Week 1: Quiz 2 Information Flashcards
TERT (total end range time) Formula
(explain it)
- Active exercise of involved area - ~ 10 minutes (active metabolic warm-up to heat the tissue structures to increase elasticity)
- Passive exercise – Heat and stretch in appropriate position to target tissue. (First TERT) [Total End Range Time – 3 sets x 20 minutes = 60 minutes/day] (No “bad” pain). Clinical reality – many times start the stretching for 10 minutes because of patient tolerance
- **(Purpose of 1 & 2 is to prepare the tissues by warming them up. The literature demonstrates all tissues have more elasticity when they are warmer – inside and outside warm-ups)**
- Manual therapy interventions: mobilizations, strain-counter-strain, myotherapy, mobs with movement, etc.) (Whatever seems to work best in your hands)
- Exercises to gain dynamic stability of the newly gained PROM (KEY to maintaining PROM)
- Other: TAS,TLS,TBS
- Passive exercise – Cold and stretch in appropriate position to target tissue. (Second TERT). (No “bad” pain). Clinical reality – many times start the stretching for 10 minutes because of patient tolerance. Purpose is to get the tissue that has been heated, stretched, mobilized, and exercised to remain in the elongated state)
- Third TERT-HEP. Using positional stretching, splints, casts, CPMs, etc. to complement the stretching time in the clinic to total 60 minutes per day. (Example: if 20 minutes of stretching performed in clinic, then 40 minutes in third TERT of HEP. Example: if 30 minutes of stretching performed in clinic, then 30 minutes in third TERT of HEP.)
What are Davies Top 10 Shoulder Ex?
- Scaption with thumb up
- Press downs
- Rowing
- Push up with a plus
- Prone ER with horizontal extension
- Flexion
- RTC IR
- RTC ER
- Elbow flexors
- Elbow extensors
Davies Top 10
Scaption with thumb up: What muscles?
Scaption with thumb up (GH and scapulothoracic joints)
- Muscles: elevators
- Upper traps (ST)
- Supraspinatus (GH)
- Anterior deltoid (GH)
- Middle deltoid (GH)
Davies Top 10
Press downs: What muscles?
Press downs (GH and scapulothoracic joints)
- Muscles - depressors
- Lower traps
- Latissimus dorsi
- Teres major
- Pectoralis minor
- Lower fibers of the pectoralis major
- Lower fibers of infraspinatus (GH)
- Teres minor (GH)
- Lower fibers of subscapularis (GH)
Davies Top 10
Rowing: What muscles?
Rowing (scapulothoracic)
- Muscles - retractors
- Rhomboids
- Middle traps
Davies Top 10
Push up with a plus: What muscles?
Push up with a plus (scapulothoracic)
- Muscles - protractors
- Serratus anterior
Davies Top 10
Prone ER with horizontal extension: What muscles?
Prone ER with horizontal extension (GH)
- Muscles (extensors)
- Infraspinatus (GH)
- Teres minor (GH)
- Posterior deltoid (GH)
Davies Top 10
flexion: What muscles?
Flexion (GH)
- Muscles (flexors)
- Anterior deltoid (GH)
- Coracobrachialis (GH)
Davies Top 10
RTC IR: what muscles?
RTC IR (GH)
- Muscles
- Subscapularis (GH)
- Anterior deltoid (GH)s
- Pectoralis major (GH)
- Latissimus dorsi (GH)
- Teres major (GH)
Davies Top 10
RTC ER: what muscles?
RTC ER (GH)
- Muscles
- Infraspinatus
- Teres minor
- Posterior deltoid
Davies top 10
Muscles for
- Elbow flexors
- Elbow extensors
- Elbow flexors
- Muscles: Biceps
- Elbow extensors
- Muscles: Triceps
Davies top 10: Four for Scapulothoracic recommended by Moseley, et al.
- Scaption with thumb up
- Press downs
- Rowing
- Push up with a plus
**Can think of these as addressing the top, bottom, back and front of the scapulothoracic joint.
Davies top 10: Four for GH joint recommended by Townsend, et al.
- Scaption with thumb up (duplicate)
- Press downs (duplicate)
- Prone ER with horizontal extension
- Flexion
**Can think of these as addressing the top, bottom, back and front of the GH joint.
Davies top 10: what are the two exercises for total arm strengthneing?
Elbow flexion / Biceps
Elbow extension / Triceps
30/30/30 Reasons: 30 degrees abduction
- Prevents the ‘wringing out” effect on the supraspinatus tendon with arm in 90 degrees abducted position,
- with a weak subscapularis, infraspinatus, and teres minor (or pain/reflex inhibition) the deltoid overpowers the lower RTC muscles (which cannot create the dynamic caudal glide) and causes a compression on the bursal side of the supraspinatus tendon causing the “wringing out” effect
- Facilitates the blood flow (nutrients, O2, etc) to the tendon to help with the healing process
- WIth the arm in the adducted position, the humeral head compresses on the articular side of the supraspinatus tendon causing the “wringing out” effect
30/30/30 Reasons: 30 degrees Scaption
- Functional arc of motion of the shoulder
- Decreases strain on the anterior capsule to stress shield it
- Pre-stretches the infraspinatus and teres minor on the physiological length-tension curve to increase power.
30/30/30 Reasons: 30 degree diagonal tilt relative to the transverse plane
- The diagonal plane places the muscle fibers (subscapularis, infraspinatus, teres minor) in direct line of force for power production
- Dr. Davies’ pt’s taught him it was a more comfortable position (allows for “freer” GH motion)
- Prevents iatrogenically created stress (injury) to the posterior shoulder
30/30/30 Reasons: reasons for bolster under arm
- Increases the EMG activity of the posterior shoulder muscles (which are weakest muscles in the kinematic chain) (overflow, irradiation, synergistic co-contraction)
- The adducting muscle activity led to statistically significant increase of the subacromial space width in all arm positions
Explain how to progress exercises from the 30/30/30 position
30/30/30 to
shoulder horn at 90/90 to
no shoulder horn at 90/90
Describe Acromion Morphologies
Type 1- flat
Type 2- Slightly Curved
Type 3- Hook
2 questions to ask yourself when you get an impingement patient
What type of impingement? (classification) and
what is the cause? (more important)
What are the three impingement classifications?
What is one-two words that characterize them or underlying cause?
Primary (hypomobility)
Secondary (hypermobility)
Internal (macro or micro instability)
Three reasons for primary impingment
Primary (hypomobility)
- Tendon and bursal thickening
- Subacromial crowding/morphology
- Capsular hypomobility
Three reasons for secondary impingement
Secondary (hypermobility)
- Glenohumeral instability
- Three reasons why unstable:
- Weakness of cuff
- Lose dynamic caudal glide
- Scapular dyskinesis
Explain internal Impingement
Internal (macro or micro instability)
- Articular side of infraspinatus/supraspinatus impinge against post/superior labrum
- Can be microinstability (most common) OR macroinstability
- Find out if they are hypomobile or hypermobile and treat them based on that
what are 11 pain generators for the subacromial space?
- Bursa (Number 1)
- RTC tendon (Number 2)
- LHB (Number 3)
- Periosteum on inferior acromion
- Inferior capsule of AC joint
- Fascia
- Fat
- NV triad
- Synovium on RTC tendons
- Superior capsule
- Synovial lining within capsule
- THL (anterior pain generator)
what are the top 3 pain generators for the subacromial space? (in correct order)
- Bursa (Number 1)
- RTC tendon (Number 2)
- LHB (Number 3)
What is an anterior pain generator?
THL (anterior pain generator)
What does GIRD/ERG stand for?
Stands for Glenohumeral IR deficit, ER gain.
GIRD/ERG
PART B: What population is in commonly seen in?
Seen in children who start throwing sports early, due to an anatomical change in the humerus (“[using] both MRI and CT scans, it is now well documented that the humerus of the throwing arm is more retroverted than the nondominant arm.”)
GIRD/ERG
PART C: What is the total arc of motion?
160*
GIRD/ERG
PART D: What makes GIRD the appropriate diagnosis?
Total arc in one arm must be less than the other arm for GIRD to be the diagnosisTotal arc in one arm must be less than the other arm for GIRD to be the diagnosis
- External Rotation: Stabilize acromion and patient slowly goes down (ER)
- Total ER= 115*
- Internal rotation
- Isolated and composite
- Composite = 70*
- Isolated = when acromion moves ~45*
- Isolated and composite
- Total Arc of Motion
- 160*
Proprioceptive Measurements: 7 positions
7 Positions
- Flexion above 90*
- Flexion below 90*
- Abduction above 90*
- Abduction below 90*
- IR (supine) - only one position
- ER (supine)
- Less than 45*
- More than 45*
DO NOT DO EXTENSION BC IT IS NOT FUNCTIONAL
Proprioceptive Measurements: norm plus standard deviations for men and women
Men- +/- 3 STD= 2 (difference of 5)
Women- +/- 4 STD= 3 (difference of 7)
Proprioceptive Measurements
Instructions for performing test at each angle
Take them to an angle, tell them to concentrate on the angle, let them stay for 5-10 seconds, return to neutral, tell them to match the angle
Proprioceptive Measurements
something you could do to save time
In the clinic, you could do scaption above and below 90* bc that will incorporate flexion and abduction and save time in the clinic
What type of radiograph is used to see the acromion?
Supraspinatus Outlet view
What are the borders of the subacromial space?
Superior: Coracoid, CA ligament, acromion
Inferior: soft tissue on the superior surface of the humeral head
How big is the subacromial space in 0 degrees elevation?
how about at 90 degrees elevation?
11 mm of space (5.7 with elevation due to greater tuberosity)
What is a PASTA lesion?
Partial Articular Supraspinatus Tendon Avulsion
What is a pain generator on the anterior side?
THL- transverse humeral ligament
Which side of the “oreo” is ALWAYS involved in primary impingement?
Bursal side
Which side of the “oreo” is ALWAYS involved in internal impingement?
Internal: articular
Which side(s) of the “oreo” is involved in secondary impingement?
Secondary: bursal and/or articular
Draw and lable the “oreo”
Bursal
Intrinsic
Articular
What is the only special test used to indicate an internal impingement?
Jobe subluxation, relocation test
What motion is the true cause of internal impingement?
Horizontal extension
What types of activities/ motions would irritate a patient’s pain with an internal impingement problem?
Overhead athletes throwing, driving with hand on opposite headrest, reaching into back seat of vehicle
What type of surgery would you do for a type 3 acromion morphology?
SAD (subacromial decompression)
Acromioplasty
Where would a patient point to as their spot of pain if they have internal impingement?
Posterior glenohumeral joint in a specific spot (not generalized to whole shoulder joint)
Davies mentioned inferior sulcus, at posterior shoulder
At 90*90* during ER
posterolateral corner
What position do you MMT in for each muscle for scapulothoracic
(obviously break this question up into like just the ones you do in sitting or just the ones for GH or ST)
Scapulothoracic
- Sitting
- Upper traps and levator scap
- Serratus anterior
- Prone
- Middle trap
- Lower trap
- Rhomboids
What position do you MMT in for each muscle for GH?
(obviously break this question up into like just the ones you do in sitting or just the ones for GH or ST)
Glenohumeral
- Sitting
- Flexion
- Abduction
- Scaption
- Supine
- Horizontal adduction
- Prone
- Extension
- Horizontal Extension
- IR
- ER (use only 2 fingers)
What position do you MMT in for each muscle for GH and scapulothoracic in sitting?
(obviously break this question up into like just the ones you do in sitting or just the ones for GH or ST)
- Scapulothoracic
- Upper traps and levator scap
- Serratus anterior
- Glenohumeral
- Flexion
- Abduction
- Scaption
What position do you MMT in for each muscle for GH and scapulothoracic in Prone?
(obviously break this question up into like just the ones you do in sitting or just the ones for GH or ST)
- Scapulothoracic
- Middle trap
- Lower trap
- Rhomboids
- GH
- Extension
- Horizontal Extension
- IR
- ER (use only 2 fingers)
What position do you MMT in for each muscle for GH and scapulothoracic in Supine?
(obviously break this question up into like just the ones you do in sitting or just the ones for GH or ST)
- GH
- Horizontal adduction
