American College of Osteopathic Pediatricians

Robert Hostoffer, DO,FACOP, FAAP

edited by Eric Hegybeli, DO, FACOP

questionnaires by Michael Rowane, DO

Born in Virginia in 1828 The son of a Methodist minister and

physician. At an early age, Still decided to follow in

his father's footsteps as a physician. After studying medicine and serving an

apprenticeship under his father, Still became a licensed M.D. in the state of Missouri.

Completed additional coursework at the College of Physicians and Surgeons in Kansas City, Missouri [Early 1860's]

Union Army Surgeon during the Civil War.

After the Civil War and following the death of three of his children from spinal meningitis in 1864, Still concluded that the orthodox medical practices of his day were frequently ineffective, and sometimes harmful.

He devoted the next ten years of his life to studying the human body and finding better ways to treat disease.

Discovered Osteopathy in 1874

• His research and clinical observations led him to believe:

• The musculoskeletal system played a vital role in health and disease

• The body contained all of the elements needed to maintain health, if properly stimulated.

• By correcting problems in the body's structure, through osteopathic manipulative treatment, the body's ability to function and to heal itself could be greatly improved.

• Promoted the idea of preventive medicine

• Endorsed the philosophy that physicians should focus on treating the whole patient, rather than just the disease.

http://www.aacom.org/OM/history.html

An average competitive swimmer can complete between 6,000 yrads in a two hour session.

Approximately 20-40 miles per week. Approximately 1 million stroke cycles

per year.

Laxity vs. Instability Poor stroke mechanics Excessive fatigue Improper or excessive stretching Improper weight training Excessive use of kick boards

Laxity: normal; pain free ROM of a joint

Instability: Pathologic subluxation or dislocation resulting in pain or functional impairment.

Many swimmers have joint laxity Laxity may foster glenohumoral

instabilty leading to impingement

Excessive stress Fatique

Poor TechniqueIncreased Drag

Wringing out of supraspinatus Crossing Midline Flat Body Positioning

• Promote impingement• Hawkin’s Position

Dropped elbow• First sign of fatigue or pain• Minimizes time in impingement position

Breathe bilaterally• Increases body roll

Maitain high elbow during recovery• Lessens demand on scapular stabilization

musculature

Swimming promotes strengthening of the glenohumoral internal rotators and pectoral musculatures

Most swimmers excessively stretch the anterior capsule• Buddy stretches

Swimmers without pain

Swimmers with multidirectional instability or shoulder pain

A gentle warm up should replace pre-workout stretching

Minimize abduction and external rotation• Lat pulldowns, military press, shoulder

abduction Emphasize scapular retractors,

glenohumoral external rotators and core musculatures

Excessive use of board promotes impingment

Neer’s position

Stage I refers to those with edema and hemorrhage;

Stage II refers to those with fibrosis and tendinitis;

Stage III refers to those with tear of the rotator cuff, ruptured biceps or bone excrescence

3 phases• Acute• Recovery• Functional retraining

RICE NSAIDs Possible subacromial injections Avoiding impingment positions OMT A/AAROM Modalities

• Ultrasound• TENS

Restore normal AROM-OMT Restore strength and endurance to

shoulder stabilizing musculature and rotator cuff• High repetition of low weight or low

resistance elastic bands

Entrance Criteria• Normal Shoulder AROM• Rotator cuff strength at least 4/5• Normal and functional kinetic chain

Goals• Sports specific training• No muscle in isolation

Swim Bench• Isokinetic exercise

Return to pool with gradual increase in yardage/intensity

Plyometric exercises• Neuromuscular intergration• Very high force generation• Complementary muscle group coordination

and strengthening

Indications• Failure of conservative management• Paresthesias, dead arm• Significant instability• Difficulty with ADLs ( activity of daily living)

secondary to pain

Inferior Capsular Shift Anterior capsulolabral reconstruction Arthroscopic repair Thermal Capsular Shrinkage

Painful arc/rotator cuff pain in the shoulder of a swimmer can occur in any of the following movements:

1. Adduction of the arm at the shoulder 2. When this movement is blocked3. Flexion of the arm at the shoulder

4. When this movement to left or right is blocked.

The acromioclavicular joint may develop degenerative arthritic changes, particularly from damage in resistance weight training.

Arthritis of the glenohumeral joint may be seen in the masters age group, though it is rare in the young.

the alignment of the knee centre relative to the hip centre during the start of the breast-stroke kick affects the development in the medial collateral ligament and capsule. The optimum initiating position from the breast-stroke kick is with the hip and knee centres aligned. When the knee centre is narrow or wide of the hip centre, it causes increased stress on the medial collateral joint structures. Exceeding the elastic limits of the ligament will cause damage and injury. In young swimmers, this form of stress could open growth plates of the femur and tibia and cause micro-injury which will result in inflammation and thus seriously impair training.

There is a high risk of the patella riding laterally during the breast-stroke kick. This is magnified when the patella tendon attachment site at the tibial tubercle is placed in an extremely rotated position. Weakness of the vastus medialis can decrease effectiveness in ensuring central tracking of the patella. If dislocation occurs, surgery is almost certain.

Acromiolclavicular joint

Rotator Cuff Muscles:

•Supraspinatus

•Infrspinatus

•Teres Minor

•Subscapularis Biceps muscles Humerus

Subacromial impingement ( swimmers shoulder ) is a condition that affects the athlete's abililty during the catch phase, early to mid-pull, and through arm adduction in the recovery phase.  It is an inflammation of the supraspinatus located on the long head of the biceps tendon.  Most often it is a result of incorrect form and overuse.

Poor Stroke Technique : Improper stroke technique can result in joint and muscle imbalance.

Unilateral Breathing : Most swimmers are comfortable breathing in one direction, this results in muscle imbalance in swimmers.

Overuse : These are chronic injuries that occur because of repeated stress to the muscles, tendons and joints.

Step 1—extension with elbow flexed;

step 2—flexion with elbowextended;

step 3—compression circumduction;

step 4—circumductionwith traction with elbow extended;

step 5a—abductionwith internal rotation with elbow flexed;

Step 5b- adduction and external rotation

step 6—adduction and internal rotation with upper extremity behind the back;

step 7—stretching tissues and pumping fluids with the arm extended

1) Put both arms overhead in the streamlined position, then lean first to the left side as far as possible, then to the right.

2) Put both arms behind your back, fingers interlaced, and slowly, steadily raise your arms upward behind you as far as possible.

3) Put one arm across your body so that the shoulder is under your chin and hand, forearm and upper arm are parallel to the ground. Without turning your body, use your other hand to pull the arm close as close to your chest as possible.

Innervation TableInnervation TableOrgan/System Parasympathetic Sympathetic Ant.

Chapman'sPost.

Chapman's

EENT Cr Nerves (III, VII, IX, X)

T1-T4 T1-4, 2nd ICS

Suboccipital

Heart Vagus (CN X) T1-T4 T1-4 on L, T2-3

T3 sp process

Respiratory Vagus (CN X) T2-T7 3rd & 4th ICS T3-5 sp process

Esophagus Vagus (CN X) T2-T8 --- ---

Foregut Vagus (CN X) T5-T9 (Greater Splanchnic) --- ---

Stomach Vagus (CN X) T5-T9 (Greater Splanchnic) 5th-6th ICS on L

T6-7 on L

Liver Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 5 on R T5-6

Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 6 on R T6

Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 7 on L T7

Pancreas Vagus (CN X) T5-T9 (Greater Splanchnic), T9-T12 (Lesser Splanchnic)

Rib 7 on R T7

Midgut Vagus (CN X) Thoracic Splanchnics (Lesser)

--- ---

Small Intestine Vagus (CN X) T9-T11 (Lesser Splanchnic) Ribs 9-11 T8-10

Appendix    T12 Tip of 12th Rib

T11-12 on R

Hindgut Pelvic Splanchnics (S2-4)

Lumbar (Least) Splanchnics --- ---

Ascending Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) R Femur @ hip

T10-11

Transverse Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) Near Knees ---

Descending Colon Pelvic Splanchnic (S2-4)

Least Splanchnic L Femur @ hip

T12-L2

Colon & Rectum Pelvic Splanchnics (S2-4)

T8-L2 --- ---

Question1: A, B, C, D, E. Question2: A, B, C, D, E. Question3: A, B, C, D, E.

Swimmer’s shoulder is due to• A. Subluxation of shoulder posterior• B. Subluxation of shoulder anterior• C. Subacromial impingement • D. Rotator cuff sprain• E. Scapular imposition

Swimmer shoulder injury is due to:• A. Poor technique• B. Unilateral Breathing• C. Overuse• D. Catchman’s triangle misalignment• E. A, B, C.

A 12 year old boy presents to your office with a throbbing shoulder with pain increasing with movement. He has swum competitively since six years of age. There is no history of trauma. You feel he has subacromial impingement. Your osteopathic therapeutic option would be:• A. Galbreath maneuver• B. Spencer’s Technique• C. First Rib manipulation• D. Thoracic HVLA• E. OA HVLA

I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__

Signatures: Pediatric Resident ____________________ Pediatric Residency

Director____________

( Please print and give to program director.)