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OCS prep > Shoulder APTA (1) > Flashcards

Shoulder APTA (1) Flashcards

1
Q

What kind of joint is the GH joint?

A
  • triaxial synovial joint
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2
Q

What is the angle of inclination of the humerus?

A
  • angle of the head relative to the humeral shaft

- 130*

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3
Q

What is considered “normal” alignment between the head of the humerus and the shaft in the transverse plane? What is the range of what can be normal?

A
  • angled 30* posteriorly (retroversion)

- anywhere from -6.7 to 47.5* per one study

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4
Q

What is the orientation of the glenoid fossa relative to the scapula?

A
  • slight lateral rotation (7*)
  • slightly posteriorly oriented
  • slight superior angulation (5*)
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5
Q

What type of tissue is the labrum made of?

A
  • fibrocartilage
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6
Q

What two aspects of the labrum help improve stability for the GH joint?

A
  • deepens the fossa

- creates intraarticular vacuum with the capsule which also helps stability

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7
Q

Where are the attachment points of the GH joint capsule?

A
  • the glenoid neck and labrum

- anatomical neck of the humerus, except inferomedially where it extends a slight ways down the humeral neck

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8
Q

What are the two openings to the GH joint capsule?

A
  • between the humeral tubercles, allowing the biceps tendon to exit the joint
  • connection between the joint and the subscapularis bursa
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9
Q

Most extracapsular ligaments are where relative to the GH joint?

A
  • superior and anterior
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10
Q

The superior GH ligament resists what motion, when the arm is in which position?

A
  • restrains inferior translation

- when the arm is in an adducted position at the side

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11
Q

Tears or damage to the superior capsule may result in increased translation in which direction(s)?

A
  • anterior and inferior
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12
Q

The middle GH ligament resists what motion, when the arm is in which position?

A
  • anterior humeral translation when the arm is abducted up to ~45*
  • external rotation when the arm is at the side
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13
Q

Describe the orientation and makeup of the inferior GH ligament.

A
  • expansive band of tissue in the inferior capsule with thickened anterior and posterior portions
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14
Q

What is the general function of the inferior GH ligament?

A
  • anterior and posterior bands work in conjunction to limit anterior translation when the GH joint is abducted to 90*
  • during ER and abduction, the anterior band wraps around the front of the GH joint and limits anterior translation
  • during IR, posterior band wraps around and limits posterior translation
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15
Q

How far from the vertebrae is the medial (vertebral) border of the scapula in a neutral position?

A
  • ~5 cm
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16
Q

The scapula spans which levels of the thoracic spine?

A
  • 2nd superiorly

- 7th inferiorly

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17
Q

The plane of the scapula is rotated ~ ___ to ___ from the coronal plane.

A
  • ~30* to 45*
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18
Q

What is the neutral orientation of the scapula relative to vertical?

A
  • 10-20* superiorly

- 10-20* anteriorly

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19
Q

The only skeletal articulation between the axial region and the appendicular upper limb occurs: ____

A
  • at the sternoclavicular joint
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20
Q

The most important ligament at the SC joint is likely the _______. What movements does it limit?

A
  • posterior sternoclavicular ligament

- limits anterior and posterior translations

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21
Q

What is thought to be the function of the interclavicular ligament?

A
  • restrains inferior forces on the medial clavicle
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22
Q

T or F;

The disc in the AC joint becomes degenerated early in life.

A
  • T
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23
Q

Describe the structure of the AC joint.

A
  • synovial planar joint with 3 degrees of freedom

- has a joint capsule, and a disk/meniscus that isn’t well understood

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24
Q

What two ligaments add stability to the AC joint?

A
  • Conoid

- coracoclavicular (trapezoid)

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25
Q

What happens to the cartilage in the AC joint during aging?

A
  • the hyaline cartilage changes to fibrocartilage at ~17yo on the acromial side, and ~24yo on the clavicular side
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26
Q

What are the connections/orientations for the conoid and trapezoid ligaments?

A
  • conoid runs vertically between the coracoid px and clavicle
  • trapezoid (coracoclavicular) runs superior/lateral from the coracoid px and clavicle
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27
Q

What motion results from the restrictions of the AC ligaments?

A
  • posterior rotation during clavicle elevation
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28
Q

What does “scapulohumeral rhythm” refer to?

A
  • the 2:1 ratio of movement between the scapula and humerus
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29
Q

Describe the deltoid-rotator cuff force couple.

A
  • During initial arm elevation, the deltoid creates a superiorly directed force, which is offset by the inferior/medial forces from the infraspinatus, teres minor, and subscapularis, as well as the compressive force from the supraspinatus
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30
Q

Describe the trapezius-serratus anterior force couple.

A
  • serratus anterior and lower trap in conjunction with the upper trap and levator scap create upward rotation of the scapular with UE elevation
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31
Q

At what arm positions is the serratus anterior/lower trap most important for scapular rotation and stabilization?

A
  • at ~ 90* abduction and greater elevation
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32
Q

What is a typical motor pattern for the scapular musculature with a patient with impingement syndrome?

A
  • decreased SA activity
  • delayed middle and lower trap firing
  • upper trap/levator scap dominant pattern
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33
Q

Describe the anterior-posterior RC force couple.

A
  • anterior based subscapularis
  • posterior based teres minor and infraspinatus
  • creates a concavity-compression, stabilizing the humeral head in the glenoid, most active in the mid-ranges of movement
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34
Q

T or F;

An isolated supraspinatus tear won’t impact the anterior-posterior RC force couple.

A
  • T
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35
Q

What is the normal position of the dominant shoulder relative to the non-dominant?

A
  • dominant will usually be significantly lower in neutral, non-stressed postural positions, especially with unilateral athletes (baseball, tennis)
  • not clear why this happens. May be due to increased UE mass, or elongation of periscapular musculature due to eccentric loading
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36
Q

What is one recommended position to observe muscle atrophy during clinical examination?

A
  • standing with hands on hips; brings shoulders into ~50* abduction and slight IR
  • can see focal pockets of atrophy along scapular border, as well as over the infraspinatus fossa of scapula
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37
Q

What may cause excessive scalloping in the infraspinatus fossa due to atrophy?

A
  • suprascapular nerve impingement
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38
Q

What shoulder condition can result in suprascapular nerve impingement?

A
  • superior labral lesions

- can occur in the suprascapular notch and spinoglenoid notch with paralabral cyst formation

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39
Q

What is a method of assessing scapular dyskinesia during exam?

A
  • Kibler scapular slide test
  • assess at neutral and 90* positions; measuring from T-spine to inferior angle
  • difference of more than 1 or 1.5 cm is considered abnormal
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40
Q

What are the 3 rotational and 2 translational movements that occur with scapular movement?

A
  • upward/downward, IR/ER, anterior/posterior

- superior/inferior, protraction/retraction

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41
Q

Injury to which nerve results in a true pathological scapular winging?

A
  • long thoracic nerve
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42
Q

What are the 3 scapular dysfunction classifications per Kibler?

A
  • inferior angle
  • medial border
  • superior
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43
Q

When assessing for scapular dysfunction, what positions should the scapula be viewed in, and through what movements?

A
  • resting in neutral and with hands on hips

- active in sagittal, scapular, and frontal planes

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44
Q

Describe inferior angle scapular dyskinesia per Kibler.

A
  • prominent inferior angle due to anterior tipping in resting position
  • most commonly seen in RC impingement, as the anterior tipping of the scapula puts the acromion in a more provocative position when the shoulder elevates
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45
Q

Describe medial border scapular dysfunction per Kibler.

A
  • entire medial border is displaced posteriorly due to IR of the scapula in the transverse plane in resting position
  • most commonly seen in pts with GH instability
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46
Q

Describe superior scapular dysfunction per Kibler.

A
  • early and excessive superior scapular elevation during arm elevation
  • typically due to RC weakness and force couple imbalances
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47
Q

What is the reliability of Kibler’s scapular assessments?

A
  • 0.4 - 0.5 kappas. really not the most reliable
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48
Q

Is visual observation a valuable method for evaluating scapular dysfunction?

A
  • loaded question. Yes, it does seem to be, but the methods could use some tightening up. Kibler’s classifications seem to be the most universally studied, but aren’t super specific or sensitive, although they’re not terrible either.
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49
Q

What are 3 more tests for assessing for scapular dysfunction?

A
  • scapular assistance test
  • scapular retraction test
  • flip sign
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50
Q

Describe teh scapular retraction test.

A
  • pt performs movement that was painful or unable without stabiliztion. Therapist stabilizes the scapula in retraction.
  • if improved strength with stabilization, then treatment should focus on kinetic chain vs RC strength
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51
Q

Describe the scapular assistance test.

A
  • AROM, then same movement with assist for scapular motion from therapist.
  • positive if increased ROM or decreased pain with the assistance
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52
Q

Describe the scapular flip sign/test.

A
  • resisted ER at 0* abd. Observe medial border of scapula. If it “flips” away from the thorax, it is considered positive.
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53
Q

What GH ROM is considered important to assess, and why?

A
  • IR and ER
  • Loss of IR due to posterior capsule tightness and increased anterior humeral head translation is an established relationship
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54
Q

What movement will occur with increased posterior capsule tightness?

A
  • generally anterior-superior translation with arm movement, but can be posterior-superior with excessive tightness
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55
Q

What is a concern associated with posterior-inferior capsule tightness?

A
  • has been found to increase subacromial contact with the rotator cuff
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56
Q

What two motions of the GH joint are associated with rotator cuff injury?

A
  • anterior translation

- superior migration

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57
Q

What two interventions have been found to be appropriate for pts with posterior impingement and loss of IR?

A
  • posterior shoulder stretching

- mobs of the GH joint

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58
Q

T or F;

It doesn’t make a difference if the scapula is stabilized or not when measuring GH IR.

A
  • F;

- there is a lot of variability in IR measurements if the scapula isn’t stabilized.

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59
Q

T or F;

It’s adequate to assess GH AROM using functional/combined movements (e.g., Apley’s scratch test, etc).

A
  • F;

- really need to use isolated movements in multiple planes to be able to identify ROM impairments

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60
Q

IR/ER should be measured at what shoulder position?

A
  • 90* abduction
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61
Q

Kelley et al used EMG studies to determine optimal positions for shoulder MMT using what 4 criteria?

A
  • maximal activation of the muscle
  • minimal contribution of shoulder synergists
  • minimal provocation of pain
  • good test-retest reliability
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62
Q

Per Kelley, optimal positioning for supraspinatus MMT is: _____.

A
  • 90* of scaption with neutral hand position; full can position; pt seated
  • empty can position in scaption
  • champagne toast position; 90* scaption, slight ER, and 30* elbow flx
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63
Q

What is the optimal positioning for infraspinatus MMT per Kelley?

A
  • pt seated, 0* GH elevation, and 45* IR
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64
Q

What is an optimal position for teres minor MMT?

A
  • 90* elevation in scaption w/ elbow bent to 90*
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65
Q

What is the optimal position for subscapularis muscle activation?

A
  • essentially functional IR and then lift off
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66
Q

What general differences in RC strength have been found between dominant and non-dominant arms with HHD?

A
  • significantly greater IR strength in the dominant arm

- equivalent ER strength between dominant and non-dominant arms

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67
Q

What tests are commonly used to clear the cervical spine during a shoulder eval?

A
  • overpressure with flexion, extension, lateral flexion, and rotation
  • quadrant or Spurling’s test (combined extension w/ ipsilateral lateral flexion/rotation)
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68
Q

What is the general specificity/sensitivity of Spurling’s?

A
  • sensitivity: 30%
  • specificity: 93%
  • less of a screen, and more helpful to rule in a cervical radiculopathy
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69
Q

What are two tests commonly used to clear the elbow during a shoulder eval?

A
  • valgus stress test

- laterally based extensor provocation test

70
Q

What are common tests for impingement?

A
  • Neer’s: forced flexion
  • Hawkin’s Kennedy: forced IR in the scapular plane
  • coracoid impingement test: forced IR in the sagittal plane
  • cross-arm adduction: forced horizontal adduction w/ palm down
  • Yocum: hand to opposite shoulder and lift elbow up (active test)
71
Q

What is the specificity/sensitivity of Neer’s and Hawkin’s Kennedy?

A
  • Neers: specificity (53%), sensitivity (79%)

- HK: specificity (59%), sensitivity (79%)

72
Q

What two general types of tests are used to assess for instability?

A
  • humeral head translation tests

- provocation tests

73
Q

What is the average amount of anterior, posterior, and inferior translation in normal shoulders?

A
  • anterior: 7.8mm
  • posterior: 7.9mm
  • inferior: 10mm
74
Q

Describe the multi-directional instability test.

A
  • pt sitting w/ arm in neutral position w/ hand resting on lap. Therapist holds the distal humerus, stabilizes the scapula, and performs a few quick downward pulls.
  • Looking for a sulcus sign
75
Q

What pt position is recommended for anterior/posterior instability testing?

A
  • supine
76
Q

What is a consideration when testing for anterior/posterior instability?

A
  • translatory force should be anteromedial and posterolateral to account for the 30* tilt of the glenoid
77
Q

Testing for anterior instability should be done at what ranges, and to test for what structures?

A
  • superior GH ligament: 0-30* abd
  • middle GH ligament: 30-60* abd
  • inferior GH ligament: 90* abd
78
Q

Testing for posterior instability should be done at what ranges?

A
  • 90* abduction
  • there are no real distinct bands of tissue posteriorly, with the exception of the posterior band of the inferior GH ligament complex
79
Q

What are the different grades of GH translation according to Altchek and Dines?

A
  • Grade I: humeral translation within the glenoid WITHOUT edge loading or translation over the glenoid rim
  • Grade II: humeral translation up and over the glenoid rim with spontaneous return upon removal of stress; indicative of laxity NOT instability
  • Grade III: humeral translation over the glenoid rim without relocation upon removal of stress; instability
80
Q

T or F;

Grade II GH translation is indicative of instability.

A
  • F

- laxity, not necessarily pathological

81
Q

T or F;

Should only use the glenoid rim as a marker for assessing translation, not end feel or other markers.

A
  • T;
  • intrarater reliability is improved with use of the glenoid rim as the reference point, and decreases with use of other aspects
82
Q

When trying to assess for a subtle anterior instability in pts with symptoms in overhead positions, what is an appropriate test?

A
  • subluxation relocation test
83
Q

Describe the subluxation relocation test.

Include description of interpretation for dx based on varied findings.

A
  • pt is supine with arm in 90* abduction and max ER
  • a mild anterior subluxation force is provided looking for symptom provocation
  • If symptoms reproduced, then a mild posterior force is provided, looking for symptom alleviation
  • if provoked, then alleviated, it’s considered positive
  • If not provoked in the first position, it is retrialed 110* and 120*
  • subtle anterior instability with secondary GH shoulder impingement is indicated with positive result and anterior pain
  • posterior/internal impingement is indicated with a positive result and posterior pain
  • concern for posterior Type II SLAP lesion with a positive test as well
84
Q

What is the Beighton hypermobility scale? How is it helpful?

A
  • general assessment of global hypermobility
  • passive extension of 5th metacarpal phalangeal joint
  • passive thumb opposition to the forearm
  • elbow hyperextension
  • knee hyperextension
  • standing trunk flexion with knees fully extended
  • varied grading; some use 2/9 to call someone hypermobile, others use 4/9.
85
Q

What tests are appropriate for assessment of instability?

A
  • MDI test
  • anterior/posterior translation in supine
  • subluxation/relocation
  • Beighton hypermobility assessment
86
Q

In a throwing athlete, anterior translation force can be as high as ____% of body weight with the arm in ______.

A
  • 50% body weight

- 90* abduction and ER

87
Q

What are the rates of where labral tears are found?

A
  • anterior-superior: 60%
  • posterior-superior: 16%
  • anterior-inferior: 1%
  • 22% had tears in multiple locations
88
Q

What did a 3-year follow-up for labral debridement find for success of procedure?

A
  • 72% of patients had initial relief in the first year
  • only 7% reported consistent symptom relief by the 2nd year.
  • in general, most patients described a consistent deterioration over time; labral debridement is probably not a great idea
89
Q

What is the difference between a labral tear and a Bankart or SLAP lesion?

A
  • Bankart and SLAP are labral detachments, not just tears.
90
Q

Describe a Bankart lesion.

A
  • labral detachment between the 2-6 o’clock positions on the R
  • 6-10 o’clock positions on the L
  • generally an anterior-inferior detachment
91
Q

A Bankart lesion is found in what percentage of dislocations?

A
  • ~85%
92
Q

A Bankart lesion should present with increased translations in which directions?

A
  • anterior and inferior
93
Q

Describe a SLAP lesion.

A
  • detachment of the labrum between ~2-10 o’clock positions
  • superior labrum anterior posterior
  • involves the LH biceps tendon anchor
94
Q

A SLAP lesion will have a significant effect on the loading of which ligament, likely the most?

A
  • anterior band of the inferior GH ligament

- has significant effect on the static stability of the GH joint

95
Q

What is the proposed mechanism for a SLAP lesion?

A

There are 2:

  • the significant force on the bicep tendon as it decelerates elbow extension while throwing, coupled with the violent, relative distraction on the shoulder at the end of throwing
  • the “peeling back” of the biceps and posterior labrum during abduction and maximal ER that occurs during throwing/OH motions
96
Q

What are 4 general tests for labral integrity, and what mechanism are they generally using?

A
  • Clunk test
  • circumduction test
  • compression/rotation test
  • crank test
  • use long-axis compression through the humeral head to catch/scour the labrum to provoke symptoms; mortar and pestle
97
Q

What are 4 tests used to assess for SLAP lesions?

A
  • O’Brien Active compression test
  • Mimori test
  • biceps load test
  • ER supination test
98
Q

Describe the Mimori test.

A
  • pt seated with arm abducted to 90-100*, with arm brought into ER by therapist.
  • forearm then brought into max supination, and then max pronation.
  • positive if more pain in pronated position
99
Q

Describe the Biceps Load test (Kim test I).

A
  • pt supine, elbow at 90* and 90* abduction.
  • passive ER until apprehension or end range, then resist elbow flexion.
  • positive with continued apprehension or pain
100
Q

Describe the O’Brien’s test.

A
  • pt standing w/ arm flexed to 90* and elbow extended. Arm then horizontally adducted to 10-15* and medially rotated to point thumb down.
  • force applied downward
  • thumb pointed up, and force reapplied
  • If pain on the joint line, or painful clicking inside the shoulder on the first part, then and eliminated or decreased on the second part, it is considered positive
  • locks/loads the AC joint, so must be careful to differentiate with other tests
101
Q

What may the O’Brien’s test confuse a SLAP lesion with?

A
  • AC joint degradation
102
Q

Describe the ER supination test.

A
  • probably variations, but essentially tries to recreate the peel-back mechanism
  • pt in supine with arm abducted to 90* and elbow flexed 65-70*.
  • Pt then supinates against resistance from the examiner, while examiner laterally rotates shoulder to end range
  • positive with anterior shoulder pain, reproduction of symtpoms, catching/clicking
  • negative if posterior shoulder pain, no pain, or apprehension per Magee
103
Q

Is MRI a good method for identifying labral lesions?

A
  • actually not too much better than clinical tests. Not super specific or sensitive.
104
Q

Standard x-ray for the shoulder is usually indicated when _____ and what do they consist of?

A
  • indicated with acute trauma or acute loss of function

- at least 3 views: AP, scapular Y, and axillary views

105
Q

What on imaging would indicate subluxation or dislocation?

A
  • greater than 7-8mm between bottom of acromion and top of humeral head
106
Q

T or F;

The medial headof the humerus should slightly overlap the posterior glenoid fossa.

A
  • T
107
Q

What soft tissue issues can be demonstrated on X-ray?

A
  • chronic rotator cuff tear

- calcifications

108
Q

On x-ray, the following may be indicative of what condition:

  • irregularity of the greater tuberosity
  • sclerosis of the underside of the acromion
  • elevated humeral head
A
  • chronic RC tear
109
Q

What is CT imaging most useful for with shoulder diagnoses?

A
  • subtle or complex fractures
  • loose bodies
  • arthritic changes
  • e.g., Hill-Sachs lesions
110
Q

What is MRI most useful for finding in imaging?

A
  • soft tissue injury, although it’s still good for bony structures as well
111
Q

Adding intraarticular contrast is useful for identifying what type of structural defects?

A
  • RC tears and labral tears
112
Q

What reference should be used to learn about functional tests that are appropriate for the shoulder complex?

A
  • Reiman and Manske
113
Q

What is the purpose of the closed kinetic chain UE stability test?

A
  • assessment of power of the shoulder complex

- gives an indication of strength and endurance as well…

114
Q

Describe the closed kinetic chain UE stability test.

What is an advantage of this test?

A
  • pt places hands within 2 pieces of tape placed 3’ apart
  • pt then alternates touching each piece of tape as quickly as possible; number of touches in 15” is counted
  • assesses closed-chain function without the potentially aggravating loading that occurs w/ push-ups on the anterior shoulder
115
Q

What is an appropriate functional shoulder test for an overhead throwing athlete? What does it consist of?

A
  • functional throwing performance index
  • pt performs a series of repetitive throws at a target where accuracy and ability to functionally throw are graded
  • has reliability of 0.83
116
Q

What is a second functional throwing shoulder test that can be used other than the FTPI?

A
  • Underkoffler softball throw for distance

- 3 underhand throws in a row for max distance; no reliability or validity data for this one

117
Q

What are 2 benefits of isokinetic testing over MMT?

A
  • ability to test the GH joint at faster, more functional angular velocities
  • able to pull out asymmetries that may not be found with static MMT; ER differences of 13-18%, and IR differences of 15-28% found in one study that were judged equivalent with MMT
118
Q

What is the modified base position used for isokinetic testing?

Why is this position used?

A
  • pt’s GH in 30* abd, 30* scaption, with 30* tilt of dynamometer head in transverse plane
  • places the GH joint in a midrange position for ligamentous tension, enhancing the length-tension relationship of scapulohumeral musculature
119
Q

What position shoulder the shoulder be in for the most functionally appropriate ER/IR isokinetic testing for overhead throwing athletes?

A
  • 90* abduction; more closely mimics the alignments/positions used
120
Q

T or F;

Muscle imbalances developed due to repetitive and forceful IR (e.g., tennis serve, pitching) can jeopardize optimal muscular stabilization.

A
  • T

- did not state that this leads to injury or has a clear association with pathology

121
Q

What is the normal ratio of strength between ER and IR?

A
  • ER is ~66% in normal healthy individuals
122
Q

In overhead athletes, would one expect an ER/IR ratio of > or < 66%?

A
  • less due to increased strength of IRs
123
Q

T or F;

It has been recommended to bias the ratio during shoulder rehab to 75% or greater with patients with RC injury or anterior instability.

A
  • T; hammer the ERs
124
Q

What does the “functional ratio” in shoulder rehab refer to?

A
  • the ratio between eccentric ER strength and concentric IR strength
125
Q

What are 5 mechanisms for RC “disease”…I hate that term.

A
  • primary impingement
  • secondary impingement
  • tensile overload
  • macrotraumatic tendon failure
  • posterior (undersurface) impingement
126
Q

What does primary impingement refer to?

A
  • impairment as the direct result of compression of the RC tendons between the humeral head and the overlying anterior third of the acromion, coracoacromial ligament, coracoid, or AC joint
127
Q

T or F;

There is a significant difference in subacromial space between those with shoulder pain and those without shoulder pain.

A
  • F;

- not really; typically 7-13mm for pain, and 6-14mm for those without

128
Q

Where to peak forces of compression within the subacromial space tpically happen?

A
  • 85-136*
129
Q

What are the 3 stages of primary impingement per Neer?

A
  • Stage I: Edema and hemorrhage
  • Stage II: fibrosis and tendinitis
  • Stage III: bone spurs and rupture
130
Q

What are the characteristics of Stage I primary impingement?

A
  • edema and hemorrhage
  • occurs more often in younger, athletic populations
  • described as reversible with conservative PT
131
Q

What are the primary symptoms/signs of a primary impingement?

A
  • positive impingement sign
  • painful arc
  • varying degrees of muscular weakness
132
Q

What are the characteristics of Stage II primary impingement?

A
  • fibrosis and tendinitis
  • may see fibrosis/thickening of subacromial bursa
  • usually in age range of 25-40yo
133
Q

What are the 3 types of acromion shapes?

A
  • Type I: flat
  • Type II: curved
  • Type III: hooked
134
Q

In a cadaveric study, what was the % of acromial types compared with those who had full thickness RC tears?

A
  • 3% had type I
  • 70% had type III
  • didn’t mention Type II
  • takeaway is that a Type III acromion is strongly associated with RC tendon damage
135
Q

What is secondary impingement?

A
  • impingement/compressive symptoms that occur due to instability in the GH joint
  • e.g., capsular laxity or labral defects
136
Q

What types of activities are often associated with the concept of tensile overload causing RC pathology?

A
  • heavy, repetitive eccentric stress during overhead activities; e.g., throwing sports
137
Q

Is it normal for a healthy RC tendon to rupture with a single macro trauma?

A
  • less likely to be normal. Healthy tendons aren’t likely to rupture.
  • tendons that rupture from a single event are thought to have been often weakened/degraded over time prior to the event
138
Q

What is a posterior impingement?

A
  • an internal impingement between the humeral head and the posterior-superior glenoid rim when the shoulder is in 90* abduction and 90* ER
  • may be exacerbated by anterior translation/laxity
139
Q

What was found with an arthroscopic survey of the dominant shoulders of 41 professional throwing athletes?

A
  • All of them had posterior impingement
  • 93% had undersurface fraying of RC tendons
  • 88% showed fraying of the posterior-superior glenoid
140
Q

What may be considered an important component of evaluation with an overhead athlete with respect to posterior impingement?

A
  • assessing horizontal abduction
  • significantly greater contact pressure occurs with 30-45* of horizontal abduction compared to 15* of horizontal abduction
  • thus should look at horizontal abduction with 90* of abduction
141
Q

What are the primary components of early management of RC impingement?

A
  • protect RC from further compression; modify functional activity
  • increase blood supply to local area
  • scapular stabilization via manual techniques
  • ROM/mobilization techniques as indicated
142
Q

T or F;

Estim, US, and iontophoresis are appropriate for management in the early stages.

A
  • T; no research that shows one is better than another

- can improve blood flow and pain control early on

143
Q

What is a non-modality method to improve bloodflow to the local area with early management of RC impingement?

A
  • submax exercise
144
Q

What are two priorities for scapular stabilization in the early phase of RC impingement management?

A
  • scapular retraction

- upward rotation (serratus anterior/LT)

145
Q

Which population of RC impingement pts would be inappropraite for accesory motion techniques?

A
  • secondary impingement; they’re impinging due to laxity
146
Q

What ROM limitation associated with impingement in overhead athletes is most likely appropriate for manual techniques?

A
  • IR is the most studied limitation; may be muscular vs posterior capsule
147
Q

What is an expected exam finding with an overhead athlete?

A
  • dominant arm has increased ER and decreased IR compared to the other arm
148
Q

What are structural reasons for increased ER and decreased IR?

A
  • tight posterior capsule
  • decreased muscle-tendon length in posterior RC
  • humeral retroversion
149
Q

What is considered an optimal position for capsular stretching (specifically the posterior capsule)?

A
  • 30* of elevation in the scapular plane
150
Q

What two stretches are appropriate for an IR ROM deficiency and why?

A
  • sleeper stretch
  • cross arm adduction (**likely more effective per some research)
  • both use inherent means of scapular stabilization
151
Q

What is the general theme of the second phase of RC impingement management?

A
  • strength/endurance training of RC and scapular stabilizers in patterns that avoid impingement
152
Q

What are initial RC/scapular strengthening exercises that are recommended per this author?

A
  • starting w/ sidelying ER and prone shoulder extension w/ thumb out (externally rotated)
  • the progress to horizontal abduction in prone and 90/90 ER in prone
153
Q

What initial sets/reps are recommended by this author for initial strengthening?

A
  • 3x15-20

- goal more endurance/fatigue

154
Q

What are benefits of using a roll between the body and humerus when doing ER/IR therex?

A
  • assists isolation of exercise
  • improved infraspinatus activation
  • reduces “wringing out” phenomenon; improves blood flow
  • isometric adduction may increase subacromial space during movement; less chance of irritation
155
Q

What is a good target for effort to optimize RC activation during resistance training?

A
  • ~40% max effort

- higher intensity may facilitate larger muscle group compensation

156
Q

What is an exercise that optimizes lower trap activation while minimizing upper trap activation?

A
  • scapular retraction w/ ER w/ TB
  • LT activation at a rate 3.3x higher than UT
  • shoulder in neutral, elbows 90*, ER and retract
157
Q

What exercise is appropriate for serratus anterior strengthening?

A
  • push-up plus exercises
158
Q

What exercises are appropriate to improve endurance for scapular stabilizers? (3)

  • How long should holds be?
A
  • closed-chain step ups
  • quadruped position rhythmic stabilization
  • variations of the pointer position (unilateral arm and ipsilateral leg
  • 30” or more
159
Q

As a pt w/ RC impingement progresses, what is a primary guiding factor for continued strengthening?

A
  • strengthening must occur in similar ROMs as the desired function
160
Q

What is one appropriate early abduction exercise near 90*?

A
  • rhythmic stabilization on therapy ball at 90* scaption on wall
161
Q

What is the “statue of Liberty” position for therex beneficial for?

A
  • 90/90 position in scaption for strengthening in a functional range
162
Q

What is a primary reason to focus on ER endurance/strength?

A
  • ER fatigue is associated decreased posterior scapular tilt and decreased scapular ER
  • improving ER endurance is associated with less scapular compensation
163
Q

Initial RC strengthening would progress from iso_____ exercise to iso______ exercise

A
  • isotonic at ~2-3#, then to isokinetic in the modified base position
164
Q

What are appropriate target ranges for isokinetic RC therex for non-athletic vs athletic populations?

A
  • 120-210* per second for non-athletic

- 210-360* per second for athletic

165
Q

What is a good goal for ER/IR strength with rehab?

A

Equal to that of the contralateral limb; however dominant arms can be 15-30% stronger, so keep that in mind

166
Q

T or F;

IR/ER strength gains increase flexion/extension/abd/add strength as well.

A
  • T
167
Q

What is an appropriate strength ratio to aim for with ER/IR with a patient with anterior instability??

A
  • 75-80%

- normal is considered 66%, but bump it up with anterior instability

168
Q

What kind of training is appropriate for overhead athletes following progression through isokinetic training at the modified base position?

For how long?

What other aspect of training is often started at this time?

A
  • isokinetic training at 90* scaption
  • ~6 weeks
  • plyometrics
169
Q

Are plyometrics appropriate for rehab with RC impingement/tendinopathy?

A
  • yes in later stages
  • effective in 90* abduction as well as other alignments
  • has been shown to generally improve UE function
170
Q

What tests/measures should be considered for return to sport/discharge for RC impingement/tendinopathy?

A

Normalization of:

  • re-test previously positive tests (e.g., Neers, etc)
  • ROM
  • strength
  • functional status
171
Q

Is it ok to d/c an overhead athlete w/ RC impingement who has not regained full ER ROM, who otherwise has full strength, negative provocation tests, etc?

A
  • it’s ok to d/c, but they run a significant risk of overloading the elbow/shoulder with throwing
  • i.e., no, it’s not ok. They need full range back
172
Q

What functional shoulder scales are appropriate for use with d/c assessment for overhead athletes?

A
  • American shoulder elbow surgeons (ASES) scale
  • UCLA scale
  • Rowe scale

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