210: Shoulder
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| relationship of humeral head to glenoid | Golf ball on a tee
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| _____ positions of motion are available at the shoulder | 1000's of
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| mobility of the shoulder gives up ____ | stability
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| what structures provide static stability for the shoulder joint? | Joint capsule; Synovial fluid and negative joint pressure; Glenoid labrum deepens fossa
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| what structures provide dynamic stability for the shoulder joint? | Rotator cuff; Deltoid; Long head of biceps brachii
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| ____ and ____ stabilizers must be coordinated | static and dynamic
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| muscles of rotator cuff | supraspinatus, infraspinatus, teres minor, subscap
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| what mm ER the shoulder | teres minor; infraspinatus
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| what mm IR the shoulder | subscap
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| The combined effect of the short rotator muscles (infraspinatus, teres minor, and subscapularis) produces stabilizing _____ and _____ translation of the humerus in the glenoid | compression and downward
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| the head of humerus must glide ____ for the shoulder to flex/ abduct | inferior
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| The supraspinatus muscle has a significant ____, ____ and _____translation effect on the humerus during arm elevation. | stabilizing, compressive, and slight upward
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| supraspinatus functions with the ____ in humeral elevation | deltoid
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| AC joint has a weak ____ | capsule
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| what ligaments reinforce AC joint capsule | Superior and inferior AC jt ligaments
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| what supports the AC ligaments? | coracoclavicular ligament
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| the AC joint slides in the ____ direction the scapula moves | same
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| SC joint | articulation of the medial end of clavicle with sternum, has a disk
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| what ligaments make up the SC joint | SC ligaments and interclavicular and costoclavicular ligaments
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| what causes movement on the SC joint? | scapular movements
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| ____ is an accessory motion in the SC joint | rotation
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| what stabilizes the SC joint | ligaments—no muscles cross joint for dynamic stability
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| motions of the scapula | elevation, depression, protraction, retraction, upward rotation, downward rotation, winging and tipping
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| elevation, depression, protraction, and retraction of scapula are ____ motions of the humerus | component
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| upward/downward rotation of scapula is a _____ motion of the humerus | concurrent
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| winging of scapula | medial borer lifts (horizontal add)
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| when does tipping of the scapula occur? | with internal rotation and extension
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| •MM of scapula function in _____to control scapular position | synchrony
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| Position of scapula important for _____ _____ relationship of scapulo-humeral mm | length-tension
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| scapula is _____ for rotator cuff mm | home base
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| how many degrees of GH motion for every degree of scapular motion | 2
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| how does faulty posture affect the shoulder? | Decreased flexibility in pec minor, scalenes and lev scap; Position of scapula changes position of humerus in glenoid; Internal rotators tight; ER stretch weakness
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| what makes up the coracoacromial arch | Arch is acromion and coracoacromial ligament
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| what is found in the subacromial space under the coracoacromial arch | ▫Sub deltoid bursa, Supraspinatus tendon, Long head of biceps
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| supraspinatus tendon has an attachment into ___ ____ | superior labrum
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| scapular plane | 30˚ anterior of the frontal plane; motion in this plane called scaption
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| benefits of movment in scapular plane | Less tension on the capsule, Greater elevation is possible, Functional position, No IR or ER necessary to prevent greater tubercle impingement
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| The deltoid causes ____ translation of humerus | upward
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| if no force opposes the deltoid, what can it cause | impingement in subacromial space; need rotator cuffs to oppose
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| MM imbalance or timing causes _____ | microtrauma
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| what can cause GH hypomobility? | RA and OA, traumatic arthritis, post immobilization, idiopathic frozen shoulder
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| stage 1 frozen shoulder | Gradual onset of pain that increases with movement and is present at night, Loss of external rotation motion with intact rotator cuff strength is common.
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| duration of frozen shoulder phase 1 | less than 3 months
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| stage 2 of frozen shoulder (freezing) | Intense pain, even at rest, Limited motion from 2-3 wks after onset
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| duration of stage 2 frozen shoulder (freezing) | Acute symptoms may last 10-36 wks
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| stage 3 frozen shoulder (frozen) | Pain with movement, Significant adhesions, Limited GH motion, increased substitutions, Atrophy of RC, deltoid, biceps, triceps
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| duration of stage 3 frozen shoulder (frozen) | 4-12 months
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| stage 4 frozen shoulder (thawing) | No pain and no synovitis, significant capsular restriction
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| duration of stage 4 frozen shoulder (thawing) | ▫Lasts 2 - 24 months
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| frozen shoulder can be ____ _____ with spontaneous recovery BUT, Some patients never regain full motion | self limiting
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| treatment of hypomobility in protection phase | ▫PROM with progression to AAROM, AROM
▫**Must ensure quality motion over quantity**
▫ GH mobs Grade I and II in pain free position
▫Pendulum exercises for joint distraction
▫Isometrics
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| what should exercises should you do after shoulder immobilization to guard against RSD or CRPS | Hand, wrist, elbow exercises
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| treatment of shoulder hypomobility in controlled motion phase | ▫Increase time out of sling
▫Progress ROM up to point of pain
▫Instruct in self assisted ROM techniques
▫Increase joint and soft tissue mobility
▫GH mobs grade III and IV with stretching at end range motion
▫Strengthening to address mm imbalances
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| **Must have adequate____ ROM before stretching OH ** | ER
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| treatment of shoulder hypomobility in return to function phase | ▫Stretching and strengthening exercises progress
▫Aggressive ROM techniques at this stage
▫Functional activities
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| what joint mob may be needed if pt lacks ER? | posterior glide of humerus in ER
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| shoulder manipulatio | pt goes under anesthesia for surgeon to break up adhesions by moving the shoulder
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| when does AC joint arthritic changes often start? | after 3rd decade
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| what causes AC joint arthritic changes | Repetitive use at waist level, Repetitive diagonal extension, add, IR
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| what causes AC joint subluxation or dislocation | Land on top of shoulder, Also termed sprains or separation
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| what can cause hypomobility of the clavicle | faulty posture
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| tx for AC or SC joint dysfunction | •Use of sling
•Cross fiber FM
ROM to shoulder to prevent decreased ROM of GH joint
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| anterior approach total shoulder uses ____ inscision | deltopectoral
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| anterior total shoulder procedure | release of subscap, anterior capsulotomy, exposure of humeral head and debridement of glenoid; may include repair of deficient RC, re-attach subscap, acromioplasty, bone graft
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| TSA rehab precautions | No ER stretching, resisted IR, avoid excess extension
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| shoulder hemi-arthroplasty | Humeral component is prosthesis; No joint capsule
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| what is left relatively intact with shoulder hemi-arthroplasty? | glenoid fossa
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| what needs to heal shoulder hemi-arthroplasty | tuberosities
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| shoulder hemi-arthroplasty precautions | no ER first 6 weeks
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| what TSA procedure takes longer to heal? | shoulder hemi-arthroplasty: bone healing must occur
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| reverse TSA | No joint capsule, no rotator cuff
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| what allows for ER with reverse TSA | posterior fibers of deltoid
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| reverse TSA precautions | Need bone ingrowth into glenoid, no motion for 6 wks.
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| Repair of RC or deficient RC progressed ____; Intact RC progressed more _____ | slowly, rapidly
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| what are ROM goals for shoulder based on? | based on what was available under anesthesia post operatively
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| TSA tx in protection phase | •PROM - AAROM within limitations; No end range stretching; Do not stress anterior capsule
•Have patient face pulley if used
•Modalities for pain control
Maintain mobility of adjacent joints
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| how to avoid stressing anterior capsule after TSA | Towel roll under arm (keeps them out of extension); No horizontal abd or hyper extension; No reaching behind back (towel stretch)
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| when should pt wear sling after TSA | Wear sling in crowded areas/ outside and sleeping. No lifting—waist level only, eating, brushing teeth okay.
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| when does controlled motion phase begin with TSA? | 4-12 weeks
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| how long does controlled motion phase of TSA last? | 12 to 16 weeks or longer
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| TSA tx in controlled motion phase | •90˚ of shoulder elevation, 45˚ of ER; Begin low intensity pain free stretching; Gentle mobilization techniques; Table slides; Door or dowel ER stretch; Towel stretch for IR; Cross body horiz add stretch
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| strengthening for TSA in controlled motion phase | AROM but no anti-gravity abd; Scapular and GH stabilization ex; Progress to dynamic scapular and GH exercises with t-band or light weights below 90˚; Emphasize RC mm; UE UBE
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| scapular and GH stabilization exercises | Alternating isometrics; Rhythmic stabilizations; Submaximal isometrics
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| TSA tx in return to function phase | Full AROM for function is goal (or goal set by surgeon); Pain free strengthening progressed; HEP continues after D/C
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| criteria for return to function phase in TSA | Full PROM or 130-140 ˚shoulder flex, 120˚abd; ER 60˚ in plane of scapula; 4/5 strength for RC and deltoid
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| impingement syndrome can be ____ or ____ | structural or mechanical
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| primary impingement syndrome | Mechanical Wear and Tear against acromion in subacromial space
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| intrinsic factors that can contribute to impingement syndrome | Acromion types I, II and III
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| what type of acromion in impingement can do well with conservative PT | types 1 and 2
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| what type of acromion in impingement likely needs surgery | type 3
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| extrinsic factors that contribute to impingement syndrome | ▫Tight posterior capsule; Poor RC control; Faulty scapulo-thoracic posture; Weak peri-scapular mm; Weak serratus
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| Excessive ____ ____ engagement and ____ ____ is linked to impingement syndrome | upper trap, anterior deltoid
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| what areas do you need to target to help with impingement syndrome | strengthen scapular mm and relax the upper trap, strengthen lower trap, stretch chest mm, thoracic spine exercises
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| upper crossed syndrome | a muscle imbalance pattern located at the head and shoulder regions. It is most often found in individuals who work at a desk or who sit for a majority of the day and continuously exhibit poor posture
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| what mm are overactive/tight in upper crossed syndrome | upper trapezius, levator scapulae, sternocleidomastoid and pectoralis muscles, and reciprocal weakness of the deep cervical flexors, lower trapezius & serratus anterior
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| what will cause pain with supra and infra spinatus tendinitis | OH activity
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| what head of biceps is involved in biceps tendonitis | long head
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| when will biceps tendonitis have pain? | ▫Pain with Speed's test
▫Pain can radiate down into mm belly
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| types of shoulder instabilities | Multi directional, Unidirectional, Dislocation
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| what needs to be strengthened in shoulder instabilities | Need strong dynamic stabilizers (RC and scap stabilizers)
- closed chain ext is good
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| ROM restrictions for TSA with intact rotator cuff 0-4 weeks | no elevation of arm (up to 120 degrees), no ER (up to 30 deg)
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| ROM restrictions for TSA with intact rotator cuff 4-6 weeks | no GH extension past neutral
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| ROM restrictions for TSA with intact rotator cuff 6-12 weeks | combined ADD, IR, and extension allowed
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| revers shoulder arthroplasty precautions/ROM restrictions | *limit for 12 weeks or more*: no GH extension or IR, no combined GH extension, ADD, or IR
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| rotator cuff tears can be ____ or ____ | partial or full thickness
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| what is typically cause of rotator cuff tear? | repetitive microtrauma
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| does rotator cuff always need surgery? | •No surgery if asymptomatic
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| rotator cuff surgery | Repairs can be arthroscopic, mini open, open subacromial decompression performed
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