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TECHNIQUE LIST FOR LOWER EXTREMITY LOWER EXTREMETIES (HIP: FEMUR-FEMOROACETABULAR JOINT) The somatic dysfunction is named for the way the muscle likes to go. Ex: A shortened or tight Abductor (Abduction Somatic Dysfunction) prefers abduction and will be restricted in adduction. I. Muscle Shortening (tight hip muscles) Diagnostic Findings – Kimberly, P. 276 1. Shortened Hip Extensors (hamstrings): Supine, Direct Method, ME: 4613.11A, Kimberly, Pgs. 276-277 OMM Muscle Energy Hamstring Stretching 4731 Notes: SHORT OR TIGHT HAMSTRING = your somatic dysfunction. Your hamstrings like to EXTEND AT THE HIP AND FLEX AT THE KNEE. So, you preference of motion for a tight hamstring will be to do the motion it likes. Therefore, to diagnose which hamstring is tighter (which is the one you want to treat), you need to REVERSE The diagnosis that the tight hamstring would normally like to do (so, put the pt into flexion of the hip and extension of the knee). 2. Shortened (quadriceps): Prone, Direct Method, ME: 4613.11F, Kimberly, P. 281 OMM Quadriceps Stretching 4724 Notes: SHORT OR TIGHT QUADS = your somatic dysfunction. Your quads like to FLEX AT THE HIP AND EXTEND AT THE KNEE. So, you preference of motion for a tight hamstring will be to do the motion it likes. Therefore, to diagnose which quads are tighter (which is the one you want to treat), you need to REVERSE the diagnosis that the tight quads would normally like to do (so, put the pt into extension of the hip and flexion of the knee…you really just focus more on flexion at knee here while the pt is prone). 3. Shortened Hip Flexors (Iliopsoas): Supine, Direct Method, ME: 4613.11G, Kimberly, P. 282 OMM Muscle Energy Iliopsoas Stretching 4727 Notes: You best be using a Thomas test to check this out: o This means when they pull their knee to their chest, the other leg (contralateral leg) will bend at the knee and it cannot lay flat on the table = + Thomas test = tight iliopsoas. (if that knee would have stayed flat on the table that is a – Thomas test = not a tight iliopsoas) Absolutely understand you are testing the contralateral (opposite) psoas when the knee is flexed up….you are not testing the psoas on the side you are flexing at the knee and bending to the chest. Be sure you stand on the same side as the psoas you want to treat, while bracing the opposite ASIS. Let that leg hang off the table on the side you want to treat (just to where the femur comes to the edge) and brace at the quads, not on the knee o This puts that psoas into extension which is exactly opposite the way it likes to go (you better know that the tightest hip flexor in the body = the iliacus (so this is included in the iliopsoas). 4. Shortened Hip Adductors: Supine, Direct Method, ME: 4613.11B, Kimberly, Pgs. 277-278 OMM Muscle Energy Hip Adduction Stretching 4728 Notes: If you have SHORT HIP ADDUCTORS = your somatic dysfunction. These like to adduct, so the preference of motion will be to adduct, meaning it will not like to abduct at the hip. Therefore, you need to TEST IN ABDUCTION, and whichever has restricted motion = the side you want to treat. Remember to stand on the same side as the dysfunction when treating, and this time you brace the ASIS ON the side you are treating. 5. Shortened Hip Abductors: Supine, Direct Method, ME: 4613.11C, Kimberly, P. 278 OMM Muscle Energy Hip Abduction Stretching 4730 Notes: If you have SHORT HIP ABDUCTORS = your somatic dysfunction. These like to abduct, so the preference of motion will be to abduct, meaning it will not like to adduct at the hip. Therefore, you need to TEST IN ADDUCTION, and whichever has restricted motion = the side you want to treat. Remember to stand on the opposite side of the dysfunction, bracing the ASIS on the side you are treating. II. Rotators 6. Internal Rotation with Posterior Glide Diagnostic Findings – Kimberly, P. 269 Supine, combined method, ME: 4611.11A, Kimberly, Pgs. 269-271 I cannot find a video for this 7. External Rotation with Anterior Glide Diagnostic Findings – Kimberly, P. 273 Supine, combined method, ME: 4612.11A, Kimberly, Pgs. 273-275 I cannot find a video for this 8. Piriformis – Muscle Energy Nicholas Atlas, P 301 OMM Muscle Energy Piriformis Stretching 4726 Notes: You better know that the piriformis is an external rotator when the leg is extended and when the knee is flexed it is an abductor. How to find this TP: o Have the pt laying prone, find the iliac crest, find the PSIS on both sides, come medial to the sacral base, and in between this and the ILA there is a midpoint on the lateral boarder of the sacrum (mark this with a finger). Now find the greater trochanter, and in between this and where you have your finger = TP Stand on the same side as the dysfunction, while your finger is on the TP and your pt is prone, flex the knee and internally rotate at the hip (the opposite of what the piriformis likes to do). Do this by letting the foot and leg fall out from the midline towards you. Have the pt try to resist this by externally rotating (pulling their leg back in towards the midline) III. Counterstrain (THIS IS INDIRECT…YOU ASSIGN the pain scale, never move your finger off the TP, set it up, and hold them for about 90 seconds (“Find it, fold it, hold it”), then you move the pt back to the original position they were in (don’t let them help you and your finger should still be on the original TP), then reassess) 9. Posas Major TP, Nicholas Atlas, P. 279 OMM Counterstrain Psoas Tenderpoint 4741 Notes: How to find this TP: o Have the pt laying supine, find their ASIS, go 2/3 into the midline, push straight down Stand on the same side as the TP, and since the psoas likes to flex, flex the hips and knees, and sidebend towards the TP by pulling the ankles towards you until you feel a release or the pain decreases 10. Iliacus TP, Nicholas Atlas, P. 180 OMM Counterstrain Iliacus Tenderpoint 4744 Notes: How to find this TP: o Have the pt laying supine, find the ASIS, go 1/3 into the midline, push down and a little lateral Stand on the same side as the TP, cross the legs by putting the non-dysfunction leg over the dysfunctional leg (the one on the side of the TP) (you can remember this by “good over evil”), flex the hips, let the knee fall out until you feel a release or the pain decreases 11. Piriformis TP, Nicholas Atlas, P. 193 OMM Counterstrain Piriformis Stretching 4742 Notes: How to find this TP: o Have the pt laying prone, find the iliac crest, find the PSIS on both sides, come medial to the sacral base, and inbetween this and the ILA there is a midpoint on the lateral boarder of the sacrum (mark this with a finger). Now find the greater trochanter, and in between this and where you have your finger = TP On the side you want to treat, have the pt prone, hang the leg off the side on the table, Flex the knee and hip, externally rotate the hip and abduct the leg o Can add a small amount of compression to the knee Myofascial Release For both of the techniques = OMM Direct Myofascial Release and Push Pull Technique Iliotibial Band 4739 12. Supine Direct Myofascial Release: Iliotibial Band, Shown on PowerPoint slide. Note: Pt should be supine, you should be on the side of the dysfunction, push medially and posteriorly (about 20lbs of pressure) hold for about 20 sec until you feel a release, then push further and repeat (this is a direct technique) 13. Fascia Lata / Iliotibial Band Kneading (“Push/Pull”) technique on PowerPoint slide. Note: Pt should be prone, you should be on the opposite side of the dysfunction. Flex the knee on the side of the dysfunction, externally rotate that leg at the hip (let the knee and ankle fall out away from the midline) = push, and at the same time you pull the IT band towards you with the other hand = pull. KNEE a. Popliteal fascia release (see lecture notes) OMM Supine Popliteal Fascial Release 4713 i. Patient supine ii. Exert an anterior force with fingers in midline of fossa iii. While patient extends knee (maintaining heel on table), exert a firm, spreading force with fingertips (laterally) iv. Reassess b. Gastocnemius Counterstrain (see lecture notes) OMM Counterstrain Gastroc Tenderpoint 4743 i. since this is counterstrain, THIS IS INDIRECT…YOU ASSIGN the pain scale, never move your finger off the TP, set it up, and hold them for about 90 seconds (“Find it, fold it, hold it”), then you move the pt back to the original position they were in (don’t let them help you and your finger should still be on the original TP), then reassess ii. Pt should be prone iii. Identify Counterstrain points at the proximal insertion of the gastrocnemius (because remember, you have both a medial and lateral head of this muscle…test both by pressing on it.) iv. Treatment is usually aimed at the medial head of the gastrocnemius (although the lateral should also be assessed). v. The knee is flexed, and the ankle is strongly extended with the patient prone add a slight compression force if you’d like vi. Reassess c. Interosseous membrane (Kimberly p. 299 – 4633.11A) OMM Balanced Ligamentous Tension Interosseus Membrane 4745 i. Supine, indirect method ii. Knee in partial flexion with leg resting on DO’s hands iii. One thumb on posterior fibula and other thumb on posterior lateral malleolus (you can invert the foot too) iv. Balance of ligamentous tension done with respiratory phases d. Fibular head dysfunction (Kimberly p. 294-298 – 4631.11A, 11B, 11C, 11D; 4632.11A, 11B, 11C) OMM Diagnosing Fibular Head 4740 Check both anterior and posterior motion, and then medial and lateral motion As you plantar flex, and invert, and adduct = moves the fibular head posterior (and the lateral malleolus As you dorsiflex, and evert, and abduct = moves the fibular head anterior (and the lateral malleolus posterior) Diagnose the way the “spring better” at the fibular head = the way they like to go i. Muscle energy techniques for posterior fibular head (4631.11C) OMM Seated Direct Method Muscle Energy Fibular Head Posterior 4722 1. Patient seated with leg hanging off table 2. DO places thumb behind fibular head posteriorly, applying and anterior force 3. DO dorsiflexes and everts the foot 4. Patient is instructed to “turn your foot inward” with DO counterforce 5. Recheck after routine time / repeats ii. Muscle energy technique for anterior fibular head (4632.11B) OMM Seated Direct Method Muscle Energy Fibular Head Anterior 4723 1. Patient seated with leg hanging off table 2. DO grasps fibular head between thumb and middle finger, applying a posterior force 3. DO plantarflexes and inverts the foot 4. Patient is instructed to “turn your foot outward” with DO counterforce 5. Recheck after routine time / repeats TECHNIQUE LIST ANKLE AND FOOT I. Ankle Talotibial Joint 1. Deltoid Stretch (Shown in Lab) OMM Ankle Deltoid Stretch 4765 Notes: dorsiflex and evert while stretching 2. Talus Plantar flexed with anterior glide OMM Talar Tug Talus Plantar Flexed with Anterior Glide Supine Direct Method HVLA 4778 a. Diagnostic Findings, Kimberly Manual-Pg. 300 b. Supine – Direct Method – HVLA, Kimberly Manual-Pgs. 300-301, 4641.11A Note: They will like plantar flexion with this, so when you put them into dorsiflexion, the one that is restricted you treat - bring into dorsiflexion and give a quick tug 3. Lateral Ankle Fibularis or Peroneus Longus, Brevis, or Tertius OMM Lateral Ankle Fibularis or Peroneus Longus Brevis Tertius Counterstrain 4780 doesn’t link correctly (you will see today) a. Counterstrain, Nicholas Atlas, P. 211 (see this for location of TP) II. Foot Talocalcanel Joint 4. Eversion with anteromedial glide of talus OR inversion with posterolateral glide of talus a. Diagnostic Findings, Kimberly Manual-Pg. 303 Notes: KNOW when you invert (supinate) posterior lateral glide of the talus , and when you evert (pronate) anterior medial glide of the talus b. Seated – Direct Method – Articulatory with traction, Kimberly Manual, P. 303, 4651.11A OMM Eversion with Antemedial Glide and Inversion with Posterolateral Glide 4768 Notes: apply traction make a figure 8 Intertarsal Joints 5. Cuboid everted with plantar glide OR Navicular inverted with plantar glide OR cuneiform plantar glide a. Diagnostic Findings, Kimberly Manual-Pg. 306 b. Supine – Direct Method – Articulatory with patient cooperation, Kimberly Manual, Pgs. 307-308, 4652.11B OMM Cuboid Everted With Planted Glide or Navicular Inverted with Plantar Glide 4767 Note: For the transverse arch, if any of the three things are wrong then this can cause a drop in the arch (flat floot): - Navicular inverted, Cuboid everted, or cuneiform dropped down Plantar Fascia 6. Flexion Calcaneus/Quadratus Plantae a. Counterstrain, Nicholas Atlas, P. 212 OMM Plantar Fascia Flexion Calcaneus Quadratus Plantae 4773 Note – plantar flex the foot and try to wrap the foot around the TP as much as you can