Gain SUPINATION in Record Time
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[00:00:00] All right, I'm sharing. All right. Um, I hope you can see the screen a little bit. Um, that's how I want to look, but whatever. We're not going to worry about aesthetics right now. I got a question in and I wanted to share it with all of you. So it's a TFCC. repair. So there's a scar that comes down the side of the arm.
There's I saw like a scar, um, up on top, let's say, right. So, um, this person, like, so let's think about the symptoms, right? I, I told you the, the surgery. So that can give you an indication of the type of injury. It's a TFCC injury. Um, so if you think about, tfcc is what type of injury is that when you look at the framework, the fast track framework, it's a ligament issue, right?
That's the primary problem. But what it does is it creates different issues for the [00:01:00] joint and for the muscles and tendons. And when you have surgery, you now have scar and fascia issues that you have to be able to work through. Now, one thing that I would say is you can, you can think and look at the nature of the injury, right?
The tissue, um, TFCC surgery. Okay. What's the protocol? When can you start moving them? So, um, I don't know exactly this case, but this person is allowed to gain more and more emotion. So I'm guessing this is a minimum of six to eight weeks out, right? From a working forwards or backwards, you can, you can sort of take a very educated guess in terms of what that person is allowed to do.
Um, which then tells you how long, how long it's been like timeframe wise. So we look at that, then we look at like, what are the structures around there so we can get to treating because the symptoms are lack of supination and there's some popping. So why can't someone, [00:02:00] why can't someone get better supination?
When you take a look at the scar, you take a look at the, you know, take a look at all the structures, um, and then you have to combine them in order to be able to think through that process of what are, you know, why aren't they, um, so that not only do you know what to gain, like how to work with it, but why they're having the problems they're having so you can actually tell them in a very, um, You know constructive way like an understanding way, right?
So let's go to the structures your tfcc Is right here. And what it does is it allows what's the job you always think about what's the job of the tfcc? To, um, take impact of forces. The TFCC also helps to stabilize the DRUJ, right? If I'm remembering correctly, . So the TFCC and the DRUJ play a role together.
They don't work separately, but the DRUJ then [00:03:00] also allows you. supinate pronate, right? So from a joint perspective, sometimes they're just stiff, right? From a ligament perspective, they're also stiff because what happens with the TFCC, it's all ligament issues and the surgery, uh, stiffens them up. Right repairs, but also stiffens them up and then the process of therapy is to slowly loosen them in a Stabilized way, right?
so the fact that you're gaining motion slowly is actually a good thing because you don't want to be too fast and too aggressive and That will go against the whole point of the surgery Right. Um, and then you look at you look at muscles and tendons, right? So here's the kicker, right? So that's why knowing understanding your anatomy and the job of each of those structures Plays a role in helping you decide what to do next and that It's quite normal.
And then how do I continue to work for it? Right? So, [00:04:00] um, on the ulnar side you have the, the ECU, sorry, the FCU and then the ECU, right? So the ECU requires when you sting pronate that it sort of rotates a little bit. So every single time you hear that snap, you know, that popping, usually that popping is that tendon rolling over what maybe it shouldn't do, right?
So sometimes it could be too weak. Sometimes it could be, you know, the structures around it are too tight and it's causing it to not move as well. Um, and some of the times it's because of all the scarring. So if someone has a surgery, the scarring sort of limits how you're moving and moving as well. So if you have symptoms of, um, snap, crackle and pop, um, and then you also have [00:05:00] lack of motion, then, um, Then how do we gain some of that motion back?
So this is understand supination happens at two points. It happens at the elbow and happens at the wrist level, right? So you have to be in order to be able to supinate and pronate well, um, your muscles and tissue have to be to move well at the elbow in order for it to move better distally. So when someone can't move that well, sometimes controlling their elbow can help you get better motion more distally because where are your muscles coming from?
Your muscles are coming, you know, to move your wrists. and fingers into supinate and pronate. All those muscles also start up here at the elbow before they move down here, um, distally. And the ECU, the tricky thing about ECU actually functions better. It's a stronger [00:06:00] risk sensor. When the, forearm is in supination.
So because it's not working like it's supposed to work, it's going to give you problems. So how do we fix that? So, um, so two places here and here. So you start here because they're scarring. Don't think of the scars going up and down. Think of the scar as going across as well in all directions. So sometimes if I pull Because it's so tight to the scar.
If I pull it so that it's it releases some of the tension, can they move better? Or can they move with less pain? So if you can do that, if that reduces their symptoms, then you can need to do more of that. So don't think of just scarring up and down. Think about how can I, how can I move that skin and that scar?
You see how my skin is moving? [00:07:00] So you can move into ease versus restriction. So sometimes I'll take that and I'll just move the skin into one direction. which direction feels easier feels better for the patient if it's this way or if it's this way and then you just move 10 20 times and then you check in the other direction and see because every time you move you're moving it regardless of direction so why not move into ease versus like butting heads into pain right because pain causes them to guard more so that's one way now after that You know, that's manual techniques after that.
How can you promote more motion with it? So you can pinch them, you can hold them, you can, um, put a little bit of piece of kinesio tape on there. Like there's so many things that you could do with that essentially can help you start to think through like, what can I do to move the tissue? So that they can get better active range motion.
So sometimes you [00:08:00] do the more passive hands on stuff and then you get them to follow up with actively right here. The other part is that you can mobilize them here, their tissues here. So the radius is a floating bone. And so if you can mobilize or stabilize that. And can they move with less clicking and popping?
If you can, that's telling you that that muscle is not moving as well. And so then it just, it's okay that that's happening. So you can then tell your patient, it's okay that's happening. What we need to do is just actually get you a little bit stronger up here, like more proximally, so that we can gain more distally.
Right. If we start to work a little bit more at your elbow and at your shoulder to get those muscles a little stronger, you'll have more supination, more pronation with less clicking. Does that make sense? Let me know if that makes sense. Right. So then you can, [00:09:00] you can actually hold and squeeze. So sometimes you just hold and squeeze, uh, especially with TFCC people, they tend to be too loosey goosey, right?
And then you need to, to stabilize them. Sometimes you just need to work the tissue, like the muscles. right? Maybe they're a little tight so you can work the tissue to loosen them up. And then you make sure that you're working supination and pronation can't work without elbow flexion extension. So sometimes working that in supination with elbow flexion extension can be helpful.
Sometimes working in pronation can be really helpful too. Using a towel underneath, will you be able to see how much supination pronation they have? without compensating with their shoulder. Shoulders always going to compensate for supination and pronation. And then you would advance them based on what they're allowed to do.
If they start to allow to do more strengthening, you can actually move up that chain. But I wanted to share this because I [00:10:00] want you to be able to, to, Look at, um, one. I want you to look at the structure. So using the fast track framework as you're studying for the CHC, use a fast track framework to think about all your structures, right?
And then what you want to do is use the focus framework to then take you through the diagnosis. Right? Well, what's the structure? So general knowledge, what are the structure? What's the anatomy? What's the job of all these things? How do you evaluate them? So a lot of times we think about evaluating just on the first day, but every single time a person comes to you, you're reevaluating, you're evaluating, what are their problems?
What are their symptoms? You know, that way it's going to lead you to, um, their protocol, right? So I almost thought of protocol first. So I was like, cause that's going to guide my. Treatment and you gotta be able to take them through the treatment no matter what phase or [00:11:00] you know Where they are in their journey.
This is a six to eight week Person right, but what if that person came at two months? What if that person came at three months? What if that person is a year from now and still lacking motion? How would you treat it? You still have to be able to think they're okay. Well, what are what's wrong with the structures?
If the structures, um, you know, a year later are still not working correctly. You know, what could be wrong? Maybe the TFCC is fine, but the other structures around it are not working well. That's why you evaluate. Is it a joint issue? Is it, is it, you know, a muscle tendon issue? What's going on with the scar and fascia?
Now, the CHC exam won't necessarily have a ton of scar and fascia questions, but in terms of treatment, you have to understand that scar plays a role and how scars, you know, what's the job of, um, [00:12:00] Oh, this comes into wound care a little bit. And then, and then it goes into like, well, what happens once a wound closes, scar is developed.
And then what do you do? you know, what's the nature of the scar so that you can know how to treat it. So now you can manually mow bit, you can use, you know, taping, there's all sorts of methods to, um, to taking care of scar. But this is why you take the, the found foundational stuff, break it down. And then you have to take all these fundamental pieces and Combine that when you're treating, which is what happens on the exam to write.
So I hope this helps you to break down. Um, you know how to use those two frameworks for the different types of cases that you're currently treating, but then tie it to how you want to be studying in order to in order to be [00:13:00] able to hit all four domains. You gotta hit all four domains. That's a fast track framework that helps and reminds you to get to come back to how do I treat this?
Um, and then be able to think forward and backwards. So, you know, thinking forward is like, uh, you know, okay, I'm doing this treatment. Does it work? Does it not work? Why is it not working? Why does it work? All right. And then, and then working yourself backwards through, okay, this is a diagnosis. This is a surgery.
These are the structures. So you can, you want to be able to mentally go either way because this is happening to you live with patients, but this is going to happen on the exam. They're going to give you a snapshot of something, and then you're going to have to be able to critically think through it.
That's, You know, majority of the questions, the treatment domain is 32 percent of the total score when you break down that [00:14:00] exam. So, you know, starting to be able to think through it with your patients is, um, you It's I think some of the best ways to go about it and then, and then putting, you know, like adding in like those tidbits of knowledge that you have to learn and the anatomy and the kinematics and the surgery and what types of surgery, right?
So it always comes back to treatment. So I hope this video helps you to see how you want to use those two major frameworks to not only study, but help you through your cases. Thanks.
