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.