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WorksheetsTREX II final
Total questions: 63
Worksheet time: 1hrs 21mins
What may make someone at risk for shoulder problems? (select all that apply)
repetitive forceful work
previous neck and shoulder injuries
overhead athletes
high demand work place positions
what is the scapulohumeral rhythm ratio?
0-30°
no scapular movement, all GH
30-90°
scapula moves 1° for every 2° of GH
90°
1:1 ratio of scapula and GH
What is a way to check for compensations for reaching overhead
What are possible pathologies and etiologies of GH hypomobility (select all that apply)
Rheumatoid arthritis
traumatic sequelae
post-immobilization
adhesive capsulitis
What are the clinical signs and symptoms of arthritis?
pain
muscle guarding
swelling deep in capsule (not palpable)
capsular tightness
typical pattern of loss with greatest loss of ER followed by abduction
pain at all ends of ROM
limited joint play
decreased joint play
loss of function
aching in deltoid area
How is adhesive capsulitis (AC) defined?
ROM loss >50% in at least 2 movement planes and ≥25% loss of passive ER compared to uninvolved shoulder
ROM loss <25% in at least 2 movement planes and ≤50% loss of passive ER compared to uninvolved shoulder
ROM loss >25% in at least 2 movement planes and ≥50% loss of passive IR compared to uninvolved shoulder
ROM loss >25% in at least 2 movement planes and ≥50% loss of passive ER compared to uninvolved shoulder
What are the risks factors for AC
female
>40 years old
having AC on one side
HLA-B27 positivity
diabetes
following a trauma
prolonged immobilization of GH
Match the stages of AC
stage 1
inflammatory
stage 2
painful/freezing
stage 3
frozen
stage 4
thawing
What are the clinical signs and symptoms of AC
gradual onset of pain with movement AROM+PROM
pain at night
minimal or no loss of ER
rotator cuff is strong
3 month duration
more intense pain even at rest
all ROM limited
PT may not be beneficial at this point
3-9 months
pain only during movement
scapular compensation
atrophy of deltoid, rotator cuff, biceps, triceps
9-15 months
minimal pain
resolving pain
may be showing some improvement in ROM
15-24 months
As a PT your treatment approach for AC should be based on the level of irritability the patient is having
True
False
Organize these interventions based on the level of irritability for AC
activity modification
manual therapy
limit number of visits
low intensity GH exercises
motion at adjacent regions
progressive manual therapy
mild stretching + strengthening activities
basic functional activities
stretching
manual therapy (for low)
resistive exercises
higher demand physical activities
What would you observe in a patient with GH joint hypomobility
decreased joint play
decreased ROM
ER and abduction greatest loss of ROM
scapular protraction
scapula anteriorly tilted
elevated shoulder(s)
decreased arm swing
general weakness
poor endurance
compensation via upper trapezius and levator scapulae
C spine muscle pain
Which of these is an acute phase, non-operative management of GH hypomobility, goal?
maintain scar tissue and joint integrity and instability
maintain integrity and function of associated regions
PROM, AAROM in pain free range
increase the extensibility of soft and contractile tissue
Goals for non-operative management of GH hypomobility
progressively increase joint and soft tissue mobility
correct faulty biomechanics
improve joint tracking
improve muscle performance
progressively increase flexibility and strength
prepare for functional demands
if conservative measures fail: manipulation under anesthesia, joint replacement
what does MWM stand for?
movement with mobilization
mobilization with movement
muscles with motion
mobility with muscles
what are the 4 principles of MWM?
1) pain is desired
2) overpressure is provided in end range to gain new range
3) results are expected at time of treatment
4) results are long lasting
1) no pain
2) overpressure is provided at the starting range to gain new range
3) results are expected after multiple visits
4) results are long lasting
1) no pain
2) overpressure is provided in end range to gain new range
3) results are expected at time of treatment
4) results are long lasting
1) no pain
2) overpressure is provided in end range to gain new range
3) results are expected at time of treatment
4) results are temporary
Which of these options is an indication for MWM?
full orthopedic examination has yet to be completed
a specific biomechanical analysis reveals localized loss of movement and/or pain associated with function
manual therapy is contraindicated
one or more comparable signs are not identified during the exam
what are the goals and dosages for MWM?
goals:
-increase AROM
-decrease pain at rest and with AROM
goals:
-increase PROM
-decrease pain at rest and with PROM
dosage:
2-4 reps/6-10 sets as tolerated
dosage:
6-10 reps/2-4 sets as tolerated
What is a primary indication for GH total shoulder arthroplasty (TSA)?
distal humeral fracture
loss of strength and function
loss of mobility or stability
persistent and incapacitating pain
What is the mechanism of injury for anterior shoulder dislocation?
humerus is rapidly and forcefully moved posteriorly when in position of ER and abduction
humerus is rapidly and forcefully moved anteriorly when in position of ER and abduction
humerus is rapidly and forcefully moved posteriorly when in position of IR and adduction
humerus is rapidly and forcefully moved posteriorly when in position of flexion and extension
What are the precautions and contraindications for each phase after a traumatic shoulder dislocation?
Precaution: ER with humerus at side of body, starting at abdomen and going to 0-10° ER only
contraindication: extension >0°
contraindication: all joint mobilizations
none
Match the following
intrinsic impingement
caused by factors in tendon itself
extrinsic impingement
caused by factors outside of tendon
primary extrinsic impingement
anatomical or biomechanical factors
secondary extrinsic impingement
hypermobility or instability of GHJ
posterior extrinsic impingement
occurs during elevation, H.ABD, max ER
Match the following type and shape of the acromion
type I
flat
type II
curved
type III
hooked
what is the common mechanism of injury for each of these shoulder structures
supraspinatus tendinitis and bursitis
overhead reaching
infraspinatus tendinitis
across body reaching, eccentric injury
bicipital tendinitis
eccentric lowering
Which of these is a structural/functional impairment of painful shoulder syndrome
decreased lumbar ROM
rotator cuff strength and flexibility
hypomobile posterior GH joint capsule
impaired muscle activation and atrophy
What are the 2 types of rotator cuff tears?
acute degenerative
chronic degenerative
acute avulsion
chronic avulsion
Organize these options into the right categories for the types of rotator cuff tears
>40 years old
typically SIT muscles
comprise the majority of tears
may be associated with history of subacromial impingement/shoulder pain
acute subscapularis tears are seen follwing a fall with hyperabduction and ER
acute SIT tears in patients >40 years old occur as a result of a shoulder dislocation
Match the following
small tear
0-1 cm
medium tear
1-3 cm
large tear
3-5cm
massive tear
>5cm
What are the predictors for a successful rotator cuff repair?
confidence in physical therapy
the amount of visits
low activity level
surgeon
What are the criteria that surgeons look at for type of procedure they will perform?
thickness of tear
number of tendons involved
associated lesions
acuity: gradual vs. traumatic
surgeon's preference
What are the 3 general rehab principles for postoperative RC management?
immediate or early post op motion of GH joint
gain control of scapula for dynamic stability
gain control of GH for dynamic stability
gradual restoration of muscle performance
Match the following for how long a patient will be in sling for post op
small tear
1-2wks, off day 1 for therapy
medium to large tear
3-6wks, removal 1-2 days post op
massive tear
6-8wks, removal 1-3 days post op
You have been treating a patient for 4 weeks for post rotator cuff surgery. They say that their shoulder is feeling much better and would like to progress with their home exercise program. Will you progress them, why or why not?
What interventions should be done in each phase for rotator cuff repair postoperative management?
maximum protection phase
moderate protection phase
return to function phase
PROM in pain free range
AROM without compensation
full function
gradual progression
task specific training
AROM vs passive stretching to increase motion
supine position, cue to control scapula to avoid impingement
multiple angle isometrics
endurance over strength if prior chronic condition
AAROM to AROM in late phase
good posture in spine
isometrics week 6
What are very strong post op precautions for motion after rotator cuff repair
avoid end range stretching
no vigorous stretching for 6-12wks
No UE weight bearing activities for 6wks
Only passive, non assisted ROM in supine (6-8wks)
Most ADLs require what range of motion at the elbow joint?
70° arc from 30-130°
120° arc from 50-130°
100° arc from 30-130°
30° arc from 100-130°
What is the most common direction for elbow dislocation?
anterior
posterior
lateral
medial
vertical
What is one etiology of Myositis Ossificans?
trauma to the anterior elbow, brachialis or joint capsule
ulnar head fracture, fracture dislocation, tear of brachioradialis tendon
gentle passive stretching and/or prolonged immobilization post injury
If you have had it in the thigh
What are some signs and symptoms of myositis ossificans?
pain with resisted flexion
pain with passive extension
tender to palpation of proximal brachialis
asymptomatic
What is a contraindication when treating someone with myositis ossifcans?
elbow flexion
passive stretching and resistance exercise
extension pass 0°
extension + adduction + IR (putting arm behind the back)
Elbow joint hypomobility impairments
joint effusion
muscle guarding
decreased motion
decreased joint play
capsular pattern: flexion more restricted than extension
PROM: hard or boney end feel
pronation/supination limited by proximal R/U joint
What is a key way to avoid elbow joint hypomobility during the acute phase?
PROM, AAROM all directions, UBE
muscle setting in all directions
gentle grade 1 or 2 distraction and oscillation techniques in resting position to inhibit pain and improve synovial fluid dispursion
come out of sling
Keep shoulder, hand , wrist mobile as tolerated
What interventions are appropriate at the controlled motion phase for a hypomobile elbow? (select all that apply)
grade 3 sustained or grade 4 oscillations for motion
muscle setting --> isometrics --> dynamic full range endurance-strength-power, single plane to multi plane
grade 1 or 2 distraction and oscillation techniques in resting position
progress to functional patterns for work, sports, ADLS
What are the fixed segments of the hand? (select all that apply)
trapezium
trapezoid
capitate
hamate
2nd and 3rd metacarpals
The arrangement of the fixed segments allows for what?
Allows the mobile segments to be even more mobile
stability with rigidity
enhances function of thumb and fingers for power and/or precision grip
enables the hand to move more sporadically and with speed
What are the functional contributions of the hand arches? (select all that apply)
enable hand to grasp objects
extrinsic muscles maintain the arches
direct motor skill of fingers and control power of grasp
intrinsic muscles maintain the arches
What is the cause of Jersey finger injury?
All the above
rapid finger extension that tears the tendon
jamming your finger against something
rapid finger flexion from a extended position that tears the tendon
Categories the key features of each finger
most important digit
60% of hand function
key feature: mobility and force
second most important digit
key features: strength and its interaction with the thumb
loss of finger = loss of pulp- to pulp pinch and power grip
strongest in flexion
important for both precision and power grips
greatly enhances power grip
affects the capacity of the hand
holds object against thenar eminence
Label these power grips
hook
cylinder
spherical
fist
What are precision patterns?
fingers and palm work in opposition to hold object
involve manipulating object that is in contact with the palm
involve manipulating object that is not in contact with the palm
gross motor adjustments
what are combined grips?
include fist where index or middle and thumb hold isometrically and 3-5 supplement with power
include pinch where pinky or ring and thumb hold isometrically and 3-5 supplement with power
include pinch where index or middle and thumb hold isometrically and 3-5 supplement with power
include pinch where index or middle and palm hold isometrically and 3-5 supplement with power
What structural and functional impairments would you expect to see related to finger joint hypomobility?
Decreased ROM, weakness (a) , effusion
What would you expect to detect with PROM for finger joint hypomobility?
hard end feel, pain with over pressure
soft end feel, pain with over pressure
firm end feel, pain with over pressure
empty end feel, no pain with over pressure
Precaution: after trauma, be alert to fracture that may not appear initially on x-ray
True
False
Match the following RA deformities
fingers shift to ulnar side
subluxation of proximal phalanges
rupture of collateral ligaments at MCP resulting in bowstringing of tendons
hyperextension of PIP and flexion of DIP
PIP flexion and DIP extension
MCP dislocation of thumb with swan or boutonniere deformity
Finger hypomobility: RA, OA, Post trauma Acute stage
joint protection
avoid prolonged positions
use utensils on ulnar side of hand
avoid rotation
grade 1 distraction or oscillations only if tissues are intact
medication from MD
soft tissue mobilization for edema reduction
for protection and rest
remove for ROM
when RA is in an acute flare up
What is the goal of the acute phase for finger hypomobility from RA, OA, and post trauma?
strengthen the adjacent regions near the hand
maintain AROM and decrease pain
improve joint and tendon mobility and muscle integrity
maintain joint and tendon mobility and muscle integrity
What are the goals for controlled motion and return to function phases of finger hypomobility?
increase joint play and accessory motions
maintain joint and tendon mobility and muscle integrity
improve joint tracking and pain free motion
progressive strengthening
For lateral elbow tendinopathy (tennis elbow) what is the primary overused muscle?
ECRB
ECRL
FCRB
FCRL
What are the risk factors for lateral tendinopathy? (select all that apply)
repetitive manual task
handling heavy tools
repetitive elbow/wrist flexion/extension for more than 2 hours a day
repetitive forearm twisting/rotating (pronation/supination) movements
Low job control, low social support
What is the pathoanatomy of lateral elbow tendinopathy?
typically caused from trauma
typically begins as a micro tear of the origin of ECRB
typically begins as a macro tear of the origin of ECRB
typically begins as a sprain of the lateral ulnar collateral ligament
What might the patient complain of and what functional/structural impairments might be present? (select all that apply)
pain with gripping activities
pain with resisted wrist flexion
decreased grip strength
tenderness at ECRB insertion at lateral epicondyle
What should you do after a mobilization with movement?
stretching
MWM in the other direction
functional exercise
You should end the treatment session with an MWM
