Shoulder Flashcards Preview

OCS > Shoulder > Flashcards

Flashcards in Shoulder Deck (129):
1

After a traumatic dislocation, what is the initial strengthening focus for the shoulder? IR, ER, scapular stabilizers?

Scapular stabilizers are first addressed

2

What is the action of the coracoacromial ligament?

prevents superior translation of humerus "roof" for tendons and bursa

3

With undersurface RTC tears, what 2 conditions is this associated with?

tensile loads and GH joint instability

4

Patient has limited ER and inferior translation. What portion of the rotator interval is affected - medial or lateral aspect?

medial aspect

 

lateral aspect - only restrains ER

5

According to Park et al 2005, what 3 test signify...A. Impingment B.) full thicknessRTC tear

A.) Impingement ER weakness, painful arc, H-K + B.) full thicknessRTC tear Drop arm, painful arc, ER weakness

6

You have a patient with shoulder joint pain, weakness in ER, weakness with ABD. What 2 peripheral nerves might you suspect? Where is it being injured at?

Suprascapular nerve – suprascapular notch as infra and supra are both affected

 

Could also be Axillary nerve - deltoid and teres minor - pinched at the peripheral nerve

7

scapular dyskinesia and hypomobility of the posterior capsule are hallmark signs of this impingement.

Secondary impingement

8

Your 36 y.o. patient comes to therapy with a dx of shoulder impingement. Upon examination, she has limited and painful  shoulder flexion and abd. She states the pain is mild rating it 2-4/10 over the past week. She has + Neer's and Hawkin's Kennedy. 

Shoulder ROM is as follows

Active/passive

Shoulder Flexion          105/137 with mild pain with empty end feel due to pain

Shoulder abduction      96/122 with mild pain with empty end feel due to pain

 

What is this patient's primary diagnosis? Based on this dx, where would you stage this patient to classify her?

Impingment

Stage 2 - 25-40 y.o., + impingement signs; AROM < PROM

9

What is the best strengthening exercise for teres minor?

prone extension + ER

10

Where is the location of pain for Undersurface impingement?

Posterior shoulder

11

What exercises showed the greatest EMG activity for supra, infra, and teres? Ortho Secrets

Supra: prone scaption with ER – however an advanced exercise – use caution due to impingment

Infra and Teres Minor: Sidelying ER

12

You patient has adhesive capsulitis with a history of diabetes. Is this primary or secondary Frozen shoulder?

secondary

13

What is the gold standard imaging technique for adhesive capsulitis?

arthrography

14

What views is Hills Sachs seen on XRay?

IR view and stryker views

15

What nerves are affected by an upper trunk injury?

Suprascapular, musculocutaneous, and axillary, parts of median and radial

16

A patient complains of severe shoulder and neck pain with a drooped shoulder following a cervical lymph node resection. What do you suspect is the cause? What muscle(s) are affected?

CN XI - accessory usually SCM is spared and trapezius muscles are affected

17

A patient complains of heaviness in his arm especially during the late cocking phase of throwing. What is this called. What 3 shoulder pathologies would you consider?

Dead arm syndrome 1. anterior shoulder subluxation 2. RTC tear 3. labral tear- SLAP type 2

 

neurological compromise is rare

18

Where is the location of the Bankart lesion?

anteroinferior - R shoulder = 3-6 o'clock

19

What are 2 metabolic disease which are risk factors for adhesive capsulitis?

Diabetes and Hypothyroidism

20

What mobilization increased ER with frozen shoulder?

Shown posterior vs. anterior mobilization was better for improving ER

21

Neer impingement impinges what structures against what?

Biceps and Suprspinatus b/w the greater tubercle and acromion

22

Your patient has a full thickness RTC tear. What type of acromion is associated with this? Type 1, 2, or 3

Type 3 – hooked Others: Type 2 = curved Type 1 = flat

23

What is the most common MOI for posterior GH instability

an axial load with the shoulder in adduction, flexion, and internal rotation

24

What ligament is usually cut with an arthroscopic RTC surgery?

acromial attachment of the coracoacromial ligament

25

What does Yocum test identify?

Pt’s ability to control superior humeral head translation during active arm elevation in a compromised position (arm on opp shoulder and raising up)

26

What is ALSPA?

anterior labroligamentous periosteal sleeve avulsion - accompanies traumatic anterior dislocation

27

In a general sense, discuss the operative mgmt of bank art lesion.

suturing of the anterior capsule and labrum to the anterior glenoid rim

28

In the case of frozen shoulder, is higher grade or lower grade joint mobilizations more effective?

High grade group did better but only a minority reached statistical significance - the difference was small

therefore performing low grade mobilizations can result in significant changes in motion and function

29

Your patient is a 23 year old male who comes to therapy with complaints of anterolateral shoulder pain after doing heavy lifting. You see no signs of scapular dyskinesia. His GH joint mobility is normal to the other side. He has +H-K and Neer. His infraspinatus MMT = 4-/5. 

What Neer Classification is this patient?

Neer Stage 1 - < 25 y.o.; edema hemorrhage

30

What is the type of nerve injury sustained by the axillary nerve during anterior instability?

traction neurapraxia

31

You notice superior scapular elevation during arm elevation. What 2 things could this indicate?

RTC weakness and force couple imbalances

32

Your patient has increased anterior GH joint instability with anterior shoulder pain. He has a positive Neer and H-K. What type of Impingement Type does he have? Primary, Secondary, OR Posterior

Secondary Impingement

33

Patients are typically >40 years old, have decreased ROM and strength, and are unable to sleep on their involved shoulder. What type of impingement?

Primary

34

What are the 4 tests for superior Labral tears?

Obrien’s active compression

Mimori test 90/90 with forearm pronation

Biceps load

ER supination test

35

What is the mobilization utilized to target the rotator cuff interval?

inferior glide with the arm at the side in ER

36

What direction does the conoid ligament resist?

anterior and superior

37

What is the position to isolate the teres minor? What is the name of the test?

Patte Test: 90/90 position

38

Patients are typically >40 years old, have decreased ROM and strength, and are unable to sleep on their involved shoulder. What type of impingement?

Primary

39

What is the strongest ligament of the SC joint?

costoclavicular lig

40

What are the 2 force couples of the shoulder

Deltoid- RTC : Deltoid Infra/teres minor, subscap, supraspinatus Scapular Upward Rotation: UT, LS, Middle and Lower Trap, Serratus

41

You notice inferior angle scapular dysfunction. What is your primary hypothesis?

RTC impingement

42

What is the load shift test?

compressive axial load first to reduce humerus into glenoid then assess anterior/posterior translation of humerus in glenoid has good specificity but only under anesthesia

43

Which manipulation is more effective for frozen shoulder - MUA or translation manipulation

Translation manipulation with inter scalene block

44

What is the stretch position to stretch the posterior/superior capsuloligamentous structures that limits functional IR?

sidelying arm at side inferior glide in ADD and Ext (HBB position)

45

What is the classification of SC injuries?

Type 1: mild sprain Type 2: moderate sprain - subluxation - ligs partially disrupted Type 3: severe sprain - dislocation total disruption of ligaments

46

What does the subluxation/relocation test assess? What injured structure may it be prominent in - Bankart, SLAP type 2, impingement?

Anterior subluxation - anterior instability, secondary GH joint impingement (anterior pain), or internal impingment in posterior pain SLAP Type 2 has be shown to be seen with this test

47

L shoulder has an Bankart tear. Do you classify this as 3-6 OR 6-9 tear?

6-9

48

Your patient is a 23 year old male who comes to therapy with complaints of anterolateral shoulder pain after doing heavy lifting. You see no signs of scapular dyskinesia. His GH joint mobility is normal to the other side. He has +H-K and Neer. His infraspinatus MMT = 4-/5.

What condition does he suffer from? 

Primary imingement

49

What direction does the trapezoid ligament restrain?

horizontal and vertical displacement when the clavicle moves in axial compression toward the acromion

50

If you have weakness in infraspinatus, but full supraspinatus strength, what nerve is affected and where?

Suprscapular nerve at the spine of the scapula

51

What is the evidence for corticosteroid injection vs. PT for frozen shoulder?

greater short term improvement with shot, but no long term differences - however increase adverse reactions

52

Once a patient's shoulder goes past 55 degrees of flexion what is the obligate motion - anterior or posterior of the humeral head?

anterior

 

**extension > 35 - posterior olbigate motion

53

Describe the concave/convex relationship of the SC joint.

elevation of clavicle - convex clavicle on concave sternum protraction/retraction - concave clavicle on convex sternum

54

You patient has scapular winging which is made worse with shoulder abd, but not shoulder flexion. What nerve is affected. What muscles are affected?

Spinal Accessory Nerve: CN XI – trapezius weakness

55

What are the degrees of abd to test the inferior, middle, and superior GH ligs?

0-30: superior 30-60: middle 90: inferior

56

How do you identify calcific tendinitis?

insidious onset of pain that is not relieved by position changes in the acute stages. Pain is typically in the lateral upper arm Forward elevation often exacerbates this condition It is a self-limiting condition that usually resolves within one week of onset

57

A Bankart lesion is a labral detachment at what area?

R shoulder = 2-6 o’clock L shoulder = 6- 10 o’clock

58

You have a patient with winging of the scapula which is increased during forward elevation. What nerve is affected? What muscle is affected

Long thoracic nerve – serratus anterior

59

What part of the brachial plexus is affected by a burner?

burner/Stinger affects the upper trunk of the brachial plexus or C5-6 nerve roots

60

The Patterson 2010 study showed what about immobilization following anterior dislocation?

ER bracing vs. IR bracing may provide clinically important benefit of lower risk of recurrence of dislocation, but the pooled data did not achieve a significant difference

61

A patient is Stage II Neer RTC pathology/impingement. If conservative rx does not help, what is the surgical recommendation?

subacromial decompression

62

What does the Cochrane Review in 2003 say about calcific tendon Rx and modalities?

Cochrane Review 2003: PT for shoulder pain “ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis” **these studies had no comparisons

63

What 2 Xray views show a Hill Sachs lesion?

stryker view or IR

64

What are the outcomes for brisement technique for adhesive capsulitis?

minimal immediate increase in ROM, but then more significant improvement of ROM in the next weeks

brisement = arthrographic distention with saline

65

What is the most common MOI for anterior GH subluxation/dislocation

an indirect trauma with the arm abducted, externally rotated, and extended.

66

Differentiate C5-6 nerve root lesion vs. upper trunk lesion.

Upper trunk lesion spares dorsal scapular nerve to the rhomboids and the long thoracic nerve to the serratus anterior

67

What is the drop sign indicative of?

Infraspinatus insufficiency/attenuation due to weakness – 90/90 position then released and asked to hold

68

For 1st time traumatic anterior dislocations of the shoulder, what had a better outcome, rehab or early surgical stabilization?

in those under 30 - early surgical stabilization

69

Patient with a positive Flip sign. What should you next evaluate?

Serratus anterior and trap force couple

70

What are the tests for impingement in the monograph?

H-K, Neer, coradcoid impingement test (forced IR in sagittal plane), cross arm ADD, Yocum test

71

What is the most common MOI for SLAP?

Sudden downward force on a supinated outstretched arm fall directly on lateral arm

72

Your 36 y.o. patient comes to therapy with a dx of shoulder impingement. Upon examination, she has limited and painful  shoulder flexion and abd. She states the pain is mild rating it 2-4/10 over the past week. She has + Neer's and Hawkin's Kennedy. 

Shoulder ROM is as follows

Active/passive

Shoulder Flexion          165/165 with mild pain

Shoulder abduction      160/160 with mild pain

 

What is this patient's primary diagnosis? Based on this dx, where would you stage this patient to classify her?

 

 

 

 

 

 

Adhesive capsulitis

Stage 1 - pre-adhesive - since the patient does not have acute very painful end range of motion - she is not in Stage 2.

 

73

Your patient receives a corticosteroid injection to treat Adhesive capsulitis pain. When can the patient return back to therapy?

Day 4

74

With the arm abd 90 degrees, what ligament provides posterior stabilization

posterior band of the inferior GH ligament

75

What is Rusack Palsy?

Upper trunk injury affecting the long thoracic nerve

76

What GH joint ligaments are affected the most with Bankart lesion?

anterior band of inferior &amp; middle GH ligaments

77

What is the acronym SICK scapula

Scapular malposition Inferior medial border prominence Coracoid pain dys Kinesia

78

How do you stretch the superior portion of the capsuloligamentous complex?

sidelying hand on hip and push the elbow toward the treatment table - 

79

Why is supine serratus punch not good?

pec major and minor working too much

80

What does the Jerk Test assess?

Posteroinferior labral tear of shoulder

81

A 60 year old female with the diagnosis of right shoulder adhesive capsulitis presents to the your clinic with 2/10 pain, no pain at night, a score of 20 on the DASH, active right shoulder flexion of 110°, and passive right shoulder flexion of 115°. At the present time, which of the following interventions would be the most appropriate based on clinical guidelines?

Low grade mobilization

 Low resistance strengthening

 Moderate stretching

 Basic functional activities

 

 

Low resistance strengthening

based on levels of irritability - patient is mild irritability = low resistance strenghtening

82

A 50 year old female with the diagnosis of right shoulder adhesive capsulitis presents to the your clinic with 6/10 pain, occasional pain at night, a score of 50 on the DASH, active right shoulder flexion of 95°, and passive right shoulder flexion of 100°. At the present time, which of the following interventions would be the most appropriate based on clinical guidelines?

Low grade mobilization

Low resistance strengthening

 Moderate stretching

high grade mobilization

 

Moderate stretching

based on guidelines, patient is moderate irritability = moderate stretching and functional activities

 

 

83

What is the primary restraint for the AC joint?

acromioclavicular ligament

84

What does the H-K assess?

Impingement of supraspinatus against greater tubercle and anterior coracoacromial ligament

85

What does the sulcus test look at? What ligaments are stressed?

MDI of the GH joint; superior GH ligament &amp; corcohumeral ligament

86

Your patient states she has only 2-3/10 pain and gross stiffness in her shoulder such that she cannot reach behind her back or over her head. You suspect Adhesive capsulitis. What stage is she in?

Stage 3 -Frozen stage

87

What does HAGL stand for?

avulsion of the "humeral attachment of the GH ligament" - analogous to Bankart lesion (avulsion of glenoid of the GH ligament)

88

What has been shown regarding immobilization vs. non immobilization for traumatic anterior dislocation

No difference with recurrence rates b/w the 2

89

What 2 scapular movements are diminished with RTC impingement?

diminished scapular movement in 1. posterior tilting and 2. superior translation

90

Where in the ROM of motion are the GH joint ligaments most lax?

Mid range - the RTC contributes most to stability of GH joint; at end range, the GH ligaments contribute more to stability

91

Which part of the supraspinatus tendon acts as the primary contractile unit - anterior or posterior?

anterior

92

What would be a treatment with a patient experiencing posterior shoulder impingement?

Eccentric strengthening of subscap

93

What is the gold standard imaging technique for RTC tear

single contrast arthrogram

94

Which conditions respond to positional changes? Deltoid tendinitis, calcific tendinitis, impingement

deltoid tendinitis and impingement syndrome **calcific tendinits - does not respond to positional changes (pillows)

95

When doing pulleys for flexion, should the elbows be straight or flexed ?

straight - this allows for obligatory humeral IR to occur

96

What are the Neer Stages of Primary Imingement?

Stage 1: edema/hemorrhage – young, atheltes + imingement sign painful arc of movement muscle weakness Stage 2: Fibrosis and tendonitis 25-40 y.o.; thickening/fibrosis of the subacromial bursae Stage 3: bone spurs and tendon rupture 40 years of age MMT of ABD and ER is typically weak with pain often a “squaring” of the acromion (associated with deltoid and RC atrophy) has RTC tear usually Stage 4: cuff tear arthropathy > 60 – progressive disability with torn cuff

97

What is a bigger subscap exercise IR at 90 deg abd or at 0 deg?

90 deg abd - patient has too much pec major activation at 0

98

Describe the grading system for assessing Humeral Head translation test

Grade 1: within the glenoid Grade II: Translation up and over the rim with spontaneous return on removal of stress – indicates laxity; Not necessarily instability Grade III: translation over rim without return

99

If conservative mgmt fails with an atraumatic multidirectional instability patient, what is the surgical choice?

inferior capsular shift

100

If there is increase in retrotorsion of the glenoid or humerus, what condition is the patient more susceptible to?

posterior instability

101

What tendons get pinched with Undersurface or Posterior Impingement?

Supra and Infra

102

You have a patient who has acute discomfort and very painful end ranges . What stage of adhesive capsulitis is this patient in?

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

Stage 2 - freezing stage

103

A 52 year old female with the diagnosis of right shoulder adhesive capsulitis presents to the your clinic with 8/10 pain, fairly consistent pain at night, a score of 90 on the DASH, active right shoulder flexion of 40°, and passive right shoulder flexion of 52°. At the present time, which of the following interventions would be the most appropriate?

Low grade mobilization

 Low resistance strengthening

 Moderate stretching

 Basic functional activities

low grade mobilization - higher irritability

 

104

Which full thickness tear, U shaped or crescent, does not usually retract far from the greater tuberosity?

Crescent shaped tears

105

A patient with limited functional IR has tightness in what part of the capsule?

superior capsular structures and of course posterior

106

If the glenoid is more superiorly inclined, what is the patient more susceptible for?

RTC tear

107

Which ligament of the AC joint -AC lig or CC lig- is responsible for A. horizontal displacement B. vertical displacement?

horizontal = AC lig vertical = CC lig

108

What is Sprengl's deformity?

lack of scapular descent in a developing child (high riding scapula)

109

You observe medial border scapular dysfunction. What is your primary hypothesis?

GH joint instability

110

What is the strength ratio for... IR:ER ADD:ABD Flex:Ext

IR:ER: 3:2 ADD:ABD: 2:1 Flex:Ext: 4:5

111

What is the O, I, and action of subclavius?

O: 1st rib I: Clavicle Innervation: nerve to subclavius from superior trunk A: stabilizes sternoclavicular joint during strenuous activity

112

What are the 3 findings on MRI which indicate adhesive capsulitis?

1. thickening of coracohumeral lig 2. thickening of rotator interval > 7 mm 3. obliteration of the fat triangle b/w the GH ligament and coracoid process

113

What is the position for infraspinatus MMT?

45 deg of IR resisting ER

114

You decide the patient has secondary RTC impingement due to an underlying GH joint laxity. Which of the following would NOT confirm your hypothesis?

A bone scans demonstrate increased uptake in the supraspinatus tendon insertion into the superior facet of the greater tuberosity of the humerus

B. CT scans are normal

C. XRay demonstrates AC degenerative joint disease

D. T2 MRI deomsntates increased signal in the supraspinatus tendon

C. XRay demonstrates AC degenerative joint disease

115

What areas of the glenoid are affected with posterior impingmenet?

postero-superior glenoid rim

116

With a throwing athlete, what is the most important isokinetic strength testing assessment?

ecc ER and concentric IR

117

Your patient has limited GH IR ROM. You suspect GH joint hypomobility. What is the test called to assess for this?

Posterior load & shift or posterior drawer test

arm abd 90 with 30 deg anterior to coronal plane - apply posterolateral pressure

 

If patient has a grade II (goes over the rim) mobilization is not indicated 

incorrect in performing posterior or arm only in coronal plane - false positive

118

What are 3 structural reasons for lack of IR GH ROM

1. Humeral retroversion

2. tightness in posterior RTC

3. Posterior capsule tightness

119

What did Reinold show regarding the effects of throwing/pitching on GH IR ROM for professional athletes 

an acute episode of throwing led to muscle-tendinous adaptations from the eccentric loading causing IR limitations

120

What is the obligate movement of the humeral head during IR stretching?

Anterior or posterior?

Obligate = anterior

121

Manually stretching the posterior capsule, which position has been shown to be effective?

30 deg elevation in scapular plane with IR

122

What are the 4 Jobe Isotonic exercises suggested in the monograph?

Sidelying ER

Prone shoulder ext with the arm held in ER (thumb out)

Prone T - thumb up

90/90 ER

123

What are the reasons for the towel roll for ER strengthening?

1. increases infra activity by 10%

2. prevents wringing out of the supraspinatus (enhanced blood flow)

3. add isometric into the towel creates opening of the subacromial space

124

What does the research show regarding deltoid vs. infra strengthening with ER isotonics?

use of lower intensity strengthening 40% max effort optimized effort of the cuff and de-emphasized the deltoid while 70% max effort turned on the deltoid more

125

What is the normal ER/IR ratio?

66%

126

What is the difference b/w laxity and instability?

Instability is excessive SYMPTOMATIC trnaslation of the humeral head relative to the glenoid

127

What motion loss is the hallmark sign of frozen shoulder?

< 30 deg passive ER at side OR > 50% loss of passive motion into ER

128

What was shown in frozen shoulder study when comparing patients who performed exercises not to exceed the pain threshold and those who performed exercises up to and beyond the pain threshold?

both groups had significant improvements - the pain free group achieved a Constant score of >80% compared to only 63% in the other group

129

What is TERT

Total end range time - amount of time the joint is held at or near end range position

multiply the frequency and duration of time spent at the end range