November Links and Review

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

Don’t beat yourself up if you aren’t hitting perfection day in and day out. Consistent progress over time is the key.

There have been many days where I wasn’t motivated to stay on task, and faltered. The key to getting back on the proverbial horse the next day was to not beat myself up. Instead, acknowledge that these things happen, understand I’m human, and get after it the next day.

You’d be amazed at what this shift in perspective can do.

Quote of the Month

“Greatness is a lot of small things done daily” ~ MJ Demarco

MJ Demarco again takes the cake this month. This quote made me reflect a lot on just how many small, quality habits, can make an impact on life. What small things can you do to become great?

Hike of the Month

A late steal this month, but got a chance to check out Death Valley National Park.

Salt > snow. Equally as pretty, less slippery, and DEFINITELY warmer

I wasn’t really sure what to expect with this place since, ya know, it’s hot and things are kinda dead n’ stuff, but the variety in landscape was quite unbelievable. Landscape that I have never experienced before, whether salt lands or sand dunes. I’d definitely consider checking this awesome place out.

Rehabilitation

 

Here’s a little sneak preview of the free talk I’ll be putting up for you guys once I re-record it!

Blog: What Evidence Based Practice is Not

Doug Kechijian always telling it like it is. This time, my younger older brother discusses how to think about evidence based practice. How it is much more than a bomb of Pubmed citations. I also love how he touches on effective discussion on the internet.

Here is a little variation on differential tendon gliding you can try next time you see someone with a flexor tendon repair.

Blog: Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Mike Reinold again coming on strong with this post. This time, Mike looks at a systematic review comparing early vs. delayed motion after a cuff repair, and I love his interpretation.

Training

Video: Kettlebell Swing Tutorial w/ Justice Williams (via Tony Gentilcore)

My kettlebell game is something I’m hoping to improve upon over the next year, and this was a great intro point to it. Here, Tony Gentilcore and Justice Williams provide an excellent coaching tutorial on the wonderful/brutal exercise known as the kettlebell swing.

 

Productivity

 

Article: Trick Yourself Into Writing Well by Telling Yourself to Write Badly

Lifehacker is an awesome website for many reasons, and this article is an example of that.

Many times, getting started writing is the hardest part, here, the peeps at Lifehacker give you a trick to getting started. Works wonders for those days I don’t want to write.

Making this one little tweak to how I plan email checking throughout my day has made a big difference.

Personal Development

Book: What to do When It’s Your Turn

A dear friend of mine got me this book, which has become my pre-bed reading and I love it. Seth Godin, marketer extraordinaire, writes in this book about handling fear of failure, getting the courage to start something up, and how timing is never right. These are a few of many great topics that I’ve come across, and I always fall asleep in a good mood after I read a few pages 🙂

Blog: These are the 8 Friends You Need to be Happy in Life

Social engagement is something we don’t discuss much when we are trying to reach our health and performance goals. Here, Eric Barker talks about the eight people you should have in your life. How many do you have?

Article: How Frequently Should You Take A Vacation?

This is probably the most comprehensive guide to vacationing that I have come across. It turns out, vacations are incredibly important to your health.

Don’t like vacations? Consider your increase for cardiovascular disease elevated. Read the guide to maximizing them.

Just need to make life a vacation #movesomewherewarm

Blog: How One Young Couple Repaid $87,000 of Student Loan Debt in 27 Months

If you have student loans. Read this. It’s hard work, gruesome, but paying off debt has been a rewarding experience for me. If you are lacking motivation, or can’t see the light at the end of the tunnel, here is some hope.

Blog: Struggling Against Good Decisions with Bad Results

This was just a phenomenal message that can be extrapolated not to just finances, but life. Here, Trent Hamm discusses the importance of sticking to sound principles, even if those principles don’t always result in a desirable outcome

Book: Discipline Equals Freedom Field Manual

If you need a swift kick in the ass to get back into gear, this is the book. Many of the pages are snippets from Jocko Willink’s podcast, but the message is not lost. Jocko will make you rethink everything your doing, and eliminate the excuses for you not doing. Change your life, and read this book.

Book: Unscripted

After you’ve been kicked down by Jocko, let MJ Demarco pull off the finisher. This guy is becoming one of my favorite authors because he is brutally honest and pulls no punches in explaining how we fall into business and work traps that not only hinder us, but minimize helping others. If you want to be an entrepreneur (and you all should, this book tells you why) then this is a must read.

My favorite part? “The goal isn’t to make money, but to provide value to others.”

Health and Wellness

 

Podcast: Dr. Ruscio – The Real Deal with Gut Microbiota

I’ve been binge listening to Robb Wolf’s podcast, and I’ve come across Dr. Ruscio a couple different times. I admire his brutal honesty and simple approach to dealing with the gut microbiome, and I hope you guys like it as well.

Want to know some of my big keys for starting my day off right? Check out this week’s quick hit.

Podcast: Dr. Richard Maurer – The Blood Code

Again, another simplified and stratified approach to functional medicine courtesy of the Robb Wolf podcast. Here, Dr. Maurer outlines his key blood markers and first-tier treatment to help individuals with their health and wellness goals.

Article: Do You Need to Refrain from Coffee to Get the Maximal Effect of Caffeine?

If you want to maximize performance, do you need to give up coffee for a bit to get the benefits? Researchers compared how caffeine affects performance in heavy, moderate, and low users.

The answer might surprise you!

The addiction is now #ebp #blessed

 

Which goodies did you find useful? Comment below and let me know what you think.

Photo Credits

Nick Kenrick

Julius Schorzman

Intro to Hand Therapy Course Review

The hand has always been a weak area of mine, anatomy, treatment, the whole 9 yards. Thus, I was inspired to take an Intro to Hand Therapy Class taught by Patricia Roholt, a certified hand therapist (CHT) with 30+ years of experience.

 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.

if the above areas are what you consider to be a hole in your game, I’d consider checking out her online offerings to see if her courses would be right for you.

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.

Hand Anatomy

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.

‘ppreciate these bones, fam

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.
  • Finger retinaculum

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:

Well I’m no Picasso, but do you like it?

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…

Don’t stress about the FDS

 

…while FDP flexes the DIPJ.

You down with FDP? Yeah, you know me.

 

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.

So gangsta that I grew up on that extensor hood, fam!

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.”

Makes me think of that Wu-tang song every time

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 Thumb

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
  • Opponens pollicis
Scalpel not included

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.

Yellow = Median; Green = Ulnar; Pink = Radial

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?

Finger 4 is a swan neck, finger 5 is a boutonniere

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.

Wound Classificiations

 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.

First Intention

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.

Second Intention

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.

Third Intention

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:

  • 2 weeks:3-5%
  • 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:

  1. Static – These splints lack moving parts, used for rest, protection, positioning, or function in some cases (e.g. nerve injury).
  2. 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)
  3. 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.

I’d rather some more IPJ extension, but like me, this splint is close to ideal, though not perfect #yesimsingleladies

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.

Sum Up

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.

To summarize:

  • 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!

Photo Credits

Anatomist90

Becguglielmino

Henry Gray

Wikipedia

Anatomist90

Anatomist90

Harrygouvas

Henry Gray

Henry Gray

Grant, John Charles Boileau

Grant, John Charles Boileau

Scars, Hands, and Handling not Getting Jobs – Movement Debrief Episode 19

Just in case you missed last night’s Movement Debrief Episode 19, here is a copy of the video and audio for your listening pleasure.

Here were all the topics:

  • Is treating scars essential?
  • My thoughts on what hand therapy should look like
  • How to act and react when you don’t get a job you think you want
  • The R&B concert I went to…yes we riffed on that for awhile

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 8:30pm CST.

Enjoy.

 

 

                

Here were the links I mentioned tonight

Three Dimensional Mathematical Models for the Deformation of Human Fascia

Camp Lo – Luchini

K-Ci & JoJo

Ginuwine

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