Osteopathic Board Exams: High-Yield OMM Techniques and Clinical Scenarios for a Passing Score

Osteopathic board questions reward pattern recognition and safe, sensible choices. If you know which autonomic levels match an organ, how ribs move, and when to pick gentle techniques over force, you can earn a lot of easy points. This guide focuses on the highest‑yield OMM findings, why they matter clinically, and how to pick the best answer under test pressure.

What the OMM section really tests

Safety first. Boards prioritize techniques that won’t harm fragile patients (elderly, osteoporotic, pregnant, post‑op). That’s why answers often favor indirect or gentle methods. Why: If two answers could work, the safest one is usually correct.
Autonomics drive many stems. Viscerosomatic reflexes, Chapman points, and rib raising show up again and again. Why: Treating the right levels explains both diagnosis and therapy in a single step.
Choose the key lesion. In ribs, groups, and sacrum, you often treat the one segment that locks the rest. Why: Fixing the “key” normalizes the pattern with the least force.
Predictable anatomy. Rib mechanics, Fryette’s principles, and basic cranial patterns are tested because they are consistent. Why: The exam wants physiology you can trust under pressure.

Autonomics and viscerosomatic reflexes that keep showing up

Sympathetics (T1–L2)—know the organ map. It explains referred pain and directs treatment (e.g., rib raising at the right levels).

Head and neck: T1–T4
Heart: T1–T5 (left‑sided bias)
Lungs: T2–T7
Stomach: T5–T9 (left)
Liver/Gallbladder: T6–T9 (right)
Pancreas: T5–T11 (right)
Spleen: T7 (left)
Small intestine: T9–T11
Colon: Proximal to splenic flexure T10–T11; distal (incl. rectum) T12–L2
Appendix: T12
Kidneys: T10–L1
Bladder: T12–L2
Uterus: T10–L2; ovaries/testes: T10–T11
Upper extremity: T2–T8; lower extremity: T11–L2

Parasympathetics

Vagus (CN X): Thoracic organs and foregut/midgut; also kidneys and upper ureters.
Pelvic splanchnics (S2–S4): Hindgut, pelvic organs, lower ureters, bladder, and erectile tissue.

Why this matters: You can pick targeted autonomic treatments that match the organ and the complaint. It also explains physical findings like paraspinal texture changes, side dominance, and referred pain.

Examples

Acute MI: T1–T5 sympathetics get facilitated, often more on the left. Best OMM choices: gentle rib raising T1–T5 and suboccipital inhibition to balance vagal tone. Avoid forceful pumps or HVLA.
Cholecystitis: T6–T9 on the right. Expect right upper thoracic hypertonicity and possibly a right‑sided diaphragmatic restriction. Gentle rib raising and doming the diaphragm are logical choices.
Constipation: Sympathetics T12–L2, parasympathetics S2–S4. Combine lumbar soft tissue/rib raising with sacral rocking. Add mesenteric lift to improve flow.
Nephrolithiasis: T10–L1 facilitation with ureteral colicky pain to the groin. Treat sympathetics and consider psoas/QL myofascial to ease guarding.

Chapman points you really need

Chapman reflexes are small, tender, pea‑like nodules. Use them to support a diagnosis, not as the only finding.

Appendix: Anterior—tip of right 12th rib; Posterior—right T11 transverse process. Why: Classic board favorite; early appendicitis stem often includes this point.
Myocardium: Anterior—left 2nd intercostal space near the sternum. Why: Helps distinguish cardiac chest pain from costochondritis.
Lungs: Upper—3rd ICS; Lower—4th ICS (bilateral). Why: Pneumonia and bronchitis questions.
Liver/Gallbladder: 5th–6th ICS (right for both; GB emphasized at 6th). Why: RUQ pain workup.
Stomach: Acidity—5th ICS (left); Peristalsis—6th ICS (left).
Pancreas: 7th ICS (right); Spleen: 7th ICS (left).
Colon: Along the iliotibial bands—right IT band for ascending/cecum; left IT band for descending/sigmoid. Why: Constipation/IBS stems.

How to use on test day: If a stem gives a specific tender anterior point that matches an organ, pick the organ diagnosis or its related autonomic treatment.

Rib mechanics and treatment pearls

Know how ribs move:

1–5 pump‑handle: Increase AP diameter.
6–10 bucket‑handle: Increase transverse diameter.
11–12 caliper: Posterolateral motion.

Named for ease of motion. Inhalation dysfunction = rib likes inhalation, stuck up; exhalation dysfunction = rib likes exhalation, stuck down.

Key rib rule (BITE): Bottom Inhalation, Top Exhalation.

Group inhalation dysfunction: Treat the bottom rib.
Group exhalation dysfunction: Treat the top rib.

Muscle energy muscle map (depressed rib = exhalation dysfunction → assist inhalation):

Rib 1: Anterior and middle scalenes
Rib 2: Posterior scalene
Ribs 3–5: Pectoralis minor
Ribs 6–8: Serratus anterior
Ribs 9–10: Latissimus dorsi
Ribs 11–12: Quadratus lumborum

Example: After a coughing fit, a patient can’t take a deep breath. Exam shows an exhalation dysfunction of ribs 3–6. The key rib is the top (rib 3). Best treatment: muscle energy using pectoralis minor to elevate rib 3 during inhalation.

Spine diagnosis essentials

Fryette I (neutral): Sidebending and rotation are opposite; usually a group curve. Why: Neutral postural patterns (e.g., scoliosis‑like) test you on group logic.
Fryette II (non‑neutral): In flexion or extension, sidebending and rotation are the same; usually single segment. Why: Acute pain often localizes to one level.
Third principle: Motion in one plane limits motion in others. Why: Helps explain combined restrictions.

Cervical specials:

OA: Primarily flexion/extension; sidebending and rotation are opposite (type I‑like).
AA: Mostly rotation.
C2–C7: Sidebending and rotation to the same side (type II‑like mechanics).

Safety: Avoid cervical HVLA in rheumatoid arthritis, Down syndrome, severe osteoporosis, or known atlantoaxial instability. Pick counterstrain, indirect myofascial, or muscle energy instead.

Sacrum and pelvis made simple

Innominate rotations:

Anterior rotation: ASIS inferior, PSIS superior, leg appears long. Often seen in runners on their push‑off side.
Posterior rotation: ASIS superior, PSIS inferior, leg appears short. Often from hamstring tightness.

Superior/inferior shear: One innominate rides up or down (trauma, falls). Very restricted motion; gentle indirect or balanced ligamentous tension is safer on test day than HVLA.

Sacral torsions (oblique axis):

Forward torsions (L/L or R/R): Negative spring test; common with neutral lumbar mechanics.
Backward torsions (L/R or R/L): Positive spring test; common with non‑neutral lumbar mechanics.
Seated flexion test: Positive on the side opposite the oblique axis.

Example: Positive seated flexion on the left; deep right sulcus; posterior/inferior left ILA; spring test negative → R/R forward torsion. Best approach: gentle muscle energy or indirect to promote sacral flexion.

Cranial findings you can trust

SBS flexion: Head widens (↑ transverse), decreases AP; paired bones externally rotate.
SBS extension: Head narrows (↓ transverse), increases AP; paired bones internally rotate.
Physiologic strains: Torsion; sidebending‑rotation. Why: Often accommodation to posture.
Non‑physiologic: Vertical, lateral strains, SBS compression. Why: Usually traumatic; symptoms more pronounced.

Clinical tie‑ins:

Otitis media / eustachian tube dysfunction: Temporal bone external rotation and Galbreath technique (mandibular drainage) improve middle ear ventilation. Why: ET runs in the temporal bone; motion changes drainage.
Sinus congestion: Sphenopalatine ganglion release can promote nasal drainage. Why: It influences mucosal secretions.
Newborn poor latch: Condylar decompression reduces hypoglossal nerve irritation. Why: CN XII exits near the occipital condyles.

On exams: Pick gentle cranial and lymphatic drainage for ENT issues; avoid forceful techniques in acute infection or post‑op ENT cases.

Lymphatics: sequence and safety

Treat central pathways first, then push fluid. If you don’t open choke points (thoracic inlet, diaphragms), pumps do little.

Step 1: Thoracic inlet myofascial release.
Step 2: Balance autonomics (rib raising T1–T6 for lungs, T5–L2 for GI as appropriate).
Step 3: Free the diaphragms (suboccipital, thoracoabdominal doming, pelvic diaphragm).
Step 4: Regional drainage (pectoral traction, rib raising, effleurage).
Step 5: Pumps (thoracic, pedal, splenic/hepatic) if not contraindicated.

Common contraindications (pick gentle alternatives):

Absolute: Frank CHF decompensation, untreated DVT, PE, or active hemorrhage.
Relative: Post‑op incisions, severe COPD with air trapping (be careful with high‑amplitude thoracic pump), metastatic cancer to bones, acute fracture.

Examples:

Pneumonia: Thoracic inlet release → rib raising T1–T6 → doming diaphragm → pectoral traction → gentle thoracic pump if stable. Why: Improves ventilation/perfusion and immune flow without excess stress.
Post‑op ileus: Lower thoracic/lumbar rib raising, mesenteric lift, pelvic diaphragm release, sacral rocking. Why: Reduces sympathetics and enhances pelvic splanchnic activity to restore motility.

Counterstrain and muscle energy: go‑to setups

Counterstrain basics: Find tenderpoint, passively position to maximal comfort (often 70% pain reduction), hold ~90 seconds, then slowly return. Why: It down‑regulates muscle spindle overactivity—safe in acute pain and fragile patients.

High‑yield tenderpoints

Psoas (anterior hip pain, lumbar flexion): TP 2–3 cm medial to ASIS. Treat with marked hip flexion, slight external rotation, sidebending toward. Why: Shortened psoas prefers flexion and ER.
Iliacus (anterior hip ache): TP 1–2 cm medial to ASIS. Treat with hip flexion and significant external rotation. Why: Matches its fan‑shaped fibers.
Piriformis (posterior buttock pain, sciatica mimic): TP near medial upper greater trochanter. Treat with flexion, abduction, external rotation (FABER‑like). Why: Short piriformis relaxes in FABER.
Levator scapulae (medial superior scapular angle): Position with shoulder internal rotation and traction inferiorly. Why: Unloads the muscle’s scapular attachment.
Infraspinatus (posterior shoulder pain): TP on infraspinous fossa; position shoulder in flexion, abduction, external rotation. Why: Puts fibers on slack.

Muscle energy favorites

Rib dysfunctions: Use the muscle map above to assist inhalation for exhalation lesions; for inhalation lesions, treat the bottom rib and emphasize exhalation with downward pressure (often “respiratory assist”). Why: Engages the correct rib elevators or depressors.
Innominate rotations:
- Anterior rotation: Use hamstrings (hip extension) to pull innominate posteriorly.
- Posterior rotation: Use hip flexors/quadriceps (hip flexion) to pull innominate anteriorly.
Why: You recruit muscles that attach to the pelvis to rotate it across the SI joint.
Piriformis hypertonicity: Patient pushes knee medially against resistance from FABER position. Why: Post‑isometric relaxation lengthens the muscle.

Common clinical scenarios and the best OMM answers

STEMI in the ED with chest pain: Pick gentle rib raising T1–T5 and suboccipital inhibition. Avoid HVLA and vigorous lymphatic pumps. Why: Balance sympathetics/vagal tone without stressing an ischemic heart.
Community pneumonia, stable vitals: Thoracic inlet release, rib raising T1–T6, doming the diaphragm, pectoral traction. Consider gentle thoracic pump if no contraindications. Why: Improves lymphatic flow and ventilation.
Post‑op day 2 ileus after colectomy: Mesenteric lift, sacral rocking, lumbar soft tissue, rib raising lower thoracics. Avoid high‑amplitude pumps over fresh incisions. Why: Enhances parasympathetic tone and bowel motility safely.
Pregnant patient with low back pain (third trimester): Counterstrain, myofascial, sacral rocking; modified positioning (left lateral). No HVLA to lumbosacral region. Why: Gentle and position‑safe.
Otitis media in a child: Galbreath technique, temporal bone balancing, lymphatic drainage of neck. Why: Improves eustachian tube drainage and immune flow.
Elderly osteoporotic woman with acute neck pain: Counterstrain or indirect myofascial; avoid cervical HVLA. Why: Prevent fracture or vertebral artery stress.
Lateral elbow pain after overuse (tennis elbow): Counterstrain for lateral epicondyle, myofascial, ME of wrist extensors. Why: Targets common extensor tendon safely.
GERD symptoms with epigastric ache: Treat T5–T9 (left) sympathetics, doming diaphragm, rib raising, and consider addressing crural tension. Why: Reduces sympathetic tone and lowers LES stress via diaphragmatic balance.
Acute low back spasm after lifting: Counterstrain (psoas or quadratus lumborum points), indirect myofascial, gentle ME. Avoid lumbar HVLA in severe spasm. Why: Spindles are irritable; gentle reset works best.

Fast rib and spine traps to avoid

Misusing BITE: Remember, exhalation group → treat the top rib; inhalation group → treat the bottom rib. The exam loves this trick.
Forcing HVLA in fragile patients: Osteoporosis, RA C‑spine, or pregnancy? Choose indirect or soft tissue.
Skipping the thoracic inlet in lymphatic cases: Always open the inlet first or pumps are less effective.
Wrong parasympathetic source: Vagally innervated organs are thorax/foregut/midgut; hindgut and pelvis are S2–S4. Don’t give pelvic splanchnics to the small intestine.

How to think through a tough OMM question

Step 1: Identify the system. Is this autonomics, lymphatics, structural mechanics, or cranial?
Step 2: Match the anatomy. Which spinal levels or structures explain the symptoms?
Step 3: Pick the safest effective technique. If acutely ill or fragile, go gentle and indirect.
Step 4: Treat the key lesion. In groups, pick the key rib or the axis‑defining segment.

Rapid study plan for a passing score

Day 1–2: Memorize autonomic levels and the rib muscle map. Drill BITE until it’s reflex.
Day 3: Sacrum/pelvis: seated flexion side, spring test logic, forward vs backward torsions, innominate rotations.
Day 4: Cranial patterns: flexion/extension cues, torsion vs sidebending‑rotation, common clinical uses (ear, sinus, latch).
Day 5: Lymphatic sequence and contraindications. Be able to build a safe plan for pneumonia and ileus.
Day 6: Counterstrain hits: psoas, iliacus, piriformis, levator scapulae, infraspinatus. Practice the positions in your head.
Day 7: Timed mixed questions. After each, ask “why is the wrong answer unsafe or mismatched to anatomy?”

One‑page cheats to build and review daily:

Autonomic map + Chapman highlights.
Rib mechanics + muscle map + BITE.
Sacrum quick grid: seated flexion side, sulcus/ILA, spring test → name diagnosis.
Lymphatic flow sequence + absolute contraindications.
Top five counterstrain positions.

Final takeaways

Anchor answers to anatomy. Levels and attachments dictate the right technique.
Safety wins ties. If two answers fit, pick the gentler, system‑appropriate option.
Treat the choke point or key lesion. Open thoracic inlet before pumps; treat the top rib in exhalation groups and bottom rib in inhalation groups.
Use patterns to decode stems. Left T1–T5 facilitation in chest pain? Think heart. Right T6–T9 in RUQ pain? Think hepatobiliary.

Master these high‑yield patterns, and you’ll spot the correct answer faster. That’s how you turn OMM from a time sink into free points.

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com