Ambrose Loc Ngo, M.S.¹; Truong Ho, B.S.¹; Rachana Tadakamalla, M.S.¹; Uyen Tam Nguyen, B.S.¹; Jennifer Serfin, M.D.^2
1Kansas City University, College of Osteopathic Medicine
²University of North Carolina Chapel Hill, Department of Surgery

Abstract

Orthopedic trauma remains a leading cause of disability worldwide, with complications such as delayed union, nonunion, infection, and postoperative pain, often prolonging recovery. A growing interest exists in integrating Osteopathic Manipulative Medicine (OMM) into orthopedic rehabilitation as a holistic, hands-on approach to promote healing and functional recovery. This narrative review aims to summarize the current evidence on the therapeutic role of OMM in fracture healing and its potential to mitigate postoperative complications.  Relevant clinical and mechanistic literature examining OMM’s effects on bone healing, circulation, lymphatic flow, and immune modulation was narratively synthesized. Findings from small-scale trials, case reports, and meta-analyses suggest that OMM may support postoperative recovery through improvements in blood flow, lymphatic drainage, and oxygen delivery to healing tissues. Mechanistic evidence supports OMM’s potential to influence inflammatory cytokines, stimulate angiogenesis, and modulate the autonomic nervous system, which are fundamental biological processes involved in bone repair and regeneration. Although promising, the current literature is limited by small sample sizes, inconsistent protocols, and a lack of large randomized controlled trials specific to orthopedic trauma. Overall, OMM may represent a safe, patient-centered, and potentially effective adjunct to traditional orthopedic management. Future research should aim to establish standardized treatment protocols, quantify long-term outcomes, and further define the role of OMM within multidisciplinary orthopedic trauma rehabilitation.

Keywords: Osteopathic manipulative medicine; osteopathic manipulative treatment; orthopedic trauma; fracture healing; postoperative recovery; musculoskeletal rehabilitation

Introduction
Orthopedic trauma encompasses injuries affecting the bones, joints, and surrounding soft tissue. Jarman et al. (2020) estimated that more than seven million orthopedic injuries occur annually in the United States, with approximately one million cases requiring emergency surgical intervention. Fall-related injuries accounted for about 51% of all orthopedic trauma cases and 61% of emergency orthopedic procedures. Beyond their high incidence, these injuries are frequently associated with complications that increase postoperative morbidity and delay recovery. Orthopedic trauma injuries frequently present with complications that can impair functional recovery. Common complications include delayed union, characterized by impaired bone healing, and nonunion, where bone fragments fail to unite into a single structure (Bowers et al., 2024). Infection represents another significant complication that can impair tissue healing and increase the risk of recurrent injury (Nicholson et al., 2020). Complications can prolong recovery and can result in chronic pain, diminished mobility, and restricted range of motion, which can ultimately lead to a diminished quality of life (Nicholson et al., 2020).

Osteopathic Manipulative Medicine (OMM) is a treatment approach that employs manual techniques to diagnose, treat, and prevent injury and illness (White et al., 2024). OMM is grounded in the principle of physiologic integration, emphasizing the dynamic interrelationship of structure and function within the body (White et al., 2024). OMM treatment functions to restore the body’s normal range of motion, circulation, and self-healing capabilities (White et al., 2024). This narrative review aims to summarize current literature on the role of OMM in fracture healing and its potential role in mitigating postoperative complications.

Methods
This narrative review synthesizes published literature examining osteopathic manipulative medicine (OMM) in orthopedic trauma, with emphasis on fracture healing, postoperative recovery, and relevant biologic mechanisms. Relevant literature was identified through searches of PubMed and Google Scholar and was narratively synthesized to describe current mechanistic and clinical evidence regarding the potential role of OMM in orthopedic trauma care.

Discussion
The literature reviewed included randomized controlled trials, cohort studies, case-control studies, systematic reviews, and meta-analyses addressing OMM and its potential role in postoperative recovery, musculoskeletal rehabilitation, and biologic mechanisms relevant to orthopedic trauma. The available evidence is discussed thematically below.

Potential Mechanisms of Action in Bone Healing
The mechanism of action attributed to bone regeneration can be traced back to various elements, including cytokines, inflammatory response, autonomic, and mechanosensors. A study conducted on OMM demonstrated rapid changes in cytokine circulation, specifically in blood dendritic cell mobilization. The theory tested and showed how mechanotransduction via OMM may promote the acceleration of dendritic cells into tissues to enhance the body’s defenses (Walkowski et al., 2014). Blood supply is an essential factor in fracture healing, and the local circulation must be adequate to achieve proper bone healing. VEGF, being one of the modulators at play, signifies the importance of angiogenesis and recruitment of mesenchymal stem cells for osteogenic differentiation (Qin et al., 2022). OMM has been reported to improve vascular function as an adjunct therapy in patients with peripheral artery disease, including improvements in vasodilation. Another study demonstrates how OMM can induce an acute increase in nitric oxide, which can lead to clinical differences in bone healing for patients, a process that requires adequate oxygenated circulation (Lombardini et al., 2008). While much of the existing evidence is derived from mixed surgical populations, the physiologic mechanisms underlying OMM, including enhanced perfusion, lymphatic drainage, and inflammatory modulation, are directly applicable to orthopedic trauma, where bone healing and soft tissue recovery are highly dependent on these processes.

OMM in Reducing Orthopedic Trauma Complications
OMM has been evaluated in various postoperative settings to address common factors that can impact recovery following orthopedic trauma surgery, including swelling, range of motion, and infection. Post-traumatic joint stiffness is a known complication in orthopedic trauma and is a viable target for OMM. A case report presented a type I supracondylar humerus fracture managed with cast immobilization and subsequently received four weeks of OMM treatment (Paiva et al., 2022). Within two and a half weeks (5 sessions), the patient regained full elbow range of motion and had progressive reduction in pain/stiffness over the four-week treatment course (Paiva et al., 2022). Because type I supracondylar humerus fractures generally have an excellent prognosis following immobilization alone, these findings should be interpreted cautiously and represent preliminary evidence from a single case report rather than proof of treatment efficacy.

Adding lymphatic drainage techniques also helped reduce soft tissue swelling of the elbow and upper extremity (Paiva et al., 2022). Postoperative infections pose a significant concern in orthopedic surgery due to the presence of hardware and deep tissue involvement. While OMM does not serve as a direct antimicrobial intervention, some studies suggest it may strengthen the immune response. A study by Walkowski et al. demonstrated that OMM can induce early plasma cytokine release and mobilization of blood dendritic cells, indicating an enhanced immune response (Walkowski et al., 2014). Using OMM postoperatively may support immune function and facilitate healing; however, evidence demonstrating a direct reduction in postoperative infections remains limited (Zhou et al., 2022). Existing evidence demonstrates that lymphatic pump techniques may increase both lymphatic circulation and immune cell mobilization. A study by Kilgore investigated the impact of a lymphatic OMM protocol in patients with lower-extremity edema and venous stasis ulcers, demonstrating a reduction in wound surface area and leg volume (Kilgore, 2018). These findings suggest that OMM may alleviate edema, potentially leading to expedited recovery times and improved patient outcomes. 

Postoperative and chronic pain are commonly encountered complaints in orthopedic trauma that can affect quality of life and frequently lead to long-term disability. A comprehensive study by Henwood et al. (2024) identified that postoperative patients treated with various OMM techniques experienced substantial pain alleviation and a reduction in hospital stays. These findings suggest that OMM may be an effective adjunctive intervention in mitigating postoperative pain and shortening hospital stays, thereby potentially mitigating joint stiffness and muscle atrophy (Kim et al., 2016). OMM presents a non-pharmacological approach to pain management by addressing somatic dysfunctions and promoting homeostasis. The American Osteopathic Association recommends the use of OMM for the treatment of chronic low back pain in patients with somatic dysfunction (Licciardone et al., 2020). Evidence supports the use of OMM for managing chronic low back pain, with clinical trials and observational studies demonstrating improvements in pain intensity and functional status (Rehman et al., 2020; Popovich et al., 2024).

Clinical Innovations & Pilot Studies Relevant to Postoperative Recovery
One key area of interest is OMM’s potential influence on postoperative recovery time and hospital stay. A meta-analysis (Henwood et al., 2024) examined multiple surgical populations and found that patients receiving OMM experienced a reduction in hospital stay by an average of over two days. Although the finding did not reach statistical significance, the trend suggests a clinically relevant improvement in recovery timelines, which could reduce hospital-associated complications such as infections or deep vein thrombosis (Henwood et al., 2024).

Further evidence from studies (Ivanov et al., 2016; Kim et al., 2017) supports the idea that OMM can be safely used in a range of surgical settings, including orthopedic procedures. The studies highlighted improvements in functional recovery, pain relief, and gastrointestinal motility (Roncada et al., 2020; Vismara et al., 2020), all factors that can influence the rate and quality of surgical healing. Although most of the studies were small, their consistent findings suggest OMM’s potential in integrated post-surgical care. In addition to functional improvements, the feasibility and safety of using OMM immediately postoperatively have been validated in small-scale clinical studies. For instance, a pilot study (Belsky et al., 2024; Hubbard et al., 2017) investigated the use of OMM in hospitalized children and adolescent young adults with cancer, a medically complex and vulnerable population. The study concluded that OMM was both feasible and safe, with no adverse events reported during or after treatment sessions. While the study was conducted in an oncology setting rather than orthopedics, its findings offer preliminary support for the broader use of OMM in post-acute care, including after orthopedic trauma, especially considering the similar concerns of inflammation, pain, and reduced mobility in both populations.

OMM in fracture prevention
Our review would not be complete without mentioning the potential for fracture prevention with the use of OMM. A study conducted of cross-country athletes across the NCAA aimed to assess the incidence of stress fractures following osteopathic manipulative treatment (Brumm et al, 2013). The study focused on reducing the risk of stress fractures and involved students primarily performing muscle energy and articulatory techniques on athletes. The study demonstrated a significant decrease in stress fractures in men, while no significant decrease in fractures was observed in women (Brumm et al, 2013). The implementation of osteopathic structural examinations and OMM into athletic examinations may help identify and address somatic dysfunctions that could contribute to musculoskeletal stress; however, evidence supporting fracture prevention remains limited and requires further investigation. By establishing specific guidelines for sports rehabilitation in athletes, OMM may serve as an adjunctive strategy to optimize musculoskeletal function before athletic activity; however, larger prospective studies are needed to determine whether these interventions reduce fracture risk.

Key Findings
This review highlights emerging evidence suggesting a potential role for OMM as an adjunctive therapy in orthopedic trauma recovery, as shown in Table 1. OMM has potential in several key domains, including supporting biologic processes involved in fracture healing, such as improved circulation, oxygenation, and osteogenic activity;  potential mitigation of postoperative factors associated with recovery, including edema, infection, and delayed union, via lymphatic pump and myofascial release techniques; and improved functional recovery and pain management through the correction of somatic dysfunction and restoration of musculoskeletal balance. Several studies, including Paiva (et al., 2022) and Henwood (et al., 2024), reported improvements in functional recovery and, in some surgical populations, shorter hospital stays among patients receiving OMM compared to standard rehabilitation. Mechanistic studies suggest that OMM may modulate inflammatory cytokines (Walkowski et al., 2014; Rehman et al.,2020) and enhance angiogenesis through nitric oxide-mediated vasodilation (Lombardini et al., 2009; Bagagiolo et al.,2022), thereby promoting tissue repair and bone regeneration. Additionally, OMM may contribute to decreased postoperative pain intensity and improved range of motion, which may translate into lower rates of chronic pain and joint stiffness (Licciardone et al., 2020; Popovich et al., 2024). Despite these encouraging findings, current literature is limited by small sample sizes, variable protocols, and a lack of large-scale randomized controlled trials specific to orthopedic populations (Levy et al., 2019).

Preliminary studies suggest that OMM may offer functional benefits during fracture rehabilitation, including improvements in range of motion and overall limb function; however, larger studies are needed to validate these findings (Paiva et al., 2022). In the available case-based evidence, “fracture recovery” primarily refers to the time required to regain functional mobility and range of motion following immobilization, rather than radiographic time to bony union or return to occupational activity. In the available case report, functional recovery was observed within four weeks following OMM-assisted rehabilitation; however, because this represents a single patient with a fracture type that often has an excellent prognosis after immobilization alone, these findings should be interpreted cautiously and cannot establish a causal effect of OMM. Although OMM is not currently incorporated into standard orthopedic trauma protocols, the observed improvements highlight its potential as a complementary strategy. Given the limited scope of existing evidence and the absence of large-scale randomized trials, further rigorous investigation is warranted to clarify its role in orthopedic trauma care (Paiva et al., 2022).

Table 1. Summary of Key Studies Evaluating Osteopathic Manipulative Treatment (OMT) in Postoperative and Musculoskeletal Recovery.

Abbreviations: ABI, ankle-brachial index; BLT, balanced ligamentous tension; FPR, facilitated positional release; HVLA, high-velocity, low-amplitude; IL, interleukin; ME, muscle energy; MFR, myofascial release; OA, occipitoatlantal; OMM, osteopathic manipulative medicine; OMT, osteopathic manipulative treatment; ROM, range of motion.

Limitations
Despite promising outcomes, the current body of literature on OMM in orthopedic trauma is constrained by several methodological and practical limitations. First, most existing studies feature small sample sizes and lack robust randomization, which restricts generalizability. Heterogeneity in OMM protocols, including technique selection, frequency, and duration, further complicates direct comparisons across studies. In addition, many investigations are case reports or pilot studies rather than large-scale clinical trials, making it difficult to establish definitive cause-and-effect relationships.

Another limitation is the absence of long-term follow-up data, which limits understanding of OMM’s sustained benefits in orthopedic trauma recovery. Blinding and placebo control are also difficult to implement in manual therapy research, introducing potential bias. Furthermore, existing studies rarely evaluate cost-effectiveness, patient adherence, or interdisciplinary integration within standard orthopedic care. Addressing these limitations through multicenter randomized controlled trials and standardized treatment protocols will be crucial to establishing OMM’s evidence-based role in orthopedic trauma management.

Future Outlook
There are limited studies investigating the long-term efficacy of OMM in orthopedic trauma. Future research should prioritize longitudinal studies that provide extended data on the effects of OMM on these conditions. Additionally, many studies using OMM lack a control group or comparison of efficacy to conventional rehabilitation methods. It is crucial to determine whether OMM produces comparable results to current first-line treatments or impacts the efficacy of other treatments. This information would provide clinicians with stronger evidence when recommending OMM as a treatment option to patients. Future studies may also explore the potential adjunctive effects of OMM with other physiotherapy treatments; combining different therapeutic methods may further improve patient outcomes. Another potential avenue for future research would be biomechanical studies that could measure the direct impact of OMM on bone density. This would allow for insight into OMM’s physiological impact and provide further evidence for its use in treating orthopedic trauma.

Conclusion
Overall, emerging evidence suggests that OMM may serve as a potential adjunct in orthopedic trauma care by enhancing circulation, modulating inflammatory responses, and improving functional recovery. While current findings are promising, they remain limited by small sample sizes and heterogeneity in study design. Large-scale, orthopedic-specific randomized controlled trials are necessary to establish standardized treatment protocols and define the clinical role of OMM in postoperative fracture management. Integration of OMM into multidisciplinary care pathways may represent a promising avenue for future investigation aimed at improving patient-centered outcomes in orthopedic surgery.

Ethics Approval and Consent to Participate
Not applicable. This study is a narrative review of previously published literature and did not involve human participants, human data, human tissue, or animals. Institutional Review Board (IRB) approval was therefore not required.

Consent for Participation
Not applicable.

Consent for Publication
Not applicable.

Conflict of Interest
The authors declare that they have no competing interests.

Funding
The authors received no specific funding for this work.

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