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OCS Prep > Shoulder > Flashcards

Shoulder Flashcards

1
Q

What is the evidence to support the clinical course of frozen shoulder?

A

Moderate evidence for a course of 12- 18 months.

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2
Q

What are the four stages of frozen shoulder and how long does each stage last?

A
  • stage 1
    • 0-3 months
  • stage 2
    • 3-9 months
  • stage 3
    • 9-15 months
  • stage 4
    • 15 months or greate
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3
Q

What are the symptoms of frozen shoulder During stage 1?

A
  • Pain with A/ prom
  • limited flexion,abd, Ir,er
  • pathological changes: hypertrophic, hypervascular, rare inflammatory cell infiltrates,normal underlying capsule
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4
Q

What are the characteristics of stage 2 frozen shoulder?

A
  • duration 3-9 months
  • chronic pain with a/prom
  • significant limitation of flexion, abduction, er,Ir
  • pathological changes: hypervascular, hypertrophic synovitis, with pervaxsular subsynovial scarring, fibroblasts and scar formation in underlying capsule
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5
Q

What are the characteristics of stage 3 for frozen shoulder?

A
  • duration 9-15 months
  • significant rom deficits with rigid endfeel
  • minimal pain except at end range
  • pathological changes: burnt out synovitis without hyper trophy, or hypervascularity, dense scar formation in the capsule
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6
Q

What are characteristics of stage 4 frozen shoulder?

A
  • thawing stage - 15-24 months
  • minimal pain
  • progressive improvement in ROM
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7
Q

What is the evidence for risk factors in frozen shoulder?

A
  • Weak evidence
    • diabetes
    • thyroid disease
    • 40 - 65 yo female
    • previous episode of frozen shoulder
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8
Q

What is the evidence for corticosteroid injections for treatment of frozen shoulder?

A
  • Strong evidence
    • use of injections combined with shoulder mobility and stretches are more effective than exercises alone for short term pain relief
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9
Q

What is the evidence to support patient education, activity modification and stretching?

A

Moderate evidence

  • patient education
  • activitymodification
  • match intensity of stretch to the patients level of irritability
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10
Q

What is the level of evidence to support modalities in testing frozen shoulder?

A

Weak evidence for modalities

-clinicians may use modalities combined with mobility and stretching to reduce pain.

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11
Q

What is the evidence for joint mobilizations in treating frozen shoulder?

A

Weak evidence for joint mobs and transitional manipulations

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12
Q

How would you treat a patient who presents with high irritability with frozen shoulder?

A
  • Activity modification
  • Short duration stretching (1-5 sec) pain free p/ Aaron
  • low grade mobs
  • patient Ed
  • injection
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13
Q

How would you treat someone who presents with moderate irritability?

A

Modalities ( heat, ice, estim)

  • activity modification
  • short duration (5-15 sec) prom/ arom / Aarom
  • low to high grade mobs
  • patient Ed
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14
Q

How would you threat someone with low irritability for frozen shoulder?

A
  • Endrange overpressure
  • high grade sustained mobs
  • low to high resistance strengthening
  • high demand functional activities
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15
Q

How would a patient with high irritability for frozen shoulder present?

A
  • high pain (>7/10)
  • consistent night pain/ resting pain
  • high disability on the DASH, ASES, PSS
  • paint prior to end range of motion
  • arom
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16
Q

How would a patient with moderate irritability for frozen shoulder?

A
  • Moderate Pain (4-6/10)
  • intermittent night/ resting pain
  • moderate disability on DASH, ASES, PSS
  • Pain at end range
  • arom=prom
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17
Q

How would someone present with low irratibility?

A
  • Low Pain (=<3/10)
  • no resting or night pain
  • minimal pain with overpressure
  • Arom= prom
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18
Q

What is the MOI for SLAP lesion?

A

Sudden downward force on a supinated overstretched upper extremity

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19
Q

What is a type 1 SLAP lesion?

A

Type 1
- degenerative fraying of the superior labrum
- biceps anchor intact
Superior labrum is debrided

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20
Q

What is a type 2 SLAP lesion?

A

Type 2

  • biceps and anchor pulled away from glenoid
  • lesion is repaired ( anchors, tacks, staples)
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21
Q

What is a type 3 SLAP lesion?

A

Type 3

  • bucket handle tear of the superior labrum
  • biceps intact
  • surgery- torn fragment is resected
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22
Q

What is a type 4 SLAP lesion?

A

Type 4

  • tear extends to biceps tendon
  • biceps tendon/ labrum displaced to the joint
  • <30% tear resected,
  • > 30% tear older population labrum is debrided
  • younger population - suture repair
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23
Q

What are two special tests to diagnose SLAP lesions?

A

Biceps load 1 and 2

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24
Q

Describe the biceps load 1 and 2 exam.

A
  • patient supine with shoulder in 90 degrees abd and er
  • forearm supinated
  • PT externally rotates until the patient is apprehensive, then resists elbow flexion
    • if pain stays the same or worsens
  • (-) if apprehension improves
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25
Q

Name four complications of dislocations:

A
  1. Reoccurrence
  2. Vascular
  3. RC tear
  4. Nerve injuries
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26
Q

In what position of the arm does the superior GH ligament provide stability?

A

The sup. GH ligament resists huh translation with the arm adducted

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27
Q

What ligament provides stability with the arm abducted to 45 degrees?

A

The middle GH ligament provides stabilizing force with the arm abducted to 45 degrees.

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28
Q

What ligament provides stability with the arm at 90 degrees?

A

The inferior GH ligaments provide stability with the arm at 90 degrees of abduction.

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29
Q

Which ligament provides anterior stability?

A

The anterior inferior ligament provides anterior stability

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30
Q

What ligament provides posterior stability.

A

The posterior inferior ligament provides posterior stability?

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31
Q

Describe dynamic stability of the GH joint?

A
  1. Provides joint compression.
  2. Synergistic contraction of the RC
  3. Tensioning of the G H ligaments
  4. Weak SA,UT can lead to decrease in dynamic stability
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32
Q

What is the most common position of the arm in anterior dislocations?

A
  • arm is extended,abducted and externall rotated by an indirect force
  • majority are from trauma
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33
Q

What is the most common nerve injured during anterior dislocations?

A
  • The axillary nerve is the most common nerve injured.
  • happens at the region of surgical neck of the humerus
  • traction and neuropraxia
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34
Q

What is the most common position for posterior dislocations?

A

Arm is adducted, flexed and internally rotated.

- MOI is a blow to the front of the shoulder

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35
Q

Shoulder dislocation: clinical exam neurovasc

A
  • Acute
    • Pre/post reduction neurovascular exam
      • axillary, suprascapular, long thoracic nerve
      • axillary most common injury
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36
Q

Shoulder dislocation: clinical exam presentation

A
  • Arm held against trunk, supported by the other arm, patient will resist attempts to move arm
  • Sharp deltoid contour, more prominent acromion
  • palpable fullness below coracoid
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37
Q

Shoulder dislocation sub acute exam

A

1) load and shift
2) apprehension/ relocation test
3) sulcus test

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38
Q

Radiological examination for shoulder dislocations pre reduction

A

Plain films

  • Pre reduction
  • AP w/ slight IR - greater tuberosity fracture
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39
Q

Radiological examination Post reduction

A
  • Scapular AP- glenoid fossa Fox
  • West Point Modified Axillary view
    • IGHL avulsion, bony Bankart lesion, anterior- inferior glenoid deficiency
  • Stryker Notch View - Hill- Sachs lesion
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40
Q

MRI for dislocations

A

Contrast enhancement is best

- in an acute injury hemarthrosis provides contrast- no contrast needed

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41
Q

Treatment of dislocations:

A
  • Ages 15-25
    • acute repair best
    • rates of reinjury decrease from 80-90% down to 3-15% in young athletes
  • Ages 25-40
    • conservative care
  • Age > 40
    • conservative care
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42
Q

Immobilization for dislocations

A
  • Can be up to six weeks, but depends on the patient
    • younger patients<30 years
      • sling in add,Ir for 2-3 weeks
  • Patients >30 years
    • sling 1-2 weeks
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43
Q

Non operative management for anterior dislocations:rehab

A
  1. Avoid er+abd
  2. Focus on scapular stabilization
  3. RC strengthening in the scar plane
  4. Strengthen infraspinatus and teres minorto draw HH posterior.
  5. Avoid pushups,bench press, IR, horizontal add and flexion
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44
Q

How does a patient with posterior dislocation present?

A
  • Flattening of shoulder region

- arm held in adduction and Ir

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45
Q

What is the best radiological view for a Hill’s Sachs lesion?

A

Stryker notch view

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46
Q

What does AMBRI stand for?

A 
Atraumatic
Multidirectional instability
Bilateral involvement 
Rehabilitation as first line of therapy
Inferior capsule shift as best alternative surgical method
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47
Q

Explain why younger population has higher rate of reoccurrence of dislocation.

A

Theory
- Collegen type 3 fibers are supple + elastic. With each decade, we make less collagen producing cells, making collagen tougher (type 1 fibers)

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48
Q

TUBS anacronym

A

Traumatic
Unilateral
Bankart lesion
Surgery

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49
Q

What is a Bankart Lesion?

A
  • Avulsion or detachment of the anterior GH ligament and glenoid labrum off the glenoid rim
  • decreases the glenoid depth by 50%
  • Incidence of 87-100% with initial dislocations
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50
Q

Bankart lesion special tests

A

Clunk test 1
- position: supine with GH joint in max scaption and caudal glide
Clunk test 2
- supine with GH abd 90-180 degrees
Crank test
- supine GH 150 degrees scaption, then IR, ER

51
Q

Describe Bankart repair surgery

A
  1. Arthroscopic
  2. Capsulolabral avulsion is repaired with anchors
  3. Inferior to superior shift allows for IGHL tensioning
52
Q

Bankart repair rehab guidelines:

A 
0-6 weeks
- Immobilizer
  - Codman exercises begin immediately
  -AAROM  ER 0-30 degrees, FE 0-90 degrees
  - cryotherapy
6-12 weeks
  - AAROM started to full range
  - no strengthening until full range
12 weeks
  - begin strengthening
16-20 weeks
- sport specific exercises
20-24 weeks
-return to contact sports
53
Q

Describe a Hill Sachs lesion:

A
  • A compression fracture of the post- lateral aspect of the humeral head associated with anterior dislocations
54
Q

Describe the IRRST test

A
  • Patient sitting with UE in 90 degrees abduction and 80 degrees ER
    • if Er greater than IR, test is positive for intra- articular pathology
    • if IR strength greater than ER, then test is positive for RC pathology
    • if ER = IR then test is positive for extra- articular pathology
    • SP .96, SN . 86, + Lr 22.0, - LR .13, + PTP 91.7%, - PTP 6.1%
55
Q

What are intra- articular pathologies?

A
  • Anterior Capsulolabral instability
  • Posterior capsulolabral Instability
  • Bankart lesions
  • SLAP lesions
  • Articular internal impingement syndrome
56
Q

What are RC pathologies?

A
  • RC impingement

- RC tear

57
Q

What are extra- articular pathologies?

A
  • AC joint lesions
  • LHB lesions
  • Shoulder Pain referred from another body region
58
Q

What is the supraspinatus test cluster by Biederwolf?

A
  • ERLS

- + LR 15.5- 34, - LR .2-.32, +PTP 88%

59
Q

What is the supraspinatus test cluster by Hegedus?

A

Age >65
Infra MMT
Night pain
-+ LR 9.8, - LR .54

60
Q

What is the subscap tear cluster by Bender wolf?

A

IRLS

-+ LR 24.3, - LR .03, PTP 92%, -PTP 1.4%

61
Q

What is the test cluster for infraspinatus tear?

A

ERLS

- + LR15.5-34.5, - LR.2-.32

62
Q

What are the combined special tests for anterior instability?

A 
Apprehension
  - + LR 20-53, - LR .29-.47
Anterior release
  - + LR 8.3- 58, -LR .09- .37
Apprehension and Relocation
- + LR 39, - LR .19
63
Q

What are the test cluster for SLAP lesions?

A

Biceps load I and II
- + LR 30, -LR.10
Passive distraction and active compression
- + LR 7, -LR .11

64
Q

What is the test cluster for post. Inferior instability ?

A

Jerk test
- + LR 36.5, PTP 94.8%, - PTP 12.3%
KIm Test
- + LR 13.3, - LR .21, PTP 86.9%. - PTP 9.5%

65
Q

Describe the Kim test:

A
  1. Axial load with arm 90 degrees of abd.
  2. Elevate the arm 46 degrees, apply downward/ backward pressure
    • if sudden onset of Pain is provoked
66
Q

Describe the Jerk test?

A
  1. axial load with the arm at 90 degrees Abd+ Ir
  2. Maintain axial load, then adducted arm horizontally
    • if pain or increased translation posterior
67
Q

Test cluster for AC joint pathology

A
  • Cross body abduction
  • AC resisted extension test
  • O’Brien’s test
    • all three positive + LR 8.3, + PTP 80.5%, - PTP 27.8%, - LR .77
68
Q

Combine test cluster for Impingement/ tendonopathy.

A
  • Hawkins Kennedy
  • painful arc
  • infra MMT
    • 3/3 + LR 10.5, + PTP 95%
    • 2/3 + LR 5.03, +PTP 91%
69
Q

What is the presentation for Primary impingement ?

A 
Cause
  -  abnormal mechanical relationship between RC and coracoacromial arch
History
- >40 years old
- anterior arm pain
- unable to sleep on affected side
Exam
- + HK, NEERS
- worse with IR, abd >90
70
Q

What is secondary impingement.

A

Decrease in SAJ space

Bio mechanical in nature

71
Q

How does secondary impingement present?

A 
History
- younger patients, overhead athletes, c/ o arm dead
Exam
- + apprehension
-+ full/ empty can
-+ SICK scapula
-+ tight post capsule
72
Q

What is upper crossed syndrome?

A

Described by Yanda

  • short UT,LS, Pecs, SVM
  • long and weak Mid/ lower trap, deep cervical flexors
  • kyphosis to T 4
  • lead to decreased SAJ
73
Q

What are the three types of RC repair types?

A
  • Arthroscopic
  • slower progression post op due to weaker fixation
  • Mini Open
    • vertical split between anterior and middle deltoid
    • allows for early deltoid arom
  • Full open
    • Deltoid is released from clavicle
    • no deltoid AROM. 6-8 weeks
74
Q

How are RC tears classified?

A

Small - <1 cm
Medium- 2-4 cm
Large- >5 cm

75
Q

What is the diagnostic cluster by Park for RC tears?

A

Pre test probability 39%

  • Drop arm
  • Painful arc sign
  • infraspinatus MMT
    • 3/3 + LR 15.57, + PTP 91%
    • 2/3 + LR 3.57, + PTP 69%
76
Q

How will strength be affected in RC tendinopathy?

A

ER deficits at 0 and 90 degrees

  • RC activation reduced by 23% due to excessive scap protraction
  • strength will test normal once scap is retracted
77
Q

How does Flexibility affect cause RC tendinopathy?

A

IR tightness causes:

  • AROM Flexion - ant/ sup HH translation
  • AROM ER @ 90 - post/ sup HH translation
  • AROM follow through - excessive scap protraction results in subacromial impingement
78
Q

What s the janitor’s sign on an X-ray indicative of?

A

Ac joint seperation

- need bilateral views, weighted and unweighted to ASES if clavicle is fractured

79
Q

What are the symptoms of calcific tendonitis?

A
  • Insidious onset
  • Pain at lateral arm
  • intense, throbbing pain
  • little relief in acute phase
    -severe pain with rom
    + TTP distal acromion
80
Q

What is the treatment for calcific tendonitis?

A

Self limiting

  • typically resolves in one week
  • NSAIDS
81
Q

Best exercise for supraspinatus

A
  1. Full can
    - enhances scap position
    - decreases deltoid involvement
    - decreases chance of superior HH translation
  2. Prone full can
    - enhance scap position
    - high post deltoid activity = supraspinatus
    - high supraspinatus activity + lower trap
82
Q

Best exercises for infraspinatus

A
  1. S/L ER
    - position of shoulder stability= min. Capsular strain
    - increased moment arm at 0 degrees = greatest Emg activity
    - most effective at recruiting infraspinatus
  2. Prone ER @90 abduction
    - challenging position = increased capsular strain
    - high emg activity
    - strengthens with lower trap
83
Q

Best exercises for infraspinatus ( cont)

A
  1. Er with towel
    - allows for proper form
    - high emg activity + adductors
    - enhances muscl recruitment + synergy
84
Q

Best exercise for subscap

A
  1. IR at 0 degrees
    - similar subscap activity at 0 and 90
    - position of stability
    - static stability
  2. IR at 90 abduction
    - position of shoulder instability
    - enhances scap position, decreases sub acromion space
    - strengthens in challenging position
85
Q

Best exercises for subscap (. Cont)

A
  1. Ir diagonal exercise
    - more functional
    - increased emg activity
    - effective strengthening in functional pattern
86
Q

Best exercises for serratus anterior

A
  1. Push up plus
    - easiest position to produce resistance against protraction
    - increased emg activity
    - + sub scap
  2. Dynamic Hug
    - performed below 90 degrees
    - increased emg activity
    - can be performed by patient wh9 can not elevate arms
87
Q

Exercises for serratus anterior cont.

A
  1. Serratus punch at 120 degrees
    - increased emg activity
    - dynamic activity
    - combines punch with upward rotation
88
Q

Best exercise for lower trap

A
  1. Prone full can
    - properly aligns exercise with muscle fibers
    - increased emg
    - recruits supraspinatus
  2. Prone ER at 90
    - prone below 90 degrees
    - increased emg
    - recruits teres minor, infraspinatus
89
Q

Best exercisesfor lower trap cont.

A
  1. Prone horizontal abduction @ 90
    - good ratio of lower to UT activity
    - recruits middle trap
  2. B ER
    - scap control without arm elevation
    - good ratio lower to UT activity
    - recruits infraspinatus and teres minor
90
Q

Best exercise for middle trap

A
  1. Prone row
    - prone exercise below 90
    - increased emg
    - good ratio of UT, MT, LT activity
  2. Prone horizontal abduction@ 90 with 90 Er
    - prone below 90
    - increased emg
    - effective, recruits lower trap
91
Q

Rom goals for arthroscopic capsulolabral repair week 0-3

A

Week 0-3:

  • PFE 90
  • PER 10-30
  • PER @ 90 contraindicated
  • AFE NA
92
Q

Rom goals for arthroscopic capsulolabral repair 6 weeks

A

6 weeks

  • PFE 135
  • PER 35-50
  • PER @90 45
  • AFE 115
93
Q

Rom goals week 9 for arthroscopic capsulolabral repair

A

Week 9

  • PFE 155
  • PER 50-60
  • PER @90 75
  • AFE 145
94
Q

Rom goals week 12 for arthroscopic capsulolabral repair

A

Week 12

  • PFE WNL
  • PER WNL
  • PER @ 90 WNL
  • AFE WNL
95
Q

What are the primary dynamic stabilizers of the GH joint?

A
  1. RC muscles

2. Deltoid and biceps

96
Q

What are the secondary dynamic stabilizers if theGH joint?

A
  1. Teres major
  2. Lattisimus dorsi
  3. Pec major
97
Q

What is the most optimal position for blood flow to the RC?

A

Position humerus 30 degrees of scap abduction

98
Q

What is the function of the Glenoid labrum?

A
  1. Adds to the concavity- increases stabi,it’s by 50%
    - attachment of GH ligaments
  2. Compression becomes more effective with concave glenoid and convex HH
  3. Increases resistance to GH translation up to 20%.
99
Q

SICK acronym

A

Scapula malposition
Inferior medial border prominence
Coracoid Pain and malposition
K- dyskinesis of scapula movement

100
Q

What are three types of scapula dyskinesis?

A
  1. Anterior tilt
    - prominence of inferior medial scapula border
    - labral involvement in SICK overhead athletes
  2. IR
    - prominence of medial scap border
    - labral involvement in SICK overhead athletes
  3. Downward rotation
    - prominence of superomedial border
    - impingement/ RC disease in overhead athletes
101
Q

What are the contributors to SICK scapula?

A
  1. Pec. minor tightness and short head of biceps tightness
    • lowers leading edge of scapula
    • decreases ability to achieve full fwd flexion
  2. Scapula tilts and rotates laterally, traction on lavatory scap creates muscle spasm
    • can often be corrected with scapula retraction test
102
Q

Describe the scapula retraction test

A

Patient in supine and forward flexes UE; flexion is limited due to pec minor tightness
- scapula in manually repositioned by PT and full fwd flexion is achieved with a decrease in coracoid process pain

103
Q

How is SICK scapula diagnosed?

A
  • Dropped scapula on dominant arm
  • pec minor tightness
    • coracoid tilts infriorly
    • coracoid shifts laterally away from midline
    • coracoid becomes tender
    • insidious onset
104
Q

Diagnosing SICK visual appearance

A
  1. Infra - visual appearance of dropped scap due to tilting/ protraction
  2. Lateral displacement from spine
  3. Abducted away from spine
105
Q

Symptoms of SICK scap

A

Insidious onset

  • Pain in coracoid 80%
  • coracoid/ post sup scap 70%
  • sub acromial/ lateral pain 20%
  • ac joint 5%
  • TOS 5%
106
Q

SICK scorecard

A 
Score 0-20
- subjective
- objective
Asymptomatic -0
Most symptomatic  0-14
Begin interval throwing 4-6
Return to sport 0-2
107
Q

Scapula dyskinesia rehab progression:

A 
Scap orientation
  - provide motion first
  - teach post tilt and upward rotation
Scap co- contraction
  - inferior glide
  - low row
  - lawn mower
  - robbery
108
Q

Cocontraction kinetic chain variations

A

Push-up with extended contralateral hip will increase lower trap activity

Low row- one legged stance on contralateral limb improves lower trap activity
- focus on trunk/ leg mobility

109
Q

What is an appropriate prescription for strengthening?

A

3 sets of 15-20 reps has shown to result in increase in strength of 8-10% after 4 weeks.

110
Q

SICK rehab cont.

A

Improve scapula mobility/ stability to improved provide base for RC:

  • low row
  • scap clocks
  • HH depression + rotations
  • wall washes
  • punches
111
Q

What is dead arm syndrome?

A

Pathological shoulder condition in which the athlete is not able to throw with pre- injury velocity and control

112
Q

What are contributed to dead arm syndrome?

A
  1. Tight post - inferior capsule causes GIRD and posterior shift in GH rotation
    - increases shear stress on post/ sup labrum
  2. Peel back forces in late cocking that add to labral shear stress
  3. Hyper external rotation of the humerus increases the clearance of GT over the glenoid
  4. Scap protraction
113
Q

According to the rotational unity rule, what ratio should GIRD be to ERG

A

GIRD should be less than ERG for healthy rotational kinematics

  • GIRD/ERG greater than 1. = problems
  • GIRD that exceeds 10 percent of contralateral shoulder’s rotational arc will produce GIRD/ERG ratio greater than 1
114
Q

What are characteristics on NON msk behavior?

A
  1. Rest does not relieve symptoms
  2. Symptoms not exacerbated with specific activity
  3. Pain varies with activity of the involved system
115
Q

What are non msk referral sources?

A 
R shoulder
  - liver
  - stomach 
  - pancreas
  - pancoast tumor.  
L shoulder
  - heart
  - spleen
116
Q

Why is GIRD significant.

A

Correlates with anterior humeral head translation

  • increased anterior Humeral shear forces
  • increased superior HH migration during elevation
  • HH shifts to post/ superior direction due to excessive tightness
117
Q

GIRD stretches

A

IR with scap stabilized
PEC minor stretch
Sleeper stretch
Cross body stretch

118
Q

What are the four grades for instability with load and shift test?

A 
Normal
- mild translation 0-25%
Grade 1
- HH rides up to glenoid rim 25-50%
Grade 2 
- HH overrides glenoid rim, but spontaneously reduces >50%
Grade 3
- HH overrides glenoid rim and remains dislocated
119
Q

FEDS acronym

A

Frequency
Etiology
Direction
Severity

120
Q

What are Rockwoods 6 types of ac joint injury?

A
  1. Acromioclavicular ligament sprain, ac intact
  2. Acromiclavicular ligament rear, caracoclavicular ligament intact, ac subluxed
  3. acromiclavicular/caracoclavicular ligament torn 100%
  4. complete dislocation w/ posterior displacement of distal clavicle
  5. Exaggerated displacement superior dislocation 100/300%
  6. Complete dislocation. With inferior displacement of distal clavicle into subacromial position
121
Q

What makes up the Rotator Cuff Interval?

A
  • Suprapinatus
  • subscapularis
  • SGHL
  • coracohumeral ligament
122
Q

What is the Quadrangular space?

A
  • Contains posterior circumflex artery and vein

- Axillary nerve

123
Q

What does the triangular space contain?

A

Triangular space contains circumflex artery

124
Q

What can cause internal impingement?

A
  • Seen in overhead athletes
  • infraspinatus and supraspinatus rotate posteriorly
  • associated with anterior instability

OCS Prep (7 decks)

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