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Pectoral explosion
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Pectoral explosion - April 4, 2008 10:51:37 AM
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PTupdate.com
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Conferred with an ortho last night, as he was introducing me to someone I get to treat soon. Very avid bodybuilder, which we thought was going to be a pec tear....off the humerus as usual. I was fortunate and happy that this would be my second pec repair in 1 year.....something most PT's won't even get in a lifetime.
But, the meeting was to inform me and the patient that the pec tore mid muscle. He indicated it looked like someone took a big rump roast, cut it in half, and then used an M-80 to blow up the two ends.
He had to use suture runs along the length of the tear, then pull those two suture runs together in order to not cut thru and/or strangulate the muscular ends. Patient is in IR immobilization, and now we have to put our heads together to develop a rehab routine that will prevent all the crap that can occur with such an injury (frozen shoulder, severe scarring, inability to contract muscle effectively, re-rupture or re-tear, etc) and perhaps even get this guy back to some form of lifting as well.
Thoughts?
I am looking into a bone stimulator, as a very educated PCP was in for treatment last night, and felt that perhaps that could afford the same tissue benefits as it does bone
I will look into GAKIC, as that was moved into the exercise community after use during muscle traumas.
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Pectoral explosion - April 4, 2008 12:40:44 PM
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Shill
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From: Madison WI USA
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....and what is GAKIC John? I hope you arent referring to Giraffe Assisted Kinetic Isometric Contractions. Those giraffes charge a fortune! But seriously, what is it?
What about a shoulder CPM? I cant say Im familiar enough with these, if they exist, to know of one could be set up in a way that would help and not harm.
< Message edited by Shill -- April 4, 2008 12:45:24 PM >
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Steve Hill PT
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RE: Pectoral explosion - April 4, 2008 2:11:34 PM
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PTupdate.com
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Steve: It stands for Glycine L-Arginine Alpha Ketoisocaproic Acid.....I did a few articles on PTupdate...you're a member, so just scan thru the Archives
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Pectoral explosion - April 4, 2008 2:11:57 PM
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PTupdate.com
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And, one can read on www.gakic.com
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Pectoral explosion - April 4, 2008 7:26:39 PM
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mwells144
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what a case...i am a little jealous, better than your typical TKA. Seems to me your first focus would be on preventing scar tissue (with scar mobs) along incison site while mobilizing the joint to prevent it from getting frozen. This guy is going to be hurting with his passive movements and I would forget about myofascial lengthening and focus on the glenohumeral joint first. Why are you worried about the strength? Unless the neural system was disrupted wouldn't you expect functional return after A LONG rehab? He may not be throwing up the big weights anytime soon but I would think returning to weight training wouldn't be out of the question...then again you never know until you actually SEE the patient. Best of luck keep us updated?
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RE: Pectoral explosion - April 5, 2008 12:17:46 AM
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bonez
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Would there be any benefit to some form of ecswt stimulation to the myo tendonous structures to help with the disuse atrophy?
In his first text Levitt used an assisted and or self done supported L.A.E. type traction to affect the inferior region of the capsule. His goal was to limit the capsular adhesions in the inferior folds.
It likely could be modified to keep the internal rotation as long as the neurovascular bundle was protected. I have found it to be handy to keep gains made in adhesive capsulitis mobility treatment.
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RE: Pectoral explosion - April 5, 2008 8:04:54 AM
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SJBird55
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From: Michigan
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I hate responding to specific patient situations because I can't visualize crap and I really use my eyes a lot every day. I can picture the injury, yes.... in my head, I would wonder about the healing position of that structure. To me, a sling putting him in internal rotation just doesn't seem right in my head and I can't actually verbalize why. My head tells me that his thumb in a back jean pocket might be a better position for the pectoralis structure. My head is known to be wrong, but that's my first gut thought.
A few what if questions... What if the patient could wear something like a figure 8 clavicular brace to assist with keeping the involved shoulder from falling forward like we see with folks with tight pectoral muscles? What if initially as the pectoral muscle is healing, the patient lies on a rolled up towel under the thoracic spine to keep the spine mobile and provide gentle stretching to the anterior chest wall? What if the patient were to lie supine on a big ball - initially with the shoulder protected, but slowly increasing the stretch by altering the shoulder position? How tight was the pec sewed up? Could these things begin like at week 2?
If he was a bodybuilder, the other aspect I'd be concerned about would be heterotopic ossifications. Again... I haven't read anything about that, but I'm betting he's got a large bulk of tissue compared to me. LOL
If the surgeon could get most of the tissues lined up and the trauma that occurred is really recent, then I'd tend to believe the structure will heal. Will altering the environment of the tissues speed recovery? I tend to believe we heal and in my mind, it just makes us feel better mentally when we add nutrition or supplements or whatever, but statistically do the tissues really heal faster? I tend to think probably not.
You're not going to know anything about the ability for that muscle to contract for quite a while, in my opinion. I think the biggest thing right now is to allow it to heal in a position that allows movement.
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RE: Pectoral explosion - April 8, 2008 12:01:32 PM
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PTupdate.com
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One of my site members emailed me a good article from the North American Journal of Sports PT from Manske on the standard tendon-bone tear, and I look forward to reading that.
mwells: Yes, I do plan on doing some manual work at incision site, and where the tear is as well. I worry about the strength, and length, as a complete transection of a muscle is going to change the overall contractile properties....each half may or may not be able to contract, depeding on motor unit attachment sites, etc. I think it's going to change the ability of the whole muscle to shorten during contraction, instead leaving a few half muscle mediocre contractions.
bonez: Not sure about the Levitt idea that you noted....you may have to elaborate more.
I'll speak to the surgeon today about ossification, and during follow ups perhaps he can radiograph and see if any develops, I could always use acetic acid iontophoresis on that.
I've tried using my own hand on my pec while I go through ROM to see where I start to notice motion/stretch, and may work on this guy's GH joint in the same manner. I think using the works of Woo et al may indicate some stress needs to occur across the tissue to facilitate stronger and more aligned scar tissue. I am hoping that he can do isolated pec contractions, as just those alone may help (not everybody can do that, but I can even make my pecs.....man boobs as my staff calls them....dance to the rhythm of a song. A humerous parlor trick)
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Pectoral explosion - April 8, 2008 2:21:26 PM
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bonez
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The technique(it's old) involves placing the patient's axilla over the therapist's shoulder.(patient is often standing while therapist sits on a high stool) The arm is then grasped at the elbow and lite traction is delivered in a long axis direction. The sustained traction is resisted isometrically at the usual relaxation/expiration phase the traction is slowly lengthened. Several cycles can be repeated and different amounts of internal or external rotation can be applied.
Done correctly you should not generate much force on the pec structures.
I put it out for your consideration.
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RE: Pectoral explosion - April 8, 2008 9:25:15 PM
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PainFree
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