O steopathic Manipulative Medicine for Upper Extremity Pain in Adolescent Athletes

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

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

3. Objectives • Discuss common causes and diagnoses in regards to adolescent shoulder and elbow pain • Discuss basic tenets of examination of shoulder, elbow, and wrist • High-yield and efficient osteopathic manipulative medicine treatments for shoulder, elbow, and wrist • Practice , Practice, Practice!

4. Pediatric Population • MUST consider the maturation of the physisor growth plates • Weakness at the physis and decreased resistance to shear and tensile forces compared to the surrounding ligaments, tendons, and muscles, PREDISPOSE this population to injury.

5. Mechanism of Injury of Shoulder Pain • Repetitive micro trauma or overuse mechanisms: • Acceleration: Athletes uses optimum load to generate force • Example: racquet and pitching sports • Dynamic force: arm is moving against sustained resistance • Example: swimming • Static force: action of the shoulder muscles when then are held in a constant position with isometric contraction • Example: dancer or gymnast

6. Basics on Throwing or Tennis • Worst position: abducted to 90⁰, externally rotated, and extended. • MOST tension on anterior articular capsule and anterior glenohumeral ligament • Rotator Cuff and deltoid active • Subscapularis is compromised • Accerate forward: pectoralis and subscapularis are required to quickly internally rotate the humerus • ANOTHER bad biomechanical position for shoulder

7. Articular Units of Shoulder Complex Covered Today • Glenohumeral Joint • Sternoclavicular and Acromioclavicular Joints • Scapulothoracic Joint Remember: Shoulder Pain is NOT JUST Rotator Cuff! Shoulder involves Ribs, Thoracics, Lumbars, Cervicals, Cranial bones Innominates, and Sacrum

8. Epidemiology, Pathology and OMM treatment Most Common Adolescent Athlete Shoulder Injuries

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

10. Glenohumeral Joint Anatomy

11. 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 rate • Skeletally immature athletes = EXTREMELY careful in evaluating because of the high chance of fracture of proximal humerus.

12. Anterior Dislocation • 90% of traumatic dislocation • Mechanism of Injury: high energy injury of a fall on an outstretched hand while shoulder in abduction and external rotation • S/S: “dead arm”- transient loss of sensation or numbness in involved extremity (axillary nerve), obvious deformity, pt hold arm internally rotated, + anterior apprehension test • Diagnosis: Pt history, physical exam, x-rays • Treatment: Primary- closed reduction of dislocation, Secondary- surgery due to recurrence rate with conservative treatment .8

13. Anterior Dislocation X-ray

14. 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 glenoidfossa when the humeral head dislocates. Bankart Lesion (Red arrow): avulsion of anteroinferiorglenoid labrum where the inferior glenohumeral ligament attaches

15. 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 blocking • S/S: May not have deformity, + posterior apprehension test, complain of shoulder pain and have limited external rotation with <90⁰ shoulder flexion • Treatment: rotator cuff rehab is most successful after closed reduction

17. Atraumatic Instability • Majority are bilateral, multidirectional • Hypermobility (generalized joint laxity) of joints from sports that weaken rotator cuff from overhead motions • Examples: gymnastics and swimming • S/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 latissimusdorsi) • Treatment: conservative rehab with strengthening NOT stretching exercises

19. “Little League Shoulder”9 • Proximal humeral epiphysiolysis • MOI: repetitive strain injury to proximal humeral epiphysis from overtraining and improper biomechanics seen in over-head sports. (Example: Baseball) • Ages: 11-15 • S/S: • Pt has pain in superior lateral aspect of the shoulder with dynamic/resisted over-head activites • palpation 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

20. “Little League Shoulder”

21. Osteopathic Manipulative Medicine for Shoulder Pain/Dysfunction in Adolescent Athlete

22. 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 surgery • Contraindications: Septic joint, acute dislocation, fracture, cancer

23. BLT Humerus/Rotator Cuff- Seated

24. 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.

25. Direct Myofascial Release Technique-Anterior Cervical Fascia

26. 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 insertion • Pt. drapes arms over Dr.’s and flexes head and neck. Allows fingers to sink into the supraclavicular space • Pt breathes deeply. During inhalation, the Dr. resists the superior movement of the supraclavicular fasciae • During exhalation, the pt. exaggerates flexed posture of head and neck as the Dr. follows tissues as they descend into the thoracic inlet

27. Anatomic Mechanism of OMM Clavicle treatment • According 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.

28. 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, latissimusdorsi, teres major and lower trapezius muscles.

29. BLT Scapulothoracic Joint Seated

30. 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 latissimusdorsi • 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

31. Topics not addressed but are influential in shoulder pain/dysfunction treatment • OMM 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

32. Osteopathic Manipulative Medicine for Elbow Pain/Dysfunction in Adolescent Athlete

33. Lateral Elbow Anatomy AL: Annular Ligament RCL: Radial Collateral Ligament LUCL: Lateral Ulnar Collateral Ligament ECRL: Extensor Carpi RadialisLongus ECRB: Extensor Carpi RadialisBrevis EDC: Extensor DigitorumCommunis ECU:Extensor Carpi Ulnaris CET: Common Extensor Tendon

34. Most common Mechanism of Injury in Lateral Elbow Pain • Precipitated by activities that require repetitive wrist extension, radial deviation and forearm supination • Examples: Hammering, painting, tennis backhand

35. Common Presentation • Patient 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 symptoms

36. Physical Exam • Musculoskeletal and Neurologic Exam 1st! • Tenderness with palpation at origin of Extensor Carpi RadialisBrevis (ECRB) • Tenderness with resisted supination • Resisted Wrist Extension Test • Enhanced by: • Straightening elbow • Making a fist • Pronating the forearm • Radially deviating wrist

37. Physical Exam • Middle Finger Test • Resist the extension of the proximal interphalangeal joint of 3rd digit • Stresses the extensor digitorum and ECRB • Positive if pain is over the lateral epicondyle.

38. Differential Diagnosis • Posterior interosseous nerve entrapment (radial tunnel syndrome) • Osteoarthritis • Cervical radiculopathy • Musculocutaneous nerve entrapment • RadiocapitellumOsteochondritisdissecans lesions • Lateral collateral ligament strain • Stress Fracture • Humeral Fracture • Synovitis of the radiohumeral joint

39. Anatomy of Medial Elbow PL: PlanarisLongus PT: PronatorTeres FCR: Flexor Carpi Radialis FDS: Flexor DigitorumSuperficialis FCU: Flexor Carpi Ulnaris AL: Annular Ligament MCL: Medial Collateral Ligament

40. Mechanism of Injury Medial Elbow Pain • Forceful and/or continuous flexion and pronation at the wrist • Activities requiring a large amount of stabilization applied by the wrist • Common Activities Examples: • Racquet sports • Swimming • Swinging a Golf Club • Throwing • Computer Keyboard • Playing Piano • Certain occupations • Examples • Carpenters • Plumbers • Meat cutter

41. Common Presentation in Medial Elbow Pain • Pain and tenderness along medial elbow extending into forearm • Difficulty gripping without pain • Decreased wrist strength • Tightness/stiffness when stretching elbow and wrist

42. Physical Exam: Medial Elbow Pain • Testing for Valgus Stability in Extension: • MCL • Anterior Capsule • Bony articulations

43. Differential Diagnosis of Medial Arm Pain • Fracture • Osteochondritisdissecans • Osteoarthrosis • MCL injury • Little League elbow- increased valgus angle in adolescent throwing athletes • Flexor-Pronator Strain • Ulnar neuropathy (neuritis, entrapment) • Pediatric- avulsion fracture

44. X-ray-Pediatric Patient with Medial Elbow Pain

45. MRI of Medial Epicondylitis

46. Osteopathic Manipulative Medicine for Elbow Pain

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

48. Osteopathic Manual Medicine OMT Techniques Presented Address: • Radial Head • Humero-Radial Joint • Humero-Ulnar Joint • Distal Radio-Ulnar Joint • Carpal Joints

49. Diagnosing Somatic Dysfunction of the Elbow • Patient seated with elbows flexed at 900 and forearms at 00 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.

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