AN OSTEOPATHIC APPROACH TO THE KINETIC

CHAINDAVID KANZE, DO

MARCH 15, 2019

AAO CONVOCATION, ORLANDO, FLORIDA

OBJECTIVES

• Define the kinetic chain

• Identify areas that could become dysfunctional and ultimately lead to throwing problems

• Comprehend what to treat

• Introduce new techniques to treat the dysfunctions encountered

• Learn how to apply what you have learned here to any injury

THE KINETIC CHAIN

PULLIES AND STRUTS

• With pullies, the idea is to increase the mechanical advantage. That is to decrease the amount of work needed to provide the force.

• Ideal mechanical advantage is equal to the number of muscle and tendinous (rope) segments pulling on the object. The more muscle and tendinous (rope) segments that help to do the work, the less force that is needed for the job.

Elroy M. Avery School Physics (New York: Sheldon and Company, 1895) 149

https://lehmansbaseball.wordpress.com/2015/12/03/front-leg-strength-predicts-throwing-velocity-great-research/pitching-motion-forces/

legs

shoulder elbowwrist

Transfer of force

THE KINETIC CHAIN

• A complex, full body activity directed towards overhead throwing

• A set of sequential forces transferring motions that end with the act of throwing

• A continuous, fluid group of movements that begin with the lower extremities and core

• It provides support and build kinetic energy that is ultimately transferred through the throwing arm to the release of the object from the fingers

• There are other kinetic chains but we will only focus on this one today

• Chu, S. K., Jayabalan, P., Kibler, W. B., & Press, J. (2016). The Kinetic Chain Revisited: New Concepts on Throwing Mechanics and Injury. PM&R, 8(3), S69-S77.

• Edmonds, E. W., & Dengerink, D. D. (2014). Common conditions in the overhead athlete. American family physician, 89(7).

THE KINETIC CHAIN• In baseball, the chain begins with the

the plant foot which is contralateral to the throwing arm.

• The pitcher stands on the back leg, lifts the plant foot, creating potential energy

• The weight shifts to the plant foot producing kinetic energy in a linear momentum

• The instant the plant foot strikes the ground, all the linear momentum becomes rotational

• The power comes from leg drive and the torque of the hips and shoulders

THE KINETIC CHAIN

• Dysfunction anywhere along the chain can result in a catastrophic injury for the pitcher.

• Rotator cuff

• UCL (AKA: Tommy John lig) in the elbow

CASE• A 17-year old left-handed, male baseball pitcher presented to

the office with 2 weeks of decreasing pitch velocity

• Also noted increasing, aching, non-radiating, up to 6/10 left shoulder pain that began 1 week after slipping off the mound and noting LBP

• He stated that his right leg, his plant foot, slid forward and turned outward during the pitch and that his back pain began shortly thereafter.

• Assoc. sx include lack of “cut” on his slider

• Pain is worse with “breaking pitches”

• Decreased with the arm taped across his body in adduction and iced

HISTORIES

• Medical/surgical: none and specifically no prior injury to the shoulder; did note some “elbow difficulties” the year prior

• Sports/Work: Baseball, specifically pitcher

• Trauma History: negative

• Birth History: Full term non-induced vaginal delivery without instrumentation to a G1P1 mother.

• Allergies: No know food or drug allergies

• Medications: occasional ibuprofen (up to 600mg) for pain

PHYSICAL EXAM

• Vitals: 6’7” 195 lb. BP 128/78 P 60 R 18• Constitutional: AAOx 3; NAD; WDWN; physically

fit

• Neck: FROM; negative Spurling’s bilaterally; negative Lhermitte’s; negative cervical compression test (axial)

• Cardiac: RRR without M/R/T. +S1/S2 without S3 or S4

• Respiratory: CTA B/L no R/R/W

• Musculoskeletal: • Left scapula inferior, medial boarder was`

prominent; tenderness to palpation of the left coracoid process

• Full active and passive range of motion of the right shoulder, elbow and wrist

• Decreased left shoulder abduction (actively and passively) and flexion (actively and passively) due to pain

• Full active and passive range of motion of the left elbow and wrist.

• Full can, empty can, Hawkins, Neer’s, lift off, and O’Brien’s test were negative bilaterally

PHYSICAL EXAM

• Neurologic:• Reflexes 2/4 B/L all stations

• Strength was 5/5 bilaterally at shoulder flexors, extensors, internal rotators, external rotators, adductors and abductors except left shoulder abduction was 4+/5 due to pain.

• Strength was 5/5 at elbow flexors, extensors, pronators, supinators, wrist flexors, extensors and lumbricals, hip flexors, adductors, abductors, hamstrings, quadriceps, foot dorsiflexors and plantar flexors bilaterally.

• Gait:• Out toeing of right foot with mild external

rotation of the right lower extremity and decreased extension of the right lower extremity and left upper extremity with ambulation.

• Throwing motion observation:• Back pain reported with right leg lift, and right

leg drive and shoulder pain reported with arm cocking and mostly with maximum internal rotation during arm deceleration

OSTEOPATHIC STRUCTURAL EXAM

• Tight right plantar fascia with a dropped median cuneiform

• Tight right gastrocnemius and soleus• Tight right hamstrings• Outflare of the right innominate• Right on right sacral torsion• L3-5NSRRL • Tight linea alba• Very tight left latissimus• Tight paraspinal muscles from the sacrum through

the thorax

• T12FRSR

• Tight left rhomboid and trapezius with decreased scapular thoracic joint glide bilaterally left greater than right

• Tender points in the left supraspinatus, left infraspinatus and about the left coracoid process with mild internal rotation of the left humerus and left ulnar proximal adduction

• Elevated left 1st rib with ribs 3-5 on the left being inhaled

• C7 FRSR, C2FRSR• Mild left side bending rotation of the sphenobasilar

synchondrosis.

DIAGNOSIS

• Pain in left shoulder due to SICK Scapular syndrome (M25.512)

• Lumbago (M54.5)• Latissimus strain (S46.812A) (Strain of other

muscles, fascia and tendons of the left upper extremity)

• Somatic dysfunction of head (M99.00)• Somatic dysfunction of neck (M99.01)• Somatic dysfunction of thorax (M99.02)• Somatic dysfunction of lumbar (M99.03)• Somatic dysfunction of sacrum (M99.04)• Somatic dysfunction of pelvis (M99.05)• Somatic dysfunction of lower extremity (M99.06)• Somatic dysfunction of upper extremity (M99.07)• Somatic dysfunction of rib (M99.08)• Somatic dysfunction of abdomen (M99.09)

SICK SCAPULAR WHAT?

• SICK Scapular Syndrome is defined as scapular malposition, inferior medial border prominence, coracoid pain and malposition and dyskinetic motion of the scapula

• Burkhart, S. S., Morgan, C. D., & Kibler, W. B. (2003). The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy, 19(6), 641-661.

GREAT SO WHAT NOW?!?

From Sobotta 14th edition

Back to basics, you must go

THE SHOULDER-A JOINT FOR MOBILITY NOT STABILITY

• Glenohumeral joint

• Acromioclavicular joint

• Sternoclavicular joint

• Scapulothoracic pseudojoint

• 17 muscles directly attach to the scapula

• Multiple others influence its motion

From Sobotta 14th edition

LOTS OF ANATOMY! WHERE DO WE BEGIN?• You just learned from Dr. Stiles that treating the key

lesion is, well, key!

• Treat what you find!

• If you suspect a kinetic chain injury, find the initiating injurious event to the chain and treat that.

• It maybe all you have to do

• “Cause and effect are perpetual. Cause may not be as large in the beginning in some cases as in others, but time adds to the effect…”—Autobiography of AT Sill p202

• “Doing something to a problem is technique; working with the inherent mechanism within the problem is an application of principle, not a technique.”—Rollin Becker, DO (Life in Motion p246)

• We do not do anything to the patient, we simply open the door for the Health to do the work

REMEMBER OUR CASE

• The pitcher slipped off the mound and injured his foot

• In turn, this led to back pain

• And eventually to shoulder pain

• Where should we start?

RELEASE THE SHOCK

• All injuries cause shock to the system

• Remove the shock and restoring breath is key to any injury

GO TO THE INITIATING INJURY

• Our pitcher slipped off the mound

• The foot and ankle were treated with a modified version of the the technique to the left

ASCEND THROUGH THE KINETIC CHAIN TREATING WHAT YOU FIND

HE HAD A TERRIBLE LATISSIMUS DORSI SPASM

• This muscle attaches to the iliac crest, the obliques (esp external), the lower 3-4 ribs, the erector spinae esp about T12, T8, cross over the inferior angle of the scapula and attaches to the intertubercular groove of the humerus anterior to the teres major.

• It’s action is adduction, extension and medial rotation of the arm and shoulder.

• Treatment consist of balancing the entire muscle (at once or in parts). Remember that the lat has influence from the contralateral pelvis and sacrum due to its investment in the thoracodorsal fascia.

• This muscle connects the pelvis and sacrum to the arm!!!

TREAT THAT SHOULDER

WHEN IN DOUBT MAKE SOMETHING UP

THE COMBINED SHOULDER TECHNIQUE• The combined shoulder technique is divided into two distinct parts and can be used as such. The

“scapular wheel” will be described first and the muscle energy/LAS (MELAS) technique for the glenohumeral joint and rotator cuff second.

• Other than my previous fellows and rotating students and Dr. Crow, you are the first to be taught this

THE WHEEL IS TURNING AND IT CAN’T SLOW DOWN

• Indirect MFR to the anterior and posterior fascia and musculature of the shoulder

• Patient supine

• Physician seated

• Pressure is applied through the acromion to “steer” the scapula into its’ direction of ease while the caudad hand guides the scapular angle into the direction of ease. This position is held until a balance point is obtained and maintained until a release is felt.

MELAS (MUSCLE ENERGY WITH LAS)

• Set up:

• Patient supine with the physician seated on the affected side. The arm is abducted to 90 degrees with the elbow flexed. The patient’s elbow is placed into the abdomen (not chest) of the physician. The feather edge of the barrier of external rotation is obtained with the patient’s hand on the posterior deltoid of the physician. The balance point of the glenohumeral joint should be obtained before applying the muscle energy portion of the technique.

MELAS (MUSCLE ENERGY WITH LAS)

• Technique:

• While maintaining the balance point of the glenohumeral joint with the physician’s abdomen, the patient will internally rotate (throw) the affected arm against the physician’s deltoid. The physician resists for 3-5 seconds. This will be followed by a 2 second pause and then the arm will be repositioned to the next barrier’s feather edge. This will be repeated 3-5 times. Motion and pain will then be reassessed.

OUR PITCHER

• He returned to the clinic, for his 2 week follow up, pain free and more importantly to him, throwing harder than he had prior to treatment.

• He reported being pain free approximately 2 days after his treatment and also noted pain free “long toss” warm up sessions.

• He began throwing harder 4-days post OMT without discomfort and was up to his full velocity and back to throwing breaking pitches 3 days after that (1-week post OMT).

• He was treated again as some his prior dysfunction recurred and some new ones had arisen

• After his 2nd treatment, his pitching (left) shoulder had great ROM than his right.• This is typical of pitchers

WHAT DID WE LEARN?

• There is a lot of physics in OMT

• Patterns are common in professional athletes, performers, workers, medical students… and should never be overlooked but…

• Utilize principles and not techniques—TREAT THE WHOLE AND WHAT YOU FIND NOT JUST PATTERNS• FYI: there are complete PT practices to treating the kinetic chain in patterns and books dedicated to the kinetic

chain as a pattern

• Sometimes you have to create to get the job done

• “DIG ON”

THANKS FOR LISTENING AND DIG ON!

References• Are noted throughout the presentation• Karageanes, Steven J., ed. Principles of manual sports

medicine. Lippincott Williams & Wilkins, 2005.

• LAS images used with permission via William Thomas Crow, DO, FAAO from Speece CA, Crow WT & Simmons SL. Ligamentous articular strain: osteopathic manipulative techniques for the body. Revised edition. Seattle, WA: Eastland Press; 2009.

• Art images by Adam Trachtman• This case was part of my FAAO project and the complete

case should be published in the near future!

Questions• Please feel free to contact me at dave@arcanacenter.com• We are always happy to have you come rotate with us as

well!

mailto:dave@arcanacenter.com

An Osteopathic Approach to the kinetic chainObjectivesThe kinetic chainPullies and struts Slide Number 5Slide Number 6The kinetic chainThe kinetic chainThe kinetic chainCaseHistoriesPhysical examPhysical examOsteopathic structural examDiagnosisSICK Scapular What?Great so what now?!?The shoulder-a joint for mobility not stabilityLots of anatomy! where do we begin?Remember our caseRelease the shockGo to the initiating injury Ascend through the kinetic chain treating what you findHe had a terrible latissimus dorsi spasmTreat that shoulderWhen in doubt make something upThe wheel is turning and it can’t slow downMELAS (muscle energy with LAS)MELAS (muscle energy with LAS)Our pitcherWhat did we learn?Thanks for listening and Dig On!