It was quite surreal to be interviewed by a guy who I have tremendous respect for, and who has been a huge influence on me.
MR was one of the people who I was initially exposed to when I got into this field. After reading all the cool things he wrote on t-nation, I bought most of his products, became a huge reader of his blog, and applied many of his teachings to my own training.
Zac = fanboy.
Can you imagine what it was like the first time I met him and Bill at IFAST? Like meeting rockstars, fam. Then he we are, having a conversation as peers.
Point being with this story, if there was no Mike Robertson, we wouldn’t be having this conversation right now.
The Life of A Mercenary PT
Here were some of the things we discussed in this podcast:
How I got started in the world of physical prep.
What life is really like in the NBA/D-League, and what it’s like to transition from therapy to performance at the highest level.
What skills I was comfortable with, and how he grew and evolved to take his coaching skills to the next level.
My biggest struggles in pro sports.
Movement Variability: What it is, and why you probably need more of it.
What it’s like to transition from the biggest stages in sport, to working in a smaller setting with a more general population.
How I get it all done – from working as a mercenary PT, to writing, to public speaking, etc.
The BIG Question.
A really fun lightning round where we discuss pops Daddy-o Bill Hartman, his favorite hip hop groups, why I started the Movement Debrief, and what’s up next for me.
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
Life ought to focus on creating value, for the people you work with, for others, for the world, for yourself. When you create value, rewards will come.
Quote of the Month
“Common 99% thinking won’t get you uncommon 100% results” ~ MJ Demarco
MJ Demarco is becoming one of my favorite authors, and he inspired the biggest lesson above.
Hike of the Month
I didn’t get much hiking in this past month, namely because I was prepping for my talks in the land of China. However, while in China, my hotel was right next to this really cool park that I walked through frequently. Amazing amalgamation of architecture, flora, and people.
The Trick to a Perfect Rear Foot Elevated Split Squat
My son, Trevor Rappa, gave us a great cue on nailing the rear foot elevated split squat. Perfect for those people who sag into the back leg.
Weight Position During the Squat
Want to more effectively load the legs when you are squatting? Here is one of the most impactful changes I’ve made when coaching squats.
Daddy-O Pops Bill Hartman just killing it with the content, fam. This time around, he discusses how he approaches individuals who get knee pain during split stance activities; a common problem I’ve struggled with in the past. Thank you for helping a son out, pops.
Want to get into mediation but don’t want to spend the buck on Headspace or Calm? Then Insight Timer is your answer. There are several different styles of meditation available in this completely free app.
I will admit, you have to sift through a lot of crap to find the particular meditations that work for you, but once you find one’s that work, you are golden.
My favorites so far are “The Warrior” by Michelle DuVal and Franko Heke 5 Min Guided Meditation
Eric Barker’s “Barking Up the Wrong Tree” blog is hands down one of my favorite blogs on the internet. He spends a great deal of time researching multitudes of topics, getting quotes from others, and writing about damn interesting material. This time, he discusses meditation, multiple “yous,” and so much more.
I’ve been binge listening to Robb Wolf’s podcast as of late (a great thing about vacations), and I found this one to be particularly fascinating. Here Dr. Alleman discusses how he is saving healthcare by using a subscription-based system for his patients. It’s quite fascinating how this system is saving his clients, including small businesses, money. I’d definitely check this one out.
I’m a big time ruminator on things. Something I’ve been trying to work on. Here, my boi Seth Oberst discusses how movement can help reduce the urge to ruminate, and how it’s a much better alternative than being on your phone.
Man this hit home for me on many levels. My man Dean Somerset wrote an awesome post on what it feels like to experience imposter syndrome, and how all of us have to start from the bottom. It’s about the process, and continuing to grow the process.
This book has really hit me hard and made me think about the way I am approaching finances, making money, and many other things. This book will challenge all your preconceived notions about what to do with your money.
Eric Barker is one of my favorite bloggers and I am enjoying his book quite a bit. Do you want to find out if nice guys finish last? Or maybe you want to learn from prison inmates how important trust is. He has so many great nuggets in this book that I’m certain you won’t be disappointed.
This is probably one of the coolest things I have ever seen. Want to hear every music genre that has ever existed, then get a Spotify playlist having music within that genre? Because That is exactly what this site does. Un…be…lievable.
[WARNING, EXPLICIT CONTENT] Good…Lord…Listen to this. Royce is by far one of my favorite rappers. Like, in my top 10, pushing to get into my top 5. Here is a dope mixtape he put together where he just expresses his lyricism; many on some of your favorite beats.
Some of my favorite include “C Dolores,” “Still Waiting,” “Gov Ball,” and “Chopping Block”
Side note: got to meet Royce at a concert with like 10 people. He really is 5’9″. And he’s a cool cat.
[WARNING, EXPLICIT CONTENT] Some call him the modern day 2pac, Gangsta Gibbs himself takes street rap to a whole new level. This joint gets him talking about his time he was in jail overseas. It’s a great mix of some serious stuff with his typical gangsta fare. Freddie is currently one of my favorite modern rappers, so please give him a listen. Crushed Glass and Homesick are my favorite two.
Which goodies did you find useful? Comment below and let me know what you think.
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