General osteopathic principles

General information


  • Approach: layer by layer, superficial to deep
  • Layers (from superficial to deep): skin → subcutaneous tissue → vessels → deep fascia → muscle → ligament → bone
    • Skin: note color, temperature, skin drag, texture, turgor
    • Subcutaneous tissue: normally spongy, edematous with acute changes
    • Vessels: look for congestion or vascular formation
    • Deep fascia: smooth, firm
    • Muscle: follow muscle fibers, observe tension or hypertonicity
    • Ligaments: note tenderness
    • Bone: follow contours, landmarks, structure, symmetry

Somatic dysfunction

  • An impairment or altered function of musculoskeletal structures and their associated lymphatic, neural and vascular elements
  • Characterized by TART
    • Tissue texture changes
      • Acute: Tissue may be edematous, tender, boggy, and/or red.
      • Chronic: Tissue may be rigid, ropey, and/or atrophic.
    • Asymmetry: posture or joint function lacks symmetry compared to the complementary side
    • Restriction of motion
    • Tenderness: pain felt upon palpatory examination
  • Named after the freedom of motion (versus restricted motion)

Acute versus chronic changes

Acute changes Chronic changes
  • Increased
  • Decreased (or slight increase)
Skin drag test
  • Increased drag
  • Decreased drag
  • Rigid
  • Ropey, stringy
  • Moderate-severe
  • Mild
  • Increased (thin film)
  • Dry
Erythema test
  • Persistent redness
  • Redness fades quickly or blanching
  • Boggy, rough
Blood vessels
  • Venous congestion
  • Present
  • Absent

Greenman's modified 10-step screening examination

Step 1: posture screening

Step 2: gait analysis

  • Assess gait by observing patient walk.
  • Assess lower extremity weakness by having patient squat, walk, and stand back up (duck walk).

Step 3: active truck side bending

  • Assess lateral spinal curvature by having patient side bend to each side.

Step 4: standing flexion test

Step 5: stork test

  • Assess motion of ilium and sacrum on relation to each other by performing a stork test.

Step 6: seated flexion test

Step 7: screening of the upper extremities

  • Assess range of motion of the upper extremities.
    • Have patient abduct the arms until the backs of the hands are touched (∼ 180° if possible).
    • Have patient cross the arms and hold onto the elbows.
    • Have patient flex the arms to ∼ 90°, interlock the fingers from opposite sides, and bring the hands through the arms.

Step 8: trunk mobility testing (side bending and rotation)

  • Assess side bending and rotation of the truck while in a seated position (active and passive).

Step 9: head and neck mobility

  • Assess head and neck range of motion.

Step 10: quick total body screen

Fryette's laws of spinal motion

Fryette's first law of spinal motion

  • The spine exhibits a neutral mechanic.
    • Side bending and rotation of the segment occur in opposite directions (e.g., thoracic segment is side bent left and rotated right).
    • Rotated and side bent segment does not realign when placed into flexion or extension.
  • Present in type 1 somatic dysfunctions

Fryette's second law of spinal motion

  • Spine exhibits a non-neutral mechanic
    • Side bending and rotation of the segment occur to the same side (e.g., lumbar segment is side bent and rotated right).
    • Rotated and side bent segment realigns when placed into either flexion or extension (non-neutral mechanics).
  • Present in type 2 somatic dysfunctions
    • Dysfunction is isolated to one segment.

Fryette's third law of spinal motion

  • Motion of an isolated segment in one plane engages its motion in the other planes (e.g., engaging flexion also engages the rotational and side bending component of the dysfunction).

Osteopathic therapeutic modalities

Articulatory techniques

  • Active direct techniques
  • Increase range of motion of restricted joints
  • Utilize gentle rhythmic spinning motions or concentric movements of a joint
  • Typically performed prior to advanced musculoskeletal manual techniques (i.e., muscle energy)

Myofascial techniques

Muscle energy

  • Description
    • Developed by Dr. Fred L. Mitchell, Sr.
    • Active direct technique
    • Clinical uses
      • Muscle contracture
      • Congestion
      • Muscle weakness
      • Increase range of motion of a restricted joint
    • Utilizes voluntary muscle contraction against equal and opposite resistance from the examiner
    • Contraction of the opposing muscle or muscle group causes a reflexive relaxation of the contracted muscle.
  • Procedure
    1. Perform soft tissue techniques.
    2. Place patient's joint into restrictive barrier (e.g., flexion of the hip joint).
    3. Ask patient to move joint toward its freedom of motion (e.g., extension of the hip joint).
    4. Apply an equal and opposite counterforce to induce an isometric contraction for 3–5 seconds.
    5. Relax for 5 seconds.
    6. Place joint further into its restrictive barrier and repeat.
    7. Reassess joint mobility for symmetry.

Facilitated positional release

  • Description
    • Developed by Dr. Stanley Schiowitz and Dr. Eileen L. DiGiovanna
    • Modeled after the strain-counterstrain system
    • Indirect functional technique
    • Improves joint function and reduces tissue tension
  • Procedure
    1. Perform soft tissue techniques.
    2. From a neutral position, add a compressive force on the joint.
    3. Place the patient's joint into its freedom of motion (e.g., flexion, right rotation, and left side bending of a thoracic segment).
    4. Hold for 3–5 seconds.
    5. Relax.
    6. Reassess.

Still technique

  • Description
    • Developed by Dr. Richard van Buskirk
    • Modeled after the high-velocity low-amplitude technique
    • Allows for gentle movement of a joint back into its neutral position
  • Procedure
    1. Place dysfunction into its freedom of motion (e.g., flexion, right rotation, and right side bending of a cervical segment).
    2. Add a compressive force for 3–5 seconds.
    3. While maintaining a compressive force, place the dysfunction into its barriers (e.g., extension, left rotation, and left side bending of a cervical segment).
    4. Relax.
    5. Reassess.


High-velocity low-amplitude

Progressive inhibition of neuromusculoskeletal structures (PINS)

  • Position: seated, supine, or prone
  • Procedure
    1. Palpate and isolate the most tender point (primary point).
    2. Locate the insertion site of the affected muscle (endpoint).
    3. Apply inhibitory pressure to both points for ∼ 30 seconds.
    4. Locate a new point along the affected muscle near the previous primary point.
    5. Determine if new point is more or less tender.
      • If the second point is more tender, then this will be the new primary point.
    6. Repeat steps 3–5.
    7. Continue along the affected muscle until the endpoint is reached.


Zink Patterns (common compensatory pattern)

  • Description
    • Assess the following four junctions:
    • Rotational component of each dysfunction characterizes each pattern
  • Patterns
    • Common compensatory pattern
      • OA: rotated left
      • Thoracic inlet: rotated right
      • 12th rib: rotated left
      • Innominate: right anteriorly rotated
    • Uncommon compensatory pattern
      • OA: rotated right
      • Thoracic inlet: rotated left
      • 12th rib: rotated right
      • Innominate: left anteriorly rotated
    • Uncompensated pattern: a pattern that does not alternate

Muscle imbalance syndromes

  • First described by Dr. Vladimir Janda
  • A predictable crisscross configuration of overlapping overactive (hypertonic and shortened) and underactive (weak and lengthened) muscle groups
  • Causes acute, and if left untreated, chronic muscle pain, joint degeneration (e.g., glenohumeral, sacroiliac), and pronounced postural changes
  • Divided into upper and lower cross syndromes
  • A combination of both upper and lower cross syndrome is called Layer syndrome (or stratification syndrome).
  • May be associated with various somatic dysfunctions
  • Treatment consists of strengthening the weak muscles and stretching the tight ones.

Upper cross syndrome

Lower cross syndrome (anterior pelvic tilt)

  • Seffinger M. Foundations of Osteopathic Medicine. LWW; 2018.
  • Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business; 2015.
last updated 12/03/2019
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