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57 Cards in this Set

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Crank test
Relocation test
Inferior apprehension test
This test was initially described by Feagin, and further refined by Itoi et al,16 who suggested the name ABIS (abduction inferior stability). For this test, the upper limb is held in abduction, with the patient's forearm resting on the examiner's shoulder. The examiner exerts downward pressure over the neck of the humerus. If the shoulder is unstable, the head will be pushed down, and a groove will appear; also, the patient may show apprehension (Fig. 7).
SMC Knot
Sulcus test
Drawer tests
GAGEY test
Traumatic Undirectional Bankart Surgery
Atraumatic Multidirectional Bilateral Rehabilitation
Inferior Capsular shift
Acquired Instability of Overstressed Shoulder
“Distal mobility with proximal stability”
… mobilit‚à dell’omero si basa paradossalmente sulla stabilit‚ della
Stabilizzatori della spalla
Stabilizzatori dinamici
Muscoli rotatori

Stabilizzatori statici
• Versione glenoidea
• Versione omerale
• Congruenza articolare
• Cercine
• Strutture capsulo-legamentose
• Pressione intra-articolare negativa
Pressione intra-articolare negativa
 Il peso del braccio ,che tende a sublussare inferiormente la testa omerale rispetto alla glenoide, € contrastato dalla pressione
negativa intracapsulare o effetto vuoto creato da uno spazio articolare sigillato.
 In una spalla con una capsula lassa o di volume articolare troppo grande (in basso a sinistra), la testa omerale pu traslare
inferiormente fino a quando la pressione negativa € sufficiente a contrastare l'ulteriore traslazione.
 In una spalla con lesione capsulare o difetto capsulare nell'intervallo dei rotatori, il volume del compartimento articolare trova uno
sbocco ed viene perso l'effetto vuoto. La testa omerale pu ora migrare inferiormente fino a che la tensione capsulare superiore
si oppone alla traslazione inferiore.
E' bene che la seduta inizi (e finisca) con una massoterapia palpatoria atta a mettere in evidenza lo stato nel quale si
trovano le strutture teno-muscolari
 La rieducazione prosegue con la mobilizzazione passiva atta a ricentrare la testa omerale nella glena
 Seguir‚ la fase di rinforzo muscolare dapprima con contrazioni isometriche, in seguito se non c'€ dolore con contrazioni
concentriche/eccentriche. Durante il rinforzo va posta l'attenzione onde evitare lo stiramento eccessivo della parete
capsulare anteriore.
 Seguendo lo schema delle 3 PS, il recupero della forza parte dai ProtectorS e dai PivotorS per terminare in una fase
avanzata con il potenziamento dei PositionerS.

Successivamente si possono proporre esercizi propriocettivi come quelli di stabilizzazione ritmica (facendo chiudere gli occhi
al paziente).
 Quando il paziente avr€ "coscientizzato" la propria spalla e il suo corpo rispetto ad essa, potr€ seguire gli esercizi di
rinforzo, autogestirsi con elastici e/o pesi, sempre sotto la supervisione del terapista.
 Dopo il raggiungimento di una buona forza si pu‚ introdurre l'allenamento isocinetico per i rotatori di spalla con una
posizione del braccio prima a 30ƒ sul piano scapolare per poi progredire sul piano coronale fino a 45ƒ. Si utilizzano velocit€
angolari medie.
 Il paziente deve sapere quali sono i movimenti da non fare (lavori over head, sollevamenti di pesi elevati), le posture da
evitare e gli esercizi da fare di fronte ad episodi di insorgenza del dolore (ad esempio l'esercizio di Codman per detendere
muscoli periarticolari contratti e dolenti).
I tre "PS" della spalla (instabilità) e i "power drivers"

(Disorders of the shoulder: diagnosis & management, Volume 1 Di Joseph P. Iannotti,Gerald R. Williams)
I muscoli della cuffia dei rotatori.
vanno rinforzati dapprima in contrazione isometrica,
successivamente se non dolenti in contrazione isotonica ed isocinetica.
Muscoli rotatori della scapola. Il rinforzo di questi muscoli va iniziato da subito; gli esercizi sono rivolti al potenziamento di diversi
gruppi muscolari
Il rinforzo dei muscoli deltoide (tre capi, gran pettorale va introdotto nel programma dopo che le altre due PS sono state
adeguatamente potenziate

Gran pettorale e gran dorsale
Innervazione Spalla
Paralysis of this NERVE will result in a marked drooping and down turning of the affected shoulder at rest because of the loss of the ability to elevate and upwardly rotate the scapula. The latter loss will also prevent the patient from abducting their arm above the horizontal (shoulder level).
Accessory nerve - innervates the trapezius muscle.
Any attempt to retract the scapula will be accompanied by a marked upward rotation of the shoulder because the rhomboideus can no oppose the upward rotation on the scapula exerted by the trapezius. The patient will have difficulty retracting the scapula against resistance on the affected side
Dorsal Scapular nerve - innervates the rhomboideus muscles
Active contraction of this muscle results in scapula protraction and upward rotation. When the scapula is passively protracted by action of the pectoralis major muscle on the humerus , the serratus anterior acts to stabilize the scapula and keep it applied to the thoracic wall. Such action occur when a boxer throws a jab or a cross. Paralysis of the serratus anterior prevents the scapula from moving smoothly across the thoracic wall resulting in a bowing out of the medial border of the scapula. This condition is called "winged" scapula. In addition, the ability to actively upwardly rotate the shoulder is diminished and the patient can not abduct the humerus above the horizontal.
Long thoracic nerve - Innervates the serratus anterior muscle.
Paralysis of this nerve will result is weakness of the rotator cuff muscles resulting in pain form impingement and an inability of the patient to begin shoulder abduction. Such patients tend to swing the affected limb away from their side in order to provide momentum to start abduction.
Suprascapular nerve - innervates the supraspinatus and infraspinatus muscles.
Since the deltoid plays a major role in movement of the glenohumeral joint, paralysis will cause a loss &/or weakness of most shoulder functions.
Axillary nerve (ascellare) - innervates the deltoid and teres minor muscles
Symptoms of deltoid paralysis
A. loss or roundness to the shoulder and a very visible acromion process
B. inability to abduct the glenohumeral joint more than a few degrees away from the side.
C. inability to laterally rotate the humerus
D. weakened movements of glenohumeral flexion and extension
E. loss of sensation just below the point of the shoulder
atrophy of supraspinatus and infraspinatus muscles and rhomboid muscles (white arrow); on the right: scapular tilting and rotation caused by serratus anterior muscle weakness (white arrow with *)
severe scapular winging caused by serratus anterior paralysis (white arrow)
atrophy of supraspinatus and infraspinatus muscles (white arrow), and trapezius muscle (white arrow with *) showing underlying rhomboid muscles
Severe atrophy of the deltoid muscle (white arrow) and moderate atrophy of the biceps brachii muscle (white arrow with *)
Ultrasound Effect on Healing
Regarding tendon healing
Induce an increased rate of collagen synthesis and improve collagen alignment at the healing.
May enhance healing properties of rotator cuff repair
By accelerating bone remodeling at the attachment site
By improving collagen synthesis and alignment at the attachment site or a combination of both mechanisms.
Literature on Cuff Healing
Healed cuffs do better
Harryman (JBJS 1991)
82% “Re-tear” (Walton 2004)
Healed cuffs stronger (Boileau 2004)
Only 43% heal if greater age 65 (Boileau)
If just SS > 89% healed
If SS+IS > 50% healed
Collagen is Different in the Healing Area
Galatz … J Ortho Res 2006
More Type III Collagen
Growth Factors Influence Healing
TGF-B (Transforming Growth Factor Beta)
Associated with
… scar and adhesions
… cell migration and angiogenisis
FGF (Fibroblast Growth Factor)
Repair site unorganized histologically and biomechanical inferior.
Cuff: Debridement of the Tendon Edge?
Immunochemistry shows no difference in procollage production near or away from tendon edge.
Cuff: Bone: Abrade or Repair Tendon to Cortical Surface
“No significant benefit from the creation of a trough to expose the tendon to cancellous bone or just repair to cortical bone in goats.
At both six and twelve weeks, the tendon-to-bone healing process of the two groups appeared similar
The biomechanical properties were approximately equal.

St Pierre … JBJS 1995
Cuff: Footprint: “Double Row” Repair
Suture anchor covers 67% of the footprint
Cuff: Where is the best place to put a suture anchor?
Articular margin
Tension band
Double Row
Cuff: What to do with the bursa?
Blood supply to cuff
Provides cells and vessels for healing
No inflammation in the bursa
? Other opinion
Ulthoff says bursa is good

Consider Incorporating Bursa into Repair
Cuff: Acromioplasty
Probably not necessary
Does not prevent future tears.
Preserve the arch
How Soon After a Cuff Tear Should You Do a Repair?
Coleman … Warren JBJS 2004

Early surgery should prevent muscle fat accumulation
and Muscle Contraction
James C. Esch, M.D.
Tri-City Orthopaedics
Oceanside, CA
Dr. Louis U. Bigliani
Chief, The Shoulder Service
Chairman, Dept. of Orthopaedic Surgery
Columbia University
College of Physicians and Surgeons
New York, New York
Rotator Cuff Repair History:
1st repair
Rotator Cuff Repair History: Harrison McLaughlin
Surgical repair
Results of 100 cases
JBJS 1944

Successful Repair
Tension free
Continuity of cuff
Smooth acromion
JBJS 1951
Cuff: Open Results
Pre Post
FE > 90° 109 (59%) 169 (91%)
ER > 30° 123 (66%) 173 (93%)

85% Good to Excellent results
87% patient satisfaction
3.2% complication rate
Cuff. Why Switch from Open Repair?
Deltoid detachment/ scarring
Early post-operative pain
Post-op stiffness
Longer incision
Longer rehabilitation

Arthroscopic RCR: Current Results: Arthroscopic Repair of Supraspinatus
Boileau, JBJS, June 2005
65 Patients- Tension Band Technique
Follow up Arthro CT (51), MRI (15)
60/65 patients (92%) Good to Excellent results
Healed 46/65 (71%)
Partial 3/65 (4%)
Retear 16/65 (25%)
Age > 65 10/23 (43%) Healed

Bishop, Flatow, et al ASES Open 2004
Cuff integrity by MRI, min 1 yr F/U
In tears > 3 cm:
Open 62% intact
Arthroscopic 24% intact
Cuff: Factors That Affect Cuff Fixation
From Bardana et al 2003
Ken Yamaguchi, MD

Marilyn and Sam Fox Distinguished,
Professor of Orthopedic Surgery
Chief, Shoulder & Elbow Service
Dept. of Orthopaedic Surgery
Barnes-Jewish Hospital
Washington University School of Med
St. Louis, MO
Cuff: How strong does it need to be?
270 - 300 N

Muscle force: 200-300 N
Suture load: 35-60 N
Anchor load: 70-120 N

Burkhart et al., Arthroscopy 1993, 2000
Clavicle Fractures
Clavicle Fractures
SC Joint Dislocation
AC Joint Separation
General and clasification
AC Joint Separation
AC Joint Separation
Operative Techniques
AC Arthritis
AC Arthritis
Distal Clavicle Osteolysis