Shoulder

Question 1

How far does the scapula rest from the vertebral column?

Answer 1

About 5 cm

Question 2

What ligaments stabilize the AC joint?

Answer 2

1. Conoid- resist clavicular elevation and protraction

2-Trapezoid-Secondary roll of resisting elevation and protraction

Question 3

Grading for humeral translation?

Answer 3

1. Grade 1-Translation of the humeral head With in the gleniod
2. Grade2-Translation of humeral head up over the glenoid rim with spontaneous return on removal of stress
3. Grade 3-Translation of humeral head over the glenoid rim without relocation upon removal of stress

Question 4

What causes intrinsic tension overload?

Answer 4

Heavy, repetitive eccentric forces incurred by the posterior rotator cuff musculature during the deceleration and follow-through phases of overhead sport activities.

Question 5

What causes excessive scapular elevation during arm elevation?

Answer 5

Rotator cuff weakness and force couple in balance.

Question 6

What is the plane of the scapula?(degrees)

Answer 6

1. The joint is angled about 30 to 45° in coronal plane.

2. Puts glenoid foss more anterior.

Question 7

Two types of tests for shoulder instability?

Answer 7

Humoral head translation tests and provocation test.

Question 8

What are compressive force in the shoulder?

Answer 8

1. .42 times body wt
2. Peak forces 85-136 degrees
3. Abrasions to supraspinatus, infraspinatus, and biceps tendon

Question 9

Upper trap/serrated anterior force couple (6)

Answer 9

1. Allows for rotation of the scapula maintaining the glenoid service for optimal positioning
2. Maintain an efficient length tension relationship for deltoid
3. Prevents impingement of the rotator cuff
4. Provide a stable scapular base for recruitment of scapulohumeral muscles
5. Lower trap and serratus anterior are the primary component of upper rotation
6. Patient with impingement have decreased levels of serratus anterior and delayed firing of lower trap

Question 10

What is inferior angle scapular dysfunction?

Answer 10

1. Inferior border of the scapula very prominent
2. Anterior tipping of the scapula in the sagittal plane
3. Rotator cuff impingement

Question 11

What does the inferior glenohumeral ligament restrain?

Answer 11

1. Anterior and posterior band “hammock”
2. Anterior band limits anterior translation in either direction with at 90° abduction
3. During ER and abduction limits anterior translation
4. Posterior band limit post your translation in internal rotation

Question 12

What does the middle Glenohumeral ligament restrain?

Answer 12

1. Restrain anterior translation with arm and mid range abduction 45°
2. Limits external rotation with arm at side.

Question 13

What does the superior glenohumeral ligament restrain?

Answer 13

Restrained inferior translation with arm in adducted position.

Question 14

What will a chronic rotator cuff tear present on shoulder x-ray?(3)

Answer 14

1. Irregularities of the greater tuberosity
2. Sclerosis of the underside of the acromion
3. Elevated to humeral head due to deltoid muscle been unopposed from rotator cuff

Question 15

What is the deltoid/rotator cuff force couple? (2)

Answer 15

1. Vertical force of deltoid is offset by horizontal force of rotator cuff as they act in opposite directions
2. pressure from humeral head into coracoacromial arch increase 60% when rotator cuff is not working.

Question 16

Stage one of RTC primary Impingement according to Neers?(4)

Answer 16

1. Edema and hemorrhage
2. Mechanical irritation of tendon incurred with overhead activities
3. Reversible condition with conservative management
4. Sign-positive impingement sign, painful arch of movement, and varying degrees of muscle weakness.

Question 17

What does soft tissue conditions are seen in shoulder radiographs? (2)

Answer 17

Calcifications and rotator cup tears.

Question 18

Stage three of RTC primary Impingement according to Neers?(4)

Answer 18

1. Bone spurs and tendon ruptures
2. Continue mechanical irritation cause full thickness tears, partial thickness tears, bicep tendon lesions, and bony alterations of acromion
3. Sign-positive impingement sign, painful arch of movement, and varying degrees of muscle weakness.

Question 19

What are the standard imaging series in a shoulder x-ray? (3)

Answer 19

AP (IR/ER), scapular Y, and scullery view

Question 20

Why are CT scans used for shoulders? (4)

Answer 20

1. Complex or subtle fractures
2. Arthritic changes
3. Loose bodies
4. Hill-Sachs and reverse Hill-Sachs lesions

Question 21

What are the two most common labral detachments

encountered clinically?

Answer 21

Bankart lesion and SLAP lesion

Question 22

What is tensile overload of the shoulder?

Answer 22

1. Repetitive eccentric forces by the posterior rotator cuff during the deceleration and follow through phase of overhead sports activity.
2. Pathological changes angiofiblastic hyperplasia-Degenerative process

Question 23

Anterior posterior rotator cuff force couple

Answer 23

1. Subscapularis and Infraspinatus/trees minor work together
2. Create inferior dynamic stability (depressed humeral head)
3. Compresses humeral head in to Gleniod

Question 24

What causes macrotraumatic tendon failure?

Answer 24

1. Single traumatic event per history
2. Full-thickness tears of RTC with bony avulsions of the greater tuberosity can result from single traumatic episodes
3. 30% or more of the tendon must be damaged to produce a substantial reduction in strength.

Question 25

What is normal distance in the subacromial space?

Answer 25

1. 9-10 mm in normal shoulders

Question 26

What would indicate a subluxation or dislocation of shoulder in the x-rays

Answer 26

More than 7 mm to 8 mm of distance between the bottom of the acromion and top of humeral head.

Question 27

Three different types of a acromions?

Answer 27

1. Type I-flat, Type II-curved, Type III hooked | 2. Type III acromion was found in 70% of cadaver shoulder with rotator cuff tears. 3% RTC tears with Type I

Question 28

What is medial border dysfunction?

Answer 28

1. The medial border posteriorly displaced from the thoracic wall 2. Internal rotation of the scapula in the transverse plane 3. Glenohumeral joint instability

Question 29

What does the acromion do?

Answer 29

1. Lever arm for deltoid | 2. Articulates with the clavicle and ACJ

Question 30

What is a calcification in the shoulder?

Answer 30

Calcifications of the supraspinatus is a common condition in which a bloody hemorrhage has coagulated and calcified.

Question 31

What are the 3 force couples of the shoulder?

Answer 31

1. Deltoid/rotator cuff 2. Upper trap/serrated anterior 3. Anterior/posterior rotator cuff

Question 32

What are two functional shoulder tests?

Answer 32

1. Close kinetic chain upper extremity stability test | 2. Functional throwing performance index

Question 33

What is the ER/IR ratio?

Answer 33

1. Objective measure of agonist/antagonist muscular ratios. 2. 66% in healthy adults 3. Shoulder pts and overhead athletes may get gross imbalances 4. Over developed IR

Question 34

Stage two of RTC primary Impingement according to Neers?(4)

Answer 34

1. Fibrosis and tendinitis 2. Mechanical inflammation may include thickening or fibrosis of subacromial bursa 3. typical age 20-40y.o 4. Sign-positive impingement sign, painful arch of movement, and varying degrees of muscle weakness.

Question 35

What does Tightness of the posterior capsule cause? (2)

Answer 35

1. Increase superior migration of the humeral head and shoulder elevation. 2. The humeral head will shift in an anterior-superior direction.

Question 36

What is a force couple?

Answer 36

Two groups of muscles that work together to produce motion and provide joint stability.

Question 37

What ligament are tested in the sulcus test? (2)

Answer 37

Integrity of the superior Glenohumeral ligament and the coracohumeral ligament.

Question 38

What is a Bankart lesion and cause? (3)

Answer 38

1. .Labral detachment-found in as many as 85% of dislocations 2.labral detachment occurs between 2 o’clock and 6 o’clock on a R shoulder and between the 6 o’clock and 10 o’clock positions on a L shoulder 3. anterior-inferior detachment decreases GH joint stability by interrupting the continuity of the glenoid labrum and compromising the GH capsular ligaments.

Question 39

What is primary compressive disease or impingement of the shoulder?

Answer 39

Compression of the rotator cuff tendons between the humeral head and overlying 1/3 of the acromion, coracoacromial ligament, coraciod, or ACJ.

Question 40

What is secondary compression disease?

Answer 40

1. Impingement results from underlying instability of the GH joint. 2. Anterior instability causes biceps and RTC to become impinge

Question 41

Between what vertebrae does the scapula sit?

Answer 41

Superior T2 and inferior T7

Question 42

What is Posterior or “undersurface” impingement?(2)

Answer 42

1. Posterior orientation of the supraspinatus and infraspinatus aligns them such that the undersurfaces of the tendons rub on the posterior-superior glenoid lip and become pinched or compressed between the humeral head and the posterior-superior glenoid rim. 2. 90° of abduction and 90° or more of ER, typically from overhead positions in sport or industrial situations,

Question 43

What are goals for initial non op shoulder impingement rehabilitation? (3)

Answer 43

1. Decrease in pain to allow for initiation of submaximal rotator cuff and scapular exercise, 2. Normalization of capsular relationships through the use of specific mobilization and stretching techniques 3. Early submaximal rotator cuff and scapular resistance training.

Question 44

Clinical prediction rules for full thickness rotator cuff tears?(3)

Answer 44

1. Age > 65 y.o. 2. Weak in ER 3. Night Pain

Question 45

What are subscapularis precautions following surgery?(4)

Answer 45

1. No external rotation past 30° 2. No horizontal abduction 3. No active internal rotation 4. No body weight support for 12 weeks

Question 46

After a reverse total shoulder procedure patient should avoid what? How long?

Answer 46

1. Internal rotation 2. Adducation 3. Extension 4. 12weeks

Question 47

What is the rotator cuff interval? Pathology?(3)

Answer 47

1.Triangular space between- tendons of subscapularis and supraspinatus and the base of the coracoid process. 2. Pathology - rotator interval tear - long head of biceps tendon dislocation - rotator interval changes in adhesive capsulitis

Question 48

What is the quadrilateral space? (4) Contents?(2)

Answer 48

``` Boarders- superior - subscapularis and teres minor inferior - teres major medial - long head of triceps brachii lateral - surgical neck of the humerus ``` contents 1. axillary nerve (C5 nerve root, posterior cord) 2. posterior circumflex humeral artery

Question 49

What are static stabilizers of the shoulder?(5)

Answer 49

1. Glenoid labrum 2. joint capsule 3. glenohumeral ligaments 4. Coracohumeral ligament 5. Coracoacrominal ligament

Question 50

What are active stabilizers of the shoulder?(5)

Answer 50

1. Rotator cuff 2. biceps 3. deltoid 4. pectoralis major 5. latissimus dorsi

Question 51

What does the coracohumeral ligament do?

Answer 51

Resist in inferior translation but only in positions of external rotation.

Question 52

What positions of the shoulder cause subacromial Impingement?(3)

Answer 52

1. Flexion 2. Horizontal Adduction 3. IR during the acceleration and follow through phase of throwing

Question 53

What is a Type I SLAP lesion?

Answer 53

Degneration/fraying of labrum, biceps and labrum attached firmly to glenoid

Question 54

What is a Type II SLAP lesion?

Answer 54

Superior labrum and biceps detached from superior glenoid – most common (Dead arm syndrome)

Question 55

What is a Type III SLAP lesion?

Answer 55

Bucket handle type tear of labrum, intact biceps anchor

Question 56

What is a Type IV SLAP lesion?

Answer 56

Bucket handle tear that splits into the biceps Single traumatic event – compression of superior labrum while subluxation occurs

Question 57

What are examples of the secondary OA?(2)

Answer 57

1. Post traumatic i.e. interaarticular fracture | 2. post surgical i.e. capsulorrhaphy

Question 58

What are examples of inflammatory arthritides?(3)

Answer 58

1. RA 2. Ankylosing Spondylitis 3. Paoriatic Arthritis

Question 59

What are examples of other arthritides?(6)

Answer 59

1. Atraumatic osteonecrosis or AVN 2. Coracosteriod use 3. Alcoholism 4. Gaucher disease 5. Sickle cell disease 6. Irradiation

Question 60

What is the expected average forward elevation for pts with TSH with intact rotator cuff?(2)

Answer 60

Between 117 and 131deg Or between 138 and 145deg

Question 61

Approximately how many pts that have a TSA for RA have a full thickness rotator cuff tear?

Answer 61

24%-30%

Question 62

What is the average forward elevation for patients with TSH due to RA?

Answer 62

Flexion avg 104-119deg

Question 63

In a TSA or HA, due to 3-4 part fracture, are functional outcomes poorer?

Answer 63

1. Tuberosity and prosthetic placement

Question 64

What is the average elevation for PT’s with TSA or HA from acute fracture?

Answer 64

Avg elevation 101deg, ER 18deg,IR L3

Question 65

Risk factors for adhesive capsulitis?(4)

Answer 65

1. Women over age of 40-65yo 2. Previous episode on contralateral arm 3. Diabetes I or II 4. Thyroid disease (hypo or hyper)