COMSAE Phase 1 Form 114 Actual Exam Prep | 200+ High-Yield
Questions with Verified Answers & Detailed Rationales | Complete
Review for COMLEX-USA Level 1 & NBOME Osteopathic Medical
Knowledge Self-Assessment | Latest 2026/2027 Blueprint | Graded
A+
SECTION 1: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP) – SOMATIC
DYSFUNCTION DIAGNOSIS AND FRYETTE'S PRINCIPLES (Questions 1–45)
1. A 45-year-old male presents with low back pain after lifting a heavy box. On
examination, the standing flexion test shows superior movement of the right
posterior superior iliac spine (PSIS). Which somatic dysfunction is most likely?
A. Right anterior innominate
B. Left posterior innominate
C. Right sacral torsion on a left oblique axis
D. Bilateral innominate rotation
E. Left anterior innominate
Answer: A
Rationale: The standing flexion test is positive on the side of an iliosacral
dysfunction. Superior movement of the PSIS on the right indicates that the right
ilium is fixed in an anterior rotation. In a right anterior innominate, the right
anterior superior iliac spine (ASIS) is more inferior, causing a functional short
1
,right leg and a positive standing flexion test on the right . In an anterior
innominate, the ilium rotates anteriorly relative to the sacrum, causing the PSIS
to move superiorly .
2. According to Fryette's first principle (Type I mechanics), when the spine is in a
neutral position, sidebending and rotation occur in which direction?
A. To the same side
B. To opposite sides
C. Rotation only without sidebending
D. Sidebending only without rotation
E. To the side of greatest restriction
Answer: B
Rationale: Fryette's first principle states that in a neutral spine (neither flexed
nor extended), sidebending and rotation occur to opposite sides. This applies to
groups of vertebrae in Type I mechanics . For example, sidebending to the right
is accompanied by rotation to the left.
3. A patient has a somatic dysfunction described as "left fibular head, posterior."
What motion is restricted?
A. Posterior glide of the fibular head
B. Anterior glide of the fibular head
C. Superior glide of the fibular head
2
,D. Inferior glide of the fibular head
E. Medial rotation of the fibular head
Answer: B
Rationale: A posterior fibular head is fixed posteriorly, so anterior glide is
restricted. Treatment restores anterior motion . The fibular head should glide
anteriorly during knee flexion; restriction of this motion can cause lateral knee
pain.
4. Which condition is an absolute contraindication to cervical HVLA thrust?
A. Degenerative disc disease
B. Rheumatoid arthritis with atlantoaxial instability
C. Acute whiplash injury
D. Cervical radiculopathy
E. Tension headache
Answer: B
Rationale: Ligamentous laxity from rheumatoid arthritis (especially
atlantoaxial instability) is an absolute contraindication to HVLA due to risk of
spinal cord injury and neurological compromise . Atlantoaxial instability can
cause C1-C2 subluxation with catastrophic results. Other contraindications to
cervical HVLA include vertebral artery insufficiency and acute fracture.
3
, 5. A 28-year-old female presents with chronic headaches and cervical spine
tenderness. The occipitoatlantal (OA) joint is restricted in flexion and
sidebending to the right. What is the most appropriate OMT for this
dysfunction?
A. Direct HVLA with patient supine, OA joint flexed, rotated left, sidebent right
B. Direct HVLA with patient supine, OA joint extended, rotated left, sidebent
right
C. Muscle energy technique with the patient seated
D. Counterstrain at the suboccipital tender point
E. Cranial osteopathy only
Answer: A
Rationale: The OA joint is a modified synovial joint. If restricted in flexion and
sidebending to the right, the restrictive barrier is in flexion and right
sidebending. HVLA positioning for this dysfunction should be: flex, rotate left
(away from restriction), sidebent right (toward barrier) . This positions the joint
at the restrictive barrier for a direct thrust.
6. A patient has a somatic dysfunction of the sacrum. The left sulcus is deeper
than the right, and the left ILA is more posterior than the right. What is the
diagnosis?
A. Left on Right sacral torsion
B. Right on Left sacral torsion
C. Left on Left sacral torsion
4
Questions with Verified Answers & Detailed Rationales | Complete
Review for COMLEX-USA Level 1 & NBOME Osteopathic Medical
Knowledge Self-Assessment | Latest 2026/2027 Blueprint | Graded
A+
SECTION 1: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP) – SOMATIC
DYSFUNCTION DIAGNOSIS AND FRYETTE'S PRINCIPLES (Questions 1–45)
1. A 45-year-old male presents with low back pain after lifting a heavy box. On
examination, the standing flexion test shows superior movement of the right
posterior superior iliac spine (PSIS). Which somatic dysfunction is most likely?
A. Right anterior innominate
B. Left posterior innominate
C. Right sacral torsion on a left oblique axis
D. Bilateral innominate rotation
E. Left anterior innominate
Answer: A
Rationale: The standing flexion test is positive on the side of an iliosacral
dysfunction. Superior movement of the PSIS on the right indicates that the right
ilium is fixed in an anterior rotation. In a right anterior innominate, the right
anterior superior iliac spine (ASIS) is more inferior, causing a functional short
1
,right leg and a positive standing flexion test on the right . In an anterior
innominate, the ilium rotates anteriorly relative to the sacrum, causing the PSIS
to move superiorly .
2. According to Fryette's first principle (Type I mechanics), when the spine is in a
neutral position, sidebending and rotation occur in which direction?
A. To the same side
B. To opposite sides
C. Rotation only without sidebending
D. Sidebending only without rotation
E. To the side of greatest restriction
Answer: B
Rationale: Fryette's first principle states that in a neutral spine (neither flexed
nor extended), sidebending and rotation occur to opposite sides. This applies to
groups of vertebrae in Type I mechanics . For example, sidebending to the right
is accompanied by rotation to the left.
3. A patient has a somatic dysfunction described as "left fibular head, posterior."
What motion is restricted?
A. Posterior glide of the fibular head
B. Anterior glide of the fibular head
C. Superior glide of the fibular head
2
,D. Inferior glide of the fibular head
E. Medial rotation of the fibular head
Answer: B
Rationale: A posterior fibular head is fixed posteriorly, so anterior glide is
restricted. Treatment restores anterior motion . The fibular head should glide
anteriorly during knee flexion; restriction of this motion can cause lateral knee
pain.
4. Which condition is an absolute contraindication to cervical HVLA thrust?
A. Degenerative disc disease
B. Rheumatoid arthritis with atlantoaxial instability
C. Acute whiplash injury
D. Cervical radiculopathy
E. Tension headache
Answer: B
Rationale: Ligamentous laxity from rheumatoid arthritis (especially
atlantoaxial instability) is an absolute contraindication to HVLA due to risk of
spinal cord injury and neurological compromise . Atlantoaxial instability can
cause C1-C2 subluxation with catastrophic results. Other contraindications to
cervical HVLA include vertebral artery insufficiency and acute fracture.
3
, 5. A 28-year-old female presents with chronic headaches and cervical spine
tenderness. The occipitoatlantal (OA) joint is restricted in flexion and
sidebending to the right. What is the most appropriate OMT for this
dysfunction?
A. Direct HVLA with patient supine, OA joint flexed, rotated left, sidebent right
B. Direct HVLA with patient supine, OA joint extended, rotated left, sidebent
right
C. Muscle energy technique with the patient seated
D. Counterstrain at the suboccipital tender point
E. Cranial osteopathy only
Answer: A
Rationale: The OA joint is a modified synovial joint. If restricted in flexion and
sidebending to the right, the restrictive barrier is in flexion and right
sidebending. HVLA positioning for this dysfunction should be: flex, rotate left
(away from restriction), sidebent right (toward barrier) . This positions the joint
at the restrictive barrier for a direct thrust.
6. A patient has a somatic dysfunction of the sacrum. The left sulcus is deeper
than the right, and the left ILA is more posterior than the right. What is the
diagnosis?
A. Left on Right sacral torsion
B. Right on Left sacral torsion
C. Left on Left sacral torsion
4
