shoulder Flashcards by Lindsey Morse

Tx post-op total shoulder replacement: Maximum protection phase

CONTRAS

important to initiate PROM/AAROM exercises within limits
forward elevation in plane of scapula to tolerance (up to 120 deg)
ER no more than 30 deg
No GH extension past neutral
IR until forearm rests on chest
AROM by 4-6 wks EXCEPT IR (NO active IR for at least 6 weeks)

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Total Shoulder replacement: max protection phase ADL precautions

no reaching behind back or into hip pocket
no GH extension past neutral
light ADL with elbow at waist level (writing)
NWB on the affected UE
1 lb lifting limit

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Total shoulder replacement: moderate protection phase precautions

gentle stretching after 6-8 weeks
week 4-6: no extension past neutral
week 6-12: combined adduction, IR and extension permitted
progress to low resistance dynamic strengthening of elbow and wrist, ST, and GH joints

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Total shoulder replacement: moderate protection phase ADL precautions

week 6-12: limit unilateral lifting to 3 lbs

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Total shoulder replacement: minimal protection phase precautions

after 12 weeks: bilateral lifting limit 10-15 lbs, gradual return to functional activities

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TSA (intacts rotator cuff)

Phases:

Immobilization:

ROM restrictions:

Phases: phase I = 0-4 weeks, phase II = 4-12 weeks, phase 3 = 12+ weeks

Immobilization:

no immobilizer unless rotator cuff repaired. possible sling only

ROM: 0-4 wks: elevation to 120 deg, ER to 30 deg (arm at side)

4-6 wks: no GH extension past neutral

6-12 wks: combined add, IR, ext permitted

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TSA (reversed)

phases:

immobilization:

ROM restrictions:

phases: phase I = 0-6 weeks, phase II = 6-12 or 16 weeks, phase III = 12+ or 16+

Immobilization: abduction splint worn 24 hrs/day for first 3-4 weeks (up to 6 weeks)

ROM: limit for 12 weeks or more. no GH ext, IR pas neutral, no combined GH ext, edd, IR; 0-20 deg ER and up to 90-120 deg arm elevation in scapular plane

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TSA (intact rotator cuff)

ROM/exercises etc:

resistance exercises:

ROM/exercises etc: PROM to AAROM GHJ (perform in supine 0-3 weeks), AROM GHJ by 4-6 wks

No active IR for at least 6 weeks, gentle stretching after 6-8 wks

Resistance exercises:
phase I = light NWB isos of ST and deltoid mm
phase 2 = submax isos of GH mm, light WBing through UE, no resisted rotation until subscap healed, progress to low-resisted dynamic strengthening

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TSA (reversed)

ROM/exercises, etc:

Resistance exercises:

ROM/exercises, etc: when immobilizer can be removed PROM only of GHJ.

AAROM to AROM of GHJ during phase 2

Resistance exercises: See TSA, but use phase time phases for rTSA

NWBing exercises through week 12

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TSA ADL precautions

4-6 weeks:

6-12 weeks:

after 12 weeks:

4-6 weeks: no reaching behind back, support arm on pillow when supine, light ADL with elbow at waist level, no leaning on involved arm, lifting limit of 1 lb

6-12 weeks: unilateral lifting = 3lbs

after 12 weeks: bilat lifting = 10-15 lbs, gradual return to light functional activities

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TSA (reversed) ADL precautions:

first 12 weeks

5-7 weeks

12-16 weeks

first 12 weeks: no reaching behind back, support arm on pillow when supine

5-7 weeks: light ADL permitted with elbow at waist level, no leaning on involved arm, restricted lifting 12-16 weeks (no heavier than cup o coffee)

12-16 weeks: unilateral lifting = 6 lbs, bilateral lifting = 10-15 lbs, gradual return to light functional activities

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common impairments with Rotator Cuff Disease and Painful Shoulder Syndromes

positive impingement sign and painful arc near 90 deg elevation
hypomobile posterior GHJ capsule
with a complete rotator cuff tear, inability to abduct the humerus against gravity
C5 and C6 reference zones

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referred pain from related tissues: over trapezius to tip of shoulder

dermatome c4

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referred pain from related tissues: over deltoid region and lateral arm

dermatome c5

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referred pain from related tissues: upper trap region

diaphragm

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referred pain from related tissues: left axilla and pectoral region

heart

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referred pain from related tissues: tip of shoulder and scapular region

gallbladder

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arthritis/DJD and adhesive capsulitis can be categorized as:

joint hypomobility

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GHJ arthritis cause (3)

traumatic injury, or

microtrauma from faulty mechanics/overuse

from lack of movement

During the _____ phase of GHJ arthritis:

pain sometime radiates below elbow and mm guarding

ER and abduction ROM limited

pain can disturb sleep

tenderness below edhe of acromion process between ant and middle deltoid

acute

during the ______ phase of GHJ arthritis:

capsular tightness with limited motion consistent with a capsular pattern

pain at end range

limited joint play

subacute

during the _____ phase of GHJ arthritis:

significant loss of function secondary to increased capsular tightness

aching localized to deltoid region

chronic

IF conservative treatment does not work for GHJ arthritis ________ may be performed before considering a TSA

manipulation under anesthesia (MUA)

post-manipulation under anesthesia:

arm is kept….

emphasis on ___ and ____ in 90 deg or higher abducted position

arm is kept in elevated overhead abduction and external rotation position

emphasis on ER and IR

indications for a TSA (5)

severe deterioration of one or both surfaces of the GH joint - pain - loss of shoulder mobility or stability and UE strength - loss of UE function - acute non-union fracture of the proximal humerus

3 types of shoulder arthroplasty:

- total shoulder arthroplasty - hemiarthroplasty - reverse total shoulder arthroplasty (rTSA)

type of shoulder arthroplasty: used when the articular surface and underlying bone of the humeral head have deteriorated but glenoid fossa is reasonably intact (only replace the humeral head)

hemiarthroplasty

characterized by the development of dense adhesions, capsular thickening, and capsular restrictions insidious onset and usually occurs between ages 40-65 It is a self limiting function over an 18 month period

Adhesive capsulitis | frozen shoulder

possible causes of frozen shoulder:

- provoking chronic inflammation in musculotendinous or synovial tissue, along with faulty posture, mm imbalance, and overuse genetic component strong association with diabetes and thyroid disease

Frozen shoulder stage _____: - gradual onset of pain - pain increases with movement - pain present at night - loss of ER - intact rotator cuff strength

stage 1 Lasts less than 3 months

frozen shoulder stage ____: - persistent and more intense pain - pain at rest - motion limited in all directions - motion unable to be restored with intra articular injection

stage 2 lasts 3-9 months after onset

frozen shoulder stage ____: - pain only with movement - significant adhesions - limited GHJ motions - excessive scapulothoracic movement - atrophy of the deltoid, rotator cuff, biceps and triceps

stage 3 9-15 months after onset

frozen shoulder stage ____: - minimal pain - no synovitis but significant capsular restrictions from adhesions - motion may gradually improve - may never regain normal ROM

stage 4 15-24 months after onset

structural integrity of the musculotendinous structures and include vascular changes in the rotator cuff tendons, tissue tension, overload, and collagen disorientation and degeneration involve the deep articular side of the tendons may progress to articular-side rotator cuff tears

intrinsic impingement

occurs as a result of mechanical compression of the rotator cuff against the anteroinferior one-third of the acromion in the suprahumeral space during arm elevation tendon compression results from anatomical or biomechanical factors that decrease the suprahumeral space

extrinsic impingement

there are primary and secondary extrinsic impingements secondary impingements are caused from

multidirectional instability or unidirectional instability with or without impingement

compression fracture at the posterolateral margin of the humeral head (occurs with anterior dislocation)

hill sachs

________ impingement occurs in a position of elevation, horizontal abduction, and maximum external rotation primary in throwing athletes associated with posterior GH capsule tightness and scapula kinematic alterations

internal extrinsic impingement

_________ symptoms: - near musculotendinous junction - results in painful arc with overhead motions - pain with provocation tests - pain on palpation of the tendon just inferior to the anterior aspect of the acromion when pts hand placed behind back

supraspinatus tendonitis

_________ symptoms: - near musculotendinous junction - results in painful arc with overhead, forward, and cross body motions - may present as deceleration injury - occurs with palpation of tendon just inferior to the posterior corner of the acromion when pt horizontally adducts and ER humerus

infraspinatus tendonitis

______ symptoms: - lesions involves long tendon in bicipital groove beneath or just distal to transverse humeral ligament - pain with Speed's test - pain with palpation of bicipital groove - rupture or dislocation of bicep tendon may compromise role as a humeral depressor during elevation

bicipital tendonitis

______ symptoms: - same symptoms as seen with supraspinatus tendonitis when inflamed - once inflammation reduce, no symptoms with resisted motion

bursitis (subdeltoid or subacromial)

_____________ occurs in persons over age of 40 occurs after repetitive microtrauma to the rotator cuff or long head of the biceps with degeneration, calcification and eventual tendon rupture may occur

insidious (atraumatic) onset stage 3 impingement syndrome

anterior instability special tests (4):

- load and shift test - apprehension (crank) test - relocation (fowler's) test - rowe test

posterior instability special tests: (3)

- load and shift test - posterior apprehension test - rowe test

inferior instability special tests: (3)

- sulcus sign - feagin test - rowe test

labrum special tests (4)

- clunk test (Bankart) - obrien test (SLAP) - anterior slide test (SLAP) - bicep tension test (SLAP)