Manual Therapy Forum

UPDATE: Mobilization of the AC Joint

 

In the following video, we show an update to a different way of mobilizing the AC joint than you might be used to.  You can see that video here.  That previous video was something I came up with in the clinic.  However, this video is an adaptation of a technique that I learned from Erl Pettman of NAIOMT.  I’ve been more successful trying it this way, so I’ve stuck with it.  So, take a gander and give it a shot for yourself in the clinic.  Then, share it and write a comment here or on our social media accounts.  Enjoy!

 

 

 

Jack Stagge PT, OCS, FAAOMPT

 

“When we got to see them [pioneers in the field of manual therapy], what I realized was, they all asked the question ‘What if?’.  And that ‘What if?’ question normally came when they made a mistake with a patient.”

– Jack Stagge

 

 

“Very few of them were full of themselves.  The majority of the ‘greats’ that I was around felt that they were given a gift, and felt that they weren’t that special… they just didn’t stop looking.”

– Jack Stagge

 

“As a profession, we have two kinds of people in physical therapy.  Those that have a job, and those that have a profession.  If you’re going to be a professional in anything, I don’t care what it is, it’s going to take more time and more effort… and sacrifice!”

– Jack Stagge

 

Welcome back everyone!  This conversation is with my friend Jack Stagge.  As you will hear, Jack has a lot of training with some of the best in manual therapy history.  You will also notice rather quickly that he is a wonderful story-teller.  As with many of our other podcasts and conversations, Jack has incredible insight when it comes to life as a professional, as well as balancing that with personal life.  One unique aspect of our friendship is that I’ve gotten to know Jack somewhat personally for a short time as I was a student intern and he was my clinical instructor.  So, I can personally attest to Jack’s skill as a clinician and how great of a guy he truly is.  Please enjoy this conversation with Jack Stagge!

 

 

Listen in here:

 

Or tune in here:

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Listen to Stitcher

 

 

“As a profession, we are the most gifted.  We have a lot of scientific backing… we’ve been gifted with this huge thing!  […] We have the ability to impact people on all levels.  Physical, emotional, spiritual, whatever!  […] Beceause we give all the time, there’s a giving and a connection.  We can make an impact on a person… a whole person.”

– Jack Stagge

 

“As a therapist, always be looking for a place you can give and get nothing back.”

– Jack Stagge

 

 

 


 

Links of interest:

International Manual Therapy Seminars

Faces 4 Hope

 

 

 

Case Study #1 – Elbow Pain

 

For our first case study, we present a patient referred to physical therapy because of elbow pain.  See the details to follow and add your thoughts in the comments!

 

Patient demographics:  51 year old female

Referral diagnosis:  Lateral epicondylitis

Past Medical and Surgical History:  Nothing reported per patient

 


 

Subjective History:  Patient reports that she recently began having right elbow pain that began about four weeks ago.  She does not recall any particular incident or injury that has lead to the onset of her symptoms.  Also, she reports no significant change in her everyday activities that could have brought on her pain.  When asked, she reports that her pain is along the posterior elbow about 1.5 inches below her radial head.  She also feels radiating pain down toward her hand, but cannot recall exactly where this is located.  This patient has also noticed a deep aching pain within her right shoulder, as well as right sided neck pain that radiates down toward her right posterior scapula.  She reports that she has not had any significant history of neck/shoulder/elbow/wrist/hand pain, nor injuries/traumas/accidents to any of these areas.

 


 

Observation:  The patient demonstrated a mild forward head posture.  However, the most significant finding from observation was the her right scapula was elevated and downwardly rotated.  There were no other significant differences between either upper extremity in terms of posture, nor head head/neck position (other than the above).

 


 

Objective Examination:

  • Left shoulder range of motion – full and painless
    • Flexion = 180 degrees
    • Abduction = 180 degrees
    • Extension = 70 degrees
    • External rotation = 90 degrees
    • Internal rotation = 80 degrees
  • Right shoulder range of motion – painless
    • Flexion = 160 degrees
    • Abduction = 160 degrees
    • Extension = 70 degrees
    • External rotation = 90 degrees
    • Internal rotation = 80 degrees

 

  • Left elbow range of motion – full and painless
  • Right elbow range of motion – full and painless

 

  • Scapula range of motion (protraction, retraction, depression, elevation) – full and painless

 

  • Cervical range of motion – painless
    • Flexion = 80 degrees
    • Extension = 80 degrees
    • Right rotation = 70%
    • Left rotation = 70%
    • Right side-bending = ~15 degrees
    • Left side-bending = ~15 degrees

 

  • Palpation – reproduction of patient’s symptoms with pressure applied to the biceps tendinous insertion to the radial tuberosity, as well as the anterior portion of the distal biceps tendon.

 

  • Manual resistance tests – reproduction of symptoms most significantly with resisted elbow flexion and supination from a lengthened range, less significantly with resistance to supination from elbow flexion at 90 degrees.

 

  • Neurodynamic assessments – not limited, nor symptomatic

 

  • Specific joint assessments
    • Normal mobility throughout the right gleno-humeral joint, elbow joint, wrist and hand
    • Significant hypomobility noted of the right AC joint
    • Significant hypomobility of the C2/3 and C5/6 segments
      • C2/3 FRS left – loss of posteroinferior glide on the right side
      • C5/6 ERS right – loss of anterosuperior glide on the right side

 


 

Overall initial impression:  At this point, it is pretty obvious that this patient has a distal biceps tendinopathy.  However, there is no evidence at this time from the patient that there is a clear reason for this pathology.  Without any significant history to indicate an event that acutely overloaded these tissues, nor any change in her daily activities that would chronically overload the same tissues, we are left with the combination of mechanical and neuromuscular dysfunctions that have eventually eroded the ability for these tissues to handle every day stresses that were placed on them.

The combination of mechanical dysfunctions of the AC joint and cervical segments led to an over-recruitment and hypertonicity of the right levator scapula and subsequent inhibition of the upward rotators of the scapula.  This would account for the neck pain, posterior scapula pain, and deep aching in the shoulder.  However, the distal biceps tendinopathy is the result of chronic alteration of neural “flow” due to the dysfunctions within the cervical spine… essentially, the elbow pain was “driven” from the neck (well, and the rest of the upper quadrant).

 


 

Initial treatment:  Interventions at the initial evaluation were limited due to time constraints.  However, we were able to perform the following… upper cervical ligamentous laxity screen (-), ROM/mobility screen for cervical arteries (-), manipulation of the C2/3 segment from below to restore lost joint motion (consent was given), neuromuscular re-education to the C2/3 segment for the restored motion, manipulation of the C5/6 segment from the contralateral side to restore lost joint motion (consent given), neuromuscular re-education to the C5/6 segment for the restored motion, and lastly resisted axial elongation to the C2/3 segment (was found to be most inhibited) to reduce global inhibition throughout the cervical spine and restore proper resting tone to the key muscles innervated by those segments.  The patient was educated to perform a home exercise program of self-resisted axial elongation specific to the C2/3 segment (again, this was the most inhibited segment on assessment) once every hour for 1-2 minutes at a time.  Also, she was instructed to limit (to the best of her ability) positioning her head/neck into either forward head position (i.e. computer work) or looking down (i.e. reading a book).

 


 

Initial outcome:  The patient reported a significant reduction in elbow pain (at least 50%) and decreased pain in the neck and shoulder girdle.

 


 

Follow up visits will be performed on a weekly basis and are planned to include further mechanical treatment to the AC joint, extensive neuromuscular re-education to the right shoulder girdle to maintain appropriate scapula positioning at rest and when using the right shoulder/arm.  Local modalities will also be utilized to aid in the healing of the biceps tendinopathy.  Therapeutic exercises will be used to effectively stress the injured tissues for an appropriate healing response until the patient can perform all of her daily activities without any symptoms or limitations.

 


 

Well, that’s it so far for this case study.  What are your thoughts?  Would you have chosen to do anything differently?  We’d love to hear what you have to say in the comments below…

 

 

Eric Hitchcock PT, MSPT

 

There’s always a third-degree black belt out there to let you know you don’t have it figured out!

 

– Eric Hitchcock

 

Today, we get to speak with Eric Hitchcock.  Eric is a friend and very well respected work colleague with us here in Chico, CA.  I’ve actually been wanting to record something with him for a long time.  However, as you will hear from Eric, he had hesitations for quite some time.  Thankfully, he succumbed to peer pressure!  Aside from speaking with a great person like Eric, this podcast is unique because it is more of a freestyle episode where we didn’t have a set list of questions.  Instead, we actually get to discuss some topics that weren’t brought up in previous episodes.  So, I hope you enjoy this time spent with Eric.  He’s a special guy and I believe all who listen will learn a lot!

 

What are you doing, and why are you doing it?  Have purpose with everything that you do.

 

– Eric Hitchcock

 

 

I can’t believe how many times I have belly laughs every day.  That’s a wonderful thing in my life.

 

– Eric Hitchcock

 

 

Listen here:

 

Or tune in down here:

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I think we are all brothers and sisters on this planet.  I think we are here to help each other.  And I think everyone in this room, individually, and as a group, we are all situated in this time and space to fulfill that part of our human destiny.  To help others.  So, get out there and keep on doing it.

 

– Bill Snyder (as quoted by Eric Hitchcock)