Shoulder

Question 1

Posterior drawer test/Posterior load and shift test

• Position
• Mistakes with testing

Answer 1

Position: 90 deg abd in scapular plane
Mistakes: testing in coronal plane and direct posterior glide instead of posterolateral motion

Question 2

Testing IR passively

- Position

Answer 2

Coronal plane in supine with posterior translation along coracoid (anterior aspect) and shoulder

Question 3

IR ROM stretching position for high posterior capsule strain

Answer 3

30 deg shoulder elevation in scapular plane (scaption)

Question 4

6 types of synovial joints

Answer 4

1. Pivot 2. Ball and Socket 3. Plane 4. Hinge 5. Condyloid 6. Saddle

Question 5

AC joint ligaments (3)

Answer 5

1. Acromioclavicular 2. Coracoacromial 3. Coracoclavicular (conoid, trapezoid)

Question 6

Glenohumeral ligaments (3)

Answer 6

1. Superior 2. Middle 3. Inferior

Question 7

Pectoral region muscles (4)

Answer 7

Pectoralis major and minor, serratus anterior, subclavius

Question 8

Pec major

A, F, I

Answer 8

Attachment: anterior medial half of clavicle; sternum, costal cartilages of ribs 1-6; anterior layer of rectus sheath; greater tubercle of humerus
Innervation: lateral pectoral n. to clavicular head (C5-7); medial pectoral n. to sternal head (C8, T1)

Question 9

Subcalvius

A, F, I, AS

Answer 9

A: clavicle subclavian groove; origin: first rib
F: depression of clavicle elevation, elevation of 1st rib
I: subclavian n.
AS: thoracoacomial trunk, clavicular branch

Question 10

Serratus Anterior

A, F, I, AS

Answer 10

A: 2nd<>9th ribs (origin) costal aspect of medial margin of scapula (insertion)
F: protracts/stabilizes scapula, assist with upward rotation
I: long thoracic n. (C5-C7)
AS: lateral thoracic a., superior thoracic a. (upper part), thoracodorsal a. (lower part)

Question 11

Upper brachial plexus injury MOIs and presentation

Answer 11

MOIs: 1. birthing traction on neck 2. fall on neck
Presentation: dislocated look of shoulder

Question 12

Lower brachial plexus injury MOIs and presentation

Answer 12

MOIs: 1. hanging from branch/ladder with a fall 2. birthing traction on baby’s arm; claw hand with radial n. finger extension deficit

Question 13

Sections of brachial plexus

Answer 13

Roots, Trunks, Divisions, Cords, Terminal branches

Question 14

Dorsal scapular n.

• root(s)
• innervates

Answer 14

• C5

- Rhomboids and levator scapulae muscles

Question 15

Long thoracic n.

• root(s)
• innervates

Answer 15

• C5-7

- SA muscle

Question 16

Suprascapular n.

• root(s)
• direction/location
• innervates

Answer 16

• C5-6
• passes through scapular notch
• supraspinatus, infrapsinatus, and shoulder joint

Question 17

N. to the subclavius
roots
innervates

Answer 17

• C5-6

- Subclavius and slips to SCJ

Question 18

Median n.
branches in arm? 
muscles innervated (general) 
cutaneous innervation area
entrapment?

Answer 18

No branches in arm
Forearm and hand muscles
cutaneous distribution in hand
Commonly entrapped

Question 19

Upper lesions of brachial plexus 
dx name  
roots involved 
nerves involved
presentation

Answer 19

Dx: Erb-Duchenne Palsy “waiter’s tip”
Roots: C5-6 torn
Nerves affected/involved: suprascapular n., musculocutaneous n., axillary n.
Presentation: atrophy of deltoid and biceps br. and medially rotated (IR) arm

Question 20

Lower brachial plexus injury
dx name
roots involved
nerves involved
presentation (and why)

Answer 20

Dx: Klumpke palsy
Roots: C8, T1 torn
Nerves involved: Median and ulnar n’s.
Claw like hand
- lumbrical muscle and interosseous muscle dysfunction
- forearm extensors and flexors unopposed

Question 21

Winged scapular - peripheral n. damage

- which nerve?

Answer 21

Long thoracic n. => SA inhibition/dysfunction

Question 22

Wrist drop - peripheral n./brachial plexus damage

Answer 22

Radial n. => forearm extensor force production (posterior compartment of forearm)

Question 23

Saturday Night Syndrome - what is it? what nerves/structures involved?

Answer 23

compression injury of brachial plexus with potential axillary artery/vein occlusion => ischemia

Question 24

Pectoralis minor

A, F, I, AS

Answer 24

attachment: 3rd-5th ribs to medial border and superior surface of the coracoid process of the scapula
function: stabilizes scapular - protracts scapular, rib elevation with inspiration
innervation: medial pectoral n. (C8)
arterial supply: pectoral br. of the thoracoacromial tr.

Question 25

Types of ACJ injuries: 6 types including structures involved

Answer 25

1. AC sprain w/o tear. 2. AC ligament and capsule are ruptured 3. Complete AC and CC ligaments ruptures - "step off deformity" 4-6. similar to type 3 with increasing soft tissue trauma and clavicular displacement.

Question 26

Shoulder motions that place increased stress on ACJ

Answer 26

IR behind the back horizontal adduction end-range flexion and extension

Question 27

MOI for ACJ injuries - common types - common activities leading to injury(ies)

Answer 27

direct blow or fall on shoulder w/ adduction football, hockey, skiing, snowboarding, and bicycling **common in football athletes with shoulder injuries

Question 28

Ligaments of the ACJ

Answer 28

Coracoclavicular ligament complex (conoid and trapezoid) and acromioclavicular ligament

Question 29

Acromioclavicular ligament function

Answer 29

stabilization of ACJ in AP plane

Question 30

Coracoclavicular ligament complex (conoid and trapezoid) function + conoid restricts what?

Answer 30

majority of vertical stability | conoid ligament: restricts superior and anterior translation and superior and anterior rotation of the clavicle

Question 31

Motion that places greatest strain on coracoclavicular ligament (conoid and trapezoid)

Answer 31

Shoulder extension

Question 32

Two common/safest surgical interventions for ACJ repair

Answer 32

Tightrope and end button closed loop - both use drilled holes with buttons through coracoid and acromion. - allograft or autograft

Question 33

standard bracing for ACJ repair for how long

Answer 33

Platform bracing for 6-8 weeks

Question 34

Four points of conservative rehabilitation for Type 1-3 ACJ injuries

Answer 34

Short term immobilization Medication for symptom relief Progressive ROM Strengthening

Question 35

``` Frozen shoulder/Adhesive capsulitis: percentage of population affected increased risk populations common age group(s) odds of second shoulder being affected in presence of one side ```

Answer 35

2-5% of population affected 11-38% likelihood with pts with thyroid dz and DM 40-65 years old females more than males increased risk of 2nd shoulder experiencing FS (5-34%, 14% chance of B shoulders at once/same time

Question 36

What is the Rotator Cuff Interval?

Answer 36

RCI = anterior edge of supraspinatus, superior aspect of superior glenohumeral ligament, superolateral border of subscapularis and deep surface of coracohumeral ligament

Question 37

Areas of shoulder to focus on mobilizing with FS/adhesive capsulitis

Answer 37

GH capsuloligamentous complex and rotator cuff interval

Question 38

What are the four stages of FS per Neviaser and Neviaser?

Answer 38

1. Pre-adhesive stage - painful (commonly misdx'd as RC impingement 2. Acute adhesive stage (Freezing) - thickened red synovitis; 3-9 month period; highly painful 3. Fibrotic stage (Frozen) - 12-15 months after onset; significant stiffness, less pain 4. Thawing stage - painless stiffness; remodeling leads to improved motion by 15-24 months

Question 39

Diagnosis of FS

Answer 39

>25% loss of ROM in IR, flexion, and abduction with >50% ER PROM compared to contralateral side or <30 deg ER on affecte side with PROM * most RC impingement won't show the significant ER loss present with FS

Question 40

FS: idiopathic vs primary

Answer 40

Are the same

Question 41

Three types of secondary FS

Answer 41

1. Systemic (i.e. DM, thyroid dz) 2. Extrinsic (i.e. w/ CVA, MI, COPD, CDD, distal extremity failure) 3. Intrinsic (RC tendinopathy, biceps tendinopathy, CJ or GHJ athropathy)

Question 42

What is the irritability level classification?

Answer 42

System used to assess pt pain, assisting with relative grading of present pain (particularly useful for FS monitoring)

Question 43

Dosage of "stretching" for pt's with FS are (2)

Answer 43

1. Stage of FS | 2. Irritability classification

Question 44

What is TERT?

Answer 44

Total end-range time = Frequency x Duration of time at end-range motion

Question 45

When stretching the capsuloligamentous complex, how should it be visualized?

Answer 45

with the circle concept