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How much AP translation of the GH joint?
4mm
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How much sup-inf traslation of the GH joint?
0.5-3mm
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What is the primary restraint to AP clavicular translation at the SC joint?
Posterior capsular ligament
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What is normal ROM of the SC joint?
- Elevation - 45
- Depression - 10
- Protraction - 30
- Retraction - 30
- Rotation - 15-40
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At what amount of GH range does SC movement primarily occur?
Below 90-10 deg
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What is the primary restraint to posterior translation at the AC joint?
Superior & inferior capsular lig
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What AC joint motion does the conoid lig resist?
Clavicular elevation, protraction, superior and anterior displacement.
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What AC joint motion does the trapezoid lig resist?
Compression, and is also a secondary restrain to elevation and protraction.
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What are the 4 scapulothoracis exercises recommended?
- 1. Scaption with thumb up
- 2. Press down
- 3. Push-up with pluss
- 4. Retraction
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What are the 4 glenohumeral exercises recommended?
- 1. Scaption with thumb up
- 2. Press down
- 3. Flexion with thmb up (to 90deg)
- 4. Prone ER with horizontal extension (prone horizontal abd with ER)
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What is the normal ration of IR:ER and what is it in a posterior dominant shoulder?
- Normal = 66%
- Posterior dominant shoulder = 76%
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List the cluster of signs for impingement.
- Lateral pain
- Pain with overhead lifting/painful arc
- Pain at night
- Compensatory shrug
- >40 yo
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List the cluster of signs for full-thickness tear of rotator cuff.
- Macrotrauma
- Functional disability
- Pain: lateral; dull, constant ache; night; awakens
- Compensatory shrug
- >40 yo
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Describe the treatment of a stage 1 rotator cuff.
Inflammation, edema, hemorrhage (pt usually < 25 yo
- Anti-inflam techniques (ice, phono, HVE, NSAIDs, ionto)
- Joint mobiliztions: posterior and inferior as capsular tightness dictates
- Dynamic stabilization drills
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Describe the treatment of a stage 2 rotator cuff.
Lesion progresses to fibrosis and RC tendonitis ( pt usually <25-40 yo)
- Use healing treatments (MHP, cont US, transverse friction)
- Exerisse: eccentrics, dynamic stabilization
- Joint mobs: posterior and inferior as capsulra tightness dictates
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Describe the treatment of a stage 3 rotator cuff.
Formation of bone spurs, tendon failure (pt usually >40 yo)
- Healing treatments (MHP, Cont US, transverse friction massage)
- Exercise: eccentrics, dynamic stabilization
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List considerations of an arthroscopic rotator cuff repair.
- usually single-row fixation which leads to reduced fixation strength
- Less pain & stiffness
- Rehab more cautiosly
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List considerations of an open rotator cuff repair.
- Double-row fixation - usually stronger
- More pain
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List considerations of an arthroscopic with double row fixation rotator cuff repair.
- Evolving
- May allow for more progressive rehab
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What is important about early rotator cuff repairs?
Early repairs have greater stiffness post op - progressed more quickly
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What is important about later rotator cuff repairs?
have less inflammation - progressed more conservatively
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List the cluster signs of biceps involvement.
- Tenderness over intertubercular sulcus - most common symptom
- Pain moves laterally with ER
- Pain will radiate into muscle belly
- MOI: eccentric deceleration activities
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What are the three typs of biceps involvement?
- Inflammation
- Instability
- Rupture
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What are the positives and negatives of a biceps tenodesis?
- Better cosmesis
- Better supinator strength (8% deficit)
- Longer recovery
- Used in active patients <55 yo
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What are the positives and negatives of a biceps tenotomy?
- Preferred method
- Faster return to work
- Equivalent elbow flexion strength
- Supinator strength deficit (21%)
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Describe a type I SLAP tear.
- - fraying and degeneration of the superior labrum, normal biceps (no detachment);
- - most common type of SLAP tear (75% of SLAP tears);
- - often associated with rotator cuff tears;
- - these are treated w/ debridement;
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Describe a type II SLAP tear.
- detachment of superior labrum and biceps insertion from the supra-glenoid tuberlce;
- - when traction is applied to the biceps, the labrum arches away from the glenoid;
- - typically the superior and middle glenohumeral ligaments are unstable;
- - may resemble a normal variant (Buford complex);
- - 3 subtypes: based on detachment of labrum involved anterior aspect of labrum alone, the posterior aspect alone, or both aspects;
- - posterior labram tears may be caused by
- impingement of cuff against the labrum with the arm in the abducted and
- externally rotated position;
- - as noted by Tae Kyun Kim et al. type-II lesions in patients older than 40 years of age were associated with a supraspinatus tear where as
- in patients younger than 40 years were associated
- with participation in overhead sports and a Bankart lesion;
- - treatment involves anatomic arthroscopic repair;
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Describe a type III SLAP tear.
- - bucket handle type tear;
- - biceps anchor is intact;
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Describe a type IV SLAP tear.
- - vertical tear (bucket-handle tear) of the superior labrum, which extends into biceps (intrasubstance tear);
- - may be treated w/ biceps tenodesis if more than 50% of the tendon is involved;
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These types of SLAP lesions are debrided.
Type I and III
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These types of SLAP lesions are repaired.
Type II and IV
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List the cluster of signs of a SLAP lesion.
- Vague deep joint pain
- History of macrotrauma: force that pushes the humeral head over or away from the superio rlabrum
- History of deceleration activites/overhead cocking position
- Complaint of locking, popping, catching
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What is the most sensitive image to detect a SLAP lesion?
Gadolinium MRI because dy extravasates into labrum tears.
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Describe primary adhesive capsulitis (idiopathic)
- Insidious, rogressive, global loss of AROM & PROM
- Affects joint capsule and GH ligs (not muscle or fascia)
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Describe secondary adhesive capsulitis.
- Acquired (post surgical, post traumatic)
- Afects joint, capsulre, GH ligs and extra-articular tissues and fascia
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What is the capsular pattern of the shoulder?
ER, Abduction, IR
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List the cluster of signs of adhesive capsulitis.
- Sulcus sign at 0 deg (superior capsule/ligs)
- Sulcus sign at 90 deg (inferior capsule/ligs)
- Anterior load and shift
- Posterior lad and shift
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What is the time frame and findings of adhesive capsulitis in stage I?
- 0-3 months
- Progressive pain
- Global loss of AROM & PROM due to pain
- Arthroscopy reveals hypertrophic vascular synovitis
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What is the time frame and findings of adhesive capsulitis in stage II?
- 3-9 months
- Persistent pain
- Progressive loss of ROM (due to pain & reduced capsular volume)
- Arthroscopy reveals dense hypervascular synovitis, perivascular scar formation, capsular fibroplasia, disorganized collagen fibrils, NO inflammatory infilitrates
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What is the time frame and findings of adhesive capsulitis in stage III?
- 9-14 months
- Reduced pain
- Significant global ROM limitations (due to capsular fibrosis and decreased capsular volume)
- Arthroscopy reveals unremarkable, patches of synovial thickening, no evidence of hypervascularity, presence of dense hypercellular collagenous tissue.
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What is the time frame and findings of adhesive capsulitis in stage IV?
- Greater than 14 months
- Similar to stage III
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What are the precuations of a stage I adhezive capsulits?
Avoid aggressive ROM and joint mogs as these can potentially accelerate disease process and not needed as histologic changes have not occured.
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For what stages of adhesive capsulitis is a steroid injection appropriate?
Stage I and II
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