Intro/Shoulder

Question 1

Why do most MSK patients come to us for help

Answer 1

Pain

Question 2

How do we begin to help a patient with their pain?

Answer 2

1 Very thorough subjective examination
2 Planning an objective exam
3 Based on info gathered, employ detailed exam with the goal of reproducing your patient’s complaints of pain

Question 3

Why would we not be able reproduce the patients pain (the pain that they are coming to see us for)?

Answer 3

1 They may not have a MSK problem
2 We may be missing something
3 We need to know when it is time to refer them to another physician

Question 4

What gives clues as to if the symptoms are mechanical or inflammatory?

Answer 4

The behavior of symptoms in response to activity and rest

Question 5

For the subjective exam, we establish SIN which is?

Answer 5

S: Severity - severe symptoms make holding a position difficult
I: Irritability - a small amount of activity provokes symptoms, and they last
N: Nature - mechanical vs. inflammatory

Question 6

In order to ensure safety of the patient you must first know ?

Answer 6

Must know how far they can go so that we do not push them too hard

Question 7

MSK is mostly?

Answer 7

Mechanical

Question 8

What are the 5 categories that the subjective exam is divided into?

Answer 8

Kind of disorder
Site and nature of symptoms
Behavior of symptoms
Special questions
History

Question 9

When asking a patient about their pain should you ..
1 keep it general/ vague
2 ask specific questions

and why?

example?

After you establish the disorder you are dealing with, you should ask the patient …?

Answer 9

1 keep it vague

you will get more information if you ask general questions in an open way and let the patient speak

for example: “what brings you in to see us” “what do you think your main problem is”

What is their goal, what would they like to be able to do that they cannot at the time of the evaluation

Question 10

Using a body chart is recommended in order to help find

It is very important to know specifically where the ___ is coming from on the patient

Answer 10

site and nature of symptoms

pain

Question 11

In regards to pain….

1 a constant ache indicates?
2 acute nerve pain is more likely to be?
3 somatic referred pain is more likely to be?
4 chronic nerve pain is more likely to be?
5 catching pains may indicate?

Answer 11

1 inflammation or venous congestion
2 sharp, burning, or shooting
3 deep, dull, and aching
4 aching in quantity
5 fragment in a joint

Question 12

In regards to unvarying or constant pain what should be done

Answer 12

Everything that you as a therapist can do, but if it cannot be treated it may not be a MSK problem so they should be referred

Question 12

You should always aim to establish a patients ___

Answer 12

SIN

Question 13

Mechanical pain symptoms can usually be relieved or eliminated by?

But inflammatory pain in nature cannot always be relieved by? What are characterized by?

When inquiring about a patients pain in regards to rest and intensity what should be asked? (3)

Why does mechanical pain get worse at the end of the day?

Answer 13

A position or movement

Rest, they are characterized by soreness or stiffness lasting longer than 1/2 - 1 hour after a prolonged rest period

What reproduces your pain and can you relieve it? Can you find a comfortable position to sleep in at night? - What makes your pain worse? Is the pain constant?

Overuse during the day

Question 14

Compare and contrast chemical vs mechanical pain

Morning or nocturnal?
When does pain occur?
Does rest relieve it?
Duration of morning stiffness?

Answer 14

Chemical: constant or continuous nocturnal, pain is unaffected by rest, night pain may disturb sleep, morning stiffness lasting longer than 2 hours

Mechanical: intermittent, eased by rest, can sleep without waking from pain, morning stiffness lasting less than a few minutes and relieved with appropriate activity

Question 15

What are a few general health questions that should be asked (special questions category or subjective exam)? (3)

Answer 15

1 How is your general health (heart/lung issues, recent surgeries)?
2 Any recent weight loss (>5% BW in 4 weeks is considered significant)
3 Are you taking any medication (blood thinners, prolonged steroid use, dizziness is a common side effect)

Question 16

For history (category of subjective exam) what should be asked?

We should inquire about if they have been treated for this before and if so ….

Answer 16

When and how did the current episode begin - if it is specific find out the position at the time of injury and the magnitude of force

Ask what worked/what didn’t/ if the treatment was successful, must be very specific

Question 17

Possible cauda equina issues

Answer 17

Bowel or bladder problems
Saddle area tingling
Sexual dysfunction
Severe bilateral sciatic pain

Question 18

Innert vs Contractile tissues

Answer 18

Innert: joint capsules, bursae, ligaments
Contractile: muscle-bone attachments, muscle belly, body of tendon

Question 19

For non contractile tissues AROM, and PROM are painful the ____ direction

Where does pain usually occur

For contractile tissues PROM and AROM are in ____ direction

Answer 19

same

end range

opposite (because it is being stretched)

Question 20

Normal end feels for elbow and knee
bone to bone
capsular

Answer 20

soft
abrupt stop (elbow extension)
abrupt stop (hip rotation)

Question 21

Interpreting resisted testing results:

strong and painless
strong and painful
weak and painless
weak and painful
all painless
all painful

Answer 21

-working nerve or muscle
-working nerve or “minor” muscle problem/tendon
-potential nerve lesion and/or “old” complete muscle rupture (nervous system disorder)
-potential nerve lesion and/or significant muscle tear - gross lesion
-no contractile lesion
-very low threshold or FOS (:

Question 22

physiologic movements
vs
accessory movements

Answer 22

plane movements (external rotation)
vs
2 joints moving on each other (patient cannot do it themselves)

Question 23

most common dislocated major joint in the shoulder

ultimate key to pain free function

where is the greatest bony congruity/ what are the other stabilizers of this joint

Answer 23

glenohumeral joint

functional glenohumeral stability

between 60 and 120 degrees, glenoid labrum, shoulder capsule

Question 24

Compression by the _________ and ________ can help stabilize the humeral head in the absence of a supraspinatus IF the glenoid cavity is intact

Answer 24

infraspinatus and subscapularis

Question 25

What works with serratus to upwardly rotate the scapula What downwardly rotates it

Answer 25

upper middle and lower trapezius pec minor, rhomboids, levator

Question 26

Muscles for internal rotation Muscles for external rotation

Answer 26

- subscap, pec major, latt, teres major - infrasp, teres minor, post delt

Question 26

Does the area of the pain tell us anything

Answer 26

no

Question 27

Proximal stability before

Answer 27

distal mobility

Question 28

GIRD commonly seen in proposed cause of tight posterior capsule/GIRD in throwers

Answer 28

glenohumeral internal rotation deficit overhead athletes repetitive tensile load on capsule with follow through, forces aren't controlled by stabilizers, capsule hypertrophies in response

Question 29

Scapular dyskinesis

Answer 29

the set of abnormal scapular motions and positions

Question 30

SICK Scapula potential test?

Answer 30

Scapular malposition Inferior medial border prominence Coracoid pain and malposition Dyskinesis of scapular movement dropped shoulder

Question 31

Causes of scapular dyskinesis (6)

Answer 31

-lack of protraction (increases deceleration forces on the cuff) -too much protraction (GH capsular tightness, weakness in rotractors) -lack of appropriate acromial elevation (impingement of cuff) -loss of coordinated retraction/protraction -lack of full retraction -unstable scap in general (cervical pain)

Question 32

The 2 categories of shoulder instability AMBRI TUBS

Answer 32

atraumatic multidirectional bilateral rehab indicated traumatic unidirectional bankart injury surgery indicated

Question 33

Adhesive capsulitis/Frozen shoulder stages (3)

Answer 33

- classic loss of ROM in all directions - Freezing: deltoid (eventually severe pain at night) - Frozen: pain primarily at end range only )eventually minimal pain with stiffness) - Thawing: gradual improvement of motion - ^ all progress from 12-18 months (freezing - thawing)

Question 34

TERT

Answer 34

total end range time

Question 35

Resisted tests for scapula (6)

Answer 35

ER at 0 abd Ir at 0 abd Flexion at 90 abd ABD at 90 ABD Scaption at 90 ABD ER/IR at 90/90 position (possibly)

Question 36

Scapular tests (3)

Answer 36

Wall push ups for winging (5-10) Kibler's lateral slide test (3 positions) Scapular assistance test

Question 37

Types of end feels

Answer 37

bone on bone spasm capsular springy block tissue approximation empyt

Question 37

1 Pain before resistance - 2 Pain synchronous with resistance - 3 Resistance before pain -

Answer 37

1 active lesion, extra articular lesion - no stretching 2 capsular feel gentle/moderate stretching (grade 1 or 2) 3 strong stretching (grade 3 or 4)

Question 38

For capsular patterns of the GH joint what are the movements most limited in order which is more restricted anterior or posterior or inferior most important movements

Answer 38

ER>ABD>IR ant>inf>post hand behind back, IR, ER, ABD

Question 39

SAIS impingement syndrom aka causes? The 4 acromial shapes

Answer 39

bursal side impingement 1 acromial shapes 2 humeral head depression 3 scapular rotator/ stabilizer weakness 4 posterior shoulder tightness 5 GH instability 1 flat 2 increased angel 3 curved 4 hooked

Question 40

Can patients do accessory movements?

Answer 40

No, we as PTs do them

Question 41

Reverse capsular pattern

Answer 41

reverse of the normal pattern

Question 42

During abd of the arm where does it hurt the most in a patient with an injury Strategies for impingement patients

Answer 42

When the arm is lifted above 90 degress or shoulder level referring to shoulder impingement syndrome posterior shoulder stretching, scapular stabilization, pec/min/major stretching, levator scap strecth, RTC strengthening, possible biceps

Question 43

During internal impingement what 2 movements occur? What is the cuff pinched between? What is typically limited? The GH joint is inherently _______?

Answer 43

external rotation and abd labrum and greater tuberosity hand behind back, sleeper stretch, and IR/ER unstable

Question 44

laxity vs instability generally laxity vs instability in regards to shoulder

Answer 44

loseness of limb or muscle/ amount of motion you have when a motion turns into a painful condition the ability of the humeral head to be passively translated on the glenoid fossa clinical condition in which unwanted translation of the humeral head comprises the comfort and function of the shoulder

Question 45

Spectrum of instability overhead athletes usually start out in the _____ of the spectrum as they shift to the right there is an increased dependency on the (2) RTC muscles

Answer 45

TUBS (torn loose) ------> AMBRI (born loose) middle RTC, scapular stabilizers subscaplularis, infraspinatus, supraspinatus, teres minor

Question 46

In regards to supraspinatus what is empty can and what does it increase? what does it decrease? what should be used instead of empty can? which exercise is NOT appropriate early on?

Answer 46

thumb facing down as if you are pouring out a can, increases scapular internal rotation and anterior tilting subacromial space full can wall walks

Question 47

Strong depressors in the RTC muscles The 3 functions of the RTC muscles manual test for RTC are only accurate if there is a > __ % deficit

Answer 47

infraspinatus and teres minor (they act together to stabilize the joint) subscapularis dynamic stabilization fine tuner movement 20

Question 48

3 tests for the RTC When adding a new exercise what do you need to know regarding what is safe?

Answer 48

drop arm painful arm pain or weakness with ER when the strength of the surgery is SIGNIFICANTLY greater than the STRESS THE EXERCISE PUTS ON THE REPAIR

Question 49

Mechanisms of injury (what actions does each include and how) ANT sublux/dislocation - POST ^ - MDI (multidirectional shoulder instability) -

Answer 49

- ABD, ER, Horizontal ABD and sometimes ext (tackle) - FLEX, horizontal ADD, IR, direct blow (MVA) - usually born with or trauma with signif INF translation

Question 50

Hill Sachs lesion involves Reverse Hill Sachs lesion With throwers, surgery should be avoided but if it is needed when should it happen? When is surgery desirable?

Answer 50

- posteriolateral fx of the humeral head (associated with ANT dislocations) - ANT fx of the humeral head (less common, seen with posterior dislocations) - 3-6 months of appropriate physical therapy - recurrent instability, end of session, when pt cant afford recurrence bc of job or etc.

Question 51

Bankart repair SLAP tears

Answer 51

surgical technique for repair of recurrent shoulder joint dislocation superior labral anterior posterior

Question 52

Functions of labrum Injuries to the labrum occur during which 2 phases in throwers

Answer 52

increases depth of glenoid by 50%, acts like a seal or gasket cocking phase or acceleration phase or follow through phase

Question 53

Pre-Slap Syndrome and shoulder at risk examples

Answer 53

- complains of tightness in POST shoulder - they cannot get loose - usually GIRD or SICK

Question 54

Nam and Synder Slap Classifications Type 1-4 Type 5,8,&9 Slap classification

Answer 54

Type 1: fraying and edge 2: detached biceps anchor with fraying 3: bucket handle tear 4: splitting of superior labrum that continues into bicep tendon 8: anteroinferior labral detachment (BANKART) 9: posteroinferior labral detachment (POSTERIOR BANKART) 10: Firestone lesion (360 degree detachment)

Question 55

OA is more common in the AC or GH joint? Ways to help AC joint (5) Grading of AC seperation (3)

Answer 55

AC 1. scapular reatractors 2. increase GH, SC, and TH mobility 3. Pec minor/ major stretching 4. stretch post shoulder 5. manual disctractions 1. some widening of the joint 2. rupture of AC ligaments (subluxation) 3. no contact between clavicle and acromion (dislocation)

Question 56

Overuse injury is almost exclusively seen in youth baseball pitchers because of _____ _____ seperation

Answer 56

growth plate

Question 57

X rays are good for seeing ?

Answer 57

Bone issues