OPP / OMM COMAT Command Center OPP / OMM Shelf Exam Command Center

1. Tissue texture abnormality, 2. Asymmetry of anatomical landmarks, 3. Restriction of motion (pathological barrier), 4. Tenderness

• At least two of the four criteria (most commonly motion restriction and tissue texture change) are required to make the diagnosis of somatic dysfunction.
• Acute somatic dysfunction: Erythematous, boggy, warm, edematous, hypertonic, sharp tenderness. Chronic: Pale, cool, fibrotic, ropy, dull ache.

Primary Motion: Flexion and Extension ('nodding'); Sidebending and Rotation occur to OPPOSITE sides

• The OA joint accounts for approximately 50% of total cervical flexion and extension. Sidebending and rotation are always coupled to opposite sides, behaving like Fryette Type I mechanics regardless of sagittal flexion/extension posture.

Primary Motion: Pure Rotation (50% of total cervical rotation); Stabilized by the Transverse Ligament of the Atlas

• The AA joint provides approximately 45 degrees of rotation to each side with minimal sidebending or flexion/extension.
• The transverse atlantal ligament prevents posterior displacement of the dens into the brainstem/spinal cord. It is pathologically lax or absent in Down syndrome and eroded in severe Rheumatoid Arthritis, making HVLA strictly contraindicated.

Rotation and Sidebending occur to the SAME side in both flexion and extension (Type II-like behavior)

• Governed by the 45-degree angle of the superior articular facets (facing backward, upward, and medially: BUM).

OA Extension, Sidebent Right, Rotated Left (OA E SR RL)

• Always named for the direction of freedom of motion (ease of motion). In the OA joint, sidebending and rotation are always in opposite directions.

Fully flex the cervical spine to 45 degrees, then assess passive rotation to the right and left

• Full cervical flexion locks the facet joints of C2 through C7, isolating rotation exclusively to the AA joint.

Suboccipital Nerve (dorsal ramus of C1) and the Vertebral Artery

• Suboccipital muscle hypertonicity can compress the vertebral artery and greater occipital nerve (C2), precipitating cervicogenic tension headaches.

Physiological: End of active voluntary range; Anatomical: End of passive range before structural/ligamentous tissue damage; Pathological: Restrictive barrier encountered within normal physiological range

• OMT aims to engage or treat the pathological (restrictive) barrier to restore normal physiological range of motion.

Hyperextension followed by hyperflexion, causing bilateral anterior cervical strain (longus colli, scalenes, SCM) and upper thoracic/rib dysfunctions

• Acute whiplash causes severe spasm of deep cervical flexors, reciprocal inhibition of extensors, and flattening or reversal of the normal cervical lordosis.

C5 Nerve Root (C4–C5 Intervertebral Disc Herniation)

• Motor: Deltoid and Biceps; Sensory: Lateral shoulder and upper arm; Reflex: Biceps tendon reflex. In the cervical spine, nerve roots exit ABOVE their corresponding numbered vertebrae (C5 root exits between C4 and C5).

1. Inherent motility of the central nervous system (brain and spinal cord), 2. Fluctuation of the cerebrospinal fluid (CSF), 3. Mobility of reciprocal tension membranes (dura mater), 4. Articular mobility of the cranial bones, 5. Involuntary mobility of the sacrum between the ilia

• Normal Cranial Rhythmic Impulse (CRI) rate is 10 to 14 cycles per minute. Decreased in depression, stress, chronic fatigue; increased in fever and acute exercise.

SBS rises (flexes); Cranial transverse diameter widens (AP diameter decreases); Paired bones Externally Rotate; Sacral base moves Posteriorly (cranial nutation / counternutation)

• During cranial extension, the reverse occurs: SBS drops, transverse diameter narrows, AP diameter lengthens, paired bones internally rotate, and sacral base nutates anteriorly.

Midline Bones: Sphenoid, Occiput, Ethmoid, Vomer -> Undergo Flexion/Extension; Paired Bones: Parietals, Temporals, Maxillae, Zygomae -> Undergo External/Internal Rotation

• Midline bones flex and extend around transverse axes; paired bones rotate around longitudinal/oblique axes.

One Anteroposterior (AP) Axis; Named for the Greater Wing of the Sphenoid that is Superior

• Sphenoid and occiput rotate in OPPOSITE directions around a single AP axis extending from the nasion through the opisthion. Example: In a Right Torsion, the right greater wing of the sphenoid moves superiorly while the right occiput moves inferiorly.

Three Axes: 2 Vertical axes (rotation in opposite directions for sidebending) + 1 AP axis (rotation in same direction for rotation); Named for the Side of the Wide, Inferior Base (side of concavity)

• The sphenoid and occiput sidebend toward the same side and rotate toward the same side. The vault feels wide and low on the side of the dysfunction.

Vertical Strain: 2 Transverse axes (sphenoid and occiput rotate in SAME direction) -> Named for direction of sphenoid base (Superior or Inferior); Lateral Strain: 2 Vertical axes (rotate in SAME direction) -> 'Parallelogram head'

• Both vertical and lateral strains are non-physiological strain patterns typically caused by traumatic blows to the head.

Direct anterior-to-posterior or circumferential force (e.g., blow to frontal bone); Feels hard, bowling-ball-like, with severely diminished or absent CRI

• SBS compression severely restricts cranial fluctuation and dural tension, and is clinically associated with severe depression, exhaustion, and chronic headaches.

Glossopharyngeal (CN IX), Vagus (CN X), and Accessory (CN XI)

• Compression of the occipitomastoid suture or condylar compression can impinge CN IX, X, and XI, causing poor suckling, swallowing difficulties, colic, and torticollis in newborns.

Hypoglossal Nerve (CN XII) / Condylar Compression

• Condylar compression of the occipital condyles on the lateral masses of C1 impinging CN XII causes tongue protrusion weakness and poor nursing latch in neonates.

Gently encourages cranial extension while resisting cranial flexion until a 'still point' is reached; Resets and enhances CRI and autonomic balance

• The physician cups the occiput medially, encouraging the lateral angles to approximate (extension) while discouraging widening (flexion). Used to stimulate labor in post-term pregnancy and reduce systemic fevers.

Ribs 1–5: Pump-handle motion (increases AP diameter); Ribs 6–10: Bucket-handle motion (increases transverse diameter); Ribs 11–12: Caliper motion (downward and lateral)

• Pump-handle motion moves around a coronal axis; bucket-handle motion moves around an AP/sagittal axis.

Rib 5 (The Lowest / Bottom Rib); Mnemonic: B-I-L-L (Bottom Inhalation, Lowest Last/Lowest Key)

• In an inhalation dysfunction, ribs are held up in inhalation and restricted in exhalation. The bottom rib prevents the superior ribs from moving downward into exhalation. Treating the bottom rib frees the group.

Rib 2 (The Top / Highest Rib); Treated using the Posterior Scalene muscle

• In exhalation dysfunction, ribs are held down and restricted in inhalation. The top rib prevents the inferior ribs from elevating. Treating the top rib frees the group.

Rib 1: Anterior/Middle Scalene; Rib 2: Posterior Scalene; Ribs 3–5: Pectoralis Minor; Ribs 6–9: Serratus Anterior; Ribs 10–11: Latissimus Dorsi; Rib 12: Quadratus Lumborum

• Contracting the specific muscle against physician resistance elevates the key exhalation rib superiorly.

Posterior: Body of T1; Lateral: 1st ribs and costal cartilages; Anterior: Superior border of manubrium (manubrial notch)

• Sibson's fascia (suprapleural membrane) covers the thoracic inlet, through which the thoracic duct and right lymphatic duct empty into the subclavian veins. The inlet must ALWAYS be released before performing peripheral lymphatic pumps.

1. Open the Thoracic Inlet (Sibson's fascia) -> 2. Abdominal Diaphragm redome -> 3. Pelvic Diaphragm release -> 4. Efferent Lymphatic Pumps (Thoracic/Pedal pump)

• Always clear proximal restrictions before mobilizing distal fluid; pumping against a closed inlet increases central venous pressure and worsens lymphatic stasis.

Thoracic Duct: Entire body EXCEPT the right arm, right hemicranium, right neck, and right hemithorax/heart/portions of lungs -> which drain into the Right Lymphatic Duct

• The thoracic duct drains into the junction of the left internal jugular and left subclavian veins.

Known or suspected Deep Vein Thrombosis (DVT), acute fracture, active local metastatic malignancy, untreated severe bacteremia/tuberculosis, and decompensated congestive heart failure

• Pumping a leg with DVT can dislodge the thrombus causing fatal pulmonary embolism.

T1–T3: SP at same level as TP; T4–T6: SP 1/2 vertebral level below TP; T7–T9: SP 1 full level below TP (SP of T7 is at level of T8 TP); T10: 1 level below; T11: 1/2 level below; T12: same level

• Essential for accurate palpatory localization of transverse processes during spinal exam.

Locks the anterior rib cage downward, decreasing functional residual capacity and vital capacity, worsening work of breathing

• Treating the key exhalation rib (Rib 1) elevates the rib cage, restores thoracic volume, and enhances diaphragmatic excursion.

Occurs in Neutral; Sidebending and Rotation occur to OPPOSITE sides; Involves groups of 3 or more segments (e.g., L1–L4 N Sl Rr)

• Maintained by long polyarticular paraspinal muscles (erector spinae). Facet joints are in neutral position.

Occurs in Non-Neutral (marked Flexion or Extension); Sidebending and Rotation occur to the SAME side; Involves a single isolated segment (e.g., L3 F Rr Sr)

• Maintained by short monoarticular muscles (rotatores, intertransversarii). Follows acute trauma or hyperflexion/extension.

Initiating motion of any spinal segment in one plane reduces or restricts its range of motion in the other two planes

• For example, flexing a lumbar segment restricts the available degrees of rotation and sidebending.

1. L1 or L2 Type II dysfunction rotated/sidebent to the side of the tight psoas, 2. Pelvic shift to the OPPOSITE side, 3. Ipsilateral short leg with foot externally rotated, positive Thomas test

• Severe psoas spasm pulls the anterior pelvis forward and creates a contralateral compensatory pelvic shift.

Normal: 25 to 35 degrees; Increased angle (> 35°) increases anterior shear stress on the lumbosacral junction, predisposing to spondylolisthesis and low back pain

• Measured between the horizontal and the superior articular surface of the sacrum.

Spondylolysis: Fracture of the Pars Interarticularis ('Collar on the Scotty Dog'); Spondylolisthesis: Anterior displacement of one vertebra over another ('Decapitated Scotty Dog')

• Most common at L5-S1. Graded I (0-25%), II (25-50%), III (50-75%), IV (75-100%).

L4–L5 herniation compresses the L5 root (weak great toe dorsiflexion [EHL], sensory loss on dorsum of foot); L5–S1 herniation compresses the S1 root (weak plantarflexion, absent Achilles reflex, lateral foot sensory loss)

• Paracentral herniations compress the traversing (lower) root.

Straight Leg Raise: Passive elevation of straight leg causes shooting pain down leg between 30° and 70°; Braggard: Lower leg 5° below pain threshold and dorsiflex foot (confirms nerve root traction vs. hamstring tightness)

• Highly sensitive for L4-S1 lumbar disc herniation.

Neurogenic: Pain relieved by sitting or bending forward ('shopping cart sign'), pulses intact; Vascular: Pain relieved simply by stopping walking, pulses diminished, dependent rubor

• Lumbar flexion increases the cross-sectional area of the spinal canal, relieving root compression.

Patient supine brings one knee to chest; if the opposite thigh lifts off the examination table, it confirms contracture/hypertonicity of the Iliopsoas on the extended leg

• Classic positive finding in acute Psoas Syndrome.

1. L5 Sidebending and the Sacral Oblique Axis are on the SAME side; 2. L5 Rotation and Sacral Rotation are in OPPOSITE directions; 3. The Seated Flexion Test is positive on the side OPPOSITE the oblique axis

• Example: If L5 is sidebent left and rotated right -> Left Oblique Axis, Right Sacral Rotation -> Left on Left or Right on Left.

Right-on-Left (R on L) Backward Sacral Torsion

• Seated flexion test positive on right -> Left oblique axis. Positive spring test (poor spring / hard end-feel) -> Backward torsion. Deep sulcus is on right, prominent ILA is on left -> Right on Left.

Seated flexion positive on right; Deep sulcus on left; Posterior/inferior ILA on right; Negative spring test (good spring / soft end-feel); Asymmetry improves in extension (Sphinx test)

• Forward sacral torsions demonstrate a negative spring test and improve when the patient prows up on elbows (Sphinx test).

Bilateral Flexion: Both sulci deep, both ILAs anterior/superior, Spring test negative (good spring); Bilateral Extension: Both sulci shallow, both ILAs posterior/inferior, Spring test positive (no spring)

• Bilateral sacral flexion is common post-partum and causes increased lumbar lordosis.

Standing flexion test positive on right; Right ASIS is INFERIOR; Right PSIS is SUPERIOR

• Associated with a functionally longer leg on the side of the anterior rotation.

Standing flexion test positive on left; Left ASIS is SUPERIOR; Left PSIS is INFERIOR

• Associated with a functionally shorter leg on the side of the posterior rotation.

Standing flexion test positive on affected side; BOTH ASIS and PSIS are SUPERIOR on that side; Pubic tubercle is superior on that side

• Typically caused by sudden vertical impact (e.g., stepping off a curb or slamming brake pedal in collision).

1. Superior Transverse Axis: Respiratory and Cranial motion (at S2 level); 2. Middle Transverse Axis: Postural motion (sacral flexion/extension in standing/walking); 3. Inferior Transverse Axis: Dynamic iliosacral motion (innominates rotating on the sacrum)

• Remember: Superior = Respiratory/Craniosacral; Middle = Postural; Inferior = Innominate.

Anterior Rotation: Engage Hamstrings (flex hip and have patient push heel down against resistance); Posterior Rotation: Engage Rectus Femoris / Psoas (extend hip and have patient push knee forward against resistance)

• Hamstrings pull the innominate posteriorly; rectus femoris pulls the innominate anteriorly.

Forward Torsion: Face-DOWN (Sims position, chest flat); Backward Torsion: Face-UP (lateral recumbent, chest rotated backward)

• In both positions, the axis side is placed DOWN on the table.

Heart: T1–T5 (Left side = myocardium/arrhythmias; Right side = SA node/SVT); Vagus (CN X). Lungs: T2–T7; Vagus. Stomach: T5–T9 (Celiac); Vagus. Liver/Gallbladder: T5–T9 (Celiac); Vagus

• Acute viscerosomatic reflexes present with boggy paraspinal fullness at these specific cord levels.

Kidneys & Upper Ureters: T10–T11 sympathetics; Vagus parasympathetics. Lower Ureters & Bladder: T12–L2 sympathetics; Pelvic Splanchnics (S2–S4) parasympathetics

• Note the transition: upper urinary tract receives vagal parasympathetics; lower urinary tract receives pelvic splanchnics.

At the junction of the proximal two-thirds and distal one-third of the Transverse Colon (Cannon's point / Splenic Flexure)

• Everything proximal receives CN X; everything distal receives S2–S4.

Small (2–3 mm), tender, pea-sized fibroelastic nodules located in the deep fascia or periosteum representing neurolymphatic gangliform contractions

• Produced by excessive sympathetic stimulation causing localized lymphatic congestion and tissue texture changes.

Anterior: 2nd Intercostal Space adjacent to the sternum; Posterior: Between the T2 and T3 spinous processes / transverse processes

• Extremely high-yield board question for acute coronary syndrome and tachycardia.

Anterior: 3rd and 4th Intercostal Spaces adjacent to the sternum; Posterior: Between T3–T4 and T4–T5 transverse processes

• Tender in asthma, bronchitis, and pneumonia.

Kidneys: 1 inch superior and 1 inch lateral to the umbilicus; Adrenals: 2 inches superior and 1 inch lateral to the umbilicus

• Posterior points: Kidneys between T12–L1; Adrenals between T11–T12.

Tip of the Right 12th Rib anteriorly; Posterior point is between T11 and T12 transverse processes on the right

• Frequently tested in acute appendicitis vignettes alongside Rovsing and psoas signs.

On the anterior/lateral aspect of the Iliotibial (IT) band from the greater trochanter down to just above the knee

• Maps from proximal colon at the hip to distal colon near the knee.

Prostate & Broad Ligament: Along the posterior border of the Iliotibial (IT) band; Bladder: Periumbilical region

• Palpated in chronic pelvic pain syndrome, prostatitis, and endometriosis.

Direct: Moves toward and engages the pathological (restrictive) barrier; Indirect: Moves away from the barrier into the position of ease / freedom of motion

• Direct examples: Muscle Energy, HVLA, Soft Tissue, Articulatory (Springing). Indirect examples: Counterstrain, Facilitated Positional Release (FPR), Cranial (some), Functional.

Shortens the strained muscle spindle, silencing abnormal gamma efferent firing; Hold in position of ease for 90 seconds (120 seconds for ribs), then slowly passively return to neutral

• The tenderpoint must improve by at least 70% (scale 10 down to <= 3) while monitoring the tenderpoint throughout.

Post-Isometric Relaxation (Golgi Tendon Organ activation causing reflex relaxation of agonist) and Reciprocal Inhibition (contracting antagonist relaxes agonist)

• Muscle Energy is an active, direct technique requiring isometric contraction for 3 to 5 seconds, followed by complete relaxation, taking up the slack to the new barrier.

AC Tenderpoints (AC1–AC8): Marked FLEXION, Sidebending, and Rotation AWAY from tenderpoint (F SARA); PC Tenderpoints (PC1–PC8): Marked EXTENSION, Sidebending, and Rotation AWAY (E SARA)

• Exception: AC1 (mandible) = Flex, Rotate Away (F RA); PC1 inion = Flexion, Sidebent and Rotated Away.

Marked bilateral hip flexion, external rotation, and sidebending toward the affected side (F ER ST)

• Also described as patient supine with ankles crossed, knees pulled up to chest.

Prone; Hip flexed to 135 degrees (high flexion), Abducted, and Externally Rotated (F ABD ER)

• High flexion relaxes the piriformis muscle across the greater sciatic notch.

FPR adds an activating compressive or torsional force to the neutral spine, shortening treatment time to only 3 to 5 seconds (vs. 90 seconds for Counterstrain)

• FPR is an indirect technique described by Stanley Schiowitz.

Starts INDIRECT in position of ease -> applies an activating compressive force -> moves through a smooth arc DIRECTLY through the restrictive barrier

• Invented by A.T. Still; converts from indirect to direct in a continuous smooth motion.

Adson: Palpate radial pulse while rotating head toward side and extending neck (anterior scalene); Eden: Shoulders drawn down and back (costoclavicular space); Wright: Hyperabduct arm above head (pectoralis minor)

• Diminution of the radial pulse or reproduction of paresthesias confirms compression of the neurovascular bundle.

Ober Test: Assesses Iliotibial (IT) Band and Tensor Fasciae Latae contracture (failure of abducted leg to drop below horizontal); Thomas Test: Assesses Iliopsoas contracture

• Tight IT band is a major contributor to lateral knee pain (iliotibial band syndrome) and trochanteric bursitis.