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Carpal Friendly and Unfriendly Movers
1.5k Plays2 years ago
Josh and Miranda discuss what muscles contribute to carpal friendly movements and unfriendly movements based on the type of instability pattern of the wrist.
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Transcript
Introduction to Carpal Kinematics
00:00:05
Speaker
Hi guys, I'm Josh and I'm Miranda and we are going to be talking about carpal kinematics today and we're going to be specifically talking about what are friendly movers and unfriendly movers based on the type of injury and this kind of piggybacks off the previous one we did about BC and DC.
00:00:26
Speaker
Josh is definitely the more analytical one. And so he does a much better job at describing these and I'll jump in as needed. So why don't you hit it, Josh? All right. So it's
Wrist Movement Mechanics
00:00:38
Speaker
a little bit of a complicated subject and I'm a visual learner and teacher, but we're on an audio only platform. So let's see if we can cover this.
00:00:46
Speaker
The scaphoid and triquetra move opposite in this helical movement, right? And so they move opposite each other. The scaphoid moves into flexion and what we call pronation. And the triquetra moves into extension and that wrist pronation. And then when we get wrist extension,
00:01:06
Speaker
The scaphoid moves into extension and more towards supination, not necessarily rolling the forearm into supination, but it shows its volar surface and presents that more. That's what we're referring to as supination. So in this conversation, when we say supination, pronation, it's the plane of movement that the scaphoid is doing, not the reflective movement of the forearm. So we're talking about different concepts here.
00:01:31
Speaker
When we talk
Tendon and Ligament Interactions
00:01:32
Speaker
about tendons, external structures that help stabilize the wrist, some of them encourage the scafolunate ligament to be a little bit more taught and held together. And some of them encourage the lunotracuetral ligament to be taught and held together. And so we're gonna talk about which ones are friendly to the SL and which ones are friendly to the LT. So the SL friendly tendon, musculotendinous units are the ECRL, ECRB,
00:02:01
Speaker
the abductor pollicis longus, and the flexor carpi ulnaris. And so think
Muscle Groups and Ligament Friendliness
00:02:06
Speaker
about what those muscles do. They pull the wrist on the radial side into extension and a little bit of radial deviation.
00:02:14
Speaker
And then the FCU pulls that wrist into flexion. And because of its line of pull, has a little bit of an oblique pull and pulls it into a rotation that looks like it's a little bit of supination. And so those muscles, when grouped together, help to approximate the scaphoid up against the lunate. Those are friendly to the SL, but they are unfriendly the LT. So the same is true of the LT if I have
00:02:41
Speaker
the ECU, that muscle pulls the muscle tendency unit, pulls the wrist into extension and ulnar deviation. And the FCR has a tendency to be a little bit of also LT friendly because it pulls the wrist into flexion and a little bit of that rotational movement obliquely into pronation. Now the FCR, because of its pull around the skateboard, the second half of the movement is a little bit less LT friendly, but the
00:03:11
Speaker
FCR and ECU are LT friendly and SL unfriendly. The ECRL, ECRB, APL, and FCU are SL friendly and LT unfriendly. Lots of stuff there. We've got charts for this stuff, but just to give you the audio version of it, that's the friendly and unfriendlies. Just to recap, SL friendly is ECRL, ECRB, APL, APB.
00:03:40
Speaker
and FCU. And then sometimes FCR is a carpal friendly, but it's only for partial SL injuries. Yeah, it's not the same. It's not the same universal truth with that one. That one has some variation to it. And I think that one, you know, there's different publications showing different things. So I think the FCR is a little debatable for being an SL friendly. I think there's some studies showing it is and some that isn't. So I would do that one with caution and
00:04:08
Speaker
Maybe if only it was a minor or partial tear. And so
Proprioceptive Feedback in Injury Treatment
00:04:13
Speaker
what do you mean when you say we would work with that one? What does it look like to treat someone with an LT or an SL and think, OK, I know these muscles and I can see a list or whatever. These are friendly and unfriendly. What does it mean to actually do those, do something with those? Yeah, so I think at least in my clinic, I'll start by doing isometrics. I feel like those are easier for people to grasp than some of the more dynamic movements like dart throwers.
00:04:37
Speaker
So we'll start with doing some isometrics. I showed them how to do it using their other hand or maybe up against a wall. And then maybe doing a little bit of axial loading through the front where they're pushing lightly into something. But also with that one, I think you have to be careful engaging their pain level because we don't want to stress with the SL with too much loading. It's just more for getting some proprioceptive input.
00:05:03
Speaker
So doing isometrics, if you're gonna do dart throwers, making sure that the patient knows how to do it correctly. So there are dart thrower splints you can make, but I think those are overly complicated and sometimes hard for patients to use. So when I'm showing them the dart throwers, I might just tell them, hey, pick up this light object or cup off of the table. I don't say like a coffee cup, but maybe like a plastic one. So they're getting that movement into a dart thrower's type plane.
00:05:32
Speaker
So those are kind of the, I think, gold standard for SL injuries. And then if I'm going to do FCR, it would be with isometrics. And then that's just based on, and usually I don't do that one, but I'm not against it, I guess what I say. So if I see like another therapist was doing it, I would say, okay, that makes sense. There is some evidence supporting using it.
00:05:57
Speaker
Yeah, and in an area of the body, the wrist can be so unstable and unpredictable, it's easier to stick with the things that we know are a little bit more certain and sure. So sticking with the ECU on an LT injury, it's an easier, simpler way to go.
00:06:13
Speaker
It's less about range of motion and more about stability. Lots of
Stability vs Mobility in Hypermobility Treatment
00:06:16
Speaker
proprioceptive input, lots of stabilizing stuff, isometrics, that's all really effective. But yeah, doing the FCR certainly supported by the literature as sometimes good, but because there's an as an if factor in there, I'd stick with the ECU for sure. Yeah, and you're saying ECU for LT.
00:06:33
Speaker
Yes. Yes. And not, you definitely don't do ECU for SL injuries. So correct. Right. Right. Just to recap that. And then what about when you have mid-carpal instability? So I think in our clinics, Josh and I see a lot of hypermobility disorders. So sometimes these patients will have mid-carpal instability. And what type of exercises are you doing for that? Or what, what muscles are friendly for mid-carpal instability?
00:07:00
Speaker
So for those patients, because they're so mobile, I tell them we're not working range of motion. We're not working strength. I'm working to tighten everything up and get things as stable as possible. So that's when I really rely on the research that's showing that lots of static or isometric proprioceptive hold and static dynamic stability. So I'll do like, you know, maybe I'll pull out the power web or teach them how to do it into a pillow where they're doing some axial loading, all with intolerance, all very light load, just to get that,
00:07:29
Speaker
a little bit of compression, but it's like standing on one foot, your ankle is super active, but it's not really going anywhere. And so I try to get them to do those kinds of activities, static holds, axial, and those kinds of things to be a little bit less dynamic on a joint that has too much movement in those cases. Right. And I think with risks, you know, we always tell patients, we want you to have a strong, stable, pain-free risk, not this like really mobile, loose risk, because we know that leads to problems, instability patterns, pain,
00:07:58
Speaker
long term. So with a lot of the risk stuff, I, you know, I'm a big fan of airing more on the side of stability over mobility. Yes. Yeah. Yeah. For sure. Um, stretching the wrist is something we need to do with precaution to make sure we're not just kind of plowing through one of these ligament injuries for sure. Right. And of course that's different with like a distal radius fracture. Um, but
00:08:20
Speaker
definitely with some of the carpal instability patterns. We don't want to do a lot of aggressive manual therapy with these patients. And real quick,
Dart Thrower Splints vs Wrist Support
00:08:28
Speaker
Miranda did mention a dart thrower splint. That's something that's kind of in our wheelhouse. We're certainly able to do. I tend to go away from it. It's a very complicated splint to make and explain to the patient. And you never truly know if you got the exact arc of motion. I'm a fan of make a standard wrist support and then teach them all the exercises outside of it that they can come out of and do on the regular.
00:08:46
Speaker
It just is less chance for error on our side when we're fabricating a splint in a unique plane of motion. Right. Okay. So I
Contact Information for Josh and Miranda
00:08:53
Speaker
think that caps are carpal kinematics talk for more information. You can email us at info at hand therapy academy.com or you can look us up at www.handtherapyacademy.com. See you guys. See you.