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00:00:01
CMC Developments
928 Plays2 years ago
Josh and Miranda talk about the CMC joint and how it gets its stability.
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Transcript
Valuable Conference Insights
00:00:05
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. One of my favorite things about coming back from a conference is all the little tidbits of information you learn. And if you're paying attention during lectures and not kind of nodding off a little bit, you can get some really interesting things. Some of them will change how you practice, and some of them just kind of raise your awareness to a new topic that you want to keep on your radar moving forwards. Yeah, definitely. And I've just noticed a change in you as well. You're so refreshed and energetic.
00:00:36
Speaker
Not that you're not always, but it's just, I don't know. You can just tell. It's a nice refresher, I feel like.
Challenging Thumb Stability Wisdom
00:00:42
Speaker
It is. It's good to come back from a course and kind of like have a renewed interest in things going on. So some of the things I learned at this one are specific to the thumb joint and how we perceive how it moves and all of that.
00:00:56
Speaker
Yeah, and Josh, I know you were telling me a little bit about it before this call and some of it seems almost unbelievable. It's kind of like debunking things we've known our whole career, right? So why don't you start by telling some of the things you told me that I think are quite fascinating.
00:01:13
Speaker
Yeah, the first one that really stood out to me was in one of the group lectures. Everyone gets together, and we're all supposed to be in the same lecture hall, and they had a surgeon from Spain. I would butcher her name, so I'm not going to try. But you can look her up on the ASHD website. She did a fantastic job. She talked about a cadaver study that she did. And in this cadaver study, they ruptured the AOL, the anterior oblique ligament.
00:01:38
Speaker
And when they did that, there was no dorsal radial subluxation of the metacarpal off of the trapezium. There was no dorsal radial CMC subluxation. They said that they found that there are no mechanoreceptors within the anterior oblique ligament. That that and the only collateral ligament have little to no mechanoreceptors in them.
00:02:01
Speaker
As opposed to the posterior oblique ligament and the radial collateral ligament, those two are very densely populated with mechanoreceptors. And when they ruptured those, you did have significant dorsal radial subluxation, which is exact opposite of everything we've learned to this point that the AOL is the crux. It is the biggest role player in CMC stability.
Impact of New Findings on Clinical Practices
00:02:28
Speaker
It, this isn't about, um, opponents, policies or aperture policies, brevis or any of those and those dynamic stabilizers about the static stabilizers. And they said that AOL and owner collateral are not the primary role players that we thought, well, what do we do with this information? Right? Because that changes everything.
00:02:47
Speaker
Right, or is it enough information to debunk everything else we've learned, right? Because we've always learned, like you said, the AOL ligament is so important for CMC stability, right? That's like the most important one. It's written in textbooks. It's written in journal articles. So does this one article debunk that information? Are you ready to say that?
00:03:11
Speaker
No, I'm not ready to say that. I want to see more things that duplicate that study with cadavers. I want to see more because that may have been just a handful and they were quirks. There may have been a methodology that was wrong when they were
00:03:27
Speaker
supporting that cadaver hand in this device and testing things may have been a weird line of pull on something. So I want to see studies that duplicate that effort. I want to see other things that support that. But that puts it on my radar to say, hey, wait a minute, maybe I need to second think all of this stuff. And I don't think it changes what I do in treatment.
00:03:46
Speaker
If this is, in fact, counterintuitive and it is valid and it stands the test of time and other research, then I don't know that it changes what I do in my practice, what I do to stabilize that joint, as much as it changes how I think about it and how I would talk about it to other people. Right now, as kind of a, I don't know what to say, I'll talk about loose ligaments and instability causes subluxation of the joint, but the patient doesn't need to know if it's AOL or POL.
00:04:15
Speaker
but I'm going to kind of reserve, I'm not going to change everything yet until I know more.
Exam Preparation and Content Updates
00:04:19
Speaker
Right. And I guess for the purpose of this, if you're doing proprioceptive exercises for the thumb, it's going to do the whole thumb capsule, right? So it doesn't necessarily change that specific proprioceptive exercise.
00:04:35
Speaker
Correct. I think it means more to surgeons who are trying to do reconstructive work, trying to reduce an instability. I think it's more for them, but it certainly is important for us to understand and say like, okay, well, let's, let's follow that article, see where else it's referenced moving forwards to see if people are debunking that article or corroborating it. Right. That's very interesting. So say you had, okay, so Josh and I get lots of questions from members, right? So this is maybe someone that's getting ready to take the CHT exam.
00:05:05
Speaker
And they ask you a question. They say, hey, the exam is going to be, um, it's coming up. I was wondering since maybe the anterior oblique ligament is not as important for CMC civility. Um, or if that was a multiple choice question, what would you put or how would you answer that? Yeah. There's a reason why we tell students studying for the CHC exam to go based off of rehab at the hand and not the most recent journal articles, because the test was written in the past.
00:05:34
Speaker
and it's not updated every time a new article comes out. So go with what is the standard current known gold standard of information, not what's new and fresh in the last journal article that came out. So I would say still answer AOL, knowing that there may be something that flips that on its head, but then it's up to the HTCC people. If we flip that entirely, it's up to them to update it and they should let people know. Right.
00:06:01
Speaker
And so I think one thing is that we've talked about too, and Josh, you have a little bit more experiences with this, and maybe we're getting too far off topic, but if they can write in stuff, right? So you could write something in on the test to say that, but it doesn't necessarily change that test question, it just might change it in the future.
00:06:20
Speaker
Yeah, I said it on the HTCC two-hour thing where they talk to people who want to take the test about what the test is and what it means, and then they have five or so people come up and say, this is how I studied and what I did to pass. And one of the things he said was, when you write in something on that test question as a comment on it, that helps future test takers, not your cohort.
00:06:42
Speaker
So if there's a question on the AOL and you say like, well, but this article said this, they're not going to change it for you, but that does educate them for future ones to say, maybe we should take it out. Now, if you have an article that refuted exactly that may raise, raise some questions, but you're not necessarily helping you. You're helping future test takers. Okay. Back to the CMC.
Screw Home Technique for Thumb Pain
00:07:05
Speaker
Yes. I know you shared another fact about reducing it.
00:07:10
Speaker
Do you want to talk a little bit about that? So they talked in two different lectures, two different groups talked about this screw home technique. I had never heard of it before, but it's the idea of when a thumb is painful.
00:07:20
Speaker
And it is beginning to sublux, but it's not effective if the thumb is a full on shoulder sign and it's fully sublux, dorsal radially, that's not clinically reducible. But a patient who has pain, I can do this axial load of the first metacarpal into that CMC joint. Not just axial loading though, I need to rotate it into pronation and then axially load it.
00:07:48
Speaker
In one of the talks, I think she had just flipped her arrow on the graphic and it looked like supination loading and then axial. But the article I found that followed up on it, I found that they had definitely pronation first and then axial loading. And what this does is it rotates it and screw home, screws it into position, and then it nests more. Because when it dorso-radially subluxes, it's actually a rotational load too. And so you want to rotate it and axially load it.
00:08:16
Speaker
This should decrease pain. It should give them proprioceptive feedback. And then I would hold it there manually, passively, while they do, whether it's just serial to the opposition of the index finger, or maybe it's a functional task. I might maybe Kinesio tape them into that position, but that is a rotational component needed in order to relocate that not fully sublux joint. Oh, interesting. That would be an interesting article review.
00:08:44
Speaker
Yeah. So I'll have to go find that again. Cause that night I went and checked into it and said like, well, what is this? And so I found it, I'm sure it was in general hand therapy. Um, that's where most of these things land, but maybe we need to have our students do a journal article review of that just to see like, what is the implication for what we were doing in the clinic? And I had one patient that loved it. She said, well, that feels really comfortable. Do that more, but what's the carry over? Cause when I take my hands off.
00:09:09
Speaker
Does it just collapse right back out? Or is it something they can do for themselves? If it's just pain relieving, that's not bad. Or does it help them mechanically in the future if sub looks less? Yeah, it might be something, you know how we'll do like the first web space release and we show patients how to do that. It might be something that they could carry on for pain relief at home. And I think it's a good proprioceptive exercise as well. They have to try to hold it there.
Upcoming Resources from Hand Therapy Academy
00:09:34
Speaker
Yeah, yeah, could be an interesting thing to apply, but again, I need to know more about it before I start throwing it into my practice. Right, right. Okay, so look forward to that article review. If you guys don't know, you can sign up for our free article review and blog post. Those come out two times a month, so that's free to everyone. Or if you're interested in taking any of our courses or memberships, you can find that at handtherapyacademy.com.