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SLAP ?
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SLAP ? - January 26, 2007 3:59:00 PM
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valawee3
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I am currently treating a athlete that was referred to me 6 months s/p SLAP repair. Pt's only current complaint is pain over the coracoid process in left shoulder. Follow up MRI was completed - results negative. I though originally this was muscular in nature and would be treated and relieved successfully. However, at this time nothing at all seems to be relieving the pain(conservative treatment for muscle strain)...any ideas? Why pain only over coracoid?
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Re: SLAP ? - January 27, 2007 5:45:00 AM
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PTupdate.com
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What causes the pain over the coracoid? Is it constant, or with A/PROM, or even resisted ROM? Is palpation to the area capable of reproducing the pain, or is it just painful (may be the same on the opposite shoulder)
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: SLAP ? - January 27, 2007 8:06:00 AM
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dfjpt
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The musculocutaneous nerve (branch of the median) pokes up and out through coracobrachialis. Might be a tunnel syndrome of one of its twigs.
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Re: SLAP ? - January 27, 2007 10:19:00 AM
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valawee3
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Pain seems to be constant. Aggrivated slightly with activity. Palpation is capable of reproducing the pain, however in a much stronger manner.
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Re: SLAP ? - January 30, 2007 2:07:00 AM
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Shill
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You may want to get an operative report, to see whether they have redesigned anything that attaches to the coracoid. Sometimes, they fail to mention this stuff.
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Re: SLAP ? - January 30, 2007 1:09:00 PM
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Marc Bronson
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From: Toronto
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Try some manual muscle testing to see which one (if any) brings out the pain (more so than others...)
MMT
Coracobrachialis
Pec Minor
Biceps (Short Head)
Make sure it's not the subclavius Trp acting up as well, since that's in the viscinity. Since you mentioned SLAP, which is long head biceps, I would clinically guess that a short head biceps tendonopathy would fit the bill as it would likely have to compensate for the injury/inactive period of the long head which was peeled off during the accident...
Interesting case!
M.
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BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: SLAP ? - January 30, 2007 4:32:00 PM
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jlharris
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Ok, I know I'm relatively inexperienced, but how does one isolate the coracobrachialis, pec minor or short head of the biceps to do MMT??
I've always just consider Shoulder flex, horizontal adduction w/o specifying the muscle.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: SLAP ? - January 31, 2007 2:47:00 PM
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Marc Bronson
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From: Toronto
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Jason,
Although MMT can never be completely specific in picking out only 1 muscle as there would likely always be some degree of co-contraction, you can try to isolate muscles a bit more by putting synergists in positions of physiological insuffienciency.
I use standardized protocols from Kendall et al. which I find brilliant. IMHO, any manual/movement therapist should be aware of this resource as at the very least it helps out with palpation skills...
http://www.lww.com/product/?978-0-7817-4780-6
So, onto the show! All tests performed bilaterally, of course!
Short head biceps:
Essentially Yergasons Test, shoulder 0 degrees flexion, elbow 90 degrees flexion, resist further flexion and supination. You can palpate the short head biceps and find your way up to the tendon at the coracoid. I use repetitive testing (5-10 reps) to make sure some latent weakness/inhibition doesn't slip by me.
Coracobrachialis
Shoulder flexion 90 degree, elbow maximally flexed with forearm supination so the palmar surface of the hand is touch the anterior deltoid/AC part of the shoulder. This puts the biceps in an insuffiency position. From there, you are trying to pull the from the olecranon inferiorly and laterally (on an angle rougly equal to the attachment of the coracobrachialis).
Pec Minor
Supine. Patient keeps straight arm and slighltly horizontally adducts it so the palm is facing the opposite hip. Anteriorly tip the shoulder so the scapula is no longer resting flat on the table. Practioner tries to pull the arm from the wrist while pushing posteriorly on the G-H joint.
Also, check the antagonist muscles of and see if they are short/tight and faciliated. These functionally reciprocal arrangements are important to the global functioning of the shoulder. Clinically I've found serratus anterior and the long thoracic nerve to be dysfunction/inhibition to be prevalent in many shoulder conditions so I would screen that one as well.
Fubol, are there any issues with the other scapular joints (scapulothoracic, A/C, S/C?).
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: SLAP ? - February 1, 2007 2:01:00 AM
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jlharris
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Excellent, thank you. I actually have the text. I assume it was the focus of my PT education that didn't put a lot of emphasis on the need to isolate specific mm for MMT. Especially mm that have the same MOA.
It's my approach to start simple and get more complex as needed. I'm sure many of us are that way. For example, MMT elbow flexion and find weakness vs. the contralateral side. If it's significant in their functional limitations, strengthen using resisted elbow flexion. This is, obviously ignoring neurologic injuries or obvious mm disruptions. Then, if needed d/t lack of expected progress, I would get more specific on which elbow flexor was the real culprit.
It's my opinion that 90+% of pt's will do just fine this way and the extra MMT specification would be an inefficient use of time and, often, excessive information that doesn't help in the POC.
Take that with a grain of salt. As I'm early in my career, my practice will (hopefully) change and evolve. Maybe it will begin to include ART and MMT that does a better job of isolating specific muscles. :)
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Jason L. Harris, PT, DPT
My PT Blog
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Re: SLAP ? - February 1, 2007 2:59:00 AM
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Marc Bronson
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From: Toronto
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Jason,
I'm early into my career as well (first 6 months!) so I'm always flexible re: my approach as long as there is preferably some research for it or there is good construct validity in the theory/test.
In terms of time, it takes me about 2-5 min to screen the shoulder/elbow using MMT, so it doesn't take an excessive amount of time which is which I tend to incorporate it. I also use the results as an outcome measure as well especially with diagnoses of functional/dynamic instability.
Regarding the ART and MMT, I take it with a grain of salt as well, as it purports to be more specific but I'm cognizant that there's been no verifiable studies to prove it's specificity. Still, I found it great in terms of palpation and a good review of the muscles, nerves and tunnel syndromes that can crop up.
Cheers,
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: SLAP ? - February 1, 2007 4:24:00 AM
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proud
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Okay, Just for more clinical fun..
Does this individual have scapular dyskinesis?
If so, how about the conoid and trapezoid ligs as a source of irritation? You can( apparently) stress these.
Conoid: Pt side lying pull inferior border of scapula away from thoracic spine.
Trapezoid: Pt side lying and pull medial border away from thoracic spine.
I also like dfjpt's thought process.
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