O steopathic Manipulative - PowerPoint Presentation

Osteopathic Manipulative Medicine for Upper Extremity Pain in Adolescent Athletes Anne Marie C Zeller, MSc, DOFamily Medicine Resident: Year 2Undergraduate Osteopathic Manipulative Medicine Fellow- Graduated ChiefFaculty:Michael P. Rowane, DO, MS, FAAFP, FAAO

“I have no desire to be a cat, which walks so lightly that it never creates a disturbance.” -A. T. Still

ObjectivesDiscuss common causes and diagnoses in regards to adolescent shoulder and elbow painDiscuss basic tenets of examination of shoulder, elbow, and wristHigh-yield and efficient osteopathic manipulative medicine treatments for shoulder, elbow, and wrist Practice , Practice, Practice!

Pediatric PopulationMUST consider the maturation of the physis or growth platesWeakness at the physis and decreased resistance to shear and tensile forces compared to the surrounding ligaments, tendons, and muscles, PREDISPOSE this population to injury.

Mechanism of Injury of Shoulder PainRepetitive micro trauma or overuse mechanisms: Acceleration: Athletes uses optimum load to generate forceExample: racquet and pitching sportsDynamic force: arm is moving against sustained resistanceExample: swimmingStatic force: action of the shoulder muscles when then are held in a constant position with isometric contractionExample: dancer or gymnast

Basics on Throwing or TennisWorst position: abducted to 90⁰, externally rotated, and extended. MOST tension on anterior articular capsule and anterior glenohumeral ligamentRotator Cuff and deltoid activeSubscapularis is compromisedAccerate forward: pectoralis and subscapularis are required to quickly internally rotate the humerus ANOTHER bad biomechanical position for shoulder

Articular Units of Shoulder Complex Covered TodayGlenohumeral Joint Sternoclavicular and Acromioclavicular JointsScapulothoracic JointRemember: Shoulder Pain is NOT JUST Rotator Cuff! Shoulder involves Ribs, Thoracics, Lumbars, Cervicals, Cranial bones Innominates, and Sacrum

Most Common Adolescent Athlete Shoulder InjuriesEpidemiology, Pathology and OMM treatment

“ Doctor, shouldn’t you leave treating cervical dysfunctions to the OB/GYN physicians?”-Anonymous Lawyer

Glenohumeral Joint Anatomy

Epidemiology of in the Glenohumeral Joint Injuries Traumatic events makes up 86% of Glenohumeral instability in adolescent athletes 16 and older.Skeletally mature athletes with GH instability = surgery due to 80-90% recurrence rateSkeletally immature athletes = EXTREMELY careful in evaluating because of the high chance of fracture of proximal humerus.

Anterior Dislocation90% of traumatic dislocation Mechanism of Injury: high energy injury of a fall on an outstretched hand while shoulder in abduction and external rotationS/S: “dead arm”- transient loss of sensation or numbness in involved extremity (axillary nerve), obvious deformity, pt hold arm internally rotated, + anterior apprehension testDiagnosis: Pt history, physical exam, x-raysTreatment: Primary- closed reduction of dislocation, Secondary- surgery due to recurrence rate with conservative treatment .8

Anterior Dislocation X-ray

Hill-Sachs Fracture and Bankart Lesion Hill-Sachs (Blue Arrow): compression fracture at the posterolateral head of the humerus due to impingement against anterior rim of glenoid fossa when the humeral head dislocates.Bankart Lesion (Red arrow): avulsion of anteroinferior glenoid labrum where the inferior glenohumeral ligament attaches

Posterior Dislocation< 5% of traumatic shoulder dislocations MOI: Fall on an outstretched hand with shoulder in adduction and internal rotation or direct anterior trauma. Example: Offensive Linemen: forward flexed and internally rotation of shoulder for blockingS/S: May not have deformity, + posterior apprehension test, complain of shoulder pain and have limited external rotation with <90⁰ shoulder flexionTreatment: rotator cuff rehab is most successful after closed reduction

Atraumatic InstabilityMajority are bilateral, multidirectional Hypermobility (generalized joint laxity) of joints from sports that weaken rotator cuff from overhead motionsExamples: gymnastics and swimmingS/S: nonspecific shoulder pain, feeling of shoulder dislocation with overhead activities, hyperextension of other joints of UE, + apprehension signs, + sulcus sign, strength deficits in rotator cuff muscles and scapular stabilizers (serratus anterior, pectoralis, and latissimus dorsi) Treatment: conservative rehab with strengthening NOT stretching exercises

“Little League Shoulder”9 Proximal humeral epiphysiolysisMOI: repetitive strain injury to proximal humeral epiphysis from overtraining and improper biomechanics seen in over-head sports. (Example: Baseball)Ages: 11-15S/S: Pt has pain in superior lateral aspect of the shoulder with dynamic/resisted over-head activitespalpation of proximal humeral epiphysis is tender active ROM is full and pain free resisted muscle testing in over-head position reproduces pain. X-ray is BEST visualization of pathology

“Little League Shoulder”

Osteopathic Manipulative Medicine for Shoulder Pain/Dysfunction in Adolescent Athlete

Osteopathic Manipulative Medicine for Shoulder Pain in Adolescent Athlete Rule out: Fracture and Dislocations with history, physical exam and X-rays or MRI Cautions: chronic dislocations, joint hypermobility, recent shoulder surgeryContraindications: Septic joint, acute dislocation, fracture, cancer

BLT Humerus/Rotator Cuff- Seated

BLT Humerus/Rotator Cuff- Seated Dr. grasps humeral shaft with both hands and fingers interlock on medial side (avoiding NV bundle) Dr. pushes with both hypothenar eminences against humeral shaft. Cause humeral head to become abducted as the humerus is adducted by pt.Pt places his ipsilateral hand on the opposite side of his chest (causing internal rotation and adduction)Pt moves elbow forward and backward (internal and external rotation)Dr. determines which direction enhances balanced tension. Pt is instructed to maintain arm in the position. Dr. fine tunes the tensions at the GH joint to achieve balanced tension.

Direct Myofascial Release Technique-Anterior Cervical Fascia

Direct Myofascial Release Technique-Anterior Cervical Fascia Pt is seated and facing Dr. Dr. places thumbs along superior portion of the clavicles, just distal to the SCM insertionPt. drapes arms over Dr.’s and flexes head and neck. Allows fingers to sink into the supraclavicular spacePt breathes deeply. During inhalation, the Dr. resists the superior movement of the supraclavicular fasciaeDuring exhalation, the pt. exaggerates flexed posture of head and neck as the Dr. follows tissues as they descend into the thoracic inlet

Anatomic Mechanism of OMM Clavicle treatmentAccording to Sutherland model, the claviopectoral fascia has a similar role to the interosseous membranes of the forearm and lower leg in that it guides and limits movement of the bone.

What is the Scapulothoraic Joint? Serratus anterior, rhomboid and teres major are viewed as the functional ligaments of the joint.BLT treatment presented addresses Serratus anterior, subscapularis, rhomboid, latissimus dorsi, teres major and lower trapezius muscles.

BLT Scapulothoracic Joint Seated

BLT Scapulothoracic Joint Seated Pt seated. Dr. uses thumb as a fulcrum beneath the scapula in the axilla.Palmar surface of thumb is placed on the lateral surface of the 2nd and 3rd rib with the tip facing posteriorly. Anterior to the latissimus dorsi Dr. gently slides her thumb posteriorly along the surface of the rib until it rests between the scapula and rib. Dorsal surface of thumb on subscapularis . Plantar surface of thumb contacts the serratus anterior. Dr. places other hand over the posterior aspect of the scapula. Base of hand at Apex and finger grasp the spine of the scapula Dr.’s posterior hand protract, retract, adduct, abduct, elevate and depress the scapula to achieve balanced tension in all tissues attached

Topics not addressed but are influential in shoulder pain/dysfunction treatmentOMM Treatment of Ribs, Cranial bones, Cervical Vertebrae, Thoracic Vertebrae, Lumbar Vertebrae, Innominates, Sacrum with S/CS, ME, Indirect Myofascial, Still, or FPR.Extensive information on Throwing and other sport mechanisms in the shoulder and its contributions to shoulder injury and pain

Osteopathic Manipulative Medicine for Elbow Pain/Dysfunction in Adolescent Athlete

Lateral Elbow Anatomy33 ECRL: Extensor Carpi Radialis LongusECRB: Extensor Carpi Radialis BrevisEDC: Extensor Digitorum CommunisECU:Extensor Carpi UlnarisCET: Common Extensor TendonAL: Annular LigamentRCL: Radial Collateral LigamentLUCL: Lateral Ulnar Collateral Ligament

Most common Mechanism of Injury in Lateral Elbow PainPrecipitated by activities that require repetitive wrist extension, radial deviation and forearm supination Examples: Hammering, painting, tennis backhand34

Common PresentationPatient typically reports an insidious onset but will often relate a history of overuse without trauma.Pain with gripping objects (“coffee cup sign) and shaking hands (“politician’s sign”) Numbness or tingling: Suggest radicular symptoms35

Physical ExamMusculoskeletal and Neurologic Exam 1st ! Tenderness with palpation at origin of Extensor Carpi Radialis Brevis (ECRB)Tenderness with resisted supinationResisted Wrist Extension TestEnhanced by:Straightening elbowMaking a fistPronating the forearmRadially deviating wrist 36

Physical ExamMiddle Finger TestResist the extension of the proximal interphalangeal joint of 3 rd digitStresses the extensor digitorum and ECRBPositive if pain is over the lateral epicondyle. 37

Differential DiagnosisPosterior interosseous nerve entrapment (radial tunnel syndrome) OsteoarthritisCervical radiculopathyMusculocutaneous nerve entrapmentRadiocapitellum Osteochondritis dissecans lesionsLateral collateral ligament strainStress FractureHumeral FractureSynovitis of the radiohumeral joint 38

Anatomy of Medial Elbow39 PL: Planaris LongusPT: Pronator TeresFCR: Flexor Carpi RadialisFDS: Flexor Digitorum SuperficialisFCU: Flexor Carpi UlnarisAL: Annular LigamentMCL: Medial Collateral Ligament

Mechanism of Injury Medial Elbow PainForceful and/or continuous flexion and pronation at the wrist Activities requiring a large amount of stabilization applied by the wristCommon Activities Examples:Racquet sportsSwimmingSwinging a Golf ClubThrowingComputer KeyboardPlaying PianoCertain occupationsExamplesCarpentersPlumbersMeat cutter 40

Common Presentation in Medial Elbow PainPain and tenderness along medial elbow extending into forearmDifficulty gripping without painDecreased wrist strength Tightness/stiffness when stretching elbow and wrist41

Physical Exam: Medial Elbow PainTesting for Valgus Stability in Extension:MCL Anterior CapsuleBony articulations 42

Differential Diagnosis of Medial Arm PainFractureOsteochondritis dissecans OsteoarthrosisMCL injuryLittle League elbow- increased valgus angle in adolescent throwing athletesFlexor-Pronator StrainUlnar neuropathy (neuritis, entrapment)Pediatric- avulsion fracture 43

X-ray-Pediatric Patient with Medial Elbow Pain44

MRI of Medial Epicondylitis45

Osteopathic Manipulative Medicine for Elbow Pain

Osteopathic Manipulative Medicine Considerations in Elbow Pain Diagnose and treat Somatic Dysfunctions in: Cervical spine, Thoracic spine, Ribs , Scapula, and ClavicleTo reduce and/or correct somato-somatic reflexes and some of the myofascial pain referralsTo improve the venous and lymphatic drainage

Osteopathic Manual MedicineOMT Techniques Presented Address: Radial Head Humero -Radial JointHumero-Ulnar JointDistal Radio-Ulnar Joint Carpal Joints

Diagnosing Somatic Dysfunction of the ElbowPatient seated with elbows flexed at 900 and forearms at 0 0 of pronation and supination (thumbs up). Then check for supination or pronation restrictions. The radial head moves posteriorly with pronation and anteriorly with supination.Therefore a pronated forearm (with restricted supination ) will have a posterior radial head somatic dysfunction . Supinated forearm (with restricted pronation ) will have an anterior radial head somatic dysfunction.

Diagnosing Somatic Dysfunction of the Elbow50 Example: Pt is restricted in PRONATION, Freedom of Motion is in Supination Diagnosis: Anterior Radial Head

Range of Motion Correction of the Radial Head51           Step 1 Step 2 Step 4 Step 3 * Sit next to patient as depicted to make this work * Start in full Pronation and end in full Supination

STILL MOBILIZATION OF THE DISTAL RADIOULNAR JOINT52  Step 1Step 2 Mobilization of distal radioulnar joint isometric; to 4 th barrier in pronation, repeat in supination Treat restrictions of pronation/supination (proximal or distal) Free-up the interosseous membrane* Improve venous and lymphatic return (carpal tunnel syndrome ) *Piano key sign

Articulatory- Wobble Technique Patient is supine Right arm abducted 45 degrees Hand positioned midway between supination and pronation (thumb up towards ceiling). Both hands are placed around the elbow and motion is medial and lateral to produce the articulation of the radial head with the ulna or humerus or articulation of the humeroulnar joint.53**Examine for Valgus / Varus instability before performing technique

Carpal Separation54 Fingers should be applying lateral traction to the thenar & hypothenar eminences and the thumbs should be applying pressure to gently separate the ulna and radius from the carpal bonesWrist Flexion, Extension, Radial and Ulnar Deviation

STRAIN/COUNTERSTRAIN FOR THE ELBOW 55 Anterior Tender Points

Radial Head Tender PointElbow is flexed fully. Forearm is pronated and arm is internally rotated - so back of hand approximates chest. Forces are pronation of the forearm and internal rotation of the humerus until a position of comfort is found.Hold this position for 90 seconds and then slowly return to neutral.Retest for tenderness.Coronoid TP- Same position but external rotation of the humerus56

ConclusionALWAYS perform a musculoskeletal and neurologic exam FIRSTOMT learned today for shoulder and elbow Glenohumeral JointSternoclavicular and Acromioclavicular jointScapulothoraic jointRadial Head Humero-Radial JointHumero-Ulnar JointDistal Radio-Ulnar Joint Carpal Joints

ReferencesWojtys E. et al. “Sports injuries in the immature athlete.” Orthop Clin North Am 1987; 18 (4): 689-708.Ogata et al.early development and ossification of the human clavicle—an embryologic study.1990, Vol. 61, No. 4 , Pages 330-334 Gardner E.”The embryology of the clavicle.” Clin Orthop 1968;58:9 Carreiro , Jane D.O. Pediatric Manual Medicine . (2009). Churchill Livingstone. BRIAN L. MAHAFFEY, M.D.PATRICK A. SMITH, M.D. “ Shoulder Instability in Young Athletes.” American Family Physician Lawton RL et al. “Pediatric shoulder instability: presentation, findings, treatment, and outcomes.” J Pediatric Orthop 2002.; 2252-61. Good CR et al. “Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment.” Curr Opin Pediatr 2005; 17:25-9. Jakobsen BW et al. “Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up.” Arthroscopy 2007; 23 (2): 118-23. Krabak et al . “Shoulder and Elbow Injuries in the Adolescent Athlete.” Phys Med Rehabil Clin N Am . 19 (2008) 271-285. American Osteopathic Association. Foundations in Osteopathic Medicine. (2003)

ReferencesYoung et.al (2011) “Lateral Epicondylitis.” 5-minutle Sports Medicine Consult. Lippincott Williams & Wilkins.Zeisig E. et al.(2006) Extensor origin vascularity related to pain in patients with Tennis elbow. Knee Surg Sports Traumatol Arthrosc.14(7):659. Walz D, et al (2010). Epicondylitis: Pathogenesis, Imaging, and Treatment. Radiographics. 30: 167-184. Gruchow (1979). “Epidemiologic Study of Tennis Elbow. Incidence, recurrence, and effectiveness of prevention strategies”. American Journal of Sports Medicine. 7(4): 234-238. Young et.al (2011) “Medial Epicondylitis .” 5-minutle Sports Medicine Consult. Lippincott Williams & Wilkins. Smidt , N. et al (2002). “Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis : a randomized controlled trial.” Lancet. 359: 657-662. 59

References 17. Bisset L, et al. (2005) “A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine. 39: 411-422.18. Grewal R. (2009) “Functional outcome of arthorscopic extensor carpi radialis brevis tendon release in chronic lateral epicondylitis .” Journal of Hand Surgery. 34: 849-857. 19. Des Moines University OMM Department. “Treatment of Elbow Somatic Dysfunctions Laboratory Handout.” Updated 2010. 20. Figueroa J. Professional collaboration with AOA Lateral and Medial Epicondylitis Lecture. 21. Lewis D. Upper Extremity IV Lab and Lecture. Spring 2011. Des Moines University . 22. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1. Upper Half of Body. 2nd Ed. Baltimore, Williams & Wilkins, 1999, pp. 485-907 60

APPENDIX: SUPPLEMENTAL OMM Techniques

Spencer SequenceStep 1: Extension Isometric Contraction the patient is trying to flex shoulder is used to lengthen the Pectoralis Major, Pectoralis Minor and anterior deltoid

Spencer SequenceStep 2: Flexion Isometric contraction of Patient extending shoulder engages latissimus dorsi, teres major and minor, posterior deltoid

Spencer SequenceStep 3: Circumduction without traction

Spencer SequenceStep 4: Circumduction with Traction

Spencer SequenceStep 5: Abduction Isometric Contraction of patient adduction engages Pectoralis Minor, Teres Minor, and Infraspinatus

Spencer SequenceStep 6: Adduction Isometric contraction of patient pushing elbow superior engages subscapularis and teres major

Spencer SequenceStep 7: Internal Rotation Isometric contraction pt. pushes elbow posterior (external rotation) engages the supraspinatus and infraspinatus muscles

Spencer SequenceStep 8: Abduction with Resisted Traction

Referral Pattern Considerations with Myofascial Pain in the Elbow Structures referring to the lateral elbowScalenesSupraspinatusTeres MinorDeltoidTricepsSubclaviusPictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint SlidesLateral and Medial Epicondylitis- Anne Marie C. Zeller70

Referral Pattern Considerations With Myofascial Pain in the Elbow Structures referring to the medial elbowLatissimus DorsiSubscapularisTricepsSternalisSerratus Posterior SuperiorPictures of Trigger Points, Referral Patterns, and Stretches in Appendix of Powerpoint Slides Lateral and Medial Epicondylitis- Anne Marie C. Zeller 71

Treatment of Myofascial PainIdentify the trigger points:Taut bandTender to palpation Recognition of PainReferral of pain (“triggers pain somewhere else”)Treat by stretchingMay use spray and stretchTreat by needlingDry needle or infiltrate trigger point with lidocaineLateral and Medial Epicondylitis- Anne Marie C. Zeller72

Myofascial Triggerpoints for Lateral Elbow Pain 73

Myofascial Triggerpoints for Medial Elbow Pain 74