NOMF: Low Back Pain

Jay B. Danto, DO
Associate Professor & Vice Chair
NMM/OMM Department
COMP-Northwest
Classification of LBP
System Approach Billable (signs & sx’s)
Musculoskeletal Low back pain
Neurologic Radiculopathy
Visceral or vascular Sciatica
Psychologic Duration
Acute (0-3 months)
Idiopathic
Chronic (>3 months)
– Early phase: 3-6 mo
– Intermediate phase
v 6-24 months
Late phase: >2 yrs
MSKTL Pathology
 Functional factors
 Muscles & fascias
 Intervertebral disc
 Facet joints &
supporting structures
 SI joint
 Psychosocial factors
 Metabolic factors
 Inflammation &
chemical sources
Straight-Leg Raising Test

Test: The physician’s cephalad hand monitors the patient’s

contralateral ASIS & he uses the caudad hand to flex the
patient’s leg while maintaining a straight knee.
Results: If pain is felt by the patient in her back or down her leg
at 30 degrees flexion, then this may represent a lumbar
radiculopathy. The physician will have to correlate specific muscle
& nerve tests to confirm the diagnosis. Limited range of flexion,
either unilateral or bilateral, may also be due to tight hamstring
muscles. The patient should be able to flex their leg up to 90
degrees at the hip.
Neurological Testing
NOMF

FUNCTIONAL
DIAGNOSIS OF LBP
 Piriformis Adductors
Iliopsoas TFL
Postural Muscles
hypertonic

Hip Region
Pseuodoparesis

Movement Muscles
weak
Gluteus Gluteus
Medius Maximus
Pseudoparesis: Patient Perception
Muscle Balance
The firing pattern
should be:
1. Ipsilateral
hamstring
2. Ipsilateral Gluteus
maximus
3. Contralateral
e.spinae
4. Ipsilateral e. spinae
Muscle Balance
The firing pattern
should be:
1. Ipsilateral Gluteus
Medius
2. Ipsilateral TFL
3. Ipsilateral QL
4. Ipsilateral e. spinae.
Muscle Balance
The firing pattern
should be:
1. Ipsilateral
hamstring
2. Ipsilateral Gluteus
maximus
3. Contralateral
e.spinae
4. Ipsilateral e. spinae

Muscle Balance
The firing pattern
should be:
1. Ipsilateral Gluteus
Medius
2. Ipsilateral TFL
3. Ipsilateral QL
4. Ipsilateral e. spinae.
 Lumbar Sidebending Test of QL

Positive

Negative

Hip Extension Test Piriformis ROM Test

Patient Position: Supine with her A
buttocks very near the end of the
table; The patient actually starts in
the seated position at the end of the
table with her feet supported by a
stool & just lays down.
Test: The patient is then instructed
to grasp the thigh behind one knee B
and bring it to her chest. The stool
is removed & the other leg is
allowed to dangle. The dangling leg
should extend downward toward
the ground (figure A). A tight
iliopsoas or rectus femoris will
result in loss of extension (figure B).
The tight rectus can be removed
from the equation by help from the C
physician who straightens the knee
(figure C). Check both sides.
NOMF

FUN WITH OMT &

ACUPRESSURE
Bladder Channel

http://www.acupuncture.com.au/education/mer
idians/urinarybladder-meridian.html
Kidney Channel

http://www.acupuncture.com.au/education/mer
idians/kidney-meridian.html
Acupuncture
NOMF

MYOFASCIAL RELEASE
Thoracolumbar MFR
Lumbosacral MFR
MFR
Pseudoparesis: Patient Perception
Revisited
NOMF

COUNTERSTRAIN &
MUSCLE ENERGY
TECHNIQUE
Iliopsoas & QL
QL Counterstrain
 Iliopsoas Counterstrain

Psoas Belly Tx
Iliacus Upper Tx
(AL1)
Iliacus Lower Tx
(AL2)
QL

MET

Cool & Stretch

Piriformis Counterstrain
 Patient position: prone or
lateral recumbent on non-
involved side
 TrP Identification: the muscle
is in a line from the top of the
greater trochanter to the lower
pole of the ipsilateral SI joint
 Treatment: The patient’s leg
extended & externally rotated.
Minor adjustments are made
with respect to these motions
until the TP dissipates. The leg is
held in this position of ease for
at least 90 seconds. The patient
is slowly returned to neutral and
the point is retested.
 LE Adductor Counterstrain

Longus, Brevis, Pectineus

& Gracilis

Magnus
 TFL Counterstrain
 Patient position: prone or
lateral recumbent
 TrP Identification: the TP/s
are located by flat palpation
 Treatment: The patient’s
leg is abducted. Minor
adjustments are made with
respect to
traction/compression, flexion
(minimal) & abduction until the
TP dissipates. This position of
ease is held for at least 90
seconds. The patient is slowly
returned to neutral and the
point is retested.
Counterstrain

Vastus Vastus Rectus

Medialis Lateralis Femoris
 QL Counterstrain

Piriformis

LE Adductor Counterstrain TFL Counterstrain

Patient position: prone or
lateral recumbent
TrP Identification: the TP/
s are located by flat palpation
Treatment: The patient’s
leg is abducted. Minor
adjustments are made with
respect to traction/
compression, flexion
(minimal) & abduction until
the TP dissipates. This
Longus, Brevis, Pectineus position of ease is held for at
& Gracilis least 90 seconds. The patient
is slowly returned to neutral
and the point is retested.
Magnus
NOMF

FUNCTIONAL
DIAGNOSIS OF LBP –
A REPRISE
Muscle Balance
The firing pattern
should be:
1. Ipsilateral
hamstring
2. Ipsilateral Gluteus
maximus
3. Contralateral
e.spinae
4. Ipsilateral e. spinae

Muscle Balance
The firing pattern
should be:
1. Ipsilateral Gluteus
Medius
2. Ipsilateral TFL
3. Ipsilateral QL
4. Ipsilateral e. spinae.
Oblique Rotation Test

A B
Patient Position: The patient is examined in the seated
position with her arms folded.
Test: The physician rotates the patient through her shoulders
comparing right & left trunk rotation. Trunk rotation in either
direction should be 90 degrees optimally (figure A is a
negative test), but it may diminish with age or arthritic
pathology (figure B is a positive test). Recheck this test after
treatment because there may also be restriction present on
the other side.
External Oblique Tension Test
Applying pressure just
inferior to the costal margin
(origin of the external
obliques)
Since these muscles are
primarily for movement they
should be relatively relaxed
in the seated position.
However, when facilitated
tension may be palpated on
one side more than the other.
Recheck this test after
treatment because there may
also be restriction present on
the other side.
Internal Oblique Tension Test
Apply pressure just superior
to the iliac crest (origin of the
internal obliques)
Since these muscles are
primarily for movement they
should be relatively relaxed
in the seated position.
However, when facilitated
tension may be palpated on
one side more than the other.
Recheck this test after
treatment because there may
also be restriction present on
the other side.
NOMF

LBP EXERCISE RX
 Rectus Femoris Stretch

A B
 Standing Stretch
 Stand with your legs a little more
than shoulder width apart and
reach your arm down your thigh
toward your knee, figure A.
 Look up with your head & eyes
while inhaling deeply, figure B. Then,
exhale and look down, figure C.
 Upon looking down your hand
should be able to creep down your
leg more.
 Repeat 3-5 times and then switch
sides.
 The whole exercise should be
repeated 2-3 times a day.
Iliopsoas Self-treatment 2
Iliopsoas Self-treatment
 Piriformis Self-treatment

Lay on your back. Cross one leg over the other, as shown above. Grab your
hip pointer & hold your hip against the table. Place your other hand on the
outside of your thigh. Inhale deeply & gently press your thigh into your hand.
Then, exhale, relax your leg and allow your thigh hand to pull your leg further
towards the other side. Repeat this 3-5 times & then repeat the whole activity
2-3 times a day.
 Piriformis Self-treatment

Start off on all fours & bring your involved

leg as close to the horizontal position as
possible, figure A. Then, go down onto
your forearms & slide your other leg further
down the floor, figure B. Hold this position
for 20 seconds. Repeat this 3-5 times &
then repeat the whole activity 2-3 times a
day.
NOMF: Ankle/LE Pain
Jay B. Danto, DO
Associate Professor & Vice Chair
NMM/OMM Department
COMP-Northwest
NOMF

LET’S TOUCH OUR

TOES!
Heel Pain
Counterstrain
Stretch & Deep Pressure
NOMF

LET’S TOUCH OUR

TOES!
Anatomy

Gastrocnemius Soleus & Plantaris

Activating/Aggravating Factors
Calf Muscle Pain/Injury

Life
Sx: Gastrocnemius
Both G1 & G2 are likely to be associated with
nocturnal calf cramps:
Occasionally, patients discover the stretch which
results in full relief of pain: The combined position
of hip extension & knee flexion required to stretch
the rectus.
Latent TrPs result mainly in calf cramps.
Active TrPs result pain as described.
Pain in the back of the knee with use: when climbing
inclines, over rocks or when walking on the beach, or on
the slope of a domed road.
If standing flat footed, the patient cannot usually fully
extend the knee.
 Sx: Gastrocnemius TrP Pain Pattern
★ G1 with local pain &
referred pain to the instep
of the ipsilateral foot, with G1 G2
a spillover of pain
extending from the distal
posterior thigh over the
back of the knee & along
the posteromedial aspect
of the leg to the ankle.
★ G2, G3 & G4 all have their
pain mostly locally with
minimally referral
G3 G4
★ On the rare occasion that all
4 TrPs occur together, G3 &
G4 become apparent only
after treatment of G1 & G2.
Sx: Soleus
Upper soleus TrPs may interfere with the
musculovenous pump, resulting in symptoms of
calf & foot pain with edema of the foot & ankle.
Soleus TrPs restrict ankle dorsiflexion.
The restriction of ankle dorsiflexion results in
difficulty lifting properly. Patients with this
restriction have to bend more at the waist to
compensate for the poor flexibility in their
ankles.
Patients cannot squat unless on their
toes.
Very active soleus TrPs results in difficulty
walking & even immobilization.
Sx: Soleus TrP Pain Pattern
★ S1 with local pain & referred
pain to medial Achilles tendon &
heel, with spillover slightly S2
forward of the heel to the instep.
★Weight bearing on the heel
may result in unbearable pain. S1
★An active S1 may hurt at rest
in the evening.
★ S2 causes diffuse pain over the
upper ½ of the calf.
★ S3 refers pain deep in the lateral
aspect of the ipsilateral SI joint,
which may cause a less intense
spillover in the region of the TrP
itself & over the posterior &
plantar surfaces of the heel
(similar to S1). S3 rarely
★On a rare occasion it radiates
into the ipsilateral TMJ and S3
side of the face.
Differential Diagnosis
Radiculopathy
 Posterior knee, calf & foot
pain may be
misinterpreted as an S1
radiculopathy.
 Gastrocnemius TrPs may
be activated by
radiculopathy.
 EMG, NCS &/or MRI are
diagnostic
Spurs, Bursitis &
Tendinitis
 Heel spurs: treat the TrP,
the spur may be an
incidental finding
 Achilles Tendinitis:
when severe it may cause
swelling, crepitus & have
a tender nodule
associated
 Retrocalcaneal Bursitis:
Growing Pains
 Over 90% of children with
growing pains may either
be the result of, result in,
or may have
gastrocnemius TrPs
associated
Vascular Pathologies
 Intermittent
Claudication: TrPs may
result from peripheral
vascular disease &/or be
a significant contributor to
the pain thought
associated with it.
 Phlebitis: Presents with a
diffuse warmth within the
muscle, redness, swelling,
tenderness of the foot &
leg, & a constant pain
regardless of muscular
activity.
◦ Ultrasound, magnetic
resonance &/or
venography (gold
standard) are
diagnostic.
 Counterstrain
Patient position: prone
 The patient’s leg is flexed at the
knee and the dorsum of the foot
rests on the physician’s thigh.
 The physician directs a force
through the foot accentuating
plantar flexion & through the leg
axially compressing towards the
knee joint.
 The medial gastrocnemius is
treated with internal rotation of
the leg added & the lateral
gastrocnemius is treated with
external rotation added.
 Minor adjustments are made with
these motions until the TP
dissipates.
 This position of ease is held for at
least 90 seconds.
 The patient is slowly returned to
neutral and the point is retested.
Laser/Cool & Stretch w/ MET:
Gastrocnemius
Patient position: prone with
the feet hanging off the end of
the table.
Laser/Cool & Stretch:
Dorsiflexion at the patient’s
foot is controlled & encouraged
through the physician’s leg or
knee contact on the forefoot. Ice
or vapocoolant is applied in a
proximal to distal direction, as
illustrated in above.
MET: After coolant
administration, the patient is
instructed to apply a plantar
flexion force against the
physician’s resistance for 5
seconds. Upon relaxation after
the 5 second force the foot is
dorsiflexed more. This is
repeated 3-5 times.
NOMF – Touch our toes time!

ANKLE/LE PAIN
RETRAINING
EXERCISES
  Avoid high heels
 Minimize driving, less
pain with:
◦ Use of cruise control
◦ Block beneath the heel so
Home Prescription
that the forefoot is higher
up on the accelerator.
◦ Change foot position often.
 When seated, the feet
should be well
supported by the floor
in a comfortable
manner.
◦ Sitting at barstools with
heels hooked on a rung
should be avoided.
 Avoid shoes with
smooth leather
surfaces. It is better to
have good traction &
control when you
walk.
 Walking on uneven or
rough surfaces should
be avoided.
◦ Sand should be avoided.
◦ Walk at the apex of a non-
busy street, if necessary
 Socks & stockings
◦ Socks with tight elastic
band tops that compress
the skin excessively at the
calf should be avoided
◦ Long warm sock worn in
bed for sleep to keep your
Home Prescription
 If the patient is
experiencing pain
upon awakening, then A
use a foot bracing
pillow, see figure A.
 If the patient’s feet B
don’t sit at right
angles (figure B) or
an appropriate angle
on the floor, then use
a sandbag or C
footstool, see figure
C.
Gastrocnemius Towel
Self-Stretch
Follow
1. Thethis sequence:
patient is sitting
comfortably
against
or with
a wall
belt around
forefoot. & aher
her back
towel
2. The patient pulls the
towel back maximally
towards her. 1
3. The patient presses her
toes into the towel for 5
seconds.
4. Upon stopping the press
the towel should come
back more towards her,
along with her toes/foot.
5. Repeat steps 2-4 for 3-5 2
times & then the whole
procedure 3 times a day.
 Soleus Self-Stretch
1. The patient sits & places the
heel of her foot on the chair 1
& she cups her forefoot in
her hands
2. She then pulls her toes &
forefoot towards her nose.
3. She then presses her toes &
forefoot into her hands for 3
deep breaths or 15 seconds.
4. Upon relaxing the press she
should find that her foot
bends even more at the
ankle towards her nose.
5. She is to repeat this exercise
2&3
on both sides for 3-5 times &
then 3 times a day.
Holding Up the Wall-stretch
The patient leans against the wall
with one foot forward & the other
back, but she keeps both feet flat
on the floor.
The forward leg should be bent
at the knee & the back leg should
have the knee straight to stretch A
the gastrocnemius (figure A).
The back leg can be bent as long
as the heel doesn’t leave the
floor to stretch the soleus (figure
B).
This position is held for 15-30
seconds & then repeat on the
other side.
This exercise is repeated on both
sides for 3-5 times & then 3 times
a day.
B
Leaning Soleus Stretch
The patient places her palms
on a table or counter &
positions one foot about a
foot in front of the other.
She then sinks deeper &
deeper into her front foot,
keeping her forward heel on
the ground.
This position is held for 15-
30 seconds & then repeated
on the other side.
This exercise is repeated on
both sides 3 times & then 3
times a day.
 Stair Stretch & Strengthen
1. The patient stands on a stair
allowing gravity to lower her heels
lower than her toes.
2. She then presses with her toes so
that her whole body rises
maximally.
1 2
3. Then, she allows gravity to lower
herself back to the start position.
4. She repeats this 15 times and 3
sets.
- Once she is strong enough, then
she can do one leg at a time.
- Strengthening exercises should
not be done unless the patient is
painfree.
 Soleus Kneeling Stretch
Shoeless, the patient kneels upon her
knees with her toes tucked
underneath, figure A.
Placing her hands in the prayer
position corrects upper postural
imbalances, figure B.
The patient should place just enough A
weight upon her toes as she sits back
so that she is at “the feather’s edge
of discomfort” & hold this position for B
15 seconds.
The next part of this exercise brings
her forward onto her elbows, taking
the weight off of her heels, figure C. C
Hold this position for 3 deep breaths.
Then return to the start position.
This exercise is repeated 3-5 times &
then 3 times a day.
 1. The patient is sitting
comfortably with her feet
flat on the floor
2. She press her toes into the
ground for 5 seconds &
then return to the starting
position for 5 seconds.
3. She then lifts her toes off
Pedal Retraining Exercise

the ground rocking her feet 1

onto her heels for 5
seconds & then return to
the starting position for 5
seconds.
4. She should repeat steps 2-3 2
for 6-15 repetitions.

Perform this balancing exercise 3

every ½ hour when sitting for
extended periods.
Last word about exercise...
Walking, probably the best exercise for this
muscle.
Make sure that she has a good posture while walking
and that her hips are able to fully extend at toe-off.
She should feel her gluteus maximus contract when
in this hip extended position.
If she doesn’t feel it, then recommending stretching for
her hip flexors, as well as the gluteus maximus, is a must.
Running and cycling, as well as using an elliptical
trainer, are also great exercises to strengthen the
quadriceps. Remember to stretch before & after
these exercises to decrease your chance of a
recurrence of injuring your quadriceps.
NOMF

LET’S TOUCH OUR

TOES!