ICSC 06 Upper Extremity Injuries in Sport

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Part 1_ Basics of Biomechanics

English PDF direct download – ICSC6 Part 1 Basics of Biomechanics.txt

ICSC06 Upper Extremity Module 6
Part1 Basics of Biomechanics
Instructor: Steven Smilkstein
Video Lesson: 21:54

Welcome to the basics of biomechanics. This is a simple guide that will teach you the basic principles of biomechanics that we can later apply to the upper limb, the spine, and the lower limb. In this section, we will be looking at basic concepts in joint anatomy and the types of diarthrodial joints, joint function in the form of kinematic chains, and also arthrokinematics. We will also be looking at muscle and tendon physiology, muscle physiology and biomechanics, common injuries in muscle, injury grading of muscle, and related sports and rehabilitation. Before we go into the details of joints and anatomy, we need to know the fundamentals of anatomical positioning, the axis of rotation, and the anatomy of a synovial joint.

The axis of rotation. This is characterized by 3 lines that dissect the body. The X-axis is a line that runs transversely across the body from left to right, the Y-axis is a line that runs vertically through the body from cranial to caudal, and the Z-axis is a frontal line that runs from anterior to posterior. The X, Y, and Z axis combined in pairs form different planes. As you will see ahead of the slide, we will work in these planes and see what movements go about these planes.

The Sagittal Plane. This divides the body into left and right halves. It is demarcated by the Y and Z axis combined. The movements of flexion and extension move through this plane. If we had to visualize flexion at the shoulder joint, we would see an anterior movement of the upper extremity through the sagittal plane where there was a point of rotation about the X-axis at the center of rotation of the shoulder joint.

The Coronal Plane. This divides the body into anterior (ventral) and posterior (dorsal halves). It is demarcated by the Y and X axis combined. Movements of abduction and adduction are seen to move through this plane. If we had to visualize the abduction of the shoulder joint, we would see the upper limb being elevated through the coronal plane, laterally away from the body. The point of rotation would be seen at the shoulder joint rotating about the Z-axis.

The Transverse Plane. This divides the body into superior and inferior halves. It is demarcated by the X and Z axis combined. Movements of rotation move through this plane. If we had to visualize the medial rotation of the upper limb with the elbow bent, we would see a translation of the hand medially towards the tummy. This is a rotation at the center point of the joint about the Y-axis of the shoulder joint.

The anatomy of a typical diarthrodial joint is also known as a synovial joint. It is characterized by free-moving ends or epiphyses encapsulated within a synovial lined joint space. The articular surfaces are free to move relative to each other because of no connective tissue directly connecting the surfaces. The shape of the joint surface dictates the motion potential of the joints.

The Joint Structure. The structure of the joints of the human body reflects the functions that the joints are designed to serve. The demand on the limb or segment that needs to move will dictate the type, shape, and size of the joint needed. As the joints become larger and have more range of motion, the less stable the joint is. Therefore, we will see more stabilizing factors in some joints and less range of motion in others. This can be seen as an example in the shoulder joint or the glenohumeral joint, specifically, where there is an extensive range of motion but at the sacrifice of stability. The rotator cuff muscles and the rotator interval capsule have to apply different forces in order to stabilize the shoulder as accessory stabilizers for the joint.

These two diagrams are an example of how the joint functions and how the associated tissues replace the stabilization because of the joint shape. As said above, the glenohumeral joint is a large joint with very little stability in order to allow for large ranges of motion. The small stabilizers, being the rotator cuff muscles, and the rotator interval capsule maximize the ability as best as possible.

Here are a few examples of synovial joints and their specific locations: the condyloid joint which is found at the atlantooccipital joint; the ball and socket joint, found at the glenohumeral joint and the coccyx femoral joint; the gliding joint which is found in articular processes between vertebrae; the saddle joint which is found at the carpometacarpal joints; the pivot joint which is found at the dens of the axis between atlas and axis; and the hinge joint which is also found at the elbow.

Kinematic chains. This is a biomechanical term used for a series of rigid links that are interconnected by joints that allow the limb to move in a predictable manner. It can either be an open kinematic chain or a closed kinematic chain. In an open kinematic chain, one joint is able to move independently to the approximal joints and has the freedom to move through space. In a closed kinematic chain, the distal end of the limb is fixed but the segments are able to move. There is no net change in limb position but the movement has occurred–for example, when standing and shifting off balance yet you have not moved from your original position.

Muscle and tendon physiology. In order to understand muscle behavior, we need to understand the smallest contractile unit of the muscle. This is known as the Sarcomere. It is a small fibrous structure formed by I-bands and A-bands. It is composed of actin and myosin. It has a sarcoplasmic reticulum that provides calcium in order to create a polar bond between actin and myosin heads in order to mediate muscle contraction. In order to understand gross muscle contraction, we need to understand the concept of muscle length-tension relationships. In this diagram, we can see the relative link between the length of muscle tissue and the ability to contract as muscle contractile tissue. We have an optimal zone that is needed for maximal actin and myosin interaction.

If the actin and myosin are packed too closely together, the sarcomere is unable to contract as there is a restriction of space, therefore, the sarcomere is rendered useless. If the actin and myosin are separated too far apart, there is no ability for the calcium to create the polar bond and linkage, and therefore, there is no contraction as there is no linkage between actin and myosin.

Active and passive inhibition. This is, too, a biomechanical concept that describes the behavior of muscle when set in anatomical fields. Active inhibition is where the muscle contracts to the point where it is unable to move the limb any further due to soft tissue obstruction. The muscle is self-able to generate a contraction but unable to move further. In passive inhibition, the muscles are not able to contract eccentrically as the limb is stretched beyond the anatomical limits of the sarcomere. The muscle is unable to initiate contraction unless the length is reduced.

Muscle physiology and biomechanics. The muscles are our powerhouses and our movers of the body, because of this, they tend to fatigue easily and can potentially get injured. By looking at the behavior of muscle in contraction, we are able to determine when a muscle is injured or underperforming due to altered mechanics and general muscle pain syndromes such as Delayed Onset Muscle Soreness. Muscle testing is a simple and effective method of assessing muscle behavior and potential injury.

The factors that affect muscle strength are motor-unit summation and increase rate coding. In motor-unit summation, the more motor units the muscle uses to contract, the more summative contraction can be achieved. We see this in explosive forceful contractions such as that in sprinting. In increase rate coding, increasing the right to fire each specific motor unit increases the total rate of recovery and reconstruction of the muscle. This is seen in a gradual build-up of muscle contraction such as applying weight in weightlifting.

The factors affecting muscle tension are primarily dictated by the number of muscle fibers in that unit: the size of the fibers, i.e. the larger the fibers, the more tension that can be generated; specific tension per cross-sectional area, i.e. smaller slow twitch fibers generate approximately 1.73kg of tension per square centimeter, and larger fast twitch fibers generate about 2.23kg of tension per square centimeter.

Common muscle injuries are usually seen as muscle strains. These are the most common and most feared by any athlete. They may occur due to overuse (e.g. repetitive motion such as pitching in baseball) or due to forceful overloading in sports activity (e.g. hamstring strain during the launch of the plate in a long jump). They are graded from grades 1 to grade 3.

This is a simple grading scale that can be used to understand and note what type of muscle strain you are dealing with. In a grade 1 muscle strain, minor or microscopic tissue damage is noted. It is painful for the patient. They usually experience a severe cramp or spasm. It is not usually palpable, and it usually takes about 7 to 10 days for normal recovery, back to 100% function. In grade 2 muscle strain, it is a moderate or macroscopic or partial thickness tear of muscle tissue. It is extremely painful for the patient. There is a muscle cramp or spasm. It is palpable by torn fibers in the muscle tissue and rehabilitation is required for 10 to twenty-one days for normal recovery, usually between 80 and 100 percent return of normal muscle function depending on the thickness of the tear. Grade 3 muscle strength is usually a severe maximal or full thickness tear of the muscle tissue. The patient usually doesn’t feel much pain initially due to the loss of tension. It is usually a physical muscle deformity as the muscle has had a full thickness tear. The muscle sheath or fascia may still remain attached to the tendon. Surgery and rehabilitation are usually required with a 3-week to 6 months recovery.

Tendonitis or tendonosis. These are inflammatory conditions that affect the tendons directly. The most common mechanism of injury is due to overuse or increase leverage on the tendons in sports such as record-based sports. The most common forms are usually tennis elbow, golfer’s elbow, and jumper’s knee.

The grading of tendon strains is similar to that of what we saw in muscle. Grade one, again, is minor or microscopic tissue damage. This is painful for the patient. It is not palpable and has a 7 to 10-day recovery period usually with non-steroidal anti-inflammatory drugs and/or compression. In grade 2 tendon strains, it is a moderate or macroscopic effect on the tendon tissue. It is extremely painful for the patient. There is a palpable deficit in the tendon usually in the form of swelling such as in tenosynovitis. Rehabilitation is required and it is commonly called enthesopathy. Grade 3 tendon strain is known as severe or maximal or full thickness tears of the tendon. It is usually associated with avulsion fractures as it is usually affected at the tenderness junction between the bone and the tendon.

Delayed Onset Muscle Soreness or DOMS. This is where the products of collagen break down from intense rapid training that may act as a chemotactic agent and inflammatory marker causing macrophages to travel into the muscle tissue and begin an inflammatory response. The macrophages are nonspecific phagocytes and break down imperfect and normal cells, thus causing tissue damage. Hydroxyproline or OHP is a urine marker for early-onset DOMS. If DOMS is severe enough that it affects large amounts of tissue, the degradation will be seen by a rise of Creatine Kinase and may lead to Rhabdomyolysis or other complications.

Common treatments for DOMS include cryotherapy, regular stretching, ultrasound, light-low resistance exercise, hyperbaric therapy, compression, massage therapy, and drugs in the form of non-steroidal anti-inflammatory drugs.

Ligament physiology. The ligaments are the primary restraints and guides for the joints. They provide the main line of support for normal joint motion. They are the last line of defense for joint hyperextension and instability. They are subject to continuous loading and are most affected by the phenomenon of creep. Creep is a physiological phenomenon where there is tissue distortion over a period of time when a constant force is applied over a long period of time. We see this in general ligament laxity, the winner’s shoulder is overused or overstretched.

Common injuries of ligaments include ligament sprains. They are commonly due to joint malposition during a weight-bearing exercise. The most common version is the inversion sprain of the ankle, commonly in running and in stop-or-start sports such as netball or basketball. Joint hyperextension and instability. There is usually an overload of the ligaments which may induce capsular stretching. There is also joint dislocation which is commonly found in contact sports due to the force of impact and it commonly happens in juvenile-level sports where the ligaments are still stretching due to bone growth.

As seen before with a muscle injury, we refer to a grade 1, grade 2, or grade 3 grading system for ligament damage. In grade 1 ligament sprains, you will see minor or microscopic tissue damage. It is painful for the patient. They usually experience acute or moderate swelling and minor hematoma formation. It is not usually palpable defect. The joint stability is usually maintained but they may have minor instability masked by exaggerated apprehension and pain. It takes about 7 to 10 days to heal and the weight-bearing or proprioception is affected.

In a grade 2 ligament sprain, there is moderate or macroscopic partial-thickness tearing. It is extremely painful for the patient. There is a large or significant swelling and hematoma. The muscle cramp or spasm may mask instability but instability is seen easily with the naked eye. When the joint is placed under pressure or weight-bearing, it is unbearable for the patient, and proprioception is affected. Immobilization is required as soon as possible. In a grade 3 ligament sprain, there is severe or maximal tissue tearing. The patient does not feel pain initially due to the loss of tension. There is gross joint instability which is commonly seen and may also see repetitive joint dislocation if associated with a joint displacement. The proprioception is completely disrupted and may affect voluntary joint control. Surgery is commonly required with rehabilitation.

For more information on related sports and rehabilitation, please refer to the following text for a basic understanding of rehabilitative exercises and chiropractic therapies in order to treat some of the injuries discussed.

Thank you for taking the time to learn about the basics of biomechanics. I hope this information serves you well and helps you guide and assess your patients correctly and efficiently, and also improved your own standard of practice.



Part 2_ Basics of Biomechanics

English Direct Download PDF ICSC6 Part 2 Basics of Biomechanics.txt

ICSC06 Upper Extremity Module 6
Part 2 Basics of Biomechanics
Instructor: Steven Smilkstein
Video Lesson: 48:444 minutes

This is a simple guide to pick up on normal and abnormal biomechanical limb in the upper extremity. In this section, we will be looking at basic concepts in joint anatomy and the types of diarthrodial joints, joint function in the form of kinematic chains and arthrokinematics. We will also be looking at muscle and tendon physiology, muscle physiology and biomechanics, common injuries in muscles, injury-grading of muscles, and related sports and rehabilitation. We will also be looking at ligament physiology, common injuries in ligaments, injury-grading of ligament injuries, and related sports and rehabilitation.

The shoulder complex may seem very complicated, but if we divide it into the four main joints that compose the shoulder complex, we are able to simplify it by understanding the anatomy, the structure, and the function of each joint. We will look at the sternoclavicular or SC joint, the scapulothoracic or ST joint, the acromioclavicular or AC joint, and the glenohumeral, or GH joint. We are going to look at the concepts of stabilization and the ranges of motion that the shoulder can go about.

As said previously, the shoulder can be divided into four separate joints: three true joints and one false or pseudo joint. The three true joints are the acromioclavicular or AC joint, the sternoclavicular or SC joint, and the glenohumeral or GH joint. The pseudo joint or false joint is the scapulothoracic joint, which interacts with the posterior chest wall. It is known as an intermuscular joint as the surface of the subscapularis and the chest wall interact with each other.

The sternoclavicular joint or SC joint. This is the direct link for the entire shoulder complex to the axial skeleton directly. It consists of two concave surfaces separated by an intra-articular joint disc. This is the main connection between the manubrium of the sternum and the medial head of the clavicle. It is a planar type of joint with three degrees of freedom. The movements that we can see at this joint are elevation and depression of the clavicle, protraction-retraction of the clavicle, and anterior and posterior rotation of the clavicular complex. It is supported and limited by very strong and elastic ligaments, namely the sternoclavicular, the costoclavicular, and the interclavicular ligaments.

The most common injury seen at the SC joint is ‘SC joint separation’ or ‘subluxation’. It is commonly seen in contact sports or where there is impact to the shoulder. The subluxation can occur either in an anterior manner where we see the clavicle displaced anteriorly, or in a posterior manner where the clavicle has displaced posteriorly. A posterior subluxation can result in respiratory distress and needs to be treated as a medical emergency, which either includes immediate reduction or manipulation of the arm to the point where the [inaudible] the stress is eliminated before we can get the patient to an emergency room.

The acromioclavicular joint, or AC joint, forms, a protective bony arch above the glenohumeral joint. This is a planar synovial joint where the two convex surfaces, one from the acromion process of the scapula, and the second from the lateral head of the clavicle, will slide across each other. The joint is supported by a very strong joint capsule and is further supported by two major extrinsic ligaments being the coracoacromial ligament and the coracoclavicular ligament. There may be an intra-articular disc. The primary motions at the acromioclavicular joint are seen as anterior or posterior tipping of the scapula, or medial or lateral rotation of the scapula, or superior and inferior translation of the clavicle on the acromion or the acromion on the clavicle. The SC joint is susceptible to degeneration and trauma due to the of muscle tissue and fat pads that protect most joints.

Most common injury to the AC joint is AC joint separation. It is commonly injured in contact and impact sports. It is graded by the direction and amount of displacement noted. There are two main thoughts of classification regarding AC joint separation. The first is the standard ligament injury grading system where you see Type 1, which is minor microscopic injury to the ligament with little or no displacement of the joint. Type 2 with macroscopic but non full thickness tearing of the ligament, which can be seen in ultrasound and or felt in palpation. There is some minor displacement or instability found at the joint. Type 3 is macroscopic full-thickness tear of the ligament tissue, and you can see quite apparent displacement of the joint itself.

Your second type of classification is your Rockwood’s six types of classification of AC joint separation. Your first three stages are the same as your standard grading ligament injuries system. Your Type 4, you see separation but also minor injury to the trapezius and deltoid muscles. Your Type 5 is the complete separation of the clavicle away from the joint itself and sometimes, penetration through the trapezius muscle. Your type 6 classification, this is only in an overhead injury where the scapula is over-rotated over the clavicle, and the clavicle is displaced and moved under the bicep’s tendon and pectoralis minor muscle. This is clinically significant as it may be impinging on the apex of the lung and all pulling onto the brachial plexus. This is quite a radical injury and needs immediate surgical intervention.

The scapulothoracic or ST joint. This joint is considered to be a false joint, or a pseudo joint, as it does not have the typical characteristics of a normal diarthrodial joint. The joint itself is lacking any synovial lining or hyaline cartilage interactions. The joint is made up of an inter-muscular articulation between the anterior surface of the scapula covered by the subscapularis muscle, and the posterior chest wall and intercostal muscles. The joint itself does form a true closed kinematic chain and support system for the AC and SC joints while allowing dynamic motion to occur at the glenohumeral joint with dynamic support. The movements that can be seen at the scapulothoracic joint are elevation and depression of the scapula, protraction and retraction of the scapula on the chest wall, and upward and downward rotation, or tipping, of the scapula.

Scapula winging or dyskinesis. This kind of injury is commonly caused by falls, impact, and or contact sports. It can also happen insidiously by postural changes and or connective tissue disorders. There are three types of scapular wing: true winging, pseudo-winging or false winging and voluntary winging. True winging is due to weakness only of the serratus anterior muscle which may be caused by a long thoracic nerve palsy. This can happen due to tackles under the arm into the chest region just in line or anterior to the scapula, and or falls onto the side of the chest. Rhomboid or pseudo-winging is caused by palsies to the rhomboid muscle or damage to the rhomboid muscles. The third or voluntary winging is commonly caused by connective tissue disorders, where the patient is able to move the scapula and also lifted voluntarily off the chest wall.

Pay attention to the difference in characteristics of each type of winging. For example, in true winging, the interior angle of the scapula lifts off the chest wall. This is due to the anatomical location of the serratus anterior and therefore, the rest of the scapula is able to stabilize and plant itself on the chest wall. In false winging or pseudo-winging, we see the complete medial border of the scapula lifting. Therefore, the two differences in patterns do indicate what structures are causing the problem. Involuntary winging. A clear history will indicate whether the patient is in a state of voluntary winging or if the other two pathologies are more prominent.

Glenohumeral joint or GH joint. This is the most mobile yet most unstable joint in the entire body. It is a ball-and-socket joint with three degrees of freedom. The humeral head is three times larger than that of the surface of the glenoid. Therefore, it is extremely mobile but very unstable. In order to support this, the body has grown very strong ligaments, but they are not able to support the extremes of motion. The glenoid labrum develops in order to deepen the glenoid socket in order to create congruency for the articulation.

The glenohumeral joint is stabilized by two main factors: one, static stabilization, and the second, dynamic stabilization. This incorporates both the rotator interval capsule and the rotator cuff muscles. Accessory, stabilizers are also incorporated, that being the two heads of the biceps brachii muscles. In these two images, you will see the dense connective tissue and ligaments that support the glenohumeral joint. Also, the design and the shape of the glenoid labrum in order to deepen the socket for the glenohumeral joint. This is the most important factor that stabilizes the shoulder.

Glenohumoral dislocations and subluxations.  Dislocations and subluxations are the most common injuries in high force contact sports such as rugby and football. They can also be due to instabilities caused by throwing sports such as water polo, cricket, or baseball. All glenohumeral dislocations result in an inferior displacement of the humerus, but also have a distinct pattern depending on the direction of displacement anterior or posterior to the glenoid. On an anterior dislocation, the humerus is usually displaced in an abduction, external rotation, and extension combination of movements. Therefore, the upper limb will be stuck in abduction, extension, and external rotation. In a case of a posterior dislocation, the humerus is usually displaced in adduction, internal rotation and flexion. Therefore, the upper limb will be fixated in an adduction, internal rotation, and flexion position.

When dealing with a patient with a shoulder dislocation or instability, it is very important to remember several factors which may influence your decision to reduce on size. The most important factors are: ‘are you able to reduce it immediately?’, ‘are you able to get the patient to hospital, which is a primary care facility?’, ‘do you have a good follow on post-adduction imaging system such as x-rays or CT scans?’, ‘do you have sufficient professional involvement in EMTs or other doctors?’, ‘what is the risk reward factor of reducing on-site immediately?’

Posterior dislocations of the shoulder are the less common version of shoulder dislocations because it needs quite a hard force at the length of the humerus in order to displace the head of the humerus posteriorly against the bony protective acromial arch. The patients present with the shoulder slightly flawed, forward inflection, adduct it, therefore the elbow, would be closer towards the trunk, and internally rotated as the posterior lip of the glenoid will be pushing on the anterior aspect of the intertubercular groove.

Anterior dislocation of the shoulder is the most common version of shoulder dislocation due to the lack of bony restraint on the anterior aspect of the glenohemural joint. Anterior dislocations present with the shoulder in an external rotation, abduction, and extension position. Therefore, the patient will present with the elbow tucked posteriorly, the arm externally rotated, and the shoulder or elbow slightly abducted away from the torso of the patient.

Biomechanics of the shoulder as a whole. The first shoulder biomechanical concept that we will be discussing is ‘scapulohumeral rhythm.’ This is the rate of movement between the shoulder at the glenohumeral joint and the scapulothoracic joint in order to accommodate the glenoid surface to maintain congruency of the glenohemural joint during movements of abduction. It is the overall contributions of movement from scapular and the humerus in the motion of abduction. When the arm is abducted in an arc of 0 degrees to 180 degrees, the humerus and the scapula move at a ratio of two to one. The scapula movement allows for stability and increased congruency between the glenoid and the head of the humerus during abduction. Any pathology of the shoulder has a tendency to reverse the ratio, and we see a one to two ratio called ‘reverse scapulohumeral rhythm.

It is thickened by mechanical concept that we will be discussing true shoulder stabilization. This can be divided into two forms of stabilization at the glenohumeral joint. Firstly, static stabilization with the rotator interval capsule and resting muscle tone are responsible for stabilization at the glenohumeral joint while the arm is dependent. The second dynamic stabilization is when active rotator cuff muscle interaction creates a counter force and a compressive joint force on the glenohumeral joint.

Static stabilization of the glenohumeral joint. When the arm hangs at the side, the humeral head rests in the glenoid fossa and labrum. Gravity, being the main force that acts on the upper limb, will pull down in a parallel force to the shaft of the humerus. The upper limb needs to maintain equilibrium or an inferior dislocation of the joint will occur. There is no muscle contraction found in this mechanism. Gravity acts on the humerus as a translate-free force distant from the center of the rotation, and results in an adduction moment on the joint. The adduction moment is counterbalanced by the tension of the rotator interval capsule. Only when the passive counter force of the rotator interval capsule is inadequate for static stabilization, there will be involvement from the supraspinatus muscle. Although the supraspinatus and subscapularis muscles are not active in the unloaded arm at the side, if they are paralyzed or dysfunctional, it can lead to a gradual inferior subluxation of the glenohumeral joint as their fibers invest in the rotator interval capsule.

In these two diagrams, you can see how static stabilization maintains equilibrium by creating a vector-pulling force that will draw the humerus out of an adduction moment. If you look at the green cross in figure 7.34, it signifies the axis of rotation at the glenohumeral joint. The act of gravity will pull the humerus parallel to the shaft, and due to the shape of the humeral head and the angle of inclination, the humerus will have a tendency to move into an adduction position. Hence, the term ‘adduction moment.’

The natural muscle tone of the supraspinatus and subscapularis muscles will counterbalance that adduction moment unless they are paralyzed. The rotator interval capsule is a small triangular piece of anterior capsule found between the tendons of the supraspinatus muscle and the subscapularis muscle. Therefore, any damage or injury to the muscles will have an effect on the rotator interval capsule that makes stabilization of the glenohumeral joint. This is where stabilization is implemented during the initiation of abduction.

The direct action of the deltoid muscle can be identified as two components: one, a large translate reforms upwards; and two, a small compressive force or rotary component as an abduction moment. Abduction from the deltoid can only be achieved when the humerus has abducted past 15 degrees, which is initiated by the supraspinatus muscle. The translatory upward force of the deltoid, if unopposed, would cause the humeral head to shift upwards and impact against the correct acromial arch. The inferior translatory pull of gravity is not enough to offset the resultant force of the deltoid because that forced must exceed that of gravity before any rotation can occur. Therefore, another force or state of forces must be introduced to the glenohumeral joint.

The rotator cuff tendons blend with and reinforce the glenohumeral joint capsule. The component forces of the calf muscles create some rotation of the humerus and also compresses the head of the humerus into the glenoid fossa. Combined with contraction of the rotator cuff creates a downward translatory force that is strong enough to counteract the pull of the deltoid.

The supraspinatus contraction has a rotary component that generates a compressive force and provides a stable force as it compresses the humeral head into the fossa. This creates the rotary potential needed for the deltoid in order to elevate the arm in abduction.

The elbow and forearm complex. In this section, we are going to look at the anatomy structure and function of the humero-ulnar joint, the radio-ulnar joint, and the associated ligaments around the elbow and forearm complex. We will also look at the common injuries around it as they are mostly biomechanically implicated.

The ulnar joints anatomy is very simple. It is composed of three bones forming four articular components that influence the movement of the hand. These four articulations are: the humero-ulnar joint, the humero-radial joint, and the proximal and distal radio-ulnar joints. The elbow, as a whole, is a hinge-type joint with a uniaxial or single degree of motion. We only see flexion and extension at the elbow joint.

There are three ligaments that protect the elbow joint: the radial co-lateral ligament or RCL, the ulnar co-lateral ligament or UCL, and the annular ligament. There are five major muscles that directly work on the joint through reflexes and to extensors. The articulating surfaces are the most significant in the biomechanics of the elbow and dictate tension on the RCL and UCL, common extensors and flexors, and the epicondylar apophyses.

In this diagram, we can see the articulations of the elbow joint and the close relations that the radial collateral ligament, or RCL, in yellow, the ulnar collateral ligament, UCL, in red, and the annular ligament in blue, have to the joint capsule and influence the lineup of the elbow joint.

The ulnar collateral, ligament or UCL. It is comprised of three parts: the anterior bundle, posterior bundle, and transverse bundle or Cooper’s ligament. The anterior bundle is the primary stabilizer for all valgus force from 20 degrees to 120 degrees of elbow flexion. The posterior bundle is less involved in checking valgus force, but it guides the interaction of the Olecranon process and the trochlea. The transverse bundle or Cooper’s, ligament is between the Olecranon and ulnar coronoid process and it is believed to maintain a varus compressive force on the humeroulnar articulation.

The radial collateral ligament or RCL. This is a fan-shaped ligament and it offers the small degree of resistance against varus stress because the bony elements of the humerus, being larger on the lateral aspect, do not allow for varus movement. This prevents joint distraction and is more elastic than the UCL. The fibers are taut at about 110 degrees of elbow flexion.

The annular ligament. This is a strong ligament which forms a four fifths ring encircling the radial head. Its inner surface is covered with cartilage and therefore, serves as a joint surface for the head of the radius. The lateral aspect is reinforced by fibers from the LCL. It maintains radial head interaction with the ulnar and allows for pivoting in pronation and supination of the forearm.

The interosseous membrane. This is a broad dense membrane rich in collagen, which runs between the radius and the ulna from proximal to distal. It runs distally and medially. It allows transmission of forces from the hand and distal end of the radius to the ulna, especially in forces of compression from the hand upwards into the upper limb. Indirectly, it acts as a locking mechanism for the elbow and wrist during weight bearing and gripping.

This is a simple diagram to let you remember before on flexor muscles, that come from the common flexor tendon. This diagram represents the complex forearm extensor muscles as seen from the common extensor tendon.

The most common biomechanical injuries that we see in the elbow is lateral epicondylitis or ‘tennis elbow’ and medial epicondylitis or ‘golfer’s elbow.’ In tennis elbow, it is commonly seen in racket-based sports which directly increases the length of the forearm lever, which increases the stress on the elbow. This is caused by repeated forceful contractions of the wrist extensors, and because of this repeated tensile stress on the inelastic tendon, it can result in microscopic tears at the muscular tenderness junction, and thus forming tendinitis. For golfer’s elbow, it is also caused by extension or instrument-based sports such as golf. It is caused by forceful repetitive contractions of the pronator teres, flexor carpi radialis and flexor carpi ulnaris. The injury usually involves elbow extension, pronation and wrist flexion. The most common form of treatment can include a brace around the forearm just distal to the muscle insertion site in order to move the point of leverage and allow the person to still use the arm while in the healing phase.

Elbow dislocations. This is a common contact sport injury usually found in sports such as football, ice hockey, basketball, gymnastics, rugby, and wrestling. It commonly displaces posteriorly, behind the joint. It is uncommon for an anterior displacement and usually associated` with a supracondylar fracture. It is always important to send these patients to the emergency room as reduction may result in laceration of the brachial artery and result in a Volkmann’s Ischaemic contracture. The process of reduction and immobilization needs to be considered with the following factors: reduce as soon as possibl; is there a hospital availability; follow on post-reduction: x-rays, CT, or MRI; check for professional involvement especially with orthopedic surgeons; and risk for potential return to play from coaches or from parents.

Forearm fractures. Even though they are uncommon, they do happen in contact sports. They are usually overlooked by EMTs and emergency medical personnel. It is always important that if you suspect a forearm fracture, look for the following symptoms. It is always important to notice whether the forearm is in locked in a position or unable to move in another position. In this case, this young man was a 26-year old rugby player. He fractured his forearm while in a tackle. This was missed by EMTs and was allowed to return to play. The arm was locked in pronation and he was unable to supinate actively. The protocol followed was to splint, immobilize, send for X-rays, and refer on for further cause. The wrist and hand complex with regards to prehension and gripping. In this section, we will be looking at the anatomy, structure, and function of the wrist and hand complex. Also, the relation to grip and the types of grip that we see in sports.

The structure and function of the wrist. It is the most complex joint in the body, both anatomically and physiologically. It is also known as the ‘carpus’ and consists of two compound joints: the radiocarpal joint and the midcarpal joint. The function of the wrist is to control and allow fine adjustments of grip and manipulation of objects within our hands. The secondary function is placement of the hand in space. It is a biaxial joint with movements of flexion and extension around the coronal axis, and radial and ulnar deviation, or abduction and adduction, around an AP axis. Variations in movements are due to ligament laxity, the shape of the articular surfaces, and the constraining effects of muscles.

The Carpal Rows. Anatomically, it is always important to know which carpal bone you are looking at. There is a simple way to remember this, from proximal to distal, and from radial to ulnar. The order of the bones are as follows: the scaphoid, lunate, triquetrum, and pisiform, the trapezium, trapezoid, the capitate, and the hamate. In the Carpal Rows, there is a two joint system at the wrist in order to facilitate the following: a large range of motion, prevention of structural pinch at the extremes of ranges of motion for the carpal tunnel contents, and for flatter multi-joint surfaces more capability of withstanding pressure from the hand into the forearm.

The intercalated segment. How does the intercalated segment work? When compressive forces are applied across an intercalated segment, the middle segment tends to collapse and move in the opposite direction from the segments above and below. Example: compressive-extensive forces across the wrist complex results in proximal row of the carpals flexing and the distal row extending. However, some stabilization is required in order to prevent complete collapse of the middle segment.

This mechanism involves the scaphoid and its attachments to the lunate and to the distal carpal row. The scaphoid tends to Flags, while the lunate and the triquetrum tend to extend. These counter rotations within the proximal row are prevented by ligaments of the wrist. These linkages will cause the proximal couples to collapse synchronously into flexion and pronation, while the distal carpals move into extension and supination. This counter rotation between the rows increases ligamentous tension and thereby increases stability,

Here is a simple diagram that shows how an intercalated segment works while under compression. As you can see, there is also two instances of complete instability if the intercalated segment does not function properly. The first being VISI or volar intercalated segment instability with displacement of the carpal row moves anteriorly during extension, or DISI or dorsal intercalated segments instability, where on extension, the Carpal Row shifts dorsally.

Anatomy of the Hand. Here is a simple diagram to refresh your anatomical knowledge on the hand. Prehension. This is the act of grasping or taking hold of an object between any two surfaces of the hand. The fingers, usually function to hold an object into the palm. They sustain flexion which varies with size, shape, and weight of the object. The thumb creates an additional surface area for contact, ie: it adducts in order to clamp the object down in the hand.

Prehension can be divided into two forms of grip: power grip and precision handling. Power grip is the forceful act resulting in flexion at all the finger joints so that the objects are held between the thumb and the palm. Precision handling is more skillful with the placement of an object between the fingers or finger-and-thumb, or the palm is not involved.

Power grip can be subdivided into four more types of grip, being cylindrical grip, spherical grip, hook grip, or lateral prehension. Cylindrical grip uses flexors to carry the fingers around and maintain the grasp on an object, mainly in the flexor digitorum profundus. Contraction. Power grip. This uses the flexors to carry fingers around and maintain the grasp on an object.

The interossei flex the metacarpophalangeal joints with some abduction over adduction. The thumb usually flexes and adducts to close the grip. The wrist is usually in the neutral position with slight ulnar deviation. This puts the thumb in line with the form and positions the object better to be able to be moved by pronation or supination of the forearm, and maintains long finger. flexors’ optimum length to tension relationship. The more on the deviation by the flexor carpi ulnaris, the more tension on the flexor retinaculum, which gives hypothenar muscles, a more stable base on which to contract.

Spherical grip is similar to cylindrical grip except that the fingers are more spread out to encompass the object. Therefore, there’s more interosseous activity. The metacarpophalangeal joints do not all deviates ulnarly, but tend to abduct. This allows for more wrist rotation or manipulation of the hand while gripping.

Hook grip. This primarily involves the fingers. It may include the palm but it never includes the thumb. This can be sustained for a long period of time. For example, for carrying bags or handles on suitcases.

Lateral prehension. This is seen as contact between two adjacent fingers. It is not considered a conventional form of power grip but similar in that position is maintained so that the object can be moved by the more proximal joints. The metacarpophalangeal joints and the interphalangeal joints generally extend, and the metacarpophalangeal can adduct or abduct. The extensor muscles play a part in this by maintaining the finger position.

Precision grips. It can be divided into three different categories of what surface of the hand is being used in order to maintain grip. This is divided into pad to pad grip, tip to tip grip, or pad to side grip.

The biomechanics of throwing. Here is a simple diagram that shows you the several phases of throwing. As you can see from beginning: the wind up, early cocking phase, late cocking phase, acceleration phase, the deceleration phase, and the follow-through. Bear these in mind as we discuss the biomechanics of throwing. The wind up phase. This is the preparatory phase. It usually involves two-legged stance. The arm begins movement towards cocking, there is little or no strain on the shoulder, and any loss of control of balance or stability will cause an increased demand of force on the shoulder.

The cocking phases of throwing can be divided into early cocking and late cocking. In early cocking phase, the arm moves towards full external rotation at 90 degrees of abduction. The external rotators, ie: the infraspinatus and teres minor muscles, are active and thus, store elastic energy. In late cocking, there is strong activity of the internal rotators, ie: the subscapularis and latismus dorsi, to decelerate the externally rotating arm. The glenohumeral joint capsule is stretched anteriorly and rotation wrings the capsule posteriorly compromising the vascularity of the upper rotator cuff tendons. The trunk begins to rotate and medial motion of the humerus, signifies the onset of the acceleration phase.

The acceleration phase. This is where medial rotation and for translation of the arm takes place, ending with the release of the object being thrown. The shoulder remains at 90 degree abduction. The lateral trunk flexes in order to give the appearance of side arm throwing.

The release phase. The arm is parallel to the line of the shoulders. The external rotators undergo eccentric loading in order to decelerate the arm which can lead to overuse or high-force trauma injuries to the shoulder.

The follow-through phase. This is where the external rotators and posterior fibers of the deltoid contract eccentricly in order to decelerate the arm. The serratus anterior and trapezius muscles stabilize the scapula. The forward movement of the arm, medial rotation of the shoulder, and protraction of the scapula are decelerated by eccentric contraction. The long, deep follow through, the arm passes down and across the body so that the hand finishes lateral to the contralateral knee. The shallow, follow through increases contribution of smaller muscles, therefore requires more muscle contraction and flexibility. The trunk flexes and rotates. Weight is transferred to the leading leg, and the hip and knee flex in order to lower the center of gravity which allows larger muscles to assist in deceleration.

The pathomechanics in throwing. There are two noticeable points where pathomechanics can be identified. One, in cocking patterns, and two, in follow through. Pathomechanical cocking patterns can be seen when externally rotating the shoulder too early causes an increased stress on the anterior shoulder as the trunk rotates and the shoulders remain in an open position. It can also be seen where over extension of the elbow in early cocking causes the arm to arrive late in the late cocking position, and the acceleration stresses the rotator cuff muscles. Bringing the arm too far back across the midline due to excessive trunk rotation requires rapid acceleration for the arm to catch up with the trunk, and thus stresses both the shoulder and the elbow.

Pathomechanical follow through. This is seen as a shallow follow through. It increases contribution of smaller muscles and therefore requires flexibility. The trunk flexes and rotates, and weight is transferred to the landing leg. The hip and knee flex in order to lower the center of gravity, which allows larger muscles to assist in deceleration. This large force couple can A, end up in throwing the body off balance, or B, cause muscle injury due to large eccentric muscle contraction?

Thank you for taking the time to learn about the basics of biomechanics.



Part 3_Shoulder Intro Examination and Conditions

English Direct Download PDF ICSC6 Part 3 Shoulder part 1 Intro Examination and Conditions

ICSC06 Upper Extremity Module 6
Part 3 Shoulder Intro Examination and Conditions
Instructor: Tim Stark
Video Lesson: 1:35 Hour/minutes

My name is Tim Stark I have been involved with FICS since I was in chiropractic school, well, over 25 years ago, and have been honored to represent FICS in multiple capacities. My history goes back to being the Chair of the Education Commission. I was the Chair of the Education Commission for almost about 10 years and I was the past director of the Human Performance Center at Northwestern Health Sciences University. The past coordinator for the Northwestern Health Science University Sports and Rehabilitation Continuing Educational programs. Currently, I am involved with a couple of opportunities. One is a consulting service called Stark i3, which stands for ideate, innovate, and integrate. I am the Chief Executive Officer for Back2Life Incorporated, which is an integrated multidisciplinary collaborative clinic system in North Dakota providing primary services to our military veterans and other service personnel. I am honored to be asked to contribute to the International Sports Chiropractic certificate through FICS.

Let us get started with what we are going to be discussing. When I teach and  start off a new topic or a new course, I like to start with an Ipsative Assessment and Ipsative Challenge. There is a long list of questions here, you can stop the video and read the questions yourself, but I want to highlight a few to think about as we are going through this lecture. The questions get a little bit more challenging as you progress through and then end up with more of a practical application, for example. Starting off simply, what joints make up the shoulder complex? Is it just the glenohumeral joint or are there other joints that we should consider? I know you have just completed a refresher the biomechanics module, so we are going quickly run through the biomechanics component of this presentation. In regard to shoulder pain and ranking, where does it rank in regards the low back pain? What are some of the more common athletic shoulder injuries that one might see? Does posture even play a role in shoulder pathologies? In regard to dislocations, how do they typically dislocate? What is the mechanism of injury? If that humeral head is going in a particular direction, which direction does it typically go? True or false. Can Doctor of Chiropractic manage any non-surgical shoulder case? We will talk a little bit about that as we go through it. What are some of the more common pediatric injuries that one is likely to see or are they more likely to see chronic injuries? As a doctor, are you more likely to see traumatic or acute injuries? Is a child athlete more likely to suffer a sprain or a strain? Do you know the answer to that one?

We have some literature as well, some recommended reading for you which is included in this module and I found a pediatric article going back to 2016 that I thought highlighted athletic injury shoulders to pediatrics really well. There are some practical applications, too, in regard to some orthopedic tests and joint manipulation of the shoulder for you to consider. In all of this, keep these thoughts in mind as you go through. There might be some other questions that you might have as we go through this discussion. What we are going to do first of all, in regard to our objectives and this entire shoulder topic, is to break it up into 2 components. This will be part 1 an introduction to shoulder conditions examination, your traditional clinical examination. Then the 2nd part will be more of your functional examination or functional assessment in rehabilitation but, primarily covering everything in regard to our objectives. What we want to cover is we want you to be able to identify what are some of the more common acute and chronic injuries identified in sport. I am sure you can name 3 or 4 of them right now.

We will highlight a few considerations for athletic injuries within the sport, including epidemiology and other mechanisms of injury shoulder examination, again. Clinical examination flow, functional examination flow, do a little bit more of a deeper dive on pediatrics. I think most, maybe a good percentage of chiropractic schools do a pretty good job on covering extremities. It might not peel away the layers and get into our special populations such as pediatrics. Then, talk about some injury risk mitigation and some management of these common mechanisms. We might get into discussions about medical-legal concerns, and some conditions. Then, manipulative therapy and we have some literature here for you to do a deeper dive on the benefits of chiropractic manipulative therapy for shoulder dysfunction.

Anatomy of the shoulder complex. Surely, you should have graduated from chiropractic school and have a pretty good understanding of what the different joints are of the shoulder. These 4 joints are important to address each one of them when you are dealing with a shoulder complex condition. Clearly, we are dealing with 3 buoyant bones forming, these 4 joints. We want to clearly understand that the mechanisms and mechanics, the Kinesiology, and the study of the movement of the shoulder complex can be quite complicated that is why I like it so much. It is a more challenging condition and region of the body, for sure.  I will reference you to the biomechanics module for further details on kinesiology and the study of the biomechanics of the shoulder complex. When we start looking at the shoulder as a moving mechanism and pathophysiology, pathomechanics of a shoulder and managing that. We really need to consider that if you injure the glenohumeral joint, it is quite likely the AC joint, SC joint, and the scapulothoracic physiologic joint, probably is involved as well to some degree. When you are addressing the entire shoulder complex, you would be remiss if you did not look at the entire shoulder complex.  As chiropractors will want to look at the axial components as well as the cervical spine and the thoracic spine.

Let us look at some foundation information, some high-level information. Shoulder pain is responsible for approximately 16% of all musculoskeletal complaints, with a yearly incidence of about 15 new episodes for every 1,000 patients seen in the primary care setting.  That is quite a bit and we have some older literature here and we have known this has held true and the reason why they are listed here as some of the older literature, is just to make you aware that this has not changed. Shoulder conditions and shoulder problems have been prevalent for a long time. An estimated 20% of the population will suffer shoulder pain at some point, within their lifetime. Shoulder pain is second only to low back pain in patients seeking care for musculoskeletal ailments in the primary care setting so interesting.  You might be good at axial skeletal condition management, cervical spine, thoracic spine, and lumbar spine. It would be wise of you to become very good at the shoulder.

I remember on my first year of practice, after I left my residency at Northwestern plus I was playing a lot of competitive volleyball at that time, I saw a lot of my fellow volleyball players. I naturally had a very busy shoulder practice right away from the beginning. But even then, even when my vertical jump started going lower and lower, and I moved away from playing volleyball, I still appreciated a large shoulder practice. Wrap your head around shoulder complaints. Do not just depend on these 2 parts in the ICSC and the current literature being published constantly, be digging into shoulder conditions and becoming very good at managing shoulder problems. Clearly, there is a long list of possible shoulder conditions that one should be considering from acute injuries to chronic injuries, and of course, the list is even more extensive than this, but this will give you some idea of what some of those more common shoulder conditions are. As you are addressing shoulder conditions, we as doctors, need to be very good historians, very good historians. We need to be very good at asking questions and asking the right question. To understand one’s history, we need to be able to ask a question so that we get an answer that helps us clinically reason to come to a lengthy differential diagnosis and eventually, narrow that down into a working diagnosis and maybe a couple of other differentials. But our history is really important, and the history can give us some really good ideas on what may be problematic or pathologic for the patient.


For example, just dealing with the age of the patient, which really is not in history, I guess, it is more of a demographic. But in regard to the age of the patient, if the patient is younger than 40 years of age, we can lean towards the diagnosis of shoulder instability or rotator cuff tendon apathy. If the patient is older than 40 years, we can lean towards a patho-diagnosis of rotator cuff tears, adhesive capsulitis, or glenohumeral osteoarthritis. If they have underlying comorbidities, such as diabetes or thyroid disorders, maybe we are going to lean more towards adhesive capsulitis. If there is trauma, which if we are working with athletes, primarily it makes sense that you were probably going to see more trauma in our offices. If there is a history of trauma, if the patient is older or younger than 40 years of age, we might think of luxation or subluxation and if they are older than 40 years of age, we might think of rotator cuff tears. This is important to complete a proper history and asking the right questions is really helpful for us to understand and come to a working diagnosis. Understanding where the location of the pain is very helpful.

Let us talk about sports participation. Did the shoulder condition start because of shoulder participation? If so, we might think about shoulder instability as one of our primary conditions, and again, this is just very preliminary thinking in our clinical reasoning process. Of course, we are going to do an examination to rule in and rule out. But history really helps us quite a bit to narrow down this long list of differential diagnoses. When we are performing a history, let us say a patient says, “I have left shoulder pain.” As soon as the patient says they have left shoulder pain, we should start thinking of our differential diagnosis and not just MSK, not just musculoskeletal diagnosis. We must consider these zebras and what I mean by zebras, that might not carry over across the waters. There is a saying that if it looks like a horse, acts like a horse, and smells like a horse, it is probably a horse. In other words, if they have been playing football, if they have been playing tennis and they have shoulder pain, it is probably a strain of an injury. But we should consider maybe it is not a horse, what if it is a zebra, what if it is one of these stranger things that could be causing shoulder pain? That is what I mean by we must consider zebras and we have to clearly consider neurological causes for shoulder pain. Myofascial causes for shoulder pain, skeletal or osseous causes, including joint causes for shoulder pain, and visceral and vascular causes for shoulder pain. This picture depicts somebody who has presenting to you with left shoulder pain, it could be a left lung, it could be the heart, or it could be maybe a spleen issues causing left shoulder symptoms. Do not forget that as competent clinicians, as we are managing our patients.

This was an interesting paper published a few years ago in 2002 and it talked about chronic conditions within the shoulder. This paper defined chronic shoulder conditions as symptoms lasting more than 6 months, which is interesting. When we talk about the chronicity of almost any condition, it is maybe 2 weeks or 4 weeks. But this paper talked about how shoulder should be considered to be chronic shoulder conditions or shoulder pathology pain, for example, should be considered chronic, if it is 6 months or longer. We will take that into account whether we agree that 6 months is appropriate for chronic or if you would refer to other references saying something around 2 weeks or 2 months. But nonetheless, the paper further went on then and said, “If they do have chronic shoulder conditions lasting 6 months, we could probably break these conditions down into 6 diagnostic categories.” One being the rotator cuff and other soft tissue conditions such as tendinosis. Second, in adhesive capsulitis. The third is glenohumeral osteoarthritis. Fourth, is glenohumeral instability. Fifth, acromioclavicular joint pathology is ranging from joint brains to osteolysis of the distal clavicle, etc., and sixth being other chronic conditions that are just simply less common. It is an interesting paper, nonetheless. The literature is listed there for you if you wish to do a deeper dive on that paper.

After we perform a history on our patient in our traditional clinical examination, there is a particular flow that I teach my students. I have been teaching this to the undergrad chiropractic students. I have been teaching it to other disciplines when I am speaking to physical therapy students and other providers within the healthcare field. I have been teaching this amongst the sports chiropractic postgraduate level, as well. It is a simple acronym, and it is H-I-P-P-I-R-O-N-I-L-S. If you write that down, HIPPIRONILS, H-I-P-P-I-R-O-N-I-L-S. It starts with history. Then, of course, after history, there is a little silent V that I didn’t mention. V for vitals. We clearly want to take the vitals of our patients. If they do have a cardiovascular event causing left shoulder pain, we clearly want to have appropriate vitals to help us qualify that. Then, I stand for inspection. P stands for palpation. The second P stands for percussion, and we go from least invasive to most invasive by the way, in this examination. History, vitals, inspection, palpation, percussion. Then the next I stands for instrumentation. Then, we have R for a range of motion / O for orthopedics / N for neurovascular evaluation / I for imaging / L for laboratory assessments /S for special tasks. I realize across the languages, HIPPIRONILS may not carry through but nonetheless, you can clearly write this out. Maybe create your own acronym that fits your own language for the time being, but this will really help you with the flow. If you are a younger doctor, maybe you are still struggling with how to properly flow this out. If you are an older doctor, like myself, I still occasionally miss things, and I like to have a system like that to be able to refer back to make sure I do not miss anything.

Let us get back to the slides here. Inspection, normal anatomy and I have an X-ray here and we are not jumping to the I, we are not jumping to imaging. But I generally put an X-ray up first when I am teaching when I talk about normal anatomy. Because I think it is important to know that when we look at a picture such as this when we have a patient in front of us, they have hills and valleys. Some of these hills are created by osseous structures, it is not necessarily swelling. The reason why I put this here is we cannot forget about our anatomy when we are looking at and inspecting our patients. We want to make sure that we understand what normal anatomy is and where these hills and valleys are created. For example, the valleys above and below the clavicle, and the hill that is created by the clavicle itself. When we are evaluating our patient with a normal posture and it is about as normal as I could find when I was searching for normal postural pictures, we are going to see quite a few abnormal ones here in the upcoming slides. We want to make sure that the shoulders maybe are close to average height. The head is in a normal plum, not laterally flexed, not rotated, etc. Clearly, you should understand inspection well.

This is not an uncommon inspection finding. I have seen this, especially in my younger athletes as they come in and they are just apathetic to life sitting on your table, not really wanting to be in your office, in the first place and so, they tend to slouch. Then, they go into this increased thoracic spine kyphosis, increase cervical lordosis a lot of cranial extensions, and maybe anterior carriage of the head. That are all real typical things that we see but let us point at the shoulder here for a second.  If you look at the acromion process just on the end here. If you look at my mouse here, the acromion process and if we look at how the acromion process is really close to the manubrium, as compared to how far it is from the CT junction. We put them in a proper posture which we consider maybe to be a little bit more proper. We have the acromion process now, which is pretty centered right in between the manubrium and the CT junction. That is one of the things that I look for when I am looking at a patient from the side in regard to shoulder position. What would cause this? We know that is probably scapular protraction. Scapular protraction that is causing our shoulder to round forward. Therefore, we have a lot of apparently lengthen tissues posteriorly and aberrantly shortened tissues anteriorly. The glenohumeral joint will likely respond or compensate to the scapular protraction by externally rotating. Let me say that again, a humorous, oftentimes compensates to the scapular protraction by externally rotating. If they maintain this posture for a long period of time, we can maybe imagine as well, that the posterior capsule is getting shorter and shorter and shorter. Therefore, we may need to be able to consider some interventions to manage that. More postures, typical where we see a decent posture versus an aberrant posture and where that glenohumeral joint and that acromion process is positioned in between the manubrium in the CT Junction.

Let us look at some front views. Here we have a couple of individuals as they are standing. If we look from head to toe, toe to head, we can clearly see a lot of asymmetries in these individuals from the angle of how they are towing in or towing out from the bottom up. We can see maybe some differences regarding their knee positioning and their pelvic height. If we look at the spaces between the elbows and the ribs, comparing left to right, we can see that there are some differences. For example, on this one here, we can see light all the way from his axilla back to down to his wrist. As compared to the other side, we just do not see that. That may be a good indication that he has scoliosis. As you can see, he is not plum as well, his sternum is shifted to the side. He clearly, most likely has some sort of involved scoliosis. Then, we ask those questions. How does that play a role with shoulder complex function? If they have scoliosis, it is going to affect them. We are going to talk about a case later when a scoliosis is significantly called the cause of dyskinesia of the shoulder complex. We do know that postures just are not static, like the previous pictures we have just looked at. Especially in athletics, postures are quite dynamic. A dynamic posture from doing crazy things of bending over backwards from their spine to pulling and pushing people in particular sports. Of course, these younger athletes and college athletes are going to school and if they have vision issues, that could clearly affect how their functional posture is being influenced on a day-to-day basis. We want to ask those historical questions about what sport are they in? Are there particular activities within their sport that seemed to exacerbate things? What about school? Is it worse with school, etc.?

Let me start asking you some questions and let us play a little bit of a game here. This posture is typical of what we might see in a younger lean athlete. At any point in time, you can stop the video and just take a longer look at some of these slides. Take a look at this picture and write down a few things of postural issues that you might see. We are making some predictions, as to some of these postural things that you see. This would be a good thing to consider writing.

Let us take a look at what we might see. We see clearly, a bit of space between the right elbow in the ribs and that base is quite a bit larger on the left-hand side. That might be indicative of scoliosis or at least, some sort of posture and maybe an intelligent posture influencing this patient’s view. We can clearly see that he is got scapular winging on the left-hand side as compared to the left and what indications might be involved with that. I know many of you are probably thinking that the serratus anterior is weak, but we cannot make clinical determinations of motor weakness or motor strength based on posture. If we are making a clinical indication that a muscle is weak, it has to be tested for strength. You just cannot look at a particular muscle and make that determination of strength or weakness. Yes, we can maybe make that prediction that the serratus anterior might be weak. Therefore, the next thing down the clinical examination flow at some point in time is maybe to manually muscle test or use a handheld dynamometer to test the serratus anterior to quantify it. Some other considerations in regard to some postural gases or predictions of this might be maybe his pec minor is chronically short and that is causing an anterior tilt of his scapula. It is only a prediction, a guess. Therefore, the next thing we do is go palpate that pec minor, maybe do some range of motion and see if that pec minor is short. But we can make a fair number of predictions based upon what we see in a postural examination. Here is a youngster with sprinkles deformity and again we can see that his scapula is quite elevated on that one side again. Then, therefore, elevator scapula is probably chronically short here. The upper trapezius is probably chronically short. Maybe mid to lower trap is chronically long, etc. so, are we going to make much for changes in these types of conditions? Maybe you can, but if anything can help this individual manage some ongoing discomfort that they might be experiencing.

When looking at inspection and common conditions that we see in athletics, seeing an AC sprain is pretty common, especially if you are dealing with collision and contact sports. AC sprains, I like this picture because we can see what he looks like on our gross anatomy view as compared to what he might look like on his radiographic imaging. Here we have on his R-view in right, his left shoulder, we see an AC joint that looks fairly healthy. Just a little bit of a bump, you can see that maybe he is a little bit older. Maybe he got a little bit of osteoarthritis there. When we look at the right-hand side, if we can see the skin shadow and feel free to pause this and blow it up if you need to. If you look at the skin shadow, you can see that it is significantly different as compared to his other side. If we were to take an X-ray of this individual, which I clearly would advise you to because a fracture could be involved, we will talk about that later. We can clearly see that this is a grade 3 AC sprain, maybe even more significant than that. But at least a grade 3 AC sprain, which we were going to talk about on the next slide, these different grades. We can see that the integrity of the acromioclavicular joint and the coracle clavicular joints are disrupted.

Let us talk about the different grades of AC joints before moving on past our inspection. We have a normal healthy scapular shoulder complex on the left-hand side. Now, typically, and quite commonly, we talked about 3 grades of AC sprains. We generally rarely talk about grades 4, 5, and 6. But we generally talk about grades 1, 2, and 3. Grade 1, would be a mild sprain of the AC joint. The AC ligaments are still intact, and we would not see an elevation on our gross inspection on a type 2 AC sprain. The acromioclavicular ligament is disrupted as we see in this picture, but the coracle clavicular ligaments are still intact, which is maintaining a healthy position of the clavicle. In these type 2 sprains, there is still not any elevation of the distal clavicle. However, if you take a weighted X-ray, which is the second step of taking these anterior views of AC sprain diagnosis. You take an unweighted X-ray, you take a weighted X-ray, especially if there is no elevation. If there is elevation, you do not need to take away the X-ray, it is already unstable. We will get to that here in a bit.

The reason why we take a weighted X-ray is to determine whether it is a type 1 or type 2. If we weigh them, we strap, we do not have them hold on to a dumbbell or a bag. We do not have them hold on to it because the increased muscle tone potentially will increase the muscle tone of the shoulder which could cause a false stabilization of the AC joint. We want to hang it, we want to strap it around the wrist, and we want a fair amount of weight literature as variances on how much weight we will put around the wrist. It will depend on whether it is a child, whether it is a grandma and grandpa, or a 28-year-old athlete. We want to weigh them and distract the entire shoulder complex inferiorly. If we see an increased gapping of the AC joint, as well as the distance between the clavicle and the coracoid in an X-ray, then we can assume that there is a type 2.

Then, grade 3s. Grade 3 AC sprains, as we saw in the previous picture, this one right here. Clearly, when we look at that, that patient in our gross anatomy evaluation, we are going to see that the distal clavicle is elevated. We again, want to take X-rays. You do not need to do weighted ones for a grade 3 because we know that these ligament structures are disrupted because we can visibly see an elevation, but we do want to take an X-ray because trauma was involved. One of the more common indications, especially for sports chiropractors to take an X-ray. Because of the trauma, there could have been a fracture involved as well and I will show you an X-ray or a case later.

What about these other 3 types of AC sprain? We have type 4, where it is significant or severe. Sometimes these types 1, 2, and 3 AC Sprains are referred to as mild, for type 1, moderate for type 2, and severe AC sprains for type 3. A type 4 is a severe AC sprain, but the clavicle migrates. It migrates posterior, so there might have been a force from anterior to posterior and locking almost the clavicle on the posterior aspect behind the acromion process and sometimes within the belly of the supraspinatus and the trapezius muscles. Type 5 is a significant separation. We can see this high elevation, the distal clavicle, the SC joints are often involved with a sprain of this, and the scapula is depressed, quite significantly. I have seen one of these. It was a snowboarder who was snowboarding in Montana and he had a significant injury, he fell on his shoulder. His shoulder was very depressed at the point, at the acromion process, and the clavicle was quite elevated. He went to the emergency room and the emergency room doctor told him that his clavicle was out of place, and he needs to see a chiropractor have it put back in place. Of course, I have never seen this gentleman before, but I had seen his wife before, so his wife recommended myself. He came in, and he told me a story, I took X-rays just to rule out fracture and I said, “This is not something that can be adjusted. That may involve surgery.”

We will talk about AC sprains and how to manage them. This was a case that I saw almost 20 years ago. Back then, we were still doing surgeries for significant AC sprains like this. Type 6 AC sprain. This is where the distal clavicle again, has a severe sprain, a severe tear of a distal clavicle, and a clavicle migrates anteriorly and may get locked underneath the pec minor depending on the mechanism of injury. You can imagine that if the elbow or the shoulder was in horizontal extension and abduction that the clavicle could migrate anteriorly and become lodged under the pec minor. Just to review 6th grades. The first 3 are the ones that you really need to wrap your head around. You might see a type 5. Otherwise, I have never seen the type 4, type 6, and probably never will.

When I am taking films of my patients, sometimes I do a left film or a right film because I think it is important for me to understand and be able to compare and contrast the different joints because sometimes they do look uniquely different, especially in my pediatric films. But one of the things to consider when we are looking at these films is that when the underside of the clavicle if you follow that, it should go almost straight to the underside of the acromion process. As compared to the AC sprain joint, there is clearly a step in this indication. I do not know if these are weighted films. If they are weighted films, this could be a high grade, too. I am guessing, It is not weighted because it has no mention of this film being weighted. It is probably a grade 3 AC sprain.

Here is another case I want you to consider. This was one of my patients quite some time ago. He is a high-level volleyball player and he presented with ongoing right shoulder pain especially after striking a volleyball. He was right-handed. I want you to write down a few things that you see. You can see that there is a fair amount of space different from the left side to the right side, it is a little dark on this side, but you must take my word for it that there is quite a bit of a larger space in the right side compared to the left. That could be an indication of scoliosis. There is another indication of scoliosis on this picture, and it is skin folds. If we look at the skin fold on the left-hand side, we have one major skin fold and a real minor one here. If you look at the right, we have a smaller major one here. More of a major one and another major one. You clearly see there are more skin folds on one side than the other, another indication of scoliosis. Not to mention that his shoulder is lower on the right side than the left. But he is right-handed and so, it is not unusual to see the dominant shoulder being a bit depressed as compared to the left-hand side. What else do we see? Some people talk about hypertrophy here, which is not hypertrophy what the problem is, I am just being a little trickery here with you. The infraspinatus is atrophied. We have atrophy of the infraspinatus and again, he was a high-level volleyball player, a very fit individual, and not uncommon to ballistic overhead athletes. Such as picture volleyball players may develop a cyst in the suprascapular notch causing atrophy and diminished axonal flow of the suprascapular nerve. This is not an uncommon finding, this is infraspinatus atrophy. Again, ballistic overhead athletes. This individual complained of chronic right shoulder pain, especially after striking a volleyball and it turned out that before he came to see me, he went to go see an orthopedist. An orthopedist did an MRI, and they diagnosed him with a full-thickness rotator cuff tear. A full-thickness rotator cuff tear. We are going to come back and visit that term in our conditions about a full thickness rotator cuff tear and what does that mean.


Long story short, we are able to treat him, he was scheduled for surgery. He was supposed to have surgery within a 2-week period, and I had mentioned that I would be happy to give him another opinion or help him out. Well, at the time of playing volleyball with him, he said that he was cool with getting that surgically corrected and he was going to move in that direction. Well, about 3 days later, I missed a volleyball practice, 3 days later, I see him in my practice the next day and I thought, “Oh, he had a change of heart. He just wants another opinion.” Well, he came in my office with a cast on his left hand. In the practice that I had missed, he went up to block and while he was blocking, he took a volleyball strike right on the end of his finger, shattering part of his hand. Here, he was going to be in a cast now on the left-hand side for 4 to 6 week and then they sling and swathe if he had this surgery on the right hand. It is hard to take care of grooming yourself. If you are unable to utilize either of your hands, so he postponed the surgery for at least 4 weeks up to 6 weeks, and I am talking about the rotator cuff surgery. He said “I am all yours for 4 weeks. Let us see what you can do.” Well, after about 2 weeks of care, we cancelled his rotator cuff surgery because he was doing so well. We will talk about why he responded so well. It was not because I did great care. it was because it was a particular type of injury that maybe at that time, probably would not have responded well to surgery anyway and probably would have responded better to conserve care, which is what we did.

What do we see in this case? You can pause the video here. But if this individual came off a football field hockey and there was some trauma involved, you might consider a few diagnoses. Here are some considerations. What we see is he is holding this arm so, this right arm is probably the injured side. There are going to be some and clearly, there are some differences on that right side compared to the left side. Some of you know right away what it is but if you have not seen this walk up to you, you might still wonder what is going on. Some considerations, look like his pec is different than the other side. Yes, maybe, but that is not the problem. What about a clavicle fracture? Yes, maybe, but that is not quite the problem. Some things to consider here is he is got a bit of a sulcus sign underneath the acromion process. The acromion process is very prominent compared to the other side, he has a bit of a sulcus sign underneath the acromion process.

This is a real typical presentation of a glenohumeral luxation. A glenohumeral luxation. Most likely, the humeral head dislocated anteriorly and inferiorly. It is probably sitting underneath that coracoid process and that is why we have this vacancy right here. If you were to go in and palpate right here, the humeral head just would not be there as compared to palpating underneath the acromion process on the other side. If you were to palpate anteriorly, you would palpate in the osseous structure there, where you would not find that same osseous structure underneath the left side. This individual most likely has a glenohumeral dislocation or luxation. Something that we want to do certainly on inspection, is to palpate. We have already talked about some palpation findings already. One of the things that we want to palpate is this space right here, the lateral deltoid. We want to just lightly touch it and make sure he has sensation there and then touch both sides and make sure that the sensation is equal. If it is numb here, if he has diminished sensation there, that could be silver dollar sign. A silver dollar is a structure about this big, about 2 to 3 inches in diameter, and the axillary nerve provides sensation to the lateral deltoid in the space. If he has a humerus fracture, either with or without luxation, he would likely have what is called silver dollar sign diminished sensation. That is one thing that you always want to do before you do much more of an examination. If so, you sling and swath them and you get them off to a hospital somewhere. The next thing regarding inspection and palpation is palpating for distal pulses and making sure he has distal pulses on the radial pulses. Make sure he has a capillary refill, and he has a good station in his fingers.


On palpation so, remember these HIPPIRONILS, after inspection now, we are going to palpate. When we are palpating, we want to palpate soft tissues and we want to palpate osseous tissues. Clearly, when we are looking at the SC joint or looking at their shoulder complex, we want to palpate the SC joint all along the clavicle. In the AC joint, osseous structures of the rest of the shoulder complex, and all these soft tissues, including the soft tissues that are within the axilla. It seems like some doctors tend to skip opening that axilla and palpating the axilla in the structures within it. There is a lot that could be going on in that area and that could be causing your patient’s shoulder pain. Palpating is important. You are going to find that when we talk about orthopedics a little bit that palpating the AC joint, for example, we can see that this individual clearly has a grade 3 AC sprain. This is going to be tender, and palpation of the AC joint is one of the most sensitive tests. When I talk about sensitivity and specificity, it is one of the most sensitive tests we have, but it is not very specific to anything, and we will talk about that when we get to this slide.

Same with this patient, if you look on, if you want to blow up the picture, you sure can. But when we are dealing with a case such as this, which is a rather rare case, and you can see that he has a fracture of the distal clavicle. It is not commonly fracture. If the clavicle is going to fracture, it is usually that middle third. But here we have a distal fracture, and it is important to take an X-ray when we have trauma. This reminds me of a case that I had when I was in Mexico in 1998 for the all-Mexican Juvenile Olympic Games. There was a young girl that came in and she was not happy. She did not speak any English and I did not speak any Spanish. I was depending on a Spanish-speaking Mexican physio to help me and as we are trying to find the lower pain, I asked where it was, and she pointed to the AC joint.  I want to start a little bit away from it. I was palpating the SC joint and working my way up to the clavicle and when I got to the distal clavicle vast when she did not like me to palpate that area.  AC palpation is highly sensitive, but it is not very specific. What does this mean? The mechanism of injury was that she was pushed and fell on another body, as well as her body fell onto her shoulder so, that is a lot of mass. She does not recall and hears any popping or clicking sensations at the time of the injury. It was hard to get that translated through anyway.

With this individual, she had exquisite AC tenderness. One would think for sure; an AC Sprain and it could be a grade 2 because I do not really see a lot of elevation. We could do a weighted X-ray, but I continued with my examination. I went to percussion. When we percuss, we do not want to percuss directly over where the pain is because we already know that it hurts. We want to percuss elsewhere. We want to create an osseous vibration. I started percussing down at the SC joint and when I percuss down here, she said it hurt. We must clearly ask where it hurt. Did it hurt where I percussed? She said, “No, no. It hurt to back up in here again.” I percuss on the other SC joint and there was no radiation to the AC.  I came back to this one and percuss it one more time. It is always okay to do a test twice, just for confirmation and sure enough, it hurt here. Then, because she had percussive pain, if she had an AC sprain, percussion probably would not hurt. But if she had a fracture where that periosteum is involved, and the vibration is going to be very nociceptive. It is going to be very toxic and noxious to nociceptors. I am leaning now more towards a fracture and so, we sent her off. This is the end of this Mexican athlete’s story. I send her off to the medical doctors to take an X-ray. The medical doctor said, they looked at her, they hardly touched her because I heard from the coach later. They hardly touched her, and they said, “No, she does not have a fracture. She does not need X-rays. Go back to the physiotherapist”. Thankfully, the physiotherapist, they saw was the physiotherapist that I had helped me translate.

I see this athlete coming back, she is still unhappy. The coach is now with her, and the coach is mad. I went over to the physiotherapist and said, “What is going on?” The physiotherapist translated back to me saying that the medical doctor thinks she just contused her shoulder, or maybe sprained it, and does not have a fracture. I looked at the physio and I said, “Do you agree with me or do not agree with me that she likely has a fracture?” The physiotherapist said, yes. The physiotherapist then referred to the medical doctors again for a diagnosis of fracture. They finally did take the X-ray, and this is almost an identical X-ray of what they found, is that she clearly did have a fracture. Now, when she came back, she and the coach were very happy. She was not all happy because they know what the problem was. They caught a bad injury, and she was in a sling and swath, and she was out of the games for the rest of the week. I was unhappy in that regard, but happy that we insisted on having an X-ray taken.

Your HIPPIRONILS flow instrumentation is something to consider, we can quantify pain. This image here, I granted this is not a shoulder, but you can understand that we can use this algometers. A device that measures and quantifies pain for a patient. Another way of using instrumentation is assessing for proprioception and we are going to demonstrate that in our rehabilitation part 2 of the shoulder case and then measuring girth. One example, and I am not really impressed with this orthopedic test, but there are orthopedic tests available saying that if you think your patient has a shoulder dislocation, you should take a tape measure and wrap it around the glenohumeral joint, and if this is larger than the non-injured side, they are probably dislocated. It bothers me quite a bit because I think if you are a competent clinician based on history, inspection of your patient, and some palpation, you should be able to identify that the glenohumeral joint is dislocated. You should not have to measure it. It is a lot of unnecessary movement of that shoulder to get this measurement where you could be reducing that shoulder at a much earlier time. But nonetheless, this is an example of instrumentation taking a cloth tape measure and measuring girth, so you can measure around the bicep as well for identifying maybe chronic thoracic outlet syndrome.

Moving on to the range of motion. When we perform a range of motion, we want to perform an active range of motion, first. Then, passive range of motion, and then maybe resisted range of motion. Once we start adding all that together, we are  performing O’Donohue’s test for the shoulder. Biomechanics again, I am going to refer you to the biomechanics module for what normal motion from the range of motion of the shoulder should be. But let us talk about a case here of abnormal shoulder. Let me turn off the volume. She has a normal range of motion on the right-hand side and if we look at the left-hand side, that does not look very normal. Let us go back and watch that one more time. On the right-hand side, she has a normal range of motion and a full range of motion. On the left-hand side, you can see that it is quite rough, and I just want to stop that right there. If you want to again, stop the film and write down some ideas and what you think your differential diagnosis would be, feel free to do that.

Some of our differential diagnoses of this athlete that we saw in Australia at our student clinic there, and we publish this case. Dr. Sivar and myself, along with some others at Murdoch University published this case. It is about a high school rower who had significant scoliosis as she was going through her adolescence. She ended up having this dyskinetic shoulder. One of the things that I do now for my range of motion assessment is I perform a range of motion like you just saw. Then, I add a second component. If I see dyskinesia or if I have a patient reporting pain during the range of motion, I then asked the patient to perform the range of motion again, but I have them co-contract or co-activate that region. For this patient, I had her co-contract her shoulder which involves conscious contraction of several different muscles. The entire rotator cuff complex, the mid trap, and pec minor. If we can track pec minor appropriately, it should turn down the tone a little bit and I hate saying that term, “turn down the tone” but it tends to make sense for most people. If we are contracting pec minor appropriately, it tends to diminish the tone of the upper trapezius and we do not get as much hip shoulder hiking. But let us look at this again. We have a normal range of motion, and we will let it play out this time. We have a dyskinetic shoulder. We are going to have her co-contractor shoulder and it is almost normal. It is almost normal, so, we will probably revisit this case when we talk about rehabilitation in part 2 of this section. But this tells me that this patient is probably an ideal candidate for rehabilitation. Even though our differential diagnosis included dysplasia of the humeral head and dysplasia of the glenoid process, maybe her [inaudible] and her shoulder luxating or subluxing and reducing again, spontaneously. We took X-rays and if you read this case, if you go on PubMed and you type in Stark T, you will see where we publish this case, and you can see other videos including a fluoroscopy. We will talk a little bit more about that reference.

Then, we get in the orthopedic evaluations. Orthopedic evaluations. Man, there are so many tests that we can do for the shoulder. There is clearly a shorter list that we should be focusing on. This is just a short list that I generally tell my undergraduate students when they are taking the American boards. Just focus on these because these are  the key test that the boards are focused on. Not necessarily the best test out there based upon sensitivity and specificity, but this is what the boards tend to focus on. let us look at how we can identify what the best tests are. You are done with chiro school, you should have gone through orthopedic evaluation tests and hopefully, your instructors taught you about the sensitivity and specificity of assessments. Earlier, we are talking about acromioclavicular sprains, and we talked about palpation of the acromioclavicular joint. If they have tenderness at this AC joint, you can see that the sensitivity is almost perfect. It is 96% meaning, there is something wrong if they have tenderness at the AC joint 96% positive, 96% likely that there is a problem there, some sort of condition. But you can see the specificity is only 10%. In other words, there is a problem there, but we just do not know what it is. It could be an AC sprain and different severities of it. It could be osteolysis of the distal clavicle. It could be OA. It could be a long list of things. This is an example of how to read and understand sensitivity and specificity, and likelihood ratio. With likelihood ratios, we want to test it above one. But if it is way above one, like the lift-off subscapularis tests, often referred to as Gerber’s lift-off test. You can see that it has a relatively okay sensitivity, but a good specificity. In other words, if they tested positive for this lift-off test, the likelihood of it being a problem is a strain or a tear of the subscapularis muscle. The likelihood ratio was high in that particular case. We do not want to get into research too detailed. You can do some more reading on your own about likelihood ratio, sensitivity, and specificity.

We are moving into the neurological or neurovascular component of our assessments, and this is where oftentimes, I might perform muscle testing. Manual muscle testing or using a hand-held dynamometer, H-H-D, hand-held dynamometer. You can see in the pictures that the provider here has the device that’s between the stabilized patient and this patient pushing up, assessing shoulder abduction. This is a case where this instrument can measure and quantify how much force a person is able to produce an abduction compared to the other side. There are just several different positions here for internal rotation and external rotation. If you look in the mirror here, you can see she is performing a Gerber lift-off subscapularis test, but the doctor or the providers measuring how much force they are able to perform. In this picture over here, we talked about serratus anterior with some potential weakness if we see some medial border winging of the scapula and so, this is an example. There are many ways of testing serratus anterior. I find that this is more of an accurate way of testing it from my own experience. But it is hard to demonstrate that in this type of didactic lecture. Hopefully, if you have questions about that, you can either shoot me an email and I will give you my email here later. Or maybe see you at a hands-on lecture at some point in time.

In the neurological evaluation, we want to do sensation assessments for peripheral nerves and our spinal nerve roots and you should be able to have a good understanding of that already. Then, we move into imaging, if there is trauma, I take X-rays. It is pretty rare that I would have an athlete come in, complaining of a history of trauma. They have shoulder pain and did not take an X-ray. 9 times out of 10 for sure, I am going to be taking an X-ray especially, if they are youngsters and we will talk about why when we get into a pediatric lecture here in just a few minutes. But, this is an X-ray of a youngster and we can clearly see that there are some growth plates here. When it comes to the shoulder, some of the latest closures of joint spaces or growth plates are within the shoulder complex. It does make a complex for us to come to a diagnosis conclusion of whether there was a fracture there or not. Then, as we finish our HIPPIRONILS flow, performing laboratory tests might be appropriate for some of your patients. Especially, if they have particular conditions that we think are causing shoulder complications such as gout and maybe they have an infection. Maybe they have some sort of crystalline appetite deposition disease, or maybe diabetes, rheumatoid arthritis, and then a special test. Special tests are one of the last things I do. It is to where I perform my motion palpation of the shoulder complex. Sometimes, I save my muscle testing in my handheld dynamometry for this and some other fitness types of tests.

To conclude this part 1, let us talk about some common shoulder conditions. We are about maybe two-thirds of the way through this part 1. Let us talk about AC joint injuries. We already talked a little bit about them in the different grades. You should remember there are 6 grades, and 3 more common ones. But typically, let us go through a few bullet points about AC joint injuries, as being one of our more common sports injuries. Historically, usually, there is trauma. Especially, to the point of the shoulder either hitting somebody or landing on the ground or the pitch causing an AC separation. Sometimes, there is overuse of an injury-causing this AC sprains FOOSH fall on an outstretched hand. If the acronym does not carry over across languages, FOOSH mechanism is a fall on an outstretched hand that could cause an AC sprain. Oftentimes, athletes might come in and say, “I was diagnosed with a separated shoulder.” When they talk about a separated shoulder, they are usually talking about an AC sprain. When you are looking at the athlete again, we talked about a step deformity. If we see a step deformity what grade could it be? If we see it, it is probably a grade 3 or worse. If you do not see it, it could still be a grade 1 or grade. What do we do to differentiate the two? We take an X-ray, a weighted X-ray. We are always going to take an X-ray on an AC sprain anyway. We are going to take a weighted X-ray if we do not see step deformity because we need to differentiate between grade 1 and grade 2.

With palpation clearly, there is going to be a lot of tenderness at the AC joint. We talked about how sensitive that is. There may be AC laxity. I am not really a fan of this bullet point. Because if they have some significant tenderness of the AC joint, they are not going to let you get in there and wiggle it around and identify whether there is laxity there or not. We want to take an x-ray and we want to weigh it if we think that there might be a grade 2. In regard to managing it, PRICE it. Now, I know the PRICE. Protect, rest, ice, compression, and elevate. It is an acronym hoping it carries across through languages but in case it does not, PRICE stands for Protect, Rest, Ice, Compress, and Elevate. I know some of you are probably rolling your eyes that we do not PRICE or RICE anything anymore. The reason why we have navigated away from it in literature, is because of the Icing, and it does not make sense to ice for inflammation management for an injury. I agree, I do not think I have ever iced for inflammation management. I have generally applied ice for pain mitigation. When it comes to evidence for ice for pain mitigation, the evidence is still good. We know from contemporary literature that icing for inflammation management maybe is not that good. So, I still tend to lean towards PRICE in it, especially with acute injuries and we want to protect it.

This is an example of a Kenny Howard or a modified Kenny Howard brace where we have got a weight over that injured AC joint. The arm is being supported upwards. There is tension in this band right here. Pulling the arm upward so that we can unweight the scapula and put more weight because of this strap over the top of the distal clavicle. I used to recommend these quite a bit. Then, I would tape, as well. When they are in the shower and they must take the Kenny Howard off and sometimes even sleeping, the tape would do some work to keep that AC stable. The reason why I did that was I was optimistic, keeping my fingers crossed, optimistic that maybe that clavicle will settle down. Maybe it will heal back to the acromion process and after almost 30 years of practice, I do not think I have ever seen a distal clavicle heal back to the acromion process where there was a lot of stability.

The last 10-15 years, I have told my AC sprain, especially my grade 3s, my athletes who have had a grade 3 AC sprain to just understand that they’re probably going to have an ugly shoulder for the rest of their life. That shoulder is probably never going to look even again and if you get that in their head and just have them have some sort of comfort level with that, they tend to tolerate the fact that that is probably going to be the outcome. We will keep our fingers crossed that they do have some stability, but it may not happen. These types of braces though, I have noticed that throughout the day depending on what are doing throughout the day, whether they are a student or they are going back to work, it does provide them with some symptomatic relief. It may not help close and bring that clavicle down and encourage healing there, but it does seem to offer some symptomatic relief.

Back in my earlier days, like this snowboarder that came in from Montana with this class 5 AC sprain. He did go in and he had surgery for that. We are not suggesting surgery much nowadays, but that was 20 plus years ago, 25 years ago. Back then, we are just finding that the long-term outcomes regarding chronic pain and overall function are just not that great. But historically, if you are looking at old x-rays of somebody, you might see pins, you might see other types of stabilizing bars, you might see K-wires, and you might even have a history where the bicep tendon was split off and ran up through the coracoid process into the clavicle. There is several different ways in which these have been stabilized. One thing I have done is to create protective pads for some of my players, especially my ice hockey players. My ice hockey players, not uncommon, they go to check somebody, and they end up spraining their own AC joint. I have never applied a pad like this, this just looks horribly uncomfortable having a strap underneath your armpit. But what I have done, is created a similar-looking pad just with a cushion and cut out a hole, a donut where the AC is. Then, I might place a couple of them on top of each other to create some thickness, and then, the ice hockey pads would go over the top of that and it would prevent the ice hockey pad from rubbing on this elevated clavicle, which really did help substantially and got my guys back to playing hockey faster.

Clavicle fractures are very common in athletics. As we mentioned earlier, common location for these fractures to occur is the middle third because the lateral third and the medial third are stable regarding all those ligaments stabilizing it. Back in the day as well, there used to be a surgical intervention to help stabilize this, and then after that or even less severe clavicle sprains, a Figure-8 brace. I have put several athletes in Figure-8 braces. Now, that the current management is to put them in a sling and swath and that is it. The Figure-8 braces seem to not be that much beneficial to these individuals’ clavicle fractures. If you just sling and swath them after a couple of weeks, they start developing some stability if they are being good about limiting their motion.

Glenohumeral instability is very, very common, especially in our younger athletes. Let us talk a little bit about glenohumeral instability in the different components of them. They may have unidirectional instability or multidirectional, meaning the ball and socket will just move in one direction and have just instability in one direction. Multidirectional means, that it is unstable in a lot of different directions. In the old days, we used to talk about acronyms for unidirectional and multi-directional. Let me go back. TUBS, Traumatic, Unidirectional, Bankart is what the B stands for, and S stands for surgical. A TUBS injury was usually a result of a traumatic injury and usually resulted in a luxation or a dislocation. As traumatic, unidirectional, and unilateral meaning one shoulder, and a Bankart lesion were not uncommon. I will show you Bankart lesions here in a bit in regard to dislocations and might require surgery to correct that.


The other option or other consideration for instability of the shoulder is an AMBRE. Where A stands for atraumatic, M stands for multidirectional, inferior, anterior, posterior instabilities, B stands for bilateral, R stands for rehab. This patient tends to respond better to rehab than those that have luxated and I can speak eloquently to shoulder dislocations in a second. Then, I stand for an inferior shift. If the athlete responds poorly to rehabilitation, they may require a capsular shift which is done surgical to stabilize that shoulder. Anterior and inferior is the most common direction, in which the humeral head dislocates or has instability. Excessive range of motion or a FOOSH fall on an outstretched hand is a common mechanism for an unstable shoulder. It can easily become chronic and a dead arm syndrome. A dead arm syndrome, when I was playing competitive volleyball, I had dead arm syndrome for quite some time until I went through some rehabilitation. But every time I would go up and strike with my right hand, especially if I was playing the right-hand side, and I would have to turn my hand in, to cut down the line, and if you play volleyball, you know what that means. My arm would go numb, and I was hoping that I scored because then we could probably stop until I went around and assume the serving position. But a dead arm position might be indicative of a chronic thoracic outlet syndrome or other chronic conditions within the shoulder complex.

A deep dive and a lot of clinical examination are necessary to identify the problem with this individual. The patient might report a popping sensation when the mechanism of injury occurs. It could be a subluxation or a luxation. As we have described earlier, we will talk about luxation later. When you observe this patient, the patient might move when they walk, they may not swing their arm as much on that side. When they are going through ranges of motion again, they are going to be probably limiting their motion. When we take an x-ray of somebody with an unstable shoulder, especially if they have a history of a luxation, they may have what’s called a Bankart lesion and or a Hill Sachs lesion. Two common fractures. If there was a test after test, this would most likely be one of those test questions. But the 2 more common fractures are associated with luxation of a shoulder complex, particularly the glenohumeral joint. Then palpating, when we are palpating the rotator cuff insertions, it might be rather tender. How do we access the rotator cuff tendon, I’m going to stand on my tippy toes here a little bit if we internally, rotate our shoulder. We are internally rotating; I have my hand behind my back right now. The very front part of the humeral head is where the rotator cuff conjoined tendon tends to insert, is right in that general area. That area might be rather sensitive. We clearly want to assess the shoulder in multiple directions, and we want to test distal pulses and sensation to rule in or rule out some other nerve complex complications.

You may want to stop and write down these YouTube video URLs. These videos represent several glenohumeral dislocations. If you are a little squeamish, you may want to pass looking at some of these videos. But there are some ways of reducing these shoulders that are better than others. One way is the Coker maneuver, so it is this one right here. They refer to as the Cunningham technique, but it is referred to as a Coker Maneuver. Almost every shoulder that I have reduced with the exception of my own shoulder dislocation that I had about a year and a half ago, almost every other shoulder dislocation I have ever reduced, was done through this Coker Maneuver and so take a look at this. This is done in a clinical environment. Some of them are done out in a grassy area or in the basement of a house and so keep in mind that some of these, and I put little comments on here about horrible patient movement and this technique I would not recommend it. If you have time to only watch one video, clearly watch this one. This is probably the clinical technique that you would want to consider.

Regarding Chronic instability, some clinical things that we tend to see is the sulcus sign. Here we have an individual. There is a downward pressure on the humerus. The clinician here is just pulling down on the humerus and we see the humeral head being pulled in inferiorly, so if you have the acromion process here, the humeral head is being pulled inferiorly, which creates then a vacuum or a sulcus, right where the arrow is. This sulcus sign is maybe indicative of chronic instability. Here we have a Hill Sachs lesion which is a little hatchet formation or fracture of the humeral head and here we have a Bankart lesion which is the anterior aspect of the glenoid process and as that humorous was being forced anteriorly, it tended to take a piece of the anterior glenoid process. In this view, we have the Bankart lesion and here with posteriorly, we see the Hill-Sachs deformity. In fact, there is two of them and there are some theories in which these Hill-Sachs are formed. One theory is that as the humeral head is blasting past the glenoid process when it slams back into the glenoid process, that causes a fracture. Well, I do not know how far that humeral head must go forward for it to slam back. It just seems a little ludicrous if you ask me. Mine certainly, didn’t do that. I think what more likely happens is these Hill-Sachs deformities are more likely caused from a chronic luxation. It was left out of joint too long and the athlete might have been moved around a little bit in which the muscles are in spasm, the ligaments are trying to hold it tight and therefore this part of the humeral head is grinding on the anterior glenoid process and that’s probably causing little micro fractures of the humor head. It is my own theory. I have read another literature as well as it being a possible theory rather than this dynamic recoil.

Let us talk about SLAP Lesions. SLAP Lesions, SLAP is an acronym that stands for Superior, Labral, Anterior to Posterior. It is the superior part of the glenohumeral joint that has a pathology and it tends to start anteriorly and migrate its way posteriorly as it becomes worse. Generally, the biceps tendon, which is this structure right here, is involved with the pathology and tends to worsen with eccentric biceps work. In other words, a lengthening contraction as the biceps is loaded and if it is being forced to lengthen, it tends to exacerbate pain, there is an orthopedic tests called “speeds test”, that does just that. There are a number of different causes or grades of SLAP lesions and it depends on the literature you’re looking at. But this figure reference 4 different grades of SLAP Lesions, this one being the first one where there is just a little bit of degradation or fibrillation of the proximal biceps tendon as it inserts into the labrum. The second one is we are starting to get some tearing of the labrum. The third, Grade 3, we start seeing a bucket handle tear of the labrum and this is where the shoulder might have some significant clunking movement similar to what we saw in that one video earlier, as it goes through a range of motion. Then in grade 4, we start seeing not just a bucket handle tear, but we start seeing tearing down the longitudinal part of the biceps tendon. Now, what literature says, is the most common presentation, is this type 2. Why is that? Because these type ones might be a real mild insignificant complaint of the athlete, not significant enough to really encourage them to go see a provider. What we typically see in our offices is this progression to type 2, where we already see some injury and I clearly do not like seeing SLAP injuries. I try to rehab the heck out of these if the shoulder is not presenting with like a bucket handle tear, where there is a lot of clunking and dyskinesia of the shoulder. I try hard to rehab them and we will talk about some of the rehabilitation interventions for SLAP lesions and other shoulder conditions as we get into part 2.

Biceps tendinopathy goes hand in hand with the the SLAP injuries. Typically, what we see is that they might have a history of a rotator cuff tear. PMH stands for Past, Medical, History. They might have had a past medical history of a rotator cuff tear, that then now has resulted in biceps tendinopathy. It could be chronic, it could be an acute onset, it could be caused by a forced range of motion, either into external rotation or forced horizontal extension of the glenohumeral joint and usually while it is under load, such as a rugby forward, trying to catch somebody as they’re running past them. As we observe our athlete, they might have some altered mechanics over the shoulder, moving it a little bit differently as compared to the healthy shoulder. In regard to inflammation, this bullet point, it came from this particular reference, you may or may not see inflammation like visibly see it. Depending on where that tear is and how lean they are. In regard to palpation clearly, there is going to be some tenderness, maybe over that bicipital groove, we want to make sure that the transverse ligament is intact. If the transverse ligament is not intact, if it has been torn, the biceps tendon can luxate, and it usually will luxate immediately. Especially, as the humerus is horizontally extended and externally rotated, and I have only seen one of those in one of my ice hockey players.

Now, I know there is several my colleagues out there that are adjusting the bicep tendon, on a lot of patients and I apologize, I put quotations around it because I just do not get it. I do not understand how you can adjust the biceps tendon back in the groove. If the transverse ligament is intact, that biceps tendon should not be going anywhere and maybe it is time to go back and look at our cadavers and see how tight that groove is when that transverse ligament is intact. This hockey player that had a dislocated biceps tendon was because he had an acute rupture of the transverse ligament. It dislocated when we were taking his jersey off and then, we brought him into internal rotation and abduction, and we were able to manipulate the biceps tendon back into the groove and I did my best stabilizing it with some tape. But that was a challenge, we just told him to not horizontally extend and externally rotate or else that biceps tendon is going to pop immediately again. Then, he did have to have a surgery. He was already getting a full ride scholarship to a division 1 college to play ice hockey, which is a big deal here in the USA. I can talk further about that, but if you have any questions, feel free to email me on that. What we are going to do in our examination, we are probably going to see some muscle weakness, especially when testing the biceps.

Rotator cuff tendon apathy? Very common. One of the more common things you are going to see in our athletes and what commonly happens is, it is more of an insidious onset. It starts a little bit slower. It is generally not in acute tear unless they fell on an outstretched hand or went to tackle somebody. In their past medical history, they might have had a previous diagnosis of an impingement or some previous medical history of instability. For observation, when we were looking at our athletes, their range of motion is going to be limited. They might hike their shoulder because they do not want to abduct their glenohumeral joint. There might be some atrophy as we saw in the earlier inspection athlete where their infraspinatus was atrophied. When we palpate, there is probably going to be some tenderness right over that rotator cuff insertion. Remember how to do that? We anteriorly rotate the humerous and palpate the anterior aspect of the humeral head and there might be some tenderness in other spaces around the shoulder complex.

Orthopedic tests, you could probably name off more Orthopedic test of rotator cuff tendon apathy than me, but be sure that we have good sensitivity and specificity when we are doing them. Go ahead and do a deeper dive on that. Managing rotator cuff tendon apathy, it depends on whether there is a full thickness tear and whether there is separation. We will talk a little bit about that here. One of the mechanisms for rotator cuff strains is an excessive eccentric motion and here we see a picture of a water polo athlete getting ready to throw a ball and the eccentric motion, for a subscapularis tear, as he is trying to slow down that cocking phase, the subscapularis is contracting intense to slow down that particular motion. Then, when he starts concentrically contracting subscapularis and other internal rotators, he is going to throw the ball. Once he releases the ball, the external rotators now, are eccentrically to try to decelerate that humoral internal rotation. These excessive eccentric motions or muscle contractions seem to be contributors to rotator cuff strains, trauma certainly can be a component of it. We again see swelling, if there is a lot of muscle mass and other mass around their shoulder, they are probably not going to see much for swelling. However, it is something that we should be looking forward or look in to. When we are palpating, the course again that they were going to have tenderness at these rotator cuff insertions.

A recent publication, in fact this just came out this month, December of 2020. They looked at a 2-year follow-up for rotator cuff tears and whether they were managed conservatively or not, the conclusion is here, and you can read it on your own. But if I were to paraphrase it, they are saying every rotator cuff tear unless it was a full thickness tear, and I want to qualify that. What they said in conclusion was, if it was a full thickness tear or if it was not a full thickness tear, if it was a strain, it should be rehabbed. It should go through a solid course of shoulder rehabilitation, and even if that rehabilitation fails in a 2-year follow-up, these individuals were still doing pretty good compared to those that had surgery. Their conclusion was, if it is not a full thickness tear, you should consider rehabilitation and even if the rehabilitation fails, they probably should not have surgery. They did discuss though that if it is a full thickness rotator cuff tear, that surgery may yield superior improvements.

Let me talk about full thickness rotator cuff tears. When I am looking at an MRI of a rotator cuff tear, it is one thing for me to read the report and they say it is a full thickness tear. What I want to know is if the entire conjoined tendon was torn, the entire conjoined tendon, and whether there was separation in that tear. If we are looking down at the top of the conjoined tendon a full thickness tear, and if you can see my finger going through this tendon, that is a full thickness tear. It does not mean the whole width is torn. It means that there is a tear, going through the thickness of the conjoined tendon not necessarily the entire width of it, so there could still be a lot of attachment of the rotator cuff to the humerus. That is a full thickness tear, it is not a full width tear. When it is full thickness and full-width tear, then we might start seeing some separation and it might get wider and wider, and when we have a wide mean, that’s what I start looking for. Is the report of how wide that separation is, there is a small tear, there is a moderate tear, there is large tears, and there are massive tears. What the literature is saying is that large tears, a 3-centimeter gap, that is when you should start considering surgery. If it is a small or a moderate tear, 1, 2 centimetres of separation, it will probably heal with some slinging and swatting, some good nutrition, some cross friction massage, and some other therapies to create good scar tissue so that it lays back down on the humeral head and we have a good outcome. The way I manage it like I have mentioned earlier, I am not afraid to PRICE it. Ice for that pain mitigation, not for inflammation. If a tear is larger than 3 cm, I am probably going to refer them off for surgical consult. If it is smaller, depending on the athletes and the individual, there are a million-dollar athlete or probably maybe they are going to send them in for a surgical consult as well because we might need to get them back faster.

Of course, some other therapies that we can do for rotator cuff tears are myofascial release technique, that’s what MRT stands for. We are maybe going to adjust the rest of the shoulder complex or probably going to stay away from manipulating the glenohumeral joint for a little while then maybe we want to consider making sure the rest the joints are working the way that they are supposed to. Some other physical therapies for pain mitigation and healing potential and then, we rehab the heck out of that shoulder, and we will talk about that in part 2.

Shoulder impingement. I think this might be our last condition. With shoulder impingement again, common. They oftentimes precede a rotator cuff tear. They are usually chronic. Oftentimes seen in overhead athletes, surely by definition, they have painful abduction arcs. They might have some tenderness of the rotator cuff which might be some early indication of some rotator cuff tendon apathy as well and you will probably list off a long list of Orthopedic tests that have good sensitivity and specificity for shoulder impingement.

Thoracic outlet syndrome. A lot of things can cause thoracic outlet syndrome and hence, the word syndrome. Syndrome is a collection of signs and symptoms that are manifesting with shoulder pain and sometimes odd arm conditions. Historically, and maybe upon radiographic examination, you notice that they have cervical ribs in the lower cervical spine vertebra. Maybe they have elongated TPS these by literature, have shown to predispose 12 TOS types of symptoms. Distally, they might complain of tingling and numbness in the distal part of their hand. X-rays may show these C7, findings that we mentioned earlier, poor posture, my experience is that this poor posture that we saw earlier does predispose them to TOS types of symptoms. Upon further examination, we might see a decrease pulse, some altered sensation, and joint edema. I cannot recall ever seeing joint edema with any of my patients with TOS diagnosis. There is a long list of Orthopedic tests of Alan’s test and Coastal clavicular Test. Be sure you are looking at the sensitivity and specificity of these tests before you are performing them.

In regard to managing them, it depends on really what the cause is. The cause is an elongated TP of T1 or cervical ribs, what are you going to do about that? Well, we can probably still try it, a course of conservative management. Maybe there is some muscle tension, maybe it is anterior scalenus syndrome that is causing this outlet that is associated with these elongated TPs or maybe some myofascial release work over the anterior and middle scalene might be appropriate, some physiotherapy, maybe some adjusting might be appropriate to manage these patients.

Last couple slides on Pediatrics. This is a literature that I’m going to try to include for you to read. I thought it was a good article, if you have not jumped into pediatric shoulder conditions much, this was a good concise piece of literature. They talk about overuse injuries and chronic injuries of Pediatrics and acute injuries. They say that overuse injuries predominate over your more acute traumatic injuries. In other words, are more common. 60% of all sports injuries in youth, are from overuse. They tend to be osseous and soft tissue in nature and radiographs should be considered to rule out trauma to the vices. As we see in this picture and a comparison, I take pictures or x-rays images of both shoulders, so that I can compare especially these youngsters because these vices honestly, they just freaked me out until I can look at what a normal physis looks like, it always looks bad to me. Be sure to take bilateral films. These overuse injuries in Pediatrics tend to be more prominent in females. However, 50% of these overuse injuries can be prevented and so, if we look at some of the causes of shoulder injuries in our youth, it is usually due to volume and too much activity or too much volume, too many pitches, too many volleyball hits, things like that. Some predictors that we might appreciate in our children, is that they will present with shoulder pain, maybe some complained of “My shoulder feels tired, it feels fatigue.” They probably won’t say fatigue, they would probably say tired and then, when you’re looking at their baseball throws or their volleyball hits for example or netball throws, you will probably notice that they’re not throwing as hard or they are throwing slower, that might be an indication that they’re overtraining and they’re starting to develop some early symptoms of an injury.

Little League shoulder, you may have heard of Little League Elbow, there is something called Little League Shoulder and that is what this is. It is a small little fracture of the physis of the shoulder and then of course, anterior instability and multi-directional instability can be noted, most likely with the multi-directional instability and a sulcus sign that we saw as we pull down on the humerus, I saw that in the children far more often than I saw in adults, and if it is equal on both sides, they just might have an AMBRE, a multi-directional instability of both shoulders and maybe they will grow out of it. But clearly, it would want to start stabilizing the shoulder complex and then eventually start strengthening it.

Let us talk about acute injuries of our Pediatrics. When we see an acute injury of a youngster, we might want to think of sprain or fracture. They tend to be more common in our youngsters, they have sprain or fracture as compared to strains. Now depending on the school that you go to, some teachers will just say sprain/strain or strain/sprain. They say it as if it is one word and if you know me, you know that drives me absolutely bananas because clearly it is different anatomy. A strain is different than a sprain anatomically. Sometimes the mechanism of injury is different between a strain and a sprain. Oftentimes, the treatment is different between a strain and a sprain. This statement right here, is another reason why we must call it like it is, it is either a sprain or it is a strain. Sometimes it could be both, clearly, sometimes could be both. But stop saying, sprain/strain, it drives me crazy.

With our children, often times, we may see a sprain over a strain, and we should think about fractures. Looking at the proximal humerus fracture, and that is what we see in this film right here, you can see that the proximal humerus is fractured. In this individual, what did we call when we were talking about luxations earlier and we tested the sensation of the lateral aspect of the deltoid about the size of a silver dollar sign. This individual, this youngster right here, probably presented with silver dollar sign. It was numb right here. In that case, sometimes these cases when they present to you, it looks like a shoulder dislocation. That is why you still palpate though, when you palpate under the acromion process, there is going to be a lot of bone there, still most likely, which means it is not dislocated and then you’re going to help touch the skin, and sure enough there might be some numbness and paresthesia there, some tingling. But usually, numbness and hence a silver dollar sign. It is fractured, you stabilize them, treat for shock and you get them off to the hospital.

Proximal humerus fractures. Clavicle fractures are fairly common in our youngsters, as they are throwing their bodies around the football fields and something to keep in mind, in regard to fractures of the clavicle is one of the final bones that is going to fully ossify as these youngsters is growing up. It tends not to ossify until they are in their early 20s. When you are taking these x-rays, do not be fooled by a growth plate on the distal, especially the distal aspect of the clavicle. As we mentioned earlier, the medial lateral clavicles are stable. It is the middle part of the clavicle that tends to fracture on the middle part of it. Mechanism of injury usually, for these clavicle fractures is a fall on a shoulder or fall on an outstretched hand that drives energy into that clavicle and fractures that. If they do not fracture their clavicle, some of the sprains they might experience, might be an AC sprain, in which we have talked about in a sternoclavicular sprain.

That concludes our introduction and includes our clinical examination and concludes our conditions discussion. Part 2, we will talk about shoulder functional assessment and rehabilitation.




Part 4_Shoulder Functional Assessment Rehab

English Direct Download PDF –ICSC6 Part 4 -Shoulder Functional Assessment Rehab

ICSC06 Upper Extremity Module 6
Part 4 – Shoulder Functional Assessment Rehab
Instructor: Tim Stark
Video Lesson: 1:29:11 Hour/minutes

Welcome back to part two of the ICSC: Shoulder Conditions and Rehabilitation. We continued on this next part into looking at and discussing shoulder functional assessment and rehabilitation. Our outline for the next 60 to 90 minutes looks like this. We will be discussing functional assessment and you will see this term tiers one through five if my mouse is moving on the screen here for you. That concept of tiers one through five basically talks about a progression, a progression of functional assessment. Within that progression of functional assessment, we are going to be talking about some outcome forms at a very, very high level. Many of you have these outcome forms in your clinical environment.

We talk about posture, at a very high level and some functional assessments. Things that you can consider utilizing in your office to quantify function or lack of function. Then we are going to spend most of our time probably discussing physical rehabilitation. We have these tiers one through five, it is a progression that I view for a long time, teaching it for a long time and have a couple of publications based on this process. There is some peer review evidence supporting these progressions, which just summarize each tier.

The first tier we talk about Removing the Negatives. It may be negative is the wrong word, maybe we can talk about removing hurdles that might prevent your patient from progressing appropriately in a rehabilitation program. So those are some of the first things that we want to address. Then secondly, the second tier, discussing Static Stabilization and implementing some sort of cardiovascular exercise. We will tackle a little bit deeper into each of these as we progress on. The third tier would be discussing Dynamic Stabilization. We will discuss and explain how Static Stabilization differs from Dynamic Stabilization, how these exercises differ. Then the fourth phase would be Mobilizer Conditioning. That is the term I prefer to use versus strengthening. I think the term “strengthening” is misused too much within the rehabilitation field and we’ll discuss that too as we go on. So, Mobilizer Conditioning would be that fourth phase. Then the fifth phase: Activities of Daily Living. We are working primarily with athletes, so we want to assure that we are returning the athlete back to their activities during their sport. Whether they are a power sport, a strength sport, or a speed and agility sport. We want to make sure that they can return to those activities in a safe and effective manner.

These tiers are based on a couple of pyramids that we published. You can see the pyramid being referenced in these articles that we published back in the mid-2000s, 2006-2007. The pyramid is simply just a learning tool like the nutrition pyramid years ago. I realized we do not use the nutrition pyramid much anymore, but the pyramid was a nice device basically to teach my patients, as well as teach my Chiropractic students how to implement a progressive rehabilitation program. This is one of the pyramids that we have published. If you look at the top, you can see that it is a Pyramid for Functional Assessment. If you look on the outside of the pyramid, we talk about outcome assessments. Outcome assessments and these are assessments on which you put a number on.

Most often you think about a subjective outcome assessment. A piece of paper that a patient fills out and answers particular questions. With that, each question has a particular number pertaining to it, and you end up with a total. Not all outcome assessments have to be paper. I want you to consider all your assessments, whether it is a hand on assessment or a paper assessment, trying to put some sort of quantified number on them.

Then on the other side of the pyramid, we talk about motor control deficits. Throughout the entire assessment process of your patient, you are going to be trying to identify whether they have some sort of aberrant movement pattern or motor control deficit. Then you can see in the center we have these different tiers if you will. Tier one, tier two, tier three, four, and five. One of the negative comments I received on my papers when I was submitting them through peer review was that the tiers themselves are rather wordy. Sure, that is fine, I get that. What I tried to do was simplify it a little bit and we will show you what I mean by that.  Tier one is the least invasive thing that we can do to functionally assess our patients. Then tier two would be the next invasive. As we get up to and progress onto such as tier four, we are starting to ask our athlete to do some pretty aggressive things, such as jump as far as you can or as high as you can or throw this medicine ball as far as you can. Clearly, if we were starting a rehabilitation program for a patient, we would not start there.

You can understand that we would progress from least invasive to most invasive. So let us talk about the first thing that we are going to be doing. The first thing we are going to be considering with our patients is basically observing them and palpating them or looking at touching to simplify things. Then we are going to ask the patient to move, but we are going to ask them to move without any load. We are going to give you examples of these as we proceed on. We are going to ask them to move without any load, such as a Gait analysis or going through a range of motion, or some sort of orthopedic evaluation.

Then the third tier is asking the patient to maybe move with some light sustained load, or contract with a light sustained load, or a brief heavy load such as a manual muscle test or a handheld dynamometry test. The fourth one, I gave some examples already, we are going to be possibly performing some fitness testing, maybe sprint to 40 meters, throw a medicine ball, Max testing, one rep max or ten rep max testing. The last thing we want to do is perform a reassessment. The fifth tier is basically just a reminder of how important it is to reassess your patients on a regular basis. We will talk about a study by Han back in 2004 and what he found. This particular functional assessment goes from least invasive to most invasive, so let us look at some of these examples.

In tier one, the least invasive thing that we want to do is basically just look at your patient. Try to identify whether there are some clinical indications for some somatic or neurologic or other physiologic problems. We saw this individual in part one lecture if you remember, we anticipated that he probably has a bit of scoliosis because of the number skin fold are varied on one side versus the other. The difference between his arms was different, his right shoulder a little bit lower. We also pointed out some atrophy in his right Infraspinatus area. So that is just to remind you a little bit of what we found and discussed in part one lecturer. Some of the things from a functional assessment perspective, that we did not discuss earlier was looking at the breeding pattern. Do they have a paradoxical breeding pattern? We know that if a patient does suffer from a paradoxical breathing pattern that is rather inefficient. They spend extra energy trying to breathe and it may result in chronic pain. So that is something to consider.

Faulty mechanics, we want to identify faulty mechanics. What I mean by this, especially talking to sports chiropractors, would be more of your motion palpation assessment, trying to identify joint average function, maybe some capsular contractor, for example. Then some sort of static posture findings. This individual has a little bit of a right lower shoulder so we can maybe assume. Then his cervical spine is compensating pretty well so we can maybe assume that maybe the left upper trapezius muscles are a little bit shorter than his right side, hence identifying length and tissues versus some shortened tissues. Therefore, if we know that, we know that maybe it might be contributing to the patient’s shoulder symptoms and we can implement some sort of soft tissue therapy once we start discussing and putting together a treatment plan, so that is tier one.

Moving on to tier two. The next more invasive section of the functional assessment would be asking the patient to move without any load. Range of motion clearly is a fit within that description. My preference is to perform active range of motion first in almost every physical exam book that I have ever looked at. It talks about asking the patient to be active with their range of motion first so that they can stop if it hurts. Then after they have done their active range of motion, all the ranges, then to perform passive range of motion. I think the most important component of passive range of motion is applying that little bit of overpressure so that we can identify if that endpoint is bone on bone or if it is tissue stretch.  If it causes increased pain for a patient.  I like Apley’s Scratch Test or Apley’s Test Range of Motion- test for the shoulder. I put that into almost a range of motion assessment because it is now combining different planes of range of motion for the shoulder. We recall that Apley’s includes three different components of testing reaching out the back, as we can see in the mirror, reaching over the opposite shoulder, and then down the back if they can, and then reaching over the ipsilateral shoulder and down the back if they can. We can see all this in the mirror.

You can see the provider as well, marking or making notes where their fingertips are touching on that spine level. I have been teaching for a fair amount of time, and I have been teaching all over the world. I see students doing different things in regard to this Apley’s Scratch Test, and I will see if I can demonstrate this, I see a lot of students doing both hands at the same time. In other words, if we look at this picture on the left-hand side, her right arm would be reaching her upper back and her left arm would be reaching over the same shoulders, same shoulder ipsilateral shoulder trying to touch their fingers.

I am not a fan of doing Apley’s in that particular manner. I think there is just too much going on. Yes, it is faster but when we are losing quality of testing, I would rather take a little bit of extra time and do it slower. I do one arm at a time and discourage my students from doing two arms at a time. If that works out really well for you, continue on, but I just want you to think about that a little bit more.

One thing that also a lot of orthopedic textbooks do not discuss when discussing Apley’s is watching what the scapula does during this test. Especially when we are asking the patient to internally rotate the glenohumeral joint and extend and abduct the glenohumeral joint. What often happens is if that posterior capsule of the glenohumeral joint is tight, the scapula tends to tip anteriorly. We can see sometimes anterior tipping or winging of the scapula. Sometimes a medial border is rather prominent when we have them perform this maneuver.  Be sure to make note of that. It is one thing to note how far their fingers are reaching up their spine. It is a second thing and very important thing to know how much scapular movement there is or winging as compared to the opposite side. That is why I like to do just one hand at a time.

In regard to testing internal rotation of the glenohumeral joint and identifying whether the glenohumeral capsule, particularly the posterior capsule, is potentially aberrantly tight. I like to perform an internal rotation assessment of the glenohumeral joint and compare from left side or right side. I have seen this done several times and started doing this many years ago. Started teaching it to sports chiropractors and chiropractic students, and then IASTM technique since 2004. Teaching medical doctors and physical therapists and osteopaths how I performed this internal rotation assessment. It is different from what everybody else seems to have been taught. They tend to perform this test supine rather than prone.

As you can see in the picture, they perform at supine. Otherwise, they do everything the same. My frustration is I do not really know what the scapula is doing when the patient is supine. When I put the patient prone, I can keep a finger on the scapula and identify what is going on with the scapula.

Let us watch this video.

What we are going to be doing is lying the patient prone. We are going to position the elbow so that it is at the height of the glenohumeral joint. I apologize, my internet is really slow here in the country, so I hope this is going to work better for you. But with my left hand, I am going to palpate the inferior angle of the scapula. While I am palpating the inferior angle of the scapula, I am internally rotating the humerus. Once I feel that the inferior angle is just starting to lift off the rib cage, I take my inclinometer and I place it on the forearm, a consistent spot on the forearm, and identify that angle of the forearm. Let us play that again and watch what is going on here.


I position the glenohumeral joint at 90 degrees of abduction, placing the elbow at the height of the glenohumeral joint. I internally rotate the glenohumeral joint just until the inferior angle of the scapula starts to lift off. Hold the humerus or the humerus in that position, and then grab my inclinometer and measure the antebrachium or the forearm at that particular angle. Then I compare it to the other side. What I commonly see is if this individual was winging on that side of when we are doing posture testing, if they wing on that side or during Apley’s, eight times out of ten, almost 100% of the time. Probably being conservative with 80%, almost 100% of the time I see a reduced internal rotation of glenohumeral joint. I am assuming that is posterior capsule tightness because when I go to motion palpate and glide the humerus posteriorly, there seems to be a restriction on that side compared to the other side.

Another tier two consideration is looking at scapular rhythm. We can look at scapular rhythm from a static perspective and a dynamic perspective. Statically, when we look at scapula statically what we are looking at is the distance from the medial border of the scapula which I have a little red dot here to the spinal process of the spine and then we compare it to the other side. It makes sense that for the most part, these two sides should be pretty similar in distance. When we measure both of these, if one side is significantly larger than the other, we can assume maybe that there are some motor issues, some muscle imbalances. Then also we want to watch the scapula move as we bring them into more of a dynamic movement.

Looking at dynamic scapular rhythm we want to watch the medial borders laterally rotate and biomechanics textbooks are different. For the most part, once the humerus starts to abduct, and I think we talked about this earlier in part one lecture, the scapula really should not move. It is not until the humerus gets out to about 15 to 30 degrees depending on what reference you read, that is when the scapula starts too laterally rotate or upper rotate. This kinesis that we are trying to identify is really important. When we talk about shoulder injury mitigation or shoulder injury prevention, scapular dyskinesis seems to be one of these things that we want to identify. We will talk about a study here later in this presentation. But let us look at an aberrant movement and some scapular dyskinesis.

Video Placement: 17:08

What we are going to see in this video, is one of the shoulders is going to abduct just fine as we can see on the left and when he is trying to abduct on his right side, we see him hiking his shoulder.

In other words, early firing may be of the upper trapezius, maybe we can call it those levator scapulae. We can also maybe think that maybe there is poor centration of the glenohumeral joint, things that we need to investigate further or make some predictions basically by looking at this. We can maybe make some assumptions that the inferior trap and the serratus anterior and maybe latissimus dorsi, to some degree, are not working quite as well, also may be a little delayed in firing because the upper turret trap might be firing a little bit early and causing this hiking of the right shoulder. We call this a reversed glenohumeral rhythm. A reversed glenohumeral rhythm, common in some of our injured rotator cuff patients and our early signs of adhesive capsulitis.

This is a young lady that we saw in part one lecture. If you recall clearly, she has scattered dyskinesis. This was a paper that we published quite a few years ago and if you go to this link, you will see not just this video, but you will see X-rays, you will see the entire case. You also see a fluoroscopy of this case, and the fluoroscopy is pretty cool. The fluoroscopy basically shows four repetitions of her dyskinetic shoulder. Then she co-contracts. Remember, in part one lecture we talked about co-contracting causing centration of the glenohumeral joint and centration of the scapula thoracic complex.


Normalizing in her case, normalizing her glenohumeral rhythm and her scapula rhythm. With her right shoulder, we realized that she had normal, good, healthy, full range of motion. When she did it on her left, it was very disconnected and clunky, if you will. Then she co-contracted and she had a nice healthy rhythm. This is an important component for me to determine whether a patient is going to be a really good rehabilitation patient. If the patient can co-contract and following co-contraction, their pain decreases or their neuromotor control and their motor pattern improves. I think in my book and from my experience, the patient is going to be a really good rehabilitation patient.

We have covered a few different things to consider in tier two. Tier two is movement, but no load. Real simple things, some orthopedic tests, and range of motion and maybe a range of motion with co-contraction. Here is another simple, low-tech, low-cost assessment that you can quantify. It is called the Upper Body Flexibility Test, and this was from a peer-reviewed manuscript, I have the manuscript reference here. Just to standardize things, they suggested you place the patient’s heels 45 centimeters away from the wall, and their heels 35 centimeters apart. What I noticed is when I have got some of my children or my shorter people doing this test, 45 centimeters is a long way. What I did to try to standardize it was to try to have the hips roughly about 30 degrees angle from the wall. 45 again, 45 centimeters might be just too far or maybe not far enough for some of our longer athletes.

Nonetheless, I have my patients relatively in this position. I also made one change from the standardized, from the publication. I noticed that if my patients had their arms apart, and you can see that basically, the premise of the test is to raise her arms up over her head and reach as far as she can. I notice that as they reach up above their head, they started bringing their arms further and further and further apart, basically cheating. One change I made, and you can pause this video and have a real quick practice, is to put your thumbs together.

I asked the patient to put their thumbs together right at their hips with their elbows straight, and they have to keep their elbow straight throughout this entire test. With their thumb still touching each other. They have to go up over their head as far as they can. They could not separate their thumbs and they could not bend their elbows. I found that to be far more consistent and I was able to standardize it more effectively.

Here is how we quantify this. It is on a scale of zero to two. If the patient is able to go all the way up and go flat handed on the wall without arching her back. You can see if she is arching her back a little bit, but we do not want them to arch their back but you can see that she had to in order to go flat handed. If the patient is able to maintain their back and their head against the wall, keep their thumbs together and go flat handed on the wall, that is a two. If they cannot quite reach the back or the wall behind them with the back of their hands. But if they extend their wrist, as you can see in the picture, and touch their fingertips, then they get one point. If they extend their wrist and still cannot touch their fingertips, then they score a zero. What I always ask my athlete is if they score a zero or one, why cannot they go further? What is stopping them? Surprisingly, the most common response I get from my athletes is I feel a pinch in my thoracolumbar junction, which was kind of surprising.

We are going to talk about a paper later that might help us understand that. What I commonly do when it comes time to treat is I clearly look at that TL junction and again, there is a CMT, a chiropractic manipulative therapy paper that we will talk about.  I almost adjust everybody’s TL junction if there is a restriction there when I have a patient coming with a shoulder complaint. But nonetheless, I tend to adjust that and before they leave, I retest. In the retesting, surprisingly, and maybe not too surprisingly, they do much better on this test.  If they are able to do better or perform better on this test, great. Sometimes they complain of shoulder pinching or tightness in their neck.  Then we are going to look in those particular areas.


Let us just review this. Thumbs together, right in front of the pelvis, elbow straight, reach out their head up over their head as far as they can. If they cannot touch with extended wrists, it is a zero. If they can touch their fingertips with an extended wrist, it is a point of one. If they can go flat handed, it is a point of two.

Another simple test that allows us to quantify and measure proprioception, it is utilizing a pretty well-studied measurement now, or intervention called Angle Recreation. We are just trying to recreate an angle that we had the patient assume earlier in the test. So let us play it as a video here. This is from a peer-reviewed study, and they found that there were good outcomes. What we are going to do is ask this patient to sit, close his eyes, hold his arm in a particular position. You can see she is got a digital inclinometer measuring the angle. We are going to ask the athlete to fully extend and fully internally rotate. Then try to recreate that same starting angle. When it comes to that same starting angle and he feels like he is in a pretty same spot, the doctor, the provider is going to go back in and measure again. What we are finding is, in regard to clinical relevance.

If they are consistently off by ten degrees, that might be clinically relevant. More than ten degrees consistently might be clinically relevant. We are going to compare left side to right side. Oftentimes a symptomatic shoulder does seem to be consistently more than ten degrees off when recreating this. We are asking him to start with a specific angle that we have already measured. We are going to have him fully, externally rotate, fully internally rotate as far as it does not matter. Which do you do first, internal or external? Does not matter. Then you come back to that same angle recreation position, and you remeasure.

We are now moving into Tier Three Assessment, we are going to apply a light sustained load or a heavy, brief load. Regarding a light sustained load, what I tend to look at is looking at scapular stability. We can have the patient assume what is called a 4-point position, many of you might be familiar with this. When the patients in this 4-point position, just a little bit of weights on this closed chain shoulder, the scapula might tend to wing a little bit, and then same thing.

If the patient is unable to assume this 4-point position, a less aggressive position might be just to do a push-up position. A position of performing a push-up on the wall. With these top two pictures, you can see that is what she is doing. When she assumes a little bit of load on her shoulder complex, in a closed chain position, you can see that both scapula wing just a little bit, but her right shoulder is a bit more significant. Then we thought, well, let us put a little bit more load on and see what we can find. We did put her in the 4-point position with these two pictures, and you can see clearly that her right scapula does wing a bit more than her left side.

Knowing that co-contraction of a shoulder complex might improve motor control deficits or motor coordination. Maybe decrease pain and improve function of range of motion, do you think it pays and makes sense to have the patient co-contract doing this test? Then retest them and see if the scapular control is improved. This individual, was a high-performance swimmer, which was one of my students. He was a high-performance swimmer. You may have heard the name Michael Phelps, a really good multi-medal swimmer for USA in the Olympics. This individual that we are looking at here has been in the pool with Michael Phelps and has competed in similar races as Michael Phelps. We clearly appreciate that swimmers need a significant functional range of their shoulder complex in order to perform their sport. It might not be too surprising that this individual, when placed in a light sustained load position in a closed chain position, that we saw this much scapular winging. What makes me feel good, if anything, is that it is symmetric. But it does concern me that I am curious.

With his range of motion, he actually had a good range of motion. There was not any disc easier, so that is important. But I do believe that if he does not have the motor control to stabilize the scapula to the rib cage, that he could be predisposed and we will talk about a study later as well. He could be predisposed to a more significant shoulder injury. So here is what we did. We put a light sustained load on him, and this is what we found. As you can see initially in this picture, his hips are over his knees and so he is leaning forward. There is a little bit more, more load on his shoulders. What we asked him to do was lean back and take the load off his shoulders. Then we taught him how to co-contract his shoulder complex by putting our thumb in his axilla, putting our fingers on the posterior scapula, giving a little bit of a squeeze, and asking him if he can contract these muscles. That is a crude description. If you need more information and videos or whatever, just reach out to me. But what we want him to be able to contract is subscapularis posterior shoulder muscles, including mid trap, low trap, and rotator cuff muscles. The pec minor should be contracting a little bit, but the upper trapezia should be turning off.

Once we have him actively co-contractor shoulder complex, then we had him lean forward. Once he leaned forward, similar to the first position, you can see that the amount of scapular winging was significantly less. In my mind, this patient is a great rehabilitation patient. Now the question is, he is no longer swimming at a highly competitive intensity. My question and concern as a sports medicine person, sports chiropractic person, would be if I taught him how to co-contract effectively at his shoulder, would it potentially diminish his productivity in the pool?

That is clearly not what we want to do for a high-performing athletes. But to some degree, you might want to improve it a little bit. That is a bit of the art of being a sports doctor, is understanding what might be appropriate for the right patient. An example of a heavy, brief load for tier three. In other words, manual muscle testing or using a handheld dynamometer. We talked a little bit about this in part one lecture. This is a paper that a systematic review that myself and Dr. Renee Fejer and Bruce Walker published in 2011. Systematic reviews are very complicated, it took about two and a half years to publish this paper. But nonetheless, I use handheld anemometry quite a bit and it helps me quantify whether there is a difference between the left side and the right side for a particular movement. I do not feel like I test specific muscles, I feel like I am testing movement. For example, the upper right, I am testing resisted abduction at 90 degrees. Here I am testing resisted external rotation, again in 90 degrees of abduction, and resisted internal rotation in 90 degrees abduction. Here is resisted internal rotation while the glenohumeral joint is more in a neutral position and so on. I think serratus anterior strength is important, but neural-motor control, is even more important for the scapula. In fact, when we look back at this previous case that we just discussed with all the scapular winging, I am sure some of you are thinking, wow, his scapular interior is really weak, and we need to strengthen it.  I do not think that it is a weak, using the words strength and weak, I think we use them incorrectly. In order to say that it is a weak, we actually need to muscle test it, so this is one of many positions in which we can test the strength of serratus  anterior against a heavy load in a unidirectional pivot vector. That is the definition of strength testing. You cannot do a light sustained load and claim your testing strength, you may be testing motor endurance at that point. To test strength, that needs to be a higher resistance and mostly in a unidirectional state, such as in this position. I have noticed a lot of people like this individual, his serratus anterior is ridiculously strong when I muscle tested him. It was just at the serratus anterior and other muscle structures. Just did not know what it was supposed to do. It was strong, but it was stupid, and did not clearly understand that it needed to stabilize the scapula to the rib cage.  That was tier three, light sustained load and heavy brief load.

Let us talk about Tier Four which we briefly and affectionately called it Fitness and Maximum Testing. There is a lot of fitness and maximum tests that we can do. One of them would be muscle endurance test.  If you just simply Google standardized muscle tests for motor endurance or muscle endurance, push-ups is clearly going to be one of those tests that you are going to see. Depending on the standardized data collected, you want to perform the push-up the way the data has been collected for the group of that study. So oftentimes what you see is males will be in a toe and hand position, whereas women might be more in a knee and hand position. Then they perform push-ups in a particular manner. Sometimes, depending on the standardized test, they will perform push ups until they fail. Sometimes it will be a maximum number of push ups in 30 seconds or 60 seconds. Sometimes the standardized tests are just performed up to 75 push-ups and then you are done. If you do, you have performed excellently. So be sure to look at the parameters of the standardized test that you choose to use. I like testing for power on almost all of my athletes and using a medicine ball can be really simple. Look at the standards and the description of the standardized test that you are looking at. Medicine ball throws can vary quite a bit. From throwing it forward, from throwing it over your head backward, from taking three steps.

This is an example where my athlete took three steps before she threw the ball. As you can imagine, that can be rather complicated to make sure you are taking three steps in time and everything just right. But this is an example of a YouTube where if you want to look at it and just pause the video and open up another window. But you can see where it is a standardized way of testing power by utilizing a medicine ball throw.The last thing with our assessment pyramid is to reassess. I mentioned that reassessing is really important. The question really is when do we reassess? Well, there is no wrong answer. You can reassess in the same visit, the first and the same visit, which I think is important that we do that you can reassess each visit they come back, and again, I think that is really important. Or to do periodic testing, maybe weekly, every two weeks, every month. But be sure to make sure that you are reassessing on discharge to assure that whatever positive tests that you found initially have now been improved.

The reason why I like to assess frequently and within every visit is from the study that I found in 2004, quite a few years ago by Han. Han found that intrasession, within the same session, reassessment was shown to predict intercession improvement. Intercession improvement, in other words, is the patient going to continue to improve after that first visit? They found that if I treated somebody on a Monday and before they left on my Monday appointment, they had already improved. Maybe their range of motion or their pain went from an eight down to a four. If they improved in that same visit, they were three and a half times more likely to continue to improve until I saw them on Wednesday or Friday or later that week. I think it is really powerful for a number of reasons to test that patient before they leave. One, if it is improved again, we know that the therapy was beneficial and the patient’s likely to continue to improve. But I think it provides and lends credibility to what you did to the patient, and the patient can leave knowing they already improved. Sometimes it is just a strength improvement. That is why I use handheld dynamometry, is I can show the patient the numbers on the LCD screen. I can show the patient the numbers showing them that they improve by 20% on the one side when they were clinically positive.

What can we do with this assessment information? What does it mean? Can we use this assessment information to help us determine whether a patient is going to be injured at a later time? Maybe we can, maybe we can’t. In this particular study from 2018, a systematic review showed that when evaluating overhead athletes, there were really no modifiable measures that were predictive in preventing shoulder injuries of these overhead athletes. That bothers me. I like to think that there is got to be something in the exam that I can see or test that might predispose a patient to injury. If I can mitigate that or make changes, positive changes, that maybe I can prevent an injury to this athlete. With a systematic review, we clearly have to give that some acclaim and give us some respect. But I did find a paper in 2015, it was before the systematic review, but interestingly, the systematic review looks at overhead athletes and looking at ways of preventing shoulder injuries or identifying predictors of injuries of the shoulder. Interestingly, I looked at the systematic review and looked at all the papers they included in the review. They did not include this paper from Cools, for whatever reason. Maybe they just did not look at the Brazilian Journal of Physiotherapy within their search. Interestingly, this particular paper in 2015 did find some possible predictors for shoulder injuries and I thought it was important. The three predictors that they found were decreased glenohumeral internal rotation. Now you know how to not only test for it if you did not know about it before, but also quantifiably test for it. Performing, placing the patient in a prone position, internally rotating the glenohumeral joint, as we demonstrated in an earlier video. If you need to go back and review that video, please do so.  Diminished internal rotation and keep these three things in mind because we are going to be coming back to these as we go through rehabilitation discussions.

The second thing they found was rotator cuff strength using a handheld dynamometer. Quantifying that strength, especially when testing an external rotation, seem to be a possible predictor for shoulder injuries. Then scapular dyskinesis. We have seen some videos of some multiple patients with scapular dyskinesis. We know that if we have them co-contract when going through that range of motion or when performing a slight light sustained load, that their scapular dyskinesis might improve. We will get into the rehab components of that here in a bit. But keep these three things in mind, reflect back on what we just discussed in regard to assessment and then we will move forward and talk about rehabilitation. But before we move on, it seems like we have got some conflicting evidence here and that is how I would basically respond to a coach, a parent, or an athlete in that when they ask you, can injuries be prevented?  In particular, overhead athletes, we can say there is conflicting evidence. One systematic review shows that there does not seem to be any modifiable means of preventing injuries. Although there does seem to be some evidence to show that if we consider three key things of shoulder function that maybe we can possibly prevent some shoulder injuries. I think there are things that we can do, and I tend to lean towards that way. I guess I want to be optimistic that we can benefit our patients from a strength conditioning perspective.

When we start talking about rehabilitation, this paper I thought was pretty interesting because this study when talking about rehabilitation, which looked at a number of different considerations. They look at passive interventions, such as just injecting attendants, performing strength training, and these are all different groups. One group just had a passive intervention and that is it. One group had strength training and that is it. One group had motor control and that is it, and one group had everything.

This group that only had passive intervention, they did not have strength training, or motor control. The outcome was undesirable that patients still had pain, performance was diminished and recalcitrants. Recalcitrants basically mean the patient was not very compliant. The patient did not perform or respond very effectively and was not as compliant with their frequent visits as compared to the other groups.

The next group did strength training only, which is pretty common if you think about physical therapy, physiotherapy, other sports, chiropractic offices, and physical medicine clinics. They might only be implementing strength conditioning. This group had strength conditioning only, which meant that they built strength and they had the capacity to perform tasks. But there were no motor control exercises and the result of this group again was undesirable. They still had pain, they still had performance issues and compliance was still a concern. The next group was having motor control exercises only, no strengthening. In other words, they really did not develop strength to perform tasks effectively. They were able to control their function a little bit more, but the result was less pain. The performance was a little bit better, but the capacity to perform higher loads of their activities was a bit diminished.

When we looked at the final group, the group that included both strength and conditioning and motor control, we had the best outcomes. They had good motor control, they had plenty of strength to be able to perform their tasks within their activities of day of living. Therefore, the result were more ideal.

Moral the story, make sure that we are including just not just motor control and not just strength conditioning, but a combination of both. You will see as we go through the rehabilitation pyramid and the protocol that I think works pretty well is to include motor control first and build strength in a stable environment. We will give you some ideas of what that means as we progress. Another reason why I think it is important to establish neuromotor control first before establishing strength and range of motion. Improving range of motion is really important, and that is one of the first things that I work on but while doing that I want to make sure that they have adequate neuromotor control. This was a really good study and has seven articles that support this notion. One of the final slides is a reference page that has these seven listed. This was a study looking at a lit review, basically. Looking at a young group, 25 years of age and a really common problem. Glenohumeral joint instability, really common within our athletes. They found that if these athletes went through a traditional shoulder rehabilitation program, and when I mean and say traditional shoulder rehabilitation, I am talking about performing a range of motion exercises and strengthening. That is like rotator cuff strengthening exercises against air band and dumbbells. We found that if they are not including stability exercises, they fail the rehab 60% to 94% of the time. If we are doing anything and we are failing 60% to 94% of the time, what are we doing?

We need to reassess, audit, and change path. My direction is to include stability first and then start including and adding strength onto that stability. This is one of the rehabilitation pyramids again that we published, and this is more rehabilitation. If you look at the top here, the earlier pyramid that we looked at was for functional assessment, this is for rehabilitation. If we look at the rehabilitation pyramid, we talk about education. Doctor means teacher. We should be educating our athletes on everything they do, explaining why they are doing it, not just how to do it. Throughout the rehabilitation process, we want to make sure that their motor patterns, their engrams, are going down a path of an optimum engram. Make sure that they are not supporting, endorsing, encouraging a poor motor habit. We go from least invasive rehabilitation exercises to more aggressive. One of the first things we want to do is remove hurdles, remove negatives. If a joint is restricted, such as a TL junction, joint restriction is preventing my patient from going, performing over an upper body flexibility test, then let us adjust the lower thoracic spine. If there is some muscle tightness, let us do some myofascial release, and so on. We will go through some of these.

The first thing I want to do in my rehabilitation process is remove the negatives. The question always is, how long does it take to remove negatives? Sometimes it is that day and the next thing I can do right away is give them some stabilization exercises. Sometimes it is just that within that first day, sometimes it takes me a week or two or three to remove some of these hurdles so that I can then move to my next tier and implement static stabilization and cardiovascular exercises. It depends on the region and the complexity and the chronicity.

The next tier is implementing static stabilization exercises and cardiovascular exercises. As the patient has demonstrated competency and capacity for static stabilization, we will talk about that, then we can move on to dynamic stabilization. We will explain what dynamic stabilization is and how it differs from static. Once we develop a really solid, stable environment for the shoulder complex, now I am going to start building strength on it. Then lastly, we want to make sure that with their shoulder they can perform power movements, strength movements, speed, and agility movements. Maybe they are a boxer and they need to move fast and with power. We want to make sure that they can affectionately move through this pyramid from least invasive to more aggressive interventions in a safe and effective manner.

Tier one, removing negatives or removing hurdles. Well, there is several things that we can do. Some of the key things that I found to be very beneficial is to control a few things. One is to control inflammation and maybe look at their nutrition and see if their nutrition is complicating their healing. If they are eating a bunch of garbage, that is something that we can easily make some suggestions and changes to. Of course, I would encourage you to revisit your nutrition module within the ICSC because it discusses a lot about inflammation and nutrition.

Neuromotor control or neuromotor facilitation. Cognitive facilitation means making a conscious effort to make changes. If the patient is hiking their shoulder and they have a reverse glenohumeral rhythm, they may have to make a conscious co-contraction effort to facilitate centration of their shoulder in order to move through a more fluid range of motion. That is what I mean by cognitive facilitation.


Sometimes taping is beneficial, whether it be kinesiology taping, dynamic taping, or rigid strapping. We will talk about a case where I might use rigid strapping here in just a bit. Joint dysfunctions, adjust if needed. Sometimes it immediately helps significantly with shoulder function. Then tissue lengthening, so if there are some tight tissues and we can maybe make those predictions on posture and then confirm it with palpation range of motion, maybe some interventions such as proprioceptive neuromuscular facilitation might be of benefit.

PIR is Post Isometric Relaxation. If you have never heard of PIR but you have been doing PNF stretching, I am willing to bet you are doing PIR. I do encourage you if you are unfamiliar with how these two differ is to do some Google searches and do a little bit more of a deeper dive on it. Proprioceptive Neuromuscular Facilitation is different than Post Isometric Relaxation. There is a part of PIR in PNF, but it is quite small. I think there are a lot of people that do PNF stretching and that is what they call it, but it is really PIR. PNF is very complicated and involves a lot of angular movements and neuromotor control. Do a little bit of a deeper dive on that so you are speaking eloquently when you are referring to PNF. Then myofascial release techniques. Many of you know several ways of doing that, maybe using IASTM to assist you with it and some active lengthening exercises.

This is a real quick case from the FICS sport chiropractic team treating athletes at the World Games in Poland. Dr. Brian Nook was a chef de Mission, and as usual, he knocks it out of the park. He is just an awesome leader. He led a group of sports chiropractors very well. We were continually reminded every night that do not go into the field of play, where it might be on the bench, it might be on the pitch, it might be on the court, but do not go on the field of play.  One time he said, unless you are invited by team doctor or the paramedics that are there, you are not to go onto the field of play. When we are at the World Games, we are we are working with the other medical staff, working closely with the paramedics and massage therapists. Each team brought their own providers, maybe even another chiropractor so it is really important that when you are at an event as part of the FICS team, you work in a collaborative environment, and we do not go to a venue all high and mightly, trying to fix all injuries.

So back to this case. This was an individual we were sidelined at roller hockey and playing in a game. He was checked up against the boards, fell down and was holding his arm. They had a medical doctor, which I had worked with before, with them on their bench. Having worked very closely with the medical doctor, I had developed a very good rapport four years earlier. In fact, when he walked in on day one of the competition, he recognized me. He did not speak very good English, and I certainly did not speak his language very well either, but we realized we recognized each other. The doctor pointed to the table where I was and said, “Can you bring his athletes here?” I figured that out, and I said, “Yes, absolutely. That is why we are here.” So nonetheless, that rapport was there and working collaboratively and developing a rapport relationship is really important.

This individual was checked against the board and fell holding his shoulder. The other chiropractor that was with me, were playing a game of “Guess That Injury”. I was wrong and he was right. He said, “I bet he dislocated his shoulder.” I said, “No, I bet he broke his arm because the way he was holding his arm, his antebrachium.” They helped him off the ice, and took him to the bench. Because I knew the medical doctor, I walk behind the bench. I am still not in the field of play, but I am standing behind the bench. He sits the athlete down, and they take off his jersey. Right away you could see the shoulder was dislocated. If you remember back in part one lecture, it looks pretty clear when someone’s shoulder is dislocated.

I could clearly see that it was standing from where I was at. The medical doctor is looking at me, and this guy is in a lot of pain, and he is waving me into where the medical doctor was. I said, no, hold on, I saw the paramedics walking around the ice rink or the field to play, to come in there. The paramedics are all standing there, and the medical doctor is looking at the shoulder and palpating. I think he was palpating the clavicle like the SC joint. I am shaking my head, no, that is not it. I keep pointing towards the glenohumeral joint. He is palpating along the clavicle, and he is looking at me, and I am going, yes, you are getting warmer. Then he got the glenohumeral joint. I said, yes, right there. He looks down, and his eyes got really big. He realized he had a dislocated shoulder. He waves me in again. I point to the paramedics, and I knew one of the four spoke English, and I said, Is it okay if I come in? He said, yes.  I got approval, from Dr. Nook from the medical doctor of this team, and the paramedics.  I came in, and reduced the shoulder, one of the more complicated reductions, but he reduced, and he went off. I would put him in a slinging swath just in case, and suggested he go in for an X-ray just to make sure there was not what type of two fractures. A bank hurt fracture, bankart lesion, or a Hill-Sachs.  We want to make sure he does not have one of those fractures. It was one of the first times he ever dislocated. There is a higher risk of fracture, just so you know as well. Prior to reducing the shoulder, I checked for silver dollar sign. Remember we talked about silver dollar sign, which was palpating the lateral part of the deltoid? Making sure he is not numb there, which would be an actual nerve rupture. Maybe due to a humoral head fracture, which sometimes is more common as well with first-time dislocators. Nonetheless, he came back later from the ER, and the X-rays were negative. He did not have a fracture. Guess what? He wanted to play. We evaluated him when we had some time, however we knew he was not going to be playing that day, but he wanted to play the next day. I looked at the coach. I said, you really need him the next day. He said, well, it would be nice to have him. I evaluated him, and you would think that because he just dislocated his shoulder, for one, he would be in a lot of pain and you would not want to play. But athletes are unique, and you would think there would be some instability. Well, I evaluated him and he had full range of motion, and he was not wincing at all. I muscle tested every position of the shoulder I can imagine, and he was strong and solid, as strong as the uninjured side.

I checked for sulcus sign instability and for apprehension, which is has high sensitivity and specificity if you refer back to that one chart. I checked for apprehension, and he was negative. I clearly had no good clinical reason to hold him out from sport. I had a good historical reason because he had just luxated, but I had no clinical reason to hold him out.  The next day comes about, and we re-evaluate him again. I thought, when he comes back the next day, he is going to be swollen and sore, and his range of motion is going to be bad. Sure enough, he comes back the next day, no problem. Strong, no pain. I really get in there and dig on that anterior capsule, no tenderness. This athlete was like, Superman. I talked to the coach and I said, do you need him today? He said, you know what, we could probably do without him today. I said, great, let us lift this brooder heal up. Sure enough, two days later, the coach said, I could really use them. The athlete said, yes, he wants to play, so we did some rigid strapping.

Let us talk about this rigid strapping. You should learn this in your taping hands-on for FICS.  What we did is we created a basket weave right over the anterior part of the shoulder. We have tape running this way, we have tape running this way, so basically creating a basket weave, which makes it very strong. The way we taped them was to prevent the humeral head from gliding anteriorly, which is where it dislocated. Now, generally, I do not put the strapping right here. But when we were traveling, we could not take any aerosol cans with us, and I had no tough skin to make the skin really sticky. If the skin is sticky or tacky, this tape will stick really well. But because I did not have that, I had to make sure the tape was not going to come off.

I had to do some extra strapping around his rib cage. We want to make sure it is functional. That is why I took a picture of him with his hockey stick. He is left-handed with his hockey stick, I wanted to make sure that he was functional and he could perform most of his motions with his hockey stick. When he went out to play, I was keeping my fingers crossed every time he was on the ice. He went out for 60 to 90 seconds on every shift, about nine or ten shifts during the game. He performed wonderfully. Every time he got hit, I was a little concerned, but he would get up. He injury held up, and he was very thankful as was the whole team afterward. Sports chiropractors at these international games, can contribute to the athletes wellbeing and performance.


I apologize for the length of that case, but I thought that was an interesting acute case. Because for the most part, we see and discuss chronic cases.

Let us talk about some more tier one hurdle. One of them could be inflammation. There is several different ways that we can control inflammation. Earlier we talked about icing, when we mentioned P.R.I.C.E. and why we do not ice for inflammation. That is basically what the contemporary literature is saying anyway. But there are other ways of controlling inflammation. Here is compression. Here is an example of compression using a game. Ready? This is me at Rio in 2016 Olympics. We had four-game readies where athletes are basically coming in asking for it by name. It is a cold or cryo-compression unit and works great. Then NormaTec- NormaTec is more of a pnue. Pneu as in P-N-E-U, or air compression device. It squeezes from the fingers to the wrist to the elbow all the way up to the shoulder and then does that repeatedly to manipulate inflammation in the upper extremity. So here are several literature articles talking about how compression might clear out inflammation. We also know that nutrition can assist with inflammation management, and there is a long list of articles much longer than this. But prolific enzymes and fishing oils are just a couple of means of managing inflammation through nutrition.

Cognitive facilitation, so if this patient has poor posture, it might be predisposing them to some shoulder injuries, maybe through scapular dyskinesis. This is an interesting brooder’s exercise or a posture exercise where we wrap the band or some sort of elastic band around the feet, around the toes. We cross it at the heels. The first thing we do is we have them dorsiflex and then we have them separate their heels from each other. We have them abduct their hips and externally rotate. You can see the air band wrapped around their thighs. We have them supinate. We have them externally rotate, and then we have them abduct and horizontally extend their shoulders. Really firing the mid trap and low trap. You can see him tucking his chin. To reverse it, I want to go super slow, much slower than what he does. We want to bring the elbows in slowly, internally rotate, slowly pronate, slowly abduct the hips, and internally rotate the hips. Slowly bring the ankles together and slowly plan a flexible ankle, and do this repeatedly. This is a super simple exercise.

We will watch this video here.

Really simple exercise we can have our athletes working on a day-to-day basis. They can do a little bit of this before they study, a little bit after they study, maybe a couple of times a day. But this really assists with improving posture. I feel it does anyway. It is something we send them home with and we can progressively make it more challenging. Here he is using a red band. If this patient was able to repeatedly rep out this exercise for 90 seconds to two minutes and really not reach fatigue, then I would go up to maybe green. Depending on the color scheme of the company you use. So green would be a little bit more aggressive. Repeatedly just repetition, repetition, repetition. If they can do it for 90 seconds to two minutes and really not feel much fatigue, then I make it a little bit more challenging.

Some more tier one interventions and I am not going to go through a lot of this literature, which is in your notes which talks about chiropractic manipulative therapy for the upper extremity. You can read this on your own, taking a deeper dive later as you look up the articles. But there is one article that I want to refer to and it talks about the thoracic spine. I mentioned earlier that almost on every shoulder case now, I look at the lower thoracic spine. If I am going to adjust one area of the spine, I am going to adjust the lower thoracic spine. I thought the cervical spine was going to be the most important, and I had four years into my practice. Now I find that my outcomes are a lot better if I address a lower thoracic spine. This study supports the notion of looking at the thoracic spine for improved shoulder function. The premise is that the lower trapezius muscle seems to elevate or have improved tone, muscular tone for better scapular control.


Tier one still trying to remove some of these negatives or hurdles, and soft tissue restrictions. Soft tissue restriction is common. This is an example of me performing motion palpation of the soft tissues in the axilla. What I am feeling is for axilla soft tissue tone subscapularis, the medial latissimus dorsi, the lateral side of the trapezius. I am just basically motion palpating. I am gliding the fascia layers of fascicles of the muscles on each other trying to find a restriction. Once I find a restriction and know the plane of the restriction, I then have the patient relax and I thrust into that plane of restriction, of that farcical restriction. I hope that makes sense. You might need to rewind that and hear that again. But the soft tissue manipulation is very fast, very effective. Another way of manipulating soft tissues is to have the patient do some home exercises. The posterior capsule, measuring it on internal rotation in that prone position if I feel the posterior capsule is tight. This what is called a sleeper stretch. A sleeper stretch seems to be beneficial for the patients when they go home, and they can do something proactive on their own. I have the patient lie in a position of scaption.

Let us talk about this because when I look at videos, YouTube videos, textbooks, and look at other literature, I see this being done in a position where I am not happy with it. When I say scaption, you can see that she is angled back here a little bit. She is angled back at about 30 degrees. She is got all of her weight on the scapula, the flat body of the scapula, and then the glenohumeral joint is at about 90 degrees abduction. The elbow is at 90 degrees. Then she internally rotates when she feels that there is some resistance there. Then she takes her other hand and applies a little bit of overpressure. She should feel a deep ache in the posterior, glenohumeral joint. If she feels it in the front, then put a slight little pillow or wedge underneath the elbow to lift the elbow off the floor or the therapy table. That might put a little bit more of a stretch on that posterior capsule. Sometimes it takes a little bit of playing with it. Where the mistake I see oftentimes is they are straight up and down lines clearly on the glenohumeral joint and not on the scapula. I think our intention here, lying in scaption, is to stabilize the scapula to the floor so it does not wing away from the shoulder or the rib cage.

To do this in your office, it is very similar positioning for that internal rotation assessment. So let us talk about these positions.  What I want to do is place my forearm on the scapula blade- the blade of the scapula, and then that same arm is going to come across and stabilize the humerus in 90 degrees glenohumeral abduction. My other hand is, and you are going to be in a lunge position, is grabbing onto the distal antebrachium or the forearm and internally rotate the glenohumeral joint, and you will internally rotate until the patient says, yes, I feel it. Then the question is, where do they feel it? Do they feel a deep ache in the posterior glenohumeral joint? If so, that is what our goal is.

If they say, oh yes, I feel it in front of my shoulder, we do not want them to feel it in front of their shoulder. Then we are stretching the anterior capsule. What you want to do then is drop the elbow closer to the floor, right? Horizontally flex the glenohumeral joint just a little bit, just like we did in this other video over here. So again, stabilizing the scapula, stabilizing the humerus with the same arm, and then internally rotating the humerus with the other hand. Then I hold that position for about five deep breaths. I want them to take a deep breath and relax., dep breath, relax five times. Then I let it off a little bit and then I go back into the stretch. A little pearl and some of these slides that you may have noticed, I think some of these pearls are things that I found to be very beneficial in my clinical practice.

Some more literature here real quick, and we talk about stabilization. I think it is important in these first couples of tiers to really hit stabilization. In other words, centrate-teaching the shoulder complex. In this case teaching the shoulder complex how to centrate. This article from 2009 said established stabilization of centration of the glenohumeral joint gap of thoracic joints. They also stated that when you are strengthening- not strengthening, but conditioning. Conditioning is a better word. When you are conditioning the rotator cuff, you want to condition it for the function of the rotator cuff.


What is the primary function of the rotator cuff? To centrate the humeral head in the glenoid process. So we want to train or condition the rotator cuff to be a glenohumeral stabilizer. We do not want to train it to be a mobilizer, in other words, firing against a dumbbell or tubing in one direction against the higher resistance. That is developing strength. That is not what we want to do initially. This is my view, and it is worked out really well.  We want to train or condition the stratus anterior to be a scapula stabilizer, making a scapula fire against a resistance in one direction, doing like protraction strengthening exercises. It might make it strong, but it might not make it smart. It probably does not understand the neuromotor control function of the scapula interior. Keep those things in mind as we progress on. This article concluded that an operant scapula position and humoral rotation can affect injury risk during humoral elevation. Making sure that we have good centration and stabilization before developing strength, so we have optimum motor control. I think is going to be helpful for your patient.

Tier two, now we want to start implementing stability. We have removed some of the hurdles, some of the joint restrictions, and the tight muscles, to implement some stability. This is in the background here, we see Carl Lewis, one of the most medal Olympians ever in the history of the Olympics and he is wearing high heels. This athlete is strong, he is powerful, he is fast, he is agile. But you put him in heels, and you lose that stability. He clearly is not going to be able to perform like he did with being in regular shoes. So, tier two, let us talk about some exercises. How do we implement stability? We want the patient to co-contract and then train that co-contraction. We want them to contract their rotator cuff muscles, a stratus anterior, the mid to low trap, pec minor. We want them to turn off or turn down a little bit the upper trapezius. Turn up the mid and lower trapezius. I find the body blade to be very helpful in this context. This is a very easy position with the elbow nearby. I have them oscillated back and forth.  My goal is to have them perform this body blade motion for 90 seconds to two minutes without reaching moderate fatigue. If they reach moderate fatigue at 40 seconds, I want them to continue with this exercise until they develop motor endurance.

If they can do 90 seconds to two minutes and barely reach mild fatigue, then I am going to make things more challenging for them. One way of making things more challenging is to move the elbow further away from the body. So similar concept oscillating back and forth is called Oscillatory Stabilization, by the way. Having the elbow further away from the body does make it more challenging. Here we are even further away from the body and clearly does make it more challenging. We want to make sure the reason why he is doing it in a mirror. We can see a different view, but oftentimes I have my athletes doing in the mirror because if they are oscillating back and forth, oscillating, and if they are hiking their shoulder, that is not good neuromotor control. We want to make sure that they are looking at what they are doing so they can do these exercises  correctly.

A slosh bar basically is a PVC pipe, a plumbing pipe that is sealed on both ends and it has a little bit of water in it, and this one is probably one of the heaviest ones that I have. It is only about 15 pounds, so it is not very heavy, 15 to 16 pounds is about as heavy as I am ever going to go, even with some of the strongest athletes that I have. Because controlling this bar is important. So with tier two, we do not want the shoulder to go through a range of motion. We want the shoulders to stay stable. Hence, tier two is referred to as static stabilization. The shoulder complex is staying stable other than oscillating, but it is not going to a range of motion. In this video, you can see this individual, his shoulder complex is remaining static, but he is doing lunges. He is making a little bit challenging for himself because the water is sloshing all over the place and he is really struggling to try to centrate and keep his shoulder complex stable.

Here is another video of him performing a lunge and he is going fast. He is a high performance, athlete. Muay Thai, Brazilian jiu-jitsu, mixed martial artist. He is strong and stable, but I truly think that going slower is harder. So have your athletes do these lunging exercises when they are ready, but slow. So, another thing to consider now in regard to duration and total volume of exercise. I am less concerned about how many squats he is doing or how many lunges he is doing. It is less important to me of the counting, the number of repetitions he does with squats and lunges. It is more important to me to have him develop motor endurance, motor control endurance. Co-contracting the shoulder complex for 90 seconds to two minutes. If he can do squats really slow or lunges really slow for 90 seconds to two minutes and not really reach much fatigue with the shoulder complex, then he is able to move on to probably tier three and do more dynamic stabilization. Earlier in this lecture we mentioned that tier two was also for cardiovascular conditioning. We want to implement cardiovascular conditioning as early as we possibly can. But we do not want to introduce it so early, where their hurdles, remember tier one, those hurdles are being reinforced. If they have a poor motor pattern, we do not want that poor pattern to be reinforced. With cardio, I generally started with when I clear out some of these hurdles and implement cardio as early as possible.

The reason why is we want cardiac output to go up. We want blood to go round and round. In other words, an injury is not going to heal if it does not get adequate blood supply. So cardiovascular exercises that published a paper back in 1997 that was a literature review. looking at cardiovascular exercises and those that did cardiovascular exercise early in rehabilitation shortened their rehabilitation time, which is one of our goals.

It is important to select a cardiovascular exercise that your athlete enjoys. Me, personally, I do not like water. To have my therapist tell me to go on water and do rehab, I am probably not going to be very compliant. I would rather get on a bike or hit a heavy bag or something like that. Make sure we are picking exercise that your athletes are going to enjoy. Tier three is dynamic stabilization and when we refer to dynamic stabilization, we are referring to the shoulder complex. Moving to a range of motion while performing oscillatory stabilization or some other exercise. In this video, the athlete played baseball when he was in college. He is showing me his baseball pitch, and going through his range of motion. I am going to try to replicate that because athletes want this to be beneficial for their sport. I would have him also reverse. In this video, if you were to imagine I hit rewind, I would have him oscillate all the way back to that starting point again and then go forward. Here, he is going through his sport motion, and I am now implementing an oscillatory stabilization exercise throughout this entire range of motion. Now, again, I do not care about how many times he does it, I am more concerned about the duration of it because I want to build endurance at this point. I want to have him perform this exercise with a goal in mind of 90 seconds to two minutes. If he starts fatiguing, moderately fatiguing at 40 seconds, then he is going to continue doing this exercise day in and day out until he builds up that endurance.

This is just another exercise, but it depicts the point of him going through shoulder flexion while he is performing this oscillatory stabilization maneuver with the body blade. Utilizing the dynamic slosh bar in tier three. In tier three, as dynamic stabilization, we have the shoulder complex go through a range of motion, preferably a full range of motion. We need to have stabilization throughout a full range and see him slowly going through shoulder flexion while trying to stabilize this bar. So now you can see this bar is a bit smaller in diameter. This bar probably weighs 6 pounds, 9 pounds somewhere in that range. You know, 3-4 kilograms. I do not care how many repetitions he does, it is all about time, 90 seconds to two minutes as a goal. He goes up and down as slow as he possibly can, controlling that until he reaches moderate fatigue. If it takes two minutes, then we can move him forward. Maybe he is ready for strength training, which would be tier four.

Another thing to consider with controlling the intensity of this exercise is the width of his hands. The wider his hands are, the easier it is going to be. If he is wide, let us say he fatigues at two minutes here. That really was not that hard before moving him to strength training. I might just move his hands closer, which makes it more challenging to control the water that is in that tube. Here is an example of a tier three slosh bar intervention. You saw this individual earlier holding the bar over his head and just doing a squat here. He is doing a push press squat, and moving his shoulder complex while he is trying to also balance and stabilize the water that is in this bar. We are looking for 90 seconds to two minutes for the goal duration. If you do not have a slosh bar or body blade, you probably have a gym ball. You can perform a lot of these static and dynamic stabilization exercises with a gym ball.

Here is an example with a medicine ball over her head. She is co-contracting her shoulder complex. She has got good posture, her feet are rather wide apart, and she is sitting on an unstable gym ball, right? Gym balls round, it is going to roll around. It is fundamentally unstable if she can hold that ball over her head statically. We are talking tier two and for two minutes and not really reach much for fatigue. We can bring her feet together and make it less stable. With her feet apart, it is more stable. With her feet closer together, it is less stable. We can then as we move into tier three, we can have her then move her shoulder complex to a range of motion while in this unstable environment. When we go from tier two to tier three, we might want her to move her feet wider apart again to develop a stable base. But as she progresses, narrows the base once again. Here are some examples of doing some push-ups or some static stabilization. Closed chain exercises with their hands fixed to the floor while performing a variety of different core tucks and push up positions on an unstable surface of the gym ball.

We talked about strengthening earlier. I is important for me to stabilize the shoulder complex before developing strength onto it. This was a study that looked at weightlifters and all they did was strength training. It was done on 88 females, and they broke them up into two different groups. Well, when they were attracting the subjects, 31 of them were non-lifters. They have never really lifted before, at least doing bench press types of exercises. Then 57 of the 88 were recreational weightlifters. They had experience weightlifting, so they put both groups together and did some pretesting first. They tested internal rotation and overall strength, several parameters. You can see that little pearl right here, this was an important study. But they did some preliminary range of motion and functional tests prior to the study, then they had both of these groups go through a weightlifting program and a strengthening program. At the end, they did all these physical parameter tests once again, and they found that the weight lifters compared to those that did not lift. They did split up the group of individuals, and had half of the group do weightlifting. I think it was a six-week study. Half did weightlifting, the other half did not. They found that those that did weightlifting, strength training, they had decreased internal rotations statistically across the weightlifters. They also found posterior capsule tightness and increased anterior glenohumeral capsule laxity.

Really important, that I feel that we have appropriate stability of the shoulder complex before building strength. When we are building strength, maintaining that stability, and maintaining the overall functional range of motion. Some more tier four exercises, we are developing mobilizer conditioning, which is the term we use in the pyramid. We also refer to this tier as strengthening. This is where we are firing against a heavier load in a unidirectional or single plane, a single motion.  Scapular dips, here she is using her body weight and she is basically contracting lower trap, maybe some mid trap, maybe some latissimus dorsi. Trying to depress her scapula against resistance. In this case, the body and gravity are her resistance. Then for scapular push ups, many of you might think that this is a rattus anterior strengthening exercise and that is great. Remember, serratus anterior motor control is far more important than serratus anterior strength, at least initially. If I found that when I muscle tested my patient’s serratus anterior if I found that it was weak, then I would strengthen. But if it is strong like that swimmer that we talked about earlier, we may not need to strengthen. In fact, I am all about strengthening. As I get older, I realize how important strength is.

After 30 years of rehabbing patients and prior to the sports chiropractic world, I was in the strength conditioning world. I found that most of my patients would go through these first three tiers and they would be done. They were already strong because I was dealing with athletes for the most part and I did not need to strengthen them.  Those first three tiers when we are rehabbing a patient, especially with the shoulder complex, are going to be the most important. I do not mean to be little tier four in the strengthening phase, but I want you to understand that the first three phases clearly, truly are more important.


Exercise for developing strength, for retraction of the scapula which is basically protracting here in an eccentric manner, and then concentrate on contracting her scapula retractors. Internal-external rotation using thera-tubing. This is probably what a lot of you have done for rehabbing the shoulder. This is a strengthening exercise because you are firing against a single resistance or firing in a single plane against a heavier resistance. You can see that she was initially going slow and then she lessened the intensity and started doing some faster range of motion. There is some evidence to show that at the good progression is to fire against a higher resistance slower. Then to lessen the resistance and then finish off a few of the last repetitions at a higher speed. You can see that she has what she is going to do here with internal rotation and just a little bit faster. Same full range of motion.

Then here, this is more of like an empty can position. Some of you might think it is a supraspinatus strengthening exercise. Sure, we can call it that. It is shoulder abduction in my world, or in the position of scaption, which is about 30 degrees forward flexion.

I basically took an orthopedic test, Gerber’s lift-off test. We talked about this in part one, I took that subscapularis muscle test and turned it into a little exercise. I call these subscapular push ups. We have the patient with her heels just a little bit away from the wall, and then we have her recline back. We have a mirror strategically placed here so that you can see a couple of different angles of what she is doing.

Thank you


Part 5_Shoulder Continues

English Direct Download PDF – ICSC6 Part 5 Shoulder.txt

ICSC Upper Extremity Module 6
Part 5 _Shoulder Continues
Instructor: Tim Stark
Video Lesson: 13:50

One of the things that I consider as an alternative to strengthening the internal rotators and glenohumeral joint adductors when performing this exercise is when she pushes off the wall and it is an even steady push, she uses both hands. Let us say it’s the right shoulder that needs more strengthening, in that case, what I would do is lessen the push with the left hand, and maybe even consider pulling the left hand out and slowly lowering her, in other words, focusing on that eccentric contraction with the right side only: the injured side only. Pushing with both hands and in a more advanced exercise focusing only on the injured shoulder during the eccentric return.

I found these push-ups, the subscapular push-ups to be effective. I find that when I have done second opinions for other clinicians in my area and looking at chronic shoulder complaints that just aren’t responding to care, oftentimes the clinicians, it does not matter the profession, medical physicians, chiropractic physicians, osteopathic, et cetera, they tend to not look at the subscapularis. They don’t test it for muscular strength. They don’t test it for neuromotor control. They don’t take their fingers in that axillary or palpate the subscapularis and try to identify hypertonicity, hypotonicity, fascia lesions, et cetera. Do not forget to look at the subscapularis when you have these acute and chronic shoulder complaints.

As we continue discussing strengthening exercises, tier 4 exercises for the shoulder, this is where we start considering some of your more traditional rotary types of strengthening exercises. Now, this first set of exercises Section A here or Set A, I guess from all here and things from that. In this picture on the left-hand side where the arrow is, you can see that she is hanging off of a table, and then she is horizontally extending with a little bit of external rotation. She should be retracting her scapula as well. You can imagine what muscles are involved here: the rhomboids, middle, or upper middle to upper trapezius, and put some of the humerus external rotators such as teres minor and infraspinatus.

The next pictures or the ones in the middle are here. Here, this is typical of rotary types of exercises. You can see that she is doing an external rotation strengthening exercise and lying prone. Her elbow was flexed in here, you might not be able to see that clearly in the picture, but our elbow was flexed in that top picture and she has a bit of weight and it can be a thera-band, it can be a milk jug, but she is externally rotating. Keep in mind that she is firing in a single plane against the resistance, and therefore she is mostly firing the external rotators of the glenohumeral joint and through reciprocal inhibition, there is a fair degree of inhibition of the internal rotators. Again, firing against resistance with the external rotators is appropriate and by definition a strengthening exercise. Unfortunately, we are getting a degree of internal rotation inhibition. Therefore, we are losing that neuromotor control for centration to some degree in. That is why I emphasized in tiers, two and three, to focus on co-contraction and centration of the glenohumeral joint and the scapula-thoracic joint because when we start doing these types of strengthening exercises, we are almost diminishing the neuromotor control, the training, and the habit or the engram of centricity or of centration.

Then, in the far right-hand picture, you can see that she is doing a little bit more of a straight Pierre horizontal extension again with probably a rhomboid, scapular retraction contracting those rhomboids, and some of the horizontal extensors of the glenohumeral joint.

When I am teaching strengthening and strength conditioning; whether it is speed work or power work, we cannot ignore principles that are oftentimes taught, and sometimes it’s not taught in the Chiropractic program. I want to make sure that we at least cover this principle which has been around for a long time. It is called the said principle-specific adaptations to imposed demands. If we think back to what we were discussing with centration exercises, trying to establish our neuromotor control for centering the humeral head into the glenoid fossa for example, or centering the scapula to the thoracic cage for stability so that we can move the glenohumeral joint on the scapula. However, the shoulder complex is going to make specific adaptations to how we train it.  Based upon this principle, if we are training only with strengthening types of exercises, based on our definition of firing against the resistance in a single plane, such as using a thera-band, or a dumbbell, that is how the shoulders going to learn how to function. Similar to this last slide that we just discussed with external rotation against and using a dumbbell and firing into external rotation only, if we continually train the external rotators to fire without the internal rotators firing as well to create that centration to some degree, we are probably going to establish some sort of aberrant centration and establish an E-centration of the shoulder complex which may result to subacromial impingement sometime down the road, et cetera. We want to really make sure that we are focusing on tiers, two and three initially, making sure that we have good habits and good engrams established before moving on to our strengthening exercises.

Then, tier 5. Tier 5, the Rehabilitation pyramid is looking specifically at tasks that our athletes will likely be returning to; if they are speed athletes; if they are agility athletes, or if they are power athletes. We want to make sure that this athlete has the stability and the strength to add speed, agility, and power to their basis of function. Then we start working on speed work and agility, we can power work, making sure that we can return them safely to the sports that they need to perform.

One of the studies that I wanted to touch on before we bring to a close this presentation is a study from 2005 and again, this just plays on the point of needing to focus on the primary function of particular muscle groups. For example, the rotator cuff muscles play a significant role in the centration of the glenohumeral joint and other muscles with the scapula-thoracic joint. These muscles, even though the centration in the glenohumeral joint, and then secondarily involved with movement: external rotation, internal rotation, et cetera, you want to keep in mind that the primary role of the stabilizer muscles to centrate, play a role even into the end ranges of motion. When we are training, the rotator cuff muscles, for example, we want to make sure that we are training them to centrate the glenohumeral joint, through the full end ranges of motion. That’s why you saw us earlier with the body blade and the slosh bars to take that in tier 3, to take the body blade and take the slosh bars, et cetera, through a full range of motion.

In this study, what it noted was if there is less rotator cuff muscle contraction and I would even say co-contraction and more mobilizer contractions which are larger superficial muscles such as the pectoralis muscles and the deltoid muscles. When we get more mobilizer contractions versus the stabilizer contractions, we result in less joint centration and if we have fewer joint centration, we could probably theorize that there is less joint stability.

I want to close by talking about a case. This is an Australian floorball athlete and she presented to me with bilateral shoulder pain and weakness, mostly with her slapshot. She was only a few weeks out from going to what I believe is the World Championship in another country. I think was from China at the time and she noticed that her performance, especially when taking a slapshot was significantly influenced. Her productivity was going down and of course, the coach was noticing that.

This is the slapshot and you will notice that she has her stick in hand. I wanted to understand what her motions specifically were; what her shoulders are doing; what our core is doing; what our hips and lower extremities are doing during the motion. I had a pretty good understanding of specifically what that activity was and what device was in her hand. Then, I took the device out of her hand and I had her go through those same motions. I wanted to understand what her arms, shoulders, core, hips, and all that uppers are doing without the device in her hands so that I could imagine placing body blades or sloshed bars or medicine balls or whatever I might need to try to mimic the motion.

In the end, applying the said principle-specific adaptations to imposed demands. These are the actions that she wants to be able to perform in a matter of a few weeks and we needed to try to sort out this bilateral pain in her shoulders when she was doing her slapshot. What we did then is we started introducing tier 3 stabilizing exercises. We took body blades and we had to try to mimic that same motion. Through oscillatory stabilization, oscillating and bouncing these body blades, we were able to establish and elevate co-contraction of not just her shoulder complex, but her entire core, her hips, and her knees. When she was initially doing this exercise, we had her go slow and really focus on co-contracting. Through the oscillatory stabilization input, it was easier for her to understand what co-contraction is and we were able to go through this motion. We spent a few days aggressively because our timeline or window for returning her back to her sport was short. She was highly compliant. It was great. She responded well.

What we were able to do was progress her quickly through this body blade component of her rehab. We were able to progress her through this tier 3 aggressively, and she felt pretty good already. We were doing some other soft tissue interventions with instrument assistance and the soft tissue mobilization and some joint manipulation of her full spine and shoulder complex, of course. Then we progress to more tier 5 types of power activities because we wanted to try to mimic the power of her slapshot. I wasn’t always around to bounce a medicine ball to her. We use this rebounder to try to mimic some of her shoulder functions and her trunk rotation or hip motion.

We need to do forehand and backhand types of motions. She progressed well. We can resolve almost completely her symptoms, allowing her to go to her world competition and perform the way she needed to. This is a rather quick progression of a case of how we took a patient, with symptoms of course, in a very short timeline and progress her through tear 2. We did not move her through a range of motion as you would probably know going back to the slides here. We had her just body blade and particular motions where she was more symptomatic, which was on, I believe the follow-through is where she was mostly symptomatic. We mostly work with body blades in that position, initially with tier 2.

Then as you saw in the video, tier 3 was taken through the entire slapshot, and then finished with these power exercises. We did not really do much first-tier 4 strengthening exercise because she was a high-performance athlete. She was very strong when we muscle tested her. She did not really need strengthening exercises. She needed neuromotor control. Then, we needed to add the power movements to this neuromotor control.



Part 6_Elbow and Hand

English Direct Download PDF – ICSC6 Part 6 Elbow and Hand.txt

ICSC06 Upper Extremity Module 6
Part 6 Elbow and Hand
Instructor: Kevin Schroeder
Video Lesson: 1:29 hour

This talk is titled Elbow, Wrist, and Hand: Looking at Injury Assessment and Management of orthopedic issues related to the elbow, wrist, and hands.  Our objectives are pretty straightforward. We are going to review some of the anatomy for the elbow, wrist, and hand very, very briefly. We are going to spend the majority of our time exploring different orthopedic pathologies that affect the elbow, wrist, and hand. Of course, along similar lines are discussing the management strategies that we can utilize for these pathologies of the elbow, wrist, and hand. I do not need to tell you guys that the elbow is a pretty complex structure. We have a lot of musculature that crosses the elbow joint and that influences wrist and hand function, which we will get to a little bit later on more specifically, but I think we tend to forget sometimes the complexities of this anatomy. I want to point out a few things here that if you look at some of the soft tissue structures, the tendons, for example.  The ligaments, specifically, they go in a lot of different directions, which can be problematic sometimes for a clinical evaluation, so we have to keep that in mind. Then, keeping in mind, too, that we have a lot of musculature that is occurring at the elbow joint, but does not necessarily influence the range of motion of the elbow joint as much as it influences wrist and hand.

If we were to look at the 10,000 foot view of what elbow assessment were to look like, components you want to look at, of course, starting with your usual history components, previous medical history, your family history, so on and so forth. We also want to look at, of course, the present condition in orthopedics. That is obviously the main thing that we really want to look at. We are going to look for the location, the onset of those signs and symptoms.  We really want to figure out the mechanism injury, if at all possible. Sometimes, it is not possible to determine that. We also want to determine what are their activities of daily living or their sport that they are involved with that is influencing some of the pathology, the problems that they are having. One of the biggest things that we will see with the elbow specifically, especially when it comes to sports, is throwing and throwing mechanics.

If you are not as familiar with throwing mechanics, the phases of throwing, I would strongly encourage you to look this concept. I have put a reference to a great seminal article here from a publishing, Sports Health. It is a little dated, it is from 2010, but it has still got a lot of great pertinent information that is still valid today. Sports Health is an open access journal, so you should not really have any issues finding this article.  After our history is complete, we know we can get into that more of that physical exam. We are looking from an inspection’s perspective; we need to look at all four sides of the elbow. For an interior perspective, things that I would be looking at is their carrying, or how are they holding their elbows within a guarded position, or is it in a kind of relaxed neutral position.

We also want to look at the Cubital Fossa. From a medial perspective, we want to look for the Flexor Mass and as well as the Medial Epicondyle, because there is a handful of pathologies that specifically speak to these two structures that we will discuss a little bit. Then, similar from a lateral perspective, we want to look at the Cubital Recurvatum, and how is that position looking, as well as the Extensor Mass. We can even add in the Lateral Epicondyle there, as well.

What does the alignment of the forearm and the wrist look like from that lateral positioning? Is it in a neutral position? Or again, does it look like it is kind of guarded or malaligned? That could be influencing how we proceed with our physical exam there. From a posterior perspective, we want to look at bony alignments again. How does that humerus look as it articulates with the radius and the ulnar there? What does that olecranon process look like, and what does that olecranon bursa look like? If that is inflamed, or irritated, or ruptured, that is going to really inhibit our ability to really visualize some of those posterior structures. When we palpate, of course, with orthopedics, we always want to start remote and then move our way towards any kind of suspected injury, as a means to protect the patient and build a trust and rapport with those patients. We do not want to go straight to any kind of sites of fracture or anything like that. Of course, we want to gradually build up our palpation towards the suspected area. We want to look from an anterior, medial, and a lateral perspective here.

Anterior speaking, we want to look at the biceps brachii. So, at the elbow, of course, we want to look at the attachment site, or the distal biceps attachment site, the cubital fossa again, that brachioradialis musculature, and then the wrist flexors. Specifically speaking, the pronator teres, our flexor carpi radialis and ulnaris, and then the palmaris longus. If the patient has a palmaris longus, we know that a percentage of the population does not have one present.  One easy, quick way to tell if they do have a palmaris longus is to have them do resistive wrist flexion, and right at the wrist on the anterior side, if we are looking from an anatomically correct position of the anterior side of that wrist. If you see two tendons pop up, they have got a palmaris longus present. From a medial structures perspective, we want again to look at that medial epicondyle, the ulna, as well as the ulnar collateral ligament or UCL.

Then from a lateral perspective, we want to make sure that you are palpating the lateral epicondyle, the radial head, radial collateral ligament or RCL, the capitulum, annular ligament, and as well as any lateral aspects of that UCL. Remember that UCL has a very funky shape, so we really need to be really cognizant about how we palpate it and how we visualize it, if we are suspecting any kind of damage or trauma to that UCL.  From a posterior perspective, again, that olecranon process, that olecranon fossa, the triceps brachii which is that distal attachment there. The anconeus, the ulnar nerves, especially because it is so superficial there, right at the elbow there. Our wrist extensors, extensor carpi ulnaris or extensor carpi radialis longus and brevis. Then, our finger extensors, as well here, the extensor digitorum and extensor digiti minimi. We even might want to even palpate all the way down into the musculature of the thumb, a little bit, since some of those have attachments close to the elbow, like the extensor pollicis longus and brevis, as well as the radial tunnel.

When we talk about our physical examination, we want to look at joint and muscular assessments. Goniometry is critical. It gives us a nice quantitative outcome measure that is nice for documentation purposes. It also gives the patient something that they can tangibly hold onto. Not to mention that insurance companies really like those quantitative values for reimbursement purposes.  First, if we are able to, we can do goniometry. Then we move into active range of motion, then manual muscle testing, and then our passive range of motion. We do not really want to do those out of order because, again, if we pick up on something that could be potentially dangerous or harmful to the patient, we do not want to further cause harm to the patient by doing these out of order. So, active first, then manual muscle testing, and then passive range of motion.

For the elbow, we are looking at the four main cardinal movements there, which is flexion, extension. We must remember that pronation and supination, although we kind of visualize that at the wrist and hand, it is truly an elbow motion. We need to make sure that we are assessing pronation and supination of the elbow there. Joint stability testing.  For the most part, it is limited for the elbow. It is just valgus and varus testing, which we can do for suspecting any kind of ligamentous problems. But more importantly, maybe, is the joint play and looking at articulations between the humerus, the radius, and the ulna, there.

Of course, our neurological screening can always involve an upper quadrant screening. We want to look at dermatomes and myotomes and then specifically to those upper extremities. It is going to be those deep tendon reflexes with the biceps, triceps, and brachioradialis reflexes. Once we get into these specific pathologies, which we are about to hit here in a second, we will start talking about some regional-specific pathologies and with those selective specific stress test or special test that deal with those specific pathologies there. One of the more traumatic things that you could potentially see in sport is an elbow dislocation. Of course, this would be an acute onset. The mechanism of injury or MOI is an axial load to the forearm when the arm is placing some kind of load-bearing position. One acronym you might see a lot of times in orthopedic references is a FOOSH, or a falling on an outstretched hand, very common injury for elbow, wrist, hand injuries there.

But with an elbow dislocation, not only would we see some axial load. Probably a FOOSH is also with some supination occurring. Pain is going to be localized to the elbow. There is going to be radicular symptoms that may be described down to the forearm and the wrist, especially if we are concerned about some neurological involvement. Predisposing conditions could involve things, like, if they have got a history of elbow instability, they are significantly at a higher risk for re-injury dislocation.  Even in our patients that we have seen surgical interventions here, we kind of see they are just a little bit more stable than non-surgical patients here. If patients have a shallow olecranon fossa, especially if that olecranon tip is prominent, it is just a kind of an anatomical variant that predisposes them to more of an elbow dislocation. We did tend to see these a little bit more in children from an incidence perspective.

We will look at a functional assessment. In this case, just how is the patient presenting and what are they able to do? Are they guarding? They are obviously going to be very limited in what they can do with the elbow, wrist, hand. They are going to be guarding; they are not going to want to use it. They are going to be protecting it, probably holding it pretty close to the core of the body there. From an inspection and palpation perspective, there is going to be an obvious deformity. There is probably going to be edema and there is probably going to be tenderness to palpation on a lot of those structures.

We know we do not want to continue on with a lot of these functional testings. We do not want to be testing a range of motion and then you are mostly testing any of these surrounding structures here. We certainly do not want to be doing any kind of stress test or special testing. I do want to make sure that I am keeping an eye on the neurovascularity of the upper extremity at this point in time, especially distally. I want to be kind of assessing any impairments to radial, median, and ulnar nerves, and we can do that pretty easily in the hand.

We know that the first and second finger are primarily radially innervated there. The middle finger there. The third finger is more of that median nerve and the last, fifth finger and part of the fourth finger, more of that ulnar nerve innervation route. It is easy to just do a sensation check there and then making sure that we do still have a quality radial pulse or capillary refill. If you are not familiar with capillary refill, all you are simply doing is you are just visualizing the nail bed, squeezing the nail. You should see the blood escape from that nail bed and then as you let go, the blood should return quickly.

This just may be challenging if they have got painted fingernails. A trick of the trade, I like to always keep some acetone or nail polish remover in my kit in case I need to do something like this. They make acetone wipes now that are just like alcohol prep pads. They come in little square packets that you can just keep and rip open quickly if you need to use it.

From an imaging perspective, we get your normal set of X-rays in AP and a lateral view there. But if I am concerned about any kind of ongoing or deeper soft tissue damage issues, things along those lines, that are probably not going to visualize on an X-ray, I am going to get a CT scan there. Then if we are really, really concerned about trauma, really concerned about vascularity, which is not something we would commonly see in sport, we could do an Angio there to visualize the vascularity.

Important thing here to note, though, is lots of times with these elbow dislocations, it is not common for them to be isolated. There is usually going to be some fracture associated with these as well, which is why we do not like to reduce them in the field, and it is really hard sometimes to definitively determine whether or not a fracture is present. Unless you are 110% sure that there is no fracture, you really should not be reducing these in the field or in the sport until after you get an X-ray to visualize, specifically the coronoid process there in the radial head and the olecranon process.  How do we manage this? Well, this is going to be a referral to the ED. We will just splint it in place. We do not really want to move it. We do not want to run the risk of dislodging any kind of bony pieces that may act, essentially, as like a razor and cut neurovascularity there. So, we always just splint in place. We want to continue to assess and reassess neurovascular. If there is a loss, we definitely want to refer them to the ED right away, usually via ambulance.

Another trick of the trade, easy kind of splinting—if you have some vacuum splints and whatever, that is great and you can use them, that is awesome. What I have found in my own personal clinical experience is that those can still be tricky to get on sometimes even if the patient is kind of positioned in a nice 90-degree elbow flexion position. It is just to take a pillow, like a normal pillow that you have on your bed and just sandwich it between the underside and the outer side of the elbow and it just kind of conforms a nice little sandwich around the elbow.

Then, you can just use like a big, long ACE Wrap and go around the pillow, squeezing the pillow against their core. Then, you can use the ACE Wrap to go around the outside of the pillow and their whole body, their core. It is just a great, easy way and you can still have easy access, then, to continue to check radial pulse and/or capillary refill. There is a fair number of patients, too, that will go into shock with these injuries for whatever reason. As always, any time we have a patient with shock, we need to refer them immediately to the ED for further care. So that is an automatic 911 call there.

We talked about elbow fractures. If we are concerned about a fracture, they are probably going to have a FOOSH mechanism—that falling on an outstretched hand—with some kind of hyperextension of the elbow. Of course, this is an acute onset there, and the pain is going to be pretty much localized to the elbow, unless we have got other conditions going on with comorbidities. If they have got a shoulder dislocation or something along those lines, there could be radiating pain up and down.

The other thing I will say that is, again, if there is some kind of neural involvement with the elbow fracture, they may have radiating pain through the distribution of that nerve. That is something else to keep in mind. So, predisposing conditions specifically for elbow fractures, things like osteoporosis or skeletal immaturity, especially with children, obviously. Then, from a functional perspective, it is going to be very similar to an elbow dislocation. They just are not going to want to use the elbow, wrist, hand at all. They are going to have that elbow protected close by that inter-core stomach area. They are not going to want you to move it, touch it.

If we have got any kind of obvious deformity or edema, you know, that is pretty much the end of our evaluation. We are just going to go ahead and refer them. We will get X-rays, imaging, anything like that. We need in-clinic or whatever. But if we are not sure, we are still trying to rule this out, you may start to do some very basic range of motion, manual muscle testing, but you are going to find out really quickly that they are not a fan of you doing that. Obviously, we would not be doing range of motion and manual muscle testing with an injury like this. Same thing with our special or stress test. We would not be doing any kind of specific testing for this type of pathology. Neurovascular speaking, again, we are concerned about impairments of nerve distributions, radial, median, and ulnar nerves. We want to continue to assess those, as well as assessing either radial pulse and/or capillary refill.

From an imaging perspective, again, an AP lateral X-ray, you might see something, we will call a fat pad sign, which is indicative of bleeding into the joint space surrounding the elbow there. It is not always present, but it is something that if you note and you have kind of got a clinical correlation, that could be a pretty good sign that they have got some fracture going on that may be visualized on an X-ray. If it is not, then we need to think about probably doing a CT scan if that is the case. But most of the time, these are easy to visualize on an X-ray.  What I am also concerned about, though, with these elbow fractures is a lot of times, if the distal humerus is fractured, or there is a fracture involvement there, it is going to be intra-articular. There is going to be bleeding inside of that joint there. If the fracture is open, I mean that any time there is a fracture that is open anywhere in the body, that is of course after a medical emergency and automatic referral, we must get that fixed. That is probably a surgical intervention as well as some antibiotics and a lot of other fun things going on there.  We can probably see some elbow dislocation occurring in conjunction with a fracture. Here is that fat pad sign I was discussing here. If you look at the space, the kind of the darker soft tissue spaces surrounding the joint, there surrounded by these arrows, you can see that it is a little bit darker in those soft tissue spaces there.  That is that fat pad sign, again, it is not always present, but if you have got a mechanism, if you have got a clinical correlation that is at least letting you think it is one of your differentials of an elbow fracture there, this is probably what you have got going on. That is a referral there. We want to splint this in place, do not move it around, or change anything so as not to run the risk of causing further damage or harm. Continue to assess and reassess neurovascular integrity there, if it is absence, we get them to the ED right away because that is a surgical intervention in there.

You can use that pillow elastic wrap technique there to really get them in a good, nice,  stabilized position. If you do not have a pillow on the sidelines but you might have something like a heavy jacket or something, or a blanket. Something along those lines might be around, then you can always use as well. Then, of course, as with any kind of acute trauma, we want to monitor for shock and transport, if that is present.

Moving a little bit away from more of the traumatic elbow injuries into some of the more manageable orthopedic injuries that we can see. Ulnar collateral ligament sprains, or UCL sprains, these are commonly seen in sports. They can present in a lot of different ways; they can be very acute, or they can have this kind of insidious, almost elusive, onset. We are probably going to see this more times than not in a patient who has a throwing type of sport or mechanism. The mechanism of injury here from an acute perspective is going to be a valgus force. This could be seen in football, this could be acute trauma, especially if there is a pileup. Somebody rolls onto an arm, that is where you might see more of the acute version of this. But from a more insidious perspective, it is going to be repetitive activities with some valgus stress to that elbows that you see, so like a baseball pitcher, for example. The pain is pretty much localized to the medial elbow.

Predisposing conditions have internal rotation deficits, they are more likely to have a UCL sprain. This goes back to our throwing mechanics in our pitchers. That is why we tend to see this a lot more in baseball pitchers than probably any other groups out there. Functionally speaking, overhead throwing patients will describe a significant difference in how accurate they are with their throwing, or how faster the velocity, the endurance, or the number of pitches they are able to throw kind of a deal. That could be another one of those kind of subtle, but telling signs that there is some kind of UCL sprain going on. You have to remember, the shape of the UCL ligament is very unique. It has got a lot of different fiber orientation. Even just palpating the more superficial aspect is just one band of it, so we cannot just necessarily rule out that there is no UCL sprain just because we palpated the superficial aspects and there was minimal to no pain, kind of a deal. We have got to have a high suspicion there to, maybe, some of those more inner bands might be the parts that have this sprain going on.

From an inspection and palpation perspective, there might be an effusion, ecchymosis. There could be a potential for some scapular dyskinesis. This is probably developing from some throwing mechanics compensation. They have not been throwing the right way for some time, and as a result, moving up the kinetic chain, that shoulder, that scapula is not moving the same way that it should. That could also be another telling sign that extra stress is being transmitted through that UCL to compensate. There may also be some tenderness to palpation over that medial epicondyle or the coronoid process.

From a range of motion and manual muscle testing perspective, again, we are going to always start with the active range of motion. What can the patient do by themselves without assistance from an outside source? That range of motion might be limited secondary to pain, but they are able to go through usually a full range of motion there. Manual muscle testing: there might be some decreased strength with wrist flexors, there may also be some pain present but not necessarily.

Then, from a passive perspective, once we get to the end-range, especially with supination and extension with wrist extension, you will see some more pain pop up with that. We can do valgus testing. We want to do that both at 0 degrees full extension, and then, as well as at 15 to 25 degrees of elbow flexion. It just helps us to isolate different aspects of that UCL ligament when we are in full extension versus slightly flex. That is why we want to test both. From a neurovascular perspective, it is usually unremarkable. You do not see much issues there, then from an imaging perspective, we rarely need to get imaging done. If we are suspecting there might be a tear, especially with some of those more inner bands, then we are going to be looking at an MRI. But usually, we can treat this well and without having to get any imaging. What, if anything, I would recommend is, unless you think there is a tear going on, try some conservative therapies first, which we will talk about here on the next slide and before getting an MRI and going down that route. If we are worried about any kind of gapping with valgus testing, we could get an X-ray, especially if they are an overhead throwing patient with medial opening. Just if we are worried about any kind of avulsion, or fractures, or any kind of bony pathology, maybe because of the concurrently with a UCL sprain. The management, we can start with the conservatives: the R.I.C.E., the NSAIDs, manual therapies. In my own clinical practice, all test that dry needling has done, I would not say it cures the problem, but it does help to alleviate a lot of their symptomatology, which can help make their other therapies, like, therapeutic exercises, go a lot more smoothly. So, therapeutic exercises, even if there is a partial tear, depending on the level of competition that they are engaged in, they may do very well with therapeutic exercises and continue to function pretty well.

Rarely are they going to be done with exercise or rehab and then they do not ever have to visit rehab again. They do need to be on a continued maintenance program for as long as they continue to be on sport. But what we want to do here is, of course, is we want to examine and correct any poor mechanics, especially if it is throwing mechanics, we want to be able to visualize and correct. For me, my pitching coaches are phenomenal at this. They are great to help us with this and really break down. We can take some video if we want. If we take video, we want to make sure we are doing it from a head-on, as well as from a side view, and really slow it down and really be nit-picky with a lot of the different phases of throwing.  If throwing is not your strong suit, I strongly recommend reviewing a lot of the throwing mechanics in the phases of throwing and what should be occurring throughout each throwing phase, because we can see a lot of different pathologies manifest throughout these different throwing phases. So anyways, going back to therapeutic exercises, the ultimate goal is that we want to strengthen elbow flexors and extensors. It is a lot of forearm work, in addition to upper arm, bicep, tricep work there.

Lateral epicondylalgia, or Tennis Elbow, have got this very insidious, nonspecific onset. It is usually from some kind of overuse with repetitive, forceful wrist extension, especially if there are these eccentric muscle contractions. Eccentric muscle contractions tend to be the source of a lot of different orthopedic issues, and this is certainly no exception to that. From a pain perspective, we could have tenderness over the lateral epicondyle, as well as into that common wrist extensor tendon mass. As you palpate, and even if you start to palpate the actual muscle bellies, or some of those extensors, you will start to notice that they light up easily, it is painful quick. Predisposing conditions here, we tend to see lateral epicondylalgia in patients that have rotator cuff pathology. Again, it is a compensation thing that is developed over time. DeQuervain’s, which we will talk about a little bit later. Carpal tunnel syndrome, smoking, and oral corticosteroids: smoking and oral corticosteroids just degrade tendons over time, so that is where we tend to see that as a predisposing condition.

From a functional perspective, we have pain weakness or some compensation occurring with gripping activities. Anything that has got a repetitive elbow flexion, extension motion, which makes sense, like, it is called tennis elbow. If they are constantly flexing, extending the wrist and the elbow to hit the ball over the net and back and forth. Inspection and palpation, they will have that pain with palpation. There could be some crepitus, some swelling over that lateral epicondyle, and then a common extensor mass. But do not bet on it being there all the time. Some of these things may not always be present.

Range of motion. Actively speaking, pain with wrist extension and elbow flexion, as well as pronation, supination, might be limited secondary to the pain, but they are able to go through that full range of motion. From a manual muscle testing perspective, wrist extension with metacarpophalangeal joint extension, with elbow extension, is going to be painful. Passive range of motion: there is going to be pain or limited end-range of passive wrist extension and elbow extension occurring concurrently.

There is a tennis elbow test. There is also stress testing; for the most part, it is going to be unremarkable, so you can try the tennis elbow test. It is not the greatest test, but it does sometimes give you some direction as far as what is going on. From a neurovascular perspective, this is rather unremarkable, there is not much going on that is of concern there.  From an imaging perspective, we do not see a lot of imaging done for this. You are not going to see anything on an X-ray or CT, probably. But if you do suspect that some of the soft tissues are degenerating, like the tendons from the common extensor mass, you could get an MRI. But even more easily, you could do it in a musculoskeletal ultrasound to help visualize some of that tendon thickening.

Before we talk about management strategies for lateral epicondylalgia, I want to talk about medial epicondylalgia because the management strategies are pretty much the same for both of these. Let us hit this first before we talk about treatment management strategies. So, medial epicondylalgia, or Little Leaguer’s Elbow, has that insidious onset, it is from repetitive, forceful wrist extension or pronation occurring. We have pain at that medial epicondyle along that common wrist flexor mass and the pronator is there. Repetitive activities, or history of repetitive activities that eccentrically load that medial elbow musculature. Things where there is a club involved: the golf club, a baseball bat, or even sometimes, throwing would be an area where I would see this as a potential pathology.  Functionally speaking, they are probably going to have decreased grip strength as secondary to that pain, again. They will probably have some compensatory patterns or motions that are going to require weird-looking gripping or motions, especially when they must perform elbow flexion and extension.

For my inspection and palpation perspective, it is very similar to the lateral epicondylalgia. There is pain with that potential for crepitus or swelling over that medial epicondyle and common flexor mass. All range of motion speaking, actively, there is going to be pain with wrist extension, and elbow flexion. There is pronation, and supination might be limited secondary to pain, but not necessarily all the time.

Manually muscle testing pain with wrist extension, as well as MCP joint extension. The knuckles extend with the wrist extending, they are going to have some kind of pain shooting up towards that medial epicondyle. Then from a passive range of motion perspective, that pain is limited to their end-range or passive flexion with the elbow extended. There is not any great special testing or stress testing for this; that is always rather unremarkable.  Then from a neurovascular perspective, for concern that there might be something else going on, we could potentially do an upper quarter screening to rule out any kind of cervical involvements, or cervical nerve outlet involvement. But that is usually unremarkable, unless there is something else going on cervically speaking.

Same thing with the imaging. It is rare we need to do any imaging, but we could do some X-ray if we wanted to rule out any kind of osteophytes arthritis, osteochondritis dissecans, or fractures. We can use the musculoskeletal ultrasound or an MRI to visualize any kind of tendon thickening or degeneration that might be occurring. How do we manage this? Well, we can try some of the more conservative things: the RICE, the NSAIDs, the manual therapy is, in my own personal clinical practice, I have seen some good results with dry needling. In addition to some of the other things, another thing could be the soft tissue mobilization in certain assisted soft tissue mobilizations that you could do, as well.

Therapeutic exercises are important here. Though, for long-term management, you want to examine and correct any kind of poor mechanics. Then you want to work on strengthening forearm, upper arm, as well as rotator cuff to help correct any kind of imbalances that might be going on there.  You also can try something called a tennis elbow strap. These are things that you can get from, gosh, and you can get these online, you can get these from big-box stores. You can get these from pharmacies. These are everywhere. They probably run you about $20, give or take, they are not that expensive. But what they do is they compress the flexors and extensors of the wrist close to their origin site, with the idea that they compress the muscle belly. It slightly alters the angle of pull of the tendons at the attachment sites there. It helps to pay to essentially try to alleviate some of that pain that could be caused by that.

In some people, this is all that they need, and they do well. They continue playing sport with ease. These are not usually banned in sports; they can continue to be playing with them. In other people, it does not do anything for them. You have to explore some of these other options there. It is just an easy thing to try. It is quick. It is not really going to harm anything. It is like $20 out of the pocket. If it does not work, not a big deal, but it is something out there that is a tool.

Distal biceps tendon rupture, this is a little bit more of a concern, although it can sometimes be a little alluding to diagnose. This has an acute onset; it is usually from some eccentric loading of the biceps brachii with the elbow flexed. They will have pain at the cubital fossa that, at first, will be a moderate to severe pain but will decrease over time. We primarily see this in individuals who are 40 years of age or plus, and/or a history of smoking, anabolic steroid use, or cholesterol statin drug use. They are going to have a visible difficulty with lifting-type of activities, especially when they are trying to lift anything in front of the body, where they might be in a kind of already slightly flexed, double-flexed position there. But any kind of lifting activity is going to be challenging for them.

You might be able to feel a palpable defect at the distal biceps tendon insertion. It is a little bit challenging. Sometimes, it is just based upon a little bit of individual anatomy, how long they may have waited, as well as what other things they might have happened on there first. For example, they have some swelling, it may be difficult to palpate where you would anticipate that attachment being.

So, what you can do is you can do something called the Hook Test. Essentially, what that is, is where you can have the patient put their arm out in front of them and you can have them make a closed fist grip, and you can take your hand as the examiner and try to hook your thumb into what would be the bicep, the distal biceps tendon. They should be pretty easy to find if it is attached. If it is not easy to find, it is probably detached and it is probably retracted a little bit there. So that is a really easy test that you can do really quick to just determine if it is still intact.

All range of motion speaking, actively, this could be normal because there are, of course, there is other musculature that help to do flexion/extension on the elbow, as well as pronation and supination. Manual muscle testing is going to be decreased strength for the elbow flexion and forearm supination. Remember, that is the primary motion of the biceps. It is not just an elbow flexor; it is primarily more of a supinator, if anything else. So, those are the two things that I am really going to be looking for from a muscular perspective, what does the quality of their supination and their elbow flexion look like there?

Passively speaking, it probably will be normal. It might be a little bit painful if there is a partial tear, since there is more stress now going through less fibers, but that potentially could even be normal as well. The Hook Test, I already explained that to you. In the neurovascular speaking, it is usually unremarkable. If I am concerned about any kind of ongoing swelling that might be pressing on some of that neurovasculature, we might have some secondary trauma going on. Then from an imaging perspective, you know, we can start with an X-ray to visualize some of the bony anatomy, especially if we are worried about any avulsion, fractures, anything like that. But then, we can also use either an MRI or CT could be ordered to rule out some of the other bonier things like coming into fracture, things like that.

You can try conservative management. If it is successful, that is great, but it is probably they will not have the greatest quality of life from that. Surgical intervention is more preferred. What that looks like is after that is performed, it is a rehab process. It takes about eight weeks, after that surgery is complete, for the full range of motion to come back. Those first eight weeks are really focusing on regaining range of motion. Then you can progressively go through strengthening elbow flexors and extensors once that full range of motion has returned.

Neuropathies of the elbow, this can be a little challenging to identify sometimes. Other times it is straightforward, just because we have three distinct nerve root distributions here. But anyways, this is an insidious onset with nerve compression traction, or inflammation occurring there. Think about the anatomy and the distribution of the three main nerves coming through here. The ulnar nerve is going to be more that medial aspect of the elbow, forearm down into that fifth and part of the fourth finger there.  The median nerve is that anterior forearm with going down to the hand and into the more lateral aspect of that fourth finger and the entire third finger. Then, that radial nerve is that more dorsal forearm, wrist extensor region down into the hand and the thumb, and index or second finger there.

Predisposing conditions here, diabetes, circulatory impairments, fractures, the normal things that you would be concerned about with a neuropathy in a patient are still going to play here. Functionally speaking, the hand/elbow may have atrophied, there may be some visualization of the atrophy, especially in the thenar, hypothenar region. They also may have some weakened strength or movement. There might be some swelling present, there may not. There might be some pain present or there may not. There might be some paresthesia present, or not. We just must examine each distribution of the nerves there. Active range of motion: it might be limited; it might be normal. Manual muscle testing: there is probably going to be some weakness, especially when we think about the musculature that is innervated by the specific nerve that we are suspecting.

Then from a passive range of motion, this could be normal, but there might be some increased signs or symptoms with the nerve involvement when the nerve is maximally tensioned. For most of these nerves, it involves wrist extension, finger extension. Then we can move them into radial or ulnar deviation, whichever direction we are trying to go there.  Tinel’s Sign. If you are not familiar with Tinel’s Sign, it is a sign that we can use for a lot of different points along the body. But what we are doing here is we are just tapping on superficial aspects of the nerve and what we are trying to do is elicit neurological response.  Here with Tinel’s Sign, we could do it at the carpal tunnel. We could also do this up at the elbow with the ulnar nerve being so superficial there. We just tap back and forth over the nerve, and you start gently, and then you can get progressively a little bit more forceful and faster if you want, if they start to not get it. What you are looking for is, again, any kind of neurological symptomology. So, shooting pain, sharp pain, numbness, tingling, things along those lines. That might be indicative that there is compression occurring along that nerve’s distribution.

We can also do an upper quarter screening, again, if you want to rule out cervical involvement. If we really are concerned, if we really cannot get to the bottom of it, we can always do some electrodiagnostics, like a Nerve Conduction Study. But these are not fun for the patient. These are not pleasant tests to go through. These are not something that should be willy-nilly ordered off the bat. These are things that you have tried a few other things, you have tried to diffuse different routes of diagnosis, you have tried some therapy before ordering some of these tests, because these are not fun tests for the patient.

Imaging, we can do an AP lateral and an oblique view of X-rays which may visualize some bony involvement. But if we are not expecting any kind of bony involvement, there is not much imaging we can do. Just keep in mind that, of course, this nerve could be compressed or have trauma at several points along the distribution. We do not want to rely just strictly on one site. If we treat it, we think it is going to go away. There is probably going to be multiple sites that need to be addressed.  It really depends on etiology as far as how we are going to approach the management. We can always start with some of the more conservative therapies: NSAIDs, RICE, again, dry needling tends to do well. If we are concerned about some other soft tissues like musculature, spasming, pressing against some of the nerves, we can always do some therapeutic exercises working on trying to shift or offload pressure from one area of the form to another that might be contributing to some pain or pressure along the nerve distribution.

If there is entrapment and you are not getting success with some of these more conservative therapies, then look at a surgical intervention if we really need to. But again, these surgical interventions are not always the greatest, they do not always provide the most amount of relief and in some instances, they can end up causing more problems than they resolve. It is really a balancing of options there. Wrapping up the elbow here from some of the more common and more traumatic things that we would see, obviously, we are talking about Sports and Sports Medicine here. So, how do we evaluate the elbow on the field?  With any on-field evaluation, it is always wanting to rule out any life- or limb-threatening injury, and then are we able to move the athlete or move the patient off the field safely. Since we are talking about elbow, wrist, and hand movement, ambulation, probably, is not really going to be too much of an issue.

But we could still be concerned about a limb-threatening injury.  We want to go through a quick history. If we were not able to visualize what occurred, we did not see the mechanism of injury, which sometimes happens, there is a thousand things going on during a sporting event. Sometimes, I am not looking at just the right person at the right time, you miss it. You need to either look at video tape, or you can have the patient describe it, or maybe a coach or another player saw it. You can collect information from other people. But most importantly is, how are they positioning that upper extremity at the time of the mechanism of injury, and how are they presenting to you after the fact?

Look at forearm and wrist alignment, look at that posterior triangle of the elbow, making sure that it looks kind of normal and well-aligned. If not, that might be indicative of fracture or displacement going on. You can do a quick palpation of some of the bony structures. We do not want to work away from, but work towards, so we can do mid-shaft of the humerus down into the distal aspect of this humerus. Then from the distal aspect of the radius and ulna, more towards the proximal end, we can do a quick range of motion assessment, active, and manual muscle testing quick if we really needed to.

More times than not, when I am on the field, I am going to have them do in a quick active range of motion. If that is problematic, I am going to stop everything there and just take them off the field. I can continue to do the rest of this evaluation on the sideline. The other thing I would want them to rule out quick, is to make sure there is no neurovascular trauma going on there.

Wrist and hand anatomy.  Just remember that the hand is pretty complex when it comes to anatomy. Here, we have got many, different bones going on here, with phalanges at the most distal ends, then the metacarpals, and then the carpals more proximally here.  From a muscular perspective, we have got several different layers and lengths of muscles going from the elbow down into the most distal aspects, the fingertips of the fingers and everything in between. We have got intrinsic, as well as extrinsic, we have got a lot of anatomy, lot of soft tissue. Sometimes we have to be very meticulous about our evaluation and sometimes it takes some time to really dive through some of the anatomy that we have to go through and review. The 10,000 foot view here, we are talking about what does a wrist and a hand assessment look like. It is going to be fairly similar to the elbow in some respects, but very different in other respects. You always want to start with previous medical history, family history, anything along those lines. Then of course, history of the present condition at hand. What is the location, the onset of that injury? What is the mechanism of injury, and have they had any results in changes in activity because of it? This is probably more important if this is more of a sub-acute or chronic condition.

If this is acute and we were there, we witnessed the injury, for example, we may not have an ability to really assess any changes in activity because they have not done much since the injury. But, if they notice that they have got slightly decreased grip like when they go to turn a doorknob or something along those lines, those subtle changes could be big key players in a clinical assessment.

For the functional assessment, you can always ask them what activities make the signs and symptoms worse. I am specifically looking at ADLs, activities of daily living, as well as throwing mechanics, since we are talking specifically about sports medicine here. General inspection: again, what was the hand and wrist posture? Are there any gross deformities? Looking at the palmar creases, is there any swelling, or redness, or any bumps, or anything along those lines?  Lacerations or scars, something you can look for, not so much necessarily specific to sports medicine, but something that you might potentially see, because of just the nature of sport is something called Russell’s Sign. Russell’s Sign is when you start to see scarring along the knuckles from individuals who purge, after either binge eating or eating disorder. There starts to be scarring from the teeth hitting the knuckles during the gag reflex. That could be a sign, especially in your sports where body image is important, gymnastics, dance, even some combat sports like wrestling. That might be something that you could potentially see.

Inspection of the wrist and the hand: so, what does the continuation of the radius and the ulna look like? Is it parallel? Is it uniform? Or are there any kind of abnormal jumps, bumps, things along those lines? The same thing with the carpals and metacarpals. We want to look at the alignment of the MCP in the IP joints, the metacarpal phalangeal, and the interphalangeal joints there. Does the patient have a ganglion cyst? Ganglion cysts are extremely common in the hand. More times than not, they are not harmful or problematic. But occasionally, they do lead us to two problems. Or they can be indicative of what people at slightly increased risk for some pathologies. We will talk about a few of those here in a few minutes.

Of course, we want to inspect the fingers and the thumb. What does the quality of the skin look like, especially at the fingernails? Do they have a kind of any sub-ungual hematoma, or blood underneath the fingernails itself? Any kind of finger bed infections? Their fingernail alignment? One of the things that we can do, too, is we can have the patient curl their fingers like this. If their fingers are rotated or switched, or they are not uniform across the hand, that can be indicative of either of certain types of hand fractures or of misalignment, non-union recovery from certain hand fractures. Then, we want to look at finger posture, of course, as well. From a palpation perspective, we have a lot to palpate here. Tons of structures, from the palmar side of the wrist: the radius, the flexor carpi radialis, the palmaris longus, again, if they have one, the carpal tunnel, the ulna, the flexor carpi ulnaris, the TFCC or triangular fibrocartilage and its complex. We will talk about that in depth a little bit. The pisiform, the hamate.

From the dorsal side, or the back side of the wrist and the hand: there are the ulna, ulnar styloid process, that ulnar collateral ligament, extensor carpi ulnaris.  Lister’s tubercle, we tend to forget sometimes about lister’s tubercle that runs along that dorsal side of the wrist there, as well, along the radius there. That distal radius/styloid process, the radial collateral ligament, and all of your carpals there, especially the scaphoid, lunate, and hamate.

We are going to talk about a few, unique pathologies to those carpals there as well today, and then of course, the extensor carpi radialis longus and brevis. There is a lot of musculatures going on through the forearm and down into the hand. It is important to have a good understanding of origins, insertions, innervations, and actions for these musculatures. It is because it can really be the information that you need to really be meticulous during a clinical exam. Then finally, from a palpation perspective: we want to look at the hand, as well, so that thenar eminence, the hypothenar compartment or eminence as well, as well as that central compartment, the metacarpals, the phalanges, the metacarpophalangeal or MCP collateral ligaments, the IP or interphalangeal collateral ligaments, extensor digitorum, the extensor pollicus longus, and the abductor pollicis longus and brevis.

From a functional perspective, there is a handful of tools that we can utilize. Goniometry is really great. We are going to do active, then manual muscle testing, then passive range of motion testing. For the wrist and hand, we want to look at flexion/extension of the wrist and of the MCPs and the IP joints, as well as radial and ulnar deviation. Remember, that while the word deviation implies otherwise, radial deviation is when we sideways tilt the hand towards the radius; ulnar is sideways towards the ulna.

From a thumb perspective, thumb has a few additional movements because being a saddle joint. Goniometry, still, we want to use that. Active, manual muscle testing, passive range of motion, and we want to look at flexion/extension, as well as abduction, adduction, and opposition. Remember, opposition is when we take the thumb and bring it across the palmar aspect of the hand towards that fifth finger.  Same thing with the fingers here, we want to look at flexion/extension, abduction and adduction, or AB- and AD-duction, as well as IP flexion there. We can assess grip dynamometry, if we feel so. There are tons of different grip dynamometers out there. I just gave you two examples that are out there. There are tons on the market. I am not aware of any research that says that any one is better than the other. I think it is just kind of more personal preference.

In my own clinic, I have got more so that red dynamometer there on the left. It does have an adjustable grip depth, those little notches in the silver pole sticking out there. You can change how far back or forward that is based upon the person’s hand size, which just helps give you a better idea of true grip strength there.  Our joint stability tests, it is so important here to compare bilaterally because these are not necessarily the strongest movements as it is. We want to make sure that we are comparing bilaterally. We want to be looking at radial and ulnar collateral ligaments at the wrist. We want to be looking at radial and ulnar collateral ligament in all the fingers, along those PIP and DIP joints, as well as the thumb IP joint.

Wrist joint play. How much translation or movement is there with movement at the radius, ulna, the dorsal, and palmar glides there. You can even do inter-carpal glides there, as well, although it can be a little painful sometimes for the patient. We want to be a little bit aware of that.  Neurological screening is not always necessary here, but we could do an upper quarter screening if we are concerned about, again, radiating discomfort down into the hand, as well as a Tinel’s Sign. That is that tapping over a superficial nerve. They try to elicit some kind of neurological symptomology. Finger deformities, you will see these. Some are more concerning than others. The first one being a Jersey Finger. This is when we have an avulsion of the flexor digitorum profundus tendon down into that DIP. Their distal interphalangeal joint of anyone of fingers two through five is ruptured, and so they cannot flex the fingertips, is essentially what is happening. This is a problematic thing. This is an automatic referral to a hand specialist. They need to get in to see a hand specialist within 24 hours. I would say 48 hours is really pushing it because the tendon can start to retract.

Then it can be an involved surgery, and it can cause a lot more problems there. Immediately speaking, what we do is we want to splint that DIP into a joint flexion there. We are concerned about vascularity supply, so we want to get them referred to this right away and get this figured out. It is probably a surgical intervention that is going to occur for them.

A mallet finger is similar, in that we have an avulsion of the extensor digitorum tendon, but it is at that DIP joint as opposed to that PIP joint.  The DIP here is postured at approximately 25 degrees, 35 degrees, give or take, of forced flexion. They cannot actively extend this. You, as the clinician, could come in and move this up. It probably would not feel too great to the patient, but you could do it. How do we treat this? Well, we want to splint that DIP into extension, and that needs to stay splinted for about three to four weeks. It is critical that you educate the patient that they do not remove that splint at all. It has got to stay on. Even for a second or two, if they let that splint come off, and that finger starts to move, it can basically have to restart the whole process of that another three or four weeks. It has got to stay on 24/7.

Stack splints are these plastic slide-over splints that work really great for this kind of thing. You do have to be a little cognizant, though, because we are keeping the splint on for three, four weeks straight. If they are doing things like showering or washing their hands, you do not want to have skin maceration occurring or anything like that. We want to be cognizant about making sure that the skin tissue integrity is okay. We really do not necessarily need to see a hand specialist for this, for surgery, but we do want them to be seen, just to get eyes on it and make sure that, again, we are not missing anything or mis-visualizing anything here. We do want to refer, but surgery is rarely required for a mallet finger.

Boutonnière deformity, is where we have an avulsion of the extensor digitorum tendon. There is something called a pseudo-boutonnière deformity, which is where the volar plate itself becomes ruptured. So how do we treat this? Well, we essentially, again, it is a stack splint kind of a deal. We can splint the PIP and the DIP into extension. They need to be in that splint for three to six weeks. Afterwards, we can start to do therapeutic exercises. specifically for a lot of the wrist-hand strengthening, and some finger-hand intrinsic strengthening, just to get that hand moving again. Surgery is not the most common thing we need for this. It is rare that we would need surgery, but we do want to have a hand specialist get eyes on this again, just to make sure that everything is progressing accordingly.  Another thing that we could potentially see here is arthritic responses, rheumatoid arthritis and things. We might see these boutonnière deformities if arthritis or autoimmune is a cause for this. This is something we would want to refer to a hand specialist because normal orthopedic interventions that we would do in sports medicine is not necessarily going to have the same outcomes. So, we would want them to be seen by a hand specialist for that, specifically.

Distal forearm fractures, these can come in a couple different shapes, sizes, and varieties. But by and large, they kind of present the same way. This is going to be an acute onset, and have hyper-extension of the wrist with possible tendon rotation, including a FOOSH.  The patient might also have some immediate, sharp, or other distal forearm or proximal wrist pain. Predisposing conditions can include osteoporosis. Thinking about that weakening of it. Another group that we might see it with is prepubescent or pubescent children, teenage children, especially at the growth plates, the distal growth plates there, along the radius, the ulna.  Functional assessments, not really much to see there. From an inspection and palpation perspective, there is potential for gross deformity. Although it is not going to be necessarily a given, it could be a non-displaced fracture. For example, if we do have an open fracture and that is readily evident, that is an automatic referral to the ED because that is going to require some kind of fixation, as well as antibiotics

Boney palpation is probably going to be omitted. If we are suspecting a fracture, it is going to be omitted. If there is a form of gross deformity present, we do not want to be, again, dislodging or causing any further trauma or problems to the bone there. There might be discontinuation along the bone. There might also be tenderness to palpation along those long bones. There may not be.

Range of motion: if you are suspecting a fracture, we do not want to do anything. Manual muscle testing: if you are suspecting a fracture, we do not want to do anything. Same thing with special testing. Neurovascular speaking, we just want to ensure that, again, the nerve distributions appear normal, that they have good quality sensation, that they have got good distal refill. If I am concerned about a distal forearm fracture, I do not want to be doing a radial pulse. I want to be doing more of a capillary refill so as not to risk causing further problems, pain, trauma, to the distal fracture, if that is the case, I will probably do more of a capillary refill.

Imaging: of course, we will start with an X-ray. Sometimes, depending on visualization issues or complexity of a fracture, we may order more than that, but we would just start with an X-ray from there. Then treatment. Splints, we want to monitor them for shock, and of course, refer them to the ED or to Ortho for splinting and casting and determining if there is surgical intervention that might need to occur. There is something called a Colles Fracture. This is where the radius will displace here. Anteriorly, there is something called a reverse Colles fracture where, instead of anteriorly, it just displaces posteriorly, it is a common fracture that we see.

Scaphoid fractures are really interesting, to be completely honest. A lot of times, these have an acute onset, a lot of times, they have some sort of forceful wrist extension, and they fall on it. This is falling on an outstretched hand, where there is compression that goes through the scaphoid. So, they not only fall in that outstretched hand, but maybe they fell over more on that thumb side of the hand as they fell, and it just happened to be just enough force and direction to fracture that scaphoid. Patients, a lot of times, would not seek care for this or they will delay care, because it just feels like a very subtle, very minor type of pain. Forceful hyperextension of the wrist, again, here, is what we are looking for, though, from that mechanism.

From the pain perspective, that lateral wrist into the anatomical snuffbox is really what I am looking for. If I have got any kind of tenderness to palpation in the anatomical snuffbox, I am going to have a high suspicion of some kind of scaphoid fracture going on. Who do we see this with mostly is under 40 years old males who play sports. Functionally speaking, they might have some reduced grip strength, pain with gripping, or activities that require ulnar deviation. Just because the tendons are then stretched over the scaphoid, and it pushes extra pressure along the top of that scaphoid. So that is why we see it there. There might be swelling, there might not. There might be a little bit of an increase in tenderness to palpation in the anatomical snuffbox. There might be a lot of increase in tenderness to palpation over the anatomical snuffbox. But if there is point tenderness in that anatomical snuffbox, I am instantly thinking, as one of my differentials, is being a scaphoid fracture.  Active range of motion is pain at the terminal wrist range of motion, specifically with wrist extension and ulnar deviation. It is going to be probably unremarkable from a manual muscle testing. The scaphoid does not really have a whole lot of say with muscular attachments. We are not going to probably see a lot there. From passive range of motion, as we put over pressure into wrist extension and ulnar deviation, we could probably see a slight increase in pain there.

Radial collateral ligament stresses will increase lateral wrist pain due to the compression there. Pain might also increase with radio-carpal joint play in that scaphoid area. You can also take the first metacarpal and axial load it into the scaphoid and see if that processes any pain, which could also kind of be an indication that there is pathology affecting the scaphoid there. From a neurovascular perspective, the screening is going to look normal in an X-ray. We are going to do a PA X-ray. But I will tell you what, the sensitivity and specificity are poor in the few days following the trauma. You will have a better sensitivity and specificity the longer you wait. But the problem with waiting is that we are concerned about necrosis and vascular compromise. The scaphoid already does not have a great vascularization as it is. If we fracture it over, we disrupt any further neurovascular supply to it, we could have the scaphoid die. This is where the CT would come into play. We would want to get this evaluated by a hand specialist to really make sure that we do not have any of that kind of compromise going on.

A hamate fracture is an acute onset. We are looking at, again, a FOOSH mechanism with force being transmitted via long modality: so, a golf club, a baseball, bat, or racquet. What we see a lot of times, is that, if it is not a FOOSH, the force is transmitted up that instrument. Pick up a baseball bat, for example, or golf club, and there is just enough vibration that is generated into that hamate that causes it to fracture.  There could also just be a direct blow to the hamate, like a crush type of injury, for example. The ulnar side of the hand has pain adjacent to that fifth metacarpal and over time, that pain becomes less specific and more diffused in the general hand area. You are going to see a reduced grip strength and pain with gripping with possible swelling and tenderness to palpation over the hamate.

From a range of motion perspective, finger ab and adduction at the fifth finger might be painful. There might be pain during resistive flexion of the fourth and fifth fingers, with the wrist more in an ulnar deviation. Or with pain with resisted abduction of the fifth MCP. From a passive perspective, you might see some pain with passive extension of the wrist and the fifth MCP. You may see it, as well, with the fourth, but not as likely as you would see with the fifth.

From a special test perspective, there is not much that you are going to see there. It is going to look normal. From a neurovascular perspective, it is going to have potential paraesthesia from that fourth and fifth finger primarily from ulnar nerve trauma, or nerve compression because of the swelling in that area, or because of a comorbidity of just isolated nerve trauma, as well. You want to evaluate that, as well.

X-ray we would want to get a carpal tunnel view with the wrist supinated, but keep in mind that this does have a fair potential for a false negative. So even though the X-ray may come back normal, we still might want to order a CT scan just to double check and make sure. We do want this to get evaluated by a hand specialist, because these do have a fair amount of mal-union or non-union secondary to them being mistreated, or misdiagnosed, or under-treated, which can obviously cause hand impairment over the course of the lifespan if that is not addressed.

Perilunate, or lunate dislocations look similar, so, an acute onset. Mechanism of injury again is that FOOSH-ing, that falling on an outstretched hand. There might be ulnar deviation present with that perilunate dislocation, but the mechanisms can be one and the same a lot of times, as well. From a pain perspective, we are going to see something along the lateral wrist and hand, and again, they are going to have that reduced grip strength and pain with gripping. There is the potential for some swelling in that lunate region. It is also possible that the lunate will be very prominent with palpation if it is displaced. Range of motion, actively speaking, will be limited with wrist extension, and finger flexion might be painful. The manual muscle testing, there could be pain with weakness at the PIP and the DIP flexed. Possibly, this could be normal as well.

Then, from a passive perspective, there is limited wrist extension here that would be pain-free. Passive finger extensions probably can also produce some pain here, as well. Not a lot, in the realm of special testing or stress testing here. From a neurovascular perspective, I would just want to check the distribution of that median nerve, make sure that there is no impingement. Then, from an imaging perspective, we could start with an X-ray again, an AP and a PA, as well as a lateral view of the hand there and then a CT scan if we are still not 100% sure what is going on. What we do need to do again is to make sure that we get this referred to a hand specialist. Not so much for the lunate, per se, but I am, worried about that scaphoid getting fractured because of that lunate moving around, especially if it is partially displaced or there was a subluxation there, too, that could occur sometimes.

Scapholunate dislocations are acute, and there is tensile force that is placed on these ligaments as the joint is essentially forced past its normal range of motion. It emanates from the palmar and dorsal sides of the wrist from the joint line when we are looking at pain. Functionally speaking, again, decreased grip strength, increased pain with the grip, and the patient may want to protect the range of motion with their hand and with their wrist there.  If this is acutely evaluated, we could see some swelling. But if this has gone on for a few days, we may not see as much swelling. But one of the tell-tale signs is just going to, of course, be that true tenderness to palpation of that scapholunate joint. Active range of motion might be decreased with wrist flexion/extension. If we passively move them, we might see some limited flexion/extension. If there is that bone sticking out, it acts as a boney block so we cannot get into that full range of motion. But it might be hard to tell, so this is a poor scenario when we want to compare this bilaterally.

Manual muscle testing is probably going to be unremarkable, though. There is a potential for hyper-mobility in that scapholunate joint where you can take it, and you can try to move it and push it around a little bit yourself. You just want to be cognizant that you are not applying enough pressure that you cause it to become further damaged, further dislocated, or something along those lines.  By and large, neurovascular concerns are non-existent, it is going to be looking normal there. We can try to visualize this with an X-ray in a clenched fist view, or an AP view. But we are probably going to have to use an MRI over a CT. They just tend to be more specific in this case. To be honest, conservative treatment is successful with treating these.  We do want to refer to a hand specialist for an evaluation, what would be the best course of action for that specific patient there.

All right, TFCC or triangular fibrocartilaginous complex injuries. These are interesting. They can be traumatic or degenerative. If it is acute, the patient may not report the injury for some time because it just might feel like they “sprained their wrist” or did something relatively minor. They tend to seek evaluation and help weeks, sometimes months, after the injury. A lot of times with these because it is just such a dull, nagging pain. It is not anything super concerning up to the patient usually affirms. FOOSH-ing, of course, is a mechanism, as well as repeated or forced wrist hyperextension. From a pain perspective, distal ulna along the medial half of the wrist. The wrist UCL ligament could be tender. There may also be an audible click present.

Functional assessment speaking, there is increased signs and symptoms with weight-bearing of the arm, or with activities where there it requires a lot of ulnar or radial deviation. We could see this a lot of time, say like, with gymnasts where what they are doing a lot is pushing up from their seated position, like on the horse, or something along those lines. Then there is a rotation component where they are putting them into this ulnar or radial deviation back and forth. From an inspection palpation perspective, we are talking about diffused swelling around the wrist, if possible, but it is not usually present, so do not go out of your way looking for it.  Tenderness to palpation over that distal tip of the ulna, there, along the medial half of that wrist joint line. There might be some palm tenderness over that ulnar collateral ligament of the wrist there. Range of motion is going to be limited secondary to pain, especially with wrist extension and ulnar deviation. We are putting prime force onto that TFCC in that position. From a strength or manual muscle testing perspective, it is going to be unremarkable. They are going to have full strength there.

From a special test or stress test, again, we can try to force that UCL and stress that wrist UCL to see if we can elicit some pain. But there is not going to be any laxity seen with the UCL. From a neurovascular perspective, it is going to look normal. From an imaging perspective, I put an MRI up there, but really, it is going to have to be an MR arthrogram here. We are going to have to inject that dye.  It is just a very difficult structure to see here. Even then with the MRI, it is not the greatest because it does not have the greatest vascularization occurring there, but I would recommend an MRA over an MRI there. You can try conservative therapies first; it is kind of hit-or-miss. It is a lot of grips strengthening, wrist strengthening. But ultimately, what will probably have to happen is a referral to a hand specialist for the potential exploration of some surgical intervention. I will say that if they do have a history of ganglion cyst, especially on that radial palmar side, because the root of those cysts tends to be very close to where a TFCC is, we tend to see TFCCs more commonly tearing with those patients.

Carpal tunnel syndrome, so, CTS. Sometimes you will see the abbreviate CTS. This is a very insidious onset. This is from repetitive wrist motion that involves a lot of wrist flexion/extension, primarily wrist extension, but it can be flexion, as well. We are going to have radiating pain along the median nerve distribution into the hand, and potentially up into the forearm. These patients will complain that they mostly experience this at night or with activities like typing. They are seated at a desk typing on a keyboard.

From a functional perspective, this is almost an ergonomic thing. What we are looking for, a lot of times, is these patients have a very forward head posture, their neck, their shoulder postures. Everything is very much forward faced. It is just very poor mechanics and starts to translate into poor mechanics down the kinetic chain into that wrist carpal tunnel area.

The palmar aspect of the wrist, especially over that carpal tunnel, might feel thickened. There could be some atrophy of that thenar eminence. So again, you can compare left to right. If they have got a bilateral case of CTS, this might be difficult to examine. Their tenderness to palpation or tenderness even with sustained pressure over that palmar aspect of the wrist, especially close to that carpal tunnel, which could be problematic for the patient.

From an active range of motion perspective, they might be slightly limited due to the stiffness, although, there could be some normal-looking responses there. If there is manual muscle testing, we can look for chronic strength decreases that may be seen with the abductor pollicus brevis, the flexor pollicus brevis, as well as the opponens pollicus. From a passive perspective, the median nerve symptomology may increase with wrist flexion and extension range motion. We can use Tinel’s Sign to examine that symptomology there. We can reproduce it there, so we can do just a nice little Tinel’s tapping right over the palmar aspect of that carpal tunnel there and see if that elicits any pain. As well as Phalen’s Test, which is where you just have the patient actively press the dorsal side of both of their hands together as hard as they can for 20 or 30 seconds. They might start to get some of that neurological sensation, that numbness, tingling pain that they feel with Phalen’s Test there.

From a neurovascular perspective, there could be some decreased sensation along that median nerve distribution. If you wanted to quantify it, you could do two-point discrimination to do that. From an imaging perspective, you want to rule out any kind of bony involvement. If there is bony overgrowth occurring that is causing the compression, then there would obviously have to be a surgical intervention to help correct that. But if it is more of a soft tissue compression component, we would need an MRI to visualize that.  I would not necessarily jump to imaging right away. I think that you can get away with some of these conservative treatments first, and then if they consistently persist, then we can look at imaging and seeing if there is something else going on here. But from a treatment perspective, first and foremost is activity modification. We want to identify what is going on, making sure that they have got good posture when they are sitting at a desk or that they have got good posture when they are sleeping.

If we need to, we can always put them in a night splint, for example, or even in a splint during ADLs or sport if we need to. For bowling, for example, they do make bowling wrist splints. As well as making sure that they are taking breaks from activity, that they are not pushing through activities where they need to be resting. We talked splints already. Meds: you can try NSAIDs, you could try corticosteroid. Sometimes they provide some relief, sometimes they do not.

Manual therapy is hit-or-miss. Sometimes this does well, sometimes it does not. The biggest thing here is the activity modification, though, as well as these therapeutic exercises, where the goal here is to strengthen the wrist and the grip. But if this is ongoing, these conservative treatments are not successful, then we can refer to a hand specialist. They would do a surgical release of that tunnel, and that tends to have some pretty good outcomes there.

Metacarpal fractures, we are looking at any one of the five metacarpal fractures here. More times than not, we are going to see the fifth, more common than the fourth, more common than the third, second, and first metacarpals. So, this is an acute onset. There is longitudinal compression like a punch. They punch a wall, for example, that is a very common thing in sport. A crushed force where they get stepped on. Again, think about football, for example. They pile up and somebody gets up, or gets pushed onto somebody else, they could be stepped on and crush the hand there. Or sheer force with the finger being hyper-extended, so that the hand gets caught under something and causes it to get pulled in an abnormal direction. There is definitely going to be pain along that diaphysis of the metacarpal in question.

From a functional perspective is they really are just not going to want to do much of anything with that hand. It is going to be difficult with any kind of grip. Grip is going to be painful.

From inspection perspective, if there is any kind of gross deformity, it makes for an easy diagnosis and makes for an automatic referral to the ED, because that might need a quick surgical intervention. Fracture of the fifth and, sometimes, of the fourth may result in a shortening of the knuckles. As you visualize the hand, it will look like the knuckles have kind of shifted places and it looks like they are shortened. But that is not always necessarily present.  Another thing, too, is you can do the abnormal finger rotation. You can have the patient hold out their fingers towards you, and if you see any kind of left-to-right comparison, if one is rotated more oddly than the other, that could be an indication that that metacarpal has not only been fractured, but there is rotation going on. We have got to, look at surgical intervention to correct that. We do not, obviously, want to palpate a gross deformity if it is present, especially with these more delicate bones like the metacarpals because we do not want to cause further damage. We do not want the bone to become an open fracture where it starts to protrude through the skin and things like that. We want to be cognizant about that. We want to be very gentle with our palpation skills in this area.

Something else we can visualize is this look like a false joint or sometimes we hear it called tenting, where the two ends of the bone might still be sort of connecting, but they are not connecting 100%. So, it will push up against the skin and it looks like a little tent under the skin. That is another clear sign that there is metacarpal fracture that is going to need some kind of surgical intervention there.

By no means should you be doing range of motion, manual muscle testing. If you do not have any of the gross deformities there, you are not 100% sure, you can do the long bone compression test, which is where you basically have the patient gently curl their hand down. You can gently tap down the length of the metacarpals and see if that lights up any pain there. Rarely do you need to get down that far because usually just even with just light palpation over it, you are going to let them up and they are going to know that there is something abnormal going on there.

From a neurovascular perspective, this is usually okay. I am concerned that if anything starts to shift, or we have any kind of bony fragments that we could have vascular disruption there, so we do want to check capillary refill. We do want to get an X-ray, and we do want to refer it to the ED because, again, this might need more of an immediate surgical intervention to correct.

DeQuervain’s is a little odd. What we are seeing here with this is insidious onset of repetitive stress, that is usually involving radial deviation. The extensor pollicus brevis, and abductor pollicus longus, the radial styloid process, and the thenar eminence are all painful. That probably extends into the distal forearm a little bit, too, especially when they are moving from ulnar and radial deviation. There is increased symptomatology with activities involving radial deviation. This could be some types of racquet sports, for example. Video games could be another thing that we might see a lot of this with, as well. Inspection could be swelling over the radial styloid process and some of those surrounding tendons. From a range of motion perspective, actively speaking, there is pain with the ulnar, radial deviation. From a thumb perspective, we could see pain with flexion and extension, specifically at the MCP joint, but we could see with the IP as well, as well as with abduction and adduction.

Manual muscle testing, is going to be painful with that resistive radial deviation of the thumb. Pain with all of these motions, but primarily with extension and abduction of that CMC, that carpometacarpal joint. Then from a passive perspective, the wrist will have some pain towards the end-range of the ulnar deviation and the thumb, passively speaking, pain with flexion and adduction at that carpometacarpal joint again.

You can do Finkelstein’s Test, which is basically where you just have the patient tuck the thumb into the hand, and they grasp the hand, and then they just radially deviate, and they will start to feel that pain sensation occurring in there in the hand, like what they were coming in and describing to you before.

Neurovascular perspective: it is usually normal. From an imaging perspective, I mean, there is just going to be an image there, so that is not going to be an issue. What do we do? We want to do some of the more conservative exercises, like the ice and the splinting. We want to do activity modifications. NSAIDs really do not do a lot. They have not been shown to be very successful with research. So, if you want, you can tell them that they can try NSAIDs, but that is not going to probably be their golden ticket there. If it continues to go on, we can do some surgery to release some of those tendon sheaths. This does have a high success rate with very few complications. So that is an option there.

Ulnar collateral ligaments can be acute or chronic. From a mechanism’s perspective, we can have more of a hyper-extension or hyper-abduction of that first MCP joint if we are talking about finger UCLs there. Chronic might be just more of those repetitive type of motions of extension. We are going to get pain along the ulnar aspect of the first MCP.  From a functional perspective, there can be pain or weakness with gripping-type tasks. Then from an inspection perspective, there could be some localized, potentially extensive, swelling occurring, just because of how easily the pockets of the hand, there, can work and allow for fluid movement. There could be some swelling in the adductor compartment, as well as into that thenar eminence, with some potential for possible ecchymosis.

Range of motions perspective, actively speaking, the pain does increase with extension, abduction, and opposition of that thumb. From a manual muscle testing perspective, weakness is experienced during that metacarpophalangeal flexion and carpometacarpal adduction, as well as the pinch grip might be decreased. From a passive perspective, there could be some pain at the end-range of the thumb in extension and abduction there.

Stress testing we can do those valgus stress tests. We can do it with any kind of ulnar collateral ligament. We can also just do ulnar collateral ligament stability testing, which is where we just try to open up and the gap at different areas of flexion, extension, opposition. Try to rotate down and pull out towards the patient there.

Neurovascular speaking, usually this is normal. If we do have something abnormal, it is probably not going to be from the UCL. We have got something else going on there. If we are concerned about any kind of a bulging fracture, we could get an X-ray. Other than that, though, we are not going to need to visualize anything there. The treatment is going to depend on severity. Less severe really does do well with conservative therapies: your RICE, your NSAIDs, therapeutic exercises. Wanting to work on hand intrinsic and things like that. But if this is more severe, we are looking at a partial or even a complete thumb UCL tear, we are going to have to look at a surgical intervention.