COMLEX
STRUCTURE
OMM
Chapman’s Reflex Points
ANTERIOR POINT
POSTERIOR POINT
CNS retina, conjunctiva cerebellum ENT sinuses middle ear pharynx tonsils tongue neck GI esophagus stomach (parietal) stomach (peristalsis) small intestine appendix colon
lateral superior humerus tip of the coracoid process medial inferior clavicle medial superior clavicle superior lateral edge of manubrium middle lateral edge of manubrium 2nd costosternal joint medial superior humerus superior aspect of 3 rd intercostal space left 5th intercostal space left 6th intercostal space 8th, 9th, and 10th intercostal spaces tip of the 12 th rib iliotibial band
T2-T3 between SP and TP T5 between SP and TP T6 between SP and TP T11 between SP and TP
flip the colon over; cecum near the greater trochanter and hepatic flexure near knee)
rectum
lesser trochanter of femur HINT: attachment site of psoas major
SNS GANGLIA celiac ganglion superior mesenteric ganglion inferior mesenteric ganglion ORGANS heart, thyroid, bronchi upper lung lower lung liver gallbladder pancreas spleen adrenal ovary prostate URINARY kidneys bladder urethra
below xiphoid process between umbilicus and xiphoid process above umbilicus left 2nd intercostal space 3rd intercostal space 4th intercostal sapce right 5th and 6th intercostal spaces right 6th intercostal space right 7th intercostal space left 7th intercostal space 1in lateral, 2in superior to umbilicus lateral to pubic symphysis (superior edge) posterior ilotiband
T2-T3 between SP and TP T3 between SP and TP T4 between SP and TP right T5-T6 between SP and TP right T6 between SP and TP right T7 between SP and TP left T7 between SP and TP T11-T12 between SP and TP
1in lateral, 1in superior to umbilicus periumbilical superior pubic ramus, 2cm lateral to symphysis
T-12-L1 between SP and TP upper edge L2 TP L2 TP
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COMLEX
OMM
Chapman’s Reflex Points
retina, conjunctiva sinuses
cerebellum
retina, conjunctiva
neck larynx pylorus small intestines
appendix (R)
middle ear nasal sinuses pharynx tonsils tongue esophagus, bronchus thyroid, myocardium upper long lower lung stomach (acidity) (L)
thyroid upper lung, myocardium upper lung lower lung stomach (acidity) (L) liver (R) stomach (peristalsis) (L) liver, gallbladder (R)
adrenals left adrenal left kidney Bladder area
Umbilicus intestinal peristalsis
middle ear pharynx, tongue, larynx, sinuses, arms neck, esophagus, bronchus
ovaries, urethra uterus
kidneys abdomen, bladder urethra uterus vagina, prostate, uterus, broad ligament rectum, groin glands Fallopian tubes, seminal vesicles
cerebellum nasal sinuses cerebrum arms (and pectoralis minor) neuroansthesia (and pectoralis minor)
pyorus (R) ovaries intestines (peristalsis) appendix (R)
large intestines
sciatic nerve (posterior)
hemorrhodial plexus
rectum clitoris, vagina
prostate or broad ligament
colon
sciatic nerve (anterior)
Most likely to be asked about on COMLEX (all are possible)
COMLEX
OMM
STRUCTURE
sinuses , eustachian tube, lacrimal glands thyroid trachea, bronchi lower 2/3 esophagus aortic arch heart lungs stomach dudodenum liver gallbladder, biliary tree spleen pancreas small intestine proximal colon distal colon appendix adrenal glands, kidney, upper ureter, ovary and testes lower ureter, bladder, trigone/sphincter, uterus, prostate genital cavernous tissue, penis, seminal vesicle mammary glands arms legs
ANS Innvervation
SEGMENT
T1-4 T1-4 T1-6 T5-6 T1-5 T1-6 T2-4 T5-9 left T5-9 T5 right T6 right T7 left T7 right T10-T11 T10-T12 T12-L2 T12 T10-11 T12-L1 T12-L2 L2 T1-6 T2-8 L11-L2
STRUCTURE
SEGMENT
pupils (constriction aka miosis)
CN III (midbrain) ! ciliary ganglion CN VII (pons) ! sphenopalatine ganglion CN VII (pons) ! submandibular ganglion CIX (medulla) ! otic ganglion
lacrimal and nasal glands submandibular and sublingual glands parotid gland heart, bronchial tree, esophagus (lower 2/3), stomach, small intestine, liver, gallbladder, pancreas, kidney and upper ureter, ovaries and testes, ascending and transverse colon, ascending/transverse colon lower ureter and bladder, uterus, prostate, genitalia, descending colon, sigmoid, and rectum
CN X (medulla) ! dorsal motor nucleus
Nucleus Solitarius
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Dorsal motor nucleus ! (.&/( #6,*&*%+8
pelvic splanchnic (S2-4)
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COMLEX
OMM
ANS Innvervation
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COMLEX
OMM
Upper Extremity
NERVE
INNERVATES
Axillary (C5, C6)
deltoid and teres minor (arm abduction, external rotation)
Radial (C5-T1)
sensory shoulder arm and forearm (wrist) extensors supinator
NOTES
injured by dislocated shoulder
common injury with fracture of midshaft humorous RES – radial, extensors, supinator
Median (C5-8, T1)
sensory posterior arm and forarm sensory part of thenar eminence on palmar hand, PIPs and proximal dorsu of hand from thumb to half of ring finger wrist flexors, pronator teres lumbricals 1 and 2, thenar muscles, cutaneous sensation
Meat-LOAF Median nerve, 2 Lateral Lumbricals, Oponens pollicus, Abductor pollicis brevis, Flexor pollicis
brevis
Ulnar (C8, T1)
Musculocutaneous (C5-7)
sensory palmar hand ! thumb, first and second digit, half of third digit sensory dorsal hand ! PIP and distal thumb, index, middle, and half of ring finger flexor carpi ulnaris intrinsic hand muscles lumbricals 3 and 4, hypothenar muscles, interossei, adductor pollicis, flexor pollicis brevis sensory fifth and ! fourth digit on both dorsal and palmar side anterior (flexor) compartment of the arm
MFP – median, flexors, pronator
A OF A OF A first AOF thenar muscles Adductor pollicis, Opponens digit minimi, Flexor digiti minimi, Abductor digiti minimi
biceps brachii, brachialis, coroacobrachialis flexion and supination
sensory lateral arm
Supraspinatus – initiation of abduction, suprascapular nerve (C5) Infraspinatus – external rotation, suprascapular nerve (C5-C6 Teres minor – external rotation, axillary nerve (C5) Subscapularis – internal rotation, upper and lower subscapular nerve (C5-C6) “SITS” muscles
Pectoralis major – one of two primary adductors, lateral and medial pectoral nerves (C5-T1) Deltoid (anterior) – primary flexor, axillary nerve (C5-C6) Deltoid (middle) – primary abductor, axillary nerve (C5-C6) Deltoid (posterior) – one of three primary extensors, axillary nerve (C5-C6) Teres major – one of three primary extensors, axillary nerve (C5-C6) Latissimus dorsi – primary extensor and adductor, thoracodorsal nerve (C6-C8)
COMLEX
OMM
Upper Extremity
NERVE/MUSCLE
TYPICAL INJURY
MOTOR DEFICIT
Axillary (C5, C6)
Fractured surgical neck of humerus, dislocation of humeral head Fracture at midshaft of humerus; “Saturday night palsy” (extended compression of axilla by back of chair or by crutches) Fracture of suprachondylar humerus (proximal lesion
Deltoid – arm abduction at shoulder “BEST extensors” – Brachioradialis, Extensors of wrist and fingers (C6-7) Supintor, Triceps
Over deltoid muscle
Atrophied deltoid
Posterior arm and dorsal hand and thumb
Wrist drop
Opposition of thum Lateral finger flexio Wrist flexion (C7-8)
Dorsal and palmar aspects of lateral 3/12 fingers, thenar eminence
Fracture of medial epicondyle of humerus, “funny bone” Hook of hamate injury (bicycle riders) Upper trunk compression
Medial finger flexio Wrist flexion (C7-8)
Medial 1 ! fingers, hypothenar eminence
“Ape hand”; “Popes blessing” (hand) Travels through the two heads of pronator teres Radial deviation of wrist upon wrist flexion
Biceps, brachialis, coracobrachialis Flexion of arm at elbow
Lateral forearm
Radial (C5-T1)
Median (C5-8, T1)
Ulnar (C8, T1)
Musculocutaneous (C5-7)
acute, sharp pain in shoulder followed by ongoing dull achh and tenderness at acromion process
SENSORY DEFICIT
more commonly an injury of the tendons rather than the actual m uscles supraspinatus tendon most frequently affected
because it passes below the acromion
(+) drop arm test, weak abduction
treat less severe cases with RICE, NSAIDS, and OMT
the site of injury usually occurs at the point of insertion at the greater tubercle of the
A nterior radial head ! radial head does not glide posteriorly; Restricted Pronation, +/- pain with pronation most likely to occur with backswords fall on extended arm Posterior fibular head ! radial head does not glide anteriorly; Restricted Supination; wrist and elbow pain FOOSH injury (fall on out-stretched hand) “R
SIGN/NOTES
COMLEX
OMM
Upper extremity
DYSFUNCTION
DEFINITION
ETIOLOGY
NOTES
Erb-Duchenne palsy
injury to upper brachial plexus, usually lateral stretching injury to lower branchial plexus,
infant ! lateral traction on neck during delivery adult ! trauma most often trauma during childbirth
long thoracic n injury ! paralysis of serratus anterior muscle compression of brachial plexus, subclavian vein, and subclavian artery
trauma to the long thoracic n shoulder blow, repetitive movements, mastectomy) can occur between: ant and mid scalenes clavicle and 1 st rib pectoralis minor and upper ribs
waitor’s tip posturing, C5-6 upper trunk arm extended and pronated paralysis of intrinsic hand muscles C8-T1 sensory loss +/- Horner’s syndrome while patient pushes anteriorly (e.g. against a wall) scapula protrudes posteriorly ache and/or paresthesia of neck or arm
Klumpke’s Palsy
winged scapula
thoracic outlet syndrome
COMLEX
OMM
Upper Extremity
COMLEX
OMM
Upper Extremity
STRUCTURE
EVALUATES
TECHNIQUE
Apley’s scratch test
range of motion
Adson’s test
thoracic outlet syndrome
Roos’s test
thoracic outlet syndrome
drop arm test
rotator cuff tear
Speed’s test
biceps tendon
Yergason’s test
stability of biceps tendon in bicipital groove
patient reaches behind head to scratch back – evaluates abduction and external rotation; patient reaches across chest to scratch other should and/or reaches around the back at waist and scratches back – evaluates internal rotation and adduction patient extends elbow and arm, turns head towards ipsilateral side. positive if radial pulse markedly weakened or absent patient abducts both arms to 90˚, externally rotates, then flexes the elbows to 90˚; patient repetitively opens and closes firsts for 3min positive if exacerbations of symptoms patient abducts arm to 90 degrees and slowly drops arm to side positive if arm rapidly falls patient extends elbow; supinates forearm while flexing the arm at the shoulder against resistance positive if there is tenderness in the bicipital groove patient flexes elbow to 90 degrees while clinician holds the patient’s wrist with one hand and elbow with the other clinician resists the patient’s flexion/pronation force while passively externally rotating positive if there is pain in biceps tendon as it pops out of the bicipital groove
STRUCTURE
EVALUATES
TECHNIQUE
Tinel’s test
carpal tunnel syndrome
clinician taps over volar aspect of patient’s traverse carpal ligament (Tinel Tap) !test = paresthsia of thumb, index, ring fingers patient's wrist passively but maximally flexed (extended in reverse) by the clinical, held for one minute !test = paresthsia of thumb, index, ring fingers patient opens and closes hand several times an makes a tight first clinician occludes one artery and has patient open hand test failed if hand remains pale patient makes a tight first with thumb tucked into first clinician induces adduction of the wrist !test = pain over tendons of wrist
Phalen’s (and reverse Phalen’s) tests
Allen’s test
Finkelstein test
carpel tunnel syndrome
radial and ulnar artery patency/blood flow
tenosynovitis of pollicis longus and extensor pollicis brevis (DeQuervain’s tenosynovitis)
COMLEX
OMM
Lower Extremity
NERVE
TYPICAL INJURY
MOTOR DEFICIT
Obturator (L2-L4)
Anterior hip dislocation
Thigh adduction
Medial thigh
Thigh flexion and leg extension Foot eversion and dorsiflexion; toe extension Foot inversion and plantarflexion; to flexion Thigh abduction
Anterior thigh and medial leg Anterolateral leg and dorsal aspect of foo
Can’t jump, climb stairs, or rise from seating position; can’t push downwards
Lateral forearm
Femoral (L2-4)
Pelvic fracture
Tibial (L4-S3)
Trauma or compression of lateral aspect of leg or fibula neck fracture Knee trauma
Superior gluteal (L4-S1)
Posterior hip dislocation or polio
Inferior gluteal (L5-S2)
Posterior hip dislocation
Common peroneal (L4-S2)
SENSORY DEFICIT
Trendelenberg sign contralateral hip drops when standing on leg ipsilateral to lesion
!
Sciatic nerve (L4-S3) – posterior thigh, splits into common peroneal and tibial nerve
MUSCLE
ACTION
INNVERVATION
Ilopsoas
hip flexion
L1, L2, L3
gluteus maximus
hip extension
inferior gluteal n (L5, S1, S2)
gluteus medius, minimus
thigh abduction
superior gluteal n (L5, S1)
hamstrings
knee flexion
L5, S1, (S2)
(hip extension)
tibial n tibial n tibial n common peroneal n
hip adduction
obturator n (L2, L3)
pirformis
abduction of flexed thigh
S1, S2
quadriceps
knee extension
femoral n (L2, L3, L4)
adductors adductor brevis, longus, magnus, and minimus gracilis
rectus femoris vastus lateralis, medialis, and intermedius (deep)
Foot drop, foot slap, steppage gait
Sole of foot
PED = Peroneal E verts and Dorsiflexes; if injured, foot droPED TIP = Tibial Inverts and Plantarflexes; if injured, can’t stand on TIPtoes
semitendinosus semimembranosus biceps femoris (long head) biceps femoris (shorthead)
SIGN
COMLEX
OMM
Lower Extremity
MUSCLE
ACTION
INNVERVATION
anterior tibialis
dorsiflexion and inversion of foot
deep peroneal n (L4)
extensor halluces longus
foor dorsiflexion and great toe extension
deep peroneal n (L5)
gastrocnemius
foot plantarflexion
tibial n (S1, S2)
peroneus longus and brevis
foot eversion
superficial peroneal n (S1)
A nterior fibular head ! foot stuck in internal rotation and plantarflexion; treat with muscle energy by placing the foot in Inversion (loose pack fibula), External rotation of tibia, and Dorsiflexion Tx = AED plus inversion Posterior fibular head ! 9**, (,68; +& .H,.- -*,#,+*& #&/ /*-(+91.H+*&S ,-.#, 7+," %6(81. energy by placing the foot in Inversion (loose pack fibula), Internal rotation of the tibia, and Plantarflexion Tx = PIP plus inversion
COMLEX
OMM
Lower Extremity
Neuromuscular disorder in which the sciatic nerve is compressed by the piriformis muscle. Characterized by tingling and numbness in buttocks descending into the lower thigh and leg Treatment includes muscle energy and counterstrain: ME: patient abducts against resistance CS: patient prone, knee and thigh flexed, thigh abducted and externally rotated (“peeing dog” position) “peeing dog with a problem” is for LPL5 point alternate treatment is extension on prone patient
Ankle strain ! muscular injury Ankle sprain ! ligament injury Grade 1 (first degree) microtears Grade 2 (second degree ) partial tear Grade 3 (third degree ) complete tear
Lateral ankle sprain much more common than medial ankle sprain (deltoid ligament supporting medial ankle very strain) Classifications Type I = sprained ATFL ATFL “Always Tears First Ligament” Type II = sprained ATFL and CFL Type III = sprained ATFL, CFL, and PTFL
Femoral head angulation ! the angulation between the neck of the femur and the shaft of the femur >135 degrees = coxa valgum <120 degrees = coxa varum Q Angle ! angulation between a line drawn from ASIS through the middle of the patella and a line from the tibial tubercle through the middle of the patella >12 degrees = genu valgum <10 degrees = genu varum
Coxa varum = <120˚
Normal = 120˚
Coxa valgum = >135˚
left: femoral head angulation right: Q angle; shaded region is the angle
Pain and swelling over the tibial tuberosity Exacerbated by squatting, climbing stairs, extending knee against resistance C
X-Ray ! tibial tuberosity may appear separated with new bone growth beneath TX: modifying physical activity to decrease stress on tendon Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling
