The Shoulder Flashcards
The glenohumeral joint rotates around how many axes?
three (triaxial joint)
What is the orientation of the glenoid fossa?
laterally from the scapula (7°), posteriorly, slight (5°) superior tilt relative to the medial border of the scapula
What about the orientation of the glenoid fossa is thought to assist with joint stability?
slight superior tilt provides greater resistance to inferior forces (may assist with joint instability)
What type of connective tissue is the glenoid labrum?
fibrocartilage
What is the glenoid labrum and what role does it play in the function of the shoulder?
fibrocartilage tissue that surrounds the glenoid;
- deeps the fossa, supplies a negative intraarticular vacuum effect (seals the joint & assists with stability)
How do injury of the glenohumeral capsule or labrum lead to glenohumeral instability?
disruption of the seal of the glenohumeral joint / intraarticular vacuum effect
Describe the attachments of the glenohumeral joint capsule
arises from the glenoid neck & labrum, inserts into the articular margin of the anatomical neck of the humeral head
(Except inferio-medially, where it extends a slight ways down the humeral neck)
Where are there openings in the glenohumeral joint capsule?
- between the humeral tubercles (biceps tendon exits)
- connection between the superior and middle glenohumeral ligaments (subscapularis bursa communicates with joint cavity)
Which bursa communicates with the glenohumeral joint cavity?
subscapular(is) bursa
Where are the glenohumeral ligaments located in relation to the joint capsule?
extracapsular ligaments surround superior and anterior joint, while posterior is thin
What motion(s) does the superior glenohumeral ligament resist?
inferior translation of humeral head when arm is in adduction at side
What connective tissue structure rests over the head of the humerus & directly beneath the rotator cuff?
superior glenohumeral ligament
What is the relationship between injury of the superior glenohumeral capsule and translation of the humeral head?
- tear in the capsule at the greater tuberosity (may be seen with partial RTC tear) increases anterior & inferior translation
- defect seen in massive RTC tear increases translations in all directions
What motion does the middle glenohumeral ligament resist?
anterior humeral translation with arm in mid-range abduction, limits external rotation with arm at side
Describe the structure of the inferior glenohumeral ligament complex.
- expansive band of tissue in inferior capsule
- thick in anterior and posterior bands
- “hammock” type axillary pouch
What motions does the inferior glenohumeral ligament resist?
Anterior and posterior translation of the humeral head after 90° of abduction:
- during external rotation and abduction, the anterior band wraps around the front and limits anterior translation
- during internal rotation, the posterior band wraps around and limits posterior translation
Name the 3 borders of the scapula
superior border, axillary border, vertebral border
Name the 3 angles of the scapula.
superior medial angle, inferior medial angle, lateral (glenoid) angle
At which spinal level is the superior margin of the scapula?
T2 spinous process
At which spinal level is the medial spine of the scapula?
T3 spinous process
At which spinal level is the inferior medial angle of the scapula?
T7 spinous process
What is the plane of the scapula?
30° to 45° from the coronal plane
What are the two roles of the acromion?
- serves as a lever arm for the deltoid
- articulates with the lateral end clavicle (AC joint)
What is the shape of the sternoclavicular joint? What motions does this shape allow?
saddle-shaped: protraction/retraction, elevation/depression, & some rotation around its long axis
Describe the capsuloligamentous structures of the sternoclavicular joint.
relatively weak capsule supported by thickenings (anterior and posterior sternoclavicular ligaments)
What is the most important ligament in the sternoclavicular joint & why?
posterior sternoclavicular ligament; sectioning of this structure causes significant increases in anterior and posterior translations
What is the interclavicular ligament & what motions does it resist?
connects both clavicles medially; resists inferior forces on the medial clavicle
What are the attachments of the costoclavicular ligament complex?
runs from superior surface of 1st rib to undersurface of the medial clavicle
Which ligament runs from the 1st rib to the medial clavicle?
costoclavicular ligament
What motion does the costoclavicular ligament resist?
resists superior force on medial clavicle when the lateral clavicle / shoulder is depressed (posterior & anterior bodies)
How many degrees of freedom does the acromioclavicular joint have? What are they?
three: protraction/retraction, elevation/depression, & rotation
What ligaments stabilize the acromioclavicular joint?
Conoid ligament (behind) & Trapezoid ligament (in front); Collectively, they are referred to as coracoclavicular ligaments
How does the acromioclavicular joint tissue change throughout life?
hyaline articular cartilage becomes fibrocartilage on the acromial side (age 17) & then on the clavicular side (age 24)
What is the role of the acromioclavicular joint meniscus?
increase stability by improving the fit between the two surfaces
What are the attachments of the conoid ligament?
runs vertically from the coracoid process to the clavicle
What motions does the conoid ligament resist?
resists elevation and protraction of the clavicle
What motions does the trapezoid ligament resist?
resists acromioclavicular joint distraction (provides joint compression), and secondarily resists clavicle elevation and protraction
These ligaments resist elevation of the distal clavicle.
Coracoacromial ligaments (conoid and trapezoid)
Due to its ligamentous attachments, what other motion does the clavicle undergo when it is elevated?
Posterior rotation of the clavicle
Describe the concept of scapulohumeral rhythm (“2 to 1”)
shoulder elevation is created by both movement of the scapula (60° rotation) and of the glenohumeral joint (120° elevation);
The rhythm of “2 to 1” refers to the fact that approximately 2° of motion occurs at the glenohumeral joint for every 1° of the scapula.
Describe the concept of a force couple.
two or more muscles or groups of muscle on opposite sides of a joint work together to provide stability or movement of a joint segment
Describe the Deltoid / Rotator Cuff force coupling that occurs in the shoulder.
The vertical force by the deltoid is offset by the horizontal (inferior and medial) forces of the rotator cuff as they act in opposite directions on either side of the center of rotation of the humeral head (infraspinatus, subscapularis, and teres minor provide inferior/medial force, while supraspinatus compresses the humeral head in the glenoid)
Without the rotator cuff, what would happen during attempted arm elevation?
the deltoid would pull the humeral head superiorly and the greater tuberosity would hit the underside of the acromion / coracoacromial arch
How does pressure from the humeral head onto the coracoacromial arch change when the rotator cuff is not working properly?
force increases 60%
At what general ranges of motion is glenohumeral cavity-compression the greatest?
compression of the humeral head into the glenoid fossa is more common at mid-ranges (where capsular structures are lax), it may also occur at end-ranges where humeral joint forces are increased
Give three examples of force couples that occur in the shoulder.
- Deltoid / Rotator Cuff
- Upper Trapezius / Serratus Anterior
- Anterior-Posterior Rotator Cuff Muscles
What are the four functions of the Trapezius / Serratus Anterior force coupling that occurs in the shoulder.
- allows for upward (lateral) rotation of the scapula, maintaining the glenoid for optimal positioning
- maintains an efficient length-tension relationship for the deltoid
- decreases “impingement”
force on subacromial structures - provides stable scapular base, “enabling appropriate recruitment of scapulohumeral muscles”
What movement is produced with the Upper Trapezius / Serratus Anterior force coupling in the shoulder?
Upward (lateral) scapular rotation
Describe the Upper Trapezius / Serratus Anterior force coupling that occurs through varying degrees of shoulder abduction.
Lower portion of Serratus Anterior & Lower Trap. contract in conjunction with Upper Trap. & Levator Scapula. The result is rotation of the scapula around a moving axis.
Early in abduction, the axis is near the medial border of the scapular spine (this gives a the Lower Trap. a very small lever arm, since it attaches near this spot).
As abduction continues, the axis moves laterally along the scapular spine toward the ACJ, creating an increasingly longer lever arm for the Lower Trap.
At 90° or more of shoulder elevation, Serratus Anterior and Lower Trap. are primary components of scapular rotation and stabilization.
What muscular abnormalities have been recorded in patients with Impingement Syndrome of the shoulder?
decreased levels of Serratus Anterior activity, delayed firing of Middle and Lower Trap., and increased activity of Upper Trap. and Levator Scapula
Describe the Anterior-Posterior Rotator Cuff force coupling in the shoulder
Subscapularis (anteriorly) and Infraspinatus & Teres Minor (posteriorly) create both inferior and compressive stability;
Describe the concept of the rotator cuff muscles as a “suspension bridge” that influences humeral head movement.
Subscapularis, Infraspinatus, and Teres Minor create inferior and compressive stability / create a stable fulcrum to allow for concentric rotation of the humeral head on the glenoid
In what ranges of shoulder elevation are the Subscapularis, Infraspinatus, and Teres Minor most active?
Mid ranges
What imbalances are frequently found in the Anterior-Posterior Rotator Cuff force couple?
selective development of the internal rotators and subscapularis in athletes / active individuals without development of the posterior rotator cuff
What is the effect of an isolated supraspinatus tear on the “suspension bridge” phenomenon of the shoulder?
the anterior-posterior force couple remains intact
What are the 7 components of the clinical examination of the shoulder?
- Observation and posture
- Scapular evaluation
- Glenohumeral joint range of motion
- Manual muscle testing (supraspinatus, infraspinatus, teres minor, subscapularis)
- Related referral joint testing (cervical, elbow)
- Special tests (impingement, instability, labrum)
- Functional testing
What are the theoretical explanations for shoulder height asymmetry?
dominant shoulder is typically lower: increased mass in the dominant arm; elongation of periscapular musculature secondary to eccentric loading
What is the purpose of performing visual observation of the patient in standing during an examination of the shoulder?
In quiet standing and hands-on-hips standing, you can observe for muscle symmetry and focal atrophy
When performing the posture/observation portion of a shoulder examination, why have the patient perform hands-on-hips standing as opposed to neutral arm position?
it places the shoulder in 45°-50° of abduction and slight internal rotation; It allows the patient to relax the arms and allows a better chance of spotting atrophy of the muscles along the scapular border and infraspinous fossa
What might cause observable atrophy of the infraspinatus?
- rotator cuff dysfunction
- suprascapular nerve involvement (severe atrophy)
Where does impingement of the suprascapular nerve commonly occur?
suprascapular notch (a.k.a. the spinoglenoid notch)
What are paralabral cysts and how to they impact nearby tissue?
swellings / collections of fluid that occur within 1 cm of the labrum; they can compress and impinge on the suprascapular nerve as it travels around the spinoglenoid notch on its way to the infraspinatus
Injury to what area of the shoulder joint labrum is most often associated with paralabral cyst formation?
superior
Explain how a shoulder joint labral lesion can directly lead to atrophy of the infraspinatus.
Superior labral lesions can cause the formation of a paralabral cyst, which can impinge on the supraspinous nerve and disrupt the innervation of the infraspinatus.
What is the appropriate course of action if extreme wasting of the infraspinatus muscle is observed?
recommend further diagnostic testing to rule out suprascapular nerve involvement
Describe the Kibler Scapular Slide test.
Measure the distance between the closest thoracic spinous process and the inferior angle of the scapula in 3 positions:
- arms by sides
- hands on hips
- arms at 90° abduction + internal rotation
a difference between sides of 1.5cm (one finger-width) or greater may indicate scapular muscle weakness or poor overall stabilization of the scapulothoracic joint
What are the 3 dysfunctions of the scapula described by Kibler et al?
- inferior angle
- medial border
- superior
Describe inferior angle scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?
- anterior tipping of scapula in frontal plane (inferior border is prominent)
- commonly seen with subacromial pain syndrome (anterior tipping causes the acromion to press down on an elevated humerus?)
Describe medial border scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?
internal rotation of the scapula tilts the glenoid forward (“antetilting”), which allows for and opening up of the front half of the glenohumeral joint articulation.
- commonly seen with glenohumeral joint instability & thought to be a component of subluxation/dislocation
Describe superior scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?
- early & excessive superior scapular elevation during arm elevation
- typically results from rotator cuff weakness & force couple imbalances
What does a kappa score measure in research? Why is it useful? How is it measured?
- measures inter-rater or intra-rater reliability
- it’s better than a simple percentage of agreement between two raters, because it that takes into account the possibility of an agreement occurring by chance
- measured on a scale from 0.01 - 1.00.
- 0.01-0.2 = none/slight
- 0.21-.4 = fair
- 0.41-0.6 = moderate
- 0.61-0.8 = substantial
- 0.81-1.0 = almost perfect agreement
What statistical support does classification of scapular dysfunction have?
- evaluations of 26 - 56 individuals
- Interrater reliabilities range from k = 0.40 to 0.61 (moderate score)
List 4 tests that might be used during an evaluation of the scapula.
- Scapular Slide test
- Scapular Assistance test
- Scapular Retraction test
- Flip Sign
Describe the Scapular Assistance test.
Examiner’s hands on inferior medial aspect & superior base of scapula; examiner assists with rotation during active elevation in either scaption or flexion;
(+) if ROM is increased or pain is decreased
Describe the Scapular Retraction test.
Examiner manually retracts the scapula while the patient performs the painful movement (usually IR or ER at 90° abduction - common in overhead athletes with posterior impingement and RTC pathology);
(+) if ROM is increased or pain is decreased
Describe the Flip Sign.
Examiner resists ER with shoulder in slight abduction;
(+) if medial border of scapula “flips” away from the thorax;
indicates a loss of scapular stability
If a patient with shoulder pain presents with a (+) Flip Sign, what exercises are likely to help.
(+) Flip Sign is indicative of a loss of stability of the scapula; Exercises to strengthen/increase the serratus anterior / trapezius force couple will help to increase scapular stability
Why is the loss of glenohumeral internal rotation clinically important? What populations consistently present with this issue?
- loss of IR can indicate posterior capsule tightness
- can cause increased anterior humeral head translation
- increased anterior humeral shear (happens during the follow-through of a throw or swing/serve)
- increased superior migration of humeral head during shoulder elevation
- cadaver studies show that humeral head shifts antero-/superiorly with arm in 90° abd / 90° ER position
- increased subacromial contact area & contact forces on RTC
- common in overhead athletes (esp. tennis players and baseball pitchers)
List 3 manual muscle test positions are used to evaluate the supraspinatus? Which is most highly recommended by the monograph’s authors & why?
- Full can test
- Empty can test
- Champagne Toast test;
authors recommend Champagne Toast test, because it seems to have the best ratio of supraspinatus to deltoid activation
What is the optimal position to test the strength of the infraspinatus muscle, according to Kelly et al?
- Patient seated
- 0° shoulder flexion
- 45° internal rotation
Describe the purpose and performance of the Patte test.
- isolate the teres minor muscle to assess strength / tolerance for loading
- 90° shoulder scaption
- 90° external rotation
- pt resists external rotation
According to Kelly et al, what is the optimal position for testing the strength of the subscapularis muscle?
Gerber lift-off position
(back of hand lifting away from inferior border of ipsilateral scapula)
Using handheld dynamometers, what did Reimann et al conclude about rotator cuff strength differences between dominant and non-dominant shoulders?
The dominant limb was found to have significantly stronger internal rotation. External rotation was equal.
Describe the interpretation of the Spurling’s Compressive Test in an examination of a patient with shoulder pain.
Spurling’s test is not sensitive (30%), but it is specific (93%) for cervical radiculopathy. Just because it doesn’t recreate shoulder pain doesn’t mean there isn’t any cervical involvement/referral.
What are two reasons that you might screen the elbow when you suspect shoulder pathology?
- Shoulder injury can refer symptoms to the elbow
- Elbow injuries can occur alongside shoulder injuries (in throwing athletes & during sling use following surgery)
During a shoulder examination, what two elbow tests are recommended by the monograph authors?
- Valgus Stress Test
- Laterally-based Extensor Provocation Test
Describe the Valgus Stress test of the elbow. What is this testing?
- elbow placed in 15-25° of flexion (puts capsule on slack and “unlocks” the olecranon from the olecranon fossa)
- apply medial force to stress the Ulnar Collateral Ligament
Describe the Laterally-based Extensor Provocation Test. What is this testing?
- elbow is fully extended
- resist wrist extension
- loads the lateral epicondylar region
What are the three categories of special tests for the shoulder described by the monograph authors?
- Impingement tests
- Instability tests
- Labral tests
Describe the 5 shoulder impingement tests listed in the monograph. Which of these are the best supported?
- Neer Impingement test
- Hawkins-Kennedy Impingement test
- Coracoid Impingement test
- Cross-arm Adduction test
- Yocum test
- Neer test is 53% sp, 79% sn; Hawkins-Kennedy is 59% sp, 79% sn
Compare/contrast the Hawkins-Kennedy Impingement with the Coracoid Impingement test.
both include forced shoulder internal rotation, but the Hawkins-Kennedy test is 90° of scaption. The Coracoid Impingement test is performed in 90° of flexion.
What are the two main types of shoulder instability tests?
- Humeral head translation tests
- Provocation tests
What is the approximate ratio of normal anterior-to-posterior humeral head translation in the glenoid?
1:1 (7.8-7.9 mm)
What is the average normal inferior displacement of the humeral head in the glenoid?
1 cm
Describe the MDI Sulcus test
a.k.a. Multi-directional Instability Sulcus Test
- patient seated
- shoulder in neutral
- hands resting on lap
- several brief, relatively rapid downward pulls on the humerus
- (+) “sulcus sign” if there is tethering of the skin between the lateral acromion and the humerus (widening of subacromial space)
The MDI Sulcus test assesses the integrity of which two structures of the shoulder?
superior GH ligament & coracohumeral ligament
Which shoulder special test is used to assess the integrity of the superior glenohumeral ligament and/or the coracohumeral ligament?
Multi-directional Instability Sulcus test
Why should a patient be positioned in supine in order to test for anterior/posterior shoulder joint laxity?
allows the patient’s shoulder to be tested in multiple degrees of abduction (selectively stresses different portions of the capsule and capsular ligaments)
List the 5 shoulder instability tests described in the monograph.
- MDI Sulcus test
- Supine Anterior Humeral Head Translation test
- Supine Posterior Humeral Head Translation test
- Subluxation Relocation test
- General hypermobility testing (e.g. the Beighton hypermobility scale/index)
Describe the Anterior and Posterior Humeral Head Translation tests.
- designed to assess laxity of the anterior/posterior capsule and/or capsular ligaments
- patient is supine, shoulder in scapular plane
- because the glenoid is angled at 30°, translation should be antero-medial / postero-lateral
- anterior translation performed at 3 ranges of abduction (0-30°, 30-60°, 90°)
- posterior translation only performed at 90°
During the Anterior Humeral Head Translation test, in what range of degrees of abduction would you place the shoulder in order to test the integrity of the superior glenohumeral ligament?
0-30° abduction
During the Anterior Humeral Head Translation test, in what range of degrees of abduction would you place the shoulder in order to test the integrity of the middle glenohumeral ligament?
30-60° abduction
During the Anterior Humeral Head Translation test, in how many degrees of abduction would you place the shoulder in order to test the integrity of the inferior glenohumeral ligament?
90°
Why is the Posterior Humeral Head Translation test performed in 90° of abduction?
there’s no distinct thickenings of the capsule in the posterior portion aside from the posterior band of the inferior glenohumeral ligament complex, which is stressed most in 90° of abduction
Describe the grading system for Humeral Head Translation testing.
Grade I: translation of humeral head without “edge loading” or translation of the humeral head over the glenoid rim
Grade II: translation up and over the glenoid rim with spontaneous return
Grade III: no return/relocation (rare in PT clinic)
How reliable is the grading system Humeral Head Translation testing?
- Of the 3 grades, interrater reliability is best in distinguishing between grades I and II (does the head of the humerus traverse the glenoid rim?)
- adding on other estimators like end-feel decreases interrater reliability
Describe the Subluxation Relocation test. Why is this test a useful supplement to the MDI Sulcus test and Anterior/Posterior Translation testing?
- pt supine
- 90° shoulder abduction
- max ER
- PT provides mild anterior subluxation force
- if anterior/posterior sx are reproduced, PT applies a gentle postero-lateral force to the anterior shoulder
- failure to reproduce symptoms leads PT to reattempt at 110° and 120° abduction
- (+) test is when symptoms are reproduced with anterior translation & diminished with poster-lateral translation
What is “occult” shoulder instability? What is a clinical indicator of this type of instability, according to the monograph authors?
- Shoulder pain (common to overhead athletes) due to subtle lack of ligamentous restraint that is currently difficult to measure
- apprehension with anterior translation of the humeral head during the Subluxation Relocation test is (+) indicator
Contrast the reproduction of anterior vs posterior shoulder pain during the Subluxation Relocation test.
- anterior pain: anterior instability / secondary glenohumeral joint impingement
- posterior pain: posterior or internal impingement
Aside from shoulder joint instability, what other condition may be implicated in patients with a positive Subluxation Relocation test?
Type II superior labrum anterior to posterior (SLAP) lesion
What scale is used in assessing general hypermobility?
the Beighton hypermobility scale/index
Describe the 9 items in the Beighton hypermobility scale/index.
(Bilateral)
1 & 2: 5th MCP hyperextension
3 & 4: Passive thumb to forearm
5 & 6: Elbow hyperextension
7 & 8: Knee hyperextension
9: Standing trunk flexion with knees fully extended
How many items does the Beighton hypermobility scale/index consist of?
9
How many items of the Beighton scale must be positive in order to grade the patient as “hypermobile”?
No consensus. Some studies say 2 out of 9, some say 4 out of 9. The testing is better for an overall understanding of the patient’s tendency toward ligamentous laxity & guide progression rates for ROM or mobilization.
List the 8 shoulder labral tests described in the monograph.
General tests:
1. Clunk test
2. Circumduction test
3. Compression Rotation test
4. Crank test
Location-specific tests:
5. O’Brien Active Compression test
6. Mimori test
7. Biceps Load test
8. ER Supination test
What are the 2 categories of shoulder labral tests described in the monograph? What is the difference between the two?
- General: uses long axis compression to scour the glenoid with the humeral head (traps torn/detached labral segment)
- Location-specific: use muscular tension via the long head of the bicep on the superior labrum (specifically used for identifying superior labral lesions)
What are the two main functions of the glenoid labrum?
- deepens the glenoid fossa, enhancing the concavity
- serves as an attachment site for the glenohumeral ligaments (secures the humeral head in the glenoid)
What is the effect of injury to the labrum on glenohumeral joint compression?
labral injury has been shown to decrease concavity compression up to 50%
Describe the effect of anterior translation forces on the humeral head in overhead throwing athletes.
Anterior translation forces can be up to 50% of body weight during arm acceleration of the throwing motion (arm in 90° abduction & ER)
How does increased capsular laxity / generalized joint hypermobility affect forces on the glenoid labrum in both the short- and long-term?
increased humeral head translation, which can subject the labrum to increased shear forces
- repeated translation of the head against the labrum can lead to tearing or detachment from the glenoid
List the 5 types of glenoid labrum tears described in the monograph.
- transverse
- longitudinal
- flap
- horizontal cleavage
- fibrillated
In what parts of the labrum do tears most commonly occur?
- anterior-superior (60%)
- posterior-superior (18%)
- only 1% in anterior-inferior labrum
- multiple areas (22%)
What are the general outcomes of arthroscopic labral debridement procedures in patients with shoulder joint hypermobility? What are the clinical implications of these outcomes?
- 72% of people report acute relief of symptoms during the first year, but only 7% reported relief at 2 years
- debridement is not an effective long-term solution for labral tears
- underlying instability in overhead athletes needs to be address to improve pain and return to function in the long run
What is the difference between a SLAP or Bankart lesion vs. a labral tear?
SLAP / Bankart lesions are labral detachments of the labrum from the rim
What are the two most common labral detachments?
SLAP lesion & Bankart lesion
What is a Bankart lesion? What is its relationship to dislocation?
labral detachment that occurs between 2 o’clock and 6 o’clock (on a right shoulder)
- up to 85% of people with dislocation have a Bankart lesion
What is a SLAP lesion? Why is the loss of shoulder stability so significant with these lesions?
- labral detachment that occurs in the superior aspect of the labrum
- involves the tendon of the long head of the biceps, which is no longer anchored to the glenoid (loss of static stability)
What was the effect of a surgically-induced SLAP lesion on glenohumeral joint stability?
- experimenters created a SLAP lesion between the 10 o’clock and 2 o’clock positions
- 11-19% decrease in ability of the GH joint to withstand rotational force
- 100%-120% increase in strain on anterior band of the inferior GH ligament
What is the “peel back mechanism” that is hypothesized to cause glenoid labral injury?
the torsional force created with the abducted arm is brought into maximal ER “peels back” the biceps and labrum
What activity puts the most strain through the biceps tendon in overhead athletes? What other forces on the shoulder are relevant in this situation?
decelerates the extending elbow during the follow-through phase of pitching
- coupled with the large (“violent”) distraction forces produced during follow-though, this is a hypothesized mechanism of SLAP lesions
What can cadaver studies tell us about mechanisms of superior labral injuries?
- experimenters looked at load vs failure in cadavers
- compared distraction vs “peel back” simulation models
- significantly lower load to failure for peel back model (90° abduction, max ER)
Which 4 special tests of the shoulder attempt to mimic the “peel back” mechanism?
- O’Brien Active Compression test
- Mimori test
- Biceps Load test
- ER Supination test
Discuss the diagnostic accuracy of clinical tests to identify glenoid labrum pathology.
The sensitivity and specificity of these tests varies among studies (Sn 76-92%, Sp 42-91%), so they should be used in clusters and confirmed by MRI with contrast.
What pathologies might be detected via shoulder radiographs?
fracture, calcification (esp. in supraspinatus), rotator cuff tears
How might a shoulder radiograph show signs of a rotator cuff tear?
- irregularity of greater tuberosity
- sclerosis of underside of acromion
- elevated humeral head (deltoid unopposed by RTC)
How does calcification of the supraspinatus typically occur?
bloody hemorrhage coagulates and calcifies
What shoulder pathologies might be detected via computed tomography?
-subtle or complex fractures of humerus or glenoid
- arthritic changes
- loose bodies
- Hill-Sachs lesions
What intra- and extra-articular structures of the shoulder can be assessed using MRI?
- Intra-articular: ligaments, capsules, synovium, labrum
- Extra-articular: ligaments, bursae, tendons
What is the effect of adding contrast to a shoulder MRI?
- increases the ability to determine RTC tears and labral tears
- gadolinium distends the joint and separates intraarticular structures, extending into defects/tears in the tissue
What 2 functional tests for the shoulder are recommended by the monograph authors?
- Closed Kinetic Chain Upper Extremity Stability test
- Functional Throwing Performance Index
Describe the Closed Kinetic Chain Upper Extremity Stability test.
- 2 pieces of tape 3 feet apart on floor
- patient assumes push-up position with hands just inside the tape
- patient alternates touching opposite tape for 15 seconds
What does the Closed Kinetic Chain Upper Extremity Stability test assess? Why is this better than simply performing a push-up?
- the ability of the shoulder to function in a closed kinetic chain environment
- better than a push-up, because it doesn’t stress the anterior shoulder (happens during push-up descent)
Describe the Functional Throwing Performance Index.
- series of repetitive throws at a target
- scores both accuracy and ability to functionally perform the throwing motion
Why might isokinetic testing of shoulder musculature be more beneficial than manual muscle testing?
accommodating resistance & ability to test glenohumeral joint at faster, more functional angular velocities
What are the limitations of manual muscle testing of the shoulder joint?
- when there is a minor strength impairment or isolated strength deficit
- difficult to assess antagonist/agonist muscular strength imbalances
What are the 5 key pathophysiologic factors that lead to rotator cuff disease?
- Primary impingement
- Secondary impingement
- Tensile overload
- Microtraumatic tendon failure
- Posterior / undersurface impingement
What is primary rotator cuff compressive disease also known as?
primary impingement
What is primary rotator cuff impingement?
compression of rotator cuff tendons between the humeral head and the anterior 1/3 of the acromion, coracoacromial ligament, coracoid, or acromioclavicular joint
During primary rotator cuff impingement, the rotator cuff tendons can be compressed between the humeral head and what 4 structures?
- anterior 1/3 of the acromion
- coracoacromial ligament
- coracoid
- acromioclavicular joint
What did Poppen & Walker discover about subacromial
compressive forces during shoulder elevation?
compressive forces are 42% of body weight
At what angles of shoulder elevation are subacromial compressive forces the highest?
between 85° and 136° of elevation
What phases of the throwing motion are most likely to produce subacromial compression?
acceleration and follow-through
What are the shoulder motions during the follow-through phase of throwing that cause subacromial compressive forces?
flexion, horizontal adduction, and internal rotation
What musculotendinous structures are most likely to experience abrasion due to subacromial impingement/compression during the throwing motion.
supraspinatus, infraspinatus, or biceps tendon
According to Neer, what are the 3 stages of primary rotator cuff impingement?
- Stage I: edema and hemorrhage
- Stage II: fibrosis and tendonitis
- Stage III: bone spurs and tendon rupture
What is Stage I Primary Rotator Cuff Impingement?
a.k.a edema and hemorrhage
- mechanical irritation of tendon via impingement during overhead activity
- reversible with PT
Describe the typical profile and clinical presentation of a patient with stage I primary rotator cuff impingement.
- young, athletic patients
- painful arc
- (+) impingement sign
- varying degrees of muscular weakness
What is Stage II Primary Rotator Cuff Impingement?
a.k.a fibrosis and tendonitis
- repeated episodes of inflammation
- thickening/fibrosis of the bursa
- ages 25-40
What is Stage III Primary Rotator Cuff Impingement?
a.k.a bone spurs and tendon rupture
- continued mechanical compression of the tendons
- full- or partial-thickness tears of the rotator cuff
- biceps tendon lesions
- bony alterations of the acromion
- bony alterations of the acromio-clavicular joint
- correlation between “hooked” acromion shape and full-thickness rotator cuff tears
Describe Secondary Rotator Cuff Compressive Disease.
a.k.a. Secondary Impingement
- impingement/compression that occurs as a result of instability
- excessive demands on static stabilizers (labrum/ligaments) cause anterior instability
- throwing/overhead athletes
- dynamic stabilizers (RTC and biceps) are fatigued/injured
- can lead to rotator cuff tearing
Describe the relationship between tensile overload and rotator cuff tears.
heavy, repetitive eccentric forces in posterior rotator cuff muscles during deceleration & follow-through phases of overhead sport activities lead to overload failure of the tendon
- angiofibroblastic hyperplasia
In the arm deceleration phase of throwing, tensile strength of the rotator cuff resists which forces? How great are these tensile forces when measured?
- tensile elements of rotator cuff resist joint distraction, horizontal adduction, and internal rotation
- forces are reported to be as high as 1090 N (~225lbs) in even highly skilled pitchers
Describe microtraumatic tendon failure of the rotator cuff.
repeated microtrauma and degeneration over time create a weakened tendon that eventually fails under a heavy load,
What percentage of a rotator cuff tendon can be torn without a substantial loss of strength?
Up to 30%
Describe undersurface rotator cuff impingement.
a.k.a. posterior or inside impingement
- When the shoulder is in 90/90 position, the supraspinatus & infraspinatus tendons rotate posteriorly and become pinched between the humeral head & posterior-superior glenoid rim.
What diagnosis should be considered in a patient with posterior shoulder pain brought on by positioning the arm in 90/90 & is either an overhead athlete or industrial worker?
posterior/inside/undersurface rotator cuff impingement
What is the relationship between anterior humeral head translation and undersurface impingement?
produces mechanical rubbing and fraying on the undersurface of the rotator cuff tendons
What is the relationship between posterior impingement and the deltoid musculature?
in 90/90 position, the posterior deltoid’s angle of pull compresses the humeral head against the glenoid, increasing the force on the bone, tendons, and labrum.
What is the primary initial objective in treating rotator cuff pathology?
decrease stress on rotator cuff (either compressive or tensile) without decreasing function
What is the role of isometrics in treating rotator cuff impingement / pathology?
What movements are recommended by the monograph authors?
- early submaximal exercise increases local blood flow
- even submaximal contractions of rotator cuff muscles produced increased perfusion and latent hyperemia following
- isometric internal/external rotation & submax manual resistance in scapular plane with low levels of elevation
What is the first force couple that should be addressed when treating rotator cuff impingement / pathology? Why?
- Serratus Anterior / Lower Trapezius force couple
- key component of early management is scapular stabilization and retraction
Describe the sequence of scapular stabilization treatment recommended by the monograph authors.
- side-lying manual resistance of scapular retraction
- rhythmic stabilization applied to proximal aspect of the extremity
- rhythmic stabilization to distal extremity in 80° and 90° of scaption
- add in scapular protraction to emphasize serratus anterior
When treating rotator cuff impingement / pathology, what portion of physical examination is critical to guide ROM and mobilization treatment? Why?
anterior and posterior humeral head translation
- too much: instability that contributes to secondary impingement (no mobilization)
- too little: hypomobility that will benefit from accessory joint mobilization
What specific ROM limitation is most studied in overhead athletes with rotator cuff pathology? What is the first step in addressing this?
- loss of IR
- clinical examination needs to identify the tissue involved (restrictions in the posterior capsule vs. injury of the muscle tendon unit)
What are two reasons why glenohumeral internal rotation may be limited in the overhead athlete with rotator cuff pathology?
- restrictions in posterior capsule
- injury of the rotator cuff musculotendinous unit
How do you determine if limited glenohumeral internal rotation is due to posterior capsule tightness?
Posterior Load & Shift, a.k.a. Posterior Drawer test
How is the Posterior Load & Shift / Posterior Drawer test performed? What are common mistakes in administering this test?
- pt is supine
- PT holds glenohumeral joint in 90° of scaption
- postero-lateral glide
- if grade II translation is present (translation of humeral head over glenoid rim), then posterior capsule is probably not a contributor to limited IR
- common mistakes are to (1) perform test in the coronal plane rather than scaption and (2) perform glide without lateral component, which can compress the head of the humerus into the glenoid and give a false positive for capsular tightness
What ROM finding is common in overhead athletes’ dominant arm vs non-dominant? What are 3 proposed mechanism to explain this phenomenon?
- dominant arm tends to have increased external rotation and decreased internal rotation vs non-dominant
- several proposed mechanisms:
1. humeral retroversion
2. tightness of posterior musculotendinous structures
3. tightness of posterior GH joint capsule
What is the acute effect of pitching on glenohumeral ROM?
- after 50-60 pitches at full intensity:
- IR was decreased by 9.5°
- total rotation is decreased by 10.7°
What is the ideal glenohumeral joint position to perform passive internal rotation stretching?
30° of scaption + internal rotation produces strain in the posterior capsule and muscle tendon unit
What technique do the monograph authors recommend when attempting to increase glenohumeral internal rotation?
- 30° scaption + passive IR
- PNF contract-relax following a low-load prolonged stretch-type paradigm
What stretches do the monograph authors recommend to increase glenohumeral internal rotation? Which is more effective?
- sleeper stretch & cross arm adduction stretch
- cross arm adduction may be more effective as home exercise
What are 3 goals in the initial phase of non-operative rehabilitation of rotator cuff impingement / pathology?
- decr pain to allow for introduction of submax rotator cuff and scapular exercise
- normalization of capsular relationships through mobilization and stretching
- early submax rotator cuff and scapular resistance training
Describe the progression of rotator cuff exercises given in the monograph (Jobe Isotonics)
- Sidelying ER
- Prone Shoulder Extension (in ER)
- Prone Horizontal Abduction (thumb up)
- Prone 90/90 ER
(3 sets of 15-20 reps)
Why is prone horizontal abduction a good alternative to the traditional empty can position as a rotator cuff strengthening exercise?
- prone horizontal abduction is used at 90° of abduction, which minimizes subacromial contact
- high levels of supraspinatus muscle activation
- empty can position can cause impingement through combined IR and elevation
What are the advantages of performing ER strengthening exercises with a towel roll?
- increased activtation (10%) of infraspinatus
- enhanced bloodflow in the supraspinatus
- isometric adduction increases subacromial space
Why might it be beneficial to intentionally use lower intensities for ER strengthening exercise in patients with rotator cuff impingement/pathology?
- increased infraspinatus activity relative to middle and posterior deltoid at 40% of maximal effort (less deltoid compensation)
Give 4 examples of of scapular stabilization exercises that emphasize the lower trapezius for patients with rotator cuff impingement/pathology.
- manual protraction/retraction exercise
- prone 90/90 ER
- bilateral ER with retraction
- multiple seated rowing variations
Give 3 examples of closed-chain exercises that use the “plus” position for patients with rotator cuff impingement/pathology. How are these exercises progressed?
- closed-chain step-ups
- quadruped position rhythmic stabilization
- variations of pointer position (unilateral arm and ipsilateral leg extension weight-bearing)
(endurance-oriented - timed sets of 30 seconds or more)
When performing functional stability exercises such as rhythmic stabilization against a therapy ball, why should the shoulder be in 90° of scaption as opposed to flexion or abduction?
- optimal position of humeral head on the glenoid
- rotator cuff is best able to maintain stability in this position
What is the “statue of liberty” exercise, and what patient population may benefit from it?
- eccentric internal rotation (strengthening external rotators) in 90° abduction & 90° ER
- ER fatigue resistance training is important to prevent scapular tilting and ER in tennis serves or throwing in baseball
Where are full-thickness tears of the rotator cuff often initiated? What areas of the rotator cuff are subsequently affected?
- often starts in the zone of the supraspinatus and extend to include the infraspinatus, teres minor, and subscapularis
A tear in what region of the rotator cuff is associated with the biceps tendon?
tear in subscapularis tendon is often associated with long head of the biceps tendon subluxation from the intertubercular groove or partial/complete bicep tendon tears
What are the two general areas that partial-thickness rotator cuff tears occur?
superior surface (bursal side) or undersurface (articular side) of the rotator cuff
Partial-thickness rotator cuff tears on the superior surface (bursal side) are generally associated with what conditions?
- primary and secondary compressive disease / impingement
- macrotraumatic tendon failure
Partial-thickness tears on the undersurface (articular side) of the rotator cuff are generally associated with what conditions?
- tensile loads
- glenohumeral joint instability
Partial-thickness rotator cuff tears on the undersurface (articular side) are commonly associated with what populations?
- overhead throwing athletes with anterior instability / capsular and labral insufficiency / muscular imbalances
What are the two patterns of complete rotator cuff tears?
crescent-shaped and U-shaped
Following a repair of a medium-sized rotator cuff tear, how many weeks post-op should isotonic RTC strengthening exercise be introduced? Give examples.
- 6 to 8 weeks
- sidelying ER, prone extension, prone horizontal abduction, supine IR, flexion to 90°
Why is early passive ROM into external rotation safe following a rotator cuff repair?
30° and 60° of ER in neutral showed a decrease in tension on the supraspinatus tendon
What tissues are subject to increased tensile loads if early internal rotation is applied following a rotator cuff repair?
increased loads on supraspinatus, infraspinatus, and teres minor
Contrast seated pulleys vs supine assisted ROM elevation following rotator cuff repair.
both produce low levels of inherent muscular activation, but pulleys show more than supine assisted ROM
What is the relationship between early passive ROM and incidence of re-tear following arthroscopic rotator cuff repair?
early PROM is not a risk factor for re-tear at 1 year follow-up
Following a rotator cuff repair, when should resistive exercise for the rotator cuff and scapular musculature generally be initiated? Why?
- 6 weeks
- early theoretical healing is assumed in the repaired tissues
Compare and contrast empty vs full can scaption for rotator cuff strengthening.
- both involve the supraspinatus as a primary mover with decreased activation of the deltoid (theoretically decreases subacromial compression during elevation)
- empty can shows really good activation in EMG studies, but clinically it is easy to compensate with scapular internal rotation / anterior tilt
During rotator cuff rehab, strengthening of what specific scapular muscles are targeted?
lower trapezius & serratus anterior (force couple)
Using scapular plane elevation as a strengthening exercise can cause activation of the upper trapezius. What exercise is offered by Cools et al as an alternative?
Bilateral Scapular Plane Elevation with External Rotation Elastic Resistance
- patient stands with elbows bent and elastic loop around hands
- external rotation is applied
- arms are lifted in bilateral scaption
Generally, what degree of recovery can be expected following mini-open / arthroscopic rotator cuff repair?
-return of nearly full range of AROM and PROM
- deficits in muscular strength ranging from 10-30% in IRs and ERs (more often in ERs)
Contrast joint dislocation vs subluxation?
- dislocation occurs when there is complete separation of the two articular surfaces
- subluxation requires excessive translation of the humeral head on the glenoid in association with symptoms, but without a complete separation of the joint surfaces
Contrast shoulder joint laxity vs joint instability. Why can making a differentiation between the two be difficult?
- overall laxity, a.k.a. generalized ligamentous laxity is often found bilaterally and asymptomatic
- instability is defined as excessive symptomatic translation of the humeral head when stress is applied
- a certain amount of “joint play” is considered normal
Shoulder instability is generally considered to occur most often in what direction?
anterior instability (though recent reports have found higher rates of posterior and combined instability than previously reported)
When is nonoperative treatment of shoulder instability warranted?
in almost all cases, even if surgical intervention is planned
What should initial treatment of shoulder instability broadly consist of?
- patient education
- activity modification to decrease pain
- and controlling inflammation
- improve rotator cuff and scapular muscular strength/endurance (force couples)
- functional dynamic stabilization
During nonoperative treatment of shoulder instability, how can strengthening rotator cuff muscles affect ligamentous structures like the glenohumeral joint ligaments and capsule?
because the rotator cuff tendinous unit blends with the ligaments and capsule, muscular contraction can help tension lax / redundant portions of the capsule & provide increased joint stability during shoulder movements
What is the current state of the evidence when it comes to theories of capsular and ligament tissue healing following shoulder instability surgery?
although we’ve made some great strides in understanding soft tissue healing, theories are based on basic science and surgeon & physical therapist opinion/experience
What are 4 of the most popular forms of surgery to treat shoulder instability
- arthroscopic capsular plication
- inferior capsule shift
- anterior capsulolabral repair (ACLR)
- Bankart repair
Arthroscopic capsular plication, Inferior capsule shift, Anterior capsulolabral repair (ACLR), and Bankart repair are all examples of surgical procedures used to treat what condition?
shoulder stabilization procedures used to address shoulder instability
What are the 4 goals of physical therapy immediately following surgical stabilization of the shoulder?
- protect healing/repaired tissue
- prevent joint hypomobility
- decrease pain/inflammation
- regain normal firing patterns for rotator cuff and scapular muscles
During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 0-3?
- Flexion 0°-90° (ACLR is much more at 120°-140°)
- Extension 10°-25°/30°
- IR 0°-30°/35° in neutral
- ER 0°-20°/30° in neutral
During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 4-6?
- Flexion 0°-140° (much more for ACLR at 160°)
- Extension 30°-35°
- IR 30°/35°-60°
- ER 30°-40°/60° in neutral
During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 6-9?
- Flexion 140°-165°/175°
- Extension 40°-45°
- Internal rotation 60°-80°/full
- ER 40°-65°/85°
During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 10-12+?
- Flexion Full (Bankart may still be less than full at ~165°)
- Extension Full
- IR Full
- ER Full (may be less with Bankart at 65°/70° in neutral, but you should be able to progress to 90/90 exercise)
Following surgical stabilization to address shoulder instability, when would you expect to reach the following ROM goals:
- Flexion 0°-90° (ACLR is much more at 120°-140°)
- Extension 10°-25°/30°
- IR 0°-30°/35° in neutral
- ER 0°-20°/30° in neutral
Weeks 0-3
Following surgical stabilization to address shoulder instability, when would you expect to reach the following ROM goals:
- Flexion 0°-140° (much more for ACLR at 160°)
- Extension 30°-35°
- IR 30°/35°-60°
- ER 30°-40°/60° in neutral
Weeks 4-6
Following surgical stabilization to address shoulder instability, when would you expect to reach the following ROM goals:
- Flexion 140°-165°/175°
- Extension 40°-45°
- Internal rotation 60°-80°/full
- ER 40°-65°/85°
Weeks 6-9
Following surgical stabilization to address shoulder instability, when would you expect to reach the following ROM goals:
- Flexion Full (Bankart may still be less than full at ~165°)
- Extension Full
- IR Full
- ER Full (may be less with Bankart at 65°/70° in neutral, able to progress to 90/90 exercise)
Weeks 10-12+
When progressing ROM following shoulder stabilization surgery, what is the general rule of thumb?
Err on the side of caution. Excessive stress to the tissue can create a failure of the repair. It’s always easier to stretch tight tissue later than to be too aggressive in the beginning of rehab. Start in the scapular plane during mobility exercise and move into the coronal plane as tolerated.
Give 4 reasons to implement early motion following shoulder stabilization surgery.
- promotes blood flow / healing
- improves collagen organization
- stimulates joint mechanoreceptors
- decreases pain via neuromuscular modulation
Following shoulder stabilization surgery, why is it important to distinguish between ROM exercise and stretching?
Stretching is contraindicated. ROM exercise should be taken to tolerance and begin in “low-tension” positions like 30°-45° ER in neutral.
Describe a Capsular Shift & Plication procedure for the shoulder.
- to treat shoulder instability
- extra capsular tissue is folded over and fixed to the labrum/glenoid via suture or anchor
Describe an Arthroscopic Anterior Capsulolabral Repair procedure for the shoulder.
- to treat shoulder instability
- anchors pin the labral tear to the glenoid & sutures are used to fold/tighten the capsule
What surgical procedure is considered the “gold standard” for treating anterior shoulder instability?
Bankart reconstruction
Describe a Bankart reconstruction procedure for the shoulder.
- to treat shoulder instability
- torn labrum is sutured/anchored to the glenoid
- glenoid rim may be abraded to create a bleeding base for healing of the labrum to the bone after repair
- not always necessary to shift/tighten the capsule
Describe an Anterior Latarjet procedure.
-used for many years to treat chronic shoulder instability when repair of the labrum in the shoulder is not possible
- coracoid process is transferred (with short biceps tendon attached) through the subscapularis and anterior capsule to attach to the glenoid
- creates more anterior stability (along with subscapularis)
Give 3 conditions for which an Anterior Latarjet procedure might be indicated.
- Anterior bone loss due to chronic dislocations
- large engaging Hill-Sachs lesion
- General instability-related loss of function
What is a top priority during rehab immediately following an Anterior Latarjet procedure?
subscapular and anterior stabilization precautions:
- protected ER for 6 weeks (caution with strengthening)
- early strengthening is isometric ER & scapular stabilization
- IR and typical rotator cuff /scapular exercise after 6 weeks
- sport-specific stuff should wait 3 months or more
During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 0-4?
- most of the time, a sling is used, but can be taken off for exercise
- PROM, AAROM
- isometrics / rhythmic stabilization
During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 4-6?
- once the sling is removed, light isotonic exercise for the shoulder & arm
During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 6-8?
- tissue should be healed enough to start higher-level exercise like PNF, neuromuscular control drills, & co-activation (prone scapular exercise or placing the shoulder in more functionally demanding positions)
During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 12-16?
- higher-level, sport-specific activities (underhand throwing sooner than overhand)
- plyometrics
- eccentric strengthening
- full-body stability deficits
Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?:
- PROM, AAROM
- isometrics / rhythmic stabilization
0-4 weeks
Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?:
- light isotonic exercise for the shoulder & arm
4-6 weeks
Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?:
-PNF
- Neuromuscular control drills
- Co-activation (prone scapular exercise or placing the shoulder in functionally demanding positions)
6-8 weeks
Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?:
- sport-specific activities (underhand throwing sooner than overhand)
- plyometrics
- eccentric strengthening
- full-body stability deficits
12-16 weeks
What reason do the monograph authors give for assessing balance/stability deficits in athletes with shoulder instability?
- correlation found in Division III NCAA overhead athletes between trunk stability / balance deficits and shoulder dysfunction
Which type(s) of SLAP lesions tend to respond well to nonoperative management?
early Type I
Which type(s) of SLAP lesions tend not to respond well to nonoperative management?
Type II-IV (though conservative treatment should still be attempted with Type II)
What should nonoperative treatment of SLAP lesions entail?
it shoulder concentrate on:
- the strength and endurance of the rotator cuff & scapular stabilizers
- posterior shoulder tightness (mobs and stretching) that limits IR
What is the likelihood that an overhead athlete will return to sport following a SLAP lesion repair?
only 66% return to sport (though functional ability and quality of life are good at 3-year follow-up
Most symptomatic SLAP lesions that are treated surgically are which type?
Type II (superior labrum & biceps anchor detached)
How long is the early protective phase generally following type II SLAP lesion repair?
4 weeks
- sling use / immobilization (allow inflammatory phase to run its course without loading the shoulder
How should shoulder ROM be advanced following type II SLAP lesion repair?
- gradual increase of ER (risk of peel-back?) of about 10° per week after week one, not to exceed 30° by week 4
- performed in 45° or less of abduction
- ER in 90° of abduction is not recommended until 6 weeks (risks peel-back again)
Following type II SLAP lesion repair, AROM exercise is allowed for all elbow, hand, and wrist movements except which?
- elbow flexion and forearm supination place tension across the biceps anchor repair site
Following type II SLAP lesion repair, when can scapular isometric strengthening begin?
since there’s no surgical insult to the scapular muscles, isometrics can begin in 2 weeks post-op and progress to isotonics
Following type II SLAP lesion repair, when is full symmetrical glenohumeral motion expected?
3 months
Following type II SLAP lesion repair, when should active elbow flexion & supination be initiated? When should heavy loading begin?
weeks 5-6; heavy loading is discouraged until week 10
Following type II SLAP lesion repair, when should ROM exercise be progressed to 145° flexion & 50° ER?
weeks 5-6
In weeks 5-6 following type II SLAP lesion repair, ROM exercise can be progressed to what degrees of flexion and external rotation?
145° flexion & 50° ER
In addition to ROM progressions and introduction of active elbow flexion/supination, what other exercises would be useful to introduce in weeks 5-6 following type II SLAP lesion repair?
low-level scapular exercises like low row and ?inferior glide?
Following type II SLAP lesion repair, how do rehab goals shift in weeks 7-12?
- shift from ROM and low-level scapular exercise to restoring muscular strength and balance of the rotator cuff and scapular muscles
- ROM can progress more aggressively if restrictions remain
Following type II SLAP lesion repair, by what week should you expect to see full elevation, 90° ER (in 45° or less of abduction), and 70° IR?
week 9
By week 9 following type II SLAP lesion repair, what ROM should have been reached?
- full elevation
- 90° ER (in 45° or less of abduction)
- 70° IR
List 9 resistive exercises should be performed in weeks 7-12 following type II SLAP lesion repair.
- sidelying external rotation
- scaption
- seated press-up
- rowing
- push-up plus
- serratus punch
- dynamic hug
- prone lower trap raise
- horizontal adduction with external rotation (serratus anterior)
- flexion to 125° with scapular protraction (serratus anterior)
Following type II SLAP lesion repair, when should full ER in the 90/90 position be achieved?
12 weeks
Following type II SLAP lesion repair, how would you determine if an athlete is appropriate to return to overhead throwing or swinging?
- 4 months post-op
- full ROM
- full strength
- no pain
What two groups of ligaments might be injured in an Acromioclavicular Joint injury?
acromioclavicular ligament and/or coracoclavicular ligaments (conoid & trapezoid)
The Acromioclavicular joint ligament largely provides stability in what plane?
anterior-posterior
Compare and contrast the functions of the conoid and trapezoid ligaments (coracoclavicular ligaments)?
both:
- provide vertical stability during shoulder elevation
- assist with scapular motion during shoulder elevation
the conoid:
- plays a primary role in constraining anterior & superior rotation
- limits anterior and superior clavicle displacement
What is a “step-off” deformity in the shoulder?
occurs with a clavicle fracture / type III AC joint injury that involves a complete rupture of the acromioclavicular & coracoclavicular ligaments, allowing the acromion to drop & the clavicle to get pulled up by the upper trap
Which acromioclavicular joint injury types are typically treated conservatively?
- types I-III do just as well as surgery
(types IV-VI have degrees of soft tissue trauma and clavicle displacement that needs to be addressed surgically)
What is the 4-phase treatment approach for type II acromioclavicular joint injury rehab give in the monograph?
1: immobilization, ice, analgesics; AAROM in low positions
2: full ROM, strengthening ex (avoid pressing like OHP and bench)
3: strengthening in all positions (intro pressing)
4: sport-specific exercise
During the 4-phase AC injury rehab protocol given by the monograph authors, when should the patient progress to phase 2? What does phase 2 consist of?
- ROM is 75% full
- pain/tenderness to palpation is mild
- deltoid and upper trap strength are 4-5/5
phase 2: full ROM, strengthening ex (avoid pressing like OHP and bench)
During the 4-phase AC injury rehab protocol given by the monograph authors, when should the patient progress to phase 3? What does phase 3 consist of?
- motion is pain-free
- strength is 75% of uninvolved side
phase 3: strengthening in all positions (intro pressing)
During the 4-phase AC injury rehab protocol given by the monograph authors, when should the patient progress to phase 4? What does phase 4 consist of?
- motion is full and pain-free
- palpation is pain-free
- strength is close to 100%
4: sport-specific exercise
What are some motions that may be more difficult or painful during AC joint injury rehab?
movements that place addition stress on AC joint:
- IR behind the back
- horizontal adduction
- end-range flexion
- end-range extension
During AC joint rehab, which functional activities should be avoided in early phases?
anything that emphasizes downward displacement of the arm
- sustained lifting/carrying (i.e. suitcase or toolbox)
During early AC joint rehab, performing exercises in which position may be more easily tolerated?
closed-chain (i.e. against a wall/table, or in quadruped)
What did Gumina et al discover about the relationship between the cervical spine and the AC joint?
higher prevalence of cervical hyperlordosis and more cervical pain symptoms in those with chronic AC joint injury
What is the general prognosis following an AC joint injury?
both surgical and conservative treatment of types I-V had good to excellent results at 2-year follow-up
In what situation(s) might surgery for an AC joint injury be warranted?
- symptoms/functional limitations last longer than 3 months of conservative care
- significant visual deformity
- need to perform heavy labor
- need to perform sustained or repetitive shoulder activity (athletes)
- severe soft tissue injury (types IV-VI)
How soon should surgery be considered following severe AC joint injury?
there may be a trend toward better results if surgery is performed in the first 3 weeks, but its largely considered better to wait since outcomes seem to be equal between early and late reconstruction
What is the 3-phase post-op rehab approach following surgery for acromioclavicular joint injury?
- phase 1: 0-4 week protective phase; sling use and firm pillow to reduce load on graft / promote healing
- phase 2: weeks 4-12, gradual return of ROM and strength; AAROM, resisted IR/ER at neutral, resisted flexion/abduction up to 90°
- phase 3: 12-24 weeks, functional movements; sport- and occupation-specific activities
Following surgery for acromioclavicular joint injury, when would you expect to begin ROM and strengthening exercise? Describe specific precautions and contraindications to be mindful of.
4-12 weeks (phase 2)
- resisted ER/IR in neutral
- resisted flexion/abduction to 90°
Following surgery for acromioclavicular joint injury, when would you expect to introduce functional sport- and occupation-specific activities?
weeks 12-24 (phase 3)
What populations are most at risk for primary Frozen Shoulder?
40-65 years old, females more than males
What are cytokines and what role do they play in the etiology of Frozen Shoulder?
- Cytokines are small secreted proteins released by cells have a specific effect on the interactions and communications between cells. Along with other growth factors, they increase tissue repair/remodeling during the inflammatory process
- Elevated cytokine levels could result in a disproportionate response to even minor injury, causing sustained inflammation and exaggerated fibrous connective tissue formation.
Why is the beginning phase of Frozen Shoulder so painful?
- elevated cytokines keep the synovium inflamed
- new nerve growth in the GH capsule and ligaments
What is the rotator cuff interval and what role does it play in Frozen Shoulder?
- triangular-shaped tissue that connects the distal supraspinatus and subscapularis tendons (also the superior GH ligament and coracohumeral ligament)
- can become inflamed and adaptively shortened in patients with Frozen Shoulder
Patients with early-stage Frozen Shoulder are often misdiagnosed with which other condition. How is this avoided?
- Rotator cuff impingement/injury
- need to recognize the loss of external rotation with an intact rotator cuff during FS pre-adhesive / “painful” stage:
- patients with rotator cuff tendinopathy may present with significant restricted and painful AROM & PROM, but rarely have significant restrictions of passive ER in neutral
- patients with FS are more likely to have weakness of internal rotation
- Jobe test / impingement signs are generally unhelpful, since they can be painful for both
What are the clinical findings that generally indicate Frozen Shoulder?
- ROM loss greater than 25% in at least 2 planes
- passive ER loss greater than 50% of uninvolved shoulder or less than 30° ER (in neutral)
What should and should not be the goals for rehab of Frozen Shoulder?
- successful treatment shouldn’t be defined by restoring “normal” motion
- goals should include reducing pain and beginning to improve passive and functional movements
What is the role of modalities in treating Frozen Shoulder?
things like heat, ultrasound, and TENs can improve stretching exercise, but are not effective on their own
When treating Frozen Shoulder, how is the dosage of stretching exercise determined?
- depends on the level of irritability and response to treatment
- stretching should not exceed pain threshold
- calculate daily total end range time (TERT): frequency x duration
- TERT is maximized by low-load prolonged stretching (LLPS)
What did Vermeullen et al determine about the role of joint mobilization in treating Frozen Shoulder?
grade I-II anterior, inferior, posterior glides (performed 2x/week for 30 minutes) for 12 weeks showed significant improvement in motion and function
What is the role of corticosteroid injections in treating Frozen Shoulder?
- strong evidence that it helps with short-term pain relief (3-6 weeks) in conjunction with joint mobilization and exercise
When treating Frozen Shoulder, what factors would determine whether the patient completes supervised therapy vs an independent home exercise program?
supervised therapy if:
- high irritability
- greater disability
- more co-morbidities
- low social support
- low educational level
- high fear & anxiety
If a patient with Frozen Shoulder elects not to receive a corticosteroid injection but shows limited progress, how long into conservative management should an injection be reconsidered? Surgical treatment?
- 3-6 months of limited progress, injection should be reconsidered
- 6 months+ of poor response to conservative care, and surgery (manipulation or capsular release) may be warranted
What are most important things to include in patient education during the early phases of Frozen Shoulder rehab?
- natural course of Frozen Shoulder
- promote activity that encourages function, pain-free ROM
- allay fears of catastrophic illness
- prepare patient for an extended rehab process
Describe the ROM home exercise program for a patient with Frozen Shoulder that is recommended by the monograph authors.
- heat first (ice after optional)
1. pendulums
2. PROM supine flexion
3. PROM supine external rotation in scaption
4. AAROM standing extension
5. AAROM standing internal rotation
6. AAROM standing horizontal adduction - in patients with mod-sev irritability, hold stretches 1-5 sec, 20x, 2-3x per day
- in patients with low-mod irritability pulleys and longer hold times (30 seconds) can be performed
When treating Frozen Shoulder, how should treatment frequency be determined?
- if after one week of HEP stretching, the patient reports that they can A.) sleep through the night or B.) have a significant reduction in irritability (less pain with end-range overpressure or less pain overall), they have an excellent prognosis and are seen 1x/week - biweekly
- if there is minimal improvement with the first week of home stretching, irritability is moderate/high, and the patient demonstrates a significant “in-treatment response” (i.e. > 15° gain in ER or elevation), they should be seen 2x/week
- if symptoms persist or worsen, refer for steroid injection
When treating a patient with Frozen Shoulder, how can heat be used in a treatment session?
- 5 minutes of heat in supine / 40° of scaption
- short (5-15 sec) PROM ER stretches with heat still applied for 10-20 repetitions
- measure ROM change (common to see 10°-15° improvement)
- if no significant improvement in low-irritability patient, muscle guarding is likely not the cause of ROM loss
Describe a typical treatment session for Frozen Shoulder.
- heat with short PROM ER stretches (5-15 sec x 10-20 reps)
- PROM supine flexion
- ant./post./inf. mobilizations with traction/rotational oscillation between bouts
- manual stretching
- HEP ROM and pulley exercises
GH joint glides in which direction can improve ER?
both anterior & posterior
When treating Frozen Shoulder, how is the appropriate stretch intensity determined?
pain should completely resolve once removed from end range
When treating Frozen Shoulder, as pain and irritability lessen, how should mobilization and stretching exercise progress?
- increased grades of mobilization and intensity of stretching
- mobilizations are also moved to end-range positions (consider mobilization with movement)
- hold-relax techniques can be implemented to assist with PROM
- quadrant stretch in supine to stretch pec hypertonicity
When treating Frozen Shoulder, if a patient presents with limited functional IR (standing), what structures are thought to be involved? What techniques can address this?
- indicates tightness of superior capsular and posterior structures
- inferior glide in adduction/extension and IR
In many patients with Frozen Shoulder, the Rotator Cuff Interval may be adaptively shortened. Describe the technique that is used to address the RCI specifically.
RCI stretch:
- pt is sidelying with treatment side up
- pt’s hand is placed on the ipsilateral hip
- PT has one hand on the pt’s hand and the other gently applies downward pressure on the elbow
For a patient with Frozen Shoulder, what stretch (when tolerated) can be helpful in improving internal rotation ROM?
sleeper stretch
When treating Frozen Shoulder, how often should ROM be assessed?
at the beginning and end of every treatment session
Following a corticosteroid injection to address a patient with Frozen Shoulder that was responding poorly to conservative management, what exercises should be performed immediately after the procedure?
- only pendulums several times per day
- PT can be resumed ~ 4 days after
When treating Frozen Shoulder, what 7 specific discharge criteria do the monograph authors list? Why discharge the patient before full ROM and strength is achieved?
- improved pain status
- improved satisfaction
- improved function
- low irritability
- minimal to no end-range pain
- within-session gain of 10° or less
- stagnant motion gain between visits
- remaining ROM deficits at this point are likely due to fibroblastic contracture that will improve with time, consistent stretching, and tissue remodeling (consider having the patient return in 2-3 months for exercise progression)
What prolonged stretching technique to improve elevation/external rotation is suggested by the monograph authors to treat Frozen Shoulder
standing with cane on table (shoulder in ~90° scaption & end-range ER)
Approximately how many patients with Frozen Shoulder will fail conservative treatment and require manipulation or capsular release?
1 in 10
Of the large joints, how common is OA in the shoulder?
It’s the third most common next to hips and knees
Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase I?
0-3 weeks
Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase II?
3-8 weeks
Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase III?
8-16 weeks
Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase IV?
16+ weeks
Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase I?
0-6 weeks
Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase II?
6-12 weeks
Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase III?
12-16 weeks
Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase IV?
16+ weeks
Generally, how many phases does post-operative rehab following shoulder total/hermiarthroplasty?
4
Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 5 goals of phase I (weeks 0-3)?
- patient education (precautions & HEP 4-6x per day)
- allow healing of subscapularis
- control pain & inflammation
- begin ROM exercises (family/caregiver instruction)
- PROM: elevation 90°-120°, ER 20°-30°
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following goals:
- decrease pain & inflammation
- PROM elevation 120°, ER 30°
- begin strengthening exercise
phase II (weeks 3-8)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following treatments:
- supine passive scaption
- supine passive ER in < 30° scaption
- active scapular adduction
phase I (weeks 0-3)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following treatments:
- emphasis on elevation progression exercise
- begin AAROM extension & horizontal adduction
- begin PROM IR & pulleys
- begin submaximal rotator cuff isometrics
- progress to strengthening with resistance (ER, IR, extension)
- progress to manual resistance / PNF patterns
- progress scapular strengthening
phase II (weeks 3-8)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following goals:
- PROM elevation 140°, ER 30°-40°
- AROM elevation 120°-140°
- increase scapular stabilizer strength
phase III (weeks 8-16)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following treatments:
- progress elevation to AROM in standing
- begin strengthening in abduction, flexion, and 45° ER
- PNF diagonals
- progress intensity of shoulder shrugs, scapular retraction, biceps, triceps
phase III (weeks 8-16)
Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 4 goals of phase II (weeks 3-8)?
- decreased pain & inflammation
- increased ADLs
- PROM: elevation 120°, ER 30°
- begin strengthening exercises
Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 4 goals of phase III (weeks 8-16)?
- PROM: elevation 140°, ER 30°-40°
- AROM: elevation 120°-140°
- increase functional activities
- increase strength of scapular stabilizers
Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 2 goals of phase IV (weeks 16+)?
- functional activities (demand-dependent)
- return to work or sport
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following goal:
- PROM: elevation 90°-120°, ER 20°-30°
Phase I (weeks 0-3)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following goal of returning to work/sport?
phase IV (weeks 16+)
Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following treatment:
- full-body ROM and strengthening exercise
- work- or sport-specific training
phase IV (weeks 16+)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following goals:
- PROM: elevation 80°-120°, ER 30°
phase I (weeks 0-6)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following treatments:
- supine passive scaption
- supine pass ER in scaption
phase I (weeks 0-6)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following goals:
- decrease pain & inflammation
- PROM: elevation 90°-120°, ER 30°
phase II (weeks 6-12)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following treatments:
- begin elevation progression
- gentle AAROM/PROM IR, extension, horizontal adduction
phase II (weeks 6-12)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following goals:
- full, pain-free ROM
- begin rotator cuff strengthening exercise
phase III (weeks 12-16)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following treatments:
- light resistance strengthening of ER, IR, extension
phase III (weeks 12-16)
Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail functional strengthening?
phase IV (weeks 16+)
Following a Shoulder Total or Hemiarthroplasty with standard goals, list 8 treatments in phase I (weeks 0-3).
- patient education / precautions
- pendulums
- elbow AROM
- hand squeezes
- supine passive scaption
- supine passive ER in < 30° scaption
- active scapular retraction
- ice
Following a Shoulder Total or Hemiarthroplasty with standard goals, list 7 treatments in phase II (weeks 3-8).
- review precautions
- emphasize elevation progression exercises
- begin AAROM extension, horizontal adduction
- begin standing passive functional IR at 4 weeks
- begin pulleys at 4-6weeks
- begin manual PNF patterns through partial range at 6-8 weeks
- scapular strengthening
Following a Shoulder Total or Hemiarthroplasty with standard goals, list 4 treatments in phase III (weeks 8-16).
- progress elevation to AROM in standing
- begin strengthening with resistance in abduction, flexion, & 45° ER
- PNF diagonals
- progress resistance of shrugs, retraction, biceps, triceps
Following a Shoulder Total or Hemiarthroplasty with standard goals, list 3 treatments in phase IV (weeks 16+).
- full-body ROM & strengthening
- work- or sport-specific training
- modifications to work, sport, or functional activities
Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 5 goals of phase I (weeks 0-6)?
- stress importance of precautions and performance of HEP 4-6x per day
- allow healing of subscapularis
- control pain & inflammation
- begin ROM exercises (family/caregiver education)
- PROM: elevation 80°-120°, ER 30°
Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 3 goals of phase II (weeks 6-12)?
- decrease pain & inflammation
- increase ADLs
- PROM: elevation 90°-120°, ER 30°
Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 3 goals of phase III (weeks 12-16)?
- ROM full and pain-free
- increase functional activities
- begin rotator cuff strengthening
Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 2 goals of phase IV (weeks 16+)?
- return to functional activities
- continue to improve strength
Following a Total Shoulder Arthroplasty for a patient with limited goals, list 6 treatments in phase I (weeks 0-6).
- patient education on precautions
- pendulums
- elbow AROM
- hand squeezes
- supine passive scaption
- supine passive ER in scaption (within limits of range achieved in OR)
Following a Total Shoulder Arthroplasty for a patient with limited goals, list 2 treatments in phase II (weeks 6-12).
- begin elevation progression
- gentle AAROM/PROM IR, extension, horizontal adduction
Following a Total Shoulder Arthroplasty for a patient with limited goals, list 2 treatments in phase III (weeks 12-16).
- progress elevation exercise
- light resistance strengthening of ER, IR, extension
Following a Total Shoulder Arthroplasty for a patient with limited goals, list 3 treatments in phase IV (weeks 16+).
- progress all stretches & strengthening
- functional strengthening
- add progressive strengthening if able
Following a Total or Hemiarthroplasty (with/without limited goals), how often should a HEP be performed?
4-6x per day, 10-20 reps, (begin with 5-10 second holds depending on tissue irritability)
What are inflammatory arthritides? Give 3 examples that might affect shoulder health.
- systemtic diseases in which an overactive immune system “attacks” synovial joints and nearby structures
1. rheumatoid arthritis
2. ankylosing spondylitis
3. psoriatic arthritis
Which soft tissues are most impacted by a total/hemi- shoulder arthroplasty?
- deltoid (retracted laterally)
- subscapularis (released from anterior capsule)
- anterior capsule is released/excised
- pectoralis major may be released
- often in TSAs, the long head of the biceps tendon is tenodesed or released
During a total/hemi- shoulder arthroplasty, why might the surgeon release the pectoralis major?
added exposure or correction of a severe IR contracture
What differentiates a Total Shoulder Arthroplasty from a Hemiarthroplasty?
In a hemiarthroplasty, the glenoid is left intact (though it may be reamed/resurfaced). It depends on whether the glenoid angle is present.
During a total/hemi- shoulder arthroplasty, the surgeon will select the size of the prosthetic humeral head that allows for what specific shoulder muscle to be appropriate tensioned? What ROM measurement is used to determine this? What other soft tissue structure must the surgeon consider when making this determination.
- subscapularis
- ER should be a minimum of 30°-40°
- posterior capsule may need to be tightened if there is still posterior laxity
List conditions which might warrant a Shoulder Arthroplasty. Which patient population has the highest likelihood of regaining AROM?
- primary osteoarthritis
- rheumatoid arthritis
- posttraumatic arthritis
- rotator cuff arthropathy
- patients with primary OA and an intact rotator cuff have better outcomes than the others
What ROM can the average patient receiving a Shoulder Total/Hemiarthroplasty expect to regain?
average of 113°-145° flexion (TSA outcomes are better)
What is the general prevalence of rotator cuff tears in populations with advanced primary glenohumeral osteoarthritis? What other condition of the rotator cuff may be present?
- most patients with advanced primary OA do not have rotator cuff tears (1/10 have a repairable supraspinatus tear)
- moderate to severe fatty degeneration of the infraspinatus & subscapularis may limit elevation ROM
What is the general prevalence of rotator cuff tears in populations receiving a TSA for rheumatoid arthritis?
since RA attacks both articular cartilage and soft tissues (RTC, bursae, biceps tendon), prevalence of rotator cuff thinning and tears are relatively high (25-30% have full thickness tear)
Following a Shoulder Total/Hemiarthroplasty for Rheumatoid Arthritis, what is a reasonable long-term expectation for flexion, ER, and IR ROM?
averages at 6.5 year follow-up:
- flexion 103°
- ER 47°
- standing IR L4
Following a Shoulder Hemiarthroplasty for a proximal humeral fracture, what must be kept in mind during the early phase of rehab?
- these patients present with greater stiffness, and aggressive stretching can disrupt tissue healing (especially PROM ER greater than 50° too early post-op)
What ROM outcomes can patients expect following a Shoulder Hemiarthroplasty for a proximal humeral fracture?
relatively disappointing outcomes
- elevation 70°-102°
- ER 15°-24°
- standing IR L4-L1
(only 50% of patients could perform above shoulder-level activities)
What other condition is commonly developed following a proximal humeral fracture?
nerve injury (~67% of patients have persistent neurological deficits that reduce functional outcomes)
- axillary nerve is most common, but combinations are common
List 5 conditions that would have standard post-op rehab goals following a Shoulder Total/Hemiarthropathy.
- OA and/or RA with an intact RTC
- Osteonecrosis
- Acute proximal humeral head fracture
- Posttraumatic arthritis without greater tuberosity osteotomy
- Capsulorraphy arthroplasty
List 6 conditions that would have limited post-op rehab goals following a Shoulder Total/Hemiarthropathy.
- RTC arthropathy
- RA with irreparable RTC tear
- Acute proximal humeral head fracture with tuberosity concerns/migration
- Posttraumatic arthritis with greater tuberosity osteotomy
- Septic arthritis
- Capsulorraphy arthroplasty with instability
What is capsulorraphy arthritis?
degeneration of articular cartilage due to repeated dislocations
Describe the role and outcomes of Shoulder Arthropathy procedures for rotator cuff arthropathy?
- outcomes are not great
- usually, the RTC is irreparable
- without an intact rotator cuff, the humeral head tends to migrate superiorly
- in a TSA, the glenoid component can loosen
- HA is usually the preferred method, but RSA is becoming a good alternative
- pain relief is significant, but elevation ROM is probably going to be less than 120° (sometimes as low as 70°)
During supine PROM exercise following Shoulder Arthroplasty, how can the patient protect the subscapularis?
limit ER to 20°-30°
What is an alternative to the typical supine PROM shoulder elevation exercise? Why might this be used?
standing chair stretch
During rehab following a Shoulder Arthroplasty, how often shoulder ROM measurements be taken?
at the beginning and end of each session
During rehab following a Shoulder Arthroplasty, when might a therapist “dial out” ROM exercise?
If patients achieve too much motion (e.g. > 30° ER before phase III)
Why might we be interested in exercise that produces less EMG muscular activation rather than more?
post-op (e.g. TSA) in order to protect soft tissue structures & minimize pain
What 3 conditions warrant a Reverse Shoulder Arthroplasty?
- massive or irreparable rotator cuff damage
- proximal humeral fracture resulting in a deficient rotator cuff
- revision of previous arthroplasty with concurrent rotator cuff deficiency
How does a Reverse Shoulder Arthroplasty address superior humeral head migration?
Deltoid causes elevation and the “glenosphere” creates a fulcrum for the distal socket to move on
Following a Reverse Shoulder Arthroplasty, how long should the sling be used?
for the first 4-6 weeks
Following a Reverse Shoulder Arthroplasty, what movements should be avoided in the early phases of rehab?
extension and adduction; ER in the frontal plane
What soft tissue structures are most affected in a Reverse Shoulder Arthroplasty?
- deltoid (in “deltoid splitting approach”, it is released from the clavicle & acromion and reattached)
- often, there are massive rotator cuff tears that involve the supraspinatus, infraspinatus, and subscapularis
- some surgeons will perform latissimus dorsi / teres major transfer to repair the RTC
Following a Reverse Shoulder Arthroplasty, when should the patient begin PROM exercise? Which exercises are recommended by the monograph authors?
- within the first 7-10 days post-op
- supine passive flexion
- supine passive ER from 0°-30°
Describe the shoulder elevation progression program (5 exercises) described by the monograph authors.
- supine bilateral wand flexion
- supine unilateral wand flexion
- seated theraball roll
- gatching
- ball roll on wall
What is gatching?
supine active flexion on an incline
Squeezing a ball results in activation of what shoulder muscles?
internal rotator activation
Following a Reverse Shoulder Arthroplasty, when should AAROM/AROM exercises begin? Which movements?
- 6 weeks
- elevation progression program
What stretch do the authors suggest for improving ER at 90° of elevation?
supine, hands behind the head
Following a Shoulder Arthroplasty, what two tests do the authors recommend to assess patient response to strengthening? Why these two?
ER Lag Sign & Abdominal Compression test
- these tests load the infraspinatus and subscapularis tendons
Following Shoulder Arthroplasty, when introducing manual resistance, which exercises should be emphasized?
- submaximal isometrics in ER and elevation
- modified PNF patterns, progressing to resistance with band and then in standing
Following a Shoulder Arthroplasty, when can patients expect to return to golfing, swimming, bicycling, aerobics, and running?
4-6 months
Following a Reverse Shoulder Arthroplasty, when can patients expect to make a full recovery?
6 months, with another 6 months of HEP stretching
Following a Reverse Shoulder Arthroplasty, when should PROM be introduced and to which limits?
- first 3 weeks
- to 90° elevation & 20°-30° ER
Following Reverse Shoulder Arthroplasty, when can PROM be progressed to 120°? 140°?
120° after 4 weeks, 140° after 6 weeks
Following a Reverse Shoulder Arthroplasty, what ROM can patients expect by 4 months post-op?
typically 80°-120° of elevation by 4 months
