For effective shoulder function, each of the following is necessary except:
Greater mobility in the external rotators than the internal rotators.
Appropriate movement and stability of the scapula.
A balance in strength of the external and internal rotators.
Thoracic extension and axial extension of the cervical spine.
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?
Upper and lower trapezius and pectoralis minor
Serratus anterior and levator scapulae
Pectoralis minor and levator scapulae
Upper and lower trapezius and serratus anterior
Pendulum (Codman’s) exercises are used most effectively:
As a strengthening exercise when a weight is held in the hand or placed around the wrist.
As a grade II oscillation technique to inhibit pain and maintain mobility.
To stretch the shoulder musculature and increase range of motion (ROM) when a patient does not have antigravity control of shoulder movement.
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.
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?
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
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
Grade III joint-mobilization techniques, self-stretching, and strengthening exercises
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)
Which of the following is a true statement about glenohumeral arthroplasty?
Hemiarthroplasty is most often performed using an arthroscopic approach.
The primary indication for glenohumeral arthroplasty is limited mobility of the shoulder.
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.
For adequate exposure of the joint during surgery, the muscle that routinely must be released (and reattached prior to closure) is the anterior deltoid.
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?
Wand exercises for active-assistive external rotation to neutral with the arm positioned near the side of the chest
Wand exercises for active-assistive shoulder extension (combined with internal rotation) by placing the wand behind the back and sliding it up the back
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
Results of numerous outcome studies have demonstrated that the most predictable outcome after shoulder arthroplasty is:
Increased active shoulder ROM.
Increased shoulder-joint stability.
Improved function of the rotator cuff mechanism.
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?
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?
Hypertrophic degenerative changes of the acromioclavicular joint
Vascular changes in the rotator cuff tendons
The shape of the acromion
Increased thoracic extension
Muscles that typically are shortened in patients with increased thoracic kyphosis; forward head; and protracted, forward tilted scapula are the:
Teres major and minor, subscapularis, infraspinatus, and triceps.
Pectoralis major and minor, latissimus dorsi, infraspinatus, and teres minor.
Pectoralis minor, subscapularis, and levator scapulae.
Pectoralis major, teres major and minor, and serratus anterior.
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:
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).
Reinforce the importance of maintaining an erect trunk during elevation of the arm.
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.
Strengthen key scapular stabilizers, such as the serratus anterior, middle trapezius, and lower trapezius, in closed-chain and open-chain positions.
Which of the following is a true statement about an arthroscopic subacromial decompression procedure?
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.
It is indicated for a patient with secondary impingement syndrome due to glenohumeral joint hypermobility/instability.
It may or may not involve resection of the anterior acromial protuberance and contouring of the undersurface of the remaining acromion.
During surgery, the deltoid must be detached for adequate exposure of the suprahumeral space.
Which of the following is a true statement about surgical repair of the rotator cuff and postoperative management?
Regardless of the size of the cuff tear, the shoulder is immobilized in an abduction splint for a period of time after surgery.
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.
Detachment of the deltoid from its proximal insertion is a necessary component of a traditional open repair or an arthroscopically assisted repair (mini-open).
The quality of the patient’s tissues (tendon and bone) has little to no impact on the progression of rehabilitation.
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:
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.
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.
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.
Delay weight-bearing/closed-chain exercises on the operated upper extremity for about 6 weeks.
Of the following activities, which is the most appropriate choice for developing stability of the scapulothoracic joint?
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.
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.
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.
Have the patient hold the arms in various positions in space (perform isometric contractions) as the therapist applies resistance in various directions.
Each of the following is a true statement about rehabilitation following dislocation of the glenohumeral joint except:
Anterior dislocation is far more common than posterior dislocation.
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).
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.
A fall on the arm when it is positioned in flexion, adduction, and internal rotation can result in a posterior dislocation.
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?
With the shoulder in the resting position, apply a grade III anterior glide of the humerus.
With the shoulder in the resting position, apply a grade II distraction of the humerus.
With the shoulder in the resting position, externally rotate the shoulder and apply a grade III distraction of the humerus.
With the shoulder placed at the end of the available range of external rotation, apply a grade III anterior glide of the humerus.
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?
Anterior capsular shift
SLAP lesion repair
Which of the following is true about postoperative precautions and the rate of progression of rehabilitation after surgery for glenohumeral instability?
Progress exercises more slowly/cautiously if the origin of the instability was traumatic versus atraumatic.
Progress upper extremity weight-bearing exercises more slowly/cautiously after surgery for posterior instability than for anterior instability.
Progress exercises more slowly/cautiously after an arthroscopic capsular shift involving imbrication and suturing the capsule than after an arthroscopic thermally assisted capsular shift.
Progress ROM into internal rotation more slowly/cautiously after surgery for anterior instability than for posterior instability.
Which of the following functional activities should a patient avoid for the longest period of time after rTSA?
Fastening a bra behind the back
Hugging with both arms
Reaching into abduction in the plane of the scapula at a drive-through window
Each of the following muscles work to rotate the scapula upwardly except the:
An increased thoracic kyphosis is often accompanied by any of the following impairments except:
Tightness in the pectoralis minor.
Weakness in the shoulder internal rotators.
Weakness in the shoulder external rotators.
Tightness in the scalenes.
Your patient has been identified as having impingement syndrome of the shoulder secondary to faulty posture in the shoulder girdle. Typically, which pair of muscles will need strengthening exercises?
Deltoid and pectoralis major
Supraspinatus and teres minor
Infraspinatus and teres minor
Teres minor and teres major
The scaption plane is often preferable to the frontal or sagittal plane for exercise because of each of the following reasons except:
More functional activities occur in the scaption plane than the others.
Less muscle effort is required to raise the arm in the scaption plane.
No external rotation is required to prevent impingement from the greater tubercle.
There is less tension on the joint capsule in the scaption plane.
The stage of idiopathic frozen shoulder that is characterized by pain only with movement, substitute scapular motions, and atrophy of the deltoid and rotator cuff is which of the following?
Stage 2, or freezing stage
Stage 4, or thawing stage
Stage 3, or frozen stage
Appropriate interventions for your patient with glenohumeral hypomobility during the protection phase could include any of the following except:
Gentle isometric exercise to scapular muscles.
Grade III glenohumeral joint distraction.
Passive range of motion in pain-free ranges.
Your patient has had a glenohumeral joint manipulation under anesthesia, and you are asked to provide patient education. You counsel the patient to sleep with her arm in what position as much as is possible?
Shoulder girdle elevation and shoulder flexion
Shoulder abduction and external rotation
Shoulder girdle elevation and shoulder adduction
Shoulder adduction and internal rotation
The primary goal of total shoulder arthroplasty is which of the following?
Improve range of motion of the glenohumeral joint
Improved function with ADLs
Improved strength of glenohumeral muscle groups
Your patient has supraspinatus tendonitis with impingement syndrome, and you are applying ultrasound to promote healing. You place the shoulder in which of the following positions to best access this area?
Shoulder horizontal abduction
Shoulder internal rotation with hand behind the back
Shoulder external rotation in the 90/90 position
You are working on closed-chain stabilization with a patient in quadruped, and you are applying alternating isometric resistance to the scapular muscles. If your patient does not have adequate scapular stabilization, you will observe which of the following?
The most frequently torn tendon of the rotator cuff is which of the following?
Which of the following is generally not indicated as an intervention during the moderate protection phase after rotator cuff surgical repair?
Self-assisted range of motion
Passive shoulder stretching
Supine shoulder elevation
Upper extremity ergometry
Which of the following motions is contraindicated during the protection phase after an anterior shoulder dislocation and reduction?
Shoulder external rotation with elbow at side
Shoulder internal rotation with elbow at side
Shoulder extension beyond 0°
You are doing a manual stretch in which you kneel behind the patient and grasp the patient’s elbows as he brings them out to the sides with hands clasped behind the head. As the patient exhales, you hold the elbows at end range. Which muscles are you stretching?
After surgical repair of a rotator cuff tear, all of the following are done to minimize anterior translation of the humeral head except:
In supine, support the humerus on a folded towel.
For passive internal rotation, position the humerus in slight flexion and 45° abduction.
For passive external rotation, position the humerus in slight flexion and 45° abduction.
For initial shoulder-assisted extension, position the patient prone and work from 90° to 0° extension.
The plan of care for your patient with diagnosis of infraspinatus tendonitis includes performing cross-friction massage to the tendon. Where will you palpate to locate the tendon for treatment?
Superior to the coracoid process with the patient’s hand at his side
Just inferior to the anterior aspect of the acromion with the patient’s hand positioned behind his back
Inferior to the posterior corner of the acromion with the patient’s arm in 90/90 and horizontal adduction
Medial to the bicipital groove of the humerus with the patient’s arm in external rotation
Your patient has a diagnosis of shoulder impingement syndrome, and you have been asked to teach him a home exercise to strengthen the supraspinatus muscle. All of the following would be safe and effective to include except:
“Full can” arm elevation
“Empty can” arm elevation
Elastic resistance to elevation of the arm while in shoulder abduction and external rotation
Elevation and depression of the scapula occur in which anatomical plane?
Your patient has shoulder instability and you are focusing treatment on stabilization of the scapulothoracic region. Which of the following exercise techniques is the most effective for activation of these muscles according to recent research?
Shoulder flexion and abduction with the Bodyblade
Shoulder flexion and abduction with free weights
Shoulder flexion and abduction with elastic resistance
Closed-chain wall leans in a position of flexion and abduction
Your patient, a 19-year-old college student, sustained a nondisplaced fracture of the distal humerus, which was managed by closed reduction and 6 weeks of immobilization in a cast. Yesterday the cast was removed and the patient is to begin exercises to improve range of motion (ROM) and strength of the elbow. Your examination reveals significant limitation of elbow flexion/extension and forearm pronation/supination as well as reduced joint play at the elbow. The patient describes her elbow as feeling “very stiff,” but pain occurs only when overpressure is applied at the end of the available ranges. One of the goals in this patient’s treatment plan is to increase elbow ROM. With which of the following techniques should you begin to increase ROM?
Manual passive stretching to lengthen muscles that cross the elbow
Cross-fiber massage of the tendons inserting at the elbow
Joint-mobilization techniques to stretch the restricted joints (grade III sustained glide or grade IV oscillation techniques) after evaluating the reactivity of the elbow joints with grade II sustained glides
Passive ROM within pain-free ranges
When a period of continuous immobilization of the elbow is required after trauma or surgery, the elbow often is positioned in only a moderate amount of flexion (20 to 30) rather than 90 of flexion. This position is selected to:
Decrease the risk of radial neuropathy from compression of the radial nerve in the cubital tunnel.
Decrease the risk of ulnar neuropathy from compression of the ulnar nerve in the cubital tunnel.
Decrease the risk of median nerve neuropathy from compression in the cubital tunnel.
Decrease the risk of overstretching the lateral collateral ligament complex of the elbow that could cause posterior translation of the radial head.
The most common fracture in the elbow region is a fracture of the head and neck of the radius. All of the following are true about medical management of this injury except:
Improved ROM is the primary indication for surgery and the primary goal of postoperative rehabilitation following a radial head fracture.
Open reduction and internal fixation is the preferred technique if stable fixation can be achieved and the patient is a young, active adult.
Closed reduction is preferred for radial head fractures in children.
Biomechanical studies demonstrate that implant arthroplasty after a severely comminuted fracture restores stability and kinematics similar to the native radial head.
A person with a long history of polyarticular rheumatoid arthritis is experiencing severe, dominant-side elbow pain that is interfering with personal grooming, light housework, and work-related responsibilities as a computer programmer. In addition to pain, physical findings include persistent synovitis despite ongoing medical management, limited elbow ROM, and complete loss of the joint space of the humeroulnar and humeroradial joints. Given these findings, this person is most likely a candidate for which of the following surgical procedures to relieve pain and improve daily function?
Total elbow arthroplasty
Excision of the radial head coupled with prosthetic implant
Arthrodesis of the elbow
Which of the following is true about total elbow arthroplasty (TEA)?
A semiconstrained, linked prosthesis allows flexion and extension of the elbow but not varus, valgus, or rotational motions.
One of the more common, long-term complications after TEA is joint instability, particularly with unlinked implants or in patients who previously underwent excision of the radial head.
The typical method of fixation of the implants is all-cementless (all-biological) fixation.
The surgical approach most often used leaves the triceps tendon intact.
Each of the following is a precaution that should be taken after TEA involving a triceps-reflecting or triceps-splitting approach except:
Limit assisted elbow flexion to about 90 to 100 for the first 3 to 4 weeks postoperatively.
For about the first 3 to 4 weeks, perform active elbow flexion/extension only while lying in the supine position.
Postpone elbow extension against manual resistance or light weights for 6 weeks or longer.
Avoid pushing motions with the operated upper extremity during functional activities, such as pushing up from a chair, for at least 6 weeks.
Which of the following is true about myositis ossificans (heterotopic bone formation) in the elbow region?
After the acute inflammatory period, heterotopic bone is laid down within muscle fibers and within the joint.
The muscle most often affected in the elbow region is the biceps brachii.
It is distinguished from traumatic arthritis of the humeroulnar joint in that passive extension is more limited than flexion.
Before the bony mass in the muscle has matured, the muscle should be stretched and massaged regularly to prevent a contracture.
You place your patient’s wrist in a splint because he is experiencing an acute episode of lateral epicondylitis. Which of the following is the least appropriate intervention while the inflamed soft tissue is healing?
Have the patient remove the splint several times a day and perform gentle muscle-setting exercises, elongating the involved muscle-tendon unit slightly after each contraction but not beyond the pain-free ranges.
Have the patient remove the splint several times each day and perform active or self-assisted ROM of the wrist within pain-free ranges.
Have the patient wear a splint to immobilize the wrist continuously for at least 2 weeks or until there is no pain.
Apply cross-fiber massage at the site of the lesion.
You are modifying a home exercise program for a patient recovering from an episode of medial epicondylitis. Although pain has subsided, there is evidence of mild limitation of motion and pain when the involved muscle-tendon unit is placed on a stretch and overpressure is applied at the end of the available ROM. To fully lengthen the muscle-tendon unit typically involved in medial epicondylitis, have the patient perform a self-stretch by using the opposite hand to:
Extend and ulnarly deviate the wrist and extend the fingers while the elbow is extended and the forearm is pronated.
Flex and radially deviate the wrist and flex the fingers while the elbow is extended and the forearm is supinated.
Flex and ulnarly deviate the wrist and flex the fingers while the elbow is extended and the forearm is pronated.
Extend and radially deviate the wrist and extend the fingers while the elbow is extended and the forearm is supinated.
To strengthen the elbow extensors in a closed chain, you have the patient perform push-ups, using body weight as the source of resistance. Which of the following variations of push-ups provides the greatest amount of resistance to the elbow extensors?
Bilateral push-ups while in a fully prone position on the floor with weight on the hands and toes
Bilateral wall push-ups while in a standing position and leaning into and pushing away from the wall
Bilateral push-ups while standing and leaning on the hands on a kitchen countertop
Bilateral push-ups in a prone position with weight on the hands and knees
Using a handheld weight as the source of resistance, which of the following positions to strengthen the elbow extensors begins with the long head of the triceps brachii fully lengthened?
Have the patient assume a prone-lying position with the shoulder in 90 abduction, the upper arm supported on the table, and the elbow flexed to 90
With the patient standing or sitting in a chair, begin with the elbow fully flexed and the arm elevated overhead and stabilized to maintain the shoulder in as much flexion as possible.
Have the patient assume the supine position with the shoulder flexed to 90 and the elbow flexed so the handheld weight touches the opposite shoulder.
While the patient is in a standing position and the hips are flexed to 90, begin with the shoulder in hyperextension.
Your goal is to increase end-range elbow flexion using joint-mobilization techniques. Which of the following techniques is appropriate?
Stabilize the distal humerus and apply a proximal glide of the ulna
Stabilize the distal humerus and apply an ulnar (lateral) glide of the ulna
Apply a valgus stress at the elbow
Stabilize the humerus and apply a dorsal glide to the head of the radius
You are educating your patient about returning to functional activities following a radial head resection with an implant. What should you tell her about returning to high-demand, high-impact activities?
Because she had a radial head implant, she may return to these activities after 6 months.
Avoid these activities on a permanent basis.
She may return to heavy lifting after 6 months, but not high-impact (tennis or golf) activities because of the ballistic force these activities create.
She should have had a TEA if she wanted to return to these activities.
Tennis elbow may involve all of the following structures except the:
Extensor carpi radialis brevis.
Current research shows that the “survival rate” for TEA is:
30% over a 10-year period.
Greater for patients with rheumatoid arthritis than for those with traumatic arthritis or osteoarthritis.
Highly correlated with the type of implant (prosthesis).
Greater for young, active adults who provide consistent stress to the fixation, encouraging increased bone formation and less loosening of the implant.
A patient who is a golfer places the most stress on which of the elbow ligaments?
Medial collateral ligament
Lateral collateral ligament
Coracoacromial arch ligament
The elbow flexor that is least affected by shoulder or forearm position is which of the following?
The distal upper extremity nerve that passes through the cubital tunnel posteromedial to the olecranon process is which of the following?
The mechanism of injury for a pulled elbow could be any of the following except:
A fall on an outstretched hand.
Lifting a child off the ground by the hand.
Hanging by the arms from a high bar at the playground.
Jerking to lift a heavy object such as a suitcase.
Surgical options for a person with elbow joint disease include any of the following except:
Resection of the radial head.
Any of the patients with the following conditions could be at risk for developing myositis ossificans except one with:
Traumatic brain injury.
Tear of the brachialis tendon.
Your patient has lateral epicondylitis and is in the acute stage of recovery. You want to initiate gentle isometric exercise and so place the wrist in which of the following positions?
Your patient with medial epicondylitis is in the controlled motion phase of recovery, and you are initiating muscle performance exercises with free weights. You use which of the following dosages of exercise?
High weight, high repetitions
High weight, low repetitions
Low weight, low repetitions
Low weight, high repetitions
Open-chain combined pushing motions to focus on the elbow could be any of the following except:
Upper extremity ergometry.
“Walking” hands on a stair-climbing machine.
Which of the following interventions is contraindicated in your patient with traumatic injury to the brachialis muscle?
Submaximal isometric exercises
Stretching to the elbow flexors
Cryotherapy to the injured area
Passive range of motion of the elbow
Precautions after a total elbow arthroplasty would include any of the following except:
Avoid recreational activities such as golf and tennis.
Perform ROM exercises only within the range achieved during surgery.
Avoid any single lift of more than 25 lb.
If symptoms of ulnar nerve compression are noted, avoid prolonged positioning in end-range flexion.
Factors that could lead to implant loosening of an elbow arthroplasty can include any of the following except:
Lack of adherence to postoperative activity modification.
Plyometric exercises for the elbow are primarily done to improve which of the following?
The best starting position in which to use a wrist roller to build strength and endurance of the muscles affected by medial epicondylitis is which of the following?
Elbows extended, forearms pronated
Elbows flexed, forearms supinated
Elbows flexed, forearms pronated
Elbows extended, forearms supinated
A dynamic splint used to help improve an elbow flexion contracture is affecting which of these soft tissue properties?
All of the following are correct terms for a medial elbow tendinopathy except:
You are evaluating a patient with rheumatoid arthritis (RA) of the hand and wrist. You notice several deformities, including hyperextension of the proximal interphalangeal (PIP) joints and flexion of the distal interphalangeal (DIP) joints of digits 2, 3, and 4. This deformity is called:
What is the biomechanical cause of a Boutonnière deformity?
Rupture of the central band (central slip) of the extensor hood mechanism, causing the lateral bands to slip in a volar direction at the PIP joint
Overstretching of the volar plate (palmar plate) and bowstringing of the lateral bands of the extensor hood mechanism
Volar displacement of the extensor carpi ulnaris tendon, causing a flexion force at the wrist joint
Overstretching or rupture of the collateral ligaments of the metacarpophalangeal (MP) joints
Each of the following is true regarding management of the patient with RA of the hands except:
With MP joint deformities, forceful pinch and grip exercises are contraindicated.
Principles of joint protection and energy conservation are integral components of patient education to reduce deforming forces on involved joints and reduce excessive fatigue.
Progressive resistance exercise is contraindicated so long as there are signs of inflammation.
Application of an orthosis should be avoided in the rheumatoid hand because it promotes loss of joint mobility.
Your patient has a 5-year history of RA. There are no obvious deformities, but during this current exacerbation of the disease, the wrist and MP joints are swollen, red, tender, and warm. There is generally decreased range of motion (ROM), pain during joint motion, and increased pain at the end of the available range of each joint. An appropriate short-term goal and intervention is:
Minimize deforming forces by maintaining ROM with gentle, passive stretching to the involved joints.
Maintain joint mobility and decrease pain by using grade I or II joint-oscillation techniques.
Increase muscle length by using contract–relax (hold–relax) techniques.
Control pain by imposing continuous rest and using orthoses on the wrists and hands.
A patient with RA of the hands and wrists is experiencing an acute flare of the disease. To protect the inflamed joints and minimize deforming forces on the hands and wrists, you should teach the patient to:
Avoid all activities with the hands until there is no pain.
Avoid strong gripping motions that require wrist extension, radial deviation of the wrist, and ulnar deviation of the fingers.
Exercise the hands in functional ways such as wringing out a dishrag under warm water.
Stretch the extrinsic finger tendons across all the joints simultaneously to gain mobility and counter contractures.
Which of the following is a relative or absolute contraindication for wrist arthroplasty despite debilitating pain in the wrist region and diminished hand and upper extremity function from advanced arthritis?
The need to perform high-load, high-impact occupational tasks postoperatively
Significant, arthritis-related, ipsilateral limitation of motion of joints proximal and distal of the wrist
Subluxation or dislocation of the radiocarpal joint
Previous arthritis-related arthrodesis of the opposite wrist where arthrodesis of both wrists would potentially reduce, rather than improve, function
Which of the following is least appropriate after arthroplasty of the wrist?
Manual stretching techniques to restore full ROM of the wrist during the final phase of rehabilitation
Active wrist flexion/extension (greater emphasis on extension) and forearm pronation/supination (greater emphasis on supination) as soon as the immobilization device can be removed for exercise
Low-intensity (about 1 lb) dynamic resistance exercises of the wrist and hand during the intermediate and late phases of rehabilitation
Use of the hand for light functional activities at about 3 months postoperatively
Which of the following is a true statement about MP arthroplasty and postoperative management of the fingers?
After MP arthroplasty and removal of the postoperative compression dressing, a dynamic orthosis with an outrigger is worn to maintain the MP joints in full extension when the fingers are relaxed but allow active MP flexion within a limited range and unrestricted interphalangeal (IP) motions.
Repair of ruptured extrinsic finger flexor tendons often is coupled with MP joint replacement arthroplasty for the patient with RA and chronic tenosynovitis.
If a patient has an ulnar drift deformity of the fingers, use of a dynamic orthosis is contraindicated postoperatively.
Use of a static orthosis has been shown to be an ineffective alternative to a dynamic orthosis for improving ROM and function after MP arthroplasty.
Each of the following is correct about PIP arthroplasty, associated soft tissue reconstruction, and postoperative management except:
After PIP arthroplasty that included correction of a swan-neck deformity, emphasize PIP flexion and DIP extension more so than PIP extension and DIP flexion.
When initiating ROM of the PIP joint after PIP arthroplasty, stabilize the MP and DIP joints in neutral.
Because correction of a boutonnière deformity during PIP arthroplasty involves a central slip-splitting approach, it is important to postpone resisted PIP extension exercises for at least 6 to 8 weeks.
For functional grasp after PIP arthroplasty, more flexion of the PIP joints of the index and middle fingers is necessary than flexion of the ring and little fingers.
Which of the following is a true statement about carpometacarpal (CMC) arthroplasty of the thumb and postoperative management?
For a patient with erosion of the articular surfaces and subluxation of the CMC joint, joint replacement arthroplasty with prosthetic implants is a far more common procedure than trapezial resection/tendon interposition arthroplasty with ligament reconstruction.
After CMC arthroplasty, the thumb is immobilized in palmar abduction.
A longer period of immobilization of the thumb is required after total joint arthroplasty with prosthetic implants than after trapezial resection/tendon interposition arthroplasty with ligament reconstruction.
A priority in a postoperative exercise program is to gain active radial adduction combined with palmar adduction of the thumb (sliding the thumb across the palm) as early as possible.
Each of the following descriptions of the flexor zones of the hand and forearm is correct except:
Zone IV includes the carpal tunnel; the extrinsic flexor tendons can adhere in the tunnel following inflammation.
Zone III is in the palm of the hand; injury in this area can damage the lumbricales and interfere with MP flexion.
Zone II, known as “no-man’s land,” is where the extrinsic flexor tendons (flexor digitorum superficialis and profundus) lie in close proximity; range-limiting adhesions that prevent tendon gliding are likely to develop in this area after injury and repair.
Zone I is where the flexor digitorum superficialis (FDS) tendon inserts; if the tendon avulses, the patient will be unable to flex the DIP joint.
Each of the following is true about the use of early controlled motion after tendon repair in the hand and forearm except:
When ROM exercises are initiated, they are performed within a protected range to minimize the risk of excessive stress on the repair site and gapping of the repaired tendon ends.
It is used more often after extensor tendon repair than after flexor tendon repair.
It has been shown to increase the tensile strength of the scar at the repair site more effectively than the use of prolonged immobilization after a surgical repair.
It is thought to improve synovial fluid diffusion, thereby improving tendon nutrition and promoting tendon healing.
During the subacute stage of soft tissue healing after injury and repair of the flexor tendons of the hand or forearm, each of the following is an important intervention except:
Gentle prolonged stretch.
Scar management with pressure on the scar.
Progressive resistance exercise.
Your patient sustained a laceration of the palmar aspect of the fingers in zone II (“no-man’s land”) of the hand. The patient subsequently underwent a repair of the lacerated tissues. During the subacute (moderate protection) phase of healing, it is critical to:
Begin tendon-gliding exercises to minimize the formation of range-limiting adhesions.
Keep the fingers immobile because there is poor circulation and therefore poor healing in this area.
Initiate maximum-level resistance exercises of the extrinsic flexors to regain normal strength of the injured muscle-tendon unit.
Limit exercise to passive ROM to protect the healing tendons.
Which of the following is true about regimens that employ customized orthoses and early controlled motion after flexor tendon repair in zone I, II, or III?
May involve the use of a dorsal tenodesis orthosis that allows full active extension of the wrist and MP joints
May involve the use of a dynamic dorsal blocking orthosis with elastic bands attached, allowing limited active finger extension and providing passive finger flexion
May involve the use of a dynamic dorsal blocking orthosis with elastic bands attached, providing full passive extension of the fingers and allowing limited active flexion of the fingers
May involve the use of a volar tenodesis orthosis that allows full ROM of the wrist while maintaining the fingers in full extension
Each of the following is true about lesions of the extensor tendons of the wrist and hand except:
A laceration of the extensor tendons in zone VII can cause a wrist flexion deformity and requires surgery to repair the lesion.
A lesion of the central tendon (central slip) of the extensor hood, if untreated, will result in a PIP flexion contracture and boutonnière deformity over time.
A mallet finger is a lesion of the extensor mechanism of the DIP joint and is managed nonoperatively with an orthosis for positioning in full extension.
If a tendon lesion occurs in zone V, PIP and DIP extension is disrupted, but MP extension remains intact.
“Place-and-hold” exercises are:
Gentle muscle setting (isometric/static) exercises used during the early phase of rehabilitation after, for example, a tendon repair, whereby an involved finger is placed passively in a particular position (by the therapist or by the patient using the sound hand); the patient then is asked to try actively to hold the position without assistance.
A form of dynamic exercises in which the patient actively moves through a series of hand positions to prevent tendon adhesions.
A form of isometric exercise in which the therapist places a finger in a particular position and then asks the patient to hold the position as manual resistance is applied to the contracting muscle.
A form of stretching exercise in which a patient is asked to perform an isometric contraction of a muscle-tendon unit against low-intensity resistance followed by relaxation and elongation of that muscle.
Each of the following is true about flexor tendon-gliding exercises except:
Maintain or develop free gliding between the FDS and FDP tendons and adjacent bones.
To perform these exercises, the patient actively moves the fingers into five different positions.
Maintain or develop free gliding between the FDS and FDP tendons.
To perform these exercises, the therapist passively moves the patient’s fingers into five different positions in a particular sequence.
Your patient has an “extensor lag” of the MP joints. What does this suggest?
It is possible to extend the MP joint passively through the full range of extension, but full active MP extension is not possible, owing to weakness of the extensor digitorum.
Posterior (dorsal) sliding of the proximal phalanx on the head of the metacarpal is restricted.
Full passive MP extension is not possible.
It is possible to extend the MP joint passively through the full range of extension, but full active MP extension is not possible, owing to weakness of the lumbricales.
Your patient has an “extensor lag” of the MP joint. The exercise of choice to remediate this problem is which of the following?
Have the patient move actively from the full fist position of the hand to the hook fist position.
While stabilizing the IP joints of one finger in extension, passively extend the MP joint of that finger.
Have the patient move actively from the straight fist position to the tabletop position of the hand.
Have the patient move actively from the full fist position of the hand to the tabletop position.
Prerequisites for successful PIP arthroplasty include all of the following except:
Adequate bone stock.
No history of chronic synovitis.
Intact neurovascular system.
Functioning flexor/extensor mechanism.
The type of grip in which muscles function primarily in an ISOM manner is which of the following?
Each of the following is an example of a precision pattern grip except:
Pad to side.
Tip to tip.
Pad to pad.
All of the following are impairments that may be present as a result of osteoarthritis in the hands except:
Subluxation of affected joints.
Any of the following interventions are appropriate in the protection phase of recovery for a person with osteoarthritis of the hands except:
Grade III mobilization techniques.
Gentle ISOM exercises.
Active assistive ROM exercises.
Which position of the wrist is preferable for a strong functional grasp?
One of the interventions appropriate during the protection phase of rehabilitation for tendinopathy is cross-fiber massage. If your target tendon is the extensor pollicis longus tendon, the best results are achieved by applying cross-fiber massage to the sheath with the thumb in which of the following positions?
It does not matter
Halfway between full flexion and extension
A laceration in “no man’s land” is in which of the following anatomical zones of the volar surface of the distal upper extremity?
The concept of passive insufficiency guides you to avoid which of the following combinations of movement with a repaired flexor tendon?
Wrist flexion, finger flexion
Wrist extension, finger extension
Wrist flexion, finger extension
Wrist extension, finger flexion
Which of the following hand positions for flexor tendon gliding exercises is also known as the intrinsic plus position?
Exercises that follow the progression of active isolated MCP extension, isolated PIP and DIP extension, and terminal range extension of IP joints describe which of the following?
Extensor lag exercises
Place and hold exercises
Friction massage to adhesive scar tissue is best applied by which of the following methods?
Tendon lengthened, massage parallel to tendon and longitudinally proximal and distal
Tendon lengthened, massage perpendicular to tendon and longitudinally proximal and distal
Tendon shortened, massage perpendicular to tendon and longitudinally proximal and distal
Tendon shortened, massage parallel to tendon and longitudinally proximal and distal
Which of the following methods is the most effective when stretching to increase wrist extension?
Palm on table with fingers extended; patient moves forearm over stabilized hand
Palm on table with fingers flexed over the edge; patient moves forearm over stabilized hand
Dorsum of hand on table with fingers flexed; patient moves forearm over stabilized hand
Dorsum of hand on table with fingers extended; patient moves forearm over stabilized hand
Which of the following methods is the correct way to teach a patient to stretch the lumbrical and interossei muscles?
Flexion of MCP joints, flexion of IP joints
Flexion of MCP joints, extension of IP joints
Extension of MCP joints, extension of IP joints
Extension of MCP joints, flexion of IP joints
You are working to strengthen the extensor carpi radialis muscle. The best technique would be which of the following?
Resist on dorsal surface of second and third metacarpals
Resist on volar surface of second and third metacarpals
Resist on dorsal surface of fourth and fifth metacarpals
Resist on volar surface of fourth and fifth metacarpals
Precautions after wrist arthroplasty include all of the following except:
Avoid functional activities that place loads on the wrist while the forearm is supinated.
If an ambulation aid is required, use platform attachment initially.
Avoid weight bearing on operated hand during transfers initially.
Permanently refrain from high-impact recreational activities such as racquet sports.