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Flashcards in Shoulder McGee Deck (65):
1

AMBRI

Atraumatic Multidirectional Bilateral Rehabilitation (as appropriate) and rarely Inferior capsular shift surgery - Not typically recommended for surgery & May be a primary instability factor for Secondary Impingement

2

TUBS

Traumatic Unilateral anterior with a Bankart lesion responding to Surgery

3

Empty can vs full can which is better for testing supraspinatus?

Full Can position tests supraspinatus strength better than Empty Can - Empty can position: strength tends to be limited by pain

4

Rotator Cuff avascular zone

Glenohumeral 0°: poor vascularity to RC tendons & 30-45° Abduction: vascularity to RC tendons optimized

5

Primary Anterior Stabilizers of Glenohumeral Joint

GH 0°: Subscapularis, GH 45°: Subscapularis & Middle Glenohumeral Ligament, GH >90°: Inferior Glenohumeral Ligament & Biceps Brachii

6

Primary mechanism of anterior Glenohumeral dislocation

Trauma; indirect blow with shoulder in abduction, extension, & ER

7

Primary mechanism of posterior Glenohumeral dislocation

Axial loading of arm with shoulder in adduction, flexion, & IR, trauma to front of the shoulder, FOOSH

8

Traumatic dislocations can be associated with what nerve injuries

Axillary

9

Humeral shaft fractures can be associated with what nerve injuries

radial

10

What RTC repair has a slower progression due to weaker fixation of repair

Arthroscopic

11

What RTC repair has a vertical split between anterior and middle deltoid, but allows early initiation of deltoid AROM

Mini-Open

12

What RTC repair has a Deltoid detachment/release from clavicle or acromion, and has no deltoid AROM for 6-8 weeks

Open

13

RTC describe small, medium, and large tears:

5cm (large)

14

Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a small tear

Sling 7-10 days; Full ROM 4-6 weeks, 2-3 wks for isotonic ex

15

Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a medium tear

Sling 2-3 weeks; Full ROM 8-10 weeks, 3-4 weeks for isotonic ex

16

Describe basic guidelines for miniopen repair for RTC for sling, ROM, and istonic exercise for a larger tear

Sling 2-3 weeks; Full ROM 10-14 weeks, 3-4 weeks for isotonic ex

17

Which has a lower reoccurrance rate for instability surgery open or arthoscopic?

Open: standard procedure (recurrence rate <5%) vs Arthroscopic: slower rehab (recurrence rate 8-17%)

18

What type of surgery is used for instability?

Bankart and capsular shift (which spends more time in a immobilizer)

19

What directions can shoulder instability exist?

Ant, post, and multidirectional

20

Describe a Type I SLAP injury:

Degenerative fraying of superior labrum, Biceps attachment intact, Biceps anchor intact

21

Describe a Type I SLAP surgery

Superior labrum is debrided

22

Describe a Type I SLAP rehab

Pendulum after 1 week NO ER > neutral/extension of arm behind body x 4 weeks No stressful biceps activity x 3 months

23

Describe a Type II SLAP injury:

Biceps anchor pulled away from glenoid

24

Describe a Type II SLAP surgery

Lesion repaired with tacks, staples, or suture anchors

25

Describe a Type II SLAP rehab

More conservative than type I - Sling x 3 weeks

26

Describe a Type III SLAP injury:

Bucket-handle tear of superior labrum, Biceps anchor intact

27

Describe a Type III SLAP surgery

Torn fragment is resected

28

Describe a Type III SLAP rehab

Same as Type 1

29

Describe a Type IV SLAP injury:

Similar to Type 3- Tear extends to biceps tendon & Torn biceps tendon and labrum displaced into joint

30

Describe a Type IV SLAP surgery

30% tendon torn Older patient: labrum debrided, tendon tenodesis Young patient: arthroscopic suture repair

31

Describe a Type IV SLAP rehab

More conservative - Sling x 3 weeks

32

AC seperation MOI

Trauma to superior shoulder

33

AC seperation physical exam

Step deformity at AC (possible) (+) AC shear test Tenderness to AC joint Pain with shoulder elevation and/or abduction (+) xray findings

34

AC seperation differential Dx

Chronic conditions can increase stress to RC Concomitant clavicle fracture RC tear

35

AC seperation Tx

varies on grade, typically grade I, II, and usually III do not require surgery - grades higher than III do require surgery

36

Acute Bursitis/Calcific Tendonitis Hx and demographic

Idiopathic; can result from Tendonosis or viral infection Women > men Middle age > older > younger

37

Acute Bursitis/Calcific Tendonitis presentation

Capsular pattern: ER > ABD > IR Joint play restrictions in all directions, especially inferiorly: Histological changes in area of redundant fold Chronic cases can lead to secondary impingement

38

Acute Bursitis/Calcific Tendonitis differential Dx

Impingement Subscapularis spasm/tightness

39

Acute Bursitis/Calcific Tendonitis Tx

Regain motion at GH joint Regain ST rhythm Strengthen Typically self-limiting within 6-12 months Aquatic therapy should be considered

40

Bicipital Tendonitis Hx

Overuse/overtraining Overhead sports with racquet/throwing Pain at anterior shoulder

41

Bicipital Tendonitis presentation

Tenderness along Long Head of Biceps tendon (proximal portion) (+) Speeds test Pain with resisted shoulder flexion (typical); elbow flexion (occasional) (+) Horizontal Adduction with overpressure for symptom reproduction

42

Bicipital Tendonitis differential Dx

Supraspinatus tendonitis Subscapularis tendonitis Impingement

43

Bicipital Tendonitis Tx

Anti-inflammatory & rest Overhead activity modification Posterior capsule stretching Eccentric-specific strength training RC & ST strengthening

44

Neer Stages of Impingement Stage 1

Age: < 25 Pathology: Edema Clinical Presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test, RROM Abd/ER strong + pain

45

Neer Stages of Impingement Stage 2

Age: 25-40 Pathology: Fibrosis, tendonitis/bursitis Clinical presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test RROM Abd/ER strong + pain, Capsular pattern

46

Neer Stages of Impingement Stage 3

Age: >40 Pathology: bone spurs, tendon disruption Clinical presentation: Subacromial pain/tenderness, Painful arc; (+) Neer test RROM Abd/ER weak + pain, Capsular pattern, “Squaring” of acromion (atrophy of deltoid and RC)

47

Neer Stages of Impingement Stage 4

similar to stage 3

48

Describe Primary Impingement

Abnormal mechanical relationship between rotator cuff and coracoacromial arch - Typically a “narrowing” of that arch

49

Primary Impingement Hx

Typically > 40 years old c/o anterior shoulder and upper lateral arm pain unable to sleep on affected side

50

Primary Impingement physical exam

Decreased ROM and strength (secondary to pain) (+) Hawkins-Kennedy & Neer Impingement signs Typically concomitant AC arthrosis exacerbated by: 1. internal rotation 2. abduction >90°

51

Primary Impingement differential Dx

RC tears Calcific tendonitis AC joint arthrosis Glenohumeral instability SLAP lesions Bicepital tendonitis Early adhesive capsulitis Tumors

52

Primary Impingement Tx

Surgical subacromial decompression (acromioplasty)

53

Describe Secondary Impingement

Narrowing of the subacromial space due to glenohumeral or scapulothoracic instability. Attempts by RC to compensate for lack of ligamentous/capsular stabilization results in fatigue of RC and superior migration of humeral head

54

Secondary Impingement Hx

Younger populations Typically participate in overhead sports: combinations of school and community league sports does not allow for “off-season” in pre/adolescent populations reports of “arm going dead”

55

Secondary Impingement physical exam

Glenohumeral instability with (+) apprehension test +) Full can, Empty can tests Scapular dyskinesia, winging, or abnormal motion Tight posterior Glenohumeral capsule

56

Secondary Impingement Tx

Addressing underlying impairment should resolve the problem

57

Posterior (Internal) Impingement: population and Hx

Typically in overhead athletes (tennis players, swimmers, throwers) During ABD+ER (cocking phase) the supraspinatus and infraspinatus muscles get ‘pinched’ at superior/posterior glenoid Occurs on undersurface (instead of bursa side) of RC Typically associated with anterior instability

58

Describe Neer

Maximal passive flexion of arm (overhead) compresses greater tuberosity against anteroinferior acromion

59

Describe Hawkins-Kennedy

Flexion to 90°, max passive IR, compresses supraspinatus against anterior coracoacromial ligament

60

Describe Cross-over

Stabilize superoposterior shoulder and maximally horizontal adduct patient’s arm across their body

61

Describe Painful arc

ROM that is painful, Typically 60-120°

62

Describe Lift-off

Dorsum of hand placed against back pocket, Patient lifts hand away from back, Inability to perform is (+)

63

Describe Drop sign

Passively place arm in 90° elbow flexion and abduction & max ER. Release arm. Inability for patient to maintain position (+)

64

Describe IR Lag

Same position as lift off, only examiner lifts arm away and asks patient to maintain position. (+) inability to maintain

65

Describe ER Lag

Passively place arm in 20° scapular elevation and 90° elbow flexion. Maximally ER. (+) inability to maintain position