1. Manual Therapy for Athletes Bryan Bourcier DPT, ATC, COMT, CSCS

2. Outline Manual Therapy basics Contraindications Indications Spine Mobilizations for Athletes Upper extremity Peripheral Mobilization Lower extremity Peripheral Mobilizations

3. Manual Therapy Basics Grading Mobilizations Comparable Sign Resistance vs Pain – R1 vs R2 – P1 vs P2 Grades of Mobilizations – I – Small amplitude short of resistance – II – large amplitude short of resistance – III – Large amplitude midway between R1 and R2 – IV - Small amplitude midway between R1 and R2 – V- At R2 High velocity low amplitude +, ++, -, -- variations IV++ and III++

4. Contraindications (Red/Yellow Fracture (red) Hypermobility / empty end feel (Yellow) Pregnancy (yellow) Cord Compression (Red) Cancer (Red) Patient comfort (yellow) Open wounds (yellow) Fusions (Red and Yellow) Manipulation into spasm (Red)

5. Treatment Options for Low Back Pain in Athletes – Ryan C. Petering, MD and Charles Webb, DO Despite the high prevalence of low back pain and the significant burden to the athletes, there are few clearly superior treatment modalities. Superficial heat and spinal manipulation therapy are the most strongly supported evidence-based therapies. Nonsteroidal anti-inflammatory medications and skeletal muscle relaxants have benefit in the initial management of low back pain; however, both have considerable side effects that must be considered.

6. Indications Stiffness Pain management Scar tissue management “locking” or “Pinching” (Spine) Evidence – When combined with exercise, speed up recovery – Not better if used without exercise

7. Common Cervical Spinal Mobilizations for Athletes Suboccipital Release – Concussions Traction MET Soft tissue

8. What are we treating ConcussionWhiplash neck pain and stiffness, headache, dizziness fatigue jaw pain activity intolerance postural weakness visual disturbances tinnitus increased symptoms with fatigue neck pain and stiffness, headache, shoulder and arm pain dizziness fatigue activity intolerance jaw pain postural weakness visual disturbances tinnitus back pain increased symptoms with fatigue

9. Subocciptial release Long sustained pressure on suboccipitals. – Can be done unitlaterally – Make sure knees are bent – If too painful, try traction first.

10. Common Cervical Spinal Mobilizations for Athletes Suboccipital Release – Concussions Traction – Manual Vs Mechanical MET – when and when not Soft tissue – positional release and first rib

11. Common Thoracic Spinal Mobilizations for Athletes CT junction Pistol Screw

12. C-T Junction Have the patient lay on their stomach while placing their arms above their head. Once you have the level that you want have the athlete look to the opposite side hand. Gently apply pressure on the junction while applying pressure on the patient’s head and rotating.

13. Pistol Make and fist while extending your index finger and thumb. Place your fist over the level that you want to manipulate. The area where your fingers meet your palm should lay over the spine. Index finger and thumb should be over transverse processes. Have the patient put their hands on their neck, with elbows together and knees bent. Have the patient exhale and while exhaling push the athlete over your hand as a fulcrum.

14. Screw Have the patient lay on their stomach. Once you have the level that you want, place one hand one the level above and the other hand on the level below. The palm of your hands should be on the level. Then apply pressure down while turning your hands inward.

15. Common Lumbar Spinal Mobilizations for Athletes Rotational Mobilization – Grade I-III – Manipulation Chicago Roll Shotgun SI / IS MET Leg Pull A/P

16. Rotational Have the athlete lay on their side facing you. Straighten the bottom leg and push it to the opposite side of the table. Bend the top leg and bring it towards you. Have the patient interlock their arm with yours. Place your other arm on the bottom part of their back and over their SI joint. Rotate their top shoulder down to the table and pull their hips towards you with the other arm.

17. Chicago Roll Have the patient lay on the side of the table nearest you. Bring their legs together and to the side of the table. Put one hand under their back shoulder and the other hand on the ASIS. Rotate their shoulder up and towards you while applying pressure on the ASIS.

18. Shotgun Have the patient lay on their back with their knees bent and feet together. Then have them squeeze your forearm.

19. Upper extremity Mobilizations Shoulder – “Fish Flop” (Shoulder pain control) Elbow – Radial Head Wrist – Distal Radial ulnar distraction

20. Lower Extremity Hip – Lateral glides (FAI) – AP and PA Knee – Extension with ER and IR (post op and Hamstrings) Ankle – Lateral malleolus glides (Ankle Sprains)

21. Soft Tissue Palpation and Manual Therapy Craig Shannon, MPT, OCS, ATCCraig Shannon, MPT, OCS, ATCTherapyONE

22. Overview Palpation of Structures Palpation of Structures Palpation of Movement Palpation of Movement Joint Mobilization Joint Mobilization Soft Tissue Mobilization Soft Tissue Mobilization Multiple Methods Multiple Methods Improving your sense of touch Improving your sense of touch

23. Palpation of Structures Palpation of Surface Anatomy Palpation of Surface Anatomy Know your surface anatomy Know your surface anatomy Know where structures are in relation to the Spinal Levels Know where structures are in relation to the Spinal Levels

24. Palpation of Movement Spinal Movement Spinal Movement Joint Movement Joint Movement Soft Tissue Movement Soft Tissue Movement

25. Palpation of Spinal Movement AROM of all planes of motion AROM of all planes of motion Feeling for Symmetry Feeling for Symmetry Feeling for Segmental Restriction or Hypermobility Feeling for Segmental Restriction or Hypermobility Passive mobility testing Passive mobility testing Checking the “R’s” Checking the “R’s” Endfeels Endfeels

26. Palpation of Joint Movement AROM AROM Feeling for Feeling for Crepitus Crepitus Endfeels Endfeels Muscle Guarding Muscle Guarding Symmetry Symmetry Special Testing Special Testing

27. Soft Tissue Palpation What is the Nature of the Injury? What is the Nature of the Injury? History and Symptom Patterns History and Symptom Patterns Mechanism of Injury Mechanism of Injury Acute Trauma Acute Trauma Chronic Chronic Postural Postural Repetitive Repetitive Type of Injury Type of Injury Tear Tear Adhesion Adhesion Crush Crush Myofascitis Myofascitis Tissues Involved Tissues Involved Muscle Muscle Joint Capsule Joint Capsule Nerve Nerve

28. Soft Tissue Palpation 4 Keys to Soft Tissue Palpation 4 Keys to Soft Tissue Palpation Tissue Texture Tissue Texture Tissue Tension Tissue Tension Tissue Movement Tissue Movement Tissue Function Tissue Function

29. Tissue Texture Inflammatory Phase Inflammatory Phase 1 st 24-72 hours 1 st 24-72 hours Typically swelling is fluid like and easily moveable Typically swelling is fluid like and easily moveable Usually undefined borders Usually undefined borders Sub-Acute Phase Sub-Acute Phase 2-14 days 2-14 days Increased tension in tissues – Hypertense Increased tension in tissues – Hypertense Feels Stringy Feels Stringy Borders become more well defined and palpable Borders become more well defined and palpable

30. Tissue Texture Early Chronic Early Chronic 2 weeks – 3 months 2 weeks – 3 months Tissues healing through Fibrosis Tissues healing through Fibrosis Texture transitions from Stringy to Lumpy Texture transitions from Stringy to Lumpy Chronic Chronic 3 months + 3 months + Tissues become Leathery and Tough Tissues become Leathery and Tough Altered vascularity and more scar-like Altered vascularity and more scar-like

31. Tissue Tension Difficult to be objective Difficult to be objective Must rely on the Contralateral side to compare Must rely on the Contralateral side to compare If ROM restricted – tissue tension considered Abnormal If ROM restricted – tissue tension considered Abnormal Must be specific of what structure is involved Must be specific of what structure is involved Palpate tissues at rest and with ROM Palpate tissues at rest and with ROM Compare surrounding tissue tension Compare surrounding tissue tension Clinician will need to develop a Feel for what is Normal Clinician will need to develop a Feel for what is Normal

32. Tissue Movement How do the tissues move with each other How do the tissues move with each other Skin and superficial fascia Skin and superficial fascia Fascia and Muscle Fascia and Muscle Muscle and Joint Capsule Muscle and Joint Capsule Nerves and Fascia/Muscle Nerves and Fascia/Muscle Need to learn to palpate to the proper level Need to learn to palpate to the proper level Peeling Onions Peeling Onions Palpate with and without movement Palpate with and without movement

33. Tissue Function What about the tissues is dysfunctional? What about the tissues is dysfunctional? Weak Weak Restricted Restricted Neurogenic issues (paresthesias) Neurogenic issues (paresthesias) The rest of your examination should help tease this out The rest of your examination should help tease this out

34. Joint Mobilization What Bryan Said! What Bryan Said!

35. Soft Tissue Mobilization Massage Massage Cross-Friction Massage Cross-Friction Massage Tool Assisted STM Tool Assisted STM ASTM ASTM Graston Graston SASTM SASTM Knife and Spoon Knife and Spoon Active Release Techniques (ART) Active Release Techniques (ART) Myofascial Release Myofascial Release

36. Soft Tissue Mobilization Basics Need to develop your sense of touch Need to develop your sense of touch Like putting in golf, shooting a 3, juggling a soccer ball Like putting in golf, shooting a 3, juggling a soccer ball Know your Anatomy…Specifically Know your Anatomy…Specifically What is your targeted tissue or tissues What is your targeted tissue or tissues Don’t “Press and Guess” Don’t “Press and Guess” What is the goal of your treatment? What is the goal of your treatment? Relaxation Relaxation Decrease pain Decrease pain Decrease swelling Decrease swelling Restore tissue mobility Restore tissue mobility Restore joint or muscle ROM Restore joint or muscle ROM

37. Improving Palpation Skills Need to know what Normal is before you can Identify Abnormal Need to know what Normal is before you can Identify Abnormal Use a Soft Contact to help Identify structures and tissues Use a Soft Contact to help Identify structures and tissues Chiropractic Tricks to improving a sensitive sense of touch Chiropractic Tricks to improving a sensitive sense of touch Hair in a phone book trick Hair in a phone book trick Nose on a Quarter trick Nose on a Quarter trick Practice and Patience Practice and Patience You won’t find anything if the tissues are too swollen You won’t find anything if the tissues are too swollen Save the “digging” for treatment Save the “digging” for treatment

38. Thank You