OPP Study Tables

Lecture 1 & 2: Thoracic and Lumbar Biomechanics

and Thoracolumbar Anatomy
Alex Sobczak
1/22/2024

Study Tables Disclaimer: The Department of Medical Education offers non-mandatory study tables for courses throughout
the semester based on the availability of student tutors. In the event a qualified student tutor cannot be obtained for a
specific course, a study table session may not be provided. The purpose of the study tables is to review the information
presented in class by the instructor. All material from the instructor remains the official information students will be tested
on. Discrepancies in the material presented by the student tutors will not be eligible for consideration on the exams.The
following PowerPoint Presentations are resource material meant for individual student use not for distribution.The Following
PowerPoint Presentations are resource material meant for individual student use not for distribution.
Thoracic and Lumbar Biomechanics

● Purpose of the Spine: Protect the spinal cord and help support the body
● Vertebrae:
○ Reference point: anterior + superior most point of the vertebral body
○ Posterior point: spinous process
○ Lateral point: transverse process
● Motions of the spine:
○ Flexion
○ Extension
○ Sidebending
○ Rotation
● Landmarks:
○ T3=Spine of scapula
○ T7= Inferior border of scapula
● Concave vs Convex Lecture slide 21: Thoracic and Lumbar Biomechanics
○ Concave: Inside the curve (think inside a CAVE)
○ Convex: Outside the curve (think EXiting outside)
Thoracic and Lumbar Biomechanics

● Reference of motion: Anterior-superior most point of vertebral body

○ Right rotation: Reference point rotates to the right
■ Spinous process moves opposite direction
○ Right sidebending: References point tilts to the right
■ Spinous process moves same direction
○ Flexion: Reference point moves inferiorly
■ Spinous process moves superiorly
○ Extension: Reference point moves superiorly
■ Spinous process moves inferiorly
● Planes and Axes of Motion: “SportsCenter ReTweeted my EXes”
○ Sidebending=Coronal plane=Anterior-posterior axis
○ Rotation=Transverse plane=Vertical axis
○ Flexion and Extension=Sagittal plane=Transverse axis
Thoracic and Lumbar Biomechanics
● Rule of Threes for the Thoracic Spine
○ T1-T3: Spinous process level with transverse
process
○ T4-T6: Spinous process ½ segment below
transverse process
○ T7-T9: Spinous process 1 segment below
transverse process
○ T10: Spinous process one segment below
transverse process
○ T11: Spinous process ½ segment below
transverse process
○ T12: Spinous process level with transverse
process
https://www.amboss.com/us/knowledge/thoracic-spine-and-ri
b-osteopathy
Thoracic and Lumbar Biomechanics

● Fryette’s Laws of spinal motion (used for thoracic and lumbar spine)
● Type I: NEUTRAL
○ Group curve (at least 3 segments)
○ No preference for flexion or extension (worsens in flexion AND extension)
○ Sidebending to one side and rotation to the opposite side
○ Apex: segment with the most rotation (usually the middle of curve)
○ Larger muscles involved (scoliosis, posture)
● Type II: FLEXION/EXTENSION
○ Single vertebra (sometimes 2) involved
○ Better in flexion OR extension
○ Sidebending and rotation to the same direction
○ Smaller muscles involved (localized)
● Law III: Motion in 1 plane with modify motion in other two planes
Thoracic and Lumbar Biomechanics

● Cervical spine mechanics:

○ C0-C1(OA joint): Sidebending and rotation in opposite directions (OA= OPPOSITE ALWAYS)
○ C1-C2 (AA joint): Only rotation
○ C2-C7: Sidebending and rotation always in the SAME direction (Think Fryette Type 2)
Thoracic and Lumbar Biomechanics

● Somatic Dysfunction: Altered function of components of somatic system

○ Described by:
■ Position of body part
■ Direction of freer motion
■ Direction of restricted motion
○ TART: Tenderness, Asymmetry, Restricted ROM, Tissue text change
■ Palpation: Which transverse process is more posterior
■ Motion: Restriction of movement
■ Ex: Right rotation:
● Right TP: feels more posterior
● Right TP: Restricts anterior pressure
○ Primary: trauma or repetitive microtrauma
○ Secondary: other pathology (local arthritis, scoliosis, viscerosomatics)
Thoracic and Lumbar Biomechanics

● Naming Somatic Dysfunctions of the Vertebral Spine

○ Name dysfunctional segments based on direction of EASE
○ How to eliminate wrong answers:
■ If option has E/F then sidebending and rotation must be in same direction
■ If option has N then sidebending and rotation must be in opposite direction
● Functions of vertebral components
○ ROM: transverse process, spinous process, intervertebral discs, ligaments, soft tissue
○ Load bearing: vertebral bodies
● Facet Orientation:
○ Cervical: Backwards, upwards, medial (BUM)
○ Thoracic: Backwards, upwards, lateral (BUL)
○ Lumbar: Backwards and medial (BM)
 Thoracolumbar Anatomy

Muscle Function Somatic Dysfunction Other Notes

Erector Spinae ● Extension Medial to Lateral: Spinalis,

● Ipsilateral SB longissimus, iliocostalis

Transversospinales ● Stabilize Multifidus, rotatores,

thoracolumbar and semispinalis thoracis
sacral spine

Quadratus Lumborum ● Fix 12th rib during ● Inhalation dysfunction Origin: inferior border of 12th
respiration of rib 12 rib
● Lateral flexion of trunk ● SD of L1-L4 Insertion: TP of L1-L4,
and hip hiker ● Superior shear of iliolumbar ligament, posterior
innominate third of iliac crest
● Iliolumbar ligament Nerve: anterior primary rami
tenderness (T12-L3)

https://www.yoganatomy.com/qu
adratus-lumborum-yoga-anatomy/
Muscle Function Somatic Dysfunction Other Notes

Iliopsoas ● Strong Hip Flexor ● If tight, can cause hip Origin: T12-L4/5 vertebral bodies
flexion or in reverse and TP
action trunk flexion
● Psoas spasm: lumbar Insertion: Lesser trochanter of
spine flexes causing femur
L1/L2 to SB towards
shortened muscle.
Innominate posterior.
LB and hip pain.
https://www.kenhub.com/en/libra
ry/anatomy/iliopsoas-muscle
Flexion during
standing.

Diaphragm ● Separates thoracic from ● L1, L2, L3 SD Pierces diaphragm: Aorta, inferior
abdominal cavity ● Lower 6 rib SD esophagus, IVC
● Breathing ● Lower 6 thoracic Nerve: C3,C4,C5 keeps the
● Posture vertebrae SD diaphragm alive (phrenic nerve)
● Phonation Origin:
● Digestion, Vertebral: crura of L1-L3 on right
● Venous return and L1-L2 on left
Costal: lower 6 ribs
Sternal: posterior aspect of
xiphoid
Insertion: Central tendon
 Thoracolumbar Anatomy
Muscle Function Somatic Dysfunction Other Notes

Obliques ● Internal oblique:

ipsilateral trunk rotator
● External oblique:
contralateral trunk
rotator

Thoracolumbar Fascia ● Provide reticulatum Strong connection to PSIS

for paraspinal and sacrotuberous ligaments
muscles in lumbar
region Maintain integrity of lower
● Insertion site for lumbar spine and SI joint
majority of
abdominal/trunk Has mechanoreceptors,
extremity nociceptors, and
● Provides stability at proprioceptors
extremes of motion in
https://www.braceability.com/blogs/articles lumbar spine
/remedy-thoracolumbar-fascia-pain
Thoracolumbar Anatomy

● Anatomical Landmarks
○ T3: Spine of scapula
○ T7: Inferior angle of scapula
○ Iliac Crest: L4/L5 interspace
○ 12th rib wraps superomedially to T12 vertebra
● Muscle mechanics:
○ Short restrictors: cross 1 vertebral segments (TYPE II SD)
■ Rotatores, levatores, costarum, interspinales, intertransversarii
○ Long restrictors: cross >2 segments (Type I SD)
■ Multifidus, semispinalis, thoracis, spinalis, longissimus, iliocostalis
Thoracolumbar Anatomy
● Vertebrae
○ Segment: 1 vertebra
○ Unit: 2 adjacent vertebrae, arthrodial, ligamentous, muscular, vascular, neural, lymph elements
■ Coupled motion
■ Movement of one vertebrae means that the inferior one moves as well
○ Movement: “SportsCenter ReTweeted my EXes”
■ Sidebending/Coronal/Anterior-posterior axis
■ Rotation/Transverse/Inferior-superior axis
■ Extension and Flexion/ Sagittal/Right-left axis
○ Facet Joints:
■ Orientation of the superior facets of a vertebra determines preferred spinal motion
■ Cervical (BUM)
■ Thoracic (BUL): prefers rotation and SB is restricted by rib attachment
■ Lumbar (BM): prefers flexion and extension
Questions!

When palpating the thoracic spine, you find the transverse processes of a
segment are between the spinous process of that segment and the one
above.Which region are you in?

A. T1-T3
B. T4-T6
C. T7-T10
D. T11-T12
Questions!

When palpating the thoracic spine, you find the transverse processes of a
segment are between the spinous process of that segment and the one
above.Which region are you in?

A. T1-T3
B. T4-T6
C. T7-T10
D. T11-T12
Questions!

In clinic you palpate a patient's back and find a somatic dysfunction at T10.
Where would you find the transverse processes of that segment?

A. At the level of the SP

B. ½ above the SP
C. ½ below the SP
D. At the level of T9
E. At the level of T11
Questions!

In clinic you palpate a patient's back and find a somatic dysfunction at T10.
Where would you find the transverse processes of that segment?

A. At the level of the SP

B. ½ above the SP
C. ½ below the SP
D. At the level of T9
E. At the level of T11
Questions!

Which of the following statements follows Fryette’s laws?

A. In the neutral position, sidebending and rotation occur in opposite directions

B. In the neutral position, sidebending and rotation occur in the same direction
C. In the flexed position, sidebending and rotation occur in the same direction
D. In the extended position, sidebending and rotation occur in opposite
directions
E. A and C
F. B and D
Questions!

Which of the following statements follows Fryette’s laws?

A. In the neutral position, sidebending and rotation occur in opposite directions

B. In the neutral position, sidebending and rotation occur in the same direction
C. In the flexed position, sidebending and rotation occur in the same direction
D. In the extended position, sidebending and rotation occur in opposite
directions
E. A and C
F. B and D
Questions!

Which of the following statement regarding the cervical spine is true?

A. C0-C1 (OA joint) rotates and side bends in the same direction
B. C1-C2 (AA joint) only side bends
C. C2-C7 rotate and side bend in the same direction
D. C2-C7 rotate and side bend in the opposite direction
Questions!

Which of the following statement regarding the cervical spine is true?

A. C0-C1 (OA joint) rotates and side bends in the same direction
B. C1-C2 (AA joint) only side bends
C. C2-C7 rotate and side bend in the same direction
D. C2-C7 rotate and side bend in the opposite direction
Questions!

A 40-year-old woman presents to clinic with back pain. Examination of her

thoracic spine shows the transverse process at T4 is more prominent on the left
and evens out with the other transverse processes when she extends her back.
What is the diagnosis?

A. T4 NRLSR
B. T4 NRLSL
C. T4 ERLSL
D. T4 FRRSL
Questions!

A 40-year-old woman presents to clinic with back pain. Examination of her

thoracic spine shows the transverse process at T4 is more prominent on the left
and evens out with the other transverse processes when she extends her back.
What is the diagnosis?

A. T4 NRLSR
B. T4 NRLSL
C. T4 ERLSL
D. T4 FRRSL
Questions!

Which muscle is responsible for fixing the 12th rib during respiration?

A. Erector spinae muscle

B. Iliopsoas
C. Internal oblique
D. Quadratus lumborum
Questions!

Which muscle is responsible for fixing the 12th rib during respiration?

A. Erector spinae muscle

B. Iliopsoas
C. Internal oblique
D. Quadratus lumborum
Questions!

What is the function of the iliopsoas muscle?

A. Ipsilateral rotation
B. Hip flexion
C. Hip extension
D. Contralateral side bending
Questions!

What is the function of the iliopsoas muscle?

A. Ipsilateral rotation
B. Strong hip flexor!
C. Hip extension
D. Contralateral side bending
Questions!

What is the motion of the internal and external obliques?

A. Internal causes ipsilateral rotation; external causes contralateral rotation

B. Internal causes ipsilateral rotation; external causes ipsilateral rotation
C. Internal causes contralateral rotation; external causes contralateral rotation
D. Internal causes contralateral rotation; external causes ipsilateral rotation
Questions!

What is the motion of the internal and external obliques?

A. Internal causes ipsilateral rotation; external causes contralateral rotation

B. Internal causes ipsilateral rotation; external causes ipsilateral rotation
C. Internal causes contralateral rotation; external causes contralateral rotation
D. Internal causes contralateral rotation; external causes ipsilateral rotation
Questions!

Where is the reference point for spinal motion?

A. Anterior inferior aspect of vertebral body

B. Anterior superior aspect of vertebral body
C. Posterior inferior aspect of vertebral body
D. Posterior superior aspect of vertebral body
Questions!

Where is the reference point for spinal motion?

A. Anterior inferior aspect of vertebral body

B. Anterior superior aspect of vertebral body
C. Posterior inferior aspect of vertebral body
D. Posterior superior aspect of vertebral body
Questions

Alex Sobczak:

as5048@nova.edu
 OPP Study Tables
Lecture 3: Lumbar Radiculopathy
Alex Sobczak
1/29/2024

Study Tables Disclaimer: The Department of Medical Education offers non-mandatory study tables for courses throughout the
semester based on the availability of student tutors. In the event a qualified student tutor cannot be obtained for a specific course,
a study table session may not be provided. The purpose of the study tables is to review the information presented in class by the
instructor. All material from the instructor remains the official information students will be tested on. Discrepancies in the material
presented by the student tutors will not be eligible for consideration on the exams.The following PowerPoint Presentations are
resource material meant for individual student use not for distribution.The Following PowerPoint Presentations are resource
material meant for individual student use not for distribution.
Lumbar Radiculopathy

● Definition: Disease of the nerve root

● Common location: lumbar spine
● Pain follows the nerve root and can be caused by pressure, inflammation, or
irritation
● Etiologies: herniated disc, tumor, bone spur, spinal stenosis, infection,
systemic disease
● Spinal cord ends at L2
● Herniated disc will affect inferior nerve root
○ (Herniated disc @ L4/L5 affects L5 nerve root)

https://www.youtube.com/watch?v=AWR1M90NG5s
Lumbar Radiculopathy

Symptoms

● Lower back pain (common cause of work-related disability in men <45 y/o)
● Lower extremity weakness/back spasm
● Lumbar scoliosis
● Paresthesias/numbness
● Describe the pain: unilateral below the knee, burning, radiating along nerve
distribution, posterolateral location
○ Acute: Pain aggravated w/ activity and improves w/ rest
○ Chronic: Constant pain
Lumbar Radiculopathy

Causes
● Disc Degeneration:
○ Microtrauma, small tears, weakened annulus, trauma
○ Repeated stress on disc→circumferential tears→radial tears→herniated
material→loss of disc height→disc degeneration and pain
■ Loss of water→disc compression→facet compression→bone spur
○ Most common location is L4/L5
■ Lots of motion in lumbar spine, narrowed posterior longitudinal ligament,
posterolateral weakness
Lumbar Radiculopathy

Differential Diagnosis: (CAUDA EQUINA SYNDROME)

● Large central disc herniation/space-occupying lesion compresses the cauda
equina
● Bilateral or unilateral sciatica
● Saddle anesthesia
● Urinary retention
● Decreased sphincter tone
● Surgical emergency: Decompression within 12 hours of loss of bladder
control or permanent neurological damage
Lumbar Radiculopathy

Differential Diagnosis: (Abdominal Aortic Aneurysm)

● Outpouching due to weakness of the wall of the aorta

● Surgery if:
○ >5cm
○ Increasing size of hematoma
○ Impending rupture
○ Bleeding into pleural space
Lumbar Radiculopathy

Examination and Testing

● Gold standard testing: electrodiagnostic testing
● Deep tendon reflexes
○ Patella (L4)
○ Achilles (S1)
● Sensory testing
○ Pin prick or light touch
● Motor function
○ Hip flexors (L1-L2) and extensors (L4-L5)
○ Knee flexors (L5-S1) and extensors (L3-L4)
https://www.nejm.org/doi/10.1056/NEJMcp1
○ Dorsiflexion (L4-L5) and plantar flexion (S1-S2) 512658
○ Great toe extension (L5-S1)
Lumbar Radiculopathy

Treatment/Management

● OMT→MFR, CS, ME, HVLA

● Pharmacology→NSAIDS, analgesics, corticosteroids, muscle relaxants
● Consultation→specialist
● Surgery→only 2-5% of patients w/ herniated disc
○ Indications: cauda equina syndrome, progressive neuro deficit, intolerable pain
Questions!

Which spinal nerve root is responsible for the achilles deep tendon reflex?

A. L3
B. L4
C. L5
D. S1
Questions!

Which spinal nerve root is responsible for the achilles deep tendon reflex?

A. L3
B. L4
C. L5
D. S1
Questions!

Which nerve root is affected if a patient comes in with numbness in the web
space of his big toe?

A. L3
B. L4
C. L5
D. S1
Questions!

Which nerve root is affected if a patient comes in with numbness in the web
space of his big toe?

A. L3
B. L4
C. L5
D. S1
Questions!

Which symptom is not expected in someone with cauda equina syndrome?

A. Increased sphincter tone

B. Urinary retention
C. Decreased sphincter tone
D. Saddle anesthesia
Questions!

Which symptom is not expected in someone with cauda equina syndrome?

A. Increased sphincter tone

B. Urinary retention
C. Decreased sphincter tone
D. Saddle anesthesia
Questions!

Patient comes in with numbness along the anteromedial aspect of their knee,
Inflammation to which nerve root is responsible?

A. L3
B. L4
C. L5
D. S1
Questions!

Patient comes in with numbness along the anteromedial aspect of their knee,
Inflammation to which nerve root is responsible?

A. L3
B. L4
C. L5
D. S1
Questions!

Where is the most common location of disc degeneration?

A. L1/L2
B. L2/L3
C. L3/L4
D. L4/L5
Questions!

Where is the most common location of disc degeneration?

A. L1/L2
B. L2/L3
C. L3/L4
D. L4/L5
Questions?

Alex Sobczak

as5048@mynsu.nova.edu
 OPP Study Tables
Lecture: Clinical Syndromes of the Lumbar and Thoracic Spine (4), Osteopathic
Approach to the Patient with Low Back Pain (5), and Scoliosis and Short Leg
Syndrome (6)
Alex Sobczak
2/19/2024

Study Tables Disclaimer: The Department of Medical Education offers non-mandatory study tables for courses throughout the
semester based on the availability of student tutors. In the event a qualified student tutor cannot be obtained for a specific
course, a study table session may not be provided. The purpose of the study tables is to review the information presented in
class by the instructor. All material from the instructor remains the official information students will be tested on.
Discrepancies in the material presented by the student tutors will not be eligible for consideration on the exams.The following
PowerPoint Presentations are resource material meant for individual student use not for distribution.The Following PowerPoint
Presentations are resource material meant for individual student use not for distribution.
Lecture 4: Thoracolumbar Clinical Syndromes

Ankylosing Spondylitis (Flattening of AP curve at thoracic region)

● Seronegative arthritis
● More common in young men
● Genetic predisposition (HLA-B27 antigen present)
● Most common symptom is low back pain
● First SI joint fusion then progresses to whole spine
● Stiff with inactivity and worse in morning and night
● Extra-articular involvement: eyes, heart, lungs, neuro

https://radiopaedia.org/cases/ankylosin
g-spondylitis-68
Lecture 4: Thoracolumbar Clinical Syndromes

Scheuermann’s Disease (Increase AP curve at thoracic region)

● Typically in 13-16 year olds

● Wedging occurs in the vertebral spine leading to sharp angles
● Most common at T7-T10
● X-ray will show lucent areas surrounded by sclerosis

https://www.scoliosisassociates.com/scheue
rmanns-kyphosis/
Lecture 4: Thoracolumbar Clinical Syndromes

Osteoporosis (Increase AP curve at thoracic region)

● Occurs in postmenopausal women (lack of estrogen)

● Wedge fractures
● Most common fracture at T12 and apex of thoracic spine
● Dowager’s hump
● Questions to ask: Vitamin D deficiency, corticosteroid use, weight,
alcohol, smoke, age, relatives with fractures

https://health.clevelandclinic.org/how-you-c
an-fix-a-dowagers-hump-prevention-tips
Lecture 4: Thoracolumbar Clinical Syndromes

Psoas Syndrome (Flatten AP curve at lumbar region)

● 20% of lower back pain

● Non-neutral dysfunction at L1-L2
● Backward sacral torsion
● Contralateral pelvic shift
● Contralateral piriformis spasm
● Contralateral sciatic irritation
Lecture 4: Thoracolumbar Clinical Syndromes

Spondylolisthesis (increased AP curve of lumbar spine)

● Fracture and forward slippage of vertebra on another
● Fracture of pars interarticularis
● X-ray shows step off
● Back pain worse on extension
● Scotty-dog decapitated on x-ray
● Grading
○ 0-25: Grade I
○ 25-50: Grade 2
○ 50-75: Grade 3
○ 75-100: Grade 4 https://radiopaedia.org/articles/s
● Spondyloptosis: Grade 5 (greater than 100% slippage) pondyloptosis

● Spondylolysis: Fracture without slippage (scotty dog with collar)

Lecture 4: Thoracolumbar Clinical Syndromes

Thorax Posture Syndromes:

● Pectus Excavatum
○ Caved in chest
○ Compression of sternum into chest
○ May require surgical intervention
● Pectus Carinatum
○ Pigeon chest
○ Protrusion of sternum
○ No intervention necessary https://www.marfantrust.org/articles/pectus-update
Lecture 4: Thoracolumbar Clinical Syndromes

Non-Posture Thoracic/Lumbar Back Pain:

● Spine Fracture
○ High energy trauma
○ Whiplash
○ Risk: osteoporosis, tumor, infection, steroid use
○ Neurologic symptoms: numbness, tingling, weakness
■ If bowel/bladder issues then it is a surgical emergency
○ Reversing curve: indirect techniques for paraspinal spasms after MVA
Lecture 4: Thoracolumbar Clinical Syndromes

Non-Posture Thoracic/Lumbar Back Pain:

● Disc Herniation
○ Common in lumbar spine
○ Use MRI
○ Positive straight leg test
○ Pain with prolonged sitting and flexion
○ Relieved with extension
○ Radiates below knee
○ Conservative treatment unless:
■ Severe sciatic pain
■ Impaired nerve root conduction
■ Impaired bowel/bladder function
■ Gross motor weakness
https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/sy
c-20354095#dialogId19563645
Lecture 4: Thoracolumbar Clinical Syndromes

Chest Pain

● Most patients have MSK component of pain

● ALWAYS RULE OUT CARDIAC CAUSE
● Pain worse with deep breathing but without shortness of breath=somatic
● Pain worse with positional changes and not with exertion=somatic
Lecture 5: Osteopathic Approach to Back Pain

● Back pain is #2 most common reason for clinician visit

● Risk factors: obesity, smoking, old age, female, psychological stressors
● Spondylolisthesis
○ Grade I/II: no surgery required
○ Grade III/IV: may need surgery
● Spondylosis: arthritis of spine
● Spondylolysis: fracture of pars interarticularis
● Cauda equina syndrome: loss of bladder and bowel control
● Piriformis: piriformis compressed sciatic nerve
Lecture 5: Osteopathic Approach to Back Pain

Thought process:

● Dysfunction: OMT
● Derangement: Herniation
● Degeneration: Arthritis
○ If osteoarthritis then assess diet

Anatomy

● Ribs lie underneath transverse process of vertebra

● Ligaments best treated with counterstrain
Lecture 5: Osteopathic Approach to Back Pain

Lecture 5: slide 13
Lecture 5: Osteopathic Approach to Back Pain

Differential Diagnosis of Thoracic Region:

● Malignancy, metastases, multiple myeloma
○ If multiple myeloma then lytic lesions and compression fractures throughout spine
● Osteoporotic or trauma fractures
○ If osteoporotic compression fracture then look for vertebral wedging
● Visceral causes
○ Aortic dissection, pneumonia, pneumothorax, hepatobiliary disease, kidney stones
● Shingles
○ Presents with pain along dermatome
● Ribs mediated
○ Intercostal neuritis, costovertebral joint pain
○ Can present with chest pain so rule out cardio
Lecture 5: Osteopathic Approach to Back Pain

Differential Diagnosis of Thoracic Region:

● Diffuse idiopathic skeletal hyperostosis
○ Hyperostosis: bone grows around disc due to arthritis
● Vertical Disc Herniation
○ Look for Schmorl’s nodes
● Neural foramen encroachment
○ Look for compressed nerve root
● Other Spinal Disease:
○ Disc herniation, spondylosis, stenosis https://www.spineinfo.com/ https://www.advancedosm.com/dif
conditions/schmorls-nodes- fuse-idiopathic-skeletal-hyperostosi
definition-causes-symptoms- s-dish--orthopaedic-sports-medicine-
and-treatment/ specialist-cypress-houston-tx/
Lecture 5: Osteopathic Approach to Back Pain

Differential Diagnosis of Lumbar Region:

● Cauda equina→bowel and bladder problems

● Muscular cause→psoas or piriformis or QL
● Ligamentous→Iliolumbar, interspinous, anterior-posterior longitudinal
● Nerve→sciatic or cluneal
● Facetogenic→pain with extension and rotation
● Lumbosacral→ pain with standing and sitting
Lecture 5: Osteopathic Approach to Back Pain

Dirty Half-Dozen in “Failed low back pain”

● Non neutral dysfunction (flexion or extension)

● Dysfunction at pubic symphysis
● Restriction of anterior nutational movement of sacral base
● Innominate shear
● Short-leg/pelvic tilt
● Muscle imbalance
Lecture 5: Osteopathic Approach to Back Pain

● OMT
○ Image first!
○ Indirect OMT for acute pain
○ Address compensatory dysfunction
● Imaging takeaways
○ If radiculopathy-MRI in 4-6 weeks if conservative treatment doesn’t improve symptoms
○ Risk of metastatic cancer-MRI STAT
○ Any signs of cauda equina syndrome-MRI STAT
○ Significant neurological symptoms-MRI STAT
Lecture 5: Osteopathic Approach to Back Pain

Intervention

● Prolotherapy→inject irritant to stimulate healing response

● Muscle spasm→spray and stretch or injection (dry needle)
● Epidural
● Facet block
● Nerve block
● Physical therapy
○ Mckenzie protocol: Back exercises to reposition displaced intervertebral discs and
strengthen surrounding muscles
Lecture 6: Scoliosis and Short Leg

Scoliosis: Lateral curvature of the vertebral column

● Recognize early if possible

● Can have pain and cardiopulmonary complications if severe enough
● Females more likely
● Named for convexity, severity, and location
● Types: structural (no correction) or functional (partial/complete correction
with sidebending)
Lecture 6: Scoliosis and Short Leg

Severity of Scoliosis
● Mild: 5-15
● Moderate: 20-45
● Severe: >50
● >50 affects lungs
● >75 affects heart
Causes
● Idiopathic (70-90% of cases) https://www.coreconcepts.com.sg/article/cob
● Congenital (75% are progressive) b-angle-and-scoliosis/

● Acquired (trauma or sacrum issues)

Lecture 6: Scoliosis and Short Leg

Location
● Most common: double curve in opposite directions
● Single thoracic
○ Side Bend to the right typically
● Single lumbar
● Thoracolumbar or cervicothoracic junction
○ More symptoms present

Screening
● Look and feel for curve
● Check for rib humps
● Use radiology measurements for severity
https://atlaszone.org/scoliosis/
Lecture 6: Scoliosis and Short Leg

Osteopathic Considerations

● The body keeps the eyes level for balance

● Rotation occurs into the convexity
● Ribs on convex side will separate and move posterior
● Ribs on concave side will move closer and anterior
● Disc space narrows on concave side
● Scoliosis causes growth restrictions in vertebral plates
Lecture 6: Scoliosis and Short Leg

Cobb Angle
● If <10 degrees reevaluate 6-12 months
● If >10 degrees follow up every 4-6 months
○ Treat if progress by >5 degrees
● If initial curve >30 degrees then treat
● Curves <20 degrees in skeletally mature adult will not progress
Treatment Goals
● Prevent progression and determine cause
● Can use braces (Milwaukee or Boston)
● Surgery if >45
Lecture 6: Scoliosis and Short Leg

SHORT LEG
Biomechanics
● Sacral base unleveling
● Spine compensates by changing curve
● Innominates rotation
● Pelvic rotation and side shift
● Goal is to balance and relevel
Lecture 6: Slide 29
Assessment
● Levelness of horizontal planes: Mastoid process, AC joint, inferior angle of scapular, iliac
crest, greater trochanters
Lecture 6: Scoliosis and Short Leg

Compensation:
● C-shaped scoliotic curve (early) S-shaped curve (late)
● Head and shoulder depressed on opposite side of pelvic
depression
● Pelvis side shifts and rotates away from sacral base decline
● Sacral base tilts towards short leg
● Innominate rotates forward on side of short leg
● Long leg will internally rotate and foot will pronate
● Spine convexity rotates toward side of short leg and side
bends away
Lecture 6: Slide 30
Lecture 6: Scoliosis and Short Leg

To help make diagnosis:

● Recurrent somatic dysfunction of pelvis, spine, cranium

● Soft tissue compensation
○ Concave side shorten and increased EMG activity
○ Convex side lengthen
● Iliolumbar ligament and SI joint on side of convexity becomes stressed
● Long leg will have unilateral sciatica and hip pain
● Increased sympathetic hyperactivity between T1-L2
Lecture 6: Scoliosis and Short Leg

Treatment
● DO OMT to correct somatic dysfunction then standing posture x-ray
● Functional short leg treated with OMT
● Anatomical short leg treated with heel lift
● Lift Therapy
○ Less than 5mm is not treated typically
○ Fragile patient: 1.5mm heel lift with no faster than 1.5mm every two weeks
○ Flexible spine: begin with 3mm heel lift with no faster than 1.5mm per week or 3mm every
two weeks
○ Sudden loss of leg length on one side: Lift the full fractional amount that was lost
○ Final lift height in a chronic short leg syndrome may only be 50-75% of shortness in the
measured leg
Questions?

Alex Sobczak

as5048@nova.edu
 OPP Study Tables
Lecture: Compartment Syndrome (7) and Fibromyalgia (8)
Alex Sobczak
March 4th, 2024

Study Tables Disclaimer: The Department of Medical Education offers non-mandatory study tables for courses throughout the
semester based on the availability of student tutors. In the event a qualified student tutor cannot be obtained for a specific
course, a study table session may not be provided. The purpose of the study tables is to review the information presented in
class by the instructor. All material from the instructor remains the official information students will be tested on. Discrepancies
in the material presented by the student tutors will not be eligible for consideration on the exams.The following PowerPoint
Presentations are resource material meant for individual student use not for distribution.The Following PowerPoint
Presentations are resource material meant for individual student use not for distribution.
Compartment Syndrome

Compartments
● Forearm: anterior, posterior, and lateral
● Hand: interosseous compartment
● Foot: interosseous, lateral, calcaneal, medial, and superficial
● Leg: anterior, lateral, superficial posterior, and deep posterior
○ Superficial posterior
○ Anterior (deep fibular nerve, anterior tibial vessels)
○ Lateral (superficial fibular nerve)
○ Deep Posterior (tibial nerve, fibular vessels + posterior tibial vessels)
● Thigh: anterior, medial, and posterior
○ Anterior (nerve to vastus medialis, saphenous nerve, femoral vessels)
○ Medial (deep femoral vessels)
○ Posterior (sciatic nerve)
Compartment Syndrome

● Definition:
○ Increased pressure within a
compartment compromises function of
the tissues
○ Compromised circulation can lead to
ischemia and irreversible deficits
● 80% occur in the leg
● Can occur anywhere skeletal muscle
is surrounded by fascia
● Most common in anterior
compartment of the lower limb
https://1stchoicesportsrehab.com/posterior-compartment-syndrome/
Acute Compartment Syndrome

● Pathogenesis
○ Increased pressure within a fixed
compartment due to trauma, tissue damage,
etc.
○ →Reduced venous outflow further increasing
venous pressure
○ →Blood shunted away from the compartment
○ →Lack of oxygen causes capillaries to
collapse
○ →Increased release of vasoactive substances
○ →Release of fluid from capillaries https://boneandspine.com/compartment-syndrome/
Acute Compartment Syndrome
Nerve Ischemia Muscle Ischemia
■ 1 hour: normal conduction ■ 4 hours: Reversible damage
■ 1-4 hours: reversible damage ■ 4-8 hours: variable
■ 8 hours: irreversible damage ■ 8 hours: irreversible damage
Acute Compartment Syndrome

● Etiology
○ Trauma/microtrauma (fractures account for nearly 75% of acute compartment syndrome)
○ Nontrauma (burns, snake bites, ischemia/reperfusion injuries)
● Symptoms
○ Pain out of proportion to observed injury
○ 5 P’s (not reliable)
■ pain, pallor, paralysis, pulselessness, paresthesias
● Physical exam
○ Pain on passive stretching of muscles
○ Tense compartment and muscle weakness
○ Decreased touch discrimination
○ Paralysis (late sign)
■ Lose sensation before motor
https://www.osmosis.org/answers/5-ps-cir
culation-assessment-mnemonic
Acute Compartment Syndrome

● Diagnosis
○ Measuring compartment pressure (stryker device)
■ Normal: 0-4 mmHg
■ Fasciotomy:
● Absolute theory: >30-45 mmHg
● Pressure gradient theory: Tissue pressure within 20 mm Hg of DBP
○ Look for clinical findings and assess patient pain
○ Radiographs if fracture is suspected
● Treatment
○ Remove restrictive covering
○ Keep extremity at heart level
○ Serial exams
○ Decompress compartments if indicated
○ Fasciotomy: fully decompresses involved compartment (DON’T DO if there is muscle death (>8hours))
● Can have poor outcomes if delayed or missed diagnosis
Chronic Compartment Syndrome

● Overuse injuries (typically in lower limb of young endurance athletes)

● Pathogenesis:
○ Exercise induced increase in blood flow to muscles
○ →Increased swelling and noncompliant fascia
○ → Increased compartment pressure
○ →Reduced blood flow can cause muscle ischemia and pain
● Symptoms:
○ Gradually increased pain in area (aching, cramping, squeezing)
○ Pain resolves with rest (10-15 mins)
○ Often bilateral
○ Potential neurologic symptoms (numbness/weakness)
Chronic Compartment Syndrome

● Physical Exam
○ Usually unremarkable
○ Examine after exercise (increased muscle weakness)
○ Abnormal distal pulses (only sometimes)
● Diagnosis
○ Compartment pressure measurements
■ Pre-exercise: >/= 15 mmHg
■ 1-minute post exercise: >/=30mmHg
■ 5-minute post exercise: >/= 20 mmHg
○ Imaging only if fracture or other diagnosis are suspected
● Treatment
○ Conservative: Doesn’t do much unless activity is discontinued
https://www.orthobullets.com/trauma/1001/leg-compartment-sy
○ Fasciotomy: >90% pain relief and improvement ndrome
■ 8-12 week return to play
Fibromyalgia

● Most common cause of chronic

widespread musculoskeletal pain
● Fatigue, Brain fog, and somatic symptoms
● Diagnosed between age 20-55 years old
● 75-90% are female
● Prevalence increases with age
● Takes around 5 years to diagnosis
because of overlap of symptoms with
multiple disorders

https://www.knoxvillespineandsports.com/fibromyalgia-treatment-in-
knoxville/
Fibromyalgia

● Causes
○ Dysregulation of pain processing in the CNS:
■ Increased response to stimulation and decreased pain modulation
○ Physiologic abnormalities
■ Low blood flow to thalamus
■ Increased Substance P and Glutamate in muscle causing excitation
■ HPA axis hypofunction
■ Decreased serotonin and tryptophan causing lack of inhibition
■ Cytokine function abnormalities
○ Genetics
■ COMT gene (may affect catecholamine inactivation)
Fibromyalgia

● Central sensitization (at dorsal horn) and Peripheral sensitization (at nerve terminal)
○ Damaged tissue and increased inflammation leads to:
■ Increased production of ion channels
■ Increases excitability of terminal nociceptive receptors
■ Lower threshold fo activation of nociceptor receptors
● Primary sensitization
○ →Intense pressure on tissue
○ →Cell damage lowers pH
○ →Increased K+
○ → Prostaglandins and bradykinins
● Secondary sensitization
○ →Pain impulse sent to spinal cord
○ →Release of substance P
○ →vasodilation+neurogenic edema
○ →Histamine and serotonin release

https://www.futuremedicine.com/doi/10.2217/fmeb2013.13.160
Fibromyalgia

● Diagnosis Criteria
■ Widespread pain in all four quadrants for a
minimum of 3 months
■ Tenderness in 11/18 tender points on palpation
● Tender point=no referring pain
● Trigger point=referring pain
● Chief complaint
○ Chronic relapsing diffuse aching pain
○ Often bilateral
● Symptoms
○ Fatigue ( morning>evenings)
■ Does not reach stage 4 sleep
○ Stiffness (all day long) https://creakyjoints.org/about-arthritis/fib
https://www.verywellhealth.com/fibromyalgia-
■ Does not go away with activity romyalgia/fibromyalgia-overview/fibromy
algia-tender-points/
symptoms-716139
Fibromyalgia

● Concomitant problems: ● Aggravating Factors

○ Weather
○ Migraine ○ Poor sleep
○ IBS ○ Physical activity
○ TMJ ○ Anxiety or stress
○ Urinary frequency ● Differential Diagnosis
○ Paresthesias ○ Complex regional pain syndrome
○ Chronic fatigue syndrome
● Psychosocial ○ Depression
○ Physically tasking jobs ○ Hypothyroidism
○ Poor coping strategies ● Labs To Order
○ Decreased pain perception threshold ○ CBC
○ CRP/ESR
○ Anxiety
○ CPK
○ TSH
○ B12
Fibromyalgia

Treatment: Improve symptoms, function, and quality of life

○ Analgesics ○ Exercise
■ NSAIDS ■ Aerobic therapy
■ SSRIs ■ Heated pool
○ Opioids ■ Gentle stretching
■ Asses risks for addiction ○ OMT
○ FDA approved drugs
■ Counterstrain
■ Pregabalin
■ MFR
■ Duloxetine
■ Milnapracin ■ Lymph
■ NO HVLA
Questions

Email:

Alex Sobczak

as5048@mynsu.nova.edu