Grand Rounds – Round 2 – Answers
RE: Grand Rounds January 12, 2021
Andrea McAllister, Joanne Carswell, Elaine Maheu, Scott Whitmore Answers to questions submitted during the presentation.
Note from Andrea McAllister: I really appreciate everyone’s thoughts and input into managing this case. It was a great learning experience for me and if I am presented with a similar situation in the future will have new ways to consider the symptoms, thanks to the panelists and the participants.
- A possible excessive inferior translation of the humeral head in ABD 90 deg could also be a cause of limitation and sensitivity of the ULTT3? Could be interesting that when you do ULTT3 , hold the HH in its socket and see if his range would be more and less sensitive? how can you fix that?
AM: Given that Mark* could independently and actively sublux his humeral head antero- inferiorly, I also was wondering about the various directions of laxity as well. As a matter of habit, in assessing neurobiomechanics and mechanosensitivity, I ask the patient to perform the ULNT actively in sitting before performing the test passively. If Mark had an uncontrolled instability inferiorly, I would have expected to see a difference in sitting versus supine. That said, that would be an interesting test to perform to accelerate any changes that would be brought on by inferior translation. It is not something I checked. As for managing it, he is doing work on centering the humerus, controlling movement “sucking it in” and Watson’s work on upward rotation of the scapula. Even if I did find that the inferior translation was excessive, that is how I would approach it.
- If we are considering a biopsychosocial framework, what questions were asked to this individual to capture these constructs? Can the panelists please comment on treatment other than just biomedical?
AM: Considering Mark’s age and the importance of baseball to him, I was aware of the potential impact of his inability to pitch on him as a person. Mark was not great at providing feedback as I noted, and perhaps Elaine’s suggestion of the FAST questionnaire may have provided some direction. That said, in conversation during his sessions, we discussed (and he agreed) the importance of still attending practice and workouts and addressing non-pitching skills to stay connected with his team. I had given him a note for his phys ed teacher so he didn’t have to explain the situation and participated when he could. He had good family support and other activities and academics which were emphasized. In retrospect, I suspect though, that my desire to provide him with “meaningful” exercises likely lead to moving into exercises that could have been too early, as Scott noted.
Joanne suggested these Biopsychosocial questions:
Yellow – Does he understand why he needs to take time off throwing?
Is his team getting together for practices?
Could he still attend and do some interval running or rover in the field
Are they zooming if not meeting so he can still be a part of the team
How is his relationship with his coach, will he be supportive of his time off and in rehab
Is he able to get together with his personal training coach to work on some of his exercises and strengthen his core
Does he participate in any other activities…music etc
Black – At school can he talk to his phys ed teacher to let them know that he can’t do any overhead loading or heavy weighted exercises with his arm right now and ask if there are other things he could do?
Blue – Does he have a part time job, will he be able to still do this job with his shoulder. Are there other duties he can do?
Pink – What are his goals for baseball? When does he see himself getting back to playing (was addressed that he is not thinking the majors and Andrea had originally hoped in the New year) Is he comfortable doing the exercises that have been prescribed and not pushing it too hard?
- One wonders with his history of glut med tendinopathy and patellar tendinopathy whether his throwing technique was compromised further by reduced contribution from his lower quadrant mechanics and a less-than-ideal force transfer during repetitive throwing motion. Did he have a growth spurt in recent years as well?
AM: I suspected the whole-chain thing and dissipation of forces as well, particularly once I got past the shoulder-focused perspective and noted the core etc. I think this also was the impetus behind my desire to provide him with throw-like activities where he was considering his whole motion while controlling the shoulder, albeit perhaps too early, as per Scott. And yes, his mom said that prior to his glute issues of a year ago, there had been a rapid spurt (starting right when he presented with patellar tendon issues).
EM: In the article by van der Hoeven & Kibler (2006), they discuss the role of the proximal part of the chain (leg/hip/trunk) and that breakage in the link in the proximal part will lead to higher demand on more distally located segments (shoulder/elbow/wrist) which are more susceptible to overuse and injury.
- If he practiced for about 25 min at a time, how many innings did he pitch on the weekend in question?
AM: He pitched 2 full games on one weekend and “most of” a third on the second weekend. He said that the coach had ‘talked to him’ about the load, but the back-up pitcher was not at that tournament and there were provincial scouts present. He knew it was too much but didn’t realize he would end up injured.
- With his generalized low muscle tone, poor motor control and very poor core stability, was the presence of retained primitive reflexes assessed? Were there any birthing issues?
AM: In his scan, plantar response was negative and there was no upper or lower clonus. I did not test for any more primitive reflexes, but it is an interesting point. I do treat his mom for intermittent LBP and SI issues and have asked her about her pregnancies/births which she describes as normal. Mark’s older brother was not much bulkier at 15.
- Joanne, do you have an article or resource recommendation for more information on how peripheral nerve irritation can cause an autonomic response on dorsal root ganglion that you discussed earlier.
AM: references below
- Any concerns of connective tissue disorder like ED? (e.g. hypermobile in c-sp, hypermobile in both shoulders not just his throwing arm).
AM: This was one of my differentials for sure and was the rationale behind the Beighton scale and sending him to the GP with a note including findings, concerns and family history of hypermobility but no ED diagnosis. GP sent him to sports med, so I have forwarded my thoughts to that physician, with whom I have a good, respectful relationship.
- Was there imaging? Any thoughts on if little league shoulder could be part of the differential diagnosis for this athlete?
AM: There has not been any imaging. In fact, Mark had never seen his GP (which was a barrier in itself). Thanks for mentioning a condition with which I was not familiar. I will head to the literature.
- With his motor control issues and Lats/Pec Major so dominate I would suspect subscapularis to be weak. Did you do specific subscap tests? It can refer to medial elbow and may influence axillary n.
AM: Subscap was weak, but no more so than the rest of the RC. Thanks for the reminder of its referral patterns!
- Was there any incorporation of neck activation and endurance exercises (ie. DNF, DNE ms) in order to reduce HFP and compensation in larger muscle groups?
AM: Yes, he had chin tucks in the beginning and then was cued ++ about maintaining positioning when we added Watson and other loading activity. He was cued similarly in his prone MFT ex to keep alignment and add a slight head lift when doing his retraction. It is possible that this area was rushed as well.
- What does he get to do for fun/activity while he can’t throw? Does he have a non-overhead sport interest? May be tough to have a 15 year old follow a long term specific program with minimal real-life satisfactory progressions?
AM: This was difficult. He was quite compliant to whatever I gave him to do, but again, I think this was an issue that may have caused me to overlook the timeframe and progress his exercises to something meaningful potentially too soon. I encouraged him to still go to practice and do other activities related to baseball and his team. I encouraged more strength work and whatever else I could latch on to for him. His other sports of interest are volleyball and badminton.
- Was there any education to the family about how long this could actually take so that he won’t be potentially lost to non-treatment, and possibly self-selection out of pitching?
AM: Not initially, given that Mark had responded so well to other tendon issues in the past. We did agree in mid Sept to keep him out of pitching for the first semester of school, and as time went on and he had a couple of flare-ups from minor incidents and attempting volleyball during phys ed at school, I have had discussions with his parents and with him separately. The parents are supportive of this prognosis. Mark is still hopeful, albeit a bit more realistic than he was in the past.
- As far as patient management goes, how do you deal with discussing diagnosis, prognosis and treatment times that are realistic if you are unsure after the initial assessment?
AM: After the initial assessment, the combination of neuro mechanosensitivity, the multiple areas of pain and the ‘weird’ axillary tingling, I was able to educate Mark and his parents that this was unlikely to resolve as quickly as the other issues had. We discussed that, likely, the tendon/motor control thing would take at best 6-8 weeks and that the nerve symptoms were not likely to start to resolve until after we had the mechanical problem well on the way, adding another 4-6 weeks. That was how we reached the 3-month hold on pitching agreement. I have been very transparent with them regarding his unique presentation.
EM: In more involved cases such as this one, my take on it is to tell the patient/family about my initial hypotheses but for the prognosis or number of treatments, I prefer to say that I will see the patient at least 3-4 X first to see how he responds before I can make a judgment call on those issues.
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