Case of the Week 4-14-14: Cleared For Sport?
It never fails to amaze me, after being in practice for 16 years how incompetent others in our profession can be. On my birthday, I met some parents of a young and very talented gymnast at my daughter's gymnastics meet.
Her father mentioned she had fractured her forearm on the bars 4 weeks ago and just was "cleared" by her PT to return to practice and competition. I checked her elbow quickly, and said she did not have enough motion, but he said "It will come back in time." Fast forward to 1 month later at another meet where she almost had to be scratched due to elbow pain during tumbling. I again examined her elbow and forearm and found she was missing a good amount of both passive extension and flexion, plus both motions had pain at end range. I posted it on my facebook wall and got a good reaction!
The father even saw it because one of his friends follows my facebook page for this blog. He brought her to see me shortly afterward and I this is her short case write-up.
Subjective: Pt was practicing on the uneven bar, when she fell from the higher bar, landed face first, fracturing and dislocating her left proximal radius. She was immobilized for 3 weeks, then had a few sessions of PT. A recent x-ray and visit to her ortho cleared her for return to sport. According to the daughter, her grandmother, father and mother (I spoke to them all), she had between 2-5 visits of physical therapy that consisted of moist heat, and squeezing putty. She was then told, "I cannot do anything else for you, you're cleared to return to gymnastics." The patient currently c/o sharp pain in her left elbow joint with floor and beam events, greater than bar. (tumbling and compression > distraction). Her complaints have been worsening as she practices more.
- I don't know about you, but the LEAST anyone can do is look for asymmetry! Apparently her grip strength was up to par for that PT.
Cervical Motion: All FN
Shoulder Patterns: All FN
breakout - which should be done for shoulder patterns despite FN in the presence of UQ complaints
Shoulder IR on the left was DN, mod loss
elbow extension and flexion on the left were both DP, actively and passively with similar limitation
forearm supination was DN, mod loss on the left
MSR, MSF, MSE all FN - watching a gymnast do the multisegmental movement patterns makes you feel like a steel rod
SLS Left DN Right FN
Assessment: Signs and Sx consistent with left elbow movement dysfunction with accompanying shoulder and forearm loss of motion status post immobilization.
Visit 1: light IASTM and functional mobilization to the lateral upper arm pattern, anterior and posterior radial bony contours, plus light humeroradial distractions. This restore her elbow flexion to FP, and elbow extension to DP, but now to neutral. However, her right elbow had at least 25 degrees of hyperextension.
She was instructed on repeated forearm supination and elbow extension for HEP. She was instructed to tell her coaches she was seeing a new PT who recommended no tumbling for now.
Visit 2: Pt reports "soreness" from HEP for the first two days, but improved ROM and decreased pain overall. She now had about 5 degrees of hyperextension, which was still DP, but elbow flexion was now FN actively and passively, forearm supination was still DN, only mild improvement. We reviewed HEP, was performing repeated elbow extension correctly, not taking forearm to end range supination.
IASTM and mobilizations as above, and then her elbow extension was about 10 degrees, DN, no longer DP.
Some functional testing:
Pushups were previously painful at practice, now no longer painful, but deviates to the right after 3 reps and progressively becomes harder. Unable to perform a wall pushup without pain.
Visit 3: Less soreness between visits, still avoiding tumbling at practice but elbow feels 50% better overall. Pushups are now much improved. After Tx, which concentrated mostly on elbow motion as shoulder and forearm motion were now FN, wall pushups were now pain free, but very difficult. She was unable to do a pullup without moderate biceps pain.
After this visit, it was even more clear that her strength, ROM, and function were so asymmetrical, it's a wonder any PT and ortho with a brain could have cleared her to perform high level gymnastics. Homework was to keep up with elbow extensions, and start with floor and wall pushups for conditioning. She was going to use her father's universal to work on pullup strength at a pain free resistance until she can do body weight.
Visit 4: She was feeling much better but a older student was running in the hallway at school, barreled into her and struck her head. She was cleared again by the school nurse. Two days later, after having headaches, and dizziness, I followed up with her. Cervical ROM was still FN. Her convergence was WNL, but slow tracking revealed some beating nystagmus to the right when testing to the left. I tried a modification of the reaction time test, and she was unable to catch it bilaterally (I was using a ruler). However, I did not have a baseline. Considering she just may have had a concussion two days prior, I pulled her from that nights gymnastics practice to her father and grandmother's relief.
The good news is the her motion is about 80% returned in elbow extension and still DN, all motion motions are now FN. Previously a round-off (kind of cartwheel with feet together) was previously painful and we tested this quickly, and was completely pain free, but this increased her HA, so I stopped there. - I probably should not have tested that.
That's it so far, she's on vacation for 1 week so I instructed her to rest and she will continue with her strengthening and conditioning when she returns. I will update on her progress but with only a few weeks left until states, I am not sure she'll be getting the 9.9's she was earlier in the year. Still, she and her family are happy with her progress.
Keeping it Eclectic...