Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses when, why, and how to perform cupping to the deltoid muscle.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How is it going? Welcome to Technique Thursday. My name is Dr. Lindsay Hughey. I am division lead of extremity management along with Dr. Mark Gallant, and I am here to talk to you about a deltoid myofascial decompression technique. So in honor of deltoid week, I want to share just a common technique we'll use. First, I will kind of give a little context of why we would use this technique, and then I'm literally going to show you how we'll do cup placement, and then how we'll follow that up with active movement. So we do passive, and then we actually do a little neuroreeducation to that area.

WHY CUP THE DELTOID? So why we might choose this technique is someone that literally has pain with palpation at that deltoid, baby with abduction, they have a painful arc, and or when you manually muscle test into abduction and or flexion, they have some pain symptoms. So this would lead us to want to do this treatment. In our extremity management course, we usually call this the weak shoulder bucket. A lot of these folks fall under that umbrella. So I actually have an assistant with me today. So Paul is going to come and sit, and I'm actually going to have him sit like this. I usually have the patient either lay in supine, side lying, or prone to do this technique. But for ease of you all to view the deltoid, I want to have him sit, and then we'll have him lay on his side. So we want so just to orient us to the deltoid and I'm going to move this camera just a little bit right so the deltoid actually gets its name because it looks like an upside down delta so if these points all the way down to that deltoid tuberosity by the way to dive deep into the anatomy of the deltoid check out Clinical Tuesday with Ellison Melrose because we are doing all things deltoid this week. And she did a fabulous episode on not only the anatomy, but the function. So take a look at that. But here we're going to target, we want to target the anterior, the medial, and that posterior region. So some people think of this as like clavicle, acromion, or spinal. So what we're going to do is attach our cups to each of those regions and then all the way to that deltoid tuberosity. So I'm going to grab my gadgets. So practical things we need are some kind of lubricant. I'm going to use Free Up today, but it doesn't really matter, kind of your favorite lotion oil that'll help this stick. So I'm going to put a little lotion anterior, medial, and then that posterior, right? Because we have three main parts here. And then we'll go down to this deltoid tuberosity area. So I'm going to use these nice curved cups. These are actually the newest cups from our colleague and friend, Cup Therapy. So Chris DiPrato just came out with these and his team, and they are awesome for suction. We really, by the way, love myofascial decompression because it's really the only thing we have that really offloads tissue versus like our dry needling, our exercise, our massage, our wonderful treatment adjuncts. but they're compressive in nature. So sometimes this decompressive technique is just a novel stimulus to help that muscle relax and move better and activate better.

CUPPING THE DELTOID So I'm going to start with that middle portion and I want For muscle, we usually want about 300 to 600 millimeters of mercury or pressure taken off. And there are gauges that pumps that actually show you that pressure. This is just a standard pump today, but just to keep that knowledge in your back pocket. And then we're going to go posteriorly. So again, I want to make sure lotion is there. I'm going to attach here. How are we doing, Paul? Such a good patient. Such a good model. And then we're going to go anterior. So I'll just kind of shift my body so that you all can see that. Again, we're pumping up. We try to get enough besides that 300 to 600 millimeters or mercury, but enough that they don't pop off. And if this do pop off during this demo, we'll just reattach. And then finally, down here, a little bit more lotion. And then we'll pump. We're getting a little slidey there, doing OK. Sometimes you're doing OK. Sometimes hair gets us, and we might. User error is always fun, too, when your hands are sliding. I'm just going to change this out. Here we go. That one, we needed to go, I think, a little bit smaller. That one was a little too big for the surface. That's why there's different size cups. OK. To visualize, we have anterior, medial, posterior, so we're hitting all parts of that deltoid. And then we're trying to sink into that deltoid tuberosity. For our treatment, I'm going to have Paul lay in sideline, so that shoulder is up. First part of this, and I'll just adjust the Instagram camera a little bit, is we're going to do some passive movement. So we're never just having the patient sit with the cups and doing nothing. It's very rare that we would just let this be a static treatment. So I'm going to take Paul's arm, and then I'm going to move him into all the motions that the deltoid produced. So that anterior is more flexion, internal rotation, abduction for that medial and then posterior contributes to extension and external rotation. So I'm gonna move in and out of all those positions. So I'll demo just a couple of those and then the next part is let's let the patient own this movement with some neural re-education. So then Paul will do those movements and I'll show you our favorite sideline trio for that. So I'm going to flex him and I'm moving my body with this. And then I might mess with a little bit of internal external rotation. And when you're up close to the cups, what you see is some pumping on off of that tissue. And I'll do just a couple more of these. And then I can even abduct. A little bit for Paul on off, and I would spend like a minute or so kind of going off on off and deflection, internal external rotation. I might even go into a little bit of extension. And then I want him to do some of these movements. So I'm going to go from behind to direct Paul and get out of your way. But one of our favorite things for the weak shoulder and to really light up that deltoid and even the cuff, because we know they work together in upward elevation, is we're going to do external rotation. Elbow straight, do flexion, come down, and then go to 90 and do horizontal abduction. So we're hitting all parts of that deltoid and the cuff with this movement. And we'll have Paul do a few of these reps unloaded, but then I'm going to give him a change plate, and I'm actually going to have him load this up. And probably the hardest part is just remembering all the movements. It doesn't quite matter what order you do it in, but what matters is kind of targeting all the different areas of that beautiful deltoid muscle. So go back to external rotation, and this is just like a real patient, right? There's going to be some error in each movement. Again, it doesn't matter necessarily the order. And then horizontal abduction. To make it a little harder, we're going to go ahead and give him a weight. So he's going to go ahead externally rotate. I'll just guide him through those first reps, elbow straight, go ahead and flex. Meanwhile, the pods are still attached, offloading that tissue. He'll come back to 90 and then horizontally AB duct, right? And then we'd give him a sweet spot. You can go ahead and relax. A sweet spot, what we call an extremity management, the rehab dose because we are targeting local tissue. So our rehab dose is anywhere from 8 to 20 reps, 3 to 4 sets, and we're taking a rest break of about 60 to 90 seconds. And our intensity varies from 30% to 80% depending on tissue irritability. But we've done this out.

SUMMARY So some key things, we apply the cups, right? But then we actually move the human passively. Then we have them actively do the thing, neuroreeducation. And then finally, we take the cups off. And what we would do is reassess one of those things that blipped an exam, whether it was palpation, whether it was that presence of a painful arc, and or our manual muscle testing to see, did NPRS change with our palpation? Did painful arc, was quality of movement improved, and or NPRS, less pain associated with that elevation? The other thing, one little other pearl I want to share with the cups. So we remove the cups and then we'll massage that area a little bit. But what's neat is you can even take some pressure off. I'm taking this last cup off, but I can reduce the pressure a tiny bit and I can end with like a sliding technique where there's a little bit of offloading still present, but we're sliding along that tissue. for overall treatment dur be more than like 3 to 5 technique. And what's neat asterix very quickly. And pain. The motor bands tha immediately are a little and then they're able to elevate their arm better. And so this quick and efficient technique is one that I would really encourage you to use with your folks that have any deltoid and or cuff issues. You've heard me throw out some terms today regarding weak shoulder, the rehab dose, and the sideline trio. These are all terms that are really common to our extremity management course. So if you haven't taken it yet, Mark and Cody and I and our team to see you on the road an offerings. If you check u dot com in the summer. So in Salt Lake City with Ja and 14th will be in Kent, Washington again. And then July 20th, 21st will be in Hendersonville. So Cody will be there. That is bound to be a blast with that Hendersonville crew. And then it keeps on coming. We have another course in July, Bend, Oregon. So a lot of West Coast opportunities. So my West Coasters join me. I will be doing all those West Coast courses. And then we have more offerings in August. So you can't miss us. Thank you for joining me on Technique Thursday to learn a little bit more about the deltoid. And thanks to Paul, my patient who always looks like he's sleeping, but he's actually awake and with it. I hope you all have a beautiful day. Take care.

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