Shoulder

Question 1

TSA

Answer 1

total shoulder arthroplasty

Question 2

RTSA

Answer 2

reverse total shoudler arthroplasty

Question 3

RCR

Answer 3

rotator cuff repair

Question 4

What is replaced in a TSA?

Answer 4

glenoid and humeral surfaces

Question 5

RCTR

Answer 5

rotator cuff total repair

Question 6

Unconstrained

Answer 6

1. rotator cuff must be intact
2. small, shallow glenoid component
3. allows greatest freedom of motion, not inherent stability

Question 7

Semiconstrainsted

Answer 7

1. larger glenoid component
2. some degree of stability provided
3. rotator cuff may be mildly deficient prior to repair

Question 8

Reverse ball and socket

Answer 8

Small humeral socket that slides on a larger ball shaped glenoid component
Provides some stability with mobility for rotator cuff deficient shoulders that cannot be repaired

Question 9

Constrained

Answer 9

Greatest amount of stability
Fixed fulcrum, ball in socket designs
Rarely used to due high rate of loosening and failure of components

Question 10

TSA vs Hemiarthroplasty…may be accompanied by:

Answer 10

• Rotator cuff repair
• Subscapularis reattachment and lengthening if a contracture is present that significantly limits external rotation
• Capsular tightening for chronic subluxation/dislocation (usually posterior) of GH joint
• Anterior acromioplasty (if hx of impingement syndrome)
• Bone graft of the glenoid

Question 11

Postoperative complications of shoulder replacement

Answer 11

Pulmonary embolism, DVT

Infection

Question 12

Postoperative complications during acute phase of care

Answer 12

Axillary and/or suprascapular nerve damage. . . .
Dislocation
Fracture
Re-tearing a repaired rotator cuff
-suturing was insufficient
-ROM was too aggressive

Question 13

Positioning

Answer 13

Sling for comfort; abduction splint for stability
Elbow flexed to 90; shoulder flexed 10-20 with slight abduction and IR
HOB at 30 degrees

Question 14

Precautions

Answer 14

Absolutely NO end-range stretching; esp. to subscapularis 
NO AROM in antigravity position
NO dynamic shoulder exercises
NO resistance exercises
NO weight bearing on operative UE
NO lifting
NO reaching behind the back

Question 15

Interventions

Answer 15

Mobility of adjacent joints and of whole person!
Patient education of precautions
Splint use/positioning/protection of implant and healing tissues
Postural Rehab!!!!!

Question 16

Shoulder mobility during maximum protective phase

Answer 16

PROM in allowable range; attempt in supine
Pendulum exercises (Codman’s)
Scapular stabilization exercises in NWB position

Question 17

At end of maximum protective phase

Answer 17

Self-assisted ROM (Other hand, wand, resting on table)

Question 18

If rotator cuff was repaired during TSA, how long until AROM and light isometrics?

Answer 18

6 weeks

Question 19

Rehab: hospital to home

Answer 19

Passive external rotation to neutral or to less than 30 degrees

• avoid stress to the anterior capsule
• teach scapular stabilization exercises on the non surgical shoulder; instruct patient to begin these at approx. 4 to 6 weeks post/op

Question 20

Criteria to advance to Moderate Protection/controlled motion phase 6-12 weeks

Answer 20

90 degrees passive elevation
45 degrees of ER
70 degrees of IR in the plane of the scapula with minimum pain; or full, PROM with little to no pain
NO subscapularis tendon pain with resisted, isometric IR

Question 21

Progressing TSA Weeks 12-16 Criteria to progress to Minimum Protection/Return to Functional Activity ;

Answer 21

Full, PROM of the GHJ (based on intraoperative ranges). . .or at least 130-140 degress PROM or AAROM shoulder flexion and 120 degrees of abduction
60 degrees pain free, PROM ER and 70 degrees IR in the plane of the scapula
AROM 100-120 degrees in the plane of the scapula with proper joint stability: NO OVERFIRING OF . . .TRAPS
Strength of rotator cuff and deltoid muscles 4/5

Question 22

Reverse TSA rehab protocol

Answer 22

Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 12
weeks postoperatively.

Question 23

Reverse TSA patients typically dislocate with the arm

Answer 23

in internal rotation and adduction in conjunction with extension.

Question 24

Rotator cuff repair performed when:

Answer 24

Are symptomatic and have functional limitations after a trial of nonoperative treatment (Neer classification stage II and stage III lesions).
Have acute, traumatic rupture of rotator cuff tendons, often combined with other GH joint trauma.
Subacromial decompression; deltoid splitting; deltoid detachment then repair

Question 25

Most commonly torn cuff tendon:

Answer 25

supraspinatus

Question 26

Common elements of rotator cuff repair:

Answer 26

Immediate or early post-op GH joint movement* Control of the rotator cuff for dynamic stability Gradual restoration of strength and muscular endurance

Question 27

How long is rotator cuff repair--maximum protection phase?

Answer 27

3-8 weeks post-op depending if surgery was for small or medium repair vs. large to massive repair

Question 28

When is the moderate protection phase of a rotator cuff repair?

Answer 28

begins 6 to 12 weeks post op | 6 weeks for small tear repair

Question 29

Criteria for moderate protection phase of rotator cuff:

Answer 29

Well healed incision Minimal pain with AAROM of shoulder Progressive improvement in ROM

Question 30

Minimum Protection/Return to Function Phase for Rotator Cuff Repair

Answer 30

usually begins 12 to 16 weeks post-op

Question 31

Criteria for Minimum Protection/Return to Function Phase for Rotator Cuff Repair

Answer 31

Full, pain-free PROM Progressive improvement of shoulder strength and muscular endurance Stable GH joint

Question 32

Common sources of referred pain in the shoulder region

Answer 32

C3-C4 C4-C5 Nerve root C4 Nerve root C5

Question 33

Referred pain from related tissues

Answer 33

``` C4 dermatome C5 dermatome Diaphragm Heart Gallbladder irritation ```

Question 34

Nerve disorders in the shoulder girdle region

Answer 34

Brachial plexus in the thoracic outlet Suprascapular nerve in the suprascapular notch Radial nerve in the axilla

Question 35

Possible nonoperative causes of GH joint hypomobility

Answer 35

Rheumatoid arthritis and osteoarthritis Traumatic arthritis Post immobilization arthritis or stiff shoulder Idiopathic frozen shoulder (adhesive capsulitis)

Question 36

Three phases of frozen shoudler

Answer 36

1. Freezing: 2. Frozen 3. Thawing

Question 37

Freezing shoulder:

Answer 37

intense pain, even at rest, and limitation of motion by 2-3 weeks after onset may last 10-36 weeks

Question 38

Frozen shoulder

Answer 38

pain only with movement, significant adhesions, limited GH motions, substitute motions in scapula Atrophy of deltoid, rotator cuff, bicep and triceps occurs may last 4-12 months

Question 39

Thawing shoulder

Answer 39

No pain and no synovitis, but significant capsular restrictions from adhesions may last 2-24 months, some patients never regain normal ROM

Question 40

GH treatment option goals

Answer 40

-control pain, edema, and joint effusion

Question 41

GH treatment options

Answer 41

``` PROM Passive joint mobilization techniques Pendulum exercises Self-mobilization techniques Manual stretching Self-stretching exercises Ensure correct mechanics with shoulder movements ```

Question 42

Nonoperative causes of AC and SC joint hypomobility

Answer 42

Overuse syndromes Subluxations or dislocations Sustained faulty postures

Question 43

Painful shoulder syndromes

Answer 43

-tendinitis/bursitis -shoulder instability/subluxation Impaired posture Muscle imbalance Decreased thoracic ROM Rotator cuff overuse or fatigue

Question 44

Primary mover in a RTSA

Answer 44

deltoid muscle becomes primary mover of GH joint

Question 45

Primary mover in a TSA?

Answer 45

functioning rotator cuff muscles move GH joint