The authors are from the Osteopathic Manipulative Medicine and Sports Medicine Department, Edward Via College of Osteopathic Medicine, Virginia Campus, Blacksburg, Va. Dr Rogers is also from Virginia Tech, Blacksburg, and Pulaski Mariners, Rookie Affiliate of Seattle Mariners, Pulaski, Va.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Mark Rogers, DO, MA, CAQSM, Osteopathic Manipulative Medicine and Sports Medicine, Edward Via College of Osteopathic Medicine, Virginia Campus, 2265 Kraft Drive, Blacksburg, VA 24060; e-mail: email@example.com.
Athletes tend to keep a certain pregame ritual, including their medical treatment. At our institution, we use many approaches when treating our athletes. One part of our pregame treatment routine includes offering osteopathic manipulation. For some, this is a preventive approach, but for others it is a treatment for an injury, such as an injured back or ankle, as the athlete is returning to play.
Manipulation has been used in sports dating back to Hippocrates, who was known for his use of manipulation with the Greek athletes in approximately 400 BC, and later by Galen, who was the principle physician to the Gladiators. One of the best known sports figures to use osteopathic manipulative treatment for injured athletes was Forrest “Phog” Allen (1885–1974), known as the Father of Basketball Coaching. After starting his coaching career at his alma mater, Allen took a hiatus to attend the American School of Osteopathy. He was known to have a “magic touch” with his athletes and those who came to his private practice for ailments such as bad backs, knees, and ankles.1
What Is Osteopathic Manipulative Treatment?
According to the Foundation of Osteopathic Medicine, osteopathic manipulative treatment is
the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction, i.e. impaired or altered function of related components for the somatic (body framework) system: skeletal, arthrodial and myofascial structures.2(p1097)
Osteopathic manipulative treatment employs a variety of techniques, including high velocity/low amplitude, muscle energy, counterstrain, myofascial release, osteopathy in the cranial field.2High velocity/low amplitude
has been defined as:
an osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction.2(p669)
Other techniques include muscle energy and counterstrain. Muscle energy
is defined as:
a form of osteopathic manipulative treatment in which the patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed counterforce.2(p1098)Counterstrain
is defined as:
A system of diagnosis and treatment developed by Lawrence Jones, DO, which considers the dysfunction to be a continuing, inappropriate strain reflex that is inhibited by applying a position of mild strain in the direction exactly opposite to that of the reflex. This accomplished by specific directed positioning about the point of tenderness to achieve the desired therapeutic response.2(p1097)
A variety of other techniques can be used, and we encourage the reader to do further research using the Foundations of Osteopathic Medicine
What Exactly Are You Doing?
At our institution, osteopathic manipulative treatment is used frequently to treat minor injuries. For example, it can be used to treat an ankle sprain by restoring the correct positioning, and therefore function, of the ankle. This is essential because if normal motion and positioning are not restored, function and performance can be affected by acute pain not only in the injured region, but also in other places in the kinetic chain. Using our ankle example, the athlete could have pain in the ankle or in the knees, hips, or low back due to compensation.
During an injury evaluation, athletic trainers should consider a biomechanical approach in addition to obtaining a full history and performing a physical examination. If biomechanical asymmetry is found, then manipulation can be used to remove the obstruction and help to restore or improve motion.
To better explore injuries biomechanically, we can examine what occurs in an inversion ankle sprain. As the foot inverts, the ligaments attached to the lateral foot, such as the anterior talofibular and the calcaneofibular ligaments, first become tight and then become stretched. These ligaments are attached to the lateral malleolus of the fibula. When they are stretched, the distal portion of the fibula moves anteriorly and the fibular head moves posteriorly. The talus moves anteriorly compared with the tibia. These structures can become restricted and remain in the dysfunctional position, leading to a somatic dysfunction.3
Long-term exposure of ligaments to static or dynamic loads in such a position could lead to an inflammatory response and, ultimately, to a chronic neuromuscular disorder.4 As a result, this could affect the range of motion, particularly the dorsiflexion of the ankle, proprioception, balance, slowed nerve conduction velocities, impaired cutaneous sensation, and strength deficits.5 Arch function can be decreased, as can knee and hip motion through the kinetic chain. Ultimately, over time, performance can be affected. This is a simplified example but demonstrates the point that multiple areas can be affected from one minor injury.
There are several other structures that were not discussed in our example, such as the interosseous membrane, deltoid ligament, and talofibular ligament, as well as the fascia, vascular, and nerves. These would be affected and can impede healing and promote edema and pain, decreasing performance. One goal of osteopathic manipulative treatment is to return the body to its optimal form, which will allow for improved performance, function, and healing.3,6 This treatment is then followed by neuromuscular retraining, strengthening, and conditioning to reinforce the natural positioning of the structures.
Osteopathic manipulative treatment also has multiple physiologic effects. Mechanically, the treatment causes articular release and enhanced joint motion. Neuromuscularly, the treatment generates afferent input to the dorsal root ganglia, diminishing motor neuron discharge and relaxing muscle fibers.7 Vascularly, some types of treatment may increase nitric oxide concentration in the blood, promoting vasodilatation and increasing blood flow to peripheral vascular tissue.8 Neurochemically, the treatment can transiently increase serum levels of anandamide, stimulating cannabinoid receptors in the brain.9
What Does the Research Show?
Unfortunately, there are few studies of the use of osteopathic manipulative treatment in an athletic population. That being said, it does make biomechanical and physiological sense to use manipulation in this setting to improve function (ie, range of motion), decrease pain, and improve performance.
In addition to the previous discussion, some evidence has been found demonstrating an increase in erector spinae isometric output via electromyography following spinal manipulation.10 In a large double-blinded study, it showed a direct correlation with cortical responses in the brain following cervical manipulation.11 Also, a case report by Gormin describes a visual perception deficit related to cervical neck strain that resolved following cervical spinal manipulation.12 These studies imply that brain and vision function may be influenced and activated by cervical spinal manipulation.
Many other studies have been performed using manual manipulation. These studies vary on the practitioner in the study, from chiropractor, physical therapist, and osteopath. Andersson13 compared osteopathic manipulative treatment in the spinal region with standard care for 178 patients with low back pain. The author found that standard care versus osteopathic manipulative treatment plus standard care had similar clinical results. However, the treatment group used less medication than the standard care group.13
Sounds Good to Me, You Just Have to Get the Athletes to Agree
At our institution, a pilot study was conducted to further investigate the relationship between manipulation and the athlete’s desire for manipulation and perceived benefits of such a treatment using a self-report tool. A non-blinded study by Brolinson et al14 is the first to examine the use of precompetition manipulation and relate it to athletes’ perception. Of note, many (55%) of the players reported that their reason for getting precompetition manipulation was related to their perceived improved performance. Approximately one-third reported it was to manage pain associated with competition or recent injury and approximately one-half sought treatment for both reasons. Data collection is ongoing. With this preliminary data, it would seem that osteopathic manipulative treatment may help with perceived pain and improve performance, but further investigation is needed.
As sports medicine providers, our role is to promote health, aid in recovery from injury, enhance performance, and assist with successful outcomes in the athletic arena. Therefore, the next time you see a routine ankle sprain or other injury, consider some of the biomechanical factors that might influence the athletes’ return to play and how manipulation might augment your typical treatment approach.
- Brolinson PG, McGinley S. Osteopathic manipulative medicine and the athlete. Curr Sports Med Rep. 2008;7:49–56.
- Chila AG, ed. Foundations of osteopathic medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
- Blood SD. Treatment of the sprained ankle. J Am Osteopath Assoc. 1980;79:680–692.
- Solomonow M. Sensory-motor control of ligaments and associated neuromuscular disorders. J Electromyogr Kinesiol. 2006;16:549–567. doi:10.1016/j.jelekin.2006.08.004 [CrossRef]
- Hertel J. Functional instability following lateral ankle sprain. Sports Med. 2000;29:361–371. doi:10.2165/00007256-200029050-00005 [CrossRef]
- Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103:417–421.
- Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Baltimore, MD: Williams & Wilkins; 1997.
- Salamon E, Zhu W, Stefano G. Nitric oxide as a possible mechanism for understanding the therapeutic effects of osteopathic manipulative medicine. Int J Mol Med. 2004;14:443–449.
- McPartland JM, Guiffrida A, King J, et al. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc. 2005;105:283–291.
- Keller T, Collocoa C. Mechanical force spinal manipulation increases trunk strength assessed by electromyography: A comparative clinical trial. J Manipulative Physio Ther. 2000;23:585–595. doi:10.1067/mmt.2000.110947 [CrossRef]
- Carrick FR. Changes in brain function after the manipulation of the cervical spine. J Manipulative Physiol Ther. 1997;20:529–545.
- Gormin RF. Case report: Spinal strain and visual perception deficit. Chiropr J Aust. 1994;24:131–143.
- Andersson GB. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Eng J Med. 1999;341:1426–1431. doi:10.1056/NEJM199911043411903 [CrossRef]
- Brolinson PG, Pheley A, Goforth M, Tilley G. Manipulation and sports performance. Poster presented at: Virginia College of Osteopathic Medicine Research Day. ; September 2004. ; Blacksburg, VA. .