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the liver, stomach, and pancreas all refer pain to which shoulder?
the myocardium and spleen refer pain to which shoulder?
which shoulder do pancoasts tumors refer to?
kidney inflammation and GI inflammation due to GI bleeds can cause irritation to what?
originating from an organ system or structure different from the structure perceived as causing the pain
originating from a nerve root
function of the shoulder is dependent upon?
- c-spine/c-t junction
- upper thoracic spine
- upper ribs
- core stability
T/F: just because they dont report pain in a specific location it does not mean there is not a dysfunction there.
T/F: the scapulothoracic articulation is a true joint.
what are the synovial joints of the shoulder?
the glenohumeral, coracohumeral ligaments and the labrum are the ____________ for the GH joint.
what are the passive stabilizers of the AC joint?
superior and inferior AC ligaments
which of the shoulder joints has a disc
what is the force couple muscles of the scapula?
what stabilizes the GH joint?
rotator cuff muscles
inhibition or disorganization of activation patterns in scapular stabilizing muscles
what does scapular dyskinesia do to the scapula?
alters the normal motion that should be generated by the force couples
which 2 muscles are susceptible to inhibition secondary to pain in the shoulder as an early non specific response?
what is more important within the force couples than isolated strength of the individual muscles of the scapula?
balancing the muscle activity
55 degrees abduction
30 degrees horiz adduction
this is what position for the GH jt?
which muscle "sucks" the scapula against the thorax?
what are the first two muscles to initiate during shoulder abduction?
at the start of shoulder abduction, does the deltoid have a whole lot of involvement?
at how many degrees of GH motion during shoulder abduction does it take for the scapula to start to rotate?
at what degrees does the head of the humerus start to glide inferiorly?
when does external rotation of the humerus take place during shoulder abduction?
when do the corococlavicular ligaments tighten?
T/F: to reach full elevation, the thoracic spine sidebends. if both arms are raised the spine will extend to accommodate for full elevation
what is the closed packed postion for the GH jt?
full abduction and external rotation
what is the closed packed postion for the SC jt?
what is the closed packed postion for the AC jt?
abduction 90 degrees
what is the capsular pattern for the GH jt?
external rotation, abduction, internal rotation
what is the capsular pattern for the AC and SC joints?
pain at end range
what is the most common injured "nervy" area for the shoulder?
what are the 3 most commonly injured nerves from shoulder injuries?
- radial (in axilla or radial groove)
- axillary nerve
what is the most common cause of shoulder pain in laborers, athletes and people who perform repetitive overhead lifting
shoulder impingement syndrome
what are the 3 most common causes for shoulder impingment syndrome?
- lacking mobility
- improper recruitment or lack of coordination
what are some of the secondary issues to shoulder impingement syndrome?
- RC tears
- labral tears
- bone spurs
what are the three classifications for shoulder impingement?
what type of shoulder impingement has issues with the AHI; between the RC and either the AC , coricoacromial ligament or the coracoid
what type of shoulder impingement is due to underlying instability of the GH joint or scapular dyskinesia?
what type of shoulder impingement is undersurface impingement with posterior pain when the supra and infra get pinched between the humeral head and the posterosuperior glenoid rim in a 90/90 position
the space between the head of the humerus and the acromion?
acromiohumeral interval (AHI)
activation of what muscles promotes increase in the size of the AHI
- teres minor
protracted sapular resting postion
these all have what in common?
they decrease the AHI or increase the AHI pressure
what is the most innervated tissue in the shoulder?
long head of the biceps tendon
what do these structures all have in common?
potentially involved in shoulder impingement
how many stages are there to shoulder impingement?
what stage with shoulder impingement do you typically see edema and hemorrhage?
what stage with shoulder impingement do you typically see fibrosis and tendonitis?
what stage with shoulder impingement do you typically see bone spurs, RT tears and biceps ruptures?
what is the most commonly involved tendon with shoulder impingement?
pain at musculotedninous junction of involved muscle-
painful arc between 80-130 abduction
issues with scapulohumeral rhythm
non capsular pattern of limitation
muscle imbalances that lead to faulty kinematics
these are s/s of what?
what does the hawkins kennedy test for?
shoulder impingement with internal rotation
what makes a neer test positive?
pain with scapular elevation
what has to be addressed with shoulder impingement rehabilitation?
scapular weakness, lack of mobility, and/or instability of the CT junction/t-spine
what are some good exercises for shoulder impingement rehab?
- t-band for RC
- pivot prone
in order for the body to work as a whole you must address
- closed kinetic chains
- core stabilization
- functional movement patterns
what type of protocol do you use for shoulder impingement rehab?
what are the main goals of phase 1 rehab for shoulder impingement?
- avoid provocative movements
- control inflammation and promote healing
- maintain integrity and mobility of soft tissues
- develop support in related regions
what are the main goals for phase 2 of shoulder impingement rehab?
- improve posture
- develop balance in length and strength of shoulder girdle muscles
- develop co-contraction, stabilization, and endurance of scapular/shoulder muscles
- progress shoulder function and total body patterns including core and lE
what are the main goals for phase 3 of shoulder impingement rehab?
- increase musclular endurance
- develop quick motor responses to imposed stresses
- develop function
insufficient subacromial joint space causing pain with overhead activites
stage 2 impingement with nonreversible fibrosis or degenerative spurring
intact or minor tears of RTC, calcific depistis in RC tendons, symptomatic crepitus
unsuccessful conservative management for 3-12 months
these are clinical indicators for what?
surgical intervention for shoulder impingement
the subacromial decompression surgical technique for shoulder impingement is used when there is?
anterior acromioplasty surgical technique for shoulder impingement is used when?
they have a hooked acromion
is the a RC repair surgery with and without compression?
T/F: position and duration of immobilization of shoulder and initiation of progression of exercise varies with surgical approach
how is the shoulder usually postioned after surgery?
adduction and medial rotation with forearm supported in sling with elbow flexed to 90 degrees
do acute RC tears typically occur with the younger or middle aged population?
a pt. presents after a traumatic injury with c/o pain and sudden weakness (passive motion intact, active unable/limited in abduction with weakness in flexion and rotation)
what would you suspect?
acute RC tear
No Hx of trauma, present with vague c/o intermittent shoulder pain that is progressing with s/s of impingement in a 45 y/o male.
what would you suspect was wrong?
chronic RC tear
type of repair
size of tear
location of tear
onset of tissue failure
MD's philosophical approach
the all have what in common?
factors affecting rehab after RC repair
what is the first goal after RC repair?
maintain the integrity of the repair
what are the 2nd and 3rd goals after RC repair?
re-establish FROM and dynamic humeral head control
how long is phase 1 of RTC tears?
`approx 6 weeks
what is the main thing you dont want to do during phase 1 for the first 4 weeks at least of RTC tears?
what is the most flexion PROM for phase 1 of RTC tears?
what is the most ER PROM for phase 1 RTC tears>
what is the most abduction PROM for phase 1 RTC tears?
before a pt. can progress to phase 2 of RTC tears they must have achieved what?
- pain free PROM
- 140 degrees flex
- 40 degrees ER
- 60-80 degrees abduction
during phase 2 of RTC tears when can they progress to AROM?
after full AAROM is achieved
how long is phase 2 of RTC tears?
how long is phase 3 of RTC tears?
when can you start doing joint mobs with RTC tears?
phase 3 with MD approval
when would you being closed kinetic chain exercises with RTC tears?
what are the static stabilizers of the shoulder?
- glenoid concavity and version
- labral height
- glenohumeral ligaments
what are the dynamic stabilizers of the shoulder
- scapulothoracic musculature
- rotator cuff
- proprioceptive and neuromuscular control
what is a failure of compensatory mechanisms regardless of the underlying structure leading to the_____________.
what does AMBRI stand for?
- A: atraumatic
- M: multidirectional
- B: bilateral
- R: rehabilitation
- I: inferior capsular shift
what does TUBS stand for?
- T: traumatic
- U: unilateral
- B: bankart
- S: lesions
what does SLAP stand for?
- S: superior
- L: labrum
- A: anterior
- P: to posterior
what are bankart lesions?
injury to the anterior inferior labrum from anterior dislocation; atraumatic
EMG evidence has shown that pt.'s with MDI have?
- abnormal patterns of muscle activity
- increased hand position errors with proprioceptive testing
- abnormal dnamic humeral head centering
Which is more common, anterior shoulder dislocation or posterior?
what is the combined force that causes the humerus to dislocate posteriorly?
flexion, abduction, and medial rotation; fall on out stretched arm
what is the combine force that causes the humerus to dislocate anteriorly?
extension, laterally rotated, abducted
what lesion is a avulsion of capsule and glenoid labrum off the anterior rim of glenoid due to traumatic anterior dislocation?
what is the lesion that is a compression or impaction fx of postero-lateral aspect of humeral head as result of anterior shoulder instability?
during the max protection phase after anterior dislocation how long is the shoulder immobilized in a sling?
What do you want to avoid during the max protection phase after anterior dislocation of the GH?
avoid the humeral head from moving into the direction of injury
What is indicated during the max protection phase after anterior dislocation of the GH?
- managment of pain and swelling
- grade II jt. mobs
- submax isometrics in sling
- strengthening/ROM of elbow and wrist
When is an anterior dislocation of the GH said to be in the moderate protection phase?
what do you begin working on during the moderate protection phase after anterior GH dislocation?
- increase shoulder mobility
- increase stability and strength of RTC and scapular muscles
What 3 things must an GH anterior dislocation pt. meet before progressing to the min. protection phase?
- full, pain-free ROM
- no palpable tenderness
- continued progression of shoulder strength
what are the functions of the GH labrum?
- increase surface area
- promotes stability
- prevents surface distraction by maintaining negative pressure
The protocol for posterior dislocation of the GH is the same for anterior dislocation except for one thing. What is that one thing?
avoid flexion with adduction and medial rotation
What is "frozen shoulder" lay term for?
Post-op management for anterior/posterior GH dislocation depends mostly on what?
technique and MD protocol
how long is the freezing time frame with adhesive capsulitis?
how long is the frozen time frame with adhesive capsulitis?
how long is the thawing time frame with adhesive capsulitis?
controlling pain and inflammation, and stimulating pain free motion and decrease muscle guarding is indicated during what phase of frozen shoulder?
distention hydroplasty and mobilization is indicated during what phase of frozen shoulder?
normalizing motion, scapular movments and stabilization, jt. mobs, and strengthening are indicated during what phase of frozen shoulder?
How are acromioclavicular (AC) sprains/dislocations graded and how many grades are there?
according to injury; 3
what grade would you give an AC ligament that has partial tearing, jt. tenderness without instability and min loss of function?
what grade would a complete rupture of AC ligaments and partial tear of coracoacromial ligaments with moderate pain and decreased abd/add and there is a palpable gap between acromion and clavicle?
what would you grade a dislocation between acromion and clavicle; AC and coracoclavicular ligaments torn; distal clavicle displaced superiorly; marked pain; severe limitations in ROM
With a grade 1 AC sprain, what do you want to focus on and when can a pt. typically return to work/activity?
focus on symptom relief; 2 weeks
with a grade 2 AC sprain, typically how long is a pt. in a sling?
what is indicated tx with a grade 2 AC sprain?
pain relief and submax isometrics of shoulder girdle muscles
what do you want to avoid with grade 2 AC sprains?
downward displacement of scapula and humeral distraction
With a clavicular fx, what should you avoid until after 4-6 weeks?
active shoulder flexion > 40-50 degrees
what are the four areas in which proximal humeral fx's are classified?
- humeral head
- lesser tuberosity
- greater tuberosity
- humeral shaft
T/F: a pt. with a proximal humeral fx can have radial nerve issues
you receive a POC for a TSA pt. and it says they are are in the max protection phase. What would focus your treatment on?
- maintain mobility of adjacent joints; elbow, hand wrist
- regain shoulder mobility; PROM/AAROM
- minimize muscle atrophy; gentle muscle setting
- scapular stabilization
You have a TSA pt. in the moderate protection phase. What do you focus your treatment on?
- Active control of shoulder while increasing shoulder mobility
- re-establish mobility and control of shoulder motions
- improve strength, endurance & stability of shoulder girdle
What is the earliest a TSA pt. can progress to the min. protection what and what criteria must they meet?
- 6 weeks
- pain free AROM thru functional ranges
- >3/5 strength
What will you focus your treatment on for a pt. in the min. protection phase of TSA?
improve mobility, strength, stability and endurance
what diagnosis is multi-factoral and can involve several different structures and dysfunctions or combinations therof related to the peripheral nerves?
thoracic outlet syndrome
what are the special considerations for TSA?
- rotator cuff integrity
- posture concerns
- immobilization and post op positioning
what are the 2 categories of TOS and what are the 2 subcategories of those?
- vascular: arterial & venous
- Neurogenic: true (obj. findings) disputed (clinical findings)
EAST/Roos, Cyriax Release, and palpation of the plexus are ___________ tests for _____.
You are reading a initial eval for your pt. who has c/o numbness and pain that comes and goes in the RUE. You see the PT screened the cervical spine, upper ribs and T-spine and the shoulder. What was the PT screening for?
regional interdependence with TOS
What are the ways in which you can develop TOS?
- compression of nerves through the brachial plexus
- faulty posture; forward head, thoracic kyphosis
- neural tissue entrapment
what what joint does the elbow extend and flex?
humeroulnar and humeroradial
at what joint does forearm pronation supination happen?
what nerve causes sensory changes in ulnar border of hand?
what nerve causes sensory changes in lateral aspect of forearm to anatomic snuffbox, radial side of dorsum of wrist/hand?
what nerve causes sensory changes in the palmar aspect of digits, dorsal aspect of distal phalanges
medial collateral ligament issue
ulnohumeral joint dysfunction
ulnar nerve irritation or subluxation
these are possible causes for what?
medial elbow pain
olecranon tip fx
posterior impingment (throwers)
these are possible causes for what?
posteromedial elbow pain
ulnohumeral jt. dysfunction
radial head injury
radial nerve/radial tunnel
these are possible causes for what?
lateral elbow pain
dislocation of the elbow
these are possible causes of what?
anterior elbow pain
what is the most common work-related injury of the elbow?
they found sufficient evidence to support that _______________________ have strong association with lateral epicondalgia
repetitive, forceful movements and posture
what are the indicators for poor prognosis with lateral epicondalgia?
- forceful, repetitive movements
- awkward postures
- unskilled or untrained workers
what is lateral epicondalgia most commonly referred to as?
When is where is pain most felt with lateral epicondalgia?
wrist extensor tendons along lateral epicondyle with gripping activities
T/F: lateral epicondalgia is an overuse syndrome.
what is indicated during the protection phase of lateral epicondalgia?
- control pain, edema and spasm
- maintain soft tissue and joint mobility
- maintain integrity of UE function
- posture and proximal stability
what is indicated during the controlled motion/return to function phase of lateral epoconalgia?
- gradually increase flexibility of muscle and create mobile scar
- strengthen muscle and improve muscular endurance
- progress to functional training and conditioning
with laterl epicondalgia you want to focus on __________ phase exercises to gradually increase ___________ to more stress
what is commonly referred to as "golfers elbow"
what is the overuse condition affecting orgin of pronator teres, FCR, flexor digitorum and FCU
what is the acute MOI for MCL sprain?
valgus force or FOOSH
what is the chronic MOI for MCL sprain?
throwers, repetitive valgus
with MCL reconstruction when could you expect to have the brace unlocked, resume light activity and resume full activity?
with medial valgus stress overload when can strengthening and stretching of the shoulder begin?
what do you need to be especially mindful of with fractures near the forearm?
what are the three compartments of the forearm??
- volar (palmar)
- mobile wad
what is defined as critical increase in pressure within an enclosed myofascial space that decreases tissue oxygenation and can cause permanent muscular or nerve damage?
what are the 4 conditions associated with volkmanns?
- arterial injury
what is the hallmark of volkmanns?
pain out of proportion to the injury
Volkmanns treatment indicates avoidance of what?
there are 2 types of supracondylar fractures. what are they?
- type 1: fall on extended, outstretched arm; most common
- type 2: direct trauma to posterior aspect of elbow
how long is a closed reduction distal humerus fx immobilized?
why is the arm immobilized in a flexed position with distal humerus fx?
to allow the triceps to help maintain fx in stable position
Do you want to focus on the contralateral limb during distal humerus fx? why?
yes; central neurilaztion
what are some complications with distal humerus fx?
- joint contracture
- volkmanns ischemic contracture
what are intercondylar "T" and "Y" fx?
fractures occuring between the condyles of the humerus.
what are the 4 types of T & Y fx?
- type 1: nondisplaced; immobilized 3 weeks
- type 2: displaced fx w/o rotation of fragments
- type 3: displaced fx w/ rotational deformity-ORIF
- type 4: severely comminuted fx with sinificant separation btw condyles; ORIF or "bag of bones technique"
what is the bag of bones technique?
compression hoping that gravity pulls it all together and it heels- no forces thru the elbow early on
radial head fractures typically result from?
what is the carrying angle of men
what is the carrying angle of women?
a radial head fracture can lead to increased valgus deformity called?
what are the 4 classifications for radial head fractures?
- type 1: nondisplaced; immobil. 5-7 days up to 4 weeks
- type 2: marginal fx w/ displacement; ORIF or excise radial head
- type 3: comminuted fx of entire radial head; fx area excised
- type 4: any radial head fx w/ dislocation
how do olecranon fx typically occur?
fall on the point of the elbow or forceful contraction of triceps
how is nondisplaced olecranon fx treated?
immobilzation 6-8 weeks
how is a displaced olecranon fx treated?
what is the most common complication of olecranon fx?
decreased elbow extension
how is an olecranon fx immobilized?
a _____ degree flexion contracture is common with olecranon fx/
what does the median nerve innervate in the forearm and where does it pass thru?
flexors and hand intrinsics on thenar side; carpal tunnel at wrist
what does the ulnar nerve innervate in the forearm?
hand intrinics especailly on hypothenar side
what does the radial nerve innervate on the forearm?
elbow, forearm, and extrinisic finger extensors
What are the 4 neurogenic hand pathologies?
- cubital tunnel syndrome
- radial tunnel syndrome
- PIN syndrome
what is sensory loss and motor weakness that occurs when the median nerve is compromised in the carpal tunnel?
carpal tunnel syndrome
what is CTS secondary to?
what types of exercise can you do in the max protection phase after CTS surgery?
- tendon and nerve glides
- Active wrist extension, passive flexion
- active pronate/supinate/deviate
- shoulder and elbow
when does the mod/min phase of rehab after CTS surgery begin?
when do you being strengthening after CTS surgery?
what is described as inflammation of the abductor pollicis longus and extensor pollicis brevis occuring from continued repetive use in ulnar deviation postion?
De Quervain's Tenosynovitis
what is an example of a traumatic TFCC injury?
loaded wrist in pronation;bad hand stand
what is a degenerative injury to the TFCC typically from?
A complex ligament wrist sprain of the wrist can be treated in what two ways?
- rigid cast immobilization for 6-12 weeks
- ORIF immobilized for 2 months then cast for 4 weeks
with a complex sprain to the wrist, after the cast/spint is removed what types of exercise would you begin and when would you progress it?
- AROM in pain-free ranges
- resistance can be added once AROM is increased and pain is decreased
what is a colle's fracture?
what is the most common MOI for colle's fx?
what does rehab begin for a colles fx pt?
immeditely after immobilization
with a colle's fx when can you add resistance?
after bone union; typically 5-8 weeks
what is known as a reversed colles fracture?
T/F: ulnar fractures typically don't happen alone, instead they are typically found with distal radial fx's.
what accounts for 60% of all carpal fx and what is the typical MOI?
how long does it typically take for a scaphoid fx to show on xray and how many views does it usally take for 1 to have a positive?
2 weeks; 6 shots
______________ or ______________ are contraindicated after immobilization of scaphoid until bone union is confirmed.
passive stretching, mobilizations
what is an acute sprain of ulnar collateral ligament of the thumb?
what is the MOI for skiers thumb?
sudden valgus stress and hyperextension
where would you palpate for a scaphoid fx?
a fx of the 2nd, 3rd, 4th, or 5th metacarpal neck is called what?
boxers (fighter) fracture
what is a bennetts fx?
subluxation of 1st proximal metacarpal
what does dupuytrens contractures typically affect?
palmar fasica of hands and feet
what tendon is injured with a mallet finger?
extensor tendon at the DIP joint
what tendon is injured with a boutonniere defromity?
central extensor tendon at the PIP joint
what are some common deformities you might see in the hands of RA patients?
- ulnar drift of MCP's, radial deviated wrist
- bouchards nodes