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OCS - Current Concepts of Ortho PT > Shoulder > Flashcards

Shoulder Flashcards

1
Q

Position of scapula? (what plane and facing ant vs retro)

A

Anteverted 30° in frontal plane

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2
Q

Position of glenoid fossa? (what plane and facing ant vs retro)

A

Tipped superiorly in relation to scapula, retroverted in transverse plane (varies but <7°)

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3
Q

Dominant shoulders tend to have more humeral anteroversion or retroversion?

A

Retroversion

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4
Q

T/F: total rotation ROM of the GH joint is affected by retroversion of humerus?

A

False, total range is same. Excessive retroversion = increased ER, decreased IR

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5
Q

What is the balance stability angle?

A

Angle between the glenoid arc and center of the glenoid

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6
Q

What happens if forces from muscles around the joint are directed outside of the balance stability angle?

A

Joint can be unstable

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7
Q

Causes of excessive GH retroversion? What ° would be excessive?

A

Developmental abnormality, OA, secondary post-traumatic arthritis, inflammatory conditions
- >7° retroversion

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8
Q

Concentric wear of the glenoid

A

Symmetrical or even along glenoid, centration (CENTRAL)

aka “Type A”

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9
Q

Eccentric wear

A

Uneven wear of POSTERIOR glenoid, causing retroversion and post humeral head subluxation, can cause biconcave glenoid

aka “Type B”

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10
Q

Type C glenoid changes

A

Retroversion of more than 25°, regardless of erosion or location

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11
Q

What type of GH OA responds less to TSA surgery

A

eccentric deformities (negative impact with higher failure rate vs concentric)

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12
Q

Glenoid anteversion predisposes the shoulder to what type of instability

A

Anterior

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13
Q

Glenoid retroversion predisposes the shoulder to what type of instability

A

posterior, also leads to posterior labral tears

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14
Q

What angle of retroversion is correlated with poor outcomes to restore stability to GH joint?

A

> 15° retroversion angle

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15
Q

Which causes more instability: humeral retroversion vs glenoid changes?

A

Glenoid changes

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16
Q

Hill-Sach’s fracture
- Location
- Associated w/ what type of instability/dislocation

A
  • Compression fx of posterior superior humeral head
  • Common with anterior/inferior dislocations
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17
Q

What % of bone loss with humeral lesions (i.e. Hill-Sachs) should be addressed surgically?

A

20-25%

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18
Q

How to calculate true glenoid track width?

A

84% length - Glenoid defect width = track width

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19
Q

AC joint ligaments provide stability in which directions?

A

Ant/Post

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20
Q

Coraclavicular ligaments (2)

A

1) Conoid
2) Trapeziod

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21
Q

Coraclavicular ligaments prevent against which movements at the AC joint?

A

Sup/Inf

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22
Q

Amount of clavicular rotation with humeral elevation in scapular plane?

A

5-8° posteriorly

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23
Q

AC joint: Type I strain

A

AC: strained, partially torn
CC: none

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24
Q

AC joint: Type II strain

A

AC: Rupture
CC: Stretched but intact

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25
Q

AC joint: Type III strain

A

AC: Rupture
CC: Rupture

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26
Q

AC joint is what type?

A

Diarthrodial w/ fibrocartilaginous disc

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27
Q

The (congruency/incongruency) of the AC disc contributes to high rate of early degenerative changes?

A

Incongruency

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28
Q

SC joint: which direction of dislocation is more common?

A

Anterior

NOTE: post very dangerous

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29
Q

What structures (3) form a pulley that stabilizes the biceps tendon?

A

1) Superior GH ligament
2) Coracohumeral ligament
3) distal subscap tendon

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30
Q

Buford complex (GH capsule)

A

Congenital labrum variant where the anterior/superior labrum is absent from 1-3 “o-clock”

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31
Q

Middle GH ligament contributes the most to stability in what position?

A

Shoulder abducted to 45° and ER

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32
Q

Superior GH ligament contributes the most to stability in what position? Resists what?

A

Neutral rotation, 0° abd

Resists inferior

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33
Q

Bankart lesion

A

Avulsion of anterior band of INF GH lig

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34
Q

Which of the inferior GH ligaments has the highest tensile strength? Which direction does it stabilize?

A

Anterior band, resists anterior translation when shoulder is 90° abd and ER

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35
Q

What GH ligament is the main stabilizer against inferior GH jt translation

A

Inferior complex

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36
Q

2 categories of GH joint instability?

A

1) TUBS
2) AMBRI

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37
Q

What does TUBS stand for?

A

Traumatic
Unilateral
Bankart lesion
Surgery

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38
Q

What does AMBRI stand for?

A

Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift

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39
Q

Multidirectional instability is categorized by instability in how many directions?

A

At least 2

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40
Q

Posterior band of GH ligament stabilizes the shoulder when in what position?

Common injury in which sport/position

A

Flexion and IR

Football linemen (blocking)

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41
Q

Difference between Bankart vs bony bankart

A

Bankart: just ligament
Bony bankart: both lig and anterior glenoid

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42
Q

Reverse bankart

A

Lesion of post labrum and post INF GH ligament, can be bony

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43
Q

Depth of the glenoid is increased by what % due to labrum?

A

50%

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44
Q

What part of the labrum is more loosely attached (superior/anterior/posterior/inferior)

A

Superior

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45
Q

T/F: Dynamic stability of the labrum is controlled by the attachment of the long-head of the biceps tendon?

A

True

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46
Q

SLAP stands for?

A

Superior
Labrum
Anterior to Posterior

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47
Q

What population is at high risk for SLAP lesions?

A

Overhead throwing athletes (eccentric biceps activity)

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48
Q

Vascularization of the GH labrum

A

Historically poor, but found to be more dense in periphery (best in anterosuperior)

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49
Q

Does the GH labrum have nerve endings?

A

Yes, causing injuries to be painful, can contribute to proprioception

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50
Q

Rotator cuff interval

A

Located between supraspinatus and subscapularis, triangle shaped in anterior shoulder

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51
Q

Rotator cable

A

Semicircular thickening of the GH joint capsule. It travels between tubercles of the humerus and interweaves with the supra- and infraspinatus muscle tendons. The rotator cable anchors these tendons to the tubercles, playing the role of a suspension bridge

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52
Q

What part of the supraspinatus is the stiffest?

A

Bursal side and higher ant vs post

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53
Q

Rotator cresent

A

Located between rotator cable and insertions on the greater tuberosity

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54
Q

Vascularization of rotator crescent?

A

Avascular, but noted to be greater on bursal side of the tendon

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55
Q

Which is stronger - rotator cable vs crescent?

A

Cable is 2.59 thicker

NOTE: cable is better to stress shield with age

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56
Q

Cable vs crescent dominant in young and old?

A

Young: crescent dominant
Old: cable dominant

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57
Q

What is a force couple?

A

2 forces directed in opposite directions that cause rotation in a specific direction

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58
Q

Subscapularis is in a force couple with which muscle on the scapula?

A

Infraspinatus

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59
Q

Rotator cuff (collectively) is in a force couple with which muscle around the GH jt?

A

Deltoids and pecs

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60
Q

What position of the shoulder does the long-head of the bicep provide stability in?

A

Abd and ER

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61
Q

What are intrinsic factors of rotator cuff pathology?

A

Alterations in biology, hypercholesterolemia, family hx of RTC tears

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62
Q

Neer proposed that what % of RTC tears were caused by impingment?

A

95%

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63
Q

Which has better outcomes: surgical subacromial impingement decompression vs non-operative tx?

A

Neither, they have the same outcomes

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64
Q

T/F: Combined removal of the acromion and bursectomy was more beneficial vs bursectomy alone?

A

False, no difference

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65
Q

What angle of elevation/flexion does the smallest distance between the acromion and supraspinatus occur?

A

30-70° elevation

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66
Q

Neers sign may be indicative of which type of impingement?

A

Internal

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67
Q

Painful Arc test is in which ° range?

A

60°-120° of abduction

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68
Q

Posterior internal impingement is commonly found in what population?

A

Throwing athletes (late cocking phase)

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69
Q

What is the primary intrinsic factor for RTC pathoanatomy?

A

Age (vascularity is significantly decreased after age 40)

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70
Q

What 2 systemic conditions put a person a higher risk for developing tendinopathy?

A

Hypercholesteremia and diabetes

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71
Q

Does smoking affect tendon healing? If so, how?

A

Yes, it inhibits delivery of O2

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72
Q

Do genetics contribute to risk for RTC pathology?

A

Yes, small role

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73
Q

What is the most common partial thickness tear of the rotator cuff? (intra-tendinous, bursal-sided, articular-sided)

A

Intra-tendinous

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74
Q

Degenerative tears in the RTC tend to initially occur where?

A

Within the RTC crescent and the juction between the supra and infraspinatus

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75
Q

What happens to shoulder function with tears inside the crescent?

A

Well maintained as long as there is no disruption in the rotator cable

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76
Q

T/F: rotator cuff atrophy has no impact in outcomes post-repair?

A

False, RTC atrophy has been correlated to higher post-op re-tear rates

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77
Q

How soon after RTC tear (not operated on yet) can you see cartilage damage?

A

12 weeks

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78
Q

6 Muscles responsible for stabilization of the scapulothoracic joint

A

1) Trapezius
2) Romboid major
3) Romboid minor
4) SA
5) LS
6) Pectoralis minor

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79
Q

Scapulohumeral rhythm is defined as what ratio?

A

2:1 ratio - 60° scap upward rotation and 120° GH jt movement

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80
Q

What shoulder force couple is responsible for posterior scapula tilting?

A

Lower trap and SA

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81
Q

What muscle is the primary upward rotator and protractor of the shoulder girdle?

A

Serratus Anterior

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82
Q

What muscle is the primary stabilizer of the scapula?

A

Trapezius

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83
Q

Scapular muscle imbalance/altered motor control is believed to contribute to dyskinesis in what 2 ways?

A

1) Excessive UT activation
2) Decreased/delayed activation of lower/middle traps and SA

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84
Q

Innervation of SA muscle?

A

Long thoracic nerve

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85
Q

Innervation of the traps and SCM?

A

Spinal accessory nerve XI

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86
Q

Common presentation of damage to the spinal accessory nerve (CN XI)

A

Asymmetric neckline (depressed), a drooping shoulder, protraction and winging of the scapula, and weakness of forward elevation

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87
Q

Cervical lymph node removal or radical dis’c dissection due to cancerous tumors can cause damage to which nerve responsible for scapular motion?

A

Spinal accessory nerve (CN XI)

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88
Q

What are the factors of pain behavior?

A
  • Aggravating/alleviating factors
  • 24hr pattern
  • Pain severity and irritability
  • Chronicity
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89
Q

Hypothesized pathoanatomic diagnosis:
- Persistent pain in ant/lat shoulder
- Inability to sleep d/t pain
- Gradual loss of ROM
- Female
- Age 40-65 y/o
- Presence of diabetes or hypothyroidism

A

Adhesive capsulitis - primary

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90
Q

Hypothesized pathoanatomic diagnosis:
- Gradual onset pain
- Decreased ROM
- Age 60+
- Crepitus/catching w/ end ranges
- AM stiffness

A

GH OA

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91
Q

Hypothesized pathoanatomic diagnosis:
- Ant/lat shoulder pain
- Pain w/ overhead activity
- Painful arc
- Pain at night

A

Subacromial pain syndrome

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92
Q

Hypothesized pathoanatomic diagnosis:
- Ant/lat shoulder pain
- Loss of strength
- Pain worst at night
- Age 40+

A

RTC tear

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93
Q

Hypothesized pathoanatomic diagnosis:
- Anterior shoulder pain
- apprehension
- pain in end-range abd/ER
- Hx ant/inf trauama
- Recurrent sublux/dislocaations
- Jt clicking/clunking
- Jt locking
- “dead arm syndrome”

A

Anterior instability/labral tear

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94
Q

Hypothesized pathoanatomic diagnosis:
- Instability
- Apprehension
- Pain in flex/horiz add w/ post force through humerus
- Hx of trauma w/ or w/o dislocation

A

Posterior instability

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95
Q

Hypothesized pathoanatomic diagnosis:
- Deep anterior pain
- Clicking/clunking/jt locking
- Pain w/ throwing or bicep loading

A

SLAP lesion

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96
Q

Hypothesized pathoanatomic diagnosis:
- Post pain during abd/ER (especially w/ hyperabduction)
- Overhead athletes

A

Posterior internal impingement

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97
Q

Hypothesized pathoanatomic diagnosis:
- Anterior pain
- Bicipital groove w/ shoulder flex and supination

A

Long head of the biceps tendinopathy

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98
Q

Hypothesized pathoanatomic diagnosis:
- Superior pain increases w/ end-range elevation and/or horiz add
- Hx heavy weightlifting
- Hx trauma (especially inf force through shoulder girdle)

A

AC joint arthropathy/injury

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99
Q

What is SINSS model?

A

Severity, Irritability, Nature, Stage and Stability (SINSS) model for pain

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100
Q

Characteristics of HIGH pain irritability:

A
  • ≥7/10 pain
  • Constant night or rest pain
  • High disability level
  • Pain limits ROM (AROM > PROM)
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101
Q

Characteristics of MODERATE pain irritability:

A
  • 4-6/10 pain
  • Intermittent at night and rest
  • Moderate disability
  • Little discrepancy between PROM and AROM
  • Pain primarily @ end-range
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102
Q

Characteristics of MILD pain irritability:

A
  • ≤3/10 pain
  • No resting or night pain
  • Minimal pain @end-range
  • AROM = PROM
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103
Q

Polymyalgia Rheumatica

A

An inflammatory disorder causing muscle pain and stiffness around the shoulders and hips & almost flu-like symptoms
- Common in 60+ y/o

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104
Q

Parsonage-Turner syndrome (PTS)

A
  • Neuro disorder characterized by rapid onset of severe pain in the shoulder and arm. - This acute phase may last for a few hours to a few weeks and is followed by wasting and weakness of the muscles (amyotrophy) in the affected areas.
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105
Q

Validated standardized screening tool to identify medical red flags

A

OSPRO-Review of systems tool

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106
Q

T/F: Delayed surgical repair in the presence of an acute rotator cuff tear negatively impacts patient outcomes

A

True

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107
Q

How can chronicity of RTC tear be determined?

A

MRI
- Muscle atrophy
- Fat infiltration

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108
Q

What is the first choice imaging for shoulder pain (traumatic)?

A

XR/radiographs
- 2-3 views

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109
Q

T/F: US is comparable to MRI for detection of full thickness RTC tears

A

True

110
Q

Gold standard imaging for detecting osseous lesions, early avascular necrosis, soft tissue abnormalities

A

MRI

111
Q

CT of the shoulder is indicated to rule out what?

A

Fracture or fracture/dislocation, prosthetic jt

112
Q

MRA of the shoulder is indicated to rule out what?

A

Autraumatic instability, labral, smaller articular-sided RTC tears when MRI inconclusive

113
Q

Common red flags for shoulder pain

A
  • Tumors
  • Infection
  • Visceral pathology
  • Rheumatological conditions
114
Q

Yellow flag screening is useful for what?

A

Identifying psychosocial risk in development of prolonged disability following onset of pain

115
Q

Examples of yellow flag domains

A

Depression, fear avoidance, anger, anxiety, kinesiophobia, catastrophizing

116
Q

Tool to identify yellow flags

A

OSPRO - yellow flag assessment

117
Q

What is the minimal clinically important difference (MCID) of the 0-10 pain scale in shoulder pain?

A

2 point threshold

118
Q

Shoulder/RTC atrophy in young adults, no MOI, overhead athletes

A

Neurogenic cause such as suprascapular neuropathy (compression @spinoglenoid notch associated with a paralabral cyst)

119
Q

Compression or entrapment along suprascapular notch would affect what/which muscle(s)?

A

Supraspinatus & Infraspinatus

120
Q

Compression or entrapment along spinoglenoid notch would affect what/which muscle(s)?

A

Infraspinatus ONLY

121
Q

Paralabral cysts

A

Swellings that arise around the socket of the shoulder joint (glenoid)
- Can cause neuropathies via compression in scap notches

122
Q

Excessive scapular downward rotation and depression suggests what?

A

Injury to SAN (CN XI) or AC jt pathology (type III seperation)

123
Q

T/F: Mild asymmetry of scapular posture can indicate a pathology or movement problem

A

False.

In itself, posture does not implicate an issue

124
Q

Tool to discriminate nociceptive pain from neuropathic pain

A

Modified painDETECT questionnaire

  • Sensitive and reliable
  • Score ≥12 suggests neuropathic
125
Q

T/F: Scapular dyskinesis is a pathoanatomic diagnosis

A

False, it’s a movement impairment

126
Q

Excessive scapular motion in a pattern of hiking or increased upward rotation and posterior tilt is consistent with what shoulder girdle issue?

A

GH Hypomobility

127
Q

Excessive scapular medial border or inferior angle winging during elevation in mid-range or with resisted elevation @90 is consistent with what shoulder girdle issue?

A

Scapular upward rotator weakness (SA) or movement coordination impairments

128
Q

Referral for EMG is indicated for what scapular presentation?

A

Dyskinesis, substantial weakness (<3/5) or progressive weakness

129
Q

Scapular assistance test

A

Manually inducing scapula upward rotation and posterior tilt, ask for pain change (MCID 2/10 change)

  • Acceptable inter-rater reliability
130
Q

Scapular reposition test

A

Manually inducing scapular posterior tilt (slight ER) and MCID 2/10

131
Q

A + scapular assistance test could indicate 2 common issues

A

1) Reduced posterior tilt
2) Decreased pec minor muscle length

132
Q

T/F: + scapular assistance test is shown to predict a good outcome with PT

A

True

133
Q

Normal total arc of shoulder motion

A

165-180°

134
Q

GIRD

A

Pathologic Glenohumeral IR deficit

  • Occurs when loss of IR EXCEEDS the increase in ER

aka
Loss of total arc by >5° or loss of IR ROM of 10-25°

135
Q

What would be a + GIRD test?

A

Loss of total arc by >5° or loss of IR ROM of 10-25°

136
Q

Horizontal adduction w/ 90° flexion to assess what structures? What is normal ° from vertical?

A

Posterior capsule tightness, 15° is normal

137
Q

What position creates the most strain of the posterior shoulder capsule:
a. IR @90° abd
b. IR in low angle of flexion (60°)

A

b. IR in low angle of flexion (60°)

138
Q

Pain resistance sequence

A

Used to determine irritability of the pain

139
Q

What is the gold standard for strength assessment?

A

Isokinetic testing

140
Q

Which is better: HHD or MMT for strength assessment

A

HHD

  • Strength assessment with “normal” MMT have shown deficits up to 20% when using HHD
141
Q

“Make” test with HHD

A

Patient gradually increases pressure, more reliable vs break test

142
Q

Minimal detectable change (MDC) when using a HHD

A

Change in strength of more than 15%

143
Q

When pain is present with strength testing does the validity of the test change?

A

Yes, strength tests have limited validity due to potential for pain to limit generating max effort

144
Q

T/F: Weakness in ER is a risk factor for UE injury in which populations?

A

Overhead athletes

145
Q

3 major pathoanatomic and regional pain source categores of the STAR-shoulder classification

A

1) Subacromial pain syndrome
2) Adhesive capsulitis
3) GH joint instability

NOTE: there is an “OTHER” category for remainder of conditions

146
Q

What diagnosis are included in the subacromial pain category of the STAR-shoulder classification

A

RTC tendinopathy, partial- or full-thickness RTC tears, bicipital tendinopathy, bursitis, secondary instability, SLAP lesions

147
Q

What diagnosis are included in the GH joint instability category of the STAR-shoulder classification

A

Traumatic subluxations and dislocations, atraumatic instability

148
Q

Cluster of 5 tests for subacromial pain syndrome

A

1) Neer sign
2) Hawkins sign
3) Jobe (Empty can)
4) Painful arc
5) Pain/weakness w/ resisted shoulder ER

149
Q

How may of the 5 tests for subacromial pain syndrome need to be positive for some confidence for ruling in/out?

A

3/5

(+LR 2.93, -LR 0.3)

150
Q

What 3 of the subacromial pain syndrome cluster tests are the BEST for ruling IN/OUT

A

Hawkins sign, painful arc, pain or weakness w/ resisted ER

If 3 are + = good at ruling in (+LR 10.56)
If 3 are - = good at ruling out (-LR 0.17)

151
Q

Litaker et al., 2000: Symptoom/risk factor cluster for rotator cuff tears

A

1) >65 y/o
2) night pain
3) Weakness in ER

Specificity 94.4%, +LR 9.8
aka good at ruling IN

152
Q

Drop arm test is used to identify large tears in which muscle?

SN/SP?

A

Supraspinatus

SN: 10-44 (aka poor)

SP: 98-100 (aka REALLY good at ruling IN)

153
Q

ER lag sign test is used to identify large tears in which muscle?

SN/SP?

A

Teres minor and infraspinatus

SN: 69-98 (mod to good)

SP: 98 (GREAT)

154
Q

If hornblower is negative, can you rule out rotator cuff tear?

A

Yes, good at ruling in AND out for teres minor

155
Q

If drop arm is negative, can you rule in/out rotator cuff tear?

A

Good for IN, bad for OUT

156
Q

4 Special tests for subscapularis tears

A

1) IR lag sign
2) Lift off test
3) Belly press
4) Bear hug

NOTE: low quality evidence

157
Q

Best subscap tear test for ruling in/out

A

IR lag sign (high SN/SP)

Remaining tests have good SP for ruling IN but not great for OUT

NOTE: bear hug is worst

158
Q

Sequential test cluster for shoulder joint instability

A

1) Apprehension
2) Relocation
3) Anterior release (suprise)

159
Q

Which tests in the cluster for shoulder joint instability are the best?

A

Combo of apprehension and relocation

SN: 81%
SP: 98%

160
Q

Pain with apprehension and relocation in posterior shoulder indicates what?

A

Posterior internal impingement sign

161
Q

Pain with apprehension and relocation in anterior shoulder indicates what?

A

Anterior instability

162
Q

Posterior apprehension test

SN/SP

A

Assesses posterior GH joint instability

SN: bad (19)
SP: GOOD (99)

163
Q

Beighton score

A

For hypermobility:
- Hands on floor
- Hyperextend elbows
- Hyperextend knees
- Hyperextend thumbs
- Hyperextend pinkie fingers

9 points, >4/9 = hypermobility

164
Q

Criteria for MDI

A

At least 2 directions of shoulder instability and the presence of a positive Beighton score

165
Q

Shoulder hyperabduction tests

A

For inferior instability

Positive test: Apprehension or
Increased laxity with >105° abduction w/ scapula stabilized

166
Q

O’Brien’s test

A

Used for SLAP lesion, can implicate AC joint issues

Positive test: ER position hurts less vs IR

167
Q

Confidence level to rule out SLAP lesion on exam only

A

Little confidence

168
Q

Is imaging indicated/helpful for atraumatic AC joint injuries?

A

NO, given high prevalence of asymptomatic degenerative changes

169
Q

Key factor for ruling in AC joint involvement

A

Location of symptoms

170
Q

Cluster to rule IN AC joint pathology

SN/SP

A

1) Pain with palpation
2) + O’Brien
3) Pain on top of shoulder

SN: 7%
SP: 97% (GREAT)

171
Q

T/F: Aerobic activity and isometric exercise are not appropriate for those with nociplastic pain

A

False, They may reduce central excitability and enhance descending pain inhibition

172
Q

Factors that increase compliance with HEP

A

Perceived simplicity, short duration, immediacy of benefit, absence of side effects

173
Q

STAR-Shoulder Adhesive Capsulitis in ICF language

A

Shoulder pain and and mobility deficits

174
Q

STAR-Shoulder Subacromial pain syndrome in ICF language

A

Shoulder pain and muscle performance deficits

175
Q

STAR-Shoulder Joint Instability in ICF language

A

Shoulder pain and motor coordination deficits

176
Q

Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (HIGH irritability)

A

1) Pain education
2) Active rest
3) Graded exposure
4) Psychologically-informed rehabilitation
5) Isometrics and aerobic exercise (enhance descending inhibition)
6) Referral for adjunctive care

177
Q

Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (MODERATE irritability)

A

1) Pain education
2) Active rest
3) Graded exposure
4) Psychologically-informed rehabilitation
5) Isometrics and aerobic exercise (enhance descending inhibition)
6) Referral for adjunctive care

178
Q

Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (LOW irritability)

A

1) Pain education
2) Active rest
3) Graded exposure
4) Psychologically-informed rehabilitation
5) Isometrics and aerobic exercise (enhance descending inhibition)
6) Referral for adjunctive care

179
Q

Interventions ->
Nociceptive pain and functional activity intolerance (HIGH irritability)

A

1) Activity modification (unloading focus)
2) Physiological ROM in mid-ranges
3) Manual therapy
4) Electrophysical agents
5) Aerobic activity

180
Q

Interventions ->
Nociceptive pain and functional activity intolerance (MODERATE irritability)

A

1) Activity modification (progressive loading)
2) Manual therapy
3) Limited electrophysical agent use
4) Aerobic activity

181
Q

Interventions ->
Nociceptive pain and functional activity intolerance (LOW irritability)

A

1) Activity re-integration - progressive high-loading focus
2) NO electrophyscial agents
3) Aerobic activity

182
Q

Interventions ->
Neuropathic pain (HIGH irritability)

A

1) Low-grade neural mobs
2) Physiologic ROM (mid-range)

183
Q

Interventions ->
Neuropathic pain (MODERATE irritability)

A

1) High-grade neural mobs
2) Intermittent end-range ROM and stretching

184
Q

Interventions ->
Neuropathic pain (LOW irritability)

A

1) High-grade neural mobs
2) End-range ROM and stretching (longer duration and frequency)

185
Q

Interventions ->
Limited passive mobility: jt/muscle/neural tissues (HIGH irritability)

A

1) ROM (pain-free)
2) Manual therapy

Typically not to end-range

186
Q

Interventions ->
Limited passive mobility: jt/muscle/neural tissues (MODERATE irritability)

A

1) ROM
2) Stretching
3) Manual therapy

Comfortable end-range, typically intermittent

187
Q

Interventions ->
Limited passive mobility: jt/muscle/neural tissues (LOW irritability)

A

1) ROM
2) Stretching
3) Manual therapy:

End-range, high-grade, longer duration and frequency

188
Q

Interventions ->
Excessive passive mobility (HIGH irritability)

A

1) Protect jt/tissue from end-range ROM
2) Limited immobilization
3) Isometrics of surrounding musculature

189
Q

Interventions ->
Excessive passive mobility (MODERATE irritability)

A

1) Develop active muscular/jt control in mid-range (AVOID end-range)
2) Treat hypo-mobility of adjacent tissues/joints

190
Q

Interventions ->
Excessive passive mobility (LOW irritability)

A

1) Develop active muscular/jt control in full ROM
2) High-level functional activity
3) Address hypomobility of adjacent joints/tissues

191
Q

Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (HIGH irritability)

A

1) AROM within pain-free range

192
Q

Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (MODERATE irritability)

A

1) Progressive resisted exercise, light to moderate loading mid-range

193
Q

Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (LOW irritability)

A

1) Moderate or high resistance to fatigue

194
Q

Interventions ->
Neuromuscular control/weakness/muscle activation (HIGH irritability)

A

1) AROM within pain-free ranges
2) Consider biofeedback, NMES, or other neural activation strategies

195
Q

Interventions ->
Neuromuscular control/weakness/muscle activation (MODERATE irritability)

A

1) Neuromuscular control training w/ ROM and focus on quality and precision rather than loading according to motor learning principles

196
Q

Interventions ->
Neuromuscular control/weakness/muscle activation (LOW irritability)

A

1) High demand neuromuscular control training with focus on quality rather than resistance

197
Q

Hallmark of adhesive capsulitis

A

Spontaneous loss of shoulder motion and specifically ER

198
Q

Adhesive capsulitis most common in which demographics/med hx

A
  • Women
  • Age 40-65 y/o
  • Diabetes
  • Hypothyroidism
  • Auto immune issues
199
Q

Are x-rays important when assessing a suspect adhesive capsulitis?

A

Yes, to rule out sinister pathology (infection, septic arthritis, malignancy, inflammatory arthropathy including polymyalgia rheumatica)

200
Q

Cause of secondary adhesive capsulitis

A

Immobilization

201
Q

Thawing stage of adhesive capsulitis comes on after how many months

A

18 months

202
Q

Best current evidence for interventions for adhesive capsulitis

A

Intra-articular steroid injections in combo with mobility and stretching exercises

203
Q

What level of evidence supports the use of pt education to guide their HEP and modification of activities

A

Moderate evidence

204
Q

Is prolonged stretching indicated in adhesive capsulitis?

A

Yes within pt tolerance, moderate evidence

205
Q

Better intervention for adhesive capsulitis:
High-grade mobs w/ terminal passive stretching V.S. education and HEP for ROM

A

Education and HEP for ROM

206
Q

Post GH jt mobs are (equal/better/worse) vs ant jt mobs at increasing ER ROM for shoulders with adhesive capsulitis

A

Better

207
Q

Surgical tx for adhesive capsulitis would be indicated when?

A

Those who have protracted symptoms (3-6 months) with little relief, regardless of tx.

208
Q

Type of surgical intervention for adhesive capsulitis

A

MUA, brisement (hydrodiliation), and arthroscopic capsular release

NOTE: all focus on increasing capsular volume

209
Q

Post-op course of PT for adhesive capsulitis would include

A

Minimal sling use and frequent arm motion/activity

210
Q

Cluster of findings to rule IN subacromial pain syndrome

A

1) painful arc
2) + impingement signs (Neers, Hawkins, Jobe/empty can)
3) Pain or weakness w/ resisted ER

Best combo to rule in: Hawkins, painful arc, pain or weakness w/ ER

211
Q

Surgery vs subacromal pain syndrome outcomes

A

Comparable

212
Q

First choice of intervention for subacromial pain syndrome

A

Exercise, optimal dosing unclear

213
Q

What level of evidence to include manual therapy in the initial phase of tx for subacromial pain syndrome

A

Strong evidence

214
Q

Post-op subacromial decompression full return to function timeline

A

6 wks to 3 months

215
Q

T/F: subacromial decompression w/ acromioplasty > bursectomy

A

True, better outcomes

216
Q

RTC tear sizes (small, medium, large, massive)

A

Small <1cm
Medium 1-3cm
Large >3-5cm
Massive >5cm

217
Q

T/F: clinical assessment can identify small RTC tears

A

False, clinical tests are not sensitive enough to differentiate small tears from subacromial pain syndrome

218
Q

When should referral to ortho be a priority with RTC tears?

A

Traumatic rotator cuff tears

Not indicated w/ atraumatic degenerative RTC tears that occur in >60 y/olds

219
Q

Interventions for small to medium RTC tears should include:

A
  • Exercise (focus on balance of ant/post force couples)
  • Stretching (especially post-capsule)
  • Mobilization of shoulder girdle
220
Q

Tears involving which 2 RTC muscles have a greater proportion of patients that are able to achieve greater than 160° shoulder elevation

A

Supraspinatus and infraspinatus

Still preliminary in evidence

221
Q

RTC repairs are indicated in which populations?

A
  • Traumatic mechanism
  • Younger individuals
  • Those participating in high demand activities
222
Q

Demographics of GH joint instability

A
  • Typically young (<40 y/o)
  • Hx of dislocation or feeling that shoulder is unstable
223
Q

Is graded motor imagery helpful with adhesive capsulitis?

A

Yes, shown to decrease kinesiophobia and fear

224
Q

Traumatic instability more common in (males/females)

A

Males, 7x more likely

225
Q

Traumatic instability most common in which age groups

A

15-29 and 70+ y/o

226
Q

Brachial plexus injuries occur in what % of disclocations?

A

18-71%, primarily in axillary nerve

227
Q

Is UE motor/sensory/reflex testing important in shoulder instability cases?

A

Yes, due to high frequency of brachial plexus or axillary nerve injuries

228
Q

Common causes of posterior dislocations

A

Trauma (67%)
Seizures (31%)

229
Q

Subluxation vs dislocation more common in patients with posterior shoulder instability

A

Subluxation

230
Q

Higher success rate with non-surgical management:
Anterior instability vs posterior instability?

A

Posterior instability

231
Q

How long to wear sling post-primary dislocation?

A

Limited to 1 week

Longer does NOT reduce risk of reoccurance

232
Q

Early interventions for primary GH jt dislocation should include

A
  • Limited immobility (sling wear of 1 wk max)
  • Isometrics of RTC and periscapular muscles
  • Activities to address proprioception, motor control, kinesiophobia, anxiety
233
Q

What factor can be key contributor to patient satisfaction and decreased post-injury depression when returning to sport after episode of shoulder instability

A

Social support from physical therapist

234
Q

Standard rehab including tband RTC and scap exercises vs SINEX program for shoulder instability

A

SINEX program showed better function, pain levels, clinical signs of instability at 12 weeks vs standard program

235
Q

What is the best overall evidence based management of traumatic shoulder instability?

A

A progressive neuromuscular motor control program that integrates the kinetic chain, and that is matched to the shoulder irritability level

236
Q

Watson vs Rockwood for atraumatic instability?

A

Watson and programs that emphasize neuromuscular control (superior to strengthening alone)

237
Q

NMES use in posterior shoulder instability

A

May be helpful

238
Q

Symptoms of SLAP tear

A

Deep shoulder pain
Popping with rotation
Post shoulder tight
Fatigue w/ overhead activities (“Dead arm”)

239
Q

Proximal humerus fx is common in (men/women), (young/old), and after what event?

A

Women, older, fall

240
Q

More common after proximal humerus fx: surgical vs non-surgical

A

75% non surgical

241
Q

Common mechanism of AC joint sprain

A

Blow to top of shoulder (w/ arm at side) or fall onto outstretched arm (shove arm up into acromion)

242
Q

Pt education important for non-surgical AC jt sprain (type I & II)

A

50% may have persistent pain 10 years down the road

243
Q

Type III AC jt sprain outcomes: surgical vs conservative

A

Comparable

244
Q

T/F: Post-AC jt sprain (Type III) there is limited time for surgical repair to be effective?

A

Nope, delays in surgery doesn’t affect outcome

245
Q

Rehab for patients with AC joint traumatic injury should initially include:

A
  • Sling (1-3 wks)
  • Pain management

PROGRESS to: P/AROM as symptoms allow

246
Q

Patients with persistent AC jt instability (Type III) are at risk for developing what symptoms?

A

Cervical symptoms

247
Q

Hallmark findings of GH OA include

A

Increasing stiffness, loss of ROM, pain w/ compression to the joint (scour), specific functional limitations

248
Q

Outcomes of TSA in older, low demand patients

A

Good

249
Q

Most important non-operative technique to manage mild to moderate GH jt OA

A

Education

250
Q

RTC repair: Exercises to restore mobility that produce less than ?% of maximum voluntary contraction of the supraspinatus has been advocated in early phase I?

A

15%

251
Q

Bankart surgery post-op protocol: Phase I
- ROM

A

AAROM -> AROM in 0-3 wks
Flexion = 0-135°
ER @0° = 0-30°
ER @90° (NOT until wk 6) = to 45°

252
Q

Bankart surgery post-op protocol:
Phase II
- ROM
- Strengthening

A

AROM progress to functional as tolerated, open/closed chain scap and RTC exercises, emphasize uniplanar motion

253
Q

Bankart surgery post-op protocol:
Phase III
- ROM
- Strengthening

A

No limit to ROM
Advance to multiplanar motion
Combine concentric and eccentric load

254
Q

Bankart surgery post-op protocol:
Phase IV
- Strengthening

A

Loading to sport

254
Q

Laterjet procedure

A

Used in those with instability that combines soft tissue pathology with significant bone loss (>15% of glenoid) or off track lesions

254
Q

Laterjet post-op protocol

A
  • Sling for 1-4 wks
  • ROM activities started in first week
  • NO ER until 6 wks
  • Strength at 6-8 wks and progressed at 12 wks
  • Return to sport in 3wks to 6 months
255
Q

TSA post-op protocol:
Phase I
- ROM

A

Flex: 0-90°
ER: 0-20°

P/AAROM

255
Q

TSA post-op protocol:
Phase II
- ROM

A

Flex: 120-130°
ER: 0-30°
IR: hand to hip

AAROM to AROM

256
Q

TSA post-op protocol:
Phase III
- ROM
- Strengthening

A

No limit on ROM
Start low loading exercises (focus on muscle performance below 90°)

257
Q

TSA post-op protocol:
Phase IV
- ROM
- Loading

A

Loading progressed cautiously, monitor symptoms

258
Q

rTSA post-op protocol:
Phase I
- ROM
- Loading

A

Flex: 0-90° for 2wks, 120°+ by 4-6wks
ER: 0-20° for 2 wks, 45° max by 4-6wks

P/AAROM
Begin AROM wk 4

259
Q

rTSA post-op protocol:
Phase II
- ROM
- Loading

A

Functional ROM for flex and AROM, deltoid isometrics

260
Q

rTSA post-op protocol:
Phase III
- ROM
- Loading

A

Gradual progression of light deltoid exercises

261
Q

rTSA post-op protocol:
Phase IV
- ROM
- Loading

A

Loading progressed cautiously, monitor symptoms

262
Q

Most commonly used shoulder specific PROM’s (Patient reported outcome measures)

A

ASES, PSS, SPADI

263
Q

Validated UE functional tests

A

YBT-UQ
CKCUEST
SMBT
SARTS
PSET
TFAST

264
Q

Purpose of The Charlson Comorbidity Index

A

Categorize medical comorbidities and health risk stratification

265
Q

Purpose of The Keele STarT MSK tool

A

Stratify intervention pathoways for pt’s with musculoskeletal conditions based on the likelihood of persistent pain, disability, and poor treatment outcome

266
Q

Purpose of The OSPRO red flag screening tool

A

Detect red flags that may result in change in patient care pathway

267
Q

Purpose of The painDETECT

A

To differentiate between nociceptive and neuropathic pain

268
Q

Watson neuromuscular strengthening and scapular upward rotation exercises are meant for what condition?

A

MDI

269
Q

SINEX is meant for what condition?

A

Unilateral instability (anterior dislocations)

OCS - Current Concepts of Ortho PT (12 decks)

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