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COMSAE Phase 1 Form 111 COMPLETE 176 REAL EXAM
QUESTIONS CORRECT VERIFIED ANSWERS & DETAILED
RATIONALES (MOST RECENT 2026 UPDATE)
SECTION 1: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP) – Questions 1–50
Question 1
A 45-year-old woman presents with epigastric burning and bloating after meals
for several months. On osteopathic structural exam, you find tenderness and
increased tissue texture at the right T6–T8 paraspinal region. Which
viscerosomatic reflex best explains this finding?
A) Stomach
B) Gallbladder
C) Pancreas
D) Liver
: Correct Answer : A) Stomach
Rationale: Viscerosomatic reflexes map spinal cord levels to organs. The stomach
corresponds to T6–T9, often on the right side. Gallbladder (T7–T9) also presents
on the right, but the epigastric symptoms point specifically to the stomach.
Recognizing spinal levels for common organs is essential for COMSAE.
Question 2
A 34-year-old male has chronic abdominal pain and fatty stools. Physical
examination reveals an anterior Chapman reflex point at the right 7th intercostal
space near the costochondral junction. Which organ is most likely associated?
A) Kidney
B) Pancreas
pg. 1
,2
C) Ovary
D) Appendix
: Correct Answer : B) Pancreas
Rationale: The anterior Chapman point for the pancreas is the right 7th
intercostal space near the costochondral junction; the posterior point is between
T7 and T8 on the right. Pancreatic dysfunction often presents with epigastric pain
radiating to the back and steatorrhea (fatty stools).
Question 3
Osteopathic structural examination of a 28-year-old female reveals a positive
seated flexion test on the left side. The left sacral sulcus is deep, and the left
inferior lateral angle (ILA) is prominent posteriorly and inferiorly. What is the
most likely diagnosis?
A) L on L forward sacral torsion
B) R on L backward sacral torsion
C) Left unilateral sacral flexion
D) Left unilateral sacral extension
: Correct Answer : C) Left unilateral sacral flexion
Rationale: In unilateral sacral shears (flexions or extensions), the positive seated
flexion test identifies the dysfunctional side. In unilateral flexion, the deep sacral
sulcus and the posterior/inferior ILA are on the same side. In sacral torsions, the
deep sulcus and posterior/inferior ILA are on opposite sides.
Question 4
A patient with a structural exam reveals a restricted T5 segment. The segment
prefers rotation to the right and sidebending to the right. It improves when the
patient slumps forward into spinal flexion. What is the correct diagnosis?
A) T5 Neutral SR RL
B) T5 Extended RR SR
pg. 2
,3
C) T5 Flexed RR SR
D) T5 Flexed RL SL
: Correct Answer : C) T5 Flexed RR SR (Extended, Rotated Right, Sidebent Right)
Rationale: As the dysfunction improves in flexion, the segment is in Flexion.
Rotation and sidebending are to the same side (right) per Fryette’s Second Law.
This indicates a Type II (non-neutral) dysfunction.
Question 5
A patient with a respiratory somatic dysfunction is diagnosed with an “exhaled
rib” on the left. This dysfunction is characterized by:
A) The rib is elevated and restricted in depression.
B) The rib is depressed (inferiorly) and restricted in elevation.
C) The rib is elevated and restricted in elevation.
D) The rib is depressed and restricted in depression.
: Correct Answer : B) The rib is depressed (inferiorly) and restricted in
elevation
Rationale: An “exhaled rib” is positioned inferiorly, limiting inspiration (elevation)
but allowing full expiration. Conversely, an “inhalation rib” is elevated and
restricted in depression.
Question 6
A patient has low back pain with a right short leg in the supine position that
equalizes when sitting. The most likely diagnosis is:
A) Structural short right leg
B) Anterior innominate rotation on the left
C) Anterior innominate rotation on the right
D) Iliosacral shear
: Correct Answer : C) Anterior innominate rotation on the right
Rationale: A functional short leg that resolves when sitting indicates a pelvic
rotation rather than a true anatomic leg length discrepancy. Anterior innominate
pg. 3
, 4
rotation on the right typically presents with a functional short leg in supine that
equalizes in the seated position.
Question 7
According to Fryette’s first principle (Type I mechanics), when the spine is in a
neutral position (neither flexed nor extended), which of the following occurs?
A) Side-bending and rotation occur to the same side
B) Side-bending occurs without rotation
C) Side-bending and rotation occur to opposite sides
D) Rotation occurs without side-bending
: Correct Answer : C) Side-bending and rotation occur to opposite sides
Rationale: Fryette’s first principle describes that when multiple vertebral
segments are in a neutral position, side-bending and rotation occur in opposite
directions. This is a key distinction from Type II mechanics.
Question 8
A 35-year-old with chronic low back pain has a somatic dysfunction of the lumbar
spine characterized by ease of side-bending to the right and restriction of side-
bending to the left. According to Fryette’s laws, this most likely represents:
A) Type I dysfunction (neutral mechanics)
B) Type II dysfunction (non-neutral mechanics)
C) Type III dysfunction (somatic dysfunction)
D) A normal functional spinal unit
: Correct Answer : B) Type II dysfunction (non-neutral mechanics)
Rationale: Fryette’s 2nd law states that when the spine is in a non-neutral
position (flexed or extended), side-bending and rotation occur in opposite
directions. Restriction of side-bending to one side indicates a Type II dysfunction.
Question 9
A 28-year-old presents with acute torticollis after sleeping in an awkward
pg. 4
COMSAE Phase 1 Form 111 COMPLETE 176 REAL EXAM
QUESTIONS CORRECT VERIFIED ANSWERS & DETAILED
RATIONALES (MOST RECENT 2026 UPDATE)
SECTION 1: OSTEOPATHIC PRINCIPLES & PRACTICE (OPP) – Questions 1–50
Question 1
A 45-year-old woman presents with epigastric burning and bloating after meals
for several months. On osteopathic structural exam, you find tenderness and
increased tissue texture at the right T6–T8 paraspinal region. Which
viscerosomatic reflex best explains this finding?
A) Stomach
B) Gallbladder
C) Pancreas
D) Liver
: Correct Answer : A) Stomach
Rationale: Viscerosomatic reflexes map spinal cord levels to organs. The stomach
corresponds to T6–T9, often on the right side. Gallbladder (T7–T9) also presents
on the right, but the epigastric symptoms point specifically to the stomach.
Recognizing spinal levels for common organs is essential for COMSAE.
Question 2
A 34-year-old male has chronic abdominal pain and fatty stools. Physical
examination reveals an anterior Chapman reflex point at the right 7th intercostal
space near the costochondral junction. Which organ is most likely associated?
A) Kidney
B) Pancreas
pg. 1
,2
C) Ovary
D) Appendix
: Correct Answer : B) Pancreas
Rationale: The anterior Chapman point for the pancreas is the right 7th
intercostal space near the costochondral junction; the posterior point is between
T7 and T8 on the right. Pancreatic dysfunction often presents with epigastric pain
radiating to the back and steatorrhea (fatty stools).
Question 3
Osteopathic structural examination of a 28-year-old female reveals a positive
seated flexion test on the left side. The left sacral sulcus is deep, and the left
inferior lateral angle (ILA) is prominent posteriorly and inferiorly. What is the
most likely diagnosis?
A) L on L forward sacral torsion
B) R on L backward sacral torsion
C) Left unilateral sacral flexion
D) Left unilateral sacral extension
: Correct Answer : C) Left unilateral sacral flexion
Rationale: In unilateral sacral shears (flexions or extensions), the positive seated
flexion test identifies the dysfunctional side. In unilateral flexion, the deep sacral
sulcus and the posterior/inferior ILA are on the same side. In sacral torsions, the
deep sulcus and posterior/inferior ILA are on opposite sides.
Question 4
A patient with a structural exam reveals a restricted T5 segment. The segment
prefers rotation to the right and sidebending to the right. It improves when the
patient slumps forward into spinal flexion. What is the correct diagnosis?
A) T5 Neutral SR RL
B) T5 Extended RR SR
pg. 2
,3
C) T5 Flexed RR SR
D) T5 Flexed RL SL
: Correct Answer : C) T5 Flexed RR SR (Extended, Rotated Right, Sidebent Right)
Rationale: As the dysfunction improves in flexion, the segment is in Flexion.
Rotation and sidebending are to the same side (right) per Fryette’s Second Law.
This indicates a Type II (non-neutral) dysfunction.
Question 5
A patient with a respiratory somatic dysfunction is diagnosed with an “exhaled
rib” on the left. This dysfunction is characterized by:
A) The rib is elevated and restricted in depression.
B) The rib is depressed (inferiorly) and restricted in elevation.
C) The rib is elevated and restricted in elevation.
D) The rib is depressed and restricted in depression.
: Correct Answer : B) The rib is depressed (inferiorly) and restricted in
elevation
Rationale: An “exhaled rib” is positioned inferiorly, limiting inspiration (elevation)
but allowing full expiration. Conversely, an “inhalation rib” is elevated and
restricted in depression.
Question 6
A patient has low back pain with a right short leg in the supine position that
equalizes when sitting. The most likely diagnosis is:
A) Structural short right leg
B) Anterior innominate rotation on the left
C) Anterior innominate rotation on the right
D) Iliosacral shear
: Correct Answer : C) Anterior innominate rotation on the right
Rationale: A functional short leg that resolves when sitting indicates a pelvic
rotation rather than a true anatomic leg length discrepancy. Anterior innominate
pg. 3
, 4
rotation on the right typically presents with a functional short leg in supine that
equalizes in the seated position.
Question 7
According to Fryette’s first principle (Type I mechanics), when the spine is in a
neutral position (neither flexed nor extended), which of the following occurs?
A) Side-bending and rotation occur to the same side
B) Side-bending occurs without rotation
C) Side-bending and rotation occur to opposite sides
D) Rotation occurs without side-bending
: Correct Answer : C) Side-bending and rotation occur to opposite sides
Rationale: Fryette’s first principle describes that when multiple vertebral
segments are in a neutral position, side-bending and rotation occur in opposite
directions. This is a key distinction from Type II mechanics.
Question 8
A 35-year-old with chronic low back pain has a somatic dysfunction of the lumbar
spine characterized by ease of side-bending to the right and restriction of side-
bending to the left. According to Fryette’s laws, this most likely represents:
A) Type I dysfunction (neutral mechanics)
B) Type II dysfunction (non-neutral mechanics)
C) Type III dysfunction (somatic dysfunction)
D) A normal functional spinal unit
: Correct Answer : B) Type II dysfunction (non-neutral mechanics)
Rationale: Fryette’s 2nd law states that when the spine is in a non-neutral
position (flexed or extended), side-bending and rotation occur in opposite
directions. Restriction of side-bending to one side indicates a Type II dysfunction.
Question 9
A 28-year-old presents with acute torticollis after sleeping in an awkward
pg. 4
