Shoulder Flashcards
1
Q
Position of scapula? (what plane and facing ant vs retro)
A
Anteverted 30° in frontal plane
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°)
3
Q
Dominant shoulders tend to have more humeral anteroversion or retroversion?
A
Retroversion
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
5
Q
What is the balance stability angle?
A
Angle between the glenoid arc and center of the glenoid
6
Q
What happens if forces from muscles around the joint are directed outside of the balance stability angle?
A
Joint can be unstable
7
Q
Causes of excessive GH retroversion? What ° would be excessive?
A
Developmental abnormality, OA, secondary post-traumatic arthritis, inflammatory conditions
- >7° retroversion
8
Q
Concentric wear of the glenoid
A
Symmetrical or even along glenoid, centration (CENTRAL)
aka “Type A”
9
Q
Eccentric wear
A
Uneven wear of POSTERIOR glenoid, causing retroversion and post humeral head subluxation, can cause biconcave glenoid
aka “Type B”
10
Q
Type C glenoid changes
A
Retroversion of more than 25°, regardless of erosion or location
11
Q
What type of GH OA responds less to TSA surgery
A
eccentric deformities (negative impact with higher failure rate vs concentric)
12
Q
Glenoid anteversion predisposes the shoulder to what type of instability
A
Anterior
13
Q
Glenoid retroversion predisposes the shoulder to what type of instability
A
posterior, also leads to posterior labral tears
14
Q
What angle of retroversion is correlated with poor outcomes to restore stability to GH joint?
A
> 15° retroversion angle
15
Q
Which causes more instability: humeral retroversion vs glenoid changes?
A
Glenoid changes
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
17
Q
What % of bone loss with humeral lesions (i.e. Hill-Sachs) should be addressed surgically?
A
20-25%
18
Q
How to calculate true glenoid track width?
A
84% length - Glenoid defect width = track width
19
Q
AC joint ligaments provide stability in which directions?
A
Ant/Post
20
Q
Coraclavicular ligaments (2)
A
1) Conoid
2) Trapeziod
21
Q
Coraclavicular ligaments prevent against which movements at the AC joint?
A
Sup/Inf
22
Q
Amount of clavicular rotation with humeral elevation in scapular plane?
A
5-8° posteriorly
23
Q
AC joint: Type I strain
A
AC: strained, partially torn
CC: none
24
Q
AC joint: Type II strain
A
AC: Rupture
CC: Stretched but intact
25
AC joint: Type III strain
AC: Rupture
CC: Rupture
26
AC joint is what type?
Diarthrodial w/ fibrocartilaginous disc
27
The (congruency/incongruency) of the AC disc contributes to high rate of early degenerative changes?
Incongruency
28
SC joint: which direction of dislocation is more common?
Anterior
NOTE: post very dangerous
29
What structures (3) form a pulley that stabilizes the biceps tendon?
1) Superior GH ligament
2) Coracohumeral ligament
3) distal subscap tendon
30
Buford complex (GH capsule)
Congenital labrum variant where the anterior/superior labrum is absent from 1-3 "o-clock"
31
Middle GH ligament contributes the most to stability in what position?
Shoulder abducted to 45° and ER
32
Superior GH ligament contributes the most to stability in what position? Resists what?
Neutral rotation, 0° abd
Resists inferior
33
Bankart lesion
Avulsion of anterior band of INF GH lig
34
Which of the inferior GH ligaments has the highest tensile strength? Which direction does it stabilize?
Anterior band, resists anterior translation when shoulder is 90° abd and ER
35
What GH ligament is the main stabilizer against inferior GH jt translation
Inferior complex
36
2 categories of GH joint instability?
1) TUBS
2) AMBRI
37
What does TUBS stand for?
Traumatic
Unilateral
Bankart lesion
Surgery
38
What does AMBRI stand for?
Atraumatic
Multidirectional
Bilateral
Rehabilitation
Inferior capsular shift
39
Multidirectional instability is categorized by instability in how many directions?
At least 2
40
Posterior band of GH ligament stabilizes the shoulder when in what position?
Common injury in which sport/position
Flexion and IR
Football linemen (blocking)
41
Difference between Bankart vs bony bankart
Bankart: just ligament
Bony bankart: both lig and anterior glenoid
42
Reverse bankart
Lesion of post labrum and post INF GH ligament, can be bony
43
Depth of the glenoid is increased by what % due to labrum?
50%
44
What part of the labrum is more loosely attached (superior/anterior/posterior/inferior)
Superior
45
T/F: Dynamic stability of the labrum is controlled by the attachment of the long-head of the biceps tendon?
True
46
SLAP stands for?
Superior
Labrum
Anterior to Posterior
47
What population is at high risk for SLAP lesions?
Overhead throwing athletes (eccentric biceps activity)
48
Vascularization of the GH labrum
Historically poor, but found to be more dense in periphery (best in anterosuperior)
49
Does the GH labrum have nerve endings?
Yes, causing injuries to be painful, can contribute to proprioception
50
Rotator cuff interval
Located between supraspinatus and subscapularis, triangle shaped in anterior shoulder
51
Rotator cable
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
52
What part of the supraspinatus is the stiffest?
Bursal side and higher ant vs post
53
Rotator cresent
Located between rotator cable and insertions on the greater tuberosity
54
Vascularization of rotator crescent?
Avascular, but noted to be greater on bursal side of the tendon
55
Which is stronger - rotator cable vs crescent?
Cable is 2.59 thicker
NOTE: cable is better to stress shield with age
56
Cable vs crescent dominant in young and old?
Young: crescent dominant
Old: cable dominant
57
What is a force couple?
2 forces directed in opposite directions that cause rotation in a specific direction
58
Subscapularis is in a force couple with which muscle on the scapula?
Infraspinatus
59
Rotator cuff (collectively) is in a force couple with which muscle around the GH jt?
Deltoids and pecs
60
What position of the shoulder does the long-head of the bicep provide stability in?
Abd and ER
61
What are intrinsic factors of rotator cuff pathology?
Alterations in biology, hypercholesterolemia, family hx of RTC tears
62
Neer proposed that what % of RTC tears were caused by impingment?
95%
63
Which has better outcomes: surgical subacromial impingement decompression vs non-operative tx?
Neither, they have the same outcomes
64
T/F: Combined removal of the acromion and bursectomy was more beneficial vs bursectomy alone?
False, no difference
65
What angle of elevation/flexion does the smallest distance between the acromion and supraspinatus occur?
30-70° elevation
66
Neers sign may be indicative of which type of impingement?
Internal
67
Painful Arc test is in which ° range?
60°-120° of abduction
68
Posterior internal impingement is commonly found in what population?
Throwing athletes (late cocking phase)
69
What is the primary intrinsic factor for RTC pathoanatomy?
Age (vascularity is significantly decreased after age 40)
70
What 2 systemic conditions put a person a higher risk for developing tendinopathy?
Hypercholesteremia and diabetes
71
Does smoking affect tendon healing? If so, how?
Yes, it inhibits delivery of O2
72
Do genetics contribute to risk for RTC pathology?
Yes, small role
73
What is the most common partial thickness tear of the rotator cuff? (intra-tendinous, bursal-sided, articular-sided)
Intra-tendinous
74
Degenerative tears in the RTC tend to initially occur where?
Within the RTC crescent and the juction between the supra and infraspinatus
75
What happens to shoulder function with tears inside the crescent?
Well maintained as long as there is no disruption in the rotator cable
76
T/F: rotator cuff atrophy has no impact in outcomes post-repair?
False, RTC atrophy has been correlated to higher post-op re-tear rates
77
How soon after RTC tear (not operated on yet) can you see cartilage damage?
12 weeks
78
6 Muscles responsible for stabilization of the scapulothoracic joint
1) Trapezius
2) Romboid major
3) Romboid minor
4) SA
5) LS
6) Pectoralis minor
79
Scapulohumeral rhythm is defined as what ratio?
2:1 ratio - 60° scap upward rotation and 120° GH jt movement
80
What shoulder force couple is responsible for posterior scapula tilting?
Lower trap and SA
81
What muscle is the primary upward rotator and protractor of the shoulder girdle?
Serratus Anterior
82
What muscle is the primary stabilizer of the scapula?
Trapezius
83
Scapular muscle imbalance/altered motor control is believed to contribute to dyskinesis in what 2 ways?
1) Excessive UT activation
2) Decreased/delayed activation of lower/middle traps and SA
84
Innervation of SA muscle?
Long thoracic nerve
85
Innervation of the traps and SCM?
Spinal accessory nerve XI
86
Common presentation of damage to the spinal accessory nerve (CN XI)
Asymmetric neckline (depressed), a drooping shoulder, protraction and winging of the scapula, and weakness of forward elevation
87
Cervical lymph node removal or radical dis'c dissection due to cancerous tumors can cause damage to which nerve responsible for scapular motion?
Spinal accessory nerve (CN XI)
88
What are the factors of pain behavior?
- Aggravating/alleviating factors
- 24hr pattern
- Pain severity and irritability
- Chronicity
89
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
Adhesive capsulitis - primary
90
Hypothesized pathoanatomic diagnosis:
- Gradual onset pain
- Decreased ROM
- Age 60+
- Crepitus/catching w/ end ranges
- AM stiffness
GH OA
91
Hypothesized pathoanatomic diagnosis:
- Ant/lat shoulder pain
- Pain w/ overhead activity
- Painful arc
- Pain at night
Subacromial pain syndrome
92
Hypothesized pathoanatomic diagnosis:
- Ant/lat shoulder pain
- Loss of strength
- Pain worst at night
- Age 40+
RTC tear
93
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"
Anterior instability/labral tear
94
Hypothesized pathoanatomic diagnosis:
- Instability
- Apprehension
- Pain in flex/horiz add w/ post force through humerus
- Hx of trauma w/ or w/o dislocation
Posterior instability
95
Hypothesized pathoanatomic diagnosis:
- Deep anterior pain
- Clicking/clunking/jt locking
- Pain w/ throwing or bicep loading
SLAP lesion
96
Hypothesized pathoanatomic diagnosis:
- Post pain during abd/ER (especially w/ hyperabduction)
- Overhead athletes
Posterior internal impingement
97
Hypothesized pathoanatomic diagnosis:
- Anterior pain
- Bicipital groove w/ shoulder flex and supination
Long head of the biceps tendinopathy
98
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)
AC joint arthropathy/injury
99
What is SINSS model?
Severity, Irritability, Nature, Stage and Stability (SINSS) model for pain
100
Characteristics of HIGH pain irritability:
- ≥7/10 pain
- Constant night or rest pain
- High disability level
- Pain limits ROM (AROM > PROM)
101
Characteristics of MODERATE pain irritability:
- 4-6/10 pain
- Intermittent at night and rest
- Moderate disability
- Little discrepancy between PROM and AROM
- Pain primarily @ end-range
102
Characteristics of MILD pain irritability:
- ≤3/10 pain
- No resting or night pain
- Minimal pain @end-range
- AROM = PROM
103
Polymyalgia Rheumatica
An inflammatory disorder causing muscle pain and stiffness around the shoulders and hips & almost flu-like symptoms
- Common in 60+ y/o
104
Parsonage-Turner syndrome (PTS)
- 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.
105
Validated standardized screening tool to identify medical red flags
OSPRO-Review of systems tool
106
T/F: Delayed surgical repair in the presence of an acute rotator cuff tear negatively impacts patient outcomes
True
107
How can chronicity of RTC tear be determined?
MRI
- Muscle atrophy
- Fat infiltration
108
What is the first choice imaging for shoulder pain (traumatic)?
XR/radiographs
- 2-3 views
109
T/F: US is comparable to MRI for detection of full thickness RTC tears
True
110
Gold standard imaging for detecting osseous lesions, early avascular necrosis, soft tissue abnormalities
MRI
111
CT of the shoulder is indicated to rule out what?
Fracture or fracture/dislocation, prosthetic jt
112
MRA of the shoulder is indicated to rule out what?
Autraumatic instability, labral, smaller articular-sided RTC tears when MRI inconclusive
113
Common red flags for shoulder pain
- Tumors
- Infection
- Visceral pathology
- Rheumatological conditions
114
Yellow flag screening is useful for what?
Identifying psychosocial risk in development of prolonged disability following onset of pain
115
Examples of yellow flag domains
Depression, fear avoidance, anger, anxiety, kinesiophobia, catastrophizing
116
Tool to identify yellow flags
OSPRO - yellow flag assessment
117
What is the minimal clinically important difference (MCID) of the 0-10 pain scale in shoulder pain?
2 point threshold
118
Shoulder/RTC atrophy in young adults, no MOI, overhead athletes
Neurogenic cause such as suprascapular neuropathy (compression @spinoglenoid notch associated with a paralabral cyst)
119
Compression or entrapment along suprascapular notch would affect what/which muscle(s)?
Supraspinatus & Infraspinatus
120
Compression or entrapment along spinoglenoid notch would affect what/which muscle(s)?
Infraspinatus ONLY
121
Paralabral cysts
Swellings that arise around the socket of the shoulder joint (glenoid)
- Can cause neuropathies via compression in scap notches
122
Excessive scapular downward rotation and depression suggests what?
Injury to SAN (CN XI) or AC jt pathology (type III seperation)
123
T/F: Mild asymmetry of scapular posture can indicate a pathology or movement problem
False.
In itself, posture does not implicate an issue
124
Tool to discriminate nociceptive pain from neuropathic pain
Modified painDETECT questionnaire
- Sensitive and reliable
- Score ≥12 suggests neuropathic
125
T/F: Scapular dyskinesis is a pathoanatomic diagnosis
False, it's a movement impairment
126
Excessive scapular motion in a pattern of hiking or increased upward rotation and posterior tilt is consistent with what shoulder girdle issue?
GH Hypomobility
127
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?
Scapular upward rotator weakness (SA) or movement coordination impairments
128
Referral for EMG is indicated for what scapular presentation?
Dyskinesis, substantial weakness (<3/5) or progressive weakness
129
Scapular assistance test
Manually inducing scapula upward rotation and posterior tilt, ask for pain change (MCID 2/10 change)
- Acceptable inter-rater reliability
130
Scapular reposition test
Manually inducing scapular posterior tilt (slight ER) and MCID 2/10
131
A + scapular assistance test could indicate 2 common issues
1) Reduced posterior tilt
2) Decreased pec minor muscle length
132
T/F: + scapular assistance test is shown to predict a good outcome with PT
True
133
Normal total arc of shoulder motion
165-180°
134
GIRD
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
What would be a + GIRD test?
Loss of total arc by >5° or loss of IR ROM of 10-25°
136
Horizontal adduction w/ 90° flexion to assess what structures? What is normal ° from vertical?
Posterior capsule tightness, 15° is normal
137
What position creates the most strain of the posterior shoulder capsule:
a. IR @90° abd
b. IR in low angle of flexion (60°)
b. IR in low angle of flexion (60°)
138
Pain resistance sequence
Used to determine irritability of the pain
139
What is the gold standard for strength assessment?
Isokinetic testing
140
Which is better: HHD or MMT for strength assessment
HHD
- Strength assessment with "normal" MMT have shown deficits up to 20% when using HHD
141
"Make" test with HHD
Patient gradually increases pressure, more reliable vs break test
142
Minimal detectable change (MDC) when using a HHD
Change in strength of more than 15%
143
When pain is present with strength testing does the validity of the test change?
Yes, strength tests have limited validity due to potential for pain to limit generating max effort
144
T/F: Weakness in ER is a risk factor for UE injury in which populations?
Overhead athletes
145
3 major pathoanatomic and regional pain source categores of the STAR-shoulder classification
1) Subacromial pain syndrome
2) Adhesive capsulitis
3) GH joint instability
NOTE: there is an "OTHER" category for remainder of conditions
146
What diagnosis are included in the subacromial pain category of the STAR-shoulder classification
RTC tendinopathy, partial- or full-thickness RTC tears, bicipital tendinopathy, bursitis, secondary instability, SLAP lesions
147
What diagnosis are included in the GH joint instability category of the STAR-shoulder classification
Traumatic subluxations and dislocations, atraumatic instability
148
Cluster of 5 tests for subacromial pain syndrome
1) Neer sign
2) Hawkins sign
3) Jobe (Empty can)
4) Painful arc
5) Pain/weakness w/ resisted shoulder ER
149
How may of the 5 tests for subacromial pain syndrome need to be positive for some confidence for ruling in/out?
3/5
(+LR 2.93, -LR 0.3)
150
What 3 of the subacromial pain syndrome cluster tests are the BEST for ruling IN/OUT
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
Litaker et al., 2000: Symptoom/risk factor cluster for rotator cuff tears
1) >65 y/o
2) night pain
3) Weakness in ER
Specificity 94.4%, +LR 9.8
aka good at ruling IN
152
Drop arm test is used to identify large tears in which muscle?
SN/SP?
Supraspinatus
SN: 10-44 (aka poor)
SP: 98-100 (aka REALLY good at ruling IN)
153
ER lag sign test is used to identify large tears in which muscle?
SN/SP?
Teres minor and infraspinatus
SN: 69-98 (mod to good)
SP: 98 (GREAT)
154
If hornblower is negative, can you rule out rotator cuff tear?
Yes, good at ruling in AND out for teres minor
155
If drop arm is negative, can you rule in/out rotator cuff tear?
Good for IN, bad for OUT
156
4 Special tests for subscapularis tears
1) IR lag sign
2) Lift off test
3) Belly press
4) Bear hug
NOTE: low quality evidence
157
Best subscap tear test for ruling in/out
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
Sequential test cluster for shoulder joint instability
1) Apprehension
2) Relocation
3) Anterior release (suprise)
159
Which tests in the cluster for shoulder joint instability are the best?
Combo of apprehension and relocation
SN: 81%
SP: 98%
160
Pain with apprehension and relocation in posterior shoulder indicates what?
Posterior internal impingement sign
161
Pain with apprehension and relocation in anterior shoulder indicates what?
Anterior instability
162
Posterior apprehension test
SN/SP
Assesses posterior GH joint instability
SN: bad (19)
SP: GOOD (99)
163
Beighton score
For hypermobility:
- Hands on floor
- Hyperextend elbows
- Hyperextend knees
- Hyperextend thumbs
- Hyperextend pinkie fingers
9 points, >4/9 = hypermobility
164
Criteria for MDI
At least 2 directions of shoulder instability and the presence of a positive Beighton score
165
Shoulder hyperabduction tests
For inferior instability
Positive test: Apprehension or
Increased laxity with >105° abduction w/ scapula stabilized
166
O'Brien's test
Used for SLAP lesion, can implicate AC joint issues
Positive test: ER position hurts less vs IR
167
Confidence level to rule out SLAP lesion on exam only
Little confidence
168
Is imaging indicated/helpful for atraumatic AC joint injuries?
NO, given high prevalence of asymptomatic degenerative changes
169
Key factor for ruling in AC joint involvement
Location of symptoms
170
Cluster to rule IN AC joint pathology
SN/SP
1) Pain with palpation
2) + O'Brien
3) Pain on top of shoulder
SN: 7%
SP: 97% (GREAT)
171
T/F: Aerobic activity and isometric exercise are not appropriate for those with nociplastic pain
False, They may reduce central excitability and enhance descending pain inhibition
172
Factors that increase compliance with HEP
Perceived simplicity, short duration, immediacy of benefit, absence of side effects
173
STAR-Shoulder Adhesive Capsulitis in ICF language
Shoulder pain and and mobility deficits
174
STAR-Shoulder Subacromial pain syndrome in ICF language
Shoulder pain and muscle performance deficits
175
STAR-Shoulder Joint Instability in ICF language
Shoulder pain and motor coordination deficits
176
Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (HIGH irritability)
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
Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (MODERATE irritability)
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
Interventions ->
Impairment: Nociplastic pain and functional activity intolerance (LOW irritability)
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
Interventions ->
Nociceptive pain and functional activity intolerance (HIGH irritability)
1) Activity modification (unloading focus)
2) Physiological ROM in mid-ranges
3) Manual therapy
4) Electrophysical agents
5) Aerobic activity
180
Interventions ->
Nociceptive pain and functional activity intolerance (MODERATE irritability)
1) Activity modification (progressive loading)
2) Manual therapy
3) Limited electrophysical agent use
4) Aerobic activity
181
Interventions ->
Nociceptive pain and functional activity intolerance (LOW irritability)
1) Activity re-integration - progressive high-loading focus
2) NO electrophyscial agents
3) Aerobic activity
182
Interventions ->
Neuropathic pain (HIGH irritability)
1) Low-grade neural mobs
2) Physiologic ROM (mid-range)
183
Interventions ->
Neuropathic pain (MODERATE irritability)
1) High-grade neural mobs
2) Intermittent end-range ROM and stretching
184
Interventions ->
Neuropathic pain (LOW irritability)
1) High-grade neural mobs
2) End-range ROM and stretching (longer duration and frequency)
185
Interventions ->
Limited passive mobility: jt/muscle/neural tissues (HIGH irritability)
1) ROM (pain-free)
2) Manual therapy
Typically not to end-range
186
Interventions ->
Limited passive mobility: jt/muscle/neural tissues (MODERATE irritability)
1) ROM
2) Stretching
3) Manual therapy
Comfortable end-range, typically intermittent
187
Interventions ->
Limited passive mobility: jt/muscle/neural tissues (LOW irritability)
1) ROM
2) Stretching
3) Manual therapy:
End-range, high-grade, longer duration and frequency
188
Interventions ->
Excessive passive mobility (HIGH irritability)
1) Protect jt/tissue from end-range ROM
2) Limited immobilization
3) Isometrics of surrounding musculature
189
Interventions ->
Excessive passive mobility (MODERATE irritability)
1) Develop active muscular/jt control in mid-range (AVOID end-range)
2) Treat hypo-mobility of adjacent tissues/joints
190
Interventions ->
Excessive passive mobility (LOW irritability)
1) Develop active muscular/jt control in full ROM
2) High-level functional activity
3) Address hypomobility of adjacent joints/tissues
191
Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (HIGH irritability)
1) AROM within pain-free range
192
Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (MODERATE irritability)
1) Progressive resisted exercise, light to moderate loading mid-range
193
Interventions ->
Neuromuscular weakness associated with disuse, atrophy, and deconditioning (LOW irritability)
1) Moderate or high resistance to fatigue
194
Interventions ->
Neuromuscular control/weakness/muscle activation (HIGH irritability)
1) AROM within pain-free ranges
2) Consider biofeedback, NMES, or other neural activation strategies
195
Interventions ->
Neuromuscular control/weakness/muscle activation (MODERATE irritability)
1) Neuromuscular control training w/ ROM and focus on quality and precision rather than loading according to motor learning principles
196
Interventions ->
Neuromuscular control/weakness/muscle activation (LOW irritability)
1) High demand neuromuscular control training with focus on quality rather than resistance
197
Hallmark of adhesive capsulitis
Spontaneous loss of shoulder motion and specifically ER
198
Adhesive capsulitis most common in which demographics/med hx
- Women
- Age 40-65 y/o
- Diabetes
- Hypothyroidism
- Auto immune issues
199
Are x-rays important when assessing a suspect adhesive capsulitis?
Yes, to rule out sinister pathology (infection, septic arthritis, malignancy, inflammatory arthropathy including polymyalgia rheumatica)
200
Cause of secondary adhesive capsulitis
Immobilization
201
Thawing stage of adhesive capsulitis comes on after how many months
18 months
202
Best current evidence for interventions for adhesive capsulitis
Intra-articular steroid injections in combo with mobility and stretching exercises
203
What level of evidence supports the use of pt education to guide their HEP and modification of activities
Moderate evidence
204
Is prolonged stretching indicated in adhesive capsulitis?
Yes within pt tolerance, moderate evidence
205
Better intervention for adhesive capsulitis:
High-grade mobs w/ terminal passive stretching V.S. education and HEP for ROM
Education and HEP for ROM
206
Post GH jt mobs are (equal/better/worse) vs ant jt mobs at increasing ER ROM for shoulders with adhesive capsulitis
Better
207
Surgical tx for adhesive capsulitis would be indicated when?
Those who have protracted symptoms (3-6 months) with little relief, regardless of tx.
208
Type of surgical intervention for adhesive capsulitis
MUA, brisement (hydrodiliation), and arthroscopic capsular release
NOTE: all focus on increasing capsular volume
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Post-op course of PT for adhesive capsulitis would include
Minimal sling use and frequent arm motion/activity
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Cluster of findings to rule IN subacromial pain syndrome
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
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Surgery vs subacromal pain syndrome outcomes
Comparable
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First choice of intervention for subacromial pain syndrome
Exercise, optimal dosing unclear
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What level of evidence to include manual therapy in the initial phase of tx for subacromial pain syndrome
Strong evidence
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Post-op subacromial decompression full return to function timeline
6 wks to 3 months
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T/F: subacromial decompression w/ acromioplasty > bursectomy
True, better outcomes
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RTC tear sizes (small, medium, large, massive)
Small <1cm
Medium 1-3cm
Large >3-5cm
Massive >5cm
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T/F: clinical assessment can identify small RTC tears
False, clinical tests are not sensitive enough to differentiate small tears from subacromial pain syndrome
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When should referral to ortho be a priority with RTC tears?
Traumatic rotator cuff tears
Not indicated w/ atraumatic degenerative RTC tears that occur in >60 y/olds
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Interventions for small to medium RTC tears should include:
- Exercise (focus on balance of ant/post force couples)
- Stretching (especially post-capsule)
- Mobilization of shoulder girdle
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Tears involving which 2 RTC muscles have a greater proportion of patients that are able to achieve greater than 160° shoulder elevation
Supraspinatus and infraspinatus
Still preliminary in evidence
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RTC repairs are indicated in which populations?
- Traumatic mechanism
- Younger individuals
- Those participating in high demand activities
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Demographics of GH joint instability
- Typically young (<40 y/o)
- Hx of dislocation or feeling that shoulder is unstable
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Is graded motor imagery helpful with adhesive capsulitis?
Yes, shown to decrease kinesiophobia and fear
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Traumatic instability more common in (males/females)
Males, 7x more likely
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Traumatic instability most common in which age groups
15-29 and 70+ y/o
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Brachial plexus injuries occur in what % of disclocations?
18-71%, primarily in axillary nerve
227
Is UE motor/sensory/reflex testing important in shoulder instability cases?
Yes, due to high frequency of brachial plexus or axillary nerve injuries
228
Common causes of posterior dislocations
Trauma (67%)
Seizures (31%)
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Subluxation vs dislocation more common in patients with posterior shoulder instability
Subluxation
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Higher success rate with non-surgical management:
Anterior instability vs posterior instability?
Posterior instability
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How long to wear sling post-primary dislocation?
Limited to 1 week
Longer does NOT reduce risk of reoccurance
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Early interventions for primary GH jt dislocation should include
- Limited immobility (sling wear of 1 wk max)
- Isometrics of RTC and periscapular muscles
- Activities to address proprioception, motor control, kinesiophobia, anxiety
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What factor can be key contributor to patient satisfaction and decreased post-injury depression when returning to sport after episode of shoulder instability
Social support from physical therapist
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Standard rehab including tband RTC and scap exercises vs SINEX program for shoulder instability
SINEX program showed better function, pain levels, clinical signs of instability at 12 weeks vs standard program
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What is the best overall evidence based management of traumatic shoulder instability?
A progressive neuromuscular motor control program that integrates the kinetic chain, and that is matched to the shoulder irritability level
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Watson vs Rockwood for atraumatic instability?
Watson and programs that emphasize neuromuscular control (superior to strengthening alone)
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NMES use in posterior shoulder instability
May be helpful
238
Symptoms of SLAP tear
Deep shoulder pain
Popping with rotation
Post shoulder tight
Fatigue w/ overhead activities ("Dead arm")
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Proximal humerus fx is common in (men/women), (young/old), and after what event?
Women, older, fall
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More common after proximal humerus fx: surgical vs non-surgical
75% non surgical
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Common mechanism of AC joint sprain
Blow to top of shoulder (w/ arm at side) or fall onto outstretched arm (shove arm up into acromion)
242
Pt education important for non-surgical AC jt sprain (type I & II)
50% may have persistent pain 10 years down the road
243
Type III AC jt sprain outcomes: surgical vs conservative
Comparable
244
T/F: Post-AC jt sprain (Type III) there is limited time for surgical repair to be effective?
Nope, delays in surgery doesn't affect outcome
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Rehab for patients with AC joint traumatic injury should initially include:
- Sling (1-3 wks)
- Pain management
PROGRESS to: P/AROM as symptoms allow
246
Patients with persistent AC jt instability (Type III) are at risk for developing what symptoms?
Cervical symptoms
247
Hallmark findings of GH OA include
Increasing stiffness, loss of ROM, pain w/ compression to the joint (scour), specific functional limitations
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Outcomes of TSA in older, low demand patients
Good
249
Most important non-operative technique to manage mild to moderate GH jt OA
Education
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RTC repair: Exercises to restore mobility that produce less than ?% of maximum voluntary contraction of the supraspinatus has been advocated in early phase I?
15%
251
Bankart surgery post-op protocol: Phase I
- ROM
AAROM -> AROM in 0-3 wks
Flexion = 0-135°
ER @0° = 0-30°
ER @90° (NOT until wk 6) = to 45°
252
Bankart surgery post-op protocol:
Phase II
- ROM
- Strengthening
AROM progress to functional as tolerated, open/closed chain scap and RTC exercises, emphasize uniplanar motion
253
Bankart surgery post-op protocol:
Phase III
- ROM
- Strengthening
No limit to ROM
Advance to multiplanar motion
Combine concentric and eccentric load
254
Bankart surgery post-op protocol:
Phase IV
- Strengthening
Loading to sport
254
Laterjet procedure
Used in those with instability that combines soft tissue pathology with significant bone loss (>15% of glenoid) or off track lesions
254
Laterjet post-op protocol
- 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
TSA post-op protocol:
Phase I
- ROM
Flex: 0-90°
ER: 0-20°
P/AAROM
255
TSA post-op protocol:
Phase II
- ROM
Flex: 120-130°
ER: 0-30°
IR: hand to hip
AAROM to AROM
256
TSA post-op protocol:
Phase III
- ROM
- Strengthening
No limit on ROM
Start low loading exercises (focus on muscle performance below 90°)
257
TSA post-op protocol:
Phase IV
- ROM
- Loading
Loading progressed cautiously, monitor symptoms
258
rTSA post-op protocol:
Phase I
- ROM
- Loading
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
rTSA post-op protocol:
Phase II
- ROM
- Loading
Functional ROM for flex and AROM, deltoid isometrics
260
rTSA post-op protocol:
Phase III
- ROM
- Loading
Gradual progression of light deltoid exercises
261
rTSA post-op protocol:
Phase IV
- ROM
- Loading
Loading progressed cautiously, monitor symptoms
262
Most commonly used shoulder specific PROM's (Patient reported outcome measures)
ASES, PSS, SPADI
263
Validated UE functional tests
YBT-UQ
CKCUEST
SMBT
SARTS
PSET
TFAST
264
Purpose of The Charlson Comorbidity Index
Categorize medical comorbidities and health risk stratification
265
Purpose of The Keele STarT MSK tool
Stratify intervention pathoways for pt's with musculoskeletal conditions based on the likelihood of persistent pain, disability, and poor treatment outcome
266
Purpose of The OSPRO red flag screening tool
Detect red flags that may result in change in patient care pathway
267
Purpose of The painDETECT
To differentiate between nociceptive and neuropathic pain
268
Watson neuromuscular strengthening and scapular upward rotation exercises are meant for what condition?
MDI
269
SINEX is meant for what condition?
Unilateral instability (anterior dislocations)
