Osteopathic Treatment and Clinical Application by Region

Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Risk factors that cause a predisposition to CTS include obesity, female sex, pregnancy, diabetes, inflammatory conditions, genetic predisposition, and occupational factors. A clinical diagnosis may be made on the basis of history and physical examination and confirmed with electrodiagnostic testing. Conservative management includes splinting and physical therapy; more severe cases may require surgical correction.

The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. The muscles of the hand are classified as extrinsic (forearm-based) or intrinsic (hand-based) depending on the location of the muscle belly. These muscles are also grouped by area or type: thenar, hypothenar, lumbricals, and interossei.

Pelvic fractures are a disruption in the cortex of a pelvic bone involving iliac wing fractures, acetabular fractures, or those causing loss of integrity of the pelvic ring (the sacrum and the 2 innominate bones). Patients often present with a history of trauma or a fall, limb length discrepancy, intense pain on palpation, and mechanical instability. Elderly patients with osteoporosis may have nontraumatic fragility fractures. Diagnosis is made clinically and confirmed with diagnostic imaging. Initial management includes control of bleeding, fluid resuscitation, and mechanical fixation. Surgery is often indicated in patients with high-energy trauma. After recovery, decreased quality of life may be reported.

Scoliosis is a structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane. Scoliosis can be classified as idiopathic (in most cases) or secondary to underlying conditions. Other classifications are according to etiology, location, and severity. Patients present with spinal asymmetry and often have associated pain. Diagnosis is initially clinical and is confirmed later by X-ray. Management can be conservative or surgical, depending on the severity.

Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Evaluation of acute shoulder pain requires an understanding of the mechanism of injury, as well as the appropriate physical examination and radiologic studies needed in the acute setting. A focused history and physical examination is essential and should include inspection, palpation, and a thorough neurovascular exam. Imaging begins with plain radiographs and is occasionally supplemented by MRI or CT imaging. Management includes pain control and varies based on diagnosis.

Shoulder pain is considered chronic when present for > 6 months. Common conditions resulting in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and joint arthritis. Shoulder pain can be intrinsic or extrinsic to the joint. The potential of serious causes of referred pain to the shoulder such as cardiovascular and abdominal etiologies should be considered. A focused history and physical examination is essential and should include inspection, palpation, range of motion (ROM), and provocative testing. Imaging often includes plain radiographs occasionally supplemented with MRI. Management varies related to specific disorders and frequently requires physical therapy.

The wrist connects the forearm to the hand. It consists of 8 carpal bones, multiple joints, and various supporting ligaments, as well as the distal bones of the forearm and the proximal portion of the 5 metacarpal bones of the hand. The wrist is crucial for the functioning of the upper limb, and it provides stability while positioning the hand for intricate motions.

The shoulder complex comprises the glenohumeral joint, sternoclavicular joint, acromioclavicular joint, and the scapulothoracic articulation, and connects the upper limb to the trunk. This group of joints consists of the clavicle, scapula, and humerus bones, multiple muscles and supporting ligaments, cartilage, and bursae. The muscles ensure the mobility and stability of the shoulder and upper limb and are divided into 3 groups: anterior axioappendicular, posterior axioappendicular, and scapulohumeral muscles.

The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Tolerating these forces is possible thanks to the bony alignment and substantial support from the static and dynamic stabilizers of the hip. Several muscle groups attach to the components of the hip joint, allowing for the joint's range of motion. The muscles that attach to the hip joint include those of the gluteal region and thigh.

The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. The muscles are grouped into 2 compartments: anterior and posterior. The function of these muscles is flexion and extension of the wrist and fingers, while also contributing to flexion of the elbow.

Hand and wrist pain is very common among the general population. Up to 30% of adults will have hand pain during their lives, and half of all cases progress to chronic pain. The causes of hand and wrist pain can be classified into mechanical (e.g., fractures, inflammation, ligament tear), neurologic (e.g., nerve entrapment), and systemic (e.g., autoimmune arthritis). Reaching an accurate diagnosis involves following an evidence-based systematic approach. Treatment includes reducing stress on the ligaments, pain management, and surgery.

The elbow is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm. The elbow consists of 3 joints, which form a functional unit enclosed within a single articular capsule. The elbow is the link between the powerful motions of the shoulder and the intricate fine-motor function of the hand. To provide that link, the motions of the elbow include extension and flexion as well as pronation and supination of the forearm.

Ankle pain accounts for up to 20% of cases of musculoskeletal complaints in outpatient clinics. The most common etiologies of foot and ankle pain can be categorized into arthritis, trauma, sprains, and systemic causes. The diagnosis is clinical with imaging and/or laboratory studies to confirm the suspected diagnosis. Management involves rest, ice packs, compression, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs). Surgical repair is rarely needed.