The Shoulder

Question 1

The glenohumeral joint rotates around how many axes?

Answer 1

three (triaxial joint)

Question 2

What is the orientation of the glenoid fossa?

Answer 2

laterally from the scapula (7°), posteriorly, slight (5°) superior tilt relative to the medial border of the scapula

Question 3

What about the orientation of the glenoid fossa is thought to assist with joint stability?

Answer 3

slight superior tilt provides greater resistance to inferior forces (may assist with joint instability)

Question 4

What type of connective tissue is the glenoid labrum?

Answer 4

fibrocartilage

Question 5

What is the glenoid labrum and what role does it play in the function of the shoulder?

Answer 5

fibrocartilage tissue that surrounds the glenoid;
- deeps the fossa, supplies a negative intraarticular vacuum effect (seals the joint & assists with stability)

Question 6

How do injury of the glenohumeral capsule or labrum lead to glenohumeral instability?

Answer 6

disruption of the seal of the glenohumeral joint / intraarticular vacuum effect

Question 7

Describe the attachments of the glenohumeral joint capsule

Answer 7

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)

Question 8

Where are there openings in the glenohumeral joint capsule?

Answer 8

• between the humeral tubercles (biceps tendon exits)
• connection between the superior and middle glenohumeral ligaments (subscapularis bursa communicates with joint cavity)

Question 9

Which bursa communicates with the glenohumeral joint cavity?

Answer 9

subscapular(is) bursa

Question 10

Where are the glenohumeral ligaments located in relation to the joint capsule?

Answer 10

extracapsular ligaments surround superior and anterior joint, while posterior is thin

Question 11

What motion(s) does the superior glenohumeral ligament resist?

Answer 11

inferior translation of humeral head when arm is in adduction at side

Question 12

What connective tissue structure rests over the head of the humerus & directly beneath the rotator cuff?

Answer 12

superior glenohumeral ligament

Question 13

What is the relationship between injury of the superior glenohumeral capsule and translation of the humeral head?

Answer 13

• 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

Question 14

What motion does the middle glenohumeral ligament resist?

Answer 14

anterior humeral translation with arm in mid-range abduction, limits external rotation with arm at side

Question 15

Describe the structure of the inferior glenohumeral ligament complex.

Answer 15

• expansive band of tissue in inferior capsule
• thick in anterior and posterior bands
• “hammock” type axillary pouch

Question 16

What motions does the inferior glenohumeral ligament resist?

Answer 16

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

Question 17

Name the 3 borders of the scapula

Answer 17

superior border, axillary border, vertebral border

Question 18

Name the 3 angles of the scapula.

Answer 18

superior medial angle, inferior medial angle, lateral (glenoid) angle

Question 19

At which spinal level is the superior margin of the scapula?

Answer 19

T2 spinous process

Question 20

At which spinal level is the medial spine of the scapula?

Answer 20

T3 spinous process

Question 21

At which spinal level is the inferior medial angle of the scapula?

Answer 21

T7 spinous process

Question 22

What is the plane of the scapula?

Answer 22

30° to 45° from the coronal plane

Question 23

What are the two roles of the acromion?

Answer 23

• serves as a lever arm for the deltoid
• articulates with the lateral end clavicle (AC joint)

Question 24

What is the shape of the sternoclavicular joint? What motions does this shape allow?

Answer 24

saddle-shaped: protraction/retraction, elevation/depression, & some rotation around its long axis

Question 25

Describe the capsuloligamentous structures of the sternoclavicular joint.

Answer 25

relatively weak capsule supported by thickenings (anterior and posterior sternoclavicular ligaments)

Question 26

What is the most important ligament in the sternoclavicular joint & why?

Answer 26

posterior sternoclavicular ligament; sectioning of this structure causes significant increases in anterior and posterior translations

Question 27

What is the interclavicular ligament & what motions does it resist?

Answer 27

connects both clavicles medially; resists inferior forces on the medial clavicle

Question 28

What are the attachments of the costoclavicular ligament complex?

Answer 28

runs from superior surface of 1st rib to undersurface of the medial clavicle

Question 29

Which ligament runs from the 1st rib to the medial clavicle?

Answer 29

costoclavicular ligament

Question 30

What motion does the costoclavicular ligament resist?

Answer 30

resists superior force on medial clavicle when the lateral clavicle / shoulder is depressed (posterior & anterior bodies)

Question 31

How many degrees of freedom does the acromioclavicular joint have? What are they?

Answer 31

three: protraction/retraction, elevation/depression, & rotation

Question 32

What ligaments stabilize the acromioclavicular joint?

Answer 32

Conoid ligament (behind) & Trapezoid ligament (in front); Collectively, they are referred to as coracoclavicular ligaments

Question 33

How does the acromioclavicular joint tissue change throughout life?

Answer 33

hyaline articular cartilage becomes fibrocartilage on the acromial side (age 17) & then on the clavicular side (age 24)

Question 34

What is the role of the acromioclavicular joint meniscus?

Answer 34

increase stability by improving the fit between the two surfaces

Question 35

What are the attachments of the conoid ligament?

Answer 35

runs vertically from the coracoid process to the clavicle

Question 36

What motions does the conoid ligament resist?

Answer 36

resists elevation and protraction of the clavicle

Question 37

What motions does the trapezoid ligament resist?

Answer 37

resists acromioclavicular joint distraction (provides joint compression), and secondarily resists clavicle elevation and protraction

Question 38

These ligaments resist elevation of the distal clavicle.

Answer 38

Coracoacromial ligaments (conoid and trapezoid)

Question 39

Due to its ligamentous attachments, what other motion does the clavicle undergo when it is elevated?

Answer 39

Posterior rotation of the clavicle

Question 40

Describe the concept of scapulohumeral rhythm (“2 to 1”)

Answer 40

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.

Question 41

Describe the concept of a force couple.

Answer 41

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

Question 42

Describe the Deltoid / Rotator Cuff force coupling that occurs in the shoulder.

Answer 42

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)

Question 43

Without the rotator cuff, what would happen during attempted arm elevation?

Answer 43

the deltoid would pull the humeral head superiorly and the greater tuberosity would hit the underside of the acromion / coracoacromial arch

Question 44

How does pressure from the humeral head onto the coracoacromial arch change when the rotator cuff is not working properly?

Answer 44

force increases 60%

Question 45

At what general ranges of motion is glenohumeral cavity-compression the greatest?

Answer 45

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

Question 46

Give three examples of force couples that occur in the shoulder.

Answer 46

- Deltoid / Rotator Cuff - Upper Trapezius / Serratus Anterior - Anterior-Posterior Rotator Cuff Muscles

Question 47

What are the four functions of the Trapezius / Serratus Anterior force coupling that occurs in the shoulder.

Answer 47

1. allows for upward (lateral) rotation of the scapula, maintaining the glenoid for optimal positioning 2. maintains an efficient length-tension relationship for the deltoid 3. decreases "impingement" force on subacromial structures 4. provides stable scapular base, "enabling appropriate recruitment of scapulohumeral muscles"

Question 48

What movement is produced with the Upper Trapezius / Serratus Anterior force coupling in the shoulder?

Answer 48

Upward (lateral) scapular rotation

Question 49

Describe the Upper Trapezius / Serratus Anterior force coupling that occurs through varying degrees of shoulder abduction.

Answer 49

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.

Question 50

What muscular abnormalities have been recorded in patients with Impingement Syndrome of the shoulder?

Answer 50

decreased levels of Serratus Anterior activity, delayed firing of Middle and Lower Trap., and increased activity of Upper Trap. and Levator Scapula

Question 51

Describe the Anterior-Posterior Rotator Cuff force coupling in the shoulder

Answer 51

Subscapularis (anteriorly) and Infraspinatus & Teres Minor (posteriorly) create both inferior and compressive stability;

Question 52

Describe the concept of the rotator cuff muscles as a "suspension bridge" that influences humeral head movement.

Answer 52

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

Question 53

In what ranges of shoulder elevation are the Subscapularis, Infraspinatus, and Teres Minor most active?

Answer 53

Mid ranges

Question 54

What imbalances are frequently found in the Anterior-Posterior Rotator Cuff force couple?

Answer 54

selective development of the internal rotators and subscapularis in athletes / active individuals without development of the posterior rotator cuff

Question 55

What is the effect of an isolated supraspinatus tear on the "suspension bridge" phenomenon of the shoulder?

Answer 55

the anterior-posterior force couple remains intact

Question 56

What are the 7 components of the clinical examination of the shoulder?

Answer 56

1. Observation and posture 2. Scapular evaluation 3. Glenohumeral joint range of motion 4. Manual muscle testing (supraspinatus, infraspinatus, teres minor, subscapularis) 5. Related referral joint testing (cervical, elbow) 6. Special tests (impingement, instability, labrum) 7. Functional testing

Question 57

What are the theoretical explanations for shoulder height asymmetry?

Answer 57

dominant shoulder is typically lower: increased mass in the dominant arm; elongation of periscapular musculature secondary to eccentric loading

Question 58

What is the purpose of performing visual observation of the patient in standing during an examination of the shoulder?

Answer 58

In quiet standing and hands-on-hips standing, you can observe for muscle symmetry and focal atrophy

Question 59

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?

Answer 59

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

Question 60

What might cause observable atrophy of the infraspinatus?

Answer 60

- rotator cuff dysfunction - suprascapular nerve involvement (severe atrophy)

Question 61

Where does impingement of the suprascapular nerve commonly occur?

Answer 61

suprascapular notch (a.k.a. the spinoglenoid notch)

Question 62

What are paralabral cysts and how to they impact nearby tissue?

Answer 62

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

Question 63

Injury to what area of the shoulder joint labrum is most often associated with paralabral cyst formation?

Answer 63

superior

Question 64

Explain how a shoulder joint labral lesion can directly lead to atrophy of the infraspinatus.

Answer 64

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.

Question 65

What is the appropriate course of action if extreme wasting of the infraspinatus muscle is observed?

Answer 65

recommend further diagnostic testing to rule out suprascapular nerve involvement

Question 66

Describe the Kibler Scapular Slide test.

Answer 66

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

Question 67

What are the 3 dysfunctions of the scapula described by Kibler et al?

Answer 67

- inferior angle - medial border - superior

Question 68

Describe inferior angle scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?

Answer 68

- 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?)

Question 69

Describe medial border scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?

Answer 69

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

Question 70

Describe superior scapular dysfunction, as per Kibler et al. What other condition is this commonly seen with?

Answer 70

- early & excessive superior scapular elevation during arm elevation - typically results from rotator cuff weakness & force couple imbalances

Question 71

What does a kappa score measure in research? Why is it useful? How is it measured?

Answer 71

- 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

Question 72

What statistical support does classification of scapular dysfunction have?

Answer 72

- evaluations of 26 - 56 individuals - Interrater reliabilities range from k = 0.40 to 0.61 (moderate score)

Question 73

List 4 tests that might be used during an evaluation of the scapula.

Answer 73

- Scapular Slide test - Scapular Assistance test - Scapular Retraction test - Flip Sign

Question 74

Describe the Scapular Assistance test.

Answer 74

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

Question 75

Describe the Scapular Retraction test.

Answer 75

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

Question 76

Describe the Flip Sign.

Answer 76

Examiner resists ER with shoulder in slight abduction; (+) if medial border of scapula "flips" away from the thorax; indicates a loss of scapular stability

Question 77

If a patient with shoulder pain presents with a (+) Flip Sign, what exercises are likely to help.

Answer 77

(+) 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

Question 78

Why is the loss of glenohumeral internal rotation clinically important? What populations consistently present with this issue?

Answer 78

- 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)

Question 79

List 3 manual muscle test positions are used to evaluate the supraspinatus? Which is most highly recommended by the monograph's authors & why?

Answer 79

- 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

Question 80

What is the optimal position to test the strength of the infraspinatus muscle, according to Kelly et al?

Answer 80

- Patient seated - 0° shoulder flexion - 45° internal rotation

Question 81

Describe the purpose and performance of the Patte test.

Answer 81

- isolate the teres minor muscle to assess strength / tolerance for loading - 90° shoulder scaption - 90° external rotation - pt resists external rotation

Question 82

According to Kelly et al, what is the optimal position for testing the strength of the subscapularis muscle?

Answer 82

Gerber lift-off position (back of hand lifting away from inferior border of ipsilateral scapula)

Question 83

Using handheld dynamometers, what did Reimann et al conclude about rotator cuff strength differences between dominant and non-dominant shoulders?

Answer 83

The dominant limb was found to have significantly stronger internal rotation. External rotation was equal.

Question 84

Describe the interpretation of the Spurling's Compressive Test in an examination of a patient with shoulder pain.

Answer 84

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.

Question 85

What are two reasons that you might screen the elbow when you suspect shoulder pathology?

Answer 85

- Shoulder injury can refer symptoms to the elbow - Elbow injuries can occur alongside shoulder injuries (in throwing athletes & during sling use following surgery)

Question 86

During a shoulder examination, what two elbow tests are recommended by the monograph authors?

Answer 86

- Valgus Stress Test - Laterally-based Extensor Provocation Test

Question 87

Describe the Valgus Stress test of the elbow. What is this testing?

Answer 87

- 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

Question 88

Describe the Laterally-based Extensor Provocation Test. What is this testing?

Answer 88

- elbow is fully extended - resist wrist extension - loads the lateral epicondylar region

Question 89

What are the three categories of special tests for the shoulder described by the monograph authors?

Answer 89

1. Impingement tests 2. Instability tests 3. Labral tests

Question 90

Describe the 5 shoulder impingement tests listed in the monograph. Which of these are the best supported?

Answer 90

1. Neer Impingement test 2. Hawkins-Kennedy Impingement test 3. Coracoid Impingement test 4. Cross-arm Adduction test 5. Yocum test - Neer test is 53% sp, 79% sn; Hawkins-Kennedy is 59% sp, 79% sn

Question 91

Compare/contrast the Hawkins-Kennedy Impingement with the Coracoid Impingement test.

Answer 91

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.

Question 92

What are the two main types of shoulder instability tests?

Answer 92

1. Humeral head translation tests 2. Provocation tests

Question 93

What is the approximate ratio of normal anterior-to-posterior humeral head translation in the glenoid?

Answer 93

1:1 (7.8-7.9 mm)

Question 94

What is the average normal inferior displacement of the humeral head in the glenoid?

Answer 94

1 cm

Question 95

Describe the MDI Sulcus test

Answer 95

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)

Question 96

The MDI Sulcus test assesses the integrity of which two structures of the shoulder?

Answer 96

superior GH ligament & coracohumeral ligament

Question 97

Which shoulder special test is used to assess the integrity of the superior glenohumeral ligament and/or the coracohumeral ligament?

Answer 97

Multi-directional Instability Sulcus test

Question 98

Why should a patient be positioned in supine in order to test for anterior/posterior shoulder joint laxity?

Answer 98

allows the patient's shoulder to be tested in multiple degrees of abduction (selectively stresses different portions of the capsule and capsular ligaments)

Question 99

List the 5 shoulder instability tests described in the monograph.

Answer 99

1. MDI Sulcus test 2. Supine Anterior Humeral Head Translation test 3. Supine Posterior Humeral Head Translation test 4. Subluxation Relocation test 5. General hypermobility testing (e.g. the Beighton hypermobility scale/index)

Question 100

Describe the Anterior and Posterior Humeral Head Translation tests.

Answer 100

- 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°

Question 101

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?

Answer 101

0-30° abduction

Question 102

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?

Answer 102

30-60° abduction

Question 103

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?

Answer 103

90°

Question 104

Why is the Posterior Humeral Head Translation test performed in 90° of abduction?

Answer 104

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

Question 105

Describe the grading system for Humeral Head Translation testing.

Answer 105

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)

Question 106

How reliable is the grading system Humeral Head Translation testing?

Answer 106

- 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

Question 107

Describe the Subluxation Relocation test. Why is this test a useful supplement to the MDI Sulcus test and Anterior/Posterior Translation testing?

Answer 107

- 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

Question 108

What is "occult" shoulder instability? What is a clinical indicator of this type of instability, according to the monograph authors?

Answer 108

- 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

Question 109

Contrast the reproduction of anterior vs posterior shoulder pain during the Subluxation Relocation test.

Answer 109

- anterior pain: anterior instability / secondary glenohumeral joint impingement - posterior pain: posterior or internal impingement

Question 110

Aside from shoulder joint instability, what other condition may be implicated in patients with a positive Subluxation Relocation test?

Answer 110

Type II superior labrum anterior to posterior (SLAP) lesion

Question 111

What scale is used in assessing general hypermobility?

Answer 111

the Beighton hypermobility scale/index

Question 112

Describe the 9 items in the Beighton hypermobility scale/index.

Answer 112

(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

Question 113

How many items does the Beighton hypermobility scale/index consist of?

Answer 113

9

Question 114

How many items of the Beighton scale must be positive in order to grade the patient as "hypermobile"?

Answer 114

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.

Question 115

List the 8 shoulder labral tests described in the monograph.

Answer 115

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

Question 116

What are the 2 categories of shoulder labral tests described in the monograph? What is the difference between the two?

Answer 116

- 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)

Question 117

What are the two main functions of the glenoid labrum?

Answer 117

1. deepens the glenoid fossa, enhancing the concavity 2. serves as an attachment site for the glenohumeral ligaments (secures the humeral head in the glenoid)

Question 118

What is the effect of injury to the labrum on glenohumeral joint compression?

Answer 118

labral injury has been shown to decrease concavity compression up to 50%

Question 119

Describe the effect of anterior translation forces on the humeral head in overhead throwing athletes.

Answer 119

Anterior translation forces can be up to 50% of body weight during arm acceleration of the throwing motion (arm in 90° abduction & ER)

Question 120

How does increased capsular laxity / generalized joint hypermobility affect forces on the glenoid labrum in both the short- and long-term?

Answer 120

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

Question 121

List the 5 types of glenoid labrum tears described in the monograph.

Answer 121

1. transverse 2. longitudinal 3. flap 4. horizontal cleavage 5. fibrillated

Question 122

In what parts of the labrum do tears most commonly occur?

Answer 122

- anterior-superior (60%) - posterior-superior (18%) - only 1% in anterior-inferior labrum - multiple areas (22%)

Question 123

What are the general outcomes of arthroscopic labral debridement procedures in patients with shoulder joint hypermobility? What are the clinical implications of these outcomes?

Answer 123

- 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

Question 124

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

Answer 124

SLAP / Bankart lesions are labral detachments of the labrum from the rim

Question 125

What are the two most common labral detachments?

Answer 125

SLAP lesion & Bankart lesion

Question 126

What is a Bankart lesion? What is its relationship to dislocation?

Answer 126

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

Question 127

What is a SLAP lesion? Why is the loss of shoulder stability so significant with these lesions?

Answer 127

- 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)

Question 128

What was the effect of a surgically-induced SLAP lesion on glenohumeral joint stability?

Answer 128

- 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

Question 129

What is the "peel back mechanism" that is hypothesized to cause glenoid labral injury?

Answer 129

the torsional force created with the abducted arm is brought into maximal ER "peels back" the biceps and labrum

Question 130

What activity puts the most strain through the biceps tendon in overhead athletes? What other forces on the shoulder are relevant in this situation?

Answer 130

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

Question 131

What can cadaver studies tell us about mechanisms of superior labral injuries?

Answer 131

- 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)

Question 132

Which 4 special tests of the shoulder attempt to mimic the "peel back" mechanism?

Answer 132

- O'Brien Active Compression test - Mimori test - Biceps Load test - ER Supination test

Question 133

Discuss the diagnostic accuracy of clinical tests to identify glenoid labrum pathology.

Answer 133

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.

Question 134

What pathologies might be detected via shoulder radiographs?

Answer 134

fracture, calcification (esp. in supraspinatus), rotator cuff tears

Question 135

How might a shoulder radiograph show signs of a rotator cuff tear?

Answer 135

- irregularity of greater tuberosity - sclerosis of underside of acromion - elevated humeral head (deltoid unopposed by RTC)

Question 136

How does calcification of the supraspinatus typically occur?

Answer 136

bloody hemorrhage coagulates and calcifies

Question 137

What shoulder pathologies might be detected via computed tomography?

Answer 137

-subtle or complex fractures of humerus or glenoid - arthritic changes - loose bodies - Hill-Sachs lesions

Question 138

What intra- and extra-articular structures of the shoulder can be assessed using MRI?

Answer 138

- Intra-articular: ligaments, capsules, synovium, labrum - Extra-articular: ligaments, bursae, tendons

Question 139

What is the effect of adding contrast to a shoulder MRI?

Answer 139

- 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

Question 140

What 2 functional tests for the shoulder are recommended by the monograph authors?

Answer 140

1. Closed Kinetic Chain Upper Extremity Stability test 2. Functional Throwing Performance Index

Question 141

Describe the Closed Kinetic Chain Upper Extremity Stability test.

Answer 141

- 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

Question 142

What does the Closed Kinetic Chain Upper Extremity Stability test assess? Why is this better than simply performing a push-up?

Answer 142

- 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)

Question 143

Describe the Functional Throwing Performance Index.

Answer 143

- series of repetitive throws at a target - scores both accuracy and ability to functionally perform the throwing motion

Question 144

Why might isokinetic testing of shoulder musculature be more beneficial than manual muscle testing?

Answer 144

accommodating resistance & ability to test glenohumeral joint at faster, more functional angular velocities

Question 145

What are the limitations of manual muscle testing of the shoulder joint?

Answer 145

- when there is a minor strength impairment or isolated strength deficit - difficult to assess antagonist/agonist muscular strength imbalances

Question 146

What are the 5 key pathophysiologic factors that lead to rotator cuff disease?

Answer 146

1. Primary impingement 2. Secondary impingement 3. Tensile overload 4. Microtraumatic tendon failure 5. Posterior / undersurface impingement

Question 147

What is primary rotator cuff compressive disease also known as?

Answer 147

primary impingement

Question 148

What is primary rotator cuff impingement?

Answer 148

compression of rotator cuff tendons between the humeral head and the anterior 1/3 of the acromion, coracoacromial ligament, coracoid, or acromioclavicular joint

Question 149

During primary rotator cuff impingement, the rotator cuff tendons can be compressed between the humeral head and what 4 structures?

Answer 149

1. anterior 1/3 of the acromion 2. coracoacromial ligament 3. coracoid 4. acromioclavicular joint

Question 150

What did Poppen & Walker discover about subacromial compressive forces during shoulder elevation?

Answer 150

compressive forces are 42% of body weight

Question 151

At what angles of shoulder elevation are subacromial compressive forces the highest?

Answer 151

between 85° and 136° of elevation

Question 152

What phases of the throwing motion are most likely to produce subacromial compression?

Answer 152

acceleration and follow-through

Question 153

What are the shoulder motions during the follow-through phase of throwing that cause subacromial compressive forces?

Answer 153

flexion, horizontal adduction, and internal rotation

Question 154

What musculotendinous structures are most likely to experience abrasion due to subacromial impingement/compression during the throwing motion.

Answer 154

supraspinatus, infraspinatus, or biceps tendon

Question 155

According to Neer, what are the 3 stages of primary rotator cuff impingement?

Answer 155

- Stage I: edema and hemorrhage - Stage II: fibrosis and tendonitis - Stage III: bone spurs and tendon rupture

Question 156

What is Stage I Primary Rotator Cuff Impingement?

Answer 156

a.k.a edema and hemorrhage - mechanical irritation of tendon via impingement during overhead activity - reversible with PT

Question 157

Describe the typical profile and clinical presentation of a patient with stage I primary rotator cuff impingement.

Answer 157

- young, athletic patients - painful arc - (+) impingement sign - varying degrees of muscular weakness

Question 158

What is Stage II Primary Rotator Cuff Impingement?

Answer 158

a.k.a fibrosis and tendonitis - repeated episodes of inflammation - thickening/fibrosis of the bursa - ages 25-40

Question 159

What is Stage III Primary Rotator Cuff Impingement?

Answer 159

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

Question 160

Describe Secondary Rotator Cuff Compressive Disease.

Answer 160

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

Question 161

Describe the relationship between tensile overload and rotator cuff tears.

Answer 161

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

Question 162

In the arm deceleration phase of throwing, tensile strength of the rotator cuff resists which forces? How great are these tensile forces when measured?

Answer 162

- 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

Question 163

Describe microtraumatic tendon failure of the rotator cuff.

Answer 163

repeated microtrauma and degeneration over time create a weakened tendon that eventually fails under a heavy load,

Question 164

What percentage of a rotator cuff tendon can be torn without a substantial loss of strength?

Answer 164

Up to 30%

Question 165

Describe undersurface rotator cuff impingement.

Answer 165

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.

Question 166

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?

Answer 166

posterior/inside/undersurface rotator cuff impingement

Question 167

What is the relationship between anterior humeral head translation and undersurface impingement?

Answer 167

produces mechanical rubbing and fraying on the undersurface of the rotator cuff tendons

Question 168

What is the relationship between posterior impingement and the deltoid musculature?

Answer 168

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.

Question 169

What is the primary initial objective in treating rotator cuff pathology?

Answer 169

decrease stress on rotator cuff (either compressive or tensile) without decreasing function

Question 170

What is the role of isometrics in treating rotator cuff impingement / pathology? What movements are recommended by the monograph authors?

Answer 170

- 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

Question 171

What is the first force couple that should be addressed when treating rotator cuff impingement / pathology? Why?

Answer 171

- Serratus Anterior / Lower Trapezius force couple - key component of early management is scapular stabilization and retraction

Question 172

Describe the sequence of scapular stabilization treatment recommended by the monograph authors.

Answer 172

- 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

Question 173

When treating rotator cuff impingement / pathology, what portion of physical examination is critical to guide ROM and mobilization treatment? Why?

Answer 173

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

Question 174

What specific ROM limitation is most studied in overhead athletes with rotator cuff pathology? What is the first step in addressing this?

Answer 174

- loss of IR - clinical examination needs to identify the tissue involved (restrictions in the posterior capsule vs. injury of the muscle tendon unit)

Question 175

What are two reasons why glenohumeral internal rotation may be limited in the overhead athlete with rotator cuff pathology?

Answer 175

- restrictions in posterior capsule - injury of the rotator cuff musculotendinous unit

Question 176

How do you determine if limited glenohumeral internal rotation is due to posterior capsule tightness?

Answer 176

Posterior Load & Shift, a.k.a. Posterior Drawer test

Question 177

How is the Posterior Load & Shift / Posterior Drawer test performed? What are common mistakes in administering this test?

Answer 177

- 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

Question 178

What ROM finding is common in overhead athletes' dominant arm vs non-dominant? What are 3 proposed mechanism to explain this phenomenon?

Answer 178

- 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

Question 179

What is the acute effect of pitching on glenohumeral ROM?

Answer 179

- after 50-60 pitches at full intensity: - IR was decreased by 9.5° - total rotation is decreased by 10.7°

Question 180

What is the ideal glenohumeral joint position to perform passive internal rotation stretching?

Answer 180

30° of scaption + internal rotation produces strain in the posterior capsule and muscle tendon unit

Question 181

What technique do the monograph authors recommend when attempting to increase glenohumeral internal rotation?

Answer 181

- 30° scaption + passive IR - PNF contract-relax following a low-load prolonged stretch-type paradigm

Question 182

What stretches do the monograph authors recommend to increase glenohumeral internal rotation? Which is more effective?

Answer 182

- sleeper stretch & cross arm adduction stretch - cross arm adduction may be more effective as home exercise

Question 183

What are 3 goals in the initial phase of non-operative rehabilitation of rotator cuff impingement / pathology?

Answer 183

1. decr pain to allow for introduction of submax rotator cuff and scapular exercise 2. normalization of capsular relationships through mobilization and stretching 3. early submax rotator cuff and scapular resistance training

Question 184

Describe the progression of rotator cuff exercises given in the monograph (Jobe Isotonics)

Answer 184

1. Sidelying ER 2. Prone Shoulder Extension (in ER) 3. Prone Horizontal Abduction (thumb up) 4. Prone 90/90 ER (3 sets of 15-20 reps)

Question 185

Why is prone horizontal abduction a good alternative to the traditional empty can position as a rotator cuff strengthening exercise?

Answer 185

- 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

Question 186

What are the advantages of performing ER strengthening exercises with a towel roll?

Answer 186

- increased activtation (10%) of infraspinatus - enhanced bloodflow in the supraspinatus - isometric adduction increases subacromial space

Question 187

Why might it be beneficial to intentionally use lower intensities for ER strengthening exercise in patients with rotator cuff impingement/pathology?

Answer 187

- increased infraspinatus activity relative to middle and posterior deltoid at 40% of maximal effort (less deltoid compensation)

Question 188

Give 4 examples of of scapular stabilization exercises that emphasize the lower trapezius for patients with rotator cuff impingement/pathology.

Answer 188

- manual protraction/retraction exercise - prone 90/90 ER - bilateral ER with retraction - multiple seated rowing variations

Question 189

Give 3 examples of closed-chain exercises that use the "plus" position for patients with rotator cuff impingement/pathology. How are these exercises progressed?

Answer 189

- 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)

Question 190

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?

Answer 190

1. optimal position of humeral head on the glenoid 2. rotator cuff is best able to maintain stability in this position

Question 191

What is the "statue of liberty" exercise, and what patient population may benefit from it?

Answer 191

- 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

Question 192

Where are full-thickness tears of the rotator cuff often initiated? What areas of the rotator cuff are subsequently affected?

Answer 192

- often starts in the zone of the supraspinatus and extend to include the infraspinatus, teres minor, and subscapularis

Question 193

A tear in what region of the rotator cuff is associated with the biceps tendon?

Answer 193

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

Question 194

What are the two general areas that partial-thickness rotator cuff tears occur?

Answer 194

superior surface (bursal side) or undersurface (articular side) of the rotator cuff

Question 195

Partial-thickness rotator cuff tears on the superior surface (bursal side) are generally associated with what conditions?

Answer 195

- primary and secondary compressive disease / impingement - macrotraumatic tendon failure

Question 196

Partial-thickness tears on the undersurface (articular side) of the rotator cuff are generally associated with what conditions?

Answer 196

- tensile loads - glenohumeral joint instability

Question 197

Partial-thickness rotator cuff tears on the undersurface (articular side) are commonly associated with what populations?

Answer 197

- overhead throwing athletes with anterior instability / capsular and labral insufficiency / muscular imbalances

Question 198

What are the two patterns of complete rotator cuff tears?

Answer 198

crescent-shaped and U-shaped

Question 199

Following a repair of a medium-sized rotator cuff tear, how many weeks post-op should isotonic RTC strengthening exercise be introduced? Give examples.

Answer 199

- 6 to 8 weeks - sidelying ER, prone extension, prone horizontal abduction, supine IR, flexion to 90°

Question 200

Why is early passive ROM into external rotation safe following a rotator cuff repair?

Answer 200

30° and 60° of ER in neutral showed a decrease in tension on the supraspinatus tendon

Question 201

What tissues are subject to increased tensile loads if early internal rotation is applied following a rotator cuff repair?

Answer 201

increased loads on supraspinatus, infraspinatus, and teres minor

Question 202

Contrast seated pulleys vs supine assisted ROM elevation following rotator cuff repair.

Answer 202

both produce low levels of inherent muscular activation, but pulleys show more than supine assisted ROM

Question 203

What is the relationship between early passive ROM and incidence of re-tear following arthroscopic rotator cuff repair?

Answer 203

early PROM is not a risk factor for re-tear at 1 year follow-up

Question 204

Following a rotator cuff repair, when should resistive exercise for the rotator cuff and scapular musculature generally be initiated? Why?

Answer 204

- 6 weeks - early theoretical healing is assumed in the repaired tissues

Question 205

Compare and contrast empty vs full can scaption for rotator cuff strengthening.

Answer 205

- 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

Question 206

During rotator cuff rehab, strengthening of what specific scapular muscles are targeted?

Answer 206

lower trapezius & serratus anterior (force couple)

Question 207

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?

Answer 207

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

Question 208

Generally, what degree of recovery can be expected following mini-open / arthroscopic rotator cuff repair?

Answer 208

-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)

Question 209

Contrast joint dislocation vs subluxation?

Answer 209

- 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

Question 210

Contrast shoulder joint laxity vs joint instability. Why can making a differentiation between the two be difficult?

Answer 210

- 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

Question 211

Shoulder instability is generally considered to occur most often in what direction?

Answer 211

anterior instability (though recent reports have found higher rates of posterior and combined instability than previously reported)

Question 212

When is nonoperative treatment of shoulder instability warranted?

Answer 212

in almost all cases, even if surgical intervention is planned

Question 213

What should initial treatment of shoulder instability broadly consist of?

Answer 213

- patient education - activity modification to decrease pain - and controlling inflammation - improve rotator cuff and scapular muscular strength/endurance (force couples) - functional dynamic stabilization

Question 214

During nonoperative treatment of shoulder instability, how can strengthening rotator cuff muscles affect ligamentous structures like the glenohumeral joint ligaments and capsule?

Answer 214

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

Question 215

What is the current state of the evidence when it comes to theories of capsular and ligament tissue healing following shoulder instability surgery?

Answer 215

although we've made some great strides in understanding soft tissue healing, theories are based on basic science and surgeon & physical therapist opinion/experience

Question 216

What are 4 of the most popular forms of surgery to treat shoulder instability

Answer 216

1. arthroscopic capsular plication 2. inferior capsule shift 3. anterior capsulolabral repair (ACLR) 4. Bankart repair

Question 217

Arthroscopic capsular plication, Inferior capsule shift, Anterior capsulolabral repair (ACLR), and Bankart repair are all examples of surgical procedures used to treat what condition?

Answer 217

shoulder stabilization procedures used to address shoulder instability

Question 218

What are the 4 goals of physical therapy immediately following surgical stabilization of the shoulder?

Answer 218

1. protect healing/repaired tissue 2. prevent joint hypomobility 3. decrease pain/inflammation 4. regain normal firing patterns for rotator cuff and scapular muscles

Question 219

During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 0-3?

Answer 219

- 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

Question 220

During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 4-6?

Answer 220

- Flexion 0°-140° (much more for ACLR at 160°) - Extension 30°-35° - IR 30°/35°-60° - ER 30°-40°/60° in neutral

Question 221

During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 6-9?

Answer 221

- Flexion 140°-165°/175° - Extension 40°-45° - Internal rotation 60°-80°/full - ER 40°-65°/85°

Question 222

During post-op rehab following shoulder stabilization surgery, what are the general ROM goals in weeks 10-12+?

Answer 222

- 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)

Question 223

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

Answer 223

Weeks 0-3

Question 224

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

Answer 224

Weeks 4-6

Question 225

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°

Answer 225

Weeks 6-9

Question 226

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)

Answer 226

Weeks 10-12+

Question 227

When progressing ROM following shoulder stabilization surgery, what is the general rule of thumb?

Answer 227

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.

Question 228

Give 4 reasons to implement early motion following shoulder stabilization surgery.

Answer 228

1. promotes blood flow / healing 2. improves collagen organization 3. stimulates joint mechanoreceptors 4. decreases pain via neuromuscular modulation

Question 229

Following shoulder stabilization surgery, why is it important to distinguish between ROM exercise and stretching?

Answer 229

Stretching is contraindicated. ROM exercise should be taken to tolerance and begin in "low-tension" positions like 30°-45° ER in neutral.

Question 230

Describe a Capsular Shift & Plication procedure for the shoulder.

Answer 230

- to treat shoulder instability - extra capsular tissue is folded over and fixed to the labrum/glenoid via suture or anchor

Question 231

Describe an Arthroscopic Anterior Capsulolabral Repair procedure for the shoulder.

Answer 231

- to treat shoulder instability - anchors pin the labral tear to the glenoid & sutures are used to fold/tighten the capsule

Question 232

What surgical procedure is considered the "gold standard" for treating anterior shoulder instability?

Answer 232

Bankart reconstruction

Question 233

Describe a Bankart reconstruction procedure for the shoulder.

Answer 233

- 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

Question 234

Describe an Anterior Latarjet procedure.

Answer 234

-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)

Question 235

Give 3 conditions for which an Anterior Latarjet procedure might be indicated.

Answer 235

1. Anterior bone loss due to chronic dislocations 2. large engaging Hill-Sachs lesion 3. General instability-related loss of function

Question 236

What is a top priority during rehab immediately following an Anterior Latarjet procedure?

Answer 236

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

Question 237

During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 0-4?

Answer 237

- most of the time, a sling is used, but can be taken off for exercise - PROM, AAROM - isometrics / rhythmic stabilization

Question 238

During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 4-6?

Answer 238

- once the sling is removed, light isotonic exercise for the shoulder & arm

Question 239

During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 6-8?

Answer 239

- 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)

Question 240

During post-op rehab following shoulder stabilization surgery, what are the general exercise progressions by weeks 12-16?

Answer 240

- higher-level, sport-specific activities (underhand throwing sooner than overhand) - plyometrics - eccentric strengthening - full-body stability deficits

Question 241

Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?: - PROM, AAROM - isometrics / rhythmic stabilization

Answer 241

0-4 weeks

Question 242

Following surgical stabilization to address shoulder instability, when would you expect to reach the following exercise progressions?: - light isotonic exercise for the shoulder & arm

Answer 242

4-6 weeks

Question 243

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)

Answer 243

6-8 weeks

Question 244

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

Answer 244

12-16 weeks

Question 245

What reason do the monograph authors give for assessing balance/stability deficits in athletes with shoulder instability?

Answer 245

- correlation found in Division III NCAA overhead athletes between trunk stability / balance deficits and shoulder dysfunction

Question 246

Which type(s) of SLAP lesions tend to respond well to nonoperative management?

Answer 246

early Type I

Question 247

Which type(s) of SLAP lesions tend not to respond well to nonoperative management?

Answer 247

Type II-IV (though conservative treatment should still be attempted with Type II)

Question 248

What should nonoperative treatment of SLAP lesions entail?

Answer 248

it shoulder concentrate on: - the strength and endurance of the rotator cuff & scapular stabilizers - posterior shoulder tightness (mobs and stretching) that limits IR

Question 249

What is the likelihood that an overhead athlete will return to sport following a SLAP lesion repair?

Answer 249

only 66% return to sport (though functional ability and quality of life are good at 3-year follow-up

Question 250

Most symptomatic SLAP lesions that are treated surgically are which type?

Answer 250

Type II (superior labrum & biceps anchor detached)

Question 251

How long is the early protective phase generally following type II SLAP lesion repair?

Answer 251

4 weeks - sling use / immobilization (allow inflammatory phase to run its course without loading the shoulder

Question 252

How should shoulder ROM be advanced following type II SLAP lesion repair?

Answer 252

- 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)

Question 253

Following type II SLAP lesion repair, AROM exercise is allowed for all elbow, hand, and wrist movements except which?

Answer 253

- elbow flexion and forearm supination place tension across the biceps anchor repair site

Question 254

Following type II SLAP lesion repair, when can scapular isometric strengthening begin?

Answer 254

since there's no surgical insult to the scapular muscles, isometrics can begin in 2 weeks post-op and progress to isotonics

Question 255

Following type II SLAP lesion repair, when is full symmetrical glenohumeral motion expected?

Answer 255

3 months

Question 256

Following type II SLAP lesion repair, when should active elbow flexion & supination be initiated? When should heavy loading begin?

Answer 256

weeks 5-6; heavy loading is discouraged until week 10

Question 257

Following type II SLAP lesion repair, when should ROM exercise be progressed to 145° flexion & 50° ER?

Answer 257

weeks 5-6

Question 258

In weeks 5-6 following type II SLAP lesion repair, ROM exercise can be progressed to what degrees of flexion and external rotation?

Answer 258

145° flexion & 50° ER

Question 259

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?

Answer 259

low-level scapular exercises like low row and ?inferior glide?

Question 260

Following type II SLAP lesion repair, how do rehab goals shift in weeks 7-12?

Answer 260

- 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

Question 261

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?

Answer 261

week 9

Question 262

By week 9 following type II SLAP lesion repair, what ROM should have been reached?

Answer 262

- full elevation - 90° ER (in 45° or less of abduction) - 70° IR

Question 263

List 9 resistive exercises should be performed in weeks 7-12 following type II SLAP lesion repair.

Answer 263

1. sidelying external rotation 2. scaption 3. seated press-up 4. rowing 5. push-up plus 6. serratus punch 7. dynamic hug 8. prone lower trap raise 9. horizontal adduction with external rotation (serratus anterior) 10. flexion to 125° with scapular protraction (serratus anterior)

Question 264

Following type II SLAP lesion repair, when should full ER in the 90/90 position be achieved?

Answer 264

12 weeks

Question 265

Following type II SLAP lesion repair, how would you determine if an athlete is appropriate to return to overhead throwing or swinging?

Answer 265

- 4 months post-op - full ROM - full strength - no pain

Question 266

What two groups of ligaments might be injured in an Acromioclavicular Joint injury?

Answer 266

acromioclavicular ligament and/or coracoclavicular ligaments (conoid & trapezoid)

Question 267

The Acromioclavicular joint ligament largely provides stability in what plane?

Answer 267

anterior-posterior

Question 268

Compare and contrast the functions of the conoid and trapezoid ligaments (coracoclavicular ligaments)?

Answer 268

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

Question 269

What is a "step-off" deformity in the shoulder?

Answer 269

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

Question 270

Which acromioclavicular joint injury types are typically treated conservatively?

Answer 270

- 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)

Question 271

What is the 4-phase treatment approach for type II acromioclavicular joint injury rehab give in the monograph?

Answer 271

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

Question 272

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?

Answer 272

- 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)

Question 273

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?

Answer 273

- motion is pain-free - strength is 75% of uninvolved side phase 3: strengthening in all positions (intro pressing)

Question 274

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?

Answer 274

- motion is full and pain-free - palpation is pain-free - strength is close to 100% 4: sport-specific exercise

Question 275

What are some motions that may be more difficult or painful during AC joint injury rehab?

Answer 275

movements that place addition stress on AC joint: - IR behind the back - horizontal adduction - end-range flexion - end-range extension

Question 276

During AC joint rehab, which functional activities should be avoided in early phases?

Answer 276

anything that emphasizes downward displacement of the arm - sustained lifting/carrying (i.e. suitcase or toolbox)

Question 277

During early AC joint rehab, performing exercises in which position may be more easily tolerated?

Answer 277

closed-chain (i.e. against a wall/table, or in quadruped)

Question 278

What did Gumina et al discover about the relationship between the cervical spine and the AC joint?

Answer 278

higher prevalence of cervical hyperlordosis and more cervical pain symptoms in those with chronic AC joint injury

Question 279

What is the general prognosis following an AC joint injury?

Answer 279

both surgical and conservative treatment of types I-V had good to excellent results at 2-year follow-up

Question 280

In what situation(s) might surgery for an AC joint injury be warranted?

Answer 280

- 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)

Question 281

How soon should surgery be considered following severe AC joint injury?

Answer 281

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

Question 282

What is the 3-phase post-op rehab approach following surgery for acromioclavicular joint injury?

Answer 282

- 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

Question 283

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.

Answer 283

4-12 weeks (phase 2) - resisted ER/IR in neutral - resisted flexion/abduction to 90°

Question 284

Following surgery for acromioclavicular joint injury, when would you expect to introduce functional sport- and occupation-specific activities?

Answer 284

weeks 12-24 (phase 3)

Question 285

What populations are most at risk for primary Frozen Shoulder?

Answer 285

40-65 years old, females more than males

Question 286

What are cytokines and what role do they play in the etiology of Frozen Shoulder?

Answer 286

- 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.

Question 287

Why is the beginning phase of Frozen Shoulder so painful?

Answer 287

- elevated cytokines keep the synovium inflamed - new nerve growth in the GH capsule and ligaments

Question 288

What is the rotator cuff interval and what role does it play in Frozen Shoulder?

Answer 288

- 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

Question 289

Patients with early-stage Frozen Shoulder are often misdiagnosed with which other condition. How is this avoided?

Answer 289

- 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

Question 290

What are the clinical findings that generally indicate Frozen Shoulder?

Answer 290

- 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)

Question 291

What should and should not be the goals for rehab of Frozen Shoulder?

Answer 291

- successful treatment shouldn't be defined by restoring "normal" motion - goals should include reducing pain and beginning to improve passive and functional movements

Question 292

What is the role of modalities in treating Frozen Shoulder?

Answer 292

things like heat, ultrasound, and TENs can improve stretching exercise, but are not effective on their own

Question 293

When treating Frozen Shoulder, how is the dosage of stretching exercise determined?

Answer 293

- 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)

Question 294

What did Vermeullen et al determine about the role of joint mobilization in treating Frozen Shoulder?

Answer 294

grade I-II anterior, inferior, posterior glides (performed 2x/week for 30 minutes) for 12 weeks showed significant improvement in motion and function

Question 295

What is the role of corticosteroid injections in treating Frozen Shoulder?

Answer 295

- strong evidence that it helps with short-term pain relief (3-6 weeks) in conjunction with joint mobilization and exercise

Question 296

When treating Frozen Shoulder, what factors would determine whether the patient completes supervised therapy vs an independent home exercise program?

Answer 296

supervised therapy if: - high irritability - greater disability - more co-morbidities - low social support - low educational level - high fear & anxiety

Question 297

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?

Answer 297

- 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

Question 298

What are most important things to include in patient education during the early phases of Frozen Shoulder rehab?

Answer 298

- 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

Question 299

Describe the ROM home exercise program for a patient with Frozen Shoulder that is recommended by the monograph authors.

Answer 299

- 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

Question 300

When treating Frozen Shoulder, how should treatment frequency be determined?

Answer 300

- 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

Question 301

When treating a patient with Frozen Shoulder, how can heat be used in a treatment session?

Answer 301

- 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

Question 302

Describe a typical treatment session for Frozen Shoulder.

Answer 302

- 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

Question 303

GH joint glides in which direction can improve ER?

Answer 303

both anterior & posterior

Question 304

When treating Frozen Shoulder, how is the appropriate stretch intensity determined?

Answer 304

pain should completely resolve once removed from end range

Question 305

When treating Frozen Shoulder, as pain and irritability lessen, how should mobilization and stretching exercise progress?

Answer 305

- 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

Question 306

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?

Answer 306

- indicates tightness of superior capsular and posterior structures - inferior glide in adduction/extension and IR

Question 307

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.

Answer 307

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

Question 308

For a patient with Frozen Shoulder, what stretch (when tolerated) can be helpful in improving internal rotation ROM?

Answer 308

sleeper stretch

Question 309

When treating Frozen Shoulder, how often should ROM be assessed?

Answer 309

at the beginning and end of every treatment session

Question 310

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?

Answer 310

- only pendulums several times per day - PT can be resumed ~ 4 days after

Question 311

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?

Answer 311

1. improved pain status 2. improved satisfaction 3. improved function 4. low irritability 5. minimal to no end-range pain 6. within-session gain of 10° or less 7. 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)

Question 312

What prolonged stretching technique to improve elevation/external rotation is suggested by the monograph authors to treat Frozen Shoulder

Answer 312

standing with cane on table (shoulder in ~90° scaption & end-range ER)

Question 313

Approximately how many patients with Frozen Shoulder will fail conservative treatment and require manipulation or capsular release?

Answer 313

1 in 10

Question 314

Of the large joints, how common is OA in the shoulder?

Answer 314

It's the third most common next to hips and knees

Question 315

Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase I?

Answer 315

0-3 weeks

Question 316

Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase II?

Answer 316

3-8 weeks

Question 317

Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase III?

Answer 317

8-16 weeks

Question 318

Following a Shoulder Total or Hemiarthroplasty for a patient with standard goals, what is the timeframe for phase IV?

Answer 318

16+ weeks

Question 319

Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase I?

Answer 319

0-6 weeks

Question 320

Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase II?

Answer 320

6-12 weeks

Question 321

Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase III?

Answer 321

12-16 weeks

Question 322

Following a Total Shoulder Arthroplasty for a patient with limited goals, what is the timeframe for phase IV?

Answer 322

16+ weeks

Question 323

Generally, how many phases does post-operative rehab following shoulder total/hermiarthroplasty?

Answer 323

4

Question 324

Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 5 goals of phase I (weeks 0-3)?

Answer 324

1. patient education (precautions & HEP 4-6x per day) 2. allow healing of subscapularis 3. control pain & inflammation 4. begin ROM exercises (family/caregiver instruction) 5. PROM: elevation 90°-120°, ER 20°-30°

Question 325

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

Answer 325

phase II (weeks 3-8)

Question 326

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

Answer 326

phase I (weeks 0-3)

Question 327

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

Answer 327

phase II (weeks 3-8)

Question 328

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

Answer 328

phase III (weeks 8-16)

Question 329

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

Answer 329

phase III (weeks 8-16)

Question 330

Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 4 goals of phase II (weeks 3-8)?

Answer 330

1. decreased pain & inflammation 2. increased ADLs 3. PROM: elevation 120°, ER 30° 4. begin strengthening exercises

Question 331

Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 4 goals of phase III (weeks 8-16)?

Answer 331

1. PROM: elevation 140°, ER 30°-40° 2. AROM: elevation 120°-140° 3. increase functional activities 4. increase strength of scapular stabilizers

Question 332

Following a Shoulder Total or Hemiarthroplasty with standard goals, what are the 2 goals of phase IV (weeks 16+)?

Answer 332

1. functional activities (demand-dependent) 2. return to work or sport

Question 333

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°

Answer 333

Phase I (weeks 0-3)

Question 334

Which phase/timeframe of post-op rehab following Total or Hemiarthroplasty (standard goals) would entail the following goal of returning to work/sport?

Answer 334

phase IV (weeks 16+)

Question 335

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

Answer 335

phase IV (weeks 16+)

Question 336

Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail the following goals: - PROM: elevation 80°-120°, ER 30°

Answer 336

phase I (weeks 0-6)

Question 337

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

Answer 337

phase I (weeks 0-6)

Question 338

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°

Answer 338

phase II (weeks 6-12)

Question 339

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

Answer 339

phase II (weeks 6-12)

Question 340

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

Answer 340

phase III (weeks 12-16)

Question 341

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

Answer 341

phase III (weeks 12-16)

Question 342

Which phase/timeframe of post-op rehab following Total Shoulder Arthroplasty (limited goals) would entail functional strengthening?

Answer 342

phase IV (weeks 16+)

Question 343

Following a Shoulder Total or Hemiarthroplasty with standard goals, list 8 treatments in phase I (weeks 0-3).

Answer 343

1. patient education / precautions 2. pendulums 3. elbow AROM 4. hand squeezes 5. supine passive scaption 6. supine passive ER in < 30° scaption 7. active scapular retraction 8. ice

Question 344

Following a Shoulder Total or Hemiarthroplasty with standard goals, list 7 treatments in phase II (weeks 3-8).

Answer 344

1. review precautions 2. emphasize elevation progression exercises 3. begin AAROM extension, horizontal adduction 4. begin standing passive functional IR at 4 weeks 5. begin pulleys at 4-6weeks 6. begin manual PNF patterns through partial range at 6-8 weeks 7. scapular strengthening

Question 345

Following a Shoulder Total or Hemiarthroplasty with standard goals, list 4 treatments in phase III (weeks 8-16).

Answer 345

1. progress elevation to AROM in standing 2. begin strengthening with resistance in abduction, flexion, & 45° ER 3. PNF diagonals 4. progress resistance of shrugs, retraction, biceps, triceps

Question 346

Following a Shoulder Total or Hemiarthroplasty with standard goals, list 3 treatments in phase IV (weeks 16+).

Answer 346

1. full-body ROM & strengthening 2. work- or sport-specific training 3. modifications to work, sport, or functional activities

Question 347

Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 5 goals of phase I (weeks 0-6)?

Answer 347

1. stress importance of precautions and performance of HEP 4-6x per day 2. allow healing of subscapularis 3. control pain & inflammation 4. begin ROM exercises (family/caregiver education) 5. PROM: elevation 80°-120°, ER 30°

Question 348

Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 3 goals of phase II (weeks 6-12)?

Answer 348

1. decrease pain & inflammation 2. increase ADLs 3. PROM: elevation 90°-120°, ER 30°

Question 349

Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 3 goals of phase III (weeks 12-16)?

Answer 349

1. ROM full and pain-free 2. increase functional activities 3. begin rotator cuff strengthening

Question 350

Following a Total Shoulder Arthroplasty for a patient with limited goals, what are the 2 goals of phase IV (weeks 16+)?

Answer 350

1. return to functional activities 2. continue to improve strength

Question 351

Following a Total Shoulder Arthroplasty for a patient with limited goals, list 6 treatments in phase I (weeks 0-6).

Answer 351

1. patient education on precautions 2. pendulums 3. elbow AROM 4. hand squeezes 5. supine passive scaption 6. supine passive ER in scaption (within limits of range achieved in OR)

Question 352

Following a Total Shoulder Arthroplasty for a patient with limited goals, list 2 treatments in phase II (weeks 6-12).

Answer 352

1. begin elevation progression 2. gentle AAROM/PROM IR, extension, horizontal adduction

Question 353

Following a Total Shoulder Arthroplasty for a patient with limited goals, list 2 treatments in phase III (weeks 12-16).

Answer 353

1. progress elevation exercise 2. light resistance strengthening of ER, IR, extension

Question 354

Following a Total Shoulder Arthroplasty for a patient with limited goals, list 3 treatments in phase IV (weeks 16+).

Answer 354

1. progress all stretches & strengthening 2. functional strengthening 3. add progressive strengthening if able

Question 355

Following a Total or Hemiarthroplasty (with/without limited goals), how often should a HEP be performed?

Answer 355

4-6x per day, 10-20 reps, (begin with 5-10 second holds depending on tissue irritability)

Question 356

What are inflammatory arthritides? Give 3 examples that might affect shoulder health.

Answer 356

- systemtic diseases in which an overactive immune system "attacks" synovial joints and nearby structures 1. rheumatoid arthritis 2. ankylosing spondylitis 3. psoriatic arthritis

Question 357

Which soft tissues are most impacted by a total/hemi- shoulder arthroplasty?

Answer 357

- 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

Question 358

During a total/hemi- shoulder arthroplasty, why might the surgeon release the pectoralis major?

Answer 358

added exposure or correction of a severe IR contracture

Question 359

What differentiates a Total Shoulder Arthroplasty from a Hemiarthroplasty?

Answer 359

In a hemiarthroplasty, the glenoid is left intact (though it may be reamed/resurfaced). It depends on whether the glenoid angle is present.

Question 360

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.

Answer 360

- subscapularis - ER should be a minimum of 30°-40° - posterior capsule may need to be tightened if there is still posterior laxity

Question 361

List conditions which might warrant a Shoulder Arthroplasty. Which patient population has the highest likelihood of regaining AROM?

Answer 361

1. primary osteoarthritis 2. rheumatoid arthritis 3. posttraumatic arthritis 4. rotator cuff arthropathy - patients with primary OA and an intact rotator cuff have better outcomes than the others

Question 362

What ROM can the average patient receiving a Shoulder Total/Hemiarthroplasty expect to regain?

Answer 362

average of 113°-145° flexion (TSA outcomes are better)

Question 363

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?

Answer 363

- 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

Question 364

What is the general prevalence of rotator cuff tears in populations receiving a TSA for rheumatoid arthritis?

Answer 364

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)

Question 365

Following a Shoulder Total/Hemiarthroplasty for Rheumatoid Arthritis, what is a reasonable long-term expectation for flexion, ER, and IR ROM?

Answer 365

averages at 6.5 year follow-up: - flexion 103° - ER 47° - standing IR L4

Question 366

Following a Shoulder Hemiarthroplasty for a proximal humeral fracture, what must be kept in mind during the early phase of rehab?

Answer 366

- these patients present with greater stiffness, and aggressive stretching can disrupt tissue healing (especially PROM ER greater than 50° too early post-op)

Question 367

What ROM outcomes can patients expect following a Shoulder Hemiarthroplasty for a proximal humeral fracture?

Answer 367

relatively disappointing outcomes - elevation 70°-102° - ER 15°-24° - standing IR L4-L1 (only 50% of patients could perform above shoulder-level activities)

Question 368

What other condition is commonly developed following a proximal humeral fracture?

Answer 368

nerve injury (~67% of patients have persistent neurological deficits that reduce functional outcomes) - axillary nerve is most common, but combinations are common

Question 369

List 5 conditions that would have standard post-op rehab goals following a Shoulder Total/Hemiarthropathy.

Answer 369

1. OA and/or RA with an intact RTC 2. Osteonecrosis 3. Acute proximal humeral head fracture 4. Posttraumatic arthritis without greater tuberosity osteotomy 5. Capsulorraphy arthroplasty

Question 370

List 6 conditions that would have limited post-op rehab goals following a Shoulder Total/Hemiarthropathy.

Answer 370

1. RTC arthropathy 2. RA with irreparable RTC tear 3. Acute proximal humeral head fracture with tuberosity concerns/migration 4. Posttraumatic arthritis with greater tuberosity osteotomy 5. Septic arthritis 6. Capsulorraphy arthroplasty with instability

Question 371

What is capsulorraphy arthritis?

Answer 371

degeneration of articular cartilage due to repeated dislocations

Question 372

Describe the role and outcomes of Shoulder Arthropathy procedures for rotator cuff arthropathy?

Answer 372

- 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°)

Question 373

During supine PROM exercise following Shoulder Arthroplasty, how can the patient protect the subscapularis?

Answer 373

limit ER to 20°-30°

Question 374

What is an alternative to the typical supine PROM shoulder elevation exercise? Why might this be used?

Answer 374

standing chair stretch

Question 375

During rehab following a Shoulder Arthroplasty, how often shoulder ROM measurements be taken?

Answer 375

at the beginning and end of each session

Question 376

During rehab following a Shoulder Arthroplasty, when might a therapist "dial out" ROM exercise?

Answer 376

If patients achieve too much motion (e.g. > 30° ER before phase III)

Question 377

Why might we be interested in exercise that produces less EMG muscular activation rather than more?

Answer 377

post-op (e.g. TSA) in order to protect soft tissue structures & minimize pain

Question 378

What 3 conditions warrant a Reverse Shoulder Arthroplasty?

Answer 378

1. massive or irreparable rotator cuff damage 2. proximal humeral fracture resulting in a deficient rotator cuff 3. revision of previous arthroplasty with concurrent rotator cuff deficiency

Question 379

How does a Reverse Shoulder Arthroplasty address superior humeral head migration?

Answer 379

Deltoid causes elevation and the "glenosphere" creates a fulcrum for the distal socket to move on

Question 380

Following a Reverse Shoulder Arthroplasty, how long should the sling be used?

Answer 380

for the first 4-6 weeks

Question 381

Following a Reverse Shoulder Arthroplasty, what movements should be avoided in the early phases of rehab?

Answer 381

extension and adduction; ER in the frontal plane

Question 382

What soft tissue structures are most affected in a Reverse Shoulder Arthroplasty?

Answer 382

- 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

Question 383

Following a Reverse Shoulder Arthroplasty, when should the patient begin PROM exercise? Which exercises are recommended by the monograph authors?

Answer 383

- within the first 7-10 days post-op - supine passive flexion - supine passive ER from 0°-30°

Question 384

Describe the shoulder elevation progression program (5 exercises) described by the monograph authors.

Answer 384

1. supine bilateral wand flexion 2. supine unilateral wand flexion 3. seated theraball roll 4. gatching 5. ball roll on wall

Question 385

What is gatching?

Answer 385

supine active flexion on an incline

Question 386

Squeezing a ball results in activation of what shoulder muscles?

Answer 386

internal rotator activation

Question 387

Following a Reverse Shoulder Arthroplasty, when should AAROM/AROM exercises begin? Which movements?

Answer 387

- 6 weeks - elevation progression program

Question 388

What stretch do the authors suggest for improving ER at 90° of elevation?

Answer 388

supine, hands behind the head

Question 389

Following a Shoulder Arthroplasty, what two tests do the authors recommend to assess patient response to strengthening? Why these two?

Answer 389

ER Lag Sign & Abdominal Compression test - these tests load the infraspinatus and subscapularis tendons

Question 390

Following Shoulder Arthroplasty, when introducing manual resistance, which exercises should be emphasized?

Answer 390

- submaximal isometrics in ER and elevation - modified PNF patterns, progressing to resistance with band and then in standing

Question 391

Following a Shoulder Arthroplasty, when can patients expect to return to golfing, swimming, bicycling, aerobics, and running?

Answer 391

4-6 months

Question 392

Following a Reverse Shoulder Arthroplasty, when can patients expect to make a full recovery?

Answer 392

6 months, with another 6 months of HEP stretching

Question 393

Following a Reverse Shoulder Arthroplasty, when should PROM be introduced and to which limits?

Answer 393

- first 3 weeks - to 90° elevation & 20°-30° ER

Question 394

Following Reverse Shoulder Arthroplasty, when can PROM be progressed to 120°? 140°?

Answer 394

120° after 4 weeks, 140° after 6 weeks

Question 395

Following a Reverse Shoulder Arthroplasty, what ROM can patients expect by 4 months post-op?

Answer 395

typically 80°-120° of elevation by 4 months