Clinical Applications of OMM

by Tyler Cymet, DO, FACOFP

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    00:00 Hello there.

    00:02 We’re going to talk about the clinical applications of osteopathic manipulative medicine.

    00:06 Today’s topic is short leg syndrome. When you think of short leg syndrome, people think of a short leg.

    00:12 But that’s actually a misnomer. Short leg syndrome is an abnormality in the hip flexors, the hip extensors, that make it look like one leg is a different length than the other.

    00:24 In actuality, yes. One leg will be longer or shorter but not because there’s a leg length inequality but because the hip extensors and flexors have made one leg come shorter or look longer than the other.

    00:38 This is something that we use just in general functioning. You look at a person. You look at how they walk.

    00:45 You look at how they stand. You look at whether or not there’s symmetry. Some things stand out.

    00:50 They just, you can’t help but notice it, and a big one is whether or not the legs look equal.

    00:58 When we talk about short leg syndrome, we talk about what’s going on with the person’s gait what they look like. So we still call it a short leg syndrome even though it is not a leg length inequality.

    01:16 It is a disorder of the hip flexors, hip extensors affecting the functioning of the pelvis and the sacrum.

    01:24 There are causes that are unrelated to leg lengths causing the short leg syndrome.

    01:30 We’re calling it a syndrome because there are multiple symptoms and multiple findings.

    01:35 Some people may get lower sacral pain. Some people may say that when they run or walk they feel that all of the work is coming from one leg or the other. Those are common symptoms that don’t always lend themselves to needing to come to a doctor but do make it harder to function.

    01:52 So the sacral base will be unlevel causing one leg to be higher or shorter on the bottom than the other.

    02:00 The innominates or the pelvis may be rotated. You may have a curve on the side away from the sacral base where you have the anomaly. If there is a true leg length discrepancy and there may be for nutritional reasons, trauma, mechanical reasons then that’s a leg length inequality, not a short leg syndrome. For short leg syndrome, a lot of times one somatic dysfunction will cause other somatic dysfunctions to develop.

    02:30 We want to treat all somatic dysfunction diagnoses as well as getting X-rays and an evaluation before you say there is a leg length inequality. Again, a short leg syndrome can be easily corrected.

    02:47 When you do an X-ray, you want to measure the coronal values of the iliac crest, of the scapular base of the shoulders, and of the skull to make sure that you have a good sense of where the body is in alignment. Just be aware that when you get an X-ray, you’re always going to see some discrepancy. Some of that is errors in measurement.

    03:13 Some of that is the picture and 2 mm in difference is not something we treat or even note as a diagnosis.

    03:23 It may just be part of measuring and what we can do comfortably.

    03:27 So when somebody comes to you saying that I feel like I’m walking with one leg, or I’m not running right, or I need help to run more efficiently, or to walk more efficiently, or when I walk upstairs, I feel like I’ve got to hike up my hip, those are just vague complaints that you’re going to dig deeper on. You’re going to ask the person about acute symptoms.

    03:48 Does this happen all of a sudden? Are you walking when you feel it happen? Or is this a chronic problem? Has this been going on for years? Have you always noticed it? Has it gotten worse lately or more chronic to where it doesn’t go away? How long has this been happening? Is this one week, one month, one year? Has it correlated with the change in activity? Is there pain or discomfort or dis-ease in functioning? Where does that pain or discomfort go? When does it occur? Are there any medications or changes in your functioning that we need to know about? Then we look at the person.

    04:27 You look at how they’re standing. Are they standing to one side? Are they trying to compensate? Are they twisting? When they move, do they move fluidly? Do they get up side to side or do they look comfortable when they do it or do they look lanky and uncomfortable? Can you notice just by looking whether or not there’s a leg length discrepancy? Often you can. Have you noticed a limitation or restriction in how they move? Do they tend to turn to the right or can they turn to the right and the left? When you look at the muscle strength, do you notice major changes when you add some resistance? Are there any abnormalities of the neurologic exam, any sensory abnormalities or functional abnormalities? We’ll go through a bunch of tests you can do to see which muscle group, which bony group, and what level of functioning you need to focus on.

    05:23 Again, I would refer you back to the 10-step osteopathic examination video which will go through a full osteopathic examination. Let’s start with a case.

    05:33 You have a patient come in with a chief complaint of chronic, intermittent low back pain and moderate right hip pain. The patient is a 46-year old man who presents with a history of chronic, intermittent low back pain, worse with exacerbations from sports or lifting and it’s been going on for about 28 years, started when he was moving furniture into his dorm room in college. It gets better with rest. NSAIDS help.

    06:00 Occasionally, an ice pack or heating helps. Generally, everything gets it better.

    06:06 But the patient’s also got moderate right hip pain for the past two to three years.

    06:11 That’s there more than it’s not there. This intermittent pain radiates to the right lower extremity as well. Now, you’ve got some radiation.

    06:20 This person has a past medical history of hypercholesterolemia.

    06:25 So you have to worry about whether or not there are medications.

    06:28 Surgical history is significant only for a skin lesion removal which was benign and it was on the left shoulder. Family history is significant for a father with hypertension, mother with osteoarthritis. The patient is a non-smoker, no alcohol, no drugs, married for 20 years. He has two daughters. He likes to play the jazz saxophone with the local band.

    06:51 Medication: He is on Niaspan for the hypercholesterolemia, 1000 mg every night which raises issues of side effects. Allergies: The patient has no known drug allergies.

    07:04 Review of systems: The pertinent positives show that he has moderate low back pain and right hip pain. Pertinent negatives, there is no neurological findings.

    07:15 Urinary review of systems: There is no urinary urgency, frequency, dysuria or history of recent infection. In general, this is a well-developed, well-nourished man in no acute distress, alert and oriented x 3. He is ambulating well without a cane, no help, slightly leaning to the right with his gait, and the posture is slightly twisted.

    07:43 HEENT: Normocephalic, atraumatic, extraocular motility is intact.

    07:49 So, you have no neurologic symptoms.

    07:52 Clear TMs and the throat is clear. Neck is supple, no lymphadenopathy.

    07:57 Heart: Regular rate and rhythm with mo murmurs. Lungs: Clear to auscultation.

    08:02 No rales, rhonchi or wheezing, good expansion and excursion.

    08:06 Abdomen: Bowel sounds are present. The back: Negative Lloyd’s, no signs of pain.

    08:12 Skin: Clear, no lesions. Extremity exams show full range of motion.

    08:18 Lower extremities have a full range of motion.

    08:23 But the right side has some decreased internal rotation of the hip joint.

    08:28 We’ll get to those tests in a little while.

    08:30 Neurologic exam is intact. Deep tendon reflexes are 2/4 in the bilateral upper and lower extremities. Muscle strength is 5/5.

    08:39 On the musculoskeletal exam, straight leg raising is negative.

    08:46 But there is a positive Thomas test on the right side and a positive FABERE test on the right as well.

    08:54 So some findings that the musculoskeletal system has some abnormalities that we will get to in detail in a little bit.

    09:02 The hip drop test is limited because of the pain and discomfort.

    09:07 Osteopathic structural exam: The left lumbar paraspinal musculature is hypertonic So you’re going to feel some tightness, thickness, and just different.

    09:17 The right lumbar paraspinal musculature shows some hypertrophy.

    09:21 The L1 is rotated right, side-bent right which is telling you there is type 2 mechanics.

    09:30 There is a right on right forward sacral torsion and a right anterior innominate with left piriformis muscle showing some hypertonicity.

    09:45 The piriformis is a flexor of the hip as well.

    09:51 There is a left piriformis tender point with moderate right psoas spasm.

    09:56 The right malleolus is slightly higher than the left malleolus.

    10:01 The right tibial and femoral leg length discrepancy was noted at about a half an inch difference with the right extremity being shorter.

    10:11 So the ASIS to medial mallelous is visualized to be asymmetrical.

    10:17 The knees are also noted to be asymmetrical. A radiological procedure was done.

    10:23 We did get a postural study and it showed sacral base unleveling and the SBU of 3/4” as the sacral base unleveling was noted.

    10:34 There was a lumbar right convexity as well with side-bending and rotation only and no wedging.

    10:42 MRI showed an L2-L3 mild disc bulge. That’s the end of the examination.

    10:49 Now, we have to think about where we are with therapy and with treatment and intervention.

    10:56 That usually gets to a lift.

    10:59 When we talk about lifts and we have a noted abnormality on MRI and radiology, some kind of chronic therapy like a lift will be needed.

    11:08 We use David Heilig’s formula of the lift equals the sacral base unleveling over the duration and the chronicity.

    11:17 So we look at the sacral base unleveling of about three quarters of an inch.

    11:25 We put that over the duration and number of years which is 28 years, which will give you a 2, and the compensation where he had some side-bending and rotation.

    11:38 That will give you the formula to figure out how much of a lift is required.

    11:45 The patient was given stretches of the rectus abdominis, piriformis, to help loosen the muscles as well as the psoas, education on lifting technique to avoid lumbar strain and also to give the back time to heal.

    12:03 The MRI did show a disc bulge.

    12:06 We do know that disc bulge, once present, is going to be chronic and will take anywhere from three months to two years to get better.

    12:16 So we’ve got to find a way of keeping this patient comfortable, keeping them functioning, and get them to be as efficient in their musculoskeletal functioning as possible.

    12:27 We are going to start this patient on medication because once you have these findings, you’re going to have swelling.

    12:33 The body is no longer functioning comfortably.

    12:36 It looks like the patient is heading from normal neutral mechanics to non-neutral mechanics which is going to make the problem even more chronic and harder to deal with.

    12:47 Medication like an anti-inflammatory will help, and this patient was started on meloxicam 7.5 mg daily in order to help.

    12:56 Osteopathic manipulative therapy will free up motion, bring the patient back to the functional ability.

    13:02 In this case, facilitative position or release technique was used for the diskogenic pain syndrome.

    13:10 Going back to the examination. One of the things you’re going to use to evaluate how effective the initial interventions were is looking at the whole body.

    13:20 So yes, you know the sacral base is unlevel, but you have to check the innominate.

    13:24 You have to check the scapular, the inferior angle of the scapula.

    13:30 You have to check the shoulder levels and the level of the occiput and the evenness.

    13:35 This all goes to the symmetry of the body, the ease of functioning and how the body reacts to motion and activity.

    13:45 Does the patient go into an asymmetry when they’re static, but once they get kinetic and start moving, the symmetry returns? That’s one of the first signs because when you start moving, the body goes back into neutral mechanics.

    14:00 So look at all these levels, the base of the skull, the shoulders, the inferior angle of the scapula, the pelvis, and the sacral base.

    14:10 When you observe a patient, here’s a picture of a person’s back, look at the iliac crest, are they level? We always check the posterior superior iliac spine and make sure that both sides are equal.

    14:24 We check the anterior superior iliac spine to see if it’s compensatory and to make sure that there’s a mechanical logic to what’s going on.

    14:33 You check the curvatures of the spine, both side to side and anterior posterior looking for kyphosis or lordosis, as well as side-bending.

    14:43 You look at the orientation of the knees and feet to see how the person is compensating and what action does for them.

    14:52 This diagram just shows anteriorly, you’re going to check the ASIS, the knees, and the medial malleoli.

    14:59 I know I use the medial malleoli a lot because you're at the end of the exam table, you can see differences and the patient notices it as well.

    15:08 So it’s a good confirmation to the patient that something is going on and it reinforces to the person that their pain has a real mechanical cause.

    15:17 After you do a treatment and ease up motion, they’ll be able to feel and see the difference.

    About the Lecture

    The lecture Clinical Applications of OMM by Tyler Cymet, DO, FACOFP is from the course Osteopathic Treatment and Clinical Application by Region. It contains the following chapters:

    • Clinical Applications of OMM
    • Short Leg Syndrome
    • Patient Case Example

    Included Quiz Questions

    1. "Short leg syndrome"
    2. "Leg length inequality"
    3. "Psoas syndrome"
    1. Levels of the iliac crests
    2. Curvatures of the spine
    3. Sacral ischia bilaterally
    4. Medial malleolus bilaterally
    5. Foot length

    Author of lecture Clinical Applications of OMM

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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