superior vertical strain

Superior Vertical Strain: What you Need to Know


The superior vertical strain is a common diagnosis you may see on test questions, or even sometimes in real life if you make a habit of doing OMM on your patients.

Like all cranial somatic dysfunctions, this is named for the directionality of the sphenoid bone.

Also, as difficult as it can be sometimes to make the right diagnosis and get those questions right for cranial, there are a lot of buzz words if you will that make it easier to get the right diagnosis.

Also, these buzz words help you get the question right faster, saving time!

This article breaks down the methods I used to absolutely rock my COMLEX and especially the OMM portion of it.

Lets dive into the details of a superior vertical strain.

Superior Vertical Strain Key Points: ie how to diagnose

If you are in the Vault hold you will notice:

  • Your pinky’s tell you the diagnosis: They move superior on flexion of the SBS
  • Index fingers do the opposite of the diagnosis: They move inferior on flexion of the SBS
  • Named for the direction of the sphenoid

How superior vertical strains present in test questions

Typically you can expect the question to be after some sort of trauma.

For example:

A 37 year old male comes into your clinic for a headache that has been going on for a few weeks now. He states that he was in a bar fight about a week ago after his NFL team lost.

He got punched pretty hard from an uppercut.

He initially presented to the ED where imaging ruled out any intracranial hemorrhage, after taking his history it doesn’t seem to be a migraine.

You decide to do an Osteopathic Structural exam focusing on the cranium and you find that whenthe patients SBS flexes your 5th fingers move toward the crown of the patients head and your index fingers move toward his sacrum.

What is the diagnosis?

  1. Left lateral strain
  2. Inferior vertical strain
  3. Superior vertical strain
  4. Right sidebending rotation

Correct answer: I bet you can guess, this patient has a superior vertical strain dysfunction.

Why is this?

  • First: He had trauma, that should key you into the fact that there is a somatic dysfunction in the cranium
  • Second: The pinky fingers move cephalad and the index fingers move caudad. The only time they move in opposite directions that distinctly with the cranium is when there is a dysfunction.

In summary:

  • There is trauma
  • Pinky’s move toward the top of the head
  • Index fingers move toward the sacrum
  • Sometimes questions will ask you about the axis of a vertical strain.
  • This strain occurs around 2 horizontal axis’s and the sphenoid and occiput rotate in the same direction about both of them.

How this was discussed above is how all OMM is taught in my course, CPM OMM.

Check it out below.

Tips to get the right answer

  • Know which direction your index and pinky fingers are moving
  • Recognize that the question is looking for a cranial strain diagnosis
  • Know that the dysfunction is named for the direction of the sphenoid

Also, knowing the axis and which direction the sphenoid and occiput rotate around that/those axis’s can be super low hanging fruit.

Concluding thoughts on Superior Vertical Strains

When it comes to diagnosing the cranium on your exams, it can be difficult. There is so much for you to learn, and when it comes to tough topics like cranial OMM most students typically just say nope, and decide not to study it since it is only a small portion of your exam.

This can be a very simply way for you to get some points and those points will be valuable because others won’t be getting these questions right, so that will move you up in the percentile.

Bonus: Cranial diagnosis Pearls (buzz words for questions)

Buzz Word #1: “Parallelogram feel”

If you see this word, then you need to immediately think about a lateral strain. Then follow the direction of your index fingers and you will get the diagnosis. If they move right, then it is a right lateral strain.

Buzz Word #2: “Decreased CRI after hit with ball”

This implies a compression of the SBS. If you see this phrase, then look for compression of the SBS, as this is a favorite of most test question writers, as it is so easy to write this question.

This is such low hanging fruit that you can quickly and easily lock down that point.

Buzz Word #3: “Convex side”

If you see this in the context of cranial diagnostics, then immediately think about sidebending rotation cranial dysfunctions.

This is the only cranial dysfunction that has a convex component to it.

Buzz Word #4: “Index and pinky fingers move in opposite directions”

This is a cranial torsion. No other dysfunction will move them in opposite directions in a twisting motion. If they move in opposite directions, such as index moves right and pinky fingers move left, then this is lateral strain.

If it happens in a twisting motion, then it is hands down a torsion.

Bonus: Diagnosing Cranial Dysfunctions Guide

Step 1:

Vault hold

What is the Vault hold

This is the placement of your hands over the patients head, in order to diagnose and treat cranial somatic dysfunctions.

There is specific placement of each finger on each side of the skull.

See below for how to actually do the vault hold.

How to do it?

-Index Finger: Over the greater wing of the sphenoid

-Middle Finger: Just in front of the ear on the temporal bone

-Ring Finger: Just behind the ear on the temporal bone

-Pinky Finger: As close to the mastoid portion of the occipitomastoid suture as possible

-Thumbs: Gently rest wherever they fall

Step 2:

Direction of 5th (pinky) and 2nd (index finger) fingers

This is where the money is when it comes to diagnosing the cranium, and it is where question writers will focus hard.

The questions will focus first on the actual parts of the skull and their movement. Truth be told, this is complicating.

If you focus on the motion of the fingers, then it becomes simple. Almost all questions will include which direction the index and 5th fingers are moving.

Step 3: Correlate to the SBS

Dysfunctions are typically all named for what they do in relation to the SBS.

This is the part that will get you those extra few points. Diagnosing can be kept simple by focusing on the fingers, the next level points form from correlating to the SBS.

This is something I go over in detail in the CPM OMM course.

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