COMLEX

OMM

Chapmans Reflex Points

Chapman Reflex Points

STRUCTURE

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
rectum
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

Diagnosis and Treatment

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 3rd intercostal space
left 5th intercostal space
left 6th intercostal space
8th, 9th, and 10th intercostal spaces
tip of the 12th 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)

lesser trochanter of femur

HINT: attachment site of psoas major

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

Chapmans)points)are)diagnosed)
anteriorly)and)treated)posteriorly.))
)
Treatment)involves)pressure)applied)
with)a)circular)rotation)until)
release)is)felt)

It)is)unlikely)to)be)asked)a)question)
about)actual)treatment)on)
COMLEX.)More)likely,)question)will)
directly)test)on)location)of)either)
anterior)or)posterior)Chapman)
point)

COMLEX

OMM

Chapmans Reflex Points

Anterior Chapmans Points:

Posterior Chapmans 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)
left adrenal
left kidney
Bladder area

Umbilicus
intestinal
peristalsis

ovaries, urethra
uterus

middle ear
pharynx, tongue,
larynx, sinuses, arms
neck, esophagus, bronchus

cerebellum
nasal sinuses
cerebrum
arms
(and pectoralis minor)

thyroid
upper lung, myocardium
upper lung
lower lung
stomach (acidity) (L)
liver (R)

neuroansthesia
(and pectoralis minor)

stomach (peristalsis) (L)

liver, gallbladder (R)

pyorus (R)
ovaries
intestines (peristalsis)
appendix (R)

adrenals
kidneys
abdomen, bladder
urethra
uterus
vagina, prostate, uterus,
broad ligament
rectum, groin glands

large intestines

sciatic nerve (posterior)

Fallopian tubes,
seminal vesicles

hemorrhodial plexus

rectum
clitoris, vagina

prostate or
broad ligament

sciatic nerve (anterior)

colon

Most likely to be asked

about on COMLEX
(all are possible)

COMLEX

OMM

ANS Innvervation

Segmental Sympathetic Innervation

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

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

Parasympathetic Innervation

Vagal nuclei

STRUCTURE

SEGMENT

pupils (constriction aka miosis)

CN III (midbrain) ! ciliary ganglion

lacrimal and nasal glands

CN VII (pons) ! sphenopalatine ganglion

submandibular and sublingual glands

CN VII (pons) ! submandibular ganglion

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

CIX (medulla) ! otic ganglion

CN X (medulla) ! dorsal motor nucleus

pelvic splanchnic (S2-4)

Nucleus Solitarius !)visceral)Sensory)

information)(e.g.)taste,)baroreceptors,)
gut)distention).)
) CN)VII,)IX,)X)
)
Nucleus aMbiguus)!)Motor)innervation)of)
pharynx,)larynx,)and)upper)esophagus))
(e.g.,)swallowing,)palate,)elevation))
) CN)IX,)X)
)
Dorsal motor nucleus)!)sends)autonomic)
(parasympathetic))fibers)to)heart,)lungs,)
and)upper)GI)
NOT)motor)fibers,)despite)the)name)
) CN)X)
)

COMLEX

Treatment order

OMM

ANS Innvervation

1.))Treat'the'dysfunction'segment)responsible)for)initiating)the)facilitated)spinal)cord)
segment)
E.g.)cervical,)thoracic,)lumbar)somatic)dysfunction)
)
2.))Affect'SNS'activity')
Chapmans)reflex)points,)treating)the)sympathetic)chain)ganglia)(rib'raising),)and)
then)treating)the)collateral)ganglia)(preaortic)and)cervical)ganglia)))
rib'raising))initially)stimulates)sympathetics)!)reflexive)inhibition)of)SNS)mediated)))))
by)medulla)
)
3.))Encourage'lymphatic'drainage)and)improved)venous)return)
release)thoracic)inlets,)abdominal)diaphragm,)mesenteries,)pelvic)diaphragm)
utilize)lymphatic)pump)techniques)
release)the)craniocervical)junction)
treat)fascial)restrictions))
open'diaphragms'! 'then)treat'pumps)
)
4.)))Affect'PNS'activity))
OA)(vagus)n),)sacral)splanchnic)nerves,)pelvic)splanchnic)nerves))
)

COMLEX

OMM

Upper Extremity

Upper extremity nerves

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)

Ulnar (C8, T1)

Musculocutaneous
(C5-7)

sensory posterior arm and forarm

sensory part of thenar eminence on
palmar hand, PIPs and proximal dorsum
of hand from thumb to half of ring
finger
wrist flexors, pronator teres
lumbricals 1 and 2, thenar muscles,
cutaneous sensation
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

Rotator cuff muscles

Other shoulder muscles

)
)
)
)

Meat-LOAF
Median nerve, 2 Lateral Lumbricals, Oponens
pollicus, Abductor pollicis brevis, Flexor pollicis
brevis

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

)
Upper extremity nerve injuries
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 thumb
Lateral finger flexion
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 flexion

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)

SENSORY DEFICIT

Tear of rotator cuff muscles )

acute, sharp pain in shoulder followed
by ongoing dull achh and tenderness at
acromion process

more commonly an injury of the tendons rather

than the actual muscles

(+) drop arm test, weak abduction

supraspinatus tendon most frequently affected

because it passes below the acromion

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

)
)

Radial head somatic dysfunction )

Anterior 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)
Re stric te d A PPS

SIGN/NOTES

COMLEX

OMM

Upper extremity

Shoulder dysfunctions
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 1st rib
pectoralis minor and
upper ribs

waitors tip posturing,

C5-6 upper trunk
arm extended and pronated
paralysis of intrinsic hand muscles
C8-T1 sensory loss
+/- Horners syndrome
while patient pushes anteriorly (e.g.
against a wall) scapula protrudes
posteriorly
ache and/or paresthesia of neck or arm

Klumpkes Palsy

winged scapula

thoracic outlet
syndrome

COMLEX

OMM

Upper Extremity

COMLEX

OMM

Upper Extremity

Upper Extremity Special Tests

STRUCTURE

EVALUATES

TECHNIQUE

Apleys scratch test

range of motion

Adsons test

thoracic outlet syndrome

Rooss test

thoracic outlet syndrome

drop arm test

rotator cuff tear

Speeds test

biceps tendon

Yergasons 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 patients wrist with one
hand and elbow with the other
clinician resists the patients flexion/pronation
force while passively externally rotating
positive if there is pain in biceps tendon as it
pops out of the bicipital groove

Wrist Special Tests

STRUCTURE

EVALUATES

TECHNIQUE

Tinels test

carpal tunnel syndrome

clinician taps over volar aspect of patients

traverse carpal ligament (Tinel
Tap)

Phalens (and reverse Phalens)

tests

carpel tunnel syndrome

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

Allens test

radial and ulnar artery

patency/blood flow

Finkelstein test

tenosynovitis of pollicis
longus and extensor
pollicis brevis
(DeQuervains
tenosynovitis)

patient opens and closes hand several times and

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

COMLEX

OMM

Lower Extremity

Lower extremity nerves

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; toe
flexion
Thigh abduction

Anterior thigh and

medial leg
Anterolateral leg and
dorsal aspect of foot

Cant jump, climb

stairs, or rise from
seating position;
cant push
downwards

Lateral forearm

Femoral (L2-4)
Common peroneal
(L4-S2)

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

SENSORY DEFICIT

Trendelenberg sign
contralateral hip
drops when standing
on leg ipsilateral
to lesion

Lower extremity muscles

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 Everts and Dorsiflexes; if injured, foot droPED

TIP = Tibial Inverts and Plantarflexes; if injured, cant stand on TIPtoes
Sciatic nerve (L4-S3) posterior thigh, splits into common peroneal and tibial nerve

semitendinosus
semimembranosus
biceps femoris (long head)
biceps femoris (shorthead)

SIGN

COMLEX

OMM

Lower Extremity

Lower extremity muscles (continued)

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)

)
)
)
)
)
)
)
)
)
)
)
)
)

Fibular head somatic dysfunction

)
)
)
)

Anterior 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)!)foot)stuck)in)external)rotation)and)dorsiflexion;)treat)with)muscle)
energy by placing the foot in Inversion (loose pack fibula), Internal rotation of the
tibia, and Plantarflexion
Tx = PIP plus inversion

COMLEX

Piriformis syndrome )

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 sprains

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

Important angles

) angulation ! the angulation between

Femoral head
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 )

Osgood-Schlatter Disease )

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