Shoulder Flashcards
what is the issue with the medical model?
- no reliable correlation with symptoms
- does not guide rehab clinical decision making
what does the medical model exam/treatment consist of?
- take history
- perform exam
- assign a diagnosis
- prescribe treatment based on that diagnosis
T or F: there are special tests that are 100% sensitive and specific
F
special tests are most useful for ruling _______ conditions
out
T or F: treatment based on the medical model works well for most rehab patients
F: patients with the same medical diagnosis can present very differently and therefore need different treatments
two cases in which the medical model is valid
fracture management
surgery
you have a patient with subacromial pain syndrome suffering an exacerbation (9/10 pain) after painting. what is the optimal management for this patient
rest, NSAIDs, isometrics, education on prevention
you have another patient with SA pain syndrome who only experiences intermittent pain, especially with elevation. he has 0/10 pain at rest. what is the optimal management for this patient?
sleeper stretch
eccentric posterior RC exercises
long term endurance training depending on goals
what are two major things that guide intervention?
impairments and SINS
SINS (acronym)
- Severity (how functionally limiting)
- Irritability
- Nature (trauma/overuse)
- Stage (acute/chronic)
what are the two most important questions to ask during subjective
age and onset
examples of common overall impairments
- motion restriction
- strength
- endurance
- fear avoidance
- central sensitization
ultimate goal of PT is to identify the most relevant _________- and apply the optimal ________ for it
impairment
intervention
T or F: the rehab model can include a medical diagnosis
T: patients want a label and other medical providers are familiar with them
the main focus of the rehab model is…
impairments
T or F: most atraumatic MSK pain is linked to a pathoanatomical (medical) diagnosis
F
what are two approaches to always avoid with atraumatic MSK pain?
1 - linking image finding to pain presentations
2 - linking interventions to a “fix”
T or F: imaging findings are common without symptoms
T: disk degeneration, cuff tears, etc.
you want patients to have an _________ locus of control. What does this mean?
internal
they are in control of the situation *image findings can shift them to external
it is important to talk about lifestyle changes with your patients. these can include… (3)
tobacco use
weight loss
managing pain
screening determines what?
if a patient is appropriate for PT?
your pt is a 71 y/o who c/o R shoulder pain. there was not MOI. he has weakness with RC muscle testing. is this pt appropriate for PT?
yes, based on how rehab goes he may benefit from imaging or surgical eval
your pt is a 23 y/o who c/o R shoulder pain after falling down the stairs and catching himself on an outstretched hand. he is very guarded and you were not able to complete a full exam due to pain. is this pt appropriate for PT?
no, you need an ortho opinion first, he may be appropriate after
you pt is a 50 y/o male complaining of L shoulder pain that also radiates to the jaw. he is short of breath. you are unable to reproduce the pain with shoulder testing. is this patient appropriate for PT?
no - these are red flags. 911
red flags
serious pathology (cauda equina, heart attack, cancer, fracture, infection, etc.)
orange flag
psychiatric symptoms (depression and anxiety)
yellow flags
beliefs and pain behavior
blue flags
work related
black flags
system or contextual obstacles (insurance, litigation, overly helpful/unhelpful family)
cervical radiculopathy special tests
compression, spurlings, quadrant
thoracic outlet special tests
roos, wrights, adsons, tinels
myelopathy
- what is it?
- signs/symptoms?
- compression of spinal cord
- UMN, bowel/bladder issues, clumsiness
SINS guide the ________ of the treatment whereas impairments guide ______ of the treatment
intensity
location
how many levels of irritability
3 (high, moderate, low)
signs of high stage of irritability
- high pain (7/10 or more)
- consistent night/rest pain
- pain before end range
- AROM < PROM
- high disability
signs of moderate stage of irritability
- mod pain (4-6/10)
- intermittent night/rest pain
- pain at end range
- AROM - PROM
- mod disability
signs of low stage of irritability
- low pain (<3/10)
- no night/rest pain
- min pain w/ overpressure
- AROM = PROM
- low disability
treatment approach for high level of irritability
- modify activity to not stress affected tissue but don’t stop all activity
- therex and manual to reduce symptoms
- isometrics
in patients with _______ irritability, is may be difficult to reproduce comparable signs
low
if you can’t replicate the aggravating task in the clinic have them do it before
treatment for pain from injury
- rest
- avoid aggravating activities but don’t stop moving
- NSAIDs
- RICE
- isometrics
- maintain motion
TORDS (central sensitization s/s)
- Tenderness to diffuse palpation
- Overreaction
- Regional disturbances
- Distraction testing
- Simulation testing
treatment for central sensitization
- motivational interviewing
- SMART goals
- PNE
- meditation
- exercise
- diet
T or F: central sensitization can be acute or chronic
T
what are some causes of limited ROM? (5)
pain
healing
tightness
fear
weakness
*identify cause to determine treatment
treatment options for ROM
PNF, AAROM, mobilizations, strengthening
what are some causes of excessive motion?
- behavioral
- strength
- endurance (sx after hours of activity)
- proprioception
T or F: there is an optimal level of strength
F: it depends on what the patient needs to get back to
in addition to pt education and strengthening to treat hypermobility what could you also possible recommend for the pt during activity
bracing
painless weakness could be due to…
a neurological issue
disuse atrophy could be due to… (2)
compensation patterns
poor conditioning
reduced motor control could be due to _____ entrapment
nerve
weakness of what muscle can cause scapular winging
serratus anterior
SA is an upward rotator of the scapula
T or F: strengthening above 90 degrees is indicated for most patients
F: but it is for overhead athletes
T or F: activity intolerance is always an issue of overuse
F: it is more likely inconsistent use
treatment for activity intolerance
- structured return to activity program
- progress according to symptoms
- modify but increase overall exercise
T or F: all patients are likely to respond to manual therapy
T: but magnitude of response is variable
is a cavitation required for manual therapy
no
is one technique of manual therapy better than another
no
are a specific number of treatments required for manual therapy
no
T or F: manual therapy should be used alone
F: always combine with active interventions
5 grades of joint mobilization
1 = small amplitude, no resistance
2 = large amplitude, no resistance
3 = large amplitude into resistance
4 = small amplitude into resistance
5 = high velocity thrust
ROM progression
active range in protected arc > full AROM > AAROM > PROM > PROM w/overpressure > end range mobilizations > muscle energy technique
strength progression
submax isometric > max isometric > multi-angle isometrics > limited range concentric > full range concentric > heavy slow resistance > eccentrics > heavy load eccentrics > pylometrics
T or F: patients tend to overuse supervised rehab
T
what do they reconstruct for AC joint reconstruction
cc lig complex
two possible causes of shoulder instability
soft tissue
bone
what is important to prevent during AC injury management
stiff shoulder
sling use puts you shoulder in what position
protracted scapula
rounded shoulders
*this can create pain and tightness
which grade of AC joint injury has no consensus on management?
Grade 3 (some operative, some non-operative)
<3 = non operative
>3 = operative
conservative management of grade 3 ac joint injury includes
- maintain/return ROM
- pain free strengthening
- address scap diskinesia
most pts with grade 3 AC joint injuries that are managed conservatively return to work in ______ days
9
pts with grade 3 AC joint injuries that are managed conservatively may have limits with what movements
bench press strength (manual laborers, weightlifters)
T or F: operative management to repair AC joint (weaver-dunn) has a high failure rate
T
T or F: there are many complications with AC joint operations
T: fracture risk, malposition, persistent pain/instability due to graft tensioning
AC ligaments resist _______ movement and cc ligaments resist ________ movement
anterior-posterior
superior-inferior
pts with AC joint reconstruction are in a shoulder immobilizer for __________ weeks
4-6
at 4 weeks post-op AC joint reconstruction, you can do AAROM _______ to 90 degrees and ________ as tolerated
flexion
ER
At _______ weeks post-op AC joint reconstruction, you can do full motion
6-12
_______ months post-op AC joint reconstruction you can begin strengthening and after _______ months you can return to sports
3, 6
what is the definition of failure after AC joint reconstruction
loss of reduction
you pt really wants to stop wearing his sling 2 weeks after AC joint reconstruction. you explain that is not a good idea. why is it important to follow guidelines for sling usage?
having the arm hanging at your side causes a lot of stress on the AC joint and can lead to a loss of reconstruction
what is the primary complication of shoulder dislocation
recurrence
risk factors for shoulder dislocation recurrence
age (younger)
contact sports
severity of injury
what is the most common dislocation of the shoulder?
anterior-inferior
what nerve should you test after shoulder dislocation and how?
axillary
palpate deltoid and have then push out into your hand… feel for contraction
what is the primary goal after shoulder dislocation?
no instability
*also avoid stiff shoulder
T or F: there are studies that show bracing is effective for shoulder instability
F
what position does a sully shoulder stabilizer prevent
apprehension position
bankhart procedure
soft tissue
*sling use is variable
laterjet
bone transfer procedure (coracoid to glenoid)
*sling use for about 6 weeks and restricted ER
a laterjet is indicated with > _____% of glenoid bone loss
25%
*also performed if Bankart fails
does a bankhart or laterjay procedure have a harder recovery?
laterjay… b/c you are screwing bone into bone
other names for subacromial pain syndrome (SAPS)
RC tendonitis, SA bursitis, impingement
T or F: most SAPS responds w/o surgery
T
what is the primary goal when treating SAPS
avoid painful position
common interventions for SAPS
- cuff strengthening
- scap stabilization
- posterior capsule stretching
subacromial decompression
- attempt to cut out the pain caused by SAPS
- debridement, acromioplasty, LH biceps tenodesis/tenotomy, distal clavical excision
LH biceps tenodesis vs tenotomy
tenodesis = attaching biceps tendon to humerus
tenotomy = cut the biceps tendon and let it retract
*tenodesis can fail!
treatment for post op subacromial decompression
- allowing healing
- prevent stiff shoulder
- sling use outside home/maybe at night
T or F: most RC tears require surgical consultation
F
T or F: most RC tears do not cause shoulder symptoms and are a normal part of an aging shoulder
T
what is the most common RC tear? why?
supraspinatus
- hypovascular zone, location, high activity (it works even at rest)
most RC tears benefit from ______ weeks of trial rehab
6
2 reasons to get a surgical consult with a RC tear
1 - full thickness tear (b/c risk of retraction)
2 - tear with increasing symptoms
what is Bakody’s sign?
placing arm on top of head reduces peripheral symptoms in the UE
*suggestive of cervical radiculopathy
what are some treatment you could do for radiating pain due to cervical radiculopathy?
supine maual traction
SB opening home exercise
what are some scapular exercises?
high rows
mid rows
low rows
robber?
face pull
what motion should you avoid during face pulls?
IR
what are some treatments you could provide for limited IR due to posterior capsule tightness?
- A/P glides
- sleeper stretch
- wall slides
what kind of ROM do you do if ROM loss is due to pain?
PROM and AAROM
exercises that produce high levels of activity for supraspinatus and infraspinatus
1 - push up plus
2 - prone horizontal abduction
- prone ER at 90
4 - full can scaption
exercises that produce high levels of activity for subscapularis (4)
1 - resisted elevation
2 - standing row
3 - IR at 90 of ABD
4 - resisted shoulder extension
