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. 

Shoulder Care with Eric Cressey

Last weekend I jetted off to Denver for a visit with family and a continuing education course.  The family time was fantastic - a few hours of biking around Denver - far more than I'm used to doing as I'm not a fan of bike seats - some really delicious tacos - beautiful art and the backdrop of the Rocky Mountains!

The course was "Shoulder Assessment, Corrective Exercise, and Programming" presented by Eric Cressey of Cressey Sports Performance and it was hosted at Landow Performance in Centennial CO.  Loren Landow is the newly hired Strength and Conditioning Coach for the Denver Broncos and his facility is beautiful with state-of-the-art equipment and autographed jerseys all over the walls from numerous professional athletes.  His bio says he has trained WNBA athletes, too - so extra points in my book!  If you're not familiar with Eric's work, he's a Strength and Conditioning coach with facilities in Hudson, MA and Jupiter, FL and, though he is most well known for his work with professional baseball players, he also works with the general population and is considered to be an expert in the shoulder.  He's published tons of research and has a blog with articles posted starting in 2002 with regular high quality content.  I previously wrote about one of his older blog posts here.  Most importantly, Eric is a UConn grad, so I've followed his work since I first learned about him somewhere around 2005 when I was in a class with Dr. William Kraemer, one of Eric's mentors, and have been looking forward to meeting him and attending one of his seminars for a long time.

With Eric Cressey June 24, 2018

Why did I want to take this class?  Beyond wanting to hear Eric speak live and get the chance to ask him questions, I previously took a course with a strength and conditioning coach (Matthew Ibrahim) in conjunction with a physical therapist (Zak Gabor) which I wrote about here, and felt that learning from people with different backgrounds was really impactful for me.  The audience was primarily strength and conditioning coaches who work with baseball players... but there were also a handful of physical therapists, chiropractors, massage therapists, personal trainers, and baseball coaches.  People had traveled from Australia and Korea and all over the United States, some of which trained athletes from unique sports like Professional Disc Golf or MMA fighters. The variety of people present was really neat... but also, the content is applicable to so many other sports.

More importantly, I have been treating a lot of patients and athletes with shoulder injuries and recently completed Mike Reinold's shoulder seminar, but also wanted a live course to better observe how other providers evaluate and treat shoulder pathologies. Eric's approach to shoulder treatment does not look like Mike's.  They have different "favorite" screening tools and exercises that they use.  If you observe their social media, you could probably pick up on these differences and similarities.  I'd say the biggest overlap I observed was that both of them regularly use the prone low trap exercise for rotator cuff strengthening which Eric has a video for here.

When it comes to my work with the Seattle Storm, though, we also have to consider that we're working in an overhead sport with repetitive action.  Shooting a basketball is nothing like the motion of throwing a baseball, but it still requires significant mobility and stability - and very different from baseball, it requires the athlete to be reactive to opponent players slapping at their arms while they're doing it.  The arm care programs used by the Seattle Storm should not look like the arm care programs used by the Boston Red Sox - but the principles involved in developing them do match.

I learned a lot from this course which I'm still processing, but was able to immediately use some of the skills in the clinic. Here are my top 5 favorite Eric Cressey quotes and take-aways from the weekend.

1) The biggest key for the shoulder is "Keep the ball on the socket." Simple.  Having a better biomechanical understanding of the force vectors of the rotator cuff is vital. If the scapula is sitting in a depressed position, the lats may be over-active which will influence upward rotation when getting overhead.  Similarly, if the scapula is tilted anteriorly, could there be shoulder impingement with elevation or is there enough muscular balance to safely overhead press?

2) Rehab and training are the same thing!  I've previously written about physical therapists' role as strength coaches here - and this came up in the course.  Eric Cressey is not a physical therapist and he discloses this and discusses how he interacts with PTs all over the country.  So it surprised me to see the differences between what Mike Reinold and what Eric Cressey do considering this statement, but I would not expect Eric to be seeing athletes post-op day 1 following labrum repair.  So, I took this to mean that once the acute healing phase is completed, rehab and training are the same thing.  There is a need for progressive loading to tissues and a need to understand periodization, even if your PT treatment sessions are not written like a periodized training program.

3) Scapular winging is a garbage term. It does not describe what is going on with the scapula.  I document scapular winging all the time - so this will be a change I need to consider moving forward.  Is the scapula winging because it is anteriorly tilted?  Upwardly rotated?  Because there is a flat thoracic spine so the medial border is just more pronounced?  And is this inherently pathological?  Or just a finding that you're documenting.  I can't promise I'll stop using the term scapular winging entirely, but I can commit to adding at least one descriptor of the scapular position to better describe the situation moving forward.

4) Stop telling people to bring their shoulder blades down and back.  It would only be a slight exaggeration to say that Eric Cressey is begging people to stop using this cue.  Too many people use this resulting in patients pulling their elbows back with anterior humeral head translation and improper mechanics that we could be creating problems!  I asked him what cue he likes instead - and he said he manually puts people into the position he wants them to be in, using optimal muscle activation, until they can do it independently.

5) Push:Pull ratios are not accurate nor are they adequate.  It has been well ingrained into my training that for every push exercise, you should be doing at least 2, probably more like 3 pull exercises.  I've been trained to teach that focusing on the back musculature 2-3x more than the front helps combat many of the anterior shoulder issues that are seen in the clinic.  However, Eric points out two key points that make you think about this more carefully.  First, the push:pull ratio is almost always considered for front:back motion and ignores top:bottom... but both planes need to be considered.  I think John Rusin tries to deal with this by including upper body push, upper body pull, and carries into his 6 foundational movement patterns, but the balance needs to be considered for both planes.  Second: not all pushes can be considered alike.  The bench press is a push exercise that necessitates the scapulae being blocked on a bench... compared to the push up where they are moving freely on the body.  This is also an important consideration as you're not getting the benefit for scapular control through the pushing motion when doing a bench press - and Eric says he doesn't have his baseball players bench pressing.

I'd be lying if I said this even touched the surface of all the things I learned at the class... but these were big takeaways that made me think and will change how I operate to some degree.   Thanks for an awesome course, Eric!

Social Media Impact on my PT Practice

with Mike Reinold!

with Lenny Macrina!

I love social media.  If you've been following the news lately, you probably know that Mark Zuckerberg, Facebook CEO, has been testifying in front of Congress regarding improper use of data and basically explaining how the internet works.  Through social media, it is possible to interact with millions of people, watch silly cat videos, become a viral sensation, or watch my nephew on the ski slopes and my niece at her dance recital all the way across the country.

One thing I really like about social media is that I have the opportunity to interact with famous people.  For example, I wished Justin Timberlake a Happy Birthday.  He probably didn't see it because he has 49.4 Million Instagram followers, but I was able to do it.  There's a slight chance that he noticed my comment out of the 38,391 comments there. I recently read an article (but now can't remember where) that outlined the impact of the various ways you could interact on social media platforms.  A high percentage of followers may see a post, less will "like" it, but only a small fraction will comment on it, and even a smaller percentage will somehow directly connect, separating from the herd.

Slightly less famous than Justin Timberlake, (38 Million Facebook followers), are Mike Reinold (106,918 Facebook followers) and Lenny Macrina (1,788 followers on Facebook), co-owners of Champion PT and Performance (50,000 followers for the company) in Boston.  They're also the hosts of "The Ask Mike Reinold Show" podcast, and if you've read any of my previous work, they're major influences on how I practice physical therapy.  The connection here is that these guys do a lot of research, treat a lot of patients/clients, and own a business while regularly using various social medial platforms to spread their knowledge and have been able to impact me in this way.

Last week I attended Lenny's "Evaluation and Treatment Algorithm for Medial Elbow Pain" course at the Pacific Northwest Orthopedic and Sports Medicine Symposium in Portland, Oregon.  Because I've previously interacted with Lenny directly via Facebook and indirectly through their podcast,  he recognized me when he walked into the room.

SOAP BOX: To ALL student physical therapists and new grad physical therapists (and PTAs, and any other rehab/sports professionals), you need to follow this crew. NEED!  If you're interested in gymnastics at all - follow Dave Tilley.  If you're interested in Crossfit, follow Dan Pope.  If you're interested in golf - follow Mike Scaduto.  If you like UConn Basketball or want online personal training guidance, follow Kiefer Lammi, their Director of Fitness.  If you work with baseball players, they've developed Elite Baseball Performance. If you treat shoulders and knees - these guys are for you. And if you're a parent of a youth athlete, they're an awesome resource for that also. 

Moving on... I've previously written about how important it was for me to get a new mentor in this post.  But mentors don't necessarily need to be people you know or spend time with in real life.  They don't even need to be your teachers or coworkers.  I have mentors I can call or email at any time who filled those roles, but then there's Mike and Lenny - who really don't know me beyond the brief moments photographed above, but who I respect in the field of physical therapy and whose work I try to read consistently to improve my practice.

In addition to Lenny's Elbow class last week, I've taken the time to go through their podcast episodes - which are really great - and have had two of my questions answered in them: Episode #107 and Episode #109 so you can check them out.  The episodes are short and formatted as three questions and their answers.  I also just completed Mike's Shoulder Seminar. I happened to be attending Lenny's Elbow course while I was finishing the seminar and the two paralleled each other nicely.  Both have had an immediate impact on my treatments.  Following all the recent learning I've had from this crew, here are the four changes I've recently made in how I practice PT.  (Keep in mind - the two courses I took were intended for the upper extremity).

First - side-lying external rotation and prone row exercises were previously absent from my treatment sessions and home exercise programs.  Not any more! The Shoulder Seminar included the research supporting their use such including EMG studies on the muscles being used.  This paralleled with Lenny's course showing how he implements these exercises into his routines.

Second - rhythmic stabilizations and PNF patterns have often been in my treatment sessions in the past, but I've ramped up their volume considerably.  Where before I may have done 2-3 rounds of 30 seconds of rhythmic stabilizations and a set of 10 reps of resisted PNF D2 at occasional visits, I've now started doing the stabilizations in A LOT more positions with more total time spent on dynamic stability.  I'm not just doing this because Mike and Lenny said to... at Lenny's course we had lab sessions doing these treatments to each other so (thanks to my partner and fellow Seattle PT Bruk Ballenger) I felt the impact of doing these on my own shoulder.  These are really fatiguing!

Third - upper extremity weight bearing progressions.  I've never had someone standing at their treatment table with their hands on the surface with low loads of weight bearing in that position.  I like it for a gentle joint compression or co-contracting activity without the shoulder flexion in a quadruped or standing with the arm against the wall closed kinetic chain activity.

Fourth - I've been working with some coworkers at Seattle Children's Hospital on a return to sport testing protocol for patients following rehab for upper extremity injuries.  We've had numerous discussions about the components to include, but The Champion crew uses a hand-held dynamometer (HHD) for measurable strength testing.  Fortunately, I studied under HHD guru Dr. Richard Bohannon at UConn and Seattle Children's already uses it in our lower extremity testing.  Manual Muscle testing just isn't sufficient enough to identify the subtle but potentially significant differences in strength.

So, I've learned a lot from this crew, and I found them via Facebook and other social media means.  I'm looking forward to getting started on Mike and Lenny's knee seminar in the next few weeks, and if any of the Champion PT and Performance Crew comes across this post, please know how grateful I am for all that you do.