We’re going to talk about osteopathic
manipulative medicine of the extremities.
We’re going to start with the lower extremities.
But I want to start by saying
when people think of manipulation,
they think of the spine.
But there’s nothing magical
about the spine.
We’re talking biomechanics of the
There’s nothing that would preclude you from
manipulating the arms or the legs
from applying the same principles of
biomechanics to the legs.
We’re going to talk about the
anatomy, the physiology,
and the pathology of the lower leg
and the upper extremity.
When you start thinking about
the lower extremity,
the first thing you do
is you look at it.
It’s important that it not
be in one position.
One view is no view.
One way of examining a patient
may give you a biased
Every time you look at the leg, you want to
look at it standing and walking.
You may want to look at it sitting.
But don’t look at it in one position.
When you look at it, you’re not just
looking at the architecture.
You’re looking at the color.
You’re looking at the shape.
You’re looking for any asymmetry,
signs of trauma,
erythema, any lumpy-bumpiness
to the muscles,
anything that may draw your mind
to something going on.
Then you want to palpate, palpate
initially the bony landmarks,
understand the anterior superior iliac spine,
anterior inferior iliac spine,
as well as the posterior
superior iliac spine,
and the pubic tubercles, and the ilium,
and the ischium.
You also want to palpate the
greater trochanter to understand
how the lower extremity
fits into the pelvis.
All of these things are
going to be important.
Then you get to palpating the muscles
both the anterior and posterior leg
as well as calf muscles to tell you
about flexors, the extensors
and the movement in the knee.
You want to check the range of motion.
You want to make sure that the
hip range of motion is full;
the knee range of motion,
the ankle range of motion,
the toe range of motion
are all present.
Absence of any particular
type of activity,
whether it be inversion or eversion
will affect the entire lower extremity.
With the knee, while it’s just
flexion and extension,
it also affects the joint above
and the joint below.
When talking about the ankle and foot, it gets a little bit more complicated
because yes, you have plantar
flexion and dorsiflexion
but you have to worry about
abduction and adduction,
inversion and eversion of the foot.
Those are sometimes tricky
because the motion is occurring at places
that are tough to palpate.
We’ll talk a little bit about
touching the navicular bone
and the sustentaculum tali
and the difference spaces
where ligaments attach that
we treat as areas of importance.
So, with the lower extremity,
with the hip motion,
you’ve got flexion and extension,
abduction and adduction,
internal rotation and external rotation, very similar to the ankle.
We have plantar flexion, dorsiflexion, abduction
and adduction, inversion and eversion.
The knee, we’re just looking
at flexion and extension.
We’re going to start with the foot because
the foot has three separate arches.
You have a medial and lateral longitudinal arch
that come up anterior and posterior.
You have anterior transverse arch
just under the toes.
Those three arches create
the arch of the foot.
They attach to the ankle
through the ankle mortise.
The ankle mortise have three bones
that form a very tight
and very specific joint that’s going to
help the foot move up and down.
The knees, you also want to
check the bony landmarks,
particularly the patellar, as well as
the lateral condyles.
When you move up to the hip, you’re
looking at the greater trochanter.
You’re checking the gluteal folds
for evenness, extension,
how far it goes out.
You want to check the ASIS,
the PSIS, the iliac crest, and the anterior inferior iliac spine.
Getting back down to the foot, one of the
main problems you’re going to see
and hear about is plantar fasciitis
or an irritation of the fibrous tissue
that connects the front
and back of the foot.
That gives that arch a lot of its stability
that supports the foot,
allows sponginess when you come
down and support the weight.
You also want to look at issues
related to chronic foot use,
everything from skin wear down,
skin hardening, skin calluses,
things that chronic repetitive stress can do
to a foot and affect its functioning.
The other thing with plantar fasciitis is it can
happen from excessive pronation,
or just feet that have
excessively high arches
or arches that are uneven will
lead to a plantar fasciitis.
We’re going to look at the
the connections of the bones that
are holding them together,
as well as the presence
of sesamoid bones
that you may be able to feel
or note the tenderness
when you’re trying to
feel it on people.
When you’re thinking about plantar
fasciitis, one-third of patients
who have plantar fasciitis
will have it bilaterally.
A lot of that is because patients
who have flat feet,
fallen arches are more likely
to have plantar fasciitis.
It’s more likely to see a plantar fasciitis
in runners, basketball players
and volleyball players
have a very high risk.
A lot of people who have
plantar fasciitis will develop
of sesamoid bones.
You’ll see spurring and pulling
and bone formation in areas
where the aponeurosis are pulling
on the bone like the calcaneus.
That’s often seen on X-rays.
That’s due to calcium deposits
along the lines of stress and the increased
pressure that’s occurring
from the pulling. Again,
you’ll see it on X-ray.
When you evaluate a patient
for plantar fasciitis,
you’re going to have
some localized heel pain.
You’ll typically be able to palpate it
and note the severe tenderness
when you touch it. It’s usually
worse in the morning
and after people have had
prolonged periods of rest.
It’s a clinical diagnosis even though
an X-ray will show you
tightness of the aponeurosis and may show you
the bony formation of the spurring.
It is still a clinical diagnosis based
on your history and physical exam.
When you’re evaluating for plantar fasciitis,
let’s take a runner for example.
You’re going to ask them about the shoes
they wear, the comfort of the shoes
and whether or not they notice
whether it’s more comfortable
in certain shoes or
at certain times.
You want to know the surface they’re walking on,
the surface they’re living on.
Are they standing on carpeting?
Are they standing on a hard floors?
You want to know
how fast they run.
The faster they run the harder
the strike, the more bounciness
and more likelihood of developing
a plantar fasciitis.
You want to ask them about their stretching
habits, whether they stretch at all.
You want to ask about the strength of their
workout, and the structure of their feet,
and what’s going on
looking at their arches.
When we’re thinking about it
from an osteopathic perspective,
again the body is connected and
you're worried about the foot.
But it does affect the gastrocnemius,
the thigh muscles, as well as the hip.
You do worry about the iliopsoas, the hip flexor,
the hamstrings, the biceps femoris,
semimembranosus and semitendinosus,
the gastrocnemius, and the soleus.
It’s also important to note that for the
foot, the counterstrain points
as you can clearly see here are going to be
just anterior to the calcaneus
and at the bottom of the gastrocnemius
embedded in the aponeurosis.
When you have a patient with
plantar fasciitis, self-stretching,
self-rubbing is very common. Typically,
people would do it of the feet.
But rubbing the calves and the
hamstrings also will help release
some of the tension and make
people more comfortable.
OMMs can help increase activity,
make people more comfortable.
We often brace people. We wrap
people, splint people,
anything that helps them be aware
of their proprioceptive sense,
of where their foot is, where their legs are,
what is going to be uncomfortable
so that they protect themselves and
don’t overdo it and over work it.
NSAIDs help prevent inflammation and help
prevent the pain from getting worse.
There’s always a surgical intervention
which are not curative,
can relieve some of the pain
for a short period of time.
When you look at the osteopathic considerations
for treating plantar fasciitis,
it’s an osteopathic disease
and a concept.
You have to treat the whole body. We’re going to
start treating plantar fasciitis
from treating the lumbar spine because
when you have problems with the foot,
it’s going to extend to the calf,
the hips, and the back.
You want to treat the lumbar spine,
the sacrum, and the pelvis.
Then you want to move distally to the hamstrings,
the calf, and finally the foot.
You do have releases of the plantar
fascia which includes rubbing,
myofascial release, and
The gastrocnemius will
It will become tight. It’s going to respond
pretty severely to plantar fasciitis.
When we treat the gastrocnemius, I generally
have the patient lie supine.
I sit at the side of the bed grabbing
the gastrocs, both heads
of the gastrocnemius, putting my hands
on the side under the gastrocnemius
trying to separate it because generally you get
and you are able to separate it.
Then I massage them,
do some lymphatic pump and just trying
to loosen up the muscles.
I generally put the force on the whole muscle,
on the whole body of the muscle
loosening up when I get
to the aponeurosis
because I don’t feel you get much
more benefit from that.
The pressure is maintained
the whole time.
You’re massaging the muscle,
and waiting, and measuring,
and monitoring the gastrocnemius
for a release
and for hypertonicity to go away.
So you want to do this
until you feel some
comfort in the patient.
You feel increased motion. You don’t feel
the tightness in the muscle.
You look to make sure that you
haven’t developed asymmetry,
if there’s no swelling, no restriction,
no tenderness or dysfunction.
Then I move down to the foot.
When I move down to the foot,
I generally use myofascial release. Again, having
the patient supine
and letting me sit at the table and
grab the foot and use the foot
and initiating motion is generally
the most comfortable.
I use my thumb in order to get enough
pressure to push down on it,
which often feels very
uncomfortable for the patient.
Some doctors will put an X
where their thumbs are
so they know they’re keeping
it in the same place
and know the area of concern and
go back to the same place.
Once you’ve got the
foot aponeurosis covered
and you’re trying to massage
the plantar fascia,
you continue with the pressure
until you hit a barrier.
Once that barrier is met, then
you’re trying get it released
with gentle internal and external
eversions, just moving the foot.
When you do move it and
you are able to move it,
you will feel some release by the patient
and an increased ease of motion.
You want to repeat both sides
because one-third of the time,
you’re going to have it on both feet
and you want to make sure
you monitor and are
aware of what’s going on.
Again, always reassess at the
end of a treatment
to make sure you can tell what
effect the treatment has had.
If you feel uncomfortable doing
strain counterstrain can
be done in the foot.
Again I gave you
the two points.
One of the problems with strain counterstrain
is there isn't as much motion in the foot.
Generally, you find the counterstrain
point and then you move
the foot until you have that
70% relief of the pain.
Without much motion you’re going back and
forth in the same direction quite a bit.
But that’s okay. Find the area
of ease and then hold it.
Here are the ankle counterstrain points.
One is anterior to the calcaneus.
When you get that point, you want to flex the
forefoot and move it forward
until you can feel a release of the pain
and the patient says it’s gone down.
On the medial ankle just inferior to the medial
malleolus along the deltoid ligament
is another tender point. That’s a tender point
that you can hold the medial aspect
of the ankle and create the inversion
of the ankle until the pain goes away.
There’s also a tender point
on the lateral ankle
which is inferior and anterior to the
lateral malleolus and the sinus tarsi.
You want to hold that too.
You generally have to evert the foot
to get the pain to go away.
Again, we’re talking about
small amounts of motion.
So doing that same motion
repeatedly and just adding some
plantar flexion and dorsiflexion
while you do it may be helpful.
The gastrocs point which is just inferior
to the gastrocnemius and the aponeurosis is another area I use.
Even though it's somewhat outside the foot,
it does get to the gastrocnemius.
With plantar fasciitis, a lot of times
you’ll do the calcaneal counterstrain.
We’re going to show you in a video later
on how to do a calcaneal counterstrain.
But I generally have the patient lie supine,
sitting at the end of the table.
I find the plantar fascia and hold it,
put my hand over it.
Generally, the patient's going
to be uncomfortable.
They’re going to tell you that it hurts.
When you find the area that hurts,
that’s when you start to plantar flex, invert and
evert until you find the area of comfort.
Monitor the tender point with one
thumb over the tender point
until the patient says they’ve got
relief just by positioning
and by relieving some of the
pressure by plantar flexing
and maybe flexing the ankle and
finding up the area of ease.
You may want to suppinate or pronate
or go back and forth until you find it
and then hold it for
I find it hard to hold the foot for 90 seconds
in other areas of the body.
We are looking at easier ways of
doing it but have not found it.
At this point, you do have to hold it
for 90 seconds.
Then afterwards slowly return
the foot to a neutral position
and then reassess the tender point
to make sure you had an effect.