Shoulder APTA (2) Flashcards
1
Q
What is a primary factor that determines rehabilitative course for RC tear?
A
- tear type; partial vs full, and size of tear
2
Q
What defines a “full-thickness” RC tear?
A
- the tear comprises the entire thickness (from top to bottom) of the RC tendon/tendons.
3
Q
Full thickness RC tears are often initiated with which RC muscle first?
A
- supraspinatus, then extending down to the infraspinatus, teres minor, and potentially subscap
4
Q
What is often associated with a subscapularis tear?
A
- subluxation of the LH biceps from the intercondylar groove
- partial or complete tears of the biceps tendon
- i.e., biceps tendon involvement
5
Q
What is a partial thickness RC tear?
A
- a tear that does not completely span the top/bottom of the tendon
6
Q
What are the two types of partial thickness RC tears?
A
- superior surface involvement (bursal side)
- inferior surface involvement (articular side)
7
Q
What is the difference in etiology between bursal vs articular side partial thickness tears?
A
- bursal/superior tears are thought most often to be the result of subacromial impingement; either primary or secondary compressive disease. Macrotrauma is also always an option.
- articular/inferior surface tears are thought to be the result of increased tensile loading, as associated with GH instability; labral/capsular insufficiency, etc
8
Q
What are the different “sizes” of full thickness RC tears?
A
- small: <1 cm
- medium: 1-3 cm
- large: 3-5 cm
- massive: >5 cm
9
Q
What type of suture placement is most secure:
- simple
- mattress
- combination (modified Mason-Allen)
A
- type probably doesn’t matter.
10
Q
What two aspects of the suture for a RC repair are probably most important for integrity of the repair?
A
- how securely sutures are tied
- how much load is carried across each suture
11
Q
What are the benefits of a double-row suture repair?
A
- not likely more secure
- however, in theory maximizes load per suture, and results in the closest approximation of RC geometry
- most repairs match the width, but not overall size of the original RC insertion
12
Q
What are the implications of a single vs double-row suture repair for PT?
A
- while current evidence does not demonstrate a meaningful difference in outcomes, cadaveric studies show decreased gapping of the repair with a double row.
- improved repair integrity increases confidence for safety in the early stages of mobilization/rotational ROM to reduce stiffness
13
Q
What is the general footprint of the supraspinatus tendon on the greater tuberosity (a/p and medial/lateral)?
A
- anterior/posterior: ~12 mm
- medial/lateral: ~24 mm
14
Q
What technique may be even better than double-row suture repair?
A
- transosseous equivalent; aka suture bridge
- shown to be stronger than double-row in laboratory settings
15
Q
In which direction (IR/ER) is there greater tension on the supraspinatus with passive ROM in ~30* elevation, and then 30-60* of rotation?
A
- IR showed greater tension than ER
- of interest as repairs often limit ER more than IR
16
Q
A study looked at humeral rotation in the frontal, scapular, and sagittal planes for a relationship between those alignments and tensile loading. What was found?
A
- rotation with the humerus in the sagittal plane created the most tensile loading
17
Q
What plane is likely best to conduct rotational PROM to minimize tensile loading on the repaired RC tendon?
A
- the scapular plane
18
Q
What are some considerations for early PROM for the infraspinatus?
A
- IR ROM at shoulder elevation of 30-60* increases tension along the inferior most portion of the infraspinatus tendon
19
Q
Is cross-arm adduction safe in the early stages of RC repair?
A
- probably. Doesn’t seem to increase supraspinatus or infraspinatus loading compared to neutral positions
20
Q
Which produces more supraspinatus muscular activation: supine assisted ROM activities or pulley activities?
A
- pulleys….phooey
21
Q
What is a concern for using a weight with Codman’s pendulums?
A
- increased anterior translation
- oddly, does not increase muscle activation over unweighted.
- Pendulums are not going to be completely passive exercises…there will be some muscle activation
22
Q
What drives the progression of ROM and resistance training for RC rehab?
A
- pt tolerance
23
Q
Typically how long is PROM done following RC repair?
A
- through the first 4-6 weeks
24
Q
T or F;
Therapist assisted elevation and ER result in increased muscle activation in the RC musculature; probably note a good idea in early stages.
A
- F; they don’t. probably good to do to facilitate early joint motion
25
What is the "balance point" position? What can it be helpful for? When can it be used?
- 90* flx in supine
- small active motions from flx/ext to initiate recruitment
- in early rehab; probably in the 3-6 week timeframe
26
Is early PROM or immobilization better following RC repair?
- has been studied a lot, and is currently inconclusive
- some evidence for improved ROM at 3, 6, and 12 months, but it was primarily for flexion; this study didn't include massive tears
- other evidence supports early PROM
27
What is the rationale for early PROM or immobilization?
- early PROM may likely mitigate the most common complication of RC repair which is post-op stiffness
- immobilization should reduce the risk of re-tear
28
Progression to early resistance therex usually happens by which timeframe for RC repair?
- 6 weeks post-op, but there's a lot of variability, depending on type of tear, size of tear, tissue health, etc
29
What are the standard key components to early resistance exercise following RC repair?
- generally low levels of loading
- higher rep ranges (15-20)
- smaller lever arm alignments
- GH positions less than 90* of elevation, and anterior to the coronal plane
- RC and scapular stabilizers, avoiding larger muscle group involvement (lower intensities of movement/strength)
30
Is the empty can exercise good for RC rehab?
- no. thought to be good for supraspinatus activation, but it's not worth the IR and anterior tipping created in teh scapula
31
Scapular stabilizer strength typically focuses on which muscles?
- lower trap
| - serratus anterior
32
What two movements are emphasized with scapular therex in the early stages?
- ER and scapular retraction
33
What can be added to scapular elevation to maximize lower and middle trap activation?
- ER resistance w/ band
| - UT is otherwise the max contributer to trap contraction
34
What is the range of post-op strength deficits following RC repair?
- 10-30% deficits
35
What RC musculature is most likely to be deficient following post-op rehab for RC repair?
- posterior musculature, despite the emphasis on ER in rehab
36
When is it appropriate to begin isometrics for RC repair?
- can begin within the first two weeks; as early as immediately
- ....this all depends on the surgeon's protocol
37
When can resisted biceps/triceps curls begin post RC repair?
- as early as 3-6 weeks as long as the GH joint is in a supported position
38
When can active scapular exercise begin (beyond sidelying) post RC repair?
- as early as 3-6 weeks
39
When can isotonic resistance exercise usually begin post RC repair?
What are 5 examples that can be good to start with?
- ~6-8 weeks
- sidelying ER
- prone extension
- prone horizontal abduction (start to 45*)
- supine IR
- flexion to 90*
40
When is it appropriate to begin closed-chain step-ups or quadruped rhythmic stabilization post RC repair?
- 8 weeks
41
When is it appropriate to begin submax isokinetic therex post RC repair? What should the patient be able to do, criteria wise?
- 10 weeks
- should be able to complete isotonic routine w/ 2-3# and w/o pain
- should have greater IR/ER than is required for the isokinetic therex
42
When is it expected to start max isokinetic therex post RC repair?
- 12 weeks
43
When should the formal assessment for appropriateness for return to sport begin post RC repair?
- 12 weeks-ish
44
What criteria should be met before beginning return to sport programs post RC repair?
- IR/ER strength of at least 85% of the contralateral UE
- ER/IR ratio of 60% or higher (66-75% goal, usually)
- pain-free ROM
- negative impingement and instability signs
45
How long can a general RC repair rehab course be expected to last?
- about 4 months-ish is appropriate per the guidelines here
46
What direction of instability is most prevalent?
- anterior instability
47
How often is posterior instability reported with GH instability?
- traditionally, 2-5% of the time
- one new study indicates much higher rates of posterior and combined instability, estimating as much as 40% of operatively managed cases being due to these dxs
48
What are the primary intervention approaches for nonoperative management of shoulder instability?
- pt education
- activity modification to reduce pain/inflammation
- RC and scapular stabilizer strengthening
49
How many different procedures exist to surgically manage shoulder instability?
- over 250.
| - takeaway is that communication with the surgeon is important
50
T or F;
There is high quality research that helps guide instability repair rehab.
- F; most expectations are guided by expert opinion and basic science research re: tissue healing
51
What are 4 primary goals of post-op surgical stabilization?
- protect healing tissue
- prevent joint hypomobility
- diminish pain/inflammation
- regain normal firing patterns for RC and scapular musculature
52
Early training following most surgical stabilization should be conducted in which plane of movement?
- scapular plane
| - least stress on anterior structures
53
One would expect protocols for most surgical stabilizations to have goals for full ROM by what timeframe?
- about the 10-12 week mark
54
What is contraindicated with surgical stabilization repairs?
- stretching
| - eventually, I guess it's ok, but really not appropriate in the first couple of months
55
What movements are more likely safe to take to tolerance with PROM following surgical stabilization? (4)
- flexion
- scapular plane elevation
- horizontal adduction
- IR
56
Early ROM following stabilization procedures is likely appropriate for what movement, due to a "low tension" zone in what range?
- likely ok for earlier ER between 30-45* from neutral
57
What is "obligate motion" and how does it relate to surgical stabilization?
- obligate translation may occur when unchecked/unrecognized posterior capsule tightness leads to unwanted anterior translation against newly plicated tissue
58
What is the "gold standard" for anterior instability surgical repair?
- Bankart reconstruction
59
What are 4 standard surgical procedures for anterior instability?
- Bankart reconstruction
- capsular shift and plication
- arthroscopic anterior capsulolabral repair (ACLR)
- anterior latarjet
60
What are indications for use of an anterior latarjet procedure?
- typically used with instability where labral repair is not possible
- anterior bone loss due to chronic dislocations
- large engaging Hill-Sach's lesion
61
What general precautions can be expected after an anterior latarjet procedure?
- same as subscapularis and anterior stabilization precautions
- additionally, protected ER for the first 6 weeks or so
- depending on the procedure, may need to be careful with subscapularis activation
62
When can light strengthening therex (beyond submax isometrics) w/ light bands or isotonics typically begin following stabilization surgery?
- expect ~4-6 weeks
63
T or F;
Increases in shoulder dysfunction is associated with increased balance/stability deficits.
- T; implies importance of core stability
64
T or F;
Underhand sports can go back to sport earlier than overhead athletes.
- T; usually 1-2 months earlier
65
SLAP lesions are common in what type of athletes?
- overhead athletes
66
How many sub-types of SLAP lesions are there, and what are the standard surgical managements?
- Type I: debridement
- Type II: repair biceps anchor attachment
- Type III: Debridement of bucket-handle tear type
- Type IV: Same as III; plus repair biceps anchor, biceps tenodesis, or tenotomy
- other classifications have up to 7 subtypes, but classically there are 4
67
T or F;
Labral tears are pretty common.
- T
68
Conservative management is appropriate for what types of SLAP lesions?
- typically for Type I and II; essentially all of them, but pretty much always initially indicated for I and II
69
Non-operative treatment for SLAP lesions should focus on: ______
- strength and endurance of RC and scapular stabilizers
| - stretching/mobilization of the posterior shoulder
70
Why is posterior shoulder stretching/mobilization thought to be important for SLAP lesion management?
- lack of posterior shoulder mobility is thought to obligate superior and posterior translations of the humeral head
71
What can be expected for success following non-operative management of SLAP lesions in overhead athletes?
- generally successful at 3 year followup
| - however, only ~66% fully returned to overhead sports
72
T or F;
Most symptomatic SLAP lesions that are surgically managed are what subtype?
- Type II
73
Shoulder slings are typically used how long for SLAP repairs?
- up to 4 weeks
74
What are the recommendations for ER mobilization post SLAP repair?
- varies. More conservative protocols don't allow ER for the first 4 weeks to minimize risk of peel back.
- Authors advocate for no > than 10* per week, not to exceed 30* by week 4, in no > than 45* of abduction
- also recommended not to attempt ER at 90* abduction until week 6, to reduce risk of peel back
75
When is it appropriate to begin isometric RC therex following SLAP repair?
- ~ 2 weeks following repair
| - isometric/isotonic scapular therex can begin early
76
With SLAP repair, what changes happen around the 5-6 week mark?
- elevation limits increase to ~145 as tolerated
- ER to 50*
- active elbow flexion/supination
77
When is full GH ROM expected following SLAP repair?
- at around 12 weeks
78
When is submax exertion for elbow flx/supination typically more ok to start following SLAP repair?
- ~10 weeks
79
With a SLAP repair, what is the shift in focus around the 7-10 week mark?
- towards strength/balance of RC and scapular musculature
80
When is it appropriate to begin gentle stretching/mobilization with a SLAP repair?
- no early than the 7 week mark
81
What are the considerations to improve ER following SLAP repair?
- at the 7 week mark, can start stretching/mobilizing.
| - want to see at least 45* in the neutral position, prior to stretching in the 90* abduction position
82
What are the goals for ROM at week 10 after a SLAP repair?
- full elevation
- ER to 90*
- IR to 70*
83
When can submax isometrics for elbow flexion begin for SLAP repair?
- around 10 weeks
84
When should full ER ROM in the 90/90 position be achieved following SLAP repair?
- 12 weeks
85
When can light plyometric exercises begin following SLAP repair?
- ~13 weeks
86
When can someone be expected to be able to return to overhead activities following SLAP repair? E.g., throwing.
- 16 weeks/4 months
| - this is just the return to the motion, not 100% intensity
87
What is the common clinical presentation for an AC injury?
- following a direct blow/trauma on the outside of the shoulder when the humerus is adducted
- typical of MVA, football, hockey, skiing/snowboarding, cycling
88
What percentage of shoulder injuries sustained in competition are due to AC joint separation?
- ~40%
89
What are the roles of the coracoclavicular ligaments (conoid and trapezoid) for the shoulder and its mechanics?
- provide the majority of vertical stability
- assist in passive scapular motion during elevation
- conoid ligament is a primary contributor to restricting anterior and superior rotation/displacement of the clavicle
90
What are the subtypes of AC joint injury?
- Type I: sprain of the AC ligament without tearing
- Type II: AC ligament and capsule are ruptured without injury to the CC ligaments
- Type III: complete rupture of AC and CC ligaments
- Type IV-VI: AC/CC rupture with increasing degrees of soft tissue trauma and clavicular displacement
91
At what level of severity (Type) of AC injury will a step-off deformity begin to be expected?
- Type III and worse; rupture of both AC ligaments
92
What levels of AC injury are typically managed conservatively?
- Type I-III
93
What does the core of conservative management for AC injury look like?
- immobilization, active rest, ice, ROM, and NSAIDs
| - PT is typically indicated with persistent symptoms or limitations; may be w/ or w/o corticosteroid injection
94
What is recommended for Phase 1 of AC type II rehab?
What are the criteria for progression?
- immobilization, ice, analgesics
- AAROM in low positions
- ROM is 75% of full, no > than mild pain/tenderness to palpation, 4/5 strength for deltoids and UT
95
What is recommended for Phase 2 of AC type II rehab?
What are the criteria for progression?
- restore full ROM in all planes
- progress strengthening, avoiding provocative movements such as bench/military press
- pain-free ROM and 75% of strength compared to uninvolved side
96
What is recommended for Phase 3 of AC type II rehab?
What are the criteria for progression?
- progress strengthening into provocative positions
| - motion is full and pain-free; strength is close to 100%
97
What is recommended for Phase 4 of AC type II rehab?
- sports specific activities and throwing
98
What are motions/positions that should be minimized in early AC rehab due to symptom provocation?
- horizontal adduction
- IR behind the back
- end range flx/ext
99
Why are sustained lifting activities such as carrying heavy groceries, a toolbox, weights, etc, discouraged during rehab of AC joint injury?
- may create some downward displacement
100
T or F;
Scapular stablization/strength should begin early with AC joint injury rehab.
- T; don't need to wait
101
T or F;
There is no advantage to operative management over conservative management for Type I-III AC joint injury.
- T; even with elite athletes
102
What are benefits of surgical management for Type III AC injury?
- pts have higher subjective mobility, pain, and appearance
103
What is an advantage of non-operative management for Type III-VI AC injury?
- typically quicker return to function
104
What are the 4 main surgical options for AC injury management?
- primary fixation using hardware or suture wires; w/ or w/o ligament repair reconstruction
- primary fixation at the CC interval w/ or w/o AC ligament reconstruction
- distal clavicle excision w/ or w/o CC ligament repair or CA ligament transfer
- muscle transfer w/ or w/o distal clavicle excision
105
What is an issue with rigid internal fixation techniques for AC injury?
- excessive hardware loading and failure due to the restriction of normal movement
106
How long is immobilization recommended following AC joint repair?
- ~6-8 weeks w/ a strict platform brace
107
When should full ROM following AC joint repair be achieved?
- 10 weeks, with the exception of functional IR (behind back)
108
When does isotonic strengthening begin for AC joint repair?
- ~12 weeks
109
Frozen shoulder is reported in what % of the population?
- 2-5%
110
Frozen shoulder incidence increases to what percentages with diabetes and thyroid disease?
- 11-38%
111
What 2 conditions are more often associated with frozen shoulder?
- diabetes
| - thyroid disease
112
Frozen shoulder occurs most often between ___ and ___ yo and impacts which gender more?
- 40-65yo
| - females more than males
113
The occurrence of frozen shoulder places the individual at risk for opposite shoulder involvement with what %? How often simultaneously?
- 5-34% get opposite shoulder involvement
| - can happen simultaneously 14% of the time
114
What is the general thought for pathophysiology of frozen shoulder?
- related to elevated serum cytokine levels
- cytokines facilitate tissue repair/remodeling as part of the inflammatory pathway
- with increased cytokine levels, a minor insult may set off an exaggerated response, with initial irritation due to synovial inflammation
- progresses to fibrosis within the capsoligamentous complex, and contracture of the RC interval
- also, new nerve growth
115
What makes up the rotator cuff interval?
- triangle shaped
- between the anterior supraspinatus tendon edge, upper subscapularis border; includes superior GH ligament and coracohumeral ligament
116
T or F;
Frozen shoulder is not associated with full thickness RC tears.
- T
- however partial thickness tears may be present...not really sure how much this says, given partial thickness tears often just exist.
117
Stretching and joint mobilization should target which structures?
- the rotator cuff interval
| - the anterior capsuloligamentous complex
118
What are the 2 models for phases of frozen shoulder?
- painful, stiff, and thawing phase (traditional)
- pre-adhesive stage, acute adhesive (freezing) stage, fibrotic (frozen) stage, thawing stage (severe capsular restriction without synovitis)
119
What are the hallmarks of the pre-adhesive stage of FS? How long does it last?
- mild erythematous synovitis
- sharp pain at end ranges of motion
- achy pain at rest
- sleep disturbance
- may last up to 3 months
120
What are the hallmarks of the acute adhesive (freezing) stage of FS? How long does it last?
- thickened, red synovitis
- achy discomfort
- very painful end ranges of all motions
- 3-6 months
121
What are the hallmarks of the fibrotic (frozen) stage of FS? How long does it last?
- less synovitis
- more mature capsoligamentous fibrosis
- significant stiffness, but less pain
- up to 6 months
122
What are the hallmarks of the thawing stage of FS? How long does it last?
- severe capsular restriction without synovitis
- typically improves with remodeling
- can last up to 9 months
123
What is the typical timeline for FS?
- considered a 12-18 month self-limited process
- however mild symptoms may remain for years (have been found out to 7 years) depending on the degree of fibrosis
- occurs on a continuum
124
What is the traditional clinical exam definition of adhesive capsulitis?
What is the more current one?
- traditionally, a capsular restriction with normal/painless strength, however this has proved an inconsistent presentation
```
- ROM loss of >25% in at least 2 planes
AND
- passive ER loss >50% of uninvolved side
OR
- passive ER less than 30*
```
125
What's the difference between primary and secondary adhesive capsulitis?
- primary is essentially idiopathic
| - secondary is associated with trauma or other dx
126
What are the 3 subtypes of secondary adhesive capsulitis?
- systemic (diabetes, thyroid condition)
- extrinsic (CVA, MI, COPD, chronic liver disease, distal extremity failure)
- intrinsic (RC tendinopathy, calcific tendinitis, acromioclavicular/GH arthropathy, proximal humeral fx)
127
What is the non-pathoanatomical system for classifying adhesive capsulitis?
- based on irritability; mild, moderate, high
- degree of pain, ROM, and extent of disability
- those on the mild end are more likely to have stiffness as a primary complaint, rather than pain
- can be more relevant to clinicians, since intervention is based on irritability
128
Typically, pts in the early stages of AC will have _____ (low/high) irritability, while those in the later stages will have _____ irritability.
- early is more likely to be high, later is more likely to be low
129
What outcome measures are appropriate to track progress w/ pts with adhesive capsulitis?
- the Constant Score
- Disibilities of the Arm, Shoulder, and Hand
- SPADI
- Penn Shoulder Score
130
T or F;
Adhesive capsulitis can present with a greater IR restriction than abduction.
- T
131
What is the hallmark of adhesive capsulitis?
- ER limitation of 50% or greater, or less than 30* ER with arm at side
132
T or F;
RC tendinopathy can often present with significant ER limitations.
- F
| - that would be an atypical presentation
133
What are the differences between RC tendinopathy and AC in terms of MMT?
- pts w/ AC will often have greater IR weakness than those w/ tendinopathy
- AC will also have weakness in abd/ER, but the more abnormal difference is IR
134
T or F;
Successful treatment is determined by the return to normal ROM.
- F; determined by symptom reduction, improved functional mobility, and pt satisfaction
135
T or F;
The affected tissue in the capsule never returns to normal.
- F-ish
| - it should remodel over time. Maybe doesn't become completely normal, but it isn't necessarily altered for life
136
What is the recommendation re: modalities for adhesive capsulitis?
- there's only weak evidence out there, but no modalities are NOT recommended...so if US, heat, shortwave diathermy, etc have an impact on pain, they may help the efficacy of manual or exercise interventions
...there is one study that recently showed reduced likelihood of favorable outcomes when modalities are used...but overall it's just not conclusive right now
137
What % of pts in stage 2 idiopathic AC are likely to have good outcomes when treated with stretching and HEP?
- 90%
138
What was the study done examining "intensive PT" intervention vs "supervised neglect?
- supervised neglect pts performed exercises not to exceed the pain threshold
- intensive PT pts performed active exercise up to and beyond the pain threshold, passive stretching, joint mobs, and HEP
- both groups got better at the 2 year mark
- the "supervised neglect" group had significantly higher outcomes scores
139
T or F;
There is minimal to no difference in outcomes for pts at 3-6 months after therapist-directed HEP vs other interventions.
- T
| - ...both groups tend to get better
140
What 3 factors should be considered when prescribing dosage of stretching?
- intensity, frequency, and duration
141
What are the differences in dosage for stretching with highly irritable pts vs low irritable pts?
- high irritability: low intensity/low duration
| - can be more liberal with dosing when the pt is less irritable, along that spectrum
142
Are long duration, low intensity stretches considered to produce high tensile stress doses?
- yes. dosage is frequency with duration and intensity. The long holds, typically result in overall higher volumes of tensile loading
143
Are joint mobilizations appropriate for AC treatment?
- yes. When combined with exercise, better than exercise alone, however both will produce improvement
144
Are high grade (III-V) mobilizations better than low grade (I-II) when treating adhesive capsulitis?
- not really. One study did show an increased effect for high-grade, but it was just on the edge of statistically significant
- re-inforces the role of pain and mechanoreceptors in the pt's recovery
145
Are corticosteroids appropriate for AC management?
- yes. In the short term, is more effective than PT alone
- effects are short-term, with greatest effects in the 3-6 week timeframe
- no long-term benefits are currently supported
146
When should a corticosteroid injection be considered during PT management of AC?
- recommended around the 3-6 month mark, if pt is not making much progress
147
What further management for AC is available for pts that do not respond after 6 months of treatment?
- manipulation under anesthesia
| - surgical release
148
What would place a pt in a "high irritability" tier for AC?
- high levels of pain (7/10 or >)
- consistent night or resting pain
- high disability on DASH, ASES, or Penn
- pain prior to end ROM
- AROM < PROM, secondary to pain
149
What would place a pt in a "moderate irritability" tier for AC?
- mid levels of pain (4-6/10)
- intermittent night or resting pain
- moderate disability on DASH, ASES, or Penn
- pain at end ROM
- AROM ~ PROM
150
What is the recommended stretching interval for pts w/ severe/high irritability? What is the frequency for stretching exercises?
- 1-5 seconds
| - 20 reps, 2-3x/day (there's no evidence to support this)
151
What are the author's "core" recommended exercises?
- pendulum
- passive supine forward elevation
- passive ER w/ the arm in ~40* of scaption (supine)
- AAROM in extension, IR, and horizontal adduction (standing)
152
What is a consideration for elbow position during pulley use during AC management?
- should be close to full extension
| - if bent, the CLC slack is taken up by the initial "forced" rotation, limiting overall elevation
153
Mobilizations for AC should initially be performed in which directions and which general joint position(s)?
- anterior, posterior, and inferior
| - loose-packed position
154
What would indicate that a pt is appropriate for increased frequency of treatment? (2x/week)
- if the pt doesn't have a significant change with HEP after a week, but does have significant in-clinic improvements (e.g., 15* improvement in ER or elevation)
155
T or F;
Both anterior and posterior glides are appropriate to improve ER in pts w/ AC.
- T
| - due to the RCI/CLC being circular, an improvement in one spot is an improvement everywhere
156
What mobilization technique is appropriate to target the RCI to improve ER?
- inferior glide in ER w/ arm at side.
| - in supine. scapula not stabilized by therapist hand.
157
What is the quadrant stretch in supine?
- hands behind head in supine, letting elbows fall. Appropriate for AC as tolerated.
158
What is a sign of appropriate stretch intensity?
- elimination of pain once removed from end range
159
Pts with limited IR, likely have restrictions where in the capsule? What technique of mobilization is appropriate?
- superiorly and posteriorly
- inferior glide in adduction, extension, and IR; done in sidelying. Basically place in a position of functional IR and pull inferiorly w/ scapular stabilization
160
What stretch can be used to target superior CLC structures?
- sidelying with hand on hip; gently add pressure to elbow
| - can progress to sleeper stretch
161
How long is it recommended to wait after a corticosteroid injection prior to restarting therapy?
- this author says 4 days.
162
What is a rough guideline for the minimum amount of within-session ROM gains one would way to see, without other improvements, for consideration for DC?
- at least 10*
163
T or F;
D/c with AC is usually based on long-term criteria.
- F; more short term, with the expectation that CLC remodeling (a long term process) will take place once pain is under control
