Transcript Pediatric OMT Swimmers Module

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American College of
Osteopathic
Pediatricians
Robert Hostoffer,
DO,FACOP, FAAP
edited by
Eric Hegybeli, DO,
FACOP
questionnaires by
Michael Rowane, DO
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Born in Virginia in 1828
The son of a Methodist minister and
physician.
At an early age, Still decided to follow in his
father's footsteps as a physician.
After studying medicine and serving an
apprenticeship under his father, Still became
a licensed M.D. in the state of Missouri.
Completed additional coursework at the
College of Physicians and Surgeons in Kansas
City, Missouri [Early 1860's]
Union Army Surgeon during the Civil War.
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After the Civil War and following the
death of three of his children from spinal
meningitis in 1864, Still concluded that the
orthodox medical practices of his day
were frequently ineffective, and
sometimes harmful.
He devoted the next ten years of his life to
studying the human body and finding
better ways to treat disease.
Discovered Osteopathy in 1874
• His research and clinical
observations led him to believe:
• The musculoskeletal system played a
vital role in health and disease
• The body contained all of the elements
needed to maintain health, if properly
stimulated.
• By correcting problems in the body's
structure, through osteopathic
manipulative treatment, the body's ability
to function and to heal itself could be
greatly improved.
• Promoted the idea of preventive
medicine
• Endorsed the philosophy that
physicians should focus on treating
the whole patient, rather than just the
disease.
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http://www.aacom.org/OM/history.html
 An
average competitive swimmer can
complete between 6,000 yrads in a two
hour session.
 Approximately 20-40 miles per week.
 Approximately 1 million stroke cycles
per year.
 Laxity
vs. Instability
 Poor stroke mechanics
 Excessive fatigue
 Improper or excessive stretching
 Improper weight training
 Excessive use of kick boards
 Laxity: normal; pain
free ROM of a joint
 Instability: Pathologic subluxation or
dislocation resulting in pain or functional
impairment.
 Many
swimmers have joint laxity
 Laxity may foster glenohumoral instabilty
leading to impingement
Excessive stress
Increased Drag
Fatique
Poor Technique
 Wringing
out of supraspinatus
 Crossing Midline
 Flat Body Positioning
• Promote impingement
• Hawkin’s Position
 Dropped
elbow
• First sign of fatigue or pain
• Minimizes time in impingement position
 Breathe
bilaterally
• Increases body roll
 Maitain
high elbow during recovery
• Lessens demand on scapular stabilization
musculature
 Swimming
promotes strengthening of the
glenohumoral internal rotators and
pectoral musculatures
 Most swimmers excessively stretch the
anterior capsule
• Buddy stretches
 Swimmers
without pain
 Swimmers
with multidirectional
instability or shoulder pain
 A gentle warm up should replace preworkout stretching
 Minimize
abduction and external rotation
• Lat pulldowns, military press, shoulder
abduction
 Emphasize
scapular retractors,
glenohumoral external rotators and core
musculatures
 Excessive
use of
board promotes
impingment
 Neer’s position
 Stage
I refers to those with edema and
hemorrhage;
 Stage II refers to those with fibrosis and
tendinitis;
 Stage III refers to those with tear of the
rotator cuff, ruptured biceps or bone
excrescence
3
phases
• Acute
• Recovery
• Functional retraining
 RICE
 NSAIDs
 Possible
subacromial injections
 Avoiding impingment positions
 OMT A/AAROM
 Modalities
• Ultrasound
• TENS
 Restore
normal AROM-OMT
 Restore strength and endurance to
shoulder stabilizing musculature and
rotator cuff
• High repetition of low weight or low resistance
elastic bands
 Entrance
Criteria
• Normal Shoulder AROM
• Rotator cuff strength at least 4/5
• Normal and functional kinetic chain
 Goals
• Sports specific training
• No muscle in isolation
 Swim
Bench
• Isokinetic exercise
 Return
to pool with gradual increase in
yardage/intensity
 Plyometric exercises
• Neuromuscular intergration
• Very high force generation
• Complementary muscle group coordination and
strengthening
 Indications
• Failure of conservative management
• Paresthesias, dead arm
• Significant instability
• Difficulty with ADLs ( activity of daily living)
secondary to pain
 Inferior
Capsular Shift
 Anterior capsulolabral reconstruction
 Arthroscopic repair
 Thermal Capsular Shrinkage
 Painful
arc/rotator cuff pain in the
shoulder of a swimmer can occur in any
of the following movements:
1. Adduction of the arm at the
shoulder
2. When this movement is blocked
3. Flexion of the arm at the shoulder
4. When this movement to left or right
is blocked.
 The
acromioclavicular joint may develop
degenerative arthritic changes,
particularly from damage in resistance
weight training.
 Arthritis
of the glenohumeral joint may
be seen in the masters age group, though
it is rare in the young.
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the alignment of the knee centre relative to the hip centre during
the start of the breast-stroke kick affects the development in the
medial collateral ligament and capsule. The optimum initiating
position from the breast-stroke kick is with the hip and knee
centres aligned. When the knee centre is narrow or wide of the hip
centre, it causes increased stress on the medial collateral joint
structures. Exceeding the elastic limits of the ligament will cause
damage and injury. In young swimmers, this form of stress could
open growth plates of the femur and tibia and cause micro-injury
which will result in inflammation and thus seriously impair
training.
 There
is a high risk of the patella riding
laterally during the breast-stroke kick.
This is magnified when the patella
tendon attachment site at the tibial
tubercle is placed in an extremely
rotated position. Weakness of the vastus
medialis can decrease effectiveness in
ensuring central tracking of the patella. If
dislocation occurs, surgery is almost
certain.
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Acromiolclavicular joint
Rotator Cuff Muscles:
• Supraspinatus
• Infrspinatus
• Teres Minor
• Subscapularis
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Biceps muscles
Humerus
 Subacromial
impingement ( swimmers
shoulder ) is a condition that affects the
athlete's abililty during the catch phase,
early to mid-pull, and through arm
adduction in the recovery phase. It is an
inflammation of the supraspinatus
located on the long head of the biceps
tendon. Most often it is a result of
incorrect form and overuse.
 Poor
Stroke Technique : Improper stroke
technique can result in joint and muscle
imbalance.
 Unilateral Breathing : Most swimmers are
comfortable breathing in one direction,
this results in muscle imbalance in
swimmers.
 Overuse : These are chronic injuries that
occur because of repeated stress to the
muscles, tendons and joints.
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Step 1—extension with elbow flexed;
step 2—flexion with elbow
extended;
step 3—compression circumduction;
step 4—circumduction
with traction with elbow extended;
step 5a—abduction
with internal rotation with elbow
flexed;
Step 5b- adduction and external
rotation
step 6—adduction and internal
rotation with upper extremity behind
the back;
step 7—stretching tissues and
pumping fluids with the arm extended
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1) Put both arms overhead in the streamlined position, then lean
first to the left side as far as possible, then to the right.
2) Put both arms behind your back, fingers interlaced, and slowly,
steadily raise your arms upward behind you as far as possible.
3) Put one arm across your body so that the shoulder is under your
chin and hand, forearm and upper arm are parallel to the ground.
Without turning your body, use your other hand to pull the arm
close as close to your chest as possible.
Innervation Table
Organ/System
EENT
Parasympathetic
Sympathetic
Ant.
Chapman's
Post.
Chapman's
T1-T4
T1-4, 2nd ICS
Suboccipital
Heart
Cr Nerves (III, VII, IX,
X)
Vagus (CN X)
T1-T4
T3 sp process
Respiratory
Vagus (CN X)
T2-T7
T1-4 on L,
T2-3
3rd & 4th ICS
Esophagus
Vagus (CN X)
T2-T8
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T3-5 sp
process
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Foregut
Vagus (CN X)
T5-T9 (Greater Splanchnic)
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Stomach
Vagus (CN X)
T5-T9 (Greater Splanchnic)
Liver
Vagus (CN X)
Gallbladder
T6-7 on L
T5-T9 (Greater Splanchnic)
5th-6th ICS on
L
Rib 5 on R
Vagus (CN X)
T5-T9 (Greater Splanchnic)
Rib 6 on R
T6
Spleen
Vagus (CN X)
T5-T9 (Greater Splanchnic)
Rib 7 on L
T7
Pancreas
Vagus (CN X)
Rib 7 on R
T7
Midgut
Vagus (CN X)
T5-T9 (Greater Splanchnic), T9T12 (Lesser Splanchnic)
Thoracic Splanchnics (Lesser)
Small Intestine
Vagus (CN X)
T9-T11 (Lesser Splanchnic)
Ribs 9-11
T8-10
Tip of 12th Rib
T11-12 on R
Appendix
Hindgut
Ascending Colon
Transverse Colon
T12
Pelvic Splanchnics (S24)
Vagus (CN X)
Vagus (CN X)
Lumbar (Least) Splanchnics
T9-T11 (Lesser Splanchnic)
T5-6
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--T10-11
T9-T11 (Lesser Splanchnic)
R Femur @
hip
Near Knees
L Femur @ hip
T12-L2
Descending Colon
Pelvic Splanchnic (S2-4)
Least Splanchnic
Colon & Rectum
Pelvic Splanchnics (S24)
T8-L2
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 Question1: A, B, C, D, E.
 Question2: A, B, C, D, E.
 Question3: A, B, C, D, E.
 Swimmer’s
shoulder is due to
• A. Subluxation of shoulder posterior
• B. Subluxation of shoulder anterior
• C. Subacromial impingement
• D. Rotator cuff sprain
• E. Scapular imposition
 Swimmer
shoulder injury is due to:
• A. Poor technique
• B. Unilateral Breathing
• C. Overuse
• D. Catchman’s triangle misalignment
• E. A, B, C.

A 12 year old boy presents to your office with a
throbbing shoulder with pain increasing with
movement. He has swum competitively since six years
of age. There is no history of trauma. You feel he has
subacromial impingement. Your osteopathic
therapeutic option would be:
•
•
•
•
•
A. Galbreath maneuver
B. Spencer’s Technique
C. First Rib manipulation
D. Thoracic HVLA
E. OA HVLA
 I, _________________________,
successfully completed the Pediatric
OMT Module on __ __ 20__
Signatures:
 Pediatric Resident ____________________
 Pediatric Residency
Director____________
(
Please print and give to program
director.)