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pre-op presentation of a pt who's a candidate for TSA
- loss of shoulder ROM in a capsular pattern
- muscle atrophy
- tightness in subscap/pec minor/lats
- decreased scap mobility
- possible cervical spine ROM restrictions
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pre-op goals for TSA
- pt edu on goals, expectations, precautions
- ROM
- strength
- maximize scap-hum rhythm
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medical indications for TSA
- osteoarthritis
- severe fracture
- osteonecrosis (avascular necrosis)
- rheumatoid arthritis
- post traumatic arthritis
- rotator cuff arthropathy
- failure of conservative management
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contraindications for TSA
- paralysis of deltoid and RC muscles
- active infection
- pt unwilling to participate in rehab post-op
there are other issues that are "considerations" but we can work with these
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which part of the shoulder capsule is leas supported and most lax?
inferior
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primary bursa in the shoulder w any pathology
subacromial
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when does ER kick in with humerus elev, and why?
- at 75 degrees ER occurs
- it prevents compression of greater tubercle against the acromion
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2 "force couples" muscle pairs of the shoulder
- deltoid + supraspinatus
- upper trap + serratus
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in a TSA what's cut, retracted, or released
- cut: clavipectoral fascia
- medial retraction: coracobrachialis, pec minor, short head of biceps
- released: coracoacromial lig, subscap (tendon?) may be divided or released
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when reattaching the subscap tendon, how can you do it to improve an IR contracture?
- attach tendon more medially on prox humerus
- 1cm = 10 degrees ER
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week 1 of phase 1 post op
- max protection phase
- work on transfers
- distal ROM
- pendulums
- cryotherapy
- AA/P ROM FF and ER to neutral
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reasons to work in scapular plane (30 degrees from coronal plane)
- humeral head is centered in glenoid fossa
- optimal length tension rel
- max elevation
- more comfortable for pt
- joint compression/stability
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what position relaxes the subscap?
45 degrees abd
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weeks 2-4 of phase 1 post op TSA
- advance FF in supine
- scap ROM exercises in sidelying
- do sub-max deltion isometrics in neutral (against a wall)
- humeral head control exercises
- ER isometrics
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generic info for phase I of TSA
- cryotherapy
- control edema
- indep HEP
- avoid lifting beyond normal ADLs (nothing heavier than a toothbrus)
- keep ROM w/i MD's limits
- GOAL: get ROM to 120 ff and ER to 30
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TSA phase II weeks 4-10
- restrictions are gradually lifted
- pt should use arm in ADLs
- hydrotherapy
- pulleys
- theraband
- CKC scap stabilizing exercise - wt shifting on a ball or wall
- airdyne/UBE
- GOAL: PROM FF to 150, ER to 45
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what happens at 6 weeks post TSA
- ER/IR isometrics in neutral pos
- AROM FF in supine
- work on IR (use towel or wand)
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phase III TSA wks 10-16
- progress ROM
- normalize scap-hum rhythm up to horizontal
- gentle joint mobs
- isometrics awy from neutral
- rhythmmic stabilization
- "thumbs up" exercise for scaps
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goals in phase III wks 10-16
- FF to 160
- ER to 60
- IR to T12
- MMT to 4/5
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phase IV weeks 16-22
- assess/address remaining deficits in ROM, flexibility, strength
- PNF - initiate supine manual resistance D1 & D2
- return to sport, but not contact sports!
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ultimate ROM goals for TSA
attain approx 2/3 or ROM
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advantage and disadvantages of reverse shoulder arthroplasty
- ad: deltoid has a longer moment arm so it can generate more force
- disad: decreased ROM, increased impingement due to changes of center of rotation
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