Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Materi and we are Hand Therapy Academy.
josh MacDonald: We wanted to talk about ligaments today, kind of a giant topic, so we decided to keep it just to like TFCC and distal to that. We're not going to be exhaustive. That's not our format here, but let's talk a little bit about ligaments, kind of some of the implications and tensions and when things are moving and tight and all that. Let's talk about ligaments a little bit.
Miranda Materi: Yeah, so let's talk about ligaments. So first, what is a ligament, right? So we know it's a structure that connects two different bones together. We know that some ligaments have proprioceptive input fibers, um but we know that they're basically a static stabilizer for different structures. So not dynamic, but static.
josh MacDonald: them. They have very little elastin or no elastin in them. So there's there's the ability to to remodel and change with a stretch to them, but they're not going to have this stretch and respond reaction to them. So unlike muscles and and tendons, there's just way less elastin.
Miranda Materi: Yep. Less elastic for sure.
josh MacDonald: Yes.
Miranda Materi: Yeah.
josh MacDonald: So let's talk about TFCC. I feel like something that changed from when I started studying all of this to more recent is we have now not just an understanding of palmar and dorsal radial ulnar ligaments but now there's like a second set of them whose function or whose whose tension and slack is op opposite of what i'll call the outer um dorsal and palmar inner ligaments
Miranda Materi: yeah I think that's kind of how we started too, was just thinking more about as a peripheral structure, but then you have the deeper ones. So the first one is the volar proximal radial ulnar ligament. And we know that this one is tight when the wrist is in supination. So if you injure that ligament, you're going to want to sp split or splint it on a bit of slack, right? And then the...
Miranda Materi: The same is true for the opposite, for the dorsal radial ulnar ligament. That's tight in pronation, so you want to um splint them in a little bit of supination. But I think a lot of times we don't know, right?
Miranda Materi: Like how many times do you get a doctor telling you exactly what ligament or which ligament was injured?
josh MacDonald: Yeah.
Miranda Materi: Sometimes we kind of know, but a lot of times we don't. So then what do you do in those cases? And I'll let you answer that question.
josh MacDonald: Um, just a ah quick, um, revisit there. She was talking about those are the more superficial ligaments. Um, the deep ones are opposite. So the deep polymer and the deep, um, dorsal are the opposite tensions. Um, just to clarify that, um, honestly, if I have a patient come in with a general diagnosis of TFCC injury, and I know there's been ligament damage and I know there's, there's a need to split them in a position. I'll start with what their current tolerance is. And I feel like if I can get them into a position one direction or another, I, that's not just like locked in neutral. I try to gauge like, what's their response to like, if I go this way a little bit, putting such light tension on there, but finding their end point of where that ligament is, if they are sensitive to one direction or the other, I'm just working to stay away from that painful tight position and coming back the other direction. um Unless like everything hurts. And then I'm just going to go neutral to put everything on as little tension as possible.
Miranda Materi: Yeah, definitely. And a lot of times I think we don't we don't know because it's really hard to test. Is it just the superficial or is it a superficial and a deep one? and or And or is it both, right? And I think the only way to really know that is with usually if the doctor does an arthroscope or something and goes in and can differentiate those structures. And as part of our CHT prep group, we do have like a nice diagram showing the superficial and the deep ones, which I think is really helpful. But when you actually go in and look at the anatomy of a real wrist, it's just like all these like ligaments interplayed and laced together. Like it's very hard to go in and say, this is that one. And that's that one, right? Like you have to really tease it out. And there's a lot of other fashion, things like that around the ligaments that make it even harder to separate.
Miranda Materi: So I think you saying, you know, how you lead by examining them clinically is really what what we do and what we have to do and and what physicians do as well.
josh MacDonald: Yeah. I think about that, you know, when we're teaching students like here's this ligament and this ligament, when you're looking at a cadaver or in a surgery situation, it's just a mess of connective tissue, right? It's all this ligamentous structure. And it's, it's not like there's all these individual point A to point B lines everywhere. And so I think about like the volar and dorsal carpal ligaments, and you look at a diagram and, oh, there's a chevron pattern and there's the radioscafe ocapitate. Like, like, it's just a hot mess in there. And I think whoever has done the, the dive into all of the ligaments of the, like,
josh MacDonald: The first person who opened that up and paid attention to it must have just been like, i don't know, it's all one big giant structure.
Miranda Materi: Yeah, but then they really work to the linea, especially, i know we're not talking about the shoulder right now, but the shoulder ones, right? And they even say like when these are tight, when they're not.
josh MacDonald: Yeah.
Miranda Materi: But when you when you actually look at a cadaver, they all look like they're one conjoined ligament, even though they're
josh MacDonald: Yeah. Yeah. And so you can understand why a patient would have like an SL ligament injury. And like, well, how come it's tight way over here on the ulnar side of my wrist when my injury and my surgery was over here?
josh MacDonald: like It is all one big mess. And the I feel like the analogy of the the sweater where you pull on a thread of a sweater and the whole thing shifts like for fascia tissue really applies to these ligamentous structures around a joint.
josh MacDonald: It's all interconnected and you tug on one and it's going to have an impact all the way around the corner on the other side.
Miranda Materi: Right. It might tighten something and then loosen something else.
josh MacDonald: Yeah.
Miranda Materi: I think that's a great way to picture it and know that it's not dragged. It doesn't always make it tight, but it can make some stuff tight and some stuff loose.
josh MacDonald: Yeah. Yeah. And that can lead to symptoms that, that you could kind of chase your tail on trying to address like, well, why is this tight here? It's, it's tight or it's painful or it's loose or it's clicking or it's popping because there's dysfunction in this global system. And we're trying to stabilize, but add some mobility without the, without sacrificing stability or pain as a result.
Miranda Materi: Right. And then oftentimes I think as clinicians, we're always trying to pinpoint the main problem, right? So we're like, okay, we can pinpoint this, but really sometimes we don't know, right?
Miranda Materi: So like you said, we're just trying to stabilize things. And even the providers sometimes don't know, they'll say, well, go try therapy first and we'll see where you get with it. Right. And then we will maybe have to go back and do some further diagnostics.
josh MacDonald: Yeah.
Miranda Materi: But a lot of times the first line of treatment is therapy. Right.
josh MacDonald: Yeah. Yeah. And with the ligaments in particular, we're not just trying to prioritize stability over mobility, but we're also trying to make sure that we're giving that proprioceptive feedback. And I think that's huge in the whole risk treatment of like ulnar-sided wrist pain. There's a whole proprioceptive um trend in the treatment that we're doing now just to get those mechanoreceptors firing and saying like, hey, we can tighten all of this up and improve the healing capacity of ligaments and structures around the wrist specifically, but to other ligaments as well. If we work on
josh MacDonald: proprioceptive stuff and not just on range of motion and joint mobs and the the biomechanical stuff if we can go towards that sensory processing stuff.
Miranda Materi: Right. Definitely. And then I think there's times where it really does matter when we talk about like diagnostics and that would be like things with like an SL ligament tear, right? Like we know if you start doing a bunch of extension flexion of the wrist, you can make the condition much worse. Right. And you can cause, um, where there's more widening of the ah SL gap. So it's important to know. And if you don't know, then maybe like Josh was saying, you know, stick to some of those proprioceptive type things.
josh MacDonald: Yeah. Yeah. And, and the, the first rule rule of do no harm, like let's make sure we're not making things worse and saying like, well, I'm just going to do wrist flexion and extension and, and just keep pushing that. Cause that'll make it better. Right? Like we just want more range of motion. Dark throwers is a great functional place to go with things. And it puts very little differential movement on a cell ligament and some of those volar and carpal ligaments.
josh MacDonald: um That's a really great functional way to get patients a lot of mobility and head the right direction without risking doing damage to structures we may not know about. Yeah,
Miranda Materi: Right. And speaking of dart throwers, I think that's an easy one to start with. Like you said, a safe one to start with. And I think sometimes explaining to patients how to do dart throwers can be a little tricky. don't know if any of your patients have problems making that connection. So oftentimes, Tom, just practice picking up a cup and pretending like you're drinking out of it.
josh MacDonald: yeah yeah. I've seen therapists teach patients like hold a pen like you're going to write with it, elbow down and hand up and draw and and work that pen front to back. And that kind of simulates that same movement.
Miranda Materi: That's a good idea.
josh MacDonald: Lots of different options for teaching that. Some dynamic ball rolling where you're moving in that that dart throws plane of motion. Lots of different options there. I'll oftentimes have them do it with the unaffected side.
josh MacDonald: I'll do passive first and then we do active assist. Then we do active. i okay Now let's go to your injured side where the proprioception is poor to begin with. And then we'll start doing it with that side just so they understand what I'm even asking them to do.
Miranda Materi: Yeah.
josh MacDonald: Yeah.
Miranda Materi: Those are great pointers.
josh MacDonald: So lots of stuff to talk about with ligaments and it's hard to even like touch base on it. But I think from a global perspective, it's good to have some understanding of. We're protecting stability over mobility and how to get them moving in a safe way. So hopefully this answered some questions for you. If you have any other questions or any thoughts on this, feel free to reach out to us, info at handtherapyacademy.com, or you can reach us on social media, Hand Therapy Academy.
