Seattle Children's Youth Upper Extremities Injuries Conference

This past Saturday, March 23rd, the Seattle Children's Hospital Sports Physical Therapy Education Committee organized a full-day conference: Youth Upper Extremity Injuries: Medical and Rehabilitation Management for Return to Play. I had the pleasure of presenting Anatomy and Biomechanics of the Shoulder to a crowd of about 75 people.  There were PT students, many Athletic Trainers, a few Occupational Therapists and Physical Therapists in attendance and the other presenters were Seattle Children's Orthopedic Physicians and fellow Sports Physical Therapists.  It was fun learning from the doctors whose patients I have the opportunity to treat and from my fellow therapists. Here are some highlights from the day!

Dr. John Lockhart

We kicked off with a presentation from Dr. John Lockhart who presented Pediatric Cases of Common Upper Extremity Injuries.  He included shoulder, elbow, wrist, and hand cases through the lens of when it’s really imperative for athletes to be held from sport. Sometimes injuries won't get worse with playing in the championship game, or its acceptable to delay the rest period without a huge risk.  Other times there could be a potential for long term damage with continued participation.  For example, Little League Shoulder, medically known as proximal humeral epiphysitis, requires rest immediately.  It is not a condition that can be played through because it is essentially a stress fracture to a kid's growth plate.  These kids should not be allowed to play through their pain.  Same thing applies to little league elbow.  However, a shoulder impingement that is uncomfortable and acute may be able to continue playing while rehabilitating and working on throwing mechanics without worsening the condition. It feels terrible to be the one to tell a kid they need to stop playing the sport they love... but sometimes we have to be the "bad guy" for the greater good. Safety First.

Dr. Kyle Nagle

Then Dr. Kyle Nagle, Team Physician for Paralympic Nordic Skiing, highlighted the difference between Olympics, Special Olympics, and Paralympics in his presentation on Upper Extremity Injuries for Adaptive Athletes.  Last summer I volunteered at the Special Olympics and wrote about that experience here, but couldn't really have described the differences until now.

The Special Olympics focus on an athlete's ability, what they're able to do, and is for athletes with intellectual disabilities.  They try to level the playing field so that competitions are within 15% ability from those competing against each other as best they can, and it's meant to encourage inclusive participation with opportunities to compete for everyone.  Paralympics are primarily for physically disabled or visually impaired athletes.  Dr. Nagle has participated as a classifier for these athletes and, unfortunately, they look more through a lens of impairment - what the athlete cannot do - to try to categorize the athletes for participation.  Paralympics athletes have a physical impairment or a visual impairment, though they have previously had intellectual disabilities as an category and this is potentially going to return for more sports in the future.  

Dr. Nagle discussed the common shoulder injuries in adaptive athletes. Spoiler alert- they’re the same as any other athlete! But the impact on life function may be more impactful if, for example, they only have 1 arm and injure it, and the financial implications Dr. Nagle described for these athletes are much larger than I expected.

Dr. Michael Saper

The third physician to speak was Seattle Children's orthopedic surgeon Dr. Michael Saper.  He presented upper extremity surgerical procedures, why he likes arthroscopies more than open surgery, and a little about the protocols he has us follow for our rehab. 

He specifically commented on anterior shoulder dislocations and how in a youth athlete, a high number  (about 50% between age 15-20 years old) have repeated dislocation and should be considered for surgery, so he would want to see them as soon as possible following their injury to determine if this is necessary.  Oftentimes these athletes return to athletics without surgery, but the risk of long-term shoulder instability and repeated dislocation is very high if the first time dislocation occurs before age 40, according to the above linked article.

Image of an OATS procedure (kinda gross, sorry)

Dr. Saper also discussed Osteochondritis Dessicans (OCD) at the elbow, more commonly seen at the knee but we've treated both locations in the clinic recently.  With OCD the patient has degeneration of the cartilage that normally covers bone so there is less protection to the bone surface.  Sometimes the condition progresses so that there is damage occurring at the bone.  Patients who have this condition generally undergo surgery and there are various options - selection of procedure based on the size of the cartilage lesion.  So a small hole in the cartilage, less than 1 cm, could be repaired using a microfracture procedure in which the cartilage is "cleaned up" (debrided) and then the surface of the bone is poked with a needle to make it bleed, which should facilitate healing at that surface.  If the injury is larger, the OATS procedure is used.  OATS stands for OsteoArticular Transfer System where a graft is made using either the patient's own cells or a donor's cartilage made into plugs that are put into the damaged space.  Both are long, slow-healing procedures but tend to do well in the clinic with the OATS procedure looking like it has better long-term outcomes, particularly in higher level athletes.

Dr. Lockhart and Dr. Saper teamed up to demonstrate special tests they use when screening their patients. The recommendation was to fine tune the order of evaluation tests you do in the clinic so that you're thorough, systematic, efficient, and don't forget anything.

Dr. Lockhart assessing Dr. Saper's A-C joint

There were some key overarching themes between the physicians:

1) Taking a thorough medical history is essential to appropriate care of our patients.  It can help identify the problem, and even more importantly, the solution.

2) Being honest about expectations at the beginning of recovery from injury is essential.  We as physical therapists need to be discussing the process of rehabilitation and what the progression looks like so that there aren't surprises or questions about the duration of recovery. 

3) Anyone returning to sporting activity should follow appropriate recovery timelines, but they also need to be mentally ready before they get back into it.  An apprehensive or fearful athlete puts themself at risk for injury, even if they have physically achieved all the recovery milestones.

Following the discussions from the physicians, the physical therapists took over the show.  I kicked it off with my presentation on the anatomy and biomechanics of the shoulder.  Based on the amount of time allotted, I structured the presentation to overlap the anatomy with the biomechanics with occasional applications rather than the ways I have previously learned anatomy.  I thought it was successful, though I wasn't humerus...

Then came Steve Cisco, sports physical therapist at the Seattle Children's - Bellevue location, who presented about the mechanics of throwing a baseball.  I'm not sure anyone loves baseball as much as Steve does and his passion for the topic showed.  Chris Wong, another Bellevue physical therapist presented the upper extremity return to sports assessment battery of tests which a group of us had previously presented and I wrote about here.  And then there were some really excellent break-out sessions lead by PTs Steve (more throwing), Kaite Thompson (gymnastics), Brandon Tom (swimming), and Athletic Trainer Holly Runtzel (athletic training topics).  I attended Kaite and Brandon's talks and learned some fun new things to use in the clinic for those patient populations.

Overall - it was a fun day of learning, nice to head over to the main hospital and see my colleagues who work in different locations - and a great way to learn that I actually like presenting.  I'm looking forward to the chance to do so again in the future and am grateful to the Sports Physical Therapy Education Committee for giving me the opportunity and putting together a great course. 

Happy Pi Day!

I had a pretty busy last two weeks with cross country travel, climbing some stairs in support of Multiple Sclerosis, studying, having a student, and just plain life. This week - I'm bringing 5 random thoughts your way...

1) Happy Pi Day Everyone!  In case you're not familiar with Pi, it's a mathematical number that is used in a bunch of equations and is approxmiately 3.14159... so since today is 3.14 - it's Pi Day.

2) A friend told me that the way we know I'm still young is that I can still tolerate red eye flights home to Connecticut.  Ha!  I have it down to a system now, but read a few articles, like this one,  that made suggestions for how to make this the best travel option:

• Get a window seat - always - and I prefer to lean left, so I always pick an A seat - but this way you don't have to get up if someone in your row needs to use the bathroom and you've chosen the aisle. 
• Take the latest flight out possible so you're staying up past your normal bed time and will be tired enough to sleep on the plane.
• Consider your travel attire to optimize sleep on the plane.  I personally have a travel pillow, travel blanket, and face mask to block out the light and usually wear a hoodie to make sure I'm warm.  Airplanes are cold and I hate sleeping cold. 
• Sleep aids.  I personally take Nyquil to fly on my red eyes and as long as I take it early enough, I'm pretty much good to go on the other end.  

3) I went to the eye doctor today.  I've been trying to get contact lenses but I've had previously two eye surgeries that may have impacted the shape of my eyeballs and it has been challenging to find a pair that is comfortable and lets me see well.  The current trial lenses I'm in are the best I've had yet, but I keep feeling them in my eyes, which suggests my eyes are dry.  It's not them (contacts)... it's me.  So my eye doctor took some photos of my eyelids and told me all about how oil glands in your eyes work and should look on this picture.  The glands are the white stripy things and they're supposed to be pretty straight, but mine are bending a little, which isn't too bad but does impact the lubrication of my eyes and may impact my success with contacts.  Cool pic?  Or creepy?

4) It's National MS Awareness Week!  This was my fifth year participating in Climb to the Top (of Rockefeller Center) raising funds for Multiple Sclerosis.  I've previously written about MS here and the work that this fundraiser alone has done is so inspiring.  My team captain was featured here doing some awesome things to raise funds, awareness, and hope for those who live with MS. 

5) Tonight I'm hosting my first PT Pub Night, since Seattle hasn't had one in a few months and I wanted to see my favorite PTs from around the city.  I previously wrote about the top reasons you should attend PT Pub Night here, but right now, the top reasons to attend in Seattle tonight are that you could meet the PT Student I have working with me and tell her all your favorite things about being a physical therapist... so she doesn't have to hear it all from me.

That's all for now... hopefully the photo of my eyeballs won't give you nightmares!

To Dynamic Valgus - Or Not to Dynamic Valgus? That is the Question

Ann Strother

I was recently watching a Medbridge video on knee injuries when this image appeared on the screen.  HEY!  That's Ann Strother!  Hey girl!  A UConn Women's Basketball star overlapping with two of my years there as team manager, professional basketball player in the WNBA for a few teams while I was working for the Connecticut Sun, on my list for top 10 most beautiful three-point shots, and for sure one of the kindest people on Planet Earth - I was so excited to see her on the screen - except that it was with regard to knee injuries. 

The video was discussing her inverted "V" position called knee valgus which, according to several research articles (like this 2005 paper, and this 2003 paper, and this 2018 paper) may be one of many factors that increase risk of ACL injury in female athletes.  Medbridge had used this image demonstrating her continuing to exhibit this "faulty pattern" after already having had torn and rehabilitated from tearing her ACL. Ann tore her ACL during her sopomore year of high school.  Despite the injury, she was the 2002 Gatorade High School Basketball Player of the Year (her high school senior year) before heading to UConn where she was ultimately a two-time NCAA National Champion.

Kevin Durant

Anyways - seeing her on my computer made me think back to a few weeks earlier when I headed to California to see the Golden State Warriors play against the Los Angeles Lakers only for LeBron James to be out for the night.  I wrote about that here, but while watching the game, I observed that same knee posture repeatedly demonstrated by Kevin Durant of the Golden State Warriors.  See how he's standing at the free throw line about to shoot with his knees almost touching and his feet wider than his shoulders?  He does this a lot.  It's the same position.  While sitting at the game, I snapped this shot and sent it to all my favorite physical therapists and my current student in the clinic... because this knee position is repeatedly considered to be a big problem.

So... is it really a problem?  According to a lot of research, as I've previously mentioned, yes it is because of it's increased risk for injury.  But... is it a problem for Kevin Durant?  Should we be correcting this position in all of our patients who exhibit it?  Is it still a problem for Ann Strother, who I'm pretty sure is not currently playing basketball... but is still running around chasing after her two young children?  What I'm saying is - does every person who shows up in the PT clinic with this presentation need to have it "corrected" or do only some of them need to change it?  Or should we not be correcting it at all?  ACL injury prevention programs constantly work to strengthen the body to prevent exhibiting this type of movement and in PT school we're trained to squat "perfectly" without showing this pattern.  I'm constantly telling my patients to keep their knees out...but half of the time I'm wondering if it really matters. This is the movement pattern I see DAILY in my patients at Seattle Children's Hospital, most frequently in teenage girls who have knee pain, but certainly in boys and in all ages and with varying conditions.  I can tell you from experience that changing the squat position so that they don't do this inverted V is usually much less painful in many of these patients.  I can't tell you that training them to move without the V will prevent them from having an injury later on in life.

So what do we do about it?  As Robert Frost says, "Two roads diverged in a wood..." There appear to be different approaches to dealing with this presentation.  On the one hand, you can work to strengthen and reinforce a more "sturdy" pattern with the knees more straight above the feet rather than angled inward.  Glute strengthening, squatting, and training "proper" jump and landing form tend to be the typical components of a rehab program that works on this pathway.  Repeatedly trying to target a better posture and moving away from this dynamic valgus presentation is a common treatment approach. 

But Kevin Durant is paid about $30 Million per year... do you think he's going to let me change his free throw shot form?  Or anyone on his sports medicine staff for that manner?  Is he actually stable in this position?  Does he train in this position?   So the other option, that some people are now advocating for, is to train into these "suboptimal" positions on purpose.  There are recommendations to purposefully train ankle mobility and control into the position that is common for ankle sprains, particularly in those patients who have already sprained an ankle.  the thought process here seems to be that you can purposefully move into these patterns and try to develop control there so that you're less likely to injure yourself if you end up in that position.  In my search for literature on this approach, I came up empty-handed for scientific papers.  I know that when I injured my ankle years ago, putting it into the position of injury was painful and I wouldn't want to put myself there... years later I still don't purposefully do that motion... but if I play sports and accidentally end up there, I could see how I might be risking injury because I haven't trained my body to tolerate the position.  I did find some non-scientific articles that suggest doing this approach, like this one that discusses the idea of purposefully training into the movement patterns that you were injured in.  There are some people that suggest that if you don't train the injury pattern, you won't be resilient enough if life or your sport puts you into that position and you'll suffer another injury. 

And so...to dynamic valgus or not to dynamic valgus... that is the question. I'm here to tell you that I don't know the answer.  There's not enough evidence to support one way or the other - though there is definitely evidence showing that this position increases risk of injury - so the two approaches both suggest we need to be able to either avoid the position or control the position - not just ignore that position.  I think it might be a combination of both approaches.  I'm certainly not about to go give my patients who squat with dynamic valgus heavy load and have them repeatedly use that pattern - because that seems harmful, and as I've already written - we should Do No Harm.  But I'm also not afraid to consider putting people into and out of positions like this inverted V to see what they tolerate and show them that the human body can do some fascinating things.  What do you all think?