Question 1

According to Neer's classification of rotator cuff disease, which of the following stages is seen most often in patients 25 to 40 years of age and characterized by tendonitis or bursitis but not a rotator cuff tendon rupture?
A)Stage I
B)Stage II
C)Stage III
D)Stage IV

Accepted Answer

Stage II of Neer's classification is most often seen in patients aged 25 to 40 and is characterized by tendonitis or bursitis without a rotator cuff tendon rupture.

Question 2

Which of the following surgical procedures is performed for recurrent anterior instability or dislocation of the glenohumeral joint and involves reattachment and repair of the capsulolabral complex to the anterior rim of the glenoid?
A)Anterior capsular shift
B)Bankart repair
C)Hill-Sachs repair
D)SLAP lesion repair

Accepted Answer

The Bankart repair is the surgical procedure performed for recurrent anterior instability or dislocation of the glenohumeral joint and involves reattachment and repair of the capsulolabral complex to the anterior rim of the glenoid. The anterior capsular shift is a procedure that tightens and shifts the capsular tissue to reduce excessive glenohumeral translation. The Hill-Sachs repair is performed for impaction fractures of the humeral head that occur with anterior dislocation or instability. The SLAP lesion repair is performed for injuries to the superior labrum, typically from repetitive overhead throwing or traumatic events.

Question 3

You are developing an exercise program for a patient who has adhesive capsulitis of the right shoulder.You have determined that the signs and symptoms identified during your examination are consistent with stage 2, the "freezing" stage, of this disorder.In addition to maintaining mobility of joints distal to the shoulder, which of the following interventions for the shoulder is most appropriate at this time?
A)Low-intensity progressive resistance exercise, mobilization with movement techniques, and manual stretching of the shoulder and scapular stabilization exercises with progressive weight bearing through the upper extremity
B)Grade III joint-mobilization techniques, self-stretching, and strengthening exercises
C)Gentle weight bearing on the involved upper extremity to develop scapular control and active ROM of the shoulder (e.g., wand and wall-climbing exercises)
D)Grades I and II joint distraction and gliding techniques, pendulum exercises, passive or active-assistive ROM within pain-free ranges, and muscle setting exercises for shoulder musculature

Accepted Answer

During the "freezing" stage of adhesive capsulitis, the focus of treatment should be on pain control and maintaining range of motion through gentle, pain-free exercises. Therefore, Grades I and II joint distraction and gliding techniques, pendulum exercises, and passive or active-assistive ROM are appropriate interventions. Strengthening exercises should be avoided at this stage to prevent further pain and inflammation.

Question 4

Which of the following is a true statement about glenohumeral arthroplasty?
A)Hemiarthroplasty is most often performed using an arthroscopic approach.
B)The primary indication for glenohumeral arthroplasty is limited mobility of the shoulder.
C)A reverse total shoulder arthroplasty (rTSA) is an appropriate procedure for a patient with marked instability of the glenohumeral joint and a rotator cuff that is not repairable.
D)For adequate exposure of the joint during surgery, the muscle that routinely must be released (and reattached prior to closure) is the anterior deltoid.

Accepted Answer

A reverse total shoulder arthroplasty (rTSA) is specifically designed for patients with marked instability of the glenohumeral joint and a rotator cuff that is not repairable. Hemiarthroplasty may be performed arthroscopically, but it is not the most common approach. The primary indication for glenohumeral arthroplasty is pain and/or loss of function, not limited mobility alone. To expose the joint during surgery, the subscapularis muscle is typically released, not the anterior deltoid.

Question 5

You are treating a patient with a painful shoulder as the result of supraspinatus tendonitis from chronic impingement.There is no evidence of tendon rupture or joint instability.Acute symptoms have subsided.Each of the following is appropriate to improve active elevation of the arm at this stage of rehabilitation except:
A)Reinforce the importance of maintaining an erect trunk during elevation of the arm.
B)Teach the patient to apply cross-fiber massage to the supraspinatus tendon while it is on a stretch, followed by isometric contractions of the muscle.
C)As the patient actively elevates the arm within the pain-free range, apply an anterior glide of the head of the humerus (mobilization with movement technique).
D)Strengthen key scapular stabilizers, such as the serratus anterior, middle trapezius, and lower trapezius, in closed-chain and open-chain positions.

Accepted Answer

Applying an anterior glide of the head of the humerus during active elevation of the arm could potentially increase impingement of the supraspinatus tendon under the acromion, which is counterproductive in the rehabilitation of supraspinatus tendonitis from chronic impingement. The goal is to reduce impingement, not potentially exacerbate it.

Question 6

For effective shoulder function, each of the following is necessary except:
A)Appropriate movement and stability of the scapula.
B)Greater mobility in the external rotators than the internal rotators.
C)A balance in strength of the external and internal rotators.
D)Thoracic extension and axial extension of the cervical spine.

Accepted Answer

Greater mobility in the external rotators than the internal rotators is not necessary for effective shoulder function. In fact, having balanced mobility and strength between the internal and external rotators is important for proper shoulder stability and function. However, appropriate movement and stability of the scapula, a balance in strength of internal and external rotators, and thoracic and cervical spine extension are all necessary for effective shoulder function.

Question 7

Muscles that typically are shortened in patients with increased thoracic kyphosis; forward head; and protracted, forward tilted scapula are the:
A)Teres major and minor, subscapularis, infraspinatus, and triceps.
B)Pectoralis major and minor, latissimus dorsi, infraspinatus, and teres minor.
C)Pectoralis major, teres major and minor, and serratus anterior.
D)Pectoralis minor, subscapularis, and levator scapulae.

Accepted Answer

Increased thoracic kyphosis, forward head, and protracted, forward-tilted scapula are typically associated with shortened pectoralis minor, subscapularis, and levator scapulae muscles. These muscles contribute to the posture by pulling the shoulders forward and elevating or tilting the scapula.

Question 8

Each of the following is correct about precautions that should be taken after repair of a full-thickness rotator cuff tear associated with chronic impingement except:
A)After a traditional open repair for a massive cuff tear, postpone active ROM exercises until about 2 weeks postoperatively to avoid avulsion of the deltoid that was detached and reattached during the procedure.
B)When the patient is lying in the supine position during the early postoperative days, place a folded towel under the humerus to position the arm slightly anterior to the frontal plane of the body to minimize anterior translation of the head of the humerus and the potential for impingement.
C)Before initiating active elevation of the arm in the sitting or standing position, restore strength in the rotator cuff muscles, especially the supraspinatus and infraspinatus muscles, to prevent superior translation of the head of the humerus during active elevation of the arm.
D)Delay weight-bearing/closed-chain exercises on the operated upper extremity for about 6 weeks.

Accepted Answer

Active ROM exercises can be initiated soon after surgery but should be done cautiously to avoid excessive tension on the sutured cuff. Postponing active ROM exercises until 2 weeks after surgery is not necessary.

Answer: D
 Weight-bearing/closed-chain exercises can put excessive stress on the healing cuff and should be avoided for about 6 weeks after surgery.

Option B and C are correct statements about precautions that should be taken after repair of a full-thickness rotator cuff tear associated with chronic impingement.

Question 9

Of the following activities, which is the most appropriate choice for developing stability of the scapulothoracic joint?
A)While in the supine position, have the patient perform repeated concentric contractions of the scapular protractors against manual resistance applied to the anterior aspect of the shoulder.
B)While standing, have the patient place the arms in a reverse-T position while holding a piece of elastic tubing between the hands.Then have the patient attempt to "pinch the shoulder blades together" repeatedly against the elastic resistance.
C)Have the patient stand, face a wall, place the hands on the wall, and lean into the wall as the therapist applies alternating resistance against the shoulders.
D)Have the patient hold the arms in various positions in space (perform isometric contractions) as the therapist applies resistance in various directions.

Accepted Answer

The answer of Of the following activities, which is the...

Question 10

Which of the following is a true statement about an arthroscopic subacromial decompression procedure?
A)It is indicated for a patient who sustains a full-thickness, traumatic tear of the rotator cuff if coupled with a repair of torn cuff tissues.
B)It may or may not involve resection of the anterior acromial protuberance and contouring of the undersurface of the remaining acromion.
C)It is indicated for a patient with secondary impingement syndrome due to glenohumeral joint hypermobility/instability.
D)During surgery, the deltoid must be detached for adequate exposure of the suprahumeral space.

Accepted Answer

The arthroscopic subacromial decompression procedure may or may not involve resection of the anterior acromial protuberance and contouring of the undersurface of the remaining acromion depending on the surgeon's preference and the patient's specific condition. It is not indicated for a traumatic tear of the rotator cuff if coupled with a repair, nor is it necessary to detach the deltoid muscle during the procedure. It is primarily indicated for patients with subacromial impingement syndrome.

Question 11

Your patient exhibits a forward head posture and excessive thoracic kyphosis.Considering the muscles that typically are weak with this faulty posture, which of the following muscles of the shoulder girdle are most important to strengthen?
A)Pectoralis minor and levator scapulae
B)Serratus anterior and levator scapulae
C)Upper and lower trapezius and serratus anterior
D)Upper and lower trapezius and pectoralis minor

Accepted Answer

With a forward head posture and excessive thoracic kyphosis, the upper and lower trapezius and serratus anterior are the most important muscles to strengthen. The upper trapezius and levator scapulae tend to be overactive and tight in this posture, so strengthening them may not be beneficial. Meanwhile, pectoralis minor may be lengthened and weak, but it is not as crucial to address as the other muscles mentioned.

Question 12

Which of the following is a true statement about surgical repair of the rotator cuff and postoperative management?
A)Regardless of the size of the cuff tear, the shoulder is immobilized in an abduction splint for a period of time after surgery.
B)If the size and severity of the tears are similar, rehabilitation after repair of an acute, traumatic cuff tear typically progresses more rapidly than after repair of an atraumatic tear associated with chronic impingement.
C)Detachment of the deltoid from its proximal insertion is a necessary component of a traditional open repair or an arthroscopically assisted repair (mini-open).
D)The quality of the patient's tissues (tendon and bone) has little to no impact on the progression of rehabilitation.

Accepted Answer

Rehabilitation after repair of an acute, traumatic cuff tear typically progresses more rapidly than after repair of an atraumatic tear associated with chronic impingement if the size and severity of the tears are similar.

Question 13

After closed reduction of an anterior dislocation of the glenohumeral joint, which of the following is the safest and most effective procedure to increase mobility of the joint for external rotation of the shoulder?
A)With the shoulder in the resting position, apply a grade II distraction of the humerus.
B)With the shoulder in the resting position, apply a grade III anterior glide of the humerus.
C)With the shoulder placed at the end of the available range of external rotation, apply a grade III anterior glide of the humerus.
D)With the shoulder in the resting position, externally rotate the shoulder and apply a grade III distraction of the humerus.

Accepted Answer

The answer of After closed reduction of an anterior dislocation...

Question 14

Rotator cuff disease is multifactorial and is associated with both intrinsic and extrinsic factors affecting the structures in the suprahumeral space.Of the following contributing factors, which is classified as an intrinsic factor?
A)Vascular changes in the rotator cuff tendons
B)Hypertrophic degenerative changes of the acromioclavicular joint
C)The shape of the acromion
D)Increased thoracic extension

Accepted Answer

Vascular changes in the rotator cuff tendons are considered intrinsic factors because they originate within the structure of the rotator cuff itself. Hypertrophic degenerative changes of the acromioclavicular joint and the shape of the acromion are extrinsic factors that affect the suprahumeral space. Increased thoracic extension can also be considered an extrinsic factor because it affects the position and movement of the shoulder joint, rather than originating within the rotator cuff itself.

Question 15

Which of the following is an inappropriate component of an exercise program 1 to 3 weeks postoperatively for a patient without preoperative rotator cuff deficiency who underwent total shoulder replacement?
A)Wand exercises for active-assistive external rotation to neutral with the arm positioned near the side of the chest
B)Wand exercises for active-assistive shoulder extension (combined with internal rotation) by placing the wand behind the back and sliding it up the back
C)Pendulum exercises
D)Wand exercises for active-assistive elevation of the arm in the plane of the scapula to approximately 90° while in a supine or sitting position

Accepted Answer

Wand exercises for active-assistive shoulder extension (combined with internal rotation) by placing the wand behind the back and sliding it up the back should be avoided in the first 3 weeks postoperatively for a patient without preoperative rotator cuff deficiency who underwent total shoulder replacement. This exercise places excessive tension on the subscapularis, which is one of the rotator cuff muscles that may have been repaired during the surgery. The other choices are appropriate exercises for this patient population during the early postoperative phase.

Question 16

Results of numerous outcome studies have demonstrated that the most predictable outcome after shoulder arthroplasty is:
A)Increased active shoulder ROM.
B)Increased shoulder-joint stability.
C)Pain relief.
D)Improved function of the rotator cuff mechanism.

Accepted Answer

Numerous outcome studies have consistently shown that the most predictable outcome after shoulder arthroplasty is pain relief. Other outcomes, such as increased active shoulder ROM, increased shoulder-joint stability, and improved function of the rotator cuff mechanism, may also occur but are less predictable.

Question 17

Pendulum (Codman's) exercises are used most effectively:
A)As a grade II oscillation technique to inhibit pain and maintain mobility.
B)As a strengthening exercise when a weight is held in the hand or placed around the wrist.
C)To stretch the shoulder musculature and increase range of motion (ROM) when a patient does not have antigravity control of shoulder movement.
D)As a grade III distraction technique to increase ROM when mobility of the scapula is normal but there is chronic stiffness of the glenohumeral joint.

Accepted Answer

Codman's pendulum exercises are used as a grade II oscillation technique to inhibit pain and maintain mobility.

Question 18

Each of the following is a true statement about rehabilitation following dislocation of the glenohumeral joint except:
A)After an initial dislocation and a course of nonoperative management, recurrence of a dislocation is higher in older patients (greater than 40 years of age) than in younger patients (less than 30 years of age).
B)Anterior dislocation is far more common than posterior dislocation.
C)A compression fracture of the posterolateral margin of the humeral head is an associated lesion that may occur as the result of a traumatic anterior dislocation.
D)A fall on the arm when it is positioned in flexion, adduction, and internal rotation can result in a posterior dislocation.

Accepted Answer

The statement in option A is false. After an initial dislocation and a course of nonoperative management, recurrence of a dislocation is higher in younger patients (less than 30 years of age) than in older patients (greater than 40 years of age).

Question 19

Which of the following functional activities should a patient avoid for the longest period of time after rTSA?
A)Reaching overhead
B)Hugging with both arms
C)Reaching into abduction in the plane of the scapula at a drive-through window
D)Fastening a bra behind the back

Accepted Answer

Fastening a bra behind the back typically requires both internal rotation and extension, movements that are significantly restricted or advised against for an extended period after reverse total shoulder arthroplasty (rTSA) to ensure proper healing and to avoid dislocation or damage to the surgical repair.

Question 20

Which of the following is true about postoperative precautions and the rate of progression of rehabilitation after surgery for glenohumeral instability?
A)Progress upper extremity weight-bearing exercises more slowly/cautiously after surgery for posterior instability than for anterior instability.
B)Progress exercises more slowly/cautiously if the origin of the instability was traumatic versus atraumatic.
C)Progress exercises more slowly/cautiously after an arthroscopic capsular shift involving imbrication and suturing the capsule than after an arthroscopic thermally assisted capsular shift.
D)Progress ROM into internal rotation more slowly/cautiously after surgery for anterior instability than for posterior instability.

Accepted Answer

Posterior instability requires more cautious progression of weight-bearing exercises due to the nature of the instability and the structures involved.

Quiz 17: The Shoulder and Shoulder Girdle

According to Neer's classification of rotator cuff disease, which of the following stages is seen most often in patients 25 to 40 years of age and characterized by tendonitis or bursitis but not a rotator cuff tendon rupture?

Which of the following surgical procedures is performed for recurrent anterior instability or dislocation of the glenohumeral joint and involves reattachment and repair of the capsulolabral complex to the anterior rim of the glenoid?

Which of the following is a true statement about glenohumeral arthroplasty?

For effective shoulder function, each of the following is necessary except:

Muscles that typically are shortened in patients with increased thoracic kyphosis; forward head; and protracted, forward tilted scapula are the:

Each of the following is correct about precautions that should be taken after repair of a full-thickness rotator cuff tear associated with chronic impingement except:

Of the following activities, which is the most appropriate choice for developing stability of the scapulothoracic joint?

Which of the following is a true statement about an arthroscopic subacromial decompression procedure?

Your patient exhibits a forward head posture and excessive thoracic kyphosis.Considering the muscles that typically are weak with this faulty posture, which of the following muscles of the shoulder girdle are most important to strengthen?

Which of the following is a true statement about surgical repair of the rotator cuff and postoperative management?

After closed reduction of an anterior dislocation of the glenohumeral joint, which of the following is the safest and most effective procedure to increase mobility of the joint for external rotation of the shoulder?

Rotator cuff disease is multifactorial and is associated with both intrinsic and extrinsic factors affecting the structures in the suprahumeral space.Of the following contributing factors, which is classified as an intrinsic factor?

Which of the following is an inappropriate component of an exercise program 1 to 3 weeks postoperatively for a patient without preoperative rotator cuff deficiency who underwent total shoulder replacement?

Results of numerous outcome studies have demonstrated that the most predictable outcome after shoulder arthroplasty is:

Pendulum (Codman's) exercises are used most effectively:

Each of the following is a true statement about rehabilitation following dislocation of the glenohumeral joint except:

Which of the following functional activities should a patient avoid for the longest period of time after rTSA?

Which of the following is true about postoperative precautions and the rate of progression of rehabilitation after surgery for glenohumeral instability?