 American College of Osteopathic Pediatricians  Robert Hostoffer, DO,FACOP, FAAP edited by Eric Hegybeli, DO, FACOP questionnaires by Michael Rowane, DO

 Born in Virginia in 1828  The son of a Methodist minister and physician.  At an early age, Still decided to follow in his father's footsteps as a physician.  After studying medicine and serving an apprenticeship under his father, Still became a licensed M.D. in the state of Missouri.  Completed additional coursework at the College of Physicians and Surgeons in Kansas City, Missouri [Early 1860's]  Union Army Surgeon during the Civil War.

 After the Civil War and following the death of three of his children from spinal meningitis in 1864, Still concluded that the orthodox medical practices of his day were frequently ineffective, and sometimes harmful.  He devoted the next ten years of his life to studying the human body and finding better ways to treat disease.  Discovered Osteopathy in 1874

His research and clinical observations led him to believe: The musculoskeletal system played a vital role in health and disease The body contained all of the elements needed to maintain health, if properly stimulated. By correcting problems in the body's structure, through osteopathic manipulative treatment, the body's ability to function and to heal itself could be greatly improved.

Promoted the idea of preventive medicine Endorsed the philosophy that physicians should focus on treating the whole patient, rather than just the disease. 

 An average competitive swimmer can complete between 6,000 yrads in a two hour session.  Approximately miles per week.  Approximately 1 million stroke cycles per year.

 Laxity vs. Instability  Poor stroke mechanics  Excessive fatigue  Improper or excessive stretching  Improper weight training  Excessive use of kick boards

 Laxity: normal; pain free ROM of a joint  Instability: Pathologic subluxation or dislocation resulting in pain or functional impairment.

 Many swimmers have joint laxity  Laxity may foster glenohumoral instabilty leading to impingement

Stroke Mechanics Excessive stressFatique Poor Technique Increased Drag

 Wringing out of supraspinatus  Crossing Midline  Flat Body Positioning Promote impingement Hawkin’s Position  Dropped elbow First sign of fatigue or pain Minimizes time in impingement position

 Breathe bilaterally Increases body roll  Maitain high elbow during recovery Lessens demand on scapular stabilization musculature

 Swimming promotes strengthening of the glenohumoral internal rotators and pectoral musculatures  Most swimmers excessively stretch the anterior capsule Buddy stretches

 Swimmers without pain

 Swimmers with multidirectional instability or shoulder pain  A gentle warm up should replace pre- workout stretching

 Minimize abduction and external rotation Lat pulldowns, military press, shoulder abduction  Emphasize scapular retractors, glenohumoral external rotators and core musculatures

Kicking  Excessive use of board promotes impingment  Neer’s position

 Stage I refers to those with edema and hemorrhage;  Stage II refers to those with fibrosis and tendinitis;  Stage III refers to those with tear of the rotator cuff, ruptured biceps or bone excrescence

 3 phases Acute Recovery Functional retraining

 RICE  NSAIDs  Possible subacromial injections  Avoiding impingment positions  OMT A/AAROM  Modalities Ultrasound TENS

 Restore normal AROM-OMT  Restore strength and endurance to shoulder stabilizing musculature and rotator cuff High repetition of low weight or low resistance elastic bands

 Entrance Criteria Normal Shoulder AROM Rotator cuff strength at least 4/5 Normal and functional kinetic chain  Goals Sports specific training No muscle in isolation

 Swim Bench Isokinetic exercise  Return to pool with gradual increase in yardage/intensity  Plyometric exercises Neuromuscular intergration Very high force generation Complementary muscle group coordination and strengthening

 Indications Failure of conservative management Paresthesias, dead arm Significant instability Difficulty with ADLs ( activity of daily living) secondary to pain

 Inferior Capsular Shift  Anterior capsulolabral reconstruction  Arthroscopic repair  Thermal Capsular Shrinkage

 Painful arc/rotator cuff pain in the shoulder of a swimmer can occur in any of the following movements: 1. Adduction of the arm at the shoulder 2. When this movement is blocked 3. Flexion of the arm at the shoulder 4. When this movement to left or right is blocked.

 The acromioclavicular joint may develop degenerative arthritic changes, particularly from damage in resistance weight training. weight training

 Arthritis of the glenohumeral joint may be seen in the masters age group, though it is rare in the young.

 the alignment of the knee centre relative to the hip centre during the start of the breast-stroke kick affects the development in the medial collateral ligament and capsule. The optimum initiating position from the breast-stroke kick is with the hip and knee centres aligned. When the knee centre is narrow or wide of the hip centre, it causes increased stress on the medial collateral joint structures. Exceeding the elastic limits of the ligament will cause damage and injury. In young swimmers, this form of stress could open growth plates of the femur and tibia and cause micro-injury which will result in inflammation and thus seriously impair training.

 There is a high risk of the patella riding laterally during the breast-stroke kick. This is magnified when the patella tendon attachment site at the tibial tubercle is placed in an extremely rotated position. Weakness of the vastus medialis can decrease effectiveness in ensuring central tracking of the patella. If dislocation occurs, surgery is almost certain.

 Acromiolclavicular joint  Rotator Cuff Muscles: S upraspinatus I nfrspinatus T eres Minor S ubscapularis  Biceps muscles  Humerus

 Subacromial impingement ( swimmers shoulder ) is a condition that affects the athlete's abililty during the catch phase, early to mid-pull, and through arm adduction in the recovery phase. It is an inflammation of the supraspinatus located on the long head of the biceps tendon. Most often it is a result of incorrect form and overuse.

 Poor Stroke Technique : Improper stroke technique can result in joint and muscle imbalance.  Unilateral Breathing : Most swimmers are comfortable breathing in one direction, this results in muscle imbalance in swimmers.  Overuse : These are chronic injuries that occur because of repeated stress to the muscles, tendons and joints.

 Step 1—extension with elbow flexed;  step 2—flexion with elbow extended;  step 3—compression circumduction;  step 4—circumduction with traction with elbow extended;  step 5a—abduction with internal rotation with elbow flexed;  Step 5b- adduction and external rotation  step 6—adduction and internal rotation with upper extremity behind the back;  step 7—stretching tissues and pumping fluids with the arm extended

 1) Put both arms overhead in the streamlined position, then lean first to the left side as far as possible, then to the right.  2) Put both arms behind your back, fingers interlaced, and slowly, steadily raise your arms upward behind you as far as possible.  3) Put one arm across your body so that the shoulder is under your chin and hand, forearm and upper arm are parallel to the ground. Without turning your body, use your other hand to pull the arm close as close to your chest as possible.

Innervation Table Organ/SystemParasympatheticSympatheticAnt. Chapman's Post. Chapman's EENTCr Nerves (III, VII, IX, X) T1-T4T1-4, 2 nd ICSSuboccipital HeartVagus (CN X)T1-T4T1-4 on L, T2-3 T3 sp process RespiratoryVagus (CN X)T2-T73 rd & 4 th ICST3-5 sp process EsophagusVagus (CN X)T2-T8--- ForegutVagus (CN X)T5-T9 (Greater Splanchnic)--- StomachVagus (CN X)T5-T9 (Greater Splanchnic)5 th -6 th ICS on L T6-7 on L LiverVagus (CN X)T5-T9 (Greater Splanchnic)Rib 5 on RT5-6 GallbladderVagus (CN X)T5-T9 (Greater Splanchnic)Rib 6 on RT6 SpleenVagus (CN X)T5-T9 (Greater Splanchnic)Rib 7 on LT7 PancreasVagus (CN X)T5-T9 (Greater Splanchnic), T9- T12 (Lesser Splanchnic) Rib 7 on RT7 MidgutVagus (CN X)Thoracic Splanchnics (Lesser)--- Small IntestineVagus (CN X)T9-T11 (Lesser Splanchnic)Ribs 9-11T8-10 Appendix T12Tip of 12 th RibT11-12 on R HindgutPelvic Splanchnics (S2- 4) Lumbar (Least) Splanchnics--- Ascending Colon Vagus (CN X)T9-T11 (Lesser Splanchnic)R hip T10-11 Transverse Colon Vagus (CN X)T9-T11 (Lesser Splanchnic)Near Knees--- Descending ColonPelvic Splanchnic (S2-4)Least SplanchnicL hipT12-L2 Colon & RectumPelvic Splanchnics (S2- 4) T8-L2---

 Question1: A, B, C, D, E.  Question2: A, B, C, D, E.  Question3: A, B, C, D, E.

 Swimmer’s shoulder is due to A. Subluxation of shoulder posterior B. Subluxation of shoulder anterior C. Subacromial impingement D. Rotator cuff sprain E. Scapular imposition

 Swimmer shoulder injury is due to: A. Poor technique B. Unilateral Breathing C. Overuse D. Catchman’s triangle misalignment E. A, B, C.

 A 12 year old boy presents to your office with a throbbing shoulder with pain increasing with movement. He has swum competitively since six years of age. There is no history of trauma. You feel he has subacromial impingement. Your osteopathic therapeutic option would be: A. Galbreath maneuver B. Spencer’s Technique C. First Rib manipulation D. Thoracic HVLA E. OA HVLA

 I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__ Signatures:  Pediatric Resident ____________________  Pediatric Residency Director____________  ( Please print and give to program director.)