INJURIES DIAGNOSIS AND TREATMENT

BONE AND HEALTH

JASSIN M. JOURIA Dr. Jassin M. Jouria is a practicing Emergency Medicine physician, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e- module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

Over time, the potential for injury or just general wear and tear on and can impact a person’s quality of life. Even in younger individuals, repetitive activities, such as repeatedly throwing a baseball, can cause arthritic pain and joint tears that cause pain and limit a person’s body to function as it was designed. However, many treatment options, both surgical and non-surgical, are available to provide relief and to restore normal functioning.

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hour (30 minutes).

Statement of Learning Need

Issues related to and joint health are an evolving area of orthopedic care that involves a multidisciplinary approach to treatment, including medical clinicians, nursing, physiotherapy, occupational therapy and home care. Clinicians need to be informed of how wear and tear on the bones and joints can specifically impact quality of life, and of patient care needs when shoulder and knee surgery is required due to arthritis pain and joint tears.

Course Purpose

To provide health clinicians with knowledge of shoulder and knee joint disease and recommended treatments, surgery and rehabilitation needed to address pain issues and to improve a patient’s quality of life.

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience

Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The ______joint is the major joint of the shoulder.

a. b. humeral c. glenohumeral d. scapula

2. The rotator cuff adheres to the glenohumeral capsule and also attaches to the

a. clavicle. b. humeral head. c. radial head. d. lateral epicondyle.

3. True or False: The rotator cuff keeps the humeral head in the glenoid cavity when a person elevates his or her arm.

a. True b. False

4. The ______are two filmy and sac like structures that allow smooth gliding between bone, tendons, and muscles; they protect and cushion the rotator cuff.

a. menisci b. brachii c. bursae d. glenoid labrum

5. ______are bands of tissues that connect bones and muscles.

a. Ligaments b. Tendons c. Bursae d.

4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction

The human shoulder is uniquely constructed for lifting, pulling, and pushing objects. It is also mobile enough to allow for a wide range of actions of the hands and arms. These actions or functions may be limited by shoulder pain due to injuries and inflammation of a shoulder tendon, joint, surrounding ligament, or periarticular structure. A shoulder examination is needed to evaluate a patient for the possibility of a rotator cuff tendinopathy, , frozen shoulder, osteoarthritis, or any number of other disorders at or around the shoulder. Causes of injuries, diagnoses, and treatments, including when surgery should be an option, are important clinical considerations when attempting to determine the course of care for a shoulder injury.

Shoulder Anatomy: Overview

An understanding of human shoulder anatomy is the starting point for a clinician to know how to treat shoulder injuries, and the associated pain. It is also helpful for educating patients on rehabilitation and recovery.89,90

The shoulder consists of three bones and associated muscles, ligaments, and tendons. The three shoulder bones include the clavicle (collarbone), scapula (shoulder blade), and humerus (upper arm bone). The scapula forms the glenoid cavity, and displays prominent, projecting structures known as the acromion and coracoid processes.

Shoulder joints are articulations between the bones of the shoulder. The glenohumeral joint is the major joint of the shoulder, which leads to some clinicians calling it the shoulder joint; however, the shoulder includes the acromioclavicular joint.

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The glenohumeral joint is where the humerus attaches to the scapula with the head sitting in the glenoid cavity.89,90 It is a ball and socket joint and is formed by the articulation between the lateral scapula (the glenoid cavity of the scapula) and the head of the humerus. The ball part of the ball and socket of the shoulder is a rounded medial anterior surface of the humerus. The socket part is formed by the glenoid cavity – the dish shaped portion of the lateral scapula. It allows the arm to rotate in a circular way or to hinge out and away from the body.

Surrounding the shoulder’s ball and socket joint are ligaments, muscles, and tendons that support the bones and maintain a relationship one to another. These supporting structures attach to the humerus, clavicle, and scapula.

The capsule of the shoulder is a soft tissue envelope. It encircles the glenohumeral joint and attaches to the scapular, humerus, and head of the biceps. A synovial membrane lines the capsule. It is strengthened by the coracohumeral ligament, which attaches the coracoid process of the scapula to the greater tubercle of the humerus.

The glenoid ligaments are three other ligaments that attach the lesser tubercle of the humerus to the lateral scapula. The transverse humeral ligament passes from the lesser tubercle to the greater tubercle of the humerus.

The Rotator Cuff

The rotator cuff is an anatomical term given to four muscles and related tendons that surround the shoulder joint. Each muscle of the rotator cuff has a tendon attached to it and to the humerus. The muscles associated with the tendons are in the upper back, which is where they attach to the scapula (shoulder blade).

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The rotator cuff adheres to the glenohumeral capsule and also attaches to the humeral head. It keeps the humeral head in the glenoid cavity and prevents upward migration of the humeral head as caused by the pulling of the deltoid muscle at the time of arm elevation.

Rotator Cuff Muscles

The four muscles and their specific movements include: • Supraspinatus (used for lifting the arm) • Infraspinatus (help rotate the arm outward) • Teres minor (help rotate the arm outward) • Subscapularis (helps rotate the arm inward)

The four rotator cuff muscles work together through contractions. As a person moves the arm, the rotator cuff muscles stabilize and control the humeral head that is the ball part of the ball and socket joint. Each muscle works independently but with other muscles and fibers, they work together to articulate shoulder movement; i.e., the teres minor and infraspinatus with the anterior fibers of the deltoid muscle allow for external rotation of the arm.89-91

Rotator Cuff Tendons

The four tendons of the rotator cuff converge to form the rotator cuff tendon that is the upper arm band. The tendons attach to the side and front of the humerus and the greater and lesser tubercles that are part of the upper humerus. The rotator cuff tendon with the articular capsule glenohumeral ligament complex and coracohumeral ligament come together into a sheet before inserting into the humeral tuberosities. The teres minor and infraspinatus fuse near their musculotendinous junctions. The supraspinatus and subscapularis tendons join as a sheath surrounding the bicep tendon near the entrance of the bicipital groove.89-91

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The supraspinatus tendon is the most vulnerable and important part of the rotator cuff as it is essential for lifting the arm. As mentioned above, the infraspinatus and teres minor rotates the arm outward, and the subscapularis rotates the arm inward.

Other Shoulder Joints and Cartilage

The acromioclavicular joint and the play a role in shoulder movement. The articular cartilage, at the end of bones, lets the bones glide and move on each other. The bursae are two filmy and sac like structures that allow smooth gliding between bone, tendons, and muscles; they protect and cushion the rotator cuff.

The labrum is a fibrocartilaginous ring found at the rim of the glenoid, providing additional stability. The glenoid labrum is different from articular cartilage; glenoid labrum is rigid and more fibrous than the cartilage at the ends of the ball and socket. Glenoid labrum is located around the socket where it is attached.

Due to the shallowness of the cavity there is a relatively loose connection of the shoulder to the rest of the body. This allows the arm to have great mobility, which also places the shoulder at greater risk of dislocation than other joints of the body. The glenoid cavity is deeper due to the fibrocartilaginous ring of the glenoid labrum.43,44

Other Shoulder Muscles

The following is an overview about other muscles in the shoulder area in addition to the four muscles of the rotator cuff. The deltoid muscle and teres major muscles also are in the shoulder region. The deltoid muscle covers the shoulder joint at three sides and arises from the front upper third of the clavicle, the acromion, and the spine of the scapula.

8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com The deltoid muscle travels to insert on the deltoid tubercle of the humerus. Contractions of each part of the deltoid assist with movements of the humerus including the clavicular part (flexion), middle part (abduction), and scapular part (extension). The teres major attaches to the outer part of the scapula at the back and goes beneath the teres minor and attaches to the humerus at the upper part, helping the medial rotation of the humerus.

Shoulder Injuries

With a complex network of anatomical structures, the shoulder has great mobility – greater than any other part of the body. The mobility of the shoulder is because of the shallow depth of the glenoid and limited contact of the glenoid and humeral head. About 25 percent of the humeral head surface is in contact with the glenoid. The shoulder or glenohumeral joint is constrained loosely in a thin capsule and the capsule is bounded by muscles and ligaments. Stability is provided for the most part by extrinsic support. The muscles and ligaments provide this support, including the superior, middle, and inferior glenohumeral ligaments.

The glenohumeral joint is susceptible to injury and instability due to the shallowness and small surface area of the glenoid. In addition to this, the complex muscles and ligaments that provide support to the shoulder may be injured or impaired. Shoulder injuries and medical management of varied types of injuries are reviewed below.42-56,59,63,64,88,92

Rotator Cuff Tendinopathies

Tendons are bands of tissues that connect bones and muscles. Repeated activities and overuse can injure tendons and cause impaired function and pain. Tendinopathy is a broad term that refers to an injury or impairment to a tendon. It is a general term that has been used to include tendinitis and

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com tendinosis. The use of the word “tendinitis” has been dropped by some clinicians and the terms “tendinopathy” and “tendinosis” are used instead to describe injuries or impairments to a tendon. In this article, the word tendinitis is used at times to describe inflammation of the tendon.

Tendinopathy can impact different tendons of the body, including those in the shoulder and . The most common cause of shoulder pain is a problem with the rotator cuff. Tendinopathy is more often seen in people who perform routine activity requiring repetitive movement that puts stress on tendons. This is especially true for those over the age of 30 as tendinopathies become more common as people age.

Tendinopathies caused by overuse were traditionally referred to as tendinitis because the primary cause of pain and swelling was inflammation of a tendon. A census of overuse tendinopathies disclosed that most cases were not caused by inflammation but rather chronic degeneration without inflammation, due to hypoxic degeneration. Tendon degeneration may occur due to atrophy, such as is the case with tendinosis, which is also a chronic degenerative condition. Chronic degeneration occurs when an injured tendon fails to heal.

When a tendon does not heal, the condition is known as tendinosis. The tendon is damaged at a cellular level leading to chronic degeneration without inflammation. Most tendinopathies involve tendinosis, as confirmed by tissue analysis of injured patients.

Causes

Rotator cuff tendinopathy occurs when tendons are injured and reinjured because of repetitive overhead reaching, lifting, or pushing with outstretched

10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com arms. At risk are athletes who perform overhead activity such as gymnastics, swimming, tennis, golf, throwing, weightlifting, and volleyball. The tendons of the rotator cuff can be torn because of an injury or chronic overuse, or a combination of the two. Injury can result from a fall, direct blow, or use of force.

Diagnosing

Tendinopathy symptoms concerning the rotator cuff include shoulder pain at the tip of the shoulder and upper and outer arm. Greater pain comes with reaching, pushing, pulling, lifting, lying on the side, or placing the arm above the shoulder level. Daily activity can be painful, including brushing hair or putting on clothing. Pain can prevent and awaken a person from sleep.

There are several factors to consider when evaluating a patient with shoulder pain. The diagnosis of a tear of the rotator cuff can be based on the patient’s medical history, symptoms, and a . Inflammation is not always present especially if over 36 hours passed since the aggravating event. Tendinosis could be the diagnosis instead of tendinitis. X-ray imaging and other imaging tests may not be needed at this point. If symptoms do not improve after conservative treatment, an imaging test could be obtained to confirm the diagnosis. Imaging tests can include X- ray, ultrasound, and magnetic resonance imaging (MRI). With a suspected rotator cuff tear, an ultrasound or MRI test is recommended to confirm the tear.

Tear symptoms concerning the rotator cuff generally include weakness in the muscle tendon area and pain in the shoulder. Some people have no symptoms or few symptoms. The severity of the tear may not correlate with the pain level. A person with a partial tear can have severe pain. A complete tear could have little or no pain.

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com To determine if a rotator cuff has a tear, the shoulder may be injected with a local anesthetic. If there is no tear, the anesthetic relieves pain and muscle strength can be normal. With a tear the anesthetic relieves pain but muscle function does not improve.

Basic Approaches of Treatment of Rotator Cuff Injuries

Preserving the ability to move the shoulder is important in the beginning as a primary goal of treating rotator cuff injuries. If a person has a decreased ability to move the shoulder they could use the joint less frequently. This can lead to a frozen shoulder and a further reduction of . The two basic approaches to treatment are conservative (nonsurgical) and surgical.

Inflammation:

Treatment for inflammation (tendinitis) focuses on resting the injured tendon to allow for healing, decreasing inflammation, and correcting the imbalance that caused the stress and injury to the tendon. Tendinitis can resolve with treatment, and can also go away without treatment.

Rotator Cuff Tear:

When treating a rotator cuff tear, identification of the factors that caused the injury should be the first step. A physical examination and review of the patient history can help as can a biomechanical assessment. Developing a treatment plan is the next step.

Treatment plan interventions for a rotator cuff injury can include those listed here. • Exercises for strengthening and stability to restore balance and coordination of the shoulder complex

12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Exercises for the thoracic spine, scapulothoracic joint, glenohumeral joint, and cervical spine to improve shoulder mechanics • Ergonomic adjustments that can include placing keyboards, monitors, and chairs at optimal heights • Training and education to improve sitting, sleeping, and standing postures • Treatment of tissue with manual therapy • Treatment with cross-friction massage, instrument assisted soft tissue mobilization, taping, dry needling, injections, ice, heat, and nonsteroidal anti-inflammatories (NSAIDs)

Conservative treatment can help for a majority of people. A person with a small or medium size tear can improve with physical therapy, ice application, rest, and anti-inflammatory drugs or steroid injection. A patient must stop the activity that caused the stress or pain. Treatment may also include certain exercises.

After three to six months of physical therapy if shoulder strength and function do not improve a surgical repair could be an option. A younger person with a medium or large tear, especially for the dominant arm, can be a candidate for surgical repair. Surgery can also be an option for an older person who has significant pain to a rotator cuff tear.

When a clinician treats a patient and there is no improvement in weakness or pain, and the clinician suspects the patient has a larger tear, the patient should be referred to an orthopedic shoulder specialist for management and evaluation. The eventual treatment for a rotator cuff injury focuses on decreasing pain and swelling of the tendon and can include preserving or restoring normal range of motion, strengthening muscles needed for shoulder function, and restoring normal shoulder mechanics.

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Ice Application:

Ice is used to reduce inflammation often occurring with a rotator cuff injury. Application of ice is generally to the upper and outer portions of the shoulder muscles. It should be used 15 to 20 minutes every 4 to 6 hours.

A patient’s injury may respond to ice applications in a variety of ways because the rotator cuff tendons are deep within the shoulder; i.e., a patient may experience immediate relief with an ice application whereas another may have no improvement or minimal improvement.

Rest:

Rest to the affected shoulder helps alleviate strain to the injured area and results in less pain. It involves avoiding activity that can cause symptoms to get worse. This includes overhead activity that causes pain.

The restricted activities depend on which tendon is irritated. Examples include overhead reaching, lifting, and reaching behind as with putting on a jacket or reaching into a back seat. It is safer to keep the arm down and in front of or close to the body. An arm sling could lead to a frozen shoulder so an arm sling is not an option. The following are guidelines on decreasing shoulder strain.

• The side stroke or breast stroke should be used when swimming • Objects should be lifted close to the body • Light weights should only be lifted and lifting limited to below the shoulder level • Balls should be thrown sidearm or underhand • There should be no overhand plays in tennis • Pushing exercises should be avoided such as pushups, bench presses, and the shoulder press

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Good posture should be maintained during assembly work, when writing, and when completing other tasks, with a focus on maintaining a tall spine, keeping down and back and ribs down

Evaluation And Treatment Of Other Shoulder Conditions

In addition to tendinopathies associated with the shoulder, a patient may present with other shoulder conditions. These include a frozen shoulder and a tear of the superior labral from anterior to posterior (SLAP).

Frozen Shoulder

A frozen shoulder is also known as adhesive capsulitis. It is a condition that includes pain and stiffness in a shoulder joint. Symptoms can be gradual and worsen over time, then resolve over the course of one to three years. The risk of developing a frozen shoulder gets greater if a patient is recovering from a condition preventing the movement of the arm.

Treatment can include exercises involving range of motion, corticosteroids, medications injected into the capsule, and arthroscopic surgery to loosen the joint capsule so it moves more freely, with this being done in a small percentage of cases. It can recur in the opposite shoulder. It is unusual for recurrence in the same shoulder.

The cause of a frozen shoulder is unknown. It is a very painful and disabling disorder where the shoulder capsule – connective tissue around the glenohumeral joint of the shoulder – becomes inflamed. The shoulder becomes stiff and greatly restricted in motion, and chronically painful. The pain is usually constant and worse at night and with cold weather. Some movements can cause tremendous pain. The condition could be caused by trauma or injury at the site. It could involve an autoimmune factor.

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Treatment can include physical therapy, medication, occupational therapy, massage therapy, surgery, and hydrodilatation (a treatment applied by a radiologist where contrast medium, anesthetic, and cortisone are injected into the joint followed by injection of a saline solution to stretch the joint capsule). Treatment can also include manipulation under anesthesia. This breaks up adhesions and scar tissue in the joint. It can help restore range of motion.

Someone with a frozen shoulder can have severe pain. Sleep deprivation can occur due to pain that gets worse when lying still and with restricted movement. A person with the condition can have problems with concentration, working, and completing daily life activity. Treatment can also include analgesics and NSAIDs to treat pain and inflammation.

A frozen shoulder condition can resolve without surgery and over time. Most people obtain about ninety percent of their shoulder motion.

Epidemiology

Frozen shoulder occurs in less than five percent of the general population. It is rare in children and people under the age of 40. It peaks for people between 40 and 70 years of age. It is more common in women than men and more common in a diabetic patient.

A patient is at higher risk for a frozen shoulder if they had or have heart disease, a stroke, lung disease, or rheumatoid arthritis. If there is surgery or an injury to the shoulder or arm, this can cause damage to blood flow or the capsule to tighten as there is reduced use during recovery. These can all be factors to consider.

16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Symptoms and Diagnosis

Severely restricted movement of the shoulder is a symptom. Loss of active and passive range of motion is another symptom. This can result from an injury that leads to pain and a lack of use or it can happen with no obvious trigger. Recent can also cause limitation and pain similar to a frozen shoulder.

In a frozen shoulder, there is a lack of synovial fluid. Synovial fluid normally helps the shoulder (ball and socket) joint move, and lubricates the gap between the humerus and socket of the shoulder blade. The shoulder capsule thickens; it also swells and tightens as bands of scar tissue (adhesions) form inside the capsule. Less room develops in the joint for the humerus. Movement of the shoulder becomes painful and stiff.

Restricted space between the capsule and ball of the humerus is distinctive of a frozen shoulder as compared to a still shoulder that is less painful. A frozen shoulder involves a tight joint. The joint is so stiff it is difficult or almost impossible to carry out a simple movement. This can include raising the arm, and external rotation of the shoulder is inhibited. Pain and stiffness typically worsen at night. The pain is aching and dull and can get worse with motion. Limited shoulder movement is a typical sign of the condition and supports a diagnosis of frozen shoulder.

If there are limits to range of motion, including both active and passive range of motion, the diagnosis of a frozen shoulder is possible. An MRI scan or can confirm the diagnosis but is not typically required.

A frozen shoulder can have three stages. First, the freezing or painful stage can last from six weeks to nine months. The patient can have a slow onset of pain. As the pain gets worse, the shoulder loses motion. Second, the

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com frozen or adhesive state is marked by slow improvement in pain but stiffness remains. This can last from four to six months. Finally, is the thawing or recovery phase. Shoulder motion slowly returns to normal and this can last from five to twenty-six months.

MRI and Ultrasound:

Magnetic resonance imaging, arthrography, and invasive can be accurate in the diagnosis of a frozen shoulder. Features of a frozen shoulder can also be seen in an MRI without contrast. MRI and ultrasound can also be helpful for a diagnosis. They can help assess a coracohumeral ligament. There can be edema or fluid at the rotator interval, which is a space in the shoulder joint normally containing fat between the supraspinatus and subscapularis tendons, medial to the rotator cuff.

A frozen shoulder typically thickens at the axillary pouch and rotator interval; this appears as a dark signal on an MRI with edema and inflammation. A frozen shoulder on an ultrasound can show hypoechoic material surrounding the long head of the biceps tendon. This is at the rotator interval and reveals fibrosis. With a Doppler ultrasound during the painful stage, hypoechoic material can show increased vascularity.

Prevention and Management

There are several factors to consider in the prevention of a frozen shoulder. The shoulder joint should be kept fully moving. A shoulder will hurt when it begins to freeze; and this pain can discourage movement. Adhesions can develop, restricting movement unless the joint continues to move a full range in all directions. Full range of movement in all directions includes adduction, extension, abduction, flexion, and rotation.

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Management of a frozen shoulder can include restoring joint movement and reducing shoulder pain. Physical and occupational therapy can help to keep the area moving. It can also include medications, surgery, and ongoing treatment for months. NSAIDs can help reduce pain in a frozen shoulder. Corticosteroids can also be used systemically or through a local injection. Other treatments to consider include massage therapy and daily extensive stretching. Osteopaths, chiropractors, and physiotherapists may be helpful, in addition to manipulation under general anesthesia to break up adhesions.

An osteopathic approach that can help is the Spencer technique. This is also known as the seven stages of Spencer. It is an articulatory technique and used in osteopathic medicine. It helps to relieve pain and restriction in the shoulder and used to treat a frozen shoulder (adhesive capsulitis). The following is a sequence for the Spencer technique commonly used.

• Glenohumeral extension • Slow gentle springing motions at the point of resistance • Glenohumeral flexion • Circumduction with compression • Circumduction with traction • Abduction of the shoulder joint • Internal Rotation • Joint Pump

One study showed the Spencer technique helped counteract the negative effects of repeated throwing in collegiate baseball players, impacting the glenohumeral joint. Additional studies are needed that focus on the safety and effectiveness of this method on returning players to the sport after injury.

19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com With a frozen shoulder, the condition may become so prolonged and severe that surgery may be required to cut adhesions (capsular release). This procedure may be done using arthroscopy. In addition, surgical evaluation of other problems of the shoulder may include a rotator cuff tear or subacromial bursitis.

Superior Labral Tears

The cartilaginous extensions previously mentioned are called the glenoid labrum. A superior labral from anterior to posterior (SLAP) tear or SLAP lesion is an injury to the glenoid labrum. This is the fibrocartilaginous rim attached around the margin of the glenoid cavity. Common causes of the superior labral tear includes an overhead throwing injury, a compression injury such as bracing for a forward fall, and traction injuries.

When there is damage to the uppermost (superior) area of the labrum, a SLAP tear or lesion occurs. Recent descriptions of athletes who have such a tear have led to public awareness of the injury. There are varieties of SLAP lesions, as listed below. • Type 1 involves fraying of the superior portion of the labrum; fraying is degenerative, remaining attached firmly to the glenoid rim. • Type 2 is a separation of the superior part of the glenoid labrum and tendon of the biceps brachii muscle from the glenoid rim. • Type 3 involves tears of the superior part of the labrum extending into the biceps tendon; these are bucket handle tears that are longitudinal tears. • Type 4 involves tears of the superior part of the labrum with no involvement of the biceps brachii (long head) attachment; these are bucket handle tears. • Type 5 involves tears of the superior part of the labrum extending into the biceps tendon; these are bucket handle tears.

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Type 6 is a lesion that extends upward to include a separation of the biceps tendon; this is an antero inferior Bankart lesion that is an injury of the inferior (anterior) glenoid labrum of the shoulder due to an anterior shoulder dislocation with a pocket at the front of the glenoid forming to allow the humeral head to dislocate into it • Type 7 involves unstable radial flap tears; these are associated with separation of the biceps anchor • Type 8 is an anterior extension of a SLAP lesion beneath the middle glenohumeral ligament.

Symptoms and Diagnosis

Symptoms to consider in a diagnosis of SLAP include a dull and aching pain. The patient can also experience throbbing pain brought on with exertion and difficulty sleeping due to pain in the shoulder. A drop in the shoulder can happen as the SLAP lesion decreases stability of the joint, which is made worse when lying in bed.

Loss of strength for an athlete when throwing is another symptom. Loss of velocity in throwing for an athlete and impingement brought on with an applied force overhead of pushing into the shoulder are additional possible symptoms.

The diagnosis of a SLAP tear can come from a physical examination or an MRI test. Diagnostic arthroscopy may be needed. Debridement or repair also follows, as necessary. Debridement is the removal of dead or infected tissue to improve healing. This means the healing potential improves for the remaining healthy tissues. Removal can be mechanical, surgical, or chemical.

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A SLAP lesion involves the superior labrum, anterior and posterior, as raised previously. Symptoms that are part of the diagnosis can include instability and pain with movement. Dead arm syndrome can be part of the diagnosis. This syndrome starts with forces on the posterior capsule of the shoulder. It also involves repetitive motion. This posterior capsule is a band of fibrous tissue. This band connects with tendons of the rotator cuff of the shoulder.

Hypertrophy can result with overuse that leads to a buildup of tissues around the posterior capsule. It also involves tightness of the posterior capsule. This is called posterior capsular contracture. This problem reduces how much the shoulder can rotate inward.

With time and enough force, a tear of the labrum could develop, compromising the labrum’s ability to hold the head of the humerus in the joint. Dead arm phenomenon can result and the shoulder may be unstable and potentially vulnerable to dislocation.

Dead arm syndrome does not go away without treatment. With a SLAP lesion, surgery alone can repair the problem. If the injury comes before a SLAP tear, physical therapy can restore it. Stretching and exercise could be beneficial.

Treatment

Nonsurgical treatments include rest, nonsteroidal anti-inflammatories (NSAIDs), and physical therapy. With physical therapy can come strength that supports muscles in the shoulder joint and return of stability in the shoulder. If there is no improvement after three months of nonsurgical therapies, surgery for a superior labral tear could then be an option.

With surgical treatments, the success rate for repairing an isolated SLAP tear can be over 75 percent. Surgery can be traditional or arthroscopic, which is

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com less intrusive and has a lower chance of infection. Reports of complications are great for those over 40 years and for those who have an additional rotator cuff injury. Remember that a SLAP tear is an injury to the labrum of the shoulder (which is the ring of cartilage surrounding the socket of the shoulder joint), and the cause of the injury can be trauma or repetitive shoulder motion. Superior labral tears can also happen from wearing down of the labrum. This can happen slowly and over time. For a patient over the age of 40, fraying and tearing of the superior labrum can be a part of the aging process in contrast to an acute injury in a person who is less than 40 years old.

Nonsurgical treatments include medication, physical therapy, and exercise. Surgical treatment could be an option if pain does not improve with nonsurgical methods. A partial repair can be appropriate for a patient with a retracted rotator cuff tear.

Arthroscopy:

Arthroscopy is a surgical technique commonly used to treat a SLAP injury. It involves inserting a camera called an arthroscope into the shoulder joint. The camera displays images on a screen, and the surgeon looks at these images to guide surgical instruments.

The arthroscope and surgical instruments are thin. The surgeon uses small incisions and cuts in contrast to the large incisions needed for standard and open surgery.

Several repair options are available to address SLAP tears. Determination of how best to repair a SLAP injury can occur after observation with an arthroscope. Repair can include removing the torn part of the labrum, and

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com the surgeon can then reattach the torn part with stitches. In some cases, cutting the bicep tendon attachment could be needed.

A surgeon will look for the best repair option. This is based on the type of tear plus the activity level and age of the patient. The surgeon also looks at other injuries observed during the surgery. Factors to consider are complications, rehabilitation, wearing of a sling, physical therapy, and returning to sports activity.

Complications are rare after shoulder arthroscopy. While there are always risks with surgery, with shoulder arthroscopy the complications can be minor and treatable, such as infection, blood clots, shoulder stiffness, excessive bleeding, and damage to nerves or blood vessels.

Rehabilitation After Surgery

Rehabilitation after surgery is supervised and progressive. The first phase has a focus on early motion. It usually occurs at weeks one through three after the surgery. The goal is to restore passive range of motion to the shoulder, forearm, elbow, and wrist joints. Manual resistance exercises for scapular protractions, elbow extension, and pronation and supination can be included. Elbow flexion resistance is not normally included because of the bicep contraction generated. The labral repair needs to be protected for at least six weeks. Patients can wear a sling for comfort at the first phase. The second phase normally occurs at weeks four through six. This involves progression of strength and range of motion. The attempt is to achieve progressive abduction. The attempt is also external rotation in the shoulder joint.

The third phase usually covers weeks six through ten. This phase permits elbow flexion resistive exercise. At weeks 10 through 12-16, isokinetic

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com exercises can begin. This can include advanced strengthening and a return to full activity based on the strength and functional range of motion for the patient. Final phases can include four and five of the final goals of healing following surgery and stability and generally involves a postsurgical evaluation.

Rehabilitation starts with the understanding that the repair should be protected while the labrum heals. Wearing an arm sling keeps the arm from moving.

Physical therapy can involve several considerations. It should start after initial pain and swelling subside and be individualized to fit the needs of the patient. The focus at first is on flexibility. Stretching that is gentle improves range of motion and prevents stiffness in the shoulder. Exercises for strengthening the shoulder muscles and rotator cuff get added to the program as healing progresses, typically four to six weeks after surgery.

Returning to sports activity is managed by the patient’s physician and can be about three to four months after surgery. There are several factors concerning outcomes after surgery for a SLAP tear. The majority of patients report less pain after surgery and improved shoulder strength. Complete recovery time varies from patient to patient, based on varied health conditions. Complete recovery can take several months in the case of a complicated repair and injury. Rehabilitation can be slow but is vital to a successful outcome.

Treatment Options for Rotator Cuff Injury

In addition to the treatment options above, there are a number of treatments that a clinician may consider for a patient with a rotator cuff injury.

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Stem Cells or Growth Factor

One possible treatment to promote rotator cuff healing is to inject a patient’s own stem cells or another growth factor into the repair site. Another treatment could be to install scaffolds that are a natural or artificial support to maintain tissue contour.

Tenodesis and Tenotomy

For a patient with a rotator cuff tear and a bicep tendon lesion, alternatives for treatment could be bicep tenodesis and tenotomy. Tenodesis is a minimally invasive shoulder procedure that is an open or arthroscopic procedure. The tendon is released and then sutured into place. Tenodesis generally restores strength and function. With a tenotomy, the surgeon releases the injured biceps tendon from its attachment to the shoulder joint, and does not reattach it. The remaining tendons provide adequate stability in this case. This leads to relief of the pain that was caused by the tear and lesions. Tenotomy tends to be more for an older patient. It is a shorter surgery with less, required rehabilitation.

A tendon transfer is an option usually for a young patient with an active cuff tear. The patient has weakness, no pain, and decreased range of motion. The technique is not appropriate for older patients. It is also not appropriate for a patient with pre-operative stiffness or nerve injuries.

Hemiarthroplasty

For a patient diagnosed with glenohumeral arthritis and rotator cuff anthropathy, an option is hemiarthroplasty. This involves replacing the humerus part of the shoulder joint. For an older patient with degenerative glenohumeral arthritis and cuff tears that recur, a total () could be an option. A reverse total shoulder arthroplasty is

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com another surgery that could be effective. A reverse shoulder replacement installs the ball part of an artificial joint into the shoulder blade. The socket part goes into the arm bone.

Oral Medications

Treating inflammation and pain can be through oral medication, such as an NSAID. Patients should check with a health clinician before taking high doses of NSAIDs.

Massage and Heat

Light massage to surrounding tissue can be effective when preparing an area for range of motion and strength exercises. Heat can also prepare tissues for range of motion exercises. Heat and massage are recommended before performing these exercises. A good method to warm tissues is to take a warm shower or bath for ten to fifteen minutes. Local heat such as a moist heating pad or hot pack warmed in a microwave oven is an option. Local heat may not be as effective as the rotator cuff tendons are located deep in the shoulder.

Stretching and Range of Motion

There are many factors to consider regarding exercising for stretching and range of motion. Early in the recovery period the use of range of motion exercises to maintain joint mobility and flexibility of the muscles and tendons of the shoulder should be done. Stretching exercises should be performed once every day. Exercising should not cause more than a mild pain level.93

If a patient experiences pain they should decrease the intensity of the stretching and number of repetitions. If a patient feels sharp or tearing pain, they should stop exercising immediately and consult with a health clinician.

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Pendulum Stretch:

The pendulum stretch exercises the space where the tendons pass and helps prevent a frozen shoulder. A patient can start this exercise almost immediately after a shoulder injury, and also after receiving a steroid injection into the shoulder joint. Guidelines on performing this exercise are highlighted here.

• Relax the shoulder muscle • Stand or sit and keep the arm vertical and close to the body as bending over too far can pinch the rotator cuff tendons • Let the arm slowly swing back and forth, side to side, and in small circles in each direction without added weight, doing this for three to seven days • Increase the stretch by adding one to two pounds per week and gradually increasing the diameter of the movement not to exceed 18 to 24 inches

Pulley Exercises:

Guidelines for forward flexion using a pulley with a weight of 1.5 to 2 pounds attached to one handle are listed below.

• Sit with back to the door • Allow the pulley to lift the involved arm upward within a pain free range of motion slowly and painlessly for two minutes; use slow and steady movement with 2 to 3 seconds to raise and two to three seconds to lower the weight • Keep motion in a pain free range • Stop the exercise if pain develops

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Wand Exercises:

The purpose of wand exercises is to extend the arm at shoulder height at 90 degrees from the body by using a long wooden rod or broom stick. This is done as follows.

• Hold the end of the rod with the hand from the injured side and with the other hand hold the rod in the middle • With the hand at middle of the rod guide the rod so the arm with the injury extends away from the body and until it is about shoulder height or lower if you feel pain, keeping the injured arm straight at all times • Slowly lower the injured arm until it is next to the body • Rest as needed and repeat 15 to 20 times each day

As a variation, the rod can be used to direct the hand in front of the body but not higher than shoulder height and slightly behind the body. This should be stopped if the stretch causes pain. Once the arm can be extended to shoulder height, the exercise can be modified as listed below.

• Lie on the back • Hold the rod against the abdomen with both elbow straight and hands that are shoulder wide apart • Keep elbow straight • Lift arms up to shoulder height and keep shoulder blades squeezed down and back together • Return want to rest on the abdomen • Complete this exercise 5 to 10 times; lift the want to 90 degrees at shoulder height and if there is no pain move the wand slowly through a full range of motion with no pain, and increasing to two sets

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Posterior Capsule Stretching

Tightness in the ligaments and capsule of the shoulder can develop with a rotator cuff injury. Tightness can contribute to further abnormalities in movement and pain in the shoulder. Factors that can cause tightness are poor posture (forward shoulder posture), history of repetitive throwing or racquet sport, guarded movement as when protecting the shoulder, and injury to the shoulder to include rotator cuff strains, partial tears, and complete tears.

A skilled health clinician can most effectively passively stretch the posterior capsule as outlined here.

• Reach the affected arm across the body at check height • Use the other hand to pull the arm closer to the body • Hold for 30 seconds • Do this regularly throughout the day

Strength and Function Exercises

Strength and function exercises are important for restoration of strength and coordination of the rotator cuff, functional use of the arm and prevention of future injuries. Exercises should begin if they do not cause pain. The patient’s health clinician should always be consulted on exercising following surgery.

The difficulty of these exercises should be increased as pain subsides. Increasing the difficulty is needed to improve shoulder strength and control to the degree this reduces the chance of a re-injury. Expect mild soreness when doing these exercises. Pain should not continue for more than 24 hours. The exercises should be stopped for a few days if severe or sharp

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com pain is experienced during or after doing exercises. This can indicate a flare of the underlying problem.

Guidelines to follow to prepare for strengthening exercises are listed here.

• Before completing strength exercises focus therapy on restoring maximum mobility of the shoulder • Stretch the injured should using the pendulum stretch or wand exercise • Rest after stretching for two to three minutes • Perform repetitions using flexible rubber tubing, a bungee cord, or a large rubber band • Do not perform strengthening exercises if acute discomfort or pain in the shoulder are felt • Do not allow strengthening exercises to cause any sharp or severe pain while doing them

Scapular Squeezes:

• Lie on the back • Keep knees bent back and feet flat • Keep arms straight out at 6 to 12 inches away from the side of the body • Keep the palms facing upward • Keep the lower back flat against the ground • Squeeze the shoulder blades downward and towards each other, towards the spine • Make an effort to not shrug the shoulders • Keep the neck relaxed • Feel the lower muscles between the shoulder blades contracting • Hold for five seconds • Rest as needed • Repeat 10 to 15 times

31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Do this two to three times a day • Increase the difficulty by completing the squeezes while sitting • Hold a piece of tubing in each hand and pull the hands apart while squeezing the shoulder blades together

Elbow taps on all fours (quadruped):

• Assume a position on all fours • Keep weight on the arms and legs • Keep a flat back with palms flat on the ground and straight • Remove the uninjured arm and place that hand on the opposite shoulder • Do not lose the position of the trunk and spine or arm and shoulder, maintaining proper body position • Hold this position for five to eight seconds • Return the hand to the ground and pause three to five seconds • Repeat the exercise for five to eight repetitions on each side • Feel the arm that holds the body up as well as the trunk • Make this exercise easier by rocking back toward the legs to remove weight from the arms

Outward Rotation Exercise:

• Hold elbows at 90 degrees, close to the sides • Hold a towel between the torso • Note that the inside of the elbow provides cues to keep the elbow by the side • Hold one end of a long rubber band such as a Theraband in each hand • Rotate the injured forearm outward two or three inches • Hold for five seconds • Repeat 10 to 15 times • Complete the exercise through all available pain free ranges of motion

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Keep the shoulder blades squeezed down and back when completing this exercise

Inward Rotation Exercise:

• Hold the elbow at 90 degrees and close to the side • Hook a rubber band such as a Theraband onto a door handle • Grasp with one hand only • Rotate the forearm toward the body two or three inches • Hold for five seconds • Swing the forearm like a door • Repeat 10 or 15 times

Abduction Exercise:

• Bend the elbow to 90 degrees • Place a rubber band such as a Theraband near the elbows • Keep the shoulder blades squeezed down and backwards • Lift arms up four or five inches away from the body, holding for five seconds • Repeat 10 to 15 times • Avoid shrugging the shoulders during this exercise

Scapular Strengthening Exercises:

When doing these exercises a person should lie face down on an elevated surface such as a bed, large exercise ball, or exercise bench. As an alternative, take a quadruped position on all fours, keeping the trunk and shoulder positions maintained with the non-moving arm while the other arm performs the Y, T, W, and L exercise.

Guidelines for the Y exercise: • Hold the head in line with the body.

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Hang over the edge of the bed or bench. • Let the arms rest below the body. • Extend the arms next to the head to form a Y. • Keep thumbs facing up. • Hold the position for a second or two. • Let the arms return to the floor. • Repeat 10 to 15 times. • Keep movements steady, smooth, and pain free.

Guidelines for the T exercise: • Use the same body position. • Squeeze shoulder blades down and backward toward the spine while moving the arms to for a T • Raise the arms straight out to each side • Keep the arms parallel to the floor • Keep the thumbs up or down • Hold for a second or two • Return the arms to the starting position • Repeat 10 or 15 times

Guidelines for the W exercise: • Position the arms to form a W • Hold the arms bent with elbows pointed toward the feet • Keep hands pointed toward the head • Squeeze the shoulder blades and raise the arms until they are parallel with the floor • Hold for a second or two • Return arms to the starting position • Repeat 10 or 15 times

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Guidelines for the L exercise: • Position the arms to form an L • Hold the arms bent with the upper arms parallel to the floor and hands pointed toward the floor • Rotate the arms so that the forearms are parallel with the floor • Hold for a second or two • Return to the starting position • Repeat 10 or 15 time

To increase the difficulty of these exercises, the number of repetitions should be 20 to 30 times. One pound weights to further increase the difficulty should be used.

Maintenance Exercises

When rehabilitation is completed, a patient should keep the shoulder muscles strong. This is important for maintenance of shoulder fitness and to prevent a recurrence of pain. Athletes and non-athletes should continue to exercise.

Athletes should perform exercises similar to those needed in their sport. For example, a tennis play should complete an overhead serving type of motion with a five-pound dumb bell. A pitcher could perform a throwing motion with a three-pound dumb bell.

If frequent overhead activities are performed, strong shoulder blades and rotator cuff muscles should be maintained. This will prevent overuse injuries in these areas. The muscles are important to preventing aggravation of the tendons. After 6 to 12 weeks of rehabilitation most people with rotator cuff tendinitis see improvement in pain and function. If a patient does not see

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com improvement in shoulder pain after several weeks of physical therapy exercise, the patient could seek further evaluation with an imaging study.

If an imaging study confirms tendinitis, an injection could help. A steroid local anesthetic mix is injected into the joint. This does not help in all cases however some people do benefit. For those who benefit, pain and inflammation can improve promptly and this can occur within a few days. Some patients benefit with an injection once a month for up to three months.

If the cause of pain is not tendinitis, it could be a rotator cuff tear, nerve impingement, or other cause. Referral to an orthopedic surgeon could help.

Surgical Repair of a Rotator Cuff Tear

Several factors contribute to the decision that a surgical repair of a torn rotator cuff is a good option. The factors include the severity of the tear, activity levels, and age.

Surgery can be an option and is recommended for someone with a complete rotator cuff tear. This is especially true if a person is young and active. Surgery can be a good option shortly after the injury. This can prevent the muscle and tendon from shrinking.

For a partial tear, surgery is not usually recommended. Also, a nonsurgical approach that is conservative is more in order for someone who is older, less active, and when minimal pain is present. The first recommendation is for conservative treatments such as stretching and strengthening exercises, plus injection of a steroid. If a patient gets no improvement after stretching and strengthening exercises, surgery could be an option. It could be recommended also if a person has persistent pain and limited strength.

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com A candidate for surgery could also be someone who has arthritis or spurs that cause pain and interfere with rehabilitation. A new injury or previous rotator cuff injury can also make a person a candidate for surgery.

There are several ways to repair a rotator cuff including arthroscopic and open techniques. Open repairs require a three to four-inch incision in the skin over the shoulder. An arthroscopic repair requires several smaller incisions through which a telescope like camera and light – called an arthroscope – and other instruments are inserted. An advantage to arthroscopic surgery is usually less pain and a more rapid return to normal activities and sport.

Most of these surgeries take place in a hospital or surgical center. General anesthesia is normally required. The surgery takes one to two hours. Most patients go home several hours after completion of the surgery.

There are many factors to consider in a return to activities after surgery. Most people require about six months of rehab before shoulder function and strength returns to normal. Postsurgical rehab is necessary with use of the shoulder limited. After surgery, patients are allowed to use the affected arm while keeping the elbow at their side when eating, using a keyboard or telephone, and driving. Three months after surgery above the shoulder activity is usually allowed but not before.

A return to sporting activities can be gradually restarted. After four months, patients may return to golf and light weight lifting is allowed. After five months swimming is allowed. After five to six month throwing and tennis are allowed.

37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Summary

The human shoulder is uniquely constructed for lifting, pulling, and pushing objects. It is also mobile enough to allow for a wide range of actions of the hands and arms. These actions or functions may be limited by shoulder pain. This can include injuries and inflammation of a shoulder tendon, joint, surrounding ligament, or periarticular structure. A shoulder examination is needed to evaluate a patient for the possibility of a shoulder condition. Causes of shoulder injuries, diagnoses, and treatments, including when surgery should be an option, are important clinical considerations when attempting to determine the course of care for a shoulder injury.

Several factors contribute to the decision to proceed with shoulder surgery. The factors include the severity of injury, and the age and activity level of the patient. Surgery can be an option and is recommended for someone with a complete rotator cuff tear, especially if a person is young and active. Partial rotator cuff tears are not generally recommended for surgical treatment. Nonsurgical approaches are viewed as more appropriate for older, less active individuals, and also when pain is minimal. The accepted wisdom is to try conservative treatment first, such as stretching and strengthening exercises, and anti-inflammatory and pain medication. If a patient has no improvement with conservative measures, surgery could be an option. Surgery could also be recommended if a person has persistent pain and limited strength, such as someone who has arthritis or spurs. A new injury or previous rotator cuff injury can also make a person a candidate for surgery.

Rotator cuff injury repairs include arthroscopic and open surgical techniques. An advantage to arthroscopic surgery is usually less pain and a more rapid return to normal activities and sport.

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Rehabilitation through strength and function exercises are important for restoration of strength and coordination of the rotator cuff, functional use of the arm and prevention of future injuries. Exercises should begin if they do not cause pain. The patient’s health clinician should always be consulted on exercising following surgery. When rehabilitation is completed, a patient should keep the shoulder muscles strong, which is important for the maintenance of shoulder health.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. The ______joint is the major joint of the shoulder.

a. rotator cuff b. humeral c. glenohumeral d. scapula

2. The rotator cuff adheres to the glenohumeral capsule and also attaches to the

a. clavicle. b. humeral head. c. radial head. d. lateral epicondyle.

3. True or False: The rotator cuff keeps the humeral head in the glenoid cavity when a person elevates his or her arm.

a. True b. False

4. The ______are two filmy and sac like structures that allow smooth gliding between bone, tendons, and muscles; they protect and cushion the rotator cuff.

a. menisci b. brachii c. bursae d. glenoid labrum

5. ______are bands of tissues that connect bones and muscles.

a. Ligaments b. Tendons c. Bursae d. Cartilage

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. If a patient’s tendon does not heal, and the tendon is damaged at a cellular level leading to chronic degeneration without inflammation, the patient has

a. a frozen shoulder. b. tendinitis. c. tendinosis. d. bursitis.

7. Tears to a rotator cuff always includes the following symptoms:

a. weakness in the muscle tendon area. b. pain in the shoulder. c. inflammation. d. None of the above

8. If a patient who has a rotator cuff tear is injected with a local anesthetic in the area of the injury, the patient will experience

a. pain relief but no improved muscle function. b. improved muscle function and pain relief. c. no pain relief but will have improved muscle function. d. inflammation accompanied by pain relief.

9. True or False: Inflammation of a shoulder tendon can resolve with treatment or without treatment.

a. True b. False

10. An ergonomic adjustment that a patient may make to help improve shoulder function could include

a. training and education to improve standing postures. b. treatment with cross-friction massage. c. exercises for the cervical spine to improve shoulder mechanics. d. adjusting a work chair to an optimal height.

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11. Ice applications for inflammation of a rotator cuff should be used

a. 30 minutes or more to be effective. b. 15 to 20 minutes every 4 to 6 hours. c. with cross-friction massage. d. only once a day.

12. Which of the following exercises should be avoided by a patient with a sore or strained shoulder?

a. The side stroke when swimming. b. Lifting light objects below shoulder level. c. The breast stroke when swimming. d. Throwing a ball overhand.

13. A frozen shoulder is also known as

a. bursitis. b. tendinitis. c. adhesive capsulitis. d. tendinosis.

14. True or False: A patient is at higher risk for a frozen shoulder if they had or have heart disease, a stroke, lung disease, or rheumatoid arthritis.

a. True b. False

15. A patient with a frozen shoulder

a. lacks synovial fluid. b. will require surgery to resolve the condition. c. can expect to recover about 50% shoulder function. d. All of the above

16. ______is an articulatory technique that is used in osteopathic medicine to treat a frozen shoulder.

a. Elson's technique b. The Lachman technique c. The open technique d. The Spencer technique

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17. A superior labral from anterior to posterior (SLAP) tear or SLAP lesion is an injury to

a. the teres minor. b. the subscapularis. c. the glenohumeral capsule. d. the glenoid labrum.

18. Rehabilitation after arthroscopic shoulder surgery does NOT include

a. exercises for elbow extension. b. passive range of motion for the wrist joints. c. elbow flexion resistance. d. exercises for scapular protractions.

19. A patient with a rotator cuff tear and a bicep tendon lesion who is treated with a procedure known as a tenotomy can expect

a. the tendon to be repaired and reattached to the shoulder joint. b. relief from shoulder pain. c. a lengthy rehabilitation period. d. restoration of full strength and function.

20. True or False: A tendon transfer is a procedure usually used for older patients.

a. True b. False

21. A procedure used to replace the humerus part of the shoulder joint is called

a. an arthroscopy. b. a tenotomy. c. an arthroscopic debridement. d. a hemiarthroplasty.

43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22. ______and massage are recommended before performing range of motion and strength exercises.

a. Heat b. Ice applications c. Opioid medications d. Restrictive taping

23. The purpose of ______is to extend the arm fulling at shoulder height at 90 degrees from the body by using a long wooden rod or broom stick.

a. wand exercises b. the pendulum stretch c. pulley exercises d. capsule stretching

24. For an older patient with a partial tear of the rotator cuff

a. surgery is the necessary, preferred treatment. b. injection of a steroid is a recommended treatment. c. stretching exercises must be avoided. d. strengthening exercises must be avoided.

25. True or False: Most patients go home several hours after completion of surgery to repair a rotator cuff.

a. True b. False

44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com CORRECT ANSWERS:

1. The ______joint is the major joint of the shoulder.

c. glenohumeral

“The glenohumeral joint is the major joint of the shoulder, which leads to some clinicians calling it the shoulder joint; however, the shoulder includes the acromioclavicular joint.”

2. The rotator cuff adheres to the glenohumeral capsule and also attaches to the

b. humeral head.

“The rotator cuff adheres to the glenohumeral capsule and also attaches to the humeral head.”

3. True or False: The rotator cuff keeps the humeral head in the glenoid cavity when a person elevates his or her arm.

a. True

“The rotator cuff ... keeps the humeral head in the glenoid cavity and prevents upward migration of the humeral head as caused by the pulling of the deltoid muscle at the time of arm elevation.”

4. The ______are two filmy and sac like structures that allow smooth gliding between bone, tendons, and muscles; they protect and cushion the rotator cuff.

c. bursae

“The bursae are two filmy and sac like structures that allow smooth gliding between bone, tendons, and muscles; they protect and cushion the rotator cuff.”

5. ______are bands of tissues that connect bones and muscles.

b. Tendons

“Tendons are bands of tissues that connect bones and muscles.”

45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6. If a patient’s tendon does not heal, and the tendon is damaged at a cellular level leading to chronic degeneration without inflammation, the patient has

c. tendinosis.

“When a tendon does not heal, the condition is known as tendinosis. The tendon is damaged at a cellular level leading to chronic degeneration without inflammation. Most tendinopathies involve tendinosis, as confirmed by tissue analysis of injured patients.”

7. Tears to a rotator cuff always includes the following symptoms:

a. weakness in the muscle tendon area. b. pain in the shoulder. c. inflammation. d. None of the above [correct answer]

“Tear symptoms concerning the rotator cuff generally include weakness in the muscle tendon area and pain in the shoulder. Some people have no symptoms or few symptoms. The severity of the tear may not correlate with the pain level. A person with a partial tear can have severe pain. A complete tear could have little or no pain.”

8. If a patient who has a rotator cuff tear is injected with a local anesthetic in the area of the injury, the patient will experience

a. pain relief but no improved muscle function.

“To determine if a rotator cuff has a tear, the shoulder may be injected with a local anesthetic. If there is no tear, the anesthetic relieves pain and muscle strength can be normal. With a tear the anesthetic relieves pain but muscle function does not improve.”

9. True or False: Inflammation of a shoulder tendon can resolve with treatment or without treatment.

a. True

“Tendinitis can resolve with treatment, and can also go away without treatment.”

46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10. An ergonomic adjustment that a patient may make to help improve shoulder function could include

d. adjusting a work chair to an optimal height.

“Ergonomic adjustments that can include placing keyboards, monitors, and chairs at optimal heights.”

11. Ice applications for inflammation of a rotator cuff should be used

b. 15 to 20 minutes every 4 to 6 hours.

“Ice is used to reduce inflammation often occurring with a rotator cuff injury. Application of ice is generally to the upper and outer portions of the shoulder muscles. It should be used 15 to 20 minutes every 4 to 6 hours.”

12. Which of the following exercises should be avoided by a patient with a sore or strained shoulder?

d. Throwing a ball overhand.

“These are guidelines on decreasing shoulder strain: The side stroke or breast stroke should be used when swimming. Objects should be lifted close to the body. Light weights should only be lifted and lifting limited to below the shoulder level. Balls should be thrown sidearm or underhand. There should be no overhand plays in tennis. Pushing exercises should be avoided such as pushups, bench presses, and the shoulder press.”

13. A frozen shoulder is also known as

c. adhesive capsulitis.

“A frozen shoulder is also known as adhesive capsulitis. It is a condition that includes pain and stiffness in a shoulder joint.”

47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14. True or False: A patient is at higher risk for a frozen shoulder if they had or have heart disease, a stroke, lung disease, or rheumatoid arthritis.

a. True

“A patient is at higher risk for a frozen shoulder if they had or have heart disease, a stroke, lung disease, or rheumatoid arthritis.”

15. A patient with a frozen shoulder

a. lacks synovial fluid.

“Someone with a frozen shoulder can have severe pain.... The condition can resolve without surgery and over time. Most people obtain about ninety percent of their shoulder motion.... In a frozen shoulder, there is a lack of synovial fluid.”

16. ______is an articulatory technique that is used in osteopathic medicine to treat a frozen shoulder.

d. The Spencer technique

“An osteopathic approach that can help is the Spencer technique. This is also known as the seven stages of Spencer. It is an articulatory technique and used in osteopathic medicine. It helps to relieve pain and restriction in the shoulder and used to treat a frozen shoulder (adhesive capsulitis).”

17. A superior labral from anterior to posterior (SLAP) tear or SLAP lesion is an injury to

d. the glenoid labrum.

“A superior labral from anterior to posterior (SLAP) tear or SLAP lesion is an injury to the glenoid labrum.”

48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18. Rehabilitation after arthroscopic shoulder surgery does NOT include

c. elbow flexion resistance.

“Rehabilitation after surgery is supervised and progressive. The first phase has a focus on early motion. It usually occurs at weeks one through three after the surgery. The goal is to restore passive range of motion to the shoulder, forearm, elbow, and wrist joints. Manual resistance exercises for scapular protractions, elbow extension, and pronation and supination can be included. Elbow flexion resistance is not normally included because of the bicep contraction generated.”

19. A patient with a rotator cuff tear and a bicep tendon lesion who is treated with a procedure known as a tenotomy can expect

b. relief from shoulder pain.

“Tenodesis is a minimally invasive shoulder procedure that is an open or arthroscopic procedure. The tendon is released and then sutured into place. Tenodesis generally restores strength and function. With a tenotomy, the surgeon releases the injured biceps tendon from its attachment to the shoulder joint, and does not reattach it. The remaining tendons provide adequate stability in this case. This leads to relief of the pain that was caused by the tear and lesions. Tenotomy tends to be more for an older patient. It is a shorter surgery with less, required rehabilitation.”

20. True or False: A tendon transfer is a procedure usually used for older patients.

b. False

“A tendon transfer is an option usually for a young patient with an active cuff tear. The patient has weakness, no pain, and decreased range of motion. The technique is not appropriate for older patients. It is also not appropriate for a patient with pre-operative stiffness or nerve injuries.”

49 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21. A procedure used to replace the humerus part of the shoulder joint is called

d. a hemiarthroplasty.

“For a patient diagnosed with glenohumeral arthritis and rotator cuff anthropathy, an option is hemiarthroplasty. This involves replacing the humerus part of the shoulder joint.”

22. ______and massage are recommended before performing range of motion and strength exercises.

a. Heat

“Light massage to surrounding tissue can be effective when preparing an area for range of motion and strength exercises. Heat can also prepare tissues for range of motion exercises. Heat and massage are recommended before performing these exercises.”

23. The purpose of ______is to extend the arm fulling at shoulder height at 90 degrees from the body by using a long wooden rod or broom stick.

a. wand exercises

“The purpose of wand exercises is to extend the arm fulling at shoulder height at 90 degrees from the body by using a long wooden rod or broom stick.”

24. For an older patient with a partial tear of the rotator cuff

b. injection of a steroid is a recommended treatment.

“Surgery is usually not recommended for a partial tear. A nonsurgical approach that is conservative is more in order for someone who is older, less active, and when minimal pain is present. The first recommendation is for conservative treatments such as stretching and strengthening exercises, plus injection of a steroid.”

50 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25. True or False: Most patients go home several hours after completion of surgery to repair a rotator cuff.

a. True

“There are several ways to repair a rotator cuff including arthroscopic and open techniques.... Most of these surgeries take place in a hospital or surgical center. General anesthesia is normally required. The surgery takes one to two hours. Most patients go home several hours after completion of the surgery.”

References Section

The reference section of in-text citations includes published works intended as helpful material for further reading. [References are for a multi-part series on Bone And Joint Health].

1. Mayo Clinic. (2017). ACL injury. Retrieved online at http://www.mayoclinic.org/diseases-conditions/acl-injury/home/ovc- 20167375 2. Mayo Clinic. (2017). Posterior cruciate ligament (PCL) injury overview. Retrieved online at www.mayoclinic.org/diseases-conditions/pcl- injury/home/ovc-20268314. 3. Gokeler, A., et al. (2017). Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review. EFFORT Open Reviews. Retrieved online at http://www.efortopenreviews.org/content/2/10/410. 4. Yoon, J.R., et al. (2017). Proprioception in patients with posterior cruciate ligament tears: A meta-analysis comparison of reconstructed and contralateral normal knees. PLoS One. 2017 Sep 18;12(9). Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/28922423. 5. Dexter, W. (2017). Medial collateral ligament injury of the knee. UpToDate. Retrieved online at https://www.uptodate.com/contents/medial-collateral-ligament-injury- of-the-knee 6. Mayo Clinic. (2016). Knee pain: Symptoms. Retrieved online at http://www.mayoclinic.org/symptoms/knee-pain/basics/causes/sym- 20050688

51 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7. Mayo Clinic. (2015). Sprains and strains. Retrieved online at http://www.mayoclinic.org/diseases-conditions/sprains-and- strains/basics/definition/con-20020958 8. Morrison, J. (2015). Lateral collateral ligament sprain and injury. Retrieved online at http://www.healthline.com/health/lateral-collateral- ligament-lcl-injury#outlook7 9. Kijowski, R., et al. (2014). Imaging following acute knee trauma. Osteoarthritis Cartilage. 2014 Oct;22(10):1429-43. 10. Mayo Clinic. (2017). ACL injury. Mayo Clinic. Retrieved online at http://www.mayoclinic.org/diseases-conditions/acl-injury/home/ovc- 20167375. 11. Friedberg, R. (2017). Patient education: Anterior cruciate ligament injury (Beyond the Basics). UpToDate. Retrieved online at https://www.uptodate.com/contents/anterior-cruciate-ligament-injury- beyond-the- basics?search=anterior%20cruciate&source=search_result&selectedTitl e=6~150&usage_type=default&display_rank=6. 12. Mayo Clinic. (2017). Symptoms and causes (ACL injury). Retrieved online at http://www.mayoclinic.org/diseases-conditions/acl- injury/symptoms-causes/dxc-20167379 13. van Eck, C.F., et al. (2013). Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc; 21:1895. Retrieved online at https://link.springer.com/article/10.1007%2Fs00167-012-2250-9 14. Lobo, J., et al. (2017). Case of Acute Concomitant Rupture of Anterior Cruciate Ligament and Patellar Tendon of Knee: Surgical Decision Making and Outcome. J Orthop Case Rep. 2017 May-Jun;7(3):5-8. 15. Mulligan, E., et al (2017). THE DIAGNOSTIC ACCURACY OF THE LEVER SIGN FOR DETECTING ANTERIOR CRUCIATE LIGAMENT INJURY. Int J Sports Phys Ther. 2017 Dec;12(7):1057-1067. 16. Mayo Clinic. (2017). ACL injury diagnosis. Retrieved online at http://www.mayoclinic.org/diseases-conditions/acl-injury/diagnosis- treatment/diagnosis/dxc-20167388 17. American Academy of Orthopaedic Surgeons. (2014). Management of Anterior Cruciate Ligament Injuries: Evidence-Based Clinical Practice Guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons. Retrieved from http://www.aaos.org/research/guidelines/ACLGuidelineFINAL.pdf 18. McMahon P. (2014). Sports medicine. In HB Skinner, PJ McMahon, eds., Current Diagnosis and Treatment in Orthopedics, 5th ed., pp. 88-155. New York: McGraw-Hill

52 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19. Friedberg, R. (2017). Anterior cruciate ligament injury. Retrieved from http://www.uptodate.com/contents/anterior-cruciate-ligament-injury- beyond-the- basics?source=search_result&search=ACL&selectedTitle=1%7E2 20. Voskanian, N. (2013). ACL Injury prevention in female athletes: review of the literature and practical considerations in implementing an ACL prevention program. Curr Rev Musculoskelet Med. 6(2): 158–163. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702781/ 21. Assi, C., et al. (2017). Novel anatomical-based surgical technique for positioning of the patellar component in total knee arthroplasty. Sicot J. 2017;3:67. doi: 10.1051/sicotj/2017053. Epub 2017 Dec 11. 22. McLendon, K. and Attia, M. (2017). Deep Venous Thrombosis (DVT), Risk Factors. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017-2017 Nov 26. 23. Tetreault, MW., et al (2017). A classification-based approach to the patella in revision total knee arthroplasty. Arthroplast Today. 2017 Aug 7;3(4):264-268. 24. Victor, J. (2013). Total knee arthroplasty at 15–17 years: Does implant design affect outcome? Int Orthop.; 38(2): 235-241. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923951/ 25. Martin, G. (2016). Total (arthroplasty). Retrieved online at https://www.uptodate.com/contents/total-knee-replacement- arthroplasty-beyond-the- basics?source=search_result&search=arthroplasty&selectedTitle=1%7E 3 26. Moucha, C., Weiser, M., and Levin, E. (2016). Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/26803543 27. Cao, X. and Pan, F. (2017). Comparison of liposomal bupivacaine infiltration versus interscalene nerve block for pain control in total shoulder arthroplasty: A meta-analysis of randomized control trails. Medicine (Baltimore). 2017 Sep;96(39):e8079. doi: 10.1097/MD.0000000000008079. 28. Moucha, C., Weiser, M., and Levin, E. (2016). Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. Retrieved online at

53 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com https://www.ncbi.nlm.nih.gov/pubmed/26803543 29. Greengard, S. (2015). Clinical Outcomes and Statistics of Knee Replacement. Retrieved online at http://www.healthline.com/health/total-knee-replacement- surgery/outcomes-statistics-success-rate#54. 30. Cluett, J. (2016). How long do knee replacements last? Retrieved online at https://www.verywell.com/how-long-do-knee-replacements-last- 2549612. 31. American Academy of Orthopaedic Surgeons. (2014). Common knee injuries. Retrieved online at http://orthoinfo.aaos.org/topic.cfm?topic=a00325 32. Beutlier, A. (2016). Knee Pain: Beyond the Basics. UpToDate. Retrieved online at http://www.uptodate.com/contents/knee-pain-beyond-the- basics?source=search_result&search=knee&selectedTitle=2~29 33. Cross, M. (2015). Complications of total knee arthroplasty. Retrieved online at http://emedicine.medscape.com/article/1250540-overview 34. Rabin, S. (2016). Periprosthetic and Peri-implant Fractures. Retrieved online at http://emedicine.medscape.com/article/1269334-overview 35. Kapoor, V., et al (2016). Retrospective comparison of functional and radiological outcome, between two contemporary high flexion knee designs. SICOT J. 2016; 2:35. 36. Cleveland Clinic. (2016). Total knee replacement surgery. Retrieved from https://my.clevelandclinic.org/health/articles/total-knee- replacement-surgery 37. Fernandez-Sampedro, M., et al (2017). Accuracy of different diagnostic tests for early, delayed and late prosthetic joint infection. BMC Infect Dis. 2017 Aug 25;17(1):592. 38. Basu, S., et al (2014). FDG-PET for diagnosing infection in hip and knee prostheses: prospective study in 221 prostheses and subgroup comparison with combined 111In-labeled leukocyte/99mTc- sulfur colloid bone marrow imaging in 88 prostheses. Clin Nucl Med. 39(7): 609–615. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113396/. 39. Martin, M., Thornhill, T. and Katz, J. (2015). Complications from total knee arthroplasty. UpToDate. Retrieved online at http://www.uptodate.com/contents/complications-of-total-knee- arthroplasty?source=search_result&search=osteolysis+knee+replaceme nt&selectedTitle=2%7E150.

54 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40. Muderis, M., et al (2017). Single-stage osseointegrated reconstruction and rehabilitation of lower limb amputees: the Osseointegration Group of Australia Accelerated Protocol-2 (OGAAP-2) for a prospective cohort study. BMJ Open. 7(3): Retrieved online at https://www.ncbi.nlm.gov/pmc/articles/PMC5372148/. 41. Martin, G. and Crowley, M. (2017). Total knee arthroplasty. UpToDate. Retrieved online at https://www.uptodate.com/contents/total-knee- arthroplasty?source=search_result&search=total%20knee%20arthropla sty&selectedTitle=1~105. 42. Simons S. and Dixon J. (2017). Physical examination of the shoulder. UpToDate. Retrieved online at http://www.uptodate.com/contents/physical-examination-of-the- shoulder?source=search_result&search=Superior+labral+tears+shoulde r&selectedTitle=3%7E150 43. Ireland, M. and Hatzenbuehler, J. (2016). Superior labrum anterior posterior (SLAP) tears. UpToDate. Retrieved online at http://www.uptodate.com/contents/superior-labrum-anterior-posterior- slap- tears?source=search_result&search=Superior+labral+tears+shoulder&s electedTitle=1%7E1 44. Field, K. (2016). Evaluation of the patient with shoulder complaints. UpToDate. Retrieved online at http://www.uptodate.com/contents/evaluation-of-the-patient-with- shoulder- complaints?source=search_result&search=Superior+labral+tears+shoul der&selectedTitle=2%7E150 45. Finnoff, J. (2017). Musculoskeletal ultrasound of the shoulder. UpToDate. Retrieved online at https://www.uptodate.com/contents/musculoskeletal-ultrasound-of- the- shoulder?search=ultrasound%20shoulder&source=search_result&select edTitle=1~150&usage_type=default&display_rank=1. 46. Simons, S., Dixon, J., and Kruse, D. (2017). UpToDate. Presentation and diagnosis of rotator cuff tears. Retrieved online at https://www.uptodate.com/contents/presentation-and-diagnosis-of- rotator-cuff-tears 47. Mayo Clinic. (2016). Rotator cuff injury. Retrieved online at http://www.mayoclinic.org/diseases-conditions/rotator-cuff- injury/home/ovc-20126921

55 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48. Modarresi, S. and Jude, C. (2016). Radiological evaluation of the painful shoulder. UpToDate. Retrieved online at http://www.uptodate.com/contents/radiologic-evaluation-of-the- painful- shoulder?source=search_result&search=radiological+evaluation+of+the +painful+shoulder&selectedTitle=3~150 49. Factor, D. and Dale, B. (2014). Current concepts of rotator cuff tendinopathy. Int J Sports Phys Ther. 9 (2): 274–88. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/. 50. Sherman, S. (2016). Shoulder dislocation and reduction. UpToDate. Retrieved online at http://www.uptodate.com/contents/shoulder- dislocation-and- reduction?source=search_result&search=Codman+exercises&selectedTi tle=1%7E4 51. Booker, S., et al. (2015). Use of scoring systems for assessing and reporting the outcome results from shoulder surgery and arthroplasty. NIH. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363806/ 52. Mayo clinic. (2013). Surgery Could Be Best Option For Biceps Injury. Retrieved online at http://newsnetwork.mayoclinic.org/discussion/surgery-could-be-best- option-for-biceps-injury/ 53. Hashiuchi, T., Sakurai, G., and Morimoto, M. (2017). Complications of proximal biceps tenotomy and tenodesis. Clin Sports Med; 35:181. 54. Mayo Clinic. (2014). Reverse shoulder replacement. Retrieved online at http://www.mayoclinic.org/diseases-conditions/rotator-cuff- injury/multimedia/img-20128285 55. Fields, K. (2016). Evaluation of the patient with shoulder complaints. UpToDate. Retrieved online at https://www.uptodate.com/contents/evaluation-of-the-patient-with- shoulder-complaints 56. Mayo Clinic. (2015). Frozen shoulder. Retrieved from http://www.mayoclinic.org/diseases-conditions/frozen- shoulder/basics/definition/con-20022510 57. Prestgaard, T. (2017). Frozen shoulder (adhesive capsulitis). UpToDate. Retrieved online at https://www.uptodate.com/contents/frozen- shoulder-adhesive- capsulitis?source=search_result&search=frozen%20shoulder&selectedTi tle=1~30. 58. Mayo Clinic. (2017). A guide to basic stretches. Retrieved online at http://www.mayoclinic.org/healthy- lifestyle/fitness/multimedia/stretching/sls-20076840 59. Curcio, J., et al (2017). Use of the Spencer Technique on Collegiate Baseball Players: Effect on Physical Performance and Self-Report

56 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Measures. The Journal of the American Osteopathic Association, Vol. 117, 166-175. Retrieved online at http://jaoa.org/article.aspx?articleid=2607293 60. Mayo Clinic. (2015). Frozen shoulder. Retrieved online at http://www.mayoclinic.org/diseases-conditions/frozen- shoulder/basics/definitiaion/con-20011510. 61. Prestgaard, T. (2017). Frozen shoulder: beyond the basics. UpToDate. Retrieved online at https://www.uptodate.com/contents/frozen- shoulder-beyond-the- basics?search=frozen%20shoulder&source=search_result&selectedTitle =3~31&usage_type=default&display_rank=3. 62. Modarresi, S. and Jude, C. (2016). Radiological evaluation of the painful shoulder. UpToDate. Retrieved online at http://www.uptodate.com/contents/radiologic-evaluation-of-the- painful- shoulder?source=search_result&search=shoulder+replacement&selecte dTitle=4%7E13 63. Simons, S. (2017). Patient education: Rotator cuff tendinitis and tear (Beyond the Basics). Retrieved online at http://www.uptodate.com/contents/rotator-cuff-tendinitis-and-tear- beyond-the- basics?source=search_result&search=Patient+education%3A+Rotator+ cuff+tendinitis+and+tear+%28Beyond+the+Basics%29&selectedTitle= 1%7E150 64. Factor, D. and Dale, B. (2014). Current concepts of rotator cuff tendinopathy. Int J Sports Phys Ther. 9 (2): 274–88. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004132/ 65. Mayo Clinic. (2015). Rheumatoid arthritis pain: Tips for protecting your joints. Mayo Clinic. Retrieved online at http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/in- depth/arthritis/art-20047954. 66. Kim, Y., et al. (2017). Diagnosis and Treatment of Inflammatory Joint Disease. Hip Pelvis. 2017 Dec;29)4):211-222. 67. van Ballegooijen, A., et al. (2017). The Synergistic Interplay between Vitamins D and K for Bone and Cardiovascular Health: A Narrative Review. UpToDate. Retrieved online at Int. J Endocrinol. 2017; Retrieved online https://www.ncbi.nlm.nih.gov/pubmed/29138634. 68. Gecht-Silver, M. (2017). Joint protection program for the upper limb. UpToDate. Retrieved https://www.uptodate.com/contents/joint- protection-program-for-the-upper- limb?search=joint%20care&source=search_result&selectedTitle=3~150 &usage_type=default&display_rank=3.

57 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69. Gecht-Silver, M. and Duncombe, A. (2017). Overview of joint protection. UpToDate. https://www.uptodate.com/contents/overview- of-joint- protection?search=joint%20care&source=search_result&selectedTitle=1 ~150&usage_type=default&display_rank=1. 70. Mayo Clinic. (2015). Rheumatoid arthritis pain: Tips for protecting your joints. Retrieved online at http://www.mayoclinic.org/diseases- conditions/rheumatoid-arthritis/in-depth/arthritis/art-20047954 71. National Institutes of Health. (2014). Arthritis and rheumatic disease. Retrieved online at https://www.niams.nih.gov/Health_Info/Arthritis/arthritis_rheumatic.as p 72. Barbour, K., et al. (2016). Prevalence of Severe Joint Pain Among Adults with Doctor-Diagnosed Arthritis — United States, 2002–2014. 65(39);1052–1056. Retrieved online at https://www.cdc.gov/mmwr/ 73. Center for Disease Control. (2016). Arthritis Basics. Retrieved online at https://www.cdc.gov/arthritis/basics/index.html 74. March, L., et al. (2014). "Burden of disability due to musculoskeletal (MSK) disorders.". Best practice & research. Clinical rheumatology. 28 (3): 353–66. 75. Mayo Clinic. (2014). Lupus. Retrieved online at http://www.mayoclinic.org/diseases-conditions/lupus/in- depth/definition/con-20019676 76. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2015). Handout on Health: Systemic Lupus Erythematosus. Retrieved online at https://www.niams.nih.gov/health_info/Lupus/default.asp 77. Mayo Clinic. (2016). Psoriatic arthritis. Retrieved online at http: //www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/home/ovc- 20233896 78. Martin, S. and deWeber, K. (2017). Lateral collateral ligament injury and related posterolateral corner injuries of the knee. UpToDate. Retrieved online at http://www.uptodate.com/contents/lateral-collateral-ligament- injury-and-related-posterolateral-corner-injuries-of-the- knee?source=search_result&search=LCL+injury&selectedTitle=1%7E15 0 79. Society Guideline Links: Total Knee Arthroplasty. UpToDate. Retrieved online at https://www.uptodate.com/contents/society-guideline-links- total-knee- arthroplasty?search=partial%20knee%20replacement&source=search_r esult&selectedTitle=4~6&usage_type=default&display_rank=4. 80. Mayo Clinic. (2017). Posterior cruciate ligament. Retrieved from http://www.mayoclinic.org/diseases-conditions/pcl-injury/home/ovc- 20268314

58 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81. Mayo Clinic. (2017). ACL Injury. Retrieved from http://www.mayoclinic.org/diseases-conditions/acl-injury/home/ovc- 20167375 82. Khan, K. and Scott, A. (2017). Overview of overuse (chronic) tendinopathy. UpToDate. Retrieved online at https://www.uptodate.com/contents/overview-of-overuse-chronic- tendinopathy?search=tendonitis&source=search_result&selectedTitle=1 ~150&usage_type=default&display_rank=1. 83. Maruvada, S. and Bhimji, S. (2017). Anatomy, Upper Limb, Shoulder, Rotator Cuff. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017 Jun 15. Retrieved online at https://www.ncbi.nlm.nih.gov/books/NBK441844/. 84. Mayo Clinic. (2016). Osteoarthritis. Retrieved online at http://www.mayoclinic.org/diseases- conditions/osteoarthritis/home/ovc-20198248 85. Jaggi, A. and Alexander, S. (2017). Open Ortho. Rehabilitation for Shoulder Instability – Current Approaches. PMCID: PMC5611703; Suppl-6, M13. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611703/. 86. Simons, S. and Dixon, B. (2017). Physical examination of the shoulder. UpToDate. Retrieved online at https://www.uptodate.com/contents/physical-examination-of-the- shoulder?search=shoulder%20muscles&source=search_result&selected Title=1~150&usage_type=default&display_rank=1. 87. Koehler, S.M. (2017). Acromioclavicular joint disorders. UpToDate. Retrieved online at https://www.uptodate.com/contents/acromioclavicular-joint- disorders?search=glenohumeral%20joint&source=search_result&select edTitle=8~150&usage_type=default&display_rank=8. 88. Krill, M., et al (2017). A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review. The Physician and Sportsmedicine. Vol. 45; No. 4. 89. Fields, K. (2017). Evaluation of the patient with shoulder complaints. UpToDate. Retrieved online at https://www.uptodate.com/contents/evaluation-of-the-patient-with- shoulder- complaints?search=shoulder%20conditions&source=search_result&sele ctedTitle=1~150&usage_type=default&display_rank=1. 90. Blache, Y. et al (2017). Muscle function in glenohumeral joint stability during lifting task. Plos One. Retrieved online at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.01894 06. 91. Ma, C. (2015). Rotator Cuff Problems. Retrieved online at https://medlineplus.gov/ency/article/000438.htm

59 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 92. American Academy of Orthopaedic Surgeons. (2012). Rotator Cuff and Shoulder Conditioning Program. Retrieved online at http://orthoinfo.aaos.org/topic.cfm?topic=A0066393 93. Athwal, G. and Fabing, M. (2017). Reverse total shoulder replacement. Retrieved online at http://orthoinfo.aaos.org/topic.cfm?topic=a00504 94. Manner, P. (2016). Knee replacement implants. Retrieved online at http://orthoinfo.aaos.org/topic.cfm?topic=a00221 95. Young, B., et al (2017). Trends in Surgery in Patients with Rheumatoid Arthritis. J Rheumatol. 2017 Dec 1. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/29196384. 96. Nordquist, D. and Halaszinsky, T. (2014.). Perioperative Multimodal Anesthesia Using Regional Techniques in the Aging Surgical Patient Pain Res Treat. 2014; 2014: 902174. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918371/ 97. American Academy of Orthopaedic Surgeons. (2014). Preparing for joint replacement surgery. Retrieved online at http://orthoinfo.aaos.org/topic.cfm?topic=a00220 98. Frombach, A., et al. (2017). Humeral Head Replacement and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fracturesm. Open Orthop J. 2017 Sep 30;11:1108-1114. Retrieved online at https://www.ncbi.nlm.nih.gov/pubmed/29152005.

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