Osteopathic Principles applied to Sports Medicine - Virginia ...

Osteopathic Principles applied to Sports MedicineMark Rogers, DO, MA199

Osteopathic Medicine• “To find health shouldbe the object of thedoctor. Anyone canfind disease.”--Dr. A.T. Still,1874Why Name it “Osteopathy” ?“ Osteopathy is compounded of twowords, osteon, meaning bone, (and)pathos, (or) pathine), to suffer. ““I reasoned that the bone, “Osteon”,was the starting point from which I wasto ascertain the cause of pathologicalconditions, and so I combined the“Osteo” with the “pathy” and had as aresult, Osteopathy.”Early History• Charles Bell (1811)– Discovers the function ofindividual spinal nerves for motorand sensory function• Dr. William Beaumont (1833)– Published first experiments ongastric digestion and responseto foods and emotion from apatient with a gunshot wound inabdomen201

Early History• Thomas Brown MD (1828)– ”Spinal Irritation”– Pain about an internal organ maybe caused by a disturbed spinalvertebrae with a shared nervesupply• John Hilton MD (1863)– Anatomist and Surgeon– “Sympathies”– Visceral pain without sore spots orinflammation– Treatment of viscera by resting thespineHistorical Aspects of Manipulation• Chinese Manual Therapy PredatesAcupuncture• Bone Setters– Healing practitioners who usedmanual therapy as an integral part oftheir care• Sir Herbert Barker– Was a well known British bonesetterof the late 1800s, who was knightedby the crown for his eminence• Early published papers in TheLancet and British Medical JournalHistorical Aspects of Manipulation& Sports• Hippocrates– “Father of Medicine”– 460 BC– Well known Greek SportsPhysician– Physician for the Olympics– Use of manipulation welldocumented• “Physical structure is thebasis of medicine”202

Historical Aspects of Manipulation& Sports• Galen– 150 AD– Followed Hippocrates’teachings– The most influential RomanPhysician– Served under MarcusAurelius– Principal Physician to theGladiators– Wrote up to 600 worksHistorical Aspects of Manipulation& Sports• “Phog” Allen, D.O.– Legendary BasketballCoach at Kansas University– Osteopathic Physician– Athletic Trainer– Well known for his use ofmanipulation in ailingathletesOsteopathic Medicine’s Roots inVirginia• Andrew Taylor Still– Born in Jonesville, Va. in1828 to a Methodist ministerwho practiced medicine andfarming– Dr. Still maintained his mindbody-spiritapproach tomedicine– Coined the osteopathicprinciples in 1874– Kirksville College ofOsteopathic Medicine (1892)203

Early Osteopathy“A perfectly adjusted body…willproduce pure blood and plenty ofit, deliver it on time and inquantity sufficient to supply alldemands in the economy of life”-- A.T. Still, M.D.Classical Osteopathic Philosophyof Health• Health is a natural state ofharmony between body,mind and spirit• The human body is a perfectmachine created for healthand activity• A healthy state exists as longas there is normal flow ofbody fluids and nerve activityClassical Osteopathic Philosophyof Disease• Disease is an effect of underlying,often multi-factorial causes• Illness is often caused by mechanicalimpediments to normal flow of bodyfluids and nerve activity• Environmental, social, mental, andbehavioral factors contribute to theetiology of disease and illness, thusneed to be addressed in management• Removal of mechanical impedimentsallows optimal body fluid flow, nervefunction, and restoration of health204

4 Tenets of Osteopathic Philosophy• The body is a unit• The body possesses self-regulatory,self-healing, and health maintenancemechanisms• Structure and function are reciprocallyinterrelated• Rational therapy is based on anunderstanding of body unity, selfregulatorymechanisms, and theinterrelationship of structure andfunctionSomatic Dysfunction• Impaired or altered function ofrelated components of the somatic(body framework system) skeletal,arthrodial, and myofascial structures;and related vascular, lymphatic andneural elements• Includes changes related to:• Tissue Texture• Asymmetry• Restriction of Motion• TendernessActive range of motionPhysiologic barrierAnatomic barrier205

Motion LossActive range of motionPathologic barrierPhysiologic barrierAnatomic barrierShift of midlineActive range of motionPathologic barrierLoss of motionThe Goal of OMM• Therapeutic application ofmanually guided forces toimprove physiologic functionand /or support homeostasis• Utilizing concepts of theunity of the living organism’sstructure (Anatomy), andfunction (Physiology) andusing the art of medicine206

General Concepts of OMM inAthletes• Restore maximal, pain freemovement of the musculoskeletalsystem in postural balance• Minor injuries can producedisabilities– May affect overall function• Effective diagnosis and treatmentrequires an understanding of theSTRUCTURE and FUNCTIONrelationshipCurr. Sports Med. Rep., Vol. 7, No. 1, pp. 49‐56, 2008Evidence-Based OsteopathicManipulation SummaryBenefit > Risk for• Acute, subacute andchronic mechanical lowback and neck pain• Cervicogenic headaches• Knee Osteoarthritis• Prenatal OB• Pediatric NeurologicDevelopmentCan reduce:• Pain• Medication use• PT utilization• Hospital days• Disability/Impairment• Work days lost• Post-op pulmonarycomplications• Post-op ileus• Post-MI complicationsIncrease in:• Patient satisfactionHow is Manipulation Proposed to Work?• Biomechanical orientation…– Release of facet joint synovialentrapment– Relaxation of hypertonicmusculature by suddenstretching– Unbuckling of motion segmentsthat have becomedisproportionately displaced– Disruption of articular orperiarticular adhesions207

Functional Biomechanical Exam• Postural examination• Approximate footposition• A-P and lateral curves• Examine foot, kneeand hip alignment• Leg lengthsFunctional Biomechanical ExamBrolinson PG. Curr Sports Med Rep 2003; 2:47‐56Kuchera, M. Foundations for Osteopathic Medicine, 2 nd edition,. 2003“Routine” Pre-Competition OMT• Standing Flexion Test• Assess leg length• Assess transitional areas in Tand L spine• Assess innominants• Assess any rib dysfunctions• Assess C spine• Determine any sacraldysfunction208

“Routine” Pre-Competition OMT• Begin ST of thoracic and lumbarspine– TART changes• Lateral recumbent roll for SI andlumbar dysfunction• SI and pubic symphysis MEtechnique• Thoracic HVLA• Rib articulatory treatment– Especially 1 st rib• Cervical ST and HVLA• Any particular treatment for otherspecific dysfunctions as indicatedInversion Ankle Sprain• Typically with plantar flexion– Thin posterior portion of talus offerslittle ankle stability– Relying dynamically on soft tissuesupport• Peroneal muscles are eccentricallyloaded rapidly• Weight of body coming down ‘jams’ talusinto the crural (distal tib/fib) articulationInversion Ankle SprainStich Woodbridge Ankle Injury209

Inversion Ankle SprainInversion Ankle Sprain• Soft tissues– Peroneal muscles– Anterior tibialis– Extensor digitorum• Navicular/cuboid dysfunction• Talus dysfunction• Fibular head• Tibia• Femur• Hip• Sacrum• 3 rd rib/thoracic vertebraInversion Ankle Sprain Soft Tissue210

Inversion Ankle SprainFoot Dysfunction• Somatic dysfunction– Navicular– Cuboid– Diagnosed by painand decreased motion• Trigger pointsNavicular Dysfunction• Mechanism– Chronic Posterior Tibialisdysfunction– Calcaneo-navicular (spring)ligament insufficiency– Acute inversion ankle sprain• Exam– Prominent (& usually tender)navicular bone– May have increased pronationPeroneus LongusInsertion Spring LigamentTreatment of Navicular DysfunctionArticulatory Technique• Restore arch bygapping superioraspects of navicularbone & applying plantarto dorsal pressure– Can be done with onerapid action or with slowsteady pressure• Recheck findings211

Cuboid Dysfunction• Mechanism– Chronic peroneus muscledysfunction– Calcaneo-cuboid ligamentinsufficiency– Often concomittant with naviculardysfunction• Exam– Prominent (& usually tender)cuboid bone– Supination may be noticeableTreatment of Cuboid DysfunctionArticulatory Technique• Grasp cuboid snugly &‘chalking’ the 5 thmetatarsal head onto thecuboid gently• Or ‘chalking’ the cuboidonto the calcaneus.“Chalking the cue stick!”Inversion Ankle SprainTalus Dysfunction• Anterior dysfunction– Restricted in dorsiflexion• Pt will complain of anteriortalar pain or ‘jamming’ withattempted dorsiflexion, &possibly of reduced calfstretch when attempted• Diagnose by “Swing Test”212

Treatment of Talus DysfunctionHVLA Technique (Talar Tug)Treatment of Talus DysfunctionArticulatory TechniqueTreatment of Anterior TalusMuscle Energy Technique• Flex knee and keep footparallel to floor until barrieris felt• Have patient gentlyplantarflex (away frombarrier) while maintainingposition• 2 to 3 seconds rest• Engage new barrier• Repeat 3-5 times Pushing the talus back into thetalocrural joint213

Treatment of Posterior TalusMuscle Energy Technique• Extend knee and keepfoot parallel to floor untilbarrier is felt• Have patient gentlydorsiflex (away frombarrier) while maintainingposition• 2 to 3 seconds rest• Engage new barrier• Repeat 3-5 timesPulling the talus out of thetalocrural jointInversion Ankle SprainFibular Head Dysfunction• Anterior restriction• Can be associated withiliotibial tendonitis, and/ormimic lateral meniscal tears• Pt will complain of lateralknee pain, usually withweight bearing & pivoting• Rule out Maisonneuve Fx ifknown to be a traumaticmechanismInversion Ankle SprainFibular Head Dysfunction• Remember plane of tib-fib jointis about 30 0– Anterolateral– Posteromedial• Goal of all the followingtreatments are for the return ofanterolateral glide of theproximal fibular head & toallow external rotation of tibia214

Treatment of Posterior Fibular HeadArticulatory TechniqueTreatment of Posterior Fibular HeadArticulatory Technique215