Marian University - inosteo.org Annual...“Under Foot! OMM Clinical Pearls” Indiana Osteopathic...

“Under Foot!OMM Clinical Pearls”

Indiana Osteopathic Assoc. (May 2016) Michael L. Kuchera, DO, FAAO (MUCOM)

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Michael L. Kuchera, DO, FAAO

Professor Osteopathic Manipulative Medicine

[email protected]

Marian University –College of Osteopathic Medicine

Marian University College of Osteopathic Medicine& Home Office of the Indiana Osteopathic Association



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Dozen (+/-) Clinical Pearls to Toss Out

Use in 3 Common Conditions

Multi-Task; Multi-Use

Exposure to Multiple Methods

Short Time so 3 Labs to Practice

Clinically-Useful Stuff



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1. Clinical pearls that “stick” with you

2. Something practical that you can

take back to your patients

3. Integrate structure & function for OMT

4. Provide ongoing resource options

◦ Myofascial TrP electronic text

Other: Lower Extremity

information (Foundations for

Osteopathic Medicine - LE author)

5. Sneak in some EBM

Caught You Flat Footed! Know Your “Arch Nemesis”◦ Lab 1a: “Bootjack” Technique Hindfoot-Midfoot Integration

◦ Lab 1b: Hiss Whip & Locke Technique Navicular-Cuboid-Cuneiform

◦ Lab 1c: Soft Tissue OMT Arches

Malicious Malalignment Syndrome: Are These Knees

Made for Running?◦ Lab 2a: Counterstrain Vastus medialis & patella

◦ Lab 2b: BLT Tibiofemoral joint

Recurrent Ankle Sprains◦ Lab 3a: BLT Talocalcaneal through Fibular Head

◦ Lab 3b: Muscle Energy & HVLA Talus-in-the-Ankle-Mortis



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“Because my genetic programmingprevents me from asking directions…

...that’s why!!!”

After: [email protected] to MU-COM SAAO

The Lower Extremities are the Foundation of body & a major

determinant of posture, balance, gait, etc

Talocalcaneal = “Shock Absorber” ◦ Functional Demand Can calculate “Accumulated Impact

Loading”

Major Biomechanical Risk Factors: ◦ Malicious (“Malignant”) Malalignment Syndrome: Predictable

Somatic Dysfunction; Coxa varus with Genu valgus with Increased

Q-angle; Pronated Foot (“highest risk for runners” plus arch problems);

High Levels of Accumulated Impact Loading (AIL)

◦ Supination Ankle Sprain: Most common ankle sprain; Predictable

Somatic Dysfunction; Posterolateral glide of T-C joint; plantar

flexion of ankle joint; posterior fibular head (etc); high AIL



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Factoids for Foot & Ankle

1. Flexibility of foot & stability of ankle are reciprocally related

2. The talus is wider anteriorly so in the mortis joint dorsiflexion is more stable

3. Know most common (supination) ankle sprain pattern backwards & forwards as moves up lower extremity!!!

4. Talocalcaneal (subtalar) joint is the #1 shock-absorber of the foot

5. Pronated foot is #1 risk factor for running injuries

6. Fibular head dysfunctions (esp posterior) increase risk of common fibular nerve involvement (“foot drop”)

7. Somatic dysfunction often maintained by minor glides of the joints that accompany gross motions

Opposites so if

learn one then

know both

Helps to coordinate

OMT approach

Can stack joints to

do fascial

unwinding of LE

region to save time

& integrate

tensegrity



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Note the following elements:◦ Wide hips

◦ Coxa varus (angle < 120o) … n = 120-135o

◦ Genu valgus (Q-angle > 15/20o) … n = 0-20o (age)

… adult Q-angle usually 10-12o

◦ Pronated foot with pes planus (flat-footed)

◦ Talocalcaneal joint SD (anteromedial)

⇧Risk:◦ ⇧Accumulated impact loading with ⇧ascending

injury risk if run (distanceXweight is involved)

◦ Patellar tracking problem/Chondromalacia patellae

Knock-kneed

Flat footed

Memory NOTE = SD opposite supination sprain pattern

Pes planus: “Foundation”

affects posture above; rigidifies

ankle joint; changes functional

leg length; gait; biomechanics

of shock absorption (&

therefore risk of ascending

injury)

Genu recurvatum (concern

about hypermobility, Ehlers-

Danlos, etc; may wish to stick

to indirect OMT; somatic clues

to systemic issues like Marfan

Syndrome)

Dudley J. Morton Foot

Foot-Ankle Relation



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Pronated Foot

Accumulated Impact Loading

Heel Pain (& Plantar Fasciae)

Lab: Treatment of the Pronated Foot & Arches

OMT for the Fallen Arch



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(Mechanoreceptor& Proprioceptor Input)

Chopart

Joint

Lisfranc

Joint

Hindfoot



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Review Ankle-Foot Anatomy

Dudley J Morton Foot: Long 2nd MT

Observe arch:

See if

collapses

under weight

Look for

TART (tender

edges of

“dropped

tarsals” )

Check minor

glides (TART)



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Redoming Plantar Arches

Patient Coop (Toes Up & Down)

Pivot on bottom

Pull edges around

Transverse

Arch

Note importance of

L5 & of peroneus muscles

in both (Note peroneus &

fibular head relationship)



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Visualize

anatomy

Cuboid &

Navicular

drop & roll

2nd cuneiform

drops

inferior

Dropped edge

very tender

Specific Mid-Foot Joint Somatic Dysfunction

◦ Fallen Tarsal or Transverse Arch Muscle Energy & Articulatory

◦ “Dropped” Navicular

◦ “Dropped” Cuboid

◦ “Dropped” 2nd Cuneiform

Specific Forefoot Joint Somatic Dysfunction

◦ Tarsal – Metatarsal Anterior or Posterior Glide

HVLA (“Dr. Locke”) OMT

◦ MTP, PIP & DIP

BLT (Stacking) or FPR

HVLA – Hiss Whip}



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Redome ArchesRedome with MET (Pivot around Thumbs)

Obviously … if part of pronated (flat foot) then need to treat THAT

pattern of somatic dysfunctions and not just the arch

Simple biomechanical / articulatory OMT

Sx: Plantar fasciitis; pes planus; puffy feet Shorten bottom of foot with slight toe bend Stroke with rolling/dragging motion on plantar

aponeurosis Sense softening of plantar fascia & increased ROM in

fore-foot & mid-foot; Less tender medial calcaneal tubercle



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Good for pes planus or rigid midfoot

Both thumbs under

longitudinal arch Wringing motion to

re-establish

Demo: Cuboid & Navicular Somatic Dysfunction

Tender to palpationCentral edge of each

Key Palpatory Finding!



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Best stand with 2-thumb reinforced hold; start “rocking” motion in specific direction of thrust◦ “Whip” is dorsal-medial on the navicular◦ “Whip” is dorsal-lateral on the cuboid◦ “Whip” is straight dorsal for dropped cuneiform

Direct HVLA (Hiss Whip)Cuboid or Navicular or Cuneiform

Direction of “Whip” depends on bone

Navicular: “down” + more medial

Cuboid: “down” + more lateral

2nd Cuneiform: straight “down”



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Direct HVLA

Metatarsal Glide SD

Emphasis on Glide

Short Lever vs Long Lever

Dr. Locke Technique for 1st

Metatarsal

5th MT

Also demo for MTP’s using toe traction

with pressure over metatarsal heads

“Heel Spur” – Sign of failing biomechanics ◦ Treat problem prior to considering

treating spur

Plantar fasciitis

Shoe problem?

Somatic dysfunction foot/ankle

Myofascial TrP’s◦ Quadratus Plantae

◦ Soleus could also cause

Quadratus plantae

MTrP

Soleus MTrP



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Supination with TC

Posterolateral Glide

Pronation with TC

Anteromedial glide

Talus gliding along

articulation on the

calcaneus (Review)

Direct Talocalcaneal

Gap OMT Use traction to unlock

and stabilize the hind-

foot

PLUS Indirect BLT of

Foot/Ankle & MFR

Plantar Fascia Curl toes & use indirect

MFR to balance hind-foot

to rest and release

plantar fascia



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1. Hiss Whip (HVLA: Navicular; Cuboid;

2nd Cuneiform)

2. Locke Glide (HVLA @ foot division)

3. “Bootjack” (Direct talocalcaneal;

Indirect forefoot/midfoot)

4. Redome Arches (MET/Artic/SoftTs)

Choose 1-4

OMT for the

Knee



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Malicious Malalignment Syndrome Q-Angle & Patellar Tracking Syndrome

Buckling Knee Syndrome

Lab: OMT for Knee & Thigh Muscles;

Fascial Unwinding (Entire Lower Extremity)

Often due to tracking disorder of

patella (biomechanical alignment,

muscle imbalance)

Wear cartilage off back of patella

patellar grinding & knee pain

Postural/Biomechanical Model:

Treatment involves OMT to improve

alignment & muscle function/balance

Metabolic Model: Often add

nutriceuticals to help cartilage &

exercise with tonic-phasic issues in

mind

Findings (Note Tonic-Phasic Pair)

• Tight hamstrings (OMT 1st)• Weak quadriceps (esp Vastus

Medialis Obliquus)

VMO Trigger Points



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Biomechanical Alignment: Optimize Q-Angle (OMT to hip &

knee joints; foot mechanics)

Muscle Imbalance: Stretch hamstrings (tonic) strengthen

quadriceps-VMO (phasic); alternatives MET, counterstrain, etc◦ Professional equipment vs simple home exercises

Ergonomic: Educate to reduce kneeling / overuse

Nutritional: Glucosamine – Chondroitin Sulfate

Tensegrity/Balance goal for lower extremity addressing muscles &/or using lower extremity

stacking / unwinding OMT is helpful

PEARL: 1st stretch/tx

Hamstrings; then OMT

Quadriceps; then

strengthen quadriceps

CS opposite MET



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Measure Q-angle (later on own)

Patellar apprehension test

(pay attention to VMO firing)

Perform patellar grind test

Patellar ballotment

Indirect Fascial Unwinding OMT (Simultaneous stack of minor motions of hip-knee-ankle)

◦ “Joint Pump” OMT◦ Exercise Considerations (“PACE” in Pool)



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1. Muscle Balance

(MET Hamstrings)

2. Muscle Balance

(Counterstrain Vastus Medialis)

3. LE Unwinding

(Indirect stacking hip, knee, ankle)

CS: Vastus medialis

LE Unwinding

Supination Sprain Pattern

Addressing Joint &

Muscle Stability

Labs: OMT for Ankle &

Foreleg



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Supination ankle sprain

Most common sports injury in LE

Implications for total body

Predictable somatic dysfunction

pattern

Failure to correct SD recurrence

Ankle Sprain Clinical Discussion:◦ Ottawa Ankle Rule Examination

◦ Classifications (varies # ligs; degree of tear; etc)

◦ Imbalance

Tonic (Gastroc/Soleus)

Phasic (Peroneus/TA)

Section #3a



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Pain in Malleolar Zone or

Midfoot Zone

PLUS one of following … Inability to bear weight

immediately & in EM Dept

A or B Bone Tenderness

(posterior or tip of either

malleolus)

C or D Bone Tenderness

B

D

C

A

97% Sensitivity

Tuning Fork Pearl

Classification by

amount of tear

(Strain Partial

Complete Tear)

Classification by

number of

ligaments

affected (ATF

CF PTF)

Foundations for

Osteopathic Med

Ant Draw(er) Test for ATF Ligament



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Eversion TalarTilt Test

Strong ligament … often bone will fracture before ligament fully torn

BLT

Wrap (RICE):

Talus wider in

front so more

stable in

dorsiflexion (with

posterior glide)Plantar flexion + anterior glide

Dorsiflexion + posterior glide

LAB: Anterior Drawer + Talar Tilt + Ottawa Rule Check + Glides BLT



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SD: Plantar flexed talus in mortise with anterior glide (talotibial joint note perspective difference if say tibiotalar joint)

Hint: Pick lower extremity off table so that minor motion of posterior glide is engaged

HVLA: Traction with slight “scooping” dorsiflexion ME Variation: Pt plantar flex ball of foot against resistance; Accentuate

the posterior glide (minor motion often the KEY)

Try to place 5th

digits over talus

Common in chronic supination sprain

Direct OMT Plantar flex talus with anterior glide to barrier

Dorsiflex talus with posterior glide to barrier

Activating forces

MET rubric

If use HVLA, thrust posteriorly◦ Consider talotibial vs tibiotalar like treated

knee for femorotibial vs tibiofemoral

◦ Lift-traction HVLA for chronic plantar

flexion

MET

HVLA

If dorsiflexed SD …



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Direct or Indirect OMT Supination with posterolat TC glide

Pronation with anteromed TC glide

Activating forces BLT review – take to balance point

(glide PL or AM); use respiratory

cooperation with air hunger

HVLA rubric AM or PL thrust through

talus while stabilizing calcaneus

HVLA

BLT

Fibular Head Often Posterior in Supination Sprain Pattern

Diagnosis & Treatment(Reciprocal Motion of Fibula)

Also longitudinal for Interosseous Membrane

Fibular head

possible impact

on common

peroneal

(fibular) nerve



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1. Plantar Flexed Talus with ant glide

(HVLA traction tug)

2. Talocalcaneal

(BLT for TC posterolateral glide)

3. Fibular Head

(Indirect for posterior FH

PLUS interosseous membrane BMT)

BLT with BMT

BLT of TC joint• Glide talus

posterolateral

• Slight twist of

calcaneus

If Time or If a Fast Group!Integrated BLT in Common

SD in Supination Sprain

Cuboid Plantar glide & lateral rotationNavicular Plantar glide & medial rotationTalocalcaneal Talus slides posterolateralyTalocrural Plantar flexion (anterior glide)Fibular Head Posterior FH (posteromedial glide)Femorotibial Ext Rot (anteromedial glide)

Note that dysfunction extends up to lumbars (less predictable) Kuchera in Foundations of Osteopathic

Medicine



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Congratulations!

[email protected]

“The regimen I adopt will be for the benefit of my patients according to my abilities and judgment.”

--Hippocrates

“Dig On!”

--A.T Still

Marian University - inosteo.org Annual...“Under Foot! OMM Clinical Pearls” Indiana Osteopathic...

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