSTEOPATHIC MANUAL THERAPY PROCEDURE NOTE Body Region, Somatic dysfunction: Lower Extremities: L anterior talus, R tibia externally rotated, L posterior fibular head, left quads htn, R hamstring and psoas htn, R tib-fib interosseous mem restriction Treatment Modalities: ME, MFR, CS Results: Patient tolerated well, improved somatic dysfunction, improved pain Patient advised to drink plenty of fluids today. Continue stretching and exercise as able. Follow up in 3-4 weeks.