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KNSS 220 Athletic Therapy > Shoulder > Flashcards

Shoulder Flashcards

(101 cards)

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1
Q

What joint is on top of the shoulder?

A

AC (acromioclavicular) joint

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2
Q

What joint is what we think of as the shoulder?

A

GH (glenohumeral) joint

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3
Q

What is scapulothoracic?

A

scapula and ribs

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4
Q

What is sternoclavicular?

A

clavicle and sternum joint

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5
Q

What are the 4 rotator cuff muscles?

A
  • supraspinatus
  • infraspinatus
  • teres minor muscle
  • subscapularis muscle
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6
Q

What do we look for in shoulder assessment observations?

A
  • forward head
  • rounded shoulders
  • winging scapula
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7
Q

How does forward head affect the shoulder?

A

pressure on nerves in neck, will refer to arm

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8
Q

How does rounded shoulders affect the shoulder?

A

​shortened​ ​muscles​ ​on​ ​front,​ ​elongated​ ​muscles​ ​in​ ​back,​ ​changing how​ ​the​ ​arm​ ​sits

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9
Q

What is winging scapula?

A

scapula sits out from body, not tight to ribcage

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10
Q

Separations are specific to which joint?

A

AC joint

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11
Q

Dislocations are specific to which joint?

A

GH joint

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12
Q

Where does AC joint sprains occur?

A

at very top of shoulder

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13
Q

What is the MOI of AC joint sprains?

A
  • vulnerable in collision sports
  • FOOSH (upwards force on clavicle)
  • ex. bike riders hitting ground, hockey players hitting boards
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14
Q

What are the signs and symptoms of a grade 1 AC joint sprain?

A
  • stretch of ligaments, no tearing

- mild symptoms

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15
Q

What are the signs and symptoms of a grade 2 AC joint sprain?

A
  • some stretch, some tearing
  • moderate symptoms
  • will see laxity with special tests
  • will see some deformity
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16
Q

What are the signs and symptoms of a grade 3 AC joint sprain?

A
  • rupture of all of the main ligaments in that joint
  • not physically attached
  • severe symptoms
  • severe deformity
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17
Q

Grades 4-6 of AC joint sprains involve what?

A

fractures or displacement of the clavicle

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18
Q

What is step deformity?

A
  • as you have less ligaments holding it, the end of the clavicle sneaks up
  • tends to be lifelong
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19
Q

How do we manage 1st and 2nd degree AC joint sprains?

A
  • RICE
  • Modalities​ ​to​ ​calm​ ​down​ ​spasm
  • Strengthen​ ​joint
  • Regain​ ​ROM
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20
Q

How do we manage grades 3+ AC joint sprains?

A
  • Need​ ​to​ ​be​ ​seen​ ​at​ ​the​ ​hospital
  • Check​ ​for​ ​fractures
  • Check​ ​to​ ​see​ ​if​ ​clavicle​ ​is​ ​still​ ​where​ ​it​ ​should​ ​be
  • May​ ​need​ ​surgery​ ​(fracture:​ ​bar​ ​and​ ​pin)
  • Immobilized​ ​in​ ​sling​ ​for​ ​usually​ ​5-6​ ​weeks
  • Start​ ​doing​ ​some​ ​rehab​ ​at​ ​weeks​ ​2-3
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21
Q

What are the special tests for AC joint sprains?

A
  • physically looking for deformity

- cupping and pushing clavicle up and down

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22
Q

What are positive tests for AC joint sprains?

A
  • Pain​ ​is​ ​1st​ ​degree
  • Pain​ ​and​ ​laxity​ ​is​ ​2nd​ ​degree
  • No​ ​pain​ ​and​ ​laxity​ ​is​ ​3rd​ ​degree
  • Grades​ ​4-6​ ​would​ ​not​ ​be​ ​able​ ​to​ ​touch​ ​it
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23
Q

50% of all dislocations occur where?

A

at the shoulder

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24
Q

dislocations =

A
  • sprains and strains
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25
In what direction do GH dislocations occur?
- can occur in any direction - anterior dislocations are most common - can go straight backward (arm gets hit, humerus goes backwards) - can go inferior (arm abducted, hit on top)
26
Dislocations can either...
stay out or move out and come back into place
27
What is the MOI for GH dislocations?
- ​abduction​ ​with​ ​external​ ​rotation | - ​any​ ​large​ ​trauma​ ​to​ ​shoulder
28
What are subluxations?
- partly out of place and coming back in | - usually muscle or ligament stops it from going all the way out
29
Why do GH dislocations need to be seen by a doctor at a hospital?
- Arteries,​ ​veins,​ ​nerves,​ ​don’t​ ​want​ ​secondary​ ​injury - X-rays - Everything​ ​is​ ​sitting​ ​where​ ​it​ ​should
30
What is a complication from GH dislocations?
- Labrum​ ​is​ ​cup​ ​that​ ​sits​ ​inside​ ​shoulder​ ​blade - Common​ ​to​ ​tear​ ​and​ ​have​ ​extra​ ​injury - Makes​ ​rehab​ ​more​ ​complicated
31
What are the signs and symptoms of GH dislocations?
- sulcus deformity - Pain​ ​and​ ​disability - Can​ ​be​ ​physically​ ​stuck​ ​in​ ​the​ ​position - Generally​ ​aching​ ​pain,​ ​not​ ​sharp​ ​pain - Will​ ​have​ ​full​ ​movement​ ​in​ ​through​ ​elbow​ ​and​ ​hand - No​ ​ability​ ​to​ ​move​ ​shoulder - Can​ ​fully​ ​shoulder​ ​shrug​ ​(doesn’t​ ​involve​ ​GH​ ​joint)
32
What is sulcus deformity?
- Deltoid​ ​is​ ​holding​ ​humerus​ ​into​ ​place​ ​(being​ ​hung) - Deltoid​ ​muscle​ ​will​ ​be​ ​very​ ​flat - Will​ ​look​ ​like​ ​they​ ​have​ ​very​ ​little​ ​shoulder​ ​development​ ​on​ ​one​ ​side
33
What is backwards rehab?
scar the joint down
34
Doing too much early in rehab of GH dislocations could result in?
can turn into someone who can pop out shoulder all the time
35
Describe rehab for GH dislocations.
- backwards rehab - Nothing​ ​to​ ​hold​ ​it​ ​back​ ​in​ ​place​ ​(ligaments​ ​and​ ​muscles​ ​are​ ​sprained​ ​and​ ​strained) - Put​ ​in​ ​brace​ ​(big​ ​harness),​ ​left​ ​for​ ​6​ ​weeks,​ ​no​ ​ROM​ ​at​ ​shoulder - Can​ ​start​ ​isometrics​ ​in​ ​that​ ​position - After​ ​6​ ​weeks,​ ​if​ ​it​ ​seems​ ​fused​ ​in​ ​there,​ ​then​ ​we​ ​will​ ​start​ ​ROM - All​ ​ROM​ ​is​ ​to​ ​be​ ​below​ ​90​ ​degrees​ ​(horizontal) - After​ ​3​ ​months​ ​post​ ​injury,​ ​we​ ​add​ ​ROM​ ​above​ ​90​ ​degrees
36
What are the special tests for GH dislocations?
- sulcus test - apprehension position - anterior and posterior drawer
37
What is the sulcus test?
- Flattened​ ​deltoid - Pull​ ​down​ ​on​ ​arm​ ​to​ ​create​ ​more​ ​of​ ​an​ ​effect - Will​ ​see​ ​gap​ ​below​ ​acromion
38
What is apprehension position?
- Full​ ​external​ ​rotation​ ​with​ ​abduction - Will​ ​not​ ​like​ ​their​ ​position - Uncomfortable​ ​and​ ​unstable - Makes​ ​it​ ​feel​ ​like​ ​their​ ​shoulder​ ​is​ ​going​ ​to​ ​pop​ ​out
39
Describe the anterior drawer and what a positive test looks like.
- physically​ ​pulling​ ​humerus​ ​forward,​ ​stressing​ ​ligaments​ ​on​ ​anterior​ ​side of​ ​joint - Laxity:​ ​more​ ​movement​ ​forward - Need​ ​to​ ​make​ ​sure​ ​pecs​ ​are​ ​stronger
40
Describe the posterior drawer and what a positive test looks like.
- Physically​ ​pushing​ ​humerus​ ​backward,​ ​stressing​ ​ligaments​ ​on posterior​ ​side​ ​of​ ​joint - Laxity:​ ​more​ ​movement​ ​backward - Need​ ​to​ ​make​ ​sure​ ​rotator​ ​cuff​ ​muscles​ ​and​ ​triceps​ ​are​ ​stronger
41
What is the most commonly fractured bone in the body, especially in sport?
clavicle
42
What is the MOI for a clavicle fracture?
- FOOSH - direct impact to the side of the body - direct impact to the clavicle itself
43
Which part is the weakest part of the clavicle?
part in bone that changes direction
44
What are the signs and symptoms of a clavicle fracture?
- Inflamed​ ​at​ ​site - Can​ ​be​ ​obvious​ ​deformity - Even​ ​if​ ​it​ ​is​ ​just​ ​a​ ​crack,​ ​there​ ​will​ ​be​ ​a​ ​deformity​ ​(bump) - Point​ ​tender - Lot​ ​of​ ​heat - Lots​ ​of​ ​redness
45
What is a complication from clavicle fractures?
- Blood​ ​vessel​ ​going​ ​to​ ​arm​ ​is​ ​right​ ​underneath - No​ ​feeling​ ​in​ ​fingers​ ​or​ ​pulse​ ​in​ ​arm​ ​=​ ​medical emergency - Lots​ ​of​ ​bruising​ ​from​ ​direct​ ​hit​ ​=​ ​ambulance​ ​(could​ ​have​ ​hit​ ​subclavian​ ​artery)
46
What do we do for people with clavicle fractures immediately?
want​ ​to​ ​support​ ​their​ ​arm​ ​and​ ​tilt​ ​their​ ​head​ ​that​ ​way
47
What do they do with clavicle fractures if the 2 pieces are not connected?
pin
48
pins and plates =
less immobilization
49
no pins and plates =
longer immobilization
50
Describe the management for clavicle fractures.
- 6-8 weeks immobilization | - can follow normal protocol for rehab after immobilization (not like dislocations)
51
What is the special test for clavicle fractures?
- no special test | - will hate horizontal (cross) flexion (adduction)
52
Describe the anatomy of why biceps tendonitis occurs.
- Long​ ​head​ ​tendon​ ​sits​ ​in​ ​grove​ ​on​ ​front​ ​of​ ​shoulder,​ ​white​ ​membrane​ ​overtop - Structural​ ​issue​ ​(grove​ ​not​ ​formed​ ​properly)
53
Biceps tendonitis usually occurs in .....
the long head (in front of shoulder)
54
What is the MOI for biceps tendonitis?
- Overhead​ ​activities​ ​irritate​ ​(back​ ​strokers,​ ​volleyball​ ​players) - Overuse
55
What are the signs and symptoms of biceps tendonitis?
- Pain​ ​locally​ ​at​ ​front​ ​of​ ​shoulder - Long​ ​head​ ​biceps​ ​tendon​ ​is​ ​point​ ​tender - Mild​ ​inflammation​ ​right​ ​at​ ​the​ ​front​ ​of​ ​the​ ​shoulder - Won’t​ ​change​ ​based​ ​on​ ​degree - Crepitis​ ​in​ ​tendon - Tendonitis:​ ​hurts​ ​after​ ​the​ ​sport...​ ​usually​ ​won’t​ ​stop playing - Usually​ ​won’t​ ​come​ ​see​ ​you​ ​until​ ​stage​ ​3​ ​where​ ​it​ affects​ ​their​ ​sport
56
People with biceps tendonitis will have pain with ... but no pain with ....
- pain with ​anything​ ​over​ ​head​ ​(only​ ​in​ ​the​ ​front​ ​of​ ​the​ ​shoulder) - no pain with anything​ ​involved​ ​with​ ​biceps​ ​at​ ​the​ ​elbow​ ​(elbow​ ​flexion)​
57
How do we manage bicep tendonitis?
- Not​ ​likely​ ​for​ ​them​ ​to​ ​stop​ ​doing​ ​whatever​ ​it​ ​is​ ​that​ ​is​ ​causing​ ​the​ ​problem - Ultrasound​ ​to​ ​break​ ​down​ ​scar​ ​tissues - Local - Current​ ​to​ ​calm​ ​down​ ​swelling​ ​and​ ​pain - Laser​ ​to​ ​help​ ​it​ ​heal - Something​ ​to​ ​help​ ​them​ ​during​ ​activity
58
What is the stretch for long head of biceps?
arm​ ​behind,​ ​raised,​ ​roll​ ​shoulder​ ​forward,​ ​burning feeling
59
What is the special test for biceps tendonitis?
speeds test
60
Describe the speeds test.
- Firing​ ​the​ ​long​ ​head​ ​biceps - Arm​ ​straight,​ ​flexed​ ​at​ ​60​ ​degrees​ ​in​ ​front - Resisting​ ​shoulder​ ​flexion​ ​(not​ ​elbow​ ​flexion) - Will​ ​have​ ​pain​ ​local​ ​to​ ​where​ ​the​ ​biceps​ ​tendon​ ​is - Only​ ​pain,​ ​not​ ​laxity - Long​ ​head​ ​biceps​ ​is​ ​tender
61
What is happening anatomically for someone with shoulder impingement?
- Supraspinatus​ ​tendon​ ​and​ ​bursa​ ​and​ ​long​ ​head​ ​of​ ​biceps​ ​tendon​ ​come​ ​in​ ​between acromion​ ​and​ ​head​ ​of​ ​humerus - No​ ​space​ ​for​ ​anything​ ​to​ ​be​ ​inflamed,​ ​one​ ​of​ ​the​ ​tissues​ ​are​ ​damaged​ ​and​ ​inflamed, making​ ​less​ ​space​ ​for​ ​everything​ ​else​ ​in​ ​the​ ​channel
62
How can bone cause shoulder impingement?
- Rounded​ ​shoulders​ ​can​ ​bring​ ​2​ ​bony​ ​surfaces​ ​together - Less​ ​room​ ​for​ ​structures​ ​in​ ​channel
63
We typically see shoulder impingement in people that do lots of _______ activities. Give examples.
- overhead | - ex.​ ​Swimmers,​ ​volleyball​ ​players, painters,​ ​roofers,​ ​siders​ ​etc.
64
What is the tell tale sign for shoulder impingement?
painful arc
65
Describe the painful arc.
- When​ ​they​ ​abduct​ ​their​ ​arm,​ ​from​ ​60​ ​degrees​ ​to​ ​120​ ​degrees,​ ​they​ ​have​ ​pain - No​ ​pain​ ​from​ ​0-60​ ​degrees - No​ ​pain​ ​at​ ​very​ ​top​ ​of​ ​movement - Aching​ ​type​ ​sensation,​ ​not​ ​burn - Generally​ ​will​ ​point​ ​to​ ​glenohumeral​ ​joint
66
What is responsible for the first 30 degrees of shoulder abduction?
supraspinatus
67
How do rotator cuff tendons affect shoulder impingement?
- Rotator​ ​cuff​ ​tendons​ ​attach​ ​onto​ ​humerus - Pull​ ​humerus​ ​into​ ​right​ ​position​ ​so​ ​that​ ​channel​ ​is​ ​big​ ​enough - If​ ​they​ ​are​ ​not​ ​doing​ ​that,​ ​there​ ​is​ ​not​ ​enough​ ​space
68
What are the signs and symptoms of shoulder impingement?
- Can​ ​see​ ​swelling,​ ​heat,​ ​redness:​ ​depends​ ​on​ ​how​ ​bad​ ​it​ ​is,​ ​generally​ ​not​ ​because deltoid​ ​is​ ​overtop - Aggravated​ ​from​ ​doing​ ​more​ ​things​ ​overhead
69
Overuse injury means ...
we probably won't see them until stage 3
70
How does stretching the supraspinatus help relieve symptoms of shoulder impingement?
tight​ ​muscle​ ​=​ ​shortened​ ​=​ ​taking​ ​up​ ​more​ ​space​ ​in​ ​channel
71
How do we manage shoulder impingement?
- stretch supraspinatus - rotator cuff exercises - scapular stabilization exercises - do all modalities locally - ultrasound won't do much - need to solve problem, not numb it
72
Give examples of rotator cuff exercises.
External​ ​rotation:​ ​weight​ ​on​ ​side,​ ​tubing,​ ​cable
73
Give examples of scapular stabilization exercises.
- Pull​ ​scapula​ ​back​ ​and​ ​down,​ ​hold,​ ​release - Lying​ ​on​ ​stomach,​ ​hold​ ​position - Retract​ ​scapula​ ​and​ ​do​ ​Ts,​ ​Ys,​ ​and​ ​Is - 3​ ​sets​ ​of​ ​10 - Slow​ ​steady​ ​movement​ ​and​ ​do​ ​not​ ​release​ ​retraction​ ​or​ ​position​ ​until​ ​the​ ​rep​ ​is done - Rotator​ ​cuff​ ​movement​ ​in​ ​overhead​ ​type​ ​movement
74
What is the special test for shoulder impingement?
neers test
75
Describe the neers test.
- Passive​ ​abduction​ ​above​ ​their​ ​head - Pain​ ​in​ ​middle​ ​of​ ​movement​ ​60-120​ ​degrees - Pain​ ​in​ ​ROM,​ ​no​ ​laxity - Might​ ​physically​ ​be​ ​stuck​ ​if​ ​it​ ​is​ ​really​ ​bad
76
What is the other name for frozen shoulder?
Adhesive​ ​Capsulitis
77
What is happening anatomically for someone with frozen shoulder?
- Capsule​ ​of​ ​shoulder​ ​blade​ ​is​ ​completely​ ​stuck​ ​down - Allows​ ​no​ ​movement - Completely​ ​restricts​ ​ROM​ ​in​ ​shoulder - Generally​ ​happens​ ​in​ ​people​ ​over​ ​the​ ​age​ ​of​ ​45,​ ​but​ ​can​ ​happen​ ​at​ ​any​ ​age - humeral head pulled in
78
What is the MOI for frozen shoulder?
- No​ ​idea​ ​why​ ​this​ ​happens | - No​ ​MOI
79
What is the typical cycle that someone with frozen shoulder will go through?
- 6-6-6 - Worse​ ​for​ ​6​ ​months - Stays​ ​the​ ​same​ ​for​ ​6​ ​months - Gets​ ​better​ ​for​ ​6​ ​months - Regardless​ ​of​ ​what​ ​we​ ​do - No​ ​pain,​ ​physically​ ​cannot​ ​get​ ​their​ ​arm​ ​past​ ​60​ degrees​ ​(passive,​ ​active)
80
How much shoulder movement does someone with frozen shoulder have?
About​ ​60​ ​degrees​ ​of​ ​movement​ ​in​ ​shoulder​ ​in​ ​every​ ​direction
81
What needs to happen anatomically to move the shoulder past 60 degrees?
- Related​ ​to​ ​rhythm​ ​of​ ​movement​ ​in​ ​shoulder​ ​complex - First​ ​60​ ​degrees​ ​is​ ​only​ ​glenohumeral​ ​joint - Past​ ​60​ ​degrees,​ ​shoulder​ ​blade​ ​(scapula)​ ​needs​ ​to​ ​move​ ​as​ ​well - Scapulothoracic​ ​rhythm - 2​ ​to​ ​1​ ​ratio,​ ​shoulder​ ​blade​ ​moves​ ​twice​ ​as​ ​much - Once​ ​at​ ​120​ ​degrees,​ ​clavicle​ ​needs​ ​to​ ​move​ ​up,​ ​rotate​ ​back
82
How do we manage frozen shoulder?
- Calm​ ​down​ ​any​ ​other​ ​muscle​ ​spasms​ ​going​ ​on​ ​in​ ​shoulder​ ​and​ ​neck - Local​ ​treatment - Can​ ​do​ ​all​ ​modalities​ ​but​ ​won’t​ ​make​ ​ROM​ ​of​ ​shoulder​ ​any​ ​better - Just​ ​to​ ​make​ ​them​ ​as​ ​comfortable​ ​as​ ​possible
83
What is the special test for frozen shoulder?
- no special test | - Can’t​ ​get​ ​past​ ​60​ ​degrees​ ​actively​ ​or​ ​passively
84
Where do humeral fractures occur?
- Can​ ​fracture​ ​anywhere​ ​along​ ​humerus - Most​ ​common​ ​in​ ​shaft​ ​or​ ​neck - Generally​ ​in​ ​top​ ​half​ ​of​ ​humerus
85
What is the MOI for humeral fractures?
- MOI:​ ​direct​ ​impact - MOI:​ ​FOOSH - Can​ ​get​ ​this​ ​from​ ​complication​ ​from​ ​dislocation​ ​of​ ​shoulder​ ​or​ ​elbow
86
Why are small humeral fractures hard to see?
- Large​ ​muscle​ ​mass​ ​in​ ​biceps​ ​and​ ​triceps​ ​can​ ​make​ ​small​ ​fractures​ ​hard​ ​to​ ​see - Difficult​ ​to​ ​palpate​ ​humerus - Palpate​ ​humerus​ ​in​ ​between​ ​muscle​ ​mass​ ​on​ ​front​ ​and​ ​back
87
What are the signs and symptoms of humeral fractures?
- Through​ ​and​ ​through​ ​break​ ​=​ ​translation​ ​(not​ ​lined​ ​up) - Muscles​ ​are​ ​strong,​ ​will​ ​pull​ ​bones​ ​out​ ​of​ ​place​ ​if​ ​they​ ​are​ ​apart - Cause​ ​nausea,​ ​feel​ ​physically​ ​ill
88
What are complications that can arise from humeral fractures?
- Top​ ​half​ ​of​ ​humerus:​ ​watch​ ​for​ ​brachial​ ​artery - Nerves​ ​run​ ​close​ ​to​ ​bone​ ​in​ ​upper​ ​half​ ​of​ ​humerus - Any​ ​pins​ ​and​ ​needles,​ ​tingling​ ​or​ ​can’t​ ​find​ ​pulse​ ​=​ ​ambulance - Big​ ​red​ ​bruise​ ​where​ ​brachial​ ​artery​ ​is​ ​=​ ​ambulance
89
How do we manage humeral fractures?
- Stabilize - X​ ​rays - Smaller​ ​breaks​ ​=​ ​cast​ ​(4-6​ ​weeks)​ ​usually​ ​in​ ​90​ ​degree​ ​arm​ ​bend - Because​ ​of​ ​muscle​ ​mass​ ​that​ ​can​ ​pull - Through​ ​and​ ​through​ ​break​ ​=​ ​pinned​ ​or​ ​plated - Bones​ ​solidify​ ​in​ ​first​ ​2-3​ ​weeks
90
Give rehab and exercises in cast after 2-3 weeks for humeral fractures.
- Isometric​ ​exercises - Flexion​ ​and​ ​extension​ ​of​ ​elbow - Flexion​ ​and​ ​extension​ ​of​ ​wrist - Ball​ ​squeezes​ ​(muscles​ ​in​ ​forearm) - No ROM at elbow
91
What is the special test for humeral fractures?
- Palpation - Either​ ​side​ ​(medial​ ​and​ ​lateral)​ ​of​ ​muscle​ ​mass - Ridiculous​ ​amount​ ​of​ ​point​ ​tenderness
92
Biceps generally rupture or strain at the ______ of the muscle.
top
93
Triceps generally rupture or strain at the ______ of the muscle
bottom or top third
94
What are the signs and symptoms of a grade 1 muscle strain?
- Mild​ ​symptoms - Stretching​ ​no​ ​tearing - Full​ ​function - Pain
95
What are the signs and symptoms of a grade 2 muscle strain?
- Tearing - Loss​ ​of​ ​function - Loss​ ​of​ ​strength​ ​(resisted​ ​testing) - bruising
96
What are the signs and symptoms of ruptured biceps or triceps?
- Rupture - Biceps​ ​rupture​ ​at​ ​top,​ ​sit​ ​in​ ​a​ ​ball​ ​at​ ​elbow - Rupturing​ ​biceps:​ ​brachialis​ ​underneath,​ ​will​ ​still​ ​be​ ​able​ ​to​ ​flex - Hear​ ​pop​ ​or​ ​snap - Triceps​ ​rupture​ ​at​ ​either​ ​end
97
Rupture at bottom =
hang
98
Rupture at top =
roll up in a ball
99
How do we manage Muscle​ ​Strains​ ​and​ ​Ruptures​ ​to​ ​Biceps​ ​and​ ​Triceps?
- Decrease​ ​inflammation,​ ​pain - Increase​ ​strength - Ruptures​ ​will​ ​be​ ​surgically​ ​repaired
100
What is the special test for muscle strains and ruptures to the biceps and triceps?
for muscle strength: resisted ROM
101
Describe the resisted ROM test.
- Grade​ ​1:​ ​pain - Grade​ ​2:​ ​pain​ ​and​ ​lack​ ​of​ ​strength - Grade​ ​3:​ ​complete​ ​loss​ ​of​ ​strength

KNSS 220 Athletic Therapy (14 decks)

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