Study done in 2016 on myodural bridge and its connection to post-concussive symptoms, may suggest that treating suboccipital musculature early on may reduce post-concussive headaches and/or other symptoms.
Neck strengthening and conditioning – 6-9 min
Neck girth and strength = reduced impact to the head and neck
Strength exercises must be done in all planes!
“The effects of rest and treatment following sport-related concussion: a systematic review of the literature”
The study revealed that soccer females wearing headgear had greater head acceleration compared to males who had a slight decrease in head acceleration. This suggests that headgear may not be appropriate for all athletes.
Measuring Neck Strength – 10 min
“Neck Strength: A Protective Factor Reducing Risk for Concussion in High School Sports”
This study showed that “smaller mean neck circumference, smaller mean neck to head circumference ratio, and weaker mean overall neck strength were significantly associated with concussion.”
Vestibular balance is also treatable – 15 min
BESS/ Sway app / Force plate
Balance work = decreased risk of lower body injuries relating to prior concussions
Vestibular-ocular – 17 minutes
“Does it feel unstable to you?” “Rocky boat”
Are they experiencing vertigo?
Increased s/s if they were previously experiencing motion sickness
Vestibular-ocular issues are a “major source of fatigue, headaches, and cognitive problems
Vestibular Ocular Motor Screen (VOMS);
smooth pursuits, horizontal and vertical saccades, horizontal vestibulo-ocular reflex, near point convergence, visual motion sensitivity
Home exercises; Eply/Brandt-Daroff exercises and gaze stabilization
Beginning vestibular therapy at two weeks will greatly impact and help during post concussion recovery
Training for professionals in vestibular rehab techniques is available
CAUTION!
v-o issues may cause difficulties while driving, showering, and going downstairs
Baseline assessments can be viewed as more of a luxury than a necessity.
Computerized testing;
Impact, C3 Logix, and CNS Vital Signs
Important qualities needed;
“Appropriate psychometric properties, interpretation by a qualified professional, and an appropriate environment and motivation are key factors.”
They can be more useful in RTP clearance than as a diagnostic tool.
Symptom Reporting – 31 minutes
Post-Concussion Symptom Scale can be helpful in individualizing treatment and rehab.
Psychological / Emotional – 33
Some individuals experience;
Increased anxiety levels and withdrawal (missing school, work, sport)
Depression and Poor sleep (may cause an increase in s/s)
Autonomic Dysfunction – 34 min
Damage of the long fibers that connect the brain stem and midbrain to the cortex which cause dysfunction in communication.
This is an imbalance of the sympathetic and parasympathetic nervous systems.
Signs and symptoms of Dysautonomia:
Orthostatic hypotension
Diaphoresis
Blurred/double vision
Photophobia
Bowel problems
Exercise intolerance
Feeling winded
Insomnia
Dizziness
HR (tachycardia/bradycardia)
Tunnel vision
Weakness
Vertigo
Brain fog
Many cardio-vascular responses in concussive patients are altered.
Assessment – 38 minutes
Ways to assess autonomic dysfunction; orthostatic BP/HR (lying and standing), exercise intolerance, Valsalva maneuver (baroreceptor functioning), HRV, head-up tilt table.
Buffalo Concussion Treadmill Test (BCTT), assesses “physiologic measures of ANS to help differentiate if post-concussive symptoms are physiologically based.”
Take away –42min
After about 48hrs you can begin manual treatment of the head and neck.
After about 72hrs, if the symptom checklist has decreased, you may begin a controlled exercise program.
Begin treatment in the EARLY recovery phase.
Incorporate neck strengthening as a concussion prevention tool.
A concussion is a multi-system and functional injury that requires comprehensive evaluations.
Watch the video recording of Concussions Are Treatable
Matt Holland joins us on the podcast today from Trinity University to talk about the Thrower’s Elbow.
Why do we see so many elbow injuries in throwers?
“A great deal of stress is placed on the elbow with throwing, particularly in the late cocking and acceleration phase. The forearm musculature has a limited ability to help with the stress load so the bone and ligaments of the elbow absorb a significant amount.”
Also contributing to the rise of injuries is the early commitment of young athletes to year-round baseball, especially in the south. As well as great rehab that doesn’t address mechanics or the importance of core and lower extremity strength as well as balance.
Are there factors that can be indicative that an athlete may suffer an elbow injury?
Rotator cuff weakness, altered scap position, altered throwing mechanics, GIRD and not using the core or lower extremity during throwing contribute to the elbow being injured. Dr. James Anderson states, “the #1 cause of elbow injuries is bad mechanics, and the #2 cause is overuse. Combine those two factors and you are doomed.”
UCL tears aren’t the only injuries we see in the elbow. What other ones might we come across?
Triceps tendonitis is common among throwers. Most often this is an overuse issue and athletes recover quickly with rest.
Flexor tendon tears can occur but are incredible frequent especially in younger throwers.
Valgus extension overload can cause repetitive abutment of the olecranon. It is important to look at mechanics here and ensure that there isn’t a UCL injury causing this.
Little League elbow is very similar to a UCL tear. However the weakest link in a skeletally immature body is the growth plate so this becomes injured instead of the UCL. The key to healing this is rest, rest and more rest coupled with parent education.
How important is rest with elbow injuries?
In a recent study published in 2019 the thickening of the UCL and the increased joint space of the elbow found in thrower’s experiencing elbow pain returned to normal on imaging after rest. However, if these athletes had GIRD that wasn’t addressed, that correlated with a continued increased joint space in the elbow.
What questions should we ask an athlete who comes to us with elbow pain?
What position do you play or combination of positions?
What is your volume of play?
Do you take time off?
Where is your motion does it hurt?
This question is of particular importance because if the pain is happening during the maximum external rotation found in late cocking it is usually a UCL issue.
What are the rehab guidelines post-TommyJohn surgery?
Protect the graft for 6 weeks and return normal strength to not only the elbow but to the shoulder, core and lower extremity. Focus on balance and at the 4-5 month mark throwing can begin. It is a long process because once throwing is started that is how we strengthen the ligament with little stressors. Throwing should include working on mechanics but stressing the ligament a little bit followed by rest. It’s also important to note the type of revision done because some revisions like the modified Jobe move the nerve and this becomes important to know while doing soft tissue work.
Does the UCL reconstruction have favorable Return-to-play?
Yes! 90% of post-surgical patients return to normal throwing biomechanics post-surgery.
What is important to remember regarding elbow injuries in the throwing athlete?
Great rehab is important but it doesn’t help if it is coupled with poor mechanics and it is critical that we have continued conversations with parents educating them on detrimental effects of year-round throwing in high volume without rest.
High loads with high-speed movements
Angular velocity of the shoulder is anywhere between 7 to 8 thousand degrees per second as the shoulder does from max external rotation to an internal rotated position. Then the elbow goes from a flexed to an extended position at 3 to 4 thousand degrees per second in which if there is a small break down in mechanics, strengths, and/or anatomical structure thats when things begin to go sideways.
Phases of throwing
Wind up: is when the athlete begins to move.
Early cocking (stride): In this phase the hands break and the arm moves into adduction, stride length increases the distance in which acceleration occurs so its basically storing the kinetic energy. Pelvic tilt and rotation also happen in this phase.
Supraspinatus, infraspinatus, and teres muscles act late in order to get your arm into an externally rotated position. The phase ends as the lead foot hits the ground. Due to the minimal involvement of the muscular structures, this is known as the power position of the shoulder.
Late cocking: In this phase this is when things begin to fire up.
From lead foot contact to max external rotation then when you add stride component and spine tilt that is when your arm is laid back from 165 to 180 degrees. Due to the angle of pull of the supraspinatus this provides glenohumeral compression at this time.
Max pelvic rotation and trunk rotation velocity. At the end of this phase, when your arm is laid back into max external rotation, the subscapularis, pec major, and latissimus dorsi all fire eccentrically in order to stop your arm from laying back completely and they also stop external rotation. The elbow has the most stress.
Due to the amount of stress at the elbow site, an elite fast ball is enough to tear the ligament if you were to repeatedly do that motion in a lab. “Everytime you throw a fastball its 35 newtons, at 33 newtons is what it takes to break a ligament in the lab”.
Acceleration phase: This is from the max external rotation position until the ball is released. The scapula has to retract and anteriorly tilt with serratus anterior creating the shoulder muscle forces that was slowing your arm down, are now shifting to concentric in order to create the acceleration to throw the ball.
Subscapularis activity is at its highest and this is also where you get the max 3 to 4 thousand degrees per second of the elbow going from a flexed to an extended position quickly.
Deceleration (ball release): This is considered to be the most violent phase for the shoulder, not so much to the elbow. There is an excessive distraction, posterior sheer, and high eccentric loads to the posterior cuff as well as an incredible amount of eccentric bicep activity in order to slow the elbow down to keep it from going into full extension.
Cocking, ball release and acceleration are the primary phases that you will see the most problems in.
Factors affecting injury
RC weakness
Altered scapular position
DIRD
Decreased use of LE/ Core
Decreased balance
Poor mechanics
Throwing Mechanics
Must address throwing mechanics in order to promote return to throwing after injury
Volume discussion in youth baseball
Dr. Andrews –
#1 is overuse
#2 is bad mechanics
If you have both you are … doomed
Pathomechanics – 11mins
Muscle contribution
Soft tissue
Flexor-pronator tendinitis – pain felt at ball release and not during the cocking phase of throwing.
Really common early in the season
Flexor tendon tears – not common
Nerve injury – more in adults
Numbness in 4th and 5th finger after throwing
Ulnar nerve subluxation
Bony Injuries – 15 min
Valgus extension overload
Radial capitellar joint
Little league elbow – 17 min
REST
Parental education is critical
Increased with year-round play
Growth plate is often weakest
Elbow ROM in pro pitchers
Elbow extension dec by 8 deg
Flexion dec by 6 deg
Total flexion ext arc dec by 15 deg
Flexion contractures up to 25deg deficit
Questions to ask
Position played
Volume
Baseball only
Year-round baseball
How much time off
How long have you been off throwing
Where in your motion does it hurt
UCL injuries – 22min
Rest from throwing 6-12 weeks
Normal cuff and scapular strength
Normal scapular control
Restoration of normal IR
Throwing Mechanics correction
Interval throwing program critical
UCL with internal bracing
Similar to ACL internal bracing
Much faster than a traditional UCL reconstruction
Balance and UCL tears – 26 min
In a study done by Craig Garrison from Fort Worth looked at 30 guys with UCL tears and without. The guys with tears showed a decrease in single leg with the Y balance test compared to the guys without the injury. So, if you have a kid who comes up and can't hold their balance and drops their elbow putting their elbow in a bad position those are the kids who get hurt.
During Rehab, by week 4 post-op you should be having these kids doing a lot of core, hip, and balance exercises then look at the shoulder.
UCL Surgery –
The elbow is made up of 2 bundles, the anterior and posterior bundle. The Anterior bundle is the main focus when talking about UCL surgery. It runs from the inferior aspect of the medial epicondyle and inserts into the sublime tubercle. The posterior bundle is pretty much the floor of the cubital tunnel. In the anterior bundle, you have an anterior and posterior band, the posterior band is the one that gets injured in baseball players. It primarily restrains valgus stress throughout its functional range of motion.
Importance of rest
Preseason GIRD vs post season – baseline returned to normal after 6 to 8 weeks of rest.
IT WENT BACK TO NORMAL WITH 6 WEEKS OFF
Shoulder tightness increases the risk of elbow injury
Only 42% of MLB pitchers with TJ returned to pitch 10 games or more.
Cost of TJ in MLB – $395 million average of 180 days
Biomechanical evaluation – 36 min
After shoulder surgery, you lose horizontal extension and external rotation which are two critical components in throwing.
RTP after shoulder surgery in baseball is at best 60%
Dr. Jason Magonye and Dr. Shawn Scott put together an Upper Extremity Neuro Eval session at the Trinity University Sports Medicine workshop.
Complete the CEU course FREE from Methodist San Antonio
Be familiar with the nuero anatomy of the upper extremity
Cranial nerves – remember they are contra lateral
Dermatomes – sensory innervation to the upper extremity
If it is intact distal,it is intact proximal. Start distal and work proximal
Brachial Plexus – 11 min
Latisimus dorsi is the ladder climbing muscle
Subscapular – don’t let them pull their hands off their belly
Supraspinatus – starts abduction until the deltoid takes over.
Hornblower test – teres minor
Ulnar nerve (C7/C8-T1)
Median Nerve (C5-C8, T1) tip of fingers, the palm of the hand
Anterior Interosseous Nerve (AIN) 22 min
Radial nerve – extension nerve (C5-T1)
Posterior interosseous nerve – supinator
Most of the extensors
Nerve Entrapment -24 min
When nerves get entrapped they get irritated.
IF YOU CATCH THEM EARLY YOU CAN PREVENT THE NERVE DESTRUCTION PROGRESSION.
If they are having weakness then we need to really push to have that person looked at
Median nerve entrapment
Pronator syndrome is similar to carpal tunnel syndrome.
Carpal tunnel – positive tinels or phalens
Pronator teres syndrome.
Catch the rest in the podcast or on Facebook.
Do not be afraid to ask your athlete to provide copies of imaging and reports.
Case #1
16-year-old football player who presents with bilateral hand pain. Pushed from behind during a game and landed face down with his hands in front of his body.
During further questioning of his hands symptoms he states that both of his middle fingers were tingling.
Due to the fact that the patient is experiencing bilateral symptoms, you must go to the source in which would be the spine (C7 nerve)
Ulnar nerve splits the 4th digit.
If you have someone who presents with tingling and numbness on the inner aspect of the hand you know that is C8.
Radial nerve does not go to the tip of the fingers.
Case #2
Saddle bronc rider came off his horse and landed on his head. He walked out of the arena and did not complain of neck, head, or arm symptoms. After driving from Colorado to Texas he went to the sports medicine room stating that he had started to experience bilateral middle finger tingling sensations.
Worse thing to do when you have bilateral symptoms, trauma, and numbness and tingling would be to compress the neck.
Range of motion, neurological testing, and gentle palpation are appropriate to perform in the exam. Orthopedic testing would not be appropriate for this exam.
Do you personally have a Diagnostic Accuracy cutoff in terms of diagnostic factors to determine if you would use the test?
No, but if there are multiple tests available I look at the most accurate ones. I do not really like it when clinicians do every test available just because.
Are we image happy?
X-ray, MRI, Ultrasound – it is visual, so it gives us something to see
But blood tests do not really give us that. It has to be done against controls.
Having every injury get an MRI would be great, but it is cost-prohibitive for a lot of people
“If we are sending every patient to get an ultrasound image, then why are we there?”
Talk about treating the patient vs treating the image or diagnostic test.
In Athletics, the nice thing is most injuries are life-threatening.
But for internal injuries MRIs are lifesavers.
It is hard to argue with an x-ray showing a fracture
What is the conversation you would have with parents before the season begins about your confidence in your evaluations and role at the school?
If I think we can treat them here we will if I think they need imaging I will refer them to our team doctor and he can order the images.
Mention this though: “a non-sports medicine doctor will likely default to out two weeks” once they do that we are obligated to follow that before beginning rehab and return to play work.
Is there any uncertainty in using diagnostic accuracy values in Athletic Training?
YES! There is untold value – the new ATs have learned this but it is a new development in AT education.
How do we make Diagnostic Accuracy Language more universal?
It is growing as we have more and more ATs learning about it as part of their education.
More talks at conventions with catchy names
When would you not focus on diagnostic accuracy measures?
In short, yes you can go with your gut and try a few other tests when things seem off.
How do you get students to buy-in?
This is how you win arguments.
If someone questions you and your evaluation you Have numbers and research to back it up…this usually will end the argument.
Make them understand it is not just statistics.
Some orthopedic tests have minimum research or no reported value, where does proof of the value come in?
Yes, you can still do the test if there is a value that is not reported.
ALWAYS do a neurovascular assessment. Every single dislocation should experience this before reduction.
With the Shoulder there is a risk of axillary nerve entrapment
Typically if the nerves are intact distally then they are intact all the way up the nerve, therefore do your nerve tests at the distal end of the limb.
A dysvascular limb becomes a medical emergency so do a pulse check on both sides. double and triple check if there is no pulse as some are harder to palpate
Dr. Mundluru also recommends having the functional tests distal to check nerve and muscle function
OK sign
Thumbs up
Cross fingers
Scratch test
Repeat the scratch test at the deltoid and check bilaterally having the patient note any difference in sensation
A good motor assesment for dislocation management is having the patient press backwards at the elbow into the examiners hand. most other ROM tests will be limited or elicit pain.
They also discuss:
Brachial Plexus Crush
Transient symptoms after dislocation
Self-Reduction
Sports Specific RTP
When does it become surgical?
Elbow Dislocations
Hip Dislocations
Patella and Knee
Whenever possible treat young patients non-operatively.
Have stories of Dislocation Management gone well or poorly?
Dr. Mark Knoblauch shares the mic as we are live in Katy, Texas learning.
What is a normal day like for radiologists?
Most are sitting in front of a computer looking at images, coming up with a diagnosis, and sending them back.
Dr. Nicks has a unique set up as he has a viewing room in the middle of the ortho floor. He regularly gets out of the office to interact with doctors and patients.
He, at times, even scrubs in with the surgeons to help and learn.
How much info are you usually given with the images to make a diagnosis?
Usually one or two lines at most. This is part of the reason he gets out of the office to see and interact with the doctors.
“Garbage in gets garbage out” plays true in imaging and sports injuries too.
Are there specialties in radiology as well?
Absolutely, If Dr. Kumaravel were to get a neuro MRI he would be sending it right along.
Where are we headed with Imaging and sports injuries?
Clinical Skills need to be an emphasis in radiology education. We are moving away from using clinical skills and he believes it is showing in the results.
Continued improvement and growth. we are now able to see bone marrow edema with CT scans
Ultrasound is the next big wave in the United States. It is becoming an extension of the physical exam.
The hardest part about an AT using the US machine is knowing what it means and interpreting the results.
