Functional Stability Training for the Upper Body

My latest educational program with Eric Cressey, Functional Stability Training for the Upper Body, is now available!  

FST for the Upper Body is the third program in out Functional Stability Training system, adding to the popular Core and Lower Body programs.  When Eric and I started to brainstorm what we wanted to teach with these programs, we wanted to share our approaches to rehabilitation and performance training, but more importantly how we integrate the two together.  This makes the FST products a great resource for any rehabilitation, fitness, or performance specialist.

 

Functional Stability Training for the Upper Body

Functional Stability Training for the Upper BodyIn order to function properly, our body needs to be strong and mobile, but control and stabilization of this mobility is often less than optimal.  Unfortunately, stabilization is often overlooked in the design of rehabilitation and performance programs.  Traditional program design relies too much on mobilizing what is tight and strengthening what is weak.  We are missing the boat on stabilization and it’s effect on enhancing optimal movement patterns.

Proper function of the upper extremities is complicated and requires the arm to work in conjunction with the scapula, thorax, cervical spine, and core to provide mobility, strength, and power to the entire body.  Any deficits in stability throughout the body’s kinetic chain can lead to injury, dysfunction, and a decrease in performance in the upper body.  FST for the Upper Body aims to help formulate rehabilitation and training programs designed to optimize how the upper body functions.

By addressing alignment, strength, mobility, and dynamic motor control, you can maximize your rehabilitation and training programs to reach optimal performance.

Think about a few of these:

  • Can the lumbopelvic and thoracic regions impact shoulder function?
  • Can the cervical spine impact the elbow?
  • Can scapular position decrease shoulder performance?

The answer to all of these questions is ABSOLUTELY!  Functional Stability Training for the Upper Body discusses all this and more, showing you exactly how you can assess and correct issues within the kinetic chain to optimize stability and performance of the upper extremity.

Here is an outline of the presentations and lab demonstrations that we perform.  Eric and I combine presentations with real life examples so you can see how we both manage specific individuals based on our assessments.  You get to see Eric and I at work together working with people:

  • How posture and position influence upper extremity function
  • Understanding and managing joint hypermobility
  • Understanding the elbow: functional anatomy, common injuries, and conditions
  • Elbow injuries: evaluation and management
  • Assessment and management of thoracic mobility restrictions
  • Assessment and management of muscles imbalances of the shoulder and scapula
  • Assessment and management of scapular position
  • Assessment and management of elbow epicondylitis

 

Optimal Shoulder Performance

For those that are familiar with Eric and I’s other education program Optimal Shoulder Performance, Functional Stability Training for the Upper Body takes this information to the next level by showing how we integrate the entire body to optimize upper body function.  

FST for the Upper Body integrates the concepts learned from FST for the Core and FST for the Lower Body, and serves as the sequel to their previous educational program, Optimal Shoulder Performance.  FST for the Upper Body is perfect as a stand alone program, but also builds off Optimal Shoulder Performance to help take your knowledge to the next level.  Putting the information from all of these products together will give you a complete understanding of how we approach our integration of rehabilitation and performance.

We had great reviews from the live filming of this program:

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Special Sale Price This Week Only

Functional Stability Training for the Upper Body is available now and is on sale for $20 off to celebrate the launch.  

If you haven’t purchased any of the other FST products in the past, you can get all three FST programs for the Upper Body, Core, and Lower Body together in one bundle and save another $20.

These special sale prices are for this week only and end Sunday May 18th at midnight EST.  Click below to learn more and order before this sale price ends!

 

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Self Myofascial Release for the Forearm

I wanted to show a quick video of a technique I use for self-myofascial release of the forearm.  Obviously, this is a hard area to get with a foam roll and some of the techniques I have seen using the various trigger point balls don’t seem to apply enough pressure for me.  Here is a quick clip demonstrating:

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The video uses the new Thera-Band Roller Massager+.  Obviously you can use you stick of choice, like the original Massage Stick or Tiger Tail, however I must admit that the Thera-Band stick is my current go-to massage stick device.  I was a little skeptical at first about the ridges, thinking it was just a way to differentiate itself from the competition, but it really does feel better than the other sticks.  The rubber surface with the ridges makes for a nice combination of compression and superficial drag.

 

Self Myofascial Release for the Forearm

In the video above you’ll notice a few things:

  • I position the stick at an ~45 degree angle and really wedge it into a firm surface.  This gives me a nice rigid platform to roll on.
  • I use this just like a foam roll.  I start with simply rolling back and forth the length of the muscle groups, then stop on any trigger points that I find and hold for a sustained released, then I progress to include multidirection movements that include fascial release techniques.
  • For the flexor and pronator group, I start with the wrist flexed and pronated and as I roll I extend and supinate.
  • This is reverse for the extensor and supinator group, I start with the wrist extended and supinated and as I roll I flex and pronate

This is a great warm-up for the forearm and also a great technique to include in home exercise programs for those with injuries such as medial epicondylitis and lateral epicondylitis.  Try it and let me know what you think about this or if you have any other self-myofascial release techniques for the forearm that you find to be helpful.

Are Tennis Elbow Straps Effective?

Lateral epicondylitis, or tennis elbow, is one of my least favorite injuries.  It can be disabling, nagging, and sometimes even relentless!  A commonly recommended treatment involves the use of a tennis elbow strap.  There has been some support in the literature regarding these orthotics, however results in the literature have varied.

A nice new study published in a recent issue of JOSPT assessed the efficacy of these devices in a group of 52 subjects with lateral epicondylitis.  The study examined the amount of pain-free grip strength and maximum grip strength is subjects with a variety of tennis elbow straps, including a placebo strap.

 

How Do Tennis Elbow Straps Work?

image The theory behind counter-force bracing is similar to the mechanics of a guitar.  When a finger is placed on a string along the neck of the guitar, it reduces tension on the string distal to the fret where your fingers are located.  A counter-force tennis elbow strap can be thought of as your fingers on the neck of the guitar (your forearm) and the extensor muscles, especially the extensor carpi radialis brevis, would be the guitar string, thus reducing tension of the muscles as they attach to the lateral epicondyle.  The authors of the study review this concept well.

 

Counter-force Bracing is Effective

Results indicate that strapping was effective in allowing subjects to produce significantly more pain-free force.  Subjects were able to produce 16% more strength without pain using a strap.  There was no difference between two of the devices they used (a strap vs. a sleeve with a built in strap), indicating the strap itself is likely the significant factor.  The image below on the left is just the strap and the image on the right is the sleeve with a built in strap:

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One of my original concerns with the study involved the rest time between repetitions of grip strength.  As anyone that routinely assesses grip strength knows, the amount of force produced can drop significantly if the rest time between repetitions is not adequate.  However, the study design used a mean of 4 repetitions for each device and allowed 5 minutes of rest between testing sessions.  This was adequate for me and I was happy to see this methodology.

 

Clinical Implications

  • I like this study because bracing is simple, cheap, and effective.  People can go to any CVS or Target and get a nice tennis elbow strap these days.
  • Counter-force tennis elbow straps are effective at allowing patients with lateral epicondylitis to produce more grip strength with less pain.
  • The strap should be placed around 2.5 cm distal to the lateral epicondyle.
  • While it is unclear if the size of the strap is important, the study used straps that were between 5-8cm in width.  Considering there is some conflicting results in the literature, I would recommend you try to replicate the width of the strap.  There are some straps on the market that are very skinny.
  • Straps can be an effective way to allow people with lateral epicondyltis to return to athletics or weight lifting when painful gripping can severely limit activities.

 

Fahimeh Sadat Jafarian, Ebrahim Sadeghi Demneh, Sarah F. Tyson (2009). The Immediate Effect of Orthotic Management on Grip Strength of Patients With Lateral Epicondylosis J Orthop Sports Phys

Complications Following Distal Radius Fractures

clip_image002This week’s guest post is from Trevor Winnegge PT, DPT, MS, OCS, CSCS.  Your may recognize the name, Trevor is a frequent commenter here on this website.  Trevor has been practicing PT for over 8 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.

A Review of Several Complications Following Fracture of the Distal Radius

It is the time of year (at least here in the Northeast United States) where snow starts falling and the ground becomes icy. With these weather conditions comes an increase in the amount of slip and fall injuries seen by doctors and therapists. One of the most common fractures seen, comprising about 13% of all fractures, is the distal radius fracture. Whether these fractures are intra- or extra-articular; non-operative or post-operative, complications following this fracture often arise. These injuries are not always managed by a specialized hand surgeon, so it is important for therapists to be aware of some of the more common complications following this fracture.

Vascular injury and nerve injury can occur, however these are most likely to be picked up by the referring physician before they enter your clinic. Post-traumatic arthritis is common, yet takes longer to set in and may occur after discharge from therapy. I chose to focus this post on the following common forms of chronic pain after distal radius fracture: Scaphoid fractures, TFCC tears, Distal radioulnar joint instability/ulnar impaction syndrome, carpal instability and Extensor Pollicis Longus rupture.

 

Fractures

clip_image003The most common mechanism of injury for a distal radius fracture is a fall on an outstretched hand, or FOOSH injury. This is also the direct mechanism of fracture of the scaphoid carpal bone. This fracture can be sometimes overlooked due to the more pressing displacement of the distal radius. Signs to watch for in an associated scaphoid fracture include tenderness to direct palpation over the anatomic snuff box, swelling, and pain with wrist and thumb movements, as well as with gripping activities. The presence of swelling in the snuff box is variable, as some cases present with no swelling. Chen describes a scaphoid compression test, in which compression through the thumbs longitudinal axis should produce pain in the presence of fracture. Reliability and validity of this test are in question, as different studies have show mixed results, but I think it is a good quick test to add to the rest of your objective findings. Referral for scaphoid view xrays can be helpful. These are taken with clenched fist and wrist in ulnar deviation. If Xrays are negative and fracture is still suspected, an MRI or CT scan will assist in ruling in/out fracture. Failure to recognize a scaphoid fracture can result in non-union and chronic thumb and wrist pain.

 

TFCC Tears

clip_image004The TFCC is comprised of a fibrocartilage disc interposed between the proximal row of carpals on the ulnar side of the hand and the distal ulna. It’s primary function is to enhance joint stability of the distal radioulnar joint and also acts to absorb some of the compressive forces through the hand and wrist. According to Richards et al, Triangular Fibrocartilage Complex, or TFCC, tears occur in 53% of extra-articular distal radius fractures and 35% of intra-articular fractures. Mechanism of injury for TFCC tears is also a FOOSH injury, typically while the forearm is pronated. Symptoms of a TFCC tear are pain just distal to the ulnar styloid process, clicking with pronation or supination which worsens when the wrist is in ulnar deviation and rotating, and pain with wrist/hand and gripping movements. Nonoperative PT care focuses on restoring wrist ROM and strength, as well as stability of the wrist.

 

Distal Radioulnar Joint Instability/Ulnar impaction syndrome

Instability of the distal radioulnar joint following a distal radius fracture occurs in conjunction with a TFCC tear. Other factors suggestive of instability are widening of the joint on x-ray, a positive ulnar variance, and a shortened radius. Neutral ulnar variance is when the borders of the radius and ulna are level across in height. A common complication following fracture of the distal radius is when the radius shortens. This leads to what is know as a positive ulnar variance. Positive ulnar variance is used to describe a forearm where the distal ulna is no longer in line with the distal radius, resulting in the ulnar being longer. The amount of variance is measured on xray and is usually millimeters. (For the record, a negative ulnar variance occurs when the ulna is shorter). In a neutral (normal) variant wrist, the radius absorbs 80% of the weightbearing load, and the ulnar 20%. In a wrist with positive ulnar variance, the ulnar weight bearing load increases to as much as 42%. Over time, this increased load can lead to a condition called ulnar impaction syndrome. This is one of the more common reasons patients have chronic ulnar sided wrist pain following a distal radius fracture. This occurs when the distal end of the ulna with its increased weightbearing load, wear through the TFCC. Symptoms include restricted ROM-particularly with supination/pronation and ulnar deviation. It can also lead to lunate-triquetral instability and carpal chondral lesions. PT management would include strengthening/stability training and restoring rom. However, often times another procedure is indicated. Surgical options include an arthroscopic waffer procedure, osteotomy, or a hemiresection arthroplasty.

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Figures: Ulnar variance (left), positive ulnar variance – note the radial border of the ulna is elevated (middle), negative ulnar variance – note the radial border of the ulna is depressed (right).

 

Carpal Instability

I mentioned lunate-triquetral instability occurring as a result of the ulnar positive variance following a distal radius fracture. In addition, and more commonly, the scapholunate joint often becomes unstable following a distal radius fracture. It is estimated that in 54% of distal radius fractures, there will be an associated scapholunate instability. Symptoms are pain over the joint line with weight bearing activity, clicking, weakness and a positive instability with joint play testing. Treatment includes splinting, stability and strengthening exercises and activity modification. If a patient does not modify their activity that causes pain, it can lead to a scapholunate dissociation over time, where the scaphoid dislocates. This often requires reduction and internal fixation. Symptoms of this are extreme pain and functional loss of strength, and is easily picked up on x-ray.

 

EPL Rupture

clip_image005Lastly, I want to review the extensor pollicis longus (EPL) muscle and tendon. This is unique in that it occurs following a distal radius fracture in up to 3% of all cases, yet it is poorly understood why this occurs. The EPL inserts on the distal phalanx of the thumb, and acts as a joint extender of the thumb. Rupture of the EPL can occur up to 8 weeks after the initial distal radius fracture. Since it has a poor blood supply, it is postulated that chronic tenosynovitis following this injury wears away the tendon sheath, making it vulnerable to rupture. Testing for a rupture is a simple manual muscle test, where you block the IP joint of the thumb and isolate the distal phalanx. You then ask the patient to extend the distal phalanx and if they are unable to or have trouble doing so, rupture of this tendon should be suspected.

In summary, there are numerous possible complications following a distal radius fracture. I highlighted several of the more common ones. Chronic wrist pain can be difficult to treat as a therapist and aggravating for the patient. Being aware of the possible causes of such pain can lead to a quicker proper diagnosis and preservation of hand and wrist function.

References:

  1. Palmer,AK. The Distal Radioulnar Joint. Anatomy, biomechanics, and triangular fibrocartilage complex abnormalities. Hand Clin. 1987 Feb;3(1):31-40.
  2. Chin HW, Visotsky,J. Wrist fractures in the hand in emergency medicine. Emerg Med Clin North Am 1993; 11:703-735.
  3. Perron AD et al. Orthopedic pitfalls in the ED: scaphoid fracture. Am J Emerg med 2001; 19:310-316.
  4. Wadsworth CT. Anatomy of the hand and wrist. In:Manual Examination and treatment of the Spine and Extremeties. Baltimore, Md: Williams & Wilkins; 1988:128-138.
  5. Cheng et al. An Analysis of causes and treatment outcome of chronic wrist pain after distal radius fractures. Hand Surg. 2008;13(1):1-10. 
  6. Rutgers et al. Combined fractures of the distal radius and scaphoid. J Hand Surg Eur Vol. 2008 Aug;33(4):478-83.
  7. Richards et al. Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radius fractures. J Hand Surg [Am]. 1997 Sep;22(5):772-6.
  8. Forward et al. Intercarpal ligament injuries associated with fractures of the distal part of the radius. J Bone Joint Surg [Am]. 2007 Nov;89(11):2334-40.
  9. Bickel KD. Arthroscopic treatment of ulnar impaction syndrome. J Hand Surg [Am]. 2008 Oct;33(8):1420-3.
  10. Bonatz et al. Rupture of the extensor pollicis longus tendon. Am J Orthop. 1996 Feb;25(2):118-22.
  11. Owers et al. Ultrasound changes in the extensor pollicis longus tendon following fractures of the distal radius-a preliminary report. J Hand Surg Eur Vol. 2007 Aug;32(4):467-71.
  12. Chen, SC. The scaphoid compression test. J Hand Surg 1989; 14: 323-325.
  13. Dutton,M. Orthopedic Examination, Evaluation & Intervention. New York: McGraw-Hill; 2004
  14. www.wheelessonline.com

H. S. Cheng, L. K. Hung, P. C. Ho, J. Wong (2008). AN ANALYSIS OF CAUSES AND TREATMENT OUTCOME OF CHRONIC WRIST PAIN AFTER DISTAL RADIAL FRACTURES Hand Surgery, 13 (01) DOI: 10.1142/S0218810408003748