Okay, so everyone, welcome to the overhead athlete community for the APR 2020 virtual conference. My name is Jason's Ramsey I'm your chair for this session. If you have entered the right link I never thought I would say that before but if you've entered right link this is physical examination of the overhead athlete, what you need to know what you need to become an expert through clinical and physical exam pearls. Just some housekeeping details. If everyone. We would also like to thank everybody for attending. We also want to encourage everyone to join our community. So there's been a lot of fantastic communities so far. This community is the Hoover athlete community. If you are interested, I would encourage you to sign on to the next link, which is immediately following this session, the sports medicine community link. And that is, can PM&R doctors be head team physicians? That is going to be led by Dr. Mark Ellen. That's from 5.30 to 7 p.m. Central Standard Time. So obviously if you're in different time zones, you can adjust accordingly. Another housekeeping note, to claim CME credit, in order to claim it, you will need to complete an evaluation for each session you attend live or watch on demand during the assembly. And you will have the ability to do this through January 31st of 2021. You can visit the member resource center through aapmr.org if there's any questions. And please, of course, please provide feedback for our program planning committee. So we can improve our annual assemblies in the future. And of course, a special thank you to all of our AAPM&R staff in Chicago that has worked constantly to make this virtual meeting a success. For those of you who may be signing on for the first time, the meeting started Sunday with the medical student symposia. And we've started with some community sessions, Monday, Tuesday, and then today. And tomorrow night we have Dr. Gittler's presentation as president of AAPM&R. And there's plenty of fantastic live sessions. So thank you to all of the staff that has worked tirelessly for many, many months to make this a success. So real quick, the lineup for this community session will be myself, then Dr. William Micheo, Dr. Ken Moutner, Dr. Carly Day, and Dr. Melody Rubesh. You can see all their titles there. I'm gonna introduce each of them via slide. And then I'm gonna give kind of an introductory course just to kind of get us warmed up before I hand it over to the four of our expert speakers. So Dr. William Micheo is professor, chairman, and sports medicine fellowship director of physical medicine rehabilitation and sports medicine at the department in the University of Puerto Rico School of Medicine. He's the former vice chair of the American Board of PM&R. He's the co-director of the sports injuries unit for the Center for Sports Health and Exercise Sciences Olympic Training Center. He's a past president of AAPM&R, the Puerto Rico Sports Medicine Federation, and formerly known PASOR, for those of you who remember PASOR. From 1992 until 2010, he was the residency trained director for the PM&R program affiliated with the University of Puerto Rico. And he's also a past member of the residency review committee, has also represented PM&R in the sports medicine subspecialty examination for many years, and he is board certified in multiple subspecialties. Dr. Ken Moutner is associate professor in the Department of Physical Medicine Rehabilitation and the Department of Orthopedic Surgery at Emory University in Atlanta. He's the head team physician for the Lion Hawks and a team physician for the Braves, Emory, Agnes Scott, Pace Academy. He's also a consulting physician for Georgia Tech. He's an elected board member, excuse me, board director member for the American Medical Society for sports medicine. He's a former program chair for AMSM in 2017. Dr. Moutner is the sports medicine fellowship director at Emory, and he's actually the one who started the fellowship. He's board certified in PM&R with the subspecialty certification in sports medicine. He is a co-author of many manuscripts and texting from the one I listed below, and some of you may actually have already. He's an amazing expert with respect to musculoskeletal medicine, musculoskeletal ultrasound and orthobiologics. He's active member of many sports medicine associations. Dr. Carly Day is the head team physician for Purdue University. She's an elected member of the board of directors for AMSSM. She's also a team physician for the United States U-20 Women's National Soccer Team. She's board certified in PM&R with a subspecialty certification in sports medicine. She's a member of AOA Medical Society, as well as a member of PM&R, ACSM, and AMSSM. She's the former head primary team physician for Notre Dame College in South Euclid, Ohio, and she's a former clinical associate professor at the Cleveland Clinic Memorial College of Medicine at Case Western Reserve University. Dr. Melody Rubesh is the director of primary care sports division for the New York region of Rothman Orthopedics. She's the medical director for the Radio City Rockettes. She's also a team physician for the United States Soccer Federation and has previously worked with the United States Gymnastics Team. She specializes in ultrasound guide procedures, regenerative medicine, and electrodiagnostic medicine. She's a board director for the Performing Arts Medicine Association, OSPAMA. She is also an active member and serves on committees for AMSSM, ACSM, the International Association for Dance Medicine, as well as AAPM&R, and she is board certified in PM&R with a subspecialty certification in sports medicine. And that's me. My name is Jason Zremski. I am at the University of Florida, and you guys can read all of this stuff, but we can go on. So my introductory talk is try to get, this is kind of a tongue-in-cheek thing, but arm pain to overhead athlete, you mean not all injuries are Tommy John injuries. There seems to be, particularly in the springtime, that every time there's an injury, particularly an elbow injury, everyone immediately jumps to, oh my gosh, it's Tommy John injury. And that's just not the case. What's really important, and really this talk is really geared more to our younger members, is you gotta remember your mechanism of injury, the location of the injury, especially in elbow injuries and throwers is really important. In the historical context, is this a new injury? Is this a previous injury? Is it a previous injury or a current injury in the exact same location? Overuse questions, in particular for our younger athletes, are your athletes' feces open or closed? Has there been a recent growth spurt in the last three to six months? Has there been a recent change in the distances, particularly for pitchers from 46 to 54, 60 feet, or if you're running the bases, from 60 to 70 to 90 feet, because that will change the distance throwing across the infield, as well as for catchers. It's difficult in our adolescence, but it is important to ask the question when in the throwing or pitching cycle pain presents itself, such as maximum external rotation. If you don't know, as a provider, what maximum external rotation is, it's something that you maybe wanna work on if you wanna take care of overhead-throwing athletes. And honestly, the best piece of advice I ever gave came from a very experienced athletic trainer and physician assistant. He always asked, point with one finger where it hurts, because as we know, especially for our younger athletes, we just hear, oh, it just hurts here, or here to here, or in some cases, it just hurts everywhere. So point with one finger. So this case actually occurred in my clinic, and this was, I think it was last summer, but as most of us know now, time is sort of relative with everything going on. But it's a 15-year-old male pitcher with right elbow pain with throwing. HPI, no prior injuries to right elbow or the throwing shoulder. There's pain with throwing and pitching. Can't really say when during the motion, but he does note that there's pain when he extends his arm, or as we would say, terminal extension. There's no clicking, or locking, or buckling. On palpation, there is mild tenors to the lepranon and the sublime tubercle. And again, for any residents or even medical students that are on, I always like to test our trainees where exactly the sublime tubercle is. And if you don't know it's part of the ulna, then that's something you need to be aware of. When performing a valgus and a moving valgus maneuver, it was negative for laxity or for pain. A shoulder exam was completely normal. That includes strength and neurovascular examination. So what do we do next? What's our differential? Now, I personally love a lot of imaging, but some places may not have access to it. I work in orthopedic departments. We have x-rays that are literally 50 feet away from my exam rooms. We have a CAT scan machine on the first floor and we can get MRIs pretty quickly. But we have to think about what's going on. So I always recommend, particularly for our trainees or for our younger physicians, definitely develop at least three to five things on your differential. What's most likely? Is there a stress injury? Is there a sprain? Is there a rupture? Is there a fracture, which would be extremely rare? So there's things you need to keep in mind. So imaging, x-rays were normal. So I'm just gonna put up the highlights. This is of the MRI arthrogram. To put up the T2-weighted images, and you can see right in the center of the screen, you can see a coronal T2, and then you see on what should be your right-hand side of the screen, you'll see a sagittal T2. Now, what I hope comes up on your screens, you can see with the circles, is some white edema in what would be the olecranon and the sublime tubercle. Now, why does that matter? Well, one, if this is on a T2-weighted image, and just to let you know, there was no concern on T1-weighted images, this is likely a stress reaction of the bone in that location. It's also important to know where your ulnar-claral ligament, particularly the anterior band, inserts, inserts into the sublime tubercle. However, the UCL is normal. So what this young man developed is a sublime tubercle and olecranon stress reaction, or a bony stress reaction. So what's the plan for this? And I pull image up of something that one of our physical therapists and one of our athletic trainers, I was fortunate enough to collaborate with on a manuscript last year. And again, we're not reinventing the wheel, but we need to identify our risk factors. We need to talk about overuse factors. We need to think about connect chain train program. We have to think about biomechanics, but all that doesn't matter when there's a bony stress reaction. For a thrower, in particular, the elbow, the first thing is you really just can't throw or load the elbow for at least a month depending on the severity. So he was shut down for four weeks completely. I actually have seen him back. He was doing really well. So then we started non-throwing physical therapy for an additional about a month to six weeks or so. If you want to get really specific, you still want to be very careful when you're loading the elbow, particularly in valgus, because you don't want to stretch that ulnar collateral ligament where there was some resolving edema. Then I see him back one more time. I'm supposed to see him back right after Thanksgiving as long as he's doing okay. Then he begins a very slow return to throw or return to pitch program. Now, some of you may be a little jealous and for someone who grew up North, I would be too, because remember high school baseball season, assuming there's no delays, it actually starts down where I live between the third and fourth week of January. So that's what I have to work with from a timeframe standpoint. For anyone who maybe lives up North, maybe in Chicago or New York or Ohio, it's going to be March or April. So that's something to also consider. So what I'm going to do now is I'm going to stop sharing and I'm going to turn this over to Dr. Micheo, who I believe is next up. And I'm going to let everyone go for about 15 minutes and then we'll have 15 minutes for Q&A at the end. However, the chat function is open. So if anyone has questions or they see someone online that they want to meet with, by all means, you can chat back and forth. This is informal. All right, I'm going to hand it over to Dr. Micheo. Jason, can you see my screen? No, we can't see your screen. I got you. Yeah, I got you. Now you got it. All right, sorry guys. Can you see it now. All good. Okay, so sorry about that. So my, my talk this afternoon. First of all, I'd like to thank Jason and the overhead community for inviting me to talk in this session. Second, I'd like to hope everybody is doing well in this trying times and hopefully we'll be able to see each other next year. So my topic for this afternoon is the proximal kinetic chain from the scapula to the glenohumeral joint and back again. The objectives, I have for, I have nothing to disclose, except I'm the oldest guy here the only one with gray hair and the speakers. My objectives are very simple. I'm going to go over some concepts of the kinetic chain and how it relates to overhead athlete symptoms and assessment. I'm going to present briefly the critical components of the clinical history and physical examination. And at the end I'm going to highlight clinical correlations of the history of the physical examination. This topic would be one that we could talk for an hour. There's a lot of information on your slides available for you. And I'm going to skim over the information that I think is critical when you assess the overhead athlete. As we know, the shoulder has significant mobility at the expense of stability. It requires optimal function and between the dynamic stabilizers and preserves that and static stabilizers in multiple degrees of freedom. And understanding the components of the shoulder and the kinetic chain and how they participate in the throwing motion is mandatory in the assessment and management of the throwing athlete. There are several key components of the shoulder assessment that are critical for people involved in this area. There are four major areas that have been usually spoken about in the medical literature. The first is the role of scapula and the throwing motion. The second is shoulder ROM or range of motion adaptations that occur in the overhead athlete. The third is rotator cuff function and how it affects the throwing motion. And last but not least are the contributions of the kinetic chain, particularly the lower extremities to overhead sports activity. In our clinic, we also add the function of the static and dynamic stabilizers. We assess the opposite shoulder trying to look to see if the patients have congenital versus acquired symptoms or instability. So what is the role of the scapula? Briefly, the scapula has three major functions. It works in coordination with the humeral head to maintain the central rotation of the shoulder in the overhead motion. Second, it positions the scapula positions itself to allow the athlete to bring the arm of up the head, elevate the acromion for optimal function, and at the end of throwing motion, protracts and decelerates the throwing shoulder. It also serves as a stable base in the function of being the origin of the intrinsic muscles of the shoulder or the rotator cuff. As a corollary to this, we know that scapula dysfunction or dyskinesis will affect shoulder function. Second area that's important to assess is the area of range of motion. We know that overhead activity is associated in many sports, particularly baseball and tennis, with acquired changes in shoulder motion. In general, the concept is that athletes have an increase in shoulder rotation, particularly external rotation, with loss of internal rotation. The key point is if the total arc of motion is equal to the opposite arm, this is considered an adaptation and not a maladaptation. General tennis players tend to lose more internal rotation than gain external rotation. There are several things that are associated with these changes, and these include humeral retroversion in athletes who start at a very young age, humeral head elevation, and posterior capsular changes that are present and associated to secondary impingement. Here in this slide, you get the left side, the A, you have increased shoulder motion similar to the loss of a rotation. Internal rotation is lost at the same degree that external rotation is gained. That is considered a normal adaptation. In the right side of the slide, the C, you see 20 degrees of loss of internal rotation in addition to the gain of external rotation, and that is considered a maladaptation. Third area that needs to be addressed is the area of the rotator cuff. We know that the rotator cuff maintains the instant center of rotation of the glen or humeral joint when the arm is elevated. It works in forced couples with the deltoid, acting as a humeral head depressor, maintaining the instant center of rotation of the shoulder as the arm is elevated. Weakness or fatigue of the cuff allows migration of the humerus and many times leads to secondary impingement. Here in this slide, we see on the right side, the summation of forces of the deltoid as a humeral head elevator and the summation of forces of the rotator cuff as a humeral head depressor. On the left side of the slide, you see the rotator cuff muscles on both sides of the joint, resulting in cuff compression as the arm is elevated. The last point that we need to understand is the concept of the kinetic chain. We know that activation in the kinetic chain or throwing starts in the ground. About 50% of the forces come from the ground and the acceleration. The ground legs and trunk are force generators. The shoulder is a funnel that acts as a force regulator, and the arm is a force delivery mechanism. There is a very well-described sequence of stride, pelvis rotation, torso rotation, shoulder, internal rotation that I've seen in many throwers. Kinetic chain dysfunction and loss of lower extremity strength or force transmission results in shoulder injury. This slide here is a commonly seen slide in sports medicine circles. This comes from Jack Gropo, and you see here that the kinetic chain starts in the leg, through the trunk and back, through the shoulder, elbow, all the way down to the wrist. And here, this is an interesting slide for you guys to remember. This is the shoulder muscle activation sequence, and the scapula, starting with the serratus anterior and the upper trapezius, going to the delta and supraspinatus that elevate the arm. Infraspinatus and teres minor rotate the arm externally. The subscap, pec major, and lat dorsi internally rotate the arm to accelerate the throwing motion, and the posterior muscles decelerate the arm at the end of the throwing motion. So these are concepts that you should be aware of, the four areas that we should be looking at when we assess the thrower's shoulder. So what are the key points that we need to obtain from the history? We need to see age of patients. If they started early in sports, years of sport participation and level of competition. Volume and intensity of competition. Is the injury acute or chronic? Is it severe enough to lose time from practice or competition? Is it an overuse injury that improves with warmup? Is it a severe injury that persists with pain at night? Are the symptoms in the early phases versus the late phases of throwing? Is there a history of shoulder traumatic dislocation that may lead to secondary laxity or instability? Or is this an atraumatic history of instability? And does the athlete have bilateral symptoms that could be compatible with congenital laxity? What is the response to previous treatment? And key concepts in the history include the understanding of the role of mechanical symptoms in the history. And complaints of dead arm that are usually associated with labral injury. So how do we organize a physical examination? It needs to be in an orderly manner, similar to what we do in other areas of physical medicine and rehabilitation. Looking at all the areas that we see here in this slide. What is the key areas to look at in the inspection of the shoulder? And this is a key concept. From the frontal plane, we see dominant arm depression. From the cellular plane, we will see forward head and forward shoulder or protracted scapula. And in many instances, we may see scapular winging at rest. And in some athletes, and particularly tennis players, I'm very cognizant of the fact that they may have suprascapular neuropathy. And I'm looking for supraspinatus and infraspinatus atrophy, particularly infraspinatus atrophy. So what are the clinical correlates of these findings in inspection? We look for, particularly in the anterior shoulder, for tight pec minor, weak cervical muscles, weak serratus anterior and lower trap muscles. And in case of atrophy, we look for suprascapular nerve injury in overhead athletes. In terms of palpation, we try to differentiate between pain generators that are related to the joints, AC, SC, or glenohumeral joints, and pain generators that are soft tissue, such as the scapular stabilizing muscles, such as the upper trap, the rhomboids. And we also look for pain at the insertion of the rotator cuff and pectoral muscles. We also look for localized tenderness. And something that was key to us is this reproducible pain that is related to the athlete's symptoms. So clinical correlate of palpation or tenderness, it would be trying to identify areas of tissue primary injury and areas of tissue secondary overload. Third area in the exam that's key in throwers is the evaluation of range of motion. I look for three areas here. I look for the relationship between active motion and passive motion. We look for active patients that lose active motion but maintain full passive motion. We look for athletes that lose both active and passive motions. And we also look for asymmetries in rotation, looking in particular for loss of internal rotation or GERD, looking at over 15 to 20 degrees of GERD or internal rotation glenohumeral deficit. So what are the clinical correlates of these findings? We look for pain inhibition, muscle weakness, nerve injury, rotator cuff or other area of tears, and posterior structure and capsular tightness. So these are the things we look for when we assess range of motion. So in terms of manual muscle testing, we look for weakness in extrinsic versus intrinsic muscles, particularly the rotator cuff. We try to test muscles in positions of pain-free so that we're looking at pain-free muscle strength and avoiding muscle inhibition because of pain. We usually assess muscles in mid-range of motion, and we attempt initially to isolate muscles. And this is something that's very key in the shoulder and rotator cuff muscle. So we try to assess supraspinatus, infraspinatus, teres minor, isolated function, subscap, isolated function, and usually we assess scapula stabilizers as a group. So we usually look for weakness associated to forced couple abnormalities. In terms of the neurologic assessment, I think this is key because some of the shoulder symptoms may mimic neurologic injury. So we look for numbness in the radial and ulnar aspects of the forearm, and we look for symptoms related to the dutt arm syndrome, usually associated to shoulder laxity. We assess muscle stretch reflexes. We correlate this with focal entrapment, cervical radiculopathy, or plexopathy. We look for upper trap and scapular muscle trigger points, which may reproduce radiating pain because of trigger points. We look for findings of clinical or disputed thoracic outlet syndrome, particularly in athletes that have very tight pec muscles. And we look for short shoulder laxity associated to symptoms of dutt arm or arm numbness. This is key in our examination. Special tests, we look for combinations of findings. This usually are tests that would like to reproduce symptoms. We usually look for impingement using both maneuvers Hawkins and Near. We see the patients have impingement in combination with apprehension or looking at instability in association with impingement. So we do impingement maneuvers. We look at apprehension testing in the asymptomatic and the symptomatic arm. We usually test the arm sitting, and some athletes who may also test the apprehension maneuvers with the athlete supine. In terms of the apprehension maneuvers, we look for pain in the posterior shoulder, thinking that this may be associated with internal impingement or with slab lesions in the anterior shoulder. And we look at this combination of pain with the apprehension maneuver with the O'Brien's test, and we would like to look for labral injury. So in general, in the special tests, in this first part of the examination, we look for isolated impingement, or we look for impingement in combination with labral injury and or secondary impingement associated to shoulder laxity. Finally, we look for unilateral versus multilateral or multidirectional instability or laxity. So we use a load and shift maneuver with the arm at side to look for posterior laxity in addition to anterior laxity, and we look for the sulcosign producing inferior subluxation with the humerus headed side. This key to do this maneuver is both in the symptomatic and in the asymptomatic side. So if we have somebody that has a positive laxity test in the asymptomatic side, we look for patients having a traumatic multidirectional instability. For scapular dyskinesis, we tend to use lateral slide tests. That was discussed by Ben Kibler many years ago, looking for the arm asymmetry of the scapula with the positions of the arm at side, arm at the hips, and at 90 degrees of abduction, having an asymmetry of more than 1.5 centimeters on the other side being a positive test. We also always, in athletes who are participating in overhead activity, do kinetic chain assessments, including single leg squats and balance, particularly the dominant arm, but also assess the non-dominant arm for rotation deficits and poor balance as well, which correlates with poor transmission of forces with the throwing motion. So how do we put this together in an exam cluster? And we call these groups exam clusters. So we look at depressed dominant shoulders and scapular winging associated to tenderness over the anterolateral shoulder, associated with loss of internal rotation. These athletes usually present with weak rotator cuff, particularly the external rotators and weak scapular stabilizers. They have positive Hawkins and near impingement tests with pain reproduction. Many of these athletes have positive apprehensions maneuver and relocation maneuver with posterior shoulder pains in those that have internal impingement. We usually have a negative O'Brien's test in the absence of labor pathology, and we look for a lateral slide test in patients who do have a scapular dysfunction or scapular dyskinesis. So once we put all these together, what are the things that we need to get to know better related to the physical examination with a kinetic chain and a throwing athlete? We need to understand better what are the optimal clinical evaluation protocols for athletes of different ages, level of competition, and type of sport. And we need to understand if some of these findings can help us to identify individuals prior to injury development. We need to understand the correlation of physical examination changes and prediction of clinical recovery and clinical performance, and in the future we hope to have more information related to instrumented strength testing and functional evaluation in return to play following injury in correlation with physical examination similar to what we have in the anterior cruciate ligament of the knee. So what did we learn today? Hopefully you learned something. This is a very, very fast talk. The clinical assessment of the shoulders should include an understanding of the whole kinetic chain. The history should identify changes in volume or intensity, which are the key components of a crossing injury. We should know if the athletes had previous injury, previous treatment strategies, the mechanism of the injury, and how severe is the injury. And the physical examination should be performed in an orderly manner, assessing the function of the scapula, changes of range of motion, particularly rotation, rotator cuff strength, and balance. Kinetic chain components, including the dominant and non-dominant lower extremities. And we should assess the shoulder static stabilizes bilaterally to look for patients who have congenital instability or laxity that should be managed usually conservatively without surgery and those who have only unilateral acquired laxity or instability associated with those symptoms. So these are my references, and there's my email. I know it was a very, very fast talk, and if you have any questions or any concerns about my talk, I'll be happy to answer your questions if you write to me in the email. I think you should be able to have these slides available to you. Don, Jason. Perfect. 530 Eastern time, exactly. So thank you very much. Next up, Dr. Ken Mountner. You're up. All right. Everyone can hear me now? Sorry. I was trying to get off the mute, so if no one's texting me, I'm assuming I'm on. So sorry. Thanks for having me here, Jason. And I appreciate being part of the overhead community and being invited to give this talk. And it's too bad we can't all be together to see each other. So my topic of my talk is, you know, the Morton-Elva diagnosis and just ordering an MRI. And tips to accurately assess common elbow and forearm injuries in overhead athletes. And honestly, I'm going to be talking a lot about ultrasound of the elbow as my way to accurately assess these injuries, because it's a great tool to have in our office. A lot of them do. And I'll kind of go through the way we look at these things. So first the case. This is a 36-year-old major league pitcher, 46 weeks of worsening of the medial elbow pain with pitching. This is Darren O'Day. He is the pitcher. He gave me permission to use him for this talk. You can see he's kind of got a submarine style of pitching, which I won't go into that too much today. But he has been injured a lot, specifically the previous year. He was injured with some hamstring issues, which required surgery. So he was just coming back. You know, pain was worse in late cock and early acceleration. No moment of injury reported. He had decreased control and cannot currently pitch at his previous level. So you know, what do we want to do next with him? This has changed over the 15 years, you know, 16 years I've been in practice. So when I was a fellow, if you had asked this question, we would have, I did my fellowship down at Dr. Andrews and Dr. Ray down in Birmingham. And we would have gotten stress use. I don't know how many of you all have seen this machine where they literally, it's like a torture device. They put the elbow in this and they put this standard amount of pressure on their elbow to get the stress use of the elbow. And then that would immediately be followed by an MR arthrogram. And that's where our decision-making would come from those two images. So now, you know, we typically will get x-rays of the elbow, MR arthrogram, if you're a high level pitcher or a major league pitcher, you know, as much as I take care of major league baseball players, usually by the time they see me, they've already had an MRI done. But we're going to talk a lot about the role of ultrasound with evaluation of these elbow injuries and not just the UCL either. So if you're having an athlete come in with medial elbow pain and the overhead athlete, right, that's going to be your most common area. This is kind of a checklist of what we should be looking at with ultrasound, starting medially and then going posteriorly and even anteriorly. We'll talk about what things you may say, even associated with that medial elbow pain, things like valgus extension overload and capitella OCDs and other things like that. So just to go over some quick pathology here and medial elbow evaluation. So, you know, in the common flexor tendon, you'll see some tendon problems in major league pitchers. But remember, anytime you have an overhead athlete with medial elbow pain, the ulnar collateral ligament certainly needs to be evaluated. But you may see partial tears of the common flexor tendon. You can see thickening associated with tendinopathy. You can see small calcifications in the area. And then with videos, I'm not going to spend the time to try and get them to work, but with videos, you can actually see more findings as you kind of scan up and down to the tendon, both longitudinally as well as in short axis views. Partial tears, once again, common flexor pronator muscle partial tear here. We can't see the video here, but if you could, this is a partial tear right at the muscle tendon junction. And as this opens up, you'll see some gapping here of the common flexor tendon there. So if none of my videos work, give me just one second here. Sorry. I'm going to try this something. I'm going to stop sharing for just a second. Sorry. Sorry, Jason, I'll be right back with you. I'm going to try to restart my PowerPoint and see if it... So while Dr. Mautner is working on restarting the videos, for anyone, there's already been a couple of questions on the chat room area. So by all means, feel free to think of some that we can have. I know one question that has been brought up at other associations and is a laxity of the UCL. So I'll let Dr. Mautner get started. That could be something we can talk about in the Q&A also. Okay. So hopefully it'll work this time. So how do we kind of do this windshield wiper where we're kind of get from the common flexor tendon to the ulnar collateral ligament? So if you look here, here's your common flexor tendon, this is kind of the angle. And then we want to keep the proximal end position here. We want to just kind of do this windshield wiper to get the ulnar collateral ligament to view. And so if you look at that video-wise, as we kind of scan down, you can see now we've kind of gotten over our ulnar collateral ligament right here, which it goes to that sublime tubicle or the coronary process of the sublime tubicle there. So we just kind of kept our proximal pole anchored and we kind of scanned down to see that area. So let's talk about the UCL and this is where I really wanted my videos working for this part especially. So propositioning. So we know with our clinical exam, we get people back in this kind of milking maneuver here where you can do kind of a nodriscal sign or a wave sign. Well, we can reproduce the same thing with ultrasound. And so usually we'll use a table to help stabilize them. And when you have this table here and you put their elbow area here, if you were to draw a line, you see the ulnar collateral ligament there. And when you dynamically stress the ulnar collateral ligament, we can see now the ligament pulling on both ends. That's the insertion here at the proximal end here, and you can look at the gap and that occurs in the ulnar humeral joint right there. Once again, if you're measuring this, they talk about, the studies would talk about peak to peak distance. So you get the peak of the ulnar and the peak of the humerus here, and you can measure the distance between those peaks here, as you can see by the arrowheads here and here. So this is 2.3 millimeters of rest and 6.3 millimeters with force valgus. And you can kind of pause it or you can take a video and then save two images and measure it. And anything less than two millimeters is normal, or side to side one millimeter difference is considered abnormal as well. However, as you get to players who've been in the major leagues for a while, sometimes you'll start to see more changes to the ligaments, even in the asymptomatic population. So this is showing another one of my athletes, and you can see this is their symptomatic side. So it was good to look at the asymptomatic side. If you look here, 0.32, 3.2 millimeters, maybe a little bit of extra gap in there, the 7.1 millimeters when you actually open them up. And so with gapping, you can see how much the four millimeters increase, which is definitely significant. This is showing a partial tear of the ulnar glottal ligament. So dynamic views, it's really important in terms of looking here. And so as you dynamically stress the ligament here, once again, distal here, proximal here, you can see this kind of little area as the ligaments kind of pulling apart in the mid substance area. So that's a partial tear, it's not completely torn, there's some fibers still there, but that's a partial tear of the UCL. Here's another partial tear here, and it'll be kind of the same thing where you can see this little gapping going on in between here, right? So we're looking to see these two sides move together, and a lot of time we'll see these hypo or anechoic changes occurring through the ligament as we forcefully put them into that stress remover. Full thickness tears, usually they're fairly easy, you see an anechoic area or a complete area that is torn. As you can see here, you can see some ligament here, and then you're going to see ligament proximal. Dynamically, you'll see sometimes the ligament pulling straight off the bone as well. So always use a combination of your static and dynamic images, because you may have a part of the UCL that has a full thickness tear, but it may not be full width, and so you want to make sure you scan the whole width of that tendon as well. So you know, I was trying to look for articles that kind of compare MRI to ultrasound to see which is better for evaluating UCLs, if you only had one tool to do an arthrogram or an ultrasound, and there wasn't really anything comparative out there that I could find. But this is interesting, where they took folks who evaluated for UCL injuries, they had an MRI, and they had a dynamic ultrasound done. And what they found was that they showed sonographic joint laxity, which showed this ring down artifact. And what the ring down artifact means, and maybe some of y'all have seen this, but when you actually stress the joint, you get these kind of lines here, which represent some kind of gas in the joint, and you see this kind of ring down artifact here, multiple times in the ulnar humeral joint. And if you had that, and you had tenderness with that stress, much more significant for those folks to go on to have surgery done on the ulnar collateral ligaments. So MRI alone is good, but the MRI plus laxity plus tenderness actually improves your overall accuracy, as well as some of your sensitivity for detecting these injuries. So moving on to cubital tunnel, I got about five minutes, so we'll try and finish up on time here. So I'll kind of breathe through some of this stuff here. So now we're looking at the ulnar nerve, people with ulnar collateral ligament injuries, medial elbow pain may often have some ulnar neuritis as well, so we want to evaluate this area. So on the top of the cubital tunnel is Osborne's fascicle, the poster band of the UCL goes on the bottom of it. You can see the tendons on the side. As we start to scan up and down this area, once again, we're scanning distal here. And so if you look here, it's going to kind of show us where we're scanning on the body, right? So here's Osborne's ligament here, here's the UCL, we're just kind of scanning back and forth a little bit, just like we're showing over here. We're not really getting to the FCU muscles here, here are the two heads that are going to come together as we move a little bit more forward. So this is showing us a little bit further. Here's the ulnar nerve, here's the two heads of the FCU coming together. Once you get between the two heads, you can really see the nerve very well. Usually the pathology though is under Osborne ligament, right at the proximal end here before the FCU kind of comes into play there. And then you want to look at the nerve longitudinally, and you can sometimes see notching of the nerve, if you can get a good longitudinal view, it is a little bit tortuous in that area. A couple of pathology of the cubital tunnel, right? So neconeous epitrochial areas, if you're in the cubital tunnel and you see a muscle superficial to the ulnar nerve, that's neconeous epitrochial areas, which is common, 23% of people have them, but if they have them there, they're more likely to get cubital tunnel syndrome. You can look for an enlarged nerve as well. If you see this nerve right here, we're going to scan distally here, you can see this really large nerve, almost looks like a muscle is so big right in the middle of my screen here as we're scanning down. And you can see in that large nerve, you can't really make out the fascicles of the nerve very well, or it's pretty severe ulnar neuropathy. Dynamically, we want to look for subluxating of the nerve, and so we'll show these pictures really quick. And you can see on the normal side, when you flex the elbow, you can see how you can keep them stable. So you don't have to use two hands to do it and keep your hands on the probe. You can see on this side how the nerve is kind of subluxating over as you go into full flexion there. Once again, not unusual, 18% of even asymptomatic folks will have subluxating nerves in that area. So this patient, she had a subluxating nerve. She had on one side, she could have a subluxating nerve that was asymptomatic. On the other side, she felt a double pop as she was bending her elbows. And so look here, this is her asymptomatic side, and here's her nerve coming over the top right here, subluxating in and out. This is her other side here, see the nerves going out? And then she's also getting this coming out with it. So in addition to her subluxating ulnar nerve, she's got a medial head and triceps, which is snapping as well, causing a much more vicious extraction out of the groove there, which often may need a surgery to resect that area to correct that. This video here, this person almost has a split of the ulnar nerve, they have a spur right here, and you can see that spur just kind of impaling on the nerve. So a lot of things you'll see on ultrasound, which you'll never see on MRI. So I think they can complement each other, and you can really get some good dynamic information about what might be causing their compressive symptoms. So a couple more things to go over, associated pathology, right? So when we're looking at the medial elbow, we know folks may have some post-medial elbow impingement, something associated with something called valgular extension overload. Often they'll have some spurring in the back of their elbows. I couldn't find a really good video of this, but even just looking at pictures here, if you have an elbow here in flexion, and if you extend the elbow, you may see some spurring here, and you'll see them reproducing some pinching as you do it. They may have some sinusitis back here, you have some fluid in the back of the joints. You can get some clues that maybe the joints irritated back here from the olecranon spur and reproduction of their symptoms when you do it. OCD of the capitellum, right? So with the stress in the medial elbow laterally, they're prone to get some capitella OCDs. MRI has been traditionally the way to look for these OCDs of the capitellum, although x-ray can see them as well. There was this study where if you look on the lateral side of these OCD, they kind of staged them by one through threes. They didn't include the grade fours, but 24 underwent ultrasound pre-op and 22 underwent MRI pre-op. And when they did the ultrasound on pre-op, they actually had better correlation with what they found arthroscopically than when they did the MRI. And so you can see cortical regularity, you can see cartilage loss looking at these capitella injuries on the lateral side. So real quickly, my last minute here, back to my case here. So Darren did have an MRI before he came to see me. So on that MRI, they read this as a near full thickness tear of his proximal UCL. So you can see it's distal on here, proximally, you can see there's, doesn't look like there's much attaching there. So they wanted me to look at it with ultrasound and see what I could see. So if you look statically, I would say things look pretty good here on both these images. It looks like there's ligaments coming from proximal all the way to distal. When you look at it dynamically though, you can see on the proximal edge, although the ligament didn't pull off, there was definitely some gapping and hyperechromatic changes right at that proximal attachment there. So this was a partial thickness tear of his ulnar collateral ligament. He still had intact fibers in the area. So with him, based on where we were in the season, we did a one leukocyte pore PRP under ultrasound guidance into his ulnar collateral ligament. We kind of peppered the whole ligament, but focused a lot on his proximal area. We also put a little bit in his common flexor attachment there to strengthen that as well. We shut him down for six weeks. We started his endothelium program at week seven, nine weeks post-procedure. He had a little slight setback, which we shut him down for another week, but he returned to baseball after that and pitched in the playoff. This was last season, not this season, we just have the one before in the same season as going through this. And just before I finish up here, a couple of studies to refer you to. This is, you know, Luca Podesta did the study everyone talks about in 2013 on partial UCLA treated with PRP and found high return to play. I just talked to him last week and he's about to publish his 10 year followup of these athletes showing persistent good recoveries. Major League Baseball came out last year and showed that people who had PRP or not PRP didn't have much of a difference in the survivorship, but whether they went on to surgery or not. But this is a very flawed study, meaning it's very biased by the selection bias and who they did PRP on and who they didn't do it on, as well as what type of PRP they used. You know, I have had, I would honestly say about 90% success rate with my partial UCL tears and PRP. So my take home points, medial elbow pain is the most common area to look for in issues in overhead athletes. Diagnostic ultrasound is a great way to evaluate these athletes and can be very complimentary to MRIs or MR arthrograms, but don't just look at the medial elbow. Look at other areas for clues to help with the diagnosis, mostly in the front and the back as well. Sorry for the brief technical difficulties, but I am done now. Awesome. Thank you so much, Dr. Mautner. Next up, Dr. Carly Day. Hello, everybody. I'm going to pull up my slides here. So I'm going to go down to the low back and the hips and talk a little bit about how that area can affect growing athletes. One second. All right. So, like Jason said, I'm the head team physician for Purdue University. I do take care of our baseball and softball teams, in addition to most of our other teams. So we are in the middle of football season right now, as interesting as it is to say that. So wish us luck. So some of the other presenters have discussed history taking. And I just want to point out that depending on the level of your athlete, some people might understand, you know, some of us who are used to treating overhead athletes a lot might say, oh, are you feeling pain and cocking, you know, acceleration? Some people who are recreational athletes might not know that. So you have to figure out your terminology. Do you say, does it hurt when you bring your arm back? Or are you using more technical terms? Some other things you might want to think about in baseball or softball players is asking if they recently changed position. It's pretty common for our college athletes to come in playing one position in high school and they might be switched to another position. So if someone recently was switched from infield to catcher, clearly the strain on their body is going to have been very different from one position to the other. And then with our younger athletes, as Jason mentioned, is asking how many teams do you play on? How many games do you play a week? Looking at some of the overload. When we talk about the hip, first of all, you know, you start from the inside out. So there's the osteochondral layer, which is just looking at the bony structures and the joint. Then it's followed by the inner layer, which is more static stability. So labrum, joint capsule. When you start moving out and you get into dynamic stability, looking at the musculature around the hip and the pelvis, and then the neuromechanical layer, which is a little more of the mechanics, neuromuscular control, and you put that all together and that's going to create a functioning hip for someone who's an athlete. When you look at what causes hip injuries in baseball players, and this is in professional baseball, the predominant injuries are actually extra articular, 95%. So I think a lot of us think, oh, hip pain, it's FAI, it's a labral tear. But when you looked at, you know, the hip injuries that professional baseball players were dealing with, only less than 5% were intraarticular. So a lot of adductor groin issues, iliopsoas, gluteus, sports hernia, all of those types of issues. So understanding the musculature is just as important, if not more important than the joint. Most of us know how to do a basic physical exam, so I'm just going to focus on some pearls or maybe a couple of new maneuvers that might not be as common. When someone's standing, you know, I do look at their alignment, iliac crest height, pelvic tilt, look at their gait, look at single leg stance. When they're seated, you can do your hip range of motion, sensation reflexes, straight leg raise. And then supine is my favorite place to do hip range of motion and really get, you know, some good internal external rotation, look at the abduction, the adduction, do a groin and abdominal exam, and then palpate some of the bony landmarks to make sure they're not having pain there. And obviously, the age of your athlete is going to be very significant here. We know that younger kids are more likely to get a bony avulsion of the ASIS or the AIS and iliac crest, where your older athletes are not likely to get that. So one test that's my favorite is the modified Thomas test. To me, this is a really great, quick and easy way to look at hip tightness and figure out where it's coming from. So the modified Thomas test, if you look at this picture, they're taking the left knee and bring it all the way up to the chest as much as they can, and then you're looking at the right leg to see what it does when it's relaxed. So if it flexes at the hip, that's more psoas tightness, and if it extends at the knee, that's more quadriceps tightness because it crosses the knee joint. So again, when you're trying to figure out where are they tight, I find this super helpful. Now I think everyone on this talk, everyone here is going to be familiar with Faber and Fadir, but the dextrate and the DERI are a little less commonly discussed, and that stands for the Dynamic External Rotary Impingement Test and then the Internal Rotary Impingement. I like to think of it as the McMurray's of the hip, if you will. You're sort of grinding on a joint and rotating and seeing if you can get it to hurt. So A is just, in this picture, is them getting into position, and then B, you can see some of that internal rotation and adduction, and then the opposite in C. And then D is a Posterior Impingement Test, or it's a little bit like a Faber, but instead of them crossing their foot over and putting their ankle on a contralateral knee, you're actually trying to pinch the posterior aspect of the joint, so you bring them out a little bit more into abduction. When you're looking at the lateral side of the hip, we know how to palpate the trochanteric bursa and evaluate some gluteal strength, but something that you can think about with the Ober's test is that you can use some modified versions to evaluate different structures of the lateral hip. So if you look at A here, that's more of a TFL test, where you keep the knee straighter and more extension and see how tight they are there. B, I think, is what most of us consider a more classic Ober test, which really puts some strain on the glute med, and then the Glute Max test is C, where you actually bring them into knee extension, but then if you look at their chest, they're actually bringing their right shoulder there, rotating it down to the ground and really seeing how tight the glute max is. And then prone exam, femoral anteversion is something you can look at in picture A here. You usually just internally and externally rotate the hip, try to get the trochanter as lateral as you can, and then looking at the angle of the femur onto the tibia, and then looking for a rectus contracture, Eli test, and B, where you're flexing the knee and seeing if the pelvis rotates, seeing if the knee comes off the table. Some of these studies, they've looked at hip range of motion in throwing athletes, and we're trying to figure out how do those correlate. So one thing they looked at is hip range of motion in pitchers versus position players. And when they looked at it, it seemed like internal rotation and then the overall arc of motion were significantly decreased in the pitchers. So the pitchers had decreased hip range of motion compared to the position players in this study. And then the same study, they then broke it down by people who have a hip injury and people who do not. And what they found was that the same group, that the no injury group had increased range of motion and internal rotation and arc of motion compared to the injury group. Now this was a softball specific study, and I'm a big proponent of looking at different genders and Gretchen Oliver publishes a lot in softball. We don't know that men and women are created equal in their throwing, there's different throwing mechanisms in their bodies or their pelvises are a little different. So it's nice to see some studies in softball players as well, and not just all baseball players. So this study looks at one is hip range of motion, and then the other one is strength. And this is actually looking at people with upper extremity pain. So again, we're trying to say, how much does the hip affect the upper extremity, and they did find a couple areas where it differed for those who had upper extremity pain and those who did not. If you look at range of motion, the throwing side hip external rotation is the one area that seemed to have a pretty significant difference between the two groups. And then when you looked at strength, interestingly, it was the throwing side hip internal rotation, and then the glove side hip external rotation. And when I think about throwing athletes, it's a little different than other sports, because even soccer players might be a little more commonly to kick with one side than the other side, but they kick with both legs. But your throwers are really throwing with the same side, and so when you look at their left and their right leg, they're going to have some differences there, that they're really overusing one part of one hip and one part of the other hip, whether they're throwing side or glove side. So I found that really interesting. And we're going to transition from the hip to the back, and here's a study that showed that hip internal rotation deficits were predictive of back and abdominal injuries, but not predictive of shoulder and elbow injury. And again, just thinking this is all connected, so we're just working our way up the chain from the hip to the back. And obviously, back injuries are multifactorial, it has to deal with strength and motion, flexibility, form, all of those come together, and then you do repetitive high velocity, whether it's throwing or hitting, putting pressure on the back that can lead to pain. Now most of us can do a good basic lumbar physical exam, I would say, you know, just inspection, palpation, range of motion, strength, sensation, reflexes, even a decent resident should be able to do one of those, but just want to throw out some pearls as well. One is everyone loves the STORC test to look for a spinal lysis, but you know, it's an okay test, just like any test, you use it to give you some information, but you add it together with the history and the remainder of your exam, because the specificity is not very good, and the sensitivity is okay, but it's still not great. When we talk about straight leg raise, making sure you actually know what you're doing when you're doing a straight leg raise, so if you're doing a true one, the pain should really be between 30 and 70 degrees of flexion at the hip, because if it's under 30 degrees, you're really not actually pulling on the nerve, there's not a neural tension there. And then when you're greater than 70, then you're starting to sort of get into some people's hamstring limits and put a little pressure there. So really, you want to see pain between 30 and 70 degrees to feel good that it's a straight leg, a positive straight leg raise. And it is slightly more sensitive for L4-5 and L5-S1 issues than L1 through L4, so just something to keep in mind. From Dr. Malanga's book back in 2006, they brought a couple other points about straight leg raise. One is the crossed straight leg raise, which I think a lot of people have heard about, which is pain on the affected side with a contralateral leg raise, which can be fairly specific. The bowstring sign, which is not as commonly taught, is that you basically do a straight leg raise, then you flex the knee, but then apply pressure in the coppital fossa and see if you can reproduce the pain, and you're really, again, just bowstringing the nerve to put tension on it. And brackered sign, I think this one's a really good and probably underused version of the straight leg raise, which is that when you do a straight leg raise and it hurts, you bring it down to a non-painful range and then dorsiflex the ankle and reproduce the pain. So again, I know a lot of people use dorsiflexion, but sometimes they're already in pain, and then they dorsiflex them to make them hurt more, but if you get them down to the range where you don't have pain and then dorsiflex to see if you can reproduce pain, that's actually quite sensitive if you look at this. And then, you know, when you can get to the higher levels of motion analysis, that's obviously going to be key for some of your elite athletes and looking at, you know, what's their knee angle when they make contact with the ground, how much lumbar hyperextension do they have and trying to figure out that perfect form that's not creating too much overuse. What common injuries are there in baseball? So again you know stress fracture spondylolisis this is present in up to one-third of athletes with low back pain and some studies will suggest in adolescent athletes presenting to a clinic with back pain it can be up to a half of them have a spondylolisis so you really have to almost convince yourself it's not to be honest if someone has extension based low back pain and a repetitive extensions for yes you can have muscle injuries although in my experience most muscle injuries get better in a week or two so you know when I work with my college athletes usually the muscle injuries are better before they even get sent to me I don't see a lot of those. You can have anything else like a disc herniation, facet pain, something to remember about SI joint pain is if you have an athlete with bilateral SI joint pain to think about rheumatologic etiologies. I actually did diagnose an 18-year-old once with ankylosing spondylitis based on bilateral SI joint pain that he presented to my sports clinic with so don't forget about that. So this is my my favorite pitcher from back in the day Bartolo Colon back in his Cleveland Indians days and that when you look at these pitchers I mean he is a very powerful pitcher and we always say and Dr. Macheo mentioned it before their power comes from their legs when you see these real hefty pitchers and when they throw they hurl their body with their legs and the arm just is following through on that motion. So again the hips in the back are really important when you're looking at power and even probably to a little bit control. Those are my references and these are my kiddos. By the way Dr. Mays special special credit for putting Bartolo up on your slides that was well done there. All right next up Dr. Rubesh and after she finishes we'll then have time for Q&A and if no one has questions then I have been known to call people out before on Zoom calls so just letting everybody know in advance. Okay you guys can see my screen. Yes all right so I get to talk about not the upper extremities. I love this so as as PM&R docs we're really taught to treat somebody holistically and sports medicine is how we really make that work. So when somebody comes to you and they have pain you don't just address where they have pain you look everywhere. So we're going to talk about a little more of the foot and ankle in our overhead athletes so I don't have any conflicts of interest. We're going to talk about anatomy, range of motion, strength in the overhead athlete. I'm really going to try to build a case for why you should look at the lower extremities when you have an upper extremity athlete. I'm going to talk about some physical exam maneuvers and screening and then let's talk about some treatment some treatment strategies. So I always say to patients it's super easy to figure out what's wrong. What why you came to see me was to figure out how do we fix it? How do we keep it from going wrong again? So when we talk about ankle range of motion for somebody who's just playing catch in the backyard with their kid or they want their dog to be able to get a good workout they don't necessarily care about the last miles per hour or accuracy but when we talk about elite athletes or people who are trying to make the last cut those last miles per hour or a little bit more range of motion or how they're going to maybe make the team. So we think about volleyball players so we always get this picture in the middle that's the that's the shot that the press gets right but this is the prep shot and this guy's got to have more ankle and foot range of motion to get up here. We also think about this is the generation of the force but this is also generation of force so you can see he's got a good dorsiflexion moment of his ankle so he's using his whole body. So when we think about the biomechanical chain really everything is to achieve maximal acceleration of the largest possible speed at the end of linked segments and I would also add accuracy as well. So how does it work? So the motion is initiated at proximal segments and then more distal segments initiate motion at the same time that the proximal segment hits maximal speed that should build and build each successive segment until you get to the more most distal segment. So how does that have any correlation to your foot and ankle? Well we know that there's a significant positive correlation to serve speed with non-dominant arm wide balance anterolateral reach and bilateral single leg hops. So we isolate just the lower extremity and we can actually correlate to how somebody's tennis serve speeds up. Also ankle mobility predicts pitching performance so the non-dominant passive ankle so the back leg the dorsiflexion correlates to ball velocity. You increase the range of motion of the ankle you're going to increase torque and you're going to have a greater force coupling at the end of pitch delivery. So ground reaction forces acting through the pitcher's feet can be linked to ball speed. So with the push-off the pitcher's exerts downward and posterior force onto the mound and that allows him to do the opposite reaction with his body so that allows him to go upward and forward and that generates momentum towards home plate. And what we know is that the peak anterior reaction ground reaction force real results in the time of peak anterior reaction force. It's correlated with how how fast he pushes off the ground correlates to how fast his hand moves. So pitchers come in with pain. Baseball players come in with pain. Tennis players come in with pain in their shoulder and they don't even take their pants off right? They don't even want to take their shoes off but if they're coming in with anterior shoulder pain medial elbow pain maybe they get a chronic oblique strain. They have some lateral hip pain. Look at all the ways this guy's biomechanical chain could break down if this foot doesn't let him do what he needs to do. He might have some medial knee pain. He might have some patella femoral tracking disorder. He might get some IT. All of these things could be resulting from this foot not moving. So that linear momentum we know that the stride length is transferred to the upper body and it increases the momentum of the trunk which is going to increase the momentum of the ball. So if you have hallux rigidus if you can't roll over that toe you're going to decrease your stride length and that's going to also decrease the ball velocity. So you're going to have to also compensate with other abdominal muscles and maybe your shoulder to generate force. So that's how you can get shoulder pain if you're not able to use your entire chain. So the way that we decrease joint loads and in the upper extremity athlete we're always thinking of how do we decrease the load of this joint that we're asking to do such a fantastic force. We want to maximize the velocity and force production. We have to consider everything. As rehab docs we always do but we're going to consider the knee and the ankle mobility as well. So what are we going to do? How do we screen these people? So you can do a Y balance. We talked about that. A single leg stability that uses their whole body. Check their ankle dorsiflexion. We're going to go through how you got to do that. First MTP extension. That usually in the first visit will reveal some issues, some breakdown and then you work on it. So a lot of times there's tricks and tips and you can watch them pitch, serve and throw. I usually save that because just by a biomechanical screen we pick out multiple areas we can intervene to help them. I save the pitch watching them and videoing them until we've already gotten them through and I can't really visualize their mistakes anymore and then we're picking things apart. So watch them pitch, serve and throw but at these high level athletes you really have to video them. You have to video them so that you can slow it down and you can, one, a picture is worth a thousand words. They can actually see these deficits and two, you can kind of move backwards and forwards and you can document any small motions that you might miss with the naked eye. I love the Y balance test. It's easy. It's not hard. It doesn't take up a lot of space in your office and patients think that they're going to rock it. It's so much harder than it thinks, than they think. So I love to do the Y balance test just to see, you know, how do they move through their body. Make them do it. You can have them do it in their cleats or you can have them do it barefoot. It will change your outcome. The single leg stability test. This is a great one for, again, I have them do it in their shoes and then I take them out of their shoes so they realize how much they're cheating. You really have to check passive ankle dorsiflexion and you need to do it weight bearing. So you can do passive ankle dorsiflexion with them lying down and it seems to be easier because you're not having to get down on the ground. But if you really want to see how they're able to use their foot when they're bearing weight, it's got to be weight bearing. Same thing with first MTP extension. So you can always start, especially if you don't have a ton of time with the athlete, you can always start with them seated. But as you're getting them back into the sport, you have to see how they're actually weight bearing and transferring their weight over. This is a spring, right? So they're hitting, they're coming through, and if they can't spring off, then they've lost so much velocity through here. So always make sure that you control the hind foot. See how this works? See how they're letting him lift off a little bit? They're letting him cheat. Okay, so how are we going to treat this? We always have to increase range of motion. We want to improve the balance. Increase the strength and the strength of the ankle and foot controllers. But especially when we're in season, sometimes you just got to cheat. How do we increase the range of motion? Usually athletes know how to stretch. We know that passive stretching, static stretching is the least sophisticated and can actually put more pressure on joints that are already irritated. So I tend to not recommend passive stretching for the foot and ankle. Mobilization, a lot of great athletic trainers know how to mobilize these joints. You can stiffen up, the ankle can stiffen up similar to the shoulder. Myofascial release is a big one. You think about the flexor hallucis longus, it's up in the proximal calf. And you come down, it comes all the way medially, and then it goes inferiorly at that first MTP to flex the first hallux. So if you're going to passively stretch, look at the pressure you're going to put through that joint. And then they come in, that joint is already irritated. So you want to actually instead of put pressure through, myofascial release of that and teach them how to do it themselves. Because if they can do it a few times a day, that's going to be more valuable than them seeing a massage therapist once a week. That's great too, but they can really add to that. And then don't forget the whole posterior chain as well. And then a dynamic warm-up. So when we ask people to go out and be at 100% of their exertion, we don't ask them to just jump on the pitch or jump onto the court. We know they have to do a dynamic warm-up, that increases the range of motion, that warms things up. Make sure they're not doing static stretching before that. So we really have to improve their balance, have them do a single leg quarter squat. And then we have to make this more functional. So add resistance bands, try them on an uneven or a softer surface with or without different types of shoes and cleats, and then add distractions. So have them do multiplication, make crowd noise, ask them questions, do things, because that's what happens during an actual game scenario. So we need to do all of these different things to replicate that. And then we have to think about strengthening. So yes, functional range of motion is important, but that muscle has to actually be strong. One of the biggest mistakes I see when people are trying to strengthen the foot intrinsics is they do the towel technique where they put their foot on the ground and they're told to just crunch their toes. That is not actually strengthening your foot intrinsics. That's strengthening your toe flexors. I have not mentioned toe flexors in this talk because they are really integral to how you're pitching or throwing or jumping. But your foot intrinsics are a big deal. That's going to change the biomechanics of your foot. So we talk about shortening the foot. So that's the foot doming exercises. So when patients say they're doing exercises, have them demonstrate it because either they're not doing the right exercises, they haven't been taught it correctly, or maybe they've been taught it correctly and they didn't internalize correctly. So always make sure of that. That tip posterior is a big one, especially for our flat-footed athletes. That's important to keep the foot in a neutral position so that you can use it as a spring to push off. And then just briefly some cheats. So I love taping. Everybody loves taping. You can see sometimes people will come in and say, you know, only the blue kinesio tape works for me. You know, okay, that's a placebo. But for this, for example, when you lose some of the first MTP range of motion, we want to think about how can we improve or encourage its range of motion? So this is a great one for that if it's just the first MTP. However, if they're falling through the first MTP because their hind foot and ankle complex are falling through, think about changing how they're taping their foot. Again, ideally, as a purist, they can use their body perfectly. But in season, when we're asking these athletes to maybe do more than their body's able to do, we have to get them back quickly. So these are just ways to get them back a little faster while you're doing the down and dirty, the real foundational stuff. So this actually causes a bit of supination at the foot, and then it follows underneath and causes a little bit of external rotation. This is one of my favorite orthotics. So when we think about a pes plano valgus, everybody knows about the hind foot, and we really need to provide a medial arch support to the hind foot. However, that's not enough. We also have to address the medial, the middle part of the foot complex as well. And that's with the metatarsal arch. So if you combine this and they're falling through here, you messed up. So this little bump here helps support under the arch, that metatarsal arch, the longitudinal one, so that they can push off here instead of fall through here and lose. These, so let's say they have hind foot or like posterior chain tightness, and they can't get that 20 degrees of dorsiflexion that is the bare minimum. Maybe think about putting in some heel wedges. Again, this is not ideal, but if it can allow them to roll over that foot a little easier, decrease the pain, and increase the range of motion, that's going to give us a fast win. A fast win. Same thing with these, we call these dancer pads. All they are is a cutout, so that, and these come, these can come quite thick. If you place these medial and, sorry, lateral and posterior proximal to that first MTP, when this person bears weight, they actually don't have to dorsiflex that first MTP as much. So it allows them to, again, roll over their foot without requiring as much extension while you're doing all the other things we talked about. We got some good references. There's some really great, great research on this, and, sorry, there's a lot of great research on this. So I'm in New York. I'm in, I'm with Rothman Orthopedics in Gramercy and up in Westchester, and that's my email. If you guys have any questions, I'm happy to share and discuss further. You know how much I love mechanics. All right, thank you very much, Dr. Rubesh. Okay, so we have about 10 to 12 minutes for some Q&A. Now, again, for everyone who's on, unlike the majority of the APNR conference, which is on Entrato as the platform, we're actually on Zoom meeting. We did that on purpose, so whoever wants to can take their video, put their video on, and if you have questions, you are more than welcome to either ask them or come rhyme in the chat. I have one or two, Rago, or if any of our panel members have something they want to bring up, more than welcome to. I'll give you someone a few seconds to either type something in or come up. If not, I'll try and break the ice. Aw, come on, out of 101 of you, no one? All right. So, you know, one thing that I think has been very challenging, not to make this a COVID question, because I think I might chase off Dr. Day if I did that, but from the perspective of overuse, particularly our adolescents, and not just our typical overuse, it says getting our bodies back in shape, and if, you know, with the perspective of this talk, getting our arms back in shape, and as, you know, someone who's in a warm weather climate where baseball doesn't really stop, same with Dr. Micheo and to a certain extent Dr. Moutner, it's been very challenging the amount of overuse injuries because someone either shut down or just their body has not gotten acclimated and then now the season's coming up. Does anyone on our panel have any suggestions or things that they might recommend that might be beyond the usual, you know, slowly a four, six, eight week return to pitch program when this is more of a full body thing and something that we've never really dealt with before? I'm going to call on Dr. Micheo because that's probably the only time I'll ever get to call on him. So we're starting to see athletes in Puerto Rico go back to to overuse type activity and injury. We have limited data on how to look at endurance related assessment from some of these athletes. So I think what we're trying to do is we use percentage of activities. So my rule of thumb is somebody that has symptoms with activity might get better after warm-up by cutting back 50 percent. Anybody that has symptoms with activity and during activity, I rest them until they get fully asymptomatic at rest and my examination. In terms of our assessments, I think that one good thing that we could add is seeing some of the athletes for assessment right after activity and see the physical examination changes. So our younger athletes that we're seeing now, most of them are getting early season type overuse injuries, most of them related to lack of preparation, muscle imbalances, and I think most of them that we're finding are related to kinetic chain type abnormalities. So lower extremity, trunk control, neuromuscular control, that's what we see in most of these athletes that are coming back to our clinics early on after just restarting injuries. We have a baseball specific school out of the Olympic Training Center and most of the young kids that we're seeing coming into these type of activities are kinetic chain type abnormalities, trunk control, core weakness, and poor neuromuscular balance. So another question that I had and this one will probably go towards Dr. Mountner and everyone else can kind of chime in. I sort of alluded to it before when Dr. Mountner was fixing his videos, but UCL laxity, particularly as you go up the chain and how good someone pitches and up the chain in terms of high school, college, and above. Dr. Mountner, what would you recommend? Do you think that pre-season ultrasounds to look for UCL laxity, even if you're asymptomatic, is worthwhile? And I don't mean it from like the major league level because that's a little different patient population, but what about for our high school and college kids, especially our pitchers and use of UCL for pre-season testing for laxity? Yes, a good question. We don't have all the data. I know, you know, something that Lev Nazarian's study where he went around to major league baseball camps in the pre-season and tested UCLs for a number of years in a row and was testing laxity and some of what he found was that sometimes throughout the season the ligament did become a little bit more lax, whether or not it became symptomatic or not, right? And so what do you do with asymptomatic laxity and do we know enough to predict injury? And the answer is no, we don't know enough to predict injury. But so I would say at the high school level, probably not worthwhile to do unless you're doing it just for injury tracking data, right? For study purposes, I think it's great to do actually because I don't know the best studies ever been done at the high school level. At the college level, you may want to start considering doing it, but the main reason to do it actually is that if they have an injury and you have a baseline, then you can really see if they're more lax or they're more stressed after they've had that injury. That's where I think it gives you valuable information just to compare to what they were like before their injury to know if that was their baseline or not. I have a question. Go ahead. So let me introduce myself. My name is Victor. I'm a third year medical student from Miami and I hope my question isn't too basic. But I am definitely curious about the panel's judgment regarding passive stretching versus active stretching. So I had a coach in a swimming class that once told me, yeah, I never recommend my students do passive stretching. They can do active stretching after they warm up. But then other coaches, they always told me you've got to stretch before exercise, during exercise, and after exercise. We already had a panel member saying advocating against passive stretching. What are the rest think? I would clarify first. I'll let Dr. Rubesh go. Yeah. So first off, you have to make sure you know when you're doing it. So one thing we know about passive stretching and aggressive stretching preactivity is that you lose a lot of power. So you have to be careful when you do it. And then when we think about passive stretching, what you're really doing is putting pressure on the shortest aspect of that muscle when in reality, we need to think about more of the triggers or the smaller parts of the muscle, the tighter ones that are restricting the entire muscle's range of motion. That's where we talk about more myofascial release. We know the proprioceptive neuromuscular facilitation is one of the most effective ways to mobilize and lengthen a muscle. So everything in its place, that's where I'll leave it. And I'll let somebody else dig in. But yeah, it's all connected in how we use it. So Victor, in general, we recommend dynamic stretching prior to activity and static after activity. Sometimes it's very difficult to isolate some muscles to stretch appropriately. And technique is very critical for this. But I think in general, the literature shows that dynamic prior, static after, and if you do static immediately prior to activity, you may lose power, Dr. Hoover says. And technique is key. Some of these facilitated stretches are very good, but you need somebody who knows how to teach them to the athlete or do them with them. If nobody else has a question, I have another one. I think someone, I'm going to add, someone just wrote in for a question. Deborah Weiss just asked, if anyone's familiar with pickleball, which is a popular sport in Florida for our retired population, for sure. There seems to be a lot of injury to the shoulder or elbow. And if anyone has had experience with the sport, if you've seen, if the injury is more shoulder or elbow, if you might, if anyone might be able to chime in. I can mention that, so where University of Florida is about an hour north of an area called the Villages, which is kind of like retirement area for retirees, but like Disney World for retirees. It's about 125,000 folks there, my in-laws and parents included. And pickleball is quite a popular sport. A lot of the things that I've seen in the past, I've seen a lot of people say, oh, I've seen a lot of people say, oh, I've seen a lot of people say, oh, I've seen a lot of people and pickleball is quite a popular sport. A lot of it depends. It goes back to biomechanics, which will make Dr. Rubish happy. So you can almost think of pickleball like sidearm pitching. It sort of depends on what you're doing with your mechanics of it. So is it your back? Are you balancing with your back leg? And then if you fall through, are you putting more strain on the medial aspect of your elbow and your anterior shoulder, kind of like a windmill pitcher and softball, or are you doing more of an overhead? So a lot of it will depend when you see your patients who do pickleball, and again, on the entire kinetic chain. But I would be very curious what their lumbar spine range of motion is and the rotational range of motion is, as typically, not always, but typically the age population is more in the 50 plus, 60 plus population. Right. I mean, we're seeing it a lot actually in anywhere from like the 40s to the 60 plus, right? Once they get beyond them, once they get to their 70s, they're moving a teensy bit slower, but we're seeing the younger people are coming out, and the first thing they do is they tear their Achilles because they didn't realize how fast they had to move. And then as they get a little older, within a couple months, we're seeing elbow injuries, and we're not really sure if it's coming from their shoulder and which way they're moving. Yeah, and again, part of it's going to be, you know, it might be a case by case basis. I would suspect, as I think you might know, that obviously with the change in the water content and collagen content as we get older, someone's going to be stiffer, where is the weak link in the chain? You know, I think of the panel, probably Dr. Micheo is the most published on this, as well as within APNR, someone like Joel Press, and obviously anything by Ben Kibler is going to be great to take a look at. But then where's the weak link? Is it the dorsiflexion of the ankle that Dr. Rubish talked about? Is there a lumbar and or hip issue that Dr. Day talked about, which then I'm very much suspecting they're not going to have a significant external rotation of their dominant shoulder, like maybe they did when they're in their 20s or 30s. So I think part of it, it might, again, this is suspecting, but just be a case by case basis. We have time for one more question before, again, I want to make sure everyone's aware that if you would like to join in, you have to re-sign into the other link, but for the sports medicine community session, in three minutes, Dr. Allen is leading. But we have time for one more quick question. So I'll actually bring up a topic, because I'm contractually obligated by the CDC to talk about COVID every time I open my mouth. So one thing to think about when you're returning someone, especially a pitcher, someone who has overuse injuries is the way most people, and this is not everyone, but most people at least at the collegiate level are handling COVID is those in isolation. So they tested positive, they are supposed to not exercise. Now we say, we tell our pitchers, like you can do some arm carry, you can do some soft toss if you have someone either against a wall or what have you, but like they're really not pitching, getting their heart rate up. Whereas those in quarantine are allowed to exercise unless they develop symptoms at rest or with exercise. So our quarantiners, we actually, you know, at first when COVID came out, we were so scared about like fomites, like, you know, something on a baseball that you would get it. And most people that are adults and not like five year olds wiping their mouth all the time, we'll let our quarantiners talk, stay separated and toss a ball back and forth and, you know, even pitch or throw against a wall. So our quarantiners are not in bad shape when they return to play. They basically get set loose more or less when it comes, you know, we're not in season, so they're still going to transition them back slowly, but it's an easy transition. Whereas our positives, at least in the big 10, we have to do mandated cardiac testing at day 14, and then we have a mandated seven-day return to play. But for our pitchers, obviously we're going to do a lot longer than seven days. Again, we're out of season, so we don't get a lot of pushback on that now, but it'll be interesting to see in season how quickly they're trying to get these guys back and the worries about overuse injuries when it comes down to those who tested positive. That's a great point. Thanks. Thanks, Carly. So it is about 30 seconds until 6 30, so I'd like to thank our entire panel and, again, our AAP Menar staff behind the scenes, Sean, Myra, everyone else for helping out. If anybody has any questions, by all means, you're more than welcome to email us or email AAP Menar. This has been recorded, so the video should be made available as long as you've registered for the meeting. And with that, we're going to sign off, and if you'd like, you can join Dr. Ellen's session right about now. Thanks, everybody, for joining. Stay safe. Jason, thank you. Very nice session.

ultrasound

elbow injuries

forearm injuries

overhead athletes

UCL tears

ulnar nerve

cubital tunnel

dynamic views

post-medial elbow impingement

osteochondritis dissecans

sports medicine

range of motion