I recently did a little spot on IFAST University regarding how I approach, assess, and progress people along the physical activity continuum. Read the little intro below, and if you want to watch the video, click on the picture or the link.
As a bonus, I put together a little PDF outlining how I improve the movement variability side of physical activity. If you sign up for IFAST University, you’ll get access to it.
Without further adieu, here is the post.
The Four Step Process to Address Movement Limitations
I’m in the business of creating change, but — as you know — that stuff is HARD TO DO.
How do you simplify the process?
I like to outline things. When thoughts have a directional flow, it’s easier to keep everything straight. So I have to ask myself questions about each and every situation.
What kind of person is in front of me? And what am I going to do with him or her?
In this post, I’ll outline my process of helping people achieve their health and performance goals. We’ll discuss:The 4 areas where we can start creating change
My main area of focus: physical activity
The 4 steps physical activity
Each step from my physical therapy view
Each step from my performance coach view
My progression for mobility
The 3 active mobility tests I use
Testing for arm motion with lower body tests
Runners who get pain after they run 5 miles
Patients who get back pain after they sit for 4 hours
Athletes who can’t play the whole game without pain
…and a bunch of other short examples to relate this system to your own clients
The intent of this class was to provide a broad overview of all things hand therapy. We dove into hand anatomy, evaluation, treatment, splinting, and specific conditions.
My favorites parts were the anatomy, evaluation, and splinting sections. All of these areas were weak points of mine, and I definitely achieved quite a bit of clarity with these concepts. P-Ro is an absolute monster when it comes to splint making, and I loved all the tricks up her sleeve she had to make effective splints. It’s an area I’d like to dive into a bit more.
Check out the full review in the video below. Once you got my final verdict, check out some of the meaningful highlights in the notes below.
Let’s look at some of the fascinating anatomy that accompanies the hand.
The Carpal Bones
Laying your anatomy foundation starts with carpal bone appreciation, and the potential accompanying clinical problems.
As you can see, there are two rows of carpals. In the proximal row, the scaphoid and lunate articulate with the radius, and the lunate and triquetrum articulate with the ulna. The pisiform is in this row as well, but doesn’t articulate with any other bones. Its function is to allow for passing of the ulnar nerve and artery, and provide a distal attachment for the flexor carpi ulnaris (FCU).
The big red clinical red flag that can occur in this row is a scaphoid fracture. Because of poor blood supply to this bone, people often needed to be casted for 2-4 months to allow for healing.
Fractures in this region are often not immediately visible on imaging. Thus, a subsequent x-ray ought to be performed 2-3 weeks after the initial injury.
The second row of carpal bones consists of the trapezium, trapezoid, capitate, and hamate.
The trapezium is a bone of interest. In individuals undergoing surgery for thumb carpometacarpal joint (CMCJ) arthritis, part or all of this bone is often removed to increase space. Space is further increased by harvesting the palmaris longus tendon and shaping it into a pseudo-trapezium.
The Hand’s Retinacular System
The retinacular system ensures that tendons stay adhered to the hand while gliding, allowing for optimal hand function.
We can break up the retinacular system into three areas:
Extensor retinaculum – made up of six compartments (with first compartment potentially contributing to DeQuervains tenosynovitis)
Flexor retinaculum – Contain several synovial sheaths. Fingers II-IV all have their own sheath, whereas fingers I & V share a sheath.
The most complex of these systems is the finger retinaculum. There are several pulleys that compose this system to adhere the flexor tendons to the finger: five annular pulleys (A1-A5) and three cruciate bands.
These pulleys are arranged in the following sequence:
For reference, here are the location of the Annular pulleys:
A1 – Metacarpophalangeal Joint (MCPJ)
A2 – Half the length along the proximal phalanx
A3 –Proximal interphalangeal joint (PIPJ)
A4 – Middle phalanx
A5 – Distal interphalangeal joint (DIPJ)
Trigger finger is a condition implicated within this system. Inflammation and swelling can adhere flexor tendons to the A1 pulley, restricting finger extension. Surgically, the A1 pulley is cut to alleviate this condition.
The Zones of the Hand
There are five zones of the hand to describe portions of the volar surface. It is important to know these zones from a surgical standpoint.
Pink = zone 1; black = zone 2; purple = zone 3; green = zone 4; blue = zone 5
Zone 1 – Proximal to Flexor digitorum profundus (FDP) insertion
Zone 2 – From Zone 1 to A1 (considered no man’s land due to poorest recovery times, as hand intrinsics reside here)
Zone 3 – From A1 pulley to volar carpal ligament
Zone 4 – Carpal tunnel
Zone 5 – Proximal to carpal tunnel up through forearm
Keeping flexor tendons healthy post-surgery involves differentially gliding their tendons. These movements help prevent flexor tendons adhering to the pulleys.
To understanding how to effectively perform these maneuvers, we need to understand flexor tendon muscles.
The big two that we are differentiating are flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP).
FDS primarily flexes the PIPJ…
…while FDP flexes the DIPJ.
Thus, maneuvers must be performed to ensure individual gliding:
It is also important to note that FDP has two separate muscle bellies: one that goes to finger II, and the other that is shared by III-V. Thus, injuries along these particular areas require protection of all fingers, and may require joint blocking exercises to ensure tendon health.
The Extensor Mechanism
Whew, this part is a beast and very complicated structure. Let’s see if we can sift our way through it.
Here we see all the pieces that make up the extensor mechanism, which combines hand extrinsic and intrinsic muscles.
Let’s start with extensor digitorum communis (EDC), which acts to extend the MCPJ. This guy runs centrally along the finger, and splits off into sagittal bands that surround and stabilize the MPJ. In the picture, these would be a part of the “hood.”
The EDC attaches to the middle phalanx, assisting with PIPJ extension. The fibers then split off into lateral bands, which are the criss crossed above past the middle phalanx. These bands are a merging with the hands intrinsic to perform DIPJ extension. The other muscles that would make up the lateral band insertion include the dorsal and palmar interossei, and the lumbricals—all helping to create DIPJ extension.
The big thumb intrinsic muscles are the called the thenar muscles, which help the thumb perform the important opposition movement. These include…
Abductor pollicis brevis
Flexor pollicis brevis
These muscles attach proximally at the volar carpal ligament. This attachment is important to consider with someone who has a carpal tunnel release, as this surgery disrupts the thenar muscle attachment, potentially compromising thumb function.
Nerve Supply to the Hand
The big three nerves relevant to the hand are the median, ulnar, and radial nerve.
The median nerve is the big dog when it comes to thenar muscles and first two lumbricals. Injury to this nerve will impact thumb opposition and sensation.
The ulnar nerve innervates many of the muscles of the hand, including lumbricals 3 and 4, all the interossei, and the hypothenar muscles. Thus, an injury to this nerve can have severe repercussions to hand function. Limitations could include inability to perform a lateral pinch (requires adductor pollicis activity), can’t abduct finger V (need abductor digiti minimi), and will have difficulty utilizing extensor mechanism.
The radial nerve is less of a big dog, predominantly responsible for sensation. There will be alterations in wrist and finger extension, but since hand intrinsics are innervated by the median and ulnar nerve, some finger extension is preserved.
Common Hand Pathologies
Ever seen a swan neck or boutonniere deformity before?
With a swan neck deformity, the proximal interphalangeal joint (PIPJ) upwardly displaces secondary to a disrupted transverse retinacular ligament. These ligaments prevent dorsal displacement of the lateral bands.
With the boutonniere deformity, a PIP extensor tendon defect causes the proximal phalanx to migrate upwardly as the DIPJ extends.
The de facto treatment for the boutonniere is splinting the PIPJ in extension and the DIPJ in flexion.
Evaluation of the Hand
Most of this section was your typical evaluation fare: history, range of motion, posture, palpation, etc. But there were a few key pearls I gleaned.
Measuring Thumb Opposition
Measuring opposition according to this grading system is something I am employing much more. We measure opposition via a 10-point grading criteria:
Stage 0 – Thumb tip to lateral aspect of proximal phalanx of index finger
Stage 1 – Thumb tip to lateral aspect of middle phalanx of index
Stage 2 – Thump tip to lateral aspect of distal phalanx of index
Stage 3 – Thumb tip to index tip (considered early true opposition)
Stage 4 – Thumb tip to middle tip
Stage 5 – Thumb tip to ring tip
Stage 6 – Thumb tip to small tip
Stage 7 – Thumb tip crosses small finger DIPJ
Stage 8 – Thumb tip crosses small finger PIPJ
Stage 9 – Thumb tip crosser small finger proximal finger crease
Stage 10 – Thumb tip crosses distal palmar crease.
With stages 6-10, you want to make sure that the thumb slides down the small finger to ensure accurate opposition, as patients can compensate with thumb adduction, providing a false measure.
Sensation Return After an Injury
There are many ways to assess post-injury nerve function. One test used is tinel’s, in which you tap along the nerve to determine nerve regeneration. If you tap a portion of the nerve, it will produce an electric shock sensation to the point where the nerve has regenerated. This test can also signify potential nerve entrapment.
Based on how the nerve heals, constant and moving touch are some of the first sensations to return. Until these sensations are felt, true sensory re-education cannot be performed.
A weak spot of mine has always been wound care. Patricia helped stratify decision making for wounds in this class by classifying wound healing types. There are three.
This type of wound is a sutured wound, in which range of motion across joints that may compromise the wound ought to be limited for 2 weeks after initial suturing.
This type of wound is an open wound, in which the treatment varies. The intent is to maintain a wound that is not too dry or wet.
This wound is intentionally left open at first to clean and debride, then is sutured and grafted once healed. Treat as a second intention wound until suturing/grafting occurs, then first intention once the wound is closed.
Scar Healing Times
Scars have a specific healing times as well in the hands, which drive decision making in terms of progressing range of motion.
Coloring can be informative of how well the scar is healing. Typically, the redder the scar, the more immature the tissue is. Whereas white scars are a bit more mature.
Compared to normal skin, scar strength improves according to the following timeline:
3 weeks = 15% (tolerates AROM)
4 weeks = 30-50% (safe for most activities)
2 months (70%)
3-6 months (80%).
Splinting the Hand
The splinting section was one of my favorite aspects of the course and really where Patricia shined.
The overarching goal of splinting is to give the hand what it cannot achieve.
Splints can be classified into three different types, either prefabricated or custom:
Static – These splints lack moving parts, used for rest, protection, positioning, or function in some cases (e.g. nerve injury).
Serial static/static progressive – These splints are used to increase mobility in joints and soft tissues via low load long duration stretching. The former requires therapist-remolding, whereas the latter is changed by modifying components (screw/Velcro)
Dynamic – Splints that contain moving parts to compensate for motor loss, correct for contracture, protect tendons (by pulling in direction they cannot actively contract), or exercise muscles.
There were several different types of splints she suggested, but the real treat was watching her make splints. She had developed some pretty neat tricks to save on cost and maximize function. I don’t necessarily have any specifics, as the splints she makes were quite customized to the individual’s needs.
The Ideal Position to Splint the Hand
To illustrate important components of hand anatomy, it helps to look at how the hand is often splinted after an injury.
The common position to splint the fingers in is with the MCPJ in flexion, and the PIPJ and DIPJ in extension.
This position maintains tautness of all the collateral ligaments of each joint: the MPJ collaterals are taut in flexion, and the PIPJ and DIPJ in extension. This position also protects the volar plate, which is a ligamentous structure that limits PIPJ hyperextension. These structures must be preserved at all costs to avoid contracture in these areas.
There is a broad overview of Patricia’s Intro to Hand Therapy course. Though not perfect, it sparked many treatment ideas for me and helped me better appreciate the complexity of the hand.
Understanding hand anatomy is important in developing treatment paradigms
Flexor tendons must be differentially glided to ensure health post-surgery
Splinting acts to give the hand functions it cannot achieve on its own
What tricks do you have up your sleeve for assessing and treating hand complaints? Comment below and let us know!
I went to this course for a few reasons. First off, I of course support the home team. I can’t even front, Douglas Kechijian, Trevor Rappa, Greg Spatz, and I go way back, and are very much related through IFAST family and directly (Doug is my younger older brother, Trevor is my son, and Greg is my stepson #dysfunctionalfamily).
That said, there is were a couple big things I wanted to take away from this course, which I did in spades:
Mastering basic movement
In these two areas, the Resilient fellas delivered in spades. Knowing what good technique is in the basic movement patterns, how to coach, and how to regress, are all underappreciated topics that these guys teach quite well.
So should you take this course? An emphatic hell yes. I give a more indepth review as to why in the video below, so go ahead and check that out.
Once you got the verdict, check out my favorite takeaways in the course notes, and then for the love of God sign up for a course of theirs!
Click here to check out the Resilient Seminar Page
This week we have a guest post brought to you from my boi Benjamin Fergus, a Chiropractor friend of mine, who sent me an incredibly comprehensive video on squat mechanics.
I first met Ben at a DNS course way back in the day, and he was a pretty sharp kid then. Having watched this video, I can see that his knowledge base has only grown.
In this spot, Ben goes over the mechanics of the bodyweight squat, and I think you folks will tremendously appreciate his explanation of what is occurring at the knee.
Once you’ve finished watching the video, check his stuff out at GRIP Approach. You won’t be mistaken.
The Knee’s Position in the Squat
This overview of the ‘Complex Movements of the Knee Complex’ is not intended to tell you the right way to squat, but rather to show what is happening with the anatomy during movement and why. It also will show you how to read/name the movements with observation from the side and front.
Here on earth gravity is king in a squat. We like to keep the line of gravity and center of mass (COM/COG) situated over the midfoot. All variations of the squat can be seen as unique attempts to move our mass closer to the ground while keeping the COM over the midfoot.
There are no rights or wrongs named in this video, just a look at the possibilities of joint motion. What does ‘ knee internal rotation’ mean? We’ll look at that terminology and study what that translates to at the hip, femur, and shin in this biomechanics breakdown.
Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.
Here were the goodies that my peeps got their learn on from this past August.
If you want to get a copy of my weekend learning goodies every Friday, fill out the form below. That way you can brag to all your friends about the cool things you’ve learned over the weekend.
Biggest Lesson of the Month
Much of our successes and failures can be linked back to the habits we have. I noticed many times this past month that ineffective habits I had picked up were hampering my progress and productivity. One simple change (eliminating a to-do list, blocking out time to do things) was a complete game changer for me.
If you are doing something you don’t like, how do your habits keep you falling into that trap?
Quote of the Month
“Quality is not an act. It is a habit.” ~ Aristotle
Very much linked to the above lesson. We need quality to become automatic, and who better to illustrate this than an O.G. like Aristotle.
Hike of the Month
This was a tough decision to make on multiple fronts. This month I hiked four National Parks, saw a National Monument, and did all types of ill stuff.
Though Sequoia National Park will forever hold a dear place in my heart, Yosemite was hands down one of the most impressive things I’ve ever seen. The variety of terrain, the challenge of the 18+ miles I hiked, and the #views are hard to beat. I go back and forth on if I liked Yosemite or Zion better. But regardless, you should probably check it out.
I wish I had this podcast when I was first starting out. My boi Mike Robertson lists several high quality tips that young coaches should apply to get the most out of many things–internships, networking, life. These tips are really good for anyone to apply in any situation.
Doug Kechijian just continues to destroy the internet. In this article, he uses recent research on the hip thrust to critique a larger problem in science and performance–transfer-ability. Many times we argue about minutiae, when we really need to validate broader scope problems more effectively. Who better to discuss this issue than my buddy Douglas.
This past week’s quick hit goes into detail on how I coach landing mechanics, perhaps the most important piece to jumping safely and effectively. There are three keys to effective landing. What are those? Well, check out the vid.
There is a reason why Daddy-o pops is such a huge part of my life. Besides being an incredible human being, every time I listen to him I pick up something new. In this podcast Bill goes into detail on the importance of routines, and he gives a sneak preview of his new book (out September 15th), going into detail on the principles he employs to building fitness post-injury. Also, if you want his book, click here.
If you hurt, the thing to do is to stop all movement right?!? WRONG. A more prudent method is to find a different variation of a movement that gets the goal you want but doesn’t hurt. Here is an example
After I finished this article I was like “damn.” I think so many times as clinicians we chase pain relief for pain relief’s sake, without considering if the patient is truly suffering. I think about how many times I’ve been a part of the problem, even when trying to provide the solution. This one will definitely make you think.
Chris Kresser again with another gem (long road trips tend to have me consume a lot of info from one source). Here CK goes over many practical tips towards being an effective consumer and appraiser of the research. If you think research is tough to understand in rehab and performance, don’t even think about looking at nutrition. Yuck.
My two baby boys have grown up so fast! It is so refreshing to hear two well-respected physical therapists discuss expanding the PT scope into aggressive fitness. I love how both of these guys espouse not making injured people seem fragile, but always pushing intensity. The more you can expose someone to intensity, the easier return to performance becomes. We can’t just stop at success on the table.
This article was just absolutely awesome. In it the authors explain how nociception, both acute and chronic, impacts motor control both short and long term. They also sprinkle in some really cool things with the sympathetic nervous system and movement variability. These are all reasons why we cannot ignore nociceptive drive in chronic pain states.
If you are a PT, unattached, have a crap ton of student loans, and like adventures, you should strongly consider travel PT. Traveling makes it feel like you are on vacation the entire time you are on assignment, and it feels good to actually make a dent on student loans. Here are all your questions, answered.
For those of us who are coffee lovers; you are welcome. In this podcast my man Chris Kresser discusses all the amazing health benefits of drinking copious amounts of coffee. Wait until you here him compare the antioxidant values to some of those highly touted antioxidant fruits. #mindblown.
While we can often talk about how to time sleep, supplementation, and such with travel, one thing often not discussed is what equipment you should bring when you travel. Having the right stuff can make travel much less stressful. What stuff? Check out the vid to find out.
This podcast took me back to the days I was obsessed with poker. In this wonderful Tim Ferriss podcast, world class poker player Phil Hellmuth discusses many of the trial, tribulations, successes, and failures he has come across in his life. Many words of wisdom were had. Making my goal sheet now!
This blog really hit home for me. After getting let go from my NBA gig, I spent a great deal of time evaluating things I needed to change about myself. This is a hard conversation to have with yourself, but can often by life changing. Here Eric Cressey talks about his life changing conversation that made him the great coach that he is.
Ramit Sethi does an excellent job providing simple, yet effective financial device. I’ve been reading this book a bit slow, but applying every single lesson he’s recommended in each chapter with outstanding results. I was able to convince my credit card company to up my limit, give me 0% APR for a year, and doubled my interest rate on my savings account just by following these steps. Definitely a worthwhile read.
Tim Ferriss has really impressed upon me the importance of having a broad skillset. Mastery, or even competency, doesn’t take that long to achieve. A bit of focused study, and you will have most of what you need to be successful at your craft. This is why I am expanding my learning into areas such as sleep, nutrition, and more.
Incubus is one of my favorite rock bands, as I just love how diverse their sound is. And it seems like they rarely fail with their experiments.
This album goes a little back to some rock roots, and man does it have some heft to it. I trained to this when I first heard it, and I’m pretty sure my arm circumference increased by 3 inches…even though I was training legs!
Give “No Fun” and “Nimble Bastard” a listen
Which goodies did you find useful? Comment below and let me know what you think.