Shoulders (pt 1 overview-Ad Cap)

Normal shoulder external rotation w/90 degree abduction? a. 40-50 b. 50-60 c. 80-90 d. 90-100

d (90-100)

What is the most commonly torn tendon of the rotator cuff, usually the result of repetitive overhead movements or trauma? a. teres minor b. infraspinatus c. supraspinatus d. subscapularis

c (supraspinatus)

which rotator cuff muscle is responsible for forward flexion and abduction? a. teres minor b. infraspinatus c. supraspinatus d. subscapularis

c (supraspinatus)

you have patient abduct shoulder to 90 degrees then move to 30 degrees forward and have them internally rotate so that their thumb is down, then you apply downward force on their arm asking them to resist, this is testing what muscle(s)? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor

c (supraspinatus, aka the empty can test)

which is NOT a muscle of the rotator cuff? a. teres minor b. infraspinatus c. teres major d. supraspinatus e. subscapularis

c (teres minor is part of cuff, not major)

which type of SLAP lesion has bucket handle tear with intact biceps? a. type I b. type II c. type III d. type IV

c (type III)

55 year old male presents to office with compliant of left arm pain, states he works with heavy machinery and was lifting something yesterday and felt a pop, now has a positive "popeye" sign on the left arm, bruising and has weakness with elbow flexion. What is appropriate treatment? a. immediate biceps tenodesis b. rotator cuff repair c. conservative management d. biceps tenotomy

c (usually manage this conservatively, try PT and make sure pt can do his job, if his job were impacted he may need a tenodesis but start with conservative)

Which patient would most likely benefit from an arthroscopic SLAP repair with biceps tenotomy? a. college baseball player with type I lesion b. 60 year old painter with type II lesion c. college baseball player with type III lesion d. 45 year old who plays tennis for fun with friends and has type II lesion

c (usually only going to do the SLAP repair if patient is young and athlete who needs the full throwing ability, if others need surgery will just be arthroscopic debridement and either tenotomy or tenodesis)

which item on a patients skin, surrounding the shoulder, may give you an indication that they have had previous surgeries? a. color b. abrasions c. lacerations d. scars

d (surgical scars are fairly obvious and in predictable patterns)

which condition can result in shoulder impingement? a. tendinitis b. bursitis c. partial thickness rotator cuff tear d. massive rotator cuff tear e. rotator cuff arthropathy f. all of the above

f (impingement is an umbrella term)

you have patient place hand behind their back, palm facing out, elbow at about 90 degrees, then have patient attempt to lift arm off thier back while you apply resistance, this is testing what muscle(s)? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor e. rhomboid

a (subscapularis)

normal forward flexion for a young healthy adult without shoulder pathology: a. 130 b. 150 c. 165 d. 180

d (in real life you won't see this for most of your patients, but that's what the book says)

you have patient bend arm at the elbow to 90 degrees, so upper arm is adducted at their side, then have patient attempt external rotation while you apply force medially. this is testing what muscle(s)? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor e. rhomboid

d (infraspinatus/teres minor)

having patient sitting, arm to FF 90 degree, elbow flexed 90 degrees, examiner applies axial load to humerus, observing for palpable click vs excessive laxity of humeral head relative to glenoid, this is what test a. obreins b. apprehension c. load and shift d. jerk test

d (jerk test, must also do this bilaterally)

which rotator cuff muscle is responsible for internal rotation? a. teres minor b. infraspinatus c. supraspinatus d. subscapularis

d (subscapularis)

Which type of SLAP lesion has bucket handle tear with torn biceps? a. type I b. type II c. type III d. type IV

d (type IV)

what items should you make sure to palpate when examining a shoulder? a. joints b. lymph nodes c. any deformities or bumps d. muscles e. trigger points f. all of the above

f (not just looking at bony landmarks, have to make sure you get surrounding soft tissue, evaluate joint for effusion/edema)

having the patient extend arm to 90 degree FF, elbow at 90 degrees, and move patient into internal rotation, pain as the greater tuberosity/RC impinge on coracoacromial ligament/acromion is a positive _____ sign

Hawkins

if a patient can move muscle but can not lift against gravity they have a grade ___ strength

2

40% of people >___ yoa have at least partial thickness rotator cuff tear

60

which rotator cuff muscles are responsible for external rotation? (2) a. teres minor b. infraspinatus c. supraspinatus d. subscapularis

a and b (teres minor and infraspinatus)

Pt. presents to office complaining of night time "arm pain" states its all in the front of his arm, not his shoulder. When you press in the anterior aspect of the humeral head the patient states he feels pain right there. He has a positive speeds test and positive neers sign and states that pain is replicated right down the front of the arm. Still has almost full range of motion but feels the pain when extending to full forward flexion. What is patient most likely struggling with? a. rotator cuff tear b. biceps tendonitis c. adhesive capsulitis d. long head biceps tendon rupture

b (biceps tendonitis classically is the pain down the front of the arm, when you palpate the bicipital groove they'll often have pain right there, during tests they will feel the pain down the front of the arm)

if you have patient abduct shoulder to 90 degrees, then you apply downward force, asking patient to resist and hold arm at 90 degrees, you are testing what muscle? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor

b (deltoid)

A positive apprehension test indicates: a. rotator cuff arthropathy b. anterior instability c. posterior instability d. impingement

b (means potential anterior dislocation, most common dislocation is anterior/inferior)

46 year old female presents to office with complaint of right shoulder pain, states she has difficult reaching behind her in the car. doesn't recall any injury, feels like this just kind of happened suddenly. On exam you see she can only go to 120 degrees of FF, when you try passively you can't get her past 120 FF either. You give her a corticosteroid injection and tell her to do physical therapy. How long should you tell her it will resolve in? a. 2-5 days b. 6-8 weeks c. 12-18 months d. 18-24 months

b (pt has AdCap with CSI and movement patient should heal in about 6-8 weeks, if you do nothing at all, just NSAIDs and wait will heal on its own between 1-2 years, although he says 18-24 months)

46 year old female presents to office with complaint of right shoulder pain, states she has difficult reaching behind her in the car. doesn't recall any injury, feels like this just kind of happened suddenly. On exam you see she can only go to 120 degrees of FF, when you try passively you can't get her past 120 FF either. Which item would you most expect to be in the patients history? a. Cushings disease b. Diabetes Mellitus c. African American d. Rotator Cuff Repair

b (pt has adhesive capsulitis, a classic sign is passive ROM= active ROM, normally with a tear you as the provider could lift arm past where they can do actively, with Ad Cap the pts capsule is literally stuck, common risk factors include female gender and diabetes mellitus)

have patient extend arm to 90 degree FF, adduct across body then have patient point thumb down, provider applies downward force while patient tries to resist. pain with this test indicates possible: a. biceps tendonitis b. anterior labral tear c. rotator cufff tear d. glenohumeral joint OA

b (this is positive Obreins test, pain may indicate anterior labral tear)

in early scapulothoracic motion, there is (more/less) articulation b/w the thorax and scapula than in late forward frlexion

less (from 0-30 degree FF there is no movement of scapula, from 30-60 there is 1:1 movement of GH and scapula, in late, 60-180 FF there is more GH ROM than scapulothoracic)

alternative to lift off, have patient use heel of hand and press into abdomen while holding elbow forward, if patient is unable to hold elbow forward this is a positive belly press test and indicates weakness/tear in what muscle? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor e. rhomboid

a (subscapularis)

Pt. is a 55 year old women who plays recreational USTA in the summer to stay active, she is now struggling with a SLAP lesion that has left her unable to play a full match due to pain, shes tried advil but that doesnt seem to help at all, what would be the best first choice of treatment? a. PT or injections b. NSAIDs c. arthroscopic repair d. debridement and biceps tenodesis

a (pt already tried NSAIDs, give her an injection and try PT first, then if needed consider debridement if she fails multiple rounds of CSI)

during what stage of rotator cuff disease is patient usually under 25 yoa, has acute inflammation, edema and hemorrhage in the rotator cuff that is usually reversible with non-operative treatment? a. stage 1 b. stage 2 c. stage 3 d. stage 4

a (stage 1)

Pt. is a college baseball player who presents to office with complaint of right shoulder pain. They have a positive OBrein's test, painful FF, painful abduction/external rotation; patient is tender at the anterior shoulder. You order an MRI with expectation that you will see: a. SLAP lesion b. full thickness Rotator cuff tear c. biceps tendonitis d. subacromial bursitis

a (SLAP lesion common in throwing athletes, mimics impingement on physical exam, but history is consistent)

with patients arm relaxed down to side, provider applies downward traction via humerus, observe for sulcus or cleft between acromion and humeral head. If patient has bilateral 2 cm widening this is likely: a. normal b. sign of RC tear b. sign of bilaterally inferior instability d. indication for labral repair

a (if its bilateral the same, likely a normal variation, but patient may still have a little increased laxity)

During which stage of rotator cuff disease is patient usually 25-40 yoa, the RC tendon has progressed to fibrosis and tendonitis, usually won't respond to conservative treatment, requires operative intervention? a. stage 1 b. stage 2 c. stage 3 d. stage 4

b (Stage 2)

At what stage of shoulder impingement would a patient likely need an arthroscopic subacromial decompression, distal clavicle resection, and evaluation of a possible RC repair? a. stage 1 b. stage 2 c. stage 3

b (Stage 2, should also try conservative treatments though)

Which type of SLAP lesion has detachment of superior labrum and proximal biceps? a. type I b. type II c. type III d. type IV

b (Type II)

A patient can reach only to 90 degree of forward flexion, but when you assist them, you can get the arm up to 150, which of the following statements is true regarding this patient? a. pt. has passive ROM< active ROM b. pt has active ROM < passive ROM c. patient has passive ROM = active ROM d. we can't tell anything about ROM from this case

b (active ROM is what the patient does on their own, passive is what you as the provider can reach when you move arm for them)

Which factor in a patients social history has been documented to decrease ability of patient to heal effectively? a. previous surgeries b. tobacco use c. illicit drugs d. alcohol use e. being obese

b (tobacco)

patient presents to office with complaint of "tooth ache" type pain in lateral deltoid, worse at night, has pain with overhead movements that radiates down the upper arm. Has a positive neer sign, and positive hawkins sign, on MRI you see small rotator cuff tear. Patient retains good range of motion. What would be appropriate treatment? a. refer to ortho for surgery b. try one shot and round of NSAIDs c. order an MRI and refer d. try at least 3 rounds of shots before referral

b (try one shot, a round of NSAIDs, pt likely in stage one, physical therapy may also help)

cross body adduction test, having patient move arm into FF 90 degree and then across the body, you're looking for pain where? a. glenohumeral joint b. bicipital groove c. AC joint d. rotator cuff

c (AC joint)

What is the normal variant of superior labral detachment? a. glenoid instability b. superior laxity c. buford complex d. speeds deformity

c (Buford Complex)

At what stage of shoulder impingement would a patient possibly need an open rotator cuff repair or a total shoulder arthroplasty? a. stage 1 b. stage 2 c. stage 3

c (Stage 3)

Normal internal rotation? a. L5 b. buttock c. T7 d. T2

c (T7, many doctors use the spine as a scale for IR, having patient reach back and up as far as possible, if they can only get to their side you'd call it hip, or buttock if they cant get to midline)

If a patient presents to your office complaining of shoulder pain, what is the last question you should ask them in their HPI? a. what was mechanism of action? b. any alleviating factors? c. do you have any opinion about diagnosis? d. have you seen anyone else for this problem?

c (find out what they think it is)

having a patient lie supine, with GH joint over the edge of table, examiner grasps humerus while stabilizing scapula and applies pressure moving humeral head anteriorly/posteriorly, observing for excessive laxity or palpable click. must be compared bilaterally. this is known as what test? a. obreins b. apprehension c. load and shift d. jerk test

c (load and shift)

during what stage of rotator cuff disease is patient usually over 40 yoa, may lead to mechanical disruption of the rotator cuff tendon, changes in coracoacromial arch with osteophytosis along anterior acromion, usually need surgery a. stage 1 b. stage 2 c. stage 3 d. stage 4

c (stage 3)

When should you refer a patient who is struggling with adhesive capsulitis? a. if they haven't resolved pain following PT and NSAIDs b. if MRI shows they also have RCT c. if patient is diabetic and can't have corticosteroid injections and has failed PT d. all of the above

d

When would it be appropriate to refer a patient with shoulder impingement to ortho? a. if patient has RCT b. if you try one shot ,a round of NAIDS and PT and it doesnt work c. if you're unsure of what to do d. all of the above

d

If a patient has what item in their social history do you have to be worried about increased bleeding time? a. previous surgeries b. tobacco use c. illicit drugs d. alcohol use e. being obese

d (alcohol use to the pt where it has affected the liver will decrease availability of clotting factors)

Pt. presents to office with compliant of left arm pain, states he works with heavy machinery and was lifting something yesterday and felt a pop, now has a positive "popeye" sign on the left arm, bruising and has weakness with elbow flexion. Pt. is most likely struggling with? a. rotator cuff tear b. biceps tendonitis c. adhesive capsulitis d. long head biceps tendon rupture

d (classic pop and popyeye deformity, usually dont need studies, except if you think RCT concurrent)

patient presents to office with complaint of "tooth ache" type pain in lateral deltoid, worse at night, has pain with overhead movements that radiates down the upper arm. Has a positive neer sign, and positive hawkins sign, what would be appropriate test to determine if this is a rotator cuff tear? a. xray b. obreins test c. apprehension test d. MRI

d (gold standard for RCT is MRI)

have patient put hands on hips, push arms forward at elbow then palpate vertebral border of scapula, if scapula remains against thorax, this indicates what muscle is intact? a. subscapularis b. deltoid c. supraspinatus d. infraspinatus/teres minor e. rhomboid

e (rhomboid)

when the provider moves the patients arm into full passive forward flexion with elbow extended, and there is pain over the top of the shoulder this is a positive _____ sign

neer's

when inspecting the shoulder the patient should have their shirt (on/off)

off (so you can inspect it, duh)