COMSAE Phase 2 BSA –OMM and Osteopathic
Principles with Questions, Answers and
Rationales 2026/2027 Update
Section 1: Sacral and Pelvic Somatic Dysfunction
Question 1
A 45-year-old man presents with chronic lower back pain that worsens after prolonged sitting.
Structural examination reveals that the left sacral base is deep, the right inferior lateral angle is
posterior and prominent, and the seated forward flexion test is positive on the right.
What is the correct sacral somatic dysfunction?
A. Left on Right forward sacral torsion
B. Left on Left forward sacral torsion
C. Right on Left backward sacral torsion
D. Right on Right forward sacral torsion
Correct Answer: A. Left on Right forward sacral torsion
Rationale: In a forward sacral torsion, the axis of rotation and the side of the deep sacral base
are on the same side, while L5 rotates in the opposite direction. A deep left sacral base combined
with a posterior and prominent right inferior lateral angle and a positive right seated flexion test
confirms a Left on Right forward sacral torsion.
Question 2
A 30-year-old postpartum woman presents with right-sided pelvic girdle pain and difficulty
walking. Examination shows that the right anterior superior iliac spine is inferior and medial, the
right posterior superior iliac spine is superior, the right pubic tubercle is elevated, and the right
lower extremity appears longer in the supine position.
What is the correct diagnosis of the right innominate?
A. Right innominate anterior rotation somatic dysfunction
B. Right innominate posterior rotation somatic dysfunction
C. Right innominate superior shear somatic dysfunction
, D. Right innominate inflare somatic dysfunction
Correct Answer: A. Right innominate anterior rotation somatic dysfunction
Rationale: An anteriorly rotated innominate bone is characterized by an anterior superior iliac
spine that moves inferiorly and medially relative to the opposite side, a superiorly displaced
posterior superior iliac spine, an elevated ipsilateral pubic tubercle, and an apparent lengthening
of the lower extremity on the affected side.
Section 2: Cervical Spine Mechanics
Question 3
A physician performs an osteopathic structural exam on a patient with chronic neck stiffness.
During cervical motion testing, the physician notes that the third cervical vertebra is rotated and
sidebent to the right, and these asymmetries worsen significantly into extension.
What is the correct cervical somatic dysfunction diagnosis?
A. C3 Extended, Rotated Right, Sidebent Right
B. C3 Flexed, Rotated Right, Sidebent Right
C. C3 Extended, Rotated Left, Sidebent Right
D. C3 Flexed, Rotated Left, Sidebent Left
Correct Answer: A. C3 Extended, Rotated Right, Sidebent Right
Rationale: In the mid-cervical spine, rotation and sidebending occur in the same direction (Type
II-like mechanics). When motion testing findings worsen into extension, the dysfunction is
extended. If rotation is to the right and sidebending is to the right, sidebending and rotation are
coupled ipsilaterally: Extended, Rotated Right, Sidebent Right.
Question 4
A patient presents with acute mechanical neck pain following a motor vehicle collision.
Structural examination reveals that the fifth cervical vertebra is sidebent to the left and rotated to
the left, and these findings improve significantly when the cervical spine is placed into flexion.
What is the correct cervical somatic dysfunction diagnosis?
A. C5 Flexed, Rotated Left, Sidebent Left
B. C5 Extended, Rotated Left, Sidebent Left
, C. C5 Neutral, Rotated Right, Sidebent Left
D. C5 Flexed, Rotated Right, Sidebent Right
Correct Answer: A. C5 Flexed, Rotated Left, Sidebent Left
Rationale: When mid-cervical somatic dysfunction improves or normalizes with positioning into
flexion, the vertebra is in a flexed position. Because mid-cervical vertebrae exhibit type II-like
mechanics with ipsilateral rotation and sidebending, left rotation and left sidebending in flexion
yields a Flexed, Rotated Left, Sidebent Left diagnosis.
Section 3: Thoracic and Rib Mechanics
Question 5
During a routine structural examination of a 50-year-old man with mid-back pain, a physician
evaluates the fourth thoracic vertebra and finds that it is neutral, rotated to the left, and sidebent
to the right.
What is the correct description of these spinal mechanics?
A. Type I neutral group mechanics where sidebending and rotation occur in opposite
directions
B. Type II non-neutral mechanics where sidebending and rotation occur in the same direction
C. Type III physiologic motion restriction occurring exclusively during deep inhalation
D. Uncoupled motion artifact without underlying somatic dysfunction
Correct Answer: A. Type I neutral group mechanics where sidebending and rotation occur
in opposite directions
Rationale: In the thoracic and lumbar spine, neutral mechanics (Type I) involve groups of three
or more vertebrae where sidebending and rotation occur in opposite directions, with rotation
occurring toward the convexity of the curve.
Question 6
A physician evaluates a patient with upper chest wall pain and suspects a key rib restriction
involving the upper ribs. Upon deep inhalation, ribs three through five on the right side fail to
move upward properly and remain stuck in a depressed position.
What is the correct somatic dysfunction diagnosis and the appropriate treatment muscle to
engage during muscle energy technique?
, A. Exhaled rib lesion (inhalation restriction), treated by engaging the pectoralis minor muscle
for rib three through five
B. Inhaled rib lesion (exhalation restriction), treated by engaging the anterior scalene muscle
for rib one only
C. Exhaled rib lesion, treated by engaging the sternocleidomastoid muscle for rib six through
eight
D. Inhaled rib lesion, treated by engaging the latissimus dorsi muscle for rib nine through ten
Correct Answer: A. Exhaled rib lesion (inhalation restriction), treated by engaging the
pectoralis minor muscle for rib three through five
Rationale: An exhaled rib (inhalation restriction) is a rib that fails to move superiorly during
inhalation. Ribs three through five are treated in an exhaled position by engaging the pectoralis
minor muscle, while upper ribs use scalenes and lower ribs use specific regional muscle
activations.
Section 4: Treatment Modalities and Principles
Question 7
A physician performs myofascial release treatment on a patient with severe thoracic spine
restriction. The physician engages the restrictive barrier by moving the tissue into the direction
of ease, where the patient's tissues relax and follow the physician's guiding force.
What classification of osteopathic treatment technique does this represent?
A. Indirect osteopathic treatment technique
B. Direct osteopathic treatment technique
C. High-velocity low-amplitude thrust technique
D. Balanced ligamentous tension technique
Correct Answer: A. Indirect osteopathic treatment technique
Rationale: An indirect osteopathic technique involves engaging the restrictive barrier by moving
the dysfunctional tissues away from the barrier into the direction of ease or balance, allowing
intrinsic forces and inherent tissue relaxation to release the somatic dysfunction.
Question 8
Principles with Questions, Answers and
Rationales 2026/2027 Update
Section 1: Sacral and Pelvic Somatic Dysfunction
Question 1
A 45-year-old man presents with chronic lower back pain that worsens after prolonged sitting.
Structural examination reveals that the left sacral base is deep, the right inferior lateral angle is
posterior and prominent, and the seated forward flexion test is positive on the right.
What is the correct sacral somatic dysfunction?
A. Left on Right forward sacral torsion
B. Left on Left forward sacral torsion
C. Right on Left backward sacral torsion
D. Right on Right forward sacral torsion
Correct Answer: A. Left on Right forward sacral torsion
Rationale: In a forward sacral torsion, the axis of rotation and the side of the deep sacral base
are on the same side, while L5 rotates in the opposite direction. A deep left sacral base combined
with a posterior and prominent right inferior lateral angle and a positive right seated flexion test
confirms a Left on Right forward sacral torsion.
Question 2
A 30-year-old postpartum woman presents with right-sided pelvic girdle pain and difficulty
walking. Examination shows that the right anterior superior iliac spine is inferior and medial, the
right posterior superior iliac spine is superior, the right pubic tubercle is elevated, and the right
lower extremity appears longer in the supine position.
What is the correct diagnosis of the right innominate?
A. Right innominate anterior rotation somatic dysfunction
B. Right innominate posterior rotation somatic dysfunction
C. Right innominate superior shear somatic dysfunction
, D. Right innominate inflare somatic dysfunction
Correct Answer: A. Right innominate anterior rotation somatic dysfunction
Rationale: An anteriorly rotated innominate bone is characterized by an anterior superior iliac
spine that moves inferiorly and medially relative to the opposite side, a superiorly displaced
posterior superior iliac spine, an elevated ipsilateral pubic tubercle, and an apparent lengthening
of the lower extremity on the affected side.
Section 2: Cervical Spine Mechanics
Question 3
A physician performs an osteopathic structural exam on a patient with chronic neck stiffness.
During cervical motion testing, the physician notes that the third cervical vertebra is rotated and
sidebent to the right, and these asymmetries worsen significantly into extension.
What is the correct cervical somatic dysfunction diagnosis?
A. C3 Extended, Rotated Right, Sidebent Right
B. C3 Flexed, Rotated Right, Sidebent Right
C. C3 Extended, Rotated Left, Sidebent Right
D. C3 Flexed, Rotated Left, Sidebent Left
Correct Answer: A. C3 Extended, Rotated Right, Sidebent Right
Rationale: In the mid-cervical spine, rotation and sidebending occur in the same direction (Type
II-like mechanics). When motion testing findings worsen into extension, the dysfunction is
extended. If rotation is to the right and sidebending is to the right, sidebending and rotation are
coupled ipsilaterally: Extended, Rotated Right, Sidebent Right.
Question 4
A patient presents with acute mechanical neck pain following a motor vehicle collision.
Structural examination reveals that the fifth cervical vertebra is sidebent to the left and rotated to
the left, and these findings improve significantly when the cervical spine is placed into flexion.
What is the correct cervical somatic dysfunction diagnosis?
A. C5 Flexed, Rotated Left, Sidebent Left
B. C5 Extended, Rotated Left, Sidebent Left
, C. C5 Neutral, Rotated Right, Sidebent Left
D. C5 Flexed, Rotated Right, Sidebent Right
Correct Answer: A. C5 Flexed, Rotated Left, Sidebent Left
Rationale: When mid-cervical somatic dysfunction improves or normalizes with positioning into
flexion, the vertebra is in a flexed position. Because mid-cervical vertebrae exhibit type II-like
mechanics with ipsilateral rotation and sidebending, left rotation and left sidebending in flexion
yields a Flexed, Rotated Left, Sidebent Left diagnosis.
Section 3: Thoracic and Rib Mechanics
Question 5
During a routine structural examination of a 50-year-old man with mid-back pain, a physician
evaluates the fourth thoracic vertebra and finds that it is neutral, rotated to the left, and sidebent
to the right.
What is the correct description of these spinal mechanics?
A. Type I neutral group mechanics where sidebending and rotation occur in opposite
directions
B. Type II non-neutral mechanics where sidebending and rotation occur in the same direction
C. Type III physiologic motion restriction occurring exclusively during deep inhalation
D. Uncoupled motion artifact without underlying somatic dysfunction
Correct Answer: A. Type I neutral group mechanics where sidebending and rotation occur
in opposite directions
Rationale: In the thoracic and lumbar spine, neutral mechanics (Type I) involve groups of three
or more vertebrae where sidebending and rotation occur in opposite directions, with rotation
occurring toward the convexity of the curve.
Question 6
A physician evaluates a patient with upper chest wall pain and suspects a key rib restriction
involving the upper ribs. Upon deep inhalation, ribs three through five on the right side fail to
move upward properly and remain stuck in a depressed position.
What is the correct somatic dysfunction diagnosis and the appropriate treatment muscle to
engage during muscle energy technique?
, A. Exhaled rib lesion (inhalation restriction), treated by engaging the pectoralis minor muscle
for rib three through five
B. Inhaled rib lesion (exhalation restriction), treated by engaging the anterior scalene muscle
for rib one only
C. Exhaled rib lesion, treated by engaging the sternocleidomastoid muscle for rib six through
eight
D. Inhaled rib lesion, treated by engaging the latissimus dorsi muscle for rib nine through ten
Correct Answer: A. Exhaled rib lesion (inhalation restriction), treated by engaging the
pectoralis minor muscle for rib three through five
Rationale: An exhaled rib (inhalation restriction) is a rib that fails to move superiorly during
inhalation. Ribs three through five are treated in an exhaled position by engaging the pectoralis
minor muscle, while upper ribs use scalenes and lower ribs use specific regional muscle
activations.
Section 4: Treatment Modalities and Principles
Question 7
A physician performs myofascial release treatment on a patient with severe thoracic spine
restriction. The physician engages the restrictive barrier by moving the tissue into the direction
of ease, where the patient's tissues relax and follow the physician's guiding force.
What classification of osteopathic treatment technique does this represent?
A. Indirect osteopathic treatment technique
B. Direct osteopathic treatment technique
C. High-velocity low-amplitude thrust technique
D. Balanced ligamentous tension technique
Correct Answer: A. Indirect osteopathic treatment technique
Rationale: An indirect osteopathic technique involves engaging the restrictive barrier by moving
the dysfunctional tissues away from the barrier into the direction of ease or balance, allowing
intrinsic forces and inherent tissue relaxation to release the somatic dysfunction.
Question 8
