Hey, this is Sandy. And Randy? And we're here on AT Corner. Being an Athi trainer comes with ups and downs, and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of AT Corner. For this week's episode, we have an education episode that I feel like everyone will give two thumbs up. Unless they're injured. And then maybe one thumb up, one thumb down. Yeah. So if you haven't noticed, we'll be talking about the thumb.
So this is a CEU episode, so if you're listening to it as it comes out, it is a free category. AC EU. If you're listening to it as it is one of our older episodes, you can purchase it from. Thank you so much to clinically pressed and athletic training chat show notes down in the show notes below where all the details are how to get your certificate. It will automatically be generated if you do your quiz and course evaluation. So just check those out.
And we also have other CE us. So if you are interested in staying on top of those, it is a reporting year and please share to your friends who also need C us. Yes, definitely. So what are we talking about today, Randy? Yeah, so we're going to talk about the relevant anatomy of the thumb because why not? Because it's rad. Thumbs up.
Get it Rad. All right, moving on, we'll discuss the evaluation and treatment of various thumb pathologies and then we'll also kind of discuss some of those return to play considerations after thumb pathology. It's interesting, like some of that return to play is like it's
really different based on sport. And like, you know, like in sports like football, you can kind of get away with a couple things 'cause you can kind of protect it a little bit better than say, if you like, play a hand kind of dominant sport. Absolutely, and it also depends on position. Though, yeah, it depends on the position for sure. If your quarterback, you're not going to see your quarterback with the club. It's a little weird. Yeah, maybe a splint. But maybe a splint?
Yes. But not a claw depending on what it is. So let's get started with the anatomy. Yeah. So when we talk about thumb injuries, right, it's really important to understand just the ligamentous anatomy of the thumb. That's really kind of where we tend to see a lot of these injuries, I mean. It's such a mobile joint. Yeah, for sure. And I definitely have seen it with my volleyball athletes. That's a lot of. People just getting crushed when
they're going up for a block. So our static stabilizers are the thumb include the UCLRCL, the voltar plate, and then the dorsal capsule, right? But in particular, we're going to really talk about and focus on the UCL and RCL. So both of these ligaments do have two bundles because, you know, why not? Can't make it easy, just have one bundle. All right, So the UCL has 2 bundles. 1 is referred to as the proper, and this provides that
valgus stability in flexion. In particular, the maximum stability is in about 30° of flexion. So. Keep that in mind as you think about how do I evaluate this? And then it has what's referred to as an accessory section or bundle that provides the valgus stability when you're in extension. Any any specific angle or just in?
General full, like full MCP extension and it really again, just really goes on just how the anatomy is and just how they kind of course around the thumb and the directions that they run that they really find their roles of being of. At what degrees do they have stability for the RCL? It's slightly similar as the UCL. The RCL is the primary radial stabilizer for the thumb.
What's really important about the difference between kind of the RCLUCL kind of area is the UCL has a lot more muscular protection. The muscular attachments around the kind of the ulnar side of the thumb are a lot more compared to the RCL. There's really not a lot of attachments there, so that it's really hard to kind of protect that joint dynamically. So what does protect it? So that RCL again has two bundles. So you have again, kind of the same names.
You have the proper bundle, which is your kind of main stabilizer again, inflection, and then your accessory, which is the main stabilizer and extension. So when you kind of think about evaluation, it's kind of like your knee, right? You do your valgus and varus at 0, valgus, varus at 30. So same thing for the thumb. You're just trying to see what bundles are kind of damaged when you do the evaluation. That's a good point because I feel like most people just do it in kind of 1.
Yeah. And you, yeah. When you, you know, it's funny you say that because when I was reading this, I was kind of thinking it was like, oh, I should do that, right? Like because I fall into that do where everybody just. Oh yeah, yeah. And especially like finger evals, you know, you check for fracture, check for stability and you're like, OK, like. Go egg. Let's get them, Chief. And usually it's like a sidelining evals really quick, you know. Yeah, for sure.
So yeah, I know that isn't that was kind of an important thing that I'm like, Oh yeah, that kind of brings in a good point. And I believe, you know, in our our kind of hand injury when we talked about fingers, it was the same thing, right? You do extension and then you also want to go down into some flexion to also test it that way as well. We will talk about some like Bony injuries. So kind of getting an idea of the Bony anatomy.
I think like again, I think most people understand the phalanges, the proximal distal, right. So I'm not we don't need to necessarily go that far into it. So I think one of the more kind of noteworthy aspects of the Bony anatomy for the thumb is that articulation between the first metacarpal and the trapezium, because this is what's actually creating that kind of saddle joint. And like you said, that's what gives us our thumb, the mobility because it. Is a pretty mobile mobile, right?
Some people have argued this is what makes us human posable thumbs. Actually, I was just about to say that. Yeah, yeah, right. We can open doors, right? So I think that's kind of 1 aspect that's very important. I mean, obviously, we know the the metacarpal in the first MCP and stuff like that. But I think very noteworthy is really considering that saddle joint. So now we kind of have that baseline of just simple anatomy kind of going into talking about
some of these pathologies. And really when you think of the thumb, there could be a number of issues that can pop up, right? But in particular, we're going to talk about kind of like more kind of Bony pathologies and then the collateral ligament damage. So when we talk about Bony, right, we have the dislocation of the first CMC, that's not Christian McCaffrey for all the Niner fans out there, it is the Carpo Carpo metacarpal joint,
right? So this is actually that can that kind of that connection between the first metacarpal, the trapezium, and this tends to be rare. You really don't see a lot of dislocations here. You're going to see more maybe a subluxation or a sprain being a little bit more common. And really the mechanism is just an axial load with a flex thumb, which again, you can kind of see why it's kind of difficult. It's really hard to kind of land
like that. Well, I had a quarterback who landed like that and he literally just, no one was around him. He just stepped back. We were playing on a grass field and he stepped back and fell backwards and fell like with a flex thumb and literally just came off. And he was like, my thumb's broken. And I was like, no, it's not. And I just popped it back in. And then I was like, and then
he's like, oh, OK, cool. And he went to move it and it just came back out and I was like, oh, that's weird. So I put it back and I was like, let's test that. I was, this is like, I think I was like 6 months certified. Yeah. And then boom, pops out again. And I was like, no, no, you're done. We're sending this. And then what did the what did the doctor say? He ended up having surgery.
He he tore everything in his thumb he just from falling and he said he hadn't seen one of those in 10 years and the last time he saw it was because of a car accident. That's great. And you saw it at six months certified? Yeah, there you go. Very welcome. Yeah, welcome. One thing to kind of consider with these injuries is it may be associated with a Bennett's fracture, which is a fracture to the that proximal end of the first metacarpal in particular
in the actual joint as well. So that's something to kind of keep in mind and be careful of when they kind of present to you, right. They may present with kind of an adducted thumb, and basically more than likely the thumb will be displaced dorsally. You know how I remember a Bennett fracture? Because my program director was named Doctor Bennett. And so the way he taught us, because Bennett's number one, yeah, thumb side is number 1. So it's the fracture associated with the first.
Did he make sure to emphasize that Bennett was #1? Yes. Oh yeah. That's pretty funny. I still remember it to this day. I mean, who could forget that? All right, So transitioning to another dislocation pathology, kind of just keep in mind is that first MCP joint dislocation, so the metacarpal phalangeal joint. And again, this tends to be in kind of that dorsal direction and can result from
hyperextension of the thumb. How they kind of categorize it is you can have a complex dislocation and this is something that's like, you can't reduce this like just normally, right? This is going to require surgery to actually produce. And how you can kind of tell the difference is it'll present with like some puckering of the skin right at the metacarpal head. So it's almost like it probably looks like it'll kind of get sucked under.
And I'll kind of give you an indication, hey, I probably shouldn't try to reduce this on the field. I think you. Probably they won't let. You, yeah, they probably won't want you to. And then a simple category is just something that it doesn't present that way and you could reduce it on the on the field. So those are dislocations. We'll kind of talk about a little bit about the management in the next section.
So don't worry. I didn't forget about that Going into our kind of ligament pathologies. You have your UCL sprain and this is kind of the most common injury in the thumb and some have considered, I think some have found the most common injury in the hand as well. I could. I could see that. Yeah, I feel like it does happen quite a bit. And really it's anything that's just causes that excessive the valgus force in the thumb, right?
So this is what's commonly referred to as like skiers thumb because when you fall, I guess when you fall skiing and your thumb hits the ground, boom, that. Would cause a skiers thumb. Right. So evaluation is pretty simple, right? You're going to have pain over your UCL, right? And there might be some laxity with valgus stress tests, right? The one thing to keep in mind when evaluating these is high
levels of laxity. So when that bad boy really opens up, right, that could indicate A rupture. And I think like technically numbers are like, oh, if it has valgus of over 30°, right? That's like complete rupture. And like, I don't know how many people are pulling out their Goni when they're doing stress tests, but basically. Just make sure that you're doing it at different very various. Levels, that's true, yes. Various angles of flexion.
But one thing that I actually did learn from the reading and something to keep in mind, is another indication of a UCL rupture in the thumb is the presence of a stenor lesion. And what this is, is a palpable mass right over that kind of ulnar side of the thumb, right over where the UCL would be. And basically this is this occurs when the UCL evol basically an avulsion fracture of the proximal failings. A Steiner lesion. Yeah. So you'll actually feel like a a more prominent bump here and
you're like, oh, that's weird. How many of us are feeling our thumbs right now 'cause I, I am? I I've literally been tapping at this whole time. So shifting from ulnar to go into the rad side. This is the rad side of the episode. It's a lot more rare than the UCL and. Have you ever seen one of? These I was gonna say when I started thinking I was like, I guess I don't have a lot of athletes complain of RCL pain.
I have had people complain of them, but I haven't had any laxity that I can remember off the top of my head. Dude, I actually had sorry not to go back to the owner side. It's not as rad. Literally like a few weeks ago, one of like one of our incoming basketball guys came in and he was like, hey, can you take my thumb? I was like, yeah, I'm going to take a look. And I'm like, I did the valgus. I'm like, oh boy. And it moved a lot. Oh, it was basically floating.
I was like, no, that needs more than tape. Yeah, you're like, sorry, tape won't fix this one. No. But yeah, so RCL a lot more rare and again, it just happens with the reverse, right? It just a various force over just overcomes the RCL. But interestingly, it can happen with torsional force too. So kind of that kind of torsion on the thumb.
OK, you know, what was funny is actually I was trying to think of the people who I've had like an RCL pain with are usually like an axial load jam or like something like that or like a torsional. So. So that makes sense that that would cause because I can't really think of anything that would. I can't think of anyone who's complained to me about a various force on their thumb. I was gonna. Say, I feel like that's really hard to do. I just kind of think of the anatomy of like getting it
caught enough to do that. So yeah, like if axle load I could see and it gives that way, I could see that, especially because there's not a lot of dynamic stability on that side. Too right, Right. Yeah, because it doesn't have those muscular stabilizers. Evaluation again same thing as UCLRA instead of algus. You do varus at different at. Damn it, just going to say. That. All right, so now the bread and butter, what probably everyone's
here for is the management. We got to manage this thing. Yeah, yeah, I do it, right. So for your dislocations and I like, I really don't want to talk about the reduction techniques, right. I think this is a better thing to bring up to your team physicians. Again, NATA put out a great position statement on joint reductions. So I think that's a great conversation to have with your team physicians on, hey, how exactly do we do this? Should we be doing this?
Should you be doing this? Did we do a position statement on? Did we do that episode? I think we did an interview episode on it. With Nicolette, we did a how to talk to your team physician about reducing dislocations. Yes, Yeah. So check out check out that episode. I don't remember what number it is, but I'll try to link it. It's an. Early one actually, like I feel like it kind of it was it was a. It was a while ago, yeah. It was a while ago, going back in the archives a little.
Bit MVP. Nicolette MVP. But in general, right, if, if the going kind of more long term kind of follow up with these, if they're stable after reduction, right, it can be treated conservatively. So it could be casted or splinted for about 6-4 to six weeks was kind of consistent between all the, between the two dislocations. We talked about if surgery is necessary, 'cause it's just even with reduction, it's just not stable like a certain case study we just heard.
So he was, I was trying actually remember it was our last game and then I went into basketball season. He was still in a cast through at least part of basketball season. He he wasn't a basketball athlete. A lot of these kids like they played multiple sports. I don't think he was a basketball athlete. So I'd I'd kind of lost contact with that, but I remember seeing him in this freaking giant cast because he had pins. Yes yeah in it. And so then the pins had to be casted too.
And he's like this high school kid. So it was, it was the biggest cast I had seen at the time. Yeah. So obviously that timetable after surgery can really increase, right? How long you're immobilized for and how long before you can do things. I actually don't even know. I don't even remember his name. I can't even picture him. Actually, I can picture his thumb I mean. You were there for. It was like it was an impactful time, but I feel like it it was like a fairly short relatively.
Short time I only knew him for season I guess. Yeah. And you weren't necessarily there every day, right, Like it was only a couple times a week, Yeah. So that is hard to try and get everyone down kind of going towards the sprain something again a little bit more that we have a little more control of and kind of management. If you have a a high grade UCL sprain right really, it's recommended that that's going to be managed surgically. Especially like thumb, like any
opposition or like. Yeah, it's really important, right to how we function as humans. Or if you want to give someone a thumbs up again. Yeah, 'cause yeah. A stable thumbs up, yeah. Exactly, you don't want thumbs slipping out every time you come up. You're looking at basically after surgery, they're going to be in a cast for about 6 weeks. They'll transition to a splint for an extra for a little bit
longer. Really, they could start kind of strengthening outside the splint at around week 8 post op, but you're not looking at unrestricted activity away from the splint until around 12 to 16 weeks. Now there is some like depending on the sport and how they're doing, right, you might be able to get away if it's protected in the splint for certain sports, they might be able to get away
with it from what I was reading. But again, I think that's a better conversation with the surgeon and your team physician of how, how plausible is it that this person can play at this time frame. I know something that we've done in and Juan talks about it in our football episode is a soft cast and he's introduced me to those, the soft cast.
And you could just take like it's a soft cast material and you just make it to them and then you just cut it off and then you can re put it on with like Coflex. And it's not like as hard as a traditional cast, but like it's like a good transitional cause I've used like orthoplast. I was just about to ask what's the difference? Like what have you noticed different? Orthoplast is so stiff like that you're not moving that like it's very hard where the soft cast it has some give to.
It. So if they need to like catch, for example, you can like pad it like I've used it like on a tight end. That would be a lot better than like an orthoplast. I would use probably for like an O line or like D line or someone that's like really like I really don't want that thing to move. Whereas like someone who has to have some give, I'd probably use more of a soft cast and depending on like when it is in the in the recovery. Yeah, yeah, for sure. Right.
And I think that's a good point. Like I, I, I think especially working football, you've seen a lot of the ways that you could protect these, especially thumb injuries and get someone to play. Whereas it's really hard in some of the sports that I work because they are so hand dominant that it's really hard to like I, well, I can't make it too bulky. So this tends to kind of limit me more than I think you guys have a lot more play on. OK, what? Can we do?
Right right Basketball 1 inch elastic. On volleyball, one inch elastic. That's basically what I mean. I have for volleyball, I have done the ortho orthoplast, but I just made it a little bit smaller so they they actually have some thumb motion, but also protecting that MCP. That worked a lot. That worked pretty well, right? Again, like, she's not really like a setter, so I'm not really worried about that. I'm more worried about hey, let's protect while you're blocking and hitting.
Right. So that actually. That that that was helpful. Something that Juan's also introduced me to that just just specifically for that is he does just like a one inch spica of the orthoplast on the thumb and that's it and then he tapes it on. Holy smokes, I like that. Yeah. I would have to see that, yeah. I'm down, count me in. It's really small. It's just the the I feel like that. The people are uncomfortable. That's interesting. I like that.
You just have to stretch it out a little bit so it's not too. Yeah, too constrained. Because it once it's hard, like, yeah, it it's like a ring. Yeah, Yeah, it's, that's what you, what I pictured, right. So as you kind of, as we've kind of alluded to, partial tears can be managed conservatively and really in general, right, we're really kind of gearing for immobilization for four to six weeks, right? So we want to put them in a splint during their recovery
around 4:00 to six weeks. Really grip strength and pinching shouldn't begin until they either get full range of motion or at about six weeks time to let that heal. Returning to sport usually depends on the severity and the nature of the sport, right? So again, minor injuries, you could see a return two to four weeks with a splint. I'm sure it could probably be a little bit sooner if it's very mild and if you could protect it very well and then contact
sports again, right? It might need a little bit longer. They might need to actually be protected for like 6 weeks right to prevent it from being re injured while they're out there. I feel like especially football, usually if something needs to be protected, it's like you're being protected for the rest of the season. Well, I mean, OK, so when you think about like, think about that number like 6 weeks, I mean, shoot, your guys's season, at least for college, is basically ten.
Yeah, that's pretty much the year. Right, right, right. So. You might as well just keep it going because then you know what happens is the day they take it off. They're going to re injure it and then. Come back. And at that point, they're used to it, yeah, Although sometimes they are dying to get out of whatever, whatever splint. For sure, but then. Rap but. Then when they are and then it gave her three injured, then you're kicking yourself like, oh, she just kept it. On right.
So that's UCL right now going again, we're going back to the RAD. We're finishing on Rad. There's not a lot of clear guidance on how to manage a complete rupture of RCL. So. I can't like if you managed to rupture your RCL like a lot. Of damage. Like what else? Yeah, what else is damaged? Some have advocated for, hey, maybe it should be similar to the UCL. You should probably need surgery. I know if I have someone who's full ruptured, I'm referring
that bad boy just in case. Like, yeah, let's is this surgery or not? But the protocol for like that whole management after surgery is similar to UCL, all right? So it's not really, it doesn't deviate that much. For partial tears, again, it's very similar, right?
You're going to mobilize 4 to 6 weeks and then you can start transitioning to a removable splint one that they can kind of take on and off probably, again, probably mostly for games that they'll have it on for like an additional 2 weeks. Nice. Yeah, Some bonus rehab. Something that we've been doing lately is we took a tennis ball and we cut a slit in it so it looks like Pac-Man and they have
to pick up marbles. Oh my gosh, I saw you guys doing that or I saw a video or something and I'm like, that's genius. I saw it. I saw it on Instagram. I want to do that now because. You know what's actually really great? Look up hand. Like occupational therapists or like hand therapists and they are like they have you. I thought I exhausted, I've exhausted my brain of rehab
exercise for the hand. But then you go on Instagram, there are so many that you can do, especially for some people who like specialize in this area, I would say. Like O TS man, that's the that's. The bread and butter, right? So that and it makes it fun. It's some, I would say it's some different than the because you could do like the marble pick up by hand, but then it's like, what are we doing? Like I feel like that's not stressing enough for like an athlete.
So what I learned is if the bigger you make the slit in the tennis ball, the easier it is to squeeze. Minimal. So if you if you make a small slit, obviously it's going to be harder. So I think I'm going to make another one with a smaller because I like started with the small and then I was like, oh, the mouth isn't big enough. And then and like, OK, you know, like that. Measure twice, cut once. Yeah, no. Oh, OK, but also like tennis balls, like dime a dozen. Exactly.
Exactly. Or just go like right outside of the tennis courts after they're done. Oh, there's plenty of. Like dead balls. Yeah, I was just about to say the ones that are dead. Yeah, they don't. They're going to get rid of them anyways, right? What I use, sorry not not to go on tangent, but lacrosse balls, if you have a lacrosse team or any kind of lacrosse that practices on your campus, just go out there after they're done. You'll find a good lacrosse ball
somewhere. Or you could just ask them. But like if you don't know them. You should probably ask them. Saying sometimes you'll find them in the bushes and you're like, yes. You're funny, yes. What is your action item for this? Thumbs cool, man. You mean like thumbs up, thumbs up, thumbs up? Cool. I think from reading this, I think that the management, I feel like a lot of people don't think of that immobilization time with one hand injuries, wrist injuries and like thumb
injuries. Like I feel like you look at it and you're like, Oh yeah, it's sprained. We can tape that. But then I feel like we're like, I know for me, like I, it was really hard for me to think of like, Oh yeah, you should be splinting this when you're not doing things. You know, I have to say I am a changed woman from wrist braces. I love them. They are my favorite piece of equipment.
Yeah, and I think that's one thing like this year, like I never had like the actual thumb splints, but this past year I, I, I ordered the braces for it and that has been a game. Changer, they make such a difference. Like literally I the way I get by in is I give them the wrist brace. If that like a wrist sprain. We could talk about thumb sprains too, but like just specifically I get more wrist sprains.
So I give them the wrist brace and I say, just hear me out for 24 hours, put it on for 24 hours. If it works, we can keep it. If it doesn't, then what's 24 hours right? I have not had anyone who hasn't gotten at least a little bit better in 24 hours. And most of the time they're like, Oh yeah, I'll keep this on good because it helps. Well, because you're probably going to need to keep it on four to six weeks, so it'll get
comfy. I usually don't keep it on that long, but yeah, so that's what I I make them. Usually I it's about a week at top tops maybe like 4-5 days average, yeah. So I would say I don't forget that time of actually protecting the tissue. Like, I know it seems like it's kind of bulky and oh, it's not cool. And like, you know, the athletes will complain. Some of them might, maybe not all of them. Tell them to like wear a a hoodie like with the sleeves like over their hands.
Yeah, that's what I'd say is don't, don't forget that time to actually protect the healing ligaments. And then, yeah, think of some cool creative ways to do rehab because it you, it feels like you're so limited on hand rehab and I feel like you're just kind of doing the same thing. So yeah, like the Pac-Man thing, like that's really cool. You can only stretch putty so many. You can only play with the putty and the webbing for so much. Or the rice bucket. Or the right or the sand.
Or the sand. I haven't done sand. Yeah, you can only do that so many times before you're like, OK. So if you're interested in the references that Randy used to read on up on this episode, you can head to our website, which is also in the show notes, where you will also find a bunch of fun goodies and stuff like Medbridge, who we work with to bring you C us like promo codes
for them. We have every episode that we do is education like this Cus or we do story episodes where we bring stories from real life athletic trainers. We are actually doing a story episode next week and because it's end of May, it will be our last episode of season 5. That's crazy. So we will be back in August as we run August through May. We take June and July just to prep for next season, but we will still be active on our Instagram, so keep an eye out and we will be at NATA.
So if you're going to NATA, please let us know, we'd love to meet you. Give us a thumbs up. We'll we'll know what that means. Now if I remember, now, if I remember, someone's going to be like doing thumbs up at me. I'm going to be like, yeah. As long as you don't give us a thumbs down. Yeah, that would sting a little. In person, just like walk of like. Yeah, that one would actually probably sting a little. Yeah, maybe don't do that, please. All right. Do you have anything else? Nope.
Thank you for helping us showcase Athi training behind the tape. Bye.