General osteopathic principles

Last updated: April 18, 2023

General informationtoggle arrow icon

Principles of osteopathic philosophy

  1. The body is a unit; mind, body, and spirit connect to make the whole person.
  2. The body is capable of self-regulation, self-healing, and health maintenance.
  3. Structure and function are reciprocally interrelated.
  4. Rational treatment is based upon the understanding of these basic principles.

Five models of osteopathic care

  1. Biomechanical
  2. Respiratory–circulatory
  3. Neurological
  4. Metabolic–energy
  5. Behavioral


  • Function
    • Touch: human interaction; conveys empathy and professionalism; must always be appropriate
    • Palpation: diagnostic touch; therapeutic; differentiate shape, size, consistency, position, and health of underlying tissues
  • Approach: layer by layer, superficial to deep; use finger pads, not fingertips; ample communication
  • Layers (from superficial to deep): skinsubcutaneous tissue → vessels → deep fascia → muscle → ligament → bone
    • Skin: Note color, temperature, skin drag, texture, and turgor.
    • Subcutaneous tissue: normally spongy; edematous with acute changes
    • Vessels: Look for congestion or vascular formation.
    • Deep fascia: normally smooth, firm
    • Muscle: Follow muscle fibers. Observe tension or hypertonicity.
    • Ligaments: Note tenderness.
    • Bone: Follow contours, landmarks, structure, and 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, ropy, 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 rather than the restricted motion (e.g., rib 3–5 inhalation dysfunction → ease during inhalation → restriction during exhalation)

Acute versus chronic changes

Acute changes Chronic changes
  • Increased
  • Decreased (or slight increase)
Skin drag test
  • Increased drag
  • Decreased drag
  • Rigid
  • Ropy, stringy
  • Moderate to 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 examinationtoggle arrow icon

Step 1: posture screening

Step 2: gait analysis

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

Step 3: active trunk side bending

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

Step 4: standing flexion test

Step 5: stork test

Step 6: seated flexion test

Step 7: screening of the upper extremities

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

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

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

Step 9: head and neck mobility

Step 10: quick total body screen

Fryette's laws of spinal motiontoggle arrow icon

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., the thoracic segment is side bent left and rotated right).
    • The 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

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

Fryette's third law of spinal motion

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

Osteopathic therapeutic modalitiestoggle arrow icon

This section covers the techniques commonly used by osteopathic physicians with the goal of alleviating pain and enhancing function.

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
    • 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.

Viscerosomatic and somatovisceral reflexestoggle arrow icon

Viscerosomatic and somatovisceral reflexes

  • The neurophysiological basis for reflex interactions refers to the relationship between somatic structures and visceral organs.
  • In both of these reflexes, the original stimuli can either have an excitatory or inhibitory influence on the corresponding structure.
  • This influence is primarily facilitated by the sympathetic and parasympathetic nervous systems. Understanding their effects and the segmental innervation of these individual visceral structures is an important diagnostic tool, which can be used to employ targeted manipulative techniques to attenuate the autonomic nervous system activity and any associated visceral dysfunction.
Overview of ANS innervation of organs
Organs Sympathetic Parasympathetic
Head and Neck T1–T4 CN III, VII, IX, X
Heart T1–T5 Vagus nerve (occiput, C1, C2)
Lung T2–T7
Esophagus T2–T8
Stomach T5–T9
Proximal duodenum
Distal duodenum T10–L1
Ascending colon
Proximaltransverse colon
Proximal ureter
Adrenal glands T8–T10
Ovaries/Testes T10–T11
Uterus T10–L2 S2S4
Distal ureter T11–L2
Distaltransverse colon L1–L2
Descending colon
Sigmoid colon
  • The corresponding segmental innervations may vary between sources.

Miscellaneoustoggle arrow icon

Zink Patterns (common compensatory patterns)

  • 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
  • Description
    • Assess the following four junctions:
    • The manner in which the four junctions are rotated characterizes each pattern

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 syndromes 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)

Referencestoggle arrow icon

  1. Seffinger M. Foundations of Osteopathic Medicine. LWW ; 2018
  2. Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business ; 2015

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 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer